Nepal DHS Final Report (2011)

Publication date: 2012

Nepal Demographic and Health Survey 2011Dem ographic and H ealth Survey N epal 2011 Nepal Demographic and Health Survey 2011 Population Division Ministry of Health and Population Government of Nepal Kathmandu, Nepal New ERA Kathmandu, Nepal ICF International Calverton, Maryland, U.S.A. March 2012 New ERA Ministry of Health and Population The 2011 Nepal Demographic and Health Survey (2011 NDHS) was implemented by New ERA under the aegis of the Ministry of Health and Population (MOHP). Funding for the survey was provided by USAID. ICF International provided technical assistance for the survey through the MEASURE DHS program, a USAID- funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. Additional information about the survey may be obtained from the Population Division, Ministry of Health and Population, Government of Nepal, Ramshahpath, Kathmandu, Nepal; Telephone: (977-1) 4262987; New ERA, P.O. Box 722, Kathmandu, Nepal; Telephone: (977-1) 4423176/4413603; Fax: (977-1) 4419562; E-mail: info@newera.wlink.com.np. Information about the DHS program may be obtained from MEASURE DHS, ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@measuredhs.com, Internet: http://www.measuredhs.com. Recommended citation: Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland. Contents • iii CONTENTS Tables and Figures . ix Foreword. xv Acknowledgments . xvii Technical Advisory Committee and Technical Working Committee . xix Contributors to the Report . xxi Millennium Development Goal Indicators . xxiii Map of Nepal . xxiv CHAPTER 1 INTRODUCTION . 1 1.1 History, Geography, and Economy . 1 1.1.1 History . 1 1.1.2 Geography . 1 1.1.3 Economy . 3 1.2 Population . 3 1.3 Population and Health Policies and Programs . 4 1.4 Objectives of the Survey . 5 1.5 Organization of the Survey . 6 1.6 Sample Design . 6 1.6.1 Sampling Frame . 7 1.6.2 Domains . 7 1.6.3 Sample Selection . 7 1.7 Questionnaires . 8 1.8 Hemoglobin Testing . 8 1.9 Listing, Pretest, Training, and Fieldwork . 9 1.9.1 Listing . 9 1.9.2 Pretest . 9 1.9.3 Training of Field Staff . 9 1.9.4 Fieldwork . 10 1.10 Data Processing . 10 1.11 Response Rates . 10 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 13 2.1 Household Characteristics . 13 2.1.1 Water and Sanitation . 13 2.1.2 Housing Characteristics . 16 2.1.3 Household Possessions . 18 2.2 Socioeconomic Status Index . 19 2.3 Household Population by Age and Sex . 20 2.4 Migration Status . 22 2.5 Household Composition . 25 2.6 Birth Registration . 25 2.7 Children’s Living Arrangements, Orphanhood, and School Attendance . 26 2.8 Education of Household Population . 28 2.8.1 Educational Attainment of Household Population . 28 2.8.2 School Attendance Ratios . 30 2.8.3 Early Childhood Development Centers . 33 2.9 Possession of Mosquito Nets . 34 2.10 Prevalence and Causes of Food Insecurity and Coping Strategies . 35 iv • Contents CHAPTER 3 CHARACTERISTICS OF RESPONDENTS . 41 3.1 Characteristics of Survey Respondents . 41 3.1.1 Spousal Separation . 43 3.2 Educational Attainment by Background Characteristics . 44 3.3 Literacy . 47 3.4 Access to Mass Media . 49 3.4.1 Access to Specific Radio and Television Programs . 51 3.4.2 Preferred Media Source for Health-Related Programs . 53 3.5 Employment . 54 3.5.1 Employment Status . 54 3.5.2 Occupation . 57 3.5.3 Earnings, Employers, and Continuity of Employment . 60 3.6 Use of Tobacco . 61 CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY . 65 4.1 Current Marital Status . 65 4.2 Polygyny . 66 4.3 Age at First Marriage . 67 4.4 Median Age at First Marriage . 68 4.5 Age at First Sexual Intercourse . 70 4.6 Median Age at First Sexual Intercourse . 71 4.7 Recent Sexual Activity . 71 CHAPTER 5 FERTILITY . 75 5.1 Current Fertility . 75 5.2 Fertility Differentials . 76 5.3 Fertility Trends . 77 5.4 Children Ever Born and Living . 78 5.5 Birth Intervals . 79 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 81 5.7 Menopause . 82 5.8 Age at First Birth . 82 5.9 Teenage Pregnancy and Motherhood . 83 CHAPTER 6 FERTILITY PREFERENCES . 85 6.1 Desire for More Children . 85 6.2 Desire to Limit Childbearing by Background Characteristics. 86 6.3 Ideal Family Size . 88 6.4 Fertility Planning . 90 6.5 Wanted Fertility Rates . 90 CHAPTER 7 FAMILY PLANNING . 93 7.1 Knowledge of Contraceptive Methods . 94 7.2 Current Use of Contraception . 94 7.3 Current Use of Contraception by Background Characteristics . 95 7.4 Trends in Current Use of Family Planning . 97 7.5 Timing of Female Sterilization . 98 7.6 Source of Contraception . 99 7.7 Brands of Pills and Condoms Used . 100 7.8 Informed Choice . 101 7.9 Contraceptive Discontinuation Rates . 102 7.10 Reasons for Discontinuation of Contraceptive Use . 102 Contents • v 7.11 Knowledge of Fertile Period . 103 7.12 Need and Demand for Family Planning Services . 103 7.13 Future Use of Contraception . 105 7.14 Exposure to Family Planning Messages . 105 7.15 Contact of Nonusers with Family Planning Providers . 107 7.16 Counseling During Postpartum and Post-abortion . 108 7.17 Men’s Attitudes towards Contraception . 110 CHAPTER 8 INFANT AND CHILD MORTALITY . 111 8.1 Assessment of Data Quality . 112 8.2 Levels and Trends in Infant and Child Mortality . 113 8.3 Socioeconomic Differentials in Childhood Mortality . 114 8.4 Demographic Differentials in Mortality . 115 8.5 Perinatal Mortality . 116 8.6 High-risk Fertility Behavior . 117 CHAPTER 9 MATERNAL HEALTH . 119 9.1 Antenatal Care . 119 9.1.1 Number and Timing of Antenatal Visits . 121 9.2 Components of Antenatal Care . 121 9.3 Tetanus Toxoid Vaccination . 123 9.4 Place of Delivery . 124 9.5 Assistance during Delivery . 126 9.5.1 Care and Support during Delivery . 128 9.5.2 Birth Preparedness . 130 9.6 Postnatal Care . 130 9.6.1 Timing of First Postnatal Checkup for the Mother . 131 9.6.2 Provider of First Postnatal Checkup for Mother . 132 9.7 Newborn Care . 132 9.7.1 Provider of First Postnatal Checkup for the Newborn . 134 9.7.2 Newborn Care Practices. 135 9.8 Abortion . 136 9.8.1 Knowledge that Abortion is Legal in Nepal . 137 9.8.2 Knowledge about Places That Provide Safe Abortions . 138 9.8.3 Pregnancy Outcomes . 139 9.8.4 Reason for the Most Recent Abortion . 140 9.8.5 Type of Abortion Procedure . 141 9.8.6 Place and Provider for Abortion . 142 9.8.7 Complications during and after Abortion and Contraception . 143 9.8.8 Abortion and Post-abortion Cost . 143 9.9 Uterine Prolapse . 143 9.10 Problems in Accessing Health Care . 143 9.10.1 Awareness and Practice of Health Services in the Government Sector . 144 CHAPTER 10 CHILD HEALTH . 147 10.1 Child’s Weight and Size at Birth . 148 10.2 Vaccination Coverage . 149 10.3 Vaccination by Background Characteristics . 150 10.4 Trends in Immunization Coverage . 152 10.5 Acute Respiratory Infection . 152 10.6 Fever . 153 10.7 Diarrhea . 155 vi • Contents 10.8 Diarrhea Treatment . 156 10.9 Feeding Practices during Diarrhea . 158 10.10 Knowledge of ORS Packets . 159 10.11 Disposal of Children’s Stools. 160 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN . 163 11.1 Nutritional Status of Children . 164 11.1.1 Measurement of Nutritional Status among Young Children . 164 11.1.2 Data Collection . 165 11.1.3 Measures of Child Nutrition Status . 165 11.1.4 Trends in Children’s Nutritional Status . 168 11.2 Breastfeeding and Complementary Feeding . 169 11.2.1 Initiation of Breastfeeding . 169 11.3 Breastfeeding Status by Age . 171 11.4 Duration of Breastfeeding . 173 11.5 Types of Complementary Foods . 174 11.6 Infant and Young Child Feeding (IYCF) Practices . 175 11.7 Prevalence of Anemia in Children . 177 11.8 Micronutrient Intake among Children . 179 11.9 Nutritional Status of Women . 182 11.10 Prevalence of Anemia in Women . 184 11.11 Micronutrient Intake among Mothers . 185 CHAPTER 12 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 189 12.1 Introduction . 189 12.2 HIV and AIDS Knowledge, Transmission, and Prevention Methods . 190 12.2.1 Knowledge of AIDS . 190 12.2.2 Knowledge of HIV Prevention Methods . 191 12.2.3 Comprehensive Knowledge of HIV and AIDS Transmission . 193 12.3 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 196 12.4 Accepting Attitudes toward those Living with HIV and AIDS. 197 12.5 Attitudes toward Negotiating Safer Sex . 199 12.6 Multiple Sexual Partners . 201 12.7 Payment for Sex . 202 12.8 Testing for HIV . 203 12.9 Self-reporting of Sexually Transmitted Infections . 206 12.10 Prevalence of Medical Injections . 207 12.11 HIV and AIDS-related Knowledge and Behavior among Youth . 208 12.11.1 Knowledge about HIV and AIDS and of Sources for Condoms . 209 12.11.2 Age at First Sexual Intercourse among Youth . 210 12.11.3 Premarital Sex . 211 12.11.4 Multiple Sexual Partners among Youth . 212 12.11.5 Age Mixing in Sexual Relationships among Women Age 15-19 . 213 12.11.6 Recent HIV Tests among Youth . 214 CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 215 13.1 Employment and Form of Earnings . 216 13.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s and Their Husbands’ Earnings . 218 13.3 Control over Husbands’ Earnings . 219 13.4 Women’s and Men’s Ownership of Selected Assets . 222 Contents • vii 13.5 Women’s Participation in Decision-making . 224 13.6 Women’s Empowerment Indicators . 227 13.7 Current Use of Contraception by Women’s Status . 229 13.8 Ideal Family Size and Unmet Need by Women’s Status . 230 13.9 Reproductive Health Care and Women’s Empowerment . 231 13.10 Infant and Child Mortality and Women’s Empowerment . 232 CHAPTER 14 DOMESTIC VIOLENCE . 233 14.1 Measurement of Violence . 234 14.1.1 Use of Valid Measures of Violence . 234 14.1.2 Ethical Considerations in the 2011 NDHS . 235 14.1.3 Subsample for the Violence Module . 235 14.2 Experience of Physical Violence . 236 14.3 Perpetrators of Physical Violence . 237 14.4 Experience of Sexual Violence . 237 14.5 Perpetrators of Sexual Violence . 238 14.6 Experience of Different Forms of Violence . 239 14.7 Forced at Sexual Initiation . 239 14.8 Violence during Pregnancy . 239 14.9 Marital Control by Husband. 240 14.10 Forms of Spousal Violence . 241 14.11 Spousal Violence by Background Characteristics . 243 14.12 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 244 14.13 Frequency of Spousal Violence . 245 14.14 Onset of Spousal Violence . 247 14.15 Physical Consequences of Spousal Violence . 247 14.16 Violence by Women against Their Husbands . 248 14.17 Help-seeking Behavior by Women Who Experience Violence . 250 REFERENCES . 253 APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION . 261 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 267 APPENDIX C DATA QUALITY TABLES . 281 APPENDIX D PERSONS INVOLVED IN THE 2011 NEPAL DEMOGRAPHIC AND HEALTH SURVEY . 287 APPENDIX E QUESTIONNAIRES . 291 Tables and Figures • ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators . 3 Table 1.2 Results of the household and individual interviews . 11 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION Table 2.1 Household drinking water . 14 Table 2.2 Household sanitation facilities . 15 Table 2.3 Hand washing . 16 Table 2.4 Household characteristics . 17 Table 2.5 Household possessions . 18 Table 2.6 Wealth quintiles . 20 Table 2.7 Household population by age, sex, and residence . 21 Table 2.8 Migration status . 22 Table 2.9.1 Migration status: Men . 23 Table 2.9.2 Migration status: Women . 24 Table 2.10 Household composition . 25 Table 2.11 Birth registration of children under age five . 26 Table 2.12 Children’s living arrangements and orphanhood . 27 Table 2.13.1 Educational attainment of the female household population. 29 Table 2.13.2 Educational attainment of the male household population . 30 Table 2.14.1 School attendance ratios: Primary school . 31 Table 2.14.2 School attendance ratios: Secondary school . 32 Table 2.15 Children enrolled in school-based pre-primary classes and Early Childhood Development centers . 34 Table 2.16 Possession of mosquito nets . 35 Table 2.17 Household food security . 37 Table 2.18 Coping strategies of households with food insecurity . 38 Table 2.19 Causes of household food insecurity . 39 Figure 2.1 Population Pyramid . 21 Figure 2.2 Age-specific Attendance Rates of the de facto Population 5 to 24 Years . 33 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 42 Table 3.2 Spousal separation. 44 Table 3.3.1 Educational attainment: Women . 45 Table 3.3.2 Educational attainment: Men . 46 Table 3.4.1 Literacy: Women. 47 Table 3.4.2 Literacy: Men . 48 Table 3.5.1 Exposure to mass media: Women . 49 Table 3.5.2 Exposure to mass media: Men . 50 Table 3.6.1 Exposure to specific health programs on radio and television: Women . 51 Table 3.6.2 Exposure to specific health programs on radio and television: Men . 52 Table 3.7.1 Preferred media source for health-related information: Women . 53 Table 3.7.2 Preferred media source for health-related information: Men . 54 Table 3.8.1 Employment status: Women . 55 Table 3.8.2 Employment status: Men . 57 x • Tables and Figures Table 3.9.1 Occupation: Women . 58 Table 3.9.2 Occupation: Men . 59 Table 3.10.1 Type of employment: Women . 60 Table 3.10.2 Type of employment: Men . 61 Table 3.11.1 Use of tobacco: Women . 62 Table 3.11.2 Use of tobacco: Men . 63 Figure 3.1 Women’s Employment Status in the Past 12 Months . 56 CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY Table 4.1 Current marital status . 65 Table 4.2 Number of co-wives and wives . 67 Table 4.3 Age at first marriage . 68 Table 4.4 Median age at first marriage by background characteristics . 69 Table 4.5 Age at first sexual intercourse . 70 Table 4.6 Median age at first sexual intercourse by background characteristics . 71 Table 4.7.1 Recent sexual activity: Women . 72 Table 4.7.2 Recent sexual activity: Men . 73 Figure 4.1 Trend in Proportion Never Married among Women and Men 15-24 Years . 66 CHAPTER 5 FERTILITY Table 5.1 Current fertility . 76 Table 5.2 Fertility by background characteristics . 77 Table 5.3.1 Trends in age-specific fertility rates . 77 Table 5.3.2 Trends in fertility . 78 Table 5.4 Children ever born and living . 79 Table 5.5 Birth intervals . 80 Table 5.6 Postpartum amenorrhea, abstinence, and insusceptibility . 81 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 82 Table 5.8 Menopause . 82 Table 5.9 Age at first birth . 83 Table 5.10 Median age at first birth . 83 Table 5.11 Teenage pregnancy and motherhood . 84 Figure 5.1 Trends in Fertility . 78 CHAPTER 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . 86 Table 6.2.1 Desire to limit childbearing: Women . 87 Table 6.2.2 Desire to limit childbearing: Men . 87 Table 6.3 Ideal number of children by number of living children . 88 Table 6.4 Mean ideal number of children by background characteristics . 89 Table 6.5 Fertility planning status . 90 Table 6.6 Wanted fertility rates . 91 CHAPTER 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods . 94 Table 7.2 Current use of contraception by age . 95 Table 7.3 Current use of contraception by background characteristics . 96 Table 7.4 Trends in current use of contraceptive methods . 97 Table 7.5 Timing of sterilization . 98 Tables and Figures • xi Table 7.6 Source of modern contraception methods . 99 Table 7.7 Use of social marketing brand pills and condoms . 100 Table 7.8 Informed choice . 101 Table 7.9 Twelve-month contraceptive discontinuation rates . 102 Table 7.10 Reasons for discontinuation . 103 Table 7.11 Knowledge of fertile period . 103 Table 7.12 Need and demand for family planning among currently married women . 104 Table 7.13 Future use of contraception . 105 Table 7.14 Exposure to family planning messages . 106 Table 7.15 Contact of nonusers with family planning providers . 108 Table 7.16 Information on family planning methods and counseling . 109 Table 7.17 Men’s attitudes towards contraceptive use . 110 Figure 7.1 Trends in Contraceptive Use among Currently Married Women . 98 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 113 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 115 Table 8.3 Early childhood mortality rates by demographic characteristics . 116 Table 8.4 Perinatal mortality . 117 Table 8.5 High-risk fertility behavior . 118 Figure 8.1 Trends in Childhood Mortality, Nepal 1991-2010 . 114 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 120 Table 9.2 Number of antenatal care visits and timing of first visit . 121 Table 9.3 Components of antenatal care . 122 Table 9.4 Tetanus toxoid injections . 124 Table 9.5 Place of delivery . 125 Table 9.6 Reasons for not delivering in a health facility . 126 Table 9.7 Assistance during delivery . 127 Table 9.8 Care and support during delivery . 129 Table 9.9 Birth preparedness. 130 Table 9.10 Timing of first postnatal checkup . 131 Table 9.11 Type of provider of first postnatal checkup for the mother . 132 Table 9.12 Timing of first postnatal checkup for the newborn . 133 Table 9.13 Type of provider of first postnatal checkup for the newborn . 134 Table 9.14 Use of clean home delivery kits and other instruments to cut the umbilical cord . 135 Table 9.15 Newborn care practices . 136 Table 9.16 Knowledge that abortion is legal in Nepal . 138 Table 9.17 Knowledge about places that provide safe abortions . 139 Table 9.18 Pregnancy outcomes by background characteristics . 140 Table 9.19 Main reason for the most recent abortion in the past five years . 141 Table 9.20 Abortion services in the past five years . 142 Table 9.21 Problems in accessing health care . 144 Table 9.22 Awareness and practice of health services in government sector . 145 CHAPTER 10 CHILD HEALTH Table 10.1 Child’s weight and size at birth . 149 Table 10.2 Vaccinations by source of information . 150 Table 10.3 Vaccinations by background characteristics . 151 xii • Tables and Figures Table 10.4 Prevalence of symptoms of ARI . 153 Table 10.5 Prevalence and treatment of fever . 154 Table 10.6 Prevalence of diarrhea . 156 Table 10.7 Diarrhea treatment. 158 Table 10.8 Feeding practices during diarrhea . 159 Table 10.9 Disposal of children’s stools . 161 Figure 10.1 Trends in Vaccination Coverage among Children 12-23 Months, Nepal 1996-2011 . 152 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN Table 11.1 Nutritional status of children . 166 Table 11.2 Initial breastfeeding . 170 Table 11.3 Breastfeeding status by age . 172 Table 11.4 Median duration of breastfeeding . 174 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 175 Table 11.6 Infant and young child feeding (IYCF) practices . 176 Table 11.7 Prevalence of anemia in children . 178 Table 11.8 Micronutrient intake among children . 180 Table 11.9 Presence of adequately iodized salt in household . 182 Table 11.10 Nutritional status of women . 183 Table 11.11 Prevalence of anemia in women . 185 Table 11.12 Micronutrient intake among mothers . 187 Figure 11.1 Nutritional Status of Children by Age. 167 Figure 11.2 Trends in Nutritional Status of Children under Five Years . 169 Figure 11.3 Infant Feeding Practices by Age . 172 Figure 11.4 IYCF Indicators on Breastfeeding Status . 173 CHAPTER 12 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 12.1 Knowledge of AIDS . 191 Table 12.2 Knowledge of HIV prevention methods . 192 Table 12.3.1 Comprehensive knowledge about AIDS: Women . 194 Table 12.3.2 Comprehensive knowledge about AIDS: Men . 195 Table 12.4 Knowledge of prevention of mother-to-child transmission of HIV . 196 Table 12.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 198 Table 12.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 199 Table 12.6 Attitudes toward negotiating safer sexual relations with husband . 200 Table 12.7 Multiple sexual partners . 201 Table 12.8 Payment for sexual intercourse and condom use at last paid sexual intercourse . 203 Table 12.9.1 Coverage of prior HIV testing: Women . 204 Table 12.9.2 Coverage of prior HIV testing: Men . 205 Table 12.10 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 206 Table 12.11 Prevalence of medical injections . 208 Table 12.12 Comprehensive knowledge about AIDS and of a source of condoms among youth . 209 Table 12.13 Age at first sexual intercourse among youth . 211 Table 12.14 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 212 Table 12.15 Multiple sexual partners in the past 12 months among young men . 213 Table 12.16 Age mixing in sexual relationships among women age 15-19 . 213 Table 12.17 Recent HIV tests among youth . 214 Figure 12.1 Women and Men Seeking Advice or Treatment for STIs . 207 Tables and Figures • xiii CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 13.1 Employment and cash earnings of currently married women and men . 216 Table 13.2 Reasons for women not being employed in the past 12 months . 217 Table 13.3.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings: Women . 219 Table 13.3.2 Control over men’s cash earnings . 220 Table 13.4 Woman’s control over their earnings and over those of their husbands . 221 Table 13.5.1 Ownership of assets: Women . 223 Table 13.5.2 Ownership of assets: Men . 224 Table 13.6 Participation in decision-making . 225 Table 13.7.1 Women’s participation in decision-making by background characteristics . 226 Table 13.7.2 Men’s participation in decision-making by background characteristics . 227 Table 13.8 Indicators of women’s empowerment . 229 Table 13.9 Current use of contraception by women’s empowerment . 230 Table 13.10 Women’s empowerment and ideal number of children and unmet need for family planning . 230 Table 13.11 Reproductive health care by women’s empowerment. 231 Table 13.12 Early childhood mortality rates by indicators of women’s empowerment . 232 Figure 13.1 Percent Distribution of Currently Married Women with their Score on Each of the Two Women’s Empowerment Indices . 228 CHAPTER 14 DOMESTIC VIOLENCE Table 14.1 Experience of physical violence . 236 Table 14.2 Persons committing physical violence . 237 Table 14.3 Experience of sexual violence . 238 Table 14.4 Persons committing sexual violence . 238 Table 14.5 Experience of different forms of violence . 239 Table 14.6 Forced sexual initiation . 239 Table 14.7 Violence during pregnancy . 240 Table 14.8 Marital control exercised by husbands . 241 Table 14.9 Forms of spousal violence . 242 Table 14.10 Spousal violence by background characteristics . 244 Table 14.11 Spousal violence by husband’s characteristics and women’s empowerment indicators . 245 Table 14.12 Frequency of spousal violence among those who report violence . 246 Table 14.13 Onset of marital violence . 247 Table 14.14 Injuries to women due to spousal violence . 248 Table 14.15 Violence by women against their spouse . 249 Table 14.16 Help seeking to stop violence . 250 Table 14.17 Sources from where help was sought . 251 Figure 14.1 Specific Forms of Physical and Sexual Violence Committed by Husbands . 243 APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION Table A.1 Enumeration areas . 262 Table A.2 Population . 262 Table A.3 Sample allocation of clusters and households . 263 Table A.4 Sample allocation of expected number of completed interviews . 263 Table A.5 Sample implementation: Women . 264 Table A.6 Sample implementation: Men . 265 xiv • Tables and Figures APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Nepal, 2011 . 269 Table B.2 Sampling errors for national sample, Nepal 2011 . 270 Table B.3 Sampling errors for urban sample, Nepal 2011 . 271 Table B.4 Sampling errors for rural sample, Nepal 2011 . 272 Table B.5 Sampling errors for Mountain region, Nepal 2011 . 273 Table B.6 Sampling errors for Hill region, Nepal 2011 . 274 Table B.7 Sampling errors for Terai region, Nepal 2011 . 275 Table B.8 Sampling errors for Eastern region, Nepal 2011 . 276 Table B.9 Sampling errors for Central region, Nepal 2011 . 277 Table B.10 Sampling errors for Western region, Nepal 2011 . 278 Table B.11 Sampling errors for Mid-western region, Nepal 2011. 279 Table B.12 Sampling errors for Far-western region, Nepal 2011 . 280 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 281 Table C.2.1 Age distribution of eligible and interviewed women . 282 Table C.2.2 Age distribution of eligible and interviewed men . 282 Table C.3 Completeness of reporting . 283 Table C.4 Births by calendar years . 283 Table C.5 Reporting of age at death in days . 284 Table C.6 Reporting of age at death in months . 285 Table C.7 Nutritional status of children based on NCHS/CDC/WHO International Reference Population . 286 Foreword • xv FOREWORD The 2011 Nepal Demographic and Health Survey is the fourth nationally representative comprehensive survey conducted as part of the worldwide Demographic and Health Surveys (DHS) project in the country. The survey was implemented by New ERA under the aegis of the Population Division, Ministry of Health and Population. Technical support for this survey was provided by ICF International with financial support from the United States Agency for International Development (USAID) through its mission in Nepal. The primary objective of the 2011 NDHS is to provide up-to-date and reliable data on different issues related to population and health, which provides guidance in planning, implementing, monitoring, and evaluating health programs in Nepal. The long term objective of the survey is to strengthen the technical capacity of the local institutions to plan, conduct, process and analyze data from complex national population and health surveys. The survey includes topics on fertility levels and determinants, family planning, fertility preferences, childhood mortality, children and women’s nutritional status, the utilization of maternal and child health services, knowledge of HIV/AIDS and STIs, women’s empowerment and for the first time, information on women facing different types of domestic violence. The survey also reports on the anemia status of women age 15-49 and children age 6-59 months. In addition to providing national estimates, the survey report also provides disaggregated data at the level of various domains such as ecological region, development regions and for urban and rural areas. This being the fourth survey of its kind, there is considerable trend information on reproductive and health care over the past 15 years. Moreover, the 2011 NDHS is comparable to similar surveys conducted in other countries and therefore, affords an international comparison. The 2011 NDHS also adds to the vast and growing international database on demographic and health-related variables. The 2011 NDHS collected demographic and health information from a nationally representative sample of 10,826 households, which yielded completed interviews with 12,674 women age 15-49 in all selected households and with 4, 121 men age 15-49 in every second household. This survey is the concerted effort of various individuals and institutions, and it is with great pleasure that I acknowledge the work that has gone into producing this useful document. The participation and cooperation that was extended by the members of the Technical Advisory Committee in the different phases of the survey is greatly appreciated. I would like to extend my appreciation to USAID/Nepal for providing financial support for the survey. I would also like to acknowledge ICF International for its technical assistance at all stages of the survey. My sincere thanks go to the New ERA study team for their generous effort in carrying out the survey work. I also would like to thank the Population Division of the Ministry of Health and Population for its effort and dedication in the completion of the 2011 NDHS. Praveen Mishra Secretary Ministry of Health and Population Acknowledgments • xvii ACKNOWLEDGMENTS The 2011 Nepal Demographic and Health Survey (NDHS) was conducted under the aegis of the Population Division, Ministry of Health and Population of the Government of Nepal. The United States Agency for International Development (USAID) provided financial support through its mission in Nepal while technical assistance was provided by ICF International. The survey was implemented by New ERA, a local research firm with extensive experience in conducting such surveys in the past. We express our deep sense of appreciation to the technical experts in the different fields of population and health for their valuable input in the various phases of the survey including the finalization of the questionnaires, training of field staff, monitoring the data collection, reviewing the draft tables and providing valuable inputs towards finalizing the report. Our sincere gratitude goes to all the members of Technical Advisory Committee for their time, support and valuable input. We would like to extend or sincere gratitude to Dr. Sudha Sharma, Ex-secretary, Ministry of Health and Population for her guidance and valuable input. Our sincere thanks go to Mr. Surya Prasad Acharya and Mr. Krishna Prasad Lamsal for their support during the different phases of the survey as chiefs of the Population Division, Ministry of Health and Population. We would like to express our heartfelt gratitude to the USAID mission in Nepal. We acknowledge the technical input and support provided by Ms. Anne M. Peniston, Director, Office of Health and Family Planning, Ms. Shanda Steimer, Director, Office of Health and Family Planning, Mr. Han Kang, Deputy Director, Office of Health and Family Planning, and Mr. Deepak Paudel, Senior MNCH Program Management Specialist, Office of Health and Family Planning. Our deep sense of gratitude goes to Dr. Pav Govindasamy, Regional Coordinator for Anglophone Africa and Asia, ICF International for her technical support. We would like to thank Dr. Alfredo Aliaga, Sampling Expert for designing the sample for the survey. Our sincere thanks go to Mr. Albert Themme, Data Processing Specialist for his invaluable input, guidance, and untiring support in making the use of tablet computers materialize in the Nepal DHS for the first time. Similarly, we extend our gratitude to Mr. Alexander Izmukhambetov, Data Processing Specialist and other ICF International staff for their valuable contribution. Special thanks goes to the core staff of New ERA, Ms. Anjushree Pradhan, Project Director; Mr. Yogendra Prasai, Technical Advisor; Mr. Kshitiz Shrestha and Ms. Jyoti Manandhar, Research Officers; Mr. Sachin Shrestha, Senior Research Assistant; Mr. Rajendra Lal Singh Dangol, Senior Data Processing Specialist and Ms. Sarita Vaidya, Data Processing Officer; Mr. Gehendra Man Pradhan and Mr. Babu Raja Dangol, Data Supervisors; Mr. Sanu Raja Shakya and Ms. Geeta Shrestha Amatya, Word Processing Staff, and other staff of New ERA for managing technical, administrative and logistical needs of the survey. Our special thanks go to the field coordinators, the quality control staff, field supervisors and enumerators for their tireless effort in making the fieldwork successful. We are also grateful to Dr. Megha Raj Dhakal, Under-Secretary, Mr. Naresh Khatiwada and Anil Thapa, Demographers, and Ms. Lila K.C., Section Officer, Population Study and Research Section, and other staff at the Ministry of Health and Population for their active support. Similarly, we would like to extend our gratitude to the authors for their valuable contribution to the report. We greatly acknowledge the support we received from various institutions in implementing the survey. We would especially like to thank the local level agencies including the District Health Offices, Health-Posts, Sub-health Posts, District Development Committees and the Village Development Committees for their support throughout the survey period. The FCHVs require special mention here, whose support has been highly appreciated. We extend our deepest gratitude to all the respondents for their time in responding to the survey. Sidhartha Man Tuladhar Padam Raj Bhatta Executive Director Chief, Population Division New ERA Ministry of Health and Population Technical Advisory Committee and Technical Working Committee • xix TECHNICAL ADVISORY COMMITTEE AND TECHNICAL WORKING COMMITTEE 2011 NEPAL DHS TECHNICAL ADVISORY COMMITTEE Secretary (Population), Ministry of Health and Population Chairperson Secretary, Ministry of Health and Population Member Dr. Ram Hari Aryal, Secretary, Ministry of Science and Technology Member Dr. Bal Gopal Baidya, Member, National Population Committee Member Dr. Gajananda Agrawal, Member, National Population Committee Member Dr. Ram Sharan Pathak, Member, National Population Committee Member Dr. Chandrakala Bhadra, Member, National Population Committee Member Dr. Prabha K Hamal, Member, National Population Committee Member Mr. Yogendra Bahadur Gurung, Member, National Population Committee Member Director General, Department of Health Services Member Director General, Central Bureau of Statistics Member Chief, PPICD, Ministry of Health and Population Member Chief, PHA, Monitoring and Evaluation Division, Ministry of Health and Population Member Chief, Curative Service Division, Ministry of Health and Population Member Chief, Administrative Division, Ministry of Health and Population Member Chief, HR and Financial Resource Management Division, Ministry of Health and Population Member Director, Family Health Division, Department of Health Services Member Director, Child Health Division, Department of Health Services Member Director, NCASC, Ministry of Health and Population Member Director, NHIECC, Ministry of Health and Population Member Chairperson, National Health Research Council Member Chief, Social Division, National Planning Commission Member Director General, Family Planning Association Member Representative, USAID Member Representative, UNFPA Member Dr. Pav Govindasamy, ICF International Member Head of Department, Central Department of Population Studies Member Executive Director, New ERA Member Chief, Population Division, Ministry of Health and Population Member-Secretary xx • Technical Advisory Committee and Technical Working Committee 2011 NEPAL DHS TECHNICAL WORKING COMMITTEE Joint Secretary/Chief, Population Division, Ministry of Health and Population Chairperson Dr. Bal Krishna Suvedi, PPICD, Ministry of Health and Population Member Dr. Megha Raj Dhakal, Under Secretary, Population Study and Research Section, MOHP Member Mr. Kabi Raj Khanal, Under Secretary, Ministry of Health and Population Member Dr. Babu Ram Marasini, Public Health Administrator, Ministry of Health and Population Member Mr. Raj Kumar Pokharel, Public Health Administrator, CHD, Department of Health Services Member Mr. Naresh Khatiwada, Statistical Officer/Demographer, Ministry of Health and Population Member Mr. Anil Thapa, Demographer, Ministry of Health and Population Member Mr. Badri Bahadur Khadka, NHIECC Member Chief, Demographic Section, FHD, Department of Health Services Member Mr. Pawan Kumar Ghimire, Chief, HMIS, Department of Health Services Member Mr. Nebin Lal Shrestha, Director, Central Bureau of Statistics Member Mr. Jhabindra Prasad Pandey, Demographer. Family Health Division Member Dr. Laxmi Bilash Acharya, FHI Member Dr. Yagya Bahadur Karki, Demographer Member Dr. Prakash Dev Panta, Family Health International 360 Member Dr. Pushpa Kamal Subedi, Assoc. Professor, Central Department of Population Studies, T.U. Member Mr. Ajit Singh Pradhan, Demographer, Nepal Health Sector Support Program Member Mr. Bharat Ban, Nepal Family Health Program Member Representative, National Center for AIDS and STD Control Member Representative, Nepal Health Research Council Member Representative, New ERA Member Chief, Population Study and Research Section, Population Division Member-Secretary Contributors to the Report • xxi CONTRIBUTORS TO THE REPORT AUTHORS Mr. Padam Raj Bhatta, Population Division, Ministry of Health and Population Mr. Surya Prasad Acharya, Ministry of Health and Population Mr. Upendra Adhikari, Ministry of Women and Social Welfare Dr. Megha Raj Dhakal, Population Division, Ministry of Health and Population Mr. Naresh Khatiwada, Population Division, Ministry of Health and Population Mr. Anil Thapa, Population Division, Ministry of Health and Population Ms. Lila Kumari K.C., Population Division, Ministry of Health and Population Mr. Raj Kumar Pokhrel, Child Health Division, Department of Health Services Mr. Mukti Nath Khanal, Family Health Division, Department of Health Services Mr. Paban Ghimire, Management Division, Department of Health Services Mr. Ramesh Adhikari, District Health Office, Kaski Dr. Purusotam Raj Shedain, Child Health Division, Department of Health Services Mr. Parshu Ram Shrestha, Child Health Division, Department of Health Services Mr. Dilli Raman Adhikari, National Centre for AIDS and STD Control, Department of Health Services Mr. Jhabindra Prasad Pandey, Ministry of Health and Population Mr. Kshitiz Shrestha, New ERA Ms. Jyoti Manandhar, New ERA Dr. Pav Govindasamy, ICF International Ms. Anjushree Pradhan, ICF International RESOURCE PERSONS Mr. Gauri Pradhan, Member, National Human Rights Commission Dr. Sudha Sharma, Ministry of Health and Population Dr. Ram Hari Aryal, Secretary, Ministry of Science and Technology Dr. Bal Krishna Suvedi, Ministry of Health and Population Dr. Chandrakala Bhadra, Member, National Population Committee Dr. Ram Sharan Pathak, Member, National Population Committee Mr. Yogendra Bahadur Gurung, Member, National Population Committee Dr. Y.V. Pradhan, Director General, Department of Health Services Mr. Bed Prasad Bhattarai, Director, National Human Rights Commission Dr. Naresh Pratap K.C., Department of Health Services, Ministry of Health and Population Dr. Shyam Raj Uprety, Child Health Division, Department of Health Services Dr. Ramesh Kharel, National Center for AIDS and STD Control Dr. B.R. Marasini, Ministry of Health and Population Dr. Kedar Baral (PAHS) Dr. R.K. Adhikari, KIST Medical College Dr. Prakash Dev Pant, Family Health International 360 Dr. Suresh Tiwari, Nepal Health Sector Support Program Mr. Ajit Singh Pradhan, Nepal Health Sector Support Program Mr. Ashoke Shrestha, Nepal Family Health Program Dr. Rajendra Bhadra, Nepal Family Health Program Mr. Bharat Ban, Nepal Family Health Program Mr. Dirgha Raj Shrestha, Nepal Family Health Program Mr. Deepak Paudel (USAID) Dr. Amit Bhandari, DFID Ms. Iva Schildbach (GIZ) Mr. Manav Bhattarai, World Bank Mr. Satish Raj Pandey, Family Health International 360 Mr. Shailesh Neupane, Valley Research Group Mr. Shital Bhandari (PAHS) Dr. Sudhir Khanal, UNICEF Mr. Sunil Acharya, Central Department of Population Studies, Tribhuvan University Ms. Pooja Pandey, Helen Keller International Mr. Yogendra Prasai, New ERA Millennium Development Goal Indicators • xxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators Nepal, 2011 Indicator Sex Total Male Female 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under five years of age1 29.6 28.0 28.8 2. Achieve universal primary education 2.1 Net enrollment ratio in primary education2 94.6 89.0 91.9 2.3 Literacy rate of 15-24 year olds3 94.6a 82.7 88.6b 3. Promote gender equality and empower women 3.1a Ratio of girls to boys in primary education4 na na 0.9 3.1b Ratio of girls to boys in secondary education4 na na 1.0 3.1c Ratio of girls to boys in tertiary education4 na na 0.8 4. Reduce child mortality 4.1 Under-five mortality rate (per 1,000 live births)5 63 62 54 4.2 Infant mortality rate (per 1,000 live births)5 54 52 46 4.3 Proportion of 1 year-old children immunized against measles6 89.7 86.3 88.0 5. Improve maternal health 5.2 Proportion of births attended by skilled health personnel7 na na 36.0 5.3 Contraceptive prevalence rate8 na 49.7 na 5.4 Adolescent birth rate9 na 81.0 na 5.5a Antenatal care coverage: at least 1 visit by skilled health professional na 58.3 na 5.5b Antenatal care coverage: at least 4 visits by any provider na 50.1 na 5.6 Unmet need for family planning na 27.0 na 6. Combat HIV/AIDS, malaria and other diseases 6.2 Condom use at last high-risk sex: youth 15-24 years10 65.8a na na 6.3 Percentage of population 15-24 years with comprehensive knowledge of AIDS11 33.9a 25.8 29.8b Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved drinking water source12 93.5 87.8 88.6 7.9 Percentage of population with access to improved sanitation13 58.1 36.7 39.5 na = Not applicable. 1 Proportion of children age 0-59 months who are below -2 standard deviations from the median of the WHO Child Growth Standards in weight-for-age. 2 The rate is based on reported attendance, not enrollment, in primary education among primary school age children (6-10 year- olds). The rate also includes children of primary school age attended in secondary education. This is proxy for MDG indicator 2.1, net enrollment ratio. 3 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence. 4 Based on reported net attendance, not gross enrollment, among 6-10 year-olds for primary, 11-15 year-olds for secondary and 16-20 year-olds for tertiary education. 5 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the 5-year period preceding the survey. 6 Among children age 12-23 months vaccinated at any time before the survey. 7 Among births in the 5-year period preceding the survey. 8 Percentage of currently married women age 15-49, using any method of contraception. 9 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19 10 High-risk sex refers to sexual intercourse with a non-marital, non-cohabiting partner. Expressed as a percentage of men and women age 15-24 who had high-risk sex in the past 12 months. Information for female suppressed as only few women had high-risk sex. 11 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission or prevention of the AIDS virus: AIDS can be transmitted by mosquito bites; a person can become infected by sharing food with someone who has AIDS. 12 Percentage of de-jure population whose main source of drinking water are: a household connection (piped), public standpipe, tubewell or borehole, protected well or spring, rainwater collection, or bottled water. 13 Percentage of de-jure population with access to flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share this facility with other households. a Restricted to men in sub-sample of households selected for the male interview b The total is calculated as the simple arithmetic mean of the percentages in the columns for males and females xxiv • Map of Nepal Introduction • 1 INTRODUCTION 1 1.1 HISTORY, GEOGRAPHY, AND ECONOMY 1.1.1 History The history of Nepal goes back thousands of years, with early dynasties of Ahirs and Gopalas and Kirant kings ruling the country. It appears that the Kirant people were one of the first to settle in Nepal; they are said to have ruled the country for about 2,500 years. Subsequent dynasties of Licchavi and Thakuri kings ruled the country before the Malla period began in the 12th century. The Malla era is considered to be the golden age of Nepal, and Malla kings were famous for their contribution to art and culture. In 1765 A.D., King Prithvi Narayan Shah—the first Shah king of Nepal—embarked on his mission to unify the country, which had previously been divided into small independent kingdoms. After several battles and sieges, he managed to unify the Kathmandu Valley and surrounding territories three years later in 1768. However, factionalism inside the royal family led to the emergence of the Rana lineage, founded by military leader Jung Bahadur Rana, who assumed power by killing hundreds of military personnel and administrators loyal to Shah rulers in 1846 (Thingo and von der Heide, 1997). Backed by newly emerging pro-democracy movements and political parties, King Tribhuwan Shah ended the century-old system of rule by hereditary Rana premiers and instituted a cabinet system of government in 1951. Reforms in 1990 established a multiparty democracy within the framework of a constitutional monarchy. In early 1996, the Nepal Communist Party (Maoist) launched a movement that capitalized on the growing dissatisfaction among the general population with the lack of reforms expected from a democratically elected government. The constant conflict between the Maoists and the elected government resulted in the displacement of the population. Growing numbers of people began migrating out of their usual places of residence to urban centers and neighboring countries to escape the conflict and to search for employment. Citing dissatisfaction with the government’s lack of progress in addressing the Maoist insurgency, King Gyanendra Bir Bikram Shah dissolved the government, declared a state of emergency, imprisoned party leaders, and assumed power in February 2005. The mass movement of April 2006 in Nepal restored parliament and the democratic process and initiated a peace movement that called for an end to the 10-year-long armed conflict. After nearly three weeks of mass protests organized by the seven-party opposition and the Maoists, the king allowed parliament to reconvene on 8 April 2006. A comprehensive peace agreement was signed between an alliance of the seven major political parties and the Nepal Communist Party (Maoist) on 21 November 2006. An interim constitution was drafted, and the restored parliament dissolved to pave the way for an interim legislature and interim government. The Nepal Communist Party (Maoist) joined the democratic competition, and constituent assembly elections were held in April 2008 to devise a constitution to manage the root causes of the conflicts afflicting the nation. After the dethroning of King Gyanendra Bir Bikram Shah and the obliteration of the monarchy in Nepal, the ruling seven-party alliance announced substantive structural reforms such as the declaration of the country as secular and federal, civilian control of the Nepal Army, nationalization of royal property, and empowerment of the prime minister as head of state (Dahal, 2008). 1.1.2 Geography The total land area of Nepal is 147,181 square kilometers, with India to the east, south, and west and China to the north. It is a land-locked country occupying an area from 26º 22' to 30º 27' north latitude and 80º 4' to 88º 12' east longitude; elevations range from 90 meters to 8,848 meters. Nepal is rectangular in shape and stretches 885 kilometers in length (east to west) and 193 kilometers in width (north to south). According to the 2 • Introduction preliminary results of the 2011 Population Census, the population of Nepal stands at 26.6 million (Central Bureau of Statistics, 2011a). Topographically, Nepal is divided into three distinct ecological zones: mountain, hill, and terai (or plains). The mountain zone, which accounts for 35 percent of the total land area, ranges in altitude from 4,877 meters to 8,848 meters above sea level and covers a land area of 51,817 square kilometers. Because of the harsh terrain, transportation and communication facilities in this zone are very limited, and only about 7 percent of the total population lives here. In contrast, the hill ecological zone, which ranges in altitude from 610 meters to 4,876 meters above sea level, is densely populated. About 43 percent of the total population lives in the hill zone, which covers an area of 61,345 square kilometers and occupies 42 percent of the total land area. The population distribution in the hills varies, with a fairly dense population in the valleys but notably lower population numbers above 2,000 meters (6,562 feet) and very low numbers above 2,500 meters (8,202 feet), where snow occasionally falls in the winter. This zone includes the Kathmandu Valley, the country’s most fertile and urbanized area. Although the terrain is also rugged in this zone, because of the higher concentration of people, transportation and communication facilities are much more developed here than in the mountains. The terai zone in the southern part of the country can be regarded as an extension of the relatively flat Gangetic plains of alluvial soil. This region has a subtropical to tropical climate. The outermost range of foothills, the Siwalik or Churia range, crests at 700 to 1,000 meters (2,297 to 3,281 feet) and marks the limit of the Gangetic plains; broad, low valleys called the inner terai lie north of these foothills. The terai consists of dense forest areas, national parks, wildlife reserves, and conservation areas. This area, which covers 34,019 square kilometers, is the most fertile part of the country. While it constitutes only 23 percent of the total land area in Nepal, 50 percent of the population lives here (Central Bureau of Statistics, 2011a). Because of its relatively flat terrain, transportation and communication facilities are more developed in this zone than in the other two zones of the country, and this has attracted newly emerging industries. The climatic conditions vary substantially by altitude. There are five climatic zones, broadly corresponding to altitude. The tropical and subtropical zones lie below 1,200 meters, the temperate zone 1,200 to 2,400 meters, the cold zone 2,400 to 3,600 meters, the subarctic zone 3,600 to 4,400 meters, and the arctic zone above 4,400 meters. In the terai, temperatures can go up to 44º Celsius in the summer and fall to 1º Celsius in the winter. The corresponding temperatures for the hill and mountain areas are 43º Celsius and 29º Celsius, respectively, in the summer and -1º Celsius and far below 0º Celsius, respectively, in the winter. The annual mean rainfall in the country is around 1,500 millimeters (Central Bureau of Statistics, 2006a). For administrative purposes, Nepal is divided into five development regions: Eastern, Central, Western, Mid-western, and Far-western. Similarly, the country is divided into 14 zones and 75 administrative districts. Districts are further divided into smaller units, called village development committees (VDCs) and municipalities. The VDCs are rural areas, whereas municipalities are urban. Currently, there are 3,915 VDCs and 58 municipalities. Each VDC is composed of 9 wards, and the number of wards in each municipality ranges from 9 to 35. Kathmandu is the capital city as well as the principal urban center of Nepal (Central Bureau of Statistics, 2006b). The 2001 census listed 103 diverse ethnic/caste groups, each with its own distinct language and culture (Central Bureau of Statistics, 2003). The major groups are as follows: Chhetri, Brahmins, Magar, Tharu, Tamang, and Newar. The 2001 census also identified about 92 mother tongues. Most of these languages originated from two major groups: the Indo-Europeans, who constitute about 79 percent of the population, and the Sino-Tibetans, who constitute about 18 percent of the population. Nepali is the official language of the country and is the mother tongue of about half of the population. However, it is used and understood by most people in the country. The other two major languages are Maithili and Bhojpuri, spoken by about 12 percent and 8 percent of Introduction • 3 the population, respectively. According to the 2001 census, the majority of Nepalese are Hindus; there are also substantial numbers of Buddhists, Muslims, and Kirants (Central Bureau of Statistics, 2003). 1.1.3 Economy Nepal has considerable scope for exploiting its resources in areas such as hydropower and tourism, but a lack of political will, weak implementation of state policies, and the government’s failure to maintain law and order have substantially curbed the growth of the economic sector. Although the country has attracted the interest of foreign investors in recent years, lack of security and unnecessary interference by workers and trade unions are continuously diminishing any such prospects. Similarly, the country’s small economy and its technological backwardness, remoteness, and susceptibility to natural disasters also restrict the prospects of foreign trade. The preliminary estimate of per capita gross domestic product (GDP) at current prices stands at Nepalese Rupees 41,851 for 2009-2010. As measured by GDP, the economic growth of the country was 3.4 percent in 2009-2010 against the target of 4.5 percent, due to the slow growth in the nonagricultural sector. Nearly one-fourth of the population lives below the poverty line according to the 2010-2011 Nepal Living Standard Survey (Central Bureau of Statistics, 2011b). According to the Nepal Living Standard Survey 2010- 2011, only 2 percent of the population in Nepal is unemployed. Agriculture is the major occupation, with 76 percent of households involved in agricultural activities. Remittances have become one of the foremost sources of income in Nepal, with nearly 56 percent of households receiving some sort of remittance (Central Bureau of Statistics, 2011c). 1.2 POPULATION Population censuses have been carried out in Nepal since 1911 at decennial intervals. However, detailed information about the size and structure of the population has been available only since the 1952/1954 census. Table 1.1 provides a summary of the basic demographic indicators for Nepal from the census data for 1971, 1981, 1991, and 2001 and the recent preliminary findings from the 2011 census. According to the preliminary 2011 census findings, the population of the country stands at 26.6 million, with an increase of 3.5 million in the last 10 years. The population has more than doubled in the last 40 years. The population grew at a rapid rate between 1971 and 1981 from 2.1 percent to 2.6 percent but has since slowed to just over 2 percent in 1991 and 1.4 percent in 2011. The population density of Nepal is estimated to be 181 per square kilometer. Table 1.1 Basic demographic indicators Selected demographic indicators for Nepal, 1971-2011 Indicator 1971 census 1981 census 1991 census 2001 census 2011 census (preliminary) Population (millions) 11.6 15.0 18.5 23.2 26.6 Intercensal growth rate (percentage) 2.1 2.6 2.1 2.2 1.4 Density (pop./km2) 79 102 126 157 181 Percent urban 4.0 6.4 9.2 13.9 17.0 Life expectancy (years) Male 42.0 50.9 55.0 60.1 u Female 40.0 48.1 53.5 60.7 u Source: Central Bureau of Statistics, 2003:3, 383; Ministry of Population and Environment and Central Bureau of Statistics, 2003:8; Central Bureau of Statistics, 2011a u = No information The Kathmandu district has the highest population density (4,408) and Manang (3) the lowest. The decennial population growth has been highest in Kathmandu (61 percent) and lowest in Manang (-31 percent) (the overall level in Nepal is 15 percent). Currently, 4.5 million people (17 percent) reside in urban areas. The largest percentage of the population is in the Central development region (36 percent) and the smallest in the Far-western region (10 percent). The sex ratio (number of males per 100 females) is estimated at 94.4 in the current census, as compared to 99.8 in the previous census in 2001. The average household size has decreased from 5.4 in 2001 to 4.7 in 2011 (Central Bureau of Statistics, 2011a). 4 • Introduction 1.3 POPULATION AND HEALTH POLICIES AND PROGRAMS In the Third Development Plan (1965-1970), family planning was a major component of planned development activities, and the Nepal Family Planning and Maternal and Child Health (FP/MCH) Project was subsequently launched under the Ministry of Health (National Planning Council, 1965). Before that, family planning activities were undertaken by the Family Planning Association of Nepal (FPAN), a nongovernmental organization established in 1959 to create awareness about the need for and importance of family planning. While the Fourth Development Plan (1970-1975) targeted the provision of family planning services to 15 percent of married couples by the end of the plan period (National Planning Commission, 1970), the Fifth Development Plan (1975-1980) initiated the expansion of family planning services through outreach workers, and serious attempts were made to reduce the birth rate by direct and indirect means. A population policy coordinating board was established in 1975 under the National Planning Commission (NPC) to coordinate the government’s multisectorial activities in population and reproductive health. The board was upgraded in 1978 to become the National Commission on Population (National Planning Commission, 1975). From the Fifth Development Plan (1975-1980) until the end of the Seventh Development Plan (1985- 1990), population issues were addressed from both policy and programmatic points of view. This included launching population-related programs in reproductive health, agriculture, forestry, urbanization, manpower and employment, education, and women’s development, as well as community development programs (National Planning Commission, 1985). In 1990, the National Commission on Population was dissolved, and its role was given to the Population Division of the NPC. The Eighth Development Plan (1992-1997) continued with the integrated development approach taken in earlier plans (National Planning Commission, 1992). The Ninth Development Plan (1997-2002) aimed to reduce population growth through social awareness and expansion of education and family planning programs. The long-term objective of the plan was to lower fertility to replacement level in the subsequent 20 years (National Planning Commission, 1997). The primary objectives of population management in the Tenth Development Plan (2002-2007) were to encourage a small family norm, promote the development of an educated and healthy population, and discourage the out-migration of skilled labor (National Planning Commission, 2002). Similarly, the Second Long Term Health Plan (1997- 2017) was formulated to improve the health status of the population; particularly vulnerable groups whose health needs often are not met, including women and children, the poor, and underprivileged and marginalized groups. The plan would address disparities in health status, assuring equitable access to quality health care services with full community participation and gender sensitivity. In 2001, the Nepal Family Health Program (NFHP), funded by the United States Agency for International Development (USAID), was implemented in partnership with the government of Nepal under the leadership of the Ministry of Health and Population (MOHP). The program ran from 2001 to 2006 and focused on reducing fertility and protecting family health through increased use of quality family planning services and selected maternal and child health services. NFHP emphasized household- and community-level services by strengthening health service delivery systems. To maximize the long-term impact, technical assistance and activities were planned and implemented in close collaboration with the MOHP. Similarly, NFHP II (2007- 2012) aims to increase access to health services for all Nepalese, particularly the rural poor, by improving public sector services, community-based family planning services, and maternal, newborn, and child health services in a manner that builds local capacity and engages stakeholders (Johns Hopkins University Center for Communication Programs, 2011; USAID/Nepal, 2010). The Nepal Health Sector Program Implementation Plan (NHSP-IP 2004-2009) was launched by the Ministry of Health and Population to improve the health status of the Nepalese population through increased utilization of essential health services; another goal was to increase the coverage and raise the quality of essential health care services, with a special emphasis on improved access for poor and vulnerable groups through an efficient sector-wide health management system developed with the provision of adequate financial resources (Ministry of Health and Population, 2011a). A further major aim was to achieve the health sector Millennium Development Goals (MDGs) in Nepal through improved health outcomes for the poor and those Introduction • 5 living in remote areas and a consequent reduction in poverty. The program included a number of new actions as part of the Agenda for Reform of the Health Sector. Similarly, NHSP-IP II (2010-2015) represents a continuation and further refinement of earlier policies and plans that were based on the implementation of cost-effective, evidence-based health interventions. A major goal is to sustain and build on a program delivering excellent results. NHSP-IP I did not have a strong focus on gender and social exclusion issues in the initial design. These issues came into greater prominence during the implementation of NHSP-IP II, particularly with the extension of free services. NHSP-IP II is designed to focus from the start on improving the health of poor and marginalized groups. NHSP-IP II also aims to reconsider how best to achieve improved efficiency and accountability in order to sustain government and external development partner (EDP) support and make the best use of limited resources. Furthermore, the plan has set out to meet specific targets with respect to improving key maternal and child health indicators such as maternal mortality ratio (MMR); total fertility rate (TFR); neonatal, infant, and under-five mortality rates; contraceptive prevalence rate; and percentage of underweight children (Ministry of Health and Population, 2010a). The three-year interim development plan (2007/2008-2010/2011), drafted after the historic people’s movement in 2006, accepted the global principle of health as a fundamental right. Among others, the plan set out to meet specific objectives such as increasing the percentage of family planning users, increasing the percentage of women receiving maternity services from health workers, and reducing the TFR, MMR, and infant and child mortality rates. The subsequent three-year interim development plan (2010/2011-2012/2013) has aimed to evaluate achievements against the set targets and continue with the specific objectives set in the earlier plan. Recently, the Population Perspective Plan (PPP) 2010-2031 was formulated based on a multidisciplinary approach in order to integrate population aspects with relevant economic and social sectors. It also provides a thematic focus on three aspects: poverty reduction, gender mainstreaming, and social inclusion. Among other objectives, the plan aims to help prioritize specific sectoral program areas related to population that bear on poverty alleviation and sustainable development. The plan also attempts to address commitments that Nepal had made in endorsing plans of action related to population issues in various international forums, particularly the 1994 International Conference on Population Development and the 2000-2015 MDGs (Ministry of Health and Population, 2010b). Furthermore, the PPP aims to provide guidance in the formulation of population policies that can be implemented with consideration of population as a crucial development variable. The plan also provides a basis for effective institutional arrangements for the coordination, implementation, and monitoring of population programs. 1.4 OBJECTIVES OF THE SURVEY The principal objective of the 2011 Nepal Demographic and Health Survey (NDHS) is to provide current and reliable data on fertility and family planning, child mortality, children’s nutritional status, utilization of maternal and child health services, domestic violence, and knowledge of HIV/AIDS. The 2011 NDHS also provides population-based information on the prevalence of anemia among women age 15-49 and children age 6-59 months. The specific objectives of the survey are to: • collect data at the national level that will allow the calculation of key demographic rates • analyze the direct and indirect factors that determine fertility levels and trends of fertility • measure the level of contraceptive knowledge among women and men by method and use of contraception among women by urban-rural residence and region 6 • Introduction • collect high-quality data on family health, including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under five, and maternity care indicators such as antenatal visits, assistance at delivery, and postnatal care • collect data on infant and child mortality • collect data on child feeding practices, including breastfeeding, and anthropometric measurements to use in assessing the nutritional status of women and children • collect data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS and evaluate patterns of recent behavior regarding condom use • conduct hemoglobin testing of women age 15-49 and children age 6-59 months in the households selected for the survey to provide information on the prevalence of anemia among women of reproductive age and young children • collect information to assess the situation of domestic violence against women Data from the 2011 NDHS survey allow for comparison of information gathered over a period of time and add to the vast and growing international database on demographic and health-related variables. Information from the survey is essential for informed policy decisions and for planning, monitoring, and evaluation of health programs in general, and reproductive health programs in particular, at both the national and district levels. A long-term objective of the survey is to strengthen the technical capacity of local organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the 2011 NDHS is comparable to similar surveys conducted in other developing countries and therefore affords national and international comparisons. The first Demographic and Health Survey (DHS) in Nepal was the 1996 Nepal Family Health Survey (NFHS), conducted as part of the worldwide DHS program; subsequently, surveys have been conducted every five years, in 2001, 2006, and now in 2011. Wherever possible, the 2011 NDHS data are compared with data from the earlier DHS surveys in Nepal, which also sampled women age 15-49. Men age 15-49 were also interviewed in the 2011 NDHS to provide comparable data for male respondents over the last 10 years. 1.5 ORGANIZATION OF THE SURVEY The 2011 NDHS is the fourth nationally representative comprehensive survey conducted as part of the worldwide DHS project in the country. It was carried out under the aegis of the Ministry of Health and Population. The survey was implemented by New ERA, a private research firm in Nepal that also conducted the 1996 NFHS and the 2001 and 2006 NDHS. ICF International provided technical assistance through its MEASURE DHS project. The survey was funded by the United States Agency for International Development through its mission in Nepal. A technical advisory committee was formed under the Secretary of the Ministry of Health and Population to be responsible for coordination, oversight, advice, and decision-making on all major aspects of the survey. A technical working committee was also formed under the chairmanship of the chief of the MOHP, Population Division. Both committees included key members from different divisions of the ministry, the National Population Committee, external development partners, and other concerned stakeholders. The committee members provided their technical input throughout the various stages of drafting and finalizing the questionnaires, participated in training and field supervision, and provided feedback in finalizing the report. 1.6 SAMPLE DESIGN The primary focus of the 2011 NDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately. In Introduction • 7 addition, the sample was designed to provide estimates of most key variables for the 13 eco-development regions. 1.6.1 Sampling Frame Nepal is divided into 75 districts, which are further divided into smaller VDCs and municipalities. The VDCs and municipalities, in turn, are further divided into wards. The larger wards in the urban areas are divided into subwards. An enumeration area (EA) is defined as a ward in rural areas and a subward in urban areas. Each EA is classified as urban or rural. As the upcoming population census was scheduled for June 2011, the 2011 NDHS used the list of EAs with population and household information developed by the Central Bureau of Statistics for the 2001 Population Census. The long gap between the 2001 census and the fielding of the 2011 NDHS necessitated an updating of the 2001 sampling frame to take into account not only population growth but also mass internal and external migration due to the 10-year political conflict in the country. To obtain an updated list, a partial updating of the 2001 census frame was carried out by conducting a quick count of dwelling units in EAs five times more than the sample required for each of the 13 domains. The results of the quick count survey served as the actual frame for the 2011 NDHS sample design. 1.6.2 Domains The country is broadly divided into three horizontal ecological zones, namely mountain, hill, and terai. Vertically, the country is divided into five development regions. The cross section of these zones and regions results in 15 eco-development regions, which are referred to in the 2011 NDHS as subregions or domains. Due to the small population size in the mountain regions, the Western, Mid-western, and Far-western mountain regions are combined into one domain, yielding a total of 13 domains. In order to provide an adequate sample to calculate most of the key indicators at an acceptable level of precision, each domain had a minimum of about 600 households. Stratification was achieved by separating each of the 13 domains into urban and rural areas. The 2011 NDHS used the same urban-rural stratification as in the 2001 census frame. In total, 25 sampling strata were created. There are no urban areas in the Western, Mid-western, and Far-western mountain regions. The numbers of wards and subwards in each of the 13 domains are not allocated proportional to their population due to the need to provide estimates with acceptable levels of statistical precision for each domain and for urban and rural domains of the country as a whole. The vast majority of the population in Nepal resides in the rural areas. In order to provide national urban estimates, urban areas of the country were oversampled. 1.6.3 Sample Selection Samples were selected independently in each stratum through a two-stage selection process. In the first stage, EAs were selected using a probability-proportional-to-size strategy. In order to achieve the target sample size in each domain, the ratio of urban EAs to rural EAs in each domain was roughly 1 to 2, resulting in 95 urban and 194 rural EAs (a total of 289 EAs). Complete household listing and mapping was carried out in all selected EAs (clusters). In the second stage, 35 households in each urban EA and 40 households in each rural EA were randomly selected. Due to the nonproportional allocation of the sample to the different domains and to oversampling of urban areas in each domain, sampling weights are required for any analysis using the 2011 NDHS data to ensure the actual representativeness of the sample at the national level as well as at the domain levels. Since the 2011 NDHS sample is a two-stage stratified cluster sample, sampling weights were calculated based on sampling probabilities separately for each sampling stage, taking into account nonproportionality in the allocation process for domains and urban-rural strata. 8 • Introduction 1.7 QUESTIONNAIRES Three questionnaires were administered in the 2011 NDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire (Appendix E). These questionnaires were adapted from the standard DHS6 core questionnaires to reflect the population and health issues relevant to Nepal at a series of meetings with various stakeholders from government ministries and agencies, nongovernmental organizations, EDPs, and international donors. The final draft of each questionnaire was discussed at a questionnaire design workshop organized by the MOHP, Population Division on 22 April 2010 in Kathmandu. These questionnaires were then translated from English into the three main local languages—Nepali, Maithali, and Bhojpuri—and back translated into English. Questionnaires were finalized after the pretest, which was held from 30 September to 4 November 2010, with a one-week break in October for the Dasain holiday. The Household Questionnaire was used to list all of the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. For children under age 18, the survival status of the parents was determined. The Household Questionnaire was used to identify women and men who were eligible for the individual interview and women who were eligible for the interview focusing on domestic violence. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, ownership of mosquito nets, and household food security. The results of salt testing for iodine content, height and weight measurements, and anemia testing were also recorded in the Household Questionnaire. The Woman’s Questionnaire was used to collect information from women age 15-49. Women were asked questions on the following topics: • background characteristics (education, residential history, media exposure, etc.) • pregnancy history and childhood mortality • knowledge and use of family planning methods • fertility preferences • antenatal, delivery, and postnatal care • breastfeeding and infant feeding practices • vaccinations and childhood illnesses • marriage and sexual activity • work characteristics and husband’s background characteristics • awareness and behavior regarding AIDS and other sexually transmitted infections • domestic violence The Man’s Questionnaire was administered to all men age 15-49 living in every second household in the 2011 NDHS. The Man’s Questionnaire collected much of the same information as the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health, nutrition, or domestic violence. 1.8 HEMOGLOBIN TESTING In the 2011 NDHS, anemia testing was conducted in every second household (i.e., in households where male interviews were conducted). In such households, all women age 15-49 and children age 6-59 months were tested for anemia. The protocol for hemoglobin testing was approved by the Nepal Health Research Council and the ICF Macro Institutional Review Board in Calverton, Maryland, USA. Selected interviewers were trained to conduct this procedure. Respondents (and their parent or guardian in the case of unmarried minors) were asked for their consent to participate in the anemia testing. The interviewers explained the purpose of the test, informed prospective subjects and/or their caretakers that the results would be made available as soon as the test was completed, and requested permission for the test to be Introduction • 9 carried out. Levels of anemia were classified as severe, moderate, or mild according to criteria developed by the World Health Organization (DeMaeyer et al., 1989). To measure the level of hemoglobin, capillary blood was taken in the field from a finger using sterile, one-time-use lancets that allowed for a relatively painless puncture. The concentration of hemoglobin in the blood was measured using the HemoCue system. Before the blood was taken, the finger was wiped with an alcohol prep swab and allowed to air-dry. Then the palm side of the end of the finger was punctured with a sterile, non-reusable, self-retractable lancet. A drop of blood was collected with a HemoCue microcuvette and placed in a HemoCue photometer, where the results were displayed. For children age 6 to 11 months who were particularly undernourished and bony, a heel puncture was made to draw a drop of blood. The results were recorded in the Household Questionnaire, as well as on a brochure given to each woman, parent, or responsible adult explaining what the results meant. Women or children whose results indicated severe anemia were provided with a card referring them to the nearest health facility. 1.9 LISTING, PRETEST, TRAINING, AND FIELDWORK 1.9.1 Listing From the sampling frame, a total of 289 clusters were selected throughout the 13 subregions. A listing operation was conducted from 27 September to 14 December 2010 by 26 teams of two members each, with one member working as a lister and the other as a mapper. Altogether, 52 listers and mappers were recruited from all regions to do the listing of the households. Training was provided using standard DHS manuals and guidelines modified for Nepal that described the listing procedures in detail. Training included classroom demonstrations and field practice, and instructions were given on the use of Global Positioning System (GPS) units to obtain location coordinates for selected clusters. 1.9.2 Pretest Prior to the start of the fieldwork, the questionnaires were pretested in Nepali, Bhojpuri, and Maithali to make sure that the questions were clear and could be understood by the respondents. One of the important components of the pretest was to test the entry program on tablet personal computers (PCs), as 2011 marked the first time the NDHS used tablet PCs to collect data from the field. The data file transfer process using the Internet File Streaming System (IFSS), through which data from the field could be transferred to the main office via the Internet, was also tested. In order to conduct the pretest, 12 interviewers were recruited to interview in the three local languages. Training for the pretest was held at the New ERA office. The pilot survey was conducted (as mentioned) from 30 September to 4 November 2010 in three selected sites. The areas selected for the pretest were Kathmandu (for the Nepali language), the Parsa district (for the Bhojpuri language), and the Dhanusha district (for the Maithili language). Both rural and urban households were selected for the pretest in all three districts. Based on the findings of the pretest, the Household Questionnaire, Woman’s Questionnaire, and Man’s Questionnaire were further refined in all three languages. Similarly, necessary revisions in the computer program files were made based on the suggestions and feedback obtained in the pretest. 1.9.3 Training of Field Staff A stringent recruitment process was carried out in which candidates had to complete a written examination, a computer aptitude test, and an oral interview to qualify for training. A total of 96 persons were trained to serve as fieldwork supervisors, interviewers, quality control staff, and reserves. The main training took place in Kathmandu from 15 December 2010 to 16 January 2011. Training consisted of two components: training on paper questionnaires and training on the use of tablet PCs. The New ERA research team led the three-week training on paper-based questionnaires and biomarkers, while MEASURE DHS staff led the two-week training on tablet PC use. 10 • Introduction The training included theoretical and practical sessions and presentations, practical demonstrations, practice interviewing in small groups, and several days of field practice. The participants were also trained in measuring women and children’s height and weight and in conducting anemia testing. Special classes on several topics were organized during the training sessions, including Nepal’s health delivery system, family planning, maternal health, abortion, child health, nutrition, women’s empowerment, and domestic violence. These classes were led by experts from the different divisions of the Ministry of Health and Population. During the training sessions, several rounds of mock interviews were also conducted so that the interviewers had ample opportunities to understand the questionnaire and become accustomed with the new technology of conducting interviews with tablet PCs before they started the real fieldwork. 1.9.4 Fieldwork Data collection was carried out by 16 field teams, each consisting of three female interviewers, one male interviewer, and a male supervisor. Teams were initially deployed around Kathmandu on 23 January 2011 to enable intense supervision and technical backstopping. Each team completed one cluster and electronically sent the data to the central office via the Internet. A review session was organized to share the experiences of the teams. The core team provided necessary feedback to the field teams. Field teams traveled to their respective designated clusters on 2 February 2011, and the fieldwork was completed on 14 June 2011. Fieldwork supervision was done by six quality control teams, each consisting of one male and one female member. Additionally, two field coordinators monitored overall data quality. Close contact between the New ERA central office and the teams was maintained through field visits by New ERA senior staff, members of the technical advisory and working committees, staff of the Ministry of Health and Population, and staff of USAID/Nepal. Regular communication was maintained through cell phones. Two review sessions were held to share field issues and refill supplies. The first was held after one month of fieldwork, on 3-5 March 2011, and the second was held on 21 April 2011. These sessions were helpful in updating progress, providing feedback to the teams based on field check tables and field observations, and discussing data inconsistencies and problems faced by the teams. 1.10 DATA PROCESSING The 2011 NDHS used ASUS Eee T101MT tablet PCs with data entry programs developed in CSPro. Code division multiple access (CDMA) wireless technology via Internet File Streaming System (IFSS) was used to transfer data from the field to the central office in Kathmandu. The IFSS package was developed by MEASURE DHS and tested for the first time in Nepal. The data were sent to the central office at New ERA by the teams once they had checked and closed each EA file. This was mostly done before the team left the EA. In the central office, the data were edited by a senior data supervisor who had been specially trained for this task. The concurrent processing of the data was an advantage because field check tables to monitor various data quality parameters could be generated almost instantly and sent to the teams through the field coordinators, the quality control teams, and the core study team members. This allowed the field teams to receive immediate feedback and improve their performance. The data entry and editing phase of the survey was complete by the end of June 2011. 1.11 RESPONSE RATES Table 1.2 shows household and individual response rates for the 2011 NDHS. A total of 11,353 households were selected, out of which 10,888 were found to be occupied during data collection. Interviews were completed for 10,826 of these existing households, yielding a response rate of 99 percent. In the selected households, 12,918 women were identified as eligible for the individual interview. Interviews were completed for 12,674 women, resulting in a response rate of 98 percent. Of the 4,323 eligible men identified in the selected subsample of households, 4,121 were successfully interviewed, yielding a 95 percent response rate. Response rates were higher in rural than urban areas, especially for eligible men. Introduction • 11 Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Nepal 2011 Result Residence Total Urban Rural Household interviews Households selected 3,331 8,022 11,353 Households occupied 3,182 7,706 10,888 Households interviewed 3,148 7,678 10,826 Household response rate1 98.9 99.6 99.4 Interviews with women age 15-49 Number of eligible women 3,822 9,096 12,918 Number of eligible women interviewed 3,701 8,973 12,674 Eligible women response rate2 96.8 98.6 98.1 Interviews with men age 15-49 Number of eligible men 1,451 2,872 4,323 Number of eligible men interviewed 1,351 2,770 4,121 Eligible men response rate2 93.1 96.4 95.3 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 13 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 This chapter provides an overview of demographic and socioeconomic characteristics of the household population, including information on housing facilities and characteristics, household assets, wealth status, education, and food security; these data serve as a basis for understanding the socioeconomic status of households. In addition, information is provided on migration, which plays a vital role in demographic dimensions, especially within the context of Nepal. Finally, the chapter presents information on birth registration, children’s living arrangements and orphanhood, and children’s educational attainment, helping provide an understanding of the general social environment in which children live. In the 2011 NDHS, a household is defined as a person or group of related and unrelated persons who usually live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as the head of the household, and who have common cooking and eating arrangements. Information is collected from all usual residents of a selected household (de jure population) as well as persons who had stayed in the selected household the night before the interview (de facto population). The difference between these two populations is very small, and all tables in this report refer to the de facto population unless otherwise specified, to maintain comparability with other DHS reports. 2.1 HOUSEHOLD CHARACTERISTICS Access to basic utilities, sources of drinking water and water treatment practices, access to sanitation facilities, housing structure and crowdedness of dwelling spaces, and type of fuel used for cooking are physical characteristics of a household that are used to assess the general well-being and socioeconomic status of household members. Millennium Development Goal 7 (MDG 7), which focuses on environmental sustainability, is measured according to the percentage of the population using solid fuels, the percentage with sustainable access to an improved water source, and the percentage with access to improved sanitation (National Planning Commission [NPC], 2010a). This section provides information from the 2011 NDHS on household drinking water, household sanitation facilities, hand-washing practices, housing characteristics, and possession of basic amenities and utilities. 2.1.1 Water and Sanitation The basic determinants of better health, such as access to safe water, and sanitation, are still in a critical state in Nepal. Poor access to safe drinking water and sanitation facilities and poor hygiene are associated with Key Findings: • The vast majority of households in Nepal (89 percent) have access to an improved source of drinking water. • Thirty-eight percent of households have an improved toilet facility that is not shared with other households. • Seventy-six percent of households have electricity. • Forty percent of households are exposed daily to secondhand smoke. • A large proportion of the Nepalese population (37 percent) is under age 15. • Twenty-eight percent of households are female-headed. • Fifty-seven percent of households have at least one person who has migrated at some time in the past 10 years. • Only one in two households in Nepal (49 percent) is food secure and has access to food year round. 14 • Housing Characteristics and Household Population skin diseases, acute respiratory infection (ARI), and diarrheal diseases, the leading preventable diseases. ARI and diarrheal diseases remain the leading causes of child deaths in Nepal. Among the top 10 causes of morbidity observed in outpatient visits in the country’s health institutions are gastritis, intestinal worm infestations, ARI/lower respiratory tract infections, headaches/migraines, upper respiratory tract infections, impetigo and noninfectious diarrhea, presumed noninfectious diarrhea, and amoebic dysentery (Ministry of Health and Population [MOHP], 2011a). Table 2.1 presents the percent distribution of households and the de jure population, according to urban or rural setting, by source of drinking water, time taken to obtain drinking water, regularity of water source, and water treatment practices adopted by households. Table 2.1 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Nepal 2011 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source Piped into dwelling/yard/plot 42.6 19.0 22.4 41.0 17.5 20.6 Public tap/standpipe 12.6 26.5 24.5 12.1 25.4 23.6 Tube well or borehole 31.0 40.2 38.9 33.6 43.0 41.7 Protected well 3.3 1.7 1.9 3.7 1.5 1.8 Protected spring 0.1 0.2 0.2 0.1 0.2 0.2 Rain water 0.0 0.0 0.0 0.0 0.1 0.0 Bottled water 3.7 0.4 0.9 2.9 0.3 0.6 Non-improved source Unprotected well 2.2 2.1 2.1 2.5 2.1 2.2 Unprotected spring 0.2 1.1 1.0 0.2 1.1 1.0 Tanker truck/cart with drum 1.8 0.5 0.7 1.5 0.4 0.6 Surface water 2.2 8.1 7.3 2.1 8.5 7.7 Other source 0.2 0.0 0.0 0.2 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 93.4 88.1 88.9 93.5 87.8 88.6 Time to obtain drinking water (round trip) Water on premises 79.1 53.9 57.5 79.2 55.0 58.2 Less than 30 minutes 16.9 38.4 35.3 17.0 37.3 34.7 30 minutes or longer 3.8 7.6 7.1 3.8 7.6 7.1 Don’t know/missing 0.1 0.0 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Use of water source (regularity) All year 93.5 94.3 94.2 93.8 94.5 94.4 Part of the year 6.5 5.6 5.8 6.2 5.4 5.5 Total 100.0 100.0 100.0 100.0 99.9 100.0 Water treatment prior to drinking1 Boiled 20.9 6.5 8.6 20.5 5.5 7.5 Bleach/chlorine added 4.0 1.0 1.4 4.0 1.0 1.4 Strained through cloth 1.4 1.4 1.4 1.4 1.3 1.3 Ceramic, sand, or other filter 34.3 6.3 10.3 33.2 5.3 8.9 Solar disinfection 1.4 0.3 0.4 1.2 0.2 0.3 Other 0.3 0.2 0.2 0.4 0.2 0.2 No treatment 54.1 86.9 82.2 55.5 88.6 84.2 Percentage using an appropriate treatment method2 45.8 12.9 17.6 44.3 11.2 15.6 Number 1,546 9,280 10,826 6,338 41,785 48,123 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. Most households in Nepal (89 percent) obtain drinking water from an improved source, while 11 percent still rely on non-improved sources. There has been some improvement in access to an improved water source since 2006, when 82 percent of the households used an improved source of drinking water (MOHP, New ERA, and Macro International, 2007). Households in urban areas have greater access to an improved source of drinking water than households in rural areas (93 percent versus 88 percent), but the urban-rural gap has narrowed in the last five years. The most common source of drinking water in urban areas is water piped into the Housing Characteristics and Household Population • 15 dwelling/yard/plot, with more than two-fifths of households having access to this source. In contrast, a tube well or borehole is the most common source of drinking water in rural areas, used by two-fifths of households. Fifty- eight percent of households have a source of drinking water within their premises, compared to 46 percent five years ago. Thirty-five percent of households spend less than 30 minutes on gathering water, while about 7 percent of households spend 30 minutes or longer. Accessing drinking water takes longer in rural areas than urban areas, with 8 percent of households taking 30 minutes or more to obtain water. There has been little change in the past five years in the time taken to access drinking water. The vast majority of households are able to access drinking water from their main source all year (94 percent), with little urban-rural difference. The majority of households (82 percent) do not treat drinking water, and rural households are particularly likely not to do so (87 percent, compared to 54 percent of urban households). Forty-six percent of households in urban areas treat drinking water, compared to 13 percent in rural areas. Overall, a ceramic, sand, or other filter is the most common treatment method (10 percent), followed by boiling water prior to drinking (9 percent). Table 2.2 presents information on household sanitation facilities by type of toilet/latrine. Nearly two in five households (38 percent) have an improved (not shared) toilet facility; 19 percent use a facility that would be considered improved if it were not shared with other households. Facilities that are shared are not considered to be as hygienic as those that are not shared. About two in five households use a non-improved toilet facility (43 percent). Thirty-six percent of households still use a bush or open field for defecation, but this is an improvement over 2006, when one in two households had no toilet facility (MOHP, New ERA, and Macro International, 2007). Rural households are more likely than urban households not to have a toilet facility (40 percent versus 9 percent). Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Nepal 2011 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 52.5 35.8 38.2 58.1 36.7 39.5 Flush/pour flush to piped sewer system 15.9 1.4 3.5 18.0 1.3 3.5 Flush/pour flush to septic tank 32.0 23.7 24.9 35.0 23.9 25.4 Flush/pour flush to pit latrine 2.1 3.3 3.1 2.3 3.4 3.3 Ventilated improved pit (VIP) latrine 0.4 0.6 0.6 0.4 0.6 0.6 Pit latrine with slab 2.1 6.6 6.0 2.4 7.3 6.7 Composting toilet 0.0 0.2 0.2 0.0 0.2 0.2 Shared facility1 36.7 15.9 18.9 29.5 12.6 14.9 Flush/pour flush to piped sewer system 11.4 1.7 3.1 8.4 1.2 2.2 Flush/pour flush to septic tank 22.6 10.0 11.8 18.7 7.7 9.2 Flush/pour flush to pit latrine 1.2 1.3 1.3 1.0 1.1 1.1 Ventilated improved pit (VIP) latrine 0.3 0.3 0.3 0.3 0.3 0.3 Pit latrine with slab 1.2 2.6 2.4 1.1 2.3 2.1 Non-improved facility 10.8 48.3 42.9 12.4 50.6 45.6 Flush/pour flush not to sewer/septic tank/pit latrine 0.4 0.3 0.3 0.4 0.2 0.3 Pit latrine without slab/open pit 1.6 8.0 7.1 1.7 7.7 6.9 No facility/bush/field 8.7 39.9 35.5 10.3 42.7 38.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,546 9,280 10,826 6,338 41,785 48,123 Note: Total includes three households using bucket under non-improved facility not shown separately. 1 Facilities that would be considered improved if they were not shared by two or more households Hand washing, which provides protection against communicable diseases, is promoted by the government of Nepal and included in the framework of the Nepal Health Sector Program II (MOHP, 2010a). Table 2.3 provides information on designated places for hand washing in households and the use of water and cleansing agents for washing hands according to place of residence (urban, rural), ecological region, and wealth quintile. 16 • Housing Characteristics and Household Population Interviewers were instructed to observe the place where household members usually washed their hands. They looked for regularity of water supply and observed whether households had cleansing agents near the place of hand washing. Such observations were made in almost all selected households. About half of households (48 percent) had soap and water at the place where household members washed their hands, 16 percent had water and other cleansing agents (ash, mud, sand, etc.), 17 percent had water only, and 2 percent had soap but no water. Overall, 14 percent of households did not have water or any cleansing agent. In general, these households did not have a fixed designated place for hand washing. Table 2.3 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap, and other cleansing agents, Nepal 2011 Background characteristic Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed, households that had: Number of households with place for hand washing observed Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Total Residence Urban 99.4 1,546 75.6 6.3 10.8 1.6 0.8 4.8 100.0 1,536 Rural 99.8 9,280 43.2 17.4 18.1 1.6 4.3 15.4 100.0 9,258 Ecological zone Mountain 99.9 761 27.1 19.3 15.2 2.0 6.7 29.6 100.0 760 Hill 99.6 4,563 44.9 15.1 14.9 2.4 5.9 16.8 100.0 4,545 Terai 99.8 5,502 53.1 15.9 19.1 0.9 1.7 9.3 100.0 5,489 Wealth quintile Lowest 99.9 2,029 10.0 21.5 20.1 1.9 10.2 36.3 100.0 2,027 Second 99.8 2,168 23.4 25.8 25.2 1.6 5.8 18.2 100.0 2,163 Middle 99.7 2,068 41.2 22.6 21.6 2.0 2.7 9.9 100.0 2,062 Fourth 99.8 2,185 68.4 9.8 13.5 1.3 1.2 5.9 100.0 2,181 Highest 99.3 2,377 89.4 1.4 6.2 1.4 0.0 1.6 100.0 2,361 Total 99.7 10,826 47.8 15.8 17.0 1.6 3.8 13.9 100.0 10,793 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only, as well as those with soap and another cleansing agent Seventy-six percent of the households in urban areas had soap and water, compared to 43 percent of rural households. More than half of households (53 percent) in the terai had soap and water, compared to 45 percent of households in the hill zone and 27 percent of households in the mountain zone. Thirty percent of the households in the mountain region did not have water or any cleansing agents for hand washing. Soap and water was very common (89 percent) among households in the highest wealth quintile but much less so in the lowest wealth quintile (10 percent)1. Thirty-six percent of households in the lowest quintile had a designated place for hand washing but did not have water and cleansing agents. 2.1.2 Housing Characteristics Housing characteristics and household assets can be used as a measure of the socioeconomic status of household members. Cooking practices and cooking fuels also impact the health of family members and the environment. For example, use of biomass fuels exposes household members to indoor pollution, which has a direct bearing on their health and surroundings. Table 2.4 presents information on the availability of electricity, type of flooring material, number of rooms for sleeping, type of fuel used for cooking, and place where cooking is done. The table shows that 76 percent of households in Nepal have access to electricity. This is a marked improvement from the 2006 NDHS, which showed that only 51 percent of households had access to electricity. Access to electricity has increased sharply in rural areas in the last five years, with 73 percent of rural households having electricity in 2011 as compared to 43 percent in 2006. This increase can be partially attributed to the rural electrification programs implemented in recent years, including decentralized small hydropower plants, micro-hydropower plants, and 1 Refer to Section 2.2 for details on the wealth index. Housing Characteristics and Household Population • 17 solar energy and biomass sources (ITECO, 2011; Rai, 2010). Urban electricity availability has also been on the rise, with 97 percent of urban households having access to electricity in 2011, compared to 90 percent in 2006. Earth and sand are the most common flooring materials used in Nepalese households (66 percent), and these materials are predominantly used in rural areas (73 percent). The use of cement has increased in the past five years from 11 percent to 22 percent, with increases seen in both urban and rural areas. Urban households remain more likely to use cement (42 percent) than rural households (18 percent). Eight percent of households use carpet as flooring material. The number of rooms used for sleeping provides an indication of the extent of crowding in households. Overcrowding increases the risk of contracting infectious diseases such as acute respiratory infections and skin diseases, which particularly affect children and the elderly population. The proportion of households using one room for sleeping has decreased from 42 percent to 33 percent in the last five years. The presence and extent of indoor pollution are dependent on cooking practices, places used for cooking, and types of fuel used. According to the 2011 NDHS, 71 percent of households cook inside the house, while 20 percent cook in a separate building and 8 percent cook outdoors. The percentage of households that cook within the dwelling unit is higher in urban areas (79 percent) than in rural areas (70 percent). About one in five households in rural areas cooks in a separate building. Coal, lignite, charcoal, and wood are the fuels most commonly used for cooking, reported by 66 percent of households. Use of these fuels is more common in rural areas (73 percent) than in urban areas (28 percent). On the other hand, use of liquid petroleum gas, natural gas, and biogas is much more common in urban (68 percent) than rural (16 percent) areas. Use of gas for cooking has increased significantly in the past five years in both urban and rural households. Use of solid fuel for cooking has declined from 83 percent in 2006 to 75 percent in 2011, primarily due to a decline in rural areas. More than 8 in 10 rural households use solid fuel for cooking, compared with 3 in 10 households in urban areas. A major concern for the government of Nepal is the effect of secondhand smoke (SHS) on the health of children and neonates. The purpose of the Tobacco Related Products (Control and Regulation) Act of 2011 is to control tobacco and tobacco-related product use Table 2.4 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Nepal 2011 Housing characteristic Residence Total Urban Rural Electricity Yes 97.0 72.9 76.3 No 3.0 27.1 23.7 Total 100.0 100.0 100.0 Flooring material Earth, sand 20.0 73.3 65.7 Dung 0.3 0.5 0.4 Wood/planks 0.6 1.9 1.7 Parquet or polished wood 1.2 0.3 0.4 Vinyl or asphalt strips 5.3 1.1 1.7 Ceramic tiles 0.9 0.2 0.3 Cement 42.0 18.3 21.7 Carpet 29.5 4.4 8.0 Other 0.2 0.1 0.1 Total 100.0 100.0 100.0 Rooms used for sleeping One 36.3 32.8 33.3 Two 32.6 36.2 35.7 Three or more 31.0 30.9 30.9 Missing 0.1 0.2 0.2 Total 100.0 100.0 100.0 Place for cooking In the house 79.0 70.1 71.4 In a separate building 14.5 20.6 19.7 Outdoors 5.7 8.5 8.1 Other 0.1 0.0 0.0 No food cooked in household 0.8 0.7 0.7 Total 100.0 100.0 100.0 Cooking fuel Electricity 0.2 0.1 0.1 LPG, natural gas, biogas 67.6 16.2 23.5 Kerosene 2.0 0.3 0.5 Coal, lignite, charcoal, wood 28.1 72.6 66.2 Agricultural crop, straw, shrubs, grass 0.3 4.7 4.1 Animal dung 1.0 5.4 4.8 No food cooked in household 0.8 0.7 0.7 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 29.3 82.7 75.1 Frequency of smoking in the home Daily 26.2 41.9 39.6 Weekly 4.1 5.3 5.1 Monthly 3.0 3.8 3.7 Less than monthly 6.4 7.5 7.4 Never 60.3 41.5 44.2 Total 100.0 100.0 100.0 Number 1,546 9,280 10,826 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung LPG = Liquefied petroleum gas 18 • Housing Characteristics and Household Population and distribution (Nepal Law Commission, 2011). Information on smoking was collected in the 2011 NDHS to assess the percentage of households exposed to SHS, which is a risk factor for children and adults who do not smoke. Pregnant women who are exposed to SHS have a higher risk of giving birth to a low birth weight baby (Windham et al., 1999). Also, children who are exposed to SHS are at a higher risk of respiratory and ear infections and poor lung development (U.S. Department of Health and Human Services, 2006). Table 2.4 provides information on household exposure to SHS according to frequency of smoking, used here as a proxy for level of SHS exposure. Forty percent of households are exposed daily to SHS, and rural households (42 percent) are more likely to be exposed than urban households (26 percent). 2.1.3 Household Possessions Possession of durable consumer goods is another useful indicator of household socioeconomic status. The possession and use of household durable goods have multiple effects and implications. For instance, having access to a radio or television exposes household members to updated daily events, information, and educational materials. Similarly, a refrigerator prolongs food storage and keeps food fresh and hygienic. A means of transportation allows greater access to services away from the local area and enhances social and economic activities. The 2011 NDHS collected information on possession of durable commodities, means of transportation, and ownership of agricultural land and farm animals. Table 2.5 shows that radios, televisions, and mobile telephones are very common information and communication devices possessed by most households. Possession of mobile phones has sharply increased from 6 percent in 2006 to 75 percent in 2011. More than 9 in 10 households in urban areas and 7 in 10 households in rural areas possess mobile phones. Half of households have a radio, and a similar proportion have a television. Urban households are slightly more likely to possess a radio (54 percent) than rural households (50 percent). Seventy-six percent of urban households and 42 percent of rural households possess a television. Possession of a radio has decreased from 61 percent to 50 percent in the last five years, while ownership of a television has increased from 28 percent to 47 percent. A refrigerator is available in 11 percent of households, with urban households more than three times as likely (29 percent) as rural households (8 percent) to own one. Ninety-one percent of households in the country possess a bed. Households possessing computers have increased from 2 percent in 2006 to 8 percent in 2011, with a marked increase in urban areas (from 8 percent to 24 percent). Table 2.5 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, Nepal 2011 Possession Residence Total Urban Rural Household effects Radio 53.6 49.8 50.3 Television 76.2 42.0 46.9 Mobile telephone 91.6 71.9 74.7 Non-mobile telephone 25.7 6.8 9.5 Refrigerator 29.3 7.5 10.6 Table 79.8 48.5 53.0 Chair 71.7 42.8 46.9 Bed 97.9 90.2 91.3 Sofa 33.4 10.4 13.7 Cupboard 66.5 38.5 42.5 Computer 23.8 4.9 7.6 Clock 69.0 39.5 43.7 Fan 65.9 33.0 37.7 Dhiki 15.7 38.8 35.5 Means of transport Bicycle/rickshaw 42.1 39.3 39.7 Animal-drawn cart 1.2 3.2 3.0 Motorcycle/scooter 27.8 8.0 10.9 Car/truck/tempo 6.0 1.7 2.3 Ownership of agricultural land 45.1 71.3 67.6 Ownership of farm animals1 29.7 78.4 71.4 Number 1,546 9,280 10,826 1 Buffalo, milk cows, bulls, horses, donkeys, mules, goats, sheep, chickens, ducks, pigs, or yaks Housing Characteristics and Household Population • 19 Bicycles and rickshaws continue to be the most common means of transportation in Nepal; two in five households own a bicycle or rickshaw, with little difference between rural and urban households. Ownership of a motorcycle is much more common in urban areas (28 percent) than in rural areas (8 percent). Nepal is predominantly agricultural, with a large proportion of the population engaged in this sector. NDHS data indicate that 68 percent of households own agricultural land, with rural households more likely to own land (71 percent) than urban households (45 percent). Seventy-one percent of households in the country possess farm animals. Almost 80 percent of rural households own farm animals, as compared with 30 percent of urban households. 