Pakistan - Demographic and Health Survey - 2008

Publication date: 2008

Pakistan Demographic and Health Survey 2006-07 Pakistan Demographic and Health Survey 2006-07 National Institute of Population Studies Islamabad, Pakistan Macro International Inc. Calverton, Maryland USA June 2008 NIPS This report summarizes the findings of the 2006-07 Pakistan Demographic and Health Survey (PDHS) carried out by the National Institute of Population Studies. The Government of Pakistan provided financial assistance in terms of in-kind contribution of government staff time, office space, and logistical support. Macro International provided financial and technical assistance for the survey through the MEASURE DHS programme, which is funded by the U.S. Agency for International Development (USAID) and is designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. Additional support for the PDHS was received from the United Nations Population Fund (UNFPA)/Pakistan and from UNICEF/Pakistan. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of the donor organisations. Additional information about the survey may be obtained from the National Institute of Population Studies (NIPS), Block 12-A, Capital Inn Building, G-8 Markaz, P.O. Box 2197, Islamabad, Pakistan (Telephone: 92-51-926-0102 or 926-0380; Fax: 92-51-926-0071; Internet:: www.nips.org.pk) Information about the DHS programme may be obtained from MEASURE DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, U.S.A. (Telephone: 1-301-572-0200; Fax: 1-301-572-0999; E-mail: reports@macrointernational.com; Internet: measuredhs.com). Suggested citation: National Institute of Population Studies (NIPS) [Pakistan], and Macro International Inc. 2008. Pakistan Demographic and Health Survey 2006-07. Islamabad, Pakistan: National Institute of Population Studies and Macro International Inc. CONTENTS Page TABLES AND FIGURES . ix FOREWORD . xv ACKNOWLEDGMENTS . xvii SUMMARY OF FINDINGS . xix MAP OF PAKISTAN . xxvi CHAPTER 1 INTRODUCTION Shahid Munir and Khalid Mehmood 1.1 Geography, Climate, and History . 1 1.2 Economy and Population . 2 1.3 Organization and Implementation of the 2006-07 PDHS . 3 1.3.1 Objectives of the Survey . 3 1.3.2 Institutional Framework . 4 1.3.3 Sample Design . 4 1.3.4 Questionnaires . 5 1.3.5 Training of Field Staff . 7 1.3.6 Field Supervision and Monitoring. 7 1.3.7 Fieldwork and Data Processing . 8 1.3.8 Field Problems . 8 1.4 Response Rates . 9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Aysha Sheraz and Zafar Zahir 2.1 Household Population by Age and Sex . 11 2.2 Household Composition . 14 2.3 Education of the Household Population . 16 2.3.1 Educational Attainment of Household Population . 16 2.3.2 School Attendance Ratios . 18 2.4 Housing Characteristics . 21 2.5 Household Possessions . 24 2.6 Socioeconomic Status Index . 25 2.7 Availability of Services in Rural Areas . 26 2.8 Registration with the National Database and Registration Authority . 27 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Zahir Hussain and Zafar Iqbal Qamar 3.1 Characteristics of Survey Respondents . 29 3.2 Educational Attainment and Literacy . 30 3.3 Employment . 33 3.3.1 Employment Status . 33 Contents | iii 3.3.2 Occupation . 36 3.3.3 Type of Earnings . 37 3.3.4 Employment before and after Marriage . 37 3.4 Knowledge and Attitudes Concerning Tuberculosis . 39 CHAPTER 4 FERTILITY Syed Mubashir Ali and Ali Anwar Buriro 4.1 Current Fertility . 41 4.2 Fertility Trends . 44 4.3 Children Ever Born and Children Surviving . 46 4.4 Birth Intervals . 48 4.5 Age at First Birth . 49 4.6 Teenage Fertility . 51 CHAPTER 5 FAMILY PLANNING Iqbal Ahmad and Mumtaz Eskar 5.1 Knowledge of Contraceptive Methods . 53 5.2 Ever Use of Family Planning Methods . 55 5.3 Current Use of Contraceptive Methods . 56 5.4 Differentials in Contraceptive Use by Background Characteristics . 58 5.5 Use of Social Marketing Contraceptive Brands . 60 5.6 Timing of Sterilization . 61 5.7 Source of Contraception . 62 5.8 Cost of Contraceptive Methods . 63 5.9 Informed Choice . 64 5.10 Future Use of Contraception . 65 5.11 Reasons for Not Intending to Use . 65 5.12 Exposure to Family Planning Messages . 66 5.13 Contact of Nonusers with Family Planning Providers . 68 CHAPTER 6 OTHER DETERMINANTS OF FERTILITY Mehboob Sultan and Mubashir Baqai 6.1 Marital Status . 69 6.2 Polygyny . 70 6.3 Consanguinity . 70 6.4 Age at First Marriage . 72 6.5 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 73 CHAPTER 7 FERTILITY PREFERENCES Syed Mubashir Ali and Faateh ud din Ahmad 7.1 Desire for More Children . 77 7.2 Need for Family Planning . 81 7.3 Ideal Number of Children . 83 7.4 Wanted and Unwanted Fertility . 86 iv � Contents CHAPTER 8 INFANT AND CHILD MORTALITY Zulfiqar A. Bhutta, Anne Cross, Farrukh Raza, and Zafar Zahir 8.1 Data Quality . 89 8.2 Levels and Trends in Infant and Child Mortality . 90 8.3 Socioeconomic Differentials in Infant and Child Mortality . 91 8.4 Demographic Differentials in Infant and Child Mortality . 92 8.5 Perinatal Mortality . 93 8.6 High-risk Fertility Behaviour . 95 8.7 Causes of Death of Children Under Five . 96 8.7.1 Methodology . 96 8.7.2 Results . 97 8.8 Causes of Stillbirths . 100 8.9 Implications of the Findings . 100 CHAPTER 9 REPRODUCTIVE HEALTH Rabia Zafar and Anne Cross 9.1 Prenatal Care . 101 9.1.1 Number and Timing of Prenatal Visits . 103 9.1.2 Components of Prenatal Care . 104 9.1.3 Reasons for Not Receiving Prenatal Checkups . 106 9.1.4 Tetanus Toxoid Vaccinations . 107 9.1.5 Complications during Pregnancy . 108 9.2 Delivery Care . 111 9.2.1 Preparedness for Delivery . 111 9.2.2 Place of Delivery . 112 9.2.3 Reasons for Not Delivering in a Facility . 114 9.2.4 Use of Home Delivery Kits . 115 9.2.5 Assistance during Delivery . 116 9.3 Postnatal Care . 118 9.3.1 Timing of First Postnatal Checkups . 118 9.3.2 Complications during Delivery and the Postnatal Period . 120 9.3.3 Fistula . 121 CHAPTER 10 CHILD HEALTH Arshad Mahmood and Mehboob Sultan 10.1 Birth Weight . 123 10.2 Child Immunization . 124 10.2.1 Vaccination Coverage . 125 10.2.2 Differentials in Vaccination Coverage . 126 10.2.3 Trends in Vaccination Coverage . 128 10.3 Childhood Diseases . 129 10.3.1 Prevalence and Treatment of ARI . 129 10.3.2 Prevalence and Treatment of Fever . 131 10.3.3 Prevalence of Diarrhoea . 133 10.3.4 Treatment of Diarrhoea . 134 10.3.5 Feeding Practices during Diarrhoea. 136 Contents | v CHAPTER 11 NUTRITION Syed Mubashir Ali and Mehboob Sultan 11.1 Breastfeeding and Supplementation . 139 11.1.1 Initiation of Breastfeeding . 139 11.1.2 Breastfeeding Patterns. 141 11.1.3 Complementary Feeding . 144 11.2 Micronutrient Intake . 144 11.2.1 Micronutrient Intake among Children . 145 11.2.2 Micronutrient Intake among Women . 145 CHAPTER 12 MALARIA Mehboob Sultan and Syed Mubashir Ali 12.1 Household Ownership of Mosquito Nets . 147 12.2 Use of Mosquito Nets and Other Repellents . 148 12.3 Malaria Prevalence and Treatment during Pregnancy . 151 12.4 Malaria Case Management among Children . 151 CHAPTER 13 KNOWLEDGE OF HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS Faateh ud din Ahmad and Adnan Ahmad Khan 13.1 Knowledge of AIDS . 155 13.2 Knowledge of Ways to Avoid Contracting HIV/AIDS . 157 13.3 Comprehensive Knowledge of HIV/AIDS Transmission . 159 13.4 Knowledge of Mother-to-Child Transmission . 160 13.5 Attitudes towards People Living with HIV/AIDS . 162 13.6 Knowledge of Sexually Transmitted Infections . 163 13.7 Safe Injection Practices. 164 CHAPTER 14 ADULT AND MATERNAL MORTALITY Farid Midhet and Sadiqua N.Jafarey, Dr. Azra Ahsan, Aysha Sheraz 14.1 Introduction . 167 14.2 Methods of Data Collection . 169 14.2.1 Development and Validation of the VA Questionnaire . 169 14.2.2 Implementation of VAs in Sample Households . 170 14.2.3 Review of VA Questionnaires and Assignment of Causes of Death . 171 14.3 Adult Mortality Rates . 172 14.4 Response to the Verbal Autopsy . 174 14.5 Causes of Death Among Women Age 12-49 . 175 14.6 Pregnancy-Related Mortality and Maternal Mortality . 177 14.7 Discussion . 180 REFERENCES . 183 APPENDIX A ADDITIONAL TABLES . 189 vi � Contents Contents | vii APPENDIX B SAMPLING IMPLEMENTATION . 185 APPENDIX C ESTIMATES OF SAMPLING ERRORS . 197 APPENDIX D DATA QUALITY TABLES . 209 APPENDIX E PERSONS INVOLVED IN THE 2006-07 PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY . 215 APPENDIX F QUESTIONNAIRES . 221 TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 12 Table 2.2 Household population by age, sex, and province . 13 Table 2.3 Sex ratios by age . 13 Table 2.4 Trends in age distribution of household population . 14 Table 2.5 Household composition . 15 Table 2.6 Children's orphanhood. 16 Table 2.7.1 Educational attainment of the female household population . 17 Table 2.7.2 Educational attainment of the male household population . 18 Table 2.8 School attendance ratios . 19 Table 2.9 Household drinking water . 21 Table 2.10 Household sanitation facilities . 22 Table 2.11 Housing characteristics . 23 Table 2.12 Household durable goods . 25 Table 2.13 Wealth quintiles . 26 Table 2.14 Availability of services in rural areas . 27 Table 2.15 Registration with NADRA . 28 Figure 2.1 Population Pyramid . 12 Figure 2.2 Age-Specific Attendance Rates of the De-Facto Population Age 5 to 24 Years . 20 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 30 Table 3.2 Educational attainment . 31 Table 3.3 Literacy . 33 Table 3.4 Employment status . 34 Table 3.5 Occupation. 36 Table 3.6 Type of earnings . 37 Table 3.7 Employment before and after marriage . 38 Table 3.8 Knowledge and attitudes concerning tuberculosis . 39 Figure 3.1 Women’s Employment Status in the Past 12 Months . 35 Figure 3.2 Women's Current Employment by Residence and Education . 35 CHAPTER 4 FERTILITY Table 4.1 Current fertility . 42 Tables and Figures | ix Table 4.2 Fertility by background characteristics . 43 Table 4.3 Current marital fertility . 44 Table 4.4 Trends in fertility . 45 Table 4.5 Trends in fertility by background characteristics . 46 Table 4.6 Trends in age-specific fertility rates . 46 Table 4.7 Children ever born and living . 47 Table 4.8 Trends in children ever born . 48 Table 4.9 Birth intervals . 49 Table 4.10 Age at first birth . 50 Table 4.11 Median age at first birth . 50 Table 4.12 Teenage pregnancy and motherhood . 51 Figure 4.1 Total Fertility Rate by Background Characteristics . 44 Figure 4.2 Trends in Total Fertility Rates . 45 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 53 Table 5.2 Knowledge of contraceptive methods by background characteristics . 54 Table 5.3 Trends in knowledge of contraceptive methods . 55 Table 5.4 Ever use of contraception . 56 Table 5.5 Current use of contraception by age . 56 Table 5.6 Current use of contraception by background characteristics . 59 Table 5.7 Use of social marketing brand pills and condoms . 61 Table 5.8 Timing of sterilization . 61 Table 5.9 Source of modern contraception methods . 62 Table 5.10 Cost of modern contraceptive methods . 63 Table 5.11 Informed choice . 64 Table 5.12 Future use of contraception . 65 Table 5.13 Reason for not intending to use contraception in the future . 66 Table 5.14 Exposure to family planning messages . 67 Table 5.15 Family planning messages . 67 Table 5.16 Contact of nonusers with family planning providers . 68 Figure 5.1 Trends in Contraceptive Use . 57 Figure 5.2 Trends in Current Use of Specific Methods among Married Women . 58 Figure 5.3 Differentials in Contraceptive Use .60 CHAPTER 6 OTHER DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 69 Table 6.2 Cohabitation and polygyny . 70 Table 6.3 Marriage between relatives . 71 Table 6.4 Age at first marriage . 72 Table 6.5 Median age at first marriage . 73 Table 6.6 Postpartum amenorrhoea, abstinence, and insusceptibility . 74 Table 6.7 Median duration of postpartum amenorrhoea, abstinence, and insusceptibility . 75 Table 6.8 Menopause . 75 Table 6.9 Pregnancy terminations . 76 x | Tables and Figures CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 78 Table 7.2 Desire to limit childbearing . 80 Table 7.3 Desire to limit childbearing by sex of living children . 82 Table 7.4 Need and demand for family planning among currently married women . 83 Table 7.5 Ideal number of children . 85 Table 7.6 Mean ideal number of children . 86 Table 7.7 Couple's agreement on family size . 87 Table 7.8 Fertility planning status . 88 Table 7.9 Wanted fertility rates . 89 Figure 7.1 Fertility Preferences of Currently Married Women Age 15-49 . 78 Figure 7.2 Desire to Limit Childbearing among Currently Married Women, by Number of Living Children . 79 Figure 7.3 Percentage of Ever-Married Women with Four Children Who Want No More Children, by Background Characteristics . 81 Figure 7.4 Trends in Unmet Need for Family Planning . 84 Figure 7.5 Mean Ideal Number of Children, by Background Characteristics . 87 Figure 7.6 Total Wanted Fertility Rate and Total Fertility Rate . 89 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 90 Table 8.2 Trends in infant and under-five mortality rates . 91 Table 8.3 Early childhood mortality rates by socioeconomic characteristics . 91 Table 8.4 Early childhood mortality rates by demographic characteristics . 93 Table 8.5 Perinatal mortality . 94 Table 8.6 High-risk fertility behaviour . 96 Table 8.7 Child verbal autopsy response rates . 98 Table 8.8 Causes of child deaths by age . 98 Table 8.9 Causes of under five deaths by sex and residence . 99 Table 8.10 Causes of under five deaths by province . 100 Table 8.11 Causes of stillbirth . 100 Figure 8.1 Differentials in Under-Five Mortality . 92 CHAPTER 9 REPRODUCTIVE HEALTH Table 9.1 Prenatal care . 102 Table 9.2 Number of prenatal care visits and timing of first visit . 104 Table 9.3 Components of prenatal care . 105 Table 9.4 Reasons for not getting prenatal care . 106 Table 9.5 Tetanus toxoid injections . 107 Table 9.6 Pregnancy complications . 109 Table 9.7 Pregnancy complications and place of treatment . 110 Table 9.8 Pregnancy complications and reasons for no treatment . 111 Table 9.9 Preparations for delivery . 112 Table 9.10 Place of delivery . 113 Table 9.11 Reasons for not delivering in a facility . 115 Tables and Figures | xi Table 9.12 Use of home delivery kits . 116 Table 9.13 Assistance during delivery . 117 Table 9.14 Timing of first postnatal checkup . 119 Table 9.15 Type of provider of first postnatal checkup . 120 Table 9.16 Complications during delivery and postnatal period . 121 Table 9.17 Fistula . 122 Figure 9.1 Source of prenatal care . 103 Figure 9.2 Percentage of Births Protected against Tetanus, by Wealth Quintile . 107 Figure 9.3 Complications during Pregnancy for the Most Recent Birth . 110 Figure 9.4 Percentage of Births Delivered at a Health Facility, by Residence, Province, and Mother’s Education . 114 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth . 124 Table 10.2 Vaccinations by source of information . 125 Table 10.3 Vaccinations by background characteristics . 127 Table 10.4 Trends in vaccination coverage . 128 Table 10.5 Prevalence and treatment of symptoms of ARI . 130 Table 10.6 Prevalence and treatment of fever . 132 Table 10.7 Prevalence of diarrhoea . 134 Table 10.8 Diarrhoea treatment . 135 Table 10.9 Feeding practices during diarrhoea . 137 Figure 10.1 Percentage of Children 12-23 Months Who Received Specific Vaccines Any Time Before Survey . 126 Figure 10.2 Percentage of Children Age 12-23 Months Who Are Fully Immunized, by Background Characteristics . 128 Figure 10.3 Prevalence of Acute Respiratory Infection (ARI) and Fever in the Two Weeks Prior to Survey by Age of Child . 131 Figure 10.4 Percentage of Children with Acute Respiratory Infection and Fever Taken to Health Facility . 131 Figure 10.5 Children under Five with Fever . 133 CHAPTER 11 NUTRITION Table 11.1 Initial breastfeeding . 140 Table 11.2 Breastfeeding status by age . 142 Table 11.3 Median duration and frequency of breastfeeding . 143 Table 11.4 Foods and liquids consumed by children . 144 Table 11.5 Micronutrient intake among children . 145 Table 11.6 Micronutrient intake among mothers . 146 Figure 11.1 Among Last Children Born in the Five Years Preceding the Survey Who Ever Received a Prelacteal Liquid, the Percentage Who Received Various Types of Liquids . 141 Figure 11.2 Infant Feeding Practices by Age . 142 xii | Tables and Figures CHAPTER 12 MALARIA Table 12.1 Ownership of mosquito nets . 148 Table 12.2 Use of mosquito nets by children . 149 Table 12.3 Use of mosquito nets by women . 150 Table 12.4 Other anti-mosquito actions . 150 Table 12.5 Prevalence of malaria during pregnancy . 151 Table 12.6 Prevalence and prompt treatment of fever . 152 Table 12.7 Type and timing of antimalarial drugs . 153 CHAPTER 13 KNOWLEDGE OF HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS Table 13.1 Knowledge of AIDS . 156 Table 13.2 Knowledge of HIV prevention methods . 158 Table 13.3 Comprehensive knowledge about AIDS . 160 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 161 Table 13.5 Accepting attitudes towards those living with HIV/AIDS . 162 Table 13.6 Knowledge of sexually transmitted infections (STIs) and STI symptoms . 163 Table 13.7 Prevalence of medical injections . 164 Figure 13.1 Percentage of Ever-Married Women Who Have Heard of AIDS, by Background Characteristics . 157 Figure 13.2 Percentage of Ever-Married Women Who Know of Specific Ways to Prevent HIV/AIDS . 159 Figure 13.3 Source of Last Medical Injection . 165 Figure 13.4 Percentage of Women Whose Last Injection Was Given with a Syringe and Needle Taken from a New, Unopened Package, by Type of Facility Where Last Injection Was Received . 166 CHAPTER 14 ADULT AND MATERNAL MORTALITY Table 14.1 Previous sources of data on the maternal mortality ratio . 168 Table 14.2 Adult mortality . 172 Table 14.3 Adult women verbal autopsy response rates . 174 Table 14.4 Respondents for the adult women verbal autopsies . 175 Table 14.5 Causes of adult female deaths by age group . 175 Table 14.6 Causes of adult female deaths by residence . 176 Table 14.7 Causes of adult female deaths by province . 176 Table 14.8 Pregnancy-related mortality rates and ratios by age . 178 Table 14.9 Maternal mortality rates and ratios by age . 178 Table 14.10 Pregnancy-related mortality rates and ratios by residence . 179 Table 14.11 Maternal mortality rates and ratios by residence . 179 Table 14.12 Causes of maternal deaths . 180 Figure 14.1 Mortality Rates by Age Group for Women and Men Age 15-49 . 173 Figure 14.2 Mortality Rates by Age Group for Women Age 15-49, Pakistan 2005 and 2006-07 . 173 Figure 14.3 Mortality Rates by Age Group for Men Age 15-49, Pakistan 2005 and 2006-07 . 174 Tables and Figures | xiii xiv | Tables and Figures APPENDIX A ADDITIONAL TABLES Table A.1 Educational attainment of the total household population . 189 Table A.2 Household drinking water . 190 Table A.3 Household sanitation facilities, . 191 Table A.4 Housing characteristics . 192 Table A.5 Household durable goods . 193 APPENDIX B SAMPLE IMPLEMENTATION Table B.1 Sample implementation . 195 APPENDIX C ESTIMATES OF SAMPLING ERRORS Table C.1 List of selected variables for sampling errors for the women sample . 200 Table C.2 Sampling errors for national sample . 201 Table C.3 Sampling errors for urban sample . 202 Table C.4 Sampling errors for rural sample . 203 Table C.5 Sampling errors for Punjab sample . 204 Table C.6 Sampling errors for Sindh sample . 205 Table C.7 Sampling errors for NWFP sample . 206 Table C.8 Sampling errors for Balochistan sample . 207 APPENDIX D DATA QUALITY TABLES Table D.1 Household age distribution . 209 Table D.2 Age distribution of eligible and interviewed women . 210 Table D.3 Completeness of reporting . 210 Table D.4 Births by calendar years . 211 Table D.5 Reporting of age at death in days . 212 Table D.6 Reporting of age at death in months . 213 Foreword | xv FOREWORD The 2006-07 Pakistan Demographic and Health Survey (PDHS) is the fifth in a series of demographic surveys conducted by the National Institute of Population Studies (NIPS) since 1990. However, the PDHS 2006-07 is the second survey conducted as part of the worldwide Demographic and Health Surveys programme. The survey was conducted under the aegis of the Ministry of Population Welfare and implemented by the National Institute of Population Studies. Other collaborating institutions include the Federal Bureau of Statistics, the Aga Khan University, and the National Committee for Maternal and Neonatal Health. Technical support was provided by Macro International Inc. and financial support was provided by the United States Agency for International Development (USAID). The United Nations Population Fund (UNFPA) and United Nations Children's Fund (UNICEF) provided logistical support for monitoring the fieldwork for the PDHS. The 2006-07 PDHS supplements and complements the information collected through the censuses and demographic surveys conducted by the Federal Bureau of Statistics. It updates the available information on population and health issues, and provides guidance in planning, implementing, monitoring and evaluating health and population programmes in Pakistan. Some of the findings of the PDHS may seem at variance with data compiled by other sources. This may be due to differences in methodology, reference period, wording of questions and subsequent interpretation. This fact may be kept in mind while analyzing and comparing PDHS data with other sources. The results of the survey assist in the monitoring of the progress made towards meeting the Millennium Development Goals (MDGs). The 2006-07 PDHS includes topics related to fertility levels and determinants, family planning, fertility preferences, infant, child and maternal mortality and their causes, maternal and child health, immunization and nutritional status of mothers and children, knowledge of HIV/AIDS, and malaria. The 2006-07 PDHS also includes direct estimation of maternal mortality and its causes at the national level for the first time in Pakistan. The survey provides all other estimates for national, provincial and urban-rural domains. This being the fifth survey of its kind, there is considerable trend information on reproductive health, fertility and family planning over the past one and a half decades. The survey is the result of concerted effort on the part of various individuals and institutions, and it is with great pleasure that we would like to acknowledge the work that has gone into producing this useful document. The participation and cooperation that was extended by the Technical Advisory Committee during different phases of the survey is greatly appreciated. We would like to extend our appreciation to USAID/Pakistan for providing financial support for the survey. We extend our sincere thanks to Macro International Inc. for their technical support. The earnest effort put forth by the core team of the PDHS in the timely completion of the study is highly appreciated. We would also like to admire the ceaseless efforts of the entire staff of NIPS and their dedication in the successful completion of the 2006-07 PDHS. This report serves not only as a valuable reference but is a call for effective action both for the health and population programmes of the country. (Nayyar Agha) (Khushnood Akhtar Lashari) Secretary, Secretary, Ministry of Population Welfare Ministry of Health ACKNOWLEDGMENTS The 2006-07 Pakistan Demographic and Health Survey (PDHS) is the result of the ceaseless efforts of different individuals and organizations. The survey was conducted under the aegis of the Ministry of Population Welfare and implemented by the National Institute of Population Studies (NIPS). The United States Agency for International Development provided financial support through its mission in Pakistan. The United Nations Population Fund (UNFPA) and United Nations Children Funds (UNICEF) provided logistic support for monitoring the fieldwork of the survey. The Federal Bureau of Statistics (FBS) provided assistance in the selection of the sample and household listing for the sampled primary sampling units. Technical assistance for the survey was provided by Macro International Inc. USA. To all these agencies, NIPS is highly indebted. We express our deep sense of appreciation to the technical experts in the different fields of population and health for their valuable input during various phases of the survey including the finali- zation of questionnaires, training of field staff, reviewing the preliminary results and providing valuable inputs and finalizing the report. The input provided by the Technical Advisory Committee is highly appreciated. The fieldwork of the survey spanned a six-month period during which the entire staff of NIPS and the fieldwork force worked relentlessly with full devotion and commitment. The efforts of the supporting staff including Ms. Rabia Zafar, Questionnaire Coordinator, and Mr. Asif Amin and Mr. Muhammad Arif, Office Coordinators, were instrumental in organizing a disciplined training pro- gramme, dispatching questionnaires to the data collection teams and managing the completed ques- tionnaires and tracking their movement. We acknowledge the contribution of each one of them with appreciation. The administrative and financial staff of the Institute made it possible to release funds on time and make logistic arrangements for the fieldwork. The contribution of Mr. Iqbal Ahmad, Director (HRD), Mr. Amanullah Bhatti, Secretary (Management and Finance) and Mr. Muhammad Hafiz Khokar, Accounts Officer, is appreciated and acknowledged with thanks. Monitoring the fieldwork of the survey was an arduous job assigned to the core team members including Mr. Zahir Hussain, Ms. Aysha Sheraz, Mr. Zafar Zahir, Mr. Zafar Iqbal Qamar, Mr. Ali Anwar Buriro, and Mr. Mubashir Baqai. Each one of them showed full commitment and devotion and we appreciate their contribution in the survey. We appreciate and acknowledge the untiring efforts, interest, and dedication of Mr. Faateh ud din Ahmad and his data processing team, including Mr. Zahid Zaman, Deputy Data Entry Supervisor, Mr. Muhammad Shoaib Khan Lodhi, and Mr. Takasur Amin, Assistant Data Entry Supervisors. Mr. Faateh ud din also contributed in the generation of final tables for the main report. Dr. Tauseef Ahmed, Consultant for Macro International, remained with the project from the initial stage through the completion of the fieldwork and provided immense help, support and tech- nical assistance for which we are highly thankful. Ms. Anne Cross, Macro International, was a source of inspiration and encouragement throughout the survey operation. We acknowledge with deep grati- tude and thanks, the relentless and committed efforts of Ms. Cross who provided immense moral support and technical assistance at each stage of the project. We are thankful to Ms. Jeanne Cushing for all her work on data processing, analysis, production of tables for the report, and training of staff. We would also like to thank Dr. Alfredo Aliaga for computing the sampling error tables and providing technical input in the design of the study. Thanks also go to Ms. Joy Fishel, Ms. Kaye Mitchell, Ms. Melissa McCormack, Dr. Sidney Moore, Mr. Chris Gramer, Mr. Andrew Inglis, and Ms. Avril Acknowledgments | xvii xviii | Acknowledgments Armstrong for assisting with developing, reviewing, editing, formatting, and proofreading this report. We would also like to thank those involved in analyzing the verbal autopsies, including Dr. Zulfiqar Bhutta, Ms. Arjumand Rizvi, Mr. Farrukh Raza, Dr. Sadiqua N. Jafarey, Dr. Farid Midhet, and Dr. Azra Ahsan. Dr. Saeed Shafqat, former Executive Director of the Institute, initiated the project, created an environment of team work at NIPS, brought together health and population experts from all over the country, steered the implementation of the project as a consultative process, and encouraged and facilitated the core team to put in their best and complete the survey on time. We express our gratitude for his sincere leadership and professional approach. We are deeply indebted to Mrs. Sarod Lashari, Additional Secretary, Ministry of Population Welfare/Executive Director, NIPS for her guidance, support, and personal interest needed to maintain the speed of the project. (Mehboob Sultan) Project Director (Syed Mubashir Ali) Principal Investigator SUMMARY OF FINDINGS The 2006-07 Pakistan Demographic and Health Survey (PDHS) is the largest household- based survey ever conducted in Pakistan. Teams visited 972 sample points across Pakistan and collected data from a nationally representative sample of over 95,000 households. Such a large sample size was required to measure the maternal mortality ratio at the national level. In fact, this is the first survey that provides direct estimates of the maternal mortality ratio at the national level. The PDHS is the fifth national survey on demographic and health issues carried out by the National Institute of Population Studies (NIPS) and the second survey as part of the worldwide Demographic and Health Survey (DHS) project. The primary purpose of the 2006-07 PDHS is to furnish policymakers and planners with detailed information on fertility, family planning, infant, child and adult mortality, maternal and child health, nutrition, and knowledge of HIV/AIDS and other sexually transmitted infections. The Woman’s Questionnaire was administered to 10,023 ever-married women of reproductive age. FAMILY PLANNING Nearly all Pakistani women know of at least one method of contraception. Contraceptive pills, injectables, and female sterilization are known to over 85 percent of currently married women, while somewhat lower proportions report know- ing about the IUD and condoms. A higher pro- portion of respondents report knowing a modern method than a traditional method. Almost half of currently married women have ever used a family planning method, with most women having ever used a modern method (39 percent). The methods most commonly ever used by currently married women are condom, withdrawal, and the rhythm method. Three in ten currently married women re- ported using a method of contraception at the time of survey. Nearly three-fourths of these women were using a modern method. The most widely used method is female sterilization (8 percent), followed by the condom (7 percent). Use of male sterilization and the more recently introduced method of implants is negligible. The use of modern contraceptive methods among currently married women increased from 9 percent in 1990-91 to 22 percent in 2006-07. The use of contraception is higher in urban areas and among women with higher levels of education. It also increases with age and parity. Contraceptive use increases from 16 percent of currently married women in the lowest wealth quintile to 43 percent of those in the highest quintile. The government sector remains the major source of contraceptive methods, with 48 percent of users of modern methods going to a public source compared with 30 percent who use private medical sources. Government sources largely supply long-term methods such as female sterilization, IUDs, and injectables. Half of the currently married women who were not using any family planning method at the time of the survey said they intend to use a method in the future. Among currently married nonusers who do not intend to use a method of contraception in the future, a majority cited fertility-related reasons, primarily responses like “it is up to God” or responses related to sub- fecundity or infecundity. Twenty-three percent of women cited opposition to use, especially reli- gious opposition, while 12 percent do not intend to use because of method-related reasons, pri- marily fear of side effects. In spite of an almost threefold increase in the contraceptive prevalence rate over the past 16 years, there continues to be considerable scope for increased use of family planning. Twenty- five percent of currently married women in Pakistan have an unmet need for family planning services, of which 11 percent have a need for spacing and 14 percent have a need for limiting. Overall, 55 percent of Pakistani women have a demand for family planning. In other words, only just over half of the demand for contraception is currently being satisfied. Summary of Findings | xix Family planning information is largely re- ceived through the television, with limited exposure through the radio. Forty-one percent of currently married women saw a family planning message on television in the month before the survey, while 11 percent of women heard such a message on the radio. However, the vast majority of women (84 percent) who were exposed to a family planning message considered it effective. FERTILITY Survey results indicate that there has been a decline in the total fertility rate, from 5.4 children per woman in 1990-91 to 4.1 children in 2006-07, a drop of over one child in the past 16 years. Conspicuous differentials in fertility are found by level of women’s education and wealth quintile. The TFR is 2.5 children lower among women having higher education than among uneducated women. The difference between the poorest and richest women is nearly three chil- dren per woman. Research has demonstrated that children born too close to a previous birth are at increased risk of dying. In Pakistan, one-third of births occur less than 24 months after a previous birth, the same proportion as in 1990-91. AGE AT MARRIAGE In Pakistani society, where sexual activity usually takes place within marriage, marriage signals the onset of a woman’s exposure to the risk of childbearing. The length of time women are exposed to the risk of childbearing affects the number of children women potentially can bear. Thus, in Pakistani society, the age at marriage is an important determinant of fertility levels. Presently, 62 percent of women of child- bearing age are currently married, one-third (35 percent) have never married and the remaining three percent are divorced, separated, or wid- owed. The low proportion (1 percent) of women age 45-49 who have never been married indicates that marriage is still almost universal in Pakistan. Once marriages are commenced, they tend to remain stable. Divorce and separation are so- cially discouraged, and hence are uncommon (1 percent). Though teenage marriages are on the decline, one out of six women age 15-19 is already married. The median age at first marriage has increased by about half a year in the last 16 years, i.e., from 18.6 years in 1990-91 to 19.1 years in 2006-07. Important differentials in median age at first marriage are found on the basis of educational level and wealth quintile. FERTILITY PREFERENCES The study of fertility desires in a population is crucial, both for estimating potential unmet need for family planning and for predicting future fertility. The PDHS data show that more than half of currently married women age 15-49 (52 percent) either do not want another child at any time in the future or are sterilized. Over four in ten women want to have a child at some time in the future—21 percent want one within two years, 20 percent would prefer to wait two or more years, and 2 percent want another but are undecided as to when. Since the 1990-91 PDHS, there has been a substantial increase (12 percentage points) in the proportion of married women who want to limit childbearing (from 40 to 52 percent). Future fertility preferences depend not only on the number of living children, but also on the sex composition of the children. Most couples want to have some children of both sexes; however, in Pakistan, there is a stronger preference for sons over daughters. For example, among women with three children, 65 percent of those with three sons want to have no more children, compared with only 14 percent of those with three daughters. Similarly, among women with five children, 85-90 percent of women with four or five sons say they want no more children, as opposed to only 65 percent of those with no sons or only one son. The mean ideal number of children is 4.1 for both ever-married and currently married women. It increases from 3.7 children among childless women to 5.0 among women with 6 or more children, which could either be due to the fact that those who want larger families tend to achieve their goals or to the fact that women rationalize their larger families by reporting their actual number of children as their ideal number. The mean ideal number of children among ever- married and currently married women has re- mained the same as in 1990-91. xx � Summary of Findings Substantial differences are observed across provinces, ranging from a mean ideal number of children of 3.8 in Punjab to 5.9 in Balochistan. There is a steady decrease in the mean ideal family size as the education and wealth quintile of the woman increases. Whether a birth was planned (wanted then), mistimed (wanted later), or not wanted at all, provides some indication of the extent of unwanted childbearing. Overall, 24 percent of births in the five years preceding the survey were not wanted at the time of conception, with 13 percent wanted at a later time and 11 percent not wanted at all. Overall, the total wanted fertility rate is 24 percent lower than the total fertility rate. Thus, if unwanted births could be eliminated, the total fertility rate in Pakistan would be 3.1 births per woman instead of 4.1 births. INFANT AND CHILD MORTALITY The study of infant and child mortality is critical for assessment of population and health policies and programmes. Infant and child mor- tality rates are also regarded as indices reflecting the degree of poverty and deprivation of a popu- lation. For the most recent five-year period pre- ceding the survey, infant mortality is 78 deaths per 1,000 live births and under-five mortality is 94 deaths per 1,000 live births. The pattern shows that over half of deaths under five occur during the neonatal period, while 26 percent occur during the postneonatal period. Under-five mortality has declined from 117 in 1986-90 to 94 in 2002-06, a 20 percent decline in 16 years. Differentials by place of residence show that the under-five mortality rate is 28 percent higher in rural areas than in urban areas (100 vs. 78 deaths per 1,000 live births). As might be expected, rates are lower in major cities than in other urban areas. Female mortality is lower than that of males for the neonatal period only, while males have the advantage during the postneonatal period up to age five years. As is common in most popula- tions, first births generally have higher mortality rates than later births. The length of birth interval has a significant correlation with a child’s chances of survival, with short birth intervals considerably reducing the chances of survival. For example, the under- five mortality rate is twice as high for children born after an interval of less than 2 years, compared with those born four or more years after a previous sibling (122 vs. 61 deaths per 1,000 live births). Size of the child at birth also has a bearing on the childhood mortality rates. Children whose birth size is small or very small have a 68 percent greater risk of dying before their first birthday than those whose birth size is average or larger. The major causes of death among children under five are birth asphyxia (accounting for 22 percent of deaths), sepsis (14 percent), pneu- monia (13 percent), diarrhoea (11 percent), and prematurity (9 percent). As expected, causes of death are highly correlated with the age at death. Deaths during the neonatal period (first month of life) are almost entirely due to birth asphyxia, sepsis, or prematurity. Deaths in the postneonatal period (age 1-11 months) are mostly due to diarrhoea and pneumonia, while the main causes of deaths to children age 1-4 years are diarrhoea, pneumonia, injuries, measles, and meningitis. These results support a strong focus on addres- sing newborn deaths and a continued focus on reducing deaths from diarrhoea and pneumonia. REPRODUCTIVE HEALTH Promotion of maternal and child health has been one of the most important objectives of the health programme in Pakistan. Prenatal care, care at the time of delivery and postnatal care are the three important components of reproductive health. The quality of prenatal care can be assessed by the type of provider, the number of prenatal visits, and the timing of the first visit. Sixty-one percent of mothers receive pre- natal care from skilled health providers that is, from a doctor, nurse, midwife or Lady Health Visitor. Only 3 percent of women receive pre- natal care from a traditional birth attendant (dai). In addition, one percent of mothers receive pre- natal care from a Lady Health Worker, a dis- penser or compounder, or a hakim. Thirty-five percent of women receive no prenatal care at all. There has been a significant improvement over Summary of Findings | xxi the past ten years in the proportion of mothers who receive prenatal care from a skilled health provider, increasing from 33 percent in 1996 to 43 percent in 2001 to 44 percent in 2003 to 61 percent in 2006-07. The PDHS data show that more than one- fourth (28 percent) of pregnant women make four or more prenatal care visits during their entire pregnancy. Urban women (48 percent) are more than twice as likely as rural women (20 percent) to have four or more prenatal visits. Thirty-one percent of women make their first prenatal care visit before the fourth month of pregnancy. The median duration of pregnancy at the first prenatal care visit is 4.2 months. The percentage of women who made four or more prenatal care visits during their pregnancy has increased during the last ten years, from 16 percent in 1996 to 24 percent in 2003 to 28 percent in 2006-07. Overall, there has been some improvement in the utilization and quality of prenatal care services in recent years. For example, the percentage of mothers who received at least two tetanus toxoid injections during pregnancy has nearly doubled—from 29 percent in 2001 to 53 percent in 2006-07. Only 34 percent of births in Pakistan take place in a health facility; 11 percent are delivered in a public sector health facility and 23 percent in a private facility. Three out of five births (65 percent) take place at home, with a majority of mothers saying the main reason they did not deliver their most recent baby in a health facility is because it is not necessary. The percentage of births that take place in a health facility has doubled in the past ten years, increasing from 17 percent in 1996 to 23 percent in 2000-01 and to 34 percent in 2006-07. Less than two-fifths (39 percent) of births take place with the assistance of a skilled medical provider (doctor, nurse, midwife, or Lady Health Visitor). Traditional birth attendants assist with more than half (52 percent) of deliveries, while friends and relatives assist with 7 percent of deliveries. Prompt checkups following delivery are crit- ical for monitoring complications for both the mother and the baby. In the five years preceding the survey, two-fifths (43 percent) of women received postnatal care for their last birth, mak- ing it far less common than prenatal care (65 percent). More than one-fourth of women re- ceived postnatal care within four hours of delivery, while 6 percent received care within the first 4-23 hours, 7 percent of women received postnatal care two days after delivery and 3 percent of women were seen 3-4 days following delivery. Just over one-quarter of mothers (27 percent) received postnatal care from a skilled health provider, while 16 percent received care from traditional birth attendants. One of the most serious injuries of child- bearing is obstetric fistula, a hole in the vagina or rectum usually caused by prolonged labour with- out treatment. Only 3 percent of ever-married women who have ever given birth have experi- enced the most common symptom of fistula, the constant dribbling of urine. CHILD HEALTH The status of child health in the PDHS is determined by birth weights, level of immuni- zation among children, as well as the prevalence and treatment of a number of common childhood illnesses including diarrhoea, acute respiratory infections and fever. Babies whose birth weight is low not only have lower chances of survival but also face higher risk of morbidity and mortality. In Pakistan, because a large proportion of births occur at home, mothers were asked to report the size of the child at birth. Contrary to expectations, the proportion of births reported by the mother to be very small or smaller than average has increased from 22 percent in 1990- 91 to 31 percent in 2006-07. This implies that it would be very difficult for the Government of Pakistan to achieve the targets for improving low birth weight set for 2010. There has been a steady upward trend in the proportion of children who are fully immunized from 35 percent in 1990-91 to 47 percent in 2006-07. In 2006-07, according to information from the vaccination records and mothers’ recall, 80 percent of children aged 12-23 months have received a BCG vaccination, 75 percent have received the first dose of DPT, and 93 percent have received the first dose of polio vaccine. Coverage declines for subsequent doses of DPT and polio; only 59 and 83 percent of children receive the third doses of DPT and polio, xxii � Summary of Findings respectively. Six percent have not received any vaccinations at all. The PDHS data show that 14 percent of children under age five had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey and 31 percent had a fever in the same period. About two-thirds of children who showed symptoms of ARI or fever were taken to a health facility or medical provider for treatment. Half of children with ARI received antibiotics. Twenty-two percent of children under five were reported to have had an episode of diarrhoea during the two-week period before the survey and three percent had diarrhoea with bloody stools. Of all children with diarrhoea, two in five were given fluid made from an oral rehydration salt (ORS) packet, 16 percent were given a recommended homemade fluid (RHF), and more than half (55 percent) were given ORS, RHF, or more fluids than usual. Forty-seven percent of children with diarrhoea were given some kind of pill or syrup to treat the disease, while 14 percent were given home remedies or herbs. About one in five children with diarrhoea was not treated at all. The data show that 41 percent of children with diarrhoea were given the same quantity of fluids as usual, while 21 percent received more fluids than usual, and 34 percent received some- what or much less fluid than usual. These results suggest that in Pakistan, about one in three moth- ers still curtail fluid intake when their children have diarrhoea, a very dangerous practice which should be addressed with a national educational campaign. NUTRITION Poor nutritional status is one of the most important health and welfare problems facing Pakistan today and particularly afflicts women and children. Poor breastfeeding and infant feed- ing practices have adverse consequences for the health and nutritional status of children. Fortu- nately, breastfeeding in Pakistan is almost uni- versal and generally of fairly long duration. Nevertheless, only 70 percent of newborns are breastfed within one day after delivery. According to the 2006-07 PDHS, a majority (55 percent) of children under the age of two months are exclusively breastfed. This represents a doubling from the 27 percent of children under two months who were exclusively breastfed in 1990-91, an encouraging trend. Overall, only 37 percent of infants under 6 months are exclusively breastfed, far lower than the recommended 100 percent exclusive breastfeeding for children under 6 months. The median duration of breastfeeding among Pakistani children is 19 months, one month lower than reported in 1990-91, suggesting that during the last decade and a half the patterns have changed only slightly. The median duration of exclusive breastfeeding is estimated at a little less than one month. Ensuring that children between 6 and 59 months receive enough vitamin A may be the single most effective child survival intervention. Survey results show that 60 percent of children age 6-59 months received a vitamin A supple- ment in the six months preceding the survey. Night blindness—an indicator of severe vitamin A deficiency to which pregnant women are especially prone—is common in Pakistan. Five percent of women with a recent birth reported having had difficulty seeing only at night during the pregnancy of the last birth. Overall, only four in ten women take iron or calcium supplements during pregnancy. MALARIA Women who had a live birth in the five years preceding the survey were asked whether they suffered from malaria during pregnancy and if yes, whether they received any treatment. One in five women suffered from malaria during their pregnancy, the vast majority of whom received treatment for the disease. The prevalence of malaria is higher in rural areas (22 percent), in the province of Balochistan (30 percent), among women with no education (22 percent) and among those who are in the lowest (29 percent) and second lowest wealth quintiles (23 percent). Among children under five, 31 percent are reported to have had fever in the two weeks preceding the survey. Of those, only three percent took antimalarial drugs. Summary of Findings | xxiii xxiv � Summary of Findings Mosquito nets are not common in Pakistan; only 6 percent of households have a net. KNOWLEDGE OF HIV/AIDS The HIV/AIDS pandemic is one of the most serious health concerns in the world today be- cause of its high case fatality rate and the lack of a cure. The Ministry of Health and UNAIDS estimate that approximately 80,000 people are currently living with HIV in Pakistan. In spite of vast media campaigns, only four in ten ever-married women age 15-49 in Pakistan have heard about AIDS. Awareness of AIDS has barely increased over the last decade, from 41 percent to 44 percent of ever-married women. Overall, only five percent of women are classified as having comprehensive knowledge about AIDS, i.e., knowing that consistent use of condoms and having just one faithful partner can reduce the chance of getting infected, knowing that a healthy-looking person can be infected, and knowing that AIDS cannot be transmitted by sharing food or by mosquito bites. This low level of knowledge should be a matter of concern to policymakers and for the National AIDS Control Programme. ADULT AND MATERNAL MORTALITY By collecting information to measure not only the maternal mortality ratio, but also causes of adult female deaths through verbal autopsies, the 2006-07 PDHS fulfilled a longstanding desire of reproductive health professionals in Pakistan. Most estimates of the maternal mortality ratio available before this survey were based on mathematical models or indirect estimation. Through its unique design, the 2006-07 PDHS provides a wealth of information about adult female deaths. The maternal mortality ratio as measured in the survey is 276 maternal deaths per 100,000 births. This is slightly lower than the generally accepted previous estimates of around 320 ma- ternal deaths per 100,000 births. Postpartum haemorrhage is the leading direct cause of ma- ternal deaths, followed by puerperal sepsis and eclampsia. Obstetric bleeding (postpartum and antepartum haemorrhage) is responsible for one- third of all maternal deaths. The data imply that roughly 1 in 89 women in Pakistan will die of maternal causes during her lifetime (lifetime risk). Adult female and male mortality rates for ages 15-49 as measured through the survey are plausible. Among adult women, complications of pregnancy and childbirth emerge as the outstand- ing cause of death in the reproductive years, accounting for one-fifth of deaths to women of childbearing age in Pakistan. Cancer, tubercu- losis, and other infectious diseases are the next most important causes of death among women in reproductive ages. xxvi | Map of Pakistan xxvi | Map of Pakistan INTRODUCTION 1 Shahid Munir and Khalid Mehmood Pakistan’s first Demographic and Health Survey was undertaken in 1990-91. Since then, other surveys focusing on fertility and family planning, reproductive health, and status of women were conducted. The current demographic and health survey has special features, including maternal mortality and infant and child health, mortality, and morbidity, in addition to the conventional areas that most demographic and health surveys cover. Before deliberating on the findings of the survey, a short description of the salient features of Pakistan—including its geography, climatic conditions, history, economy, and population size and growth—as well as details regarding the sample size and field operations, is given to enable readers to place the findings of the survey in proper sociodemographic and geographic perspective. 1.1 GEOGRAPHY, CLIMATE, AND HISTORY Pakistan is the “Land of the Indus River,” which flows through the country for 2,500 kilometres (1,600 miles) from the Himalaya and Karakoram mountain ranges to the Arabian Sea. It is a land of snow-covered peaks, hot deserts and barren land, as well as a vast area of irrigated plains. Pakistan is located between 24� and 37� N latitude and between 61� and 75� E longitudes. It occupies a strategically important position. On its east and southeast lies India, to the north and northwest is Afghanistan, to the west is Iran, and in the south is the Arabian Sea. It has a common frontier with China on the border of its Gilgit Agency in the northeast. Tajikistan, formerly in the USSR, is separated from Pakistan by a narrow strip of Afghan territory called Wakhan. Pakistan comprises a total land mass of 796,096 square kilometres. There are three main regions: the mountainous region in North, which has three world famous mountain ranges (the Hindukush, the Karakoram, and the Himalayas); the enormous but sparsely populated plateau of Balochistan; and the Punjab and Sindh plains of the Indus River and its main tributaries. Pakistan is divided into four provinces. Balochistan province is in the southwest, and the Punjab and Sindh provinces are plains with the world’s largest irrigation system. North-West Frontier Province (NWFP) is located in the northwest. Pakistan is strategically located at the crossroads of Asia, where the road from China to the Mediterranean meets the route from India to Central Asia. For thousands of years, this junction has been a melting pot of diverse cultures, attracting warriors, traders and adventurers. Now the old Chinese trade route is reopened, providing access to the spectacular Karakorams and Pamirs, following the ancient Silk Route and entering China over the 4,733 metre (15,528 feet) Khunjerab pass, the highest asphalt border crossing in the world. In the northeastern tip of the country, Pakistan controls about 84,159 square kilometres of the former state of Jammu and Kashmir. This area consists of Azad Kashmir (11,639 square kilometres) and most of the Northern Area (72,520 square kilometres), which includes the ruggedly mountainous and beautiful Gilgit and Baltistan. In fact, the Northern Area has five of the world’s 14 highest mountain peaks, each over 8,000 metres high. It also has extensive glaciers including the Siachen glacier that it is sometimes called the “third pole.” Pakistan enjoys a considerable variety of weather. The north and northwestern high mountain ranges are extremely cold in winter, while the summer months from April to September are very pleasant. The vast plains of the Indus Valley are hot to very hot in summer and have cold weather in winter. The coastal strip in the south has a temperate climate. Although it is in the monsoon region, Introduction | 1 which falls late in summer, the average rainfall varies between 76 and 127 cm. The province of Balochistan is the driest, where on average only 21 cm of rain falls, mostly in winter. Pakistan achieved independence from Britain on the 14th of August 1947 as a result of the long struggle by Muslims of India for a separate homeland of their own. In fact, its foundation was laid when Mohammad Bin Qasim—a Muslim leader of Saudi Arabia—subdued Sindh in 711 AD as a reprisal against sea pirates that had taken refuge in Raja Dahir’s kingdom. But the areas constituting Pakistan have had a historical individuality of their own even before the advent of Islam. Archaeological sites and imposing monuments scattered over the country richly illustrate Pakistan’s 4,000-year history. Brick cities like Moenjodaro and Harrapa from the Indus civilization, which flourished around 2000 BC, stand beside Buddhist ruins contemporaneous with the birth of Christianity. Magnificent Muslim tombs, mosques, and forts built by the mogul emperors from the 12th century to the 16th and 17th centuries are a common site found in this part of the world. 1.2 ECONOMY AND POPULATION Pakistan’s economy continues to gain traction as it experiences the longest spell of its strongest growth in years. The outcomes of the 2006-07 fiscal year indicate that Pakistan’s economic momentum remains on track. Economic growth accelerated to 7 percent in 2006-07 at the back of robust growth in agriculture, manufacturing, and services. Pakistan’s growth performance over the last five years has been striking. Average real gross domestic product (GDP) growth during 2003-07 had the best performance in decades, and it now seems that Pakistan has decisively broken out of the low growth rut that it was in for more than 10 years. Pakistan’s economy continues to perform impressively and its economic fundamentals have gained further strength in the fiscal year 2006-07. The most important achievements of this year include the following: • Strong economic growth of 7 percent despite the pursuance of a tight monetary policy, resulting in an interest rate increase; • Strong recovery in agricultural growth at 5 percent and major crops at 7.6 percent on the heels of the highest ever production of wheat (23.5 million tonnes) in the country’s history and an impressive 23 percent increase in sugar cane production (54.7 million tonnes); • Continued large-scale growth (8.8 percent) in manufacturing, although this is a somewhat less torrid pace than last year; • Continued expansion of the overall service sector at a solid pace of 8 percent; and • Strong average economic growth of over 7.5 percent during the past four years that maintains Pakistan’s position as one of the fastest growing economies in the Asian region along with China, India, and Vietnam. This good economic performance has resulted from a combination of generally sound economic policies, on-going structural reforms, and a benign international economic environment. Based on the performance of half a decade of strong, stable, resilient, and broad-based economic growth, it appears that Pakistan’s economy will continue to be a high mean, low variance economy over the medium-term (Government of Pakistan, 2007). The population of Pakistan is estimated around 160 million as of mid-2007 and is growing at 1.9 percent per annum (Government of Pakistan, 2007). The population growth rate has receded from a record high of 3.7 percent per year in the 1960s. About two-thirds of the population is rural. Pakistan is the sixth most populous country in the world (PRB, 2007) and is adding around three million persons per year (NIPS, 2007b). Forty-one percent of its population is below 15 years of age, 2 | Introduction which is indicative of high fertility in the past. Women of reproductive age constitute almost one- quarter of the total population. Marriage is universal and the fertility rate is far above replacement level. The government’s population policy, promulgated in 2002, aims to reduce fertility to replacement level by 2020 (MOPW, 2002). However, population stabilization would still be two generations away even if replacement-level fertility were attained by that date. The rapid increase in population has resulted in a quadrupling of the population over the past five decades. This has jeopardized economic gains; in spite of a 327-fold increase in the national GDP between 1960 and 2006, the per capita income has increased only nine-fold. Although the literacy rate has increased since the early 1960s, illiterates number more than 52 million. Unemployment has grown by 11 times in the past 35 years, per capita availability of water has declined to below 1,200 cubic metres per year, and an investment of over 7.4 billion US dollars is required to keep the 2006 level of per capita income of US$847 (NIPS, 2006). The rapid increase in population is also adversely affecting health indicators. Huge funds are required to maintain the existing ratio of population per health facility. At present, there is only one hospital available for over 170,000 persons; one rural health centre available for more than 184,000 persons living in rural areas; one basic health unit available for more than 19,000 persons in rural areas; and one maternal and child health centre available for more than 4,400 expecting mothers and newborns. There is only one doctor available for over 1,300 people and one nurse for 4,600 persons. The rapid increase in population constrains economic gains and stretches the already overburdened health facilities (Government of Pakistan, 2007). The population welfare programme has taken a number of initiatives to reduce the rapid increase in population. The programme has been in the process of engaging different stakeholders in the public, private, and nongovernmental sectors to cater to the family planning and reproductive health needs of men and women across Pakistan. The programme aims to provide universal access to modern contraceptive methods by 2010 and reduce the unmet need for family planning. Pakistan's national language is Urdu, which is widely understood in most parts of the country. However, in the provinces, local languages are also spoken. In northern and southern Punjab, the local languages are Punjabi and Saraiki, respectively. Sindhi is widely spoken in Sindh, except in Karachi, where Urdu is the main language. Pushto is the local language of NWFP and the Federally Administered Tribal Areas (FATA), although Hindko is also spoken in certain parts of NWFP. Balochi, Pushto, and Brahvi are widely spoken languages in Balochistan. The official language of the federal and provincial governments is English. The vast majority of the population is Muslim (97 percent). Minorities include Christians, Hindus, Parsis, Marwaris, Mangowars, and Ahmadies. 1.3 ORGANIZATION AND IMPLEMENTATION OF THE 2006-07 PDHS 1.3.1 Objectives of the Survey The 2006-07 Pakistan Demographic and Health Survey (PDHS) was undertaken to address the monitoring and evaluation needs of maternal and child health and family planning programmes. The survey was designed with the broad objective to provide policymakers, primarily in the Ministries of Population Welfare and Health, with information to improve programmatic interventions based on empirical evidence. The aim is to provide reliable estimates of the maternal mortality ratio (MMR) at the national level and a variety of other health and population indicators at national, urban-rural, and provincial levels. More specifically, PDHS had the following objectives: Introduction | 3 • Collect quality data on fertility levels and preference, family planning knowledge and use, childhood—and especially neonatal—mortality levels and awareness regarding HIV/ AIDS and other indicators relevant to the Millennium Development Goals and the Poverty Reduction Strategy Paper; • Produce a reliable national estimate of the MMR for Pakistan, as well as information on the direct and indirect causes of maternal deaths using verbal autopsy instruments; • Investigate factors that impact on maternal and neonatal morbidity and mortality (i.e., antenatal and delivery care, treatment of pregnancy complications, and postnatal care); • Improve the capacity of relevant organizations to implement surveys and analyze and disseminate survey findings. 1.3.2 Institutional Framework The Ministry of Population Welfare executed the 2006-07 PDHS project, whereas the National Institute of Population Studies (NIPS) undertook the responsibility of implementing the project. A Steering Committee, chaired by the Secretary of the Ministry of Population Welfare and co-chaired by the Secretary of the Ministry of Health, included members from federal social sector ministries and provincial health and population departments. The Steering Committee provided guidance, administrative support, and facilitation during the survey process. A Technical Advisory Committee consisting of population professionals, experts, and researchers from relevant fields was formed to provide guidance and support at various stages of the survey. NIPS was responsible for planning, organizing, and overseeing the survey operations, including hosting meetings to discuss the survey with representatives from major users, technical institutions, and international bodies; recruiting, training, and supervising fieldworkers and data processing staff; and analyzing and writing this report. The Federal Bureau of Statistics (FBS) provided the sample design and household listings for the sampled areas across Pakistan. Macro International Inc. provided technical assistance to NIPS for the design and implementation of the PDHS project. Funds for the project were provided by the United States Agency for International Development (USAID), while the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF) provided logistic support for monitoring the survey operations. 1.3.3 Sample Design The 2006-07 PDHS is the largest-ever household based survey conducted in Pakistan. The sample is designed to provide reliable estimates for a variety of health and demographic variables for various domains of interest. The survey provides estimates at national, urban and rural, and provincial levels (each as a separate domain). One of the main objectives of the 2006-07 Pakistan Demographic and Health Survey (PDHS) is to provide a reliable estimate of the maternal mortality ratio (MMR) at the national level. In order to estimate MMR, a large sample size was required. Based on prior rough estimates of the level of maternal mortality in Pakistan, a sample of about 100,000 households was proposed to provide estimates of MMR for the whole country. For other indicators, the survey is designed to produce estimates at national, urban-rural, and provincial levels (each as a separate domain). The sample was not spread geographically in proportion to the population; rather, the smaller provinces (e.g., Balochistan and NWFP) as well as urban areas were over-sampled. As a result of these differing sample proportions, the PDHS sample is not self-weighting at the national level. The sample for the 2006-07 PDHS represents the population of Pakistan excluding the Federally Administered Northern Areas (FANA) and restricted military and protected areas. Although the Federally Administered Tribal Areas (FATA) were initially included in the sample, due to security and political reasons, it was not possible to cover any of the sample points in the FATA. 4 | Introduction In urban areas, cities like Karachi, Lahore, Gujranwala, Faisalbad, Rawalpindi, Multan, Sialkot, Sargodha, Bahawalpur, Hyderabad, Sukkur, Peshawar, Quetta, and Islamabad were considered as large-sized cities. Each of these cities constitutes a stratum, which has further been sub- stratified into low, middle, and high-income groups based on the information collected during the updating of the urban sampling frame. After excluding the population of large-sized cities from the population of respective former administrative divisions, the remaining urban population within each of the former administrative divisions of the four provinces was grouped together to form a stratum. In rural areas, each district in Punjab, Sindh, and NWFP provinces is considered as an independent stratum. In Balochistan province, each former administrative division has been treated as a stratum. The survey adopted a two-stage, stratified, random sample design. The first stage involved selecting 1,000 sample points (clusters) with probability proportional to size—390 in urban areas and 610 in rural areas. A total of 440 sample points were selected in Punjab, 260 in Sindh, 180 in NWFP, 100 in Balochistan, and 20 in FATA. In urban areas, the sample points were selected from a frame maintained by the FBS, consisting of 26,800 enumeration blocks, each including about 200-250 households. The frame for rural areas consists of the list of 50,588 villages/mouzas/dehs enumerated in the 1998 population census. The FBS staff undertook the task of a fresh listing of the households in the selected sample points. Aside from 20 sample points in FATA, the job of listing of households could not be done in four areas of Balochistan due to inability of the FBS to provide household listings because of unrest in those areas. Another four clusters in NWFP could not be covered because of resistance and refusal of the community. In other words, the survey covered a total of 972 sample points. The second stage of sampling involved selecting households. In each sample point, 105 households were selected by applying a systematic random sampling technique. This way, a total of 102,060 households were selected. Out of 105 sampled households, ten households in each sample point were selected using a systematic random sampling procedure to conduct interviews for the Long Household and the Women’s Questionnaires. Any ever-married woman aged 12-49 years who was a usual resident of the household or a visitor in the household who stayed there the night before the survey was eligible for interview. 1.3.4 Questionnaires The following six types of questionnaires were used in the PDHS: • Community Questionnaire • Short Household Questionnaire • Long Household Questionnaire • Women’s Questionnaire • Maternal Verbal Autopsy Questionnaire • Child Verbal Autopsy Questionnaire The contents of the Household and Women’s Questionnaires were based on model questionnaires developed by the MEASURE DHS programme, while the Verbal Autopsy Questionnaires were developed by Pakistani experts and the Community Questionnaire was patterned on the basis of one used by NIPS in previous surveys. NIPS developed the draft questionnaires in consultation with a broad spectrum of technical experts, government agencies, and local and international organizations so as to reflect relevant issues of population, family planning, HIV/AIDS, and other health areas. A number of meetings were organized by NIPS and the inputs received in these meetings were used to finalize survey questionnaires. These questionnaires were then translated into Urdu, Punjabi, Sindhi, and Pushto Introduction | 5 languages. After the pretest, which was done in Peshawar, Rawalpindi, and Hyderabad, the questionnaires were finalized on the basis of feedback of the pretest. The Community Questionnaire, a brief form that was filled out for each sample point in rural areas, included questions about the availability of various kinds of health and family planning facilities and services. Also, information on the availability of transportation, education, and communication facilities was recorded. The geographic coordinates were taken for each sample point using a geographic positioning system (GPS) unit. The Short Household Questionnaire was administered in 92,340 households to list all the usual members and visitors. Likewise, the Long Household Questionnaire was used in the 9,720 households where the Women’s Questionnaire was also administered. In addition to some basic information collected on characteristics like age, sex, marital status, education, and relationship to the head of the household of each person listed, another purpose of the two household questionnaires was to record births and deaths that occurred since January 2003 and, for verbal autopsies, to identify any death of child under age 5 since January 2005 and any death to a woman age 12-49 since January 2003a. In addition, the Long Household Questionnaire collected more details, e.g., current school attendance, survivorship status of parents of children under age 18, and the registration status of each person. It also identified eligible ever-married women age 12-49 for interview with the Women’s Questionnaire. The Long Household Questionnaire also collected information regarding various characteristics of the dwelling unit, such as the source of water; type of toilet facilities; type of cooking fuel; materials used for the floor, roof, and walls of the house; ownership status of various durable goods; ownership of agricultural land; ownership of livestock/farm animals/poultry; and ownership and use of mosquito nets. As mentioned above, the Women’s Questionnaire collected information from ever-married women age 12-49 years on the following topics: • Background characteristics (education, literacy, native language, marriage characteristics, etc.) • Reproductive history • Knowledge and use of family planning methods • Prenatal and postnatal care • Child immunization, health, and nutrition • Fertility preferences • Breastfeeding practices • Woman’s work and husband’s background characteristics • Awareness about HIV/AIDS and other sexually transmitted infections • Other health issues (knowledge of tuberculosis and hepatitis, experience with fistula, use of clean syringes for injections). The Verbal Autopsy Questionnaire for deaths of women was administered in households in which a death of a woman aged 12-49 was reported since 2003. The questionnaire covered details about the woman’s characteristics and the symptoms and circumstances prior to her death. A verbatim history was also recorded so as to help assign a cause of death. Questions were also asked about any treatment or health care that might have been sought before her death. The Child Verbal Autopsy Questionnaire was administered in households in which a death of a child under age five years or a stillbirth was reported in 2005 or later. The questionnaire elicited details about the illness and causes of death from the parents and/or others who were present at the time of death of the child. Separate teams of physicians reviewed both these verbal autopsy questionnaires to assign causes of death. 6 | Introduction 1.3.5 Training of Field Staff The main survey training was held during a three-week period in August and was attended by all interviewers, supervisors, quality control personnel, field coordinators, and data entry staff. The training included lectures, demonstrations, practice interviewing in small groups, and examinations. Separate training was arranged for interviewers selected for collecting information through verbal autopsies for women and children. All teams participated in three days of field practice. 1.3.6 Field Supervision and Monitoring Ensuring high-quality data was a prime objective of the survey and was assured through regular supervision and monitoring of NIPS teams during fieldwork. NIPS designated six professional staff to act as field coordinators who visited the teams assigned to them on a regular basis. From the first week of data collection, all professional NIPS staff followed the field teams to support and facilitate them in using the questionnaires, understanding the sample selection procedures, conducting interviews in all five questionnaires, using field control sheets, assigning interviewers, editing the questionnaire, linking with FBS offices, observing team coordination, and ensuring efficient use of time. The field coordinators visited the teams at least once a month. The quality control interviewers accompanied these field coordinators. Quality control interviewers were deputed to work with various teams for three to four days to undertake several tasks: observe on-going interviews for delivery of questions, verify and validate information recorded by interviewers by revisiting and re-interviewing respondents, review completed interviews/questionnaires, and provide on-the-job training for weaker field staff. They also edited completed questionnaires and reviewed any errors with the team members. Finally, they assisted the teams to resolve any problems. The monitoring checklist was shared with the team members and supervisors to maintain transparency and openness in the process. Close communication was maintained at all times between the NIPS, field supervisors, and interviewers during fieldwork. Team supervisors were responsible for the performance of their teams. Team performance was judged by team cohesion and discipline, timely arrival at primary sampling units (PSUs) and visits and revisits to households to complete all 105 questionnaires, use of supervisory control sheets, and efficient use of time by team members. For supervision of each member of a field team, the NIPS’ field coordinators and quality control interviewers maintained close contact with the teams under their responsibility and with the PDHS core team. Over the period of the survey, all teams were visited five to six times in the field. Monitoring was also undertaken by Agha Khan University colleagues in various districts to see the quality of data being recorded on child death verbal autopsies. The project director, principal investigator, and project consultant visited the field regularly and communicated to team supervisors and team members on a regular basis. A consultant from Macro visited NIPS in November 2006 to meet the PDHS core team and visit field teams across Pakistan to see their work and to review the data coding and entry processes. A set of quality control check tables for critical indicators was produced periodically during the fieldwork using the computerized data at NIPS. Problems that appeared from review of these tables were discussed with the relevant teams and attempts made to ensure that the problems did not persist. Regular meetings of the core staff and field coordinators were held at NIPS to exchange views on progress, performance, problems, solutions, and future strategies. These meetings were helpful in resolving field problems and improving the quality of data collected from the field. NIPS established a comprehensive system to ensure sufficient funds were transferred to team supervisors and interviewers to cover the costs of operating vehicles, communications, and per diem payments to all team members. NIPS also formed a system that ensured that the interviewing teams received necessary materials on a timely basis. Two courier services were contracted for rapid and safe delivery of material to the field and dispatch of completed questionnaires to NIPS. Introduction | 7 1.3.7 Fieldwork and Data Processing Twenty-nine teams collected the survey data. Most teams consisted of six female interviewers and a male supervisor. Data collection using the Short and Long Household Questionnaires, Women’s Questionnaire, Child Verbal Autopsy Questionnaire, and Maternal Verbal Autopsy Questionnaire was assigned to different interviewers in each team. The fieldwork began in early September 2006 and was completed in February 2007. As mentioned earlier, senior DHS technical staff, field coordinators, and quality control teams visited teams regularly to review the work and monitor data quality. The processing of the data entry of the 2006-07 PDHS questionnaires started shortly after the fieldwork commenced. Completed questionnaires were returned regularly from the field to NIPS headquarters in Islamabad, where they were edited and entered by the data processing teams who were specifically trained for this task. The NIPS computer programmer who attended a three-week training course in data entry and editing at Macro’s headquarters in the United States, supervised the data processing. Other data processing personnel included an office coordinator who ensured that the expected number of questionnaires from each cluster was received, several office editors, 20 data entry operators working in two shifts, and secondary editors. A double-entry system was adopted for data entry. The concurrent processing of the data was an advantage because the senior PDHS technical staff and field coordinators were able to advise field teams of problems detected during the data entry. Copies of the verbal autopsies were promptly made and dispatched to the reviewing teams of doctors. Field check tables were timely generated and, as a result, specific feedback was given to the teams to improve performance. The data entry and editing phase of the survey was completed in April 2007. 1.3.8 Field Problems A number of problems were encountered during the fieldwork. Initially, the sample design had included collecting data from the FATA. This, however, was not possible, because the FBS was unable to provide household listings for the selected clusters due to the prevailing unrest in the area. In addition, the FBS was also not able to provide household listings for four clusters in Balochistan province due to the same reasons. In NWFP, the data collection teams experienced hostilities from four communities and hence could not complete data collection or could not carry out the fieldwork in those areas. Hostility at individual households was also experienced in a few places. In all areas of NWFP, the data collection teams had to get permission from village or area elders before starting the fieldwork. This was sometimes possible after hours of deliberations (jirga) with the community leaders, especially in rural areas. However, in most of the areas and especially in rural Sindh and NWFP, teams were offered food and drinks and sometimes gifts to keep up with their traditions because the team members were visiting those households for the first time. A few members of the data collection teams got sick, were hospitalized, or were bitten by dogs. A harsh winter in parts of Balochistan and NWFP also welcomed the data collection teams and resultantly prolonged their working hours. However, the fieldwork was successfully completed in the stipulated time frame. 8 | Introduction Introduction | 9 1.4 RESPONSE RATES Table 1.1 presents household and individual response rates for the survey. A total of 102,037 households were selected for the sample, of which 97,687 were occupied at the time of fieldwork.1 The main reason for the difference is that some of the dwelling units that were occupied during the household listing operation were either vacant or the household was away for an extended period at the time of interviewing. Of the occupied households, 95,441 (98 percent) were successfully interviewed. In the 9,255 households interviewed with the Long Household Questionnaire, a total of 10,601 ever-married women aged 12-49 were identified, of whom 10,023 were successfully interviewed, yielding a response rate of 95 percent. The principal reason for non-response among eligible women was the failure to find individuals at home despite repeated visits to the household. Response rates are only slightly lower in urban areas than in rural areas.2 Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Pakistan 2006-07 Residence Result Total urban Major city Other urban Rural Total Household interviews (total) Households selected 40,827 21,297 19,530 61,210 102,037 Households occupied 39,060 20,430 18,630 58,627 97,687 Households interviewed 37,909 19,729 18,180 57,532 95,441 Household response rate 97.1 96.6 97.6 98.1 97.7 Household interviews (short questionnaire) Households selected 36,941 19,272 17,669 55,384 92,325 Households occupied 35,278 18,461 16,817 52,961 88,239 Households interviewed 34,223 17,822 16,401 51,963 86,186 Household response rate1 97.0 96.5 97.5 98.1 97.7 Household interviews (long questionnaire) Households selected 3,886 2,025 1,861 5,826 9,712 Households occupied 3,782 1,969 1,813 5,666 9,448 Households interviewed 3,686 1,907 1,779 5,569 9,255 Household response rate1 97.5 96.9 98.1 98.3 98.0 Interviews with ever-married women Number of eligible women 4,104 2,086 2,018 6,497 10,601 Number of eligible women interviewed 3,830 1,929 1,901 6,193 10,023 Eligible women response rate2 93.3 92.5 94.2 95.3 94.5 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents 1 In a few clusters, the number of households selected was slightly fewer than the stipulated 105 for various reasons. 2 Because there were only three ever-married women under age 15 (all of whom were 14), they were all made to be age 15. HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 Aysha Sheraz and Zafar Zahir This chapter provides a summary of the socioeconomic characteristics of households and respondents surveyed, including age, sex, place of residence, and educational status. It also provides information on household facilities and household characteristics, such as source of drinking water, electricity, sanitation facilities, housing construction materials, possession of durable goods, and ownership of a homestead, land, and farm animals. Information was also collected on the type of treatment, if any, used to make the water safe for drinking. Information collected on the characteristics of the households and respondents is important in understanding and interpreting the findings of the survey and also provides indicators of the representativeness of the survey. The information is also useful in understanding and identifying the major factors that determine or influence the basic demographic indicators of the population. The 2006-07 Pakistan Demographic and Health Survey (PDHS) collected information from all usual residents of a selected household (the de jure population) and persons who had stayed in the selected household the night before the interview (the de facto population). Because the difference between these two populations is very small, and to maintain comparability with other DHS reports, all tables in this report refer to the de facto population unless otherwise specified. A household was defined as a person or group of related and unrelated persons who live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as head of the household, and who have common arrangements for cooking and eating. As mentioned in Chapter 1, the PDHS used two types of Household Questionnaires: one for use in about 90 percent of households—the Short Household Questionnaire—and the other used in a 10-percent subsample—the Long Household Questionnaire. Data on the age, sex, and education distribution of household members is based on information from both types of questionnaire, i.e., from all households, whereas data on current school attendance, orphanhood, and housing characteristics are derived from the long questionnaire and thus are based on a smaller number of households. Nevertheless, these indicators are representative at national, urban-rural. and provincial levels as well. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Age and sex are important demographic variables and are the primary basis of demographic classification in vital statistics, censuses, and surveys. They are also very important variables in the study of mortality, fertility, and nuptiality. In general, a cross-classification with sex is useful for the effective analysis of all forms of data obtained in surveys. The distribution of the household population in the 2006-07 PDHS is shown in Table 2.1 by five-year age groups, according to urban-rural residence and sex. The total population counted in the survey was 688,937, with males slightly outnumbering females. Two-thirds of the population (67 percent) reside in rural areas. Of the one-third who live in urban areas, the proportion living in a major city slightly exceeds the proportion living in smaller urban areas. Household Population and Housing Characteristics | 11 Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population in all households by five-year age groups, according to sex and residence, Pakistan 2006-07 Residence Total urban Major city Other urban Rural Total Age Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total <5 11.8 11.8 11.8 11.4 11.4 11.4 12.3 12.3 12.3 14.5 14.0 14.2 13.6 13.3 13.4 5-9 12.5 12.5 12.5 11.3 12.0 11.7 14.1 13.2 13.6 15.8 14.6 15.2 14.7 13.9 14.3 10-14 12.7 12.4 12.5 12.1 12.0 12.1 13.5 12.8 13.1 13.5 12.7 13.1 13.2 12.6 12.9 15-19 12.5 12.9 12.7 12.5 12.9 12.7 12.5 12.9 12.7 11.3 11.6 11.4 11.7 12.0 11.9 20-24 10.7 11.2 10.9 11.5 11.7 11.6 9.7 10.5 10.1 8.2 9.4 8.8 9.0 10.0 9.5 25-29 8.2 8.5 8.3 8.8 8.7 8.7 7.3 8.2 7.7 6.7 7.8 7.3 7.2 8.1 7.6 30-34 5.8 6.1 5.9 6.1 6.2 6.1 5.4 6.0 5.7 5.1 5.9 5.5 5.4 5.9 5.7 35-39 5.5 5.8 5.6 5.7 5.9 5.8 5.3 5.7 5.5 4.9 5.4 5.2 5.1 5.6 5.3 40-44 4.8 4.7 4.7 5.0 4.9 5.0 4.5 4.3 4.4 4.1 4.1 4.1 4.4 4.3 4.3 45-49 4.1 4.1 4.1 4.3 4.2 4.3 3.8 4.0 3.9 3.6 3.6 3.6 3.8 3.8 3.8 50-54 3.1 3.0 3.1 3.3 3.1 3.2 3.0 2.8 2.9 2.9 2.8 2.8 3.0 2.9 2.9 55-59 2.3 2.1 2.2 2.2 2.1 2.2 2.3 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 60-64 2.2 1.8 2.0 2.2 1.7 1.9 2.2 1.9 2.0 2.3 2.0 2.2 2.3 1.9 2.1 65-69 1.3 1.1 1.2 1.2 1.1 1.1 1.4 1.2 1.3 1.6 1.4 1.5 1.5 1.3 1.4 70-74 1.2 0.9 1.1 1.2 1.0 1.1 1.3 0.9 1.1 1.5 1.1 1.3 1.4 1.0 1.2 75-79 0.5 0.4 0.5 0.5 0.4 0.5 0.6 0.4 0.5 0.7 0.5 0.6 0.6 0.5 0.6 80 + 0.8 0.7 0.7 0.7 0.7 0.7 0.9 0.7 0.8 1.1 0.8 1.0 1.0 0.8 0.9 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 Number 117,379 113,225 230,607 66,510 63,492 130,004 50,869 49,733 100,602 230,859 227,464 458,331 348,238 340,689 688,937 Note: Total includes 10 persons whose sex was not stated. The age structure of the household population is typical of a society with a youthful population. The sex and age distribution of the population is shown in the population pyramid in Figure 2.1. Pakistan has a pyramidal age structure due to the large number of children under 15 years of age. It is evident that the pyramid is broad-based but slightly narrower at the lowest base (age group 0-4 years), a pattern that typically describes a high fertility but with a recent declining trend. Children under 15 years of age account for 41 percent of the population in Pakistan, a feature of populations with high fertility levels. Fifty-five percent of the population are in the age group 15-64 years and 4 percent are over 65. Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 PDHS 2006-07 Male Percent Female Age 12 | Household Population and Housing Characteristics Table 2.2 indicates that more than half of the population in Pakistan live in Punjab province (58 percent), followed by Sindh (23 percent), North West Frontier Province (NWFP) (14 percent), and Balochistan (4 percent). The age structure of the four provinces indicates that Punjab province has the lowest proportion of children compared with the other three provinces (Table 2.2). For example, the proportion of the population reported to be under age 15 varies from 39 percent in Punjab to 46 percent in Balochistan. Table 2.2 Household population by age, sex, and province Percent distribution of the de facto household population in all households by five-year age groups, according to sex and province, Pakistan 2006-07 Province Punjab Sindh NWFP Balochistan Total Age Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total <5 13.0 12.6 12.8 14.1 14.3 14.2 14.8 13.8 14.3 14.5 15.0 14.7 13.6 13.3 13.4 5-9 13.9 13.1 13.5 15.2 14.8 15.0 15.9 14.7 15.3 17.9 17.7 17.8 14.7 13.9 14.3 10-14 13.0 12.4 12.7 13.0 12.4 12.7 14.5 13.6 14.0 13.6 12.8 13.2 13.2 12.6 12.9 15-19 11.7 12.2 12.0 11.4 11.5 11.4 12.6 12.5 12.5 10.7 10.7 10.7 11.7 12.0 11.9 20-24 9.1 10.1 9.6 9.4 10.3 9.8 8.6 9.5 9.0 8.3 9.1 8.7 9.0 10.0 9.5 25-29 7.1 8.0 7.6 7.9 8.2 8.1 6.2 7.6 6.9 7.5 9.0 8.2 7.2 8.1 7.6 30-34 5.4 6.0 5.7 5.7 6.0 5.9 4.8 5.7 5.2 5.6 5.8 5.7 5.4 5.9 5.7 35-39 5.2 5.8 5.5 5.3 5.3 5.3 4.1 5.2 4.7 5.1 5.0 5.1 5.1 5.6 5.3 40-44 4.6 4.5 4.6 4.2 3.9 4.0 3.9 4.1 4.0 3.7 3.7 3.7 4.4 4.3 4.3 45-49 4.0 3.9 3.9 3.5 3.7 3.6 3.1 3.5 3.3 3.6 3.6 3.6 3.8 3.8 3.8 50-54 3.1 2.9 3.0 2.8 2.8 2.8 2.9 2.8 2.9 2.6 2.3 2.5 3.0 2.9 2.9 55-59 2.3 2.3 2.3 2.1 2.1 2.1 2.2 2.1 2.1 2.1 1.6 1.9 2.2 2.2 2.2 60-64 2.5 2.1 2.3 2.0 1.8 1.9 2.2 1.8 2.0 1.6 1.4 1.5 2.3 1.9 2.1 65-69 1.7 1.5 1.6 1.2 1.1 1.1 1.4 1.3 1.4 1.2 0.7 1.0 1.5 1.3 1.4 70-74 1.6 1.2 1.4 1.1 0.9 1.0 1.2 0.9 1.1 0.8 0.6 0.7 1.4 1.0 1.2 75-79 0.7 0.5 0.6 0.5 0.4 0.4 0.6 0.5 0.5 0.4 0.3 0.4 0.6 0.5 0.6 80 + 1.2 0.9 1.1 0.6 0.5 0.6 1.0 0.6 0.8 0.7 0.6 0.7 1.0 0.8 0.9 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 Number 201,669 198,760 400,435 82,612 78,328 160,944 47,945 48,658 96,603 16,012 14,943 30,955 348,238 340,689 688,937 Note: Total includes 10 persons whose sex was not stated. The results indicate an overall sex ratio of 102 males per 100 females, an implausibly high ratio that is most probably due to a tendency to underreport women. The sex ratio is higher in urban areas (104 males per 100 females) than in rural areas (101 males per 100 females). As shown in Table 2.3, the sex ratio varies by age group, being over 100 in the younger and older age groups and under 100 at ages 20-39. The lower ratios in the prime working ages may be due in part to men leaving the country to work overseas or to differential age misreporting by sex. Table 2.3 Sex ratios by age Sex ratios for the house- hold population by five- year age groups, Pakistan 2006-07 Age group Sex ratio1 0-4 105 5-9 108 10-14 107 15-19 100 20-24 93 25-29 91 30-34 93 35-39 94 40-44 105 45-49 102 50-54 106 55-59 104 60-64 119 65 and over 128 Total 102 1 Sex ratio = (males/females)*100 Despite the implausibly high sex ratio in the PDHS, it is lower than that from previous surveys (Table 2.4). Comparison of PDHS results with those from previous surveys and the census show that the reported sex ratio varies from 108 males per 100 females in 1990-91 and 1998 to the current ratio of 102 males per 100 females (Table 2.4). The narrowing of the male- female ratio could be explained by the fact that during the 2006-07 PDHS, the enumeration of household members, especially females, was done in a careful and thorough manner, thus leading to a more plausible sex ratio. Table 2.4 also shows that about half of the total female population falls into the reproductive age group (15-49 years). The fact that this segment has been increasing over the last two decades has an impact, because they are in the childbearing years and hence contribute to overall population growth. Household Population and Housing Characteristics | 13 Table 2.4 Trends in age distribution of household population Percent distribution of household population by five-year age groups, overall sex ratio, and percent of women age 15-49, Pakistan 1990-2007 Age group PDHS 1990-91 PFFPS 1996-97 Census 1998 PRHFPS 2000-01 SWRHFPS 2003 PDHS 2006-07 0-4 13.4 14.4 14.8 13.8 13.1 13.4 5-9 17.4 15.4 15.7 14.3 14.2 14.3 10-14 13.7 13.3 13.0 13.2 13.5 12.9 15-19 10.2 11.4 10.4 11.9 11.5 11.9 20-24 8.1 8.6 9.0 9.3 9.3 9.5 25-29 7.1 7.4 7.4 7.4 7.2 7.6 30-34 5.4 5.6 6.2 5.8 5.6 5.7 35-39 4.6 4.7 4.8 4.9 5.4 5.3 40-44 4.0 3.6 4.4 3.9 4.1 4.3 45-49 3.0 2.9 3.5 2.8 3.5 3.8 50-54 3.2 3.2 3.2 3.6 3.6 2.9 55-59 2.4 2.7 2.2 2.4 2.4 2.2 60-64 2.7 2.6 2.0 2.5 2.5 2.1 65 and over 5.0 4.3 3.5 4.2 4.3 4.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Sex ratio 108 107 108 103 106 102 Female (15-49) 42.6 44.0 46.2 46.4 47.4 49.7 PFFPS = Pakistan Fertility and Family Planning Survey PRHFPS = Pakistan Reproductive Health and Family Planning Survey SWRHFPS = Status of Women, Reproductive Health, and Family Planning Survey Sources: PDHS 1990-91: NIPS and Macro, 1992; PFFPS 1996-97: Hakim et al., 1998; Census 1998: Government of Pakistan, 1998; PRHFPS 2000-01: NIPS 2001; SWRHFPS 2003: NIPS 2007a 2.2 HOUSEHOLD COMPOSITION In the PDHS, a household was defined as a person or group of related and unrelated persons who live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as head of the household, and who have common arrangements for cooking and eating. The household is considered to be the basic social and economic unit of society. Changes at the household level, therefore, have repercussions at the aggregate level of a country as a whole. Such changes also have an impact on the distribution of goods and services and on the planning and requirements of community institutions, schools, housing, and health infrastructure (Ekouevi et al., 1991). Table 2.5 shows the distribution of households in the survey by the sex of the head of the household and by the number of household members in urban and rural areas. Households in Pakistan are predominantly male-headed, with 92 percent of households being headed by a male and only 9 percent being headed by a female. The proportion of female-headed households is about the same in rural (9 percent) and urban areas (8 percent). This could be attributed to out-migration of the male population from rural areas to urban areas or even overseas for employment purposes. Female headship of households is of concern to policymakers, particularly those dealing with poverty issues, because it is usually financially difficult for a woman to manage a household alone (Osaki, 1991). The proportion of female-headed households has not changed much over the last two decades (data not shown). Households in Pakistan tend to be large because of the predominance of the extended and joint family system. Economic pressure can also force middle- and lower-income families to live with their in-laws and other relatives because they cannot afford to build or rent separate dwellings. The 2006-07 PDHS data show that the average household size observed in the survey is 7.2 persons (Table 2.5). The household size is slightly smaller in urban areas than in rural areas (7.0 persons versus 7.3 persons, respectively). It is interesting to note that the mean household size in major cities is smaller than that in other urban areas (6.9 persons compared with 7.3 persons, respectively). 14 | Household Population and Housing Characteristics The mean household size in Pakistan has increased from 6.9 in 2003 (NIPS, 2007) to the current size of 7.2 persons. The upward trend in household size could be due to two factors: first, a more complete enumeration of household population in the 2006-07 PDHS and, second, an increasing imbalance between the growth of housing stock and the growth of the population (Zahir, 2003). Table 2.5 Household composition Percent distribution of all households by sex of head of household and household size, and mean size of household, according to residence, Pakistan 2006-07 Residence Characteristic Total urban Major city Other urban Rural Total Household headship Male 91.8 91.2 92.6 91.3 91.5 Female 8.2 8.8 7.4 8.7 8.5 Total 100.0 100.0 100.0 100.0 100.0 Number of usual members 1 1.3 1.3 1.3 1.1 1.2 2 3.7 4.0 3.2 4.0 3.9 3 6.1 6.3 5.8 6.3 6.2 4 9.9 10.4 9.1 9.6 9.7 5 13.6 14.5 12.4 12.1 12.6 6 15.5 16.3 14.6 13.8 14.4 7 13.8 13.4 14.5 13.2 13.4 8 10.8 10.2 11.5 11.2 11.1 9+ 25.3 23.6 27.7 28.6 27.5 Total 100.0 100.0 100.0 100.0 100.0 Mean size of households 7.0 6.9 7.3 7.3 7.2 Number of households 32,547 18,779 13,767 62,894 95,441 Note: Table is based on de jure household members, i.e., usual residents. Detailed information on children’s orphanhood is presented in Table 2.6. In Pakistan, the majority of children under age 18 (95 percent) have both parents alive, 3 percent have only their mother alive, and 2 percent have only their father alive. Overall, 4 percent of children under 18 have one or both parents dead. Differences in children’s orphanhood by background characteristics are quite small, except for age. The proportion with one or both parents dead increases steadily with age, ranging from 1 percent among children 0-4 years old to 10 percent among those age 15-17. Household Population and Housing Characteristics | 15 Table 2.6 Children's orphanhood Percent distribution of de jure children under age 18, by survival status of parents, and the percentage of children with one or both parents dead, according to background characteristics, Pakistan 2006-07 Background characteristic Both alive Mother alive, father dead Father alive, mother dead Both dead Missing information on father/ mother Total Percentage with one or both parents dead Number of children Age 0-4 97.7 0.5 0.5 0.0 1.2 100.0 1.1 8,760 <2 97.8 0.3 0.4 0.0 1.5 100.0 0.7 3,443 2-4 97.6 0.6 0.6 0.1 1.1 100.0 1.3 5,317 5-9 96.4 1.7 1.3 0.1 0.5 100.0 3.1 9,409 10-14 93.2 3.7 2.3 0.4 0.5 100.0 6.3 8,555 15-17 89.0 5.9 3.5 0.4 1.2 100.0 9.9 4,766 Sex Male 94.4 2.8 1.7 0.2 0.9 100.0 4.6 16,146 Female 95.1 2.3 1.7 0.2 0.7 100.0 4.2 15,341 Residence Total urban 94.4 2.8 1.7 0.2 0.9 100.0 4.7 9,847 Major city 95.5 2.3 1.3 0.2 0.7 100.0 3.8 5,207 Other urban 93.2 3.4 2.1 0.2 1.1 100.0 5.7 4,640 Rural 94.9 2.4 1.7 0.2 0.7 100.0 4.3 21,643 Province Punjab 94.8 2.5 1.6 0.2 0.9 100.0 4.3 17,482 Sindh 94.3 2.7 2.2 0.2 0.7 100.0 5.0 7,695 NWFP 94.9 2.6 1.3 0.4 0.7 100.0 4.3 4,792 Balochistan 95.8 2.0 1.1 0.1 0.9 100.0 3.3 1,521 Wealth quintile Lowest 94.8 2.7 1.8 0.2 0.5 100.0 4.7 7,049 Second 94.1 2.7 1.9 0.4 1.0 100.0 4.9 6,642 Middle 94.0 2.6 2.2 0.0 1.2 100.0 4.8 6,428 Fourth 95.3 2.6 1.3 0.1 0.6 100.0 4.0 6,039 Highest 95.8 2.0 1.2 0.2 0.7 100.0 3.5 5,331 Total <15 95.8 1.9 1.4 0.2 0.7 100.0 3.5 26,724 Total <18 94.8 2.6 1.7 0.2 0.8 100.0 4.4 31,490 Note: Table is based on de jure members, i.e., usual residents. Total includes 2 children with sex missing. 2.3 EDUCATION OF THE HOUSEHOLD POPULATION Studies show that education is one of the major social factors that influence a person’s behaviour and attitude. In general, the higher the level of education of a woman, the more knowledgeable she is about the use of health facilities, family planning methods, and the health of her children. In Pakistan, there are several levels of education. Children generally enter primary school at age 5; this level comprises Classes 1 through 5. Middle school consists of Classes 6 through 8, secondary school is Classes 9 and 10, and higher secondary is Classes 11 and 12. Class 13 and above is college and university level education. 2.3.1 Educational Attainment of Household Population Tables 2.7.1 and 2.7.2 show the percent distribution of the de facto female and male household population age five and over by highest level of education attended, according to background characteristics.1 Survey results show that more than half of women and about one-third of men in Pakistan have no education. Overall, females are less educated than males. Twenty-seven percent of females and 33 percent of males have attended primary school only, 8 percent of females and 13 percent of males have attended middle school only, and 7 percent of females and 14 percent of males have attended secondary education only. Overall, 6 percent of females and 10 percent of males 1 A similar table for both sexes combined appears as Table A.1 in the appendix. 16 | Household Population and Housing Characteristics have attended higher than secondary education. The gender differentials in education could be attributed to cultural norms and the social constraints faced by women in Pakistan. When investigating the changes in educational attainment by successive age groups, survey results show that there has been a marked improvement in the educational attainment of both women and men. For example, the proportion of women with no education has declined significantly from 94 percent among women age 65 and over to 30 percent among women age 10-14. A similar pattern is noticeable among men, with the proportion of men with no education declining from 67 percent among those age 65 and over to just 17 percent among those age 10-14. Table 2.7.1 Educational attainment of the female household population Percent distribution of the de facto female household population age five and over by highest level of schooling attended and median years completed, according to background characteristics, Pakistan 2006-07 Education1 Median years completed Background characteristic No education Primary Middle Secondary Higher secondary+ Missing Total Number Age 5-9 35.8 63.9 0.0 0.0 0.0 0.3 100.0 47,494 0.0 10-14 29.5 52.3 16.6 1.5 0.0 0.1 100.0 42,850 2.2 15-19 36.6 20.7 17.1 17.0 8.5 0.1 100.0 40,912 4.4 20-24 42.5 16.5 9.7 14.1 17.1 0.2 100.0 34,037 4.2 25-29 52.8 14.5 7.5 11.9 13.1 0.2 100.0 27,428 0.0 30-34 63.4 12.5 5.6 8.7 9.6 0.2 100.0 20,226 0.0 35-39 69.8 12.4 4.6 6.8 6.3 0.1 100.0 18,914 0.0 40-44 74.0 10.8 4.7 5.6 4.8 0.1 100.0 14,563 0.0 45-49 78.8 9.7 3.4 4.5 3.6 0.1 100.0 12,814 0.0 50-54 82.0 8.1 3.1 3.6 3.0 0.3 100.0 9,723 0.0 55-59 87.0 6.0 2.4 2.5 1.9 0.2 100.0 7,408 0.0 60-64 90.5 4.3 2.0 1.4 1.5 0.3 100.0 6,611 0.0 65+ 94.2 2.9 1.1 0.9 0.5 0.4 100.0 12,404 0.0 Residence Total urban 32.8 28.7 11.9 13.2 13.2 0.2 100.0 99,877 3.3 Major city 28.0 27.2 13.0 15.3 16.3 0.2 100.0 56,276 4.4 Other urban 39.0 30.6 10.6 10.4 9.3 0.2 100.0 43,601 1.2 Rural 61.3 26.4 5.8 3.9 2.3 0.2 100.0 195,622 0.0 Province Punjab 46.0 30.2 9.1 8.1 6.5 0.2 100.0 173,732 0.0 Sindh 56.4 22.7 6.5 6.8 7.3 0.2 100.0 67,107 0.0 NWFP 61.9 24.5 6.2 4.1 3.0 0.2 100.0 41,956 0.0 Balochistan 69.5 19.1 4.9 3.5 2.6 0.5 100.0 12,704 0.0 Wealth quintile2 Lowest 83.2 15.2 0.9 0.2 0.1 0.3 100.0 8,450 0.0 Second 70.2 24.9 3.0 1.1 0.5 0.3 100.0 9,831 0.0 Middle 55.7 32.2 7.1 3.6 1.2 0.2 100.0 9,149 0.0 Fourth 38.7 34.4 12.3 9.3 5.1 0.1 100.0 8,337 1.1 Highest 21.8 28.1 13.8 17.6 18.6 0.2 100.0 8,055 5.0 Total 51.6 27.2 7.9 7.0 6.0 0.2 100.0 295,499 0.0 1 Primary = Class 1-5; middle = Class 6-8; secondary = Class 9-10; higher = Class 11 or more 2 Data refer only to individuals in households interviewed with the Long Household Questionnaire. As expected, the proportion of respondents with no education is much higher among the rural than the urban population. For example, 61 percent of females in rural areas have no education compared with only 33 percent of females in urban areas. Among men, the proportion with no education varies from 36 percent of those in rural areas to 20 percent of those in urban areas. The urban-rural difference in educational attainment is undoubtedly due to a lack of education facilities or their inaccessibility in rural areas. Regarding provincial variation, the proportion of women and men with no education is highest in Balochistan (70 and 46 percent, respectively) and lowest in Punjab (46 and 28 percent, respectively). Educational attainment is strongly associated with wealth; the proportion of both Household Population and Housing Characteristics | 17 women and men with no education is highest among those in the lowest quintiles and decreases steadily with increasing wealth. Eighty-three percent of women in the lowest wealth quintile have no education compared with only 22 percent in the highest quintile. Similarly, 58 percent of men in the lowest quintile have no education compared with 10 percent in the highest quintile. The proportion of women and men with no education has decreased significantly since the 1990-91 PDHS, while the proportions who have attended each level of education have increased. Table 2.7.2 Educational attainment of the male household population Percent distribution of the de facto male household population age five and over by highest level of schooling attended and median years completed, according to background characteristics, Pakistan 2006-07 Education1 Median years completed Background characteristic No education Primary Middle Secondary Higher than secondary Missing Total Number Age 5-9 27.9 71.7 0.1 0.0 0.0 0.3 100.0 51,098 0.0 10-14 16.8 62.3 19.3 1.4 0.1 0.1 100.0 45,995 2.9 15-19 20.0 21.8 26.6 23.5 7.9 0.1 100.0 40,815 6.3 20-24 21.2 16.9 17.8 24.5 19.4 0.2 100.0 31,513 7.4 25-29 24.5 15.2 15.6 24.6 19.9 0.3 100.0 25,008 7.5 30-34 30.1 14.3 13.2 21.9 20.3 0.3 100.0 18,703 7.1 35-39 37.1 15.2 11.4 18.0 18.0 0.3 100.0 17,712 4.8 40-44 41.6 15.0 11.7 16.9 14.6 0.2 100.0 15,230 4.4 45-49 43.3 15.0 10.9 17.8 12.6 0.3 100.0 13,069 4.2 50-54 47.3 14.8 9.7 15.6 12.3 0.4 100.0 10,303 2.8 55-59 50.2 16.1 9.2 13.3 11.0 0.3 100.0 7,696 0.0 60-64 56.5 15.4 8.0 12.2 7.4 0.4 100.0 7,894 0.0 65+ 67.4 13.3 6.6 7.5 4.6 0.5 100.0 15,834 0.0 Residence Total urban 20.2 30.5 14.7 17.4 17.0 0.2 100.0 103,543 4.9 Major city 18.9 28.5 14.8 18.4 19.2 0.2 100.0 58,956 5.7 Other urban 22.0 33.2 14.6 16.0 14.0 0.3 100.0 44,587 4.5 Rural 35.5 34.2 12.8 11.7 5.6 0.2 100.0 197,449 1.4 Province Punjab 27.8 34.1 14.7 14.7 8.4 0.2 100.0 175,516 3.5 Sindh 34.1 31.3 9.9 11.3 12.9 0.4 100.0 70,946 2.3 NWFP 28.9 33.1 15.0 14.1 8.7 0.2 100.0 40,833 2.7 Balochistan 45.7 25.0 10.0 10.3 8.6 0.4 100.0 13,697 0.0 Wealth quintile2 Lowest 57.5 30.6 5.6 4.5 1.4 0.4 100.0 9,018 0.0 Second 40.0 36.2 11.4 8.6 3.3 0.5 100.0 9,970 0.1 Middle 30.0 37.8 13.8 12.8 5.4 0.3 100.0 9,084 2.4 Fourth 20.1 35.8 16.3 17.9 9.5 0.4 100.0 8,522 4.4 Highest 10.2 26.6 15.9 22.9 24.3 0.2 100.0 8,034 7.7 Total 30.3 32.9 13.4 13.6 9.5 0.2 100.0 300,992 2.9 1 Primary = Class 1-5; middle = Class 6-8; secondary = Class 9-10; higher = Class 11 or more 2 Data refer only to individuals in households interviewed with the Long Household Questionnaire. 2.3.2 School Attendance Ratios Data on net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by school level and sex, according to residence, province, and wealth index, are shown in Table 2.8. The NAR indicates participation in primary schooling for the population age 5-9 and in middle/secondary school for the population age 10-14. The GAR measures participation at each level of schooling among those of any age. The GAR is nearly always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level.2 A NAR of 100 percent would indicate that all those in the official age range for the level are attending at that level. The GAR can exceed 100 percent if there is significant over-age or under-age participation at a given level of schooling. 2 Students who are over-age for a given level of schooling may have started school over-age, may have repeated one or more grades in school, or may have dropped out of school and later returned. 18 | Household Population and Housing Characteristics Table 2.8 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Pakistan 2006-07 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Total urban 78.4 76.4 77.4 0.97 114.4 105.1 109.8 0.92 Major city 81.9 78.7 80.3 0.96 118.0 106.8 112.4 0.90 Other urban 74.7 73.9 74.3 0.99 110.7 103.3 107.1 0.93 Rural 66.4 56.3 61.6 0.85 103.2 83.2 93.7 0.81 Province Punjab 76.5 73.2 75.0 0.96 112.8 102.8 108.1 0.91 Sindh 58.7 49.7 54.4 0.85 87.9 69.3 79.0 0.79 NWFP 72.0 53.0 62.3 0.74 121.5 82.9 101.7 0.68 Balochistan 46.7 37.0 42.2 0.79 86.5 73.7 80.6 0.85 Wealth quintile Lowest 49.2 32.2 41.5 0.65 76.8 49.9 64.6 0.65 Second 64.5 53.3 58.8 0.83 113.4 79.7 96.2 0.70 Middle 75.3 71.6 73.5 0.95 111.8 110.4 111.1 0.99 Fourth 84.4 81.1 82.9 0.96 125.9 115.1 120.8 0.91 Highest 87.7 87.8 87.8 1.00 117.5 109.4 113.5 0.93 Total 69.8 62.2 66.2 0.89 106.3 89.7 98.4 0.84 MIDDLE/SECONDARY SCHOOL Residence Total urban 35.9 40.2 37.9 1.12 62.2 68.3 65.2 1.10 Major city 38.4 43.6 40.9 1.13 65.1 70.6 67.8 1.09 Other urban 32.9 36.0 34.4 1.10 58.9 65.5 62.0 1.11 Rural 25.9 18.0 22.1 0.70 53.3 33.0 43.4 0.62 Province Punjab 31.9 30.6 31.2 0.96 57.4 53.3 55.5 0.93 Sindh 24.9 20.3 22.7 0.82 46.7 33.5 40.2 0.72 NWFP 28.5 17.4 22.9 0.61 67.6 32.7 50.1 0.48 Balochistan 19.4 12.6 16.1 0.65 54.1 32.8 43.8 0.60 Wealth quintile Lowest 12.3 4.9 8.7 0.40 25.6 7.7 16.9 0.30 Second 19.4 9.6 14.7 0.50 46.1 19.3 33.0 0.42 Middle 30.3 22.5 26.5 0.74 58.7 44.6 51.8 0.76 Fourth 37.2 40.3 38.7 1.08 70.1 74.7 72.3 1.07 Highest 50.3 54.4 52.3 1.08 86.0 84.4 85.2 0.98 Total 29.2 25.3 27.3 0.87 56.3 44.5 50.6 0.79 1 The NAR for primary school is the percentage of the primary-school-age (5-9 years) population that is attending primary school. The NAR for middle/secondary school is the percentage of the middle/secondary-school-age (10-14 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for middle/secondary school is the total number of middle/secondary school students, expressed as a percentage of the official middle/secondary-school-age population. If there are significant numbers of over-age and under-age students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. The Gender Parity Index for middle/secondary school is the ratio of the middle/secondary school NAR (GAR) for females to the NAR (GAR) for males. Sixty-six percent of primary-school-age children are currently attending primary school. At the same time, only 27 percent of middle/secondary-school-age youths are attending that level. The NAR is higher among males than among females at both primary and middle/secondary levels. Attendance ratios are much lower in rural than urban areas and are the lowest in Balochistan and highest in Punjab. Household Population and Housing Characteristics | 19 The GAR is higher among males than females—106 and 90, respectively, at the primary- school level and 56 and 45, respectively, at the secondary-school level—indicating higher attendance among males than among females. Although the overall GAR at the primary-school level is 98, there are significant levels of over-age and/or under-age participation in the urban areas (110) and also in Punjab (108) and NWFP (102). There is a strong relationship between household economic status and schooling that can be seen at both the primary and middle/secondary levels. For example, the primary- school NAR increases from 42 percent among the student-age population from poorer households (lowest wealth quintile) to 88 percent among those from richer households (highest wealth quintile). Similarly, the middle/secondary school NAR rises from 9 percent of those in the lowest wealth quintile to 52 percent among those in the highest wealth quintile. The Gender Parity Index (GPI) represents the ratio of the GAR for females to the GAR for males. It is presented at both the primary and middle/secondary levels and offers a summary measure of gender differences in school attendance rates. A GPI less than one indicates that a smaller proportion of females than males attends school. In Pakistan, the GPI is less than one (0.8) for both primary and middle/secondary school attendance. There are marked differences in the GPI by place of residence and by province. The primary and middle/secondary school GPI is lower in rural areas than in urban areas, with the difference being more pronounced for middle/secondary school attendance. Looking at provinces, the GPI for both primary and middle/secondary education is highest in Punjab and lowest in NWFP. The age-specific attendance rates for the population age 5-24 years by sex are shown in Figure 2.2. These rates indicate participation in schooling at any level, from primary to higher levels of education. The minimum age for schooling in Pakistan is five. Nevertheless, only half of boys and about four in ten girls age five are attending school, indicating that a significant proportion of children that age in Pakistan have not entered the school system. It is possible that a substantial proportion of the children age five are not attending school because they turned five after the start of the school year and were thus too young to start in that year. Between ages 5 and 11 the proportion of both males and females attending school generally increases, and then it starts declining steadily thereafter. Overall, a higher proportion of males than females attends school for all ages. Figure 2.2 Age-Specific Attendance Rates of the De-Facto Population Age 5 to 24 Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Male Female PDHS 2006-07 20 | Household Population and Housing Characteristics 2.4 HOUSING CHARACTERISTICS The physical characteristics and availability and accessibility of basic household facilities are important in assessing the general welfare and socioeconomic condition of the population. In the 2006-07 PDHS, respondents in the sub-sample in which the Long Household Questionnaire was administered were asked about household drinking water and household sanitation facilities that included questions on the source of drinking water, time taken to travel to the nearest source of water, the person who usually collects drinking water, water treatment before drinking, and questions on sanitation facilities. Table 2.9 presents information on household drinking water. The majority (93 percent) of households in Pakistan have access to an improved source of drinking water with access in urban areas slightly higher than in rural areas (95 and 92 percent, respectively). The most common source of improved drinking water in urban areas is piped water, with 66 percent of households having access to this source, most commonly with a pipe directly into the house or plot. On the other hand, only 24 percent of rural households have access to piped water. The major source of improved drinking water in rural areas is a tubewell, borehole, or hand pump (62 percent). Table 2.9 Household drinking water Percent distribution of households and de jure population by source and time to collect drinking water; and percentage of households and the de jure population by treatment of drinking water, according to residence, Pakistan 2006-07 Households Population Characteristic Total urban Major city Other urban Rural Total Total urban Major city Other urban Rural Total Source of drinking water Improved source1 94.5 92.8 96.9 91.9 92.8 94.0 92.1 96.4 91.9 92.6 Piped into dwelling/yard/plot (piped) 62.3 77.8 41.6 22.0 35.8 61.7 77.9 41.3 23.2 36.3 Public tap/standpipe (piped) 3.6 3.2 4.2 1.8 2.4 3.6 3.2 4.2 1.6 2.3 Tubewell/borehole/hand pump 25.4 8.3 48.4 62.1 49.6 25.9 8.3 48.1 61.0 49.1 Protected dug well 1.3 0.6 2.3 5.0 3.7 1.4 0.7 2.3 5.0 3.8 Protected spring/karez 0.0 0.0 0.1 0.6 0.4 0.1 0.0 0.1 0.8 0.5 Rainwater 0.1 0.0 0.1 0.3 0.2 0.1 0.0 0.1 0.3 0.2 Bottled water 1.7 2.8 0.3 0.0 0.6 1.2 2.1 0.2 0.0 0.4 Non-improved source 4.0 5.4 2.1 7.1 6.1 4.7 6.3 2.6 7.2 6.3 Unprotected dug well 0.0 0.0 0.1 1.8 1.2 0.0 0.0 0.1 1.7 1.1 Unprotected spring 0.0 0.0 0.0 1.7 1.1 0.0 0.0 0.0 1.6 1.1 Tanker truck/cart with tank 2.7 3.7 1.5 0.6 1.3 3.2 4.2 1.9 0.6 1.5 Surface water 1.2 1.8 0.5 3.1 2.5 1.4 2.1 0.6 3.3 2.7 Other 1.3 1.5 0.9 1.0 1.1 1.1 1.2 0.8 0.9 0.9 Missing 0.2 0.3 0.1 0.0 0.1 0.3 0.3 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 89.2 89.1 89.2 78.0 81.8 88.9 88.4 89.6 77.9 81.6 Less than 30 minutes 5.6 5.4 5.8 11.4 9.4 5.4 5.6 5.2 11.1 9.2 30 minutes or longer 3.5 3.7 3.2 9.2 7.3 3.7 3.8 3.5 9.4 7.4 Don't know/missing 1.7 1.7 1.7 1.4 1.5 2.0 2.2 1.7 1.7 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment2 Boiled 17.9 27.9 4.6 1.2 6.9 16.0 25.0 4.6 1.3 6.2 Bleach/chlorine 1.3 1.9 0.5 0.1 0.5 1.5 2.1 0.6 0.2 0.6 Strained through cloth 3.7 5.2 1.8 1.1 2.0 3.7 5.2 1.7 1.1 2.0 Ceramic, sand or other filter 3.3 5.0 1.2 0.3 1.3 3.1 4.7 1.1 0.3 1.3 Solar disinfection 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.1 0.0 0.0 Let it stand and settle 1.2 1.7 0.5 0.3 0.6 1.1 1.6 0.5 0.3 0.6 Other 0.1 0.2 0.0 0.1 0.1 0.1 0.2 0.0 0.1 0.1 No treatment 74.8 61.8 92.3 96.9 89.4 76.8 64.5 92.2 96.8 90.0 Percentage using an appropriate treatment method3 24.5 37.4 7.4 2.7 10.1 22.6 34.6 7.4 2.8 9.5 Number 3,159 1,808 1,350 6,096 9,255 22,389 12,485 9,904 43,757 66,145 1 Households using bottled water for drinking are classified as using an improved source. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. Household Population and Housing Characteristics | 21 More than eight in ten households (82 percent) report having water on their premises. Households not having access on their premises were asked for the time taken to fetch water. About one-tenth of all households take less than 30 minutes to fetch drinking water, while 7 percent take 30 minutes or longer to do so. In the survey, household respondents were asked whether they treat water before drinking. An overwhelming majority of households (89 percent) do not treat drinking water. Urban households (25 percent) are much more likely than rural households (3 percent) to treat drinking water, mostly by boiling. Even in major cities, only 37 percent of the households treat their drinking water appropriately. Appendix Table A.2 presents information on household drinking water by province. Data show that availability of an improved source of drinking water is highest in Punjab (96 percent) and lowest in NWFP (83 percent). On the other hand, the practice of appropriate water treatment is highest in Sindh (22 percent) and lowest in NWFP and Balochistan (3 percent each). The sanitation situation of a household has direct implications on the hygienic and health status of household members. Absence of sanitary disposal of waste exposes people to risk of acquiring infections and other diseases. Table 2.10 presents information on household sanitation facilities by type of toilet/latrine. Three in ten Pakistani households do not have any toilet facility, a statistic that is considerably higher among rural households (43 percent) than urban households (4 percent). Overall, half of households use improved toilets that are not shared with other households. Urban households (78 percent) are more than twice as likely as rural households (36 percent) to have improved toilet facilities. In urban areas, a flush/pour flush to piped sewer system (60 percent) is the major type of improved toilet facility, while in rural areas a flush/pour flush to septic tank facility (16 percent) is the most common type of improved facility. The seriousness of the sanitary situation is evident from the fact that only 28 percent of households have a toilet that flushes into a piped sewer system. As expected, Balochistan has the highest proportion of households with no toilet facility at all (43 percent), while Punjab and Sindh have the lowest (29 percent each; see Appendix Table A.3). Table 2.10 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Pakistan 2006-07 Households Population Type of toilet/latrine facility Total urban Major city Other urban Rural Total Total urban Major city Other urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 59.6 77.0 36.3 11.7 28.0 59.3 77.4 36.5 12.2 28.2 Flush/pour flush to septic tank 11.2 5.1 19.4 16.3 14.6 11.5 5.3 19.3 17.3 15.4 Flush/pour flush to pit latrine 5.7 3.6 8.4 6.0 5.9 6.1 3.9 8.8 6.6 6.4 Ventilated improved pit (VIP) latrine 0.3 0.0 0.7 0.8 0.7 0.4 0.0 0.9 0.8 0.7 Pit latrine with slab 1.0 1.1 0.8 1.0 1.0 1.1 1.3 0.9 1.1 1.1 Non-improved facility Any facility shared with other households 9.3 10.4 8.0 4.9 6.4 8.6 9.6 7.4 4.4 5.9 Flush/pour flush not to sewer/septic tank/pit latrine 2.2 0.8 4.1 2.6 2.5 2.5 0.7 4.8 2.8 2.7 Pit latrine without slab/open pit 0.8 0.1 1.7 3.7 2.7 0.8 0.1 1.7 4.0 2.9 Bucket 0.5 0.2 0.9 1.8 1.3 0.5 0.1 0.9 1.9 1.4 Hanging toilet/hanging latrine 5.3 0.3 11.9 7.4 6.7 5.2 0.3 11.3 7.1 6.5 No facility/bush/field 3.6 0.8 7.2 43.3 29.8 3.4 0.8 6.7 41.2 28.4 Other 0.0 0.0 0.0 0.2 0.1 0.0 0.0 0.0 0.2 0.1 Missing 0.7 0.7 0.6 0.3 0.4 0.7 0.5 0.8 0.2 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,159 1,808 1,350 6,096 9,255 22,389 12,485 9,904 43,757 66,145 22 | Household Population and Housing Characteristics Information on housing characteristics such as availability of electricity; type of material used in the floors, roof, and walls; number of rooms used for sleeping; type of fuel used for cooking; place for cooking; and type of fire/stove is shown in Table 2.11. About nine in ten households in Pakistan have electricity, with a strong difference by place of residence. Only 84 percent of households in rural areas have access to electricity compared with 98 percent of urban households. Half of Pakistani households have earth or sand floors and three in ten have cement floors. Rural households are more likely than urban households to have earth, sand, or mud floors, while urban households are more likely than rural households to have floors made with cement. Table 2.11 Housing characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking, according to residence, Pakistan 2006-07 Households Population Housing characteristic Total urban Major city Other urban Rural Total Total urban Major city Other urban Rural Total Electricity Yes 98.3 99.6 96.7 84.4 89.2 98.5 99.7 97.0 85.2 89.7 No 1.5 0.3 3.2 15.5 10.7 1.4 0.2 2.9 14.7 10.2 Missing 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth/sand/mud 13.0 4.2 24.9 67.9 49.2 13.6 4.3 25.3 68.1 49.6 Chips/terrazo 15.7 21.4 8.0 2.3 6.8 15.4 21.2 8.0 2.4 6.8 Ceramic tiles 2.0 2.6 1.1 0.7 1.1 1.8 2.5 1.0 0.6 1.0 Marble 5.7 7.6 3.2 0.7 2.4 5.7 7.4 3.7 0.7 2.4 Cement 49.5 53.4 44.2 19.4 29.6 49.2 54.0 43.1 19.3 29.4 Carpet 1.8 3.0 0.2 0.1 0.7 1.7 2.9 0.2 0.1 0.6 Bricks 11.9 7.1 18.2 8.4 9.6 12.2 7.4 18.3 8.2 9.6 Other/missing 0.4 0.6 0.3 0.5 0.5 0.4 0.5 0.3 0.6 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Main wall material Mud/stones 5.2 2.0 9.6 29.6 21.3 5.6 1.9 10.3 30.3 22.0 Bamboo/sticks/mud 2.0 0.5 3.9 11.1 8.0 2.1 0.7 3.8 11.0 8.0 Unbaked bricks/mud 2.7 1.2 4.6 6.9 5.5 2.7 1.2 4.5 7.0 5.5 Stone blocks 1.0 0.9 1.1 0.5 0.7 0.9 0.7 1.1 0.5 0.6 Baked bricks 18.7 9.2 31.3 22.2 21.0 19.3 9.4 31.8 22.2 21.2 Cement blocks/cement 70.0 85.4 49.3 28.8 42.9 69.0 85.4 48.2 28.1 41.9 Other/missing 0.5 0.8 0.2 0.9 0.7 0.5 0.7 0.3 1.0 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Main roof material Thatch/palm leaf 12.7 7.2 20.1 43.8 33.2 12.9 7.4 19.9 44.0 33.5 Iron sheets/asbestos 6.1 8.1 3.4 1.8 3.3 6.3 8.3 3.8 1.8 3.3 T-iron/wood/brick 30.8 17.7 48.5 40.8 37.4 31.2 18.0 47.9 40.7 37.5 Reinforced brick cement/ reinforced concrete cement 49.8 66.5 27.4 13.2 25.7 49.2 66.0 27.9 13.3 25.5 Other/missing 0.5 0.6 0.6 0.3 0.5 0.4 0.4 0.6 0.3 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 31.6 31.9 31.2 38.1 35.9 24.5 24.9 24.0 29.7 27.9 Two 41.4 40.0 43.3 40.4 40.8 40.5 38.2 43.4 40.3 40.4 Three or more 25.9 26.6 25.0 20.8 22.6 34.1 35.5 32.3 29.4 31.0 Missing 1.0 1.5 0.4 0.7 0.8 1.0 1.5 0.4 0.7 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.2 0.1 0.3 0.3 0.2 0.2 0.1 0.4 0.2 0.2 Cylinder gas 6.1 3.1 10.0 3.9 4.6 5.7 3.2 8.8 3.3 4.1 Natural gas 70.0 90.2 42.9 3.9 26.5 69.2 89.9 43.1 4.3 26.3 Biogas 1.0 0.4 1.7 1.9 1.6 1.2 0.5 2.1 2.0 1.7 Charcoal 0.1 0.0 0.3 0.6 0.4 0.1 0.0 0.2 0.6 0.4 Wood 18.8 4.2 38.4 67.5 50.9 19.5 4.2 38.7 69.0 52.2 Straw/shrubs/grass 0.9 0.5 1.5 6.5 4.6 1.0 0.7 1.4 5.9 4.3 Agricultural crop 0.4 0.0 0.9 5.5 3.7 0.3 0.0 0.8 5.4 3.7 Animal dung 2.0 0.8 3.5 9.5 6.9 2.4 1.0 4.2 9.1 6.9 No food cooked in household 0.4 0.4 0.3 0.2 0.2 0.1 0.1 0.1 0.0 0.0 Other/missing 0.2 0.2 0.3 0.2 0.2 0.2 0.2 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 22.2 5.4 44.5 89.6 66.6 23.4 6.0 45.3 90.0 67.4 Number of households 3,159 1,808 1,350 6,096 9,255 22,389 12,485 9,904 43,757 66,145 1 Includes charcoal, wood, straw/shrubs/grass, agricultural crops, and animal dung Household Population and Housing Characteristics | 23 More than two in five households use cement blocks or cement for the construction of the main walls of the dwelling, much more so in urban areas (70 percent) than in rural areas (29 percent). Furthermore, one in five households uses either mud and stones or baked bricks for the main walls. Thirty-seven percent of Pakistani households use T-iron, wood, or brick as the main roofing material for their dwellings, while 33 percent use thatch or palm leaves and 26 percent use reinforced brick cement or reinforced concrete cement (RCC). The most commonly used material for con- struction of roofs in urban areas is reinforced brick cement or RCC, while in rural areas it is thatch or palm leaves. Data were also collected on the number of sleeping rooms per household. Forty-one percent of households have two rooms for sleeping, 36 percent have only one room, and 23 percent have three or more rooms for sleeping. There are no major variations in the number of rooms used for sleeping by urban-rural residence. Slightly over half of households (51 percent) use wood for cooking, while more than one in four (27 percent) use natural gas. Wood is the most common form of cooking fuel in rural areas (68 percent), while natural gas is the most common form of cooking in urban areas (70 percent). Sixty- seven percent of the households in Pakistan use solid fuel for cooking (e.g., charcoal, wood, straw/shrubs/grass, agricultural crops, or animal dung) that generates smoke that is unhealthy to breathe. Rural households are much more likely than urban households to use solid fuels for cooking (90 and 22 percent. respectively). Data on housing characteristics by province are shown in Appendix Table A.4. 2.5 HOUSEHOLD POSSESSIONS Information on ownership of durable goods and other possessions is presented in Table 2.12. In general, ownership of household effects, means of transportation, and agricultural land and farm animals is indicative of a household’s social and economic well-being. The survey results show that about one-third (32 percent) of all households have a radio, more than half (56 percent) have a television, 46 percent have a telephone, and 37 percent have a refrigerator. Furthermore, 60 percent of households own a sewing machine, 43 percent own a washing machine, and 39 percent own a water pump. In general, households in rural Pakistan are much less likely to possess consumer items like televisions, telephones, refrigerators, sewing and washing machines, or water pumps than urban households. In general, Pakistanis are not very likely to own a means of transport. Bicycles are the most common means of transport, with 41 percent of households owning a bicycle. Overall, about one-fifth (18 percent) of households own a motorcycle or scooter and 7 percent own a car, truck, or tractor. Urban households are much more likely than rural households to own a motorcycle, a scooter, or a car. A large majority of rural households, in contrast to urban households, own agricultural land (50 and 13 percent, respectively) or farm animals (71 and 17 percent, respectively). 24 | Household Population and Housing Characteristics Table 2.12 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land, and livestock/farm animals, according to residence, Pakistan 2006-07 Households Population Possession Total urban Major city Other urban Rural Total Total urban Major city Other urban Rural Total Radio 28.8 27.4 30.6 33.2 31.7 29.5 27.8 31.6 35.6 33.5 Television 80.5 87.5 71.1 42.9 55.7 80.8 87.1 72.8 45.4 57.3 Telephone 65.9 72.4 57.2 35.2 45.7 67.2 73.3 59.5 38.7 48.3 Refrigerator 61.7 71.7 48.3 23.7 36.7 62.0 72.1 49.3 25.6 37.9 Room cooler/air conditioner 27.7 29.9 24.7 7.6 14.5 27.3 29.3 24.6 8.4 14.8 Washing machine 71.8 80.8 59.9 27.2 42.5 72.9 81.8 61.8 29.7 44.3 Water pump 53.2 53.6 52.7 31.4 38.8 54.4 55.0 53.6 32.6 40.0 Bed 83.4 83.9 82.7 69.3 74.1 83.5 83.3 83.8 71.0 75.2 Chair 66.4 67.1 65.4 48.9 54.9 66.4 67.3 65.3 49.4 55.2 Cabinet 67.8 77.4 54.9 31.2 43.7 69.3 78.4 57.8 33.8 45.8 Clock 92.2 97.2 85.6 69.3 77.1 92.9 97.6 86.9 71.4 78.7 Sofa 50.0 60.7 35.8 17.5 28.6 50.2 60.8 36.8 19.1 29.6 Sewing machine 75.6 80.2 69.5 52.5 60.4 77.8 82.3 72.2 55.9 63.3 Camera 20.1 24.1 14.9 6.1 10.9 20.6 23.5 17.0 7.2 11.7 Personal computer 18.5 24.4 10.6 2.8 8.1 18.0 23.3 11.2 3.1 8.1 Watch 88.2 90.6 85.0 76.8 80.7 89.3 91.3 86.8 79.7 83.0 Bicycle 37.5 34.6 41.2 42.4 40.7 40.6 38.3 43.5 45.1 43.6 Motorcycle/scooter 28.4 34.3 20.5 13.3 18.4 30.0 35.9 22.6 16.1 20.8 Car/truck/tractor 10.2 13.4 5.8 4.8 6.7 10.5 13.4 6.9 6.2 7.7 Animal-drawn cart 3.3 1.9 5.3 13.2 9.8 3.7 2.0 5.8 15.4 11.4 Boat with a motor 0.2 0.3 0.1 0.2 0.2 0.3 0.3 0.2 0.2 0.2 Ownership of agricultural land 13.1 8.0 19.8 49.7 37.2 14.2 9.1 20.6 51.3 38.7 Ownership of farm animals1 16.6 7.0 29.5 71.2 52.6 19.2 8.6 32.6 74.8 56.0 Number 3,159 1,808 1,350 6,096 9,255 22,389 12,485 9,904 43,757 66,145 1 Buffalo, cows, bulls, camels, donkeys, mules, horses, goats, sheep, chickens 2.6 SOCIOECONOMIC STATUS INDEX One of the background characteristics used throughout this report is an index of socio- economic status. The index used here was recently developed and tested in a large number of countries in relation to inequalities in household income, use of health services, and health outcomes (Rutstein et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The economic index was constructed using household asset data including ownership of a number of consumer items ranging from a television to a bicycle or car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities, and type of material used for flooring. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardized in relation to a normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed for the whole sample; separate indices were not prepared for urban and rural populations. Household Population and Housing Characteristics | 25 Table 2.13 presents data on wealth quintiles by residence and provinces. Overall, by definition, equal proportions of the Pakistani population fall in each quintile (20 percent each). However, the distribution by wealth quintile varies significantly by urban-rural residence. Forty-six percent of the population in urban areas is in the highest wealth quintile in contrast to 7 percent of the rural population. On the other hand, 29 percent of the rural population fall in the lowest quintile compared with only 3 percent of the urban population. The wealth quintile distribution by province shows large variation, with a relatively higher percentage of the population in Sindh and Punjab provinces (the most urbanized provinces) in the higher wealth quintiles and a higher percentage of the population in Balochistan in the lower wealth quintiles. Interestingly, Sindh province has relatively high proportions of population in both the lowest and highest wealth quintiles, implying that the province has relatively fewer middle-class households. Table 2.13 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, according to residence and region, Pakistan 2006-07 Wealth quintile Residence/region Lowest Second Middle Fourth Highest Total Number Residence Total urban 2.9 6.2 15.8 29.2 45.9 100.0 22,369 Major city 0.4 1.9 8.6 29.3 59.8 100.0 12,474 Other urban 6.1 11.6 24.8 29.0 28.4 100.0 9,895 Rural 28.7 27.0 22.2 15.3 6.7 100.0 43,718 Province Punjab 16.5 17.6 23.0 21.5 21.4 100.0 38,134 Sindh 29.0 15.6 12.3 19.7 23.3 100.0 15,697 NWFP 14.7 35.7 19.7 17.7 12.2 100.0 9,213 Balochistan 33.5 25.0 23.4 9.8 8.4 100.0 3,043 Total 20.0 20.0 20.0 20.0 20.0 100.0 66,088 2.7 AVAILABILITY OF SERVICES IN RURAL AREAS The 2006-07 PDHS used a Community Questionnaire that was administered in each of the 610 selected rural sample points. It included questions about the availability of various public services, such as schools, shops, transport, and health facilities. Because the data were provided by community informants and distances were not verified, the data should be viewed with some caution. Table 2.14 shows the percent distribution of rural households by distance to various services. There is a wide range in the distance of services from rural households. As might be expected, the vast majority of rural households are 10 or more kilometres from the district headquarters, ambulance services, ultrasound services for pregnant women, a functioning maternal and child health centre, and a hospital. Banks, rural health centres, and family welfare centres are also not likely to be close to rural households. In fact, the most available health-related personnel are dais (traditional birth attendants), dispensers/compounders of medicines, and hakims and homeopaths. A large majority of rural households are in communities in which primary schools are located; however, it is interesting that primary schools for boys are more likely to be in the community than primary schools for girls. 26 | Household Population and Housing Characteristics Table 2.14 Availability of services in rural areas Percent distribution of rural households by distance to selected services in their communities, Pakistan 2006-07 Number of kilometres to service Service In community1 1-4 km 5-9 km 10+ km Don’t know/ missing Total District headquarters 0.6 1.4 4.0 89.9 4.1 100.0 Medical store 25.4 23.2 18.6 29.1 3.7 100.0 General store or shop 65.4 7.3 8.2 15.6 3.5 100.0 Motorized public transport 63.2 14.5 6.3 11.4 4.5 100.0 Non-motorized public transport 70.2 8.9 3.7 7.8 9.4 100.0 Post office 31.7 22.7 14.3 27.8 3.5 100.0 Bank 12.2 18.0 23.0 41.8 4.9 100.0 Primary school for boys 88.5 7.0 1.2 0.8 2.6 100.0 Primary school for girls 78.2 8.5 5.2 5.6 2.6 100.0 Secondary school for boys 30.9 22.9 20.6 21.6 3.9 100.0 Secondary school for girls 21.1 20.0 21.2 32.8 5.0 100.0 Any ambulance service 8.1 8.4 16.7 60.3 6.4 100.0 Ultrasound services for pregnant women 8.4 9.4 16.2 60.5 5.5 100.0 Dai (traditional birth attendant) 60.5 14.2 8.9 11.5 4.9 100.0 Functioning basic health unit (BHU) 20.8 27.3 22.5 19.5 10.0 100.0 Rural health centre (RHC) 6.0 15.0 24.2 45.8 9.0 100.0 Government dispensary 14.4 18.6 23.5 31.9 11.7 100.0 Functioning maternal and child health (MCH) centre 5.2 9.6 17.4 56.8 10.9 100.0 Private doctor 18.1 20.6 21.3 33.9 6.2 100.0 Dispenser or compounder 54.7 15.6 9.8 13.1 6.8 100.0 Family welfare centre/source of family planning 18.7 14.0 18.5 41.0 7.9 100.0 Hakim or homeopath 39.6 14.1 14.1 27.0 5.2 100.0 Hospital 8.6 14.0 17.9 54.1 5.3 100.0 Note: Table is based on 62,894 rural households 1 Includes responses of “0” kilometres 2.8 REGISTRATION WITH THE NATIONAL DATABASE AND REGISTRATION AUTHORITY In March 2000, the Government of Pakistan established the National Database and Registration Authority (NADRA) to oversee the registration of the population. All children under 18 years are registered using the “Bay Form,” and adults age 18 years and older are issued a computerized national identity card (NIC). These documents are compulsory for obtaining any official document such as a passport or a driver’s license or for admission in schools or being hired in government jobs. In the 2006-07 PDHS, information was collected regarding the registration status of all household members. Results are shown in Table 2.15. Overall, three in ten children under age 18 have a Bay Form, while seven in ten adults have a NIC. This means that altogether four in ten Pakistanis do not have any form of registration. Females, rural residents, people living in NWFP and Balochistan, and those in the lower two wealth quintiles are less likely to be registered with NADRA when compared with other sub-groups. Differences in NADRA registration by sex are all due to a lower proportion of adult women with an identity card, because girls are as likely as boys to have a Bay Form. On the other hand, differences by urban-rural residence are almost entirely due to the differing proportions of children with Bay Forms; there are only minimal differences by residence in the proportion of adults with a NIC. Similarly, differences by province are largely in the registration of children with Bay Forms. Household Population and Housing Characteristics | 27 28 | Household Population and Housing Characteristics Table 2.15 Registration with NADRA Percentage of de jure household population who are registered with NADRA, according to back- ground characteristics, Pakistan 2006-07 Among those under age 18 Among those age 18 or over Among all ages Background characteristic Percentage with Bay Form Number Percentage with NIC Number Percentage with neither1 Number Sex Male 31.5 16,146 83.1 17,226 39.7 33,373 Female 31.2 15,341 63.7 17,430 48.1 32,771 Residence Total urban 38.8 9,847 75.5 12,542 37.1 22,389 Major city 44.6 5,207 76.7 7,278 33.0 12,485 Other urban 32.3 4,640 73.9 5,264 42.3 9,904 Rural 27.9 21,643 72.1 22,114 47.3 43,757 Province Punjab 39.8 17,482 74.7 20,686 38.1 38,168 Sindh 25.3 7,695 72.9 8,016 47.9 15,711 NWFP 15.7 4,792 67.7 4,429 57.4 9,221 Balochistan 13.3 1,521 73.8 1,525 54.6 3,046 Wealth quintile Lowest 20.2 7,049 66.4 6,184 56.4 13,233 Second 22.9 6,642 69.1 6,574 51.7 13,216 Middle 33.2 6,428 71.7 6,811 44.0 13,239 Fourth 38.7 6,039 75.2 7,198 38.1 13,237 Highest 45.8 5,331 82.1 7,890 29.3 13,221 Total 31.3 31,490 73.3 34,656 43.9 66,145 1 Excludes those who have a document appropriate for the other age group NADRA = National Database and Registration Authority (see text) NIC = National identicy card CHARACTERISTICS OF RESPONDENTS 3 Zahir Hussain and Zafar Iqbal Qamar This chapter provides a demographic and socioeconomic profile of ever-married women age 15-49 interviewed in the 2006-07 Pakistan Demographic and Health Survey (PDHS). Information on basic characteristics such as age, level of education, marital status, native language, and wealth status was collected. Literacy status was also examined, and detailed information was collected on employment status, occupation, and earnings. Such background information is important for better understanding the social and demographic findings presented in this report. Understanding how women’s education and employment are related to reproductive attitudes and behaviours can be helpful in promoting change, especially in patriarchal societies like Pakistan where the status of women is generally low. The slowing of the population growth is not only affected by the direct means of fertility management (family planning, age at marriage, duration of breastfeeding, abortion), but also indirectly by motivation to control fertility, which includes many factors. Central among these factors are reduced mortality, education (particularly of women), economic development (particularly poverty reduction), and the general status of women (Ministry of Population Welfare, 2002). 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 provides information on the background characteristics of the 10,023 ever-married women age 15-49 who were interviewed. This table is important in that it provides the background for interpreting findings presented later in the report. The proportion of ever-married women increases sharply from 6 percent in the 15-19 age group to 20 percent in the 25-29 age group, and falls steadily thereafter to 12 percent for the 45-49 age group. About six in ten (59 percent) women are under age 35. The majority of surveyed women (95 percent) are married, 3 percent are widowed, and 1 percent each are divorced or separated (Table 3.1). Place of residence is another characteristic that determines access to services and exposure to information pertaining to reproductive health and other aspects of life. Two-thirds (67 percent) of ever-married women age 15-49 in Pakistan reside in rural areas, while one-third (33 percent) reside in urban areas. About six in ten women live in Punjab province (58 percent) and one-quarter in Sindh province (24 percent), while the remaining reside in North-West Frontier Province (NWFP) (14 percent) and Balochistan (5 percent). Education is an important factor influencing an individual’s attitude and outlook on various aspects of life. A large majority of ever-married women in Pakistan (65 percent) have no education and only 6 percent have attained Class 11 or higher. Wealth and work status are important characteristics that shed light on the socioeconomic status of women in the society. Surveyed women are distributed almost equally among all five wealth quintiles. Looking at work status, it is important to note that six in ten ever-married women have never worked. One in four women in Pakistan is currently working. Characteristics of Respondents | 29 Table 3.1 Background characteristics of respondents Percent distribution of ever-married women age 15-49 by selected background characteristics, Pakistan 2006-07 Background characteristic Weighted percent Number of women Weighted Unweighted Age 15-19 5.7 569 578 20-24 15.0 1,499 1,560 25-29 20.0 2,006 2,010 30-34 17.8 1,786 1,716 35-39 16.5 1,654 1,649 40-44 13.0 1,301 1,282 45-49 12.1 1,208 1,228 Marital status Married 95.3 9,556 9,580 Divorced 0.5 53 44 Separated 1.0 98 79 Widowed 3.2 316 320 Residence Total urban 33.4 3,350 3,830 Major city 18.9 1,898 1,929 Other urban 14.5 1,452 1,901 Rural 66.6 6,673 6,193 Province Punjab 57.9 5,800 4,263 Sindh 24.0 2,410 2,716 NWFP 13.5 1,351 1,862 Balochistan 4.6 462 1,182 Education No education 65.0 6,511 6,665 Primary 14.2 1,423 1,344 Middle 6.3 634 589 Secondary 8.1 809 759 Higher 6.4 646 666 Wealth quintile Lowest 19.4 1,944 1,956 Second 20.0 2,001 2,036 Middle 19.4 1,944 1,946 Fourth 20.5 2,055 2,028 Highest 20.7 2,078 2,057 Work status1 Currently working 25.9 2,595 2,515 Worked only before marriage 7.5 752 749 Worked only after marriage 2.1 212 217 Worked before and after marriage 4.1 415 418 Never worked 60.2 6,037 6,113 Total 15-49 100.0 10,023 10,023 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Total includes 12 women missing work status. 1 Categories are mutually exclusive. 3.2 EDUCATIONAL ATTAINMENT AND LITERACY Education plays an important role in a country’s development, and progress can be a good investment for improving the quality of life of the people and for human development in general. National development programmes can be successfully accomplished if the population of the country is educated and adequately provided with knowledge and skills. Islam places great emphasis on acquiring education. Generally, education provides people with new ideas and increases their potential to learn, to respond to new opportunities, to adjust to social and cultural changes occurring around the world, and to participate in the sociocultural and political activities in the country. Education also can redirect the attitudes and behaviours of the population towards improvement in the quality of life. Furthermore, education helps to overcome poverty, increase income, improve health 30 | Characteristics of Respondents and nutrition, and reduce family size. Therefore, its relationship to population growth cannot be underestimated. Table 3.2 shows variations in the level of education among ever-married women, according to background characteristics. Overall, 65 percent of women in Pakistan have no education at all, 14 percent have attended primary school only, and 6 percent have reached middle school only, while 8 percent have some secondary education (Class 9-10) and 6 percent have reached Class 11 or higher. As expected, women in the 45-49 year age group are most likely to have no education. For example, the proportion of uneducated women is 79 percent among ever-married women age 45-49 compared with 55 percent among those aged 25-29. Slightly higher proportions of ever-married women age 15- 19 and 20-24 are uneducated, which can be explained by the fact that uneducated women are more likely to marry at a younger age than educated women. Table 3.2 Educational attainment Percent distribution of ever-married women age 15-49 by highest level of schooling attended or completed, according to background characteristics, Pakistan 2006-07 Education Background characteristic No education Primary (1-5) Middle (6-8) Secondary (9-10) Higher (11+) Total Number of women Age 15-19 65.7 17.8 9.8 5.5 1.2 100.0 569 20-24 57.6 18.1 9.3 9.7 5.3 100.0 1,499 25-29 54.8 16.2 7.1 12.3 9.6 100.0 2,006 30-34 62.7 12.0 6.8 8.9 9.6 100.0 1,786 35-39 70.1 14.1 4.0 5.9 5.8 100.0 1,654 40-44 72.4 11.9 4.5 6.8 4.5 100.0 1,301 45-49 79.0 10.0 4.2 3.3 3.4 100.0 1,208 Residence Total urban 43.1 15.5 10.3 16.1 15.0 100.0 3,350 Major city 35.0 14.6 11.4 19.8 19.1 100.0 1,898 Other urban 53.5 16.8 9.0 11.2 9.6 100.0 1,452 Rural 76.0 13.5 4.3 4.1 2.2 100.0 6,673 Province Punjab 59.7 16.9 7.9 8.9 6.6 100.0 5,800 Sindh 66.8 11.8 4.6 8.7 8.1 100.0 2,410 NWFP 77.4 10.1 3.9 4.9 3.8 100.0 1,351 Balochistan 85.0 4.9 2.6 4.3 3.2 100.0 462 Wealth quintile Lowest 95.1 4.2 0.6 0.1 0.0 100.0 1,944 Second 84.4 11.6 2.4 1.2 0.3 100.0 2,001 Middle 74.8 15.9 4.9 3.0 1.4 100.0 1,944 Fourth 50.1 22.9 10.7 11.0 5.2 100.0 2,055 Highest 23.5 15.8 12.4 24.0 24.3 100.0 2,078 Work status Currently working 74.6 9.6 4.5 4.6 6.7 100.0 2,595 Worked only before marriage 49.7 15.6 6.0 13.4 15.3 100.0 752 Worked only after marriage 63.1 18.8 5.4 4.6 8.2 100.0 212 Worked before and after marriage 76.3 10.5 5.2 2.4 5.7 100.0 415 Never worked 62.0 16.1 7.3 9.4 5.3 100.0 6,037 Total 65.0 14.2 6.3 8.1 6.4 100.0 10,023 Note: Education refers to the highest level attended, whether or not that level was completed. Total includes 12 women for whom work status is missing. As expected, the proportion of uneducated women is much lower in the urban areas than the rural areas (43 and 76 percent, respectively), while the proportion of educated women is higher in urban areas than in rural areas for all levels of education. Generally, women in major cities are better educated than those in other urban areas. Characteristics of Respondents | 31 Provincial variation in educational attainment follows the national pattern of development. Punjab province, being more developed, has the lowest proportion of uneducated women (60 percent), followed by Sindh (67 percent). In comparison, 85 percent of Balochi women and 77 percent of women residing in NWFP have no education. Among ever-married women, the highest proportion of women at every education level is found in Punjab, except for Class 11 and higher, where the highest proportion is found in Sindh. The lowest proportion of women in each education category is found in Balochistan. A clear inverse relationship exists between women’s education and wealth quintile. For example, ever-married women in the lowest quintile are four times more likely to be uneducated (95 percent) than those in the highest quintile (24 percent). Moreover, nearly half the women in the highest wealth quintile have attained secondary or higher education. When looking at the relationship between education and working status of women, it is worth noting that ever-married women who are either currently working or who worked before and after marriage are most likely to be uneducated, while those who worked only before marriage are the least likely to have no education. The overall proportion of uneducated women has decreased significantly from 79 percent in 1990-91 to 65 percent in 2006-07. The distribution of women’s education by age indicates that substantial progress has been made in all age groups since the 1990-91 PDHS. Literacy is widely acknowledged as benefiting the individual and the society and is associated with a number of positive outcomes for health and nutrition. In the 2006-07 PDHS, literacy status was determined based on the respondents’ ability to read all or part of a sentence. During data collection, interviewers carried a card on which simple sentences were printed in all of the major languages for testing a respondent’s reading ability. Only those who had never been to school and those whose highest grade at school was Class 1-8 were asked to read a sentence in the language they were most likely able to read; those who had attained middle school or above were assumed to be literate. Table 3.3 presents the percent distribution of ever-married women age 15-49 by level of schooling and level of literacy, according to background characteristics. Data show that only one-third (35 percent) of ever-married women age 15-49 in Pakistan are literate. The level of literacy increases from 32 percent among women age 15-19 to 45 percent among those age 25-29 and thereafter decreases substantially to 22 percent among women 45-49. Urban women are much more likely to be literate than rural women (58 and 24 percent, respectively), with the highest level of literacy being among women residing in a major city (66 percent). Provincial differences in literacy are marked, with literacy being highest among women in the predominantly urban Punjab province (41 percent) and lowest in the predominantly rural Balochistan province (15 percent). There is also a marked difference in literacy levels by women’s wealth status, ranging from a low of 6 percent among women in the lowest wealth quintile to a high of 75 percent among women in the highest wealth quintile. By work status, the highest level of literacy is found among ever-married women who worked only before marriage (49 percent), while the lowest is among those who worked before and after marriage (26 percent) and those who are currently working (27 percent). 32 | Characteristics of Respondents Table 3.3 Literacy Percent distribution of ever-married women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Pakistan 2006-07 No schooling or primary school Background characteristic Class 9 or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Percent- age literate1 Number Age 15-19 6.8 18.5 6.2 67.9 0.0 0.2 0.4 100.0 31.5 569 20-24 15.0 19.3 8.2 57.2 0.1 0.2 0.1 100.0 42.4 1,499 25-29 21.9 15.9 7.3 54.5 0.0 0.1 0.2 100.0 45.2 2,006 30-34 18.5 13.1 5.9 62.2 0.0 0.1 0.2 100.0 37.5 1,786 35-39 11.7 12.9 6.4 68.7 0.0 0.1 0.2 100.0 31.0 1,654 40-44 11.3 11.6 6.4 70.5 0.1 0.0 0.1 100.0 29.3 1,301 45-49 6.8 9.4 6.0 77.4 0.2 0.1 0.2 100.0 22.1 1,208 Residence Total urban 31.1 19.2 7.9 41.6 0.0 0.1 0.2 100.0 58.1 3,350 Major city 39.0 20.6 6.5 33.7 0.1 0.0 0.2 100.0 66.1 1,898 Other urban 20.8 17.3 9.6 51.9 0.0 0.3 0.2 100.0 47.7 1,452 Rural 6.2 11.7 6.1 75.6 0.1 0.1 0.2 100.0 24.1 6,673 Province Punjab 15.5 18.1 7.3 58.9 0.0 0.1 0.1 100.0 40.9 5,800 Sindh 16.8 10.0 6.5 66.0 0.2 0.2 0.3 100.0 33.3 2,410 NWFP 8.7 9.3 5.1 76.6 0.0 0.0 0.4 100.0 23.0 1,351 Balochistan 7.5 2.5 5.0 84.6 0.1 0.0 0.4 100.0 15.0 462 Wealth quintile Lowest 0.1 2.8 3.0 94.0 0.1 0.0 0.1 100.0 5.9 1,944 Second 1.5 7.7 5.9 84.5 0.2 0.2 0.1 100.0 15.1 2,001 Middle 4.4 14.6 7.1 73.4 0.1 0.1 0.2 100.0 26.2 1,944 Fourth 16.2 24.2 11.2 48.1 0.0 0.1 0.1 100.0 51.6 2,055 Highest 48.3 21.0 6.1 24.2 0.0 0.1 0.3 100.0 75.3 2,078 Work status Currently working 11.3 10.4 5.4 72.7 0.1 0.1 0.1 100.0 27.1 2,595 Worked only before marriage 28.7 14.4 6.3 50.0 0.0 0.3 0.3 100.0 49.4 752 Worked only after marriage 12.8 21.3 6.4 59.5 0.0 0.0 0.0 100.0 40.5 212 Worked before and after marriage 8.0 13.2 4.8 72.0 0.8 0.6 0.5 100.0 26.1 415 Never worked 14.7 15.6 7.5 62.0 0.0 0.1 0.2 100.0 37.8 6,037 Total 14.5 14.2 6.7 64.2 0.1 0.1 0.2 100.0 35.4 10,023 Note: Total includes 12 women for whom work status is missing. 1 Refers to women who completed Class 9 or higher and women who can read a whole sentence or part of a sentence 3.3 EMPLOYMENT 3.3.1 Employment Status Participation in the labour force not only gives women an opportunity to earn income, but also exposes them to the outside world and to authority structures and networks other than kin-based ones (Dixon-Muller, 1993). The empowering effects of employment are dependant on factors such as type of occupation, the continuity of employment, and the type of income. It is generally accepted that women who have a regular job, who earn money, and who perceive that their contribution is a substantial part of total household earnings are more likely to be empowered than other women (Youssef, 1982; Mahmud and Johnston, 1994). The 2006-07 PDHS respondents were asked a number of questions regarding their employment status, including whether they were working in the seven days preceding the survey and, if not, whether they had worked in the 12 months before the survey. Results are shown in Table 3.4. Characteristics of Respondents | 33 Table 3.4 Employment status Percent distribution of ever married women age 15-49 by employment status, according to background characteristics, Pakistan 2006-07 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Missing/ don't know Total Number of women Age 15-19 23.6 5.2 70.6 0.6 100.0 569 20-24 23.1 5.0 71.7 0.3 100.0 1,499 25-29 22.8 4.6 72.3 0.2 100.0 2,006 30-34 26.4 3.7 69.4 0.5 100.0 1,786 35-39 27.1 3.2 69.4 0.3 100.0 1,654 40-44 30.0 4.4 65.5 0.1 100.0 1,301 45-49 28.9 3.8 67.3 0.0 100.0 1,208 Marital status Married 25.1 4.1 70.5 0.3 100.0 9,556 Divorced/separated/widowed 42.6 5.1 51.9 0.5 100.0 467 Number of living children 0 24.1 5.0 70.5 0.4 100.0 1,349 1-2 22.9 3.8 72.7 0.6 100.0 2,697 3-4 25.7 3.5 70.8 0.0 100.0 2,725 5+ 29.3 4.6 65.9 0.2 100.0 3,252 Residence Total urban 18.9 3.9 76.8 0.3 100.0 3,350 Major city 18.3 3.7 77.9 0.2 100.0 1,898 Other urban 19.8 4.2 75.5 0.5 100.0 1,452 Rural 29.4 4.3 66.0 0.3 100.0 6,673 Province Punjab 26.8 3.7 69.1 0.4 100.0 5,800 Sindh 32.9 6.5 60.3 0.2 100.0 2,410 NWFP 10.6 1.4 87.9 0.1 100.0 1,351 Balochistan 22.3 6.0 71.5 0.1 100.0 462 Education No education 29.8 5.0 65.0 0.3 100.0 6,511 Primary 17.5 3.0 79.3 0.3 100.0 1,423 Middle 18.3 2.5 78.8 0.4 100.0 634 Secondary 14.7 1.8 82.9 0.6 100.0 809 Higher 26.8 3.2 69.9 0.0 100.0 646 Wealth quintile Lowest 40.8 7.1 52.0 0.2 100.0 1,944 Second 31.2 4.3 64.1 0.3 100.0 2,001 Middle 26.6 4.5 68.5 0.4 100.0 1,944 Fourth 18.8 3.3 77.5 0.4 100.0 2,055 Highest 13.2 1.9 84.8 0.1 100.0 2,078 Total 25.9 4.2 69.7 0.3 100.0 10,023 1 "Currently employed" is defined as having done work in the past seven days, but also includes those who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. The data show that, at the time of the survey, only about one-fourth (26 percent) of ever- married women were currently employed and an additional 4 percent were not employed but had worked sometime during the preceding 12 months. An overwhelming majority—seven in ten women—were not employed in the preceding 12 months (Figure 3.1). The proportion of women who are currently employed remains constant at 23-24 percent for age groups 15-19, 20-24, and 25-29, after which it generally increases slightly with age. A much higher proportion of the divorced, widowed, and separated women are currently employed when compared with those who are currently married (43 and 25 percent, respectively). The proportion of women who are working increases slightly with the number of children the woman has. In Pakistan, many women take up jobs because of financial constraints, which generally increase as family size increases. 34 | Characteristics of Respondents There are notable variations in the proportion of women currently employed by place of residence and province. Rural women are more likely to be currently employed than urban women (29 percent and 19 percent, respectively). There is considerable variation by province in the proportion of women who are currently employed. Thirty-three percent of women residing in Sindh are currently employed compared with 11 percent among those residing in NWFP. PDHS 2006-07 Not employed in the 12 months preceding the survey 70% Not currently employed 4% Currently employed 26% Figure 3.1 Women’s Employment Status in the Past 12 Months Current employment and education have an interesting relationship (Figure 3.2 and Table 3.4). The highest proportions of currently employed women are among those with no education (30 percent) and those with higher than secondary education (27 percent), while the lowest proportion is among women with secondary education (15 percent). There is a decrease in the percentage of employed women by wealth quintile, with those in the lowest quintile much more likely to be employed than those in the highest quintile (41 percent and 13 percent, respectively). 19 29 30 18 18 15 27 26 RESIDENCE Total urban Rural EDUCATION No education Primary Middle Secondary Higher Total 0 10 20 30 Percentage employed Fi 40 PDHS 2006-07 gure 3.2 Women's Current Employment by Residence and Education Characteristics of Respondents | 35 When looking at trends over time, the data show that there was an increase in the proportion of ever-married women currently employed, from 17 percent in the 1990-91 PDHS to 20 percent in the 1996-97 Pakistan Fertility and Family Planning Survey (PFFPS). This was followed by a decrease to 16 percent as reported in the 2003 Status of Women, Reproductive Health, and Family Planning Survey (SWRHFPS), and a significant increase thereafter to the current level of 26 percent. 3.3.2 Occupation Respondents who were currently employed or had worked in the 12 months preceding the survey were further asked to specify their occupation. Table 3.5 shows the distribution of employed ever-married women by occupation, according to background characteristics. Forty-two percent of working women are engaged in an agricultural occupation, with the next most common occupation being jobs in sales and services (37 percent). Only 8 percent of employed women work in professional, technical, or managerial jobs, while 6 percent are unskilled manual workers and 4 percent work in domestic service. Table 3.5 Occupation Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey, by occupation, according to background characteristics, Pakistan 2006-07 Background characteristic Profes- sional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agricul- ture Missing Total Number of women Age 15-19 3.4 0.0 33.5 1.1 5.6 0.0 56.4 0.0 100.0 164 20-24 5.6 0.0 44.9 1.0 7.5 0.6 39.9 0.4 100.0 420 25-29 7.9 0.0 40.1 2.2 7.9 3.0 38.5 0.4 100.0 550 30-34 12.2 0.0 34.3 2.8 5.9 3.3 41.2 0.2 100.0 537 35-39 8.3 0.3 38.1 2.5 6.1 3.7 40.9 0.2 100.0 501 40-44 7.8 1.9 35.7 2.8 4.3 6.9 40.4 0.1 100.0 447 45-49 6.8 0.2 31.6 2.2 5.3 7.5 46.4 0.0 100.0 395 Marital status Married 7.9 0.2 37.8 2.3 6.0 3.3 42.2 0.2 100.0 2,791 Divorced/separated/widowed 9.2 2.6 30.7 0.8 9.1 10.2 37.3 0.0 100.0 223 Number of living children 0 10.8 0.0 36.2 1.6 5.8 1.9 43.6 0.0 100.0 393 1-2 11.6 0.3 39.3 1.7 7.4 1.9 37.7 0.3 100.0 722 3-4 9.8 0.1 36.0 2.7 5.7 5.6 39.6 0.4 100.0 796 5+ 3.4 0.7 37.3 2.4 5.9 4.5 45.6 0.1 100.0 1,102 Residence Total urban 17.9 1.4 54.2 5.3 7.7 7.5 5.7 0.3 100.0 765 Major city 20.1 2.4 52.3 7.2 8.8 7.8 1.3 0.3 100.0 417 Other urban 15.3 0.3 56.4 3.0 6.4 7.2 11.1 0.3 100.0 348 Rural 4.7 0.0 31.5 1.2 5.7 2.6 54.2 0.2 100.0 2,248 Province Punjab 8.8 0.4 32.8 2.0 5.4 4.7 45.8 0.2 100.0 1,769 Sindh 5.4 0.3 40.7 3.2 8.1 2.6 39.4 0.3 100.0 951 NWFP 16.6 0.6 39.8 0.2 6.9 4.3 31.6 0.0 100.0 162 Balochistan 5.7 0.0 70.2 0.3 2.8 1.0 19.9 0.1 100.0 131 Education No education 0.7 0.0 34.8 2.1 6.6 4.5 51.1 0.2 100.0 2,262 Primary 0.6 0.0 58.2 2.1 5.1 3.7 29.8 0.5 100.0 291 Middle 7.4 5.3 65.2 4.2 6.5 2.8 8.5 0.0 100.0 132 Secondary 38.1 0.7 43.9 4.7 5.6 0.0 6.5 0.5 100.0 134 Higher 84.1 1.0 11.5 0.1 3.1 0.0 0.0 0.2 100.0 194 Wealth quintile Lowest 0.6 0.0 24.5 1.2 7.1 2.2 64.5 0.0 100.0 930 Second 1.5 0.0 32.9 2.7 6.9 4.3 51.4 0.2 100.0 711 Middle 4.5 0.2 46.6 1.6 4.5 5.5 36.5 0.6 100.0 605 Fourth 13.9 1.0 53.7 4.6 6.5 4.5 15.8 0.0 100.0 455 Highest 42.9 1.7 43.4 1.9 5.0 3.5 1.3 0.3 100.0 313 Total 8.0 0.4 37.3 2.2 6.2 3.8 41.9 0.2 100.0 3,013 36 | Characteristics of Respondents The analysis of occupation by background characteristics suggests that the proportion of working women with jobs in sales and services, skilled manual labour, and agriculture is higher among currently married women than among those who are divorced, separated, or widowed. Residence has a strong relationship with the type of occupation. As expected, the largest urban-rural differentials are found among women working in the agricultural sector; 54 percent of women in rural areas work in agriculture compared with only 6 percent in urban areas. More than half (54 percent) of working women residing in urban areas are employed in sales and services compared with only one- third (32 percent) among their rural counterparts. Looking at the provincial variations, 46 percent of working women in Punjab are engaged in the agricultural sector compared with only 20 percent of women in Balochistan. On the other hand, 70 percent of working women residing in Balochistan are engaged in sales and services compared with 33 percent of women residing in Punjab. Interestingly, a much higher proportion of women in NWFP are engaged in professional, technical, or managerial work (17 percent) when compared with women in Punjab (9 percent), Sindh (5 percent), and Balochistan (6 percent). The relationship between education and type of occupation is especially strong. For example, the proportion of employed women who work in agriculture decreases significantly with education, from 51 percent among ever-married women with no education to virtually 0 percent among those with higher education. The reverse is true for women who work in professional, technical, or managerial fields; more than eight in ten (84 percent) women with higher education work in such jobs compared with less than 1 percent of women with no education or only primary education. A large majority (65 percent) of working women in the lowest wealth quintile are engaged in the agricultural sector compared with only 1 percent of women in the highest quintile. On the other hand, the proportion of women working in professional, technical, and managerial fields or in sales and services increases with wealth. 3.3.3 Type of Earnings Table 3.6 shows the percent distribution of ever-married, currently employed women by type of earnings (cash or non-cash), according to type of employment (agricultural or nonagricultural). Overall, 87 percent of currently employed women receive money for their work. As expected, the proportion of women who receive money for their work is much higher in the nonagricultural than in the agricultural sector (95 percent and 76 percent, respectively). Table 3.6 Type of earnings Percent distribution of ever-married women age 15-49 currently employed, by type of earnings, according to type of employment (agricultural or nonagricultural), Pakistan 2006-07 Type of earnings Agricultural work Nonagricultural work Total Receives money 76.4 94.9 86.8 Does not receive money 23.6 5.0 13.2 Total 100.0 100.0 100.0 Number of women currently employed 1,135 1,455 2,595 Note: Total includes 5 women with missing information on type of employment who are not shown separately. 3.3.4 Employment before and after Marriage Table 3.7 presents data on the proportion of ever-married women who worked before and after marriage, according to background characteristics. The data show that 28 percent of ever- married women worked before marriage, 32 percent worked after marriage, and 21 percent worked Characteristics of Respondents | 37 both before and after marriage. However, a large majority (60 percent) of women neither worked before marriage nor after marriage; in other words, they have never worked. Younger women are somewhat more likely than older women to work before marriage, whereas older women are more likely to have worked after marriage. A much higher proportion of divorced, widowed, and separated women work either before or after marriage than currently married women. For example, 52 percent of divorced, separated, or widowed women work after marriage compared with 31 percent of those who are currently married. The proportion of women who work after marriage increases steadily with the number of children the woman has. For example, 27 percent of women with one child worked after marriage compared with 40 percent of women with six or more children. As expected, there are no major variations in the proportion of ever-married women who worked before marriage and the number of children they have. Table 3.7 Employment before and after marriage Percentage of ever-married women age 15-49 who worked before marriage and after marriage, according to background characteristics, Pakistan 2006-07 Percentage who worked Number of ever-married women Background characteristic Before marriage After marriage Neither Both Age 15-19 35.0 27.9 61.4 24.3 569 20-24 31.2 28.5 61.2 20.9 1,499 25-29 30.1 28.7 61.2 19.9 2,006 30-34 27.6 32.2 60.1 19.9 1,786 35-39 24.7 32.2 63.2 20.1 1,654 40-44 26.1 37.3 57.3 20.7 1,301 45-49 26.8 38.4 57.3 22.4 1,208 Marital status Married 28.2 31.1 61.1 20.4 9,556 Divorced/separated/widowed 30.6 51.8 45.3 27.7 467 Number of children ever born 0 33.5 26.6 60.9 21.0 1,223 1 29.5 26.7 63.9 20.1 1,179 2 28.0 27.3 64.0 19.3 1,306 3 27.6 29.8 61.1 18.5 1,266 4 24.4 30.1 63.3 17.8 1,244 5 27.3 36.2 58.7 22.1 1,049 6+ 28.0 39.5 55.8 23.4 2,755 Residence Total urban 22.2 26.0 63.5 11.8 3,350 Major city 21.3 26.0 63.0 10.3 1,898 Other urban 23.4 26.1 64.2 13.8 1,452 Rural 31.3 35.2 58.8 25.2 6,673 Province Punjab 28.8 32.6 59.3 20.6 5,800 Sindh 37.6 42.1 48.9 28.6 2,410 NWFP 8.3 13.0 84.8 6.0 1,351 Balochistan 32.6 30.4 62.1 25.1 462 Education No education 31.2 36.6 57.6 25.4 6,511 Primary 20.9 23.4 68.4 12.7 1,423 Middle 17.7 23.5 69.3 10.5 634 Secondary 19.5 17.1 70.4 7.1 809 Higher 37.1 33.1 49.1 19.2 646 Wealth quintile Lowest 44.4 49.8 44.4 38.7 1,944 Second 31.0 36.6 57.8 25.4 2,001 Middle 27.9 32.5 60.4 20.8 1,944 Fourth 19.5 24.9 67.4 11.8 2,055 Highest 19.7 17.9 70.7 8.3 2,078 Total 28.3 32.1 60.2 20.7 10,023 38 | Characteristics of Respondents There are notable variations in the proportions employed before and after marriage by place of residence and province. Rural women are more likely to have worked either before or after marriage (31 percent and 35 percent, respectively) than urban women (22 percent and 26 percent, respectively). By province, the highest proportion of women who worked either before or after marriage is among those in Sindh (38 percent and 42 percent, respectively), while the lowest is among women who reside in NWFP (8 percent and 13 percent, respectively). Employment before and after marriage varies by education. Women with no education or with higher education are the most likely to have worked before or after marriage. On the other hand, women with middle level education are the least likely to have worked before marriage, while those with secondary level education are the least likely to have worked after marriage. The proportion of women who worked before or after marriage decreases steadily with increase in wealth. 3.4 KNOWLEDGE AND ATTITUDES CONCERNING TUBERCULOSIS The 2006-07 PDHS collected data on women’s knowledge and attitudes concerning tuberculosis (TB). Table 3.8 shows the percentage of women who have heard of TB, and among those who have heard of TB, the percentage who know that TB is spread through air by coughing, the percentage who believe that TB can be cured, and the percentage who have ever been told by a doctor or nurse that they have TB. Table 3.8 Knowledge and attitudes concerning tuberculosis Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentage who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who have ever been told by a doctor or nurse that they have TB, by background characteristics, Pakistan 2006-07 Among respondents who have heard of TB Percentage who report that TB is spread through the air by coughing Percentage who have ever been told by doctor/nurse they have TB Among all respondents Percentage who believe that TB can be cured Background characteristic Percentage who have heard of TB Number of women Number of women Age 15-19 78.1 569 38.6 81.2 1.7 444 20-24 86.0 1,499 47.1 87.2 2.7 1,288 25-29 88.5 2,006 51.5 89.7 2.9 1,775 30-34 87.6 1,786 55.0 89.3 3.5 1,565 35-39 88.2 1,654 55.7 91.0 3.9 1,458 40-44 89.7 1,301 57.7 90.6 4.5 1,167 45-49 90.5 1,208 57.3 87.9 4.6 1,094 Residence Total urban 92.9 3,350 60.4 93.0 3.6 3,111 Major city 95.0 1,898 60.7 95.1 4.4 1,803 Other urban 90.0 1,452 60.0 90.0 2.4 1,307 Rural 85.1 6,673 49.1 86.7 3.4 5,681 Province Punjab 86.5 5,800 49.7 86.8 2.7 5,018 Sindh 90.4 2,410 54.2 94.2 5.4 2,179 NWFP 87.2 1,351 59.4 93.3 3.8 1,178 Balochistan 90.4 462 70.2 75.3 2.8 417 Education No education 83.9 6,511 47.8 85.5 3.8 5,460 Primary 92.6 1,423 52.7 91.2 3.9 1,317 Middle 93.5 634 59.6 96.3 3.8 592 Secondary 97.5 809 65.2 95.8 1.9 789 Higher 98.0 646 77.9 98.5 2.0 634 Wealth quintile Lowest 79.1 1,944 39.9 79.1 4.4 1,538 Second 83.5 2,001 51.0 84.6 3.4 1,671 Middle 87.6 1,944 51.2 89.1 3.6 1,704 Fourth 90.7 2,055 53.7 93.5 3.9 1,864 Highest 97.0 2,078 65.9 95.7 2.4 2,015 Total 87.7 10,023 53.1 88.9 3.5 8,792 Characteristics of Respondents | 39 40 | Characteristics of Respondents Eighty-eight percent of ever-married women in Pakistan have heard of TB. Older women, those who live in urban areas, those who reside in Sindh and Balochistan provinces, those who have secondary or higher education, and those who belong to the highest wealth quintile are more likely to have heard of TB than their counterparts in other categories. Among women who have heard of TB, 53 percent know that TB is spread through the air by coughing. Younger women age 15-19, rural women, women living in Punjab, women with no education, and women in the lowest wealth quintiles are the least likely to know that TB is spread through coughing. Nine in ten respondents who have heard of TB believe that TB can be cured. Among provinces, the percentage of people who believe that TB can be cured ranges from 75 percent of women in Balochistan to 94 percent of women in Sindh. The proportion of women who know that TB can be cured increases with education and wealth. Among women who have heard of TB, only 4 percent indicated that they were ever told by a doctor or nurse that they have TB. FERTILITY 4 Syed Mubashir Ali and Ali Anwar Buriro A major objective of the 2006-07 Pakistan Demographic and Health Survey (PDHS) is to examine fertility levels, trends, and differentials in Pakistan. Fertility is one of the three principal components of population dynamics, the others being mortality and migration. In view of the fast growing population of Pakistan, the government has been trying since the 1960s to reduce the fertility rate through implementation of various population policies. However, the fertility transition in this country only started about two decades ago. Fertility levels that remained more or less constant at more than six children per woman from the 1960s to the mid-1980s started to decline in the late 1980s (Feeney and Alam, 2003; Arnold and Sultan, 1992). The 2006-07 PDHS is another effort to observe and monitor the pace of fertility transition in Pakistan. This chapter presents an analysis of the fertility data collected in the 2006-07 PDHS. It includes a discussion on levels, trends, and differentials in fertility by selected background characteristics; data on lifetime fertility (children ever born and living); and a scrutiny of age at first birth and birth intervals. Thereafter, a brief discussion on teenage fertility, which has become critical to the issue of fertility transition, is also included in this chapter. The fertility data were collected by asking ever-married women of reproductive age (15-49 years) to provide complete birth histories of all of their live births, including those who were currently living with them, those who were living away, and those who had died. In addition, the following information was collected for each live birth: name, sex, date of birth, survival status, current age (if alive), and age at death (if dead). Unlike the previous conventional practice of recording births in the birth history starting from the first birth, in this survey, the order was reversed and started by recording the last birth first, followed by all preceding births. In societies with poor recall of dates, this procedure is thought to result in better reporting of birth dates, because the more recent events are assumed to be recalled more accurately. This lends confidence in the accuracy of current fertility estimates that are based on the births in the three years preceding the survey. Also, during training, efforts were made to impress upon the interviewers the importance of collecting information in the birth history on all live births. However, it is important to mention here that the birth history approach has some limitations that might distort fertility levels and patterns. For instance, women may include relatives’ children as their own or omit children who died at a young age, while older women may leave out grown children who have left home (UN, 1983). Accordingly, the results should be viewed with these caveats in mind. 4.1 CURRENT FERTILITY Some current fertility measures are presented in Table 4.1 for the three-year period preceding the survey. Age-specific fertility rates (ASFRs) are calculated by dividing the number of births to women in a specific age group by the number of woman-years lived during a given period.1 The total fertility rate (TFR) is a common measure of current fertility and is defined as the average number of children a woman would have if she went through her entire reproductive period (15-49 years) 1 Numerators for the age-specific rates are calculated by summing the births that occurred during the 1-36 months preceding the survey, classified by the age group of the mother at the time of birth in five-year age groups. The denominators are the number of woman-years lived in each five-year age group during the 1-36 months preceding the survey. Because rates must be based on all women and Pakistan is an ever-married sample, the number of women was increased using a factor based on all de facto women listed in the household who had never been married. The “all women” factors were based on age in the household and background information available at the household level. Fertility | 41 reproducing at the prevailing ASFR. Two additional measures of fertility reported in this table are the general fertility rate (GFR), which represents the annual number of births per 1,000 women age 15- 49, and the crude birth rate (CBR), which represents the annual number of births per 1,000 population. The CBR was estimated using the birth history data in conjunction with the household schedule population data. Table 4.1 shows a TFR of 4.1 children per woman for the three-year period preceding the survey. Fertility is considerably higher in the rural areas (4.5 children per woman) than the urban areas (3.3 children per woman), a pattern that is evident at every age. In fact, this urban-rural differential in fertility rates increases as the woman’s age increases. The persistence of a disparity in fertility between urban and rural women is most probably due to factors associated with urbanization, such as better education, higher status of women, better access to health and family planning information and services, and later marriage. Table 4.1 Current fertility On the whole, peak fertility occurs at age 25-29, a pattern that is also evident in the rural areas as well as total urban, other urban, and major cities. Fertility falls sharply after age group 35-39. Differentials in fertility levels by urban-rural residence, province, educational attainment, and wealth quintile are shown in Table 4.2 and Figure 4.1. Fertility is slightly lower in Punjab province (3.9 children per woman) than the other three provinces (Sindh and NWFP with 4.3 each, and Balochistan with 4.1 children per woman). Except for Balochistan where estimated fertility is expected to be higher than in other provinces,2 these provincial differentials in fertility are as expected and are closely associated with regional disparities in knowledge and use of family planning methods, median age at marriage, age at first birth, and the status of husbands staying elsewhere (see Tables 4.11, 5.2, 5.6, 6.2, and 6.5). Age-specific fertility rates, total fertility rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Pakistan 2006-07 Residence Age group Total urban Major city Other urban Rural Total 15-19 39 36 44 58 51 20-24 152 131 178 194 178 25-29 218 213 225 248 237 30-34 161 157 167 194 182 35-39 65 46 95 127 106 40-44 24 19 33 54 44 45-49 7 0 16 23 18 TFR 3.3 3.0 3.8 4.5 4.1 GFR 113 103 127 147 135 CBR 27.6 25.6 30.2 32.3 30.7 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates refer to the 1-36 months preceding the survey. Because rates are based on all women and Pakistan is an ever-married sample, the number of women was increased using a factor based on all de facto women listed in the household who had never been married. The “all women” factors were based on age in the household and background information available at the household level. TFR = Total fertility rate, expressed per woman GFR = General fertility rate, expressed per 1,000 women CBR = Crude birth rate, expressed per 1,000 population As expected, education of women is strongly associated with lower fertility. The TFR decreases consistently and dramatically from 4.8 for women with no education to 2.3 for women with higher than secondary education. Fertility is also strongly associated with wealth. Data show that the lower the wealth quintile, the higher the fertility. The difference in fertility between the poorest and the richest women is close to three children per woman. Table 4.2 also presents a crude assessment of fertility trends in various subgroups by comparing current fertility with a measure of completed fertility—the mean number of children ever born to women age 40-49. In every category, current fertility falls substantially below lifetime fertility. This provides further evidence that fertility has fallen considerably over time for all of these subgroups. Overall, the table shows that fertility has fallen by about two children per woman in recent periods (from 5.9 to 4.1). 2 Because of political disturbances in the province of Balochistan, the survey monitoring teams could not visit and perform their duties as frequently as desired. As a result, the data from the birth history section of the Women’s Questionnaire that requires extra effort to complete—especially when the number of children born to a woman is large—was affected. Nevertheless, because Balochistan accounts for only 5 percent of the total population of Pakistan, the fertility estimates will not have any appreciable effect at the national level. 42 | Fertility Furthermore, Table 4.2 indicates that 8 percent of women were pregnant at the time of the survey. This is likely to be an underestimate, as women in the early stages of pregnancy may be unaware or unsure that they are pregnant, while some may refuse to declare that they are pregnant. Noticeably, differentials in pregnancy levels are generally consistent with the pattern depicted by the TFR across the various subgroups, except for women in the provinces of Balochistan and NWFP and those in the highest wealth quintile. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of all women age 15-49 currently pregnant, and mean number of children ever born to all women age 40-49 years, by background characteristics, Pakistan 2006-07 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Total urban 3.3 6.6 5.6 Major city 3.0 6.0 5.3 Other urban 3.8 7.3 6.0 Rural 4.5 8.4 6.1 Province Punjab 3.9 7.1 5.7 Sindh 4.3 8.7 6.3 NWFP 4.3 8.0 6.3 Balochistan 4.1 11.5 6.2 Education No education 4.8 8.9 6.2 Primary 4.0 8.0 5.7 Middle (3.2) 6.3 5.7 Secondary 3.1 6.2 4.1 Higher (2.3) 4.9 3.2 Wealth quintile Lowest 5.8 10.7 6.8 Second 4.5 9.1 6.5 Middle 4.1 7.3 5.9 Fourth 3.4 6.1 5.7 Highest 3.0 6.5 4.9 Total 4.1 7.8 5.9 Note: Total fertility rates are for the period 1-36 months prior to interview. They are based on all women, regardless of marital status (see note on Table 4.1). Total fertility rates in parentheses are based on 500-750 unweighted women. Fertility | 43 3.3 3.0 3.8 4.5 3.9 4.3 4.3 4.1 4.8 4.0 3.2 3.1 2.3 5.8 4.5 4.1 3.4 3.0 RESIDENCE Total urban Major city Other urban Rural PROVINCE Punjab Sindh NWFP Balochistan EDUCATION No education Primary Middle Secondary Higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0.0 2.0 4.0 6.0 8.0 Number of children PDHS 2006-07 Figure 4.1 Total Fertility Rate by Background Characteristics Table 4.3 shows age-specific marital fertility rates by residence. Marital fertility rates are calculated in the same fashion as the normal age-specific fertility rates except that they are based only on women who are currently married. The table shows a total marital fertility rate (TMFR) of 6.6 children per married woman for the three years preceding the survey. As expected, the marital fertility is slightly higher in rural as opposed to urban areas (6.8 versus 6.4 children per married woman, respectively). A lower marital fertility in urban areas may be due to better access to health and family planning facilities and/or to preferences for fewer children. The age-specific marital fertility rates show a peak at age group 20-24. There has been a decline in marital fertility; for example, the TMFR was reported as 7.6 children per married woman in 1992-96 (Hakim et al., 1998), which represents a decline of one child over the past decade. Table 4.3 Current marital fertility Age-specific marital fertility rates for the three years preceding the survey, by residence, Pakistan 2006-07 Residence Age group Total urban Major city Other urban Rural Total 15-19 366 385 349 280 300 20-24 353 349 356 342 346 25-29 276 270 285 296 289 30-34 178 172 187 211 199 35-39 73 51 106 138 117 40-44 27 20 38 57 47 45-49 6 0 14 26 19 Total marital fertility rate 6.4 6.2 6.7 6.8 6.6 4.2 FERTILITY TRENDS Pakistan is blessed with a wealth of demographic data from surveys and censuses, with several organizations generating data at regular intervals. The Federal Bureau of Statistics (FBS), the National Institute of Population Studies (NIPS), the Pakistan Institute of Development Economics (PIDE), the Population Council (Pakistan), and the Population Census Organization (PCO) are a few organizations that generate demographic data at the national level. Hence, there is a wealth of data available to examine trends over time. Table 4.4 and Figure 4.2 indicate trends in fertility during the last two decades. They show that the TFR declined slowly during the last 15 years of the 20th century, changing from a high of 6.0 children per woman in 1984 to 5.4 children in 1992-96. However, fertility began declining quickly after 1992-96 to reach 4.1 children per woman in 2004-06 (Population Welfare Division, 1986; Hakim et al., 1998). 