Pakistan - Demographic and Health Survey - 1992

Publication date: 1992

Pakistan Pakistan Demographic and Health Survey 1990/1991 Nationat Institute of Population Studies ~DHS Demographic and Health Surveys IRD/Macro International inc. Pakistan Demographic and Health Survey 1990/1991 National Institute of Population Studies Islamabad, Pakistan IRD/Macro International Inc. Columbia, Maryland USA July 1992 This report summarises the findings of the 1990-91 Pakistan Demographic and Health Survey (PDHS) conducted by the National Institute of Population Studies, in collaboration with the Federal Bureau of Statistics. IRD/Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development and the Govemment of Pakistan. The PDHS is part of the worldwide Demographic and Health Surveys (DHS) programme, which is designed to collect data on fetaility, family planning, and maternal and child health. Additional information on the Pakistan survey may be obtained from the National Institute of Population Studies, No. 8, Street 70, F-8/3, Islamabad, Pakistan (Telephone 850205; Fax 851977; Telex 54139 NIPS PK). Additional information about the DHS programme may be obtained by writing to: DHS, IRD/Macro lntemational Inc., 8850 Stanford Boulevard, Suite 4000, Columbia, MD 21045, USA (Telephone 410-290-2800; Fax 410-290-2999; Telex 198116). CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Map of Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiv 3 INTRODUCTION by Abdul Razzaque Rukanuddin and Tauseef Ahmed 1.1 Physical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Climate, Rainfall, and Seasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Administrative Divisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.4 People, Culture, Religion, and Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.5 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.6 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.7 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.8 Literacy and Educational Attainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.9 Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.10 Population and Family Planning Policies and Programmes . . . . . . . . . . . . . . . . . . . . . . 5 1.11 Health Policies and Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 SURVEY DESIGN AND IMPLEMENTATION by Tauseef Ahmed, M.D. Mallick and Alfredo Aliaga 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Objectives of the Pakistan Demographic and Health Survey . . . . . . . . . . . . . . . . . . . . 9 Organisation of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Recruitment, Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Data Entry and Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Field Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Coverage of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS by Tauseef Ahrned and Syed Mubashir Ali 3.1 3.2 3.3 3.4 3.5 3.6 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Age-sex Distribution of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Educational Attainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Presence of Household Durable Goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 i i i 4 6 7 8 Page 3.7 3.8 Background Characteristics of Female Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Exposure to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 FERTILITY by Fred Arnold and Mehboob Sultan 4.1 4.2 4.3 4.4 4.5 Fertility Levels and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Teenage Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 KNOWLEDGE AND USE OF FAMILY PLANNING by Nasra M. Shah and Syed Mubashir Ali 5.1 5.2 5.3 5.4 5.5 5.6 Knowledge of Family Planning Methods and Sources . . . . . . . . . . . . . . . . . . . . . . . . . 53 Contraceptive Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Knowledge of the Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Age at Sterilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Source of Supply and Accessibility of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . 68 Cost of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 FAMILY PLANNING ATTITUDES by Abdul Razzaque Rukanuddin and Mehboob Sultan 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Discussion of Family Planning Among Couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Attitudes of Couples Toward Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Family Planning Messages on Electronic Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . 77 Acceptability of Family Planning Messages on Electronic Mass Media . . . . . . . . . . . 79 Intentions About Future Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Reasons for Nonuse of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Preferred Future Method of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 PROXIMATE DETERMINANTS OF FERTILITY by Zeba Sathar and Tauseef Ahmed 7.1 7.2 Marriage Patterns and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Breastfeeding and Postpartum Infecundibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 FAMILY SIZE PREFERENCES by Syed Mubashir Ali and Abdul Razzaque Rukanuddin 8.1 8.2 8.3 8.4 8.5 Desire for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Sex Preference for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Need for Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 iv Page INFANT AND CHILD MORTALITY by Tauseef Ahmed, Mansoor-ul-Hassan Bhatti and George Bicego 9.1 9.2 9,3 9.4 9.5 9.6 Definitions of Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Levels and Trends in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Causes of Death in Early Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 High-risk Fertility Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 10 MATERNAL AND CHILD HEALTH by Abdul Razzaque Rukanuddin and K, Zaki Hasan 10.1 10.2 Maternal Care Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Child Care Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 11 FEEDING PATTERNS AND THE NUTRITIONAL STATUS OF CHILDREN by Tauseef Ahmed and Mohammad Ayub 11.1 11.2 Breastfeeding and Nutritional Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Nutritional Status of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 12 HUSBANDS' SURVEY by Sultan S. Hashmi 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Knowledge and Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Prospective Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Approval of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Acceptability of Media Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Fertility Desires and Sex Preference for Childrcn . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Ideal Number of Children for Husbands and Wives . . . . . . . . . . . . . . . . . . . . . . . . . . 186 APPENDICES Appendix A Appendix B Appendix C Appendix D Pakistan Demographic and Health Survey Staff . . . . . . . . . . . . . . . . . . . . . . . . 189 Estimates of Sampling Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Data Quality Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 V Table 1.1 Table 2.1 Table 2.2 Table 2.3 Table 2A I able 2.5 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Tab'e 3.8 Table 3.9 Table 3.10 Table 3.11 Table 4.1 Table 4.2 "Iable 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 TABLES Page Population size and distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Sample coverage for urban and rural areas combined . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Sample coverage for urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Sample coverage for rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Results of the household and individual interviews for the women's sample . . . . . . . . . 16 Results of the household and individual interviews for the husbands' sample . . . . . . . . 17 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Household population by age, sex and marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Educational level of household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 School enrolment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Background characteristics o f female respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Exposure to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Crude birth rates according to selected surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Current fertility according to selected surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Fertility trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 vii Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 5.11 Table 5.12 Table 5.13 Table 5.14 Table 5.15 Table 6.1 Table 6.2 Page Children ever born according to selected surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Mean number of children ever born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Age at first birth by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Teenage fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Children ever 10ore to teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Knowledge and source of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Trends in contraceptive knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Knowledge of modem contraceptive methods and source o f methods . . . . . . . . . . . . . . 56 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Use of contraception by non-pregnant women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Trends in contraceptive use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . . . . . . 63 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Brand names of condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Timing of sterilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Source of supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 T ime to source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . 70 Costs of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Discussion of family planning by couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Attitudes of couples toward family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 viii Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 7.6 Table 7.7 Table 7.8 Table 7.9 Table 7.10 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Table 8.7 Table 8.8 Page Family planning messages on radio and television . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Perceived effectiveness of mass media messages on use of family planning . . . . . . . . . 78 Acceptability of media messages on family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Future contraceptive use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Reasons for not intending tu use contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Mean age at marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Ideal age at marriage for women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Marriage between relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Breasffeeding, postpartum amenorrhoea, abstinence and insusceptibility . . . . . . . . . . . . 93 Median duration of postpartum insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Preferred sex of next child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Mean ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Planning status of births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 ix Table 8.9 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 10.6 Table 10.7 Table 10.8 Table 10.9 Page Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Indices of early infant deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Sex differentials in infant and neonatal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Reporting of age at death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . . . . . 116 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . 118 Causes of death in early childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 High-risk fertility behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 128 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Characteristics of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Vacc inat ionsbybackgroundchamcter i s t i cs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Vaccinations in first year of life by current age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Table 10.10 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . . . . . . . 138 Table 10.11 Prevalence and treatment of fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Table 10.12 Prevalence o f diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Table 10.13 Knowledge and use of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Table 10.14 Treatment of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Table 10.15 Feeding practices during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 X Table 11.1 Table 11.2 Table 11.3 Table 11.4 Table 11.5 Table 11.6 Table 11.7 Table 11,8 Table 11.9 )'age Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Liquids and food items given before breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Nutritional intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Breastfeeding and supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Type of supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Age at which liquids and foods were introduced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Reasons fors topp ingbreast feed ing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Table 11.10 Nutritional status by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Table 12.1 Husbands' background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Table 12.2 Age difference between spouses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Table 12.3 Husband's level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Table 12.4 Knowledge of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Table 12.5 Knowledge of contraception among couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Table 12.6 Knowledge and use of modem methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Table 12.7 Current use of contraception reported by couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Table 12.8 Reasons for not intending to use contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Table 12.9 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Table 12.10 Wife's perception of husband's attitude about family planning . . . . . . . . . . . . . . . . . . 181 Table 12.11 Husband's perception ofwife's attitude about family planning . . . . . . . . . . . . . . . . . . 181 Table 12.12 Acceptability of mass media messages on family planning . . . . . . . . . . . . . . . . . . . . . 182 Table 12.13 Perceived effectiveness of mass media messages on family planning . . . . . . . . . . . . . 183 Table 12.14 Reproduction intentions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 xi Page Table 12.15 Desire to limit future births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Table 12.16 Desire for more children by wives and their husbands . . . . . . . . . . . . . . . . . . . . . . . . . 185 Table 12.17 Ideal number of children of wives and their husbands . . . . . . . . . . . . . . . . . . . . . . . . . 187 Appendix B Table B.1 List of selected variables for sampling errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Table B.2 Sampling errors: Entire sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Table B.3 Sampling errors: Urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 TableB.4 Sampling errors: Major cities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Table B.5 Sampling errors: Other urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Table B.6 Sampling errors: Rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Table B.7 Sampling errors: Punjab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Table B.8 Sampling errors: Sindh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Table B.9 Sampling errors: NWFP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Table B.10 Sampling errors: Balochistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 Table B.I1 Sampling errors: Age group 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Table B.12 Sampling errors: Age group 25-34 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Table B.13 Sampling errors: Age group 35-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Appendix C Table C.1 Age distribution of household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Table C.2 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Table C.3 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Table C.4 Births by calendar year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Table C.5 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 Table C.6 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 xii N~3.1 Ngure3.2 Figure3.3 Figure4.1 ~gure4 .2 ~gure5.1 Figure 5.2 Figure 5.3 Figure 5.4 Figure 6.1 ~gure7.1 Figure 8.1 Figure 8.2 Figure 9.1 Figure 9.2 Figure 9.3 Figure 10.1 Figure 10.2 FIGURES Population pyramid of Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 School enrolment by age and place of residence . . . . . . . . . . . . . . . . . . . . . . . . 26 Distribution of currently married women by age, Pakistan 1975-1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Age-Specific fertility rates, Pakistan 1970-1991 . . . . . . . . . . . . . . . . . . . . . . . . 40 Total fertility rate (TFR) and mean number of children ever bom (CEB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Knowledge of modem contraceptive methods and sources among currently married women by residence . . . . . . . . . . . . . . . . . . . . . . . . . 57 Current use of modem contraceptive methods among currently married women 15-49 by residence and province . . . . . . . . . . . . . . . . 64 Current use of modem contraceptive methods among currently married women 15-49 by education . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Sources of family planning among current users of modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Approval of family planning among currently married women by residence and education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Marriage between relatives and between nonrelatives among ever-married women 15-49, Pakistan and major cities . . . . . . . . . . . . . . . 91 Fertility preferences among currently married women 15-49 . . . . . . . . . . . . . . . . 99 Fertility preferences among currently married women 15-49 by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Distribution of deaths under five by age at death . . . . . . . . . . . . . . . . . . . . . . 115 Infant and child mortality by place of residence . . . . . . . . . . . . . . . . . . . . . . . 117 Infant mortality by mother's age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . 119 Antenatal care, place of delivery, and assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Percentage of children 12-23 months who are fully vaccinated . . . . . . . . . . . . . 136 xiii Figure 10.3 Figure 10.4 Figure 10.5 Figure 11.1 Figure 11.2 Figure 11.3 Figure 11.4 Figure 11.5 Figure 11.6 Figure 12.1 Figure 12.2 Figure 12.3 Figure 12.4 Page Prevalence of ARI symptoms and fever in the two weeks preceding the survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Knowledge and use of ORS by residence and province . . . . . . . . . . . . . . . . . . 143 Percentage of children receiving treatment for diarrhoea by type of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Percentage of children given selected liquids before being put to the breast by province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Percentage of children given water, milk, or solid/mushy food the day before the interview . . . . . . . . . . . . . . . . . . . . . . . . 154 Breastfeeding among children age 0-23 months . . . . . . . . . . . . . . . . . . . . . . . 156 Age at which liquids and solid/mushy food were first given to children age 24-59 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Percentage of children under five who are underweight by age . . . . . . . . . . . . . 165 Undemutrition among children under five years of age . . . . . . . . . . . . . . . . . . 166 Age difference between husbands and wives . . . . . . . . . . . . . . . . . . . . . . . . . 171 Percentage of couples in which both the husband and wife know specific contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Knowledge of modem contraceptive methods, knowledge of sources, and current use among husbands by province . . . . . . . . . . . . . . . . . 177 Desire for more children among husbands and wives by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 xiv PREFACE One of the major objectives of the National Institute of Population Studies (NIPS) is to assist the Ministry of Population Welfare by assessing and evaluating the Population Welfare Programme. The Pakistan Demographic and Health Survey (PDHS) has been one of the major activities in this context. This survey is a part of the worldwide exercise to assess the changing demographic and health situation through 60 surveys in different countries. This effort is being coordinated by the Demographic and Health Surveys programme of IRD/Macro International Inc., Columbia, Maryland. Planning for the PDHS began in June 1990 and the survey was executed between December 1990 and May 1991. While the data processing was done simultaneously with the fieldwork, the tabulation was done during June and July 1991 and the preliminary report was released in August 1991. This survey, which is a follow-up of the Pakistan Contraceptive Prevalence Survey undertaken during 1984-85, was given high priority in the work plan of the Institute. The survey provides us with an up-to-date set of relevant data useful to evaluate population, health and family planning programmes and to assess the overall demographic situation in the country. The results produced in this report provide social scientists, policy makers, and planners with a clear picture about thc current level of demographic and health indicators and trends in the recent past and illuminate the likely direction for the future. The importance of the PDHS lies in the fact that it provides basic resource material for the Eighth Five-Year Plan presently being formulated. For undertaking this arduous task, the Institute cooperated with IRD/Macro International Inc., which provided technical assistance and data processing equipment. The Federal Bureau of Statistics provided assistance in the selection of the sample and the fieldwork. The United States Agency lor International Development (USAID) and the Government of Pakistan provided financial assistance and staff for the execution of this activity. To all these agencies, NIPS is highly indebted. Since this project is a research exercise, there could be differences in the findings of this survey and other data available from different sources. This is an understandable situation; questions have especially been raised about the data on immunisations, the contraceptive method mix and fertility estimates. The users of these data may use caution while interpreting these differences and may draw their own conclusions. Those who actually worked on the project from its inception to its completion deserve special appreciation. I am also thankful to Mr. K. U. Faruqui and Mr. K. M. Chima for their interest, support and guidance during their stay at NIPS as Project Director. We also acknowledge the services of Dr. A. Ghayur who worked as Principal Investigator for the initial part of the project. Islamabad 1992 M. S. Jillani, Ph.D. Executive Director XV ACKNOWLEDGMENTS The Pakistan Demographic and Health Survey (PDHS) was completed as a part of an international exercise undertaken in collaboration with IRD/Macro Intemational Inc. (IRD), Columbia, Maryland. The PDHS was conducted in order to update information on human reproduction, infant and child mortality, contraceptive use, maternal and child care, and the nutritional status of children. The major objective of the PDHS was to provide a data base for evaluating programme efforts and developing strategies and plans for the furore programme. As in the case of all previous demographic surveys, the successful completion depended on a joint effort of a number of organizations and individuals. The National Institute of Population Studies undertook the responsibility of implementing the project only when IRD provided assistance in terms of technical knowhow and equipment, USAID/Islamabad fully financed it, and the Federal Bureau of Statistics (FBS) provided the sampling frame, field supervisory personnel and almost all logistical support for the fieldwork. Conducting the fieldwork was a huge task and all activities were accomplished on time only with the dedicated, relentless and devoted efforts of the PDHS staff at the headquarters, data entry staff, the office editors, able FBS supervisors and drivers and all our field teams. Many thanks to each one of them for undertaking an enormous amount of hardship during the winter and maintaining the speed and efficiency of work during the month of Ramadan and during unexpected rains from February to April 1991. We are deeply indebted to Dr. M. S. JiUani, former Secretary of the Ministry of Population Welfare, for the guidance and personal interest needed to maintain the speed of the project. The timely release of funds by him was definitely a big boost for all. Later, his support as a Project Director worked as a catalyst for finalizing and releasing the preliminary and final report of the PDHS. The PDHS was undertaken in several stages: establishment of the office, questionnaire design and modification, sample design, pretesting of the questionnaire, training of field teams, fieldwork, questionnaire editing, and data entry. As an integral part of the survey activities, every activity was appraised and guided by the Technical Advisory Committee. This is to acknowledge the efforts and timely advice of the members of the Committee in the successful completion of the survey. Many thanks are due to the late Mr. S. M. Ishaque, former Director Genera/, FBS for his professional association and help to the PDHS. We also acknowledge with deep gratitude all the moral and logistic support that we received from the offices of all provincial Director Generals, Population Welfare Departments and a large number of District Population Welfare Officers in conducting our field survey in very remote areas of Pakistan. Special thanks are also due to the reviewers of various chapters which include Ms. Anne R. Cross, Dr. Elisabeth Sommerfelt, Dr. Kate Stewart and Dr. Fred Arnold. We would also like m thank the following IRD personnel for their assistance in producing tabulations, designing the survey and the sample, and editing and typing the report: Mr. Noureddine Abdermhim, Dr. Alfredo Aliaga, Dr. Ties Boerma, Mr. Trevor Croft, Ms. Jeanne Cushing, Ms. Thanh Le, Dr. A.M. Marckwardt, Ms. Kaye Mitchell, Dr. Sidney Moore, Mr. Luis Ochoa, Mr. Guillermo Rojas, Dr. Jeremiah Sullivan, and Ms. Jane Weymouth. The amount of work put in by Dr. S. S. Hashmi and Dr. A. Razzaque Rukanuddin to review and finalize this report needs to be fully xvii acknowledged and appreciated. Finally, we would like to acknowledge with deep gratitude and thanks the relentless and committed efforts of Dr. Fred Arnold who provided immense moral support and technical assistance at each stage of the project. Tauseef Ahmed, Ph.D. Principal Investigator xviii SUMMARY OF FINDINGS The Pakistan Demographic and Health Survey (PDHS) was fielded on a national basis between the months of December 1990 and May 1991. The survey was carried out by the National Institute of Population Studies with the objective of assisting the Ministry of Population Welfare to evaluate the Population Welfare Programme and maternal and child health services. The PDHS is the latest in a series of surveys, making it possible to evaluate changes in the demographic status of the population and in health conditions nationwide. Earlier surveys include the Pakistan Contraceptive Prevalence Survey of 1984-85 and the Pakistan Fertility Survey of 1975. Until recently, fertility rates had remained high with little evidence of any sustained fertility decline. In recent years, however, fertility has begun to decline due to a rapid increase in the age at marriage and to a modest rise in the prevalence of contraceptive use. The lotal fertility rate is estimated to have fallen from a level of approximately 6.4 children in the early 1980s to 6.0 children in the mid-1980s, to 5.4 children in the late 1980s. The exact magnitude of the change is in dispute and will be the subject of further research. Important differentials of fertility include the degree ofurbanisation and the level of women's education. The total fertility rate is estimated to be nearly one child lower in major cities (4.7) than in rural areas (5.6). Women with at least some secondary schooling have a rate of 3.6, compared to a rate of 5.7 children for women with no formal education. There is a wide disparity between women's knowledge and use of contraceptives in Pakistan. While 78 percent of currently married women report knowing at least one method of contraception, only 21 percent have ever used a method, and only 12 percent are currently doing so. Three-fourths of current users are using a modem method and one-fourth a traditional method. The two most commonly used methods are female sterilisation (4 percent) and the condom (3 percent). Despite the relatively low level of contraceptive use, the gain over time has been significant. Among married non-pregnant women, contraceptive use has almost tripled in 15 years, from 5 percent in 1975 to 14 percent in 1990-91. The contraceptive prevalence among women with secondary education is 38 percent, and among women with no schooling it is only 8 percent. Nearly one-third of women in major cities arc current users of contraception, but contraceptive use is still rare in rural areas (6 percent). The Government of Pakistan plays a major role in providing family planning services. Eighty-five percent of sterilised women and 81 percent of IUD users obtained services from the public sector. Condoms, however, were supplied primarily through the social marketing programme. The use of contraceptives depends on many factors, including the degree of acceptability of the concept of family planning. Among currently married women who know of a contraceptive method, 62 percent approve of family planning. There appears to be a considerable amount of consensus between husbands and wives about family planning use: one-third of female respondents reported that both they and their husbands approve of family planning, while slightly more than one-fifth said they both disapprove. The latter couples constitute a group for which family planning acceptance will require concerted motivational efforts. The educational levels attained by Pakistani women remain low: 79 percent of women have had no formal education, 14 percent have studied at the primary or middle school level, and only 7 percent have attended at least some secondary schooling. The traditional social structure of Pakistan supports a natural fertility pattern in which the majority of women do not use any means of fertility regulation. In such populations, the proximate determinants of fertility (other than contraception) are crucial in determining xix fertility levels. These include age at marriage, breastfeeding, and the duration of postpartum amenorrhoea and abstinence. The mean age at marriage has risen sharply over the past few decades, from under 17 years in the 1950s to 21.7 years in 1991. Despite this rise, marriage remains virtually universal: among women over the age of 35, only 2 percent have never married. Marriage patterns in Pakistan are characterised by an unusually high degree of consangninity. Half of all women are married to their first cousin and an additional 11 percent are married to their second cousin. Breasffeeding is important because of the natural immune protection it provides to babies, and the protection against pregnancy it gives to mothers. Women in Pakistan breastfeed their children for an average of20months. Themeandurationofpostpartumamenorrhoeais slightly more than 9 months. After tbebirth of a child, women abstain from sexual relations for an average of 5 months. As a result, the mean duration of postpartum insusceptibility (the period immediately following a birth during which the mother is protected from the risk of pregnancy) is 11 months, and the median is 8 months. Because of differentials in the duration of breastfeeding and abstinence, the median duration of insusceptibility varies widely: from 4 months for women with at least some secondary education to 9 months for women with no schooling; and from 5 months for women residing in major cities to 9 months for women in rural areas. In the PDHS, women were asked about their desire for additional sons and daughters. Overall, 40 percent of currently married women do not want to have any more children. This figure increases rapidly depending on the number of children a woman has: from 17 percent for women with two living children, to 52 percent for women with four children, to 71 percent for women with six children. The desire to stop childbearing varies widely across cultural groupings. For example, among women with four living children, the percentage who want no more varies from 47 percent for women with no education to 84 percent for those with at least some secondary education. Gender preference continues to be widespread in Pakistan. Among currently married non-pregnant women who want another child, 49 percent would prefer to have a boy and only 5 percent would prefer a girl, while 46 percent say it would make no difference. The need for family planning services, as measured in the PDHS, takes into account women's statements concerning recent and future intended childbearing and their use of contraceptives. It is estimated that 25 percent of currently married women have a need for family planning to stop childbearing and an additional 12 percent are in need of family planning for spacing children. Thus, the total need for family planning equals 37 percent, while only 12 percent of women are currently using contraception. The result is an unmet need for family planning services consisting of 25 percent of currently married women. This gap presents both an opportunity and a challenge to the Population Welfare Programme. Nearly one-tenth of children in Pakistan die before reaching their first birthday. The infant mortality rate during the six years preceding the survey is estimaled to be 91 per thousand live births; the under-five mortality rate is 117 per thousand. The under-five mortality rates vary from 92 per thousand for major cities to 132 for rural areas; and from 50 per thousand for women with at least some secondary education to 128 for those with no education. The level of infant mortality is influenced by biological factors such as mother's age at birth, birth order and, most importantly, the length of the preceding birth interval. Children born less than two years after their next oldest sibling are subject to an infant mortality rate of 133 per thousand, compared to 65 for those spaced two to three years apart, and 30 for those born at least four years after their older brother or sister. XX One of the priorities of the Government of Pakistan is to provide medical care during pregnancy and at the time of delivery, both of which are essential for infant and child survival and safe motherhood. Looking at children born in the five years preceding the survey, antenatal care was received during pregnancy for only 30 percent of these births. In rural areas, only 17 percent of births benefited from antenatal care, compared to 71 percent in major cities. Educational differentials in antenatal care are also striking: 22 percent of births of mothers with no education received antenatal care, compared to 85 percent of births of mothers with at least some secondary education. Tetanus, a major cause of neonatal death in Pakistan, can be prevented by immunisation of the mother during pregnancy. For 30 percent of all births in the five years prior to the survey, the mother received a tetanus toxoid vaccination. The differentials are about the same as those for antenatal care generally. Eighty-five percent of the births occurring during the five years preceding the survey were delivered at home. Sixty-nine percent of all births were attended by traditional or trained birth attendants, while 19 percent were assisted by a doctor or nurse. The Expanded Programme on Immunisatlon in Pakistan has met with considerable success. Among children 12 to 23 months of age, 70 percent had received a BCG vaccination, 50 percent a measles vacci- nation, and 43 percent had received all three doses of DPT and polio vaccine. Only 35 percent, however, had received all of the recommended vaccinations, while 28 percent had received none at all. Thirty-nine percent of boys were fully protected, compared to 31 percent of girls. Sixteen percent of children under the age of five had been ill with a cough accompanied by rapid breathing during the two weeks preceding the survey. Children 6-11 months old were most prone to acute respiratory infections (23 percent). Two-thirds (66 percent) of children who were sick were taken to a health facility or provider. All but 15 percent of the sick children received some kind of treatment. About the same proportion of children (15 percent) had suffered from diarrhoea in the two weeks preceding the survey, with the highest incidence among children under two years of age. Nearly half (48 percent) were taken to a health facility or provider. About two of five (39 percent) children with diarrhoea were treated with oral rehydration solution prepared from ORS packets. Knowledge of oral rehydration therapy is widespread: 90 percent of mothers recognise ORS packets. Nearly two-thirds (63 percent) of mothers have used ORS packets at some time, and among these, three-quarters had mixed the solution correctly the last time they prepared it. Thirty percent of children had suffered from fever in the two weeks preceding the survey. Those most prone to illness were age 6 to 11 months. Two-thirds of children with fever were taken to a health facility or provider. Inadequate nutrition continues to be a serious problem in Pakistan. Fifty percent of children under five years of age suffer from stunting (an indicator of chronic undemutrition), as measured by height for age. The prevalence of stunting increases with age, from 16 percent for children under 6 months to 63 percent of four-year olds. The lowest prevalence is found in Punjab (44 percent), and the highest in Balochistan (71 percent). The mother's level of education is an important factor; the prevalence of stunting varies from 18 percent for mothers with some secondary education to 56 percent for mothers with no education. Acute undemutrition, low weight for height, is less of a problem in Pakistan than chronic undemutrition. Nine percent of children suffer from acute undemutrition (wasting). The prevalence of wasting does not vary substantially between geographic groupings. The largest differential is for mother's xxi education: 4 percent of children of mothers with some secondary school or higher education are wasted, compared to 10 percent of children of mothers with no schooling. A systematic subsample of households in the women's survey was selected to obtain information from the husbands of currently married women. The focus was on obtaining information about attitudes, behaviour, and the role of husbands regarding family planning. Husbands' responses concerning knowledge and use of contraception were remarkably similar to women's responses: about four-fifths knew of at least one method, two-thirds knew of a source of supply, one-fourth reported that they and their spouses had used contraception sometime in the past, and about one-seventh were current users. Although a majority of husbands (56 percent) approve of family planning, wives are more likely to favour family planning than their husbands. Since husbands usually have a predominant role in family decision making, the family planning programme should increase efforts to educate and motivate husbands. xxii PAKISTAN ~-- ~ CHINA GILGIT AFGHANISTAN PE$HAWAR ISLAMABAD JAMMU & KASHMIR ~SPUT~ AREA) LAHORE • QUETTA PUNJAB IRAN BALOCHISTAN INDIA SINDH [11 KARACHI ARABIAN SEA "~ xxiv CHAPTER 1 INTRODUCTION Abdul Razzaque Rukanuddin and Tauseef Ahmed This report gives the major findings of the Pakistan Demographic and Health Survey (PDHS) conducted from December 1990 to May 1991 on a nationwide basis. After the preliminary report, published in August 1991, this is the first in a series of reports on the PDHS findings with the objective of improving the Population Welfare Programme and health services in Pakistan. Besides presenting results at the national level, this report presents information by urban-rural areas and by province. Before presenting the major findings, this chapter discusses the physical features, people, culture, religion, language, population distri- bution and size, fertility and mortality levels, literacy and educational attainment, economy, population and family planning and health policies and programmes of the country. The objective of this presentation is to make the reader familiar with the historical, geographic, socioeconomic and demographic features of the country. 1.1 Physical Features Pakistan, situated in the northwestern part of the South Asian subcontinent, obtained independence from the British on August 14, 1947 after the subdivision of the Indian subcontinent. It is a land mass of diversified relief with vast plains in the Indus basin, a rocky expanse of plateaus in the southwest and majestic mountains in the north with beautiful valleys, snow-covered peaks and glaciers. Pakistan extends from 24 ° to 37°N latitude and from 61 ° to 75°E longitude. On its east and southeast lies India, to the north and northwest is Afghanistan, to the west is Iran and in the south, the Arabian Sea. It has a common frontier with China on the border of its Gilgit Agency. Tajikistan, formerly in the USSR, is separated from Pakistan by a narrow strip of Afghan territory called Wakhan. This variety of landscape divides Pakistan into six major regions: the Northern High Mountainous Region, the Western Low Mountainous Region, the Balochistan Plateau, the Potohar Uplands, and the Punjab and Sindh fertile plains. Pakistan is a land of great rivers like the Indus and its tributaries, large dams like Tarbela, and high mountain peaks like K2 (Mount Goodwin Austin - 8,611 metres) and Nanga Parbat (8,126 metres). 1.2 Climate, Rainfall, and Seasons Pakistan has a continental type of climate, characterized by extreme variations of temperature depending on the topography of the country. Pakistan experiences a general deficiency of rainfall. Although it is in the monsoon region, it is arid, except for the southem slopes of the Himalayas and the submountalnous tract where the annual rainfall varies between 76 and 127 cm. Balochistan is the driest part of the country with an average rainfall of 21 cm. There are four well-marked seasons in Pakistan, namely: 1. Cold season (December to March) 2. Hot season (April to June) 3. Monsoon season (July to September) 4. Post-monsoon season (October to November). 1.3 Administrative Divisions The total land area of Pakistan is about 796,000 square kilometres. Pakistan is comprised of the provinces of Punjab, Noah West Frontier, Balochistan and Sindh and the Federally Administered Tribal Areas (FATA) of the north and northwest (see map, page xxiv). Each province is divided into administrative divisions, districts, tehsils and talukas. There were 16 divisions and 72 districts in the country in 1991. Islamabad, the capital of Pakistan, which lies in the northem part of the country at the bottom of the Margala hills near Rawalpindi, is a well-planned city which was constructed beginning in the 1960s. 1.4 People, Culture, Religion, and Language Pakistan historically attracted migrants from many nations in the northwest and the northeast. These include Dravidians, Aryans, G reeks, Turks, Persians, Afghans, Arabs and Mughals. The dominant racial type in Pakistan is Indo-Aryans. In the cultural arena, Pakistan has inherited a rich heritage. A highly developed way of life was attained by the people of Pakistan in the Indus Valley Civilization about 5000 years ago which came to an end around 1500 B.C. About 500 B.C., the northern city of Taxila emerged as a famous centre of Buddhist leaming and culture which existed for a thousand years. Pakistan is an ideological state which came into existence as a result of the demand for a separate homeland for the Muslims of the Indian subcontinent. The Muslim majority areas were mostly carved out into Pakistan. Therefore, the large majority of the population of Pakistan is comprised of Muslims. A negligible minority of Hindus is settled mainly in the border districts of Sindh. Christians are widely spread throughout the country and form about three percent of the total population. The Parsis (Zoroastrians), whn number about 20,000, are an economically notable minority, mostly settled in Karachi. The constitution of Pakistan guarantees the right of minorities to profess, practice and propagate their religion and every administrative position is open to them with the exception of the Head of State and the Prime Minister. Urdu is the language most commonly spoken throughout the country. Balochi and Brohi are spoken in most of Balochistan, Pushto in North West Frontier Province (NWFP) and also in some parts of Balochistan, Punjabi in Punjab, and Sindhi in the Province of Sindh. Saraiki is widely spoken in southern Punjab in the districts of Multan, Bahawalpur and Dera Ghazi Khan and adjoining areas in Balochistan, NWFP and Sindh. The medium of education is Urdu but English continues to be used in higher education and professional colleges, particularly in scientific and technical fields. English is widely used for commercial, legal and other official business in the country. 1.5 Population Population Size Pakistan is the ninth most populous country in the world after China, India, the former USSR, USA, Indonesia, Brazil, Japan, and Nigeria. The population of Pakistan was 16.6 million at the beginning of the twentieth century (in 1901). By the time of independence in 1947, the population was estimated to have doubled to 32.5 million. In the first decennial census (1951), the population of Pakistan was reported to be 33.8 million while in the last decennial census in 1981 the population size was 84.3 million (see Table 1.1). In 1991, the population was estimated to be around 115 million with males comprising 52.5 percent of the population. The sex ratio of the population is estimated to be 111 males per 100 females. Since independence, the population has increased at an average growth rate of 2.9 percent per annum. The present growth rate of the population is estimated to be around three percent. 2 Table 1.1 Population size and distribution Distribution of population, intercensal change and average annual growth ra~ of population by residence. Pakistan, 1951-1981 Census year Area 1951 1961 1972 1981 Urban 6,019 Rural 27,798 Total 33,817 Urban 17.8 Rural 82.2 Total 100.0 Urban Rural Total Urban Rural Total Population (in OOOs) 9,655 16,594 23,841 33,324 48,727 60,412 42,978 65,321 84,254 Percent distribution 22.5 25.4 28,3 77.5 74.6 71.7 100.0 100.0 100.0 Intercensal percent change 60.4 71.9 43.7 19.9 46.2 24.0 27.1 52.0 29.0 Average annual growth rate 4.88 4.77 4.38 1.84 3.32 2.58 2.45 3.67 3.06 Source: Population Census Orgadisation (1985). Population Distribution The population of Pakistan is unevenly distributed among its various provinces. Punjab is the most densely populated province with about one-quarter (26 percent) of the total land area of the country and more than half (56 percent) of the total population. The next most densely populated provinces are Sindh, with less than one-fifth (18 percent) of the land area and 23 percent of the total population and North West Frontier Province (NWFP) and the Federally Administered Tribal Area (FATA) with 13 percent of the land area and 16 percent of the total population. Balochistan, which is the largest province by area (with 44 percent of the total land area), has the lowest proportion of Pakistan's total population (5 percent). The population density in the country increased from 43 persons per square kilometre in 1951 to 106 persons per square kilometre in 1981 and further to around 145 persons per square kilometre in 1991. Urban-Rural Distribution Pakistan is predominantly an agricultural country with just over 50 percent of the work force employed in occupations related to agriculture. The 1981 Census reported that 72 percent of the total population lived in rural areas. However, urban growth over the years has been dramatic. The proportion 3 urban increased from 18 percent in 1951 to 28 percent in 1981. In terms of absolute numbers, the urban population nearly quadrupled from 6.0 million in 1951 to 23.8 million in 1981. However, the intercensal average annual growth rate of the urban population declined from 4.9 percent for the period 1951-61 to 4.4 percent for the period 1972-81, primarily due to a change in the definition of urban areas (see Table 1.1). 1.6 Fertility Several attempts have been made in Pakistan to estimate fertility rates through direct as well as indirect techniques. A number of estimates have been made based on different sets of data, methods and assumptions. Given the trend in population growth, the inevitability of fertility as an important focus of population studies cannot be overemphasized. But a major problem in Pakistan is the wide variations in fertility estimates derived from different sets of data (Rukanuddin and Farooqui 1988), reflecting problems in data inconsistency due to methodological and procedural differences. For instance, the direct fertility estimates based on the 1975 Pakistan Fertility Survey and the 1984-85 Pakistan Contraceptive Prevalence Survey are lower than the indirect estimates based on the Population Growth Surveys (conducted between 1968 and 1979) and the Pakistan Demographic Surveys (conducted annually since 1984). However, prior demographic surveys confirm the persistence of a high level of fertility in Pakistan but with a gradual decline over time. The principal decline has been observed for the younger age groups and is attributed primarily to an increase in the age at marriage. Changes over time in other proximate determinants of fertility in Pakistan such as contraceptive use and breastfeeding are less conducive to lower fertility. Since 1974, surveys have estimated the crude birth rate to vary from 37 to 43 per thousand population and the total fertility rate to range between 5.9 and 6.9 children per woman. 1.7 Mortality In Pakistan, the systematic study of trends, levels and differentials in mortality is impeded by a lack of reliable data. Although a system of vital registration has been in existence in the country since the last quarter of the 19th century, the recorded data suffer from errors in coverage and inaccuracies in the information provided. It is estimated that at the time of independence, the crude death rate (CDR) was around 25 to 30 per thousand population. The decline in mortality after the Second World War has been very rapid, with the CDR falling to about 10 to 12 deaths per thousand in the 1980s. This has been due inter alia to improvements in the availability of food through higher levels of production, the effective control of procurement and distribution of food grains, and the increasing pace of socioeconomic development. Epidemics have also been eliminated and diseases brought under control with the development of effective public health measures and medical services such as inoculation and vaccination programmes. The infant mortality rate was around 150 to 180 deaths per thousand live births at the time of independence in 1947. This has declined to less than 100 in 1991, mainly due to improved health services and a successful immunisation programme. Available evidence suggests that slightly more than one-third (36 percent) of all deaths occur during infancy in Pakistan. Moreover, one-third of all infant deaths occur within one week of birth. An additional 22 percent of deaths occur in the second to fourth week. In other words, more than half of infant deaths are neonatal deaths that occur within four weeks of birth. Much could be done to eliminate some of the causes of neonatal deaths such as short birth intervals and high parity births. Maternal deaths, associated with complications of pregnancy and childbirth, are quite high. Four of five deliveries are attended by traditional birth attendants or elderly women. Repeated and closely spaced pregnancies and births coupled with high parity pregnancies are found to result in a high incidence of maternal deaths. In Pakistan it is estimated that around 500 matemal deaths occur per hundred thousand live births. Although a gradual decline in mortality has been taking place in the country, health care coverage is still insufficient. Only 55 percent of the population has access to health services. A significant augmentation of services is necessary in order to reduce mortality, especially in rural areas. The life expectancy at bin2h has increased from 35-38 years at the time of independence to close to 60 years around 1990. The single largest increase in longevity occurred after the 1960s. In the past, males in Pakistan, on the whole, enjoyed a longer life expectancy (3-4 years longer than females) because of higher female mortality at younger ages and during the reproductive years (although this result might have been affected by differential underreporting of mortality by sex). Recently this difference has been reduced. 1.8 Literacy and Educational Attainment Pakistan has one of the lowest literacy rates (31 percent) in the world. Moreover, in 1985 there was a wide gap between male (43 percent) and female (18 percent) literacy rates. The lowest femaie literacy rate (4 percent), as of the 1981 Census, was observed for Balochistan. The literacy rate among rural females was only 2 percent in Balochistan and 4 percent in NWFP (Rukanuddin and Farooqui 1988). The primary school enmlment ratio is also very low (49 percent). The corresponding figures for males and females are 63 percent and 35 percent, respectively. Primary education in Pakistan is further characterized by drop-out and repeater rates which are considered to be among the highest in the world. Only 50 percent of the students who enter primary school complete the five years of primary school. Students, on the average, go to school for 1.7 years, which is very low compared to the average years of schooling in other developing countries (United Nations Development Programme 1991). 1.9 Economy Pakistan is intrinsically an agricultural country with more than 70 percent of its population living in rural areas. Agriculture is the largest single sector of the economy, employing more than 50 percent of the labour force. Agriculture accounts for 24 percent of the gross domestic product (GDP) and 70 percent of export earnings (Rukanuddin and Farooqui 1988). Development in agriculture and industry has transformed the economy of Pakistan and moved the country toward self sufficiency in meeting its basic needs. In 1990-91, the average per capita income in Pakistan was about Rs 9000 (US$400). The average rural monthly income per household in Pakistan is around one-third lower than the per household urban income. Moreover, it has been estimated that about 30 percent of the population in Pakistan live below the poverty line. Pakistan also has a low gross domestic savings rate of 13 percent of the GDP. The average annual growth rate of the GDP during the period 1985-90 was about 5.8 percent. 1.10 Population and Family Planning Policies and Programmes Pakistan was a pioneer among the most populated developing countries in supporting and implementing family planning activities start'rag in the 1950s. Concern has been expressed in successive Five-Year Development Plans (1955-60 to 1988-93) about rapid population growth and provisions have been made to support a family planning programme to deal with this burgeoning problem. Different approaches and strategies have been adopted during each plan period to promote the concept of a small family norm and to encourage the use of modem methods of family planning. These strategies have varied in design, coverage, outreach, supervision and guidance. However, due to a lack of consistent government commitment and social and cultural constraints, the programme has not been adequately effective in providing family planning services or generating widespread demand for the adoption of contraceptives. Financial and operational obstacles have also hindered the coverage of the programme, which is in the range of 25-30 5 percent of the total population. Family planning facilities are more concentrated in urban areas than in rural areas. The fertility inhibiting effect of the family planning programme has been low in Pakistan and contraceptive use has remained low despite the existence of the programme for the last three decades. The environment for family planning in Pakistan has been quite difficult. Factors which are generally associated with high fertility rates worldwide also pertain to Pakistan: high illiteracy and low educational attainment (particularly among females), poverty, high infant and child mortality, high maternal mortality, a preference for sons, poor access to health facilities, low socioeconomic status of women, ignorance, conservatism, fatalism and religiosity. These factors reinforced one another in maintaining high and stable fertility rates in the country. After many years of effort, the coverage of family planning services does not exceed one-third of the population. Various fertility surveys have found a wide gap between knowledge and the use of contraception in Pakistan. These surveys, however, have also indicated the existence of a potential demand for family planning expressed by Pakistani women (Population Welfare Division 1986). I.II Health Policies and Programmes The Ministry of Health provides health care services through government hospitals and other health outlets. The objective of the health policy is to reduce the incidence of morbidity and mortality by providing preventive and curative care to the whole population. Specific attention is given to reducing infant and child mortality, curtailing severe undemutrifion among children and mothers, and improving child survival and safe motherhood. In order to combat high childhood morbidity and mortality due to infectious and communicable diseases, an immunisatlon programme was initiated in 1978 to protect infants and young children against six common diseases and pregnant mothers against tetanus. This programme was greatly accelerated in 1982 with the collaboration of the World Health Organisation and UNICEF. The Expanded Programme on lmmu- nisation (EPI) is a major component of this scheme to provide universal immunisation. High maternal mortality is a priority area for health policy and coverage is provided to mothers through ante- and postnatal services performed at maternal and child health centres. These efforts are complemented by projects focusing on child survival and nutritional status through growth monitoring, adequate food supplementation and the promotion of breastfeeding. The government is committed to improving the quality of health services and the coverage of primary health care services, especially in the rural areas, through its Basic Health Units and Rural Health Centres. The provincial Health Departments of the respective provinces provide these services through their outlets. It was only in 1991 that the new health policy provided for family planning services to be offered through all health outlets as an integral part of health services. 6 REFERENCES Population Census Organisation [Pakistan]. 1985. Hand Book of Population Census Data. Islamabad: Statistics Division. Population Welfare Division [Pakistan]. 1986. Pakistan Contraceptive Prevalence Survey, 1984-85. Islamabad: Ministry of Planning and Development. Rukanuddin, Abdul Razzaque, and M. Naseem lqbal Farooqui. 1988. The State of Population in Pakistan, 1987. Islamabad: National Institute of Population Studies. United Nations Development Programme. 1991. Human Development Report, 1991. New York: Oxford University Press. 7 CHAPTER 2 SURVEY DESIGN AND IMPLEMENTATION Tauseef Ahmed, M. D. Mallick and Alfredo Aliaga This chapter outlines various aspects of the design and implementation of the Pakistan Demographic and Health Survey--namely, the objectives and organisation of the survey, the sample design, the ques- tionnaire design, training and fieldwork, data processing, and implementation. 2.1 Objectives of the Pakistan Demographic and Health Survey The primary objective of the Pakistan Demographic and Health Survey (PDHS) was to provide national- and provincial-level data on population and health in Pakistan. The primary emphasis was on the following topics: fertility, nuptiality, family size preferences, knowledge and use of family planning, the potential demand for contraception, the level of unwanted fertility, infant and child mortality, breastfeeding and food supplementation practices, maternal care, child nutrition and health, immunisations and child morbidity. This information is intended to assist policy makers, administrators and researchers in assessing and evaluating population and health programmes and strategies. The PDHS is further intended to serve as a source of demographic data for comparison with earlier surveys, particularly the 1975 Pakistan Fertility Survey (PFS) and the 1984-85 Pakistan Contraceptive Prevalence Survey (PCPS). 2.2 Organisation of the Survey In April, 1990, the National Institute of Population Studies (NIPS), on behalf of the Government of Pakistan, signed a contract with the United States Agency for International Development (USAID) and IRD/Macro International Inc. (IRD), Columbia, Maryland, to carry out the Pakistan Demographic and Health Survey in collaboration with the Federal Bureau of Statistics, Statistics Division, Government of Pakistan. Technical assistance was provided by IRD for all phases of the survey through the Demographic and Health Surveys programme. The survey was funded by the United States Agency for Intemationai Development (USAID) and the Govemment of Pakistan. 2.3 Sample Design The sample design adopted for the Pakistan Demographic and Health Survey is a stratified, clustered and systematic sample of households. The universe consists ofaU urban and rural areas of the four provinces of Pakistan as defined in the 1981 Population Census, excluding the Federally Administered Tribal Areas (FATA), military restricted areas, the districts of Kohistan, Chitral and Malakand, and protected areas of North West Frontier Province (NWFP). The population of excluded areas constitutes about 4 percent of the total population. For the urban sample, the sampling frame used was the master sample prepared by the Federal Bureau of Statistics. This frame was developed by dividing each city/t0wn into enumeration blocks of approximately 200-250 households with detailed and clearly recognizable boundary particulars and maps. The updating of the frame was done on the basis of the information obtained from the 1988 Census of Establishmants. For the rural sample, the sampling frame used was the village list published by the 1980 Housing Census. The primary sampling units in the urban domain were enumeration blocks; in the rural domain they were mouzas/dehs/villages. 9 Sample Size and Allocation The PDHS sample is a subsample of the Federal Bureau of Statistics master sample, which includes 7,420 primary sampling units (PSUs). Consideration in the selection of the PDHS sample was given to the population parameters and geographic levels for which estimates were required, the resources available, and the expected rate of nonresponse. A sample of 8,019 households (secondary sampling units) was selected for coverage from 408 sample areas (PSUs). The distribution of primary sampling units, secondary sampling units (SSUs), eligible women and eligible husbands and their actual coverage in the four provinces is given in Tables 2.1, 2.2 and 2.3. Stratification Plan Cities having a population of 500,000 and above (Faisalabad, Gujranwala, Hyderabad, Karachi, Lahore, Multan, Peshawar, and Rawalpindi) were included to form the domain for the major cities. Quetta, which had a population of less than 500,000 but is the capital of Balochistan, was also included as a major city. For the selection of the sample, each of these cities constituted a separate stratum which was further stratified into low, middle, and high income areas, based on information collected in each enumeration block at the time the urban sampling frame was updated. For the remaining urban cities/towns, divisions of NWFP, Sindh, Punjab and Balochistan were grouped together to form a stratum. For the rural domain, each district in each province was considered a stratum, except in Balochistan where each division constituted a stratum. A two-stage stratified sample design was adopted for the survey. The sample PSUs from each urban stratum were selected with probability proportional to the number of households. The sample PSUs from each rural stratum were selected with probability proportional to the population enumerated in the 1981 census. Table 2.1 Sample coverage for urban and rural mess combined Coverage of primary sampling units (PSUs), secondary sampling units (SSUs), efigible women and eligible husbands, Pakistan 1990-91 Number of SSUs Number of Number of Number of PSUs (households) eligible women eligible husbands Not Not Not Not Province Covered covered Total Covered covered Total Covered covered Total Covered covered Total Pu~ab 155 0 155 2598 192 2790 2207 124 2331 461 103 564 Sindh II0 0 110 2071 189 2260 1798 102 1900 364 175 539 NWFP 82 0 82 1609 147 1756 1665 24 1689 313 81 394 B~ochistan 60 1 61 915 298 1213 941 43 984 216 44 260 Total 407 1 408 7193 826 8019 6611 293 6904 1354 403 1757 10 Table 2.2 Sample coveral~e for urban areas Coverage of urban primary sampling units (PSUs), secondary sampling units (SSUs), eligible women and eligible husbands, Palfistan 1990-91 Province Number of SSUs Number of Number of Number of PSUs (households) eligible women eligible husbands Not Not Not Not Covered covered Total Covered covered Total Covered covered Total Covered covered Total Pu~ab T 72 0 72 1178 118 1296 995 71 1066 212 56 268 M 39 0 39 667 71 738 558 51 609 116 36 152 O 33 0 33 511 47 55g 437 20 457 96 20 116 Sindh T 70 0 70 1167 93 1260 1059 72 1131 206 120 326 M 49 0 49 835 65 900 755 57 812 147 85 232 O 21 0 21 332 28 360 304 15 319 59 35 94 NWFP T 42 0 42 699 57 756 749 12 761 144 51 195 M 14 0 14 247 23 270 261 5 266 56 25 81 S 28 0 28 452 34 486 488 7 495 88 26 114 B~ochistan T 41 0 41 558 180 738 581 28 609 134 32 166 M 18 0 18 234 90 324 246 12 258 61 11 72 O 23 0 23 324 90 414 335 16 351 73 21 94 Totsl T 225 0 225 3602 448 4050 3384 183 3567 696 259 955 M 120 0 120 1983 249 2232 1820 125 1945 380 157 537 O 105 0 105 1619 199 1818 1564 58 1622 316 102 418 T ~- ToUd M = Major city 0 = Other urban Table 2.3 Sample coverage for rural areas Coverage of rural primary sampling units (PSUs), secondary sampling units (SSUs), eligible women and eligible husbands, pakistan 1990-91 Ptovino~ Number of PSUs Number of SSUs Number of Number of (households) eligible women eligible husbands Not Not Not Not Covered cove~v.d Total Covered covered Total Covered covered Total Covered covered Total Punjab 83 0 83 1420 74 1494 1212 53 1265 249 47 296 Sindh 40 0 40 904 96 1000 739 30 769 158 55 213 NWFP 40 0 40 910 90 1000 916 12 928 169 30 199 B~ochistan 19 1 20 357 118 475 360 15 375 82 12 94 Total 182 1 183 3591 378 3969 3227 110 3337 658 144 802 11 Households within each sample PSU were considered secondary sampling units (SSUs). A fixed number of SSUs were selected systematically with equal probability using a random start and a sampling interval: 18 SSUs from each PSU in the urban domain in the four provinces and in the rural domain of Punjab Province and 25 SSUs from each PSU in the rural domain of the remaining three provinces of Sindh, NWFP and Baiochistan. Unlike previous surveys in Pakistan, the PDHS did not allow the substitution of households in the case of nonresponse. From the selected sample of SSUs, a systematic subsample of one in three households was chosen for inclusion in the husbands' sample. The husbands of eligible women in these households were eligible to be interviewed, provided that they slept in the household the night before the interview. The sample was designed to produce reliable estimates of population and health indicators separately for Karachi and for urban and rural areas ofPnnjab, Sindh, NWFP and Balochistan. This objective required an oversampling of all urban areas as well as the provinces of NWFP, Balochistan and Sindh. Because of the nature of the PDHS sample, a separate weighting factor was required for every PSU. The weighting procedure has two major components: the design component and the response differential component, with the design component being the major one. The weights were standardized so that the weighted number of completed cases at the national level is equal to the unweighted total. After data entry, weights were applied to the households and individuals in each PSU, to insure that the weighted sample would properly represent the actual geographic distribution of the population of Pakistan. Weights for husbands followed the same methodology as weights for women, except that the husbands' nonresponse rates were used in the calculations. The target was to interview 8,019 ever-married women age 15-49. The size of the target sample was based on an assumption of 1.1 eligible women per household and a nonresponse rate of 10 percent. A summary of the distribution of eligible women and eligible husbands by province and urban-rurai residence is presented in Tables 2.1,2.2 and 2.3. In general, the sample was adequate in size and sufficiently representative of the population to provide reliable estimates for the country as a whole, for urban areas, for rural areas, and for each province. However, for smaller groups, the sampling errors are generally higher. The calculated sampling errors for selected variables are shown in Appendix B. 2.4 Questionnaires Three types of questionnaires were used in the PDHS: the Household Questionnaire, the Woman's Questionnaire and the Husband's Questionnaire (see Appendix D). The contents of the questionnaires were based on the DHS Model B Questionnaire, which is designed for use in countries with low contraceptive prevalence. Additions and modifications to the model questionnaire were made after extensive consultatious with related ministries and interested organisations and with members of the PDHS Technical Advisory Committee. The questionnaires were translated from the original English version into the national language (Urdu) and three regional languages (Panjabi, Sindhi and Pushto). The Household Questionnaire listed all usual residents of a sampled household, plus all visitors who slept in the household the night before the interview. Some basic information was collected on the charac- teristics of each person listed, including their age, sex, marital status, education and relationship to the head of the household. The main purpose of this section oftbe Household Questionnaire was to identify women and men who were eligible for the Women's Questiotmaire and the Husband's Questionnaire. In addition, the Household Questionnaire collected information on the household itself, such as the source of water, type 12 oftullet facilities, materials used in the construction of the house, and ownership of various durable consumer goods. The Woman's Questionnaire was used to collect information from eligible wometr--that is, all ever-marriedwomenage 15-49whosleptinthehouseholdthenightbeforethehonseholdinterview. Eligible women were asked questions about the following topics: Background characteristics Reproductive history Knowledge and use of contraeeption Pregnancy and breasffeeding Vaccinations and the health of children Marriage Family size preferences Husband's background In addition, interviewing teams measured the height, weight and arm circumference of all respond- ents' children under age five. The PDHS was the first national survey that collected demographic, health and anthropometric data simultaneously. The questionnaire was designed to be completed in an average interview time of about 60 minutes. The actual mean time for the individual interview was 53 minutes. The interview time ranged from 47 minutes for women with no children born since January 1986 to 60 minutes for women who had three or more children during that period. Interviews were also conducted with a subsample of husbands of eligible women who were married at the time of the survey. The Husband's Questionnaire consists of a subset of the questions on the Woman's Questionnaire, with particular emphasis on family planning, marriage, and family size preferences. 