2.2 SOCIOECONOMIC STATUS INDEX The wealth index used in this survey is a measure that has been used in many DHS and other country- level surveys to indicate inequalities in household characteristics, in the use of health and other services, and in health outcomes (Rutstein et al., 2000). It serves as an indicator of level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The index was constructed using household asset data via a principal components analysis. In its current form, which takes better account of urban-rural differences in scores and indicators of wealth, the wealth index is created in three steps. In the first step, a subset of indicators common to urban and rural areas is used to create wealth scores for households in both areas. Categorical variables to be used are transformed into separate dichotomous (0-1) indicators. These indicators and those that are continuous are then examined using a principal components analysis to produce a common factor score for each household. In the second step, separate factor scores are produced for households in urban and rural areas using area-specific indicators. The third step combines the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting area-specific scores through a regression on the common factor scores. This three-step procedure permits greater adaptability of the wealth index in both urban and rural areas. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index is computed, national-level wealth quintiles (from lowest to highest) are obtained by assigning the household score to each de jure household member, ranking each person in the population by his or her score, and then dividing the ranking into five equal categories, each comprising 20 percent of the population. Table 2.6 presents distributions across the five wealth quintiles by residence, ecological region, development region, and subregion. These distributions indicate the degree to which wealth is evenly (or unevenly) distributed according to geographic area. An overwhelming majority of urban residents (62 percent) are from the richest quintile, while a much lower proportion of rural residents (14 percent) fall in the same category. Rural households are almost equally distributed in the lowest, second, and middle wealth quintiles (around 22 percent each). Among the three ecological zones, the population in the terai (23 percent) is more likely to fall in the highest wealth quintile than the population living in the hill zone (20 percent). Less than 1 percent of the population in the mountain zone (0.5 percent) is in the highest wealth quintile. Within the hill zone, 49 percent of households in the Central hill subregion (which includes the Kathmandu Valley) are in the wealthiest quintile. On the other hand, the Western mountain subregion has the highest proportion of the population in the lowest wealth quintile (60 percent). Among the development regions, the Central, Western, and Eastern regions have large population segments in the highest wealth quintile. Relatively smaller proportions of households in the Mid-western (10 percent) and Far-western (8 percent) regions fall in the highest quintile. 20 • Housing Characteristics and Household Population Table 2.6 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and Gini coefficient, according to residence and region, Nepal 2011 Residence/region Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 3.1 3.3 7.8 23.6 62.3 100.0 6,338 0.12 Rural 22.6 22.5 21.8 19.5 13.6 100.0 41,785 0.22 Ecological zone Mountain 41.4 30.7 19.8 7.7 0.5 100.0 3,358 0.18 Hill 31.9 21.1 14.6 12.5 19.9 100.0 19,501 0.28 Terai 8.0 17.8 24.2 27.4 22.7 100.0 25,264 0.21 Development region Eastern 16.2 18.9 20.3 23.8 20.9 100.0 11,481 0.21 Central 13.7 18.8 20.7 20.7 26.1 100.0 16,011 0.24 Western 14.8 21.4 20.9 22.0 21.0 100.0 9,895 0.22 Mid-western 41.5 20.1 16.3 12.1 10.0 100.0 5,911 0.24 Far-western 34.5 23.7 19.5 14.3 7.9 100.0 4,826 0.20 Subregion Eastern mountain 37.1 28.5 23.4 10.0 1.0 100.0 904 0.17 Central mountain 18.9 41.3 29.3 9.9 0.6 100.0 1,021 0.10 Western mountain 60.1 24.5 10.7 4.7 0.1 100.0 1,433 0.17 Eastern hill 34.4 27.9 19.5 14.0 4.2 100.0 3,703 0.18 Central hill 19.8 13.2 5.0 12.8 49.2 100.0 5,679 0.23 Western hill 23.3 26.2 22.9 14.9 12.7 100.0 5,757 0.24 Mid-western hill 55.8 17.4 10.7 9.2 6.9 100.0 2,648 0.25 Far-western hill 58.6 21.0 13.9 6.0 0.5 100.0 1,714 0.14 Eastern terai 3.6 12.7 20.3 30.9 32.4 100.0 6,874 0.18 Central terai 9.4 19.7 29.3 26.8 14.8 100.0 9,310 0.20 Western terai 2.8 14.8 18.1 31.9 32.4 100.0 4,138 0.20 Mid-western terai 21.1 20.7 23.8 18.3 16.1 100.0 2,519 0.22 Far-western terai 10.1 26.4 26.0 22.0 15.3 100.0 2,422 0.19 Total 20.0 20.0 20.0 20.0 20.0 100.0 48,123 0.24 Table 2.6 also includes information on the Gini coefficient, which indicates the level of concentration of wealth (0 being an equal distribution and 1 a totally unequal distribution). This ratio is expressed as a proportion between 0 and 1. Wealth inequality, as measured by the Gini coefficient, is higher in rural than urban areas. Inequality in wealth is highest in the hill region, the Central and Mid-western development regions, and the Mid-western hill subregion. 2.3 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.7 shows the distribution of the de facto household population by age and sex according to urban and rural residence. The 2011 NDHS enumerated a total of 47,570 persons (25,667 females and 21,903 males). A large proportion of the Nepalese population (37 percent) is under age 15 (Figure 2.1), although this proportion has declined from 41 percent in 2006. Eleven percent of the population is under five years, a decrease since 2006 indicating a declining trend in fertility. Persons age 65 and over account for about 6 percent of the total population, an increase from 4 percent in 2006. There is a smaller proportion of children under five in urban than rural 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 concentration of the population is high in the 10-14 age group, creating pressure for schooling and adolescent care. Housing Characteristics and Household Population • 21 Table 2.7 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Nepal 2011 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 8.2 8.0 8.1 13.3 10.4 11.7 12.6 10.1 11.2 5-9 11.8 9.6 10.7 14.2 11.4 12.7 13.8 11.2 12.4 10-14 11.8 10.9 11.3 15.4 12.6 13.9 14.9 12.4 13.6 15-19 11.8 11.5 11.6 9.9 10.7 10.3 10.1 10.8 10.5 20-24 9.6 10.6 10.1 6.1 9.3 7.9 6.6 9.5 8.2 25-29 7.9 10.3 9.1 5.4 8.0 6.8 5.8 8.3 7.1 30-34 7.7 8.5 8.1 4.9 6.6 5.8 5.3 6.8 6.1 35-39 6.8 6.9 6.8 5.2 6.1 5.7 5.4 6.2 5.9 40-44 5.4 5.5 5.5 4.2 5.0 4.7 4.4 5.1 4.8 45-49 4.4 4.1 4.2 4.1 3.8 3.9 4.2 3.8 4.0 50-54 4.2 4.2 4.2 4.2 4.6 4.4 4.2 4.6 4.4 55-59 3.5 2.8 3.1 3.8 3.2 3.5 3.7 3.2 3.4 60-64 2.3 2.3 2.3 3.1 2.8 3.0 3.0 2.8 2.9 65-69 1.6 1.7 1.7 2.4 2.0 2.2 2.3 2.0 2.1 70-74 1.3 1.2 1.3 1.7 1.5 1.6 1.7 1.4 1.5 75-79 0.7 1.0 0.9 1.2 1.0 1.1 1.1 1.0 1.0 80+ 0.9 1.0 1.0 0.8 1.0 0.9 0.9 1.0 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,028 3,250 6,278 18,875 22,417 41,292 21,903 25,667 47,570 8 6 4 2 0 2 4 6 8 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Percentage Age Figure 2.1 Population Pyramid Male Female The overall sex ratio (the number of males per 100 females) is 85, less than the sex ratio in the 2006 NDHS (89) and the 2011 census (94). It is, however, consistent with the results of the 2010-2011 Nepal Living Standard Survey (NLSS), which indicated that the sex ratio is 86 (Central Bureau of Statistics, 2011c). The sex ratio is lowest in the 20-29 age group, indicating a low proportion of the male population in that group. The sex ratio also differs by residence. Urban areas have a higher sex ratio (93) than rural areas (84). The significantly low proportion of the male population in rural areas could be attributed to greater out-migration, especially movement among those in the working age group to urban areas. 22 • Housing Characteristics and Household Population 2.4 MIGRATION STATUS The 2011 NDHS collected information on migration among individuals who lived in the interviewed households in the past 10 years but have since moved away. Migrants are people who either move from their place of birth to another area or frequently change their residence. Migration may be seasonal, temporary, semipermanent, or permanent depending on the duration of and reasons for migration within a defined geographical area (KC, 2003). Migration brings significant demographic dynamics to a society and carries socioeconomic implications for both the origin and destination. Culture and customs, opportunities for education and employment, and geographic hardships are among the major causes of migration. The 2011 NDHS collected information on former household residents who migrated elsewhere in the 10 years prior to the survey. Information was collected by sex, age, date of migration, cause of migration, and destination. These data provide information on period migration and lifetime migration. Period migration simply indicates the mobility patterns of internal migrants five years before the survey in terms of where they were living then. Lifetime migration, on the other hand, indicates a permanent shift in place of residence since more than five years prior to the survey. Fifty-seven percent of households reported that at least one person had migrated away from the household at some time in the past 10 years. Among households that reported migration of former residents, on average about two persons were likely to have migrated. Table 2.8 provides a brief overview of the background characteristics of the migrant population. Two-thirds migrate at the age of 24 or younger. Twenty- two percent of men migrate at age 20-24, whereas women are most likely to migrate at an earlier age (15-19 years), primarily due to marriage. Overall, 74 percent of males migrate before age 30, while almost 84 percent of females migrate before age 25. Men migrate mostly for work (72 percent), while women primarily migrate due to marriage (54 percent). Another common reason for migrating is educational pursuits, with 17 percent of men and 14 percent of women citing this as a reason. Women also tend to migrate due to family reasons, such as accompanying their spouse or accompanying their children who move to urban areas for education. The vast majority of migrants are from rural areas and from the hill and terai regions. Nearly half of migrants come from the Central and Eastern terai and the Western hill region. Table 2.8 Migration status Percent distribution of men and women who migrated in the 10 years before the survey by selected background characteristics, Nepal 2011 Background characteristic Men Women Total Age at migration <15 16.3 20.2 18.0 15-19 19.5 35.5 26.2 20-24 22.4 28.1 24.8 25-29 15.4 8.4 12.4 30-34 10.4 3.4 7.4 35-39 7.8 1.7 5.2 40-44 4.2 0.8 2.8 45-49 1.9 0.6 1.4 50+ 2.1 1.2 1.8 Total 100.0 100.0 100.0 Reason for migration Work 72.3 9.1 45.6 Study 17.2 14.0 15.8 Marriage 0.3 54.4 23.2 Family reasons 9.4 21.9 14.7 Security 0.1 0.1 0.1 Other 0.7 0.5 0.6 Don’t know 0.1 0.1 0.1 Total 100.0 100.0 100.0 Residence Urban 9.2 10.2 9.6 Rural 90.8 89.8 90.4 Total 100.0 100.0 100.0 Ecological zone Mountain 7.4 7.1 7.3 Hill 42.8 44.9 43.7 Terai 49.8 48.0 49.0 Total 100.0 100.0 100.0 Development region Eastern 25.8 26.2 26.0 Central 29.8 31.0 30.3 Western 24.5 24.9 24.7 Mid-western 9.8 9.5 9.7 Far-western 10.0 8.5 9.4 Total 100.0 100.0 100.0 Subregion Eastern mountain 2.0 2.0 2.0 Central mountain 3.1 3.0 3.1 Western mountain 2.2 2.1 2.2 Eastern hill 8.9 9.5 9.2 Central hill 9.0 11.1 9.9 Western hill 16.4 17.1 16.7 Mid-western hill 5.2 4.4 4.9 Far-western hill 3.3 2.7 3.0 Eastern terai 14.9 14.6 14.8 Central terai 17.6 16.9 17.3 Western terai 8.1 7.8 8.0 Mid-western terai 3.7 3.9 3.7 Far-western terai 5.5 4.8 5.2 Total 100.0 100.0 100.0 Wealth quintile Lowest 18.1 17.0 17.6 Second 22.9 22.5 22.7 Middle 21.3 20.9 21.1 Fourth 20.3 20.4 20.4 Highest 17.3 19.2 18.1 Total 100.0 100.0 100.0 Number of men and women who migrated in the past 10 years 6,829 5,002 11,831 Housing Characteristics and Household Population • 23 Table 2.9.1 shows information for male migrants. An assessment of time since migration shows that the majority of male migrants (85 percent) moved out within the five years prior to the survey, indicating a high proportion of period migration. Fifteen percent of migrants migrated more than five years before the survey. Migration within Nepal is high, with almost half of migrants moving within the country. The most popular out-of-country destination for Nepalese migrants is India, to which 20 percent of all male migrants relocate. One-third of male migrants move to countries other than India, with the most popular destinations being countries in the Middle East and Malaysia. Among men migrating for work, the majority migrated within the last five years, indicating a recent outflux of labor migration. Those migrating for work are most likely to go to countries other than India (44 percent). A quarter of such men migrate to India, while 32 percent move internally within Nepal. Table 2.9.1 Migration status: Men Percentage of male migrants by years since migration and percent distribution of male migrants by destination, according to background characteristics and reason for migration, Nepal 2011 Background characteristic Time since migration Destination Number of male migrants <1 year <5 years1 5+ years Within Nepal India Other countries Total Age at migration <15 30.8 80.1 19.9 81.0 18.0 1.0 100.0 1,115 15-19 31.4 81.9 18.1 60.8 22.6 16.5 100.0 1,330 20-24 36.5 84.6 15.4 37.2 17.6 45.1 100.0 1,527 25-29 40.3 87.3 12.7 32.1 18.4 49.0 100.0 1,049 30-34 38.6 89.4 10.6 24.5 17.6 57.8 100.0 708 35-39 47.9 90.9 9.1 25.9 20.9 53.2 100.0 532 40-44 39.0 86.2 13.8 36.6 18.8 44.4 100.0 289 45-49 50.3 93.9 6.1 37.4 31.2 31.4 100.0 132 50+ 55.8 88.9 11.1 51.9 38.9 8.7 100.0 146 Reason for migration Work 40.1 86.8 13.2 31.8 24.0 44.2 100.0 4,936 Study 27.8 82.8 17.2 86.2 4.7 9.0 100.0 1,172 Family reasons 32.1 78.5 21.5 80.8 16.9 2.2 100.0 642 Other 23.1 67.9 32.1 79.5 7.7 8.9 100.0 78 Residence Urban 35.6 84.6 15.4 45.0 15.1 39.7 100.0 627 Rural 37.2 85.1 14.9 46.4 20.3 33.2 100.0 6,202 Ecological zone Mountain 37.9 82.5 17.5 65.9 13.3 20.4 100.0 504 Hill 32.6 81.6 18.4 50.4 17.3 32.2 100.0 2,926 Terai 40.7 88.5 11.5 39.8 22.9 37.2 100.0 3,399 Development region Eastern 35.5 87.6 12.4 42.3 11.4 46.1 100.0 1,764 Central 38.1 87.1 12.9 52.7 12.5 34.6 100.0 2,033 Western 31.4 80.8 19.2 43.1 18.3 38.6 100.0 1,676 Mid-western 41.7 81.8 18.2 52.0 31.4 16.5 100.0 670 Far-western 46.8 86.7 13.3 39.4 55.4 5.2 100.0 686 Subregion Eastern mountain 31.5 84.2 15.8 53.6 3.1 42.1 100.0 139 Central mountain 36.2 77.2 22.8 72.8 7.3 19.9 100.0 214 Western mountain 46.1 88.5 11.5 67.5 31.2 1.4 100.0 151 Eastern hill 32.7 87.2 12.8 49.2 7.3 43.6 100.0 607 Central hill 35.3 83.3 16.7 59.9 5.5 34.3 100.0 617 Western hill 26.6 77.5 22.5 49.7 14.5 35.8 100.0 1,122 Mid-western hill 40.0 81.0 19.0 47.8 36.3 15.7 100.0 354 Far-western hill 43.4 83.3 16.7 35.7 60.4 3.9 100.0 226 Eastern terai 37.8 88.2 11.8 36.7 15.1 48.2 100.0 1,018 Central terai 39.9 90.7 9.3 45.4 17.0 37.3 100.0 1,202 Western terai 41.1 87.5 12.5 29.8 25.9 44.3 100.0 553 Mid-western terai 46.8 82.5 17.5 53.6 24.8 21.6 100.0 251 Far-western terai 46.6 87.4 12.6 35.5 57.7 6.8 100.0 375 Wealth quintile Lowest 38.8 85.6 14.4 44.3 32.9 22.6 100.0 1,237 Second 40.5 86.5 13.5 49.9 24.0 25.8 100.0 1,565 Middle 38.8 83.3 16.7 45.4 18.2 36.4 100.0 1,453 Fourth 35.2 85.3 14.7 45.7 14.2 40.1 100.0 1,390 Highest 30.6 84.6 15.4 45.2 9.1 45.6 100.0 1,185 Total 37.0 85.1 14.9 46.3 19.8 33.8 100.0 6,829 Note: Total includes six men with missing information on destination not shown separately. 1 Includes those who migrated since less than a year prior to the survey 24 • Housing Characteristics and Household Population A higher proportion of urban than rural migrants go to other countries (40 percent versus 33 percent). Migrants from the terai are most likely to migrate to India and other countries, while those from the mountain (66 percent) and hill (50 percent) zones are more likely to migrate within the country. The majority of male migrants from the Far-western region move to India (55 percent), and very few go to other countries. On the other hand, the largest proportion of male migrants from the Eastern region go to countries other than India (46 percent). Men from the highest wealth quintile are more likely to migrate to other countries (46 percent) than those from the lowest wealth quintile (23 percent). Table 2.9.2 shows the migration status of women. One in four women had migrated within one year, 72 percent within five 5 years, and 28 percent five or more years prior to the survey. Eighty-six percent of women who migrated moved within Nepal. Eight percent migrated to India and very few to other countries. About one- third of women who migrated for work moved to countries other than India. Women were less likely to migrate to other countries for non-work-related reasons. Women in the Far-western terai were more likely to migrate to India, primarily due to cross-border marriage practices. India was the second common destination for women migrants from the lowest wealth quintile, while those in the highest wealth quintile were more likely to migrate to other countries. Table 2.9.2 Migration status: Women Percentage of female migrants by years since migration and percent distribution of female migrants by destination, according to background characteristics and reason for migration, Nepal 2011 Background characteristic Time since migration Destination Total Number of female migrants <1 year <5 years1 5+ years Within Nepal India Other countries Age at migration <15 24.5 71.9 28.1 87.9 10.8 1.1 100.0 1,011 15-19 18.8 66.4 33.6 91.3 6.9 1.8 100.0 1,775 20-24 24.0 73.1 26.9 88.4 6.2 5.5 100.0 1,405 25-29 28.2 76.5 23.5 72.0 11.8 16.2 100.0 418 30-34 36.0 83.6 16.4 70.5 10.8 17.6 100.0 170 35-39 41.1 89.3 10.7 60.8 14.3 24.9 100.0 87 40-44 (30.4) (72.4) (27.6) (56.8) (20.5) (22.8) 100.0 41 45-49 (49.5) (77.4) (22.6) (63.8) (17.9) (18.3) 100.0 31 50+ 40.7 86.6 13.4 84.4 5.3 10.4 100.0 62 Reason for migration Work 35.1 89.8 10.2 56.8 7.7 35.1 100.0 455 Study 35.7 86.3 13.7 88.8 3.6 7.5 100.0 699 Marriage 14.2 61.6 38.4 93.6 6.0 0.4 100.0 2,719 Family reasons 34.2 79.2 20.8 79.3 17.7 3.0 100.0 1,095 Other (47.1) (82.4) (17.6) (85.3) (2.9) (11.8) 100.0 34 Residence Urban 25.9 76.3 23.7 77.2 11.0 11.9 100.0 508 Rural 23.5 71.1 28.9 87.5 8.0 4.4 100.0 4,494 Ecological zone Mountain 31.1 72.5 27.5 91.3 4.4 4.3 100.0 357 Hill 21.5 70.2 29.8 91.2 4.0 4.7 100.0 2,246 Terai 24.7 72.8 27.2 81.2 13.0 5.8 100.0 2,399 Development region Eastern 23.5 71.4 28.6 85.2 8.6 6.1 100.0 1,310 Central 27.4 74.1 25.9 87.2 6.0 6.8 100.0 1,549 Western 17.6 68.0 32.0 88.7 6.1 5.0 100.0 1,247 Mid-western 25.9 70.5 29.5 88.2 10.0 1.8 100.0 473 Far-western 27.1 74.7 25.3 78.7 20.4 1.0 100.0 423 Subregion Eastern mountain 27.2 70.0 30.0 98.4 0.0 1.6 100.0 102 Central mountain 32.5 73.1 26.9 86.9 3.7 9.4 100.0 148 Western mountain 33.0 74.2 25.8 90.4 9.6 0.0 100.0 107 Eastern hill 20.4 71.3 28.7 92.9 2.6 4.2 100.0 476 Central hill 28.6 74.9 25.1 89.0 2.3 8.7 100.0 557 Western hill 15.9 67.4 32.6 92.8 2.7 4.3 100.0 857 Mid-western hill 25.3 69.3 30.7 91.6 8.4 0.0 100.0 222 Far-western hill 25.5 65.8 34.2 83.0 16.8 0.2 100.0 133 Eastern terai 24.9 71.7 28.3 78.3 13.8 8.0 100.0 732 Central terai 25.6 73.8 26.2 86.0 9.0 5.0 100.0 844 Western terai 21.4 69.3 30.7 79.8 13.7 6.6 100.0 390 Mid-western terai 23.9 70.7 29.3 83.9 11.6 4.5 100.0 193 Far-western terai 27.1 79.9 20.1 73.6 24.8 1.6 100.0 241 Wealth quintile Lowest 22.9 70.9 29.1 87.6 10.3 2.1 100.0 851 Second 24.1 71.7 28.3 88.2 8.8 2.7 100.0 1,126 Middle 22.2 69.0 31.0 89.6 6.7 3.7 100.0 1,043 Fourth 26.0 73.7 26.3 87.3 6.5 6.2 100.0 1,022 Highest 23.4 72.6 27.4 78.7 9.8 11.5 100.0 960 Total 23.7 71.6 28.4 86.4 8.3 5.2 100.0 5,002 Note: Total includes five women with missing information on destination not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes those who migrated since less than a year prior to the survey. Housing Characteristics and Household Population • 25 2.5 HOUSEHOLD COMPOSITION Information on household composition is critical for understanding family size, household headship, and orphanhood and for implementing meaningful population-based policies and programs. Household composition is also a deter- minant of better health status and well-being. Table 2.10 presents information on household composition. The majority (72 percent) of households are headed by men, although the proportion of female-headed households has risen from 23 percent in 2006 to 28 percent in 2011, with the rise more marked in rural than urban areas. This could be attributed in part to the size- able out-migration of the male population from rural areas. The average household size is 4.4 persons, as compared with 4.9 in 2006; household sizes are larger in rural (4.5) than urban (4.1) areas. This decrease in overall household size is consistent with findings from the 2011 census (Central Bureau of Statistics, 2011a). The 2011 NDHS also collected informa- tion on the presence in households of foster children and orphans. Foster children are children under age 18 living in households with neither their mother nor their father present; orphans are children with one (single orphans) or both parents (double orphans) dead. Foster children and orphans are of concern because they may be at increased risk of neglect or exploitation with their mothers or fathers not present to assist them. There is little difference in the distribution of orphans by rural and urban areas. Eleven percent of households have foster children, and more urban than rural households have foster children (14 percent and 11 percent, respectively). Single orphans are present in 6 percent of households, whereas double orphans are present in less than 1 percent of households. 2.6 BIRTH REGISTRATION Although Nepal has a legal and administrative structure stipulating official registration of births according to standard procedures, few births are registered officially. The practice of formally registering births is not widely adhered to in the country, even though the registration system was implemented 30 years ago and enforced with the Birth, Death and Other Personal Events (Registration) Act of 1976 (Nepal Law Commission, 2006). Table 2.11 presents the percentage of the de jure population under five years whose births are registered with the civil authorities, according to background characteristics. Birth registration information was solicited for children age 0-4. More than two in five (42 percent) children have their births registered. Thirty-eight percent of children under age five have a birth certificate. Although the Three-Year Development Plan (2010- 2013) aims at registering the births of 90 percent of children under age five by 2013, this target is far from being met. The reason is a weak birth registration system coupled with the difficulties encountered in registering births with lack of staff in local registration offices (NPC, 2011). Table 2.10 Household composition Percent distribution of households by sex of head of household and by household size, mean size of household, and percentage of households with orphans and foster children under age 18 years, according to residence, Nepal 2011 Characteristic Residence Total Urban Rural Household headship Male 76.2 71.0 71.8 Female 23.8 29.0 28.2 Total 100.0 100.0 100.0 Number of usual members 0 0.1 0.0 0.0 1 7.0 4.5 4.9 2 13.2 13.6 13.6 3 20.9 16.6 17.2 4 24.1 20.3 20.8 5 14.4 16.9 16.5 6 9.6 12.6 12.2 7 5.0 7.1 6.8 8 2.5 3.9 3.7 9+ 3.2 4.5 4.3 Total 100.0 100.0 100.0 Mean size of households 4.1 4.5 4.4 Percentage of households with orphans and foster children under age 18 Foster children1 13.7 10.8 11.2 Double orphans 0.4 0.4 0.4 Single orphans2 4.7 5.6 5.5 Foster and/or orphan children 16.4 14.3 14.6 Number of households 1,546 9,280 10,826 Note: Table is based on de jure household members (i.e., usual residents). 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2 Includes children with one dead parent and an unknown survival status of the other parent 26 • Housing Characteristics and Household Population Table 2.11 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, according to background characteristics, Nepal 2011 Background characteristic Children whose births are registered Number of children Percentage who had a birth certificate Percentage who did not have a birth certificate Percentage registered Age <2 26.2 2.4 28.6 2,023 2-4 45.0 5.8 50.8 3,247 Sex Male 38.8 5.2 44.0 2,716 Female 36.7 3.7 40.4 2,554 Residence Urban 38.1 6.1 44.2 498 Rural 37.7 4.3 42.1 4,772 Ecological zone Mountain 40.9 5.0 45.9 412 Hill 32.3 4.8 37.1 2,083 Terai 41.4 4.2 45.6 2,775 Development region Eastern 44.5 6.1 50.7 1,238 Central 34.3 3.7 38.0 1,663 Western 35.1 4.4 39.5 992 Mid-western 41.4 3.8 45.2 783 Far-western 33.1 4.3 37.3 593 Subregion Eastern mountain 29.3 3.9 33.2 97 Central mountain 33.4 6.2 39.6 98 Western mountain 49.4 5.0 54.4 217 Eastern hill 37.6 5.7 43.4 405 Central hill 31.7 5.0 36.7 471 Western hill 33.3 4.2 37.5 592 Mid-western hill 27.2 3.6 30.7 372 Far-western hill 29.9 5.9 35.8 243 Eastern terai 50.4 6.6 57.0 736 Central terai 35.5 3.0 38.5 1,095 Western terai 37.7 4.7 42.4 400 Mid-western terai 45.4 4.3 49.8 295 Far-western terai 42.4 1.5 43.9 249 Wealth quintile Lowest 31.2 4.5 35.6 1,360 Second 37.8 4.2 41.9 1,163 Middle 39.4 3.7 43.1 1,111 Fourth 38.3 5.2 43.5 883 Highest 46.7 5.4 52.1 753 Total 37.8 4.5 42.3 5,269 Although the vital registration system of the government requires that a newborn be registered within 35 days of birth with the respective municipality or village development committee, Table 2.11 indicates that children under 2 are much less likely to be registered than children age 2-4 (29 percent and 51 percent, respectively). The registration of older children is primarily driven by the practice of asking parents to produce a child’s birth certificate for school admission, although it is not legally required. Table 2.11 shows that birth registration is higher among male (44 percent) than female (40 percent) children, higher in urban (44 percent) than rural (42 percent) areas, and higher in the mountain and terai (46 percent each) than in the hill zone (37 percent). The Eastern development region has a higher proportion of children with their births registered (51 percent) than the Far-western region (37 percent). Among the subregions, 57 percent of children from the Eastern terai and 54 percent from the Western mountain subregion are registered. Less than half of the children in the other subregions are registered. Children from the highest wealth quintile are more likely to have their births registered (52 percent) than children in the lowest quintile (36 percent). However, the lowest wealth quintile has seen an improvement since 2006, when only 22 percent of children from that quintile were registered. 2.7 CHILDREN’S LIVING ARRANGEMENTS, ORPHANHOOD, AND SCHOOL ATTENDANCE The 2011 NDHS collected information on living arrangements of children and orphanhood. Living arrangements should be monitored together with the proportion of foster and orphan children because of their Housing Characteristics and Household Population • 27 significant effects on the comprehensive development of children. Table 2.12 shows the percent distribution of children under age 18 by living arrangements and survivorship of parents. The proportion of children in Nepal who are orphans and/or foster children is high and is a reflection of the political turmoil in the country over the past decade and the prevailing poverty in various parts of the country. About 61 percent of children less than age 15 and 60 percent of children less than age 18 live with both of their parents. Similarly, 4 percent of children less than age 15 and 6 percent of those less than age 18 are living away from their parents, even if both are alive. In the case of 4 percent of children less than age 15 and 5 percent of children less than age 18, one or both parents are dead. Table 2.12 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Nepal 2011 Background characteristic Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Percentage not living with a biological parent Percentage with one or both parents dead1 Number of children Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing informa- tion on father/ mother Age 0-4 62.6 34.3 0.7 0.3 0.2 1.6 0.1 0.1 0.0 0.1 100.0 1.8 1.2 5,269 <2 65.2 34.0 0.5 0.0 0.0 0.1 0.2 0.0 0.0 0.0 100.0 0.3 0.7 2,023 2-4 60.9 34.4 0.9 0.4 0.3 2.5 0.1 0.1 0.0 0.1 100.0 2.8 1.5 3,247 5-9 59.4 30.8 1.8 1.6 0.6 4.7 0.5 0.4 0.2 0.1 100.0 5.7 3.4 5,930 10-14 60.5 23.6 3.9 2.0 1.7 6.5 0.8 0.6 0.4 0.1 100.0 8.3 7.3 6,488 15-17 58.0 15.9 5.0 1.4 1.4 15.5 0.8 1.4 0.5 0.1 100.0 18.2 9.1 3,152 Sex Male 60.5 28.1 2.8 1.4 1.0 5.1 0.5 0.4 0.2 0.1 100.0 6.2 4.9 10,539 Female 60.1 26.3 2.6 1.4 0.9 7.2 0.6 0.6 0.3 0.1 100.0 8.6 5.0 10,300 Residence Urban 64.2 18.9 2.3 1.3 0.9 10.2 0.7 0.9 0.3 0.3 100.0 12.1 5.1 2,308 Rural 59.8 28.2 2.7 1.4 1.0 5.6 0.5 0.5 0.2 0.1 100.0 6.8 4.9 18,531 Ecological zone Mountain 65.7 22.1 2.9 1.3 1.0 5.4 0.6 0.5 0.4 0.0 100.0 6.9 5.5 1,565 Hill 59.7 27.9 2.9 1.1 1.0 6.1 0.5 0.5 0.3 0.1 100.0 7.3 5.1 8,337 Terai 60.0 27.3 2.4 1.6 0.9 6.2 0.6 0.6 0.2 0.1 100.0 7.6 4.7 10,938 Development region Eastern 58.9 26.4 2.5 1.7 1.2 7.9 0.5 0.7 0.2 0.0 100.0 9.3 5.1 4,900 Central 64.8 23.9 1.8 1.4 1.0 5.7 0.7 0.4 0.2 0.1 100.0 7.0 4.1 6,704 Western 54.2 34.6 2.9 1.4 0.5 5.2 0.4 0.5 0.3 0.1 100.0 6.4 4.6 4,121 Mid-western 63.7 23.5 3.8 1.1 1.2 5.5 0.5 0.6 0.2 0.0 100.0 6.7 6.2 2,822 Far-western 57.3 29.8 3.7 0.9 0.9 6.0 0.5 0.4 0.5 0.0 100.0 7.4 6.0 2,292 Subregion Eastern mountain 65.3 22.4 1.4 2.3 0.6 6.4 1.0 0.4 0.2 0.0 100.0 8.0 3.6 412 Central mountain 57.9 29.6 2.1 1.4 0.6 7.4 0.4 0.2 0.3 0.0 100.0 8.4 3.6 425 Western mountain 70.5 17.6 4.2 0.7 1.6 3.6 0.6 0.7 0.6 0.0 100.0 5.5 7.6 727 Eastern hill 62.4 23.3 3.1 1.6 1.1 7.2 0.6 0.5 0.1 0.1 100.0 8.5 5.4 1,625 Central hill 69.2 17.8 1.1 1.2 1.3 8.1 0.4 0.5 0.3 0.1 100.0 9.3 3.6 2,120 Western hill 52.0 37.0 3.5 0.8 0.5 4.9 0.4 0.4 0.3 0.1 100.0 6.1 5.2 2,391 Mid-western hill 57.0 31.0 3.0 1.1 1.1 5.5 0.6 0.5 0.1 0.1 100.0 6.7 5.3 1,336 Far-western hill 56.8 31.7 5.2 0.4 1.1 3.4 0.5 0.3 0.6 0.1 100.0 4.7 7.7 865 Eastern terai 55.9 28.7 2.4 1.6 1.4 8.5 0.4 0.9 0.2 0.0 100.0 9.9 5.2 2,863 Central terai 63.3 26.4 2.1 1.5 0.9 4.3 0.9 0.4 0.1 0.2 100.0 5.7 4.4 4,160 Western terai 57.1 31.3 2.1 2.2 0.5 5.7 0.4 0.6 0.2 0.0 100.0 6.8 3.8 1,730 Mid-western terai 66.4 19.4 4.6 1.4 0.9 6.0 0.4 0.6 0.3 0.0 100.0 7.2 6.8 1,109 Far-western terai 56.4 29.1 2.4 1.3 0.7 8.9 0.5 0.3 0.3 0.0 100.0 10.0 4.2 1,076 Wealth quintile Lowest 64.7 24.7 3.4 0.8 1.5 3.6 0.6 0.4 0.3 0.0 100.0 4.8 6.2 5,034 Second 60.0 28.9 3.2 1.1 1.1 4.6 0.3 0.5 0.2 0.0 100.0 5.6 5.4 4,429 Middle 59.0 29.5 2.7 1.0 0.8 5.4 0.9 0.3 0.2 0.1 100.0 6.8 5.0 4,149 Fourth 54.9 30.8 1.8 2.6 0.7 7.8 0.3 0.8 0.1 0.1 100.0 9.1 3.7 3,819 Highest 62.0 21.8 1.7 1.4 0.5 10.8 0.6 0.7 0.4 0.2 100.0 12.5 3.9 3,408 Total <15 60.7 29.2 2.2 1.4 0.9 4.4 0.5 0.4 0.2 0.1 100.0 5.5 4.2 17,687 Total <18 60.3 27.2 2.7 1.4 1.0 6.1 0.5 0.5 0.2 0.1 100.0 7.4 4.9 20,839 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both dead and one parent dead but missing information on survival status of the other parent. A high proportion of children age 15-17 (18 percent) are not living with either parent, even when both parents are alive. This may be due to children moving to a relative’s house to pursue further education or for purposes of seeking work. Table 2.12 shows that the percentage of children not living with their parents increases with age. Rural children are more likely to live with either parent than urban children. The highest proportion of children not living with either parent is observed in the Eastern development region (9 percent), while the lowest proportion is found in the Western development region (6 percent). 28 • Housing Characteristics and Household Population 2.8 EDUCATION OF HOUSEHOLD POPULATION Studies have shown that education is one of the major socioeconomic factors that influence a person’s behavior and attitude. In general, the higher the level of education of a woman, the more knowledgeable she is about the use of health facilities, family planning methods, and the health of her children. Inspired by the collective commitment expressed in the Dakar Framework for Action 2000, Nepal has already adopted the “Education for All” (EFA) strategy. To achieve this, a National Plan of Action (NPA, EFA 2001-2015) has been in place since 2001 (Department of Education, 2004). In order to meet MDG targets, Nepal is committed to ensuring that by 2015 all children, and in particular girls, children in difficult situations, and children from ethnic minority groups, have access to a complete, free, compulsory, and good-quality primary education (UNICEF, 2006). To cope with the demand for education, the government of Nepal has opened investment in the education sector to private parties. Education is divided into two broad categories, primary and secondary (Department of Education, 2004). In addition, private parties have invested in opening up non-graded-level schools (e.g., nursery, lower kindergarten, and upper kindergarten), known as pre-primary schools. To gauge the spread of such schools in Nepal, the 2011 NDHS included questions on pre-primary school attendance. Secondary-level schooling includes lower secondary and upper secondary schools, where students can receive an education up to grade 10. More recently, the government has encouraged existing high schools to add two additional years of school (10+2) by affiliating with the Higher Secondary Education Council (on the recommendation of the District Health Education Office and the Department of Education). The goal of the Three Year Plan (2010-2013) of the government of Nepal is to provide free, essential, and quality basic-level education (grade 1 to 8) and expand equitable and participative access to quality education to the secondary level (grade 9 to 12) (NPC, 2010a). In order to promote job-oriented education, skill development schools with a vocational and technical focus have increased over the years in various parts of the country. The interim constitution of Nepal (2007) explicitly stipulated free education up to the secondary level in the public sector and provisioned for reservation and other promotional arrangements for children and women. 2.8.1 Educational Attainment of Household Population Tables 2.13.1 and 2.13.2 show the percent distribution of the de facto female and male household population age 6 and above by level of education and background characteristics. Table 2.13.1 shows that 41 percent of women have never been to school, 23 percent have an incomplete primary education, 6 percent have completed primary school but not continued on to the next level of schooling, 25 percent have some secondary education or have completed secondary school and have not continued on, and about 5 percent have more than a secondary school education. While 7 percent of girls age 10-14 had no education, 12 percent of girls age 6-9 had no education indicating that school enrollment is quite late among girls. A relatively low proportion of girls in the 6-9 age group have attended some primary education (88 percent), particularly with respect to the MDG target of 100 percent by 2015. The proportion of women with no education increases with age, indicating that older women are less likely to be educated than younger women. Women in rural areas are far behind their urban counterparts with 44 percent having no education and median years of schooling is less than one, compared to urban women with 27 percent having no education and a median years of schooling completed of nearly five years. Forty-eight percent of women in the mountain zone have no education compared with 43 percent in the terai and 39 percent in the hill. Women in the Housing Characteristics and Household Population • 29 Table 2.13.1 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nepal 2011 Background characteristic No education1 Some primary2 Completed primary3 Some secondary Completed secondary4 More than secondary Total Number Median years completed Age 6-9 11.7 87.6 0.7 0.0 0.0 0.0 100.0 2,311 0.1 10-14 6.6 47.6 17.4 28.4 0.0 0.0 100.0 3,181 3.7 15-19 12.5 9.4 6.6 49.9 16.5 5.0 100.0 2,775 7.2 20-24 23.1 11.7 7.9 23.3 16.6 17.4 100.0 2,431 6.5 25-29 35.9 15.1 6.9 21.7 10.4 10.0 100.0 2,126 3.8 30-34 44.8 12.8 7.1 20.0 8.8 6.4 100.0 1,744 1.9 35-39 60.9 10.9 4.4 14.2 4.4 5.3 100.0 1,597 0.0 40-44 70.4 11.4 3.3 8.2 3.6 3.0 100.0 1,309 0.0 45-49 78.2 9.3 2.7 5.3 2.3 2.2 100.0 979 0.0 50-54 84.6 6.5 2.5 3.8 1.3 1.3 100.0 1,178 0.0 55-59 90.0 4.1 0.9 3.5 0.7 0.8 100.0 811 0.0 60-64 95.4 1.7 0.4 1.4 0.6 0.5 100.0 711 0.0 65+ 96.8 1.7 0.2 1.0 0.1 0.2 100.0 1,376 0.0 Residence Urban 26.5 19.9 5.5 22.2 11.9 13.9 100.0 2,947 4.6 Rural 43.7 23.5 6.3 17.8 5.4 3.3 100.0 19,582 0.4 Ecological zone Mountain 47.8 25.5 5.7 15.8 3.7 1.5 100.0 1,539 0.0 Hill 38.5 22.5 7.0 19.7 6.2 6.0 100.0 9,143 1.8 Terai 42.8 23.0 5.6 17.7 6.6 4.1 100.0 11,847 0.5 Development region Eastern 35.1 25.7 5.7 21.1 8.2 4.1 100.0 5,441 2.1 Central 46.3 20.9 5.3 15.4 5.5 6.6 100.0 7,430 0.0 Western 37.9 20.9 8.2 22.0 6.7 4.3 100.0 4,752 2.2 Mid-western 43.2 25.9 6.1 17.0 4.9 2.9 100.0 2,633 0.5 Far-western 46.0 24.5 6.3 15.9 4.4 2.8 100.0 2,274 0.0 Subregion Eastern mountain 36.0 27.9 6.0 22.5 5.5 2.1 100.0 424 1.7 Central mountain 49.4 23.0 5.9 16.5 3.6 1.5 100.0 506 0.0 Western mountain 54.6 25.9 5.3 10.5 2.5 1.1 100.0 609 0.0 Eastern hill 37.4 25.0 7.4 21.7 5.9 2.4 100.0 1,759 1.8 Central hill 33.7 20.8 5.8 18.4 7.9 13.4 100.0 2,619 3.0 Western hill 39.4 20.9 8.1 21.8 6.3 3.4 100.0 2,806 2.1 Mid-western hill 41.7 24.8 6.9 17.9 4.8 3.9 100.0 1,172 0.7 Far-western hill 49.2 25.2 6.8 14.7 2.3 1.6 100.0 787 0.0 Eastern terai 33.7 25.8 4.8 20.6 9.8 5.3 100.0 3,257 2.3 Central terai 53.6 20.7 4.9 13.5 4.2 3.1 100.0 4,305 0.0 Western terai 35.6 20.8 8.4 22.2 7.3 5.5 100.0 1,945 2.5 Mid-western terai 41.7 26.8 5.4 18.0 5.5 2.6 100.0 1,159 1.1 Far-western terai 41.6 24.0 6.3 17.9 6.3 3.9 100.0 1,180 0.6 Wealth quintile Lowest 54.7 29.1 5.7 9.4 0.7 0.3 100.0 4,316 0.0 Second 51.7 23.8 6.4 15.2 2.4 0.4 100.0 4,488 0.0 Middle 45.9 22.7 5.7 19.3 4.7 1.6 100.0 4,486 0.0 Fourth 35.3 21.9 6.6 22.3 9.4 4.3 100.0 4,606 2.6 Highest 20.8 17.8 6.4 25.1 13.4 16.4 100.0 4,633 6.1 Total 41.4 23.0 6.2 18.4 6.2 4.7 100.0 22,529 1.0 1 Includes those who have never attended school and those in Early Childhood Development (ECD) centers 2 Includes those who have completed 0-4 years of school and those in school-based pre-primary classes 3 Completed grade 5 at the primary level 4 Completed grade 10 at the secondary level Central and Far western regions have relatively lower levels of education than women in the other regions. Women in the Western mountain subregion are most likely to have no education (55 percent) while women in the Central hill and Eastern terai regions are least likely (34 percent). Overall the median number of years completed in Nepal is only one year among women. Wealth exerts a positive influence on educational attainment. Women from the highest wealth quintile are more likely to be educated than others. Seventy-nine percent of women from the highest wealth quintile have attended school, and half have completed at least six years of schooling; only 45 percent of women in the lowest wealth quintile have some educational attainment. Table 2.13.2 shows the educational attainment of the male household population. Eighty percent of males have attained some level of education. Thirty-nine percent have attained a primary education only, and 33 percent have some secondary education or have completed secondary schooling but did not continue on. Only 9 percent of males have attained more than a secondary-level education. The median number of years of schooling completed is almost 4. Ninety-four percent of males in the highest wealth quintile have attained any level of education, with a median of 8.1 years of schooling, as compared with only 68 percent of males in the lowest wealth quintile, with a median of 1.3 years. 30 • Housing Characteristics and Household Population Table 2.13.2 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nepal 2011 Background characteristic No education1 Some primary2 Completed primary3 Some secondary Completed secondary4 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 6.1 93.0 0.6 0.1 0.0 0.2 0.0 100.0 2,470 0.1 10-14 2.2 50.6 17.5 29.6 0.0 0.0 0.0 100.0 3,269 3.8 15-19 3.6 9.9 5.8 54.9 20.8 5.0 0.1 100.0 2,217 7.8 20-24 5.4 10.1 6.5 27.2 20.8 29.8 0.1 100.0 1,449 9.0 25-29 12.4 15.3 8.2 30.2 15.1 18.7 0.2 100.0 1,266 7.2 30-34 17.6 14.6 6.9 28.6 14.4 17.7 0.2 100.0 1,167 7.1 35-39 17.3 16.9 7.1 26.8 14.9 17.0 0.0 100.0 1,187 6.7 40-44 26.3 18.1 8.0 24.3 9.8 13.3 0.2 100.0 957 4.7 45-49 32.5 20.6 6.8 17.6 11.1 11.1 0.3 100.0 916 3.4 50-54 40.4 20.7 8.2 16.0 6.4 8.2 0.0 100.0 915 2.0 55-59 47.9 19.7 6.8 15.0 5.3 5.2 0.1 100.0 820 0.3 60-64 59.2 16.3 5.8 9.2 4.4 5.0 0.2 100.0 654 0.0 65+ 76.5 8.5 2.4 6.5 3.6 2.2 0.4 100.0 1,303 0.0 Residence Urban 10.1 24.0 6.1 24.1 14.9 20.5 0.3 100.0 2,726 6.9 Rural 21.2 32.5 7.9 23.7 8.0 6.6 0.1 100.0 15,865 3.5 Ecological zone Mountain 22.7 34.2 8.2 24.2 6.2 4.5 0.1 100.0 1,255 3.0 Hill 17.3 30.6 8.2 24.5 9.0 10.3 0.1 100.0 7,477 4.3 Terai 20.9 31.4 7.1 23.2 9.3 7.9 0.1 100.0 9,859 3.6 Development region Eastern 16.9 31.7 7.6 25.6 10.7 7.4 0.1 100.0 4,451 4.2 Central 22.8 29.3 7.0 20.6 8.9 11.2 0.2 100.0 6,338 3.6 Western 17.1 31.5 8.1 26.4 8.8 8.0 0.2 100.0 3,781 4.2 Mid-western 22.0 32.8 7.9 23.5 7.7 6.1 0.0 100.0 2,224 3.3 Far-western 17.2 34.4 8.5 25.6 7.4 6.9 0.0 100.0 1,796 3.8 Subregion Eastern mountain 18.8 36.6 7.4 26.5 6.8 3.9 0.0 100.0 342 3.4 Central mountain 30.2 32.5 8.2 20.5 6.1 2.4 0.0 100.0 382 2.2 Western mountain 19.7 33.8 8.7 25.3 5.9 6.5 0.1 100.0 531 3.4 Eastern hill 20.0 33.5 8.8 25.9 7.7 4.1 0.1 100.0 1,386 3.5 Central hill 14.5 25.6 7.3 21.9 11.1 19.2 0.3 100.0 2,400 5.5 Western hill 18.3 30.1 8.5 26.5 8.8 7.8 0.0 100.0 2,131 4.2 Mid-western hill 20.1 35.5 8.2 21.8 8.1 6.3 0.0 100.0 943 3.3 Far-western hill 14.5 36.9 9.2 28.7 6.4 4.4 0.0 100.0 617 3.9 Eastern terai 15.1 30.2 7.0 25.3 12.7 9.6 0.1 100.0 2,723 4.7 Central terai 27.6 31.5 6.7 19.7 7.6 6.7 0.1 100.0 3,556 2.5 Western terai 15.7 33.3 7.6 26.2 8.8 8.2 0.3 100.0 1,650 4.1 Mid-western terai 24.3 30.3 7.2 24.4 7.8 6.1 0.0 100.0 999 3.4 Far-western terai 18.5 32.6 8.2 23.7 8.5 8.3 0.1 100.0 930 3.8 Wealth quintile Lowest 32.3 40.8 7.8 16.2 1.9 1.0 0.0 100.0 3,365 1.3 Second 28.0 36.5 9.5 20.6 3.5 1.8 0.1 100.0 3,570 2.2 Middle 21.3 32.4 8.1 26.5 7.9 3.8 0.1 100.0 3,693 3.5 Fourth 13.9 27.3 8.0 28.9 13.1 8.6 0.1 100.0 3,891 5.1 Highest 5.7 21.4 5.1 25.4 16.8 25.3 0.3 100.0 4,071 8.1 Total 19.6 31.3 7.6 23.8 9.0 8.6 0.1 100.0 18,591 3.9 1 Includes those who have never attended school and those in Early Childhood Development (ECD) centers 2 Includes those who have completed 0-4 years of school and those in school-based pre-primary classes 3 Completed grade 5 at the primary level 4 Completed grade 10 at the secondary level Survey results show that about one in five men and about two in five women have never attended school. Additionally, twice as many females as males (12 percent versus 6 percent) age 6-9 have never been to school (in 2006, the corresponding proportions were 16 percent and 10 percent). The percentage of men and women with no education has declined since 2006, with improvements observed across all education categories. This decline is the result of various interventions by the government to enhance the overall quality of education and improve school enrollment (NPC, 2010a). 2.8.2 School Attendance Ratios The net attendance ratio (NAR) indicates participation in primary schooling for the population age 6-10 and secondary schooling for the population age 11-15. The gross attendance ratio (GAR) measures participation at each level of schooling among those of any age from 5 to 24 years. The GAR is almost always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level. An NAR of 100 percent would indicate that all of those in the official age range for that level are attending at that level. The GAR can exceed 100 percent if there is significant overage or underage participation at a given level of schooling. Housing Characteristics and Household Population • 31 Tables 2.14.1 and 2.14.2 provide data on net attendance ratios and gross attendance ratios by sex and level of schooling. There has been a rise in the NAR at the primary level from 87 percent in 2006 to 89 percent in 2011, while at the secondary level it has increased from 47 percent to 59 percent over the same period. The rural primary school NAR has increased from 86 percent in 2006 to 89 percent in 2011, with a rise from 91 percent to 94 percent in urban areas over the same period. Among the subregions, the Central terai has the lowest NAR and GAR at the primary as well as at the secondary level. Table 2.14.1 School attendance ratios: Primary school Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population at the primary level by sex and level of schooling, and the Gender Parity Index (GPI), according to background characteristics, Nepal 2011 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 Residence Urban 94.8 92.7 93.8 0.98 131.4 123.9 127.8 0.94 Rural 91.9 85.4 88.7 0.93 141.3 130.7 136.1 0.93 Ecological zone Mountain 93.5 93.0 93.2 0.99 135.3 132.7 134.0 0.98 Hill 92.1 89.2 90.7 0.97 135.8 133.2 134.5 0.98 Terai 92.1 83.0 87.7 0.90 143.9 127.0 135.8 0.88 Development region Eastern 94.0 89.1 91.6 0.95 142.0 129.9 135.9 0.91 Central 89.8 78.4 84.1 0.87 138.1 114.7 126.4 0.83 Western 91.5 90.1 90.9 0.98 140.7 142.9 141.7 1.02 Mid-western 93.4 91.1 92.3 0.98 141.3 138.6 140.0 0.98 Far-western 95.0 92.2 93.7 0.97 139.6 145.1 142.3 1.04 Subregion Eastern mountain 94.8 93.1 94.0 0.98 139.9 131.9 135.9 0.94 Central mountain 89.6 94.1 92.0 1.05 127.4 131.4 129.5 1.03 Western mountain 94.8 92.1 93.5 0.97 136.7 134.0 135.4 0.98 Eastern hill 92.6 88.6 90.5 0.96 136.7 127.3 131.7 0.93 Central hill 94.1 88.4 91.2 0.94 135.4 120.7 128.0 0.89 Western hill 89.1 91.2 90.1 1.02 132.3 145.6 138.6 1.10 Mid-western hill 92.7 87.3 90.2 0.94 139.3 138.4 138.9 0.99 Far-western hill 93.2 90.7 92.0 0.97 138.8 140.8 139.7 1.01 Eastern terai 94.6 88.8 91.8 0.94 145.1 131.2 138.4 0.90 Central terai 87.6 71.3 79.5 0.81 140.4 109.6 125.2 0.78 Western terai 94.3 88.4 91.8 0.94 150.5 139.1 145.7 0.92 Mid-western terai 94.2 94.4 94.3 1.00 148.5 143.5 145.9 0.97 Far-western terai 96.1 93.7 94.9 0.98 138.7 148.3 143.3 1.07 Wealth quintile Lowest 86.1 81.8 83.9 0.95 136.6 127.1 131.7 0.93 Second 90.9 81.8 86.5 0.90 139.4 130.3 135.0 0.93 Middle 93.3 88.2 91.0 0.95 144.7 139.0 142.1 0.96 Fourth 95.9 89.3 92.6 0.93 148.4 129.4 139.0 0.87 Highest 97.5 94.3 96.0 0.97 132.7 125.1 129.1 0.94 Total 92.2 86.3 89.3 0.94 140.1 129.9 135.1 0.93 1 The NAR for primary school is the percentage of the primary school age (6-10 years) population that is attending primary school. By definition, the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary school age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100.0. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. Over the past five years, the rise in the NAR and GAR at the secondary level for females has been noticeable, with the NAR increasing from 43 percent in 2006 to 58 percent in 2011 and the GAR increasing from 67 percent in 2006 to 87 percent in 2011. In addition to extensive educational programs, these increases can be credited to government interventions providing specific scholarship initiatives for girls, members of the Dalit ethnic group, children with various disabilities, children of martyrs, and other groups of needy children. The 2006 Scholarship Regulation provisioned for the inclusion in programs of the poor, women, and conflict- affected and disabled populations (Department of Education, 2006). “Welcome to school” programs and the “School Tiffin program” have been maintained over the past five years. 32 • Housing Characteristics and Household Population Table 2.14.2 School attendance ratios: Secondary school Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population at the secondary level by sex and level of schooling, and the Gender Parity Index (GPI), according to background characteristics, Nepal 2011 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 Residence Urban 70.5 70.9 70.7 1.00 95.7 99.8 97.6 1.04 Rural 57.7 56.2 56.9 0.97 84.3 85.4 84.8 1.01 Ecological zone Mountain 67.3 60.9 64.1 0.91 104.8 94.4 99.5 0.90 Hill 65.9 66.0 66.0 1.00 92.1 97.7 94.9 1.06 Terai 52.9 50.8 51.8 0.96 78.0 77.4 77.7 0.99 Development region Eastern 60.8 60.1 60.5 0.99 87.0 92.6 89.8 1.06 Central 54.4 51.7 53.1 0.95 75.0 76.3 75.6 1.02 Western 62.3 64.4 63.4 1.03 89.5 93.6 91.5 1.05 Mid-western 59.3 60.5 59.9 1.02 94.2 90.6 92.4 0.96 Far-western 63.5 54.5 59.1 0.86 96.6 89.7 93.2 0.93 Subregion Eastern mountain 57.1 63.3 60.3 1.11 97.1 101.9 99.6 1.05 Central mountain 71.2 71.2 71.2 1.00 103.7 109.4 106.8 1.05 Western mountain 70.6 50.9 61.4 0.72 109.6 76.9 94.3 0.70 Eastern hill 64.4 68.3 66.3 1.06 93.9 117.7 105.4 1.25 Central hill 68.8 66.9 67.9 0.97 84.7 92.0 88.2 1.09 Western hill 67.0 67.6 67.3 1.01 95.6 97.4 96.6 1.02 Mid-western hill 58.7 64.2 61.7 1.09 90.7 90.4 90.5 1.00 Far-western hill 66.8 57.8 62.2 0.87 100.3 88.5 94.4 0.88 Eastern terai 59.2 55.1 57.2 0.93 81.7 77.4 79.6 0.95 Central terai 43.8 41.4 42.6 0.94 65.9 64.0 64.9 0.97 Western terai 56.2 59.7 57.9 1.06 81.5 88.1 84.7 1.08 Mid-western terai 56.0 56.9 56.5 1.02 88.5 90.9 89.6 1.03 Far-western terai 59.3 54.6 57.0 0.92 94.5 98.6 96.5 1.04 Wealth quintile Lowest 46.0 41.4 43.6 0.90 70.7 62.8 66.5 0.89 Second 52.3 47.5 49.8 0.91 82.4 78.6 80.4 0.95 Middle 59.3 58.5 58.9 0.99 88.3 91.1 89.7 1.03 Fourth 64.5 68.9 66.5 1.07 90.0 105.6 97.1 1.17 Highest 75.5 78.8 77.1 1.04 97.8 103.7 100.8 1.06 Total 59.2 57.8 58.5 0.98 85.6 86.9 86.3 1.02 1 The NAR for secondary school is the percentage of the secondary school age (11-15 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. 2 The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary school age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100.0. 3 The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. Tables 2.14.1 and 2.14.2 also show the Gender Parity Index (GPI), which represents the ratio of the NAR and GAR for females to the NAR and GAR for males. It is a more precise indicator of gender differences in the schooling system. A GPI less than one indicates that a smaller proportion of females than males attend school. The indexes for NAR and GAR at the primary and secondary levels are slightly less than one (0.9), indicating that the gender gap is very narrow. It is worth noting here that the gender gap in attendance has remained unchanged at the primary level but has narrowed over the past few years at the secondary level. Figure 2.2 shows that females have a lower level of school attendance than males. Attendance is high up to age 8 for both males and females and then drops off gradually after age 14. Housing Characteristics and Household Population • 33 0 10 20 30 40 50 60 70 80 90 100 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percentage Age Figure 2.2 Age-specific Attendance Rates of the de facto Population 5 to 24 Years Male Female 2.8.3 Early Childhood Development Centers In order to promote pre-primary education for children under five, the government has introduced Early Childhood Development (ECD) centers under Nepal’s Preliminary Child Education regulations. Data collected nationally show that a total of 26,773 ECD centers and school-based pre-primary classes had been established up to the 2010 school year (NPC, 2010a). These school-based centers are mostly managed by the government, while other community-based ECD centers are mostly supported by nongovernmental organizations (NGOs). The 2011 NDHS collected information on the percentage of children age 3-4 enrolled in these centers. Table 2.15 shows that nearly one-third of children age 3-4 are enrolled in school-based pre-primary classes or in ECD centers. School-based pre-primary classes are relatively more widespread; 23 percent of all children age 3-4 are enrolled in these classes, with only 7 percent of children enrolled in ECD centers. Overall, enrollment in pre-primary classes, including ECD centers, has increased from 23 percent in 2006 to 30 percent in 2011. No significant differences in enrollment by gender were observed. Young children in urban areas are more likely to be enrolled in school-based pre-primary classes (43 percent) than are young children in rural areas (21 percent), while the proportion of children enrolled in ECD centers is slightly higher in rural than in urban areas (7 percent versus 5 percent). But it is interesting that enrollment of children from urban areas in school-based pre-primary classes has declined from 50 percent to 43 percent between 2006 and 2011, while enrollment of children in rural areas has increased from 13 percent to 21 percent during the same period. Children in the hill zone are more likely to be enrolled in pre-primary classes or ECD centers (32 percent) than those in the other ecological zones, with most children from the Western region (45 percent) and Western terai (46 percent) enrolled in early education. Children in the highest wealth quintile (61 percent) are significantly more likely to have access to early education than those in other households, especially those in the lowest quintile, where only 14 percent are enrolled in early education. 34 • Housing Characteristics and Household Population Table 2.15 Children enrolled in school-based pre-primary classes and Early Childhood Development centers Percentage of de facto children age 3-4 enrolled in school-based pre-primary classes and Early Childhood Development centers according to background characteristics, Nepal 2011 Background characteristic Percentage of children age 3-4 Number of children School-based pre-primary Early Childhood Development centers Total Sex Male 23.7 5.6 29.3 1,134 Female 23.0 8.0 31.0 1,048 Residence Urban 42.5 4.6 47.1 211 Rural 21.3 7.0 28.3 1,971 Ecological zone Mountain 12.0 17.0 29.0 169 Hill 22.5 9.4 31.9 860 Terai 25.7 3.3 29.0 1,153 Development region Eastern 24.1 4.0 28.1 527 Central 19.7 7.4 27.2 687 Western 37.1 7.8 44.9 393 Mid-western 15.3 8.0 23.3 322 Far-western 20.8 7.5 28.3 253 Subregion Eastern mountain 18.7 13.7 32.5 39 Central mountain 20.0 23.7 43.7 44 Western mountain 4.8 15.0 19.8 86 Eastern hill 14.3 6.1 20.3 183 Central hill 32.2 12.6 44.8 190 Western hill 35.6 8.7 44.3 228 Mid-western hill 8.4 9.0 17.3 157 Far-western hill 12.0 11.1 23.1 102 Eastern terai 30.6 1.5 32.1 305 Central terai 14.5 3.6 18.1 452 Western terai 39.1 6.5 45.6 165 Mid-western terai 27.8 1.7 29.5 118 Far-western terai 35.3 4.0 39.3 112 Wealth quintile Lowest 5.3 9.1 14.3 575 Second 15.3 6.2 21.5 489 Middle 20.6 7.6 28.2 436 Fourth 37.8 4.3 42.1 364 Highest 55.7 5.2 60.9 317 Total 23.4 6.8 30.1 2,182 2.9 POSSESSION OF MOSQUITO NETS Since 1954, USAID has promoted malaria control programs through the Insect Borne Disease Control Program. The malaria eradication program, launched in 1958, reverted to a malaria control program in 1978. In 1993, the World Health Organization initiated the Global Malaria Control Strategy to focus on problem areas. Areas with a high incidence of malaria were identified, and 12 priority districts in the forest area, foothills, and inner terai were targeted for focused initiatives under the Roll Back Malaria strategy. Currently, malaria control activities are in place in 65 of the country’s 75 districts (MOHP, 2011a). In addition to preparing for a malaria pre-elimination strategy, the MOHP has initiated visceral leishmaniasis (kala-azar) elimination programs. An important strategy in the control of malaria and kala-azar is prevention through indoor residual spraying and use of long-lasting insecticide-treated bednets (LLINs). This strategy has been implemented through the promotion of personal protection measures, including the use of simple mosquito nets or LLINs. The MOHP has been distributing nets through various channels in affected areas, and it set a target of 80 percent of people in high-risk areas sleeping under LLINs by 2011 (MOHP, 2011a). The 2011 NDHS collected information on the possession and number of mosquito nets in households. Table 2.16 shows that about 68 percent of households have mosquito nets (78 percent in urban areas and 66 percent in rural areas). Households in the terai (90 percent) are much more likely to possess mosquito nets than households in the hill (49 percent) and mountain (20 percent) zones. This is primarily because the terai is a high- Housing Characteristics and Household Population • 35 risk area for malaria transmission. Households in the Eastern region are more likely to possess nets than other households in the other regions. More than 90 percent of households in the Eastern terai, Western terai, and Far- western terai have mosquito nets. Among households with nets, 24 percent own one net, 55 percent own two or three nets, and 22 percent own at least four nets. Households in the fourth and highest wealth quintiles are more likely to possess mosquito nets (88 percent and 85 percent, respectively) than households in the other wealth quintiles. Households in the lowest wealth quintile are least likely to have nets (26 percent). Table 2.16 Possession of mosquito nets Percentage of households with mosquito nets, and among households with mosquito nets, the percent distribution by number of nets in the household, according to background characteristics, Nepal 2011 Background characteristic Percentage of households with nets Number of households Number of nets in household Number of households with nets 1 2-3 4+ Total Residence Urban 77.9 1,546 23.5 55.7 20.8 100.0 1,205 Rural 66.1 9,280 23.7 54.6 21.7 100.0 6,137 Ecological zone Mountain 20.4 761 30.0 50.2 19.8 100.0 156 Hill 48.7 4,563 26.5 54.3 19.2 100.0 2,220 Terai 90.3 5,502 22.2 55.2 22.6 100.0 4,966 Development region Eastern 76.2 2,685 19.7 56.0 24.3 100.0 2,045 Central 69.7 3,627 27.6 55.3 17.1 100.0 2,529 Western 68.8 2,304 19.6 53.4 27.0 100.0 1,586 Mid-western 51.2 1,241 29.6 51.8 18.6 100.0 635 Far-western 56.3 969 25.2 55.7 19.1 100.0 546 Subregion Eastern mountain 30.0 206 24.1 50.4 25.5 100.0 62 Central mountain 25.6 266 30.1 51.0 19.0 100.0 68 Western mountain 8.9 289 44.0 48.0 8.0 100.0 26 Eastern hill 49.7 847 23.8 54.5 21.7 100.0 421 Central hill 52.2 1,386 29.1 55.4 15.5 100.0 724 Western hill 54.9 1,415 23.8 53.5 22.7 100.0 777 Mid-western hill 37.4 577 33.0 50.7 16.3 100.0 216 Far-western hill 24.3 339 25.8 60.6 13.6 100.0 82 Eastern terai 95.7 1,632 18.4 56.7 24.9 100.0 1,563 Central terai 88.0 1,975 26.9 55.4 17.7 100.0 1,737 Western terai 90.9 889 15.6 53.3 31.1 100.0 808 Mid-western terai 79.3 519 27.3 52.5 20.2 100.0 411 Far-western terai 91.7 487 24.6 55.0 20.4 100.0 446 Wealth quintile Lowest 26.1 2,029 45.3 49.9 4.9 100.0 530 Second 58.0 2,168 37.9 54.5 7.5 100.0 1,258 Middle 78.6 2,068 24.2 57.7 18.0 100.0 1,625 Fourth 87.9 2,185 15.8 56.7 27.6 100.0 1,921 Highest 84.5 2,377 16.1 52.2 31.7 100.0 2,008 Total 67.8 10,826 23.7 54.8 21.5 100.0 7,341 2.10 PREVALENCE AND CAUSES OF FOOD INSECURITY AND COPING STRATEGIES Food security refers to the availability of food and one’s access to it. A household is considered food- secure when its occupants do not live in hunger or fear of starvation (Hunt, 2009). In 1996, the World Food Summit defined food security as “the situation when all people at all times have access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life” (Food and Agriculture Organization of the United Nations, 2002). Common to most definitions of food security are the elements of availability, access (physical and economic), utilization, and stability or sustainability. Food insecurity is rooted in poverty and leads to poor health, low productivity, low income, food shortage, and hunger (Khanal and Dahal, 2010). The interim constitution (2006-2007) of Nepal recognized food security as a fundamental human right for all citizens, and this is reflected in the Three Year Interim Plan (2010-2013). With respect to MDG 1, Nepal aims to reduce the proportion of the population living below a minimum level of dietary energy consumption to 25 percent by 2015 (NPC, 2010a). In the absence of representative information on levels of household food insecurity, the 2011 NDHS provided a good opportunity to collect baseline data on food insecurity in Nepal. 36 • Housing Characteristics and Household Population The series of questions on food insecurity included in the 2011 NDHS was adopted from the Household Food Insecurity Access Scale indicators developed in USAID’s Food and Nutrition Technical Assistance (FANTA) project. However, the questions were modified to be specific to Nepal, with seven of the nine generic questions included and the reference period for assessment extended to 12 months from one month to allow for seasonal variations. The food insecurity scale designed from this methodology provides information on a household’s “access” to food, one of the three components of food insecurity—Availability, Access and Utilization. Although the questions on food insecurity included in the Household Questionnaire were administered to the household head, they reflect food insecurity for the household as a unit. The questions, arranged in order of degree of severity and frequency of occurrence, capture the household’s perception of food vulnerability or stress and behavioral responses to food insecurity. Based on responses to these questions, four food insecurity categories were created: 1. Food secure households: These households do not experience any food insecurity (access) conditions and rarely worry about such conditions. 2. Mildly food insecure households: These households worry about not having enough food sometimes or often, and/or are unable to eat preferred foods, and/or eat a more monotonous diet than desired and/or some foods considered undesirable but do so only rarely. They do not cut back on quantity or experience any of the three most severe conditions (running out of food, going to bed hungry, or going a whole day and night without eating). 3. Moderately food insecure households: These households sacrifice quality more frequently, by eating a monotonous diet or undesirable foods sometimes or often, and/or have rarely or sometimes started to cut back on quantity by reducing the size of meals or number of meals. However, they do not experience any of the three most severe conditions. 4. Severely food insecure households: These households have cut back on meal size or number of meals often and/or have experienced any of the three most severe conditions (running out of food, going to bed hungry, or going a whole day and night without eating), even if only rarely. In other words, any household that has experienced one of these three conditions even once in the last 12 months is considered severely food insecure (Coates et al., 2007). Table 2.17 shows that 49 percent of households in Nepal are food secure and have access to food year round. Twelve percent of households are mildly food insecure, 23 percent are moderately food insecure, and 16 percent are severely food insecure. Urban households are more food secure (67 percent) than rural households (46 percent). The proportion of food secure households is higher in the terai (52 percent), which includes the country’s most fertile land areas, than in the hill (47 percent) and mountain (41 percent) zones. Households in the Eastern development region are most likely to be food secure (56 percent), while households in the Mid- western region tend to be least food secure (32 percent). The latter finding is consistent with the government’s recent declaration of the hill districts of the Mid-western region (namely, Humla, Mugu, Kalikot, Rukum, Surkhet, and Jajarkot) as severely food insecure areas (The Himalayan, 2010). The 2011 NDHS indicates that 27 percent of the households in this region are severely food insecure and that 29 percent are moderately food insecure. Overall, two in three households in this region are food insecure at some level. Housing Characteristics and Household Population • 37 Table 2.17 Household food security Percent distribution of households by level of food insecurity, according to background characteristics, Nepal 2011 Background characteristic Food secure Mildly food insecure Moderately food insecure Severely food insecure Total Number of households Residence Urban 67.3 10.1 14.1 8.5 100.0 1,546 Rural 46.2 12.2 24.9 16.7 100.0 9,280 Ecological zone Mountain 40.5 18.2 26.1 15.1 100.0 761 Hill 47.2 12.3 28.7 11.8 100.0 4,563 Terai 52.1 10.7 18.6 18.6 100.0 5,502 Development region Eastern 55.9 11.1 19.0 13.9 100.0 2,685 Central 52.8 11.4 20.1 15.6 100.0 3,627 Western 51.4 11.3 27.1 10.1 100.0 2,304 Mid-western 31.9 12.5 28.5 27.1 100.0 1,241 Far-western 34.2 16.0 32.1 17.7 100.0 969 Subregion Eastern mountain 56.8 15.4 17.4 10.3 100.0 206 Central mountain 44.3 15.1 33.3 7.3 100.0 266 Western mountain 25.4 23.1 25.8 25.8 100.0 289 Eastern hill 49.6 14.4 25.3 10.7 100.0 847 Central hill 58.4 11.7 21.0 8.9 100.0 1,386 Western hill 46.6 11.6 34.5 7.2 100.0 1,415 Mid-western hill 28.9 11.4 30.8 29.0 100.0 577 Far-western hill 29.3 13.7 40.2 16.8 100.0 339 Eastern terai 59.1 8.9 16.0 16.0 100.0 1,632 Central terai 50.1 10.7 17.8 21.4 100.0 1,975 Western terai 59.1 10.9 15.3 14.7 100.0 889 Mid-western terai 39.8 13.5 26.1 20.6 100.0 519 Far-western terai 37.4 12.7 29.0 20.9 100.0 487 Wealth quintile Lowest 18.1 11.8 38.9 31.2 100.0 2,029 Second 32.6 13.6 29.2 24.7 100.0 2,168 Middle 46.3 14.0 25.4 14.2 100.0 2,068 Fourth 62.0 12.4 18.2 7.4 100.0 2,185 Highest 81.9 8.0 7.8 2.3 100.0 2,377 Total 49.2 11.9 23.4 15.5 100.0 10,826 Not surprisingly, households in the highest wealth quintile are much more likely to be food secure (82 percent) than households in the lowest wealth quintile (18 percent). A large proportion of households in the lowest wealth quintile fall in the moderately food insecure category (39 percent), and 31 percent fall in the severely food insecure category. Among households that suffered from food insecurity, further questions were posed on coping strategies and causes. Table 2.18 provides information on strategies adopted by households to cope with food insecurity. Seven of 10 households with food insecurity took a loan to meet their food needs. Other coping strategies included consuming seeds that were meant for the next planting season (19 percent), selling livestock (31 percent), selling other household assets (9 percent), and working in short-term labor positions (4 percent). Households in rural areas were more likely to take loans (71 percent) than urban households (63 percent). Households in the highest wealth quintile are least likely to take loans (54 percent), and households in the lowest wealth quintile are most likely to do so (76 percent). Households that are severely food insecure are more likely to take a loan (82 percent) than households that are moderately (67 percent) or mildly (61 percent) food insecure. 38 • Housing Characteristics and Household Population Table 2.18 Coping strategies of households with food insecurity Among households with food insecurity, the percentage using various coping strategies according to background characteristics, Nepal 2011 Background characteristic Took loan Consumed seed Sold livestock Sold other household assets Worked as labor Number of food insecure households Residence Urban 63.0 5.9 12.8 8.4 1.9 506 Rural 70.8 20.3 33.0 8.7 4.2 4,990 Ecological zone Mountain 73.1 28.1 40.7 8.0 10.8 453 Hill 72.4 23.1 37.3 7.2 4.0 2,409 Terai 67.5 13.7 23.9 10.2 2.7 2,634 Development region Eastern 72.3 13.0 41.3 10.5 1.6 1,184 Central 65.6 14.2 25.6 7.8 1.5 1,711 Western 66.3 13.6 25.9 4.7 6.1 1,119 Mid-western 72.0 36.7 35.5 13.9 11.0 845 Far-western 82.2 29.0 31.1 7.9 1.8 638 Subregion Eastern mountain 81.6 27.4 56.5 5.4 0.2 89 Central mountain 61.0 17.7 36.6 4.9 10.8 148 Western mountain 77.9 35.5 37.1 11.2 15.2 216 Eastern hill 74.9 17.6 55.6 8.1 0.0 427 Central hill 61.3 17.5 29.4 6.0 0.6 577 Western hill 66.8 14.0 29.8 4.3 5.5 755 Mid-western hill 87.7 49.0 47.7 14.2 12.1 410 Far-western hill 86.5 30.4 30.0 5.7 0.8 239 Eastern terai 69.4 8.1 30.1 12.7 2.9 668 Central terai 68.8 11.8 21.7 9.3 0.6 986 Western terai 65.3 12.8 17.8 5.5 7.3 364 Mid-western terai 51.7 18.6 22.8 12.9 3.3 312 Far-western terai 77.6 28.4 26.2 10.5 3.1 305 Wealth quintile Lowest 76.1 31.5 40.3 9.0 5.7 1,662 Second 73.3 17.3 32.4 8.3 4.3 1,462 Middle 70.2 13.6 29.4 10.0 3.9 1,110 Fourth 60.6 11.5 26.1 9.7 1.7 830 Highest 54.3 4.8 6.1 3.7 0.8 431 Degree of food insecurity Mildly food insecure 60.9 8.4 25.1 3.4 2.2 1,286 Moderately food insecure 67.1 17.4 32.6 7.0 3.6 2,531 Severely food insecure 81.8 29.6 33.7 15.4 5.9 1,679 Total 70.1 19.0 31.2 8.7 4.0 5,496 The 2011 NDHS also collected information on the causes of food insecurity. Table 2.19 describes the unexpected causes (drought, flood, landslide, crop failure) and temporary causes (financial problems) that were reported. Twenty-seven percent of households reported an unexpected natural disaster as a cause of their food insecurity, with 25 percent reporting a drought or crop failure. Two percent reported a flood or landslide as the major cause of their food insecurity. Financial problems were reported by 96 percent of the households facing food insecurity. Droughts and crop failures are more common in rural areas, the mountain zone, the Mid- western region, the Western mountain subregion, and households in the lowest wealth quintile. The relationship between household food insecurity and the nutritional status of children is analyzed in Chapter 11. Housing Characteristics and Household Population • 39 Table 2.19 Causes of household food insecurity Among households with food insecurity, the percentage that experienced food insecurity due to various causes, according to background characteristics, Nepal 2011 Background characteristic Drought/ crop failure Flood/ landslide Financial problems Other causes Number of food insecure households Residence Urban 6.3 0.3 96.1 6.0 506 Rural 27.1 2.0 95.6 6.6 4,990 Ecological zone Mountain 56.4 5.1 95.1 11.8 453 Hill 31.7 2.0 95.4 8.7 2,409 Terai 13.9 1.2 96.0 3.7 2,634 Development region Eastern 29.1 1.3 95.3 7.3 1,184 Central 20.0 1.8 95.9 5.7 1,711 Western 10.5 0.5 98.7 6.9 1,119 Mid-western 45.8 2.5 91.5 8.8 845 Far-western 30.2 4.3 96.2 3.8 638 Subregion Eastern mountain 43.1 2.0 94.1 14.3 89 Central mountain 49.3 5.1 94.8 13.7 148 Western mountain 66.7 6.4 95.7 9.5 216 Eastern hill 52.4 1.1 93.9 9.8 427 Central hill 24.2 3.3 95.7 8.0 577 Western hill 10.3 0.8 99.0 8.4 755 Mid-western hill 60.4 2.2 89.3 13.2 410 Far-western hill 31.3 3.7 96.8 2.0 239 Eastern terai 12.4 1.4 96.4 4.8 668 Central terai 13.2 0.5 96.2 3.2 986 Western terai 11.0 0.0 98.0 3.8 364 Mid-western terai 16.8 0.0 93.9 0.8 312 Far-western terai 19.9 5.5 94.5 5.6 305 Wealth quintile Lowest 42.0 3.1 95.0 9.1 1,662 Second 22.8 1.4 97.2 5.5 1,462 Middle 20.1 1.8 95.5 5.0 1,110 Fourth 12.3 0.8 95.0 5.5 830 Highest 6.6 0.5 94.8 6.4 431 Degree of food insecurity Mildly food insecure 23.0 1.0 93.5 5.3 1,286 Moderately food insecure 25.4 1.9 95.9 6.4 2,531 Severely food insecure 26.6 2.4 97.0 7.8 1,679 Total 25.2 1.9 95.7 6.6 5,496 Characteristics of Respondents • 41 CHARACTERISTICS OF RESPONDENTS 3 The purpose of this chapter is to create a demographic and socioeconomic profile of individual female and male respondents. This information helps in the interpretation of findings presented later in the report and provides an indication of the representativeness of the survey. The chapter begins by describing basic background characteristics, including age, marital status, religion, ethnicity, and wealth status. It then provides more detailed information on education, media exposure, employment, and tobacco use. In 2011, for the second time, the NDHS gathered information from all women and men irrespective of their marital status; earlier surveys had sampled only ever-married women and men. The discussion in this report is therefore with reference to all women and men. However, when comparing information with past surveys, the data have been rerun for ever-married women and men wherever possible to enable comparability between surveys. Throughout this report, numbers in the tables reflect weighted numbers. Percentages based on 25 to 49 unweighted cases are shown in parentheses, and percentages based on fewer than 25 unweighted cases are suppressed and replaced with an asterisk, to caution readers when interpreting data that a percentage based on fewer than 50 cases may not be statistically reliable.1 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS A description of the basic characteristics of the 12,674 women and 4,121 men age 15-49 interviewed in the 2011 NDHS is presented in Table 3.1. Relatively high proportions of both female and male respondents are in the younger age groups, with more than half of the respondents (56 percent of women and 54 percent of men) under age 30. In general, the proportion of women and men in each group declines as age increases, reflecting the comparatively young age structure of the population in Nepal as a result of past high fertility levels. The vast majority of women and men are Hindu (84 percent), 9 percent are Buddhist, and 4 percent of women and 3 percent of men are Muslim. Two percent of women and men are Kirat, and another 2 percent are Christian. 1 Parentheses are used if mortality rates are based on 250 to 499 children exposed to the risk of mortality in any of the component rates; mortality rates are suppressed if they are based on fewer than 250 children exposed to the risk of mortality in any of the component rates. Key Findings: • Forty percent of women and 14 percent of men age 15-49 have no education. However, the percentage of women and men with at least some secondary education or higher has increased by 48 percent and 26 percent, respectively, in the last five years. • Thirty-two percent of married women report that their husbands live away from home. • Thirty-three percent of women and 20 percent of men are not exposed to any media source. • Sixty percent of women were employed in the 12 months preceding the survey, with the majority (75 percent) employed in the agricultural sector. • The majority (61 percent) of working women are not paid for their work. In contrast, most men (76 percent) earn cash or cash and in-kind payments. 42 • Characteristics of Respondents Hill Janajatis are the dominant ethnic group, with 25 percent of women and 24 percent of men belonging to this group. Nearly one-fifth (19 percent) of both women and men are hill Chhetris. Fourteen percent of women and 15 percent of men are hill Brahmins, 10 percent of women and 12 percent of men are terai Janajati, 10 percent of women and 9 percent of men are hill Dalit, and 8 percent of women and 9 percent of men are other terai caste. The rest of the ethnic groups represent less than 5 percent of the population. More than one-fifth of women (21 percent) and more than one-third of men (35 percent) have never been married. The majority of women (76 percent) and men (64 percent) are currently married, with a very small percentage divorced or separated. The majority of respondents reside in rural areas, with only 14 percent of women and 17 percent of men residing in urban areas. More than half (54 percent) of the respondents live in the terai, two-fifths (40 percent) live in the hill zone, and 6 percent live in the mountain zone. Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Nepal 2011 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 21.7 2,753 2,790 23.7 978 1,009 20-24 18.1 2,297 2,281 16.6 685 693 25-29 16.6 2,101 2,129 14.1 581 567 30-34 13.7 1,734 1,697 12.1 499 492 35-39 12.3 1,557 1,561 13.1 542 533 40-44 10.1 1,285 1,266 10.6 438 458 45-49 7.5 947 950 9.7 399 369 Religion Hindu 84.2 10,672 10,829 84.2 3,472 3,486 Buddhist 8.8 1,112 1,058 8.6 354 352 Muslim 3.7 470 331 3.1 128 107 Kirat 1.5 195 215 2.1 86 92 Christian 1.7 220 236 1.9 77 80 Other 0.0 5 5 0.1 5 4 Ethnicity Hill Brahmin 14.2 1,805 1,798 14.5 597 618 Hill Chhetri 19.2 2,436 3,199 18.9 780 1,000 Terai Brahmin/Chhetri 1.2 156 169 1.3 54 55 Other Terai caste 7.9 1,003 730 9.0 372 303 Hill Dalit 9.6 1,214 1,402 8.6 352 381 Terai Dalit 4.4 559 306 3.9 163 96 Newar 4.3 541 532 4.8 196 180 Hill Janajati 24.9 3,154 2,986 23.5 968 906 Terai Janajati 10.4 1,313 1,198 12.1 497 463 Muslim 3.7 468 327 3.1 127 106 Other 0.2 25 27 0.3 14 13 Marital status Never married 21.4 2,708 2,837 34.8 1,433 1,444 Married1 75.8 9,608 9,460 63.7 2,626 2,628 Divorced/separated 0.8 100 109 0.9 39 32 Widowed 2.0 258 268 0.5 23 17 Residence Urban 14.4 1,819 3,701 17.4 717 1,351 Rural 85.6 10,855 8,973 82.6 3,404 2,770 Ecological zone Mountain 6.4 805 2,033 5.9 245 618 Hill 40.2 5,090 4,974 40.2 1,658 1,582 Terai 53.5 6,779 5,667 53.8 2,218 1,921 Development region Eastern 24.1 3,057 3,019 24.2 996 978 Central 33.4 4,236 3,009 35.1 1,448 1,002 Western 21.0 2,660 2,304 19.4 798 706 Mid-western 11.7 1,478 2,275 12.0 493 781 Far-western 9.8 1,242 2,067 9.3 385 654 Subregion Eastern mountain 1.8 229 737 1.6 66 223 Central mountain 2.0 258 669 1.7 69 177 Western mountain 2.5 319 627 2.7 110 218 Eastern hill 7.5 956 1,043 7.1 293 331 Central hill 12.3 1,563 1,132 15.0 616 423 Western hill 11.9 1,513 1,101 10.7 440 337 Mid-western hill 5.1 649 887 4.6 189 259 Far-western hill 3.2 409 811 2.9 120 232 Eastern terai 14.8 1,873 1,239 15.5 638 424 Central terai 19.1 2,415 1,208 18.5 763 402 Western terai 9.1 1,147 1,203 8.7 358 369 Mid-western terai 5.3 668 1,071 5.9 242 399 Far-western terai 5.3 676 946 5.3 217 327 Continued… Characteristics of Respondents • 43 Table 3.1—Continued Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Education No education 39.8 5,045 4,876 13.8 567 498 Primary 17.4 2,209 2,149 19.7 814 815 Some secondary 24.4 3,088 3,172 34.9 1,437 1,431 SLC and above 18.4 2,331 2,476 31.6 1,303 1,377 Wealth quintile Lowest 16.7 2,120 2,446 14.8 610 711 Second 18.9 2,393 2,296 16.9 695 688 Middle 20.5 2,600 2,336 20.1 830 727 Fourth 21.5 2,722 2,516 22.3 920 861 Highest 22.4 2,839 3,080 25.9 1,066 1,134 Total 15-49 100.0 12,674 12,674 100.0 4,121 4,121 Note: Education categories refer to the highest level of education attended. SLC = School Leaving Certificate 1 Includes one woman and two men who are living together. The distribution of respondents by development region shows that about one-third is from the Central region, nearly one-fourth from the Eastern region, and about one-fifth from the Western region. Twelve percent of the respondents live in the Mid-western region, and 10 percent of women and 9 percent of men are from the Far-western region. The subregional distribution shows the highest concentration of women and men in the Central terai (19 percent), followed by the Eastern terai (15 percent of women and 16 percent of men), Central hill (12 percent of women and 15 percent of men), and Western hill (12 percent of women and 11 percent of men) subregions. The proportion of women and men is less than 10 percent in each of the remaining subregions. Education is one of the most influential factors affecting an individual’s knowledge, attitudes, and behaviors in various facets of life. Educational attainment in Nepal is very low among women, who are much more disadvantaged than men. Forty percent of women do not have any formal education, as compared with 14 percent of men. Seventeen percent of women and 20 percent of men have a primary-level education. Nearly one-fourth (24 percent) of women and more than one-third (35 percent) of men have some secondary education, and nearly one-fifth (18 percent) of women and one-third (32 percent) of men have completed their School Leaving Certificate (SLC) or gone on to higher levels of education. 3.1.1 Spousal Separation The proportion of women whose spouses have been living away from home for a considerable period of time may have reproductive, demographic, and health implications. The 2011 NDHS collected detailed information on husbands living away from home. Table 3.2 presents the percent distribution of currently married women age 15-49 whose husbands live away from home, according to selected background characteristics. Thirty-two percent of women reported that their husbands live away from home, 52 percent reported a spousal separation of less than seven months’ duration, and 35 percent reported a separation lasting one or more years. Women under age 34 are more likely to have husbands living away from home than older women. More rural women than urban women reported that their husbands live away from home (34 percent and 22 percent, respectively). Spousal separation is most prevalent in the Western development region (40 percent). About one in two women in the Eastern region reported that their husband has been away for more than 12 months. This is especially true for women in the Eastern mountain region (57 percent). Women with no education are least likely to be separated from their husband for any length of time. Women with a primary education (37 percent) or some secondary education (36 percent) more often reported that their husbands live away from home. Women in the highest wealth quintile are least likely to report spousal separation. 44 • Characteristics of Respondents Table 3.2 Spousal separation Percentage of currently married women age 15-49 whose husbands live away from home, and among those whose husbands live away, percent distribution by duration away from home, according to background characteristics, Nepal 2011 Background characteristic Husband is away Number of women Duration away from home Number of women <7 months 7-11 months 12+ months Don’t know Total Age 15-19 37.3 792 63.7 18.3 17.8 0.2 100.0 295 20-24 42.7 1,761 54.2 15.3 30.5 0.0 100.0 752 25-29 38.3 1,914 50.2 11.9 37.7 0.2 100.0 732 30-34 32.6 1,659 50.6 12.3 37.1 0.0 100.0 540 35-39 29.1 1,461 45.8 10.2 44.0 0.0 100.0 425 40-44 20.0 1,190 44.3 10.0 45.7 0.0 100.0 238 45-49 11.4 832 57.5 4.9 37.6 0.0 100.0 95 Number of living children 0 35.8 1,075 64.4 12.2 23.1 0.2 100.0 385 1-2 37.2 4,442 49.3 13.5 37.1 0.1 100.0 1,652 3-4 28.3 3,091 49.3 13.0 37.7 0.0 100.0 874 5+ 16.6 999 58.7 6.2 35.1 0.0 100.0 166 Residence Urban 21.8 1,261 50.8 10.5 38.4 0.3 100.0 275 Rural 33.6 8,346 51.8 13.0 35.1 0.1 100.0 2,802 Ecological zone Mountain 27.2 630 59.4 9.8 30.8 0.0 100.0 172 Hill 32.2 3,784 53.1 11.9 34.9 0.2 100.0 1,217 Terai 32.5 5,193 50.0 13.8 36.2 0.0 100.0 1,689 Development region Eastern 32.5 2,293 37.5 12.1 50.3 0.0 100.0 745 Central 26.9 3,210 53.4 11.4 35.0 0.2 100.0 865 Western 39.7 2,031 50.2 14.7 34.9 0.1 100.0 807 Mid-western 29.7 1,149 68.4 11.5 20.1 0.0 100.0 341 Far-western 34.6 925 66.0 14.6 19.4 0.0 100.0 320 Subregion Eastern mountain 30.3 169 31.3 11.5 57.2 0.0 100.0 51 Central mountain 33.7 190 70.8 5.2 24.0 0.0 100.0 64 Western mountain 20.8 271 72.1 13.5 14.4 0.0 100.0 56 Eastern hill 30.9 702 38.1 13.2 48.7 0.0 100.0 217 Central hill 19.1 1,103 50.9 5.6 42.7 0.8 100.0 211 Western hill 41.8 1,164 52.9 13.6 33.3 0.1 100.0 487 Mid-western hill 36.6 510 66.7 12.7 20.6 0.0 100.0 187 Far-western hill 38.1 305 63.3 11.8 24.9 0.0 100.0 116 Eastern terai 33.5 1,421 38.0 11.7 50.3 0.0 100.0 477 Central terai 30.8 1,918 52.5 14.1 33.4 0.0 100.0 590 Western terai 36.9 867 46.1 16.4 37.4 0.1 100.0 320 Mid-western terai 27.8 499 70.0 10.2 19.8 0.0 100.0 139 Far-western terai 33.4 488 66.6 16.6 16.9 0.0 100.0 163 Education No education 28.3 4,580 51.1 13.0 36.0 0.0 100.0 1,297 Primary 37.2 1,844 51.2 11.2 37.6 0.0 100.0 686 Some secondary 36.0 1,833 48.1 14.7 37.2 0.0 100.0 661 SLC and above 32.1 1,350 59.9 11.9 27.7 0.6 100.0 433 Wealth quintile Lowest 31.0 1,664 52.7 13.8 33.5 0.0 100.0 516 Second 35.8 1,846 58.8 12.4 28.9 0.0 100.0 660 Middle 35.0 2,022 52.1 13.4 34.5 0.0 100.0 707 Fourth 34.4 2,052 46.4 12.9 40.8 0.0 100.0 706 Highest 24.1 2,023 48.3 11.3 39.9 0.5 100.0 488 Total 15-49 32.0 9,608 51.7 12.8 35.4 0.1 100.0 3,077 SLC = School Leaving Certificate 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Tables 3.3.1 and 3.3.2 show the distribution of respondents by educational attainment, according to background characteristics. Table 3.3.1 shows that two-fifths (40 percent) of women age 15-49 have never been to school, 12 percent have only some primary education, 6 percent have completed primary school, 24 percent have only some secondary education, 11 percent have completed secondary school, and 8 percent have a secondary education or higher. Older women and those who reside in rural areas are most likely to have no education. The urban-rural difference in level of education is pronounced for those who have completed secondary school or have more than a secondary education. For example, women in urban areas are more than twice as likely as those in rural areas to have a secondary education or more than a secondary education (38 percent and 15 percent, respectively). Characteristics of Respondents • 45 Table 3.3.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Nepal 2011 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 17.1 11.0 6.6 38.2 16.7 10.3 100.0 7.0 5,050 15-19 11.9 10.2 6.4 49.7 17.1 4.7 100.0 7.2 2,753 20-24 23.4 12.0 6.8 24.5 16.3 17.1 100.0 6.4 2,297 25-29 36.3 15.3 6.0 21.7 10.3 10.5 100.0 3.7 2,101 30-34 46.9 14.2 5.3 19.1 8.6 6.0 100.0 1.2 1,734 35-39 60.3 10.6 5.0 14.2 4.5 5.3 100.0 0.0 1,557 40-44 70.5 11.3 3.5 7.8 3.7 3.3 100.0 0.0 1,285 45-49 80.5 8.4 2.5 5.3 1.6 1.6 100.0 0.0 947 Residence Urban 22.0 9.8 4.5 25.6 17.9 20.1 100.0 7.8 1,819 Rural 42.8 12.3 5.7 24.1 9.4 5.7 100.0 2.6 10,855 Ecological zone Mountain 52.0 12.7 4.6 21.0 6.7 3.0 100.0 0.0 805 Hill 35.5 12.3 6.2 25.6 10.3 10.0 100.0 4.4 5,090 Terai 41.6 11.6 5.1 23.8 11.3 6.7 100.0 3.2 6,779 Development region Eastern 31.0 14.2 4.5 29.2 14.6 6.5 100.0 5.1 3,057 Central 45.0 11.5 4.5 19.2 9.1 10.7 100.0 1.9 4,236 Western 32.3 11.4 8.1 29.0 11.4 7.7 100.0 4.8 2,660 Mid-western 47.8 11.8 4.8 22.6 8.0 5.0 100.0 1.0 1,478 Far-western 50.3 9.2 6.4 22.1 7.4 4.6 100.0 0.0 1,242 Subregion Eastern mountain 32.6 16.1 6.4 30.8 10.2 4.0 100.0 4.2 229 Central mountain 51.9 12.7 4.8 20.7 6.8 3.1 100.0 0.0 258 Western mountain 66.0 10.4 3.0 14.2 4.1 2.2 100.0 0.0 319 Eastern hill 32.2 15.2 5.9 32.2 9.8 4.6 100.0 4.4 956 Central hill 30.7 11.3 4.3 20.9 12.2 20.5 100.0 6.2 1,563 Western hill 32.0 12.6 8.8 29.3 11.2 6.1 100.0 4.6 1,513 Mid-western hill 45.4 11.9 5.7 22.6 8.1 6.4 100.0 2.1 649 Far-western hill 58.5 9.2 5.6 19.2 4.5 3.1 100.0 0.0 409 Eastern terai 30.3 13.4 3.6 27.4 17.6 7.7 100.0 5.6 1,873 Central terai 53.5 11.5 4.6 17.9 7.2 5.2 100.0 0.0 2,415 Western terai 32.7 9.8 7.2 28.6 11.7 9.8 100.0 5.0 1,147 Mid-western terai 45.1 11.7 4.8 25.3 8.8 4.3 100.0 2.4 668 Far-western terai 42.2 9.3 7.3 25.2 10.0 5.9 100.0 3.6 676 Wealth quintile Lowest 63.9 14.3 5.4 14.5 1.3 0.7 100.0 0.0 2,120 Second 54.6 12.3 6.5 21.7 4.2 0.8 100.0 0.0 2,393 Middle 44.8 14.0 5.9 24.9 7.6 2.8 100.0 1.7 2,600 Fourth 30.7 12.7 5.3 28.8 15.5 7.0 100.0 5.3 2,722 Highest 13.6 7.3 4.5 29.3 21.0 24.3 100.0 8.6 2,839 Total 39.8 11.9 5.5 24.4 10.6 7.8 100.0 3.5 12,674 1 Completed grade 5 at the primary level 2 Completed grade 10 at the secondary level Respondents of the hill zone are more likely than those in the mountain and terai zones to have more than a secondary-level education. One in two women in the Far-western region has no education, compared with one in three women in the Eastern region. Among the subregions, two-thirds of women living in the Western mountain subregion have no education, compared with less than one in three women living in the Eastern terai. Respondents’ educational attainment is directly related to their economic status. An examination of education by wealth quintile indicates that women in the highest wealth quintile are most likely to have a secondary education or higher. For example, 45 percent of women in the highest wealth quintile have completed secondary school or have more than a secondary education, compared with just 2 percent of women in the lowest wealth quintile. Nationally, women have completed a median of 3.5 years of school. Urban women have completed a median of 7.8 years, as compared with 2.6 years among rural women. Median number of years of schooling completed is highest among women from the Eastern region (5.1) and lowest among women in the Far-western region (0.0). There is a notable difference in median number of years completed by wealth quintile (8.6 in the highest quintile versus 0.0 in the lower two quintiles). 46 • Characteristics of Respondents A similar educational attainment pattern is found among men (Table 3.3.2). However, men are more educated than women in all categories. Nationally, 14 percent of men age 15-49 have no education, and the same proportion have only some primary education. Thirty-five percent of men have only some secondary schooling, and 32 percent have a secondary education or higher. Men age 45-49 are more likely to have no education (31 percent) than men age 15-24 (4 percent). Men from urban areas have higher levels of educational attainment than their rural counterparts. Six percent of urban men have no formal education, compared with 15 percent of their rural counterparts. More than half (52 percent) of men in urban areas have a secondary education or higher, compared with slightly more than one-fourth (28 percent) in rural areas. Overall, men age 15-49 have completed a median of 7.4 years of schooling. Median years of schooling completed increases with wealth, from 3.3 years among men in the lowest quintile to 9.5 years among men in the highest quintile. Table 3.3.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Nepal 2011 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 4.3 7.5 4.9 44.3 22.5 16.5 100.0 8.3 1,663 15-19 4.0 6.7 4.8 55.3 22.6 6.6 100.0 8.0 978 20-24 4.8 8.6 5.2 28.6 22.4 30.5 100.0 9.1 685 25-29 13.4 16.1 6.6 34.6 14.3 15.0 100.0 6.9 581 30-34 21.1 15.1 7.1 29.9 11.1 15.8 100.0 6.5 499 35-39 18.0 15.8 6.7 29.8 13.2 16.5 100.0 6.8 542 40-44 21.3 22.5 7.0 26.1 10.0 13.2 100.0 4.9 438 45-49 30.5 23.1 5.5 18.7 10.8 11.5 100.0 3.3 399 Residence Urban 6.0 10.3 4.6 27.6 22.1 29.5 100.0 9.1 717 Rural 15.4 14.6 6.2 36.4 15.1 12.4 100.0 7.0 3,404 Ecological zone Mountain 14.8 18.6 9.0 35.8 13.0 8.7 100.0 6.5 245 Hill 9.8 15.0 5.8 35.0 16.5 18.0 100.0 7.8 1,658 Terai 16.6 12.4 5.7 34.7 16.5 14.1 100.0 7.1 2,218 Development region Eastern 8.6 13.4 5.8 39.2 19.8 13.2 100.0 7.8 996 Central 17.4 13.6 5.9 29.7 14.5 18.9 100.0 6.9 1,448 Western 10.6 14.1 5.9 36.9 17.3 15.3 100.0 7.8 798 Mid-western 19.4 14.6 7.2 33.1 13.9 11.8 100.0 6.8 493 Far-western 12.8 14.1 4.8 41.2 14.8 12.2 100.0 7.2 385 Subregion Eastern mountain 8.6 15.8 7.7 47.7 12.3 8.0 100.0 6.8 66 Central mountain 15.0 26.8 8.6 31.8 11.9 5.9 100.0 4.9 69 Western mountain 18.3 15.1 10.1 31.2 14.2 11.0 100.0 6.6 110 Eastern hill 8.2 14.5 7.5 45.2 16.4 8.2 100.0 7.6 293 Central hill 9.5 12.9 4.7 27.7 17.5 27.7 100.0 8.4 616 Western hill 8.4 17.6 5.6 36.5 17.2 14.8 100.0 7.7 440 Mid-western hill 17.8 15.1 7.4 31.9 13.9 13.8 100.0 7.1 189 Far-western hill 7.3 17.8 5.3 46.5 13.3 9.7 100.0 7.1 120 Eastern terai 8.8 12.7 4.8 35.6 22.1 16.0 100.0 8.0 638 Central terai 24.0 12.9 6.6 31.0 12.4 13.0 100.0 5.8 763 Western terai 13.2 9.9 6.3 37.4 17.4 15.8 100.0 8.1 358 Mid-western terai 20.7 14.8 5.8 33.9 14.1 10.7 100.0 6.6 242 Far-western terai 15.0 11.1 3.9 41.2 15.4 13.4 100.0 7.3 217 Wealth quintile Lowest 32.1 23.8 7.4 30.0 4.7 2.0 100.0 3.3 610 Second 21.4 19.2 8.9 37.2 8.5 4.9 100.0 5.1 695 Middle 17.6 15.9 7.4 40.1 12.4 6.5 100.0 6.3 830 Fourth 6.1 11.4 5.1 39.3 23.1 15.0 100.0 8.0 920 Highest 1.9 5.1 2.8 28.2 25.1 36.9 100.0 9.5 1,066 Total 15-49 13.8 13.8 5.9 34.9 16.3 15.3 100.0 7.4 4,121 1 Completed grade 5 at the primary level 2 Completed grade 10 at the secondary level The percentage of women who completed some secondary education or had a secondary education or higher increased by 48 percent from 29 percent in 2006 to 43 percent in 2011. A smaller increase (26 percent) was seen among men, from 53 percent in 2006 to 67 percent in 2011. Characteristics of Respondents • 47 3.3 LITERACY The ability to read and write empowers women and men. Literacy statistics are important for policymakers and program managers to gauge the health and nutrition status and overall well-being of the population. In the 2011 NDHS, literacy was determined by respondents’ ability to read all or part of a simple sentence. During data collection, interviewers carried a set of cards on which simple sentences were printed in three of the country’s major languages (Nepali, Maithili, and Bhojpuri) for testing a respondent’s reading ability. Those who had never been to school and those who had only a primary education were asked to read the cards in the language they were most familiar with. Those with a secondary education or higher were assumed to be literate. Table 3.4.1 indicates that two-thirds of women in Nepal (67 percent) are literate, which represents an increase from the 2006 figure of 55 percent. The level of literacy is much higher among women age 15-19 than among women in other age groups. This suggests that younger women have had more opportunity for learning than older women. Literacy varies by place of residence. Eighty-three percent of women residing in urban areas are literate, compared with 64 percent of rural women. Literacy is higher among women living in the hill zone (73 percent) than women living in the mountain and terai zones (58 percent and 63 percent, respectively). Table 3.4.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Nepal 2011 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Age 15-24 65.3 12.7 4.7 17.3 0.0 100.0 82.7 5,050 15-19 71.5 10.8 3.6 14.1 0.0 100.0 85.9 2,753 20-24 57.8 15.0 6.0 21.2 0.0 100.0 78.8 2,297 25-29 42.4 18.5 8.3 30.6 0.1 100.0 69.3 2,101 30-34 33.6 19.9 9.9 36.6 0.0 100.0 63.4 1,734 35-39 24.1 18.4 11.1 46.4 0.0 100.0 53.6 1,557 40-44 14.8 16.4 11.1 57.7 0.0 100.0 42.2 1,285 45-49 8.6 14.5 13.0 63.8 0.0 100.0 36.2 947 Residence Urban 63.7 12.5 6.6 17.1 0.2 100.0 82.8 1,819 Rural 39.2 16.4 8.3 36.0 0.0 100.0 64.0 10,855 Ecological zone Mountain 30.7 17.7 9.5 42.1 0.0 100.0 57.9 805 Hill 46.0 19.1 8.1 26.8 0.1 100.0 73.2 5,090 Terai 41.8 13.2 7.8 37.2 0.0 100.0 62.8 6,779 Development region Eastern 50.3 15.0 6.6 28.1 0.0 100.0 71.9 3,057 Central 39.0 13.2 7.4 40.3 0.1 100.0 59.6 4,236 Western 48.1 20.0 8.9 23.0 0.0 100.0 77.0 2,660 Mid-western 35.6 18.5 8.1 37.8 0.0 100.0 62.2 1,478 Far-western 34.2 14.9 12.1 38.8 0.1 100.0 61.2 1,242 Subregion Eastern mountain 45.0 22.6 8.1 24.3 0.0 100.0 75.7 229 Central mountain 30.6 22.7 8.6 38.2 0.0 100.0 61.8 258 Western mountain 20.6 10.0 11.3 58.1 0.0 100.0 41.9 319 Eastern hill 46.7 20.9 6.2 26.3 0.0 100.0 73.7 956 Central hill 53.7 15.3 7.1 23.8 0.1 100.0 76.1 1,563 Western hill 46.6 23.6 8.8 21.1 0.0 100.0 78.9 1,513 Mid-western hill 37.1 19.3 7.5 36.2 0.0 100.0 63.8 649 Far-western hill 26.7 12.5 15.3 45.3 0.2 100.0 54.5 409 Eastern terai 52.8 11.0 6.7 29.5 0.0 100.0 70.5 1,873 Central terai 30.3 10.9 7.5 51.3 0.0 100.0 48.7 2,415 Western terai 50.2 15.2 9.0 25.6 0.0 100.0 74.4 1,147 Mid-western terai 38.5 19.7 8.1 33.7 0.0 100.0 66.3 668 Far-western terai 41.1 17.5 10.2 31.2 0.0 100.0 68.8 676 Wealth quintile Lowest 16.4 17.6 10.1 55.8 0.0 100.0 44.1 2,120 Second 26.7 18.4 7.8 47.1 0.0 100.0 52.9 2,393 Middle 35.3 16.5 9.1 39.1 0.0 100.0 60.9 2,600 Fourth 51.4 16.6 8.5 23.5 0.0 100.0 76.5 2,722 Highest 74.6 11.1 5.3 8.9 0.1 100.0 91.0 2,839 Total 42.8 15.8 8.1 33.3 0.0 100.0 66.7 12,674 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 48 • Characteristics of Respondents Regional and subregional differences are notable, with literacy being highest among women in the Western region (77 percent) and lowest in the Central region (60 percent). The percentage of literate women is highest in the Western hill subregion (79 percent) and lowest in the Western mountain subregion (42 percent). There is also a significant difference in literacy by household wealth, with the literacy rate ranging from 44 percent among women in the lowest wealth quintile to 91 percent among women in the highest quintile. This reaffirms the positive association between economic status and literacy. Men are more likely to be literate than women (Table 3.4.2). Eighty-seven percent of Nepalese men age 15-49 are literate, an increase from 81 percent in 2006. The pattern of male literacy is similar to that of females. However, there are marked differences between men and women across age groups. Seventy-seven percent of men age 45-49 are literate, compared with 36 percent of women in the same age group. The gap in urban-rural literacy among men is smaller than that among women, suggesting that men in rural areas are better able to access learning than women. Men in the Eastern, Western, and Far-western development regions are more likely to be literate than those in the other development regions. Table 3.4.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Nepal 2011 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all Blind/ visually impaired Age 15-24 83.3 8.1 3.2 5.4 0.0 100.0 94.6 1,663 15-19 84.5 6.9 2.9 5.6 0.0 100.0 94.4 978 20-24 81.5 9.8 3.6 5.1 0.0 100.0 94.9 685 25-29 63.9 16.7 7.1 12.2 0.1 100.0 87.7 581 30-34 56.7 17.4 4.4 21.5 0.0 100.0 78.5 499 35-39 59.5 14.8 8.5 17.2 0.0 100.0 82.8 542 40-44 49.2 25.3 6.9 18.6 0.0 100.0 81.4 438 45-49 40.9 27.7 7.8 23.1 0.5 100.0 76.5 399 Residence Urban 79.2 11.1 4.9 4.8 0.1 100.0 95.1 717 Rural 63.8 15.9 5.6 14.7 0.1 100.0 85.3 3,404 Ecological zone Mountain 57.6 20.7 8.2 13.5 0.0 100.0 86.5 245 Hill 69.4 17.3 6.0 7.3 0.0 100.0 92.7 1,658 Terai 65.3 12.8 4.7 17.1 0.1 100.0 82.8 2,218 Development region Eastern 72.1 13.4 5.3 9.2 0.0 100.0 90.8 996 Central 63.1 14.9 4.5 17.4 0.0 100.0 82.6 1,448 Western 69.4 15.4 6.1 9.1 0.0 100.0 90.9 798 Mid-western 58.8 18.0 7.3 15.7 0.2 100.0 84.1 493 Far-western 68.2 15.4 5.4 10.7 0.3 100.0 89.0 385 Subregion Eastern mountain 67.9 20.8 5.1 6.2 0.0 100.0 93.8 66 Central mountain 49.5 28.0 10.4 12.0 0.0 100.0 88.0 69 Western mountain 56.4 16.1 8.7 18.8 0.0 100.0 81.2 110 Eastern hill 69.8 17.9 5.9 6.4 0.0 100.0 93.6 293 Central hill 72.9 15.7 4.3 7.0 0.0 100.0 93.0 616 Western hill 68.4 18.5 6.9 6.1 0.0 100.0 93.9 440 Mid-western hill 59.7 18.5 8.7 13.1 0.0 100.0 86.9 189 Far-western hill 69.6 16.9 6.5 7.0 0.0 100.0 93.0 120 Eastern terai 73.7 10.5 5.0 10.8 0.0 100.0 89.2 638 Central terai 56.5 13.1 4.2 26.2 0.1 100.0 73.7 763 Western terai 70.7 11.4 5.2 12.7 0.0 100.0 87.3 358 Mid-western terai 58.8 17.9 6.4 16.6 0.3 100.0 83.0 242 Far-western terai 70.0 14.7 3.4 11.4 0.6 100.0 88.0 217 Wealth quintile Lowest 36.8 25.7 9.7 27.8 0.0 100.0 72.2 610 Second 50.5 22.1 5.4 21.8 0.1 100.0 78.1 695 Middle 59.0 17.7 7.1 16.0 0.2 100.0 83.8 830 Fourth 77.4 10.9 4.3 7.4 0.0 100.0 92.6 920 Highest 90.3 5.8 2.7 1.2 0.0 100.0 98.8 1,066 Total 15-49 66.5 15.0 5.4 13.0 0.1 100.0 87.0 4,121 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Respondents • 49 3.4 ACCESS TO MASS MEDIA In the 2011 NDHS, exposure to media was assessed by asking respondents whether they listened to a radio, watched television, or read newspapers or magazines at least once a week. This information is useful for program managers and planners in determining which media may be more effective for disseminating health- related information to targeted audiences. Media exposure in Nepal is higher among men than women. Seven percent of women and 20 percent of men are exposed to all three media at least once a week (Table 3.5.1 and Table 3.5.2). Forty-four percent of women and 59 percent of men listen to the radio at least once a week, and 47 percent of women and 55 percent of men watch television at least once a week. Table 3.5.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Nepal 2011 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 17.6 52.2 55.0 10.8 24.4 2,753 20-24 15.7 50.7 46.2 8.8 30.1 2,297 25-29 12.7 49.3 42.3 7.6 32.7 2,101 30-34 12.0 48.5 40.0 6.8 33.9 1,734 35-39 9.6 41.4 40.8 5.5 38.7 1,557 40-44 6.8 40.4 36.7 3.4 40.9 1,285 45-49 4.1 38.7 35.4 2.6 43.5 947 Residence Urban 35.1 79.7 46.5 20.4 12.8 1,819 Rural 8.8 42.0 43.8 5.2 36.3 10,855 Ecological zone Mountain 5.6 26.9 56.9 3.5 34.8 805 Hill 15.1 43.4 51.6 8.1 29.2 5,090 Terai 11.6 52.9 37.1 7.3 35.6 6,779 Development region Eastern 16.5 53.7 52.7 10.7 24.8 3,057 Central 16.2 50.2 38.4 9.0 35.1 4,236 Western 8.8 50.5 43.8 4.9 31.3 2,660 Mid-western 6.3 32.5 42.6 3.3 41.7 1,478 Far-western 6.4 33.6 45.9 3.6 39.0 1,242 Subregion Eastern mountain 5.6 26.7 65.2 2.5 28.5 229 Central mountain 10.1 40.3 64.0 7.1 26.4 258 Western mountain 1.9 16.3 45.3 1.3 46.3 319 Eastern hill 8.2 33.0 67.9 5.1 24.3 956 Central hill 33.9 64.5 48.1 17.1 17.4 1,563 Western hill 7.7 42.9 51.4 4.6 31.6 1,513 Mid-western hill 6.0 24.9 40.5 3.2 46.8 649 Far-western hill 1.4 18.4 45.7 1.0 49.1 409 Eastern terai 22.0 67.6 43.4 14.5 24.6 1,873 Central terai 5.4 41.9 29.4 4.0 47.5 2,415 Western terai 10.3 60.7 33.7 5.2 30.9 1,147 Mid-western terai 8.1 43.7 47.0 4.2 32.9 668 Far-western terai 10.1 46.8 43.2 5.4 33.8 676 Education No education 0.2 25.0 30.1 0.1 55.0 5,045 Primary 2.9 44.4 41.1 1.5 33.1 2,209 Some secondary 15.9 60.9 56.1 9.1 17.2 3,088 SLC and above 44.2 80.9 61.8 26.3 6.0 2,331 Wealth quintile Lowest 0.9 5.9 35.8 0.2 61.2 2,120 Second 2.2 17.4 43.6 1.2 49.9 2,393 Middle 3.8 41.6 45.4 2.4 36.2 2,600 Fourth 12.4 68.2 47.6 7.8 21.2 2,722 Highest 38.3 89.2 46.7 21.9 6.0 2,839 Total 12.6 47.4 44.2 7.4 33.0 12,674 SLC = School Leaving Certificate Young women and men under age 25 are more likely to be exposed to the mass media than older women and men, presumably in part because of their higher level of education. There is a wide gap in exposure to mass media by place of residence. For example, the proportion of newspaper readers is significantly higher among urban women (35 percent) and men (60 percent) than among their rural counterparts (9 percent and 29 50 • Characteristics of Respondents percent, respectively). Not surprisingly, media exposure is highly related to the educational level as well as economic status of respondents. While 26 percent of women and 41 percent of men with an SLC and higher level of education access all three media at least once a week, less than 1 percent of women and men with no education do so. Likewise, 22 percent of women and 39 percent of men from the highest wealth quintile access all three media at least once a week, while less than 1 percent of women and men from the lowest quintile do so. The reason for the lower level of exposure to media among poor respondents may be that they are less likely to own a radio or television and, therefore, less likely to be consistently exposed to these media sources. Women and men residing in the Eastern region are more likely to be exposed to all three media on a weekly basis than those in the other regions. The proportion of newspaper readers is highest among women in the Central hill subregion (34 percent) and men in the Central hill and Eastern terai subregions (54 percent each). The proportion of television viewers is highest in the Eastern terai subregion for both women (68 percent) and men (78 percent). Table 3.5.