44 | Fertility Table 4.4 Trends in fertility Age-specific and total fertility rates from selected surveys, Pakistan, 1984 to 2006-07 Survey and approximate calendar period PCPS 1984-85 PDHS 1990-91 PCPS 1994-95 PFFPS 1996-97 PRHFPS 2000-01 SWRHFPS 2003 PDHS 2006-07 Age group 1984 1985-90 1994 1992-96 1997-00 2001-03 2004-06 15-19 64 84 44 83 65 60 51 20-24 223 230 227 249 211 190 178 25-29 263 268 307 278 258 233 237 30-34 234 229 243 215 206 194 182 35-39 209 147 179 148 128 117 106 40-44 127 73 92 75 61 56 44 45-49 71 40 36 24 26 33 18 TFR 6.0 5.4 5.6 5.4 4.8 4.4 4.1 Note: Age-specific fertility rates are per 1,000 women, while the total fertility rate is per woman. PCPS = Pakistan Contraceptive Prevalence Survey PFFPS = Pakistan Fertility and Family Planning Survey PRHFPS = Pakistan Reproductive Health and Family Planning Survey SWRHFPS = Status of Women, Reproductive Health, and Family Planning Survey Sources: PCPS 1984-85: Population Welfare Division, Ministry of Planning and Development, 1986; PDHS 1990-91: NIPS and Macro, 1992; PFFPS 1996-97: Hakim et al., 1998; PRHFPS 2000- 01: NIPS 2001; SWRHFPS 2003: NIPS 2007a Figure 4.2 Trends in Total Fertility Rates 6 5.4 5.6 5.4 4.8 4.4 4.1 1984 (PCPS) 1985-90 (PDHS) 1994 (PCPS) 1992-96 (PFFPS) 1997-00 (PRHFPS) 2001-03 (SWRHFP) 2004-06 (PDHS) 0 1 2 3 4 5 6 7 Percent 6.0 Table 4.5 shows the changes in fertility between the 1990-91 and the 2006-07 PDHS surveys by selected background characteristics. Overall, the TFR declined from 5.4 children per woman in the six years before the 1990-91 PDHS to 4.1 in the three years before the 2006-07 PDHS. Fertility decreased in all four provinces. With respect to education, the data show that fertility declined the most for women who have attained education up to middle level (through Class 8). By place of residence, the decrease in fertility is more conspicuous in urban than rural areas (decline of 33 percent and 20 percent, respectively). Fertility | 45 Table 4.5 Trends in fertility by background characteristics Total fertility rates and percent change according to back- ground characteristics, Pakistan 1990-91 and 2006-07 Background characteristic PDHS 1990-91 PDHS 2006-07 Percent change 1985-90 2004-06 Residence Total urban 4.9 3.3 -32.7 Major city 4.7 3.0 -36.2 Other urban 5.2 3.8 -26.9 Rural 5.6 4.5 -19.6 Province Punjab 5.4 3.9 -27.8 Sindh 5.1 4.3 -15.7 NWFP 5.5 4.3 -21.8 Balochistan 5.8 4.1 -29.3 Education No education 5.7 4.8 -15.8 Primary 4.9 4.0 -18.4 Middle 4.5 3.2 -28.9 Secondary + 3.6 2.7 -25.0 Total 5.4 4.1 -24.1 Note: Age-specific fertility rates are per 1,000 women, while the total fertility rate is per woman. Table 4.6 shows the trends in age-specific fertility rates in Pakistan for five-year periods preceding the 2006-07 PDHS. The data are derived from the information on dates of birth in the birth history from the 2006-07 PDHS only. The declining trend noted earlier (Table 4.4) is also observed here over the past 20 years for all mother’s age-at-birth groups. Table 4.6 Trends in age-specific fertility rates 4.3 CHILDREN EVER BORN AND CHILDREN SURVIVING The number of children ever born and the mean number of living children is presented in Table 4.7 for all women and all currently married women age 15-49 years. The estimates for all women are based on the assumption that all births occur within marriage. Among women age 15-19, 94 percent have never given birth. However, this proportion declines rapidly to 12 percent for women age 30-34 years; only 4 percent of women at the end of their reproductive age remain childless, indicating that childbearing among Pakistani women is nearly universal. On average, Pakistani women attain a parity of 6.3 children per woman at the end of their childbearing. This number is more than two (2.2) children above the TFR (4.1 children per woman), a discrepancy that is attributable to the decline in fertility. Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Pakistan 2006-07 Mother's age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 55 81 111 130 20-24 187 250 273 292 25-29 241 297 309 336 30-34 190 236 265 [317] 35-39 114 158 [206] 40-44 46 [89] 45-49 [17] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 46 | Fertility Table 4.7 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Pakistan 2006-07 Mean number of children ever born Number of women Mean number of living children Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total ALL WOMEN 15-19 93.5 5.0 1.2 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 3,551 0.08 0.07 20-24 64.1 13.9 12.5 6.0 2.6 0.8 0.1 0.1 0.0 0.0 0.0 100.0 3,123 0.72 0.66 25-29 29.5 12.2 17.2 16.4 12.6 7.1 3.2 1.5 0.3 0.1 0.0 100.0 2,500 2.14 1.92 30-34 12.4 6.5 12.1 14.8 15.9 15.6 10.0 6.9 3.0 1.2 1.6 100.0 1,916 3.77 3.37 35-39 7.2 3.6 6.3 10.3 15.2 14.5 15.2 11.2 8.8 4.0 3.7 100.0 1,705 4.97 4.44 40-44 6.9 3.4 4.7 9.2 12.2 12.1 11.8 14.1 9.9 7.1 8.6 100.0 1,343 5.57 4.97 45-49 4.4 2.7 3.2 6.2 10.1 11.1 12.8 15.1 11.7 9.2 13.5 100.0 1,225 6.31 5.56 Total 15-49 42.7 7.7 8.5 8.2 8.1 6.8 5.5 4.8 3.2 2.0 2.4 100.0 15,362 2.53 2.25 CURRENTLY MARRIED WOMEN 15-19 58.6 31.6 7.9 1.7 0.0 0.2 0.0 0.0 0.0 0.0 0.0 100.0 559 0.54 0.46 20-24 24.8 28.7 26.2 12.8 5.3 1.7 0.2 0.2 0.0 0.0 0.0 100.0 1,463 1.52 1.38 25-29 12.1 14.6 21.6 20.6 15.9 9.0 4.0 1.8 0.4 0.1 0.0 100.0 1,965 2.69 2.41 30-34 5.5 6.5 12.8 15.8 17.4 17.0 10.9 7.7 3.4 1.3 1.7 100.0 1,729 4.10 3.67 35-39 3.8 3.4 6.3 10.1 15.8 15.2 15.6 11.9 9.4 4.3 4.1 100.0 1,565 5.21 4.67 40-44 3.8 2.8 4.8 9.6 12.5 12.5 12.5 14.7 10.3 7.3 9.1 100.0 1,208 5.80 5.19 45-49 2.7 1.8 2.8 5.5 10.2 10.8 13.0 15.8 12.3 10.2 14.8 100.0 1,067 6.61 5.81 Total 15-49 12.1 11.5 13.2 12.6 12.5 10.5 8.4 7.4 4.9 3.0 3.8 100.0 9,556 3.88 3.47 The same pattern is replicated for currently married women, with the difference that the proportion of married women age 15-19 who have not borne a child is reduced to 59 percent. Further- more, currently married women age 45-49 have, on average, borne 6.6 children each. The difference in childbearing between all women and currently married women can be explained by the presence of many young unmarried and widowed, divorced, and separated women in the “all women” category. As expected, women older than 40 years have much higher parities, with substantial proportions having eight or more births by the end of their childbearing years. The overall picture that emerges from Table 4.7 is that the mean number of children ever born and mean number of living children increases with rising age of women, thus presupposing minimal or no recall lapse, which heightens confidence in the reported birth history. Cumulative fertility for currently married women has shown a decline since the 1994-95 Pakistan Contraceptive Prevalence Survey (PCPS) in almost all age groups of women. The overall mean number of children ever born declined from 4.5 in 1994-95 to 3.9 in 2006-07. Interestingly, the declining trend in the mean number of living children is not as sharp as in the case of children ever born. This trend reflects improvement in child survival because of the improvements in the associated socioeconomic indicators that affect the child survival. As shown in Table 4.8, there has been a modest but steady downward trend since 1990-91 in the mean number of children ever born among all women by age group. Overall, the mean has declined from 3.0 children born per woman in 1990-91 to 2.5 in 2006-07. Fertility | 47 Table 4.8 Trends in children ever born Mean number of children ever born by age group of woman, from selected surveys, Pakistan 1984 to 2006-07 Survey PDHS 1990-91 PFFPS 1996-97 PRHFPS 2000-01 SWRHFPS 2003 PDHS 2006-07 Age group 15-19 0.2 0.1 0.1 0.1 0.1 20-24 1.0 1.0 0.9 0.7 0.7 25-29 2.6 2.8 2.4 2.2 2.1 30-34 4.3 4.6 4.3 4.0 3.8 35-39 5.5 5.6 5.3 5.1 5.0 40-44 6.3 6.5 6.4 5.8 5.6 45-49 6.4 7.2 6.7 6.6 6.3 Total 3.0 2.8 2.6 2.5 2.5 PFFPS = Pakistan Fertility and Family Planning Survey PRHFPS = Pakistan Reproductive Health and Family Planning Survey SWRHFPS = Status of Women, Reproductive Health, and Family Planning Survey Sources: PDHS 1990-91: NIPS and Macro, 1992; PFFPS 1996-97: Hakim et al., 1998; PRHFPS 2000-01: NIPS 2001; SWRHFPS 2003: NIPS 2007a 4.4 BIRTH INTERVALS Previous research has demonstrated that children born too close to a previous birth are at increased risk of dying (NIPS and Macro, 1992). In the context of this finding, the examination of birth intervals is important in providing insights into birth spacing patterns and, subsequently, maternal and child health. Table 4.9 provides a glimpse into the birth intervals of children born to Pakistani women of reproductive age during the five years preceding the survey across selected subgroups. Overall, the median birth interval is 29 months. The shortest birth intervals are observed among children born to women age 15-19 (21 months) and children whose preceding sibling died (22 months). The longest intervals are among children born to women age 40-49 (36 months) and children in Balochistan (33 months). It is also interesting to note that there is a slightly shorter birth interval after the birth of a female child than after the birth of a male child. Taken as a whole, 34 percent of Pakistani children are born less than 24 months after a previous birth, an interval perceived to be “too short.” The largest proportion (60 percent) of such children born less than 24 months after a previous birth is found among children born to mothers age 15-19. 48 | Fertility Table 4.9 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Pakistan 2006-07 Median number of months since preceding birth Number of non- first births Background characteristic Months since preceding birth 7-17 18-23 24-35 36-47 48-54 55-59 60+ Total Age 15-19 30.3 29.4 33.3 0.9 0.3 4.0 1.9 100.0 66 20.9 20-29 20.2 20.2 36.5 14.0 4.3 1.1 3.7 100.0 3,229 26.0 30-39 14.0 15.1 31.6 18.5 6.3 3.4 11.0 100.0 3,204 31.6 40-49 9.7 12.0 28.3 19.1 6.3 3.7 21.0 100.0 700 36.0 Sex of preceding birth Male 14.4 16.9 34.2 16.7 5.7 2.6 9.4 100.0 3,694 29.6 Female 18.7 17.5 32.7 16.0 5.1 2.1 7.8 100.0 3,506 28.0 Survival of preceding birth Living 14.5 17.0 34.4 17.1 5.6 2.5 9.0 100.0 6,571 29.6 Dead 37.6 19.4 23.8 9.4 3.7 1.7 4.4 100.0 629 21.9 Birth order 2-3 17.8 19.5 34.5 14.5 5.4 2.0 6.4 100.0 3,100 27.4 4-6 15.9 15.2 32.5 17.4 5.5 2.5 11.0 100.0 2,777 30.0 7+ 14.9 16.1 33.2 18.8 5.2 3.0 8.8 100.0 1,323 30.2 Residence Total urban 18.0 17.9 30.0 15.5 5.1 2.2 11.4 100.0 2,058 28.7 Major city 18.2 17.5 28.6 14.6 5.6 2.3 13.2 100.0 1,061 30.0 Other urban 17.8 18.2 31.4 16.4 4.6 2.1 9.4 100.0 997 28.1 Rural 15.9 16.9 34.9 16.8 5.5 2.5 7.5 100.0 5,142 28.9 Province Punjab 16.6 18.3 33.7 15.8 4.9 2.3 8.3 100.0 4,005 28.2 Sindh 18.0 15.8 33.8 16.3 5.8 2.2 8.2 100.0 1,824 28.7 NWFP 14.9 16.4 32.1 17.1 6.1 2.9 10.5 100.0 1,057 30.0 Balochistan 11.9 14.3 33.3 22.7 6.7 2.4 8.7 100.0 314 33.0 Education No education 16.6 17.2 33.5 16.7 5.4 2.5 8.2 100.0 4,949 28.7 Primary 15.0 17.5 34.5 16.4 4.7 2.7 9.2 100.0 1,024 29.4 Middle 16.5 20.4 32.5 13.2 5.1 0.8 11.6 100.0 370 28.8 Secondary 17.3 14.9 34.1 14.9 7.3 1.2 10.3 100.0 510 29.8 Higher 19.3 17.1 30.1 17.6 5.2 3.0 7.7 100.0 346 28.0 Wealth quintile Lowest 16.6 16.6 35.3 16.9 4.9 2.8 6.9 100.0 1,799 28.7 Second 16.0 16.3 34.7 16.1 6.4 2.5 8.0 100.0 1,546 28.6 Middle 18.9 17.8 33.0 18.4 4.3 2.2 5.5 100.0 1,463 27.8 Fourth 13.7 18.2 33.0 16.2 5.9 1.8 11.2 100.0 1,269 30.0 Highest 17.3 17.6 30.1 13.5 5.7 2.6 13.3 100.0 1,122 29.4 Total 16.5 17.2 33.5 16.4 5.4 2.4 8.6 100.0 7,200 28.8 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 4.5 AGE AT FIRST BIRTH The onset of childbearing has a direct bearing on fertility. Early initiation into childbearing lengthens the reproductive period, which in turns increases the chances of higher fertility. Bearing children at a young age also entails risks to the health of the mother and the child. Table 4.10 shows the median age at first birth as well as the percentage of women who gave birth by a given exact age, by five-year age groups of women. According to this table, the median age at first birth for all women is 21.8 years, an increase of 0.5 years since the 1990-91 PDHS. The largest increase (1.7 years) since 1990-91 in the median age at first birth is among women age 25-29 years. Fertility | 49 Table 4.10 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Pakistan 2006-07 Percentage who have never given birth Median age at first birth Percentage who gave birth by exact age Number of women Current age 15 18 20 22 25 15-19 0.5 na na na na 93.5 3,551 a 20-24 1.3 10.2 22.5 na na 64.1 3,123 a 25-29 2.2 14.6 30.0 45.4 61.6 29.5 2,500 22.7 30-34 3.2 20.6 37.4 53.1 70.2 12.4 1,916 21.6 35-39 3.3 19.8 39.0 56.4 75.9 7.2 1,705 21.2 40-44 2.5 18.9 36.4 54.9 73.4 6.9 1,343 21.4 45-49 2.1 18.1 35.3 54.2 74.5 4.4 1,225 21.5 20-49 2.3 16.0 31.8 a a 27.5 11,811 a 25-49 2.7 18.1 35.2 52.0 69.9 14.3 8,689 21.8 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Among the age groups for which the median age at first birth can be measured, the age group with the highest median age is 25-29 years. This pattern is in congruence with the declining fertility, particularly among younger women (see Table 4.4). Additional insights into initia- tion of childbearing can be discerned by examining the percentage of women who had a first birth by the given exact ages for various age groups of women. While this percentage increases progressively by increasing exact ages as expected, the proportion having their first birth by age 18, for instance, is lower for younger women compared with older women. This observation is consistent with the rising age at first birth. Table 4.11 Median age at first birth Differentials in age at first birth by socioeconomic and demographic char- acteristics of women age 25-49 years are shown in Table 4.11. A higher median age at first birth is observed in the major cities (22.4 years) compared with rural areas (21.5 years). Among the provinces, a higher median age at first birth is recorded in Balochistan (22.3 years) for women age 25-49, followed by Punjab province (22.1 years), and NWFP (21.2 years), while the lowest age was reported in Sindh province (21.1 years). This implies that women in Sindh and NWFP provinces, on average, have their first birth a little over one year earlier than women living in Balochistan province. Median age at first birth among women age 25-49 years, according to background characteristics, Pakistan 2006-07 Background characteristic Age Women age 25-29 30-34 35-39 40-44 45-49 25-49 Residence Total urban 23.9 22.4 20.9 21.7 21.3 22.2 Major city 24.4 22.8 20.8 21.7 21.4 22.4 Other urban 23.3 22.1 20.9 21.7 21.3 22.0 Rural 22.1 21.1 21.4 21.3 21.6 21.5 Province Punjab 23.2 22.1 21.7 21.6 21.5 22.1 Sindh 21.6 21.0 20.1 21.2 21.2 21.1 NWFP 22.3 20.9 20.4 20.9 21.7 21.2 Balochistan 22.7 21.7 22.2 21.9 23.0 22.3 Education No education 21.2 20.6 20.9 21.0 21.3 21.0 Primary 22.5 21.3 21.5 21.8 21.6 21.8 Middle 24.3 23.0 20.4 20.6 (20.7) 22.3 Secondary (23.5) 23.0 21.9 22.7 (23.1) 23.0 Higher * 26.2 23.8 26.1 (26.4) a Wealth quintile Lowest 20.7 19.9 21.3 20.2 21.8 20.7 Second 21.5 21.4 21.3 21.2 21.2 21.3 Middle 22.7 20.8 20.9 21.6 21.7 21.5 Fourth 23.2 22.1 21.2 21.7 21.4 22.1 Highest 24.6 23.4 21.5 21.7 21.3 22.8 Total 22.7 21.6 21.2 21.4 21.5 21.8 Note: Numbers in parentheses are based on 25-49 unweighted women; an asterisk represents a figure based on fewer than 25 unweighted women that has been suppressed. a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 50 | Fertility Clearly, the onset of childbearing is related to the education of women. According to Table 4.11, women with secondary education begin their childbearing two years (23.0 years) later than women with no education (21.0 years). Wealthier women, relative to poorer ones, also show delayed onset of childbearing of a little over two years. 4.6 TEENAGE FERTILITY It is important to examine teenage fertility for various reasons. First, children born to very young mothers are normally predisposed to a higher risk of illness and death. Secondly, teenage mothers are more likely to experience complications during pregnancy and are less likely to be prepared to deal with them, which often leads to maternal death. Third, their early entry into reproduction denies them the opportunity to pursue academic goals. This is detrimental and harmful to their prospects for good careers, which often lowers their status in society. Table 4.12 displays the percentage of women age 15-19 who were mothers or were pregnant with their first child at the time of the 2006-07 PDHS, by selected background char- acteristics. Generally, teenage fertility has declined; for example, the proportion who have begun childbearing has gone down from about 16 percent at the time of the 1990-91 PDHS to 9 percent now. The proportion of teenage mothers has also decreased from 12 percent in 1990-91 to 7 percent in 2006-07, while the proportion of women pregnant with their first child also decreased from 4 percent in 1990-91 to less than 3 percent in 2006-07. These find- ings suggest that there is a trend towards delayed childbearing at least until they have completed their teenage years. Table 4.12 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child and percentage who have begun childbearing, by background characteristics, Pakistan 2006-07 Percentage who: Background characteristic Have had a live birth Are pregnant with first child Have begun child- bearing Number of women Age 15 0.4 0.5 0.9 613 16 2.0 1.2 3.3 777 17 4.2 3.1 7.3 703 18 10.1 2.6 12.7 923 19 16.9 6.1 23.1 535 Residence Total urban 4.6 2.0 6.6 1,260 Major city 3.3 1.3 4.6 761 Other urban 5.9 2.7 8.6 556 Rural 7.6 2.9 10.5 2,289 Province Punjab 5.9 2.4 8.3 1,895 Sindh 8.3 2.9 11.2 875 NWFP 6.7 2.4 9.2 583 Balochistan 4.2 3.2 7.4 170 Education No education 11.4 4.0 15.5 1,317 Primary 6.8 1.9 8.8 698 Middle 3.6 2.4 6.0 632 Secondary 1.3 1.4 2.7 543 Higher 1.0 0.3 1.3 333 Wealth quintile Lowest 11.2 4.5 15.8 577 Second 8.7 2.9 11.6 705 Middle 5.9 1.9 7.8 749 Fourth 5.3 2.7 8.0 800 Highest 2.8 1.2 4.0 673 Total 6.5 2.6 9.1 3,551 Note: Because the survey was based on an ever-married sample, the number of women was increased using a factor based on all de facto women listed in the household who had never been married. The “all women” factors were based on age in the household and background information available at the household level. Women who have never married are assumed to have never been pregnant. Because the number of all women is not normalized, the weighted numbers will not necessarily sum to the “total.” The proportion of teenagers who have begun childbearing increases with age. For example, at age 15, only about 1 percent has begun childbearing. This proportion increases to 23 percent by age 19. The percentage of teenagers who have begun childbearing is highest (11 percent) in Sindh province and lowest (7 percent) in Balochistan. About 16 percent of teenage women with no education have begun childbearing compared with only 1 percent of women with higher than secondary education. This finding suggests that increas- ing educational level has a negative relation- ship with the beginning of childbearing in Pakistan. Teenagers from poorer households are more likely (16 percent) to have begun childbearing compared with those from wealth- ier households (4 percent). Fertility | 51 FAMILY PLANNING 5 Iqbal Ahmad and Mumtaz Eskar To attain a balance between resources and population, the Population Policy of Pakistan seeks to promote family planning as an entitlement based on informed and voluntary choice by motivating couples to adopt a family planning method through improved access to quality of reproductive health services. In this context, the level of knowledge about family planning methods is important because adequate information about the available methods of contraception enable couples to develop a rational approach to planning their families. An assessment of knowledge and use of contraceptive methods, therefore, constituted one of the primary objectives of this survey. This chapter describes women’s knowledge, ever use, and current use of contraceptive methods; the sources and cost of modern methods; accessibility to family planning services; contraceptive use intentions; and informed choice. Furthermore, exposure to family planning messages and level of contact of nonusers with family planning providers is also assessed. Where appropriate, comparisons are also made with findings from previous family planning surveys conducted in Pakistan. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Development of a profile regarding knowledge of family planning methods was one of the major objectives of the survey, because knowledge of methods is a prerequisite for making the decision to initiate contracep- tive use. Information on knowledge of contraception was collected during the survey by asking ever-married women to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the inter- viewer described a method and asked if the respondent recognized it. In this manner, information was collected about eight modern methods (female sterilization, male sterilization, the pill, intrauterine device [IUD], inject- ables, implants, male condoms, and emergency contra- ception) and two traditional methods (rhythm or calendar method and withdrawal). Provision was also made in the questionnaire to record any other methods named spon- taneously by the respondent. Table 5.1 shows the level of knowledge of contraceptive methods among ever-married and currently married women age 15-49. Table 5.1 Knowledge of contraceptive methods Knowledge of family planning in Pakistan is nearly universal; 96 percent of ever-married and currently married women age 15-49 know of at least one method of family planning. Modern methods are more widely known than traditional methods. For example, 96 percent of currently married women have heard of at least one modern method, while only 64 percent have heard of a traditional method. Percentage of ever-married and currently married women age 15-49 who know any contraceptive method, by specific method, Pakistan 2006-07 Method Ever- married women Currently married women Any method 95.7 95.9 Any modern method 95.5 95.7 Female sterilization 86.6 86.7 Male sterilization 40.9 40.7 Pill 91.5 91.7 IUD 74.7 74.8 Injectables 89.3 89.5 Implants 31.9 32.1 Condom 67.7 68.1 Emergency contraception 17.8 18.0 Any traditional method 63.7 63.8 Rhythm 49.1 49.2 Withdrawal 48.7 48.9 Folk method 2.9 2.9 Mean number of methods known by women 15-49 6.0 6.0 Number of women 10,023 9,556 Among currently married women, pills (92 percent), injectables (90 percent), female sterilization (87 percent), IUD (75 percent), and condoms (68 percent) are the most widely known methods of family planning. The least widely known methods are emergency contraception (18 percent), implants (32 percent), and male sterilization (41 percent). About half of currently married Family Planning | 53 women have heard of the rhythm method (49 percent) and withdrawal (49 percent). The mean number of methods known by ever-married as well as currently married women is six. Table 5.2 shows currently married women age 15-49 who have heard of at least one contraceptive method and at least one modern method by selected background characteristics the percentage. Differences by age group are very slight except among women age 15-19, where contraceptive knowledge is somewhat lower. These teenagers are newly weds and they are more likely to want to become pregnant as soon as possible and hence may not be as interested in contraceptive methods as older women. Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method, by background characteristics, Pakistan 2006-07 Background characteristic Heard of any method Heard of any modern method1 Number Age 15-19 87.5 87.4 559 20-24 96.0 95.8 1,463 25-29 96.9 96.6 1,965 30-34 96.4 96.1 1,729 35-39 96.7 96.5 1,565 40-44 96.3 96.2 1,208 45-49 95.8 95.6 1,067 Residence Total urban 98.5 98.2 3,191 Major city 99.1 99.0 1,815 Other urban 97.6 97.2 1,376 Rural 94.6 94.4 6,365 Province Punjab 96.9 96.7 5,495 Sindh 97.3 97.0 2,317 NWFP 91.9 91.5 1,301 Balochistan 88.2 88.0 443 Education No education 94.6 94.4 6,165 Primary 97.8 97.6 1,371 Middle 97.8 97.7 609 Secondary 98.4 98.4 785 Higher 99.4 99.2 626 Wealth quintile Lowest 92.0 91.5 1,847 Second 93.4 93.3 1,897 Middle 97.0 96.8 1,846 Fourth 97.6 97.6 1,957 Highest 99.2 99.0 2,009 Total 15-49 95.9 95.7 9,556 1 Female sterilisation, male sterilization, pill, IUD, injectables, implants, condoms, emergency contra- ception, and other modern methods Differences in the level of contraceptive knowl- edge between urban and rural areas are minimal. Among provinces, women in Punjab and Sindh report the highest levels of knowledge (97 percent each), followed by NWFP (92 percent) and Balochistan (88 percent). The level of contraceptive knowledge increases slightly with education and wealth quintile. Table 5.3 presents a comparative picture of trends in contraceptive knowledge over time. It shows that the proportion of married women who had heard of a contraceptive method increased substantially in the late 1980s and early 1990s, from 62 percent in 1984-85 to 94 percent in 1996-97. Because of the high levels reached, there has been a plateau in this figure over the past decade. The same pattern—large increases in the late 1980s and early 1990s with little change since then— generally holds for knowledge of specific methods, with a few exceptions. Knowledge of male sterilization and implants has continued to increase since 2000-01, while knowledge of the IUD appears to have declined since 2000-01, particularly in the past few years. Knowledge of the rhythm method and withdrawal has increased substantially over time, although the trends for both methods are somewhat erratic. 54 | Family Planning Table 5.3 Trends in knowledge of contraceptive methods Percentage of currently married women age 15-49 who know any contraceptive method, by specific method, Pakistan 1984 to 2006-07 Method 1984-85 PCPS 1990-91 PDHS 1994-95 PCPS 1996-97 PFFPS 2000-01 PRHFPS 2003 SWRHFPS 2006-07 PDHS Any method 61.5 77.9 90.7 94.3 95.7 95.4 95.9 Any modern method u 77.2 90.5 93.4 95.0 95.0 95.7 Female sterilization 50.5 69.7 86.2 88.5 88.8 85.9 86.7 Male sterilization 18.8 20.2 15.4 31.0 31.6 41.5 40.7 Pill 54.1 62.2 72.6 86.6 91.1 90.7 91.7 IUD 43.4 51.5 73.4 82.4 84.4 82.1 74.8 Injectables 46.7 62.2 79.4 86.0 90.2 88.2 89.5 Implants u u u 14.9 19.9 26.9 32.1 Condom 28.9 35.3 46.0 61.2 69.9 65.2 68.1 Any traditional method u 25.7 38.2 54.3 50.3 45.4 63.8 Rhythm 5.8 17.8 22.4 33.7 23.8 25.4 49.2 Withdrawal 9.0 14.3 28.4 40.7 42.4 35.7 48.9 Other 1.5 3.5 4.3 3.7 1.9 1.7 2.9 Number of women 7,405 6,364 u 7,584 u 8,427 9,556 u = Unavailable PCPS = Pakistan Contraceptive Prevalence Survey PFFPS = Pakistan Fertility and Family Planning Survey PRHFPS = Pakistan Reproductive Health and Family Planning Survey SWRHFPS = Status of W omen, Reproductive Health, and Family Planning Survey Sources: PCPS 1984-85: Population Welfare Division, Ministry of Planning and Development, 1986; PDHS 1990-91: NIPS and Macro, 1992; PFFPS 1996-97: Hakim et al., 1998; Census 1998: Government of Pakistan, 1998; PRHFPS 2000-01: NIPS 2001; SWRHFPS 2003: NIPS 2007a 5.2 EVER USE OF FAMILY PLANNING METHODS All women who said that they had heard of a method of family planning were asked whether they had ever used that method in order to delay or avoid getting pregnant. Table 5.4 shows the percentage of ever-married and currently married women who have ever used specific methods of family planning. This table shows that almost half (49 percent) of currently married women have used a contraceptive method at some time in the past. Thirty-nine percent of currently married women have used a modern method, while 26 percent have used a traditional method. The methods most commonly ever used by currently married women are the condom, withdrawal, and the rhythm method, each of which has been used by 17 percent of women. These are followed by the pill (12 percent), injectables (11 percent), female sterilization (8 percent), and the IUD (8 percent). Less than 1 percent of women reported ever having used emergency contraception, implants, and male sterilization. As expected, ever use of any contraceptive method rises steadily with age, from 16 percent among currently married women age 15-19 to 61 percent among women age 40-44, before falling slightly among those age 45-49. Female sterilization is more likely to have been used by older women, while use of condoms is more common among women age 25-39. Rhythm and withdrawal are almost equally popular among all age groups of women age 25 and older. Family Planning | 55 Table 5.4 Ever use of contraception Percentage of ever-married and currently married women age 15-49 who have ever used any contraceptive method, by method, according to age, Pakistan 2006-07 Modern method Emer- gency contra- ception Any tradi- tional method Traditional method Age Any method Any modern method Female sterili- zation Male sterili- zation Pill IUD Inject- ables Im- plants Condom Rhythm With- drawal Folk method Number of women EVER-MARRIED WOMEN 15-19 15.6 9.8 0.0 0.2 3.7 0.6 2.0 0.0 5.6 0.3 9.1 5.7 5.3 0.2 569 20-24 29.8 20.5 0.9 0.1 5.0 3.0 5.5 0.3 11.7 0.6 17.7 11.7 11.7 0.1 1,499 25-29 45.4 36.5 2.0 0.0 12.5 6.9 12.4 0.5 20.6 1.1 25.3 16.4 17.6 0.7 2,006 30-34 55.1 45.3 7.0 0.1 14.7 10.3 14.2 0.4 21.2 1.3 27.4 17.4 17.4 0.8 1,786 35-39 57.9 48.0 12.1 0.1 16.3 11.8 13.1 0.9 19.5 0.9 28.6 19.8 19.2 0.9 1,654 40-44 58.6 49.0 18.3 0.3 14.2 10.6 13.4 0.8 17.2 0.6 28.7 18.8 19.4 1.4 1,301 45-49 52.5 39.1 15.3 0.2 12.7 8.2 10.4 0.8 11.1 1.0 28.6 19.6 19.8 0.8 1,208 Total 47.7 38.0 8.0 0.1 12.2 8.0 11.1 0.6 16.8 0.9 25.0 16.5 16.8 0.7 10,023 CURRENTLY MARRIED WOMEN 15-19 15.7 9.7 0.0 0.2 3.8 0.6 2.0 0.0 5.4 0.3 9.2 5.8 5.4 0.2 559 20-24 30.3 20.8 0.9 0.1 5.1 3.0 5.7 0.3 11.8 0.6 18.0 12.0 11.9 0.1 1,463 25-29 45.8 36.8 1.9 0.0 12.7 7.0 12.4 0.5 21.0 1.1 25.6 16.6 17.9 0.7 1,965 30-34 56.3 46.3 7.2 0.1 15.0 10.5 14.4 0.4 21.7 1.3 28.1 17.9 17.9 0.9 1,729 35-39 59.3 49.4 12.5 0.1 16.9 12.2 13.5 1.0 20.2 0.9 29.1 20.2 19.7 1.0 1,565 40-44 60.8 50.9 19.1 0.4 15.0 10.5 13.9 0.9 18.0 0.6 30.0 19.4 20.2 1.5 1,208 45-49 54.8 41.3 16.7 0.2 12.9 8.8 11.2 0.7 11.3 0.9 29.6 19.9 20.3 0.9 1,067 Total 48.7 38.8 8.2 0.1 12.4 8.1 11.4 0.6 17.2 0.9 25.5 16.8 17.1 0.8 9,556 5.3 CURRENT USE OF CONTRACEPTIVE METHODS Table 5.5 shows that 30 percent of currently married women report they are currently using some method to delay or prevent pregnancy. About three-fourths of current users are using a modern method and slightly more than one-fourth are using a traditional method. The most widely used method is female sterilization (8 percent), followed by condoms (7 percent), withdrawal (4 percent), and the rhythm method (4 percent). The IUD, injectables, and pills are each used by 2 percent of married women. Use of male sterilization and the more recently introduced implant are negligible. Table 5.5 Current use of contraception by age Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to age, Pakistan 2006-07 Modern method Any tradi- tional method Traditional method Age Any method Any modern method Female sterili- zation Male sterili- zation Pill IUD Inject- ables Im- plants Con- dom Rhythm With- drawal Folk method Not currently using Total Number of women 15-19 6.7 4.2 0.0 0.0 0.8 0.5 0.3 0.0 2.6 2.5 1.2 1.3 0.0 93.3 100.0 559 20-24 15.4 10.6 0.9 0.0 1.3 1.2 2.0 0.1 5.2 4.8 2.1 2.6 0.1 84.6 100.0 1,463 25-29 24.8 17.2 1.9 0.0 2.0 2.1 2.7 0.3 8.1 7.6 3.4 4.0 0.2 75.2 100.0 1,965 30-34 35.6 26.9 7.2 0.0 3.2 3.4 3.7 0.1 9.3 8.7 3.6 5.0 0.1 64.4 100.0 1,729 35-39 39.9 29.8 12.5 0.1 2.7 3.8 2.0 0.1 8.6 10.2 4.5 5.4 0.3 60.1 100.0 1,565 40-44 41.6 31.4 19.1 0.3 2.1 1.8 2.2 0.0 5.9 10.3 4.9 5.1 0.3 58.4 100.0 1,208 45-49 31.5 23.6 16.7 0.2 1.2 1.2 1.5 0.3 2.6 7.8 4.4 3.4 0.0 68.5 100.0 1,067 Total 29.6 21.7 8.2 0.1 2.1 2.3 2.3 0.1 6.8 7.9 3.6 4.1 0.2 70.4 100.0 9,556 Note: If more than one method is used, only the most effective method is considered in this tabulation. 56 | Family Planning Use of any contraceptive method rises with age from 7 percent among married women age 15-19 to a peak of 42 percent at age 40-44 and then declines to 32 percent among women age 45-49. The most popular methods among women under age 30 are the condom, followed by withdrawal and the rhythm method. Women in their early 30s tend to use condoms and sterilization, while among women in their late 30s and 40s, female sterilization is by far the most widely used method. As shown in Figure 5.1, there has been a substantial increase in contraceptive use since the mid-1980s, with some indication of a possible plateau in recent years. This plateau in contraceptive use could be due to various factors, including non-devolution of the programme from central control, thus leading to lack of ownership of the programme at provincial and district levels; lack of support from the health sector, especially its Lady Health Workers programme; and a disconnect between the community and facilities providing services, caused by abolishing the Village Based Family Planning Worker component. Figure 5.1 Trends in Contraceptive Use 9 12 18 24 28 32 30 1984-85 PCPS 1990-91 PDHS 1994-95 PCPS 1996-97 PFFPS 2000-01 PRHFPS 2003 SWRHFPS 2006-07 PDHS 0 5 10 15 20 25 30 35 Percent * Based on currently married non-pregnant women * Note: Calculated as the percentage of currently married women using any method As shown in Figure 5.2, changes in use of specific methods over the past 16 years have been small, with a slight decline since 2003 in the use of the pill, IUD, injectables, and withdrawal, while female sterilization has remained the same and the use of condoms has increased slightly during this period. Family Planning | 57 Figure 5.2 Trends in Current Use of Specific Methods among Married Women 1 1 1 3 4 1 2 3 1 4 6 5 3 4 3 6 8 5 2 2 2 7 8 4 Pill IUD Injectables Condom Female sterilization Withdrawal Method 0 2 4 6 8 10 Percent 1990-91 1996-97 2003 2006-07 5.4 DIFFERENTIALS IN CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS As shown in Table 5.6 and Figure 5.3, some women are more likely to use contraceptives than others. Women in urban areas are more likely to use contraceptives (41 percent) than those in rural areas (24 percent), a pattern that also applies for each of the specific methods except injectables, which are used by equal proportions of urban and rural women. Contraceptive use among currently married women is highest in Punjab province (33 percent), followed by Sindh province (27 percent) and NWFP (25 percent). and is lowest in Balochistan province (14 percent). In Punjab and Sindh, female sterilization is the most commonly used contraceptive method, followed by condoms, while in NWFP, condoms and withdrawal are the most popular methods; contraceptive use in Balochistan consists almost entirely of the pill and female sterilization. Contraceptive use increases with women’s level of education, from 25 percent among currently married women with no education to 43 percent among those with higher education. In general, women do not begin to use contraception until they have had at least one child, after which use increases rapidly with the number of children. It might be expected that women who are working would be more likely to use contraception than those who are not working. However, the data in Table 5.6 show that the relationship between contraceptive use and work status is more complex. Contraceptive use among married women who are currently working is about the same as among those who never worked and only slightly higher than among those who worked only before marriage and those who worked before and after marriage but not currently. Use is highest among women who worked only after marriage. Contraceptive use increases dramatically with increasing wealth quintiles. The contraceptive prevalence rate increases from 16 percent of currently married women in the lowest quintile to 43 percent of those in the highest quintile. 58 | Family Planning Table 5.6 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Pakistan 2006-07 Modern method Background characteristic Any meth- od Any mod- ern meth- od Fe- male steri- liza- tion Male steri- liza- tion Pill IUD Inject- ables Im- plants Con- dom Any tradi- tional meth- od Not cur- rently using Total Number of women Traditional method Folk meth- od Rhythm With- drawal Residence Total urban 41.1 29.9 10.2 0.2 2.6 2.6 2.3 0.2 11.9 11.2 4.9 6.1 0.1 58.9 100.0 3,191 Major city 45.9 33.0 10.7 0.1 2.9 2.8 1.9 0.2 14.4 12.9 6.3 6.6 0.0 54.1 100.0 1,815 Other urban 34.7 25.8 9.5 0.2 2.3 2.3 2.9 0.1 8.5 8.9 3.2 5.5 0.3 65.3 100.0 1,376 Rural 23.9 17.7 7.2 0.0 1.8 2.1 2.3 0.1 4.2 6.2 2.9 3.1 0.2 76.1 100.0 6,365 Province Punjab 33.2 23.1 9.2 0.1 1.4 3.1 2.0 0.2 7.1 10.1 5.3 4.6 0.2 66.8 100.0 5,495 Sindh 26.7 22.0 9.0 0.0 2.3 1.0 2.3 0.1 7.2 4.7 1.5 3.1 0.0 73.3 100.0 2,317 NWFP 24.9 18.7 3.6 0.1 3.1 1.7 4.0 0.0 6.1 6.2 1.0 5.1 0.1 75.1 100.0 1,301 Balochistan 14.4 13.4 4.6 0.0 5.3 0.6 1.4 0.0 1.6 1.0 0.3 0.5 0.2 85.6 100.0 443 Education No education 25.3 18.9 8.6 0.0 2.0 1.9 2.1 0.2 4.1 6.4 3.0 3.2 0.2 74.7 100.0 6,165 Primary 34.4 25.8 9.0 0.1 2.0 2.6 3.7 0.1 8.4 8.6 3.5 4.9 0.1 65.6 100.0 1,371 Middle 37.2 26.5 8.1 0.0 1.8 1.8 3.2 0.0 11.5 10.8 5.5 5.1 0.2 62.8 100.0 609 Secondary 39.1 25.8 5.3 0.2 2.1 3.3 1.7 0.3 12.8 13.3 6.5 6.8 0.0 60.9 100.0 785 Higher 42.6 31.4 5.6 0.2 2.9 4.5 1.1 0.0 17.0 11.1 4.0 7.2 0.0 57.4 100.0 626 Husband's education No education 25.0 18.8 9.7 0.0 1.8 1.3 1.7 0.1 4.1 6.2 3.3 2.8 0.2 75.0 100.0 3,308 Primary 27.9 20.7 7.7 0.1 1.8 2.1 2.8 0.1 6.0 7.2 2.9 4.0 0.4 72.1 100.0 1,546 Middle 29.3 20.8 6.1 0.2 2.1 3.2 2.5 0.2 6.4 8.5 3.8 4.6 0.2 70.7 100.0 1,253 Secondary 32.3 23.4 7.9 0.0 1.6 2.4 2.9 0.2 8.6 8.9 4.1 4.7 0.1 67.7 100.0 1,994 Higher 38.7 28.4 7.4 0.1 3.3 3.6 2.3 0.1 11.6 10.3 4.1 6.2 0.0 61.3 100.0 1,422 Number of living children 0 0.6 0.5 0.0 0.0 0.1 0.0 0.0 0.0 0.4 0.1 0.1 0.0 0.0 99.4 100.0 1,278 1-2 20.3 13.2 1.3 0.0 1.7 1.1 1.7 0.1 7.4 7.0 3.3 3.7 0.0 79.7 100.0 2,565 3-4 39.2 28.9 9.7 0.1 2.8 3.8 3.0 0.1 9.4 10.3 4.5 5.6 0.2 60.8 100.0 2,604 5+ 41.2 31.5 15.9 0.1 2.6 2.9 3.2 0.2 6.6 9.7 4.5 5.0 0.2 58.8 100.0 3,109 Work status Currently working 29.2 20.9 8.9 0.1 1.8 2.8 2.1 0.0 5.2 8.4 3.9 4.3 0.3 70.8 100.0 2,397 Worked only before marriage 28.1 19.7 6.2 0.0 1.2 1.7 2.7 0.2 7.8 8.4 2.5 5.9 0.0 71.9 100.0 739 Worked only after marriage 38.0 28.8 14.5 0.0 3.7 1.9 3.2 0.0 5.6 9.2 5.5 3.7 0.0 62.0 100.0 194 Worked before and after marriage 26.6 23.3 11.3 0.0 1.0 2.8 2.1 0.0 6.1 3.3 1.4 1.9 0.0 73.4 100.0 389 Never worked 29.9 22.1 7.7 0.1 2.3 2.1 2.3 0.2 7.4 7.8 3.7 4.0 0.1 70.1 100.0 5,826 Wealth quintile Lowest 15.6 12.4 7.0 0.1 1.5 1.0 1.6 0.1 1.2 3.2 1.7 1.3 0.3 84.4 100.0 1,847 Second 20.8 15.5 6.0 0.0 1.8 1.5 2.5 0.1 3.6 5.3 2.5 2.7 0.0 79.2 100.0 1,897 Middle 30.1 21.9 8.3 0.0 1.9 2.8 3.2 0.1 5.6 8.1 3.6 4.4 0.1 69.9 100.0 1,846 Fourth 36.8 26.3 9.8 0.1 2.6 1.7 2.7 0.3 9.0 10.4 4.7 5.3 0.4 63.2 100.0 1,957 Highest 43.4 31.6 9.6 0.1 2.4 4.2 1.6 0.1 13.7 11.8 5.2 6.6 0.0 56.6 100.0 2,009 Total 29.6 21.7 8.2 0.1 2.1 2.3 2.3 0.1 6.8 7.9 3.6 4.1 0.2 70.4 100.0 9,556 Note: If more than one method is used, only the most effective method is considered in this tabulation. Totals include a small number of cases with missing information. Family Planning | 59 41 46 35 24 33 27 25 14 25 34 37 39 43 RESIDENCE Urban Major city Other urban Rural PROVINCE Punjab Sindh NWFP Balochistan EDUCATION No education Primary Middle Secondary Higher 0 10 20 30 40 50 6 Percent PDHS 2006-07 Figure 5.3 Differentials in Contraceptive Use Note: Use of any method among currently married women 0 5.5 USE OF SOCIAL MARKETING CONTRACEPTIVE BRANDS Social marketing plays an important role in provision of contraceptive methods in Pakistan. The “Greenstar” and “Key” programmes are the two components of contraceptive social marketing in Pakistan, working since 1991 and 1996, respectively. They provide family planning information and services to mainly urban and peri-urban residents at reduced rates. The range of activities includes advertisement/promotional campaigns; training of doctors, paramedics, and chemists; and sales of condom brands like Sathi and Touch (Greenstar), and Intense, Spark, and Hamdam (Key Social Marketing). Other contraceptives sold by Greenstar include two low-dose oral contraceptive brands, three injectables (1, 2, and 3-month options), two IUDs, and an emergency contraceptive introduced in 2003. Voluntary surgical contraception was started through Greenstar Plus clinics in 2001. In addition to the condom brands mentioned, Key-supported products also include two injectables and two low-dose oral contraceptive brands. Table 5.7 shows by residence and province the percentage of pill and condom users who are using a social marketing brand. Because many women who are currently using pills and condoms were not able to report the brand they were using, the data are based on small numbers. This table reflects that a majority of pill users (74 percent) are using a social marketed brand (Nova, Novadol, and Famila 28). Among condom users who know the brand name, 82 percent reported that they are using Sathi, a social marketing brand. The number of pill users who reported their brand is too small to allow any meaningful analysis by residence or province. Among women who rely on condoms, the Sathi brand is more likely to be reported by rural than by urban women, and by women in Punjab and NWFP than by women in Sindh. 60 | Family Planning Table 5.7 Use of social marketing brand pills and condoms Percentage of pill and condom users age 15-49 using a social marketing brand, by background characteristics, Pakistan 2006-07 Background characteristic Percentage of pill users using a social marketing brand1 Number of women using the pill Percentage of condom users using a social marketing brand2 Number of women using condoms Residence Total urban 74.5 49 77.9 213 Rural 73.2 52 87.1 161 Province Punjab (86.9) 32 85.9 223 Sindh (67.0) 36 71.4 107 NWFP (61.6) 25 86.5 43 Balochistan (92.6) 7 * 1 Total 73.9 101 81.9 374 Note: Table excludes pill and condom users who do not know the brand name (49 percent of pill users and 43 percent of condom users). Condom use is based on women's reports. Figures in parentheses are based on 25-49 unweighted cases, while an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Greenstar distributors, Nova, Novadol, and Famila 28 2 Sathi 5.6 TIMING OF STERILIZATION Table 5.8 shows the percent distribution of currently married, sterilized women by age at the time of sterilization and median age at sterilization, according to the number of years since the operation. The table indicates more women are sterilized at age 30-34 than in any other age group, but it also indicates that almost one-third of sterilized women had the operation when they were relatively young, i.e., under age 30. The data shows that the median age at the time of sterilization has been highest among those sterilized between 6-7 years ago. Table 5.8 Timing of sterilization Percent distribution of currently married sterilized women age 15-49 by age at the time of sterilization, and median age at sterilization, according to the number of years since the operation, Pakistan 2006-07 Years since operation Number of women Median age1 Age at time of sterilization <25 25-29 30-34 35-39 40-44 45-49 Total <2 7.4 18.9 26.1 25.0 17.1 5.5 100.0 137 32.6 2-3 7.0 20.6 26.4 28.8 11.9 5.3 100.0 144 32.3 4-5 5.0 15.9 36.6 29.5 13.0 0.0 100.0 119 32.8 6-7 7.4 19.7 32.3 32.6 8.0 0.0 100.0 135 33.8 8-9 7.6 23.9 31.8 33.4 3.3 0.0 100.0 76 31.9 10+ 12.7 40.8 37.2 9.3 0.0 0.0 100.0 169 a Total 8.1 24.1 31.8 25.1 8.9 1.9 100.0 781 31.9 a = Not calculated due to censoring. 1 Median age at sterilization is calculated only for women sterilized before age 40 to avoid problems of censoring. Family Planning | 61 5.7 SOURCE OF CONTRACEPTION Information on where women obtain their contraceptives is useful for family planning programme managers and implementers for logistic planning. In the 2006-07 PDHS, women who reported using a modern contraceptive method at the time of the survey were asked where they obtained the method the last time they acquired it. Because some women may not exactly know in which category the source they use falls (e.g., government hospital, private health centre, etc.), interviewers were instructed to note the full name of the source or facility. Supervisors were instructed to verify that the name and source type were consistent, asking informants in the clusters for the names of local family planning outlets, if necessary. This practice was designed to improve the accuracy of source reporting. Table 5.9 shows the percent distribution of users of modern contraceptive methods by the most recent source of method. It indicates that 48 percent of modern method users rely on public sector institutions, while 30 percent use the private medical sector and 12 percent use other sources. In the public sector, the most important sources of family planning services are government hospitals and reproductive health service centres (RHSC; 32 percent of users). Lady Health Workers are also an important source, supplying 8 percent of all users of modern methods. Only 3 percent of users rely on Lady Health Visitors, while 2 percent go to family welfare centres and rural health or maternal and child health (MCH) centres. The main contributors in the private medical sector are private nongovernmental organization (NGO) hospitals and clinics (16 percent of users), followed by pharmacies and chemists (9 percent of users). Ten percent of modern method users obtain their methods from shops other than pharmacies or chemists. Table 5.9 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Pakistan 2006-07 Source Female sterili- zation Pill IUD Injectables Condom Total Public sector 72.4 46.1 52.4 51.2 16.9 48.2 Government hospital/RHSC 67.5 13.0 27.5 16.1 2.7 32.4 Rural health centre/MCH centre 2.4 0.0 2.0 4.1 0.1 1.6 Family welfare centre 0.0 2.5 6.0 8.1 0.2 1.8 Mobile service camp 1.0 0.0 0.0 0.0 0.2 0.5 Lady Health Worker 0.4 28.2 6.4 13.4 10.9 8.4 Lady Health Visitor 0.7 2.5 8.3 5.9 1.9 2.6 Basic health unit 0.3 0.0 2.2 3.5 0.5 0.9 Male mobilizer 0.0 0.0 0.0 0.0 0.2 0.1 Other public 0.1 0.0 0.0 0.0 0.1 0.0 Private medical sector 25.8 31.2 41.0 41.7 27.3 30.1 Private/NGO hospital/clinic 22.8 10.5 34.6 20.5 2.1 16.2 Pharmacy/chemists 0.0 16.1 0.6 2.7 22.9 9.0 Private doctor 3.0 2.1 4.3 12.2 0.6 3.3 Dispenser/compounder 0.0 2.0 0.9 6.0 1.0 1.2 Other private medical 0.0 0.6 0.5 0.4 0.8 0.4 Other source 0.0 13.8 6.6 4.2 31.4 12.2 Shop (not pharmacy/chemist) 0.0 7.2 0.0 1.6 30.5 10.3 Friend/relative 0.0 4.3 0.0 1.3 0.2 0.6 Dai/traditional birth attendant 0.0 1.2 6.6 1.3 0.2 1.0 Other 0.0 1.0 0.0 0.0 0.6 0.3 Don't know 1.2 7.7 0.0 2.5 24.0 9.0 Missing 0.5 1.1 0.0 0.4 0.4 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 781 196 216 221 646 2,078 Note: Total includes other modern methods with too few users to show separately RHSC = Reproductive Health Service Centre MCH = Maternal and Child Health 62 | Family Planning As expected, government sources supply a larger proportion of users of long-term methods such as female sterilization, IUDs, and injectables, as compared to users of pills and especially condoms. For example, almost three in four women who are sterilized obtained the operation at a government facility, mostly government hospitals and RHSCs. On the other hand, almost six in ten women who rely on condoms say the method is obtained from private or other sources, mostly shops and pharmacies. The public sector also plays a lead role in providing IUDs (52 percent) and injectables (51 percent). Lady Health Workers serve as the source for more than one-quarter of pill users and more than 10 percent of users of injectables and condoms. 5.8 COST OF CONTRACEPTIVE METHODS Table 5.10 reflects the percentage of current users of modern contraceptive methods who received the method for free and the median cost for those who paid and could report a cost. According to the table, almost one-third (32 percent) of users of modern contraceptive methods do not pay for the method. As expected, women who get their family planning methods from public (government) sources are far more likely to get them for free (58 percent) than those who use private sources (8 percent). As far as specific contraceptive methods are concerned, more than half of female sterilization clients (59 percent) reported that it was free of cost. Thirty percent of pill users, 15 percent of IUD users, 14 percent of condom users, and 13 percent of injectable users reported getting their methods free of charge. Among those who paid, the median cost for specific methods is Rs. 9,972/- for sterilization, Rs. 12/- for one cycle of pills, Rs. 198/- for the IUD, Rs. 46/- for the injectable, and Rs. 5/- for a package of condoms. As expected, the cost of contraceptive methods is higher when the source is private than when it is a public source. Table 5.10 Cost of modern contraceptive methods Percentage of current users of modern contraception age 15-49 who did not pay for the method and who do not know the cost of the method and the median cost of the method, by current method, according to source of current method, Pakistan 2006-07 Source of method/cost Female sterili- zation Pill IUD Inject- ables Condom Total Public sector Percentage free 72.4 51.7 22.4 21.1 70.6 58.3 Do not know cost 6.8 14.3 5.9 5.1 14.4 8.1 Median cost (in rupees)1 7,992 (6) 114 38 * 49 Number of women 565 91 113 113 109 1,002 Private medical sector/other Percentage free 23.2 11.7 7.2 4.7 2.3 8.2 Do not know cost 18.8 35.4 4.2 11.1 70.0 43.8 Median cost (in rupees)1 9,973 20 294 71 4 64 Number of women 216 106 103 108 537 1,076 Total Percentage free 58.8 30.1 15.1 13.1 13.8 32.4 Do not know cost 10.1 25.7 5.1 8.0 60.6 26.6 Median cost (in rupees)1 9,972 12 198 46 5 54 Number of women 781 196 216 221 646 2,078 Note: Costs are based on the last time current users obtained method. Costs include consultation costs, if any. For condoms, costs are per package; for pills, per cycle. For sterilization, data are based on women who received the operation in the 5 years before the survey. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Median cost is based only on those women who reported a cost. Family Planning | 63 5.9 INFORMED CHOICE Current users of modern methods who are informed about the side effects and problems associated with methods and know of a range of method options are better placed to make an informed choice about the method they would like to use. Current users of various modern contraceptive methods who started the last episode of use within the five years preceding the survey were asked whether, at the time they were adopting the particular method, they were informed about side effects or problems that they might have with the method and what to do if they experienced side effects or if they were informed about other methods that they could use. Table 5.11 shows that 33 percent of modern method users were informed about the side effects or problems of the method and 29 percent were informed about what to do if they experienced side effects. Thirty-eight percent of users were informed of other methods available. The results indicate that IUD users are more likely than users of other methods to be informed about side effects, what to do if they experience side effects, and about other methods available. These data imply that there is considerable room for improvement in terms of providing women with information about family planning methods. With regard to the source of supply, users who obtain their methods from Lady Health Workers are more likely to be informed about side effects and other methods than users who obtain their methods from other sources. In general, differences between public sector and private sector sources are minimal. Table 5.11 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods that they could use, by method and source, Pakistan 2006-07 Among women who started last episode of modern contraceptive method within five years preceding the survey: Method/source Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed of other methods that could be used Number of women Method Female sterilization 26.4 23.8 29.5 344 Pill 33.2 26.5 44.1 151 IUD 50.6 47.5 46.6 178 Injectables 30.5 23.7 37.8 197 Total1 33.4 29.1 37.7 881 Source of method2 Public sector 32.5 28.0 38.4 503 Government hospital/RHSC 28.4 24.9 32.3 314 Family welfare centre (35.4) (27.5) (37.6) 29 Lady Health Worker 47.1 40.4 53.2 91 Other public (31.5) (27.3) (53.4) 47 Private medical sector 36.1 32.1 36.8 315 Private/NGO hospital/clinic 35.7 31.5 53.2 52 Pharmacy/chemists 38.2 35.7 36.5 211 Private doctor (25.4) (15.3) (24.1) 32 Other private (26.8) (24.3) (29.4) 34 Note: Table excludes users who obtained their method from friends/relatives. Figures in parentheses are based on 25-49 unweighted cases. RHSC = Reproductive Health Service Centre 1 Includes users of implants 2 Most recent source; totals include sources with too few users to show separately. 64 | Family Planning 5.10 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which nonusers of contraception plan to use family planning in the future. In the PDHS, currently married women age 15-49 who were not using a contraceptive method were asked about their intention to use family planning in the future. The results are presented in Table 5.12. Fifty percent of currently married nonusers say that they intend to use family planning in the future, while 43 percent do not intend to use, and 7 percent are unsure. The proportion who intend to use varies with the number of living children, increasing from 48 percent among those with no children to a peak for those with one child (58 percent) and then declining to 45 percent among those with four or more children. Table 5.12 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to province and number of living children, Pakistan 2006-07 Number of living children1 Intention 0 1 2 3 4+ Total Intends to use 48.0 58.0 54.7 51.3 44.9 49.9 Unsure 14.7 8.4 4.9 6.6 4.6 7.0 Does not intend to use 37.0 33.2 39.9 41.9 50.1 42.8 Missing 0.3 0.3 0.5 0.2 0.4 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 940 1,129 1,058 900 2,701 6,727 1 Includes current pregnancy 5.11 REASONS FOR NOT INTENDING TO USE As mentioned above, the majority of married Pakistani women are not using contraception. Consequently, the reasons why they are not using family planning methods is of great interest. Table 5.13 presents the distribution of currently married nonusers who do not intend to use a contraceptive method in the future by the main reason why they do not intend to use. The data show that fertility-related reasons (58 percent), opposition to use (23 percent), and method-related reasons (12 percent) were mainly cited. The most common single reasons for not intending to use are “up to God” (28 percent), “infertile/can’t get pregnant” (15 percent), and “husband opposed” (10 percent). Only 8 percent of nonusers say they do not intend to use because they are opposed to contraception and only 5 percent cite religious reasons for nonuse. Family Planning | 65 Table 5.13 Reason for not intending to use contracep- tion in the future Percent distribution of currently married women age 15-49 who are not using contraception and who do not intend to use in the future, by main reason for not intending to use, Pakistan 2006-07 Reason Percentage Fertility-related reasons Infrequent sex/no sex 4.2 Menopausal/had hysterectomy 6.0 Infertile/can’t get pregnant 14.5 No menstruation since birth 0.9 Breastfeeding 1.5 Up to God 28.4 Wants more children 2.9 Method-related reasons Health concerns 3.6 Fear of side effects 5.4 Costs too much 0.8 Inconvenient to use 0.3 Interferes with body's normal process 2.0 Opposition to use Respondent opposed 7.7 Husband opposed 9.9 Others opposed 0.4 Religious prohibition 5.0 Lack of knowledge Knows no method 2.2 Knows no source 0.8 Other 0.9 Don't know 2.2 Missing 0.4 Total 100.0 Number of women 2,876 5.12 EXPOSURE TO FAMILY PLANNING MESSAGES For some time, the Population Welfare Programme has been using the electronic media to inform the population about family planning issues. Information on the level of public exposure to a particular type of media allows policymakers to assess the most effective media for various target groups in the population. To gauge the effectiveness of such media on the dissemination of family planning information, the 2006-07 PDHS asked respondents whether they had heard or seen a family planning message on the radio or television in the month preceding the interview. Table 5.14 shows that 56 percent of currently married women 15-49 have not been exposed to a family planning message through either radio or television. Eleven percent of women heard a family planning message on the radio and 41 percent saw a message on the television. The youngest and oldest women are least likely to have heard or seen family planning messages on the radio or television. Although there is little difference by residence in exposure to family planning messages on the radio, there are large differences for television messages; 58 percent of urban women saw a family planning message on television in the month before the survey compared with only 33 percent of rural women. Variation by province in exposure to family planning messages is very large; 87 percent of married women in Balochistan did not hear or see a family planning message in the media compared with only 49 percent of women in Punjab. Exposure to family planning messages through the media—especially through television—increases with the level of education and with wealth. 66 | Family Planning Table 5.14 Exposure to family planning messages Percentage of currently married women age 15-49 who heard or saw a family planning message on the radio or television in the month preceding the survey, according to background characteristics, Pakistan 2006-07 Background characteristic Radio Television Neither of these media sources Number Age 15-19 8.3 30.1 66.9 559 20-24 12.5 43.6 53.6 1,463 25-29 11.8 44.6 52.7 1,965 30-34 9.7 41.1 56.7 1,729 35-39 10.1 40.5 57.1 1,565 40-44 11.3 43.0 55.4 1,208 45-49 10.5 37.2 60.2 1,067 Residence Total urban 10.2 57.9 41.2 3,191 Major city 8.6 61.0 38.2 1,815 Other urban 12.4 53.7 45.2 1,376 Rural 11.1 33.0 63.9 6,365 Province Punjab 12.1 48.5 49.2 5,495 Sindh 10.4 36.5 61.1 2,317 NWFP 8.5 29.7 67.4 1,301 Balochistan 4.0 11.1 87.4 443 Education No education 9.3 29.8 67.6 6,165 Primary 14.2 54.0 42.9 1,371 Middle 13.8 62.4 35.5 609 Secondary 11.0 67.4 31.2 785 Higher 15.3 73.2 26.2 626 Wealth quintile Lowest 5.9 7.3 88.9 1,847 Second 10.1 25.3 71.2 1,897 Middle 13.3 44.2 52.7 1,846 Fourth 12.4 55.8 42.9 1,957 Highest 12.3 70.8 28.7 2,009 Total 15-49 10.8 41.3 56.3 9,556 Table 5.15 shows information about the messages conveyed over the media. A majority of the respondents who heard or saw a family plan- ning message in the month preceding the interview said that the message was about limiting the size of the family (55 percent), 48 percent said the mes- sage promoted use of contraceptives, and 42 per- cent said the message concerned birth spacing. Table 5.15 Family planning messages Among currently married women age 15-49 who heard or saw a family planning message on radio or television in the month preceding the survey, percentage who cite specific messages conveyed and percent distribution by effectiveness, Pakistan 2006-07 Message/ effectiveness Percentage Type of message Limiting the family 55.3 Higher age at marriage 6.7 Spacing of children 42.3 Use of contraceptives 48.0 Welfare of family 20.7 Maternal and child health 15.8 Fewer children means prosperous life 10.0 More children means poverty and starvation 5.1 Importance of breastfeeding 1.9 Other 0.6 Effectiveness of message Effective 84.1 Not effective 6.8 Don't know 9.0 Missing 0.1 Total 100.0 Number 4,176 The vast majority of those who were ex- posed to a family planning message (84 percent) said that the messages were effective. Only 7 per- cent of respondents considered the messages to be ineffective. Family Planning | 67 68 | Family Planning 5.13 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS In the 2006-07 PDHS, married women who were not using any family planning method were asked if they had been visited by a fieldworker or a Lady Health Worker who talked to them about family planning in the 12 months preceding the survey. This information is especially useful for determining if nonusers of family planning are being reached by family planning programmes. The results show that less than one-quarter (23 percent) of nonusers are being reached by fieldworkers to discuss family planning issues (Table 5.16). Only 9 percent of these women received information on family planning, 3 percent received family planning supplies, 2 percent received a referral to a health facility, 2 percent received treatment for side effects, and 1 percent received other assistance from fieldworkers or Lady Health Workers in the previous 12 months. Differentials by background characteristics are generally not large. Married nonusers age 15-19, women living in major cities or in Balochistan, and women in the lowest wealth quintile are less likely than other nonusers to have been visited by a fieldworker or Lady Health Worker in the 12 months before the survey. Table 5.16 Contact of nonusers with family planning providers Among currently married women age 15-49 who are not using contraception, the percentage who were visited in the 12 months preceding the survey by a fieldworker or Lady Health Worker (LHW) who discussed family planning, and the percentage who were visited and received specific services, by background characteristics, Pakistan 2006-07 Percentage of women who were visited by fieldworker or LHW who discussed family planning Number of currently married women not using contra- ception Percentage of women who were visited by a fieldworker or LHW in the past 12 months and who received: Background characteristic Information FP supplies Referral to facility Treatment of side effects Other Age 15-19 17.9 5.6 0.2 1.8 0.2 1.0 521 20-24 23.7 10.3 2.2 1.5 2.8 1.1 1,238 25-29 22.7 8.4 3.9 1.3 1.3 1.0 1,478 30-34 24.5 11.1 4.1 3.4 0.4 0.9 1,113 35-39 25.7 9.8 4.0 2.6 1.7 1.0 940 40-44 20.7 5.4 1.8 1.6 2.3 1.2 705 45-49 25.4 7.0 2.4 1.3 0.9 1.6 732 Residence Total urban 21.9 8.1 2.7 1.8 1.1 1.4 1,881 Major city 11.5 4.1 1.9 1.0 0.8 1.0 982 Other urban 33.2 12.4 3.6 2.7 1.4 1.9 898 Rural 23.9 9.0 3.1 2.0 1.6 1.0 4,846 Province Punjab 23.0 6.6 2.9 1.2 2.0 1.7 3,671 Sindh 25.3 14.8 2.6 0.8 0.8 0.5 1,699 NWFP 24.0 7.4 5.0 7.4 0.6 0.2 978 Balochistan 16.2 5.1 0.2 0.2 0.9 0.0 379 Education No education 21.5 7.9 2.3 1.5 1.0 0.7 4,608 Primary 29.5 10.9 6.0 2.9 3.4 1.1 899 Middle 27.2 12.1 1.6 1.6 4.7 3.8 382 Secondary 28.9 10.2 4.9 3.0 1.1 2.3 478 Higher 19.7 8.5 2.6 3.8 0.0 1.0 360 Wealth quintile Lowest 14.6 7.1 1.7 0.9 0.5 0.9 1,559 Second 23.4 10.6 3.0 1.3 1.6 0.1 1,502 Middle 28.3 10.1 3.6 2.8 1.9 1.7 1,291 Fourth 30.7 9.6 4.0 3.1 2.1 1.4 1,238 Highest 21.4 5.9 2.8 1.9 1.3 1.6 1,137 Total 23.3 8.7 3.0 1.9 1.5 1.1 6,727 OTHER DETERMINANTS OF FERTILITY 6 Mehboob Sultan and Mubashir Baqai The levels and trends in fertility are influenced by various physiological, cultural, social, economic, behavioural, demographic, and ecological factors. Research shows that fertility levels in most populations can be explained by some key proximate determinants that define the risk of becoming pregnant. These determinants are marriage, postpartum amenorrhoea, abstinence from sexual relations, and onset of menopause. This chapter addresses the principal factors other than contraception that affect a woman’s risk of becoming pregnant. In Pakistani society, where sexual activity usually takes place within marriage, marriage signals the onset of a woman’s exposure to the risk of childbearing; postpartum amenorrhoea and sexual abstinence affect the duration of a woman’s insusceptibility to pregnancy, which in turn affects birth spacing; and the onset of menopause marks the end of a woman’s reproductive life. These variables taken together determine the length and pace of a woman’s reproductive life and are, therefore, important for understanding fertility dimensions. 6.1 MARITAL STATUS In Pakistan, marriage is a social and religious obligation. The length of time women are exposed to the risk of childbearing affects the number of children women potentially can bear. Thus, an increase in the age at marriage can play a vital role in reducing fertility levels, because it reduces the period of exposure to childbearing. Table 6.1 shows the distribution of women of reproductive age by marital status. The category “married” refers to those who are currently married, while those who are divorced, separated, or widowed are referred to as “formerly married.” The combined categories of currently married and formerly married gives the proportion “ever married.” Table 6.1 Current marital status Percent distribution of all women age 15-49 by current marital status, according to age, Pakistan 2006-07 Marital status Age Never married Married Divorced Separated Widowed Total Number of women 15-19 84.0 15.7 0.1 0.2 0.0 100.0 3,551 20-24 52.0 46.9 0.3 0.6 0.2 100.0 3,123 25-29 19.8 78.6 0.4 0.9 0.4 100.0 2,500 30-34 6.8 90.3 0.5 0.7 1.8 100.0 1,916 35-39 3.0 91.8 0.3 1.0 3.9 100.0 1,705 40-44 3.1 90.0 0.5 0.8 5.7 100.0 1,343 45-49 1.4 87.2 0.8 0.8 9.8 100.0 1,225 Total 15-49 34.8 62.2 0.3 0.6 2.1 100.0 15,362 Table 6.1 shows that 62 percent of women of childbearing age are currently married, one- third (35 percent) are never married and the remaining 3 percent are divorced, separated, or widowed. The proportion of women never married decreases with age. The low proportion of 1 percent of women of age group 45-49 who have never been married indicates that marriage is still a common phenomenon in Pakistan. Once marriages are consummated they remain stable. Divorce and separation are socially discouraged, and hence are uncommon (1 percent). Although teenage marriages are on the decline, one of six women age 15-19 is already married. By age 25-29, 80 percent of women of reproductive age have ever married. Other Determinants of Fertility | 69 It should be noted that the 2006-07 Pakistan Demographic and Health Survey (PDHS) and all preceding surveys undertaken by the National Institute of Population Studies (NIPS) considered the age at marriage as the date the marriage was consummated. In Pakistan, as in other neighbouring countries, the contract of marriage is sometimes finalized months or years before the time the husband and wife actually start living together. The ceremony in which the contract of marriage is signed is called Nikah, whereas the subsequent ceremony after which the bride and the bridegroom start living together is called Rukhsati. Because the interest in marriage in the survey is mainly as it affects exposure to the risk of pregnancy, interviewers were instructed to ask the questions about marriage not in the sense of formal marriage, but as cohabitation. 6.2 POLYGYNY Table 6.2 Cohabitation and polygyny Polygyny is legal in Pakistan. However, according to the Muslim Family Laws Ordinance promulgated in 1961, the husband needs to obtain written permission from his first wife if he wants to marry a second wife. Table 6.2 shows that 1 in 15 currently married women (7 percent) reported that their husbands have other wives. The prevalence of polygynous marriages has increased by over 2 per- centage points since the 1990-91 PDHS. Surpris- ingly, the highest proportion of women in polygy- nous marriages is found in the age group 15-19, which appears to be a recent phenomenon. Among women in age groups 20-49, the prevalence of polygynous marriages increases slightly with age. Polygynous marriages are almost twice as common in Balochistan (11 percent) than in Punjab (6 percent). Women with no or low education and those who are poor are more likely to live in polygynous marriages. Table 6.2 also shows that around 12 percent of married women reported that their husbands were not staying with them at the time of interview. Husbands from rural areas and NWFP are more likely to be living away from their families than husbands in other areas, most probably in order to earn their livelihoods. 6.3 CONSANGUINITY Pakistan has one of the highest reported rates of consanguineous marriages in the world. Table 6.3 provides data on marriages between relatives reported in the 2006-07 PDHS. The results show that more than half of all marriages (61 percent) are between first and second cousins. First-cousin marriages are more common on the father’s side (32 percent) but also occur between first cousins on the mother’s side (21 percent). Eight percent of marriages are between second cousins, 7 percent are between other relatives, and one-third are between non-relatives. There is some evidence that cousin marriage may affect both fertility and the health of children. Percentage of currently married women age 15-49 whose husbands are staying elsewhere and whose husbands have other wives, according to background characteristics, Pakistan 2006-07 Background characteristic Percentage staying elsewhere Percentage in polygynous union Number of women Age 15-19 12.9 8.6 559 20-24 13.4 5.4 1,463 25-29 12.4 6.4 1,965 30-34 12.0 6.4 1,729 35-39 12.2 7.3 1,565 40-44 10.1 7.5 1,208 45-49 8.6 7.7 1,067 Residence Total urban 7.2 6.4 3,191 Major city 5.7 6.3 1,815 Other urban 9.1 6.4 1,376 Rural 14.1 7.0 6,365 Province Punjab 12.1 5.6 5,495 Sindh 6.8 8.2 2,317 NWFP 22.6 7.9 1,301 Balochistan 2.2 10.5 443 Education No education 11.2 7.7 6,165 Primary 13.4 5.8 1,371 Middle 12.4 5.0 609 Secondary 12.9 4.7 785 Higher 12.2 5.0 626 Wealth quintile Lowest 9.1 8.5 1,847 Second 13.2 7.3 1,897 Middle 13.8 7.9 1,846 Fourth 12.3 5.2 1,957 Highest 10.5 5.4 2,009 Total 11.8 6.8 9,556 Differences in marriage patterns are visible by urban-rural residence. First-cousin marriages are most common in rural areas (57 percent) and are less common in major cities where about 40 percent of marriages are between first cousins. 70 | Other Determinants of Fertility Sindh has the highest proportion of marriages among first cousins (56 percent), followed by Punjab (53 percent), Balochistan (52 percent), and NWFP (43 percent). As expected, first-cousin marriages are less common among educated women than among women with no education. Among women with more than secondary education, the proportion marrying first cousins falls to below 40 percent. The association with education is more distinct in marriages between non-related spouses. For example, 52 percent of women with more than secondary schooling marry spouses who are not related compared with only 29 percent of women with no education. Similarly, consanguineous marriages are more common among poor women than women who are in upper wealth quintiles. Table 6.3 Marriage between relatives Percent distribution of ever-married women by relationship to their husbands, according to background characteristics, Pakistan 2006-07 First cousin Background characteristic Father's side Mother's side Second cousin Other relation Not related Total Number of women Age 15-19 36.3 25.9 10.1 5.0 22.7 100.0 569 20-24 35.3 20.3 8.1 5.8 30.5 100.0 1,499 25-29 30.0 23.1 6.9 8.3 31.7 100.0 2,006 30-34 29.8 20.0 8.0 6.2 36.0 100.0 1,786 35-39 30.1 19.7 9.6 6.5 34.0 100.0 1,654 40-44 31.6 17.8 8.2 6.0 36.2 100.0 1,301 45-49 31.8 21.5 6.9 5.8 34.0 100.0 1,208 Age at marriage < 15 33.1 18.3 8.7 6.7 33.1 100.0 1,495 15 34.0 21.4 7.0 7.1 30.4 100.0 969 16-17 33.8 22.6 10.0 6.4 27.3 100.0 2,211 18-19 32.4 21.6 7.2 7.2 31.6 100.0 1,997 20-21 30.4 22.1 8.0 6.5 33.0 100.0 1,364 22-23 27.8 20.9 6.8 6.8 37.6 100.0 810 24+ 26.0 17.7 6.9 4.3 45.1 100.0 1,178 Residence Total urban 24.5 18.5 8.0 6.5 42.4 100.0 3,350 Major city 21.1 18.8 7.2 6.0 46.9 100.0 1,898 Other urban 29.0 18.2 9.1 7.1 36.6 100.0 1,452 Rural 35.1 22.0 8.1 6.5 28.3 100.0 6,673 Province Punjab 30.0 23.1 7.6 7.1 32.2 100.0 5,800 Sindh 37.4 19.0 7.8 5.6 30.1 100.0 2,410 NWFP 27.7 14.9 8.5 5.6 43.1 100.0 1,351 Balochistan 31.9 20.1 13.5 6.3 28.1 100.0 462 Education No education 34.8 21.3 8.1 6.5 29.2 100.0 6,511 Primary 29.1 21.4 8.1 6.8 34.5 100.0 1,423 Middle 26.6 19.1 9.3 6.1 39.0 100.0 634 Secondary 22.8 20.7 8.4 6.7 41.4 100.0 809 Higher 20.4 16.8 5.6 5.7 51.5 100.0 646 Wealth quintile Lowest 40.2 24.1 7.1 6.1 22.4 100.0 1,944 Second 35.9 19.9 8.7 6.2 29.2 100.0 2,001 Middle 30.1 21.1 8.1 7.8 32.9 100.0 1,944 Fourth 28.0 19.8 8.4 6.1 37.7 100.0 2,055 Highest 24.1 19.6 7.9 6.3 42.1 100.0 2,078 Total 31.5 20.9 8.1 6.5 33.0 100.0 10,023 Other Determinants of Fertility | 71 6.4 AGE AT FIRST MARRIAGE In Pakistan, marriage defines the onset of the socially acceptable time for childbearing. Women who marry early will have, on average, a longer period of exposure to pregnancy that often leads to a higher number of children ever born. The minimum legal age at marriage in Pakistan is 18 years for males and 16 years for females. As mentioned earlier, two terms are important in this respect: Nikah and Rukhsati. Nikah means that a girl is legally married, but that she may or may not have yet started living with her husband. Rukhsati is the ceremony when the bride goes to her husband’s house and thereafter husband and wife start living together. Women are considered to be exposed to the risk of pregnancy only after the Rukhsati. Interviewers in this survey were instructed to probe to differentiate the Nikah from the Rukhsati. Thus, in the following discussion, marriage refers to Rukhsati rather than Nikah. Table 6.4 shows the percentage of women who have married by specific ages and the median age at first marriage, according to their current age. The data show that more than half of women in Pakistan marry by age 20 and over one-third marry by age 18. Around 12 to 13 percent of women enter marriage before their 15th birthday. However, the data imply that median age at first marriage has been increasing over time. The median age at first marriage increases from under 19 years for women age 45-49 to over 20 years for those age 25-29. The proportion of women marrying before age 15 has declined over time, from 15 percent among women in the oldest cohort to 7 percent among women age 20-24. Another indication of increasing age at first marriage is that the singulate mean age at marriage has increased from 21.7 in 1990-91 to 23.1 in 2006-07 (data not shown). Table 6.4 Age at first marriage Percentage of women age 15-49 who were first married by specific exact ages, and median age at first marriage, according to current age, Pakistan 2006-07 Percentage never married Median age at first marriage Percentage first married by exact age: Current age 15 18 20 22 25 Number 15-19 3.5 na na na na 84.0 3,551 a 20-24 6.7 24.0 35.7 na na 52.0 3,123 a 25-29 10.7 31.3 48.0 59.6 73.3 19.8 2,500 20.3 30-34 13.9 41.7 57.8 69.9 82.6 6.8 1,916 18.9 35-39 14.7 44.2 63.5 76.0 87.0 3.0 1,705 18.5 40-44 14.7 41.4 60.8 74.6 85.4 3.1 1,343 18.8 45-49 14.6 44.2 63.9 77.3 88.9 1.4 1,225 18.5 20-49 11.6 35.4 51.7 na na 20.0 11,811 19.8 25-49 13.4 39.5 57.4 69.9 82.1 8.4 8,689 19.1 Note: The age at first marriage is defined as the age at which the respondent began living with her first husband. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Table 6.5 shows the median age at first marriage for women age 25-49 by background characteristics. Urban women tend to marry about one year later than their rural counterparts. The difference is larger for younger age cohorts, which suggests that for older women, marriage at a younger age was a common phenomenon both in urban and rural areas. The variation in median age at marriage by province is not large; however, women in Sindh and NWFP generally enter into marriage earlier than women in the other two provinces. The difference in median age at marriage between Punjab and Sindh provinces has been widening over time; there is almost a two-year difference among women age 25-29 and 30-34 but smaller differences among older women. Similarly, large variations exist in median age at first marriage on the basis of educational levels and wealth quintiles. For example, the median age at first marriage is 18 years among women with no education; however, it is almost 25 years among women with more than secondary schooling. 72 | Other Determinants of Fertility Table 6.5 Median age at first marriage Median age at first marriage among women age 25-49, by five-year age groups, according to background characteristics, Pakistan 2006-07 Background characteristic Age Women age 25-49 25-29 30-34 35-39 40-44 45-49 Residence Total urban 21.6 20.2 18.5 19.1 18.6 19.7 Major city 22.1 20.7 18.5 19.3 18.7 20.0 Other urban 21.0 19.8 18.6 18.7 18.5 19.4 Rural 19.6 18.4 18.5 18.7 18.5 18.8 Province Punjab 21.0 19.6 19.0 19.1 18.8 19.6 Sindh 19.2 17.8 17.7 18.0 17.3 18.1 NWFP 19.9 18.5 17.9 18.7 19.1 18.7 Balochistan 20.1 18.6 18.8 18.9 19.5 19.3 Education No education 18.7 17.9 18.1 18.3 18.2 18.2 Primary 19.8 18.5 18.8 19.2 18.9 19.1 Middle 21.3 21.0 17.9 19.1 18.6 19.8 Secondary 22.0 21.0 20.0 20.3 20.6 21.1 Higher a 24.2 22.2 24.1 24.2 24.5 Wealth quintile Lowest 18.1 17.0 18.1 17.3 17.9 17.7 Second 19.0 18.5 18.5 18.7 17.9 18.7 Middle 20.4 18.4 18.4 19.1 18.7 18.9 Fourth 21.0 19.2 18.5 18.7 18.6 19.2 Highest 22.7 21.8 19.0 19.6 19.0 20.7 Total 20.3 18.9 18.5 18.8 18.5 19.1 Note: The age at first marriage is defined as the age at which the respondent began living with her first husband a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group The median age at marriage has increased slightly since 1990-91, from 18.6 to 19.1 among women age 25-49. 6.5 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea is defined as the period between childbirth and the resumption of menstruation after childbirth, which generally approximates the return of ovulation. This period is largely determined by the duration and intensity of breastfeeding. The risk of conception in this period is very low. The duration of postpartum amenorrhoea and sexual abstinence after birth jointly determines the length of the insusceptibility period. Thus, women are considered insusceptible if they are either abstaining from sex after childbirth or are amenorrhoeic. In the 2006-07 PDHS, women who gave birth in the five years preceding the survey were asked about the duration of amenorrhoea and sexual abstinence after each birth. The results are presented in Table 6.6 for the three years before the survey. The results show that almost all women (93 percent) are insusceptible to pregnancy within the first two months after childbirth due to amenorrhoea and abstinence. However, after the second month, the proportions of women who are amenorrhoeic, and especially those who are abstaining, fall sharply. At six to seven months after birth, 30 percent of women are still amenorrhoeic, but only 14 percent are abstaining. Thus, the principal determinant of the length of the period of insusceptibility is postpartum amenorrhoea. Other Determinants of Fertility | 73 Table 6.6 Postpartum amenorrhoea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Pakistan 2006-07 Months since birth Percentage of births for which the mother is: Number of births Amenorrhoeic Abstaining Insusceptible1 < 2 85.0 84.3 93.4 298 2-3 59.5 30.1 66.5 399 4-5 42.1 14.7 49.4 340 6-7 30.2 14.3 35.8 331 8-9 23.9 10.4 31.1 291 10-11 26.0 4.5 28.2 272 12-13 13.5 5.7 17.8 373 14-15 13.5 2.9 15.6 327 16-17 7.4 4.8 12.1 301 18-19 7.4 1.8 9.0 240 20-21 7.8 4.7 10.8 194 22-23 2.2 1.5 3.7 228 24-25 2.8 2.9 5.5 390 26-27 1.9 3.1 5.0 338 28-29 3.4 5.0 7.3 296 30-31 0.7 1.9 2.2 294 32-33 1.8 4.7 6.1 253 34-35 0.5 4.3 4.8 238 Total 19.7 11.8 24.0 5,401 Median 3.9 2.1 4.8 na Mean 6.9 4.4 8.4 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstain- ing (or both) after birth Overall, the median duration of amenorrhoea is 3.9 months, abstinence is 2.1 months, and insusceptibility is 4.8 months. The duration of abstinence has remained constant since 1990-91, most probably because of the Muslim tradition of abstaining for 40 days after birth. However, the median period of amenorrhoea has declined by more than 2 months since 1990-91 (NIPS and Macro, 1992). Table 6.7 shows the median durations of postpartum amenorrhoea, abstinence, and insusceptibility by background characteristics of the respondents. The median duration of abstinence in Pakistan does not vary much by background characteristics; therefore, insusceptibility varies directly according to duration of amenorrhoea. Older women (age 30-49) have a slightly longer median period of insusceptibility than those aged 15-29. Women living in rural areas also have a longer median duration of amenorrhoea and hence a longer period of insusceptibility than urban women. The median duration of postpartum amenorrhoea generally declines as the wealth status increases. The poorest women have the longest duration of amenorrhoea and insusceptibility but have a shorter duration of abstinence. While the start of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a given population. One indicator of infecundity is the onset of menopause. Menopausal women are defined by the PDHS as women who are neither pregnant nor postpartum amenorrhoeic but who have not had a menstrual period in the six months before the survey. 74 | Other Determinants of Fertility Table 6.7 Median duration of postpartum amenorrhoea, abstinence, and insusceptibility Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility, after birth in the three years preceding the survey, by background characteristics, Pakistan 2006-07 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 3.7 2.1 4.5 30-49 4.3 2.2 5.7 Residence Total urban 3.1 2.1 4.1 Major city 3.5 2.2 (4.2) Other urban 2.7 2.0 3.9 Rural 4.2 2.1 5.1 Province Punjab 4.0 2.3 5.0 Sindh 4.2 1.8 4.7 NWFP 4.5 2.2 5.9 Balochistan * * * Education No education 4.4 2.0 5.5 Primary (3.6) (2.2) 4.2 Middle * * * Secondary (2.4) (2.2) (3.1) Higher * * * Wealth quintile Lowest 4.9 1.7 6.5 Second 4.1 2.2 5.4 Middle 3.6 2.2 4.7 Fourth 4.0 2.3 4.4 Highest 2.8 2.3 3.9 Total 3.9 2.1 4.8 Note: Medians are based on the status at the time of the survey (current status) at two-month smoothed durations since birth. Figures in parentheses are based on fewer than 25 unweighted births in the relevant duration cell, and an asterisk represents a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) after birth Table 6.8 shows the percentage of women age 30-49 who are menopausal, by residence and age. Overall, 12 percent of women age 30-49 reported that they were menopausal. As expected, menopause increases with age, from only 2 percent of women 30-34 to almost half of women age 48-49. Table 6.8 Menopause Percentage of ever-married women age 30-49 who are menopausal, by residence and age, Pakistan 2006-07 Residence Total urban Major city Other urban Rural Total Age Percentage menopausal1 Number of women Percentage menopausal1 Number of women Percentage menopausal1 Number of women Percentage menopausal1 Number of women Percentage menopausal1 Number of women 30-34 1.0 623 0.6 359 1.6 264 2.0 1,163 1.7 1,786 35-39 4.4 561 3.9 319 5.1 242 3.8 1,093 4.0 1,654 40-41 12.2 244 12.0 153 12.7 92 9.8 417 10.7 661 42-43 13.1 146 19.5 92 2.2 54 9.1 278 10.5 424 44-45 25.4 199 29.6 118 19.2 81 21.6 382 22.9 581 46-47 38.8 166 43.1 106 31.4 60 35.6 267 36.9 433 48-49 52.5 136 62.0 69 42.6 67 46.6 274 48.5 410 Total 12.8 2,075 14.3 1,216 10.7 858 11.3 3,875 11.8 5,949 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey Other Determinants of Fertility | 75 76 | Other Determinants of Fertility Another important factor affecting the level of fertility is abortion and other pregnancy “wastage,” such as miscarriages and stillbirths. Although it is extremely difficult to get accurate information about the level of induced abortion, the 2006-07 PDHS included several questions about pregnancies that did not end in live births. Table 6.9 shows that 8 percent of ever-married women report that they had a miscarriage in the five years before the survey, about 2 percent said they had an abortion, and 3 percent reported having a stillbirth. The level of miscarriages is high and may include some induced abortions that are reported as miscarriages. Differences by background characteristics are minimal. Table 6.9 Pregnancy terminations Among ever-married women, the percentage who had a miscarriage, abortion, and/or stillbirth since 2001, according to background character- istics, Pakistan 2006-07 Pregnancy terminations since January 2001 Background characteristic Percentage who had miscarriage Percentage who had abortion Percentage who had stillbirth Number of women Age 15-29 10.4 1.5 3.7 4,074 30-49 6.5 1.6 2.2 5,949 Residence Total urban 8.9 2.1 2.1 3,350 Major city 8.9 2.3 1.6 1,898 Other urban 8.8 1.9 2.6 1,452 Rural 7.7 1.3 3.2 6,673 Province Punjab 8.4 1.5 2.6 5,800 Sindh 8.4 1.5 3.8 2,410 NWFP 7.6 2.1 2.6 1,351 Balochistan 3.3 0.9 0.9 462 Education No education 7.4 1.1 3.1 6,511 Primary 9.1 2.2 2.8 1,423 Middle 8.7 2.1 2.8 634 Secondary 10.2 2.7 1.7 809 Higher 9.7 2.3 0.8 646 Wealth quintile Lowest 7.1 1.0 3.9 1,944 Second 9.1 0.8 3.5 2,001 Middle 7.7 1.8 2.4 1,944 Fourth 8.1 1.8 2.5 2,055 Highest 8.4 2.3 1.8 2,078 Total 8.1 1.5 2.8 10,023 FERTILITY PREFERENCES 7 Syed Mubashir Ali and Faateh ud din Ahmad The subject of future reproductive preferences is of fundamental importance for population policy and family planning programmes. Whether couples want to cease childbearing or delay the next pregnancy determines the demand for family planning. Moreover, insight into the fertility desires in a population is crucial, both for estimating potential unmet need for family planning and for predicting future fertility. This chapter presents data from the Pakistan Demographic and Health Survey (PDHS) on the fertility intentions and family size norms of Pakistani women. The extent to which contraceptive behaviour diverges from expressed fertility desires is explored. The chapter also looks at the level of unwanted and mistimed pregnancies and considers the effect on recent fertility rates if these pregnancies had been prevented. Because fertility preferences are subjective and adhered to with varying degrees of intensity, a structured questionnaire like the one used for the 2006-07 PDHS may not fully capture the desired intentions. To know for sure about their childbearing desires, PDHS respondents were first asked if they wanted to have additional children, after which several additional questions were asked. The responses to these additional questions ascertain the validity of the responses given to the first question. A woman’s fertility preference may not necessarily predict her reproductive behaviour, because childbearing decisions are not made solely by the woman but are frequently affected by the attitudes of other family members, particularly the husband and, in Pakistani society, the mother-in- law, both of whom may exert a major influence on reproductive decisions. If a woman was pregnant at the time of survey she was asked whether she wanted to have another child after the birth of the child she was carrying. Taking into account the way in which the preference variable is defined for pregnant women, a current pregnancy is treated as being equivalent to a living child. Women who have been sterilized are classified as wanting no more children. 7.1 DESIRE FOR MORE CHILDREN Women’s preferences concerning future childbearing serve as indicators of future fertility. However, sterilized women and women who state that they are infecund (declared infecund) have no impact on future fertility because their potential contribution to fertility has been curtailed. The data on fertility preference also provide information on the potential need for contraceptive services for spacing and limiting births. In order to obtain information on future childbearing, currently married, non-sterilized, non- pregnant women were asked: “Would you like to have (a/another) child, or would you prefer not to have any (more) children?” If the response was in the affirmative, they were asked: “How long would you like to wait from now before the birth of (a/another) child?” For currently married, non-sterilized, pregnant women, the questions were phrased a little differently: “After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?” In the case of affirmative answers, they were asked, “After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?” Responses to these questions are presented in Table 7.1 by the number of living children for all currently married women. Table 7.1 and Figure 7.1 show that more than half of currently married women age 15-49 (52 percent) either do not want another child at any time in the future or are sterilized. More than four in ten women want to have a child at some time in the future—21 percent want one within two years, Fertility Preferences | 77 20 percent would prefer to wait two or more years, and 2 percent are undecided as to when. Since the 1990-91 PDHS there has been a substantial increase (12 percentage points) in the proportion of married women who want to limit childbearing (from 40 to 52 percent). But there has also been a marginal increase in the desire for more children (Ali and Rakanuddin, 1992). Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women age 15-49 by desire for children, according to number of living children, Pakistan 2006-07 Number of living children1 Total 15-49 Desire for children 0 1 2 3 4 5 6+ Have another soon2 81.3 38.6 24.0 15.1 8.2 4.7 1.8 21.1 Have another later3 5.2 49.9 39.7 22.8 13.2 5.7 3.4 19.6 Have another, undecided when 2.7 4.2 3.6 2.2 0.6 0.8 0.6 2.0 Undecided 3.0 1.6 3.6 2.9 2.2 2.6 1.7 2.4 Want no more 0.5 4.1 24.6 48.2 60.2 68.2 72.3 43.3 Sterilized4 0.0 0.4 2.0 6.3 12.9 16.1 15.2 8.2 Declared infecund 7.0 1.2 2.1 2.4 2.6 2.0 4.9 3.2 Missing 0.3 0.1 0.4 0.1 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 947 1,298 1,408 1,365 1,312 1,090 2,136 9,556 1 The number of living children includes the current pregnancy. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization PDHS 2006-07 Figure 7.1 Fertility Preferences of Currently Married Women Age 15-49 Undecided 2% Undecided 2% Have another later 20% Have another, unsure of timing 2% Have another soon 21% Declared infecund 3% Want no more, sterilized 52% The desire for terminating childbearing is strongly associated with the number of children that a woman already has. The desire to stop childbearing (including those women who are sterilized) increases with the number of living children (Figure 7.2), reaching 55 percent among women with three living children and 88 percent among those with six or more children. For women who want to have another child, a reverse relationship emerges; that is, the proportion of women who want to have another child soon or later decreases with the number of living children. 