2.5 Recruitment, Training and Fieldwork The selection of field teams was done at the regional level in order to insure that interviewers were accustomed to local dialects and cultural norms and were acquainted with localities in adjacent areas. The majority of field interviewers had received either a bachelor's or a master's degree. In September-October 1990, prior to the main survey, a pretest of the questionnaires and field procedures was carried out. A two-week training session for interviewers and supervisors was conducted at Punjab University, Lahore. The training session was followed by two weeks of fieldwork. A total of 309 pretest interviews were completed in urban and rural areas of all four provinces in Pakistan (Punjab, Sindh, North West Frontier Province, and Balochistan). Training for the main survey took place in November-December 1990. Training was held simul- taneonsly at the Regional Training institutes of the Ministry of Population Welfare in three cities--Karachi, Lahore and Peshawar. Staff members from the National Institute of Population Studies, the Federal Bureau of Statistics, the Regional Training Institutes and IRD/Macro Intematinnal conducted the training sessions. Participants in the training course included 16 statistical officers from the Federal Bureau of Statistics (FBS) and more than 80 female and male interviewers. The four-week training course consisted of instruction in general interviewing techniques and field procedures, a detailed review of the questionnaires, practice in weighing and measuring children, and practice interviews in the field. Trainees who performed satisfactorily in the training programme were selected as interviewers for the main survey. The female interviewers whose performance was rated as superior were selectexl as field editors. 13 The fieldwork for the PDHS was carried out by 15 interviewing teams. Each team consisted of one field supervisor from FBS, one field editor, three female interviewers, one male interviewer and one driver (see Appendix A for a complete list of survey staff). The fieldwork started in December 1990 and was completed by May 1991. Transportation for the field teams was provided by FBS, provincial Population Welfare Departments, and NIPS. Assignment of PSUs to the teams and various logistic decisions were made by the PDHS staff. Each team was allowed a fixed period of time to complete fieldwork in a PSU before moving to the next PSU. All the teams started their fieldwork close to or adjacent to their headquarters. The main duty of the field editors was to examine the completed questionnaires in the field and ensure that all necessary corrections were made. An additional duty was to examine the on-going interviews and verify the accuracy of information collected on the eligibility of respondents. Throughout the survey, PDHS staff maintained close contact with all 15 teams through direct communication and spot-checking. The objective was to provide support in the field and advice to enhance data quality and the efficiency of interviewers. This objective was accomplished by communicating data problems and possible solutions to the interviewing teams, reminding interviewers about proper probing techniques, and examining the fieldwork of the supervisors. Each team supervisor was provided by FBS with the original household listing and the household sample selected by computer for each designated PSU. In case of any error in the sample information, the supervisors contacted FBS headquarters to resolve the problem. 2.6 Data Entry and Processing All completed questionnaires for the PDHS were sent to the National Institute of Population Studies for data entry and processing. The data entry operation consisted of office editing, coding, data entry and machine editing. Although field editors examined the completed questionnaires in the field, these were re-edited at the PDHS headquarters by specially trained office editors. This re-examination covered: checking all skip sequences, checking circled response codes, and checking the information recorded in the filter questions. Special attention was paid to the consistency of responses to age questions and the accurate completion of the birth history. A second stage of office editing comprised the assignment of appropriate occupational codes and the addition of commonly mentioned "other" responses to the coding scheme. One supervisor and five data entry operators were responsible for the data entry and computer editing operations. The data were processed using five microcomputers and the DHS data entry and editing programmes written in ISSA (the Integrated System for Survey Analysis). The data entry started in the first week of January 1991, within one week of the receipt of the first set of completed questionnaires. The data entry was done directly from the precoded questionnaires. All data entry and editing operations were completed by July 1991. A series of computer-based checks were done to clean the data and remove inconsistencies. Age imputation was also completed at this stage. As in all DHS surveys, age variables such as current age, age at first marriage, and the ages of all living or dead children were imputed for those cases in which information was missing or incorrect entries were detected. The PDHS followed the DHS tabulation plan, in order to maintain comparability with other countries where DHS surveys have been conducted. Some additional tables were inchided to examine special topics included on the modified PDHS questionnaire. 2.7 Field Problems Every survey is subject to a variety of field problems, which cannot be fully anticipated. The major problems encountered in the PDHS are highlighted below, with a discussion of their possible effects. 14 Transportation: Each field team was assigned a vehicle to visit dispersed PSUs and to move quickly from one sample area to the next. Unexpected heavy rains during the months of March, April, and May brought landslides and flooding in Punjab, NWFP and Balochistan, causing substantial delays. Tube-boats were, therefore, hired in some areas. Several attempts were made to reach engulfed PSUs. At times, travel on foot for several miles was necessary to reach the designare, xl PSUs. Security of Teams: The law and order situation in Sindh was at its worst from January through April, Teams in Sindh were advised to take full precautions before going to any disturbed rural PSU. In addition, local security officers had to accompany interviewing teams to several PSUs in Balochistan. One PSU in Balochistan could not be reached by a Sindh team because of the insecure situation and a lack of police protection for the PDHS team. Supervision: In some instances, the work of certain supervisors was found to be weak: they were not moving to new PSUs as planned; they lacked coordination among team members; they did not dispatch the questionnaires from completed PSUs on time; they gave unauthorized leave to interviewers; they sent in an incomplete set of questionnaires; and at times they did not help female interviewers to locate sample households. Funds: Funds for the fieldwork were often not released by responsible agencies in a timely fashion. These delays caused frustration for interviewers as they had to rely on borrowed money rather than their own salaries. A loan of Rs. 2 million from the Ministry of Population Welfare provided timely relief and faci- litated the full execution of the fieldwork. Timing: The actual fieldwork was planned to be completed before the month of Ramadan which started in March 1991. Due to the unfortunate delays caused by heavy rains, almost all teams worked throughout the month of Ramadan without any break. Noncooperation: In a few areas in NWFP and Sindh, where the main cash crop is poppies or where dacoits reside, almost all households were apprehensive about talking to the interviewers, especially when questions were asked about household members and the ownership of durable consumer goods. PDHS team members were sometimes mistaken for members of the narcotics board or as television license examiners. Cultural Norms: In several PSUs in Balochistan and NWFP, respondents willingly completed the interview but refused to allow anthropometric measurements to be taken. Most women did not want any outsider to touch their children. Moreover, mothers did not want others to know the weight and height of their children to protect them from the evil eye. Sample Selection: The sample for the PDHS was selected at FBS headquarters. Some errors were detected in the sampling interval for households in the overall sample and in the husbands' sample. These problems caused some delays and confusion in the field. Most of these problems resulted in short-term difficulties but did not deter the overall progress of the project. 2.8 Coverage ofthe Survey Tables 2.4 and 2.5 show the results of the household and individual interviews for the women's sample and the husbands' sample. A total of 8,019 households were selected for the women's sample. About 90 percent of the selecl~l households were successfully contacted and interviewed. The shortfall was primarily due to dwellings that were vacant or households which were absent when they were visited by interviewers. Of the 7,404 households found to be occupied (including listed dwellings that could not be found), 97 percent were successfully interviewed. In other words, once a household was contacted, it was 15 Table 2.4 Results of the household and individual intelviewe for the women's sample Percent distribution of households and eligible women in the women's sample by results of the homehcld and individual interviews, and response rates, according to residence and province. Paldstan 1990-91 Residence Provino~ Result of intervlcw To ml Major Oth*r and response rate urban city urban Rural Punjab Sindh NWFP Balochistan Total SelectM households for women's sample Completed (C) 88.9 88.8 89.1 90.5 Household present but no 0.9 1.0 0.7 1.0 competent respondent at homo fliP) Refused (R) 1.0 1.4 0.4 0.4 Dv,~Uing not found (DNF) 1.0 0.6 1.6 0.9 Household absent (HA) 2.6 2.6 2.7 2.2 Dw~11ing v ac~nffadd~css 4.6 4.9 4.2 3.1 not a dwelling (DV) Dwelling destroyed (DD) 0.2 0.2 0.3 0.3 Other (O) 0.7 0.5 1.0 1.6 Total percent 100.0 100.0 100.0 100.0 Number 4050 2232 1818 3969 Household response rate for women's sample (HRR) ! 93.1 91.6 91.6 75.4 89.7 0.9 1.9 0.2 0.5 1.0 0.9 0.7 0.5 0.7 0.7 0.4 0.1 0.2 5.0 1.0 0.6 2.6 1.8 7.1 2.4 3.2 2.6 3.2 g.7 3.9 0.2 0.3 0.4 0.1 0.2 0.7 0.2 2.2 2.5 1.2 100.0 100.0 100.0 100.0 100.0 2790 2260 1756 1213 8019 96.8 96.7 97.0 97.5 97.7 97.2 99.1 9Z3 97.2 Eligible women Completed (EWC) 94.7 93.5 96.2 96.7 94.7 94.6 98.6 95.1 95.7 Not at home (EWNH) 2.3 2.9 1.5 1.9 2.1 4.0 0.7 0.8 2.1 Refused CEWR) 1.7 2.3 1.0 0.7 1.9 0.8 0.5 1.7 1.2 partly completed (EWPC) 0.5 0.6 0.3 0.3 0.9 . . . . 0.5 0.4 Other (EWe) 0.8 0.7 0.9 0.4 0.4 0.6 0.3 1.9 0.6 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3572 1947 1625 3338 2331 1900 1689 990 6910 Eligible women response rate (EWRR) 2 95.5 94.2 97.1 97.1 95.0 95.2 98.9 96.9 96.3 Overall response rate for women (ORRW# 92.5 91.0 94.2 94.7 92.9 92.5 98.0 89.5 93.5 -- Less than 0.05 percent fUsing the number of households falling into specific response categories, the household response rate (HRR) is calculated as: C C+ HP +R + DNF ZUsing the number of eligible women falling into specific response categories, the eligible women response rate (EWRR) is calculated as: EWC EWC + EWNH + EWR + EWPC ~The overall lesponse rate for women (ORRW) is calculated as: ORRW = HRR * EWRR 16 Table 2.5 Results of the household and individual interviews for the husbands' sample Percent distribution of households and eligible husbands in the husbands' sample by resultJ of the household and individual interviews, and response rates, aoc, ording to residence and province, Pakistan 1990-91 Residence Province Result of interview Total Major Other and response rate urban city urban Rural Punjab Sindh NWFP Balochistan Total Selected households for husbands' sample Completed (CH) Household present but no competent respondent at home (HPIO Refused (RH) Dwelling not found (DNFH) Household absent 0J~AH) DweUthg vacant/address not a dwelling (DVH) Dwelling destroyed (DDH) Other (OH) Total percent Number Household response rate for husbands' sample (HRRH) t ~ .0 89.8 90.3 90.7 93.0 91.4 93.8 77.0 90.3 0.7 0.7 0.8 1.2 1.0 2.0 -- 0.5 1.0 1.1 1.6 0.5 0,4 1.0 0.8 ~3 1.0 0.8 0.8 0.7 1.0 0.8 ~1 0.3 -- 4.7 0.8 2.3 2.3 2.3 1.9 0,4 2.1 1.7 6.4 2.1 4.1 4.3 4.0 3.3 3.3 3.0 2.0 8.4 3.7 . . . . . . 0.4 0.1 0.4 0.2 -- 0.2 0.9 0.7 1.2 13 1.1 - 2.0 2.0 1.1 1~.0 1~.0 1~.0 1~.0 1~.0 1~.0 1~.0 1~.0 1~.0 1351 7~ 6~ 1342 930 760 598 ~5 2693 97.1 96.8 97.5 97.4 97.9 96.8 99.6 92.6 97.2 Eligible husbands Completed (EHC) 72.9 70.8 75.6 82.0 81.7 67.5 79.4 83.1 77.1 Not at home (EHNH) 23.9 25.7 21.5 15.1 16.3 29.9 16.5 11.9 19.9 Postponed (EHP) 0.3 -- 0.7 . . . . . . . . 1.2 0.2 Refused 0SHR) 1.6 2.0 1.0 0.9 0.9 0.9 1.8 1.9 1.3 Partly completed 0SHPC) 0.3 0.4 0.2 0.5 0.5 0.4 0.3 0.4 0.4 Other 0SHO) L0 1.1 1.0 1.5 0.5 1.3 2.0 1.5 1.3 Total percent 100.0 100.0 100.0 100.0 100.0 I00.0 100.0 100.0 100.0 Number 955 537 418 802 564 539 394 260 1757 Eligible husbands response rate (EHRR) 2 73.7 71.6 76.3 83.3 82.2 68.4 81.1 84.4 78.0 Overall response rate for husbands (ORRI~ 71.6 69.3 74.4 81.1 80.5 66.2 80.8 78.2 75.8 -- Less than 0.05 percent 1Using the number of households falling into specific ~sponse categories, the household response ram for the husbands' sample (HRRH) is calculated as: CH CH+ HPH + RH + DNFH 2Using the number of eligible husbands falling into specific response categcflcs, the eligible husbands' response rate (EHRR) is calculated as: EHC EHC + EHNH + EHP + EHR + EHPC 3The ovendl response rate for husbands (ORRH) is calculated as: ORRH = HRRH * EHRR 17 almost certain to complete the household interview. The highest response rate for the household interview was recorded for NWFP (99 percent); the lowest was recorded for Baiochistan (92 percent). In more than 15 percent of the cases in Balochistan, either the dwellings were vacant or the households were absent due to the temporary migration of households because of severe cold weather in that region. In the interviewed households, 6,9 I0 women were identified as eligible for the individual interview. Interviews were successfully completed for 96 percent of the eligible women. The difference between the number of women targeted for interviewing and actual contacts was mainly due to the fact that the actual number of eligible women per household was lower than assumed in the sample design. The principal reason for nonresponse among eligible women was the failure to find them at home, despite repeated visits to the household. The refusal rate was low (only 1.2 percen0. A sample of 1,757 husbands of eligible women was identified as being eligible for the husbands' interview. However, only 77 percent of eligible husbands could be comacted and have interviews completed. The response rate was particularly low in Sindh where almost one-thinl of eligible husbands were not at home and in major cities where one-quarter of husbands were not at home. The major reason for the high level of nonresponse among husbands was their absence from the households and the fact that male interviewers could not contact them even after several visits. 18 CHAPTER 3 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Tauseef Ahmed and Syed Mubashir All A profile of the demographic and socioeconomic characteristics of the population in the sample households is presented in this chapter to provide background information about the respondents interviewed in the PDHS. The characteristics of the population are compared with those reported from earlier surveys and censuses, wherever possible, to examine differentials and trends. 3.1 Household Composition Data on the household composition of the de jure population are presented for urban and rural areas in Table 3.1. The results show that households in Pakistan are predominantly headed by males) Only seven percent of all households are headed by females. This figure is slightly higher than the corresponding six percent obtained in the 1979-80 Population, Labour Force and Migration Survey. Pakistani households tend to be large with an average of six to seven persons living and eating together in a single household. The typical household in Pakistan has an average of 6.7 persons, but about one-quarter (26 percent) o f all households have four or fewer members. The breakdown by place of residence shows that there are more members in urban households (7.2 persons) than in rural households (6.5 persons). These results are consistent with the findings of the Pakistan Contraceptive Prevalence Survey (PCPS) and the Population, Labour Force and Migration Survey (PLM). The lower mean size of households in rural areas could be due partly to the migration of some household members to urban areas. Joint and extended family living arrangements are the norm in Pakistan. More than 60 percent of households have three or more related adults, while one-third have two related adults. Only one household in twenty had just one adult among the usual residents of the household. Another topic for which data are generally not available in Pakistan is the extent to which children live with families other than their own parents. In the PDHS, only one percent of households contained children under 15 years of age, who were not living with either of their natural parents. Many of these children are likely to be domestic servants, although some may be adopted or foster children. tRespondents to the household questionnaire were asked to identify the head of the household themselves. No standard definition was provided since the objective was to determine who was the head of the household according to the rcspondent's own definition of that concept. 19 Table 3.1 Household composition Percent distribution of households by sex of head of household, household size, and kinship of household members, and the percentage of households with children not living with either of their natural parents, according to orban-rmal residence, Pakistan 1990-91 Household Total Major Other char aeteristic urban city urban Rural Total Household head Male 92.1 93.0 90.9 93.2 92.9 Female 7.9 7.0 9.1 6.8 7.1 Total I00.0 I00.0 100.0 I00.0 I00.0 Number of usual members I 1.9 1.3 2.7 3.4 2.9 2 4.6 4.3 5.1 6.6 6.0 3 6.4 6.2 6,7 7.8 7.4 4 8.5 9.6 6.9 9.9 9.5 5 11.6 11.6 11.7 12.5 12.3 6 13.5 14.1 12.7 13.3 13.4 7 12.4 12.7 12.0 11.6 11.8 8 12.6 11.6 14.0 11.6 11.9 9 + 28.5 28.7 28.2 23.2 24.8 Total 100.0 100.0 100.0 100.0 100.0 Mean size 7.2 7.2 7.2 6.5 6.7 1979-80 PLM mean size 6.6 U U 6.1 6.3 1984-85 PCPS mean size 7.3 7.4 7.2 6.7 6.9 Kinship of household members One adult 3.0 2.2 4.2 5.4 4.7 2 related adults opposite sex 27.8 27.6 28.0 32.9 31.4 2 related adults same sex 1.4 1.3 1.6 1.7 1.6 3+ related addts 65.8 65.9 65.7 59.5 61,4 Other 1.9 3.0 0.6 0.5 0.9 Total 100.0 100.0 100.0 100.0 100.0 Percentage of households with children not living with either of their natural parents 1.0 0.6 1.6 1.1 1.1 Number of households 2120 1202 918 5073 7193 U = Unknown; no information 3.2 Age-sex Distr ibut ion of the Household Populat ion As in many developing countries, data collection efforts in Pakistan are subject to age misreporting and heaping on certain ages due to digit preference. Because of these limitations, special attention was paid in the PDHS to minimizing age reporting errors. Interviewers were given training in the techniques of probing to elicit age information that is as accurate as possible. Interviewers were also provided with reference calendars to help them in determining an approximate age for those respondents who were not able to report their exact age or date of birth. One calendar listed the dates of major national and local events for the last fifty years. Another calendar showed how to convert seasonal and Islamic months into dates in the 20 Gregorian calendar. Finally, interviewers were provided with an age conversion table to allow them to check the consistency of age and date of birth responses. In most rural areas, where knowledge about ages and dates of birth is not the norm, the PDHS interviewers were largely successful in estimating age information by using the calendars or calculating the ages of individuals relative to the age of any household member whose age could be determined. Nevertheless, errors in recording ages and dates of birth could not be totally eliminated. Table 3.2 shows the age distribution of the de facto male and female population enumerated in the PDHS and sex ratios by five-year age gmups. Because of continuing high levels of fertility, Pakistan's population is relatively young (see Figure 3.1). The median age of the de facto population is 17.6 years. Some age misreporting is evident from an examination of the age distributions. The sex ratios further help to highlight some of the errors in the data. The overall sex ratio for Pakistan is 1.08 males for each female. The sex ratios for the population as a whole am fairly stable up to age 40-44, but rather erratic thereafter. The relatively high sex ratio at age 45-49 (particularly in urban areas) suggests that in some cases interviewers may have "aged" women in that age group across the 50-year age boundary so that the women would be ineligible for the individual interview. Table 3.2 Household population by ase I residence and sex Percent d/strib~fion of the de facto household populatinn by five-year age group, according to urban-rural residence and sex, Pakistan 1990-91 Total urban Major city Other urban Rural Total Sex Sex Sex Sex Sex Age group Male Female ratio Male Female nttio Male Female ratio Male Female rado Male Female ratio 0-4 12.6 13.6 0.98 12.3 13.7 0.95 13.0 13.4 1.02 13.4 13,6 1.08 13.2 13.6 1.05 5-9 15.2 16,5 0.97 14.7 15.5 1.00 16.0 17.9 0.94 18.2 17,9 1.11 17,3 17.5 1.07 10-14 13.4 14.3 0.99 12.8 14.1 0.96 14.2 14.6 1.02 13.9 13.3 1.14 13.8 13.7 1.09 15-19 11.7 11.3 1.09 11,8 11.5 1.08 11,5 11.1 1.10 9.7 9.5 1.11 10.3 10.1 1.10 20-24 9.0 8.7 1.10 9.6 9.4 1.07 8.3 7.6 1.15 7.4 8.0 1.02 7.9 8.2 1.05 25-29 7.2 7.5 1.02 7.7 7.8 1.04 6,6 7.0 0.98 6.3 7.7 0.90 6.6 7.6 0.94 30-34 5.5 5.5 1.06 5.4 5.3 1.07 5.7 5.7 1.05 5.3 5.5 1.05 5.3 5.5 1.05 35-39 5.3 5.0 1.12 5.6 5.3 1.10 5.0 4.6 1.16 4.2 4.3 1.07 4.6 4.5 1.09 40-44 4.1 3.7 1.16 4.3 3.7 1.20 3,8 3.6 I.II 4.0 4.1 1.06 4.0 4.0 1.09 45-49 3.6 2.7 1.43 3.9 2,5 1.65 3.3 2.9 1.18 3.1 2.8 1.20 3.2 2.7 1.27 50-54 2.9 3.6 0.86 3.1 3,3 0.98 2.8 4.0 0.74 2.8 3.7 0.83 2.9 3.7 0.84 55-59 2.1 2.2 L04 2,1 2.2 1.01 2.2 2.1 1.09 2.1 3.0 0.78 2.1 2.7 0,85 60-64 2.6 2.2 1.24 2,7 2.3 1.21 2.6 2.1 1,28 3.2 2.5 1.38 3.0 2.4 1.34 65-69 1.6 I.I 1.51 1.5 1.2 1.38 1.6 1,0 1.70 1.9 1.7 1.21 1.8 1.5 1.28 70-74 1.5 1.0 1.47 1.3 I.I 1.28 1.6 1.0 1.75 2.5 1.2 2.36 2.2 I.I 2.09 75-79 0.5 0.2 2.37 0.5 0.2 3.~0 0,4 0.3 1.67 0.6 0,4 1.57 0.6 0.3 1.73 80 + I.I 0.9 1.20 0.9 0.9 I.I0 1.3 1.0 1.32 1,5 0.8 2.0~ 1.4 0.8 1.76 Mhalng] 0.I -- * . . . . * 0.I 0.I * 0.I 0.I * 0.I 0.I 1.38 Don't know Total 100.0 100.0 1.06 100.0 100.0 1.06 100.0 100.0 1.0~ 100.0 100.0 1.10 1(30.0 100.0 1.08 Nmnber 7480 7089 14569 4303 4070 8373 3177 3019 6196 16293 14876 31169 23773 21965 45737 - Len than 0.05 perccm * Baited on fewe~ than 25 tmweighted crees. Numhor not shown. 21 Age 80* 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0 -4 Figure 3.1 Population Pyramid of Pakistan Mal~ 10 8 6 4 2 0 2 4 Percent 6 8 10 PDHS 19g0-91 Table 3.3 Population by age from selected sources Percent distribution of the population by age group, 1990-91 PDHS, 1984-85 PCPS and 1981 census 1990-91 1984-85 1981 Age PDHS PCPS census 0-4 13.4 16.4 15.3 5-9 17.4 16.3 16.0 10-14 13.7 12.8 13.2 15-19 10.2 10.1 9.5 20-24 8.1 8.0 7.6 25-29 7.1 6.9 6.7 30-34 5.4 5.3 5.6 35-39 4.6 4.9 5.1 40-44 4.0 4.1 4.7 45-49 3.0 3.2 3.7 50-54 3.2 3.1 3.6 55-59 2.4 2.3 2.0 60-64 2.7 2.6 2,7 65 -69 1.7 1.3 1.2 70-74 1.7 1.3 1.4 75 and over 1.6 1.4 1.7 Total 100.0 100.0 100.0 Source: Original data from Pakistan Contraceptive Prevalence Survey; Populatlon Census Organlsadon (1984) 22 The overall distribution of the population by age is quite similar to that of the 1981 census and previous demographic surveys (see Table 3.3). The percentage of the population below age five, however, is smaller in the PDHS than in the other sources. This shift in age composition can be attributed partly to a reduction in fertility levels in the recent past. However, some of this shift is due to the omission of young children and displacement in their ages, particularly in rural areas (see the discussion of omission and age displacement in Chapter 4). It is interesting to note that despite substantial differences among the three sources in the first three age categories, the percentage of the total population that is under age 15 years of age is exactly the same (44.5 percent) in the 1981 census and in the PDHS. 3.3 Mar i ta l Status The PDHS gathered information on the marital status of all household members age 15 and over. Examination of the marital status data for the de facto population (see Table 3.4) reveals a consistent picture, Table 3.4 Household population by age t sex and marital status Percent distribution of the de facto household population by marital status, acc.ordin 8 to age and sex, Pakistan 1990-91 MALE Never Divorced/ Age group married Married Widowed separated Missing Total Number 15-19 93.8 3.5 0.0 0.0 2.6 100.0 2448 20-24 75.3 23.1 0.4 0.0 1.2 100.0 1883 25-29 38.7 59.4 0.9 0.3 0.7 100.0 1561 30-34 15.1 82.2 1.6 0.5 0.6 100.0 1269 35-39 7.6 90.8 1.1 0.5 -- 100.0 1083 40-44 2.8 93.3 2.5 1.4 -- 100.0 951 45-49 2.0 93.4 3.7 1.0 -- 100.0 766 50-54 2.1 92.8 4.5 0.6 -- 100.0 678 55-59 1.8 93.3 4.6 -- 0.3 100.0 506 60-64 0.7 87.8 1 I. I 0.3 0. I 100.0 708 65+ 1.0 78.2 19.3 0.9 0.5 I00.0 1398 Total 35.3 59.5 3.8 0.4 0.9 100.0 13265 FEMALE Never Divorced/ Age group married Married Widowed separated Missing Total Number 15-19 78.1 18.4 0.3 0.2 3.0 I00.0 2219 20-24 39.4 59.7 0.1 0.6 0.2 I00.0 1798 25-29 11.8 86.0 0.9 1.0 0.4 100,0 1669 30-34 3.8 93.2 1.5 1.6 -- I00.0 1207 35-39 2.0 93.1 3.9 0.9 - 100.0 996 40-44 2.3 92.7 4.6 0.3 - 100.0 871 45-49 2.0 90.5 7.3 0.2 - 100,0 602 50-54 0.7 81.8 15.5 2.0 0.1 100.0 805 55-59 0.3 77.3 21.4 0.7 0.2 100.0 597 6{)-64 0.5 72.1 26.2 0.I I.I I00.0 528 65+ 0,3 48.1 48.9 0.3 2.4 100.0 839 Total 22.6 67.8 8.0 0.7 0.9 I00.0 12143 Note: Total includes 14 males and 10 females whose age is unknown. - Less than 0.0~ percent 23 relative to previous surveys, with regard to the universality of marriage for both males and females. Almost all females get married by their early thirties and males by their early forties. However, women tend to get married much earlier than men. For example, 60 percent of women age 20-24 am currently married but only 23 percent of men in that age group are married. Females exhibit an earlier transition than males to widowhood or to being divorced or separated. This finding is consistent with the cultural norm which permits the remarriage of widowed or divorced men but discourages the remarriage of women. The earlier transition of women to widowhood is also due to the age difference between husbands and wives and to higher male mortality in the older age groups. Nearly half of all women age 65 and over are widows, whereas only 19 percent of men in that age group are widowers. 3.4 Educational Attainment The level of educational attainment in a society is an important indicator of social development. Moreover, education is considered to be a major factor underlying social status. Educational attainment has also been shown to have a significant effect on fertility behaviour, contraceptive use, infant and child mortality, morbidity and issues related to family health and hygiene. Table 3.5 presents the distribution of the household population age five and over by level of education, according to sex, age, place of residence and province. Education has been one of the few neglected sectors which has not caught up with the growing population in Pakistan. Table 3.5 shows that 43 percent of males and 68 percent of females have never attended school. Overall, less than one-third of males (30 percent) and one-fifth of females (20 percent) have attended only primary school, while 16 percent of males and 7 percent of females were reported to have reached secondary school or higher. On average, males have completed 3.2 years of schooling, whereas females have completed only 1.6 years. The data indicate that males receive much more education than females. Such differentials are more prominent at higher levels of education. Men are 50 percent more likely than women to have attended only primary school, twice as likely to have attended middle school without going on to secondary school, and 2.3 times as likely to have attended secondary school or higher education. The differentials in level of education according to age group provide an indication of the develop- ment in the educational attainment of the population over time. A steadily increasing pememage of both males and females have attended school and the increases are particularly dramatic at the secondary level of education and above. The sex differential in educational attainment continues to be significant for all ages, with little indication that the gap is decreasing, except in the youngest age group. The findings further indicate that one-half of males (51 percent) and four-fifths of females (79 percent) in rural areas have received no education. Among both males and females, the relative urban-roral differentials are most pronounced at the highest educational level. The median and mean number of years of schooling are slightly higher in major cities than in other urban areas. The urban-rural difference is undoubtedly due to a lack of facilities or their inaccessibility in rural areas, while male-female differentials could be attributed to cultural norms and the social constraints faced by women. Punjab and Sindh have relatively low percentages of females who have received no education, while in NWFP and Baiochistan more than 80 percent of females have never been to school. The level of educational attainment is much higher for males than for females in all provinces, but the disparity is particularly striking in NWFP. The PDHS also asked about the current status of school attendance for all persons under age 25. Table 3.6 presents the percentage of the de facto male and female population (age 6-24) who are enrolled in school by age, sex and place of residence. Overall, more than half (54 percent) of all school age children (age 6-15) were currently enrolled in school; the figures were 64 percent formales and 44 percent for females. The enrulment rate is much higher in major cities (75 percent) than in rural areas (46 percent) (see Figure 3.2). 24 Table 3.5 Educational level of bouscheld population pcxcer~ distribution of the de facto male and female household population age five and over by highest level of cducauJon ammded, accordin 8 to ~lec~l background charactc~cs, pakistan 1990-91 MALE Nmnber Backsrcund No of Median Mean characteristic education Primary Middle Secondary+ Missing Toad peaom years years Ap group 5-9 44.4 54.8 0,4 -- 0.4 100.0 4102 0.7 0.6 10-14 23.8 51.4 20.0 4.5 0.3 180,0 3274 3.6 3.2 15-19 28.4 17.8 20,8 32`6 0.3 100.0 2448 6.3 5.3 20-24 33.9 19,1 13.2 33.5 0.3 100.0 1883 5.7 5.4 25-29 39.7 20.7 12.4 27.1 0.1 100.0 1561 5.2 4.8 30.34 45.5 16.7 11.3 26.0 0.4 1~).0 1269 4.4 4.4 35-39 44.7 17,1 10,2 27.7 0.3 100.0 1083 4.5 4.5 40-44 50.6 20,2 8,1 20.9 0.2 100,0 951 0.0 3.8 4549 54.3 14.3 8.7 22.3 0.4 100.0 766 0.0 3.7 50.54 61.6 15.9 6.1 16.0 0.4 180.0 678 0.0 2.9 55-59 64.6 17.2 6.1 11.4 0.8 180.0 505 0.0 2.4 60-64 73.8 11.3 5.6 9.3 0.1 100.0 708 0,0 1.8 65+ 80.1 9.3 5.0 5.2 0.4 100.0 1398 0.0 1.3 Resldeace Toad mban 26.9 29.8 13.7 29.4 0.3 100.0 6535 5.0 5.0 Major city 27.0 27.0 13.4 32.3 0.2 180.0 3772 5.2 5.2 Other urbtn 26.7 33.5 14.0 2.5.6 0.3 100.0 2763 4.7 4.6 Rural 50.7 29.8 9.3 9.8 0.4 100.0 14106 0.0 2.4 Province Punjab 40.8 30.2 12.0 16.9 0,1 100,0 12330 1.8 3.4 Sindh 44.0 31.5 7.8 16.0 0.7 100.0 4962 1.0 3.2 NWFP 46.7 27.6 II.0 14.4 0.2 100.0 2.597 1.0 3.0 Balochistan 63.4 20.8 6.6 7.1 2,0 100.0 752 0,0 1.7 Total 43.1 29.8 10,7 16,0 0,3 100.0 20641 1.3 3.2 FEMALE Number Background No of Median Mean characteristic education Prhnary Middle Secondary+ Missing Total persons years years Age Ilroup 5-9 58.7 IO-14 48.5 15-19 54.9 20-24 63,9 25-29 72.0 30-34 75.3 35-39 79.0 40-44 83.4 45-49 86,3 50.54 93.0 55-59 92.8 60-64 94.5 65+ 95,3 Residence Tots] uxbtn 42`8 Major city 37.6 Omer ta~m 49.9 Rural 79.4 province Punjab 63.7 ShuSh 66.2 NV/PP 81.6 Balochadan 88.5 Total 67,6 ~.7 0.1 -- 0.4 I~.0 3340 0.0 0.4 35.5 12.4 3.2 0.5 1~.0 2998 1.0 2.1 15.5 10,5 18,9 0,2 I~.0 ~19 0.0 3.2 13.6 6,4 16,1 0,1 1~.0 1798 0.0 2.8 10.0 5.0 12.9 -- 1~.0 1669 0.0 2.2 10.4 4.0 9.5 0,7 1~,0 1207 0.0 1.8 9.1 4.8 6.9 0.2 1~.0 996 0,0 1.5 7.0 3.3 6.0 0.3 1~.0 ~1 0.0 1.2 6.5 2.8 3,4 1,0 I~.0 602 0.0 0.9 3.0 1.9 1.7 0,4 1~,0 805 0.0 0,5 3,9 1.5 1.0 0,7 I~.0 597 0,0 0.4 1,8 1,3 1.6 0,9 I~,0 528 0.0 0.3 2.2 ~3 0.9 1,4 1~,0 ~9 0.0 0.2 28.4 10.5 18,0 0.3 100.0 6126 1.5 3.4 28.9 11,6 21.6 0.3 100.0 3511 2.8 4.0 27.6 9.0 13.2 0.2 100.0 2615 0.9 2.7 15.8 2.6 1.6 0.5 100.0 12855 0.0 0.7 22.2 6A 7.7 0,2 100.0 11389 0.0 1.8 20.2 4.6 0.2 0.8 100.0 4345 0.0 1.7 12.2 3.0 2.9 0.3 100.0 2570 0.0 0.8 7.1 1.4 1.2 1.8 100.0 675 0.0 0.4 19.9 5.2 6.9 0.4 100.0 18981 0.0 1.6 Note: Excludm 14 males and 10 females whine age is enknovm. -- Le~ than 0.05 pezc~t 25 Table 3.6 School enrolment Percentage of the de facto household population 6-24 ye~s of age cttrrendy enrolled in school by age, sex and urban-rural residence, Pakistan 1990-91 Male Female Total Total Major Other Total Major Other Total Major Other Age group urban city urban Rural Total urbaa city urban Rural Total urban city urban Rural Total 6-15 76.3 75.8 76.9 58.6 63.8 68.1 73.3 61.9 31.9 43.6 72.2 74.6 69.2 46.1 54.1 6-10 78.1 77.9 78.4 56.8 62.6 71.7 75.5 67.1 33.2 44.8 74.9 76.7 72.7 45.7 54.1 11-15 74.1 73.4 75.0 61.4 65.5 63.8 70.6 55.8 29.8 41.8 68.9 72.0 65.1 46.8 54.2 16-20 40.8 41.5 39.8 32.4 35.4 31.2 35.1 24.8 5.4 14.3 36.1 38.3 32.8 19.0 25.0 21-24 15.4 15.9 14.6 8.6 11.1 7.2 8.1 5.7 1.9 3.9 11.6 12.2 10.5 5.4 7.7 100 80 60 40 20 0 Percent Figure 3.2 School Enrolment by Age and Place of Residence 6-15 16-20 21-24 Age (Years) [ m Major City ~ Other Urban ~-~ Rural i [ I PDHS 1990-91 Since the concentration of the population is relatively high in urban areas, there is a greater incentive for both public and private agencies to invest in setting up schools. The increased school enrolment in urban areas is likely to be a function of the greater availability and easy accessibility of educational institutions in general as well as higher educational aspirations for children in urban areas. 26 At age 16-20, one in four children was still attending school. By age 21-24, fewer than one in ten was still in school. Table 3.6 shows the greater enrolment of male than female children at all ages. The sex differentials in enrolment am more pronounced in rural areas, and to some extent in small cities and towns, but nearly disappear in major cities. The sex differentials in enrolment increase with age, which at least partially reflects the greater dropout rate for female children. 3.5 Housing Characteristics Selected housing characteristics are shown in Table 3.7 for households with at least one eligible woman who completed the interview. Electricity is nearly universal in urban areas (96 pereen0 while less than half of rural households (47 percent) were reported to have electricity. Overall, 61 percent of all households have electricity. The questionnaire included information on the source of drinking water for the household. A safe, accessible source of drinking water is important for the health and welfare of household members. Table 3.7 shows that only 18 percent of all households have water piped inside their houses and 9 percent have water piped onto their property. In total, more than 90 percent of all households in major cities have access to running piped water. Piped water is available to only 63 percent of households in other urban areas and 15 percent of households in rural areas. In rural areas, nearly 70 percent of households obtain their drinking water from wells and tubewells, while 13 percent rely on rivers, canals and kamzes for their drinking water. The use of different types of sanitation facilities varies greatly by place of residence. About 90 percent ofaU households in major cities have flush toilets in their houses compared to 55 percent in other urban areas. 2 In contrast, the toilet facilities in mral areas are quite rudimentary. Seventy-two percent of rural households have no toilet facility at all and an additional 22 percent have only a pit latrine or a bucket. One of the more important socioeconomic indicators for survey households is the quality of their housing, as measured by the construction material of the walls and roofs. More than 92 percent of households in major cities have baked brick and cement walls, compared to only two-thirds of households in other urban areas. In contrast, 60 percent of rural households live in houses with mud or unbaked brick walls and about 16 percent of their houses have wooden or bamboo walls. Similarly, a large majority of bouseholds in major cities (73 percent) live in houses with roofs made of concrete or T-irons or wood with bricks. Fifty-eight percent of households in other urban areas live in houses which have the same type of roofing materials. The other extreme is reported in rural households, where the roofs of houses are made primarily of wood or bamboo (72 percent). At the national level, a little more than one-third of households live in houses with cement and baked brick walls and roofs made with concrete or bricks with T-irons. Finally, the number of persons per room used for sleeping was calculated as a measure of crowding. At the national level, only 20 percent of households have 1-2 persons per room and 37 percent of households have 3-4 persons sleeping in one morn. At the other extreme, 20 percent of households have seven or more persons sleeping in one room. On the average, five persons sleep in one room. The degree of crowding was nearly as great in urban areas as in rural areas. 2 Flush toilets are defined as toilets in which water is carried down waste pipes, whether the water is piped into the to'flet or poured in by buckets. 27 Table 3,7 Housleli characterlsfic= Percem ~fisttilanlon ~ houscholds with eliaible women by housing characteristics, according to ud~m- rand residence, Paldstan 1990-91 Housing Total Major Other characteristic urbmx city urban Rural Total FJec~ldty Yes 95.7 98.1 92.5 46.6 61.4 No 4.3 1.9 7.5 53.4 38.6 Total I00.0 I00,0 I00.0 I00,0 I00.0 Source of drinking water Piped into resklence 48.1 58.5 34.1 5.5 18.3 Piped omo property 20.3 20,1 20.6 4.4 9.2 Public tap 11.2 13.4 8.1 5.4 7.1 Well with pmnp. tubewell 15,5 4.7 30.0 55.1 43.2 Well without lured pump 2.2 0.7 4.2 13.5 10.1 River. canal, knrez 0.9 0.8 1.1 12.5 9.0 Tanker, vendor 0,3 0,3 0,2 0.5 0.4 Rainwater . . . . . . 0.9 0.6 Other 1.3 1.2 1.3 1,7 1.6 Missing 0.3 0.2 0.4 0.4 0,4 Total 100,0 I00.0 100.0 100.0 100,0 Sanitation facility Flush 74.5 89.3 54.6 5.8 26.5 Bucket 14.4 6.2 25,4 10.0 11.3 Plt lmrine 4.4 2.8 6.5 11.5 9.3 Other 0,7 0.5 0.9 0.1 0.3 No facilities 6,0 1,1 12.6 71.9 52,1 MAssing 0.I 0.I 0.I 0.7 0.5 Total 100,0 100.0 100,0 100,0 100.0 Material of walls Baked bdchs, cement 81,1 92,4 65.9 19.2 37.8 Unbaked bclcks, mud 16.3 6.9 28.9 60.0 46.9 Wood/baraboo 2.3 0.6 4.7 15.7 11.6 Other 0.3 0,1 0.5 5.1 3.6 Total 100.0 100.0 I00.0 I00.0 I00.0 Material of reef RCC/RBC 45.0 57.8 27.9 4,1 16,4 T-Iron/wood/brick 21.5 15.2 29.9 19,5 20,1 Asbestos/into shceu 10.6 16.7 2.4 3.6 5.7 Wood/bamboo 22.8 10.2 39.6 72.2 57.3 Other 0,1 0.1 0.1 0.6 0.4 Total 100.0 100.0 100.0 100,0 100.0 Persons per ~deeplng roem 1-2 21.6 22.4 20.5 19.3 20.0 3-4 39.6 39.2 40.1 36.1 37.2 5-6 20.6 21,3 19.6 23,9 22,9 7 + 18.1 17.1 19.6 20.4 19,7 Missing/Don't know 0,1 0,1 0.2 0,2 0.2 Total 100.0 100,0 100.0 100,0 100,0 Mean 4.6 4.5 4.6 4.8 4.7 Number ef homelmlds 1633 936 698 3796 5429 o. Less than 0,05 l~t 28 3.6 Presence of Household Durable Goods In order to obtain additional information on the socioeconomic status of households, household respondents were asked if specific household goods were present in their homes. Table 3.8 shows that 35 percent of all households in Pakistan have a radio and a little more than one-quarter (27 percent) have a television. As expected, both these items show large differenlials between urban and rural areas, but the differential for televisions is particularly prominent. Table 3.8 Household durable goods Percentage of households possessing vm'ious durable consumer goods, by urban-rural residence, Pakistan 1990-91 Total Major Other Item urban city urban Rural Total Radio 51.9 58.4 43.2 28.3 35.4 Television 64.2 74.7 50.1 10.9 27.0 Refrigerator 37.6 46.3 26.0 4.0 14.1 Room cooler 13.2 13.0 13.5 1.2 4.8 Washing machine 43.4 50.2 34.2 2.9 15.1 Water pump 23.0 21.5 25.0 3.2 9.2 Bicycle 39.9 34.4 47.2 31.4 33.9 Motorcycle 17.6 21.4 12.5 3.3 7.6 Car, van or ta'aeter 6.4 7.1 5.5 3.8 4.6 Number of households 1633 936 698 3796 5429 Refrigerators, room coolers, and washing machines are all concentrated in urban areas. Only a few households in rural areas reported owning any of these items. Bicycles are the most commonly owned means of transport in all areas. At the national level, 34 percent of all households own at least one bicycle. About 8 percent of all households have a motorcycle, but motorcycles are more common in major cities (21 percent). Less than five percent of households own a car, a van or a tractor. 3.7 Background Characteristics of Female Respondents Women were eligible for the individual interview if they were ever married, age 15-49, and stayed in the household the night before the household interview was conducted. Eligible women were asked their age, marital status, educational level, place of residence, work status and physical mobility, in addition to many other questions on demographic and health status. Table 3.9 presents information on the background characteristics of all 6,611 eligible women who were interviewed. More than half of these women (57 percent) were in the 20-34 age group, with the largest number in age 25-29. The age distribution of currently married women in their childbearing years from four sources is compared in Figure 3.3. The PDHS age distribution is closest to the age distribution for the PCPS. The relatively low proportion of currently married women age 15-24 in the PDHS is consistent with the evidence that the average age of marriage in Pakistan has been rising over time. 29 A large majority of ever-married women (96 percent) were currently married and only a negligible proportion were either widowed, divorced or separated. About 80 percent of women had never attended school and only 7 percent were educated up to the secondary or higher levels. Alraost 70 per- cent of women were residents of rural areas, 17 percent resided in major cities and the rest were located in other urban areas. A majority of respondents (60 percent) were from Pun- jab, 23 percent were from Sindh, 13 percent from NWFP and 4 percent from B alochistan. The norm in Pakistan is for women to stay home and take care of the house and the children. It is not common for women to join the labor market and their mobility is often restricted. In the PDHS, only 17 per- cent of women were reported to be currently working at the time of the survey and an additional 4 percent had worked only before marriage. Three-quarters of all women stated that they had never worked. To gauge the extent of their physical mobility, women were asked whether they would need to be accompanied by someone if they needed to go to a hospital or clinic for medical treat- ment. While one-quarter of women reported that they could go to a hospital alone, 71 percent reported that they would need to be accompanied by someone. The restriction on their physical mobility can be explained partly by cultural norms. An alternative hypothesis is that women usually do not seek medical treatment for minor illnesses and they leave the house only when their illness has become serious. Under these circum- stances, they would need to be accompanied to go to a hospital. Table 3.9 Background characteristics of female respondents Percent distrlbutinn of ever-runrrled women by background characteristics, Paldstan 1990-91 Weighted Unweighted Background Weighted number of number of characterize percent women women Age 15-19 6.5 428 407 20-24 16.0 1059 1064 25 -29 22.6 1494 1469 30-34 18.0 1187 1200 35-39 14.8 951 1031 40-44 12.8 844 820 45-49 9,3 617 620 Marital status Married 96.3 6364 6393 Widowed 2.4 159 148 Divorced 0.3 22 19 Separated 1.0 65 51 Residence Total urban 30.5 2019 3384 Major city 17.4 1151 1820 Other urban 13,1 868 1564 Rural 69.5 4592 3227 Province Punjab 59.7 3948 2207 Sindh 23.1 1529 1798 NWFP 13.3 878 1665 Balochistan 3.9 255 941 Education level attended No education 79.2 5237 5055 Prima~ 9,1 601 600 Middle 4.4 288 320 Secondary 6.2 410 522 Higher 1. l 75 114 Work status Currently working 16.8 1111 1057 Worked only before marriage 4.4 290 292 Worked only after marriage 0.7 44 52 Worked before and after marriage 1.1 72 74 Never worked 1 76.7 5073 5111 Missing 0.3 21 25 Mobtllty Could go to hospital alone 25.1 1660 1699 Would need to be accompanied 70.8 4682 4441 Depends or missing 4.1 269 471 Total 100.0 6611 6611 b'Never worked" means that the woman il not currently working and whe did not work either before marriage or just after marriage. 30 25 Figure 3.3 Distribution of Currently Married Women by Age, Pakistan, 1975-1991 Percent 20 15 10 O i i - ] i i 15-19 20-24 25-29 30-34 35-39 40-44 Age 45-49 i PDHS 1990-91 -- PCPS 1984-85 | I ~ Pop. Ceneus 1981 + PFS 1975 Source. Population Welfare Division (1986) In Table 3.10, variations in the level of education by age group, place and province of residence, and work status are examined. In all age groups, no less than three-quarters of women reported that they had never atCnded school. In general, younger women were more likely to have attended school than older women. A comparison of educational attainment as measured by the 1975 PFS and the PDHS confirms that levels of educational achievement for women have been increasing over time. Even among women residing in major cities, 48 percent had no education and only one-quarter had attended a secondary school or a higher level of education. At the other extreme, 90 percent of women from rural areas had no education and only 1 percent had attended secondary school. The provincial educational pattern foUows the general pattern of development. Punjab and Sindh, which are more developed, have a lower percentage of women who had no education and 8-9 percent had attended secondary school or gone beyond secondary school. In Balochistan, 96 percent of women had no education and only 1 percent had reached secondary school. Women who were currently working were the least educated group. Eighty-four percent of working women had never been to school and only seven percent had some secondary or higher education. The highest average level of education was exhibited by those who worked only before marriage or both before and after marriage. Those who worked just after marriage also had a relatively high level of education: 13 percent reported that they had attended secondary school or a higher level of education. 31 Table 3.10 Level of education Percent distribution of ever-mm'ried wornea by the highest level of education aaonded, according to selected background characteristics, Pakisum 1990-91 Background No charactczisfic education Primal 7 Middle Secondary Higher Total Number Age 15-19 81.0 10.9 3.6 4.2 0.2 100,0 428 20-24 75.3 12.6 5,l 5,9 1.0 100,0 1059 25-29 75.7 8,7 5.6 8.8 1.1 100.0 1494 30-34 77.7 9.2 4.0 7.5 1.6 100.0 1187 35-39 79.8 8.8 4.2 5.8 1.4 I00.0 981 40-44 84.0 7.2 3A 4.3 1,l 100.0 g44 45-49 88.5 5.4 2.7 2.5 0.8 100.0 617 Residence Total u~ban 55.0 14.g 9.1 17.5 3.6 100.0 2019 Major city 47.7 15.7 10.6 20.7 5.3 100.0 1151 Other urban 64.6 13.6 7.1 13.3 1.5 100.0 868 Rural 89.9 6.6 2.3 1.2 -- 100.0 4592 Province Punjab 76.5 10.3 5.2 6.7 1.3 100.0 3948 Sindh 76.8 10.2 3.8 7.9 1.3 100.0 1529 NWFP 90.6 4.0 2.4 2.7 0.3 100.O 878 Balochistan 96.3 1.9 0.6 1.0 0.2 100.0 255 Work status x Currently working 84.3 5.8 3.0 5.1 1.8 100.0 1111 Worked only before marriage 64.2 11.6 6.3 13.5 4.4 100.0 290 Worked only after marriage 74.0 9.1 3.8 12.4 0.6 100.0 44 Worked before & after marriage 63.9 15.1 4.8 7.1 9.1 100.0 72 Never worked 2 79.2 9.6 4.6 6.0 0.7 I(D.0 5073 Total 79.2 9.1 4.4 6.2 1.1 I00.0 6611 -- Less than 0.05 percant 1Excludes 21 women with missing information on work status. 2"Never worked" means that the woman is not currently working and she did not work either before marriage or just after marriage. 3.8 Exposure to Mass Media As an indicator of exposure to mass media, each woman interviewed was asked whether she usually reads a newspaper, watches television, or listens to radio at least once a week. Table 3.11 shows that 14 percent of women read a newspaper weekly, 30 percent watch TV and 27 percent listen to radio. As expected, there is a close association between the level of education and exposure to the three types of media. The low level of exposure to radio and TV among uneducated women may be explained by their lack of access to these facilities. There is also a large differential in media exposure between urban and 32 rural women, Women in major cities are more likely to watch TV (78 percent) than to read newspapers (43 percent) or listen to the radio (47 percent). In contrast, rural women listen to radio (21 percent) more than they watch "IV (13 percent) or read newspapers (5 percent). Women from small cities or towns follow a pattern similar to women from major cities, however exposure to all forms of media is the highest in major cities. Women in Sindh are more exposed to all types of media than women in other provinces. Women in Punjab have a pattern of media exposure similar to the national pattern. More than four times as many women in NWFP are exposed to radio and TV as are exposed to newspapers, while Balochi women are most often exposed to radio. In general, Balochi women have the least access to these media, perhaps because of a lack of media facilities in Balochistan and because of the large geographical area over which the population is dispersed. Table 3.11 Exposure to mass media Percentage of ever-merried women who usually read a newspaper, wash television, or listen to radio at least once a week by selected background characteristics, Pakistan 1990-91 Read Watch Listen Number Background newspaper TV to radio of characteristic weekly weekly weekly women Age 15-19 11.0 24.8 31.8 428 20-24 14,9 28.8 30,3 1059 25-29 17.3 30.2 29.3 1494 30-34 14.7 30.5 26.5 1187 35-39 14.8 31.7 26.6 981 40-44 10.1 30.6 22.0 844 45-49 8.7 28.9 21.9 617 Residence Total urban 34.1 67.5 41.1 2019 Major city 42.6 77.9 46.5 1151 Other urban 22.7 53.6 34.0 868 Rural 5.1 13.3 20.9 4592 Province Punjab 14.4 29.1 26.3 3948 Sindh 19.6 40.2 33.1 1529 NWFP 5.4 21.5 23.8 878 B alochistan 2.8 7.3 15.0 255 Education level attended No education 1.8 18.8 21.5 5237 Primary 43.1 57.8 43.1 601 Middle 65.9 70.4 50.4 288 Secondary 75,8 88.0 53.1 410 Higher 93.8 99.5 59.4 75 Total 13.9 29.8 27.1 6611 33 REFERENCES Population Census Organisation [Pakistan]. 1984. 1981 Census Report of Pakistan. Islamabad: Population Census Organisation (Census Report No. 69). Population Welfare Division [Pakistan]. 1986. Pakistan Contraceptive Prevalence Survey, 1984-85. lslamabad: Ministry of Planning and Development. 34 CHAPTER 4 FERTILITY Fred Arnold and Mehboob Sultan One of the major objectives of the PDHS is to estimate fertility levels, trends and differentials. Information on fertility will help to determine the impact of changes in the use of family planning and other changes in the proximate determinants of fertility. The fertility estimates presented in this chapter are based on the reported birth histories of ever-married women 15-49 years old who were interviewed in the PDHS. Respondents were first asked to report the aggregate number of sons and daughters they had ever given birth to in their lifetime. To encourage complete reporting, women were asked separately about children still living at home, those living elsewhere and children who had died. The birth history also obtained information on the sex, date of birth and survival status of each child. This information was used to calculate measures of current fertility and fertility trends over time, as well as cumulative measures of the number of children ever born. In addition, estimates of birth intervals and the mother's age at the initiation of childbearing were calculated from data on the timing of births. To obtain complete and accurate information on reproduction, interviewers were trained to probe carefully to facilitate the respondent's recall and to check any documents that may include birth dates for children. Moreover, for any intervals of more than three years between births, interviewers were required to record the reason for the long interval to help identify any live births that may have been missed during that time period. In spite of the precautions taken, the PDHS is subject to the same types of errors that are typical of all retrospective demographic surveys. These include the underreporting of births (particularly for children who died immediately after birth or at a very early age) and the mistiming of births. These types of problems are particularly prevalent in countries such as Pakistan where the level of female literacy is low. In previous demographic surveys in Pakistan, births have been misplaced away from the survey date because of a pattern of exaggerating children's ages that increases with age (Rethefford, et al. 1987). A further complication in the PDHS is the displacement of births out of the most recent five-year period (from 1986 to the time of the survey). This has been a significant problem in many DHS surveys in other countries (Arnold 1990). The apparent reason for this type of displacement is that interviewers were trying to avoid a lengthy set of questions on health that were asked only about children bom since January 1986. Because of the needs of policy makers for more detailed health data, the health section has been lengthened in recent DHS surveys and the displacement problem persists. Moreover, since height, weight and ann circumference measurements were also taken only on living children born in 1986 or later, there is an even stronger incentive for moving the dates of children's births out of that time period. In the PDHS, displacement was a serious problem, with nearly twice as many births being reported in 1985 as in 1986 (see Appendix C, Table C.4). For this reason, fertility and mortality rates in this report are presented for six-year periods, so that the transference of most displaced births will occur within a single time period rather than across time period boundaries. The omission of recent births has been a feature of all retrospective demographic surveys in Pakistan. This problem is often attributed to inaccurate reporting by respondents. In the PDHS, the omission of recent births may be compounded by the underenumeration of births by interviewers who are trying to circumvent the health questions and to avoid weighing and measuring young children. The decline in the average annual number of births from 1556 in 1982-85 to 1145 in 1986-90 (Appendix C, Table C.4) is undoubtedly due in part to the omission of children born in the five years before the survey. 35 It is difficult, however, to correct the fertility estimates for the incomplete reporting of births since some of the estimated fertility decline is a real phenomenon and an unknown portion is attributable to data er rors . 4.1 Fertility Levels and Trends Until recently, fertility rates in Pakistan have remained high with little evidence of a sustained fertility decline (Shah and Cleland 1988; Rukanuddin and Farooqui 1988; Shah, Pullum and Irfan 1986; Retherford and Alam 1985). In recent years, however, fertility has begun to decline in response to a rapidly increasing age at marriage and a rise in the prevalence of contraceptive use. Various summary measures of fertility have been calculated from the PDHS to provide a complete picture of recent fertility, including the crude birth rote (CBR), the general fertility rate (GFR), age-specific fertility rates (ASFR) and the total fertility rate (TFR). These estimates are described in the following sections. Crude Birth Rate The crude birth rate (per thousand population) is the least sophisticated measure of fertility, but it is the most commonly used and easily understood. Several attempts have been made to estimate the CBR in Pakistan, but there is still no agreement on its precise magnitude. In the PDHS, the CBR is calculated by summing the product of the age-specific fertility rates and the proportion of women in each age group out of the total de facto (male and female) population at all ages. Since the ASFRs relate to births during the past six years, the CBR calculated from the PDHS pertains to the same period and is centered on the years 1987-88. Table 4.1 shows the crude birth rates for selected years derived from various surveys. The PDHS estimates a CBR of 35 per thousand population. The CBRs estimated from previous surveys are 39 for the 1968-69 National Impact Survey (NIS), 41 for the 1975 Pakistan Fertility Survey (PFS), and 37 for the 1984-85 Pakistan Contraceptive Prevalence Survey (PCPS). The Pakistan Demographic Survey (PDS) estimated a CBR of 43 for each year during the period 1984-87 and 40 for 1988. The PDS rates are, however, based on indirect measures involving the matching of vital events and are considered to be on the high side. The CBRs by residence indicate that fertility is slightly higher in rural areas (36) than urban areas (34). The provincial differentials are also worth noting. The lowest CBR is observed for Sindh (33) and the highest for Balochistan (38). Karachi had a slightly higher CBR (36) than major cities as a whole (34). This may be due to an age-sex distribution which favours higher fertility or the somewhat lower level of contraceptive prevalence in Karachi than in other major cities. Comparing the CBRs from the 1984-85 PCPS and the 1990-91 PDHS, it is observed that there was a small decline of four percent in the CBR between the two surveys. The CBR declined in each type of place of residence and each province, except for major cities and for Sindh where it exhibited a slight increase. It should be noted that the CBRs obtained from various sources are the by-products of methodological procedures, response errors, enumerator biases, problems of coverage and sampling errors, which may be of different nature and magnitude in different surveys. However, it appears that the fertility transition at least started in Pakistan after the mid-1970s. 36 Table 4.1 Crude birth rates according to selected surveys Crude birth rate per thousand for selected surveys 1968-1991, Pakistan Urban-rural residence 1990-91 1984-85 1975 1968-69 and province PDHS PCPS PFS NIS Residence Total urban 33.7 U U U Major city 33.5 32.6 U U Other urban 34.0 38.5 U U Rural 35.6 37.1 U U Province Punjab 35.5 37.6 U U Sindh 32.8 32.0 U U Karachi 36.2 U U U NWFP 35.3 36.4 U U Balochistan 38.3 45.4 U U Total 35.0 36.6 40.5 39 Note: The period covered by the CBR estimates is six years prior to the interview for the PDHS and one year prior to the interview fur the other three surveys. The estimated crude birth rate from the PDHS for one year prior to the survey is 34.2. U = Unknown; no information Source: Population Planning Council of Pakistan (1976), Population Welfare Divison (1986) General Fertility Rate The general fertility rate (GFR) is calculated by dividing the number of births occurring during a specific period of time by the number of women of reproductive age (15-49 years of age) and multiplying the result by 1,000. The PDHS estimated the GFR to be 177 for the country as a whole--that is, 177 births to every 1,000 women (see Table 4.2). The observed GFR is higher in rural areas (184) than urban areas (163). Within urban areas, the GFR is lower in major cities (157) than in other urban areas (170). The highest GFR is observed in Balochistan (201), followed by Punjab and NWFP (178 each) and Sindh (171). The GFR for Pakistan was almost the same in the PDHS and the PCPS with an increase in urban rates and a slight decrease in rural rates between the two surveys. 37 Table 4.2 Currant fertility Age-specific and cumulative fertility rates and the crude birth rate f~ the six yeats preceding the survey, by urban-tufa/residence and province and for Karaehi. pakistan, 1990-91 Residence Province Total Major Other Age urban city urban Rural Punjab Sindh NWFP Ba/ochislan Karacbi Total 15-19 59 55 64 97 79 88 86 149 70 84 20-24 224 225 222 235 226 235 227 267 241 230 25-29 268 259 281 268 275 242 287 251 272 268 30-34 225 211 243 231 237 211 233 190 213 229 35-39 126 116 141 157 159 l lS 149 116 119 147 4044 [49] [47] [531 [851 [70] [79] [771 [82] a [63] a [73] 45-49 [29] [21] a [38] a [44] [30] a [51] a [41] a b b [40] TFR 15-49 4.90 4.67 5.21 5.58 5.39 5.12 5.50 5.84 5.03 5.36 TFR 15-44 4.86 4.56 5.02 5.36 5.24 4.86 5.30 5.28 4.89 5.16 GFR 162.5 157.0 170.4 184.1 178.0 170.7 177.8 201.1 173.5 177.0 CBR 33.7 33.5 34.0 35.6 35.5 32.8 35.3 38.3 36.2 35.0 Note: Rates are calculated for all women 15-49, using infornmtlon on women's age and marital states from the household questionna/le and on the number of births from the woman's questionnaire. Figures in brackets are partially truncated rates. aBased on fewer than 500 person-months of exposure bBased on fewer thma 250 person-months of exposure, rates not shown TFR: Total fe~lity rate expressed per woman GFR: Genera/fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Age-Specific and Total Fertility Rates Although the GFR is a more refined measure than the CBR, beth are crude summary measures. The changes observed in these rates may not provide a complete picture; better estimates of fertility can be obtained by examining the age-specific fertility rates (ASFRs) and the total fertility rate (TFR). A historical series of fertility estimates from four national surveys is shown in Table 4.3. The total fertility rate flTR) is a summary measure that indicates the number of children a woman would bear during her reproductive years if she were to experience the age-specific fertility rates prevailing at the tune of the survey. Mathematically, the 'I'FR is five times the sum of the age-specific fertility rates for each five-year age group. The Pakistan Contraceptive Prevalence Survey (PCPS) includes only currently married women in its sample, whereas the other three surveys interviewed ever-married women. In order to calculate the fertility rates for all women, it is assumed that no births occur outside of marriage. 38 Table 4.3 Current fertility according to selected surveys Age-specific fertility rates for selected surveys 1975-1991, Pakistan 1990-91 1984-85 1979-80 1975 Age group PDHS PCPS PLM PFS 15-19 84 64 99 131 20-24 230 223 283 275 25-29 268 263 313 315 30-34 229 234 263 259 35-39 147 209 188 188 40-44 73 127 101 77 45~19 40 71 48 11 Total fertility rate, 15-49 5.4 6.0 6.5 6.3 Source: Alam, Irfim mad Farooqui [1984] and Population Welfare Division (1986) According to the Pakistan Fertility Survey (PFS) and the Population, Labour Force and Migration Survey (PLM), the total fertility rate in the 1970s was between 6.3 and 6.5 children per woman. The PCPS recorded a drop to 6.0 children per woman and the PDHS registered a further decline to 5.4 children per woman (a decline of 10 percent since the 1984-85 PCPS and 15 percent since the 1975 PFS). 1 According to the PDHS, if current age-specific fertility rates were to remain unchanged in the future, the average woman in Pakistan would have 1.6 children by the time she reaches age 25, 2.9 children by age 30, more than four children by her thirty-filLh birthday, and 5.4 children by the end of her childbearing years. Trends in age-specific fertility rates are somewhat erratic, although fertility is generally lower in the two most recent surveys (see Table 4.3 and Figure 4.1). A comparison of the fertility estimates from the PFS and the PDHS shows that fertility declined most rapidly (by more than one-third) in the 15-19 age group, reflecting a pattem which is consistent with the increasing age at marriage. Substantial fertility declines are also evident at ages 20-39. lit should be noted, however, that the average "II~K estimated by the Pakistan Demographic Survey for 1984-1988 (6.9 children per woman) would suggest that fertility has not yet begun to decline in Pakistan (Federal Bureau of Statistics 1990). 39 Figure 4.1 Age-Specific Fertility Rates Pakistan, 1970-1991 Births per 1,000 Women 350 300 250 200 150 100 50 0 i i i i 15-19 20-24 25-29 30-34 35-39 40-44 Age 45-49 PDH$ t990-91 (6 yra) PLM 1979-80 (1975-79) - - PCP$ 1984-85 (1 yr) + PF8 1975 (1970-75) i Source : A lam, I r lan and Farooqgl [1984l; Population Welfare Division (1986) Differentials in fertility by type of place of residence are shown in Table 4.4 and Figure 4.2. Overall, urban areas have lower fertility rates than rural areas and within urban areas major cities have lower fertility. Fertility rates in urban and rural areas were very similar during the prime childbearing years (ages 20-34), but differences in urban and rural fertility levels arc striking in the youngest and oldest age groups (see Table 4.2). Overall, at current fertility rates, the average woman living in a large city can be expected to have ncarly one child less than her rural counterpart (4.7 children compared to 5.6 children). Provincial differences in fertility are quite modest. The TFR for women age 15-49 ranges from 5.1 in Sindh to 5.8 in Balochistan. For women age 15-44, the range of fertility estimates is even more restricted. At the provincial level, it is preferable to compare the estimates of fertility at ages 15-44 rather than 15-49 since the age-specific fertility rates at age 45.49 are based on only a small number of years of exposure to the risk of pregnancy. An additional reason for focusing on the 15-44 age group is that the l l ,R which includes women age 45.49 uses data which are progressively truncated as one moves back in time. A separate estimate of fertility is shown for Karachi, which has a total fertility rate of 5.0 for women age 15-49 and 4.9 for women age 15-44. While Karachi's fertility is lower than the national average, it is somewhat higher than the fertility reported for other major cities in Pakistan. As noted earlier, this finding is consistent with the fact that the reported contraceptive prevalence rate for Karachi is lower than that reported for other major cities. 40 Current fertility rates are related not only to the geographical area in which a woman resides but also to her educational attainment. Women without any formal education have a rvR that is nearly one child higher than women who have attended primary school and two children higher than women who have gone beyond the middle school level (see Table 4.4). Table 4.4 also shows the mean number of children ever born to women age 40-49---that is, women who are approaching the end of their child- bearing years. A comparison of this cumulative measure of childbearing with the "l'lq~. gives a rough indication of the trend in fertility over the last several decades. For all women, the total fertility rate is exactly one child less than the mean number of children ever born. This difference provides further evidence that fertility has started to decline in Pakistan, although if there are errors in recording recent births in the birth history, the decline may not be as rapid as the comparison suggests. The differences between the two meas- ures am greatest for women in Sindh and Punjab as well as for those living in urban areas (particularly in Kamchi and other major cities). Therefore, women in these areas appear to be leading the way in the early stages of the fertility decline. Educa- tional attainment is strongly related to both cumu- lative and current fertility levels, suggesting that educated women have been experiencing lower fer- tility for a long period of time. The most direct way of observing fertility trends is to examine changes in age-specific fertili- Table 4.4 Fertility b,y background characteristics Total fertility rate for the six years preceding the survey, and mean number of children ever born (CEB) to women 40-49 years of age, by selex:ted background characteristics Pakistan 1990-91 Total Me~m no. Background fertility of CEB eheraeteristic rate (women 40-49) Res~ence To~ ~ban 4.9 6.3 M~ore~ 4.7 6.3 Other~ban 5.2 6.4 Rural 5.6 6,4 Pro~nce Punj~ 5.4 6.3 Sin~ 5.1 6.6 Karac~ 5.0 7.1 NWFP 5.5 6.1 Ba~c~stan 5.8 5.7 Educatlon level attended No education 5.7 6.5 Primary 4.9 6.1 Middle 4.5 5.3 Secondary+ 3.6 4.3 To~ 5.4 6.4 Note: Figures are calculated for all women 15-49, using information on women's age and marital status from the household questionnaire and on the number of births from the woman's questionnaire. ty rates over time based on the PDHS birth history data (see Table 4.5). The trend in fertility over a period of more than two decades can be seen for women age 15-34. Only partial information is available for older women because of truncation in the data for earlier time periods. The lowest estimated fertility rate in every age group is observed for the most recent six-year period. A comparison of the two most recent periods reveals that estimated fertility has fallen most rapidly (by over forty percent) in the youngest and oldest age groups. Fertility also reportedly declined by more than one-quarter in every other age group. Declines of the magnitude shown for the middle and older age groups seem unlikely given the continuing low level of contraceptive prevalence in Pakistan. The fertility decline in these age groups is probably exaggerated by errors in the coverage and timing of births in the PDHS. This conclusion seems particularly warranted in light of the experience of previous demographic surveys in Pakistan. In evaluating the quality of three large-scale national demographic surveys and the 1981 census, Rethefford et al. (1987) noted that the estimated "tl"K fell below five children per woman during the two years preceding each of the surveys. However, there was no credible evidence that fertility had actually fallen during any of these periods. The authors concluded that fertility was severely underestimated in the five- year period preceding each survey. 41 Figure 4.2 Total Fertility Rate (TFR) and Mean Number of Children Ever Born (CEB) RESIDENCE Urban Rural PROVINCE Punjab Sindh NWFP Balochistan EDUCATION No edue. Primary Middle Seoondary* 1 2 3 4 5 6 Number of Births [ ~ TFR (Preoeding 6 yrs) ~ CEB (Women 40-49) PDHS 1990"91 Table 4.5 Fertility trends Age-specific fertility rates for six-year periods preceding the survey, by mother's age at the t/me of birth, Pakistan 1990-91 Number of years preceding survey Mother's age 0-5 6-11 12-17 18-23 15-19 84 145 139 116 20-24 230 317 294 278 25-29 268 367 331 [3341 30-34 229 319 [3091 ,. a 35-39 147 [212] [227]" U 4044 [73] [137] U U 45-49 [4O] U U U Note: Age-specific fertility rat~s are per 1,000 womea~, Figures in brackets are partially I~qmeated rates. U = Unknown; no hfform.ation Based on fewer than 250 person-months of exposure, rates not shown ased on fewer than 500 person-months of exposure 42 Table 4.5 also shows that fertility registered modest gains in the two earliest intervals between six- year periods. Fertility may have actually risen over that time period but possible data errors again need to be considered in interpreting the results. The apparent rise in fertility in the earlier periods may be due to a commonly observed tendency among older women to underreport early births or to displace the birth dates of those children forward in time (Potter 1977). The pattern of fertility change over time discussed above is also evident for women with marital durations of less than 10 years, but estimated fertility has fallen steadily over time for women married more than 15 years (see Table 4.6). In the most recent six-year period, the estimated fertility rate declines consistently as the duration of marriage increases. Women who have been married for more than 15 years reported sharply lower fertility than women with shorter marriage durations. Table 4.6 Fertility by marital duration Fertility rates for ever-married women by duration since first marriage in years fur six-yeas periods preceding the survey, Pakistan 1990-91 Number of years preceding survey Mastiagedurafion at birth 0-5 6-11 12-17 18-23 04 339 386 343 309 5-9 298 412 381 379 10-14 248 346 325 341 15-19 186 263 286 a 20-24 98 187 a a 25-29 52 (95) a NA Note: Rates in parentheses are based on fewer than 500 person-months of IgXpe$1~'l~, NA = Not applicable abased on fewer than 250 person-months of exposure, rates not shown 4.2 Children Ever Born The cumulative number of children ever born is shown in Table 4.7 for all women and for currently married women. The figures for all women are calculated by assuming that all births occur within marriage. Women in their childbearing years in Pakistan have had an average of three children and currently married women have had an average of just over four children. The steady increase in the average number of children ever born by age is a normal function of the family building process. Women who are currently at the end of their childbearing years have had, on average, more than six births. Mortality has had a significant impact on family size, however, since the average woman age 40-49 has had one child who died by the time of the survey. Taking the difference between the mean number of children ever born (6.6) and the mean number of children surviving (5.6), it is seen that, overall, there has been a loss of 15 percent of births among currently married women age 40-49. Early childbearing is relatively rare in Pakistan. Only 12 percent of women in the 15-19 age group have ever had a child and even in the 20-24 age group only a minority of women have ever given birth. Eventually, however, nearly all women bear children. Among currently married women age 35-49, 43 only three percent have never had a child. This low level of childlessness indicates that primary sterility is low in Pakistan. This is consistent with the findings of a low level of primary sterility in the 25 DHS surveys carried out from 1986 to 1989 (Arnold and Blanc 1990). T@le 4.7 Children ever born and livin s Percent distribution of all women and cummtly marred wo~nen by nmnbcr d children ever born (CEB) and mean number of children ever born and living, accorc~g to age group, Paldllan 1990-91 Number of d~Idnm ever born Age 0 1 2 3 4 5 6 7 8 9 Number Mean Mean no. of no, of of living 10+ Tond women CEB children ALL WOMEN 15-19 87.8 9.2 1.9 1.0 0.I . . . . . . I0¢.0 1720 0.2 0.I 20-24 54.3 17.0 15.3 8.2 3.6 0.9 0.6 0.I . . . . I(~.0 1747 1.0 0,8 25-29 23.0 10.4 15.0 17.4 15.3 11.0 4,6 2.3 0.8 0.2 0.I 100.0 1745 2.6 2.3 30-34 9.2 5.0 8.8 14.8 16.7 13.6 12,7 9.4 5.1 2.9 1.9 I00.0 1241 4.3 3.7 35-39 5.4 3.4 4.3 8.6 10.2 16.8 16,9 12.9 8.8 6.2 6.4 I00.0 1005 5.5 4.8 40-44 5.5 1.5 3.0 7.3 9.0 12.0 13.2 15.4 11.5 7.1 14.6 100.0 865 6.3 5.4 45-49 5,5 2.7 3.3 7.7 5.8 10.5 13,4 11.4 13.8 I0.0 15.8 I(i0.0 630 6.4 5.5 To~al 34.7 8.5 8.5 9.4 8.4 8.0 6,9 5.5 3.9 2,5 3.5 I00.0 8953 3.0 2.6 CURRENTLY MARR/ED WOMEN 15-19 51.4 36.8 7.5 4.0 0.2 . . . . . . . . 