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Nepal 2011 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of men Age 15-19 35.2 61.3 65.3 23.2 14.0 978 20-24 46.0 59.0 66.4 25.4 10.2 685 25-29 33.0 55.3 55.2 18.2 19.7 581 30-34 32.7 53.7 50.5 18.7 24.5 499 35-39 33.4 51.3 52.3 18.2 25.6 542 40-44 30.4 47.7 56.5 18.2 26.1 438 45-49 20.5 43.3 53.5 12.6 27.3 399 Residence Urban 60.3 77.6 55.8 33.3 8.4 717 Rural 28.7 49.8 59.0 17.3 21.9 3,404 Ecological zone Mountain 12.4 26.2 70.9 6.6 22.8 245 Hill 35.0 50.7 64.3 19.3 16.8 1,658 Terai 36.0 60.7 52.7 22.2 21.2 2,218 Development region Eastern 39.7 62.8 63.4 26.7 14.3 996 Central 37.6 58.4 56.4 21.2 19.5 1,448 Western 34.4 60.1 56.3 19.5 18.3 798 Mid-western 23.7 33.6 57.5 12.4 27.8 493 Far-western 20.2 35.1 59.0 10.1 25.0 385 Subregion Eastern mountain 13.0 29.4 73.9 5.7 21.0 66 Central mountain 17.1 38.7 73.8 12.0 18.6 69 Western mountain 9.2 16.5 67.4 3.7 26.6 110 Eastern hill 15.6 38.2 71.3 10.4 20.0 293 Central hill 53.9 65.6 59.4 28.5 11.5 616 Western hill 31.5 55.4 65.1 18.3 17.3 440 Mid-western hill 26.7 28.9 66.1 13.2 21.8 189 Far-western hill 10.6 22.4 66.7 6.6 26.6 120 Eastern terai 53.6 77.5 58.7 36.4 11.0 638 Central terai 26.2 54.5 52.4 16.1 26.0 763 Western terai 37.9 65.8 45.5 20.9 19.6 358 Mid-western terai 25.8 42.6 48.0 14.5 32.1 242 Far-western terai 27.2 45.2 53.1 12.9 24.6 217 Education No education 0.8 19.9 36.4 0.2 52.1 567 Primary 8.8 38.0 52.1 4.2 30.4 814 Some secondary 31.3 57.7 61.7 18.2 14.9 1,437 SLC and above 67.8 76.8 68.5 40.8 3.6 1,303 Wealth quintile Lowest 3.4 6.2 50.3 0.6 47.3 610 Second 10.3 23.3 60.8 4.8 33.0 695 Middle 24.0 51.6 61.6 14.2 19.7 830 Fourth 44.8 74.4 61.0 27.9 10.0 920 Highest 66.2 88.2 57.0 39.1 2.9 1,066 Total 15-49 34.2 54.7 58.5 20.1 19.5 4,121 SLC = School Leaving Certificate Characteristics of Respondents • 51 3.4.1 Access to Specific Radio and Television Programs Dissemination of population and health information through the electronic media, and especially through the radio, is not new in Nepal. The National Health Education, Information and Communication Center, USAID, UNICEF, and other organizations have launched several different radio and television programs to raise awareness, especially related to health issues. The 2011 NDHS collected information on exposure to several specific television and radio programs: Jana swasthya radio karyakram, Janasankhaya chetanaka swore haru radio karyakram, Hamro swastha radio karyakram, Ama radio and Ama TV karyakram, Hamro swastha TV karyakram, Jeevan chakra TV karyakram, Thorai bhaya pugi sari TV karyakram, Sathi sanga manka kura, and Jeevan Jyoti radio Karyakram. Tables 3.6.1 and 3.6.2 show the percentages of men and women who have heard or seen such programs in the past few months preceding the survey. Table 3.6.1 Exposure to specific health programs on radio and television: Women Percentage of women age 15-49 who have heard or seen specific health programs on the radio and television, according to background characteristics, Nepal 2011 Background characteristic Jana swasthya radio karyakram Janasankhya chetanaka swore haru radio karyakram Hamro swastha radio karyakram Ama radio karyakram Sathi sanga manka kura radio karyakram Jeevan jyoti radio karyakram Hamro swastha TV karyakram Jeevan chakra TV karyakram Thorai bhaye pugi sari TV karyakram Ama TV karyakram Number of women Age 15-19 18.4 15.0 15.8 9.7 49.7 4.4 13.4 33.1 29.1 13.4 2,753 20-24 19.2 15.6 17.3 8.5 42.6 4.4 13.9 30.5 29.8 13.4 2,297 25-29 16.9 13.0 12.5 7.7 33.0 3.4 13.9 26.6 27.0 12.7 2,101 30-34 16.5 11.5 14.3 8.3 25.5 3.3 13.7 27.5 27.7 14.1 1,734 35-39 15.1 10.4 13.2 8.5 24.1 4.6 11.9 23.1 25.1 10.9 1,557 40-44 13.7 9.4 13.9 7.6 19.7 3.2 11.0 20.5 22.7 12.3 1,285 45-49 14.4 10.0 10.9 7.3 16.6 2.7 9.0 22.2 22.6 11.2 947 Residence Urban 18.5 14.7 13.6 6.7 34.6 4.8 20.0 36.1 39.0 20.6 1,819 Rural 16.6 12.4 14.6 8.7 33.5 3.7 11.7 26.0 25.1 11.5 10,855 Ecological zone Mountain 24.4 16.4 24.9 10.3 37.9 6.1 9.7 14.7 10.8 7.7 805 Hill 18.5 14.0 16.5 10.1 38.9 3.9 11.7 22.7 21.9 10.5 5,090 Terai 14.7 11.4 11.6 6.9 29.3 3.5 14.1 32.6 32.9 15.1 6,779 Development region Eastern 18.0 14.6 16.3 7.6 41.9 5.1 16.6 33.1 34.0 15.6 3,057 Central 12.9 10.4 10.8 5.1 25.7 3.1 12.5 26.9 27.8 12.2 4,236 Western 17.9 13.0 14.3 11.4 37.1 3.2 12.1 30.1 27.1 14.9 2,660 Mid-western 18.2 12.8 15.1 12.8 33.6 4.1 8.5 17.8 16.0 7.3 1,478 Far-western 23.4 15.8 21.8 10.2 33.5 4.4 11.6 21.0 20.3 10.0 1,242 Subregion Eastern mountain 32.0 19.5 29.5 9.4 55.3 6.8 10.3 12.2 11.1 6.8 229 Central mountain 20.8 19.0 20.7 9.5 39.7 7.2 12.9 21.2 16.9 11.8 258 Western mountain 21.9 12.1 25.0 11.5 23.9 4.8 6.7 11.3 5.7 4.9 319 Eastern hill 15.2 12.0 17.9 7.2 48.6 3.4 10.8 19.2 18.4 6.7 956 Central hill 19.0 15.7 14.3 6.8 35.9 4.8 17.6 34.5 36.5 18.2 1,563 Western hill 18.6 13.4 15.9 13.0 40.2 3.1 9.7 20.5 17.7 9.1 1,513 Mid-western hill 20.7 15.0 18.0 17.0 37.3 4.6 7.5 14.7 12.2 5.4 649 Far-western hill 20.4 13.1 22.1 8.3 25.3 3.8 5.1 6.6 4.6 3.8 409 Eastern terai 17.8 15.3 13.9 7.5 36.8 5.8 20.3 42.8 44.8 21.2 1,873 Central terai 8.2 6.1 7.4 3.5 17.7 1.6 9.2 22.7 23.3 8.5 2,415 Western terai 17.1 12.6 12.3 9.3 32.9 3.3 15.3 42.9 39.5 22.5 1,147 Mid-western terai 17.0 11.1 12.6 9.2 34.1 3.3 10.4 21.9 21.5 9.5 668 Far-western terai 23.4 18.0 18.2 11.0 39.1 4.7 16.1 32.6 33.8 15.1 676 Education No education 9.2 5.9 8.0 4.6 14.0 2.0 4.7 11.3 11.7 5.4 5,045 Primary 14.0 10.6 13.7 7.7 30.9 3.5 10.1 23.6 23.6 9.9 2,209 Some secondary 22.3 18.0 19.0 12.1 50.5 5.4 17.3 39.3 36.4 17.2 3,088 SLC and above 28.9 22.9 23.0 12.5 56.6 6.2 27.4 50.5 51.1 25.9 2,331 Wealth quintile Lowest 11.7 8.2 11.5 6.7 24.1 2.5 2.1 3.6 3.1 1.3 2,120 Second 15.0 10.5 13.9 7.7 31.4 3.1 4.7 9.8 9.3 3.5 2,393 Middle 15.1 11.3 13.9 8.1 31.7 2.8 8.9 21.4 20.9 9.2 2,600 Fourth 19.2 15.5 16.7 9.6 39.7 5.1 19.3 44.8 41.7 18.5 2,722 Highest 21.5 16.8 15.4 9.3 38.8 5.3 25.2 49.0 51.6 27.0 2,839 Total 15-49 16.9 12.8 14.4 8.4 33.7 3.9 12.9 27.5 27.1 12.8 12,674 SLC = School Leaving Certificate 52 • Characteristics of Respondents Table 3.6.2 Exposure to specific health programs on radio and television: Men Percentage of men age 15-49 who have heard or seen specific health programs on the radio and television, according to background characteristics, Nepal 2011 Background characteristic Jana swasthya radio karyakram Janasankhya chetanaka swore haru radio karyakram Hamro swastha radio karyakram Ama radio karyakram Sathi sanga manka kura radio karyakram Jeevan jyoti radio karyakram Hamro swastha TV karyakram Jeevan chakra TV karyakram Thorai bhaye pugi sari TV karyakram Ama TV karyakram Number of men Age 15-19 28.4 20.9 21.5 14.7 58.5 5.3 17.5 40.5 34.3 21.0 978 20-24 31.5 21.5 26.6 11.6 60.1 8.0 20.6 35.3 38.9 20.1 685 25-29 25.0 15.8 18.4 8.9 44.9 6.7 15.5 26.0 29.9 13.2 581 30-34 27.2 20.9 16.7 11.2 37.5 7.9 19.9 28.5 29.2 15.4 499 35-39 31.5 21.0 19.3 14.2 33.2 8.6 24.7 28.0 33.6 20.6 542 40-44 31.3 20.7 22.4 16.0 30.2 7.3 17.0 20.3 26.3 13.9 438 45-49 26.8 21.3 27.8 13.3 30.6 4.6 19.5 24.2 30.6 18.9 399 Residence Urban 28.7 21.4 21.8 10.5 45.6 7.0 27.4 37.8 46.3 25.3 717 Rural 28.9 20.1 21.7 13.4 45.2 6.8 17.4 29.3 29.6 16.5 3,404 Ecological zone Mountain 36.8 23.0 31.3 18.4 47.6 10.0 11.9 14.5 11.3 7.0 245 Hill 32.3 21.4 24.7 15.5 52.7 6.7 17.5 27.7 31.4 19.7 1,658 Terai 25.4 19.2 18.4 10.3 39.4 6.6 21.2 34.9 35.7 18.1 2,218 Development region Eastern 27.5 22.0 19.5 9.8 49.3 8.8 19.9 35.4 36.9 16.2 996 Central 29.3 20.2 20.3 10.5 44.2 7.3 20.4 32.2 38.4 21.1 1,448 Western 26.9 18.1 20.8 15.9 46.0 4.0 21.2 32.5 31.7 24.5 798 Mid-western 33.2 17.8 28.8 19.6 44.2 7.5 15.5 21.1 17.9 8.9 493 Far-western 29.0 24.2 25.7 14.9 38.9 4.7 12.6 22.1 19.7 9.8 385 Subregion Eastern mountain 23.2 16.7 18.8 7.1 56.0 8.1 5.5 11.8 12.7 8.8 66 Central mountain 31.7 24.1 26.5 10.9 51.1 9.6 15.1 19.0 18.3 10.7 69 Western mountain 48.2 26.1 41.7 29.8 40.4 11.5 13.8 13.3 6.0 3.7 110 Eastern hill 33.4 23.8 21.8 9.4 62.3 11.2 14.0 23.8 29.9 12.7 293 Central hill 30.8 19.8 20.9 9.7 48.1 6.7 20.8 33.5 43.7 23.5 616 Western hill 31.0 23.5 26.6 21.9 56.5 3.6 21.1 31.2 30.3 26.8 440 Mid-western hill 39.8 17.5 38.1 28.8 52.2 8.2 11.3 17.2 12.9 10.5 189 Far-western hill 30.7 21.5 24.0 16.0 40.2 4.5 5.6 10.8 5.0 4.9 120 Eastern terai 25.3 21.7 18.6 10.2 42.6 7.9 24.1 43.2 42.6 18.6 638 Central terai 27.9 20.1 19.3 11.2 40.4 7.6 20.6 32.3 35.9 20.1 763 Western terai 21.8 11.5 13.7 8.6 33.0 4.6 21.4 34.1 33.3 21.6 358 Mid-western terai 25.5 18.4 18.4 10.1 39.2 5.6 18.7 25.7 25.1 9.3 242 Far-western terai 22.4 22.4 22.8 10.6 37.4 3.7 17.0 30.9 30.5 13.5 217 Education No education 16.8 10.4 13.7 8.5 18.9 4.5 3.0 6.6 6.5 2.4 567 Primary 21.6 16.2 18.2 10.3 31.3 5.8 10.1 19.1 20.9 9.3 814 Some secondary 28.4 20.9 23.7 13.1 52.4 8.4 19.0 34.0 33.1 17.5 1,437 SLC and above 39.1 26.6 25.4 16.2 57.6 6.8 31.9 45.0 50.4 30.9 1,303 Wealth quintile Lowest 25.2 16.6 20.4 12.2 33.5 7.1 2.7 4.2 4.1 2.6 610 Second 23.5 15.7 18.2 11.2 45.2 5.7 6.6 15.1 13.5 6.8 695 Middle 31.5 22.8 26.7 14.2 44.1 5.7 16.6 24.8 24.0 12.0 830 Fourth 32.9 23.2 25.4 16.4 52.8 10.1 27.3 48.4 50.3 25.8 920 Highest 28.8 21.0 17.8 10.3 46.5 5.5 31.6 45.6 52.5 32.3 1,066 Total 15-49 28.8 20.3 21.7 12.9 45.3 6.8 19.1 30.8 32.5 18.1 4,121 SLC = School Leaving Certificate About one in three (34 percent) women and 45 percent of men age 15-49 listened to Sathi sanga manka kura, which is the most popular radio program among women and men in Nepal, especially the younger generation. There is minimal urban-rural variation in women and men listening to this program. The next most popular radio program among women and men is Jana swasthya radio karyakram (17 percent and 29 percent, respectively). Among the four TV programs, Thorai bhaye pugi sari and Jeevan chakra are the most popular. Young women and men are more likely to view television programs than older women and men. Overall, urban women are slightly more likely than rural women to access both radio and television programs. Urban women more often listen to Jana swastha radio karyakram (19 percent versus 17 percent) and Janasankhaya chetanaka swore haru radio karyakram (15 percent versus 12 percent). Not surprisingly, respondents’ level of education and economic status are directly associated with their exposure to specific health programs. Respondents who are highly educated and come from the wealthiest households are more likely to have heard or seen these programs than their counterparts in the other education and wealth categories. Characteristics of Respondents • 53 3.4.2 Preferred Media Source for Health-Related Programs In 2011 the NDHS, for the first time, collected information on the media source preferred by women and men for receiving health-related information. This information, important for targeting health-related messages more effectively, is presented in Tables 3.7.1 and 3.7.2. Table 3.7.1 Preferred media source for health-related information: Women Percent distribution of women with preferred media source to receive health-related information, according to background characteristics, Nepal 2011 Background characteristic Radio Nepal FM station Television Newspaper/ magazine Poster Hoarding/ billboard Other Total Number of women Age 15-19 13.6 39.3 40.9 4.2 0.8 0.1 1.0 100.0 2,753 20-24 15.0 36.8 44.1 2.4 0.5 0.3 0.8 100.0 2,297 25-29 14.1 35.0 46.2 2.3 1.0 0.1 1.1 100.0 2,101 30-34 14.6 35.3 46.7 1.5 0.7 0.0 1.2 100.0 1,734 35-39 15.2 34.6 45.7 1.5 1.4 0.0 1.5 100.0 1,557 40-44 14.8 32.2 48.3 0.7 1.5 0.0 2.2 100.0 1,285 45-49 17.8 31.0 46.0 0.3 2.5 0.2 2.1 100.0 947 Residence Urban 13.1 21.1 58.6 5.4 0.4 0.2 1.1 100.0 1,819 Rural 15.0 38.1 42.6 1.7 1.1 0.1 1.3 100.0 10,855 Ecological zone Mountain 18.1 41.9 35.6 1.3 2.1 0.0 1.0 100.0 805 Hill 18.8 35.9 40.2 2.8 1.0 0.1 1.1 100.0 5,090 Terai 11.2 34.8 49.5 1.9 1.0 0.1 1.5 100.0 6,779 Development region Eastern 12.1 36.7 46.1 2.7 1.2 0.3 0.8 100.0 3,057 Central 10.6 35.8 48.5 2.4 0.6 0.1 2.0 100.0 4,236 Western 9.4 36.2 50.3 2.1 0.8 0.0 1.3 100.0 2,660 Mid-western 26.0 35.8 33.4 1.2 2.4 0.1 1.1 100.0 1,478 Far-western 33.1 31.8 31.8 1.7 1.1 0.0 0.5 100.0 1,242 Subregion Eastern mountain 14.5 42.6 38.6 1.7 0.6 0.0 2.0 100.0 229 Central mountain 14.5 37.2 45.0 1.2 1.4 0.0 0.7 100.0 258 Western mountain 23.6 45.1 25.8 1.1 3.7 0.0 0.5 100.0 319 Eastern hill 13.1 48.7 34.0 3.0 0.3 0.0 0.8 100.0 956 Central hill 20.0 22.3 51.3 4.6 0.4 0.2 0.8 100.0 1,563 Western hill 8.9 42.6 44.2 1.8 1.1 0.0 1.5 100.0 1,513 Mid-western hill 35.4 34.5 24.2 0.7 3.5 0.1 1.6 100.0 649 Far-western hill 37.7 35.9 23.1 1.7 0.5 0.0 1.1 100.0 409 Eastern terai 11.3 29.8 53.3 2.7 1.7 0.4 0.7 100.0 1,873 Central terai 4.1 44.4 47.0 1.0 0.6 0.0 2.9 100.0 2,415 Western terai 10.1 27.7 58.3 2.5 0.4 0.0 1.0 100.0 1,147 Mid-western terai 17.3 36.9 43.0 1.7 0.4 0.1 0.6 100.0 668 Far-western terai 32.7 24.1 39.5 1.8 1.6 0.0 0.3 100.0 676 Education No education 15.9 38.1 41.6 0.1 1.8 0.0 2.4 100.0 5,045 Primary 13.5 35.8 47.3 1.6 0.8 0.2 0.7 100.0 2,209 Some secondary 13.6 36.4 45.5 3.6 0.4 0.1 0.5 100.0 3,088 SLC and above 14.6 29.7 49.0 5.5 0.4 0.3 0.7 100.0 2,331 Wealth quintile Lowest 28.3 41.2 24.5 1.2 2.4 0.0 2.1 100.0 2,120 Second 16.0 45.7 34.1 1.2 1.2 0.0 1.7 100.0 2,393 Middle 9.9 41.6 45.0 1.3 0.9 0.0 1.4 100.0 2,600 Fourth 10.7 32.7 53.1 1.7 0.7 0.2 0.8 100.0 2,722 Highest 11.6 20.6 61.2 5.2 0.3 0.3 0.8 100.0 2,839 Total 15-49 14.7 35.7 44.9 2.2 1.0 0.1 1.3 100.0 12,674 Note: Total includes three women who prefer brochures/leaflets and six women who prefer flipcharts who are not shown separately. SLC = School Leaving Certificate Among the different types of electronic and print media, television is the most preferred source of information among women and men. Forty-five percent of women and 43 percent of men prefer television, while only 15 percent of women and men prefer Radio Nepal, a government-supported radio channel. Approximately one-third of women and men prefer FM radio stations for receiving health-related messages. While the preference for print media is negligible among women, 7 percent of men prefer newspapers and magazines over other sources. 54 • Characteristics of Respondents Table 3.7.2 Preferred media source for health-related information: Men Percent distribution of men with preferred media source to receive health-related information, according to background characteristics, Nepal 2011 Background characteristic Radio Nepal FM station Television Newspaper/ magazine Poster Hoarding/ billboard Other Total Number of men Age 15-19 12.0 33.2 46.0 6.3 0.3 0.3 2.0 100.0 978 20-24 15.7 32.5 40.2 10.3 0.1 0.1 1.1 100.0 685 25-29 16.7 33.8 41.1 7.2 0.5 0.1 0.5 100.0 581 30-34 12.9 34.7 44.5 7.4 0.0 0.0 0.4 100.0 499 35-39 14.6 31.8 45.3 7.3 0.5 0.0 0.4 100.0 542 40-44 19.4 31.6 42.1 6.1 0.2 0.4 0.2 100.0 438 45-49 18.1 35.2 41.2 3.9 0.8 0.0 0.4 100.0 399 Residence Urban 12.4 18.1 56.8 10.8 0.2 0.1 1.4 100.0 717 Rural 15.7 36.4 40.3 6.3 0.3 0.1 0.8 100.0 3,404 Ecological zone Mountain 21.3 43.4 31.2 2.9 0.2 0.0 0.8 100.0 245 Hill 13.9 36.0 41.4 7.1 0.2 0.3 1.0 100.0 1,658 Terai 15.3 30.0 45.8 7.6 0.4 0.0 0.9 100.0 2,218 Development region Eastern 10.9 33.7 44.6 9.4 0.6 0.2 0.6 100.0 996 Central 12.9 33.3 44.7 8.0 0.2 0.0 0.8 100.0 1,448 Western 10.8 30.6 51.9 5.6 0.0 0.2 0.9 100.0 798 Mid-western 30.9 34.8 28.7 4.3 0.2 0.2 0.9 100.0 493 Far-western 23.0 34.9 34.1 4.6 0.8 0.3 2.3 100.0 385 Subregion Eastern mountain 6.7 57.8 31.4 3.0 0.0 0.0 1.2 100.0 66 Central mountain 19.4 28.7 44.8 5.4 0.8 0.0 0.2 100.0 69 Western mountain 31.2 44.0 22.5 1.4 0.0 0.0 0.9 100.0 110 Eastern hill 7.7 55.2 30.4 5.9 0.3 0.3 0.0 100.0 293 Central hill 11.4 24.6 51.0 11.5 0.0 0.0 1.4 100.0 616 Western hill 11.7 36.0 46.8 4.4 0.0 0.4 0.6 100.0 440 Mid-western hill 30.6 37.0 26.6 3.6 0.0 0.4 1.7 100.0 189 Far-western hill 23.6 45.9 23.2 2.7 2.2 1.0 1.5 100.0 120 Eastern terai 12.8 21.4 52.5 11.6 0.8 0.1 0.8 100.0 638 Central terai 13.6 40.7 39.7 5.4 0.3 0.0 0.3 100.0 763 Western terai 9.7 23.8 58.2 7.2 0.0 0.0 1.1 100.0 358 Mid-western terai 31.2 32.3 30.4 5.4 0.3 0.0 0.3 100.0 242 Far-western terai 20.5 25.1 44.4 6.8 0.2 0.0 3.0 100.0 217 Education No education 18.0 53.6 26.3 0.5 1.2 0.0 0.4 100.0 567 Primary 17.1 38.5 41.7 2.4 0.1 0.1 0.1 100.0 814 Some secondary 14.2 33.4 45.1 6.3 0.2 0.2 0.6 100.0 1,437 SLC and above 13.6 20.8 49.4 13.9 0.3 0.1 1.9 100.0 1,303 Wealth quintile Lowest 21.2 55.4 18.8 3.3 0.6 0.0 0.6 100.0 610 Second 16.4 47.9 30.0 4.1 0.7 0.3 0.5 100.0 695 Middle 15.5 39.5 38.7 5.1 0.2 0.1 1.0 100.0 830 Fourth 14.9 24.6 51.4 8.0 0.3 0.2 0.6 100.0 920 Highest 10.7 13.4 62.1 12.0 0.1 0.1 1.5 100.0 1,066 Total 15-49 15.1 33.2 43.2 7.1 0.3 0.1 0.9 100.0 4,121 Note: Total includes two men who prefer brochures/leaflets who are not shown separately. SLC = School Leaving Certificate Television and FM radio stations are popular in all age groups of women and men, while Radio Nepal is most popular among women age 45-49. Women in the terai, Western region, and Central terai subregion are less likely to prefer Radio Nepal than women in other areas. Education and income status are directly related to the preferred media source for health-related information. Women and men with no education and those in the lowest wealth quintile are more likely to prefer Radio Nepal than those with an SLC and higher level of education and those in the highest wealth quintile. 3.5 EMPLOYMENT 3.5.1 Employment Status The 2011 NDHS asked respondents a number of questions regarding their employment status, including whether they were working in the seven days preceding the survey and, if not, whether they had worked in the 12 months before the survey. The results for women and men are presented in Tables 3.8.1 and 3.8.2. At the time of the survey, 60 percent of women were currently employed and 15 percent were not employed but had worked sometime during the past 12 months (Figure 3.1). Characteristics of Respondents • 55 Table 3.8.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Nepal 2011 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 48.4 16.4 35.1 100.0 2,753 20-24 52.4 17.2 30.3 100.0 2,297 25-29 59.4 14.6 25.9 100.0 2,101 30-34 65.4 15.3 19.4 100.0 1,734 35-39 71.0 13.4 15.6 100.0 1,557 40-44 71.4 13.9 14.7 100.0 1,285 45-49 70.2 14.1 15.7 100.0 947 Marital status Never married 53.6 14.6 31.8 100.0 2,708 Married 61.0 15.8 23.2 100.0 9,608 Divorced/separated/widowed 83.7 6.9 9.4 100.0 358 Number of living children 0 52.2 16.3 31.5 100.0 3,823 1-2 58.9 13.9 27.3 100.0 4,591 3-4 67.3 16.2 16.6 100.0 3,207 5+ 71.5 15.4 13.1 100.0 1,053 Residence Urban 45.3 11.9 42.8 100.0 1,819 Rural 62.5 15.9 21.6 100.0 10,855 Ecological zone Mountain 88.8 6.6 4.5 100.0 805 Hill 74.7 9.7 15.6 100.0 5,090 Terai 45.6 20.6 33.8 100.0 6,779 Development region Eastern 59.2 14.0 26.8 100.0 3,057 Central 50.8 17.5 31.8 100.0 4,236 Western 64.1 13.9 22.0 100.0 2,660 Mid-western 68.6 14.5 16.9 100.0 1,478 Far-western 74.7 15.2 10.1 100.0 1,242 Subregion Eastern mountain 89.9 4.5 5.7 100.0 229 Central mountain 90.8 5.3 3.8 100.0 258 Western mountain 86.4 9.3 4.3 100.0 319 Eastern hill 78.6 14.3 7.1 100.0 956 Central hill 64.3 8.6 27.1 100.0 1,563 Western hill 78.1 9.3 12.5 100.0 1,513 Mid-western hill 75.9 8.4 15.7 100.0 649 Far-western hill 90.7 6.1 3.2 100.0 409 Eastern terai 45.6 15.0 39.4 100.0 1,873 Central terai 37.7 24.5 37.8 100.0 2,415 Western terai 45.6 20.0 34.5 100.0 1,147 Mid-western terai 58.1 20.9 21.0 100.0 668 Far-western terai 61.3 22.8 15.9 100.0 676 Education No education 65.2 16.9 17.8 100.0 5,045 Primary 63.9 14.7 21.4 100.0 2,209 Some secondary 55.9 15.3 28.7 100.0 3,088 SLC and above 50.4 12.4 37.1 100.0 2,331 Wealth quintile Lowest 79.5 14.6 5.9 100.0 2,120 Second 70.5 16.1 13.4 100.0 2,393 Middle 60.3 18.4 21.4 100.0 2,600 Fourth 52.6 17.0 30.4 100.0 2,722 Highest 43.5 10.8 45.7 100.0 2,839 Total 60.0 15.3 24.7 100.0 12,674 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. SLC = School Leaving Certificate The proportion of women currently employed increases with age. Current employment is lowest among women age 15-19 (48 percent) and highest among those age 35-49 (70 percent or higher). Women who are divorced, separated, or widowed are more likely to be currently employed than other women (84 percent versus 61 percent or lower). Women who have five or more children are more likely to be employed (72 percent) than those with no children (52 percent). 56 • Characteristics of Respondents Currently employed 60% Not currently employed, but worked in last 12 months 15% Not employed in the 12 months preceding the survey 25% Figure 3.1 Women’s Employment Status in the Past 12 Months Notable variations are seen in the proportion of women currently employed by place of residence and region. Rural women are more likely to be currently employed than urban women (63 percent versus 45 percent). Women in the mountain zone are more likely to be economically active than women residing in the other ecological zones. Women in the Far-western, Mid-western, and Western regions are more likely to be currently employed (75 percent, 69 percent, and 64 percent, respectively) than those living in the Eastern and Central regions (59 percent and 51 percent, respectively). The proportion of women currently employed decreases with level of education. For example, 65 percent of women with no education are currently employed, compared with 50 percent of women with an SLC or higher level of education. Women living in the poorest households are much more likely to be employed (80 percent) than women in the wealthiest households (44 percent). This could partly be due to the economic needs of poorer households that drive women to seek employment. The proportion currently employed is higher among men than women (Table 3.8.2). The percentage of currently employed men rises with age, from 46 percent among men age 15-19 to 92 percent among men age 45-49. Ever-married men, those living in the mountain zone, those residing in the Eastern mountain and Eastern hill subregions, those with little or no education, and those living in the poorest households are more likely to be employed than their counterparts. Twenty-five percent of women and 13 percent of men were not employed during the 12 months preceding the survey. Characteristics of Respondents • 57 Table 3.8.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Nepal 2011 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 46.0 15.2 38.8 100.0 978 20-24 75.5 11.2 13.3 100.0 685 25-29 88.9 7.5 3.6 100.0 581 30-34 89.6 8.1 2.3 100.0 499 35-39 90.9 7.8 1.4 100.0 542 40-44 91.7 7.0 1.3 100.0 438 45-49 92.3 4.9 2.9 100.0 399 Marital status Never married 53.1 13.7 33.1 100.0 1,433 Married 90.8 7.4 1.8 100.0 2,626 Divorced/separated/widowed (75.1) (16.0) (8.9) 100.0 62 Number of living children 0 58.4 13.5 28.0 100.0 1,755 1-2 90.9 6.7 2.4 100.0 1,232 3-4 92.3 7.3 0.5 100.0 836 5+ 92.4 6.8 0.8 100.0 298 Residence Urban 76.1 6.2 17.7 100.0 717 Rural 77.8 10.5 11.8 100.0 3,404 Ecological zone Mountain 83.4 13.4 3.2 100.0 245 Hill 78.2 10.4 11.4 100.0 1,658 Terai 76.3 8.8 14.9 100.0 2,218 Development region Eastern 80.7 9.1 10.2 100.0 996 Central 80.5 6.9 12.5 100.0 1,448 Western 72.8 8.8 18.4 100.0 798 Mid-western 68.5 21.1 10.4 100.0 493 Far-western 78.7 9.2 12.1 100.0 385 Subregion Eastern mountain 92.3 5.9 1.8 100.0 66 Central mountain 86.6 7.4 6.0 100.0 69 Western mountain 76.1 21.6 2.3 100.0 110 Eastern hill 91.9 5.0 3.1 100.0 293 Central hill 80.2 6.6 13.2 100.0 616 Western hill 73.2 9.1 17.7 100.0 440 Mid-western hill 57.3 33.8 8.9 100.0 189 Far-western hill 85.7 11.5 2.9 100.0 120 Eastern terai 74.4 11.2 14.4 100.0 638 Central terai 80.3 7.2 12.5 100.0 763 Western terai 72.3 8.5 19.2 100.0 358 Mid-western terai 79.5 6.8 13.6 100.0 242 Far-western terai 70.6 10.0 19.4 100.0 217 Education No education 90.2 8.7 1.1 100.0 567 Primary 90.9 6.1 3.0 100.0 814 Some secondary 71.0 10.9 18.2 100.0 1,437 SLC and above 70.7 11.2 18.1 100.0 1,303 Wealth quintile Lowest 83.4 12.7 3.9 100.0 610 Second 81.8 8.8 9.4 100.0 695 Middle 80.2 9.9 9.9 100.0 830 Fourth 73.8 10.0 16.2 100.0 920 Highest 72.3 8.3 19.4 100.0 1,066 Total 15-49 77.5 9.7 12.8 100.0 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. SLC = School Leaving Certificate 3.5.2 Occupation Respondents who were currently employed or had worked in the 12 months preceding the survey were asked to specify their occupation. The results are presented in Table 3.9.1 and Table 3.9.2, which show data on employed women and men, respectively, by occupation according to background characteristics. 58 • Characteristics of Respondents Table 3.9.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Nepal 2011 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Other/ missing Total Number of women Age 15-19 2.5 1.0 7.0 4.1 2.2 83.0 0.2 100.0 1,786 20-24 7.9 2.1 11.2 5.5 3.1 70.0 0.2 100.0 1,600 25-29 6.5 1.2 14.7 6.3 2.5 68.5 0.3 100.0 1,556 30-34 3.5 1.0 15.2 5.9 3.1 71.0 0.3 100.0 1,398 35-39 4.4 1.5 13.7 3.7 3.0 73.8 0.1 100.0 1,314 40-44 2.2 0.4 14.1 2.4 2.4 78.4 0.0 100.0 1,096 45-49 1.4 0.3 9.4 1.2 2.1 85.4 0.1 100.0 798 Marital status Never married 7.6 1.7 10.2 6.1 2.3 71.6 0.4 100.0 1,846 Married 3.6 0.9 12.2 4.2 2.7 76.3 0.1 100.0 7,378 Divorced/separated/widowed 2.5 2.4 20.3 2.7 3.4 67.8 0.9 100.0 324 Number of living children 0 7.4 1.7 10.8 6.3 2.2 71.2 0.4 100.0 2,619 1-2 5.7 1.5 16.4 5.3 3.0 67.8 0.2 100.0 3,339 3-4 1.0 0.4 10.1 3.1 2.7 82.6 0.0 100.0 2,675 5+ 0.0 0.3 5.8 0.4 2.3 91.0 0.1 100.0 915 Residence Urban 12.0 4.2 33.2 10.1 5.9 33.6 1.0 100.0 1,041 Rural 3.4 0.8 9.5 3.8 2.3 80.2 0.1 100.0 8,508 Ecological zone Mountain 2.7 0.5 6.5 1.2 0.9 88.2 0.0 100.0 769 Hill 5.3 1.3 11.0 4.3 1.7 76.0 0.3 100.0 4,294 Terai 3.7 1.0 14.1 5.2 3.8 72.0 0.1 100.0 4,485 Development region Eastern 4.2 1.0 15.9 5.6 2.2 70.9 0.1 100.0 2,239 Central 5.8 1.8 13.1 6.5 2.6 69.7 0.6 100.0 2,891 Western 4.1 0.7 11.2 3.2 2.3 78.4 0.0 100.0 2,075 Mid-western 2.7 0.9 9.8 1.8 3.1 81.7 0.0 100.0 1,228 Far-western 3.1 0.7 5.8 2.3 3.8 84.2 0.1 100.0 1,116 Subregion Eastern mountain 2.7 0.3 10.2 0.8 0.3 85.5 0.2 100.0 216 Central mountain 3.2 0.6 3.5 2.5 0.2 90.1 0.0 100.0 248 Western mountain 2.2 0.7 6.3 0.3 1.8 88.7 0.0 100.0 305 Eastern hill 3.5 0.3 7.7 2.5 0.8 85.2 0.0 100.0 888 Central hill 10.7 3.5 21.3 11.0 2.6 49.8 1.1 100.0 1,140 Western hill 3.5 0.5 8.0 2.0 1.7 84.4 0.0 100.0 1,323 Mid-western hill 3.7 1.3 9.3 1.7 1.7 82.4 0.0 100.0 547 Far-western hill 1.5 0.2 1.6 0.7 1.5 94.5 0.0 100.0 396 Eastern terai 5.0 1.6 23.5 9.1 3.7 57.0 0.1 100.0 1,135 Central terai 2.4 0.7 8.5 3.7 3.0 81.3 0.2 100.0 1,503 Western terai 5.1 1.2 17.0 5.2 3.4 68.0 0.1 100.0 752 Mid-western terai 1.9 0.5 10.2 2.3 4.9 80.1 0.0 100.0 528 Far-western terai 4.3 1.0 9.5 4.1 6.0 74.8 0.2 100.0 568 Education No education 0.1 0.3 6.6 2.4 3.0 87.3 0.2 100.0 4,146 Primary 0.2 0.9 11.3 6.4 4.1 77.0 0.1 100.0 1,736 Some secondary 1.2 0.6 14.5 7.0 2.0 74.5 0.2 100.0 2,201 SLC and above 25.9 4.5 24.8 4.3 0.7 39.3 0.4 100.0 1,465 Wealth quintile Lowest 0.5 0.2 0.9 0.5 2.0 95.8 0.0 100.0 1,993 Second 1.1 0.3 2.7 1.9 3.3 90.7 0.1 100.0 2,073 Middle 2.1 0.5 6.1 3.7 3.2 84.3 0.1 100.0 2,045 Fourth 5.0 1.3 17.2 7.4 2.8 65.9 0.3 100.0 1,895 Highest 15.8 3.9 40.8 10.6 1.7 26.7 0.6 100.0 1,542 Total 4.3 1.1 12.1 4.5 2.6 75.1 0.2 100.0 9,548 SLC = School Leaving Certificate In Nepal, the agricultural sector remains the main employer, with 75 percent of women and 35 percent of men engaged in agricultural occupations. These figures are lower than those in the 2006 NDHS, when 86 percent of women and 52 percent of men were employed in agricultural occupations. The survey indicates that 7 percent of employed women are manual workers (skilled and unskilled), while 4 percent are in professional, technical, and managerial fields. Sales and services is an emerging sector, with more than one-tenth (12 percent) of women and more than one-fifth (22 percent) of men engaged in this sector. This is an increase since 2006, when 7 percent of women and 13 percent of men were involved in the sales and service sector. Type of occupation varies greatly by gender. As women are less likely than men to be highly educated or to have attended vocational or technical schools, their employment in the professional, technical, and managerial sector is somewhat lower than men’s (4 percent compared with 8 percent). Twenty-eight percent of men age 15-49 do manual work (skilled and unskilled), while only 7 percent of women work in this field. Men are also more likely than women to be engaged in clerical work (6 percent versus 1 percent). Characteristics of Respondents • 59 Table 3.9.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Nepal 2011 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Other/ missing Total Number of men Age 15-19 3.0 4.6 14.2 14.9 11.3 49.1 2.9 100.0 598 20-24 9.8 9.4 27.1 15.1 9.3 27.7 1.5 100.0 594 25-29 6.2 5.5 23.7 21.5 12.3 30.6 0.3 100.0 560 30-34 9.1 6.4 27.4 19.6 11.1 26.3 0.1 100.0 488 35-39 6.8 5.1 26.7 20.7 9.3 31.2 0.1 100.0 534 40-44 9.5 3.7 20.0 18.3 11.2 37.3 0.0 100.0 432 45-49 11.3 6.9 15.4 13.7 7.1 45.6 0.0 100.0 387 Marital status Never married 7.9 6.4 22.3 14.6 10.1 36.2 2.4 100.0 958 Married 7.7 5.9 22.6 18.9 10.1 34.6 0.2 100.0 2,579 Divorced/separated/widowed (3.5) (3.1) (9.1) (19.2) (24.3) (40.8) (0.0) 100.0 56 Number of living children 0 7.4 6.5 22.8 14.9 10.1 36.2 2.0 100.0 1,263 1-2 10.7 5.7 26.4 18.2 11.2 27.5 0.2 100.0 1,202 3-4 5.6 6.4 19.4 21.2 8.7 38.6 0.0 100.0 832 5+ 2.8 3.7 11.4 18.2 12.1 51.9 0.0 100.0 296 Residence Urban 14.4 9.8 35.5 19.5 9.3 10.2 1.3 100.0 590 Rural 6.4 5.2 19.7 17.4 10.5 40.0 0.7 100.0 3,003 Ecological zone Mountain 6.3 3.7 12.0 8.4 10.4 58.9 0.3 100.0 237 Hill 9.6 6.2 20.7 16.7 7.6 38.6 0.7 100.0 1,469 Terai 6.4 6.1 24.8 19.8 12.5 29.4 1.0 100.0 1,887 Development region Eastern 7.9 4.8 26.4 16.2 7.4 35.1 2.1 100.0 895 Central 7.7 8.1 22.8 18.4 11.9 30.5 0.6 100.0 1,267 Western 9.3 5.4 23.4 20.5 11.1 30.0 0.2 100.0 652 Mid-western 5.7 3.2 18.3 16.7 13.5 42.6 0.0 100.0 442 Far-western 6.7 6.1 12.6 15.4 6.6 52.5 0.1 100.0 338 Subregion Eastern mountain 6.8 4.1 8.7 5.8 7.9 65.5 1.2 100.0 65 Central mountain 8.5 5.6 14.1 7.9 12.9 51.0 0.0 100.0 65 Western mountain 4.7 2.3 12.7 10.3 10.3 59.6 0.0 100.0 107 Eastern hill 4.2 0.7 21.4 12.1 3.5 56.1 2.0 100.0 284 Central hill 14.2 11.8 25.8 17.1 8.9 21.5 0.8 100.0 535 Western hill 8.4 4.1 18.1 22.3 6.5 40.6 0.0 100.0 362 Mid-western hill 8.7 1.9 17.4 14.2 12.2 45.6 0.0 100.0 172 Far-western hill 6.2 6.7 8.8 12.0 7.7 58.5 0.0 100.0 117 Eastern terai 10.0 7.0 31.1 19.6 9.4 20.7 2.2 100.0 546 Central terai 2.4 5.3 21.2 20.5 14.2 35.7 0.6 100.0 667 Western terai 10.5 7.1 30.1 18.1 16.8 16.8 0.5 100.0 290 Mid-western terai 4.7 5.1 20.2 20.5 13.6 35.9 0.0 100.0 209 Far-western terai 6.1 5.9 15.6 19.3 7.1 45.8 0.1 100.0 175 Education No education 0.5 5.7 6.7 19.0 22.5 45.7 0.0 100.0 561 Primary 0.6 5.8 12.3 25.7 13.6 41.5 0.6 100.0 789 Some secondary 2.6 5.1 23.5 19.7 9.0 39.4 0.9 100.0 1,176 SLC and above 22.4 7.3 36.6 9.2 3.1 20.2 1.3 100.0 1,068 Wealth quintile Lowest 0.9 1.4 4.1 14.1 14.9 64.6 0.1 100.0 586 Second 3.7 5.5 7.6 15.5 13.5 54.1 0.1 100.0 629 Middle 3.2 5.2 17.1 25.3 12.3 35.7 1.2 100.0 748 Fourth 7.6 6.8 27.2 22.2 9.7 25.6 1.0 100.0 771 Highest 19.3 9.4 45.6 11.5 3.8 9.2 1.2 100.0 859 Total 15-49 7.7 6.0 22.3 17.8 10.3 35.1 0.8 100.0 3,593 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate The relationship between occupation and age is mixed. One notable finding is that relatively high percentages of women age 25-29 and 30-34 (15 percent) and men age 20-24, 30-34, and 35-39 (27 percent each) are employed in sales and services. In addition, 8 percent of women age 20-24 are employed in professional, technical, and managerial positions, indicating a gradual shift in occupation among the younger generation. Residence has a significant effect on type of occupation. As expected, a high proportion of respondents in rural areas—80 percent of employed women and 40 percent of employed men—are engaged in agricultural work. Urban women and men (33 percent and 36 percent, respectively) are more likely to be engaged in sales and services than in other occupations. Women in the mountain zone and those in the Far-western region are more likely to be involved in agriculture (88 percent and 84 percent, respectively). However, since 2006 employment in agriculture has 60 • Characteristics of Respondents declined by 6 percent and 12 percent in these regions, respectively, with a shift to other occupations. A similar pattern is observed among men. The lowest proportion of women engaged in the agricultural sector live in the Central hill subregion, and the lowest proportion of men in this sector live in the Western terai region. There is a positive relationship between women’s education and their involvement in sales and services. For example, one-fourth of women with an SLC and higher level of education are involved in this sector, as compared with 15 percent of women or less in the other education categories. A similar pattern is found among men. This is probably because both women and men with no education have few employment opportunities except in the agricultural sector, in contrast to educated women and men, who find it easier to obtain employment in the nonagricultural sector. Almost all employed women (96 percent) in the lowest wealth quintile work in agriculture, whereas only 27 percent of women in the highest wealth quintile do so. Agricultural work is also less common among men with an SLC or higher and men in the highest wealth quintile. There has been an increase since 2006 in the proportion of individuals involved in the nonagricultural sector, from 14 percent to 25 percent among women and from 48 percent to 64 percent among men. This is partly due to urbanization and partly due to greater opportunities in the nonagricultural sector. 3.5.3 Earnings, Employers, and Continuity of Employment Tables 3.10.1 and 3.10.2 show the percent distribution of women and men by type of earnings and employment characteristics. These tables also present data on whether respondents are involved in agricultural or nonagricultural occupations. More than three-quarters (76 percent) of women engaged in agricultural work are unpaid, and women working in this sector are most likely to be employed by family members. Ten percent of women employed in the agricultural sector are paid in-kind only. Women are more likely to be paid in cash if they are employed in the nonagricultural sector: 80 percent of women employed in this sector are paid in cash, compared with 13 percent of women who are employed in agriculture (including cash and in-kind). Table 3.10.1 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Nepal 2011 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 5.9 80.0 24.3 Cash and in-kind 7.3 3.4 6.3 In-kind only 10.4 0.7 8.0 Not paid 76.4 15.9 61.4 Total 100.0 100.0 100.0 Type of employer Employed by family member 82.8 26.0 68.7 Employed by nonfamily member 14.6 42.4 21.5 Self-employed 2.6 31.6 9.8 Total 100.0 100.0 100.0 Continuity of employment All year 45.8 77.8 53.8 Seasonal 47.4 8.6 37.7 Occasional 6.8 13.5 8.5 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 7,172 2,375 9,548 Note: Total includes one woman with missing information on type of employment who is not shown separately. Characteristics of Respondents • 61 Table 3.10.2 Type of employment: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Nepal 2011 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 11.7 92.0 63.8 Cash and in-kind 27.4 4.5 12.6 In-kind only 18.2 0.4 6.7 Not paid 42.7 3.0 17.0 Total 100.0 100.0 100.0 Continuity of employment All year 40.6 76.4 63.9 Seasonal 51.2 16.4 28.6 Occasional 8.2 7.2 7.5 Total 100.0 100.0 100.0 Number of men employed during the last 12 months 1,262 2,331 3,593 Overall, 61 percent of employed women are not paid at all, while 31 percent earn cash or cash and in- kind payment for their work. In contrast, 17 percent of employed men are unpaid (Table 3.10.2). Forty-three percent of men who work in agriculture are unpaid, as compared with 3 percent who work in the nonagricultural sector. Sixty-nine percent of women work for a family member and 10 percent are self-employed. Twenty-two percent of employed women work for someone outside the family. More than four in five women employed in the agricultural sector are working for a family member, compared with 26 percent of women employed in the nonagricultural sector. The proportion of women employed by someone outside the family is higher among those working in the nonagricultural sector than among those in the agricultural sector (42 percent versus 15 percent). Only 3 percent of employed women working in the agricultural sector are self-employed, compared with 32 percent in the nonagricultural sector. 3.6 USE OF TOBACCO Smoking and other forms of tobacco use can cause a wide variety of diseases and can lead to death. Smoking is a risk factor for cardiovascular disease, lung cancer, and other forms of cancer, and it contributes to the severity of pneumonia, emphysema, and chronic bronchitis symptoms. Also, secondhand smoke may adversely affect the health of children and aggravate childhood illnesses. In the 2011 NDHS, women and men age 15-49 were asked whether they currently smoked cigarettes and, if so, how many cigarettes they had smoked in the past 24 hours. Those who reported not currently smoking cigarettes were asked whether they use any other forms of tobacco, such as a pipe, chewing tobacco, or snuff. Tables 3.11.1 and 3.11.2 show the percentage of women and men who smoke cigarettes or use other tobacco products according to background characteristics. Table 3.11.2 also shows the percent distribution of male cigarette smokers by number of cigarettes smoked in the preceding 24 hours. 62 • Characteristics of Respondents Table 3.11.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, according to background characteristics and maternity status, Nepal 2011 Background characteristic Uses tobacco Does not use tobacco Number of women Cigarettes Pipe Other tobacco Age 15-19 0.5 0.0 0.7 98.7 2,753 20-24 1.9 0.3 1.7 96.5 2,297 25-29 5.7 0.4 5.5 89.7 2,101 30-34 9.4 1.1 6.8 85.1 1,734 35-39 15.5 1.2 9.9 77.3 1,557 40-44 22.2 1.4 13.6 68.3 1,285 45-49 24.9 1.9 15.1 64.6 947 Maternity status Pregnant 5.0 0.9 4.1 91.6 621 Breastfeeding (not pregnant) 6.8 0.9 6.2 88.1 2,859 Neither 9.6 0.6 6.1 85.9 9,193 Residence Urban 4.6 0.1 2.7 93.3 1,819 Rural 9.4 0.8 6.6 85.6 10,855 Ecological zone Mountain 18.2 4.1 7.1 76.1 805 Hill 11.0 0.8 7.8 83.4 5,090 Terai 5.9 0.2 4.5 90.4 6,779 Development region Eastern 5.0 0.0 9.3 87.2 3,057 Central 9.4 0.4 4.0 88.0 4,236 Western 7.2 0.1 5.9 88.2 2,660 Mid-western 15.6 4.5 6.6 79.6 1,478 Far-western 10.5 0.4 4.4 86.4 1,242 Subregion Eastern mountain 7.7 0.0 9.4 85.7 229 Central mountain 22.0 2.4 9.8 75.0 258 Western mountain 22.8 8.3 3.3 70.0 319 Eastern hill 7.4 0.0 18.3 77.7 956 Central hill 11.9 0.3 3.2 86.6 1,563 Western hill 8.8 0.1 6.2 86.1 1,513 Mid-western hill 17.5 5.2 10.9 77.0 649 Far-western hill 13.7 0.1 1.8 84.5 409 Eastern terai 3.4 0.0 4.7 92.2 1,873 Central terai 6.5 0.2 3.9 90.3 2,415 Western terai 5.1 0.0 5.5 90.9 1,147 Mid-western terai 11.2 0.9 3.7 86.0 668 Far-western terai 6.6 0.7 5.7 89.8 676 Education No education 17.9 1.7 10.8 74.5 5,045 Primary 7.1 0.1 6.8 86.9 2,209 Some secondary 1.4 0.0 2.0 96.7 3,088 SLC and above 0.1 0.0 0.2 99.6 2,331 Wealth quintile Lowest 20.1 3.0 14.4 69.6 2,120 Second 11.6 0.6 7.5 83.1 2,393 Middle 7.0 0.4 5.0 88.8 2,600 Fourth 5.2 0.0 4.0 91.5 2,722 Highest 2.7 0.0 1.4 96.0 2,839 Total 8.7 0.7 6.0 86.7 12,674 SLC = School Leaving Certificate Characteristics of Respondents • 63 Table 3.11.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Nepal 2011 Background characteristic Uses tobacco Does not use tobacco Number of men Percent distribution of men who smoke cigarettes by number of cigarettes smoked in the last 24 hours Total Number of cigarette smokers Cigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Age 15-19 13.1 0.1 11.0 80.2 978 11.3 33.6 25.6 16.9 12.5 100.0 128 20-24 26.5 0.3 28.8 56.2 685 8.4 32.7 26.6 9.7 22.5 100.0 182 25-29 36.4 0.3 50.1 35.7 581 10.2 30.3 29.5 10.7 19.3 100.0 212 30-34 32.0 0.6 50.6 35.8 499 8.5 24.7 30.2 12.2 24.4 100.0 160 35-39 33.0 0.7 55.3 31.5 542 12.7 19.2 30.0 8.2 29.9 100.0 178 40-44 42.5 0.9 51.5 30.8 438 7.6 17.9 26.9 20.0 27.7 100.0 186 45-49 46.0 0.9 47.5 30.1 399 4.9 19.0 29.9 13.1 33.2 100.0 184 Residence Urban 25.0 0.0 30.3 55.7 717 8.8 26.6 31.0 12.8 20.7 100.0 180 Rural 30.8 0.5 39.6 46.4 3,404 9.0 24.8 28.1 12.8 25.3 100.0 1,049 Ecological zone Mountain 40.4 4.6 28.1 46.6 245 5.3 10.9 25.1 11.6 47.2 100.0 99 Hill 29.1 0.4 31.3 51.7 1,658 5.3 19.1 28.4 17.8 29.4 100.0 482 Terai 29.2 0.0 44.0 45.5 2,218 12.3 31.7 29.1 9.3 17.6 100.0 648 Development region Eastern 29.5 0.2 38.5 48.3 996 11.1 21.5 33.4 11.5 22.5 100.0 294 Central 32.0 0.0 36.9 46.4 1,448 10.7 28.0 22.4 14.2 24.7 100.0 463 Western 23.4 0.0 39.1 50.8 798 9.9 24.0 29.0 18.9 18.2 100.0 187 Mid-western 34.8 2.9 37.6 46.3 493 1.4 21.7 33.1 10.0 33.8 100.0 171 Far-western 29.6 0.5 38.3 50.2 385 6.6 29.5 33.1 4.5 26.3 100.0 114 Subregion Eastern mountain 30.5 1.0 27.3 54.0 66 14.2 17.6 26.5 15.9 25.8 100.0 20 Central mountain 35.1 0.6 28.3 48.0 69 3.4 6.8 13.6 19.5 56.7 100.0 24 Western mountain 49.5 9.2 28.4 41.3 110 2.8 10.2 29.6 6.5 50.9 100.0 54 Eastern hill 31.0 0.3 36.1 46.9 293 6.6 22.1 31.6 15.8 23.9 100.0 91 Central hill 33.3 0.0 21.5 56.0 616 5.5 14.8 26.3 19.3 34.0 100.0 205 Western hill 21.8 0.0 37.3 51.0 440 6.1 22.4 28.0 19.9 23.5 100.0 96 Mid-western hill 29.2 3.0 37.1 48.9 189 1.5 18.5 35.6 14.7 29.8 100.0 55 Far-western hill 29.2 0.5 38.8 48.7 120 5.1 28.5 21.2 12.5 32.7 100.0 35 Eastern terai 28.7 0.0 40.7 48.4 638 13.0 21.7 35.0 8.9 21.4 100.0 183 Central terai 30.6 0.0 50.2 38.5 763 15.9 41.8 19.8 9.2 13.3 100.0 234 Western terai 25.4 0.0 41.2 50.6 358 13.9 25.6 30.0 17.9 12.6 100.0 91 Mid-western terai 35.9 0.1 40.1 45.7 242 1.9 29.9 31.0 6.9 30.2 100.0 87 Far-western terai 24.7 0.0 40.5 52.9 217 7.7 35.6 45.2 0.5 11.0 100.0 54 Education No education 50.4 1.0 60.8 19.9 567 7.5 29.1 24.2 11.7 27.6 100.0 286 Primary 40.4 0.7 52.3 30.5 814 4.6 18.1 32.4 16.3 28.7 100.0 329 Some secondary 26.4 0.4 34.1 54.5 1,437 12.4 25.2 29.4 11.5 21.5 100.0 379 SLC and above 18.1 0.2 23.3 64.1 1,303 11.5 30.0 27.0 11.2 20.3 100.0 236 Wealth quintile Lowest 39.0 2.2 45.6 35.3 610 2.2 21.7 25.9 16.1 34.2 100.0 238 Second 34.2 0.6 41.8 44.0 695 8.7 19.6 31.9 15.0 24.8 100.0 237 Middle 32.8 0.2 47.8 40.7 830 13.3 29.7 26.0 10.6 20.4 100.0 272 Fourth 25.0 0.0 34.4 54.1 920 8.9 30.1 32.8 8.9 19.3 100.0 230 Highest 23.7 0.0 26.3 58.5 1,066 11.2 24.0 26.5 13.6 24.8 100.0 252 Total 15-49 29.8 0.5 37.9 48.1 4,121 9.0 25.1 28.5 12.8 24.6 100.0 1,229 SLC = School Leaving Certificate Tobacco use is more common among Nepalese men than women (52 percent compared with 13 percent). Thirty percent of men smoke cigarettes, while 38 percent consume other forms of tobacco. The other forms of tobacco include smokeless tobacco, mainly the chewing tobacco locally known as khaini, gutcha, or zarda. Among women, 9 percent smoke cigarettes and 6 percent consume other forms of tobacco. Among men, use of tobacco is more common among older men, those living in rural areas, those with no education, and those in the lowest wealth quintile. A similar pattern is observed among women. Five percent of pregnant women and 7 percent of breastfeeding women smoke cigarettes. Additionally, 4 percent of pregnant women and 6 percent of breastfeeding women consume other forms of tobacco. Men and women living in the mountain zone are more likely to smoke cigarettes than those in the hill or terai zone. Regional variations are notable, with smoking among men being highest in the Mid-western region (35 percent) and lowest in the Western region (23 percent). Regional and subregional variations are also common among women. For example, nearly one-fourth (23 percent) of women in the Western mountain subregion smoke cigarettes, compared with about 3 percent in the Eastern terai subregion. 64 • Characteristics of Respondents Among men who smoke cigarettes, 9 percent had not smoked a cigarette in the last 24 hours, 25 percent had smoked 1-2 cigarettes, 29 percent had smoked 3-5 cigarettes, 13 percent had smoked 6-9 cigarettes, and 25 percent had smoked 10 or more cigarettes. Among women who smoke, 24 percent had smoked more than 10 cigarettes in the 24 hours before the survey (data not shown). Marriage and Sexual Activity • 65 MARRIAGE AND SEXUAL ACTIVITY 4 This chapter discusses the principal factors other than contraception that affect women’s chances of becoming pregnant. These factors include marriage and sexual activity. Marriage signals the onset of exposure to the risk of pregnancy for most women, and thus it is an important fertility indicator. In the context of the 2011 NDHS, marriage also includes living with partners in a consensual but informal union. In addition, this chapter includes information on more direct measures of the beginning of exposure to pregnancy and level of exposure, for example, age at first sexual intercourse and frequency of recent sexual intercourse. 4.1 CURRENT MARITAL STATUS Table 4.1 shows current marital status by age and sex. Seventy-six percent of women and 64 percent of men age 15-49 are currently married. A higher proportion of men (35 percent) than women (21 percent) have never been married. In combination, divorce, separation, and widowhood are almost twice as high among women as among men (3 percent and less than 2 percent, respectively). Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Nepal 2011 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Divorced Separated Widowed WOMEN 15-19 71.0 28.8 0.0 0.2 0.0 100.0 28.8 2,753 20-24 22.6 76.6 0.1 0.3 0.2 100.0 76.6 2,297 25-29 7.0 91.1 0.2 0.6 1.2 100.0 91.1 2,101 30-34 2.0 95.7 0.1 0.6 1.6 100.0 95.7 1,734 35-39 1.4 93.8 0.1 1.0 3.6 100.0 93.8 1,557 40-44 1.2 92.6 0.1 1.0 5.0 100.0 92.6 1,285 45-49 1.3 87.9 0.2 2.3 8.3 100.0 87.9 947 Total 15-49 21.4 75.8 0.1 0.7 2.0 100.0 75.8 12,674 MEN 15-19 92.9 6.9 0.0 0.2 0.0 100.0 6.9 978 20-24 54.4 44.7 0.2 0.7 0.0 100.0 44.7 685 25-29 17.3 81.0 0.4 1.1 0.2 100.0 81.0 581 30-34 6.4 91.9 1.5 0.0 0.1 100.0 91.9 499 35-39 2.4 95.3 0.3 0.9 1.1 100.0 95.3 542 40-44 1.4 96.6 0.6 0.2 1.2 100.0 96.6 438 45-49 0.2 96.3 0.0 1.1 2.4 100.0 96.3 399 Total 15-49 34.8 63.7 0.4 0.6 0.5 100.0 63.7 4,121 The results further show that more teenage girls age 15-19 (29 percent) are in formal marriage than teenage boys (7 percent). The proportion of married women increases rapidly from 29 percent among women age 15-19 to 77 percent among those age 20-24 and more than 90 percent among women age 25-44. A slightly Key Findings: • There is clear evidence of a rising age at marriage among women and men in Nepal. • The percentage of never-married women and men has increased in the past 10 years. Among women age 15-19, this proportion has grown from 60 percent in 2001 to 71 percent in 2011; among men in the same age group, it has increased from 89 percent to 93 percent. • The percentage of women married by age 15 declines from 24 percent among those age 45-49 to 5 percent among those age 15-19. A similar trend is seen among men. • Nepalese men marry four years later than women. The median age at first marriage among women age 25-49 is 17.5 years, and the median age among men is 21.6 years. • Nepalese women generally initiate sexual intercourse at the time of their first marriage. In contrast, men initiate intercourse a year earlier than their first marriage. 66 • Marriage and Sexual Activity lower percentage of women age 45-49 are in a union, primarily due to widowhood at older ages. Among men, the percentage married also rapidly increases from 7 percent in the youngest age group to 45 percent among those age 20-24 and 81 percent among those age 25-29; marriage is nearly universal among those age 30 and above. The proportion never married decreases sharply with age for both women and men. Among women, the proportion decreases from 71 percent in the 15-19 age group to less than 2 percent among those age 35 or above; among men, it decreases from 93 percent in the 15-19 age group to less than 2 percent in the 40-49 age group. The proportion never married has increased gradually over time, from 18 percent in 2001 to 21 percent in 2011 among women and from 32 percent in 2001 to 35 percent in 2011 among men. Figure 4.1 shows the trend in proportion never married for women and men age 15-19 and 20-24. Among women age 15-19 the proportion never married increased from 60 percent in 2001 to 71 percent in 2011 and for men it increased from 89 percent to 93 percent. A similar trend can be seen for women and men in the 20-24 age group. 60 89 17 44 68 90 18 44 71 93 23 54 0 10 20 30 40 50 60 70 80 90 100 Women Men Women Men 15-19 years 20-24 years Pe rc en t Figure 4.1 Trend in Proportion Never Married among Women and Men 15-24 Years 2001 NDHS 2006 NDHS 2011 NDHS 4.2 POLYGYNY Marital unions are predominantly of two types, those that are monogamous and those that are polygynous. The distinction has social significance and probable fertility implications, although the association between union type and fertility is complex and not well understood. Polygyny, the practice of having more than one wife, has connotations for the frequency of sexual intercourse and thus may have an effect on fertility. The extent of polygyny was measured in the 2011 NDHS by asking all currently married female respondents whether their husband or partner had other wives (co-wives) and, if so, how many. Currently married men were also asked whether they had one or more wives or partners with whom they were living. Table 4.2 shows the percent distribution of currently married women with co-wives and the percentage of currently married men with two or more wives. The data show that the majority of Nepalese women and men are in monogamous unions. Four percent of married women and 2 percent of married men are in polygynous unions. At least 6 percent of women age 35 or above report that they have co-wives. In contrast, less than 1 percent of men age 20-39 report having more than one wife, with this percentage rising to 2 percent among men age 40-44 and 5 percent among men age 45-49. Polygyny is more practiced in the hill zone, with 5 percent of women and 2 percent of men reporting being in a polygynous union. Polygyny is highest in the Eastern hill subregion (6 percent of women and 3 percent of men). Education is negatively associated with polygyny, with the proportion of women in a Marriage and Sexual Activity • 67 polygynous union decreasing from 6 percent among those with no education to 1 percent among those with a School Leaving Certificate (SLC) or above. There are no notable differences among men by education. Although the proportion of currently married women in a polygynous union declined between 1996 and 2001 (from 6 percent to 4 percent), there has been little change in the last decade. The proportion of currently married men who have more than one wife also has changed only minimally during the past 10 years. Table 4.2 Number of co-wives and wives Percentage of currently married women age 15-49 with co-wives and percentage of currently married men age 15-49 with two or more wives, according to background characteristics, Nepal 2011 Background characteristic Women Men Percentage with co-wives Number of women Percentage with 2+ wives Number of men Age 15-19 1.1 792 0.0 67 20-24 2.3 1,761 0.9 306 25-29 3.0 1,914 0.6 471 30-34 3.3 1,659 0.9 459 35-39 6.0 1,461 0.6 516 40-44 6.5 1,190 2.4 423 45-49 6.6 832 5.2 384 Residence Urban 3.6 1,261 1.4 425 Rural 4.0 8,346 1.7 2,201 Ecological zone Mountain 3.9 630 0.5 179 Hill 4.7 3,784 2.2 1,057 Terai 3.4 5,193 1.4 1,390 Development region Eastern 3.6 2,293 0.9 607 Central 4.0 3,210 2.3 950 Western 4.2 2,031 1.8 482 Mid-western 4.5 1,149 1.3 340 Far-western 3.8 925 1.2 247 Subregion Eastern mountain 3.1 169 0.8 42 Central mountain 4.1 190 0.0 50 Western mountain 4.3 271 0.6 87 Eastern hill 6.3 702 2.8 191 Central hill 4.8 1,103 2.3 385 Western hill 4.7 1,164 1.9 270 Mid-western hill 3.8 510 1.4 133 Far-western hill 2.6 305 2.3 77 Eastern terai 2.2 1,421 0.0 374 Central terai 3.5 1,918 2.4 515 Western terai 3.6 867 1.7 211 Mid-western terai 5.3 499 1.4 157 Far-western terai 4.4 488 0.9 133 Education No education 5.5 4,580 1.4 504 Primary 3.5 1,844 1.9 640 Some secondary 2.9 1,833 2.1 799 SLC and above 0.9 1,350 1.1 684 Wealth quintile Lowest 4.6 1,664 0.9 439 Second 3.8 1,846 1.7 452 Middle 4.6 2,022 1.5 569 Fourth 3.8 2,052 2.5 541 Highest 3.2 2,023 1.6 626 Total 4.0 9,608 1.7 2,626 SLC = School Leaving Certificate 4.3 AGE AT FIRST MARRIAGE Whether or not the start of marriage coincides with the initiation of sexual intercourse, and thus the beginning of exposure to the risk of pregnancy, it is an important social and demographic indicator and, in most societies, represents the point in a person’s life when childbearing first becomes acceptable. Duration of exposure to the risk of pregnancy depends primarily on the age at which women first marry. Women who marry early, on average, are more likely to have their first child at a young age and give birth to more children overall, contributing to higher fertility. 68 • Marriage and Sexual Activity Table 4.3 shows the percentage of women and men who have married by specific ages, according to current age. Age at first marriage is defined as the age at which the respondent began living with her or his first spouse/partner. Marriage occurs relatively early in Nepal; among women age 25-49, 55 percent were married by age 18, and 74 percent were married by age 20. The median age at first marriage among women age 25-49 is 17.5 years. The proportion of women married by age 15 declines from 24 percent among those age 45-49 to 5 percent among those age 15-19 indicating clear evidence of a rising age at first marriage. Table 4.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Nepal 2011 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 5.0 na na na na 71.0 2,753 a 20-24 10.1 40.7 59.8 na na 22.6 2,297 18.9 25-29 15.3 50.9 69.2 80.4 89.7 7.0 2,101 17.9 30-34 16.6 55.1 73.5 84.7 93.0 2.0 1,734 17.6 35-39 18.7 56.5 74.4 86.4 95.4 1.4 1,557 17.4 40-44 19.5 59.4 78.1 87.4 95.5 1.2 1,285 17.2 45-49 23.5 58.7 76.7 87.2 95.0 1.3 947 17.2 20-49 16.2 52.0 70.5 na na 7.6 9,921 17.8 25-49 18.0 55.4 73.7 84.6 93.2 3.1 7,624 17.5 MEN 15-19 0.0 na na na na 92.9 978 a 20-24 0.0 11.1 23.7 na na 54.4 685 a 25-29 0.0 17.1 33.8 49.5 70.3 17.3 581 22.1 30-34 0.0 19.5 37.7 50.5 66.9 6.4 499 21.9 35-39 0.0 16.7 36.3 53.2 73.4 2.4 542 21.6 40-44 0.0 20.5 39.2 56.6 76.8 1.4 438 21.0 45-49 0.1 23.0 37.5 55.2 79.7 0.2 399 21.3 20-49 0.0 17.3 33.9 na na 16.7 3,143 a 25-49 0.0 19.1 36.7 52.7 73.0 6.2 2,458 21.6 Note: Age at first marriage is defined as the age at which the respondent began living with her/his first spouse or partner. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women or men began living with their spouse or partner for the first time before reaching the beginning of the age group Men in Nepal marry more than four years later than women. The median age at first marriage among men age 25-49 is 21.6 years. Thirty-four percent of men age 25-29 were married by age 20, compared with 69 percent of women in the same age group. Only 11 percent of men age 20-24 were married by age 18, as compared with 41 percent of women in the same age group. By age 25, 80 percent of men age 45-49 are married, compared with 95 percent of women. 4.4 MEDIAN AGE AT FIRST MARRIAGE Table 4.4 shows the median age at first marriage for women age 20-49, women age 25-49, and men age 25-49 according to background characteristics. Urban women age 25-49 marry one year later than rural women, and women from the hill zone marry about one year later than women from the terai and mountain zones. Similarly, there is a two-year difference in median age at marriage between women age 25-49 living in the Eastern development region (18.7 years) and women living in the Far-western region (16.6 years). There is a three-year difference in median age at first marriage between women age 25-49 living in the Central terai (16.1 years) and women living in the Eastern hill subregion (19.3 years). A positive association is seen between median age at first marriage and level of education. Women with an SLC and higher education marry five years later than those with no education (21.8 years and 16.6 years, respectively). In addition, women from the highest wealth quintile marry about two years later than those from the other quintiles. Education and wealth clearly are delaying factors for age at first marriage. Marriage and Sexual Activity • 69 A similar pattern is seen among men age 25-49. Urban men marry two years later than rural men. Men from the hill zone marry one year later than men from the terai and mountain zones. Men in the Eastern region marry nearly three years later than men in the Far-western and Mid-western regions. Median age at first marriage among men living in the Far-western hill subregion is three years earlier than among men in the Central hill subregion. Education and wealth quintile have the same association on age at first marriage for men as for women. Table 4.4 Median age at first marriage by background characteristics Median age at first marriage among women age 20-49 and age 25-49, and median age at first marriage among men age 25-49, according to background characteristics, Nepal 2011 Background characteristic Women age: Men age 25-49 20-49 25-49 Residence Urban 19.0 18.5 23.6 Rural 17.7 17.4 21.2 Ecological zone Mountain 17.5 17.4 21.0 Hill 18.4 18.0 22.2 Terai 17.5 17.2 21.3 Development region Eastern 18.9 18.7 22.6 Central 17.4 17.0 22.0 Western 17.9 17.7 21.7 Mid-western 17.2 17.1 20.2 Far-western 17.0 16.6 20.1 Subregion Eastern mountain 19.1 19.2 22.3 Central mountain 17.7 17.4 20.3 Western mountain 16.4 16.3 20.6 Eastern hill 19.5 19.3 22.3 Central hill 19.4 18.8 23.2 Western hill 18.0 17.8 22.4 Mid-western hill 17.0 16.9 20.3 Far-western hill 16.7 16.5 19.9 Eastern terai 18.6 18.3 22.8 Central terai 16.5 16.1 21.0 Western terai 17.9 17.5 21.0 Mid-western terai 17.5 17.3 20.1 Far-western terai 17.4 16.9 20.1 Education No education 16.6 16.6 20.1 Primary 17.4 17.3 20.5 Some secondary 18.5 18.5 21.1 SLC and above a 21.8 a Wealth quintile Lowest 17.0 17.0 20.4 Second 17.2 17.1 20.3 Middle 17.2 17.0 20.3 Fourth 17.9 17.5 21.9 Highest 19.7 19.1 24.6 Total 17.8 17.5 21.6 Note: Age at first marriage is defined as the age at which the respondent began living with her or his first spouse or partner. a = Omitted because less than 50 percent of the respondents began living with their spouse or partner for the first time before reaching the beginning of the age group SLC = School Leaving Certificate There has been a marked increase in median age at marriage among women age 20-49 over the last 15 years, from 16.4 years in 1996 to 17.8 years in 2011. In case of men age 25-49, the median age at marriage increased over the last 5 years, from 20.2 years in 2006 to 21.6 years in 2011. This is another clear indication of a continuing shift to later marriage in Nepal for both men and women. 70 • Marriage and Sexual Activity 4.5 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is often used as a proxy for the onset of women’s exposure to the risk of pregnancy. However, because some women are sexually active before marriage, the age at which women initiate sexual intercourse more precisely marks the beginning of their exposure to pregnancy. Table 4.5 shows the percentage of women and men who had first sexual intercourse by specific ages and the median age at first intercourse, irrespective of marital status. This information allows an assessment of the age at which women and men start having sexual intercourse and its trend across age cohorts. Table 4.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had sexual intercourse, and median age at first sexual intercourse, according to current age, Nepal 2011 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had sexual intercourse Number Median age at first sexual intercourse 15 18 20 22 25 WOMEN 15-19 4.6 na na na na 71.0 2,753 a 20-24 9.9 40.4 58.7 na na 22.6 2,297 19.0 25-29 14.7 49.4 67.5 79.2 88.0 7.0 2,101 18.1 30-34 14.4 53.0 71.8 82.7 91.1 2.0 1,734 17.7 35-39 17.0 55.4 73.1 84.8 93.6 1.5 1,557 17.5 40-44 17.1 57.0 75.7 84.7 92.3 1.3 1,285 17.4 45-49 21.1 57.4 75.8 85.8 93.9 1.3 947 17.4 20-49 14.8 50.6 68.9 na na 7.6 9,921 17.9 25-49 16.3 53.7 72.0 na na 3.1 7,624 17.7 15-24 7.0 na na na na 49.0 5,050 a MEN 15-19 3.7 na na na na 79.3 978 a 20-24 2.2 22.2 43.6 na na 32.4 685 a 25-29 2.1 25.0 44.5 62.0 81.2 9.2 581 20.6 30-34 3.0 27.0 49.4 60.7 76.4 2.9 499 20.1 35-39 2.2 24.2 45.0 58.7 76.4 2.0 542 20.7 40-44 2.5 25.8 44.1 62.1 77.2 1.4 438 20.6 45-49 1.5 24.0 41.9 58.2 79.5 0.1 399 20.8 20-49 2.2 24.6 44.8 na na 9.8 3,143 a 25-49 2.3 25.2 45.1 na na 3.5 2,458 20.5 15-24 3.1 na na na na 59.9 1,663 a na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Sixteen percent of women age 25-49 had first sexual intercourse by age 15, 54 percent by age 18, and 72 percent by age 20. The median age at first intercourse among women age 25-49 (17.7 years) is only marginally higher than the median age at marriage (17.5 years), suggesting that Nepalese women in general initiate sexual intercourse at the time of their first marriage, with few exceptions. The median age at first sexual intercourse among men age 25-49 (20.5 years) is three years higher than among women in the same group (17.7 years), mostly because men tend to marry later than women. Two percent of men age 25-49 had first sexual intercourse by age 15, 25 percent by age 18, and 45 percent by age 20, much later than among women age 25-49. The median age at first sexual intercourse among men age 25-49 is one year earlier than the median age at marriage, suggesting premarital sexual intercourse among men. Furthermore, the data show that 3 percent of women and 4 percent of men age 25-49 have never had sexual intercourse. It is noteworthy that half of women and three-fifths of men age 15-24 have not had sexual intercourse. Marriage and Sexual Activity • 71 4.6 MEDIAN AGE AT FIRST SEXUAL INTERCOURSE Table 4.6 shows median age at first sexual intercourse among women and men age 25-49 by background characteristics. The variation in the median age at first sexual intercourse among women according to background characteristics is nearly identical to the variation in the median age at first marriage, and therefore it is not discussed separately here. For the most part, differences in the median age at first sexual intercourse among men age 25-49 by background characteristics are similar to those discussed for median age at first marriage. However, it is worth noting that the differences in median age at sexual intercourse by development region and subregion are substantial. Men in the Mid-western region (19.0 years) commence sexual intercourse 2.7 years earlier than men in the Eastern region (21.7 years), two years earlier than men in the Central region (20.9 years) and one year earlier than men in the Western (20.2 years) and Far-western (19.9 years) regions. Men residing in the Western mountain subregion (19.2 years) initiate sexual intercourse three years earlier than men in the Eastern mountain (21.9 years) and Central hill (22.1 years) subregions. Men with an SLC or higher education initiate sexual intercourse about four years later than men with no education (23.2 years and 19.4 years, respectively). Similarly, men from the highest wealth quintile (22.8 years) initiate sexual intercourse about three years later than men from the lowest and second quintiles (19.6 years each). 4.7 RECENT SEXUAL ACTIVITY In the absence of contraception, the possibility of pregnancy is related to the frequency of sexual intercourse. Thus, information on intercourse is important for refining measurement of exposure to pregnancy. All women and men were asked how long ago their last sexual contact occurred. Tables 4.7.1 and 4.7.2 show the percent distribution of women and men age 15-49 by the timing of their last sexual intercourse, according to background characteristics. Table 4.7.1 shows that half of women age 15-49 were sexually active during the four weeks preceding the survey. Eighteen percent had been sexually active in the 12 months preceding the survey, but not in the past month, and 12 percent had not been sexually active for one or more years. One in every five women (21 percent) has never had sexual intercourse. The percentage of women age 15-19 who reported never having had sexual intercourse increased from 68 percent in the 2006 NDHS to 71 percent in the 2011 NDHS. The proportion of women who were sexually active in the four weeks preceding the survey increases with age; from 18 percent at age 15-19 to 68 percent by age 40-44, and then decreases to 59 percent at age 45- 49. The majority of women age 15-19 have never had sexual intercourse, which is not surprising. Also as expected, practically all never-married women have never had sexual intercourse (99 percent). About two-thirds (65 percent) of women who are currently in a union were sexually active in the four weeks preceding the survey. Women married for less than 15 years were less likely to be sexually active in the four weeks preceding the survey than women married for longer periods. Women who have been married more than once were much more likely than women married just once to be sexually active in the four weeks preceding the survey. Table 4.6 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 20-49 and age 25-49, and median age at first sexual intercourse among men age 25-49, according to background characteristics, Nepal 2011 Background characteristic Women age: Men age 25-49 20-49 25-49 Residence Urban 19.1 18.6 22.5 Rural 17.8 17.5 20.2 Ecological zone Mountain 17.6 17.5 20.1 Hill 18.5 18.2 21.0 Terai 17.6 17.3 20.3 Development region Eastern 19.0 18.9 21.7 Central 17.6 17.2 20.9 Western 18.0 17.8 20.2 Mid-western 17.4 17.3 19.0 Far-western 17.1 16.7 19.9 Subregion Eastern mountain 19.2 19.2 21.9 Central mountain 17.9 17.7 19.6 Western mountain 16.6 16.5 19.2 Eastern hill 19.5 19.3 21.4 Central hill 19.6 19.1 22.1 Western hill 18.1 17.9 20.7 Mid-western hill 17.2 17.1 19.2 Far-western hill 16.8 16.6 19.9 Eastern terai 18.7 18.6 21.9 Central terai 16.6 16.2 20.1 Western terai 17.9 17.6 19.6 Mid-western terai 17.7 17.5 18.8 Far-western terai 17.5 17.0 19.9 Education No education 16.7 16.7 19.4 Primary 17.5 17.5 19.7 Some secondary 18.6 18.6 20.1 SLC and above a 21.8 23.2 Wealth quintile Lowest 17.2 17.1 19.6 Second 17.4 17.2 19.6 Middle 17.4 17.1 19.3 Fourth 18.1 17.7 20.9 Highest 19.8 19.3 22.8 Total 17.9 17.7 20.5 a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group SLC = School Leaving Certificate 72 • Marriage and Sexual Activity Table 4.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Nepal 2011 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years Age 15-19 17.7 9.2 2.2 71.0 100.0 2,753 20-24 43.8 22.7 10.9 22.6 100.0 2,297 25-29 56.5 22.2 14.4 7.0 100.0 2,101 30-34 63.7 21.2 13.1 2.0 100.0 1,734 35-39 64.7 16.9 17.0 1.5 100.0 1,557 40-44 67.5 15.8 15.4 1.3 100.0 1,285 45-49 59.4 20.6 18.6 1.3 100.0 947 Marital status Never married 0.4 0.1 0.2 99.3 100.0 2,708 Married 64.6 23.4 11.9 0.1 100.0 9,608 Divorced/separated/widowed 0.3 6.5 92.3 0.9 100.0 358 Marital duration2 0-4 years 60.3 29.6 9.5 0.6 100.0 1,975 5-9 years 59.9 25.4 14.6 0.0 100.0 1,722 10-14 years 60.3 24.8 14.9 0.0 100.0 1,593 15-19 years 69.4 19.1 11.5 0.0 100.0 1,423 20-24 years 70.0 16.7 13.3 0.0 100.0 1,144 25+ years 69.8 20.4 9.7 0.0 100.0 1,301 Married more than once 73.3 21.6 5.2 0.0 100.0 451 Residence Urban 49.4 14.7 8.5 27.4 100.0 1,819 Rural 49.0 18.4 12.2 20.3 100.0 10,855 Ecological zone Mountain 55.3 16.4 9.6 18.7 100.0 805 Hill 47.1 17.8 12.6 22.5 100.0 5,090 Terai 49.8 18.1 11.2 20.8 100.0 6,779 Development region Eastern 46.6 15.9 14.9 22.5 100.0 3,057 Central 53.1 16.1 9.0 21.7 100.0 4,236 Western 43.8 20.8 14.9 20.5 100.0 2,660 Mid-western 53.5 19.0 8.5 19.1 100.0 1,478 Far-western 47.5 21.6 9.4 21.6 100.0 1,242 Subregion Eastern mountain 46.1 14.8 15.1 24.1 100.0 229 Central mountain 49.4 18.0 8.6 24.0 100.0 258 Western mountain 66.7 16.3 6.5 10.5 100.0 319 Eastern hill 44.6 16.4 15.2 23.8 100.0 956 Central hill 53.7 10.7 8.7 26.8 100.0 1,563 Western hill 41.6 23.0 16.2 19.2 100.0 1,513 Mid-western hill 49.8 21.7 10.1 18.5 100.0 649 Far-western hill 44.1 23.4 11.7 20.8 100.0 409 Eastern terai 47.6 15.8 14.8 21.7 100.0 1,873 Central terai 53.1 19.4 9.3 18.2 100.0 2,415 Western terai 46.7 17.8 13.2 22.3 100.0 1,147 Mid-western terai 53.0 17.1 7.9 21.9 100.0 668 Far-western terai 45.9 21.6 8.1 24.3 100.0 676 Education No education 60.2 20.4 14.7 4.7 100.0 5,045 Primary 50.6 21.3 13.9 14.2 100.0 2,209 Some secondary 37.2 14.2 9.4 39.2 100.0 3,088 SLC and above 39.3 14.1 6.0 40.6 100.0 2,331 Wealth quintile Lowest 50.4 19.1 12.3 18.1 100.0 2,120 Second 48.6 20.1 11.2 20.0 100.0 2,393 Middle 48.5 20.1 12.0 19.5 100.0 2,600 Fourth 46.6 17.6 13.9 21.9 100.0 2,722 Highest 51.4 13.4 9.1 26.1 100.0 2,839 Total 49.1 17.9 11.7 21.4 100.0 12,674 1 Excludes women who had sexual intercourse within the last four weeks 2 Excludes women who are not currently married SLC = School Leaving Certificate The results show that there is no noticeable variation in sexual activity within the last four weeks preceding the survey by urban-rural residence. Recent sexual activity is relatively lower among women who live in the hill zone (47 percent) than women who live in the terai (50 percent) and mountain (55 percent) zones. Forty-four percent of women living in the Western region had recent sexual intercourse, compared with 54 percent in the Mid-western region and 53 percent in the Central region. Recent sexual intercourse is highest in the Western mountain subregion (67 percent) and lowest in the Western hill subregion (42 percent). Women Marriage and Sexual Activity • 73 with no education (60 percent) are more likely to have been sexually active in the past four weeks than those with a primary education (51 percent). Women with some secondary education and an SLC and higher education are least likely to have been sexually active in the past four weeks (37 percent and 39 percent, respectively). More than half (57 percent) of men age 15-49 were sexually active in the four weeks preceding the survey, 12 percent were sexually active in the past year but not in the past four weeks, and 5 percent had not been sexually active for one or more years (Table 4.7.2). One in four men had never had sexual intercourse. Table 4.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Nepal 2011 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the past 4 weeks Within 1 year1 One or more years Age 15-19 7.8 8.0 5.0 79.3 100.0 978 20-24 43.3 17.3 7.0 32.4 100.0 685 25-29 72.5 13.7 4.5 9.2 100.0 581 30-34 84.1 9.1 3.9 2.9 100.0 499 35-39 87.5 7.5 3.0 2.0 100.0 542 40-44 83.6 11.8 3.2 1.4 100.0 438 45-49 78.4 15.5 6.0 0.1 100.0 399 Marital status Never married 3.7 12.4 8.4 75.4 100.0 1,433 Married 87.9 10.6 1.5 0.0 100.0 2,626 Divorced/separated/widowed (8.3) (30.6) (61.0) (0.0) 100.0 62 Marital duration2 0-4 years 85.8 13.2 0.9 0.1 100.0 536 5-9 years 89.1 10.4 0.5 0.0 100.0 460 10-14 years 92.3 7.3 0.4 0.0 100.0 407 15-19 years 87.6 9.6 2.8 0.0 100.0 391 20-24 years 88.3 8.7 2.9 0.0 100.0 328 25+ years 84.4 15.3 0.4 0.0 100.0 261 Married more than once 86.3 10.0 3.7 0.0 100.0 243 Residence Urban 51.3 13.8 4.1 30.8 100.0 717 Rural 58.7 11.1 4.9 25.3 100.0 3,404 Ecological zone Mountain 67.0 9.7 2.6 20.7 100.0 245 Hill 56.7 12.8 4.3 26.2 100.0 1,658 Terai 56.9 10.8 5.4 26.9 100.0 2,218 Development region Eastern 52.3 13.9 4.7 29.1 100.0 996 Central 57.9 12.6 5.2 24.3 100.0 1,448 Western 56.8 9.9 4.6 28.7 100.0 798 Mid-western 64.9 9.4 4.8 20.9 100.0 493 Far-western 60.8 7.6 3.8 27.9 100.0 385 Subregion Eastern mountain 56.9 12.4 1.7 29.0 100.0 66 Central mountain 64.1 10.9 3.2 21.7 100.0 69 Western mountain 74.8 7.3 2.8 15.1 100.0 110 Eastern hill 54.9 13.7 5.0 26.3 100.0 293 Central hill 52.8 17.2 3.9 26.1 100.0 616 Western hill 57.3 9.8 4.6 28.4 100.0 440 Mid-western hill 67.3 9.1 4.7 18.9 100.0 189 Far-western hill 62.7 4.8 2.7 29.8 100.0 120 Eastern terai 50.6 14.2 4.9 30.3 100.0 638 Central terai 61.5 9.0 6.4 23.1 100.0 763 Western terai 56.1 10.0 4.6 29.2 100.0 358 Mid-western terai 60.6 9.6 5.2 24.6 100.0 242 Far-western terai 56.4 9.8 4.8 29.0 100.0 217 Education No education 77.5 12.1 5.0 5.3 100.0 567 Primary 69.6 12.3 4.2 13.9 100.0 814 Some secondary 49.8 10.1 4.4 35.7 100.0 1,437 SLC and above 49.5 12.4 5.5 32.7 100.0 1,303 Wealth quintile Lowest 63.6 10.3 4.9 21.2 100.0 610 Second 60.2 11.2 3.4 25.2 100.0 695 Middle 63.5 9.7 4.2 22.6 100.0 830 Fourth 49.0 13.9 7.7 29.4 100.0 920 Highest 54.6 11.9 3.6 29.9 100.0 1,066 Total 15-49 57.4 11.5 4.8 26.2 100.0 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes men who had sexual intercourse within the last four weeks 2 Excludes men who are not currently married SLC = School Leaving Certificate 74 • Marriage and Sexual Activity Men in urban areas (51 percent), those in the hill zone and terai (57 percent each), those in the Eastern development region (52 percent), and those in the Eastern terai subregion (51 percent) were less likely to have been sexually active in the four weeks prior to the survey than their counterparts in the other areas. Men with some secondary education and SLC and higher level of education (50 percent each) and men in the fourth wealth quintile (49 percent) also reported less sexual activity in the four weeks prior to the interview than their counterparts. A comparison of data from the 2001, 2006, and 2011 NDHS for currently married women shows gradual decreases in the percentage of women sexually active in the four weeks preceding the survey, from 71 percent in 2001 to 70 percent in 2006 and 65 percent in 2011. However, married men show the reverse pattern, with an increase from 82 percent in 2001 to 88 percent in 2006 and in 2011. The 2011 NDHS data show that 4 percent of never-married men were sexually active in the four weeks preceding the survey, as compared with less than 1 percent of never-married women. Overall, one in four never- married men had ever had sexual intercourse, compared with one percent of never-married women. Fertility • 75 FERTILITY 5 A major objective of the 2011 NDHS was 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 replacement level by the end of 2017 through empowerment of women and poverty alleviation (National Planning Commission, 2007). Fertility is one of the three principal components of population dynamics that determine the size, structure, and composition of the population in any country. This chapter focuses on a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women begin childbearing. Birth intervals are important because short intervals are associated with high childhood mortality. The age at which childbearing begins can also have a major impact on the health and well- being of both the mother and the child. To generate data on fertility, a pregnancy history was collected from each woman interviewed in the 2011 NDHS. Women were asked to report on the total number of sons and daughters to whom they had given birth in their lifetime. To ensure that all information was reported, women were asked separately about children still living at home, those living elsewhere, and those who had died. The sex, date of birth, and survival status of each child were obtained, and age at death for dead children was recorded. In addition to information on live births, the pregnancy history section incorporated questions on all pregnancies that did not end in a live birth, including information on the month and year the pregnancy ended, the duration of the pregnancy, and whether something was done deliberately to end the pregnancy. 5.1 CURRENT FERTILITY Measures of current fertility are presented in Table 5.1 for the three-year period preceding the survey, corresponding to the calendar period 2008-2010. A three-year period was chosen for calculating these rates to provide the most current information while also allowing the rates to be calculated for a sufficient number of cases so as not to compromise the statistical precision of the estimate. Age-specific fertility rates (ASFRs), expressed as the number of births per thousand women in a specified age group, show the age pattern of fertility. Numerators for ASFRs are calculated by identifying live births that occurred in the three-year period preceding the survey classified according to the age of the mother (in five-year age groups) at the time of the child’s birth. The denominators of the rates represent the number of woman-years lived by the survey respondents in each of the five-year age groups during the specified period. The total fertility rate (TFR) is the number of live births a woman would have if she were subject to the current age-specific fertility rates throughout her reproductive years (15-49 years). The general fertility rate (GFR) is the number of live births occurring during a specified period per 1,000 women age 15-44.The crude birth rate (CBR) is the number of live births per 1,000 population during a specified period. Key Findings: • The total fertility rate for the three years preceding the survey is 2.6 births per woman, with rural women having about one child more than urban women. • Fertility has decreased from 4.6 births per woman in 1996 to 2.6 births per woman in 2011, a two-child decline in the past 15 years. • Childbearing begins early in Nepal, with almost one quarter of women giving birth by age 18 and nearly half by age 20. • Seventeen percent of adolescent women age 15-19 are already mothers or pregnant with their first child. In the last five years, teenage pregnancy has fallen by 10 percent. • Half of births occur within three years of a previous birth, with 21 percent occurring within 24 months. 76 • Fertility Table 5.1 shows current fertility in Nepal at the national level and by urban-rural residence. The TFR for the three years preceding the 2011 NDHS is 2.6 births per woman. Fertility is considerably higher in rural areas (2.8 births per woman) than in urban areas (1.6 births per woman), where fertility is below replacement level. As the ASFRs show, the pattern of higher rural fertility is prevalent in all age groups. The urban-rural difference in fertility is most pronounced for women in the 35-39 age group (16 births per 1,000 women in urban areas versus 39 births per 1,000 women in rural areas). The overall age pattern of fertility, as reflected in the ASFRs, indicates that childbearing begins early. Fertility is low among adolescents, increases to a peak of 187 births per 1,000 among women age 20-24, and declines thereafter. 5.2 FERTILITY DIFFERENTIALS This section examines the association between a woman’s background characteristics and her fertility. Table 5.2 presents differentials in TFRs, the percentage of women 15-49 who are currently pregnant, and the mean number of children ever born to women age 40-49 by urban-rural residence, ecological zone, development region, education, and wealth quintile. There are considerable differentials in fertility among ecological zones, with fertility ranging from a low of 2.5 births per woman in the terai to a high of 3.4 births per woman in the mountain zone. The TFR ranges from 2.5 births per woman in the Eastern, Central, and Western regions to 3.2 births per woman in the Mid-western region. Level of fertility is inversely related to women’s educational attainment, decreasing rapidly from 3.7 births among women with no education to 1.7 births among women with a School Leaving Certificate (SLC) or above. Fertility is also associated with wealth quintile. Women in the lowest wealth quintile have an average of 4.1 births, nearly three times as many as women in the highest quintile (1.5 births). Table 5.2 also presents a crude assessment of trends in the various subgroups by comparing current fertility with a measure of completed fertility: the mean number of children ever born to women age 40-49. The mean number of children ever born to older women who are nearing the end of their reproductive period is an indicator of average completed fertility of women who began childbearing during the three decades preceding the survey. If fertility remained constant over time and the reported data on both children ever born and births during the three years preceding the survey are reasonably accurate, the TFR and the mean number of children ever born to women 40-49 are expected to be similar. When fertility levels have been falling, the TFR will be substantially lower than the mean number of children ever born among women age 40-49. The comparison suggests that fertility has fallen by nearly two births during the past 15 years, from 4.3 births per woman to 2.6 births per woman. Fertility has declined in both urban and rural areas, in all regions, at all educational levels, and for all wealth quintiles. The difference between current and completed fertility is highest in the Far-western region (2.1 births), in urban areas (1.7 births), and among women in the fourth wealth quintile (1.8 births). The percentage of women who reported being pregnant at the time of the survey is also presented in Table 5.2. This percentage may be underreported since women may not be aware of a pregnancy, especially at the early stages, and some women who are early in their pregnancy may not want to reveal that they are pregnant. Five percent of women were pregnant at the time of the survey. Rural women are slightly more likely to be pregnant than urban women. Regionally, the proportion of women who are currently pregnant is highest in the Mid-western region and lowest in the Western region. The proportion of women currently pregnant varies by education, but the pattern is mixed. The percentage currently pregnant ranges from a low of 4 percent among women in the highest wealth quintile to a high of 6 percent among women in the lowest wealth quintile. Table 5.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Nepal 2011 Age group Residence Total Urban Rural 15-19 42 87 81 20-24 135 197 187 25-29 82 134 126 30-34 38 78 71 35-39 16 39 36 40-44 0 16 14 45-49 2 5 5 TFR (15-49) 1.6 2.8 2.6 GFR 60 102 96 CBR 16.6 25.5 24.3 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women age 15-44 CBR: Crude birth rate expressed per 1,000 population Fertility • 77 Table 5.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Nepal 2011 Background characteristic Total fertility rate Percentage of women age 15- 49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 1.6 4.0 3.3 Rural 2.8 5.1 4.4 Ecological zone Mountain 3.4 5.7 4.8 Hill 2.6 4.7 4.2 Terai 2.5 5.0 4.2 Development region Eastern 2.5 5.5 4.0 Central 2.5 5.1 4.2 Western 2.5 3.5 4.0 Mid-western 3.2a 6.5 5.0 Far-western 2.8 4.0 4.9 Education No education 3.7 4.5 4.6 Primary 2.7a 5.2 4.0 Some secondary 2.1b 4.6 2.9 SLC and above 1.7b 5.8 2.2 Wealth quintile Lowest 4.1 6.1 5.5 Second 3.1 5.0 4.7 Middle 2.7 5.4 4.3 Fourth 2.1 4.5 3.9 Highest 1.5 3.9 3.0 Total 2.6 4.9 4.3 Note: Total fertility rates are for the period 1-36 months prior to the interview. SLC = School Leaving Certificate a One or more of the components of age-specific fertility rates are based on 125-249 woman-years of exposure. b One or more of the components of age-specific fertility rates are based on fewer than 125 woman-years of exposure. 5.3 FERTILITY TRENDS In addition to the comparison of current and completed fertility, trends in fertility can be assessed in two other ways. First, fertility trends can be investigated using retrospective data on pregnancy histories collected in the 2011 NDHS. Second, the TFR from the 2011 NDHS can be compared with estimates obtained in earlier surveys. Trends in fertility over time can be examined by comparing age-specific fertility rates from the 2011 NDHS for successive five-year periods preceding the survey, as presented in Table 5.3.1. Because women age 50 or above were not interviewed in the survey, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 35-39 for the period 15-19 years before the survey because these women would have been over age 50 at the time of the survey and therefore not eligible to be interviewed. Nonetheless, the results in Table 5.3.1 show that fertility has dropped substantially among all age groups over the past two decades. The decline is steepest among the cohort age 30-34, with a 50 percent decline between the period 10-14 years before the survey and the period 0-4 years before the survey. Table 5.3.1 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother’s age at the time of the birth, Nepal 2011 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 87 122 127 132 20-24 194 218 278 278 25-29 128 164 208 244 30-34 71 89 142 [172] 35-39 38 60 [95] 40-44 19 [27] 45-49 [5] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 78 • Fertility Table 5.3.2 and Figure 5.1 compare fertility trends from estimates obtained in the 1996, 2001, and 2006 NDHS with information gathered in the 2011 NDHS. Fertility declined from 4.6 births per woman in the 1996 NFHS to 2.6 births per woman in the 2011 NDHS—a drop of two births per woman in the past 15 years. The decline in fertility is most pronounced in the five years between 2001 and 2006 (a one-child decline). Fertility has declined in every age group over the past 15 years, with largest decline seen among women 25-34 years. But over the past 5 years the largest decline is observed among women 20-24 years. Many factors may have contributed to this precipitous decline in Nepal, including improved communication and greater access to modern methods of contraception. Extended spousal separations due to migrants seeking work in foreign countries, especially the Gulf countries and other Southeast Asian countries, may be another reason for the fertility decline (see Table 3.2). A decline in the ideal number of children, increasing age at marriage, and increasing use of safe abortion services are other factors that could potentially affect fertility. These are discussed in greater detail in later chapters of this report. 0 50 100 150 200 250 300 15-19 20-24 25-29 30-34 35-39 40-44 45-49 R at e (p er 1 ,0 00 w om en ) Mother’s age at birth Figure 5.1 Trends in Fertility NFHS 1996 (1993-1995) NDHS 2001 (1998-2000) NDHS 2006 (2003-2005) NDHS 2011 (2008-2010) 5.4 CHILDREN EVER BORN AND LIVING Data on the number of children ever born reflect the accumulation of births over the past 30 years and therefore have limited relevance to current fertility levels, particularly when the country has experienced a decline in fertility. Moreover, the data are subject to recall error, which is typically greater for older than younger women. Nevertheless, information on children ever born (or parity) is useful in looking at a number of issues. Parity data show how average family size varies across age groups. The percentage of currently married women in their 40s who have never had children also provides an indicator of the level of primary infertility or the inability to bear children. Comparisons of differences in the mean number of children ever born and surviving reflect the cumulative effects of mortality levels during the period in which women have been bearing children. Table 5.3.2 Trends in fertility Age-specific and total fertility rates (TFRs), Nepal 1996, 2001, 2006, and 2011 Age group NFHS 1996a (1993-1995) NDHS 2001b (1998-2000) NDHS 2006c (2003-2005) NDHS 2011 (2008-2010) 15-19 127 110 98 81 20-24 266 248 234 187 25-29 229 205 144 126 30-34 160 136 84 71 35-39 94 81 48 36 40.44 37 34 16 14 45-49 15 7 2 5 TFR 4.6 4.1 3.1 2.6 Note: Age-specific fertility rates are per 1,000 women. Rates refer to the three-year period prior to each survey. a Pradhan et al., 1997:37 b Ministry of Health, New ERA, and ORC Macro, 2002:58 c Ministry of Health and Population, New ERA, and Macro International Inc., 2007:63 Fertility • 79 Table 5.4 shows the percent distribution of all women and currently married women by number of children ever born, mean number of children ever born, and mean number of children living. Eighty-eight percent of women age 15-19 have never given birth. This proportion declines to 12 percent among women age 25-29 and to 5 percent or less among women age 30 or above, indicating that childbearing among Nepalese women is nearly universal. On average, Nepalese women nearing the end of their reproductive years have attained a parity of 4.6 children. This is two children more than the total fertility rate. The same pattern is replicated for currently married women, except that the mean number of children ever born is higher among currently married women (2.7 children) than among all women (2.1 children). The difference between all women and currently married women in mean number of children ever born is due to the substantial proportion of young and unmarried women in the former category who exhibit lower fertility. Table 5.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Nepal 2011 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 87.9 10.4 1.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,753 0.14 0.13 20-24 39.1 31.3 21.0 7.2 1.3 0.1 0.0 0.0 0.0 0.0 0.0 100.0 2,297 1.01 0.94 25-29 11.8 20.9 33.9 20.8 8.8 3.0 0.6 0.2 0.0 0.0 0.0 100.0 2,101 2.06 1.93 30-34 5.0 7.9 34.2 26.4 14.7 7.5 3.3 0.8 0.2 0.0 0.0 100.0 1,734 2.79 2.58 35-39 2.5 4.2 23.7 26.2 19.3 11.6 5.6 3.7 2.1 0.7 0.3 100.0 1,557 3.52 3.19 40-44 3.1 2.9 14.3 23.8 21.9 13.8 9.2 5.7 2.5 1.6 1.2 100.0 1,285 4.02 3.52 45-49 4.2 2.0 12.2 16.5 19.4 13.3 10.0 11.8 5.0 3.8 1.8 100.0 947 4.57 3.91 Total 29.8 13.4 19.7 15.2 9.7 5.4 2.9 2.1 0.9 0.5 0.3 100.0 12,674 2.12 1.91 CURRENTLY MARRIED WOMEN 15-19 57.9 36.1 5.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 792 0.48 0.45 20-24 21.0 40.5 27.3 9.3 1.7 0.2 0.0 0.0 0.0 0.0 0.0 100.0 1,761 1.31 1.22 25-29 5.0 22.3 36.4 22.6 9.5 3.3 0.6 0.2 0.0 0.0 0.0 100.0 1,914 2.23 2.08 30-34 2.9 7.5 35.1 27.0 15.2 7.7 3.4 0.9 0.2 0.0 0.0 100.0 1,659 2.87 2.66 35-39 0.8 3.9 23.8 27.3 20.1 11.5 5.7 3.9 2.3 0.6 0.3 100.0 1,461 3.58 3.25 40-44 1.7 2.4 14.3 24.2 22.1 14.4 9.4 6.1 2.4 1.7 1.3 100.0 1,190 4.11 3.61 45-49 2.5 1.7 11.9 16.7 19.7 13.4 10.6 11.9 5.2 4.3 2.0 100.0 832 4.71 4.02 Total 10.7 17.2 25.2 19.5 12.3 6.7 3.7 2.6 1.1 0.7 0.4 100.0 9,608 2.68 2.42 As expected, the mean number of children ever born and the mean number of children surviving rise with increasing age of women. A comparison of the mean number of children ever born with the mean number of living children reveals the experience of child loss among Nepalese women. By the end of their reproductive years (age 45-49), women in Nepal have given birth to an average of 4.6 children, with 3.9 surviving. Voluntary childlessness is uncommon in Nepal. Currently married women with no children are likely to be those who are sterile or unable to bear children. The level of childlessness among married women at the end of their reproductive period can be used as an indicator of the level of primary sterility. In Nepal, primary sterility among older currently married women is 3 percent. 5.5 BIRTH INTERVALS Birth interval is the length of time between two successive live births. Information on birth intervals provides insight into birth spacing patterns, which affect fertility as well as maternal, infant, and childhood mortality. Studies have shown that short birth intervals are associated with increased risk of death for mother and baby, particularly when the birth interval is less than 24 months. Table 5.5 shows the percent distribution of non-first births in the five years preceding the survey by number of months since the preceding birth, according to background characteristics. The median birth interval in Nepal is 36.2 months, an increase from 31.8 months in 2001. Median number of months since a preceding birth increases significantly with age, from 33.3 months among mothers age 20-29 to 46.8 months among mothers age 40-49. There is no marked difference in the length of the median birth interval by birth order or sex of the preceding birth. Studies have shown that the death of a preceding child leads to a shorter birth interval than when the preceding child survived. The median birth interval is almost 11 months shorter among births in which the 80 • Fertility previous sibling is dead than among births in which the previous sibling is alive (26.2 months and 36.9 months, respectively). This difference in birth intervals may be due to the desire of parents to replace a dead child as well as the loss of the fertility-delaying effects of breastfeeding. According to the 2011 NDHS data, birth intervals are slightly longer in urban (40.3 months) than in rural (35.9 months) areas. There are no marked differences in median birth intervals by ecological zones. The median birth interval is longest in the Western region (43.3 months) and shortest in the Far-western region (33.2 months). Birth intervals are longer in the Western terai and Western hill subregions than in the other subregions. Birth interval increases with education from 35.1 months among women with no education to 42.2 months among women with an SLC or above. Similarly, birth interval increases with wealth. The birth interval for the highest wealth quintile is nearly 4 years (46.2 months), whereas for all other quintiles it is 37.2 months or less. Table 5.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Nepal 2011 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 (30.7) (36.0) (25.1) (6.0) (2.3) (0.0) 100.0 45 (22.1) 20-29 8.2 16.6 31.0 23.0 10.3 10.9 100.0 2,134 33.3 30-39 5.4 8.8 25.4 17.2 12.0 31.2 100.0 1,148 43.0 40-49 4.2 4.9 22.9 21.0 12.1 35.0 100.0 224 46.8 Sex of preceding birth Male 7.0 13.3 27.8 19.9 12.6 19.4 100.0 1,676 36.8 Female 7.6 13.8 29.3 21.6 9.3 18.4 100.0 1,875 35.6 Survival of preceding birth Living 5.7 13.3 29.0 21.3 11.1 19.5 100.0 3,263 36.9 Dead 25.2 16.6 23.2 15.2 8.3 11.5 100.0 288 26.2 Birth order 2-3 7.2 13.7 27.4 20.9 11.3 19.4 100.0 2,361 36.8 4-6 7.4 13.9 29.7 21.2 8.8 18.9 100.0 947 35.5 7+ 7.5 11.5 35.1 18.3 14.2 13.5 100.0 243 33.7 Residence Urban 6.5 11.4 23.5 17.6 13.1 27.9 100.0 290 40.3 Rural 7.4 13.8 29.0 21.1 10.6 18.1 100.0 3,262 35.9 Ecological zone Mountain 8.3 13.9 33.1 20.9 9.3 14.4 100.0 311 34.2 Hill 6.7 12.3 30.7 19.0 11.0 20.4 100.0 1,424 36.2 Terai 7.7 14.5 26.1 22.2 11.0 18.5 100.0 1,816 36.8 Development region Eastern 8.5 14.3 24.1 22.5 12.1 18.5 100.0 790 37.0 Central 9.0 14.4 29.4 20.5 8.1 18.6 100.0 1,133 34.5 Western 5.4 10.3 23.7 19.5 13.5 27.6 100.0 625 43.3 Mid-western 4.7 12.2 34.0 20.4 12.6 16.0 100.0 570 35.6 Far-western 6.8 16.9 34.3 21.0 9.5 11.6 100.0 433 33.2 Subregion Eastern mountain 10.6 8.4 27.0 20.4 11.1 22.6 100.0 69 38.6 Central mountain 8.5 11.0 29.2 20.3 9.8 21.2 100.0 68 36.5 Western mountain 7.3 17.3 37.1 21.3 8.5 8.5 100.0 174 32.1 Eastern hill 8.9 11.9 25.9 24.2 12.4 16.8 100.0 279 37.6 Central hill 7.1 11.5 29.8 19.9 7.6 24.1 100.0 304 36.5 Western hill 5.4 10.0 26.5 17.4 12.2 28.5 100.0 381 43.1 Mid-western hill 5.0 14.2 36.5 16.8 12.5 15.0 100.0 276 33.3 Far-western hill 7.4 16.3 39.3 16.7 9.4 10.9 100.0 184 32.1 Eastern terai 8.0 16.7 22.5 21.8 12.1 18.9 100.0 443 36.7 Central terai 9.8 15.8 29.3 20.8 8.2 16.1 100.0 762 33.5 Western terai 5.5 10.7 19.4 22.7 15.6 26.2 100.0 243 44.1 Mid-western terai 3.8 9.8 27.0 24.5 14.0 21.0 100.0 198 39.4 Far-western terai 5.0 14.2 30.1 25.9 10.9 13.9 100.0 171 36.3 Education No education 7.2 15.2 29.4 21.1 9.6 17.5 100.0 2,074 35.1 Primary 7.6 12.1 30.6 19.9 10.4 19.3 100.0 698 35.8 Some secondary 9.2 10.6 24.4 18.6 15.5 21.8 100.0 501 39.0 SLC and above 4.3 10.8 24.5 24.9 12.6 23.0 100.0 279 42.2 Wealth quintile Lowest 7.1 14.9 35.2 19.8 8.8 14.2 100.0 1,099 33.2 Second 6.5 15.2 27.8 21.6 10.9 18.0 100.0 830 36.3 Middle 9.4 12.8 25.5 20.6 11.2 20.6 100.0 703 37.2 Fourth 7.4 12.3 26.3 23.2 10.5 20.3 100.0 523 37.2 Highest 5.7 9.8 20.1 19.3 16.2 28.8 100.0 396 46.2 Total 7.3 13.6 28.6 20.8 10.9 18.9 100.0 3,551 36.2 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. Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate Fertility • 81 5.6 POSTPARTUM AMENORRHEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhea is the interval between the birth of a child and the resumption of menstruation, a period during which the risk of pregnancy is much reduced. Postpartum protection from conception depends upon the intensity and duration of breastfeeding. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. A woman is considered insusceptible if she is not exposed to the risk of pregnancy, either because she is amenorrheic or because she is abstaining from sexual intercourse following a birth. In the 2011 NDHS, information was obtained about the duration of amenorrhea and the duration of sexual abstinence following childbirth for births in the three years preceding the survey. Table 5.6 shows that Nepalese women are amenorrheic for a median of 6.6 months, abstain for a median of 3.0 months, and are insusceptible to pregnancy for a median of 8.2 months. In general, the proportion of women who are amenorrheic or abstaining decreases with increasing months after delivery. The proportion of women who are amenorrheic drops from 98 percent in the first two months after birth to 22 percent at 12-13 months and less than 1 percent at 22 months or later. The majority of Nepalese women (86 percent) are still abstaining in the first two months following birth. A comparison of data from earlier surveys indicates that the median duration of postpartum amenorrhea, a proximate determinant of fertility, declined from 10.3 months in 1996 to 9.3 months in 2006 and then to 6.6 months in 2011. Table 5.6 Postpartum amenorrhea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Nepal 2011 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 < 2 98.1 86.4 99.7 136 2-3 84.8 47.7 90.2 209 4-5 61.0 39.1 71.5 202 6-7 50.0 22.7 58.2 183 8-9 40.2 15.8 46.6 188 10-11 28.9 14.2 38.0 139 12-13 21.8 12.9 31.7 181 14-15 10.9 10.1 20.8 164 16-17 10.0 12.9 20.3 204 18-19 6.1 3.7 9.0 174 20-21 2.3 9.9 11.6 172 22-23 0.6 11.4 12.1 138 24-25 0.7 6.3 6.9 163 26-27 0.0 3.9 3.9 185 28-29 0.9 2.9 3.8 202 30-31 0.4 4.5 4.9 189 32-33 0.0 3.7 3.7 189 34-35 0.7 1.7 2.4 145 Total 23.4 16.9 29.9 3,163 Median 6.6 3.0 8.2 na Mean 8.6 6.5 11.0 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth Table 5.7 shows the median duration of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics. The duration of postpartum insusceptibility is substantially longer among women age 30-49 than among women age 15-29 and among rural than urban women. Also, postpartum insusceptibility is longer among women residing in the mountain zone than women in the other zones. Women in the Mid- western region have the longest median postpartum insusceptibility. Women with no education have longer duration of postpartum insusceptibility than women with SLC and higher level of education (10.7 months versus 5.7 months). Women in the lowest wealth quintile are insusceptible almost three times longer than women in the highest wealth quintile (12.1 months versus 4.7 months). 82 • Fertility Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Nepal 2011 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother’s age 15-29 6.3 2.8 7.8 30-49 9.5 3.9 10.4 Residence Urban 6.0 4.1 7.1 Rural 6.7 2.9 8.3 Ecological zone Mountain 8.6 2.3 10.1 Hill 7.1 3.2 9.4 Terai 6.2 3.0 7.4 Development region Eastern 5.8 3.7 7.7 Central 5.7 2.5 6.8 Western 6.8 3.5 9.2 Mid-western 9.9 2.6 10.6 Far-western 8.7 2.6 10.0 Education No education 9.8 2.9 10.7 Primary 7.8 3.1 8.6 Some secondary 5.5 3.2 6.6 SLC and above 4.7 2.9 5.7 Wealth quintile Lowest 10.8 3.4 12.1 Second 8.1 2.8 8.4 Middle 5.7 2.1 8.0 Fourth 6.0 4.8 7.0 Highest 4.0 2.9 4.7 Total 6.6 3.0 8.2 Note: Medians are based on the status at the time of the survey (current status). SLC = School Leaving Certificate 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth 5.7 MENOPAUSE The risk of becoming pregnant declines with age. The term infecundity refers to a process rather than a well-defined event, and although the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a group of women. Table 5.8 presents data on menopause, an indicator of decreasing exposure to the risk of pregnancy (infecundity) for women age 30 or above. In the 2011 NDHS, women were considered menopausal if they were neither pregnant nor postpartum amenorrheic and had not had a menstrual period for at least six months preceding the survey. The proportion of women who were menopausal increased with age, from 5 percent among women age 30-34 to 50 percent among women age 48-49. Overall, 13 percent of women age 30-49 were menopausal, a decline from 16 percent in 2006. The proportion of currently married women age 48-49 who were menopausal increased between 2001 and 2006 (from 56 percent to 64 percent) before declining to 50 percent in 2011. 5.8 AGE AT FIRST BIRTH The onset of childbearing at an early age has a major effect on the health of both mother and child. It also lengthens the reproductive period, thereby increasing the level of fertility. Table 5.9 shows the median age at first birth and the percentage of women who gave birth by exact ages, according to current age. The median age at first birth is 20.1 years for the youngest cohort of women (age 25-29) for whom a median age can be Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Nepal 2011 Age Percentage menopausal1 Number of women 30-34 4.7 1,734 35-39 7.4 1,557 40-41 10.2 541 42-43 16.1 521 44-45 19.5 469 46-47 30.8 372 48-49 50.0 329 Total 12.8 5,523 1 Percentage of all women who are not pregnant and not postpartum amenorrheic whose last menstrual period occurred six or more months preceding the survey Fertility • 83 computed. Almost one-quarter of Nepalese women (23 percent) have given birth before reaching age 18, while about half (48 percent) have given birth by age 20. The median age at first birth is about 20 years across all age cohorts, indicating virtually no change in age at first birth over time. Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Nepal 2011 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 0.3 na na na na 87.9 2,753 a 20-24 1.4 19.4 39.1 na na 39.1 2,297 a 25-29 2.1 25.1 49.5 66.3 83.2 11.8 2,101 20.1 30-34 2.1 23.1 47.6 69.6 85.8 5.0 1,734 20.2 35-39 2.5 23.4 49.5 69.2 87.3 2.5 1,557 20.0 40-44 2.4 20.7 46.3 68.5 86.3 3.1 1,285 20.3 45-49 1.8 18.8 41.8 65.7 84.6 4.2 947 20.7 20-49 2.0 22.0 45.6 na na 13.6 9,921 a 25-49 2.2 22.8 47.6 68.0 85.3 5.9 7,624 20.2 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 5.10 shows that the median age at first birth is slightly higher in urban areas than in rural areas. Likewise, median age at first birth is slightly higher in the hill zone than in the other ecological zones. Median age at first birth is highest in the Eastern region (21.1 years) and lowest in the Far-western region (19.5 years). Women living in the Far-western terai subregion have the lowest median age at first birth (19.3 years). Median age at first birth increases with education, with the impact of education more obvious among women with an SLC or higher education. Women with a primary education or no education give birth to their first child four years earlier than women who have an SLC or higher education. 5.9 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy and motherhood is a major social and health issue in Nepal. Early teenage pregnancy can cause severe health problems for both the mother and child. Moreover, an early start to childbearing greatly reduces women’s educational and employment opportunities and is associated with higher levels of fertility. Table 5.11 shows that 17 percent of women age 15-19 have already had a birth or are pregnant with their first child. The percentage of women who have begun childbearing increases rapidly with age, from 1 percent among women age 15 to 39 percent among women age 19. Teenage pregnancy is twice as high in rural areas as in urban areas. Teenage childbearing is lowest in the hill zone (16 percent) and highest in the terai (18 percent); however, teenage pregnancy in the terai zone has declined markedly, from 26 percent in 2001. Not surprisingly, early childbearing is inversely related to educational level. For example, teenagers with no education are about four times more likely to have begun childbearing than those with SLC and higher education (32 percent and 8 percent, respectively). The percentage of teenagers who have begun childbearing is highest (22 percent) in the middle wealth quintile and lowest in the wealthiest households (7 percent). At the national level, the proportion of teenage pregnancies has declined by about 10 percent in the last five years. Table 5.10 Median age at first birth Median age at first birth among women age 25-49 years, according to background characteristics, Nepal 2011 Background characteristic Women age 25-49 Residence Urban 20.7 Rural 20.1 Ecological zone Mountain 20.4 Hill 20.6 Terai 19.9 Development region Eastern 21.1 Central 20.0 Western 20.1 Mid-western 19.7 Far-western 19.5 Subregion Eastern mountain 21.3 Central mountain 20.2 Western mountain 19.9 Eastern hill 21.5 Central hill 21.0 Western hill 20.3 Mid-western hill 19.8 Far-western hill 19.8 Eastern terai 20.8 Central terai 19.5 Western terai 19.9 Mid-western terai 19.6 Far-western terai 19.3 Education No education 19.7 Primary 19.7 Some secondary 20.5 SLC and above 23.7 Wealth quintile Lowest 20.0 Second 20.0 Middle 19.8 Fourth 20.0 Highest 21.2 Total 20.2 SLC = School Leaving Certificate 84 • Fertility Table 5.