78 | Fertility Preferences Figure 7.2 Desire to Limit Childbearing among Currently Married Women, by Number of Living Children 1 5 27 55 73 84 88 52 0 1 2 3 4 5 6+ Overall Number of living children 0 20 40 60 80 100 Percent PDHS 2006-07 Table 7.2 shows the percentage of currently married women who want no more children (including those women who are sterilized), by the number of children and background characteristics (including residence, province, education, and wealth index). Table 7.2 Desire to limit childbearing Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Pakistan 2006-07 Background characteristic Number of living children1 0 1 2 3 4 5 6+ Total Residence Total urban 0.7 7.5 31.9 65.9 82.9 88.7 91.7 56.9 Major city 0.1 8.5 36.1 68.4 87.3 89.9 93.4 58.8 Other urban 1.5 6.1 25.6 61.9 76.3 87.4 89.8 54.4 Rural 0.5 3.0 23.7 47.5 67.5 82.0 85.8 48.9 Province Punjab 0.6 5.4 29.0 57.8 78.6 89.0 89.0 54.4 Sindh 0.2 3.0 26.1 55.3 68.7 76.8 88.0 48.4 NWFP 1.1 3.3 21.3 47.0 65.9 78.8 84.9 50.0 Balochistan 0.0 5.0 12.7 20.5 40.4 61.0 78.8 36.6 Education No education 0.4 4.5 21.6 48.9 70.0 82.4 86.4 53.9 Primary 1.4 2.9 26.6 56.8 74.4 86.7 90.1 49.1 Middle 1.1 2.0 31.3 50.7 75.0 88.5 94.6 43.7 Secondary 0.0 5.9 37.4 65.4 86.8 93.0 97.5 50.0 Higher 0.0 8.3 34.9 72.4 82.1 (91.0) * 43.8 Wealth quintile Lowest 0.6 2.6 19.0 42.1 62.9 73.7 82.3 47.0 Second 0.0 3.3 21.5 42.0 66.7 84.5 83.7 47.4 Middle 1.4 3.1 28.1 52.5 66.8 83.2 89.6 53.7 Fourth 0.6 4.3 25.7 59.3 76.0 89.5 92.4 54.1 Highest 0.2 8.0 35.4 67.7 88.3 90.8 92.4 55.3 Total 0.5 4.5 26.6 54.5 73.1 84.2 87.5 51.6 Note: Women who have been sterilized are considered to want no more children. Numbers in parentheses are based on 25-49 unweighted cases, and an asterisk represents a figure based on fewer than 25 unweighted cases that has been suppressed. 1 The number of living children includes the current pregnancy. Fertility Preferences | 79 The table shows that urban women are more likely than rural women to want to terminate childbearing (57 percent and 49 percent, respectively). A comparison of these statistics with the 1990- 91 PDHS shows that while in urban areas the increase in the proportion of women who want to stop childbearing is negligible, a substantial increase (from 35 percent in 1990-91 to 49 percent in 2006- 07) is evident in rural areas. Moreover, the results indicate that urban women express a desire to limit family size at lower parities than rural women. For example, 66 percent of urban women with three children want to stop childbearing, compared with 48 percent of rural women. The urban-rural differential in the desire to limit childbearing narrows among women with five or more children. By province, Punjabi women are the most likely to want no more children and Balochi women are the least likely (54 percent and 37 percent, respectively). In general, differences in fertility preferences by educational attainment are not pronounced. However, at parities 3 and above, these differences are pronounced because the desire for no more children is much higher among more educated women than uneducated or less educated women (Figure 7.3). The proportion of women wanting no more children is positively associated with the wealth index. The highest proportions of women who do not want another child are found among those in the highest wealth quintile. These differentials are more prominent among women with two to five children. 83 87 76 68 79 69 66 40 70 74 75 87 82 63 67 67 76 88 RESIDENCE Total urban Major city Other urban Rural PROVINCE Punjab Sindh NWFP Balochistan EDUCATION No education Primary Middle Secondary Higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 20 40 60 80 10 Percent PDHS 2006-07 Figure 7.3 Percentage of Currently Married Women with Four Children Who Want No More Children, by Background Characteristics 0 Future fertility preferences depend not only on the total number of living children, but also on the sex composition of the children. Most couples want to have some children of both sexes; however, in Pakistan, there is a stronger preference for sons over daughters. One way to measure son preference is to examine the proportion of women who want no more children by the number of sons they already have. Because the desire to stop childbearing depends on the total number of children as well as the sex composition, the data are broken down by number of children (Table 7.3). 80 | Fertility Preferences The results show that there is still a strong preference for sons in Pakistan. For example, among women with three children, 65 percent of those with three sons want to have no more children compared with only 14 percent of those with three daughters. Similarly, among women with five children, 85-90 percent of women with four or five sons say they want no more children compared with only 65 percent of those with no sons or only one son. Table 7.3 Desire to limit childbearing by sex of living children 7.2 NEED FOR FAMILY PLANNING One of the major concerns of family planning programmes and maternal health care services is to define the size of the potential demand for contraception and to identify women who are in need of contraceptive services. Table 7.4 presents estimates of unmet need and of met need for family planning services and of the total demand for family planning in Pakistan as a whole and by selected background characteristics. “Unmet need” refers to women whose last birth or current pregnancy was mistimed or unwanted or who are not currently using contraception but do not want another child soon (see footnote in Table 7.4 for the exact definition). Menopausal and infecund women are excluded from the unmet need category.1 Women with a “met need” for family planning include women who are currently using contraception. The “total demand” for family planning is represented by the sum of unmet need and met need. Table 7.4 presents information for currently married women on unmet need, met need, and total demand for family planning according to whether the need or demand is for spacing or limiting births. According to Table 7.4, the total unmet need is 25 percent; there is a greater need for limiting births than for spacing future births (14 percent and 11 percent, respectively). The total met need for family planning (i.e., current use) is 30 percent of currently married women; among these, a large majority are using contraception because they do not want more children, with only one in five users reporting a desire to delay the next birth for two or more years. Percentage of currently married, non-pregnant women age 15-49 who want no more children, by number of living children and sons, Pakistan 2006-07 Number of living children and sons Percentage who want no more children (or are sterilized) Number of women No children 0.5 947 One child No sons 3.0 422 One son 7.1 546 Two children No sons 6.8 266 One son 36.0 586 Two sons 33.6 323 Three children No sons 14.2 102 One son 48.8 383 Two sons 67.4 518 Three sons 64.5 173 Four children No sons (14.6) 45 One son 59.7 241 Two sons 83.8 475 Three sons 84.7 321 Four sons 62.4 81 Five children No sons/one son 65.3 151 Two sons 87.1 298 Three sons 89.6 313 Four sons 89.1 179 Five sons 85.4 33 More than 5 children No sons/one son 76.1 135 Two sons 83.2 339 Three sons 89.2 489 Four sons 90.8 480 Five sons 90.2 332 Six or more sons 91.7 188 Total 53.6 8,364 Note: Numbers in parentheses are based on 25-49 unweighted women As expected, unmet need for spacing purposes is higher among younger women, while unmet need for limiting childbearing is higher among older women. Women living in rural areas tend to have greater unmet need than women in urban areas (26 percent and 22 percent, respectively). By region, Punjab has the lowest unmet need (23 percent) and Balochistan and NWFP have the highest (31 percent). 1 This definition of unmet need differs from that applied in recent surveys (see Table 7.4). Fertility Preferences | 81 Table 7.4 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Pakistan 2006-07 Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Number of women Age 15-19 18.6 1.4 20.0 6.5 0.1 6.7 25.1 1.5 26.6 25.0 559 20-24 22.1 5.1 27.2 11.6 3.8 15.4 33.7 8.9 42.5 36.2 1,463 25-29 16.6 9.8 26.5 11.7 13.0 24.8 28.4 22.9 51.3 48.3 1,965 30-34 9.6 18.8 28.4 7.8 27.8 35.6 17.4 46.6 64.0 55.7 1,729 35-39 5.3 21.3 26.6 2.6 37.3 39.9 7.9 58.6 66.5 60.0 1,565 40-44 2.3 20.7 23.0 0.7 41.0 41.6 3.0 61.7 64.7 64.4 1,208 45-49 0.9 14.6 15.5 0.4 31.1 31.5 1.3 45.7 47.0 67.0 1,067 Residence Total urban 9.1 12.8 21.9 9.2 31.9 41.1 18.3 44.7 62.9 65.2 3,191 Major city 8.1 12.0 20.1 10.5 35.4 45.9 18.6 47.4 66.0 69.5 1,815 Other urban 10.3 13.8 24.2 7.5 27.3 34.7 17.8 41.1 58.9 58.9 1,376 Rural 11.8 14.6 26.4 5.2 18.6 23.9 17.0 33.3 50.3 47.5 6,365 Province Punjab 9.0 13.9 22.8 7.3 25.9 33.2 16.2 39.8 56.0 59.2 5,495 Sindh 12.3 13.1 25.4 5.9 20.8 26.7 18.2 33.9 52.1 51.2 2,317 NWFP 13.7 16.8 30.5 5.5 19.3 24.9 19.3 36.1 55.4 44.9 1,301 Balochistan 18.4 13.1 31.4 4.3 10.2 14.4 22.6 23.2 45.9 31.5 443 Education No education 10.6 15.8 26.4 4.1 21.2 25.3 14.6 37.0 51.6 48.9 6,165 Primary 11.8 12.8 24.5 8.9 25.5 34.4 20.7 38.2 58.9 58.4 1,371 Middle 13.4 8.5 21.9 11.2 26.0 37.2 24.6 34.6 59.2 62.9 609 Secondary 10.9 10.9 21.8 11.8 27.3 39.1 22.8 38.2 61.0 64.2 785 Higher 9.5 8.6 18.1 14.4 28.2 42.6 23.9 36.8 60.7 70.2 626 Wealth quintile Lowest 13.2 17.9 31.1 2.2 13.4 15.6 15.4 31.3 46.7 33.4 1,847 Second 13.0 14.5 27.4 4.5 16.4 20.8 17.4 30.8 48.2 43.1 1,897 Middle 11.7 14.9 26.5 6.2 23.9 30.1 17.8 38.8 56.6 53.1 1,846 Fourth 7.7 12.2 19.9 8.8 28.0 36.8 16.5 40.1 56.6 64.9 1,957 Highest 9.1 11.1 20.2 10.7 32.7 43.4 19.8 43.8 63.6 68.2 2,009 Total 10.9 14.0 24.9 6.5 23.1 29.6 17.4 37.1 54.5 54.3 9,556 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose current pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrheic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrheic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. Overall, the total demand for family planning comprises 55 percent of currently married women. Nevertheless, over half of the demand for contraception is satisfied. Looking at variations in the total demand by background characteristics, demand for family planning services remains around 50-60 percent of married women in almost all subgroups; however, the percentage of those whose family planning demand is satisfied ranges from 25 percent at age 15-19 to 70 percent for those who have attained higher level of education. Differences in the definition of unmet need hinder the analysis of trends over time. Reports for previous surveys have used a definition that excludes information on the timing of a woman’s most recent menstrual period. This has the effect of increasing unmet need by not excluding women whose last menstrual period occurred six or more months before the survey or who declare themselves 82 | Fertility Preferences to be menopausal. According to this definition, unmet need has increased from 33 percent in 2003 to 37 percent in 2006-07 (Figure 7.4). Regardless of the exact definition of unmet need, it is clear that urgent attention of policymakers is required to minimize unmet need by transforming it into met need. Figure 7.4 Trends in Unmet Need for Family Planning 33 37 2003 SWRHFPS 2006-07 PDHS 0 10 20 30 40 50 Percent Note: The definition of unmet need used here differs from that in Table 7.4. SWRHFPS = Status of Women, Reproductive Health, and Family Planning Survey 7.3 IDEAL NUMBER OF CHILDREN The discussion on fertility preferences earlier in the chapter focuses on the respondent’s wishes for the future. A woman’s preferences obviously are influenced by the number of children she already has. The 2006-07 PDHS attempted to obtain a measure of fertility preferences that is less dependent on the woman’s current family size by asking about the respondent’s ideal number of children. The question about ideal family size required a woman to perform the difficult task of considering the number of children she would choose to have in her whole life regardless of the number (if any) that she had already borne. This more abstract question proved difficult for some respondents in the survey; 10 percent gave non-numeric answers, like “up to God/Allah,” and the proportion of such responses increases with the number of living children. Failure to give a definite answer suggests either an absence of conscious consideration given to the matter or a strong belief that family size is determined by God. Nevertheless, the percentage of women who did not give a numeric response to the hypothetical question on ideal family size decreased from 61 percent in the 1990-91 PDHS to 10 percent in the 2006-07 PDHS. There is usually a high positive correlation observed between actual and ideal number of children. The reasons are two-fold. First, to the extent that women implement their preferences, those who want larger families tend to achieve larger families. Second, women may adjust their ideal number of children upwards as their actual number of children increases. It is also possible that women with large families have larger ideal sizes because of attitudes they acquired 20 or 30 years ago. Fertility Preferences | 83 Despite the likelihood that some rationalization occurs in the determination of ideal number of children, respondents often state ideals that are lower than their actual number of surviving children. Thus, the data in Table 7.5 can be grouped into three categories. The first group is women who have reached their ideal family size, i.e., women whose ideal number of children is exactly the same as their number of living children. The second group consists of women whose surviving children have exceeded their ideal family size, and the last group consists of women who have not yet reached their ideal family size. Table 7.5 Ideal number of children Percent distribution of ever-married women 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to number of living children, Pakistan 2006-07 Ideal number of children Number of living children1 0 1 2 3 4 5 6+ Total 0 1.6 0.6 1.2 0.6 0.9 0.9 1.1 1.0 1 0.7 2.0 0.5 0.8 0.1 0.4 0.3 0.7 2 25.6 20.2 23.5 9.6 9.1 7.1 5.1 13.4 3 14.6 19.6 17.2 27.0 8.6 8.0 6.8 14.1 4 29.8 35.5 35.1 37.0 53.3 35.5 30.5 36.4 5 8.5 6.9 6.6 7.4 8.6 21.7 9.8 9.7 6+ 12.0 9.5 8.9 9.1 10.6 13.3 31.3 15.0 Non-numeric responses 7.3 5.7 7.1 8.4 8.9 13.1 15.1 9.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,019 1,377 1,461 1,437 1,360 1,150 2,218 10,023 Mean ideal number of children for: 2 Ever-married women 3.7 3.6 3.6 3.8 4.1 4.4 5.0 4.1 Number 944 1,299 1,358 1,316 1,239 1,000 1,884 9,040 Currently married 3.7 3.7 3.6 3.8 4.1 4.4 5.0 4.1 Number 882 1,228 1,312 1,257 1,200 947 1,809 8,635 1 The number of living children includes the current pregnancy. 2 Means are calculated excluding respondents who gave non-numeric responses. Table 7.5 shows the distribution of respondents by ideal number of children according to actual number of living children. It shows that about seven in ten ever-married women consider the ideal family size to be at least four children. Only 13 percent of women prefer a two-child family and another 14 percent consider three children as their ideal family size. The mean ideal number of children is 4.1 for both ever-married and currently married women. The data further reveal an association between the ideal number of children and the actual number of living children. The mean ideal number of children increases from 3.7 children among childless women to 5.0 among women with six or more living children. The mean ideal number of children among ever-married and currently married women has remained the same as in 1990-91. The results in Table 7.5 also clearly show that many women in Pakistan have had more children than they would now prefer. More than half of women (54 percent) with six or more children have exceeded their ideal family size, as have 52 percent of those with five children. This situation requires attention of family planning programme personnel. Table 7.6 and Figure 7.5 present the mean ideal number of children for ever-married women by selected background characteristics. The mean ideal number of children generally increases with age, from 4.0 children for ever-married women in the youngest age-group (15-19) to 4.6 among the oldest women (45-49). A considerable differential is found by urban-rural residence, with a higher mean ideal number of children observed among rural women compared with urban women (4.3 and 3.7, respectively). Substantial differences have been observed across provinces, ranging from a mean ideal number of children of 3.8 in Punjab to 5.9 in Balochistan. Similarly, education and wealth quintile also show sizeable inverse relationships with the mean ideal family size. 84 | Fertility Preferences Table 7.6 Mean ideal number of children Mean ideal number of children for ever- married women age 15-49, by background characteristics, Pakistan 2006-07 Background characteristic Mean Number of women1 Age 15-19 4.0 528 20-24 3.9 1,407 25-29 3.8 1,883 30-34 4.0 1,647 35-39 4.2 1,451 40-44 4.4 1,109 45-49 4.6 1,015 Residence Total urban 3.7 3,072 Major city 3.5 1,762 Other urban 3.9 1,311 Rural 4.3 5,967 Province Punjab 3.8 5,175 Sindh 4.3 2,252 NWFP 4.4 1,213 Balochistan 5.9 399 Education No education 4.4 5,795 Primary 3.7 1,283 Middle 3.6 586 Secondary 3.3 762 Higher 3.3 613 Wealth quintile Lowest 4.8 1,769 Second 4.5 1,795 Middle 4.0 1,722 Fourth 3.8 1,842 Highest 3.5 1,912 Total 4.1 9,040 1 Women who gave a numeric response 4.0 4.6 3.7 4.3 3.8 4.3 4.4 5.9 4.4 3.3 4.8 3.5 AGE 15-19 45-49 RESIDENCE Total urban Rural PROVINCE Punjab Sindh NWFP Balochistan EDUCATION No education Higher WEALTH QUINTILE Lowest Highest 0.0 2.0 4.0 6.0 8.0 Number of children Figure 7.5 Mean Ideal Number of Children, by Background Characteristics PDHS 2006-07 Fertility Preferences | 85 As mentioned above, decisions about childbearing are usually made by couples and not by the woman herself. Women who were interviewed in the 2006-07 PDHS were asked if they thought that their husbands wanted the same number of children that they wanted, or more or fewer children. Table 7.7 shows that a majority of women (54 percent) say that their husbands want the same number of children that they do. However, one-fifth of women report that their husbands want more children than they want, while only 4 percent say that their husbands want fewer children than they want. A sizeable proportion of women say they don’t know about their husband’s ideal number of children. Table 7.7 Couple's agreement on family size Percent distribution of currently married, non-sterilized women by whether they think their husbands want the same number of children as they want, according to woman's ideal number of children, Pakistan 2006-07 Husband’s desire for children Ideal number of children Both want same Husband wants more Husband wants fewer Don't know/ missing Total Number 0 41.7 15.0 3.4 39.8 100.0 69 1 36.3 42.8 3.0 17.8 100.0 53 2 61.6 24.2 1.3 12.9 100.0 1,182 3 61.9 21.3 3.2 13.6 100.0 1,251 4 60.1 17.2 4.9 17.8 100.0 3,207 5 47.8 21.7 3.4 27.1 100.0 842 6+ 45.1 23.3 4.2 27.5 100.0 1,332 Non-numeric response 32.2 15.0 4.5 48.3 100.0 832 Total 54.1 20.0 3.9 22.0 100.0 8,769 7.4 WANTED AND UNWANTED FERTILITY Several indicators of unwanted fertility can be derived from the 2006-07 PDHS data. First, responses to a question about the planning status of prior births, in other words, whether a birth was planned (wanted then), mistimed (wanted later), or not wanted at all, provide some indication of the extent of unwanted childbearing. In interpreting data, however, it is important to remember that women may rationalize mistimed or unwanted pregnancies, declaring them as wanted after the children are born. Table 7.8 shows the percent distribution of births in the five years preceding the 2006-07 PDHS by planning status of the birth. Overall, 24 percent of births in the five-year period preceding the survey were not wanted at the time of conception, with 13 percent wanted at a later time and 11 percent not wanted at all. The proportion of births that are mistimed or not wanted at all at the time of conception increases sharply with birth order, ranging from 5 percent of first births to 37 percent of fourth and higher births. The proportion of births considered mistimed or unwanted has increased slightly, from 21 percent to 24 percent, since the 1990-91 PDHS. The planning status of births is related to the age of the mother. In general, the older the mother at the time of birth, the larger the percentage of children that are unplanned; for example, more than half of the births (54 percent) to women age 45-49 are either wanted later or not wanted at all. This proportion has increased since 1990-91. 86 | Fertility Preferences Table 7.8 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother's age at birth, Pakistan 2006-07 Planning status of birth Birth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 94.1 4.4 0.4 1.1 100.0 2,209 2 81.1 17.6 0.7 0.6 100.0 1,911 3 77.8 17.5 4.1 0.6 100.0 1,607 4+ 62.0 14.1 22.6 1.4 100.0 4,587 Mother's age at birth <20 89.1 9.2 0.7 0.9 100.0 1,081 20-24 81.6 14.7 2.9 0.8 100.0 2,950 25-29 74.6 15.7 8.5 1.3 100.0 3,037 30-34 68.0 11.6 19.4 0.9 100.0 1,899 35-39 60.5 10.2 27.7 1.6 100.0 984 40-44 56.2 8.5 34.0 1.3 100.0 314 45-49 46.1 3.8 50.1 0.0 100.0 50 Total 74.9 13.2 10.9 1.1 100.0 10,314 A second approach to measuring unwanted fertility is to calculate what the fertility rate would be if all unwanted births were avoided. This wanted fertility rate is calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. To the extent that women are unwilling to report an ideal family size that is lower than their actual family size, the wanted fertility rate may be overestimated. Table 7.9 presents the total wanted fertility rates and total fertility rates for the three-year period before the survey for various selected background characteristics. Table 7.9 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Pakistan 2006-07 Background characteristic Total wanted fertility rate Total fertility rate Residence Total urban 2.5 3.3 Major city 2.3 3.0 Other urban 2.9 3.8 Rural 3.4 4.5 Province Punjab 3.0 3.9 Sindh 3.2 4.3 NWFP 3.2 4.3 Balochistan 3.5 4.1 Education No education 3.7 4.8 Primary 2.9 4.0 Middle 2.4 3.2 Secondary 2.4 3.1 Higher 1.8 2.3 Wealth quintile Lowest 4.2 5.8 Second 3.5 4.5 Middle 3.0 4.1 Fourth 2.6 3.4 Highest 2.4 3.0 Total 3.1 4.1 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Overall, the total wanted fertility rate is 24 percent lower than the total fertility rate. Thus, if unwanted births could be eliminated, the total fertility in Pakistan would be 3.1 births per woman instead of 4.1 births (Figure 7.6). The difference between the wanted and observed fertility rates measured here as a ratio of observed fertility to wanted fertility indicates a large gap for women living in rural areas, women in Sindh and NWFP, women in the primary and secondary educational categories, and among women in the lowest wealth quintile. For all these women, the observed fertility rate is around 30-40 percent higher than the wanted fertility rate. Moreover, socioeconomic status is strongly related to the differences between wanted and actual number of children; the higher the socioeconomic status, the smaller the gap between wanted and observed fertility. Fertility Preferences | 87 Figure 7.6 Total Wanted Fertility Rate and Total Fertility Rate 3.1 4.1 Total wanted fertility rate Total fertility rate 0 1 2 3 4 5 Percent PDHS 2006-07 88 | Fertility Preferences INFANT AND CHILD MORTALITY 8 Zulfiqar A. Bhutta, Anne Cross, Farrukh Raza, and Zafar Zahir This chapter reports information on levels, trends, differentials, and causes of neonatal, post- neonatal, infant, child, and under-five mortality. In addition, for the first time, information is provided on stillbirths and their causes using standardized verbal autopsy measurement. This information is critical for assessment of the interface of maternal and newborn health and relevant programmes. Estimates of infant and child mortality are required as an input into population projections, par- ticularly if the level of adult mortality is known from another source or can be inferred with reason- able confidence. Information on mortality of children also serves the needs of health ministries by identifying sectors of the population that are at high risk. Infant and child mortality rates are also regarded as indices reflecting the degree of poverty and deprivation of a population. Given the major focus in Pakistan on achieving the Millennium Development Goal 4 on child mortality, these data are critical in assessing the mid-term status of progress or lack thereof. The primary causes of childhood mortality change as children age, from factors related mostly to biological or congenital conditions to factors related mostly to their environment (infectious diseases). After the neonatal period, post-neonatal and child mortality are caused mainly by childhood diseases and accidents. In this chapter, age-specific mortality rates are defined as follows: Neonatal mortality: the probability of dying within the first month of life Postneonatal mortality: the difference between infant and neonatal mortality Infant mortality: the probability of dying before the first birthday Child mortality: the probability of dying between the first and fifth birthday Under-five mortality: the probability of dying before the fifth birthday All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. The data for mortality rates were collected in the birth history section of the Women’s Questionnaire.1 The section begins with questions about the aggregate childbearing experience of respondents (i.e., the number of sons and daughters who live with the respondent, those who live elsewhere, and the number who have died). For each of the births, more detailed information was collected on the sex, the month and year of birth, survivorship status, and current age or, if the child had died, the age at death. As mentioned in Chapter 4, in the 2006-07 PDHS, the birth history started with the most recent birth and proceeded backwards in time. 8.1 DATA QUALITY The quality of mortality estimates calculated from retrospective birth histories depends upon the completeness with which births and deaths are reported and recorded. Potentially the most serious data quality problem is the selective omission from the birth histories of children who did not survive, which can lead to underestimation of mortality rates. Other potential problems include displacement of birth dates, which may cause a distortion of mortality trends, and misreporting of the age at death, which may distort the age pattern of mortality. When selective omission of childhood deaths occurs, it is usually most severe for deaths in early infancy. If early neonatal deaths are selectively underreported, the result is an unusually low ratio of deaths occurring within seven days to all 1 Data on deaths were also collected in the Household Questionnaires; however, this approach is known to result in some underreporting of deaths and thus was not used to calculate childhood mortality rates. The data were collected to provide the basis for collecting verbal autopsies on causes of death. Infant and Child Mortality | 89 neonatal deaths, and an unusually low ratio of neonatal to infant deaths. Underreporting of early infant deaths is most commonly observed for births that occurred long before the survey; hence, it is useful to examine the ratios over time. An examination of the ratios (see Appendix Tables D.5 and D.6) does not indicate that any appreciable number of early infant deaths were omitted in the 2006-07 PDHS. The proportion of neonatal deaths occurring in the first week of life is high (74 percent) and is higher than the proportion recorded in the 1990-91 PDHS (62 percent).2 Moreover, the proportions are roughly constant over the 20 years period before the survey (between 70 and 77 percent). In addition, the proportion of infant deaths that occur during the first month of life is entirely plausible in level (67 percent) and is the same as the proportion recorded in the 1990-91 PDHS but higher than the proportion recorded in the 1996-97 Pakistan Fertility and Family Planning Survey (56 percent). The proportions are also fairly stable over the 20 years before the survey (varying between 61 and 71 percent). This inspection of the mortality data reveals no evidence of selective underreporting or misreporting of age at death that would significantly compromise the quality of the PDHS rates of childhood mortality. However, analysis of data by province indicates some underreporting in Balochistan (see below). 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Table 8.1 shows the neonatal, postneonatal, infant, child, and under-five mortality rates for three successive five-year periods before the survey. The use of rates for five-year periods smoothes out any year-to-year fluctuations in early childhood mortality. For the most recent five-year period preceding the survey, infant mortality is 78 deaths per 1,000 live births and under-five mortality is 94 deaths per 1,000 live births. This means that 1 in every 11 children born in Pakistan dies before reaching their fifth birthday. The pattern shows that over half of deaths under five occur during the neonatal period and 26 percent occur during the postneonatal period. Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Pakistan 2006-07 Years preceding the survey Approximate calendar period Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 2002-06 54 24 78 18 94 5-9 1997-2001 52 24 76 18 92 10-14 1992-96 56 30 86 19 103 1 Computed as the difference between the infant and neonatal mortality rates Table 8.2 shows trends in infant and under-five mortality rates from several recent surveys in Pakistan. The data show a decline in infant mortality in the late 1990s, but no appreciable change since 2003. Under-five mortality has declined from 117 in 1986-90 to 94 in 2002-06, a 20 percent decline in 16 years. In interpreting the mortality data, it is useful to keep in mind that sampling errors are quite large. For example, the 95 percent confidence intervals for the under-five mortality estimate of 94 per 1,000 are 86 and 103 per 1,000 (Appendix D) indicating that, given the sample size of the 2006-07 PDHS, the true value may fall anywhere between 86 and 103 per 1,000 births. 2 There are no models for mortality patterns during the neonatal period. However, one review of data from several developing countries concluded that, at neonatal mortality levels of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma, 1988). 90 | Infant and Child Mortality Table 8.2 Trends in infant and under-five mortality rates Infant and under-five mortality rates from various sources, Pakistan, 1990-91 to 2006-07 Survey and approximate calendar period of mortality rate 1990-91 PDHS (1986-90) 1996-97 PFFPS (1992-96) 2003 PDS (2003) 2005 PDS (2005) 2006-07 PDHS (2002-06) Rate Infant mortality rate 91 92 76 77 78 Under-five mortality rate 117 111 na na 94 na = Not applicable PFFPS = Pakistan Fertility and Family Planning Survey PDS = Pakistan Demographic Survey Sources: PDHS 1990-91: NIPS and Macro 1992; PFFPS 1996-97: Hakim et al., 1998; PDS 2005: FBS, 2007b 8.3 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Mortality differentials by place of residence, province, education level of the mother, and wealth index are presented in Table 8.3 and Figure 8.1. In order to have a sufficient number of births to study mortality differentials across population subgroups, period-specific rates are presented for a ten-year period preceding the survey (approximately equivalent to 1997-2006). Differentials by place of residence show that the under-five mortality rate is 28 percent higher in rural areas than in urban areas (100 and 78 deaths per 1,000 live births, respectively). As might be expected, rates are lower in major cities than in other urban areas. Table 8.3 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristics, Pakistan 2006-07 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Total urban 48 18 66 13 78 Major city 38 20 58 11 69 Other urban 58 17 75 16 89 Rural 55 26 81 20 100 Province Punjab 58 23 81 18 97 Sindh 53 28 81 22 101 NWFP 41 22 63 13 75 Balochistan 30 18 49 11 59 Mother's education No education 57 26 84 20 102 Primary 47 19 66 20 85 Middle 45 18 63 13 75 Secondary 39 13 52 2 55 Higher 35 21 56 4 59 Wealth quintile Lowest 63 31 94 30 121 Second 60 28 87 17 102 Middle 52 22 74 18 90 Fourth 47 20 67 14 79 Highest 38 14 53 8 60 1 Computed as the difference between the infant and neonatal mortality rates Infant and Child Mortality | 91 The rates by province display considerable differentials. Surprisingly, all rates are lowest in Balochistan, followed by North-West Frontier Province (NWFP). This pattern is implausible, given that Balochistan is the least developed of the four provinces. As mentioned previously (Chapter 4), the data from the birth histories collected in Balochistan showed evidence of under-reporting of births. The reason for the relatively low rates in NWFP is not clear. Because Balochistan accounts for only about 5 percent of the national population, rates for all of Pakistan are probably not greatly affected. Nevertheless, the mortality data for Balochistan and, to some extent, NWFP require further investigation and should be viewed with caution. Mortality rates for Punjab and Sindh provinces are higher than for the other two provinces and are similar to each other. As observed in most studies, the mother’s level of education is strongly linked to child survival. Higher levels of educational attainment are generally associated with lower mortality rates because education exposes mothers to information about better nutrition, use of contraceptives to space births, and knowledge about childhood illness and treatment. Survey results show a steady decline in all rates as mother’s education increases, the only exception being a small increase in several rates for children whose mothers have higher education. Similarly, childhood mortality rates decline as the wealth quintile increases. 78 69 89 100 122 69 67 61 121 102 90 79 60 RESIDENCE Total urban Major city Other urban Rural BIRTH INTERVAL <2 years 2 years 3 years 4+ years WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 20 40 60 80 100 120 140 Percent PDHS 2006-07 Figure 8.1 Differentials in Under-Five Mortality 8.4 DEMOGRAPHIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Childhood mortality rates by sex of child, age of mother at birth, birth order, previous birth interval, and birth size are presented in Table 8.4. Differences between the mortality of male and female children at birth are found in nearly all populations. The results show that female mortality is lower than that of males for the neonatal period only, while males have the advantage during the postneonatal period up to age five years. Most studies have documented a U-shaped pattern of childhood mortality by mother’s age at birth, with children of the youngest and oldest women experiencing the highest risk of death. Data from the 2006-07 PDHS, however, show a steadily decreasing risk of death with increasing age of the mother at birth, implying that while younger mothers have an increased risk of death for their 92 | Infant and Child Mortality children, older mothers do not experience any increased risk. It should be noted that the number of children born to women age 40-49 is small and the rates are subject to high sampling errors. There is a U-shaped pattern of mortality by birth order of the child, but only for neonatal, infant, and under-five mortality. Generally, first births have higher mortality rates than later births. The length of birth interval has a significant correlation with a child’s chances of survival, with short birth intervals considerably reducing the chances of survival. As the birth interval gets longer, the mortality risk is reduced considerably. Children born less than two years after a prior sibling suffer a substantially higher risk of death than children with intervals of two or more years. For example, the under-five mortality rate is twice as high for children born after an interval of less than two years compared with those born four or more years after a previous sibling (122 and 61 deaths per 1,000 live births, respectively). These findings are consistent with observations from other sources (Cecatti et al., 2008; Zhu et al., 1999). Size of the child at birth also has a bearing on the childhood mortality rates. Children whose birth size is small or very small have a 68 percent greater risk of dying before their first birthday than those whose birth size is average or larger. Table 8.4 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Pakistan 2006-07 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 57 23 80 14 93 Female 48 25 73 22 93 Mother's age at birth <20 85 32 116 18 133 20-29 51 23 75 19 92 30-39 45 22 67 15 81 40-49 39 16 55 (20) (74) Birth order 1 73 23 97 15 110 2-3 49 24 73 17 88 4-6 45 24 69 18 86 7+ 52 24 77 23 98 Previous birth interval2 <2 years 69 32 101 24 122 2 years 34 19 54 16 69 3 years 34 18 52 16 67 4+ years 35 17 51 10 61 Birth size3 Small/very small 66 35 101 na na Average or larger 43 17 60 na na Note: Figures in parentheses are based on 250-499 unweighted cases in one or more of the component rates. na = not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey 8.5 PERINATAL MORTALITY Pregnancy losses occurring after seven completed months of gestation (stillbirths) plus deaths of live births within the first seven days of life (early neonatal deaths) constitute perinatal deaths. When the total number of perinatal deaths is divided by the total number of pregnancies reaching seven months’ gestation, the perinatal mortality rate is derived. The distinction between a stillbirth Infant and Child Mortality | 93 and an early neonatal death may be a fine one, depending often on the observed presence or absence of some faint signs of life after delivery. The causes of stillbirths and early neonatal deaths are overlapping, and examining just one or the other can understate the true level of mortality around delivery. Table 8.5 presents the number of stillbirths and early neonatal deaths and the perinatal mortality rate for the five-year period preceding the survey, by mother’s age at birth, place of residence, mother’s education, and wealth quintile. Unlike other DHS surveys, the PDHS did not include an event “calendar” for recording the outcomes of pregnancies in the five years preceding the survey. Consequently, the perinatal mortality rates were calculated from questions asked to women about any pregnancies that they may have had that did not result in a live birth. If the respondent reported having had a pregnancy loss, she was asked when the most recent one occurred and how many months pregnant she was when she lost the pregnancy. There was space in the questionnaire to record up to seven pregnancy losses that occurred in the five years preceding the survey, with dates for the last two. Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Pakistan 2006-07 Background characteristic Number of stillbirths Number of early neonatal deaths Perinatal mortality rate Number of pregnancies of 7+ months duration Mother's age at birth (or current age for miscarriages) <20 170 56 197 1,145 20-29 648 216 145 5,947 30-39 393 80 161 2,935 40-49 85 10 228 418 Residence Total urban 438 106 173 3,149 Major city 247 45 178 1,640 Other urban 191 61 167 1,509 Rural 857 256 153 7,296 Mother's education No education 829 254 158 6,838 Primary 188 49 154 1,542 Middle 88 18 169 624 Secondary 114 31 173 839 Higher 78 10 145 602 Wealth quintile Lowest 245 89 138 2,412 Second 316 86 178 2,253 Middle 229 82 151 2,060 Fourth 246 53 158 1,897 Highest 260 52 171 1,822 Total 1,296 362 159 10,444 Results indicate that the perinatal mortality rate is 159 deaths per 1,000 pregnancies. Pregnancies of the youngest and oldest women are more likely to end in a perinatal death than are pregnancies of women age 20-39. Perinatal mortality rates are higher in urban than rural areas and they tend to increase with mother’s education except among women with higher education. Rates also show an erratic pattern by wealth quintile. 94 | Infant and Child Mortality 8.6 HIGH-RISK FERTILITY BEHAVIOUR Numerous studies have found a strong relationship between a child’s risk of dying and certain fertility behaviours. Typically, the probability of dying in early childhood is much greater if children are born to mothers who are too young or too old, if they are born after a short birth interval, or if they are born to mothers with high parity. Very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. Older women may also experience age-related problems during pregnancy and delivery. For purposes of this analysis, a mother is classified as “too young” if she is less than 18 years of age and “too old” if she is more than 34 years of age at the time of delivery; a “short birth interval” is defined as a birth occurring within 24 months of a previous birth; and a “high-order” birth is one occurring after three or more previous births (i.e., birth order 4 or higher). First births may be at increased risk of dying relative to births of other orders; however, this distinction is not included in the risk categories in the table because it is not considered avoidable fertility behaviour. Also, for the short birth interval category, only children with a preceding interval of less than 24 months are included. Short succeeding birth intervals are not included, even though they can influence the survivorship of a child, because of the problem of reverse causal effect (i.e., a short succeeding birth interval can be the result of the death of a child rather than being the cause of the death of a child). Table 8.6 presents the distribution of children born in the five years preceding the survey by these categories of increased risk of mortality. Column 1 shows the percentage of children falling into specific categories. Column 2 shows the risk ratio of mortality for children by comparing the proportion dead among children in each high-risk category with the proportion dead among children not in any high-risk category, in other words, those whose mothers were age 18-34 at delivery, who were born 24 or more months after the previous birth, or who are of parity 2 or 3. Sixty-two percent of children in Pakistan fall into a high-risk category, with 38 percent in a single high-risk category and 24 percent in a multiple high-risk category. A higher risk is associated with births to mothers aged less than 18 years under the single high-risk category (relative risk of 1.8). In general, risk ratios are higher for children in a multiple high-risk category than children in a single high-risk category. The highest risk (2.2) is associated with births to mothers under age 18 that occur less than 24 months after a prior birth; however, less than 1 percent of births fall into this multiple high-risk category. Eleven percent of births in Pakistan occur after a short birth interval to mothers who have had three or more births, with these children 50 percent more likely to die in early childhood as children who are not in any high-risk category. The last column of Table 8.6 addresses the question of what percentage of currently married women have the potential for a high-risk birth. This was obtained by simulating the distribution of currently married women by the risk category in which a birth would fall if a woman were to conceive at the time of the survey. Although many women are protected from conception due to use of family planning, postpartum insusceptibility, and prolonged abstinence, for simplicity only those who have been sterilized are included in the “not in any high-risk category.” Overall, 71 percent of currently married women have the potential for having a high-risk birth, with 30 percent falling into a single high-risk category and 42 percent in a multiple high-risk category. Infant and Child Mortality | 95 Table 8.6 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey, by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Pakistan 2006-07 Births in the 5 years preceding the survey Percentage of currently married women1 Risk category Percentage of births Risk ratio Not in any high-risk category 20.5 1.00 19.0a Unavoidable risk category First-order births between ages 18 and 34 years 18.0 1.34 9.6 Single high-risk category Mother's age <18 3.1 1.78 1.1 Mother's age >34 0.8 1.13 4.5 Birth interval <24 months 12.1 1.14 10.2 Birth order >3 21.6 0.99 13.8 Subtotal 37.7 1.11 29.6 Multiple high-risk category Age <18 and birth interval <24 months2 0.5 (2.24) 0.2 Age >34 and birth interval <24 months 0.1 * 0.2 Age >34 and birth order >3 9.3 0.89 27.2 Age >34 and birth interval <24 months and birth order >3 2.6 1.68 3.9 Birth interval <24 months and birth order >3 11.3 1.51 10.3 Subtotal 23.8 1.30 41.8 In any avoidable high-risk category 61.5 1.18 71.4 Total 100.0 na 100.0 Number of births/women 9,121 na 9,556 Note: The risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Ratios based on 25-49 unweighted cases are shown in parentheses while those based on fewer than 25 unweighted cases have been suppressed (*). na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women 8.7 CAUSES OF DEATH OF CHILDREN UNDER FIVE 8.7.1 Methodology Information on causes of child deaths was obtained using a verbal autopsy (VA) question- naire. The standard infant and child VA questionnaire (Anker et al., 2008) which had been applied in various settings (Etard et al., 2004; Baqui et al., 1998) was used. The modified instrument was also validated in prospective studies in Pakistan (Bhutta, et al., 2004) and India (Baqui et al., 2006) and further modified to evaluate causes of stillbirths for the PDHS. The latter instrument has been extensively used in field studies of perinatal mortality in rural Pakistan (Bhutta et al., 2008) and is currently the subject of a multi-country prospective validation study by the World Health Organi- zation (WHO personal communication). 96 | Infant and Child Mortality The VA instrument for the evaluation of newborn, infant, and child mortality in the 2006-07 PDHS was developed by consensus by a team of experts led by the Aga Khan University (AKU). The field survey teams undertaking the VA were composed of a male supervisor and female interviewers who had received training in the content and methodology of the VA in training workshops at NIPS as well as in the field. Subsequent field work and data collection quality control was assured through supervision and monitoring of teams during field work which also included staff from AKU. The completed VA questionnaires were entered onto computers at NIPS and the verbatim record and electronic data set were sent to the independent review team at AKU. VAs of all reported under-five deaths and stillbirths were analyzed by the AKU team. The cause of death allocation was undertaken in two ways, described below. 1. Allocation of cause of death using a computerized algorithm. To ascertain the cause of death, a hierarchal-based computerized algorithm was applied to the records for stillbirths, neonatal deaths, and postneonatal deaths. Each algorithm was based on a biologically plausible set of conditions based on the close-ended questions in the VA questionnaire. Potential overlap between various conditions was assessed and final discrete causes of deaths were assigned based on different hierarchies and biological criteria. This was modified from previously published and evaluated criteria (Baqui et al., 2006; Bhutta et al., 2008b). To illustrate: in the event that a child with asphyxia was also preterm and had a secondary infection, asphyxia was taken as the primary cause of death. Similarly, prematurity was ascribed as the cause of death if it was the dominant factor and the death occurred early. 2. Allocation of cause of death using verbatim reviews. A specific review process was undertaken to develop a cause of death allocation based on the narrative part of the VA questionnaire and related sections. The teams undertaking this at AKU consisted of trained paediatricians/neonatologists who received specific training in the cause of death analysis. The teams were provided additional training in February 2007 by an expert representing the World Health Organization in a workshop based on a diagnosis list using the most recent International Classification of Diseases (ICD10) classification. The teams were divided into two groups of two individuals each designated as Reviewers A and B. Reviewers A and B were completely blinded as to the allocations by each other and each pair reviewed roughly half the cases. In the event of concordance between Reviewer A and B, the consensus diagnosis was recorded and in the event of non-concordance, the case was referred to an expert panel for review. The panel also reviewed the cause of death allocation for cases which were not consistent with the age grouping before final allocation. Based on the two systems above, a final cause of death was allocated by a panel consensus using both the computer allocation as well as the final manual assessments by the team. This final cause of death diagnosis was then used as the basis for classification related to the ICD 10 coding system as much as possible. The same system was used for classification of stillbirths and immediate determinants such as antepartum haemorrhage but it was recognized that there was no agreed system of classification of stillbirths using the ICD10 coding system. 8.7.2 Results In the Household Questionnaire, respondents were asked to report information about deaths to any usual residents that occurred since January 2003, including the sex, month and year of death and age at death. Any stillbirths and any deaths to children under five that occurred since January 2005 were eligible for a follow-up interview with the Child Verbal Autopsy questionnaire. A total of 1,386 stillbirths and 3,232 deaths of children under five were identified as occurring since January 2005. A total of 4,438 verbal autopsies were completed, of which 1,337 were stillbirths (for a response rate of 97 percent; see Table 8.7) and 3,101 were deaths to children under five (for a response rate of 96 percent). Response rates vary only slightly by sex, residence, province, or age of the child at death. Infant and Child Mortality | 97 Table 8.7 Child verbal autopsy response rates Number of deaths to children under five and stillbirths reported in the household since 2005 and number and percentage for which a verbal autopsy was completed, by sex, residence and province, according to age at death, Pakistan 2006-07 (unweighted) Stillbirths Neonatal Post-neonatal Child Under five Sex, residence, province Number identi- fied in house- hold Number of verbal autopsies Per- centage com- pleted Number identi- fied in house- hold Number of verbal autopsies Per- centage com- pleted Number identi- fied in house- hold Number of verbal autopsies Per- centage com- pleted Number identi- fied in house- hold Number of verbal autopsies Per- centage com- pleted Number identi- fied in house- hold Number of verbal autopsies Per- centage com- pleted Sex Male 757 737 97.4 1,011 980 96.9 417 397 95.2 271 262 96.7 1,699 1,639 96.5 Female 628 599 95.4 738 696 94.3 475 464 97.7 319 301 94.4 1,532 1,461 95.4 Residence Urban 402 383 95.3 462 444 96.1 207 195 94.2 108 101 93.5 777 740 95.2 Rural 984 954 97.0 1,288 1,233 95.7 685 666 97.2 482 462 95.9 2,455 2,361 96.2 Province Punjab 519 502 96.7 670 640 95.5 319 308 96.6 186 179 96.2 1,175 1,127 95.9 Sindh 476 456 95.8 647 628 97.1 298 288 96.6 215 208 96.7 1,160 1,124 96.9 NWFP 238 229 96.2 253 241 95.3 139 131 94.2 82 71 86.6 474 443 93.5 Balochistan 153 150 98.0 180 168 93.3 136 134 98.5 107 105 98.1 423 407 96.2 Total 1,386 1,337 96.5 1,750 1,677 95.8 892 861 96.5 590 563 95.4 3,232 3,101 95.9 As shown in Table 8.8, the major causes of death among children under five are birth asphyxia (22 percent), sepsis (14 percent), pneumonia (13 percent), diarrhoea (11 percent), and prematurity (9 percent). About one in nine deaths of children under five cannot be classified as to cause (unexplained/not classified). It is interesting to note that neither malaria nor tetanus account for any appreciable proportion of deaths of children under five. Table 8.8 Causes of child deaths by age Percent distribution of neonatal, post-neonatal, child and under-five deaths by cause (weighted), Pakistan, 2006-07 Cause of death Neonatal Post- neonatal Child Under five Congenital abnormality 3.4 5.3 3.9 4.0 Tetanus 1.0 0.0 0.0 0.6 Prematurity 16.3 0.3 0.0 9.2 Birth asphyxia 39.5 0.0 0.0 22.1 Sepsis 20.0 8.0 4.7 14.2 Pneumonia 6.3 25.7 16.9 13.3 Meningitis 0.8 9.1 6.6 4.0 Diarrhoea 1.0 26.9 17.7 10.8 Accident/injuries 0.1 1.6 11.0 2.4 Measles 0.0 1.2 7.7 1.7 Severe acute malnutrition 0.0 1.3 2.7 0.8 Malignancies 0.0 0.0 0.7 0.1 Other causes 1.4 7.8 18.6 6.1 Unexplained neonatal death 9.6 0.0 0.0 5.4 Unexplained postneonatal death 0.0 12.7 9.0 4.9 Cause could not be classified 0.5 0.1 0.5 0.4 Total 100.0 100.0 100.0 100.0 Number of deaths 1,651 788 503 2,943 Causes of death are highly correlated with age at death. Deaths during the neonatal period (first month of life) are almost entirely due to birth asphyxia, sepsis, or prematurity. Deaths in the postneonatal period are mostly due to diarrhoea or pneumonia, with sepsis being a far less common cause of death. The main causes of child deaths are diarrhoea, pneumonia, injuries, measles, and meningitis. These data support a strong focus on addressing newborn deaths and a continued focus on reducing deaths from diarrhoea and pneumonia, known killers among older infants and children. 98 | Infant and Child Mortality Table 8.9 shows data on causes of death disaggregated by sex and residence of the child. The data show that boys are more likely to die of birth asphyxia, sepsis, and prematurity than girls, who, in turn, are more likely to die of pneumonia and diarrhoea. The main reason for these differences is that a greater proportion of deaths of boys under five occur in the neonatal period. Table 8.9 Causes of under five deaths by sex and residence Percent distribution of under-five deaths by cause (weighted), according to sex and residence, Pakistan 2006-07 Sex Residence Cause of death Male Female Urban Rural Total Congenital abnormality 4.1 3.7 5.7 3.5 4.0 Tetanus 0.8 0.4 0.0 0.7 0.6 Prematurity 9.7 8.8 12.0 8.6 9.2 Birth asphyxia 27.0 16.6 29.0 20.5 22.1 Sepsis 14.6 13.7 11.5 14.8 14.2 Pneumonia 11.8 15.1 10.0 14.1 13.3 Meningitis 3.5 4.5 2.3 4.4 4.0 Diarrhoea 9.4 12.4 9.9 11.0 10.8 Accident/injuries 2.2 2.7 3.0 2.3 2.4 Measles 0.9 2.6 1.4 1.7 1.7 Severe acute malnutrition 0.8 0.9 0.2 1.0 0.8 Malignancies 0.2 0.0 0.0 0.1 0.1 Other causes 5.3 6.9 5.5 6.2 6.1 Unexplained neonatal death 5.3 5.5 3.9 5.7 5.4 Unexplained postneonatal death 4.0 6.0 5.1 4.9 4.9 Cause could not be classified 0.5 0.3 0.3 0.4 0.4 Total 100.0 100.0 100.0 100.0 100.0 Number of deaths 1,561 1,380 571 2,372 2,943 Differences in causes of death by residence are minimal. Urban children are more likely to die of birth asphyxia and prematurity than rural children and less likely to die of pneumonia and diarrhoea. Again, this is due to the fact that deaths of urban children are more likely to occur in the neonatal period. This is consistent with data that show that as childhood death rates decline—mostly due to control of infectious diseases—the proportion of deaths that occur very early in life tends to increase. Table 8.10 shows provincial differences in causes of death of children under five. In all four provinces, birth asphyxia is the main cause of death. In Punjab and Sindh, this is followed by sepsis and pneumonia. In NWFP, pneumonia is the second leading cause of death, followed by sepsis, while in Balochistan, pneumonia is the second leading cause of death, followed by diarrhoea. Infant and Child Mortality | 99 Table 8.10 Causes of under five deaths by province Percent distribution of under five deaths by cause (weighted), according to province, Pakistan 2006-07 Province Cause of death Punjab Sindh NWFP Balochistan Total Congenital abnormality 4.0 3.2 5.9 3.8 4.0 Tetanus 0.5 0.5 1.1 0.3 0.6 Prematurity 8.6 10.3 11.7 3.9 9.2 Birth asphyxia 23.9 21.5 18.3 16.0 22.1 Sepsis 13.4 16.1 14.2 11.3 14.2 Pneumonia 12.2 13.7 17.0 13.8 13.3 Meningitis 3.3 5.2 3.9 4.6 4.0 Diarrhoea 11.9 10.1 6.8 13.1 10.8 Accident/injuries 2.2 1.8 4.1 4.7 2.4 Measles 1.3 2.2 1.5 2.6 1.7 Severe acute malnutrition 0.9 0.7 0.3 2.2 0.8 Malignancies 0.1 0.2 0.0 0.4 0.1 Other causes 5.6 6.4 4.9 11.4 6.1 Unexplained neonatal death 6.4 3.6 5.7 4.7 5.4 Unexplained postneonatal death 5.6 3.9 3.8 6.9 4.9 Cause could not be classified 0.2 0.5 0.9 0.6 0.4 Total 100.0 100.0 100.0 100.0 100.0 Number of deaths 1,562 891 339 151 2,943 8.8 CAUSES OF STILLBIRTHS Table 8.11 provides some insight as to what causes stillbirths in Pakistan. The data indicate that over half of all stillbirths occur in the antepartum period and 42 percent occur in the intrapartum period, most of which represent intrapartum asphyxia. Since many of the antepartum stillbirths are associated with ante- partum haemorrhage and pre-eclampsia/eclampsia, they are potentially related to preventable disorders. No cause could be identified for 34 percent of stillbirths occurring in the antepartum period indicating that a number of maternal health issues could contribute to the burden of stillbirths in Pakistan. Table 8.11 Causes of stillbirth Percent distribution of stillbirths identified in house- holds since 2005, by cause of death, Pakistan 2006-07 Cause Percentage Congenital abnormality 4.0 Antepartum maternal disorders 18.7 Antepartum probable foetal problems 0.8 Intrapartum asphyxia related 21.1 Unexplained antepartum 33.5 Unexplained intrapartum 20.9 Cause could not be classified 1.0 Total 100.0 Number of stillbirths 1,285 8.9 IMPLICATIONS OF THE FINDINGS These data have considerable implications for Pakistan and its maternal, newborn and child health programmes. They highlight the fact that infant and child mortality has hardly changed in over a decade and that newborn deaths account for a very large percentage of the under-five mortality. The PDHS also highlights an “extension” of early neonatal and potential asphyxia related deaths, namely intrapartum asphyxia related deaths which account for almost 42 percent of all stillbirths. Given the high rates of newborn deaths and stillbirths, it is clear that national programmes for maternal and newborn care need to be integrated and also scaled up if Pakistan is to meet its Millennium Development Goals #4 and #5. In addition, the PDHS data also highlight the persistent high rates of death due to diarrhoea and pneumonia after the neonatal period. These deaths are potentially avoidable with existing evidence-based interventions which can be integrated and scaled up within community and outreach programs (Jones et al., 2003; Darmstadt et al., 2008; Bhutta et al., 2005; Bhutta et al., 2008a). 100 | Infant and Child Mortality REPRODUCTIVE HEALTH 9 Rabia Zafar and Anne Cross Everyone has the right to enjoy reproductive health, which is a basis for having healthy children, intimate relationships, and happy families. In an ideal situation, every child would be wanted and every birth would be safe. The critical importance of reproductive health to development has been acknowledged at the highest level. At the 2005 World Summit, world leaders agreed to integrate access to reproductive health into national strategies to attain the Millennium Development Goals (www.unfpa.org). However, reproductive health problems remain a leading cause of ill health and death for women of childbearing age worldwide. Impoverished women, especially those living in developing countries, suffer disproportionately from unintended pregnancies, maternal death and disability, sexually transmitted infections—including HIV, gender-based violence, and other problems related to their reproductive system and sexual behaviour. In Pakistan, the National Health Policy was promulgated in June 2001. The policy provides an overall national vision for the health sector based on a “health of all” approach (Pakistan, 2001). It aims to implement the strategy of protecting people against hazardous diseases of promoting public health, and of upgrading curative health care facilities. The policy identifies a series of measures, programmes, and projects as the means for enhancing equity, efficiency, and effectiveness in the health sector through focused interventions. Improved safe motherhood services and focused reproductive health services through a life cycle approach are aimed to be provided at the doorstep. Promotion of maternal and child health has been one of the most important objectives of the health programme in Pakistan. Primary health care services are also extended through the Lady Health Worker (LHW) programme, which provides services through home visits especially in rural areas. LHWs are contributing directly to improved hygiene and higher levels of contraceptive use, iron supplementation, growth monitoring and vaccinations. 9.1 PRENATAL CARE Prenatal care is important for the health of mother and child. It refers to pregnancy-related health care checkups provided at a medical facility or at home. Ideally, prenatal care comprises at least three visits and includes monitoring the pregnancy for signs of complications; detection and treatment of pre-existing and concurrent problems of pregnancy such as anaemia; provision of advice and counselling on preventive care, diet during pregnancy, and postnatal care; and encouragement of institutional delivery by trained health care personnel. Under the National Health Policy, prenatal care should include provision of iron supplements, folic acid supplements, two doses of tetanus vaccine, blood pressure measurement, and identification and treatment of reproductive tract and sexually transmitted infections. The quality of prenatal care can be assessed by the type of provider, the number of prenatal visits, and the timing of the first visit. Prenatal care can also be monitored through the content of services received and the kind of information mothers are given during their visit. In the Pakistan Demographic and Health Survey (PDHS), information on prenatal care coverage was obtained from women who gave birth in the five years preceding the survey. For women with one or more live births during the five-year period, data refer to the most recent birth only. Reproductive Health | 101 Table 9.1 shows the percent distribution of mothers in the five years preceding the survey by source of prenatal care received during pregnancy, according to background characteristics. Women were asked to report on all persons they saw for prenatal care for their last birth. However, for presenting the results, if a woman saw more than one provider, only the provider with the highest qualification is considered. Table 9.1 Prenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by prenatal care provider during pregnancy for the most recent birth, and the percentage receiving prenatal care from a skilled provider for the most recent birth, according to background characteristics, Pakistan 2006-07 Background characteristic Doctor Nurse/ midwife/ Lady Health Visitor Dai/ tradi- tional birth attendant Lady Health Worker Dispenser/ Compounder/ Homeopath/ Hakim No one Missing Total Percentage receiving prenatal care from a skilled provider1 Number of women Mother's age at birth <20 52.3 6.7 5.4 0.2 0.5 35.0 0.0 100.0 59.0 460 20-34 58.8 4.9 2.3 0.8 0.5 32.2 0.5 100.0 63.7 4,303 35-49 44.7 4.2 2.2 0.6 0.7 46.5 1.1 100.0 48.9 915 Birth order 1 68.8 4.6 3.1 0.8 0.6 21.8 0.3 100.0 73.4 965 2-3 61.1 5.3 1.8 0.7 0.6 30.1 0.4 100.0 66.4 1,917 4-5 51.4 4.7 3.7 0.8 0.6 38.1 0.8 100.0 56.0 1,389 6+ 44.8 4.8 1.9 0.6 0.4 46.6 0.8 100.0 49.6 1,406 Residence Total urban 73.7 4.4 3.1 0.8 0.2 17.2 0.5 100.0 78.1 1,714 Major city 81.8 2.9 3.6 0.8 0.1 10.5 0.4 100.0 84.7 909 Other urban 64.6 6.1 2.6 0.9 0.3 24.7 0.7 100.0 70.7 806 Rural 48.3 5.1 2.3 0.7 0.7 42.3 0.6 100.0 53.5 3,962 Province Punjab 54.6 6.3 3.2 0.9 0.7 33.7 0.6 100.0 60.9 3,182 Sindh 68.1 2.4 1.6 0.3 0.3 26.9 0.5 100.0 70.4 1,404 NWFP 46.7 4.6 1.1 0.7 0.6 45.8 0.5 100.0 51.3 827 Balochistan 37.9 2.8 3.9 0.3 0.3 54.2 0.6 100.0 40.7 264 Mother's education No education 45.3 4.7 2.8 0.6 0.6 45.4 0.5 100.0 50.1 3,668 Primary 64.4 5.6 3.3 1.1 0.6 23.9 1.0 100.0 70.1 854 Middle 74.7 7.2 0.5 0.7 0.5 16.3 0.0 100.0 81.9 353 Secondary 84.0 4.0 1.8 1.3 0.8 7.3 0.8 100.0 88.1 461 Higher 92.4 3.8 0.0 0.6 0.0 3.3 0.0 100.0 96.1 341 Wealth quintile Lowest 34.6 2.3 2.2 0.5 0.6 59.0 0.7 100.0 36.9 1,289 Second 42.9 5.4 2.9 0.2 1.0 47.3 0.2 100.0 48.3 1,194 Middle 53.1 8.2 3.3 0.9 0.6 33.0 0.9 100.0 61.4 1,099 Fourth 67.7 6.0 3.0 1.7 0.4 20.5 0.7 100.0 73.7 1,066 Highest 89.0 2.9 1.1 0.4 0.0 6.4 0.3 100.0 91.9 1,029 Total 56.0 4.9 2.5 0.7 0.5 34.7 0.6 100.0 60.9 5,677 Note: If more than one source of prenatal care was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, and Lady Health Visitor. Sixty-one percent of mothers receive prenatal care from skilled health providers, that is, from a doctor, nurse, midwife, or Lady Health Visitor. Only 3 percent of women receive prenatal care from a traditional birth attendant (dai). In addition, 1 percent of mothers receive prenatal care from a Lady Health Worker, a hakim, or a dispenser or compounder. Thirty-five percent of women receive no prenatal care at all (Figure 9.1). Younger mothers (less than 35 years) are more likely to receive prenatal care from a skilled health provider than older mothers (age 35-49). Mothers are also much more likely to receive care from a skilled health provider for their first births (73 percent) than for births of order six and higher (50 percent). 102 | Reproductive Health PDHS 2006-07 Figure 9.1 Source of Prenatal Care Doctor 55% No one 35%Traditional birth attendant/Dai 3% Lady health worker 1% Other/ missing 1% Nurse/midwife/ Lady Health Visitor 5% Doctor 56% There are large differences in the use of prenatal care services between urban and rural women. Seventy-eight percent of urban mothers receive prenatal care from a skilled health provider compared with only 54 percent of rural mothers. The use of prenatal care services from a skilled health provider is strongly related to the mother’s level of education. Women with higher education are almost twice as likely to receive prenatal care from a skilled health provider (96 percent) than women with no education (50 percent). Similarly, women in the highest wealth quintile are two and a half times more likely to receive care from a skilled health provider (92 percent) than women in the lowest wealth quintile (37 percent). There has been a significant improvement over the past ten years in the proportion of mothers who receive prenatal care from a skilled health provider, increasing from 33 percent in 1996 (Hakim et al., 1998) to 43 percent in 2001 (NIPS, 2001) to 44 percent in 2003 (NIPS, 2007a) to 61 percent in 2006-07. 9.1.1 Number and Timing of Prenatal Visits Prenatal care is more beneficial in preventing adverse pregnancy outcomes when it is sought early in the pregnancy and is continued through delivery. The World Health Organization (WHO) recommends that a woman without complications have at least four visits to provide sufficient prenatal care. It is possible during these visits to detect health problems associated with a pregnancy. In the event of complication, more frequent visits are advised and admission to a health facility may be necessary. Table 9.2 shows that more than one-fourth (28 percent) of pregnant women make four or more prenatal care visits during their entire pregnancy. Urban women (48 percent) are more than twice as likely as rural women (20 percent) to have four or more prenatal visits. Thirty-one percent of women make their first prenatal care visit before the fourth month of pregnancy. The median duration of pregnancy at the first prenatal care visit is 4.2 months (3.6 months in urban areas and 4.8 months in rural areas). Reproductive Health | 103 The percentage of women who made four or more prenatal care visits during their pregnancy has increased during the last ten years, from 16 percent in 1996 (Hakim et al., 1998) to 24 percent in 2003 (NIPS, 2007a) to 28 percent in 2006-07. Table 9.2 Number of prenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of prenatal care visits for the most recent live birth, and by the timing of the first visit, and among women with prenatal care, median months pregnant at first visit, according to residence, Pakistan 2006-07 Residence Number and timing of prenatal care visits Total urban Major city Other urban Rural Total Number of prenatal care visits None 17.2 10.5 24.7 42.3 34.7 1 9.9 6.4 13.8 14.7 13.2 2-3 23.1 19.1 27.7 21.9 22.2 4+ 48.3 62.2 32.6 19.8 28.4 Don't know/missing 1.5 1.7 1.3 1.3 1.4 Total 100.0 100.0 100.0 100.0 100.0 Number of months pregnant at time of first prenatal care visit No prenatal care 17.2 10.5 24.7 42.3 34.7 <4 47.0 57.8 34.9 23.5 30.6 4-5 16.4 14.6 18.5 11.7 13.1 6-7 12.7 12.4 12.9 12.4 12.5 8+ 5.4 3.5 7.6 8.3 7.4 Don't know/missing 1.3 1.2 1.4 1.8 1.6 Total 100.0 100.0 100.0 100.0 100.0 Number of women 1,714 909 806 3,962 5,677 Median months pregnant at first visit (for those with prenatal care 3.6 3.3 4.3 4.8 4.2 Number of women with prenatal care 1,410 809 601 2,263 3,673 9.1.2 Components of Prenatal Care The content of prenatal care is important in assessing the quality of prenatal care services. Pregnancy complications are an important source of maternal and child morbidity and mortality, and thus teaching pregnant women about the danger signs associated with pregnancy and the appropriate action to take are essential components of prenatal care. Table 9.3 presents information on the percentage of women who took iron tablets or syrup and calcium tablets during their last pregnancy in the five years preceding the survey. The table also shows the percentage of women receiving prenatal care who were informed about the signs of pregnancy complications and the percentage who received specific routine prenatal care services. Among women with a live birth in the past five years, 43 percent took iron tablets or syrup and 44 percent took calcium tablets while pregnant with the last child. There are substantial variations in iron supplementation by background characteristics. Women age 20-34 at the time of the birth (46 percent), women pregnant with their first child (52 percent), urban women (58 percent), women residing in Sindh (54 percent), women with higher education (83 percent), and women in the highest wealth quintile (72 percent) are much more likely to have taken iron supplements during their pregnancy than their counterparts. A similar pattern by background characteristics is seen in the intake of calcium tablets. 104 | Reproductive Health Eighty percent of mothers who receive prenatal care report that they had their blood pressure taken, and two-thirds say they had an ultrasound procedure. About half of the women gave urine and blood samples for testing. Thirty-eight percent of pregnant women who sought prenatal care were weighed, but only one-fourth (25 percent) were informed about pregnancy complications during a prenatal visit. Table 9.3 Components of prenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and calcium tablets during the pregnancy of the most recent child, and among women receiving prenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific prenatal services, according to background characteristics, Pakistan 2006-07 Background characteristic Among women with a live birth in the last five years, the percentage who during the pregnancy of their last child Among women who received prenatal care for their most recent birth in the last five years, the percentage with selected services: Number of women with prenatal care for their most recent birth Number of women with a live birth in the past five years Informed of signs of pregnancy compli- cations Took iron tablets or syrup Took calcium tablets Weighed Blood pressure measured Urine sample taken Blood sample taken Ultra- sound Mother's age at birth <20 41.0 39.0 460 22.8 33.8 74.3 50.2 44.8 68.8 299 20-34 45.5 46.8 4,303 25.6 40.7 81.3 50.6 44.2 67.1 2,895 35-49 34.1 33.2 915 22.8 27.6 72.8 40.4 40.1 56.5 479 Birth order 1 51.8 50.6 965 26.2 39.3 80.7 58.0 50.3 75.0 752 2-3 48.1 49.5 1,917 27.1 45.0 81.8 55.7 50.0 71.1 1,333 4-5 39.3 41.8 1,389 24.4 36.9 81.2 43.8 38.2 60.1 849 6+ 34.8 34.0 1,406 20.9 27.5 72.9 35.1 32.2 53.9 739 Residence Total urban 57.6 60.5 1,714 26.6 54.7 87.3 63.1 57.3 74.4 1,410 Major city 66.3 72.8 909 25.5 69.7 93.2 75.1 68.9 81.6 809 Other urban 47.8 46.7 806 28.1 34.4 79.3 46.9 41.7 64.7 601 Rural 37.1 36.8 3,962 24.0 28.3 74.9 40.6 35.3 60.6 2,263 Province Punjab 39.5 44.8 3,182 23.8 39.2 75.1 48.1 41.1 71.3 2,090 Sindh 53.8 45.7 1,404 27.0 37.3 87.4 48.0 48.0 59.7 1,019 NWFP 43.5 43.7 827 27.6 39.0 83.3 60.0 50.6 62.1 444 Balochistan 32.7 25.1 264 19.9 32.7 78.8 40.2 28.7 39.0 119 Mother's education No education 33.5 32.9 3,668 20.9 25.8 73.7 36.6 32.0 54.4 1,984 Primary 48.0 53.8 854 23.6 39.4 79.7 50.4 43.7 72.4 641 Middle 55.4 60.9 353 30.6 46.8 84.4 67.4 55.4 80.1 295 Secondary 74.1 71.6 461 31.3 61.5 90.5 71.4 63.5 83.1 424 Higher 82.5 83.7 341 39.3 75.5 97.2 78.2 78.6 87.5 330 Wealth quintile Lowest 26.1 22.4 1,289 19.7 16.3 70.5 21.2 22.2 43.8 520 Second 32.5 31.6 1,194 21.1 22.7 70.0 33.7 30.9 54.8 626 Middle 40.7 41.3 1,099 23.1 26.3 71.1 41.6 32.4 57.8 727 Fourth 51.4 57.2 1,066 27.1 42.8 84.1 56.5 48.2 72.0 840 Highest 71.7 74.5 1,029 30.1 66.1 93.4 74.0 68.5 85.9 960 Total 43.3 44.0 5,677 25.0 38.4 79.6 49.2 43.7 65.9 3,673 The quality of prenatal care is particularly related to mother’s education, mother’s wealth, and residence. For example, among women who receive prenatal care, more than 75 percent of women with higher education were weighed and gave urine and blood samples for testing compared with only about one-third or less of women with no education. Similarly, women with higher education are more likely to have an ultrasound (88 percent) than women with no education (54 percent). Ninety- seven percent of highly educated women had their blood pressure measured compared with 74 percent of women with no education. Similarly, women in the highest wealth quintile and urban women are much more likely to receive each of the components of prenatal care than women in the lowest wealth quintile and women with no education. For example, two-thirds of women in the highest wealth quintile were weighed during a prenatal care visit compared with only 16 percent of women in the Reproductive Health | 105 lowest quintile. However, urban women are only slightly more likely (27 percent) than rural women (24 percent) to be provided with information about pregnancy complications. The overall quality of prenatal care has improved in the past five years; for example, the percentage of women who had blood tests taken increased from 39 percent in 2001 (NIPS, 2001) to 44 percent in 2006-07. 9.1.3 Reasons for Not Receiving Prenatal Checkups Table 9.4 shows the percentage of women who had a live birth in the five years preceding the survey and who did not receive any prenatal checkup for their most recent birth, and gave specific reasons for not receiving checkups. Almost three-quarters of the mothers did not consider having a checkup to be necessary (73 percent). The next most commonly cited reasons were that prenatal care costs too much (30 percent) and that they were not allowed by their families to go for any checkup (9 percent). Eight percent of women who did not get prenatal care said that the health facility was too far, and far fewer cited reasons such as unavailability of transport, no time to go for prenatal checkups, no one to go with her to the health facility, and lack of knowledge of where to go. Also uncommon were reasons related to quality of service, such as service not good, long waiting times, and lack of female health staff. Table 9.4 Reasons for not getting prenatal care Among women age 15-49 with a live birth in the five years preceding the survey who did not see anyone for prenatal care for their most recent birth, percentage who cite specific reasons for not getting prenatal care, according to background characteristics, Pakistan 2006-07 Percentage who did not get prenatal care because: Background characteristic Not necessary Costs too much Too far No transport No one to go with Service not good No time to go Didn't know where to go Did not want to see male doctor Long waiting time Not allowed to go Other Number of women Mother's age at birth <20 79.3 25.5 9.4 4.9 0.1 0.3 0.7 0.0 0.2 0.3 11.9 0.5 161 20-34 72.9 29.5 7.5 3.5 1.7 1.2 1.3 0.5 1.1 0.5 9.3 1.6 1,407 35-49 72.3 34.0 7.2 5.1 0.7 1.2 2.5 1.1 1.4 0.0 7.6 0.7 435 Birth order 1 74.6 19.8 11.5 4.6 1.9 0.1 0.6 0.6 0.3 0.2 12.7 0.5 213 2-3 74.3 26.6 7.1 4.5 1.6 1.0 0.9 0.4 0.9 0.7 10.6 1.5 584 4-5 75.2 30.0 6.3 2.9 1.2 0.9 1.6 0.6 1.6 0.2 9.0 1.4 540 6+ 70.4 36.7 7.8 4.1 1.2 1.8 2.2 0.8 1.1 0.4 6.7 1.3 666 Residence Total urban 73.9 21.9 1.9 0.7 2.4 1.5 2.0 0.2 1.0 0.8 10.6 1.9 304 Major city 65.1 17.1 3.5 0.0 5.4 0.8 3.7 0.0 2.3 0.0 11.4 1.9 99 Other urban 78.1 24.2 1.1 1.0 0.9 1.8 1.2 0.2 0.4 1.2 10.2 1.9 205 Rural 73.2 31.6 8.6 4.5 1.2 1.1 1.4 0.7 1.1 0.3 8.9 1.2 1,699 Province Punjab 79.7 30.6 6.7 2.1 0.8 1.0 1.6 1.0 1.4 0.4 7.5 1.6 1,092 Sindh 72.6 31.4 3.8 1.9 2.8 0.3 2.2 0.0 0.2 0.3 6.7 0.8 385 NWFP 60.8 27.6 11.7 7.8 1.9 1.8 0.7 0.3 1.0 0.4 13.7 1.5 382 Balochistan 59.7 30.3 13.6 12.8 0.6 2.4 1.0 0.5 0.8 1.1 15.6 0.3 145 Mother's education No education 73.0 32.6 8.6 4.4 1.3 1.1 1.5 0.6 1.1 0.5 8.7 1.0 1,685 Primary 74.0 19.7 3.6 0.9 2.5 0.7 1.5 0.7 0.8 0.0 11.7 1.9 213 Middle 79.3 13.4 0.0 0.4 0.0 3.0 0.0 0.9 0.4 0.0 11.7 4.5 58 Secondary (72.5) (11.6) (0.0) (1.2) (0.0) (0.8) (0.0) (0.0) (2.9) (0.0) (7.5) (2.1) 37 Higher * * * * * * * * * * * * 11 Wealth quintile Lowest 72.0 42.1 12.2 4.3 1.0 0.6 1.0 0.4 1.0 0.5 7.0 0.9 770 Second 71.7 30.8 7.7 7.0 1.2 1.7 1.4 1.3 0.8 0.1 10.8 1.5 567 Middle 75.8 18.6 2.2 0.9 1.7 1.3 2.0 0.5 1.6 0.5 9.1 1.4 372 Fourth 75.1 12.6 2.3 0.4 2.9 1.6 2.3 0.0 1.1 0.6 12.2 2.4 226 Highest 80.6 11.0 1.5 1.7 0.6 0.5 2.0 0.0 1.6 0.3 8.7 1.2 68 Total 73.3 30.1 7.6 3.9 1.4 1.1 1.5 0.6 1.1 0.4 9.1 1.3 2,004 Note: Figures in parentheses are based on 25-49 unweighted cases, and an asterisk denotes a figure based on fewer than 25 cases that has been suppressed. 106 | Reproductive Health Among women who did not receive prenatal care during their last pregnancy, younger mothers and those who were pregnant with their first child were more likely than other women to say that they did not get prenatal care because they were not allowed to go. This proportion is especially high in Balochistan (16 percent) compared with other provinces. Women with no education (33 percent) and those in the lowest wealth quintile (42 percent) are most likely to report that they do not get prenatal care because it costs too much. These results suggest the need to inform mothers and families about the availa- bility and benefits of prenatal checkups in order to help overcome traditional attitudes and other hurdles that prevent mothers from seeking prenatal care. The most common reasons reported deal with lack of concern, problems of accessibility, and cost of services. Utilization of prenatal care services could be increased by lowering direct and indirect costs and making services more accessible. Table 9.5 Tetanus toxoid injections 9.1.4 Tetanus Toxoid Vaccinations Tetanus toxoid injections are given during pregnancy for the prevention of neo- natal tetanus, historically one of the principal causes of death among infants in many developing countries. To achieve protection for herself and her newborn baby, a pregnant woman should typically receive at least two doses of tetanus toxoid. On the other hand, if a woman was fully vaccinated during a previous pregnancy, she may only require one dose during her current pregnancy to achieve such protection. Five doses are considered adequate to provide lifetime protection. Table 9.5 presents the percentage of women who had a live birth in the five years preceding the survey and whose last birth was protected against neonatal tetanus. Three in five mothers (60 percent) with a birth in the five years preceding the survey were protected against neonatal tetanus, with more than half (53 percent) of pregnant women receiving two or more tetanus injections during the last pregnancy. These results are almost identical to those provided by the 2005-06 Pakistan Social and Living Standards Measurement Survey conducted by the Federal Bureau of Statistics (FBS, 2007c), which showed that 60 percent of mothers with a birth in the three years preceding the survey were protected against neonatal tetanus and 55 percent of pregnant women received two or more tetanus injections during the last pregnancy. Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Pakistan 2006-07 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother's age at birth <20 53.2 58.2 460 20-34 55.5 62.6 4,303 35-49 43.4 47.4 915 Birth order 1 63.3 64.4 965 2-3 59.7 68.1 1,917 4-5 49.1 56.8 1,389 6+ 42.3 48.3 1,406 Residence Total urban 65.3 73.8 1,714 Major city 71.1 78.7 909 Other urban 58.9 68.3 806 Rural 48.2 53.8 3,962 Province Punjab 59.0 65.1 3,182 Sindh 51.2 58.3 1,404 NWFP 43.2 51.2 827 Balochistan 29.7 30.9 264 Mother's education No education 42.3 47.5 3,668 Primary 65.4 73.9 854 Middle 76.5 83.2 353 Secondary 79.7 88.5 461 Higher 83.2 94.1 341 Wealth quintile Lowest 31.7 35.8 1,289 Second 43.7 48.6 1,194 Middle 55.5 62.6 1,099 Fourth 65.5 73.7 1,066 Highest 77.0 85.7 1,029 Total 53.4 59.8 5,677 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth Children whose mothers are age 20-34 at the time of the birth and those of birth order 2 or 3 are more likely to be protected against neonatal tetanus than other children. There are marked differences in the tetanus coverage by province, with more than twice as many of the children born to Reproductive Health | 107 mothers in Punjab (65 percent) protected against neonatal tetanus as those whose mothers reside in Balochistan (31 percent). Education and wealth have a positive effect on whether women receive tetanus toxoid injections. Almost twice as many children born to mothers with higher education are protected against tetanus than children born to mothers with no education (94 and 48 percent, respectively). Similarly, 86 percent of births to mothers in the highest wealth quintile, compared with 36 percent of those to mothers in the lowest quintile, were protected against neonatal tetanus (Figure 9.2). Over the past six years, the percentage of mothers who received at least two tetanus toxoid injections during pregnancy has almost doubled—from 29 percent in 2001 (NIPS, 2001) to 53 percent in 2006-07. Figure 9.2 Percentage of Births Protected against Tetanus, by Wealth Quintile 36 49 63 74 86 Lowest Second Middle Fourth Highest 0 20 40 60 80 100 Percent PDHS 2006-07 9.1.5 Complications during Pregnancy In the PDHS, for the most recent birth in the five years preceding the survey, the mother was asked if she experienced any of the following problems during the pregnancy: severe headaches, blurred vision, swelling of hands, swelling of face, vaginal bleeding or spotting, fits or convulsions, and epigastric pain. Convulsions accompanied by signs of hypertension can be symptomatic of eclampsia, a potentially fatal condition. The possible health risk posed by vaginal bleeding during pregnancy varies by when in the pregnancy the bleeding takes place. Although documenting the prevalence of the symptoms of pregnancy complications is vital for planning services to reduce maternal morbidity and mortality, the information presented here is based on women’s self reports and should be interpreted with care. As shown in Table 9.6 and Figure 9.3, the pregnancy-related health problems most commonly reported are severe headaches (48 percent), followed by epigastric pain (31 percent), blurred vision (29 percent), swelling of hands (26 percent), and swelling of the face (23 percent). Only 8 percent reported any vaginal bleeding, and fits or convulsions are not common (4 percent). Sixty-eight percent of women reported having at least one problem during their most recent pregnancy and 23 percent had a severe problem. 108 | Reproductive Health Table 9.6 Pregnancy complications Among women age 15-49 who had a live birth in the five years preceding the survey, the percentage who had specific problems during the pregnancy or any severe problem for the most recent live birth, according to background characteristics, Pakistan 2006-07 Complication/problem Background characteristic Severe headaches Blurred vision Swelling of hands Swelling of face Vaginal bleeding or spotting Fits or convulsions Epigastric pain Any problem Any severe problem1 Number of women Mother's age at birth <20 47.0 27.2 21.9 18.5 5.7 2.4 28.3 65.7 21.4 460 20-34 47.1 27.9 26.7 23.5 7.9 3.5 31.5 68.2 23.0 4,303 35-49 52.4 38.0 27.0 25.1 8.0 5.3 31.9 68.6 25.9 915 Birth order 1 44.1 21.9 26.7 24.1 9.9 3.8 28.8 66.2 21.7 965 2-3 42.5 24.5 24.2 20.9 6.1 3.0 28.8 64.6 19.4 1,917 4-5 50.6 31.5 26.7 23.7 7.9 3.2 31.1 69.0 24.5 1,389 6+ 55.5 39.4 28.7 25.9 8.1 5.2 36.6 73.2 28.6 1,406 Residence Total urban 42.7 23.6 28.7 24.8 8.3 2.9 30.7 67.2 22.3 1,714 Major city 37.0 21.7 31.1 23.9 9.5 2.8 32.5 67.3 22.0 909 Other urban 49.1 25.8 26.0 25.9 7.0 3.0 28.7 67.0 22.8 806 Rural 50.2 32.0 25.3 22.7 7.4 4.1 31.6 68.5 23.7 3,962 Province Punjab 40.9 24.7 24.6 20.8 6.9 3.5 26.4 60.8 18.5 3,182 Sindh 58.2 33.1 29.7 29.7 11.8 5.3 36.5 79.3 30.8 1,404 NWFP 53.4 37.8 26.1 22.5 5.4 2.1 32.3 73.2 30.4 827 Balochistan 61.5 41.2 31.0 22.6 2.9 4.0 59.7 80.4 19.6 264 Mother's education No education 51.3 33.6 26.0 23.8 7.7 4.5 32.0 69.1 24.4 3,668 Primary 48.4 26.8 24.5 22.0 6.0 3.5 31.1 68.3 23.5 854 Middle 42.4 23.5 25.9 20.2 6.0 2.3 34.2 67.8 20.6 353 Secondary 37.6 18.5 31.1 23.4 9.4 1.0 28.7 66.0 22.3 461 Higher 30.4 11.8 28.6 25.6 11.3 1.5 24.6 59.2 15.6 341 Wealth quintile Lowest 51.7 35.4 24.5 21.9 7.0 4.7 34.2 69.6 25.4 1,289 Second 53.0 34.3 24.4 24.3 7.3 3.7 31.1 71.4 24.2 1,194 Middle 50.1 30.3 27.3 24.3 7.4 4.7 31.4 67.8 24.3 1,099 Fourth 47.0 27.2 26.7 22.5 8.5 3.0 30.7 67.4 24.3 1,066 Highest 36.1 17.8 29.6 23.8 8.5 2.3 28.4 63.4 17.6 1,029 Total 48.0 29.4 26.4 23.4 7.7 3.7 31.3 68.1 23.3 5,677 1 Refers to the question as to whether any of the problems were “so severe you thought you might die” There are few differences by background characteristics in the prevalence of any problem and any severe health problem. At the provincial level, the percentage reporting any severe problem is higher in Sindh (31 percent) and North-West Frontier Province (NWFP) (30 percent), compared with Punjab and Balochistan (19 percent and 20 percent, respectively). Mothers’ education and wealth quintile have similar patterns with regard to problems during pregnancy. For example, the prevalence of any severe problem is lower among the mothers with higher education and those in the highest wealth quintile. Reproductive Health | 109 Figure 9.3 Complications during Pregnancy for the Most Recent Birth 48 31 29 26 23 8 4 Severe headaches Epigastric pains Blurred vision Swelling of hands Swelling of face Vaginal bleeding or spotting Fits or convulsions 0 10 20 30 40 50 60 Percent PDHS 2006-07 Table 9.7 shows information as to where women seek treatment when they experience pregnancy complications. A large proportion of women do not seek treatment at all. For example, 41 percent of women who experienced severe headaches did not go anywhere for medical treatment. Similarly, 43 percent of those who had blurred vision did not get treatment. About one-third or more of women with pregnancy complications seek assistance at private hospitals and clinics, by far the most common source of treatment, followed by government hospitals and private doctors. Table 9.7 Pregnancy complications and place of treatment Among women age 15-49 who had a live birth in the five years preceding the survey and who reported having any of several specific problems during the pregnancy for the most recent live birth, percentage seeking treatment from various places, Pakistan 2006-07 Complication/problem Place(s) treatment sought Severe headaches Blurred vision Swelling of hands Swelling of face Vaginal bleeding or spotting Fits or convulsions Epigastric pain Own home 2.7 2.7 1.9 2.2 3.5 3.0 2.8 Other home 1.0 1.0 1.1 0.9 1.5 0.0 1.2 Government hospital 9.6 8.4 10.6 11.0 17.5 13.3 10.2 Rural health centre/maternal and child health centre 0.5 0.7 0.7 0.7 0.4 0.6 0.7 Basic health unit/family welfare centre 1.4 1.5 1.9 1.8 1.9 2.2 1.1 Other public 0.1 0.1 0.0 0.0 0.0 0.0 0.1 Private hospital/clinic 31.5 29.3 37.4 36.6 43.9 43.5 36.7 Private doctor 9.7 11.1 8.4 8.8 9.8 8.7 9.9 Other private medical 3.8 3.6 3.4 3.6 2.2 4.6 3.8 Other 0.9 0.8 0.7 0.7 1.2 1.2 0.8 No treatment sought 40.9 42.8 36.9 36.9 22.3 24.8 35.8 Number of women 2,722 1,671 1,496 1,326 437 212 1,778 Most women who do not seek treatment for pregnancy complications say the reason is that treatment is not necessary (Table 9.8). Another common reason cited is that treatment costs too much. About one in ten women say they didn’t go for treatment because they were not allowed to go. 110 | Reproductive Health Table 9.8 Pregnancy complications and reasons for no treatment Among women age 15-49 who had a live birth in the five years preceding the survey and who reported having any of several specific problems during the pregnancy for the most recent live birth for which they did not seek treatment, percentage citing specific reasons for not seeking treatment, Pakistan 2006-07 Complication/problem Reason(s) for not seeking treatment Severe headaches Blurred vision Swelling of hands Swelling of face Vaginal bleeding or spotting Fits or convulsions Epigastric pain Not necessary 60.3 50.8 56.6 57.8 57.1 33.1 56.5 Costs too much 35.9 44.8 38.4 40.6 47.4 57.2 41.9 Too far 8.1 9.1 7.8 6.7 6.8 3.3 10.6 No transport 4.4 5.7 3.8 3.8 2.0 5.6 5.4 No one to go with 2.4 2.7 2.3 2.8 1.1 3.1 3.3 Service not good 0.8 0.4 0.7 0.9 1.7 0.0 0.7 No time to go 2.3 2.4 2.5 1.8 1.7 4.8 1.8 Didn't know where to go 0.3 0.2 0.5 0.6 0.0 2.6 0.3 Didn't want to see male doctor 0.7 0.6 0.8 0.5 1.4 0.0 0.3 Long waiting time 0.6 0.9 0.0 0.0 0.2 0.0 0.5 Not allowed to go 9.5 11.4 12.3 11.3 11.6 12.2 11.8 Other 3.2 1.6 2.5 2.8 0.7 3.6 1.6 Number of women 1,113 715 551 489 98 52 637 9.2 DELIVERY CARE 9.2.1 Preparedness for Delivery Birth preparedness refers to advance planning and preparation for delivery by setting aside personal funds to cover the costs of travel and knowing what transport can be used to get to the hospital. Delivering with a skilled provider who has the required supplies can do much to improve maternal health outcomes. Birth preparedness helps ensure that women can reach professional delivery care when labour begins. In addition, birth preparedness can help reduce the delays that occur when women experience obstetric complications, such as recognizing the complication and deciding to seek care, reaching a facility where skilled care is available, and receiving care from qualified providers at the facility. Table 9.9 shows that about two in five women (44 percent) who gave birth in the five years before the survey discussed with their husband where to deliver the baby, and about half of the women (49 percent) set aside money in case of emergency. Mothers of lower order births are more likely to discuss with their husbands where to deliver than mothers of higher order births (50 percent and 31 percent, respectively). It is more common for urban women to discuss with their husbands where to deliver the baby (61 percent) compared with rural women (36 percent). Education and wealth quintile are positively related to both measures of birth preparedness. Only 33 percent of mothers with no education discussed with their husbands where to deliver compared with 86 percent of mothers with higher education. Similarly, the proportion of mothers who set aside money in case of a pregnancy-related emergency ranges from 41 percent of those with no education to 78 percent of those with higher education. Women in the highest wealth quintile are almost three times more likely to discuss with their husbands where to deliver than are women in the lowest wealth quintile (72 percent and 24 percent, respectively). The percentage of mothers in the highest wealth quintile who say they set aside money in case of emergency is double that of women in the lowest quintile. Reproductive Health | 111 Table 9.9 Preparations for delivery Among mothers with a live birth in the five years preceding the survey, the percentage who, during the pregnancy for the last live birth, discussed with their husbands where they would deliver and who set aside money in case of an emergency, according to background characteristics, Pakistan 2006-07 Percentage who: Background characteristic Discussed with husband where to deliver Set aside money in case of emergency Number of women Mother's age at birth <20 39.7 49.6 460 20-34 46.2 50.4 4,303 35-49 33.0 40.8 915 Birth order 1 48.9 54.7 965 2-3 49.9 52.2 1,917 4-5 43.3 48.8 1,389 6+ 31.4 40.0 1,406 Residence Total urban 61.2 58.1 1,714 Major city 71.4 61.4 909 Other urban 49.6 54.4 806 Rural 35.9 44.7 3,962 Province Punjab 43.8 45.9 3,182 Sindh 47.3 52.7 1,404 NWFP 38.4 50.2 827 Balochistan 36.2 57.6 264 Mother's education No education 32.5 41.2 3,668 Primary 50.7 54.5 854 Middle 67.2 61.8 353 Secondary 68.3 66.9 461 Higher 86.0 77.8 341 Wealth quintile Lowest 23.9 32.5 1,289 Second 31.2 41.5 1,194 Middle 40.6 47.7 1,099 Fourth 56.8 58.9 1,066 Highest 71.9 68.3 1,029 Total 43.5 48.8 5,677 9.2.2 Place of Delivery Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that may cause the death or serious illness of the mother and the baby or both. Hence, an important component in the effort to reduce the health risks of mothers and children is to increase the proportion of babies delivered in a safe and clean environment and under the supervision of health professionals. Table 9.10 presents the percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. 