100.0 418 0.6 0.6 20-24 24.3 27.9 25,2 13.7 6.1 1.6 1.1 0.1 -- 100.0 1041 1.6 1.4 25-29 9.5 IL8 17.2 20.5 18,2 13.2 5.5 2.7 0.9 0.2 0.2 100.0 1452 3.1 2.7 30-34 4.7 4.6 8.7 15.4 17.8 14.5 13.7 I0.0 5.4 3.1 2.1 I00.0 1147 4.6 4,0 35-39 2.7 3.3 4.6 9.0 8.9 I%5 17.7 13.5 9.4 6.6 6.8 I00.0 932 5.7 5.0 40-44 3.1 1,1 3.1 7.3 8.9 11.7 13.5 16.4 12,3 7.1 15.5 100.0 803 6.5 5.6 45-49 3.8 2.8 3.5 7.4 6.1 10.1 13.7 11.4 14.5 10.4 16.4 100.0 572 6.6 5.6 Total 11.5 11.4 11.5 12.8 11.4 10.8 9.4 7.5 5,4 3.4 4.8 100,0 6364 4,1 3.5 -- L~ss than 0.05 percent Although currently married women age 45-49, on average, have had 6.6 children, the range of family sizes is quite wide. Ten percent have had fewer than three children and an additional 13 percent have had three or four children. About one-quarter (24 percent) have had five or six children and another quarter (26 pcrecnt) have had seven or eight children. At the high end of the spectrum, more than one in four women have had nine or more live births and one in six women have had 10 or more births. More than half of currently married women age 45-49 have had at least seven live births. Cumulative fertility for currently married women has shown some signs of a decline over time in every age group except age 15-19 (see Table 4.8). Although the overall mean number of children ever born was identical in the 1975 Pakistan Fertility Survey and the 1984-85 Pakistan Contraceptive Prevalence Survey, the mean number of children ever born declined slightly during that period in the 44 majority of age groups. Between the 1984-85 PCPS and the 1990-91 PDHS, the overall mean number of children ever born declined from 4.3 to 4.1. Because of a decline in mortality during that period, however, the mean number of surviving children remained constant at 3.5 children per woman. In fact, the mean number of surviving children aetoally increased from 3.2 to 3.5 between the time of the 1975 PFS and the 1984-85 PCPS, again due to a decline in mortality between the two surveys rather than to an increase in the cumulative number of children ever born. Table 4.8 Children ever born ~ceording to selected surveys Mean number of children ever born and children still living for currently married women, by age group, selected surveys 1975-1991, Pakistan Mean number of children ever bern Mean number of living children 1990-91 1984-85 1975 1990-91 1984-85 1975 Age PDHS PCPS PFS PDblS PCPS PFS 15-19 0.6 0.6 0.6 a 0.6 0.6 0.5 s 20-~ 1.6 1.8 1.9 1.4 1.5 1.5 25-29 3.1 3.4 3.4 2.7 2.8 2.8 30-34 4.6 5.0 5.2 4.0 4.2 4.0 35-39 5.7 6.1 6.4 5.0 5.1 4.9 40-44 6.5 7.0 7.5 5.6 5.5 5.2 45-49 6.6 7.5 7.4 5.6 5.7 5.1 15-49 4.1 4.3 4.3 a 3.5 3.5 3.2 a alncludes currently married women age 10-14 Source: Population Welfare Division (1986) and Population Planning Coencil of Pak'tstan (1976) Differentials in cumulative fertility by selected socioeconomic characteristics of respondents and their husbands are shown in Table 4.9. The largest differentials are observed for the woman's educational attainment. Women with some secondary school education or higher have 1.4 fewer children, on average, than women with no education. For the oldest age group (age 35 or higher) this differential widens to more than two children per woman. Differentials in fertility are less pronounced for the husband's education, particularly for men whose wives are in the youngest age groups. Women whose husbands are in professional, technical, clerical or service jobs have a relatively small number of children ever born. It is surprising, however, that the woman's own work experience is only weakly related to her cumulative fertility. 45 Table 4.9 Mean number of children ever bern Mean number of children ever born by background ehm'acteristies of currently married women mad their husbands according to age, Pakistan 1990.91 Age of woman Background characteristic 15-24 25-34 35+ Total Woman's education No education 1.3 3.9 6.4 4.3 Primary 1.5 3.7 6.0 3.7 Middle 1.1 3.7 5.3 3.5 Secooda~'+ 1 .O 2.8 4.2 2.9 Woman's work status l Currently working 1.5 4.0 6.3 4.4 Worked previously 1.5 3.5 6.1 3.8 Never worked 1.3 3.7 6.2 4.0 Husband's education No education 1.3 4.0 6.4 4.4 Primary 1.4 3.7 6.5 4.1 Middle 1.3 3.6 6.7 3.7 Secondary+ 1.3 3.4 5.3 3.6 Husband's occupation Professional, technical 1.5 3.I 5.8 3.7 Administrative, managerial 1.5 3.4 5.1 4.1 Clerical 1,3 3.3 5.8 3.7 Sales 1.3 4.1 6.1 4.3 Service 1.2 3.4 5.6 3.3 Agriculture, fishing 1,3 3.8 6.3 4.3 Production, transportation, labor 1.4 3.8 6.4 4.1 Not classifiable 1.0 3.7 6.1 3.9 Total 1.3 3.7 6.2 4.1 :"Worked previously" means that the women is not eurently working and she worked before marriage end/or just after marriage. '*Never worked" means that the woman is not cur~erttly working and she did not work either before marriage or just after marriage. 4.3 Birth Intervals Previous research has demonstrated that children bom too close to the time of a previous bi~ah are at increased risk of dying. The risk is particularly high when the interval between births is less than 24 months. Previous birth intervals for children born in the five years preceding the survey are shown in Table 4.10. The median interval since the previous birth is 29 months. One of every three bit'tlm occurred less than 24 months after the previous birth and half of those had very short birth intervals of less than 18 months. Another one-third of births (36 percent) had previous birth intervals of two years and the remaining one-third (31 percent) had intervals of three years or more. 46 Tat~e 4.10 Birth intervals Percent distribution of births in the five years preceding the survey by number of months since previous birth, aeeoxding to selected background ebaracteristies, paldstan 1990-91 Median Number of months since previous birth months since Number Background previous of ebaraet~ristie 7-17 18-23 24-35 36-47 48+ Tolal birth b'u'ths Age 15-19 32.4 21.0 39.6 6.7 0.3 100.0 23.7 68 20-29 19.8 18.7 37.0 12.6 11.9 100.0 26.8 2452 30-39 14.3 15.9 35.7 14.4 19.8 100.0 30.8 2242 40+ 10.3 10.9 27.8 15.7 35.4 100.0 37.9 547 Birth order 2-3 20.2 16.7 36.6 12.5 14.0 100.0 27.4 2056 4-6 13.6 16.4 37.0 13.8 19.2 100.0 30.0 2085 7+ 16.0 17.3 31.1 14.9 20.7 100.0 30.4 1169 Sex of prior birth Male 17.7 16.2 33.3 14.8 18.0 100.0 29.1 2762 Female 15.6 17.3 37.9 12,3 16.9 100.0 29.0 2608 Survival of prior birth Living 14.7 16.3 36.6 13.9 18.7 100.0 30.0 4670 Dead 31.2 20.2 28.5 11. l 9.0 100.O 23.7 640 Residence Total urban 20.6 19.5 33.0 12.6 14.2 100.0 26.5 1649 Major city 21.9 20.6 31.9 i2.1 13.6 100.0 25.7 938 Other urban 19.0 18.0 34,5 13.4 15.1 100.0 27.7 712 Rural 14.9 15.5 36.7 14.0 19.0 100.0 30.3 3660 Province Punjab 16.3 16.3 38.4 13.2 15.8 100.0 28.9 3238 Sindh 19.9 18.1 26.8 11.4 23.9 100.0 28.3 1158 NWFP 11.5 17.3 37.2 17.2 16.9 100.0 31.3 709 Balochislan 22,5 13,7 34,3 18,8 10.7 100,0 27,3 205 Education level attended No education 15.0 16.4 36.3 14.0 18.4 100.0 29.8 4192 Primary 22.2 20.2 32.3 12.9 12.5 100.0 26.2 524 Middle 26.3 14.2 39.3 7.7 12.5 100.0 25.9 233 Secondary+ 22.6 17.1 29.5 13.9 17.0 100.0 27.5 361 Total 16.7 16.7 35.6 13.6 17.5 100.0 29.1 5310 Note: First-order births axe excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. The median birth interval is relatively short for younger women, for urban residents, for women living in Balochistan and for women who had received some formal education. In Balochistan, birth intervals are relatively short for both modem (urban, educated) women and traditional women. This 47 f'mding is probably due to a complex set of circumstances including negligible contraceptive use in Baloehistan and a later age at marriage and shorter breastfeeding among modem women. Birth intervals are also shorter than average for second and third order births, Second and third order births were also most likely to be in the high risk group---that is, births occurring within 24 months of the preceding birth. As expected, children whose prior sibling had died before the time of the survey had the shortest previous bilth intervals. A majority of children whose prior sibling had died were born less than 24 months after the birth of the previous child. 4.4 Age at First Birth The age at which a woman bears her first child has important demographic and health consequences. On the demographic side, early initiation into childbearing is generally a major determinant of large family size and rapid population growth, particularly in countries in which family planning is not widespread. On the health side, beating children at an early age entails significant risks to the health of both the mother and the child. Early childbearing also tends to restrict educational and economic opportunities for women. Table 4.11 presents the distribution of Pakistani women by their age at first birth. The majority of women in Pakistan did not have their first birth unfd after their twentieth birthday. Childbearing before age 15 has always been uncommon and it is becoming increasingly rare over time. More than one-fifth of women age 25-49, however, had their first birth before age 18 whereas about 40 percent had their first birth during their teenage years. In recent years, there has been a rapid decline in the extent to which women begin childbearing during their teenage years. For example, whereas 42 percent of women age 25-29 had their first birth before age 20, only 30 percent of women age 20-24 had their first child that early. Table 4.11 Age at first birth Percent dis~bution of ever-manSed women by age at first birth, nccording to current age, Pakistan 1990-91 Current age Median Women Age at first birth Number age at with no of first birth <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 87.8 1.5 6.7 4.1 . . . . 100.0 1720 a 20-24 54.3 3.3 13.9 13.3 10.6 4.8 -- 100.0 1747 a 25-29 23.0 5.3 18.7 18.1 15.7 14.0 5.3 100.0 1745 21.0 30-34 9.2 4.4 20.0 17.3 16.1 19.7 13.3 100.0 I?AI 20.9 35-39 5.4 3.4 16.4 18.4 16.5 20.6 19.3 100.0 1005 21.4 40-44 5.5 6.3 15.6 15.6 15.5 19.8 21.8 100.0 865 21.7 45-19 5.5 4.8 12.4 15.7 12.9 22.2 26.5 100.0 630 22.6 -- Less than 0.05 percent aLess than 50 percent of the women have had a birth by the beginning of the age group. Differentials in the age at first birth are shown in Table 4.12. The median age at first birth for all women age 25-49 is 21.3 years. Overall, there is little variation in the median age at first birth by place of residence or by education, except for women who have attended the highest education level. For the youngest age group, the median age at first birth is lowest in rural areas, in Baiochistan and among 48 Table 4.12 Age at first bitlla by backh, ruund characteristics Median age at first birth among woman aged 25-49 yeats, by current age and selected background chsaacteristics Cm~ant age Background Ages charaetea'isfic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Total urban 21.7 20.9 20.8 21.5 21,4 21,3 Major city 21.8 21.0 20.6 20.7 21.3 21.1 Other urban 21.6 20.8 21.2 22.1 21.5 21.4 Rural 20.6 20.9 22.0 21.7 23.2 21.3 Province Punjab 21.6 21.0 21.6 21.8 22.7 21.6 Sindh 19.8 20.6 21.2 21.0 21.7 20.6 NWFP 21.2 20.8 21.0 21.3 23.6 21.4 Balochistan 18.3 20.4 22.0 22.7 25.3 20.3 Education level attended No education 20.3 20.5 21.3 21.6 22.8 21.0 Primary 20.7 21.5 21.5 20.0 21.0 21.1 Middle 22.1 20.2 19.7 20.6 23.2 21.1 Secondary+ 25.0 24.7 23.0 23.3 22.5 24,0 Total 21.0 20.9 21.4 21.7 22.6 21.3 women with little or no education. These patterns, however, are not regular across all age groups. 2 The most consistent pattern is the late initiation of childbearing among women who have gone beyond middle school. 4.5 Teenage Fertility Some information on teenage fertility was already presented in the section on age at first birth. More detailed findings on teenage fertility are discussed in this section. Table 4.13 presents information on the childbearing experiences of women age 15-19. Column one shows the percentage of teenagers who are already mothers; column two shows the percentage who are pregnant with their first child. The sum of these two columns indicates the percentage of young women who have already begun childbearing. Overall, one in eight teenage women was a mother and another four percent were pregnant with their first child at the time of the survey. The proportion who have started childbearing increases with age. For example, at ages 15 and 16, only six percent of women have begun childbearing. After age 16, the proportion increases steadily to a level of 31 percent by age 19. While these figures demonstrate that there is a substantial amount of teenage childbearing in Pakistan, it is noteworthy that more than two-thirds of women who are 19 years old have not begun ch'tldbearing. Early childbearing is particularly characteristic of rural women and women who have not attended school. Regional differences in early childbearing are not as pronounced, but women in Balochistan are somewhat more likely to begin childbearing early than are women in other provinces. ~'he results for women age 45-49 should be interpreted cautiously since in demographic surveys older women often omit their first birth (particularly if the child died) or report the timing of their first birth erroneously. 49 Table 4.13 Teenage fertility Percentage of teenagers 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Pakistan 1990-91 Percentage who are: Percentage Pregnant who have Number Background with ftrst begun of characteristic Mothers child childbearing teenagers Age 15 3.0 2.5 5.5 173 16 3.7 2.5 6.1 381 17 7.6 5.4 13.0 260 18 15.1 3,8 18.9 630 19 27.4 3.3 30.6 276 Residence Total urban 7.8 2.1 9.9 583 Major city 5.7 2.1 7.9 318 Other urban 10.2 2,1 12.3 264 Rural 14.5 4.3 18.7 1137 Province Punjab 12.6 4.3 16.9 1015 Sindh 12.0 2.4 14.4 345 NWFP 11.7 2.2 13.9 281 Balochistan 15.3 5.2 20.5 52 Education level attended No education 17.4 5.0 22.4 1007 Primary 8.3 2.I 10.4 248 Middle 4.9 -- 4.9 115 Secondary+ 3.1 2. I 5.3 256 Total 12.2 3.5 15.7 1720 -- Less than 0.05 percent Teenage women who have begun childbearing are not fikely to have had more than one birth (see Table 4.14). Only one respondent age 15-17 had two or more births and fewer than 10 percent of women age 19 had given birth to more than one child. Overall, g8 percent of women 15-19 have never given birth and only three percent have delivered more than one child. These findings suggest that the recent increase in the average age at first marriage in Pakistan has had a dampening effect on early childbearing and caused the large majority of women to delay childbearing at least until they have completed their teenage years. 50 Table 4.14 Children ever born to teenagers Percent dis~bution of teenagers 15-19 by number of children ever born (CEB), sccording to single year of age, Pakistan 1990-91 Number of children ever bern Age 0 1 2+ Total Mean Number number of of CEB teenagers 15 97.0 3.0 -- 100.0 173 16 96.3 3.7 -- 100.0 381 17 92.4 7.3 0.3 100.0 0.1 260 18 84.9 11.3 3.8 100.0 0.2 630 19 72.6 17.9 9.5 100.0 0.4 276 Total 87.8 9.2 3.0 100.0 0.2 1720 -- Less then 0.05 percent or mean less then 0.05 children 51 REFERENCES Alam, Iqbal, Mohammad lffan and Naseem Iqbal Farooqui. [1984]. Fertility Levels, Trends and Differentials in Pakistan: Evidence from the Population, Labour Force and Migration Survey 1979-80. Studies in Population, Labour Force and Migration, Project Report No. 1. Islamabad: Pakistan Institute of Development Economics. Amold, Fred. 1990. Assessment of the Quality of Birth History Data in the Demographic and Health Surveys. In An Assessment of DHS-I Data Quality, 81-111. DHS Methodological Reports, No. 1. Columbia, Maryland: Institute for Resource Development/Macro Systems, Inc. Amold, Fred and Ann K. Blanc. 1990. Fertility Levels and Trends. DHS Comparative Studies, No. 2. Columbia, Maryland: Institute for Resource Development/Macro Systems, Inc. Federal Bureau of Statistics [Pakistan]. 1990. Pakistan Demographic Survey - 1988. Karachi: Statistics Division. Population Census Organisation [Pakistan]. 1984. 1981 Census Report of Pakistan. Islamabad: Population Census Organisation (Census Report No. 69). Population Census Organisation [Pakistan]. 1985. HandBook of Population Census Data. Islamabad: Statistics Division. Population Planning Council of Pakistan. 1976. Pakistan Fertility Survey: First Report, 1976. Voorburg, Netherlands: Intemational Statistical Institute. Population Welfare Division [Pakistan]. 1986. Pakistan Contraceptive Prevalence Survey, 1984-85. Islamabad: Ministry of Planning and Development. Potter, Joseph E. 1977. Problems in Using Birth History Analysis to Estimate Trends in Fertility. Population Studies 31(2):335-64. Retherford, Robert D. and lqbal Alam. 1985. Comparison of Fertility Trends Estimated Alternatively from Birth Histories and Own Children. Papers of the East-West Population Institute No. 94. Honolulu: East- West Center. Retherford, Robert D., G. Mujtaba Mirza, Mohammad Irfan, and Iqbal Alam. 1987. Fertility Trends in Pakistan -- The Decline That Wasn't. Asian and Pacific Population Forum 1(2):1-10. Rukanuddin, Abdul Razzaque and M. Naseem Iqbal Famoqui. 1988. The State of Population in Pakistan, 1987. Islamabad: National Institute of Population Studies. Shah, Iqbal H. and John G. Cleland. 1988. High Fertility in Bangladesh, Nepal, and Pakistan: Motives and Means. Paper presented at the IUSSP Seminar on "Fertility Transition in Asia: Diversity and Change," Chulalongkom University, Bangkok, March 1988. Shah, lqbal H., Thomas W. Pullum, and Muhammad Irfan. 1986. Fertility in Pakistan during the 1970s. Journal of Biosocial Science 18(2):215-29. 52 CHAPTER 5 KNOWLEDGE AND USE OF FAMILY PLANNING Nasra M. Shah and Syed Mubashir Ali In a country with a persistently high population growth rate such as Pakistan, the level of knowledge about family planning and the use of family planning methods remain very important demographic issues. Information on contraceptive use by various methods is of particular importance to policy makers, pro- gramme managers and researchers for formulating future programme strategies. An assessment of the extent of knowledge and use of contraception, therefore, constituted one of the primary objectives of the PDHS. This chapter describes women's knowledge of modem and traditional contraceptive methods as well as of their sources, the level of contraceptive use and the timing of contraceptive initiation, accessibility of family planning services and the cost of contraceptive methods. Differentials in knowledge and use according to demographic and socioeconomic characteristics of the respondents are also discussed. 5.1 Knowledge of Family Planning Methods and Sources Levels and Trends The question used to elicit knowledge about family planning was phrased: "Now I would like to talk about family planning--the various ways or methods that a couple can use to delay or avoid a pregnancy. Which ways or methods have you heard about?" The respondent was first asked to report all the methods she knew without any prompting. Once she completed her spontaneous reporting, the interviewer read out the names and a short deseription of the remaining methods on the list and asked if she knew each one of them. In this way, her "complete" knowledge of contraception was obtained. The contraceptive methods included in the survey are shown in Table 5.1. Almost four-fifths of ever-married and currently married women reported knowledge of at least one method. Almost all the women who reported such knowledge knew of a modem method. One-quarter of all women knew of a traditional method, mostly periodic abstinence or withdrawal. Female sterilisation, the pill, and injection were the best known methods. A distinction can be made, however, between prompted and unprompted knowledge. If just unprompted knowledge is considered, only about half of all women reported that they knew any method. Women who reported knowing of a method were asked if they knew where they could go to obtain the method. Of all currently married women, 25 to 30 percent knew where they could obtain the pill, an IUD, or an injection. The largest percentage (37 percent) knew where they could get sterilisation services. In the case of periodic abstinence, only 9 percent of women knew where to get advice on how to use this method. 53 Table 5.1 Knowledge and source of contraceptive methods Percentage of ever-married women and currently married women who know specific contraceptive methods mad who know a source (for information or seawices), by specific method, Pakistan 1990-91 Ever-married women Currently married women Ever- Currently manied rmnried womcn womex l Contraceptive Know Unprompted Prompted Know Unprompted Prompted Know a Know a method method knowledge knowledge method knowledge knowledge sourc~ source Any method 77.9 49.1 28.8 77.9 49.3 28.6 46.2 46.3 Any modern method 77.3 46.4 30.8 77.2 46.7 30.5 44.8 44.9 Pill 62.2 30.2 32.0 62.2 30.2 32.0 29.6 30.1 IUD 51.6 19.2 32.3 51.5 19.3 32.1 24.9 25.1 Injection 62.1 27.7 34.3 62.2 27.9 34.3 29.8 30.1 Vaginal method 12.7 3.1 9.5 12.7 3.1 9.6 7.0 7.0 Condom 35.0 14.7 20.3 35.3 14.8 20.5 19.1 19.3 Female sU~filisation 69.6 24.0 45.6 69.7 24.2 45.5 37.0 37.0 Male sterilisation 20.2 3.0 17.2 20.2 3.0 17.3 11.4 11.5 Any traditional method 25.6 10.4 15.2 25.7 10.4 15.3 NA NA Periodic abstinence 17.8 5.7 12.0 17.8 5.7 12.0 9.3 9.4 Withdrawal 14.2 3.2 11.0 14.3 3.2 11,0 NA NA Other 3.5 3.5 NA 3.5 3.5 NA NA NA Number of women 6611 6611 6611 6364 6364 6364 6611 6364 NA = Not applicable Comparison of the level of contraceptive knowledge in the PDHS with earlier surveys reveals some unusual patterns. The comparisons are not straightforward, since some surveys included prompted responses about specific methods, while others included only the respondent's spontaneous (unprompted) knowledge. Looking only at unprompted knowledge, the percentage of currently married women who reported knowing about any method fluctuated from 76 percent in the 1975 Pakistan Fertility Survey (PFS) to 26 percent in the 1979-80 Population, Labour Force and Migration Survey (PLM) to 49 percent in the 1990-91 PDHS. Looking at prompted and unprompted knowledge combined, the percentages still vary greatly, from 97 percent of married women interviewed in 1968-69 in the National Impact Survey--when the family planning programme was only four years old---to 62 percent in the 1984-85 Contraceptive Prevalence Survey and 78 percent in the PDHS (see Table 5.2). Thus, it appears that the overall level of contraceptive knowledge, which showed a decline in the last two decades, has made headway in recent years, assuming that the measurement in the PDHS was of the same quality as in the earlier surveys. The reason for the fluctuations in the level of contraceptive knowledge is uncle~ however, it is possible that the social climate that influences the respondent's reporting of knowledge of contraception might have become more restrictive beginning in the late 1970s, as was poinled out by analysts of the 1979-80 Pakistan Population, Labour Force and Migration Survey (Soomro et al. [1984]). 54 Table 5.2 Trends in contraceptive knowledge Percentage of currently married women who know specific contraceptive methods, 1990-91 PDHS, 1984-85 PCPS, and 1968-69 N-IS Contraceptive 1990-91 1984-85 1968-69 method PDHS PCPS NIS Any method 77.9 61.5 97.0 Pill 62.2 54.1 37.7 IUD 51.5 43.4 72.1 Injection 62.2 46.7 U Vagina/method 12.7 16.2 38.8 Condom 35.3 28.9 42.3 Female sterilisation 69.7 50.6 47.9 Male sterilisation 20.2 18.8 36.7 Periodic abstinence 17.8 5.8 13.7 Withdrawal 14.3 9.0 16.5 Note: Figures are for total knowledge,, i.e., knowledge based on unprompted (spontaneous) and prompted responses. U = Unknown; no information Source: Population Welfare Division (1986); Soomro et al. [1984]. Differentials in Knowledge Table 5.3 shows the knowledge of modem contraceptive methods and the source for methods among currently married women by selected background characteristics. In terms of respondent's age, women 30-39 years, who are likely to have the greatest need for contraception, reported the highest levels of knowledge (81 percent had heard of a modem method), Only 66 percent of women age 15-19 knew of a modem method of contraception. There are large differences in reported knowledge between urban and rural areas (see Figure 5.1). Ninety-four percent of currently married women residing in major cities knew of at least one modem method of contraception and three-fourths knew where to obtain a method. Among rural women, 71 percent knew of a modem method and 34 percent knew where to obtain a method. A comparison with earlier surveys indicates that the urban-rural differential in knowledge of family planning has increased over time (data not shown). While women in the provinces of Punjab, Sindh and NWFP had knowledge of modem methods ranging from 74 to 83 percent, only 37 percent of the Balochi women reported knowing of a modem method. Similarly, only about half as many B alochi women knew a source for a modem method as women in the other provinces. 55 Table 5.3 Knowledge of modem contraceptive methods and source for methods Percentage of currently married women who know at least one modem contraceptive method and who Imow a source (for information or services), by background characteristics, Pakistan 1990-91 Know Know Know source for Number Background any a modem modem of characteristic method method 1 method women Age 15-19 66.3 65.8 32.3 418 20-24 75.0 74.4 39.2 1041 25-29 77.4 76.7 43.6 1452 30-34 81.8 81.2 48.4 1147 35-39 81.5 81.3 53.2 931 40-44 78.7 77.9 47.2 803 4549 77.8 76.6 44.1 572 Residence Total urban 91.3 90.6 69.9 1930 Major city 94.5 93.8 75.7 1098 Other urban 87.2 86.4 62,3 832 Rural 72.0 71.4 34.0 4434 Province Punjab 80.6 79.9 46.2 3768 Sindh 74.4 73.9 45.3 1486 NWFP 83.6 83.3 44.8 856 Balochistan 38.5 36.5 23.8 254 Education level attended No education 73.8 73.0 37.7 5044 Primary 91.7 91.7 64.3 573 Middle 93.6 93.6 72.4 279 Secondary+ 95.6 95.0 81.9 468 Work status 2 Currently working 72.7 72.5 40.0 1033 Worked before marriage only 85.8 85.7 57.7 282 Worked after marriage only 81.9 81.9 64.1 43 Worked before and 75.7 74.5 39.2 69 after man'iage Neve~ worked 78.5 77.7 45.0 4916 Total 77.9 77.2 44.9 6364 IInolud~ pill, IUD, injec~on, vaginal methods (diaphragm/foam/jelly), condom, female sun'ilisa~un md male su~ilisatiun 2Excludes 21 women with miuing informsfion on work status. "Never worked" means that the woman is not ~dy working and she did not work either before marriage or just after marriage. 56 100 80 60 40 20 Figure 5.1 Knowledge of Modern Contraceptive Methods and Sources among Currently Married Women by Residence Percent o _/ Major City Other Urban Rural m Know a Modern Method ~ Know a Source i I PDHS 1990-91 The major difference in contraceptive knowledge by education is between women with no education and those who have at least some education. Only 73 percent of women with no education knew of a modem method, compared with 92 percent of those who had gone to primary school and 95 percent of those who had received at least some education at the secondary level. Similarly, only 38 percent of the women with no education knew where to obtain a method, compared with 82 percent of the ones with secondary or higher education. Finally, the relative level of contraceptive knowledge of working and nonworking women does not show any clear pattern. One might expect worldng women to have greater exposure and knowledge; however, the results in Table 5.3 indicate that this is not always the ease. Women who worked only before or alter marriage are more likely to know a modem contraceptive method (86 percent and 82 percent, respectively) than those who have never worked (78 percent), but those who have never worked are slightly more likely to know a modem method than those who are currently working (73 percent). Earlier research in Pakistan has shown that working women typically belong to the lower socioeconomic stratum (Shah 1986) and are likely to be less knowledgeable about contraception. This is consistent with the finding in Table 3.10 that working women are the least educated group overall. 57 5.2 Contraceptive Use Ever Use of Family Planning Methods In the PDHS all respondents who knew at least one method were asked whether they had ever used the known methods. This was further probed by asking whether they "ever used anything or tried in any way to delay or avoid getting pregnant." Table 5.4 shows that one-fifth of ever-married and of currently married women had used a contraceptive method at some time in the past. Sixteen percent of currently married women had used a modem method, while 9 percent had used a traditional method, Periodic abstinence was the most commonly used traditional method. Table 5.4 Ever use of contraception Percentage of ever-marrled and of currently married womea who have ever used any conlxaceptive method, by specific method and age. Pakistan 1990-91 Age of woman Contraceptive method 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total EVER-MARRIED WOMEN Any method 3,3 12.7 18.6 23.5 31.1 25.5 19.1 20.3 Any modern method 2.4 8.0 15.1 19.1 25.1 20.0 15.4 16.0 Pill 1.1 2.2 3.7 5.7 6.0 7.0 4.2 4.5 IUD 0.6 1.4 4.0 4.9 4.1 3.9 2.2 3.4 Injection 0.4 1.5 2.7 4.0 5.9 3.2 3.0 3.2 Vaginal method --- 0.4 0.3 0.4 1.1 0.4 0.4 0.5 Condom 1.4 3.9 8.8 9.2 10.2 6.6 4.6 7.1 Female sterilisation 0.5 0.8 2.7 7.6 7.6 6.6 3.5 Male sterilisation -- 0.1 0.1 0.2 -- 0.4 0.1 Any traditional method 1.2 6.4 8.5 9.9 13.3 9,9 6.6 8.7 Periodic abstinence 1.1 2.4 5.2 5.2 8.2 6.3 3.7 4.9 Withdrawal 0.5 3.0 3.6 5.3 6.2 2.7 1.9 3.7 Other 0.2 2.5 1.4 1.8 1.6 2.7 2.1 1.8 Nuraber of women 428 1059 1494 1187 981 844 617 6611 CURRENTLY MARRIED WOMEN Any method 3.1 12.9 19.1 24.0 32.1 25.9 19.6 20.7 Any modern method 2.3 8.2 15.5 19.4 25.8 20.1 15.8 16.2 Pill 0.9 2.3 3.7 5.9 6.3 7.0 4.5 4.5 IUD 0.4 1.4 4.1 4.9 4.1 3.6 1.8 3.3 Injection 0.4 1.6 2.7 4.2 6.2 3.2 3.3 3.3 Vaginal method -- 0.4 0.3 0.4 1.2 0.4 0.4 0.5 Condom 1.3 4.0 9.1 9.4 I0.I 6.2 4.7 7.2 Female sterilisation -- 0.5 0,9 2.7 8.0 8.0 6.8 3.5 Male sterilisation . . . . 0.1 0.1 0.2 -- 0.4 0.I Any traditional method 1.0 6.5 8.7 10.0 13,9 10.3 6.7 8.9 Periodic abstinence 0.9 2.5 5.3 5.2 8.4 6.5 3.8 5.0 Withdrawal 0.5 3.1 3.7 5.4 6.5 2.8 1.9 3.8 Other -- 2.5 1.4 1.8 1.7 2.8 2.1 1.9 Number of wom~n 418 1041 1452 1147 931 803 572 6364 - L~s than 0.05 I~rceat 58 The most commonly used modem methods were the condom (7 percent), followed by the pill (5 percent) and female sterilisation (4 percent). Less than one percent of the women reported ever having used a vaginal method such as the diaphragm, spermicides, or suppositories and a negligible proportion (0.1 percent) reported the use of male sterilisation. In terms of age, one-fifth or more of ever-married and of currently married women age 30-44 had used a modem method. Contraceptive use rates were highest in the age group 35-39, where knowledge was reported to be the highest (Table 5.3). A low use rate was observed among the youngest women: only 2 percent of those age 15-19 had ever used a modem method. The use of traditional methods was highest (13- 14 percent) in the age group 35-39, followed by 10 percent in the adjacent age groups 30-34 and 40-44. Levels of ever use from the PDHS are considerably higher (21 percen0 than those estimated from previous surveys. Data from the 1968-69 National Impact Survey (NIS), the 1975 Pakistan Fertility Survey (PFS), the 1979-80 Population, Labour Force and Migration Survey (PLM) and the 1984-85 Pakistan Contraceptive Prevalence Survey (PCPS) show levels of ever use among currently married women to be 12 percent, 11 percent, 5 percent, and 12 percent, respectively (Soomro et al. [1984]; Population Welfare Division 1986). While differences in the methods asked about andintheimplementationofthe surveysmay account for some of the differences, it seems likely that there has been a substantial recent increase in the ever use of contraception in the country. Current Use of Family Planning Methods Regarding current use at the time of survey, ~ 12 percent of currently married women reported that they were using some method to delay or prevent pregnancy (see Table 5.5). Three-fourths of the current users were using a modem method and one-fourth a traditional method. The most widely used method was female sterilisation (4 percent), followed by the condom (3 percent) and the IUD (1 percent). Less than one percent were using either the pill or injection (a recently introduced method). 1In the PDHS, no reference period was def'med for current use. The woman was asked whether she or her husband were cune~tly using a method. 59 Table 5.5 Currant use of contraception Percent distribution of curranfly married women by current use of contraceptive methods, according to age, Pakistan 1990-91 Age of woman Con l~,m~l~l~Jv@ method 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Any method 2.6 6.3 9.6 13.4 20.4 15.8 I 1.8 11.8 Any modern method 1.9 3.8 7.4 9.6 15.8 12,8 10.3 9,0 Pill 0.2 0.8 0.8 0.7 0.9 0.8 -- 0,7 IUD 0.4 0.7 1.8 1.9 1.4 1.1 0.4 1.3 Injection 0.4 0.4 0.4 0.6 1,6 1.1 1.1 0.8 Vaginal method . . . . . . . . 0.1 . . . . . . Condom 0.8 1.5 3.6 3.6 3.8 1.8 1.9 2.7 Female sterilisation -- 0.5 0.9 2.7 7.9 8.0 6.8 3.5 Male sterilisation . . . . . . 0.1 0.2 . . . . . . Any traditional method 0.7 2.5 2.3 3.8 4.5 3.0 1.5 2,8 Periodic abstinence 0.5 0.7 1.0 1.6 2.6 1.7 0.4 1.3 Withdrawal 0.1 1.1 1.0 1.9 1.8 1.3 0.3 1.2 Other -- 0.6 0.3 0.3 0.2 -- 0.8 0.3 Not currently using 97.4 93.7 90.4 86.6 79.6 84.2 88.2 88.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 418 1041 1452 1147 931 803 572 6364 -- Less than 0.05 percent The level of contraceptive use varies with the age of women, increasing from less than three percent for married women age 15-19 to a high of 20 percent for women 35-39, and decreasing thereafter. It is assumed that younger women are less likely to use contraception because they have recently started their families, while older women, whose current use is more than the national average, are more likely to use due to the pressure of frequent pregnancies and large family size. Younger women typically use a temporary method such as the condom, periodic abstinence, or withdrawal, while sterilisation is more common among older women (8 percent of women age 35-44 have been sterilised). It is notable that even among women age 35 and over, the condom is the second most widely used method. Table 5.6 shows the contraceptive use rates (ever use and current use) among non-pregnant women. A total of 22 percent of non-pregnant currently married women reported that they had ever used contraception while 14 percent were currently using various methods (11 percent modem methods and 3 percent traditional methods). Among modem methods, female sterilisation (a permanent method) was used most frequently (4 percent), followed by the condom (3 percent), IUD (2 percent), injection and the pill (1 percent each). Modem methods had been used by 17 percent of non-pregnant women and traditional methods had been used by 10 percent. The most prominent modem method among ever-users was the condom (8 percent), followed by the pill (5 percent), sterilisation and the IUD (4 percent each), and injection (3 percent). 60 Table 5.6 Use of contraception by non-pregnant women Percentage of currently married non-I~'egnant women who have ever used and ~e currently using a contraceptive method, by specific method, Pakistan 1990-91 Contraceptive Ever Currently method used using Any method 22.0 14.0 Any modern method 17.1 10.7 Pill 4.7 0.8 IUD 3.6 1.5 Injection 3.2 0.9 Vaginal method 0.5 -- Condom 7.5 3.2 Female sterilisation 4.2 4.2 Male sterilisation 0,1 -- Any traditional method 9.6 3.3 Periodic abstinence 5.4 1.5 Withdrawal 4.1 1.4 Other 2.1 0.4 Never used/Not currently using 78,0 86.0 Total NA 100.0 Number of women 5375 5375 -- Less than 0.05 percent NA = Not applicable The level of contraceptive use reported in the PDHS represents a substantial increase from that reported in either the 1975 PFS or the 1984-85 PCPS. Both these surveys calculated contraceptive use for currently married non-pregnant women; the results from all three surveys, calculated on this basis, are given in Table 5.7. Contraceptive use among married, non-pregnant women has almost tripled in 15 yeats, from 5 percent in 1975 to 9 percent in 1984-85 and 14 percent in 1990-91. In particular, female sterilisation has gained importance over the last two decades. Only 1 percent of married non-pregnant women were reported in the 1975 PFS to have been sterilised; in the 1984-85 PCPS, this had increased to 2.6 percent and by 1990- 91, to 4.2 percent, a fourfold increase in 15 years. 61 Table 5.7 Trends in contraceptive use Percentage of cun'entiy married, non-pregnant woman age 15-49 who are ~-tenfly ~mg a contraceptive method, 1990-91 PDHS, 1984-85 PCPS and 1975 PFS Contraceptive 1990-91 1984-85 1975 method PDHS PCPS PFS Any method 14.0 9.1 5.5 Any modern method 10.7 7.6 4.0 Pill 0.8 1.4 1.0 IUD 1.5 0.8 0.7 Injection 0.9 0.6 U Vaginal method 0.1 0.2 Condom 3.2 2.1 l.O Female sterilisation 4.2 2.6 1.0 Male sterilisation Any traditional method 3.3 1.5 1,5 Periodic abstinence 1.5 0.I 0.1 Withdrawal 1.4 0.9 0.1 Other 0.4 0.5 1.3 Number of women 5375 U 4441 Note: Figures for the PFS include use of prolonged abstinence as "other," which is analogous to the PCPS and PDHS, since there was no probing of methods. -. Less than 0.05 percent U = Unknown; no information Source: Population Planning Council of Pakistan (1976); Population Welfare Division (1986:88). The condom, the second roost widely used method, has gained in popularity compared to the pill. This may be due to the general availability of condoms through a commercial social marketing programme, Social Marketing of Contraceptives (SMC). Similarly, IUD use has doubled from 0.8 percent in the 1984-85 PCPS to 1.5 percent in the 1990-91 PDHS. The introduction of the Copper T into the programme has probably been the principal mason for this increase. 62 Socioeconomic Differentials In Current Use of Family Planning Table 5.8 shows the sociodemographic differentials in current contraceptive use. As in previous surveys, a large urban-rural differential continues to exist (see Figure 5.2). The pmporlion of married urban women using a modem method ( 19 percent) is almost four times greater than that of rural women (5 percent). The urban-rural differential holds for each method; for example, 9 percent of the women in major cities have been sterilised, compared to 6 percent of women in other urban areas and 2 percent of women in rural areas. It should also be noted that in both rural and urban areas, current use of any method has increased since the 1984-85 PCPS, which showed a rate of 16 percent for urban and 5 percent for rural areas. Table 5.8 Currant use of contraception by background characteristics Percent distfibmica of cmxenfly man'ied women by contraceptive method currently being used. according to background characteristics Any Female Male Any Periodic Not Bae, klp~urid Any raodern Inj~e- Vlglnal sunill- stefili- trad. abaft- With- eurr~tly chamcu~isfic method method Pill IUD fion method Condom satlan sstlon method n~nce drawal Other using Total Number Residence Tt~.al urban 25.7 18.7 1.4 2.0 1.2 -- 6.7 7.3 0.1 7.1 3.4 3.0 0.6 74.3 IDO.0 1930 Majorcity 31.0 22.3 1.4 2.4 1.0 0.1 8.9 8.5 0.1 8.7 4.2 4.0 0.5 69.0 100.0 1098 Otherurban 18.8 13.9 1.4 1.4 1.4 3.8 5.7 0.2 4.9 2.4 1.8 0.7 81.2 100.0 832 Rural 5.8 4.8 0.4 0.9 0.6 1.0 1.9 -- 1.0 0.4 0.4 0.2 94.2 100.0 4434 prov|nc~ Punjab 13.0 9.8 0.6 1.5 0.8 3.0 3.8 0.1 3.2 1.4 1.5 0.3 87.0 100.0 3768 Sindh 12.4 9.1 0.7 0.9 0.4 3.4 3.5 -- 3.4 1.7 1.3 0.4 87.6 100.0 1486 NWFP 8.6 7.6 1.3 1.1 1.1 0.1 0.8 3.2 -- 1.0 0.6 0.3 0.1 91.4 100.0 856 Balochistan 2.0 1.7 0.7 0.5 0,1 0,2 0,3 -- 0,3 0,2 0,1 98.0 100.0 254 ]~luc~tlon NoeducJtloa 7.8 6.2 0.5 1.0 0.5 1.1 3.0 -- 1.6 0.8 0.5 0.3 92.2 100.0 5044 Primary 17.8 14.0 1.5 1.5 1.2 4.5 5.1 0.2 3.8 1,7 1.8 0.3 82.2 100.0 573 Middle 29,5 21.7 1.6 1.1 3.1 0.1 8.5 6.8 0.5 7.8 3.4 3.8 0.6 70.5 100.0 279 Secondary+ 38.0 25.9 1.1 4.0 1.1 0.1 14.4 5.2 12.1 4.8 7.0 0,2 62.0 100.0 468 Number of living children 0 011 0.1 "" 0.1 . . . . . . . . 99.9 10010 810 1 3.2 2.0 0.2 -- 0.4 -- 1.4 1.2 0.5 0.5 0.2 96.8 100.0 834 2 10.7 8.0 0.8 1.4 0,3 -- 4.5 1.0 -- 2.7 1.1 1,0 0,6 89,3 100,0 812 3 11.1 7.8 0.9 1.4 0.5 -- 3.1 1.9 -- 3.3 1.2 2.0 0.1 88.9 100.0 914 4 17.1 12.6 1.2 1.5 0.8 -- 3.9 4.8 0.3 4.5 1.7 2.4 0.4 82,9 100.0 856 5 IS.0 14.0 1.4 1.7 1.8 -- 4.5 4.8 -- 3.9 2.6 1.1 0.2 82.0 100.0 647 6+ 18.4 14.8 0.6 2.1 1.3 0.1 2.1 8.5 -- 3.6 1.8 1.3 0.5 81.6 100.0 1492 Total 11.8 9.0 0.7 1.3 0.8 -- 2.7 3.5 -- 2.8 1.3 1.2 0.3 88.2 100.0 6364 -- Less than 0.05 percent In terms of provincial variation, Balochi women reported the lowest level of current use----only 2 percent were using modem methods, which is consistent with the low level of contraceptive knowledge among Balochi women. In contrast, 10 percent of women in Punjab were using modem methods. 63 Figure 5.2 Current Use of Modern Contraceptive Methods among Currently Married Women 15-49 by Residence and Province Percent Urban Rural RESIDENCE ~O 2 Punjab Slndh NWFP Balochlstan PROVINCE PDHS 1990-91 Another major differential that continues to hold is related to women's education. A strong positive relationship exists between education and the level of current use (see Figure 5.3). The percentage of married women using a modem contraceptive method increases from 6 percent of women with no education to 26 percent of women with secondary or higher education. This same association exists in the case of condom use and the use of traditional methods, with use being much greater among women who have attended secondary or higher education. The relationship is less obvious for female sterilisation and many of the other methods; the percentage of sterilised women, for example, was almost the same among those who attended primary school and those who attended secondary school or higher. Finally, a posiOve association exists between the number of living children a woman has and current use. This was especially marked regarding use of female sterilisation. Only 2 percent of the women with three children had been sterilised, compared with 5 percent of those with four or five children and 9 percent of those with six or more children. 64 Figure 5.3 Current Use of Modern Contraceptive Methods among Currently Married Women 15-49 by Education Percent 25: I 20 15 10 5 o/ No Educ, Primary Middle Secondary+ EDUCATION PDHS 1990-91 Number of Children at First Use of Contraception In order to investigate when during the family building process couples become motivated to initiate family planning use, the PDHS included a question for all women who had ever used a method as to how many living children they had when they first used a method. Overall, less than half (46 percent) of those who had ever used family planning initiated use when they had fewer than three living children (see Table 5.9). As expected, very few women initiated contraceptive use before they had any cnildren (0.5 percent). There appears to be a slight tendency for younger women to have initiated family planning use at lower parities than older women. A larger proportion of women living in major cities (34 percent) started using a method when they had fewer than four children than women living in other urban areas (19 percent) and those living in rural areas (5 percent). Users in NWFP started using a method much later than their counterparts in other provinces. Women who attended secondary school or a higher level of education started using a contraceptive method earlier than women with no education. 65 Table 5.9 Number of chilthen at first use of conttac~l~on percent dist~bution of eve~-married women by number of living children at the time of first use of contraception, according to selected background characteristics, pakistan 1990-91 Never Number of living children at the time of first use used of contraception Number Background contra- of characteristic ception 0 1 2 3 4 5 6 7+ Missing Toad women Age 15-19 96.7 0.3 2.1 0.9 100.0 428 20-24 87.3 0.8 6.3 3.2 0.8 0.7 0.1 0.1 0.6 100.0 1059 25-29 81.3 0.6 5.9 4.9 3.4 2.3 0.9 0.3 0,2 0.2 100.9 1494 30-34 76.5 0.6 4.1 5.3 3.7 4.5 2.1 1.5 1,5 0.2 100.0 1187 35-39 68.9 0.2 4.3 6.2 4.6 4.2 3.1 4.1 4.3 0.1 100.0 981 40-44 74.5 0.3 4.7 3.7 2.7 2.7 2.9 2.8 5.7 100.0 844 45-49 80.9 0.3 1.8 2.4 2.2 1.8 2.1 3.3 5,3 100.0 617 Residence Total urban 58.9 1.0 9.8 10.2 6.4 5.1 2.7 2.6 3.2 0.1 100.0 2019 Major city 51.3 1.7 12.3 12.3 7.3 5.9 2.6 3.3 3,3 0.1 100.0 1151 Other urban 69.0 0.2 6.5 7.3 5.2 4.1 2.9 1.8 2.9 0.1 100.0 868 Rural 88.8 0.2 2.3 1.6 1.2 1.5 1.1 1.2 1,7 0.3 I00.0 4592 Province Punjab 77.7 0.4 5.4 4.8 3.0 3.0 1.8 1.8 L9 0.2 100.0 394g Sindh 78.4 0.9 4.8 4.9 3.4 2.4 1.2 1.4 2.3 0.2 100.0 1529 NWFP S6,0 0.l 1.8 1.8 1.7 1.6 2.1 1,6 3.3 0,1 100.0 878 Balochisma 95.2 0.1 1.6 0.7 0.4 0.5 0,3 0.2 0,9 0.1 100.0 255 Education level attended No education 85.7 0.3 2.3 2.6 1.7 2.l 1.5 1.4 2.2 0.I 100.0 5237 Primary 67.3 0.1 5.1 8.1 5.6 3.6 3.4 3.6 2.5 0.8 100.0 601 Middle 55.9 1.4 12.4 9.5 7.9 7.0 [.1 1.1 3.4 0.4 100.0 288 Secondary+ 43.6 2.6 24.4 14.6 7.7 3.7 1.1 1.5 0.5 0.1 100.0 485 Total 79.7 0.5 4.6 4.2 2.8 2.6 1.6 1.6 2.2 0.2 100.0 6611 -- Less than 0.05 percent Use of Social Marketing Brand Condoms The increase in condom use documented in the PDHS may be attributed at least partially to the active social marketing of this method. Table 5.10 shows that more than one-third (36 percent) of all couples who were using condoms were using the social marketing brand (Sathi), 18 percent were using the brand distributed in the government's family planning programme (Sultan) and 8 percent were using other brands. These figures underestimate the importance of the social marketing brand of condoms, as well as the other brands, since they include the responses of women who did not know the brand of condoms used by their husbands. When we consider only those respondents who knew the brand name of the condoms their husbands were using, 58 percent reported Sathi, 29 percent reported Sultan and 13 percent reported the use of other brands. I 66 Table 5.10 Brand names of condoms Percent distribution of condom users by brand names of condoms currently being used, according to urban-rural residence, Pakistan 1990-91 Other Don't Residence Sathi Sultan brand know Total Number Total urban 36.3 17.2 11.2 35.4 100.0 126 Major city 37.0 17.8 10.4 34.7 100.0 94 Other urban (34.2) (15.1) (13,5) (37.2) (100.0) 32 Rural (35.4) (21.8) (--) (42.8) (100.0) 43 Total 36.1 18.3 8.4 37.2 100.0 169 Note: Excludes three women with information missing on brand name. Figures in parentheses are based on 25 to 49 unweighted women. -- Less than 0.05 percent 5.3 Knowledge of the Fertile Period Earlier in this chapter it was reported that 18 percent of the currently married women had heard about periodic abstinence as a method of contraception and 9 percent knew where to get information about this meth- od (see Table 5.1). A total of 5 percent of currently married women reported that they had ever used period- ic abstinence as a method of contraception (see Table 5.4). The successful use of periodic abstinence as a method of contraception is, to some extent, dependent on a woman's knowledge of the fertile period. Table 5.11 shows respondents' knowledge about the time dur- ing the menstrual cycle when a woman is most likely to get pregnant. Only five percent of all ever-married women could correctly identify the fertile period as being in the middle of the cycle. Even among the wom- en who said they have used periodic abstinence, less than one-third had accurate knowledge about the time a woman is at the highest risk of pregnancy. Table 5.11 Knowledge of fertile period Percent dis¢ibution of ever-marriod women and women who have ever used periodic abstinence by knowledge of the fertile period during the ovulatory cycle, Pakistan 1990-91 Ever- l~ver uF~rs Perceived married of periodic fertile period women abstinence During menstrual period 1.7 3.4 Right after period ends 6.9 38.7 Middle of her cycle 5.2 31.8 Just before period begins 1.3 8.2 At any time 0.6 0.2 Don't know 84.2 17.6 Total 100.0 100.0 Number 6611 326 Some remarks about the comprehensibility of this question are in order. The question dealing with the fertile period presented a special difficulty and often had to be repeated in order to be understood. It is therefore not surprising that 84 percent of the women said they did not know when the fertile period occurs. In a society where two-thirds of women have received no education (see Table 3.5) and knowledge about the reproductive period is obtained through informal social channels, it is not unusual that only a few women reported accurate knowledge of the fertile period. It follows that in order for periodic abstinence to be used as a programme method, a major educational effort would have to be implemented. 67 5.4 Age at Sterilisation Some information about the age and time at which women obtain sterilisation operations is given in Table 5.12. Of the total women who reported sterilisation, 45 percent were sterilised less than four years before the survey, another one-third (34 percent) were sterilised 4-7 years before the survey and the remaining one-fifth were sterilised eight or more years before the survey. For those sterilised in the most recent time period--the four years before the survey--the data show that half of the sterilised women had the operation before they were age 35 and about one-third had the operation in their late 30s. It is difficult to assess trends in the age at sterilisation since the PDHS only interviewed women age 15-49 at the time of the survey. Thus, for the period eight or more years before the survey, there are no women age 45-49 and very few age 40-44, since these women would have been age 53-57 and 48-52, respectively, at the time of the survey. A recent study sponsored by the Family Planning Association of Pakistan, however, found that the age, as well as the parity, of sterilised women showed a declining trend (Rehan, n.d.). Table 5.12 Timing of sterilisation Percent distribution of sterilised women by age at the time of sterilisation, according to the number of years since the operation, Pakistan 1990-91 Age at time of operation Number Years since of Median operation <25 25-29 30-34 35-39 40-44 45-49 Total women age 1 <4 7.5 18.4 24.3 29.6 17.1 2.9 100.0 102 33.4 4-7 1.2 15.8 41.4 29.9 11.7 -- 100.0 77 33.7 8+ 10.9 34.7 38.2 16.2 . . . . 100.0 46 30.4 Total 6.1 20.8 33.0 27.0 11.8 1.3 100.0 225 32.8 -- Less than 0.05 percent IMedian ages have been calculated only for women less them 40 years of age to avoid problems of censoring 5.5 Source of Supply and Accessibility of Contraception In order to evaluate the relative importance of various types of family planning service delivery mechanisms, the PDHS included a question about where current users obtained their methods. Overall, the government supplied over half (56 percent) of all modem methods used, while the private sector supplied 30 percent (see Table 5.13 and Figure 5.4). Four percent of users obtained their methods from other sources, while 10 percent (mostly condom users) did not know the source of their methods. The mix of public vs. private sources varied according to the method used. For clinical methods (IUD and sterilisation), the government was by far the major source of supply; 85 percent of sterilised women and 81 percent of IUD users said that they had obtained services from a govemment source. More than half (53 percent) of the users of injection also got their supply from a government source. Users of supply methods (the pill and condoms) were less dependent on the government for their supply. 68 Table 5.13 Source of supply Percent distribution of current users of modem contraceptive methods by most recent source of supply or information, according to specific method. Pakistan 1990-91 Source of supply Female All or information Pill IUD Injection Condom sterilisation methods I Total government 34.9 81.1 53.0 11.7 85.1 55.7 Hospital/clinic 13.1 45.9 29.5 4.1 78.3 42.2 Family Welfare Centre 21.3 35.2 21.3 6.1 6.7 12.8 Other government 0.5 -- 2.2 1.5 -- 0.7 Total private 56.2 15.8 42.0 47.6 13.7 30.0 Doctor 6.7 2.0 20.1 1.7 3.6 4.6 Hospital 1.3 9.3 17.6 1.9 10.1 7.5 Drugstore 41.7 -- 4.2 29.6 -- 12.5 Other shop 6.5 -- 13.1 -- 4.4 TBA -- 4.5 -- 1.3 -- 1.0 Total other sources 5.2 -- 4.7 11.5 -- 4.3 Friends/relatives 4.7 -- 4.6 3.3 -- 1.7 Other somces 0.6 -- 0.1 8.2 -- 2.5 Don't know/missing 3.7 3.1 0.3 29.2 1.2 10.0 Total 100.0 100.0 100.0 100.0 I00.0 100.0 Number 45 80 48 172 225 574 -- Less than 0.05 percent t All methods include vaginal methods and male stadlisation, which are not shown separately. As for specific sources, Family Welfare Centres, the main institutional structure through which contraceptives are pmvlded, are an important source of services: 35 percent of IUD users and 21 percent each of users of the pill and injection am served by Family Welfare Centres. Govemmem hospitals and clinics are the major source for female sterilisation, serving 78 percent of the women. These facilities served a large proportion of IUD and injection users as well. Drugstores and other shops are the major sources for pills and condoms (48 percent of pill users and 43 percent of condom users). A substantial proportion (38 percent) of women who use injection receive their shots from a private doctor or hospital. Thus, government and private sources are active in supplying various types of contraceptives. To facilitate the accessibility of contraceptive methods, both these sources need to be expanded. 69 Figure 5.4 Sources of Family Planning among Current Users of Modern Contraceptive Methods Government 56% Private 30% Other 4% :)on't Know 10% PDHS 1990-91 The case of obtaining a contraceptive method is an important factor in establishing contraceptive use. Thus, in the PDHS, each current user of a modem method was asked how long it took to travel from her home to the place where the method was obtained. These same questions were also asked of nonuscrs who kncw of a source for family planning. The results are presented in Table 5.14. Table 5,14 Time to source t~ suppl)~ for modem contraceptive methods Percent distribution of cun~nt users of modem methods of family planning, nonusers of modem methods, and all ever-married women knowing any method and a source, by time to reach source of supply, according to urban-rural residence, Pakistan 1990-91 Ever-married women who Cummt users of modem methods Nonusers of modem methods know a contraceptive method Minutes Total Major Other Total Major Other Total Major Other to source urblm city urban Rural Total urban city urban Rural Total urban city urban Rural Total 0-14 24.8 25.1 24.2 11.4 19.7 26.1 28.0 23.4 13.3 18.7 25.7 27.0 23.6 13.1 19.1 15-29 20,2 22.3 15.8 10.6 16.5 26.3 26.8 25.7 11,3 17.6 24,6 25.3 23.5 11.4 17.6 30-59 23.3 26.1 17,4 12.8 19.3 21.1 20.8 21.6 15.8 18.0 21.6 22.6 20.0 15.6 18.4 60+ 27.6 22.2 38.7 63.0 41.0 20.6 19.6 22.0 53.6 39.6 22.8 20.5 26.5 54.3 39.4 Don't know time 4.1 4.2 3.9 2.3 3.4 5.9 4.9 7.3 6.0 6.0 5.3 4.6 6.4 5.6 5.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Median 30.1 30.0 30.5 60.5 30.7 20.6 20.3 20.9 60.3 30.7 20.8 20.5 25.7 60.3 30.7 Numbez 307 206 101 187 494 713 418 295 976 1689 1014 623 391 1134 2148 Nora: T*ble excludes women who do not know a source. Table also excludes those who mentioned friends, relatives, or others as the source. Althou~ the time to get to a mobile clinic or field worker was not asked, it is assumed that these sources arc within 15 minutes of the woman's home. Nonusers of modem methods md ever-mai~ied women who know a contraceptive method exclude current users of mtditiomd methods. 70 In terms of how long it took the current users of modem methods to reach a source of supply, rural women reported a median of 61 minutes, compared with 30 minutes reported by urban women. About 63 percent of the rural users of modem methods said that it took them an hour or more to reach the facility from where they obtained their contraception, compared with 22 percent of the women in major cities and 39 percent in other urban areas. Differentials by time to reach a source reported by those who were not using modem methods and by all women who know a method were similar. 5.6 Cost of Contraception The PDHS included a question for current users of the pill, IUD, condom, injection and female sterilisation about the cost of their methods. The results are presented in Table 5.15. Caution should be exercised in interpreting these data since the number of users is small. Table 5.15 Costs of contraceptive methods Average cost of contraception for currant users and the percentage receiving method for free by contraceptive method, Pakistan 1990-91 Average cost (Rupees) Number of users Percent Contraceptive For those Who receiving method Total 1 who pay Total I paid free Pill (one packet) 7 (8) 35 29 15.5 IUD insertion 59 (100) 79 46 41.2 Injection 87 (102) 42 35 15.1 Condom 1 1 80 64 19.7 Sat.hi (1) (1) 37 34 (9.8) Female sterilisation 756 2740 199 55 72.4 Note: Table excludes users who did not know the cost of their method. Figures in parentheses are based on 25 to 49 unweightod women. l Includes those who received method flee A majority of the female sterilisations (72 percent) and 41 percent of the IUD insertions were provided free of charge, presumably by government hospitals or clinics, while alarge majority of women who were using the pill, injection, or condoms had to pay for the services. The cost of pills and condoms is fairly low as a result of government subsidies: on average, one condom costs the user one rupee (for those who paid), while a cycle of pills costs eight rupees. The cost of an injection or an IUD insertion is substantial (about 11313 rupees). In recent years injection has become a popular method and programme administrators would be well advised to encourage additional free or subsidized services for this method. Finally, those who paid for the sterilisation operation paid, on average, over 2,700 rupees. The high cost of this method puts it well beyond the reach of most couples. Hence, the programme emphasis on the provision of free sterilisations is well placed. 71 REFERENCES Population Planning Council of Pakistan. 1976. Pakistan Fertility Survey: First Report. Voorburg, Netherlands: International Statistical Institute. Population Welfare Division [Pakistan]. 1986. Pakistan Contraceptive Prevalence Survey, 1984-85. Islamabad: Ministry of Planning and Development. Rehan, N. (n.d.). FPAP Contraceptive Surgery Client Profile. Lahore: Family Planning Association of Pakistan. Shah, Nasra M. 1986. Female Employment: Trends, Structure, Utilization and Constraints. In: Pakistani Women: A Socioeconomic and Demographic Profile, ed. Nasra M. Shah, 264-301. Islamabad: Pakistan Institute of Development Economics. Soomm, G.Y., S.M. Ali, M. Khalid, H.B. Siyal, K.H. Sheikh, S.U. Grewal, and M.J. Tariq. [1984]. Prevalence of Knowledge and Use of Contraception in Pakistan. Studies in Population, Labour Force and Migration Project Report No. 3. Islamabad: Pakistan Institute of Development Economics. 72 CHAPTER 6 FAMILY PLANNING ATTITUDES Abdul Razzaque Rukanuddin and M ehboob Sultan A positive attitude toward family planning is one of the basic prerequisites for contraceptive use. This chapter discusses the interpersonal communication among husbands and wives about family planning; attitudes of couples toward family planning; whether they heard a family planning message on radio or television; their perceptions about the effectiveness of family planning messages in persuading couples to use family planning; and their attitudes toward family planning messages on radio or television. 6.1 Discussion of Family Planning Among Couples Although husband-wife discussion of family planning is not a necessary condition for adopting contraception, earlier research in Pakistan does indicate that interspousal communication on family planning creates interest in and support for regulating fertility through contraceptive use (Shah 1974). All currently married nonsterilised women who knew a contraceptive method were asked how often they talked with their husbands about family planning in the past year. Three-quarters of the women (74 percent) said they had not discussed this topic with their husbands in the previous year. Of the remaining 26 percent who had discussed the topic, 21 percent discussed family planning once or twice while 5 percent discussed it more often (see Table 6.1). A relatively high percentage of women age 30-39 (31 percent) reported that they had discussed family planning with their husbands, which is consistent with the greater use of contraception in this age group (20 percen0. Women in their early and late reproductive years were least likely to have communicated with their husbands on family planning. Substantial differences were also found on the basis of urban-rural residence, province, and educational attainment. Women in major cities were more than twice as likely as women in rural areas to have discussed family planning with their husbands (41 percent versus 20 percent). Similarly, women in Punjab were most likely to have discussed family planning (28 percent), followed by women in Sindh (25 percent), Balochistan (23 percent) and NWFP (17 percent). The findings of relatively low interspousal communication in Balochistan and NWFP are consistent with the low level of contraceptive use reported in these provinces. As expected, the extent of husband-wife communication about family planning was positively related with the educational attainment of women. For example, women with some secondary or higher education were more then twice as likely to have discussed family planning with their husbands as women with no education (46 percent versus 21 percent). Women with secondary or higher education were also more likely to have disenssed faro'fly planning with their husbands at least three times during the last year (16 percent) than women with a lower level of education or with no education at all. 73 Table 6.1 Discussion of family planning by couples Percent distribution of currently married nomterilised women who know a contraceptive method by the number of times family planning was discussed with their husbands in the year preceding the survey, sccording to background characteristics, Pakistan 1990-91 Number of times family planning discussed Once Three Number Background or or more of char acteTistie Never twice times Total women Age 15-19 83.4 14.0 2.6 100.0 277 20-24 75.7 19.8 4.6 100.0 776 25-29 72.8 21.9 5.2 100.0 1112 30-34 69.4 25.2 5.4 100.0 906 35-39 68.8 24.7 6.6 100.0 684 40-44 76.0 18.6 5.4 100.0 568 45-49 84.4 13.3 2.3 100.0 406 Residence Total urbma 63.2 27.9 9.0 100.0 1619 Major city 59.4 29.3 11.3 100.0 944 Other urban 68.5 25.9 5.6 100.0 676 Rural 79.7 17.4 2.9 100.0 3109 Province Punjab 71.7 24.3 4.0 100.0 2889 Sindh 74.6 18.9 6.5 100.0 1054 NWFP 82.6 10.6 6.8 100.0 689 Balochistan 77.1 19.3 3.6 100.0 97 Education level attended No education 78.5 18.1 3.3 I00.0 3569 Primary 69.5 23.7 6.8 100.0 495 Middle 53.0 40.6 6.4 100.0 241 Secondary + 53.6 30.9 15,5 100.0 423 Total 74.0 21.0 5.0 10O.0 4729 6.2 Attitudes of Couples Toward Family Planning Data on attitudes toward family planning were collected by asking women whether they and their husbands approved or disapproved of couples using a method to delay or avoid pregnancy. Table 6.2 presents information on the extent of consensus between women's attitudes and those of their husbands. It should be noted that the husbands' actual attitudes (reported in Chapter 12) may differ from their wives' perceptions of their attitudes. However, a wife's perception concerning her husband's attitude is important as it affects her decision with regard to the use of family planning. 74 Table 6.2 Attitudes of couples toward fan~y ]~anrdng Percent distribution of wives' approval of family planning by their perception of their hustxmds' attitude toward family planning. among cunenfly merried nonstefifised women who know of a contraceptive method, according to selected background chm'acteristics. Pakistan 1990-91 Woman approves Woman disapproves Husband Husband's Husb~d's Backgrotmd Both dis- attitude Husband attitude Both Number characteristic approve approves unknown approves unknown disapprove Other Total of women Age 15-19 33.3 10.5 17.4 2.6 19.6 15.3 1.2 100.0 277 20-24 35.6 11.0 13.9 2.3 12.3 23.9 0.9 100.0 776 25-29 34.3 12.6 18.9 2.1 12.3 19.3 0.4 100.0 1112 30-34 33.1 14.9 12.4 1.6 12.1 25.5 0.4 100.0 906 35-39 39.3 13.0 12.7 2.5 10.9 21.3 0.3 100.0 684 40-44 31.6 10.7 14.8 2.9 15.7 23.5 0.7 100.0 568 45-49 27.6 12.8 14.1 1.0 18.3 26.0 0.2 1(30.0 406 Residence Total urban 52.9 12.6 11.4 1.6 5.1 16.1 0.4 100.0 1619 Major city 59.4 11.8 10.5 2,0 3.0 12.7 0.5 100.0 944 Other urban 43.8 13.7 12.6 0.9 8.0 20.9 0.2 100.0 676 Rural 24.3 12.4 16.8 2.4 17.8 25.6 0.6 100.0 3109 Province Punjab 35.6 12.7 14.4 2.4 11.8 22.5 0.6 100.0 2889 Sindh 36.2 12.8 10.3 1.8 15.4 23.2 0.4 100.0 1054 NWFP 25.8 10.7 25.5 1.6 16.7 19.3 0.4 100.0 689 Balochistan 24.0 14.3 8.4 1,0 18.6 32.2 1.5 100,0 97 Education level attended No education 27.1 12.6 15.6 2.3 16.6 25.3 0.6 100.0 3569 Primary 43.2 11.9 15.3 2.5 5.6 21.2 0.3 100.0 495 Middle 55.4 18.2 14.3 0.8 2.7 8.5 -- 100.0 241 Secondary + 70.3 9.1 9.8 1.2 2.1 7.2 0.3 100.0 423 Total 34.1 12.5 15.0 2.1 13.4 22.4 0.5 100.0 4729 -- Less than 0.05 percent Table 6.2 shows that 62 percent of currently married, nonsterilised women who knew of a contraceptive method approved of family planning use, while 38 percent disapproved of it, Women perceived their husbands to be somewhat less favourable toward family planning. While 28 percent of women said they did not know their husband's attitude, half of the rest thought their husband disapproved of family planning. There appears to be a considerable amount of consensus between husbands and wives about family planning use. One-third of female respondents reported that both they and their husbands approved of family planning and 22 percent said they both disapproved. The latter couples constitute the hard core cases in which family planning acceptance seems unlikely, unless concerted motivational efforts are made to bring about an attitudinal change. Only 15 percent of women reported an opposite opinion to that of their husbands, and in such eases the husband was usually reported to have a less favourable attitude toward family planning. 75 Attitudes toward family planning use differ little by the age of the wife. However, urban women arc more likely than rural women to approve of family planning (see Figure 6.1). The approval of family planning by both husband and wife was more than twice as high (53 percent) in urban than in rural areas (24 percent). Conversely, disapproval by both husbands and wives was higher in rural areas (26 percent) than in urban areas (16 percent). Rural women were less likely to know their husband's attitude than urban women, a fact which is consistent with the lower level of communication about family planning in rural areas. Considering family planning approval by province, about 60 percent of women in Sindh, Punjab, and NWFP approved of family planning use, compared with only 47 percent of women in Balochistan. The highest proportion of disapproval by both husband and wife was reported in Balochistan (32 percent), followed by Sindh and Punjab (23 percent each) and NWFP (19 percent). 100 Figure 6.1 Approval of Family Planning among Currently Married Women by Residence and Education Percent 90 60 40 20 0 Major Other Rural NO Educ. Primary Middle City Urban RESIDENCE EDUCATION Note: Stied on currently married non- sterilized women age 15-49 who know a method. Sac,* PDHS 1990-91 Education of women is a crucial vaffable which is related to the approval of family planning by both husband and wife. Overall, only 55 percent of uneducated women approved of family planning compared with 89 percent of women with secondary education. Approval by both husband and wife was the lowest (27 percent) among women with no formal education. As education increased, the proportion of women who reported that both they and their husbands approve of the use of family planning increased from 43 percent in the case of primary education to 55 percent in the case of middle school and 70 percent for secondary and higher education. 76 6.3 Family Planning Messages on Electronic Mass Media The Population Welfare Programme (PWP), keeping in view the low literacy rate--particularly among females---and the rural residence of most of the population, has utilised the electronic mass media to pobliels¢ family planning messages. For more than six years, the PWP has been regularly using radio and television to promote the concept of a small family norm and to disseminate information on family planning, maternal and child health, and breastfeeding. The effort to spread family planning information through the electronic mass media has succeeded in reaching only one in five ever-married women (21 percent) at the national level (see Table 6.3). One in twenty women (5 percen0 had heard a family planning message only on radio and the same proportion had seen a message only on television. About one in nine women (11 percent) had heard a message on both radio and television in the month preceding the survey. This indicates that the electronic media have yet to play a major role in disseminating the family planning message to a large segment of the illiterate and rural population. Table 6.3 Family planning messages on radio and television Percent distribution of ever-married woman by whether they have heard a family planning message on the radio or television in the month preceding the survey, according to background characteristics, Pakistan 1990-91 Heard family planning message on radio or on television Number Background Radio Television of characteristic Neither only only Both Total women Resldenee Total urban 60.6 3.3 12.6 23.4 100.0 2019 Major city 53.7 2.8 14.6 28.8 100.0 1151 Other urban 69.7 4.0 10.l 16.3 100.0 868 Rural 86.7 5.9 1.9 5.4 100.0 4592 Province Punjab 81.6 5.1 4.7 8.6 100.0 3948 Sindh 68.1 5.1 7.7 18.9 100.0 1529 NWl~P 80.7 5.4 4.2 9.5 100.0 878 Baloehistan 90.0 4.8 0.8 3.3 100.0 255 Education level attended No education 84.4 5.5 3,0 7.0 100.0 5237 Primary 62.7 4.9 10.1 22.2 100.0 601 Middle 61.0 4.8 12.2 22.0 100.0 288 Secondary + 47.8 1.0 18.4 32.7 100.0 485 Total 78.7 5.1 5.2 10.9 100.0 6611 Urban-rural differentials in media coverage were quite prominent. One of eight rural women (13 percent) had heard a family planning message on radio or television compared to two of five urban women (39 percent). In major cities, close to half of the women (46 percent) had heard a family planning message on radio or television during the preceding month. Among the provinces, a larger proportion of women (32 percent) in the comparatively more urbanised province of Sindh had heard a family planning message, followed by NWFP (19 percent) and 77 Punjab (18 percent). Women in Baloehistan were least likely to have heard family planning messages (10 percent), probably because of the low population density and the relatively low level of coverage by mass media. Exposure to family planning messages through the electronic mass media was positively correlated with educational attainment. Only 16 percent of the uneducated respondents reported that they bad heard a family planning message on radio or television, whereas more than half (52 percent) of the women with secondary education had heard a message. The proportion hearing a message on radio alone declined with increasing education and the proportion hearing a message on TV or on both radio and TV increased with increasing education. Table 6.4 Perceived effectiveness of mass media messages on use of family planning Percent distribution of the perceived effectiveness of family planning messages in persuading couples to use family planning, among ever-married women who have heard a radio or television message about faa~il, y plmmlng, ~eording to selected b~kground characteristics, Pakistmx 1990-91 Perceived effectiveness Background Not Don't characteristic Effective effective know Missing Total Number Age 15-19 69.9 10.0 19.9 0.2 100.0 85 20-24 81,9 10,4 7,3 0.4 100,0 233 25-29 81.0 9.2 8.9 1.0 100.0 343 30-34 81.4 8.4 7.6 2,7 100.0 242 35-39 81.7 9.5 8.7 0.2 100.0 236 40-44 80.6 8.9 8.3 2.2 100.0 150 45J,9 72.6 12.7 13.3 1.4 100.0 112 Residence Total urban 84,5 9.8 4,9 0,7 100,0 795 Major city 87.1 7.8 4.6 0.5 100.0 532 Other urban 79.2 14.0 5.6 1.2 100.0 263 Rural 74.0 9.2 15.1 1.7 100.0 606 Province Punjab 82.0 7.1 9.8 1.1 100.0 724 Sindh 79.5 12.3 6.7 1.5 100.0 486 NWFP 76.0 9.3 14.3 0.4 100.0 168 Balochist an 51.I 33.2 14.5 1.2 I00.0 23 Education level attended No education 74.9 11,7 12.2 1.2 100.0 811 Primary 87.8 6.8 5.2 0.2 100.0 224 Middle 85.5 4.1 8.1 2.3 100.0 112 Secondary + 86.7 7.8 4.2 1.2 100.0 253 Total 79.9 9.6 9.3 1.2 100.0 1401 Table 6.4 presents the views of ever-married women about the effectiveness of the family planning media messages they heard on radio or saw on television. Eighty percent of the women who heard a message reported that these messages were effective, while 10 percent reported that they were not effective and 9 percent did not know. The differentials in perceived effectiveness by various social and demographic characteristics were generally small. The youngest women ( 15-19 years) and the oldest women (45-49 years) 78 were less likely to find the messages effective than women at other ages. Rural women were less likely to fred the family planning messages effective. Women in Balochistan and women with no education were least likely to rate the messages as effective. 