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Nepal 2011 Background characteristic Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 0.1 0.8 0.9 550 16 2.1 2.8 4.9 531 17 6.3 4.2 10.5 574 18 19.9 8.5 28.4 558 19 32.3 6.5 38.8 540 Residence Urban 6.1 3.2 9.3 367 Rural 13.0 4.8 17.8 2,386 Ecological zone Mountain 12.6 4.6 17.1 182 Hill 10.5 5.0 15.5 1,086 Terai 13.2 4.3 17.5 1,485 Development region Eastern 11.3 4.6 15.9 672 Central 12.3 4.7 16.9 896 Western 12.3 3.9 16.2 573 Mid-western 13.7 6.5 20.2 333 Far-western 11.3 3.3 14.5 279 Subregion Eastern mountain 11.5 2.5 14.0 54 Central mountain 9.4 1.3 10.7 63 Western mountain 16.5 9.4 26.0 65 Eastern hill 9.5 5.5 15.0 224 Central hill 8.5 4.6 13.0 305 Western hill 12.6 5.2 17.8 324 Mid-western hill 10.5 5.9 16.3 140 Far-western hill 12.0 3.2 15.2 93 Eastern terai 12.3 4.4 16.6 394 Central terai 14.8 5.1 19.9 528 Western terai 11.9 2.2 14.1 248 Mid-western terai 15.7 5.6 21.3 159 Far-western terai 10.1 3.0 13.1 156 Education No education 24.1 7.5 31.6 327 Primary 20.4 7.4 27.8 456 Some secondary 9.5 3.8 13.2 1,368 SLC and above 5.3 2.7 8.0 602 Wealth quintile Lowest 12.6 5.8 18.4 492 Second 15.7 5.0 20.6 574 Middle 15.6 6.5 22.1 597 Fourth 10.5 3.9 14.4 588 Highest 5.3 1.3 6.7 502 Total 12.1 4.6 16.7 2,753 SLC = School Leaving Certificate Fertility Preferences • 85 FERTILITY PREFERENCES 6 Information on fertility preferences is used to assess future fertility patterns and potential demand for contraception. Such data are also useful in constructing measures of unwanted or mistimed births. 6.1 DESIRE FOR MORE CHILDREN Information about the desire for more children is important for understanding future reproductive behavior. The provision of adequate and accessible family planning services is dependent on the availability of such information. In the 2011 NDHS, currently married women (whether pregnant or not) and men were asked about their intentions to have another child and, if they had such intentions, how soon they wanted the child. The same question was phrased differently in the case of pregnant women or men whose wife or wives (or girlfriends) were pregnant at the time of the interview to ensure the wantedness of subsequent children after completion of the current pregnancy. Sterilized women and men were considered to want no more children, and therefore they were not asked questions about their desire for more children. Table 6.1 shows that 8 percent of women and 10 percent of men want to have another child soon (within two years), while 14 percent of women and 17 percent of men want another child two or more years later. Half of women and three-fifths of men do not want any more children, and 23 percent of women and 9 percent of men have already been sterilized (includes both female and male sterilization). The desire to limit childbearing (including by undergoing sterilization) increases with the number of living children, from 5 percent among women with no children to 94 percent among women with six or more children. Two percent of women with no children have been sterilized. A comparison of data from the 2006 and 2011 NDHS shows a slight increase in the proportion of currently married women who want no more children or have been sterilized, from 71 percent in 2006 to 73 percent in 2011. This is a 24 percent increase from 59 percent in 1996. The desire to limit childbearing among married men increases from 2 percent among those with no children to 93 percent among those with six or more children. The proportion of currently married men (15-49) who want no more children or have been sterilized has decreased slightly from 70 percent in 2006 to 69 percent in 2011. Women are more likely to want to limit childbearing at lower parities than men. For example, 33 percent of women with one child desire to stop childbearing or have been sterilized, compared with 25 percent of men with one child. Similarly, 88 percent of women with two children desire to stop childbearing or have been sterilized, compared with 83 percent of men with two children. Key Findings: • About three-quarters of currently married women age 15-49 and two-thirds of men want no more children or are sterilized. • The desire to stop childbearing among married women has increased in the past 15 years, from 59 percent in 1996 to 73 percent in 2011. • Women and men report an ideal family size of about two children. The mean ideal number of children among currently married women has declined by nearly one child in the last 15 years, from 2.9 children in 1996 to 2.2 children in 2011. • Overall, Nepalese women have about one child more than their ideal number. This implies that the total fertility rate of 2.6 children per woman is 44 percent higher than it would be if unwanted births were avoided. 86 • Fertility Preferences Table 6.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Nepal 2011 Desire for children Number of living children Total 15-49 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 48.7 14.3 3.4 2.2 0.7 0.2 0.7 8.4 Have another later3 39.0 44.8 5.1 2.0 0.6 0.7 0.0 14.0 Have another, undecided when 1.9 2.2 0.8 0.5 0.0 0.5 0.5 1.0 Undecided 3.0 5.2 1.7 0.8 0.6 0.3 0.0 2.0 Want no more 2.7 31.0 65.7 50.8 56.3 64.1 73.0 49.7 Sterilized4 1.8 1.5 22.3 41.7 39.4 31.2 20.7 23.0 Declared infecund 3.0 1.0 1.1 2.0 2.4 3.1 5.1 1.9 Missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 802 1,878 2,759 1,996 1,155 531 487 9,608 MEN5 Have another soon2 57.0 17.1 4.4 1.5 2.2 0.9 0.7 10.1 Have another later3 32.5 49.8 11.1 4.2 2.4 1.2 2.3 17.1 Have another, undecided when 0.2 0.9 0.0 0.0 0.0 0.0 0.0 0.2 Undecided 5.4 6.8 1.7 0.9 1.2 0.4 0.0 2.6 Want no more 1.7 24.3 72.8 76.8 79.4 86.1 83.2 60.2 Sterilized4 0.0 0.2 9.7 16.6 13.7 10.6 9.6 8.9 Declared infecund 2.8 1.0 0.2 0.0 1.1 0.8 4.2 0.9 Missing 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 219 522 737 537 310 133 168 2,626 1 The number of living children includes the current pregnancy. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 5 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Fertility preference relates closely to number of living children. Almost half of women (49 percent) with no living children want to have a child soon, as compared with 1 percent of women with six or more children. Among men without children, 57 percent want to have a child soon, compared with less than 1 percent of men with six or more children. The more children a woman has, the less likely she is to want another child. 6.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS Tables 6.2.1 and 6.2.2 provide information on differences in potential demand for fertility control by background characteristics. At parities less than four, urban women are more likely to want to limit childbearing than rural women. However, at higher parities (four or more children), rural women are more likely to want to limit childbearing than urban women. Women in the mountain and hill zones (75 and 76 percent, respectively) are more likely to want to limit childbearing than women in the terai (70 percent). Women in the Western development region are more likely to want to limit childbearing than those in the other development regions (76 percent compared with 74 percent or lower). However, women in the Far-western development region with fewer than four living children have less desire to limit childbearing than women of the same parity in other development regions. Men in the mountain zone are more likely to want to limit childbearing than men in the hill and terai zones. Differences among men in the desire to limit childbearing by development region are relatively small. Overall, women and men with no education have a greater desire to limit childbearing than those with higher levels of education. However, among women and men with less than four children, those who have higher levels of education are more likely to want to limit childbearing than those with lower levels of education. A similar pattern is seen among women and men according to wealth quintile. Fertility Preferences • 87 Table 6.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Nepal 2011 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 5.6 37.4 91.8 95.3 94.8 89.6 77.3 72.7 Rural 4.3 31.6 87.2 92.2 95.8 95.8 94.4 72.7 Ecological zone Mountain 5.7 29.1 88.4 93.6 96.1 94.8 94.6 74.9 Hill 4.2 36.0 92.4 96.5 96.4 97.2 96.8 75.8 Terai 4.6 30.1 84.8 89.8 95.1 93.7 90.5 70.2 Development region Eastern 4.5 30.2 86.4 93.4 97.5 98.5 98.1 69.7 Central 4.5 34.8 85.6 89.9 95.5 95.0 87.8 72.6 Western 7.2 38.0 93.9 96.9 94.9 94.1 96.4 76.1 Mid-western 1.8 27.6 88.7 92.0 94.3 92.0 95.0 72.2 Far-western 1.2 23.5 86.3 90.3 95.8 97.5 98.1 73.9 Education No education 5.9 27.2 82.3 90.4 95.3 95.0 93.3 81.2 Primary 3.0 31.4 89.8 93.0 96.7 98.3 (97.4) 72.7 Some secondary 5.2 32.8 91.1 98.9 96.8 * * 63.3 SLC and above 3.7 37.0 93.8 99.8 (99.4) * * 56.9 Wealth quintile Lowest 1.2 22.7 84.6 91.2 93.6 96.6 96.6 75.8 Second 1.3 29.1 82.9 91.5 97.2 95.0 94.8 72.4 Middle 3.6 23.5 82.2 91.4 93.6 97.7 88.4 69.1 Fourth 5.6 38.5 90.9 93.6 98.1 91.7 (89.2) 73.0 Highest 8.7 40.6 94.0 95.5 97.1 (95.3) * 73.8 Total 4.5 32.4 88.0 92.5 95.7 95.3 93.7 72.7 Note: Women who have been sterilized are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 The number of living children includes the current pregnancy Table 6.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Nepal 2011 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 3.7 27.6 88.0 96.8 97.7 * * 66.6 Rural 1.3 23.6 81.1 92.9 92.5 96.8 93.2 69.6 Ecological zone Mountain (0.0) 12.8 83.5 96.9 96.0 (100.0) (100.0) 73.2 Hill 1.1 24.3 88.7 94.9 93.8 93.6 92.0 70.2 Terai 2.4 25.8 77.5 91.9 92.3 (99.1) 92.1 67.7 Development region Eastern (5.9) 28.7 83.5 94.6 89.7 (94.2) (89.5) 67.7 Central 0.0 26.2 79.1 94.8 91.4 * (94.1) 67.8 Western (2.7) 19.0 90.7 93.8 (97.9) * * 71.4 Mid-western (0.0) 16.5 76.7 91.6 96.5 (94.0) (100.0) 71.1 Far-western (0.0) 24.9 85.4 88.3 (92.3) (94.0) * 70.3 Education No education * (5.8) 67.8 94.4 92.0 97.8 96.3 77.4 Primary (1.1) 27.6 75.7 93.3 93.6 94.4 91.6 72.8 Some secondary 0.0 26.0 83.1 90.3 91.3 (97.5) * 66.3 SLC and above 3.3 25.2 93.9 97.1 (98.7) * * 62.8 Wealth quintile Lowest (0.0) 5.6 75.6 91.0 87.9 93.2 94.2 71.9 Second (1.1) 10.9 76.1 90.4 97.2 (97.2) (97.0) 68.3 Middle (0.0) 21.7 74.8 92.3 90.2 * (100.0) 66.8 Fourth (2.0) 37.0 79.9 95.9 92.8 * * 66.7 Highest 4.3 29.0 93.7 96.8 100.0 * * 71.8 Total 15-49 1.7 24.5 82.5 93.4 93.1 96.7 92.8 69.1 Note: Men who have been sterilized or who state in response to the question about desire for children that their wife has been sterilized are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 The number of living children includes one additional child if the respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). 88 • Fertility Preferences 6.3 IDEAL FAMILY SIZE The discussion of fertility preferences earlier in this chapter focused on respondents’ current childbearing preferences. These preferences are influenced by the number of children a respondent already has. The 2011 NDHS asked women and men age 15-49 about the total number of children they would like to have in their lifetime if they could choose the exact number to have at the time they had no children. Even though this question is based on a hypothetical situation, it provides two measures. First, for women and men who have not yet started a family, the data provide an idea of future fertility. Second, for older and high-parity women, the excess of past fertility over the ideal family size provides a measure of unwanted fertility. Table 6.3 shows that almost all women and men were able to provide a numeric response to the question asked to assess ideal family size. Table 6.3 Ideal number of children by number of living children Percent distribution of women and men 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to the number of living children, Nepal 2011 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN1 0 2.9 0.4 0.3 0.3 0.0 0.1 0.2 1.0 1 21.6 26.2 10.0 3.8 0.7 2.3 0.7 13.1 2 66.8 64.0 77.3 57.2 52.1 38.7 28.3 63.0 3 7.4 7.8 10.2 33.7 33.1 43.1 41.5 17.8 4 0.8 1.2 1.4 4.0 13.0 13.2 22.5 4.1 5 0.1 0.1 0.3 0.5 0.7 2.0 0.9 0.4 6+ 0.0 0.0 0.1 0.1 0.2 0.1 4.7 0.3 Non-numeric responses 0.4 0.3 0.2 0.3 0.2 0.4 1.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 3,550 1,934 2,851 2,068 1,199 557 515 12,674 Mean ideal number children for:2 All women 1.8 1.8 2.0 2.4 2.6 2.7 3.1 2.1 Number of women 3,537 1,928 2,845 2,061 1,196 555 508 12,630 Currently married women 1.9 1.8 2.0 2.4 2.6 2.7 3.1 2.2 Number of currently married women 802 1,872 2,754 1,988 1,153 529 481 9,579 MEN3 0 1.0 0.0 0.1 0.0 0.3 0.0 0.0 0.5 1 9.4 14.3 7.5 3.4 1.5 1.4 0.0 7.6 2 73.1 67.7 72.8 53.8 48.3 40.5 33.5 65.2 3 13.3 14.9 17.2 36.1 33.7 38.3 44.2 20.9 4 2.4 2.2 2.2 5.6 15.9 16.7 20.9 5.0 5 0.5 0.3 0.2 1.1 0.2 3.1 0.8 0.6 6+ 0.2 0.7 0.0 0.0 0.0 0.0 0.7 0.2 Non-numeric responses 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,664 534 756 548 315 135 169 4,121 Mean ideal number children for:2 All men 2.1 2.1 2.1 2.5 2.6 2.8 3.0 2.3 Number of men 1,662 534 756 548 315 135 169 4,119 Currently married men 2.2 2.1 2.1 2.5 2.6 2.8 3.0 2.3 Number of currently married men 219 522 737 537 310 133 168 2,626 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Both women and men in Nepal prefer a small family size, with only marginal differences between them (2.1 children for women and 2.3 children for men). Nearly two-thirds of women and men want to have two children, while 13 percent of women and 8 percent of men want to have only one child. Eighteen percent of women and 21 percent of men prefer a three-child family. The proportion of women and men who want four or more children is small (5 percent of women and 6 percent of men want to have four children). There has been a decline in the mean ideal number of children among currently married women over the last five years, from 2.4 children in 2006 to 2.2 in 2011. This finding could also explain the declining total fertility rate in Nepal. Fertility Preferences • 89 Table 6.3 shows that the mean ideal number of children increases with the number of living children among both women and men, from two children among respondents with no children to three children among respondents with six or more children. This positive association between actual and ideal number of children is due to two factors. First, to the extent that women are able to implement their fertility desires, women who want smaller families will tend to achieve smaller families. Second, some women may have difficulty admitting their desire for fewer children if they could begin childbearing again and may in fact report their actual number as their preferred number. Despite this tendency to rationalize, the data provide evidence of unwanted fertility, with the vast majority of women with six or more children reporting an ideal family size of fewer than six children. Table 6.4 shows that the mean ideal number of children increases with age for both women and men, ranging from 1.9 children among women age 15-19 to 2.6 among women age 45-49 and from 2.2 among men age 15-19 to 2.6 among men age 45-49. The ideal number of children for women and men is slightly lower in urban than rural areas. Differences in mean ideal number of children by ecological zone and development region are small. Table 6.4 Mean ideal number of children by background characteristics Mean ideal number of children for all women and men age 15-49 by background characteristics, Nepal 2011 Background characteristic Women Men Mean Number of women1 Mean Number of men2 Age 15-19 1.9 2,749 2.2 975 20-24 1.9 2,291 2.1 685 25-29 2.1 2,090 2.1 581 30-34 2.2 1,731 2.3 499 35-39 2.3 1,555 2.4 542 40-44 2.5 1,275 2.4 438 45-49 2.6 940 2.6 399 Residence Urban 1.9 1,811 2.0 716 Rural 2.2 10,819 2.3 3,402 Ecological zone Mountain 2.2 805 2.4 245 Hill 2.0 5,064 2.2 1,658 Terai 2.2 6,761 2.3 2,215 Development region Eastern 2.1 3,054 2.2 996 Central 2.2 4,209 2.2 1,448 Western 2.0 2,654 2.3 796 Mid-western 2.2 1,473 2.3 493 Far-western 2.2 1,240 2.2 385 Subregion Eastern mountain 2.1 228 2.3 66 Central mountain 2.0 258 2.4 69 Western mountain 2.4 319 2.4 110 Eastern hill 2.1 954 2.3 293 Central hill 1.9 1,547 2.0 616 Western hill 2.0 1,508 2.3 440 Mid-western hill 2.2 646 2.4 189 Far-western hill 2.3 409 2.3 120 Eastern terai 2.1 1,872 2.2 638 Central terai 2.4 2,404 2.4 763 Western terai 2.0 1,146 2.3 356 Mid-western terai 2.1 666 2.2 242 Far-western terai 2.0 673 2.1 217 Education No education 2.5 5,024 2.8 567 Primary 2.1 2,203 2.4 813 Some secondary 1.9 3,079 2.2 1,436 SLC and above 1.7 2,323 2.0 1,303 Wealth quintile Lowest 2.4 2,111 2.5 610 Second 2.3 2,388 2.4 695 Middle 2.2 2,592 2.3 830 Fourth 2.0 2,710 2.2 919 Highest 1.9 2,829 2.0 1,064 Total 2.1 12,630 2.3 4,119 SLC = School Leaving Certificate 1 Number of women who gave a numeric response 2 Number of men who gave a numeric response 90 • Fertility Preferences The mean ideal number of children varies inversely with the respondent’s level of education and wealth quintile. Among women, it ranges from 1.7 children for those with an SLC or higher to 2.5 children for those with no education. Among men, it ranges from two children for those with an SLC or higher to 2.8 children for those with no education. Similarly, it ranges from 1.9 children for women and two children for men in the highest wealth quintile to 2.4 children for women and 2.5 children for men in the lowest quintile. 6.4 FERTILITY PLANNING Information collected in the 2011 NDHS can also be used to estimate levels of unwanted fertility. This information provides some insight into the degree to which couples are able to control fertility. Women age 15- 49 were asked a series of questions about each child born to them in the preceding five years, as well as any current pregnancy, to determine whether the birth or pregnancy was wanted then (planned), wanted later (mistimed), or not wanted at all (unplanned) at the time of conception. In assessing these results, it is important to recognize that women may declare a previously unwanted birth or current pregnancy as wanted, and this rationalization results in an underestimate of the true extent of unwanted births. Table 6.5 shows that three in four births in the five years preceding the survey were planned, 12 percent were mistimed, and 13 percent were unwanted. The proportion of wanted births decreases and the proportion of unwanted births increases with increasing birth order. Eighty-four percent of first-order births are wanted, and 43 percent of fourth- and higher-order births are unwanted. The proportion of mistimed births is high (16-17 percent) for first- and second-order births and then declines with birth order. Table 6.5 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Nepal 2011 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Birth order 1 83.8 16.1 0.2 100.0 2,097 2 79.2 17.4 3.4 100.0 1,629 3 74.3 7.8 17.9 100.0 990 4+ 53.1 3.5 43.4 100.0 1,297 Mother’s age at birth <20 75.2 23.1 1.7 100.0 1,242 20-24 80.7 13.4 5.9 100.0 2,343 25-29 76.2 7.5 16.3 100.0 1,368 30-34 62.9 5.0 32.1 100.0 651 35-39 50.3 2.5 47.2 100.0 289 40-44 44.5 0.0 55.5 100.0 108 45-49 * * * 100.0 12 Total 74.4 12.4 13.3 100.0 6,013 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. The proportion of planned births is highest (81 percent) among mothers in the 20-24 age group. The percentage of planned births has increased from 69 percent in the 2006 NDHS to 74 percent in the 2011 NDHS. Mistimed births are more common among younger mothers (under age 30) than among older mothers (above age 30). The percentage of unwanted births increases with mother’s age at birth, rising from 2 percent among mothers below age 20 to 56 percent among mothers age 40-44 years. 6.5 WANTED FERTILITY RATES The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. It is calculated in the same manner as the total fertility rate but excluding unwanted births from the numerator. A birth is considered wanted if the number of living children at the time of conception is less than the ideal number of children reported by the respondent. The gap between wanted and actual fertility shows how successful women are in achieving their reproductive intentions. This measure also may be an underestimate to the extent that women may not report an ideal family size lower than their actual family size. Fertility Preferences • 91 The total wanted fertility rates in Table 6.6 represent the levels of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been avoided. Overall, Nepalese women have 0.8 children more than their ideal number of 1.8 children. This implies that the total fertility rate (TFR) is 44 percent higher than it would be if unwanted births were avoided. The gap between wanted and observed fertility rates is higher among women who live in rural areas (one child) than among women who live in urban areas (0.4 children). Similarly, the gap is higher among women residing in the mountain zone (1.4 children) than women residing in the hill (one child) and terai (0.7 children) zones. The difference between wanted and observed total fertility rates varies from 0.7 children per woman in the Eastern development region to one child per woman in the Far-western development region. The gap between wanted and observed total fertility rates decreases with increasing education. Women with no education have 1.2 children more than they want, compared to 0.2 children among women with at least an SLC. There is an inverse relationship between wanted fertility rate and wealth quintile. The gap between wanted and actual fertility rates ranges from 0.3 children among women in the highest wealth quintile to two children among women in the lowest wealth quintile. There has been a steady decline in the desired number of children among Nepalese women, from 2.5 children in 2001 to two in 2006 and 1.8 in 2011. The gap between wanted and actual fertility rates has narrowed over the years, from 1.1 children in 2006 to 0.8 children in 2011. Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Nepal 2011 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 1.2 1.6 Rural 1.8 2.8 Ecological zone Mountain 2.0 3.4 Hill 1.6 2.6 Terai 1.8 2.5 Development region Eastern 1.8 2.5 Central 1.7 2.5 Western 1.7 2.5 Mid-western 1.8 3.2a Far-western 1.8 2.8 Education No education 2.5 3.7 Primary 1.9 2.7a Some secondary 1.6 2.1b SLC and above 1.5 1.7b Wealth quintile Lowest 2.1 4.1 Second 2.0 3.1 Middle 2.0 2.7 Fourth 1.6 2.1 Highest 1.2 1.5 Total 1.8 2.6 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 5.2. SLC = School Leaving Certificate a One or more of the components of age-specific fertility rates are based on 125-249 woman-years of exposure. b One or more of the components of age-specific fertility rates are based on fewer than 125 woman- years of exposure. Family Planning • 93 FAMILY PLANNING 7 Family planning continues to be a priority for the government of Nepal and is highlighted in the current three-year interim development plan (2010-2012) (National Planning Commission, 2010b). It is also considered as an essential component of Nepal Health Sector Program Implementation Plan 2010-2015 (NHSP IP-II). The objectives of the National Family Planning Program include gradually reducing the population growth rate through the promotion of a small family norm to the population in general and the rural population more specifically, working toward satisfying the demand for family planning services, providing high-quality services, and reducing unmet need. Despite the high importance placed on family planning activities in national policies, strategies and plans, lack of funds and inadequate attention to family planning in recent years has meant that progress towards targets has stalled. In light of this, the Family Health Division is taking a leadership role to revitalize the family planning program in Nepal. The National Family Planning Program also seeks to expand and sustain quality family planning services throughout the health service network, including hospitals, primary health care (PHC) centers, health posts (HP), sub-health posts (SHP), primary health care outreach clinics (PHC/ORC), and mobile voluntary surgical contraception (VSC) camps (Ministry of Health and Population [MOHP], 2009). To this end, the Family Health Division (FHD) has initiated satellite clinics in all 75 districts. The Female Community Health Volunteers play an important role in providing information and distributing condoms and resupply of pills. In addition, the private sector and nongovernmental organizations (NGOs) have been encouraged to play a more effective role in the National Family Planning Program (National Planning Commission, 2002). This chapter presents information on knowledge of various contraceptive methods and discusses past and current prevalence. For users of periodic abstinence (rhythm method), knowledge of the ovulatory cycle is examined; for those relying on sterilization, the timing of the procedure is assessed. Also discussed are the source of modern contraceptive methods, informed choice, discontinuation rates and reasons for discontinuation, unmet need for family planning, nonuse of contraception, and intention to use contraceptive methods in the future. In addition, information is provided on exposure to family planning messages through the media and contact with family planning providers. These topics are of practical use to policymakers in formulating efficient and effective family planning strategies and policies. Although the main focus of this chapter is on women, results from the male survey are also presented because men play an important role in the realization of reproductive goals. Wherever possible, comparisons are made with findings from previous surveys in order to evaluate trends in family planning in Nepal over time. Key Findings: • Knowledge of contraception is universal in Nepal. • One in two currently married women is using a method of contraception, with most women using a modern method (43 percent). • The three most popular modern methods used by married women are female sterilization (15 percent), injectables (9 percent), and male sterilization (8 percent). • Use of modern methods has increased by 66 percent in the past 15 years. However, there has been little change in the last five years. • The government sector remains the major provider of contraceptive methods, catering to more than two in three users (69 percent). • Overall, 51 percent of contraceptive users discontinued using a method within 12 months of starting its use. Twenty-six percent of episodes of discontinuation occurred because the woman’s husband was away. • Twenty-seven percent of currently married women have an unmet need for family planning services, with 10 percent having an unmet need for spacing and 17 percent having an unmet need for limiting. 94 • Family Planning 7.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Knowledge of contraceptive methods is an important precursor to their use. The ability to recognize a family planning method when it is described is a simple test of a respondent’s knowledge but not necessarily an indication of the extent of her or his knowledge. The 2011 NDHS collected information on knowledge of contraception by asking respondents whether or not they have heard about eight modern methods (female and male sterilization, the pill, intrauterine devices [IUDs], injectables, implants, male condoms, and emergency contraception) and two traditional methods (rhythm method and withdrawal). Respondents were also asked whether they knew about any other methods in addition to those listed. Table 7.1 shows that knowledge of at least one contraceptive method is nearly universal in Nepal among both women and men. Modern methods are more widely known than traditional methods; almost all women know of a modern method, while 67 percent know of a traditional method. Female sterilization (99 percent), injectables (98 percent), male sterilization (95 percent), the pill (93 percent), and condoms (98 percent) are the most commonly known modern methods among women, with a slightly smaller percentage mentioning IUDs (83 percent). Emergency contraception is known by a relatively smaller percentage of women (29 percent). The extent of and patterns in knowledge of a modern method of family planning among currently married and never-married women are similar except that never-married women are slightly less knowledgeable than currently married women about contraceptive methods other than emergency contraception. Table 7.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and never-married respondents age 15-49 who know any contraceptive method, by specific method, and mean number of methods known, Nepal 2011 Method Women Men All women Currently married women Never- married women All men Currently married men Never- married men Any method 99.9 100.0 99.8 99.7 99.8 99.6 Any modern method 99.9 100.0 99.8 99.7 99.8 99.6 Female sterilization 98.9 99.4 97.0 96.2 97.9 93.0 Male sterilization 94.6 96.0 89.4 94.5 96.5 90.7 Pill 93.0 94.6 87.4 84.9 86.9 81.4 IUD 83.2 84.3 79.6 74.6 76.6 72.1 Injectables 98.4 99.0 96.0 93.7 95.5 90.5 Implants 89.6 92.5 79.6 71.8 76.3 64.3 Condom 97.6 98.2 95.7 99.1 98.9 99.6 Emergency contraception 28.8 26.2 38.8 38.7 35.3 45.8 Any traditional method 67.4 72.5 49.9 74.6 77.4 70.1 Rhythm 46.1 48.1 39.6 56.4 61.0 48.7 Withdrawal 57.8 64.4 34.9 67.9 70.6 63.5 Other 0.7 0.6 1.2 1.3 0.8 2.3 Mean number of methods known by respondents 15-49 7.9 8.0 7.4 7.8 8.0 7.5 Number of respondents 12,674 9,608 2,708 4,121 2,626 1,433 With respect to traditional methods, withdrawal and the rhythm method are known by 58 and 46 percent of all women, respectively. Overall, women know 7.9 contraceptive methods on average, while men know 7.8 methods. Because knowledge of at least one method of contraception is nearly universal, there are few differences in knowledge by background characteristics (data not shown). The high level of knowledge could be attributed to the successful dissemination of family planning messages through the mass media. 7.2 CURRENT USE OF CONTRACEPTION This section presents information on the prevalence of current contraceptive use among women age 15- 49 at the time of the survey. Level of current use is the most widely employed and valuable measure of the success of family planning programs. The contraceptive prevalence rate (CPR) is usually defined as the percentage of currently married women who are currently using a method of contraception. Family Planning • 95 Table 7.2 shows the percent distribution by age of all women and currently married women who are currently using specific family planning methods. Fifty percent of currently married women are using a method of family planning, including 43 percent who are using a modern method and 7 percent who are using a traditional method. Contraceptive use varies by age. Use is lower among younger women (because they are in the early stage of family building) and older women (some of whom are no longer fecund) than among those at intermediate ages. Female sterilization is the most widely used modern method (15 percent) among currently married women. Half as many currently married women report the use of male sterilization (8 percent), while injectables are used by 9 percent of women. The CPR increases from 18 percent among women age 15-19 to 68 percent among women age 40-44 and declines thereafter. Table 7.2 Current use of contraception by age Percent distribution of all women and currently married women age 15-49 by contraceptive method currently used, according to age, Nepal 2011 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Not currently using Total Number of women Female sterili- zation Male sterili- zation Pill IUD Inject- ables Implants Condom Rhythm With- drawal Other ALL WOMEN 15-19 5.1 4.2 0.0 0.0 0.8 0.0 1.4 0.0 1.9 0.9 0.3 0.7 0.0 94.9 100.0 2,753 20-24 22.8 18.4 2.8 0.6 2.9 0.9 6.5 0.6 4.1 4.4 0.7 3.7 0.0 77.2 100.0 2,297 25-29 42.3 36.4 10.8 3.7 4.9 1.6 9.0 1.1 5.2 5.9 0.7 5.2 0.0 57.7 100.0 2,101 30-34 57.2 50.2 18.0 9.1 5.3 1.3 10.7 1.5 4.3 7.1 0.8 6.2 0.0 42.8 100.0 1,734 35-39 64.4 57.3 23.4 12.4 4.2 1.8 10.2 2.0 3.2 7.0 1.3 5.7 0.1 35.6 100.0 1,557 40-44 63.9 56.3 25.9 14.5 2.7 1.1 8.8 1.0 2.2 7.6 1.7 5.8 0.1 36.1 100.0 1,285 45-49 49.3 44.2 21.6 13.9 1.5 0.5 5.0 0.6 1.1 5.1 1.9 3.1 0.1 50.7 100.0 947 Total 38.2 33.2 11.9 6.0 3.2 1.0 7.0 0.9 3.3 5.0 0.9 4.1 0.0 61.8 100.0 12,674 CURRENTLY MARRIED WOMEN 15-19 17.6 14.4 0.0 0.0 3.0 0.0 4.9 0.1 6.5 3.1 0.9 2.2 0.0 82.4 100.0 792 20-24 29.5 23.8 3.6 0.8 3.7 1.2 8.5 0.7 5.2 5.8 0.9 4.9 0.0 70.5 100.0 1,761 25-29 46.3 39.8 11.8 4.0 5.4 1.8 9.9 1.2 5.7 6.5 0.7 5.7 0.0 53.7 100.0 1,914 30-34 59.6 52.2 18.7 9.5 5.5 1.3 11.1 1.6 4.5 7.4 0.8 6.5 0.0 40.4 100.0 1,659 35-39 67.4 59.9 23.8 13.2 4.5 1.9 10.9 2.1 3.5 7.5 1.4 6.1 0.1 32.6 100.0 1,461 40-44 68.1 59.9 27.1 15.6 3.0 1.2 9.5 1.1 2.3 8.2 1.8 6.3 0.1 31.9 100.0 1,190 45-49 53.7 48.0 22.9 15.1 1.7 0.6 5.7 0.7 1.3 5.8 2.1 3.5 0.1 46.3 100.0 832 Total 49.7 43.2 15.2 7.8 4.1 1.3 9.2 1.2 4.3 6.5 1.1 5.4 0.0 50.3 100.0 9,608 Note: If more than one method is used, only the most effective method is considered in this tabulation. Total includes one woman who uses a modern method not listed. One of the Millennium Development Goals (MDGs) for Nepal is to increase the CPR to 67 percent by 2015. The results of the 2011 NDHS show that modern contraceptive use has not increased in the past five years. There could be various underlying causes behind the stagnation, such as the legalization of abortion; out- migration of people of reproductive age for employment, leading to spousal separation; and increased use of traditional methods. However, such possibilities can be validated only after further analysis on this topic. 7.3 CURRENT USE OF CONTRACEPTION BY BACKGROUND CHARACTERISTICS Analyzing current use of contraception by background characteristics is important because it helps identify subgroups of the population to target for family planning services. Table 7.3 presents the percent distribution of currently married women by their use of family planning methods, according to background characteristics. This table allows a comparison of levels of current contraceptive use across major population groups and an examination of differences in use in the various subgroups. There is a direct association between use of family planning methods and the number of children women have, except in the case of women with five or more children. Only 12 percent of women with no living children use contraception; the percentage increases to 47 percent among women with one or two children and 65 percent among women with three or four children before declining to 54 percent among women with five or more children. Use of female sterilization is highest among women with three or four living children (29 percent), with a decline to 18 percent among women with five or more children. Use of injectables rises with parity, from less than 1 percent of women with no children to 13 percent of women with five or more children. Injectables are popular because they are more easily accessible, with supplies available at most health facilities (MOHP, 2009). Moreover, the expansion of the Sangini Franchising Network, which franchises injectable contraceptives through a network of pharmacies under a local brand name (Sangini-Tin Mahine Sui) in all 75 96 • Family Planning districts, has increased rural women’s access to injectables (Nepal CRS Company, 2011). These injectable contraceptives work for a relatively longer duration, they are convenient to use, and their use can be kept private. There is a direct relationship between contraceptive use by a woman and the presence or absence of her husband. Use of any method is almost three times higher among women whose husbands are living with them (62 percent) than among women whose husbands do not live with them (23 percent). A similar pattern is seen in use of modern methods (53 percent and 23 percent, respectively). Table 7.3 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Nepal 2011 Background characteristic Any method Any modern method Modern method Any tradi- tional method Traditional method Not currently using Total Number of women Female sterili- zation Male sterili- zation Pill IUD Inject- ables Implants Condom Rhythm With- drawal Other Number of living children 0 12.2 9.0 0.0 1.3 1.3 0.0 0.6 0.0 5.7 3.3 0.4 2.9 0.0 87.8 100.0 1,075 1-2 46.8 38.8 8.7 5.7 5.3 1.6 10.1 0.9 6.3 8.0 1.1 6.9 0.0 53.2 100.0 4,442 3-4 65.4 60.0 28.9 12.7 3.7 1.0 9.7 1.7 2.1 5.5 1.3 4.1 0.1 34.6 100.0 3,091 5+ 54.1 47.4 17.8 9.0 3.1 2.0 12.8 1.8 1.1 6.7 1.8 4.7 0.2 45.9 100.0 999 Living arrangements Husband and wife live together 62.1 52.9 16.7 9.3 5.7 1.6 12.1 1.4 6.1 9.2 1.6 7.5 0.1 37.9 100.0 6,530 Husband lives away 23.4 22.5 12.0 4.6 0.9 0.6 2.9 0.8 0.7 1.0 0.2 0.8 0.0 76.6 100.0 3,077 Residence Urban 59.6 49.8 13.5 6.8 6.1 1.9 10.4 1.7 9.4 9.8 1.7 7.9 0.1 40.4 100.0 1,261 Rural 48.2 42.1 15.4 8.0 3.8 1.2 9.0 1.1 3.6 6.0 1.1 5.0 0.0 51.8 100.0 8,346 Ecological zone Mountain 48.3 43.1 3.0 17.1 3.0 2.4 12.3 2.4 3.0 5.3 1.5 3.8 0.0 51.7 100.0 630 Hill 48.2 40.6 7.1 10.6 4.1 1.2 10.6 1.8 5.0 7.6 1.3 6.2 0.1 51.8 100.0 3,784 Terai 51.0 45.0 22.5 4.7 4.3 1.2 7.8 0.6 4.0 5.9 1.0 4.9 0.0 49.0 100.0 5,193 Development region Eastern 46.4 36.2 10.9 2.9 5.8 0.5 12.0 0.7 3.4 10.2 2.3 7.8 0.1 53.6 100.0 2,293 Central 54.7 49.9 20.4 9.4 3.4 2.1 9.0 1.6 4.0 4.8 1.1 3.7 0.1 45.3 100.0 3,210 Western 46.1 38.7 13.5 9.8 3.9 1.2 5.8 0.7 3.9 7.4 0.8 6.6 0.0 53.9 100.0 2,031 Mid-western 46.9 42.8 11.5 9.8 3.1 1.4 9.3 2.4 5.4 4.0 0.6 3.4 0.0 53.1 100.0 1,149 Far-western 51.9 47.1 16.0 8.0 4.5 0.7 10.1 0.4 7.5 4.8 0.2 4.7 0.0 48.1 100.0 925 Subregion Eastern mountain 44.4 34.8 0.7 8.4 4.0 1.0 17.5 1.1 2.1 9.6 4.2 5.4 0.0 55.6 100.0 169 Central mountain 59.4 54.2 6.8 20.3 3.0 6.1 12.3 3.9 1.8 5.2 1.3 3.9 0.0 40.6 100.0 190 Western mountain 43.1 40.4 1.7 20.2 2.2 0.7 9.0 2.1 4.5 2.6 0.0 2.6 0.0 56.9 100.0 271 Eastern hill 42.8 32.0 3.3 4.0 5.1 0.9 14.6 1.1 3.0 10.7 2.5 8.0 0.3 57.2 100.0 702 Central hill 62.2 54.2 8.0 10.3 6.5 2.2 15.9 3.7 7.6 8.0 2.2 5.7 0.1 37.8 100.0 1,103 Western hill 42.9 35.2 8.6 14.0 2.7 0.9 4.9 0.6 3.5 7.7 0.4 7.3 0.0 57.1 100.0 1,164 Mid-western hill 41.6 37.7 7.1 12.6 2.2 0.7 7.3 2.4 5.3 3.9 0.8 3.1 0.0 58.4 100.0 510 Far-western hill 41.2 36.1 7.4 10.6 2.0 0.6 9.1 0.6 5.9 5.1 0.0 5.1 0.0 58.8 100.0 305 Eastern terai 48.4 38.4 15.8 1.7 6.3 0.3 10.0 0.5 3.8 10.0 1.9 8.0 0.0 51.6 100.0 1,421 Central terai 50.0 47.0 28.9 7.7 1.7 1.6 4.7 0.2 2.1 2.9 0.4 2.5 0.0 50.0 100.0 1,918 Western terai 50.3 43.4 20.0 4.3 5.4 1.5 6.9 0.7 4.6 6.9 1.2 5.8 0.0 49.7 100.0 867 Mid-western terai 54.2 49.3 19.0 3.8 4.0 2.1 11.8 2.2 6.4 4.9 0.7 4.2 0.0 45.8 100.0 499 Far-western terai 60.1 55.1 25.0 3.1 6.9 0.8 10.6 0.1 8.6 4.9 0.3 4.6 0.0 39.9 100.0 488 Education No education 52.8 48.8 22.5 9.3 3.3 1.1 9.4 1.3 1.9 3.9 1.1 2.8 0.0 47.2 100.0 4,580 Primary 47.0 40.5 11.8 9.1 4.0 1.3 10.0 1.5 2.9 6.6 0.8 5.6 0.1 53.0 100.0 1,844 Some secondary 46.1 37.9 8.4 5.4 6.3 1.4 9.3 0.7 6.4 8.2 1.1 7.1 0.0 53.9 100.0 1,833 SLC and above 47.7 34.6 4.0 4.5 4.5 1.7 7.2 0.8 11.9 13.1 1.8 11.3 0.0 52.3 100.0 1,350 Wealth quintile Lowest 40.4 35.6 8.5 7.9 3.2 0.7 11.4 1.9 2.1 4.8 1.2 3.6 0.0 59.6 100.0 1,664 Second 46.3 41.1 16.3 6.8 2.8 1.7 9.4 1.5 2.6 5.2 0.7 4.5 0.1 53.7 100.0 1,846 Middle 48.2 43.3 19.3 7.3 3.8 1.0 8.3 0.7 2.9 4.9 1.0 3.8 0.1 51.8 100.0 2,022 Fourth 52.0 45.3 17.2 9.5 4.2 1.0 8.5 0.8 4.1 6.7 1.0 5.7 0.0 48.0 100.0 2,052 Highest 59.6 48.9 13.5 7.5 6.4 2.0 8.8 1.2 9.4 10.6 1.8 8.8 0.1 40.4 100.0 2,023 Total 49.7 43.2 15.2 7.8 4.1 1.3 9.2 1.2 4.3 6.5 1.1 5.4 0.0 50.3 100.0 9,608 Note: If more than one method is used, only the most effective method is considered in this tabulation. Total includes one woman who uses a modern method not listed. SLC = School Leaving Certificate Urban women are more likely to use a family planning method than rural women, reflecting wider availability and easier access to methods in urban than in rural areas. The CPR for any method is 60 percent in urban areas, compared with 48 percent in rural areas. Condom use is nearly three times higher in urban than in rural areas. Overall, use of contraceptives does not vary extensively by ecological zone, although differences in use of modern methods are slightly more pronounced. Much of the variation in use of modern methods is due to differences in the use of female and male sterilization and injectables. Female sterilization is more popular in the terai, where 23 percent of currently married women are using this method, than in the hill (7 percent) or Family Planning • 97 mountain (3 percent) zone. On the other hand, male sterilization and injectables are more popular in the mountain and hill zones than in the terai. While 17 percent of women in the mountain zone and 11 percent of women in the hill zone reported using male sterilization, only 5 percent of women in the terai did so. By development region, use of modern methods is highest in the Central region (50 percent) and lowest in the Eastern region (36 percent). Female sterilization is especially popular in the Central region (20 percent). There are small variations in the use of injectables by development region, with women in the Western region showing the lowest coverage (6 percent). Current use of modern contraceptive methods is highest in the Far-western terai (55 percent) and lowest in the Eastern hill subregion (32 percent). Female sterilization is especially popular in the Central terai (29 percent) and male sterilization in the Western and Central mountain subregions (20 percent each). Injectables are popular in the Eastern mountain (18 percent), Central hill (16 percent), and Eastern hill (15 percent) subregions. Use of traditional methods is most popular in the Eastern hill subregion (11 percent). The impact of education on contraceptive use is mixed. Use of any method is higher among women with no education (53 percent) than among women with at least some education (46-47 percent). Use of a modern method is also highest among women with no education and decreases with increasing education. The primary reason for the higher prevalence of contraceptive use among women with little or no education is that a sizable proportion of these women use sterilization, while women with at least some secondary education are more likely to use non-permanent methods such as injectables. Wealth has a positive association with women’s contraceptive use. Modern contraceptive use increases as household wealth increases, from 36 percent among currently married women in the lowest wealth quintile to 49 percent among those in the highest wealth quintile. 7.4 TRENDS IN CURRENT USE OF FAMILY PLANNING Trends in current use of family planning can be used to monitor and evaluate the success of family planning programs over time. Table 7.4 and Figure 7.1 show trends in modern contraceptive use among currently married women from 1996 to 2011. Data from four DHS surveys conducted in Nepal over the past 15 years show an impressive increase in the use of modern contraceptive methods from 26 percent in 1996 to 43 percent in 2011. The increase in the use of modern contraceptives is due mainly to increased use of female sterilization, injectables, the pill, and condoms between 1996 and 2006. However, as a result of several possible factors, the increase in contraceptive use has not been sustained in the past five years. There has been a decline in the use of female sterilization and injectables, while the use of male sterilization has increased slightly. It is also notable that the long-term use of temporary methods such as implants and IUDs has been increasing over the past few years, providing options for women to drift away from permanent methods such as sterilization. Use of traditional methods has also increased over the years. Table 7.4 shows that the proportion of currently married women who are using a method of contraception has increased by 4 percent in the past five years, primarily as a result of an increase in the use of traditional methods from 4 percent in 2006 to 7 percent in 2011. Table 7.4 Trends in current use of contraceptive methods Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to selected sources, Nepal 1996-2011 Method 1996 NFHS1 2001 NDHS2 2006 NDHS3 2011 NDHS Any method 28.5 39.3 48.0 49.7 Any modern method 26.0a 35.4a 44.2 43.2 Female sterilization 12.1 15.0 18.0 15.2 Male sterilization 5.4 6.3 6.3 7.8 Pill 1.4 1.6 3.5 4.1 Injectables 4.5 8.4 10.1 9.2 Condom 1.9 2.9 4.8 4.3 Implants 0.4 0.6 0.8 1.2 IUD 0.3 0.4 0.7 1.3 Any traditional method 2.5 3.9 3.7 6.5 Rhythm 0.9 1.1 1.2 1.1 Withdrawal 1.4 2.6 2.6 5.4 Other 0.2 0.3 0.0 0.0 Not currently using 71.5 60.7 52.0 50.3 Total 100.0 100.0 100.0 100.0 Number of women 7,982 8,342 8,257 9,608 1 Pradhan et al., 1997 2 MOHP, New ERA, and ORC Macro, 2002 3 MOHP, New ERA, and Macro International Inc., 2007 a Includes users of vaginal methods 98 • Family Planning Figure 7.1 Trends in Contraceptive Use among Currently Married Women 26 12 5 1 5 2 0 0 35 15 6 2 8 3 1 0 44 18 6 4 10 5 1 1 43 15 8 4 9 4 1 1 ANY MODERN METHOD Female sterilization Male sterilization Pill Injectables Condom Implants IUD 0 10 20 30 40 50 Percent 1996 NFHS 2001 NDHS 2006 NDHS 2011 NDHS NDHS 2011 7.5 TIMING OF FEMALE STERILIZATION Given the importance of female sterilization as a means of preventing pregnancies among women in high-risk groups, the family planning program in Nepal emphasizes dissemination of information about this method. The program also provides services in accordance with a women’s age and health status. Trends in the use of sterilization as a family planning method are of interest, especially trends in women’s age at the time of the operation. Table 7.5 shows the percent distribution of sterilized women by age at the time of sterilization, according to the number of years since the operation. As expected, the vast majority (93 percent) of women were age 34 or younger at the time of sterilization. Thus, female sterilization in Nepal occurs early in women’s reproductive lives. The median age at sterilization among women sterilized before age 40 (27 years) has not changed much over the past 10 years. Table 7.5 Timing of sterilization Percent distribution of sterilized women age 15-49 by age at the time of sterilization and median age at sterilization, according to the number of years since the operation, Nepal 2011 Years since operation Age at time of sterilization Total Number of women Median age1 <25 25-29 30-34 35-39 40-44 <2 32.6 31.3 22.2 9.2 4.7 100.0 144 27.2 2-3 29.9 42.3 18.5 7.8 1.5 100.0 182 26.8 4-5 37.3 36.5 15.8 6.8 3.6 100.0 156 26.8 6-7 29.5 36.6 25.2 6.4 2.3 100.0 176 27.5 8-9 23.8 38.4 26.5 11.3 0.0 100.0 149 27.6 10+ 33.9 43.9 20.2 2.0 0.0 100.0 699 a Total 32.2 40.3 20.9 5.3 1.3 100.0 1,506 27.0 a = Not calculated due to censoring 1 Median age at sterilization is calculated only for women sterilized before age 40 to avoid problems of censoring. Family Planning • 99 7.6 SOURCE OF CONTRACEPTION Table 7.6 documents the main sources of contraception for users of different modern methods. Such information on where women obtain their contraceptive method is important for program managers and implementers in designing family planning policies and programs. All current users of modern contraceptive methods were asked the most recent source of their methods. The government sector remains the major source of contraceptive methods in Nepal, providing methods to 69 percent of current users (however, the share of the government sector as a source of modern methods has decreased from 77 percent in 2006). Within the government sector, one-third of users obtain their methods from government hospitals, 13 percent from mobile clinics, and 9 percent from government sub-health posts. Nine percent of users obtain their methods from the nongovernment sector, mostly from Marie Stopes (6 percent) and the Family Planning Association of Nepal (2 percent). Twenty percent of modern contraceptive users obtain their methods from the private sector, primarily from pharmacies (11 percent) and private hospitals/clinics (8 percent). It is worth noting that the percentage of users obtaining their methods from the private sector has increased by 43 percent in the past five years (from 14 percent in 2006). Table 7.6 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Nepal 2011 Source Female sterilization Male sterilization Pill IUD1 Injectables Implants1 Condom Total Government sector 77.8 83.6 50.9 57.9 69.0 66.6 32.3 69.0 Government hospital/clinic 55.3 47.5 6.2 24.1 9.7 30.3 4.7 33.0 PHC center 2.9 3.6 2.1 12.0 4.8 10.2 2.8 3.8 Health post 0.0 0.0 8.4 2.3 16.5 13.6 4.7 5.2 Sub-health post 0.0 0.0 16.0 9.8 30.0 3.9 10.1 9.2 PHC outreach 0.0 0.0 0.6 0.7 7.0 0.7 0.3 1.6 Other government 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Mobile clinic 19.4 32.5 0.0 9.0 0.3 7.9 0.0 13.3 FCHV 0.0 0.0 17.6 0.0 0.7 0.0 9.3 2.7 Condom box 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 Nongovernment (NGO) sector 13.6 8.7 1.1 13.8 4.8 12.3 2.1 8.5 FPAN 2.0 3.1 0.6 5.4 2.9 2.0 0.5 2.2 Marie Stopes 10.1 5.5 0.3 8.0 1.3 8.8 0.7 5.5 Nepal Red Cross 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 UMN 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Other NGO 1.2 0.1 0.2 0.3 0.6 1.5 0.8 0.7 Private medical 8.3 5.3 44.6 7.7 25.7 4.1 59.3 19.8 Private hospital/clinic 8.3 5.3 10.8 4.6 8.8 4.1 6.7 7.7 Pharmacy 0.0 0.0 31.5 2.3 12.1 0.0 52.2 10.8 Sangini outlet 0.0 0.0 2.4 0.0 4.7 0.0 0.3 1.2 Other private medical 0.0 0.1 0.0 0.9 0.0 0.0 0.0 0.0 Other source 0.0 0.0 2.7 0.0 0.5 0.0 4.8 0.8 Shop 0.0 0.0 0.4 0.0 0.1 0.0 1.7 0.2 Friend/relative 0.0 0.0 2.4 0.0 0.4 0.0 3.2 0.6 Other 0.4 0.3 0.6 0.0 0.1 0.0 1.5 0.4 Don’t know 0.0 2.1 0.0 0.0 0.0 0.0 0.0 0.4 Missing 0.0 0.0 0.0 20.6 0.0 17.0 0.0 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,506 760 400 124 882 114 421 4,208 PHC = Primary health care FCHV = Female community health volunteer FPAN = Family Planning Association of Nepal UMN = United Mission of Nepal 1 For users of implants, the source is where the respondent obtained the method when she started the current episode of use. Source of method is missing for IUD and implant users if they began using the method more than five years before the survey. Female and male sterilizations are performed mostly in government hospitals (55 and 48 percent, respectively) and mobile clinics (19 percent and 33 percent, respectively). Half of pill users obtain their supply from a government source (51 percent), primarily from female community health volunteers (FCHVs) (18 percent) and government sub-health posts (16 percent). Pill users who obtain their supply from a private medical source primarily go to pharmacies (32 percent) and private hospital/clinics (11 percent). Seven in 10 women who use injectables obtain them from a government source, primarily sub-health posts (30 percent) and health posts (17 percent). Of special note is that 17 percent of women obtain injectables from pharmacies, including 100 • Family Planning Sangini outlets. Condoms are obtained primarily from private medical sources (59 percent), of which 52 percent are pharmacies. Although these findings point to the continued reliance on government facilities as a major source of contraceptives, the role of the private sector and the nongovernment sector cannot be ignored. 7.7 BRANDS OF PILLS AND CONDOMS USED The government of Nepal, with the assistance of USAID/Nepal, has engaged in social marketing of contraceptives through the Nepal CRS Company since 1978 (MOHP, 2011a). Among the various products launched through social marketing, contraceptive methods account for a major portion. Nilocon White and Sunaulo Gulaph are the two brands of oral contraceptives that have been promoted through social marketing. Dhaal and Panther are the two condom brands launched through the CRS Company. Information on women’s use of socially marketed contraceptives is useful for monitoring and evaluating the success of social marketing programs. In 2011, for the first time, the NDHS collected information on the brands of pills and condoms used by women and men. Women age 15-49 who were using oral contraceptives and condoms were asked for the brand name of the pills and condoms they last used. Table 7.7 shows that, among pill users, Nilocon White (40 percent) and Sunaulo Gulaph (28 percent) are the most commonly used brands. Nilocon White is the most popular brand among women regardless of their background characteristics. Although there are many brands of condoms on the market, the most popular are Dhaal (26 percent) and Panther (23 percent). Table 7.7 Use of social marketing brand pills and condoms Percentage of pill and condom users age 15-49 using a specific social marketing brand, by background characteristics, Nepal 2011 Background characteristic Among pill users Among condom users Percentage using Nilocon White Percentage using Sunaulo Gulaph Number of women using the pill Percentage using Dhaal Percentage using Panther Number of women using condoms Age 15-19 (38.1) (33.0) 23 22.5 20.3 50 20-24 32.3 33.6 66 30.8 16.1 89 25-29 43.1 23.6 101 25.2 25.4 102 30-34 45.4 28.8 92 19.1 23.0 71 35-39 41.3 23.6 65 28.6 28.1 49 40-44 (27.7) (34.3) 35 (33.9) (19.0) 26 45-49 * * 14 * * 9 Residence Urban 51.0 22.5 78 22.6 29.5 113 Rural 36.9 28.9 319 26.8 20.5 283 Ecological zone Mountain (20.2) (21.8) 19 (41.7) (18.9) 18 Hill 44.0 26.3 156 22.3 25.6 179 Terai 38.2 29.0 222 27.1 21.2 199 Development region Eastern 37.3 36.3 132 34.5 28.4 78 Central 48.5 14.6 111 18.7 26.8 124 Western 48.1 28.0 76 23.5 25.1 68 Mid-western 30.1 33.9 36 19.0 19.3 57 Far-western 16.6 28.6 42 35.6 11.7 69 Education No education 32.2 21.5 148 30.0 14.2 80 Primary 34.5 27.2 75 27.1 20.0 49 Some secondary 43.1 38.9 114 25.9 23.8 114 SLC and above 57.8 22.1 60 22.7 28.2 154 Wealth quintile Lowest 11.6 28.3 51 (33.5) (10.4) 31 Second 38.3 25.1 52 35.9 18.6 44 Middle 29.2 28.5 77 33.3 11.3 57 Fourth 43.6 34.1 87 19.8 26.8 83 Highest 54.7 23.5 130 22.0 28.4 180 Total 39.7 27.6 397 25.6 23.1 396 Note: Table excludes pill and condom users who do not know the brand name. Condom use is based on women’s reports. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate Family Planning • 101 7.8 INFORMED CHOICE Informed choice is an important tool for assessing, monitoring and evaluating the quality of family planning services. Current users of modern methods of contraception were asked whether they were informed about side effects or problems they might have with a method, what to do if they experienced side effects, and other methods they could use. This information assists users in coping with side effects and decreases unnecessary discontinuations. Moreover, such data serve as a measure of the quality of family planning service provision. Table 7.8 presents results by method type and source. Sixty-three percent of modern contraceptive users were informed by a health or family planning worker about potential side effects of the method they use, 59 percent were informed about what to do if they experienced side effects, and 54 percent were informed of other available methods of contraception. Users were slightly less likely to receive information about side effects or problems from a private medical facility (60 percent) than from a government or nongovernment facility (64 percent each). The same was true of information on what to do if side effects were experienced; 55 percent of users of a modern contraceptive method were given the information in a private medical facility, as compared with 60 percent in a government facility and 62 percent in a nongovernment facility. Table 7.8 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, the percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods they could use, by method and initial source, Nepal 2011 Method/source Among women who started last episode of modern contraceptive method within five years preceding the survey: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilization 42.8 42.4 30.1 403 Pill 57.8 54.3 55.7 313 IUD 89.6 86.4 71.6 91 Injectables 72.7 64.1 63.7 642 Implants 82.2 81.5 75.3 86 Initial source of method1 Public sector 64.3 59.7 58.0 1,009 Hospital/clinic 55.7 54.3 47.4 331 PHC center 63.0 62.4 70.4 92 Health post 74.5 70.4 73.2 142 Sub-health post 69.9 60.3 59.7 282 PHC OUTREACH (75.7) (67.0) (68.1) 38 Mobile clinic 57.7 52.0 43.5 78 FCHV (64.6) (62.8) (68.6) 47 Nongovernment (NGO) sector 64.2 61.5 48.8 161 FPAN (78.3) (78.3) (70.4) 35 Marie Stopes 60.8 58.1 41.6 113 Other NGO * * * 13 Private medical 60.3 54.7 46.5 363 Private hospital/clinic/nursing home 62.3 59.0 47.5 146 Pharmacy 57.7 49.1 43.3 173 Sangini outlet (64.8) (62.9) (56.4) 41 Other * * * 2 Total 63.3 58.7 54.3 1,533 Note: Table includes users of only the methods listed individually. Total excludes users who obtained their methods from friends/relatives/shops. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Source at start of current episode of use 102 • Family Planning 7.9 CONTRACEPTIVE DISCONTINUATION RATES Couples can realize their reproductive goals only when they consistently and correctly use contraceptive methods. A prominent concern for family planning programs is the rate at which contraceptive users discontinue using their methods. In the “Calendar” section of the Woman’s Questionnaire, all segments of contraceptive use from 3-59 months prior to the survey are recorded. The month of interview and the two months prior to the survey are ignored in order to avoid the bias that may be introduced by unrecognized pregnancies. One-year contraceptive discontinuation rates based on the calendar data are presented in Table 7.9. Overall, 51 percent of the episodes of contraceptive use were discontinued within 12 months of starting its use for any reason. Twenty-six percent of episodes of discontinuation occurred because the women’s husbands were away, 12 percent was due to the fear of side effects or health concerns, and 5 percent because the woman wanted to become pregnant. Discontinuation rates vary by method. Rates are highest for pill and male condom (71 percent and 63 percent, respectively), followed by injectables (55 percent) and withdrawal (51 percent). Table 7.9 Twelve-month contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months, by reason for discontinuation and specific method, Nepal 2011 Method Method failure Desire to become pregnant Other fertility- related reasons2 Side effects/ health concerns Wanted more effective method Other method- related reasons3 Husband away Other reason Any reason4 Switched to another method5 Pill 3.0 5.7 1.9 15.0 2.0 1.1 40.8 1.1 70.6 6.4 Injectables 0.6 3.4 1.1 26.3 1.5 0.6 20.2 1.1 54.8 10.2 Male condom 4.0 11.7 3.2 0.6 5.4 4.6 29.3 4.1 63.0 8.2 Withdrawal 6.7 3.4 1.6 0.1 3.3 0.2 35.5 0.5 51.4 3.4 All methods1 2.5 4.9 1.5 11.7 2.4 1.2 25.5 1.4 51.2 6.7 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months preceding the survey. Female sterilization is excluded as there are no failure cases. 1 Implants and male sterilization are included in the discontinuation rate for all methods but not listed separately. 2 Includes infrequent sex, difficulty in getting pregnant/menopausal, and marital dissolution/separation 3 Includes lack of access/too far, costs too much, and inconvenient to use 4 Reasons for discontinuation are mutually exclusive and add to the total given in this column. 5 The episodes of use included in this column are a subset of the discontinued episodes included in the discontinuation rate. A woman is considered to have switched to another method if she used a different method in the month following discontinuation or if she cited “wanted a more effective method” as the reason for discontinuation and started another method within two months of discontinuation. 7.10 REASONS FOR DISCONTINUATION OF CONTRACEPTIVE USE Another perspective on discontinuation of modern contraceptive use is provided in Table 7.10, which shows the percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by reasons for discontinuation, according to method. The most common reason for discontinuing a method is that the husband is away (40 percent), followed by side effects or health concerns (24 percent), desire to become pregnant (13 percent), becoming pregnant while using or method failure (7 percent), and wanting a more effective method (6 percent). It is worth noting that the reason most often cited for discontinuing use of IUDs, injectables, and implants is side effects or health concerns (59 percent, 46 percent, and 40 percent, respectively). Absence of the husband was the reason most often reported for discontinuing use of the pill, condom, rhythm method, and withdrawal. Family Planning • 103 Table 7.10 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method, Nepal 2011 Reason Pill IUD Injectables Implants Condom Rhythm Withdrawal All methods Became pregnant while using 7.4 0.4 1.7 0.0 8.6 14.5 15.8 6.8 Wanted to become pregnant 8.6 4.6 9.9 17.3 21.9 33.9 14.0 12.8 Husband disapproved 0.8 0.0 0.6 5.4 3.8 3.0 1.4 1.5 Wanted a more effective method 3.8 2.9 3.9 3.9 10.0 13.2 9.8 6.1 Side effects/health concerns 24.0 59.1 46.1 39.6 1.0 0.0 0.3 24.2 Lack of access/too far 0.4 0.0 0.9 1.6 0.5 0.0 0.0 0.6 Inconvenient to use 0.8 7.1 0.1 3.1 6.6 0.0 1.0 1.8 Difficult to get pregnant/ menopausal 0.2 0.0 0.7 2.8 0.4 0.4 0.7 0.6 Infrequent sex 3.0 4.1 1.5 0.0 4.2 8.6 2.9 2.7 Marital dissolution/separation 0.2 0.0 0.7 0.0 0.1 0.0 0.1 0.3 Husband away 49.2 18.9 30.3 11.3 40.5 23.1 52.3 40.0 Other 1.2 2.9 3.4 15.0 2.0 0.3 1.5 2.4 Don’t know 0.0 0.0 0.0 0.0 0.4 2.1 0.0 0.1 Missing 0.1 0.0 0.0 0.0 0.0 0.7 0.3 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 1,125 57 1,598 51 810 76 710 4,434 Note: Total includes seven cases in which women reported discontinuation while using other methods. 7.11 KNOWLEDGE OF FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for the successful practice of the rhythm method. As shown in Table 7.1 and Table 7.3, 48 percent of married women have heard of the rhythm method, but only 1 percent are currently using the method. Table 7.11 shows women’s knowledge about the time during the menstrual cycle when a woman is most likely to get pregnant. Overall, only 25 percent of all women correctly reported the most fertile time as being halfway between two menstrual periods. Among users of the rhythm method, 52 percent were able to correctly identify a woman’s monthly cycle; 46 percent incorrectly reported that a woman’s most fertile period is directly after menstruation has ended. Knowledge of the fertile period among Nepalese women is limited; 16 percent of all women and 17 percent of those not using the rhythm method did not know about the fertile period. These results indicate a continued need for education about women’s physiology of reproduction and effective use of contraceptive methods. Table 7.11 Knowledge of fertile period Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Nepal 2011 Perceived fertile period Users of rhythm method Nonusers of rhythm method All women Just before her menstrual period begins 0.0 2.0 2.0 During her menstrual period 0.0 2.7 2.7 Right after her menstrual period has ended 46.0 45.6 45.6 Halfway between two menstrual periods 51.7 24.8 25.0 No specific time 0.5 8.4 8.3 Don’t know 1.8 16.5 16.4 Total 100.0 100.0 100.0 Number of women 110 12,564 12,674 7.12 NEED AND DEMAND FOR FAMILY PLANNING SERVICES Data in this section provide information on the extent of need and potential demand for family planning services in Nepal. Currently married fecund women who want to postpone their next birth for two or more years or who want to stop childbearing altogether but are not using a contraceptive method are considered to have an unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted. Similarly, amenorrheic women who are not using family planning and whose last birth was mistimed are considered to have an unmet need for spacing, and those whose last child 104 • Family Planning was unwanted have an unmet need for limiting. Women who are currently using a family planning method are said to have a met need for family planning. Total demand for family planning services comprises those who fall in the met need and unmet need categories. Table 7.12 shows need and demand for family planning among currently married women by background characteristics. Twenty-seven percent of currently married women have an unmet need for family planning, with 10 percent having an unmet need for spacing and 17 percent having an unmet need for limiting. Fifty percent of women have a met need for family planning. If all currently married women who say they want to space or limit their children were to use a family planning method, the contraceptive prevalence rate would increase to 77 percent. Currently, only 65 percent of the family planning needs of married women are being met. Table 7.12 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Nepal 2011 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning3 Percentage of demand satisfied Percentage of demand satisfied by modern methods Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 37.5 4.0 41.5 13.3 4.3 17.6 51.1 8.3 59.4 30.2 24.3 792 20-24 23.3 13.5 36.8 13.2 16.3 29.5 37.5 29.9 67.4 45.4 35.2 1,761 25-29 8.5 22.0 30.5 6.9 39.4 46.3 15.5 62.0 77.5 60.6 51.3 1,914 30-34 2.0 24.0 26.1 2.8 56.7 59.6 5.0 80.9 85.9 69.7 60.7 1,659 35-39 1.0 19.7 20.7 0.4 67.0 67.4 1.4 86.9 88.4 76.6 67.8 1,461 40-44 0.4 15.4 15.8 0.0 68.1 68.1 0.4 83.5 83.9 81.1 71.3 1,190 45-49 0.3 12.8 13.2 0.0 53.7 53.7 0.3 66.7 67.0 80.4 71.6 832 Residence Urban 6.4 13.1 19.6 9.4 50.2 59.6 16.5 63.4 79.9 75.5 62.3 1,261 Rural 10.1 18.0 28.1 4.8 43.4 48.2 15.2 61.6 76.8 63.4 54.9 8,346 Ecological zone Mountain 7.5 16.8 24.3 4.6 43.8 48.3 12.5 61.3 73.8 67.0 58.4 630 Hill 9.4 20.3 29.7 5.8 42.4 48.2 15.5 62.9 78.4 62.1 51.7 3,784 Terai 10.1 15.3 25.3 5.3 45.7 51.0 15.6 61.1 76.6 66.9 58.8 5,193 Development region Eastern 11.5 18.5 30.0 6.7 39.6 46.4 18.5 58.3 76.8 61.0 47.1 2,293 Central 8.1 13.5 21.6 4.9 49.8 54.7 13.3 63.5 76.7 71.8 65.1 3,210 Western 11.5 22.5 34.0 4.3 41.8 46.1 16.0 64.6 80.6 57.8 48.0 2,031 Mid-western 9.1 17.0 26.1 5.4 41.4 46.9 15.1 58.6 73.7 64.6 58.1 1,149 Far-western 6.8 17.3 24.1 6.5 45.4 51.9 13.5 62.9 76.3 68.5 61.7 925 Subregion Eastern mountain 7.7 20.6 28.3 5.7 38.7 44.4 14.3 60.5 74.8 62.2 46.6 169 Central mountain 5.5 14.4 20.0 3.3 56.1 59.4 9.3 71.2 80.5 75.2 67.3 190 Western mountain 8.8 16.1 24.9 4.7 38.4 43.1 13.7 54.9 68.5 63.7 59.0 271 Eastern hill 11.3 20.2 31.6 5.5 37.2 42.8 17.2 57.8 74.9 57.9 42.7 702 Central hill 5.3 14.9 20.2 9.2 53.0 62.2 14.9 67.9 82.8 75.6 65.4 1,103 Western hill 12.0 24.1 36.1 3.9 39.0 42.9 16.2 63.5 79.7 54.7 44.2 1,164 Mid-western hill 10.7 21.3 32.0 4.2 37.4 41.6 15.3 58.7 74.0 56.7 51.0 510 Far-western hill 7.5 24.1 31.6 3.6 37.6 41.2 11.5 61.7 73.2 56.9 49.3 305 Eastern terai 12.0 17.3 29.4 7.5 40.9 48.4 19.7 58.2 77.9 62.3 49.3 1,421 Central terai 10.0 12.6 22.6 2.6 47.4 50.0 12.7 60.1 72.8 69.0 64.6 1,918 Western terai 10.9 20.3 31.2 4.8 45.5 50.3 15.8 66.1 81.9 61.9 53.0 867 Mid-western terai 7.5 13.5 21.0 7.5 46.7 54.2 15.8 60.5 76.3 72.4 64.7 499 Far-western terai 5.9 12.6 18.5 8.2 51.9 60.1 14.2 64.7 78.9 76.6 69.9 488 Education No education 5.0 17.5 22.5 1.6 51.1 52.8 6.8 68.8 75.6 70.3 64.6 4,580 Primary 10.3 19.9 30.2 5.2 41.8 47.0 15.8 61.9 77.7 61.1 52.1 1,844 Some secondary 15.6 17.1 32.6 8.4 37.7 46.1 24.2 54.9 79.1 58.8 48.0 1,833 SLC and above 16.3 14.0 30.3 14.5 33.2 47.7 31.8 47.3 79.1 61.7 43.8 1,350 Wealth quintile Lowest 9.1 22.1 31.1 3.5 36.9 40.4 12.7 59.7 72.4 57.0 49.3 1,664 Second 9.2 18.8 28.1 4.3 42.0 46.3 13.9 61.0 74.8 62.5 54.9 1,846 Middle 12.7 15.5 28.2 3.9 44.3 48.2 16.9 59.9 76.7 63.3 56.4 2,022 Fourth 9.1 17.3 26.4 6.3 45.7 52.0 15.7 63.1 78.8 66.5 57.5 2,052 Highest 7.9 14.1 22.0 8.7 50.8 59.6 17.0 65.0 82.0 73.2 59.6 2,023 Total 9.6 17.4 27.0 5.4 44.3 49.7 15.3 61.8 77.2 65.0 55.9 9,608 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrheic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrheic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 3 Nonusers who are pregnant or amenorrheic and whose pregnancy was the result of a contraceptive failure are not included in the category of unmet need, but are included in total demand for contraception (since they would have been using had their method not failed). SLC = School Leaving Certificate Family Planning • 105 Unmet need for family planning declines with age from 42 percent among women age 15-19 to 13 percent in the oldest age group. Unmet need is higher in rural than in urban areas. Unmet need is highest in the hill zone (30 percent), the Western region (34 percent), and the Western hill subregion (36 percent). Unmet need is lowest among women with no education (23 percent) and highest among women with some secondary education (33 percent). Unmet need declines with increasing wealth, from 31 percent in the lowest wealth quintile to 22 percent in the highest quintile. Demand for family planning is highest among women age 35-39 (88 percent) and lowest among those age 15-19 (59 percent). There are small variations in demand for family planning by urban-rural residence, ecological zone, development region, and subregion. Demand increases with increasing education, from 76 percent among women with no education to 79 percent among those with at least some secondary education. A similar pattern is observed by wealth quintile. The percentage of women whose demand for modern methods is satisfied is highest among those age 45-49; those living in urban areas, the Central region, and the Far-western terai; those with no education; and those in the highest wealth quintile. 7.13 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which nonusers plan to use contraceptive methods in the future. In the 2011 NDHS, women age 15-49 who were not using any contraceptive method at the time of the survey were asked about their intention to use family planning in the future. Table 7.13 shows that, among currently married women not using contraception, 81 percent intend to use a family planning method in the future, 3 percent are unsure of their intentions, and 17 percent have no intention of using any method in the future. The proportion of women intending to use family planning peaks at 91 percent among nonusers with one child, declines to 75 percent among those with three children, and further declines sharply to 57 percent among those who have four or more children. Table 7.13 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Nepal 2011 Intention Number of living children1 Total 0 1 2 3 4+ Intends to use 89.1 90.7 85.8 74.8 57.2 80.6 Unsure 2.5 2.1 2.1 2.3 4.5 2.6 Does not intend to use 8.5 7.2 12.2 22.9 38.3 16.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 670 1,305 1,253 682 923 4,833 1 Includes current pregnancy 7.14 EXPOSURE TO FAMILY PLANNING MESSAGES The media play an important role in communicating messages about family planning. Data on level of exposure to such media as radio, television, and printed materials are important for program managers and planners to effectively target population subgroups for information, education, and communication campaigns. In Nepal, the most common media sources are the radio and posters. Television is mostly found in urban areas, while print media are accessed mostly by the educated. To assess the extent to which the media serve as a source of family planning messages, respondents were asked whether they had heard or seen a message about family planning on the radio or television, in the print media (newspaper, magazine, poster, or billboard), or at a street drama in the months preceding the survey. The results are shown in Table 7.14. Posters and billboards are the most popular source for family planning messages in Nepal, with 55 percent of women and 70 percent of men having seen a family planning message on a poster or billboard. Fifty- two percent of women and 59 percent of men age 15-49 heard a family planning message on the radio, and 40 percent of women and 45 percent of men saw a message on television. Fourteen percent of women and 34 106 • Family Planning percent of men read about family planning in a newspaper or magazine, while 6 percent of women and 14 percent of men were exposed to family planning messages at a street drama. Overall, 26 percent of women and 15 percent of men were not exposed to family planning messages in any of the specified media sources. In general, exposure to media messages on family planning decreases with age, with older women and men (age 45-49) least likely to have been exposed to family planning messages in any media. Table 7.14 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on the radio or on television or in a newspaper/magazine, poster/billboard, and street drama in the past few months, according to background characteristics, Nepal 2011 Background characteristic Women Men Radio Tele- vision News- paper/ magazine Poster/ billboard Street drama None of these five media sources Number of women Radio Tele- vision News- paper/ magazine Poster/ billboard Street drama None of these five media sources Number of men Age 15-19 57.1 40.7 18.6 60.4 8.4 21.3 2,753 60.3 46.0 34.5 73.5 17.3 11.5 978 20-24 53.4 43.4 19.5 61.1 6.8 22.9 2,297 65.1 50.5 44.3 78.1 18.0 9.3 685 25-29 52.0 41.7 15.6 57.6 5.8 24.5 2,101 54.5 40.7 31.1 71.0 12.7 14.3 581 30-34 48.9 43.5 13.4 56.2 4.6 26.0 1,734 55.9 46.3 32.9 71.1 9.0 17.7 499 35-39 51.3 36.9 11.1 53.0 5.1 28.6 1,557 58.8 48.3 34.5 69.8 11.0 14.7 542 40-44 49.3 34.0 6.3 43.9 4.0 30.7 1,285 57.1 41.5 28.7 63.0 11.7 18.8 438 45-49 45.2 31.1 4.8 37.5 3.5 36.6 947 54.6 36.7 22.1 57.0 8.8 22.0 399 Residence Urban 51.8 63.5 31.5 72.9 7.6 14.2 1,819 54.6 62.9 52.5 80.0 15.4 8.4 717 Rural 52.1 35.9 11.5 52.2 5.7 27.7 10,855 59.5 41.2 29.7 68.4 13.1 15.8 3,404 Ecological zone Mountain 60.9 25.7 7.8 51.3 5.5 24.1 805 72.9 25.1 18.0 60.5 11.5 13.9 245 Hill 59.1 38.7 15.8 58.1 5.1 21.2 5,090 62.1 42.0 33.6 69.4 9.9 12.5 1,658 Terai 45.7 42.4 14.0 53.4 6.6 29.4 6,779 54.5 49.4 35.4 72.3 16.4 16.1 2,218 Development region Eastern 54.9 45.1 17.8 59.7 5.9 21.4 3,057 58.0 46.8 33.9 66.3 17.4 15.9 996 Central 45.7 38.4 15.7 51.2 3.9 31.0 4,236 59.4 50.0 38.4 69.9 13.9 14.7 1,448 Western 55.5 47.9 13.5 58.3 5.5 23.2 2,660 53.8 49.4 33.6 73.9 10.6 15.0 798 Mid-western 58.0 28.6 9.3 56.0 9.7 23.1 1,478 63.2 31.6 26.5 67.2 11.3 14.3 493 Far-western 52.8 28.2 8.8 50.0 10.0 27.5 1,242 61.9 29.4 24.6 80.1 11.0 9.3 385 Subregion Eastern mountain 70.5 26.2 12.7 58.8 3.5 17.4 229 69.0 24.0 23.0 56.1 13.9 15.8 66 Central mountain 63.2 34.2 10.0 52.1 5.6 19.8 258 75.0 39.1 21.6 72.0 13.8 10.8 69 Western mountain 52.2 18.3 2.6 45.3 7.0 32.4 319 73.9 17.0 12.8 56.0 8.7 14.7 110 Eastern hill 61.8 28.6 9.6 50.4 2.0 23.3 956 65.9 32.9 23.0 62.3 9.9 16.2 293 Central hill 59.6 57.6 29.2 73.4 6.9 9.9 1,563 56.5 52.5 46.0 68.8 9.4 10.4 616 Western hill 58.1 38.7 11.4 50.6 2.8 27.4 1,513 61.5 46.4 32.5 72.0 9.8 14.0 440 Mid-western hill 61.4 23.8 10.0 56.7 8.5 23.4 649 73.8 28.2 25.7 68.7 11.2 12.4 189 Far-western hill 51.3 13.3 4.8 48.2 9.2 32.5 409 65.5 16.2 12.5 82.1 11.3 8.6 120 Eastern terai 49.4 55.7 22.7 64.7 8.1 20.9 1,873 53.3 55.5 40.0 69.1 21.3 15.8 638 Central terai 34.8 26.5 7.7 36.7 1.7 45.8 2,415 60.3 48.9 33.7 70.7 17.5 18.4 763 Western terai 52.0 60.0 16.2 68.4 9.1 17.6 1,147 44.4 53.0 34.9 76.3 11.6 16.1 358 Mid-western terai 56.4 35.0 10.5 58.5 11.0 21.0 668 52.3 37.8 31.1 70.4 13.1 14.3 242 Far-western terai 53.4 40.1 12.5 51.5 11.5 22.9 676 57.0 39.6 33.6 82.7 10.3 10.2 217 Education No education 39.4 20.0 0.6 34.1 2.7 43.1 5,045 44.3 14.8 0.7 41.1 4.0 38.0 567 Primary 51.8 37.7 5.0 52.0 5.3 25.2 2,209 56.9 29.7 13.1 58.9 7.1 20.2 814 Some secondary 61.7 50.3 19.4 69.1 8.7 13.8 3,088 59.6 46.7 31.3 74.4 14.2 10.3 1,437 SLC and above 67.0 71.1 46.2 85.3 10.1 4.5 2,331 65.1 65.8 63.5 86.0 20.9 5.4 1,303 Wealth quintile Lowest 45.5 8.1 2.5 35.1 4.0 42.8 2,120 60.2 8.4 7.8 50.0 4.2 25.2 610 Second 49.6 17.2 4.4 44.2 4.6 34.4 2,393 61.2 25.6 17.7 62.7 8.2 18.5 695 Middle 51.8 32.3 8.0 47.4 4.8 30.3 2,600 60.3 39.6 27.8 69.8 18.3 18.4 830 Fourth 56.1 55.9 15.4 65.7 7.3 17.4 2,722 59.6 59.6 41.1 74.6 13.6 10.5 920 Highest 55.5 74.2 36.4 76.5 8.3 9.7 2,839 54.1 70.1 56.9 84.1 18.5 6.1 1,066 Total 15-49 52.1 39.9 14.3 55.2 6.0 25.8 12,674 58.7 45.0 33.7 70.4 13.5 14.5 4,121 SLC = School Leaving Certificate Not surprisingly, women and men residing in urban areas are much more likely to have been exposed to family planning messages in any media than their rural counterparts. This is especially true for messages on television and in the print media. Women living in the hill zone are more likely than women in the mountain zone and terai to have read or seen family planning messages in a newspaper or magazine or on a poster or billboard. Women living in the Eastern region and men living in the Far-western region are more likely to be exposed to family planning messages in any media than women and men in the other regions. Similarly, women living in the Central hill subregion and men living in the Far-western hill subregion have more exposure to family planning messages in the media than those in other areas. Family Planning • 107 Education has a positive influence on media exposure. For example, 43 percent of uneducated women have no exposure to family planning information in any media, as compared with 5 percent of women with a School Leaving Certificate (SLC) and higher. A similar pattern is observed for men. Among both women and men, exposure to family planning messages increases with wealth. 7.15 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS When family planning providers visit women in the field or when women visit health facilities, family planning fieldworkers and health providers are expected to discuss reproductive needs, contraceptive options available, and to counsel them to adopt a method of family planning. In Nepal, two types of field volunteers provide family planning services and information: female community health volunteers and reproductive health volunteers (RHVs) functioning under the Family Planning Association of Nepal. To get insight into the level of contact between nonusers and health workers, women who were not using contraception were asked whether an FCHV or RHV had visited them during the 12 months preceding the survey and discussed family planning. In addition, women were asked whether they had visited a health facility in the 12 months preceding the survey for any reason and whether anyone at the facility had discussed family planning with them during the visit. Table 7.15 shows that FCHVs or RHVs discussed family planning with only 9 percent of nonusers during the 12 months preceding the survey. At the same time, only 6 percent of nonusers visited a health facility and discussed family planning at the facility. This low level of contact of nonusers with family planning providers varies little by background characteristics. Overall, 88 percent of women who could have been exposed to family planning information did not discuss family planning during a field visit or at a health facility, indicating numerous missed opportunities to inform and educate women about family planning. 108 • Family Planning Table 7.15 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the last 12 months were visited by an FCHV/RHV who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who did not discuss family planning either with an FCHV/RHV or at a health facility, by background characteristics, Nepal 2011 Background characteristic Percentage of women who were visited by FCHV/RHV who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who did not discuss family planning either with FCHV/RHV or at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 3.4 2.1 38.1 95.2 2,612 20-24 10.7 7.7 57.8 85.1 1,773 25-29 14.2 10.2 59.9 81.3 1,212 30-34 13.0 9.7 56.8 80.8 741 35-39 13.6 8.9 51.8 82.4 555 40-44 12.0 5.5 42.0 85.3 464 45-49 5.1 2.0 43.9 94.6 480 Residence Urban 4.9 5.1 52.1 91.6 1,055 Rural 9.6 6.2 48.8 87.3 6,781 Ecological zone Mountain 10.6 6.6 47.6 86.3 499 Hill 9.4 6.3 49.6 87.3 3,243 Terai 8.5 5.8 49.1 88.5 4,095 Development region Eastern 6.8 7.0 46.5 89.0 1,984 Central 7.0 5.3 47.1 90.2 2,454 Western 8.9 5.5 57.9 88.1 1,709 Mid-western 15.4 6.7 47.7 81.9 933 Far-western 13.3 5.9 45.4 84.2 757 Subregion Eastern mountain 8.8 8.6 47.2 86.8 153 Central mountain 8.3 2.2 43.2 91.1 144 Western mountain 13.6 8.3 51.0 82.6 201 Eastern hill 5.8 6.6 42.0 89.6 655 Central hill 5.2 5.4 50.9 91.6 872 Western hill 10.9 6.0 57.3 86.5 1,002 Mid-western hill 17.5 8.2 44.4 79.0 433 Far-western hill 12.6 6.2 44.4 84.0 282 Eastern terai 7.1 7.1 48.9 89.0 1,176 Central terai 8.0 5.6 45.2 89.2 1,437 Western terai 6.1 5.0 58.8 90.3 708 Mid-western terai 12.6 4.4 51.2 85.8 394 Far-western terai 14.7 5.4 43.8 83.8 379 Education No education 10.9 7.5 46.0 85.4 2,585 Primary 11.5 7.6 50.2 84.7 1,329 Some secondary 6.4 4.4 49.4 91.0 2,238 SLC and above 7.5 4.8 53.2 89.9 1,685 Wealth quintile Lowest 10.6 6.3 37.1 86.7 1,438 Second 11.1 6.8 49.3 85.6 1,526 Middle 9.9 7.0 49.0 86.5 1,615 Fourth 7.8 5.0 54.5 89.0 1,636 Highest 5.7 5.2 54.9 91.2 1,622 Total 9.0 6.0 49.2 87.9 7,837 FCHV = female community health volunteer RHV = reproductive health volunteer SLC = School Leaving Certificate 7.16 COUNSELING DURING POSTPARTUM AND POST-ABORTION The government of Nepal, under the Family Health Division of the Ministry of Health and Population, has emphasized on strengthening the family planning counseling and services to Comprehensive Abortion Care (CAC) and postpartum care. The 2011 NDHS included questions on information and counseling on family planning methods for women during the post-abortion and postpartum periods to assess these programs. Family Planning • 109 The results are shown in Table 7.16. Forty-four percent of women who had an abortion in the five years preceding the survey were given information or counseled on family planning during their post-abortion visit. Only 9 percent of women who had a live birth in the five years preceding the survey were given information or counseled on family planning during their postpartum checkup. The results indicate many missed opportunities to provide information and counseling on family planning methods and services. Table 7.16 Information on family planning methods and counseling Percentage of women with an abortion in the five years preceding the survey who were given information on family planning methods and counseling during the post-abortion visit and percentage of women with a live birth in the five years preceding the survey who were given information on family planning during the postpartum visit, according to background characteristics, Nepal 2011 Background characteristic Information on family planning during post- abortion period Number of women with abortion Information on family planning during postpartum period Number of women with a live birth in the last five years Age 15-19 * 13 6.9 333 20-24 52.8 63 7.7 1,329 25-29 38.7 154 9.9 1,310 30-34 43.5 128 9.3 670 35-39 56.2 70 7.4 317 40-44 (49.3) 25 7.7 140 45-49 * 13 (0.7) 50 Residence Urban 47.7 90 14.0 418 Rural 43.1 376 7.8 3,730 Ecological zone Mountain 51.4 23 5.8 306 Hill 43.5 197 7.9 1,669 Terai 43.7 246 9.2 2,174 Development region Eastern 47.6 90 8.4 999 Central 46.1 111 8.0 1,293 Western 36.9 137 7.6 818 Mid-western 48.2 63 10.3 598 Far-western 46.3 65 8.9 440 Subregion Eastern mountain * 3 5.4 78 Central mountain * 6 6.9 72 Western mountain (44.4) 14 5.6 155 Eastern hill * 18 3.8 331 Central hill 55.2 66 11.6 403 Western hill 31.9 67 5.7 488 Mid-western hill (40.2) 26 11.3 275 Far-western hill (38.6) 20 8.2 171 Eastern terai (45.7) 68 11.3 589 Central terai * 39 6.4 818 Western terai 41.8 70 10.4 330 Mid-western terai 55.5 30 10.7 238 Far-western terai 50.9 39 10.9 200 Education No education 52.1 113 5.2 1,822 Primary 41.4 119 9.4 835 Some secondary 43.8 146 10.9 866 SLC and above 37.5 88 13.2 627 Wealth quintile Lowest 49.4 49 3.7 979 Second 42.8 56 5.9 899 Middle 39.8 77 7.1 873 Fourth 35.8 109 12.3 748 Highest 49.8 175 16.5 649 Total 15-49 44.0 466 8.5 4,148 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 110 • Family Planning 7.17 MEN’S ATTITUDES TOWARDS CONTRACEPTION The 2011 NDHS also included questions in the male survey to elicit further information on men’s attitudes toward contraception. This information is useful in formulating family planning programs and policies geared toward men since they play a key role in women’s reproductive health. Men’s attitudes toward family planning and specific methods are also important in shaping educational activities geared toward addressing some of their misconceptions and fears. To get a sense of their attitude toward contraception in general, men were asked their opinion on a number of stereotypical statements pertaining to contraception and its use. The results are shown in Table 7.17. Thirteen percent of Nepalese men agree that contraception is a woman’s business, and 20 percent agree that women who use contraception may become promiscuous. Men living in rural areas, the terai, and the Western region, particularly the Western hill subregion, are more likely to have these perceptions than other men. Men with SLC and higher level of education and those in the highest wealth quintile are less likely to have these misconceptions regarding contraceptive use than other men. Table 7.17 Men’s attitudes towards contraceptive use Among men who know a family planning method, the percentage who agree with stereotypical statements about contraceptive use, according to background characteristics, Nepal 2011 Background characteristic Contraception is women’s business Women who use contraception may become promiscuous Number of men who know a family planning method Age 15-19 10.9 21.0 973 20-24 11.8 18.1 684 25-29 16.4 18.9 581 30-34 14.1 19.9 499 35-39 11.5 21.0 541 40-44 10.1 21.1 434 45-49 13.6 21.6 398 Residence Urban 10.1 13.6 717 Rural 13.0 21.5 3,393 Ecological zone Mountain 5.6 11.5 245 Hill 9.8 21.6 1,650 Terai 15.2 20.0 2,216 Development region Eastern 8.0 17.4 994 Central 15.1 19.9 1,447 Western 16.0 32.8 795 Mid-western 9.0 12.0 490 Far-western 11.4 12.7 385 Subregion Eastern mountain 7.6 17.2 66 Central mountain 8.3 10.2 69 Western mountain 2.8 8.8 110 Eastern hill 4.6 17.0 291 Central hill 8.8 14.4 615 Western hill 16.7 39.5 436 Mid-western hill 3.0 12.2 188 Far-western hill 13.3 19.8 120 Eastern terai 9.6 17.6 638 Central terai 20.8 25.1 763 Western terai 15.2 24.6 358 Mid-western terai 15.3 13.5 240 Far-western terai 12.2 8.7 217 Education No education 17.7 27.9 560 Primary 20.2 24.7 810 Some secondary 12.9 20.8 1,437 SLC and above 5.0 13.3 1,303 Wealth quintile Lowest 13.7 26.0 604 Second 15.1 25.5 692 Middle 14.8 22.5 829 Fourth 12.5 18.3 919 Highest 8.3 13.1 1,066 Total 15-49 12.5 20.1 4,110 SLC = School Leaving Certificate Infant and Child Mortality • 111 INFANT AND CHILD MORTALITY 8 This chapter describes levels, trends, and differentials in early childhood mortality and high-risk fertility behavior of women in Nepal. Infant and child mortality rates are important indicators of a country’s socioeconomic development and quality of life, as well as health status. Measures of childhood mortality also contribute to a better understanding of the progress of population and health programs and policies. Analyses of mortality measures are useful in identifying promising directions for health and nutrition programs and improving child survival efforts in Nepal. Disaggregation of mortality measures by socioeconomic and demographic characteristics helps to identify differentials in population subgroups and target high-risk groups for effective programs. Measures of childhood mortality are also useful for population projections. Childhood mortality in general and infant mortality in particular are often used as broad indicators of social development or as specific indicators of health status. Childhood mortality rates are used for monitoring a country’s progress toward Millennium Development Goal 4, which aims for a two-thirds reduction in child mortality by the year 2015 (UNDP, 2011a). Results from the 2011 NDHS can be used in monitoring the impact of major national neonatal and child health interventions, strategies, and policies such as the National Newborn Health Strategy-2004 (Ministry of Health and Population, 2004a) and the Nepal Health Sector Program 2005- 2009 on achievement of this goal. Neonatal, postneonatal, infant, child, and under-5 year mortality rates are calculated from birth and death data derived from vital registration or from household surveys. The reliability of mortality estimates depends on the accuracy and completeness of reporting and recording of births and deaths. Underreporting and misclassification are common, especially for deaths occurring early on in life. The 2011 NDHS provides various measures of mortality. The mortality rates presented in this chapter are computed from information gathered in the pregnancy history section of the Woman’s Questionnaire. Women age 15-49 were asked whether they had ever given birth, and if they had, they were asked to report the number of sons and daughters living with them, the number living elsewhere, and the number who had died. Women were also asked for the number of pregnancies they had that did not end in a live birth. A detailed history of all pregnancies was gathered in chronological order starting with the first pregnancy. Women were asked whether a pregnancy was single or multiple, the sex of the child, the date of birth (month and year), survival status, the age of the child on the date of the interview if alive, and, if not alive, the age at death of each child born alive or the duration in months of a pregnancy that ended before full term. Since the primary causes of childhood mortality change as children age—from biological factors to environmental factors—childhood mortality rates are expressed by age categories and are customarily defined as follows: Key Findings: • Infant and under-five mortality rates in the past five years are 46 and 54 deaths per 1,000 live births, respectively. At these mortality levels, one in every 22 Nepalese children dies before reaching age 1, and one in every 19 does not survive to his or her fifth birthday. • Infant mortality has declined by 42 percent over the last 15 years, while under-five mortality has declined by 54 percent over the same period. • Childhood mortality is relatively higher in the mountain ecological zone than in the terai and hill zone and is highest in the Far-western region. • The neonatal mortality rate in the past five years is 33 deaths per 1,000 live births, which is two and a half times the postneonatal rate. The perinatal mortality rate is 37 per 1,000 pregnancies. 112 • Infant and Child Mortality • Neonatal mortality (NN): the probability of dying within the first month of life • Postneonatal mortality (PNN): the difference between infant and neonatal mortality • Infant mortality (1q0): the probability of dying between birth and the first birthday • Child mortality (4q1): the probability of dying between exact ages one and five • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday Rates of childhood mortality are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one. Information on stillbirths and deaths that occurred within seven days of birth is used to estimate perinatal mortality, which is the number of stillbirths and early neonatal deaths per 1,000 stillbirths and live births. 8.1 ASSESSMENT OF DATA QUALITY The accuracy of mortality estimates depends on the sampling variability of the estimates and on nonsampling errors. Sampling variability and sampling errors are discussed in detail in Appendix B. Nonsampling errors depend on the extent to which the date of birth and age at death are accurately reported and recorded and the completeness with which child deaths are reported. Omission of births and deaths affects mortality estimates, displacement of birth and death dates impacts mortality trends, and misreporting of age at death may distort the age pattern of mortality. Typically, the most serious source of nonsampling errors in a survey that collects retrospective information on births and deaths is the underreporting of births and deaths of children who were dead at the time of the survey. It may be that mothers are reluctant to talk about their dead children because of the sorrow associated with their death, or they may live in a culture that discourages discussion of the dead. The possible occurrence of these data problems in the 2011 NDHS is discussed with reference to the data quality tables in Appendix C. Underreporting of births and deaths is generally more severe the further back in time an event occurred. An unusual pattern in the distribution of births by calendar years is an indication of omission of children or age displacement. In the 2011 NDHS, the cutoff date for asking health questions was Baisakh 2062 in the Nepalese calendar (corresponding to April 2005 in the Gregorian calendar). Table C.4 shows that the overall percentage of births for which a month and year of birth was reported is almost 100 percent for both children who have died and children who are alive. Table C.4 shows some age displacement across this boundary for both living and dead children. The distribution of living children and the total number of children does not show a deficit in 2062 (2005-2006) in relation to 2063 (2006-2007) but does show an excess in 2061 (2004-2005), as denoted by the calendar year ratios. The deficit in 2062 (2005-2006) can be attributed to the transference of births by interviewers out of the period for which health data were collected. Transference is proportionately higher for dead children than living children, and this displacement may affect mortality rates. The transference of children, especially deceased children, out of the five-year period preceding the survey is likely to underestimate the true level of childhood mortality for that period. Underreporting of deaths is usually assumed to be higher for deaths that occur very early in infancy. Omission of deaths or misclassification of deaths as stillbirths may also be more common among women who have had several children or in cases where a death took place in the distant past. In order to assess the impact of omission on measures of child mortality, two indicators are used: the percentage of deaths that occurred under seven days to the number that occurred under one month and the percentage of neonatal deaths to infant deaths. It is hypothesized that omission will be more prevalent among those who died immediately after birth than those who lived longer and that it will be more serious for events that took place in the distant past than for those that occurred in the more recent past. Table C.5 shows data on age at death for early infant deaths. Selective underreporting of early neonatal deaths would result in an abnormally low ratio of deaths within the first seven days of life to all neonatal deaths. Early infant deaths were not severely underreported in the 2011 NDHS Infant and Child Mortality • 113 survey, as suggested by the high ratio of deaths in the first seven days of life to all neonatal deaths (84 percent in the five years preceding the survey). Heaping of the age at death on certain digits is another problem that is inherent in most retrospective surveys. Misreporting of age at death biases age pattern estimates of mortality if the net result is the transference of deaths between age segments for which the rates are calculated; for example, child mortality may be overestimated relative to infant mortality if children who died in the first year of life are reported as having died at age one or older. In an effort to minimize misreporting of age at death, interviewers were instructed to record deaths under one month in days and deaths under two years in months. In addition, they were trained to probe deaths reported at exactly one year or 12 months to ensure that they had actually occurred at 12 months. The distribution of deaths under two years during the 20 years prior to the survey by month of death shows that there is some heaping at 5, 15, and 18 months of age, with corresponding deficits in adjacent months (Table C.6). However, heaping is not obvious for deaths in the five years preceding the survey, for which the most recent mortality rates are calculated. 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Table 8.1 presents neonatal, postnatal, infant, child, and under-five mortality rates for three five-year periods preceding the survey. Neonatal mortality in the most recent period (2006-2010) is 33 deaths per 1,000 live births. This rate is two and a half times the postneonatal rate (13 deaths per 1,000 live births) during the same period. Therefore, the risk of dying for any Nepalese child who survived the first month of life is reduced by two-fifths (i.e., 39 percent) in the remaining 11 months of the first year of life. The infant mortality rate in the five years preceding the survey is 46 deaths per 1,000 live births, and the under-five mortality rate for the same period is 54 deaths per 1,000 live births. This means that one in every 22 Nepalese children dies before reaching age 1, while one in every 19 does not survive to her or his fifth birthday. Mortality trends can be examined in two ways: by comparing mortality rates for three five-year periods preceding a single survey and by comparing mortality estimates obtained from various surveys. However, comparisons between surveys should be interpreted with caution because of variations in quality of data, time references, and sample coverage. In particular, sampling errors associated with mortality estimates are large and should be taken into account when examining trends between surveys. Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Nepal 2011 Years preceding the survey Approximate calendar year Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 2006-2010 33 13 46 9 54 5-9 2001-2005 37 23 60 10 70 10-14 1996-2000 45 25 70 19 87 1 Computed as the difference between the infant and neonatal mortality rates Data from the 2011 NDHS show that neonatal mortality has declined by 27 percent over the 15-year period preceding the survey, from 45 to 33 deaths per 1,000 live births. The corresponding declines in postneonatal, infant, and under-five mortality over the 15-year period are 48 percent, 34 percent, and 38 percent. Mortality trends can also be observed by comparing data from the 2011 NDHS with data from the 1996, 2001, and 2006 NDHS (Figure 8.1). Infant and under-five mortality rates obtained for the five years preceding the four surveys confirm a declining trend in mortality. Infant mortality has declined by 42 percent over the last 15 years, from 79 deaths per 1,000 live births in 1991-1995 to 46 per 1,000 deaths in 2006-2010. An even more impressive decline was observed in under-five mortality, which decreased by 54 percent from 118 deaths per 1,000 live births to 54 per 1,000 deaths over the same period. The data also show 34 percent and 55 percent declines in neonatal and postneonatal mortality, respectively. An examination of neonatal, infant, and under-five mortality rates in Nepal over the past 15 years reveals that neonatal mortality has decreased at a slower pace than infant and child mortality, with the result that neonatal deaths have risen from 63 percent of all infant deaths in 1996 to 72 percent in 2011 and from 42 percent of under-five deaths to 61 percent. 114 • Infant and Child Mortality 50 29 79 43 118 39 26 64 29 91 33 15 48 14 61 33 13 46 9 54 0 20 40 60 80 100 120 Neonatal Postneonatal Infant Child Under-five D ea th s pe r 1 ,0 00 l iv e bi rth s Figure 8.1 Trends in Childhood Mortality, Nepal 1991-2010 1996 (1991-1995) 2001 (1996-2000) 2006 (2001-2005) 2011 (2006-2010) Data source: NFHS 1996, NDHS 2001, NDHS 2006, and NDHS 2011 It is interesting to note that in the past five years there have been only minimal changes in neonatal, postneonatal, and infant mortality. In 2004, the Ministry of Health and Population (MOHP) developed and passed the National Neonatal Health Strategy. The first phase of the Community-Based Neonatal Care Package (CB-NCP) was implemented in 10 pilot districts in 2007 through the Child Health Division with the support of the government of Nepal and development partners (Karki et al., 2010). The MOHP further expanded the CB- NCP in 25 districts by 2011 (MOHP, 2011a). Data from the 2011 NDHS show increased antenatal care and postnatal visits, improved delivery practices, and improved maternal health and newborn care indicators (see Chapter 9). These indicators are directly or indirectly related to neonatal health. Despite these improvements, neonatal mortality has remained the same over the past five years. An in-depth examination of the reasons for the stagnation in neonatal mortality is outside the scope of this report and is suggested for further analysis. 8.3 SOCIOECONOMIC DIFFERENTIALS IN CHILDHOOD MORTALITY Table 8.2 shows differentials in childhood mortality by socioeconomic variables. To minimize sampling errors associated with mortality estimates and to ensure a sufficient number of cases for statistical reliability, the mortality rates shown in the table are calculated for a 10-year period. Table 8.2 shows that infant and child mortality is higher in rural areas than in urban areas. For example, infant mortality in rural areas is 55 deaths per 1,000 live births, compared with 38 deaths per 1,000 live births in urban areas. Rural-urban differences are also significant in the case of neonatal, child, and under-five mortality rates. Moreover, there are wide differentials in infant and under-five mortality by ecological zone, with under- five mortality ranging from 62 deaths per 1,000 live births in the terai zone to 87 deaths per 1,000 live births in the mountain zone. Under-five mortality is higher in the Far-western and Mid-western development regions than in the other regions. Similarly, infant mortality is highest in the Far-western development region (65 deaths per 1,000 live births) and lowest in the Eastern development region (47 deaths per 1,000 live births). Infant and Child Mortality • 115 Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristics, Nepal 2011 Background characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 25 13 38 7 45 Rural 36 19 55 10 64 Ecological zone Mountain 46 27 73 16 87 Hill 33 17 50 8 58 Terai 35 18 53 10 62 Development region Eastern 30 17 47 8 55 Central 36 15 52 8 60 Western 37 16 53 4 57 Mid-western 34 24 58 16 73 Far-western 41 24 65 18 82 Mother's education No education 40 22 62 12 73 Primary 34 19 53 9 62 Some secondary 27 10 37 4 41 SLC and above (20) (11) (31) (1) (32) Wealth quintile Lowest 37 25 61 15 75 Second 40 16 56 11 66 Middle 39 17 55 9 64 Fourth 37 16 53 6 59 Highest 19 13 32 4 36 Note: Figures in parentheses are based on 250-499 unweighted exposed persons. SLC = School Leaving Certificate 1 Computed as the difference between the infant and neonatal mortality rates As expected, mother’s education is inversely related to a child’s risk of dying. Under-five mortality among children born to mothers with no education (73 deaths per 1,000 live births) is more than double that of children born to mothers with an School Leaving Certificate (SLC) or a higher level of education (32 deaths per 1,000 live births). Table 8.2 also shows that the risk of dying among children below age five gradually decreases with increasing household wealth, from 75 deaths per 1,000 live births in the poorest households to 36 deaths per 1,000 live births in the wealthiest households. 