112 | Reproductive Health Table 9.10 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Pakistan 2006-07 Percentage delivered in a health facility Health facility Background characteristic Public sector Private sector Home Other Missing Total Number of births Mother's age at birth <20 10.9 21.7 66.2 0.2 1.0 100.0 32.7 963 20-34 11.2 24.9 62.9 0.0 0.9 100.0 36.1 6,984 35-49 9.2 15.4 73.9 0.0 1.4 100.0 24.7 1,175 Birth order 1 14.1 34.2 50.8 0.1 0.8 100.0 48.3 1,902 2-3 11.7 26.8 60.9 0.0 0.7 100.0 38.5 3,119 4-5 10.3 17.4 70.9 0.1 1.3 100.0 27.7 2,111 6+ 7.3 13.9 77.4 0.1 1.4 100.0 21.1 1,989 Prenatal care visits1 None 4.6 7.2 88.1 0.0 0.0 100.0 11.8 1,972 1-3 10.9 24.7 64.2 0.1 0.1 100.0 35.6 2,015 4+ 20.6 49.5 29.8 0.0 0.0 100.0 70.1 1,611 Residence Total urban 17.4 38.8 42.5 0.0 1.2 100.0 56.3 2,699 Major city 24.2 47.1 27.8 0.0 0.8 100.0 71.4 1,390 Other urban 10.2 30.0 58.2 0.0 1.6 100.0 40.2 1,310 Rural 8.2 16.8 74.0 0.1 0.9 100.0 25.0 6,422 Province Punjab 10.0 23.4 65.5 0.0 1.1 100.0 33.4 5,125 Sindh 10.5 31.2 57.3 0.0 0.9 100.0 41.7 2,284 NWFP 15.4 14.3 69.5 0.2 0.6 100.0 29.7 1,312 Balochistan 10.4 7.8 81.0 0.0 0.8 100.0 18.2 400 Mother's education No education 7.8 14.3 76.8 0.1 1.0 100.0 22.1 5,986 Primary 13.7 26.8 58.2 0.0 1.2 100.0 40.5 1,354 Middle 17.0 37.4 45.0 0.0 0.5 100.0 54.5 538 Secondary 21.6 51.2 26.4 0.0 0.8 100.0 72.8 722 Higher 18.5 65.2 15.5 0.0 0.8 100.0 83.7 522 Wealth quintile Lowest 3.8 8.6 86.5 0.0 1.1 100.0 12.4 2,153 Second 6.7 13.5 78.9 0.1 0.8 100.0 20.2 1,925 Middle 10.5 18.9 69.4 0.1 1.1 100.0 29.4 1,829 Fourth 16.5 30.5 51.6 0.0 1.3 100.0 47.0 1,651 Highest 20.5 53.3 25.6 0.0 0.6 100.0 73.8 1,563 Total 10.9 23.3 64.7 0.1 1.0 100.0 34.3 9,121 Note: Total includes those missing the number of prenatal care visits 1 Includes only the most recent birth in the five years preceding the survey Only 34 percent of births in Pakistan take place in a health facility: 11 percent are delivered in a public sector health facility and 23 percent in a private facility. Three out of five births (65 percent) take place at home. Delivery in a health facility is more common among mothers of first order births (48 percent) and mothers who have had at least four prenatal visits (70 percent). More than half (56 percent) of the children in urban areas are born in a health facility compared with 25 percent in rural areas. Delivery in a health facility also varies by provinces, being lowest in Balochistan (18 percent) and highest in Sindh (42 percent). There is a strong association between health facility delivery and mother’s education and wealth quintile. The proportion of deliveries in a health facility is only 22 percent among births to uneducated mothers compared with 84 percent among births to mothers with higher education (Figure 9.4). A similar pattern is seen in terms of wealth quintiles: delivery at a health facility is significantly lower among births in the lowest wealth quintile (12 percent) than those in the highest quintile (74 percent). Reproductive Health | 113 Figure 9.4 Percentage of Births Delivered at a Health Facility, by Residence, Province, and Mother’s Education 56 71 40 25 33 42 30 18 22 41 55 73 84 RESIDENCE Total urban Major city Other urban Rural PROVINCE Punjab Sindh NWFP Balochistan MOTHER'S EDUCATION No education Primary Middle Secondary Higher 0 20 40 60 80 10 Percent PDHS 2006-07 0 The percentage of births that take place in a health facility has doubled in the past ten years, increasing from 17 percent in 1996 (Hakim et al., 1998) to 23 percent in 2000-01 (NIPS, 2001) to 34 percent in 2006-07. This is especially impressive because most of the change occurred in the last six years. 9.2.3 Reasons for Not Delivering in a Facility The overall situation of maternal health in Pakistan is dismal. Women residing in rural areas and low-income urban neighbourhoods are the victims of poor planning, lack of commitment, and negligence on the part of the government health system. The vast majority of women have little access to modern health services, particularly during pregnancy and childbirth. Many women do not receive any prenatal care during pregnancy nor do they receive any advice or information about safe delivery practices (PAP, 2000). To get a better understanding of why women do not deliver in health facilities, the 2006-07 PDHS asked women who had a birth in the five years preceding the survey why they did not give birth in a health facility. Table 9.11 shows that the majority of women (57 percent) believe it is not necessary to give birth in a health facility, while 38 percent say that it costs too much, 7 percent mention that delivery in a facility is not customary, and 7 percent said that they did not deliver in a facility because it was too far away or that there was no transportation. In addition, 4 percent of women mentioned that the facility was not open. Only 6 percent of women reported that their husbands or family did not allow them to deliver in a health facility. The remaining reasons—not enough time to get to the facility, lack of trust or poor quality of service, lack of a female provider available at the facility—are reported by a lower proportion of women. Belief that it is not necessary to deliver in a facility is the most common reason in both urban (58 percent) and rural areas (57 percent). 114 | Reproductive Health Table 9.11 Reasons for not delivering in a facility Among women who had a live birth in the five years preceding the survey and who did not deliver the most recent birth in a health facility, percentage citing specific reasons for not delivering in a facility, according to background characteristics, Pakistan 2006-07 Percentage who cited: Background characteristic Costs too much Facility not open Too far/ no transport Don't trust facility/ poor quality No female providers Husband/ family not allow Not necessary Not customary No time Other Number of women Mother's age at birth <20 29.9 4.8 8.2 4.1 0.5 9.6 59.2 8.2 5.4 2.5 296 20-34 37.0 4.2 6.6 3.7 0.5 5.3 57.4 6.7 5.4 1.7 2,611 35-49 45.5 5.1 7.1 2.9 0.8 5.6 56.5 9.6 5.1 0.8 669 Birth order 1 26.6 5.4 8.0 4.3 0.3 7.0 63.1 6.0 4.8 2.5 469 2-3 34.0 4.5 6.8 3.5 0.6 6.0 57.9 6.2 6.2 1.2 1,086 4-5 37.9 4.0 6.0 3.2 0.6 5.5 58.0 7.7 5.4 2.4 946 6+ 47.1 4.4 7.0 3.9 0.6 5.1 53.9 8.9 4.6 0.9 1,075 Residence Total urban 29.2 2.1 3.2 7.5 0.9 5.8 57.7 4.6 6.7 2.5 702 Major city 30.3 3.9 6.4 12.1 1.1 5.4 44.6 4.6 6.7 3.0 246 Other urban 28.6 1.2 1.5 5.0 0.8 6.1 64.8 4.5 6.7 2.3 456 Rural 40.1 5.0 7.7 2.7 0.5 5.7 57.3 8.1 5.0 1.4 2,874 Province Punjab 35.3 2.1 4.7 2.8 0.5 3.8 65.5 8.1 6.3 1.5 2,024 Sindh 49.6 5.8 6.6 4.2 0.6 5.5 46.6 3.8 3.4 1.3 774 NWFP 31.2 4.2 10.7 5.3 0.5 7.8 48.2 11.9 5.4 2.6 564 Balochistan 39.8 22.6 16.9 4.8 1.8 18.8 44.3 1.5 2.7 1.5 215 Mother's education No education 42.5 5.0 7.5 3.1 0.6 5.8 55.7 7.8 4.5 1.5 2,764 Primary 27.5 2.3 4.2 5.3 0.3 6.9 62.0 6.8 6.0 1.7 489 Middle 26.5 2.5 1.8 7.2 1.5 6.0 65.6 3.2 8.1 1.3 142 Secondary 8.5 1.4 8.7 3.8 0.8 2.0 61.7 4.8 12.5 4.0 131 Higher 4.3 5.9 3.7 6.5 0.0 1.2 70.4 5.9 18.7 0.7 50 Wealth quintile Lowest 56.1 7.5 10.1 1.3 0.6 6.7 51.2 8.3 3.2 1.1 1,104 Second 40.7 3.5 7.0 2.9 0.2 5.1 56.8 9.1 3.8 1.1 927 Middle 31.7 3.2 4.4 5.2 1.0 5.4 59.8 6.2 5.6 2.6 738 Fourth 19.7 3.0 4.3 5.3 0.7 5.6 63.9 4.7 9.2 2.1 548 Highest 7.9 1.1 4.0 8.3 0.4 4.8 65.8 5.9 10.9 1.3 259 Total 38.0 4.4 6.8 3.6 0.6 5.7 57.4 7.4 5.3 1.6 3,576 The proportions of mothers who say they did not deliver in a health facility because their families did not allow them to go or because the facility was either not open or too far are highest in Balochistan and lowest in Punjab. Wealth quintile is strongly related to reporting of cost as a factor; over half of women in the lowest wealth quintile (56 percent) mentioned that they did not deliver in a health facility because it cost too much compared with only 8 percent of women in the highest wealth quintile. 9.2.4 Use of Home Delivery Kits The use of a home delivery kit is believed to promote safe and clean delivery at home. Table 9.12 presents data for women who had a live birth in the five years preceding the survey but whose last live birth was not delivered in a health facility. The table shows the percentage of these women who used a safe delivery kit for their last live birth and the percent distribution by what was used to tie the cord and the type of utensil used to cut the cord, according to background characteristics. The data show that more than one-fourth (32 percent) of the women whose last birth was not delivered in a health facility used a safe delivery kit. The urban-rural differential is quite high, with 42 percent of urban women using safe delivery kits compared with 29 percent of rural women. Reproductive Health | 115 Table 9.12 Use of home delivery kits Among women who had a live birth in the five years preceding the survey and whose last live birth was not delivered in a health facility, percentage who used a safe delivery kit for last live birth and percent distribution by what was used to tie the cord and utensil used to cut the cord, according to background characteristics, Pakistan 2006-07 Residence Province Background characteristic Total urban Major city Other urban Rural Punjab Sindh NWFP Balochistan Total Percentage using a safe delivery kit 41.8 48.3 38.3 28.8 34.2 24.2 32.2 28.3 31.4 Percent distribution by what was used to tie the cord Unboiled thread 69.4 60.1 74.5 81.7 74.9 88.1 80.3 86.0 79.3 Boiled thread 18.0 18.3 17.8 11.6 16.2 8.2 10.4 5.7 12.9 Washed clamps 5.4 11.4 2.2 1.5 2.5 2.2 2.5 0.2 2.3 Unwashed clamps 1.9 3.7 1.0 0.6 1.1 0.2 1.1 0.3 0.8 Hair 1.1 1.5 0.8 1.1 1.2 0.4 1.5 0.8 1.1 Other 0.9 1.2 0.7 0.7 0.7 0.1 2.1 0.2 0.8 Don't know/missing 3.3 3.8 3.0 2.8 3.4 0.9 2.2 6.9 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Percent distribution by what was used to cut the cord New razor blade 47.9 36.2 54.2 58.0 41.5 89.2 51.0 85.8 56.0 Old razor blade 2.8 1.6 3.4 4.1 4.8 2.5 3.2 0.8 3.8 Scissors 40.8 51.5 35.1 24.7 39.4 5.5 26.1 5.3 27.9 Knife 3.4 5.2 2.4 7.9 7.8 1.4 13.9 1.4 7.0 Toka/chopper 0.2 0.0 0.2 0.6 0.6 0.0 1.0 0.0 0.5 Other 0.5 1.3 0.1 1.4 1.5 0.1 2.1 0.1 1.2 Don't know/missing 4.5 4.3 4.7 3.3 4.4 1.2 2.6 6.6 3.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 702 246 456 2,874 2,024 774 564 215 3,576 About four-fifths of the women (79 percent) who did not deliver in a health facility used unboiled thread to tie the cord. In rural settings, women are more likely to use unboiled thread (82 percent) than in urban settings (69 percent). Provincial differences are not large. The primary care of newborns includes the proper practice of cutting the umbilical cord. Traditionally, the cord is usually cut with a razor blade, knife, sickle, or even a piece of wood, none of which is generally sterile. In some cultures, the cord is not cut until the placenta is delivered, and it is cut only after cord pulsation stops upon delivery of the placenta (Save the Children/US, 2002). More than half of the women (56 percent) reported that a new razor blade was used to cut the cord, with 28 percent reporting use of scissors. The use of new razor blades is higher in rural areas (58 percent) than urban areas (48 percent). The percentages reporting use of a new razor blade are particularly high in Sindh and Balochistan provinces. Use of old razor blades, knives, and toka/choppers to cut the umbilical cord is not common. 9.2.5 Assistance during Delivery Assistance during delivery by medically trained birth attendants is considered to be effective in the reduction of maternal and neonatal mortality. Women who had a live birth in the five years preceding the survey were asked who assisted with the delivery. Interviewers recorded multiple responses if more than one person assisted during delivery; however, for the purpose of this tabulation, only the most qualified attendant was considered if there was more than one in attendance. Table 9.13 shows the type of assistance during delivery by selected background characteristics. Less than two-fifths (39 percent) of births take place with the assistance of a skilled medical provider (doctor, nurse, midwife, or Lady Health Visitor). Traditional birth attendants assist with more than half (52 percent) of deliveries, friends and relatives assist with 7 percent of deliveries, 116 | Reproductive Health and Lady Health Workers assist with less than 1 percent of deliveries. Only a tiny fraction of births take place without any assistance at all. Skilled health providers are more likely to attend births to mothers age 20-34 and first order births (41 percent and 54 percent, respectively) than mothers 35-49 years (29 percent) and births of higher birth order (25 percent). Births in urban areas are twice as likely to be assisted by a skilled health provider (60 percent) than births in rural areas (30 percent). Births in Sindh province are most likely to be attended by a skilled health provider (44 percent). Table 9.13 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, and percentage of births assisted by a skilled provider and percentage delivered by caesarean section, according to background characteristics, Pakistan 2006-07 Person providing assistance during delivery Background characteristic Doctor Nurse/ midwife/ Lady Health Visitor Dai/ TBA Lady Health Worker Hakim Relative/ friend No one Don't know/ missing Total Percentage delivered by a skilled provider1 Percentage delivered by caesarean section Number of births Mother's age at birth <20 32.3 6.4 53.5 0.2 0.0 6.3 0.3 1.0 100.0 38.8 6.7 963 20-34 34.8 5.7 50.5 0.5 0.1 6.8 0.6 1.0 100.0 40.5 7.8 6,984 35-49 23.3 5.5 55.4 0.7 0.0 11.8 1.7 1.5 100.0 28.8 5.0 1,175 Birth order 1 46.5 7.2 40.8 0.9 0.0 3.5 0.4 0.8 100.0 53.6 13.6 1,902 2-3 37.2 6.2 48.7 0.4 0.1 6.3 0.4 0.7 100.0 43.3 9.0 3,119 4-5 26.6 5.1 58.1 0.5 0.1 7.3 0.8 1.4 100.0 31.7 3.7 2,111 6+ 20.6 4.5 58.8 0.4 0.0 12.7 1.3 1.7 100.0 25.1 2.4 1,989 Place of delivery Health facility 88.7 9.0 1.4 0.6 0.0 0.1 0.1 0.0 100.0 97.7 21.3 3,125 Elsewhere 4.1 4.1 78.7 0.5 0.1 11.3 1.0 0.2 100.0 8.2 0.0 5,906 Residence Total urban 54.6 5.5 34.6 0.8 0.0 2.6 0.5 1.2 100.0 60.1 12.9 2,699 Major city 70.1 4.8 21.0 0.6 0.0 1.9 0.5 0.9 100.0 75.0 14.3 1,390 Other urban 38.1 6.2 49.0 1.1 0.1 3.4 0.6 1.5 100.0 44.4 11.5 1,310 Rural 24.0 5.9 58.5 0.4 0.1 9.3 0.8 1.0 100.0 29.8 4.9 6,422 Province Punjab 31.2 6.5 57.5 0.6 0.1 2.3 0.6 1.2 100.0 37.7 9.2 5,125 Sindh 40.6 3.8 48.5 0.3 0.0 5.2 0.3 1.1 100.0 44.4 6.5 2,284 NWFP 30.7 7.2 33.3 0.6 0.1 26.5 1.0 0.6 100.0 37.9 2.9 1,312 Balochistan 20.7 2.3 50.6 0.5 0.3 21.8 3.0 0.8 100.0 23.0 1.5 400 Mother's education No education 21.8 4.9 60.3 0.5 0.1 10.4 0.9 1.2 100.0 26.7 3.5 5,986 Primary 37.2 9.3 49.0 0.7 0.0 2.2 0.3 1.3 100.0 46.5 8.8 1,354 Middle 53.3 6.6 37.2 0.3 0.0 1.5 0.5 0.5 100.0 59.9 14.0 538 Secondary 70.3 4.7 22.3 1.0 0.0 0.9 0.1 0.8 100.0 74.9 18.8 722 Higher 79.0 7.0 12.0 0.2 0.2 0.7 0.3 0.5 100.0 86.0 24.2 522 Wealth quintile Lowest 12.9 3.1 70.1 0.4 0.1 11.4 0.6 1.3 100.0 16.1 1.8 2,153 Second 20.4 4.3 59.4 0.5 0.0 13.2 1.4 0.8 100.0 24.7 2.2 1,925 Middle 26.5 8.9 55.7 0.4 0.1 6.2 0.9 1.2 100.0 35.5 5.1 1,829 Fourth 44.3 7.8 42.4 1.0 0.0 2.8 0.3 1.4 100.0 52.1 10.7 1,651 Highest 72.1 5.2 20.6 0.5 0.0 0.8 0.2 0.7 100.0 77.3 20.1 1,563 Total 33.0 5.8 51.5 0.5 0.1 7.4 0.7 1.1 100.0 38.8 7.3 9,121 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. TBA = Traditional birth attendant (dai) 1 Skilled provider includes doctor, nurse, midwife, and Lady Health Visitor Reproductive Health | 117 There is a strong relationship between mother’s education and delivery by a skilled health provider. Births to highly educated women are more than three times more likely (86 percent) as births to uneducated mothers (27 percent) to receive assistance from a skilled health provider. Similarly, assistance during delivery by a skilled health provider varies by women’s economic status: births to women in the highest wealth quintile are much more likely to be assisted by a skilled health provider (77 percent) than births to women in the lowest wealth quintile (16 percent). Table 9.13 also shows that 7 percent of births are delivered by caesarean section. Delivery by caesarean section is highest among births to highly educated mothers (24 percent), births to mothers in the highest wealth quintile (20 percent), urban births (13 percent), and first births (14 percent). 9.3 POSTNATAL CARE Worldwide, a large proportion of maternal and neonatal deaths occurs during the 24 hours after delivery. In addition, the first two days following delivery are critical for monitoring complications arising from the delivery. A postnatal care visit is also an ideal time to educate a new mother on how to care for herself and her newborn. Safe motherhood programs emphasize the importance of postnatal care, recommending that all women receive at least two postnatal checkups and iron supplementation for 45 days after a delivery. To assess the extent of postnatal care utilization, mothers interviewed in the PDHS were asked whether they had received a health check after the delivery of their most recent birth in the five years preceding the survey, when they received the first checkup, and what type of health provider they saw for postnatal care. 9.3.1 Timing of First Postnatal Checkups Table 9.14 shows that in the five years preceding the survey, two-fifths (43 percent) of women received postnatal care for their last birth, making it far less common than prenatal care (65 percent). More than one-fourth of women received postnatal care within four hours of delivery, 6 percent received care within the first 4-23 hours, 7 percent of women received postnatal care two days after delivery, and 3 percent of women were seen 3-41 days after delivery. Almost three out of five women reported that they did not have any postnatal checkup. Differences by mother’s age, birth order, place of residence, wealth quintile, and education are pronounced. Older mothers (age 35-49 years), mothers of children of higher birth order, rural women, women in the two lowest wealth quintiles, and mothers with no education are much less likely to have a postnatal checkup. 118 | Reproductive Health Table 9.14 Timing of first postnatal checkup Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution of the mother's first postnatal checkup for the last live birth by time after delivery, according to background characteristics, Pakistan 2006-07 Timing after delivery of mother's first postnatal checkup Background characteristic Less than 4 hours 4-23 hours 2 days 3-41 days Don't know/ missing No checkup Total Number of women Mother's age at birth <20 24.8 6.2 4.5 2.7 0.9 60.9 100.0 460 20-34 28.2 6.4 7.3 2.7 1.1 54.3 100.0 4,303 35-49 19.8 4.2 5.8 1.8 1.2 67.3 100.0 915 Birth order 1 29.5 8.1 7.8 2.5 1.7 50.5 100.0 965 2-3 29.8 7.1 6.7 2.8 1.2 52.4 100.0 1,917 4-5 26.6 5.2 6.6 2.4 1.1 58.1 100.0 1,389 6+ 20.1 3.9 6.7 2.5 0.6 66.2 100.0 1,406 Residence Total urban 35.2 9.8 7.5 3.0 1.9 42.5 100.0 1,714 Major city 38.7 12.5 8.5 1.8 2.2 36.3 100.0 909 Other urban 31.2 6.8 6.4 4.5 1.6 49.5 100.0 806 Rural 22.8 4.4 6.6 2.4 0.7 63.1 100.0 3,962 Province Punjab 26.7 4.3 5.4 2.3 1.2 60.1 100.0 3,182 Sindh 35.4 12.0 9.8 2.2 0.6 40.0 100.0 1,404 NWFP 16.2 2.8 4.4 2.4 1.6 72.6 100.0 827 Balochistan 10.0 5.1 16.1 9.1 0.2 59.5 100.0 264 Education No education 20.8 4.5 6.5 2.2 0.8 65.2 100.0 3,668 Primary 29.7 5.0 9.5 3.2 1.4 51.1 100.0 854 Middle 39.3 10.3 5.2 2.2 0.7 42.3 100.0 353 Secondary 41.3 10.1 7.1 4.4 1.3 35.8 100.0 461 Higher 47.7 14.5 5.7 3.3 3.3 25.5 100.0 341 Wealth quintile Lowest 18.4 3.7 6.3 2.5 0.6 68.5 100.0 1,289 Second 19.0 4.5 5.7 1.6 0.0 69.2 100.0 1,194 Middle 25.3 4.2 7.4 2.5 1.1 59.6 100.0 1,099 Fourth 31.1 6.5 8.9 3.7 1.4 48.4 100.0 1,066 Highest 42.3 12.2 6.2 2.7 2.5 34.1 100.0 1,029 Total 26.6 6.0 6.8 2.6 1.1 56.9 100.0 5,677 Table 9.15 presents information on the type of postnatal care provider by mother’s background characteristics. Just over one-quarter of mothers (27 percent) received postnatal care from a skilled health provider, and 16 percent received care from a traditional birth attendant. Mothers of first order births, mothers with higher education, those from the wealthiest households, and those in urban areas are more likely to have received postnatal care from a skilled health provider. Reproductive Health | 119 Table 9.15 Type of provider of first postnatal checkup Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution by type of provider of the mother's first postnatal health check for the last live birth, according to background characteristics, Pakistan 2006-07 Type of health provider of mother's first postnatal checkup Background characteristic Doctor/ nurse/Lady Health Visitor Dai/ TBA LHW/ dispenser/ compounder/ other/ don’t know/ missing No checkup Total Number of women Mother's age at birth <20 23.4 15.3 0.3 60.9 100.0 460 20-34 29.0 16.1 0.7 54.3 100.0 4,303 35-49 17.7 13.5 1.5 67.3 100.0 915 Birth order 1 35.9 13.1 0.6 50.5 100.0 965 2-3 32.8 14.0 0.7 52.4 100.0 1,917 4-5 23.4 17.7 0.8 58.1 100.0 1,389 6+ 15.4 17.4 1.0 66.2 100.0 1,406 Residence Total urban 45.3 11.6 0.5 42.5 100.0 1,714 Major city 56.9 6.5 0.3 36.3 100.0 909 Other urban 32.2 17.5 0.8 49.5 100.0 806 Rural 18.7 17.3 0.9 63.1 100.0 3,962 Province Punjab 25.1 14.4 0.5 60.1 100.0 3,182 Sindh 37.1 21.4 1.5 40.0 100.0 1,404 NWFP 19.3 7.1 0.9 72.6 100.0 827 Balochistan 14.7 25.5 0.3 59.5 100.0 264 Education No education 16.4 17.4 1.0 65.2 100.0 3,668 Primary 31.5 16.9 0.5 51.1 100.0 854 Middle 43.3 14.0 0.3 42.3 100.0 353 Secondary 55.5 8.5 0.2 35.8 100.0 461 Higher 70.0 4.0 0.5 25.5 100.0 341 Wealth quintile Lowest 10.3 19.6 1.6 68.5 100.0 1,289 Second 13.7 16.6 0.4 69.2 100.0 1,194 Middle 22.2 17.6 0.6 59.6 100.0 1,099 Fourth 35.5 15.7 0.5 48.4 100.0 1,066 Highest 58.1 7.2 0.6 34.1 100.0 1,029 Total 26.7 15.6 0.8 56.9 100.0 5,677 9.3.2 Complications during Delivery and the Postnatal Period For the most recent births in the five years preceding the survey, the mother was asked if she experienced any of the following complications during delivery and/or the postnatal period: severe headaches, blurred vision, swelling of hands and face, high fever, convulsions, prolonged labour, baby’s feet came first (breech birth), placenta came first (placenta praevia), continuous urine dribbling, bad vaginal discharge, inability to control bowel motions, and heavy vaginal bleeding. As shown in Table 9.16, the most common complications during delivery and the postnatal period are severe headaches (37 percent), followed by high fever (26 percent), blurred vision (21 percent), and prolonged labour (17 percent). One out of ten women reported swelling of hands, swelling of face, and bad smelling vaginal discharge. Eight percent of women reported heavy vaginal bleeding. Inability to control bowel motions, fits or convulsions, urinary incontinence, breech birth, and placenta praevia are less common complications. 120 | Reproductive Health Table 9.16 Complications during delivery and postnatal period Among women who had a live birth in the five years preceding the survey, percentage who had specific problems during the delivery or the 40-day period after delivery of the most recent live birth, according to background characteristics, Pakistan 2006-07 Percentage who experienced: Background characteristic Severe head- aches Blurred vision Swel- ling of hands Swel- ling of face High fever Fits/ con- vul- sions Labour for more than 12 hours Baby's feet came first Pla- centa came first Con- tinuous urine drib- bling Bad- smelling vaginal dis- charge Inability to control bowel motions1 Heavy vaginal bleed- ing Any prob- lem Any severe prob- lem1 Number of women Mother's age at birth <20 30.8 17.9 5.5 5.0 23.9 2.5 20.7 3.1 0.9 3.5 8.6 1.8 10.3 53.8 19.6 460 20-34 36.3 19.6 9.9 9.4 25.8 3.3 16.7 2.0 1.0 3.9 9.7 4.1 7.7 57.1 18.6 4,303 35-49 40.8 26.9 12.3 12.4 30.3 4.8 16.6 1.9 0.6 5.2 10.8 4.8 7.2 57.4 19.5 915 Birth order 1 31.6 17.0 8.6 7.6 21.6 2.9 19.5 1.5 0.6 3.8 8.3 3.5 9.2 55.4 18.0 965 2-3 32.6 17.0 9.1 8.4 22.9 2.9 15.9 2.3 0.9 3.3 9.9 3.9 6.5 54.7 16.5 1,917 4-5 39.3 22.0 10.0 10.2 28.4 3.3 16.8 2.0 0.9 4.6 9.8 4.4 7.2 57.8 19.0 1,389 6+ 42.6 26.7 12.0 11.7 32.5 4.8 17.0 2.2 1.2 5.0 10.7 4.3 9.3 59.9 22.2 1,406 Residence Total urban 34.1 19.0 10.3 9.3 23.5 2.7 17.1 2.4 1.3 4.8 10.9 3.8 8.8 56.6 17.4 1,714 Major city 32.9 17.5 11.4 8.8 20.1 2.5 16.5 2.4 1.7 6.3 13.3 3.7 9.3 55.9 17.4 909 Other urban 35.4 20.7 9.1 9.8 27.3 3.0 17.8 2.5 0.9 3.2 8.1 4.0 8.3 57.4 17.3 806 Rural 37.6 21.3 9.8 9.6 27.7 3.8 16.9 1.9 0.8 3.8 9.3 4.1 7.4 57.0 19.4 3,962 Province Punjab 28.5 16.7 7.8 8.1 20.7 3.2 13.9 1.7 0.7 4.3 8.4 6.0 5.0 48.1 14.9 3,182 Sindh 49.4 24.1 14.1 12.9 41.0 4.2 20.1 2.5 1.5 5.3 15.6 1.9 13.9 71.6 25.2 1,404 NWFP 39.1 24.8 9.4 8.8 23.2 2.0 14.9 2.2 1.0 2.1 6.4 1.3 7.9 56.8 21.3 827 Balochistan 57.2 35.8 15.1 11.6 27.3 7.9 44.8 3.2 0.6 2.6 5.9 0.7 9.0 84.0 23.7 264 Education No education 39.8 23.0 10.8 10.6 29.3 4.4 18.1 2.2 0.9 4.1 10.0 4.0 8.2 58.8 19.9 3,668 Primary 35.4 20.4 8.7 8.9 24.7 2.7 15.9 2.6 1.4 4.9 9.4 5.4 6.1 57.1 19.5 854 Middle 31.1 15.1 8.5 6.7 21.4 1.5 19.0 0.9 0.7 4.7 10.4 5.4 7.8 54.5 15.4 353 Secondary 27.3 12.9 7.3 6.9 18.1 0.5 11.9 1.3 0.8 3.0 9.5 2.0 8.5 48.7 14.2 461 Higher 22.8 11.8 8.6 6.0 16.2 1.7 13.0 1.5 0.3 3.4 7.9 2.2 7.6 49.3 15.0 341 Wealth quintile Lowest 40.6 22.0 12.0 11.3 33.7 6.1 17.9 2.3 0.3 4.1 10.0 3.6 8.0 60.0 22.0 1,289 Second 40.4 23.9 10.6 11.1 28.6 3.9 17.9 2.2 0.5 3.8 9.4 4.6 7.6 60.2 21.3 1,194 Middle 37.6 24.2 8.5 9.7 26.4 3.0 18.7 2.1 1.3 4.8 10.4 5.3 7.0 56.9 18.1 1,099 Fourth 33.6 17.6 8.6 7.4 24.1 2.1 17.0 2.7 1.6 4.3 9.0 4.0 8.3 55.9 17.5 1,066 Highest 28.9 14.5 9.5 7.5 17.0 1.5 13.0 0.8 1.1 3.6 10.1 2.6 8.3 50.1 14.0 1,029 Total 36.6 20.6 9.9 9.5 26.4 3.5 17.0 2.1 0.9 4.1 9.8 4.0 7.8 56.9 18.8 5,677 1 Refers to the question as to whether any of the problems were “so severe you thought you might die” About three in five women (57 percent) reported any problem during delivery and the postnatal period, and about one in five women reported any severe problem. The prevalence of any severe problem is surprisingly rather uniform across background characteristics. 9.3.3 Fistula One of the most serious injuries of childbearing is obstetric fistula, a hole in the vagina or rectum usually caused by prolonged labour without treatment. In such cases, the baby usually dies. Because the fistula leaves women leaking urine or faeces or both, it typically results in social isolation, depression, and poverty. Left untreated, fistula can lead to chronic medical problems (UNFPA, 2005). Reproductive Health | 121 122 | Reproductive Health Table 9.17 shows that only 3 percent of ever-married women who have ever given birth have experienced the most common symptom of fistula, the constant dribbling of urine. Less than half a percent of ever-married women reported leaking stool from the vagina. There are no meaningful differences by background characteristics. Table 9.17 Fistula Percent distribution of ever-married women 15-49 who have ever given birth by whether they have ever experienced symptoms of fistula, Pakistan 2006-07 Background characteristic Dribbling of urine Stool from vagina Both urine dribbling and stool from vagina Neither Don't know/ missing Total Number of women Residence Total urban 2.4 0.3 0.2 95.8 1.3 100.0 2,981 Major city 2.5 0.5 0.3 96.0 0.7 100.0 1,684 Other urban 2.2 0.1 0.1 95.4 2.2 100.0 1,297 Rural 2.8 0.2 0.1 95.5 1.4 100.0 5,819 Province Punjab 3.4 0.2 0.2 94.9 1.4 100.0 5,118 Sindh 1.7 0.4 0.0 97.4 0.5 100.0 2,102 NWFP 1.8 0.2 0.3 96.8 0.9 100.0 1,184 Balochistan 1.0 0.0 0.0 92.3 6.7 100.0 395 Education No education 2.7 0.2 0.2 95.3 1.6 100.0 5,830 Primary 3.3 0.4 0.2 95.3 0.8 100.0 1,241 Middle 2.6 0.5 0.0 95.5 1.4 100.0 520 Secondary 1.7 0.1 0.0 97.6 0.6 100.0 683 Higher 2.2 0.0 0.0 96.9 1.0 100.0 526 Wealth quintile Lowest 2.5 0.1 0.1 95.0 2.3 100.0 1,706 Second 2.6 0.3 0.2 95.7 1.2 100.0 1,743 Middle 3.2 0.4 0.0 94.7 1.6 100.0 1,720 Fourth 2.8 0.3 0.1 95.7 1.2 100.0 1,811 Highest 2.2 0.2 0.2 96.8 0.5 100.0 1,819 Total 2.7 0.2 0.1 95.6 1.4 100.0 8,800 CHILD HEALTH 10 Arshad Mahmood and Mehboob Sultan This chapter examines information from the 2006-07 Pakistan Demographic and Health Survey (PDHS) on the health status of children under the age of five. The analysis is based on the responses of mothers on the birth weights and level of immunization among children, as well as the prevalence and treatment of the common childhood illnesses diarrhoea, acute respiratory infection (ARI), and fever. Data for birth weights were taken for all live births in the five years preceding the survey, but data for immunization and illness were taken only for surviving children. The analysis will help policymakers in planning appropriate strategies to improve child health. 10.1 BIRTH WEIGHT Low birth weight has long been used as an important public health indicator. Babies whose birth weight is low not only have lower chances of survival but also face higher risk of morbidity and mortality (Mahmood, 2001). In Pakistan, a large proportion of births occur at home and it is difficult to obtain the birth weight of these babies. Results from the 2006-07 PDHS show that mothers reported a birth weight for only one in ten births. This proportion has not changed much since the 1990-91 PDHS when birth weight was reported for only 8 percent of births (NIPS and Macro, 1992). Mothers who did not report a birth weight were asked to report the size of the child at birth; responses were categorized as “very small,” “smaller than average,” and “average or larger.” Table 10.1 shows significant differentials in reporting the birth weight by mothers’ socioeconomic characteristics. It shows that more than half of the mothers (51 percent) with higher education reported birth weight, compared with a very small proportion (4 percent) of mothers with no education. Moreover, mothers in the highest wealth quintile also reported a higher proportion of birth weights, compared with mothers in the lowest wealth quintile (32 and 3 percent, respectively). One of the goals of the Declaration and Plan of Action adopted at the United Nations General Assembly Special Session on Children in 2002 was to reduce the incidence of low birth weight babies by at least one-third between 2000 and 2010. The reduction in low birth weight also forms an important contribution to the Millennium Development Goal for reducing child mortality (UNICEF, 2004). Table 10.1 shows separately the distribution by birth weight among births for which the mother reported a birth weight, as well as the distribution of all births by the child’s size at birth. Overall, among those few for whom a birth weight was reported, 26 percent were low birth weight (less than 2.5 kg), compared with 31 percent who were reported to be small or very small at birth. Contrary to expectations, the prevalence of births reported by the mother to be very small or smaller than average in the 1990-91 PDHS (22 percent) has increased to 31 percent in 2006-07. This implies that it would be very difficult for the Government of Pakistan to achieve the targets for improving low birth weight set for 2010. Low birth weight is also associated with age of the mother and birth order. The analysis shows that a higher proportion of low birth weight babies are born to mothers younger than 20 years and older than 35 years age than to mothers aged 20-34. First births and births of sixth and higher birth orders are also reported to have higher proportions with low birth weights compared with second to fifth births. Mother’s education and wealth quintile are strongly associated with low birth weight babies. Table 10.1 shows that 12 percent of the babies born to mothers with no education were reported to be very small at birth compared with 6 percent of the births to mothers with higher education. Similarly, 12 percent of babies born to mothers in the lowest wealth quintile are of very small size compared with 7 percent of those born to mothers in the highest wealth quintile. Child Health | 123 Table 10.1 Child's weight and size at birth Percent distribution of live births with a reported birth weight in the five years preceding the survey by birth weight. percent distribution of all live births in the five years preceding the survey by mother's estimate of baby's size at birth, and percentage of all births with a reported birth weight, according to background characteristics, Pakistan 2006-07 Percent- age of all births with a reported birth weight Percent distribution of births with a reported birth weight1 Percent distribution of all live births by size of child at birth Background characteristic Less than 2.5 kg 2.5 kg or more Total Number of births Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 39.2 60.8 100.0 68 7.1 14.0 22.2 62.9 0.9 100.0 963 20-34 24.2 75.8 100.0 781 11.2 10.6 19.5 68.7 1.2 100.0 6,984 35-49 28.3 71.7 100.0 72 6.1 12.0 20.8 65.6 1.6 100.0 1,175 Birth order 1 27.6 72.4 100.0 271 14.3 13.5 20.3 65.3 0.9 100.0 1,902 2-3 23.8 76.2 100.0 388 12.5 9.7 19.0 70.4 0.8 100.0 3,119 4-5 24.2 75.8 100.0 171 8.1 10.1 20.6 67.7 1.6 100.0 2,111 6+ 30.3 69.7 100.0 91 4.6 12.1 20.4 65.8 1.7 100.0 1,989 Residence Total urban 23.2 76.8 100.0 591 21.9 9.1 19.9 69.3 1.6 100.0 2,699 Major city 19.5 80.5 100.0 436 31.4 8.4 18.3 72.3 1.0 100.0 1,390 Other urban 33.6 66.4 100.0 155 11.8 9.9 21.7 66.1 2.3 100.0 1,310 Rural 30.0 70.0 100.0 330 5.1 12.0 20.0 67.1 1.0 100.0 6,422 Province Punjab 24.1 75.9 100.0 483 9.4 9.3 18.2 71.1 1.4 100.0 5,125 Sindh 27.4 72.6 100.0 376 16.5 11.7 24.4 62.9 1.0 100.0 2,284 NWFP 27.4 72.6 100.0 59 4.5 16.1 16.9 66.1 0.9 100.0 1,312 Balochistan * * 100.0 3 0.8 14.4 26.5 57.5 1.6 100.0 400 Mother's education No education 32.9 67.1 100.0 262 4.4 12.4 20.8 65.5 1.2 100.0 5,986 Primary 38.5 61.5 100.0 122 9.0 10.7 20.3 67.5 1.5 100.0 1,354 Middle 18.6 81.4 100.0 69 12.8 8.5 17.5 73.2 0.7 100.0 538 Secondary 25.0 75.0 100.0 200 27.7 7.1 15.7 76.0 1.2 100.0 722 Higher 14.9 85.1 100.0 268 51.3 5.6 17.4 76.2 0.8 100.0 522 Wealth quintile Lowest (30.9) (69.1) 100.0 54 2.5 12.4 23.4 63.1 1.1 100.0 2,153 Second 37.8 62.2 100.0 73 3.8 12.9 19.9 66.4 0.8 100.0 1,925 Middle 34.3 65.7 100.0 149 8.2 11.8 19.9 66.8 1.5 100.0 1,829 Fourth 25.3 74.7 100.0 151 9.1 10.1 18.2 69.9 1.8 100.0 1,651 Highest 20.7 79.3 100.0 494 31.6 7.4 17.1 74.6 0.9 100.0 1,563 Total 25.6 74.4 100.0 921 10.1 11.1 20.0 67.7 1.2 100.0 9,121 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Based on either a written record or the mother's recall 10.2 CHILD IMMUNIZATION The Pakistan Expanded Programme on Immunization (EPI) follows the international guidelines recommended by the World Health Organization (WHO). The guidelines recommend that all children receive a BCG vaccination against tuberculosis; three doses of DPT vaccine for the prevention of diphtheria, pertussis (whooping cough), and tetanus; three doses of polio vaccine; and a vaccination against measles during the first year of the child’s life. These vaccinations are recorded on a health card given to the parents. In addition to these standard immunizations, Pakistan’s EPI programme recommends that children also receive three doses of the hepatitis vaccine. In addition to 124 | Child Health the programme of routine immunizations, since 1994 Pakistan has also conducted a number of special national immunization days (NID) in the effort to eradicate polio. According to the EPI programme, approximately 5.1 million children are given immunization services every year. Morbidity and mortality are significantly reduced due to the immunization programme in Pakistan. It is estimated that more than 100,000 deaths due to measles, 70,000 cases of neonatal tetanus, and 20,000 paralytic cases of poliomyelitis are being prevented each year in Pakistan due to these vaccinations (NIH, 2008). In the PDHS, mothers were asked to show the interviewer the health cards of all children under the age of five. The interviewer copied from the card the date each vaccine was received. If a child never received a health card or if the mother was unable to show the card to the interviewer, the mother was asked to recall whether the child had received BCG, polio, DPT (including the number of doses for polio and DPT), and measles vaccinations. 10.2.1 Vaccination Coverage Information on vaccination coverage is presented in Table 10.2 according to the source of information used to determine coverage, i.e., the vaccination card or mother’s report. Data are presented for children age 12-23 months, thereby including only those children who have reached the age by which they should be fully vaccinated. This indicator shows the proportion of children aged 12-23 months who had been vaccinated. Mothers were able to produce health cards for 24 percent of these children. Another survey reported availability of cards for only 11 percent of children (MOH, 2006), whereas the 2005-06 Pakistan Social and Living Standards Measurement Survey (PSLM) shows availability of cards for an exceptionally high proportion (49 percent) of children in Pakistan (Federal Bureau of Statistics, 2007c). Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Pakistan 2006-07 All basic vacci- nations2 No vacci- nations Number of children Source of information Measles DPT Polio Hepatitis B BCG 1 2 3 01 1 2 3 1 2 3 Vaccinated at any time before survey Vaccination card 23.6 23.3 22.0 20.9 19.3 23.4 22.0 21.0 23.1 21.9 20.8 19.2 18.2 0.0 361 Mother's report 56.8 51.5 44.5 37.5 37.0 69.7 68.6 62.1 48.0 42.1 36.5 40.7 29.1 6.0 1,160 Either source 80.3 74.8 66.5 58.5 56.3 93.0 90.6 83.1 71.0 64.0 57.3 59.9 47.3 6.0 1,522 Vaccinated by 12 months of age3 77.6 71.7 63.9 56.1 56.0 89.1 86.5 78.6 68.2 61.3 54.5 50.2 39.2 9.1 1,522 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth and hepatitis) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. According to information from the vaccination records and mothers’ recall, 80 percent of the children aged 12-23 months have received a BCG vaccination, 75 percent have received the first dose of DPT, and 93 percent have received at least one dose of polio. Figure 10.1 shows that the coverage decreases for subsequent doses of DPT and polio. Only 59 and 83 percent of children receive the third doses of DPT and polio, respectively. Dropout rates between the first and third doses of DPT and of polio are thus 22 and 11 percent, respectively.1 The findings show that 60 percent of children aged 12-23 months have received measles vaccination and 6 percent have not received any vaccinations at all. 1 The dropout rate is the proportion of those receiving the first dose who receive the second and third doses. Child Health | 125 Overall, 47 percent of children 12-23 months are fully vaccinated according to the 2006-07 PDHS. This compares to a level of 57 percent for the 2006 Ministry of Health (MOH) survey and 71 percent in the 2005-06 PSLM. Figure 10.1 Percentage of Children 12-23 Months Who Received Specific Vaccines Any Time Before Survey 80 75 67 59 56 93 91 83 71 64 57 60 47 6 BCG DPT 1 2 3 POLIO 0 1 2 3 HEPATITIS 1 2 3 MEASLES ALL NONE 0 20 40 60 80 Percent PDHS 2006-07 100 As mentioned earlier, the Government of Pakistan expanded the immunization programme to include three doses of hepatitis B vaccine. These vaccinations should also be given before the child reaches one year of age. Immunization coverage for hepatitis B is presented in Table 10.2 and is based on vaccination cards and mothers’ reports. Although hepatitis B vaccination was recently initiated, 71 percent of children aged 12-23 have received at least one dose of the vaccine and 57 percent have completed the three-dose series.2 10.2.2 Differentials in Vaccination Coverage According to the data shown in Table 10.3 and Figure 10.2, girls are less likely than boys to have been fully immunized against the six preventable childhood diseases (44 and 50 percent, respectively). Since the national immunization programme does not discriminate by gender in service delivery, these differences are presumably due to parental discrimination in favour of boys. In addition, immunization coverage also varies across background characteristics of children. For example, the percentage of children who have been fully immunized decreases with increasing birth order, ranging from 52 percent for the first born to 42 percent for the sixth or higher children. Table 10.3 shows that children in urban areas are more likely than rural children to have completed the vaccination schedule (54 percent and 44 percent, respectively). Immunization coverage varies substantially across provinces. Provinces with the highest coverage are Punjab (53 percent) and North West Frontier Province (NWFP) (47 percent); Sindh (37 percent) and Balochistan (35 percent) have considerably lower levels of full immunization coverage. Table 10.3 also shows that in Balochistan more than one-quarter (29 percent) of the children do not 2 Note that hepatitis B vaccination was not included in the “all basic vaccination” category. 126 | Child Health have any vaccinations at all compared with less than 4 percent in Punjab. Health card coverage also varies across provinces, ranging from 11 percent in Balochistan to 34 percent in NWFP. Similarly, children whose mothers have had no education are less likely to have been fully immunized against the six preventable childhood diseases than children whose mothers have had higher education (38 percent and 71 percent, respectively). The percentage of children who are fully vaccinated varies widely by wealth quintile. Children whose mothers are in the lowest wealth quintile are far less likely to be fully immunized than children of the highest socioeconomic status (26 percent and 64 percent, respectively). Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Pakistan 2006-07 Measles All basic vaccina- tions2 No vaccina- tions Percent- age with a vaccina- tion card seen Number of children Background characteristic DPT Polio Hepatitis B BCG 1 2 3 01 1 2 3 1 2 3 Sex Male 82.2 77.2 70.1 61.3 59.4 93.4 91.2 84.4 73.9 67.4 59.8 63.1 49.8 5.1 23.9 816 Female 78.2 72.0 62.2 55.2 52.8 92.6 90.0 81.5 67.7 60.1 54.4 56.1 44.3 7.1 23.6 706 Birth order 1 83.6 81.3 71.2 62.7 58.5 93.2 90.5 82.9 75.8 69.4 61.9 65.1 52.1 5.8 29.1 324 2-3 82.9 77.5 69.8 63.2 60.3 92.5 90.4 83.3 75.3 67.5 62.2 64.7 51.8 5.7 27.7 524 4-5 78.2 72.0 64.6 55.9 53.3 92.9 90.0 79.5 67.6 60.0 53.4 54.0 41.2 6.8 20.3 334 6+ 75.4 67.1 58.8 49.7 51.0 93.8 91.8 86.5 63.3 57.4 49.2 53.3 41.7 5.8 15.9 340 Residence Total urban 89.3 83.6 77.1 68.4 61.5 93.5 91.4 81.8 80.5 74.8 67.2 68.8 54.2 5.6 26.3 484 Major city 90.9 82.5 75.1 70.5 63.4 94.4 92.0 82.3 78.0 72.5 68.5 68.8 53.9 4.7 29.5 266 Other urban 87.3 84.9 79.5 65.8 59.2 92.4 90.7 81.3 83.5 77.6 65.7 68.8 54.6 6.8 22.3 218 Rural 76.2 70.7 61.5 53.8 53.9 92.8 90.3 83.7 66.6 59.0 52.7 55.7 44.0 6.2 22.6 1,038 Province Punjab 85.5 80.9 72.3 64.5 58.6 95.5 93.4 84.6 76.9 69.4 63.6 65.1 52.6 3.8 23.8 865 Sindh 76.7 67.3 56.4 47.6 51.2 92.2 89.9 84.1 61.3 53.4 45.2 50.7 37.0 6.3 19.7 373 NWFP 71.1 67.5 62.4 56.4 62.6 91.3 87.9 81.0 67.1 62.3 56.3 56.6 46.9 7.5 33.9 222 Balochistan 63.0 60.8 60.0 46.7 32.5 69.2 66.3 62.9 60.9 58.8 46.3 54.0 35.2 28.9 10.6 61 Mother's education No education 73.7 65.8 56.1 47.5 49.5 90.9 88.3 79.9 61.9 53.7 46.1 50.6 37.5 8.0 19.0 947 Primary 87.5 83.4 75.0 65.3 56.5 96.1 94.0 87.5 76.6 69.5 64.0 66.4 53.5 2.3 26.5 231 Middle 90.1 91.1 88.3 81.0 73.3 96.3 93.9 87.6 88.5 86.4 81.4 77.4 68.8 3.7 40.1 114 Secondary 97.2 94.5 86.9 83.5 78.4 98.4 96.8 90.9 95.7 90.0 84.1 83.0 70.0 1.2 33.1 133 Higher 94.1 95.9 94.6 88.8 72.7 95.9 93.6 87.8 92.2 89.8 86.4 83.3 71.1 4.1 31.7 95 Wealth quintile Lowest 61.9 52.6 41.3 34.8 38.9 87.3 84.2 78.2 50.2 39.9 33.5 36.3 25.9 11.2 12.5 314 Second 73.3 68.9 59.7 47.6 47.5 92.0 90.2 81.2 65.4 56.5 45.7 50.5 40.0 7.3 19.6 332 Middle 85.4 80.5 71.8 62.9 58.0 96.0 92.5 86.7 74.7 67.7 62.5 65.3 51.7 2.8 26.3 291 Fourth 91.7 85.9 78.8 72.5 66.5 95.1 94.0 85.0 80.7 76.5 70.6 74.9 58.0 4.3 26.4 308 Highest 91.8 88.6 83.8 78.0 73.4 95.3 92.9 84.9 86.8 82.5 78.0 75.5 63.7 3.8 35.9 277 Total 80.3 74.8 66.5 58.5 56.3 93.0 90.6 83.1 71.0 64.0 57.3 59.9 47.3 6.0 23.7 1,522 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth and hepatitis) Child Health | 127 Figure 10.2 Percentage of Children Age 12-23 Months Who Are Fully Immunized, by Background Characteristics 50 44 53 37 47 35 38 54 69 70 71 26 40 52 58 64 47 SEX Male Female PROVINCE Punjab Sindh NWFP Balochistan MOTHER'S EDUCATION No education Primary Middle Secondary Higher WEALTH QUINTILE Lowest Second Middle Fourth Highest TOTAL 0 20 40 60 Percent PDHS 2006-07 80 10.2.3 Trends in Vaccination Coverage Table 10.4 provides data on childhood vaccination coverage from various surveys conducted in Pakistan in the past two decades. The data imply that there has been a steady upward trend in the proportion of children who are fully immunized from 1990-91 to 2004-05, followed by a dramatic decline in 2006-07. However, a closer inspection shows some anomalies in the data from previous surveys. For example, the 2001-02 Pakistan Integrated Household Survey shows a far higher proportion of children as receiving the second dose of polio as received the first dose (91 percent receiving polio 2 versus 68 percent receiving polio 1), which is clearly impossible. The 2004-05 PSLM shows that 77 percent of children are fully immunized; however, the data show almost no dropout between the first and third doses of vaccines, a somewhat implausible finding. A similar pattern is found in the 2005-06 PSLM although the complete immunization rate has come down to 71 percent in one year (data not shown). Comparison with the 2006 EPI survey shows considerably lower levels of children fully immunized in the PDHS, mostly due to lower proportions of children with DPT2, DPT3, and measles vaccines in the PDHS; the proportions with polio are higher in the PDHS than the EPI survey for each of the three doses. These differences are likely due to the different survey methodologies and in particular to the differences in the questionnaire design.3 Table 10.4 Trends in vaccination coverage Percentage of children age 12-23 months who received specific vaccines, Pakistan Survey Measles All vaccina- tions DPT Polio BCG 1 2 3 1 2 3 PDHS (1990-91) 69.7 64.1 60.0 42.7 64.8 60.5 42.9 50.2 35.1 PIHS (1995-96) 73.0 73.0 64.0 58.0 71.0 65.0 58.0 47.0 45.0 PIHS (1996-97) 76.0 76.0 70.0 63.0 80.0 76.0 67.0 49.0 49.0 PIHS (1998-99) 65.0 67.0 63.0 58.0 77.0 76.0 70.0 55.0 49.0 PIHS (2001-02) 67.0 71.0 67.0 63.0 68.0 91.0 89.0 57.0 53.0 PSLM (2004-05) 82.0 82.0 81.0 80.0 82.0 81.0 81.0 78.0 77.0 EPI (2006) 77.7 74.6 69.3 64.5 73.7 68.9 64.4 62.6 56.8 PDHS (2006-07) 80.3 74.8 66.5 58.5 93.0 90.6 83.1 59.9 47.3 Sources: NIPS and Macro, 1992; Federal Bureau of Statistics, 2007c; MOH 2006 PIHS = Pakistan Integrated Household Survey PSLM = Pakistan Social and Living Standards Measurement Survey 3 The 2006-07 PDHS used the standard DHS immunization questions. 128 | Child Health 10.3 CHILDHOOD DISEASES Aside from neonatal disorders, diarrhoea, pneumonia, and malaria are the major causes of death of children under five worldwide (Black et al., 2003). Among those most vulnerable are children with low birth weight or those whose immune systems have been weakened by malnutrition or other diseases. In the PDHS, mothers of children under five were asked if these children had symptoms associated with acute respiratory illness (ARI), fever, and/or diarrhoea in the two weeks before the survey. Information on contact with health providers and treatment practices helps assess national programmes aimed at reducing the impact of these three diseases. The extent of treatment with oral rehydration therapy or increased fluids reflects the success of programmes that encourage these behaviours. 10.3.1 Prevalence and Treatment of ARI ARI or pneumonia is a common cause of morbidity and death among children under five years of age. Pneumonia is characterized by cough with difficult or rapid breathing and chest indrawing. For severe pneumonia, hospitalization is recommended; otherwise, ambulatory treatment with antibiotics is recommended. Early diagnosis and treatment with antibiotics can prevent many deaths caused by acute lower respiratory infection. Without early treatment for ARI, children can die very rapidly. Many deaths are the result of failure to take the child to a health facility in time. Table 10.5 indicates that 14 percent of children under age five had symptoms of ARI in the two weeks preceding the survey. Differences by age group in ARI prevalence are not large (Figure 10.3). Prevalence of ARI varies only slightly by the child’s sex and place of residence. Variations by education and wealth quintile are small, except that children whose mothers have higher than secondary education are less likely to have had ARI. Table 10.5 shows that 69 percent of children who showed symptoms of ARI were taken to a health facility or medical provider for treatment. It also shows that treatment-seeking behaviour varies only slightly according to the child’s sex. Figure 10.4 illustrates the variation by age of child in the proportion of children taken to a health facility. It shows that children aged 6-11 months are the most likely to be taken for treatment for ARI. Children in urban areas are more likely than those in rural areas to be taken for treatment when they have ARI. Half of children with ARI received antibiotics. This proportion does not vary much except that it increases as education of the mother and household wealth increases. Child Health | 129 Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, and among children with symptoms of ARI, the percentage who received specific treatment, according to background characteristics, Pakistan 2006-07 Children under age five with symptoms of ARI Background characteristic Children under age five Percentage for whom treatment was sought from a health facility or provider2 Percentage who received antibiotics Number of children Percentage with symptoms of ARI1 Number of children Age in months <6 12.0 962 73.2 50.0 116 6-11 19.0 820 75.4 56.1 156 12-23 16.6 1,522 73.7 53.6 253 24-35 15.1 1,668 69.6 46.2 252 36-47 12.9 1,826 62.1 48.0 236 48-59 10.4 1,570 63.8 49.3 164 Sex Male 15.1 4,371 70.2 52.8 661 Female 12.9 3,996 68.1 47.1 517 Cooking fuel Electricity or gas 14.3 2,437 82.1 60.3 350 Charcoal 20.9 56 * * 12 Wood/straw3 13.6 5,261 65.1 45.4 718 Animal dung 16.3 606 50.6 53.1 99 Residence Total urban 12.8 2,518 80.4 54.9 323 Major city 12.0 1,307 87.0 56.5 157 Other urban 13.7 1,212 74.2 53.4 166 Rural 14.6 5,849 65.1 48.5 854 Province Punjab 13.0 4,689 70.9 59.1 611 Sindh 17.0 2,085 78.0 41.1 354 NWFP 16.5 1,221 49.8 40.6 202 Balochistan 3.1 373 (56.1) (35.3) 11 Mother's education No education 14.3 5,425 63.8 47.3 778 Primary 15.3 1,261 77.6 54.8 193 Middle 12.3 506 80.1 50.0 62 Secondary 14.7 681 80.7 65.5 100 Higher 8.9 494 (89.0) (47.8) 44 Wealth quintile Lowest 14.7 1,920 58.0 39.8 281 Second 14.4 1,742 64.4 46.9 250 Middle 13.0 1,673 66.2 55.0 217 Fourth 15.2 1,559 77.6 52.4 237 Highest 13.0 1,473 85.7 62.0 192 Total 14.1 8,367 69.3 50.3 1,178 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Symptoms of ARI (cough accompanied by short, rapid breathing that was chest-related) are considered, i.e., symptoms of ARI are considered a proxy for pneumonia. 2 Excludes pharmacy, shop, homeopath, dispenser, compounder, hakim, Dai/TBA 3 Includes grass, shrubs, crop residues 130 | Child Health Figure 10.3 Prevalence of Acute Respiratory Infection (ARI) and Fever in the Two Weeks Prior to Survey by Age of Child � � � � � � � � � � � � <06 6-11 12-23 24-35 36-47 48-59 Age of child 0 10 20 30 40 50 Percent ARI Fever� � PDHS 2006-07 <6 Figure 10.4 Percentage of Children with Acute Respiratory Infection and Fever Taken to Health Facility � � � � � � � � � � � � <06 6-11 12-23 24-35 36-47 48-59 Age of child 0 20 40 60 80 100 Percent ARI Fever� � PDHS 2006-07 <6 10.3.2 Prevalence and Treatment of Fever Almost one-third of children under five were reported to have had a fever in the two weeks preceding the survey (Table 10.6). Similar patterns were observed for prevalence of fever as for ARI among children under five years; however, the level of fever is much higher (31 percent). Child Health | 131 Table 10.6 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage of children for whom treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who took antibiotic drugs, by background characteristics, Pakistan 2006-07 Children under age five with fever Background characteristic Among children under age five: Percentage for whom treatment was sought from a health facility or provider1 Percentage who took antimalarial drug Percentage who took antibiotic drug Number of children Percentage with fever Number of children Age in months <6 27.1 962 65.2 3.6 46.6 261 6-11 41.9 820 70.4 4.3 46.3 344 12-23 39.3 1,522 69.0 3.1 51.6 598 24-35 30.9 1,668 64.7 3.6 48.4 515 36-47 27.1 1,826 63.0 4.0 47.4 494 48-59 22.7 1,570 61.7 1.3 48.1 357 Sex Male 32.0 4,371 67.0 3.5 50.6 1,397 Female 29.3 3,996 64.3 3.2 45.9 1,171 Residence Total urban 31.4 2,518 75.5 2.5 52.3 791 Major city 33.8 1,307 77.4 1.3 53.0 441 Other urban 28.9 1,212 73.2 4.0 51.4 350 Rural 30.4 5,849 61.4 3.7 46.7 1,777 Province Punjab 30.3 4,689 65.6 2.0 53.7 1,418 Sindh 35.0 2,085 75.0 4.6 42.1 730 NWFP 30.3 1,221 50.4 4.1 44.2 370 Balochistan 13.4 373 49.1 16.7 24.5 50 Mother's education No education 29.8 5,425 61.2 3.6 46.4 1,617 Primary 33.5 1,261 72.4 2.2 52.0 422 Middle 34.9 506 69.6 3.4 54.6 177 Secondary 31.0 681 69.9 4.7 50.1 211 Higher 28.6 494 87.1 2.0 51.6 141 Wealth quintile Lowest 29.9 1,920 55.7 4.1 40.2 573 Second 28.8 1,742 60.4 4.4 44.6 503 Middle 28.9 1,673 61.5 1.5 50.9 484 Fourth 33.3 1,559 77.0 3.8 51.8 519 Highest 33.2 1,473 75.3 2.7 56.1 490 Total 30.7 8,367 65.8 3.3 48.4 2,569 1 Excludes pharmacy, shop, homeopath, dispenser, compounder, hakim, Dai/TBA Overall, two-thirds of children with fever were taken to a health facility for treatment (Figure 10.5). This proportion shows little variation by age or sex of child. Children in urban areas are more likely than those in rural areas to be taken for treatment when they have fever. Children in Sindh province are the most likely to be taken for treatment when they have fever, and children in Balochistan are the least likely. Similarly, children whose mothers are more educated are more likely to be taken to a health facility for treatment. It is widely known that mother’s education makes a difference in the treatment of sick children. Educated mothers are more likely to recognize signs of illness in their children and actively seek assistance from a doctor. This proactive nature of educated mothers with regard to the health of their children lowers the mortality and morbidity rates of young children. Similarly, mothers living in households of higher wealth quintile were more likely to take 132 | Child Health their children to a health facility for ARI and fever compared with children of mothers in the lowest wealth quintile. Only 3 percent of children with fever in the two weeks preceding the survey were reported to have received an antimalarial drug and almost half were reported to have received an antibiotic. These data should be viewed with caution because many mothers may not have been told or remember the name of the medicine their child was given. Figure 10.5 Children under Five with Fever 67 64 61 72 70 70 87 56 60 62 77 75 66 SEX Male Female MOTHER'S EDUCATION No education Primary Middle Secondary Higher WEALTH QUINTILE Lowest Second Middle Fourth Highest TOTAL 0 20 40 60 80 100 Percent PDHS 2006-07 10.3.3 Prevalence of Diarrhoea Diarrhoea is an important cause of malnutrition. This is because nutrient requirements are increased during diarrhoea, whereas nutrient intake and absorption are usually decreased. Each episode of diarrhoea can cause weight loss. Moreover, if diarrhoea occurs frequently, there may be too little time to “catch up” on growth between episodes, thereby resulting in more undernourishment than among those who experience less frequent or shorter episodes of diarrhoea. A simple and effective response to dehydration is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy (ORT). ORT may include the use of a solution prepared from commercially-produced packets of oral rehydration salts (ORS) or a homemade mixture usually prepared from sugar, salt, and water. In Pakistan, the Health Program of the National Commission for Human Development (NCHD) has been training mothers how to prepare a home- made rehydration solution by visiting house to house (NCHD, 2006). In addition to these two special solutions, increasing the amount of any liquids given to a child during a diarrhoeal episode is another means of preventing dehydration. In the PDHS, mothers were asked whether any of their children under five years of age had had diarrhoea during the two weeks preceding the survey. If the child had had diarrhoea, the mother was asked about any actions that were taken to treat the diarrhoea and about feeding practices during the diarrhoeal episode. Child Health | 133 Table 10.7 shows the percentage of children under five years of age who had any diarrhoea and who had bloody diarrhoea at some time during the two-week period before the survey. Blood in the stool is a symptom of dysentery. In considering the information in Table 10.7, it is important to note that the prevalence figures may involve some report- ing error because they are based on the mothers’ subjective assessment of the child’s illness. Because there are seasonal variations in diarrhoea, the percentages in Table 10.7 represent the prevalence of diarrhoea at the time of the survey (September 2006 to February 2007) and not the situation at other times of the year in Pakistan. Table 10.7 Prevalence of diarrhoea Among children under age five, 22 percent were reported to have had an episode of diarrhoea during the two-week period be- fore the survey, and 3 percent had diarrhoea with bloody stool. Diarrhoea prevalence does not appear to differ among children living in households with “improved” or “not im- proved” sources of drinking water or types of toilet facilities. However, diarrhoeal preva- lence is markedly lower for children whose mothers have higher education and somewhat lower for those in the highest wealth quintiles. Prevalence of childhood diarrhoea is some- what higher in NWFP and Sindh than in other provinces of Pakistan. Similar to the prevalence of ARI and fever, children aged 6-11 months are the most vulnerable to episodes of diarrhoea. Children aged 6-11 months were over three times more likely to have had diarrhoea than children aged 48-59 months. This is the age when a child starts taking supplementary foods and the environment around the child affects the hygiene, resulting in increased exposure to diarrhoea. 10.3.4 Treatment of Diarrhoea The PDHS obtained information on the actions that were taken when a child had diarrhoea during the two weeks before the survey. Table 10.8 shows that more than half of the children under five whose mothers reported that they had had diarrhoea in the two weeks before the survey were taken to a health facility for consultation. Of all children with diarrhoea, two out of five were given fluid made from an ORS packet, 16 percent were given a recommended home-made fluid (RHF), and more than half (55 percent) were given ORT or more fluids than usual. Forty-seven percent of children with diarrhoea Percentage of children under age five who had diarrhoea in the two weeks preceding the survey, by background characteristics, Pakistan 2006-07 Diarrhoea in the two weeks preceding the survey Background characteristic All diarrhoea Diarrhoea with blood Number of children Age in months <6 26.3 1.0 962 6-11 39.6 4.6 820 12-23 30.7 5.1 1,522 24-35 20.7 3.8 1,668 36-47 14.2 2.0 1,826 48-59 11.0 2.0 1,570 Sex Male 22.4 3.0 4,371 Female 21.0 3.2 3,996 Source of drinking water1 Improved 21.6 3.2 7,729 Not improved 23.4 1.6 626 Toilet facility2 Improved, not shared 21.7 3.1 4,015 Non-improved or shared 21.8 3.1 4,315 Residence Total urban 21.1 1.6 2,518 Major city 22.6 1.5 1,307 Other urban 19.5 1.7 1,212 Rural 22.1 3.7 5,849 Province Punjab 20.6 3.2 4,689 Sindh 23.6 3.1 2,085 NWFP 24.7 3.0 1,221 Balochistan 16.2 1.1 373 Mother's education No education 22.0 3.3 5,425 Primary 22.5 3.9 1,261 Middle 24.3 1.3 506 Secondary 21.1 2.3 681 Higher 15.4 1.2 494 Wealth quintile Lowest 22.5 3.3 1,920 Second 24.2 4.6 1,742 Middle 21.8 3.0 1,673 Fourth 19.8 2.7 1,559 Highest 19.9 1.4 1,473 Total 21.8 3.1 8,367 Note: Total includes some cases with missing data. 1 See Table 2.9 for definition of categories. 2 See Table 2.10 for definition of categories. 134 | Child Health were given some kind of pill or syrup to treat the disease and 14 percent were given home remedies or herbs. About one in five children with diarrhoea was not treated at all. Children with bloody diarrhoea are not only more likely than those with non-bloody diarrhoea to be taken to a health facility, but they are also more likely to receive ORS fluid, RHF, pills and syrup, or increased fluids of any kind. Table 10.8 Diarrhoea treatment Among children under age five who had diarrhoea in the two weeks preceding the survey, the percentage who were taken for treatment to a health provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Pakistan 2006-07 Percent- age of children with diarrhoea taken to a health provider1 Oral rehydration therapy (ORT) ORS packets or pre- packaged liquid Recom- mended home fluids (RHF) Other treatments Background characteristic Either ORS or RHF ORT or increased fluids Increased fluids Pills, syrup Injec- tion Intra- venous solution Home remedy/ other Missing No treat- ment Number of children Age in months <6 47.1 24.6 13.1 33.6 13.1 42.2 34.8 10.8 2.8 10.7 0.0 33.3 253 6-11 57.8 41.1 14.5 45.4 18.0 50.7 46.3 17.1 2.3 12.4 0.0 25.1 324 12-23 62.6 48.3 18.1 54.5 21.0 61.2 49.1 17.8 2.5 14.2 0.2 17.7 467 24-35 50.0 43.8 16.2 50.3 22.4 58.8 51.4 16.1 2.0 14.3 0.1 15.9 345 36-47 57.0 45.9 16.8 50.0 24.9 57.4 50.4 18.5 1.7 18.0 0.0 18.8 259 48-59 42.8 33.3 17.3 40.9 25.8 55.0 42.4 19.1 3.6 12.3 1.9 16.8 173 Sex Male 55.7 41.5 16.2 47.2 20.1 54.9 46.0 16.8 2.9 13.8 0.3 20.2 981 Female 53.1 40.6 16.1 47.3 21.3 55.3 47.3 16.4 1.8 13.7 0.1 21.7 841 Type of diarrhoea Non-bloody 53.2 40.1 15.6 46.3 20.0 53.7 45.1 15.2 2.5 13.6 0.2 21.9 1,559 Bloody 63.2 47.2 19.6 53.0 23.9 64.1 56.5 25.8 2.0 14.2 0.3 14.5 256 Residence Total urban 65.5 43.8 14.9 49.5 25.1 57.3 49.2 13.8 1.0 13.1 0.2 18.1 532 Major city 68.4 41.6 13.3 47.6 33.1 59.8 51.5 13.1 1.8 10.3 0.3 16.0 295 Other urban 62.0 46.4 17.0 52.0 15.1 54.3 46.3 14.6 0.1 16.5 0.0 20.8 236 Rural 50.0 40.0 16.6 46.3 18.8 54.2 45.5 17.8 3.0 14.1 0.3 22.0 1,290 Province Punjab 53.7 35.1 15.1 40.8 23.5 49.8 36.7 12.6 3.1 16.2 0.2 27.6 968 Sindh 66.2 53.7 17.4 59.3 16.3 64.3 57.2 26.7 1.9 11.6 0.4 11.9 493 NWFP 40.1 37.5 18.0 47.0 18.3 54.0 60.8 14.6 1.1 8.0 0.3 16.4 301 Balochistan 44.9 51.8 13.4 53.7 21.6 71.1 49.1 9.8 1.4 21.1 0.3 9.6 60 Mother's education No education 50.8 40.0 15.9 45.4 17.7 52.7 47.0 17.1 2.6 13.8 0.4 21.8 1,195 Primary 56.4 47.5 17.4 55.6 25.7 63.5 46.5 17.4 3.7 15.1 0.0 16.6 284 Middle 62.8 39.3 18.8 46.9 24.1 57.0 45.4 9.3 1.4 12.6 0.0 20.2 123 Secondary 65.5 37.0 13.2 43.8 28.3 54.1 43.5 16.1 0.2 13.5 0.0 20.7 144 Higher 71.7 45.0 17.1 52.1 27.1 60.2 47.8 18.5 0.0 11.9 0.0 23.9 76 Wealth quintile Lowest 46.0 41.0 16.5 45.4 12.0 51.7 45.7 19.4 3.9 12.5 0.2 23.2 433 Second 51.2 38.7 17.3 47.1 18.4 53.2 46.9 17.7 1.1 12.0 0.6 21.8 422 Middle 53.5 43.4 14.1 48.0 22.0 55.6 45.3 15.3 3.3 14.6 0.2 21.3 365 Fourth 61.1 39.3 18.2 47.4 29.3 58.6 46.6 13.7 3.4 16.8 0.0 19.4 308 Highest 66.1 43.8 14.4 49.0 25.8 58.5 49.1 15.8 0.1 13.9 0.0 17.1 294 Total 54.5 41.1 16.1 47.2 20.6 55.1 46.6 16.6 2.4 13.8 0.2 20.9 1,821 Note: ORT includes solution prepared from oral rehydration salts (ORS), pre-packaged liquid or ORS packet, and recommended home fluids (RHF). Total includes some cases with missing values. 1 Excludes pharmacy, shop, homeopath, dispenser, compounder, hakim, Dai/TBA Child Health | 135 Table 10.8 also shows that male children with diarrhoea are slightly more likely than female children to be taken to a health facility; however, they are no more likely than female children to be treated with ORS packets, home-made fluids, or any other treatment. Moreover, children aged 12-23 months are more likely than older or younger children to be taken to health facilities when they have diarrhoea. There are some differences in the treatment of diarrhoea cases by urban-rural residence (66 and 50 percent, respectively) as well as the province of residence. The proportion of children with diarrhoea who are taken to health facilities is highest in Sindh (66 percent) and Punjab (54 percent) provinces and lowest in NWFP (40 percent). As expected, education of mothers is strongly related to treatment of childhood diarrhoea. Children whose mothers have higher education are much more likely to be taken to a health facility or medical professional when they have diarrhoea than are the children of mothers with no education. Similarly, children of mothers in the higher wealth quintiles are more likely to be taken to a health facility compared with children of mothers in the lower wealth quintiles. 10.3.5 Feeding Practices during Diarrhoea The PDHS also investigated the extent to which mothers make changes in the amount of fluids that a child receives during a diarrhoeal episode. To obtain these data, mothers who had a child under age five with diarrhoea during the two weeks before the survey were asked whether they had changed the quantity that the child was given to drink or eat during the diarrhoeal episode. Table 10.9 indicates that 41 percent of children with diarrhoea were given the same quantity of fluids as usual, 21 percent received more fluids than usual, and 34 percent received somewhat or much less fluid than usual. These results suggest that in Pakistan, about one in three mothers still curtail fluid intake when their children have diarrhoea. This is a very dangerous practice that should be eliminated by campaigning against such practices through electronic and print media as well as by using the services of Lady Health Workers. With regard to feeding practices, young children—especially those under 6 months of age—were less likely to have been offered increased liquids or food than older children. There was no gender differential observed in treatment of children during diarrhoeal episodes. Table 10.9 shows that the proportion of children given ORT or increased fluids and continued feeding during diarrhoea varies by wealth quintile of the parents. It shows that 48 percent of children in the lowest wealth quintile were given ORT or increased fluids and continued feeding compared with 57 percent of children in the highest wealth quintile. Mother’s education also shows a positive relationship with use of ORT or increased fluids and continued feeding. The analysis clearly shows that there is no gender differential found in providing increased fluids or continued feeding during diarrhoea. However, lack of mothers’ education and poverty are the main hurdles in taking children to a health facility. 136 | Child Health Child Health | 137 Table 10.9 Feeding practices during diarrhoea Percent distribution of children under age five who had diarrhoea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, the percentage of children given increased fluids and continued feeding during the diarrhoea episode, and the percentage of children given ORT or increased fluids and continued feeding during the episode of diarrhoea, by background characteristics, Pakistan 2006-07 Percent- age given increased fluids and contin- ued feeding1,2 Percent- age given ORT or increased fluids and contin- ued feeding1,3 Number of children with diarrhoea Amount of liquids offered Amount of food offered Background characteristic More Same as usual Some- what less Much less None Don’t know/ missing Total More Same as usual Some- what less Much less None Never gave food Don't know/ missing Total Age in months <6 13.1 43.1 21.8 11.2 10.7 0.1 100.0 3.4 22.6 12.0 5.8 2.1 53.5 0.6 100.0 2.8 34.6 253 6-11 18.0 43.0 22.1 12.4 4.3 0.2 100.0 6.7 34.7 19.4 10.5 4.5 24.3 0.0 100.0 10.8 48.5 324 12-23 21.0 43.6 23.7 8.5 2.9 0.3 100.0 7.5 40.2 28.4 10.9 6.4 6.2 0.3 100.0 14.1 58.9 467 24-35 22.4 35.4 23.9 14.7 2.7 1.0 100.0 6.6 40.9 26.8 19.1 3.4 2.3 1.0 100.0 17.0 57.0 345 36-47 24.9 39.8 23.6 10.1 1.6 0.0 100.0 8.3 40.9 32.1 15.4 3.2 0.1 0.0 100.0 17.8 55.9 259 48-59 25.8 40.2 19.0 12.7 1.7 0.6 100.0 10.3 43.6 23.7 18.2 2.1 1.5 0.6 100.0 21.2 53.5 173 Sex Male 20.1 43.2 22.0 10.6 3.8 0.2 100.0 6.9 38.6 23.3 12.8 3.6 14.6 0.2 100.0 13.5 52.0 981 Female 21.3 38.4 23.6 12.2 4.0 0.5 100.0 7.2 35.9 25.4 13.2 4.5 13.2 0.7 100.0 14.0 52.8 841 Type of diarrhoea Non-bloody 20.0 41.7 22.7 11.1 4.1 0.4 100.0 6.8 38.1 24.1 12.0 3.8 14.7 0.5 100.0 13.8 51.3 1,559 Bloody 23.9 37.3 23.0 13.0 2.9 0.0 100.0 8.0 33.0 25.9 18.6 5.3 9.2 0.0 100.0 13.3 59.6 256 Residence Total urban 25.1 40.5 20.2 9.6 3.8 0.8 100.0 7.5 36.5 25.5 11.1 4.1 14.0 1.3 100.0 17.6 55.3 532 Major city 33.1 38.9 17.7 6.1 2.7 1.5 100.0 9.9 35.3 25.6 9.2 3.5 14.6 2.0 100.0 24.3 57.2 295 Other urban 15.1 42.4 23.4 13.9 5.2 0.0 100.0 4.6 38.1 25.3 13.4 5.0 13.2 0.4 100.0 9.3 52.9 236 Rural 18.8 41.2 23.8 12.1 3.9 0.2 100.0 6.8 37.7 23.8 13.8 4.0 13.9 0.0 100.0 12.1 51.2 1,290 Province Punjab 23.5 45.4 19.3 6.9 4.6 0.3 100.0 7.7 39.7 22.6 10.1 3.2 16.2 0.5 100.0 15.3 46.8 968 Sindh 16.3 32.5 31.0 16.1 3.7 0.4 100.0 5.9 33.8 28.8 13.1 5.7 12.1 0.5 100.0 11.7 62.9 493 NWFP 18.3 43.5 20.1 15.7 2.1 0.3 100.0 7.7 37.6 21.6 17.3 4.7 11.2 0.0 100.0 12.8 51.6 301 Balochistan 21.6 27.4 23.9 23.4 3.0 0.8 100.0 0.9 27.2 26.8 37.5 0.8 6.0 0.8 100.0 8.4 59.7 60 Mother's education No education 17.7 40.1 24.4 13.1 4.5 0.3 100.0 6.5 37.1 23.8 14.4 4.7 13.4 0.2 100.0 10.9 49.6 1,195 Primary 25.7 41.8 20.8 8.1 2.4 1.2 100.0 5.8 37.1 25.1 10.9 3.4 16.5 1.2 100.0 16.9 61.3 284 Middle 24.1 44.1 20.8 8.0 2.8 0.2 100.0 8.7 46.1 19.4 11.0 0.9 13.6 0.2 100.0 20.1 55.1 123 Secondary 28.3 43.3 16.3 9.8 2.4 0.0 100.0 10.6 31.9 31.1 9.9 2.7 13.1 0.7 100.0 22.4 52.4 144 Higher 27.1 43.3 19.0 5.6 4.9 0.0 100.0 10.7 38.4 23.6 8.4 3.6 15.3 0.0 100.0 19.9 58.5 76 Wealth quintile Lowest 12.0 42.6 26.6 12.4 5.9 0.5 100.0 4.3 35.6 25.7 13.8 5.7 14.8 0.1 100.0 5.1 48.1 433 Second 18.4 38.9 26.4 12.8 3.5 0.1 100.0 6.1 40.2 23.6 14.5 2.2 13.4 0.1 100.0 12.4 50.5 422 Middle 22.0 42.2 17.5 14.0 4.0 0.3 100.0 5.9 38.4 21.3 15.3 5.8 12.9 0.4 100.0 13.8 53.2 365 Fourth 29.3 39.5 18.5 10.0 2.6 0.0 100.0 9.9 32.9 22.6 11.4 4.5 18.5 0.0 100.0 20.5 55.3 308 Highest 25.8 41.7 22.6 6.0 2.7 1.1 100.0 10.7 39.1 28.6 8.3 1.5 10.0 1.9 100.0 21.1 57.4 294 Total 20.6 41.0 22.7 11.4 3.9 0.4 100.0 7.0 37.3 24.3 13.0 4.0 13.9 0.4 100.0 13.7 52.4 1,821 1 Equivalent to the UNICEF/WHO indicator "home management of diarrhoea” 2 Continued feeding includes children who were given more, same as usual, or somewhat less food during the diarrhoea episode 3 Equivalent to UNICEF MICS Indicator 35 NUTRITION 11 Syed Mubashir Ali and Mehboob Sultan Nutritional status is the result of complex interactions between food consumption and overall health care practices. Poor nutritional status is one of the most important health and welfare problems facing Pakistan today and afflicts the most vulnerable groups: women and children. At the individual level, inadequate or inappropriate feeding patterns lead to malnutrition. Numerous socioeconomic and cultural factors influence the patterns of feeding and nutritional status. The 2006-07 Pakistan Demographic and Health Survey (PDHS) collected data on feeding practices, that is, breastfeeding, complementary feeding, and use of feeding bottles. Data on the intake of vitamin A and iron supplements were also collected from women with a child born in the five years before the survey. Information on experience of night blindness was also asked of these same women. This chapter presents the findings on infant and young child feeding practices and nutritional status of women. 11.1 BREASTFEEDING AND SUPPLEMENTATION Feeding practices play a pivotal role in determining optimal development of infants. Poor breastfeeding and infant feeding practices have adverse consequences for the health and nutritional status of children, which in turn have consequences on the mental and physical development of the child. On the other hand, breastfeeding has a negative effect on fertility through the mechanism of lactational amenorrhoea. Fortunately, breastfeeding in Pakistan is universal and generally of fairly long duration. This practice in turn has helped to keep fertility in check even when contraceptive practice was very low. 11.1.1 Initiation of Breastfeeding Women delivering in health facilities and at home are encouraged to initiate breastfeeding within the first 30 minutes after birth. Bottle-feeding is discouraged, and mothers are educated to breastfeed exclusively for six months. Early breastfeeding, preferably within the first 30 minutes after birth, increases the chance of breastfeeding success and generally lengthens the duration of breastfeeding. Table 11.1 indicates that 94 percent of Pakistani children are breastfed at some point. Unfortunately, the proportion of children who are breastfed within one hour of birth is just 29 percent. Nevertheless, the proportion increases to 70 percent for children breastfed within one day after delivery. Because of the near universality of breastfeeding, there is hardly any variation by background characteristics in the percentage of children who are ever breastfed (Table 11.1). The slightly lower proportions of ever-breastfed children among those whose birth was assisted by a health professional or took place in a health facility is a matter of concern, as medical professionals should be the real proponents of breastfeeding practice. The proportion of women initiating breastfeeding within one hour of birth is highest (42 percent) in Balochistan province and lowest (19 percent) in Sindh province. A relatively lower proportion of rural women initiated breastfeeding within one day compared with their counterparts in urban areas. Colostrum is a form of milk that is produced soon after birth. It is usually a sticky, yellow substance that is high in nutrients and antibodies. In some societies, this “early milk” is discarded, thus eliminating a potentially healthy tonic for the newborn. In Pakistan, almost two-thirds of babies are given colostrum. As expected, most of the children who are born in a health facility or delivered by a health professional are fed colostrum. This practice is highest among residents of major cities of Pakistan and in the province of Balochistan. The practice of giving colostrum to children is positively related to mother’s education as well as household wealth. In other words, more educated women and Nutrition | 139 those living in wealthy households are more aware of the benefits of giving colostrum to their newborn babies. Two-thirds (65 percent) of children are given something other than breast milk in the first three days of life (prelacteal feed), a practice that is discouraged because it may inhibit breastfeeding and/or introduce contaminants. Mothers in rural areas are slightly more likely (67 percent) to practise prelacteal feeding than those in urban areas (62 percent). Prelacteal feeding is most common (71 percent) in North-West Frontier Province (NWFP) and least common (52 percent) in Balochistan. Prelacteal feeding, an established health hazard for newborn babies, is so deep-rooted in Pakistan that a large proportion of the babies delivered in a health facility or delivered by a health professional are receiving a prelacteal feed. Table 11.1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and for the last children born in the five years preceding the survey ever breastfed, the percentage who started breastfeeding within one hour and within one day of birth, the percentage who received a prelacteal feed, and the percentage given colostrum, by background characteristics, Pakistan 2006-07 Breastfeeding among children born in past five years Among last-born children ever breastfed: Background characteristic Percentage ever breastfed Number of children born in past five years Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who were given colostrum Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 93.7 4,782 27.6 69.0 62.3 66.0 2,885 Female 94.9 4,339 30.3 70.1 63.4 64.3 2,483 Assistance at delivery Health professional3 92.8 3,538 28.8 71.7 73.1 61.2 2,209 Traditional birth attendant (Dai) 95.1 4,693 29.0 67.9 55.0 68.3 2,671 Other 95.6 726 31.1 73.3 64.2 70.4 414 No one 94.8 64 21.9 65.9 48.8 70.7 43 Place of delivery Health facility 92.4 3,125 28.1 72.1 74.0 59.7 1,952 At home 95.2 5,901 29.5 68.6 56.8 68.9 3,387 Residence Total urban 93.9 2,699 28.4 75.0 73.4 62.0 1,616 Major city 94.5 1,390 28.0 78.2 80.4 61.3 867 Other urban 93.2 1,310 28.8 71.4 65.3 62.9 748 Rural 94.5 6,422 29.0 67.2 58.2 66.6 3,753 Province Punjab 94.0 5,125 30.4 63.0 59.2 69.3 2,990 Sindh 94.1 2,284 19.3 75.8 64.1 55.3 1,333 NWFP 95.6 1,312 34.8 76.8 70.2 71.1 792 Balochistan 95.3 400 41.9 90.3 75.3 51.6 253 Mother's education No education 94.3 5,986 28.1 67.4 56.1 66.4 3,475 Primary 94.2 1,354 29.6 70.9 65.9 65.6 806 Middle 95.0 538 26.6 67.1 76.8 64.6 338 Secondary 94.0 722 34.1 83.0 82.3 60.9 430 Higher 94.2 522 29.5 73.8 86.2 58.1 320 Wealth quintile Lowest 94.8 2,153 24.9 63.8 45.5 65.9 1,228 Second 94.6 1,925 27.7 67.4 57.2 67.0 1,132 Middle 93.5 1,829 30.8 70.4 63.1 64.8 1,024 Fourth 94.9 1,651 31.9 72.5 71.7 66.5 1,012 Highest 93.6 1,563 29.9 75.3 81.6 61.4 972 Total 94.3 9,121 28.8 69.5 62.8 65.2 5,369 Note: Table is based on births in the last five years whether the children are living or dead at the time of interview. Total includes cases for which assistance at delivery and/or place of delivery was “other” or “missing.” 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse/midwife. or Lady Health Visitor 140 | Nutrition Figure 11.1 shows that the most common substance introduced before breast milk is some other sort of milk (given to 43 percent of newborns). The sweet herbal substance (ghutee) that is traditionally given to newborns and honey water and sugar water are also commonly used as prelacteal liquids. Figure 11.1 Among Last Children Born in the Five Years Preceding the Survey Who Ever Received a Prelacteal Liquid, the Percentage Who Received Various Types of Liquids 43 4 13 25 10 29 0 17 8 1 Milk other than breast milk Infant formula Plain water Honey or sugar water Ghee/ butter Ghutee Fruit juice Green tea Herbs/ traditional medicines Other 0 10 20 30 40 50 Percent Note: Percentages do not add to 100 because children may receive more than one type of liquid. PDHS 2006-07 11.1.2 Breastfeeding Patterns For optimal growth, it is recommended that infants should be exclusively breastfed for the first six months of life. Exclusive breastfeeding in the early months of life is correlated strongly with increased child survival and reduced risk of morbidity, particularly from diarrhoeal diseases. Table 11.2 and Figure 11.2 show that a majority (55 percent) of children under the age of two months are exclusively breastfed. This represents a doubling from the 27 percent of children under two months who were exclusively breastfed in 1990-91 (NIPS and Macro, 1992), an encouraging trend. Overall, 37 percent of infants under 6 months are exclusively breastfed. This proportion is very low when compared with the recommended 100 percent exclusive breastfeeding for children under 6 months. The propensity to feed infants under 2 months with plain water (13 percent) and other milk (28 percent) is high. At 2-3 months, the propensity to feed plain water and other milk increases further. Table 11.2 also shows that bottle-feeding is common in Pakistan. More than one-quarter (27 per-cent) of children under six months are fed with a bottle with a nipple. Bottle-feeding practices may potentially result in increased morbidity because of unsafe water and preparation facilities. Nutrition | 141 Table 11.2 Breastfeeding status by age Percent distribution of most recent births under three years who are living with their mother by breastfeeding status and the percentage currently breastfeeding, and the percentage of all children under three years using a bottle with a nipple, according to age in months, Pakistan 2006-07 Percent distribution of youngest children under three living with their mother by breastfeeding status Percentage currently breast- feeding Number of youngest children under 3 years Percentage using a bottle with a nipple1 Number of all children under three years Breastfeeding and consuming Not breast- feeding Exclusively breastfed Plain water only Non- milk liquids/ juice Other milk Comple- mentary foods Total Age in months 0-1 3.0 54.6 12.8 1.1 27.6 1.0 100.0 97.0 282 16.8 284 2-3 3.8 35.7 18.4 1.4 39.1 1.6 100.0 96.2 355 29.7 359 4-5 3.4 23.1 19.6 2.3 38.0 13.6 100.0 96.6 318 33.2 319 6-8 10.0 8.3 17.4 5.1 25.6 33.6 100.0 90.0 443 34.5 447 9-11 15.6 4.2 8.4 3.9 16.2 51.7 100.0 84.4 368 40.2 373 12-17 24.6 2.4 5.2 2.5 7.1 58.1 100.0 75.4 843 37.8 916 18-23 41.4 1.0 2.1 1.1 5.9 48.6 100.0 58.6 494 35.7 606 24-35 73.2 0.2 0.3 0.7 2.5 23.2 100.0 26.8 1,007 32.0 1,668 0-3 3.4 44.1 15.9 1.2 34.0 1.3 100.0 96.6 637 24.0 643 0-5 3.4 37.1 17.1 1.6 35.4 5.4 100.0 96.6 955 27.1 962 6-9 11.2 7.1 15.6 5.0 24.9 36.3 100.0 88.8 566 36.4 573 12-15 21.0 2.8 6.2 2.8 7.2 60.0 100.0 79.0 590 35.3 632 12-23 30.8 1.9 4.1 2.0 6.7 54.6 100.0 69.2 1,337 37.0 1,522 20-23 45.1 1.6 2.3 1.3 7.5 42.1 100.0 54.9 293 39.1 386 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no other liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, and breastfeeding and consuming plain water, nonmilk liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus, children who receive breast milk and nonmilk liquids and who do not receive complementary foods are classified in the nonmilk liquid category even though they may also get plain water. Any children who get complementary foods are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years Figure 11.2 Infant Feeding Practices by Age <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months 0 20 40 60 80 100 Percent Exclusively breastfed Breast milk and plain water Breast milk and nonmilk liquids Breast milk and other milk Breast milk and complementary foods Not breastfeeding PDHS 2006-07 142 | Nutrition Table 11.3 shows that the median duration of breastfeeding among Pakistani children is 19 months, one month lower than reported in the 1990-91 PDHS, suggesting that during the last decade and a half the patterns have changed only slightly. The median duration of exclusive breastfeeding is estimated at a little less than one month. Table 11.3 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey; percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey; and mean number of feeds (day/night), by background characteristics, Pakistan 2006-07 Median duration (months) of breastfeeding among children born in the past three years1 Frequency of breastfeeding among children under six months2 Background characteristic Any breast- feeding Exclusive breast- feeding Predomi- nantly breast- feeding3 Percentage breastfed 6+ times in past 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 19.5 0.9 2.9 95.3 6.3 5.2 483 Female 18.2 0.9 2.6 94.0 6.4 5.4 440 Residence Total urban 18.0 0.7 1.8 92.6 6.6 5.4 286 Major city 16.8 0.7 1.9 91.7 7.1 5.7 133 Other urban 19.8 0.9 1.8 93.4 6.2 5.0 153 Rural 19.4 1.0 3.3 95.6 6.3 5.3 637 Province Punjab 17.9 0.9 2.3 94.3 5.9 5.1 508 Sindh 20.3 0.8 2.3 94.2 6.4 5.3 235 NWFP 21.5 3.2 5.7 95.5 7.1 5.8 137 Balochistan 20.7 0.6 1.5 99.0 9.1 6.8 43 Mother's education No education 20.2 1.0 3.4 94.9 6.2 5.3 597 Primary 16.3 0.7 2.1 94.3 6.6 5.3 138 Middle 17.1 0.9 1.8 96.2 6.8 5.7 68 Secondary 18.4 1.1 1.8 88.9 6.6 5.0 69 Higher 15.1 0.6 0.6 (98.9) (7.1) (5.3) 51 Wealth quintile Lowest 19.6 0.9 4.4 95.6 6.0 5.5 211 Second 20.4 1.6 3.9 96.3 6.7 5.4 200 Middle 18.8 1.3 1.9 94.8 6.0 5.1 182 Fourth 19.2 0.8 2.4 93.3 6.7 5.3 172 Highest 15.2 0.6 0.6 92.7 6.7 5.4 156 Total 18.9 0.9 2.7 94.7 6.4 5.3 923 Mean for all children 18.3 3.2 5.6 na na na na Note: Median and mean durations are based on current status. Includes children living and deceased at the time of the survey. Figures in parentheses indicate a figure based on 25-49 unweighted cases. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Excludes children without a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water and/or nonmilk liquids only The median duration of any breastfeeding is slightly higher in rural areas (19 months) compared with urban areas (18 months). At the provincial level, duration of breastfeeding is longest in NWFP (22 months) and shortest in Punjab (18 months). Analysis by background characteristics of the mother indicates that educational level and socioeconomic status as measured by the wealth index are related to breastfeeding practices. Women with no education are more likely to breastfeed longer (20 months) than those who have higher than secondary education (15 months). Median duration of breastfeeding shows a similar pattern of generally declining durations as wealth quintile increases. Nutrition | 143 Frequent breastfeeding of children is common in Pakistan. Almost all infants (95 percent) under six months of age were breastfed six or more times in the 24 hours before the survey. Overall, the mean number of day feeds is one higher than the night feeds. 11.1.3 Complementary Feeding Table 11.4 Foods and liquids consumed by children Given that babies need nutritious food in addition to breast milk after the age of six months, it is recommended that children should begin receiving complementary foods at this age. To obtain full information on weaning practices, the 2006-07 PDHS collected data on breastfeeding and nonbreastfeeding children. Table 11.4 presents information on the types of complementary (weaning) foods received by children under three years of age in the day or night preceding the survey. Overall, more than half (56 percent) of breastfed children in the age bracket 6-23 months receive commercially produced infant formula or other milk. As expected, among nonbreastfed children this proportion is far higher (92 percent). Thirty-seven percent of breastfeeding children and 57 percent of nonbreastfeeding children age 6-23 months are given other liquids besides milk. By age 6-8 months, more than one-third of breastfed children and over half of nonbreastfed children have started receiving mushy or solid food. At higher ages, this proportion rises rapidly among both breastfed and nonbreastfed children. 11.2 MICRONUTRIENT INTAKE Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency can cause eye damage leading to blindness and can increase the severity of infections such as measles and diarrhoeal diseases in children. Ensuring that children between 6 and 59 months receive enough vitamin A may be the single most effective child survival intervention. Additionally, adequate intake of the vitamin during pregnancy may reduce maternal deaths. Among the most recently born living children under three years of age who are living with the mother, percentage who consumed specific types of liquids or foods in the day or night preceding the interview, according to breastfeeding status and age, Pakistan 2006-07 Liquids Age in months Infant formula/ other milk1 Other liquids2 Any mushy or solid food Number of children BREASTFEEDING CHILDREN 0-1 29.4 1.8 1.0 273 2-3 41.5 5.5 1.6 342 4-5 46.7 8.9 14.1 308 6-8 49.5 21.4 37.4 398 9-11 57.7 28.8 61.2 311 12-17 56.2 46.9 77.1 636 18-23 62.1 47.4 82.9 289 24-35 58.3 57.2 86.6 269 6-23 55.9 37.3 65.4 1,634 Total 50.8 28.8 47.9 2,826 NONBREASTFEEDING CHILDREN 0-5 (90.8) (5.8) (11.4) 32 6-8 (98.5) (32.3) (55.3) 44 9-11 88.4 54.3 73.9 57 12-17 96.7 58.3 85.1 207 18-23 86.6 61.4 91.9 204 24-35 79.0 63.3 95.0 738 6-23 91.9 56.9 84.0 513 Total 84.4 59.3 88.5 1,283 Note: Breastfeeding status and food consumed refer to a 24- hour period (yesterday and last night). Numbers in parentheses are based on 25-49 unweighted cases. 1 Other milk includes fresh, tinned, and powdered cow or other animal milk 2 Does not include plain water 144 | Nutrition 11.2.1 Micronutrient Intake among Children Table 11.5 Micronutrient intake among children Table 11.5 shows that 60 percent of children age 6-59 months received a vitamin A supplement in the six months preceding the survey. It is encouraging to observe that this proportion does not vary substan- tially by background characteristics. For example, there is hardly any male-female difference in the consump- tion of vitamin A supplements (61 and 60 percent, respectively). Children who are breastfed are slightly more likely (62 percent) to receive vitamin A supple- ments compared with their nonbreastfed counterparts (60 percent). Children age 6-8 months or 48-59 months, children of mothers age 15-19 at the time of birth, children residing in rural areas or in Balochistan province, children of uneducated mothers, and children in the lower wealth quintiles are slightly less likely than others to receive vitamin A supplements. 