6.4 Acceptabi l i ty of Fami ly P lanning Messages on Electronic Mass Media Women were further asked whether or not they considered it acceptable for family planning information to be provided on radio or television. Slightly less than half (48 percent) of the women said that these messages were acceptable to them, while 20 percent said they were not acceptable and the rest (32 percent) were not sure. Younger women, rural residents, women with no education, and women in Balo- chistan were less likely than other women to think it was acceptable to broadcast family planning messages on radio or television (see Table 6.5). Attitudes toward the acceptability of family planning messages on the electronic mass media are highly favourable among women living in major cities and among women who have gone beyond primary school. Table 6.5 Acceptability of media messages on family planning Percentage of ever-married women who believe that it is acceptable to have messages about family planning on radio or television, by age and selected background characteristics, Pakistan 1990-91 Age Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Total urban 66.4 72.0 77.1 77.2 77.1 72.9 62.0 73.9 Major city 67.3 81.7 84.2 81.8 82.9 78.5 74.1 80.9 Other urban 65.4 57.7 66.8 72.2 67.9 65.5 48.9 64.6 Rural 33.3 37.6 36.5 36.0 37.5 38.4 38.5 36.9 Province Punjab 39.3 51.1 52.8 52.9 54.8 54.0 50.5 51.9 Sindh 38.2 49.9 49.6 47.3 53.0 38.2 42.2 47.0 NWFP 49.9 35.9 40.3 38.8 42.8 44.0 40.8 41.0 Balochistan 12.8 20.7 23.5 28.6 35.0 18.3 16.2 23.6 Education level attended No education 33.2 36.9 37.3 40.2 44.8 42.6 41.2 39.7 Primary 59.1 75.6 76.9 62.5 72.7 71.3 81.1 71.7 Middle 72.6 92.0 89,4 91,6 84.9 84.3 74.1 8%3 Secondaa'y+ 82.7 79.4 90.4 91.3 87.0 88.1 91.3 88.0 Total 39.6 47.5 49.0 49.0 52.0 48.5 46.0 48.2 6.5 Intentions About Future Use of Contracept ion Information on intentions to use contraception in the future can assist family planning administrators in reaching prospective users and providing them with contraceptives of their choice. Similarly, information on method preference and the reasons for nonuse is helpful in planning future strategies and improving the 79 operational modalities of the family welfare programme. Such information also provides an estimate of the potential demand for family planning services in the country. In the PDHS, all currently married pregnant women and non-pregnant women who were not using contraception at the time of interview were asked about their future intentions regarding the use of family planning and their method preference if they intended to use. If they did not intend to use family planning at any time in the future, they were asked why they did not intend to use. Seven of 10 (71 percent) currently married nonusers reported they do not intend to use contraception in the future (see Table 6.6). One of six ( 16 percent) said that they would use in the future and 13 percent were not sure about their intentions. Seven of 10 of the intended users (69 percent) said they would use contraception within the next 12 months, one- quarter (25 percent) reported they would use at a later stage, and 7 percent were not sure when they would start using contraception. Table 6.6 Future contraceptive use Percent thsuibution of intentions to use family planning in the futme by past experience with contraception, among currently married women who are not currently using any contraceptive rr~thod, according to number of living children, Pakistan 1990-91 Number of living children I Intention 0 1 2 3 4 5 6 7+ Total Never used contraception Intends use within 12 months 0.3 3.6 6.4 6.6 7,5 9.3 9.9 13.8 7.1 Intends use later 4.7 3.9 1.9 2.7 2,6 2.0 0.9 1.4 2.6 Intends - unsure time 0.3 1.3 1.0 0.9 1.5 0.4 0.4 0.7 0.8 Unsure as to intent 13.9 12.7 13.1 14.1 10.7 11.4 8.5 10.7 12.0 Does not intend use 80.1 75.5 70.2 63.7 62.9 61.6 65.2 59.4 67.3 Previously used contraception Intends use within 12 months 0.6 2.1 4.0 5,7 7.1 4.7 5,3 3,6 Intends use later 0.6 0.9 3.1 1.4 1.8 1.2 1.2 1.3 Intends - unsure time 0.2 0.2 0.4 0.3 0,7 0,2 Unstt~ as to intent 0.2 0.8 0.8 1.9 0.7 1.9 0.9 0.9 Does not intend use 0.7 1.5 3.4 3.7 5.4 5.6 6.5 6.4 4.1 Total percent 1(30.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Currently married nonusers Intends use within 12 months 0.3 4.2 8.4 10.6 13.3 16.3 14.6 19.0 10.7 Intends use later 4.7 4.5 2.8 5.8 4.0 3.7 2.1 2.7 3.9 Intettds - unsm'e tim~ 0.3 1.3 1.2 1.1 1.9 0.7 1.1 0.7 1.1 Unstue as to intent 13.9 12.9 13.9 15.0 12.5 12.1 10.4 11.6 12.9 Does not intend use 80.8 77.1 73.6 67.4 68.3 67.1 71.7 65.7 71.4 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 601 853 744 808 737 578 498 792 5610 -- Less than 0.05 percent i Includes current p~egnaacy 80 The proportion of women who intend to use does not indicate a consistent trend by parity, although women with three or fewer children are less likely to express an intention to use family planning in the future. Among women who never used contraceptive methods before, three-quarters reported that they did not intend to use in the future. In contrast, a majori- ty of those who used in the past (but are not currently using) intended to use contraception again in the future. 6.6 Reasons for Nonuse of Contraception Currentiy-married women who do not intend to use contraception in the future were asked to indicate the main reason for their in- tentions. The largest proportion of women (43 percent) said they did not intend to use con- traception since they wanted more children (see Table 6.7). This reason was given by nearly two-thirds (64 percent) of women less than 30 years of age, but only one-quarter of women age 30 and over. Religious masons were cited by the next largest group of women (13 percent), fol- lowed by lack of knowledge about family plan- ning ( 11 percent). Although Pakistani society is considered to be male dominated, relatively few women (6 percent) mentioned their hus- band's opposition to the adoption of family Table 6.7 Reasons for not intending to use contreception Percent distribution of main reasons for not intending to use conh-aceptlon, among non.contraeepting currently married women who do not intend to use in the batore, according to age, Pakistan 1990-91 Age Reamn for not intending to use contraception 15-29 30-49 Total Wmtts children 64.0 24.6 42.7 Leck of knowledge 7.4 13.2 10.5 Husband opposed 5.4 7.3 6,4 Costs too much 0.3 0.8 0,6 Won'y about side effects 2.1 3.3 2.8 Health coneeam 0.5 2.4 1.5 Hard to get methods 0.5 1.1 0.8 Religion 9.9 16.0 13.2 Opposed to family planning 1.0 2.1 1.6 Fatalistic 2.5 3.7 3.1 Other people opposed 0.3 0.1 0.2 Infrequ~t sex 0.7 1.1 1.0 Difficuh to get pregnant 1.8 11.9 7.3 Menopeusal/had hysterectomy -- 8,3 4.5 Inconvenient -- 0.3 0.2 Other 1.5 2.3 1.9 Don't know 2.1 1.1 1.6 Total 100.0 100.0 100.0 Number 1842 2162 4005 -- less than 0.05 percent planning methods as the main reason they do not intend to use contraception. The proportion of women with a fatalistic attitude (3 percent) was less than might be expected. A significant proportion of older women reported their actual or perceived sterility as the main reason for not intending to use contraception in the future. 6.7 Preferred Future Method of Contraception Among the women who reported their intention of using contraception in the future, one of six (17 percent) reported female sterilisation as their preferred method of contraception (see Table 6.8). Less than half (45 percent) said they preferred to use modern spacing methods: injection (16 percent), the pill (13 percent), condoms (10 percent), and the IUD (7 percent). About one-quarter of these respondents did not know what method they preferred for future use, 4 percent mentioned traditional methods (2 percent periodic abstinence and another 2 percent withdrawal), while 8 percent gave other answers. Almost none of the respondents indicated male sterilisation or vaginal methods as their preferred method. 81 Table 6.8 Preferred method of contraception for future use Percent distribution of preferred contraceptive method among currently married non-contra- eapting women who intend to use in the future, according to intended timing of future use, Pakistan 1990-91 Intend to use In next After Preferred method 12 12 of contraception months months Total Pill 14.5 12.0 13.0 IUD 8.7 3.6 6.8 Injection 17.5 14.6 15.7 Diaphragm/Foam/Jelly 0.3 -- 0.2 Condom 10.4 9.5 9.5 Female sterilisation 18.9 14.1 17.1 Periodic abstinence 2.4 1.9 2.1 Withdrawal 1.5 3.4 1.9 Other 7.9 5.2 7.6 Don't know/missing 17.9 35.7 25.9 Total 100.0 100.0 1(30.0 Number 602 217 878 Note: Total includes 59 women who intend to use in the future, but who are uv.sure when they will -- Leas than 0.05 percent The choice of preferred methods was generally similar for those who intended to use within 12 months and for those who intended to use later, although the women in the latter group were less likely to state a preference for any specific method. Overall, a sizeable number of women did not know what method they would prefer to use. This suggests that method-specific knowledge needs to be disseminated to enable women to make informed choices about the use of various methods. 82 REFERENCE Shah, Nasra M. 1974. Interspousal Communication and Agreement as Variables in the Study of Family Planning. Sc.D. thesis, Johns Hopkins University, Baltimore, Maryland. 83 CHAPTER 7 PROXIMATE DETERMINANTS OF FERT IL ITY Zeba Sathar and Tauseef Ahmed Analyses of reproductive behaviour cannot omit the important role of factors related to exposure to the risk of pregnancy. The traditional social structure of Pakistan largely supports a natural fertility regime in which the majority of women do not use any means of fertility regulation. Especially in such populations, other proximate determinants of fertility are more crucial in influencing fertility levels. An inquiry into these determinants and their patterns is important in examining the course of sociodemographic change. Previous studies of the proxim ate determinants of fertility in Pakistan have pointed toward age at marriage and duration ofbreastfeeding as extremely important variables in this particular cultural context (Karim 1990, Khan 1991, Sathar 1984). Of equal significance are postpartum amenorrhoea and sexual abstinence which lead to insusceptibility to the risk of pregnancy. These factors arc also closely associated with fertility patterns, especially in the early months after a birth. This chapter examines patterns and trends in all of the inter- mediate variables for which data were collected in the PDHS, to highlight their effect on fertility levels in Pakistan. 7.1 Marriage Patterns and Trends All ever-married women interviewed in the PDHS were asked to give their age at the time they started cohabiting with their husbands. Probing was used to differentiate the nikah (the marriage contract ceremony) from the actual rukhsati (the departure for the husband's household, i.e., consummation of the marriage). It is not until cohabitation begins that women are considered to be exposed to the risk of pregnancy. The length of time women arc exposed directly affects overall fertility; for example, a later age at marriage for females would result in a shorter period of exposure to childbearing (provided other factors arc equal). Thus, any change in marriage patterns that results in later age at marriage for women can play an important role in reducing fertility, particularly in a country like Pakistan, which has a low level of contra- ceptive prevalence. In the PDHS, only 25 percent of women age 15-19 and 60 percent of women age 20-24 had ever been married (see Table 7.1). Once marriages were entered into, however, they tended to remain quite stable. Less than one percent of women were divorced or separated at the time of the survey and less than two percent were widowed. The fact that marriage is a social obligation and nearly universal in Pakistan is supported by the finding that 98 percent of women age 35-49 had married. A comparison of the proportion of women who had never been married derived from the PDHS and the 1979-80 PLM indicates that substantial changes in marriage patterns took place between the two surveys. Although the proportion of women never married rose for every age group, the changes are particularly striking at ages 20-29, which has traditionally been the peak childbearing period for women in Pakistan. Changes in marriage patterns over time arc also evident from an examination of changes in the singulate mean age at marriage (SMAM). The singulate mean age at marriage computed from various sources for males and females is presented in Table 7.2. The SMAM for females has risen by five years during the last three decades (from 16.7 years in 1961 to 21.7 years in 1990-91 ). The S MAM for males rose by three years over the same period. 85 Table 7.1 Current marital status Percent distribution of women by current marital status, according to age, 1990-91 PDHS end 1979-80 PLM 1990-91 PDHS 1979-80 PLM Nevex Percent Age married Married Divorced Widowed Separated Total Number never manhed 15-19 75.1 24.3 -- 0.3 0.2 100.0 1720 72 20-24 39.4 59.6 0.6 0.1 0.7 100.0 1747 23 25-29 14.4 83.2 0.2 1.0 1.3 100.0 1745 6 30-34 4.3 92.4 0.5 1.5 1.2 100.0 1241 3 35-39 2.4 92.7 0.5 4.0 0.4 100.0 1005 2 40~14 2.4 92.8 0.1 4.2 0.5 100.0 865 1 45-49 2.1 90.8 0.2 6.5 0.5 100.0 630 1 Total 26.2 71.1 0.2 1.8 0.7 100.0 8953 32 -- Less than 0.05 percent Source: Sathar, Ali and Zahid (1984) Table 7.2 Mean age at marriage Singulate mean age at marriage for selected sources 1951-1991, Pakistan Source Male Female Difference 1951 Census 22.3 16.9 5.4 1961 Census 23.3 16.7 6.6 1972 Census 25.7 19.7 6.0 1981 Census 25.1 20.2 4.9 1976 PGS 25.2 20.0 5.2 1988 PDS 24.9 20.6 4.3 1990-91 PDHS 26.5 21.7 4.8 Table 7.3 shows the distribution of ever-married women by the proportion married by particular ages. Early marriage (before age 15) has never been prevalent, but it occurs even less frequently among the youngest age groups. The proportion married by age 18 or age 20 has also declined sharply when comparing women age 30-34 to those age 20-24. The median age at marriage for each of the five-year age groups from age 25-49 indicates very little variation for different cohorts. This apparent lack of change is partly due to the fact that the median cannot be calculated for women under age 25 since the majority have not yet been married. The median age at marriage, however, wiU necessarily be higher than 20 years for women who arc currently in the 20-24 age group. 86 Table 7.3 Age at first mm'rlage Percentage of women ever-married by exact age 15, 18, 20, 22, ea3d 25, and median age at first marriage, according to current age, Pakistan 1990-91 Percentage ever-married by exact age: Percent Current never Median age 15 18 20 22 25 married Number age 15-19 7.3 NA NA NA NA 75.1 1720 a 20-24 11.4 31.6 48.9 NA NA 39.4 1747 a 25-29 16.5 42.3 58.4 70.1 82.1 14.4 1745 18.9 30-34 17.0 47.8 63.1 74.3 87.7 4.3 1241 18.2 35-39 16.3 43.4 60.5 75.0 88.3 2,4 1005 18.6 40-44 18.0 44.8 60.9 75.9 87.7 2.4 865 18.5 4549 16.3 40.7 57.4 68.9 81.9 2.1 630 18.8 2049 15.5 41.0 57.4 NA NA 14.5 7233 18.9 NA = Not applicable aLess than 50 percent of women in the age group were married by the beginning of the age group. Differentials in Age at Marriage Table 7.4 presents differentials in the median age at marriage for various groups of women. Overall, for women age 25-49, the median age at marriage is 18.6 years. This figure is slightly higherin urban areas (19.1 years) than in rural areas (18.4 years). Among Pakistan's four provinces, the median age is highest in NWFP and Punjab and substantially lower in Baloehistan and Sindh. Finally, there is a positive association between the median age at marriage for women and their educational attainment: women with no education marry four years earlier, on average, than women with secondary or higher education. 87 Table 7.4 Median age at first nmrriage Median age at first marriage among woman age 25-49 years, by current age and background chasacteristics, Pakistan 1990-91 Curre~tt age Background Woman characteristic 25-29 30-34 35-39 40-44 45.49 25-49 Residence Total urban 19.9 19.1 18.7 19.2 18.3 19.1 Major city 20.1 19.4 18.5 18.8 18.5 19.2 Other urban 19.5 18.4 18.9 20.1 17.8 19.0 Rural 18.4 18.0 18.6 18.3 19.0 18.4 Province Punjab 19.4 18.5 19.0 18.9 19.0 19.0 Sindh 17,5 17.2 1%6 16.5 16.0 17.1 NWFP 19,5 18.6 19.0 18,9 20.8 19.3 Balochiatan 16.8 17,7 18,3 18,2 21.9 17.7 Education level attended No education 18.2 17.8 18.4 18,4 18.8 18.3 Primary 19.1 19.1 18.6 17.7 (16.9) 18.7 Middle 20.6 18.4 (17.9) a (19.6) 18.9 Secondary + 22.9 23.3 21.5 21.6 (20.0) 22.5 Total 18.9 18.2 18.6 18.5 18.8 18.6 Note: Figures in pasantheses lae based on 25 to 49 unweighted cases. abased on fewez than 25 tmweighted cases, medium not shown Ideal Age at Marriage The PDHS included questions asking ever-married women about what they considered to be the ideal age at marriage for women. The median ideal age at marriage was 18.4 years (see Table 7.5). Although ages 20-21 were considered ideal by the largest percentage of women (23 percent), more than one-quarter said it is ideal for a woman to get married at age 15 or earlier. There is a strong positive association between the stated ideal age at marriage and the actual age at which women got married. Nevertheless, most women who got married at a relatively young age (under 18) report an ideal age at marriage that is greater than their own age at marriage. Overall, the wide range of responses suggests that there is no consensus about what the ideal age at marriage is for women in Pakistan, despite a trend toward increasing age at marriage for females over the last three decades. 88 Table 7.5 Ideal age at mm'riage for women Percent distribution of ev~-mm'ried women by ideal age at marriage for women end mextima ideal age at marriage, according to actual age at first marriage, Pakistan 1990-91 Actual age at first man'iage Ideal age at first marriage for women < 15 15 16-17 18-19 20-21 22-23 24+ Total < 15 21.8 11.0 8.6 6.9 6.6 7.3 7.7 10.6 15 21.1 22.8 16.4 15.3 11.2 14.2 10.3 16.4 16-17 13.8 15.4 18.0 13.5 15.5 13,7 9.5 14.6 18-19 14.1 18.5 18.6 25.0 19.3 18.8 19.9 19.2 20-21 17.1 18.8 24.5 26.2 28.0 22.9 27.2 23.3 22-23 2.2 3.7 5.0 ' 5.0 7.2 8.5 5.6 4.9 24 + 5.0 6.2 5.6 5.1 8.2 8.0 15.0 6.9 Non-numeric response 5.0 3.5 3.2 3.0 3.9 6.7 4.9 4.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1245 782 1302 1252 852 558 620 6611 Median age 16.4 17.1 18.3 18.6 18.8 18.7 20.0 18.4 Marriage Between Relatives One of the most salient aspects of marriage patterns in Pakistan is the frequency of marriage between blood relatives (i.e., consanguineous marriages). There is some evidence that cousin marriage may affect both fertility and the health of children. For example, Bittles et al. (1992) found that unions between close biological relatives in Pakistan were characterised by higher fei'cility as well as higher mortality among the offspring of such marriages. Shami and Zabida (1982) found significantly higher pregnancy wastage and longer first birth intervals in consanguineous marriages. Data on marriage between relatives are shown in Table 7.6 and Figure 7.1. It should be noted that such data have not previously been available for Pakistan at the national level. The PDHS presents documented evidence of the widespread prevalence of cousin marriage in Pakistan. Sixty-one percent of all marriages are consanguineous unions between first or second cousins; this is one of the highest rates reported anywhere in the world (Bittles 1990; Bittles et al. 1991). First cousin marriages occur more frequently on the father's side (30 percent), but are also common on the mother's side (21 percent). There is a negative association between current age and marriage between relatives. The incidence of consanguineous marriage is higher among younger couples than older ones. More specifically, women age 35 and above am more likely to have married nonrelatives than women under age 35. It appears, therefore, that the tr~itional pattern of cousin marriage continues to be adhered to on a wide scale. 1 The continued popularity of cousin marriage may be related to the increasing size of dowries. Some parents may not be able to afford a large dowry, but if a daughter marries her cousin, the size of the dowry may be smaller and the dowry can be kept within the family. Further investigation of this phenomenon is needed. t It should be noted, however, that the greater proportion of consanguineous marriages among younger women may partially reflect the fact that such marriages me more common for women who many at younger ages. The percentage of consanguineous maniages for the younger age cohorts may decline over time as more women in those cohorts get married. 89 Table 7.6 Marriage between relatives Percent distribution of ever-married women by relationship to their husbands, according to background characteristics, Pakistan 1990-91 First cousin Background Father's Mother's Second Other Not characteristic side side cousin relation related Missing Total Number Age 15-19 31.4 24.6 11.8 1.9 30.2 0.1 100.0 428 20-24 34.9 21,2 8.4 1.0 34.6 -- 100.0 1059 25-29 30.6 20.2 10.5 0.9 37.6 0.1 100.0 1494 30-34 27.8 21.1 13.7 1.1 35,8 0.6 100.0 1187 35-39 26.5 20.6 I0.2 1.7 40.9 0.1 100.0 981 40-44 29.2 18.9 11.2 2.6 38.1 -- 100.0 844 45-49 27.2 19.2 10.9 1.7 41.0 -- 100.0 617 Age at marriage < 15 33.8 22.2 8.7 1.1 33,9 0.4 100.0 1245 15 36.1 21.2 13.2 1.8 27.5 0.2 100.0 782 16-17 30.2 23.1 10.3 0,9 35.3 0.1 100.0 1302 18-19 28.2 17.3 11.7 1,0 41.8 -- 100.0 1252 20-21 28,7 19.7 9.l 2,4 39.8 0.2 100.0 852 22-23 26.1 19.1 9.8 1.8 43.1 -- 100.0 558 24 + 20.3 20.7 15.6 1.7 41.8 -- 100.0 620 Residence Total urban 22.8 18.2 10.3 1.8 46.7 0.3 100.0 2019 Major city 21.0 16.6 9.2 2,0 50.8 0.5 100.0 1151 Other urbm~ 25.2 20.3 11,8 1,5 41.2 -- 100.0 868 Rural 32.8 21.6 11.2 1.3 33.0 0.1 100.0 4592 Province Punjab 29.8 23.2 10.9 1.4 34.6 0.2 100,0 3948 Sindh 33.3 16.4 9.9 1.4 38.8 0.2 100.0 1529 NWFP 22.1 16.2 12.7 1.2 47.8 -- 100.0 878 Balochistan 33,9 20.5 10.8 2.7 31.6 0.4 100.0 255 Education level attended No education 31.2 21.3 10.6 1.4 35.4 0.1 100.0 5237 Primer/ 29.7 19.2 14.4 1,g 34.7 0.3 100.0 601 Middle 23.1 20.0 10.0 1.5 45.3 -- 100.0 288 Secondary + 18.0 14.5 10.8 1.3 55.1 0.3 100.0 485 Total 29.7 20.6 10.9 1.4 37.2 0.2 100.0 6611 -- Less than 0.05 p~rcent Women who marry at an early age are more likely to marry cousins. For example, cousin marriages were contracted by 67 percent of women who got married before age 16 compared to 57 percent of women who got married at age 1 g or above. There is also a clear relationship between residence and consanguinity. Women residing in major urban areas are least likely to have married a cousin, and those living in rural Pakistan are most likely to have done so. The difference is more pronounced for marriage with a cousin from the father's side, indicating stronger adherence to the traditional marriage pattern in rural areas. Rural residents may also have a greater desire to keep the dowry on the father's side of the family. Consanguineous marriages are relatively less popular in NWFP, although even in that province a majority of women marry a close relative. 90 Figure 7.1 Marriage Between Relatives and Between Nonrelatives among Ever-Married Women 15-49, Pakistan and Major Cities First Cousin Fether' l 81de 30~ Firet Cousi~ Mother's 81de aecofld Cousin 91 Other Relative Othor Rslstivo 1% Nonrelstive aT~ Pakistan First Cousin Father's Side 21% .__nrsletive 51% Major Cities PDHS 1990-91 As expected, more educated women tend to marry nonrelatives more often than women with no education. In fact, women with a secondary or higher education and those living in major cities are more likely to marry a nonrelative than a relative. These results are supported by the findings of a survey in Karachi which found that women who were educated or employed were less likely to have married relatives (Sathar and Kazi 1988). With the exception of the pattern across age groups, which reflects a trend toward more consanguineous unions over time, all other factors indicate that more modem women are less likely to enter consanguineous unions. Women who marry later, those who are exposed to urban influences and those who are more educated are less likely to marry relatives. Polygyny Another factor which has thus far been undocumented is the extent of polygynous marriages in Pakistan. Polygyny is legal in Pakistan, although according to the Muslim Family Laws Ordinance promulgated in 1961, the husband needs to obtain written permission from his first wife to marry a second wife. Even though polygyny is legal, less than five percent of currently married women reported that their husbands had more than one wife (Table 7.7). Only 0.2 percent of women reported that their husbands had more than two wives (data not shown). The prevalence of polygynous marriages is low in all groups, with the highest proportion found in the 45-49 age group, especially in rural areas. Among the provinces, polygynous unions are most common in Balochistan (12 percen0 and least common in Punjab (3 percent). Not surprisingly, female education shows a negative association with polygyny, but an erratic pattern is evident in some age groups due to the small number of cases. 91 Table 7.7 Polygyny Percentage of em'rently married women in a polygynuns union, by age and selected background characteristics, Pakistan 1990-91 Age Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Total urban 2,1 2.5 3.2 2.3 3.3 4.1 2.3 2.9 Major city 2.1 2.7 2.9 1.9 3.1 4.0 0.7 2.6 Other urban 2.1 2.1 3.7 2.8 3.6 4.1 3.9 3.2 Rural 3.7 4.1 5.0 4.8 5.2 3.9 11.4 5.2 Province Punjab 1.6 2.4 1.1 2.6 3.4 1.7 7.7 2.6 Sindh 8.6 6.0 7.5 7.6 5.0 7.3 6.2 6.8 NWFP 2.5 3.8 9.0 3.5 7.4 8.0 11.8 6.6 Balochistan 7.3 7.1 17.6 5.6 7.6 10.3 27.2 12.1 Education level attended No education 3,5 4.3 5.3 4.5 4,5 3.8 9,2 4.9 Primary 0.8 2.0 2.5 2.1 10.2 4.7 6.3 3.7 Middle -- 2.7 1.1 1.1 -- 3.9 6.5 1.7 Secondary + 10.5 -- 1.7 3.2 0.7 5.6 -- 2.3 Total 3.4 3.6 4.5 4.0 4.5 3.9 8.7 4.5 Number 418 1041 1452 1147 932 803 572 6364 -- Less than 0.05 percent 7.2 Breastfeeding and Postpartum Infecundibility Breastfeeding has a negative effect on fertility through the mechanisrn of lactational infecundibility. Since the majority of women in Pakistan have traditionally breasffed their children for fairly long periods of time, lactational infecundibility has helped to keep fertility in check. Declines in the period of lactation in Pakistan would lead to shorter birth intervals and to an increase in fertility unless other factors compensate for its effects. Brenstfeeding The PDHS provides an oppommity to assess whether the prevalence and length of breastfeoding are declining in Pakistan. More than half (57 percent) of children under three years of age were being breasffed at the time of the survey (see Table 7.8). More than 80 percent of children were being breastfed during the first year of their lives. In the second year of life, breastfeeding declines rapidly, but 42 percent of children were still being breastfed in the last two months of their second year of life, On average, Pakistani mothers breasffeed their children for 20 months, which is slightly less than the mean duration of 22 months estimated in the 1975 PFS for surviving children (Shah 1984). Breasffeeding is usually supplemen~l at an early age 92 less than 30 years of age have a median duration of amenorrhoea that is four months shorter than older women. Rural women have a median duration that is twice as long as urban women. Education is negatively associated with the duration of amenorrhoea: women with at least some secondary education have a median duration of amenorrhoea of 3.1 months compared to 7.9 months for women with no education. Table 7.9 also shows wide differentials for provinces. Women in Sindh and Balochistan experience only five months of amen- orrhoea, while the median is six months in Punjab and nine months in NWFP. For postpartum abstinence, there are only small differences in the median values, and the differentials in insusceptibility follow closely the pal- tern of differentials in amenorrhoea. Two indicators of the termination of exposure to the risk of childbearing are shown in Table 7.10. The first indicator concerns fecundity as measured by evi- dence of menopause. The lack of a menstrual period for six months among women who are neither pregnant nor postpartum amenorrhoeic is taken as evidence of meno- pause and therefore infecundity. Only two percent of women in their thirties have already reached meno- pause. By the mid-forties (age 44-45), nearly one-quar- ter of women are menopausal and the proportion in- creases rapidly in the late forties. The second indicator is a crude measure of infertility, based on the number of women who have not Table 7.10 Termination of exposure to the risk of pregnancy Indicators of menopause and infertility among cur- rently married women 30-49 years of age, by age, Pakistan 1990-91 Age Menopause I Infertility 2 30-34 1.7 15.3 35-39 2.1 22.8 40-41 10.1 42.0 42-43 12.8 49.6 44-45 22.8 64.4 46-47 41.1 67.3 48-49 60.8 85.6 Women 30-49 11.8 34.8 1Percentage of non-pregnant, non-amenorrhoeic currently married women whose last menstrual period occurred six or more months preceding the survey or who report that they are menopausal. 2Percentage of currently married women in their first union of six or more years' duration, never having used contraception, who did not have a birth in the six years preceding the survey and who are not pregnant. had a birth in the six years preceding the survey and who were not pregnant at the time of the survey. Since the survey does not include a complete history of marriage and contraceptive use, the figures are based only on women in their first union of six or more years' duration who have never used contraception. Even in their early thirties, nearly one in every six of these women is estimated to be infertile. The infertility rate rises rapidly for women in their forties, from 42 percent of women age 40-41 to 86 percent of women age 48-49. By age 44-45, nearly two-thirds of women are estimated to be infertile. 95 REFERENCES Bittles, Alan H. 1990. Consanguineous Marriage: Current Global Incidence and its Relevance to Demographic Research. Research Report No. 90-186. Population Studies Center, University of Michigan, Ann Arbor. Bittles, Alan H., Jonathan C. Grant and Sajjad A. Shami. 1992. Consanguinity, Reproductive Health and Mortality in Pakistan. Paper presented at the annual meeting of the Population Association of America, 30 April - 2 May 1992, Denver, Colorado, Bittles, Alan H., William M. Mason, Jennifer Greene and N. Appaji Ran. 1991. Reproductive Behavior and Health in Consanguineous Marriages. Science 252:789-794. Karim, Mehtab S. 1990. Proximate Determinants of Fertility in Pakistan: Policy Recommendations. In United Nations Fund for Population Activities, South Asia Study of Population Policy and Programmes: Pakistan. Islamabad: UNFPA. Khan, Zubaida. 1991. Are Breastfeeding Patterns in Pakistan Changing? Pakistan Development Review Vol.30, No.3. National Institute of Health [Pakistan]. 1988. National Nutrition Survey: 1985-87 Report. Islamabad: Nutrition Division, Government of Pakistan. Sathar, Zeba A. 1984. Intervening Variables. In Fertility in Pakistan: A Review of Findings from the Pakistan Fertility Survey, ed. lqbal Alam and Betzy Dinesen, 113-122. Voorburg, Netherlands: International Statistical Institute. Sathar, Zeba and S. Kazi. 1988. Productive and Reproductive Choices of Metropolitan Women: Report of a Survey in Karachi. Islamabad: Pakistan Institute of Development Economics. Sathar, Zeba A., Syed Mubashir Ali and G. Mustafa Zahid. 1984. Socio-Economic and Demographic Characteristics of the Population of Pakistan: Findings of the Population, Labour Force and Migration Survey 1979-80. Studies in Population, Labour Force and Migration, Project Report No. 8. Islamabad: Pakistan Institute of Development Economics. Shah, lqbal. 1984. Socio-economic Differentials in Breasffeeding. In Fertility in Pakistan: A Review of Findings from the Pakistan Fertility Survey, ed. Iqbal Alam and Betzy Dinesen, 123-147. Voorburg, Netherlands: International Statistical Institute. Shami, S.A. and Zahida. 1982. Study of Consanguineous Marriages in the Population of Lahore, Punjab, Pakistan. Biologia 28(1):1-15. 96 CHAPTER 8 FAMILY SIZE PREFERENCES Syed Mubashir All and Abdul Razzaque Rukanuddin This chapter examines women's preferences concerning family size and the gender of their children. The analysis is based on responses of ever-married women of reproductive age to questions about: (a) whether the respondent wants more children, and if so, how long she would prefer to wait before the next child, and (b) if she were to start afresh, how many children she would want. Pregnant women were asked about their desire for additional children after the one they were expecting; thus, they were treated as if they had already reached the next parity. In order to ascertain the extent of sex preference, two additional questions were asked. One gathered information on the preferred sex of the next child and the other on the ideal number of children by sex. Two other issues examined were the frequency of unwanted or mistimed births and the effect that the prevention of such births would have on fertility rates. Answers to these questions provide an assessment of the need for family planning services. Do family size preferences play an important role in accounting for actual reproductive behaviour? Demographers differ on the empirical application of this attitudinal construct. Although some have agreed that these responses are useful in predicting future fertility in developed countries, they believe that the responses may not be meaningful in developing countries (Hauser 1967; Lightboume and MacDonald 1982; Westoff and Ochoa 1991). The critics argue that the responses to questions on fertility preferences reflect unformed, ephemeral views which are held with little conviction. Moreover, they believe that the responses do not take into account the effect of social pressures or the attitudes of other family members, particularly the husband, who may exert a major influence on reproductive decisions, In Pakistan, where the contraceptive prevalence rate is still low (12 percent) and other social pressures, particularly from the woman's husband and mother-in-law apparently have an influence on reproductive decisions, the criticisms may hold true to some extent. However, a comparison of husbands' and wives' attitudes about family size in the PDHS showed that their responses are quite similar (see Chapter 12). Moreover, many demographers are of the opinion that the responses to the questions on fertility preferences could be of practical value provided the questions are correctly framed and presen~l (Gay 1971; Ware 1974). Farooq (1981) suggests that in developing countries where the contraceptive prevalence rate is low, observed fertility may not reflect the actual demand for children, but family size preferences would. 8.1 Desire for Children This seclion examines the potential need for contraceptive services for spacing as well as limiting births. Such a need is ascertained by the responses of currently married women who want either to space their next birth or to cease childbearing altogether. The majority of currently married women want to stop having children or want to delay the next birth (see Table 8.1 and Figure 8.1). This indicates that there is a general awareness of the need to regulate the level of fertility and a willingness to do so. More than one-third (36 percent) of women reported that they wanted no more children at all in the future. An additional 18 percent said that they wanted to wait at least 97 Table 8.1 Fartilit,/ preferences by number ofl ivingehildren Percent distribution of currently married women by desire for more children, according to number of living children, Pakistan 1990-91 Number of living children I Desire for more children 0 1 2 3 4 5 6 7+ Total Have another soon 2 77.8 38.4 27.3 19.0 12.8 7.6 5,3 3.1 22.5 Have another later s 7.2 40.9 32.9 23.4 14.2 8.4 4.8 1.9 17.6 Another undecided when 4 -- 1.4 3.2 1.7 1.4 0.4 0.4 0.5 1.2 Undecided 4.6 4.7 1.0 2.3 1.7 2.4 1.4 0.5 2.3 Up to Allah 4.4 8.1 15.2 14.7 15.8 14.7 15.0 14.8 13.1 Want no more 1.6 3.8 15.6 33.8 46.6 58.9 62.4 66.4 36.4 Sterilised . . . . 1.0 1.9 5.0 4.4 8.7 7.8 3.6 Declared infecund 4.1 2.5 3.2 3.0 2.0 3.2 2.1 4.8 3.1 Missing 0.2 0.2 0.5 0.1 0.5 0.3 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 602 880 830 910 883 694 601 963 6364 -- Less than 0.05 percent llncludes current pregnancy 2Wants next birth within two years 3Wants next birth after two or more years 4Includes timing up to Allah and other non-numeric responses two years before having another child. In other words, a majority of women can be considered to be potentially in need of family planning services. Only 23 percent of women wanted another child within two years. Moreover, 13 percent indicated that the decision was "up to Allah." An analysis of the 1984-85 PCPS (data not shown) indicated a pattern of preferences similar to that found in the 1990-91 PDHS. The continuing importance accorded to childbearing in Pakistan is evident from the PDHS data. Among all childless women, 85 percent definitely want children and nine-tenths of the women desiring children want a child within two years. However, the proportion who want another child within two years drops sharply to 38 percent for women already having one child. Thereafter, the desire to bear additional children within two years decreases gradually as the number of living children increases. As shown in Table 8.1 and Figure 8.2 the proportion of women who do not want more children was strongly associated with the number of living children. Although large family size norms continue to prevail in Pakistan, about one-half (52 percent) of women at parity four and almost three-quarters (71 pcrccnt) of women at parity six want to stop childbearing, t t These figures include sterilised women who make up 5 percent of women at parity four and 9 percent of women at parity six. 98 Figure 8.1 Fertility Preferences among Currently Married Women 15-49 Sterllleed 4% Undecided 2% ~en 1% Declared Infecund 3% PDHS 1990-91 Figure 8.2 Fertility Preferences among Currently Married Women 15-49 by Number of Living Children Percent 100 80 60 40 20 0 0 1 2 3 4 5 6 7+ Number of Living Children Want Soon ~ Want to Watt U Undecided Wlln! No more ~ Infecund ~ SterHiaed U U~ Io Allah I I W.n,/On.°r. Wh.n I I PDHS 199D-91 99 A fatalistic approach to childbearing is evident among a small minority of women. About 13 percent of women stated that the decision about whether or not to have another child is up to Allah. Only two percent of women are undecided about having another child. Therefore, a large majority of women were able to estimate their preferences with regard to future childbearing. Table 8.2 presents the percent distribution of currently married women by their desire for children according to age. Since age and the number of living children are highly correlated variables, future fertility preferences by age closely follow the pattern already observed between future fertility preferences and the number of living children in Table 8.1. Table 8.2 Fertility preferences by age Percent distribution of currently married women by desire for more children, according to age, Pakistan 1990-91 Age of woman Desire for more children 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Have another soon I 43.0 34.3 26.7 23.9 12.5 10.5 6.0 22.5 Have another later 2 35.7 35.8 24.5 13.6 7.0 1.8 1.1 17.6 Another undecided when 3 0.9 1.6 1.4 1.4 1.4 0.3 0.5 1.2 Undecided 7.6 2.2 3.1 1.8 1.2 0.9 0.8 2.3 Up to Allah 8.9 11.2 15.5 16.2 13.3 10.8 10.0 13.1 Want no more 3.3 11.7 26.2 37.9 55.1 62.0 61.8 36.4 Sterilised 0.5 0.9 2.8 8.1 8.0 6.8 3.6 Declared infecund 0.5 2.4 1.7 2.1 1.1 5.4 12.4 3.1 Missing 0.2 0.3 -- 0.3 0.3 0.2 0.5 0.2 Total 100.0 100.0 100.0 100.0 100.0 1(30.0 100.0 100.0 Number 418 1041 1452 1147 931 803 572 6364 -- Less than 0.05 percent IWants next birth within two years 2Wants next birth after two or more years ~Includes timing up to Allah mad other non-numeric responses The desire to stop having children increases with age and the desire to space births decreases with age. In other words, the potential need for family planning services is greatest among older women for limiting children and among younger women for spacing births. The total potential need is greatest for women age 35 and over. However, even among women in their twenties about half want to either stop childbearing or delay their next birth for two or more years. Table 8.3 presents the percentage of currently married women who want no more children by the number of living children and selected background characteristics. This table reveals that a higher proportion of women in urban than in rural areas want no more children (52 and 35 percent respectively). This differ- ential becomes more prominent when rural women are compared with the women living in major cities. The differential in preferences between major cities and other urban areas disappears for women with six or more children. By the time they have had six or more children, more than four of five urban women want to stop childbearing, whether they live in major cities or other urban areas. 100 Table 8.3 Desire to stop having children Pe~entage of eunently married women who want no more children, by number of living children and selected background characteristics, Pakistan 1990-91 Number of living children x Background characteristic 0 1 2 3 4 5 6 7+ Total Residence Total urban 0.8 4.5 28,7 55.0 66.4 76.8 84.7 82.3 52.3 Major city 1.0 6.5 33.2 59.3 72.1 79.5 84.8 82.2 54.3 Other urbma 0.5 2.0 20.8 49.1 58.6 73.4 84.5 82.5 49.7 Rural 2.0 3.5 10.8 27.3 44.7 57.0 64.7 70.4 34.6 Province Punjab 1.7 3.8 17.6 40.8 60.4 71.8 81.4 83.1 44.4 Sindh 1.6 3,8 15.4 33.0 39.5 54.8 62.3 63.6 35.8 NWFP 1.9 4.7 19.2 26.6 41.7 54.1 62.2 72.0 36.7 Balochistan -- 0.1 0.5 2.8 15.7 10.8 21.0 24.1 9.2 Education level attended No education 2.0 3.2 13.4 30.0 46.6 58.7 68.5 72.6 38.2 Primary -- 8.9 9,6 39.4 52.8 78.0 80.2 82,6 42.2 Middle 1.2 0.8 35.7 59.9 67.9 61.5 89.1 91.2 47.9 Secondary + 1.3 5.4 37.4 59.6 84.2 91.0 98.7 97.4 50.9 Total 1.7 3.8 16.6 35.8 51.5 63.3 71.1 74,2 39,9 Note: Women who have been sterilised are considered to want no more children. -- Less than 0.05 percent 1Includes current pregnancy Among the provinces, women in Punjab have the strongest preference to stop childbearing (44 percent want no more children), followed by NWFP (37 percent) and Sindh (36 percent). Balochi women indicated the least potential demand for fertility control, since only 9 percent said they did not want more children. There is an inverse association between educational level and the percentage of women who want no more children. While only 38 percent of uneducated women want to stop childbearing, the corresponding proportion was 48 percent for women with middle level education and 51 percent for those with secondary or higher education. These educational differentials were also evident among women classified by their existing number of children. The largest differential in percentage terms was found for women at parity four where the difference between the largest figure (for women who have secondary or higher education) and the smallest figure (for those having no education) is 38 percentage points. Even among women with no education, however, nearly half want to stop bearing children after they have had four children. 8.2 Sex Preference for Chi ldren Previous studies in Pakistan have found a strong preference for sons among married couples (Ali 1989a,b; Sathar 1987; Miller 1984; DeTray 1984). The desire to have more sons than daughters is an out- come of the value attached to sons for socioeconomic and cultural reasons. In rural areas, sons are valued for the help they provide for parents on farms. Sons in general are desired for carrying forward the family name and providing security for their parents during old age. 101 The PDHS results confirm that there is a continuing preference for sons in Pakistan (see Table 8.4). Yet nearly half of all women who want another child say that the sex of the next child does not matter to them. Among those who prefer a child of a particular sex, however, ten times as many prefer a son to a daughter. Among childless women, more than two-thirds do not have a preference about the sex of their first baby. This is consistent with the fact that social pressures in Pakistan place demands on a newly married woman to prove her fertility by producing a child, rather than specifically giving birth to a son. Among women who already have children, the proportion who desire a son for the next child increases with the number of daughters in the family. Moreover, a very strong desire for a son is observed among women with two or more children all of whom are daughters. Almost all (at least 92 percent) of these women want a son for their next birth, Among women with two or more children without a daughter, at most three-fifths (57 percent) at any parity wish for a daughter. In general, an increasingly large percentage of respondents with at least one daughter showed no preference regarding the sex of the next child as the number of sons increased. Table 8.4 Preferred sex of next child Percent distl ibution of preferred sex for the next child among currently married non-pregnant women who want another child, according to number of l iving children and sons. Pakistan 1990-91 Preferred sex Number of l iving Does not chi ldren and sorts Male Female matter Missing Total Number No chi ldren 31.7 0.2 67.6 0.5 100.0 512 One chi ld 49.5 4.3 46.2 -- 100.0 548 No sons 78.6 -- 21.4 -- 100.0 268 One son 21.6 8.5 69.9 -- 100.0 280 Two ch i l&en 47.5 l l .0 41.5 -- 100.0 417 No sons 93.0 -- 7.0 -- 100.0 105 One son 44.4 -- 55.6 -- 100.0 192 Two sons 12.7 38,1 49.2 -- 100.0 120 Three chi ldren 63.9 7,0 29.1 -- 100.0 329 No sons 91.9 -- 8. l -- 100.0 67 One son 78.7 0. l 21.2 -- 100.0 141 Two sons 34.4 5.7 60.0 -- 100.0 90 Three sorts (21.2) (57,2) (21.6) (--) (100.0) 31 Four chi ldren 62.8 6.4 30.6 0.2 100.0 193 No sons 100.0 . . . . . . 100.0 25 one son 95.4 -- 4.0 0.5 100.0 74 Two sons (44.3) (--) (55.7) (--) ( I00.0) 47 Three or more sons (9.8) (26,3) (63.8) (--) (100.0) 47 Five chi ldren 59.3 4,5 36.2 -- 100.0 175 Less than two sons 95.8 -- 4.2 -- 100.0 69 Two or three sons 46.9 3.0 50.0 -- 100.0 70 Four or more sons (13.8) (15.7) (70.5) (--) (100.0) 37 Total 49.1 5.2 45.6 0.1 100.0 2174 Note: Figmes in parentheses are based on 25 to 49 unweighted women. -- l ess than 0.05 percent 102 8.3 Need for Family Planning Table 8.5 presents estimates for the unmet, met and total need for family planning services by selected background characteristics/More than one-quarter of currently married women were found to have an unmet need for family planning services (11 percent for birth spacing and 18 percent for limiting births). Table 8.5 Need for family planning services Percentage of currentiy married women with unmet need for family planning, met need for family planning, and total demand for family planning services, by selected background characteristics, Pakistan 1990-91 Met need for Unmet need for family planning Total demand for family planning 1 (currently using) 2 family planning Percentage of Unmet Unmet Total Met Met Total Demand Demand demand Number Background need for need for unmet need for need for met for for Total saris- of Characteristic spacing limiting need spacing limiting need spacing limiting demand fled women Age 15-19 23.2 1.5 24.7 2.3 0.3 2.6 25.5 1.8 27.3 9.4 418 20-24 19.3 5.1 24.5 4.1 2.2 6.3 23,5 7.3 30.8 20.5 1041 25-29 14.5 13.4 27,9 3.1 6.5 9.6 17.6 20.0 37.6 25.6 1452 30-34 8.4 20.6 28.9 2.2 11.2 13,4 10.6 31.7 42.3 31.6 1147 35-39 5.0 30.1 35.1 0.8 19.6 20.4 5.8 49.7 55.5 36.7 931 40-44 1.6 30.8 32.4 0.1 15.7 15.8 1.7 46.5 48.2 32.8 803 45-49 0.5 17.2 17.8 -- 11.8 11.8 0.5 29.1 29.6 40.0 572 Residence Total urban 11.3 18.0 29.3 4.8 20.9 25.7 16.1 39.0 55.1 46.7 1930 Major city 11.0 17.5 28.5 6.8 24.2 31.0 17.8 41.6 59.5 52.1 1098 Other urban 11.7 18.8 30.5 2.1 16.7 18.8 13.8 35.5 49.3 38.2 832 Rural 10.1 17.3 27.5 0.9 4.9 5.8 11.0 22.3 33.3 17.4 4434 Province Punjab 11.4 19.0 30.5 2.2 10.9 13.0 13.6 29.9 43.5 29.9 3768 Sindh 9.0 14.9 23.9 2.8 9.7 12.4 11.7 24.6 36.3 34.2 1486 NWFP 10.1 19.4 29,6 0.7 7.8 8.6 10.9 27.2 38.1 22.5 856 Balochistan 6.2 5.1 11.4 0.9 1.1 2.0 7.1 6.2 13.3 14.9 254 Education level attended No education 9,6 18.3 27.8 0.8 6.9 7.8 10.4 25.2 35.6 21.8 5044 Primary 15.2 14.9 30.1 3.4 14.4 17.8 18.6 29.3 47.8 37.2 573 Middle 15.8 15.0 30.8 7.6 21.9 29.5 23.4 36.9 60.3 48.9 279 Secondary+ 11.3 14.8 26.1 10.2 27.8 38.0 21.5 42.6 64.0 59.3 468 Total 10.5 17,6 28.0 2.1 9.8 11.8 12.5 27.3 39.9 29.7 6364 -- Less than 0.05 percent IUnmet needfor spacing refers to: pregnant women whose pregnacy was misrimed, amenorrhoeic women whose last birth was mistimed, and women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and who say they want to wait two or more years for their next birth. Unmet need for limiting refers to: pregnant women whose pregnancy was unwanted, amenorrboeie women whose last child was unwanted, and women who are neither pregnant nor amenorrhoeie and who are not using any method of family planning and who want no more children. Excluded from the category of unrnet need ate menopausal and infertile women, defined in foomotes 1 and 2 in Table 7.10. "Met need for spacing refers to: women who axe using some method of family planning and who say they want to walt two or more years for their next child. Met need for limiting refers to: women who are using a method and who want no more children. 2 See the footnotes for Table 8.5 for definitions of the concepts used in this section. 103 Those who were practicing family planning methods (12 percent of currently married women) were considered to have a met need for family planning. Among these women only two percent were practicing family planning for spacing purposes. Assuming that the women's intentions are true, the contraceptive prevalence rate could be increased to 40 pement if all women in need of family planning services actually used contraception. Presently, less than one-third of the stated need is being met. The overall unmet need for family planning increases with age up to age 35-39 and decreases thereafter. The unmet need for spacing of births was highest among younger women, whereas the unmet need for limiting births was highest among women age 35-44. Younger women were least likely to have their need for family planning services satisfied. Only 9 percent of currently married women age 15-19 had their demand for family planning services satisfied, compared to 40 percent of women age 45-49. The unmet need for family planning is nearly the same in urban and rural areas, but urban-rural differentials are quite pronounced for current use of contraception. This results in large differentials by place of residence in the percentage of demand that is satisfied. More than half of the overall demand for family planning is satisfied in major cities compared to only 17 percent of demand in rural areas. The largest proportion of women with beth met and unmet need live in Punjab Province. In contrast, women in Balochistan revealed a minimal need for family planning services, primarily because they are less motivated to curtail childbearing. The level of unmet need for family planning varies little among women in various education categories. But the number of women using family planning services increases sharply with the level of education. 8.4 Ideal Family Size In the PDHS, the ideal family size is estimated from responses to two questions. Women who had no children were asked, "If you could choose exactly the number of children to have in your whole life, how many would that be?" For women who had children, the question was rephrased as follows: "if you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?" Although many women found this type of hypothetical ques- tion difficult to answer, the results are informative. Table 8.6 presents the distribution of ever-married women by their ideal number of children and parity. Iluee-fiflhs of women stated that the number of children that is ideal for them is up to Allah. The magnitude of such responses is unprecedented in previous national demographic surveys in Pakistan and is also high compared to the results of DHS surveys conducted in 30 other countries so far. It is not in the scope of this report to present a thorough investigation of the causes of the high proportion of such responses. However, there am a number of possible explanations. The question on ideal family size (particularly for women who already had children) is phrased in such a manner that the respondent is required to perform the difficult task of thinking abstractly and independently of her actual family size. In view of the high level of illiteracy among women, such questions may be difficult for many women to answer. Older women with many children may be reluctant to mention a smaller family size as an ideal for fear that some of their existing children may die. In fact, in Table 8.6 a larger percentage of women with large families were found to leave the decision up to Allah in response to the question on ideal family size. This finding may also be associated with cultural conservatism among older women. 104 Table 8.6 Ideal number of children Percent distribution of ideal nmnbex of children among evar-married women, and mean ideal number of children for ever-married women (EMW) and for currently married women (CMW), Be.cording to number of living children, Pakistan 1990-91 Nomber of living children t Ideal number of children 0 l 2 3 4 5 6 7+ Total 0 0.3 -- 0.2 . . . . . . . . 0.1 1 -- 0.4 0.7 0.3 0.2 . . . . 0.2 2 7.2 7.4 10.1 3.9 3.7 3.5 3.8 1.4 5.1 3 6.6 8.8 7.5 13.9 3.2 4.8 4.5 3.3 6.7 4 16.9 17.3 19.8 18.9 26.7 13.8 15.4 13.7 18.0 5 3.9 3.1 3.1 2.9 3.6 7.4 2.5 2.9 3.6 6 2.3 2.4 2.3 2.1 4.2 3.7 7.7 3.9 3.5 7+ 2.9 1.8 1.4 1.9 1.3 0.9 1.6 3.9 2.0 Up~ ~I~ 58.5 58.1 54.6 55.7 56.4 65.5 64.3 69.8 60.2 Other non-num~c 1,3 0.7 0.3 0.4 0.6 0.5 0.2 0.9 0.6 Total 100.0 100.0 1(30.0 100.0 100.0 100.0 100.0 1130.0 100.0 Nombcr 640 928 870 947 907 709 620 990 6611 EMW mean ideal 3.9 3.9 3.6 3.8 4.2 4.2 4.4 4.8 4.1 Ever-married women 257 382 392 415 390 242 220 289 2587 CMW mean ideal 4.0 3.9 3.6 3.8 4.2 4.2 4.4 4.8 4.1 Currently mwried women 249 368 379 405 386 236 213 283 2519 Note: Memas are calculated excluding women giving non-numeric responses. -- Less than 0.05 percent 1Includes current pregnancy Among women who gave a numerical answer for their ideal family size, the ideal number of children for both ever-married and currently married women is 4.1 children, on average. The average ideal number of children and the actual number of children ever born (CEB) are found to be identical in the PDHS (see Table 4.8 for the average CEB). The average ideal family size is considerably smaller in the PDHS than in previous surveys: 1984-85 PCPS (4.9 children), 1979-80 PLM (4.6 children), and 1975 PFS (4.2 children) [Ali 1989a]. The smaller ideal family size reported in the PDHS, compared to the PCPS, is consistent with the observed decline in the estimated I~R between the two surveys. Women with fewer than four children had a smaller number of children than their ideal number, whereas the pattern is the opposite for women at parity four or more. Overall, 18 percent of women consider four children as the ideal family size. This was the most popular family size expressed by women at every parity. Table 8.7 presents the mean ideal number of children for ever-married women by age group and selected background characteristics. The average ideal number of children shows only a small increase with increasing age. The ideal number of children is lower in urban areas (3.7 children) than in rural areas (4.3 children), and is lowest in major cities (3.6 children). An inverse association exists between the ideal number of child~n and the educational level of women. 105 Table 8.7 Mean ideal number of childran Mean ideal number of childa'an for ever-married women by age and selected background characteristics, Pakistan 1990-91 Age of woman B~ck~o~md charaetea'istic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Total urban 3.4 3.5 3.5 3.9 3,8 4.1 4,3 3.7 Major city (3.3) 3.3 3.4 3.6 3.7 4.0 4.1 3.6 Other urban (3.6) 3.7 3.7 4.2 4.1 4.5 (4.7) 4.0 Rural 4.2 4.1 4.4 4.3 4.4 4.7 4.6 4.3 Province Punjab 4.1 3.8 3.8 4.1 3.9 4.2 4.5 4.0 Sindh (3.5) 3.6 4.0 3.8 4.1 5.0 (4,2) 4.0 NWFP (3.8) 4.1 4.2 4.8 4.3 4.8 4.1 4,3 Balochistan * (5.4) 6.3 (6.7) (7.5) * * 6.3 Education level attended No education 4.1 4.0 4.2 4.3 4.2 4.8 4.6 4.3 Primary (4.2) 3.8 4.4 4.0 (3.8) (4.3) * 4.0 Middle * 3.4 3.5 (3.9) (3.7) * * 3.6 Secondary + * 3.2 3.3 3.5 3.5 3.4 (4.2) 3.4 To~ 3.9 3.8 4.0 4.1 4.0 4.5 4.4 4.1 Note: Means are calculated excluding women giving non-numeric responses. Figures in parentheses are based on 25 to 49 unweighted cases. *Based nn fewer than 25 unwalghted cases, mean number not shown. The most prominent departure from the average ideal number of children nationwide is found in the province of Balochistan. The average ideal family size for women in Balochistan (6.3 children) is over two children greater than the national average. A somewhat similar pattern was observed in the 1984-85 PCPS. 8.5 Fertility Planning In this section, responses to the question, "At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later or did you want no more children at all?" pave the way for a more direct assessment of the extent of excess fertility and the desire for spacing. This question was asked about every child born in the preceding five years and about the forthcoming expected child for women who were pregnant at the time of survey. Measures based on these questions, however, are not free of limitations. The respondent is required to recall accurately her wishes at one or more points in the last five years and to report them honestly, which may be affected by memory lapse. There is also a danger of rationalization since it is common for an unwanted conception to become a cherished child. Overall, more than three-fourths of the births were wanted at the time the women became pregnant (see Table 8.8). An additional 13 percent were not wanted at all and eight percent were reported to have occurred earlier than desired. First order births were found to be largely wanted when they occurred. A lack 106 Table 8.8 Planning status of births Percent distribution of births (including current pregnancy) in the five years preceding the survey by fertility planning status, aeonrding to birth order and mother's age at the time of birth, Pakistan 1990-91 Planning status of birth Birth order Number and mother's Wanted Wanted Not of age then later wanted Missing Total births Birth order 1 1 94.1 1.9 0.3 3.7 100.0 1366 2 85.2 10.0 2.6 2.2 100.0 1227 3 81.0 12.6 4.3 2.1 100.0 1101 4 78.9 11.8 8.1 1.2 100.0 964 5 72.9 9.4 16.6 1.1 100.0 833 6 66.5 7.9 23.9 1.8 100.0 622 7+ 51.8 7.2 38.2 2.8 100.0 1366 Mother's age <20 90.5 4.8 1.6 3.2 100.0 832 20-24 84.4 9.7 3.5 2.5 100.0 2205 25-29 77.7 10.2 9.9 2.2 100.0 2049 30-34 67.7 7.6 22.5 2.3 100.0 1365 35-39 60.7 5.8 32.1 1.5 100.0 655 4044 49.5 6.2 43.4 0.9 100.0 307 4549 49.6 7.4 41.6 1.4 1130.0 65 Total 76.4 8.4 13.0 2.3 100.0 7479 1Includes current pregnancy of awareness and limited availability of family planning services could be responsible for an increase in the incidence of mistimed births after the first birth. The proportion of births not wanted at all surpasses the proportion that were mistimed at the fifth and higher birth orders. A similar pattern of unwanted and mis- timed pregnancies is evident for women in different age groups. For women in their thirties, less than two-thirds of pregnancies were desired at the time they occurred. This figure drops below half for women in their forties. More than 40 percent of pregnancies to women in their forties were not wanted at all. These results confirm that there is a substantial unmet need for family planning services in Pakistan. Table 8.9 presents a comparison between the wanted total fertility ram and the actual total fertility rate (TFR) by background characteristics. The wanted 'I'I~R is calculated in exactly the same manner as the conventional TFR, except that births classified as unwanted arc omitted from the numerator. A birth is con- sidered unwanted if the number of living children at the time of the pregnancy was greater than or equal to the ideal number of children at the time of the survey, as reported by the respondent: Thus, the wanted "I'I-R 3 It is assumed that a birth was wanted if the mother's ideal number of children at the time of the sm~ey was less than the number of living children at the time of the pregnancy or if she gave a non-numeric reslgmse (e.g., "up to Allah") to the question on ideal number of children. 107 can be interpreted as the total number of wanted births a woman would bear in her reproductive span if she experienced the wanted age-specific fertility rates prevailing for the past six years. "Wanted fertility rates" express the level of fertility that theoretically would result if all unwanted births were prevented. A com- parison of the conventional "l'l-R with the wanted TFR indicates the potential demographic impact of prevent- ing unwanted births. The wanted TFR was 4.7 children per women for Pakistan as a whole, but it exceeded 5 in rural areas and in Balochistan. The wanted TI-R was particularly low (3.3 to 3.6) in Kamchi and other major cities. Education is strongly related to the wanted I~R. Wom- en with a primary school education have a wanted t~R that is 1.3 children lower than that of women with no education. Overall, the wanted "I'I-R was 0.7 children or 12 percent lower than the actual TFR. Given the fact that only a small number of births were considered un- wanted, the wanted'l'~R remained quite high---a pattern consistent with the large family size norm prevalent in the country. The differences between the actual'lt~R and the wanted TPR were highest for the major cities, implying the prevalence of substantial unwanted fertility in those areas. Major cities also had the highest proportion of women who wanted no more children (see Table 8.3). Although a relatively greater number of educated wom- en live in major cities, where contraceptive services are more available, use of family planning has still not closed the gap between the number of children women are having and their ideal family size. Table 8.9 Wanted fertility rams Total wanted fertility rates and total fertility rates for the six years preceding the survey by selected background charactaristics, Pakistan 1990-91 Total wanted Total Background fertility fertility characteristic rate rate Residence Total urban 3.8 4.9 Major city 3.3 4.7 Other urban 4.5 5.2 Rural 5.1 5.6 Province Punjab 4.8 5.4 Sindh 4.4 5.1 Karachi 3.6 5.0 NVeFP 4.9 5.5 Balochistan 5.7 5.8 Education level attended No education 5.1 5.7 Primary 3.8 4.9 Middle 3.4 4.5 Secondary + 2.9 3.6 Total 4.7 5.4 Note: Rates are based on births to women 15-49 in the period 1-72 months preceding the survey. The total fertility rates are the same ~ those presented in Table 4.4. The difference between the two measures was of almost the same magnitude in all provinces except Balochistan, where the difference was negligible. By education group, women with a primary or middle level of education had the highest differentials. 108 REFERENCES Aft, S. Mubashir. 1989a. Determinants of Family Size Preferences in Pakistan. Pakistan Development Review 28(3):207-231. All, S. Mubashir. 1989b. Does Son Preference Matter? Journal of Biosocial Science 21(4):399-408. De Tray, Dennis. 1984. Son Preference in Pakistan: An Analysis of Intentions vs. Behavior. Research in Population Economics 5" 185-200. Farooq, G. M. 1981. Concepts and Measurement of Human Reproduction in Economic Models of Fertility Behavlour. World Employment Research Working Paper. Population and Labour Policies Programme Working Paper No. 102. Geneva: International Labour Organisation. Gay, J. 1971. Mathematics andLogic in Kpelle Language. New York: International Publication Service. Hauser, Philip M. 1967. Family Planning and Population Programmes. Demography, Vol. 4, No. 3. Lightboume, Robert E. and Alphonse S. MacDonald. 1982. Family Size Preferences. WFS Comparative Studies No. 14. Voorburg, Netherlands: International Statistical Institute. Miller, B. D. 1984. Daughter Neglect, Women's Work and Marriage: Pakistan and Bangladesh Compared. Medical Anthropology 8(2): 109-126. Sathar, Zeba A. 1987. Sex Differentials in Mortality: A Corollary of Son Preference? Pakistan Development Review 26(4):555-568. Ware, Helen. 1974. Ideal Family Size. WFS Occasional Paper No. 13. Voorburg, Netherlands: International Statistical Institute. Westoff, Charles F. and Luis H. Ochoa. 1991. Unmet Need and the Demand for Family Planning. DHS Comparative Studies, No. 5. Columbia, Maryland: Institute for Resource Development/Macro International Inc. 109 CHAPTER 9 INFANT AND CHILD MORTALITY Tauseef Ahmed, Mansoor-ul-Hassan Bhatti and George Bicego Since independence in 1947, Pakistan has experienced steady but modest declines in rates of mortality at all ages. Yet early childhood mortality remains high. The most recent source of child survival data before the 1990-91 PDHS was the multi-round Pakistan Demographic Survey (PDS), which estimated infant mortality at 110 per thousand live births for the 1984-88 period. The PDHS provides an opportunity to examine infant and child mortality in more detail. Such information is important at this time because of recent efforts by the health sector in Pakistan to address the health problems of infants and young children. Major areas of child survival intervention include: (1) control of diarrhoeal disease, (2) management of acute respiratory infection, (3) the Expanded Programme on Immunisation (EPI), and (4) nutrition. Careful examination of changes in the level of infant and child mortality is essential in assessing whether and to what extent such efforts have been effective. This chapter focuses on levels, trends, determinants and differentials in the mortality of infants and children under the age of five. An analysis of high-risk fertility behaviour is also presented. 9.1 Definitions of Infant and Child Mortality All female respondents were asked to provide a complete birth history, including the sex, birth date, survival status, and current age or age at death for each live birth. These data were used to calculate the following direct estimates of infant and child mortality, 1 for three six-year periods (0-5, 6-11, and 12-17) preceding the survey: Neonatal mortality: the probability of dying in the first month of life; Postneonatal mortality: the difference between infant and neonatal mortality; Infant mortality (lq,): the probability of dying before the first birthday; Child mortality (4ql): the probability of dying between the first and fifth birthday; Under-five mortality (sq0): the probability nf dying before the fifth birthday. i A detailed description of the method for calculating the probabilities presented here is given in Rutstein (1984). The mortality estimates are not rates, but are true probabilities, calculated according to the conventional life table approach. For any calendar period, deaths and exposure in that period are first tabulated for the age intervals 0, 1-2, 3- 5, 6-11,12-23,24-35, 36-47, and 48-59 months. Then age interval specific probabilities of survival are calculated. Finally, probabilities of mortality for larger age segments are produced by multiplying the relevant age interval survival probabilities together and subtracting the product from one: |ffiZ÷n ,,q~, = 1-1-I (1-q~) lmZ 111 9.2 Assessment of Data Quality Rates of infant and child mortality are subject to both sampling and nonsampling errors. This section describes the results of some basic checks for various nonsampling errors; namely, underreporting of early childhood deaths (which would result in underestimates of mortality) and misreporting age at death (which may distort the age pattern of under-five mortality). Underreporting of deaths is generally more common for children who died shortly aRer birth than those who died later. If early neonatal deaths are selectively underreported, then an abnormally low ratio of deaths under seven days to all neonatal deaths and an abnor- mally low ratio of neonatal to infant moaality would be observed. If such underreporting is related to the child's sex orto the length of time preceding the survey, then the ratios would be affected in proportion to the extent of the underreporting. The ratios are given in Table 9.1. The proportion of neonatal deaths reported to have occurred during the first week of life (0-6 days) varies considerably for males, but little for females. The large jump in the ratio for males between 12-17 years before the survey and 6-11 years before the survey from 0.50 to 0.69 is unusual and suggests that male deaths during the early neonatal period may have been omitted in the earliest period. The ratio of neonatal mortality to infant mortality is comparatively stable for beth males and fe- males although further evidence in support of the notion of male omission for the earliest period is found in a slight increase in the male ratio between the two earliest periods, when the female ratio was declining. Since female neona- tal mortality is expected to be lower due to greater biological vigour at birth, it is unusual to find a smaller male neonatal/infant ratio for the earliest period. Table 9.1 Indices of early infant deaths Indices of early infant deaths by sex, for three six-year periods, pakistan 1990-91 Time period of death (years preceding survey) Index 0-5 6-11 12-17 Deaths in first 6 days/ all neonatal deaths Male 0.64 0.69 0.50 Female 0.62 0.62 0.59 Neonatal deaths/ all infant deaths Male 0.59 0.61 0.59 Female 0.55 0.55 0.60 Table 9.2 Sex differentials in infant and neonatal mortality Infant and neonatal mortality rates by sex, and sex ratios, for three six-year periods preceding the survey, Pakistan 1990-91 Time period of death (years preceding survey) Mortality 0-5 6-11 12-17 Infant mortality Male 100.9 98.5 101.6 Female 79.7 93.9 113. l Sex ratio 1.27 1.04 0.90 Neonatal mortality Male 59.0 60.2 59.4 Female 43.5 53.1 67.7 Sex ratio 1.36 1.13 0.88 Sex differentials in infant and neonatal mortality over time are presented in Table 9.2. By analysing trends in these differentials, it is possible to examine misreporting of mortality. Normally, there is an excess of male mortality during infancy, especially during the neonatal period. The decreasing ratio of male to female mortality going back in time is striking, and suggests that some early death.s of male children 12-17 years preceding the survey were not reperted? 