8.4 DEMOGRAPHIC DIFFERENTIALS IN MORTALITY Demographic characteristics of both mother and child play an important role in the survival probability of children. Table 8.3 shows that neonatal mortality is slightly higher among male children but that there are few significant differences in other childhood mortality rates by sex of the child. As expected, the relationship between maternal age at birth and childhood mortality is generally U- shaped, being relatively higher among children born to mothers under age 20 and over age 30 than among children born to mothers in the 20-29 age group. This pattern is especially obvious in the case of under-five mortality. In general, mortality rates are also significantly higher among first births and births of order seven or above than among births of order two or three. For example, 1 in 17 first births do not survive to the first year, compared with 1 in 20 births of order two or three. The spacing of births is another factor that has a significant impact on a child’s chances of survival. Generally, shorter birth intervals are associated with higher mortality, both during and after infancy. The 2011 NDHS data confirm this pattern. All childhood mortality rates show a strong relationship with the length of the previous birth interval. For example, infant mortality is more than three times higher among children born less than two years after a preceding sibling than among children born four or more years after a previous child (87 deaths and 26 deaths per 1,000 live births, respectively). 116 • Infant and Child Mortality Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Nepal 2011 Demographic characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 37 17 54 9 63 Female 33 19 52 10 62 Mother's age at birth <20 51 18 69 9 78 20-29 32 17 49 8 57 30-39 27 23 49 13 62 40-49 * * * * * Birth order 1 44 15 59 7 66 2-3 30 19 49 7 56 4-6 31 14 46 16 61 7+ 42 40 83 20 100 Previous birth interval2 <2 years 57 30 87 16 102 2 years 31 20 50 13 62 3 years 21 16 38 6 43 4+ years 14 12 26 7 32 Birth size3 Small/very small 51 14 65 na na Average or larger 29 12 41 na na Note: An asterisk indicates that a rate is based on fewer than 250 unweighted exposed persons and has been suppressed. 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey na = Not applicable Studies have shown that children’s birth weight is an important determinant of their survival chances. Since most births in Nepal occur at home, where children often are not weighed at birth, data on birth weight are available for only a few children. However, mothers in the 2011 NDHS survey were asked whether their child was very large, larger than average, average, smaller than average, or small at birth, since this has been found to be a good proxy for a child’s weight. As expected, the size of the baby at birth and mortality were negatively associated. For example, 1 in 15 children regarded as very small or small did not survive to the first year, as compared with 1 in 24 children regarded as average or large in size. 8.5 PERINATAL MORTALITY The 2011 NDHS asked women to report on any pregnancy loss that occurred in the five years preceding the survey. For each pregnancy that did not end in a live birth, the duration of pregnancy was recorded. In this report, perinatal deaths include pregnancy losses of at least seven months’ gestation (stillbirths) and deaths to live births within the first seven days of life (early neonatal deaths). The perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the sum of all stillbirths and live births. Information on stillbirths and infant deaths within the first week of life is highly susceptible to omission and misreporting. Nevertheless, retrospective surveys in developing countries provide more representative and accurate perinatal death rates than do vital registration systems and hospital-based studies. Table 8.4 shows that out of the 5,444 reported pregnancies of at least seven months’ gestation in the five years preceding the survey, 53 were stillbirths and 149 were early neonatal deaths, yielding an overall perinatal mortality rate of 37 per 1,000 pregnancies. Because the rate is subject to a high degree of sampling variation, differences by background characteristics should be interpreted with caution. Infant and Child Mortality • 117 Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Nepal 2011 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months’ duration Mother's age at birth <20 10 43 48 1,111 20-29 27 89 35 3,355 30-39 13 15 33 863 40-49 3 2 35 116 Previous pregnancy interval in months4 First pregnancy 19 57 44 1,732 <15 5 10 52 293 15-26 8 36 40 1,101 27-38 9 25 38 884 39+ 12 20 23 1,434 Residence Urban 4 11 29 507 Rural 49 137 38 4,938 Ecological zone Mountain 9 13 50 437 Hill 23 57 37 2,154 Terai 20 79 35 2,854 Development region Eastern 16 33 38 1,286 Central 4 58 36 1,721 Western 10 26 36 1,017 Mid-western 14 18 40 807 Far-western 9 14 37 614 Mother's education No education 25 79 40 2,575 Primary 16 26 38 1,095 Some secondary 10 40 34 1,478 SLC and above 2 4 20 297 Wealth quintile Lowest 20 32 37 1,410 Second 11 35 39 1,194 Middle 12 41 46 1,145 Fourth 5 31 38 943 Highest 5 10 19 753 Total 53 149 37 5,444 SLC = School Leaving Certificate 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months' duration, expressed per 1000 4 Categories correspond to birth intervals of less than 24 months, 24-35 months, 36-47 months, and 48+ months. The perinatal mortality rate is higher among young mothers (below age 20) and among births that occur less than 15 months after the previous birth. The perinatal mortality rate is higher in rural than in urban areas and higher in the mountain zone than in the hill and terai zones. It is highest in the Mid-western region. There is a marked difference in perinatal mortality by mother’s education. It is twice as high among women with no education as among women with an SLC or higher level of education. Perinatal mortality is lowest among women in the highest wealth quintile. Perinatal mortality has declined from 45 to 37 deaths per 1,000 pregnancies in the last five years. 8.6 HIGH-RISK FERTILITY BEHAVIOR The survival of infants and children depends in part on the demographic and biological characteristics of their mothers. Typically, the probability of dying in infancy is much greater among children born to mothers who are too young (under age 18) or too old (over age 34), children born after a short birth interval (less than 24 months after the preceding birth), and children born to mothers of high parity (more than three children). The risk is elevated when a child is born to a mother who has a combination of these risk characteristics. 118 • Infant and Child Mortality The first column in Table 8.5 shows the percentages of births occurring in the five years before the survey that fall into the various risk categories. Thirty-nine percent of births in Nepal are at an elevated risk of dying that is avoidable, while 34 percent are in a risk-free category. First births, which make up 27 percent of births, are considered an unavoidable risk. Twenty-nine percent of births are in a single high-risk category, and 11 percent are in a multiple high-risk category. The most common single high-risk category is births of order higher than three (12 percent), while the most common multiple high-risk category is births to mothers above age 34 and of birth order over three (5 percent). Table 8.5 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Nepal 2011 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high-risk category 33.6 1.00 38.8a Unavoidable risk category First-order births between ages 18 and 34 27.4 1.09 8.8 Single high-risk category Mother's age <18 6.7 1.61 1.3 Mother's age >34 1.1 * 7.3 Birth interval <24 months 8.6 1.78 8.4 Birth order >3 12.1 (0.81) 9.9 Subtotal 28.5 1.27 26.9 Multiple high-risk category Age <18 and birth interval <24 months2 0.5 2.69 0.2 Age >34 and birth interval <24 months 0.0 * 0.1 Age >34 and birth order >3 5.3 (0.60) 20.7 Age >34 and birth interval <24 months and birth order >3 0.6 3.77 1.0 Birth interval <24 months and birth order >3 4.0 2.10 3.5 Subtotal 10.5 1.46 25.5 In any avoidable high-risk category 39.0 1.32 52.4 Total 100.0 na 100.0 Number of births/women 5,391 na 9,608 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order three or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women na = Not applicable The risk ratios in the second column of Table 8.5 denote the relationship between risk factors and mortality. In general, risk ratios are higher for children in a multiple high-risk category than in a single high-risk category. The most vulnerable births are those to women older than 34 years, with a birth interval less than 24 months, and birth order of higher than three. This group of children is nearly four times as likely to die as children not in any high-risk category. Less than 1 percent of births fall in this category. The last column of Table 8.5 shows the distribution of currently married women with the potential for having a high-risk birth by category. This column is purely hypothetical and does not take into consideration the protection provided by family planning, postpartum insusceptibility, and prolonged abstinence. However, it provides insight into the magnitude of high-risk births. Twenty-one percent of women are or would be too old (over 34) and have or would have too many children (more than three) if they were to become pregnant. A slightly lower proportion of women (26 percent) have the potential of having a birth in a multiple high-risk category than in a single high-risk category (27 percent). Maternal Health • 119 MATERNAL HEALTH 9 The maternal mortality ratio (MMR) in Nepal decreased substantially between 1996 and 2006, from 539 to 281 deaths per 100,000 births (Ministry of Health and Population [MOHP], New ERA, and Macro International Inc., 2007). Improvements in maternal health services have been key in reducing the country’s MMR. The National Safe Motherhood Program has made significant progress in terms of development of policies and protocols as well as expansion of the role of service providers such as staff nurses and auxiliary nurse midwives. The National Safe Motherhood Program is a priority for the government of Nepal’s Health Sector Strategy, which works toward meeting the Tenth Five-year Poverty Reduction Strategy and health sector targets set out in the Millennium Development Goals (MDGs). The target for maternal health is to reduce the MMR by three-quarters between 1990 and 2015. The Policy on Skilled Birth Attendants, endorsed in 2006 by the MOHP, specifically identifies the importance of skilled birth attendants (SBAs) at every birth and embodies the government’s commitment to training and deploying doctors, nurses, and auxiliary nurse midwives with the required skills across the country. In order to ensure focused and coordinated efforts among various stakeholders involved in safe motherhood and neonatal health programming, the National Safe Motherhood (2002-2007) Program has been revised with wider participation by the government and nongovernmental, national, and international institutions. By the end of 2008-2009, the birth preparedness package (BPP) had been rolled out in all 75 districts. Similarly, a maternity incentive scheme was adopted in 2005 to encourage women to use health facilities for maternity care and improve access to maternity care services (MOHP, 2011a). The health care services that a woman receives during pregnancy, childbirth, and the immediate postnatal period are important for the survival and well-being of both the mother and the child. The 2011 NDHS collected information on the extent to which women in Nepal receive care during each of these stages. The findings can be used to identify subgroups of women at increased risk of mortality because of nonuse of maternal health services and to assist in the planning of appropriate improvements in services. 9.1 ANTENATAL CARE Antenatal care (ANC) from a skilled provider is important to monitor the pregnancy and reduce the risk of morbidity for mother and baby during pregnancy and delivery. The quality of antenatal care can be monitored through the content of services received and the kind of information mothers are given during their visit. Information on ANC coverage was obtained from women who gave birth in the five years preceding the survey. Among women with two or more live births during the five-year period, data refer to the most recent birth only. Table 9.1 shows the percent distribution of mothers in the five years preceding the survey by source of antenatal care received during pregnancy, according to selected characteristics. Women were asked to report on Key Findings: • About 6 in 10 mothers receive antenatal care from a skilled provider, a significant improvement from 24 percent in 1996. • Fifty percent of women make four or more antenatal care visits during their pregnancy, a five-fold increase in the past 15 years. The median duration of pregnancy for the first antenatal visit is 3.7 months. • Eighty-two percent of mothers with a birth in five years preceding the survey were protected against neonatal tetanus. • More than one in three births in the past five years have been assisted by a skilled provider. Skilled birth attendance has doubled over this period. • In the two years before the survey, 45 percent of women received postnatal care for their last birth in the first two days after delivery. • Only 38 percent of women are aware that abortion is legal in Nepal. In addition, their knowledge of the specific circumstances under which abortion is legal is poor. 120 • Maternal Health all persons they saw for antenatal care for their last birth. However, if a woman saw more than one provider, only the provider with the highest qualifications was considered in the tabulation of results. Fifty-eight percent of mothers received antenatal care from a skilled provider (a doctor, nurse, or midwife) for their most recent birth in the five years preceding the survey. In addition, 26 percent of mothers received antenatal care from trained health workers such as a health assistant or auxiliary health worker (AHW), a maternal and child health worker (MCHW), or a village health worker (VHW). Less than 1 percent of women received antenatal care from a female community health volunteer (FCHV). Fifteen percent of women received no antenatal care for births in the five years before the survey. Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Nepal 2011 Background characteristic Antenatal care provider No ANC Total Percentage receiving antenatal care from a skilled provider1 Number of women Doctor Nurse/ midwife Health assistant/ AHW MCHW VHW FCHV Mother’s age at birth <20 25.6 37.9 9.6 14.4 1.1 0.5 10.9 100.0 63.5 739 20-34 28.2 31.6 12.4 12.2 1.4 0.7 13.5 100.0 59.8 3,085 35-49 17.2 14.3 6.6 15.6 1.7 4.0 40.7 100.0 31.5 325 Birth order 1 37.1 35.8 11.2 8.9 0.8 0.3 5.9 100.0 72.8 1,302 2-3 27.6 32.6 11.6 13.4 1.6 0.7 12.4 100.0 60.2 1,895 4-5 13.9 28.5 13.2 15.5 1.4 2.2 25.3 100.0 42.4 614 6+ 6.9 12.9 8.3 20.3 2.3 1.8 47.4 100.0 19.8 337 Residence Urban 59.3 28.6 3.3 1.8 0.2 0.3 6.3 100.0 87.9 418 Rural 23.3 31.7 12.4 14.1 1.5 1.0 16.1 100.0 54.9 3,730 Ecological zone Mountain 10.1 42.0 9.7 14.9 0.4 0.3 22.6 100.0 52.1 306 Hill 23.5 29.7 12.0 11.8 0.8 1.7 20.4 100.0 53.2 1,669 Terai 31.9 31.1 11.2 13.4 1.9 0.4 10.1 100.0 63.0 2,174 Development region Eastern 26.4 34.3 14.0 11.4 1.4 0.6 11.9 100.0 60.7 999 Central 34.9 21.6 14.5 10.5 1.5 0.0 17.0 100.0 56.4 1,293 Western 29.9 30.0 8.6 12.9 1.8 1.9 14.8 100.0 59.9 818 Mid-western 14.2 39.0 7.8 15.0 1.0 1.9 21.2 100.0 53.1 598 Far-western 16.2 45.6 6.9 20.0 0.7 1.2 9.5 100.0 61.8 440 Subregion Eastern mountain 9.7 40.7 13.3 17.9 1.7 0.0 16.7 100.0 50.3 78 Central mountain 19.4 39.8 15.2 2.9 0.0 0.6 22.3 100.0 59.2 72 Western mountain 5.9 43.7 5.3 19.1 0.0 0.3 25.7 100.0 49.7 155 Eastern hill 14.5 36.9 22.4 4.0 2.2 1.0 19.0 100.0 51.4 331 Central hill 45.1 16.1 12.3 7.7 0.4 0.0 18.4 100.0 61.2 403 Western hill 23.6 27.7 10.6 13.6 0.8 2.8 21.0 100.0 51.3 488 Mid-western hill 10.3 33.1 6.5 17.0 0.0 2.7 30.4 100.0 43.3 275 Far-western hill 11.0 48.5 4.4 22.8 0.7 2.4 10.3 100.0 59.5 171 Eastern terai 35.3 32.1 9.4 14.8 0.9 0.4 7.2 100.0 67.3 589 Central terai 31.2 22.6 15.5 12.6 2.2 0.0 15.9 100.0 53.9 818 Western terai 39.3 33.5 5.7 11.8 3.2 0.7 5.8 100.0 72.8 330 Mid-western terai 21.7 39.3 10.8 15.1 2.5 1.5 9.1 100.0 60.9 238 Far-western terai 24.2 49.5 8.8 13.3 0.9 0.2 3.1 100.0 73.7 200 Education No education 14.5 27.5 12.7 17.9 1.6 1.2 24.7 100.0 42.0 1,822 Primary 19.4 36.6 14.2 13.3 1.3 0.9 14.4 100.0 56.0 835 Some secondary 35.8 36.7 12.0 7.9 1.2 0.6 5.9 100.0 72.4 866 SLC and above 60.7 28.3 3.5 4.5 1.1 0.7 1.2 100.0 89.0 627 Wealth quintile Lowest 6.8 26.5 13.6 17.7 0.8 1.6 32.9 100.0 33.3 979 Second 11.4 33.3 15.4 17.7 1.9 1.7 18.5 100.0 44.7 899 Middle 22.9 35.4 15.0 14.6 2.4 0.4 9.2 100.0 58.3 873 Fourth 42.3 35.6 7.0 7.6 1.1 0.2 6.3 100.0 77.9 748 Highest 66.1 25.7 3.2 2.6 0.2 0.3 2.0 100.0 91.8 649 Total 26.9 31.4 11.4 12.9 1.4 0.9 15.2 100.0 58.3 4,148 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. AHW = auxiliary health worker; MCH = maternal and child health worker; VHW = village health worker; FCHV = female community health volunteer; SLC = School Leaving Certificate 1 Skilled provider includes doctor, nurse, and midwife. Younger mothers (less than age 20) are more likely to receive antenatal care from a skilled provider than older mothers (age 35-49). Mothers are also much more likely to receive care from a skilled provider for their first births (73 percent) than for births of order six and higher (20 percent). There are large differences in the use of antenatal care services between urban and rural women. Eighty-eight percent of urban mothers received antenatal care from a skilled provider, compared with only 55 Maternal Health • 121 percent of rural mothers. Sixty-three percent of mothers living in the terai received antenatal care from a skilled provider, compared with 53 percent of mothers in the hill zone and 52 percent of mothers in the mountain zone. About 60 percent of mothers living in the Far-western, Eastern, and Western regions received antenatal care from a skilled provider. Less than 55 percent of mothers living in the Mid-western region received antenatal care from a skilled provider. The proportion of women who received antenatal care from a skilled provider was lowest in the Mid-western hill subregion (43 percent) and highest in the Western terai (73 percent) and Far- western terai (74 percent) subregions. The use of antenatal care services from a skilled provider is strongly related to the mother’s level of education. Women with a School Leaving Certificate (SLC) and higher are more than twice as likely to receive antenatal care from a skilled provider (89 percent) as women with no education (42 percent). Similarly, women in the highest wealth quintile are almost three times as likely to receive care from a skilled provider (92 percent) as women in the lowest wealth quintile (33 percent). The proportion of women receiving antenatal care from a skilled provider has more than doubled in the past 15 years, from 24 percent in 1996 to 58 percent in 2011. 9.1.1 Number and Timing of Antenatal Visits Regular antenatal care is helpful in identi- fying and preventing adverse pregnancy outcomes when it is sought early in the pregnancy and is con- tinued through delivery. WHO recommends that a woman should have at least four ANC visits. It is possible during these visits to detect health problems associated with a pregnancy. In the event of any complications, more frequent visits are advised, and admission to a health facility may be necessary. Table 9.2 presents information on the num- ber of antenatal visits and the timing of the first ante- natal visit for the most recent birth in the five years preceding the survey. The findings show that 50 per- cent of pregnant women make four or more antenatal care visits during their entire pregnancy. Urban women (72 percent) are more likely to have had four or more antenatal visits than rural women (48 per- cent). Fifty percent of women made their first antenatal care visit before the fourth month of pregnancy. The median duration of pregnancy at the first antenatal care visit was 3.7 months (3.4 months in urban areas and 3.8 months in rural areas). Over the past 15 years, there has been a five-fold increase in the percentage of women with four or more antenatal visits during their pregnancy (from 9 percent in 1996 to 50 percent in 2011). 9.2 COMPONENTS OF ANTENATAL CARE The content of antenatal care is an essential component of ANC service quality. Focused antenatal care hinges on the principle that every pregnancy is at risk of complications. Therefore, apart from receiving basic care, every pregnant woman should be monitored for complications. Ensuring that pregnant women receive information and undergo screening for complications should be a routine part of all antenatal care visits. To assess ANC services, mothers in the 2011 NDHS were asked a number of questions about the care they received during pregnancy for their most recent live birth in the five years preceding the survey. Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Nepal 2011 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 6.3 16.1 15.2 1 2.9 6.5 6.1 2-3 19.0 29.7 28.6 4+ 71.8 47.7 50.1 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 6.3 16.1 15.2 <4 67.3 47.7 49.7 4-5 19.9 26.8 26.1 6-7 5.6 7.6 7.4 8+ 0.7 1.8 1.7 Don’t know/missing 0.1 0.0 0.0 Total 100.0 100.0 100.0 Number of women 418 3,730 4,148 Median months pregnant at first visit (for those with ANC) 3.4 3.8 3.7 Number of women with ANC 392 3,128 3,520 122 • Maternal Health Table 9.3 presents information on the percentage of women who took iron tablets and intestinal parasite drugs during their most recent pregnancy in the five years preceding the survey. The table also shows the percentage of women who were informed about the signs of pregnancy complications and, among women receiving antenatal care, the percentage who received specific routine antenatal care services. Among women with a live birth in the past five years, 80 percent took iron tablets and 55 percent took intestinal parasite drugs during their most recent pregnancy. There are substantial variations by background characteristics. Women less than age 34 at delivery, women pregnant with their first child, urban women, women residing in the terai, women living in the Far-western and Eastern regions (and particularly the Far- western hill, Eastern terai, Western terai, Mid-western terai, and Far-western terai subregions), women with at least some secondary education, and women in the middle and higher wealth quintiles were more likely than their counterparts to take iron tablets during their pregnancy. A similar pattern by background characteristics is seen in use of drugs for intestinal parasites, with the exception of place of residence. Rural women are slightly more likely than urban women to have taken drugs for intestinal parasites. There is little variation by wealth quintile with the exception of women in the lowest quintile, who are least likely to take anti-parasitic drugs. Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Nepal 2011 Background characteristic Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Among women who received antenatal care for their most recent birth in the past five years, the percentage with selected services Took iron tablets or syrup Took intestinal parasite drugs Number of women with a live birth in the past five years Informed of signs of pregnancy complications Blood pressure measured Urine sample taken Blood sample taken Number of women with ANC for their most recent birth Mother’s age at birth <20 82.9 58.7 739 76.1 87.6 54.4 44.9 658 20-34 81.5 56.5 3,085 76.0 86.8 57.1 46.2 2,669 35-49 53.0 33.7 325 66.7 78.0 44.3 34.4 192 Birth order 1 89.7 64.4 1,302 80.7 92.5 67.3 58.2 1,225 2-3 82.0 57.3 1,895 76.4 85.4 55.0 43.7 1,659 4-5 69.2 41.1 614 65.4 79.7 38.7 27.7 459 6+ 45.2 33.0 337 57.7 71.4 29.6 16.4 177 Residence Urban 88.9 49.8 418 83.2 95.3 83.9 77.2 392 Rural 78.5 55.7 3,730 74.5 85.3 52.4 41.3 3,128 Ecological zone Mountain 73.0 58.2 306 83.5 86.0 37.7 28.3 237 Hill 75.0 50.9 1,669 80.8 84.7 52.0 41.9 1,328 Terai 83.9 58.0 2,174 70.9 87.6 60.7 49.7 1,955 Development region Eastern 82.8 60.9 999 78.8 90.6 59.7 45.5 880 Central 76.6 41.8 1,293 63.3 86.7 61.3 53.0 1,073 Western 79.0 54.2 818 77.7 83.6 58.2 47.9 697 Mid-western 74.6 62.2 598 82.8 81.3 48.5 32.3 472 Far-western 88.5 73.3 440 88.6 87.6 37.6 35.0 398 Subregion Eastern mountain 75.2 63.1 78 84.9 90.9 32.0 24.3 65 Central mountain 72.0 50.9 72 75.5 88.7 51.8 36.3 56 Western mountain 72.4 59.2 155 86.7 81.9 34.1 26.5 115 Eastern hill 73.9 53.3 331 75.7 83.1 42.0 26.8 268 Central hill 77.9 39.7 403 77.6 97.4 73.3 63.6 329 Western hill 73.6 48.2 488 81.2 79.3 51.8 42.9 386 Mid-western hill 67.9 57.4 275 88.6 77.7 48.3 30.9 191 Far-western hill 86.4 69.7 171 86.0 83.2 29.3 32.9 153 Eastern terai 88.9 64.9 589 79.5 94.3 71.8 57.3 547 Central terai 76.4 42.1 818 55.5 81.4 56.4 49.2 688 Western terai 87.0 63.0 330 73.3 88.9 66.1 53.9 311 Mid-western terai 83.3 68.4 238 76.6 84.3 51.1 33.8 216 Far-western terai 95.7 81.8 200 91.0 92.6 47.1 40.7 194 Education No education 69.0 44.4 1,822 63.9 79.2 40.7 31.0 1,372 Primary 78.8 56.4 835 74.6 85.2 52.9 40.0 714 Some secondary 89.7 67.7 866 82.6 91.5 63.0 52.8 814 SLC and above 97.2 67.2 627 92.8 97.5 83.7 73.4 619 Wealth quintile Lowest 61.8 43.8 979 69.6 77.0 31.2 20.2 657 Second 77.8 55.8 899 70.8 81.4 37.8 26.2 733 Middle 82.1 58.9 873 69.5 85.3 50.3 39.9 792 Fourth 88.6 61.7 748 81.2 91.8 75.9 63.1 701 Highest 94.8 58.7 649 88.3 97.5 87.1 80.3 637 Total 79.5 55.1 4,148 75.5 86.4 55.9 45.3 3,520 SLC = School Leaving Certificate Maternal Health • 123 More than three-fourths (76 percent) of mothers who received antenatal care reported that they were informed about pregnancy complications during an antenatal visit. Eighty-six percent of pregnant women who sought antenatal care had their blood pressure taken. Fifty-six percent and 45 percent of women had urine and blood taken for testing, respectively. The quality of antenatal care is particularly related to mother’s education, wealth, residence, and birth order. For example, 98 percent of women with an SLC and higher education had their blood pressure measured, compared with 79 percent of women with no education. Women in the lowest wealth quintile were less often provided information about pregnancy complications (70 percent) than women in the highest wealth quintile (88 percent). Slightly more urban women (83 percent) than rural women (75 percent) were provided information about pregnancy complications. The overall quality of antenatal care has improved in the past five years. The percentage of pregnant women who were informed of complications during pregnancy increased by 32 percent, the percentage who had their blood pressure measured increased by 10 percent, and the percentage who had urine samples taken increased by 77 percent during that period. 9.3 TETANUS TOXOID VACCINATION Neonatal tetanus is a leading cause of death among infants in developing countries where a considerable proportion of deliveries take place at home or at locations where hygienic conditions may be poor. Tetanus toxoid (TT) vaccine is given to women during pregnancy to prevent infant deaths caused by neonatal tetanus, which can occur when sterile procedures are not followed in cutting the umbilical cord after delivery. For full protection, women should receive at least two doses of TT vaccine during each pregnancy. If a woman has been vaccinated during a previous pregnancy or during maternal and neonatal tetanus vaccination campaigns, however, she may require only one dose for the current pregnancy. Five doses are considered to provide lifetime protection. Table 9.4 presents the percentage of women who had a live birth in the five years preceding the survey and whose last birth was protected against neonatal tetanus. More than four of five mothers (82 percent) with a birth in the five years preceding the survey were protected against neonatal tetanus. More than two-thirds (70 percent) of pregnant women received two or more tetanus injections during their last pregnancy. Younger mothers (less than age 34), mothers of lower order births (three and below), and urban mothers are more likely to have received two or more tetanus injections during their last pregnancy than their counterparts. There are marked differences in tetanus toxoid coverage by ecological zone, development region, and subregion. Over 70 percent of mothers from the terai, Eastern and Central regions, and Eastern terai, Central terai, and Western terai subregions received two or more tetanus toxoid injections. Education and wealth have a positive impact on receipt of tetanus toxoid injections, with coverage of two doses or more ranging from a low of 60 percent among mothers with no education to a high of 87 percent among mothers with an SLC and higher education. Similarly, coverage with two or more doses of tetanus toxoid ranges from a low of 50 percent among mothers in the poorest households to 88 percent among mothers in the wealthiest households. Between 2006 and 2011, the percentage of mothers who received at least two tetanus toxoid injections for their last birth and the percentage whose last birth was protected against neonatal tetanus increased by just 10 percent and 4 percent, respectively. 124 • Maternal Health Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid (TT) injections during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Nepal 2011 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 73.2 82.5 739 20-34 71.2 83.7 3,085 35-49 47.8 58.6 325 Birth order 1 80.3 87.6 1,302 2-3 71.2 85.9 1,895 4-5 57.5 69.9 614 6+ 42.6 54.6 337 Residence Urban 80.7 90.8 418 Rural 68.5 80.5 3,730 Ecological zone Mountain 60.9 69.6 306 Hill 62.4 73.0 1,669 Terai 76.5 89.8 2,174 Development region Eastern 72.2 83.6 999 Central 74.3 84.5 1,293 Western 66.3 78.8 818 Mid-western 61.0 72.1 598 Far-western 68.6 85.9 440 Subregion Eastern mountain 61.3 74.6 78 Central mountain 57.3 63.8 72 Western mountain 62.5 69.7 155 Eastern hill 63.3 73.2 331 Central hill 69.3 78.6 403 Western hill 57.1 70.0 488 Mid-western hill 56.2 63.4 275 Far-western hill 69.6 83.3 171 Eastern terai 78.7 90.7 589 Central terai 78.3 89.3 818 Western terai 79.9 91.8 330 Mid-western terai 66.7 83.6 238 Far-western terai 69.2 92.9 200 Education No education 60.4 72.6 1,822 Primary 66.4 80.0 835 Some secondary 80.4 90.7 866 SLC and above 86.5 96.8 627 Wealth quintile Lowest 49.8 59.6 979 Second 61.7 77.4 899 Middle 77.7 90.2 873 Fourth 80.5 92.1 748 Highest 87.8 96.4 649 Total 69.7 81.5 4,148 1 Includes mothers with two injections during the pregnancy of their last birth, or two or more injections (the last within three years of the last live birth), or three or more injections (the last within five years of the last birth), or four or more injections (the last within 10 years of the last live birth), or five or more injections at any time prior to the last birth SLC = School Leaving Certificate 9.4 PLACE OF DELIVERY Increasing the percentage of births delivered in health facilities is important for reducing deaths arising from complications of pregnancy. The expectation is that if complications arise during delivery in a health facility, a skilled attendant can manage the complication or refer the mother early to the next level of care. Hence, Nepal is promoting safe motherhood through initiatives such as providing financial assistance through maternity incentives schemes to women seeking skilled delivery care in a health facility. Subsidies are also provided to health institutions on the basis of deliveries conducted. Table 9.5 presents the percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. Thirty-five percent of births take place in a health facility: 26 percent are delivered in a public-sector health facility, 2 percent in a nongovernment facility, and 7 percent in Maternal Health • 125 a private facility. Still two-thirds of births (63 percent) take place at home. Delivery in a health facility is more common among mothers less than age 34 (35-41 percent) and mothers of first-order births (54 percent). Children in urban areas are more than twice as likely (71 percent) to be delivered in an institutional setting as children born in rural areas (32 percent). Delivery in a health facility varies widely by ecological region, being lowest in the mountain zone (19 percent) and highest in the terai (41 percent). Institutional deliveries range from a low of 29 percent in the Far-western and Mid-western regions to a high of 40 percent in the Eastern region, and they are most frequent in the Eastern terai subregion, where one of two mothers has a facility-based delivery. There is a strong association between health facility delivery, mother’s education, and wealth quintile. The proportion of deliveries in a health facility is nearly four times higher among births to mothers with an SLC and higher education (75 percent) than among births to mothers with no education (19 percent). A similar pattern is seen in terms of wealth quintile: delivery at a health facility is significantly lower among births in the lowest wealth quintile (11 percent) than in the highest wealth quintile (78 percent). Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Nepal 2011 Background characteristic Health facility Home Other Total Percentage delivered in a health facility Number of births Government sector Non- government sector Private sector Mother’s age at birth <20 33.0 2.2 6.1 57.7 1.1 100.0 41.2 1,101 20-34 25.2 2.1 7.9 63.2 1.6 100.0 35.2 3,910 35-49 13.6 2.5 3.8 77.1 3.1 100.0 19.9 380 Birth order 1 38.5 4.0 11.6 44.5 1.4 100.0 54.1 1,833 2-3 22.8 1.6 6.7 67.3 1.6 100.0 31.1 2,368 4-5 15.1 0.1 2.0 81.7 1.1 100.0 17.2 773 6+ 8.6 0.8 1.1 86.3 3.3 100.0 10.4 417 Antenatal care visits1 None 6.7 0.1 1.4 90.1 1.7 100.0 8.3 629 1-3 18.5 1.2 4.0 74.4 1.9 100.0 23.7 1,442 4+ 41.8 4.0 12.1 40.5 1.6 100.0 58.0 2,078 Residence Urban 51.8 2.8 16.7 27.9 0.8 100.0 71.3 503 Rural 23.3 2.1 6.3 66.7 1.7 100.0 31.6 4,888 Ecological zone Mountain 16.3 0.6 2.0 79.4 1.7 100.0 18.8 428 Hill 25.6 1.3 4.4 66.4 2.3 100.0 31.3 2,130 Terai 27.7 3.0 10.2 58.1 1.0 100.0 40.9 2,833 Development region Eastern 24.8 6.0 8.8 59.3 1.1 100.0 39.6 1,269 Central 25.7 0.5 9.5 63.0 1.2 100.0 35.7 1,717 Western 31.6 1.8 4.7 59.8 2.2 100.0 38.0 1,007 Mid-western 23.6 0.3 5.2 69.0 1.9 100.0 29.1 793 Far-western 22.8 1.7 4.4 68.9 2.2 100.0 29.0 605 Subregion Eastern mountain 17.5 0.3 1.8 79.7 0.7 100.0 19.6 101 Central mountain 19.0 2.2 5.0 72.2 1.7 100.0 26.1 96 Western mountain 14.6 0.0 0.9 82.3 2.2 100.0 15.5 230 Eastern hill 19.7 2.8 2.9 73.0 1.5 100.0 25.5 416 Central hill 35.6 0.2 10.0 52.7 1.4 100.0 45.9 495 Western hill 26.9 0.6 3.6 66.0 3.0 100.0 31.1 604 Mid-western hill 22.9 0.1 1.4 72.4 3.1 100.0 24.5 367 Far-western hill 16.3 4.2 1.8 75.3 2.4 100.0 22.3 247 Eastern terai 28.5 8.6 12.9 49.0 0.9 100.0 50.1 752 Central terai 21.9 0.4 9.7 66.8 1.1 100.0 32.1 1,126 Western terai 38.5 3.5 6.4 50.6 1.0 100.0 48.4 402 Mid-western terai 28.0 0.6 11.9 59.6 0.0 100.0 40.4 301 Far-western terai 32.9 0.0 8.3 56.6 2.2 100.0 41.1 252 Mother’s education No education 15.3 0.6 3.5 79.3 1.3 100.0 19.3 2,550 Primary 23.3 1.8 6.4 66.7 1.8 100.0 31.5 1,079 Some secondary 38.2 4.1 8.9 47.6 1.2 100.0 51.3 1,039 SLC and above 49.8 5.4 19.4 22.8 2.6 100.0 74.6 723 Wealth quintile Lowest 9.6 0.7 1.1 86.5 2.0 100.0 11.4 1,390 Second 19.7 0.4 3.1 74.9 1.7 100.0 23.3 1,182 Middle 28.4 1.1 5.9 63.2 1.4 100.0 35.4 1,133 Fourth 36.3 4.6 11.0 46.9 1.2 100.0 51.9 938 Highest 49.5 5.9 22.4 21.0 1.1 100.0 77.9 748 Total 26.0 2.1 7.2 63.1 1.6 100.0 35.3 5,391 1 Includes only the most recent birth in the five years preceding the survey SLC = School Leaving Certificate 126 • Maternal Health The percentage of births taking place in a health facility has doubled in the past five years (from 18 percent in 2006 to 35 percent in 2011) as a result of continued government encouragement of institutional deliveries through free delivery services and payment for transportation costs. Women who did not deliver in a health facility were asked for their reasons for not doing so. Table 9.6 shows that a large majority of women who did not deliver in a health facility believed that it was not necessary (62 percent). In addition, 14 percent of women said that the health facility was too far or they had transportation problems, and 10 percent said it was not customary. Eight percent of women reported that the child was delivered before reaching a health facility, and 5 percent reported cost as a barrier to having a delivery in a health facility. Table 9.6 Reasons for not delivering in a health facility Among last live births not delivered in a health facility, percentage whose mothers cite specific reasons for not delivering in a facility, according to background characteristics, Nepal 2011 Background characteristic Cost too much Facility not open Too far/ no transpor- tation Don’t trust facility/ poor- quality service No female provider at facility Husband/ family did not allow Security concerns Not necessary Not customary Child born before reaching facility Other Total number of births Residence Urban 3.6 1.0 7.6 1.5 0.0 3.1 0.0 56.8 3.9 19.0 7.2 107 Rural 4.6 1.5 13.7 2.0 0.2 2.8 0.3 62.5 9.8 7.6 4.0 2,444 Ecological zone Mountain 1.0 1.2 24.5 1.6 0.2 1.3 0.2 62.8 9.3 7.0 5.3 242 Hill 1.8 1.3 18.1 1.1 0.3 1.5 0.1 58.4 16.1 7.2 5.0 1,088 Terai 7.7 1.7 7.1 2.9 0.2 4.2 0.5 65.5 3.8 8.9 3.2 1,221 Development region Eastern 4.4 0.9 11.1 2.6 0.6 2.8 0.0 60.8 9.0 10.8 9.1 570 Central 8.0 1.1 10.0 2.6 0.1 3.3 0.4 67.1 5.6 7.2 1.5 790 Western 2.6 0.9 6.0 0.4 0.0 1.8 0.0 71.7 13.2 6.6 2.4 488 Mid-western 2.4 0.3 28.0 1.8 0.2 3.1 0.4 50.3 14.3 7.0 5.4 404 Far-western 1.7 6.3 19.7 2.4 0.4 2.5 1.2 52.6 8.8 8.9 2.8 300 Subregion Eastern mountain 1.1 2.4 14.8 2.2 0.0 2.2 0.0 54.5 13.5 16.0 8.3 62 Central mountain 3.1 0.0 21.3 0.8 0.8 1.6 0.8 71.9 12.4 2.0 3.1 53 Western mountain 0.0 1.2 30.5 1.6 0.0 0.8 0.0 63.1 6.0 4.8 4.8 127 Eastern hill 5.6 0.4 19.4 1.4 0.4 1.3 0.0 57.3 14.2 8.0 8.8 240 Central hill 1.6 3.2 13.6 2.4 0.0 2.8 0.0 59.3 11.4 11.8 3.6 196 Western hill 0.1 1.3 7.5 0.6 0.0 1.2 0.0 67.0 17.0 7.4 2.5 329 Mid-western hill 0.8 0.0 31.4 0.8 0.4 2.0 0.8 48.0 21.4 4.6 7.5 198 Far-western hill 0.9 1.9 29.8 0.5 0.9 0.0 0.0 53.1 16.1 2.3 2.0 125 Eastern terai 4.1 1.1 2.8 3.7 0.9 4.3 0.0 65.3 3.2 12.1 9.5 268 Central terai 10.8 0.5 7.6 2.8 0.0 3.7 0.5 69.5 2.8 6.0 0.6 540 Western terai 7.6 0.0 3.0 0.0 0.0 3.0 0.0 81.4 5.4 4.9 2.2 159 Mid-western terai 6.0 0.0 15.9 2.7 0.0 5.6 0.0 52.6 7.1 10.2 2.7 135 Far-western terai 3.3 13.4 10.7 5.6 0.0 6.4 3.1 41.0 3.5 19.6 2.5 119 Mother’s education No education 6.0 1.4 14.5 1.6 0.2 3.2 0.4 62.2 11.3 5.8 3.9 1,445 Primary 4.2 2.4 13.4 2.8 0.4 2.8 0.2 60.7 8.4 9.3 3.8 549 Some secondary 1.3 0.4 9.9 2.9 0.2 2.4 0.3 64.5 6.1 10.9 6.4 399 SLC and above 0.0 1.9 13.5 1.2 0.0 0.2 0.0 62.1 6.3 17.2 2.0 157 Wealth quintile Lowest 3.0 1.9 22.2 1.3 0.1 1.5 0.2 54.9 17.8 5.2 4.0 852 Second 6.7 2.0 11.0 1.6 0.2 3.9 0.4 65.4 9.0 5.0 5.1 670 Middle 6.7 0.9 9.6 1.5 0.1 3.4 0.4 64.6 4.5 10.8 3.4 554 Fourth 2.0 0.1 5.8 3.2 0.9 3.5 0.4 67.9 1.8 14.6 3.7 346 Highest 0.9 2.4 5.4 8.1 0.0 0.9 0.0 68.2 0.7 12.9 4.4 128 Total 4.5 1.5 13.5 2.0 0.2 2.8 0.3 62.2 9.5 8.0 4.1 2,551 SLC = School Leaving Certificate 9.5 ASSISTANCE DURING DELIVERY Obstetric care from a health professional during delivery is recognized as critical for the reduction of maternal and neonatal mortality. Children delivered at home are usually more likely to be delivered without assistance from a trained provider, whereas children delivered at a health facility are more likely to be delivered by a trained health professional. Table 9.7 shows delivery assistance by type of provider according to background characteristics. More than one-third (36 percent) of births take place with the assistance of a skilled birth attendant (SBA), which includes doctor, nurse, or midwife. Health assistants or AHWs assist in the delivery of 4 percent of births, FCHVs assist in 3 percent, and traditional birth attendants assist in 11 percent. Two in five (40 percent) births are attended by a relative or some other person, while 3 percent of births take place without any type of assistance. Maternal Health • 127 Births to mothers less than age 20 and first-order births (42 percent and 55 percent, respectively) are more likely to be assisted by an SBA. Not surprisingly, substantially more births delivered in a health facility than births delivered elsewhere are attended by an SBA. Seventy-three percent of urban births are assisted by an SBA, compared with 32 percent of births in rural areas. Births in the terai, and particularly in the Eastern terai subregion, are more likely to be attended by an SBA than births in other areas. Table 9.7 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider, and percentage delivered by cesarean section, according to background characteristics, Nepal 2011 Background characteristic Person providing assistance during delivery Percentage delivered by a skilled provider1 Percentage delivered by C-section Number of births Doctor Nurse/ midwife Health assistant/ AHW MCHW/ VHW FCHV Traditional birth attendant Relative/ other No one Total Mother’s age at birth <20 16.9 25.3 3.3 2.5 4.0 11.2 35.5 1.4 100.0 42.1 3.0 1,101 20-34 18.0 17.9 4.1 2.0 3.1 11.6 40.2 3.0 100.0 35.9 5.0 3,910 35-49 10.8 9.0 3.1 0.8 2.2 8.0 56.8 9.4 100.0 19.8 5.0 380 Birth order 1 27.9 27.1 3.8 2.2 3.5 7.5 27.4 0.7 100.0 54.9 7.4 1,833 2-3 15.3 16.4 4.3 2.3 3.2 12.6 43.5 2.3 100.0 31.8 4.2 2,368 4-5 6.3 12.1 3.0 1.8 3.1 16.1 50.8 6.8 100.0 18.4 1.7 773 6+ 2.2 7.9 2.9 0.5 2.1 11.0 61.2 12.3 100.0 10.1 0.0 417 Place of delivery Health facility 47.3 49.5 2.2 0.8 0.0 0.0 0.2 0.1 100.0 96.8 13.0 1,905 Elsewhere 0.9 2.0 4.8 2.7 5.0 17.4 62.4 4.8 100.0 2.8 0.0 3,487 Residence Urban 43.4 29.3 1.5 0.2 1.6 4.9 17.5 1.5 100.0 72.7 15.3 503 Rural 14.6 17.7 4.1 2.2 3.4 11.9 42.8 3.3 100.0 32.3 3.5 4,888 Ecological zone Mountain 6.2 12.7 2.3 1.4 3.6 2.3 65.6 5.9 100.0 18.9 1.4 428 Hill 14.8 15.6 3.7 1.6 3.2 2.8 52.8 5.5 100.0 30.4 3.7 2,130 Terai 20.8 22.1 4.2 2.5 3.2 19.0 27.3 1.0 100.0 42.8 5.8 2,833 Development region Eastern 22.4 19.6 4.7 2.2 2.7 6.3 40.2 1.8 100.0 42.0 6.2 1,269 Central 18.5 17.4 4.4 1.1 2.6 18.2 36.2 1.7 100.0 35.9 5.9 1,717 Western 17.8 20.0 4.5 1.8 3.4 11.3 38.6 2.6 100.0 37.8 3.8 1,007 Mid-western 8.9 19.8 2.5 2.5 2.7 7.0 47.8 8.9 100.0 28.7 2.4 793 Far-western 13.2 17.4 1.3 4.2 6.3 7.5 46.5 3.5 100.0 30.7 1.8 605 Subregion Eastern mountain 6.5 13.7 4.8 3.5 3.8 3.6 62.0 2.0 100.0 20.3 1.5 101 Central mountain 11.6 14.1 3.6 1.7 6.0 1.9 55.0 6.0 100.0 25.7 4.3 96 Western mountain 3.8 11.7 0.7 0.4 2.4 2.0 71.5 7.5 100.0 15.5 0.2 230 Eastern hill 10.6 14.5 5.6 0.2 3.7 3.9 57.0 4.4 100.0 25.1 2.0 416 Central hill 31.5 13.1 1.8 1.3 2.2 1.8 45.4 3.0 100.0 44.5 10.0 495 Western hill 12.2 17.3 6.9 1.3 3.3 3.9 52.0 3.1 100.0 29.5 2.2 604 Mid-western hill 7.0 17.3 0.9 3.0 2.5 2.4 52.9 14.0 100.0 24.3 1.5 367 Far-western hill 6.8 15.8 0.7 2.9 5.1 0.8 62.6 5.2 100.0 22.7 0.8 247 Eastern terai 31.0 23.3 4.2 3.1 2.0 8.0 28.0 0.4 100.0 54.3 9.2 752 Central terai 13.4 19.6 5.6 0.9 2.5 26.8 30.5 0.7 100.0 33.0 4.2 1,126 Western terai 26.2 24.0 0.9 2.6 3.6 22.4 18.4 1.8 100.0 50.2 6.2 402 Mid-western terai 13.2 26.2 5.1 2.8 2.3 14.3 34.4 1.7 100.0 39.4 4.6 301 Far-western terai 23.6 21.3 2.1 7.1 10.2 16.9 16.9 1.8 100.0 44.9 3.4 252 Mother’s education No education 6.9 12.5 3.7 2.0 2.5 16.9 50.5 5.1 100.0 19.4 1.8 2,550 Primary 11.5 20.5 4.5 1.8 4.5 8.0 46.7 2.6 100.0 31.9 4.1 1,079 Some secondary 27.9 25.5 4.0 3.1 4.5 6.6 27.4 1.1 100.0 53.4 6.3 1,039 SLC and above 47.2 28.8 3.4 1.0 2.0 2.9 14.5 0.1 100.0 76.0 12.9 723 Wealth quintile Lowest 3.0 7.7 2.8 1.7 3.0 5.9 67.1 8.8 100.0 10.7 1.0 1,390 Second 7.1 16.6 4.7 2.6 3.7 16.5 46.5 2.3 100.0 23.7 0.8 1,182 Middle 14.2 21.8 5.5 2.2 4.0 16.6 34.9 0.9 100.0 35.9 4.6 1,133 Fourth 26.6 26.4 4.7 2.0 2.5 12.1 24.9 0.8 100.0 53.0 7.1 938 Highest 52.8 28.7 1.0 1.7 2.5 3.8 9.2 0.4 100.0 81.5 14.1 748 Total 17.3 18.8 3.9 2.0 3.2 11.3 40.4 3.1 100.0 36.0 4.6 5,391 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. AHW = auxiliary health worker; MCHW = maternal and child health worker; VHW = village health worker; FCHV = female community health volunteer; SLC = School Leaving Certificate 1 Skilled provider includes doctor, nurse, and midwife. There is a strong relationship between mother’s education and delivery by an SBA. Births to highly educated women (SLC or higher) are nearly four times (76 percent) as likely as births to women with no education (19 percent) to receive assistance from an SBA. Similarly, assistance during delivery by an SBA varies by women’s economic status: births to women in the highest wealth quintile are much more likely to be assisted by an SBA (82 percent) than births to women in the lowest wealth quintile (11 percent). 128 • Maternal Health Table 9.7 also shows that 5 percent of births are delivered by cesarean section. Delivery by cesarean section is highest among births to highly educated mothers (13 percent), births to mothers in the highest wealth quintile (14 percent), urban births (15 percent), and first births (7 percent). Among births delivered by cesarean section, 12 percent were planned, while the rest was carried out due to complications at delivery (data not shown). The percentage of births assisted at delivery by an SBA has almost doubled in the last five years (from 19 percent in 2006 to 36 percent in 2011), while the percentage of births assisted by relatives and others has declined (from 50 percent to 40 percent). Also noteworthy is the fact that delivery assistance by an SBA in rural areas has more than doubled in the last five years, from 14 percent to 32 percent. 9.5.1 Care and Support during Delivery The government of Nepal has implemented various strategies to reduce maternal deaths. One of the primary causes of maternal deaths in Nepal is postpartum hemorrhage (PPH). The 2008-2009 Maternal Mortality Survey indicated that 24 percent of maternal deaths were due to postpartum hemorrhage (however, this was a reduction from 41 percent in 1998) (Suvedi et al., 2009). WHO reports that postpartum hemorrhage is responsible for one quarter of maternal mortality worldwide (Mathai et al., 2007). In response to the high incidence of postpartum hemorrhage, the government of Nepal has initiated use of prophylactic oxytocin immediately after birth under the Active Management of Third Stage of Labor (AMTSL) intervention program. The intramuscular oxytocin dose of 10 milligrams soon after delivery prevents postpartum hemorrhage (Ojha and Malla, 2007). Similarly, a national free delivery policy was launched in Nepal in January 2009 to address the financial barriers women face in accessing health facilities for delivery and to encourage institutional deliveries. This is known as the Aama (mother) program. It covers all of the districts in the country. Similarly, a cash incentive scheme, the Safe Delivery Incentive Program (SDIP), was initiated in 2005. This program provides cash payments (differing by ecological region) to women who deliver in health facilities and incentive payments for health workers who undertake home deliveries (Witter et al., 2011). To determine the effectiveness of the government’s program promoting maternal health, the 2011 NDHS asked women a series of questions on care and support during delivery with respect to their last birth in the two years before the survey. Mothers were asked whether they had received an oxytocin injection immediately after delivery from health personnel (doctor, nurse, midwife, health assistant, AHW, MCHW, or VHW). Information was also collected on receipt of cash incentives for women’s most recent birth at any health facility (government, nongovernment, or private), cash payments to the health facility where the delivery took place, and the time taken to reach the health facility for delivery. Table 9.8 shows that 63 percent of mothers who had a live birth in the two years preceding the survey and were assisted by health personnel received an oxytocin injection immediately after delivery. Urban women and those living in the terai were more likely to have received an oxytocin injection for their most recent delivery than rural mothers and those from the other ecological zones. Women with a primary education and those in the lowest wealth quintile were least likely to have received an oxytocin injection. As part of the government strategy to promote institutional delivery, women who deliver in any health facility are provided cash incentives to defray the cost of transportation to the facility. In addition, delivery in a health facility is provided free of cost to mothers. The findings show that 71 percent of mothers received payment to defray the cost of transportation to a health facility. Seventy-three percent of rural women received transportation incentives, compared to 60 percent of urban women. Similarly, women living in the mountain zone and the Mid-western region were more likely to have received cash incentives than women in other areas. These incentives may have contributed to the doubling of institutional deliveries in the last five years. Forty percent of women reported paying cash to the health facility where they delivered. Urban women and women in the terai were more likely to pay cash for delivery services than rural women and those living in the mountain zone. As expected, women at higher levels of education and wealth were less likely to use free services provided by the government. Maternal Health • 129 Table 9.8 Care and support during delivery Among women with a live birth in the two years preceding the survey who were assisted at delivery by a health professional, percentage who received an injection of oxytocin immediately after delivery of the last live birth; and among women with a live birth in the two years preceding the survey delivered in a health facility, the percentage who received a cash incentive for transportation, the percentage who paid cash to the health facility, and the percent distribution of women by time taken to reach the health facility for delivery, according to background characteristics, Nepal 2011 Background characteristic Received an injection of oxytocin after delivery Number of women assisted by health personnel at delivery Received cash incentive for transpor- tation Paid cash to health facility Time to reach health facility Number of women who delivered in a health facility <30 minutes 30-60 minutes 60+ minutes Don’t know Total Mother’s age at birth <20 60.5 223 80.1 34.7 28.1 27.0 44.8 0.0 100.0 199 20-34 63.8 744 68.5 41.3 28.8 27.3 43.5 0.3 100.0 652 35-49 (70.3) 38 (64.3) (39.5) (10.5) (28.9) (60.6) (0.0) 100.0 37 Birth order 1 58.6 495 76.0 39.8 26.6 28.8 44.3 0.4 100.0 454 2-3 69.0 410 62.6 43.8 29.5 25.8 44.5 0.2 100.0 349 4-5 59.2 77 75.2 20.4 24.7 32.3 43.0 0.0 100.0 65 6+ * 23 * * * * * * 100.0 20 Antenatal care visits None (60.6) 43 * * * * * * 100.0 34 1-3 63.5 228 78.1 33.0 26.4 26.6 47.1 0.0 100.0 187 4+ 63.4 734 68.7 40.5 29.0 28.2 42.5 0.3 100.0 666 Residence Urban 69.1 155 59.8 51.7 43.4 33.4 22.7 0.4 100.0 150 Rural 62.3 850 73.2 37.3 24.8 26.1 48.9 0.2 100.0 738 Ecological zone Mountain 60.6 53 81.2 17.2 28.7 21.6 49.8 0.0 100.0 46 Hill 60.5 327 75.1 37.0 28.7 27.4 43.3 0.5 100.0 298 Terai 65.0 624 67.8 43.2 27.4 27.8 44.7 0.1 100.0 544 Development region Eastern 74.0 276 71.6 39.4 27.4 24.5 48.2 0.0 100.0 241 Central 57.2 314 60.1 57.8 21.5 30.2 47.5 0.8 100.0 274 Western 55.3 195 76.6 36.6 33.2 24.4 42.3 0.0 100.0 177 Mid-western 71.0 120 83.9 14.4 33.8 29.5 36.7 0.0 100.0 110 Far-western 59.6 100 75.6 22.1 31.6 29.5 38.9 0.0 100.0 86 Subregion Eastern mountain 66.5 15 (91.5) (13.4) (28.6) (11.6) (59.8) (0.0) 100.0 12 Central mountain 37.7 15 (70.3) (39.8) (22.9) (33.1) (44.0) (0.0) 100.0 12 Western mountain (71.7) 23 (81.8) (6.8) (31.8) (20.5) (47.7) (0.0) 100.0 22 Eastern hill 64.5 58 86.6 30.1 19.8 25.0 55.2 0.0 100.0 53 Central hill 71.1 99 58.5 54.3 32.2 39.7 26.4 1.7 100.0 94 Western hill 42.6 97 79.8 39.8 36.1 15.9 48.0 0.0 100.0 83 Mid-western hill 65.5 46 82.0 14.7 26.7 29.6 43.7 0.0 100.0 41 Far-western hill 68.6 28 85.4 14.6 13.8 21.4 64.8 0.0 100.0 26 Eastern terai 77.2 204 65.8 44.0 29.6 25.1 45.3 0.0 100.0 176 Central terai 51.8 201 60.3 61.1 15.4 24.7 59.6 0.4 100.0 168 Western terai 67.9 98 73.7 33.7 30.6 32.1 37.3 0.0 100.0 93 Mid-western terai 76.0 61 83.0 16.9 42.0 30.8 27.2 0.0 100.0 57 Far-western terai 52.2 61 72.1 27.9 37.8 36.3 25.9 0.0 100.0 49 Mother’s education No education 61.7 290 70.8 39.7 20.4 27.7 51.1 0.7 100.0 233 Primary 56.7 167 68.3 38.2 23.4 33.7 42.9 0.0 100.0 154 Some secondary 66.4 271 80.0 33.6 31.3 23.1 45.3 0.3 100.0 242 SLC and above 66.1 276 64.1 46.5 34.2 27.2 38.6 0.0 100.0 258 Wealth quintile Lowest 46.6 89 87.6 28.0 16.6 20.9 62.5 0.0 100.0 74 Second 62.3 173 78.6 27.1 19.0 26.1 54.9 0.0 100.0 145 Middle 61.4 250 78.4 37.9 28.1 21.8 50.1 0.0 100.0 210 Fourth 67.7 245 72.4 36.0 27.0 36.7 35.3 1.0 100.0 219 Highest 67.7 248 53.4 56.1 37.5 26.4 36.1 0.0 100.0 241 Total 63.3 1,005 71.0 39.8 27.9 27.3 44.5 0.3 100.0 888 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate The table also describes the time taken for women to reach a health facility for delivery. Twenty-eight percent of women took less than 30 minutes to reach a health facility, 27 percent took 30-60 minutes, and 45 percent took more than one hour. One in two women in the mountains (50 percent) took more than one hour to reach a health facility for delivery. Also, two in five women in the hill zone and terai reported that it took them more than one hour to reach a health facility. 130 • Maternal Health 9.5.2 Birth Preparedness In an effort to prevent unnecessary delays related to delivery care, the MOHP has implemented the birth preparedness package, which outlines steps mothers should take to prepare for their birth. Adherence to these guidelines reduces delays in accessing delivery services, which can save lives, especially among women living in rural locations. The guidelines recommend that families save money for emergencies, arrange transportation beforehand based on local conditions, identify persons who can and are eligible to donate blood if required, identify and contact health facilities and health workers who can provide services, and have a clean delivery kit handy (USAID, New ERA, and NFHP, 2010). Table 9.9 shows that more than one in three women (36 percent) saved money for delivery. Five percent bought a home delivery kit and 2 percent contacted a health worker, which are reductions in comparison to similar data in the 2006 NDHS. More than half of women (56 percent) arranged for food and clothing for the newborn in 2011, in comparison to 26 percent in 2006. Nearly one-third of women said they had not made any preparations at all for the birth of their child. Arrangements for transportation increased from 1 percent in 2006 to 3 percent in 2011. Table 9.9 Birth preparedness Percentage of women who had made specific preparations before delivery of the most recent birth in the past five years, according to background characteristics, Nepal 2011 Background characteristic Saved money Arranged for transport Found blood donor Contacted health worker Bought clean delivery kit Arranged for food and clothing Other No preparation Number of women Residence Urban 51.8 6.1 1.3 2.3 3.8 63.3 1.7 23.8 418 Rural 34.0 3.1 0.4 1.6 4.6 54.9 2.2 36.7 3,730 Ecological zone Mountain 29.5 2.0 0.3 0.4 3.5 62.6 0.3 31.8 306 Hill 34.1 2.3 0.4 1.2 4.7 61.3 1.5 31.9 1,669 Terai 38.0 4.4 0.5 2.3 4.5 50.5 2.9 38.6 2,174 Development region Eastern 42.8 3.8 0.6 1.8 6.2 62.0 4.7 28.3 999 Central 31.8 2.4 0.4 1.4 1.8 49.7 1.3 42.5 1,293 Western 32.8 3.2 0.0 0.8 2.0 55.0 1.2 37.4 818 Mid-western 30.0 3.0 0.9 0.5 5.0 54.5 1.2 36.3 598 Far-western 45.4 6.3 0.4 5.5 12.5 62.1 2.1 25.6 440 Subregion Eastern mountain 40.7 2.3 0.4 0.6 6.5 78.2 0.0 20.4 78 Central mountain 34.7 1.1 0.0 1.1 3.4 61.4 0.0 26.4 72 Western mountain 21.4 2.3 0.3 0.0 2.0 55.3 0.7 40.1 155 Eastern hill 36.4 2.1 0.6 2.2 6.7 68.1 2.2 27.4 331 Central hill 43.7 3.1 0.6 1.0 2.4 67.6 1.2 24.9 403 Western hill 29.3 1.9 0.0 0.4 2.4 56.7 1.7 36.9 488 Mid-western hill 25.7 2.9 0.6 1.2 6.2 60.2 1.2 34.2 275 Far-western hill 34.3 1.5 0.5 2.2 10.1 47.9 0.9 38.6 171 Eastern terai 46.7 5.0 0.7 1.8 5.9 56.5 6.8 29.8 589 Central terai 25.7 2.3 0.3 1.6 1.3 39.8 1.4 52.6 818 Western terai 37.9 5.1 0.1 1.4 1.4 52.4 0.5 38.2 330 Mid-western terai 41.5 3.5 1.5 0.0 4.3 51.9 1.2 33.7 238 Far-western terai 59.0 11.5 0.2 10.2 18.6 71.6 3.8 14.0 200 Education No education 23.7 1.1 0.1 0.9 2.9 48.5 2.8 45.8 1,822 Primary 36.9 1.8 0.2 1.0 4.1 60.9 3.1 31.1 835 Some secondary 46.2 3.9 0.6 2.5 8.3 58.1 0.9 29.0 866 SLC and above 55.3 11.5 1.6 3.9 4.4 66.4 0.9 19.6 627 Wealth quintile Lowest 18.4 0.8 0.2 1.0 2.6 55.3 2.0 40.0 979 Second 34.1 2.1 0.1 1.7 5.3 57.1 2.8 37.7 899 Middle 36.2 3.2 0.2 1.4 4.4 49.0 2.9 41.8 873 Fourth 47.1 3.3 0.6 2.2 7.0 55.9 1.5 29.2 748 Highest 51.0 9.6 1.6 2.6 3.5 63.2 1.2 23.7 649 Total 35.8 3.4 0.4 1.7 4.5 55.7 2.2 35.4 4,148 SLC = School Leaving Certificate 9.6 POSTNATAL CARE The postpartum period is particularly important for women, as during this period they may develop serious, life-threatening complications after delivery. Evidence has shown that a large proportion of deaths occur during this period, with postpartum hemorrhage being an important cause. A postnatal care visit is an ideal time to educate a new mother on how to care for herself and her newborn Therefore, it is highly Maternal Health • 131 recommended that women receive at least three postnatal checkups, the first within 24 hours of delivery, the second on the third day following delivery, and the third on the seventh day after delivery (MOHP, 2011a). 9.6.1 Timing of First Postnatal Checkup for the Mother Table 9.10 shows that in the two years preceding the survey, 45 percent of women received postnatal care for their last birth within the critical first two days following delivery. One in three women received postnatal care within four hours of delivery, 7 percent received care within 4-23 hours, and 4 percent were seen 1-2 days following delivery. Differences by mother’s age, birth order, place of residence, wealth quintile, and education are pronounced and are similar to the differences discussed for delivery care. More than one in two (54 percent) women did not receive a checkup within the recommended time. Table 9.10 Timing of first postnatal checkup Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution of the mother’s first postnatal check-up for the last live birth by time after delivery, and the percentage of women with a live birth in the two years preceding the survey who received a postnatal checkup in the first two days after giving birth, according to background characteristics, Nepal 2011 Background characteristic Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Mother’s age at birth <20 37.3 8.0 2.7 1.9 0.3 0.0 49.9 100.0 48.0 381 20-34 33.5 7.4 3.6 0.5 1.3 0.2 53.5 100.0 44.5 1,525 35-49 28.1 2.5 4.5 0.2 0.0 0.0 64.7 100.0 35.1 125 Birth order 1 45.8 10.7 4.5 1.0 0.6 0.2 37.1 100.0 61.0 717 2-3 31.2 5.5 3.2 0.9 1.7 0.2 57.3 100.0 40.0 915 4-5 20.3 5.3 2.3 0.0 0.3 0.0 71.9 100.0 27.9 268 6+ 14.7 3.6 1.7 0.2 0.0 0.0 79.7 100.0 20.1 129 Place of delivery Health facility 66.8 14.2 6.3 0.6 0.4 0.2 11.4 100.0 87.3 888 Elsewhere 8.3 1.7 1.3 0.9 1.4 0.1 86.2 100.0 11.3 1,143 Residence Urban 55.7 11.1 5.6 1.9 0.9 0.9 23.9 100.0 72.4 189 Rural 31.6 6.8 3.3 0.7 1.0 0.1 56.6 100.0 41.7 1,842 Ecological zone Mountain 23.7 5.1 2.0 0.3 2.0 0.0 66.9 100.0 30.7 166 Hill 28.1 5.5 3.2 0.5 0.8 0.4 61.5 100.0 36.7 785 Terai 39.7 8.7 3.9 1.0 1.0 0.0 45.6 100.0 52.4 1,079 Development region Eastern 39.3 8.7 2.9 1.1 0.6 0.1 47.4 100.0 50.9 468 Central 30.6 7.4 4.0 0.7 1.3 0.4 55.8 100.0 41.9 658 Western 35.7 6.3 2.3 0.5 1.0 0.0 54.3 100.0 44.2 398 Mid-western 29.5 6.3 3.4 1.2 0.8 0.0 58.8 100.0 39.2 291 Far-western 34.9 6.2 5.5 0.4 1.4 0.1 51.6 100.0 46.5 215 Subregion Eastern mountain 26.9 2.6 1.8 0.0 2.6 0.0 66.0 100.0 31.3 39 Central mountain 20.7 9.1 4.6 0.0 2.3 0.0 63.3 100.0 34.4 36 Western mountain 23.5 4.5 1.1 0.6 1.7 0.0 68.7 100.0 29.1 91 Eastern hill 26.4 5.2 4.3 0.0 0.0 0.2 63.9 100.0 35.8 152 Central hill 32.2 8.6 5.3 0.6 0.0 1.5 51.7 100.0 46.1 177 Western hill 25.9 6.4 2.2 0.2 1.6 0.0 63.7 100.0 34.5 240 Mid-western hill 27.2 3.2 2.8 2.0 0.6 0.0 64.2 100.0 33.2 131 Far-western hill 29.6 0.5 0.0 0.0 2.1 0.0 67.9 100.0 30.1 85 Eastern terai 48.2 11.5 2.3 1.9 0.6 0.0 35.6 100.0 61.9 277 Central terai 30.7 6.7 3.4 0.7 1.7 0.0 56.8 100.0 40.8 445 Western terai 50.3 6.1 2.4 1.0 0.0 0.0 40.2 100.0 58.9 159 Mid-western terai 34.1 11.7 5.2 0.8 0.0 0.0 48.2 100.0 51.0 111 Far-western terai 46.5 11.2 12.9 0.3 1.4 0.3 27.5 100.0 70.6 88 Education No education 23.5 5.7 1.9 0.5 0.8 0.2 67.3 100.0 31.1 862 Primary 31.8 6.2 3.2 0.7 0.6 0.1 57.5 100.0 41.2 392 Some secondary 40.7 9.1 4.1 1.2 1.3 0.0 43.7 100.0 53.8 429 SLC and above 53.6 9.6 6.9 0.9 1.5 0.4 27.1 100.0 70.1 347 Wealth quintile Lowest 12.4 2.5 1.7 1.0 1.3 0.0 81.0 100.0 16.7 489 Second 28.8 4.9 2.1 0.2 0.4 0.0 63.7 100.0 35.7 428 Middle 36.5 8.0 3.7 0.5 0.7 0.0 50.5 100.0 48.2 469 Fourth 45.8 9.3 3.9 1.6 2.1 0.4 36.7 100.0 59.1 370 Highest 59.4 14.9 7.7 0.6 0.2 0.6 16.5 100.0 82.1 274 Total 15-49 33.9 7.2 3.5 0.8 1.0 0.2 53.5 100.0 44.5 2,030 1 Includes women who received a checkup after 41 days SLC = School Leaving Certificate 132 • Maternal Health 9.6.2 Provider of First Postnatal Checkup for Mother The skill level of the provider who performs the first postnatal checkup also has important implications for maternal and neonatal health. Table 9.11 shows that 23 percent of women received postnatal care from a nurse or midwife and 16 percent from a doctor. Six percent of women received postnatal care from a health assistant, AHW, MCHW, VHW, or FCHV. Mothers of first-order births, those who delivered in a health facility, those with an SLC and higher education, those from the wealthiest households, and those in urban areas were more likely to have received postnatal care from an SBA than other mothers. Postnatal care from an SBA was highest in the terai, in the Eastern region, and in the Eastern terai subregion. Table 9.11 Type of provider of first postnatal checkup for the mother Among women giving birth in the two years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal health check in the two days after the last live birth, according to background characteristics, Nepal 2011 Background characteristic Type of health provider of mother’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of women Doctor Nurse/ midwife Health assistant/ AHW MCHW/ VHW FCHV Mother’s age at birth <20 10.7 30.9 4.6 1.4 0.4 52.0 100.0 381 20-34 17.7 21.2 2.3 1.8 1.5 55.5 100.0 1,525 35-49 14.1 16.5 2.6 1.5 0.4 64.9 100.0 125 Birth order 1 20.7 36.1 2.9 0.7 0.6 39.0 100.0 717 2-3 16.1 17.0 2.5 2.7 1.6 60.0 100.0 915 4-5 8.9 12.6 2.1 2.0 2.3 72.1 100.0 268 6+ 6.3 9.6 4.2 0.0 0.0 79.9 100.0 129 Place of delivery Health facility 35.8 49.1 1.1 1.2 0.1 12.7 100.0 888 Elsewhere 0.9 2.2 4.0 2.1 2.1 88.7 100.0 1,143 Residence Urban 39.9 30.0 1.8 0.1 0.5 27.6 100.0 189 Rural 13.7 22.0 2.8 1.9 1.3 58.3 100.0 1,842 Ecological zone Mountain 5.4 19.4 2.6 1.6 1.8 69.3 100.0 166 Hill 13.2 19.4 2.0 1.4 0.7 63.3 100.0 785 Terai 20.0 25.6 3.2 2.0 1.5 47.6 100.0 1,079 Development region Eastern 18.2 26.3 3.7 2.3 0.3 49.1 100.0 468 Central 21.4 16.5 3.0 1.0 0.0 58.1 100.0 658 Western 14.4 24.7 2.9 1.3 1.1 55.8 100.0 398 Mid-western 10.2 23.0 1.1 2.5 2.4 60.8 100.0 291 Far-western 7.1 29.9 1.4 2.7 5.5 53.5 100.0 215 Subregion Eastern mountain 6.3 16.2 5.3 3.5 0.0 68.7 100.0 39 Central mountain 13.7 13.9 3.4 3.4 0.0 65.6 100.0 36 Western mountain 1.7 22.9 1.1 0.0 3.4 70.9 100.0 91 Eastern hill 7.8 24.0 3.4 0.0 0.7 64.2 100.0 152 Central hill 33.8 11.7 0.6 0.0 0.0 53.9 100.0 177 Western hill 8.7 20.6 2.8 1.6 0.8 65.5 100.0 240 Mid-western hill 6.0 20.4 1.2 4.9 0.6 66.8 100.0 131 Far-western hill 3.3 22.4 1.4 0.9 2.1 69.9 100.0 85 Eastern terai 25.5 29.1 3.7 3.4 0.2 38.1 100.0 277 Central terai 17.1 18.7 4.0 1.1 0.0 59.2 100.0 445 Western terai 22.9 30.8 3.0 0.7 1.5 41.1 100.0 159 Mid-western terai 18.7 26.8 1.0 0.8 3.8 49.0 100.0 111 Far-western terai 13.7 39.5 1.4 5.6 10.4 29.4 100.0 88 Education No education 9.1 16.0 3.0 2.1 1.0 68.9 100.0 862 Primary 11.9 20.3 4.5 1.9 2.4 58.8 100.0 392 Some secondary 18.4 30.5 1.5 2.2 1.3 46.2 100.0 429 SLC and above 35.6 32.5 1.6 0.1 0.4 29.9 100.0 347 Wealth quintile Lowest 2.8 9.6 2.5 0.7 1.1 83.3 100.0 489 Second 6.9 21.5 3.3 1.7 2.3 64.3 100.0 428 Middle 14.0 26.2 3.4 3.8 0.8 51.8 100.0 469 Fourth 25.2 30.1 2.0 1.1 0.7 40.9 100.0 370 Highest 46.0 32.2 2.0 0.8 1.1 17.9 100.0 274 Total 16.2 22.7 2.7 1.7 1.2 55.5 100.0 2,030 SLC = School Leaving Certificate 9.7 NEWBORN CARE Newborn care is essential to reduce neonatal problems and death. To identify, manage, and prevent complications, the government of Nepal recommends at least three postnatal checkups for the newborn within seven days of delivery, which is considered a critical time period for neonates and mothers. Table 9.12 shows the percent distribution of last births in the two years preceding the survey by timing of the first postnatal Maternal Health • 133 checkup after birth, along with the percentage of births with a postnatal checkup in the first two days after birth, according to background characteristics. Thirty percent of newborns were taken for their first postnatal checkup within the critical first two days after birth. One in four births had a postnatal checkup within three hours after birth (23 percent). Twenty-eight percent of births had a postnatal visit within 24 hours after birth. Table 9.12 Timing of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by time after birth of first postnatal checkup, and the percentage of births with a postnatal checkup in the first two days after birth, according to background characteristics, Nepal 2011 Background characteristic Time after birth of newborn’s first postnatal checkup No postnatal checkup1 Total Percentage of births with a postnatal checkup in the first two days after birth Number of births Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don’t know/ missing Mother’s age at birth <20 11.6 13.0 5.5 3.1 2.2 0.0 64.5 100.0 33.2 381 20-34 11.6 11.9 4.9 2.1 1.9 0.0 67.7 100.0 30.5 1,525 35-49 3.6 8.3 2.1 1.9 0.0 0.6 83.5 100.0 15.9 125 Birth order 1 15.7 16.9 6.9 2.6 2.5 0.0 55.3 100.0 42.2 717 2-3 10.4 10.5 4.3 2.8 1.6 0.0 70.3 100.0 28.0 915 4-5 5.2 6.9 2.1 1.0 1.5 0.0 83.2 100.0 15.2 268 6+ 2.0 3.6 2.5 0.0 0.0 0.6 91.3 100.0 8.1 129 Place of delivery Health facility 21.8 23.0 8.5 3.1 1.8 0.0 41.7 100.0 56.5 888 Elsewhere 2.7 3.2 1.9 1.7 1.8 0.1 88.6 100.0 9.6 1,143 Residence Urban 17.9 21.5 6.9 3.4 2.7 0.2 47.4 100.0 49.7 189 Rural 10.4 10.9 4.6 2.2 1.7 0.0 70.2 100.0 28.1 1,842 Ecological zone Mountain 11.0 6.1 2.9 2.2 2.7 0.0 75.1 100.0 22.2 166 Hill 10.0 10.5 4.0 1.9 2.1 0.1 71.4 100.0 26.4 785 Terai 11.8 13.7 5.7 2.6 1.5 0.0 64.5 100.0 33.9 1,079 Development region Eastern 7.7 13.7 5.3 2.0 1.4 0.1 69.9 100.0 28.7 468 Central 9.1 12.3 4.5 0.8 1.4 0.0 71.9 100.0 26.7 658 Western 14.0 11.5 4.7 2.9 1.8 0.0 65.1 100.0 33.1 398 Mid-western 15.1 10.4 4.1 3.8 1.8 0.3 64.5 100.0 33.4 291 Far-western 13.5 9.3 6.1 4.3 4.1 0.0 62.7 100.0 33.2 215 Subregion Eastern mountain 13.4 6.3 1.8 0.0 2.6 0.0 75.9 100.0 21.5 39 Central mountain 6.8 5.7 4.6 5.7 1.1 0.0 76.1 100.0 22.8 36 Western mountain 11.7 6.1 2.8 1.7 3.4 0.0 74.3 100.0 22.3 91 Eastern hill 2.9 10.3 2.9 0.9 2.0 0.2 80.8 100.0 17.0 152 Central hill 8.5 16.0 7.3 1.9 2.2 0.0 64.0 100.0 33.8 177 Western hill 7.4 10.4 3.8 3.4 1.4 0.0 73.6 100.0 25.0 240 Mid-western hill 18.6 7.1 3.0 1.4 1.2 0.6 68.0 100.0 30.1 131 Far-western hill 19.9 5.1 0.9 0.0 5.1 0.0 68.9 100.0 26.0 85 Eastern terai 9.5 16.6 7.1 2.9 0.8 0.0 63.0 100.0 36.1 277 Central terai 9.5 11.4 3.3 0.0 1.1 0.0 74.6 100.0 24.2 445 Western terai 23.9 13.0 6.1 2.2 2.4 0.0 52.2 100.0 45.3 159 Mid-western terai 11.7 15.5 7.1 7.3 1.5 0.0 56.8 100.0 41.6 111 Far-western terai 9.2 15.4 11.2 10.1 3.9 0.0 50.1 100.0 45.9 88 Mother’s education No education 6.3 7.5 3.3 1.5 2.0 0.1 79.3 100.0 18.5 862 Primary 9.9 12.6 4.9 1.5 0.7 0.0 70.3 100.0 29.0 392 Some secondary 13.8 14.1 5.5 3.8 2.2 0.0 60.6 100.0 37.2 429 SLC and above 21.0 19.0 7.7 3.5 2.1 0.1 46.6 100.0 51.1 347 Wealth quintile Lowest 5.4 4.1 1.1 0.8 1.7 0.0 86.8 100.0 11.5 489 Second 8.9 8.1 4.1 3.2 1.9 0.2 73.7 100.0 24.3 428 Middle 10.7 14.0 4.6 1.7 1.2 0.0 67.8 100.0 31.0 469 Fourth 14.0 16.9 7.2 2.7 3.3 0.0 55.8 100.0 40.9 370 Highest 21.3 20.9 9.7 4.1 1.1 0.1 42.7 100.0 56.1 274 Total 11.1 11.9 4.8 2.3 1.8 0.1 68.0 100.0 30.1 2,030 1 Includes newborns who received a checkup after the first week SLC = School Leaving Certificate The proportion of postnatal checkups within the first two days of birth is higher among births to mothers with an SLC and above (51 percent) than among births to mothers with no education (19 percent). Similarly, the proportion is higher among births to women less than age 20, first births, and births that took place in a health facility than among births in other categories. 134 • Maternal Health The majority of newborns (68 percent) did not receive a postnatal checkup. Newborns delivered outside of a health facility were less likely to receive a postnatal checkup within the first week after birth (11 percent) than newborns delivered in a health facility (58 percent). Similarly, postnatal checkups were less likely among births to mothers age 35-49, births of order six and over, rural births, and births in the Central region than among births in the other categories. 9.7.1 Provider of First Postnatal Checkup for the Newborn Table 9.13 presents the percent distribution of last births in the two years preceding the survey by type of provider of newborn care during the first two days after delivery, according to background characteristics. The findings show that 25 percent of newborns received postnatal care in the two days following birth from a doctor, nurse, or midwife. An additional 4 percent of newborns received care from a health assistant, AHW, MCHW, or VHW. About 2 percent received care from an FCHV. The distribution of newborns who received care from an SBA by background characteristics is similar to the pattern described for providers of mothers’ postnatal checkups. Table 9.13 Type of provider of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by type of provider of the newborn’s first postnatal health check during the two days after the last live birth, according to background characteristics, Nepal 2011 Background characteristic Type of health provider of newborn’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of births Doctor Nurse/ midwife Health assistant/ AHW MCHW/ VHW FCHV Mother’s age at birth <20 7.0 19.1 4.7 1.7 0.8 66.8 100.0 381 20-34 11.3 14.1 1.7 1.5 1.9 69.5 100.0 1,525 35-49 2.3 9.3 2.3 1.5 0.4 84.1 100.0 125 Birth order 1 12.9 24.8 3.0 0.7 0.7 57.8 100.0 717 2-3 10.7 10.5 1.8 2.7 2.2 72.0 100.0 915 4-5 2.7 7.8 1.9 0.4 2.3 84.8 100.0 268 6+ 3.2 2.7 2.2 0.0 0.0 91.9 100.0 129 Place of delivery Health facility 21.9 32.1 1.4 1.1 0.0 43.5 100.0 888 Elsewhere 0.7 1.3 2.9 1.8 2.8 90.4 100.0 1,143 Residence Urban 27.9 20.3 1.0 0.4 0.0 50.3 100.0 189 Rural 8.1 14.2 2.4 1.6 1.7 71.9 100.0 1,842 Ecological zone Mountain 2.9 14.8 1.0 1.3 2.1 77.8 100.0 166 Hill 9.5 12.6 1.7 1.6 1.0 73.6 100.0 785 Terai 11.4 16.3 2.9 1.5 1.9 66.1 100.0 1,079 Development region Eastern 10.3 14.4 1.4 2.4 0.2 71.3 100.0 468 Central 11.1 11.8 3.2 0.5 0.0 73.3 100.0 658 Western 12.5 14.7 2.9 1.5 1.6 66.9 100.0 398 Mid-western 7.3 17.0 1.4 2.5 5.2 66.6 100.0 291 Far-western 4.7 21.2 1.4 1.5 4.4 66.8 100.0 215 Subregion Eastern mountain 3.7 12.5 1.8 3.5 0.0 78.5 100.0 39 Central mountain 8.0 12.5 0.0 2.3 0.0 77.2 100.0 36 Western mountain 0.6 16.8 1.1 0.0 3.9 77.7 100.0 91 Eastern hill 3.6 12.1 0.7 0.0 0.7 83.0 100.0 152 Central hill 23.2 9.9 0.6 0.0 0.0 66.2 100.0 177 Western hill 7.6 10.0 3.4 2.4 1.6 75.0 100.0 240 Mid-western hill 6.0 17.4 1.2 4.9 0.6 69.9 100.0 131 Far-western hill 2.3 18.8 1.4 0.7 2.8 74.0 100.0 85 Eastern terai 14.9 16.0 1.7 3.5 0.0 63.9 100.0 277 Central terai 6.6 12.5 4.5 0.6 0.0 75.8 100.0 445 Western terai 19.8 21.8 2.2 0.0 1.5 54.7 100.0 159 Mid-western terai 12.0 16.5 1.8 0.8 10.7 58.4 100.0 111 Far-western terai 8.7 25.8 1.4 3.1 7.0 54.1 100.0 88 Mother’s education No education 4.3 8.7 2.6 1.4 1.5 81.5 100.0 862 Primary 5.5 15.3 2.9 2.1 3.1 71.0 100.0 392 Some secondary 12.6 20.0 1.5 1.7 1.3 62.8 100.0 429 SLC and above 25.9 22.4 1.8 0.8 0.2 48.9 100.0 347 Wealth quintile Lowest 0.8 6.3 2.2 0.8 1.3 88.5 100.0 489 Second 3.8 13.3 1.9 1.2 4.0 75.7 100.0 428 Middle 8.4 14.4 3.6 3.4 1.2 69.0 100.0 469 Fourth 16.0 21.4 1.9 0.9 0.8 59.1 100.0 370 Highest 30.4 23.4 1.1 1.0 0.0 43.9 100.0 274 Total 10.0 14.7 2.3 1.5 1.6 69.9 100.0 2,030 SLC = School Leaving Certificate Maternal Health • 135 9.7.2 Newborn Care Practices The MOHP has developed a series of recommendations for newborn care that focus on use of safe delivery kits, cord care, prevention and management of hypothermia, drying and bathing the newborn, and other health care services. As of 2011, the Community-Based Newborn Care Program (CB-NCP) in Nepal has been implemented in 15 districts. Based on the National Neonatal Health Strategy, the CB-NCP recommends the following practices to promote newborn care: (1) wiping the newborn with a soft, dry cloth immediately after birth; (2) putting the newborn on the mother’s chest and initiating skin-to-skin contact; (3) providing advice on early (within the first hour) initiation of breastfeeding and exclusive breastfeeding for up to six months; (4) not applying anything on the cord stump; and (5) bathing the newborn only after 24 hours post-birth (Save the Children, 2009). A series of questions were asked of women who, for their last birth in the two years preceding the survey, gave birth outside an institutional setting. Table 9.14 Use of clean home delivery kits and other instruments to cut the umbilical cord Percent distribution of non-institutional last live births in the two years preceding the survey, by type of instrument used to cut the umbilical cord, and percentage who had something placed on stump after the umbilical cord was cut, according to background characteristics, Nepal 2011 Background characteristic Instrument used to cut the umbilical cord Placed something on stump after cutting umbilical cord Number of births Instruments from a clean home delivery kit New/boiled blade Used blade Knife Hasiya (sickle) Khukuri (curved knife) Scissors Other Don’t know Total Residence Urban 19.0 70.8 1.2 0.0 1.4 0.7 0.7 2.9 3.2 100.0 46.5 39 Rural 13.9 67.9 3.7 0.4 11.1 0.4 0.9 1.3 0.3 100.0 41.0 1,103 Ecological zone Mountain 10.2 53.8 4.4 2.3 25.0 1.8 1.3 0.9 0.3 100.0 31.7 120 Hill 15.3 57.2 4.2 0.4 18.6 0.4 0.8 2.6 0.5 100.0 29.3 487 Terai 13.8 81.1 2.9 0.0 0.5 0.0 1.0 0.4 0.3 100.0 54.1 536 Development region Eastern 15.7 69.1 5.5 1.1 1.6 1.4 0.6 4.6 0.5 100.0 41.3 227 Central 8.6 79.1 3.8 0.2 5.8 0.1 1.6 0.7 0.1 100.0 49.1 384 Western 14.1 72.6 0.9 0.0 9.8 0.0 0.9 0.9 0.9 100.0 32.7 222 Mid-western 14.1 50.3 5.4 0.7 27.7 0.3 0.6 0.4 0.6 100.0 46.7 181 Far-western 27.5 50.4 2.1 0.0 19.8 0.0 0.0 0.0 0.2 100.0 24.7 129 Subregion Eastern mountain 10.8 65.7 3.8 5.0 5.4 4.2 1.3 3.8 0.0 100.0 38.2 27 Central mountain 15.5 47.8 5.2 3.4 18.9 2.4 5.2 0.0 1.7 100.0 17.9 24 Western mountain 8.1 51.1 4.4 0.7 34.8 0.7 0.0 0.0 0.0 100.0 34.1 69 Eastern hill 13.8 62.4 9.3 1.0 2.1 2.1 1.0 7.2 1.0 100.0 24.8 99 Central hill 11.0 60.7 3.8 0.0 21.1 0.0 0.0 3.3 0.0 100.0 29.1 83 Western hill 16.9 65.2 1.2 0.0 13.9 0.0 1.2 1.2 0.3 100.0 26.5 156 Mid-western hill 12.7 41.5 5.6 0.9 36.5 0.0 0.9 0.9 0.9 100.0 39.2 90 Far-western hill 23.3 46.5 2.0 0.0 27.8 0.0 0.0 0.0 0.4 100.0 29.5 59 Eastern terai 18.9 76.5 2.3 0.0 0.0 0.0 0.0 2.3 0.0 100.0 58.2 101 Central terai 7.3 87.3 3.6 0.0 0.0 0.0 1.8 0.0 0.0 100.0 57.7 277 Western terai 7.2 90.5 0.0 0.0 0.0 0.0 0.0 0.0 2.3 100.0 47.3 65 Mid-western terai 20.2 71.0 3.1 0.0 4.7 0.0 0.5 0.0 0.5 100.0 58.1 54 Far-western terai (50.0) (46.2) (3.8) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 100.0 (23.1) 38 Mother’s education No education 8.9 69.9 4.8 0.5 13.7 0.3 0.7 0.8 0.4 100.0 47.6 629 Primary 15.6 68.0 4.1 0.4 8.1 0.7 1.2 1.6 0.3 100.0 35.7 238 Some secondary 25.4 61.3 0.9 0.2 6.9 0.5 0.5 3.8 0.5 100.0 30.7 187 SLC and above 22.4 69.2 0.0 0.0 5.3 0.0 2.8 0.0 0.2 100.0 32.6 89 Wealth quintile Lowest 8.2 59.3 6.4 0.5 22.1 0.7 0.6 2.0 0.3 100.0 37.0 415 Second 13.1 68.7 3.9 0.4 10.3 0.2 1.7 0.7 0.9 100.0 40.6 283 Middle 18.9 76.9 0.9 0.5 0.7 0.2 1.0 0.8 0.1 100.0 49.4 259 Fourth 20.7 75.7 0.2 0.0 0.3 0.1 0.4 2.3 0.3 100.0 37.2 151 Highest (28.3) (67.5) (3.6) (0.0) (0.0) (0.0) (0.0) (0.0) (0.6) 100.0 (54.3) 34 Total 14.1 68.0 3.6 0.4 10.8 0.4 0.9 1.4 0.4 100.0 41.2 1,143 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate One important newborn care practice is care of the umbilical cord. Table 9.14 shows that a new/boiled blade was used to cut the umbilical cord in 68 percent of non-institutional births in the two years preceding the survey, while instruments from a clean home delivery kit were used in 14 percent of births. A hasiya (sickle) was used in 11 percent of births, and 4 percent were exposed to used, unsterile blades. Forty-one percent of babies had some material (usually oil, an ointment, turmeric, or ash) placed on their umbilical stump. Only 2 percent of babies had chlorhexidine ointment placed on their stump after cutting 136 • Maternal Health of the umbilical cord (data not shown). Nineteen percent of babies had an unknown ointment/powder placed on their stump. The 2011 NDHS asked mothers with non-institutional deliveries in the two years preceding the survey about the newborn care practices they adopted. Table 9.15 indicates that 59 percent of newborns were wiped before the placenta was delivered and 62 percent were wrapped in cloth; only 10 percent were placed on the belly or breast of the mother before the placenta was delivered. As hypothermia among newborns is one of the principal causes of neonatal death, these practices should be more common. Immediate wiping, skin-to-skin contact, and wrapping are more frequent among urban women and among those in the Far-western region. One in two newborns is bathed within an hour of birth, a practice that is not recommended. However, the practice of first bathing babies at least 24 hours after birth has improved since 2006, with one in four newborns being bathed only after 24 hours post-birth compared with only 9 percent in 2006. Table 9.15 Newborn care practices Percentage of non-institutional last live births in the two years preceding the survey that were wiped before the placenta was delivered; the percentage placed on the mother’s belly/breast before the placenta was delivered; the percentage wrapped in cloth before the placenta was delivered; and the percent distribution by timing of first bath, according to background characteristics, Nepal 2011 Background characteristic Wiped before the placenta was delivered Placed on belly/breast before placenta was delivered Wrapped in cloth before placenta was delivered Timing of first bath Number of births Within 1 hour 2-24 hours After 24 hours Don’t know/ missing Total Residence Urban 77.0 25.5 78.5 56.1 12.8 27.5 3.6 100.0 39 Rural 58.6 9.9 61.6 49.8 22.8 26.1 1.3 100.0 1,103 Ecological zone Mountain 61.0 10.2 68.3 57.7 25.8 16.2 0.3 100.0 120 Hill 58.7 8.4 61.7 60.0 16.1 22.5 1.4 100.0 487 Terai 59.4 12.3 61.2 39.1 27.5 31.7 1.7 100.0 536 Development region Eastern 58.2 10.1 61.9 55.3 11.8 32.7 0.2 100.0 227 Central 51.0 10.6 54.7 41.4 29.5 26.5 2.7 100.0 384 Western 64.3 5.0 65.0 57.2 14.1 26.5 2.3 100.0 222 Mid-western 59.9 10.0 61.8 61.3 21.5 17.1 0.0 100.0 181 Far-western 76.2 20.2 80.7 37.9 36.3 25.6 0.2 100.0 129 Subregion Eastern mountain 52.3 7.9 64.0 54.3 8.8 35.6 1.3 100.0 27 Central mountain 48.4 12.0 58.7 65.6 17.2 17.2 0.0 100.0 24 Western mountain 68.9 10.4 73.3 56.3 35.6 8.1 0.0 100.0 69 Eastern hill 44.1 6.5 51.0 66.6 7.2 26.2 0.0 100.0 99 Central hill 55.0 13.5 56.9 63.2 11.5 22.0 3.3 100.0 83 Western hill 61.1 6.2 61.1 55.9 15.4 26.3 2.5 100.0 156 Mid-western hill 62.0 5.6 65.6 63.2 20.5 16.3 0.0 100.0 90 Far-western hill 77.4 14.4 82.1 50.8 32.5 16.7 0.0 100.0 59 Eastern terai 73.7 14.2 71.9 44.5 17.2 38.4 0.0 100.0 101 Central terai 50.1 9.6 53.7 32.7 35.9 28.6 2.7 100.0 277 Western terai 72.0 2.3 74.3 60.4 10.8 27.0 1.8 100.0 65 Mid-western terai 60.6 18.5 57.5 53.3 23.9 22.7 0.0 100.0 54 Far-western terai (65.4) (35.3) (70.5) (14.7) (28.2) (56.4) (0.6) 100.0 38 Mother’s education No education 57.9 10.3 60.7 50.4 26.0 22.3 1.3 100.0 629 Primary 56.6 10.9 57.8 56.2 17.4 25.6 0.8 100.0 238 Some secondary 61.5 11.5 68.0 45.9 19.8 33.6 0.7 100.0 187 SLC and above 71.4 7.4 72.1 39.0 16.8 39.2 5.0 100.0 89 Wealth quintile Lowest 54.3 7.8 57.6 64.0 20.6 15.4 0.0 100.0 415 Second 55.7 8.2 58.4 48.4 22.2 27.5 1.9 100.0 283 Middle 60.4 12.1 62.6 38.0 26.0 33.1 2.9 100.0 259 Fourth 68.9 15.6 73.1 38.2 22.9 36.9 2.0 100.0 151 Highest (97.1) (24.4) (97.8) (35.1) (19.8) (45.1) (0.0) 100.0 34 Total 59.3 10.4 62.2 50.0 22.5 26.1 1.4 100.0 1,143 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 9.8 ABORTION Nepal made abortion legal in September 2002. The government began providing comprehensive abortion care services in March 2004 (GoN/DoHS/FHD/WHO/CHREPA, 2006). Maternal Health • 137 The abortion law allows women to terminate their pregnancy under the following conditions: pregnancies of 12 weeks gestation or less for any woman on her own decision, pregnancies of 18 weeks gestation if the pregnancy is a result of rape or incest, and pregnancies of any duration with the recommendation of an authorized medical practitioner if the life of the mother is at risk, if her physical or mental health is at risk, or if the fetus is deformed. However, the law prohibits abortions done without the consent of the woman, sex- selective abortions, and abortions performed outside the legally permissible criteria. Abortion services are provided at service delivery points with surgical facilities and medicines located at district hospitals, some primary health care centers, health posts, and private hospitals. The Nepal government, through the Ministry of Health and Population, has prioritized the national safe abortion program, and significant efforts have been made in the last five years to expand services. In collaboration with Ipas, an international NGO, the Family Health Division has scaled up service facilities. There are currently about 245 registered sites covering all 75 districts in the country (Ipas, 2010a). The 2011 NDHS included a series of questions specific to abortion, including knowledge on legalization of abortion and the legal conditions for abortion, knowledge about places that provide safe abortions, and, among women who had an abortion in the five years preceding the survey, the reason for the abortion, the type of abortion procedure, the type of provider, complications due to the procedure, and the cost of the abortion. 9.8.1 Knowledge that Abortion is Legal in Nepal Table 9.16 shows that only 38 percent of women age 15-49 believe that abortion in Nepal is legal. Women age 45-49 are least likely to know that abortion is legal. Urban women and women who reside in the Far-western region, particularly the Far-western terai subregion, are more likely than their counterparts to believe that abortion in Nepal is legal. Nearly two-thirds of women with an SLC and higher education, and half of women with some secondary education believe that abortion is legal, along with 54 percent of women in the highest wealth quintile. Those who stated that abortion is legal in Nepal were further asked under what circumstances it is legal. Among women who believe that abortion is legal in Nepal, one-third stated that it is legal for pregnancies up to 12 weeks, and one-fifth stated that it is legal for pregnancies of 18 weeks duration if they were a result of rape or incest. Fewer than 10 percent of women each believed that abortion is legal if the mother’s life is in danger, if the mother has a physical or mental condition that would make a pregnancy a health risk, or if there is a fetal abnormality. Nearly two-fifths of women did not know under what circumstances abortion in Nepal is legal. This was especially true for women in rural areas, those with no education, and those in the lowest wealth quintile. It is interesting to note that although a large proportion of women in the Far-western region believe that abortion is legal in Nepal, many of these women do not know under what circumstances it is legal. 138 • Maternal Health Table 9.16 Knowledge that abortion is legal in Nepal Percentage of women who think abortion is legal in Nepal, and among women who think abortion is legal, percentage who report specific circumstances under which abortion is legal, according to background characteristics, Nepal 2011 Background characteristic Knowledge of abortion Circumstances for legal abortion Number of women who think abortion is legal Percentage who think abortion is legal Number of women Pregnancy of 12 weeks duration or less for any woman Pregnancy of 18 weeks duration if resulted from rape/ incest Life of mother in danger Mother’s physical/ mental health at risk Fetus abnormality Other Don’t know Age 15-19 39.8 2,753 29.5 20.1 5.7 7.7 3.9 6.9 45.3 1,097 20-24 42.3 2,297 34.5 18.5 8.2 11.0 7.5 9.8 39.4 973 25-29 41.0 2,101 40.6 19.7 11.3 10.7 10.9 8.5 31.1 861 30-34 38.2 1,734 38.3 25.1 9.6 9.1 7.2 8.2 35.3 663 35-39 35.7 1,557 39.4 23.7 11.2 8.6 6.4 13.1 33.3 555 40-44 30.2 1,285 35.4 19.2 5.7 6.1 6.4 7.5 44.1 388 45-49 26.5 947 32.5 24.1 5.4 7.7 5.2 9.5 40.2 251 Residence Urban 47.2 1,819 33.7 26.1 11.0 13.0 11.5 13.8 29.8 859 Rural 36.2 10,855 35.9 19.8 7.8 8.2 5.9 7.8 40.3 3,929 Ecological zone Mountain 39.8 805 47.5 12.5 4.0 6.4 2.7 2.5 43.8 321 Hill 38.2 5,090 39.7 23.7 8.4 9.9 7.7 11.4 31.9 1,945 Terai 37.2 6,779 30.8 19.9 8.9 8.8 6.8 7.7 42.7 2,522 Development region Eastern 37.9 3,057 40.2 18.0 10.5 11.3 7.3 9.3 30.8 1,157 Central 35.1 4,236 29.0 27.4 8.4 10.4 9.6 11.6 35.3 1,488 Western 35.5 2,660 41.9 26.6 8.4 8.6 6.9 9.2 32.3 944 Mid-western 36.9 1,478 28.7 13.5 5.7 4.6 2.4 7.3 54.9 546 Far-western 52.6 1,242 38.3 9.6 6.8 6.5 3.7 2.8 53.8 653 Subregion Eastern mountain 34.6 229 57.7 22.4 8.1 13.6 4.6 1.7 27.0 79 Central mountain 43.8 258 46.0 11.1 2.9 5.0 3.4 3.8 44.5 113 Western mountain 40.4 319 42.7 7.5 2.4 3.2 0.8 2.0 53.4 129 Eastern hill 38.5 956 47.5 9.7 7.8 6.5 6.5 8.6 36.5 368 Central hill 44.0 1,563 36.5 34.6 12.1 15.3 13.7 16.8 17.2 688 Western hill 32.0 1,513 43.4 26.2 5.9 8.0 5.5 6.7 35.1 483 Mid-western hill 34.6 649 25.5 20.3 4.8 6.7 1.2 15.1 47.4 225 Far-western hill 44.2 409 43.4 7.7 7.1 5.0 1.0 4.9 49.8 181 Eastern terai 37.9 1,873 34.4 21.8 12.2 13.5 8.1 10.5 28.3 710 Central terai 28.4 2,415 18.7 22.9 5.6 6.4 6.5 7.6 51.9 687 Western terai 40.1 1,147 40.5 27.0 11.0 9.2 8.4 11.9 29.3 460 Mid-western terai 39.4 668 27.7 8.6 7.4 3.5 3.9 2.2 62.2 263 Far-western terai 59.5 676 35.6 11.0 7.4 7.6 5.2 1.8 55.2 402 Education No education 20.4 5,045 27.1 13.5 3.8 1.9 3.2 7.9 53.6 1,030 Primary 31.5 2,209 31.1 12.5 5.3 6.5 4.2 6.5 48.0 695 Some secondary 50.2 3,088 37.5 20.2 7.8 7.1 5.0 8.6 38.8 1,551 SLC and above 64.8 2,331 41.2 30.7 13.6 17.1 12.6 10.9 23.1 1,512 Wealth quintile Lowest 21.8 2,120 29.3 7.3 2.0 3.4 1.5 3.0 60.8 461 Second 28.5 2,393 35.2 13.0 5.0 4.9 3.0 6.1 46.9 681 Middle 32.5 2,600 34.4 17.3 5.1 5.6 4.6 6.1 46.6 845 Fourth 46.7 2,722 34.5 23.4 10.0 8.2 7.2 10.3 36.5 1,270 Highest 53.9 2,839 38.9 28.7 12.3 15.3 11.3 12.3 24.9 1,530 Total 37.8 12,674 35.5 21.0 8.4 9.1 6.9 8.9 38.4 4,788 Note: Other includes “can abort if no more children desired” and “unwanted.” SLC = School Leaving Certificate 9.8.2 Knowledge about Places That Provide Safe Abortions With the legalization of abortion, service providers in Nepal have been trained to conduct safe abortions. Table 9.17 shows that 59 percent of women age 15-49 report knowing a place where a safe abortion can be obtained. Knowledge of a safe abortion place is higher among urban, educated, and wealthy women than among their counterparts. Knowledge of a safe abortion place is also higher in the terai than in the hill or mountain zone and higher in the Western and Mid-western terai than in the other subregions. Women who report knowing places for safe abortion are more likely to mention the government sector (71 percent) than the private sector (58 percent) or the nongovernment sector (29 percent). Maternal Health • 139 Table 9.17 Knowledge about places that provide safe abortions Percentage of women who know about a place for safe abortion, and among those women who know about a place for safe abortion, the percentage who report specific service sectors for safe abortion, according to background characteristics, Nepal 2011 Background characteristic Knowledge on place Place for safe abortion Number of women who know a place for safe abortion Percentage who know a place for safe abortion Number of women Government sector Non- government sector Private sector Other Age 15-19 53.5 2,753 72.7 22.8 57.2 0.1 1,472 20-24 63.5 2,297 72.9 32.0 55.4 0.4 1,459 25-29 66.3 2,101 70.2 34.3 59.7 0.4 1,392 30-34 65.3 1,734 67.9 36.0 59.3 0.6 1,131 35-39 59.2 1,557 71.1 27.0 57.4 0.7 922 40-44 49.8 1,285 71.3 22.0 59.2 0.2 639 45-49 46.8 947 74.6 21.4 55.9 1.0 443 Residence Urban 63.2 1,819 71.7 36.6 61.4 1.0 1,151 Rural 58.1 10,855 71.3 27.8 57.1 0.3 6,308 Ecological zone Mountain 60.1 805 88.3 18.1 46.9 0.0 484 Hill 50.4 5,090 76.9 28.5 54.9 0.3 2,564 Terai 65.1 6,779 66.3 30.7 60.6 0.6 4,411 Development region Eastern 57.4 3,057 60.1 30.5 57.1 0.6 1,755 Central 59.5 4,236 70.7 27.7 58.9 0.4 2,520 Western 54.1 2,660 73.1 30.5 62.4 0.1 1,438 Mid-western 67.4 1,478 80.5 30.4 51.4 0.3 997 Far-western 60.3 1,242 84.7 26.6 54.7 1.1 749 Subregion Eastern mountain 58.2 229 91.7 7.3 49.4 0.0 133 Central mountain 56.5 258 76.5 27.1 68.5 0.0 146 Western mountain 64.3 319 94.5 18.6 30.0 0.0 205 Eastern hill 48.4 956 75.0 25.8 47.5 0.4 463 Central hill 55.1 1,563 73.7 35.5 60.1 0.4 861 Western hill 39.7 1,513 77.4 21.8 63.5 0.0 600 Mid-western hill 62.4 649 80.7 28.2 44.4 0.3 405 Far-western hill 57.5 409 84.2 25.4 47.0 0.5 236 Eastern terai 61.9 1,873 50.5 35.1 61.9 0.7 1,159 Central terai 62.7 2,415 68.4 23.3 57.3 0.4 1,513 Western terai 73.0 1,147 70.1 36.6 61.7 0.2 838 Mid-western terai 71.2 668 76.7 33.0 64.8 0.4 476 Far-western terai 62.9 676 83.0 31.4 61.8 1.6 425 Education No education 48.1 5,045 70.8 16.0 55.3 0.6 2,425 Primary 55.6 2,209 73.7 24.1 56.1 0.2 1,229 Some secondary 63.8 3,088 72.0 32.4 58.6 0.3 1,971 SLC and above 78.6 2,331 69.7 46.4 61.2 0.5 1,833 Wealth quintile Lowest 40.2 2,120 80.6 15.4 43.7 0.4 852 Second 51.3 2,393 75.5 15.8 56.0 0.1 1,228 Middle 60.2 2,600 67.8 22.5 60.0 0.3 1,567 Fourth 66.2 2,722 70.8 33.9 57.0 0.6 1,802 Highest 70.8 2,839 68.2 44.1 63.8 0.6 2,009 Total 58.8 12,674 71.4 29.1 57.8 0.4 7,458 SLC = School Leaving Certificate 9.8.3 Pregnancy Outcomes A pregnancy that does not end in a live birth is a stillbirth, a miscarriage, or an abortion. Table 9.18 shows the percent distribution of all pregnancies that ended during the five years preceding the survey by type of outcome. The majority of pregnancies (85 percent) end in a live birth. Eight percent of pregnancies are aborted, 7 percent result in a miscarriage, and a very small proportion end up as stillbirths (1 percent). Abortions are proportionately higher among women age 20 and above and pregnancies of order three and higher. The percentage of pregnancies ending in abortion is more than twice as high in urban as in rural areas. Abortions are relatively higher in the hill zone and terai than in the mountain zone. The Western region has a higher proportion of pregnancies ending in abortion than the other development regions, and abortions are particularly high in the Western terai subregion, where 15 percent of pregnancies are aborted. Around 10 percent of pregnancies among women with at least some education end in an abortion. The proportion of pregnancies ending in abortion rises with household wealth, from 3 percent among pregnancies in the poorest households to 18 percent in the wealthiest households. 140 • Maternal Health Table 9.18 Pregnancy outcomes by background characteristics Percent distribution of pregnancies ending in the five years preceding the survey by type of outcome, according to background characteristics, Nepal 2011 Background characteristic Pregnancy outcome Number of pregnancies Live birth Stillbirth Miscarriage Abortion Total Age at end of pregnancy <20 88.4 0.8 7.9 2.8 100.0 1,245 20-34 84.9 0.9 6.1 8.1 100.0 4,605 35-49 75.3 1.1 9.9 13.7 100.0 505 Pregnancy order 1 90.2 1.1 7.2 1.5 100.0 1,889 2 88.1 0.6 6.0 5.2 100.0 1,550 3 82.1 0.8 6.3 10.7 100.0 1,154 4 78.2 0.6 5.3 15.8 100.0 706 5+ 77.8 1.2 8.5 12.5 100.0 1,058 Residence Urban 76.5 0.5 8.2 14.7 100.0 658 Rural 85.8 1.0 6.6 6.7 100.0 5,698 Ecological zone Mountain 85.5 1.9 7.7 4.9 100.0 500 Hill 84.2 0.9 6.7 8.2 100.0 2,531 Terai 85.2 0.8 6.7 7.3 100.0 3,325 Development region Eastern 85.9 1.3 7.6 5.2 100.0 1,478 Central 88.5 0.3 5.0 6.2 100.0 1,940 Western 80.3 0.8 6.8 12.2 100.0 1,255 Mid-western 84.4 1.5 7.4 6.7 100.0 940 Far-western 81.4 1.2 8.9 8.5 100.0 744 Subregion Eastern mountain 87.9 2.4 6.9 2.8 100.0 115 Central mountain 87.1 0.4 6.9 5.6 100.0 110 Western mountain 83.9 2.2 8.3 5.6 100.0 275 Eastern hill 86.8 2.1 7.2 3.9 100.0 480 Central hill 83.5 0.0 4.6 11.8 100.0 593 Western hill 83.1 0.3 6.5 10.1 100.0 727 Mid-western hill 85.1 1.3 7.6 5.9 100.0 432 Far-western hill 82.5 1.7 9.0 6.7 100.0 299 Eastern terai 85.2 0.6 7.9 6.2 100.0 883 Central terai 91.0 0.5 5.0 3.5 100.0 1,237 Western terai 76.3 1.5 7.2 15.1 100.0 528 Mid-western terai 84.1 1.0 6.6 8.3 100.0 358 Far-western terai 78.9 0.8 9.1 11.3 100.0 320 Education No education 89.4 1.0 5.6 4.0 100.0 2,851 Primary 82.5 1.2 7.1 9.2 100.0 1,308 Some secondary 79.5 0.9 7.7 12.0 100.0 1,307 SLC and above 81.3 0.3 8.6 9.8 100.0 889 Wealth quintile Lowest 89.2 1.3 6.2 3.3 100.0 1,557 Second 88.3 0.8 6.8 4.1 100.0 1,340 Middle 86.4 1.1 6.2 6.3 100.0 1,312 Fourth 82.9 0.4 7.0 9.6 100.0 1,130 Highest 73.6 0.7 8.2 17.5 100.0 1,016 Total 84.8 0.9 6.8 7.5 100.0 6,356 SLC = School Leaving Certificate 9.8.4 Reason for the Most Recent Abortion Women who had an abortion in the five years preceding the survey were asked the reason for their most recent abortion. One in five women mentioned that the main reason for their most recent abortion was that they did not want any more children, while 12 percent said that their husband/partner did not want the child (Table 9.19). Another 10 percent of women said that they wanted to space their births, and 7 percent mentioned that they wanted to delay childbearing. Ten percent of women reported that they had an abortion because of their health, and 12 percent mentioned that they aborted because there was no money to take care of the baby. Maternal Health • 141 Table 9.19 Main reason for the most recent abortion in the past five years Percent distribution of women with an abortion in the five years preceding the survey by main reason for the most recent abortion, according to background characteristics, Nepal 2011 Background characteristic Main reason for having most recent abortion Number of women Health of mother No money to take care of baby Wanted to delay child- bearing Wanted to space child Did not want any more children Husband/ partner did not want child Other Total Age at end of pregnancy <20 (21.5) (7.7) (18.7) (22.8) (0.0) (1.0) (28.3) 100.0 34 20-34 10.7 13.3 7.5 10.1 20.4 13.8 24.2 100.0 325 35-49 2.3 10.1 0.0 1.7 30.7 10.7 44.5 100.0 61 Pregnancy order 1 (32.2) (6.9) (9.6) (6.6) (0.0) (1.2) (43.5) 100.0 28 2 7.9 6.7 21.4 36.5 3.2 2.6 21.8 100.0 79 3 11.0 16.0 6.4 4.5 21.6 15.3 25.1 100.0 112 4 13.2 13.3 1.6 3.0 32.2 12.7 23.9 100.0 92 5+ 3.6 13.3 2.3 2.6 26.5 18.8 33.0 100.0 109 Residence Urban 11.4 14.4 9.3 8.9 15.4 12.4 28.3 100.0 81 Rural 10.1 11.9 6.9 10.1 21.4 12.3 27.3 100.0 339 Ecological zone Mountain 7.9 14.0 5.6 4.2 21.8 12.9 33.7 100.0 22 Hill 9.3 11.8 7.1 10.0 20.0 10.4 31.5 100.0 183 Terai 11.6 12.7 7.7 10.3 20.4 13.8 23.5 100.0 215 Development region Eastern 17.9 7.5 8.4 13.2 11.8 12.1 29.0 100.0 68 Central 12.3 11.0 5.7 12.8 20.7 8.2 29.4 100.0 105 Western 8.7 13.3 5.1 7.7 27.5 7.8 29.9 100.0 132 Mid-western 6.0 16.2 8.4 8.6 15.1 16.6 29.0 100.0 58 Far-western 6.0 14.6 13.5 6.7 18.0 26.4 14.9 100.0 56 Education No education 10.0 14.8 4.7 4.6 23.7 20.3 22.0 100.0 103 Primary 7.5 16.4 7.3 11.1 18.1 11.3 28.3 100.0 108 Some secondary 13.7 10.0 7.3 9.2 17.9 9.7 32.2 100.0 131 SLC and above 9.2 7.6 11.1 16.3 22.6 7.5 25.8 100.0 79 Wealth quintile Lowest 12.7 19.5 1.1 4.1 26.4 14.5 21.7 100.0 47 Second 5.9 13.3 14.2 4.5 19.3 15.6 27.3 100.0 51 Middle 4.7 12.1 6.0 9.7 18.5 15.7 33.3 100.0 75 Fourth 18.3 14.0 10.7 8.8 14.3 5.6 28.4 100.0 96 Highest 9.0 8.9 5.5 14.2 23.4 13.1 25.9 100.0 151 Total 10.4 12.4 7.4 9.9 20.3 12.3 27.5 100.0 420 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 9.8.5 Type of Abortion Procedure In the past, manual vacuum aspiration was the main procedure used for safe abortion in Nepal; recently, however, the government has encouraged medical abortion. Keeping in view the lack of modern technologies in rural areas of Nepal, medical abortion seems to be a viable option. Medical abortion was piloted from December 2008 to June 2009 with successful results (Ipas, 2010b). Women who had an abortion were asked what procedure was used to terminate their pregnancy. Table 9.20 shows that 39 percent of women had a dilation and curettage (D & C), 24 percent had manual vacuum aspiration, 20 percent took unspecified tablets, and 9 percent had a medical abortion. Other actions to end a pregnancy taken by less than 5 percent of women each included injection, catheter, and other unspecified reasons. 142 • Maternal Health Table 9.20 Abortion services in the past five years Percent distributions of women receiving an abortion in the five years preceding the survey by procedure and provider used for the last abortion, and the percentage who received their last abortion in various places for abortion, Nepal 2011 Abortion services Total Procedure for abortion Took tablets 19.5 D & C 38.5 Manual vacuum aspiration 24.1 Medical abortion 9.1 Injection 3.5 Catheter 2.5 Other 2.7 Total 100.0 Provider for abortion1 Doctor 61.9 Nurse/midwife 27.4 Health assistant/health worker 2.9 Pharmacist/medical shop 5.3 Friends/relatives 0.9 No one 1.6 Total 100.0 Place of abortion2 Government sector 18.7 Nongovernment sector 34.4 Private sector 36.3 Home 9.7 Other 1.4 Number of women with abortion 420 1 If the respondent mentioned more than one person attending during abortion, only the most qualified person is considered. 2 Some respondents went to more than one place for an abortion. 9.8.6 Place and Provider for Abortion In patriarchal societies such as Nepal, having an abortion has been associated with women losing morality and status in the community, cultivating a feeling of guilt among women. Because of the stigma attached to abortion, some women end up using traditional remedies, which can be unsafe and, in some cases, even fatal. However, with legalization of abortion, services are now available in health centers where women can access better and safer care. Safe abortion services are provided at government referral-level hospitals, district hospitals, clinics, and health posts. They are also provided by nongovernmental organizations and certain private-sector hospitals and clinics. Doctors, nurses, and auxiliary midwives trained as skilled birth attendants typically provide these services. The majority of women who had an abortion in the five years preceding the survey went to a doctor (62 percent) or a nurse/midwife (27 percent) for the last abortion (Table 9.20). Five percent received services in a medical shop or from a pharmacist, while 3 percent received services from a health assistant or other health workers. The proportion of women who sought services from their friends and relatives was low (1 percent), and 2 percent of women did not receive any assistance in aborting their pregnancy. Women who had an abortion in the five years before the survey were also asked for the place of their last abortion. About one in five women went to government health facilities, while one in three went to nongovernment health facilities such as Marie Stopes and FPAN. Another one-third went to private-sector facilities (36 percent). About 10 percent of women had their abortion at home. Among those who went to government facilities and nongovernment facilities, all accessed government-listed sites for their abortion. However, among those who visited private-sector facilities, only 19 percent went to listed sites. Notably, about 8 percent of women went to India for abortion services (data not shown). Maternal Health • 143 9.8.7 Complications during and after Abortion and Contraception Women were also asked whether they experienced complications either during their last abortion or following the abortion. One in four women who had an abortion in the five years preceding the survey mentioned that they had complications during the last such procedure, and another 24 percent mentioned experiencing post-abortion complications (i.e., complications within one month following the abortion) (data not shown). The 2011 NDHS collected information on women’s use of contraception following an abortion. Forty- one percent of women who had an abortion in the five years preceding the survey used a contraceptive method after their abortion. Thirteen percent of these women used injectables, 11 percent used the pill, 2 percent used implants, and 1 percent each used female sterilization and IUDs; the remaining 13 percent of women used other methods (data not shown). 9.8.8 Abortion and Post-abortion Cost Nearly one in two (48 percent) women with an abortion in the five years before the survey said that they paid more than Nepalese Rupees 1,500 for their most recent abortion, while 36 percent paid 1,000-1,500 and 10 percent paid less than 1,000. Only 6 percent of women mentioned that they had obtained free abortion services (data not shown). The majority of women (69 percent) who had an abortion in the five years preceding the survey did not use post-abortion care services, even when they suffered from complications after their most recent abortion. Twenty-seven percent of women with an abortion in the five years preceding the survey paid less than Nepalese Rupees 1,000 while 4 percent paid more than 1,000 for post-abortion care services (data not shown). 9.9 UTERINE PROLAPSE In Nepal, uterine prolapse affects about 10 percent of women nationally (Institute of Medicine, 2006). It is the most frequently reported cause of poor health among women of reproductive age and postmenopausal women. Many women in Nepal are engaged in extremely hard work (including heavy lifting), with little or no rest during pregnancy or the postpartum period, contributing to high rates of uterine prolapse. Six percent of women who had ever given birth said they had experienced symptoms of uterine prolapse. Among these women 55 percent sought medical treatment, 9 percent sought traditional treatment, and 36 percent did not seek any treatment at all (data not shown). In 2006, 7 percent of women age 15-49 experienced uterine prolapse. 9.10 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers women may face in seeking care during pregnancy and at the time of delivery. In the 2011 NDHS, women were asked whether or not each of the following factors would be a significant problem for them in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to a health facility, and not wanting to go alone. The majority of women (72 percent) reported that at least one of these problems would pose a barrier to seeking health care for themselves when they are sick (Table 9.21). Sixty percent of women stated that not wanting to go alone is a problem in accessing health care, while getting money for treatment and distance to a health facility were each cited as a problem by around one in two women. Only 13 percent of women perceived getting permission to go for treatment as a problem. 