11.2.2 Micronutrient Intake among Women Table 11.6 presents the percentage of women with a birth in the five years preceding the survey who received a vitamin A dose in the first two months after birth, who took iron tablets or syrup or calcium tablets during pregnancy, and who suffered from night blindness during the pregnancy. In general, 20 percent received a postpartum vitamin A dose, but this varies substantially with area of residence, province, educational attainment, and wealth quintile. Women in major urban areas are more likely (33 percent) to receive vitamin A supplements than those in rural areas (18 percent). At the provincial level, the percentage of women who reported receiving a postpartum vitamin A dose is highest in Sindh province (31 percent). Among all children 6-59 months, percentage who were given vitamin A supplements in the six months preceding the survey, by background characteristics, Pakistan 2006-07 Background characteristic Percentage given vitamin A supplements in past 6 months Number of children Age in months 6-8 58.0 447 9-11 64.8 373 12-17 63.6 916 18-23 62.2 606 24-35 59.5 1,668 36-47 60.5 1,826 48-59 57.2 1,570 Sex Male 60.5 3,866 Female 59.8 3,539 Breastfeeding status Breastfeeding 61.7 1,962 Not breastfeeding 60.4 5,259 Mother's age at birth 15-19 57.8 773 20-29 60.8 4,287 30-39 59.5 2,080 40-49 62.0 265 Residence Total urban 61.9 2,219 Major city 63.1 1,167 Other urban 60.5 1,052 Rural 59.4 5,186 Province Punjab 57.5 4,157 Sindh 69.5 1,838 NWFP 56.5 1,082 Balochistan 53.6 328 Mother's education No education 58.0 4,804 Primary 64.0 1,114 Middle 62.8 439 Secondary 65.7 608 Higher 63.6 440 Wealth quintile Lowest 58.0 1,701 Second 56.1 1,534 Middle 60.4 1,481 Fourth 62.2 1,382 Highest 65.2 1,308 Total 60.2 7,405 Note: Information on vitamin A is based on the mother's recall. Total includes those missing breastfeeding status. With regard to educational level, women with no education (16 percent) are least likely to receive vitamin A doses during pregnancy. The data show that 37 percent of women with higher than secondary education have received a postpartum vitamin A dose. Vitamin A supplementation is strongly associated with household wealth, rising from 12 percent of the poorest mothers to 32 percent of the wealthiest. Night blindness—an indicator of severe vitamin A deficiency to which pregnant women are especially prone—is common in Pakistan. One in six women (16 percent) with a recent birth reported having had night blindness during their last pregnancy. When those who also reported having had difficulty in seeing during the daylight hours are subtracted, the adjusted prevalence of night blindness is reduced to 5 percent of women, still a relatively high level. The adjusted level of night blindness is higher among older (age 40-49) women, women residing in the rural areas of Pakistan, and those in the province of Sindh. Night blindness is also found to be inversely related to education of women and wealth quintile. These segments of women require immediate attention of the health planners for remedial action with vitamin A education and supplementation programmes. Nutrition | 145 146 | Nutrition As seen in Table 11.6, the intake of iron tablets or syrup during pregnancy is low. Overall, more than half of women (56 percent) do not take iron tablets or syrup during pregnancy. Intake varies considerably by area of residence. Sixty-two percent of women in rural areas, compared with 33 percent of women in major cities, do not take any iron supplements during pregnancy. Among provinces, 66 percent—the highest proportion—of women in Balochistan do not take any iron supplements during pregnancy. Table 11.6 Micronutrient intake among mothers Among women with a child born in the five years preceding the survey, percentage who received a vitamin A dose in the first two months after the birth of the last child, percentage who suffered from night blindness during the pregnancy of the last-born child, and the percentage who took iron tablets or syrup for specific numbers of days during the last pregnancy, by background characteristics, Pakistan 2006-07 Percentage who received vitamin A dose postpartum1 Number of days women took iron tablets or syrup during pregnancy of last birth Number of days women took calcium tablets during pregnancy of last birth Background characteristics Night blindness reported Night blindness adjusted2 None <60 60-89 90+ Don't know/ missing None <60 60-89 90+ Don't know/ missing Number of women Age 15-19 23.4 12.8 4.2 61.0 19.5 5.1 13.1 1.3 59.4 24.2 2.6 12.2 1.6 230 20-29 21.7 15.4 5.4 51.6 20.3 6.7 18.8 2.5 51.4 22.2 6.1 16.9 3.4 2,743 30-39 18.6 15.2 3.5 58.0 17.9 5.9 14.8 3.4 55.1 20.3 5.4 15.0 4.1 2,188 40-49 19.9 20.0 5.5 66.0 16.0 2.9 11.3 3.8 68.2 16.8 2.9 7.5 4.6 515 Residence Total urban 27.1 11.6 2.6 41.6 19.9 7.3 27.2 4.0 38.0 23.7 7.8 25.3 5.1 1,714 Major city 32.8 9.0 2.0 33.0 21.0 9.0 32.5 4.6 26.3 26.0 10.0 32.5 5.3 909 Other urban 20.6 14.5 3.2 51.2 18.7 5.3 21.4 3.4 51.3 21.0 5.4 17.3 5.0 806 Rural 17.5 17.4 5.5 61.9 18.6 5.5 11.6 2.5 61.9 19.9 4.4 10.7 3.1 3,962 Province Punjab 15.8 10.2 2.7 59.6 17.0 5.9 15.5 2.0 54.3 20.8 5.8 16.5 2.6 3,182 Sindh 31.1 23.8 9.5 45.3 22.7 7.0 21.4 3.7 52.3 21.9 5.0 15.6 5.2 1,404 NWFP 21.1 22.2 3.8 55.5 21.0 5.4 14.4 3.8 55.1 22.9 5.2 12.8 4.0 827 Balochistan 16.3 17.2 4.5 65.6 17.4 4.0 5.3 7.7 71.6 13.5 3.0 3.2 8.6 264 Education No education 16.0 18.9 5.8 65.5 17.7 4.4 9.8 2.6 65.7 19.1 3.7 8.2 3.3 3,668 Primary 24.5 13.1 4.0 50.8 20.2 7.8 18.3 3.0 44.6 25.1 6.8 20.1 3.5 854 Middle 27.3 9.3 1.4 43.6 21.5 10.0 21.6 3.3 38.9 25.7 6.5 25.0 3.9 353 Secondary 29.9 6.8 1.0 24.9 25.7 11.5 33.3 4.6 26.8 26.7 13.5 27.0 6.0 461 Higher 36.7 5.3 1.3 16.9 17.8 7.7 53.8 3.9 16.2 19.8 7.8 50.5 5.7 341 Wealth quintile Lowest 12.2 21.4 9.3 72.7 15.6 3.3 6.1 2.3 76.1 15.7 2.0 3.4 2.9 1,289 Second 14.7 19.7 5.4 66.9 17.9 4.1 8.8 2.3 67.4 18.3 3.1 8.5 2.7 1,194 Middle 20.5 14.0 3.2 58.1 19.7 5.3 14.1 2.8 57.0 22.0 4.8 12.3 3.9 1,099 Fourth 25.0 13.9 3.2 47.6 20.5 8.4 20.5 3.0 40.9 26.3 7.7 21.6 3.4 1,066 Highest 32.4 7.3 0.7 27.5 22.0 10.0 36.0 4.5 25.0 24.5 10.6 33.9 6.0 1,029 Total 20.4 15.6 4.6 55.7 19.0 6.0 16.3 2.9 54.7 21.0 5.4 15.1 3.7 5,677 1 In the first two months after delivery 2 Women who reported night blindness but did not report difficulty with vision during the day Mother’s education and wealth index show a strong inverse relationship with the likelihood of not taking iron supplements during pregnancy. By education, 66 percent of uneducated women, compared with only 17 percent of those with higher than secondary education, reported that they did not take iron tablets or syrup during their last pregnancy. Among women who took iron supplements during pregnancy, many took them for less than 60 days. A similar pattern is seen for the proportion of women who take calcium tablets during pregnancy. Slightly over half (55 percent) of women said they had not taken any calcium supplements during the pregnancy leading to their most recent birth. MALARIA 12 Mehboob Sultan and Syed Mubashir Ali In Pakistan, malaria has been a major problem threatening the health of the people due to prevailing socioeconomic conditions and the epidemiological situation. The transmission pattern has been described as a combination of stable and unstable malaria with low to moderate endemicity. There is a tendency for epidemic breakouts over a large area, particularly in Punjab and Sindh provinces. The disease is now emerging as a prominent health problem in Balochistan and the Federally Administered Tribal Areas (FATA), particularly along the international border with Afghanistan. Malaria is a disease that disproportionately affects the poorer sections of the population living in hot, humid, and remote areas that lack good health surveillance systems; consequently, morbidity and mortality in most instances go unreported. Each year about half a million people suffer from malaria (Government of Pakistan, 2007). Pakistan has been actively engaged in malaria control activities since 1950. A malaria control eradication campaign was launched in 1961 throughout the country. Pakistan became a member of the global partnership on the Roll Back Malaria (RBM) programme in 1999 and a RBM project was launched in Pakistan in 2001. The Malaria Control Programme in the Ministry of Health has a Malaria Information Resource Centre that receives monthly morbidity data from each district in all four provinces. Confirmed malaria cases (microscopically diagnosed) are reported to the Directorate of Malaria Control, Islamabad. Private sector data are not being reported. Clinically diagnosed cases in public health facilities are reported through the Health Management Information System (HMIS). According to estimates in 2003, a total of 3.9 million fever cases were treated as suspected malaria in public sector hospitals, while the total number of confirmed malaria cases reported from the provinces was about 127,000. About one-third of malaria cases are estimated to be due to falciparum malaria and are considered to be potentially dangerous. According to the Ministry of Health, during the period July to December 2006, the total number of positive cases identified through active case detection (ACD) and passive case detection (PCD) was 83,600, of which 35 percent were falciparum malaria. The parasitic incidence by the end of 2006 was 0.5/1,000 population, and the incidence of falciparum malaria is reported to be 0.18/1,000 population (Government of Pakistan, 2007). The Government of Pakistan is committed to the control and prevention of malaria. The Pakistan Health Policy 2001 lays down strategies for combating malaria through early diagnosis and prompt treatment, multiple preventive interventions, effective behaviour change communication, improved detection and response to epidemics, and development of viable partnerships with national and international partners (Government of Pakistan, 2001). 12.1 HOUSEHOLD OWNERSHIP OF MOSQUITO NETS Table 12.1 shows that mosquito nets are not popular in Pakistan. The survey found that at the national level, only 6 percent of households have a mosquito net. The proportion of households with more than one mosquito net is even smaller. The availability of mosquito nets is higher in rural (8 percent) than in urban areas (4 percent). Mosquito nets are comparably more common in Balochistan and Sindh provinces (16 percent) and among poor segments of the society (12 percent). The availability of ever-treated nets is negligible except in Balochistan, where around 4 percent of the households have treated nets. Insecticide-treated nets (ITNs) are virtually non-existent in Pakistan. Malaria | 147 Table 12.1 Ownership of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated) and an ever-treated net, by background characteristics, Pakistan 2006-07 Percentage with at least one insecticide- treated mosquito net (ITN)2 Percentage with at least one ever- treated mosquito net1 Any type of mosquito net Average number of nets per household Background characteristic Percentage with at least one Percentage with more than one Number of households Residence Total urban 3.5 2.0 0.1 0.7 0.0 3,159 Major city 2.0 1.3 0.0 0.7 0.0 1,808 Other urban 5.5 2.9 0.1 0.6 0.0 1,350 Rural 7.8 4.9 0.2 0.9 0.1 6,096 Province Punjab 2.7 1.1 0.0 0.6 0.1 5,609 Sindh 15.9 11.2 0.4 1.0 0.0 2,103 NWFP 3.3 2.1 0.1 0.7 0.1 1,173 Balochistan 16.4 10.3 0.4 3.7 0.0 370 Wealth quintile Lowest 11.9 8.3 0.3 0.4 0.0 1,943 Second 5.6 3.2 0.1 0.5 0.1 1,861 Middle 5.5 2.8 0.1 0.9 0.0 1,840 Fourth 4.4 2.5 0.1 0.9 0.1 1,816 Highest 3.7 2.3 0.1 1.3 0.1 1,795 Total 6.3 3.9 0.1 0.8 0.1 9,255 1 An ever-treated net is a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at any time. 2 An insecticide-treated net (ITN) is a net that has been soaked with insecticide within the past 12 months. Because there was no question as to how long ago pretreated nets were obtained, pretreated nets are not considered here to be ITNs. 12.2 USE OF MOSQUITO NETS AND OTHER REPELLENTS Age is an important factor in the determination of levels of acquired immunity against malaria. For the first six months of life, antibodies acquired from the mother during pregnancy protect children born in areas endemic for malaria. This is gradually lost as children start developing their own immunity over a period of time. The level of immunity developed depends on the level of exposure to malaria infection, but it is believed that in high malaria-endemic areas, children who survive are immune by the fifth birthday and no longer suffer from severe life-threatening malaria. Immunity in areas of low malaria transmission is acquired more slowly, and malarial illness affects all members of the community, regardless of age. The Government of Pakistan recognizes children less than five years of age as a high-risk group and recommends that this group should be protected by sleeping under ITNs. The government has recently been trying to provide ITNs under the malaria control programme, especially in the high prevalence areas. Mosquito nets are usually used during the humid summer months. In Pakistan, the summer season starts in May and ends in September. During this period mosquito nets are used if they are available. The fieldwork for the Pakistan Demographic and Health Survey (PDHS) was carried out from September through February. It is evident from Table 12.2 that only 2 percent of children under age five slept under mosquito nets and one in 500 children used a treated net the night before the survey. The proportion of children using any net is higher in Sindh (5 percent) and among the children living in the poorest households (4 percent). 148 | Malaria Table 12.2 Use of mosquito nets by children Percentage of children under five years of age who slept under a mosquito net (treated or untreated) and an ever-treated mosquito net the night before the survey, by background characteristics, Pakistan 2006-2007 Background characteristic Percentage who slept under any net last night Percentage who slept under an ever-treated net last night1 Number of children Age in months <1 1.8 0.3 1,883 1 1.3 0.0 1,575 2 1.6 0.1 1,750 3 1.7 0.4 1,898 4 1.7 0.1 1,673 Sex Male 1.7 0.2 4,561 Female 1.6 0.2 4,216 Residence Total urban 1.2 0.2 2,636 Major city 0.3 0.1 1,372 Other urban 2.2 0.3 1,264 Rural 1.8 0.2 6,142 Province Punjab 0.3 0.1 4,899 Sindh 5.4 0.5 2,187 NWFP 0.1 0.0 1,300 Balochistan 2.5 0.5 392 Wealth quintile Lowest 4.4 0.2 2,071 Second 1.0 0.2 1,792 Middle 0.8 0.1 1,716 Fourth 0.5 0.0 1,638 Highest 0.8 0.5 1,561 Total 1.6 0.2 8,778 1 An ever-treated net is a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at any time. Table 12.3 shows the percentage of all women aged 15-49 who slept under any kind of net and those who slept under a treated net, and the percentage of pregnant women who slept under any net the night before the survey. Nationally, only 1 percent of women age 15-49 and 2 percent of pregnant women were reported to have slept under a mosquito net the night before the survey. Pregnant women from Sindh and Balochistan provinces, those with no education, and those from poorer families are relatively more likely to use mosquito nets, though differences are small. Malaria | 149 Table 12.3 Use of mosquito nets by women Percentage of all women age 15-49 and pregnant women age 15-49 who slept under a mosquito net (treated or untreated) and an ever-treated mosquito net the night before the survey, by background characteristics, Pakistan 2006-2007 Percentage of all women age 15-49 who: Percentage of pregnant women age 15-49 who: Background characteristic Slept under any net last night Slept under an ever- treated net last night1 Number of women Slept under any net last night Number of women Residence Total urban 0.8 0.3 5,858 0.7 349 Major city 0.5 0.4 3,365 0.1 182 Other urban 1.2 0.2 2,492 1.4 167 Rural 1.2 0.1 10,357 2.0 812 Province Punjab 0.0 0.0 9,532 0.0 612 Sindh 3.9 0.6 3,708 5.3 298 NWFP 0.3 0.0 2,241 0.2 168 Balochistan 2.6 0.5 734 3.4 83 Education No education 1.4 0.2 10,124 2.1 721 Primary 0.8 0.1 2,369 1.6 185 Middle 0.1 0.0 1,160 0.6 72 Secondary 0.5 0.0 1,451 0.0 100 Higher 0.8 0.5 1,111 0.4 83 Wealth quintile Lowest 3.7 0.1 2,723 4.8 270 Second 0.8 0.1 3,077 1.7 261 Middle 0.4 0.0 3,263 0.2 221 Fourth 0.5 0.2 3,502 0.6 196 Highest 0.5 0.3 3,650 0.0 213 Total 1.1 0.2 16,215 1.6 1,161 1 An ever-treated net is a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at any time. Use of bednets is not the only action that Pakistani households can take to avoid mosquitoes. In the PDHS, interviewers inquired about other actions households might take to avoid mosquitoes. As shown in Table 12.4, almost one in four households uses anti-mosquito mats, 15 percent use coils, 5 percent use smoke, and 4 percent use spray as repellents. Such methods are more common in urban areas. Table 12.4 Other anti-mosquito actions Percentage of households using specific devices or repellents to avoid mosquitoes, by background characteristics, Pakistan 2006-07 Device or repellent Residence/ region Nothing Mosquito coils Mats Spray Electric spray repellent Insect repellent Smoke Fan Window screen Other Number of households Residence Total urban 31.2 30.1 40.4 8.5 3.9 1.2 1.0 1.6 0.1 1.0 3,159 Major city 21.3 36.8 44.2 11.2 5.5 1.1 0.3 0.9 0.1 0.6 1,808 Other urban 44.3 21.2 35.4 4.9 1.9 1.2 1.8 2.6 0.1 1.5 1,350 Rural 67.4 7.4 14.5 1.6 0.4 0.9 6.4 3.6 0.2 2.2 6,096 Region Punjab 56.8 9.7 26.5 2.9 1.6 1.0 2.9 4.0 0.1 2.4 5,609 Sindh 34.8 34.8 25.2 5.6 2.6 1.3 10.6 1.1 0.5 0.8 2,103 NWFP 75.1 7.3 9.3 5.9 0.5 0.5 2.9 1.3 0.1 0.8 1,173 Balochistan 79.0 11.8 9.7 6.1 0.3 0.2 1.5 0.9 0.1 1.1 370 Total 55.0 15.2 23.4 4.0 1.6 1.0 4.6 2.9 0.2 1.8 9,255 150 | Malaria 12.3 MALARIA PREVALENCE AND TREATMENT DURING PREGNANCY Women who had a live birth in the five years preceding the survey were asked whether they suffered from malaria during pregnancy and, if yes, whether they received any kind of treatment. The results presented in Table 12.5 show that one in five such women suffered from malaria during their pregnancy, the vast majority of whom received treatment for the disease (16 percent of all women with a birth in the preceding five years). The prevalence of malaria is higher in rural areas (22 percent), in the province of Balochistan (30 percent), among women with no education (22 percent), and among those who are in the lowest (29 percent) and second lowest wealth quintiles (23 percent). Higher proportions of urban, educated, and wealthier pregnant women receive treatment for malaria when they get infected compared with their counterparts in rural areas, those living in Balochistan, those who are uneducated, and those from poorer segments of society. Table 12.5 Prevalence of malaria during pregnancy 12.4 MALARIA CASE MANAGEMENT AMONG CHILDREN In the PDHS, mothers were asked whether their children under five years had a fever in the two weeks preceding the survey and, if so, whether any treatment was sought. Questions were also asked about the types of drugs given to the child and how soon the drugs were given. Percentages of women aged 15-49 with a live birth in the five years preceding the survey who during the pregnancy suffered from malaria and who received treatment, by background characteristics, Pakistan 2006-07 Background characteristic Percentage who suffered from malaria Percentage who received treatment Number of women with a live birth in the five years preceding the survey Residence Total urban 11.9 10.6 1,714 Major city 9.1 8.3 909 Other urban 15.1 13.1 806 Rural 22.1 18.2 3,962 Province Punjab 15.6 12.9 3,182 Sindh 27.1 24.9 1,404 NWFP 14.9 12.3 827 Balochistan 30.2 16.0 264 Education No education 22.0 17.7 3,668 Primary 17.8 15.9 854 Middle 12.7 11.7 353 Secondary 10.7 10.5 461 Higher 8.1 7.7 341 Wealth quintile Lowest 28.8 22.3 1,289 Second 23.4 19.2 1,194 Middle 17.8 15.2 1,099 Fourth 13.4 12.3 1,066 Highest 8.8 8.6 1,029 Total 19.0 15.9 5,677 Table 12.6 shows the percentage of children under five who had fever in the two weeks preceding the survey, the percentage of such children who took antimalarial drugs, and the percentage taking drugs on the same or next day. Thirty-one percent of children under five years of age are reported to have had fever in the two weeks preceding the survey. Of those, only 3 percent took antimalarial drugs, the vast majority of whom received antimalarial drugs the same or next day after the onset of illness. Prevalence of fever is higher among children under 24 months than among older children. It is also higher among male children and in major cities. However, treatment with antimalarial drugs is not highly correlated with age, residence, education, or wealth quintiles. In Balochistan, a higher proportion of children received antimalarial drugs compared with any other province. Sex of the child, urban-rural residence, level of education, and wealth are not strongly related to the prompt treatment of fever. Malaria | 151 Table 12.6 Prevalence and prompt treatment of fever Percentage of children under age five with fever in the two weeks preceding the survey, and among children with fever, the percentage who took antimalarial drugs and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, Pakistan 2006-07 Among children under age five: Among children under age five with fever: Background characteristic Percentage with fever in the two weeks preceding the survey Number of children Percentage who took antimalarial drugs Percentage who took antimalarial drugs same or next day Number of children Age (in months) <12 33.9 1,782 4.0 3.3 605 12-23 39.3 1,522 3.1 2.7 598 24-35 30.9 1,668 3.6 2.4 515 36-47 27.1 1,826 4.0 3.0 494 48-59 22.7 1,570 1.3 0.6 357 Child's sex Male 32.0 4,371 3.5 2.6 1,397 Female 29.3 3,996 3.2 2.5 1,171 Residence Total urban 31.4 2,518 2.5 2.0 791 Major city 33.8 1,307 1.3 1.1 441 Other urban 28.9 1,212 4.0 3.2 350 Rural 30.4 5,849 3.7 2.8 1,777 Province Punjab 30.3 4,689 2.0 1.5 1,418 Sindh 35.0 2,085 4.6 3.7 730 NWFP 30.3 1,221 4.1 3.3 370 Balochistan 13.4 373 16.7 10.1 50 Mother's education No education 29.8 5,425 3.6 2.5 1,617 Primary 33.5 1,261 2.2 2.0 422 Middle 34.9 506 3.4 3.2 177 Secondary 31.0 681 4.7 4.1 211 Higher 28.6 494 2.0 2.0 141 Wealth quintile Lowest 29.9 1,920 4.1 2.8 573 Second 28.8 1,742 4.4 3.1 503 Middle 28.9 1,673 1.5 1.1 484 Fourth 33.3 1,559 3.8 3.2 519 Highest 33.2 1,473 2.7 2.6 490 Total 30.7 8,367 3.3 2.6 2,569 Table 12.7 presents information on the types of antimalarial drugs given to children with fever and the proportion who took specific antimalarial drugs on the same or next day after the onset of the illness. In interpreting the data, it is important to remember that the information is based on reports from the mothers of the ill children who may not have known the specific drug given to the child. It appears that sulfadoxine and pyrimethamine (SP)/Fansidar and quinine are the more common drugs given to children with symptoms of malaria. Differences by background characteristics are minimal, except that treatment with SP/Fansidar is more common in Balochistan than in other provinces. 152 | Malaria Malaria | 153 Table 12.7 Type and timing of antimalarial drugs Among children under age five with fever in the two weeks preceding the survey, percentage who took specific antimalarial drugs and percentage who took each type of drug the same or next day after developing the fever, by background characteristics, Pakistan 2006-07 Percentage of children who took drug: Percentage of children who took drug the same or next day: Background characteristic SP/ Fansidar Chloro- quine Quinine Other anti- malarial SP/ Fansidar Chloro- quine Quinine Other anti- malarial Number of children with fever Age (in months) <12 1.2 1.3 1.3 0.5 0.9 0.9 1.3 0.4 605 12-23 1.2 0.5 0.8 0.8 1.2 0.4 0.5 0.8 598 24-35 1.6 0.5 1.1 0.5 1.1 0.5 0.6 0.3 515 36-47 2.4 0.3 1.2 0.3 1.7 0.2 1.1 0.2 494 48-59 1.3 0.0 0.0 0.0 0.6 0.0 0.0 0.0 357 Child's sex Male 1.6 0.6 0.9 0.5 1.2 0.4 0.7 0.4 1,397 Female 1.4 0.6 0.9 0.4 1.1 0.5 0.8 0.3 1,171 Residence Total urban 0.9 0.4 0.9 0.4 0.6 0.4 0.8 0.4 791 Major city 0.2 0.1 1.0 0.0 0.1 0.1 1.0 0.0 441 Other urban 1.7 0.8 0.9 0.8 1.3 0.8 0.5 0.8 350 Rural 1.8 0.6 0.9 0.5 1.4 0.4 0.7 0.4 1,777 Province Punjab 0.8 0.4 0.8 0.1 0.5 0.4 0.6 0.1 1,418 Sindh 1.3 1.0 1.6 1.0 1.0 0.6 1.4 0.7 730 NWFP 3.1 0.3 0.1 0.6 2.6 0.3 0.0 0.4 370 Balochistan 15.0 0.0 2.6 2.8 10.1 0.0 0.9 2.8 50 Mother's education No education 1.9 0.5 0.8 0.6 1.3 0.3 0.6 0.5 1,617 Primary 0.8 0.6 0.6 0.3 0.6 0.6 0.6 0.3 422 Middle 0.8 0.0 2.6 0.0 0.8 0.0 2.4 0.0 177 Secondary 2.0 0.9 1.3 0.5 1.9 0.9 0.8 0.5 211 Higher 0.0 1.4 0.6 0.0 0.0 1.4 0.6 0.0 141 Wealth quintile Lowest 1.9 0.7 1.0 0.7 1.1 0.4 0.7 0.5 573 Second 1.9 0.9 1.1 0.9 1.3 0.7 0.7 0.8 503 Middle 0.5 0.4 0.1 0.5 0.4 0.4 0.0 0.3 484 Fourth 2.7 0.2 1.1 0.0 2.4 0.2 0.8 0.0 519 Highest 0.4 0.6 1.4 0.2 0.3 0.6 1.4 0.2 490 Total 1.5 0.6 0.9 0.5 1.1 0.4 0.7 0.4 2,569 SP = Sulfadoxine and pyrimethamine KNOWLEDGE OF HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS 13 Faateh ud din Ahmad and Adnan Ahmad Khan Acquired immune deficiency syndrome (AIDS) was first recognized internationally in 1981. As of 2007, an estimated 33 million adults and children around the world were living with human immunodeficiency virus (HIV) and AIDS (UNAIDS, 2007). AIDS is caused by HIV, which weakens the immune system. A large proportion of those who are infected with HIV die within 5-10 years (Munoz et al., 1997). The HIV/AIDS pandemic is one of the most serious health concerns in the world today because of its high case fatality rate and the lack of a curative treatment or vaccines. Epidemiological studies have identified sexual intercourse, intravenous injections, blood transfusions, and foetal transmission from infected mothers as the main routes of transmission of HIV. HIV cannot be transmitted through food, water, insect vectors, or casual contact. The first case of HIV in Pakistan was diagnosed in 1987. Since then, approximately 4,000 cases have been diagnosed and reported to the Ministry of Health (National AIDS Control Programme 2007). However, because the infection remains unnoticed for many years, most infected individuals are unaware that they are infected; therefore, the actual number of those infected with HIV in Pakistan may be much larger. Indeed, the National AIDS Control Programme, Ministry of Health, and the Joint United Nations Programme (UNAIDS) estimate that approximately 80,000 people are currently living with HIV in Pakistan. Limited data suggest that infection is extremely common among sex workers and highly uncommon among the general population. A large national study of women in antenatal and labour clinics (which is an internationally accepted measure of assessing HIV in the general population) found no HIV and few sexually transmitted infections (STIs) in 2001 (NACP, 2001). Nevertheless, there have been various efforts by both government and nongovernment organizations to prevent HIV transmission, including public health education through the media. Particularly, information and education efforts are directed at increasing awareness of these issues. The findings of this Pakistan Demographic and Health Survey (PDHS) will be helpful in shaping these initiatives. The 2006-07 PDHS survey included a section of questions on HIV/AIDS in order to assess the level of knowledge about the transmission and prevention of HIV and the attitudes of ever- married women towards persons living with AIDS. The PDHS survey also includes a set of questions to assess the level of knowledge about the symptoms of STIs and use of safe injection practices. 13.1 KNOWLEDGE OF AIDS To obtain information on the level of HIV/AIDS knowledge, PDHS respondents were asked a general question about whether they had heard of the illness. Those who responded in the affirmative were asked additional questions about various modes of prevention including whether it is possible to reduce the chance of getting the AIDS virus by having just one faithful sexual partner, using a condom at every sexual intercourse, and abstaining from sex. To get an assessment of the level of possible misconceptions, respondents were also asked whether they think it is possible for a healthy- looking person to have the AIDS virus and whether a person can get AIDS from mosquito bites, sharing food with a person who has AIDS, or through witchcraft or supernatural means. Table 13.1 and Figure 13.1 show that only four in ten ever-married women age 15-49 in Pakistan have heard about AIDS. The reported knowledge of AIDS has increased only slightly over the last decade, from 41 percent to 44 percent. Knowledge of AIDS varies by background characteristics. Knowledge of HIV/AIDS | 155 Table 13.1 Knowledge of AIDS Percentage of ever-married women age 15-49 who have heard of AIDS, by background characteristics, Pakistan 2006-07 Background characteristic Has heard of AIDS Number of women Age 15-24 42.0 2,068 15-19 30.4 569 20-24 46.4 1,499 25-29 48.3 2,006 30-39 44.6 3,440 40-49 42.0 2,509 Marital status Married 44.3 9,556 Divorced/separated/widowed 42.3 467 Residence Total urban 69.2 3,350 Major city 79.2 1,898 Other urban 56.2 1,452 Rural 31.6 6,673 Province Punjab 46.8 5,800 Sindh 42.7 2,410 NWFP 42.4 1,351 Balochistan 23.8 462 Education No education 26.5 6,511 Primary 59.1 1,423 Middle 81.7 634 Secondary 89.4 809 Higher 96.2 646 Wealth quintile Lowest 8.3 1,944 Second 21.1 2,001 Middle 40.9 1,944 Fourth 63.4 2,055 Highest 84.1 2,078 Total 15-49 44.2 10,023 The level of awareness of AIDS is highest among women age 25-29 (48 percent), while ever- married women in their teens (age 15-19 years) have the lowest level of awareness about AIDS (30 percent). Respondents living in rural areas are far less likely to know about AIDS than urban residents. For example, less than one-third of rural women have heard of AIDS compared with 69 percent of urban women. Almost half of women in Punjab have heard of AIDS compared with only 24 percent of women in Balochistan province. Education and wealth quintile are strongly associated with AIDS awareness. Knowledge of AIDS is almost universal among women with more than secondary education, but it is uncommon among those with no education (27 percent). Similarly, awareness is lowest (only 8 percent) among women living in the poorest households and highest among women living in the wealthiest households (84 percent). 156 | Knowledge of HIV/AIDS 69 32 47 43 42 24 27 59 82 89 96 8 21 41 63 84 44 RESIDENCE Urban Rural PROVINCE Punjab Sindh NWFP Balochistan EDUCATION No education Primary Middle Secondary Higher WEALTH QUINTILE Lowest Second Middle Fourth Highest TOTAL 0 20 40 60 80 100 120 Percent PDHS 2006-07 Figure 13.1 Percentage of Ever-Married Women Who Have Heard of AIDS, by Background Characteristics 13.2 KNOWLEDGE OF WAYS TO AVOID CONTRACTING HIV/AIDS HIV/AIDS prevention programmes focus their messages and efforts on three important aspects of behaviour: delaying sexual debut (abstinence), limiting the number of sexual partners/staying faithful to one uninfected partner, and use of condoms. To ascertain whether programmes have effectively communicated these messages, respondents were asked specific questions about whether it is possible to reduce the chances of getting the AIDS virus by having just one faithful uninfected sexual partner, using a condom at every sexual encounter, and abstaining from sex. Table 13.2 presents the levels of knowledge about the various HIV/AIDS prevention methods, by background characteristics. Levels are low, mainly because knowledge of AIDS is also low. Only 31 percent of ever-married women are aware that the chance of getting the AIDS virus can be reduced by limiting sex to one partner, while 24 percent say it can be prevented by abstaining from sexual intercourse (Figure 13.2). In spite of the fact that a mass media campaign on the use of condoms to avoid HIV was launched in the country through both electronic and print media, only one in five women in the survey cited condom use as a means of HIV prevention. Finally, only 17 percent of women are aware of both using condoms and limiting sexual intercourse to one partner as ways to reduce the chances of getting the AIDS virus. Women age 25-29 are relatively more knowledgeable of the various modes of prevention than those in other age groups. For instance, 20 percent of ever-married women age 25-29 mentioned that using condoms and limiting sexual intercourse to one uninfected partner can reduce the risk of HIV/AIDS infection compared with only 9 percent of women age 15-19. Knowledge of HIV prevention methods is higher among women in urban areas than in rural areas. Knowledge that abstinence can prevent HIV transmission is highest among women in Punjab (27 percent) and Sindh (22 percent) and is lowest among Balochi women (6 percent). Knowledge of HIV/AIDS | 157 Table 13.2 Knowledge of HIV prevention methods Percentage of ever-married women age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is not infected and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Pakistan 2006-07 Percentage who say HIV can be prevented by Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1, 2 Abstaining from sexual intercourse Number of women Age 15-24 17.0 28.6 14.4 21.2 2,068 15-19 10.7 19.9 8.8 14.2 569 20-24 19.4 31.9 16.5 23.9 1,499 25-29 22.7 33.0 19.5 25.8 2,006 30-39 21.1 32.9 18.9 24.4 3,440 40-49 16.7 28.4 14.4 22.8 2,509 Marital status Married 19.6 31.0 17.1 23.8 9,556 Divorced/separated/widowed 16.0 29.1 13.2 20.4 467 Residence Total urban 31.5 50.0 27.7 38.5 3,350 Major city 37.3 58.3 32.7 46.0 1,898 Other urban 24.0 39.1 21.2 28.7 1,452 Rural 13.4 21.3 11.6 16.1 6,673 Province Punjab 21.7 33.2 19.0 27.2 5,800 Sindh 18.1 30.4 15.7 21.7 2,410 NWFP 16.2 28.5 14.1 17.9 1,351 Balochistan 7.8 11.5 5.8 6.1 462 Education No education 9.2 16.0 7.7 12.1 6,511 Primary 27.2 41.1 23.0 33.5 1,423 Middle 39.2 60.1 33.8 45.0 634 Secondary 44.8 70.2 41.0 53.7 809 Higher 55.1 80.6 49.9 59.0 646 Wealth quintile Lowest 3.1 4.9 2.3 4.0 1,944 Second 8.4 12.9 7.1 10.0 2,001 Middle 15.8 26.4 13.8 20.3 1,944 Fourth 26.3 43.1 22.8 31.8 2,055 Highest 42.2 64.5 37.2 50.2 2,078 Total 15-49 19.5 30.9 16.9 23.6 10,023 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners Education is positively related with respondents’ knowledge about AIDS prevention methods. For example, half of women with a higher level of education know that using condoms and limiting sexual intercourse to one uninfected partner can reduce a person’s chances of getting HIV compared with only 8 percent of women with no education. Similarly, women living in wealthier households are more likely to be aware of ways to prevent HIV transmission than those living in poorer households. 158 | Knowledge of HIV/AIDS 20 31 17 24 Using condoms Limiting to one partner Using condoms and limiting to one partner Abstaining from sexual relationship 0 10 20 30 4 Percent PDHS 2006-07 Figure 13.2 Percenta 0 ge of Ever-Married Women Who Know of Specific Ways to Prevent HIV/AIDS 13.3 COMPREHENSIVE KNOWLEDGE OF HIV/AIDS TRANSMISSION The 2006-07 PDHS also includes questions to assess the prevalence of common miscon- ceptions about AIDS and HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have the AIDS virus and whether a person can get HIV/AIDS from mosquito bites, by supernatural means like witchcraft, or by sharing food with a person who has AIDS. The data presented in Table 13.3 indicate that most ever-married women age 15-49 lack accurate knowledge about the ways in which the AIDS virus can and cannot be transmitted. Only 18 percent of ever-married women know that AIDS cannot be transmitted by mosquito bites and only a little more than one in four women is aware that a healthy-looking person can have the AIDS virus. Almost one-third of women (30 percent) correctly believe that a person cannot get the AIDS virus by supernatural means, but only 22 percent of women know that a person cannot become infected by sharing food with a person who has AIDS. Table 13.3 also provides an assessment of the level of comprehensive knowledge of HIV/AIDS prevention and transmission. Comprehensive knowledge of HIV/AIDS is defined as: 1) knowing that both condom use and limiting sex to one uninfected partner are HIV prevention methods, 2) being aware that a healthy-looking person can have HIV, and 3) rejecting the two common local misconceptions—that HIV/AIDS can be transmitted through mosquito bites and by sharing food. Table 13.3 shows that the percentage of ever-married women with comprehensive knowledge of AIDS is low. Overall, only 5 percent of women are classified as having comprehensive knowledge. This situation should be a matter of great concern to policymakers and for the National AIDS Control Programme, because it implies that there is an urgent need for an efficient strategy to increase accurate and comprehensive knowledge about HIV/AIDS. There is considerable variation in HIV/AIDS knowledge by respondents’ background characteristics. Comprehensive knowledge about AIDS increases as the level of education and wealth quintile increases. Comprehensive knowledge about AIDS is also higher among urban than rural women. Provincial variation is small, with Punjabi women having the highest proportion with comprehensive knowledge (6 percent) compared with Balochi women (2 percent). Knowledge of HIV/AIDS | 159 Table 13.3 Comprehensive knowledge about AIDS Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Pakistan 2006-07 Percentage of women who say that: Percentage who say that a healthy- looking person can have the AIDS virus and who reject the two most common local miscon- ceptions1 Background characteristic A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Percentage with a compre- hensive knowledge about AIDS2 Number of women Age 15-24 25.8 17.2 27.3 18.6 7.0 3.4 2,068 15-19 14.1 12.7 18.7 11.8 4.2 2.0 569 20-24 30.3 18.9 30.6 21.1 8.1 4.0 1,499 25-29 30.6 21.3 34.5 26.5 11.3 7.0 2,006 30-39 28.1 18.4 31.2 22.1 8.8 5.8 3,440 40-49 26.1 16.6 26.4 19.1 7.4 3.9 2,509 Marital status Married 27.6 18.4 30.0 21.6 8.6 5.1 9,556 Divorced/separated/widowed 27.4 16.6 27.3 18.8 7.3 3.7 467 Residence Total urban 44.8 31.9 49.9 37.6 16.3 9.3 3,350 Major city 53.9 37.1 56.9 44.8 21.2 12.5 1,898 Other urban 32.9 25.1 40.7 28.2 9.8 5.2 1,452 Rural 19.0 11.5 19.8 13.4 4.7 2.9 6,673 Province Punjab 31.6 18.5 31.1 23.1 9.3 5.8 5,800 Sindh 25.3 20.9 30.6 19.7 8.6 4.6 2,410 NWFP 20.8 14.7 27.4 20.6 6.4 3.5 1,351 Balochistan 9.9 13.1 17.6 13.4 5.1 2.4 462 Education No education 14.7 8.1 14.7 8.7 2.4 1.3 6,511 Primary 36.5 22.1 36.7 26.2 8.6 5.7 1,423 Middle 50.1 31.5 59.6 43.3 14.7 6.6 634 Secondary 60.8 48.4 70.9 56.5 26.3 15.2 809 Higher 74.3 61.6 86.5 75.1 42.2 27.5 646 Wealth quintile Lowest 4.2 2.6 4.7 2.7 1.1 0.7 1,944 Second 12.0 7.0 12.4 7.8 1.9 1.4 2,001 Middle 23.7 14.2 24.5 15.5 4.7 3.2 1,944 Fourth 38.4 24.1 41.4 28.7 10.6 5.4 2,055 Highest 57.7 41.9 63.9 50.8 23.5 14.1 2,078 Total 15-49 27.6 18.3 29.9 21.5 8.6 5.1 10,023 1 Two most common local misconceptions: sharing food and mosquito bites 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 13.4 KNOWLEDGE OF MOTHER-TO-CHILD TRANSMISSION Mother-to-child transmission of HIV is an important route of transmission in the general population. The government of Pakistan has recently launched a programme to reduce this route of transmission To assess the extent to which women are aware of the ways in which HIV can be transmitted from a mother to her child, PDHS respondents were asked if the virus that causes AIDS can be transmitted during pregnancy, at delivery, or by breastfeeding. As Table 13.4 shows, 31 percent of women believe the HIV virus can be transmitted from mother to child during pregnancy, 26 percent believe the virus can be transmitted at the time of delivery, and 28 percent know that the AIDS virus can be transmitted from mother to child by breastfeeding. 160 | Knowledge of HIV/AIDS Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of ever-married women who know that HIV can be transmitted from mother to child during pregnancy, at delivery, and by breastfeeding,, by background characteristics, Pakistan 2006-2007 Percentage who know that HIV can be transmitted: Background characteristic During pregnancy At delivery By breastfeeding Number of women Age 15-24 28.2 23.0 26.0 2,068 15-19 17.7 13.5 17.2 569 20-24 32.3 26.6 29.3 1,499 25-29 34.8 28.5 29.7 2,006 30-39 32.1 27.2 27.9 3,440 40-49 29.2 25.0 27.0 2,509 Marital status Married 31.2 26.0 27.7 9,556 Divorced/separated/widowed 29.7 27.6 27.3 467 Currently pregnant Pregnant 29.7 25.1 25.7 1,193 Not pregnant or not sure 31.4 26.2 27.9 8,830 Province Punjab 34.1 29.9 30.6 5,800 Sindh 29.8 21.8 25.1 2,410 NWFP 26.1 20.9 24.5 1,351 Balochistan 15.5 14.4 12.5 462 Residence Total urban 48.4 39.5 41.0 3,350 Major city 55.8 43.2 45.5 1,898 her urban 38.7 34.7 35.1 1,452 Rural 22.5 19.3 21.0 6,673 Education No education 17.3 15.2 17.0 6,511 Primary 42.9 36.2 41.0 1,423 Middle 58.0 45.4 48.3 634 Secondary 63.4 51.0 52.2 809 Higher 77.6 63.0 54.0 646 Wealth quintile Lowest 5.9 5.2 5.7 1,944 Second 14.7 13.0 15.2 2,001 Middle 27.9 24.0 26.3 1,944 Fourth 44.8 37.6 41.0 2,055 Highest 60.3 48.5 48.2 2,078 Total 15-49 31.2 26.0 27.6 10,023 The pattern of knowledge about transmission of HIV from mother to child during pregnancy, at delivery, and by breastfeeding is more or less similar across ages, urban-rural residence, provinces, and wealth quintiles. The lowest knowledge has been observed, for all other stages, among ever- married women age 15-19 years. The proportion who know about mother-to-child transmission is almost twice as high among urban than rural women for all three time periods. Punjab has the highest proportion of women who know about transmission of HIV during pregnancy, at delivery, and by breastfeeding, followed by Sindh, NWFP, and Balochistan. About half of the women in the highest wealth quintile know about all these modes of HIV transmission from mother to child, compared with only 6 percent of women in the lowest wealth quintile. Knowledge of HIV/AIDS | 161 13.5 ATTITUDES TOWARDS PEOPLE LIVING WITH HIV/AIDS Misconceptions and beliefs about HIV/AIDS affect people living with HIV/AIDS. In the 2006-07 PDHS, a number of questions were posed to respondents to measure their attitudes towards people living with HIV/AIDS, including hypothetical questions about their willingness to care for a relative who has the AIDS virus in their own household and their willingness to let others know if a family member became HIV infected. Table 13.5 shows by background characteristics the percentage of ever-married women who express positive attitudes towards people living with HIV. These responses pertain to women who have heard about HIV/AIDS. More than three in four women state that they would be willing to care for a family member with the AIDS virus in their home. Sixty-two percent of women say that they would not necessarily want to keep secret that a family member is infected with the AIDS virus. The percentage of women expressing accepting attitudes on these two measures combined is low (48 percent). Table 13.5 Accepting attitudes towards those living with HIV/AIDS Among ever-married women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes towards people with AIDS, by background characteristics, Pakistan 2006-07 Percentage of respondents who: Background characteristic Are willing to care for a family member with the AIDS virus in the woman’s home Would not want to keep secret that a family member got infected with the AIDS virus Percentage expressing accepting attitudes on both indicators Number of women who have heard of AIDS Age 15-24 80.6 59.1 46.8 868 15-19 83.2 55.5 45.0 173 20-24 80.0 60.0 47.2 696 25-29 78.0 57.8 44.6 969 30-39 76.0 63.5 47.7 1,535 40-49 77.3 66.4 51.3 1,054 Marital status Married 77.6 62.2 47.7 4,229 Divorced/separated/widowed 79.2 60.5 46.9 198 Residence Total urban 80.3 61.8 49.5 2,319 Major city 83.4 64.7 54.3 1,502 Other urban 74.4 56.5 40.8 817 Rural 74.8 62.4 45.7 2,108 Province Punjab 74.4 66.3 48.6 2,715 Sindh 89.2 57.4 51.8 1,029 NWFP 74.0 57.1 41.1 573 Balochistan 70.4 27.9 21.4 110 Education No education 77.3 58.7 45.8 1,722 Primary 77.7 67.1 50.5 841 Middle 77.9 60.3 44.2 518 Secondary 74.5 67.7 51.4 724 Higher 82.1 59.7 47.7 622 Wealth quintile Lowest 74.2 53.9 41.3 161 Second 76.9 56.7 43.7 421 Middle 74.3 58.3 42.2 795 Fourth 76.6 62.8 47.2 1,303 Highest 80.5 65.3 52.1 1,747 Total 15-49 77.7 62.1 47.7 4,427 Stigma associated with AIDS and attitudes related to HIV/AIDS do not vary much by respondents’ background characteristics. The percentage expressing accepting attitudes towards those living with HIV/AIDS slightly increases with age, from 45 percent among women age 15-19 to 51 percent among women age 40-49. Women living in urban areas are slightly more likely than rural women to accept people living with AIDS, while women in Punjab are more than twice as likely as 162 | Knowledge of HIV/AIDS women in Balochistan to have accepting attitudes towards people with AIDS (49 percent and 21 percent, respectively). Women living in households in higher wealth quintiles are more considerate towards people having HIV/AIDS. 13.6 KNOWLEDGE OF OTHER SEXUALLY TRANSMITTED INFECTIONS The importance of STIs is two-fold. Besides imposing a significant disease burden, they also represent a marker for HIV transmission (which is also transmitted sexually). The 2006-07 PDHS collected information on respondents’ awareness about other STIs and women were also asked about their knowledge of the symptoms of STIs. Table 13.6 reveals that only one in ten ever-married women age 15-49 years reports having ever heard about other infections that can be transmitted through sexual contact. Knowledge about STIs varies only slightly by background characteristics. Women in the older age groups are slightly more likely to know about other STIs than younger women, i.e., more than 10 percent of women 40- 49 years are aware of other STIs compared with 5 percent of women age 15-19 years. Education has a positive relationship, i.e., as education increases, knowledge of other STIs also increases. Table 13.6 Knowledge of sexually transmitted infections (STIs) and STI symptoms Among ever-married women age 15-49, the percentage who know about STIs and/or symptoms of an STI, by background characteristics, Pakistan 2006-07 Percentage of ever-married women who know of STIs and of specific symptoms of STIs: Background characteristic STIs other than AIDS Wound with- out pain Wound with pain Wound, pain with lots of pimples Pus- like dis- charge Dark pus- like dis- charge Sour milk- like dis- charge Sponge- like dis- charge Dis- charge with bad odour/ dirty water Itching/ back- ache Hepa- titis TB Other Number of ever- married women Age 15-24 6.9 1.2 1.0 0.5 1.1 0.7 0.5 1.1 1.5 1.0 0.4 0.8 1.1 2,068 15-19 4.9 1.1 0.8 0.2 0.6 0.9 0.5 1.1 1.1 0.8 0.1 0.0 1.1 569 20-24 7.7 1.3 1.0 0.6 1.3 0.6 0.5 1.1 1.6 1.1 0.5 1.1 1.0 1,499 25-29 8.9 2.3 2.0 1.4 1.4 1.2 1.0 1.5 2.0 0.3 1.0 0.8 1.4 2,006 30-39 11.0 2.6 2.5 1.5 1.6 1.3 1.1 1.7 2.2 0.5 1.2 1.4 2.2 3,440 40-49 10.2 2.8 2.3 1.6 2.0 1.2 1.1 1.5 2.5 0.5 1.0 1.7 1.5 2,509 Marital status Married 9.5 2.3 2.1 1.3 1.6 1.1 1.0 1.5 2.0 0.6 0.9 1.3 1.6 9,556 Divorced/separated/ widowed 9.6 2.3 1.0 1.5 0.9 0.9 0.4 0.1 3.5 0.3 1.8 1.3 1.5 467 Residence Total urban 11.0 2.9 2.7 1.7 2.0 1.3 1.1 1.2 2.0 0.6 1.3 1.0 2.2 3,350 Major city 11.2 3.5 3.0 1.8 2.4 1.6 1.1 1.1 1.6 0.7 1.9 0.9 2.1 1,898 Other urban 10.7 2.1 2.3 1.5 1.5 1.0 1.1 1.4 2.5 0.4 0.7 1.2 2.3 1,452 Rural 8.8 2.0 1.7 1.1 1.3 1.0 0.9 1.6 2.1 0.6 0.8 1.4 1.3 6,673 Province Punjab 12.4 2.8 2.3 1.3 1.9 1.2 1.2 2.0 2.7 0.9 1.3 1.9 2.1 5,800 Sindh 6.5 2.4 2.0 1.2 0.7 1.2 1.0 1.0 1.8 0.2 0.2 0.3 1.2 2,410 NWFP 4.8 0.4 1.3 1.4 1.9 0.9 0.4 0.6 0.4 0.0 0.8 0.6 0.9 1,351 Balochistan 3.3 1.0 0.8 0.6 0.9 0.2 0.3 0.3 0.6 0.0 0.6 0.7 0.3 462 Education No education 7.8 1.9 1.6 0.8 1.2 0.8 0.6 1.3 2.1 0.6 0.5 0.9 1.3 6,511 Primary 11.9 3.0 1.9 2.0 2.0 0.9 1.8 1.9 2.2 0.7 0.7 2.4 1.9 1,423 Middle 10.5 2.2 2.4 1.1 1.8 1.0 1.0 1.0 1.4 0.0 1.6 1.6 1.7 634 Secondary 9.7 2.9 2.9 2.2 2.1 1.2 1.0 1.5 1.2 0.8 1.7 1.4 1.3 809 Higher 20.7 4.6 4.8 3.9 3.8 4.6 3.1 2.3 3.8 0.2 4.3 1.6 4.8 646 Wealth quintile Lowest 6.7 1.3 1.4 0.7 0.8 1.2 0.6 1.5 2.2 0.5 0.4 0.6 1.4 1,944 Second 7.1 2.1 1.7 0.6 1.0 0.8 0.4 1.2 2.0 0.2 0.3 1.1 1.0 2,001 Middle 10.0 2.4 1.8 1.4 2.1 0.9 1.3 1.4 2.1 0.9 0.3 1.5 1.6 1,944 Fourth 10.9 2.5 2.1 1.6 1.8 0.8 1.0 1.7 2.4 0.3 1.4 1.9 1.4 2,055 Highest 12.7 3.3 3.0 2.0 2.1 1.8 1.4 1.5 1.7 0.9 2.3 1.2 2.6 2,078 Total 15-49 9.5 2.3 2.0 1.3 1.6 1.1 1.0 1.5 2.1 0.6 1.0 1.3 1.6 10,023 TB = Tuberculosis Knowledge of HIV/AIDS | 163 Table 13.6 further shows data on knowledge about specific signs of STIs other than HIV. A very low proportion of respondents could reply to the question “could you kindly tell me some signs of these infections that you know about?” Only 2 percent of women cite symptoms of STIs like “wounds without pain,” “wounds with pain,” and “discharge with bad odour/dirty water.” The proportion of women who mentioned other symptoms is even lower than 2 percentage points. 13.7 SAFE INJECTION PRACTICES Failure to follow safe injection practices increases the risk of transmission of blood-borne pathogens. To obtain information on the prevalence of injections, PDHS respondents were asked about the total number of injections that they had in the 12 months before the survey, how many of these injections were administered by a health care provider, where they obtained the syringe for the last injection, and whether the person who gave that injection took the syringe and needle from a new, unopened package. Table 13.7 presents data on the prevalence of injections among PDHS respondents. The results indicate that more than half of women had at least one injection in the 12 months before the survey, with an average of five injections per person. Table 13.7 Prevalence of medical injections Percentage of ever-married women age 15-49 who received at least one medical injection in the 12 months preceding the survey, the average number of medical injections per person in the 12 months preceding the survey, and among those who received a medical injection the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Pakistan 2006-07 Background characteristic Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the past 12 months Age 15-24 57.3 4.2 2,068 83.7 1,184 15-19 53.1 3.8 569 77.9 302 20-24 58.9 4.3 1,499 85.7 882 25-29 56.2 4.8 2,006 87.7 1,128 30-39 49.9 4.9 3,440 86.9 1,717 40-49 48.6 6.3 2,509 85.2 1,220 Residence Total urban 52.7 4.8 3,350 89.3 1,764 Major city 54.0 5.1 1,898 91.0 1,024 Other urban 50.9 4.4 1,452 87.1 740 Rural 52.2 5.2 6,673 84.3 3,486 Province Punjab 50.4 4.8 5,800 90.8 2,922 Sindh 65.3 6.2 2,410 74.6 1,574 NWFP 49.8 5.6 1,351 92.7 673 Balochistan 17.5 0.9 462 76.2 81 Education No education 49.8 5.0 6,511 81.7 3,244 Primary 61.2 5.8 1,423 91.9 871 Middle 56.7 5.7 634 92.7 359 Secondary 55.8 4.9 809 93.2 452 Higher 50.1 3.4 646 95.5 324 Wealth quintile Lowest 48.6 4.9 1,944 73.0 944 Second 48.6 4.9 2,001 82.8 972 Middle 54.8 5.2 1,944 86.1 1,065 Fourth 55.6 5.4 2,055 91.8 1,143 Highest 54.2 4.9 2,078 93.6 1,126 Total 15-49 52.4 5.1 10,023 86.0 5,249 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist or other health worker. 164 | Knowledge of HIV/AIDS Table 13.7 also shows by background characteristics the women who are receiving these injections. Although there are not large variations in either of the indicators, the results show that the prevalence of injections tends to decrease with age and increases somewhat with wealth quintile. Nevertheless, the mean number of injections received in the last 12 months increases with age. It also increases with the wealth index. In addition to the basic information on the frequency of injections, the PDHS included several questions concerning the safety of injections. Respondents who had a recent injection were asked if the provider had taken the syringe and needle from a new unopened package; 86 percent reported that the provider had followed this basic injection safety procedure. Safe injection practice is positively associated with education of women and also increases with wealth quintile. Women living in urban areas and in NWFP and Punjab province are more likely than other women to have safe injections. Figure 13.3 provides information on the source from where the syringe was obtained for the last injection. It shows that eight out of ten women who received an injection in the last 12 months obtained the syringe from the private sector (51 percent from private hospital/clinics and 26 percent from dispensers/compounders/chemists) and two in ten obtained the syringe from the public sector (12 percent from government hospitals). Regardless of the source of the syringe, the vast majority reported getting safe injections (Figure 13.4). PDHS 2006-07 Figure 13.3 Source of Last Medical Injection Government hospital/RHSC 12% BHU/FWC 2% Lady Health Worker 2% Other public 1%Private hospital/clinic/ private doctor 51% Chemist/dispenser 26% Other private medical 2% At home/ other 4% RHSC = Reproductive Health Service Centre BHU = Basic health unit FWC = Family Welfare Centre Knowledge of HIV/AIDS | 165 Figure 13.4 Percentage of Women Whose Last Injection Was Given with a Syringe and Needle Taken from a New, Unopened Package, by Type of Facility Where Last Injection Was Received 88 85 86 Public sector Private sector Total 0 20 40 60 80 100 Percent PDHS 2006-07 166 | Knowledge of HIV/AIDS ADULT AND MATERNAL MORTALITY 14 Farid Midhet and Sadiqua N. Jafarey, Dr. Azra Ahsan, and Aysha Sheraz 14.1 INTRODUCTION Maternal mortality represents the largest and the most persistent gap in health indicators between the developed and developing countries. The maternal mortality ratio (MMR), which measures the risk of death per pregnancy, is up to 40 times higher in some African countries than the countries of Northern Europe (Abou Zahr and Wardlaw, 2004). MMR is believed to be the most sensitive indicator of women’s status in a society and of the quality and accessibility of maternal health services available to women. A maternal death is not merely a result of treatment failure; rather it is the final outcome of a complex interplay between a myriad of social, cultural and economic factors. Therefore, maternal mortality is widely recognized as a key human rights issue (Rosenfield et al., 2006). In the vast majority of cases, a maternal death reflects the failure of society to look after the life and health of its mothers. It was for these reasons that the Millennium Declaration adopted MMR as an indicator of maternal health and set the goal of reducing maternal mortality from the 1990 level by 75 percent before 2015. Many experts believe that it is theoretically possible to achieve this target in a majority of developing countries where the MMR is currently higher than 100 maternal deaths per 100,000 live births. The interventions required to achieve this target are skilled birth attendance and emergency obstetric care (Campbell and Graham, 2006). Nevertheless, maternal mortality is an area where the least progress has been made since the Millennium Declaration in 2000. Most projections, using trends in maternal mortality levels since 1990, point to the fact that the fifth Millennium Development Goal will not be achieved in the vast majority of developing countries. Moreover, it is hard to measure the MMR, which requires a well-developed birth and death registration system or expensive field surveys. Indeed, this is the most important reason noted for a failure to address this MDG in the developing nations of the world (United Nations, 2004). Pakistan’s national health policy emphasizes the need to improve quality and accessibility of maternal health services, particularly in the rural areas. All national programs on primary health care have included maternal health as a core component. The country’s first maternal and child health program was launched in the early 1950s. In the 1990s, the Lady Health Worker program was introduced, which has a major emphasis on maternal health. In spite of these efforts, progress in maternal health indicators has remained slow in comparison with other health and population indicators. About 40 percent of pregnant women do not receive skilled prenatal care or full protection against tetanus (Chapter 9). Moreover, almost two in three births occur at home and 60 percent of births are not assisted by skilled medical attendants. Delays in seeking medical care for obstetric complications are common. Pakistan is a signatory to the Millennium Declaration and is committed to achieve the Millennium Development Goals (MDGs). The country’s targets for MDG-5 are to reduce the MMR to less than 140, and to increase skilled birth attendance to 90 percent by the year 2015 (Ministry of Health, 2005). To achieve these targets, the Government has recently launched a large-scale national maternal, neonatal and child health program. The major emphasis of the program is on improving the quality and accessibility of emergency obstetric and neonatal care and increasing the use of skilled birth attendance by introducing a new cadre of health workers—community midwives—along the same lines as the Lady Health Worker program. The community midwives will be fully trained health professionals who will gradually replace the traditional birth attendants in the rural areas of Pakistan. Adult and Maternal Mortality | 167 Most data on the MMR are based on local or sub-national data. No reliable MMR data are available at the national level, with the exception of an indirect estimate arising from a national survey conducted in 2001. Several local and national studies have reported widely different values for MMR, from a low of 279 maternal deaths per 100,000 births to a high of 533 (Table 14.1). Most international sources prior to 2000 reported an estimated MMR of 500 per 100,000 live births. The government currently uses a working range of 350 to 400 (Planning Commission of Pakistan, 2002). Table 14.1 Previous sources of data on the maternal mortality ratio Reference period Study/source Estimation method Geographical coverage MMR estimate 1990-1991 National Reproductive Health and Family Planning Survey 2001 (National Institute of Population Studies, 2002) Indirect sisterhood method Pakistan 533 1988-1993 Maternal and Infant Mortality Survey (MIMS) (Midhet et al., 1998) Verbal autopsy Selected rural districts of Balochistan and NWFP 392 2000-2001 Maternal and Infant Mortality Survey (MIMS) (Midhet, 2001) Statistical modelling using district characteristics as independent variables and projected into future Pakistan 279 2000 Estimates developed by WHO, UNICEF and UNFPA, (Abou Zahr and Wardlaw, 2004) Statistical modelling using country characteristics as independent variables Pakistan 500 2005 Estimates developed by WHO, UNICEF, UNFPA, and the World Bank (WHO, 2005) Statistical modelling using country characteristics as independent variables Pakistan 320 Community-based studies of maternal mortality (e.g., the Maternal and Infant Mortality Survey—MIMS) have estimated large variations in MMR by urban and rural areas, provinces and more and less developed districts. Based on statistical models, the government has classified districts into low, medium and high MMR categories (Ministry of Health, 2005). In general, Balochistan has the highest average MMR and Punjab has the lowest. The most important cause of the divergence is differences in access to emergency obstetric and neonatal care services (Midhet et al., 1998). Hospital-based studies of maternal mortality report much higher MMRs because of the selection bias (more high-risk pregnancies being referred to hospitals). The studies conducted in the large teaching hospitals in the public sector typically report MMRs that are exponentially higher than the community-based studies (Jafarey, 2002; Jafarey and Korejo, 1993; Qureshi and Qazi, 2003). Previous studies have identified postpartum haemorrhage, antepartum haemorrhage, puerperal sepsis, obstructed labour, eclampsia, and complications of abortions as the leading direct causes of maternal deaths, accounting for approximately 70 percent of all maternal deaths, both occurring in the community and in hospitals (Jafarey, 2002) Unfortunately, these causes are neither preventable nor predictable. A woman having a normal pregnancy can suddenly develop any of these complications. However, all of these causes are treatable at a modestly staffed and adequately equipped secondary care hospital, provided that the mother arrives at the hospital relatively early in the course of the complication. Because of the paucity of data on MMR and the desire to measure progress towards meeting the MDG-5 goal, the need for a national study to estimate the MMR was felt among public health professionals and government circles for a long time. It was decided that the scope of Pakistan’s 2007 Demographic and Health Survey could be expanded to measure MMR using verbal autopsies. Besides estimating the MMR, the 2007 PDHS provides valuable data on the causes and risk factors of maternal mortality, as well as on a number of process indicators, which will be of great help in programme development and monitoring and evaluation. 168 | Adult and Maternal Mortality 14.2 METHODS OF DATA COLLECTION In the 2006-07 PDHS, the Household Questionnaire elicited information on all deaths and live births occurring since January 2003. Female deaths in the age-group 12-49 years thus identified were further investigated through the verbal autopsy (VA) questionnaire, which was administered by a specially trained interviewer. The process of identifying maternal deaths through VA interviews had three stages: developing and validating the VA questionnaires; administering the validated VA questionnaires; and assignment of the cause of death to each VA questionnaire by a panel of three experts. 14.2.1 Development and Validation of the VA Questionnaire Use of VA instruments for investigating causes of deaths is now well established and a number of model VA instruments are available. VA questionnaires generally comprise a combination of precoded and open-ended questions that are used in interviews with the family and/or health care providers of the deceased. The VA can be used in combination with a large community survey or on its own; for example, in Pakistan, Lady Health Workers (LHWs) routinely conduct a short VA interview with the family of women dying in their reproductive years. The VA methodology has its limitations (such as problem of recall, misclassification of cause of death, etc.), but it is the most reliable method to use in the absence of a functioning vital registration system (Chandramohan, et al., 2001; Chandramohan et al., 1998). WHO guidelines for verbal autopsies (WHO, 1995) and several model questionnaires were consulted before designing the questionnaire for the 2006-07 PDHS; however, the modules and sequencing of questions were derived mainly from the VA questionnaire used in the Bangladesh maternal mortality study in 2001 (NIPORT et al., 2003). The VA questionnaire included the following sections: 1) personal information of the respondents for the VA interview (age, sex, relationship with the deceased woman and whether he or she was present during the fatal illness, at the time when the woman was taken to hospital, and at the time of death); 2) personal information of the deceased woman, including a short pregnancy history; 3) a detailed verbatim report of the events surrounding the death, as narrated by the respondents; 4) a check-list of signs and symptoms occurring prior to death; 5) details of a few selected signs and symptoms identified through the check-list (duration, intensity, persistence, prognosis); and 6) details of health services utilization during fatal illness. The draft questionnaire was pretested in the periurban areas of Islamabad in households where the Family Welfare Centre indicated that a maternal death had occurred during the previous year. After pretesting, the questionnaires were further refined to remove repetition and improve sequencing of questions. The questionnaire was then validated during July-September 2006 to test its sensitivity and specificity. The primary purpose of the validation was to determine the level of agreement in the cause and category of death assigned by the hospital and through review of the completed VA questionnaire. The estimated sample size for the validation study was 128. The first step was to identify 128 female deaths age 15-49 years occurring in the previous year in four tertiary care hospitals—two in Rawalpindi/ Islamabad and two in Hyderabad. Two methods were used for identifying female deaths: 1) Backward tracking (identifying all female deaths occurring in the hospital in last year and ascertaining the home address of the deceased woman through hospital records; due to incomplete hospital records, this method was not successful); 2) Forward tracking (identifying female deaths in communities residing in the vicinity of the hospitals and then finding the hospital records pertaining to that death). The latter was the more commonly used method. Female deaths in communities were identified through LHWs’ records. For each death that occurred in a hospital, the following information was collected: a certificate of cause of death from the hospital records; home address of the deceased woman; and the completed VA questionnaire. Adult and Maternal Mortality | 169 Two field supervisors first filled out a “certification of death” form with the help of the hospital staff from the hospital records (electronic records or case files). The information on the form included the name, age, address and date of death of the deceased woman; the name and address of the hospital where the death occurred; the category of death (maternal, non-maternal and unknown); and the immediate and underlying causes of death. These records were kept strictly confidential and the VA interviewers did not have access to them. Once the address of the deceased woman was confirmed, a team comprised of two experienced female interviewers (one team each in Rawalpindi/ Islamabad and Hyderabad) was dispatched to administer the draft VA questionnaire. Completed VA questionnaires were edited and entered into a computer database. Each completed VA questionnaire was then forwarded to a panel of obstetricians at the Pakistan Institute of Medical Sciences, Islamabad. The reviewing obstetricians carefully read the completed questionnaire and then filled out a “certification of death” form, which was identical to the one filled at the hospital where the death had occurred. The reviewing obstetricians were not privy to the information contained in the hospital’s certification of death form. Causes of death assigned by the hospital and the obstetrician/reviewer were compared through contingency tables and the degree of agreement was estimated using Kappa statistic. Using hospital diagnosis as the “gold standard” and regarding the VA interview as a screening test, the sensitivity, specificity and the positive and negative predictive values were computed. Only 120 female deaths could be identified and successfully tracked in the two sites .VA questionnaires were completed on all of these deaths. However, ten questionnaires had to be discarded due to ambiguous or partly missing information. There was reasonable agreement in the assignment of broad categories of the cause of death (direct maternal, indirect maternal, infectious diseases, cancer, hypertension, diabetes, and unknown). In terms of identifying maternal deaths, the VA questionnaire had a sensitivity of 86 percent, a specificity of 91 percent, a positive predictive value of 78 percent, and a negative predictive value of 95 percent. The validation exercise also provided valuable information on further refining and improving the VA questionnaires, for training the interviewers and for review panelists for coding and categorizing the causes of death. 14.2.2 Implementation of VAs in Sample Households Each PDHS data collection team included female interviewers who were specially trained to conduct verbal autopsies. These interviewers received extensive training in the VA methodology and questionnaire, during which it was emphasized that the VA interview was very different from the more customary interviewing of single respondents. Rather, interviewers were encouraged to include in the VA interview all those in the household who had knowledge of the circumstances surrounding the deceased prior to her death. The training included exercises, mock interviews, and filling of questionnaires based upon pre-designed scenarios in the form of stories. Finally, all interviewers had a chance to practice their interviewing skills (in teams) in actual field settings. Before qualifying for field work, each interviewer was examined on her comprehension of the questionnaire, interviewing techniques, and interpersonal skills. During the data collection, when a death to a woman age 12-49 was identified in the Household Questionnaire as occurring in the reference period, the team supervisor assigned a VA interviewer to the household reporting the female death. The VA interviewer visited the household to arrange a suitable time for the detailed VA interview, ideally with those household members who were most knowledgeable about the deceased woman’s symptoms preceding her death. Interviews were usually completed in one sitting and place. However, some questionnaires required multiple visits to the household. At the end of each interview, the interviewer recorded her comments on the conduct of the interview and the demeanour of the respondents during the interviewing process. The most informative and interesting part of the VA questionnaire proved to be the verbatim story of death narrated by the respondents and recorded in their own words. Since this part was filled early in the interview, it also served as a guide for conducting the pre-coded questionnaire. 170 | Adult and Maternal Mortality 14.2.3 Review of VA Questionnaires and Assignment of Causes of Death The completed VA questionnaires were returned to NIPS, where they were edited, coded and entered into a database. Three photocopies of each questionnaire were made and dispatched to the National Committee for Maternal and Neonatal Health (NCMNH) in Karachi, where the review process of the VA questionnaires was carried out. One copy was kept in the office and the others were circulated among the reviewers. There were three panels of three reviewers (two obstetricians and one general physician) each. The VA questionnaires were divided into three equal lots, each assigned to a panel. Each questionnaire was reviewed independently by the three experts in the panel. The reviewers recorded their comments on a prescribed form for cause of death assignment containing the following information: identification data; category of death (direct maternal, indirect maternal, coincidental maternal, non-maternal and “could not be determined”); main cause of death (immediate and underlying); possible cause of death (immediate and underlying); associated cause (s) of death, if any; delays in receiving treatment during fatal illness; and the reviewer’s assessment of the quality of data. To help the reviewers summarize and comprehend the complex data, a checklist was also prepared, which listed the main signs and symptoms of the fatal illness and thus facilitated assigning a cause of death. The reviewers returned the completed cause of death forms to the NCMNH office, where the information from the three cause of death forms were aggregated on a single sheet of paper. The VA questionnaire, the cause of death form and the aggregation sheet were then examined by a fourth reviewer. The job of the fourth reviewer was to give a consensus opinion on the category and cause of death. A condition was regarded as the main cause of death if it was entered in each of the three cause of death forms as either an immediate, underlying, possible, or associated cause of death. In cases where a consensus could not be formed (21 percent of cases), the three reviewers were invited for a small meeting with the fourth reviewer. The 15 cases that remained unresolved after the meeting were discussed in a larger meeting including all reviewers. Finally, all of the causes of death were assigned the standard 4–digit codes according to the International Classification of Diseases, 10th version (ICD-10) (WHO, 2007). Coding was carried out by trained personnel of the medical records depart- ment at Ziauddin University Hospital, Karachi. The coding was carried out under supervision of one of the panelist reviewers. Coded forms were randomly rechecked by the NCMNH staff for accuracy. Each reviewer assessed the quality of data on a scale of 0-10 (whereby 0 was considered as the poorest quality and 10 as the highest quality). Scoring was based on the following criteria: missing information; discrepancy within objective data; and discrepancy between objective data and verbatim history of fatal illness. Some general comments made by the reviewers include: • The quality of the verbal autopsy data was generally quite good • The verbatim section provided valuable additional information which helped in arriving at a conclusive diagnosis; however, the verbatim sections in the VA questionnaires from Balochistan and NWFP were very brief and non-descriptive • The questionnaires from Balochistan and NWFP had the highest frequency of disagreement between reviewers • There was some discussion amongst the reviewers about the cut-off gestational age at which the case could be labelled as abortion. WHO recommends 20 weeks of gestation as the cut-off point but considering the situation in Pakistan, the view of the majority of health professionals was 24 weeks of gestation • The signs/symptoms checklist sped up the reviewing process and was helpful in summarizing complex data. Adult and Maternal Mortality | 171 14.3 ADULT MORTALITY RATES Table 14.2 presents the age-specific mortality rates for women and men aged 15-49 years, by five-year age groups. Men have higher mortality rates than women at all ages except 15-19 (Figure 14.1). This is reassuring, since it is the expected pattern. Comparison for urban and rural areas separately indicates that men have higher mortality rates in each age group except 15-19 and in rural areas, in age group 35-39. It is also interesting to compare the male and female mortality rates by province. In Punjab, men age 15-49 years have higher mortality than women at each age group except the youngest. In Sindh and NWFP, the overall rates are similar, with the age-specific rates showing no consistent pattern by sex, while in Balochistan, mortality among women is higher than among men at every age group except 45-49. The excess mortality among women of reproductive ages in Balochistan compared to men could be attributed to higher maternal mortality and is consistent with the higher maternal mortality ratio in that province (Table 14.11). Table 14.2 Adult mortality Age-specific mortality rates for women and men age 15-49 based on deaths reported in the household questionnaire as occurring in the 12 months preceding the interview, Pakistan 2006-07 Residence Province Age Urban Rural Punjab Sindh NWFP Balochistan Total WOMEN 15-19 1.5 1.4 1.4 1.5 1.0 2.3 1.4 20-24 0.9 1.8 1.1 1.9 1.8 2.8 1.4 25-29 1.0 2.3 2.1 1.5 0.8 3.5 1.9 30-34 1.5 3.1 2.4 2.8 2.1 4.7 2.5 35-39 2.6 3.2 2.2 3.8 4.0 6.1 3.0 40-44 2.7 3.8 3.3 3.8 3.3 4.3 3.4 45-49 4.6 4.3 3.9 7.9 1.3 1.6 4.4 Total 1.8 2.4 2.0 2.6 1.8 3.4 2.2 MEN 15-19 1.0 1.3 1.0 1.3 1.6 1.0 1.2 20-24 1.4 2.4 2.4 1.7 0.9 1.8 2.0 25-29 2.1 2.8 2.7 2.4 2.4 1.9 2.6 30-34 2.2 3.5 3.6 2.8 1.0 1.5 3.0 35-39 5.0 2.8 3.7 4.1 1.6 4.5 3.6 40-44 4.3 5.3 5.4 5.1 3.5 0.2 4.9 45-49 8.3 6.6 8.6 4.9 5.7 3.7 7.2 Total 2.7 2.9 3.2 2.6 2.0 1.9 2.8 Note: Rates are calculated as follows: the numerator consists of the number of deaths reported as occurring in the 12 months prior to the interview, while the denominator consists of the number of woman-/man-years. For example, the denominator for women 15-19 consists of an average of the number of women listed in the household age 15-19 and 16-20, plus one-half of the deaths reported to women 15-19 in the 12 months prior to the survey. Rates are quoted per 1,000 women/men. With regard to patterns by residence, mortality rates are generally higher in rural areas than in urban areas. For example, rural women have steadily higher age-specific mortality rates than urban women, except at the extreme ages (15-19 and 45-49), when the urban and rural rates are very similar. Among men, mortality rates are higher in rural areas except at age groups 35-39 and 45-49, which is somewhat puzzling. Across provinces, mortality is highest for women in Balochistan, followed by Sindh, whereas for men, it is highest in Punjab and tends to be lowest in Balochistan. 172 | Adult and Maternal Mortality � � � � � � � � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 2 4 6 8 Deaths per 1,000 Women Men� � PDHS 2006-07 Figure 14.1 Mortality Rates by Age Group for Women and Men Age 15-49 Note: Refers to deaths in the 12 months preceding the survey These results are comparable with the age-specific mortality rates reported in the 2005 Pakistan Demographic Survey (Figures 14.2 and 14.3) (Federal Bureau of Statistics, 2001). However, the PDS has consistently lower male and female ASDRs than the 2006-07 PDHS at each age except for the women in the 20-24 years age-group. This may be due to more complete reporting of deaths in the PDHS, compared to the PDS. � � � � � � � � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 1 2 3 4 5 Deaths per 1,000 PDHS PDS� � Figure 14.2 Mortality Rates by Age Group for Women Age 15-49, Pakistan 2005 and 2006-07 Note: Refers to deaths in the 12 months preceding the survey Adult and Maternal Mortality | 173 � � � � � � � � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 2 4 6 8 Deaths per 1,000 PDHS PDS� � Figure 14.3 Mortality Rates by Age Group for Men Age 15-49, Pakistan 2005 and 2006-07 Note: Refers to deaths in the 12 months preceding the survey 14.4 RESPONSE TO THE VERBAL AUTOPSY A total of 1,125 adult female deaths were identified through the household questionnaires as occurring since January 2003. Verbal autopsies were successfully completed for 1,062, for a response rate of 94 percent (Table 14.3). The response rate was lowest in NWFP (82 percent) and highest in Punjab (98 percent). The reasons for the low completion rate in the NWFP included difficulty in revisiting the households due to security reasons and refusal of the household members from giving an interview. There were no significant differences in completion rates by age of the deceased woman or urban/rural residence. Table 14.3 Adult women verbal autopsy response rates Number of deaths to women 12-49 identified in households in 2003 or later and number and percentage for which a verbal autopsy was completed by age, residence and province, Pakistan 2006-07 Background characteristic Number of female deaths identified Number of verbal autopsies Percent completed Age < 20 218 202 92.7 20-24 152 148 97.4 25-29 167 155 92.8 30-34 133 125 94.0 35-39 162 157 96.9 40-44 149 134 89.9 45-49 144 141 97.9 Residence Total urban 392 370 94.4 Major city 211 196 92.9 Other urban 181 174 96.1 Rural 733 692 94.4 Province Punjab 484 474 97.9 Sindh 329 310 94.2 NWFP 153 126 82.4 Balochistan 159 152 95.6 Total 1,125 1,062 94.4 174 | Adult and Maternal Mortality As shown in Table 14.4, respondents for the VA interviews were usually close relatives of the deceased woman (parent, followed by brother-in-law or sister-in-law, husband, brother, or sister, parent-in-law, and son or daughter). A little over half of the VA interviews were done with multiple respondents. In nearly all cases (94 percent), at least one of the respondents for the VA interview was present at the time the deceased woman first fell ill and in 91 percent of cases, at least one of the respondents was present when the woman died. Table 14.4 Respondents for the adult women verbal autopsies 14.5 CAUSES OF DEATH AMONG WOMEN AGE 12-49 Complications of pregnancy, childbirth and the puerperium emerge as the outstanding cause of death in the reproductive years, accounting for one-fifth of deaths to women of childbearing age in Pakistan (Table 14.5). In the 20-39 age group, these causes account for about three in ten deaths to women. Cancer, tuberculosis, and other infectious diseases are the next most important causes of death among women in reproductive ages. While cancer accounts for a generally in- creasing proportion of deaths with age, deaths from tubercu- losis fluctuate erratically by age group. However, younger women are more likely to die from infectious diseases other than tuberculosis. Deaths from accidents, violence and burns and corrosions are also more common among younger women than older women. While it is not surprising that complications of pre- gnancy, delivery and postpartum period are the leading causes of death among women in the reproductive ages, it is interest- ing to note that the proportion of maternal deaths among all female deaths in the age group 15-49 years is slightly over 20 percent. The World Health Organization routinely reports maternal Among deaths to women 12-49 identified in households in 2003 or later and for which a verbal autopsy was completed, percentage with specific types of respondents, Pakistan 2006-07 Relationship to deceased Percentage Husband 17.3 Son/daughter 15.4 Son-in-law/daughter-in-law 7.0 Grandchild 0.2 Parent 24.9 Parent-in-law 15.8 Brother/sister 16.6 Brother/sister-in-law 19.2 Niece/nephew 2.1 Grandparent 1.6 Aunt/Uncle 4.8 Other relative 11.1 Adopted/foster/stepchild 0.4 Not related 1.4 Domestic servant 0.2 Not stated 0.6 Percentage with more than one respondent 54.9 Percentage with at least one respondent who was present when deceased first fell ill 94.4 Percentage with at least one respondent who was present when deceased died 91.4 Number of verbal autopsies 1,062 Table 14.5 Causes of adult female deaths by age group Percent distribution of adult women deaths aged 12-49 since January 2003 by cause of death (from verbal autopsy), according to age, Pakistan 2006-07 Age Cause of death <20 20-24 25-29 30-34 35-39 40-44 45-49 Total Tuberculosis 10.8 10.3 7.3 16.0 10.2 6.2 11.0 10.1 All other infectious diseases 19.5 7.8 11.3 12.5 6.9 4.9 4.1 10.2 All cancers 8.2 4.8 9.6 8.4 10.0 19.8 20.5 11.3 All benign tumours 1.9 1.5 0.7 0.3 0.0 4.2 0.0 1.3 Blood disorders 2.9 0.0 0.1 1.0 0.8 0.0 0.0 0.8 Diabetes mellitus 1.6 0.5 0.4 2.8 1.1 2.2 8.1 2.2 Stroke and other cardiovascular diseases 4.2 0.6 2.0 5.7 4.7 6.3 12.5 4.9 Diseases of gastrointestinal tract 5.6 14.3 5.5 5.0 8.2 11.0 12.4 8.7 Burns and corrosions 2.1 0.4 3.3 0.0 0.0 0.8 0.0 1.1 Complications following medical treatment 0.2 3.8 1.7 0.7 1.3 1.1 0.8 1.3 Accidents 4.6 6.6 7.1 4.7 1.3 1.6 4.5 4.4 Violence 2.0 1.5 0.5 0.4 0.2 1.3 0.0 0.9 Epilepsy 1.5 4.0 1.3 1.3 0.1 1.2 0.8 1.5 Respiratory disorders 2.8 0.0 0.3 0.9 1.2 1.5 0.8 1.2 Renal function disorders 4.0 1.9 5.9 3.2 1.8 4.3 3.4 3.6 Pregnancy, childbirth and the puerperium 8.2 26.9 36.7 30.5 29.8 11.6 1.9 20.3 All others 12.2 11.9 4.3 6.6 20.9 20.8 16.6 13.2 Not able to categorize 7.6 3.1 2.1 0.0 1.6 1.0 2.5 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 202 142 158 114 143 131 133 1,022 Adult and Maternal Mortality | 175 mortality from statistical models for countries lacking reliable data on births and deaths. These estimates are based on estimation of the proportion maternal through regression models. For Pakistan, the proportion maternal was reported as 16 percent and 15 percent for the 2000 and 2005 estimates, respectively; the estimated MMR for these years was 500 and 320, respectively (Abou Zahr and Wardlaw, 2004; WHO, 2005). The proportion maternal among adult female deaths is the highest in Balochistan, followed NWFP, Sindh and Punjab. NWFP has a higher percentage of maternal deaths than Sindh, even though it has a lower MMR. Table 14.6 presents a comparison by residence of the causes of death among women 12-49 years. Considerably more rural women die of pregnancy-related causes and gastro-intestinal diseases than urban women. On the other hand, deaths due to tuberculosis, respiratory diseases, renal function disorders, and benign tumours are more common among urban women. Table 14.6 Causes of adult female deaths by residence Table 14.7 presents the comparison of causes of death by province. Balochistan has by far the highest proportion of adult female deaths caused by complications of pregnancy, childbirth and puerperium, followed by NWFP, Sindh and Punjab, in that order. The proportion of deaths due to accidents is also higher in Balochistan than in the other three provinces. On the other hand, Sindh has a higher proportion of deaths attributed to gastrointestinal disorders, while NWFP has proportionally more deaths due to cancer, cardiovascular diseases, and epilepsy. Percent distribution of adult women deaths aged 12-49 since January 2003 by cause of death (from verbal autopsy), according to residence, Pakistan 2006-07 Residence Cause of death Urban Rural Total Tuberculosis 11.7 9.5 10.1 All other infectious diseases 9.9 10.4 10.2 All cancers 11.1 11.4 11.3 All benign tumours 2.5 0.8 1.3 Blood disorders 0.8 0.8 0.8 Diabetes mellitus 2.7 2.0 2.2 Stroke and other cardiovascular diseases 4.8 5.0 4.9 Diseases of gastrointestinal tract 6.4 9.6 8.7 Burns and corrosions 1.5 0.9 1.1 Complications following medical treatment 1.3 1.4 1.3 Accidents 4.2 4.5 4.4 Violence 0.8 1.0 0.9 Epilepsy 1.5 1.5 1.5 Respiratory disorders 2.2 0.8 1.2 Renal function disorders 5.4 2.8 3.6 Pregnancy, childbirth and the puerperium 14.0 22.9 20.3 All others 17.0 11.7 13.2 Not able to categorize 2.4 3.2 2.9 Total 100.0 100.0 100.0 Number 292 730 1,022 Table 14.7 Causes of adult female deaths by province Percent distribution of adult women deaths aged 12-49 since January 2003 by cause of death (from verbal autopsy), according to province, Pakistan 2006-07 Province Cause of death Punjab Sindh NWFP Balochistan Total Tuberculosis 11.0 11.8 3.3 5.2 10.1 All other infectious diseases 11.7 7.6 6.8 10.5 10.2 All cancers 12.0 7.7 16.2 10.6 11.3 All benign tumours 1.0 2.4 0.0 1.1 1.3 Blood disorders 0.7 0.9 0.1 2.6 0.8 Diabetes mellitus 1.9 3.0 3.8 0.4 2.2 Stroke and other cardiovascular diseases 5.5 2.2 10.2 2.2 4.9 Diseases of gastrointestinal tract 7.2 14.9 3.9 5.9 8.7 Burns and corrosions 1.0 1.3 1.0 1.0 1.1 Complications following medical treatment 1.8 0.6 0.8 0.8 1.3 Accidents 4.0 4.7 2.3 10.5 4.4 Violence 1.2 0.3 1.0 0.7 0.9 Epilepsy 1.2 0.1 7.0 1.3 1.5 Respiratory disorders 1.3 0.6 2.4 0.0 1.2 Renal function disorders 3.8 3.7 3.5 0.7 3.6 Pregnancy, childbirth and the puerperium 16.3 23.9 27.0 35.2 20.3 All others 14.6 11.8 10.4 9.7 13.2 Not able to categorize 3.7 2.5 0.3 1.5 2.9 Total 100.0 100.0 100.0 100.0 100.0 Number 616 245 97 63 1,022 176 | Adult and Maternal Mortality 14.6 PREGNANCY-RELATED MORTALITY AND MATERNAL MORTALITY According to the WHO, a maternal death is defined as a death of a woman while pregnant or within 42 days of the end of the pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Using data from the PDHS, there are two main ways to measure the contribution that deaths related to pregnancy and childbirth make to the overall level of adult female mortality. One is calculated from the data collected in the Household Questionnaire about deaths to usual members of the household since January 2003. For any death to a woman age 12-49, interviewers asked whether the woman was pregnant when she died and if not, whether she died during childbirth, and if not, whether she died within 6 weeks after delivery. A “yes” answer to any of these three questions resulted in the death being classified as a “pregnancy-related” death. Although not all deaths occurring during pregnancy and within 6 weeks after delivery are due to maternal causes, the vast majority are and these questions have been widely used to elicit pregnancy-related deaths. Another way to measure maternal mortality is by analyzing the verbal autopsies for causes that are either directly or indirectly due to pregnancy or childbirth. Direct maternal deaths are those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect maternal deaths are those resulting from a previously existing disease, or a disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiologic effects of pregnancy. This method provides a more exact measure of maternal deaths because it excludes deaths occurring during pregnancy or in the 6 weeks postpartum that are not related to the pregnancy or delivery. From both definitions of deaths, it is possible to construct mortality rates—which refer to deaths per 1,000 women—or mortality ratios—which refer to deaths per 100,000 live births. The most commonly cited statistic is the maternal mortality ratio which refers to the number of maternal deaths per 100,000 live births. As shown in Table 14.8, the overall pregnancy-related mortality ratio (PRMRatio) for Pakistan is 297 pregnancy-related deaths per 100,000 live births. As expected, the overall maternal mortality ratio (MMR) is slightly lower (since it excludes non-maternal deaths occurring during pregnancy and 6 weeks postpartum) at 276 maternal deaths per 100,000 live births (Table 14.9). Nevertheless, the two rates are very close and compare plausibly with previous estimates. The overall pregnancy-related mortality rate and the maternal mortality rate are the same at 0.4 per 1,000 woman- years. The data imply that approximately 1 in 89 women in Pakistan will die of maternal causes during her lifetime (lifetime risk). Both the age-specific pregnancy-related mortality rates and the maternal mortality rates show an expected pattern of being the lowest in the youngest age group, gradually increasing in the early reproductive years to reach a peak in the 35-39 years age group and then declining afterwards, as pregnancy and childbirth begin to taper off. On the other hand, pregnancy-related and maternal mortality ratios, which are based on births, are slightly higher among the youngest women (under age 20 years), decline in the 20-24 age group and then steadily increase to reach a peak in the 40-44 age group. Although pregnancy may taper off at older ages, it is also relatively riskier, resulting in higher mortality rates among those who do get pregnant. Adult and Maternal Mortality | 177 Table 14.8 Pregnancy-related mortality rates and ratios by age Pregnancy-related1 mortality ratio and rate per 100,000 based on deaths in the 36 months before the survey, by age, Pakistan 2006-07 Weighted number of woman- years2 Weighted number of deaths1 during: Pregnancy- related mortality rate3 Age- specific fertility rates4 Pregnancy- related mortality ratio5 Age Pregnancy Delivery Postpartum period Total <20 120,672 3 2 12 16 0.1 0.051 259 20-24 95,196 14 2 19 35 0.4 0.178 209 25-29 76,785 11 9 28 48 0.6 0.237 262 30-34 57,991 13 3 15 31 0.5 0.182 297 35-39 53,830 12 6 25 43 0.8 0.106 748 40-44 40,447 7 3 7 17 0.4 0.044 967 45-49 36,206 1 0 1 2 0.1 0.018 361 Total 481,127 61 24 107 193 0.4 4.100 297 1 Based on deaths in the household that occurred to a woman who died when pregnant, during childbirth, or within 6 weeks after delivery, without reference to verbal autopsy data. 2 Woman-years lived in that age group during the 36 months before the survey. For example, for age group 15-19, it is calculated by taking ½ of the number of women age 15, plus 1½ times the number age 16, plus 2½ times the number age 17, plus 3 times the number age 18, plus 3 times the number age 19, plus 2½ times the number age 20, plus 1½ times the number age 21, plus ½ times the number age 22, plus 1½ times the number of deaths to women 15-49 in the previous 36 months. 3 Deaths per 1,000 woman-years per year 4 Calculated from the birth histories of interviewed women (see Table 4.1) 5 Deaths per 100,000 live births (calculated by dividing PRMRate by the ASFR * 100); The total is obtained by dividing by the general fertility rate of 0.135 (see Table 4.1). Table 14.9 Maternal mortality rates and ratios by age Maternal1 mortality ratio and rate per 100,000 for the 36 months before the survey, by age, Pakistan 2006-07 Weighted number of woman- years2 Weighted number of deaths1 during: Maternal mortality rate3 Age- specific fertility rates4 Maternal mortality ratio5 Age Pregnancy Delivery Postpartum period Total <20 120,672 0 1 13 15 0.1 0.051 242 20-24 95,196 10 3 21 36 0.4 0.178 210 25-29 76,785 7 7 33 49 0.6 0.237 267 30-34 57,991 5 3 17 26 0.4 0.182 246 35-39 53,830 8 7 22 38 0.7 0.106 657 40-44 40,447 5 3 6 15 0.4 0.044 855 45-49 36,206 0 1 1 2 0.0 0.018 234 Total 481,127 35 25 112 179 0.4 4.100 276 1 Based on deaths in the 36 months before the survey for which there was a verbal autopsy which was classified as being either a direct or indirect maternal death. 2 Woman-years lived in that age group during the 36 months before the survey. For example, for age group 15-19, it is calculated by taking ½ of the number of women age 15, plus 1½ times the number age 16, plus 2½ times the number age 17, plus 3 times the number age 18, plus 3 times the number age 19, plus 2½ times the number age 20, plus 1½ times the number age 21, plus ½ times the number age 22, plus 1½ times the number of deaths to women 15-49 in the previous 36 months. 