2 On the other hand, female mortality may have been decreasing at a faster pace than male mortality, which could partially account for the unusual pattern seen here. 112 This would lead to a bias in the evaluation of trends, since mortality rates 12-17 years preceding the survey win be underestimated relative to roortality in more recent time periods. A problem common to roost retrospective surveys is heaping of age at death on "convenient" digits, e.g., 6, 12, and 18 months. This phenomenon introduces biases in rate calculation, if the net result is to shift deaths from one age segment to another. Thus, heaping at 12 months causes concern because a certain fraction of these deaths, though reported to occur after infancy (i.e., at ages 12-23 months), may have actually occurred during infancy (i.e., at ages 0-11 months). The infant mortality rate (lqo), in this case, is biased downwards and child mortality Gq~) upwards. Table 9.3 presents the distribution of deaths reported at ages 5 to 23 months by reported age at death for three six-year periods preceding the survey. Distinct "heaps" of deaths are evident at 6, 12, and 18 months of age, with corresponding deficits in the adjacent months, although heaping at 12 months occurs only during the roost recent period. Digit preference appears not to be serious enough, however, to substantially alter the rates calculated here. For instance, even if as many as half of the deaths reported at "12 months" were reassigned to the infant age segment, infant mortality would be increased and child mortality would be decreased by less than one percent for the period 0-5 years preceding the survey. More troublesome are the large number of deaths re- ported at "1 year," which results not from digit pref- erence, but from the failure of interviewers to correctly elicit and record the age at death in units of months as required by PDHS survey guidelines for deaths under two years of age? The rates reported here are not adjusted for this defect in the data----which, in effect, assumes that all "1 year" deaths occurred in the 12-23 month segment. In the unlikely event that half of these deaths actually occurred during the infant age segment, the infant mor- tality rate would be underestimated by less than five percent for each of the three six-year periods. While in- fant mortality may be slightly underestimated and child mortality overestimated, when age at death is reported as "1 year" (with no adjustment), trend evaluation will not be substantially affected, since there is no marked trend in such reporting. Unreported age at death is another potential prob- lem in data of this type; however, respondents failed to provide age at death in only 5 (0.2 percent) of the 3,016 Table 9.3 Reporting of age at death Distribution of reported deaths at age 5-23 months by age at death, for three six-year periods preeedin_g the sta'vey, Pakistan 1990-91 Time period of death (years preceding survey) Age at death (months) 0-5 6-11 12-17 5 16 28 15 6 39 38 22 7 13 21 20 8 18 17 10 9 21 9 24 10 18 21 12 11 9 9 4 12 20 7 5 13 2 0 0 14 1 3 1 15 10 4 3 16 5 0 3 17 2 1 0 18 16 17 10 19 0 0 0 20 0 0 0 21 l 0 l 22 1 0 0 23 0 0 0 1 year I 69 61 55 1Age at death reported to be 1 year was supposed to be recorded in months. 3 It can be argued that these deaths are more likely to be drawn from the 12-23 month age segment than deaths reported at "12 months," which presumably are drawn from beth older and younger ages (reflected in the deficit at 11 months). This is based on the notion that a report of "1 year" would commonly translate to having reached the first birthday (i.e., one completed year 0¢ 12-23 months). Any adj us tment procedure that would involve teas sign ing a fraction of these deaths from the post-infant to infant age segment is, thus, undertaken with a great deal of uncertainty. 113 deaths reported during the 18 years preceding the survey. In these cases, age at death was imputed using a hot-deck procedure. 4 In sum, internal consistency checks indicate that the mortality data from the PDHS are of reasonable quality, keeping in mind the sociocultural constraints prevalent in the society. However, with increasing time since the survey, there appears to be an increasing omission of neonatal deaths, especially deaths to boys. The effect of this omission will be to underestimate rates of infant mortality for less recent periods and thus reduce estimates ofmortalitydecline. Also, imprecisereportsofages atdeath, especially reports o f" l year," may introduce a small downward bias in the estimation of infant mortality and an upward bias in the estimation of child mortality. However, the evaluation of trends in the PDHS would not be affected. 9.3 Levels and Trends in Infant and Child Mortality Infant and child mortality rates for three six-year periods preceding the PDHS are shown in Table 9.4. The estimated infant mortality rate for the most recent period (0-5 years preceding the survey) is 91 per 1000 live births, with 57 percent of infant deaths occurring in their first four weeks of life. 5 Under-five mortality (sqo) has fallen 18 percent, from 143 to 117 per thousand in the period from 12-17 years to 0-5 years before the survey. Much of the estimated decline in mortality occurred between the periods 12-17 years and 6-11 years preceding the survey, with a slower rate of decline between the two most recent periods. Dis- proportionate gains were made in survival among children age 12 to 59 months (28 percent), while neonatal (19 percen0 and postneonatal (11 percent) survival have shown more modest improvements. As mentioned previously, the apparently unremarkable change in neonatal mortality may be an artifact of underreporting of neonatal deaths in less recent periods. Still, over half of infant mortality (neonatal plus postneonatal mortality) and 45 percent of under-five mortality occurs during the first month of life (see Figure 9.1). Thus, there exists considerable scope for improving child survival during infancy in Pakistan through programmes designed to improve maternal health and pregnancy outcome. Table 9.4 Infant and child mortality Infant and child mortality rates for three six-year periods preceding the survey, Pakistan 1990-91 Neonatal Postneonatal Infant Child Under-five Years preceding mortality mortality I mortality mortality mortality survey (NN) (PNN) (lqo) (4qt) (sqo) 0-5 51.4 39.1 90.5 29.5 117.4 6-11 56.7 40.0 96.7 29.8 123.6 12-17 63.4 43.7 107.1 40.7 1,~3.5 Note: The month of interview is excluded from the analysis. 1Computed as the difference between infant and neonatal mortality 4 The procedure assigns an age at death equal to that of the last death of the same birth order in the data file. The estimated infant mortality rate based on births and deaths for a period of 12 complete months preceding the 1984-85 PCPS was 106. 114 Figure 9.1 Distribution of Deaths Under Age Five by Age at Death Neonatal 45% Id (1-4) 23% Note, Based on death~ in the six years preceding the survey, PDHS 1990-9t 9.4 Differentials in Infant and Child Mortality Table 9.5 presents infant and child mortality rates by urban-rural residence, province of residence, level of mother's education, and use of basic maternal health services. Mortality rates are calculated for a ten-year period so that the rates for each population subgroup are based on an adequate number of events. Under-rive mortality (sq0) is 29 percent lower in urban Pakistan (94 per thousand) than in the rural setting (132 per thousand). The urban-rural differential exists at all ages (see Figure 9.2), which suggests that both social factors and access to health services are important in the greater risk of death among rural children. There is little or no difference in mortality risk between major cities and other urban areas. Among regions, under-five mortality is lowest in NWFP (98 per thousand) and highest in Punjab (133 per thousand). The higher under-five risk in Punjab is largely due to higher mortality during infancy (104 per thousand). Infant mortality was estimated to be lowest in Balochistan, but this should be interpreted with caution since sampling errors are relatively high in Balochistan, as well as in NWFP. Moreover, the unusually low rate of infant mortality relative to child mortality in Balochistan as well as a deficit of births in the year preceding the survey, suggests that there was selective underreperting of infant deaths in that province, Child survival chances in Pakistan are closely related to a mother's level of education. Children of mothers with no education experience over two and a half times (159 percent) the level of under-five mortality as children of women educated to the secondary level or higher. Indeed, each incremental change in education is associated with significant gains in survival. In the posmeonatal period, a strong education effect is observed only for the secondary and higher level of education. 115 Table 9.5 /nfant and child mortality by background characteristics Infant and child mortality rates for the tan-year period preceding the sut~ey, by background charactexlsfxcs of ~e mother, Pakistan 1990-91 Neonatal Postnannatal Infant Child Under-five Characteristic mortality mortality I mortality mortality mortality of mother (NN) (PNN) Qqo) (4ql) (~o) Residence Total urban 40.8 33.8 74.6 20.6 93.6 Major city 39.7 34.1 73.8 19.5 91.9 Other urban 42.1 33.5 75.6 22.0 95.9 Rural 58.6 43.7 102.2 33.0 131.9 Province Punjab 58.4 45.7 104.1 32.0 132.8 Sindh 44.4 36.1 80.5 27.3 105.6 NWFP 48.2 31.3 79.6 19.7 97.7 Balochistan 46.1 26.3 72.4 31.0 101.l Education level aRended No education 56.1 42.5 98.6 33.1 128.4 Primary 49.8 40.6 90.4 18.3 107.0 Middle 43.5 36.7 80.2 7.9 87.4 Secondary + 26.9 18.9 45.8 3.9 49.5 Medical maternity care z No antenatal or 57.1 47.2 104.3 31.6 132.6 delivery care Either antenatal or 32.5 32.4 64.9 40.9 103.1 delivery care Both antenatal and 46.7 22,8 69,5 10,5 79.3 delivery care Total 53.3 40.7 94.0 29.2 120.4 Note: The month of interview is excluded from analysis. IComputed as the difference between infant and neonatal mortality ~Rates are for the five-year period preceding the survey. Medical care is that given by • doctor, nurse or lxained midwife, or rece'tved in a hospital, clirftc, health centre or health unit. 116 70 60 SO 40 30 20 10 0 Figure 9.2 Infant and Child Mortality by Place of Residence Deaths per 1,000 Total Major City Other Urban Rural Note: Based on deaths in the 10 years preceding the survey. PDHS 1990-91 Use of basic maternal health services is associated with child survival chances. Under-five mortality is 67 percent higher ( 133 per thousand) among children born to women who did not receive antenatal services and did not receive delivery care from a trained health professional compared to children whose mothers received both services. The under-five differentials, however, exhibit some unexpected differences in mortality risk across service use categories. For instance, use of both services is associated with higher neonatal risk than use of one or the other. Perhaps, women who receive antenatal care do not also seek delivery care unless they experience a problem with the pregnancy. Child mortality (4qt) is lower among children whose mothers received no services than among those whose mothers received one or the other service. This aberrant pattern may be the result of small numbers, which produce large sampling errors. Nevertheless, it is unusual that the postneonatal period, and not the neonatal period, is the age segment most sensitive to the effects of maternal health service use. Table 9.6 presents differentials in infant and child mortality by various characteristics of the mother and child. The expected biological effects of sex on age-specific mortality are observed. Neonatal mortality is 30 percent higher among males than females; however, mortality during the posmeonatal period is little affected by the sex of the child. Child mortality (,~ql) is 66 percent higher among females than males, which suggests that there may be some gender-related differences in child rearing practices that favour boys over girls. 117 Table 9.6 Infant and chiM mortality by demographic characteristics Infant and child mortality rates for the ten-year period preceding the survey, by selected demographic and biological cliaracteristics, Pakistan 1990-91 Demographic/ Neonatal Post.neonatal Infant Child Under-five biological mortality mortality l mortality mortality mortality characteristic (NN) (PNN) (lqo) (4ql) (sqo) Sex of child Male 60.1 42.0 102.1 22.0 121.9 Female 46.1 39.3 85.5 36.5 118.9 Mother's age at birth <20 70.1 51.2 121.3 26.7 144.8 20-29 50.9 40.0 90.8 28.5 116.7 30-39 48.5 35.4 83.9 31.8 113.0 40-49 56.1 50.4 106.5 27.1 130.7 Birth order 1 60.9 37.7 98.5 12.9 110.2 2-3 45.0 38.6 83.6 32.1 113.0 4-6 51.9 43.0 94.8 33.6 125.2 7+ 63.4 43.5 106.9 32.3 135.7 Previous birth Interval < 2 years 74.1 58.8 132.9 42.9 170.1 2-3 years 38.9 26.3 65.2 25.5 89.0 4 years or more 13.5 16.3 29.7 15.0 44.3 Birth size 2 Very small 90.6 40.7 131.3 30.5 157.8 Small 41.9 58.0 99.9 22.9 120.5 Average or larger 40.3 31.5 71.8 27.6 97.4 Note: The month of interview is excluded from analysis. tComputed as the difference between infant and neonatal mortality 2Rates are for the five-year period before the survey. Differences in under-five mortality (sq0) by matemal age at birth follow the expected pattern: mortality is highest for children of young mothers; it falls for births to mothers age 20-39; then it rises again for births to women 40 and older (see Figure 9.3). This pattern, however, is seen exclusively during the first year of life. This same U-shaped pattern is also seen in the relationship between birth order and mortality, but only during the neonatal period. After the first month, first order births are at lowest risk, and the high birth order effect is not observed. The pace of childbearing has a powerful effect on the survival chances o f Pakistani children. Under- five mortality (.41o) is four times higher among children born after an interval of less than two years than among children born after an interval of four years or more. The birth interval effect is marked for mortality in each age group, although the strength of the association diminishes with increasing age of the child. Birth intervallength strongly affects survival chances throughout the first five years of life. This may indicate that 118 80 70 60 50 40 30 20 10 0 Figure 9.3 Infant Mortality by Mother's Age at First Birth Deaths per 1,000 Births ,20 20-29 30-39 40-49 Mother's Age 1Neonata l m Postneonatal PDHS 1990-91 the relationship in Pakistan is not simply related to maternal depletion and pregnancy outcome (which would be expected to specifically influence early infant mortality), but may also be associated with constraints on breastfeeding and other nutritional inputs, child care, and the use of health services. The size of a child at birth is closely linked to neonatal survival. Children perceived by their mothers as very small were 2.2 times more likely to die in the first four weeks than those perceived as small, average or larger. After the neonatal period, the relationship is less pronounced, although average~larger children still appear to maintain some continued advantage in survival in the postneonatal period. 9.5 Causes of Death in Early Childhood In the PDHS, an effort was made to obtain general information on the causes of death of children born during the five-year period preceding the survey. Mothers of deceased children were asked whether a doctor or health care worker had provided an explanation or cause for the child's death. If the mother responded "yes," then she was asked to give the reported causes of death. If there was no explanation from a doctor or health worker, then the mother was asked to provide her perception of the causes of death. Table 9.7 gives the percentage of deaths in the five years preceding the survey by reported causes of death, the source of information on the cause, and the age group of the child at death. The figures should be viewed with caution, especially those for children age 12-59 months, since they are based on small numbers. Furthermore, nearly half of all reported deaths could not be assigned to any specific category, making interpretation difficult. This is particularly true for reporting of causes during the neonatal period, when many deaths are attributed to a lack of viability at birth and, as such, are difficult to specify. This is further reflected in the small fraction of deaths for which a doctor or health worker's explanation of the cause of death could be elicited (26 percent during the neonatal period compared to 42 percent during the posmeonatal period and 55 percent for children age 12 to 59 months). 119 Table 9.7 Causes of death in early childhood Among nonsurviviug children born dusting the five years preceding the survey, the percentage reported to have died from selected diseases or other causes, by age at death and person reporting the cause of death, Pakistan 1990-91 Age at death Less than 1 month 1-11 months 12-59 months Total Cause reported by Cause reported by Cause reported by Cause reported by Disease or cause Doctor I Mother z Total Doctor I Mother 2 Total Doctor t Mothe~ Total Doctor 1 Mother 2 Total Diarrhoea 0.6 7.2 5.5 40.2 19.5 28.3 (30.0) (22.4) 26.6 24.1 12.8 16.9 Vonfitiug 2.2 5.6 4.7 7.2 13.1 10.6 (11.7) (19.1) 15.0 6.5 9.5 8.4 Pneumonia 7.4 2.5 3.7 16.9 0.7 7.5 (5.7) (--) 3.1 11.0 1.6 5.0 Cough 1.6 4.4 3.7 8.8 10.9 10.0 (5.4) (17.5) 10.8 5.5 7.9 7.0 Fever 19.9 14.5 15.9 33.3 40.8 37.6 (30.4) (49.6) 39.0 28.0 26.8 27,2 Convulsions 5.2 8.6 7.7 1.8 8.5 5.7 (8.1) (8.4) 8.2 4.4 8.5 7.0 Measles 4.0 1.3 2.0 5.2 1.7 3.2 (14.3) (7.0) 11.1 6.9 2.0 3.8 Other 63.8 68.6 67.4 16.2 43.6 32.0 (27.7) (33.0) 30.1 35.4 56.7 49.0 Number 69 200 268 84 114 198 45 37 82 198 350 548 Note: Percentages add to more than 100.0 because of the recording of multiple causes of death. Figmes in parentheses are based on 25 to 49 unweighted cases. -- Less than 0.05 percent 1Reperted to mother by a doctor or a health waker 2Mother's own ~ssessrnent (for mothers who were not informed about the cause by a doctor or a health worker) Despite these problems, some conclusions can tentatively be drawn from the figures on causes of death in childhood. First, over one-quarter (27 percent) of the under-five deaths were associated with fever, and about 17 percent were associated with diarrhoea (as reported either by the mother or a health worker). Cough, vomiting, convulsions, pneumonia, and measles were each reported for 4 to 8 percent of deaths, although in the case of measles, it is unlikely that the few deaths reported during the neonatal period were actually associated with measles. Deaths associated with reported convulsions may represent cases of tetanus during the neonatal period, and aRer the neonatal period often would suggest various conditions involving high fever or hypoxia such as meningitis, pneumonia, and other acute infections. During the posmeonatal period, there is a two-fold difference between mothers' reports and health workers' reports in the percentage of deaths associated with diarrhoea. This difference suggests that children with the most severe cases of diarrhoea tend to be brought to doctors for treatment. Lastly, it was mentioned above that the percentage of child deaths for which a doctor's or health worker's explanation was provided rises markedly with the age group of the deceased child. One substantive expla-nation for this pattern reflects greater use of curative health services among older children, which would increase the probability of the child having seen a health worker around the time of death, in addition, illnesses among older children may be less serious but of longer duration, thereby increasing the probability of having had some comact with health personnel. 120 In sum, acute respiratory and gastrointestinal illnesses are important morbid conditions preceding death al~ter the neonatal period in Pakistan. Causes of neonatal mortality are more difficult to ascertain with these very limited data, although it appears likely that neonatal tetanus and other acute infectious diseases play at least some role. 9.6 High-risk Fertility Behaviour Previous demographic research has shown that a strong relationship exists between a mother's pattern of fertility and her children's survival chances. Typically, infants and young children have a higher risk of dying if they are born to very young mothers or older mothers, if they are born after a short birth interval, or if their mothers have already had many children (see Table 9.6). In the following analysis, mothers are classified as too young if they are less than 18 years old at the time of the birth, and too old if they are 35 or older at the time of the birth. A short birth interval is defined as less than 24 months, and a high order birth as one occurring after five or more previous births (i.e., birtb order six or higher). Births may also be cross- classified by combinations of these characteristics. Thus, a birth may have from zero to three high-risk characteristics. Column one of Table 9.8 shows the percentage of births in various risk categories. More than half (55 percent) of all births in Pakistan fall into at least one risk category, with a third (19 percent) of these having multiple risk characteristics. Risk ratios are presented in column two; a risk ratio is the ratio of the proportion of children in a category who have died, to the proportion who have died in the reference category of births without any risk factors. This analysis indicates several things. First, older maternal age at birth (age >35) and high parity (BO >5) are essentially unrelated to mortality risk when not combined with a short birth interval (BI <24). Indeed, the two main factors leading to heightened risk are young age at birth (< 18 years) and a short birth interval (<24 months). The only multiple risk categories that exhibit higher risk are those that include a short birth interval. Since one-third of recent births in Pakistan occurred less than 24 months after a prior birth, this fmding underscores the need to reduce, through greater use of contraception, the number of closely spaced births. Column three in Table 9.8 shows the distribution of currently married women by the risk category into which a current birth would fall. A comparison of this percent distribution with the distribution of actual births in the last six years indicates that the percentage of births falling into two of the high-risk categories would increase substantially without fertility control. However, both of these categories (births to older women and births to older women of higher parity) have risk ratios of less than one and, therefore, they do not conform to the expected pattern. 121 Table 9.8 High-risk fertility behavioor Percent distribution of chil&en loom in the six years preceding the survey who are at elevated risk of mortality, and the percent distribution of currently married women at risk of conceiving a child with an elevated risk of mortality, according to category of increased risk, Pakistan 1990-91 Births in the 6 years preceding the survey Percentage of currendy Risk Percent of Risk married category births ratio women a Not in any risk category 45.1 1.00 33.3 b Single risk category Age<18: Mother's age at birth <18 3.8 Age>34: Mother's age at birth 35+ 2.7 BI<24: Birth interval <24 months 19,9 BO>5: Birth order 6 or higher 9.4 1.69 1.0 0,93 8.8 1,78 17.2 0.93 7.4 Subtotal 35.9 1.48 34.4 Multiple risk category Age<18 & BI<24 c 1.0 1.64 0.3 Age>34 & BI<24 0.5 1.17 0.8 Age>34 & BO>5 7.0 0.81 20.8 Age>34 & BI<24 & BO>5 3.1 2.01 4.7 BI<24 & BO>5 7.5 2.25 5.7 Subtotal 19.0 2.00 32.0 In any risk category 54.9 1.53 66.7 Total 100,0 NA 100.0 Number 8241 NA 6364 Note: Risk ratio is the ratio of the proportion dead of births in a specific risk category m the proportion dead of births not in any risk category. NA = Not applicable aWomeaa were assigned to risk categories according to the status they would have at the birth of a child, if the child were conceived at the time of the survey: age less than 17 years and 3 months, age older than 34 years and 2 months, latest birth less than 15 months ago, and latest ~ of order 5 or higher. h i 'h ides sterilised women C[ncindes the combined categories age <18 and birth order >5, 122 REFERENCES Federal Bureau of Statistics [Pakistan]. 1990. Pakistan Demographic Survey - 1988. Karachi. Rulstein, Shea Oscar. 1984. Infant and Child Mortality: Levels, Trends, and Demographic Differentials. Revised edition. WFS Comparative Studies No. 43. Voorburg, Netherlands: International Statistical Institute. 123 CHAPTER 10 MATERNAL AND CHILD HEALTH Abdul Razzaque Rukanuddin and K. Zaki Ha.san One of the objectives of the Pakistan Demographic and Health Survey (PDHS) was to provide information relating to the health of children and their mothers, both of which have a crucial influence on population growth and perceptions moderating fertility behaviour. High levels of infant, child, and maternal mortality in Pakistan have drawn the attention of the government, resulting in efforts to improve survival through primary health care. The PDHS, for the first time, provides information on coverage of these services. In this chapter, an analysis is undertaken of data obtained through detailed questions about antenatal and delivery care, immunisation coverage, and treatment of diarrhoea, fever, and acute respiratory diseases in children. 10.1 Maternal Care Indicators In Pakistan, health facilities are available to about 55 percent of the population (Grant 1992). Most of these health and MCH services are concentrated in urban areas, while the rural population has access to Rural Health Centrcs (RHCs), Basic Health Units (BHUs), and Family Welfare Centres (FWCs), in addition to traditional providers (dais and traditional medical practitioners, i.e., hakeems). One of the priorities of the gnvemment is to provide medical care during pregnancy and at the time of delivery, both of which are essential for infant and child survival and safe motherhood. To measure the level of care received by women during pregnancy, mothers of all children born during the five years preceding the survey were asked whom, if anyone, they had seen for an antenatal checkup and how many such visits they had made. They were also asked if they received an injection (tetanus toxoid-'I~) in the arm during pregnancy to prevent the baby from getting tetanus, i.e., convulsions after birth, and how many such injections were received. Mothers were also asked where they had given birth and who assisted during the delivery. Information about the characteristics of births was also gathered, including whether the delivery was premature or by caesarean section, and the size and weight of the baby at birth. Antenatal Care Table 10.1 and Figure 10.1 present background information on antenatal care for births in the five years preceding the survey. For 70 percent of these births, no antenatal care was received during pregnancy. When care was received, 23 percent was provided by a doctor, 3 percent by a nurse, Lady Health Visitor, or Family Welfare Worker, and 4 percent by either a gained or a traditional birth attendant. The percentage of births with no antenatal care increased with the birth order of the mother and was highest for women age 35 and over. Conversely, mothers receiving care from a doctor were slightly younger and of lower parity. 125 Table t0.l Mtountal care Percent distribution of live births in the five years preceding the survey by source of arttenatal e~e during pregnancy, according to selected background ehaxaeteristice. Pakistan 1990-91 Antenatal care provider I Nurse/ Lady Trained Traditional Number Background Health birth birth Don't know/ of live characteristic Doctor Visitor 2 aaendant etteaadent Other No one missing Total births Mother's age at birth < 20 20.3 3.0 0.8 2.7 0.1 72.6 0.5 100.0 746 20-34 24.4 3.1 1.1 2.6 -- 67.2 1.5 100.0 4843 35+ 13.6 3.0 1.0 1.3 -- 80.8 0.3 100.0 818 Birth order 1 28.1 2.6 1.0 2.9 -- 63.8 1.6 100.0 1167 2-3 26.4 3.6 0.9 2.5 -- 65.2 1.4 100.0 2031 4-5 21.2 2.7 0.9 2.3 0.1 72.1 0.5 100.0 1538 6+ 15.0 3.3 1.4 2.3 -- 76.6 1.4 100.0 1671 Residence Total urban 51.3 5.2 1.5 1.6 -- 39.6 0.8 100.0 1980 Major city 63.9 3.3 1.5 1.5 -- 28.9 0.9 100.0 1140 Other urban 34.1 7.8 1.5 1.7 0.1 54.1 0.7 100.0 840 Rural 9.6 2.2 0.8 2.9 -- 83.0 1.4 100.0 4426 Province Punjab 17.7 3.8 0.6 1.8 0.1 74.8 1.4 100.0 3933 Sindh 43.8 1.8 0.3 4.0 0.1 48.5 1.5 100.0 1364 NWFP 15.3 2.0 0.7 0.5 -- 81.3 0.2 100.0 864 Balochist an 7.1 3.2 13.9 11.8 -- 62.5 1.5 100.0 246 Edueetton level attended No education 14.0 2.6 1.2 2.7 -- 78.0 1.5 100.0 4983 Primary 33.5 4.3 0.9 1.7 -- 58.9 0.6 100.0 641 Middle 49.3 7.3 0.5 1.5 -- 41.1 0.3 100.0 304 Secondaxy + 79.3 3.7 0.5 1.5 0.2 14.6 0.2 100.0 479 Total 22.5 3.1 1.1 2.5 -- 69.6 1.2 100.0 6407 Note: figures axe for births in the period 1-59 months preceding the survey. -- Less than 0.05 percent 1If more than one source of antenatal care was mentioned, only the provider with the highest qualifications is considered. 2Includes Family Welfare Worker No antenatal care was received for 83 percent of the births in rural areas and 40 percent in urban areas (Figure 10.1). Regionally, women in the North West Frontier Province (NWFP) had the lowest level of care (81 percent received no antenatal care), followed by Punjab (75 percent), Balochistan (63 percent) and Sindh (49 percent). Women in Balochistan relied more on traditional and trained birth attendants for antenatal care (26 percent) than women in other regions (all less than 5 percent). More educated women were considerably more likely to receive antenatal care from a doctor. For 78 percent of birtl~ to mothers with no education, no antenatal care was received by the mother. In almost four of five births (79 percent) occurring to women with secondary education, antenatal checkups were done by doctors. Antenatal care provided by physicians was highest in urban areas (51 percent), particularly among residents of major cities (64 percent). 126 Figure 10.1 Antenatal Care, Place of Delivery, and Assistance During Delivery NO ANTENATAL CARE Total Urban Rural T.T. VACCINATION None 2 or more PLACE OF DELIVERY At Home Hea l th Fac i l i ty ASSISTANCE DURING DELIVERY TeA Tra ined Personne l (Doctor/Nurse/LHV/ Tra ined B i r th At tendant ) 7O 83 23 118 ~2 20 40 60 80 1 SO Percent Note: Based on b i r ths In the f lve years preced ing the survey. PDHS 1990-91 Both the number and timing of antenatal care visits are thought to have an impact on pregnancy outcome. For slightly less than one-quarter of the births (23 percent), two or more antenatal visits were made (see Table 10.2). The median number of visits was 4.1 among cases where care was received. For births where antenatal cam was received, most women had their first visit during the first five months of pregnancy. Tetanus Toxoid Immunisation Preventable neonatal mortality is a major concem of public health authorities. Tetanus is an important cause of neonatal death in Pakistan and can be prevented by immunisation of the mother during pregnancy. Immune protection is transferred to the baby through the placenta, if the mother has been immunised with tetanus toxoid. Previously, the World Health Organisation (WHO) had recommended that pregnant women receive two tetanus toxoid shots, four weeks apart, to protect the infant and the mother against tetanus for about two years. With recent advances in medicine, WHO now recommends a series of five tetanus toxoid shots to provide 10-15 years of protection. 127 Table 10.2 Number of antanatal care visits and sta~e of gre~,nancv Percent distribution of live births in the five years preceding the sm'vey by number of antenatal care (ANC) visits, and by the stage of pregnancy at the time of the first visit, Pakistan 1990-91 Antenatal visits/ Stage of pregnancy All at first visit births Number of ANC visits 0 69.6 1 4.8 2-3 8.5 4+ 14.2 Don't know, missing 2.9 Total 100.0 Median number of visits (for those with ANC) 4.1 Number of months pregnant at the time of first ANC visit No antenatal care 69.6 <6 19.8 6-7 5.6 8+ 2.5 Don't know, missing 2.5 Total 100.0 Median number of months pregnant at in'st visit (for those with ANC) Number of live births Note: Figures are for births in the period 1-59 months preceding the survey. 4.0 6407 128 Table 10.3 Tet~us toxoid vaccination Percent distribution of births in the five ye.m preceding the survey by number of tetanus toxold injections given to the mother during pregnancy and whether the respondent received an antenatal card, according to selected background characteristics, Pakistan 1990-91 Number of tetanus toxoid injections Percent Two given Number Background One doses Don't know/ antenatal of characteriatic None dose or more missing Total card births Mother's age at birth < 20 71.3 7.2 21.5 -- 100.0 11.4 746 20-34 68.7 6.5 24.6 0.2 100.0 13.8 4843 35+ 76.5 5.7 17.3 0.5 100.0 7.6 818 Birth order 1 65.0 6.3 28.5 0.2 100.0 16.1 1167 2-3 66.2 7.7 25.8 0.3 100.0 15.6 2031 4-5 73.7 6.1 20.0 0.2 100.0 11,2 1538 6+ 74.6 5,4 19.7 0.2 100.0 8.2 1671 Residence Total urban 46.9 9.0 44.0 0.2 100.0 31.4 1980 Major city 42.4 9.0 48.3 0.3 100.0 42.6 1140 Other urban 53.0 9.0 38.0 --- 100.0 16.2 840 Rural 80.3 5.4 14.1 0.2 100.0 4.4 4426 Province Punjab 69.8 6,8 23.0 0.3 I00.0 10.3 3933 Sindh 59.4 7.8 32.8 -- 100.0 24.8 1364 NWFP 81.9 3.5 14.5 -- 100.0 6.9 864 Balochistan 89.3 4.4 6.0 0.4 100.0 5.3 246 Education level attended No education 77.8 5.7 16.3 0.2 100.0 6.5 4983 Primary 55.1 6.5 38.1 0.3 100.0 19.9 641 Middle 34.9 11.2 53.6 0.3 I00.0 34.8 304 Secondary + 30,8 11.4 57.5 0,4 100.0 53,4 479 Total 70.0 6.5 23.3 0.2 I00.0 12.7 6407 Note: Figures ere for births in the period 1-59 months preceding the su~ey. -- Less than 0.05 percent For 70 percent of births in the f ive years preceding the survey, no tetanus toxoid immunisation was received during pregnancy (see Table 10.3 and Figure 10.1 ). Immunisation coverage was significantly lower in rural than in urban areas (20 vs. 53 percent). Births to women in Balochistan were least likely to be protected ( 10 percent). Women with no education, older women, and mothers ofh igher birth order children were also less likely to be immuulsed prior to delivery. Among women who had been immunised, more than three of four births were protected by two or more injections. The proportion receiving multiple injections was highest for residents of major cities (48 percent), for Sindh (33 percent), and for mothers with secondary or higher education (58 percent). In recent years, health care programmes have been encouraged to distribute antenatal cards to pregnant women at the time they receive antenatal care. While 26 percent of births were preceded by antenatal care from a doctor or nurse (see Table 10.1), only 13 percent had received an antenatal card. Not 129 Table 10.4 Place of delivery Percent distribution of births in the five years preceding the survey by place of delivery, according to selected background characteristics. Pakistan 1990-91 Place of delivery Number Background Health At Don't know/ of characteristic facility home Other missing Total births Mother's age at birth < 20 11.0 88.5 - - 0.5 100.0 746 20-34 14.6 83.7 0,1 1.6 100.0 4843 35+ 8.1 91.4 0.1 0.3 100.0 818 Birth order 1 19.8 78.3 0.3 1.6 100.0 1167 2-3 15.4 83.1 -- 1.5 100.0 2031 4-5 11.8 87.5 0.2 0.5 100.0 1538 6+ 7.9 90.6 0.1 1.5 100.0 1671 Residence Total urban 32.6 66.5 - - 0.8 100.0 1980 Major city 46.1 53.0 0,l 0.9 100.0 1140 Other urban 14.3 85.0 -- 0.7 100.0 840 Rural 4.8 93.6 0.1 1.5 100.0 4426 Province Punjab 10.5 88.0 0.1 1.4 100.0 3933 Sindh 27.8 70.4 0.1 1.7 100.0 1364 NWFP 6.6 93.0 0.1 0.3 100.0 864 Balochistan 2.5 96.3 1.2 100.0 246 Education level attended No education 6.7 91.7 0.I 1.5 100.0 4983 Primary 17.4 82.0 0.6 100.0 641 Middle 43.4 56.3 0.3 1.00.0 304 Secondary + 58.6 41.0 0.4 100.0 479 Antenatal care visits 0 2.9 96.8 0.1 0.1 100.0 4458 1-3 22.7 77.3 100.0 853 4+ 57.8 42.0 0~l 0?l 100.0 908 Don't know, missing 4.4 54.9 40.7 100.0 188 Total 13.4 85.2 0.1 1.3 100.0 6407 Note: Figures are for births in the period 1-59 months preceding the survey. -- Less than 0.05 percent surprisingly, the distribution of frequencies for antenatal cards by background characteristics (see Table 10.3) is similar to that for antenatal care. Place of Delivery and Assistance During Delivery Eighty-five percent of the births occurring during the five years preceding the survey took place at home (see Table 10.4). This proportion has declined very little since the PCPS in 1984-85, when 92 percent of the live births occurred at home. Though delivery in a health facility was less common than receiving antenatal care, more than five-sixths of all births which occurred in health facilities were to women who had received antenatal care. This may be due to differences in service availability or to complications during 130 Table 10.5 Assistance during delive W Percent distribution of births in the five years preceding the survey by type of aseiatanco during delivery, according to selected background characteristics, Pakistan 1990-91 Person providing assistance Nurse/ Lady Trained Traditional Number Background Health birth birth Don't know/ of eh~aacteristic Doctor Visitor I auendant attendant Other No one missing Total births Mother's age at birth < 20 10,3 6.8 13.7 55.4 11.1 1.9 0.9 100.0 746 20-34 13.4 6.6 16.8 50.8 9,3 1.4 1.7 100.0 4843 35+ 8.0 4.8 18.5 57.7 8.1 2.3 0.6 100.0 818 Birth order 1 18.5 6.7 13.9 48.0 9.4 1.8 1.7 100.0 1167 2-3 14.0 7.0 17.0 49.6 9.4 1.3 1.7 100.0 2031 4-5 l l .0 5.2 17.0 54.8 9.9 1.2 0.8 100.0 1538 6+ 7.4 6.4 17.8 55.8 8,8 2.2 1.6 100.0 1671 Residence Total urban 30.7 11.6 18.3 35.2 2.7 0.7 0.8 100.0 1980 Major city 41.8 9.3 18.6 27.4 1.6 0.5 0.8 100.0 1140 Other urban 15.5 14.8 17.9 45.7 4.3 1.0 0.8 100.0 840 Rural 4.2 4.0 15.9 59.8 12.3 2,0 1.7 100,0 4426 Province Punjab 9,8 6.6 19.8 56.4 4.6 I.I 1,7 I00.0 3933 Sindh 24.6 7.6 7.4 54.6 3.1 1.3 1.3 100.0 1364 NWFP 7.7 3.9 8.8 33.0 42.5 3.8 0.3 100.0 864 Balochistan 3.1 4.4 45.1 38.2 3.5 3.7 2.0 100.0 246 Education level attended No education 6.1 5.0 16.9 57,4 11.1 1.9 1.6 100.0 4983 Primary 15.1 10.4 21.5 48.4 3.3 0.1 1.3 1(30.0 641 Middle 39.1 13.0 12.7 29.9 3.4 0.2 1.7 100.0 304 Secondary + 57,2 11.6 10.1 17.1 2.8 1.0 0.2 100.0 479 Antenatal care visits 0 3.2 3.6 17.5 60.9 12.2 2.1 0.4 100.0 4458 1-3 19.1 14.5 18.5 43.3 4.0 0.5 -- 100.0 853 4+ 52.3 13.1 11.7 21.3 1.4 0.1 0.1 100.0 908 Don't know, missing 5.1 2.0 11.7 34.8 4.1 2.0 40.2 100.0 188 Total 12.4 6.4 16.6 52.2 9.4 1.6 1.5 100.0 6407 Note: If the respondent mentioned more thma one attendant, only the most qualified attendant is considered. Figures are for births in the period 1-59 months preceding the survey. -- less than 0.05 percent qneludes Family Welfare Worker pregnancy which may lead a woman to seek care. It may also suggest that antenatal visits give the provider an opportunity to develop rapport with the woman, increasing her willingness to seek proper care at the time of delivery. The pattern of home delivery by various background characteristics is similar to the distribution of cases in which no antenatal care or tetanus toxoid injections were received. The proportion of births taking place at health facilities was highest among women 20-34 years of age, among women having their first child, for residents of Sindh, and for those living in urban areas. Home births were more than twice as common among women with no education as among those with secondary or higher levels of educational attainment. 131 Sixty-nine percent of deliveries of all live births were attended by traditional or trained birth attendants, while 19 percent were assisted by a doctor or nurse (see Table 10.5). The characteristics of births attended by a doctor are consistent with those of births occurring in health facilities (Table 10.4). Characteristics of Deliveries Three percent of births were deliv- ered by caesarean section (see Table 10.6). Only two percent of births were reported as premature; however, exclusion of stillbirths from this figure results in a significant under- estimation ofprematurity overall. In addition, it is uncertain how accurately mothers are able to identify prematurity. Most of the deliveries took place at home, hence 9 of 10 (88 percent) births were not weighed at the time of birda. The resulting sample of birth weights is therefore subject to selection bias, such that the proportion of births weighing less than 2.5 kilograms (one of six births with a known birth weight) prob- ably understates the problem of low birth weight overall. Three-quarters (76 percent) of the live births were reported to be of average or larger size. Table 10.6 presents information about the average duration of labour for the most recent birth. This average was within the nor- mal range for all subgroups examined. In births delivered by a surgical procedure, the mean was higher than for others, suggesting obstructed and/or prolonged labour as an indication for some caesarean births. Table 10.6 Characteristics of delivery Percent distribution of live births in the five years preceding the survey by whether the delivery was by caesarean section, whether premature, and by birth weight and the mother's estimate of baby's size at birth, Pakistan 1990-91 Most recent birth Average duration Number Delivery of labour of characteristic Percent (in hours) births C-section delivery C-section 2.7 11.8 99 Not C-section 95.5 7.7 3679 Missing 1.8 * 21 Total 100.0 7.8 3800 Premature birth On time 96.7 7.7 3723 Premature 1.9 12.9 70 Don't know 1.5 * 7 Total 100.0 7.8 3800 Birth weight Less than 2.5 kg 1.2 12.1 50 2.5 kg or more 6.3 7.8 252 Don't know. missing 4.2 9.4 97 Not weighed 88.3 7.7 3401 Total 100.0 7.8 3800 Size at birth Very small 6.2 10.7 271 Smaller than average 15.9 7.9 668 Average or larger 76.3 7.5 2854 Don't know. missing 1.5 * 6 Total 100.0 7.8 3800 Number 6407 3800 3800 Note: Figures are for births in the period 1-59 months preceding the survey. *Based on fewer than 25 unweighted cases, number not shown 10.2 Child Care Indicators The Pakistan Demographic and Health Survey included questions on a number of indicators of child care and utilisation of child care services. The information collected focused on immunisation coverage and the prevalence of diarrhoea, fever and respiratory illnesses among children under five years of age, as well as the type of treatment sought. 132 Immunisation of Children Given the high levels of infant and child mortality in Pakistan, in 1982 the Government initiated an Expanded Programme on Immunisation (EPI) following the intemational guidelines recommended by the World Health Organisation (WHO). These guidelines recommend that by the age of 12 months all children should be immunised against the six preventable childhood diseases: a BCG vaccination for tuberculosis, three doses of DPT vaccine for the prevention of diphtheria, pertussis (whooping cough), and tetanus, three doses of polio vaccine, and one dose of measles vaccine. The ultimate aim of the EPI programme is to attain universal child immunisation in the country by the mid-1990s. Vaccinations received by infants and children are usually recorded on a health card which is given to the parents for each child at the time of first vacci- nation. In the PDHS, mothers were asked questions designed to determine whether their children under five years of age had received injections or drops to protect against the preventable childhood diseases. Mothers were also asked whether they had a vaccination card for each child. If a card was available, the interviewer was required to ask to see it and record the dates on which the child had received vaccinations against each disease. One dose each of BCG and measles vaccine and three doses of polio and DPT are required to establish immunity. Table 10.7 presents the percentage of children 12-23 months of age who were vaccinated at any time before the interview and by 12 months of age, by the source of information. The EPI programme has achieved considerable success although universal immunisation is far from a reality. Fifty percent of the children have received measles vaccine. The highest coverage was for BCG (70 percent) and the first two doses of DPT and polio. It may be noted that DPT and polio vaccinations are usually given together, which partially explains why the proportions were almost identical for these two vaccines. Because these Table 10.7 Vaccinations by source of information The percentage of children 12-23 months of age who had received specific vaccines at any time before the survey and before 12 months of age, by whether the information was from a vaccination card or from the mother, Pakistan 1990-91 Percentage of children who received: Source of information mad polio DPT Number timing of of vaccination BCG 0 1 2 3 1 2 3 Measles All t None children Vaccinated at any time before the survey Vaccinaticv card 97.9 35.1 99.6 91.2 82.6 97.3 89,5 81.9 76.3 71.7 -- 360 Mother'm r~o. 57.7 2.2 50.1 47.5 26.2 50.1 47,5 26.2 39.2 19.6 40.2 855 Either source 69.7 12.0 64.8 60.5 42.9 64.1 60,0 42.7 50.2 35.1 28.3 1215 Vaeelnatod by 12 months of age 61.1 10.0 58.1 51.1 32.6 57.9 50,6 32.7 35.5 21.8 34.7 1215 Note: The DPT coverage rate for children without a written record is assumed to be the same as that for polio vaccine since mothers were specifically asked whether the child had received POlio vaccine. Children reported by the mother to have received only two or three doses of polio vaccine were assumed to have received polio 1, 2 and 3, respecfvely. Children reported by the mother to have received four or more doses of polio vaccine were additionally assumed to have rec~ved polio 0. For children whose inftmnafion was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the stone as for children with a written record of vaccination. -- Less than 0.0~ percent tChildren who are fully vaccinated, i.e., those who have received BCG, me~les and three doses of DPT and polio vaccines 133 vaccinations are administered together, and because mothers can more easily identify polio vaccine (given as drops in the mouth), when data were collected by mother's report, only polio was asked about and DPT was assumed to be the same. For both DPT and polio, the dropout rates between the first and the second doses were very low (about 4 percentage points). However, the dropout between the second and third doses increased substantially (to about 17 to 18 percentage points). A relatively recent recommendation is the administration of a dose of polio vaccine at the time of birth (polio 0). The use of this dose has not yet become widespread in Pakistan, as only 12 percent of the children 12-23 months of age had received this dose at the time of birth. Seventy-two percent of children age 12-23 months who have a vaccination card have received all the recommended vaccinations, 1 but mothers were able to produce vaccination cards for only 30 percent of the children. The mothers' reports indicated a much lower level of complete coverage (20 percent). According to their reports, 40 percent of the children received no vaccinations. Combining data from both sources, that is, vaccination cards and mothers' reports, the proportion vaccinated against all diseases was 35 percent. Only 22 percent were fully vaccinated by 12 months of age and 36 percent had received measles vaccine within their first year of life. Table 10.8 and Figure 10.2 show vaccination coverage for children 12-23 months of age by back- ground characteristics, combining both sources of information (vaccination card information and mothers' reports.) In general, vaccine coverage is consistently higher among male children, although disparities are all less than 10 percentage points. This difference might be due to son preference, which is still prevalent in Pakistan. Differences in coverage by birth order are neither large nor consistent from one vaccine to another. Complete vaccination coverage was higher in urban (46 percent) than in rural areas (30 percent). However, more than half of the children in rural areas had received BCG and two doses of DPT and polio vaccine; while 44 percent were vaccinated against measles. The children in Punjab and NWFP were more protected than children in Sindh and in Balochistan, where the EPI programme has met with less success than elsewhere in Pakistan. As seen for the indicators of maternal health care, these findings also reflect a positive correlation between the education level of the mother and service utilisation. The results suggest that educational attainment above the primary school level may be an important factor in improving vaccination coverage of children. Table 10.9 shows vaccinations received by children in the first year of life by current age for children one to four years of age. The proportion of children whose immunisation status was determined according to a vaccination card declines as the age of the children increases. This may in part reflect increased use of vaccination cards in the recent past, as well as an improved coverage overall. In addition, vaccination cards may have been lost or discarded more frequently for older children with completed immunisations. The highest level of vaccination coverage against all diseases is noted for children age 12-23 months; coverage then declines progressively with increasing age up to 36-47 months. Thereafter, coverage again increases slightly for children 48-59 months of age. 1 It should be noted flint the vaccination rates reported in the PDHS are lower than of those reported in the 1991 EPI coverage survey conducted jointly by WHO/UNICEF and the Government of Pakistart which estimated immunisation coverage to be 86 percent for children age 12-23 months with vaccination cards. The PDHS results, however, are more in line with the preliminary results of the 1991 Pakistan integrated Household Survey. 134 Table 10.8 Vaccinations by background characteristics Percentage of children 12-23 months of age who had received specific vaccines by the time of the survey (according to the vaccination card or the mother's report) and the percentage with a vaccination card seen by the interviewer, by selected background eh~ac~ristics, Pakistan 1990-91 Percentage of children who received: Polio DPT Percentage Number Background with a of characteristic BCG 0 1 2 3 1 2 3 Measles All I None card children Sex Male 72.8 12.2 67.0 61.9 45.8 66.7 61.7 45.4 54.6 39.1 253 30.7 585 Female 66.7 11.7 62.7 59.1 40,3 61.7 58.4 40.2 46.1 31.3 31.0 28.7 629 Birth order I 76.6 11.9 70.3 65.3 39.7 69.1 64.9 39.3 57.0 33.5 21.1 29.2 228 2-3 71.4 16.5 67.1 63.6 43.0 66.4 62.6 42.9 50.6 33.8 26.8 30.0 380 4-5 65.4 II.I 65.1 59.2 44.6 65.1 59.2 44.6 48.4 36.8 31.4 31.1 276 6+ 66.4 7.5 58.0 54.5 43.6 57.3 54.1 43.2 46.5 36.2 32.2 28.3 331 Residence Total urban 84.2 21.5 80.7 77.1 55.4 80.6 7%0 55.4 64.6 45.6 14.0 34.7 383 Major city 83.5 27.7 78.8 74.6 52.9 78.7 74.5 52.9 64.4 43.7 15.3 34.5 215 Other urban 85.2 13.5 83.1 80.3 58.7 83.1 80.3 58.7 64.8 48.0 12.4 35.0 168 Rural 62.9 7.6 57.5 52.8 37.2 56.5 52.1 36.9 43.6 30.2 34.8 27.3 832 Provl[Ice Punjab 75.8 10.2 70.7 67.3 46.9 69.6 66.6 46.7 54.4 38.6 22.2 31.2 763 Sindh 60.2 20.4 54.0 50.3 33.0 54.5 50.3 33.0 41.2 25.3 38.5 25.7 244 NWFP 63.8 I0.I 60.0 52.3 44.5 60.0 51.9 44.0 48.2 37.6 33.5 31.3 165 Balochistaa 37.1 2.7 39.3 29.1 23.4 36.5 28.5 22.9 34.1 17.8 57.2 18.6 43 Education level attended No education 62.9 9.4 58.1 53.4 38.2 57.5 53.0 38.3 43.6 31.4 34.8 29.2 929 Primary 89.6 23.2 87.0 83.6 53.8 85.8 82.4 52.6 65.5 39.0 7.3 29.5 127 Middle 88.3 12.5 80.7 78.2 67.0 80.7 78.2 67.0 68.6 57.0 11.5 31.3 62 Secondary + 96.2 21.5 89.0 86.1 58.3 89.0 86.1 58.3 81.5 51.5 3.8 33.4 97 Total 69.7 12.0 64.8 60.5 42.9 64.1 60.0 42.7 50.2 35.1 28.3 29.6 1215 Note: See footnote for Table 10.7 for definitions of vaccine coverage. 1Children who are fully vaccinated, i.e., those who have ~ceived BCG, me, aslcs and three doses of DPT and polio vaccines 135 Figure 10.2 Percentage of Children 12-23 Months Who Are Fully Vaccinated Total SEX OF CHILD Male Female RESIDENCE Urban Rural PROVINCE Punjab Slndh NWFP Ba loch la tan 35 38 31 48 30 25 3g 38 10 20 30 40 50 60 Percent Note: Inc ludes hea l th card In fo rmat ion and mothers ' raports . PDHS 1990-91 Children's Morbidity and Treatment Patterns The main causes of death in infants and children in Pakistan are acute lower respiratory infections and diarrhoea. Information was collected in the PDHS for all children under five years of age on the occurrence of symptoms of acute respiratory infection (ARI), fever, and diarrhoea in the two weeks preceding the survey. Mothers were also asked about treatment provided to children with any of these conditions. 136 Table 10.9 Vaccinations in first year of life by eta'rent age The peu:entage of chilcken one to four years of age for whom a vaccination card was seen by the interviewer anti the percentage vaccinated for BCG, DPT, polio, and measles during the first year of life, by current age of the child, Pakistan 1990-91 Current age of child in months Vaccine 12-23 24-35 36~t7 48-59 All children 12-59 months Vaccination card seen 29.6 20.3 13.9 11.7 19.3 by Interviewer Percent vaccinated at 0-11 months BCG 61.1 59.5 46.4 49.9 54.5 Polio 0 10.0 5.9 5.1 2.7 6.1 Polio 1 58.1 54.1 39.9 44.9 49.5 Polio 2 51.1 50.3 35.8 42.5 45.0 Polio 3 32.6 34.1 21.6 28.0 29.2 DPT 1 57.9 54.1 39.9 45.6 49.6 DPT 2 50.6 49.9 35.8 42.5 44.8 DPT 3 32.7 35.7 22.2 28.0 29.7 Measles 35.5 26.6 25.4 38.9 31.3 All vaccinations t 21.8 16.9 13.6 20.7 18.2 No vaeeinatinrts 34.7 37.5 51.0 45.7 42.0 Number of children 1215 1141 1167 966 4489 Note: See footnote for Table 10.7 for definitions of vaccine coverage. 1Children who are fully vaccinated, i.e., those who have received BeG, measles and three doses of DPT and polio vaccines Acute Respiratory Infection Table 10.10 and Figure 10.3 present background information for children with cough accompanied by rapid breathing, i,e., acute respiratory infection (ARI), and the type of treatment given. Adjustments for seasonality have not been made in this table, though the fieldwork took place mostly in the winter, when the prevalence of ARI is expected to be higher. One in six children (16 percent) had suffered from symptoms of ARI during the two weeks preceding the survey. The most vulnerable period for this disease was the first year of life. There were only small differences according to gender and birth order. Children in major cities exhibited a lower prevalence of ARI symptoms than those in other areas. ARI symptoms were least prevalent (8 percent) in Balochistan, while the highest prevalence was observed in Punjab and Sindh. ARI symptoms were less evident among children whose mothers had secondary or more education. 137 Table 10.10 Prevalence and tazah'r~ent of acute respiratory infection Pen:enrage of children undex five who wel~ ill vc~dl a cough s.ccompamed by rapid breathing dunng the two weel~ inecedlng the survey, and the percentage of ill children who were treated with specific remedies, by selected background cbm-ac~istics, Pa~stan 1990-91 Among children with cough and rapid breathing Percentage Percentage Percentage ~eated with: of chilc~en taken to with cough a health Antibiotic Number Background and fast facility or pill or Cough Home of characteristic breathing provider 1 syrup Injection syn~p remedy Other None children Child's age <6 months 17.4 65.5 13.6 11.1 23.7 5.9 49.1 12.2 679 6-I 1 months 23.4 76.8 20.5 12.0 32.8 3.9 50.9 7.9 608 12-23 months 18.0 65.9 18.1 13.7 37.4 5.5 41.8 14.2 1215 24-35 months 16.2 64.8 14.8 17.2 35.6 7.8 33.0 17.3 1141 36-47 months 13.7 65.5 11.9 14.2 34.7 1.7 43,9 15.9 1167 48-59 months 10.4 57.8 18.9 9.4 33.4 3.6 29.4 22.2 966 Sex Male 15.8 67.5 16.2 14.5 33.4 6.3 41.8 15.2 2942 Female 16.2 65.2 16.4 12.3 33.9 3.5 41.0 14.4 2833 Birth order I 17.0 72.7 21.0 12.5 37.9 4.5 39.6 8.5 1026 2-3 14.9 62.5 17.3 9.8 36.7 6.4 34.6 16.5 1869 4-5 16.0 74.8 10.3 15.0 29.6 4.5 55.0 8.9 1377 6+ 16.7 58.8 17.0 16.8 31.0 3.9 38.2 22.3 1504 Residence Total uriah 13.8 76.2 23.9 12.8 38.0 3.1 40.6 11.4 1835 Major city 12.3 81.4 33.8 11.2 39.8 3.1 38.7 5.7 1055 Other urban 15.9 70.8 13.6 14.5 36.0 3.2 42.6 17.4 781 Rural 17.0 62.6 13.4 13.7 32.1 5.6 41.7 16.0 3940 Province Punjab 1%0 68.0 9,3 11.3 28.1 5.1 50,7 1202 3516 Sindh 17.2 63.3 32.5 18.6 38.2 3.7 22.5 23.2 1222 NWFP 12.2 61.1 19.1 15.3 53.6 7.2 29.7 12.8 815 Balocbistan 8.3 77.4 40.5 11.6 54.6 0.0 16.9 14.6 222 Education level attended No education 16.5 62.8 14.4 13.4 31.9 4.3 43.0 17.3 4457 Pnnuuy 16.6 76.8 20.2 12.7 36.4 11.2 38.1 5.2 588 Middle 13.9 92.4 19.2 21.0 53.3 5,4 37.0 2,0 277 Secondary + 11.2 78.3 34.4 9.1 38.8 1.9 27.6 6.3 454 Total 16.0 66.4 16.3 13,4 33.7 4.9 41.4 14.8 5776 Note: Fistn'es are for chikh'en born in the period 1-59 months pn~edin 8 the survey. qndudes hospital, clinic, Rural Health Cenlae, Basic Henith Unit, private doctor, Family Welfare Worke~ and Lady Health Vialtor 138 Figure 10.3 Prevalence of ARI Symptoms and Fever in the Two Weeks Preceding the Survey COUgh/Rapid Breath. ~6 Monthe 6-11 Months 12-23 Months 24-59 Months Fever ~6 Monthe 6-11 Months 12-23 Monthe 24-59 Months 0 Note: Ba led on ch i ldren age 1-59 months. ~\\\\\\\\\~ 23 10 20 30 Percent I~Taksn to Heallh Fac. 43 40 50 ~]No| Taken 1o H, FIDC. I PDHS 1990-91 Two-thirds (66 percent) of the children who suffered ARI symptoms were taken to a health facility or health provider for treatment. Children most likely to be treated were those age 6-11 months, those living in urban areas, particularly major cities, and those whose mothers had a middle school education. In Balochistan, where health facilities are sparse, the proportion of children going for treatment was the highest (77 percent), although other provinces would be expected to have better service coverage. The findings on ARI from B alochistan may reflect differences in reporting; perhaps only the most severe cases were reported and were also therefore more likely to receive care. One-third (34 percent) of the children were treated with cough syrup, while 16 percent were given anlibiotics and 13 percent were given injections. Two of five children (41 percent) were given other treatments, while 15 percent were not treated at all. Children most likely to have untreated symptoms were those four years of age, children of the highest birth orders, children in Sindh, and children whose mothers had no education. Prevalence of Fever During the period of interviewing for the PDHS, fever, a sign of malaria as well as other illnesses, was more prevalent (30 percent) than cough with rapid breathing (16 percent). The incidence of fever was particularly high (43 percent) among infants age 6-11 months (see Table 10.11 and Figure 10.3). This is the age at which young children are most vulnerable to beth fever and ARI. The prevalence of fever was found to be almost the same among males and females, in almost all birth orders, and in urban and rural areas. Its prevalence was highest (34 percent) in Sindh and lowest (16 percent) in Balochistan. Fever was also more prevalent among children of women with no education. 139 Table 10.11 Prevalence and ta~amgnt of fever Percentage of children under five with a fever dunn 8 the two weeks tneceding the su_~ey, and the percentage of children with a fever who were txeated with spe~fic remedies, by selected background characteristics, Pakistan 1990-91 Among children with fever Percentage Percentage Percentage taeated with: of taken to children a health Andblotic Number Background with facility or Anti- pill or Horm of characteristic fever provider 1 malarial syrup Injection remedy Other None children Child's age <6 months 29.5 68.7 8.5 21.5 14.8 8,8 59.5 13.9 679 6-11 months 42.6 66.6 5.8 21.2 12.4 5,1 69.9 II.0 608 12-23 months 35.5 65.0 6.1 20.9 12.2 4,4 66.5 14.0 1215 24-35 months 30.5 65.9 7.3 18.3 18.9 %9 55.5 18.3 1141 36-47 rnc~ths 23.5 67.4 5.4 15.0 14.1 2.3 67.4 15.7 1167 48-59 mottths 23.3 54.4 4.5 20.0 13.9 3.6 54.7 19.6 966 Sex Male 30.3 66.7 5.9 18.7 14.9 6.2 63.8 14.3 2942 Female 29.9 62.9 6.7 20.2 13.8 4,3 61.4 16.5 2833 Birth ceder 1 29.5 67.3 5.6 22.6 11.5 6.5 62.8 10.7 1026 2-3 29.8 64.3 6.4 19.2 12.6 5.6 67.4 12.9 1869 4-5 30.0 67.5 5.7 19.0 13,7 4.8 62.3 15.2 1377 6+ 31.0 61.5 7.1 18.0 19.0 4.6 57.0 21.5 1504 Residence Total urban 30.9 75.7 9.1 27.9 13.2 2.4 63,9 11,2 1835 Major city 31.2 78.0 7.9 33.7 11.1 1.8 67.4 8.7 1055 Other urbea 30.4 72.5 10.6 20.0 16.1 3.2 59.0 14.7 781 Rural 29.7 59.6 4.9 15.3 15.0 6.7 62.0 17.4 3940 Province Punjab 30.8 63.1 4.5 10.2 11.6 7.0 67.0 14.7 3516 S'mdh 34.2 72.4 11.4 37.1 22.0 1.5 49.6 16.7 1222 NWFP 24.9 60.8 4.1 30.7 15.0 5.1 70.7 13.1 815 Balochistan 16.1 51.7 10.5 29.5 7.2 0.3 37.1 31.6 222 Mother's education level No education 31.1 61.1 5.8 17.0 14.8 5.7 62.0 17.4 4457 Primary 29.4 80.5 7.5 24.5 14.5 4.7 63.0 9.3 588 Middle 20.6 79.4 14.1 27.3 16.5 4.9 58.7 12.0 277 Secondary + 26.6 78.5 6.4 36.7 9.0 1.0 71.0 2.7 454 Total 30.1 64.8 6.3 19.4 14.4 5.3 62.6 15.4 5776 Note: Figurts are for ch i l~n Ix~rn in the imtiod 1-59 months pt~mding the survey. l lndudm hml~tal, clinic, Rural Health Cent~, B~ic Health Unit, private doctor, F~mfily Visitor Wdfax~ Worker and Lady Health 140 As was seen for ARI symptoms, two- thirds (65 percent) of the children having fever during the two weeks pre~,eding the survey were taken to health facilities for treatment. Only 6 percent of children with a fever were treated with antimalarial medi- cine, 19 percent received an antibiotic, and 14 percent were given an injection. Almost two-thirds (63 percent) of the children who had a fever were treated with other medicine. Prevalence of Diarrhoea Diarrhoeal disease is a major cause of infant and child morbidity and mortality in Pakistan. In Table 10.12, the prevalence of diarrhoea among children under five during the preceding 24 hours and the preceding 2 weeks is presented by background character- istics of children and their mothers. Fifteen percent of all children had suffered from diarrhoea during the previous two weeks, while two percent had suffered from bloody diarrhoea. Because of the seasonality of bloody dysentery, with more cases occurring during the monsoon season and the hot sea- son, these figures may underestimate annual prevalence. Eight percent of the children were reported as having diarrhoea in the past 24 hours. The incidence of diarrhoea was highest among children under two years of age. Regionally, Balochistan had the lowest prevalence (8 percent), and Sindh the highest (20 percent). Prevalences were lowest (10 percent) among mothers with secondary or higher level education. The pattern of differ- entials for diarrhoea in the previous 24 hours is similar to that for diarrhoea in the pre- ceding two weeks. Given the low prevalence of bloody diarrhoea, it is difficult to detect differences according to background characteristics. Knowledge and Use of ORS Packets Table 10.12 Prevalence of diarrhoea Percentage of children trader five who bed diarrhoea and bloody diarrhoea in the two weeks preceding the survey, and the percentage who had diarrhoea in the preceding 24 hours, by selected beekgroond chasaeteristics, Pakistan 1990-91 Diarrhoea in the Any preceding 2 weeks t diarrhoea in Number Background All Dim'rhoea precedin~ of characteristic diarrhoea with blood 24 hours ~ childre~ Child's age <6 months 18.4 1.4 12,2 679 6-11 months 20.2 1.4 12.3 608 12-23 months 19.2 1.9 11.4 1215 24-35 months 15.9 2.3 9.4 1141 36-47 months 9.3 0.7 3.9 1167 48-59 months 7.1 1.4 3.2 966 Sex Male 15.0 2.0 8.7 2942 Female 14.1 1.1 7.9 2833 Birth order 1 15.2 1.5 8.9 1026 2-3 15.0 1.2 8.9 1869 4-5 13.5 1.9 7.6 1377 6+ 14.4 1.8 7.7 1504 Residence Total urban 15.0 0.9 7.7 1835 Major city 15.t 0.9 7.5 1055 Other urban 15.0 1.0 8.0 781 Rural 14.3 1.8 8.5 3940 Province Punjab 14.4 1.7 8.0 3516 Sindh 19.6 1.5 10.6 1222 NWFP 9.6 1.1 7.0 815 Balochistan 8.3 1.8 4.5 222 Mother's education level No education 14.6 1.7 8.3 4457 Primary 17.0 1.6 9.6 588 Middle 16.2 -- 11.0 277 Secondary + 9.5 1.1 4.7 454 Total 14.5 1.6 8.3 5776 Note: Figures are for children born in the period 1-59 preceding the survey. -- l.,ess than 0.05 percant llneludes diarrhoea in the past 24 hours 2Includes diarrhoea with blood months The government's information, education, and communication (IEC) programme has focused primarily on educating couples, particularly mothers, about the prevention of diarrhoea and childhood death due to dehydration. In the PDHS, information was obtained about knowledge and use of ORS packets. Mixed with water, the commercially prepared packets of oral rehydration salts (ORS) are used in oral rehydration therapy (ORT) to treat dehydration due to diarrhoea. Since knowledge of ORS is a prerequisite 141 for its use, special efforts were made to investigate the extent and accuracy of mothers' knowledge of ORS, in addition to determining its use for diarrheal treatment. Table 10.13 and Figure 10.4 show that knowledge of ORS is very widespread (90 percent of the mothers recognised ORS packets). Recognition was relatively low among teenage mothers, among rural women, particularly women in Balochistan, and among women with no education. Knowledge of ORS was almost universal among women with any education and among women l iving in NWFP (99 percent). Table 10.13 Knowledge and use of ORS packets Percentage of mothers with births in the five years preceding the survey who know about and have ever used ORS packets and the percentage of users who prepared the solution corr~dy, by background characteristics, Pakistan 1990-91 Percentage Percentage Percentage who of users who know have ever Number who prepared Number Background about ORS used ORS of solution of characteristic packets packets mothers correetiy I users Mother's age 15-19 83.4 45.9 209 65.0 93 20-24 88.8 60.3 774 72.5 462 25-29 91.0 67.9 1202 74.6 804 30-34 90.5 66.4 859 76.9 570 35+ 89.3 61.1 1016 70.2 616 Residence Total urban 96.7 79.9 1184 81.7 943 Major city 97.2 82.6 669 83.6 552 Other urban 96.1 76.5 515 79.0 391 Rural 86.7 56.4 2876 68.4 1603 Province Punjab 89.8 61.2 2441 75.7 1478 Sindh 89.1 65.8 893 68.5 586 NWFP 98.6 75.4 567 71.2 427 Balochistan 58.9 38.2 I59 75.2 55 Education level attended No education 87.3 58.5 3213 70.0 1861 Primary 98.3 76.8 373 78.5 286 Middle 98.9 81.7 172 77.8 138 Secondary + 99.1 86.4 301 89.0 261 Total 89.7 63.3 4059 73.3 2546 Xlt is assumed that the solution was prepared correctly if the whore packet was prepared at once and the amount of water used was 800-1200 millilitres. 142 Figure 10.4 Knowledge and Use of ORS by Residence and Province Percent 97 99 100 87 90 89 80 80 66 75 66 56 6~ 59 60 53 46 45 38 40 20 0 Urban Rural Punish Sindh NWFP BalochlMan RESIDENCE PROVINCE I --Knowledge of ORS ~Ever U.edORS EZ]Correct Pr~ ORS I Note: eased on mothers w i th ch i ld ren under age five. PDHS 1990-91 The survey indicates that about two-thirds (63 percent) of the mothers had ever used ORS packets. Frequencies for use of ORS by background characteristics of the mother followed the same pattern noted for knowledge of ORS, though knowledge was considerably more widespread than use in each subgroup. Among mothers who had used ORS packets, about three-quarters (73 percent) had mixed the solution correctly the last time they had prepared it. Women living in rural areas, those with no education and young mothers were less likely to have prepared the solution correctly. Treatment of Diarrhoea Table 10.14 and Figure 10.5 indicate that almost half (48 percent) of the children with diarrhoea in the two weeks preceding the survey were taken to a health facility for treatment. Children who live in urban areas, those in Sindh, and children of educated mothers were more likely to be taken to a health facility or provider than other children. Older children (48-59 munths) and males were less likely to be taken to a health facility. About two of five children (39 percen0 with diarrhoea were treated with ORS packets, but 50 percent were given oral rehydration therapy (ORT) or increased fluids. Allopathic medicines (antibiotics or injections) were received by about 11 percent of children who had diarrhoea. In general, children who were very young (less than 6 months), those in rural areas, and those whose mothers had little orno education were less likely to be treated appropriately, i.e., with ORT or increased fluids. There was no consistent pattern by birth order of the child, although low birth order children were generally less likely to get appropriate care. 143 Taldo 10.14 Treatment ofdia_,Thoea Percentage of children under five years who had ¢fiarrhoea in the two weeks l~eceding the su~ey who were taken for treatment to a health facility or l~ovider, the pamenU~ge who received oral rehydrafion therapy (ORT), the percentage who w.celved increased fluids, the percentage who received neither ORT nor increased fluids, and the percentage receiving other treatments, by selected background characteristics, Paldstan 1990-91 Oral rehydrafion therapy (ORT) Purc~ntage percentage receiving percentage receiving other treatments: taken to Sugar, Percentage neither Number of a health salt, Other receiving ORT nor Home children Background facility or ORS water home increased increased Anti- In- remedy, with characteristic Ftovid~ l packets solution fluid fluids fluids biotics Injection other diarrhoea Child's age <6 months 43.2 25.6 12.0 5.9 4.8 62.2 3.3 2.0 23.4 125 6-11 months 52.9 42.5 10.7 11.6 8.1 48.7 8.7 0.2 36.5 123 12-23 months 54.2 43.9 14.5 21.1 12.5 43.6 11.4 1.5 28.6 233 24-35 months 44.4 37.7 10.9 22.2 8.2 50.4 11.9 2.5 25.3 181 36-47 months 52.2 40.2 13.3 19.3 7.6 46.4 13.3 1.7 42.5 109 48-59 months 33.0 39.6 5.9 14.7 8.6 51.1 2.3 3.3 33.2 69 Sex Male 43.4 38.2 11.5 15.6 10.3 49.7 9.8 1.6 26.5 441 Female 53.6 39.4 12.4 18.4 7.l 49.4 8.9 1.9 34.7 400 Birth order 1 ¢8.0 31.9 13.4 9,9 7.0 57.4 5.9 -- 25.6 156 2-3 48.1 37.1 14.1 15.7 5.6 53,3 11,4 1,5 29.1 281 4-5 44.6 39.4 7.3 20.8 13.8 44.0 10.5 2.8 30.8 186 6+ 51.8 45.4 12.0 20.3 10.0 43.8 8.4 2.4 35.3 217 Residence Urban 62.7 46.9 24.2 17.7 12,4 38.7 14.2 1.0 30.3 276 Major city 65.6 53.8 33,4 17.2 13.3 30.6 18.0 0,9 26.8 159 Other urban 58.8 37.5 11.6 18.4 11.1 49.7 9.0 1.0 35.1 117 Rural 41.2 34.8 6.0 16.6 7.1 54.9 7.1 2.2 30.5 565 Province Punjab 43.9 35.7 8.0 14.6 8.8 54.0 5.3 1.6 30.4 505 Sindh 59.7 48.4 22.9 21.9 8.9 37.8 17.4 1.8 30.7 239 NWFP 41.5 31.2 4.6 14.7 9.9 59.2 11.1 3.4 35.8 78 Balochistan 48.3 30.2 9.8 26.0 3.4 39.2 9.1 0.3 5.1 18 Education level attended No education 45.0 37.6 9.7 17.2 6.7 50.8 8.0 2.1 30.2 653 Primary 60.7 39.9 16.2 15.8 18.1 51.2 9.5 -- 35.2 100 Middle+ 58.1 46.1 23.9 16.1 13.8 38.7 20.0 1.3 27.0 88 Total 48.3 38.8 11.9 16.9 8.8 49.6 9.4 1.8 30.4 840 Note: Oral rehydration therapy (ORT) includes solution prepazed from ORS packets, home solution made from sugax, salt and water, and other home fluids (such as rice water or lassi). Figures are for children born in the period 1-59 months preceding the su~cy. -- Less than 0.05 perce~t llnclodes hospital, clinic, Rural Health Centre, Basic Health Unit. private doctor, Fanfily Welfare Worker and Lady Health Victor 144 Figure 10.5 Percentage of Children Receiving Treatment for Diarrhoea by Type of Treatment Hea l th Fac i l i ty ORS Packet Sugar , Sal t , Water So lu t ion Other Home Fluid Ant lb lo t l c / In )ec t ion Home Remedy 48 1 ~ J 39 17 tt 0 10 20 30 40 50 60 Percent Note: Based on ch i ldren age 1-59 months who had d ia r rhoea In the two weeks Dreced lng the survey. PDHS 1990-91 The mothers whose children suffered from diarrhoea in the two weeks prior to the survey were asked whether their feeding practices changed during the episode. Among those mothers who were breastfeeding, 65 percent of the children were breastfed as usual during the diarrhoeal episode, while 13 percent either reduced their frequency of breastfeeding or stopped breastfeeding altogether (see Table 10.15). Aside from breast milk, 65 percent of the children got the same amount of fluid as before the episode. Only 9 percent got an increased amount of fluids and 21 percent received a reduced amount of fluids. The same pattern was followed with respect to the consumption of food during the diarrhoea episode. 145 Table 10.15 Feeding practices during diarrhoea Percent distribution of feeding practices among children under five years who had diarrhoea in the two weeks preceding the survey, Pakisteaa 1990-91 Feeding practice during diarrhoea Percent Breesffeedlng frequency 1 Same as usual 65.2 Increased 17.4 Reduced 12.2 Stopped 1.1 Don't know, missing 4.1 Total 100.0 Number of children 439 Amount of fluids given Same as usual 65.4 More 8.8 Less 21.1 Don't know, missing 4.7 Total 109.0 Amount of food given Same as usual 64.8 More 7.7 Less 21.9 Don't know, missing 5.6 Total 100.0 Number of children 840 Note: Figures are for children born in the period 1-59 months preceding the survey. ~Applies only to last child who is still breastfed 146 REFERENCE Grant, James P. 1992. The State of the World's Children 1992. New York: Oxford University Press. 