144 • Maternal Health Table 9.21 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Nepal 2011 Background characteristic Problems in accessing health care Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone At least one problem accessing health care Number of women Age 15-19 12.8 41.5 45.7 66.1 74.9 2,753 20-34 13.4 45.4 45.6 58.5 70.1 6,132 35-49 11.0 52.7 48.7 58.6 73.0 3,789 Number of living children 0 12.2 38.5 40.8 62.0 70.3 3,823 1-2 12.0 43.2 43.1 55.9 67.9 4,591 3-4 13.1 55.1 53.3 61.1 76.0 3,207 5+ 14.8 67.1 62.0 69.2 83.9 1,053 Marital status Never married 10.3 37.9 38.9 61.1 69.6 2,708 Married 13.3 48.7 48.7 59.9 72.4 9,608 Divorced/separated/widowed 9.2 61.8 48.8 60.3 79.8 358 Employed last 12 months Not employed 9.6 33.4 34.2 53.0 61.6 3,126 Employed for cash 9.7 45.5 36.2 52.6 66.2 2,924 Employed not for cash 15.2 53.6 57.0 66.9 79.5 6,625 Residence Urban 8.6 30.1 20.5 45.6 56.3 1,819 Rural 13.2 49.6 50.9 62.6 74.6 10,855 Ecological zone Mountain 12.6 54.6 64.8 70.7 80.9 805 Hill 14.1 48.7 48.7 62.0 74.1 5,090 Terai 11.4 44.4 42.8 57.6 69.4 6,779 Development region Eastern 10.1 46.8 45.5 61.4 72.2 3,057 Central 12.0 45.1 45.7 60.1 70.8 4,236 Western 12.8 39.5 38.4 54.2 67.1 2,660 Mid-western 15.5 52.8 56.2 64.4 77.9 1,478 Far-western 16.4 60.8 58.2 65.5 78.8 1,242 Subregion Eastern mountain 13.2 54.5 62.9 65.6 77.4 229 Central mountain 10.6 50.9 59.9 71.5 80.2 258 Western mountain 13.7 57.6 70.0 73.7 84.1 319 Eastern hill 12.6 59.3 64.3 75.9 85.7 956 Central hill 14.5 40.4 36.8 55.6 65.2 1,563 Western hill 16.4 44.8 43.8 59.2 72.9 1,513 Mid-western hill 14.3 50.4 55.2 59.9 75.1 649 Far-western hill 7.8 67.1 65.9 67.4 83.6 409 Eastern terai 8.5 39.5 33.9 53.5 64.7 1,873 Central terai 10.5 47.4 49.9 61.7 73.5 2,415 Western terai 8.1 32.4 31.4 47.6 59.5 1,147 Mid-western terai 15.6 53.6 52.1 65.1 78.2 668 Far-western terai 23.7 58.2 52.5 63.8 75.7 676 Education No education 16.9 63.6 61.3 69.4 83.7 5,045 Primary 15.8 53.5 51.4 64.0 77.3 2,209 Some secondary 9.9 37.2 38.7 57.0 67.3 3,088 SLC and above 3.6 16.5 20.5 41.0 47.9 2,331 Wealth quintile Lowest 21.1 72.1 74.5 76.8 90.1 2,120 Second 16.3 64.0 62.8 70.0 84.2 2,393 Middle 13.3 52.0 51.1 62.7 77.4 2,600 Fourth 10.3 37.6 39.0 57.4 69.3 2,722 Highest 4.6 17.3 15.1 39.8 46.0 2,839 Total 12.6 46.8 46.6 60.2 72.0 12,674 SLC = School Leaving Certificate Women with five or more children, those employed but not for cash, and those living in rural areas, the mountain zone, the Far-western region, and the Eastern hill subregion were more likely than their counterparts to cite having at least one of these problems in seeking health care for themselves, as were women with no education and women from the poorest households. 9.10.1 Awareness and Practice of Health Services in the Government Sector Women age 15-49 were also asked whether they were aware of the government health incentives to encourage women to use health facilities: free delivery services, and transportation cost for delivering in a government health facility. The vast majority of women are aware of transportation cost encouraging government facility delivery (89 percent) and free delivery services (76 percent) (Table 9.22). Maternal Health • 145 The 2011 NDHS also collected information on whether registration fees were waived for women age 15-49 who visited a government health facility in the 12 months prior to the survey and, among those who were prescribed medicines, whether some or all of the medicines were provided free of cost. Sixty-four percent of women who visited a health facility in the 12 months prior to the survey did not pay registration fees during their visit. In addition, of those who were prescribed medicines, 62 percent received some or all of the medicine free of cost. The government’s program seems to be successful in targeting the poorer sectors of the population. Rural women; women living in the mountain zone, Far-western region, and Eastern and Far-western hill subregions; women with less than an SLC; and women in the lowest and second lowest wealth quintiles were more likely than their counterparts to not pay registration fees. A similar pattern is seen for free medicine. Table 9.22 Awareness and practice of health services in government sector Percentage of women age 15-49 with knowledge on government health incentives; among women who visited a government health facility in the 12 months preceding survey, the percentage who did not pay a registration fee; and among women who visited a government health facility in the past 12 months and were prescribed medicine, the percentage who received some or all of the medicine free of cost, by background characteristics, Nepal 2011 Background characteristic Among all women age 15-49, the percentage who know about: Among those visiting a government health facility in the past 12 months: Among those visiting a government health facility in the past 12 months who were prescribed medicine: Free delivery services Transporta- tion cost for government facility delivery Number of women Percentage who did not pay registration fee Number of women Percentage who received some or all medicine free of cost Number of women Residence Urban 75.0 88.7 1,819 28.8 427 34.2 335 Rural 76.4 88.6 10,855 68.3 3,186 65.9 2,441 Ecological zone Mountain 86.8 95.3 805 71.4 328 77.9 265 Hill 75.1 87.2 5,090 68.4 1,633 66.7 1,214 Terai 75.8 89.0 6,779 57.4 1,652 54.5 1,297 Development region Eastern 79.8 90.6 3,057 67.3 902 64.3 637 Central 68.6 85.6 4,236 48.2 1,126 47.2 888 Western 72.0 84.4 2,660 68.4 703 60.1 516 Mid-western 85.6 94.1 1,478 73.1 437 75.5 352 Far-western 91.4 96.9 1,242 78.2 445 83.2 383 Subregion Eastern mountain 87.9 95.7 229 74.9 120 77.3 91 Central mountain 78.7 92.2 258 53.3 54 62.4 43 Western mountain 92.7 97.4 319 75.1 153 83.3 131 Eastern hill 84.3 92.2 956 81.5 356 72.9 221 Central hill 71.1 85.8 1,563 42.8 438 47.6 343 Western hill 65.7 81.6 1,513 74.0 467 67.4 357 Mid-western hill 82.3 90.8 649 77.3 235 77.9 183 Far-western hill 92.4 95.8 409 81.3 139 92.7 109 Eastern terai 76.4 89.1 1,873 53.2 426 54.9 325 Central terai 65.9 84.8 2,415 51.6 634 45.6 502 Western terai 80.2 88.1 1,147 57.4 236 43.4 158 Mid-western terai 87.5 96.3 668 71.0 126 68.4 106 Far-western terai 90.1 97.7 676 73.6 230 77.2 206 Mother’s education No education 68.9 85.7 5,045 64.3 1,554 64.0 1,224 Primary 77.3 87.9 2,209 67.4 695 66.7 511 Some secondary 82.4 91.8 3,088 64.8 810 61.3 627 SLC and above 82.8 91.5 2,331 55.2 555 51.9 414 Wealth quintile Lowest 70.3 84.3 2,120 80.2 708 82.5 517 Second 73.7 87.2 2,393 76.3 865 69.2 671 Middle 76.5 90.6 2,600 65.2 800 62.5 637 Fourth 80.4 90.6 2,722 51.7 687 48.6 524 Highest 78.4 89.5 2,839 35.1 553 42.0 427 Total 76.2 88.7 12,674 63.6 3,613 62.1 2,776 SLC = School Leaving Certificate Child Health • 147 CHILD HEALTH 10 Nepalese children under age five face multiple obstacles for survival and development. Exposure to infectious diseases, malnutrition, and poor hygiene and sanitation and lack of a healthy environment compromise early childhood development. In addition, a mother’s nutritional status during pregnancy and her general well-being impact the health of her child during pregnancy as well as after delivery (Ministry of Health and Population [MOHP], 2004a; BASICS II, The MOST Project, and USAID, 2004). The Child Health Division of the Ministry of Health and Population (MOHP) has launched several child survival interventions, including various operational initiatives, to improve the health of children in Nepal. These include the Expanded Program on Immunization (EPI), the Community-Based Integrated Management of Childhood Illnesses (CB-IMCI) program, the Community-Based Newborn Care Program (CB-NCP), the Infant and Young Child Feeding program, a micronutrients supplementation program, vitamin A and deworming campaign, and the Community-Based Management of Acute Malnutrition program (MOHP, 2011a). The EPI was initiated in 1979, following the eradication of smallpox; the Control of Diarrheal Diseases (CDD) Program began in 1982; and the Control of Acute Respiratory Infections (ARI) Program was initiated in 1987. The CDD and ARI programs were merged into the CB-IMCI program in 1998. A comprehensive nutrition program was also introduced in 1979. These child survival interventions were initially launched as vertical programs under the MOHP but were subsequently integrated and brought under the Child Health Division in 1995. Over the past decade, the country has had success in reducing under-five mortality, largely due to the implementation of the CB-IMCI program with vitamin A supplementation and the immunization program. The MOHP, in an effort to decrease newborn deaths, has incorporated newborn health as an integral component of safe motherhood, endorsing the National Neonatal Health Strategy in 2004. The CB-NCP was developed in 2007 with the goal of improving the health and survival of newborn babies; the program was piloted in 10 districts in 2008-2009 and scaled up to 15 more districts in 2010-2011 (MOHP, 2010a; MOHP, 2011a). The Health Sector Reform Strategy recognizes management of childhood illnesses as a core component of the Essential Health Care Strategy. This chapter presents findings on several areas of importance relating to child health, including infant birth weight and size at birth; childhood vaccination coverage by timing, source of information on coverage, and background characteristics; prevalence and treatment of ARI symptoms (a proxy for pneumonia); prevalence and treatment of fever; and prevalence of diarrhea, diarrhea treatment, feeding practices during diarrhea, knowledge of oral rehydration salt (ORS) packets, and disposal of children’s stools. Key Findings: • The percentage of children age 12-23 months who are fully immunized has doubled in the past 15 years, from 43 percent in 1996 to 87 percent in 2011. • Five percent of children under age five showed symptoms of acute respiratory infection in the two weeks before the survey, and half of them were taken to a health facility or provider for advice or treatment. • Nineteen percent of children under five had a fever in the two weeks before the survey, and two-fifths of them were taken to a health facility or provider for advice or treatment. • Fourteen percent of children under age five had diarrhea in the two weeks before the survey. • The proportion of children with diarrhea taken to a health provider for advice or treatment has increased over time, from 14 percent in 1996 to 38 percent in 2011. 148 • Child Health Information on birth weight or size at birth is important for the design and implementation of programs aimed at reducing neonatal and infant mortality. Vaccination coverage information focuses on the age group 12- 23 months (i.e., the typical age by which children should have received all basic vaccinations). Data on differences in vaccination coverage between subgroups of the population aid in program planning. Data on treatment practices and contact with health services among children ill with the three most important childhood illnesses (acute respiratory infection, fever, and diarrhea) help in the assessment of national programs aimed at reducing the mortality impact of these illnesses. Information is provided on the prevalence and treatment of ARIs, including treatment with antibiotics, and the prevalence of fever and its treatment with antimalarial drugs and antibiotics. Data on the treatment of diarrheal disease with oral rehydration therapy and increased fluids help in the assessment of programs that recommend such treatments. Because sanitary practices can help prevent and reduce the severity of diarrheal disease, information is also provided on disposal of children’s fecal matter. The information on child health presented in this chapter pertains only to children born during the five years preceding the survey unless otherwise specified. 10.1 CHILD’S WEIGHT AND SIZE AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to the risk of childhood illnesses and chances of survival. Children whose birth weight is less than 2.5 kilograms or children reported to be “very small” or “smaller than average” are considered to have a higher than average risk of early childhood death. For births in the five years preceding the survey, birth weight was recorded in the questionnaire if available from either a written record or the mother’s recall. Since birth weight may not be known for many babies, the mother’s estimate of the baby’s size at birth was also obtained. Such estimates, even though subjective, can be a useful proxy for the weight of the child. Table 10.1 presents information on children’s weight and size at birth according to background characteristics. Thirty-six percent of children born in the past five years were weighed at birth. This is not surprising given that the majority of births do not take place in a health facility, and children are less likely to be weighed at birth in a non-institutional setting. Among children born in the five years before the survey with a reported birth weight, 12 percent were of low birth weight (less than 2.5 kg). There is little difference in the percentage of children of low birth weight by birth order, mother’s smoking status, mother’s age at birth, or urban-rural residence. However, there are differences by ecological zone and development region. The percentage of low birth weight children varies from a high of 15 percent in the mountain zone to 13 percent in the hill zone and 12 percent in the terai. The percentage is highest in the Eastern region (16 percent) and lowest in the Central region (9 percent). Children in the Central mountain subregion (21 percent) are most likely to be of low birth weight, while children in the Central terai (6 percent) are least likely. Children of women with a primary education are more likely to be of low birth weight (16 percent) and children of mothers with no education less likely (10 percent). Children in the lowest wealth quintile are more likely to be of low birth weight (17 percent) than children in the other quintiles. In the absence of birth weight, a mother’s subjective assessment of the size of the baby at birth may be a useful proxy. Four percent of children were reported to be very small at birth, 12 percent were reported to be smaller than average, and 84 percent were reported to be average or larger in size. The differences in children’s size by background characteristics followed a pattern similar to that observed for reported birth weight. Children living in the mountain zone were more likely to be reported as very small or smaller than average than children living in the hill zone and terai, and children living in the Mid-western hill subregion were most likely to be reported as being smaller than average. Children of mothers with no education and those from households in the lowest wealth quintile were more likely to be reported as very small or smaller than average than their counterparts. Child Health • 149 Table 10.1 Child’s weight and size at birth Percentage of live births in the five years preceding the survey that have a reported birth weight; among live births in the five years preceding the survey with a reported birth weight, percent distribution by birth weight; and percent distribution of all live births in the five years preceding the survey by mother’s estimate of baby’s size at birth, according to background characteristics, Nepal 2011 Background characteristic Percentage of all births that have a reported birth weight1 Percent distribution of births with a reported birth weight1 Total Number of births Percent distribution of all live births by size of child at birth Total Number of births Less than 2.5 kg 2.5 kg or more Very small Smaller than average Average or larger Don’t know/ missing Mother’s age at birth <20 42.6 13.4 86.6 100.0 470 4.7 13.4 81.9 0.0 100.0 1,101 20-34 36.0 12.1 87.9 100.0 1,407 3.2 12.0 84.7 0.1 100.0 3,910 35-49 20.6 12.3 87.7 100.0 78 5.5 12.1 81.9 0.5 100.0 380 Birth order 1 54.0 12.7 87.3 100.0 989 3.7 13.7 82.6 0.0 100.0 1,833 2-3 33.3 12.3 87.7 100.0 789 3.8 10.7 85.4 0.1 100.0 2,368 4-5 16.9 11.8 88.2 100.0 131 2.4 12.4 84.8 0.3 100.0 773 6+ (11.0) (11.3) (88.7) 100.0 46 4.9 14.8 79.8 0.5 100.0 417 Mother’s smoking status Smokes cigarettes/tobacco 9.7 12.9 87.1 100.0 46 5.4 18.1 75.9 0.7 100.0 475 Does not smoke 38.8 12.4 87.6 100.0 1,909 3.5 11.7 84.7 0.1 100.0 4,917 Residence Urban 71.2 12.0 88.0 100.0 358 4.0 11.6 84.3 0.0 100.0 503 Rural 32.7 12.5 87.5 100.0 1,597 3.6 12.3 83.9 0.1 100.0 4,888 Ecological zone Mountain 18.0 14.6 85.4 100.0 77 4.7 16.3 79.0 0.0 100.0 428 Hill 32.8 12.8 87.2 100.0 700 4.2 13.9 81.7 0.2 100.0 2,130 Terai 41.6 12.1 87.9 100.0 1,179 3.1 10.4 86.4 0.1 100.0 2,833 Development region Eastern 41.5 15.8 84.2 100.0 527 5.1 11.2 83.8 0.0 100.0 1,269 Central 35.1 9.1 90.9 100.0 603 2.3 9.4 88.1 0.2 100.0 1,717 Western 39.0 10.8 89.2 100.0 392 2.3 10.9 86.5 0.2 100.0 1,007 Mid-western 29.8 14.1 85.9 100.0 236 5.8 17.0 77.1 0.1 100.0 793 Far-western 32.5 14.9 85.1 100.0 196 3.8 18.8 77.3 0.0 100.0 605 Subregion Eastern mountain 20.7 11.9 88.1 100.0 21 6.2 14.4 79.4 0.0 100.0 101 Central mountain 25.3 21.1 78.9 100.0 24 4.7 16.6 78.7 0.0 100.0 96 Western mountain 13.7 11.3 88.7 100.0 32 4.0 17.0 79.0 0.0 100.0 230 Eastern hill 28.0 14.6 85.4 100.0 117 6.1 13.7 80.2 0.0 100.0 416 Central hill 47.6 12.8 87.2 100.0 236 4.6 11.0 84.1 0.3 100.0 495 Western hill 31.6 10.0 90.0 100.0 191 2.4 11.4 85.9 0.3 100.0 604 Mid-western hill 26.7 12.2 87.8 100.0 98 4.7 19.1 76.2 0.0 100.0 367 Far-western hill 23.4 19.1 80.9 100.0 58 3.8 18.7 77.5 0.0 100.0 247 Eastern terai 51.8 16.4 83.6 100.0 389 4.4 9.3 86.3 0.0 100.0 752 Central terai 30.5 5.8 94.2 100.0 343 1.1 8.1 90.7 0.2 100.0 1,126 Western terai 50.0 11.6 88.4 100.0 201 2.2 10.3 87.5 0.0 100.0 402 Mid-western terai 39.6 15.7 84.3 100.0 119 6.7 15.6 77.4 0.3 100.0 301 Far-western terai 49.9 13.6 86.4 100.0 126 5.1 18.3 76.6 0.1 100.0 252 Mother’s education No education 19.1 9.8 90.2 100.0 487 3.7 14.3 81.7 0.3 100.0 2,550 Primary 32.4 16.4 83.6 100.0 350 3.6 10.8 85.5 0.0 100.0 1,079 Some secondary 55.5 12.7 87.3 100.0 577 3.7 10.2 86.1 0.0 100.0 1,039 SLC and above 74.9 12.1 87.9 100.0 542 3.4 10.3 86.3 0.0 100.0 723 Wealth quintile Lowest 11.8 16.8 83.2 100.0 165 5.3 15.4 79.1 0.3 100.0 1,390 Second 23.0 12.0 88.0 100.0 272 3.3 12.8 83.9 0.0 100.0 1,182 Middle 35.8 12.1 87.9 100.0 406 2.3 12.1 85.5 0.1 100.0 1,133 Fourth 54.9 11.8 88.2 100.0 515 3.1 10.9 85.8 0.2 100.0 938 Highest 79.8 12.2 87.8 100.0 597 3.7 7.7 88.5 0.0 100.0 748 Total 36.3 12.4 87.6 100.0 1,955 3.6 12.3 84.0 0.1 100.0 5,391 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Based on either a written record or the mother’s recall SLC = School Leaving Certificate 10.2 VACCINATION COVERAGE The National Immunization Program (at the time known as the Expanded Program on Immunization) was initiated in 1979 in three districts with only two antigens (BCG and DPT) and was rapidly expanded to include all 75 districts with all six recommended antigens (BCG; diphtheria, pertussis, and tetanus [DTP]; oral polio vaccine [OPV]; and measles) by 1988. In 2003, the monovalent hepatitis B (HepB) vaccine was introduced, which was later administered as a single tetravalent (DPT-HepB) injection. In 2009, a vaccination against Haemophilus influenzae type B (Hib) was introduced in phases in the country. Likewise, in 2009, the Japanese encephalitis (JE) vaccine was introduced into the routine immunization program in 16 JE-endemic districts following JE mass vaccination campaigns. All children should receive the suggested number of doses of BCG, DPT-HepB-Hib, OPV, and measles vaccines during their first year of life. Similarly, all women of childbearing age should complete five doses of TT vaccine during their reproductive life. All of the vaccines in the routine immunization schedule are provided free of cost in all public health facilities in Nepal (MOHP, 2011a; MOHP, 2011b). 150 • Child Health Universal immunization of children against the six vaccine-preventable diseases—tuberculosis, diphtheria, whooping cough, tetanus, polio, and measles—is crucial to reducing infant and child mortality. Data on differences in immunization coverage among subgroups of the population are useful for program planning and targeting resources to areas most in need. Additionally, information on immunization coverage is important for the monitoring and evaluation of the EPI. The 2011 NDHS collected information on immunization coverage for all living children born in the five years preceding the survey. According to WHO guidelines, children are considered fully immunized when they have received one dose of the vaccine against tuberculosis (BCG), three doses each of the DPT and polio vaccines, and one dose of measles vaccine. BCG is given at birth or at first clinical contact; DPT and polio require three doses at approximately 6, 10, and 14 weeks of age; and measles vaccine is given soon after 9 months of age. In the 2011 NDHS, as in previous NDHS surveys, information on immunization coverage was collected in two ways: from immunization cards shown to the interviewer and from mothers’ reports. If the cards were available, the interviewer copied the immunization dates directly onto the questionnaire. When there was no immunization card, or if a vaccine had not been recorded on the card as being administered, the respondent was asked to recall the specific vaccines given to her child. Information on vaccination coverage among children age 12-23 months is shown in Table 10.2 by source of information (i.e., vaccination record or mother’s report). This is the youngest cohort of children who have reached the age by which they should be fully immunized. Overall, 87 percent of children age 12-23 months were fully immunized by the time of the survey. With regard to specific vaccines, 97 percent of children age 12-23 months had received the BCG immunization and 88 percent had been immunized against measles. Coverage of the first dose of the DPT and polio vaccines was relatively high (96 percent and 97 percent, respectively); however, only 92 percent and 93 percent of these children went on to receive the third dose of DPT and polio, respectively, contributing to a dropout of 5 percent and 4 percent between the first and third dose of the DPT and polio vaccines, respectively. There are minimal differences between DPT and polio vaccine coverage because these vaccines are administered at the same time. The findings show that 3 percent of children 12-23 months did not receive any vaccine at all. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother’s report), and percentage vaccinated by 12 months of age, Nepal 2011 Source of information BCG DPT 11 DPT 21 DPT 31 Polio 1 Polio 2 Polio 3 Measles All basic vaccina- tions2 No vaccina- tions Number of children Vaccinated at any time before survey Vaccination card 33.7 33.8 33.6 32.5 33.8 33.6 32.5 31.0 30.7 0.0 339 Mother’s report 62.8 62.6 61.0 59.2 62.7 61.3 60.0 57.0 56.3 2.9 661 Either source 96.5 96.4 94.6 91.7 96.6 94.9 92.5 88.0 87.0 2.9 1,000 Vaccinated by 12 months of age3 96.5 96.4 94.5 91.4 96.6 94.8 92.1 82.3 80.7 2.9 1,000 1 DPT vaccinations include DPT/HepB as well as DPT/HepB/Hib. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccination. 10.3 VACCINATION BY BACKGROUND CHARACTERISTICS Table 10.3 shows the percentage of children age 12-23 months who received specific vaccines at any time before the survey according to background characteristics. Boys are slightly more likely than girls to be fully immunized (88 percent versus 86 percent). Birth order varies inversely with immunization coverage; as birth order increases, immunization coverage generally decreases. Ninety-one percent of first-born children have been fully immunized, compared with 60 percent of children of birth order six and above. Child Health • 151 Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report), and percentage with a vaccination card, by background characteristics, Nepal 2011 Background characteristic BCG DPT 11 DPT 21 DPT 31 Polio 1 Polio 2 Polio 3 Measles All basic vaccina- tions2 No vaccina- tions Percent- age with a vaccina- tion card seen Number of children Sex Male 96.9 96.2 94.5 92.1 96.4 95.1 92.9 89.7 88.2 2.8 37.6 501 Female 96.2 96.6 94.7 91.3 96.7 94.8 92.0 86.3 85.7 3.0 30.2 499 Birth order 1 98.8 99.1 97.7 94.2 99.0 97.6 95.4 92.3 91.1 0.8 35.4 348 2-3 96.7 96.2 94.8 92.5 96.3 95.1 93.0 89.2 88.3 3.1 34.3 469 4-5 98.5 97.6 95.0 93.9 97.6 95.0 93.9 86.2 86.2 1.5 34.5 109 6+ 81.6 83.4 78.2 71.6 85.0 80.9 73.2 63.1 59.6 14.3 23.1 74 Residence Urban 98.0 99.5 95.5 94.9 100.0 96.9 96.7 91.8 90.0 0.0 38.7 97 Rural 96.4 96.1 94.5 91.4 96.2 94.7 92.0 87.6 86.6 3.2 33.4 903 Ecological zone Mountain 93.7 93.7 90.4 90.4 94.3 91.1 91.1 90.9 88.2 4.3 25.9 75 Hill 96.3 96.5 95.4 93.4 96.3 95.7 93.5 90.4 89.5 3.2 35.1 402 Terai 97.1 96.7 94.6 90.6 97.0 94.9 91.9 85.8 84.8 2.5 34.1 523 Development region Eastern 98.1 96.9 95.1 93.8 96.9 95.1 94.1 87.9 87.7 1.6 40.7 229 Central 96.1 96.4 93.2 89.1 96.4 93.6 90.9 84.6 83.1 3.6 26.2 345 Western 97.3 97.3 97.3 94.0 97.9 97.9 94.6 91.2 91.2 2.1 40.6 187 Mid-western 91.4 91.8 90.1 87.7 92.0 90.7 87.5 87.4 84.7 6.7 28.2 138 Far-western 100.0 100.0 99.5 97.1 100.0 99.5 97.1 94.9 93.7 0.0 39.7 101 Subregion Eastern mountain 98.0 98.0 98.0 98.0 98.0 98.0 98.0 97.4 97.4 2.0 40.8 17 Central mountain (95.0) (95.0) (92.5) (92.5) (95.0) (92.5) (92.5) (92.5) (92.5) (5.0) (37.0) 17 Western mountain 91.3 91.3 86.3 86.3 92.5 87.5 87.5 87.5 82.5 5.0 15.0 41 Eastern hill 98.7 97.4 95.6 95.6 97.4 95.6 95.6 90.4 90.4 1.3 35.8 78 Central hill 97.1 98.3 95.9 94.2 98.3 97.1 95.4 92.5 89.6 1.7 46.1 94 Western hill 97.0 97.0 97.0 93.9 97.0 97.0 93.9 91.7 91.7 3.0 36.7 127 Mid-western hill 88.8 90.0 88.8 86.3 88.8 88.8 85.0 83.8 82.5 10.0 23.7 64 Far-western hill 100.0 100.0 100.0 97.0 100.0 100.0 97.0 91.8 91.8 0.0 20.9 38 Eastern terai 97.8 96.5 94.4 92.2 96.5 94.4 92.6 85.2 84.8 1.7 43.6 133 Central terai 95.7 95.7 92.2 86.8 95.7 92.2 89.0 80.9 79.8 4.3 17.5 234 Western terai 98.0 98.0 98.0 94.1 100.0 100.0 96.1 90.2 90.2 0.0 48.9 60 Mid-western terai 97.9 97.3 97.3 94.1 98.4 97.9 94.1 95.2 93.6 1.6 42.2 52 Far-western terai 100.0 100.0 100.0 97.2 100.0 100.0 97.2 96.7 93.9 0.0 63.3 44 Mother’s education No education 94.3 94.1 90.5 85.8 94.3 91.2 86.9 79.6 78.1 4.5 26.7 452 Primary 98.1 98.1 97.9 95.3 98.1 97.9 96.5 96.3 94.6 1.9 31.8 200 Some secondary 98.6 98.6 98.3 97.4 98.7 98.5 97.4 95.2 95.2 1.3 43.4 211 SLC and above 98.3 98.3 97.5 97.1 98.3 97.5 97.5 92.8 92.4 1.7 45.9 137 Wealth quintile Lowest 94.2 94.0 91.8 87.6 93.9 92.0 88.5 86.0 84.5 5.1 28.6 247 Second 97.3 96.3 93.5 89.7 96.8 94.0 90.2 85.2 83.9 2.0 27.1 227 Middle 94.4 94.4 94.4 90.5 94.4 94.4 91.6 85.2 84.0 5.6 31.8 217 Fourth 98.9 99.9 96.7 96.7 100.0 97.5 97.4 92.2 91.5 0.0 41.8 183 Highest 100.0 100.0 99.5 98.4 100.0 99.5 98.8 96.1 95.7 0.0 48.6 126 Total 96.5 96.4 94.6 91.7 96.6 94.9 92.5 88.0 87.0 2.9 33.9 1,000 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 DPT vaccinations include DPT/HepB as well as DPT/HepB/Hib. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) SLC = School Leaving Certificate Urban-rural differences in immunization coverage are small, with children residing in urban areas slightly more likely to be fully immunized (90 percent) than children in rural areas (87 percent). There are differences in coverage by ecological zone, with 85 percent of children fully immunized in the terai, compared with 90 percent in the hill zone and 88 percent in the mountain zone. Coverage ranges from a low of 83 percent among children living in the Central region to a high of 94 percent among children living in the Far-western region. Children living in the Eastern mountain subregion are most likely to be fully immunized (97 percent), and children in the Central terai subregion are least likely (80 percent). There are marked differences in immunization coverage between children of women with no education (78 percent) and children of women in the other education groups (above 90 percent). Children in households in the highest wealth quintile (96 percent) are much more likely to be fully immunized than those in lower three wealth quintiles (less than 85 percent). Table 10.3 also shows that an immunization card was seen for 34 percent of children age 12-23 months. Cards were most likely to have been seen for boys (38 percent), first-order births (35 percent), children living in urban areas (39 percent), children living in the hill zone, children living in the Western and Eastern regions (41 percent each), children living in the Far-western terai subregion (63 percent), children of mothers 152 • Child Health with a School Leaving Certificate (SLC) or higher education (46 percent), and children of mothers in the highest wealth quintile (49 percent). 10.4 TRENDS IN IMMUNIZATION COVERAGE Trends in immunization coverage over the past 15 years can be seen by comparing similarly collected data from the 1996 NFHS, 2001, 2006, and 2011 NDHS. Immunization coverage in Nepal has improved over the past 15 years, doubling from 43 percent in 1996 to 87 percent in 2011 (Figure 10.1). The percentage of children age 12-23 months who did not receive any of the six basic immunizations decreased from 20 percent to 3 percent over the same period. A marked increase in the coverage of polio vaccine was observed between 1996 and 2001, with little change thereafter. 76 54 51 57 43 20 85 72 92 71 66 1 93 89 91 85 83 3 97 92 93 88 87 3 BCG DPT 3 Polio 3 Measles All vaccines None 0 20 40 60 80 100 Percent NFHS 1996 NDHS 2001 NDHS 2006 NDHS 2011 Figure 10.1 Trends in Vaccination Coverage among Children 12-23 Months, Nepal 1996-2011 10.5 ACUTE RESPIRATORY INFECTION The Ministry of Health and Population recognizes acute respiratory infections as a major public health problem among children under age five (MOHP, 2011a). The CB-IMCI program is an integrated package that addresses the management of diseases such as pneumonia, diarrhea, malaria, and measles, as well as malnutrition, among children age 2 months to 5 years. The program follows WHO guidelines on standard ARI case management. Accordingly, all ARI cases assessed by health workers are classified into one of the following categories: severe or very severe pneumonia, pneumonia, or no pneumonia (cough and cold). The program recognizes the important role of mothers and other caretakers in identifying the difference between the need for home care in the case of cough and cold symptoms that do not result in pneumonia and the need for referral to health facilities in the case of severe pneumonia. Child Health • 153 ARIs are a leading cause of childhood morbidity and mortality in Nepal. Early diagnosis and treatment with antibiotics can reduce the number of deaths caused by ARIs, particularly deaths resulting from pneumonia. Pneumonia has emerged as the leading cause of death among children under age five in Nepal (MOHP, New ERA, and Macro International Inc., 2007). In 1995, a community-based ARI intervention program was initiated, with assistance from WHO, UNICEF, and USAID, to increase accessibility to care and reduce mortality resulting from pneumonia. Under this program, female community health volunteers (FCHVs) are trained to diagnose pneumonia and to treat infected children at the ward level with the antibiotic (paediatric cotrimoxazole). In the 2011 NDHS, the prevalence of ARI symptoms was estimated by asking mothers whether, in the two weeks preceding the survey, their children under age five had been ill with a cough accompanied by short, rapid breathing and difficulty breathing as a result of a problem in the chest. These symptoms are consistent with conditions leading to pneumonia. It should be noted that the data collected on ARI symptoms are subjective because they are based on a mother’s perception of the illness without validation by medical personnel. Table 10.4 shows that 5 percent of children under five years of age exhibited symptoms of ARI in the two weeks preceding the survey. Prevalence of ARI symptoms varied by age of the child. Children age 6-23 months were more likely to have symptoms of ARI (8 percent) than children in the other age groups. Children from the hill zone and the Western development region were most likely to exhibit symptoms of ARI. Symptoms were least likely to be reported for children in the highest wealth quintile (2 percent), with little difference among children in the other wealth quintiles (about 5 percent). Half of children with symptoms of ARI were taken to a health facility or health provider. Seven percent of children with ARI symptoms received antibiotics. Due to the small number of cases, these data are not shown by background characteristics. There has been an increase in the past 15 years in the proportion of cases in which treatment is sought from a health facility for symptoms of pneumonia (from 18 percent in 1996 to 50 percent in 2011). 10.6 FEVER Fever is a major manifestation of malaria and other acute infections in children. Malaria and fever contribute to high levels of malnutrition and morbidity. While fever can occur year-round, malaria is more prevalent following the end of the rainy season, particularly in the terai, inner terai, and basins of the hill districts of Nepal, where the climatic conditions are more favorable to malaria transmission. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Since malaria is a major contributory cause of death in infancy and childhood in many developing countries, presumptive treatment of fever with antimalarial medication is advocated in many countries where malaria is endemic. The 2011 NDHS fieldwork was carried out from February to mid-June 2011, before and during the rainy season. Table 10.4 Prevalence of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, according to background characteristics, Nepal 2011 Background characteristic Among children under age five: Percentage with symptoms of ARI1 Number of children Age in months <6 3.9 531 6-11 7.5 491 12-23 7.9 1,000 24-35 4.1 1,013 36-47 3.6 1,106 48-59 2.1 999 Sex Male 4.6 2,649 Female 4.7 2,490 Mother’s smoking status Smokes cigarettes/tobacco 4.6 450 Does not smoke 4.6 4,690 Cooking fuel Electricity or gas 3.5 764 Wood/straw2 4.9 4,009 Animal dung 3.5 332 Residence Urban 4.9 483 Rural 4.6 4,656 Ecological zone Mountain 3.1 400 Hill 5.2 2,033 Terai 4.4 2,707 Development region Eastern 3.6 1,210 Central 3.6 1,639 Western 6.5 965 Mid-western 5.7 760 Far-western 5.5 565 Mother’s education No education 4.4 2,410 Primary 5.0 1,032 Some secondary 5.2 995 SLC and above 4.1 703 Wealth quintile Lowest 4.7 1,322 Second 4.7 1,121 Middle 5.4 1,071 Fourth 5.6 899 Highest 2.1 726 Total 4.6 5,140 Note: Total includes 19 children living in households using kerosene, 14 children living in households using coal/lignite/ charcoal, and 1 child living in a household where no food is cooked who are not shown separately. 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related and/or by difficult breathing that is chest-related) are considered a proxy for pneumonia. 2 Includes grass, shrubs, and crop residues SLC = School Leaving Certificate 154 • Child Health Table 10.5 shows the percentage of children under five with fever during the two weeks preceding the survey and the percentage receiving various treatments, by selected background characteristics. Nineteen percent of children under five were reported to have had fever in the two weeks preceding the survey. Fever prevalence varied by age of the child. Children age 6-23 months were more prone to have fever (24-30 percent) than other children. Table 10.5 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who received antibiotics as treatment, by background characteristics, Nepal 2011 Background characteristic Among children under age five: Among children under age five with fever: Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 17.1 531 34.2 1.8 29.4 91 6-11 29.7 491 45.9 0.0 34.4 146 12-23 24.2 1,000 46.2 1.5 38.1 242 24-35 19.3 1,013 39.4 0.0 28.8 195 36-47 15.0 1,106 40.1 0.0 30.7 166 48-59 11.9 999 40.8 0.0 23.0 119 Sex Male 20.5 2,649 42.5 0.9 32.1 543 Female 16.7 2,490 41.1 0.1 31.1 417 Residence Urban 18.9 483 55.6 0.6 41.2 91 Rural 18.7 4,656 40.5 0.6 30.6 869 Ecological zone Mountain 14.7 400 43.0 0.0 27.6 59 Hill 17.0 2,033 37.5 0.2 31.0 345 Terai 20.6 2,707 44.5 0.8 32.5 557 Development region Eastern 17.8 1,210 50.7 0.3 26.9 216 Central 18.6 1,639 35.3 0.0 34.6 305 Western 23.3 965 37.9 1.0 36.1 225 Mid-western 16.1 760 44.8 2.0 32.8 122 Far-western 16.2 565 49.1 0.0 20.5 91 Subregion Eastern mountain 12.5 96 (71.4) (0.0) (21.8) 12 Central mountain 20.9 92 (44.4) (0.0) (41.4) 19 Western mountain 12.9 212 29.6 0.0 20.4 27 Eastern hill 17.7 394 37.5 0.0 24.3 70 Central hill 15.7 477 37.4 0.0 34.4 75 Western hill 21.2 576 40.5 0.0 35.8 122 Mid-western hill 13.5 355 32.0 1.7 33.2 48 Far-western hill 12.8 231 34.5 0.0 15.0 29 Eastern terai 18.6 720 55.7 0.4 28.7 134 Central terai 19.7 1,070 33.8 0.0 34.1 211 Western terai 26.4 390 34.8 2.3 36.4 103 Mid-western terai 19.9 291 61.9 2.9 38.1 58 Far-western terai 21.4 237 59.4 0.0 21.3 51 Mother’s education No education 16.9 2,410 33.4 0.9 27.6 407 Primary 18.4 1,032 43.4 0.0 27.7 190 Some secondary 23.5 995 53.7 0.0 39.0 233 SLC and above 18.4 703 45.3 1.3 37.0 129 Wealth quintile Lowest 13.4 1,322 29.8 0.3 22.5 177 Second 19.4 1,121 38.2 0.4 30.0 217 Middle 20.8 1,071 44.7 1.1 28.2 223 Fourth 23.7 899 50.1 0.8 45.2 213 Highest 18.0 726 46.4 0.0 30.6 131 Total 18.7 5,140 41.9 0.6 31.6 960 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner SLC = School Leaving Certificate Child Health • 155 Fever is more prevalent among male children (21 percent) than female children (17 percent). In addition, the prevalence of fever is higher among children residing in the terai and hill zone than among children in the mountain zone, and this is particularly true in the Western region and Western terai subregion. Fever prevalence is highest among children of mothers with some secondary education and children living in households in the fourth wealth quintile. Forty-two percent of children with fever were taken to a health facility or provider for treatment. Children age 6-23 months, male children, and children of mothers with some secondary education were more likely than other children to be taken to a health facility or provider for treatment of fever. Also, children living in urban areas, in the terai and mountain zones, in the Eastern development region, and in the Mid-western terai were more likely than children living elsewhere to be taken for treatment. The percentage of children with fever taken to a health facility or provider varied significantly by wealth quintile; children from the poorest households were least likely to be taken for treatment, and children from the fourth wealth quintile were most likely. Table 10.5 also shows that 32 percent of children with fever received antibiotics. Children age 12-23 months, children residing in urban areas, and those living in the terai and hill zones, Western region, and Mid- western terai subregion were more likely than other children to receive antibiotic treatment. Furthermore, children of mothers with some secondary education and those living in households in the fourth wealth quintile were more likely to receive antibiotics for fever than their counterparts. Less than 1 percent of children received antimalarial drugs. The percentage of children with fever for whom medical care is sought from a health facility or provider has increased steadily over the past 15 years (from 18 percent in 1996 to 24 percent in 2001, 34 percent in 2006, and 42 percent in 2011). 10.7 DIARRHEA Diarrhea continues to be a major cause of childhood morbidity and mortality in Nepal (MOHP, 2011a). The 2006 NDHS showed that 12 percent of children under five years suffer from diarrhea, and 5 percent die due to the condition (MOHP, New ERA, and Macro International, 2007). The 2011 NDHS asked mothers of children born during the five years preceding the survey a series of questions about episodes of diarrhea suffered by their children in the two weeks before the survey, including questions on feeding practices during diarrhea, treatment of the condition, and their knowledge and use of ORS. Table 10.6 shows the percentage of children under five years with diarrhea in the two weeks preceding the survey, by selected background characteristics. Overall, 14 percent of all children under five had diarrhea, with 2 percent having diarrhea with blood. As there are seasonal variations in the prevalence of diarrhea, the percentages shown in Table 10.6 may not reflect the situation throughout the year. It is noteworthy to point out that the 2011 NDHS was fielded from February to June, whereas the period of high diarrhea prevalence is April to August. Thus, the prevalence of diarrhea may be understated since the survey did not cover the entire duration of the high prevalence period. Children age 6-23 months are most susceptible to diarrhea. The prevalence of bloody diarrhea is highest among children age 12-23 months, and children living in the Mid- western region, particularly the Mid-western terai. Children of mothers with an SLC and higher and those in the highest wealth quintile are less likely than others to suffer from diarrhea. The prevalence of diarrhea is higher among children living in households with non-improved toilet facilities than in households with improved toilet facilities that are not shared. 156 • Child Health Table 10.6 Prevalence of diarrhea Percentage of children under age five who had diarrhea in the two weeks preceding the survey, by background characteristics, Nepal 2011 Background characteristic Diarrhea in the two weeks preceding the survey Number of children All diarrhea Diarrhea with blood Age in months <6 12.9 0.8 531 6-11 24.1 1.2 491 12-23 23.9 5.0 1,000 24-35 14.2 2.0 1,013 36-47 8.2 1.3 1,106 48-59 5.2 1.2 999 Sex Male 15.5 2.5 2,649 Female 12.0 1.7 2,490 Source of drinking water1 Improved 13.9 1.9 4,442 Not improved 13.2 3.0 698 Toilet facility2 Improved, not shared 12.2 1.7 1,557 Non-improved or shared 14.6 2.2 3,583 Residence Urban 13.4 1.6 483 Rural 13.9 2.1 4,656 Ecological zone Mountain 13.4 2.9 400 Hill 12.7 2.1 2,033 Terai 14.8 1.9 2,707 Development region Eastern 11.6 1.1 1,210 Central 14.9 1.6 1,639 Western 15.7 2.2 965 Mid-western 14.6 4.2 760 Far-western 11.4 2.5 565 Subregion Eastern mountain 10.8 1.5 96 Central mountain 12.8 2.9 92 Western mountain 14.9 3.6 212 Eastern hill 10.8 1.6 394 Central hill 11.2 1.2 477 Western hill 14.1 1.9 576 Mid-western hill 14.1 4.1 355 Far-western hill 13.1 2.2 231 Eastern terai 12.1 0.8 720 Central terai 16.7 1.6 1,070 Western terai 17.9 2.7 390 Mid-western terai 14.7 4.6 291 Far-western terai 8.8 2.3 237 Mother’s education No education 14.4 2.8 2,410 Primary 13.9 2.4 1,032 Some secondary 14.8 1.1 995 SLC and above 10.5 0.5 703 Wealth quintile Lowest 12.6 3.1 1,322 Second 14.4 2.5 1,121 Middle 16.9 2.1 1,071 Fourth 12.8 1.2 899 Highest 11.9 0.7 726 Total 13.8 2.1 5,140 1 See Table 2.1 for definition of categories 2 See Table 2.2 for definition of categories SLC = School Leaving Certificate 10.8 DIARRHEA TREATMENT The CB-IMCI program, under the Child Health Division, focuses on the management of diarrheal diseases among children under five years. Nepal became one of the first few countries in the region to create a zinc task force and to include zinc in the treatment protocol of diarrhea along with ORS and oral rehydration therapy (ORT) (Wang et al., 2011). USAID/Nepal, through the Nepal Family Health Project and UNICEF, supported the promotion of treatment of childhood diarrhea with both ORS/ORT and zinc. In addition, Child Health • 157 USAID/Nepal funded the global Social Marketing for Diarrheal Disease Control Plus: Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project, which was implemented by Abt Associates in partnership with Population Services International and has targeted 30 districts in Nepal (MacDonald and Mitchell, 2009). The first phase covered three districts in Kathmandu Valley, and the second phase had covered 27 additional districts by 2008. The government has a standard diarrhea case management strategy including ORT, counseling on continued feeding, and zinc tablets provided through health institutions. ORT services have been established in all hospitals, primary health care centers, health posts, and sub-health posts throughout the country. Health facilities and community health volunteers serve as the primary health providers in treating diarrhea with ORS and zinc supplementation. The national program on promotion of salt-sugar solutions as a treatment strategy was abandoned because, apart from possible difficulties in obtaining the ingredients, preparation was often imprecise and resulted in ineffective or sometimes dangerous solutions (BASICS II, The MOST Project, and USAID, 2004). ORT thus includes fluids prepared from lower osmolar ORS packets and is referred as such in this section. Caution should be exercised in comparing the 2011 NDHS results with the findings of previous NDHS surveys, in which the definition of ORT did not include increased fluids. In the 2011 NDHS, mothers of children who had diarrhea were asked about what was done to treat the illness. Table 10.7 shows the percentage of children with diarrhea who received specific treatments according to background characteristics. Thirty-eight percent of children with diarrhea were taken to a health provider. Children age 6-11 months, male children, children with bloody diarrhea, urban children, children living in the hill zone, and children living in the Far-western region were more likely than their counterparts to be taken to a health facility for treatment, as were children of mothers with some secondary education and children from households in the fourth wealth quintile. Thirty-nine percent of children were treated with ORS, 14 percent were given increased fluids, and 50 percent were given either ORS or increased fluids. Six percent were treated with zinc, and 5 percent were treated with zinc and ORS. Although not a preferred treatment, 2 percent were treated with anti-motility drugs. Thirteen percent of children with diarrhea were given antibiotic drugs, 13 percent were given other pills or syrups, 13 percent were given unknown pills or syrups, and 4 percent were treated with home remedies. However, about one-third (30 percent) of children with diarrhea did not receive any treatment at all. Use of ORS or increased fluids varies by age, from a low of 20 percent among children less than age 6 months to a high of 60 percent among children age 12-23 months. Use of ORS or increased fluids is more common among male than female children. There are differences in the use of ORS or increased fluids according to urban (55 percent) and rural (50 percent) residence and ecological zone (with the proportion ranging from 46 percent in the mountain zone to 54 percent in the hill zone). Use varies by region as well, ranging from 43 percent in the Central region to 61 percent in the Eastern region. Use of ORS or increased fluids is much higher among children of mothers with an SLC and above than among women with a primary education. Use of ORS or increased fluids ranges from a low of 44 percent among children in the middle wealth quintile to a high of 62 percent among children in the fourth wealth quintile. The proportion of children with diarrhea taken to a health provider for treatment has increased over time, from 14 percent in 1996 to 21 percent in 2001, 27 percent in 2006, and 38 percent in 2011. Twenty-four percent of children with diarrhea are taken to government health facilities, and 23 percent are taken to private pharmacies; about 3 percent are taken to an FCHV for treatment (data not shown). 158 • Child Health Table 10.7 Diarrhea treatment Among children under age five who had diarrhea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration salts (ORS), the percentage given increased fluids, the percentage given ORS or increased fluids, and the percentage who were given other treatments, by background characteristics, Nepal 2011 Background characteristic Percent- age of children with diarrhea for whom advice or treatment was sought from a health facility or provider1 Fluid from ORS packets Increased fluids ORS or increased fluids Zinc and ORS Zinc supple- ments Anti- biotic drugs Anti- motility drugs Other pill or syrup Unknown pill or syrup Non-anti- biotic injection Unknown injection Intra- venous solution Home remedy Other No treatment Number of children with diarrhea Age in months <6 32.6 5.8 13.6 19.5 0.0 1.8 6.8 1.0 17.2 3.0 0.0 0.0 0.0 1.5 7.1 53.1 68 6-11 41.6 35.2 9.3 41.5 4.6 5.7 14.9 2.6 18.1 6.9 1.9 0.7 0.0 6.4 5.8 36.3 118 12-23 40.2 48.2 17.7 60.1 6.2 6.3 14.3 2.0 16.9 15.9 0.1 4.0 0.5 3.1 4.3 20.4 239 24-35 39.2 39.9 13.0 50.7 5.2 8.1 13.4 2.4 6.5 14.5 0.0 0.0 0.0 3.9 1.6 33.6 144 36-47 31.8 39.9 9.9 54.5 8.6 8.6 10.7 0.0 6.0 19.5 0.0 0.9 0.0 2.0 9.5 23.7 90 48-59 (34.4) (45.5) (18.1) (53.2) (3.0) (3.0) (19.3) (4.5) (6.4) (6.2) (0.5) (0.0) (0.0) (3.7) (1.6) (25.1) 52 Sex Male 40.9 42.8 15.8 55.3 6.5 7.4 12.4 1.5 12.6 13.1 0.5 2.8 0.3 3.8 4.9 24.9 412 Female 34.0 34.0 11.5 42.6 3.4 4.5 14.8 2.8 13.3 12.0 0.2 0.0 0.0 3.2 4.5 36.0 299 Type of diarrhea Non-bloody 37.2 38.8 13.8 50.1 5.4 6.3 12.0 2.2 12.4 12.2 0.4 1.1 0.2 3.7 4.7 30.9 604 Bloody 42.6 40.4 15.1 49.3 4.3 5.6 21.3 1.2 15.6 15.1 0.2 4.5 0.0 3.1 4.9 22.1 107 Residence Urban 43.2 44.2 26.0 54.7 4.4 5.0 11.1 3.0 15.4 6.0 1.8 0.4 0.0 5.0 4.5 29.5 65 Rural 37.5 38.5 12.8 49.5 5.3 6.3 13.6 1.9 12.6 13.3 0.2 1.7 0.2 3.4 4.8 29.6 646 Ecological zone Mountain 35.5 35.2 19.5 46.3 5.7 6.5 9.8 0.9 23.3 6.1 0.0 0.0 0.0 2.9 3.3 32.3 54 Hill 38.6 40.3 18.8 53.8 5.9 7.1 8.8 1.3 11.7 2.8 0.7 0.3 0.0 4.2 1.6 33.6 258 Terai 38.0 38.7 10.1 48.0 4.7 5.5 16.9 2.6 12.2 19.9 0.2 2.6 0.3 3.3 6.9 26.6 400 Development region Eastern 40.0 45.4 16.5 60.7 10.3 10.3 14.1 3.7 13.0 5.0 0.0 0.0 0.0 4.6 5.7 22.9 140 Central 27.7 36.0 10.6 43.3 1.8 1.9 12.8 1.3 9.1 17.4 0.9 2.1 0.0 3.6 6.9 34.9 244 Western 42.5 29.9 12.9 43.8 3.1 4.3 14.6 2.4 10.4 18.7 0.0 1.6 0.8 3.1 1.9 33.3 151 Mid-western 43.9 45.8 18.8 57.7 8.3 9.8 14.8 1.7 21.6 6.4 0.5 2.2 0.0 4.1 4.9 22.4 111 Far-western 52.0 46.3 15.2 53.3 6.8 11.3 8.7 0.8 17.7 7.6 0.0 2.3 0.0 1.3 0.9 28.0 64 Mother’s education No education 33.9 39.3 6.0 46.5 2.1 3.0 11.0 2.0 10.3 18.0 0.1 2.4 0.3 2.9 3.3 33.1 347 Primary 37.4 30.9 14.5 46.4 8.3 10.2 18.5 2.3 17.6 6.6 0.0 1.2 0.0 1.9 5.0 33.4 144 Some secondary 49.8 46.5 20.7 54.1 9.2 9.7 13.2 1.3 13.2 8.1 1.7 1.0 0.0 5.4 7.2 21.0 147 SLC and above 35.4 38.9 37.1 65.3 5.9 5.9 15.4 3.1 14.7 7.9 0.0 0.0 0.0 6.4 6.4 22.9 74 Wealth quintile Lowest 32.7 39.3 8.3 48.3 5.6 5.7 4.2 2.1 11.2 6.5 0.1 0.5 0.0 2.8 2.4 38.7 167 Second 38.7 40.3 12.1 48.3 3.1 3.6 13.2 2.3 12.6 15.3 0.0 3.1 0.0 6.5 3.8 27.5 162 Middle 38.9 35.0 12.1 43.6 4.0 5.7 14.9 0.4 11.3 19.6 0.0 1.8 0.7 1.3 7.3 31.0 181 Fourth 44.1 45.8 17.3 61.6 9.4 11.7 18.7 2.2 17.1 12.3 1.6 1.8 0.0 2.6 6.7 18.5 116 Highest 37.1 35.7 27.7 54.1 5.4 5.4 21.3 4.6 14.4 5.5 0.8 0.3 0.0 5.8 2.7 27.8 86 Total 38.0 39.0 14.0 50.0 5.2 6.2 13.4 2.0 12.9 12.6 0.4 1.6 0.2 3.6 4.7 29.6 711 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner SLC = School Leaving Certificate The percentage of children treated with ORS increased from 29 percent in 2006 to 39 percent in 2011. Use of zinc to treat diarrhea, rare in 2006 (when less than 1 percent of children received zinc), has increased in recent years (to 6 percent in 2011). A population-based survey conducted in 2008 in the 26 POUZN target districts indicated that 15 percent of children suffering from diarrhea received zinc during their most recent episode (Wang et al., 2011). The current national coverage level of 6 percent is encouraging. 10.9 FEEDING PRACTICES DURING DIARRHEA Mothers are encouraged to continue feeding children with diarrhea normally and to increase the amount of fluids given. Table 10.8 shows that 71 percent of children who had diarrhea were given the same amount of fluid as usual, 14 percent were given more, 10 percent were given somewhat less than the usual amount, and 1 percent were given much less. Four percent of children with diarrhea were not given any liquids. Regarding the amount of food offered to children who had diarrhea, 61 percent were given the same amount of food as usual. On the other hand, 18 percent of children were given somewhat less than the usual amount of food, and 2 percent were given much less than the usual amount. Child Health • 159 Table 10.8 Feeding practices during diarrhea Percent distribution of children under age five who had diarrhea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, the percentage of children given increased fluids and continued feeding during the diarrhea episode, and the percentage of children who continued feeding and were given increased fluids during the episode of diarrhea, by background characteristics, Nepal 2011 Background characteristic Amount of liquids given Amount of food given Percentage given increased fluids and continued feeding1 Percentage who continued feeding and were given ORS and/or increased fluids1 Number of children with diarrheaMore Same as usual Some- what less Much less None Don’t know/ missing Total More Same as usual Some- what less Much less None Never gave food Don’t know/ missing Total Age in months <6 13.6 69.0 2.2 0.0 15.1 0.0 100.0 0.0 10.0 6.0 3.4 0.7 79.9 0.0 100.0 3.7 6.3 68 6-11 9.3 78.3 5.3 0.0 7.1 0.0 100.0 5.5 58.4 8.2 1.9 0.7 25.3 0.0 100.0 7.9 34.4 118 12-23 17.7 67.5 11.4 1.1 2.4 0.0 100.0 10.1 65.5 21.8 2.1 0.5 0.0 0.0 100.0 17.7 57.5 239 24-35 13.0 71.4 13.9 1.7 0.0 0.0 100.0 3.7 72.1 22.4 1.7 0.0 0.0 0.0 100.0 13.0 50.7 144 36-47 9.9 75.9 11.5 0.0 2.8 0.0 100.0 6.3 66.1 27.7 0.0 0.0 0.0 0.0 100.0 9.9 54.5 90 48-59 (18.1) (58.6) (15.1) (0.0) (0.0) (8.2) 100.0 (5.3) (71.3) (15.2) (0.0) (0.0) (0.0) (8.2) 100.0 (18.1) (53.2) 52 Sex Male 15.8 69.3 10.8 0.6 2.5 1.0 100.0 8.7 61.0 18.3 0.9 0.4 9.6 1.0 100.0 14.7 52.9 412 Female 11.5 72.6 9.5 0.8 5.6 0.0 100.0 2.9 60.6 18.5 2.7 0.3 15.0 0.0 100.0 10.2 38.1 299 Type of diarrhea Non-bloody 13.8 71.1 9.7 0.8 4.2 0.4 100.0 6.0 60.9 17.1 1.9 0.4 13.4 0.4 100.0 12.5 46.3 604 Bloody 15.1 68.2 13.6 0.0 1.3 1.8 100.0 7.8 60.4 25.9 0.5 0.0 3.6 1.8 100.0 14.6 48.8 107 Residence Urban 26.0 63.7 9.2 0.0 1.1 0.0 100.0 5.9 63.5 23.2 0.0 0.2 7.3 0.0 100.0 25.6 54.1 65 Rural 12.8 71.4 10.4 0.8 4.0 0.7 100.0 6.3 60.5 17.9 1.9 0.4 12.4 0.7 100.0 11.5 45.9 646 Ecological zone Mountain 19.5 66.9 11.6 0.0 1.9 0.0 100.0 6.8 66.7 15.2 2.5 0.8 7.9 0.0 100.0 18.0 44.6 54 Hill 18.8 66.4 12.3 0.0 1.7 0.8 100.0 7.1 63.0 22.3 0.0 0.0 6.9 0.8 100.0 18.1 53.0 258 Terai 10.1 73.9 8.8 1.3 5.3 0.6 100.0 5.6 58.6 16.4 2.7 0.5 15.6 0.6 100.0 8.6 42.8 400 Development region Eastern 16.5 71.1 8.4 0.0 2.4 1.7 100.0 6.3 64.1 15.3 1.9 0.3 10.5 1.7 100.0 16.2 60.4 140 Central 10.6 66.7 12.7 2.1 7.9 0.0 100.0 5.0 56.9 20.1 3.1 0.0 14.8 0.0 100.0 9.6 38.1 244 Western 12.9 74.4 11.1 0.0 0.3 1.3 100.0 5.1 62.7 21.0 0.0 0.8 9.1 1.3 100.0 12.9 43.1 151 Mid-western 18.8 73.2 7.0 0.0 1.0 0.0 100.0 9.6 61.5 17.0 1.7 0.8 9.4 0.0 100.0 15.9 52.5 111 Far-western 15.2 71.6 8.8 0.0 4.4 0.0 100.0 7.7 62.8 14.9 0.0 0.0 14.6 0.0 100.0 11.4 47.6 64 Mother’s education No education 6.0 74.4 12.4 1.4 5.2 0.6 100.0 3.9 61.2 19.3 1.8 0.3 12.9 0.6 100.0 5.1 43.1 347 Primary 14.5 71.3 9.1 0.0 5.1 0.0 100.0 6.1 59.4 15.3 4.0 0.6 14.6 0.0 100.0 14.3 42.4 144 Some secondary 20.7 67.1 9.6 0.0 1.0 1.6 100.0 7.2 61.3 19.9 0.0 0.3 9.7 1.6 100.0 18.9 52.2 147 SLC and above 37.1 58.8 4.1 0.0 0.0 0.0 100.0 15.8 60.7 17.1 0.0 0.0 6.4 0.0 100.0 33.7 60.7 74 Wealth quintile Lowest 8.3 71.5 15.8 0.0 3.3 1.2 100.0 5.4 61.9 17.2 0.8 0.7 12.9 1.2 100.0 7.7 46.5 167 Second 12.1 77.0 9.3 0.0 1.6 0.0 100.0 4.5 65.5 23.2 0.2 0.2 6.5 0.0 100.0 10.1 45.6 162 Middle 12.1 69.5 11.1 1.4 5.8 0.0 100.0 5.8 56.6 14.8 3.0 0.5 19.3 0.0 100.0 11.2 38.0 181 Fourth 17.3 66.7 8.0 2.2 5.9 0.0 100.0 7.4 54.4 22.1 4.3 0.1 11.6 0.0 100.0 15.1 56.4 116 Highest 27.7 64.9 2.8 0.0 1.8 2.7 100.0 10.6 67.3 14.5 0.0 0.0 4.9 2.7 100.0 27.7 54.1 86 Total 14.0 70.7 10.3 0.7 3.8 0.6 100.0 6.2 60.8 18.4 1.7 0.3 11.9 0.6 100.0 12.8 46.7 711 Note: It is recommended that children should be given more liquids to drink during diarrhea and food should not be reduced. Figures in parentheses are based on 25-49 unweighted cases. 1 Continued feeding practice includes children who were given more, same as usual, or somewhat less food during the diarrhea episode. SLC = School Leaving Certificate The practice of continuing feeding and giving ORS and/or increased fluids is recommended in the management of diarrhea. Among children suffering from diarrhea, those age 12-23 months are more likely than those in other age groups to be continually fed and given ORS and/or increased fluids during the episode. Children under six months are least likely to be given ORS and/or increased fluids and fed normally during diarrhea. There are variations in feeding practices by other background characteristics as well. Male children and children suffering from bloody diarrhea, children in urban areas, children residing in the hill zone and the Eastern region, children of mothers with an SLC and higher education, and children from the fourth wealth quintile are more likely than other children to receive ORS and/or increased fluids with continued feeding. The percentage of children with diarrhea given increased fluids and continued feeding has declined in the last five years from 20 percent to 13 percent. However, the practice of giving ORS and/or increased fluids along with continued feeding has improved over the same period, from 40 percent to 47 percent. 10.10 KNOWLEDGE OF ORS PACKETS A simple and effective response to dehydration caused by diarrhea is a prompt increase in the child’s fluid intake through some form of ORT, including the use of a solution prepared from ORS packets. To assess knowledge of ORS, mothers with a child who had suffered from diarrhea within the two weeks preceding the 160 • Child Health survey were asked about ORS packets. The commonly available brands in the country are Jeevan Jal, Nava Jeevan, and Orestal. Knowledge of ORS is universal among women giving birth in the five years preceding the survey, with 99 percent being aware of ORS packets (data not shown). 10.11 DISPOSAL OF CHILDREN’S STOOLS Unsafe disposal of human feces spreads disease, either by direct contact or through indirect transmission. Hence, the proper disposal of children’s stools is extremely important in preventing the spread of disease. Table 10.9 presents information on the disposal of stools of children less than five years of age. The stools of 41 percent of children are disposed of safely; 20 percent of children under five use a toilet or latrine, the stools of 19 percent of children are disposed of in a toilet or latrine, and the stools of 2 percent of children are buried. On the other hand, 10 percent of children’s stools are put or rinsed into a drain or ditch, 30 percent are thrown into the garbage, and 15 percent are left in the open. There is a positive relationship between both education of the mother and household wealth and the safe disposal of children’s stools. Seventy-six percent of mothers with an SLC or higher level of education dispose of their children’s stools safely, compared with only 21 percent of children of mothers with no education. Similarly, stools are disposed of in a safe manner for 85 percent of children living in households in the highest wealth quintile, as compared with only 20 percent of children living in households in the lowest wealth quintile. Safe disposal of stools increases with age of the child. Stools of children living in households in the lowest wealth quintile are most likely to be left in the open. Children’s stools are nearly two times as likely to be disposed of safely in urban areas (73 percent) as in rural areas (38 percent). In rural areas, about one-half (47 percent) of children’s stools are left in the open or thrown in the garbage, as compared with 17 percent in urban areas. Thirty-two percent of urban children use latrines, compared with 18 percent of rural children. Although the marked difference in safe disposal of children’s stools between urban and rural areas can be partially attributed to the greater access to toilet facilities in urban areas, it is notable that even in households with improved toilet facilities, children’s stools are not necessarily disposed of safely. The proportion of children whose stools are disposed of safely varies from one-third (29 percent) in the Far-western region to one-half (52 percent) in the Western region. There has been improvement in the safe disposal of children’s stools over the last 10 years. In 2001, only 18 percent of mothers disposed of their children’s stools safely, as compared with 26 percent in 2006 and 41 percent in 2011. Child Health • 161 Table 10.9 Disposal of children’s stools Percent distribution of youngest children under age five living with the mother by the manner of disposal of the child’s last fecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Nepal 2011 Background characteristic Manner of disposal of children’s stools Total Percentage of children whose stools are disposed of safely1 Number of children Child used toilet or latrine Put/rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Left in the open Other Age in months <6 0.6 16.4 2.2 27.5 34.0 7.2 12.1 100.0 19.2 530 6-11 0.7 25.7 2.3 17.9 35.7 10.0 7.7 100.0 28.7 488 12-23 3.8 28.5 3.4 8.4 38.7 12.0 5.1 100.0 35.7 952 24-35 22.0 21.1 2.5 5.3 29.8 17.2 2.2 100.0 45.5 797 36-47 38.6 11.2 2.2 3.5 22.7 19.2 2.6 100.0 52.1 756 48-59 53.1 8.5 1.2 1.1 12.6 21.3 2.2 100.0 62.8 521 Toilet facility2 Improved, not shared3 35.0 35.9 2.0 7.6 12.3 4.5 2.7 100.0 72.9 1,277 Non-improved or shared 12.3 11.7 2.6 10.5 37.7 19.4 5.9 100.0 26.5 2,765 Residence Urban 31.6 40.2 1.3 8.1 12.1 5.3 1.4 100.0 73.1 407 Rural 18.1 17.0 2.5 9.7 31.6 15.7 5.3 100.0 37.6 3,635 Ecological zone Mountain 15.3 19.8 2.1 13.8 29.2 17.6 2.3 100.0 37.2 293 Hill 24.2 23.6 2.3 7.6 20.0 14.7 7.6 100.0 50.0 1,618 Terai 16.5 16.0 2.6 10.5 37.0 14.3 3.2 100.0 35.0 2,131 Development region Eastern 19.1 27.3 3.8 8.0 25.1 12.8 3.8 100.0 50.2 968 Central 15.5 18.3 0.9 5.9 42.4 12.8 4.3 100.0 34.7 1,263 Western 30.1 19.6 1.9 10.8 18.5 8.4 10.7 100.0 51.7 795 Mid-western 17.8 13.9 3.0 12.2 25.5 24.4 3.2 100.0 34.7 584 Far-western 14.3 11.1 3.9 18.1 28.7 23.0 1.0 100.0 29.3 431 Subregion Eastern mountain 18.6 37.7 2.5 12.8 13.6 8.5 6.4 100.0 58.7 76 Central mountain 19.0 21.6 1.8 12.6 29.7 14.2 1.2 100.0 42.3 70 Western mountain 11.8 9.7 2.1 14.9 37.0 23.9 0.7 100.0 23.5 147 Eastern hill 17.2 24.0 4.8 8.2 24.0 17.5 4.3 100.0 46.1 318 Central hill 26.3 33.9 0.0 5.7 13.8 12.6 7.7 100.0 60.2 389 Western hill 32.0 24.0 1.7 5.2 18.6 5.2 13.3 100.0 57.7 474 Mid-western hill 20.3 18.4 4.4 11.0 20.2 19.6 6.0 100.0 43.2 270 Far-western hill 16.6 6.1 0.6 12.7 30.7 33.0 0.4 100.0 23.2 166 Eastern terai 20.3 27.7 3.4 7.3 27.3 10.8 3.1 100.0 51.4 574 Central terai 10.0 10.4 1.2 5.4 57.3 12.7 2.9 100.0 21.7 804 Western terai 27.4 13.2 2.2 19.2 18.2 13.1 6.7 100.0 42.8 321 Mid-western terai 16.4 10.0 1.2 13.8 27.4 30.5 0.7 100.0 27.6 235 Far-western terai 13.9 16.0 7.7 22.4 24.3 13.8 1.9 100.0 37.6 197 Mother’s education No education 11.4 7.8 2.2 9.1 43.0 22.3 4.2 100.0 21.4 1,772 Primary 20.0 16.4 2.9 11.6 25.9 16.0 7.2 100.0 39.4 809 Some secondary 29.9 26.2 2.9 10.1 19.4 6.8 4.7 100.0 59.0 846 SLC and above 27.4 46.7 1.8 7.6 10.3 2.0 4.2 100.0 76.0 615 Wealth quintile Lowest 8.8 8.1 2.6 9.3 37.4 26.7 7.0 100.0 19.6 950 Second 13.5 10.2 2.6 12.3 36.6 19.3 5.5 100.0 26.3 871 Middle 15.6 14.5 3.7 10.8 37.4 13.9 4.0 100.0 33.8 852 Fourth 28.7 26.7 2.1 9.2 22.5 6.3 4.5 100.0 57.5 731 Highest 38.0 46.3 0.4 5.1 6.3 1.3 2.5 100.0 84.7 637 Total 19.5 19.3 2.4 9.6 29.6 14.7 4.9 100.0 41.2 4,042 1 Children’s stools are considered to be disposed of safely if the child used a toilet or latrine, if the fecal matter was put/rinsed into a toilet or latrine, or if it was buried. 2 See Table 2.2 for definition of categories 3 Non-shared facilities that are of the following types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; pit latrine with a slab; and composting toilet SLC = School Leaving Certificate Nutrition of Children and Women • 163 NUTRITION OF CHILDREN AND WOMEN 11 Good nutrition is a prerequisite for the national development of countries and for the well-being of individuals. Although problems related to poor nutrition affect the entire population, women and children are especially vulnerable because of their unique physiology and socioeconomic characteristics. Adequate nutrition is critical to children’s growth and development. The period from birth to age two is especially important for optimal physical, mental, and cognitive growth, health, and development. Unfortunately, this period is often marked by protein-energy and micronutrient deficiencies that interfere with optimal growth. Childhood illnesses such as diarrhea and acute respiratory infections (ARIs) also are common. A woman’s nutritional status has important implications for her health as well as for the health of her children. Malnutrition in women results in reduced productivity, increased susceptibility to infections, slowed recovery from illness, and a heightened risk of adverse pregnancy outcomes. For example, a woman with poor nutritional status, as indicated by a low body mass index (BMI), short stature, anemia, or other micronutrient deficiencies, has a greater risk of obstructed labor, of having a baby with a low birth weight, of producing low- quality breast milk, of death from postpartum hemorrhage, and of morbidity for both herself and her baby. This chapter reviews the nutritional status of children and women in Nepal. Specific issues discussed include the nutritional status of children based on anthropometric measurements, infant and young child feeding practices based on information on initiation of breastfeeding, exclusive and continued breastfeeding status and feeding with solid or semisolid foods, diversity of foods fed and frequency of feeding, micronutrient intake among children and women, and prevalence of anemia. The discussion also covers the nutritional status of women age 15-49. In addition, relationships between the nutritional status of children and women are analyzed by various background characteristics such as education, wealth quintile, and smoking status of mothers. Key Findings: • Forty-one percent of children under five years of age are stunted, 11 percent are wasted, and 29 percent are underweight. • Breastfeeding is nearly universal in Nepal, and half of the children born in the three years before the survey were breastfed for about 34 months or longer. • Seventy percent of children less than age 6 months are exclusively breastfed, and the median duration of exclusive breastfeeding is 4.2 months. • Complementary foods are not introduced in a timely fashion for all children. Seventy percent of breastfed children have been given complementary foods by age 6-9 months. • Overall, only one-fourth of children age 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices. • Forty-six percent of children age 6-59 months are anemic, 27 percent are mildly anemic, 18 percent are moderately anemic, and less than 1 percent are severely anemic. • Eighteen percent of women are malnourished, that is, they fall below the body mass index (BMI) cutoff of 18.5. Fourteen percent of women are overweight or obese. Women’s nutritional status has improved only slightly over the years. • Thirty-five percent of women age 15-49 are anemic, 29 percent are mildly anemic, 6 percent are moderately anemic, and less than 1 percent are severely anemic. 164 • Nutrition of Children and Women 11.1 NUTRITIONAL STATUS OF CHILDREN The nutritional status of children under age 5 is an important measure of children’s health. The anthropometric data on height and weight collected in the 2011 NDHS permit the measurement and evaluation of the nutritional status of young children in Nepal. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. 11.1.1 Measurement of Nutritional Status among Young Children The 2011 NDHS collected data on the nutritional status of children by measuring the height and weight of all children under age 5 in the selected households. The data collected allow the calculation of three indices: weight-for-age, height-for-age, and weight-for-height. Indicators of the nutritional status of children were calculated using new growth standards published by the World Health Organization (WHO) in 2006. These new growth standards were generated through data collected in the WHO Multicenter Growth Reference Study (WHO, 2006). The findings of that study, which sampled 8,440 children in six countries (Brazil, Ghana, India, Norway, Oman, and the United States), describe how children should grow under optimal conditions. The WHO child growth standards can therefore be used to assess children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. The new growth standards replace the previously used NCHS/CDC/WHO reference standards. It should be noted that the new WHO child growth standards are not comparable with those based on the previously used NCHS/CDC/WHO standards. When the new WHO child growth standards are used instead of the previous reference, several changes are evident (WHO, 2006): • The level of stunting is higher. • The level of wasting in infancy is substantially higher. • The level of underweight is substantially higher during the first half of infancy (0-6 months) and decreases thereafter. • The level of overweight/obesity is higher. The three indices are expressed in standard deviation units from the Multicenter Growth Reference Study median. Anthropometry is one of the most important indicators of children’s nutritional status. The height-for-age index provides an indicator of linear growth retardation and cumulative growth deficits in children. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the WHO reference population are considered short for their age (stunted), or chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children with Z-scores below minus two standard deviations (-2 SD) are considered thin (wasted) or acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children with a weight-for-height index below minus three standard deviations (-3 SD) are considered severely wasted. Nutrition of Children and Women • 165 The weight-for-height index also provides data on overweight and obesity. Children more than two standard deviations (+2 SD) above the median weight-for-height are considered overweight or obese. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both chronic and acute malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) are considered severely underweight. 11.1.2 Data Collection Measurements of height and weight were obtained for all children born in the five years preceding the survey in the subsample of households selected for the male survey and listed in the Household Questionnaire. Children who were not biological children of the women interviewed in the survey were included. Each team of interviewers carried a scale and measuring board. Measurements were made using lightweight SECA scales (with digital screens) designed and manufactured under the authority of the United Nations Children’s Fund (UNICEF). The measuring boards employed were specially produced by Shorr Productions for use in survey settings. Children under age 2 or less than 85 cm were measured lying down on the board (recumbent length), and standing height was measured for all other children. 11.1.3 Measures of Child Nutrition Status Height-for-age Table 11.1 presents the nutritional status of children under age 5 by various background characteristics. Nationally, 41 percent of children under age 5 are stunted, and 16 percent are severely stunted. Analysis by age group shows that stunting is highest (53 percent) in children age 36-47 months and lowest (14 percent) in children age 9-11 months (Figure 11.1). Severe stunting shows a similar pattern, with the highest proportion of severe stunting in children age 36-47 months (23 percent) and the lowest in those age 6-11 months (4 percent). Stunting is slightly higher in male children (41 percent) than in female children (40 percent). There is an inverted U-shaped relationship between the length of the preceding birth interval and the proportion of children who are stunted, with stunting being higher among children born within 24 to 47 months of a previous birth than among first births and births 48 or more months after a previous birth. More than half of children whose size at birth was very small or small are stunted. Mothers’ nutritional status, as measured by their body mass index, also has an impact on the level of stunting in their children. For example, mothers who are thin (BMI < 18.5) have children with the highest levels of stunting (47 percent), while mothers who are overweight/obese (BMI ≥ 25) have children with the lowest levels (27 percent). Children in rural areas are more likely to be stunted (42 percent) than those in urban areas (27 percent), and a similar pattern is noted for severe stunting (17 percent in rural areas and 6 percent in urban areas). Ecologically, the highest proportion of stunted children (53 percent) is found in the mountain zone. Among the development regions, stunting is highest among children in the Mid-western region (50 percent). Three-fifths (60 percent) of children in the Western mountain subregion are stunted, compared with one-third of children in the Central hill, Eastern terai, and Far-western terai subregions (31-32 percent each). A mother’s level of education generally has an inverse relationship with stunting levels, ranging from a low of 26 percent among children whose mothers have a School Leaving Certificate (SLC) or higher education to a high of 48 percent among those whose mothers have no education. A similar inverse relationship is observed between household wealth and stunting levels. Children in the poorest households are more than twice as likely to be stunted (56 percent) as children in the wealthiest households (26 percent). Similarly, children in households with food security (33 percent) are less likely to be stunted than children in households with mild food insecurity (41 percent), moderate food insecurity (46 percent), and severe food insecurity (49 percent). 166 • Nutrition of Children and Women Weight-for-height Table 11.1 also shows the nutritional status of children less than age 5 as measured by weight-for- height. Overall, 11 percent of children are wasted and 3 percent are severely wasted. Analysis by age group shows that wasting is highest (25 percent) in children age 9-11 months and lowest (7 percent) in children age 36-47 months. Male children are more likely to be wasted (12 percent) than female children (10 percent). Wasting is not strongly correlated with the length of the preceding birth interval. However, the data show a substantial correlation between wasting and birth weight. Babies who were very small at birth are more likely to be wasted (15 percent) than those whose weight at birth was average or large (10 percent). Children born to mothers who are thin (BMI < 18.5) are 2.5 times more likely to be wasted than those born to mothers who are overweight/obese (BMI ≥ 25). Children residing in urban areas are less likely to be wasted (8 percent) than children in rural areas (11 percent). Wasting in children does not vary markedly by ecological zone or development region. However, wasting levels across subregions are substantial, ranging from a low of 8 percent among children in the Eastern and Central mountain, Western and Mid-western hill, and Far-western terai subregions to a high of 15 percent among children in the Central hill and Western terai subregions. Table 11.1 Nutritional status of children Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Nepal 2011 Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children Percentage below -3 SD Percentage below -2 SD2 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD2 Percentage above +2 SD Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD2 Percentage above +2 SD Mean Z-score (SD) Age in months <6 7.5 19.4 -0.8 5.3 11.8 5.7 -0.5 7.3 18.2 0.1 -1.0 227 6-8 4.3 17.7 -0.7 3.0 16.7 1.2 -0.7 5.3 18.5 2.0 -1.0 135 9-11 4.1 13.6 -1.0 6.4 24.7 3.5 -1.1 4.3 26.8 0.0 -1.3 110 12-17 13.2 28.6 -1.4 3.7 14.2 0.4 -0.9 6.1 24.9 0.0 -1.3 266 18-23 16.2 42.2 -1.7 4.5 19.4 0.6 -0.9 10.3 37.0 0.0 -1.5 221 24-35 20.2 51.7 -2.0 1.2 7.4 1.5 -0.5 7.9 30.5 0.3 -1.5 500 36-47 22.9 53.0 -2.1 1.1 7.2 0.5 -0.5 8.6 30.4 0.1 -1.6 524 48-59 16.6 43.4 -1.8 2.1 7.8 0.7 -0.6 7.9 32.0 0.4 -1.5 492 Sex Male 16.7 41.4 -1.7 3.4 12.0 1.3 -0.7 8.2 29.6 0.3 -1.5 1,268 Female 15.7 39.5 -1.6 1.8 9.7 1.5 -0.6 7.2 28.0 0.3 -1.4 1,207 Birth interval in months3 First birth4 12.6 35.0 -1.5 2.1 9.4 2.1 -0.5 4.5 23.2 0.3 -1.2 940 <24 24.4 47.3 -2.0 3.4 13.5 0.7 -0.8 13.3 35.9 0.0 -1.7 321 24-47 18.3 46.3 -1.8 2.5 11.3 0.9 -0.8 9.9 34.0 0.2 -1.6 725 48+ 13.0 36.5 -1.6 2.8 11.8 1.5 -0.6 6.4 25.6 0.4 -1.4 393 Size at birth3 Very small 20.8 50.6 -2.0 1.4 15.4 1.3 -1.0 12.7 42.8 0.0 -1.9 93 Small 21.6 50.8 -2.0 5.1 13.7 0.3 -0.9 13.1 44.6 0.0 -1.8 329 Average or larger 14.7 38.1 -1.6 2.2 10.2 1.6 -0.6 6.4 25.2 0.3 -1.3 1,952 Mother’s interview status Interviewed 16.0 40.3 -1.7 2.5 10.9 1.4 -0.7 7.6 28.6 0.3 -1.4 2,379 Not interviewed but in household (26.9) (37.4) (-1.6) (7.1) (11.9) (0.0) (-0.8) (6.3) (43.3) (0.0) (-1.5) 35 Not interviewed and not in household5 19.5 48.9 -1.9 4.1 10.4 0.9 -0.5 11.8 28.7 1.6 -1.4 62 Mother’s nutritional status6 Thin (BMI < 18.5) 18.6 47.0 -1.9 4.7 18.9 0.5 -1.1 12.7 40.1 0.0 -1.8 465 Normal (BMI 18.5-24.9) 16.2 40.0 -1.7 2.0 9.2 1.2 -0.6 6.8 27.5 0.2 -1.4 1,704 Overweight/ obese (BMI ≥ 25) 8.1 27.2 -1.1 2.1 7.0 4.9 -0.2 1.7 12.6 1.5 -0.8 224 Residence Urban 6.2 26.7 -1.2 2.7 8.2 1.8 -0.5 4.0 16.5 0.6 -1.0 216 Rural 17.2 41.8 -1.7 2.6 11.2 1.4 -0.7 8.1 30.0 0.3 -1.5 2,259 Ecological zone Mountain 22.2 52.9 -2.1 3.2 10.9 0.5 -0.7 9.9 35.9 0.2 -1.7 195 Hill 16.7 42.1 -1.7 1.7 10.6 1.6 -0.6 7.1 26.6 0.3 -1.4 989 Terai 14.9 37.4 -1.6 3.2 11.2 1.4 -0.7 7.8 29.5 0.3 -1.4 1,291 Development region Eastern 13.1 37.0 -1.6 1.8 10.2 2.1 -0.6 5.6 25.4 0.2 -1.4 596 Central 16.8 38.2 -1.6 3.1 11.6 0.9 -0.7 8.9 29.5 0.5 -1.4 767 Western 14.5 37.4 -1.6 2.5 10.4 1.9 -0.5 5.3 23.2 0.5 -1.3 463 Mid-western 21.1 50.3 -2.0 2.8 11.3 1.0 -0.7 10.7 36.9 0.0 -1.7 373 Far-western 17.5 46.4 -1.8 3.2 10.9 1.2 -0.8 8.7 32.6 0.1 -1.6 277 Subregion Eastern mountain 16.3 45.0 -1.7 0.7 8.4 0.0 -0.5 4.9 23.5 0.0 -1.3 46 Central mountain 14.2 45.5 -1.9 2.8 7.9 0.0 -0.7 7.6 34.7 0.9 -1.6 44 Western mountain 28.3 59.5 -2.3 4.4 13.2 1.0 -0.8 13.2 42.0 0.0 -1.9 105 Eastern hill 17.2 45.5 -1.8 1.3 10.5 1.6 -0.5 5.8 28.6 0.0 -1.4 191 Central hill 11.2 31.3 -1.4 2.7 15.0 1.9 -0.6 5.1 22.5 1.5 -1.2 216 Western hill 12.6 36.0 -1.5 1.0 7.6 2.1 -0.4 3.8 16.8 0.0 -1.1 294 Mid-western hill 23.4 51.7 -2.1 1.9 8.0 1.4 -0.6 11.5 37.1 0.0 -1.6 171 Far-western hill 26.9 57.5 -2.2 2.5 13.7 0.0 -0.9 14.9 39.7 0.0 -1.9 117 Eastern terai 10.5 31.4 -1.4 2.2 10.3 2.5 -0.7 5.6 24.0 0.3 -1.3 359 Central terai 19.5 40.5 -1.7 3.2 10.4 0.5 -0.7 10.7 32.0 0.0 -1.4 507 Western terai 17.8 39.9 -1.7 5.1 15.2 1.4 -0.7 8.1 34.4 1.4 -1.5 169 Mid-western terai 14.1 43.5 -1.7 3.4 13.9 0.6 -0.9 7.5 32.1 0.0 -1.6 142 Far-western terai 4.9 31.5 -1.3 3.4 7.9 2.4 -0.7 2.4 24.7 0.2 -1.2 115 Continued… Nutrition of Children and Women • 167 Table 11.1—Continued Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children Percentage below -3 SD Percentage below -2 SD2 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD2 Percentage above +2 SD Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD2 Percentage above +2 SD Mean Z-score (SD) Mother’s education7 No education 22.2 47.6 -2.0 3.1 13.3 0.6 -0.8 11.6 38.4 0.0 -1.7 1,148 Primary 13.3 40.6 -1.6 3.1 11.3 1.1 -0.6 6.3 26.1 0.0 -1.4 479 Some secondary 9.8 32.0 -1.4 1.0 5.5 3.6 -0.4 2.4 18.8 1.2 -1.1 466 SLC and above 7.7 25.6 -1.0 2.2 9.7 1.5 -0.4 2.8 13.3 0.2 -0.9 321 Wealth quintile Lowest 25.2 56.0 -2.1 2.3 12.5 1.6 -0.7 10.5 40.3 0.0 -1.7 638 Second 20.0 45.7 -1.9 2.3 10.7 0.4 -0.8 8.7 31.6 0.0 -1.7 508 Middle 12.9 34.5 -1.5 3.0 12.8 1.6 -0.8 8.2 28.8 0.1 -1.4 580 Fourth 10.2 30.5 -1.4 3.5 8.8 1.5 -0.6 6.1 22.9 0.4 -1.2 419 Highest 6.5 25.8 -1.1 2.0 7.4 2.2 -0.3 2.0 10.0 1.6 -0.8 331 Household food insecurity Secure 12.1 33.2 -1.4 2.0 9.4 1.8 -0.6 5.3 21.7 0.5 -1.2 1,057 Mildly insecure 15.5 41.2 -1.7 4.7 11.6 0.7 -0.6 9.4 27.9 0.5 -1.4 304 Moderate 18.7 45.5 -1.8 3.4 12.7 1.1 -0.8 8.6 32.3 0.0 -1.6 575 Severe 22.0 49.0 -1.9 1.9 11.5 1.3 -0.7 10.5 39.5 0.0 -1.7 540 Total 16.2 40.5 -1.7 2.6 10.9 1.4 -0.7 7.7 28.8 0.3 -1.4 2,475 Note: Table is based on children who stayed in the household on the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Figures in parentheses are based on 25-49 unweighted cases. Total includes four children with missing information on size at birth. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. 1 Recumbent length is measured for children under age 2 and in a few cases when the age of the child is unknown and the child is less than 85 cm; standing height is measured for all other children. 2 Includes children who are below -3 standard deviations from the WHO Child Growth Standards population median 3 Excludes children whose mothers were not interviewed 4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 5 Includes children whose mothers are deceased 6 Excludes children whose mothers were not weighed and measured. Mother’s nutritional status in terms of BMI (body mass index) is presented in Table 11.10. 7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. SLC = School Leaving Certificate 1 Figure 11.1 Nutritional Status of Children by Age Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a five-month moving average. # # ## #### ## ######## ## ## ######## ########### # ### # ## ### ####### # # ) )) ))))) )) ) )) )) ) )) )) )))))))))))))))))))) )) )))))))))))))) )))) 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Age (months) 0 10 20 30 40 50 60 70 Percent Stunted Wasted Underweight) # NDHS 2011 A mother’s level of education generally has an inverse relationship with wasting levels, ranging from 6-10 percent of children of mothers with at least some secondary education to 13 percent of children of mothers with no education. A similar relationship is observed between household wealth and wasting levels. 168 • Nutrition of Children and Women Weight-for-age As shown in Table 11.1, 29 percent of children under age 5 are underweight (low weight-for-age), and 8 percent are severely underweight. The proportion of underweight children is highest (37 percent) among those age 18-23 months and lowest (18 percent) among those under 6 months. Male children are slightly more likely to be underweight (30 percent) than female children (28 percent). The data show a strong correlation between underweight children and birth weight. Babies perceived by mothers as very small and small at birth are much more likely to also be underweight later in life (43 percent and 45 percent, respectively) than those perceived as average or large at birth (25 percent). Children born to mothers who are thin (BMI < 18.5) are three times more likely to be underweight (40 percent) than children born to mothers who are overweight/obese (13 percent). Rural children are more likely to be underweight (30 percent) than urban children (17 percent). Children living in the mountain zone are more likely to be underweight (36 percent) than those in the terai (30 percent) and hill zone (27 percent). The Mid-western region has the highest percentage of underweight children (37 percent), while the Western region has the lowest (23 percent). Among the subregions, the highest percentage of underweight children is found in the Western mountain subregion (42 percent), and the lowest percentage is found in the Western hill subregion (17 percent). As with wasting and stunting, mother’s education is associated with underweight, with the percentage of children who are underweight being lowest among children of mothers with an SLC and higher (13 percent) and highest among children of mothers with no education (38 percent). A similar inverse relationship is observed between household wealth and the percentage of underweight children: children in the poorest households are four times as likely to be underweight (40 percent) as children in the wealthiest households (10 percent). 11.1.4 Trends in Children’s Nutritional Status Trends in the nutritional status of children for the period 2001 to 2011 are shown in Figure 11.2. For the purpose of assessing trends, the data from the 2001 NDHS were recalculated using the WHO child growth standards adopted in 2006, as both the 2006 NDHS and 2011 NDHS are based on this reference population. In general, the nutritional status of children in Nepal has improved over the past 15 years and is close to achieving the Millennium Development Goal (MDG) target of reducing the percentage of underweight children age 6-59 months to 29 percent by 2015 (National Planning Commission, 2010a). Figure 11.2 shows a downward trend in stunting and underweight over time. The percentage of stunted children declined by 14 percent between 2001 and 2006 and declined by an additional 16 percent between 2006 and 2011. A similar pattern is observed for the percentage of underweight children, which dropped by 9 percent between 2001 and 2006 and by 26 percent between 2006 and 2011. Similarly, the percentage of wasting declined by 15 percent between 2006 and 2011. Nutrition of Children and Women • 169 Figure 11.2 Trends in Nutritional Status of Children under Five Years 57 11 43 49 13 3941 11 29 Stunting Wasting Underweight 0 10 20 30 40 50 60 70 Percent 2001 NDHS 2006 NDHS 2011 NDHS 11.2 BREASTFEEDING AND COMPLEMENTARY FEEDING Feeding practices play a critical role in child development. Poor feeding practices can adversely impact the health and nutritional status of children, which in turn has dire consequences for their mental and physical development. The duration and intensity of breastfeeding also affect a mother’s period of postpartum infertility and, hence, the length of the birth interval and fertility levels. 11.2.1 Initiation of Breastfeeding Early initiation of breastfeeding is important for both the mother and the child. Early suckling stimulates the release of prolactin, which helps in the production of milk, and oxytocin, which is responsible for the ejection of milk. It also stimulates contraction of the uterus after childbirth and reduces postpartum blood loss. The first liquid to come from the breast, known as colostrum, is produced in the first few days after delivery. Colostrum is highly nutritious and contains antibodies that provide natural immunity to the infant. It is recommended that children be fed colostrum immediately after birth (within one hour) and that they continue to be exclusively breastfed even if the regular breast milk has not yet started to flow. Table 11.2 shows the percentage of last-born children born in the two years preceding the survey according to whether they were ever breastfed, when they began breastfeeding, and whether they were fed anything other than breast milk prior to the commencement of breastfeeding. Ninety-eight percent of children have been breastfed at some time, with negligible differences by background characteristics. Less than half of children (45 percent) are breastfed within one hour of birth. The vast majority (85 percent) of children are breastfed within one day of birth. Results from the 2006 NDHS showed that 35 percent of last-born children who were breastfed in the five years preceding the survey were breastfed within one hour of birth.1 Initiation of breastfeeding within one hour and within one day of birth varies by background characteristics. 1 These figures should be compared with caution given that the 2006 NDHS accounted for last-born children in the five years preceding the survey and that, rather than being calculated among all last-born children (as in the 2011 NDHS), initiation of breastfeeding within one hour and one day of birth was calculated among children who had ever been breastfed. 170 • Nutrition of Children and Women Table 11.2 Initial breastfeeding Among last-born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth; and among last-born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, Nepal 2011 Background characteristic Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within one hour of birth Percentage who started breastfeeding within one day of birth1 Number of last- born children Percentage who received a prelacteal feed2 Number of last- born children ever breastfed Sex Male 98.1 44.5 86.8 1,027 26.4 1,007 Female 98.3 44.6 83.7 1,004 29.8 986 Assistance at delivery Skilled provider3 98.5 55.7 87.4 880 24.1 867 Other health worker4 96.6 36.0 76.8 125 35.9 121 Traditional birth attendant 96.8 27.6 74.5 197 54.9 190 Other 98.2 39.2 87.1 775 25.5 761 No one 100.0 20.4 82.2 54 15.7 54 Place of delivery Health facility 98.5 55.7 87.3 888 23.5 875 At home 98.2 36.2 83.9 1,095 31.8 1,075 Other (90.6) (29.0) (78.8) 47 (29.0) 43 Residence Urban 97.6 50.8 86.0 189 27.8 184 Rural 98.2 43.9 85.2 1,842 28.1 1,809 Ecological zone Mountain 98.0 51.3 90.3 166 17.4 163 Hill 98.6 47.1 91.1 785 18.2 774 Terai 97.9 41.6 80.2 1,079 37.0 1,056 Development region Eastern 98.7 48.4 91.8 468 21.7 462 Central 97.2 34.3 71.8 658 41.2 640 Western 97.9 49.8 92.0 398 29.8 390 Mid-western 99.4 46.8 87.9 291 21.7 289 Far-western 98.9 54.6 95.9 215 7.9 212 Subregion Eastern mountain 96.5 52.5 93.6 39 14.9 38 Central mountain 98.9 42.8 92.0 36 19.3 36 Western mountain 98.3 54.2 88.3 91 17.6 89 Eastern hill 98.7 50.2 91.0 152 17.5 150 Central hill 98.7 40.3 87.9 177 16.9 175 Western hill 97.6 48.4 92.6 240 23.5 234 Mid-western hill 99.4 46.0 88.4 131 21.4 130 Far-western hill 99.7 53.6 97.7 85 2.8 84 Eastern terai 99.0 46.8 91.9 277 25.0 274 Central terai 96.5 31.3 63.8 445 53.0 429 Western terai 98.3 51.9 91.2 159 39.2 156 Mid-western terai 100.0 45.6 90.2 111 20.8 111 Far-western terai 98.0 54.3 93.8 88 12.0 86 Mother’s education No education 97.7 34.7 78.3 862 35.1 842 Primary 98.9 44.5 92.0 392 17.8 388 Some secondary 98.7 57.6 92.6 429 22.6 424 SLC and above 97.8 52.8 85.8 347 29.4 340 Wealth quintile Lowest 99.3 40.2 86.9 489 19.9 486 Second 97.7 38.7 83.6 428 29.0 418 Middle 96.6 44.1 81.0 469 37.1 453 Fourth 98.6 52.3 89.0 370 25.3 365 Highest 99.0 51.8 87.1 274 30.0 272 Total 98.2 44.5 85.2 2,030 28.1 1,993 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children were living or dead at the time of the interview. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse, or midwife 4 Health assistant/auxiliary health worker or maternal and child health worker/village health worker SLC = School Leaving Certificate Breastfeeding within one hour of birth was more common in urban areas (51 percent) than in rural areas (44 percent). Notable variations can be seen by region. Fifty-five percent of children in the Far-western region were breastfed within one hour of birth, compared with 34 percent of children in the Central region. Initiation of breastfeeding within one hour of birth was highest in the Western mountain, Far-western hill, and Far-western terai subregions (54 percent each). Children born in a health facility were more likely to start breastfeeding within one hour of birth (56 percent) than children delivered at home (36 percent). Fifty-eight percent of children born to mothers with some secondary education started breastfeeding within one hour of Nutrition of Children and Women • 171 birth, compared with 35 percent of children of mothers with no education. Early breastfeeding increased with increasing wealth, from 40 percent among children in the lowest wealth quintile to 52 percent among children in the fourth and fifth quintiles. The practice of providing a prelacteal feed is discouraged because it limits the frequency of suckling by the infant and exposes the baby to the risk of infection. The data show that 28 percent of infants are given a prelacteal feed. Prelacteal feeding varies by ecological zone, region, and subregion. Prelacteal feeding is twice as high in the terai (37 percent) as in the mountain (17 percent) and hill (18 percent) zones. Regionally, 41 percent of children receive a prelacteal feed in the Central region, compared with only 8 percent of children in the Far-western region. Among the subregions, the highest proportion of children receiving a prelacteal feed is observed in the Central terai subregion (53 percent), while the lowest is seen in the Far-western hill subregion (3 percent). Children who were delivered at home are more likely to receive a prelacteal feed (32 percent) than children who were delivered at a health facility (24 percent). Prelacteal feeding is more common among children whose mothers have no education (35 percent) than among children whose mothers have a primary education (18 percent). In general, prelacteal feeding increases with wealth. Prelacteal feeding is highest (37 percent) among children in the middle wealth quintile and lowest among those in the poorest households (20 percent). 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed (no other liquid, solid food, or plain water) during the first six months of life (WHO/UNICEF, 2002; PAHO/WHO, 2004). The nutrition program under the 2004 National Nutrition Policy and Strategy promotes exclusive breastfeeding through the age of 6 months and, thereafter, the introduction of semisolid or solid foods along with continued breast milk until the child is at least age 2. Introducing breast milk substitutes to infants before age 6 months can contribute to breastfeeding failure. Substitutes, such as formula, other kinds of milk, and porridge, are often watered down and provide too few calories. Furthermore, possible contamination of these substitutes exposes the infant to the risk of illness. Nepal’s Breast Milk Substitute Act (2049) of 1992 promotes and protects breastfeeding and regulates the unauthorized or unsolicited sale and distribution of breast milk substitutes (Ministry of Health and Population [MOHP], 2004b). After six months, a child requires adequate complementary foods for normal growth. Lack of appropriate complementary feeding may lead to malnutrition and frequent illnesses, which in turn may lead to death. However, even with complementary feeding, the child should continue to be breastfed for two years or more. Table 11.3 shows the percentage of youngest children under 2 years living with their mother by breastfeeding status, the percentage currently breastfeeding, and the percentage using a bottle with a nipple, according to age in months. Breastfeeding in Nepal is almost universal, and exclusive breastfeeding for the first six months is widespread. The data show that 70 percent of children under 6 months are exclusively breastfed. This is an improvement from the 2006 NDHS, when the figure was 53 percent. Eighty-eight percent of infants age 0-1 months and 74 percent of infants age 2-3 months receive breast milk only, compared with 53 percent of infants age 4-5 months. Ten percent of children under age 6 months receive plain water in addition to breast milk, and 9 percent receive other milk in addition to breast milk. 172 • Nutrition of Children and Women Table 11.3 Breastfeeding status by age Percent distribution of youngest children under two years who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under two years using a bottle with a nipple, according to age in months, Nepal 2011 Age in months Not breast- feeding Breastfeeding status Total Percentage currently breast- feeding Number of youngest children under two years living with their mother Percentage using a bottle with a nipple Number of all children under two years Exclusively breastfed Breast- feeding and consuming plain water only Breast- feeding and consuming nonmilk liquids1 Breast- feeding and consuming other milk Breast- feeding and consuming comple- mentary foods 0-1 1.8 87.7 4.8 0.0 5.4 0.3 100.0 98.2 131 5.3 131 2-3 0.0 73.7 12.4 0.0 10.9 2.9 100.0 100.0 203 3.2 204 4-5 0.6 53.3 12.1 1.1 10.5 22.6 100.0 99.4 195 8.7 195 6-8 0.5 14.1 15.3 0.0 5.0 65.2 100.0 99.5 267 5.5 268 9-11 2.7 2.1 3.7 0.3 0.5 90.6 100.0 97.3 221 8.0 224 12-17 6.8 0.3 0.3 0.0 0.4 92.3 100.0 93.2 516 6.6 532 18-23 5.7 0.0 0.0 0.0 0.0 94.3 100.0 94.3 435 5.1 468 0-3 0.7 79.2 9.4 0.0 8.8 1.9 100.0 99.3 335 4.1 336 0-5 0.7 69.6 10.4 0.4 9.4 9.5 100.0 99.3 530 5.8 531 6-9 1.0 11.5 13.0 0.0 4.1 70.4 100.0 99.0 351 6.0 352 12-15 7.5 0.5 0.2 0.0 0.6 91.2 100.0 92.5 325 7.3 338 12-23 6.3 0.2 0.1 0.0 0.2 93.2 100.0 93.7 952 5.9 1,000 20-23 7.4 0.0 0.0 0.0 0.0 92.6 100.0 92.6 272 3.9 297 Note: Breastfeeding status refers to a “24-hour” period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, and breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semisolids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus, children who receive breast milk and nonmilk liquids and who do not receive other milk and who do not receive complementary foods are classified in the nonmilk liquid category even though they may also be given plain water. Any children who receive complementary food are classified in that category as long as they are breastfeeding as well. 1 Nonmilk liquids include juice, juice drinks, clear broth, and other liquids. Table 11.3 and Figure 11.3 also show complementary feeding practices among children of different ages. Three percent of children age 2-3 months, 23 percent of children age 4-5 months, 65 percent of children age 6-8 months, and 91 percent of children age 9-11 months are given complementary foods. Seventy percent of children age 6-9 months are given complementary food (a decline from 2006, when the figure was 75 percent). Although all children age 6-9 months should receive complementary foods, Table 11.3 shows that 30 percent of children in this age group did not receive complementary foods the day or night preceding the survey. Figure 11.3 Infant Feeding Practices by Age NDHS 2011 <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age in months 0 20 40 60 80 100 Percent Exclusively breastfed Breast milk and plain water Breast milk and non-milk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding Nutrition of Children and Women • 173 The Breast Milk Substitute Act discourages the use of bottles with nipples (MOHP, 2004b). The use of a bottle with a nipple, regardless of the contents (breast milk, formula, or any other liquid), requires hygienic handling to avoid contamination that may place the infant at risk for infection. The survey data show that 6 percent of infants less than age 6 months are fed using a bottle with a nipple. Figure 11.4 shows 2011 NDHS results on Infant and Young Child Feeding (IYCF) practices indicators. As noted above, 70 percent of children under age 6 months are exclusively breastfed, and 66 percent of children 6-8 months (breastfed and non-breastfed) are introduced to complementary foods at an appropriate time. Ninety- three percent of all children are still breastfeeding at age 1, and the same proportion are still breastfeeding at age 2. Four of five Nepalese children age 0-23 months are breastfed appropriately for their age. This includes exclusive breastfeeding for children age 0-5 months and continued breastfeeding along with complementary foods for children age 6-23 months. Four-fifths of children under 6 months are predominantly breastfed. This percentage includes children who are exclusively breastfed and those who receive breast milk and only plain water or nonmilk liquids such as juice. Finally, 6 percent of children under age 2 are bottle fed. 70 53 93 66 93 83 80 6 Exclusive breastfeeding under 6 months Exclusive breastfeeding at 4-5 months Continued breastfeeding at 1 year Continued breastfeeding at 2 years Age-appropriate breastfeeding (0-23 months) Predominant breastfeeding (0-5 months) Bottle feeding (0-23 months) 0 20 40 60 80 100 Percentage of children Figure 11.4 IYCF Indicators on Breastfeeding Status NDHS 2011 Introduction of solid, semisolid, or soft foods (6-8 months) 11.4 DURATION OF BREASTFEEDING Table 11.4 provides information on the median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey. The median duration of any breastfeeding in Nepal is 33.6 months, which is similar to the figure from the 2006 NDHS. The mean duration of breastfeeding for all children is 28.8 months. Differences in the median duration of breastfeeding by background characteristics are small. The median duration of exclusive breastfeeding for all children is 4.2 months, and the mean duration is 5 months. These figures are higher than those reported in 2006, when the median duration of exclusive breastfeeding was 2.5 months and the mean duration was 4 months. The differences in the median duration of exclusive breastfeeding by background characteristics are small. However, the median duration of exclusive breastfeeding among children of mothers with no education is about twice as high as the duration among children of mothers with an SLC and higher level of education. Similarly, the median duration of exclusive breastfeeding among children in the highest wealth quintile is low (2.2 months) compared with children in the lowest and second quintiles (4.6 months). 174 • Nutrition of Children and Women Table 11.4 also shows the median duration of pre- dominant breastfeeding, which is defined as exclusive breastfeeding or breastfeeding in combination with plain water, water-based liquids, or juices. The median duration of predominant breastfeeding is 5.4 months. Predominant breastfeeding is lower (4 months) among children of better educated mothers (SLC and above) than among children of mothers who have no education (7 months). Similar differences can be seen among children in the highest wealth quintile (3.4 months) compared with those in the other wealth quintiles. 11.5 TYPES OF COMPLEMENTARY FOODS It is recommended that complementary foods (solid or semisolid foods fed to infants in addition to breast milk) be started at age 6 months. The reason is that, at this age, breast milk alone is no longer sufficient to maintain the child’s recommended daily allowances of nutritional requirements to enhance growth. Children are fed small quantities of solid and semisolid foods while continuing to breastfeed up to age 2 or beyond. The amount of food is increased gradually from 6 to 23 months, which is the period of transition to eating the regular family diet. This period is characterized by an increase in the prevalence of malnutrition because of poor feeding practices and infections. Table 11.5 shows the percentage of youngest children under age 2 who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding and nonbreastfeeding status of children by age. The data show that, contrary to WHO recommenda- tions, the practice of feeding children with solid or semisolid foods starts early in life. Three percent of breastfeeding children age 2-3 months receive some kind of solid or semisolid food, and by 4-5 months the proportion is 23 percent. Overall, 92 percent of breastfed children age 6-23 months receive solid or semisolid complementary foods in addition to breast milk. These complementary foods include fortified baby foods (8 percent), foods made from grains (88 percent), fruits and vegetables rich in vitamin A (35 percent), other fruits and vegetables (21 percent), and food made from roots and tubers (65 percent). Children are also fed protein-rich foods such as legumes and nuts (49 percent); meat, fish, and poultry (17 percent); and eggs (9 percent). Other foods include cheese, yogurt, and other milk products (9 percent). Liquids other than breast milk fed to children in this age group include other milk (43 percent) and other liquids (33 percent). Use of infant formula is minimal (2 percent). Table 11.5 also presents data on the types of complementary foods consumed by nonbreastfeeding children age 6-23 months. All nonbreastfeeding children are fed solid or semisolid foods, and consumption by type of food is higher among nonbreastfeeding children than breastfeeding children with the exception of consumption of fruits and vegetables rich in vitamin A, which is higher among breastfeeding than nonbreastfeeding children. Table 11.