3 Deaths per 1,000 woman-years per year 4 Calculated from the birth histories of interviewed women (see Table 4.1) 5 Deaths per 100,000 live births (calculated by dividing MMRate by the ASFR * 100); The total is obtained by dividing by the general fertility rate of 0.135 (see Table 4.1). As shown in Tables 14.10 and 14.11, there are large differences by residence in reproductive- related mortality. For example, the maternal mortality ratio in rural areas of Pakistan is almost double that in urban areas (319 and 175, respectively). 178 | Adult and Maternal Mortality Table 14.10 Pregnancy-related mortality rates and ratios by residence Pregnancy-related1 mortality ratio and rate per 100,000 based on deaths in the 36 months before the survey, by residence and province, Pakistan 2006-07 Weighted number of woman- years2 Weighted number of deaths1 during: Pregnancy-related mortality rate3 General fertility rates4 Pregnancy- related mortality ratio5 Residence/ province Pregnancy Delivery Postpartum period Total Residence Urban 170,443 11 2 26 39 0.2 0.113 204 Rural 310,685 51 22 81 153 0.5 0.147 336 Province Punjab 284,563 22 4 62 88 0.3 0.130 238 Sindh 110,171 19 9 26 54 0.5 0.146 333 NWFP 66,202 13 7 10 30 0.4 0.139 323 Balochistan 20,192 8 4 10 21 1.1 0.123 856 Total 481,127 61 24 107 193 0.4 0.135 297 1 Based on deaths in the household that occurred to a woman who died when pregnant, during childbirth, or within 6 weeks after delivery, without reference to verbal autopsy data. 2 Woman-years lived in that age group during the 36 months before the survey. For example, for age group 15-19, it is calculated by taking ½ of the number of women age 15, plus 1½ times the number age 16, plus 2½ times the number age 17, plus 3 times the number age 18, plus 3 times the number age 19, plus 2½ times the number age 20, plus 1½ times the number age 21, plus ½ times the number age 22, plus 1½ times the number of deaths to women 15-49 in the previous 36 months. 3 Deaths per 1,000 woman-years per year 4 Calculated from the birth histories of interviewed women (see Table 4.1) 5 Deaths per 100,000 live births (calculated by dividing PRMRate by the GFR * 100); (see Table 4.1). Table 14.11 Maternal mortality rates and ratios by residence Maternal1 mortality ratio and rate per 100,000 based on deaths in the 36 months before the survey, by residence and province, Pakistan 2006-07 Weighted number of woman- years2 Weighted number of deaths1 during: Maternal mortality rate3 General fertility rates4 Maternal mortality ratio5 Residence/ province Pregnancy Delivery Postpartum period Total Residence Urban 170,443 7 3 23 34 0.2 0.113 175 Rural 310,685 29 22 89 146 0.5 0.147 319 Province Punjab 284,563 11 6 66 84 0.3 0.130 227 Sindh 110,171 14 8 27 50 0.5 0.146 314 NWFP 66,202 7 7 8 25 0.4 0.139 275 Balochistan 20,192 3 4 11 19 1.0 0.123 785 Total 481,127 35 25 112 179 0.4 0.135 276 1 Based on deaths in the 36 months before the survey for which there was a verbal autopsy which was classified as being either a direct or indirect maternal death. 2 Woman-years lived in that age group during the 36 months before the survey. For example, for age group 15-19, it is calculated by taking ½ of the number of women age 15, plus 1½ times the number age 16, plus 2½ times the number age 17, plus 3 times the number age 18, plus 3 times the number age 19, plus 2½ times the number age 20, plus 1½ times the number age 21, plus ½ times the number age 22, plus 1½ times the number of deaths to women 15-49 in the previous 36 months. 3 Deaths per 1,000 woman-years per year 4 Calculated from the birth histories of interviewed women (see Table 4.1) 5 Deaths per 100,000 live births (calculated by dividing MMRate by the GFR * 100); (see Table 4.1). Despite covering over 95,000 households, the sample size was nevertheless too small to calculate reliable estimates of maternal mortality within the provinces. Nonetheless, comparing pregnancy-related and maternal mortality rates and ratios between provinces is quite informative. Clearly, Balochistan has the highest rates and ratios, followed by Sindh, NWFP and Punjab. It may be noted here that since the urban areas of Sindh presumably have relatively lower maternal mortality, rural Sindh probably has very high levels of maternal mortality compared to rural Punjab and NWFP. Adult and Maternal Mortality | 179 As shown in Table 14.12, postpartum haemorrhage is the leading direct cause of maternal deaths, followed by puerperal sepsis and eclampsia. Obstetric bleeding (postpartum and antepartum haemorrhage) is responsible for one-third of all maternal deaths. This is consistent with the unpublished results of verbal autopsies of maternal deaths in two districts of Sindh, as well as reports from other developing countries. A signifi- cant proportion (8 percent) of maternal deaths is attributed to iatrogenic causes—described in the ICD-10 as treatment failure or complications of medical procedures—which reflects the poor quality of maternal health services available. In some instances, though, the reported delay in receiving care or inadequate care may not have been real but perceived to be so by the family. Nevertheless, the availability and quality of emergency obstetric care is a matter of great concern in the country; two other studies (one in Sindh and the other in Punjab) have shown similar results (Siddiqui et al., 1999; Fikree et al., 2006). Obstetric embolism emerges as another important direct cause of maternal mortality (6 percent). Another 6 percent of maternal deaths are attributed to compli- cations of abortion (either sepsis or haemorrhage); however, very few deaths were reported to follow an induced abortion and from the history it was quite difficult to make a distinction between induced abortion and miscarriage. The proportion of maternal deaths due to obstructed labour (3 percent) is also relatively low. Table 14.12 Causes of maternal deaths Percent distribution of maternal deaths by cause of death, Pakistan 2006-07 Cause Total Direct maternal Abortion related 5.6 Eclampsia/toxemia of pregnancy 10.4 Obstetric embolism 6.0 Iatrogenic causes 8.1 Antepartum haemorrhage 5.5 Obstructed labour 2.5 Postpartum haemorrhage 27.2 Puerperal sepsis 13.7 Placental disorders 1.2 Other direct causes 4.3 Total direct maternal 84.6 Direct/indirect not able to categorize 2.5 Indirect maternal 13.0 Total 100.0 Number 210 Only 13 percent of maternal deaths are attributed to indirect causes. The main indirect causes included complications of infectious diseases such as hepatitis, cancer, and gastrointestinal disorders. An increasing prevalence of viral hepatitis has been seen in Pakistan and for which a national program for the prevention and control of hepatitis was launched in 2005. Nearly three-fourths of maternal deaths occurred during delivery and the postpartum period. High quality care during these periods—especially to prevent and manage postpartum haemorrhage— is crucial to prevent deaths. 14.7 DISCUSSION By collecting information on maternal mortality through verbal autopsies, the 2006-07 PDHS fulfilled a longstanding desire of reproductive health professionals in Pakistan. As is evident from Table 14.1, most estimates of MMR available before this survey were based on mathematical models or indirect estimation. Moreover, the estimates derived from surveys are based on relatively small samples so they have extremely wide confidence intervals. The 2006-07 PDHS also provided an opportunity to collect in-depth information on the main causes of maternal deaths. The unique design of the study (in-depth interviews with women on their reproductive histories in 10,000 households and detailed information on the characteristics of the women dying due to maternal complications in the same areas during the same time period) will provide an excellent opportunity for future, more in-depth analysis to identify the risk factors associated with maternal mortality. Despite having an exceptionally well-qualified and efficient technical team, extensively trained and closely supervised field interviewers and use of state-of-the-art technology for data editing, entry and analysis, this study has some constraints and limitations. First, an important constraint was the need for an exceptionally large sample size to estimate the maternal mortality ratio. To keep the sample size within manageable limits, a three-year recall of births and deaths was used. 180 | Adult and Maternal Mortality Adult and Maternal Mortality | 181 This has problems in that the recall of deaths declined considerably during the second and third years before the survey, presumably due to recall errors, misreporting of dates, and/or dissolution or change in the composition of households. Information on the causes and circumstances of the death elicited through the verbal autopsy questionnaires was also of poorer quality for the deaths occurring in the second and third years of recall. Due to cultural sensitivities, direct questions were not asked about induced abortion as a cause of death and caution was taken while investigating whether the death of an unmarried woman was associated with pregnancy-related causes. 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ADDITIONAL TABLES Appendix A Table A.1 Educational attainment of the total household population Percent distribution of the de facto household population age five and over by highest level of schooling attended and median years completed, according to background characteristics, Pakistan 2006-07 Education1 Median years completed Background characteristic No education Primary Middle Secondary Higher Missing Total Number Age 5-9 31.7 67.9 0.1 0.0 0.0 0.3 100.0 98,592 0.0 10-14 22.9 57.5 18.0 1.4 0.0 0.1 100.0 88,845 2.6 15-19 28.3 21.3 21.9 20.2 8.2 0.1 100.0 81,728 5.1 20-24 32.3 16.7 13.6 19.1 18.2 0.2 100.0 65,553 5.4 25-29 39.3 14.8 11.4 17.9 16.3 0.3 100.0 52,436 4.6 30-34 47.4 13.4 9.3 15.1 14.7 0.2 100.0 38,929 2.8 35-39 54.0 13.7 7.9 12.2 11.9 0.2 100.0 36,627 0.0 40-44 57.4 12.9 8.3 11.4 9.8 0.2 100.0 29,793 0.0 45-49 60.9 12.4 7.2 11.2 8.1 0.2 100.0 25,883 0.0 50-54 64.1 11.5 6.5 9.8 7.8 0.3 100.0 20,026 0.0 55-59 68.2 11.2 5.8 8.0 6.5 0.2 100.0 15,103 0.0 60-64 72.0 10.4 5.3 7.3 4.7 0.4 100.0 14,504 0.0 65+ 79.2 8.7 4.2 4.6 2.8 0.4 100.0 28,238 0.0 Residence Total urban 26.4 29.6 13.3 15.3 15.1 0.2 100.0 203,421 4.3 Major city 23.3 27.9 13.9 16.9 17.8 0.2 100.0 115,231 4.8 Other urban 30.4 31.9 12.6 13.2 11.7 0.2 100.0 88,189 3.3 Rural 48.3 30.3 9.3 7.8 4.0 0.2 100.0 393,075 0.0 Province Punjab 36.8 32.2 11.9 11.4 7.4 0.2 100.0 349,251 1.4 Sindh 45.0 27.1 8.2 9.1 10.2 0.3 100.0 138,054 0.0 NWFP 45.6 28.7 10.5 9.0 5.8 0.2 100.0 82,789 0.0 Balochistan 57.2 22.1 7.5 7.1 5.7 0.4 100.0 26,401 0.0 Wealth quintile2 Lowest 70.0 23.2 3.3 2.4 0.8 0.3 100.0 17,468 0.0 Second 55.0 30.6 7.2 4.9 1.9 0.4 100.0 19,800 0.0 Middle 42.9 35.0 10.4 8.2 3.3 0.3 100.0 18,233 0.0 Fourth 29.3 35.1 14.3 13.7 7.4 0.3 100.0 16,859 3.2 Highest 16.0 27.3 14.8 20.3 21.4 0.2 100.0 16,089 7.0 Total 40.8 30.1 10.7 10.4 7.8 0.2 100.0 596,496 0.5 1 Primary = Class 1-5; middle = Class 6-8; secondary = Class 9-10; higher than secondary = Class 11 or more 2 Data refer only to individuals interviewed with the Long Household Questionnaire. Appendix A | 189 Table A.2 Household drinking water Percent distribution of households and de jure population by source and time to collect water, and percentage of households and the de jure population by treatment of drinking water, according to province, Pakistan 2006-07 Households Population Characteristic Punjab Sindh NWFP Baloch- istan Total Punjab Sindh NWFP Baloch- istan Total Source of drinking water Improved source1 96.0 90.9 83.3 84.8 92.8 95.8 90.7 85.0 85.5 92.6 Piped into dwelling/yard/plot 33.3 35.9 45.1 42.5 35.8 34.2 33.4 46.8 44.6 36.3 Public tap/standpipe 2.8 1.0 3.7 1.6 2.4 2.7 1.1 3.1 1.3 2.3 Tubewell/borehole/handpump 57.6 49.3 20.8 19.7 49.6 56.9 52.1 21.8 17.6 49.1 Protected dug well 1.8 2.8 12.2 11.3 3.7 1.6 2.8 11.7 11.9 3.8 Protected spring/karez 0.0 0.0 1.5 5.5 0.4 0.0 0.0 1.6 6.3 0.5 Rainwater 0.0 0.2 0.0 3.9 0.2 0.0 0.2 0.0 3.5 0.2 Bottled water 0.3 1.7 0.0 0.2 0.6 0.3 1.1 0.0 0.2 0.4 Non-improved source 2.6 8.6 15.0 15.1 6.1 2.9 8.9 13.7 14.3 6.3 Unprotected dug well 0.7 1.3 3.0 2.6 1.2 0.6 1.3 2.5 2.4 1.1 Unprotected spring 0.0 0.0 8.3 1.1 1.1 0.0 0.0 7.3 0.9 1.1 Tanker truck/cart with tank 0.4 3.7 0.7 3.5 1.3 0.4 4.0 0.7 3.9 1.5 Surface water 1.6 3.6 3.1 7.9 2.5 1.9 3.6 3.1 7.1 2.7 Other 1.3 0.4 1.6 0.1 1.1 1.2 0.3 1.3 0.1 0.9 Missing 0.1 0.1 0.0 0.1 0.1 0.1 0.2 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 90.0 72.7 69.3 50.3 81.8 90.3 72.5 70.6 53.0 81.6 Less than 30 minutes 5.9 13.0 16.7 18.4 9.4 5.5 13.2 14.8 16.9 9.2 30 minutes or longer 3.3 11.7 12.8 24.9 7.3 3.3 11.4 13.2 21.7 7.4 Don't know/missing 0.8 2.5 1.2 6.4 1.5 0.9 2.8 1.4 8.5 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment2 Boiled 5.7 13.7 2.1 1.7 6.9 5.7 11.0 1.8 1.9 6.2 Bleach/chlorine 0.1 2.0 0.1 0.1 0.5 0.1 2.3 0.1 0.1 0.6 Strained through cloth 1.1 5.0 1.1 1.0 2.0 1.0 5.1 1.0 0.9 2.0 Ceramic, sand, or other filter 1.4 2.0 0.1 0.3 1.3 1.4 1.7 0.1 0.4 1.3 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Let it stand and settle 0.7 0.5 0.2 0.0 0.6 0.8 0.5 0.2 0.0 0.6 Other 0.1 0.1 0.0 0.1 0.1 0.1 0.2 0.0 0.1 0.1 No treatment 91.8 77.7 96.3 96.3 89.4 91.9 80.3 96.7 96.1 90.0 Percentage using an appropriate treatment method3 7.8 21.6 3.3 3.1 10.1 7.7 19.0 2.9 3.2 9.5 Number 5,609 2,103 1,173 370 9,255 38,168 15,711 9,221 3,046 66,145 1 Households using bottled water for drinking are classified as using an improved source. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 190 | Appendix A Table A.3 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to province, Pakistan 2006-07 Type of toilet/ latrine facility Households Population Punjab Sindh NWFP Balochistan Total Punjab Sindh NWFP Balochistan Total Improved, not shared facility Flush/pour flush to piped sewer system 26.5 39.1 21.1 10.7 28.0 27.2 36.6 22.6 13.6 28.2 Flush/pour flush to septic tank 18.1 3.5 17.0 16.2 14.6 19.4 3.9 17.7 17.3 15.4 Flush/pour flush to pit latrine 7.5 3.7 3.7 1.2 5.9 8.2 4.5 3.6 1.2 6.4 Ventilated improved pit (VIP) latrine 0.8 0.6 0.3 0.1 0.7 0.8 0.6 0.3 0.1 0.7 Pit latrine with slab 0.3 2.5 0.8 3.1 1.0 0.2 3.2 0.8 3.1 1.1 Non-improved facility Any facility shared with other households 6.2 5.8 6.6 12.8 6.4 5.4 5.5 5.8 13.4 5.9 Flush/pour flush not to sewer/septic tank/pit latrine 1.9 5.0 1.6 1.1 2.5 1.9 5.8 1.3 1.2 2.7 Pit latrine without slab/open pit 0.7 5.7 6.0 4.6 2.7 0.8 6.0 5.9 4.7 2.9 Bucket 0.2 1.9 6.0 0.6 1.3 0.2 1.8 6.2 0.8 1.4 Hanging toilet/hanging latrine 8.7 2.6 5.0 5.0 6.7 8.0 2.6 7.0 5.6 6.5 No facility/bush/field 28.9 28.9 31.2 43.3 29.8 27.5 28.9 28.0 38.0 28.4 Other 0.1 0.0 0.3 0.0 0.1 0.1 0.0 0.3 0.0 0.1 Missing 0.2 0.8 0.4 1.1 0.4 0.2 0.6 0.4 1.1 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,609 2,103 1,173 370 9,255 38,168 15,711 9,221 3,046 66,145 Appendix A | 191 Table A.4 Housing characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking, according to province, Pakistan 2006-07 Housing characteristic Households Population Punjab Sindh NWFP Balochistan Total Punjab Sindh NWFP Balochistan Total Electricity Yes 91.3 83.8 92.7 76.2 89.2 91.6 84.5 94.5 79.0 89.7 No 8.6 16.1 7.2 23.6 10.7 8.3 15.3 5.4 20.8 10.2 Missing 0.1 0.1 0.0 0.2 0.1 0.1 0.2 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth/sand/mud 45.4 44.9 69.0 68.5 49.2 45.0 46.3 68.5 67.6 49.6 Chips/terrazo 8.6 4.3 4.4 2.6 6.8 8.7 3.8 5.2 2.6 6.8 Ceramic tiles 0.9 2.3 0.3 0.2 1.1 0.9 1.9 0.2 0.2 1.0 Marble 1.9 5.2 0.7 0.0 2.4 2.0 4.7 0.7 0.0 2.4 Cement 28.2 38.5 23.4 19.7 29.6 28.0 38.6 23.1 19.0 29.4 Carpet 0.6 1.4 0.0 0.3 0.7 0.7 1.1 0.0 0.2 0.6 Bricks 14.2 3.0 2.1 1.7 9.6 14.6 3.3 2.2 1.5 9.6 Other/missing 0.2 0.4 0.0 7.0 0.5 0.2 0.3 0.0 9.0 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Main wall material Mud/stones 15.1 15.7 45.0 70.7 21.3 14.7 16.4 45.1 70.8 22.0 Bamboo/sticks/mud 5.3 15.3 6.5 11.2 8.0 5.1 15.4 5.9 11.6 8.0 Unbaked bricks/mud 5.2 8.6 2.5 0.6 5.5 5.3 8.9 2.4 0.6 5.5 Stone blocks 0.3 0.7 1.7 2.6 0.7 0.2 0.5 1.5 3.1 0.6 Baked bricks 25.9 14.8 13.8 5.5 21.0 26.6 16.0 13.3 4.8 21.2 Cement blocks/cement 47.3 44.6 29.5 9.0 42.9 47.0 42.5 30.9 8.6 41.9 Other/missing 0.9 0.3 1.0 0.5 0.7 1.0 0.3 0.9 0.5 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Main roof material Thatch/palm leaf 23.6 37.1 56.5 82.2 33.2 22.3 37.8 56.1 82.1 33.5 Iron sheets/asbestos 0.9 7.8 5.8 5.0 3.3 0.9 7.3 5.7 5.8 3.3 T-iron/wood/brick 48.4 26.1 13.8 8.7 37.4 49.5 28.2 13.1 8.7 37.5 Reinforced brick cement/ reinforced concrete cement 26.7 28.6 22.9 2.6 25.7 27.2 26.3 24.4 2.2 25.5 Other/missing 0.2 0.4 0.8 1.4 0.5 0.2 0.4 0.6 1.1 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 34.9 42.7 31.0 27.3 35.9 27.2 34.8 22.4 17.8 27.9 Two 42.1 37.7 40.0 40.8 40.8 42.1 38.8 36.7 37.7 40.4 Three or more 22.5 18.0 28.1 31.5 22.6 30.3 24.8 40.0 44.2 31.0 Missing 0.5 1.6 0.9 0.4 0.8 0.4 1.6 0.9 0.3 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.1 0.2 0.6 1.6 0.2 0.1 0.1 0.6 1.2 0.2 Cylinder gas 5.0 1.3 8.1 6.5 4.6 4.5 1.3 6.5 6.1 4.1 Natural gas 23.5 44.1 13.1 13.3 26.5 23.9 41.7 14.1 13.0 26.3 Biogas 0.5 4.4 0.8 4.6 1.6 0.5 4.6 1.1 4.8 1.7 Charcoal 0.3 0.5 0.4 1.0 0.4 0.4 0.4 0.5 1.2 0.4 Wood 48.8 44.3 66.8 70.6 50.9 49.2 46.8 67.4 71.5 52.2 Straw/shrubs/grass 5.4 1.8 7.6 0.2 4.6 5.0 1.5 7.3 0.1 4.3 Agricultural crop 6.1 0.1 0.0 0.0 3.7 6.3 0.1 0.0 0.0 3.7 Animal dung 9.7 3.0 2.1 2.1 6.9 9.9 3.2 2.1 2.0 6.9 No food cooked in household 0.3 0.3 0.1 0.0 0.2 0.0 0.1 0.0 0.0 0.0 Other/missing 0.2 0.0 0.4 0.1 0.2 0.2 0.0 0.3 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 70.3 49.6 76.9 73.9 66.6 70.8 52.1 77.4 74.8 67.4 Number of households 5,609 2,103 1,173 370 9,255 38,168 15,711 9,221 3,046 66,145 1 Includes charcoal, wood, straw/shrubs/grass, agricultural crops, and animal dung 192 | Appendix A Appendix A | 193 Table A.5 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by province, Pakistan 2006-07 Households Population Possession Punjab Sindh NWFP Balochistan Total Punjab Sindh NWFP Balochistan Total Radio 27.2 33.0 42.6 57.4 31.7 28.0 35.1 44.7 61.1 33.5 Television 59.5 57.4 39.1 41.0 55.7 62.2 57.6 41.0 44.9 57.3 Telephone 48.1 44.5 41.2 31.2 45.7 51.4 45.7 44.8 34.9 48.3 Refrigerator 37.6 39.4 30.6 26.6 36.7 39.0 39.1 33.7 30.4 37.9 Room cooler/air conditioner 18.2 7.3 11.2 9.2 14.5 18.7 7.3 12.8 10.2 14.8 Washing machine 43.2 44.8 37.5 33.2 42.5 45.5 45.3 40.0 37.6 44.3 Water pump 47.5 31.2 16.7 21.1 38.8 50.0 32.3 17.4 22.1 40.0 Bed 71.3 86.7 71.7 52.0 74.1 72.6 86.8 72.4 56.2 75.2 Chair 65.7 31.9 56.9 16.3 54.9 66.8 31.9 58.8 18.7 55.2 Cabinet 41.7 49.4 43.1 42.9 43.7 44.3 49.3 45.3 48.2 45.8 Clock 77.0 71.0 87.9 79.7 77.1 78.7 71.5 89.7 81.8 78.7 Sofa 30.8 27.6 26.4 8.5 28.6 32.6 26.5 28.7 10.7 29.6 Sewing machine 66.4 51.1 52.3 48.4 60.4 70.1 52.8 56.9 52.9 63.3 Camera 11.0 11.2 8.1 16.1 10.9 12.0 11.0 9.4 19.2 11.7 Personal computer 8.1 9.1 6.7 7.3 8.1 8.2 8.2 7.9 8.6 8.1 Watch 79.9 76.0 88.3 94.4 80.7 82.4 77.8 90.3 95.2 83.0 Bicycle 52.2 20.7 25.1 29.3 40.7 56.4 23.1 28.8 33.3 43.6 Motorcycle/scooter 19.6 20.0 6.2 31.5 18.4 22.6 21.6 7.5 35.2 20.8 Car/truck/tractor 6.6 6.5 4.8 13.8 6.7 7.7 6.7 6.1 17.5 7.7 Animal drawn cart 11.5 8.6 4.8 6.2 9.8 13.5 10.6 5.8 5.7 11.4 Boat with a motor 0.2 0.4 0.2 0.2 0.2 0.1 0.5 0.2 0.3 0.2 Ownership of agricultural land 38.5 28.6 42.4 50.3 37.2 39.4 31.2 44.0 53.4 38.7 Ownership of farm animals1 53.1 43.5 63.4 61.9 52.6 56.3 47.8 66.0 63.6 56.0 Number 5,609 2,103 1,173 370 9,255 38,168 15,711 9,221 3,046 66,145 1 Buffalo, cows, bulls, camels, donkeys, mules, horses, goats, sheep, chickens SAMPLE IMPLEMENTATION Appendix B Table B.1 Sample implementation Percent distribution of households and eligible women by results of the household and individual interviews; and household, eligible women and overall response rates, according to urban-rural residence and region, Pakistan 2006-07 Residence Province Result Total urban Major city Other urban Rural Punjab Sindh NWFP Balochistan Total Selected households Completed (C) 92.9 92.6 93.1 94.0 94.0 91.5 93.8 96.7 93.5 Household present but no competent respondent at home (HP) 1.4 1.7 1.1 0.9 1.5 1.1 0.5 0.2 1.1 Postponed (P) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Refused (R) 0.9 1.1 0.7 0.5 0.3 0.6 1.7 0.9 0.7 Dwelling not found (DNF) 0.5 0.4 0.5 0.4 0.2 0.9 0.4 0.3 0.4 Household absent (HA) 2.0 1.8 2.3 1.8 1.6 2.5 2.2 1.2 1.9 Dwelling vacant/address not a dwelling (DV) 1.5 1.4 1.7 1.5 1.9 1.5 0.8 0.6 1.5 Dwelling destroyed (DD) 0.2 0.2 0.2 0.3 0.3 0.5 0.2 0.0 0.3 Other (O) 0.6 0.7 0.4 0.6 0.3 1.5 0.5 0.1 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 40,827 21,297 19,530 61,210 46,200 27,282 18,475 10,080 102,037 Household response rate (HRR)1 97.1 96.6 97.6 98.1 97.9 97.3 97.2 98.6 97.7 Eligible women Completed (EWC) 93.3 92.5 94.2 95.3 94.7 93.3 94.2 97.6 94.5 Not at home (EWNH) 3.0 3.0 3.1 2.4 2.6 3.1 2.6 1.6 2.6 Postponed (EWP) 0.1 0.1 0.1 0.1 0.2 0.1 0.1 0.0 0.1 Refused (EWR) 1.6 2.1 1.1 0.5 0.6 1.6 1.1 0.2 0.9 Partly completed (EWPC) 0.8 1.1 0.5 0.3 0.5 0.7 0.6 0.1 0.5 Incapacitated (EWI) 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 Other (EWO) 1.1 1.3 0.8 1.3 1.4 1.2 1.5 0.5 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 4,104 2,086 2,018 6,497 4,502 2,911 1,977 1,211 10,601 Eligible women response rate (EWRR)2 93.3 92.5 94.2 95.3 94.7 93.3 94.2 97.6 94.5 Overall response rate (ORR)3 91.0 89.6 92.4 93.7 93.3 91.0 91.2 96.3 92.6 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C ____________________ C + HP + P + R + DNF 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * EWC ________________________________________________ EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 Appendix B | 195 ESTIMATES OF SAMPLING ERRORS Appendix C The estimates from a sample survey are affected by two types of errors: 1) nonsampling errors, and 2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2006-07 Pakistan Demographic and Health Survey (PDHS) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2006-07 PDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2006-07 PDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2006-07 PDHS is the ISSA Sampling Error Module. This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: � � = =− � � � � � � � � � � � � − − == H h h h m i hi h h m z z m m x frvarrSE h 1 2 1 2 1 2 2 1)()( in which hihihi rxyz −= , and hhh rxyz −= Appendix C | 197 where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2006-07 PDHS, there were 970 non-empty clusters. Hence, 970 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − = � in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 970 clusters, r(i) is the estimate computed from the reduced sample of 969 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, ISSA 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 if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. ISSA also computes the relative error and confidence limits for the estimates. Sampling errors for the 2006-07 PDHS are calculated for selected variables considered to be of primary interest for woman’s survey and for man’s surveys, respectively. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table C.1. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the 4 provinces. Tables C.2 to C.8 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to childbearing. The confidence interval (e.g., as calculated for children ever born to women aged 40-49) can be interpreted as follows: the overall average from the national sample is 5.9 and its standard error is 0.068. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 5.9 ± 2 × 0.068. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 5.8 and 6.1. Sampling errors are analyzed for the national woman sample and for two separate groups of estimates: (1) means and proportions, and (2) complex demographic rates. The relative standard errors (SE/R) for the means and proportions range between 0.4 percent and 9.7 percent; the highest relative standard errors are for estimates of very low values (e.g., currently using rhythm method). In general, the relative standard error for most estimates for the country as a whole is small, except for estimates 198 | Appendix C of very small proportions. The relative standard error for the total fertility rate is small, 1.6 percent. However, for the mortality rates, the average relative standard error is much higher, 9.7 percent. There are differentials in the relative standard error for the estimates of sub-populations. For example, for the variable want no more children, the relative standard errors as a percent of the estimated mean for the whole country, and for the urban areas are 0.012 percent and 0.017 percent, respectively. For the total sample, the value of the design effect (DEFT), averaged over all variables, is 1.32 which means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.32 over that in an equivalent simple random sample. Appendix C | 199 Table C.1 List of selected variables for sampling errors for the women sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Variable Estimate Base population ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban Proportion Ever-married women Literate Proportion Ever-married women No education Proportion Ever-married women Secondary+ education Proportion Ever-married women Never married Proportion All women Currently married Proportion All women Married before age 20 Proportion Women age 20-49 Married to first cousin Proportion Ever-married women Currently pregnant Proportion All women Children ever born Mean All women Children surviving Mean All women Children ever born to women age 40-49 Mean Women age 40-49 Knows any contraceptive method Proportion Currently married women Ever used any contraceptive method Proportion Currently married women Currently using any contraceptive method Proportion Currently married women Currently using pill Proportion Currently married women Currently using IUD Proportion Currently married women Currently using injectables Proportion Currently married women Currently using condoms Proportion Currently married women Currently using female sterilization Proportion Currently married women Currently using rhythm method Proportion Currently married women Currently using withdrawal Proportion Currently married women Used public sector source Proportion Current users of modern methods Want no more children or sterilized Proportion Currently married women Want to delay birth at least 2 years Proportion Currently married women Ideal family size Mean All women Mothers received prenatal care for last birth Proportion Women with at least one live birth in five years before survey Mothers received tetanus injection for last birth Proportion Women with at least one live birth in five years before survey Mothers received medical assistance at delivery Proportion Births occurring 1-59 months before interview Ever had obstetric fistula Proportion Ever-married women who have ever given birth Having diarrhoea in two weeks before survey Proportion Children age 0-59 months Treated with oral rehydration salts (ORS) Proportion Children with diarrhoea in two weeks before interview Taken to a health provider Proportion Children with diarrhoea in two weeks before interview Vaccination card seen Proportion Children age 12-23 months Received BCG Proportion Children age 12-23 months Received DPT (3 doses) Proportion Children age 12-23 months Received Polio (3 doses) Proportion Children age 12-23 months Received measles Proportion Children age 12-23 months Fully vaccinated Proportion Children age 12-23 months Has heard of tuberculosis Proportion Ever-married women Has ever been diagnosed with TB Proportion Ever-married women who have heard of TB Accepting attitudes towards people with HIV Proportion Ever-married women who have heard of HIV/AIDS Total fertility rate (3 years) Rate All women 15-49 Neonatal mortality (0-4 years)1 Rate Children exposed to the risk of mortality Post-neonatal mortality (0-4 years)1 Rate Children exposed to the risk of mortality Infant mortality (0-4 years)1 Rate Children exposed to the risk of mortality Child mortality (0-4 years)1 Rate Children exposed to the risk of mortality Under-five mortality (0-4 years)1 Rate Children exposed to the risk of mortality ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 0-4 years for national only; 0-9 years for background characteristics 200 | Appendix C Table C.2 Sampling errors for national sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban 0.334 0.007 10023 10023 1.577 0.022 0.319 0.349 No education 0.650 0.008 10023 10023 1.628 0.012 0.634 0.665 Secondary+ education 0.208 0.007 10023 10023 1.637 0.032 0.195 0.222 Never married 0.348 0.009 15478 15362 1.392 0.026 0.330 0.365 Currently married 0.622 0.009 15478 15362 1.405 0.014 0.605 0.639 Married before age 20 0.517 0.005 11875 11811 1.255 0.010 0.506 0.527 Married to first cousin 0.524 0.007 10023 10023 1.448 0.014 0.510 0.538 Currently pregnant 0.078 0.003 15478 15362 1.251 0.035 0.072 0.083 Children ever born 2.527 0.046 15478 15362 1.283 0.018 2.435 2.619 Children surviving 2.254 0.041 15478 15362 1.297 0.018 2.171 2.337 Children ever born to women age 40-49 5.921 0.068 2567 2567 1.198 0.011 5.786 6.056 Knows any contraceptive method 0.959 0.004 9580 9556 1.741 0.004 0.952 0.966 Ever used any contraceptive method 0.487 0.008 9580 9556 1.516 0.016 0.471 0.502 Currently using any contraceptive method 0.296 0.007 9580 9556 1.408 0.022 0.283 0.309 Currently using pill 0.021 0.002 9580 9556 1.141 0.081 0.017 0.024 Currently using IUD 0.023 0.002 9580 9556 1.144 0.077 0.019 0.026 Currently using injection 0.023 0.002 9580 9556 1.204 0.080 0.019 0.027 Currently using condom 0.068 0.003 9580 9556 1.272 0.048 0.061 0.074 Current using female sterilization 0.082 0.003 9580 9556 1.200 0.041 0.075 0.088 Currently using rhythm method 0.036 0.003 9580 9556 1.548 0.082 0.030 0.042 Currently using withdrawal 0.041 0.003 9580 9556 1.340 0.066 0.036 0.047 Used public sector source 0.482 0.014 2032 2078 1.301 0.030 0.453 0.511 Want no more children 0.516 0.006 9580 9556 1.176 0.012 0.504 0.528 Want to delay birth at least 2 years 0.196 0.005 9580 9556 1.179 0.024 0.187 0.206 Ideal family size 4.097 0.029 8988 9040 1.575 0.007 4.038 4.155 Mother received prenatal care for last birth 0.609 0.009 5724 5677 1.377 0.015 0.591 0.627 Mother received 2+ tetanus injections for last birth 0.534 0.010 5724 5677 1.500 0.019 0.514 0.554 Mother received medical assistance at delivery 0.388 0.010 9177 9121 1.502 0.025 0.369 0.407 Ever had obstretic fistula 0.030 0.002 8758 8757 1.231 0.074 0.026 0.035 Having diarrhoea in 2 weeks before survey 0.218 0.006 8448 8367 1.313 0.029 0.205 0.230 Treated with oral rehydration salts (ORS) 0.411 0.014 1877 1821 1.131 0.034 0.383 0.439 Taken to a health provider 0.545 0.015 1877 1821 1.229 0.028 0.514 0.576 Vaccination card seen 0.237 0.014 1541 1522 1.295 0.060 0.209 0.266 Received BCG 0.803 0.012 1541 1522 1.213 0.015 0.779 0.828 Received DPT (3 doses) 0.585 0.014 1541 1522 1.139 0.025 0.556 0.614 Received Polio (3 doses) 0.831 0.012 1541 1522 1.219 0.014 0.807 0.854 Received measles 0.599 0.015 1541 1522 1.220 0.026 0.568 0.630 Fully vaccinated 0.473 0.015 1541 1522 1.195 0.033 0.442 0.503 Has heard of tuberculosis 0.877 0.005 10023 10023 1.460 0.005 0.868 0.887 Has ever been diagnosed with TB 0.035 0.002 8890 8792 1.163 0.065 0.030 0.039 Accepting attitudes towards people with HIV 0.477 0.011 4398 4427 1.439 0.023 0.455 0.499 Total fertility rate (past 3 years) 4.081 0.066 na 42966 1.237 0.016 3.949 4.213 Neonatal mortality (past 5 years) 53.699 3.113 9206 9151 1.218 0.058 47.472 59.926 Post-neonatal mortality (past 5 years) 23.954 1.857 9213 9161 1.133 0.078 20.241 27.667 Infant mortality (past 5 years) 77.653 3.828 9217 9163 1.271 0.049 69.998 85.309 Child mortality (past 5 years) 17.961 1.739 9267 9211 1.192 0.097 14.483 21.440 Under-five mortality (past 5 years) 94.220 4.214 9282 9225 1.299 0.045 85.792 102.647 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix C | 201 Table C.3 Sampling errors for urban sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban 1.000 0.000 3830 3350 ne 0.000 1.000 1.000 No education 0.431 0.015 3830 3350 1.843 0.034 0.401 0.460 Secondary+ education 0.414 0.015 3830 3350 1.911 0.037 0.384 0.445 Never married 0.248 0.009 6472 5522 1.249 0.035 0.231 0.266 Currently married 0.578 0.015 6472 5522 1.282 0.026 0.548 0.607 Married before age 20 0.447 0.009 4904 4262 1.269 0.019 0.429 0.464 Married to first cousin 0.431 0.012 3830 3350 1.496 0.028 0.407 0.455 Currently pregnant 0.066 0.004 6472 5522 1.299 0.062 0.058 0.074 Children ever born 2.253 0.072 6472 5522 1.236 0.032 2.108 2.397 Children surviving 2.050 0.067 6472 5522 1.257 0.032 1.917 2.183 Children ever born to women age 40-49 5.584 0.110 1049 912 1.342 0.020 5.363 5.804 Knows any contraceptive method 0.985 0.002 3645 3191 1.182 0.002 0.980 0.989 Ever used any contraceptive method 0.642 0.012 3645 3191 1.549 0.019 0.618 0.667 Currently using any contraceptive method 0.411 0.012 3645 3191 1.504 0.030 0.386 0.435 Currently using pill 0.026 0.003 3645 3191 1.272 0.128 0.020 0.033 Currently using IUD 0.026 0.002 3645 3191 0.945 0.096 0.021 0.031 Currently using injection 0.023 0.003 3645 3191 1.266 0.136 0.017 0.030 Currently using condom 0.119 0.007 3645 3191 1.358 0.061 0.104 0.133 Current using female sterilization 0.102 0.006 3645 3191 1.274 0.063 0.089 0.114 Currently using rhythm method 0.049 0.007 3645 3191 1.893 0.138 0.036 0.063 Currently using withdrawal 0.061 0.006 3645 3191 1.460 0.095 0.050 0.073 Used public sector source 0.361 0.020 1045 953 1.355 0.056 0.320 0.401 Want no more children 0.569 0.010 3645 3191 1.186 0.017 0.549 0.588 Want to delay birth at least 2 years 0.198 0.008 3645 3191 1.170 0.039 0.182 0.213 Ideal family size 3.704 0.034 3474 3072 1.339 0.009 3.635 3.772 Mother received prenatal care for last birth 0.781 0.011 1998 1714 1.209 0.014 0.759 0.804 Mother received 2+ tetanus injections for last birth 0.653 0.016 1998 1714 1.455 0.024 0.622 0.685 Mother received medical assistance at delivery 0.601 0.018 3145 2699 1.634 0.030 0.565 0.638 Ever had obstretic fistula 0.029 0.004 3396 2965 1.350 0.134 0.021 0.037 Having diarrhoea in 2 weeks before survey 0.211 0.010 2938 2518 1.256 0.047 0.191 0.231 Treated with oral rehydration salts (ORS) 0.438 0.026 665 532 1.196 0.058 0.386 0.489 Taken to a health provider 0.655 0.026 665 532 1.255 0.039 0.604 0.707 Vaccination card seen 0.263 0.029 554 484 1.524 0.110 0.205 0.321 Received BCG 0.893 0.015 554 484 1.167 0.017 0.862 0.924 Received DPT (3 doses) 0.684 0.023 554 484 1.137 0.033 0.639 0.729 Received Polio (3 doses) 0.818 0.022 554 484 1.322 0.027 0.775 0.862 Received measles 0.688 0.026 554 484 1.303 0.037 0.637 0.740 Fully vaccinated 0.542 0.027 554 484 1.266 0.050 0.488 0.596 Has heard of tuberculosis 0.929 0.006 3830 3350 1.560 0.007 0.916 0.942 Has ever been diagnosed with TB 0.036 0.004 3563 3111 1.310 0.114 0.028 0.044 Accepting attitudes towards people with HIV 0.495 0.016 2536 2319 1.636 0.033 0.463 0.528 Total fertility rate (past 3 years) 3.334 0.084 na 15481 1.210 0.025 3.166 3.502 Neonatal mortality (past 10 years) 47.810 4.435 6535 5520 1.492 0.093 38.940 56.679 Post-neonatal mortality (past 10 years) 18.228 2.112 6540 5525 1.173 0.116 14.005 22.451 Infant mortality (past 10 years) 66.037 4.814 6541 5525 1.395 0.073 56.410 75.665 Child mortality (past 10 years) 13.193 1.885 6554 5533 1.176 0.143 9.424 16.962 Under-five mortality (past 10 years) 78.359 5.155 6561 5539 1.376 0.066 68.048 88.670 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 202 | Appendix C Table C.4 Sampling errors for rural sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban 0.000 0.000 6193 6673 ne ne 0.000 0.000 No education 0.760 0.008 6193 6673 1.493 0.011 0.743 0.776 Secondary+ education 0.105 0.005 6193 6673 1.353 0.050 0.095 0.116 Never married 0.403 0.013 9217 9838 1.386 0.033 0.377 0.430 Currently married 0.647 0.011 9217 9838 1.410 0.017 0.626 0.668 Married before age 20 0.556 0.007 7046 7549 1.252 0.012 0.543 0.569 Married to first cousin 0.571 0.009 6193 6673 1.391 0.015 0.553 0.588 Currently pregnant 0.084 0.004 9217 9838 1.220 0.043 0.077 0.091 Children ever born 2.682 0.059 9217 9838 1.269 0.022 2.565 2.799 Children surviving 2.369 0.052 9217 9838 1.278 0.022 2.265 2.474 Children ever born to women age 40-49 6.103 0.086 1519 1656 1.130 0.014 5.932 6.275 Knows any contraceptive method 0.946 0.005 5935 6365 1.736 0.005 0.936 0.956 Ever used any contraceptive method 0.409 0.009 5935 6365 1.422 0.022 0.391 0.427 Currently using any contraceptive method 0.239 0.007 5935 6365 1.323 0.031 0.224 0.253 Currently using pill 0.018 0.002 5935 6365 1.068 0.103 0.014 0.021 Currently using IUD 0.021 0.002 5935 6365 1.233 0.109 0.016 0.026 Currently using injection 0.023 0.002 5935 6365 1.170 0.099 0.018 0.028 Currently using condom 0.042 0.003 5935 6365 1.205 0.075 0.036 0.048 Current using female sterilization 0.072 0.004 5935 6365 1.160 0.054 0.064 0.080 Currently using rhythm method 0.029 0.003 5935 6365 1.247 0.093 0.024 0.035 Currently using withdrawal 0.031 0.003 5935 6365 1.275 0.092 0.025 0.037 Used public sector source 0.585 0.019 987 1125 1.201 0.032 0.547 0.623 Want no more children 0.489 0.007 5935 6365 1.153 0.015 0.474 0.504 Want to delay birth at least 2 years 0.195 0.006 5935 6365 1.176 0.031 0.183 0.208 Ideal family size 4.299 0.039 5514 5967 1.570 0.009 4.221 4.377 Mother received prenatal care for last birth 0.535 0.011 3726 3962 1.370 0.021 0.512 0.557 Mother received 2+ tetanus injections for last birth 0.482 0.012 3726 3962 1.466 0.025 0.458 0.507 Mother received medical assistance at delivery 0.298 0.010 6032 6422 1.400 0.034 0.278 0.319 Ever had obstretic fistula 0.031 0.003 5362 5793 1.172 0.089 0.026 0.037 Having diarrhoea in 2 weeks before survey 0.221 0.008 5510 5849 1.316 0.035 0.205 0.236 Treated with oral rehydration salts (ORS) 0.400 0.017 1212 1290 1.088 0.042 0.367 0.434 Taken to a health provider 0.500 0.019 1212 1290 1.211 0.038 0.462 0.538 Vaccination card seen 0.226 0.016 987 1038 1.180 0.071 0.193 0.258 Received BCG 0.762 0.016 987 1038 1.189 0.022 0.729 0.795 Received DPT (3 doses) 0.538 0.018 987 1038 1.130 0.034 0.502 0.575 Received Polio (3 doses) 0.837 0.014 987 1038 1.165 0.017 0.808 0.865 Received measles 0.557 0.019 987 1038 1.183 0.034 0.519 0.596 Fully vaccinated 0.440 0.019 987 1038 1.163 0.043 0.403 0.478 Has heard of tuberculosis 0.851 0.006 6193 6673 1.408 0.007 0.839 0.864 Has ever been diagnosed with TB 0.034 0.003 5327 5681 1.084 0.079 0.029 0.040 Accepting attitudes towards people with HIV 0.457 0.014 1862 2108 1.187 0.030 0.429 0.484 Total fertility rate (past 3 years) 4.491 0.088 na 27477 1.205 0.020 4.315 4.668 Neonatal mortality (past 10 years) 55.234 2.875 12456 13236 1.206 0.052 49.483 60.984 Post-neonatal mortality (past 10 years) 26.156 1.709 12467 13248 1.126 0.065 22.738 29.574 Infant mortality (past 10 years) 81.390 3.556 12470 13250 1.258 0.044 74.277 88.503 Child mortality (past 10 years) 19.860 1.706 12490 13275 1.226 0.086 16.449 23.271 Under-five mortality (past 10 years) 99.633 3.876 12507 13292 1.263 0.039 91.881 107.386 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix C | 203 Table C.5 Sampling errors for Punjab sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban 0.316 0.011 4263 5800 1.549 0.035 0.294 0.338 No education 0.597 0.011 4263 5800 1.449 0.018 0.575 0.619 Secondary+ education 0.234 0.010 4263 5800 1.509 0.042 0.214 0.254 Never married 0.294 0.009 6485 8899 1.118 0.032 0.275 0.312 Currently married 0.617 0.011 6485 8899 1.124 0.018 0.595 0.640 Married before age 20 0.473 0.008 5163 7004 1.167 0.016 0.458 0.488 Married to first cousin 0.531 0.010 4263 5800 1.250 0.018 0.511 0.550 Currently pregnant 0.071 0.004 6485 8899 1.188 0.054 0.063 0.078 Children ever born 2.497 0.058 6485 8899 1.052 0.023 2.381 2.613 Children surviving 2.217 0.052 6485 8899 1.068 0.024 2.113 2.321 Children ever born to women age 40-49 5.695 0.090 1164 1570 1.109 0.016 5.516 5.874 Knows any contraceptive method 0.969 0.003 4041 5495 1.240 0.003 0.962 0.976 Ever used any contraceptive method 0.528 0.011 4041 5495 1.424 0.021 0.506 0.551 Currently using any contraceptive method 0.332 0.010 4041 5495 1.292 0.029 0.313 0.351 Currently using pill 0.014 0.002 4041 5495 1.093 0.143 0.010 0.018 Currently using IUD 0.031 0.003 4041 5495 1.040 0.092 0.025 0.036 Currently using injection 0.020 0.003 4041 5495 1.201 0.133 0.014 0.025 Currently using condom 0.071 0.005 4041 5495 1.226 0.070 0.061 0.081 Current using female sterilization 0.092 0.005 4041 5495 1.130 0.056 0.082 0.102 Currently using rhythm method 0.053 0.005 4041 5495 1.371 0.091 0.044 0.063 Currently using withdrawal 0.046 0.004 4041 5495 1.188 0.085 0.038 0.054 Used public sector source 0.482 0.020 947 1267 1.240 0.042 0.442 0.522 Want no more children 0.544 0.008 4041 5495 0.997 0.014 0.529 0.560 Want to delay birth at least 2 years 0.171 0.006 4041 5495 0.977 0.034 0.160 0.183 Ideal family size 3.791 0.026 3788 5175 1.186 0.007 3.739 3.843 Mother received prenatal care for last birth 0.609 0.013 2305 3182 1.248 0.021 0.584 0.634 Mother received 2+ tetanus injections for last birth 0.590 0.015 2305 3182 1.429 0.025 0.561 0.619 Mother received medical assistance at delivery 0.377 0.015 3705 5125 1.481 0.039 0.348 0.407 Ever had obstretic fistula 0.037 0.004 3739 5089 1.137 0.094 0.030 0.044 Having diarrhoea in 2 weeks before survey 0.206 0.009 3403 4689 1.231 0.043 0.189 0.224 Treated with oral rehydration salts (ORS) 0.351 0.020 704 968 1.059 0.058 0.311 0.392 Taken to a health provider 0.537 0.022 704 968 1.124 0.042 0.492 0.581 Vaccination card seen 0.238 0.022 628 865 1.261 0.091 0.195 0.281 Received BCG 0.855 0.016 628 865 1.109 0.018 0.824 0.886 Received DPT (3 doses) 0.645 0.020 628 865 1.072 0.032 0.604 0.686 Received Polio (3 doses) 0.846 0.017 628 865 1.180 0.020 0.811 0.880 Received measles 0.651 0.022 628 865 1.138 0.033 0.608 0.695 Fully vaccinated 0.526 0.022 628 865 1.115 0.042 0.482 0.571 Has heard of tuberculosis 0.865 0.007 4263 5800 1.314 0.008 0.851 0.879 Has ever been diagnosed with TB 0.027 0.003 3711 5018 1.047 0.104 0.021 0.032 Accepting attitudes towards people with HIV 0.486 0.016 2089 2715 1.421 0.032 0.455 0.517 Total fertility rate (past 3 years) 3.923 0.090 na 24414 1.120 0.023 3.742 4.104 Neonatal mortality (past 10 years) 58.137 3.733 7595 10427 1.211 0.064 50.670 65.603 Post-neonatal mortality (past 10 years) 22.742 1.953 7600 10433 1.087 0.086 18.836 26.648 Infant mortality (past 10 years) 80.879 4.348 7601 10434 1.234 0.054 72.183 89.574 Child mortality (past 10 years) 18.063 2.023 7619 10458 1.219 0.112 14.017 22.110 Under-five mortality (past 10 years) 97.481 4.613 7626 10467 1.227 0.047 88.256 106.707 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 204 | Appendix C Table C.6 Sampling errors for Sindh sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban 0.488 0.014 2716 2410 1.426 0.028 0.460 0.515 No education 0.668 0.015 2716 2410 1.662 0.022 0.638 0.698 Secondary+ education 0.214 0.012 2716 2410 1.573 0.058 0.189 0.239 Never married 0.454 0.027 3996 3555 1.761 0.060 0.399 0.508 Currently married 0.652 0.019 3996 3555 1.707 0.029 0.613 0.690 Married before age 20 0.608 0.009 3034 2681 1.183 0.015 0.589 0.626 Married to first cousin 0.564 0.017 2716 2410 1.758 0.030 0.531 0.598 Currently pregnant 0.087 0.006 3996 3555 1.230 0.064 0.076 0.098 Children ever born 2.615 0.107 3996 3555 1.565 0.041 2.401 2.828 Children surviving 2.307 0.095 3996 3555 1.576 0.041 2.117 2.497 Children ever born to women age 40-49 6.260 0.159 619 536 1.271 0.025 5.943 6.578 Knows any contraceptive method 0.973 0.005 2611 2317 1.446 0.005 0.963 0.982 Ever used any contraceptive method 0.421 0.013 2611 2317 1.330 0.031 0.395 0.447 Currently using any contraceptive method 0.267 0.012 2611 2317 1.331 0.043 0.244 0.290 Currently using pill 0.023 0.004 2611 2317 1.212 0.153 0.016 0.031 Currently using IUD 0.010 0.002 2611 2317 0.950 0.185 0.006 0.014 Currently using injection 0.023 0.003 2611 2317 1.167 0.149 0.016 0.030 Currently using condom 0.072 0.005 2611 2317 1.057 0.074 0.062 0.083 Current using female sterilization 0.090 0.006 2611 2317 1.081 0.067 0.078 0.102 Currently using rhythm method 0.015 0.002 2611 2317 1.028 0.162 0.010 0.020 Currently using withdrawal 0.031 0.005 2611 2317 1.592 0.174 0.020 0.042 Used public sector source 0.444 0.026 554 509 1.211 0.058 0.393 0.495 Want no more children 0.484 0.012 2611 2317 1.254 0.025 0.460 0.509 Want to delay birth at least 2 years 0.220 0.010 2611 2317 1.222 0.045 0.200 0.240 Ideal family size 4.348 0.056 2517 2252 1.413 0.013 4.237 4.459 Mother received prenatal care for last birth 0.704 0.016 1626 1404 1.427 0.023 0.672 0.737 Mother received 2+ tetanus injections for last birth 0.512 0.016 1626 1404 1.301 0.032 0.479 0.545 Mother received medical assistance at delivery 0.444 0.015 2649 2284 1.247 0.034 0.414 0.475 Ever had obstretic fistula 0.021 0.003 2371 2095 0.999 0.139 0.016 0.027 Having diarrhoea in 2 weeks before survey 0.236 0.012 2415 2085 1.259 0.050 0.213 0.260 Treated with oral rehydration salts (ORS) 0.537 0.024 595 493 1.047 0.045 0.488 0.585 Taken to a health provider 0.662 0.025 595 493 1.116 0.038 0.612 0.712 Vaccination card seen 0.197 0.021 435 373 1.090 0.107 0.155 0.240 Received BCG 0.767 0.025 435 373 1.207 0.032 0.718 0.817 Received DPT (3 doses) 0.476 0.027 435 373 1.092 0.056 0.423 0.529 Received Polio (3 doses) 0.841 0.018 435 373 1.028 0.022 0.805 0.878 Received measles 0.507 0.031 435 373 1.258 0.061 0.445 0.568 Fully vaccinated 0.370 0.027 435 373 1.150 0.073 0.316 0.424 Has heard of tuberculosis 0.904 0.008 2716 2410 1.489 0.009 0.887 0.921 Has ever been diagnosed with TB 0.054 0.005 2464 2179 1.195 0.101 0.043 0.064 Accepting attitudes towards people with HIV 0.518 0.018 1113 1029 1.188 0.034 0.482 0.554 Total fertility rate (past 3 years) 4.322 0.128 na 10695 1.326 0.030 4.067 4.578 Neonatal mortality (past 10 years) 53.241 4.012 5426 4725 1.150 0.075 45.217 61.266 Post-neonatal mortality (past 10 years) 28.159 2.645 5433 4734 1.093 0.094 22.869 33.448 Infant mortality (past 10 years) 81.400 5.186 5434 4734 1.201 0.064 71.027 91.772 Child mortality (past 10 years) 21.852 2.418 5448 4743 1.047 0.111 17.016 26.687 Under-five mortality (past 10 years) 101.473 5.854 5457 4752 1.226 0.058 89.765 113.181 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix C | 205 Table C.7 Sampling errors for NWFP sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban 0.170 0.011 1862 1351 1.285 0.066 0.148 0.193 No education 0.774 0.013 1862 1351 1.378 0.017 0.747 0.800 Secondary+ education 0.125 0.009 1862 1351 1.215 0.074 0.107 0.144 Never married 0.406 0.023 3005 2173 1.391 0.057 0.360 0.452 Currently married 0.599 0.020 3005 2173 1.409 0.034 0.559 0.639 Married before age 20 0.557 0.011 2193 1590 1.177 0.019 0.535 0.579 Married to first cousin 0.426 0.016 1862 1351 1.365 0.037 0.394 0.457 Currently pregnant 0.080 0.006 3005 2173 1.180 0.075 0.068 0.091 Children ever born 2.563 0.098 3005 2173 1.145 0.038 2.367 2.760 Children surviving 2.335 0.092 3005 2173 1.174 0.039 2.151 2.520 Children ever born to women age 40-49 6.344 0.136 462 334 1.069 0.022 6.071 6.617 Knows any contraceptive method 0.919 0.019 1792 1301 2.905 0.020 0.882 0.957 Ever used any contraceptive method 0.505 0.018 1792 1301 1.500 0.035 0.469 0.540 Currently using any contraceptive method 0.249 0.014 1792 1301 1.352 0.056 0.221 0.276 Currently using pill 0.031 0.005 1792 1301 1.158 0.153 0.022 0.041 Currently using IUD 0.017 0.003 1792 1301 1.010 0.182 0.011 0.023 Currently using injection 0.040 0.005 1792 1301 1.022 0.118 0.031 0.050 Currently using condom 0.061 0.006 1792 1301 1.103 0.102 0.048 0.073 Current using female sterilization 0.036 0.004 1792 1301 1.010 0.123 0.027 0.045 Currently using rhythm method 0.010 0.003 1792 1301 1.194 0.286 0.004 0.015 Currently using withdrawal 0.051 0.006 1792 1301 1.087 0.110 0.040 0.063 Used public sector source 0.556 0.032 361 243 1.232 0.058 0.491 0.620 Want no more children 0.500 0.017 1792 1301 1.455 0.034 0.466 0.535 Want to delay birth at least 2 years 0.232 0.016 1792 1301 1.644 0.071 0.199 0.265 Ideal family size 4.357 0.137 1689 1213 2.602 0.031 4.083 4.632 Mother received prenatal care for last birth 0.513 0.022 1113 827 1.513 0.044 0.468 0.558 Mother received 2+ tetanus injections for last birth 0.432 0.023 1113 827 1.589 0.054 0.386 0.479 Mother received medical assistance at delivery 0.379 0.021 1787 1312 1.494 0.056 0.337 0.421 Ever had obstretic fistula 0.024 0.004 1635 1179 1.168 0.186 0.015 0.032 Having diarrhoea in 2 weeks before survey 0.247 0.015 1665 1221 1.387 0.062 0.216 0.277 Treated with oral rehydration salts (ORS) 0.375 0.031 420 301 1.193 0.082 0.314 0.437 Taken to a health provider 0.401 0.037 420 301 1.450 0.093 0.326 0.475 Vaccination card seen 0.339 0.035 317 222 1.273 0.103 0.269 0.409 Received BCG 0.711 0.038 317 222 1.459 0.053 0.635 0.787 Received DPT (3 doses) 0.564 0.037 317 222 1.300 0.066 0.490 0.638 Received Polio (3 doses) 0.810 0.031 317 222 1.387 0.039 0.748 0.873 Received measles 0.566 0.035 317 222 1.224 0.062 0.496 0.636 Fully vaccinated 0.469 0.038 317 222 1.315 0.081 0.394 0.545 Has heard of tuberculosis 0.872 0.012 1862 1351 1.577 0.014 0.847 0.896 Has ever been diagnosed with TB 0.038 0.006 1648 1178 1.303 0.163 0.026 0.050 Accepting attitudes towards people with HIV 0.411 0.020 893 573 1.186 0.048 0.372 0.450 Total fertility rate (past 3 years) 4.330 0.163 na 5843 1.320 0.038 4.004 4.657 Neonatal mortality (past 10 years) 40.548 3.985 3676 2724 1.116 0.098 32.578 48.518 Post-neonatal mortality (past 10 years) 22.208 3.034 3679 2725 1.208 0.137 16.141 28.276 Infant mortality (past 10 years) 62.756 5.202 3679 2725 1.193 0.083 52.353 73.160 Child mortality (past 10 years) 12.676 2.232 3685 2729 1.133 0.176 8.212 17.140 Under-five mortality (past 10 years) 74.637 6.125 3688 2731 1.245 0.082 62.386 86.888 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 206 | Appendix C Appendix C | 207 Table C.8 Sampling errors for Balochistan sample, Pakistan 2006-07 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases Stand- –––––––––––––––– Rela- ard Un- Weight- Design tive Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban 0.238 0.020 1182 462 1.604 0.083 0.199 0.278 No education 0.850 0.013 1182 462 1.226 0.015 0.824 0.875 Secondary+ education 0.101 0.011 1182 462 1.258 0.109 0.079 0.123 Never married 0.321 0.020 1847 714 1.091 0.062 0.281 0.361 Currently married 0.620 0.024 1847 714 0.945 0.039 0.572 0.669 Married before age 20 0.504 0.015 1393 544 1.265 0.031 0.473 0.534 Married to first cousin 0.520 0.017 1182 462 1.190 0.033 0.485 0.554 Currently pregnant 0.115 0.009 1847 714 1.075 0.079 0.097 0.134 Children ever born 2.432 0.140 1847 714 1.116 0.058 2.152 2.713 Children surviving 2.268 0.129 1847 714 1.096 0.057 2.011 2.525 Children ever born to women age 40-49 6.218 0.180 324 127 1.106 0.029 5.858 6.578 Knows any contraceptive method 0.882 0.013 1136 443 1.319 0.014 0.856 0.907 Ever used any contraceptive method 0.262 0.016 1136 443 1.234 0.062 0.229 0.294 Currently using any contraceptive method 0.144 0.012 1136 443 1.185 0.086 0.120 0.169 Currently using pill 0.053 0.007 1136 443 1.130 0.142 0.038 0.068 Currently using IUD 0.006 0.002 1136 443 1.091 0.431 0.001 0.010 Currently using injection 0.014 0.004 1136 443 1.144 0.283 0.006 0.022 Currently using condom 0.016 0.004 1136 443 1.195 0.282 0.007 0.024 Current using female sterilization 0.046 0.006 1136 443 0.919 0.124 0.035 0.057 Currently using rhythm method 0.003 0.001 1136 443 0.849 0.434 0.000 0.006 Currently using withdrawal 0.005 0.002 1136 443 1.055 0.429 0.001 0.010 Used public sector source 0.513 0.058 170 59 1.503 0.113 0.397 0.628 Want no more children 0.366 0.018 1136 443 1.282 0.050 0.329 0.402 Want to delay birth at least 2 years 0.277 0.015 1136 443 1.130 0.054 0.247 0.307 Ideal family size 5.854 0.077 994 399 1.118 0.013 5.700 6.008 Mother received prenatal care for last birth 0.407 0.024 680 264 1.282 0.060 0.359 0.456 Mother received 2+ tetanus injections for last birth 0.297 0.034 680 264 1.947 0.115 0.229 0.366 Mother received medical assistance at delivery 0.230 0.019 1036 400 1.174 0.084 0.191 0.269 Ever had obstretic fistula 0.010 0.003 1013 394 0.975 0.303 0.004 0.016 Having diarrhoea in 2 weeks before survey 0.162 0.018 965 373 1.493 0.109 0.126 0.197 Treated with oral rehydration salts (ORS) 0.518 0.046 158 60 1.118 0.089 0.426 0.610 Taken to a health provider 0.449 0.047 158 60 1.152 0.105 0.354 0.543 Vaccination card seen 0.106 0.026 161 61 1.071 0.249 0.053 0.159 Received BCG 0.630 0.054 161 61 1.388 0.085 0.522 0.738 Received DPT (3 doses) 0.467 0.049 161 61 1.230 0.105 0.369 0.564 Received Polio (3 doses) 0.629 0.048 161 61 1.227 0.076 0.533 0.724 Received measles 0.540 0.051 161 61 1.264 0.094 0.439 0.642 Fully vaccinated 0.352 0.047 161 61 1.247 0.135 0.258 0.447 Has heard of tuberculosis 0.904 0.012 1182 462 1.355 0.013 0.881 0.928 Has ever been diagnosed with TB 0.028 0.007 1067 417 1.402 0.252 0.014 0.042 Accepting attitudes towards people with HIV 0.214 0.031 303 110 1.322 0.146 0.152 0.277 Total fertility rate (past 3 years) 4.081 0.246 na 1958 1.576 0.060 3.589 4.573 Neonatal mortality (past 10 years) 30.408 5.120 2294 880 1.317 0.168 20.168 40.647 Post-neonatal mortality (past 10 years) 18.495 3.985 2295 881 1.337 0.215 10.524 26.466 Infant mortality (past 10 years) 48.903 7.425 2297 881 1.417 0.152 34.052 63.753 Child mortality (past 10 years) 10.867 2.775 2292 879 1.183 0.255 5.317 16.417 Under-five mortality (past 10 years) 59.238 8.583 2297 881 1.491 0.145 42.073 76.403 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable DATA QUALITY TABLES Appendix D Table D.1 Household age distribution Single-year age distribution of the de facto household population by sex (weighted), Pakistan 2006-07 Female Male Female Male Age Number Percent Number Percent Age Number Percent Number Percent 0 9,229 3.0 9,681 3.0 36 3,303 1.0 3,066 1.0 1 8,132 2.0 8,662 2.0 37 2,270 1.0 2,052 1.0 2 8,645 3.0 9,500 3.0 38 4,082 1.0 3,434 1.0 3 9,351 3.0 9,335 3.0 39 2,048 0.0 1,651 1.0 4 9,833 3.0 10,068 3.0 40 6,714 2.0 7,796 2.0 5 10,153 3.0 11,031 3.0 41 1,760 0.0 1,664 1.0 6 9,392 3.0 10,191 3.0 42 2,843 1.0 2,901 1.0 7 10,189 3.0 10,652 3.0 43 1,822 0.0 1,603 1.0 8 10,177 3.0 10,949 3.0 44 1,425 0.0 1,266 0.0 9 7,584 2.0 8,275 2.0 45 5,418 2.0 6,138 2.0 10 10,062 3.0 11,333 3.0 46 1,945 1.0 1,796 1.0 11 6,355 2.0 6,717 2.0 47 1,542 0.0 1,420 0.0 12 10,118 3.0 11,342 3.0 48 2,478 1.0 2,446 1.0 13 7,516 2.0 7,674 2.0 49 1,430 0.0 1,268 0.0 14 8,799 3.0 8,929 3.0 50 4,718 2.0 5,297 1.0 15 8,378 2.0 8,420 2.0 51 1,230 0.0 1,146 0.0 16 9,258 3.0 8,891 3.0 52 1,709 1.0 1,749 1.0 17 7,062 2.0 6,936 2.0 53 1,036 0.0 1,089 0.0 18 10,402 3.0 10,879 3.0 54 1,030 0.0 1,021 0.0 19 5,812 2.0 5,689 2.0 55 3,324 1.0 3,525 1.0 20 10,464 3.0 9,345 3.0 56 1,224 0.0 1,240 0.0 21 4,809 1.0 4,397 1.0 57 786 0.0 903 0.0 22 7,887 2.0 7,375 2.0 58 1,286 0.0 1,201 0.0 23 5,272 1.0 4,961 2.0 59 787 0.0 826 0.0 24 5,606 2.0 5,435 2.0 60 3,990 1.0 4,929 1.0 25 8,583 2.0 7,780 3.0 61 631 0.0 770 0.0 26 5,460 1.0 5,190 2.0 62 917 0.0 983 0.0 27 4,224 1.0 3,988 1.0 63 589 0.0 663 0.0 28 6,044 2.0 5,584 2.0 64 482 0.0 548 0.0 29 3,117 1.0 2,466 1.0 65 2,426 1.0 2,930 1.0 30 8,401 2.0 8,129 2.0 66 549 0.0 665 0.0 31 2,388 1.0 1,960 1.0 67 475 0.0 475 0.0 32 4,417 1.0 4,168 1.0 68 702 0.0 669 0.0 33 2,528 1.0 2,248 1.0 69 395 0.0 461 0.0 34 2,492 1.0 2,198 1.0 70+ 7,857 3.0 10,635 2.0 35 7,211 2.0 7,509 2.0 Don't know/ missing 117 0.0 122 0.0 Total 340,689 100.0 348,238 100.0 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Appendix D | 209 Table D.2 Age distribution of eligible and interviewed women De facto household population of women age 10-54, interviewed women age 15-49, and percentage of eligible women who were interviewed (weighted), by five-year age groups, Pakistan 2006-07 Household population of women age 10-54 Ever-married women age 10-54 Interviewed women age 15-49 Percent of women Age group Number Percent 10-14 4,159 0 na na na 15-19 4,023 602 549 5.6 91.3 20-24 3,265 1,568 1,466 15.0 93.5 25-29 2,598 2,086 1,967 20.2 94.3 30-34 1,960 1,828 1,733 17.8 94.8 25-39 1,744 1,690 1,609 16.5 95.2 40-44 1,384 1,341 1,268 13.0 94.6 45-49 1,241 1,225 1,154 11.8 94.2 50-54 882 868 na na na 15-49 16,215 10,341 9,747 100.0 94.3 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household schedule. na = Not applicable Table D.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Pakistan 2006-07 Age group Reference population Percentage with missing information Number of cases Birth date Births in the 15 years preceding the survey Month only 19.0 27,007 Month and year 3.71 27,007 Age at death Deaths among births in the 15 years preceding the survey 1.04 2,599 Age/date at first union1 All women age 15-49 0.27 10,023 Respondent's education All women age 15-49 0.00 10,023 Diarrhoea in past 2 weeks Living children age 0-59 months 0.60 8,367 1 Both year and age missing 210 | Appendix D Table D.4 Births by calendar years Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living (L), dead (D), and total (T) children (weighted), Pakistan 2006-07 Calendar year Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 L D T L D T L D T L D T 2007 54 2 55 100.0 100.0 100.0 142.7 58.0 138.4 na na na 2006 1,691 155 1,847 99.5 98.8 99.4 108.4 205.9 114.1 na na na 2005 1,517 149 1,666 98.0 91.4 97.4 109.9 84.5 107.4 90.5 93.9 90.8 2004 1,660 162 1,821 95.6 83.3 94.5 115.8 112.0 115.5 99.7 110.5 100.5 2003 1,814 144 1,958 93.9 89.5 93.6 100.9 108.5 101.4 112.0 96.3 110.7 2002 1,578 137 1,715 87.4 71.6 86.2 109.0 125.6 110.2 94.1 103.2 94.8 2001 1,540 122 1,662 84.3 69.7 83.2 119.3 134.9 120.3 87.3 70.9 85.9 2000 1,951 207 2,158 80.3 60.0 78.4 118.2 112.1 117.6 115.1 127.1 116.1 1999 1,850 204 2,053 72.3 57.8 70.9 100.9 90.8 99.8 95.4 95.3 95.4 1998 1,926 220 2,146 70.5 63.3 69.8 103.4 100.4 103.1 118.1 119.2 118.2 2003-2007 6,735 612 7,348 96.7 90.7 96.2 108.6 120.1 109.6 na na na 1998-2002 8,844 890 9,734 78.5 63.4 77.1 109.6 108.5 109.5 na na na 1993-1997 7,438 919 8,357 68.9 52.2 67.1 109.9 103.0 109.1 na na na 1988-1992 6,256 797 7,053 63.6 47.9 61.8 98.4 114.4 100.1 na na na <1988 5,354 979 6,333 56.2 42.4 54.0 106.9 108.2 107.1 na na na All 34,626 4,197 38,824 73.8 57.1 72.0 107.0 109.9 107.3 na na na na = Not applicable 1 Both year and month of birth given 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x Appendix D | 211 Table D.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days, and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Pakistan 2006-07 Age at death (days) Number of years preceding the survey Total 0-19 0-4 5-9 10-14 15-19 <1 178 156 142 111 587 1 44 75 60 43 222 2 39 41 25 14 120 3 45 45 44 25 159 4 27 22 15 9 73 5 17 23 26 22 88 6 12 20 21 21 74 7 16 25 20 15 76 8 24 14 18 17 73 9 5 2 12 8 27 10 9 9 6 9 32 11 3 10 4 4 20 12 3 7 11 5 27 13 6 3 4 4 16 14 5 4 2 3 14 15 10 14 9 10 43 16 3 6 4 9 22 17 3 1 1 2 8 18 1 1 3 2 7 19 4 4 0 2 9 20 7 5 6 8 26 21 2 2 0 1 5 22 7 2 10 4 23 23 0 0 2 0 2 24 3 0 1 0 5 25 7 3 2 0 12 26 1 0 1 0 3 27 0 1 0 0 1 28 0 2 0 0 3 30 1 0 0 0 1 Missing 1 2 2 0 5 Total 0-30 481 498 450 348 1,778 Percent early neonatal1 75.2 76.8 74.1 70.3 74.4 1 Under one week/under one month 212 | Appendix D Appendix D | 213 Table D.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months, and the percentage of infant deaths reported to occur at age under one month, for five-year periods of birth preceding the survey, Pakistan 2006-07 Age at death (months) Number of years preceding the survey Total 0-19 0-4 5-9 10-14 15-19 <1a 483 500 453 348 1,783 1 40 51 57 44 192 2 19 15 31 30 95 3 36 25 34 30 126 4 24 21 23 18 86 5 9 13 19 29 69 6 18 31 29 27 104 7 17 16 21 14 68 8 16 12 14 9 50 9 8 13 11 16 48 10 3 14 6 4 26 11 6 9 6 3 25 12 30 47 42 34 153 13 3 1 1 2 7 14 2 2 5 0 9 15 0 2 2 1 5 16 0 2 2 1 6 17 0 2 1 0 3 18 2 12 8 4 26 20 0 1 2 0 3 21 2 0 1 0 3 22 0 0 0 0 1 23 0 3 1 3 7 Missing 0 0 1 0 1 1 year 3 1 6 2 13 Total 0-11 678 720 704 571 2,674 Percent neonatal1 71.2 69.4 64.2 61.0 66.7 a Includes deaths under one month reported in days 1 Under one month/under one year PERSONS INVOLVED IN THE 2006-07 PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY Appendix E PDHS-CORE STAFF Mr. Mehboob Sultan Project Director Syed Mubashir Ali Principal Investigator Mr. Zahir Hussain Field Coordinator Ms. Aysha Sheraz Field Coordinator Mr. Zafar Zahir Field Coordinator Mr. Zafar Iqbal Qamar Field Coordinator Mr. Ali Anwar Buriro Field Coordinator Mr. Mubashir Baqai Field Coordinator Supporting Staff Ms. Rabia Zafar Questionnaire Coordinator Mr. Asif Amin Khan Office Coordinator Mr. Muhammad Arif Office Coordinator Mr. Adil Wasim Office Assistant Management/Accounts Staff Mr. Iqbal Ahmad Director Mr. Amanullah Bhatti Secretary (M&F) Mr. Muhammad Hafeez Khokhar Accounts Officer Mr. Zulifiqar Ali Accountant Mr. Sajjad Umar Cashier PDHS DATA PROCESSING STAFF Data Processing Centre Mr. Faateh ud din Ahmad, Data Processing Manager Mr. Zahid Zaman, Deputy Data Entry Supervisor Mr. Muhammad Shoaib Khan Lodhi, Assistant Data Entry Supervisor Mr. Takasar Amin, Assistant Data Entry Supervisor Data Entry Operators Mr. Emad Karamat Mr. Muhammad Ismail Akbar Mr. Yasir Lateef Cheema Mr. Naveed Hussain Akhtar Mr. Muhammad Ishtiaq Mr. Ahmed Rashid Mr. Mazher Abbas Shah Mr. Ishtiaq Shoukat Mr. Muhammad Ali Mr. Syed Farhan Ali Shah Mr. Sadaqat Ali Mr. Ansar Ali Mr. Dil Nawaz Mr. Muhammad Rafique Talpur Mr. Waqas Alam Mr. Muhammad Irfan Khan Appendix E | 215 Office Editors Mr. M Shoaib Akhtar Ms. Sajida Iqbal Maria Ms. Fareeha Iqbal Ms. Ayesha Ashfaq Ms. Faiza Zahoor Ms. Fareeha Ali Ms. Aneela Javed Ms. Fouzia Anjum Ms. Mehwish Gul Ms. Nazia Yasmeen TECHNICAL ADVISORY COMMITTEE Chairman: Dr. Saeed Shafqat, Executive Director, NIPS, Islamabad Members: 01. Dr. Abdul Razzaque Rukanuddin, NIPS, Islamabad 02. Ms. Anne Cross, Macro International, USA 03. Dr. Arshad Mehmood, Population Council, Islamabad 04. Dr. Barkat-e-Khuda, TAMA, Islamabad 05. Dr. Dur-e-Nayab, PIDE, Islamabad 06. Dr. Farid Midhet, Asia Foundation, Islamabad 07. Dr. Huma Qureshi, PMRC, Islamabad 08. Mr. Khalid Mehmood, Federal Bureau of Statistics, Islamabad 09. Mr. Mazhar Hussain Hashmi, Federal Bureau of Statistics, Islamabad 10. Mr. Mehboob Sultan, NIPS, Islamabad 11. Dr. Mehtab Karim, Agha Khan University, Karachi 12. Mr. Muazzam Shah Mian, Ministry of Population Welfare, Islamabad 13. Dr. Muhammad Nizamuddin, Vice Chancellor, Gujrat University, Gujrat 14. Dr. Mumtaz Eskar, Ministry of Population Welfare, Islamabad 15. Dr. Nabila Ali, JSI, Islamabad 16. Dr. Nabila Zaka, UNICEF, Islamabad 17. Dr. Naushin Mehmood, PIDE, Islamabad 18. Ms. Pamela S., UNFPA, Islamabad 19. Mr. Peter Miller, Population Council, Islamabad 20. Dr. Sadiqua Jafarey, National Committee for Maternal and Neonatal Health, Karachi 21. Syed Mubashar Ali, NIPS, Islamabad 22. Dr. Syed Raza Mehmood Zaidi, Ministry of Health, Islamabad 23. Dr. Tauseef Ahmad, Macro International, Islamabad 24. Dr. Zahid Larik, Ministry of Health, Islamabad 25. Dr. Zarif ud din Khan, Ministry of Health, Islamabad 26. Dr. Zeba Sather, Population Council, Islamabad 27. Dr. Zulfiqar Bhutta, Agha Khan University, Karachi 216 | Appendix E PDHS FIELD STAFF Quality Control Interviewers Ms. Mehwish Ansari Ms. Abida Hassan Ms. Farah Naz Shaikh Ms. Rafia Gulani PUNJAB Team 1 - Bahawalpur Team 2- Chakwal Mr. Saeed Akbar Khan, Supervisor Mr. Muhammad Khan, Supervisor Interviewers Interviewers Ms. Ambreen Ramzan Ms. Bilqees Akhtar Ms. Shahida Parveen Ms. Erum Hassan Ms. Nasreen Akhtar Ms. Mukhtiar Bibi Ms. Riffat Yasmeen Ms. Ghulam Rubab Ms. Samina Rafique Ms. Shazia Fatima Ms. Ghulam Aisha Ms. Yasmin Akhtar Team 3 – D.G.Khan Team 4 - Faisalabad Mr. Rahmatullah Shakir, Supervisor Mr. Imran Ibrahim, Supervisor Interviewers Interviewers Ms. Mohsina Kehkashan Ms. Razia Sultana Ms. Rabia Safdar Ms. Shagufta Siddique Ms. Shagufta Noreen Ms. Nazia Qureshi Ms. Fozia Majeed Ms. Sana Hameed Ms. Afshan Farooq Ms. Asma Farooq Ms. Sumaira Bano Ms. Sadia Firdous Ms. Mamoona Haider Team 5 – Gujranwala Team 6 - Jhang Mr. Zulfiqar Hussain, Supervisor Mr. Muhammad Asif Ali, Supervisor Interviewers Interviewers Ms. Jamila Nazir Ahmed Ms. Mamoona Arshad Ms. Sobia Noreen Ms. Shakeela Chaudhry Ms. Saima Shamshad Ms. Shazia Asadullah Ms. Sumera Tull Hasan Ms. Farhat Majid Ms. Shakeela Sabir Ms. Hifsa Abdullah Ms. Aisha Saleem Ms. Saira Anees Ms. Saria Adrees Team 7 – Lahore Team 8 - Multan Mr. Salman Raza, Supervisor Mr. Muhammad Kashif, Supervisor Interviewers Interviewers Ms. Asma Naz Ms. Nausheen Butt Ms. Nadia Shahbaz Ms. Ammara Zafar Ms. Shamsa Naushahi Ms. Shabana Shafaat Ms. Fahmina Anwar Ms. Samina Malik Ms. Fakhara Rashid Ms. Farzana Naureen Ms. Shazia Malik Ms. Shaista Qaiser Ms. Shazia Mumtaz Khan Team 9 – Okara Team 10 – Rawalpindi/Islamabad Mr. Sibghatullah, Supervisor Mr. Badar-ud-Din Tanveer, Supervisor Interviewers Interviewers Ms. Rabia Bashir Ms. Nabila Tabassum Ms. Shazia Batool Ms. Asia Mustafa Ms. Asima Bashir Ms. Aisha Norin Ms. Aneela Gohar Ms. Hina Riaz Ms. Shagufta Hameed Ms. Rabia Khalil Ms. Samina Abbas Appendix E | 217 Team 11 – Sargodha Team 12 – Vehari Mr. Muhammad Nadeem, Supervisor Mr. Imdadullah, Supervisor Interviewers Interviewers Ms. Afshan Riaz Ms. Naheed Mustafa Ms. Itrat Batool Ms. Razia Parveen Ms. Aliya Riaz Ms. Shagufta Nighat Ms. Farhat Babar Ms. Shamim Akhtar Ms. Zoufishan Bushra Ms. Zareena Bibi Ms. Rabia Bashir Ms. Shazia Kalsoom SINDH Team 1 – Badin Team 2 – Hyderabad City Mr. Atta Muhammad, Supervisor Mr. Rizwan Somroo, Supervisor Interviewers Interviewers Ms. Hajani Aisha Ms. Shaheen Bhatti Ms. Hamida Thahim Ms. Navia Memon Ms. Rahima Pusio Ms. Shazia Pusio Ms. Hamida Memon Ms. Naheed Memon Ms. Amina Javed Ms. Anjeela Sheedi Ms. Nadia Munawar Ms. Shaheen Arain Team 3 – Hyderabad (Dadu) Team 4 – Karachi-I Mr. Anis-ur-Rehman, Supervisor Mr. Khadim Hussain, Supervisor Interviewers Interviewers Ms. Shazia Sultana Ms. Kaz Bano Asif Ms. Jalila Salim Ms. Saima Soomro Ms. Shahida Laghari Ms. Shazia Syed Ms. Nida Ahmed Ms. Aneeta Kumari Ms. Saira Memon Ms. Shabana Arif Ms. Ainy Bashir Ms. Saima Baig Team 5 – Karachi-II Team 6 – Khairpur Mr. Sikandar Ali Bhatti, Supervisor Mr. Awais Ahmed, Supervisor Interviewers Interviewers Ms. Saher Palijo Ms. Sarwat Laghari Ms. Saima Ashraf Ms. Anila Batool Ms. Rabia Nawab Ms. Fahimunnisa Ms. Tahzib-un-Nisa Ms. Fozia Luhrani Ms. Shabana Akbar Ms. Sidra Fardous Ms. Seema Ansari Team 7 – Shikarpur Team 8 – Sukkur Mr. Mujahid Bhutto, Supervisor Mr. Abdul Haque Baloch, Supervisor Interviewers Interviewers Ms. Naseem Bhayo Ms. Shabroz Jhulan Ms. Abida Shaikh Ms. Shamaila Ghazal Ms. Farzana Lakho Ms. Asiya Soomro Ms. Rehana Khan Ms. Neelam Arfila Ms. Noor Jahan Balooch Ms. Zahida Ali 218 | Appendix E Appendix E | 219 NORTH-WEST FRONTIER PROVINCE Team 1 – Abbotabad Team 2 – D.I.Khan Mr. Shakeel Ahmed, Supervisor Mr. Arif Ali Zaidi, Supervisor Interviewers Interviewers Ms. Summaira Bibi Ms. Nargis Bibi Ms. Mehwish Zarlasht Ms. Aysha Ali Ms. Azra Jabeen Ms. Gul Shirin Ms. Fozia Tehsin Jazia Ms. Zohara Niazi Ms. Saira Jabeen Ms. Javaria Imtiaz Ms. Nadia Zerlasht Ms. Nazia Gul Team 3 – Dir-Lower Team 4 – Kohat Mr. Niaz Muhammad, Supervisor Mr. Hazrat Gul, Supervisor Interviewers Interviewers Ms. Rabia Sultan Ms. Nazia Sultana Ms. Asma Zareen Ms. Shabana Samad Ms. Saima Begum Ms. Gul Rukh Ms. Shazia Noreen Ms. Irum Gul Ms. Azra begum Ms. Rani Samad Ms. Laila Kiran Team 5 – Mardan Team 6 – Peshawar Mr. Muslim Khan, Supervisor Mr. Amjad Ali Shah, Supervisor Interviewers Interviewers Ms. Naheed Akhtar Ms. Naila Begum Ms. Ruby Hashim Ms. Saima Qamar Ms. Erum Rafique Ms. Kaisoom Ms. Nighat Taskeen Ms. Nadeema Begum Ms. Shah Gul Ms. Rani Andaleeb Ms. Surriya Afridi Ms. Lubna Maqsood BALOCHISTAN Team 1 – Loralai Team 2 – Quetta Qari Moeenuddin, Supervisor Mr. Shahid Ali, Supervisor Interviewers Interviewers Ms. Shahzina Farnciss Ms. Shafiqa Kasi Ms. Durdana Rehman Ms. Gul Nisa Ms. Saira Wahab Ms. Farzana Siyal Ms. Shahida Afzal Ms. Samina Baloch Ms. Fozia Arbab Kasi Ms. Naeema Baloch Ms. Nasreen Rehm Ali Team 3 – Turbat Mr. Sir Buland Khan, Supervisor Interviewers Ms. Durdana Sheran Ms. Shakila Rahim Ms. Najma Sultana Ms. Munira Sultana Ms. Maimoona Malang Ms. Aliya Fida QUESTIONNAIRES Appendix F 221Appendix F | NATIONAL INSTITUTE OF POPULATION STUDIES PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY 2006 COMMUNITY QUESTIONNAIRE (FOR RURAL SAMPLE POINTS ONLY) (IF MORE THAN ONE VILLAGE IN THE SAMPLE POINT, GET INFORMATION FROM THE LARGEST IDENTIFICATION PROVINCE (PUNJAB=1; SINDH=2; NWFP=3; BALOCHISTAN=4; FATA=5) DISTRICT TEHSIL CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE / RESULT PEOPLE WHO PARTICIPATED TO PROVIDE INFORMATION (WRITE NAME AND POSITION, E.G., VILLAGE LEADER, NAZIM, COUNCILLOR, RELIGIOUS LEADER, CHOWKIDAR, LOCAL FEMALE OR MALE TEACHER, LHV OR LHW) 1 DAY MONTH 2 YEAR 3 INT. NUMBER RESULT * 4 5 6 7 8 *RESULT CODES: 1 COMPLETED 2 UNABLE TO FIND SUITABLE RESPONDENTS 9 OTHER (SPECIFY) LANGUAGE OF QUESTIONNAIRE: ENGLISH INTERVIEWER/SUPERVISOR OFFICE EDITOR NAME DATE INFORMATION ABOUT THE PARTICIPANTS KEYED BY 2 0 0 223Appendix F | NO. QUESTIONS CODING CATEGORIES SKIP 101 How far is the district headquarters from this village? ASK FROM THE CENTER OF THE LARGEST VILLAGE KILOMETERS . . . . . . . . . . . . 95 KMS. OR MORE . . . . . . . . . . . . . . 95 102 Is the road to the district headquarters mainly a katcha road MAINLY KATCHA . . . . . . . . . . . . . . . . 1 or a pukka road? MAINLY PUKKA . . . . . . . . . . . . . . . . . . 2 103 How far is it from this village to the road that goes LESS THAN 1 KM. . . . . . . . . . . . . . . 00 to the district headquarters? ASK FROM THE CENTER OF THE LARGEST VILLAGE KILOMETERS . . . . . . . . . . . . 95 KMS. OR MORE . . . . . . . . . . . . . . 95 104 How do most people get from here to the road? WALK . . . . . . . . . . . . . . . . . . . . . . . . . . . 01 RICKSHAW . . . . . . . . . . . . . . . . . . . . 02 BICYCLE . . . . . . . . . . . . . . . . . . . . . . 03 MOTORBIKE . . . . . . . . . . . . . . . . . . . . 04 PRIVATE CAR / TAXI / SUZUKI VAN TRACTOR TROLLY . . . . . . . . . . . . . . 05 TONGA/CATTLE CART . . . . . . . . . . . . 06 BUS / TRUCK . . . . . . . . . . . . . . . . . . . . 07 OTHER ______________________ 96 (SPECIFY) 105 If a woman in this village has a serious problem DHQ HOSPITAL . . . . . . . . . . . . . . . . . . 01 with her pregnancy, where would she go for treatment? THQ HOSPITAL . . . . . . . . . . . . . . . . . . 02 MCH CENTRE . . . . . . . . . . . . . . . . . . . . 03 RHC . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 (NAME OF PLACE) BHU . . . . . . . . . . . . . . . . . . . . . . . . . . . 05 PRIVATE CLINIC / HOSPITAL . . . . . . . . 06 DAI / BIRTH ATTENDANT . . . . . . . . . . 07 LADY HEALTH WORKER . . . . . . . . . . 08 106 How would she reach (NAME OF PLACE IN 105)? WALK . . . . . . . . . . . . . . . . . . . . . . . . . . . 01 108 RICKSHAW . . . . . . . . . . . . . . . . . . . . 02 BICYCLE . . . . . . . . . . . . . . . . . . . . . . 03 MOTORBIKE . . . . . . . . . . . . . . . . . . . 04 PRIVATE CAR / TAXI / SUZUKI VAN TRACTOR TROLLY . . . . . . . . . . . . 05 TONGA/CATTLE CART . . . . . . . . . . . . 06 BUS / TRUCK . . . . . . . . . . . . . . . . . . . . 07 OTHER ______________________ 96 (SPECIFY) 107 Is transport available during the night time? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DOES NOT KNOW/NOT SURE . . . . . 8 108 How long would it take to reach the facility using this means? MINUTES . . . . . . . . . . . . GIVE TIME IN MINUTES ONLY. DOES NOT KNOW . . . . . . . . . . . . . . 998 109 Is there a Lady Health Worker in this village? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DOES NOT KNOW/NOT SURE . . . . . 8 201 1. GENERAL DESCRIPTION 224 | Appendix F NO. QUESTIONS CODING CATEGORIES SKIP 110 What services does she provide? ANTENATAL CARE . . . . . . . . . . . . . . . . A DELIVERY . . . . . . . . . . . . . . . . . . . . . . B CHILD IMMUNIZATIONS . . . . . . . . . . . . C CIRCLE ALL MENTIONED. CHILD CARE SERVICE. . . . . . . . . . . . . . D FAMILY PLANNING . . . . . . . . . . . . . . E GENERAL AILMENTS . . . . . . . . . . . . . . F OTHER ______________________ X (SPECIFY) 111 Does the LHW make house visits on a regular basis? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DOES NOT KNOW/NOT SURE . . . . . 8 225Appendix F | Now I would like to ask you about facilities and other services that may be in this village or at some distance. Type of facility/service 201 Is the (FACILITY / 202 How far away is (FACILITY/ SERVICE) in this SERVICE) from this village? village? IF >95 KMS, WRITE 95. a. Medical store? YES . 1 NO 2 KMS. . . . . . . . . . . b. General store or shop? YES . 1 NO 2 KMS. . . . . . . . . . . c. Motorized public transport? YES . 1 NO 2 KMS. . . . . . . . . . . d. Non-motorized public transport? YES . 1 NO 2 KMS. . . . . . . . . . . e. Post office? YES . 1 NO 2 KMS. . . . . . . . . . . f. Bank? YES . 1 NO 2 KMS. . . . . . . . . . . g. Primary school for boys? YES . 1 NO 2 KMS. . . . . . . . . . . h. Primary school for girls? YES . 1 NO 2 KMS. . . . . . . . . . . i. Secondary school for boys? YES . 1 NO 2 KMS. . . . . . . . . . . j. Secondary school for girls? YES . 1 NO 2 KMS. . . . . . . . . . . k. Any ambulance service? YES . 1 NO 2 KMS. . . . . . . . . . . l. Ultrasound services for pregnant women? YES . 1 NO 2 KMS. . . . . . . . . . . m. A waste water drainage scheme? YES . 1 NO 2 n. A drinking water scheme? YES . 1 NO 2 o. Television service? YES . 1 NO 2 p. Cable television connections YES . 1 NO 2 q. Any land-line telephone service? YES . 1 NO 2 r. Mobile telephone coverage? YES . 1 NO 2 s. Any public call office (PCO)? YES . 1 NO 2 2. AVAILABILITY OF FACILITIES AND SERVICES 226 | Appendix F NO. QUESTIONS CODING CATEGORIES SKIP 301 Please tell me how far away each of the following facilities are from here? IF LESS THAN 1 KM PUT 00 ASK FROM THE CENTER OF THE (LARGEST) VILLAGE IF 95 KMS. OR MORE PUT 95 a. Dai? KILOMETERS . . . . . . . . . . . . b. A functioning* basic health unit (BHU)? KILOMETERS . . . . . . . . . . . . c. A rural health center (RHC)? KILOMETERS . . . . . . . . . . . . d. A government dispensary. KILOMETERS . . . . . . . . . . . . e. A functioning* MCH Centre. KILOMETERS . . . . . . . . . . . . f. A private doctor. KILOMETERS . . . . . . . . . . . . g. A dispenser or a compounder. KILOMETERS . . . . . . . . . . . . h. A family welfare center (FWC) or somewhere else to get family planning. KILOMETERS . . . . . . . . . . . . i. A hakeem or homeopath. KILOMETERS . . . . . . . . . . . . j. A hospital. KILOMETERS . . . . . . . . . . . . 302 Think back over the last 3 years, has any woman in this YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 village died because of a problem of pregnancy or NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 died during childbirth or within 6 weeks of childbirth? DOES NOT KNOW/NOT SURE . . . . . 8 GPS 303 Please tell me about the death(s). WHO IT WAS, WHEN IT OCCURRED. WHO WAS IT - NAME / WIFE OF: WHEN DID IT OCCUR: END OF INTERVIEW - NOTE GPS READING * Funtioning facility: Presence of LHV to provide required services on regular basis. 3. AVAILABILITY OF HEALTH FACILITIES 227Appendix F | Pakistan Demographic and Health Survey 2006 GPS Cluster Position Form Before recording, did you… ��Check that the estimated accuracy shown in the opening screen is 15 meters or less? ��Mark the point in the GPS unit? � Rename the point to the cluster number ? After recording the coordinates on this sheet, don’t forget to … � Save the waypoint in the GPS unit's memory Place name: Cluster: Region: Date: Day Operator name: Code Waypoint ID (as enter in GPS unit) Altitude feet (Circle one) Decimal degrees Latitude N S . (Circle one) Decimal degrees Longitude E W . Degree Degree CLUSTER AND OPERATOR IDENTIFICATION: Month Year POSITION INFORMATION: 228 | Appendix F NATIONAL INSTITUTE OF POPULATION STUDIES PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY 2006 SHORT HOUSEHOLD QUESTIONNAIRE IDENTIFICATION PROVINCE (PUNJAB=1; SINDH=2; NWFP=3; BALOCHISTAN=4; FATA=5) . . . . . . . . . . . . . . . . DISTRICT . . . . . . . . . . . . . . . . TEHSIL CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IS HOUSEHOLD SELECTED FOR: (SHORT=1; WOMAN=2; VERBAL AUTOPSY=3; WOMAN AND VERBAL AUTOPSY= 4) . . . . . . . . . . . . . . . . . . . . NAME OF HOUSEHOLD HEAD INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. NUMBER RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: TOTAL PERSONS 1 COMPLETED IN HOUSEHOLD 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME DEATHS UNDER 5/ SBs 4 POSTPONED FROM Q. 38 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED FEMALE DEATHS AGE 8 DWELLING NOT FOUND 12-49 FROM Q. 39 9 OTHER (SPECIFY) LINE NO. OF LANGUAGE OF QUESTIONNAIRE: URDU RESPONDENT SUPERVISOR FIELD EDITOR OFFICE EDITOR NAME NAME DATE DATE Signature of interviewer: Date: RESPONDENT AGREES TO BE INTERVIEWED . . . . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . . 2 END KEYED BY 1 2 3 2 0 0 229Appendix F | Now we would like some information about the people who usually live in your household or who are staying with you now. LINE USUAL RESIDENTS AND NO. VISITORS Please give me the names of What is the Is Does Did How old is Has What is the the persons who usually live relationship of (NAME) (NAME) (NAME) (NAME)? (NAME) highest class of in your household and guests (NAME) to the male or usually stay here ever school (NAME) of the household who stayed head of the female? live last attended completed? here last night, starting with household? here? night? What is school? the head of the household (NAME'S) current IF LESS marital AFTER LISTING NAMES, THAN 1 status? RELATIONSHIP AND SEX YEAR, WRITE FOR EACH PERSON, ASK 00'. Qs. 2A-2C TO BE SURE THAT THE LISTING IS IF AGE 96 COMPLETE. THEN ASK YEARS OR QUESTIONS IN COLUMNS 5-11 MORE, FOR EACH PERSON. WRITE '96'. (SEE CODES (SEE CODES (SEE CODES BELOW) BELOW) BELOW) (1) M F YES NO YES NO M W D/S N YES NO CLASS 01 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 02 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 03 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 04 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 05 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 06 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 07 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 08 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 09 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 10 1 2 1 2 1 2 1 2 3 4 1 2 NEXT CODES FOR Q. 3 RELATIONSHIP TO HEAD OF HOUSEHOLD: CODES FOR Q. 8 CODES FOR Q. 11 01 = HEAD 09 = BROTHER/SISTER IN LAW MARITAL STATUS EDUCATION CLASS: 02 = WIFE OR HUSBAND 10 = NIECE/NEPHEW 1 = MARRIED 00 = LESS THAN 1 YEAR COMPLETED 03 = SON OR DAUGHTER 11 = GRAND PARENTS 2 = WIDOWED 01 = CLASS 1; 04 = SON-IN-LAW OR 12 =AUNTS/UNCLE 3 = DIVORCED/SEPARATED 02 = CLASS 2 DAUGHTER-IN-LAW 13 = OTHER RELATIVE 4 = NEVER MARRIED . . . 05 = GRANDCHILD 14 = ADOPTED/FOSTER/STEPCHILD 10 = MATRIC, CLASS 10 06 = PARENT 15 = NOT RELATED 11 = CLASS 11 07 = PARENT-IN-LAW 16= DOMESTIC SERVANT . . . . 08 = BROTHER OR SISTER 98 = DON'T KNOW 16 = MASTER'S DEGREE OR MBBS, PhD, MPHIL, BSc (4 YEARS) 98 = DON'T KNOW (2) IN YEARS OLDER MARITAL STATUS (8)(7)(4) (5) (6)(3) IF AGE 5 YEARS OR OLDER (11)(10) EDUCATION HOUSEHOLD SCHEDULE RELATIONSHIP TO HEAD OF HOUSEHOLD SEX RESIDENCE IF AGE 12AGE OR 230 | Appendix F LINE USUAL RESIDENTS AND NO. VISITORS Please give me the names of What is the Is Does Did How old is Has What is the the persons who usually live relationship of (NAME) (NAME) (NAME) (NAME)? (NAME) highest class of in your household and guests (NAME) to the male or usually stay here ever school (NAME) of the household who stayed head of the female? live last attended completed? here last night, starting with household? here? night? What is school? the head of the household (NAME'S) current IF LESS marital AFTER LISTING NAMES, THAN 1 status? RELATIONSHIP AND SEX YEAR, WRITE FOR EACH PERSON, ASK 00'. Qs. 2A-2C TO BE SURE THAT THE LISTING IS IF AGE 96 COMPLETE. THEN ASK YEARS OR QUESTIONS IN COLUMNS 5-11 MORE, FOR EACH PERSON. WRITE '96'. (SEE CODES (SEE CODES (SEE CODES BELOW) BELOW) BELOW) OLDER MARITAL STATUS IF AGE 5 YEARS OR OLDER EDUCATION RELATIONSHIP TO HEAD OF HOUSEHOLD SEX RESIDENCE IF AGE 12AGE OR (1) (2) M F YES NO YES NO M W D/S N YES NO CLASS 11 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 12 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 13 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 14 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 15 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 16 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 17 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 18 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 19 1 2 1 2 1 2 1 2 3 4 1 2 NEXT 20 1 2 1 2 1 2 1 2 3 4 1 2 NEXT CODES FOR Q. 11 TICK HERE IF CONTINUATION SHEET USED EDUCATION CLASS: 00 = LESS THAN 1 YEAR COMPLETED Just to make sure that I have a complete household listing: 01 = CLASS 1; 02 = CLASS 2 2A) Are there any other persons such as small children or infants that we ADD TO . . . have not listed? YES TABLE NO 10 = MATRIC, CLASS 10 11 = CLASS 11 . . . . 2B) Are there any other people who may not be members of your family, ADD TO 16 = MASTER'S DEGREE OR MBBS, such as domestic servants, lodgers or friends who usually live here? YES TABLE NO PhD, MPHIL, BSc (4 YEARS) 98 = DON'T KNOW 2C) Are there any guests or temporary visitors staying here, or anyone else ADD TO who slept here last night, who have not been listed? YES TABLE NO IF NO MORE MEMBERS, GO TO COLUMN 5. (3) (4) (5) (6) IN YEARS (11)(10)(7) (8) 231Appendix F | 18 Now I would like to ask you about all the births that occurred in this household in the last 3 years, whether they were born alive or dead. Since January 2003, did any woman who was a usual resident of this household YES . 1 at that time give birth? I am interested in any birth, even stillbirths and children who did not survive. NO . . 2 27 19 How many births occurred in this household in the last 3 years? NO. What are the Is (NAME) In what month and year Was (NAME) born Is (NAME) still alive? names of the a boy or was (NAME) born? alive? LINE NUMBER FROM babies born in a girl? HOUSEHOLD the last 3 years? ROSTER (RECORD '00' IF STILL BORN, IF CHILD NOT LISTED WRITE 'BABY'. IN HH ROSTER) IF MONTH DON’T KNOW RECORD '98' 20 01 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 02 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 03 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 04 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 05 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 06 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 07 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 08 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT CONTINUED (Additional Sheet) 2 0 0 2 0 0 2 0 0 INFORMATION ABOUT BIRTHS AND DEATHS IN THE HOUSEHOLD IN THE PREVIOUS 3 YEARS 21 22 23 24 25 26 2 0 0 2 0 0 2 0 0 2 0 0 2 0 0 232 | Appendix F 27 Now I would like to ask you about any deaths that occurred in this household in the last 3 years. YES . 1 Since January 2003, God forbid, has any usual member of this household died? NO . 2 38 28 How many deaths occurred to usual residents in this household in the last 3 years? NO. What were Was In what month and year How old was (NAME) CHECK 31 the names (NAME) did (NAME) die? when he/she died? AND 33: of the people male or RECORD DAYS IF LESS WAS THIS Was Did Did who died female? THAN 1 MONTH; A WOMAN (NAME) (NAME) (NAME) in the last MONTHS IF LESS THAN AGE 12-49 pregnant die during die within 3 years? 2 YEARS; OR YEARS. WHEN SHE when she childbirth? 6 weeks DIED? died? after delivery? IF MONTH DON’T KNOW RECORD '98' 29 01 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 02 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 03 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 04 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 38. CHECK COLS. 32, 33 AND 24/23: NUMBER OF DEATHS TO CHILDREN UNDER 5 YEARS AND STILLBIRTHS IN 2005 OR AFTER 39. CHECK COLUMN 34 AND 32: NUMBER OF DEATHS TO WOMEN AGE 12-49 YEARS OLD IN 2003 OR AFTER . . . . . . . . . . . . . . . Female, 12-49 years old 2 0 0 2 0 0 2 30 31 32 33 34 35 36 37 0 0 2 0 0 233Appendix F | NATIONAL INSTITUTE OF POPULATION STUDIES PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY 2006 LONG HOUSEHOLD QUESTIONNAIRE IDENTIFICATION PROVINCE (PUNJAB=1; SINDH=2; NWFP=3; BALOCHISTAN=4; FATA=5) . . . . . . . . . . . . . . . . DISTRICT . . . . . . . . . . . . . . . . TEHSIL CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IS HOUSEHOLD SELECTED FOR ? (SHORT=1; WOMAN=2; VERBAL AUTOPSY=3; WOMAN AND VERBAL AUTOPSY= 4) . . . . . . . . . . . . . . . . . . . . NAME OF HOUSEHOLD HEAD INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. NUMBER RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: TOTAL PERSONS 1 COMPLETED IN HOUSEHOLD 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME TOTAL ELIGIBLE 4 POSTPONED WOMEN 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING DEATHS UNDER 5 /SBs 7 DWELLING DESTROYED FROM Q. 38 8 DWELLING NOT FOUND 9 OTHER FEMALE DEATHS AGE (SPECIFY) 12-49 FROM Q. 39 LANGUAGE OF QUESTIONNAIRE: URDU LINE NO. OF RESPONDENT SUPERVISOR FIELD EDITOR OFFICE EDITOR NAME NAME DATE DATE Signature of interviewer: Date: RESPONDENT AGREES TO BE INTERVIEWED . . . . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . . 2 END KEYED BY 2 0 0 1 2 3 235Appendix F | Now we would like some information about the people who usually live in your household or who are staying with you now. LINE USUAL RESIDENTS AND NO. VISITORS Please give me the names of What is the Is (NAME) Does Did How old is the persons who usually live relationship of male or (NAME) (NAME) (NAME)? in your household and guests (NAME) to the female? usually live stay here of the household who stayed head of the here? last here last night, starting with household? night? What is the head of the household. (NAME'S) current marital IF LESS status? AFTER LISTING NAMES, THAN 1 RELATIONSHIP AND SEX YEAR, WRITE FOR EACH PERSON, ASK 00'. Qs. 2A-2C TO BE SURE THAT THE LISTING IS IF AGE 96 COMPLETE. THEN ASK YEARS OR QUESTIONS IN COLUMNS 5-17 MORE, FOR EACH PERSON. WRITE '96'. (SEE CODES (SEE CODES BELOW) BELOW) (1) M F YES NO YES NO M W D/S N 01 1 2 1 2 1 2 1 2 3 4 02 1 2 1 2 1 2 1 2 3 4 03 1 2 1 2 1 2 1 2 3 4 04 1 2 1 2 1 2 1 2 3 4 05 1 2 1 2 1 2 1 2 3 4 06 1 2 1 2 1 2 1 2 3 4 07 1 2 1 2 1 2 1 2 3 4 08 1 2 1 2 1 2 1 2 3 4 09 1 2 1 2 1 2 1 2 3 4 10 1 2 1 2 1 2 1 2 3 4 CODES FOR Q. 3 RELATIONSHIP TO HEAD OF HOUSEHOLD: CODES FOR Q. 8 01 = HEAD 09 =BROTHER/SISTER IN LAW MARITAL STATUS 02 = WIFE OR HUSBAND 10 = NIECE/NEPHEW 1 = MARRIED 03 = SON OR DAUGHTER 11 = GRAND PARENTS 2 = WIDOWED 04 = SON-IN-LAW OR 12 =AUNTS/UNCLE 3 = DIVORCED/SEPARATED DAUGHTER-IN-LAW 13 = OTHER RELATIVE 4 = NEVER MARRIED 05 = GRANDCHILD 14 = ADOPTED/FOSTER/STEPCHILD 06 = PARENT 15 = NOT RELATED 07 = PARENT-IN-LAW 16= DOMESTIC SERVANT 08 = BROTHER OR SISTER 98 = DON'T KNOW (2) (3) HOUSEHOLD SCHEDULE RELATIONSHIP TO HEAD OF HOUSEHOLD SEX RESIDENCE IF AGE 12AGE OR OLDER MARITAL STATUS (8) IN YEARS (7)(4) (5) (6) 236 | Appendix F ELIGIBILITY FOR ALL AGES REGISTRATION WITH NADRA CIRCLE Has What is the Did (NAME) During this Did (NAME) Is (NAME)'s Is (NAME)'s Has (NAME) been LINE (NAME) highest class of attend school year, attend school at natural mother natural father registered with NADRA? NUMBER ever school (NAME) school at what class/grade any time during the alive? alive? OF ALL attended completed? any time [is/was] NAME previous year WOMEN school? during the attending? 2005? AGE 12-49 2006 WHO ARE year? IF YES - PROBE: MARRIED, Does (NAME) have WIDOWED NIC card or name OR entered onto a 'bay' DIVORCED form, or nothing OR at all? SEPARA- TED (SEE CODES (SEE CODES BELOW) BELOW) (SEE CODES BELOW) (9) YES NO CLASS YES NO CLASS YES NO Y N DK Y N DK NIC BF NONE DK 01 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 02 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 03 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 04 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 05 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 06 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 07 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 08 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 09 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 10 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 GO TO 15 GO TO 14 CODES FOR Q. 11 AND 13 CODES FOR Q. 17 EDUCATION CLASS: 00 = LESS THAN 1 YEAR COMPLETED (1) HAS NIC 01 = CLASS 1; (2) NAME ON 'BAY' FORM 02 = CLASS 2 (3) NEITHER OF THE ABOVE . . . (8) DOES NOT KNOW 10 = MATRIC, CLASS 10 11 = CLASS 11 . . . . 16 = MASTER'S DEGREE OR MBBS, PhD, MPHIL, BSc (4 YEARS) 98 = DON'T KNOW SCHOOLING DURING LAST YEAR IF AGE 5-24 YEARSIF AGE 5 YEARS OR OLDER (10) (14)(11) IF AGE 0-17 YEARS (15) (16) SURVIVORSHIP OF BIOLOGICAL PARENTSEDUCATION CURRENT SCHOOLING (12) (13) (17) 237Appendix F | LINE USUAL RESIDENTS AND NO. VISITORS Please give me the names of What is the Is (NAME) Does Did How old is the persons who usually live relationship of male or (NAME) (NAME) (NAME)? in your household and guests (NAME) to the female? usually live stay here of the household who stayed head of the here? last here last night, starting with household? night? What is the head of the household. (NAME'S) current marital IF LESS status? AFTER LISTING NAMES, THAN 1 RELATIONSHIP AND SEX YEAR, WRITE FOR EACH PERSON, ASK 00'. Qs. 2A-2C TO BE SURE THAT THE LISTING IS IF AGE 96 COMPLETE. THEN ASK YEARS OR QUESTIONS IN COLUMNS 5-17 MORE, FOR EACH PERSON. WRITE '96'. (SEE CODES (SEE CODES BELOW) BELOW) RELATIONSHIP TO HEAD OF HOUSEHOLD SEX RESIDENCE IF AGE 12AGE OR OLDER MARITAL STATUS (1) M F YES NO YES NO M W D/S N 11 1 2 1 2 1 2 1 2 3 4 12 1 2 1 2 1 2 1 2 3 4 13 1 2 1 2 1 2 1 2 3 4 14 1 2 1 2 1 2 1 2 3 4 15 1 2 1 2 1 2 1 2 3 4 16 1 2 1 2 1 2 1 2 3 4 17 1 2 1 2 1 2 1 2 3 4 18 1 2 1 2 1 2 1 2 3 4 19 1 2 1 2 1 2 1 2 3 4 20 1 2 1 2 1 2 1 2 3 4 TICK HERE IF CONTINUATION SHEET USED Just to make sure that I have a complete household listing: 2A) Are there any other persons such as small children or infants that we ADD TO have not listed? YES TABLE NO 2B) Are there any other people who may not be members of your family ADD TO such as domestic servants, lodgers or friends who usually live here? YES TABLE NO 2C) Are there any guests or temporary visitors staying here, or anyone else ADD TO who slept here last night, who have not been listed? YES TABLE NO IF NO MORE MEMBERS, GO TO COLUMN 5. (2) IN YEARS (4) (5) (6) (7) (8)(3) 238 | Appendix F ELIGIBILITY FOR ALL AGES REGISTRATION WITH NADRA CIRCLE Has What is the Did (NAME) During this Did (NAME) Is (NAME)'s Is (NAME)'s Has (NAME) been LINE (NAME) highest class of attend school year, attend school at natural mother natural father registered with NADRA? NUMBER ever school (NAME) school at what class/grade any time during the alive? alive? OF ALL attended completed? any time [is/was] NAME previous year WOMEN school? during the attending? 2005? AGE 12-49 2006 WHO ARE year? IF YES - PROBE: MARRIED, Does (NAME) have WIDOWED NIC card or name OR entered onto a 'bay' DIVORCED form, or nothing OR at all? SEPARA- TED (SEE CODES (SEE CODES BELOW) BELOW) (SEE CODES BELOW) SCHOOLING DURING LAST YEAR IF AGE 5-24 YEARSIF AGE 5 YEARS OR OLDER IF AGE 0-17 YEARS SURVIVORSHIP OF BIOLOGICAL PARENTSEDUCATION CURRENT SCHOOLING (9) YES NO CLASS YES NO CLASS YES NO Y N DK Y N DK NIC BF NONE DK 11 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 12 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 13 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 14 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 15 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 16 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 17 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 18 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 19 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 20 1 2 1 2 1 2 1 2 8 1 2 8 1 2 3 8 NEXT GO TO 14 CODES FOR Q. 11 AND 13 EDUCATION CLASS: CODES FOR Q. 17 (1) HAS NIC 00 = LESS THAN 1 YEAR COMPLETED (2) NAME ON 'BAY' FORM 01 = CLASS 1; (3) NEITHER OF THE ABOVE 02 = CLASS 2 (8) DOES NOT KNOW . . . 