147 CHAPTER 11 FEEDING PATTERNS AND THE NUTRITIONAL STATUS OF CHILDREN Tauseef Ahmed and Mohammad Ayub Over the years, concem has been expressed about the growing number of children living in poor conditions. Poverty affects feeding practices and both of these factors affect the overall mental and physical growth of children. This chapter focuses on the nutritional situation of young children who were born in the five years preceding the survey. Patterns of breastfeeding are of particular interest because of their effects on postpartum amenorrhoea. Some information on this topic has already been provided in the chapter on the proximate determinants of fertility (Chapter 7). Since breastfeeding and food supplementation play a vital role in determining the duration of postpartum amenorrhoea and birth intervals, the dynamics of these feeding practices are of great importance in societies like Pakistan where there is little fertility control at the indi- vidual level. In the PDHS, information was collected on the birth weight of children, breastfeeding practices, and the types of food items given to children before breastfeeding began. Details were also collected on the ages when various liquids and solid or mushy foods were first given to children on a regular basis. The mother was also asked about liquids and solid/mushy foods given to the child and the use of bottles with nipples for feeding children during the 24 hours before the interview for all children alive at the time of the survey. In the PDHS, anthropometric measurements were collected for all the respondents' children age less than five years who were present in the household. Information on breastfeeding patterns and food supplementation is also analysed in this chapter, followed by a description of the nutritional status of children derived from anthropometric measurements. During the 1970s and 1980s, several surveys in Pakistan identified infants and young children considered to be at high risk of being undernourished. One study found that 48 percent of all Pakistani children were malnourished and 10 percent were severely malnourished (Nutrition Division 1988). Anemia is another serious nutrition-related condition that has been reported for 65 percent of young children and 45 percent of pregnant mothers. Undemutrition is less prominent among infants under 6 months of age but increases rapidly with age. 11.1 Breastfeeding and Nutritional Intake In this section we focus on breastfeeding and the nutritional intake of children born in the five years preceding the survey. Table 11.1 shows the percentage of children who were ever breastfed and at what stage infants first received breast milk. It is well documented that breastfeeding is quite common in Pakistan (Population Welfare Division 1986). The PDHS data are consistent with these findings. About 94 percent of all infants born in the five years preceding the survey were ever breastfed by their mothers. This figure is similar to the values from the 1984-85 PCPS (98 percent) and the 1975 PFS (95 percent). Breastfeeding practices in traditional societies such as Pakistan are based on cultural norms and social expectations. Differentials for various background characteristics are also presented in Table 11.1. The differentials are generally quite small, since at least 89 percent of children in every subgroup had been breastfed at some time. Children born in a health facility are less likely to be breastfed (89 percent) than children born at home (96 percent). Among babies of mothers with no education 94 percent had been breastfed, compared to 89 percent of children whose mothers had some secondary or higher education. A slightly smaller proportion of babies in the major cities had been breastfed (91 percent) than babies in the rest of the country (94 percent). These 149 Table 11.1 Initial brcesffceding Percentage of all children born in the five yeEs preceding the su~ey who were ever breasffed and the percemage of last*born children who started brcesffceding within one hour and within one day of birth, according to select~l backgroond cheaacteristlcs, Pakistan 1990-91 Among last-horn children Among all children Percentage Percentage started started Number Percentage Number tncesffeeding breasffeeding of Background ever of within within last-born characteristic bvmsffed children 1 hour of birth 1 day of birth children Time since birth 0-11 months 95.3 1446 7.4 25.5 1423 12-23 months 93.7 1337 10.6 26.0 1207 24-35 months 92.2 1295 9.6 27.7 746 36-47 months 94.0 1325 7.2 24.5 439 48-59 months 91.8 1088 3.4 23.3 244 Sex of child Male 93.3 3339 8.4 25.5 2085 Female 93.7 3151 8.6 26.2 1975 Residence Total urban 92.3 1995 6.3 28.8 1184 Major city 91.0 1148 4.1 30.4 669 Other urban 94.1 847 9.1 26.7 515 Rural 94.1 4495 9.4 24.6 2876 Province Punjab 93.3 3973 6.8 15.5 2441 Sindh 92.3 1390 12.5 51.4 893 NWFP 96.1 875 8.9 23.4 567 Balochistan 94.5 252 10.5 47.8 159 F.~lucatlon level attended No education 94.1 5055 9.2 25.7 3213 Primary 94.3 649 6.4 23.1 373 Middle 90.2 305 3.8 22.5 172 Secondary+ 88.5 481 6.6 33.0 301 Assistance at delivery 1 MedicaLly trained 92.5 2283 5.9 25.9 1400 Traditional midwife 95.5 3399 10.6 26.4 2155 Other or none 96.9 715 6.4 23.4 474 Place of dellvery I Health facility 88.6 863 6.3 33.8 546 At home 95.6 5538 8.8 24.6 3488 Total 93.5 6490 8.5 25.8 4059 IExcl-d*~ 94 children and 31 lint-born childre~ with nwsing dam on assistance at delivery and 89 childre~ end 25 last-born cl~k~en with missing data or other responses on place of delivery. 150 differences may be due to family social status and, to a certain extent, to mother's education rather than cultural norms, which may be more flexible among higher status and more educated women. An important dimension relating to breastfeeding is the timing of initiation. Though 94 percent of all babies were breasffed at some time, only 9 percent started breastfeeding within the first hour of l i fe . 1 Furthermore, only 26 percent of last-bom children were put to the breast within the first day of life. The small percentage initiating breastfeeding during the first hour of life may be due to the social practice of not giving colostrum to newborns. There were no major differentials in initiating breastfeeding on the first day by gender, time since birth, or urban-rural residence. However, there were substantial differences between provinces. For instance, last-bom children in Sindh and Balochistan stand a much greater chance of being put to the breast within one day of birth than babies born in Punjab or NWFP. Similarly, infants born to mothers with secondary education or more, and those born in a medical facility have a slightly greater chance of receiving breast milk in the first day of life. For last-bom children who had ever been breastfed, mothers were asked what the newborn had been given to drink before being put to the breast. Table 11.2 shows the percentage of such children who were given various liquids or food items before being put to the breast, according to selected background characteristics. About 30 percent of the babies were given water before breastfeeding was started and similar percentages were given either ghutti or honey. Nineteen percent received milk and 13 percent were given rose water/amq or sugar. No major sex differentials in the intake of various food items were reported by mothers. For the three main items given to the youngest child, major differences are shown by place of residence. More children living in major cities were given water, ghutti, or honey than children living in other urban or rural areas. A major differential is also observed among provinces. Water was given more often in Baiochistan (43 percent) and Sindh (38 percent), while 52 percent of the children were given ghutti and 29 percent received tea in NWFP (Figure 11.1). Similarly, more than half of all children in Sindh (53 percent) were given honey before breastfeeding was started. A significant difference is also seen in giving milk. In Punjab, one-quarter of newborns were given milk before being put to the breast compared to less than 10 percent in other provinces. Giving water and honey before starting breastfeeding is positively correlated with mothers' education, which may also be taken as an indication of easy accessibility of these items to educated mothers. The presence of a medically trained person at the time of birth of a child and the place of delivery are related to what the newbom was given before breastfeeding was started. Table 11.2 shows that mothers who were assisted in their last birth by medically trained persons were more likely to give their baby various liquids than those who were assisted by traditional midwives. The intake of water and honey is higher for children whose delivery was assisted by traditional midwives or medically trained persons than for other children. Mothers who delivered at a health facility are twice as likely to have given water or honey than mothers who delivered at home. The greater propensity of giving water and honey to children born in health facilities and those assisted by medically trained personnel is related to the popularity of this practice in urban areas. This information was collected only for the last-born child. 151 Table 11.2 Liquids and food items given before breastfeeafin~ Pcrcentege of last-born chfld~n born in the five years i~recedlng the storey who were given liquids or food items before being put to the breast, according to selected background characteristics, Pakistan 1990-91 percentage given Liquid or food Araq/ Number Background rose of characteristic Water Ghu~ Honey Sugar Milk Ghee Butter Oil Tea water Other children Sex of child Male 30.3 32.7 29.6 12.6 18.4 3.6 1.2 5.0 5.9 13.6 5.5 1981 Female 28.8 30.6 31.0 13.8 18.8 3.6 1.6 6.4 5.4 11.4 4.8 1870 Residence Total urban 47.3 39.2 52.8 11.6 16.0 1.8 0.5 0.9 5.9 9.4 6.4 IIII Major dry 57.8 41.5 64.8 10.6 11.5 1.8 0.2 0.7 5.5 7.1 6.8 624 Other uaban 33.8 36.2 37.3 12.9 21.8 1.8 0.9 1.1 6.5 12.3 5.9 486 Rural 22.4 28.6 21.2 13.8 19.7 4.4 1.8 7.6 5.5 13.8 4.6 2740 ProvJnoe Punjab 28.7 29.4 26.5 15.1 27.0 4.0 1.4 7.1 1.2 20.7 5.3 2302 Sindh 38.3 28.2 52.9 10.6 8.4 0.6 2.3 0.7 2.8 0.4 5.3 847 NWFP 16.0 51.8 9.0 8.5 3.9 7.5 0.2 8.6 29.0 0.2 2.6 551 Balochistan 42.8 12.8 38.1 15.1 1.8 0.6 1.2 1.5 3.6 0.6 10.7 151 Education levd attended No education 26.3 30.1 25.1 13.3 18.7 3.9 1.6 6.8 6.2 12.3 4.6 3059 primary 32.3 37.9 41.8 14.9 18.3 3.3 1.1 2.3 4.7 17.3 5.5 353 Middle 40.3 44.9 48.1 13.6 12.7 2.2 0.6 1.4 3.9 20.6 5.8 165 Secondary+ 56.6 33.9 62.5 9.9 21.0 1.6 0.0 0.6 1.6 4.1 10.2 273 As~stance at delivery ~ Medically trained 38.0 34.3 43.7 9.5 20.4 1.8 1.1 2.4 4.4 12.7 6.5 1316 Traditional rn/dwife 26.4 29.6 25.5 15.8 19.8 2.8 1.7 6.6 4.0 14.1 4.6 2067 Other or none 20.0 33.3 14.0 11.5 8.4 12.7 1.3 I0.I 16.6 4.5 4.0 457 Place of dd|vegy 1 Health facility 50.3 31.7 59.7 I0.I 14,1 0.6 0.3 0.I 5.1 6.1 9.2 505 At home 26.4 31.7 25.9 13.6 19.3 4.0 1.6 6.5 5,7 13,5 4.5 3341 Total 29.6 31.7 30.3 13.2 18.6 3.6 1.4 5.7 5.6 12.5 5.2 3851 Note: Figun~s are for lut child~,n who wen ever b~.asffed, Pe~x~ntages add to more than 100.0 because children may have received more than one item IExdudea 11 children with missing data on assistance at delivery and 5 children with missing data ~ other responses on place of d~livei~/. 152 Figure 11.1 Percentage of Children Given Selected Liquids Before Being Put to the Breast by Province Percent 60 50 40 30 20 10 0 Water Ohutt l Honey Sugar Wafer Mi lk Tea I mPunJab mmlaindh [~]NWFP EImlBal°chletan / Note: Based on youngest child under age five. PDHS 1990-91 Another important issue is current nutritional intake. Table 11.3 and Figure 11.2 show liquids and food items given to youngest children during the 24 hours before the interview. Plain water was given to the largest proportion of children (83 percent) followed by solid or mushy food given to 63 percent of children. The intake of the major items consumed (water, fresh milk and solid or mushy food) is positively related to age. Older children are much more likely to be provided with solid or mushy foods than younger children. This is expected since older children have a greater need for solid or mushy food than younger children. The consumption of ghutti, sugar/honey water and gripe water generally declines as children grow older. After the age of six months, a substantial proportion of children start consuming solid food. However, even at age 9-11 months, only a slight majority of children are given any solid or mushy food. 153 Talde 11.3 Nutxilicml intake Percentage of youngest living chilthen under age five given various liquids and food items the day before the interview, by age of child and type of liquid of food item, pakistan 1990-91 ABe of cld]d 0-1 2-3 4-6 7-8 9-11 12-17 18-23 24-59 Liquid or food month months months months montlm mondm months months Total Plain water 46.3 56.2 65.2 73.8 73.8 9].4 91.5 97.2 83.4 Ghutti 28,8 16.6 11.2 8.6 4.9 2.3 3.3 2.2 6.4 Sugar or ho~ey water 11.6 9.0 6.3 5.4 2.1 2.1 3.1 3.8 4.5 Juice -- 0.4 1.2 5,2 2.9 4.3 10.0 6.8 4,9 Herbal tea 9.1 9.9 8.5 9.9 10.0 14.9 22.2 22.8 16.5 Gripe water 20.7 32.8 38.1 28.6 25.6 20.5 14.8 6.9 18.6 Baby formula 0.4 1.8 3.8 4.0 2.1 3.4 1.5 0.8 2.0 Fresh r~Lk 22.8 30.9 34.4 41.0 47.4 48.5 50.9 56.1 46.4 Tinned/Powdered milk 2. ] 2.4 2.7 2.8 2.3 2.4 1.9 1.4 2.0 Other liquid 6.3 9.1 5.0 ~ 3.5 6.7 4.9 8.6 7.3 6.6 Any solid or mushy food 0.3 5.5 15.2 36.6 52.0 71.9 83.4 95.2 63.2 Liquid end sofid 0.3 5.1 11.9 29.7 39.0 50.3 63.6 69.9 46.6 Number 232 270 368 229 255 700 427 1317 3797 Note: Percentages add to more than 100.0 because children may have received more than one item. -- Less than 0.05 percent Figure 11.2 Percentage of Children Given Water, Milk, or Solid/Mushy Food the Day Before the Interview Percent 100 80 Water 60 / 40 Milk . ~ " ~ "×"- 20; ~ i d / M u s h y Food O< i 0-1 2-3 4-6 7-8 9-11 12-17 Age in Months Note: Ba led on youhgelt child under age five. i 18-23 24-59 PDHS 1990-91 154 All mothers were asked about breasffeeding and food supplementation given to the youngest child in the 24 hours preceding the interview. Table I 1.4 and Figure 11.3 show the pattern of current breastfceding and food supplementation. About 4 percent of all newborns were not being breastfed in their first two months of life. About one-quarter of all infants in the first four months of life were being exclusively breasffed (that is, being fed nothing but breast milk). This percentage drops to 12 percent for children age 8-9 months. More than half of aU infants in the same age group were being brcasffed and were also receiving liquids or solid supplements other than plain water. In every age group through age 21 months, a majority of children were receiving breast milk and supplementation. Almost 72 percent of children who had just completed their first year of life got food supplementation in addition to breasffeeding, while 14 percent of children in the same age group were not being breastfed at all. Table 11.4 Breastfeeding and supplementation Percent distrilmtion of youngest children by breasffeeding status, according to child's age in months, Paldstan 1990-91 Percentage of youngest living children who are: Breasffeeding and receiving Not Plain Number Age in breast- Exclusively water Supple- of months feeding breastfecding only merits Total children 0-1 4.0 27.2 11.5 57.4 100.0 237 2-3 3.2 23.7 9.7 63.4 100.0 272 4-5 6.6 17,6 11.8 64.0 100.0 253 6-7 11.6 15.7 13.3 59.4 100.0 235 8-9 8.6 11.9 20.5 59.0 100.0 209 10-11 18.4 7.7 8.9 65.0 100.0 164 12-13 14.0 5.2 8.9 71.9 100.0 279 14-15 30.0 2.6 8.2 59.2 100.0 265 16-17 39.5 0.4 2.5 57,5 100.0 184 18-19 40.6 3.2 2.6 53.7 100.0 197 20-21 43.8 3.2 2.2 50.8 100.0 142 22-23 52.7 2.0 4.3 41.0 100.0 148 24-25 67.8 2.5 29.7 100.0 184 26-27 78.9 1.0 20.2 100.0 196 28-29 80.9 -- 1.3 17.8 100.0 200 30-31 79.9 1.7 -- 18.4 100.0 190 32-33 75.6 . . . . 24,4 100.0 188 34-35 83.8 . . . . 16.2 100.0 183 Note: Breesffeeding status refers to last 24 hours. -- Less than 0.05 percent 155 Figure 11.3 Breastfeeding among Children Age 0-23 Months Exclusive BF c4 Months Breast Milk With or Without Water Only (4 Months Breast Milk & Solids 6-9 Months Still BF 12-15 Months Still BF 20-23 Months I 25 52 78 20 40 60 Percent 80 100 PDHS 1990*91 Table 11.5 shows in more detail the types of food supplementation received by currently breasffeoding children. The table shows that infant formula was not a major supplement while children were being breasffed. On the contrary, fresh milk is a major component of the diet and its use increases progres- sively from 23 percent for the youngest infants to over 40 percent for children one to two ),cars of age. Other liquids also form a major component of supplementary food but their use decreases with age. Solids and mushy food items do not become an important part of the diet until at least age six months. The transition to solid and mushy foods as a supplement is quite rapid and almost all children arc given these before they complete their third year of life. Nevertheless, according to the mothers' reports, a substantial proportion of breasffceding children were not receiving solid or mushy food cvcn after they reached their second birthday. Of particular interest to both demographers and nutritionists is the use of a bottle with a nipple when breasffe~ding. Bottle feeding has a direct effect on the mother's exposure to the risk of pregnancy and exposes the child to unhygienic conditions (since it is difficult to properly stcrilise the nipple). The PDHS data show that about une-quarter of breasffed children under one year of age were given a boule with a nipple the day before the interview. This is of great concern since women's arnenorrhocic period is shortened when they provide their children with liquids from bottles with a nipple. Simultaneously, these children are at risk due to the use of unstcriliscd boules and the intake of unhygienic liquids. 156 Table 11.5 Type of supplementetton Pelt, enrage of hreuffendiag children who are receiving specific types of food supplementation, and the percentage using a boule with a nipple, according to child's age in months, Pakistml 1990-91 Amon 8 ~f fe~ng children ~tase feceS.ring percentage Stiid/ aria s Number Infant Other Other mushy t bottle of Age in months formula milk [/qu/d food with • n/pple child~ 0-1 0.4 22.8 51.3 0.4 16.9 228 2-3 1.2 31.8 51.2 5.6 30.8 263 4-5 3.1 33.1 54.6 10.6 29.1 236 6-7 2.8 36.0 48.1 29.9 25.7 208 8-9 2.6 31.7 36.4 34.5 26.2 191 10-11 2.4 42.3 43.0 54.7 23.9 134 12-13 4.8 46.0 31.7 57.1 19.3 240 14-15 1.9 36.8 40.4 70.7 18.6 185 16-17 1.6 36.6 44.1 85.2 5.3 111 18-19 1.6 43.9 41.4 77.7 19.3 117 20-21 1.5 23.1 47.8 75.8 14.3 80 22-23 0.3 38.3 39.6 77.7 6.7 70 24-25 3.7 43.2 56.0 82.7 23.9 59 26-27 (--) (55.2) (35.9) (85.8) (12.4) 41 28-29 (--) (39.4) (37.6) (87.3) (llA) 38 30-31 (1.0) (53.2) (23.9) (89.9) (18.4) 38 32-33 (--) (61.5) (24.2) (94.0) (4.9) 46 34-35 (3.9) (40.7) (40.8) (96.2) (7.8) 30 Note: Figures ~e for last 24 hours. P~r.eats by type of supplement since children may have received more than one type of supplement. based on fewer than 50 unweighted cases. -- Less than 0.05 percent may sum to more than 1(30.0 Figures in parentheses are The effect of breasffeeding on the mother and child can also be seen by examining the duration and frequency of breastfeeding. The PDHS data show that the median duration of breasffeeding for all children born in the five years preceding the survey was 20 months (Table 11.6). The mean values for breasffceding calculated directly (19.8 months) or using the prevalence-incidence method (20.2 months) are very dose to the median value. The mean duration of exdusive breastfeeding is three months and full breasffeeding is five months. 2 The results suggest that exclusive breasffeeding is not a common practice in Pakistan except in NWFP. There are a number of differentials in breasffeeding. For example, rural mothers tend to breasffced longer (21 months) than urban mothers (15 months). Male children am not breastfed as long (18 months) as female children (21 months), on the average. More than four-fii~hs of children less than six months of age were breasffed six or more times on the day preceding the interview. This last finding demonstrates the high intensity of breastfeeding in Pakistan. 2 The mean duration of full breasffeeding fc~ last-born children in the 1984-85 PCPS was 6.9 months. 157 Table 11.6 Medi~u duration and frequency of breamffeeding Median dntations of any, exclusive and full breastfeeding and the porcontage of children under six months of age who were breasffed six or more times in the 24 hours preceding the inte~iew, according to selected background characteristics, pa/.-istan 1990-91 Median duration (in months) 1 Numbea" of Any Exclusive Full children Background breast- breast- b~tst- under 3 charaeterimti¢ feeding feeding feedin8 ~ years of age Childrea under six months Breastfed 6+ times Number in last of 24 hours children Sex of child Male 18.3 0.5 0.6 2142 Female 2L l 0,5 0,6 1935 82.9 395 83.5 366 Residence Total urban 14.8 0.4 0.5 1232 82.6 204 Major city 14.4 0.4 0.4 714 82.4 121 Other urban 16.5 (0,5) 0,5 517 82.8 83 Rural 21.0 0.5 0.7 2845 83.4 558 Province Punjab 18.0 0.5 0.6 2504 81.7 441 Sindh 22.8 0.4 0.5 874 82.4 179 NWFP 23.0 2.6 3.9 562 90.7 117 Balochistan * (0.5) (0.6) 137 80.6 25 Mother 's education level No education 21.3 0.5 0.6 3163 83.7 595 Primary * * * 397 82.8 76 Middle * * * 198 (80.9) 32 Secondary+ 12.3 * * 319 79.8 58 Assistance at delivery 3 Medically trained 17.9 0.5 0.5 1444 Traditional midwife 20.8 0.5 0.6 2140 Other or none (24.0) (0.6) (0.7) 447 87,4 254 81.1 401 80.4 103 Total 19.9 0.5 0.6 4077 83.2 762 Mean for all children I 19.8 2.9 4.9 4077 HA HA P/I for all children 4 20.2 2.5 4.6 4077 NA NA Note: Figures in parentheses are based on 25 to 49 onweighted cases. HA = Not applicable * Based on fewer than 25 unweightod eases IMedian and mean based on current status 2Either exclusively breestfed or received only plain wate~ 3Excludes 46 childre~ with missing date on assistance at delivery 4Prey alence -incidence mean 158 All mothers with living children born in the five years preceding the survey were asked about the age at which formula or milk other than breast milk, water, other liquids or any food were first given to their children. Table 11.7 and Figure 11.4 show the age at which liquids or foods were fist given to children 24-59 months on a regular basis. One in five children was given formula or milk, and three-fuurths were given water in the first two months of life. An important determinant of children's growth is the age at which they start receiving solid or mushy foods. One-quarter of all children started receiving such food on a regular basis at 4-6 months of age and the cumulative percentage rose rapidly at higher ages. About 40 percent of all children were never given formula, milk or other liquids on regular basis, while 17 percent never received solid or mushy food on a regular basis. Table 11.7 Age at which liquids and foods were introduced Percent distribution of age at which liquids and foods were given regularly in the first two years of life to children born 24-59 months preceding the survey, Pakistan 1990-91 Food given regularly Age at Solid or ~duet ion Formula Other mushy of liquids/foods or milk Water liquids food Never given regularly 38.4 8.1 38.6 17.1 0-1 month 20.9 74.0 25.0 0.5 2-3 months 6.7 6.6 7.6 2.0 4-6 months 11.4 6.7 12.9 27.2 7-11 months 6.7 2.1 8.2 20.5 12-17 months 9.9 1.4 5.3 26.7 18-23 months 5.1 0.2 1.4 5.2 Don't know, missing 0.8 0.9 1.0 0.8 Total I00.0 I00.0 100,0 I00.0 Note: Figures axe b~scd on 3.708 children. Information was also collected on the reasons for stopping breastfeeding for children age 24-59 months (see Table 11.8). The reason for stopping breastfeeding varies with the age at which breastfeeding was stopped. Less than 18 percent of the children stopped breasffeeding by the sixth month. Among these children, 35 percent of mothers reported that the child died and 15 percent reported their next pregnancy as the main reason for stopping breasffeeding. For children who were not being breasffed by age 6-17 months, the majority of mothers reported that they stopped breastfeeding because they became pregnant again. Mother's illness and the refusal of the child to take the mother's milk were other factors responsible for stoppingbreasffeeding, lnaddition, mothers didnothavesufficientmilkin6-7pereent oftbecases. Besides pregnancy, the other major reason to stop breastfeeding after 17 months of age was that the child had reached the age of weaning. 159 Figure 11.4 Age at Which Liquids and Solid/Mushy Food Were First Given to Children Age 24-59 Months 0-1 MO Water Formula/Milk Other liquids Solid/Mushy 2-3 Moa Water Formula/Milk Other liquids Solld/Muehy m I 4-6 Molt Water Formula/Milk Other Ilquldl Solld/Mulhy Never Water Given Formula/Milk Other liquids Solid/Mushy m 21 11 74 m 7 I • m ? 2r m • =e so 0 20 40 60 Percent 80 100 PDHS 1990-91 Table 11.8 Reasons for stopping breastfeeding Percent distribution of reasons for stopping breasffeeding among ewr-breasffed children born 24-59 months preceding the survey, who stopped b~easffeeding within the first two years of fife, Pakistan 1990-91 Number Age Mother Odid Nit,pie, itopped b~easffeed~g i l l i l l Child breast No Mother Child We,ruing Became breast- stopped weak weak died problem milk wotkin 8 mfu:~.d age pregnant Other Misiing Total feeding 0-5 months 6.6 7.0 34.7 5.6 15.9 0.7 12.6 0.4 14.7 1.6 0.3 100.0 357 6-II months 8.8 1.7 7.7 3.1 7.4 0.8 9.6 1.4 57.8 1.7 -- 100.0 360 12-17 months 5.8 1.4 1.8 1.1 6.1 0.8 8.8 6.1 65.1 1.0 1.9 I00.0 644 18-23 months 6.2 1.1 0.1 1.4 5.6 0.8 6.6 23.6 52.1 1.8 0.6 100.0 603 Total 6,6 2,4 8.3 2.4 8.0 0.8 9.0 9.6 50.6 1.5 0.9 100,0 1964 -- Less than 0.05 percent 160 11.2 Nutritional Status of Children Assessment of nutritional status and related nutrition information is an important objective of the PDHS. Anthropometric measurements were used to assess growth and nutrition of young children. The measurement of children's height, weight, and arm circumference was undertaken after the children's shoes and clothes were removed. The validity of the anthropometric indices, however, depends on the accuracy of the measurements and the age data collected. Children under five years of age were weighed and measured by interviewers who were given special anthropomettie training. They were taught how to weigh children (within 100 grams) using a hanging spring balance scale, and to how to measure the children's height (within 5 millimetres) using a measuring board. In the PDHS, the height of a child under 24 months of age was actually recumbent length, measured with the child lying down on an adjustable wooden measuring board as recommended by the World Health Organisation (WHO). The same board was used to measure the standing height of older children. About 80 percent of the 5,776 children born in the period 1-59 months preceding the survey were weighed and measured. The most common reason for non-measurement was cultural. Mothers, particularly in Balochistan and NWFP, did not want strangers to weigh or measure their young children. Another reason was that the child was not present in the home at the time of the interview. Excluded from the analysis are children whose month and year of birth were not reported by the mother, and those with grossly improbable weight or height measurements due to recording error. The results presented here are based on 4,037 children age 1-59 months. Anthropometric data are particularly sensitive to errors in age reporting. In the survey, age in months was calculated from the information on the child's birth date given by the mother. These data in combination with height and weight information were evaluated using the international reference population of the U.S. National Centre for Health Statistics (NCHS) and the Centres for Disease Control (CDC), as recommended by the World Health Organisation (WHO)) The nutritional status of children was evaluated by calculating the extent to which the anthropometric measurements deviate from measurements for the standard population of healthy well-fed children as defined by the NCI-IS/CDC. Three standard indices have been used to assess nutritional status: • Height-for-age • Weight-for-beight • Weight-for-age Each of these indices provides somewhat different information about the nutritional status of a population of children. During growth, height and weight vary with age, and weight varies with height. Indicators have been developed to standardise the results for children of different ages and heights. Chil- dren who are chronically undernourished are short for their age. A child whose height-for-age is below minus two standard deviations (-2 SD) from the median of the reference population is considered stunted. Chronic undernutrition is a condition which is typically aasociaf~l with adverse environmental conditions existing over a long period of time. The weight-for-height index measures acute undernourishment. A child whose weight-for-height falls below minus two standard deviations (-2 SD) from the median of the reference population is classified as wasted or acutely undernourished. This condition is usually associated with short-term undernourishment as a result of disease or inadequate food supply or consumption. The weight-for-height index does not include age, and is thus free of bias due to age misreporting. Weight-for-age is a composite measure which captures both acute and chronic undemutrition. Children with a weight-for-age below minus two standard deviations (-2 SD) from the median nfthe reference popu- 3 Developed by the U.S. Centres for Disease Control based on data from the U.S. National Centre for Health Statistics (Dibley et al. 1987a, 1987b). 161 lation are considered underweight. Results for each indicator are discussed separately below. In a healthy, well-fed population of children, it is expected that only 2.3 percent of children will fall below minus two standard deviations (-2 SD) from the median oflhe reference population for each of the three indices. Less than one percent of children are expected to be below minus three standard deviations. Height-for-age: The results for stunting are shown in Tables 11.9 and 11.10 for different demographic and socioeconomic characteristics of the population surveyed. Thirty percent of children under five years of age are below minus three standard deviations (-3 SD) from the median of the reference population and half of the children are below minus two standard deviations (-2 SD) from the median. Thus, half of the chil- dren under five years of age are suffering from chronic malnutrition. Sex differences appear to be negli- gible, however, age is significantly correlated with the prevalence of stunting. Stunting is much less com- mon in the first year of life than at ages 1-4. This indicates that as a child grows, the gain in height is less than the standard performance. There is a marked worsening in nutritional status during the first and sec- ond year of life. The degree of stunting does not level off until after age 47 months. Seventeen percent of children under six months of age are classified as stunted compared to over 60 percent of children over three years of age. Birth order shows a positive correlation with the prevalence of stunting. The extent of stunting was also examined by birth interval. As expected, the prevalence of stunting is lower among first- born children and among children born after a long birth interval (over 47 months). The prevalence of stunting is more prominent in rural areas than in urban areas (see Table 11.10), This difference may be explained by the socioeconomic status of the family and the accessibility of better nutrition and health services for the urban population. Similarly, the prevalence of stunting appears to be associated with the overall level of development of the provinces. The rate is lowest (44 percent) in Punjab, and highest in Balochistan (71 percent), the least developed province. Mother's education is negatively correlated with stunting. The prevalence of stunting is 56 percent among children of mothers with no education and only 18 percent among children whose mothers have at least some secondary education. Weight-for-height: Children whose weight-for-heighiis below minus two standard deviations (-2 SD) from the median of the reference population are considered thin or wasted. Those who fall below minus three standard deviations (-3 SD) from the median are classified as severely wasted. About 9 percent of children are moderately wasted and less than 2 percent are severely wasted. The prevalence of wasting does not vary substantially between the sexes, although it is slightly higher among boys. The largest differentials in wasting are seen for mothers' education, which is negatively related to wasting. Ten percent of the children of mothers with no education are classified as wasted compared to 4 percent of the children of mothers with at least some secondary school education. Weight-for-age: The percentage of children classified as underweight is also given in Tables 11.9 and 11.10. Forty percent of children are below minus two standard deviations (-2 SD) from the median for the reference population. There is a positive relationship between the age of the child and the prevalence of underweight. The prevalence of underweight children grows dramatically until children reach one year of age (see Figure 11.5). This may be explained by the dependence of infants on breast milk during the first year and inadequate food supplementation thereafter. More than 40 percent of children arc underweight for their age between their first and fifth birthdays. The proportion of children who are underweight is similar for males and females. There is some increase in the proportion of underweight children with increasing birth order. This increase may be due to the small amount of food available for allocation to each child in large families and the skewed distribution of food favouring older children. First-born children and chil- dren born after a birth interval of more than 47 months are less likely to be underweight than children born after a short birth interval. 162 Table 11.9 Nutritional status by deanographic charac~istics Percentage of children undez five years of age classified as undernourished seco~ling to three a~athropometric indices of nutritional status: height-for-age, weight-for-height md weight-for-age by selected demographic characteristics, pakistan 1990-91 Demographic ch~aeterisfic Height-for-age Weight-for-height Weight-for-age Percentage Percentage Percentage Percentage Percentage Percentage Number below below below below below below of -3 SD -2 SD I -3 SD -2 SD I -3 SD -2 SD l chfldron Child's age <6 months 6.1 16.5 0.8 8.0 4.3 6-11 months 14.6 29.8 2.1 11.4 13.7 12-23 months 30.3 52.2 3.3 10.8 13.0 24-35 months 35.7 56.7 1.1 9.6 19.4 36-47 months 39.2 61.0 2.4 9.1 14.9 48-59 months 39.3 62.8 0.3 6.1 12,4 Chlld's sex Male 29.9 51.0 2.4 10.2 14,0 Female 30,2 48.9 1.2 8.2 13.4 Blrth order I 26.8 45.9 1.6 9.6 10.7 2-3 27.9 47.4 1.9 9.1 12.3 4-5 30.1 49.8 2.2 8.9 12.7 6+ 35.1 56.1 1,4 9.5 18.5 Blrth Interval First birth 26.7 45.8 1.6 9.6 10,6 <24 months 33.9 53.5 2.0 9.1 14.7 24-47 months 31.9 51.7 1.7 9.4 14.5 48+ months 22,7 44.3 1.6 8.5 13.7 Total 30.1 50,0 1.8 9.2 13.7 13.8 460 34.4 452 42.9 847 45.8 841 45.9 813 46.9 625 40.9 2058 40.0 1979 36.6 708 38.2 1304 39.9 972 46.3 1053 36.6 709 44.3 1042 40.9 1663 37.2 623 40.4 4037 Note: Figures are for children born in the period 1-59 months preceding the survey. Each index is expressed in teams of the numbe¢ of standard deviation (SD) units from the median of the NCHS/CDC/WHO inumaationei reference population. 1Includes children who are below -3 SD 163 Table ll.10 Nutritional status by background charaeteaistics Percentage of children under five years of age classified as undernourished according to the three anOu-opometric indices of nutritional status: height-for-age, weighi-for-height and weight-for-age by selected background cbaractaristics, Pakistan 1990-91 Background charactaristic Height-for-age Weight-for-height Weight-for-age Percentage Percentage Percentage Percentage Percentage Percentage Number below below below below below below of -3 SD -2 SD l -3 SD -2 SD 1 -3 SD -2 SD 1 children Residence Total urban 21.5 40.7 1.1 8.1 9.5 32.5 1394 Major city 18.8 38.3 0.3 7.6 7.9 29.6 811 Other urban 25.2 44.0 2.1 8.7 11.6 36.5 583 Rural 34.6 54.9 2.1 9.8 16.0 44.6 2642 Province Punjab 25.7 44.2 2.2 10.2 12.3 37.3 2402 Sindh 35.4 56.0 0.8 8.7 17.3 48.2 938 NWFP 35.8 60.2 1.9 6.7 12.1 38.4 593 Balochistan 50.4 70.8 0.1 6.0 23.7 56.4 104 Mother's educatinn level No education 34.5 55.5 2.1 10.3 16.5 44.9 3057 Primary 23.4 43.8 1.7 7.5 7.1 37.1 441 Middle 15.3 33.2 0.6 5.3 5.0 25.8 200 Secondary+ 7.7 18.2 -- 3.6 2.5 13.0 338 Total 30.1 50.0 1.8 9.2 13.7 40.4 4037 Note: Figures are for children born in the period 1-59 months preceding the survey. Each index is expressed in terms of the numbe~ of standard deviation (SD) units from the median of the NCHS/CDC/WHO intea~ational reference population. -- Less than 0.05 percent 1Includes children who are below -3 SD Among the social factors associated with undemutrition, mother's education is negatively corre- lated with both moderate and severe underweight status in children (Table 11.10). Severe underweight status, i.e., weight-for-age below minus three standard deviations (-3 SD) from the median for the reference population, decreases from 17 percent for children of mothers with no education to 3 percent for those women with at least some secondary school education. With respect to place of residence, major cities have the smallest proportion of underweight children (30 percent); the proportion is higher hi other urban (37 percent) and rural areas (45 percent). Similar to the case of stunting, fewer children are underweight in Punjab (37 percent) and more are underweight in Balochistan (56 percent). 164 Percent Figure 11.5 Percentage of Children Under Five Who Are Underweight by Age 46 46 47 50 43 40 34 3O 2O 10 0 ~6 6-tt 12-23 24-35 38-47 48"59 Age in Months Note: Percentage of children below -2 SO from the median of the Internaflonal referel~ce pop*JIstlon. PDH$ 1990-91 In summary, the nutritional status of children depends on a number factors, beginning with the mother's nutritional stares. ARcr birth, brcasffeeding practices, socioeconomic and demographic factors, and environmental conditions (e.g., water and sanitation facilities) affect the nutritional status of children. Information on birth weight, breasffceding, weaning and feeding practices was also gathered in the PDHS, however, an examination of the nutritional consequences of these factors is beyond the scope of this report. In Pakistan, half of children under five years of age are chronically undernourished (see Figure 11.6). There is a marked deterioration in nutritional status as early as the first year of life. Among the other factors associated with nutritional status, mother's education is the most important, followed by the birth order of the child and place of residence. Children in Salochistan are most likely to be stunted or under- weight. Mothers of these children need special education about infant feeding practices and nutritional intake so that they can improve the mental and physical growth of their children. Arm Circumference Mid-upper arm circumference is easy to measure and compares favourably to other anthropometric measures for the assessment of the risk of death (Briend et al. 1987). Arm circumference has been adopted as a quick screening method for identifying undernourished children in the 1-5 year age group. If arm circumference is between 12.5 and 13.5 cm, the child is considered to be moderately undernourished; val- ues below 12.5 cm indicate severe undemutrition (Shakir and Morley 1974), although cot-off points may vary between populations (Lindtjom 1985). In the PDHS, ann circumference was measured for 79 percent of the children under age five. Among the measured children age 1-4 years, 6 percent had an ann circum- ference of less than 12.5 cm and an additional 12 percent had an ann circumference between 12.5 and 13.5 cm. Therefore, nearly one in every five children was found to be moderately or severely undernourished according to this measure. 165 Percent Figure 11.6 Undernutrition among Children Under Five Years of Age 100 80 col 7~ 5O b Pakistan Punjab SIndh NWFP Balochistan Stunted W Underweight ~ Wasted Note: Percentage of chJldre, below -2 SD from the medien of the InternatloneJ reference population. PDHS lg90-9t 166 REFERENCES Briend, A., B. Wojtyniak, and M.G.M. Rowland. 1987. Arm Circumference and Other Factors in Children at High Risk of Death in Rural Bangladesh. Lancet 2(8561):725-727. Dibley, M. J., J. B. Goldsby, N. W. Staehling, and F.L. Trowbridge. 1987a. Development of Normalized Curves for the International Growth Reference: Historical and Technical Considerations. American Jour- nal of Clinical Nutrition 46(5): 736-748. Dibley, M. J., N. W. Staehling, P. Neiburg, and F. L. Trowbridge. 1987b. Interpretation of Z-Score An- thropometric Indicators Derived from the International Growth Reference. American Journal of Clinical Nutrition 46(5):749-762. Lindtjom, B. 1985. Measuring Acute Malnutrition: A Need to Redefine Cut-offPoints for Arm Circum- ference? Lancet 2(8466):1229-1230. Nutrition Division [Pakistan]. 1988. National Nutrition Survey 1985-87 Report. Islamabad: National Institute of Health. Population Welfare Division [Pakistan]. 1986. Pakistan Contraceptive Prevalence Survey 1984-85. Islamabad: Ministry of Planning and Development. Shakir, A. and D. Morley. 1974. Measuring Malnutrition. Lancet 1(860):758-759. 167 CHAPTER 12 HUSBANDS' SURVEY Sultan S. Hashmi A systematic subsample of one of every three households in the women's survey was selected to obtain information from the husbands of currently married women 15-49 years of age. The topics covered were: demographic, social and economic background; family planning knowledge, attitudes and practices; and fertility preferences. The questionnaire consistexl of a subset of the questions used in the woman's questionnaire (see Appendix D). Only those husbands who had spent the night before the interview in the same household as their wives were interviewed in the survey. The target for the survey was to interview the husbands of one-quarter of eligible women who had completed interviews. Because it was anticipated that the nonresponse rate would be higher for husbands than for women, one-third of all households (rather than one-quarter) were included in the husbands' subsample. Altogether, 1,757 husbands were identified as eligible, out of which 1,354 were interviewed. The response rate was only 77 percent for eligible husbands compared to 96 percent for eligibte women. Nonresponse for husbands was primarily due to the absence of husbands from the household despite repeated visits by the interviewers (at least three visits per household). A small number of the husbands interviewed were married to more than one eligible woman. Therefore, when husbands are matched to their wives, the resulting sample is composed of 1,366 married couples. Consequently, the tables for husbands alone are based on 1,354 cases, whereas the tables for matched couples are based on 1,366 cases. It is o~n alleged that in matters relating to family planning, the focus is too often on women, despite the fact that husbands are equal partners in the reproductive process and have greater responsibility for making family decisions. In addition, women otten mention their husbands as a constraint on the use of contraception (Population Welfare Division 1986). Therefore, the PDHS included a husbands' survey as an integral part of the project. This is the first time since the 1968 National Impact Survey that men have been interviewed in a nationwide demographic survey. The information presented in this chapter provides important data on issues relating to the attitude, behaviour and role of husbands with respect to family planning. These results can be useful for the planning of various components of the Population Welfare Programme--in particular, the information, education and communication (IEC) and service delivery components. In this chapter, husbands and wives are compared with respect to background characteristics and their knowledge, attitudes and practices regarding family planning. A more detailed analysis of husband-wife differentials will be published at a later date. 169 12.1 Background Characteristics Table 12.1 presents the background characteristics of the husbands who were inter- viewed. Relatively few husbands were under 25 years of age and less than one percent were under 20. Atthe upper end of the age range, 17 percent of husbands were 50 years of age and over, while there were no wives beyond age 49 years (due to eligibility requirements). This indicates that many older men are married to women who are younger than themselves. The pattern of older men marrying younger women can be seen in Table 12.2 and Figure 12.1. The wife was older than her hus- band in 5 percent of the cases; however, in the remaining 95 percent of the eases, the husband was the same age as his wife or older. In two- thirds of the cases the husband was older than his wife by 5 years or more and in over one- fourth of cases, the husband was 10 or more years older than his wife. More striking is the proportion of couples in which the husband was older than his wife by 15 or more years (11 percent). The mean difference in ages was nearly seven years in favour of males. The distribution of husbands by place and province of residence is similar to that of ever-married women, implying that the sub- sample of husbands was not significantly dif- ferent from the total sample of female res- pondents (see Tables 3.9 and 12.1)) With re- spect to education, the husbands were substan- tially better educated than the women in the PDHS sample of ever-married women. About half of the husbands had been to school, com- pared to only one-fifth of the women. The gap Table 12.1 Husbands' background characteristics Percent distribution of husbands by selected background charactcrisfice, Pakistan 1990-91 Weighted Unweighted Background Wdghted number of numb¢¢ of characttaistic pert, cot husbands husbands Age < 20 0.6 8 7 20-24 7.4 100 94 25-29 16.0 216 209 30-34 18.2 246 217 35-39 16.4 223 234 40-44 12.9 175 184 45-49 11.4 154 162 50+ 17.2 233 247 Residence Total urban 31.9 432 696 Major city 18.4 250 380 Other t~ban 13.5 183 316 Rural 68.1 922 658 Province Punjab 59.2 801 461 Sindh 25.8 350 364 NWFP 11.2 151 313 Balochistan 3.8 52 216 Education level at~nded No education 50.2 680 633 Primary 19.9 269 249 Middle 9.5 128 129 Secondary+ 20.4 276 343 Occupation Professional, technical 5.3 72 I01 Administrative, managerial 0.7 10 16 Clerical 4.2 56 79 Sales 13.4 181 235 Service 4.9 67 97 Agtle~tm~, fishing 38.7 525 363 Production, transportation, labor 28.9 391 402 Not classifiable 3.9 52 61 Total 100.0 1354 1354 is even more pronounced at higher levels of education. One-fifth of the husbands had a secondary or higher education, whereas only seven percent of ever-married women had attained that level of education. The occupations of husbands arc presented in Table 12.1. Tim PDHS occupation distribution conforms generally to the national pattern measured in the 1986-87 Labour Force Survey (Federal Bureau of Statistics 1987). Since 1986-87, there have been minor increases in the professional and technical occu- pations, sales, production and transportation, and corresponding decreases in agriculture and fishing. This reflects a shift from agricultural to nonagricultural occupations in the four-year period between the two surveys. t It should be noted that this comparison is not based on matched sets of couples. Ratber, it is based on a compari- son of all intezviewed husbands with all ever-married women interviewed in the women's survey. 170 Table 12.2 Age difference between spouses Percent distribution of the manied couples by age difference between spouses end meen age difference between spouses, according to wife's age, Pakistan 1990-91 Wife's age Husband's age - wife's age (in years) Number Mean of Negative 0-4 5-9 10-14 15+ Total difference women 15-19 -- 40.7 32.5 15.9 10.9 100.0 7.8 98 20-24 2.1 43.4 30.9 13.0 10.6 100.0 6.7 222 25-29 5.8 37.6 37.2 13.9 5.5 100.0 6.1 306 30-34 6.3 34.8 34.2 15.0 9.7 100.0 6.4 219 35-39 4.7 36.8 32.1 9.7 16.7 100.0 7.3 209 40-44 9.0 21.9 35.2 20.5 13.5 100.0 7.2 180 45-49 9.3 24.9 33.1 23.2 9.5 100.0 6.7 132 Total 5.4 34.9 33.9 15.2 10.5 100.0 6.7 1366 -- Less then 0.05 percent / 40 35 3O 25 20 15 10 5 / 0 Percent ~0 Figure 12.1 Age Difference Between Husbands and Wives 0-4 5-9 10-14 Age Difference in Years (Husband's Age - Wife'9 Age) 15" PDH8 1990-91 171 In general, younger husbands are better educated than older husbands, although husbands under age 30 are slightly less educated than those age 30-39 (see Table 12.3). Thirty-four percent of the husbands 50 years of age or over had received some education, compared to 49 percent of those age 40-49, 56 percent of those age 30-39 and 52 percent of those under age 30. A similar age pattern is observed with respect to secondary or higher education. By place of residence, more than two-thirds of husbands in urban areas had received some school- ing compared to only 41 percent of rural husbands. Urban-rural differences are particularly pronounced for secondary and higher levels of education. In the urban areas, it would be expected that the highest percent- age of educated husbands would be found in the major cities. But Table 12.3 shows that husbands in small- er urban areas were about as well educated as husbands in the major cities. Although the reasons for this phenomenon are not clear, it is possible that the presence of poorly educated rural migrants in the major cities tends to reduce the average level of education in those areas. Table 12.3 also shows that slightly more than half of the husbands in Punjab and Sindh had some education, whereas somewhat less than half of the husbands in NWFP had received some education. Balo- chistan stands out as having by far the lowest average level of education. In Balochistan, only one-fifth of the husbands had been to school. Table 12.3 Husband's level of education Percent distribution of husbands by level of education attended, according to selected background character- istics, Pakistan 1990-91 Education level attended Background No Secondary Number of characteristic education Primary Middle or higher Total husbands Age < 30 47.8 18.8 12.7 20.8 I00.0 323 30-39 43.5 20.5 10.2 25.7 100.0 468 40-49 50.8 24.0 6.9 18.3 I00.0 329 50+ 66.4 14.2 7.3 12.1 100.0 233 Residence Total urban 31.4 15.2 12.3 41.0 I00.0 432 Major city 32.7 13.3 11.3 42.6 100.0 250 Other urban 29.6 17.9 13.8 38.7 100.0 183 Rural 59.1 22.0 8.2 10.8 100.0 922 Province Punjab 48.4 18.4 11.9 21.3 100.0 801 Sindh 47.9 26.2 5.6 20.4 100.0 350 NWFP 54.9 18.2 8.0 18.8 100.0 151 B alochistan 81.3 5.3 2.7 I0.7 I00.0 52 Occupation Professional, technical, adminislrative, managerial 15.4 16.6 7.1 60.9 100.0 82 Clerical 8.3 9.8 17.7 64.2 100.0 56 Sales 32.3 27.0 12.8 27.9 100.0 181 Seawiee 39.4 17.9 6.3 36.4 100.0 67 Agriculture, fishing 68.8 18.2 6.5 6.6 100.0 525 Production, trnnsportation, labor 52.1 22.4 10.3 15.3 100.0 39I Not classifiable 26.3 11.8 20.8 41.1 100.0 52 Total 50.2 19.9 9.5 20.4 100.0 1354 172 Husbands in white collar professions had received the highest level of education and farmers had the lowest. These differences are notable as they may have important implications for the level of fertility. More than two-thirds of agricultural workers and fishermen had no education. For the white collar occupa- tions, it is surprising that one in six professional and technical workers and one in twelve clerical workers had no formal education. 12.2 Knowledge and Use of Contraception About four-fifths of husbands knew of at least one method of contraception, two-thirds knew a source from which to obtain a contraceptive method, one-fourth reported that they or their spouses had used contraception sometime in the past and about one in seven were current users (see Table 12.4). Knowledge of modem methods was highest for female slerilisation (66 percent), followed by condoms (59 percent), the pill (55 percent), and injection (50 percent). The least known methods were male sterllisation (32 percent), the IUD (29 percent), and vaginal methods (13 percent). Knowledge of traditional methods (49 percent) was far less widespread than knowledge of modem methods (78 percent). Knowledge of a source for obtaining a method (65 percent) was significantly lower than knowledge of the methods themselves (79 percent). This suggests the need for improving knowledge about family planning sources, which means strengthening the information and motivation components of the family planning programme. Table 12.4 Knowledge and use of contraception Percentage of husbmads knowing may contraceptive method, the percentage knowing a source for a method, and the percentage who have ever used and are currently using a method, by specific method, Pakistan 1990-91 Know any method Know a Contraceptive source Ever Currently method Total Unprompted Prompted for method used using Any method 79.3 50.8 28.5 65.1 24.7 15.1 Any modern method 77.7 48.4 29.4 62.4 18.2 10.1 Pill 54.9 24.1 30.8 37,6 4.6 0.8 IUD 28.6 6,8 21.8 20.9 2.9 1.4 Injection 50.0 19.5 30.5 36.9 2.9 0.5 Vaginal. method 12.6 3.2 9.4 10.4 0.4 -- Condom 58.8 32.3 26.4 50.1 12.1 3.6 Female slefilisatio~ 65.7 26,1 39.6 48.6 4.0 3.8 Male sterilisation 31.7 9.3 22.4 22.7 0.1 -- Any tradltonal method 49.4 13.2 36.2 NA 15.7 5.0 Periodic abstinence 38.9 7.1 31.7 27.7 11.7 3.2 Withdrawal 39.9 8.5 31.3 NA 8.3 1.7 Other 1.6 1.6 NA NA 0.3 0.2 Note: Figures arc for 1,354 husbands. -- Less than 0.05 percent NA = Not applicable 173 The pattem of ever use and current use of contraception reported by husbands is also shown in Table 12.4. The most common current method reported by husbands is female sterilisation, followed close- ly by condoms and periodic abstinence. No other method was reported by more than two percent of hus- bands. The use of traditional methods, as reported by the husbands, is substantial; one-third of current users were relying on such methods. Since traditional methods are far less reliable than modem methods, an important goal of the family planning programme should be to shift users of traditional methods to more effective methods. Table 12.5 and Figure 12.2 compare the contraceptive knowledge of husbands and wives. The proportion of couples in which both the husband and the wife had no knowledge of contraception was quite small (only 9 percen0. Among the remaining couples, at least one spouse had knowledge of some method. For more than 60 percent of couples, both spouses knew one or more modem methods of family planning. The best known modem method for both husbands and wives was female sterilisation, while vaginal meth- ods and male sterilisation were least well known. The second and third best known methods were the pill and injection, respectively. Male methods were more likely to be known by husbands and female methods were more likely to be known by wives. Table 12.5 Knowledge of contraception among couples Knowledge of contraception among married couples by specific method, Pakistan 1990-91 Wife Husband knows, Both knows, husband Contraceptive know wife does does Neither method method not know not know knows Total Any method 62.1 17.2 12.0 8.7 100.0 Any modern method 61.3 16.4 13.2 9.0 100.0 Pill 40.9 14.1 20.8 24.2 100.0 IUD 20.1 8.3 30.6 41.0 100.0 Injection 36.4 13.8 23.2 26.6 100.0 Vaginal method 3.2 9.3 8.8 78.8 100.0 Condom 25.6 32.8 7.1 34.5 100.0 Female sterilisation 50.8 14.8 19.0 15.4 100.0 Male sterilisation 9.0 22.7 9.5 58.8 100.0 Any traditional method 14.2 35.1 8.9 41.8 100.0 Periodic abstinence 10.0 28.8 7.0 54.1 100.0 Withdrawal 8.2 31.4 5.8 54.6 100.0 Other 0.4 1.2 2.3 96.1 100.0 Note: Figures are for 1,366 couples. 174 70 60 50 40 30 20 10 0 Figure 12.2 Percentage of Couples in Which Both the Husband and Wife Know Specific Contraceptive Methods Percent Any Any Pill IUD InJ. Vag, Condom Female Male Method Modern Method Stir . Stir, Method POHS 1990-91 Table 12.6 presents knowledge and use of modem contraception among husbands by background characteristics. Husbands residing in major cities and other urban areas were more likely to know about modem methods and the source for obtaining methods than husbands residing in rural areas. The same pattern is observed with regard to ever use and current use of contraception, with the highest level of use reported in major cities. Differences among provinces with respect to knowledge of contraception are negligible. In every province, more than three-quarters of husbands reported some knowledge of modem family planning meth- ods (Figure 12.3). Differences in knowledge of a source for a modem method, and differences in ever use and current use of modem methods are more pronounced. Husbands in Punjab and Sindh had more knowledge of family planning sources as well as higher ever-use and current use levels than husbands in NWFP and Balochistan. Husbands in Balochistan (which is less developed and sparsely populated) had very low levels of ever use and current use of contraception. The level of education has a strong positive association with all of the family planning indicators (see Table 12.6). The differences are particularly pronounced between husbands who had no education or had received a primary school education and those who had a middle school or higher education. Knowledge of contraception is uniformly high, irrespective of the number of living children, rang- ing from 71 percent for husbands who had no living children to 84 percent for those who had two living children. Regarding the source of contraception, except for those with no living children, the contraceptive knowledge of husbands varies within a narrow range from 62 percent for those who had five living children to 68 percent for those who had three living children. Regarding ever use and current use of contraception, there is a positive relationship between the number of living children and use, except for husbands with six or more living children. 175 TAble 12.6 Knowledge end use of modem contraceptive methods Percentage of husbends knowing at least one modem m ~ the percentage knowing a source for a modem method, end the percentage who have ever used end de currently using a mod~ml method, According to selected background characteristics, Pakistan 1990-91 Background chs,r ectetistic Know Ever Currently Know a modern method source used using Number fur modem modem modem of Total Unprompted Prompted method method method husbands Residence Total urban 87.2 59.4 27.8 80.5 36.9 18.9 432 Major city 87.5 53.4 34.1 81.7 41.8 20.5 250 Other urban 86.7 67.6 19.2 78.9 30.1 16.6 183 Rural 73.3 43.2 30.1 54.0 9.4 5.9 922 Province Punjab 78.9 47.8 31.1 63.8 19.9 11.5 801 Sindh 75.4 49.2 26.2 64.9 18.3 9.1 350 NWFP 77.8 53.8 24.0 52.8 14.1 7.8 151 Balochisten 75.4 35.2 40.2 52.2 2.4 1.3 52 Education level attended No education 68.6 34.9 33.7 45.9 9.8 5.4 680 Primary 75.1 49.4 25.7 64,0 12,9 6.9 269 Middle 94.6 66.1 28.6 82,7 31.6 19.0 128 Secondary + 95.0 72.2 22.7 92.1 37.7 20.5 276 Number of Hying children 1 0 71.2 40.3 30.9 43.4 2.4 -- 159 1 76.7 47.7 29.0 64.8 5.6 2.4 164 2 84.2 56.4 27.8 67.1 20.9 9.3 122 3 79.3 50.2 29.0 68.1 21.3 6.9 176 4 80.9 47.2 33.7 67.0 21.9 14.2 239 5 73.1 55.0 18.0 61.6 30.0 21.0 149 6+ 78.3 46.6 31.7 62.9 21.3 12.7 344 Fertility deslres ~ Want more children 77.4 46.0 31.4 58.9 10.1 4,0 581 Want no more children 83.0 59.2 23.8 73.5 27.5 12.4 393 Say wife can't get pregnant (57.7) (34.2) (23.6) (52.9) (21.4) (6.4) 43 Up to Allah 68.4 29.7 38.7 45.2 5.8 3.1 238 Undecided/don't know (77.5) (50.0) (27.5) (64.9) (5.0) (2.8) 43 Sterilised (100.0) (85.6) (14.4) (100.0) (100.0) (100.0) 52 Total 77.7 48.4 29.4 62.4 18.2 10.1 1354 Note: Figures in parentheses are based on 25 to 49 tmweighted cases. -- Less then 0.05 percent 1Excludes 8 husbands with an unknown number of living children 2Excludes 9 husbands with missing information on fertility desires 176 100 SO 60 40 20 0 Figure 12.3 Knowledge of Modern Contraceptive Methods, Knowledge of Sources and Current Use among Husbands by Province Percent 79 ~= 78 Punlab Slndh NWFP Balochlstan PROVINCE I'Kn°wledge ~8°urce ~Current Use i l PDHS 1990-91 Among husbands who said they did not want any more children, 83 percent knew at least one modem method of contraceprion and 74 percent knew a source for obtaining contraception. Only 12 per- cent, however, reported that they were currently using a method. This wide gap suggests that the family planning needs of respondents are not being met. One way of evaluating the reliability of responses on current contraceptive use is to compare infor- marion supplied by husbands and their wives (see Table 12.7). In the aggregate, there is exceUent agree- ment on the use of modem methods of contraceprion--10 percent of husbands say they are currently using a modem method compared to 10.3 percent of wives. On the other hand, husbands are almost twice as likely to report current use of a traditional method of family planning. For individual couples, reporting of current contraceptive use is also more reliable for modem methods than for traditional methods. 177 Table 12.7 Current use of contraeaptltm reported by couples Percent distribution of mmied couples by wife's reported current use of contraception, according to the husband's reported curreaat use of contraception mad type of method, Pakistan 1990-91 Wife's reported use of contraception c~entlyusi~g Tradi- Not Number Husband's reported use Any Modern tional currently of of contraeetpion method method method using Total Percent husbands Currently using any method 66.3 55.6 10.7 33.7 100.0 14.9 204 Modern method 84.9 78.9 6.0 15.1 100.0 10.0 136 Traditional method 29.2 9.1 20.1 70.8 100.0 5.0 68 Not currently using 3.7 2.4 1.3 96.3 100.0 85.1 1162 Total 13.1 10.3 2.7 86.9 100.0 100.0 1366 12.3 Prospect ive Users Husbands who were nonusers of contraception were asked about their intended future use of contra- ception and their method preference. A large majority of husbands did not intend to use contraception at any time in the future. The major reason for not intending to use (cited by 47 percent of husbands) was the desire for more children (see Table 12.8). For 18 percent, religious constraints were the main factor, while 11 percent lacked knowledge of family planning. Another 5 percent gave a fatalistic response and the same percentage reported that they did not need contraception since they or their wives were sterile. There were differences in the reasons given for not intending to use contraception among younger and older men. For men under age 30, the overriding reason was the desire for more children; for men age 30 and over, the reasons were more varied and perceived religious prohibitions on family planning were a major consider- afion. 1"78 Table 12.8 Reasons for not intending to use contraception Percent distribution of main reasons for not intending to use contraception among non-contracepting husbends who do not intend to use in the future, according to age, Pakistan 1990-91 Main reason for not intending Age ,30 30+ Total Went children 80.9 35.3 46.8 Lack of knowledge 5.8 12.2 10.6 Wife opposed -- 0.6 0.5 Costs too much -- 1.5 1.1 Worry about side effects 0.4 2.4 1.9 Health concerns 0.6 1.2 1.0 Hard to get methods -- 0.6 0.4 Religion 8.3 21.8 18.4 Opposed to family planning 0.6 2.0 1.6 Fatalistic 1.6 5.9 4.8 Infrequent sex -- 4.2 3.2 Hard for wife to get pregnant 0.8 5.8 4.6 Wife menopausal, had hysterectomy -- 2.1 1.6 Inconvenient -- 0.2 0.2 Other 0.5 3.3 2.6 Don't know, missing 0.5 1.0 0.8 Total 100.0 100.0 100.0 Number 213 633 846 -- Less than 0.05 percent About 15 percent of all husbands were not using contraception but intended to adopt family plan- ning in the future. Three-fourths of these husbands wanted to start using contraception within the next 12 months (see Table 12.9). The contraceptive methods preferred by those who intended to use during the next 12 months were female sterilisation (22 percent), condoms (21 percent) and injection (13 percent). About one-fifth of this group wanted to use traditional and other methods, while 14 percent were undecided. None of the husbands mentioned male sterilisation as their preferred method. Among those who intended to use contraception after more than one year, 46 percent wanted to use either injection, condoms or female sterilisation, but 41 percent did not know what method they preferred to use. 179 Table 12.9 Preferred method of contrsception for future use PeTcem distribution of contraceptive methods preferred by non- cont~acepting husb~ds who intend to use in the future, according to their intended timing of future use, Pakistan 1990-91 Intends to use Contriceptive In next 12 After 12 method months months Total Pill 9.0 3.9 7.7 IUD 1.2 -- 0.9 Injection 12.5 17.4 13.7 Condom 20.8 15.3 19.4 Female sterilisation 22.3 13.3 20.0 Periodic abstinence 12.3 -- 9.2 Withdrawal 3.0 6.7 3.9 Other 4.8 2.3 4.2 Don't know 14.2 41.0 21.0 Total 100.0 100.0 100.0 Number 149 51 200 -- Less than 0.05 percent 12.4 Approval of Family Planning Husbands as well as wives were asked about their approval of family planning and their perceptions about their spouses' attitudes toward family planning (see Tables 12.10 and 12.11). Overall, the majority of husbands (56 percent) approve of family planning, but a substantial minority (43 percent) disapprove. Wives have a more favourable attitude toward family planning than their husbands. Twice as many wives approve of family planning as disapprove. Since husbands usually have a predominant role in family deci- sion making, the family planning programme should increase efforts to educate and motivate husbands. Forty-three percent of the husbands thought that their wives approved of family planning, 20 per- cent thought that they did not approve and 33 percent did not know whether their wives approved or not. For the first two categories, the husbands' perceptions about their wives' attitudes were correct in most of the cases. In cases in which husbands did not know their wives' opinions, 54 percent of wives actually approved of family planning and 45 percent disapproved. Wives were somewhat less knowledgeable about their spouse's opinion of family planning than were husbands. Specifically, husbands are more favourable toward family planning than their wives be- lieve. In one-third of the cases in which the wife thinks her husband disapproves of family planning, the husband actually approves. Under such circumstances, improved communication between spouses may engender more favourable attitudes toward family planning overall. 180 Table 12.10 Wife's perception of husband's attitude toward family plenn'ml~ Percent distribution of married couples by husband's reported approval or disapproval of family planning, according to wife's perception of husband's approval or disapproval, Pakistan 1990-91 Husband's opinion Number Wife's perception of Husband Husband Don't know, of husband's opinion approves disapproves missing Tom/ Percent wives Wife thinks husband approves 93.1 6.6 0.3 100.0 29.7 406 Wife thinks husband disapproves 31.5 68.0 0.5 100.0 33.5 457 Wife doesn't know husband's opinion 42.7 56.3 1.0 1130.0 32.6 445 Missing 93.0 7.0 100.0 4.2 58 Tom/ 56.1 43.3 0.6 lOG.0 100.0 1366 -- Less than 0.05 percent Table 12.11 Husband's perception of wife's attitude toward family planning Percent distribution of married couples by wife's reported approval or disapproval of family plm'ming, according to husband's perception of wife's approval or disapproval, Pakistma 1990-91 Wife's opinion Number Husband's perception of Wife Wife Don't know, of wife's opinion approves disapproves missing Tom/ Percent husbands Husband thinks wife approves 95.6 3.6 0.8 I00.0 43.1 589 Husband thinks wife disapproves 20.1 79.1 0.9 I00.0 20.2 276 Husband doesn't know wife's opinion 53.7 44.9 1.4 I00.0 32.7 447 Missing 93.0 4.9 2.1 100.0 4.0 54 Total 66.5 32.4 1.0 100.0 100.0 1366 12.5 Acceptabil ity of Media Messages Husbands were asked if they had heard a message about family planning on radio or television during the month preceding the survey and whether that message was effective in persuading couples to use family planning. In addition, husbands were asked whether or not they found it acceptable for family planning messages to be provided on radio or television. Table 12.12 shows that 64 percent of husbands reported that it was acceptable to have such messages broadcast on radio or television. The acceptability of electronic mass media messages is higher among younger men and those who live in urban areas. Among the provinces, the acceptability was highest in Punjab (68 percent) and Sindh (65 percent), followed by Balochistan (54 percent) and NWFP (47 percent). Generally, there is a positive association between the acceptability of media messages and the level of education. 181 Table 12.12 Acceptability of mars media messages on family planning Percentage of husbands who believe that it is acceptable to have messages about family plmmlng on the radio or television by age end selected background characteristics, Pakistan 1990-91 Age Background ch~acteristic <30 30-39 40+ Total Residence Total urban 82.4 79.9 71.6 76.8 Major city 85.3 85.4 69.5 79.1 Other urban 76.5 72.3 73.9 73.8 Rural 65.3 55.7 56.5 58.4 Province Punjab 74.6 66.2 65.1 67.7 Sindh 70.7 67.2 60.3 65.3 NWFP 61,3 39.1 46.9 47.3 Balochistan 31,6 71.3 55,3 54.4 Education level attended No education 57.7 54.3 51,5 53.8 Primary 79.4 51.9 65.7 63.9 Middle (82,8) (83.8) (83.1) 83,3 Secondary+ 83.1 80.1 82.6 81.7 Total 70.3 63.6 61.5 64.3 Note: Figures in parentheses are based on 25 to 49 unweighted cares. Although the majority of husbands were favourable toward having family planning messages broadcast on radio orTV, only 40 percent of the husbands interviewed had actually heard such a message in the last month. Of the latter, 44 percent lived in urban areas and 56 percent lived in rural areas. Most of the husbands, irrespective of residence, thought that the family planning messages were effective (see Table 12.13). A larger percentage of those residing in major cities (88 percent) than those residing in other urban areas (78 percent) or rural areas (75 percent) thought that the messages were effective. Among the provinces, husbands residing in Punjab (84 percent) were more likely to think the messages were effective than those in Sindh (80 percent), Balochistan (60 percent) and NWFP (56 percent). A substantial percentage of husbands in NWFP (29 percent) and in Balochistan (28 percent) thought that the messages were ineffective. This suggests that attempts should be made to modify family planning messages in NWFF and Balochistan to make them more acceptable to the local population. The perceived effectiveness of family planning messages was high in all education groups and was not related to the husband's educational attainment. 182 Table 12.13 Perceived effectiveness of mass media messages on family planning Among husbands who have heard a radio or television message about family planning, the percent dislributiola of perceived effectiveness of the message in persuading couples to use family planning by background characteristics, Pakistan 1990-91 Perceived effectiveness of mass media family planning messages Background Not Don't Number of characteristic Effective effective know Missing Total husbands Residence Total urban 84.1 11,5 3,7 0.7 100.0 239 Major city 87.5 10.9 1.5 0.1 100.0 156 Other urban 77.7 12.5 7.8 1.9 100.0 83 Rural 75.3 12.7 l l .0 1.0 100.0 300 Province Punjab 83.7 7.5 8.8 -- 100.0 282 Sindh 79.9 13.7 4.5 1.9 100.0 194 NWFP 55.8 28.6 14.3 1.2 100.0 51 Balochistan 59.6 27.6 8.2 4.5 100.0 12 Education level attended No education 77.9 11.3 8.5 2.3 I00.0 197 Primary 81.1 7.4 11.5 100.0 100 Middle 75.6 13.1 11.1 0.2 100.0 71 Secondary + 81.0 15.5 3.4 0.1 100.0 171 Total 79.2 12.1 7.8 0.9 100.0 539 -. Less than 0.05 percent 12.6 Fertility Desires and Sex Preference for Children Husbands were asked about the number and gender of their living children and their desire for more children. Table 12.14 shows that 21 percent of husbands wanted another child soon (within two years). This desire is inversely associated with the number of living children. Another 20 percent wanted another child later. The largest proportion of husbands (29 percent) did not want any more children at all. The desire to stop having children is positively associated with the number of living children. The percentage of husbands who want no more children is much larger than the 15 percent of husbands who reported current use of contraception. If those who wanted to postpone having another child are combined with those who did not want any more, the sum would constitute about half of all husbands. This suggests that there is an ample need for family planning, but that motivational programmes and service delivery are not keeping pace with the need. 183 Table 12.14 Reproductive intentions Percent dislfibution of husband's desire for more children, according to number of living children. Pakistan 1990-91 Number of living children I Des~-e for children 0 I 2 3 4 5 6 7+ Total 2 Want another soon 3 67.4 41.5 27.9 19.3 14.2 8.5 8.8 4.1 21.4 Want another later* 16.5 40.1 35.4 30.7 16.4 12.2 8.5 4.9 19.8 Want another, undecided when 3 2.9 1.2 2.0 1.5 3.9 0.1 1.8 0.3 1.6 Undecided -- 0.1 2.9 3.3 3.0 2.4 8.9 4.7 3.2 Up to Allah 8.4 14.8 15.0 19.1 26.5 16.5 17.4 17.6 17.6 Want no more -- 1.3 15.9 23.3 28.0 48.9 42.5 54.9 29.0 Ste~51ised . . . . 0.8 0.4 3.2 7.5 7.3 8.9 3.8 Declared infectmd 4.4 1.0 2.3 4.4 3.4 4.4 4.6 3.2 Missing 0.5 0.2 0.5 0.5 0.3 -- 0.3 Total 100.0 100.0 I00.0 100.0 100.0 I00.0 100.0 100.0 100.0 Number 120 170 133 172 216 182 138 221 1354 -- Less than 0.05 percent Xlncludes current pregnancy 2Total includes two husbands whose number of living children is unknown 3Wants next birth within two years tWants next birth after two or more years Slncludes tin'ring up to Allah and other non-numeric responses Table 12.15 Desire to limit future births Percentage of husbands who want no more children, by number of living sons and daughters, Pakistan 1990-91 Number of living daughters Number of living sons 0 1 2 3+ Total 0 (11.0) (11.4) 2.4 1 5.7 16.0 23.5 24.4 16.7 2 (26.7) 31.8 42.2 53.6 41.3 3+ (27.5) 58.4 66.0 59.1 57.1 Total 8.6 30.2 45.3 46.2 32.8 Note: Women who have bean sterilised are considered to want no more children. Figures in parentheses are based on 25 to 49 unweighted cases. -- Less than 0.05 percent Tab le 12.15 presents husbands ' des i res to s top hav ing ch i ld ren by the number o f l i v ing sons and daughters . A t each par i ty the propor t ion o f husbands who want to s top hav ing ch i ld ren increases w i th the number o f l i v ing sons in the fami ly . Th is pat tern suggests there is a cont inu ing pre ference for sons in Pak is tan . A t the h igher par i t ies , there is a lso some ev idence o f a des i re to have at least one daughter . 184 In Table 12.16 and Figure 12.4, husbands and wives are compared with respect to their desire for more children. Among couples without children or with only one child, in at least four-fifths of the cases both the husband and wife want more children. The desire of couples for more children decreases as the number of children increases. For couples with two or more children, there is considerable disagreement about the desire to have more children. For example, for couples with three children, in 17 percent of the cases the husband wants to have more children while the wife does not. Couples with three to five children are least likely to agree on whether or not to have another child. Table 12.16 Desire for more children by wives and their husbands Percent distribution of couples by number of riving children, according to desire for more children, Pakistan 1990-91 Husband wants more Husband wants no more Husband says up to Allah Wife Wife Wife Wife Wife Wife Number Wife wants says Wife wants says Wife wants says of riving wants no up to wants no up to wants no up to children ! more more Allah more more Allah more more Allah One or both undecided/ missing/wife Percent Number can't get who of pregnant Total agree husbands 0 84.7 2.0 0.8 . . . . . . 