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, by background characteristics, Nepal 2011 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breast- feeding Exclusive breast- feeding Predominant breast- feeding2 Sex Male ≥36.0 4.1 5.3 Female 31.4 4.4 5.5 Residence Urban 31.1 3.4 4.7 Rural 33.9 4.3 5.5 Ecological zone Mountain 27.8 3.2 4.0 Hill 33.3 3.3 4.3 Terai 33.8 4.9 6.6 Development region Eastern 31.4 3.6 4.7 Central 29.8 4.7 6.0 Western 34.0 3.6 5.0 Mid-western ≥36.0 4.0 5.3 Far-western ≥36.0 5.5 6.2 Subregion Eastern mountain ≥36.0 (2.3) (2.6) Central mountain 27.9 * * Western mountain 26.7 (4.2) 5.2 Eastern hill 31.2 (2.3) (3.6) Central hill 28.8 (2.7) (4.5) Western hill ≥36.0 (3.3) (3.8) Mid-western hill ≥36.0 (4.2) (4.7) Far-western hill ≥36.0 (5.0) (5.6) Eastern terai 30.2 (4.5) 6.4 Central terai ≥36.0 5.7 7.2 Western terai 32.2 3.9 5.9 Mid-western terai ≥36.0 (4.1) (5.7) Far-western terai ≥36.0 (6.5) (7.0) Mother’s education No education 34.1 5.2 7.0 Primary 31.6 4.7 5.5 Some secondary ≥36.0 3.4 4.3 SLC and above 29.3 2.8 4.0 Wealth quintile Lowest 32.8 4.6 5.3 Second ≥36.0 4.6 5.9 Middle ≥36.0 4.7 6.0 Fourth 29.5 4.3 5.5 Highest 31.2 2.2 3.4 Total 33.6 4.2 5.4 Mean for all children 28.8 5.0 6.1 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. The median duration of any breastfeeding is shown as ≥36.0 for groups in which the exact median cannot be calculated because the proportion of breastfeeding children does not drop below 50 percent in any age group for children under age 36 months. Includes children living and deceased at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water and/or nonmilk liquids only SLC = School Leaving Certificate Nutrition of Children and Women • 175 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under two years of age who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Nepal 2011 Age in months Liquids Solid or semisolid foods Any solid or semi- solid food Number of children Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry Eggs Cheese, yogurt, other milk products BREASTFEEDING CHILDREN 0-1 0.8 5.0 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 129 2-3 1.0 11.2 1.0 0.8 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.3 2.9 203 4-5 1.5 22.1 4.2 3.4 13.0 1.8 1.9 5.2 4.6 0.4 0.2 1.1 22.7 194 6-8 2.6 38.0 21.2 9.3 54.1 15.1 10.2 26.9 27.4 3.8 6.2 5.2 65.5 266 9-11 3.7 46.1 33.3 11.6 88.5 22.9 15.6 54.3 49.6 8.3 7.5 7.1 93.1 215 12-17 2.6 41.8 37.1 7.3 96.2 40.9 22.1 76.3 55.7 21.1 9.2 8.0 99.0 481 18-23 0.8 45.4 35.0 5.3 98.9 47.0 29.1 81.4 53.6 25.2 10.8 12.4 100.0 410 6-23 2.2 42.8 32.8 7.7 87.7 34.9 20.9 64.8 48.6 17.0 8.8 8.6 91.9 1,372 Total 1.9 34.8 24.2 6.1 64.7 25.4 15.3 47.4 35.6 12.3 6.4 6.4 69.1 1,898 NONBREASTFEEDING CHILDREN 6-23 3.2 66.0 35.2 12.8 96.0 29.1 32.4 69.7 58.8 24.2 16.3 16.6 100.0 67 Note: Breastfeeding status and food consumed refer to a “24-hour” period (yesterday and last night). 1 Other milk includes fresh, tinned, and powdered cow or other animal milk. 2 Does not include plain water 3 Includes fortified baby food 4 Includes pumpkin, squash, carrots, red sweet potatoes, dark green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Table 11.6 presents the percentage of children less than age 2 living with their mother who are fed according to three IYCF practices, by breastfeeding status. These practices take into account the percentages of children for whom feeding practices meet minimum standards with respect to food diversity (i.e., the number of food groups consumed), feeding frequency (i.e., the number of times the child is fed), and consumption of breast milk or other types of milk or milk products. Breastfed children are considered to be fed within the minimum standards if they consume at least four food groups and receive food other than breast milk at least twice a day in the case of infants 6-8 months and at least three times a day in the case of children 9-23 months. Nonbreastfed children are considered to be fed in accordance with the minimum standards if they consume milk or milk products, are fed four food groups (including milk products), and are fed at least four times a day. However, because of the small percentage of nonbreastfed children in Nepal, a separate analysis for this group of children is not presented. Table 11.6 shows that, among breastfed children age 6-23 months, 28 percent were given foods from four or more food groups in the 24 hours preceding the survey. Only 21 percent of children residing in the terai were given foods from four or more food groups, compared with 36 percent of children living in the hill zone. Children living in the Western region and Western hill subregion, children of mothers with an SLC and higher education, and children from the wealthiest households were more likely than their counterparts to receive foods from four or more food groups. Seventy-eight percent of breastfed children were fed the minimum number of times in the previous 24 hours. The combined percentage of children who fall in both categories (given foods from four or more groups and fed the minimum number of times per day) is 25 percent. The proportion of breastfeeding children age 6-23 months who are given a variety of foods at least three times daily increases with the mother’s level of education and wealth. Ninety-nine percent of children age 6-23 months (both breastfed and nonbreastfed) are given either breast milk or other milk products. Twenty-nine percent of children are given foods from the appropriate number of food groups, and 79 percent are fed an appropriate number of times per day. Overall, 24 percent of Nepalese children are fed in accordance with the three recommended IYCF practices. The likelihood of children being fed appropriately also increases with mother’s education and wealth quintile. 176 • Nutrition of Children and Women Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night preceding the survey, by background characteristics, Nepal 2011 Background characteristic Among breastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: 4+ food groups1 Minimum meal frequency2 Both 4+ food groups and minimum meal frequency Number of breastfed children 6-23 months Breast milk, milk, or milk products3 4+ food groups1 Minimum meal frequency4 With 3 IYCF practices Number of all children 6-23 months Age in months 6-8 12.2 60.2 11.4 266 100.0 12.4 60.4 11.4 267 9-11 19.8 70.7 16.8 215 100.0 22.0 71.5 17.6 221 12-17 32.7 84.5 29.0 481 97.7 32.6 85.5 28.3 516 18-23 36.0 84.7 32.1 410 97.9 36.8 84.8 31.1 435 Sex Male 28.0 78.4 24.3 677 98.5 28.6 79.3 24.5 712 Female 27.4 77.0 25.0 695 98.5 28.3 77.7 24.3 727 Residence Urban 45.6 75.5 37.8 131 98.3 45.5 76.0 36.9 140 Rural 25.8 77.9 23.2 1,241 98.6 26.6 78.7 23.1 1,300 Ecological zone Mountain 25.1 80.1 23.0 118 98.9 25.7 80.4 22.3 122 Hill 36.2 82.6 33.0 571 99.0 36.4 82.8 32.9 590 Terai 21.1 73.2 17.9 683 98.1 22.5 74.6 17.9 727 Development region Eastern 31.8 83.3 29.6 326 98.2 31.4 83.9 29.1 340 Central 21.2 75.4 17.7 431 98.4 23.9 77.0 17.9 465 Western 38.4 80.5 33.7 264 98.4 39.0 80.7 33.3 274 Mid-western 21.1 74.1 19.5 217 98.4 20.6 74.3 19.0 222 Far-western 28.1 71.8 25.2 135 100.0 28.5 72.5 25.7 138 Subregion Eastern mountain 39.9 88.1 34.6 28 98.5 40.6 87.5 32.9 29 Central mountain 26.2 84.1 26.2 29 98.6 28.3 84.6 25.5 30 Western mountain 18.0 74.6 16.4 62 99.2 17.6 75.2 16.0 64 Eastern hill 36.3 89.8 35.4 114 99.1 35.7 90.0 34.8 116 Central hill 40.6 77.6 35.8 130 99.2 41.3 78.1 36.0 138 Western hill 43.0 87.5 39.1 170 98.9 43.9 88.0 39.0 176 Mid-western hill 20.4 76.3 18.0 99 98.2 19.8 76.1 17.5 102 Far-western hill 32.8 76.2 29.8 58 100.0 32.8 76.2 29.8 58 Eastern terai 27.7 78.5 25.3 184 97.6 27.4 79.7 25.1 195 Central terai 11.5 73.5 8.2 272 98.1 15.4 75.8 8.8 297 Western terai 30.2 67.7 23.9 94 97.6 30.2 67.7 23.0 98 Mid-western terai 25.9 72.8 25.2 81 98.7 25.3 73.2 24.6 83 Far-western terai 23.8 62.9 20.5 52 100.0 25.3 64.7 22.2 54 Mother’s education No education 12.1 72.9 11.3 569 97.1 12.2 74.2 11.0 603 Primary 25.5 78.4 21.8 258 99.2 26.8 78.8 21.7 269 Some secondary 43.0 80.4 38.7 309 99.9 44.2 81.0 38.4 318 SLC and above 47.6 85.0 41.5 236 99.4 49.4 85.3 41.7 250 Wealth quintile Lowest 14.5 76.1 13.9 347 99.1 14.2 76.3 13.7 354 Second 21.6 78.4 19.9 287 98.3 21.9 78.7 19.7 297 Middle 25.9 74.5 22.1 309 97.1 24.6 75.6 21.1 324 Fourth 41.0 80.1 36.3 237 99.1 43.3 81.1 35.3 250 Highest 47.1 81.7 40.7 192 99.4 49.7 83.1 41.0 214 Total 27.7 77.7 24.6 1,372 98.5 28.5 78.5 24.4 1,439 Note: As the number of nonbreastfed children is small, it is not shown separately. Total includes nonbreastfed children. 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c. vitamin A-rich fruits and vegetables (and red palm oil); d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts. 2 For breastfed children, minimum meal frequency is receiving solid or semisolid food at least twice a day for infants 6-8 months and at least three times a day for children 9-23 months. 3 Breastfeeding, or not breastfeeding and receiving two or more feedings of commercial infant formula, fresh, tinned, and powdered animal milk, and yogurt 4 Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in note 2 for breastfed children, and for nonbreastfed children age 6-23 months, minimum meal frequency is receiving solid or semisolid food or milk feeds at least four times a day. SLC = School Leaving Certificate There have been changes in the definition of the standard IYCF indicators (such as the removal of “foods made with fats” as a food group, the requirement that breastfed children receive four instead of three food groups, the requirement that nonbreastfed children receive two or more servings of milk or milk products, and the removal of cheese from the milk or milk products group) from the 2006 NDHS, and thus direct comparisons of these indicators are problematic. However, for purposes of comparison, the data were recalculated based on the former IYCF definition, and results indicated that the percentage of children fed in accordance with the recommended three IYCF practices has decreased between 2006 (57 percent) and 2011 (44 percent). However, these results should be interpreted with caution, as they could be influenced by methodological differences in data collection (data not shown). Nutrition of Children and Women • 177 11.7 PREVALENCE OF ANEMIA IN CHILDREN Anemia, characterized by a low level of hemoglobin in the blood, is a major health problem in Nepal, especially among young children and pregnant women. Anemia may be an underlying cause of maternal mortality, spontaneous abortions, premature births, and low birth weight. The most common cause of anemia is inadequate dietary intake of nutrients necessary for synthesis of hemoglobin, such as iron, folic acid, and vitamin B12. Anemia also results from sickle cell disease, malaria, and parasitic infections. A number of interventions have been put in place to address anemia in children. These include expanded distribution of multi-micronutrient powders; deworming of children age 1 to 5 years every six months, along with vitamin A distribution; and promotion of use of insecticide-treated mosquito nets for children under age 5 in malaria- endemic areas. The 2011 NDHS used HemoCue rapid testing methodology to determine anemia levels among women age 15-49 and children under age 5. Table 11.7 presents anemia levels among children age 6 months to 5 years according to selected background characteristics. The results are based on children who stayed in the household the night before the interview. Hemoglobin was measured in 2,198 children. Unadjusted (i.e., measured) hemoglobin values were obtained using the HemoCue instrument. Given that hemoglobin requirements differ substantially depending on altitude, an adjustment to sea-level equivalents was made using CDC formulas before classifying children according to level of anemia (CDC, 1998). Table 11.7 indicates that 46 percent of children in Nepal are anemic; 27 percent are mildly anemic, 18 percent are moderately anemic, and less than 1 percent are severely anemic. The prevalence of anemia among children under age 5 has declined by only 2 percentage points in the past five years. The proportion with anemia is higher among children age 6-17 months (72-78 percent) than among children in other age groups. The prevalence of anemia among children age 6-23 months is 69 percent. Severe anemia, which has a serious impact on the health of an individual, is highest among children age 12-17 months (2 percent). Male children and children residing in urban areas are less likely to be anemic. The prevalence of anemia in children varies across ecological zones. Children in the terai are more anemic (50 percent) than children in the hill zone (41 percent). Children residing in the Far-western terai (60 percent) and Mid-western terai (57 percent) subregions are more likely to be anemic than children in the Central mountain (33 percent) and Mid-western hill (36 percent) subregions. There seems to be no significant linear relationship between anemia prevalence and mother’s education or wealth quintile, although clearly children of mothers with no education are more likely to be anemic. 178 • Nutrition of Children and Women Table 11.7 Prevalence of anemia in children Percentage of children age 6-59 months classified as having anemia, by background characteristics, Nepal 2011 Background characteristic Anemia status by hemoglobin level Any anemia (<11.0 g/dl) Mild anemia (10.0-10.9 g/dl) Moderate anemia (7.0-9.9 g/dl) Severe anemia (<7.0 g/dl) Number of children Age in months 6-8 78.3 37.1 40.4 0.7 118 9-11 73.5 37.3 35.4 0.8 109 12-17 72.2 38.5 32.0 1.7 261 18-23 56.6 29.3 26.7 0.7 217 24-35 43.6 27.6 15.9 0.2 495 36-47 38.1 26.0 12.1 0.0 512 48-59 25.0 17.5 7.0 0.5 486 6-23 months 68.6 35.2 32.3 1.1 705 Sex Male 43.4 26.6 16.2 0.6 1,119 Female 49.1 28.3 20.4 0.4 1,079 Deworming status Child not eligible (<12 months old) 75.4 36.6 38.0 0.8 221 Received deworming medication in the past 6 months 41.3 25.5 15.2 0.5 1,538 Did not receive deworming medication in the past 6 months 50.6 29.2 21.3 0.2 344 Mother’s interview status Interviewed 46.4 27.3 18.6 0.5 2,104 Not interviewed but in household (45.7) (26.6) (19.1) (0.0) 32 Not interviewed and not in household1 40.5 32.1 8.4 0.0 62 Residence Urban 41.2 22.9 17.9 0.4 188 Rural 46.7 27.9 18.3 0.5 2,011 Ecological zone Mountain 47.7 26.0 21.2 0.5 179 Hill 41.0 24.6 16.0 0.3 902 Terai 50.2 29.9 19.7 0.6 1,118 Development region Eastern 47.2 27.6 19.1 0.5 534 Central 43.9 27.8 15.6 0.6 674 Western 45.5 29.4 16.1 0.0 408 Mid-western 47.8 24.9 21.9 0.9 336 Far-western 49.4 26.2 22.6 0.5 246 Subregion Eastern mountain 51.3 32.0 18.5 0.8 42 Central mountain 33.1 20.1 13.0 0.0 43 Western mountain 52.7 26.1 26.1 0.5 94 Eastern hill 42.3 22.1 20.2 0.0 180 Central hill 40.2 26.1 12.6 1.5 204 Western hill 43.6 27.4 16.2 0.0 260 Mid-western hill 36.0 21.4 14.7 0.0 152 Far-western hill 40.9 23.7 17.1 0.0 105 Eastern terai 49.5 30.2 18.6 0.7 312 Central terai 46.7 29.3 17.3 0.2 428 Western terai 48.8 32.9 15.9 0.0 148 Mid-western terai 56.9 28.4 26.5 2.0 128 Far-western terai 60.4 29.2 29.9 1.2 102 Mother’s education2 No education 50.1 29.2 20.1 0.8 1,036 Primary 42.6 24.7 17.7 0.2 421 Some secondary 42.8 24.7 17.8 0.3 404 SLC and above 43.3 28.0 15.3 0.0 275 Wealth quintile Lowest 45.3 26.9 18.1 0.3 584 Second 49.6 28.4 20.3 0.9 457 Middle 51.4 31.2 19.4 0.7 503 Fourth 43.3 23.3 19.9 0.1 366 Highest 37.5 25.6 11.5 0.4 288 Total 46.2 27.4 18.3 0.5 2,198 Note: Table is based on children who stayed in the household on the night before the interview and who were tested for anemia. Prevalence of anemia, based on hemoglobin levels, is adjusted for altitude using formulas in CDC, 1998. Hemoglobin is in grams per deciliter (g/dl). Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children whose mothers are deceased 2 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. SLC = School Leaving Certificate Nutrition of Children and Women • 179 11.8 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is a major contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, food fortification, and direct supplementation. The 2011 NDHS collected information on consumption of foods rich in vitamin A and iron and the status of children receiving vitamin A capsules, iron supplements, and deworming during national campaigns. Table 11.8 presents intake of key micronutrients among children. The table shows, by background characteristics, the percentage of youngest children age 6-23 months who are living with their mother and who consumed foods rich in vitamin A and iron in the day or night preceding the survey; the percentage of all children 6-59 months who were given vitamin A supplements in the six months preceding the survey and who were given iron supplements in the past seven days; the percentage of children 12-59 months who were given deworming medication in the six months preceding the survey; and, among all children age 6-59 months who live in households that were tested for iodized salt, the percentage who live in households with iodized salt. Vitamin A is an essential micronutrient for the immune system that plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency (VAD) can cause eye damage. VAD can also increase the severity of infections, such as measles and diarrheal diseases in children, and slow recovery from illness. Vitamin A is found in breast milk, other milk, liver, eggs, fish, butter, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Forty-seven percent of children age 6-23 months consumed foods rich in vitamin A the day or night preceding the survey. The proportion of children consuming vitamin A-rich foods increases with age. There are only slight differences in consumption by sex and breastfeeding status. Urban children are more likely to consume vitamin A-rich foods (58 percent) than children in rural areas (46 percent). Children in the hill zone consume more vitamin A-rich foods (54 percent) than children in the terai (41 percent). At the subregional level, children in the Eastern mountain subregion (63 percent) are most likely to consume vitamin A-rich foods, and those in the Central terai subregion are least likely (35 percent). Mother’s education correlates with level of consumption of vitamin A-rich foods: 40 percent of children whose mothers have no education consume vitamin A-rich foods, compared with 54 percent of children whose mothers have an SLC and higher education. Iron is essential for cognitive development, and low iron intake can contribute to anemia. Iron requirements are greatest at age 6-23 months, when growth is extremely rapid. The results of the 2011 NDHS (Table 11.8) show that one in four children consumed foods rich in iron in the 24 hours prior to the survey and that consumption of iron-rich foods is highest among children age 18-23 months, children in urban areas, children in the hill zone, children in the Eastern hill subregion, and children in the highest wealth quintile. Children whose mothers have some secondary education are twice as likely to consume iron-rich foods as those whose mothers have no education. Periodic dosing (usually every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD. In Nepal, campaigns are in place for semiannual mass supplementation of vitamin A capsules (for children age 6-59 months) and distribution of deworming tablets (for children age 12-59 moths) since the past 15 years under the National Nutrition Program. The 2011 NDHS collected data on vitamin A supplements for children under age 5. Table 11.8 shows that 90 percent of children age 6-59 months were given vitamin A supplements in the six months before the survey. The proportion of children receiving a vitamin A supplement increases with age from 70 percent at 6-8 months to 93 percent at 24-35 months before declining to 91 percent at 48-59 months. Children in rural areas are more likely to receive vitamin A supplements (91 percent) than those in urban areas (86 percent). There is only a slight difference in the proportion of children receiving vitamin A supplements by ecological zone and subregion. Similarly, mother’s education and wealth do not have an impact on use of vitamin A supplementation. 180 • Nutrition of Children and Women Table 11.8 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey; among all eligible children 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey and who were given iron supplements in the past seven days; among all eligible children 12-59 months, the percentage who were given deworming medication in the six months preceding the survey; and among all children age 6- 59 months who live in households that were tested for iodized salt, the percentage who live in households with adequately iodized salt, by background characteristics, Nepal 2011 Background characteristic Among youngest children age 6-23 months living with the mother: Among all eligible children age 6-59 months: Among all children age 6-59 months: Among all eligible children age 12-59 months: Among children age 6-59 months living in households tested for iodized salt: Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supplements in last 6 months Number of children Percentage given iron supplements in last 7 days Number of children Percentage given deworming medication in last 6 months3 Number of children Percentage living in households with adequately iodized salt4,5 Number of children Age in months 6-8 20.5 8.9 267 70.4 85 2.0 268 na na 74.3 268 9-11 31.2 14.6 221 82.5 158 2.3 224 na na 73.6 224 12-17 56.0 28.2 516 85.4 532 2.3 532 70.7 268 71.4 531 18-23 59.8 33.4 435 90.1 468 2.3 468 77.5 468 71.1 467 24-35 na na 0 93.1 1,013 3.0 1,013 86.0 1,013 73.0 1,013 36-47 na na 0 92.2 1,106 2.5 1,106 86.6 1,106 71.9 1,105 48-59 na na 0 91.4 999 2.5 999 84.6 999 73.1 993 Sex Male 46.8 22.8 712 91.5 2,252 2.1 2,369 84.4 1,997 73.7 2,362 Female 46.6 25.5 727 89.3 2,108 2.9 2,240 82.9 1,856 71.2 2,238 Breastfeeding status Breastfeeding 46.5 23.5 1,372 90.8 2,201 2.2 2,449 83.3 1,730 71.9 2,445 Not breastfeeding 51.7 37.2 67 90.0 2,158 2.8 2,160 84.1 2,123 73.1 2,154 Mother’s age at birth 15-19 35.6 24.9 160 87.9 230 3.0 263 82.6 163 69.5 263 20-29 47.3 25.2 979 90.1 2,855 2.3 3,027 83.9 2,523 74.4 3,023 30-39 51.6 20.7 268 90.8 1,073 2.7 1,117 83.8 971 70.2 1,111 40-49 43.2 15.1 32 95.8 202 4.1 202 81.6 195 60.1 202 Residence Urban 57.7 30.6 140 86.4 421 2.1 440 79.9 371 90.6 440 Rural 45.6 23.4 1,300 90.8 3,939 2.6 4,168 84.1 3,482 70.6 4,160 Ecological zone Mountain 46.2 22.1 122 92.6 350 4.6 363 88.1 303 71.2 362 Hill 54.1 28.9 590 90.5 1,764 2.8 1,858 87.0 1,557 70.4 1,857 Terai 40.8 20.6 727 90.0 2,245 1.9 2,387 80.5 1,993 74.3 2,380 Development region Eastern 52.9 33.6 340 93.4 1,040 2.3 1,099 86.5 934 76.2 1,099 Central 42.3 18.8 465 88.1 1,383 1.9 1,466 78.8 1,200 75.1 1,463 Western 51.7 25.9 274 88.8 806 0.8 851 83.5 715 82.8 848 Mid-western 40.1 19.3 222 90.8 653 6.1 696 85.6 577 63.8 693 Far-western 47.4 23.2 138 92.6 478 2.8 497 89.1 427 51.2 497 Subregion Eastern mountain 62.5 36.6 29 93.8 83 0.8 87 93.8 71 78.5 87 Central mountain 47.0 20.7 30 91.1 85 1.4 87 88.0 73 71.7 86 Western mountain 38.4 16.0 64 92.7 182 7.8 189 85.6 159 67.7 189 Eastern hill 57.5 44.2 116 94.6 340 0.9 363 89.2 307 79.4 363 Central hill 57.6 30.4 138 89.1 426 3.2 441 86.3 364 72.0 441 Western hill 59.8 27.0 176 88.9 492 0.8 520 83.1 437 78.4 520 Mid-western hill 37.6 19.6 102 89.6 306 8.6 328 87.5 272 64.2 326 Far-western hill 50.9 17.2 58 92.1 200 1.4 207 93.5 177 40.9 207 Eastern terai 48.7 26.9 195 92.8 616 3.3 649 84.1 556 74.1 649 Central terai 34.7 13.2 297 87.4 872 1.3 938 74.4 763 76.8 935 Western terai 37.2 23.8 98 88.6 314 0.7 331 84.1 278 89.9 328 Mid-western terai 43.4 20.9 83 92.1 244 0.4 263 85.0 217 57.5 261 Far-western terai 48.4 32.1 54 92.5 199 4.6 207 84.2 179 60.2 207 Mother’s education No education 40.1 17.0 603 88.5 2,083 2.9 2,179 80.6 1,885 60.8 2,171 Primary 47.4 25.5 269 92.0 892 2.3 921 85.5 794 74.1 920 Some secondary 52.9 35.2 318 92.7 840 1.4 892 87.3 712 85.7 892 SLC and above 54.2 25.7 250 91.5 545 3.0 616 87.7 463 92.3 616 Wealth quintile Lowest 47.4 19.5 354 89.4 1,154 4.5 1,201 83.7 1,031 53.4 1,197 Second 46.6 23.3 297 89.7 966 1.4 1,003 81.8 861 65.9 1,000 Middle 39.9 20.7 324 91.4 871 1.6 944 84.0 764 73.9 944 Fourth 49.8 28.5 250 91.3 747 2.7 790 84.8 648 87.7 788 Highest 52.7 33.0 214 90.8 623 1.7 671 85.0 549 96.6 671 Total 46.7 24.1 1,439 90.4 4,360 2.5 4,608 83.7 3,853 72.5 4,599 Note: Information on vitamin A is based on both mother’s recall and the immunization card (where available). Information on iron supplements and deworming medication is based on the mother’s recall. Children are considered eligible for receiving Vitamin A (6-59 months) and deworming medication (12-59 months) based on their age at the date of distribution campaign. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A. 2 Includes meat (and organ meat) 3 Deworming for intestinal parasites is commonly done for helminthes. 4 Excludes children in households in which salt was not tested 5 Salt with 15 ppm or more iodine SLC = School Leaving Certificate Use of multiple micronutrient powder (MNP) has proved to be effective in reducing anemia among children, and studies have shown a 45 percent decrease in anemia with this intervention (UNICEF, 2009). The government of Nepal, with assistance from the World Food Program (WFP) and UNICEF, has been distributing MNPs (locally known as “Vita-Mishran” and “Baal Vita”) in selected districts of the country since 2009. The Nutrition of Children and Women • 181 target population for the WFP-sponsored Vita Mishran is children age 6-59 months, while Baal Vita, supported by UNICEF, targets children age 6-24 months. Although it is too early to expect wide national coverage, the 2011 NDHS collected baseline information on the distribution of these MNPs. The survey indicated that 3 percent of children age 6-59 months were given iron supplements in the form of an MNP in the seven days preceding the survey. Coverage was relatively higher among children in the Mid-western hill (9 percent) and Western mountain (8 percent) subregions, the target areas for the WFP initiative. Certain types of intestinal parasites can cause anemia. Periodic deworming for organisms such as helminthes can improve children’s micronutrient status. Table 11.8 shows that 84 percent of children age 6-59 months received deworming medication in the six months before the survey. Children in rural areas are more likely than children in urban areas to receive deworming medication. The likelihood of receiving deworming medication increases with the child’s age, mother’s education, and mother’s wealth. Children in the Eastern mountain subregion are more likely to receive deworming medication (94 percent) than those in the Central terai subregion (74 percent). Iodine deficiency, most frequently caused by inadequate iodine intake, has serious effects on body growth and mental development. Fortification of salt with iodine is the most common method of preventing iodine deficiency. In Nepal, the compound used for fortification of salt is potassium iodate (KIO3). According to the World Health Organization, a country’s salt iodization program is considered to be on a good track in eliminating iodine deficiency when 90 percent of households are using iodized salt. Fortified salt that contains 15 parts of iodine per million parts of salt (15 ppm) is considered adequate for the prevention of iodine deficiency (ICCIDD, UNICEF, and WHO, 2001). To assess the use of iodized salt in Nepal, the 2011 NDHS included salt testing at the household level using the MBI rapid test kit. Interviewers asked households to provide a teaspoon of salt used for cooking. A recheck solution was used when the salt showed no change in color to lower the pH with high alkalinity, after which the salt was tested again. The MBI rapid test kit provides a good qualitative indication of the presence or absence of iodine. It cannot give a precise measurement of the iodine content in salt. However, as studies indicate that use of iodized salt in Nepal is universal (MOHP, New ERA, and Micronutrient Initiative, 2005), the interest from a program perspective has been in assessing the proportion of households using adequately iodized salt (15+ ppm). Given that baseline data using the MBI kit were available on the proportion of households using adequately iodized salt from the Iodine Deficiency Survey 2005, an assessment of the percentage of households using adequately iodized salt was carried out in the 2011 NDHS. Notably, the 2011 NDHS results also show that more than 95 percent of households are using iodized salt, indicating that Nepal is on track toward eliminating iodine deficiency (data not shown). The findings on salt iodization refer to children living in households with adequately iodized salt. Table 11.8 shows that 73 percent of children live in households that use adequately iodized salt, with more children in urban (91 percent) than rural (71 percent) areas living in such households. The percentage of children living in households that use adequately iodized salt is lowest in the Far-western development region (51 percent), particularly the Far-western hill subregion (41 percent). Mother’s education and household wealth are positively associated with the likelihood of children living in households with adequately iodized salt. Eighty percent of households use salt that is adequately iodized (15+ ppm) (Table 11.9). The proportion of households that use adequately iodized salt has increased by 38 percent since 2005, when the figure was 58 percent (MOHP, New ERA, and Micronutrient Initiative, 2005). The percentage of households using adequately iodized salt is far larger in urban areas (94 percent) than in rural areas (78 percent). A higher proportion of households in the terai (81 percent) than in the mountain zone (73 percent) are using salt that is adequately iodized. The Western, Central, and Eastern regions have the highest proportions of households using adequately iodized salt (88 percent, 84 percent, and 82 percent, respectively). A lower percentage of households in the Far-western hill subregion (43 percent) than in the Western terai subregion (92 percent) use adequately iodized salt. The proportion of households using adequately iodized salt rises steadily from 56 percent in the lowest wealth quintile to 98 percent in the highest wealth quintile. 182 • Nutrition of Children and Women Table 11.9 Presence of adequately iodized salt in household Among all households, the percentage with salt tested for iodine content and the percentage with no salt in the household; and among households with salt tested, the percentage with adequately iodized salt, according to background characteristics, Nepal 2011 Background characteristic Among all households, the percentage: Among households with tested salt: With salt tested With no salt in the household Number of households Percentage with adequately iodized salt1 Number of households Residence Urban 99.1 0.9 1,546 94.4 1,532 Rural 99.3 0.7 9,280 77.7 9,215 Ecological zone Mountain 99.3 0.7 761 72.6 756 Hill 99.5 0.5 4,563 79.7 4,538 Terai 99.1 0.9 5,502 81.4 5,453 Development region Eastern 99.2 0.8 2,685 81.7 2,663 Central 99.3 0.7 3,627 84.2 3,602 Western 99.3 0.7 2,304 88.3 2,288 Mid-western 99.2 0.8 1,241 67.0 1,230 Far-western 99.4 0.6 969 56.8 964 Subregion Eastern mountain 99.8 0.2 206 85.2 205 Central mountain 99.4 0.6 266 67.3 265 Western mountain 98.9 1.1 289 68.4 286 Eastern hill 99.6 0.4 847 78.6 843 Central hill 99.1 0.9 1,386 88.0 1,374 Western hill 99.7 0.3 1,415 85.8 1,411 Mid-western hill 99.3 0.7 577 68.1 573 Far-western hill 99.8 0.2 339 42.8 338 Eastern terai 98.9 1.1 1,632 82.9 1,615 Central terai 99.4 0.6 1,975 83.9 1,963 Western terai 98.7 1.3 889 92.3 877 Mid-western terai 98.9 1.1 519 63.2 513 Far-western terai 99.5 0.5 487 65.5 485 Wealth quintile Lowest 99.6 0.4 2,029 55.9 2,019 Second 99.6 0.4 2,168 71.4 2,159 Middle 99.7 0.3 2,068 80.9 2,061 Fourth 99.0 1.0 2,185 90.4 2,162 Highest 98.7 1.3 2,377 98.4 2,345 Total 99.3 0.7 10,826 80.0 10,747 1 Salt with 15 ppm or more iodine 11.9 NUTRITIONAL STATUS OF WOMEN The nutritional status of women was assessed with two anthropometric indices: height and body mass index. BMI is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). To derive these indices, the 2011 NDHS took height and weight measurements among women age 15-49. Women who were pregnant and women who had given birth in the two months preceding the survey were excluded from the analysis. Short stature reflects poor socioeconomic conditions and inadequate nutrition during childhood and adolescence. In a woman, short stature is a risk factor for poor birth outcomes and obstetric complications. For example, short stature is associated with small pelvic size, which increases the likelihood of difficulty during delivery and the risk of bearing low birth weight babies. A woman is considered to be at risk if her height is below 145 cm. According to Table 11.10, 12 percent of women are shorter than 145 cm. Adolescent women (age 15- 19) are slightly less likely to be below 145 cm (10 percent) than older women. Women in rural areas are more likely to be below 145 cm (12 percent) than women in urban areas (8 percent). Women in the Western region are most likely to be shorter than 145 cm (14 percent), while women in the Far-western region are least likely (7 percent). Similarly, the highest proportion of women below 145 cm is in the Eastern mountain subregion (16 percent), while women from the Far-western and Mid-western terai are least likely to be below 145 cm (5 Nutrition of Children and Women • 183 percent and 7 percent, respectively). The likelihood of being shorter than 145 cm decreases with level of education and wealth quintile. BMI was used to measure thinness or obesity. A BMI below 18.5 indicates thinness or acute undernutrition, and a BMI of 25.0 or above indicates overweight or obesity. A BMI below 16 kg/m2 indicates severe undernutrition and is associated with increased mortality. Low pre-pregnancy BMI, as with short stature, is associated with poor birth outcomes and obstetric complications. Table 11.10 shows that the mean BMI among women age 15-49 is 21 kg/m2. Mean BMI generally increases with age. Urban women have a slightly higher mean BMI (23 kg/m2) than rural women (21 kg/m2). There are only small differences in mean BMI among women living in the mountain, hill, and terai ecological zones. Variations by development region are also minimal. Mean BMI does not correlate with women’s level of education. With regard to wealth, mean BMI shows a steady increase from 20 kg/m2 among women in the lowest wealth quintile to 23 kg/m2 among those in the highest quintile. Table 11.10 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Nepal 2011 Background characteristic Height Body mass index1 Mean BMI Normal Thin Overweight/obese Number of women Percentage below 145 cm Number of women 18.5-24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moderately and severely thin) ≥25.0 (total over- weight or obese) 25.0-29.9 (overweight) ≥30.0 (obese) Age 15-19 10.1 1,348 20.0 71.2 25.8 15.4 10.4 2.9 2.6 0.3 1,266 20-29 11.5 2,140 21.1 69.3 19.1 12.1 7.0 11.6 10.1 1.5 1,938 30-39 11.6 1,531 22.3 69.0 12.2 8.0 4.2 18.8 15.8 3.0 1,475 40-49 13.8 1,125 22.3 62.6 15.9 10.5 5.4 21.5 16.8 4.7 1,121 Residence Urban 8.4 849 22.7 59.5 14.1 9.2 4.9 26.3 21.3 5.1 808 Rural 12.1 5,295 21.2 69.8 18.8 11.8 7.0 11.4 9.6 1.8 4,992 Ecological zone Mountain 13.6 399 21.0 75.2 16.5 12.8 3.6 8.4 6.9 1.5 371 Hill 12.4 2,455 21.8 74.1 12.4 8.8 3.6 13.5 11.2 2.3 2,316 Terai 10.8 3,291 21.2 63.3 22.7 13.3 9.4 14.0 11.7 2.3 3,112 Development region Eastern 11.1 1,481 21.7 67.4 16.2 10.7 5.4 16.5 13.8 2.7 1,376 Central 12.8 2,003 21.6 64.1 20.2 10.9 9.4 15.6 12.5 3.1 1,895 Western 13.5 1,320 21.7 72.3 14.0 9.1 5.0 13.7 11.8 2.0 1,265 Mid-western 10.2 711 20.8 72.7 19.3 12.8 6.5 8.0 6.7 1.2 661 Far-western 6.5 629 20.3 70.8 23.9 18.6 5.3 5.3 4.9 0.4 603 Subregion Eastern mountain 15.5 114 21.8 75.7 10.0 7.7 2.3 14.2 12.6 1.6 104 Central mountain 13.4 125 21.2 75.6 14.9 10.7 4.2 9.5 6.7 2.8 118 Western mountain 12.3 161 20.3 74.4 22.2 18.1 4.1 3.4 3.1 0.3 149 Eastern hill 12.7 472 21.5 76.8 11.8 8.7 3.1 11.4 11.0 0.5 441 Central hill 11.5 732 22.7 66.3 11.5 7.7 3.8 22.2 17.5 4.7 693 Western hill 14.3 742 21.9 79.9 8.3 6.0 2.3 11.8 9.5 2.3 706 Mid-western hill 11.9 307 20.8 73.7 18.6 12.8 5.8 7.7 7.1 0.6 286 Far-western hill 8.3 202 19.8 75.1 23.4 17.9 5.5 1.5 1.4 0.1 191 Eastern terai 9.7 896 21.8 61.3 19.3 12.2 7.1 19.4 15.4 4.0 831 Central terai 13.7 1,147 20.9 61.5 26.4 12.9 13.5 12.1 10.0 2.1 1,084 Western terai 12.5 578 21.5 62.6 21.3 13.0 8.3 16.1 14.6 1.5 559 Mid-western terai 7.1 324 20.7 70.7 20.2 12.6 7.6 9.1 7.1 2.0 303 Far-western terai 5.0 346 20.6 68.3 23.7 18.3 5.4 8.0 7.5 0.6 335 Education No education 15.0 2,424 21.0 66.6 22.6 14.4 8.2 10.8 9.1 1.7 2,281 Primary 12.7 1,075 21.7 68.9 15.5 8.9 6.6 15.5 12.4 3.1 1,026 Some secondary 9.6 1,510 21.5 72.0 15.3 9.6 5.7 12.7 10.5 2.3 1,427 SLC and above 6.0 1,135 21.8 66.7 15.2 10.2 4.9 18.2 15.6 2.5 1,065 Wealth quintile Lowest 15.3 1,022 20.4 75.4 21.5 14.0 7.6 3.0 2.4 0.7 945 Second 15.3 1,161 20.6 73.2 21.2 13.9 7.3 5.6 5.2 0.4 1,098 Middle 11.8 1,271 20.8 69.5 21.5 13.5 8.0 9.0 7.7 1.3 1,186 Fourth 7.8 1,311 21.6 68.0 16.6 10.3 6.4 15.4 13.3 2.1 1,240 Highest 9.3 1,379 23.2 58.6 11.9 7.0 4.8 29.5 23.6 5.9 1,331 Total 11.6 6,145 21.4 68.3 18.2 11.5 6.7 13.5 11.2 2.2 5,800 Note: Body mass index is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding two months SLC = School Leaving Certificate 184 • Nutrition of Children and Women Eighteen percent of women of reproductive age are thin or undernourished (BMI < 18.5 kg/m2). The proportions of mild thinness (17.0-18.4 kg/m2) and moderate and severe thinness (<17 kg/m2) are 12 percent and 7 percent, respectively. Despite the absence of a linear correlation with age, the data show that adolescents (age 15-19) are most likely to be thin (26 percent). Rural women are more likely to be thin (19 percent) than urban women (14 percent). The proportion of women in the terai who are thin (23 percent) is almost double the proportion in the hill zone (12 percent). A notably higher percentage of women in the Far-western development region (24 percent) than in the Western region (14 percent) are thin. Among subregions, the highest proportion of thinness is in the Central terai subregion (26 percent) and the lowest is in the Western hill subregion (8 percent). Thinness is more common among women with no education (23 percent) than among women with an SLC and higher level of education (15 percent). Women in the lowest wealth quintile are more likely to be thin (22 percent) than women in the highest wealth quintile (12 percent). Eleven percent of women are overweight (BMI 25-29 kg/m2), and 2 percent are obese (BMI 30 kg/m2 or above). The prevalence of overweight/obesity has increased by 5 percentage points since 2006. Younger women are less likely than older women to be overweight or obese. For example, 3 percent of women age 15-19 are overweight or obese, compared with 22 percent of women age 40-49. Urban women are more likely to be overweight/obese (26 percent) than rural women (11 percent). Ecologically, the proportion of overweight/obese women is higher in the terai and hill zones (14 percent each) than in the mountain zone (8 percent). The Eastern development region has the highest proportion of overweight or obese women (17 percent) and the Far-western and Mid-western regions the lowest (5 percent and 8 percent, respectively). Among the subregions, the highest proportions of overweight or obese women are seen in the Central hill and Eastern terai subregions (22 percent and 19 percent, respectively), while the lowest proportions are observed in the Far-western hill and Western mountain subregions (2 percent and 3 percent, respectively). Overweight and obesity are positively correlated with wealth quintile: the proportion of overweight/obese women increases steadily from 3 percent in the lowest wealth quintile to 30 percent in the highest wealth quintile. 11.10 PREVALENCE OF ANEMIA IN WOMEN In Nepal, a number of interventions have been put in place to address anemia in women. These include supplementation of iron with folic acid tablets for pregnant women from the second trimester to 45 days following delivery, deworming of pregnant women after completion of the first trimester, postpartum vitamin A supplements, and promotion of the use of insecticide-treated mosquito nets for pregnant women in malaria- endemic areas. Table 11.11 presents anemia prevalence among women age 15-49 based on hemoglobin levels, according to selected background characteristics. Raw measured hemoglobin levels were obtained with the HemoCue instrument and adjusted by altitude and smoking status (if known) using CDC formulas (CDC, 1998). Table 11.11 shows that 35 percent of women age 15-49 are anemic, 6 percent are moderately anemic, and a very small proportion are severely anemic (0.3 percent). Anemia prevalence has declined by only 1 percentage point since the 2006 NDHS. There is also no difference in the prevalence of mild and moderate anemia between the two surveys. The prevalence of anemia is associated with maternity status. Pregnant women are more likely to be anemic (48 percent) than women who are breastfeeding (39 percent) and women who are neither pregnant nor breastfeeding (33 percent). This could be due to the high demand for iron and folic acid during pregnancy. Anemia is more prevalent in rural areas (36 percent) than in urban areas (28 percent). Anemia prevalence is higher among women in the terai (42 percent) than among women in the mountain or hill zone (27 percent). Notable variations can be seen across subregions. Women in the Mid-western terai and Eastern terai subregions are more likely to be anemic (49 percent and 45 percent, respectively) than women in the Central mountain and Central hill subregions (19 percent and 20 percent, respectively). Women’s level of education does not have a substantial impact on their likelihood of suffering from anemia. Surprisingly, the prevalence of anemia is lower among women who smoke than among those who do not (30 percent versus 36 percent). Nutrition of Children and Women • 185 Table 11.11 Prevalence of anemia in women Percentage of women age 15-49 with anemia, by background characteristics, Nepal 2011 Background characteristic Not pregnant: Anemia status by hemoglobin level Any <12.0 g/dl Mild 10.0-11.9 g/dl Moderate 7.0-9.9 g/dl Severe <7.0 g/dl Number of women Pregnant: <11.0 g/dl 10.0-10.9 g/dl 7.0-9.9 g/dl <7.0 g/dl Age 15-19 38.5 32.5 5.7 0.4 1,341 20-29 35.9 29.8 5.9 0.3 2,113 30-39 32.4 26.0 6.0 0.4 1,513 40-49 32.5 27.0 5.2 0.3 1,121 Number of children ever born 0 36.2 29.9 5.9 0.5 1,828 1 34.6 30.1 4.4 0.2 850 2-3 34.2 28.0 5.9 0.2 2,088 4-5 33.3 26.4 6.4 0.5 900 6+ 37.8 32.1 5.4 0.2 422 Maternity status Pregnant 47.6 29.3 17.7 0.5 293 Breastfeeding 38.9 32.7 6.0 0.2 1,348 Neither 33.0 27.8 4.9 0.4 4,447 Using IUD Yes 40.8 33.4 7.4 0.0 63 No 34.9 28.9 5.7 0.3 6,025 Smoking status Smokes cigarettes/tobacco 29.8 23.1 6.4 0.3 630 Does not smoke 35.6 29.6 5.7 0.3 5,458 Residence Urban 27.6 22.5 4.7 0.4 836 Rural 36.2 29.9 5.9 0.3 5,252 Ecological zone Mountain 26.9 21.1 5.5 0.3 399 Hill 26.9 22.6 3.8 0.5 2,436 Terai 42.0 34.6 7.2 0.2 3,252 Development region Eastern 37.4 30.9 6.5 0.1 1,465 Central 32.8 27.4 5.0 0.4 1,980 Western 34.5 29.8 4.2 0.5 1,314 Mid-western 36.2 28.3 7.2 0.7 704 Far-western 35.9 28.0 7.7 0.2 624 Subregion Eastern mountain 26.5 20.7 5.6 0.3 114 Central mountain 19.2 17.8 1.5 0.0 124 Western mountain 33.1 24.0 8.5 0.6 161 Eastern hill 26.1 21.3 4.6 0.2 472 Central hill 19.5 15.8 3.2 0.5 716 Western hill 35.9 31.4 4.0 0.5 737 Mid-western hill 22.5 17.7 4.3 0.5 308 Far-western hill 28.8 25.6 2.8 0.3 202 Eastern terai 44.9 37.4 7.6 0.0 880 Central terai 42.6 35.7 6.6 0.3 1,139 Western terai 32.7 27.8 4.5 0.4 576 Mid-western terai 49.0 39.1 9.0 0.8 316 Far-western terai 41.9 30.8 11.1 0.0 341 Education No education 37.4 29.8 7.3 0.3 2,403 Primary 31.9 28.3 3.2 0.4 1,068 Some secondary 33.7 27.8 5.4 0.4 1,498 SLC and above 34.5 29.1 5.2 0.2 1,119 Wealth quintile Lowest 34.5 27.8 6.3 0.4 1,024 Second 35.4 28.6 6.3 0.4 1,152 Middle 38.6 31.8 6.4 0.4 1,265 Fourth 35.5 30.3 5.1 0.1 1,297 Highest 31.2 26.0 4.8 0.4 1,350 Total 35.0 28.9 5.7 0.3 6,088 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC, 1998. SLC = School Leaving Certificate 11.11 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects the mother and infant against anemia, which is 186 • Nutrition of Children and Women considered a major cause of perinatal and maternal mortality. Anemia also results in an increased risk of premature delivery and low birth weight. Finally, iodine deficiency is related to a number of adverse pregnancy outcomes including abortion, fetal brain damage and congenital malformation, stillbirth, and prenatal death. In Nepal, micronutrient deficiency among pregnant and lactating mothers is a common public health problem. Thus, the 2011 NDHS collected data on use of vitamin A and iron-folic acid supplements among women age 15-49 with a child born in the past five years, use of deworming medication during the last pregnancy, and the percentage of women living in households with iodized salt according to background characteristics. A single dose of vitamin A is typically given to women within 45 days of childbirth, aimed at increasing the mother’s vitamin A level and the content of the vitamin in breast milk for the benefit of the child. Because of the risk of teratogenesis (abnormal development of the fetus) resulting from high doses of vitamin A during pregnancy, the dose should not be given to pregnant women. The MOHP policy regarding maternal vitamin A supplementation is (as mentioned above) to provide a high-dose vitamin A capsule (200,000 IU) within the first 45 days after delivery (MOHP, 2004b). However, the new WHO guidelines on postpartum vitamin A supplements do not recommend providing vitamin A to postpartum women, and the policy needs to be reviewed (WHO, 2011). Table 11.12 includes measures that are useful in assessing micronutrient intake by women during pregnancy and for two months after birth (postpartum period). The findings show that only 40 percent of women received a vitamin A dose during the postpartum period. There is no substantial variation across ecological zones. A slight difference can be seen among women who received postpartum vitamin A by urban and rural residence (46 percent and 40 percent, respectively). Women in the Far-western region were most likely to take vitamin A during the postpartum period (56 percent), while women in the Central region were least likely to do so (30 percent). The proportion of women taking vitamin A after childbirth was highest in the Far-western terai subregion (66 percent) and lowest in the Central terai subregion (24 percent). Women with an SLC and higher education were more than twice as likely as mothers with no education to have received a vitamin A supplement within two months of childbirth (62 and 28 percent, respectively). The prevalence of postpartum vitamin A supplementation increases with wealth, from 29 percent in the lowest quintile to 55 percent in the highest quintile. Nutritional deficiencies such as anemia are often exacerbated during pregnancy because of the additional nutrient demands associated with fetal growth. Iron status can be enhanced by including iron supplements in food consumed by women, improving women’s diets, and controlling parasites and malaria. Iron supplementation is necessary for pregnant women because their needs are usually too high to be met solely by food intake. Pregnant women are advised to take an iron tablet daily throughout their pregnancy and lactating period, starting from the second trimester and continuing to 45 days after childbirth (MOHP, 2004b). According to Table 11.12, 56 percent of women took iron tablets daily for 90 or more days during their last pregnancy. Five percent took iron supplements for 60 to 89 days, and 19 percent took supplements for fewer than 60 days. Twenty percent of pregnant women did not take iron supplements at all. The proportion of women taking daily iron supplements for 90 or more days differs substantially between urban and rural areas (68 percent and 54 percent, respectively). Pregnant women in the terai are more likely to take iron supplements daily for 90 or more days (58 percent) than those in the mountain zone (49 percent). The proportion of women taking iron tablets for at least 90 days is highest in the Far-western region (71 percent) and lowest in the Central region (50 percent). Across the subregions, the Far-western terai subregion has the highest proportion of women taking iron supplements for at least 90 days (84 percent), while the Central terai subregion has the lowest proportion (44 percent). The proportion of pregnant women who take iron supplements daily for 90 or more days is related to age, level of education, and wealth quintile. Women with an SLC and higher level of education are more likely to take iron tablets for 90 or more days (84 percent) than women with no education (40 percent). Women in the highest wealth quintile are more than twice as likely to take iron tablets for 90 or more days (79 percent) as those in the lowest wealth quintile (37 percent). Nutrition of Children and Women • 187 Table 11.12 Micronutrient intake among mothers Among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child, the percent distribution by number of days they took iron tablets or syrup during the pregnancy of the last child, and the percentage who took deworming medication during the pregnancy of the last child; and among women age 15-49 with a child born in the past five years and who live in households that were tested for iodized salt, the percentage who live in households with adequately iodized salt, by background characteristics, Nepal 2011 Background characteristic Among women with a childbirth in the past five years: Number of women Among women with a child born in the last five years who live in households that were tested for iodized salt: Percentage who received vitamin A dose postpartum1 Number of days women took iron tablets or syrup during pregnancy of last birth Percentage of women who took deworming medication during pregnancy of last birth None <60 60-89 90+ Don’t know/ missing Total Percentage living in households with adequately iodized salt2,3 Number of women Age 15-19 32.5 14.1 18.9 3.9 62.8 0.4 100.0 63.1 333 71.9 333 20-29 44.5 16.1 18.9 4.8 60.0 0.2 100.0 59.1 2,639 76.8 2,635 30-39 35.8 27.3 18.8 4.6 49.2 0.2 100.0 47.5 986 72.6 981 40-49 18.8 56.0 18.4 4.3 20.3 1.0 100.0 26.4 190 58.5 190 Residence Urban 45.8 11.1 16.0 4.5 68.3 0.0 100.0 49.8 418 91.8 418 Rural 39.7 21.5 19.2 4.7 54.4 0.2 100.0 55.7 3,730 72.6 3,721 Ecological zone Mountain 39.9 27.0 17.6 6.6 48.7 0.0 100.0 58.2 306 72.5 305 Hill 41.4 25.0 16.0 4.3 54.5 0.3 100.0 50.9 1,669 72.7 1,668 Terai 39.4 16.0 21.2 4.7 57.9 0.2 100.0 58.0 2,174 76.2 2,166 Development region Eastern 43.2 17.2 20.6 4.7 57.3 0.2 100.0 60.9 999 77.9 999 Central 30.4 23.4 21.8 4.7 49.9 0.1 100.0 41.8 1,293 77.3 1,290 Western 44.0 20.9 16.7 5.0 56.9 0.6 100.0 54.2 818 83.9 814 Mid-western 40.4 25.4 16.7 4.2 53.6 0.0 100.0 62.2 598 65.2 595 Far-western 55.7 11.5 13.0 4.5 71.0 0.0 100.0 73.3 440 54.0 440 Subregion Eastern mountain 52.0 24.8 20.2 5.4 49.6 0.0 100.0 63.1 78 80.0 78 Central mountain 42.5 28.0 19.5 4.6 48.0 0.0 100.0 50.9 72 73.1 72 Western mountain 32.6 27.6 15.5 8.2 48.7 0.0 100.0 59.2 155 68.4 155 Eastern hill 39.3 26.1 20.4 4.8 48.6 0.0 100.0 53.3 331 78.0 331 Central hill 40.8 22.1 13.1 2.9 61.4 0.4 100.0 39.7 403 78.5 403 Western hill 39.6 26.4 16.1 5.4 51.2 0.8 100.0 48.2 488 79.3 488 Mid-western hill 42.0 32.1 13.2 3.3 51.4 0.0 100.0 57.4 275 65.4 274 Far-western hill 51.2 13.6 18.3 4.6 63.5 0.0 100.0 69.7 171 41.6 171 Eastern terai 44.2 11.1 20.7 4.5 63.3 0.4 100.0 64.9 589 77.5 589 Central terai 24.1 23.6 26.4 5.6 44.3 0.0 100.0 42.1 818 77.1 815 Western terai 50.5 12.6 17.5 4.3 65.2 0.4 100.0 63.0 330 90.9 326 Mid-western terai 42.3 16.7 21.3 3.0 58.9 0.0 100.0 68.4 238 61.5 236 Far-western terai 66.3 4.3 7.6 4.3 83.8 0.0 100.0 81.8 200 62.4 200 Education No education 27.8 31.0 23.8 5.2 39.8 0.2 100.0 44.4 1,822 62.5 1,815 Primary 41.0 21.2 21.7 4.5 52.4 0.2 100.0 56.4 835 75.7 832 Some secondary 49.8 10.1 13.0 4.5 72.2 0.1 100.0 67.7 866 85.6 866 SLC and above 62.3 2.8 8.6 3.8 84.3 0.4 100.0 67.2 627 92.6 626 Wealth quintile Lowest 29.1 38.2 19.1 5.1 37.3 0.4 100.0 43.8 979 54.6 976 Second 36.6 22.2 22.0 4.4 51.4 0.0 100.0 55.8 899 66.9 897 Middle 38.7 17.8 22.8 5.7 53.6 0.1 100.0 58.9 873 76.5 871 Fourth 48.7 11.4 15.9 5.1 67.5 0.0 100.0 61.7 748 87.6 746 Highest 54.5 5.2 12.2 2.6 79.4 0.6 100.0 58.7 649 97.4 649 Total 40.3 20.4 18.8 4.7 55.8 0.2 100.0 55.1 4,148 74.5 4,139 1 In the first two months after delivery 2 Excludes women in households where salt was not tested 3 Salt with 15 ppm or more iodine SLC = School Leaving Certificate Overall, only 38 percent of pregnant women took iron tablets for 180 days or more as recommended (data not shown separately). However, this is an improvement over 2006, when only 7 percent of women took the recommended dose (MOHP, New ERA, and Macro International Inc., 2007). Forty-one percent of women took iron tablets after childbirth, and one in two women took them for 45 days or more (data not shown separately). Helminth (intestinal parasites) infections are one of the factors contributing to anemia among pregnant women. Deworming during pregnancy is a cost-effective intervention against intestinal worms that allows better absorption of nutrients and iron, thus reducing the prevalence of anemia. In Nepal, the Ministry of Health and Population has approved and implemented a policy to provide deworming medication (MOHP, 2004b). 188 • Nutrition of Children and Women Table 11.12 shows that 55 percent of women took deworming medication during their last pregnancy. Rural women are more likely to take deworming medication (56 percent) than urban women (50 percent). Women in the hill zone are less likely to take deworming tablets (51 percent) than women in the terai and mountain zone (58 percent). At the regional level, women in the Far-western region are most likely to take deworming medication (73 percent), while women in the Central region least likely (42 percent). There is a strong association between women’s education and wealth status and their intake of deworming medication. The proportion of women taking deworming medication is higher among those with some secondary education (68 percent) than among those with no education (44 percent). The proportion of pregnant women taking deworming tablets steadily increases from the lowest to the fourth wealth quintile (44 percent to 62 percent) before decreasing slightly among women in the highest quintile (59 percent). Iodine deficiency has adverse effects on all population groups, but women of reproductive age are often the most affected. As mentioned, iodine deficiency is related to adverse pregnancy outcomes such as abortion, fetal brain damage and congenital malformation, stillbirth, and perinatal death. As a result, use of iodized salt by women of reproductive age is emphasized. Table 11.12 shows that three in four women with a child born in the five years preceding the survey live in households with adequately iodized salt. The Western region has the highest proportion of women living in households with adequately iodized salt (84 percent), while the Far-western region has the lowest (54 percent). At the subregional level, women in the Western terai subregion are most likely to live in households using adequately iodized salt (91 percent), while women in the Far-western hill subregion are least likely to live in such households (42 percent). The proportion of women living in households using adequately iodized salt is positively related to educational level and wealth status. HIV and AIDS-related Knowledge, Attitudes, and Behavior • 189 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 12 12.1 INTRODUCTION According to the 2010 UNAIDS report on the global AIDS epidemic, an estimated 64,000 adults and children in Nepal were living with HIV by the end of 2009 (up from 60,000 in 2001), of whom 20,000 were women age 15 and older (NCASC, 2010a). In addition, an estimated 4,800 people were newly infected with HIV in 2009, and there were 4,700 deaths due to AIDS in that year, up from 4,000 in 2001. Since 1988, when the first case of AIDS was detected in Nepal, the HIV situation in the country has evolved from a low prevalence of cases to an epidemic concentrated among several key affected populations: injecting drug users, female sex workers (FSWs) and their clients, and men who have sex with men (MSM). As in other developing countries, transmission of HIV in Nepal is driven by factors such as poverty, low literacy levels, low levels of male and female condom use, cultural and religious factors, and stigma and discrimination. Nepal’s National HIV Strategic Information Plan is based on the second generation surveillance approach. As part of that plan, the National Centre for AIDS and STD Control (NCASC) within the Department of Health has been conducting Integrated Bio-behavioral and Surveillance Surveys at planned intervals since 2002 among at-risk groups. The survey results show that HIV/AIDS is concentrated among the key affected populations mentioned above to varying degrees and that commercial sex, sharing of injecting needles, and migration to India are the primary risk factors. In 2009, estimated HIV prevalence was highest among injecting drug users (9 percent), followed by MSM (3 percent), FSWs (2 percent), and migrants (1 percent) (NCASC, 2010a). Additionally, the NCASC reports that HIV infections are more common among men than women, as well as in urban areas and the Far-western region of the country, where migrant labor is more widespread. Despite the challenges involved in scaling up and sustaining HIV programs at a high level, Nepal has made progress in several areas. The NCASC is the main government agency responsible for implementing prevention programs and providing technical guidance in the HIV and AIDS response. Many new initiatives have been undertaken since the development of the first AIDS policy. In 1995, a national HIV/AIDS policy was endorsed, with 12 key policy statements and supportive structures including the National AIDS Coordination Committee and the District AIDS Coordination Committee, to guide and coordinate the response at the central and district levels. In 2002, the National AIDS Council (NAC), chaired by the prime minister, was established to raise the profile of HIV/AIDS in the country. The NAC was intended to set overall policy, lead high-level advocacy, and provide overall guidance and direction to the national HIV/AIDS program (Ministry of Health and Population [MOHP], 2011a). Key Findings: • Eighty-six percent of women and 97 percent of men age 15-49 have heard of AIDS. • Comprehensive knowledge of AIDS is not widespread among either women (21 percent) or men (30 percent). • Only about one in four women (27 percent) and men (29 percent) know of ways to prevent mother-to-child transmission of HIV. • Overall, half of women and men age 15-49 express accepting attitudes toward people living with AIDS. • Thirteen percent of sexually active women and 3 percent of sexually active men age 15-49 reported having had a sexually transmitted infection (STI) and/or STI symptoms in the 12 months prior to the survey. • One-quarter of female and one-third of male youths age 15-24 have comprehensive knowledge of AIDS. 190 • HIV and AIDS-related Knowledge, Attitudes, and Behavior The first five-year national HIV/AIDS strategy, developed in 2002, focused on prevention, care, and support for the most-at-risk populations. The second national HIV and AIDS strategy (2006-2011) has focused on lowering the prevalence of HIV among these populations, reducing the vulnerability of young people, and providing quality treatment and care to infected as well as affected people (MOHP, 2011a). The second national policy on HIV and sexually transmitted infections (STIs) was developed recently with the vision of reducing the HIV infection rate and establishing an HIV and AIDS- and STI-free society (MOHP, 2010c). Based on this policy, the 2011-2015 HIV/AIDS strategy is currently being updated and finalized. The three-year interim plan identifies managing the HIV epidemic as a high priority in the health sector. The plan focuses on the need for prevention programs within an overall broader program that addresses the need for treatment, care, and support of people living with HIV/AIDS. The government is also committed to various global initiatives such as the UNGASS Declaration, the Millennium Development Goals, the universal access initiative, and the “three ones” principles. The national HIV/AIDS strategy (2006-2011) aims at achieving all HIV and AIDS commitments and targets included within these initiatives (MOHP, 2011a). The 2011 NDHS included a series of questions on knowledge of HIV/AIDS, attitudes toward AIDS, and related behavior. All women and men age 15-49 were first asked whether they had ever heard of AIDS. Those who had heard of AIDS were asked about their knowledge of HIV transmission and prevention. Respondents were also asked whether they had used condoms to prevent HIV and about their perception of the precautions a person can take to avoid becoming infected with HIV. Additional questions dealt with common local misconceptions regarding the mode of transmission of HIV. This chapter presents current levels of HIV/AIDS knowledge, attitudes, and related behaviors in the general adult population. The chapter also focuses on HIV/AIDS knowledge and patterns of sexual activity among youth, as young people are the main target of many HIV prevention efforts. 12.2 HIV AND AIDS KNOWLEDGE, TRANSMISSION, AND PREVENTION METHODS 12.2.1 Knowledge of AIDS Table 12.1 shows that 86 percent of women and 97 percent of men age 15-49 have heard of AIDS. There are notable differences in awareness among women by background characteristics. Knowledge of AIDS declines with age, being higher among women younger than age 40 than among women age 40-49. Never- married women are more likely to have heard of AIDS than married women. Knowledge of AIDS among women is higher in the hill zone than in the terai and mountain zone. Knowledge is also higher among women in the Far-western development region than among women in the other four development regions. Knowledge of AIDS is universal among women with a School Leaving Certificate (SLC) or higher level of education; however, only slightly more than 70 percent of women with no education have heard of AIDS. Similarly, awareness is lowest among women living in the poorest households and highest among women living in the wealthiest households. There is little variation in AIDS awareness among men because of the very high percentage of men who have heard of AIDS. Over the past five years, the percentage of women age 15-49 who have heard of AIDS has increased by 19 percent. Knowledge among men in the same age group has increased as well (by 6 percent), but not as much as among women. The increase in the percentage of women and men who have heard of AIDS can be attributed to the intensive HIV and AIDS prevention programs administered through nongovernmental organizations (NGOs), international NGOs, and the private and public sectors in the past decade. The NCASC has focused on awareness programs through government health facilities using mass media (radio, television, and print media), as well as through female community health volunteers across the 75 districts of the country. HIV and AIDS-related Knowledge, Attitudes, and Behavior • 191 Table 12.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Nepal 2011 Background characteristic Women Men Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-24 89.0 5,050 98.1 1,663 15-19 88.7 2,753 97.0 978 20-24 89.3 2,297 99.7 685 25-29 86.8 2,101 98.0 581 30-39 85.9 3,291 96.4 1,041 40-49 80.6 2,232 94.1 836 Marital status Never married 91.7 2,708 97.8 1,433 Ever had sex * 18 99.4 352 Never had sex 91.7 2,691 97.3 1,081 Married 85.0 9,608 96.4 2,626 Divorced/separated/widowed 81.8 358 (92.3) 62 Residence Urban 94.7 1,819 99.1 717 Rural 85.0 10,855 96.4 3,404 Ecological zone Mountain 85.9 805 97.0 245 Hill 93.9 5,090 97.4 1,658 Terai 80.7 6,779 96.4 2,218 Development region Eastern 91.5 3,057 98.9 996 Central 78.7 4,236 95.0 1,448 Western 90.2 2,660 98.3 798 Mid-western 84.9 1,478 94.1 493 Far-western 93.2 1,242 99.1 385 Subregion Eastern mountain 89.5 229 98.5 66 Central mountain 89.9 258 95.8 69 Western mountain 80.2 319 96.8 110 Eastern hill 93.6 956 98.1 293 Central hill 95.6 1,563 97.8 616 Western hill 93.5 1,513 97.2 440 Mid-western hill 90.2 649 94.4 189 Far-western hill 96.1 409 99.5 120 Eastern terai 90.7 1,873 99.3 638 Central terai 66.6 2,415 92.7 763 Western terai 85.8 1,147 99.6 358 Mid-western terai 84.1 668 93.9 242 Far-western terai 91.3 676 98.6 217 Education No education 71.3 5,045 84.8 567 Primary 89.8 2,209 95.3 814 Some secondary 98.3 3,088 99.6 1,437 SLC and above 99.9 2,331 100.0 1,303 Wealth quintile Lowest 77.9 2,120 90.8 610 Second 79.1 2,393 94.2 695 Middle 82.6 2,600 97.5 830 Fourth 91.6 2,722 99.3 920 Highest 97.2 2,839 99.4 1,066 Total 15-49 86.3 12,674 96.8 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 12.2.2 Knowledge of HIV Prevention Methods HIV is mainly transmitted through heterosexual contact. Nepal’s national HIV prevention program has sought to reduce sexual transmission of the virus by promoting HIV prevention programs that focus their messages and efforts on important aspects of behavior. Most HIV/AIDS programs that target the general population promote being faithful to a partner and condom use as the primary ways of avoiding HIV infection among sexually active men and women, who make up the majority of all adults in virtually every population. To ascertain whether programs have effectively communicated these messages, respondents were asked specific questions about whether it is possible to reduce the chances of getting the AIDS virus by having just one faithful uninfected sexual partner and using a condom during every sexual encounter. 192 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Table 12.2 shows that knowledge of HIV prevention methods is high in Nepal. Seventy-four percent of women and 89 percent of men know that using condoms every time they have sexual intercourse prevents the spread of HIV. Seventy-nine percent of women and 89 percent of men know that limiting sexual intercourse to one uninfected partner who has no other partners can reduce the chances of contracting HIV. Seventy-one percent of women and 84 percent of men know that both using condoms and limiting sexual intercourse to one uninfected partner can reduce the risk of HIV infection. Table 12.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse and by having one sex partner who is not infected and has no other partners, by background characteristics, Nepal 2011 Background characteristic Women Men Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner2 Number of men Age 15-24 78.9 83.6 76.6 5,050 91.7 91.5 87.0 1,663 15-19 78.2 83.7 76.0 2,753 90.1 91.3 85.9 978 20-24 79.8 83.4 77.2 2,297 94.0 91.7 88.5 685 25-29 76.3 80.3 73.4 2,101 89.9 92.0 85.6 581 30-39 74.0 77.7 70.3 3,291 88.7 87.2 83.7 1,041 40-49 62.0 68.0 57.5 2,232 85.1 85.0 79.0 836 Marital status Never married 82.6 87.4 80.8 2,708 91.5 91.6 87.3 1,433 Ever had sex * * * 18 94.0 92.9 88.6 352 Never had sex 82.5 87.3 80.7 2,691 90.7 91.2 86.9 1,081 Married 72.2 76.7 68.7 9,608 88.7 88.4 83.4 2,626 Divorced/separated/widowed 64.6 70.2 59.4 358 (65.4) (65.4) (55.5) 62 Residence Urban 84.8 88.0 81.5 1,819 89.9 91.1 84.5 717 Rural 72.5 77.2 69.3 10,855 89.3 88.8 84.3 3,404 Ecological zone Mountain 72.1 78.5 68.8 805 90.8 93.6 88.4 245 Hill 80.9 85.7 77.3 5,090 91.4 89.9 85.6 1,658 Terai 69.5 73.6 66.7 6,779 87.7 88.1 83.0 2,218 Development region Eastern 77.6 83.7 73.7 3,057 91.2 91.7 86.4 996 Central 66.0 69.3 62.6 4,236 87.1 87.0 82.0 1,448 Western 79.4 83.7 76.9 2,660 92.6 89.1 86.2 798 Mid-western 74.5 78.9 72.5 1,478 85.7 86.2 81.5 493 Far-western 82.5 88.1 79.3 1,242 91.1 94.5 87.6 385 Subregion Eastern mountain 78.8 85.4 76.9 229 89.8 90.5 84.6 66 Central mountain 75.0 82.1 72.5 258 90.3 95.2 89.7 69 Western mountain 64.9 70.7 60.1 319 91.7 94.5 89.9 110 Eastern hill 80.1 87.8 77.1 956 91.0 95.0 87.9 293 Central hill 82.3 85.6 77.5 1,563 91.0 87.5 83.4 616 Western hill 80.7 84.5 77.3 1,513 91.5 87.3 84.1 440 Mid-western hill 76.3 81.7 73.4 649 89.9 91.0 86.9 189 Far-western hill 85.8 91.7 82.8 409 96.5 97.5 94.5 120 Eastern terai 76.2 81.4 71.5 1,873 91.4 90.3 86.0 638 Central terai 54.6 57.4 52.0 2,415 83.7 85.8 80.2 763 Western terai 77.5 82.6 76.2 1,147 94.0 91.4 88.7 358 Mid-western terai 78.0 80.9 77.0 668 81.8 81.1 76.0 242 Far-western terai 81.6 87.3 79.2 676 86.9 92.1 82.2 217 Education No education 54.4 59.8 50.1 5,045 70.3 71.3 63.4 567 Primary 77.8 80.7 73.5 2,209 85.1 81.8 76.2 814 Some secondary 89.3 94.4 87.2 3,088 92.9 93.9 89.0 1,437 SLC and above 93.9 97.4 92.6 2,331 96.4 96.4 93.4 1,303 Wealth quintile Lowest 59.7 65.8 55.6 2,120 80.0 79.5 74.0 610 Second 65.9 71.1 62.7 2,393 85.8 85.3 79.7 695 Middle 70.7 74.7 67.2 2,600 90.3 91.7 86.6 830 Fourth 81.2 85.0 77.9 2,722 91.6 90.3 85.8 920 Highest 88.7 92.6 86.6 2,839 94.4 94.1 90.3 1,066 Total 15-49 74.2 78.8 71.1 12,674 89.4 89.2 84.3 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners HIV and AIDS-related Knowledge, Attitudes, and Behavior • 193 Knowledge of HIV prevention methods is higher among young women (age 15-24) than among older women. Also, women who have never been married and who have never had sex are more likely to know of HIV prevention methods (81 percent) than married women (69 percent) and women who are divorced, separated, and widowed (59 percent). Knowledge of HIV prevention methods is higher among women in urban than rural areas (82 percent and 69 percent, respectively). Seventy-seven percent of women living in the hill zone know that both using condoms and being faithful reduce the risk of HIV transmission, compared with 67 percent of women in the terai and 69 percent of women in the mountain zone. Knowledge of HIV prevention methods increases with level of education and wealth quintile. A similar pattern of differences by background characteristics is seen among men, although the differences are less pronounced. In contrast to women, however, knowledge of prevention methods is higher among men in the mountain zone than among men in the hill and terai areas. This result was different than in 2006, when men in the mountain zone were less aware of prevention methods (67 percent in 2006 versus 88 percent in 2011). In comparison to findings from the 2006 NDHS, knowledge of HIV prevention methods has increased among women in all regions. Women and men with no education and those from the poorest households are least likely to be aware of HIV prevention methods. 12.2.3 Comprehensive Knowledge of HIV and AIDS Transmission As part of the effort to assess HIV and AIDS knowledge, the 2011 NDHS collected information on common misconceptions about HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have HIV and whether they believe HIV is transmitted through mosquito bites, touching someone who has AIDS, or sharing food with a person who has HIV or AIDS. Comprehensive knowledge is defined as knowing that consistent condom use and having just one uninfected faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV transmission in Nepal: that HIV can be transmitted by mosquito bites and that HIV can be transmitted by sharing food with a person who has AIDS. Tables 12.3.1 and 12.3.2 show that many Nepalese adults lack accurate knowledge about the ways in which the AIDS virus is transmitted. Seventy-four percent of women know that a healthy-looking person can have HIV, compared with 85 percent of men. Only 28 percent of women and 39 percent of men know that HIV cannot be transmitted by mosquitoes. The fact that a majority of men and women still have this misconception indicates that the government should focus on awareness programs to reduce these misconceptions. Fifty-three percent of women and 67 percent of men believe that HIV cannot be transmitted by sharing food with a person who has AIDS, and 69 percent of women and 81 percent of men believe that HIV cannot be transmitted by touching a person who has AIDS. Only 21 percent of women and 30 percent of men have comprehensive knowledge about AIDS. There has not been much change in comprehensive knowledge of HIV among women over the past five years, and there has been a decline in knowledge among men. The results of the 2006 NDHS showed that 20 percent of women and 36 percent of men age 15-49 had comprehensive knowledge of AIDS prevention and transmission, indicating that the government needs to do much more to increase awareness and knowledge of HIV and AIDS among the public. 194 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Table 12.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission and prevention of AIDS virus, and the percentage with comprehensive knowledge about AIDS, by background characteristics, Nepal 2011 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about AIDS2 Number of women A healthy- looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites A person cannot become infected by sharing food with a person who has the AIDS virus The AIDS virus cannot be transmitted by touching someone who has AIDS Age 15-24 77.8 33.4 61.7 75.8 28.0 25.8 5,050 15-19 77.9 32.1 61.8 76.7 27.2 25.0 2,753 20-24 77.6 34.9 61.5 74.8 28.9 26.7 2,297 25-29 75.0 30.5 56.6 70.5 25.2 23.9 2,101 30-39 73.3 25.0 49.2 66.9 20.2 18.5 3,291 40-49 64.8 15.4 38.2 56.9 10.2 9.2 2,232 Marital status Never married 81.0 40.3 70.4 82.8 34.7 32.4 2,708 Ever had sex * * * * * * 18 Never had sex 80.9 40.5 70.6 82.8 34.8 32.5 2,691 Married 72.1 24.3 49.0 65.8 19.1 17.6 9,608 Divorced/separated/widowed 69.0 18.0 43.0 59.8 15.6 13.8 358 Residence Urban 84.1 43.1 72.1 84.6 38.0 34.9 1,819 Rural 72.2 25.0 50.3 66.7 19.7 18.3 10,855 Ecological zone Mountain 74.9 17.8 35.1 54.9 10.9 10.0 805 Hill 80.7 28.8 58.1 75.0 23.7 22.3 5,090 Terai 68.6 27.8 52.1 66.7 22.7 20.7 6,779 Development region Eastern 81.1 29.6 54.5 74.8 22.9 20.3 3,057 Central 65.8 26.6 49.8 64.0 21.8 20.3 4,236 Western 76.8 29.4 61.2 74.9 25.3 23.6 2,660 Mid-western 73.2 20.9 47.1 61.1 17.3 16.3 1,478 Far-western 78.3 29.9 54.1 71.5 22.6 21.6 1,242 Subregion Eastern mountain 82.6 19.9 43.6 68.3 14.5 13.2 229 Central mountain 76.5 20.0 39.9 54.9 12.6 12.0 258 Western mountain 67.9 14.5 25.2 45.1 6.9 6.1 319 Eastern hill 81.9 23.7 48.6 71.6 17.1 15.7 956 Central hill 84.0 39.3 68.2 83.2 34.5 32.2 1,563 Western hill 74.5 24.9 59.4 73.0 20.2 19.6 1,513 Mid-western hill 81.2 18.9 49.9 63.9 16.0 14.6 649 Far-western hill 87.9 30.5 50.4 77.1 22.5 21.7 409 Eastern terai 80.6 33.8 58.8 77.3 26.8 23.4 1,873 Central terai 52.8 19.1 39.0 52.5 14.6 13.6 2,415 Western terai 79.8 35.3 63.7 77.4 32.0 28.8 1,147 Mid-western terai 69.3 25.8 51.3 65.3 21.7 20.8 668 Far-western terai 72.3 31.6 61.6 71.1 25.9 24.8 676 Education No education 55.0 10.4 26.5 44.9 5.7 4.9 5,045 Primary 74.1 18.1 48.3 69.0 12.6 11.5 2,209 Some secondary 88.1 37.1 73.0 88.3 30.7 28.3 3,088 SLC and above 95.7 61.1 90.8 97.2 56.6 53.4 2,331 Wealth quintile Lowest 61.1 13.1 27.6 47.6 6.7 5.8 2,120 Second 65.8 15.8 39.1 57.6 12.0 11.0 2,393 Middle 67.8 21.4 47.0 64.9 15.3 14.2 2,600 Fourth 81.2 33.0 64.4 78.7 28.1 25.9 2,722 Highest 88.8 48.7 80.3 90.3 43.7 40.8 2,839 Total 15-49 73.9 27.6 53.4 69.3 22.4 20.7 12,674 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 Two most common local misconceptions: AIDS can be transmitted by mosquito bites and a person can become infected by sharing food with someone who has AIDS. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission and prevention of the AIDS virus. HIV and AIDS-related Knowledge, Attitudes, and Behavior • 195 Table 12.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission and prevention of AIDS virus, and the percentage with comprehensive knowledge about AIDS, by background characteristics, Nepal 2011 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about AIDS2 Number of men A healthy- looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites A person cannot become infected by sharing food with a person who has the AIDS virus The AIDS virus cannot be transmitted by touching someone who has AIDS Age 15-24 85.5 44.2 72.8 85.9 37.3 33.9 1,663 15-19 82.9 43.6 70.3 84.5 36.2 32.7 978 20-24 89.3 44.9 76.3 87.9 38.9 35.6 685 25-29 87.3 37.1 70.7 83.7 33.1 29.8 581 30-39 86.1 36.9 65.1 78.9 31.3 28.7 1,041 40-49 83.1 30.6 57.3 73.1 24.6 21.7 836 Marital status Never married 85.7 47.6 75.1 87.8 40.9 37.1 1,433 Ever had sex 89.8 49.3 78.0 90.6 42.6 38.3 352 Never had sex 84.4 47.0 74.1 86.9 40.4 36.7 1,081 Married 85.5 33.7 63.4 77.9 28.1 25.5 2,626 Divorced/separated/widowed (79.0) (37.2) (59.4) (71.4) (30.4) (24.4) 62 Residence Urban 87.7 51.8 80.8 90.3 45.8 40.5 717 Rural 85.0 35.8 64.6 79.3 29.9 27.2 3,404 Ecological zone Mountain 88.7 25.9 58.5 76.2 21.5 19.7 245 Hill 87.7 40.7 72.8 86.1 36.3 32.6 1,658 Terai 83.4 38.4 64.4 78.1 31.1 28.3 2,218 Development region Eastern 87.6 35.5 67.6 82.1 29.4 26.8 996 Central 82.6 38.3 64.2 78.9 31.9 28.7 1,448 Western 85.5 43.5 73.2 87.5 37.4 33.4 798 Mid-western 83.7 35.8 63.5 71.2 30.7 28.5 493 Far-western 92.6 41.0 72.1 87.5 36.6 32.9 385 Subregion Eastern mountain 89.0 30.3 58.2 74.1 25.3 21.4 66 Central mountain 83.4 18.5 55.6 81.3 14.2 13.0 69 Western mountain 91.7 28.0 60.6 74.3 23.9 22.9 110 Eastern hill 87.9 28.0 63.3 83.9 23.1 21.0 293 Central hill 88.2 47.5 79.2 89.9 43.2 38.4 616 Western hill 86.7 40.6 73.1 86.7 36.1 31.1 440 Mid-western hill 84.6 39.3 69.1 75.5 36.0 35.3 189 Far-western hill 92.9 38.8 67.6 86.9 33.8 32.8 120 Eastern terai 87.4 39.5 70.5 82.2 32.6 30.0 638 Central terai 78.0 32.6 52.9 69.8 24.3 22.3 763 Western terai 84.0 47.2 73.3 88.5 38.9 36.3 358 Mid-western terai 81.9 35.9 60.0 69.2 29.1 25.3 242 Far-western terai 91.5 44.1 77.1 88.3 40.2 34.5 217 Education No education 68.1 9.9 27.3 47.4 6.0 4.4 567 Primary 81.5 19.0 50.0 70.1 13.6 11.2 814 Some secondary 87.5 39.4 72.6 86.8 31.7 28.5 1,437 SLC and above 93.1 62.4 90.0 96.7 57.2 53.1 1,303 Wealth quintile Lowest 77.7 18.8 46.1 64.9 15.1 12.8 610 Second 80.9 24.5 53.5 73.3 18.7 17.2 695 Middle 84.0 32.3 61.7 77.6 24.6 22.9 830 Fourth 87.5 44.5 75.9 86.4 39.8 35.0 920 Highest 92.2 58.8 85.8 94.1 51.8 47.6 1,066 Total 15-49 85.4 38.6 67.4 81.2 32.6 29.5 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 1 Two most common local misconceptions: AIDS can be transmitted by mosquito bites and a person can become infected by sharing food with someone who has AIDS. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission and prevention of the AIDS virus. Comprehensive knowledge of AIDS is lower among older men and women (age 40-49), married respondents, and rural residents than among their counterparts in the other categories. It is also lower among residents of the mountain zone, men in the Eastern region and women in the Mid-western region, men in the Central mountain subregion and women in the Western mountain subregion, women and men with no education, and those living in the poorest households. 196 • HIV and AIDS-related Knowledge, Attitudes, and Behavior 12.3 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing knowledge about prevention of mother-to-child transmission (PMTCT) of HIV and using antiretroviral medication before delivery to reduce transmission is critical. In Nepal, the PMTCT program was established in 2005, and it covers 21 sites (NCASC, 2010b). To assess PMTCT knowledge, respondents were asked whether HIV can be transmitted from a mother to a child through breastfeeding and whether a mother with HIV can reduce the risk of transmission to her baby by taking certain drugs during pregnancy. Table 12.4 shows that 61 percent of women and 57 percent of men know that HIV can be transmitted through breastfeeding. Thirty-five percent of women and 44 percent of men know that the risk of mother-to- child transmission can be reduced if the mother takes special drugs during pregnancy. More than one in four women (27 percent) and men (29 percent) know of both ways to prevent mother-to-child transmission of HIV. Knowledge of PMTCT is higher among younger (age 15-24) than older (age 40-49) women and men and higher among married than formerly married respondents. There is little difference in women’s knowledge of PMTCT by urban-rural residence; however, men in rural areas are much more likely to have knowledge of PMTCT (31 percent) than their counterparts in urban areas (21 percent). Respondents in the Far-western development region and the Far-western terai subregion are much more aware of PMTCT than their counterparts in other areas. Not surprisingly, women and men with no education and those from the poorest households are least likely to be aware of PMTCT. However, women and men with SLC and higher levels of education are also less likely to be aware about PMTCT. Table 12.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Nepal 2011 Background characteristic Women Men Percentage who know that: Percentage who know that: HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 61.5 37.8 28.0 5,050 56.9 49.2 31.6 1,663 15-19 61.6 39.0 29.1 2,753 58.8 50.1 34.7 978 20-24 61.3 36.4 26.8 2,297 54.2 48.0 27.3 685 25-29 59.6 34.7 25.7 2,101 54.3 41.2 27.8 581 30-39 60.8 33.2 26.2 3,291 55.9 40.9 26.9 1,041 40-49 62.1 29.6 24.7 2,232 60.6 38.0 28.0 836 Marital status Never married 60.4 39.8 29.0 2,708 54.3 48.5 30.9 1,433 Ever had sex * * * 18 56.0 49.9 33.3 352 Never had sex 60.4 39.9 29.0 2,691 53.7 48.0 30.1 1,081 Married 61.3 33.4 26.0 9,608 58.7 41.4 28.6 2,626 Divorced/separated/widowed 60.9 29.4 24.5 358 (47.4) (31.2) (12.7) 62 Pregnancy status Pregnant 60.0 34.4 27.3 621 na na na na Not pregnant or not sure 61.2 34.7 26.5 12,053 na na na na Residence Urban 57.1 36.5 25.1 1,819 48.3 39.0 20.9 717 Rural 61.8 34.4 26.8 10,855 58.8 44.7 30.9 3,404 Ecological zone Mountain 69.8 33.2 29.2 805 70.3 37.8 30.1 245 Hill 65.3 34.6 26.4 5,090 55.0 41.7 26.4 1,658 Terai 56.9 34.9 26.4 6,779 57.0 45.9 31.1 2,218 Development region Eastern 68.1 40.9 32.3 3,057 61.7 55.3 38.1 996 Central 54.2 28.3 21.2 4,236 53.5 39.0 25.8 1,448 Western 56.5 32.8 22.8 2,660 52.3 34.4 19.4 798 Mid-western 62.9 35.3 28.6 1,478 58.2 34.6 24.8 493 Far-western 75.2 44.5 36.3 1,242 66.2 62.5 44.4 385 Continued. HIV and AIDS-related Knowledge, Attitudes, and Behavior • 197 Table 12.4—Continued Background characteristic Women Men Percentage who knows that: Percentage who knows that: HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Subregion Eastern mountain 78.0 38.3 34.2 229 68.5 41.8 32.9 66 Central mountain 70.6 29.8 26.8 258 62.6 37.9 28.1 69 Western mountain 63.3 32.2 27.6 319 76.1 35.3 29.8 110 Eastern hill 74.9 38.9 32.5 956 62.5 52.8 37.0 293 Central hill 61.1 35.1 24.9 1,563 45.2 36.1 18.1 616 Western hill 57.6 26.5 18.6 1,513 54.3 36.1 21.5 440 Mid-western hill 70.4 40.0 32.9 649 64.1 45.8 36.6 189 Far-western hill 80.1 43.6 37.1 409 75.7 57.8 45.2 120 Eastern terai 63.5 42.1 32.0 1,873 60.6 57.9 39.2 638 Central terai 48.0 23.6 18.3 2,415 59.5 41.5 31.8 763 Western terai 54.9 41.2 28.4 1,147 49.8 32.3 16.9 358 Mid-western terai 57.2 32.2 25.0 668 49.4 26.5 14.7 242 Far-western terai 73.3 47.2 37.5 676 58.4 70.0 46.7 217 Education No education 57.6 24.8 22.0 5,045 57.3 28.8 24.3 567 Primary 68.9 37.6 31.4 2,209 63.0 38.2 29.1 814 Some secondary 66.2 42.7 30.8 3,088 61.4 50.8 34.8 1,437 SLC and above 54.5 42.6 26.2 2,331 48.3 45.9 25.1 1,303 Wealth quintile Lowest 63.4 25.9 22.9 2,120 60.8 34.3 27.2 610 Second 62.5 29.8 25.1 2,393 61.3 43.8 33.6 695 Middle 61.2 32.6 26.5 2,600 63.0 46.1 32.0 830 Fourth 63.9 41.5 30.3 2,722 56.1 48.1 30.8 920 Highest 55.4 40.7 27.1 2,839 48.2 43.5 23.7 1,066 Total 15-49 61.1 34.7 26.6 12,674 57.0 43.7 29.2 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate na = Not applicable 12.4 ACCEPTING ATTITUDES TOWARD THOSE LIVING WITH HIV AND AIDS The HIV and AIDS epidemic has generated fear, anxiety, and prejudice against people living with HIV and AIDS. There is widespread stigma and discrimination against people who are HIV positive. These societal attitudes can adversely affect both people’s willingness to be tested for HIV and their initiation of and adherence to antiretroviral therapy. Reducing stigma and discrimination is therefore an important factor in the prevention, management, and control of the HIV epidemic. In the 2011 NDHS, women and men who had heard of AIDS were asked a number of questions to assess the level of stigma associated with HIV and AIDS. Tables 12.5.1 and 12.5.2 present results for women and men age 15-49, respectively. Similar proportions of women and men reported that they would be willing to take care of a family member with HIV at home (91 percent and 92 percent, respectively). However, men were slightly more likely than women to say that they would buy fresh vegetables from a shopkeeper who has HIV (75 percent versus 69 percent) and to think that a female teacher with HIV should be allowed to continue teaching (82 percent versus 79 percent). Women were much more likely than men not to want to keep secret a family member’s infection with HIV (73 percent versus 65 percent). Overall, half of women and men are likely to express accepting attitudes regarding all four situations. Accepting attitudes are generally more common among respondents in urban areas than among those in rural areas and increase with education and wealth. Women in the terai are more likely to express accepting attitudes toward people living with HIV or AIDS (54 percent) than those in the other ecological zones. Among men, those in the hill region are more likely to express accepting attitudes (52 percent) than those in the mountain and terai regions (45 percent each). 198 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Table 12.5.1 Accepting attitudes toward those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Nepal 2011 Background characteristic Percentage of respondents who: Percentage expressing accepting attitudes on all four indicators Number of women who have heard of AIDS Are willing to care for a family member with AIDS in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 91.9 76.4 84.7 72.5 54.4 4,493 15-19 92.1 76.1 85.1 72.9 54.4 2,442 20-24 91.6 76.7 84.2 72.1 54.4 2,051 25-29 91.1 71.7 81.6 73.3 50.3 1,825 30-39 90.4 65.3 75.7 73.5 47.2 2,829 40-49 87.7 55.6 68.4 75.1 40.5 1,798 Marital status Never married 93.0 80.9 88.7 74.3 58.9 2,484 Ever had sex * * * * * 18 Never had sex 93.0 81.0 88.8 74.5 59.2 2,467 Married 90.1 66.1 76.5 73.0 47.0 8,167 Divorced/separated/widowed 86.8 61.6 72.7 73.0 42.4 293 Residence Urban 93.4 81.6 89.3 68.9 54.6 1,722 Rural 90.2 67.0 77.3 74.1 48.6 9,222 Ecological zone Mountain 86.4 48.6 62.3 70.2 32.7 692 Hill 88.4 66.8 77.4 73.3 47.1 4,782 Terai 93.2 74.2 82.9 73.7 53.9 5,470 Development region Eastern 90.6 68.6 81.3 74.6 49.6 2,798 Central 93.3 74.1 83.4 73.7 52.6 3,335 Western 89.6 70.0 77.2 75.4 52.9 2,398 Mid-western 87.1 61.7 69.9 64.8 39.7 1,255 Far-western 89.2 64.1 76.2 74.0 44.7 1,159 Subregion Eastern mountain 85.0 58.4 73.6 78.4 42.4 205 Central mountain 84.1 49.9 61.8 75.3 33.3 232 Western mountain 89.5 39.6 53.7 59.0 24.5 256 Eastern hill 88.7 62.6 77.0 78.6 46.2 895 Central hill 91.4 79.5 89.0 70.8 53.6 1,494 Western hill 86.2 61.1 68.9 76.4 46.3 1,413 Mid-western hill 85.3 60.3 70.4 63.6 37.1 586 Far-western hill 88.6 58.1 75.3 74.0 41.9 393 Eastern terai 92.3 73.0 84.4 72.1 52.2 1,698 Central terai 96.4 72.6 81.3 76.2 54.4 1,608 Western terai 94.4 82.8 88.9 73.9 62.3 984 Mid-western terai 88.4 68.8 74.4 67.9 46.4 562 Far-western terai 89.8 72.6 80.6 77.0 50.4 617 Education No education 87.3 49.5 62.5 69.9 33.1 3,595 Primary 87.8 63.1 76.7 71.7 43.5 1,984 Some secondary 92.4 78.8 86.9 77.1 58.9 3,036 SLC and above 96.1 92.9 96.9 75.1 67.9 2,329 Wealth quintile Lowest 83.8 47.2 60.9 68.5 31.3 1,651 Second 89.2 57.6 68.7 72.6 39.8 1,892 Middle 90.4 66.2 77.2 75.1 48.3 2,149 Fourth 92.6 76.2 86.2 76.3 56.9 2,494 Highest 94.3 86.8 92.6 72.7 61.5 2,758 Total 15-49 90.7 69.3 79.2 73.3 49.6 10,944 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate HIV and AIDS-related Knowledge, Attitudes, and Behavior • 199 Table 12.5.2 Accepting attitudes toward those living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Nepal 2011 Background characteristic Percentage of respondents who: Percentage expressing accepting attitudes on all four indicators Number of men who have heard of AIDS Are willing to care for a family member with AIDS in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 91.6 77.8 84.1 63.7 47.5 1,632 15-19 90.6 75.8 82.5 63.2 45.5 949 20-24 93.0 80.5 86.3 64.4 50.2 683 25-29 92.1 78.0 84.5 68.0 52.4 570 30-39 91.5 73.5 80.3 64.0 47.0 1,003 40-49 92.1 69.5 77.9 67.0 44.5 787 Marital status Never married 92.2 80.3 85.3 65.4 50.5 1,402 Ever had sex 92.9 83.9 84.4 63.8 53.6 350 Never had sex 92.0 79.1 85.6 66.0 49.5 1,052 Married 91.4 72.5 80.4 65.1 46.2 2,532 Divorced/separated/widowed (93.0) (62.5) (71.6) (51.7) (28.9) 57 Residence Urban 94.9 83.3 91.3 69.3 56.5 711 Rural 91.0 73.3 80.0 64.1 45.5 3,280 Ecological zone Mountain 88.7 70.4 81.5 72.3 45.0 238 Hill 93.8 78.6 85.3 70.4 51.7 1,616 Terai 90.5 73.0 79.5 60.2 44.5 2,138 Development region Eastern 92.8 75.0 84.8 68.4 50.0 985 Central 88.6 71.2 80.2 63.9 44.5 1,376 Western 95.2 78.8 79.2 55.6 42.3 785 Mid-western 89.9 80.4 83.4 75.2 57.3 464 Far-western 95.1 75.4 85.0 67.4 50.6 381 Subregion Eastern mountain 93.7 66.4 79.2 78.4 47.5 65 Central mountain 85.4 71.8 89.9 78.3 47.1 66 Western mountain 87.7 72.0 77.7 64.9 42.2 106 Eastern hill 92.7 73.6 78.8 73.7 48.8 287 Central hill 94.7 81.6 92.5 73.7 58.5 603 Western hill 93.6 81.8 83.0 62.3 45.8 428 Mid-western hill 92.0 78.4 81.4 83.2 59.2 179 Far-western hill 94.8 64.9 78.1 55.2 34.4 119 Eastern terai 92.8 76.5 88.0 65.0 50.8 633 Central terai 83.7 62.3 68.9 54.2 32.3 707 Western terai 97.1 75.1 74.7 47.5 38.0 357 Mid-western terai 89.8 83.3 86.8 70.6 59.4 227 Far-western terai 95.9 82.9 90.2 75.8 61.8 214 Education No education 79.9 45.6 58.3 51.9 21.6 481 Primary 87.9 61.7 74.4 60.4 36.3 776 Some secondary 93.1 77.0 83.4 68.0 49.2 1,431 SLC and above 96.9 91.9 93.6 69.3 61.8 1,303 Wealth quintile Lowest 88.7 61.4 71.0 62.6 33.9 554 Second 90.1 68.5 78.5 63.2 41.0 654 Middle 86.1 68.7 75.0 65.2 44.3 809 Fourth 93.3 80.2 85.3 63.7 50.8 913 Highest 97.1 86.8 92.2 68.5 58.1 1,061 Total 15-49 91.7 75.1 82.0 65.0 47.5 3,991 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 12.5 ATTITUDES TOWARD NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent it is of little use if people feel powerless to negotiate safer sex with their partners. To gauge attitudes toward safer sex, respondents in the 2011 NDHS were asked whether they think a wife is justified in refusing to have sex with her husband and in asking that he use a condom if she knows he has an infection that can be transmitted through sexual contact. 200 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Table 12.6 shows that 90 percent of women and 74 percent of men in Nepal believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows he has sex with other women. Ninety-three percent of women and 96 percent of men believe that if a husband has an STI, his wife is justified in asking him to use a condom. Table 12.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with other women, and percentage who believe that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI), by background characteristics, Nepal 2011 Background characteristic Women Men Woman is justified in: Woman is justified in: Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of women Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of men Age 15-24 89.6 93.8 5,050 71.9 95.8 1,663 15-19 90.1 93.1 2,753 70.5 94.7 978 20-24 89.0 94.7 2,297 73.8 97.5 685 25-29 90.8 94.3 2,101 74.8 96.9 581 30-39 91.0 93.8 3,291 74.6 96.2 1,041 40-49 89.9 88.5 2,232 75.3 93.7 836 Marital status Never married 89.4 92.6 2,708 73.3 95.9 1,433 Ever had sex * * 18 69.6 95.5 352 Never had sex 89.6 92.6 2,691 74.5 96.0 1,081 Married 90.4 93.1 9,608 74.0 95.6 2,626 Divorced/separated/widowed 90.7 91.2 358 (68.9) (95.0) 62 Residence Urban 90.2 95.2 1,819 77.0 96.9 717 Rural 90.2 92.6 10,855 73.0 95.4 3,404 Ecological zone Mountain 88.0 90.1 805 83.6 98.4 245 Hill 89.3 92.9 5,090 80.3 96.1 1,658 Terai 91.2 93.3 6,779 67.6 95.1 2,218 Development region Eastern 91.8 94.9 3,057 74.1 97.5 996 Central 91.1 91.8 4,236 70.5 93.7 1,448 Western 90.5 92.5 2,660 76.2 96.6 798 Mid-western 87.2 91.9 1,478 79.1 94.7 493 Far-western 86.3 94.2 1,242 72.2 97.8 385 Subregion Eastern mountain 87.2 94.0 229 87.1 99.0 66 Central mountain 91.7 91.0 258 85.6 98.8 69 Western mountain 85.6 86.6 319 80.3 97.7 110 Eastern hill 90.0 96.2 956 79.6 97.6 293 Central hill 88.6 95.0 1,563 80.9 96.1 616 Western hill 90.3 89.3 1,513 77.4 95.4 440 Mid-western hill 87.3 91.3 649 84.8 93.4 189 Far-western hill 89.4 93.5 409 82.6 99.0 120 Eastern terai 93.3 94.3 1,873 70.3 97.3 638 Central terai 92.7 89.9 2,415 60.7 91.2 763 Western terai 90.6 96.7 1,147 74.6 98.1 358 Mid-western terai 87.0 94.1 668 75.8 95.4 242 Far-western terai 85.1 96.0 676 63.1 96.6 217 Education No education 88.8 87.0 5,045 60.9 85.8 567 Primary 89.7 93.3 2,209 72.7 94.7 814 Some secondary 91.4 97.7 3,088 75.1 97.8 1,437 SLC and above 92.3 99.1 2,331 78.3 98.2 1,303 Wealth quintile Lowest 86.5 85.4 2,120 76.5 91.8 610 Second 89.4 89.6 2,393 70.1 93.9 695 Middle 90.7 93.4 2,600 69.1 95.5 830 Fourth 92.0 96.6 2,722 73.8 97.3 920 Highest 91.6 97.6 2,839 77.7 97.8 1,066 Total 15-49 90.2 92.9 12,674 73.7 95.7 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate HIV and AIDS-related Knowledge, Attitudes, and Behavior • 201 Differences by background characteristics are small for women. However, older men, married men, men living in urban areas, men living in the mountain zone, and men living in the Mid-western region and Eastern mountain subregion are more likely than their counterparts to say that a woman is justified in refusing to have sexual intercourse with her husband if she knows he has sex with other women. Support for a wife’s right to negotiate safer sex with her husband increases with education and, in general, with wealth. 12.6 MULTIPLE SEXUAL PARTNERS Limiting the number of sexual partners and practicing protected sex are crucial in the fight against the spread of sexually transmitted infections, including HIV. Respondents to the 2011 NDHS were asked detailed questions about their sexual behavior, including the number of partners they had in the 12 months preceding the survey and condom use during their most recent sexual encounter. Results for men age 15-49 are shown in Table 12.7. Findings for women are not shown separately since a negligible percentage of women reported having multiple sexual partners. Table 12.7 Multiple sexual partners Among all men age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for men who ever had sexual intercourse, by background characteristics, Nepal 2011 Background characteristic All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 3.8 1,663 45.1 63 2.6 666 15-19 1.5 978 * 14 2.1 202 20-24 7.0 685 (43.2) 48 2.8 463 25-29 5.8 581 (12.7) 33 2.7 528 30-39 3.3 1,041 (21.4) 35 2.6 1,016 40-49 2.9 836 * 25 2.3 827 Marital status Never married 3.0 1,433 (60.2) 43 3.2 352 Married 4.0 2,626 10.4 106 2.4 2,626 Divorced/separated/widowed (10.3) 62 * 6 (5.5) 59 Type of union In polygynous union (57.4) 44 * 25 (4.0) 44 In non-polygynous union 3.1 2,583 13.6 81 2.3 2,582 Not currently in union 3.3 1,495 (60.7) 50 3.5 411 Times slept away from home in past 12 months None 3.3 932 (22.0) 31 2.1 654 1-2 2.9 864 (29.1) 25 2.4 605 3-4 3.6 830 (31.5) 30 2.1 606 5+ 4.7 1,495 25.4 70 3.0 1,171 Time away in past 12 months Away for more than 1 month 5.5 896 (30.2) 49 2.6 699 Away only for less than 1 month 3.3 2,293 25.9 76 2.6 1,684 Not away 3.3 932 (22.0) 31 2.1 654 Residence Urban 4.3 717 33.6 31 2.1 496 Rural 3.7 3,404 24.7 125 2.6 2,540 Ecological zone Mountain 2.7 245 * 7 2.4 194 Hill 3.4 1,658 34.5 56 2.3 1,224 Terai 4.2 2,218 21.8 93 2.7 1,618 Development region Eastern 3.0 996 (35.8) 30 2.9 707 Central 4.6 1,448 (23.0) 66 2.0 1,094 Western 3.4 798 (25.7) 27 3.1 569 Mid-western 4.0 493 (22.0) 20 2.7 390 Far-western 3.3 385 * 13 2.3 278 Subregion Eastern mountain 2.7 66 * 2 2.2 47 Central mountain 1.2 69 * 1 1.8 54 Western mountain 3.7 110 * 4 2.9 93 Eastern hill 2.6 293 * 8 2.1 216 Central hill 4.5 616 * 27 1.9 456 Western hill 2.4 440 * 10 3.1 315 Mid-western hill 4.0 189 * 8 2.2 153 Far-western hill 2.3 120 * 3 2.6 84 Eastern terai 3.2 638 * 20 3.3 444 Central terai 5.0 763 * 38 2.1 585 Western terai 4.6 358 * 17 3.1 253 Mid-western terai 3.7 242 * 9 2.9 182 Far-western terai 4.1 217 * 9 2.1 154 Continued… 202 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Table 12.7—Continued Background characteristic All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men Education No education 4.2 567 * 24 2.0 537 Primary 2.5 814 * 20 2.3 701 Some secondary 3.9 1,437 38.0 57 3.1 922 SLC and above 4.2 1,303 32.7 54 2.4 877 Wealth quintile Lowest 0.6 610 * 4 2.1 481 Second 3.7 695 (21.0) 26 2.2 519 Middle 5.1 830 (8.2) 42 2.5 640 Fourth 3.5 920 (22.5) 32 2.4 650 Highest 4.9 1,066 (47.3) 52 3.1 747 Total 15-49 3.8 4,121 26.5 155 2.5 3,037 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 Means are calculated excluding respondents who gave non-numeric responses. Table 12.7 presents several indicators based on information collected from men about the number of sexual partners they had during the 12-month period before the survey and over their lifetime. The first indicator is the prevalence of multiple partners. The second indicator relates to condom use during the last sexual encounter among men with two or more partners in the past 12 months. The third indicator, the mean number of sexual partners that a man has had during his lifetime, serves as a measure of lifetime exposure to elements of higher-risk sex. Four percent of men reported having had two or more sexual partners during the 12 months prior to the survey, and 27 percent of these men reported using a condom during their last sexual intercourse. Men in urban areas who had sexual intercourse with more than one partner in the 12 months preceding the survey were more likely than men in rural areas to report using a condom during their last sexual intercourse (34 percent and 25 percent, respectively). Men had an average of 2.5 sexual partners over their lifetime, an increase from 2 sexual partners in 2006. 12.7 PAYMENT FOR SEX Paid sex is considered a special category of higher-risk sex. Male respondents in the 2011 NDHS were asked whether they had ever paid for sexual intercourse and whether they had done so in the past 12 months. About 5 percent of men had ever paid for sexual intercourse, with those living in urban areas, those in the terai and Central region, those with an SLC and higher, and those in the highest wealth quintile more often paying for sex than their counterparts in the other categories (Table 12.8). Less than 2 percent reported that they had engaged in paid sex in the past 12 months. Thirty-eight percent of men who had engaged in paid sex in the past 12 months reported that they had used a condom the last time they had paid sex (data not shown separately). Men age 20-24; never-married men; men living in urban areas, the terai, and the Central region; highly educated men; and men from the fourth and fifth wealth quintiles were more likely than their counterparts to have engaged in paid sex in the past 12 months. HIV and AIDS-related Knowledge, Attitudes, and Behavior • 203 Table 12.8 Payment for sexual intercourse and condom use at last paid sexual intercourse Percentage of men age 15-49 who ever paid for sexual intercourse and percentage reporting payment for sexual intercourse in the past 12 months, by background characteristics, Nepal 2011 Background characteristic Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Age 15-24 3.3 1.7 1,663 15-19 1.0 0.4 978 20-24 6.7 3.6 685 25-29 6.7 2.4 581 30-39 6.6 1.4 1,041 40-49 3.8 0.4 836 Marital status Never married 3.4 2.2 1,433 Married 5.3 0.9 2,626 Divorced/separated/widowed (11.5) (9.9) 62 Residence Urban 5.3 2.0 717 Rural 4.6 1.4 3,404 Ecological zone Mountain 2.7 1.1 245 Hill 4.2 1.3 1,658 Terai 5.3 1.7 2,218 Development region Eastern 4.7 1.6 996 Central 6.0 2.1 1,448 Western 4.5 1.0 798 Mid-western 2.5 0.8 493 Far-western 3.2 0.5 385 Education No education 4.1 1.0 567 Primary 3.9 1.5 814 Some secondary 4.3 1.5 1,437 SLC and above 5.9 1.6 1,303 Wealth quintile Lowest 3.1 0.9 610 Second 2.4 1.0 695 Middle 5.3 1.3 830 Fourth 4.5 2.0 920 Highest 6.9 1.8 1,066 Total 15-49 4.7 1.5 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 12.8 TESTING FOR HIV Knowledge of HIV status helps HIV-negative individuals make specific decisions to reduce their risk and increase safe sex practices so that they can remain disease free. For those who are HIV infected, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. Testing of pregnant women is especially important to prevent mother-to-child transmission of HIV. Where migration is common, knowing one’s HIV status is particularly critical in curbing the spread of the infec- tion and empowering women to seek preventive and curative measures to protect themselves and their children. Knowledge of HIV status benefits both the individual and the public. As a result of advances in medical science, having HIV is not necessarily fatal, and with appropriate treatment people with HIV can live much longer and lead a relatively normal life. It is important to ensure that all people diagnosed with HIV receive such treatment, and the government of Nepal is doing all it can to establish this as a priority. If diagnosis of HIV infection is maximized, patterns of infection can be better monitored and interventions better targeted. The government of Nepal is prioritizing the provision of voluntary counseling and testing services at all levels of the health system. 204 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Women and men in Nepal age 15-49 were asked whether they know of a place where people can go to get tested for HIV. Tables 12.9.1 and 12.9.2 show that men are more likely than women to know of a place where they can go to get an HIV test (57 percent and 38 percent, respectively). Knowledge of HIV testing facilities differs by respondents’ background characteristics. Men and women age 20-24 are most likely to know of a place to get tested for HIV, and those age 40-49 are least likely to be aware of an HIV testing place. Never- married respondents, particularly never-married men who are sexually active, are more aware of a place for HIV testing than their counterparts. Also, residents of urban areas and the hill zone, women in the Far-western region, and men in the Eastern region are more aware of where to go to get an HIV test than their counterparts in other areas. Knowledge of where to go for an HIV test varies positively with education and wealth quintile for both women and men. Table 12.9.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, Nepal 2011 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 41.5 4.6 0.0 95.4 100.0 4.6 3.0 5,050 15-19 38.4 2.4 0.0 97.6 100.0 2.4 1.9 2,753 20-24 45.2 7.2 0.1 92.7 100.0 7.3 4.4 2,297 25-29 41.7 8.3 0.0 91.7 100.0 8.3 4.3 2,101 30-39 37.5 5.8 0.1 94.1 100.0 5.9 3.0 3,291 40-49 27.9 2.7 0.0 97.2 100.0 2.8 1.1 2,232 Marital status Never married 45.3 2.3 0.0 97.7 100.0 2.3 1.5 2,708 Ever had sex * * * * 100.0 * * 18 Never had sex 45.4 2.2 0.0 97.8 100.0 2.2 1.5 2,691 Married 36.2 5.9 0.1 94.0 100.0 6.0 3.2 9,608 Divorced/separated/widowed 34.6 8.1 0.3 91.6 100.0 8.4 4.4 358 Residence Urban 53.1 7.7 0.2 92.2 100.0 7.8 3.9 1,819 Rural 35.6 4.8 0.0 95.2 100.0 4.8 2.7 10,855 Ecological zone Mountain 36.6 4.1 0.0 95.9 100.0 4.1 2.4 805 Hill 41.1 6.2 0.0 93.8 100.0 6.2 3.4 5,090 Terai 36.0 4.6 0.1 95.3 100.0 4.7 2.5 6,779 Development region Eastern 37.1 3.9 0.0 96.1 100.0 3.9 2.3 3,057 Central 31.4 2.9 0.0 97.1 100.0 2.9 1.9 4,236 Western 38.5 5.2 0.1 94.7 100.0 5.3 2.7 2,660 Mid-western 43.5 7.4 0.0 92.6 100.0 7.4 4.4 1,478 Far-western 56.2 13.6 0.1 86.3 100.0 13.7 6.4 1,242 Education No education 20.0 3.2 0.0 96.7 100.0 3.3 1.7 5,045 Primary 31.6 4.4 0.1 95.5 100.0 4.5 2.3 2,209 Some secondary 48.7 5.1 0.0 94.9 100.0 5.1 2.7 3,088 SLC and above 69.2 10.4 0.0 89.5 100.0 10.5 6.3 2,331 Wealth quintile Lowest 22.8 4.8 0.0 95.2 100.0 4.8 2.8 2,120 Second 27.7 3.5 0.0 96.5 100.0 3.5 1.9 2,393 Middle 30.4 3.4 0.1 96.5 100.0 3.5 1.8 2,600 Fourth 45.1 6.2 0.1 93.7 100.0 6.3 3.5 2,722 Highest 58.6 7.6 0.1 92.4 100.0 7.6 4.2 2,839 Total 15-49 38.1 5.2 0.0 94.8 100.0 5.2 2.9 12,674 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 Includes those who have never heard of AIDS The vast majority of women (95 percent) and men (85 percent) have never been tested for HIV. Five percent of women and 14 percent of men have been tested and received their results; almost none of those tested reported not receiving their results. Women age 25-29; divorced, separated, and widowed women; urban women; women living in the hill zone and Far-western region; highly educated women; and women from the HIV and AIDS-related Knowledge, Attitudes, and Behavior • 205 wealthiest households are most likely to have been tested and to have received the results. A similar pattern is seen for men, although differences by zone, region, and subregion are not as marked. Women and men were also asked whether they had been tested for HIV in the past 12 months and received the results from their last HIV test. Three percent of women and 8 percent of men had been tested in the past 12 months and had received the test results. Table 12.9.