5.1 3.1 4.3 100.0 87.8 122 1 79.7 2.5 5.0 -- 0.6 0.7 8.9 0.5 2.1 100.0 80.8 171 2 57.5 6.8 4.8 6.6 6.3 1.5 4.0 2.3 5.0 5.1 100.0 68.8 137 3 27.5 16.9 4.9 3.2 16.7 2.0 4.8 9.4 3.9 10.7 100.0 48.1 174 4 15.5 12.1 7,8 1.9 25.8 2.3 9,8 10.8 3.6 10.4 100.0 44.9 217 5 8.5 8.4 4.5 14.7 37.5 3.8 2.9 6.5 5.0 8.4 100.0 51.0 183 6 8.3 3.1 7.3 1.2 43.5 3.7 3.5 8.5 5.6 15.3 100.0 57.4 140 7+ 1.3 6.3 2.3 0.8 55.0 5.9 2.7 9.1 4.1 12.4 100.0 60.4 221 Total 2 31.5 7.7 4.8 3.6 25.3 2.7 5.3 6.4 3.8 8.9 100.0 60.6 1366 -- Less than 0.05 percent llncludes current pregnancy reported by husband 2Total includes two husbands whose number of riving childzen is unknown. 185 Figure 12.4 Desire for More Children among Husbands and Wives by Number of Living Children Percent 100 80 60 40 20 0 0 + - + . F+-- ++ , I 1 2 3 4 5 Number of Living Children Both Want More + Both Want No More i I 6 7+ Note: Number of living ch i ld ren includes current pregnancy. PDHS 1990-91 12.7 Ideal Number of Ch i ld ren for Husbands and Wives Husbands as well as wives were asked about their ideal number of children and the results are presented in Table 12.17. About 60 percent of both husbands and wives said that the ideal number of children is up to Allah. Aside from the non-numeric responses, there is little agreement between husbands and wives about the exact number of children that would be considered ideal. For example, among women whose ideal was three children, 21 percent of their husbands also wanted three children but 17 percent of their husbands wanted fewer than three children and 18 percent wanted more than three. Overall, less than 10 percent of couples agree on a specific number of children that would be ideal for them (although the figure increases to 23 percent if only numeric responses are considered). Few couples believe that an ideal family would consist of a small number of children. 186 Table 12.17 Ideal number of c~'dldren of wives and their husbmds Perce~ disuribution of husband's ideal number of chiidrm, according to wife's ideal number of cldldcen. Pakistan 1990-91 Husband's ideal number of childre~ Wife's ideal number 2 or of children fewer 3 4 Other non- Number Up to numeric of 5+ Allah response Total women 2 or fewer 18.5 24.3 3 16.6 21.3 4 8.1 7.4 5+ 2.7 3.4 Up to Allah/other non-numeric response 1.7 3.9 Total 4.8 6.6 Number of husbands 66 90 12.0 5.4 37.2 2.6 I00.0 65 14.5 3.4 42.5 1.8 I00.0 89 27.4 13.0 42,0 2.1 100.0 263 14.1 15.8 62.0 1.9 I00,0 135 11.5 7.8 73.1 1.9 I00.0 815 15.0 9.3 62.3 1,9 100.0 1366 206 126 852 27 1366 1366 187 REFERENCES Federal Bureau of Statistics [Pakistan]. 1987. Labour Force Survey 1986-1987. Karachi: Statistics Division. Population Welfare Division [Pakistan]. 1986. Pakistan Contraceptive Prevalence Survey, 1984-85. Islamabad: Ministry of Planning and Development. 188 APPENDIX A PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY STAFF APPENDIX A PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY STAFF Dr. M. S. Jillani (Project Director) Dr. Tauseef Ahmed (Principal Investigator) Syed Mubashir Ali (Deputy Principal Investigator) Mr. Mehboob Sultan (Field Coordinator) Mr. Mansoor-ul-Hassan Bhatti (Field Coordinator) Technical Advisory Committee Chief Executive (NIPS) Mr. Khalil Siddiqui (Director General, Ministry of Population Welfare) Dr. Zeba Sathar (Chief of Research, PIDE, Islamabad) Dr. Mohammad Anwar (Chairman, Sociology Department, Punjab University, Lahore) Mr. M. D. Manick (Deputy Director General, Federal Bureau of Statistics, Karachi) Mr. Fails Rehman Khan, (Joint Secretary, Ministry of Health, Islamabad) Dr. Mushtaq A. Khan, (Principal, Children's Hospital, PIMS, Islamabad) Begum Akhlaq Hussain (Chairperson, NGOCC, Karachi) Ms. Barbara Spaid/Mr. Abdul Wasey (USAID, Islamabad) Dr. Fred Arnold (Country Monitor, DHS, IRD/Macro International, Columbia, MD, USA) Principal Investigator (PDHS, NIPS, Islamabad) Chairman Member Member Member Member Member Member Member Member Member Member/Secretary 191 Technical Consultants Dr. Fred Arnold (Country Monitor, DHS, IRD/Macro International) Dr. Nasra M. Shah (Resident Coordinator, NIPS) Ms. Jeanne Cushing (Data Processing Coordinator, DHS, IRD/Macro International) Dr. S. S. Hashmi (Resident Advisor, NIPS) Data Processing Staff Mr. Mazhar Ali (Data Processing Manager) Mr. Saeed-ur-Rehman (DEO) Mr. Abdul Hafiz Swati (DEO) Mr. Badmddin Tanvir (DEO) Mr. Asif Amin Khan (DEO) Mr. Ashraf Khan (DEO) Mr. Faateh-ud-din Ahmad (DEO) Office Editors Mr. Shahid Munir Mr. Ayazuddin Mr. Amanullah Bhatti Mr. Ali Anwar Burim Administrative Staff Mr. Iqbal Hussain Jafri (Administrative/Accounts Officer) Syed Suqlain Haider (Adrnininstrative Assistant) Trainers Karaehi: Dr. Tauseef Ahmed Ms. Anne Cross (DHS, IRD/Macro International) Mr. Mubin Abroad Arbab (FBS) Lahore: Dr. Fred Arnold (DHS, IRD/Macro International) Dr. Nasra Shah (Resident Coordinator, NIPS) Mr. Mansoor-ul-Hassan Bhatti Mr. Jallal-ud-Din (FBS) Peshawar: Syed Mubashir Ali Mr. Mehboob Sultan Dr. Kia Reinis (DHS, IRD/Macro Intemational) Mr. Shaukatullah Khan (FBS) Mr. Irwin Shorr Mr. Hussain B. Siyal 192 Lahore-I: Mr. Amar Hameed Butt (Supervisor, FBS) Mr. Shahid Munir (Supervisor, NIPS) Ms. Ms Sughra Bibi (Field Editor) Ms. Ms Salma Raves (Interviewer) Ms. Farah Deeha (Interviewer) Ms. Svema Iqhal (Interviewer) Mr. Muzakar Ahmad (Interviewer) Mr. Abdul Saved (Driver) Lahore-H: Ms. Nasim Sajid (Supervisor, FBS) Ms. Lubna Raahid (Field Editor) Ms. Shahida Parveen (Interviewer) Ms. Saeeda Parveen (Interviewer) Ms. Dilshad Tahir (Interviewer) Mr. Raza Hassan (Interviewer) Mr. Ghulam Qamar (Driver) Rawalpindi: Mr. Imtiaz Ahmad Awan (Supervisor, FBS) Mr. Saba Nazir (Field Editor) Ms. Shahida Kiyani (Interviewer) Ms. Nasira Jamila (Interviewer) Ms. Shagufta Cheema (Interviewer) Syed Hasnat Ahmad (Interviewer) Mr. Ifldltiar Ahmed (Driver) Multan: Mr. A. D. Pathan (Supervisor, FBS) Ms. Shabana Anjum (Field Editor) Ms. Farhat Kausar (Interviewer) Ms. Rehana Naurven (Interviewer) Ms. Farhana Nanreen Khan (Interviewer) Mr. Jamil Mehmood (interviewer) Mr. Allah Rakha (Driver) Sargodha: Mr. Abdul Qayum (Supervisor, FBS) Ms. Sajida Nahved (Field Editor) Ms. Shabana Shehnaz (Interviewer) Ms. Samina Amir (Interviewer) Ms. Tahira Yasmin (Interviewer) Mr. lftikhar Qamar (interviewer) Mr. Gul Nawaz (Driver) Abbottabad: Mr. Masood Anwar (Supervisor, FBS) Ms. Shazia Naurven (Field Editor) Ms. Naushaba (Interviewer) Ms. Saira Jabven Jehangeri (Interviewer) Ms. Lubna Shirin (Interviewer) Mr. Zahir Jamil Khan (Interviewer) Mr. Hamayoon Khan (Driver) 194 Peshawar: Mr. Iftikhar Aftab Afridi (Supervisor, FBS) Ms. Lmtiaz Jamal (Interviewer) Ms. Fehmida Begum (Interviewer) Ms. Fakhr un Nisa (Interviewer) Mr. Rahim Khan (Interviewer) Mr. Jamil (Driver) Swat: Mr. Hazrat Hussain (Supervisor, FBS) Ms. Somaira Hadi (Field Editor) Ms. Chand Bibi (Interviewe0 Ms. Nasreen (Interviewer) Ms. Farida Bibi (Interviewer) Mr. Asif Khan (Interviewer) Mr. Umarzadha (Drive0 Bannu: Mr. Zahir Khan (Supervisor, FBS) Mr. Ashiq M. Khan (Supervisor, FBS) Ms. Yasmin Akhtar (Field Editor) Ms. Rukhsana Umar (Interviewer) Ms. Surraya Begum (Interviewer) Mr. Liaqat Ali Khan (Interviewer) Mr. Amir Khan (Driver) Mr. Zahir Shah (Driver) 195 LIST OF AUTHORS Tauseef Ahmed, Senior Fellow, National Institute of Population Studies, Islamabad Syed Mubashlr Ali, Deputy Principal Investigator, PDHS, National Institute of Population Studies, Islamabad AIfredo Aliaga, Senior Statistical Expert, Institute for Resource Development, Macro International, Columbia, MD, USA Fred Arnold, Senior Population Specialist, Institute for Resource Development, Macro International, Columbia, MD, and Research Associate, East-West Population Institute, Honolulu, Hawaii, USA Mohamrnad Ayub, Assistant Chief, Nutrition Section, Planning and Development Division, Government of Pakistan, Islamabad Mansoor-uI-Hassan Bhatti, Fellow, National Institute of Population Studies, Islamabad George Bicego, Demographic Analyst, Institute for Resource Development, Macro International, Columbia, MD, USA K. Zaki Hasan, Principal, Baqal Medical College, Karachi Sultan S. Hashmi, Resident Advisor, National Institute of Population Studies, Islamabad M.D. Mallick, Deputy Director General, Federal Bureau of Statistics, Karachi Abdul Razzaque Rukanuddin, Director, National Institute of Population Studies, Islamabad Zeba Sathar, Chief of Research, Pakistan Institute of Development Economics, Islamabad Nasra M. Shah, Assistant Professor, Department of Community Medicine, Faculty of Medicine, Kuwait University, Safat, Kuwait Mehboob Sultan, Fellow, National Institute of Population Studies, lslamabad 196 APPENDIX B ESTIMATES OF SAMPLING ERRORS APPENDIX B ESTIMATES OF SAMPLING ERRORS Estimates derived from a sample survey are affected by two types of errors: nonsampling error and sampling error. Nonsampling error is the result of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the PDHS to minimize these types of errors, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of women selected in the PDHS is only one of many samples that could have been selected from the same population, using the same design and expected sample size. Each one would have yielded results that differ somewhat from the actual sample selected. The sampling error is a measure of the variability between all possible samples. Although it is not known exactly, it can be estimated from the survey results. Sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic as measured in 95 percent of all possible samples of identical size and design will fall within a range of plus or minus two times the standard error of that statistic. If the sample of women had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the PDHS sample design was a two-stage stratified design, and, consequently, it was necessary to use more complex formulas. The computer package CLUSTERS, developed by the International Statistical Institute for the World Fertility Survey, was used to compute the sampling errors with the proper statistical methodology. The CLUSTERS program treats any percentage or average as a ratio estimate, • = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: mr( r ) - - 1 - f mh =-~ 2 Zh x 2 ~-t ~ 2.,z~--2-- I - I **6h in which z~ -- yu - r .xu , and z h -- yh - r .xk where h mh Y~ x~ f represents the stratum which varies from 1 to H, is the total number of enumeration areas (EAs) selected in the h ~' stratum, is the sum of the values of variable y in EA i in the h tb stratum, is the sum of the number of eases (women) in EA i in the h ~ stratum, and is the overall sampling fraction, which is so small that CLUSTERS ignores it. 199 In addition to the standard errors, CLUSTERS computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result i fa simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. CLUSTERS also computes the relative error and confidence limits for the estimates. Sampling errors for the PDHS are calculated by group of eligible women and by group of husbands for selected variables considered to be of primary interest. The results are presented in this appendix for the whole country, for major cities, other urban and rural areas, for the four provinces (Punjab, Sindh, NWFP, and Balochistan), and (for women only) for three major age groups. For each variable, the type of statistic (mean or proportion) and the base population are given in Table B.I. Tables B.2 through B.13 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R-+2SE) for each variable. In general, the relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions. There are some differentials in the relative standard error for the estimates of sub-populations such as geographical areas. For example, for the variable living children, the relative standard error as a percent of the estimated mean for the whole country, for major cities and for Balochistan is 1.2 percent, 2.0 percent, and 4.5 percent, respectively. The confidence interval has the following interpretation. For the contraceptive prevalence rate (the percentage of women currently using a method), the overall average from the national sample is .118 (that is, 11.8 percent) and its standard error is .005. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e. 118:t:.010, which means that there is a high probability (95 percent) that the true prevalence rate is between .108 and .129 (that is, 10.8-12.9 percent). 200 Table B,1 List of selected variables for sampling errors t Pakistan DHS t 1990-91 WOMEN'S VARIABLE ESTIMATE BASE POPULATION URBAN NOEDUC SECOND COUSIN CUWORK SURVIV KMETHO KSOURC EVUSE CUSING CUMOD CUIUD CUCOND CUSTER PSOURC NOMORE DELAY IDEAL ANTCAR NTETAN MEDEL I RESPIR FEVER DIARR1 DIARR2 ORSTRE MEDTRE HCARD BCG12 DPT12 POLl2 MEASI2 FULVAC Urban With no education With secondary education or higher Married to first cousin Currently working Living children Knowing any contraceptive method Knowing source for any method Ever used any contraceptive method Currently using any method Currently using a modern method Currently using IUD Currently using condom Currently using female sterilisation Using public sector source Wanting no more children Wanting to delay at least 2 years Ideal number of children Mothers receiving antenatal care Mothe*s no received tetanus injection Received medical care at birth Had acute respiratory illness in last 2 weeks Had fever in lest two weeks Had diarrhoea in last 24 hours Had diarrhoea in 2 last weeks Treated with ORS packets Consulted a medical facility Showing health card Received BCG vaccination Received DIrl " vaccination (3 doses) Reeeived polio vaccination (3 doses) Received measles vaccination (3 doses) Fully vaccinated Proportion Proportion Proportion Proportion Proportion Mean Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Mean Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Proportion Ever-married women Ever-married women Ever-married women Ever-tam'tied women Ever-married women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women Currently married women ChnTently married women Currently married women Current users of modem methods Currently married women Currently married women Ever-merried women with numerical response Births in last 5 years Births in last 5 years Births in last 5 years Children under 5 Children under 5 Children under 5 Children under 5 Children under 5 with diarrhoea in last 2 weeks Children under 5 with diarrhoea in last 2 weeks Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months HUSBANDS" VARIABLE ESTIMATE BASE POPULATION HNOEDU HSEC HKMETH HKSOUR HEVUSE HCUSIN HCUMOD HCUIUD HCUCON HCUSTE HNOMOR HDELAY With no education With secondary education or higher Knowing any contraceptive method Knowing source for any method Ever rood any contraceptive method Cun-ently using any method Cmrendy using any modern method Cun'ently using IUD Currently using condom Currently using male sterilieation Wanting no more children Wmting to delay at lee~t 2 years Proportion All husbands Proportion All husbands Proportion All husbands Proportion All husbands Proportion All husbmds Proportion All husbands Proportion All husbands Proportion All husbands Proportion All husbands Proportion All husbands Proportion All husbands Proportion All husbands 201 Table B.2 Sampling errors: Entire san~le, Pakistan 1990-91 Number of cases Relative Standard standard Standani Value error Unweighted Weighted error deviation Variable (R) (SE) (N) (WN) (SER) (SD) Des/gn Relative Confidence limits effect error (DEFT) (SB/R) R-2SE R+2SE WOMEN URBAN .305 .007 6611.0 6611.0 .006 .461 NOEDUC .792 .009 6611.0 6611.0 .005 .406 SECOND .073 .006 6611.0 6611.0 .003 .261 COUSIN .503 .011 6611.0 6611.0 ,006 .500 CUWORK .168 .007 6611.0 6611.0 .005 .374 SURVIV 3.523 .043 6611.0 6611.0 .031 2.556 KMETHO ,779 .009 6393.0 6364.1 .005 .415 KSOURC .463 .011 6393.0 6364.1 .006 .499 EVUSE .207 .007 6393.0 6364.1 .005 .405 CUSING .118 .005 6393.0 6364.1 .004 .323 CUMOD .090 ,005 6393.0 6364.1 ,004 .286 CUIUD .013 .002 6393.0 6364.1 .001 .111 CUCOND .027 .003 6393.0 6364.1 .002 .162 CUSTER .035 .003 6393.0 6364.1 .002 .185 PSOURC .557 .028 655.0 573.7 .019 .497 NOMORE .364 .009 6393.0 6364.1 .006 .481 DELAY .176 .008 6393.0 6364.1 .005 .381 IDEAL 4.060 .050 2625.0 2587.3 .034 1.723 ANTCAR .292 .009 6352.0 6406.6 .007 .579 NTETAN .700 .011 6352.0 6406.6 .007 .577 MEDELI .188 .010 6352.0 6406.6 .006 .497 RESPIR .160 .009 5828.0 5775.6 .005 A l l FEVER .301 .009 5828.0 5775.6 .007 .514 DIARRI .083 .006 5828.0 5775.6 .004 .288 DIARR2 .145 .008 5828.0 5775.6 .005 .382 ORSTRE .388 .027 781,0 840.3 .018 .498 MBDTRE .483 .020 781,0 840.3 .018 .511 HCARD .296 .020 1187.0 1214.7 .013 .454 BCG12 .697 .020 1187.0 1214.7 .013 .456 DPTI2 .427 .020 1187.0 1214.7 .014 .491 POLl2 .429 .020 1187.0 1214.7 .014 .491 MEASI2 .502 .021 1187.0 1214.7 .014 .496 FULVAC .351 .018 1187.0 1214.7 .014 .474 1.205 .022 .292 .319 1.872 .012 .773 .811 1.856 .081 .061 .085 1.750 .021 .482 .525 1.605 .044 .153 .183 1.365 .012 3.437 3.609 1.793 .012 .760 .797 1.738 .023 .442 .485 1.449 .035 .192 .222 1.345 .046 .108 .129 1.295 .051 ,081 .099 1.633 .181 .008 .017 1.238 .093 .022 .032 1.392 .091 .029 .042 1.422 .050 .501 .612 1.436 .024 .346 .381 1.579 .043 .161 .191 1.483 .012 3.961 4.160 1.294 .032 .273 .311 1.450 .035 .279 .321 1.537 .051 .168 .207 1.657 .056 .142 .178 1.313 .029 .283 .319 1.644 .075 ,071 .095 1.510 .052 .130 .161 1.497 .069 .335 .441 1.117 .042 .442 .523 1.482 .066 .257 ,335 1.503 .029 .657 ,736 1.414 .047 .387 .467 1.427 .047 .389 .470 1,475 .042 ,459 .544 1.287 .050 .315 .386 HUSBANDS HNOEDU .502 .019 1354.0 1354.0 .014 .500 HSEC .204 .015 1354.0 1354.0 .011 .403 HKMETH .793 .020 1354,0 1354.0 .011 .405 HKSOOR .651 .022 1354,0 1354.0 .013 .477 HEVUSE .247 .017 1354,0 1354.0 .012 .432 HCUSIN .151 .014 1354,0 1354.0 .010 .358 HCUMOD .101 .010 1354,0 1354.0 .008 .301 HCURJD .014 .004 1354.0 1354.0 .003 .118 HCUCON .036 .006 1354.0 1354.0 .005 .185 HCUSTE .038 .007 1354.0 1354.0 .005 .192 HNOMOR .290 .017 1354.0 1354.0 .012 .454 HDELAY .198 .016 1354.0 1354.0 .011 .399 1.366 .037 .465 .540 1.403 .075 .173 .235 1.795 .025 .754 .833 1.705 .034 ,607 .695 1.411 .067 .214 .280 1.396 .090 .124 .178 1.276 .104 .080 .121 1.179 .267 .Off7 .022 1.166 .165 .024 .047 1.409 .192 .024 .053 1.342 .057 .257 .323 1.435 .079 .167 .229 202 Table B.3 Sampling ~ui~,: Urb~ areas, Pakistan 1990-91 Number of cases Standard Design Relative Confidence limits Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE WOMEN URBAN 1.000 .000 3384.0 2019.1 .000 .000 1.000 1.000 NOEDUC .550 .018 3384.0 2019.1 2.135 .033 .513 .586 SECOND .211 .018 3384.0 2019.1 2.577 .086 ,175 ,247 COUSIN .410 .011 3384,0 2019.1 1.330 .027 ,387 .432 CUWORK .130 .009 3384.0 2019.1 1.606 .071 ,112 .149 SURVIV 3.716 .062 3384.0 2019.1 1.421 .017 3.592 3.840 KMETHO .913 .007 3256.0 1929.8 1.349 .007 .900 .927 KSOURC .722 .011 3256.0 1929.8 1.442 .016 .700 .745 EVUSE .417 .013 3256.0 1929.8 1.461 .030 .392 .442 CUSING .257 .012 3256.0 1929.8 1.515 .045 .234 .281 CUMOD .187 .009 3256.0 1929.8 1.343 .049 .168 .205 CUIUD .020 .003 3256.0 1929.8 1.177 .145 .014 .026 CUCOND .067 .006 3256.0 1929.8 1.376 .090 .055 .079 CUSTER .073 .008 3256.0 1929.8 1.720 .108 .057 .089 PSOURC .497 .031 512.0 360.5 1.397 .062 .435 .558 NOMORE ,449 .012 3256.0 1929.8 1.425 .028 .424 .474 DELAY .163 .009 3256.0 1929.8 1.350 .054 .146 .181 IDEAL 3.725 .O47 1679.0 1188.8 1.385 .012 3.632 3.818 ANTCAR .596 .017 3306.0 1980.2 1.584 .029 .561 .631 NTETAN .469 .017 3306.0 1980.2 1.528 .032 .497 ,565 MEDELI .423 .020 3306.0 1980.2 1.888 .048 .382 .464 RESPIR .138 .009 3062.0 1835.2 1.331 .067 .120 .157 FEVER .309 .014 3062.0 1835.2 1.519 .046 .280 .337 DIARR1 .077 .010 3062.0 1835.2 1.859 .126 .058 .097 DIARR2 .150 .012 3062.0 1835.2 1.740 .083 .125 .175 ORSTRE .469 .038 415.0 275.6 1.504 .080 .394 .544 MEDTRE .627 .031 415.0 275.6 1.277 .050 .565 .689 HCARD .347 .020 615.0 383.1 1.031 .057 .308 .386 BCG12 .842 .025 615.0 383.1 1.765 .030 .791 .893 DPT12 .554 .026 615.0 383.1 1.342 .048 .501 .607 EOL12 .554 .(326 615.0 383.1 1.342 .048 .501 .607 MEAS12 .646 .031 615.0 383.1 1.618 .048 .584 .707 FULVAC .456 .029 615.0 383.1 1.440 .062 .399 .513 HUSBANDS HNOEDU .314 ,023 696.0 432.2 1,298 .073 .269 .360 HSEC .410 .O31 696.0 432,2 1.687 .077 .347 .473 HKMETH .882 .019 696.0 432.2 1.524 .021 .844 .919 HKSOUR .820 .022 696.0 432.2 1.529 .027 .776 .865 HEVUSE .455 .028 696.0 432.2 1.463 .061 .399 .510 HCUSIN .269 .025 696.0 432.2 1.465 .092 .220 .318 HCUMOD .189 .023 696.0 432.2 1.568 .123 .142 .235 HCUIUD .032 .009 696.0 432.2 1.396 .290 .014 .051 HCUCON .070 .013 696.0 432.2 1.334 .184 .045 .096 HCUSTE .061 .014 696.0 432.2 1.501 .224 .034 .088 HNOMOR .375 .027 696.0 432.2 1.443 .071 322 .428 HDELAY .171 .021 696.0 432.2 1.483 .124 .129 .214 203 Table B.4 Sampling ea'rors: Major cities, Pakistan 1990-91 Number of cases Variable Standard Value error (R) (SE) Design Relative Confidence limits Unweighted Weighted effect error (N) (WN) (DEFT) (SE/R) R-2SE R+2SE WOMEN URBAN NOEDUC SECOND COUSIN CUWORK SURVIV KMETHO KSOURC EVUSE CUSING CUMOD CUIUD CUCOND CUSTER PSOURC NOMORE DELAY IDEAL ANTCAR NTETAN MEDELI RESPIR FEVER DIARR1 DIARR2 ORSTRE MEDTRE HCARD BCG12 DPT12 POLl2 MEAS12 FULVAC 1.000 .000 .477 .025 .259 .024 .376 ,016 .129 .014 3.686 .072 .945 .008 .786 .012 .492 .017 .310 .017 ,223 ,012 .024 .005 .089 .010 .085 .012 .487 .038 .457 .016 .168 .013 3.586 .051 .702 .020 .424 .019 .511 .028 .123 .013 .312 .020 .075 .011 .151 .015 .538 .043 .656 .043 .345 .025 .835 .034 ,529 .031 .529 .031 .644 .035 .437 .032 1820.0 1151.1 .000 .000 1.000 1.000 1820.0 1151.1 2.175 .053 .426 .528 1820.0 1151.1 2.326 .092 .212 .307 1820.0 1151.1 1.371 .041 .344 .407 1820.0 1151.1 1.798 .110 .101 .157 1820.0 1151.1 1.200 .020 3.542 3.829 1744.0 1098.1 1.448 .008 .929 .961 1744.0 1098.1 1.253 .016 .761 .811 1744.0 1098.1 1.409 .034 .458 .526 1744.0 1098.1 1.506 .054 .277 .343 1744.0 1098.1 1.165 .052 .200 .246 1744.0 1098.1 1.248 .191 .015 .033 1744.0 1098.1 1.412 .108 .070 .108 1744.0 1098.1 1.778 .140 .061 .108 347.0 244.6 1.432 .079 .410 .564 1744.0 1098.1 1.373 .036 .424 .490 1744.0 1098.1 1.417 .075 .143 .194 1100.0 799.1 1.380 ,014 3,485 3.688 1808.0 1139,9 1.391 .028 .663 .742 1808.0 1139.9 1.292 .034 .537 ,615 1808.0 1139.9 1.852 .054 .456 .567 1671.0 1054.5 1.368 .103 .098 .148 1671.0 1054.5 1.558 .064 .272 .352 1671.0 1054.5 1.622 .149 .053 .098 1671.0 1054.5 1.578 .101 .120 .181 238.0 158.7 1.221 .080 .452 .625 238.0 158.7 1.320 .066 .570 .742 335.0 215.0 .966 .073 .294 .395 335.0 215.0 1.683 .041 .767 .903 335.0 215.0 1.142 .059 .467 .591 335.0 215.0 1,142 .059 .467 .591 335.0 215.0 1.357 .055 .573 .715 335.0 215.0 1.184 .073 .374 ,501 HUSBANDS HNOEDU .327 .030 380.0 249.7 1.247 .092 .267 .388 HSEC .426 .040 380.0 249.7 1.591 .095 .346 .507 HKMETH .892 .024 380.0 249.7 1.486 .027 .845 .939 HKSOUR .843 .028 380.0 249.7 1.523 .034 .786 .900 HEVUSE .503 .034 380.0 249.7 1.329 .068 .435 .571 HCUSIN .281 .032 380.0 249.7 1.408 .116 .216 .346 HCUMOD .205 .028 380.0 249.7 1.349 .136 .149 .261 HCUIUD .041 .014 380.0 249.7 1.332 .332 .014 .068 HCUCON .090 .019 380.0 249.7 1.288 ,211 .052 .128 HCUSTE .056 .013 380.0 249.7 1.130 .237 .030 .083 HNOMOR .355 .035 380.0 249.7 1.422 .098 .285 .425 NDELAY .189 .031 380.0 249.7 1.561 ,166 ,126 .252 204 Table B.5 Sampling erim-s: Othe~ urban areas, Pakistan 1990-91 Number of cases Standard Value error Unweighted Weighted Vmiable (R) (SE) (N) (WN) WOMEN Design Relative Confidenc~ limits effect error (DEFT) (SE/R) R-2SE R+2SE URBAN 1.000 .(300 NOEDUC .646 .027 SECOND .147 ,028 COUSIN .455 ,016 CUWORK .132 .011 SURVIV 3.757 .110 KMETHO .872 .012 KSOURC .638 .021 EVUSE .318 .019 CUSING ,188 ,016 CUMOD .139 .015 CUIUD .014 .004 CUCOND .038 .006 CUSTER .057 .010 PSOURC .517 ,052 NOMORE .438 .019 DELAY .157 .012 IDEAL 4.010 .088 ANTCAR .452 .031 NTETAN .530 .030 MEDELI .303 .028 RESPIR .159 .013 FEVER .304 ,(Y20 DIARR1 .080 .017 DIARR2 .150 .021 ORSTRE .375 .062 MEDTRE .588 .045 HCARD .350 .032 BCG12 .852 .038 DPT12 .587 .046 POLl2 .587 .046 MEAS12 .648 .053 FULVAC ,480 .051 1564.0 867.9 .000 .000 1.000 1.000 1564.0 867.9 2.192 .041 .593 .699 1564.0 867.9 3.133 .191 .091 .203 1564.0 867.9 1.276 .035 .423 .487 1564.0 867.9 1.327 .086 .109 .155 1564.0 867.9 1.728 ,029 3,536 3.978 1512.0 831.7 1.352 .013 .849 .895 1512.0 831.7 1.681 ,033 .597 .680 1512.0 831.7 1.583 .060 .280 ,356 1512.0 831.7 1.603 .086 .156 .220 1512.0 831.7 1.707 .109 .109 .170 1512.0 831.7 1.178 .250 .007 .022 1512.0 831.7 1,191 .154 .026 ,050 1512.0 831,7 1,598 .167 .038 .077 165,0 115.9 1.335 .101 .413 .621 1512.0 831.7 1.497 .044 .400 .476 1512.0 831.7 1.296 .077 .133 ,181 579.0 389.7 1.306 .022 3,835 4,186 1498.0 840.4 1.903 .067 .391 .513 1498.0 840,4 1,869 ,064 ,410 .531 1498.0 840.4 1.950 .094 .246 .360 1391.0 780.7 1.238 .084 .133 .186 1391.0 780.7 1.467 .066 .264 .344 1391,0 780.7 2,164 .216 .046 .115 1391.0 780,7 1.953 .138 .108 .191 177,0 116.8 1.853 .165 .251 .499 17%0 116.8 1.236 .077 .497 .678 280.0 168.1 1.158 .092 .285 .414 280.0 168.1 1.868 .045 .775 .928 280.0 168.1 1.631 .079 .494 .680 280.0 168.1 1.631 .079 .494 .680 280.0 168.1 1.914 ,081 .543 .754 280.0 168.1 1.746 .106 .379 .582 HUSBANDS HNOEDU .296 .036 HSEC .387 .050 HKMETH ,868 .031 HKSOUR .789 ,035 HEVUSE .389 .045 HCUSIN .253 .037 HCUMOD .166 .039 HCUIUD .020 .012 HCUCON .044 .015 HCUSTE .067 .026 HNOMOR .402 ,042 HDELAY .147 .026 316.0 182.6 1.380 .120 .225 .367 316.0 182£ 1,816 .129 .287 .487 316,0 182.6 1.614 ,036 .806 .929 316.0 182.6 1.537 .045 .718 .859 316.0 182.6 1.638 .116 .299 .479 316.0 182.6 1.512 .146 .179 .327 316.0 182.6 1.848 .233 .089 .244 316.0 182.6 1.534 .598 -.004 .045 316.0 182.6 1.315 .345 .014 .075 316.0 182.6 1.881 .396 .014 .120 316.0 182£ 1.503 .103 .319 .485 316.0 182.6 1.311 .178 .095 .200 205 Table B.6 Sampling enm's: Rurel areas, Pakistan 1990-91 Value Variable (R) Number of cases Standard Design Relative error Unweighted Weighted effect error (SE) (N) (WN) (DEFT) (SE/R) Confidence limits R-2SE R+2SE WOMEN URBAN .000 NOEDUC .899 SECOND .013 COUSIN .544 CUWORK .185 SURVIV 3.438 KMETHO ,720 KSOURC .351 EVUSE .116 CUSING .058 CUMOD .048 CUIUD .009 CUCOND ,010 CUSTER .019 PSOURC .658 NOMORE .327 DELAY .181 IDEAL 4,345 ANTCAR .156 NTETAN .803 MEDELI .082 RESPIR .170 FEVER .297 DIARR1 .085 DIARR2 .143 ORSTRE .348 MEDTRE .412 HCARD .273 RCG12 .629 DPT12 .369 POLl2 .372 MEAS12 .436 FULVAC ,302 .000 3227.0 4591.9 .000 .000 .000 .000 .010 3227.0 4591.9 1.882 .011 .879 .919 .003 3227.0 4591.9 1.492 .231 .007 ,019 .015 3227.0 4591.9 1.662 .027 .515 ,573 .010 3227.0 4591.9 1.447 .054 .165 ,204 .055 3227.0 4591.9 1.216 .016 3.329 3.548 ,013 313%0 44343 1,620 .018 .694 .746 .015 3137.0 4434.3 1.707 .041 .322 .380 ,008 3137.0 4434.3 1.482 .073 .099 .133 .006 3137,0 4434.3 1.349 .097 .047 ,069 .005 3137.0 4434.3 1.375 .109 .038 .059 .003 3137.0 4434.3 1.763 .323 .003 .015 .002 3137.0 4434.3 1.390 .252 .005 .014 ,003 3137.0 4434.3 1.269 .163 .013 .025 .052 143.0 213,2 1.319 .080 .553 .763 .011 3137.0 4434.3 1.312 .034 .305 .349 .010 3137,0 4434.3 1.464 ,056 ,161 ,201 .087 946,0 1398.5 1.384 .020 4.172 4,518 .011 3046.0 4426.4 1.397 ,070 .134 ,178 .013 3046.0 4426.4 1.507 .068 ,170 .224 ,010 3046.0 4426,4 1.650 .125 ,062 ,103 .012 2766.0 3940.3 1.548 .072 .146 .195 .011 2766.0 3940.3 1.152 .038 .275 ,320 .008 2766.0 3940.3 1.454 .092 .070 ,101 .009 2766.0 3940.3 1.332 .066 .124 .162 .035 366.0 564.8 1,412 .102 .277 .419 .026 366.0 564.8 1,019 .063 .360 .464 .027 572.0 831.6 1.488 .101 .218 ,328 .027 572.0 831.6 1.360 .043 .575 .684 .026 572.0 831.6 1.312 .071 .316 .421 .027 572.0 831.6 1,325 .071 .319 .425 .028 572.0 831.6 1,354 .064 .380 .491 .022 572.0 831.6 1,161 .073 .258 .346 HUSBANDS HNOEDU .591 HSEC .108 HKMETH .752 HKSOUR .571 HEVUSE .150 HCUSIN .096 HCUMOD .059 HCUIUD .~)6 HCUCON .019 HCUSTE .028 HNOMOR .250 HDELAY .211 .025 658,0 921.8 1.327 .043 .540 .641 .015 658.0 921.8 1.201 .135 .079 .137 .028 658.0 921.8 1.644 .037 .696 .807 .031 658.0 921.8 1.612 .054 .509 .634 .018 658.0 921.8 1.320 .123 .113 ,187 .015 658.0 921.8 1.322 .159 .065 .126 .010 658.0 921.8 1.093 .170 .039 .079 ,G03 658.0 921.8 1.143 .586 -.001 .012 ,006 658.0 921.8 1.106 .308 .007 .031 .009 658.0 921,8 1.354 .313 ,010 .045 .021 658.0 921.8 1.250 .084 .208 .293 .021 658.0 921.8 1.291 .097 .170 .252 206 Table B.7 Sampli~ erro~: Punjab, Pakistan 1990-91 Number of cases V~'ieble Svmderd Value error (R) (SE) Design Relative Confidence limits Unweighted Weighted effect error (N) (WN) (DEFT) (SE/R) R-2SE R+2SE WOMEN URBAN NOEDUC SECOND COUSIN CUWORK SURVIV KMETHO KSOURC EVUSE CUSING CUMOD CUIUD CUCOND CUSTER PSOURC NOMORE DELAY IDEAL ANTCAR NTETAN MEDELI RESPIR FEVER DIARR1 DIARR2 ORSTRE MEDTRE HCARD BCG12 DPT12 POLl2 MEAS12 FULVAC .284 .009 .765 .014 .080 .009 .530 .016 .158 .010 3.409 .062 .806 .013 .478 .015 .229 .011 .130 .008 .098 .007 .015 .004 .030 .004 .038 .005 .561 .040 .405 .012 .204 .011 3.982 ,059 .239 .013 .698 .014 .164 .013 .170 .013 .308 .012 .080 .009 .144 .011 .357 .039 .439 .028 .312 .028 .758 .026 .467 ,029 .469 .029 .544 .031 .386 .025 2207.0 3948.1 .896 .030 .267 .301 2207.0 3948.1 1.573 .019 .737 .793 2207.0 3948,1 1.519 .110 .062 .098 2207.0 3948,1 1.481 .030 .498 .561 2207.0 3948.1 1.348 .066 .137 .179 2207.0 3948.1 1.161 .018 3.286 3.533 2110.0 3767.9 1.486 .016 .780 .831 2110.0 3767.9 1.347 .031 .448 .507 2110.0 3767.9 1.148 .046 .208 ,250 2110.0 3767.9 1.026 .058 .115 .145 2110.0 3767.9 1.058 .070 .085 .112 2110.0 3767.9 1.370 .243 .008 .022 2110.0 3767.9 1.014 .126 .022 .038 2110.0 3767.9 1.170 .127 .029 .048 263.0 370.1 1,293 .071 .482 .641 2110.0 3767.9 1,158 .031 .380 .429 2110.0 3767.9 1.305 .056 .181 .227 1087.0 1670.5 1,292 ,015 3.863 4,101 2193.0 3932.6 1.115 .054 .213 .264 2193.0 3932.6 1.164 .048 .273 .331 2193.0 3932.6 1.302 .080 .138 .190 1983.0 3515.6 1.398 .078 .143 .196 1983.0 3515.6 1.048 .040 .283 .332 1983.0 3515.6 1,403 .112 .063 .098 1983.0 3515.6 1.261 .076 .122 ,165 284.0 504.8 1.320 .110 .279 .436 284.0 504.8 .905 .064 .382 .495 427.0 762.6 1.230 .089 .256 .367 427.0 762.6 1.271 .035 .705 .811 427.0 762.6 1,189 .062 .409 .524 427.0 762.6 1.201 .062 .411 .527 427.0 762.6 1.291 .057 .482 .606 427.0 762.6 1,069 .066 .336 .437 HUSBANDS HNOEDU HSEC HKMETH HKSOUR HEVUSE HCUSIN HCUMOD HCU1UD HCUCON HCUSTE HNOMOR HDELAY .484 .028 .213 .024 .806 .029 .660 .034 .278 .025 ,182 .021 .115 ,016 .020 .006 .036 .009 .045 .012 .340 .024 .215 .023 461.0 801.4 1,182 .057 .429 .539 461.0 801.4 1.232 .110 .166 .260 461.0 801.4 1,581 .036 .747 .864 461.0 801.4 1,525 .051 .593 ,728 461.0 801.4 1.220 .092 .227 .329 461.0 801.4 1.178 .117 .139 .224 461,0 801.4 1.1)78 .140 .082 .147 461.0 801.4 .949 .309 .008 .032 461.0 801.4 .992 .239 .019 .053 461.0 801,4 1.196 .258 .022 .068 461.0 801.4 1.090 .071 .292 .388 461.0 801,4 1.200 .107 .169 .261 207 Tsble B.8 Stmpling errors: Sindh, Pskist~ 1990-91 Number of cases Standerd Design Relative Confidence limits Value error Unweighted Wdght~1 effect error V~'iable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE WOMEN URBAN .469 .018 1798.0 1529.1 1.518 .038 .434 .505 NOEDUC .768 .016 1798.0 1529.1 1.568 .020 .737 .799 SECOND .092 .012 1798.0 1529.1 1.759 .131 .068 .116 COUSIN .497 .019 1798.0 1529.1 1.604 .038 .459 .534 CUWORK .249 .014 1798.0 1529.1 1.332 .055 .222 .276 SURVIV 3.764 .073 1798.0 1529.1 1.158 .019 3.618 3.909 KMETHO .744 .015 1741.0 1486.0 1.476 .02l .713 .775 KSOURC .472 .022 1741.0 1486.0 1.841 .047 .428 .517 EVUSE .218 .015 1741.0 1486.0 1.496 .068 .189 .248 CUSING .124 .012 1741.0 1486.0 1.506 .096 .101 .148 CUMOD .091 .008 1741.0 1486.0 1.162 .088 .075 .107 CUIUD .009 .002 1741.0 1486.0 1.083 .269 .004 .014 CUCOND .034 .005 1741.0 1486.0 1.095 .139 .025 ,044 CUSTER .035 .004 1741.0 1486.0 .848 .107 .027 .042 PSOURC .494 .037 189.0 134.5 1.004 .074 .421 .568 NOMORE .323 .016 1741.0 1486.0 1.386 .048 .292 .354 DELAY .145 .011 1741.0 1486.0 1.342 .078 .122 .168 IDEAL 3,986 .122 753,0 590.1 1.658 .031 3.742 4.231 ANTCAR .500 .017 1650.0 1363.7 1.035 .033 .467 .533 NTETAN .594 .022 1650.0 1363.7 1.400 .054 .363 .450 MEDELI .322 .023 1650.0 1363.7 1,533 .071 .276 .368 RESPIR .172 .016 1508.0 1222.4 1.4-46 .094 .140 .204 FEVER .342 .019 1508.0 1222.4 1.384 .055 .304 .379 DIARR1 .106 .012 1508.0 1222.4 1.374 Al l .082 .129 DIARR2 .196 .015 1508.0 1222.4 1.305 .074 .167 .225 ORSTRE .484 .037 284.0 239.1 1.128 .076 .410 .558 MEDTRE .597 .033 284.0 239.1 1.055 .055 .532 .662 HCARD .257 .022 298.0 244.5 .849 .086 .212 .301 BCG12 .602 .033 298.0 244.5 1.151 .055 .535 .668 DPT12 .330 .028 298.0 244.5 1.007 .085 .274 .386 POLl2 .330 ,028 298.0 244.5 1.007 .085 .274 .386 MEAS12 .412 .029 298.0 244.5 .985 .070 .355 .469 FULVAC .253 .025 298.0 244.5 .986 .100 .202 .303 HUSBANDS HNOEDU .479 .028 364.0 349.7 1.054 .058 .424 .534 HSEC .204 .022 364.0 349.7 1.055 .109 .159 .248 HKMETH .772 .033 364.0 349.7 1.491 .042 ,707 .838 HKSOUR .672 .030 364.0 349.7 1.198 .044 .613 .732 HEVUSE .241 .026 364.0 349.7 1.140 .106 .190 .292 HCUSIN .125 .020 364.0 349.7 1,180 .164 .084 .166 HCUMOD .091 .016 364.0 349.7 1.070 .178 .059 .123 HCUIUD .004 .003 364.0 349.7 .820 .712 -.002 .009 HCUCON .040 .010 364.0 349.7 1.006 .258 ,019 ,061 HCUSTE .035 .010 364.0 349.7 1.033 .286 .015 .055 HNOMOR .252 .027 364.0 349.7 1.199 .108 .198 .307 HDELAY .159 .025 364.0 349.7 1.300 .157 .109 .208 208 Table B.9 Sampling re'ors: N'WFP, Pakistan 1990-91 Number of cases Standard Design Relative Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE WOMEN Confidence limits URBAN .160 .008 1665.0 878.3 .855 .048 .145 .175 NOEDUC .906 .011 1665.0 878.3 1.609 .013 .883 .929 SECOND .029 .005 1665.0 878.3 1.139 .160 .020 .039 COUSIN .383 .020 1665.0 878.3 1.656 .052 .343 .422 CUWORK .039 .006 1665.0 878.3 1.334 .162 .026 .052 SURVIV 3.640 .082 1665.0 878.3 1.268 .023 3.475 3.804 KMETHO .836 .020 1620.0 856.4 2.202 .024 .796 .877 KSOURC .451 .026 1620.0 856.4 2.083 .057 .400 .503 EVUSE .141 .012 1620.0 856.4 1.413 .087 .116 .165 CUSING .086 .009 1620.0 856.4 1.342 .109 .067 .104 CUMOD .076 .008 1620.0 856.4 1.280 .111 .059 .092 CUIUD .011 .003 1620.0 856.4 1.254 .301 .004 .017 CUCOND .008 .002 1620.0 856.4 .966 .260 .004 .013 CUSTER .032 .008 1620.0 856.4 1,848 .252 .016 .048 PSOURC .649 .047 165.0 64.8 1,258 .072 .555 .742 NOMORE .335 .019 1620.0 856.4 1.599 .056 .297 .372 DELAY .131 .007 1620.0 856.4 .838 .054 .117 .145 IDEAL 4,336 .117 579.0 284.9 1.564 .027 4.101 4.571 ANTCAR .186 .018 1609.0 864.5 1.545 .098 .149 .222 NTETAN .819 .021 1609.0 864.5 1.754 .114 .140 .222 MEDELI ,116 .011 1609.0 864.5 1,178 .097 .093 .138 RESPIR .122 .011 1505.0 815.3 1.141 .086 .101 .143 FEVER .249 .014 1505.0 815.3 1.131 .057 .221 .277 DIARR1 .070 .009 1505.0 815.3 1.463 .135 .051 .089 DIARR2 .096 .009 1505.0 815.3 1,165 .091 .078 .113 ORSTRE .312 .042 139.0 78.0 1.086 .135 .228 .396 MEDTRE .415 .045 139.0 78.0 1.090 .108 .326 .505 HCARD .313 .052 301.0 164.9 1.973 .166 .209 .418 BCG12 .638 .039 301.0 164.9 1.432 .062 .559 .717 DPT12 .440 .046 301.0 164.9 1.622 .105 .348 .531 POLl2 .445 .047 301.0 164.9 1.658 .106 .351 .539 MEAS12 .482 .033 301.0 164.9 1.157 .069 .416 .548 FULVAC .376 .039 301.0 164.9 1.405 .103 .299 .454 HUSBANDS HNOEDU .549 .033 313.0 151.3 1.176 .060 .483 .615 HSEC .188 ,027 313.0 151.3 1.236 .145 .134 .243 HKMETH .778 .029 313.0 151.3 1,219 .037 .720 .835 HKSOUR .528 .044 313.0 151.3 1.569 .084 .440 .617 HEVUSE .165 .024 313.0 151.3 1.127 .143 .118 .213 HCUSIN .093 .017 313.0 151.3 1.028 .182 .059 .127 HCUMOD .078 .016 313.0 151.3 1.062 .206 .046 .111 HCU1UD ,010 ,006 313,0 151,3 1,070 ,612 -,002 .022 HCUCON .035 .011 313.0 151.3 1.029 .306 .013 .056 HCUSTE .024 .010 313.0 151.3 1.136 .408 .004 .044 HNOMOR .194 .026 313.0 151.3 1,164 .134 .142 .246 HDELAY .256 .031 313.0 151.3 1.266 .122 .193 .319 209 Table B.10 Sampling erron: Balochistan, Pakistan 1990-91 Value Variable (R) Number of cases Stmadard Design Relative error Unweighted Weighted effect error (SE) (N) (WN) (DEBT) (SE/R) Confidence limits R-2SE R+2SE WOMEN URBAN .158 NOEDUC .963 SECOND •012 COUSIN .544 CUWORK .289 SURVIV 3.443 KMETHO •385 KSOURC .239 EVUSE .043 CUSING .020 CUMOD .017 CUIUD .005 CUCOND .002 CUSTER .003 PSOURC .721 NOMORE .089 DELAY .087 IDEAL 6.332 ANTCAR .360 NTETAN .893 MEDELI .075 RESPIR .083 FEVER .161 DIARR1 .045 DIARR2 .083 ORSTRE .302 MEDTRE .483 HCARD .186 BCG12 .371 DPT12 •229 POLl2 .234 MEAS12 .341 FULVAC .178 .020 941.0 255.4 1.676 .126 .118 .198 ,008 941.0 255.4 1.363 .009 .946 .980 .002 941.0 255.4 .677 .198 .007 .017 .043 941.0 255.4 2.674 .080 .457 .631 .043 941.0 255.4 2.914 .149 .203 ,375 .155 941.0 255.4 1.950 .045 3.133 3.754 .056 922.0 253.8 3.493 .146 .273 .497 .043 922.0 253.8 3.030 .178 .154 .324 .008 922,0 253.8 1•202 .188 .027 .059 .006 922,0 253.8 1•301 .301 .008 .032 .006 922•0 253.8 1.351 .340 .005 .028 .003 922.0 253.8 1.227 .601 -.001 .010 .000 922.0 253.8 .000 .000 .002 .002 .002 922.0 253.8 .872 .507 -.000 .006 .117 38.0 4.3 1.580 .162 .488 .954 .018 922.0 253.8 1.895 .200 .053 .125 .021 922.0 253.8 2.252 .241 .045 .128 .316 206.0 41.9 1.919 .050 5.700 6.963 .046 900.0 245.8 2.165 .126 .269 .451 .026 900.0 245.8 2.077 .238 .056 .158 .018 900.0 245.8 1.606 .236 .040 .111 .017 832.0 222.3 1.692 .203 .049 .116 .018 832.0 222.3 1.321 .110 .126 .196 .015 832.0 222.3 2.120 .337 .015 .076 .024 832.0 222.3 2.244 .293 .034 .131 .069 74.0 18.4 1.176 .229 .164 .441 .093 74.0 18.4 1.370 .192 .297 .668 .049 161.0 42.7 1.576 .263 .088 .284 .113 161.0 42.7 2.942 .305 .144 .598 .082 161.0 42.7 2•451 .359 .064 .393 .081 161.0 42.7 2.404 .347 .072 .396 .068 161.0 42.7 1.786 •198 .206 .476 .065 161.0 42.7 2.119 .363 .049 .308 HUSBANDS HNOEDU HSEC HKMETH HKSOUR HEVUSE HCUSIN HCUMOD HCUIUD HCUCON HCUSTE HNOMOR HDELAY • 813 •051 • 107 •032 • 783 .074 • 717 .063 • 057 .026 .021 .010 • 013 .008 .008 .008 .001 .001 .004 .003 • 056 .021 .033 .018 H6.0 51.6 1.922 .063 .711 .915 H6.0 51,6 1.514 .298 .043 .171 216.0 51.6 2.636 .095 .635 .931 216.0 51.6 2.067 .088 .590 .844 216.0 51.6 1.651 .458 .005 .109 216.0 51.6 1.005 .470 .001 .040 216.0 51.6 1.023 .598 -.003 .029 216.0 51.6 1.271 .972 -.007 .023 216.0 51.6 .502 1.014 -.001 .003 216.0 51.6 .651 .735 -.002 .009 216.0 51.6 1.333 .373 .014 .098 216.0 51.6 1.505 .558 -.004 .069 210 Table B.11 Sampling errors: Age group 15-24, Pakistan 1990-91 Number of cases Standard Design Relative Value error Unweighted Weighted effect error V~a'iable (R) (SE) (N) (WN) (DEFT) (SFdR) R-2SE R+2SE WOMEN Confid*nce limits URBAN .260 .014 1471.0 1487.3 1.215 .053 ,232 .288 NOEDUC .770 .017 1471.0 1487.3 1.515 .022 .736 .803 SECOND .062 .009 1471.0 1487.3 1.353 .137 .045 ,079 COUSIN .560 .020 1471.0 1487.3 1.518 .035 .521 %00 CUWORK .143 .014 1471.0 1487.3 1.544 .099 .115 .171 SURVIV 1.158 .038 1471.0 1487.3 1.282 .033 1.081 1.234 KMETHO .725 .017 1447.0 1459.0 1.418 .023 .692 .759 KSOURC .383 .019 1447.0 1459.0 1.491 .050 .345 .422 EVUSE .101 .010 1447.0 1459.0 1.219 .096 .082 .120 CUSING ,052 .006 1447.0 1459.0 1.096 .123 .039 .065 CUMOD .033 .006 1447.0 1459.0 1,213 .173 .021 .044 CUIUD .006 .003 1447.0 1459.0 1.393 .467 .000 .012 CUCOND .013 .003 1447.0 1459.0 1.158 .264 .006 .020 CUSTER ,003 .002 1447.0 1459.0 1.082 .486 .000 .007 PSOURC .382 .084 59.0 47.9 1.309 .219 .214 .549 NOMORE .093 .011 1447.0 1459.0 1.474 .121 .070 .115 DELAY .358 .018 1447.0 1459.0 1.406 .050 .322 .393 IDEAL 3.839 .072 634.0 631.8 1.322 .019 3.696 3.982 ANTCAR .321 .021 1518.0 1496.0 1.344 .064 .280 .362 NTETAN .664 .020 1518.0 1496.0 1.307 .059 .297 .376 MEDELI .206 .016 1518.0 1496.0 1.234 .079 .173 .238 RESPIR .167 .018 1376.0 1341.4 1.516 .107 .132 .203 FEVER .317 .018 1376.0 1341.4 1.278 .058 .280 .354 DIARR1 ,119 .014 1376.0 1341.4 1.488 .115 .092 .147 DIARR2 .198 .016 1376.0 1341.4 1.335 .080 .166 .229 ORSTRE .340 .048 236.0 265.2 1.501 .140 .245 .435 MEDTRE .449 .048 236.0 265.2 1.459 .107 .353 .544 HCARD .254 .030 323.0 304.8 1.179 .117 .195 .314 BCG12 .695 .033 323.0 304.8 1.259 .048 .629 .762 DPT12 .343 .034 323.0 304.8 1.241 .099 .275 .412 POLl2 .344 .034 323.0 304.8 1.241 .099 .276 .412 MEAS12 .479 .041 323.0 304.8 1.426 .086 .396 .561 FULVAC .274 .033 323.0 304.8 1.291 .121 .208 .340 211 Table B.12 Sampling errors: Age group 25-34, Pakistan 1990-91 Value Vexiable (R) Number of cases Stmadm-d Design Relative error Unweighted Weighted effect error (SE) (N) (WN) (DEFT) (SE/R) Confidence limits R-2SE R+2SE WOMEN URBAN .310 NOEDUC .766 SECOND .096 COUSIN .499 CUWORK .165 SURV1V 3.211 KMETHO .793 KSOURC .471 EVUSE ,212 CUSING .113 CUMOD ,083 CUIUD .018 CUCOND .036 CUSTER .017 PSOURC .448 NOMORE ,314 DELAY .197 IDEAL 4.039 ANTCAR .309 NTETAN .688 MEDELI .205 RESPIR .155 FEVER .285 DIARR1 ,071 DIARR2 .126 ORSTRE .421 MEDTRE .522 HCARD .339 BCGI2 .706 DPT12 .447 POLl2 .451 MEAS12 .527 FULVAC .374 .011 2669.0 2681.7 1.231 .036 .288 .332 .013 2669.0 2681.7 1.526 .016 .741 .791 .010 2669.0 2681.7 1.816 .108 .075 ,116 .017 2669.0 2681.7 1.758 .034 .465 ,533 ,010 2669.0 2681.7 1.379 .060 .145 .185 .055 2669.0 2681.7 1.443 .017 3.102 3.321 .013 2606.0 2598.9 1.680 .017 .767 .820 .014 2606.0 2598.9 1.480 .031 .442 .500 .010 2666.0 2598.9 1.310 .049 .191 .233 .008 26136.0 2598.9 1.348 .074 .096 .130 .006 2606.0 2598.9 1.184 .077 .071 .096 .004 2606.0 2598.9 1.591 .229 .010 .027 .005 2606.0 2598.9 1.277 . 130 .026 ,045 .003 2606.0 2598.9 1.078 .162 .011 .022 .048 269.0 216.7 1.586 .108 .351 .544 • 013 2606.0 2598.9 1.474 .043 .287 .340 .011 2606.0 2598.9 1.455 .058 .174 .219 .069 1132.0 1131.3 1.318 .017 3.902 4.177 .013 3402.0 3457.1 1.263 .042 .283 .335 .015 3402.0 3457.1 1.435 .047 .282 .341 .013 3402.0 3457.1 1.409 .062 .180 ,231 .009 3113.0 3107.6 1.293 .060 .136 .173 .011 3113.0 3107.6 1.263 ,040 .262 .308 .007 3113.0 3107.6 1.517 .103 ,057 .086 .010 3113.0 3107.6 1.565 .081 .106 .147 .032 379.0 392.9 1.207 .075 .358 .484 .030 379.0 392.9 1.121 .058 .462 .582 .029 620.0 647.5 1.526 .084 .282 .397 .026 620.0 647.5 1.450 .037 .654 .758 .027 620.0 647.5 1.374 .060 .393 .501 • 027 620.0 647.5 1.387 .061 .396 .506 .025 620.0 647.5 1.264 .047 .477 .577 • 026 620.0 647.5 1,335 .068 .323 .425 212 Table B.13 Sampling errors: Age group 35-49, Pakistan 1990-91 Numlmr of cases Vmiable Stand~d Value error (R) (SE) Design Relative Cord~dctw.¢ limits Unweighted Weighted effect error CN) (WN) (DEFT) (SE/R) R.2SE R+2SE WOMEN URBAN NOEDUC SECOND COUSIN CUWORK SURVIV KMETHO KSOURC EVUSE CUSING CUMOD CUIUD CUCOND CUSTER FSOURC NOMORE DELAY IDEAL ANTCAR NTI~IAN MEDELI RESPIR FEVER DIARR1 DIARR2 ORSTRE MEDTRE HCARD BCG12 DPT12 POLl2 MEAS12 FULVAC .328 .010 ,835 .012 .056 .007 .472 .014 .187 .011 5.306 .064 .796 .012 .505 .016 .268 .013 .167 .010 .134 .009 .010 .003 .026 .005 .077 .007 .660 .039 .592 .013 .037 .005 4.259 .076 .222 .017 .764 .018 .126 .012 .165 .016 .322 .019 .073 .010 .137 .014 .386 .050 .447 .048 .239 .034 .675 .038 .475 .040 .475 .040 .466 .039 .383 .038 2471.0 2442.1 1.108 .032 .307 .349 2471.0 2442.1 1.610 .014 .810 .859 2471.0 2442.1 1.481 .122 .042 .070 2471.0 2442.1 1.398 .030 .444 .501 2471.0 2442.1 1.340 .056 .166 ,208 2471.0 2442.1 1.305 .012 5.178 5.434 2340.0 2306.1 1.383 .014 .773 .819 2340.0 2306.1 1.507 .031 .474 .536 2340.0 2306.1 1.406 .048 .242 .294 2340.0 2306.1 1.260 .058 .147 .186 2340.0 2306.1 1.276 .067 .116 .152 2340.0 2306.1 1.414 .286 .004 .016 2340.0 2306.1 1.450 .183 .017 .036 2340.0 2306.1 1.336 .096 .062 .091 327.0 309.1 1.475 .059 .583 .738 2340.0 2306.1 1.327 .023 .565 .619 2340.0 2306.1 1.273 .134 .027 .047 859.0 824.3 1.178 .018 4.106 4.411 1432.0 1453.5 1.252 ,075 .188 .255 1432.0 1453.5 1.318 .075 .201 .271 1432.0 1453.5 1.122 .093 .103 .150 1339.0 1326,5 1.457 .097 ,133 .198 1339.0 1326.5 1.339 .057 .285 .359 1339.0 1326.5 1.328 .135 .053 .093 1339.0 1326.5 1.497 .105 .108 .166 166.0 182.2 1,359 .130 .286 .487 166.0 182.2 1.262 .108 .351 .544 244.0 262.4 1.287 .141 .172 .306 244.0 262.4 1.322 .056 .599 .751 244.0 262.4 1.288 .083 .395 .554 244.0 262.4 1.288 .083 .395 .554 244.0 262.4 1.282 .084 .388 .545 244.0 262.4 1.270 .099 .307 .459 213 APPENDIX C DATA QUALITY TABLES APPENDIX C DATA QUALITY TABLES Table C.I A~e distribution of household population Single-year age distribution of the de facto household population by sex (weighted), Pakist~ 1990-91 Males Females Age Number Percent Number Percent <1 714 3.0 642 2.9 1 598 2.5 558 2.5 2 643 2,7 598 2.7 3 589 2.5 639 2.9 4 587 2.5 546 2.5 5 845 3.6 806 3.7 6 930 3.9 805 3.7 7 807 3.4 835 3.8 8 946 4.0 810 3.7 9 575 2.4 584 2.7 10 888 3.7 787 3,6 11 462 1.9 446 2.0 12 834 3.5 714 3.3 13 527 2.2 483 2.2 14 563 2.4 569 2.6 15 565 2.4 476 2.2 16 540 2.3 498 2.3 17 398 1.7 309 1.4 18 630 2.7 675 3.1 19 315 1.3 261 1.2 20 601 2.5 675 3.1 21 252 1.1 204 0.9 22 478 2.0 430 2.0 23 261 1.1 260 1.2 24 290 1.2 230 1.0 25 660 2.8 728 3.3 26 297 1.3 312 1.4 27 204 0.9 217 1.0 28 298 1.3 314 1.4 29 101 0.4 98 0.4 30 729 3.1 626 2.9 31 74 0.3 107 0.5 32 245 1.0 222 1.0 33 107 0.5 139 0.6 34 114 0.5 113 0.5 35 660 2,8 547 2.5 36 150 0.6 131 0.6 37 76 0.3 100 0.5 38 133 0.6 132 0.6 39 64 0.3 86 0.4 40 599 2.5 409 1.9 217 Table C.I Household age distribution (continued) Single-year age distributica of the de facto household population by sex (weighted), Pakistan 1990-91 Males Females Age Number Percent Number Percent 41 68 0.3 96 0.4 42 133 0.6 159 0.7 43 90 0.4 110 0.5 44 62 0.3 97 0.4 45 456 1.9 313 1.4 46 92 0.4 95 0.4 47 78 0.3 75 0.3 48 96 0.4 90 0.4 49 44 0.2 29 O. 1 50 398 1.7 308 1.4 51 64 0.3 133 0.6 52 118 0.5 189 0.9 53 56 0.2 109 0.5 54 42 0.2 66 0.3 55 280 1.2 374 1.7 56 89 0.4 83 0.4 57 33 0.1 49 0.2 58 61 0.3 67 0.3 59 43 0.2 24 0.1 60 523 2.2 405 1.8 61 47 0.2 38 0.2 62 68 0.3 33 0.1 63 40 0.2 34 0.2 64 30 0.1 20 0.1 65 308 1.3 233 1.1 66 33 0.1 17 0.1 67 34 0.1 31 0.1 68 35 0.1 31 0.1 69 16 0.1 20 0.1 70+ 971 4.1 506 2.3 Don't know, missing 14 0.1 10 Total 23773 1130.0 21965 100.0 Note: The de facto population includes all usual residents and nomesideats who slept in the household the night before interview. -- Less than 0.05 peree~t 218 Table C.2 Age dislribution of eligible end interviewed womea Percent distribution in five-yesr age groups of the de facto household population of all women end ever-mettled women aged I0-54 end of interviewed women age 15-49, and percentage of eligible women who were interviewed (weighted), pakistan 1990-91 Ever- Interviewed women All married Percentage Age group women women Number Percent interviewed 10-14 2998 NA NA NA NA 15-19 2219 420 414 6.6 98.7 20-24 1798 1086 1015 16.2 93.5 25-29 1669 1466 1419 22.6 96.8 30-34 1207 1162 1123 17.9 96.7 35-39 996 976 925 14.7 94.8 40-44 871 850 797 12.7 93.8 45-49 602 590 582 9.3 98.7 50-54 805 799 NA NA NA 15-49 9363 6549 6277 100.0 95.8 Note: The de facto population includes all usual residents and non-residents who slept in the ho~ehold the night before the interview. Weights for both households and interviewed wom~ are household weights. NA = Not applicable 219 Table C.3 Completeness of re~l~rtlng Percentage of observations missing information for selected demographic and health questions (weighted), Pakistan 1990-91 Subject Reference group Percentage Number missing of information cases Birth date Month only Month end year Age at d~th Age/date at first onion ~ Responclent's education Child's size at birth ~men: Height Weight Diarrhoea in last 2 weeks Last 15 ye~s 8.0 20527 0.2 20527 Last 15 years 0.6 2494 Ever-married women 0.6 6611 Ever-menSed women -- 6611 Births in last 0-59 months 1.5 6490 Living children age 1-59 months Living children age 1-59 months 19.6 5776 20.5 5776 5776 -- Less then 0.05 percent IBoth year end age missing 7"Child not measua'ixl 220 Table C.4 Births by calendar year Distribution of blxtlu by calendar year for livin 8 (L), dead (D), and all (T) children, ac~rdin 8 to repotting ccm~leteneas, sex ratio at birth, and ratio of births by calendar year (weighted), Paldstaa 1990-91 Number Percent with Sex ratio Calendar of cogr~plete at year T~'1~1 s birth date I birth 2 ratio 3 Ye~ L D T L D T L D T L D T 1991 212 17 228 100.0 100.0 100.0 148.1 58.6 138.3 HA NA NA 1990 1427 78 1505 98.0 92.4 97.7 109.4 67.9 106.8 NA NA NA 1989 1072 128 1199 97.6 91.5 96.9 90.8 159.7 96.4 82.2 111.0 84.5 1988 1180 151 1332 97.3 92.4 96.8 123.4 118.6 122.8 107.8 109.5 108.0 1987 1118 149 1267 95.6 83.3 94.1 97.0 163.7 103.1 106.1 113.8 106.9 1986 927 111 1038 93.7 94.3 93.8 96.5 100.9 96.9 64.8 54.1 63.4 1985 1745 260 2005 93.0 81.7 91.5 102.1 105.9 102.6 141.8 152.2 143.0 1984 1535 231 1766 91.2 85.2 90.4 105.7 122.5 107.8 95.1 104.2 96.2 1983 1482 183 1665 91.0 84.3 90.3 93.2 124.0 96.2 98.9 86.1 97.3 1982 1461 195 1657 90.9 84.3 90.2 l(F2.1 93.7 10L1 116.4 97.1 113.7 1987-91 5009 523 5532 97.3 89.8 96.6 106.6 125.4 108.3 NA NA HA 1982-86 7150 980 8130 91.9 84.9 91.0 100.2 109.6 101.3 NA HA NA 1977-81 5131 836 5967 90.3 86.1 89.7 109.7 83.2 105.5 NA NA NA 1972-76 3425 631 4056 89.0 81.0 87.7 109.7 99.1 107.9 NA NA NA Before 1972 2577 608 3185 85.8 77.7 84.2 108.0 116.2 109.6 NA NA NA All 23292 3578 26870 91.6 84.0 90,6 105.9 104.0 105.6 NA NA NA NA -- Not applicable 1Both year and month of birlh given 2(Bm/Bf)xl00, whea'e B m and Bf are the numbers of male and female births, respecfiwly 3[2Bx/Bx.t+Bx+t)]xl00, where B x is the number of births in calendmr year x 221 Table C.5 Reporting of age at death in days Dis~bution of ~eported deaths trader one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Pakistan 1990-91 Years preceding survey Age at death (days) 0-4 5-9 10-14 15-19 0-19 <1 47 73 65 28 213 1 68 75 60 27 230 2 17 36 18 8 79 3 25 49 35 8 117 4 8 22 14 11 54 5 17 30 8 II 65 6 14 24 22 12 72 7 20 21 29 21 91 8 13 42 13 19 87 9 3 8 I0 3 24 I0 16 18 18 6 59 II 8 4 6 4 21 12 I 11 9 9 29 13 3 5 0 3 11 14 3 2 3 7 15 15 15 15 11 3 44 16 9 10 1 6 26 17 I 6 2 1 I0 18 3 2 4 l 10 19 0 1 1 2 4 20 6 11 6 3 26 21 0 1 0 6 8 22 3 1 2 0 5 23 0 1 0 0 1 24 1 1 0 0 2 25 4 1 I 2 8 26 0 1 3 0 4 27 2 0 0 0 2 28 0 0 0 0 0 29 0 0 2 0 2 30 2 6 3 3 15 Missing 3 0 0 0 3 Percent early neonatal 1 63.3 64.7 63.8 51.3 62.1 Total0-30 309 476 349 203 1337 10-6deys/0-30 days 222 Table C.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months and the percentage of infant deaths reported to eccut at ages under one month, for five-ye,~ periods of birth preceding the survey (weighted), Pakistan 1990-91 Yes.rs preceding survey Age at death (months) 0 J, 5-9 10-14 15-19 0-19 <1 m 312 476 349 203 1340 1 48 57 44 40 189 2 34 78 32 17 160 3 35 33 28 16 113 4 14 36 23 7 79 5 9 27 17 7 60 6 25 37 23 15 100 7 4 24 15 12 56 8 14 14 12 5 45 9 20 5 15 14 55 10 16 14 12 11 53 11 3 10 6 7 25 12 11 13 2 6 32 13 1 1 0 0 2 14 1 2 1 0 5 15 0 11 2 3 17 16 5 0 0 3 8 17 0 2 1 0 3 18 5 19 12 6 42 19 0 0 0 0 0 20 0 0 0 0 0 21 0 1 0 1 2 22 1 0 0 0 1 23 0 0 0 0 0 M~sing 0 1 1 1 4 l year 43 60 46 43 193 Percent neona~ 67.3 65.7 68.2 68.7 67.2 Tota10-23months 534 812 575 354 2275 alncludes deaths under 1 month reported in days bUnder 1 month/under 1 year 223 APPENDIX D QUESTIONNAIRES PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD SCHEDULE - URDU-ENGLISH IDENTIF ICATION PLACE NAME NAME OF HOUSEHOLD HEAD PROVINCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (urban=l, rural=2) . . . . . . . . . . . . . MAJOR C ITY /D IV IS ION/DISTRICT . . . . . . . . . . . . . . . CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . MAJOR C ITY /SMALL C ITY ,TOWN/VILLAGE . (major c i ty=l /smal l c i ty , town=2/v i l lage=3) Q . . o o o o o o . o o o o . , , e o * i i e e e e o , m , o e e t o e • • • INTERVIEWER VIS ITS 1 2 3 F INAL V IS IT DATE INTERVIEWER'S NAME RESULT* NEXT VISIT: DATE T IME *RESULT CODES: i COMPLETED 2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME 3 HOUSEHOLD ABSENT 4 POSTPONED 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER (SPECIFY) NAME DATE DAY MONTH YEAR NAME I RESULT TOTAL NUMBER E OF VISITS TOTAL IN HOUSEHOLD TOTAL EL IGIBLE WOMEN TOTAL EL IGIBLE HUSBANDS FIELD EDITED BY I OFFICE EDITED BY I KEYED BY 227 HCUSENOLD SCH~DUI F N~ Me ~uid Like llo~.~, information I#Dout the.p4~Le who uaLLy Live In y~Jr ho~ehotd or ~ho ere Steyir~ with you now. LINE" USUAL RESIDENTS AND "iELATIONSNIP- RESIDENCE I SEX I AGE MARITAL I EDUCATION HATURAL PAItJENTS**** ELIGI- ~PO, V[SITONS TO NIEAD OF STATUS I l I DILITV NGJSENOLD" ' Nil What is the FQR FOR EVERYORE AGeD I I I I I I I{NN4E) Ihighnt Icy- ALL • LESS TNNd 15 YEAIt$- ~teese Dive me the 4hat ill the )o41 Did Ill HOM old rob ALL ever eL of llchooL AGED - CIRCLE Ill Of the personl Petlltionship :BNqE) (NAME) (MANE) is kGED 15 ~ (MANE) LESS Does Does LINE Jlo uSuaLly t[ve in )f (N/~IE) to mumLLy llLetp male (MA~) kAD OVER to ettet~ THAN (KNqE)*ll (MANE},s II~N ~our hou~ehotd or ~he heal Live here or in cam - - schoo l7 khat Ill the 2S na~urel n~turil OF ~re lltllying MIth y~ )f the ere? Lilt file pletal /hit Is highest YRS. Bother fether ELIGIBLE io~, starting with tc~ehoid? night? 7 yeerll? ;N[,S) class I Live In Live ir~ M(]MEN :he helKI of the mritllI (MN4E) it this thlll MiD PUT ~o~ghotd. status? c~Leted INANE) lou~ehotd houeehotd S~E ~/~ *" . t ~h . t , t lU i~ i , ,ES: ,F VEE: .ou~o, ~-;-I "~- b ~ (NAME) .b ( b/~ ~ (~) (NAME) ~J~. LeVeL? *w* llch~I? Whlt is Uhet il LINE llr nsB47 hisL~l? ~EN • " iL~GIBLE • ~! : - - . . :~ d . .~ ' '~,~".~ ~ ~.~o, z z , /g -~, :4 ~2 :~;.~ /~'4 :÷D., K- ~ , , : ,vEs, " , -" cN~) i v * / . , d'~<OI .~(,;,( : " ~; ~ . : " ' " RECC~tD RECORD .~ ~o,~" .OT.RN.S fAT.eR' S ' ~.~d~L~ LINE NO. LIME IK). I (~) . (~) . ( , ) . (6 ) (~) . (B) . (9 ) • < ) . ( ) . ( z ) (m . (1 ,1 . . ~ D - - 11 mml(1) (2) I I (4) I (5) I (6) I (7) I ca) I (9) I i I (11) I OZ) (13) i ~ ES NO rES NO M F IN TEARS YES NO LEVEL CLASS YES NO o, ~ ,, I, I ~ I - ] ,, R ~ , F1 -~m o, o, . ~ I , ,.~. , Xq-l. I-[ .I,. FI ~ . ,. ~ . M_~o~ i FR ~z_ " RR- , FR FR . - OG . rYl " '~_ .~. rY ] . n " ,R rT - . , rY ] ry]_. ~ o , o , 08 ~_. . ;;1 ,, ,, , ,R-I. FI ~,, I-IFF 1, Ji] Iqq. ~ ,o ~ ~ .''.' LJ' 'J~]. R ]'" [] [-I- '' R-1 I-i-]. IO 1, LFFI .,,.1, ,,,I-;1 rq ,, RF[- ,, JEE] [-iq. I, 1, I-I-I 1, ,, 1, R-i FI ,, E]FF 1 , FFI I-I-I ,, * CODES F(~ Q.3 ** CODES FOB Q.8 *** C~ES FOR B.lO RELATIONSHIP TO HEAD OF HOUSEHOLD: MARITAL STATUS: LEVEL OF EDUCATION: CLASS: 01= HEAD OTz PARENT'IN*LAW lzNEVER )tARRIED 1" PRKI4ARY DO=LESS TRAM 02" WIFE OR HUSBANO 08= BROTHER OR SISTER 2=CURRENTLY MARRIED 2= MIDDLE CON#LETED 03:SC44 OR DAUGHTER 09= OTHER RELATIVE 3=MIDOI~D 3: SECOMDARY 98--OK Dt*z SO~ OR OAUGNTER'~N'LA~ SO=ADOPTED/FOSTER CNILD 4~'DIVORCED 4= NIGHER 05" GRANDCHILD 11= NOT RELATED 5:SEPARATED 8= DK 06z PARENT 98= DK " 8=DK **** RECIteD O0 IF NATURAL (BIOLOGICAL) PARENT NOT MEMBER OF HOUSEHOLD, I TEAR 228 LJN£ IJ~L SEilD~ITE ,UO K, VIS|T|S :1) n 13 14 1S 16 1T Tll 19 20 21 ,I~e Elve le the i of the persorl • o vltlily live In household or hre ateyirl w|th yli ~ol, starting tlth the heed of the household. t. ~C e" '" ,j~' tELATIO~SIflp REEIOEI/CE Sl~X AGI~ NASITAL EDUCATION TO kF~kD OF STATUS ~OL~ROLD* His ~at is the - filE) ~ighiit (iv- lit Is the Dote Did li MOW old FOR ALL ever i( of Sllt 'elitlonihlp (M) (ill jIM,E) Is AiD 15 ~ (WilE) "<""'<'"'' t,:.':" ~ <hh.,,,,No,~, ,o he h. . ,,,,. ~., ;~:,',.-~<,. ,f the here? list t • lit Is hlghut io~hotd? night? (W~E'E) I IteMs - - urltal (liNE) status? l~ietKI st at this I r< . . , ¢ ~ . ( - - , I<~, ) ~ , , . . ( . . . ~ ( I ) i.iS) ill ~ ~ ( I ) D (WANe) (~, (,> ,,> (,> (,, (s> (,> ~ ~"-"';,iI7 's" Ill EQ YES NO 14 l E YEARS 'IS NO LEVEL CLASS l-FI 1, 1, 1, i-FIII-i 1, FIR- I-F-I 1, 1, 1, r-l-iI F1 1, FlIT FIG ,, i1, ,, FFI FI ,, FII-I- FF1 1, ,, 1, FR' FI 1, FII-I- 1-1--I 1 , , , 1, FR: I-I , , i-ll-r- FFI 1''1' 1' I-1-1FI 1' RFF FF1 1' '1' 1' Fi--I F1 " F1FF I-FI ' ' I' ' 1 ' I-Iq i-1 ' ' I-II-I- FFI " I1' " FFI i-I " FIFF FFI ' ' ' ' 1' t-l--i El " 1211~ NATU~J,L PABEETS**** [LIGI- • , SILITY FOR FOR EVERYORE A~ED ALL LESS rNN~ 15 YEAREI AGED CIRCLE LESS DOeS tO°eSl h i~e LIME T~L~ (ili) 'l (iSlE) ' a rltt~a ( It~e( TEl. mother father [LIGIILI - - live In W~IEW th|s this S~UARI~T ~oxmehoL ~ heuuhoI d IS IF YES: I IF YES: ABOUND I L|NE (l~) that fs i~at |a N E still tn ~er rime? his ? SECORO SE~ ; FATHER *S I~)T HER iS I LIME LINE k~MSES lU~ES (11) (12) ; (13) (1~) I YES NO 1, ITl I~l 1, 1, I-~ F ~ ,. TICK ~SE IF ~DiIilllUATl(~l E~EI ~O ~-~ Juit tO mike sure that I hive I l~Iplttt Itst|rl: 1) Ire there any other persml such . liill chiidrl~ or |nflmta that le have not tilted? rOrAL StliER Of EI.ZCiISLe UO~S ~-~ TOTAL lliiilRS OF ELIGIliLE V, USSANOS F - ~ . . , . . . . ~ ~lT D~. / : . ; <, " " YES ~ • IN TABLE NO ~.~, '~C~., .= ~I, 0 "~" ~ ':"',8 d "it" z 2) In addition, era there Iny other people who may not te mrs of y~r fili ty, such It servants, . ~ ~r)~. ~.i ~ .I,I ~ ~.,U~ ~ ~rl ( I" ~ EMTES EACH lodgers or friends who usually Live hire? YES • IW TABLE NO 3) Do ~ hive .~ i~.,. o, ,.~or.~ .I.to~. ,t.ing -- - ~ ;. , ¢~ - ~ ~MT. UCM F.,'--- else who tuLipS here List night? ~o~b~ (r ~ ~-~ here, or a; ,. O (~ ~ ~1 .~l YES • IU TABLE NO 229 NO. HI DUESTIUNS ANO FILTERS t~tit JS the source of uater your household u=es for handueshin~ end dlshueshlng? SKIP CODING CATEG~RIES I TO m PIPED INTO RESIDENCE . O ~ PIPI~D OUTO PROPERTY . 0~.'/~ PUOLIC TAP . 03 WELL UITH HANDPUI4P/TORE VELL.,.O~ ~IELL UITNOUT PUAP . 05 RiVER. KAREZ, SPRING+ CANAL, SUqFACE MATER . 06 TANKER TRUCK, OTHER VENDOR . 07 RAINWATER . 08 OTHER 09 (SPECIFY) I " -**- - - '1 and c~ back? " * I . MINUTES . "]°----'+-* I ; fr~ this same so*Jrce? YES . 1 ~HS H~ What is the source of drinking ueter for mrs of your household? PIPED INTO RESIDENCE . 01 PIPED OHTO PROPERTY . 02 PUBLIC TAP . 03 WELL WITH HANDPUMP/TUBE ~ELL,.04 WELL U]THOUT F~qP . OS RIVER, ICAREZ, SPRING, CANAL. SURFACE WATER 06 TANKER TRUCK, OTHER VENDOR . . . . . 07 RAIHI~TER . 08 OTHER 09 (SPECIFY) H5 I ~,qlat kind of toilet facility does your household hive? I I FLUSH . 1 BUCKET . E PIT . 3 OTHER & (SPECIEY) NO FACiLiTIES . 5 146 D~S your household hive: .~ .~.~'~'.,~- ,~.%i~C Elect Pie J ty? .~.~. A radio? A tetevilion? H ,,®.Y 2 A reow cooler? ~j]r.lj - .~; A umehlng Ichine? • o ,~ ;c YES NO ELECTRICITY . I 2 RADIO . 1 2 TELEVISION . 1 2 FRIDG£ . ( 2 ROOM COOLER . 1 2 WASHING MACHINE . . . . . . . . . . . . I 2 WATER PUMP . . . . . . . . . . . . . . . . . 1 2 I your hc~ehotd own: ~.:?'+.~+, : ¢.,+1" ~ A bicycle? .,.J A motorcy¢Ie? b j)(.J~. ~ j~ / A car, van or tractor? t,~.j ~. c~rj~. / +1 H9 HIO [ Hou ~ rocml in your household Ire used for s teep ingY i I MAIM MATERIAL OF OUTER blALLS. (RECORD UNSERVATIOR.) 14~IN MATERIAL OF RCOF. (RECORD nUSERVATION.) YES NO I BICYCLE . , . 1 2 NOTQHCYCLE . 1 2 CAR, VAN, OR TRACTOII . 1 2 H= . ml BAKED BRICKS/CEHENTED BLOCKS/ CEMENT . 1 UNBAKED BRICKS AND MUD . 2 NOOO/ON41100 . . . . . . . . . . . . . . . . . . . . . 3 OTHER 6 (SPECIFY) RCC/RIK: . . . . . . . . . . . . . . . . . . . . . . . . . 1 T - i tUN/WOODIER i Ct( . . . . . . . . . . . . . . . 2 ASBESTOS/IROU SHEETS . 3 UCOO/SAMNO . 4 OTHER S (SPECIFY) 230 PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY WOMAN'S OUEST IONNAIRE - URDU-ENGL ISH IDENTIF ICAT ION PLACE NAME NAME OF HEAD OF HOUSEHOLD PROVINCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (urban- l , ru ra l -2 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . MA JOR C ITY /D IV IS ION/D ISTR ICT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MA JOR C ITY /SMALL C ITY ,TOWN/V ILLAGE . . . . . . . . . . . . . . . . . . . . . . . . . (major c i ty=l / smal l c i ty , town-2 /v i l l age-3) NAME AND L INE # OF WOMAN NAME & L INE # OF HUSBAND (IF EL IG IBLE) INTERVIEWER V IS ITS 1 2 3 [ F INAL V IS IT DATE INTERVIEWERIS NAME RESULT* NEXT V IS IT : DATE T IME DAY MONTH YEAR I- RESULT TOTAL NUMBER OF V IS ITS *RESULT CODES: 1 COMPLETED 3 POSTPONED 2 NOT AT HOME 4 REFUSED LANGUAGE OF QUEST IONNAIRE . . . . . . . . . . . . . . . . . . LANGUAGE OF INTERVIEW . . . . . . . . . . . . . . . . . . . . . . NAT IVE LANGUAGE OF RESPONDENT . . . . . . . . . . . . . . TRANSLATOR USED . . . . . . . . . . . . . . . . . . LANGUAGE CODES: 5 PARTLY COMPLETED 6 OTHER , . . . ° o o o o ° o o o ° , ° o o ° o ° o , ° YES. . .1 NO. . .2 g ~ O g (SPECIFY) 01 URDU 03 S INDHI 05 BALUCHI 07 S IRA IK I 02 PUNJAB I 04 PUSHTO 06 BROHI 08 OTHER (SPECIFY) r J 231 232 NO. 102 103 QUESTIONS AND FILTERS I COOING CATEGORIES I TO RECORD THE CURRENT TIME, :::::::::::::::::::::: First 1 would Like To =sk Im q~mtl~ about you and your h~ehold. For most of the tla~ mtil you ~re 12 yeirs old, did you Live in • city or in • village? CITY . 1 VILLAGE . 2 i HOU long have I you been living continuously in iNANE OF CURRENT PLACE OF RESIDENCE)? (HAHE OF CURRENT PLACE OF RESIOEMCE) ~.~/ J<., : ' . YEARS . [-~ I ALWAYS . ~- ' - - ] VISITOR . 96 ,105 I 104 I Juat before you moved here, did you live in • city I or in • village? " I I CITY . 1 I VILLAGE . 2 105 In k11at month and year uere you born? t~OJdTH.°°.o° . ~-~ OK MONTH . 98 YEAR . M DK YEAR . 98 106 Hay old are you in completed years? COMPARE ANO CORRECT 105 AND/ON ,106 IF INCONSISTENT. i AOE ,H PLETED YEA. . l-- i 107 Are you nov married, widowed, divorced, or aeplreteci? . .:.~ ~ l - . ? .~ I 14ARRIED . 1 I HAS llIRRIAGE CONTRACT, BUT NEVER LIVED TOGETHER . 2 VI~D . 3 DIVORCED . 4 SEPARATED . 5 NEVER NAHRIED . ~ ~E~ 108 109 110 CHECK 107 ANO 108 : MARRIED ONCE ANO NEVER LIVED WITH HUSI~MO (~CE . oo°°,.°oo°* . 1 MORE THAN ONCE . 2 AMY OTHER MARITAL STATUS I i I reEl Have you ever attended school? I YES . 1 I 233 ilO. ~ g~IESTIONE ANO FILTERS 111 | Whet |~ the highest revel of school y~ attended: I prtaary, middle, 841CC]~G~ry, or higher? ,.~ ~ .,., ".,.::.d.~ W ~/~, :e ~ r~,. .~ @'> v.d.z ~, E~IP I CODING CATEGORIES I f O I- . I NIDOLE . 2 SECO~OAJtY . . . . . . . . . . . . . . . . . . . . . . . 3 H~GH[R . 4 112 | Yhet Le the highest class ~ completed | I It th&t Legit? " z : • . I E]DOLE I • (egret or n~v~pelper 11, .,,v.C= ~ : : , I ~,~;:'.~ ~,., .,,, CLASS . I EASILY . 1 VITH DIFFICULTY . 2 NOT AT ALL . 3 I'"li I I I <-'- ' ' • ' ' ' ' r ' I . I et leest once • t~eek? YES . 1 ~ ~, ~j , jr., ~ .,~,~ ,.t./ _ ~ ~. ~: ~.,/" ~f HO . z o . b . • . . , ~ YES . 1 ~" ~ ~ ~'~ -~/"~" " ~ f~ ~ ( '~ " r~ HO . z 118 Ii 19 120 Oo *ou u , . , I , . . ,<, ,eiev s ,= . , le., , o,'=e . . . , , I I :~ .~. . , " ~ , , ,~ . - , . i ; ,, . ~(,.f~.,,<.t.,,,,r,~. . , ,s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 14@ . , . C~Ci~ I~ISE~O ~RSESTIO~I~E,/ OiXU~ (4): I I k~4AH IS A VISITOil ~ kq]4AN ISUSUAL RESIDENT (CODED "2" ]H COL. &) (CODED 1" IN COL. 4) ~ )201 y .-- No¢~ let's talk shout the household where you usuaLLy Live. Whet is the source of Meter your household uses for handueshlng and dlshweshtngT PIPED INTO HESIDENCE . 01 PIPED OllTO PROPERTY . 02~lZZ PUBLIC TAP . 03 ~ELL WITH H&NDPUOqP/TUSE WELL,.04 WELL WITHOUT PUMP . OS RIVER. KAREZ. SPRING. CANAL. SURFACE WATER . 106 TANKER TRUCE, OTHER VEIIOOR . OT RAINWATER . 08 OTt¢EE 09 (SPECIFY) 121 Hou Long does it take to go there, get ~ter, NINUTES . ~ I I • Gt PREMISES . 996 122 Does your household get drird~inS water I from this sm iourceT YES . 1 -=124 2 234 NO* QUESTJO~S AMO FILTERS 123 What i• the source of drinkir~ ~lter for m r • oF your household? J ,, COPING CATEGORIES PIPED INTO RESIDENCE . . . . . . . . . . . 01 PIPED ONTO PROPERTY . 02 IqJILIC TAP . 03 WELL ~IFH HANOPUMP/TUEE WELL.O~, WELL UITI~UT PUMP . G~ RIVER, KAREZ, SPRING, CANAL, UFAC~ MATER 06 TANKER TRUCR, OTHER VEMD<~ . 07 RAINMATER . 08 OTHER 09 (SPECIFY) IK |P TO 124 I ~,t Bind of Toilet fl~i|ity doel y~Jr household hive? FLUSH . 1 I I BUCKET . 2 I ~,,~J~ c~->- i . Cj~6c* , ~ ~" Pit . 3 • OTHER 4 (SPECIFY) ~. ~ MS FACILITIES . 5 t I .+ , .+ I , . ~ ~- ~" I A redi o? ~ I A tilevJ lion? ,~3~j A f r i ckle2 A bi•lhl~ ~hine? A uater pu~? ~-~+.~U I YES NO ELECTRICITY . 1 2 ~ Z 0 . 1 2 TELEV[SIOR . 1 2 FRIOGE . I 2 ROCI4 COOLER . . . . . . . . . . . . . . . . 1 2 WASHING MACHINE . 1 ;~ k~ATER PUqP . 1 2 126 A bicycle? (" '# : I A CaP+ van or tr4uctor? YES 140 BICYCLE . 1 2 MOT~CYCLE . ( 2 CAR, VAN, OR TRACTC~ . 1 2 I 127 I HO~ ~ ro~ml in your hold•hoLd ire used for steepens? ¶ {~.~jb.~., ~ f ~. 4./;r. ~u~.~ .~. I ,(zlqs . [~1-~ I I t28 I Whit Itirt•[ ire the outer •|tl of your house made of? 129 | Whir ra t i f i e r is the roof of your I ho~e rode of? 1301 .t provil~ce do ~ usuaLLy ttvl inT I BAKED BRICKS/CENEMTED BLOCKS/ | CENEHT . 1 I UNBAKED BRICKS AND IqJD . . . . . . . . . . 2 WOCOIgAMNOO . 3 OTHER 4 (SPECIFY) RCC/RDC . 1 l T" l RON/~KX~D/BR Z CK . 2 I ASBESTOS/I ROH SHEETS . 3 ~OCO/EAMSO0 . 4 OTHER 5 ~SPECIFY) FIJNJAS . 1 I SIl~H . 2 I NgFP . 3 BALLK;HI STAM . 4 I SLAJ~SAD . 5 OTHER AREAS Of PAKISTAN . . . . . . . . . 6 OUTSIDE PAKISYN+ . . . . . . . . . . . . . . . . P I ' ' - - -Y I I • City or • vlillee~ CITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 • VILLAGE . 2 3 235 "1 201 20Z 2O3 gUESTLOIIS A uh FILTERS I I gm I tmutd tLke to e*k ~x~t oat the birth• yeu have | had durlno your Life. Nave ~u ever given birth? I I y4t. . . .~.~.Z ,.~r/-,,~ 1 °++;.++-*+-+-++ giwm birth Mbo ire i~ LtvlP41 mLth you? Hou tmny SOnS Live uith you? A~I hc~ at~y elat~hterl Live ~ith you? IF g~E, RE~ '00 +, KIP Pn~IMG CATEGORIES I TO I I YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 | I MO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ~ZOt 204 DO you have Imy sans or dllU~tters to Whom you hart givl~ birth uho are alive but do not Live ~lth you? T HOW mmtw sons are a l i ve but do not L ive u i th yo~? And how many dmu~tar l a re a l i ve but do not L ive u i th you? • • / j .~ 206 Hove you ever given birth to • boy or a girl t~o was born alive but Later di~l? IF Me, PROBE: Any baby t,he cried or sbotmd w~y sJsn of Life but only survived i few houri or daysT . • " +" " PmOeE: 1, p#l, , : . , j ~a , . . '~+d~ L/ILFNO. .v tJ • ,it" • * f + i,+, ,+,;.; ,:.,+,.+, '~+.t.;.'<+ YES. . . . . . . * . . . . , , , . . . , . . . . . . . . . *1 Me.*.2 m.L~04 207 I n eLL, ho~tmtny boy• h ive d ied? And hou mmny g i r t s have d lK l? + ~. O~ ,.:,> o.</~ ~;.",+i IF I t~E l RECORD *00+. SUN AMSUERS TO 203, 205, AI~ 207, A~ EMTER TOTAL. IF MOM| MEV.~ID '00' . TOTAL . . . . . . . . . . . . . . . . . . . . . . 4 236 RQ. kJISTlOlIS ldO FILTERS 1'09 YES 210 CHECK 206: ORE OR NOLLE CHECI( 208: Just to wake suce tl~t I have this right: you hove in TOTAL -- tlv~ births during your life. Is that correctT *. 4- . : " , , ". tC PIIORE A~O NO I I • C~ItECT 201-209 AS NECESSARY IIOIIRTNS I'~ ~011~ CATEGORIES KIP TO 1.223 I 5 237 211 NoM [ would t~ke to talk to you about eli of your birlths, ~ether stiLL alive or not, starting uith the first one you had. (RECQRO 14N4E~ Of ALL T~,E E.IBTHS IN 212. RECC&O TWINS AND TRIPLETS ON SEPARATE LINERS). '~ " ~'~ 212 Z13 ~l~•t tMM~e W~S given to your (first, next) /X ( HA~4E ) N (NAME) % (NANE) % (NAME) (NAME) (NAME) (NAME) RECOND SINGLE DR NULTIPLE BIRTH STATUS 214 21] 216 217 In ~et month IF ALIVE: and year ~s IS (NANE) born? Is (NAME HOe oLd is (NAME) (NN4E) stilt (NANIE) in • boy or Ol~#~---"¢j- .'g el(re? completed • B(,(T ~f/rC~, ~ ~ ye,r,? I f PRONE: . (NANE) . I~•t IS his/ (NAME) .~ (NAME) Her birthday? he/she born? • * . . • . iN COMPLETED 218 IF ALIVE: Is (HA4Wl) ( (v ine NI th you? ( NAME ) 219 IF LESS TH, AM 15 YRS. OF AGE: With whom doQs he/she Live? IF AGE 15+: GO TO NEXT BIRT~ 220 IF DEAD: HOw old was he/she when he/she diN? I F "1 YR . *j , PROBE: Hou man), months old was (BANE)? RECORD DAYS lE LESS THAN I MOqMTH,MONTHS iF LESS THAN TGO YEARS l ON YEARS. SING.ll BOY.1 NONTH.~]~ MULT.2I GIRL.2 YEAR. - - i S ]NG. . . l l BOY.1 MONTH.~ vaJLT.2I GIRL.2 YEAR. SING,.1, BOY.1 MONTH. NULT,.,2 GIRL.,2 YEAR., SING.1 BOY.1 MCWTH. MULT.2 GIRL.2 YEAR.,. SIHG,.,I BOY.,,1 ~TH** NULT.,*2 GIRL.2 YEAR,. SING. 1 BOY,.1 V~TH~I ~LT.,,2 GIRL.~ YEAR. SING.,.1 BOY.,1 MONTH. MULT.,,2 GIRL.~ YEAR. YES. . .1 AGE IN YEARS GO.2I v ZZ0 YES.1 AGE IN YEARS GO.2 , rV1 v 220 YES.,.1 AGE iN YEARS NO.,2 , r -9 v 220 YES.1 AGE IN YEARS NO.2 22C YES.,.) AGE IN YEARS NO.2 v 22( YES.1 AGE IN YEARS NO,.2 y 22[ YES.'1 AGE %N YEARS NO.2 22( YES . 1 (GO TO NEXT BIRTH)4 NO . 2 YES . 1 (GO TO NEXT BIRTH)4 NO . 2 YES . 1 (GO TO NEXT BIRTH)" NO . 2 YES . 1 (GO TO NEXT .IRTH) NO . 2 YES . 1 (GO TO NEXT BIRTH)4 NO . 2 YES . 1 (GO TO HEXT BIRTH) ~ NO . 2 YES . 1 (GO TO HEXT BIRTH)4 NO . 2 FATHER . 1 OAYS.,.I (GO NEXT BIRTH) OTHER RELATIVE.2 F;(YATHS,,2 (GO NEXT BIRTH) SOl4E(~ME ELSE.3 YEARS.3 GO~EXT BIRTH) ATHER . 1 DAYS.1 (GO NEXT BIRTH) - OTHER RELATIVE.2 MONTHS.2 (GO NEXT BIRTH) - SOMEONE ELSE.] YEARS.3 (GO NEXT BIRTH) FATHER . 1 DAYS.,1 (GO HEXT BIRTH) • - OTHER RELATIVE.2 MONTHS.2 (GO NEXT BIRTH) • - SOMEONE ELSE.3 YEARS.] (GO NEXT BIRTH) FATHER . 1 OAYS.T (GO NEXT BIRTH OTHER RELATIVE.2 NONTHS.2 (CO NEXT BIRTH) " " SOMEIO~E ELSE.] YEARS.] (GO NEXT BIRTH) FATHER . 1 DAYS.,.1 (GO NEXT BIRTH) OTHER RELATIVE,ZJ KONTHS.2 (GO NEXT BIRTH) - SOMEONE ELSE.3 YEARS.3 (GO NEXT BIRTH) FATHER . 1 DAYS.1 (GO NEXT BIRTH) ~THS 2 OTHER RELATIVE.2 , . (GO NEXT BIRTH i SOMEONE ELSE.3 YEARS.] (GO NEXT BIRTH) FATHER . 1 DAYS.1 (GO NEXT BIRTH) OTHER RELATIVE.2 MOIITHS.2 (GO NEXT BIRTH) SQMEE~E ELSE.,.3 YEARS,.] (GO NEXT BIRTH) 238 212 213 k~4E ~ given to your next baby? ~. " gEcogo +. ~+.~ ORB'HOLE MULTIP BIRTH STATUB 8[ S ING. . .1 ~Lr,.2 (NAM~) 09~ SIHG.,.1 MULT.2 ( NN4E ) SING.,1 NULT.2 (NAME) ~ SING.1 NULT,, .2 (NAME) 1~ SING.1 MULT,.2 (HA/~) SING, ,.1 MULT., ,2 (NAME) 214 ts (HA~) eboyo • girt? (NAME) BOY. 1 GIXL.2 BOY,.1 GIRL.2 BOY.,. 1 GIRL, .2 BOY. I GIRL, .2 IIOY. I GIRL.2 BOY. 1 GIRL, .2 215 ~16 In ~hat a~ch e~clye~r t~s (HAItE) bor~? Is (~AM£ (NAI~) atilt ~d~,,I .~u" ,u,.? Uitmt is his/ -~ her birThdAy? (BAli) OR: In ~hlt he/she i0ornT ~4'~'t * . - N(~TH.~I YES.1 YEAR.*. I10,.~ I v 22O kY)NTH.,~ YES.1 YEAR. NO.2 V 22O V~44TH,.~ YES.1 YEAR. NO,. ,.2 I v 22C 14~NTH,.~ YES.1 YEAR. 510,.2 I v i~TH. .~ TES.1 YEAR. GO.,.,2 I v 22( YEAR.,. HO.2 I 221 f 2; 217 IF ALIVE: HOW old IS (HA~) in ¢~q~tttid yttrs? ~ (NAME) RECORD AGE IN CUMPLETED YEARS AGE IN YEARS AGE IN TEARS AGE IN TEARS AGE IN YEARS AGE [H TEARS AGE IN TEARS COI~oAXE 20~ MITH kUegEX OF BIRTHS IN HISTONY AJ~VE AND HARK: 218 IF AL|~: Is (HAI4~) LivinG with you? (NAME) .'~', I, YES . 1T~ (GO TO NEXT BIRTH) NO . 2 YES . ~j (CO TO NEXT giRTH) NO . 2 YES . 1 (CO TO HEX~ BIRTH) GO . 2 YES . 1 (GO TO NEX~ HIRTH} NO . 2 YES . i (GO TO NEXT!.] 1 BIRTH) 140 . . . . . . . . 2 YES . 1 (GO TO NEXT 1 BIRTH)~ NO . 2 219 |f LESS TBAM 15 YRS. OF AGE: With ~hou he/she Live? ,4, vFI --i, i, IF AGE 15~; GO TO NEXT BIRTH FATHER . . . . . . . . . 1 (GO NEXT BIRTH) OCHER flELATIVE.Z (CO NEXT BIRTH) .T~I4.EONE ELSE.] (GO NEXT BIRTH) FATHER . I (CO NEXT BIRTH) OTHER RELATIVE.2 EGO NEXT BIRTH) SOI4ECadE ELSE.3 EGO NEXT BIRTH) FATHER . . . . . . . . . 1 IGO NEXT BIRTH) ~THEX RELATIVE,2 (GO NEXT BIRTH) $ONEORE ELSE.3 (GO NEXT BIRTH) FATHER . 1 (GO NEXT gIRTH) OTHER RELATIVE.2 (CO NEXT BXRTH) SOMEONE ELSE,.] (GO NEXT BIRTH) FATHER . 1 ~-O NEXT BIRTH) )THER RELATIVE.2 ~0 NEXT gIRTH) $~I4EONE ELSE.3 (CO NEXT BIRTH) :ATHER . 1 (GO NEXT BIRTH) tOTHER RELAHVE.2 (GO NEXT gIRtH) ,~REONE ELSE.,3 CGO NEXT BIRTH) 220 IF OEX~: Nov otd~s he/she ~henhe/idle d|~i? )F #t YR.~, pROK: Hovmany I~ l ths Dtd was (NA~E)? W ,u BECmD OArS )F LE. THAN I ~TH,~TNS IF LESS THAN T~ YEARS, OR YEARS. OATS.1 WONT~S.2 TEARS.3 DAYS.1 WORTNS.2 YEARS.3 DAYS.1 k~ITHS.2 YEARS,,.3 DAYS.1 14~4THS.,2 YEARS.3 DAYS.1 MOHTH$.2 YEARS.] OATS.1 14~4THS.2 YEARS.3 NLINBERS ~ NUI4DER$ ARE ABE SAME ~ DIFFERENT L l • (PR~E A~ RE.C I tE ) CHECK: FOR EACH LIVE NIRTH: YEAR OF BIRTH 1S RECORDED FOR EACH LIVING CHILD: CURRE#T AGE IS RECOItDED FOR EACH BIRTH INTERVAL )3 YEARS, EXPLANATION IS GIVEN FOR EACH DEAD CHILD: AGE AT DEATH ]S RECORDED FOR AGE AT DEATH 1 TEAR: RROGE TO DETERMINE EXACT NUMBER OF W)IITHS CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1986 IF NONE, ENTER O. J l 239 KIP 2Z& Are you prOllnlnt nov? I YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 i ~K~.,,,,, . ,,,,,.,_oo,,o,.~ UNUE . ~q=227 I 2~ NOV ~ no~thl ~ tr t --s . m i 226 At the tlmo you I~¢m prog~mt, did you mmt to become prognm~t thin, d|d you uamt to volt until tater. or did you not uont to become pretlrJnt It aLL? A * • THEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . t LATER . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 NOT AT ALL . 3 227 Uh~ did your Lost ~'r~truaL period start? DAYS AGO . 1 WEEKS AGO . 2 MONTHS AGO . 3 YEARS AGO . & IN HEROPAUSE . 994 BEFORE LAST BIRTH . 995 NEVER MENSTRUATED . 996 8 240 228 QUESTIONS ARO FILTERS ktmen the first clW of a ~'a Wlod md tl~ f|rat day of her r~xt period, are there certain tim kc~e~ she has • greater chance of becoming pcngn4mt then other t|m? .,.e-t,.O ~ ,', ,:,L;)i ~ ~ j~. ~ o~,.) ~ O.) ,~ at ~@cr. ~IR CATEOODIER KIP TO YEE,.,Q,,I°o,,***,.°),***°,.,,,1 ~O°.J.,°o,,,°o,,°°,,,~***).°.,2 a""I.~EA q 2L'9 During WhLch tim of the m~th does • ~ the greetnt chance of becoming prpErmnt? OURING HER PEItIQD . 1 RIGHT AFTER HER PERIOD W EGDOD . 2 IN THE HIODLE OT THE CYCLE . 3 JU6T MFORE HER PERIOD NGIHS.A AT ANY T im . . . . . . . . . . . . . . . . . . . . . 5 OTHER 6 (SPECIFY) 6K . 8 9 2A1 SECTION 3: CONTRACEPTION I I I 301 ~ I i~ild like to talk lix~t filly ptir~ln~ - the various llyl or meth~tl that i COUple cl~ ~le to ~lltey or e~lid • pr4~l~cy. Which le~i Qr Ith Re" h•~4~ you h4~Cd lihQIJt? • • . , CIRC~ CODE ~ ]. ~o2 ~o~ ERCR me?~oD NDRtlC*EO SP~RRECUS~. thEN PROCEED nollll THE COLUVil. lENDING THe NAME AND DE$CIIIPTIOR OF EACH M£TltoD ROT lIEHT[~lieD 5POI#TAHEOUSLY. CIRCLE CODE 2 IF NEINOD IS RECOGIIIZED, AND CODE ] IF NOT RECOGNIZED. THEN, F~41 EACH 14ETH~ ~[TH CODE I OR 2 CIRCLED iN )02, ASK 303-306 llEFODE PROCEEDING TO THE NEXT METHOD. I 302 Have yOU ever heard Of (METIK~O)? READ DESCRIPTION OF ~ACR NETH~ 01 PILL i Can tlke i pill yEs/SillilT . 1 avery ~,,y ~ 'S ~fs/I, Nolf~ . 2 • V 02021 laD ~ cl~ hive I lo~p or / <oil . l . . , , . ,~. th . by . / doctor or i nurse. ]J JRJECTX~'A4S ~ tin Hive in injection by a doctor or nllraa ~r, i ch atol:4 ~h~ f r~ t~e~iiMI pregnant for leveret months. -/ I•l DIAPHRAGN, FGN4,JELLY ~ tin pllce s sponge, suppository, d+aphrigl, jetty or Crelll in- side thai before lrltercourle. COliDOI Men can use a rubber sheath during sexual inter + C Rail+ lie. o YES/SP~4T . 1 YES/PROBED . 2 NO . • . / v YES IS~OI iT . . . . . . . . . . . . . . . . . . . 1 YES/PROEIED . 2 NO . * . .+.~ YE$/SPQiiT . . . . . . . . . . . . . . . . . . . 1 YES/PR(~J[D . 2 NO . , . . . . ° , . .3 YES/SPOIdT . 