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, Nepal 2011 Background characteristic Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 59.0 10.2 0.5 89.3 100.0 10.7 6.5 1,663 15-19 51.1 4.4 0.4 95.1 100.0 4.9 3.1 978 20-24 70.3 18.4 0.6 81.0 100.0 19.0 11.3 685 25-29 63.4 19.8 1.2 79.0 100.0 21.0 9.5 581 30-39 58.9 19.1 0.6 80.2 100.0 19.8 10.0 1,041 40-49 48.2 12.1 0.1 87.9 100.0 12.1 4.8 836 Marital status Never married 60.3 8.3 0.5 91.3 100.0 8.7 5.1 1,433 Ever had sex 72.9 19.9 1.2 78.9 100.0 21.1 12.8 352 Never had sex 56.3 4.5 0.2 95.3 100.0 4.7 2.5 1,081 Married 56.5 17.4 0.6 82.0 100.0 18.0 8.8 2,626 Divorced/separated/widowed (26.7) (15.8) (0.0) (84.2) 100.0 (15.8) (6.9) 62 Residence Urban 71.8 16.5 1.1 82.4 100.0 17.6 9.7 717 Rural 54.3 13.7 0.4 85.9 100.0 14.1 7.0 3,404 Ecological zone Mountain 57.0 11.3 0.7 88.0 100.0 12.0 5.3 245 Hill 61.2 14.6 0.3 85.1 100.0 14.9 8.1 1,658 Terai 54.6 14.2 0.7 85.1 100.0 14.9 7.2 2,218 Development region Eastern 66.3 14.6 0.7 84.7 100.0 15.3 7.7 996 Central 51.6 12.8 0.9 86.3 100.0 13.7 7.3 1,448 Western 58.2 17.3 0.2 82.5 100.0 17.5 8.4 798 Mid-western 52.2 13.0 0.0 87.0 100.0 13.0 6.6 493 Far-western 61.4 13.6 0.3 86.0 100.0 14.0 6.7 385 Education No education 19.3 4.1 0.1 95.8 100.0 4.2 1.9 567 Primary 36.5 8.9 0.4 90.7 100.0 9.3 3.6 814 Some secondary 60.1 16.1 0.6 83.3 100.0 16.7 9.5 1,437 SLC and above 84.0 19.7 0.8 79.5 100.0 20.5 10.1 1,303 Wealth quintile Lowest 35.9 7.1 0.0 92.9 100.0 7.1 3.9 610 Second 40.0 8.5 0.3 91.2 100.0 8.8 3.5 695 Middle 51.8 13.4 0.5 86.2 100.0 13.8 7.9 830 Fourth 65.4 16.2 0.9 82.9 100.0 17.1 9.0 920 Highest 78.5 20.9 0.8 78.3 100.0 21.7 10.4 1,066 Total 15-49 57.4 14.2 0.6 85.3 100.0 14.7 7.5 4,121 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 1 Includes those who have never heard of AIDS 206 • HIV and AIDS-related Knowledge, Attitudes, and Behavior 12.9 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS Respondents who had ever had sexual intercourse were asked whether, in the past 12 months, they had experienced an infection acquired through sexual contact or had experienced either of two symptoms associated with STIs: a bad-smelling, abnormal discharge from the vagina or penis or a genital sore or ulcer. Table 12.10 shows the self-reported prevalence of STIs and STI symptoms among both women and men. A negligible proportion of women and men reported having had an STI in the 12 months prior to the survey (less than 1 percent). It is likely that these figures, which are quite low, underestimate the actual prevalence of STIs among the sexually active population in Nepal, as many STI symptoms are not easily recognized or do not have any visible symptoms. Table 12.10 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Nepal 2011 Background characteristic Women Men STI Bad- smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer Number of women who ever had sexual intercourse STI Bad- smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/ sore or ulcer Number of men who ever had sexual intercourse Age 15-24 0.4 10.3 2.1 11.4 2,577 0.4 3.4 5.4 7.1 666 15-19 0.6 8.7 1.5 9.6 799 0.0 6.2 12.3 13.6 203 20-24 0.4 11.0 2.3 12.2 1,778 0.5 2.1 2.4 4.2 463 25-29 0.6 13.3 2.3 14.1 1,955 0.4 0.8 1.3 1.6 528 30-39 0.6 12.5 2.8 13.2 3,233 0.4 0.9 1.8 2.5 1,016 40-49 0.4 10.6 2.6 11.7 2,203 0.0 0.9 2.2 2.8 830 Marital status Never married * * * * 18 1.3 2.9 5.9 7.8 352 Married 0.5 11.6 2.5 12.6 9,595 0.1 1.0 2.1 2.7 2,626 Divorced/separated/widowed 0.3 12.2 1.4 12.2 355 (2.9) (8.9) (4.9) (9.7) 62 Residence Urban 0.6 11.4 3.1 12.9 1,321 0.0 1.1 2.3 3.2 497 Rural 0.5 11.7 2.4 12.6 8,647 0.3 1.5 2.7 3.4 2,543 Ecological zone Mountain 0.3 13.4 3.7 14.4 655 0.1 0.3 1.5 1.7 194 Hill 0.3 12.4 2.9 13.6 3,947 0.3 1.6 3.1 4.0 1,224 Terai 0.6 10.9 2.0 11.7 5,366 0.3 1.5 2.4 3.2 1,621 Development region Eastern 0.9 12.5 3.3 13.9 2,368 0.0 0.6 2.4 3.0 707 Central 0.6 10.8 2.2 11.8 3,315 0.6 2.4 3.8 5.1 1,097 Western 0.1 12.4 1.8 13.1 2,113 0.3 1.8 1.7 2.6 569 Mid-western 0.4 13.9 3.2 14.5 1,197 0.0 0.2 1.4 1.4 390 Far-western 0.4 8.2 1.8 8.9 975 0.0 0.4 2.1 2.1 278 Subregion Eastern mountain 0.4 10.7 2.9 11.8 174 0.0 0.7 0.7 1.4 47 Central mountain 0.2 17.0 5.1 18.9 196 0.3 0.3 1.1 1.1 54 Western mountain 0.4 12.7 3.2 13.0 285 0.0 0.0 2.2 2.2 93 Eastern hill 0.7 11.2 4.2 13.1 728 0.0 1.1 5.3 6.4 216 Central hill 0.4 12.3 3.7 13.9 1,144 0.4 2.2 3.5 4.9 456 Western hill 0.1 14.0 2.1 14.6 1,222 0.6 1.8 2.0 2.6 315 Mid-western hill 0.5 13.0 2.7 13.6 529 0.0 0.5 2.1 2.1 153 Far-western hill 0.0 9.3 0.7 9.6 324 0.0 0.0 1.9 1.9 84 Eastern terai 1.0 13.4 2.9 14.5 1,466 0.0 0.4 1.2 1.6 444 Central terai 0.7 9.3 1.1 9.8 1,975 0.9 2.8 4.2 5.6 587 Western terai 0.1 10.4 1.4 11.1 892 0.0 1.7 1.4 2.6 254 Mid-western terai 0.3 13.4 2.9 14.1 522 0.0 0.0 0.5 0.5 182 Far-western terai 0.6 8.3 2.9 9.2 511 0.0 0.8 2.4 2.4 154 Education No education 0.4 11.6 2.3 12.2 4,809 0.0 0.9 2.4 2.4 537 Primary 0.5 11.5 2.8 12.8 1,896 0.3 1.2 3.2 3.6 701 Some secondary 0.8 13.7 2.6 15.0 1,879 0.2 1.5 2.2 3.0 924 SLC and above 0.5 9.2 2.6 10.4 1,384 0.6 1.8 2.7 4.3 878 Wealth quintile Lowest 0.0 12.6 2.6 13.3 1,735 0.0 0.6 2.3 2.3 481 Second 0.4 11.7 2.5 12.6 1,913 0.0 2.0 3.5 3.8 519 Middle 0.8 11.6 1.7 12.2 2,094 0.3 1.5 3.0 3.5 642 Fourth 0.7 12.3 3.0 13.4 2,127 0.7 1.2 2.1 3.6 650 Highest 0.5 10.2 2.6 11.6 2,098 0.3 1.7 2.2 3.7 747 Total 15-49 0.5 11.7 2.5 12.6 9,968 0.3 1.4 2.6 3.4 3,039 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate HIV and AIDS-related Knowledge, Attitudes, and Behavior • 207 Thirteen percent of women and 3 percent of men reported having had an STI or experiencing STI symptoms (abnormal genital discharge or genital sore or ulcer) during the 12 months preceding the survey. Differences by age, marital status, residence, and ecological zone are not pronounced. Notably, the prevalence of self-reported STIs and STI symptoms among women is much lower in the Far-western region, particularly the Far-western terai subregion. A slightly higher proportion of women and men reported STIs or STI symptoms in 2011 than in 2006. Fifty-four percent of women and 46 percent of men did not seek any treatment or advice for STI or STI symptoms in the past 12 months while 44 percent of women and 54 percent of men sought advice or treatment from a clinic, hospital, private doctor, or other health professionals (Figure 12.1). 44 3 5454 0 46 0 10 20 30 40 50 60 Clinic/hospital/private doctor/other health professional Advice or treatment from any other source No advice or treatment Percent Source of advice or treatment Figure 12.1 Women and Men Seeking Advice or Treatment for STIs Women Men 12.10 PREVALENCE OF MEDICAL INJECTIONS Use of nonsterile injections in a health care setting can contribute to the transmission of blood-borne pathogens. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2011 NDHS were asked whether they had received an injection in the past 12 months; if so, they were asked how many injections they had received and whether their last injection was given with a syringe from a newly opened package. Table 12.11 shows the reported prevalence of injections. Thirty-three percent of women and 31 percent of men reported receiving a medical injection from a health worker during the 12-month period preceding the survey. Generally, women and men received an average of one medical injection during that period. The vast majority of women (98 percent) and men (99 percent) reported that the last injection was given with a syringe from a newly opened package. 208 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Table 12.11 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Nepal 2011 Background characteristic Women Men Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the past 12 months Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of men For last injection, syringe and needle taken from a new, unopened package Number of men receiving medical injections in the past 12 months Age 15-24 31.5 0.8 5,050 98.4 1,592 33.6 1.0 1,663 98.9 559 15-19 24.6 0.6 2,753 98.3 677 31.8 1.0 978 98.7 311 20-24 39.8 1.2 2,297 98.6 914 36.3 1.0 685 99.1 249 25-29 38.7 1.2 2,101 98.2 814 31.8 1.3 581 99.3 185 30-39 33.9 1.3 3,291 97.5 1,117 29.8 1.1 1,041 98.8 310 40-49 28.0 1.2 2,232 96.2 624 27.3 1.9 836 97.7 228 Marital status Never married 19.5 0.5 2,708 98.1 528 32.7 0.9 1,433 98.6 468 Ever had sex * * 18 * 4 37.4 1.2 352 99.5 132 Never had sex 19.5 0.5 2,691 98.0 524 31.1 0.8 1,081 98.3 337 Married 36.8 1.3 9,608 97.7 3,532 30.1 1.4 2,626 98.7 791 Divorced/separated/widowed 24.1 0.6 358 99.1 86 (38.5) (0.8) 62 * 24 Residence Urban 35.8 1.2 1,819 97.5 652 34.0 1.0 717 99.3 244 Rural 32.2 1.1 10,855 97.9 3,494 30.5 1.3 3,404 98.6 1,039 Ecological zone Mountain 28.5 0.9 805 96.2 230 19.1 0.6 245 98.9 47 Hill 30.9 0.9 5,090 97.1 1,572 28.2 1.0 1,658 98.4 468 Terai 34.6 1.2 6,779 98.4 2,345 34.6 1.5 2,218 98.9 768 Development region Eastern 35.9 1.5 3,057 97.7 1,099 34.4 1.2 996 99.2 343 Central 33.6 1.0 4,236 98.4 1,425 32.9 1.5 1,448 99.0 477 Western 28.3 0.8 2,660 97.2 754 33.1 1.2 798 97.5 264 Mid-western 32.2 1.0 1,478 97.7 476 20.9 0.9 493 97.7 103 Far-western 31.7 1.0 1,242 97.4 393 24.8 0.9 385 100.0 95 Subregion Eastern mountain 29.4 0.9 229 96.9 67 16.2 0.4 66 (100.0) 11 Central mountain 24.3 0.8 258 97.5 63 18.7 0.4 69 (100.0) 13 Western mountain 31.4 0.9 319 94.9 100 21.1 0.8 110 (97.8) 23 Eastern hill 33.0 1.0 956 97.3 315 28.2 0.9 293 99.6 83 Central hill 36.4 1.0 1,563 97.4 569 31.5 1.2 616 99.1 194 Western hill 23.7 0.7 1,513 96.1 358 25.4 0.7 440 96.1 112 Mid-western hill 31.9 0.9 649 96.9 207 24.0 1.0 189 97.7 45 Far-western hill 30.0 0.9 409 98.1 123 28.6 1.0 120 100.0 34 Eastern terai 38.2 1.8 1,873 97.9 716 39.2 1.5 638 99.1 250 Central terai 32.8 1.0 2,415 99.1 793 35.4 1.9 763 98.8 270 Western terai 34.5 1.1 1,147 98.3 396 42.6 1.8 358 98.4 153 Mid-western terai 33.3 1.0 668 98.9 222 19.8 0.8 242 98.3 48 Far-western terai 32.2 1.1 676 97.7 217 22.1 0.8 217 100.0 48 Education No education 32.6 1.2 5,045 97.0 1,646 25.7 1.4 567 97.9 146 Primary 32.1 1.1 2,209 97.1 710 28.5 1.2 814 96.8 232 Some secondary 31.4 0.9 3,088 98.9 969 31.6 1.1 1,437 98.9 455 SLC and above 35.2 1.0 2,331 98.7 821 34.6 1.4 1,303 99.8 451 Wealth quintile Lowest 27.4 0.8 2,120 97.7 582 20.5 0.9 610 97.4 125 Second 30.4 0.9 2,393 97.1 727 28.7 1.0 695 98.7 199 Middle 34.1 1.1 2,600 97.6 886 31.8 1.1 830 98.9 264 Fourth 35.1 1.3 2,722 98.5 957 31.4 1.3 920 98.9 289 Highest 35.1 1.3 2,839 97.8 995 38.1 1.7 1,066 98.7 406 Total 15-49 32.7 1.1 12,674 97.8 4,147 31.1 1.3 4,121 98.7 1,283 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 12.11 HIV AND AIDS-RELATED KNOWLEDGE AND BEHAVIOR AMONG YOUTH Knowledge of HIV and AIDS issues and related sexual behavior among youth age 15-24 is of particular interest because the period between sexual initiation and marriage is, for many young people, a time of sexual experimentation that may involve high-risk behaviors. This section considers a number of issues that relate to both transmission and prevention of HIV and AIDS among youth, including the extent to which youth have comprehensive knowledge of HIV and AIDS transmission and prevention modes and knowledge of a source where they can obtain condoms. Issues such as abstinence, age at sexual debut, and condom use are also covered in this section. HIV and AIDS-related Knowledge, Attitudes, and Behavior • 209 12.11.1 Knowledge about HIV and AIDS and of Sources for Condoms Knowledge of how HIV is transmitted is crucial for people to avoid contracting HIV. Young people are often at greater risk because they have short relationships with more partners or engage in other risky behaviors. Table 12.12 shows the level of comprehensive knowledge of HIV and AIDS among youth and the percentage of youth who know of a source where they can obtain condoms. As noted earlier, comprehensive knowledge of HIV and AIDS is defined as knowing that condom use and having just one HIV-negative faithful partner can reduce the chances of contracting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common misconceptions about HIV transmission in Nepal (that HIV can be transmitted by mosquito bites and that it can be transmitted by sharing food with someone who has AIDS). Table 12.12 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Nepal 2011 Background characteristic Women age 15-24 Men age 15-24 Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents Age 15-19 25.0 82.8 2,753 32.7 95.8 978 15-17 22.4 79.6 1,655 30.9 95.2 616 18-19 28.8 87.5 1,098 35.8 96.8 362 20-24 26.7 88.5 2,297 35.6 97.6 685 20-22 26.6 88.4 1,445 37.9 98.1 437 23-24 27.0 88.8 853 31.4 96.7 248 Marital status Never married 31.8 83.2 2,475 36.7 96.9 1,281 Ever had sex * * 16 35.6 99.3 285 Never had sex 32.0 83.3 2,459 37.0 96.2 996 Ever married 19.9 87.5 2,575 24.5 95.3 382 Residence Urban 40.2 87.2 692 42.3 96.1 289 Rural 23.5 85.1 4,358 32.1 96.6 1,373 Development region Eastern 25.1 83.1 1,216 31.4 96.6 407 Central 25.0 79.5 1,668 33.8 94.7 556 Western 29.3 90.2 1,026 34.8 97.7 328 Mid-western 22.1 90.5 619 34.8 97.4 198 Far-western 27.3 94.2 521 37.3 99.0 174 Subregion Eastern mountain 16.8 90.9 92 22.0 96.6 29 Central mountain 19.3 85.9 97 21.5 96.4 23 Western mountain 7.2 93.2 127 25.3 100.0 44 Eastern hill 20.8 85.8 387 28.0 98.0 118 Central hill 38.9 84.9 603 44.7 96.3 239 Western hill 24.8 86.0 560 30.3 97.2 172 Mid-western hill 20.1 89.5 273 37.7 96.8 76 Far-western hill 26.1 94.1 172 42.4 100.0 60 Eastern terai 28.3 80.6 736 34.0 96.0 260 Central terai 16.9 75.5 968 25.8 93.3 294 Western terai 34.8 95.2 466 39.7 98.2 156 Mid-western terai 27.8 91.3 278 34.6 97.1 96 Far-western terai 31.9 93.9 290 37.0 98.2 96 Education No education 3.2 69.7 866 1.1 79.8 72 Primary 9.4 78.6 887 4.6 90.9 206 Some secondary 24.5 89.0 1,930 28.8 97.0 737 SLC and above 52.4 94.6 1,368 52.7 99.7 648 Total 25.8 85.4 5,050 33.9 96.5 1,663 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission and prevention of AIDS. The components of comprehensive knowledge are presented in Tables 12.2, 12.3.1, and 12.3.2. 2 For this table, the following responses are not considered sources for condoms: friends, family members, and home. 210 • HIV and AIDS-related Knowledge, Attitudes, and Behavior The table shows that 26 percent of young women and 34 percent of young men age 15-24 have comprehensive knowledge of AIDS. Knowledge of HIV and AIDS has declined in the past five years, from 28 percent among female youth and 44 percent among male youth. The table also shows that comprehensive knowledge is higher among youth in urban than rural areas. Among both young men and young women, the proportion with comprehensive knowledge tends to increase with level of education. Among young women the level of comprehensive knowledge about HIV is highest in the Western region (29 percent), and among young men knowledge is highest in the Far-western region (37 percent). Because of the important role that condoms play in combating the transmission of HIV, respondents were asked whether they know of a source of condoms. Only responses about formal sources were counted, that is, sources other than friends, family members, and home. As shown in Table 12.12, young men are more likely than young women to know where to obtain a condom (97 percent versus 85 percent). At the regional level, young women in the Far-western region (94 percent) are most likely to know a condom source, while those in the Central region (80 percent) are least likely to know where to obtain a condom. Not surprisingly, knowledge varies markedly by education, rising from 70 percent among young women with no education to 95 percent among young women with an SLC and higher education. A similar trend is seen for young men. 12.11.2 Age at First Sexual Intercourse among Youth Age at first sex is an important indicator of both exposure to the risk of pregnancy and exposure to STIs. Young people who initiate sex at an early age are considered to be at a higher risk of becoming pregnant or contracting an STI than young people who delay initiation of sexual activity. Consistent use of condoms can reduce such risks. Table 12.13 shows the proportion of young women and men in the 15-24 age cohort who had sex before age 15 and before age 18. Seven percent of young women and 3 percent of young men had sex by age 15. Forty percent of young women and 24 percent of young men had sex by age 18, a decrease from five years ago (47 percent and 27 percent, respectively). As expected, the proportion initiating sexual activity early was higher among ever-married young women and negligible among those who had not yet married. Forty percent of ever- married young men had initiated sexual intercourse by age 18, compared with 16 percent of never-married young men. The likelihood of early sexual debut was associated with low educational attainment among both young women and young men. Sexual debut at an early age was more common among rural than urban youth: 8 percent of rural women had initiated sex by age 15, as compared with 4 percent of urban women. Likewise, 42 percent of rural women and 24 percent of urban women had initiated sex by age 18. Analysis by region showed that women in the Central region were most likely to have had their first sexual intercourse before age 15 (9 percent). HIV and AIDS-related Knowledge, Attitudes, and Behavior • 211 Table 12.13 Age at first sexual intercourse among youth Percentage of young women and young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Nepal 2011 Background characteristic Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 4.6 2,753 na na 3.7 978 na na 15-17 3.3 1,655 na na 3.3 616 na na 18-19 6.6 1,098 37.5 1,098 4.4 362 28.5 362 20-24 9.9 2,297 40.4 2,297 2.2 685 22.2 685 20-22 9.5 1,445 39.4 1,445 2.9 437 21.2 437 23-24 10.5 853 42.2 853 0.8 248 24.0 248 Marital status Never married 0.1 2,475 0.4 1,084 2.8 1,281 15.9 683 Ever married 13.7 2,575 57.8 2,311 3.9 382 40.3 365 Knows condom source1 Yes 6.4 4,312 38.7 2,995 3.2 1,605 24.5 1,019 No 10.7 738 45.5 401 0.0 58 * 28 Residence Urban 3.9 692 23.6 500 1.4 289 17.7 199 Rural 7.5 4,358 42.2 2,895 3.4 1,373 25.9 849 Development region Eastern 6.1 1,216 36.3 806 3.3 407 18.7 259 Central 8.6 1,668 39.2 1,123 2.8 556 24.2 376 Western 4.7 1,026 36.2 693 3.3 328 22.8 181 Mid-western 7.6 619 49.5 414 3.3 198 34.9 129 Far-western 7.8 521 42.3 359 2.5 174 28.9 102 Subregion Eastern mountain 5.9 92 39.2 57 2.3 29 22.8 15 Central mountain 4.8 97 34.8 58 0.0 23 (34.1) 15 Western mountain 15.3 127 63.8 88 5.7 44 57.1 32 Eastern hill 5.2 387 30.0 248 3.4 118 24.4 75 Central hill 4.3 603 22.5 439 1.2 239 20.9 188 Western hill 4.8 560 36.4 361 3.4 172 23.9 86 Mid-western hill 8.2 273 51.7 179 3.2 76 30.2 55 Far-western hill 6.5 172 50.3 121 1.3 60 25.1 35 Eastern terai 6.6 736 39.2 502 3.4 260 15.8 169 Central terai 11.7 968 51.3 626 4.3 294 27.0 173 Western terai 4.5 466 36.0 332 3.3 156 21.7 95 Mid-western terai 5.2 278 43.1 188 3.7 96 32.3 54 Far-western terai 6.9 290 33.6 196 1.5 96 24.7 55 Education No education 17.8 866 70.0 704 5.5 72 (38.4) 46 Primary 14.1 887 57.5 615 4.4 206 35.3 132 Some secondary 3.5 1,930 40.7 930 3.7 737 31.6 330 SLC and above 0.6 1,368 10.1 1,146 1.7 648 16.1 539 Total 7.0 5,050 39.5 3,395 3.1 1,663 24.4 1,047 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate na = Not available 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 12.11.3 Premarital Sex The period between initiation of sexual intercourse and marriage is often a time of sexual experimentation. Table 12.14 presents information on premarital sexual intercourse and condom use among never-married youth age 15-24 in Nepal. Ninety-nine percent of never-married young women and 78 percent of never-married young men have never had sexual intercourse. Between 2006 and 2011, the percentage of never- married young men who had sexual intercourse during the 12 months preceding the survey increased from 8 percent to 15 percent. Among never-married, sexually active young men, 73 percent used a condom during their last sexual intercourse. 212 • HIV and AIDS-related Knowledge, Attitudes, and Behavior Table 12.14 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among men who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Nepal 2011 Background characteristic Never-married women age 15-24 Never-married men age 15-24 Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married women Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married men Among men who had sexual intercourse in the past 12 months: Percentage who used a condom at last sexual intercourse Number of men Age 15-19 99.4 0.4 1,956 85.3 9.4 908 69.2 86 15-17 99.8 0.2 1,391 92.2 5.5 598 (75.4) 33 18-19 98.6 0.7 564 71.9 16.9 310 65.3 52 20-24 99.0 0.7 520 59.4 28.5 373 76.0 106 20-22 98.8 0.9 407 63.4 23.0 283 71.5 65 23-24 99.6 0.0 113 46.6 45.7 90 (83.1) 41 Knows condom source1 Yes 99.5 0.3 2,058 77.2 15.4 1,241 73.3 191 No 98.6 1.1 417 (95.0) (2.0) 40 * 1 Residence Urban 98.6 1.1 435 79.7 13.4 242 76.8 32 Rural 99.5 0.3 2,040 77.3 15.3 1,039 72.2 159 Development region Eastern 99.1 0.5 634 78.4 14.9 335 (73.0) 50 Central 99.3 0.6 813 77.5 14.1 417 (73.1) 59 Western 99.5 0.0 505 77.9 17.0 271 (74.3) 46 Mid-western 99.3 0.7 265 73.3 16.2 134 (58.7) 22 Far-western 99.9 0.1 258 81.4 12.1 123 (88.4) 15 Subregion Eastern mountain 99.8 0.2 51 81.4 15.6 22 * 3 Central mountain 98.6 0.7 58 (78.6) (18.9) 16 * 3 Western mountain 97.0 3.0 34 (78.6) (14.3) 21 * 3 Eastern hill 98.4 0.5 210 80.5 10.3 91 * 9 Central hill 98.7 1.3 357 77.6 19.5 185 * 36 Western hill 99.1 0.0 268 81.1 13.9 141 * 20 Mid-western hill 100.0 0.0 111 68.0 18.7 49 * 9 Far-western hill 100.0 0.0 85 81.4 11.2 43 * 5 Eastern terai 99.4 0.6 373 77.3 16.8 223 * 37 Central terai 100.0 0.0 399 77.3 9.1 215 * 20 Western terai 99.9 0.0 237 74.5 20.3 130 (71.7) 26 Mid-western terai 99.4 0.6 138 77.0 14.2 74 * 10 Far-western terai 99.8 0.2 157 80.8 12.9 70 * 9 Education No education 100.0 0.0 180 (74.3) (19.3) 34 * 7 Primary 99.6 0.0 289 76.2 18.7 125 * 23 Some secondary 99.2 0.5 1,147 83.7 9.6 583 76.7 56 SLC and above 99.4 0.6 859 72.0 19.6 539 79.0 105 Total 99.4 0.4 2,475 77.8 15.0 1,281 73.0 191 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 12.11.4 Multiple Sexual Partners among Youth Table 12.15 provides information on young men age 15-24 who had two or more sexual partners during the 12 months preceding the survey and among these men the percentage who used a condom at their last sexual intercourse. Overall, 4 percent of young men reported having sex with two or more partners in the 12 months preceding the survey and 45 percent of these men used a condom during their last sexual encounter. Men age 20-24 (7 percent) were more likely to have had two or more partners in the 12 months preceding the survey than those in the other age categories. Ever-married young men were more than twice as likely to have had two or more partners (7 percent) than never-married young men (3 percent). Young men with no education (7 percent) and those with an SLC and higher education (5 percent) are more likely to have two or more partners than other men. HIV and AIDS-related Knowledge, Attitudes, and Behavior • 213 Table 12.15 Multiple sexual partners in the past 12 months among young men Among all young men age 15-24, the percentage who had sexual intercourse with two or more sexual partners in the past 12 months, and among those having two or more partners in the past 12 months, the percentage reporting that a condom was used at last intercourse, by background characteristics, Nepal 2011 Background characteristic Among all men age 15-24 Among men age 15-24 who had 2+ partners in the past 12 months Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom at last intercourse Number of men Age 15-19 1.5 978 * 14 15-17 1.0 616 * 6 18-19 2.3 362 * 8 20-24 7.0 685 (43.2) 48 20-22 6.9 437 (44.7) 30 23-24 7.3 248 * 18 Marital status Never married 3.0 1,281 (61.8) 38 Ever married 6.5 382 * 25 Knows condom source1 Yes 3.9 1,605 (45.7) 62 No 1.4 58 * 1 Residence Urban 4.1 289 * 12 Rural 3.7 1,373 (40.9) 51 Education No education 6.8 72 * 5 Primary 2.5 206 * 5 Some secondary 2.7 737 * 20 SLC and above 5.1 648 (52.6) 33 Total 15-24 3.8 1,663 45.1 63 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 12.11.5 Age Mixing in Sexual Relationships among Women Age 15-19 In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the spread of HIV and other STIs because older men are more likely to have been exposed to these diseases. Using preventive methods such as negotiating safer sex is more difficult when age differences are large. To examine age mixing in the 2011 NDHS, young women age 15-19 who had sex in the 12 months preceding the survey were asked whether the man was younger, about the same age, or older than they were. If older, they were asked whether they thought he was less than 10 years older or 10 or more years older. The results presented in Table 12.16 show that, among women age 15-19 who had sexual intercourse in the 12 months preceding the survey, 11 percent had sex with a man 10 or more years older. Age mixing in sexual relationships varies little by age, knowledge of a condom source, or urban-rural residence. Although there is no clear relationship between age mixing and education, women with an SLC and higher education are twice as likely as women with no education to have had sexual intercourse with a man 10 or more years older. Table 12.16 Age mixing in sexual relationships among women age 15-19 Among women 15-19 who had sexual intercourse in the past 12 months, percentage who had sexual intercourse with a partner who was 10 or more years older than themselves, by background characteristics, Nepal 2011 Background characteristic Women 15-19 who had sexual intercourse in the past 12 months Percentage who had sexual intercourse with a man 10+ years older Number of women Age 15-17 10.7 248 18-19 10.7 491 Marital status Never married * 7 Ever married 10.8 732 Knows condom source1 Yes 10.8 626 No 10.2 113 Residence Urban 11.5 61 Rural 10.6 678 Education No education 10.9 172 Primary 8.1 188 Some secondary 9.0 283 SLC and above 20.4 96 Total 10.7 739 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. SLC = School Leaving Certificate 214 • HIV and AIDS-related Knowledge, Attitudes, and Behavior 12.11.6 Recent HIV Tests among Youth Table 12.17 shows the percentage of sexually active young women and men who were tested for HIV in the 12 months preceding the survey and received results, by selected background characteristics. Five percent of sexually active women and 13 percent of sexually active men age 15-24 had been tested for HIV in the past 12 months and received results. The differences by background characteristics were more pronounced among men than women. The percentage of sexually active young men who had been tested for HIV in the past 12 months and received results increased with age and education and was almost twice as high among never- married men as among ever-married men, as well as nearly twice as high in urban as in rural areas. A similar but less pronounced pattern was seen among young women. Table 12.17 Recent HIV tests among youth Among young women and young men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who were tested for HIV in the past 12 months and received the results of the last test, by background characteristics, Nepal 2011 Background characteristic Among women age 15-24 who have had sexual intercourse in the past 12 months: Among men age 15-24 who have had sexual intercourse in the past 12 months: Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Age 15-19 4.4 739 9.0 154 15-17 3.3 248 7.0 51 18-19 4.9 491 10.0 103 20-24 5.1 1,527 14.2 415 20-22 5.2 887 13.4 219 23-24 4.9 640 15.2 196 Marital status Never married * 11 18.3 191 Ever married 4.8 2,255 10.1 377 Knows condom source1 Yes 5.6 1,974 13.1 550 No 0.0 291 * 19 Residence Urban 6.2 243 21.8 79 Rural 4.7 2,022 11.4 489 Education No education 1.6 608 (0.6) 43 Primary 4.2 510 4.6 103 Some secondary 4.5 679 11.7 208 SLC and above 10.4 469 20.4 215 Total 4.9 2,266 12.8 569 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Women’s Empowerment and Demographic and Health Outcomes • 215 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 13 The 1994 International Conference on Population and Development declared that “advancing gender equality and equity and the empowerment of women and the elimination of all kinds of violence against women, and ensuring women’s ability to control their own fertility […] are cornerstones of population and development- related programs” (United Nations, 1994). Women’s empowerment has been defined to encompass women having a sense of self-worth, access to opportunities and resources, choices and the ability to exercise them, control over their own lives, and influence over the direction of social change (United Nations Population Information Network, 1995). Nepal is a signatory to almost all of the international conventions on human rights, women’s rights, and children’s rights, as well as to agreements on international goals regarding education, health, and poverty eradication. As a signatory to the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), adopted in 1979 by the United Nations General Assembly, the government of Nepal promises nondiscrimination, gender equity, and social justice as mandated by the 1990 Constitution of Nepal (Ministry of Law and Justice, 1999). The 2003 national plan of action approved by the government of Nepal for the effective implementation of CEDAW and other instruments related to human rights guarantees all rights as per the CEDAW covenants; there is also a plan of action in place to implement all 12 of the Beijing Platform of Action commitments. These commitments include addressing poverty among women, increasing access to education and health resources, and establishing support for programs to bring women to decision-making levels in all political, constitutional, and administrative units (UNFPA, 2007). Currently, Nepal is ranked 113th in the world (out of 187 countries) and fifth among the South Asian Association for Regional Cooperation (SAARC) countries on the Gender Inequality Index (UNDP, 2011b). Data from the 2011 NDHS discussed in earlier chapters show that women in Nepal are predominantly engaged in agriculture; few have skilled manual jobs, and women are much less likely than men to be engaged in the professional, technical, and managerial fields (see Table 3.6.1). Further, women lag behind men in educational attainment, literacy, and exposure to mass media, all of which are critical contributors to women’s empowerment, and exert considerable influence on the development of their personality and on strengthening women’s position in the household and in society in general. This chapter presents additional data on the status of women in Nepal, including information on gender differences in employment, access to and control over cash earnings, asset ownership, participation in household decision-making, and the relative earnings of husbands and wives. The chapter also explores how demographic and health indicators vary by women’s empowerment, as measured by the number of decisions in which the woman participates and her ability to negotiate safer sexual relations with her husband (see Table 12.6). The ranking of women on these indices has been found to be associated with demographic and health outcomes, including contraceptive use, unmet need for family planning, and access to reproductive health care, as well as with child survival. Key Findings: • More than half of currently married employed women who earn cash make independent decisions about how to spend their earnings. • Only 46 percent of currently married women participate in decisions pertaining to their own health care, major household purchases, and visits to their family or relatives. • Contraceptive use increases with women’s empowerment. • Unmet need for family planning decreases with improvements in women’s empowerment. • Access to antenatal care, delivery assistance from a skilled provider, and postnatal care within the first two days of delivery increase with increasing women’s empowerment. • Infant, child, and under-five mortality rates decline with improvements in women’s empowerment. 216 • Women’s Empowerment and Demographic and Health Outcomes 13.1 EMPLOYMENT AND FORM OF EARNINGS Employment, particularly employment for cash, and control over how earnings are used are important indicators of empowerment for women and men. Table 13.1 shows the percentage of currently married women and men age 15-49 who were employed at any time in the 12 months before the survey and the percent distribution of employed women and men by the type of earnings they received (cash only, cash and in-kind, in- kind only), if any. The table shows that 77 percent of currently married women age 15-49 were employed in the 12 months preceding the survey and that almost all currently married men were employed (98 percent). Women age 15-29 are less likely than older women to be employed, while there is no such variation by age among currently married men. The proportion of currently married women who are employed has declined over the past five years (from 83 percent in 2006 to 77 percent in 2011); by contrast, the decline in employment among currently married men has been minimal (from 99 percent in 2006 to 98 percent in 2011). Employed men and women differ greatly in the type of earnings they receive for their work. Eighty-one percent of men receive cash only or cash and in-kind payment, compared with only 30 percent of women. Sixty-one percent of women are not paid for their work at all, compared with only 12 percent of men. Thus, not only are currently married women much less likely than currently married men to be employed, they are also much less likely to be paid for the work they perform. Table 13.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Nepal 2011 Age Among currently married respondents: Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Total Number of employed respondents Percentage employed Number of respondents Cash only Cash and in-kind In-kind only Not paid WOMEN 15-19 63.0 792 12.1 3.5 8.2 76.2 100.0 499 20-24 68.9 1,761 22.2 3.8 7.1 66.9 100.0 1,213 25-29 73.0 1,914 28.9 6.0 9.6 55.5 100.0 1,397 30-34 80.3 1,659 27.2 8.5 8.1 56.2 100.0 1,331 35-39 84.5 1,461 25.4 8.1 9.9 56.6 100.0 1,234 40-44 84.7 1,190 21.1 8.0 11.3 59.6 100.0 1,007 45-49 83.6 832 15.4 7.4 9.5 67.7 100.0 695 Total 15-49 76.8 9,608 23.5 6.7 9.1 60.8 100.0 7,378 MEN 15-19 95.3 67 45.4 13.9 1.7 39.0 100.0 64 20-24 96.6 306 63.2 12.8 4.9 19.2 100.0 296 25-29 99.1 471 68.5 13.1 8.2 10.2 100.0 467 30-34 98.1 459 75.6 12.0 5.0 7.4 100.0 450 35-39 99.0 516 68.1 14.3 8.7 9.0 100.0 511 40-44 98.7 423 62.3 18.3 9.4 10.0 100.0 418 45-49 97.3 384 54.8 20.6 9.4 15.2 100.0 374 Total 15-49 98.2 2,626 65.5 15.1 7.6 11.9 100.0 2,579 Table 13.2 shows the percent distribution of currently married women who were not employed by reason for not being employed, according to background characteristics. The results show that the most common reason given by women for not working is having small children to look after (32 percent). The next most common reasons are that women’s family does not allow them to work (19 percent), they have a heavy workload at home (18 percent), and they do not need to work (16 percent). Only 4 percent of currently married unemployed women reported that lack of education or training prevents them from working, with another 4 percent reporting lack of opportunity. Women age 30-49 are more likely than younger women to cite “no need to work” and “workload at home” as their main reason for not being employed. As expected, younger women are more likely than women in the oldest age group to report having young children to look after as their primary reason for not working. Almost one in two women (46 percent) age 15-19 and less than one in five older women said that they are not working because their family does not allow them to work. Women’s Empowerment and Demographic and Health Outcomes • 217 Urban women are more likely to report no need to work than rural women, and rural women are much more likely to cite having small children to look after and family disapproval as their reason for not being employed. Unemployed women in the Central terai (34 percent) and those with no education (25 percent) are more likely to report that their family does not allow them to work than other women. Table 13.2 Reasons for women not being employed in the past 12 months Percent distribution of currently married women age 15-49 who were not employed in the past 12 months by reason for not being employed, according to background characteristics, Nepal 2011 Background characteristic Reasons for not being employed Number of women No need to work Workload at home Small children to look after Family does not allow Looking for work Lack education/ training No opportunity Other Total Age 15-19 12.9 7.4 20.9 45.9 3.8 3.2 2.2 3.7 100.0 293 20-24 13.0 10.6 45.3 18.7 3.0 2.0 3.5 3.8 100.0 548 25-29 12.1 15.3 47.7 12.2 3.8 3.4 4.5 1.2 100.0 517 30-34 16.5 22.2 32.7 12.4 1.5 4.2 6.3 4.2 100.0 327 35-39 18.5 28.5 16.8 13.7 3.1 8.6 5.3 5.4 100.0 226 40-44 24.5 32.2 5.3 16.3 2.0 7.9 4.0 7.8 100.0 183 45-49 35.1 26.6 2.3 16.2 3.4 4.1 2.6 9.7 100.0 137 Number of living children 0 26.5 7.9 0.0 36.8 7.1 4.4 5.8 11.5 100.0 337 1-2 14.5 15.4 44.0 13.4 2.9 3.4 3.7 2.5 100.0 1,231 3-4 13.8 26.3 26.8 19.3 1.4 5.1 3.6 3.7 100.0 526 5+ 14.5 26.8 22.4 23.8 0.0 5.4 5.6 1.6 100.0 136 Residence Urban 21.2 19.6 25.7 13.5 3.1 7.3 5.1 4.5 100.0 510 Rural 14.7 16.9 33.9 20.6 3.0 3.1 3.8 4.0 100.0 1,720 Ecological zone Mountain 12.3 13.5 41.9 4.5 1.6 7.6 2.4 16.1 100.0 21 Hill 18.7 17.8 35.0 7.5 3.3 5.4 5.0 7.2 100.0 510 Terai 15.4 17.5 31.0 22.6 2.9 3.6 3.9 3.0 100.0 1,699 Development region Eastern 12.9 21.3 33.9 15.2 4.0 1.9 7.1 3.6 100.0 588 Central 17.5 13.8 27.5 27.2 3.2 3.2 3.6 4.0 100.0 987 Western 19.2 17.4 35.1 11.5 2.2 7.3 2.8 4.5 100.0 398 Mid-western 13.1 21.5 41.4 9.6 1.9 7.5 0.6 4.5 100.0 174 Far-western 15.6 26.8 37.9 3.2 0.3 7.4 2.8 6.0 100.0 83 Subregion Eastern mountain (12.7) (23.1) (28.0) (5.7) (4.4) (13.1) (0.0) (13.1) 100.0 8 Central mountain * * * * * * * * 100.0 5 Western mountain * * * * * * * * 100.0 8 Eastern hill 24.3 7.3 44.8 4.8 4.0 0.0 2.5 12.3 100.0 42 Central hill 19.2 17.9 29.7 9.6 4.3 5.6 6.9 6.8 100.0 270 Western hill 20.5 18.6 40.2 2.7 2.3 4.7 3.5 7.4 100.0 122 Mid-western hill 11.2 21.8 40.4 10.0 1.1 9.7 1.5 4.4 100.0 71 Far-western hill * * * * * * * * 100.0 5 Eastern terai 12.1 22.4 33.2 16.2 4.0 1.9 7.6 2.8 100.0 539 Central terai 16.8 12.4 26.4 34.1 2.8 2.2 2.4 2.8 100.0 712 Western terai 18.5 16.9 32.8 15.4 2.1 8.5 2.4 3.3 100.0 276 Mid-western terai 14.8 21.4 41.9 9.3 2.6 6.3 0.0 3.8 100.0 97 Far-western terai 16.1 27.7 37.7 3.5 0.3 8.1 1.6 4.8 100.0 76 Education No education 13.9 21.1 28.4 25.2 0.7 3.7 2.3 4.8 100.0 840 Primary 12.0 17.0 31.1 23.1 4.1 6.1 4.9 1.7 100.0 408 Some secondary 19.1 16.6 34.1 15.9 2.0 5.4 3.4 3.5 100.0 494 SLC and above 20.7 12.7 36.8 8.0 7.3 1.8 7.4 5.5 100.0 487 Wealth quintile Lowest 3.9 16.0 39.5 25.7 0.0 1.3 3.9 9.7 100.0 100 Second 8.5 15.7 48.4 17.2 0.7 1.8 2.1 5.6 100.0 231 Middle 4.3 16.7 33.7 33.2 3.2 2.7 3.7 2.5 100.0 452 Fourth 16.8 19.4 30.7 18.7 3.8 3.1 3.7 3.8 100.0 593 Highest 25.5 17.3 26.7 11.4 3.3 6.5 5.2 4.1 100.0 854 Total 16.2 17.5 32.0 19.0 3.0 4.1 4.1 4.1 100.0 2,230 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. SLC = School Leaving Certificate The most common reason for not working among women in all wealth quintiles is having young children to look after. Among the other reasons, the most common one given by women in the highest wealth quintile is no need to work, while the most common reason given by women in the lowest and middle quintiles is family disapproval. 218 • Women’s Empowerment and Demographic and Health Outcomes 13.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS AND RELATIVE MAGNITUDE OF WOMEN’S AND THEIR HUSBANDS’ EARNINGS Control over cash earnings is another dimension of empowerment. Currently married women who earn cash for their work were asked who the main decision-maker is regarding the use of their earnings. They were also asked about the relative magnitude of their earnings compared with their husband’s earnings. This information provides insight into women’s empowerment within the family and the extent of their control over resources. It is expected that women who are employed and who receive cash earnings are more likely to have control over household resources. Table 13.3.1 shows the percent distribution of currently married women who received cash earnings in the past 12 months, according to the person who controls their earnings and their perception of the magnitude of their earnings relative to those of their husband. More than half of currently married women who earn cash said that they themselves mainly decide how their cash earnings are used; two in five indicated that the decision is made jointly with their husbands, and only 5 percent said that the decision is made mainly by their husbands. The proportion of currently married women who earn cash for their work and decide mainly alone on the use of their cash earnings has increased from 31 percent in 2006 to 53 percent in 2011, whereas the proportion of women who say that they jointly decide with their husbands on the use of their own earnings has decreased, from 56 percent to 40 percent. Overall, the proportion of women who participate alone or jointly with their husbands in decisions about the use of their earnings has increased from 86 percent in 2006 to 93 percent in 2011. Decision-making alone about the use of their earnings does not vary consistently with women’s age, although joint decision-making tends to increase with age. Women with five or more children are less likely to decide on how to use their cash earnings than women with one to four children and those with no children. Women’s participation in the use of their own earnings varies little by urban-rural residence. The proportion of women deciding alone about the use of their earnings declines somewhat with education; however, this decline is accompanied by a sharp increase with education in the proportion who decide jointly with their husbands on the use of their earnings. A similar pattern of variation in who decides about the use of women’s earnings is observed according to wealth index, except in the fourth quintile. There is substantial regional variation in who makes decisions on how women’s earnings are used. The proportion of employed women who mainly decide on the use of their earnings is highest in the terai region (55 percent); however, within this region, the proportion varies from a low of 39 percent in the Far-western terai to a high of 68 percent in the Western terai. Joint decision-making on the use of women’s earnings is most common in the mountain zone, at 47 percent, and ranges from 40 percent in the Eastern mountain subregion to 52 percent in the Central and Western mountain subregions. Notably, among 16 percent of employed women with earnings in the Western mountain subregion, the main decision-maker regarding the use of the women’s earnings is the husband. Table 13.3.1 also shows women’s perception of their cash earnings relative to their husbands’ earnings. Among currently married women who earn cash, 74 percent say that they earn less than their husbands, 8 percent say that they earn more than their husbands, and 15 percent say that they earn about the same amount as their husbands. Thus, almost one in four women who have cash earnings in Nepal earn about the same as or more than their husbands. The proportion of currently married women who are employed for cash and earn about the same as or more than their husbands generally increases with age, number of children, education, and wealth and is higher among urban than rural women. Notably, among the most educated women who are employed for cash and among those in the highest wealth quintile, almost 30 percent earn about the same as or more than their husbands. Women in the hill ecological zone, particularly the Mid-western and Central hill regions, are more likely than their counterparts in other regions to earn the same as or more than their husbands. Women’s Empowerment and Demographic and Health Outcomes • 219 Table 13.3.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings: Women Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how their cash earnings are used and by whether women earned more or less than their husband, according to background characteristics, Nepal 2011 Background characteristic Person who decides how the wife’s cash earnings are used: Total Wife’s cash earnings compared with husband’s cash earnings: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other More Less About the same Husband has no earnings Don’t know/ missing Age 15-19 44.5 33.4 6.7 15.3 100.0 7.5 85.1 5.1 1.2 1.1 100.0 78 20-24 52.2 37.5 5.7 4.6 100.0 5.6 80.3 10.6 3.5 0.0 100.0 316 25-29 56.5 35.9 5.0 2.6 100.0 4.7 81.1 10.7 3.1 0.4 100.0 488 30-34 54.6 40.7 4.5 0.1 100.0 8.8 74.1 13.7 2.7 0.6 100.0 475 35-39 55.9 41.1 2.3 0.8 100.0 9.0 66.7 20.2 3.1 1.1 100.0 413 40-44 43.5 47.7 8.8 0.0 100.0 10.8 66.4 17.7 2.7 2.4 100.0 293 45-49 48.2 47.4 4.5 0.0 100.0 6.1 60.9 24.4 5.8 2.8 100.0 159 Number of living children 0 52.3 37.8 3.6 6.3 100.0 8.0 77.4 9.3 5.4 0.0 100.0 199 1-2 52.2 40.5 5.4 1.9 100.0 7.4 73.1 15.0 3.3 1.2 100.0 1,188 3-4 55.1 39.8 4.0 1.1 100.0 7.7 73.7 15.8 2.1 0.6 100.0 686 5+ 44.8 46.2 9.0 0.0 100.0 7.0 71.9 16.0 3.5 1.6 100.0 148 Residence Urban 55.0 39.7 4.3 1.0 100.0 10.3 69.1 15.2 4.9 0.5 100.0 459 Rural 52.0 40.6 5.2 2.2 100.0 6.8 74.7 14.7 2.7 1.1 100.0 1,764 Ecological zone Mountain 37.9 47.3 11.6 3.2 100.0 8.7 72.0 14.7 4.4 0.1 100.0 86 Hill 50.3 43.4 4.8 1.5 100.0 10.8 65.7 17.0 4.8 1.7 100.0 772 Terai 54.9 38.3 4.7 2.1 100.0 5.6 78.1 13.6 2.1 0.6 100.0 1,365 Development region Eastern 52.4 42.4 4.2 1.0 100.0 5.2 73.4 18.3 2.6 0.5 100.0 712 Central 55.2 38.6 4.8 1.4 100.0 9.3 75.9 11.8 2.6 0.5 100.0 850 Western 56.4 35.5 5.0 3.1 100.0 7.7 70.4 13.9 4.9 3.2 100.0 370 Mid-western 40.0 48.7 7.3 4.0 100.0 7.1 66.4 20.6 4.8 1.0 100.0 161 Far-western 41.8 45.5 8.1 4.6 100.0 8.8 77.4 11.2 2.4 0.2 100.0 129 Subregion Eastern mountain 51.4 40.0 8.3 0.3 100.0 10.0 74.5 12.1 3.1 0.3 100.0 33 Central mountain 30.1 52.3 9.8 7.8 100.0 7.8 77.0 9.3 5.9 0.0 100.0 21 Western mountain 29.0 51.6 16.1 3.2 100.0 8.1 66.1 21.0 4.8 0.0 100.0 32 Eastern hill 47.4 49.2 2.6 0.8 100.0 4.3 70.7 18.6 6.4 0.0 100.0 134 Central hill 55.0 39.3 5.2 0.4 100.0 14.4 66.0 16.4 2.8 0.4 100.0 378 Western hill 43.4 46.7 6.9 3.0 100.0 8.0 63.3 14.9 7.6 6.1 100.0 173 Mid-western hill 49.3 44.4 1.2 5.2 100.0 8.7 58.9 26.5 4.8 1.2 100.0 67 Far-western hill (42.1) (49.4) (5.7) (2.8) 100.0 (17.1) (71.3) (4.9) (6.7) (0.0) 100.0 21 Eastern terai 53.7 40.8 4.4 1.1 100.0 5.1 74.0 18.6 1.7 0.6 100.0 545 Central terai 56.6 37.3 4.2 2.0 100.0 5.0 84.1 8.0 2.3 0.6 100.0 451 Western terai 67.8 25.7 3.3 3.2 100.0 7.4 76.6 12.9 2.5 0.6 100.0 197 Mid-western terai 39.5 48.5 8.5 3.4 100.0 4.8 75.8 14.1 4.1 1.1 100.0 75 Far-western terai 39.4 46.5 9.1 5.1 100.0 7.6 78.0 12.4 1.8 0.3 100.0 97 Education No education 54.9 37.2 6.2 1.8 100.0 6.5 76.0 13.5 3.0 1.1 100.0 901 Primary 55.3 35.7 6.6 2.4 100.0 6.4 76.1 12.1 3.8 1.6 100.0 401 Some secondary 51.7 40.7 5.2 2.3 100.0 6.6 72.3 17.9 2.7 0.5 100.0 421 SLC and above 47.3 49.7 1.5 1.6 100.0 11.2 68.2 16.8 3.2 0.7 100.0 500 Wealth quintile Lowest 58.5 29.5 8.8 3.3 100.0 7.3 80.9 4.9 4.6 2.4 100.0 193 Second 51.5 40.5 4.4 3.5 100.0 4.5 82.7 9.6 2.4 0.8 100.0 348 Middle 51.1 40.3 6.9 1.6 100.0 5.9 81.6 8.9 2.2 1.4 100.0 373 Fourth 56.3 37.5 4.1 2.1 100.0 7.9 70.0 17.9 3.3 0.9 100.0 572 Highest 49.5 45.5 4.1 0.9 100.0 9.5 66.1 20.4 3.5 0.5 100.0 737 Total 52.6 40.4 5.0 1.9 100.0 7.5 73.6 14.8 3.1 1.0 100.0 2,223 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 13.3 CONTROL OVER HUSBANDS’ EARNINGS Currently married men age 15-49 who receive cash earnings were asked who—the men themselves, their wife, the husband and wife jointly, or someone else—decides how their own cash earnings are used. In addition, currently married women were asked who decides how their husbands’ cash earnings are used. Table 13.3.2 shows that 47 percent of currently married men age 15-49 who receive cash earnings report that they decide jointly with their wives how their earnings will be used, while 39 percent say they mainly make these decisions themselves. Eight percent of men say that decisions on how their earnings are used are mainly made by their wives. 220 • Women’s Empowerment and Demographic and Health Outcomes Table 13.3.2 Control over men’s cash earnings Percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women age 15-49 whose husbands receive cash earnings, by person who decides how husband’s cash earnings are used, according to background characteristics, Nepal 2011 Background characteristic Men Women Person who decides how husband’s cash earnings are used: Person who decides how husband’s cash earnings are used: Mainly wife Husband and wife jointly Mainly husband Other Total Number of men Mainly wife Husband and wife jointly Mainly husband Other Total Number of women Age 15-19 (3.1) (18.7) (41.7) (36.5) 100.0 38 7.4 30.4 27.6 34.6 100.0 747 20-24 3.2 33.4 43.4 20.0 100.0 225 12.8 40.2 23.2 23.8 100.0 1,697 25-29 8.6 43.0 40.6 7.8 100.0 381 18.6 48.9 22.4 10.2 100.0 1,870 30-34 8.8 52.0 33.9 5.3 100.0 394 18.2 56.5 21.0 4.4 100.0 1,618 35-39 8.6 50.9 38.3 2.2 100.0 420 20.5 56.5 21.1 2.0 100.0 1,420 40-44 8.8 54.7 35.3 1.2 100.0 337 16.4 55.4 27.0 1.2 100.0 1,143 45-49 11.6 42.7 45.5 0.1 100.0 282 13.5 57.5 28.8 0.3 100.0 781 Number of living children 0 6.8 29.8 44.7 18.6 100.0 232 7.2 38.1 26.2 28.5 100.0 1,009 1-2 8.7 50.0 34.9 6.3 100.0 992 16.3 50.7 20.5 12.5 100.0 4,308 3-4 7.3 48.0 42.4 2.3 100.0 652 19.2 51.6 25.1 4.0 100.0 3,000 5+ 12.2 45.3 41.2 1.3 100.0 201 14.9 52.7 30.2 2.2 100.0 959 Residence Urban 10.3 52.4 33.1 4.3 100.0 400 16.3 57.2 22.1 4.4 100.0 1,214 Rural 7.9 45.3 40.4 6.3 100.0 1,677 16.1 48.7 23.8 11.3 100.0 8,063 Ecological zone Mountain 4.5 37.9 53.2 4.5 100.0 101 9.5 51.0 29.4 10.1 100.0 590 Hill 8.1 54.0 34.4 3.5 100.0 781 14.3 54.4 23.3 7.9 100.0 3,615 Terai 8.9 42.6 40.8 7.6 100.0 1,195 18.2 46.4 23.2 12.2 100.0 5,072 Development region Eastern 9.7 53.8 31.0 5.5 100.0 529 14.7 53.1 25.5 6.6 100.0 2,225 Central 8.8 43.3 42.0 5.9 100.0 799 19.0 48.8 22.7 9.5 100.0 3,147 Western 9.4 50.8 32.4 7.4 100.0 349 15.8 50.2 20.6 13.5 100.0 1,965 Mid-western 6.5 38.7 50.7 4.1 100.0 229 13.5 49.6 25.7 11.1 100.0 1,090 Far-western 2.7 42.8 47.5 6.9 100.0 170 13.2 44.6 26.2 15.9 100.0 849 Subregion Eastern mountain 6.8 58.6 27.8 6.8 100.0 30 6.8 52.6 35.8 4.8 100.0 162 Central mountain 3.4 30.2 66.3 0.0 100.0 29 15.5 48.2 27.6 8.7 100.0 181 Western mountain 3.6 28.6 61.9 6.0 100.0 42 6.8 52.1 26.5 14.6 100.0 247 Eastern hill 7.9 58.3 28.0 5.7 100.0 146 8.6 55.0 31.8 4.5 100.0 664 Central hill 9.1 57.4 32.0 1.5 100.0 327 18.6 56.9 21.2 3.3 100.0 1,076 Western hill 7.4 51.8 36.9 3.8 100.0 176 10.5 59.0 20.1 10.5 100.0 1,115 Mid-western hill 9.4 40.7 47.3 2.6 100.0 92 17.9 48.7 23.2 10.2 100.0 496 Far-western hill 0.0 50.8 36.1 13.0 100.0 40 20.7 34.7 24.1 20.5 100.0 265 Eastern terai 10.7 51.6 32.5 5.3 100.0 353 18.5 52.3 21.4 7.8 100.0 1,400 Central terai 9.0 33.7 47.7 9.6 100.0 443 19.6 44.2 23.2 13.1 100.0 1,890 Western terai 11.4 49.7 28.0 10.9 100.0 174 22.7 38.6 21.2 17.5 100.0 850 Mid-western terai 5.1 39.2 50.3 5.4 100.0 111 10.6 49.7 27.8 11.9 100.0 462 Far-western terai 3.2 42.3 50.0 4.5 100.0 114 10.7 48.7 27.8 12.9 100.0 470 Education No education 7.5 37.0 49.9 5.6 100.0 392 17.5 47.4 27.2 8.0 100.0 4,417 Primary 10.8 46.4 37.8 4.9 100.0 484 17.3 46.9 23.8 12.0 100.0 1,797 Some secondary 9.1 45.2 38.2 7.5 100.0 627 15.4 50.1 19.2 15.2 100.0 1,754 SLC and above 6.1 55.1 33.4 5.4 100.0 573 10.8 61.8 17.2 10.2 100.0 1,309 Wealth quintile Lowest 7.4 40.5 48.6 3.5 100.0 236 16.7 42.1 30.8 10.4 100.0 1,558 Second 5.8 46.4 44.7 3.1 100.0 325 14.4 48.4 26.1 11.1 100.0 1,789 Middle 8.6 40.5 41.2 9.7 100.0 482 16.4 45.9 24.5 13.2 100.0 1,965 Fourth 9.8 46.6 37.2 6.4 100.0 457 18.2 50.4 19.4 12.0 100.0 1,998 Highest 8.9 54.6 31.5 5.0 100.0 577 14.8 60.6 19.2 5.4 100.0 1,966 Total 15-49 8.4 46.7 39.0 5.9 100.0 2,077 16.1 49.8 23.6 10.4 100.0 9,276 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate The proportion of currently married employed men who have earnings and who say that they make decisions about the use of their earnings jointly with their wives is highest among men age 40-44 (55 percent); younger (age 20-24) and older (age 45-49) men are more likely to make these decisions alone. Notably, younger men (age 20-24) are more likely than older men to say that other family members decide how their earnings are used. The proportion of men making decisions alone about the use of their income is higher in rural than in urban areas and decreases with education, from 50 percent among men with no education to 33 percent among men with a School Leaving Certificate (SLC) or higher education. This proportion also declines with wealth. Notably, more than half (55 percent) of the most educated men and men in the highest wealth quintile say that they make decisions about the use of their earnings jointly with their wives. The main decision-maker regarding the use of men’s own earnings varies greatly by region. Decision- making by the man alone is highest in the mountain ecological zone. Also, it is higher in the Central and Women’s Empowerment and Demographic and Health Outcomes • 221 Western mountain subregions, where about two-thirds of currently married employed men with earnings decide by themselves how their earnings are used, than in other subregions. Decision-making about the man’s earnings mainly by the wife is most common in the terai zone, particularly the Western and Central terai. Table 13.3.2 also shows women’s responses on who makes the decision about their husbands’ earnings. Only currently married women whose husbands had cash earnings are included. Half of currently married women whose husbands receive cash earnings say that they decide jointly with their husband about the use of his cash earnings, 16 percent say that they decide by themselves, 24 percent say that their husband alone decides, and 10 percent say that someone else decides. A comparison between women’s responses about the main decision-maker regarding the use of their husbands’ earnings and men’s responses about the use of their own earnings shows both similarities and differences. Whereas a similar proportion of women and men (50 percent and 47 percent) say that they jointly make the decision with their spouse, women are twice (16 percent) as likely as men (8 percent) to say that the wife is the main decision maker. Further, men are much more likely to say that they themselves are the main decision makers regarding the use of their own earnings than women are to say that the husband is the main decision maker (39 percent versus 24 percent). The pattern of variation by background characteristics in women’s responses about the use of their husbands’ earnings is similar to that of men’s responses to the use of their earnings. In general, joint decision- making increases with age, education, and wealth and is higher in the hill region and in urban areas. Decision- making alone by the husband is generally higher in the youngest and oldest age groups. Similar to younger men, a much higher proportion of younger women report that someone else makes the decision about the use of their husbands’ earnings. The level of women’s earnings relative to their husbands’ earnings is expected to be associated with women’s control over their own and their husbands’ earnings. To examine this association, Table 13.4 shows the percent distribution of currently married women with cash earnings by the person who has the main say in the use of their earnings and the distribution of currently married women by the person who has the main say in the use of their husbands’ earnings, according to women’s perception of the size of their own earnings relative to their husbands’ earnings. Table 13.4 Woman’s control over their earnings and over those of their husbands Percent distribution of currently married women age 15-49 with cash earnings in the past 12 months by person who decides how the wife’s cash earnings are used and percent distribution of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband’s cash earnings are used, according to the relation between wife’s and husband’s cash earnings, Nepal 2011 Women’s earnings relative to husband’s earnings Person who decides how wife’s cash earnings are used: Total Number of women Person who decides how husband’s cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Mainly wife Wife and husband jointly Mainly husband Other More than husband 59.2 36.1 3.6 1.1 100.0 167 31.0 43.3 23.1 2.6 100.0 167 Less than husband 57.0 36.0 4.8 2.2 100.0 1,635 20.6 56.2 19.8 3.4 100.0 1,635 Same as husband 29.0 63.9 6.8 0.3 100.0 329 15.0 73.4 10.9 0.7 100.0 329 Husband has no cash earnings or did not work 49.3 42.7 2.7 5.3 100.0 70 na na na na na 0 Woman worked but has no cash earnings na na na na na 0 14.3 48.7 25.2 11.8 100.0 4,932 Woman did not work na na na na na 0 16.1 44.6 24.7 14.5 100.0 2,191 Total 52.6 40.4 5.0 1.9 100.0 2,223 16.1 49.8 23.6 10.4 100.0 9,276 Note: Total includes cases where a woman does not know whether she earned more or less than her husband. na = Not applicable The table shows that women’s participation in the use of their own and their husbands’ earnings does vary by their relative earnings; however, the variation is not necessarily as expected. The most consistent finding is that women who earn about the same as their husbands are most likely to jointly decide about the use of both their own earnings (64 percent) and their husbands’ earnings (73 percent). Women who earn more than their husbands are more likely than other women to be the main decision-maker about the use of their husbands’ 222 • Women’s Empowerment and Demographic and Health Outcomes earnings (31 percent), but women who earn more and women who earn less than their husbands are about equally likely to be the main decision-makers about their own earnings (59 percent versus 57 percent). 13.4 WOMEN’S AND MEN’S OWNERSHIP OF SELECTED ASSETS Ownership of assets, particularly high-value assets, has many beneficial effects for households, including protection against financial ruin. Women’s individual ownership of assets enables their economic empowerment and provides protection in the case of marital dissolution or abandonment. The 2011 NDHS collected information on women’s and men’s ownership (alone, jointly, and alone and jointly) of two high-value assets, namely, land and a house. Table 13.5.1 shows that 93 percent of women age 15-49 do not own a house and 90 percent do not own any land. Six percent of women own a house alone, and 10 percent own land alone. Notably, women who own either of these assets appear to own them mostly alone as opposed to jointly with someone else. Women’s ownership of a house and land increases with age and wealth but does not vary consistently with education. Married women are more likely to own a house (7 percent) and land (11 percent) than women who have never been married. Women who are divorced, separated, or widowed more often own a house (27 percent) and land (29 percent) alone. Urban women, those from the Eastern region, and those from the terai are more likely than rural women and women in other regions to own a house and land by themselves. A higher proportion of men than women own a house or land. As shown in Table 13.5.2, 25 percent of men age 15-49 own a house alone and/or jointly, and 27 percent own land alone and/or jointly (as compared with 8 percent and 10 percent of women, respectively). Women’s disadvantage relative to men in asset ownership is evident in every demographic and socioeconomic category. As was the case for women, ownership of land and a house among men increases sharply with age. However, the proportions of older women and older men owning these high-value assets alone are vastly different. For example, only 15 percent of women age 45-49 own a house alone and 24 percent own land alone, compared with 63 percent and 59 percent of men age 45-49, respectively. Never-married men are slightly more likely to own a house and land than never-married women. In contrast to women, rural men are more likely than urban men to own either asset. Men’s ownership of a house declines sharply with education, from 47 percent among men with no education to 18 percent among men with an SLC and higher education. Ownership of land also declines with education, but the differential is much smaller (from 36 percent among men with no education to 25 percent among men with an SLC or higher education). Surprisingly, ownership of a house declines with wealth, and ownership of land varies minimally and inconsistently with wealth. Men in the mountain zone are more likely than men in other areas to own a house and land. In particular, house and land ownership among men is highest (40 percent and 46 percent, respectively) in the Central mountain region. Women’s Empowerment and Demographic and Health Outcomes • 223 Table 13.5.1 Ownership of assets: Women Percent distribution of women age 15-49 by ownership of a house and land, according to background characteristics, Nepal 2011 Background characteristic Percentage who own a house: Percentage who do not own a house Total Percentage who own land: Percentage who do not own land Total Number of women Alone Jointly Alone and jointly Alone Jointly Alone and jointly Age 15-19 0.3 0.1 0.1 99.5 100.0 0.8 0.2 0.1 98.9 100.0 2,753 20-24 1.4 0.3 0.0 98.2 100.0 2.9 0.3 0.1 96.8 100.0 2,297 25-29 5.4 0.7 0.3 93.6 100.0 7.9 0.5 0.2 91.4 100.0 2,101 30-34 8.7 0.8 0.4 90.1 100.0 13.6 0.6 0.1 85.8 100.0 1,734 35-39 12.3 0.6 0.8 86.4 100.0 16.3 0.4 0.5 82.8 100.0 1,557 40-44 14.1 0.9 1.6 83.4 100.0 20.3 0.7 1.1 78.0 100.0 1,285 45-49 14.8 1.1 1.0 83.1 100.0 23.8 0.3 1.0 74.9 100.0 947 Marital status Never married 0.4 0.2 0.1 99.3 100.0 1.1 0.3 0.1 98.5 100.0 2,708 Married 7.4 0.7 0.5 91.4 100.0 11.4 0.4 0.4 87.8 100.0 9,608 Divorced/separated/widowed 26.7 0.7 0.8 71.9 100.0 28.6 0.8 0.6 69.9 100.0 358 Residence Urban 9.6 0.7 0.5 89.1 100.0 12.5 0.7 0.5 86.3 100.0 1,819 Rural 5.9 0.5 0.4 93.1 100.0 9.2 0.3 0.3 90.1 100.0 10,855 Ecological zone Mountain 3.4 0.2 0.2 96.2 100.0 7.2 0.1 0.0 92.7 100.0 805 Hill 5.2 0.5 0.2 94.0 100.0 8.9 0.5 0.2 90.4 100.0 5,090 Terai 7.7 0.6 0.7 91.0 100.0 10.6 0.4 0.4 88.6 100.0 6,779 Development region Eastern 9.0 0.5 0.8 89.7 100.0 13.0 0.4 0.7 86.0 100.0 3,057 Central 5.9 0.7 0.5 92.9 100.0 9.9 0.5 0.3 89.3 100.0 4,236 Western 6.8 0.5 0.4 92.3 100.0 9.7 0.3 0.2 89.8 100.0 2,660 Mid-western 4.7 0.5 0.0 94.7 100.0 7.1 0.3 0.0 92.5 100.0 1,478 Far-western 3.3 0.3 0.2 96.2 100.0 4.1 0.2 0.1 95.5 100.0 1,242 Subregion Eastern mountain 5.0 0.1 0.2 94.7 100.0 11.6 0.1 0.0 88.3 100.0 229 Central mountain 2.2 0.2 0.0 97.6 100.0 7.8 0.2 0.0 92.0 100.0 258 Western mountain 3.2 0.3 0.3 96.2 100.0 3.7 0.0 0.0 96.3 100.0 319 Eastern hill 6.5 0.1 0.1 93.3 100.0 11.4 0.5 0.2 87.9 100.0 956 Central hill 5.4 0.8 0.4 93.4 100.0 8.6 0.7 0.5 90.2 100.0 1,563 Western hill 5.7 0.5 0.3 93.5 100.0 10.2 0.4 0.1 89.3 100.0 1,513 Mid-western hill 4.6 0.7 0.0 94.7 100.0 7.3 0.5 0.0 92.2 100.0 649 Far-western hill 1.1 0.2 0.1 98.6 100.0 1.6 0.1 0.0 98.2 100.0 409 Eastern terai 10.8 0.6 1.2 87.3 100.0 13.9 0.4 1.0 84.7 100.0 1,873 Central terai 6.6 0.7 0.7 92.0 100.0 10.9 0.5 0.2 88.4 100.0 2,415 Western terai 8.2 0.6 0.5 90.7 100.0 9.0 0.1 0.3 90.5 100.0 1,147 Mid-western terai 5.1 0.4 0.0 94.5 100.0 7.5 0.3 0.1 92.1 100.0 668 Far-western terai 4.7 0.4 0.2 94.7 100.0 5.8 0.4 0.2 93.6 100.0 676 Education No education 7.3 0.6 0.7 91.5 100.0 10.3 0.3 0.4 89.0 100.0 5,045 Primary 6.3 0.7 0.0 93.0 100.0 10.3 0.3 0.0 89.4 100.0 2,209 Some secondary 5.1 0.5 0.5 93.9 100.0 7.9 0.6 0.3 91.3 100.0 3,088 SLC and above 6.6 0.4 0.4 92.6 100.0 10.3 0.4 0.5 88.8 100.0 2,331 Wealth quintile Lowest 2.6 0.3 0.2 96.9 100.0 3.9 0.1 0.0 96.0 100.0 2,120 Second 4.1 0.4 0.2 95.3 100.0 5.2 0.3 0.2 94.4 100.0 2,393 Middle 5.0 0.4 0.7 93.9 100.0 8.7 0.4 0.6 90.3 100.0 2,600 Fourth 8.0 0.8 0.3 90.9 100.0 12.9 0.6 0.2 86.3 100.0 2,722 Highest 11.2 0.9 0.7 87.2 100.0 15.6 0.5 0.6 83.2 100.0 2,839 Total 6.4 0.6 0.5 92.5 100.0 9.7 0.4 0.3 89.6 100.0 12,674 SLC = School Leaving Certificate 224 • Women’s Empowerment and Demographic and Health Outcomes Table 13.5.2 Ownership of assets: Men Percent distribution of men age 15-49 by ownership of a house and land, according to background characteristics, Nepal 2011 Background characteristic Percentage who own a house: Percentage who do not own a house Total Percentage who own land: Percentage who do not own land Total NumberAlone Jointly Alone and jointly Alone Jointly Alone and jointly Age 15-19 1.6 0.4 0.2 97.8 100.0 2.9 0.3 0.2 96.5 100.0 978 20-24 5.4 3.5 0.0 91.2 100.0 6.6 2.2 0.3 90.9 100.0 685 25-29 13.9 1.2 0.2 84.7 100.0 17.4 1.4 0.0 81.1 100.0 581 30-34 27.1 1.8 0.1 71.0 100.0 34.5 1.2 0.3 63.9 100.0 499 35-39 38.7 2.8 1.2 57.2 100.0 41.2 3.3 0.7 54.8 100.0 542 40-44 47.3 5.0 0.2 47.6 100.0 48.4 4.6 0.8 46.1 100.0 438 45-49 62.6 2.0 0.3 35.1 100.0 59.0 3.1 1.4 36.5 100.0 399 Marital status Never married 1.7 1.5 0.2 96.7 100.0 4.6 1.0 0.3 94.1 100.0 1,433 Married 33.9 2.5 0.4 63.1 100.0 35.5 2.6 0.6 61.4 100.0 2,626 Divorced/separated/widowed 31.1 0.0 0.0 68.9 100.0 32.4 0.0 0.0 67.6 100.0 62 Residence Urban 15.3 2.8 0.4 81.4 100.0 20.1 2.0 0.6 77.3 100.0 717 Rural 24.2 2.0 0.3 73.5 100.0 25.6 2.0 0.4 71.9 100.0 3,404 Ecological zone Mountain 33.2 2.2 0.0 64.6 100.0 37.3 2.9 0.0 59.8 100.0 245 Hill 22.9 2.4 0.0 74.6 100.0 26.2 2.3 0.3 71.1 100.0 1,658 Terai 21.3 1.9 0.6 76.2 100.0 22.1 1.7 0.6 75.5 100.0 2,218 Development region Eastern 25.7 4.2 0.6 69.5 100.0 28.8 2.8 1.1 67.2 100.0 996 Central 21.6 2.2 0.3 76.0 100.0 23.9 2.2 0.3 73.7 100.0 1,448 Western 20.0 0.3 0.2 79.5 100.0 21.2 0.8 0.4 77.5 100.0 798 Mid-western 27.8 2.0 0.0 70.2 100.0 27.9 2.5 0.0 69.6 100.0 493 Far-western 18.0 0.8 0.3 80.9 100.0 20.2 1.3 0.0 78.6 100.0 385 Subregion Eastern mountain 34.1 1.0 0.0 64.9 100.0 39.3 1.0 0.0 59.7 100.0 66 Central mountain 37.9 2.4 0.0 59.7 100.0 43.8 2.6 0.0 53.6 100.0 69 Western mountain 29.8 2.8 0.0 67.4 100.0 32.1 4.1 0.0 63.8 100.0 110 Eastern hill 30.1 4.2 0.1 65.6 100.0 35.5 3.3 1.0 60.2 100.0 293 Central hill 20.2 3.7 0.0 76.1 100.0 23.7 3.5 0.0 72.8 100.0 616 Western hill 19.4 0.0 0.0 80.6 100.0 22.5 0.4 0.4 76.6 100.0 440 Mid-western hill 34.5 2.7 0.0 62.8 100.0 35.7 2.7 0.0 61.6 100.0 189 Far-western hill 13.8 0.0 0.0 86.2 100.0 15.7 0.0 0.0 84.3 100.0 120 Eastern terai 22.8 4.5 0.9 71.8 100.0 24.7 2.8 1.3 71.2 100.0 638 Central terai 21.2 1.0 0.5 77.3 100.0 22.2 1.0 0.6 76.2 100.0 763 Western terai 20.6 0.7 0.4 78.3 100.0 19.7 1.2 0.4 78.7 100.0 358 Mid-western terai 20.6 0.7 0.0 78.8 100.0 19.5 1.1 0.0 79.4 100.0 242 Far-western terai 19.4 1.4 0.6 78.7 100.0 21.3 2.3 0.0 76.4 100.0 217 Education No education 45.9 0.9 0.2 52.9 100.0 34.0 1.6 0.0 64.4 100.0 567 Primary 31.9 2.2 0.0 65.9 100.0 32.5 2.0 0.2 65.3 100.0 814 Some secondary 16.2 1.5 0.5 81.8 100.0 20.3 1.2 0.3 78.2 100.0 1,437 SLC and above 14.0 3.3 0.4 82.3 100.0 20.5 3.1 1.1 75.3 100.0 1,303 Wealth quintile Lowest 31.1 1.3 0.0 67.6 100.0 28.4 1.8 0.0 69.8 100.0 610 Second 26.6 0.7 0.2 72.5 100.0 25.2 0.7 0.0 74.2 100.0 695 Middle 25.4 2.0 0.0 72.5 100.0 24.0 1.3 0.2 74.6 100.0 830 Fourth 18.3 1.5 0.5 79.7 100.0 21.4 2.5 1.4 74.8 100.0 920 Highest 17.0 4.1 0.6 78.2 100.0 25.6 3.2 0.5 70.7 100.0 1,066 Total 22.7 2.1 0.3 74.9 100.0 24.7 2.0 0.5 71.8 100.0 4,121 SLC = School Leaving Certificate 13.5 WOMEN’S PARTICIPATION IN DECISION-MAKING The ability of women to make decisions that affect their personal circumstances is an essential element of their empowerment and serves as an important contributor to their overall development. To assess currently married women’s decision-making autonomy, the 2011 NDHS collected information on their participation in three types of decisions: their own health care, making major household purchases, and visits to family or relatives. To provide an understanding of gender differences in household decision-making, currently married men were asked the same questions about their participation in decisions about their own health care and major household purchases. Table 13.6 shows the percent distribution of currently married women and men according to the person in the household who usually makes decisions concerning these matters. Women are considered to participate in decision-making if they make decisions alone or jointly with their husbands. Women’s Empowerment and Demographic and Health Outcomes • 225 Table 13.6 shows that 65 percent of women participate in making decisions regarding their own health care. By contrast, the vast majority of men (87 percent) are involved in decisions about their own health care. One-third of women and the same proportion of men say that they alone make decisions about major household purchases. Only 28 percent of women decide on their own regarding visits to their family or relatives. Table 13.6 Participation in decision-making Percent distribution of currently married women and currently married men age 15-49 by person who usually makes decisions about various issues, Nepal 2011 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Total Number WOMEN Own health care 25.7 39.7 21.8 12.4 0.4 100.0 9,608 Major household purchases 33.5 23.7 19.8 22.3 0.7 100.0 9,608 Visits to her family or relatives 27.7 33.3 17.0 21.5 0.6 100.0 9,608 MEN Own health care 6.8 31.6 55.4 5.6 0.6 100.0 2,626 Major household purchases 22.4 27.2 33.5 15.6 1.3 100.0 2,626 Table 13.7.1 shows how currently married women’s participation (alone or jointly) in decision-making varies by background characteristics. The table presents the results for the three specific types of decisions asked about, namely the woman’s own health care, making major household purchases, and visits to her family or relatives. In addition, the table includes two summary indicators: the proportion of women involved in making all three decisions and the proportion not involved in making any of the three decisions. Table 13.7.1 shows that 57 percent to 65 percent of women participate in the three decisions asked about, but less than half (46 percent) report taking part in all three decisions and about one in four (24 percent) report not participating in any of the three decisions. The percentage of women participating in all three decisions tends to increase with age and wealth. Fifty-seven percent of women in the highest wealth quintile participate in all three decisions, as compared with 40 percent of women in the lowest wealth quintile. Participation in all three decisions varies minimally and inconsistently with education. More women who are employed for cash take part in all three decisions (60 percent) than women who are employed but do not earn cash (41 percent) and women who are not employed (42 percent). Women who belong to a community group and those in urban areas are more likely to participate in all three decisions than women who do not belong to a community group and those from rural areas. Women’s participation in all three decisions ranges from a low of 29 percent in the Far-western hill region to a high of 52 percent in the Central hill and Eastern terai regions. Table 13.7.2 presents data on currently married men’s participation (alone or jointly) in two types of decisions—their own health care and making major household purchases—by background characteristics. The table shows that 87 percent of men participate in decisions about their own health care, and 61 percent participate in decisions about major household purchases. Overall, 57 percent of currently married men age 15- 49 participate in both of these decisions and only 9 percent do not participate in either. The proportion of currently married men participating in both decisions increases sharply with age but tends to decline with education and wealth. Men’s participation in both decisions is higher in rural than in urban areas and in the mountain zone than in other zones. By specific subregion, participation in both decisions ranges from 46 percent in the Eastern terai region to 75 percent in the Central mountain region. 226 • Women’s Empowerment and Demographic and Health Outcomes Table 13.7.1 Women’s participation in decision-making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Nepal 2011 Background characteristic Percentage who usually make specific decisions alone or jointly with their husband Percentage who participate in all three decisions Percentage who participate in none of the three decisions Number of women Woman’s own health care Making major household purchases Visits to her family or relatives Age 15-19 35.2 18.1 21.7 12.9 60.1 792 20-24 53.1 35.4 39.3 26.8 39.4 1,761 25-29 68.0 57.9 61.6 46.1 21.0 1,914 30-34 73.8 69.7 69.0 54.7 15.7 1,659 35-39 75.1 73.8 76.7 59.8 11.2 1,461 40-44 72.7 68.8 76.1 56.8 13.4 1,190 45-49 70.0 68.1 77.5 54.8 12.6 832 Employment (last 12 months) Not employed 57.6 52.8 53.5 41.8 32.4 2,230 Employed for cash 79.8 74.1 74.9 59.8 9.2 2,223 Employed not for cash 62.5 51.8 58.2 40.9 25.8 5,155 Belongs to a community group Belongs to a group 74.2 67.9 70.3 54.7 14.1 4,466 Does not belong to any group 57.7 47.9 52.9 37.5 31.7 5,141 Number of living children 0 45.4 25.5 31.2 19.0 48.6 1,075 1-2 67.2 56.0 59.4 45.5 23.8 4,442 3-4 70.2 68.4 71.0 53.9 15.7 3,091 5+ 64.1 61.9 68.9 48.0 19.2 999 Residence Urban 73.2 65.8 70.5 52.4 14.5 1,261 Rural 64.2 55.9 59.5 44.4 24.9 8,346 Ecological zone Mountain 59.8 52.2 59.4 40.2 25.4 630 Hill 69.9 57.4 63.9 46.3 19.1 3,784 Terai 62.8 57.6 59.0 45.5 26.4 5,193 Development region Eastern 70.4 61.1 64.6 48.6 18.9 2,293 Central 64.4 61.4 62.8 49.2 24.2 3,210 Western 69.3 54.1 59.5 44.3 22.0 2,031 Mid-western 59.2 54.8 62.2 43.3 26.1 1,149 Far-western 55.7 42.4 47.3 30.2 32.5 925 Subregion Eastern mountain 65.2 54.5 62.2 45.4 22.6 169 Central mountain 60.4 58.0 64.5 44.1 21.1 190 Western mountain 56.0 46.8 54.1 34.3 30.1 271 Eastern hill 67.1 53.1 65.1 42.5 19.7 702 Central hill 72.9 67.0 69.7 52.0 13.9 1,103 Western hill 75.8 54.7 63.8 45.9 15.3 1,164 Mid-western hill 65.2 59.5 64.6 50.8 25.1 510 Far-western hill 50.9 38.7 39.5 28.8 41.5 305 Eastern terai 72.6 65.8 64.7 52.0 18.0 1,421 Central terai 59.9 58.5 58.7 48.0 30.5 1,918 Western terai 60.5 53.3 53.8 42.1 30.9 867 Mid-western terai 53.5 51.0 59.8 35.0 25.8 499 Far-western terai 59.0 45.0 52.7 33.4 27.7 488 Education No education 62.4 58.4 63.2 46.3 24.5 4,580 Primary 63.2 56.4 58.0 43.8 25.2 1,844 Some secondary 66.9 55.6 57.7 43.8 24.1 1,833 SLC and above 76.6 56.3 62.0 47.2 17.0 1,350 Wealth quintile Lowest 59.0 50.7 56.4 39.9 29.0 1,664 Second 62.0 52.3 59.8 41.3 25.6 1,846 Middle 61.5 53.8 57.3 43.2 27.9 2,022 Fourth 66.4 58.6 58.7 45.2 23.2 2,052 Highest 76.6 68.9 71.8 56.5 13.0 2,023 Total 65.4 57.2 61.0 45.5 23.5 9,608 SLC = School Leaving Certificate Women’s Empowerment and Demographic and Health Outcomes • 227 Table 13.7.2 Men’s participation in decision-making by background characteristics Percentage of currently married men age 15-49 who usually make specific decisions either alone or jointly with their wife, by background characteristics, Nepal 2011 Background characteristic Percentage who usually make specific decisions alone or jointly with their wife Percentage who participate in both decisions Percentage who participate in neither of the two decisions Number of men Man’s own health care Making major household purchases Age 15-19 51.9 33.1 26.5 41.6 67 20-24 83.4 47.4 45.3 14.5 306 25-29 83.8 51.8 48.2 12.6 471 30-34 88.2 60.6 58.1 9.2 459 35-39 90.9 63.3 59.2 5.0 516 40-44 89.9 72.5 67.8 5.4 423 45-49 90.5 70.6 66.8 5.6 384 Employment (last 12 months) Not employed (82.4) (43.6) (43.6) (17.6) 47 Employed for cash 87.2 59.4 55.4 8.8 2,077 Employed not for cash 87.0 67.6 65.1 10.5 502 Number of living children 0 76.1 39.2 35.8 20.4 310 1-2 87.2 56.8 53.7 9.7 1,200 3-4 90.3 68.6 65.2 6.3 821 5+ 89.0 77.3 70.7 4.3 295 Residence Urban 89.3 51.5 49.5 8.6 425 Rural 86.6 62.5 58.5 9.4 2,201 Ecological zone Mountain 89.3 75.5 71.4 6.6 179 Hill 88.4 55.7 53.0 8.9 1,057 Terai 85.8 62.5 58.3 10.0 1,390 Development region Eastern 83.6 55.8 50.2 10.8 607 Central 88.9 61.6 59.3 8.8 950 Western 86.0 62.0 57.2 9.2 482 Mid-western 86.1 63.3 59.9 10.5 340 Far-western 91.9 63.0 61.0 6.1 247 Subregion Eastern mountain 82.1 69.9 65.1 13.2 42 Central mountain 95.8 76.9 75.2 2.5 50 Western mountain 89.0 77.5 72.3 5.8 87 Eastern hill 80.6 61.2 54.3 12.6 191 Central hill 94.3 48.7 48.7 5.7 385 Western hill 89.8 54.1 51.8 8.0 270 Mid-western hill 82.9 64.2 57.9 10.9 133 Far-western hill 83.4 68.8 67.2 15.1 77 Eastern terai 85.3 51.4 46.4 9.7 374 Central terai 84.2 69.8 65.7 11.7 515 Western terai 81.3 72.0 64.2 10.8 211 Mid-western terai 88.3 60.0 59.5 11.2 157 Far-western terai 97.2 53.5 52.2 1.5 133 Education No education 86.4 72.2 68.8 10.2 504 Primary 85.7 62.9 57.7 9.1 640 Some secondary 85.3 55.2 52.2 11.7 799 SLC and above 90.8 56.6 53.5 6.0 684 Wealth quintile Lowest 88.5 70.3 66.5 7.8 439 Second 87.5 68.1 64.1 8.6 452 Middle 80.2 58.3 53.9 15.4 569 Fourth 88.1 55.9 53.1 9.1 541 Highest 91.2 54.9 51.6 5.5 626 Total 15-49 87.1 60.7 57.1 9.3 2,626 Note: Figures in parentheses are based on 25-49 unweighted cases. SLC = School Leaving Certificate 13.6 WOMEN’S EMPOWERMENT INDICATORS Women’s empowerment has important implications for demographic and health outcomes, including women’s use of family planning and maternal health care services. Two summary indices of women’s empowerment were used to assess the relationship of selected demographic and health outcomes with women’s empowerment. The first index is the number of decisions that currently married women participate in alone or jointly. This index, which ranges from 0 (participates in none of the three decisions asked about) to 3 228 • Women’s Empowerment and Demographic and Health Outcomes (participates in all three decisions), provides insight into women’s control over their daily lives. The second index is based on the information presented in Table 12.6 on women’s attitudes toward negotiating safer sexual relations with their husbands. Specifically, women were asked whether they think that a wife who knows her husband has a disease that she can get during sexual intercourse would be justified in asking that they use a condom when having sex and whether a wife is justified in refusing to have sex with her husband when she knows he has sex with other women. Women’s responses to these two questions were summarized to form the second empowerment index, number of positive attitudes toward negotiating safer sexual relations with the husband. Women were given a score of 0 on this index if they answered `no’ to both questions, a score of 1 if they answered `yes’ to one of the questions and ‘no’ to the other, and a score of 2 if they answered `yes’ to both questions.1 By measuring attitudes toward women refusing sex to their husbands or negotiating safer sex, this index provides insight into women’s perceptions of gender equality in sexual roles and should relate positively to women’s self-esteem. Figure 13.1 shows the percent distribution of currently married women across the values of each of these indices. Twenty-four percent of women participate in no decisions, 31 percent of women participate in one or two decisions, and the remaining women (46 percent) participate in all three decisions. The percent distribution of women by their score on the negotiating safer sexual relations empowerment index is more skewed toward attitudes that support women’s ability to negotiate safe sex: 86 percent of women have the highest score of 2 on this index, with 12 percent having a score of 1 and only 2 percent having a score of 0. Figure 13.1 Percent Distribution of Currently Married Women with their Score on Each of the Two Women's Empowerment Indices NDHS 2011 24 31 46 2 12 86 0 1-2 3 0 1 2 0 20 40 60 80 100 Percent Number of household decisions Number of positive attitudes on negotiating safer sexual relations with husband 1 The index on women’s attitudes toward wife beating used as an indicator of women’s empowerment in the 2006 NDHS was not used in the 2011 NDHS since information was collected differently in the two surveys. Specifically, instead of asking women directly whether a husband was justified in beating his wife under specific scenarios, as was done in the 2006 NDHS, the 2011 NDHS initially asked women whether they agreed with wife beating for any reason. Only if they answered ‘yes’ to this question were they asked the questions about wife beating in specific scenarios. Because less than 1 percent of women responded `yes’ to the filter question, the data on women’s responses to questions on specific scenarios cannot be meaningfully used. Women’s Empowerment and Demographic and Health Outcomes • 229 Table 13.8 examines the relationship between the two empowerment indices by showing how the percentage of women with a score of 2 on the negotiating safer sexual relations index varies by the number of decisions in which they participate and how the percentage of women who participate in all three decisions varies by their score on the negotiating safer sexual relations index. As expected, the table shows a positive association between the two empowerment indices. The percentage of women who have positive attitudes toward negotiating safer sexual relations with their husband increases with the score on the decision-making index, from 89 percent among women who do not participate in any of the three decisions to 95 percent among women who participate in all three decisions. Similarly, the percentage of women who participate in all three household decisions increases from 35 percent among those with a score of 0 on the negotiating safer sexual relations index to 47 percent among those with a score of 2 on the index. Table 13.8 Indicators of women’s empowerment Percentage of currently married women age 15-49 who participate in all decision-making and the percentage with positive attitudes toward negotiating safer sexual relations with their husband, by value on each of the indices of women’s empowerment, Nepal 2011 Empowerment indices Percentage who participate in all decision-making Percentage who agree with both items in the negotiating sexual relations index Number of women Number of decisions in which women participate1 0 na 88.8 2,258 1-2 na 92.5 2,979 3 na 95.4 4,371 Number of positive attitudes on negotiating safer sexual relations with husband2 0 34.6 na 208 1 39.3 na 1,166 2 46.6 na 8,234 na = Not applicable 1 See Table 13.7.1 for the list of decisions. 2 Attitudes include “A wife is justified in asking that they use a condom when she knows that her husband has a disease that she can get during sexual intercourse” and “A wife is justified in refusing to have sex with her husband when she knows he has sex with other women.” 13.7 CURRENT USE OF CONTRACEPTION BY WOMEN’S STATUS A currently married woman’s ability to have only the number of children she wants, as well as her use and choice of contraceptive methods, will be affected by her control over her own life, including her sexual relationship with her husband. A woman who is unable to control other aspects of her life may be less able to make decisions regarding her fertility. She may also feel the need to choose contraceptive methods that are less obvious or do not need the approval or knowledge of her husband. Table 13.9 shows the relationship of each of the empowerment indices with current use of contraceptive methods for currently married women. As expected, contraceptive use is positively associated with both indices of women’s empowerment. Use of any contraceptive method and any modern method is higher among women who participate in one or more decisions and increases with the number of positive attitudes toward safer sexual relations increases. For example, the percentage of women using any method increases from 34 percent among those who do not participate in any decisions to 54-55 percent among women who participate in one or more decisions. Similarly, use of any method increases from 34 percent among women with a score of 0 on the negotiating safer sexual relations empowerment index to 51 percent among those with a score of 2. Women’s use of sterilization, both female and male, as well as their use of traditional methods, is positively associated with their score on the number of decisions index. Use of temporary (female and male) methods is also higher among women who participate in any decisions than among women who participate in none; however, use of temporary methods is higher (25 percent) among women who participate in one or two decisions than among women who participate in all three decisions (20 percent). In contrast, use of temporary 230 • Women’s Empowerment and Demographic and Health Outcomes Table 13.9 Current use of contraception by women’s empowerment Percent distribution of currently married women age 15-49 by current contraceptive method, by the indices of women's empowerment, Nepal 2011 Empowerment indices Any method Any modern method Modern methods Any traditional method Not currently using Total Number of women Female sterilization Male sterilization Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 34.4 29.2 10.7 3.8 10.8 3.8 5.2 65.6 100.0 2,258 1-2 54.5 47.6 14.5 8.1 19.8 5.2 6.9 45.5 100.0 2,979 3 54.3 47.3 18.0 9.7 15.6 4.0 7.0 45.7 100.0 4,371 Number of positive attitudes on negotiating safer sexual relations with husband3 0 34.3 33.1 15.5 6.4 10.7 0.5 1.2 65.7 100.0 208 1 43.4 36.9 13.8 5.8 14.5 2.8 6.5 56.6 100.0 1,166 2 51.0 44.3 15.4 8.2 16.1 4.7 6.7 49.0 100.0 8,234 Total 49.7 43.1 15.2 7.8 15.8 4.3 6.5 50.3 100.0 9,608 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, and implants 2 See Table 13.7.1 for the list of decisions. 3 Attitudes include “A wife is justified in asking that they use a condom when she knows that her husband has a disease that she can get during sexual intercourse” and “A wife is justified in refusing to have sex with her husband when she knows he has sex with other women.” (female and male) methods increases with women’s score on the second empowerment index, from 11 percent to 21 percent, but use of sterilization does not vary consistently with this index. This suggests that use of temporary methods is more dependent on women’s attitudes toward sexual relations than is women’s use of sterilization. 13.8 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS Table 13.10 shows how currently married women’s ideal family size and their unmet need for family planning vary by the two women’s empowerment indices. Women who want to delay their next birth for two or more years (space their next birth) or have no more births (limit their births), but who are not using family planning, are considered to have an unmet need for family planning. Table 13.10 shows that mean ideal family size varies only marginally with both indices of women’s empowerment. Notably, however, more empowered women have a somewhat smaller ideal family size than those who are least empowered (i.e., those with a score of 0 on each index). Table 13.10 Women’s empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by the indices of women’s empowerment, Nepal 2011 Empowerment indices Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of women For spacing For limiting Total Number of decisions in which women participate3 0 2.3 2,253 18.3 13.2 31.6 2,258 1-2 2.2 2,971 9.5 15.1 24.6 2,979 3 2.2 4,355 5.2 21.1 26.3 4,371 Number of attitudes on negotiating safer sexual relations with husband4 0 2.3 293 3.7 20.1 23.7 208 1 2.3 1,526 9.7 18.4 28.1 1,166 2 2.1 10,811 9.8 17.1 26.9 8,234 Total 2.1 12,630 9.6 17.4 27.0 9,608 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.12.1 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 13.7.1 for the list of decisions. 4 Attitudes include “A wife is justified in asking that they use a condom when she knows that her husband has a disease that she can get during sexual intercourse” and “A wife is justified in refusing to have sex with her husband when she knows he has sex with other women.” Women’s Empowerment and Demographic and Health Outcomes • 231 Unmet need varies inconsistently with the two empowerment indicators. Whereas total unmet need tends to decline with women’s participation in decision-making, it tends to increase with the number of positive attitudes toward negotiating safer sexual relations. Notably, there is greater variation in unmet need by the decision-making index than by the negotiating safer sexual relations index. The decision-making index is negatively related to unmet need for spacing and positively related to unmet need for limiting. The negotiating safer sexual relations index has the opposite relationship with the two types of unmet need: unmet need for spacing increases with women’s score on this index, whereas unmet need for limiting declines. 13.9 REPRODUCTIVE HEALTH CARE AND WOMEN’S EMPOWERMENT Table 13.11 shows use of antenatal, delivery, and postnatal care services by women’s scores on the two empowerment indices. It is expected that empowered women will be more likely to seek out health care services that better meet their reproductive health goals, including safe motherhood. The results in Table 13.11 show that women’s empowerment, as expected, is positively associated with women’s access to and use of reproductive health services. The relationship appears much stronger for the negotiating safer sexual relations index than for the decision-making index, although the relationship is positive for both. Among women with a score of 0 on the negotiating safer sexual relations index, only 29 percent received antenatal care from a skilled provider, only 8 percent received assistance from a skilled provider at delivery, and only 15 percent received postnatal care from a health care provider within the first two days after delivery; by contrast, the corresponding proportions among women with a score of 2 on the index were 60 percent, 41 percent, and 43 percent. Table 13.11 Reproductive health care by women’s empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance, and postnatal care from a skilled provider for the most recent birth, by the indices of women’s empowerment, Nepal 2011 Empowerment indices Percentage receiving antenatal care from a skilled provider1 Percentage receiving delivery care from a skilled provider1 Percentage of women with a postnatal checkup in the first two days after birth2 Number of women with a child born in the last five years Number of decisions in which women participate3 0 55.3 33.0 35.7 1,239 1-2 60.4 42.0 42.5 1,292 3 59.0 41.7 44.6 1,573 Number of attitudes on negotiating safer sexual relations with husband4 0 29.3 7.9 15.2 103 1 49.8 36.0 37.5 539 2 60.4 40.6 42.6 3,506 Total 58.3 39.1 41.2 4,148 1 Skilled provider includes doctor, nurse, and midwife. 2 Includes women who received a postnatal checkup from a doctor, nurse, midwife, health assistant, auxiliary health worker, maternal and child health worker, village health workers or FCHV in the first two days after the birth. Includes women who gave birth in a health facility and those who did not give birth in a health facility 3 Restricted to currently married women. See Table 13.7.1 for the list of decisions. 4 Attitudes include “A wife is justified in asking that they use a condom when she knows that her husband has a disease that she can get during sexual intercourse” and “A wife is justified in refusing to have sex with her husband when she knows he has sex with other women.” 232 • Women’s Empowerment and Demographic and Health Outcomes 13.10 INFANT AND CHILD MORTALITY AND WOMEN’S EMPOWERMENT A recent study conducted in Nepal indicated that there is an association between a mother’s decision- making power and the chances of survival of her children (Adhikari and Sawangdee, 2011). The ability of women to access information, make decisions, and act effectively in their own interests or in the interests of those who depend on them is essential to their empowerment. Table 13.12 shows that infant and under-five mortality rates decline as women’s empowerment index scores increase. For example, in the case of women who make no decisions, infant mortality is 67 deaths per 1,000 live births and under-five mortality is 76 deaths per 1,000 live births, compared with 46 deaths and 55 deaths per 1,000 live births, respectively, for women who make all three decisions. The sample is not large enough to reliably assess infant mortality and child mortality among women with a score of 0 on the negotiating safer sexual relations index. Even so, the relationship appears to be strongly negative since all three mortality indicators included in the table are much lower for women with a score of 2 than for women with a score of 1. Table 13.12 Early childhood mortality rates by indicators of women’s empowerment Infant, child, and under-five mortality rates for the 10-year period preceding the survey, by the indices of women’s empowerment, Nepal 2011 Empowerment indices Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which women participate1 0 67 10 76 1-2 52 10 62 3 46 9 55 Number of attitudes on negotiating safer sexual relations with husband2 0 (90) (18) (106) 1 66 12 78 2 50 9 58 Note: Figures in parentheses are based on 250-499 unweighted exposed persons. 1 Restricted to currently married women. See Table 13.7.1 for the list of decisions. 2 Attitudes include “A wife is justified in asking that they use a condom when she knows that her husband has a disease that she can get during sexual intercourse” and “A wife is justified in refusing to have sex with her husband when she knows he has sex with other women.” These data clearly show that empowerment among women is important for their use of family planning and reproductive care as well as for the survival of their children. Domestic Violence • 233 DOMESTIC VIOLENCE 14 Various population-based studies in Nepal have indicated domestic violence as a reason for poor health, insecurity, and inadequate social mobilization among women (Women’s Rehabilitation Centre Nepal, 2009). For the first time in 2011, a domestic violence module was included in the NDHS, recognizing the seriousness of the problem of gender-based violence in Nepal. Gender-based violence is defined as any act that results in, or is likely to result in, physical, sexual, or psychological harm or suffering among women, including threats of such acts and coercion or arbitrary deprivations of liberty, whether occurring in public or in private life (United Nations, 1993; United Nations, 1995). Domestic violence, one form of gender-based violence, is defined in Nepal as any form of physical, mental, sexual, or economic harm perpetrated by one person on another with whom he or she has a family relationship, including acts of reprimand or emotional harm (Ministry of Law and Justice, Nepal, 2009). Domestic violence has negative health consequences for victims, especially with respect to the reproductive health of women and the physical, emotional, and mental health of their children. In addition to ratifying a number of international and regional conventions on women’s rights, gender equality, and social inclusion, Nepal has implemented the Domestic Violence (Offence and Punishment) Act (2066 BS) of 2009 and the Domestic Violence (Offence and Punishment) Regulation (2067 BS) of 2010. It has also implemented a national action plan (2010) against gender-based violence with the Prime Minister’s declaration of 2010 as the gender-based violence free year (Office of the Prime Minister and Council of Minister, 2009) and introduced a hospital-based one-stop crisis management center in 15 selected districts (Ministry of Health and Population [MOHP], 2010d), with service centers established for victims of gender- based violence (Department of Women’s Development, 2009). The Domestic Violence (Offence and Punishment) Act emphasizes respect for the right of every person to live in a secure and dignified manner, prevention and control of violence occurring within the family or outside, making such violence punishable, and providing protection to the victims of violence. Further, it gives authority to the individuals to file complaints, provide legal remedies (including interim protection orders and compensation), and create service centers for counseling and rehabilitation, as well as defining penalties for perpetrators (Nepal Law Commission, 2009). The Three-Year Plan of Nepal (2010/2011–2012/2013) also includes as an objective elimination of various types of gender-based violence and discrimination against women and promotion of gender equality and women’s empowerment (National Planning Commission, 2011). Key Findings: • Twenty-two percent of women age 15-49 have experienced physical violence at least once since age 15, and 9 percent experienced physical violence within the 12 months prior to the survey. • Twelve percent of women age 15-49 report having experienced sexual violence at least once in their lifetime. • Overall, one-third of ever-married women age 15-49 report ever having experienced emotional, physical, or sexual violence from their spouse, and 17 percent report having experienced one or more of these forms of violence in the past 12 months. • Among ever-married women who had experienced spousal violence (physical or sexual) in the past 12 months, more than two in five reported experiencing physical injuries. • It is not common for women in Nepal to seek assistance from any source for violence they have experienced. Nearly two in three women have never told anyone about the violence they have experienced. 234 • Domestic Violence 14.1 MEASUREMENT OF VIOLENCE Collecting valid, reliable, and ethical data on domestic violence poses particular challenges because what constitutes violence or abuse varies across cultures and individuals and a culture of silence usually surrounds domestic violence and can affect reporting. The sensitivity of the topic is another issue. Assuring the safety of respondents and interviewers when asking about domestic violence in a familial setting and protecting women who disclose violence and the risk of double-victimization of respondents as they relive their experience while reporting raise specific ethical concerns. The responses to these challenges by the 2011 NDHS are described below. 14.1.1 Use of Valid Measures of Violence In the 2011 NDHS, information was obtained from ever-married women on violence committed by their current and former spouses and by others, and information was collected from never-married women on violence by anyone, including boyfriends. Since international research shows that intimate partner violence is one of the most common forms of violence against women, information on spousal violence was measured in more detail than violence by other perpetrators. This was done by using a shortened and modified version of the Conflict Tactics Scale (Strauss, 1990). Specifically, spousal violence by the most current husband/partner for currently married women and the most recent husband/partner for formerly married women was measured by asking all ever-married women the following set of questions. (Does/did) your (last) (husband/partner) ever: (a) Push you, shake you, or throw something at you? (b) Slap you? (c) Twist your arm or pull your hair? (d) Punch you with his fist or with something that could hurt you? (e) Kick you, drag you, or beat you up? (f) Try to choke you or burn you on purpose? (g) Threaten or attack you with a knife, gun, or any other weapon? (h) Physically force you to have sexual intercourse with him even when you did not want to? (i) Force you to perform any sexual acts you did not want to? For every question that a woman answered ‘yes,’ she was asked about the frequency of the act in the 12 months preceding the survey. A ‘yes’ answer to one or more of items (a) to (g) above constitutes evidence of physical violence, and a ‘yes’ answer to item (h) or (i) constitutes evidence of sexual violence. Similarly, emotional violence among ever-married women was measured by the following questions. (Does/did) your (last) (husband/partner) ever: (a) Say or do something to humiliate you in front of others? (b) Threaten to hurt or harm you or someone close to you? (c) Insult you or make you feel bad about yourself? This approach of asking about specific acts to measure different forms of violence has the advantage of not being affected by different understandings of what constitutes a summary term such as “violence.” By Domestic Violence • 235 including a wide range of acts, this approach has the additional advantage of giving the respondent multiple opportunities to disclose any experience of violence. In addition to these questions that were asked only of ever-married women, all women were asked about physical violence from persons other than the current or most recent spouse/partner.1 Respondents who answered yes to this question were asked who committed violence against them and the frequency of such violence during the 12 months preceding the survey. Women who reported experiencing different forms of violence were asked for the perpetrators of the violence. Although this approach to questioning is generally considered to be optimal, the possibility of underreporting of violence, particularly sexual violence, cannot be entirely ruled out in any survey, and this survey is no exception. 14.1.2 Ethical Considerations in the 2011 NDHS In recognition of the challenges in collecting data on violence, the interviewers in the 2011 NDHS were given special training. The training focused on how to ask sensitive questions, ensure privacy, and build rapport between interviewer and respondent. Rapport with the interviewer, confidentiality, and privacy are all keys to building respondents’ confidence that they can safely share their experiences with the interviewer. Placement of the violence questions at the end of the questionnaire also provides time for the interviewer to develop a certain degree of intimacy that should further encourage respondents to share their experiences of violence, if any. In addition, the following protections were built into the survey or the questionnaire in keeping with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001): 1. Only one woman per household was administered the questions on violence to maintain confidentiality. One in every two households was preselected for an interview on violence, and in the selected household one female respondent was randomly selected to receive the questions on domestic violence. The random selection of one woman was done through a simple selection procedure based on the Kish Grid, which was built into the Household Questionnaire (Kish, 1965). 2. As a means of obtaining additional consent, beyond the initial consent at the start of the interview, the respondent was informed that the questions could be sensitive and was reassured regarding the confidentiality of her responses. 3. The violence module was implemented only if privacy could be obtained. The interviewers were instructed to skip the module, thank the respondent, and end the interview if they could not maintain privacy during the implementation of this module. 4. A brochure that included information on domestic violence and contact information for service centers across the country was provided to all eligible women after the interview was completed, irrespective of whether they were selected for the module or not. This was d