1 YES/PRO6ED . 2 lIQ . ,.* . ,,,,,*H,3- J 303 Have yo~ ever uaed (METI~O)? 304 OR you know k~ere a peraoll CouLd go to get (METHOD)? YES . 1 NO . 2 YES . 1 NO . 2 YES . 1 NO . 2 YES . 1 YES . 1 NO . 2 YES . 1 NO . 2 YES . 1 NO . * . YES . 1 t~O., . 2 YES . 1 YES . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . , . . . . . . . . . . . . . . . . 2 10 242 I I ~r. o. (-.o)? I used (NETIK~)? I • person cOuLd 90 • " 1(N~THOD " " I to lil~t (NETHO0)? . o # ~ * T M__.] Ff.K4LE SEERILI~HOId WN~ can haw an oporitlon to ovoid having any mqre cht Ldren, '7~ PALE STERILJZAH~ ~ can have m c~eretlon to •void hiving any mort children. .~ o~. ~,a ~.r'~.,-* • . J ".~'~ ~O".:,,a'o~ e? , ? . ¢ , .,~ , . ,c '~4, 8 PERIODIC ABSTINENCE CQ4Jptes 0 can •void having sexual Inter- course 0~1 certain days Gf the m(~th )hen the woman is more likely to beccme pregnant. 9J 5/ITHORAk~L Men can be careful wld pull out before cllwx. O] Nave y~J heard of Jay other k~ys or methods that ~en O¢ aen con use to avoid pr*en4mcy? ~'w.,; ~ >.,.~,,, ~4'. g- ,~r.¢" f ~.O~*i',.FlJ'dg.,"l 1 (SPECIFY) 2 (SPECIFY) 3 PEAD OE~HlPTtQi4 OF EACH METHOD YES/SP~T . . . . . . . . . . . . . . . . . . . 1 YES/PROO~.D . 2 YES/SPG~T . 1 YES/pROBED . 2 NO. . . . . . . . . . . . °~ YES/SP~dT . 1 YES/Pm(3~D . 2 MO. .o , . . . ° , . , , , . . o , . . ° . , . ° , .~ YES/SPOIlt . 1 YEN/PItODED . 2 k~ . .,°.,*.°,°°.°o.,.~ (SPECIFY) ¥ YES/SP(;NT . 1 . °.,o°oo.°.o.,~- NlVt you EVer hid II1 operitlc~ to |void hlv|r¢ I~y more chl ldrem? .rfa Tv" YES . 1 NO.,., . .,, .~) YES,. . °.,.,1 NO . °,,2 YES . 1 NO . 2 YES . 1 NO . ,. 2 YEN. . . . . . . , . . . . . . . . . . . . . . . . ) IO.*.,.*.,.,.*N YES . 1 NO.,. . • . 2 Oo ~ kno~ ihere • person can obtain advict on hov to use periodic abstirmnce? z I f :S , ** . * . ,* . 1 YES . 1 NO . 2 YES . 1 NO . 2 YES . 1 NO . 2 11 243 ~0. 3O6 QUESTIONS AI~ FILTERS Rave you ever und anythin8 or tried In any ~y to ~etey or avoid gettlnR pregnant? SKIP ODO|RG CATEGORIES I TO m I YES . 1 I I SO . 2 ~7 307 ~/net have yc~ ~ed or done? 3O8 ROW I ~td like to ask you about the tim when you first did something or ~ed a method to avoid getting pregnant. Whet Imthoddid yo~ Lame it that time? PILL . 01 IOD . 02 ISJECTIORS . 03 DIAPHRAGN/FG/~I/JELLY . 04 FE~L~LE STERILIZATION . 06 HALE STERILIZATION . 07 PERIODIC ABSTINENCE . 08 ~ITNDRAMAL . 09 OTHER 10 (SPECIFY) 309 [ 311 312 Ro~ ~ Living chitdren did you have at that time, if ,my~ IF NOI~E, RECORD 'DO'. At the time you first started using the pitt, did you cormutt • doctor, a nur:e or • fatuity planning uorker? 'L' When yc~ mt Nith that pers~, did ycmJ already hive • preference for a I~rticuLar method of family ptanntng? • • ~ . j NUMBER OF CHILDREN . ~-~ YES . 1 NO . . . . . . . . . . . . . . . . . o . . . . . . . . .+.oZ 1 (SKIP TO 317)q / YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RO . • . . . . . . . . . . . . . . . . . . . . (SKIP TO 314 )4 12 244 NO, ~IESTI~S AHD FILTERS 313 I~n|ch method Has that? CODING CATEGORIES PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01 IUO . 02 INJECT|O~S . 03 DIAPHRAGM/FOAM/JELLY . 04 CONDGM . 05 FEMALE STER|LIZAT|ON . 06 HALE STER|LJZATJON . 07 PERIODIC ABSTINENCE . 08 ~ITtlDRAMAL . 09 OTHER 10 (SPECIFY) ~1~ I 0i~ ~ha p~o~de~ ~a|R ~o y~ ,~E o.y me~,o~- o~ha~ I TES . 1 I ~h. Th. ~il.,.L.~. '~.~.,"~ ,~ .~,.~ ,.d v.,./.L ~.t~ I RO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 ! ~-~ ~"~-~ (SNIP TO 31Z), 315 SKIP TO klhlch method or methods? (CIRCLE ALL NEHTIOIdED) IOD.° . °.,,° . 1 INJECTIONS . 1 DIAPHRAGM/FOAM/ JELLY . . . . . . . . . . . . . 1 CO~DGM . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 FEMALE $TERILIZATIO#~ . 1 MALE STERILIZATIC~d . 1 PERIODIC ABSTINENCE . 1 VITHDRAMAL . I OTHER .1 (SPECIFY) 316 317 318 319 320 321 Were y~J satisfied uith the information yc~ got from | the provider on the method(s) y~J discussed or not? I CHECK 224: OR NOT UNSURE PREGNANT [~ PREGNANT CHECK 107: CURRENTLY MARRIED NOT CURRENTLY MARRIED (CODE 1 IN 107) [~ (CODE 2-5 IN 107) v CRECK 303 (o6): vo~J~ NOT ["-1 Wg4AM STERILIZED ~ STERILIZED ~'~ v Are you cur rent [y doing something or using any method to delay or ovoid 9etting pregnant? Mhlt is the wain reason you Ire not using a method to de;ay or avo|d DettJng pregnMlt? YES . 1 NO,,° . .oooo . ,,.2 *33? p343 p322A r'- YES . 1 ~'3Z2 NO . 2 | I MARTS (14(~E) CHILDREN . 01- LACK OF KNOWLEDGE . 02 HLISDARD OPPOSED . 03 COST TOO MUCH . 04 ~ORRY ABOUT SIDE EFFECTS . 05 HEALTH CONCERNS . 06 NARD TO GET METHODS . . . . . . . . . . . . 07 RELIGIOD . 08 OPPOSED TO FAMILY PLANNING . 09 FATALISTIC . 10 OTHER PEOPLE OPPOSED . 11 INFREQUENT SEX . 12 DIFFICULT TO GET PREGNANT . 13 MENOPAUSAL/HAD HYSTERECTCI4Y. 14 ] NCONVEN I ENT . 15 HUSBAND ABSENT . 17 BREAST FEED 1NG . 18 OTHER 19 (SPECIFY) DK*., . . . ,.°o. . ~337 13 245 SO. 322 322A QUESTIONS AND FILTERS ~ich method ere you usingT , u-, , . , , , /OG' , ~> 0/~ • _ , # • CIRCLE '0~ I FOR FEMALE STERILIZATION. SICIP COOING CATEGORIES I To p LL 01 . . . . . . . . . ° . . . . . . . . . . . . . . *. I IUD . O2-- INJECTIONS . 0~ !~330 DIAPHRACJ4/FON4/JELLY . 04--.--e331 ~ON . 05 ~327 FENALE STERILIZATION . . . . . . . . . . . KALE STERILIZATION . 071)33 O PERIODIC ABSTINENCE . . . . . . . . . . . . OTHERHITHDRAWAL . ~09 336 (SPECLFY) | 323 I ,, the time you List got pills, did you consult I • doctor, • nurse or • family pLannmg ~orker? • j J ]z4 I .,y I set the pecklge of pills you ire using now? i I (RECORD NAME OF BRAND. ) YES. . . . 1 NO . . . 2 PACKAGE SEEN . 1 I WIA~ N~E ~ PACKAGE NOT SEEN . 2 i 325 Do you know the brand name of the pills ymJ ire now using? (RECG~.D ~ OF DR.~, ) -o .E rr7 DK . 98 326 I HOV much (does one packet of pills cost youT / / / # I--ES . 71 ] [ ] ] " ::::::::::::::::::::::::::::::::: I 327 I klay I see the ~ke~ of condomm you ere using nOW? I ( (NEC~O .~E OF e~um.) I PACt, AGE SEEN . 1 m BRAND BN4E [ - - -~ PACKAGE NOT SEEN . 2 I 328 Do you kr~. the ~ mm of th. cond~ i M you , r * no . . , i~? - - J ' " I ,~"3 J -~- -~ euuum NAME .~ . , 'o , , " .~ ~ " I D,~ . . (NE-- . . OF . . ) T~r ,~r : Jo , / . r~ il 14 246 NO. I GUESTIONS AND FILTERS I SKIP CODING CATEGORIES I TO ::::::::::::::::::::::::::::::::: 330 I How much did it cost For the (iUD i n ie r t io~/ | I sieriiizatio~ operatio~/Last injection)? I FREE . 999996 DK . 999998 331 CHECK 322: SHE/HE STERILIZED ~ USING ANOTHER METHOD I V v ~here did ~he Where did you obtain sterilization take (METNOD) the IBSt t i~? place? u~ ~,;~, (NAME OF HOSPITAL, CLINIC OR CENTER, %F CODE 01-05) GOVERNMENT HOSPITAL/RRSC . 01 RHC/BHU/COVERNMENT CLINIC . 02 FAMILY IJIELFARE CENTER . 03 RGO CENTER . 04 PRIVATE HOSPITAL OR CLINIC . 05 MOBILE CLINIC/EXTENSION TEAM.N7 ~] FIELD WORKER . 07 13~ PRIVATE DOCTOR . 08 HAKIN IH~ATH . . . . . . . . . . . . . . . Oq DRUGSTORE . 10 SHOP (OTHER THAN ORUGST~E).11 TRADITIONAL BIRTH ATTENDANT.12 FRIEHDS/RELATIVES . 1~ OTHER 14 (SPECIFY) ~33k OK . 98---- 332 I HO,d tong does it take to travel I from yo,Jr home to this place? ~ I IF LESS THAN 60 NINUTES, RECORD MINUTES, I OTHERMISE, RECORD HOURS. | NIRUTES . 1 I I I ED HOURS . 2 OK . 998 333 335 Is it easy or difflcutt to get there? EASY . 1 DIFFICULT . 2 CHECK 322: USING SHE/HE ANOTHER STERILIZED [~ METHOD ~] P,336 In what II~onth and year mas the sterilization operatlom performed+ 336 I For ho~ many mo~ths have you been using I (CURRENT METHOD) continuc, usly? I IF LESS THAN I 140~TH, RECORD 1001. I 15 24? NO. J OUESTiONS AND FILTERS 337 J 9o y~ intend to u~e • method to detey or •void I pregnancy st any ti~e in the future? SKIP I CODING CATEGORIES I TO J yes . , Ij.~o NO . 2 J ON . 8 ~.3 338 WAst Is the Min re.son y~J do not Inte¢~l to USe • mthod? ,j ° , • MANTS CHILDREN . 01~ LACK OF KNOk#LEDC~ . 02/~343 HUSDJUdO OPPOSED . 03 | COST TOO NUCN . ~ • WORRY ARGUT SIDE EFFECTS . OS HEALTH CONCERNS . 3/03 NARD TO GET METROS . 07-- RELIGION . 08 | OPPOSED TO FAMILY PLANNING . 0~. ~3/,3 FATALISTIC . 10 OTHER PEOPLE OPPOSED . 11 iNFREOU£NT SEX . 12- DIFFICULT TO GET PREGNANT . 13 MEI~AUSAL/NAD NYSTERECTONY.I~ INCONVERIENT . 15 ~343 NOT CURRENTLY MARRIED . ~6 OTHER 17 (SPECIFY) DR . 98 339 340 If the decist~ Nre entirely up to you, ~td you ulnt to use • mthod to delay or avoid • pregnancy et wly tim in the future? g,z/ I DO you Jntefld to use • me~hod within the n~xt 12 months? I YES . 1 HO . 2 ~ 3 D[,.°.,.,°**.,,.,,,.,.o. R J I YES . I | I HO . 2 ON . 0 3~1 Yhen you use • method, which method would you prefer to use? PILL . 01 IOD . 02 INJECTiONS . 03 DIAPHRAGM/FOAM/JELLY . Ok CONDON . 05 FEMALE STERiLIZATiON . 06 MALE STERILIZATION . 07 PERIODIC ABSTINENCE . 08 WIT NDRA~LAL . 09 OTHER 10 (SPECIFY) ONSURE . 98 ~343 342 Vhere can you get (METHOD NENTIONED IN 341)? ~,~.~- - / J - '~-~ O~(~THOD MEHTIONE0 IN 341) .or (MAINE OF HOSPITAL, CLINIC ON CENTER, IF CODE 01"05) GOVERNFENT NOSP[ TAL/RHSC . 01----1 RNC/BHU/GOVE RVA4ENT CLINIC . 02 FAMILY NELFARE CENTER . 03 345 NGO CENTER . 06 PRIVATE HOSPITAL OR CLINIC . 05 NK~ILE CLINIC/EXTENSION TEAM. . .~ FIELD WGJtNER . 07 P ~14)' PRIVATE DOCTOR . NAR I M/NOMGEORATN . 09 DRUGSTORE . . . . . . . . . . . . . . . . . . . . . . 10 345 SHOP (OTHER THAN DRUGSTORE) . TRAOITIONAL BIRTH ATTENDANT,.12 FR I ENDS/RELAT I VES . 13 OTHER 14 ~347 (SPECIFY) ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 I 16 248 NO. J QU~STIOI4S AND FILTERS J 343 | Do you kno~ of • source ultere ymJ can ~btaJn i I • method of family pLInninD? I lit i~lircl 58 thit? t ;,- ~ ~tX . . (NAME OF NQSPITAL, CLINIC ON CENTER, IF O00E 01-05) SKIP CGOIMG CATEGORIES J TO I GOVERMNEMT HQSPITAL/RHSC . 01 | RSC/DNU/GOVEDNI4£NT CLINIC . 02 J FN4ILY VELFARE CENTER . . . . . . . . . . O~ NGO CENTER . O~ PBIVATE DO~PI?AL ON ~LIMIE . 05 NONILE CLINIC/EXTENSION TEAS.06 t FIELD HONKER . 07 J~347 PRIVATE DOCTON . 08 | NAKIN/HCMO~OPATH . 09 I ORU6STONE . . . . . . . . . . . . . . . . . . . . . . 10 SHOP (OTHER TNN~ DRUGSTONE).11 TRADITIGHAL BIRTH ATTEI~U/T.,.12 FRIENDS/RELATIVES . . . . . . . . . . . . . . 1~ OTHER 14d~34~ (SPECIFY) I 345 | Ho~ tong does It teke to treve~ I fre~ yc~r h~ to this place? IF LESS TITAN 60NINUTES, liliC(HtD i OTHERMISE~ REO~O DOUItS. MINUTED. NINUTEN . 1 ~J l m ~URD.,,,*.o.,~ DK°,.°.°.,.°,.*,,.99~ '-* ° - * " - , + o.,. I--°'--T . . . ."1 347 348 349 350 In the Last month, hlve- yo~ heard • messene about fruity planning on: . . . . a~/~. ~4 , television? _e ~-~-.%e--'r s 4 , ' * CHECK 347: HEARD IIESSAGE (~] NOT HEARD (ANY YES IN ~W~TI llESSAGE [~ l / v Do you think that the msege you heard ~es effective or not e f fec t ive in per l4~dln8 coup|n to use family planning? Is it accept'kte to you or not for fMl|ty pLanntnD tnfo~tion to be provided on the radio or teLevision? YES NO RADIO . . . . . . . . . . . . . . . . . . . . . . 1 2 TELEVISION . . . . . . . . . . . . . . . . . 1 2 EFFECTIVE . 1 DOT EFFECTIVE . 2 DK.o.,,.o.oI.,,,o.oe.°.B I ACCEPTABLE . 1 MOT ACCEPTABLE . 2 ~350 I 17 249 402 403 404 SECT[ON 4A, PREGNANCY AND BREASTFEE~ING P CHECK 222 - J O~E ON ~E BIRTHS NO BIRTHS SINCE JAN. 198b 9 S]NCE JAN. 1986 [~ (SKIP TO 501) ENTER THE LINE RUNSER, MANE, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1986 IN THE TABLE• ASK THE ~4JESTIORS ABOi~T ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN ] BIRTHS, USE ADDITIONAL FORMS). NOW I ~ouLd like to ask yo~J some more questions about the health of children you had in the pest five years. (We will talk ab0*Jt or~ child at a tllne.) # ~,~ ~ • ~ ( ~ ,.,'-I,:.+ ¢ . ,--+, +,+ Z "~ ~ ,.r_ ,.~+, -_~ (, >- -.-" +-'.' .+e.-. <.-' ,~ ~ .-+"+ ,.,+: u.,.-+.<. ~,,+ ~+,.,. I LINE NUNBER FROND. 212 J ] i LAST BIRTH FROM Q. 212 NA~E AND ~. 216 ALIVE l~ DEAD E~ At the tiaze Tm beczJ!qe pregr~nt with (NAME). did you want to become pregnant then, did you want tO wait until Later or did you want no more chttdren at atL? n j ~T EMAME) J~*l l~+ .i", ~;"l.i. i~++ . <( , . " ' . ~-, ~_~Z_z t .+ i+?~, i .#+, , I L ~F v,:i <s:~ # ~ l *,,.c, How lllich Io,r~lier lloiiId you [)ke to have waited? - . . - . ,.,,/"~T.,/,_," RECORD 140(ATHS OR YEARS) NEXT'TO*LAST BIRTH SECOND-FRON-LAST BIRTH MANE NAME ALIVE [~ DEAD [~ ALIVE [~ DEAD [~ v l v V / V i THEN . 1] (SKIP TO 4DS)q LATER . 2 NO M~IE . . . . . . . . . . . . . . . . . 3 - (SKI~ TO 405)~ THEN . 1 {SKIP TO 405)4 LATER . 2 NO MORE . . . . . . . . . . . . . . . . . 3 (SKIP TO 405)~ THEN . ;.~ (SKIP TO 405) LATER . 2 NO MORE . . . . . . . . . . . . . . . . . 3 (SKIP TO 405)~ - . + - . . TEARS . . . . . . . . . . . . . 2 YEARS . . . . . . . . . . . . . 2 YEARS . . . . . . . . . . . . . 2 DK . 998 DK . 998 DN . 998 I 405 When yo~ were preQnant with (NAME), did you see anyone for antenatat care for this preRnancy? IF YES: Whom did yOU see? Anyone e(se 1 ,, TES, ~." ~ <.;'~.A& / - i + t I (CIRCLE ALL PERSONS ~' l~_+" ~ SEEN ON ANY VISIT) . v.- DOCTOR . . . . . . . . . . . . . . . . . . . 1 NURSE . . . . . . . . . . . . . . . . . . . . 1 LADY HEALTH V]SITOR . 1 FAMILY WELFARE WORKER.1 TRAINED (TRADIT IDEAL) BIRTH ATTENDANT . 1 TRADITIONAL BIRTH ATTENDANT . 1 OTHER 1 (SPECt FY) NO ONE . 1- (SKIP TO 609)9 DOCTOR . 1 NURSE . . . . . . . . . . . . . . . . . . . . 1 LADY HEALTH VISITOR . 1 FAMILY WELFARE WORKER.,,.1 TRAINED (TRADITIONAL) BIRTH ATTENDANT . ( TRADITIONAL BIRTH ATTENDANT . 1 OTHER 1 (SPECIFY) NO ORE . (SKIP TO 411)' DOCTOR . 1 NURSE . 1 LADY HEALTH V%$(TOR . . . . . . 1 F~ZLY WELFARE ~KER,,.1 TRAINED ( TRAD I T l ~44AL ) B]RTH ATTENDANT . 1 TRADITIONAL BIRTH ATTENDANT . 1 OTHER 1 (SPEC[FY) NO ORE . . . . . . . . . . . . . . . . . . . 11 (SKIP TO 411)" I 406 I Were yOU glvet~ an antenatat I card for this pregnemcy? YES . . . . . . . . . . . . . . . . . . . . . . 1 RO.+.+.o . . . . . . . . . . . . . .2 OK . . . . . . . . . . . . . . + . .+ . . . ° .8 YES . 1 NO . . . . . . . . . . . . . . . . . . . . . . . 2 DK . . . . . . . . . . . . . . . . . . . . . . . 8 YES . 1 DK . . . . . . . . . . . . . . . . . . . . . . . 8 18 250 407 HO~ =~ny months pregr~nt ~re you ~hen you first is~ aomaone for in i~tenataI check on that pregnancy? ~.~,~',~,~ ~:~,, ~,, , LAST BIRTH NAME N~THS . ~-~ OK . 98 NEXT-TO-LAST BIRTH NAME NO~THS . . . . . . . . . . . . . . [ - -~ DK . . . . . . . . . . . . . . . . . . . . . . 98 SECONO'FROM'LAST BIRTH NAME MCIITHS . OK . . .o, . .o. . .o9~ oK . 9, oK . ;;:;;.;:.:;;;.,, oK.;;:;:.;:.:;;; . "1 I 409 | D~d ~nya~e advise you to I eat more food than usual YES . 1 during that pregr~ncy? I:,' ~' ,'":* ~- ~. : I HO . , 410 411 Uere yo~ ~tghed at any tile I ~ring that prngrw~cy? J When you were pregnant wlth (NAME) were you given an i~jectlo¢l In the Orill to prevent the baby from ; getting tetanus, that is, cot~vutstons after birth? YES . 1 NO . YES . 1 NO . E (SKZP TO 413)~ DK . 8] YES . 1 NO . (SKIP TO 413)~ OK . YES . 1 NO. . (SKIP TO 413)q DK . 412 %:eo~. I~ '.'d#&l~, - ;~h l nY :in~e:tldiol~d? y°u. .; 1., '~ T[NES . @ TINES . ~ TINES . D . . . . : S ' ~ - D, . ~ oK . o o, . . I YOUR HU(~ . 01 YOUR HONE . 01 613 ki1~ere did you Rive YOUR ROME . 01 R H ~ V ~ I N ~ . birthto(NAME)? OTHERHOMEGovERRMENTROSPITAL . . O,O~ :::::::::::::::::::::: ~0~32 R~H~!iH~g~O~:::~ . • - j RHc /sHU/~T eL,SIc . . . . . o4 : : : : : ~.~f/~[~-~.~J~(HA~E) PRIVATE HOSPITAL/CLISIC.OS PRIVATE HOSPITAL/CLINIC:D5 PRIVATE HOSPITAL/CLINiC.D5 T~ OTHER 06 OTHER 06 OTHER 06 (SPECIFY) 414 Who delivered (NAME) or assisted with thedetivery? Anyone else? 7 f /p , , t ~ o ~ ,s-:. ,-,"::. ~ (BANE) ~. ,.:- ,,J cd". ~.o, g o: (CIRCLE ALL PERSONS ASS]STING) DOCTOR . 1 NURSE . 1 LADY HEALTH VISITOR . 1 FAMILY WELFARE UC~KER.*.*I TRAINED (TRADIT IORAL) BIRTH ATTENOANT . 1 TRAD [ T IORAL BIRTH ATTENDANT . . . . . . . . . . . . . . . 1 OTHER 1 (SPECIFY) NO O~E . I DOCTOR . 1 NURSE . 1 LADY 14EALTH VISITOR . 1 FAMILY WELFARE W~IKER.1 TRA] NED (TRADITIONAL) BIRTH ATTENDANT . 1 TRAD I T IOI4AL BIRTH ATTENDANT . 1 OTHER 1 (SPECIFY) 110 ONE . 1 (SKIP TO ~16) DOCTOR . 1 NOR SE . 1 LADY HEALTH VISITOR . 1 FAMILY WELFARE ~RKER.1 TRAINED (TRADITIONAL) BIRTH ATTENDANT . 1 TRAOI T [ORAL BIRTH ATTENDANT . 1 OTHER I (SPECIFY) NO ORE . 1 (SKIP TO 416) 19 251 LAST EIRTH HARE RAGE 41S HO~ long ~ere y~ in t•bor? D~ . . . . . . . . . . . . . . . . . . . . . 98 NEXT-TO-LAST BIRTH SEC~D-FR~-LAST BIRTH HA/4E 416 Was (RA~E) born on time Old five . 1 (1~ TIME . 1 Old TIGE . 1 I I °d/~mtu'"~ I I 417 [ YES . 1 YES . 1 YES 1 ~, ~, ,~. , * ,x,,,~> ~., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ ~ . . . . . . . . . . . . . . . . . . . . "" ~ ~" 'o ) ,~/ t~ I • (SKIP TD 420)*---- (SKIP TD 420) ~--- (SKIP TO 42D)~ DR . DR . DR . ~F,~;~(N~I POU~S (xmc. ~s o~c. ~u~os OWGEE ~os ~-~- -~ ~os ,~- - ]F ~ ~s . . . , DK . 99998 DK . ~ DK . 9999~ i 420 Whim (I~4NE) k~l born, use he/she: vlry tmrge, lsrger than •verlge, lvlrIDI, miler them average, or very mIl? VERY LARGE . 1 LARGER THAN AVERAGE . 2 AVERAGE . ] SMALLER THAK AVERAGE . 4 VERY SHALL . 5 SK . 8 VERY LARGE . I LARGER TItAii AVERAGE . 2 AVERAGE . 3 SNALLER THAN AVERAGE . 4 VERY St4ALL . 5 DR . 8 (SKIP TD 422) VERy LARGE . 1 LARGER THAN AVERAGE . 2 AVERAGE . 3 SNALLER THAN AVERACZ . 4 VERY SI4ALL . 5 DK.°o° . ° . *° . . . . . . . .It (SKIP TO 42Z) 42, .~. v, . :i,11 . Hes your period returned /.~,~. (H~l .0 . . . . . . . . . . . . . . . . . . ;.z 1 .~ ~_.~?. ~ ~.~,~ ,~,,l 422 Did your period return between the birth of (RNCE) and your YES . . , ° ° . . ° . , o . ° ° . . . . . , .1 NO. . . . ° * . . . . . . . . . . . . . . . . . 2 (SK IP TO 426)q ] , . . . . . . . . . . . . . . . . . . . . . . 11 I NO.° , , . , . . , . . . . . ° °**°° . **2 (SKIP TO /~6)q 423 I For how many months after I the birth of (NN4E) did y~ not hBve • speriod? . . T . . . . . . . . . . . . . . . m " ' " . . . . . . . . . . . . . . FT - ] . , . . . . . . . . . . . . . . . . . . . . . . ~ oK . . . . . . . . . . . . . . . . . . . . . . M I (SK P TO 426) I - " . . . . . . . . . . . . . . ml 20 252 A25 426 427 CNEC~ 2Z4: RE~>OI~EMT PREGNANT? i N lvt ymJ pelUllld leXUa( relltlon~ i|ll~e the b~rth of (W~IE) ? .~ <C(.,,E! ~ ,~ I For ho~ ~ months if tar the b i r th of (~Aiv~) did yola not have sexual retat|o~l? I ~,', : , t~'tr .,,~, ,.X-,,,,~ ~" I I " ' ,I ,~ , , I Did y~ ever ~lel t Eled ( NA~M~ ) ? ~. • (.~ • . ~.~.~ LAST BIRTH PREGNANT NOT , PME°'Y (,EIPYO, . - - YES . I NO.,,,,.+. . o.,~] (SKIP TO 427)* NEXT'TO'LAST DIRTN I SECOND-FRON-LABE BIRTH MANe I x+~ .Ys . . . . . . . . . . . . . . . ,~-~ OAT, . . . . . . . . . . . . . . . ,~- -~ DAY, . . . . . . . . . . . . . . . '~ - -~1 ='"= . 'M- I t ' ""= . ' I -~ I ,DENS . . . . . . . . . . . . ' t - - r l l D~C . . . . . . . . . . . . . . . . . . . . . . 99B OK . . . . . . . . . . . . . . . . . . . . . 99B O~ . . . . . . . . . . . . . . . . . . . . . 99~ l YES . +]1 YES . 1 YES . 1 + ++,o++ . . + o <++,+0++; . . . . o . . . . . . . . . . . . . . . . . . . . . . . + + o + +ii 42B klho suQge|t~ that you sho~(d not breastfeed (MANE)? .D,,IJ~t 41 f {MNqE) / M OEC(SION . 01 k~OTNER . 02 NOTNER-]N-LAW . B3 HUSBAND . 04 DOCTOR . 05 OTHER HEALTH I¢OMKER,.,.06 TRADITIONAL BIRTH ATTENDANT . 07 OTHER ,~ (SPECIFY) (1~ DECISION . 01 MOTHER . 02 MOTHER- IN-LAW . 03 SUSBAND . 06 OIX~TGN . 05 OTHER HEALTH U(~KER.06 TRAD I T IO~AL BIRTH ATTENDANT . 07 OTBER 08 (SPECIFY) O~ANOECISIOM . . . . . . . . . . . O! MOTHER . 02 MOTHER-IN'LAW . 03 HUSBAND . 04 DOCTO~t . 05 OTHER HEALTH ~iORKER.,.Ob TRADITIONAL BIRTH ATTENDANT . 07 OTMER 0~ (SPECIFY) 4Z9 IJny did you not breast feed ( NA~ME ) ? o/ . - , , ,q , / (H~) ~-,.r MOTHER ILL/~EAK . . . . . . . . 01 CHILD ILL/MEAK . 02 CHILD OlEO . 03 NIPPLF./BREAST PROBLEM.~ INSUFFICIENT MILK . O5 WORKING . 06 , CHILD REFUSED . 07 MAINTAIN BEAUTy . . . . . . . . 08 OTHER 09 (SPECIFY) (SKIP TO 438)q MOTHER ]LL/UEAK . 01 v, 1 CH%LB ILL/WEAK . 002 I CHILD DIED . . . . . . . . . . . . . 031 NIPPLE/BREAST PRO6LEM.04 INSUFFXCIENT MILK . OS WORKING . . . . . . . . . . . . . . . . 06 CNILB REFUSED . . . . . . . . . . O? KAiNTAIN BEAUTY . 08 OTMER (SPECIFY) (SKIP TO 438)4 MOTHER ILL/MEAK . B11 CHILD %LL/MEAK . 02i CHILD DIED . 03 NIPPLE/BREAST PROBLEN.D4 INSUFFICIENT MILK . 05 N(3RKLNG . . . . . . . . . . . . . . . . 06 CHILD REFUSED . . . . . . . . . . 07 NAINTAIM BEAUTY . . . . . . . . 08 OTHER (SPECIFY) (SNIP TO 438)~ 430 HOw tong after birth did yo~ first put (NANE) to the breast? + IF LESS THAN 1H(~, RECORD '00' HOURS. IF LESS THAN 24 HOURS, REC~D HOURS. OTHERWISE, RECORD BAYS. IMMEDIATELY . DO (SKIP TO 432)4 / HOURS . 1 ~ DAYS . . . . . . . . . . . . . . . 2 21 253 LAST BIRTH WANE ¢31 Whir was (NAME) fed before you UATER . ---- . . 1 put (hh~/her) to the bre~t? , GHUTTI . 1 ~---'~ Jt~ J J ) ~'/~ ~1J / (NAME) HOREY . 1 . . . . . . . . . . . . . . . . . . . . , I • OTHER 1 (SPECIFY) l (CIRCLE ALL MENTIONED) (SKIP TO G361 v G]3 JAre you still breast- YES . 1 F Feeding (NAME)? ;,; ~ i X~"~CHANE ) , j(.t~ ~ ~.~ ~ L. ~. HO . (SKIP TO G~6)" Zl HOW many times did you breastfeed last night between s~set and sunrise) (IF ANSWER IS HOT NUMERIC, PROBE FOR APPROXIMATE NUMBER) NL~GBER OF NIGHTTIME FEEDINGS NEXT'TO-LAST BIRTH NAME SECORD-FR~'LAST BIRTH NAME 435 Ho~ tinny tlt~es did yoL~ bresstfeed yesterday ~Jrtng the daylight hours? (IF ANS~R IS NOT NUMERIC, PR~E FOR APPROXIMATE NUMBER) NLAqBER OF ~ DAYL]GHT FEEDINGS 1 (SKIP TO 439 )4 4Z,5 For how many months did you breastfec~d (NAME)? I(ONTHS . . . . . . . . . . . . . . I~THS . . . . . . . . . . . . . . ~-~ .,HS . rl--71 (.37 What IS the n~aln reason that you stoppc<J breastfeedlng (HANE)~ MOTHER ILL/WEAK . 01 CHILD ILL/WEAK . 02 CHILD DIED . 03 NIPPLE/BREAST PROBLEM,,.04 INSUFFICIENT NILE . 05 WORKING . 06 CHILD REFUSED . 07 WEANING AGE . 08 BECNGE PREGNANT . 09 OTHER 10 (SPECIFY) MOTHER ILL/MEAN . 01 CHILD ILL/WEAK . 02 CHILD DIED . . . . . . . . . . . . . . 03 NIPPLE/BREAST PROBLEM,.04 INSUFFICIENT MILK . OS ~ORKING . 06 CHILD REFUSED . 07 WEANING AGE . 08 BECAME PREGNANT . 09 OTHER 10 (SPECIFY) DEXD . ) (DKIpN"'E ' .L,,E? (SKIP TO 442 TO 446) (SKIP TO 445) SK P TO 446 MOTHER ILL/bEAK . 01 CHILD ILL/WEAN . 02 CHILD DIED . 03 NXPPLE/RREAST PR~LEM,.04 INSUFFICIENT MILK . OS ~KING . . . . . . . . . . . . . . . . . 06 CHILD REFUSED . OT WEANING AGE . O~ BECAME PREGNANT . 09 OTHER 10 (SPECIFY) v (SKIP TO 445) 22 254 kU~E /.39 AT U~f time yesterday or Lest night uts (MANE) Riven amy of The fot Loutng?: (IF t'ES= Hou many times?) Ohut t i ? ¢ '~J*O~r~ IF YES: (IT YES: How many times?) 4, '~ ~T YEs: Sugar or honey water? I ( I F YES: HO~ ~ny times?) I + 0.+ >. ,.~.+ ~ J~.,o,7 ! ; / 'S J ; ,~ YES: i (IF YES; HOW many times?) I I Herl~mt~t.,~g ~r3f~ " IF YES: I (IF YES: HOW many times+) G, ,~ , ,"t~¢ "e'~ " TES: i (IF YES: Hou many times+) -YES: I I Baby fot'mola? (IF YES: HOW lltany times?) l i ., ~.,.++~; q .,_ .¢ -~/ '(.~*f; IF yES.+ Fresh milk? i (IF YES: Ho~ many times?) I + .;]. ~.,]~ - ,ES : Tinned 'or" po~dered milk? (IF YES: How many,times?) Io~. ~4~" ; .YES: /Iq~l 'SO~, s~h IS fennel I ~ater or cardamom water? (IF YES: HO~ many times?) Any sotid or mushy food? (IF '~ES: ROW many tlmes?} 4/" ~r~; [F YES: ! I 440 CHECK 439 : FOOD O~ LI~OJD GJVE~ YESTERDAY? LAST gIRTH YES NO PLAIM biATER . 1 2 ' OF TIRES . | ~ L.L~ G+TTI . . . . . . . . . . . . . . ' ' 0, T,RES . . . . . . . . . |~-~ L. L J SUGAR/HO~EYWATER.I Z ' OF TIRES . | r - -~ L,L_J JUICE . 1 z # OF TINES . |r~ L~LJ HER.AL TEA . . . . . . . . . . 1 Z R OF TIRES . /~-~ GRIPE WATER . . . . . . . . . I 2 # OF TIRES . I N t~L~ Wet T~NUtA . . . . . . . . ~ 2 I OF TIRES . 1 ~ ~L_J FRESH NJLK . . . . . . . . . . 1 2 # OF TIMES . /r~ L ~ TIRRED/POEORD RtLK,.I 2 # OF TIRES . / ~ OTHER LIQUIDS . . . . . . . I 2 • OF TINES . | ~ L,. L~J SOLiD/RUSHY FOOD.1 2 ' DE TIRES . . . . . . . . . ( ~ YES TO NO TO ALl. I " (SKIP TO /*42) MANE i I NEXT-TO-LAST BIRTH I I I~SEDDWD- FROR- LAST 111117# 23 255 Old (lltiil) drink I~fthirl from • bottle /Ith • nipple ylltircliyor list nlsht? LAST BIRTH NA~ YRS, . °o,,,°,+°°,,.ol. (SKIP T0443)9 NO.,°°*.,*°. . o,.~ ~.,,°.*.°,°., . IEXT'TO'LAST BIRTH NANE SECOID-FROI4-LAST BIRTH HA! /-,/*2 Vii (~) tvlr RiVen IVthtng To drink fr¢ll bottle iith • ni!~Dle? o,, <+-> YES . 1 NO,,. . .,,.,,.2, (SKIP TO ~ }4 ON . o,,.,--,. . CHECK 439 : FC~O OR LIQUID GIVEH YESTERDAY? HOW shy months old us (HAl() k41411 he/she stirred drinking from • bottle with • nipple on • reRu l i r bas is? AGE iN NOIITHS . . . . . ~] - - ]~ .s., YES TO NO TO ONE I~ ALL -?v ! (SKIP TO 4461 YES . 1 HO . o,.+.,.,~ (SKIP TO 469)q 445 Was (14N4E) ever given any wirer, Or something else to drink or eat (other than breastmilk)? J YES. , . . . , . * * . . . . . . . . . . . . . 1 (SKIP TO /~9], YES . 1 NO . 2] (SKIP TO 449)q 24 256 li I LAST BIBTH NAME II 4~6 B¢~ many months old vine (IMJ4E) ~ you ;t4rted 9iVlnB the foLlOWing on • reluLar besis?: Forai~Lt or milk other then ~tietmi Lk? Other i iquLda? ~/~j= Any solid or uhy food? f ~ AM IS H CllINl . I ] J NOT GIVEN . gG AGE LN'NGHTBS . NOT GLVEN . 96 r'--T'--I LN HOITHS . i J l NOT GIVEN . g6 r---T-- AGE IN ~TNS . I I NOT G|VEN . 96 iF LESS THAN 1MOIiTH. RECORD *00% 447 CHECK 466: J AGE IN i4014THS GLVEN FOR SOLLD OR HUSNY FOOD? I Ho44 m~ months old ~a$ (NAJ4E) ~hen you started giving him/her solid or iAhy foods every dly? .~. ~/~ b/~. '~ (wE) . J .~ . ! d'a L'i ~, ,Es ! NO (SKIP TO 649) I AGE iN 14014THS . NOT GIVES EVERY DAY . g6 IFJtT *TO" LAST BIRTH U~E AM LH I4MTHS . I I I NOT GIVEN . 96 ! AGt IN NOBTBS . ~'~] NOT GIVES . 96 i AGE 1' t4CdiTHS . ~--~! GOT GIVEN . 96 ! AGE IN )K)NTNS . ~['~J NOT GIVEN . 96 vEs 7 NO( (SKIP ToV669) y AGE IN i¢~4THS . NQT GLVEN EVERY DAY . 96 I~CONO'FRCi4-LAST |IBTN WU4E ABlE iN NK]ITHS . °111 NOT GLVEN . 96 AGE IN 14~TNS . J I I NOT GIVES . g6 AGi LN MONTHS . i l l NOT GLVEN . 96 AGE IN I~K~THS . I I J NOT GIVEN . g6 YES NO [~ v (SKIP TO 469) I AG~ LH k~4THS . GOT GLVEN EVERY DAY . 96 i**tewe**iGO SACK TO 403 FOR NEXT BLRTH; OR, iF NO M43itE BLRTHS, GO TO 45S ee*~t*tt*l ~5 257 SECTION 4B, IMMS*JNIZATION AND HEALTH 450 ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SJRCE JAkJUARY 19JI6 ]~ TH~ TABLE. ASK THE G4JESTIOMS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS). LINE NUMBER FROM O. 21Z AND Q. 216 /,51 DO you hive a card where (RARE iS) vacc t i~llt i oI~ are written Ck~? IF YES: May I see it, please? / 452 I Did you ever have a I vaccination card for (NAME)? LAST BIRTH NAME AL[VE [~ DEAD E~ v II~miBml V YES, SEEN . 1, (SKIP TO 453)~ YES, NOT SEEN . 2+ (SKIP TO 455)4 NO CARD . 3 NEXT-TO-LAST BIRTH SECOIdD-FROM-LAST RIRTH NAME NAME ALIVE ~ DEAD ALIVE 0 DE~ ~ v ~ v ~ v W m l YES, SEEN . 1 YES, SEEN . 1 (SKIP TO 453)¢ (SKIP TO 453)~ 1 YES~ NOT SEEN . 2 YES, NOT SEEN . 2~ (SKIP TO 455)q (SKIP TO 455)q ! NO ~RD . 3 NO CARD . 3 ,ES . ,] ,ES . ,] ,ES . ']i NO (SKIP TO 455)q 2 (SKIP TO 455)4 NO (SKIP TO 455)~ 2 . NO . 2 . 453 (1) COPY VACCINATION DATES FOR EACH VACCINE FR(]4 THE CARD, (2) WRITE '44 ~ IN ~DAY ~ COLUMN, IF CARD SHC~S THAT A VACCINATION WAS GIVEN, BUT NO DATE RECORDED. BCG POL%0 0 (AT BIRTH) POLIO 1 POLIO 2 POLIO ] oPr I OPT 2 OPT 3 MEASLES DAY 140 BCG I PO Pl P2 P3 DI D2 03 YR DAY 140 YR BCG I PO P1 e2 P3 D1 D2 D3 OAY PO P1 P~ P3 DT O~ D~ NO YR 454 Has (NAME) received any vaccinatior~s thst are not recorded or1 this cerd? • b i / ~ I I YES . 1 (PROBE FOR VACCINATIONS 1 AND WRITE '66' [N THE CORRESP(~dDIMG DAY COLUMN [N 453) YES . 1 (PROBE FOR VACCINATIONS 1 AND WRITE ~66 j IN THE COw'RESPONDING DAY COLUMN IN 653) NO . OR'~il;;i;ii~;: . . . . . YE, . 11 (PROBE FOR VACCINATIONS AND ~JfiITE '66' IN THE CORRESPONDING DAY COLUMN IN 453) |[ NO . 2 26 258 I I I 45!; Did (IL4ME) ever rKelve Mly v~cclhetl¢m~ to prevent hiWher fr~ i ~ttlni d ( leilinIT LAST lilTS .iliI YES . 1 . . . . . * . °~ (SKIP TO 457)4 D~°,*°.*,°****oo*,.*.**°.I HKXT-TO-L~ST t i l th YES . 1 KO.o****°**°H.*.°o*°.*2 (SLIP TO 45?)" DK°.°******H°°°°°.°°.°.~ I E I -F IH] I - LA IT I l l TH YES.°.°~.°°.°°.°°°°.I NO.***.°°.°°. . °°.2 (SKIP TO 457)4 DK. . . . . . o . ° . ** . . . 8} 456 I S7 458 Piles• tell me if (NN¢[) (hal) rKelVl(J any of the fot Io~inI va¢¢ i~t lanl: . , #* . , , , , , , ' / . • . A.<o v . . , . ,7 . tuberculosis, that Is, injection in tit irl lhlt t i l t I liar? PoLio vaccine, that iS, drof~ in the I~Jth? IF YES: HO~ tMny times? IF YES: M injectio~ ageir~t ieiliel? CHECK 216: CHILD ALIVE? Did e doctor or • h||Lth ~orker tell you about the cue of de•th of (KNEE)? YES . ****°1 NO . . . . . * . *2 OK*.°* . .,~ YES.,,°. . *,~1 NO . .* . 2 DK . . . *~ klIJI4JEH OF TIMES . B YES . .1 YES . I S~ . **°****H.,.o.2 DK.******. . .***.8 YES. . . . 1 MO . .°, . DK . ,. . **.H8 I~MEER OF TIMES . [] YES. . . . . . . . . . . . . . , * . . . . . . 1 EES.******.,. . ***.1 liO.°.°,,°, . .,,,2 DK . 8 YES.°.*** . DK . 8 k~JCEEH OF TINES . [~ YES . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . 2 k~ . . . . . . . . . . . . . . . . . . . . . . . 2 WO . . . . . . . . . . . . . . . . . . . . . . . 2 DK . . . . . . . . . . . . . . . . . . . . . . . 8 D[ . . . . . . . . . . . . . . . . . . . . . . . 8 DK . . . . . . . . . . . . . . . . . . . . . . . 8 t (SKIP TO /*62) (SKIP TO 462) V YES . 1 NO . 21 I (SKIP TO 660 1 ~ YES . . . . . . . . . . . . . . . . . . . . . . 1 (SKIP TO /*60 )4 (SKIP TO 462) YES . 1 SO.o. . ***. . 2 1 (SKIP TO 460 ), t Z# 259 I 459 m m Uhet did theY say vas the cm of d~ethY (O|RCLE ALL +PJIJSES ~ATIOIIfO) LAST IISTH MN4E FEVES . 1 P IAASNEA . . . . . . . . . . . . . . . . 1 t ~H,* . . . . . . . . . . . . , . . . .1 MEASLES . 1 V(141T |HG . 1 ¢~I1~4. S IGN S . . . . . . . . . . . . . I OTHI[E 1 (~CIFY) (SKip TO /.61)~------~ NEXT-TO*LAST BIRTH MANE m i FEVEE . 1 P IARKHEA . 1 COUGH.***. . ,o,o.1 NEASLES . 1 ~I4LTLNG . . . . . . . . . . . . . . . . 1 CCI4VULS lONS . 1 OTHES 1 (SPECLEY) (SK[P TO / .61)~- -~.~ SECCI) * FRON- LAST IliITP IMICE m m FEVER . 1 DLNIII4EA . 1} MEASLES . 1 VO4ITIMO . 1 O0id~lLS IONS . 1 OTSES 1 (~C|ET) (SKIP TO / . 6 1 ) ~ L~O Uhet do y~4J i:,oLie~ Mite the FEVER . 1 FEVER . 1 ¢lMI4 of death of (14N4([)? P]ANRHEA . . . . . . . . . . . . . . . . . 1 PIANRHEA . 1 CPUGH . 1 COUGH . 1 ! ~IT ISG . . . . . . . . . . . . . . . . . 1 "~11 T I NG . . . . . . . . . . . . . . . . . 1 C~Ik~JL S I Oil S . 1 COIVULS [ONS . 1 (C]SCLE ALL CAUSES NEflT|Ca4E9) OTH~EH 1 OTHER 1 /.661 * * * * * * * * * * ~ FOR NEXT I I R T H ~ T N S , SKIP TO ~99"********* HIS (NAME) be@n ill with YES . 1 YES . 1 • fever at any time Ln NO . 2 140 . 2 the Lilt 2 ~k lY OK . 8 PK . 8 FEVER . 1 OIANHHEA . 1 C~UGH. . .~ MEASLES . * . . I VG+41T LNG . 1 CCI4~JLS 10M$ . 1 OTHER I (SPECIFY) YSS. , , . * ** . . . . . . . . . . . . . . . NO. . . . , . . . . . . . . . . . . . . . . . . PK . . . . . . . . . . . . . . . . . . . . . . . 8 IItas (MN4E) been i{L with I YES . 1 46.3 a ¢ouOh at ~Y time in 140 . 2 the Laat 2 Necks? "~(NANE~i~ (SKIP TO &67), I ~ j ~ .:~ pK . b pKYES . ~I~pI oKYES . i I MS . . . . . . . . . . . . . . . . . . . . . . . 2 IK) . . . . . . . . . . . . . . . . . . . . . . . 2 (SKIP TO 467)" _J (SKIP TO /*67)4 . *,*o.* . * . HIS (MAPLE) be@n ill ~ith YES . 1 YES . 1 YES . I • ~o+ L. The L , . 2 , ho+r,Y .o . 2 . o . 2 ::::::::::::::::::::::::: pK . . . . . . . . . . . . . . . . . . . . . . . , pK . . . . . . . . . . . . . . . . . . . . . . . , . - - I ~ J~ l (ut)? i IF LESS THAN 1 DAY. RECORD '00'] DAYS . PAYS . m PAT, . 466 When (HN4E) hid the ittnees uith a cough, did he/she breathe famter thl~ usu4L uith short, rapid breaths? YES . I 140 . 2 OK. . *.***.8 YES . 1 NO . 2 PK . 8 YES, . . * * . . . . . . . . . . . . . . . . . I NO . . . . . . . . . . . . . . . . . . . . . . . 2 OK . . . . . . . . . . . . . . . . . . . . . . . 8 2& 260 ~67 i CHECK ~ ANO / ,~3: FEVER OR COUGH? I /h i t ~s given to t reat the fever/c+, If ar~thfng? Anyth lnB . e tse? -- , (CIRCLE EACH MENTIONED) LAST BIRTH "YES" IN EITHER ~6~ OR ~63 E~THER (SKIP TO 471 ) NO TREATNENT . 1 INJECTIOR . 1 ABTIBIOTtC (PILL OR SYRUP) . 1 ANT ] MALAR [kL (PILL OR SYRUP) . 1 CCfd~H SYRUP . 1 OTHER PIL L. OR SYRUP . 1 UNKMObll PILL OR SYRUP.1 H~I4E RENEDY/ NEHBAL INED 1CINE . 1 OTNEN 1 (SPECIFY) NEXT-TO-LAST DIRTH NA~ "YES" IM EITHER 46~ OR ~3 OTHER ~-~L~ ( sKi p TO 471) NO TBEATIEENT . 1 INJECTION . 1 AMTKB]OT(C (PILL OR SYRUP) . 1 ANT [I¢IALAR lAL (PILL OR SYHUP) . 1 COUGH SYRUP . 1 OTHER PILL OR SYRUP . 1 UNKMO~ PILL OR SYRUP.+1 REMEDY/ HERBAL NEDICINE . . . . . . . . . 1 OTHER 1 (SPECIFY) ! SECONO-FROR'LAST BIRTH NAPE "YES" ]M EITHER k62 OR 463 OTN[R [~-~(SKIR TO 471) NO TREATMENT . 1 tMJECTZOR . 1 AMT]BIOT[C (PILL OR SYRUP) . I ANT [ IAAL AR I AL (PILL OR SYRUP} . 1 COUGH SYRUP . 1 OTHER PILL OR SYRUP . 1 IJNKNOUN PILL OR SYRUP.1 NONE REMEDY/ HERBAL MEDICINE . 1 OTHER 1 (SPECIFY) +l+-- I ', YES . 1 YES . 1 | YES . 1 treatllnt for the fever/cOUBh?, . . ~ NO . 2 NO . 2+ MO . 2] ~" ~.t~'~'~f~j.~j .¢.'-~r ~ (SKIP TO 471), ] (SKIP TO 471)" (SKIP TO 471), 470 From ~hom did you seek Idvtce or treatm~t? Anyone else? (CIRCLE EACH MENTioNED) OOVERNMEMT HOSPITAL . 1 RNC/BXU/GOVT CLINIC . 1 PEIVATE HOSPITAL/CLINIC.1 PB[VATE DOCTOR . 1 FAMILY ~LFARE NORKER.1 LADY HEALTH VISITOR . 1 X(~I4OEOPATH . 1 HAKIM . 1 FAITH HE&LEH . 1 DRUGSTORE . 1 SHOP (OTHER THAN DRUGSTORE) . 1 OTHER ] (SPECIFY) GOVERHNSMT HOSPITAL . 1 RNC/BHU/GOVT CLIMLC . 1 PRIVATE HOSPITAL/CLINIC.1 PRIVATE DOCTOR . 1 FAMILY OCLFARE kORKER.1 LADY HEALTH VISITOR . 1 HONOEOFATH . 1 HAKIM . 1 FAITH HEALER . ( DRUGSTORE . 1 SHOP (OTHER THAN DRUGSTORE) . 1 OTHER 1 (SPECIFY) GOVERNMENT HOSPITAL . I RNC/BHU/GOVT CLINIC . 1 PRIVATE HOSPITAL/CLINIC.°1 PRIVATE DOCTOR . 1 FAMILY ~LFARE WORKER.,1 LADY HEALTH V]SITOR . 1 HOMOEOPATN . 1 HAK[M . I FAITH HEALER . 1 ORUGSTORE . 1 SHOP (OTHER THAN DRUGSTORE) . 1 OTHER 1 (SPECIFY) 471 Hie (NMCE) had diarrhea in the List. t~o t~ks? YES . 1- (SKIP TO 473)q NO . . . . . . . . . . . . . . • . 2 OK . . . . . . . . . . . . . . . . . . . . . . . 8 YES . 1 1 (SK[P TO 473)¢ / NO . 2 BK . , . o . YES . 1 (SKIP TO 473)¢ NO . , . OK.o, . °o . **o.B 472 I *********-ooBAc~ TO 651 FOR NEXT BXRTH; OR, IF MOM~E IIRTEB, SKIp TO 490 473 | Nss (NA~) h~i diarrhea I in the Lest 24 hours? - i J . I +,# . . , . . . , , I YES . 1 M~ . 2 OK . YEB . . . . . . . . . . . . . . . o*o . , , .1 NO. , , . . . . . . . . . . . . . . ° . , , . ,~ OK . . . . . . . . . . . . . . . . . . . . . . . 8 YES . . . . . . . . . . . . . . . . . . . . . . 1 | NO. . * , , . . . . . . * . . . . . . , , *o .~ I ON . . . . . . . . . . . . . . . . . . . . . . . 8 474 For ho4t mm~ydaye (her the diarrhea tastm~/did the dLJrrhea Leet)Y IF LESS THAN 1 DAY, RECORD +00' J DAYS . ~--~ DAYS . . . . . . . . . . . . . . . . ~- -~ DA*. . FiTI 29 26] 475 ~es there e~y blood In the stooL•? LAST BIRTH IUa4E YES . 1 IO. . . . .*.o~ 4}'6 4?7 CHECK &27/433: LAST CHILD STILL BREASTFED? During (NN4~).s dt•rrhel. did yo~ chMIge the f r a y of breist fstldi r~? YES NO V (SHIP TO 4791 YES . I ~O . . . (SK[P TO 479)* | NEXT-TO-LAST BIRTN SE~-FRON-LAST SIRTH NANE I YES . 1 YES . 1 NO . 2 NO . 2 DK . 8 DK . 8 i (SKIP TO &79) (SKIP TO 4~) 478 Did you tr~reese the frec~Ancy of breesffeeding or reduce the frequency or d~d you sto0 COrneL efety? .,,, g, z mr I NCREASED . 1 REDUCED . 2 STOPPED COMPLETELY . 3 A#9 {Aside from breasfmtk) Has (NAME) gwen the smne laount to drir~ •s before the dtarrhe•, or more. or Less? MORE . 2 LESS . ] DS . **.*.**. . 8 SNAE . 1 k~RE . 2 LESS . 3 OK . 8 S~E . 1 I(~E . 2 LESS . ] DK . 8 Uas (NAME) given the sloe w~unt of food as before the diarrhea, or more, or Less? /I " * t ~ ,¢ 'firs sl MOlE . 2 LESS . 3 OK . 8 S~E . 1 LESS . 3 DK . 8 S~E . 1 HaRE . 2 LESS . 3 DK . 8 /.81 | Uas (NAME) given • fluid made I from • spectil packet? t J . YES . 1 NO . 2 DK . 8 YES . 1 NO . , . Z DK . 8 YES . 1 [40 . DK . 8 30 262 II II LAST BIRTH NAME I 484 q ~,87 Was (WANE) given a~y of the For(owing ~ring the diarrhel: I /IANE NEXT'TO'LAST S[RTH ~A/~CORD'FROM-LAST BIRTH I siC''F'r~l(J~¥~,~j~.~.; Yes . I res . 1 ~ss . 1 " NO . 2 NO . 2 NO . 2 SK . . . . . . . . . . . . . . . . . . . . . . . 8 DX . . . . . . . . . . . . . . . . . . . . . . . B OK . . . . . . . . . . . . . . . . . . . . . . . a LiSt(? ' ~ • r A h~-m~ fluid me de From sugar, ut t end wirer? Any other hcme-n~e Fluid? YES . 1 YES . 1 YES . 1 gO . .2 K.| YES . °. . .°.1 BO . .°.°.~ OK . .~ YES . 1 NO . 2 DN . . . SO. . . . . . . . . . . , . . . . . . . . . . .2 INt . . . . . . . . . . . . . . . . . . . . . . .8 YES . .oo . .o.,.1 ~O . .o°o.o.,°,, . Z DK, . , . .°°°,o°,,°.,.°,8 YES . 1 NO . . . OK . 8 NO. . . . . . . . . . . . , . . , . . . . . . ,2 OB. . . . . . . . . . . . . . . . . . . . . . . 8 YES . . . 1 MO. . . . .Z OK . . . .~ YES . ( NO . . . ;~ DK . 8 CHECK 481 AND ~82: CBILO GIVEN FLUID FROM PACKET (481) ANO/OR ANY W~WE-P, ADS FLUID (482)? For ho~ mlny ~y$ MaR (NJBqE) given this fLuid~ /~ , - • J IF LESS THAW 1 DAY, RECORD ~OO* YES GIVEN NO ~ | YES GIVEN ~ E~ NO YES GIVEN NO FLUID FLUID L-T -J FLUID FLUID FLUID FLUID (PKT ,/HOME) (PKT ./HONE) (PXT ./HOME) [SKIP TO (SKIP 10 (SKIP TO 685 ) 485 ) 485 ) v v o- . m o,s . o- . . . . . . . . . . . . . . . . DK . 98 | OK . 9B DX . 98 I Uas anything given for the YES . 1 YES . I YES . I O , h (oh . h NO . . . . . . . . . . . . . . . . . . . . . . . NO . . . . . . . . . . . . . . . . . . . . . . . NO . . . . . . . . . . . . . . . . . . . . . . . fluid)? (SK(P TO 487)9 ~ (SKIP TO 487)q 8,J (SKIP TO 487)4 o,~.cJ/~) ~.~-~.~f oR . ~ . oK . j ~ J I #hat ~s Riven to treet the diarrhea? Anything else? CIRCLE ALL MERTJOMED) ANTIBIOTIC PILL G~ SYRI,~P . 1 OTHER PILL OR SYRUP . 1 UNKRONN PILL OR SYRUP . 1 INJECTION . 1 l I ,V , ) INTRAVENOUS . 1 REMEDIES~ HERBAL MEDICINES . 1 OTHER 1 (SPECIFY) ANYISIOTIC PILL I~ SYRUP . I OTHER RZLL OR SYRUP . 1 UNKMOidd P(LL OR SYRUP . 1 IMJECTIOM . 1 ( I .N . ) INTRAVENOUS . 1 ffCI4E RENEDIESI HERBAL MEDICINES . 1 OTHER 1 (SPECIFY) ANTIBIOTIC PILL OR SYRUP . 1 OTHER RILL OR SYRUP . 1 UNKNOWN PILL OR SYRUP . 1 [NJECTEOR . 1 (].V.) INTRAVENOUS . F Ya3NE BE~DIES/ HERBAL MEDIC(NEE . 1 OTHER 1 (SPECIFY) tremtmlnt For the YES . 1 YES . . . . . . . . . . . . . . . . . . . . . . ' i O~d y~ seek mdvice or YES . 1 NO . 2] H- ~'~,~L ~,~ - . . , f No . diarrhea? , /" NO . 2 2 I ~/I (SKIP TO 489), (SKP TO 4a9)- (SKIP TO 489)4 # J J., 3J~ 31 263 488 49Q 491 Froawhomdidyou seek advice or treatmlnt? AnyOne else? (CIRCLE ALL MENTIORED) LAST OIBTH NA~ GG~IERNNENT k~]~PITAL . 1 RHCIIV/JIGOVT CLINIC . 1 PRIVATE ~ITAL/CLIMLC.| PRiVATE DQCTOR . | FAMILY MELFFdtE WORKER.1" LADY HEALTH VISLTM . 1 IK]4~OPATH . 1 NJ~(IR . 1 FAITH HEALER . 1 DRUGSTORE . 1 SROP (OTHER TKAN DRUGSTORE) . I OTHER 1 (SPECIFY) NEXT'TO'LAST BIRTH MANE GC~ERNNENT HOSPITAL . 1 IHC/IkvJ/GOVl" CLINLC . 1 PRIVATE EQSPITAL/CLINIC.1 PRIVATE DOCTOR . I FAMILY IdELFAAE k(~KER.I LADY HEALTH VISITOR . 1 IICI40EORATH . 1 ;MKIN . 1 FALTS HEALER . .1 DRUGSTC~E . 1 S~ (OTHER THAN ORUGSTOIE) . 1 OTHEE 1 (SPECIFY) HECQI~-FRQN-LAST BIRTH GOVERNMENT H~)IPLTAL . 1 R~/iNU/OOVT CLLNIC . 1 PRIVATE HOSPlTAL/CLIMIC.1 PRIVATE DOCTOR . 1 FN4]LT WELFAIIE M~KER,.,,| LADY HEALTH VISITOR . 1 ~OPATH . | HAl(IN . . . . . . . . . . . . . . . . . . . . I fAITH HEALER . . . . . . . . . . . . . I ORUGSTCnE . I SI~P (OTHER THAN DEUGSTGeE) . 1 OTHER 1 (SPECIFY) +*' teetn+60 BACK TO 4S1 FOR NEXT iIRTR; OR, IF NO 14GEE IlRTHS, GO TO 490"********* CHECK 481: ORS SOLUTION MENTIONED (AMY YES [M 481) IJ OQE SOLUT 1011 WeT (311HEMTLONED ? 481 MOT ASKED v Have you ever heard of • special product ciLLed ors or Nimkot (or LOCAL MA/4E) you tin get for the treltlnent of d+lrrhee? I b693 I I YES . 1---P693 MO . . . .,,~ | 49~ HIVl yoIJ ever s lH~ • p lcket L ike thLs U I foP I? l YES . . . . . . . . . . . . .o . . . . . . . . . . . . . . . t l t We . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2----+5011 " ] ] ! ~ +, ~+L.~.-, ~ , . ,L .~ f .+.," (SHO~ PACKETS) 6. TEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 I I We . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2~496 Have ymJ ever prepared • solution with m~e of these packets to trait diarrhea in yourself or s01~-one else? (SHOW PACKETS) 32 264 SdCIP NO. I G4,JESTIORS AND FILTERS COOING CATEGCIIIES I TO 694 I Did yo~ prepare the whole packet at or~e UHOLE PACKET AT ONCE . 1 | I or only part of the packet? I ONLY PART OF PAC£ET . 2-"-~496 495 Ho~ nk~h water did yo~ use to prepare (LOCAL NAME)? 100 ML, GLASSES/CUPS . 1 200 ML, GLASSES/CUPS . 2 2S0 ML. GLASSES/CUPS . 3 500 ML. GLASSES/GOPS . 6 UNKNOWN SIZE GLASSES/GOPS,S i I i 1 SEER CORTAIREN . 990 1/2 SEER CONTAINER . 991 1/6 SEER COHTAIRER . 992 OTHER 996 (SPECIFY) DR. . ° . .o.° . 998 696 497 49B Uhere can you get the (LOCAL NAME) packet? PROSE: AnYWhere else? ,=' <.,:'t'PNoRE: (CIRCLE ALL PLACES MENTIONED) CHECK 482: SUGAR/SALT/UATER ? SUGAR/SALT/~ATER FLUID MENTIONED FLUID NOT MENTIOREO [~ (AMy YES IN 482) OR 482 NOT ASKED k'no taught yc~ to prepare the home-made fluid made from sugar, salt and aater? GOVERNMENT HOSPITAL . 1 RHC/BHU/GOVEENMENT CLINIC . 1 PRIVATE HOSPITAL/CLINIC . I PRIVATE DOCTOR . 1 FAMILY MELFARE WORKER . 1 LADY HEALTH VISITOR . 1 HAKIH/H(3r4OEOPATH . 1 DRUGSTORE . 1 SHOP (OTHER THAN DRUGSTORE) . I OTHER I (SPECIFY) GR . .oo*o . 1 GOVERNMENT HOSPITAL . 01 RHC/BHU/GOVT CLINIC . 02 PRIVATE HOSPITAL/CLINIC . O] PRIVATE DOCTOR . 04 FAMILY IdELFARE WORKER . 05 LADY HEALTH VISITOR . 06 HOMOEOPATH . . . . . . . . . . . . . . . . . . . . . 07 HAKIM . 08 II~vAJNIZATIOII TEAM MEMBER . 09 DRUGSTORE . 10 SNOP (OTHER THAN DRUGSTORE),.11 RAD IO/TV . 12 FRIEAD/RELATIVE . 13 OTHER I~ (SPECIFY] i P501 I 33 265 NO. 501 502 503 G~ESTIONS AED FILTERS CHECK 107: I~JRRENTLY MARRIED El NOT CURRENTLY (CODE 1 IN 107) NARRIED ~1 (CCOE 2-S II 107) Are yOU living u|th your husband ~ or |I he Itayi ng elsevhere?. . / : ~(~ f.~// In the Lest four ~#lkl, ~re you end your hu~m~l ott~ys Ilvini together or uere y~u a~ert SOW* of the time or ell of the tim? SKIP COOING CATEGORIES I TO I i ,509 I ::*,fj:[' ::::::::::::::::::::::::: I AL~TI LIVING TCGETNER . 1 I APART I~ Of THE TIlE . 2-~SQ6 APART ALL Of THE TINE . ] 504 I I During the Lest fo~" b~lcs, were you ~cl yc~r I APART ALL Of THE TIIG . 1 I husbend apart aLL of the tim or did 1K~ Itly ] STAYED TOGETHER IK]NE Of TINE.Z i ~n~ together . of the IiII? "1 I" . ,i * , DIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1~. - - - - - -5~ "1 " I" . ,i - " . s • - " . - / ~ f f NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - - - -~511 510 J Uhst type of re|JtlonohIp (isles) It? J FIRST COUSIN ON FATHER,S SIDE.1 I I FIRST COUSIN ON NOTHERaS S IDE. . .2 • , SEC~ CCUSIN . 3 ~ U~ ~- ~ LJ/,, OTNER RELATION 4 (IK~ICIFY) 266 NO. 511 QUESTIONS ANO FILTERS ROW old were you ~en y~J started Living with your (first) husl~end? J .1 • I ° • C~ING CATEGORIES l°.°°°*,,°°**.°.°°°°°oo°°~ S~IP TO 512 In ~hat a~nth and year did you start tiring uith him7 CGq#ARE 511 ANO 512 WITH 105 A~ 106. MAKE ¢~RECTIONS IF INCOUSISTENT. 140UTR,o°,°.,o°°°,,°°°4.°°o M OK HONTH . 96 Y~dU~°°°o°°o°,°°°°.°o°o.o°°r~ DK YEAR . 9e PRESENCE OF OTHERS AT THIS POINT. YES NO CNILD(REN) tJIIOER 10 . 1 2 HUSlMRO . 1 2 OTHER NALEtS) . 1 2 NOTHER- IN-LAY . I 2 OTHER FEMALE(S) . 1 2 35 267 NO. CHECK 322: NEITHER STESlLIZED SECTION 6. FERTILITY PREFESENCFS O~ESTIOIS AND FILTERS I HE OR SHE STERILIZED [~ C~OlMG CATE~G~IE I CHECK 107: CURRENTLY MARRIED (CODE 1 IN 107) NOT CURRENTLY MARRIED ~-~ (CODE 2"5 IN 107) 603 CHECK 224: NOT PREGNAI~T OR UNSURE (~ / NOV I have some questions ebo~t the future. ~outd you Like to have (a/another) child or would you prefer not to have any (more) chi[dren? !~<;¢ 0,,¢I PREGNANT 9 [ ¥ NOW [ have some questi~ abo~t the futqre. After the child you are expecting, ~ould you Like to have another chi[d or uoutd y~J prefer not to have any more children? f • 60, [ oh.L to # or asr r [ HAVE A (ANOTHER) CHILO . 1 NOR CItE/NONE . 2-- SAYS SSE CAN mT GET PREGNANT . 3 UP TO GOO . & UNDECIDED OR DK . 8 I SOY. r . . . . . . . . . . . . . . . . . . . . . . . . . . 1 | GIRL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 J DOESN*T MATTER . 3 IKIP I m J L15 ,611 605 CHECK 224: NOT PREGNANT OR URSURE [] / i v Ho~ Long would you LLke to wai t from nou before the birth of (a/another) c~=ld* • - ~ql PREGNANT i ¥ Nov tong would you L ike to wait after the birth of the child you are expecting before the birth of another child? ., • / . / ., Z~.J (IF NUMERICAL ANSWER GIVEN, RECORD W)NTHS OR YEARS) I(ONTNS . 1 I 1 ~ " YEARS . 2 __¢~_JSOk~ . 99& i i SAYS SHE CANIT GET PREGNANT,.990---- OTHER 996 (SPECIFY) DK . °.o.°~ ~611 36 268 NO. QUESTIONS AND FILTERS SKIP COOING CATEGOHES TO CHECK 216 AND 224: YES HAS LIVING CHILDREN ? ON PREGNANT? 607 CHECK 224: 608 6O9 NOT PREGNANT ON UHSURE 9 I V HOU old wo~td you I~ke your your~est child to be whe~ your next child is born? .,Z~. V f a*p. J_r PREGNANT NO 9 Bou old would you hke the child you are expecting to be when your next child is born? AGE OF YOUNGEST i v .BB . OK . • . .9 '611 Do you regPet that (you/your husband) had the operatic~ not to have any (more) children? Vny do you regret it? J I YES . 1 | NO . 2 )610 I RESPONDENT WANTS ANOTHER CHLLD.I~ HUSBAND WANTS ABOTHER CHILD . 2 SiDE EFFECTS . 3 615 OTHER REASOId 4 (SPECIFY) I 610 Given your present circumstances, if y~ had to do it over again, do you chink yOU would make the same decision to have a sterilization? t " - - ? " . 611 Do you think that your husband al~oroves or disapproves of couples using a method to avoid pregr~ncy? YES . 1 -- NO . ~ -- APPROVES . 1 D I SAPPROVE S . 2 OK . 8 -~615 ~12 ~ I HEVEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 How often have you and yOU husband talked about family planning i n the pas year? ~ ONCE ON TWICE . . . . . . . . . . . . . . . . . . . 2 "f , . , '~,- ' f ." " - "~.~." " /f:" ~.%~.~" ~lvJl(~ fl ~ ~1 j "~/~J~ ~ " | BORE OFTEN . 3 I 613 I Have you a~:l your husband ever discussed I YES . 1 the ruder of ch i ld ren you would L ike to have? I No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 37 269 NO. I QL~STIONS AND FILTERS I C~ING~TEGO~IES ITO 514 Do yoga think your hu~bamd mints the ~q~ SANE NUI~ER . 1 number of children that you vent, or does he ~ant ~r~r 9 MORE CHILDREH . 2 or f|~r then you Mlmt? .- ,~ / ~ l ~ FEWER CHILDREN . 3 ~15 HC~ Long should a husband and ~ife ~ait before starting sexuat intercourse after the b~rth of a baby? (IF AMSOER IS NUMERIC, RECORD DAYS OR MONTHS OE YEARS) DAYS . 1 MONTHS . 2 YEARS . OTHER (SPECIFY) 996 616 ShouLd a mother ~81t ~til she has compLeteLy stopped breastfeoding before starting to have sexuat retatio*~s again, or doesn't it matter? WAlT . 1 DOESN'T MATTER . 2 617 In generaL, do you approve or disapprove of couples using a method to avoid pregnancy'/ /'cs.,,,':.ob,/. Jj .C,s'j.,L ~s-. ~ d~ ~; ~ ~ .,.,/',-.~ APPROVE . 1 DISAPPROVE . 2 618 CHECK 216: NO L[VIMG CH)LDREM (~ | I v If you co~td choose exactly the number of children to have in your whole Life, how many MouLd that bet d;;,s,4 d., J d J'o ,1. ' • . y g HAS LIVING CHILDREN [~ ] ]f you could Do beck to the time you did not hive any children and could choose exactly the hunter of children to have in your whoLe Life, hOW maa~ ~,~Jtd thlt be? JLp j ~" p f~ • .a t ,,F.w/"gw,.e. J~,~ ~ i~ i • f ? " NUMBER . ~'~ UP TO G~O, ALLAH . 95- OTHER ANSWER (SPECIFY) ~620 38 270 hO, 619 QUESTIONS AND FILTERS NON mwly of these ¢hildr~ k~JLd you Like to be boys and ho~ away ~¢utd you like to be girls? CODING CATEGORIES BOYS GIRLS EITHER UP TO G(~, ALLAH . OT~Eg ' ~ (SPECIFY) SKIP TO 62O k~ ~JLd like to knov ho~ much schOOLing you ~ould Like y~ur chtLdr~ to have. (IF NOT STERILIZED: C~lder the children you already hive end also any children that you might have in the Future). First, Let's talk ~t a~e. Whet is the highest Level of school that ym~ k~Jid Like any of your sons to ettMld? z . , , " ' ; NOT"$T.LL,,. " ' , r . • " ! #~" O E . . . . . . , . , ° ,• . . . . . . . ° ° . . . . . . ° I PRINARY SCNOOL . 2 H|GOLE $CiKX)L . 3 SECONDARY SCItOOL . 6 HIGHER . . . . . . . . . . . . . . . . . . . . . . . . . . 5 OTHER 6 (SPECIFY) ~ / ( . . . * * ° . . . o . . ° . . . . ~ . ° ° . , , . . . * * , ~ Arid hov about daughters? Whet is the highest level of schooling that yotJ ~ld Like any of yo~- daughters to mtterld? NONE. ° . . . . . . . , , . . . ° , . . . . . . °**.1 PRIMARY SCHOOL . E NLGOLE SCHOOL . 3 SECONDARY SEHOCL . . . . . . . . . . . . . . . . & HIGHER . . . . . . . . . . . . . . . . . . . . . . . . . . 5 OTHER 6 (SPECIFY) l i l l a t do you think is the ideal age at mrriege for boys? IDEAL AGE IN TEARS . I J I OTHER 96 (SPECIFY) 623 And vhat is the Ideal age at IIrrtmge for girls? IOEAL AGE Ih TEARS . I I ] OTHER % (SPECIFY) 62A I if you heeded to 9 ° to • health clinic or a h~pitel, COJLD GO BY SELF . 1 i ¢mald you go by ymJrseif or Jeoutd you need to be I I I ac¢~led by seal-one? . . . . z ,/ ,~ # | WOULD NEED TO BE ACCOIIPANIED. Z • . i " ' I IT DEPENDS . . . . . . . . . . . . . . . . . . . 3 • v ~ ~ v v q v . - - , o .-- _ 39 2'11 RO. 702 QUESTIONS AND FILTERS CHECK 107: CURRENTLY MARRIED (CODE 1 IN 107) NOT CURRENTLY MARRIED (CODE 2-5 IN 107) Row Did is your husband in completed years? SKIP CO01M~ CATEGORIES | TO I , 703 AGE lM CONPLETED YEARS . [ ~ I DE . 98 703 ASK + .~J 'J (NJEDTIONS BELOW ABOUT CURRENT OR HOST RECENT HUSBAND YES . 1 Did your (Last) husband ever attend school? ,-, c.J,. ~<. . I / - - . - , . ' .+ _ " , ,7 - 'A t+ "~:<s . i - , ,<C-~' " . r ,o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ , . ,~ #04 What was the highest Level of school he attended: primary, mcldte, secot~dary, or higher? • b. ~' J ! .h +---~, ~. d , " / - -~ 'd .~ ' ' <s l I PRIMARY . 1 | NIOOLE . 2 I SECONDARY . . . . . . . . . . . . . . . . . . . . . . . 3 HIGHER . 4 DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ ~706 I I 705 | What was the highest class he completed at that Level? L ~ J v ¢ S ' " J"c.V'~, 4.,.:%> ~-, Z -~, CCA,, . ~ l OK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 706 707 708 Sat k+nd of work does (did) your (Last) husband mainly do? CHECK 706: WORKS (WORKED) [~ IN AGRICULTURE v DOES (DID) NOT UORK [~ IN AGRICULTURE (Does/did) your husband WOrk mainly on his ~ Land or family Land, or (does/did) he rent Land, or (does/did) he work on sameo~e etse's Land? 2., ;" L.,), +. +L/,<+_+ .+, ,~ 3.//+ z.,,7 ~ 4 +. +4,,/.~ .?{ RIS/FANLLY LAMO . 1 RENTED LAND . 2 SONEOgE ELSE'S LAND . 3 • ;'09 1 40 272 .o, I Qt~ITIOBILqO FILTERS I Aside fr¢~ your om ho~evork, ire you currently IK IP ~liO ¢ATIO011111 I TO I I YES . I ,71i NO,,,, . .,°.°.,,°,,,,°,,,.°Z I I 710 As you knew, some um~n take ~p jdoe for uhich they are paid In clih or kird. Others sell thirds, have a ill business or work on the filly firm or In the filly hultness. Are you currently doing any of these things or =ey other ~ork? .,.5,7let ~ z" ),i., ~ , , ,(, s'w, @'.~ ,-. r s ~ YES . . . . . . . . . . . . . . . . . . . . . . . . , . . . .1 ~OHoo,o,,.o.°,.,,,,.o.o.,,.o,Z I .712 711 I if y~ coula lind . suitliile i.-,/'., i,~llll yo~l/lk/.;. I tO v~rk? • # ¢i¢~'-. r i~ ~-~. ~, e¢o , J J , : I YES . I XO . 2"- -~719 ~=.o ,°°o . . . . . . . • . . . . . . . , ° °°° . . .A I 712 Uhit is yc,ar occupation, that Is, =hit kind of work do you do? 713 In your current work, do you york for a m r of your family, for someone else, or ere you self-mpioyed? <. ¢ ;¢r 4' r_, r. ! 7 , . iSec .~, , , / - - ~. J-~ ¢¢ FOR FAHILY NE~ER . . . . . . . . . . . . . . . 1 FOR SONEORE ELSE . 2 $ELF-ENPLOYED . . . . . . . . . . . . . . . . . . . 3 714 DO you earn cash for this work? PROBE: DO y~J make money for tmrking? YES. . .,.,.1 NO, . .oo. . . . 2 "1 °°h -° - - I- . 1 <. ~. J/t¢,A ~ f ~. ~ d/~, / :¢'-- ---. ~ ~ ' . . . . . . . . . . . . . . . . . . . . . . . . . 41 273 NO, 717 QUESTIONS AND FILTERS CHECK 215/216/218: HAS CHILD ilO~N SINCE YES JAN. 19~6 A NO LIVING AT HONE? Vhile you ere ~oriltHl, do you usuaLLy hive (NAME OF YOUNGEST CHILD AT 1~IIAE) with you, sometimes here hil~/her ulth you, or r~ver have him/her with yo~? ( . , OF ,ou ,=, , cNiLo At .~,~> 71~6~,~, , i¢ r~ '~. . SKIP CODING CATEGORIES I TO I ~,719 I USUALLY . l.---I,Ti9 SOMETIMES . Z I NEVER . 3 718 SO usual( y tikes care Of IMNAE OF YOUNGEST CHILD AT HCIRE) white yo4J are working? ~ ~,." ,'ll-,J~,(~i'~,~ll ''v'ji'i'LJ ~" '*" (i-- OF Y~GEST CHILD AT HONE) liU~o°,. . °°°oo01 OLDER CNILD(REN) . 02 C.~ENOPANENTS . 03 OTHER RELATIVES . 04 ~iEIOH~$ . 05 FRIENDS . 06 SERVANTS/HIRED HELP . D? CHILD IS IN SCHOOL . 08 INSTITUTIOMAL CHILDCARE . 09 OTHER lO (SPECIFY) ,.1o._,.,_. I*E, . , (first) got mrried? NO . 2 ~.~ i'd .:--G "i~ C J - - ~° L I Did you ~ork just efter you I (first) got I r r ied9 I 721 I CNEC[ 709/710/719/;'20: EVER MOCKED [~ NEVER MOaKED ~1 {ANY YES IN 709/ 7101719/7201 v YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ~0 . . . . . . . . . . . . . . . . . . . . . . . ° . , . . , .2 I HOW old .ere you who, r1 you first Itirtld Norking? I , . . I | P72A I AGE IN CCIIPLETEO YEARS . I-[-1 i 723 ~y did you start Working initiaLLy? (CIRCLE ALL REASCIIS GIVEN) I 'ECO~D THE CURRENT TINE. I FINANCIAL NEED . 1 SUPPLEMENT FAMILY'S iNCOME . 1 PERSONAL FULFILLMENT . I HUSBAND D[ED/BECANE ILL . 1 SUBSEGUENT TO DIVORCE/ SEPARATION . 1 OTHER 1 {SPECIFY) 4.2 274 SECTION 6. HEIGHT AND WEIGHT INTEEVIEVER: IN 802-80&, RECORD THE LINE IIUllERS. NAMEs, AND BIRTH DATES OF ALL LIVING CHILDREN IK)RN SINCE JANUARY 1 m 19a6 STARTING MITH THE YDUMGJEST CHILD. THEN RECORD 805"811 FOR EACH CHILD. 802 LINE 140, FROR O.21; 803 H~ FRON 0.212 8O4 DATE OF BIRTH FROM Q.215 AND ASK FI3R DAY 8O5 HEIGHT (in cm.) 8O6 HEIGHT: LYING O~ STANDING 807 WEIGHT (in k~;.) 808 ARM CIRCUMEER. (in cm.) 809 BCG SCAR CI4 AIIN 810 DATE CHILD WEIGHED AND WEASURED 811 RESULT 812 OF SEASlmER: I11 YQLJ~GEST LIVING CHILD M (M) DAY . 14QlIT H . YEAR . LYING . 1 STANDING . 2 3[3 mD SCAR SEEN . 1 NO GCNt . 2 DAY . MOI4TH . YEAR . CHILD MEASUAED.1 CHILD SICK . 2 CHILD NUT PRESENT . 3 CHILD REFUSED.4 MOTHER REFUSED.5 OTHER . 6 (sPECIFY) L2J NEXT-TO" yOJMGEST LIVING CHILD M (IM~) DAY . 14~TH . YEAR . m-1-[3 LYING . 1 STAIKIING . 2 VRD SCAR SEEN . 1 NO SCAR . 2 DAY . i4~TH . YEAR . CHILD HEASLIED.1 CHILD SIC[ . 2 CHILD NOT PRESENT . 3 CHILD REFUSED.& )tOTHER REFUSED.5 OTHER . 6 (SPECIFY) 31 SECOk~ - TO- yOUNGEST LIVING CHILD DAY . NOIIT H . YE~ . R- -D LYING . 1 STANDING . 2 F- D m[3 SCAR SEEN . 1 NO ~ . 2 I DAY . 14014TH . YEAR . CHILD HEASURED.1 CHILD SICK . 2 CHILD NOT PRE~NT . 3 CHILD REFUSED.4 NOTI~ER REFUSED,5 OTHER . . . . . . . . . . 6 (SPECIFY) m . , DE ASSISTANT: 43 275 Comments About Respondent: ~NTERVIEWER'S OBSERVATIONS (To be filled in after completing interview) Comments on Specif ic Questions: Any Other Comments: SUPERVISOR'S OBSERVATIONS Name of Supervisor: Date: EDITOR'S OBSERVATIONS 44 276 PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY HUSB~/~D'S OUEST IONNAIRE - URDU-ENGL ISH IDENTIF ICAT ION PLACE NAME NAME OF HOUSEHOLD HEAD PROVINCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBAN/RURAL (urban=l , ru ra l=2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MA JOR C ITY /D IV IS ION/D ISTR ICT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MA JOR C ITY /SMALL C ITY ,TOWE/V ILLAGE . . . . . . . . . . . . . . . . . . . . . . . . . (ma jor c i tyz l / smal l c i ty , town=2/v i l l age=3) NAME AND L INE # OF RESPONDENT NAME AND L INE # OF F IRST EL IG IBLE WIFE NAME AND L INE # OF SECOND EL IG IBLE WIFE DATE INTERVIEWER'S NAME RESULT* NEXT V IS IT : DATE T IME INTERVIEWER V IS ITS I 2 3 F INAL V IS IT DAY MONTH YEAR NAME r RESULT TOTAL NUMBER OF V IS ITS *RESULT CODES: 1 COMPLETED 3 POSTPONED 5 PARTLY COMPLETED 2 NOT AT HOME 4 REFUSED 6 OTHER LANGUAGE OF QUEST IONNAIRE . . . . . . . . . . . . . . . . . . . . . . . . . . . LANGUAGE OF INTERVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAT IVE LANGUAGE OF RESPONDENT . . . . . . . . . . . . . . . . . . . . . . . TRANSLATOR USED . . . . . . . . . . . . . . . . . . YES . . .1 NO. . .2 LANGUAGE CODES: 01 URDU 03 S INDHI 05 BALUCHI 07 S IRA IK I 02 PUNJAB I 04 PUSHTO 06 BROHI 08 OTHER (SPECIFY) (SPECIFY) NAME DATE F IELD EDITED BY OFFICE EDITED BY KEYED BY KEYED BY 277 NO. 102 SECTION 1. RESPOHDENT'S BACKGROUND O(JESTIONS AND FILTERS SR%P CODING CATEGORKES I TO RECORD THE CURRENT TIME• :::::::::::::::::::::::::::::: First I would like to ask some questions about yourself. For most of the time until you Were 12 years old, did you Live in a city or in a village? CITY . 1 VILLAGE . Z 103 How tong have you been Living co~tlr~ousty in (HA/4E OF CURRENT PLACE OF RESIDENCE)? ~,._~1"#C~. (NAHE OF CURRENT PLACE OF RESIOENCE) e.~ ~ C,6., .'or ~ *" YEARS . [ ~ ALWAYS . 95--~=. VISITOR . 96 105 I Just before you moved here, did you Live in a city or in a viLLage? .o I CITY . 1 VILLAGE . 2 I 105 J In ~hat month and year were you born? / I M4J~TN . ,--,J~ DR NONTH . 98 YEAR . ~ OK YEAR . 9B " " I ~ ~t 0 '~ ~J~" ~ ~ ,,, ~ l ~ , ,OE ,R COMPLETEO ,EAR~ . ~- -~ COMPARE AND COftRECT 105 AND/OR 106 IF INCONSISTENT, I 107 t Have<, "~;_. (~J LYou ever ~''attended~ school i I~ "/=L" ,-.* ~ I I YES . 1 J NO . 2 ='111 I 108 What Ls the highest Level of school you attended: prin~ary, middle, secondary, or higher? :~ O~." ,_S .,.,e- u-"L ~. r PRIMARY . 1 MIDDLE . 2 SECONDARY . ] NIGHER . 4 278 SKIP NO. I (~JEST](i~S AND FILTERS I cOOING CATEGORIES I TO ~-- . .b" f.~.~#~A~.~.)) 0 *'~ ~ ~,~ r CLASS . . . . . . . . . . . . . . . . . . . . . . --E I I I I essity, uith dill|curry, or r~ot st all? I VITH DIFFICULTY . 2 | I L ,(.~, ~___~.t. " J ./~.* (Jt,-ff~ ~ (~ ,,~1 .t~" ~ NOT AT ALL . 3 i ~'114 I ' "1"" ' " " ' " - ' I"" . '1 at least once s reek? YES . 1 ,~, .~/~,. ~, ~. ~ L /~. r ~. No . z " I ° Y " - " - - - I ' . I ~.~, <-/,_~., ( ~_ (~ ~ ~,,. ,., r ~ NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . "~ C(. :';" 116 117 118 What kind of ~ork do you ilniy do? ~ : i r',<" ,'~ <.,¢s o J t, ;, ~ i " ° . - CHECK 116: ~ORKS IN AGRICULTURE ? GOES NOT tdORK IN [--'] AGRICULTURE Do you verk nw|nly on your ov~ lard or flmJly land, or do you rent lend, or do you work on sameor~ eLse'l Land? J, 2 A. ,. ,/.e.e-) ~vr~. ~ z / re . J / Ob~/FANIL¥ LAND . 1 RENTED LAND . 2 SOMEONE ELSE'S LAND . 3 I m'201 I 279 SECTION 2: CO~TRACEPT%OB 201 O • PILL I d~n can take a pill everyday. ~ t ~ i No~ 1 k~JId like to talk about falily planning - the various ~aya or methods that a couple can use to delay or avoid a pregnancy. Which Nays or methods hive you heard ~bout? CIRCLE C~E I ]N 202 FOR EACH ~TH~ ~NTIOBED S~TANE~SLY. THEN PROCEED D~ THE COL~N, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED. THEN, ~ON EACH METHOD ~ITH CODE 10~ 2 CIRCLED IN 202, ASK ;~0]-204 BEFORE PROCEEDING TO THE NEXT METHOD. 202 Nave you ever 203 Have you ever 204 Do you knou ~here heard of (METHOD)? used (METHOD)? a person could go I . ~'~ to Net {METHOD)? #--~£./.-(METHOD) ~ " . " / / . "' , READ DESCR PT ON OF EACH METHOD YES/SPORT . 1 YES . 1 YES., . 1 •J [LID Wome~ can have a [cop or coil placed inside them by a doctor or a nurse. • O•J INJECTIC~S Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months. </<.c; . , ,< c, ,.: o <:/ o , 4J DIAPHRAC~,FOA/4~JELLY WOuld1 ca~ place a sponge~ supDository~ diaphragm, jelly or cre~ in- side them before intercourse. 5j CONOCI4 Men can use a rubber sheath durlr~ sexual inter ° course. YES/PROBED . Z kO . 1 y YES/$P~T . . . . . . . . . . . . . . . . . . . 1 YES/PROBED . 2 NO . Y YES/SPO~T . 1 YES/PROBED . 2 NO . V YES/$PO~T . 1 YES/PROBED . 2 NO . $ YES/SPONT . 1 YES/PROBED . 2 NO . • . NO . 2 YES . 1 NO . Z YES . 1 NO . 2 YES . 1 NO . 2 YES . 1 NO . 2 NO . 2 YES . NO . 2 YES . 1 NO . 2 YES.,°,° . .°.H,o.1 NO . 2 YES. . , . ° . , , , ° ° . , . ° . , ° ° , ° . , .1 NO . 2 280 ‘EI,SKw . ‘EWRMD . . D . . IEI,SRYT . ‘ES,PI)OBFO . 10 . ,EI,SPOYT . ,ES,PROBED . M . ES . .I 10 . .2 lEP,SPalT . 10 . IEI . .I lo . .z IES . .1 “0 . .z “ES . .I MO . .* “ES . .I WJ . .z “El . .I w . .* ‘ES . 10 . ‘ES . 10 . ,ES . 10 . 281 IlO. OUtSTIOOE AKO FILTERS I Hive you or y~ur iifl evtr ~4ed anything or tried in I any imly to dilly or Ivold • pr•illmcy? I .d I • _ _ ~ . . i , o | IKIP CODING CATEGORIES I TO I ~1 ilii hive yllJ Sod or ck~eT CI~IfCT lO]-lO~ (I 10~ IF NECESSARy). Io~ I k~Jld like to ilk yo~ i~aout the lime ~hl you PILL . O1 First did •~thlng or used • method (LID . 02 to •vo id i preiRl41ncyT INJECTIONS . . . . . . . . . . . . . . . . . . . . . 03 i~•t method did you use It that tllle~ . .o.0~ DIAPNRAC.~I/FOAM/JELLT . 04 COI~ON . 05 FEHAL[ STERILIZATION . ILl STIIILIZAIION . O# PERIODIC ABSTINENCE . 08 UITHDRAklAL . OQ OTHER 10 (SPECIFY) 2O9 i 210 211 H~ ~ living ¢hlLdre~ did you hive it thot tim, If any? IF HC~E, RECOND *DO'. CHECK 203(07) : HUSiAMO MOT [~ ~USBAMO STERILIZED STERILIZED [~ ! v l Are yo~ and 9our lille curreiltly dOing something or uSing any method to dOlly or ivoid • pregrwlcy? I HUI4SER OF CHILDREN . [ ~ i P21 4 I YES . 1 ~213 I 212 lille II thi lilin rlil~ yOU ~ yllir lift Ire lit Itl • Beth "~ to "i'(iy or •lid • f l y ? /. dZ .¢ . . k;AHTS ()R~E) CHiLDREH . 01- LACK OF KNOWLEDGE . 02 WIFE OPPOSED . O] COST TOO MUCH . 04 ~RY ABOUT SIDE EFFECTS . 05 HEALTH CONCERNS . 06 HARD TO GET METIIOOS . 07 RELIGION . 06 OPPOSED TO FAMILY PLANNING . 09 FATALISTIC . 10 OTHER PEOPLE OPPOSED . 11 [NFREOUENT SEX . 12 HARD FOR riFE TO GET PREONAHT.1] WIFE NENOIIiAUSAL/HAD HYSTRECTMY.I& INCONVENIENT . 15 V[FE IUISENT . 16 WiFE BREASTFEEDIHG . 17 VIEE IS CIJRHEHTLY PREGliANT . 16 OTHER 19 (SPECIFY) OK . . . . . . . . . . . . . . o , . .o* . , * . * . . . .98 p2~ 282 NO. 213 213A ~NJESTION$ AND FILTERS ~ch method ere you using? ~ =-,,/ d~, '-~, ;,0" L~/~, CIRCLE tO71 FOR MALE STERILIZATIOR. SKIP COOING CATEGORIES I TO PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . 01 I IOO . . . . . . . . . . . . . . . . . . . . . . . . . . . . OE-~-~ INJECTIORS . 03~219 DIAPHRAC.#4/FOAM/JELLY . 04 CORDOR . 05 ,216 FEMALE STERILIZATION . 06 MALE STERILIZATION . . . . . . . . . . . . . 07 [-219 PERIODIC ABSTINENCE . 08 : WITHDRAWAL . 09 I~2Z4 OTHER 10 J (SPECIFY) i 21& 00 you kno~ the brand name of the pills your wife Is now using? ?=- (',~" ~ ¢ c: i /~. ; (RECORD NAME OF BRAND.) BRAND NAME DK . 9B How much does one packet of piLLs cost you? : ,=.- c,: "Z ¢ : .EEB . I 216 May I see the package of condoms you ere using no~? (RECORD NAME OF BRAND.) I PACKAGE SEEN . I BRAND NAME ~ 2 1 8 PACKAGE NOT SEEN . 2 | I 217 Do you kno~ the brand name of the condoms you ere now using? i.r - /o (RECORD NAME OF BRAND.) BRAND NAME ~[~ DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 218 Ho~ much do~s one condom cost you? RUPEES . . . . . . . . . . . . . ~'F -~ FREE . . . . . . . . . . . . . . . . . . . . . . . . . 9996 DK . 9998 283 NO. 219 QUESTIONS AND FILTERS CHECK 213: HE/SHE STERILIZED ¥ Where did the steriLizatioh t~ke place? USING ANOTHER METHOD E~ Mhere did you obtain (METHOD) the (sat time? o; '~ (METHOD) ~/U~. (NAME OF HOSPITAL, CLINIC OR CENTER iF CODE 01"05) SKIP CODING CATEGORIES J TO m GOVERNMENT HOSP%TAL/RNSC . OI | RHC/BNU/GOVERIAMENT CLINIC . 02 f FAMILY UELFAME CENTER . 03 NGO CENTER . 04 PRIVATE HOSPITAL OD CLINIC . 05 MOBILE CLINIC/EXTENSION TEAM.06 FIELD N(~KER . 07 IP222 PRIVATE DOCTOR . 08 | HAKIN/HOM(3EOPATN . 09 I DNUGSTODE . 10 SHOP (OTHER THAN ORUGSTOSE).11 TRADITIONAL BIRTH ATTENDANT.12 FRiENDS/RELATIVES . 13 OTHER 14 l (SPECIFY) 222 OK . . . .~ I 220 NOW long does it take to travet from your homm To this place? IF LESS THAN 60 NIWdTES, RECORD MINUTES. OTNERMISE, RECORD HOURS. MINUTES . 1 I i J HOURS . 2 DK . 998 221 222 223 Is it easy or difficult to get there? CHECK 213: USING HE/SHE E~ ANOTHER STERILIZED NETNCO v in what month and year Mas the sterilization operation performed? EASY . 1 OZFFICULT . 2 p224 1 I M(~TH . 235 YEAR . 224 For hem many Ill~ths have you been using (CURRENT I~ETH(I)) contiNousty? IF LESS THAN 1 MONTH, RECORD '00% NONTHS . 8 YEARS OR LONGER . *.235 284 NO. QUESTIONS ANO FILTERS I I m m 225 Do you |need to u~e li method to delay or evotd I • pregnancy et any Elm In the future? I 226 Wh•t ts the Imln remson you(k) not Intend to use • me(hoot/ CODING CATEGOIIIES YES, , , . . . . . . . . . . . . . ° . . . . . . ° °° . . .1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ I OK . . . . . . . . . . . . • . . . . . . . . . . . . . . . .o~ SKIP I TO i ~2211 ~231 I WANTS CHILDREN . 01 LACK OF KNOWLEDGE . 02m~231 WIFE OPPOSED . 0] | COST TOO MUCH . O z. 1 WORRY A~K)UT SIDE EFFECTS . O~| HEALTH CONCERNS . 06.3211 HARD TO GET METHODS . . . . . . . . . . . . O? eet~l~V . O~ | OPPOSED TO FAMXLT PLANNING . 09 ~231 FATALISTIC . 10 | OTHER PEOPLE OPPOSED . 11 I INFREOUE~F SEX . 12 HARD FOR WIFE TO GET PREGNANT. . I~ | UIFE MENOPAUSAL/HAD HYSTRECTMY, I~ INCONVENIENT . I~ 231 OTHER 16 DK . 98 257 If the dec is ion .ere entirety up to you, Mould you want to use a method to detay or avoid a pregnancy It eny tin~ in the future? t . . - i i$ , ~ - ,f I YES . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 231 OK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 ---~ I 228 27P Do you intend to rule a method | within the next 12 months? I J l i nen yoo use • method e uh fch method k~u ld you prefer to use? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 PILL . 01 IUD . O~ INJECTIONS . 03 01APHRAGM/FOAM/JELLY . 04 CONDOM . 05 FEMALE STERILIZATION . . . . . . . . . . . 06 WALE STERZLIZAT ION . O? PERIODIC ABST ] HENCE . 08.- WITHDRAWAL . 09 OTHER 10 (SPEC]FY) UNSURE . 9 ~ ~231 230 Where can you get (METHOD MENTIONED IN 229)? o H<METROS MENTIONED ,. (NAME OF HOSPITAL, CLINIC OS CENTER IF CODE 01-05) GOVERNMENT HOSPITAL/NHSC . 01 RHC/BNUJGOVERNMENT CLINIC . . . . . . 0 ~ FAMILY ~'~LFARE CENTER . 03d233 NOD CENTER . 04 PRIVATE HOSPITAL O~ CLINIC . 05 MOBILE CLINIC/EXTENSION TEAM.nTOT~p FIELD IdORKER . D? 235 PRIVATE DOCTOR . HAKIM/HOMOEOPATH . 09 I DRUGSTORE . I0~10 233 SNOP (OTHER THAN DRUGSTORE).(1[ TRADITIONAL BIRTH ATTENDANT.12 FRIENDS/RELRTIVES . 1 OTHER 14 23S -- (SPECIFY) DK . 98 : 285 NO. I ~BT IORS AND FILTERS I 2.31 I Do y~ know of a pl,ce Where you cl~ obTlin I • IeThod of flmily planning? ~c;, "~=-/c> "u' ~u~, ;ep SKIP I COOING CATEGORIES i To I YEB . 'i WO . 2 235 I 232 Where is th,t? (NAME OF HOSPITAL, CLINIC OR CENTER IF COOE 01"05) GOVERNMENT HOSPJTAL/HHSC . 01 RHC/DHU/GOVERNNEWT CLINIC . 02 FANILY ~LFARE CENTER . 03 NGO CENTER . 04 PRIVATE HOSPITAL O~ CLINIC . 05 kiO~lLE CLINIC/EXTENSION TEAM.,076 ~ FIELD WORKER . 07 ~235 PRIVATE DOCTOR . 08 I HAKIN/HOMOEOPATH . 09 ] DRUGSTORE . 10 SHOP (OTHER THAN CRUGSTORE).11 TRADIT[ORAL BIRTH ATTENDANT.12 FRIENDS/RELATIVES . 13 OTHER 141~235 (SPECIFY) 233 How long does it take to Travel from your h~ tO this place? Y IF LESS THAN 60 MINUTES, RECORD MINUTES. OTHERWISE, RECORD HOURS. MINUTES . . . . . . . . . . . . . . . . . . 1 l i t HOURS . . . . . . . . . . . . . . . . . . . . 2 DR . 998 234 Is it easy or difficulT to get there? I EASY . 1 I I DIFFICULT . 2 235 237 In the InsT ~th, have you heard I ~l;iage ~out family planning on: the r~io? Television? YES RADIO . . . . . . . . . . . . . . . . . . . . . . 1 2 TELEVISION . . . . . . . . . . . . . . . . . 1 2 NOT HEARD NIESSAGE I---I Do you think thmT the message you heard was effecTive or noT effecTive in persuading couples to use fwily planning? EFFECTZVE . 1 NOT EFFECTIVE . 2 OK . 8 "-I 238 Is it accepTable or nOT acceptable TO you for fmlty I planning information TO be provided on the radio or I television? . ~ ACCEPTABLE . 1 C~ (-J.~ (.~'~" L ,~ CJ.~ ~.b; C.4, C, ~ ~ .,~I oKWOT ACCEPTABLE . . . . . . . . . . . . . . . . . . 2 8 cJ. . I 286 ~° 301 SECTION 3: MARRIAGE QUESTIONS ANO FILTERS III DO you have shy other uives besides (NAME OF FIRST ELIGIBLE WIFE FROM COVER PAGE)? (NAME OF FIRST ELIGIBLE UIFE FROM COVER PAGE) ~.; SKIP COOING CATEGORIES TO YES . 1 BO . 2 ~303 I 302 ItOU Iny other wives do you have? I NOMSER . I 303 I Have you been ~errled onty once ~/I I or ~ore thart onceT ,,k;~ ~, ~. dp 2/d., ~,/cs,¢cY~r ! 'F/'I OMCE, . ° .o° . . . . . . . . ° °°o . . . . . . . . . .1 MORE THAN OMCE . 2 304 HOW old were you k~en you started tiring uith your (first) wife? ~l~, ~ ~; ,.-, 2/ ~ j r te/r. ~,.v ~, ,; t. . .C AGE. . . . . . . . . . . . . . . . . . . . . . . . 305 In Hat month and year did you start ,tiv~ng with her? COMPARE 30,; AND 305 WITH 105 AND 106. MAKE CORRECTIONS IF INCONSISTENT. PRESENCE OF OTHERS AT THIS POINT. M(~TH . .°.~'~ OK MONTH . 98 YEAR . I . . [ - - -~ DK YEAR . 98 YES NO CHILB(REN) UNDER 10 . 1 2 VIFE . 1 2 FATHER/BROTHER(S) . 1 Z OTHER MALE(S) . 1 2 OTHER FEMALE(S) . 1 2 10 287 SECTION 4. FERTILITy PREFERENCES 401 How many own soni do you have? And how ~ny own da~hters do you have? IF NONE RECORD '00'. S :::::::::::::::::::::::: I YE, . , UNSURE . 8 404 405 CHECK ~03 : WIFE NOT PREGNANT O~ UNSURE i v NOw I have some o~.~e@tio~s about the future. Wo~td you like to have (a/ar~other) child or ~(qjtd you prefer not to have any (more) chttdren? '-~.~ .d->~ ~ ,/~ ,~, _~. . ; ~.~-f~ WIFE PREGNANT ~] r v Now I have sof~e questions about the future. After the child yc~Jr wife IS expecting, would you llke to have another child or would you prefer riot to have any more children? I HAVE A (ANOTHER) CHILD . . . . . . . . . . 1 | NO~E/RO44E . Z SAYS WIFE CAN'T GET PREGNAWT. . . .3 i UP TO ~ . ~4 410 UNDECIDED (~ DK . I girl BOY . I w~ld y~ prefer your next child to be a ~y or a ~ I or (~esn't it matter? GIRL . 2 l ~ + ~ / J~ t f~ L~ ~ I ~ DOESN'T MATTER . ] " 7 7' _. 406 HOW Long would you Like to walt frown now before the b)rth of (a/another) chltd~ w_ ~.r.i',~<' c / / r---1--I I RONTHS . I I I ~ YEARS . 2 SO(ON/NOW . . . . . . . . . . . . . . . . . . . . . . ~4 SAYS WIFE CAN*T GET PREGNANT.995 OTHER 996 (SPECIFY) DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9981 "410 11 288 NO. (NJESTIOWS ANO FILTERS Do y~J regret that (you/your wife) had the operatIo~ not to have anyv(more) children? G ,.:-. i IE_ .T, ) SKIP I CODING CATEGORIES I TO I + . I NO . 2 ,~09 I RESPOIIDENT WANTS ANOTHER CHILD. . I~ WIFE WANTS ANOTHER CHILO . . . . . . . . 2 40~ Why do yOU regret It? I . , ~ " X -J' - - L )a L~' I .('." L'~ ~ ( ~ . % OTHER SlOE EFFECTS REASON . . . . . . . . . . . . . . . . . . . . + ] +14 (SPECIFY) I Given your present clrcueltincea, tf you had to do it over agilin, do you think yoq would make the saeie decision to have m sterilization? f , Zd- t " -~ F #_ ,i<~,u: u; I YES . 1 ~414 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ! 410 Do you think that your wife approves or disapproves of co~ples using a method to avoid pregnancy? ?- • ~, ~ -+.+']~, ,¢u~v- , + ~ . v:,+, , APPROVE6 . 1 DISAPPROVES . 2 DK . 8 411 Xow often have you talked to your wife abo~t family planning in the past year? / NEVER . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ORCE OR TWICE . . . . . . . . . . . . . . . . . . . 2 MORE OFTEN . . . . . . . . . . . . . . . . . . . . . . ] 412 I Have you and your wife ever d~acussed | YES . 1 I the number of children you would like to have? I -- ~ ,.+,- , , , / , L+o~ j ,+ . . ; ,,, ~ : , .o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . z ? ' L- ' ! ~ . J 413 DO you think your wife wants the s~ number of children that you want, or does she want more or fever than you want? ._+o,+ < ++ ] " SAME NiJ~JIER, . 1 NORE CHILOREN . 2 FEliER CHILDREN . , . ~ . 3 OK . 8 12 289 414 HOW tong should a husband and wife wait before itirting sexual inter¢oclrse after the birth of a baby? (iF ANSId~R IS RUNERIC, CODE DAYS C~ k~THS OR YEARS) DAYS . 1 MONTHS . 2 YEARS . 3 OTHER (SPECIFY) 996 415 416 Sh~Jtd I mother Vail until she has compLeteLy stopped breaitfNding before starting to have sexual relations again, or doesn=t it matter? ; ~'2- ~.: In generaL, do you approve or disapprove of coupLea usino a Imthod to IVOld prltlet'cy? WAIT . 1 DCESM'T HATTER . 2 APPROVE . 1 DISAPPROVE . 2 417 CHECK 401: 140 LIVIMG CHILDREN [~ / If you could choose exactly the number of children to have in your uhote tife, hou mmny u~Jtd that be? o:, J. ~. ~ I~ r/, ,So/. HAS LIVING CHILDREN [---j 1 I v If you could go beck to the time you did not have any children and could choose exactly the number of children to have in your k~ole Life, how n~ny uoutd that be? ,,i Z ~; 4d/£~ ~ . . I r " NUNBER . UP TOG O D, ALLAH . 95- OTHER ANSWER 96 (SPECIFY) ~419 418 HOW many of these children would you Like to be boys and ho~ iny would you Like to be girls? / BOYS GIRLS EITHER --""1--1--1 [--I--I m UP TOG 0 D, ALLAH . 999995 OTHER 999996 (SPECIFY) 13 290 NO. 419 ~UEST)O~S AND FILTERS II We would like to know how much ach~Ling you expect your children To have. (IF HOT STERILIZED: consider the children you atreacly have and also any children that you might have in The future). First, Let*l tltk ab~Jt sons. t/hat is the highest Level of school that you would expect any of your sons to attend? iF N0Y STERILiZEO ) .£ ~ ~ .~'~. "- , ~. ~- x r" -( ,.e- r CC[~)MGCATEGO~IES NONE.°°° . °o . ° . *.1 PRIMARy SCHOUL . 2 MIDDLE sCHOOL . . . . . . . . . . . . . . . . . . . 3 SECONDARY SCHOOL . . . . . . . . . . . . . . . . 4 HIGHER . . . . . . . . . . . . . . . . . . . . . . . . . . 5 OTHER 6 (SPECIFY) DK . . . . . . . . . . o , . . . . . . . ° * . ° . . . . . . . 8 SKIP TO 420 And how about daughters? What is the highest Level of schooling that you would expect any of your daughters to attend? LIJ -r----or" o .-~. d ,.,r~ ~:~,~ E-~. r NONE . 1 PRIMARy SCHOOL . 2 MIGDL£ SCHOOL . 3 SECONDARY SCHOOL . 4 HIGHER . 5 OTHER 6 (SPECIFY) DK . 8 421 What do you think is the ideal age at marriage for boys? /UI " " iDEAL AGE IN YEARS . I I I OTHER 96 (SPECIFY) 422 423 And Hat is the ideal age at marriage For girts? • j / • ]f your wife needed to go to • health clinic or • hosoitet, could she go by herself or w~utd she to be eccompented by someone else? IGEAL AGE IN YEARS . I [ J OTHER 96 (SPECIFY) COULD GO BY SELF . 1 WOULD HEED TO BE ACCOMPANIED.2 iT DEPENDS . 3 424 RECORD THE CURRENT TIME, • HOUR . , MINUTES 14 291 Comments About Respondent: INTERVIEWERIS OBSERVATIONS (To be filled in after completing interview) comments on Specific Questions: Any Other Comments: SUPERVISORIS OBSERVATIONS Name of Supervisor: [~te: 292 Front Matter Title Page Contact Information Table of Contents List of Tables List of Figures Preface Acknowledgments Summary of Findings Map of Pakistan Chapter 01 - Introduction Chapter 02 - Survey Design and Implementation Chapter 03 - Characteristics of Households and Respondents Chapter 04 - Fertility Chapter 05 - Knowledge and Use of Family Planning Chapter 06 - Family Planning Attitudes Chapter 07 - Proximate Determinants of Fertility Chapter 08 - Family Size Preferences Chapter 09 - Infant and Child Mortality Chapter 10 - Maternal and Child Health Chapter 11 - Feeding Patterns and the Nutritional Status of Children Chapter 12 - Husbands' Survey Appendix A - Pakistan Demographic and Health Survey Staff Appendix B - Estimates of Sampling Errors Appendix C - Data Quality Tables Appendix D - Questionnaires Household Questionnaire Woman's Questionnaire Husband's Questionnaire

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