10 = MATRIC, CLASS 10 11 = CLASS 11 . . . . 16 = MASTER'S DEGREE OR MBBS, PhD, MPHIL, BSc (4 YEARS) 98 = DON'T KNOW (11)(10) (16)(15)(12) (13) (14) (17) 239Appendix F | 18 Now I would like to ask you about all the births that occurred in this household in the last 3 years, whether they were born alive or dead. Since January 2003, did any woman who was a usual resident of this household YES . 1 at that time give birth? I am interested in any birth, even stillbirths and children who did not survive. NO . . 2 27 19 How many births occurred in this household in the last 3 years? NO. What are the Is (NAME) In what month and year Was (NAME) born Is (NAME) still alive? names of the a boy or was (NAME) born? alive? LINE NUMBER FROM babies born in a girl? HOUSEHOLD the last 3 years? ROSTER (RECORD '00' IF STILL BORN, IF CHILD NOT LISTED WRITE 'BABY'. IN HH ROSTER) IF MONTH DON’T KNOW RECORD '98' 20 01 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 02 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 03 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 04 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 05 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 06 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 07 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT 08 BOY . 1 MONTH YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 GIRL . 2 YR NEXT NEXT NEXT CONTINUED (Additional Sheet) 2 0 0 2 0 0 2 0 0 2 0 0 26 2 0 0 INFORMATION ABOUT BIRTHS AND DEATHS IN THE HOUSEHOLD IN THE PREVIOUS 3 YEARS 21 22 23 24 25 2 0 0 2 0 0 2 0 0 240 | Appendix F 27 Now I would like to ask you about any deaths that occurred in this household in the last 3 years. YES . 1 Since January 2003, God forbid, has any usual member of this household died? NO . 2 38 28 How many deaths occurred to usual residents in this household in the last 3 years? NO. What were Was In what month and year How old was (NAME) CHECK 31 the names (NAME) did (NAME) die? when he/she died? AND 33: of the people male or RECORD DAYS IF LESS WAS THIS Was Did Did who died female? THAN 1 MONTH; A WOMAN (NAME) (NAME) (NAME) in the last MONTHS IF LESS THAN AGE 12-49 pregnant die during die within 3 years? 2 YEARS; OR YEARS. WHEN SHE when she childbirth? 6 weeks DIED? died? after delivery? IF MONTH DON’T KNOW RECORD '98' 29 01 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 02 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 03 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 04 MALE 1 MONTH DAYS . 1 YES . 1 YES . 1 YES . 1 YES . 1 NEXT NEXT FEMALE 2 YR MONTHS. 2 NO . 2 NO . 2 NO . 2 NO . 2 NEXT YEARS . 3 NEXT 38. CHECK COLS. 32, 33 AND 24/23: NUMBER OF DEATHS TO CHILDREN UNDER 5 YEARS AND STILLBIRTHS IN 2005 OR AFTER 39. CHECK COLUMN 34 AND 32: NUMBER OF DEATHS TO WOMEN AGE 12-49 YEARS OLD IN 2003 OR AFTER . . . . . . . . . . . . . . . 0 0 2 0 0 34 35 36 3730 31 32 33 2 0 0 2 0 0 2 Female, 12-49 years old 241Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 What is the main source of drinking water for members of your PIPED WATER household? PIPED INTO DWELLING . . . . . . . . 11 PIPED TO YARD/PLOT . . . . . . . . 12 103 PUBLIC TAP/STAND PIPE . . . 13 TUBE WELL OR BOREHOLE . . . . . 21 HAND PUMP . . . . . . . . . . . . . . . . 22 DUG WELL PROTECTED WELL . . . . . . . . . . 31 UNPROTECTED WELL . . . . . . . . 32 WATER FROM SPRING PROTECTED SPRING/KAREZ . . . 41 UNPROTECTED SPRING . 42 RAINWATER . . . . . . . . . . . . . . . . . . 51 TANKER TRUCK . . . . . . . . . . . . . . . . 61 CART WITH SMALL TANK . . . . . . . . 71 SURFACE WATER (RIVER/DAM/LAKE/ POND/STREAM/CANAL . . . . . . 81 BOTTLED WATER . 91 OTHER ______________________ 96 (SPECIFY) 102 How long does it take to go there, get water, and come back? MINUTES . . . . . . . . . . . . . . ON PREMISES . . . . . . . . . . . . . . . . 996 DON'T KNOW . . . . . . . . . . . . . . . . . . 998 103 Do you treat your water in any way to make it safer to drink? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 105 104 What do you usually do to the water to make it safer to drink? BOIL . . . . . . . . . . . . . . . . . . . . . . . . . . . A ADD BLEACH/CHLORINE . . . . . . . . . . B STRAIN THROUGH A CLOTH . . . . . . . . C Anything else? USE WATER FILTER (CERAMIC/ SAND/COMPOSITE/ETC.) . . . . . . . . D SOLAR DISINFECTION . . . . . . . . . . . . E RECORD ALL MENTIONED. LET IT STAND AND SETTLE . . . . . . . . F OTHER ______________________ X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . Z 105 What kind of toilet facility do members of your household usually FLUSH OR POUR FLUSH TOILET use? FLUSH TO SEWER SYSTEM . . . 11 FLUSH TO SEPTIC TANK . . . . . 12 FLUSH TO SOMEWHERE ELSE . . . 13 FLUSH, DON'T KNOW WHERE . . . 14 PIT LATRINE VENTILATED IMPROVED PIT LATRINE (VIP) . . . . . . . . . . 21 PIT LATRINE WITH SLAB . . . . . 22 PIT LATRINE WITHOUT SLAB/ OPEN PIT 23 BUCKET TOILET . . . . . . . . . . . . . . . . 41 HANGING TOILET/HANGING LATRINE 51 NO FACILITY/BUSH/FIELD . . . . . . . . 61 107 OTHER ______________________ 96 (SPECIFY) HOUSEHOLD CHARACTERISTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 106 Do you share this toilet facility with other households? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 107 Does your household have: YES NO Electricity? ELECTRICITY . . . . . . . . . . . . . . 1 2 Radio? RADIO . . . . . . . . . . . . . . . . . . . . 1 2 Television? TELEVISION . . . . . . . . . . . . . . 1 2 Refrigerator? REFRIGERATOR . . . . . . . . . . . . 1 2 Mobile telephone or land line telephone? ANY TELEPHONE . . . . . . . . . . 1 2 Room cooler, air conditioner? ROOM COOLER, AIR COND. . 1 2 Washing machine? WASHING MACHINE . . . . . . . . 1 2 Water pump? WATER PUMP . . . . . . . . . . . . 1 2 Bed? BED . . . . . . . . . . . . . . . . . . . . 1 2 Chairs? CHAIRS . . . . . . . . . . . . . . . . . . 1 2 Almirah / cabinet? ALMIRAH/CABINET . . . . . . . . 1 2 Clock? CLOCK . . . . . . . . . . . . . . . . . . 1 2 Sofa? SOFA . . . . . . . . . . . . . . . . . . . . 1 2 Sewing machine? SEWING MACHINE . . . . . . . . . . 1 2 Camera? CAMERA . . . . . . . . . . . . . . . . . . 1 2 Personal computer? PERSONAL COMPUTER . . . 1 2 108 What type of fuel does your household mainly use for cooking? ELECTRICITY . . . . . . . . . . . . . . . . . . 01 CYLINDER GAS . . . . . . . . . . . . . . . . 02 NATURAL GAS . . . . . . . . . . . . . . . . 03 BIOGAS . . . . . . . . . . . . . . . . . . . . . . 04 KEROSENE . . . . . . . . . . . . . . . . . . . . 05 CHARCOAL . . . . . . . . . . . . . . . . . . . . 06 WOOD . . . . . . . . . . . . . . . . . . . . . . 07 STRAW/SHRUBS/GRASS . . . . . . . . 08 AGRICULTURAL CROP . . . . . . . . . . 09 ANIMAL DUNG . . . . . . . . . . . . . . . . 10 NO FOOD COOKED IN HOUSEHOLD 95 OTHER ______________________ 96 (SPECIFY) 109 MAIN MATERIAL OF THE FLOOR: NATURAL FLOOR EARTH / SAND / MUD . . . . . . . . . . 11 RECORD OBSERVATION FINISHED FLOOR CHIPS / TERRAZZO . . . . . . . . . . 31 CERAMIC TILES . . . . . . . . . . . . . . 32 MARBLE . . . . . . . . . . . . . . . . . . . . 33 CEMENT . . . . . . . . . . . . . . . . . . . . 34 CARPET . . . . . . . . . . . . . . . . . . . . 35 BRICKS . . . . . . . . . . . . . . . . . . . . 36 MATS . . . . . . . . . . . . . . . . . . . . 37 OTHER ______________________ 96 (SPECIFY) 243Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 110 MAIN MATERIAL OF THE ROOF: NATURAL ROOFING THATCH / BAMBOO / WOOD /MUD 12 RECORD OBSERVATION RUDIMENTARY ROOFING CARDBOARD / PLASTIC . . . . . . . . 21 FINISHED ROOFING IRON SHEETS / ASBESTOS . . . 31 T-IRON / WOOD / BRICK . . . . . 32 REINFORCED BRICK CEMENT/RCC 33 OTHER ______________________ 96 (SPECIFY) 111 MAIN MATERIAL OF THE WALLS: NATURAL WALLS MUD / STONES . . . . . . . . . . . . . . 11 BAMBOO / STICKS / MUD . . . . . 12 RECORD OBSERVATION RUDIMENTARY WALLS UNBAKED BRICKS / MUD . . . . . 21 PLYWOOD SHEETS . . . . . . . . . . 22 CARTON / PLASTIC . . . . . . . . . . 23 FINISHED WALLS STONE BLOCKS . . . . . . . . . . . . . . 31 BAKED BRICKS . . . . . . . . . . . . . . 32 CEMENT BLOCKS/ CEMENT . . . 33 TENT . . . . . . . . . . . . . . . . . . . . . . 34 OTHER ______________________ 96 (SPECIFY) 112 How many rooms in this household are used for sleeping? ROOMS . . . . . . . . . . . . . . . . . . 113 Is this house rented, rent-free, mortgaged, or or owned by RENTED . . . . . . . . . . . . . . . . . . . . . . . . 1 a member of the household? RENT-FREE . . . . . . . . . . . . . . . . . . . . . . 2 MORTGAGED . . . . . . . . . . . . . . . . . . . . 3 OWNED . . . . . . . . . . . . . . . . . . . . . . . . 4 OTHER . . . . . . . . . . . . . . . . . . . . . . . . 6 114 Does any member of this household own: YES NO A watch? WATCH . . . . . . . . . . . . . . . . . . 1 2 A bicycle? BICYCLE . . . . . . . . . . . . . . . . . . 1 2 A motorcycle or motor scooter? MOTORCYCLE/SCOOTER . . . 1 2 An animal-drawn cart? ANIMAL-DRAWN CART . . . . . 1 2 A car or truck or Tractor? CAR/TRUCK . . . . . . . . . . . . . . 1 2 A boat with a motor? BOAT WITH MOTOR . . . . . . . . 1 2 115 Does any member of this household own any land YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 that can be used for agriculture? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 116 Does this household own any livestock, herds, other farm YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 animals, or poultry? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 118 244 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 117 How many of the following animals does this household own? Buffalo BUFFALO . . . . . . . . . . . . . . . . Milk cows or bulls? COWS/BULLS . . . . . . . . . . . . . . Camels? CAMELS . . . . . . . . . . . . . . . . . . Donkeys, or mules or horses? DONKEYS/MULES/HORSES . Goats? GOATS . . . . . . . . . . . . . . . . . . Sheep? SHEEP . . . . . . . . . . . . . . . . . . Chickens? CHICKENS . . . . . . . . . . . . . . . . IF NONE, WRITE '00'. IF > 95, WRITE '95'. IF UNKNOWN, WRITE '98' 118 Does your household have any mosquito nets that can be used YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 while sleeping? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 119 How many mosquito nets does your household have? NUMBER OF NETS . . . . . . . . . . . . . . 126 245Appendix F | ASK THESE QUESTIONS FOR TWO BEDNETS ONLY 120 When you got the net, was it already YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . 1 treated with an insecticide to kill or SKIP to 123 (SKIP TO 123) repel mosquitos? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NOT SURE . . . . . . . . 8 NOT SURE . . . . . . . . 8 121 Since you got the mosquito net, was it YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . 1 ever soaked or dipped in a liquid NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 to kill or repel mosquitos? (SKIP TO 123) (SKIP TO 123) NOT SURE . . . . . . . . 8 NOT SURE . . . . . . . . 8 122 How many months ago was the net MONTH MONTH last soaked or dipped? AGO . . . . . AGO . . . . . IF LESS THAN ONE MONTH, RECORD '00'. 25 OR MORE 25 OR MORE MONTHS AGO . . . 95 MONTHS AGO . . . NOT SURE . . . . . . . . 98 NOT SURE . . . . . . . . 98 123 Did anyone sleep under this mosquito YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . 1 net last night? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 125) (SKIP TO 125) NOT SURE . . . . . . . . 8 NOT SURE . . . . . . . . 8 124 Who slept under this mosquito net last night? NAME_____________ NAME_____________ LINE LINE NO. . . . . . NO. . . . . . NAME_____________ NAME_____________ LINE LINE RECORD THE PERSON'S NO. . . . . . NO. . . . . . LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. NAME_____________ NAME_____________ LINE LINE NO. . . . . . NO. . . . . . 125 GO BACK TO 120 FOR NEXT NET; OR, IF NO GO TO 126. MORE NETS, GO TO 126. 126 Does your household do anything (else) to avoid YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 mosquitos? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 127 What do you do? COIL . . . . . . . . . . . . . . . . . . . . . . . . . . . A MATS . . . . . . . . . . . . . . . . . . . . . . . . B CIRCLE ALL MENTIONED. SPRAY . . . . . . . . . . . . . . . . . . . . . . . . C ELECTRIC SPRAY REPELLANT . . . . . D INSECT REPELLANT . . . . . . . . . . . . . . E OTHER X (SPECIFY) 128 Do you have any medicines for treating malaria in your YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 house now? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DOES NOT KNOW . . . . . . . . . . . . . . . . 8 128 NET #1 NET #2 95 246 | Appendix F NATIONAL INSTITUTE OF POPULATION STUDIES PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY EVER-MARRIED WOMAN'S QUESTIONNAIRE IDENTIFICATION PROVINCE (PUNJAB=1; SINDH=2; NWFP=3; BALOCHISTAN=4; FATA=5) DISTRICT TEHSIL CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LARGE CITY=1; SMALL CITY=2; TOWN=3; RURAL=4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME OF HOUSEHOLD HEAD NAME AND LINE NUMBER OF WOMAN INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. NUMBER RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: 1 COMPLETED 4 REFUSED 2 NOT AT HOME 5 PARTLY COMPLETED 7 OTHER 3 POSTPONED 6 INCAPACITATED (SPECIFY) LANGUAGE OF QUESTIONNAIRE: URDU LANGUAGE OF INTERVIEW* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LANGUAGE WOMAN SPEAKS AT HOME* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * URDU = 1 SINDHI= 3 BALUCHI=5 SARAIKI=7 OTHER=9 PUNJABI=2 PUSHTO=4 ENGLISH=6 POTOHARI=8 SUPERVISOR FIELD EDITOR OFFICE EDITOR NAME NAME DATE DATE Signature of interviewer: Date: RESPONDENT AGREES TO BE INTERVIEWED . . . . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . . 2 END 2 0 0 KEYED BY 1 1 2 3 247Appendix F | SECTION 1. RESPONDENT'S BACKGROUND NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 RECORD THE TIME. HOUR . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . 102 In what month and year were you born? MONTH . . . . . . . . . . . . . . . . . . DON'T KNOW MONTH . . . . . . . . . . . . 98 YEAR . . . . . . . . . . . . DON'T KNOW YEAR . . . . . . . . . . . . 9998 103 How old are you? AGE IN COMPLETED YEARS COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT 104 What is your current marital status? Are you married, Godforbid MARRIED . . . . . . . . . . . . . . . . . . . . . . 1 widowed, divorced, or separated? WIDOWED . . . . . . . . . . . . . . . . . . . . . . 2 DIVORCED . . . . . . . . . . . . . . . . . . . . . . 3 107 SEPARATED . . . . . . . . . . . . . . . . . . . . 4 NEVER MARRIED . . . . . . . . . . . . . . . . 5 END 105 Is your husband usually living with you now or is he staying LIVING WITH HER . . . . . . . . . . . . . . . . 1 elsewhere? STAYING ELSEWHERE . . . . . . . . . . . . 2 106 Does your husband have other wives? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 107 Is/was there a blood relationship between you and your YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 husband? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 109 108 What type of relationship (is/was) it? FIRST COUSIN ON FATHER'S SIDE . 1 FIRST COUSIN ON MOTHER'S SIDE . 2 SECOND COUSIN . . . . . . . . . . . . . . . . 3 OTHER RELATIONSHIP . . . . . . . . . . . . 6 109 Have you been married only once or more than ONLY ONCE . . . . . . . . . . . . . . . . . . . . 1 once? MORE THAN ONCE . . . . . . . . . . . . . . 2 110 CHECK 109: MARRIED/ MARRIED/ MONTH . . . . . . . . . . . . . . . . ONLY ONCE MORE THAN ONCE In what month and year Now I would like to ask about DON'T KNOW MONTH . . . . . . . . . . 98 did you start living with when you started living with your husband? your first husband. In what month and year YEAR . . . . . . . . . . . . was that? DON'T KNOW YEAR . . . . . . . . . . . . 9998 112 � 248 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 111 How old were you when you first started living with him? AGE . . . . . . . . . . . . . . . . . . . . 112 Have you ever attended school? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 115 113 What is the highest class you completed? CLASS . . . . . . . . . . . . . . . . . . WRITE '00' IF LESS THAN CLASS ONE; WRITE '16' = IF MA, MPHIL, PHD, MBBS, BSC/4YEARS 114 CHECK 113 CLASS 00 - 08 CLASS 09 OR HIGHER 116 115 Now I would like you to read this sentence to me. CANNOT READ AT ALL . . . . . . . . . . . . 1 CAN READ ONLY PARTS OF SENTENCE . . . . . . . . . . . . . . . . . . . . 2 SHOW CARD TO RESPONDENT. CAN READ WHOLE SENTENCE. . . . . . 3 IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: NO CARD WITH REQUIRED LANGUAGE 4 Can you read any part of the sentence to me? (SPECIFY LANGUAGE) BLIND/VISUALLY IMPAIRED . . . . . . . 5 116 What is your mother tongue? URDU . . . . . . . . . . . . . . . . . . . . . . . . 01 PUNJABI . . . . . . . . . . . . . . . . . . . . . . 02 SINDHI . . . . . . . . . . . . . . . . . . . . . . . . 03 PUSHTO . . . . . . . . . . . . . . . . . . . . . . 04 BALOCHI . . . . . . . . . . . . . . . . . . . . . . 05 ENGLISH . . . . . . . . . . . . . . . . . . . . . . 06 BARAUHI . . . . . . . . . . . . . . . . . . . . . . 07 SIRAIKI . . . . . . . . . . . . . . . . . . . . . . 08 HINDKO . . . . . . . . . . . . . . . . . . . . . . 09 KASHMIRI . . . . . . . . . . . . . . . . . . . . 10 PAHARI . . . . . . . . . . . . . . . . . . . . . . 11 POTOWARI . . . . . . . . . . . . . . . . . . 12 MARWARI . . . . . . . . . . . . . . . . . . 13 FARSI . . . . . . . . . . . . . . . . . . 14 OTHER . . . . . . . . . . . . . . . . . . . . . . 96 249Appendix F | SECTION 2. REPRODUCTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 201 Now I would like to ask about all the births you have had during YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 your life. Have you ever given live birth? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 206 202 Do you have any sons or daughters to whom you have given YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 birth who are now living with you? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 204 203 How many sons live with you? SONS AT HOME . . . . . . . . . . . And how many daughters live with you? DAUGHTERS AT HOME . . . . . IF NONE, RECORD '00'. 204 Do you have any sons or daughters to whom you have given YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 birth who are alive but do not live with you? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 206 205 How many sons are alive but do not live with you? SONS ELSEWHERE . . . . . . . And how many daughters are alive but do not live with you? DAUGHTERS ELSEWHERE . IF NONE, RECORD '00'. 206 Have you ever given birth to a boy or girl who was born alive but later died? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 IF NO, PROBE: Any baby who cried or showed signs NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 208 of life but did not survive? 207 How many boys have died? BOYS DEAD . . . . . . . . . . . . . And how many girls have died? GIRLS DEAD . . . . . . . . . . . . . IF NONE, RECORD '00'. 208 SUM ANSWERS TO 203, 205, 207. ENTER TOTAL. IF NONE, RECORD '00'. TOTAL . . . . . . . . . . . . . . . . . . 209 CHECK 208: Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct? PROBE AND YES NO CORRECT 201-208 AS NECESSARY. 210 CHECK 208: ONE OR MORE NO BIRTHS BIRTHS 226 250 | Appendix F 211 Now I would like to record the names of all your births, whether still alive or not, starting with the last one you had. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE FIRST ROW) IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD: IF DEAD: What Were Is In what month Is How old Is RECORD How old was (NAME) Where Were there any other name was any of (NAME) and year was (NAME) is (NAME) HOUSE- when he/she died? did livebirths between given to these a boy or (NAME) born? still alive? (NAME)? living with HOLD LINE (NAME) (NAME) and (NAME your last births a girl? you? NUMBER OF die? OF PREVIOUS (next-to- twins? CHILD BIRTH), including any last) (RECORD '00' children who died after baby? IF CHILD NOT birth?* LISTED IN PROBE: HOUSE- IF '1 YR', PROBE: What is his/her WRITE HOLD). birthday? AGE IN How many months old RECORD MONTHS COM- was (NAME)? 1 THROUGH 12 PLETED OR SEASONS YEARS. RECORD DAYS IF WINTER = 21 WRITE LESS THAN 1 SPRING = 22 00' IF MONTH; MONTHS IF SUMMER = 23 UNDER 1 LESS THAN TWO MONSOON = 24 YEARS; OR YEARS. AUTUMN = 25 DON'T KNOW = 98 01 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 02 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 03 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 04 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 05 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 06 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 07 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 08 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH * NOTE: FOR FIRST BIRTH ALWAYS ASK - " WERE THERE ANY OTHER LIVEBIRTHS BETWEEN (NAME) AND YOUR (FIRST) MARRIAGE?" 212 213 YEARS AGE IN YEARS 217214 215 (NAME) AGE IN YEARS AGE IN YEARS YEARS AGE IN YEARS AGE IN 220 222218 219 221216 AGE IN YEARS AGE IN AGE IN YEARS 251Appendix F | IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD: IF DEAD: What Were Is In what month Is How old Is RECORD How old was (NAME) Where Were there any other name was any of (NAME) and year was (NAME) is (NAME) HOUSE- when he/she died? did livebirths between given to these a boy or (NAME) born? still (NAME)? living with HOLD LINE (NAME) (NAME) and (NAME your last births a girl? alive? you? NUMBER OF die? OF PREVIOUS (next-to- twins? CHILD BIRTH), including any last) (RECORD '00' children who died after baby? IF CHILD NOT birth?* LISTED IN PROBE: HOUSE- IF '1 YR', PROBE: What is his/her WRITE HOLD). birthday? AGE IN How many months old RECORD MONTHS COM- was (NAME)? 1 THROUGH 12 PLETED OR SEASONS YEARS. RECORD DAYS IF WINTER = 21 WRITE LESS THAN 1 SPRING = 22 00' IF MONTH; MONTHS IF SUMMER = 23 UNDER 1 LESS THAN TWO MONSOON = 24 YEARS; OR YEARS. AUTUMN = 25 DON'T KNOW = 98 09 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 10 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 11 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH 12 MONTH/ LINE NUMBER DAYS . . . 1 HOME 1 YES . . . . 1 SING 1 BOY 1 SEASON YES . . 1 YES . . 1 ADD YEAR MONTHS 2 HOSP 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . 2 NO . . . . . 2 (GO TO 222) YEARS . . 3 OTHER 6 NEXT DON'T KNOW 9998 220 BIRTH * NOTE: FOR FIRST BIRTH ALWAYS ASK : " WERE THERE ANY OTHER LIVEBIRTHS BETWEEN (NAME) AND YOUR (FIRST) MARRIAGE?" 223 Have you had any live births since the birth of (NAME OF LAST BIRTH)? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 IF YES, WRITE BIRTH(S) IN TABLE 224 COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK: NUMBERS NUMBERS ARE ARE SAME DIFFERENT (PROBE AND RECONCILE) CHECK: 215 FOR EACH BIRTH SINCE JANUARY 2001: MONTH AND YEAR OF BIRTH ARE RECORDED CHECK: 217 FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECK: 220 FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECK: 220 FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2001OR LATER. IF NONE, RECORD '0' AND SKIP TO 226. 215 (NAME) YEARS AGE IN AGE IN AGE IN YEARS YEARS 212 213 AGE IN 214 YEARS 222220217216 218 219 221 252 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 226 Are you pregnant now? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 UNSURE . . . . . . . . . . . . . . . . . . . . . . 8 229 227 How many months pregnant are you? MONTHS . . . . . . . . . . . . . . . . . . 228 At the time you became pregnant did you want to become THEN . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pregnant then, did you want to wait until later, or did you not want to have any (more) children at all? LATER . . . . . . . . . . . . . . . . . . . . . . . . . . 2 NOT AT ALL . . . . . . . . . . . . . . . . . . . . 3 229 Have you ever had a pregnancy that miscarried, was aborted, YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 or ended in a stillbirth? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 234 230 When did the last such pregnancy end? MONTH . . . . . . . . . . . . . . . . . . PROBE TO ASK BETWEEN WHICH BIRTHS, ETC. YEAR . . . . . . . . . . . . 231 CHECK 230: LAST PREGNANCY LAST PREGNANCY ENDED IN ENDED BEFORE 234 JAN. 2001 OR LATER JAN. 2001 232 How many months pregnant were you when the last such pregnancy ended? MONTHS . . . . . . . . . . . . . . . . . . 233 Since January 2001,how many pregnancies have you had that did not result in a live birth. How many of these NUMBER OF MISCARRIAGES . . . pregnancies were miscarried, aborted or ended in a still birth? NUMBER OF ABORTIONS . . . . . NUMBER OF STILLBIRTHS . . . . . IF 7 OR MORE, RECORD '7'. 234 When did your last menstrual period start? DAYS AGO . . . . . . . . . . . . 1 WEEKS AGO . . . . . . . . . . 2 MONTHS AGO . . . . . . . 3 (DATE, IF GIVEN) YEARS AGO . . . . . . . . . . 4 IF LESS THAN A WEEK, RECORD DAYS, IF ONE WEEK AND IN MENOPAUSE/ LESS THAN ONE MONTH RECORD WEEKS. HAS HAD HYSTERECTOMY . . . 994 IF ONE MONTHA AND LESS THAN A YEAR RECORD MONTHS, IF YEAR OR MORE RECORD YEARS. BEFORE LAST BIRTH . . . . . . . . . . . . 995 NEVER MENSTRUATED . . . . . . . . . . 996 235 Do you know about any problems or complications a woman YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 can have during pregnancy or delivery or after delivery? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 301 236 What complications or problems do you know about? (SPECIFY) 253Appendix F | SECTION 3. CONTRACEPTION 301 Now I would like to talk about family planning - the various ways or methods that 302 Have you ever used a couple can use to delay or avoid a pregnancy. (METHOD)? Which ways or methods have you heard about? FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)? CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302. 01 FEMALE STERILISATION Women can have an operation YES . . . . . . . . . . . . 1 Have you ever had an oper- to avoid having any more pregnancies. ation to avoid having any NO . . . . . . . . . . . . 2 more pregnancies? YES . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . 2 MALE STERILISATION Men can have an operation to YES . . . . . . . . . . . . 1 Has your husband ever 02 avoid having any more pregnancies. had an operation to avoid NO . . . . . . . . . . . . 2 having any more pregnancies? YES . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . 2 03 PILL Women can take a pill every day to avoid YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 becoming pregnant. NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 IUD Women can have a loop or coil placed inside them YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 04 by a doctor or a trained health worker. NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 05 INJECTABLES Women can have an injection by a health YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 provider that stops them from becoming pregnant for one or more months. NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 06 IMPLANTS Women can have several small rods placed YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years. NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 07 CONDOM Men can put a rubber sheath on their organ YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 before sexual intercourse. NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 254 | Appendix F 08 RHYTHM METHOD Every month that a woman is sexually YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 active she can avoid pregnancy by not having sexual inter- course on the days of the month she is most likely to get NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 pregnant. 09 WITHDRAWAL, AZAL Men can be careful and pull out YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 before ejaculation. NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 10 EMERGENCY CONTRACEPTION Women can take pills up YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 to five days after sexual intercourse to avoid becoming pregnant. NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 11 Have you heard of any other ways or methods that YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 women or men can use to avoid pregnancy? NO . . . . . . . . . . . . . . . . 2 (SPECIFY) YES . . . . . . . . . . . . . . . . 1 (SPECIFY) NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . 2 303 CHECK 302: NOT A SINGLE AT LEAST ONE "YES" "YES" 306 (NEVER USED) (EVER USED) 304 Have you ever used anything or tried in any way to delay or avoid YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 getting pregnant? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 322 305 What have you used or done? CORRECT 302 AND 303 (AND 301 IF NECESSARY). 306 CHECK 104: CURRENTLY MARRIED WIDOWED, DIVORCED OR SEPARATED 322 307 CHECK 302 (01): WOMAN NOT WOMAN STERILISED STERILISED 310 308 CHECK 226: NOT PREGNANT PREGNANT OR UNSURE 309 Are you currently doing something or using any method to delay or avoid getting pregnant? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 322 322 255Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 310 Which method are you using? FEMALE STERILISATION . . . . . . . . . . A MALE STERILISATION . . . . . . . . . . . . B CIRCLE ALL MENTIONED. PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INJECTABLES . . . . . . . . . . . . . . . . . . E INSTRUCTION FOR HIGHEST METHOD ON LIST. IMPLANTS . . . . . . . . . . . . . . . . . . . . . . F CONDOM . . . . . . . . . . . . . . . . . . . . . . G CIRCLE 'A' FOR FEMALE STERILISATION. RHYTHM . . . . . . . . . . . . . . . . . . . . . . H WITHDRAWAL . . . . . . . . . . . . . . . . . . I 321 OTHER ______________________ X (SPECIFY) 311 May I see the package of pills/condoms you are now using? PACKAGE SEEN . . . . . . . . . . . . . . . . 1 313 BRAND NAME RECORD NAME OF BRAND IF PACKAGE SEEN. (SPECIFY) PACKAGE NOT SEEN . . . . . . . . . . . . 2 312 Do you know the brand name of the (pills/condoms) you are using? BRAND NAME (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 RECORD NAME OF BRAND. 313 How many (pill cycles/condoms) did you or your husband get NUMBER OF PILL the last time? CYCLES/CONDOMS . . . 316 DON'T KNOW . . . . . . . . . . . . . . . . . . 998 314 Can you tell me the name of the injection you are using? BRAND NAME (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 315 Please tell me for how many weeks one injection is effective? NUMBER OF WEEKS . . . . . . . . DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 316 The last time you obtained (CURRENT METHOD), how much did you pay in total, including the cost of the method NOTHING, FREE 0000 and any consultation you may have had? Rs. IF STERILISED: How much did you or your husband pay for Rs. 10000+ . . 9995 the sterilisation, including any consultation? DON'T KNOW . . 9998 314 316 316 316 256 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 317 Where did you obtain (CURRENT METHOD) the last time? PUBLIC SECTOR GOVT. HOSPITAL/RHSC . . . . . 11 IF STERILISED: RURAL HEALTH CENTRE, MCH . . 12 Where did the sterilisation take place? FAMILY WELFARE CENTRE. . . . . . 13 MOBILE SERVICE CAMP . . . . . 14 LADY HEALTH WORKER . . . . . . . 15 LH VISITOR . . . . . . . . . . . . . . . . . . 16 BASIC HEALTH UNIT . . . . . . . . . . 17 IF SOURCE IS HOSPITAL, HEALTH CENTER, OR FWC, MALE MOBILIZER. . . . . . . . . . . . . . . 18 WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE OTHER PUBLIC ________________ 19 TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. (SPECIFY) PRIVATE/NGO MEDICAL SECTOR PRIVATE/NGO HOSPITAL/CLINIC 21 PHARMACY, CHEMISTS . . . . . 22 PRIVATE DOCTOR . . . . . . . . . . . . 23 (NAME OF PLACE) HOMEOPATH . . . . . . . . . . . . . . 24 DISPENSER/COMPOUNDER . . . . . . 25 OTHER PRIVATE MEDICAL 26 (SPECIFY) ONLY FOR MODERN METHOD OTHER SOURCE . 31 FRIEND/RELATIVE . . . . . . . . . . . . 32 HAKIM . . . . . . . . . . . . . . . . . . . . 33 DAI, TRAD. BIRTH ATTENDANT . 34 PUSHCART 35 OTHER ______________________ 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 318 At the time you obtained (CURRENT METHOD) from the above source, were you told about side effects or problems you might YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 have with the method? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 320 319 Were you told what to do if you experienced side effects or YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 problems? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 320 Were you ever told about other methods of family planning YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 that you could use? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 321 Since what month and year have you been using (CURRENT METHOD) without stopping? MONTH . . . . . . . . . . . . . . . . . . 324 IF STERILISED: In what month and year was the sterilisation performed? YEAR . . . . . . . . . . PROBE: For how long have you been using (CURRENT METHOD) now without stopping? SHOP (NOT PHARMACY/CHEMIS 257Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 322 Do you know of a place where you can obtain a method of YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 family planning? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 323 Where is that? PUBLIC SECTOR GOVT. HOSPITAL/RHSC . . . . . A RURAL HEALTH CENTRE, MCH B IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, FAMILY WELFARE CENTRE C WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE MOBILE SERVICE CAMP . . . . . D TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. LADY HEALTH WORKER (LHW) E LADY HEALTH VISITOR (LHV) . . . F BASIC HEALTH UNIT G MALE MOBILIZER H OTHER PUBLIC ________________ I (SPECIFY) (NAME OF PLACE) PRIVATE/NGO MEDICAL SECTOR PRIVATE, NGO HOSPITAL/CLINIC J PHARMACY, CHEMISTS . . . . . K Any other place? PRIVATE DOCTOR . . . . . . . . . . . . L HOMEOPATH . . . . . . . . . . . . . . M DISPENSER/COMPOUNDER . . . . N RECORD ALL PLACES MENTIONED. OTHER PRIVATE MEDICAL O (SPECIFY) OTHER SOURCE SHOP (NOT PHARMACY) . . . . . P FRIEND/RELATIVE . . . . . . . . . . . . Q HAKIM . . . . . . . . . . . . . . . . . . . . R DAI, TRAD. BIRTH ATTENDANT . S PUSH CART T OTHER ________________________ X (SPECIFY) 324 In the last 12 months, were you visited by a fieldworker or YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 a Lady Health Worker who talked to you about family planning? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 327 325 Did you receive any care and help from this woman? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 327 326 What type of help did you receive? INFORMATION . . . . . . . . . . . . . . . . . . A CONTRACEPTIVE SUPPLIES . . . . . B CIRCLE ALL MENTIONED. REFERRED TO HEALTH / FP FACILITY C TREATMENT OF SIDE EFFECTS D OTHER ________________________ X (SPECIFY) 327 In the last month, have you heard a message about family YES NO planning on: RADIO . . . . . . . . . . . . . . . . . . . . 1 2 TELEVISION . . . . . . . . . . . . . . . . 1 2 328 CHECK 327: HEARD MESSAGE NOT HEARD (ANY YES IN 327) MESSAGE 401 324 258 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 329 What messages did it convey to you? LIMITING THE FAMILY. . . . . . . . . . . . . . A HIGHER AGE AT MARRIAGE . . . . . . . . B SPACING OF CHILDREN . . . . . . . . . . . . C USE OF CONTRACEPTIVES . . . . . . . . D WELFARE OF FAMILY . . . . . . . . . . E MATERNAL AND CHILD HEALTH . . . F LESS CHILDREN MEAN PROSPEROUS LIFE. . . . . . . . . . . . . . . . G MORE CHILDREN MEAN POVERTY AND STARVATION . . . . . . . . . . . . . . H IMPORTANCE OF BREASTFEEDING . . I OTHER-1 . . . X (SPECIFY) RECORD ALL MENTIONED OTHER-2 . . . Y (SPECIFY) DON'T KNOW/NOT REMEMBER . . . . . Z 330 Do you think that the message you heard was effective or not effective in persuading couples to use family planning? EFFECTIVE . . . . . . . . . . . . . . . . . . . . 1 NOT EFFECTIVE . . . . . . . . . . . . . . . . . . 2 DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 259Appendix F | SECTION 4. PREGNANCY, LABOUR/DELIVERY AND POSTNATAL CARE 401 CHECK 225: ONE OR MORE NO 601 LIVE BIRTHS LIVE BIRTHS IN 2001 OR LATER IN 2001 OR LATER 402 ENTER IN THE TABLE THE BIRTH NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2001 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). Now I would like to ask you some questions about the health of all your children born since January 2001. (We will talk about each separately.) 403 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH BIRTH NUMBER FROM 212 BIRTH NO. BIRTH NO. BIRTH NO. 404 FROM 212 AND 216 NAME ________________ NAME ________________ NAME _________________ LIVING DEAD LIVING DEAD LIVING DEAD 405 At the time you became pregnant THEN . . . . . . . . . . . . 1 THEN . . . . . . . . . . . . 1 THEN . . . . . . . . . . . . 1 with (NAME), did you want to (SKIP TO 407) (SKIP TO 444) (SKIP TO 444) become pregnant then, did you LATER . . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 want to wait until later, or did you not want to have any (more) NOT AT ALL . . . . . 3 NOT AT ALL . . . . . 3 NOT AT ALL . . . . . 3 children at all? (SKIP TO 407) (SKIP TO 444) (SKIP TO 444) 406 How much longer would you have liked to wait? MONTHS MONTHS MONTHS YEARS YEARS YEARS DON'T KNOW . . . 998 DON'T KNOW . . . 998 DON'T KNOW . . . 998 407 Did you see anyone for antenatal HEALTH PERSON care for this pregnancy? DOCTOR . . . . . . . . A NURSE/MIDWIFE/ LHV . . . . . . . . . . B OTHER PERSON IF YES: DAI-TBA . . . . . C Whom did you see? LADY H. WORKER D HOMEOPATH . . . E HAKIM . . . . . . . . . . F DISPENSER / Anyone else? COMPOUNDER . . G OTHER X (SPECIFY) NO ONE . . . . . . . . . . Y PROBE FOR THE TYPE(S) OF (SKIP TO 417) PERSON(S) AND RECORD THE ALL MENTIONED. . .1 . .2 . .1 . .2 . .1 . .2 260 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 408 Where did you receive antenatal HOME care for this pregnancy? YOUR HOME . . . A OTHER HOME . . . B PUBLIC SECTOR GOVT. HOSPITAL . C Anywhere else? RHC/MCH . . . . . D BHU/FWC . . . . . E OTHER PUBLIC F FOR ANY HOSPITAL, (SPECIFY) HEALTH CENTRE, OR CLINIC, PRIVATE MED. SECTOR WRITE THE NAME OF THE PVT. HOSPITAL/ PLACE. CLINIC . . . . . . . . H PVT. DOCTOR . I HOMEOPATH . J DISPENSER / (NAME OF PLACE(S) COMPOUNDER . . K OTHER PRIVATE PROBE TO IDENTIFY TYPE(S) MED. L OF SOURCE(S) AND RECORD (SPECIFY) ALL MENTIONED. HAKIM . . . . . . . . . . M OTHER X (SPECIFY) 409 The first time you went for FOR PROBLEM …… 1 antenatal care did you go because you had a problem FOR CHECK-UP ONLY 2 or did you go just for a check-up? 410 How many months pregnant were you when you first received MONTHS . . . antenatal care for this pregnancy? DON'T KNOW . . . . . 98 411 How much did you pay NOTHING / FREE. 0000 for the first antenatal visit? Rs. Rs. 10000+ . . 9995 DON’T KNOW . . 9998 412 How many times did you receive NUMBER antenatal care during this OF TIMES . pregnancy? DON'T KNOW . . . . . 98 261Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 413 As part of your antenatal care during this pregnancy, were any of the following measures taken at least once? Were you weighed? YES NO WEIGHT . . . 1 2 Was your blood pressure measured? B.PRESSURE 1 2 Did you get a urine test? URINE . . . . . 1 2 Did you get a blood test? BLOOD . . . 1 2 Did you have an ultra sound exam? U/S EXAM . 1 2 414 Do you know your blood group? YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 415 During any antenatal care visit, YES . . . . . . . . . . . . . . 1 were you told about the signs of pregnancy NO . . . . . . . . . . . . . . 2 complications? (SKIP TO 418) DON'T KNOW . . . . . 8 416 During any antenatal care visit, YES . . . . . . . . . . . . . . 1 were you told where to go if you had any of these complications? NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 (SKIP TO 418) 417 Why didn't you see anyone NOT NECESSARY . A for an antenatal check-up? COSTS TOO MUCH . B TOO FAR . C NO TRANSPORT . . D NO ONE TO GO WITH E SERVICE NOT GOOD F NO TIME TO GO . . G CIRCLE CODES ALL MENTIONED. DID NOT KNOW WHERE TO GO . H DID NOT WANT TO SEE A MALE DOCTOR . I LONG WAITING TIME J NOT ALLOWED TO GO. K OTHER ______________ X 262 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 418 When you were pregnant with (NAME), did anyone talk to you YES . . . . . . . . . . . . . . 1 about how to have a safe delivery? I mean things like NO . . . . . . . . . . . . . . 2 using a safe delivery kit or a a clean blade to cut the baby's DON'T KNOW . . . . . 8 cord or asking the person who helps you to wash their hands? 419 During this pregnancy, were you YES . . . . . . . . . . . . . . 1 given an injection in the buttocks or your arm to prevent the baby NO . . . . . . . . . . . . . . 2 from getting tetanus, that is, (SKIP TO 422) convulsions after birth? DON'T KNOW . . . . . 8 420 During this pregnancy, how many times did you get this tetanus TIMES . . . . . . . . . . injection? DON'T KNOW ….…. 8 421 CHECK 420 2 OR MORE OTHER TIMES (SKIP TO 426) 422 At any time before this pregnancy, YES . . . . . . . . . . . . . . 1 did you receive any tetanus injections, either to protect NO . . . . . . . . . . . . . . 2 yourself or another baby? (SKIP TO 426) DON'T KNOW . . . . . 8 423 Before this pregnancy, how many other times did you receive a TIMES . . . . . . . . . . tetanus injection? DON'T KNOW ….…. 8 IF 7 OR MORE TIMES, RECORD '7'. 263Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 424 In what month and year did you receive the last tetanus injection MONTH . . . before this pregnancy? DK MONTH . . . . . . . . 98 YEAR ASK TO SEE THE CHILD (SKIP TO 426) HEALTH/IMMUNISATION CARD. CHECK FOR TETANUS INJECTIONS FOR MOTHER. DK YEAR . . . . . . . . 9998 425 How many years ago did you YEARS receive that tetanus injection? AGO . . . . . 426 During this pregnancy, were you YES . . . . . . . . . . . . . . 1 given or did you buy any iron tablets or iron syrup? NO . . . . . . . . . . . . . . 2 (SKIP TO 428) DON'T KNOW . . . . . 8 SHOW TABLETS/SYRUP. 427 During the whole pregnancy, for how many days did you take the DAYS . tablets or syrup? DIDN'T TAKE . . . 997 DON'T KNOW . . . 998 IF ANSWER NOT NUMERIC, ASK FOR APPROXIMATE NUMBER. 428 During this pregnancy, were you YES . . . . . . . . . . . . . . 1 given or did you take calcium tablets? NO . . . . . . . . . . . . . . 2 (SKIP TO 430) DON'T KNOW . . . . . 8 429 During the whole pregnancy for how many days did you take the DAYS . tablets? DIDN'T TAKE . . . 997 DON'T KNOW . . . 998 430 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 have difficulty with your vision during daylight? NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 431 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 suffer from night blindness [Punjabi=andirata] NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 264 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 432 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 suffer from malaria? NO . . . . . . . . . . . . . . 2 (SKIP TO 435) DON'T KNOW . . . . . 8 433 Did you receive treatment YES . . . . . . . . . . . . . . 1 for the malaria during the pregnancy? NO . . . . . . . . . . . . . . 2 (SKIP TO 435) 434 Where did you receive HOME treatment for the malaria YOUR HOME . . . 11 during this pregnancy? OTHER HOME . . . 12 PUBLIC SECTOR GOVT. HOSPITAL 21 RHC/MCH . . . . . 22 BHU/FWC . . . . . 23 IF MORE THAN ONE PLACE, LH WORKER . . . 24 ASK FOR THE MAIN ONE. OTHER PUBLIC 26 (SPECIFY) PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . 31 PVT. DOCTOR . 32 HOMEOPATH . 33 DISPENSER / COMPOUNDER . . 34 HAKIM . . . . . . . . . 35 OTHER PRIVATE MED. 36 (SPECIFY) OTHER 96 (SPECIFY) 435 When you were pregnant with (NAME), did you have any of the following problems?: Severe headaches? . . . . . . . . 1 2 Blurred vision? . . . . . . . . 1 2 Swelling of your hands? . . . . . . . . 1 2 . . . . . . . . 1 2 Vaginal bleeding /spoting . . . . . . . . 1 2 . . . . . . . . 1 2 Epigastric pains? . . . . . . . . 1 2 Swelling of your face? Fits or convulsions? NOYES 265Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 436 CHECK 435: ANY YES ALL NO (SKIP TO 442) 437 Were any of these problems YES . . . . . . . . . . . . . . 1 so severe that you were afraid you might die? NO . . . . . . . . . . . . . . 2 DO NOT REMEMBER 8 438 Did you seek advice or treatment HEALTH PERSON for the problem(s)? DOCTOR . . . . . . . . A NURSE/MIDWIFE/ LHV . . . . . . . . . . B IF YES: OTHER PERSON Whom did you see? DAI-TBA . . . . . C LADY H. WORKER D HOMEOPATH . . . E Anyone else? HAKIM . . . . . . . . . . F DISPENSER / COMPOUNDER . G OTHER X (SPECIFY) PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD NO ONE . . . . . . . . . . Y ALL MENTIONED. (SKIP TO 441) 439 Where did you seek treatment HOME for the problem(s)? YOUR HOME . . . A OTHER HOME . . . B Anywhere else? PUBLIC SECTOR GOVT. HOSPITAL C RHC/MCH . . . . . D BHU/FWC . . . . . E PROBE TO IDENTIFY TYPE(S) OTHER PUBLIC OF SOURCE(S) AND RECORD F ALL MENTIONED. (SPECIFY) PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . H PVT. DOCTOR . I HOMEOPATH . J DISPENSER / COMPOUNDER . K HAKIM . . . . . . . . . . L OTHER PRIVATE MED. M (SPECIFY) OTHER X (SPECIFY) 266 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 440 How long after you first started having the (first) problem did you HOURS . seek advice or treatment? DAYS … WEEKS IF LESS THAN ONE DAY, DON'T REMEMBER 998 RECORD HOURS IF LESS (SKIP TO 442) THAN ONE WEEK, RECORD DAYS. IF MORE THAN ONE WEEK, RECORD WEEKS. 441 Why didn't you see anyone NOT NECESSARY . A for the problem(s)? COSTS TOO MUCH . B TOO FAR . C NO TRANSPORT . . D NO ONE TO GO WITH E SERVICE NOT GOOD F NO TIME TO GO . . G DID NOT KNOW RECORD ALL MENTIONED. WHERE TO GO . H DID NOT WANT TO SEE A MALE DOCTOR I LONG WAITING TIME J NOT ALLOWED TO GO. . . . . . . . . . . . . . . . . . K OTHER __________ X (SPECIFY) 442 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 and your husband discuss where you would deliver? NO . . . . . . . . . . . . . . 2 CANNOT REMEMBER 8 443 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 set aside any money in case of an emergency? NO . . . . . . . . . . . . . . 2 CANNOT REMEMBER 8 444 When (NAME) was born, was VERY LARGE . . . . . 1 VERY LARGE . . . . . 1 VERY LARGE . . . . . 1 he/she very large, larger than LARGER THAN LARGER THAN LARGER THAN average, average, smaller than AVERAGE . . . . . 2 AVERAGE . . . . . 2 AVERAGE . . . . . 2 average, or very small? AVERAGE . . . . . . . . 3 AVERAGE . . . . . . . . 3 AVERAGE . . . . . . . . 3 SMALLER THAN SMALLER THAN SMALLER THAN AVERAGE . . . . . 4 AVERAGE . . . . . 4 AVERAGE . . . . . 4 VERY SMALL . . . . . 5 VERY SMALL . . . . . 5 VERY SMALL . . . . . 5 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 445 Was (NAME) weighed at birth? YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 447) (SKIP TO 447) (SKIP TO 447) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 . .1 . .2 . .3 267Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 446 How much did (NAME) weigh? KG FROM CARD KG FROM CARD KG FROM CARD . . . RECORD WEIGHT IN KG FROM RECALL KG FROM RECALL KG FROM RECALL KILOGRAMS FROM HEALTH CARD, IF AVAILABLE. . . . DON'T KNOW . 99.998 DON'T KNOW . 99.998 DON'T KNOW . 99.998 447 Who assisted with the delivery HEALTH PERSON HEALTH PERSON HEALTH PERSON of (NAME)? DOCTOR . . . . . . . . A DOCTOR . . . . . . . . A DOCTOR . . . . . . . . A NURSE/MIDWIFE/ NURSE/MIDWIFE/ NURSE/MIDWIFE/ Anyone else? LHV . . . . . . . . . . B LHV . . . . . . . . . . B LHV . . . . . . . . . . B OTHER PERSON OTHER PERSON OTHER PERSON DAI-TBA . . . . . C DAI-TBA . . . . . C DAI-TBA . . . . . C PROBE FOR THE TYPE OF LADY H. WORKER D LADY H. WORKER D LADY H. WORKER D PERSON AND RECORD ALL HOMEOPATH . . . E HOMEOPATH . . . E HOMEOPATH . . . E MENTIONED. HAKIM . . . . . . . . . . F HAKIM . . . . . . . . . . F HAKIM . . . . . . . . . . F RELATIVE/FRIEND RELATIVE/FRIEND RELATIVE/FRIEND IF RESPONDENT SAYS NO ONE (NOT A DAI) . . . G (NOT A DAI) . . . G (NOT A DAI) . . . G ASSISTED, ASK IF ANY OTHER X OTHER X OTHER X ADULTS WERE PRESENT AT (SPECIFY) (SPECIFY) (SPECIFY) THE DELIVERY. NO ONE . . . . . . . . . . Y NO ONE . . . . . . . . . . Y NO ONE . . . . . . . . . . Y 448 Were you given an injection to YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 induce labour to deliver (NAME) ? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . 8 DON’T KNOW . . . . . 8 DON’T KNOW . . . . . 8 449 Where did you give birth to HOME HOME HOME (NAME)? YOUR HOME . . . 11 YOUR HOME . . . 11 YOUR HOME . . . 11 (SKIP TO 458) (SKIP TO 464) (SKIP TO 464) IF SOURCE IS HOSPITAL, OTHER HOME . . . 12 OTHER HOME . . . 12 OTHER HOME . . . 12 HEALTH CENTER, OR CLINIC, PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR WRITE THE NAME OF THE GOVT. HOSPITAL 21 GOVT. HOSPITAL 21 GOVT. HOSPITAL 21 PLACE. PROBE TO IDENTIFY RHC/MCH . . . . . 22 RHC/MCH . . . . . 22 RHC/MCH . . . . . 22 THE TYPE OF SOURCE AND OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC CIRCLE THE APPROPRIATE 26 26 26 CODE. (SPECIFY) (SPECIFY) (SPECIFY) PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ (NAME OF PLACE - Last birth) CLINIC . . . . . . . . 31 CLINIC . . . . . . . . 31 CLINIC . . . . . . . . 31 OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE MED. 36 MED. 36 MED. 36 (NAME OF PLACE - next to last birth) (SPECIFY) (SPECIFY) (SPECIFY) OTHER 96 OTHER 96 OTHER 96 (SPECIFY) (SPECIFY) (SPECIFY) (NAME OF PLACE - 2nd from last birth) (SKIP TO 458) (SKIP TO 464) (SKIP TO 464) 450 Why did you deliver at the hospital/health centre? 11 22 1 2 268 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 451 How long after (NAME) was delivered did you stay there? HOURS . 1 HOURS. 1 HOURS. 1 DAYS . 2 DAYS . 2 DAYS . 2 IF LESS THAN ONE DAY, WEEKS . 3 WEEKS. 3 WEEKS. 3 RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. IF ONE WEEK OR MORE, RECORD DON'T KNOW . . 998 DON'T KNOW . . . 998 DON'T KNOW …… 998 WEEKS. 452 Was (NAME) delivered by YES . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 caesarean section? NO . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 453 In total, how much did you pay NOTHING, FREE 0000 for the delivery, including doctors' fees, facility costs and medicines? Rs. Rs. 10000+ . 9995 DON'T KNOW . 9998 454 Before you were discharged after YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 (NAME) was born, did any health (SKIP TO 482) (SKIP TO 482) personnel check on your health? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 457) 455 How many hours, days or weeks after delivery did the first check HOURS 1 take place? DAYS 2 WEEKS 3 IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, DON'T KNOW . . . 998 RECORD DAYS. IF MORE THAN ONE WEEK, RECORD WEEKS. 456 Who checked on your health HEALTH PERSONNEL at that time? DOCTOR . . . . . . . . 11 NURSE/MIDWIFE LHV . . . . . . . . . . 12 OTHER PERSON DAI- TBA . . . . . . . . 21 LADY H.WORKER 22 PROBE FOR MOST QUALIFIED HOMEOPATH . . . 23 PERSON. HAKIM . . . . . . . . . . 24 OTHER 96 (SPECIFY) (SKIP TO 472) 269Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 457 After you were discharged, did YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 any health care provider or (SKIP TO 465) a traditional birth attendant (SKIP TO 482) (SKIP TO 482) check on your health? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 472) 458 Why didn't you deliver in a health COST TOO MUCH . . A facility? FACILITY NOT OPEN . B TOO FAR/ NO TRANS- PORTATION …… C DON'T TRUST PROBE: FACILITY/POOR Any other reason? QUALITY SERVICE D NO FEMALE PROVID- ER AT FACILITY . . E HUSBAND/FAMILY RECORD ALL MENTIONED. DID NOT ALLOW . . F NOT NECESSARY . . G NOT CUSTOMARY . . H NO TIME/ BABY CAME TOO FAST . I OTHER (SPECIFY) X 459 In total, how much did you pay NOTHING, FREE 0000 for the delivery? Rs. Rs. 10000+ 9995 DON'T KNOW . . . 9998 460 Was a safe delivery kit used YES . . . . . . . . . . . . . . 1 during this delivery? NO . . . . . . . . . . . . . . 2 DOES NOT KNOW . 8 461 What was used to TIE the UNBOILED THREAD 1 umbilical cord? BOILED THREAD . . . 2 WASHED CLAMPS . 3 UNWASHED CLAMPS 4 HAIR . . . . . . . . . . . . 5 OTHER 6 462 What was used to CUT the NEW RAZOR BLADE 1 umbilical cord? OLD RAZOR BLADE 2 SCISSORS . . . . . . . . 3 KNIFE . . . . . . . . . . . . 4 TOKA, CHOPPER . . . 5 OTHER 6 463 Was the instrument boiled BOILED . . . . . . . . . . 1 before using or not boiled? NOT BOILED . . . . . 2 DON'T KNOW . . . . . 8 . . . . . 270 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 464 After (NAME) was born, did any health care provider or YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 a traditional birth attendant check on your health? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 468) 465 How many hours, days or weeks after delivery did the first check HOURS . 1 take place? DAYS . 2 WEEKS . 3 IF LESS THAN 1 DAY, RECORD HOURS. IF LESS THAN 1 WEEK, DON'T KNOW . . . 998 RECORD DAYS; IF ONE WEEK OR MORE, RECORD WEEKS. 466 Who checked on your health HEALTH PERSONNEL at that time? DOCTOR . . . . . . . . 11 NURSE/MIDWIFE LHV . . . . . . . . . . 12 OTHER PERSON DAI- TBA . . . . . . . . 21 PROBE FOR MOST QUALIFIED LADY H.WORKER 22 PERSON. HOMEOPATH . . . 23 HAKIM . . . . . . . . . . 24 DISPENSER / COMPOUNDER . . 25 OTHER 96 (SPECIFY) 467 Where did this first check HOME take place? YOUR HOME . . . 11 OTHER HOME . . . 12 PUBLIC SECTOR IF SOURCE IS HOSPITAL, GOVT. HOSPITAL . . 21 HEALTH CENTER, OR CLINIC, RHC/MCH . . . . . 22 RECORD THE NAME OF THE BHU/FWC . . . . . 23 PLACE. PROBE TO IDENTIFY OTHER PUBLIC THE TYPE OF SOURCE AND 26 CIRCLE THE APPROPRIATE (SPECIFY) CODE. PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . 31 (NAME OF PLACE) OTHER PRIVATE MED. 36 (SPECIFY) OTHER 96 (SPECIFY) 468 In the two months after (NAME) was born, did any health YES . . . . . . . . . . . . . . 1 care provider or dai or a LHW or hakim check on his/her NO . . . . . . . . . . . . . . 2 health? (SKIP TO 472) DON'T KNOW . . . . . 8 271Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 469 How many hours, days or weeks after the birth of (NAME) did the HOURS . . 1 first check take place? DAYS . . 2 WEEKS . . 3 IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN DON'T KNOW . . . 998 ONE WEEK, RECORD DAYS. IF ONE WEEK OR MORE, RECORD WEEKS. 470 Who checked on (NAME)'s health HEALTH PERSONNEL at that time? DOCTOR . . . . . . . . 11 NURSE/MIDWIFE LHV . . . . . . . . . . 12 OTHER PERSON DAI- TBA . . . . . . . . 21 PROBE FOR MOST QUALIFIED LADY H.WORKER 22 PERSON. HOMEOPATH . . . 23 HAKIM . . . . . . . . . . 24 OTHER 96 (SPECIFY) 471 Where did this first check of HOME (NAME) take place? YOUR HOME . . . 11 OTHER HOME . . . 12 PUBLIC SECTOR GOVT. HOSPITAL 21 IF SOURCE IS HOSPITAL, RHC/MCH . . . . . 22 HEALTH CENTER, OR CLINIC, BHU/FWC . . . . . 23 RECORD THE NAME OF THE OTHER PUBLIC PLACE. PROBE TO IDENTIFY 26 THE TYPE OF SOURCE AND (SPECIFY) CIRCLE THE APPROPRIATE PRIVATE MED. SECTOR CODE. PVT. HOSPITAL/ CLINIC . . . . . . . . 31 OTHER PRIVATE (NAME OF PLACE) MED. 36 (SPECIFY) OTHER 96 (SPECIFY) 472 How long after birth was (NAME) first bathed? IMMEDIATELY . . . 000 HOURS . 1 IF LESS THAN 1 HOUR, RECORD ‘00' HOURS. IF LESS THAN 24 DAYS . 2 HOURS, RECORD HOURS. IF ONE DAY OR MORE RECORD DAYS. DON'T KNOW . . . 998 272 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 473 During the delivery or in the 40- day period after the delivery of (NAME), did you experience any of the following problems? Severe headaches? . . . . . . . . 1 2 Blurred vision? . . . . . . . . 1 2 Swelling of your hands? . . . . . . . . 1 2 . . . . . . . . 1 2 High fever? . . . . . . . . 1 2 . . . . . . . . 1 2 Labor for more than 12 hours? . . . . . . . . 1 2 Baby's feet came first? . . . . . . . . . . . . . . . . 1 2 Placenta came first? . . . . . . . . 1 2 Continuous dribbling of urine even . . . . . . . . 1 2 during sleep Bad-smelling vaginal discharge? . . . . . . . . 1 2 Inability to control motions. . . . . . . . . 1 2 Heavy vaginal bleeding? . . . . . . . . 1 2 (SKIP TO 474) 473A IF YES: When did you experience this: 0 1 Later 2 CHECK 473: 474 ANY YES ALL NO (SKIP TO 480) 475 Were any of these problems so severe that you were afraid YES . . . . . . . . . . . . . . 1 you might die? NO . . . . . . . . . . . . . . 2 CANNOT REMEMBER 8 Fits or convulsions? Swelling of your face? YES In the first 24 hours birth of baby NO Immediately after � 273Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 476 Did you seek advice or treatment HEALTH PERSON for the problem(s)? DOCTOR . . . . . . . . A NURSE/MIDWIFE/ LHV . . . . . . . . . . B IF YES: Whom did you see? OTHER PERSON DAI-TBA . . . . . C LADY H. WORKER D Anyone else? HOMEOPATH . . . E HAKIM . . . . . . . . . . F OTHER X PROBE FOR THE TYPE(S) OF (SPECIFY) PERSON(S) AND RECORD THE NO ONE . . . . . . . . . . Y ALL MENTIONED. (SKIP TO 479) Where did you seek treatment HOME 477 for the problem(s)? YOUR HOME . . . A OTHER HOME . . . B PUBLIC SECTOR Anywhere else? GOVT. HOSPITAL C RHC/MCH . . . . . D BHU/FWC . . . . . E OTHER PUBLIC PROBE TO IDENTIFY TYPE(S) F OF SOURCE(S) AND RECORD (SPECIFY) ALL MENTIONED. PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . H PVT. DOCTOR . I HOMEOPATH . J DISPENSER / COMPOUNDER . K HAKIM . . . . . . . . . . L OTHER PRIVATE MED. M (SPECIFY) OTHER X (SPECIFY) 478 How long after you first started having the problem did you HOURS . seek advice or treatment? DAYS … WEEKS … IF LESS THAN 1 HOUR, DON'T KNOW . . . 998 RECORD ‘00' HOURS. (SKIP TO 480) IF LESS THAN 24 HOURS, RECORD HOURS. IF LESS THAN 7 DAYS, RECORD DAYS. OTHERWISE WEEKS. . .3 . .1 . .2 274 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 479 Why didn't you see anyone NOT NECESSARY A for the problem(s)? COSTS TOO MUCH B FACILITY TOO FAR AWAY . . . C NO TRANSPORT . . . D NO ONE TO GO WITH E SERVICE NOT GOOD F CIRCLE ALL MENTIONED. NO TIME TO GO . . . G DID NOT KNOW WHERE TO GO H DID NOT WANT TO SEE A MALE DOCTOR I LONG WAITING TIME J NOT ALLOWED TO GO. K OTHER __________ X 480 In the first two months after delivery, did you receive a YES . . . . . . . . . . . . . . 1 vitamin A dose like this? NO . . . . . . . . . . . . . . 2 SHOW AMPULES/CAPSULE/SYRUP. 481 Has your menstrual period YES . . . . . . . . . . . . . . 1 returned since the birth of (SKIP TO 483) (NAME)? NO . . . . . . . . . . . . . . 2 (SKIP TO 484) 482 Did your period return between YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 the birth of (NAME) and your next pregnancy? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 486) (SKIP TO 486) 483 For how many months after the birth of (NAME) did you not have MONTHS . . . MONTHS . . . MONTHS . . . a period? DON'T KNOW . . . . . 98 DON'T KNOW . . . . . 98 DON'T KNOW . . . . . 98 484 CHECK 226: NOT PREGNANT PREG- OR IS RESPONDENT PREGNANT? NANT UNSURE (SKIP TO 486) 485 Have you resumed sexual YES . . . . . . . . . . . . . . 1 relations since the birth of (NAME)? NO . . . . . . . . . . . . . . 2 (SKIP TO 487) 275Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 486 For how many months after the birth of (NAME) did you not have MONTHS . . . MONTHS . . . MONTHS . . . sexual relations? DON'T KNOW . . . . . 98 DON'T KNOW . . . . . 98 DON'T KNOW . . . . . 98 487 Did you ever breastfeed (NAME)? YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 495) (SKIP TO 495) (SKIP TO 495) 488 How long after birth did you first put (NAME) to the breast? IMMEDIATELY . . . 000 IF LESS THAN 1 HOUR, RECORD ‘00' HOURS. HOURS 1 IF LESS THAN 24 HOURS, RECORD HOURS. DAYS 2 OTHERWISE, RECORD DAYS. 489 Did you give the (NAME) the GAVE COLOSTRUM 1 thick milk (colostrum) that comes first or did you discard it? DISCARDED IT . . . 2 DO NOT REMEMBER 8 490 In the first three days after YES . . . . . . . . . . . . . . 1 delivery, was (NAME) given anything to drink other than NO . . . . . . . . . . . . . . 2 breast milk? (SKIP TO 492) 491 What was (NAME) given to drink? MILK (OTHER THAN BREAST MILK ) . A PLAIN WATER . . . B Anything else? HONEY OR SUGAR WATER . . . . . . C GHEE, BUTTER . . . D FRUIT JUICE. . . . . . . . E INFANT FORMULA . F RECORD ALL LIQUIDS GHUTEE . . . . . . . . . . G MENTIONED. GREEN TEA . . . . . . . . H OTHER X (SPECIFY) 492 CHECK 404: LIVING DEAD IS CHILD LIVING? (SKIP TO 494) 493 Are you still breastfeeding YES . . . . . . . . . . . . . . 1 (NAME)? (SKIP TO 496) NO . . . . . . . . . . . . . . 2 276 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 494 For how many months did you breastfeed (NAME)? MONTHS . . . MONTHS . . . MONTHS . . . STILL BF . . . . . . . . 95 STILL BF . . . . . . . . 95 IF LESS THAN ONE MONTH, DON'T KNOW . . . 98 DON'T KNOW . . . 98 DON'T KNOW . . . 98 RECORD '00' 495 CHECK 404: LIVING DEAD LIVING DEAD LIVING DEAD IS CHILD LIVING? (GO BACK TO (GO BACK TO (GO BACK TO 405 405 IN NEXT 405 IN NEXT IN NEXT-TO-LAST COLUMN; OR, COLUMN; OR, COLUMN OF NEW IF NO MORE IF NO MORE QUESTIONNAIRE; OR, BIRTHS, GO BIRTHS, GO IF NO MORE (SKIP TO 498) TO 501) (SKIP TO 499) TO 501) (SKIP TO 499) BIRTHS, GO TO 501) 496 How many times did you breastfeed last night between NUMBER OF sunset and sunrise? NIGHTTIME FEEDINGS . IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER. 497 How many times did you breastfeed yesterday during NUMBER OF the daylight hours? DAYLIGHT FEEDINGS . IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER. 498 Yesterday or last night, did (NAME) drink or eat: YES NO DK Plain water? WATER . 1 2 8 Baby formula or other milk? MILK . . . 1 2 8 Juice, soda, tea, rice water? JUICE/SODA 1 2 8 Any mushy or solid food? FOOD . . . 1 2 8 499 Did (NAME) drink anything from a bottle with a nipple yesterday YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 or last night? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 499A GO BACK TO 405 IN GO BACK TO 405 IN GO BACK TO 405 IN NEXT COLUMN; OR, IF NEXT COLUMN; OR, IF NEXT-TO-LAST NO MORE BIRTHS, GO NO MORE BIRTHS, GO COLUMN OF NEW TO 501. TO 501. QUESTIONNAIRE; OR, IF NO MORE BIRTHS, GO TO 501. 277Appendix F | SECTION 5. CHILD VACCINATION, HEALTH AND NUTRITION 501 ENTER IN THE TABLE THE BIRTH NUMBER, NAME, AND SURVIVAL STATUS OF EACH LIVE BIRTH IN 2001 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). 502 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH BIRTH NUMBER BIRTH BIRTH BIRTH FROM 212 NUMBER . . . . . . . . NUMBER . . . . . . . . NUMBER . . . . . . . 503 NAME NAME NAME FROM 212 AND 216 LIVING DEAD LIVING DEAD LIVING DEAD (GO TO 503 (GO TO 503 (GO TO 503 IN NEXT- IN NEXT COLUMN IN NEXT COLUMN TO-LAST COLUMN OF OR, IF NO MORE OR, IF NO MORE NEW QUESTIONNAIRE, BIRTHS, GO TO 601) BIRTHS, GO TO 601) OR IF NO MORE BIRTHS, GO TO 601) 504 Do you have a card where (NAME'S) YES, SEEN . . . . . . . . . . . . 1 YES, SEEN . . . . . . . . . . . . 1 YES, SEEN . . . . . . . . . . . 1 vaccinations are (SKIP TO 506) (SKIP TO 506) written down? (SKIP TO 506) YES, NOT SEEN . . . . . . . . 2 YES, NOT SEEN . . . . . . . . 2 YES, NOT SEEN . . . . . . . 2 (SKIP TO 508) (SKIP TO 508) (SKIP TO 508) NO CARD . . . . . . . . . . . . . . 3 NO CARD . . . . . . . . . . . . . . 3 NO CARD . . . . . . . . . . . . 3 IF YES: May I see it please? 505 Did you ever have YES . . . . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 a vaccination (SKIP TO 508) (SKIP TO 508) (SKIP TO 508) card for (NAME)? NO . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 506 (1) COPY DATE OF BIRTH IF GIVEN. IF NOT ON CARD, LEAVE IT BLANK. (2) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. (3) WRITE ‘44' IN ‘DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED. LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH DAY MONTH YEAR DAY MONTH YEAR DAY MONTH YEAR H2 H3 MEASLES MEA HBV 2 H2 H3 MEA HBV 3 BCG P0 P1 P2 POLIO 1 POLIO 2 BCG P0 P1 P2 H1 DPT 3 D3 POLIO 3 HBV 1 P3 H1 D3 DPT 2 D2 D2 BIRTH BIRTH BIRTH DPT 1 D1 D1 P3 BCG POLIO 0 (POLIO GIVEN AT BIRTH) 278 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 507 Has (NAME) received any YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 vaccinations that are not recorded (PROBE FOR (PROBE FOR (PROBE FOR on this card, including vaccinations VACCINATIONS AND VACCINATIONS AND VACCINATIONS AND received in a national WRITE ‘66' IN THE WRITE ‘66' IN THE WRITE ‘66' IN THE immunization day campaign? CORRESPONDING CORRESPONDING CORRESPONDING DAY COLUMN IN 506) DAY COLUMN IN 506) DAY COLUMN IN 506) (SKIP TO 510) (SKIP TO 510) (SKIP TO 510) NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 510) (SKIP TO 510) (SKIP TO 510) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 RECORD ‘YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, HBV, OR MEASLES VACCINES. 508 Did (NAME) ever receive any vaccinations to prevent him/her YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 from getting diseases, including vaccinations received in a national immunisation NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 campaign? (SKIP TO 511) (SKIP TO 511) (SKIP TO 511) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 509 Please tell me if (NAME) received any of the following vaccinations: 509A A BCG vaccination against YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 tuberculosis, that is, an injection in the arm or shoulder that usually NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 causes a scar? DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 509B Polio vaccine, that is, drops in the YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 mouth? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 509E) (SKIP TO 509E) (SKIP TO 509E) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 509C Was the first time polio drops FIRST 2 WEEKS . . . 1 FIRST 2 WEEKS . . . 1 FIRST 2 WEEKS . . . 1 were received in the first 2 weeks after birth or later? LATER . . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 509D How many times was the polio vaccine received? NUMBER NUMBER NUMBER OF TIMES . . . . . . OF TIMES . . . . . . OF TIMES . . . . . . IF 7 OR MORE TIMES RECORD 7 279Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 509E A DPT vaccination, that is, an YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 injection given in the thigh or NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 buttocks,( sometimes at the NO . . . . . . . . . . . . . . 2 (SKIP TO 509G) (SKIP TO 509G) same time as polio drops)? (SKIP TO 509G) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 509F How many times was a DPT NUMBER NUMBER NUMBER vaccination received? OF TIMES . . . . . . OF TIMES . . . . . . OF TIMES . . . . . . 509G A hepatitus HBV vaccination, that is an injection given in the thigh or buttocks, sometimes at the YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 same time as polio drops? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 509I) (SKIP TO 509I) (SKIP TO 509I) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 509H How many times was an HBV vaccination received? NUMBER NUMBER NUMBER OF TIMES . . . . . . OF TIMES . . . . . . OF TIMES . . . . . . 509I An injection to prevent measles? YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 510 Did (NAME) ever receive a polio vaccine (drops in the mouth) during a national immunisation YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 day campaign? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 IF YES, CHECK 506 OR 509D IS 1 OR MORE. 511 Has (NAME) ever received YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 a vitamin A dose like this? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 513) (SKIP TO 513) (SKIP TO 513) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 SHOW VIT.A CAPSULES. 512 How many months ago did MONTHS MONTHS MONTHS (NAME) take the last dose? AGO . . . . . AGO . . . . . AGO . . . . . DON'T KNOW . . . . . . 98 DON'T KNOW . . . . . . 98 DON'T KNOW . . . . . . 98 PUT "00" IF LESS THAN 1 MONTH 280 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 513 Has (NAME) had diarrhea in the YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 last 2 weeks? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 525) (SKIP TO 525) (SKIP TO 525) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 514 Was there any blood in the stools? YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 515 Has (NAME) had diarrhea in the YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 last 24 hours ? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 517) (SKIP TO 517) (SKIP TO 517) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 516 How many times did (NAME) pass stool in the last 24 hours ? NUMBER OF NUMBER OF NUMBER OF STOOLS . STOOLS . STOOLS . 517 Now I would like to know how much (NAME) was given to drink during the diarrhea. MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 Was he/she given less than usual to drink, about the same SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 amount, or more than usual to drink? ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 NOTHING TO DRINK. 5 NOTHING TO DRINK. 5 NOTHING TO DRINK. 5 IF LESS, PROBE: DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 Was he/she given much less than usual to drink or somewhat less? 518 When (NAME) had diarrhea, was he/she given less than usual to MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 eat, about the same amount, more than usual, or nothing to eat? SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 STOPPED FOOD . . 5 STOPPED FOOD . . 5 STOPPED FOOD . . 5 IF LESS, PROBE: NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 Was he/she given much less than usual to eat or somewhat less? DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 281Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 519 Did you seek advice or treatment YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 for the diarrhea from any source? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 522) (SKIP TO 522) (SKIP TO 522) 520 Where did you seek advice or PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR treatment? GOVT. HOSPITAL A GOVT. HOSPITAL A GOVT. HOSPITAL A RHC/MCH . . . . . . B RHC/MCH . . . . . . B RHC/MCH . . . . . . B BHU/FWC . . . . . . C BHU/FWC . . . . . . C BHU/FWC . . . . . . C LADY H.WORKER D LADY H.WORKER D LADY H.WORKER D Anywhere else? OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC E E E FOR ANY HOSPITAL, (SPECIFY) (SPECIFY) (SPECIFY) HEALTH CENTER, OR CLINIC, PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR WRITE THE NAME OF THE PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ PLACE. CLINIC . . . . . . . . F CLINIC . . . . . . . . F CLINIC . . . . . . . . F CHEMIST . . . . . . G CHEMIST . . . . . . G CHEMIST . . . . . . G PVT. DOCTOR . . . H PVT. DOCTOR . . . H PVT. DOCTOR . . . H (NAME OF PLACE) HOMEOPATH . . . I HOMEOPATH . . . I HOMEOPATH . . . I DISPENSER / DISPENSER / DISPENSER / COMPOUNDER . . J COMPOUNDER . . J COMPOUNDER . . J OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE MED. K MED. K MED. K (NAME OF PLACE) (SPECIFY) (SPECIFY) (SPECIFY) OTHER SOURCE OTHER SOURCE OTHER SOURCE SHOP . . . . . . . . . . L SHOP . . . . . . . . . . L SHOP . . . . . . . . . . L (NAME OF PLACE) HAKIM . . . . . . . . M HAKIM . . . . . . . . M HAKIM . . . . . . . . M DAI, TBA . . . . . . . . N DAI, TBA . . . . . . . . N DAI, TBA . . . . . . . . N PROBE TO IDENTIFY TYPE(S) OTHER X OTHER X OTHER X OF SOURCE(S) AND RECORD (SPECIFY) (SPECIFY) (SPECIFY) ALL MENTIONED. 521 How many days after the illness began did you first seek advice or treatment for (NAME) Days . . . . . Days . . . . . Days . . . . . IF THE SAME DAY RECORD '00' 522 Was he/she given any of the following to drink at any time since he/she started having the diarrhea: YES NO DK YES NO DK YES NO DK 522A A fluid made from a special FLUID FROM FLUID FROM FLUID FROM packet called ORS or Nimkol? ORS PKT . . 1 2 8 ORS PKT . . 1 2 8 ORS PKT . . 1 2 8 522B A drink made at home with HOMEMADE HOMEMADE HOMEMADE sugar, salt and water? FLUID . . . 1 2 8 FLUID . . . 1 2 8 FLUID . . . 1 2 8 523 Was anything (else) given to YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 treat the diarrhea? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 525) (SKIP TO 525) (SKIP TO 525) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 282 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 524 What (else) was given to treat PILLS/SYRUP . . . . . . A PILLS/SYRUP . . . . . . A PILLS/SYRUP . . . . . . A the diarrhea? INJECTION . . . . . . . . B INJECTION . . . . . . . . B INJECTION . . . . . . . . B I V DRIP . . . . . . . . C I V DRIP . . . . . . . . C I V DRIP . . . . . . . . C HOME REMEDY/ HOME REMEDY/ HOME REMEDY/ Anything else? HERBAL MEDICINE / HERBAL MEDICINE / HERBAL MEDICINE / ISPAGHOL . . . . . . D ISPAGHOL . . . . . . D ISPAGHOL . . . . . . D RECORD ALL TREATMENTS OTHER X OTHER X OTHER X GIVEN. (SPECIFY) (SPECIFY) (SPECIFY) 525 Has (NAME) been ill with a fever YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 at any time in the last 2 weeks? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 526 Has (NAME) had an illness with YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 a cough at any time in the last 2 weeks? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 529) (SKIP TO 529) (SKIP TO 529) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 527 When (NAME) had an illness with YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 a cough, did he/she breathe faster than usual with short, rapid breaths NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 or have difficulty breathing? (SKIP TO 530) (SKIP TO 530) (SKIP TO 530) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 528 Were these breathing symptoms CHEST ONLY . . . 1 CHEST ONLY . . . 1 CHEST ONLY . . . 1 due to a problem in the chest or to NOSE ONLY . . . . . . 2 NOSE ONLY . . . . . . 2 NOSE ONLY . . . . . . 2 a blocked or runny nose? BOTH . . . . . . . . . . . . 3 BOTH . . . . . . . . . . . . 3 BOTH . . . . . . . . . . . . 3 OTHER 6 OTHER 6 OTHER 6 (SPECIFY) (SPECIFY) (SPECIFY) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 (SKIP TO 530) (SKIP TO 530) (SKIP TO 530) 283Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 529 CHECK 525: YES NO OR DK YES NO OR DK YES NO OR DK HAD FEVER? (GO TO 503 IN (GO TO 503 IN (GO TO 503 IN NEXT COLUMN, NEXT COLUMN, NEXT COLUMN, OR, IF NO MORE OR, IF NO MORE OR, IF NO MORE BIRTHS, TO 601) BIRTHS, TO 601) BIRTHS, TO 601) 530 Now I would like to know how much (NAME) was given to drink during the illness with a (fever/cough). MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 Was he/she given less than SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 usual to drink, about the same amount, or more than usual to ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 drink? MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 NOTHING TO DRINK. 5 NOTHING TO DRINK. 5 NOTHING TO DRINK. 5 IF LESS, PROBE: DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 Was he/she given much less than usual to drink or somewhat less? 531 When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 MUCH LESS . . . . . . 1 same amount, more than usual, or nothing to eat? SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 STOPPED FOOD . 5 STOPPED FOOD . 5 STOPPED FOOD . 5 IF LESS, PROBE: Was he/she given much NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 less than usual to eat or somewhat less? DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 532 Did you seek advice or treatment YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 for the illness from any source? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 535) (SKIP TO 535) (SKIP TO 535) 284 | Appendix F LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 533 Where did you seek advice or PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR treatment? GOVT. HOSPITAL A GOVT. HOSPITAL A GOVT. HOSPITAL A RHC/MCH . . . . . . B RHC/MCH . . . . . . B RHC/MCH . . . . . . B Anywhere else? BHU/FWC . . . . . . C BHU/FWC . . . . . . C BHU/FWC . . . . . . C LADY H.WORKER D LADY H.WORKER D LADY H.WORKER D FOR ANY HOSPITAL, OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC HEALTH CENTER, OR CLINIC, E E E WRITE THE NAME OF THE (SPECIFY) (SPECIFY) (SPECIFY) PLACE. PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ CLINIC . . . . . . . . F CLINIC . . . . . . . . F CLINIC . . . . . . . . F PHARMACY . . . . . . G PHARMACY . . . . . . G PHARMACY . . . . . . G (NAME OF PLACE(S) PVT. DOCTOR . . . H PVT. DOCTOR . . . H PVT. DOCTOR . . . H HOMEOPATH . . . I HOMEOPATH . . . I HOMEOPATH . . . I DISPENSER / DISPENSER / DISPENSER / COMPOUNDER . J COMPOUNDER . J COMPOUNDER . J PROBE TO IDENTIFY TYPE(S) OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE OF SOURCE(S) AND RECORD MED. K MED. K MED. K ALL MENTIONED. (SPECIFY) (SPECIFY) (SPECIFY) OTHER SOURCE OTHER SOURCE OTHER SOURCE SHOP . . . . . . . . . . L SHOP . . . . . . . . . . L SHOP . . . . . . . . . . L HAKIM . . . . . . . . M HAKIM . . . . . . . . M HAKIM . . . . . . . . M DAI, TBA . . . . . . . . N DAI, TBA . . . . . . . . N DAI, TBA . . . . . . . . N OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) 534 How many days after the illness began did you first seek advice or treatment for (NAME)? DAYS . . . . . DAYS . . . . . DAYS . . . . . IF THE SAME DAY, RECORD '00'. 535 Is (NAME) still sick with a (fever/ FEVER ONLY . . . . . . 1 FEVER ONLY . . . . . . 1 FEVER ONLY . . . . . . 1 cough)? COUGH ONLY . . . 2 COUGH ONLY . . . 2 COUGH ONLY . . . 2 BOTH FEVER AND BOTH FEVER AND BOTH FEVER AND COUGH . . . . . . . . 3 COUGH . . . . . . . . 3 COUGH . . . . . . . . 3 NO, NEITHER . . . . . . 4 NO, NEITHER . . . . . . 4 NO, NEITHER . . . . . . 4 DON'T KNOW . . . 8 DON'T KNOW . . . 8 DON'T KNOW . . . 8 536 At any time during the illness, did YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 (NAME) take any medicine for the NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 illness? (GO BACK TO 503 (GO BACK TO 503 (GO BACK TO 503 IN NEXT COLUMN; IN NEXT COLUMN; IN NEXT COLUMN; OR, IF NO MORE OR, IF NO MORE OR, IF NO MORE BIRTHS, TO 601) BIRTHS, TO 601) BIRTHS, TO 601) DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 DON'T KNOW . . . . . . 8 285Appendix F | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 537 What medicine did (NAME) take? ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS QUININE . . . A QUININE . . . A QUININE . . . A CHLOROQUINE . B CHLOROQUINE . B CHLOROQUINE . B Any other medicine? FANSIDAR/SP . . . C FANSIDAR/SP . . . C FANSIDAR/SP . . . C OTHER ANTI-MALARIAL OTHER ANTI-MALARIAL OTHER ANTI-MALARIAL . . . D . . . D . . . D (SPECIFY) (SPECIFY) (SPECIFY) ANTIBIOTIC ANTIBIOTIC ANTIBIOTIC PILL/SYRUP . . . E PILL/SYRUP . . . E PILL/SYRUP . . . E RECORD ALL MENTIONED. INJECTION . . . F INJECTION . . . F INJECTION . . . F OTHER DRUGS OTHER DRUGS OTHER DRUGS ASPIRIN . . . . . . . . G ASPIRIN . . . . . . . . G ASPIRIN . . . . . . . . G PARACETEMOL/ PARACETEMOL/ PARACETEMOL/ CALPOL H CALPOL H CALPOL H BRUFEN . . . . . . . . I BRUFEN . . . . . . . . I BRUFEN . . . . . . . . I COUGH DRUGS COUGH DRUGS COUGH DRUGS PILL/SYRUP . . . J PILL/SYRUP . . . J PILL/SYRUP . . . J OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) DON'T KNOW . . . . . . Z DON'T KNOW . . . . . . Z DON'T KNOW . . . . . . Z 538 Was any medicine prescribed by a doctor, nurse, pharmacist, YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 or other health practitioner? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 539 CHECK 537: NO NO NO YES YES YES ANY CODE A-D CIRCLED? (GO TO 503 IN (GO TO 503 IN (GO TO 503 IN NEXT COLUMN, NEXT COLUMN, NEXT COLUMN, OR, IF NO MORE OR, IF NO MORE OR, IF NO MORE BIRTHS, TO 601) BIRTHS, TO 601) BIRTHS, TO 601) 540 How long after the fever SAME DAY . . . . . 0 SAME DAY . . . . . 0 SAME DAY . . . . . 0 started did (NAME) first take NEXT DAY . . . . . 1 NEXT DAY . . . . . 1 NEXT DAY . . . . . 1 the medicine? TWO DAYS AFTER TWO DAYS AFTER TWO DAYS AFTER FEVER . . . . . 2 FEVER . . . . . 2 FEVER . . . . . 2 THREE DAYS AFTER THREE DAYS AFTER THREE DAYS AFTER FEVER . . . . . 3 FEVER . . . . . 3 FEVER . . . . . 3 FOUR OR MORE DAYS FOUR OR MORE DAYS FOUR OR MORE DAYS AFTER FEVER . . 4 AFTER FEVER . . 4 AFTER FEVER . . 4 DON'T KNOW . . . 8 DON'T KNOW . . . 8 DON'T KNOW . . . 8 541 For how many days did (NAME) take the medicine? DAYS . . . . . . . . . . DAYS . . . . . . . . . . DAYS . . . . . . . . . . IF 7 DAYS OR MORE, RECORD 7. DON'T KNOW . . . . 8 DON'T KNOW . . . . 8 DON'T KNOW . . . . 8 542 GO BACK TO 503 IN GO BACK TO 503 IN GO TO 503 IN NEXT COLUMN; OR, IF NEXT COLUMN; OR, IF NEXT-TO-LAST NO MORE BIRTHS, GO NO MORE BIRTHS, GO COLUMN OF NEW TO 601. TO 601. QUESTIONNAIRE; OR, IF NO MORE BIRTHS, GO TO 601. 286 | Appendix F SECTION 6. FERTILITY PREFERENCES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 601 CHECK 104: 612 CURRENTLY MARRIED WIDOWED, DIVORCED, SEPARATED 602 CHECK 310: 612 NEITHER STERILISED HE OR SHE STERILISED 602 CHECK 104: 612 CURRENTLY MARRIED WIDOWED, DIVORCED, SEPARATED 603 CHECK 226: NOT PREGNANT PREGNANT OR UNSURE Now I have some questions Now I have some questions about the future. about the future. HAVE (A/ANOTHER) CHILD . . . . . . . . 1 Would you like to have After the child you are (a/another) child, or expecting now, would you like NO MORE/NONE . . . . . . . . . . . . . . . . 2 605 would you prefer not to to have another child, or would have any (more) children? you prefer not to have any SAYS SHE CAN'T GET PREGNANT . 3 612 more children? UNDECIDED/DON'T KNOW AND PREGNANT . . . . . . . . . . . . . . . . . . . . 4 610 UNDECIDED/DON'T KNOW AND NOT PREGNANT . . . . . . . . . . . . . . . . 5 609 604 CHECK 226: MONTHS . . . . . . . . . . . . . . 1 NOT PREGNANT PREGNANT OR UNSURE YEARS . . . . . . . . . . . . . . 2 How long would you like to wait After the birth of the child you SOON/NOW . . . . . . . . . . . . . . . . . . 993 609 from now before the birth of are expecting now, how long SAYS SHE CAN'T GET PREGNANT . 994 612 (a/another) child? would you like to wait before the birth of another child? OTHER ______________________ 996 609 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . 998 609 605 CHECK 226: NOT PREGNANT PREGNANT OR UNSURE 610 606 CHECK 309: NOT NOT CURRENTLY CURRENTLY ASKED USING USING 612 607 CHECK 604: NOT 24 OR MORE MONTHS 00-23 MONTHS ASKED OR 02 OR MORE YEARS OR 00-01 YEAR 610 287Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 608 CHECK 603: FERTILITY-RELATED REASONS INFREQUENT SEX/NO SEX . . . . . A WANTS TO HAVE WANTS NO MORE/ MENOPAUSAL/HYSTERECTOMY . B A/ANOTHER CHILD NONE INFERTILE/CAN'T GET PREGNANT C (CODE 1) (CODE 2) NO MENSTRUATION AFTER BIRTH D BREASTFEEDING . . . . . . . . . . . . . . E You have said that you do not You have said that you do not UP TO GOD, CAN'T CONTROL . . . F want (a/another) child soon, want any (more) children, but OPPOSITION TO USE but you are not using any you are not using any method to RESPONDENT OPPOSED . . . . . . . . G method to avoid pregnancy. avoid pregnancy. HUSBAND OPPOSED . . . . . . . . . . . . H OTHERS OPPOSED . . . . . . . . . . . . I AGAINST RELIGION . . . . . . . . . . . . J LACK OF KNOWLEDGE KNOWS NO METHOD . . . . . . . . . . . . K KNOWS NO SOURCE . . . . . . . . . . . . L METHOD-RELATED REASONS HEALTH CONCERNS . . . . . . . . . . . . M Can you tell me why you are Can you tell me why you are FEAR OF SIDE EFFECTS . . . . . . . . N not using a method? not using a method? LACK OF ACCESS/TOO FAR . . . . . O COSTS TOO MUCH . . . . . . . . . . . . P INCONVENIENT TO USE . . . . . . . . Q INTERFERES WITH BODY'S NORMAL PROCESSES . . . . . . . . R Any other reason? Any other reason? OTHER ______________________ X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . Z RECORD ALL REASONS MENTIONED. 609 CHECK 309: NOT NO, YES, ASKED NOT CURRENTLY USING CURRENTLY USING 612 610 Do you think you will use a contraceptive method to delay or avoid YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 612 pregnancy at any time in the future? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 611 What is the main reason that you think you will not use a FERTILITY-RELATED REASONS contraceptive method at any time in the future? INFREQUENT SEX/NO SEX . . . . . 11 MENOPAUSAL/HYSTERECTOMY . 12 INFERTILE/CAN'T GET PREGNANT 13 NO MENSTRUATION AFTER BIRTH 14 BREASTFEEDING . . . . . . . . . . . . . . 15 UP TO GOD, CAN'T CONTROL . . . 16 OPPOSITION TO USE RESPONDENT OPPOSED . . . . . . . . 21 HUSBAND OPPOSED . . . . . . . . . . . . 22 OTHERS OPPOSED . . . . . . . . . . . . 23 AGAINST RELIGION . . . . . . . . . . . . 24 LACK OF KNOWLEDGE KNOWS NO METHOD . . . . . . . . . . . . 31 KNOWS NO SOURCE . . . . . . . . . . . . 32 METHOD-RELATED REASONS HEALTH CONCERNS . . . . . . . . . . . . 41 FEAR OF SIDE EFFECTS . . . . . . . . 42 LACK OF ACCESS/TOO FAR . . . . . 43 COSTS TOO MUCH . . . . . . . . . . . . 44 INCONVENIENT TO USE . . . . . . . . 45 INTERFERES WITH BODY'S NORMAL PROCESSES . . . . . . . . 46 OTHER ______________________ 96 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 288 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 612 CHECK 216: HAS LIVING CHILDREN NO LIVING CHILDREN NONE . . . . . . . . . . . . . . . . . . . . . . . . 00 614 If you could go back to the time If you could choose exactly the you did not have any children number of children to have in NUMBER . . . . . . . . . . . . . . . . . . and could choose exactly the your whole life, how many number of children to have in would that be? your whole life, how many OTHER ______________________ 96 614 would that be? (SPECIFY) PROBE FOR A NUMERIC RESPONSE. 613 How many of these children would you like to be boys, how many BOYS GIRLS EITHER would you like to be girls and for how many would the sex not matter? NUMBER OTHER ______________________ 96 (SPECIFY) 614 CHECK 104: CURRENTLY WIDOWED, DIVORCED, MARRIED SEPARATED 617 615 CHECK 310: NEITHER HE OR SHE STERILISED STERILISED 617 616 Do you think your husband wants the same number of SAME NUMBER . . . . . . . . . . . . . . . . . . 1 children that you want, or does he want more or fewer than you MORE CHILDREN . . . . . . . . . . . . . . . . 2 want? FEWER CHILDREN . . . . . . . . . . . . . . . . 3 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 617 PRESENCE OF OTHERS AT THIS POINT. YES NO CHILDREN UNDER 10 . . . . . 1 2 HUSBAND . . . . . . . . . . . . . . 1 2 MOTHER IN LAW . . . . . . . . 1 2 OTHER MALE(S) . . . . . . . . . . 1 2 OTHER FEMALE(S) . . . . . . . . 1 2 289Appendix F | SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 701 CHECK 104: CURRENTLY WIDOWED, DIVORCED, MARRIED SEPARATED 703 702 How old is your husband? AGE IN COMPLETED YEARS 703 Did your (last) husband ever attend school? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 705 704 What was the highest class he completed? CLASS . . . . . . . . . . . . . . . . WRITE '00' IF LESS THAN CLASS ONE; DON'T KNOW . . . . . . . . . . . . . . . . . . 98 WRITE '16' = IF MA,MPHIL,PHD, MBBS, BSC(4 YEARS) 705 CHECK 701: CURRENTLY MARRIED WIDOWED, DIVORCED OR SEPARATED What is your husband's What was your (last) husband's occupation? occupation? That is, what kind of work does That is, what kind of work did he he mainly do? mainly do? 706 Aside from your own housework, have you done any work YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 709 in the last seven days? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 707 As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 709 In the last seven days, have you done any of these things or any other work? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 708 Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 illness, vacation, maternity leave or any other such reason? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 710 709 Do you receive money for the work you do? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 712 710 If you could find a suitable job, would you like to work? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 711 Have you done any work in the last 12 months? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 713 290 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 712 What is your occupation, that is, what kind of work do you mainly do? 713 Did you work at any time before you (first) YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 got married? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 714 Did you work after you (first) got married? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 291Appendix F | SECTION 8. HIV/AIDS NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 801 Now I would like to talk about something else. YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Have you ever heard of an illness called AIDS? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 814 802 Can people reduce their chance of getting the AIDS virus YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 by staying faithful to just one partner? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 803 Can people get the AIDS virus from mosquito bites? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 804 Can people reduce their chance of getting the AIDS virus by YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 using a condom every time they have sex? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 805 Can people get the AIDS virus by sharing food with a person YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 who has AIDS? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 806 Can people reduce their chance of getting the AIDS virus by YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 not having sexual intercourse at all? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 807 Can people get the AIDS virus because of witchcraft or other YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 supernatural means? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 808 Is it possible for a healthy-looking person to have the AIDS YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 virus? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 809 Do you know someone personally who has the virus that YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 causes AIDS or someone who died from AIDS? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 810 Can the virus that causes AIDS be transmitted from a mother to a child: YES NO DK During pregnancy? DURING PREGNANCY? . 1 2 8 During delivery? DURING DELIVERY? . . 1 2 8 By breastfeeding? BY BREASTFEEDING?. . 1 2 8 811 Have you ever talked about ways to prevent getting the virus YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 that causes AIDS with your (former) husband? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 292 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 812 God forbid If a member of your family got infected with the virus YES, REMAIN A SECRET. . . . . . . . . . . . 1 that causes AIDS, would you want it to remain a secret or not? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . . . . . 8 813 God forbid If a relative of yours became sick with the virus that YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 causes AIDS, would you be willing to care for her or him in your own household? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . . . . . 8 814 Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 901 815 Could you kindly tell me some signs of these infections that you know about? WOUND WITHOUT PAIN . . . . . . . . . . . . A RECORD ALL MENTIONED. WOUND WITH PAIN. . . . . . . . . . . . . . . . B WOUND, PAIN WITH LOTS . . . . . . . . . . C OF PIMPLES PUS LIKE DISCHARGE. . . . . . . . . . . . . . D DARK PUS LIKE DISCHARGE. . . . . . . . . . . . . . E SOUR MILK LIKE THICK . . . . . . . . . . . . F DISCHARGE SPONGE LIKE DISCHARGE. . . . . . . . . . . . . . G DISCHARGE WITH BAD . . . . . . . . . . . . H ODOUR/DIRTY WATER : OTHER-1 X (SPECIFY) OTHER-2 Y (SPECIFY) DON'T KNOW / NOT SURE DON'T KNOW / NOT SURE 293Appendix F | SECTION 9. OTHER HEALTH RELATED ISSUES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 901 Have you ever heard of an illness called tuberculosis or TB? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 906 902 How does tuberculosis spread from one person to another? THROUGH THE AIR WHEN COUGHING OR SNEEZING . . . . . . . . A BY SHARING UTENSILS . . . . . . . . . . . . B PROBE: BY TOUCHING A PERSON WITH TB . C Any other ways? THROUGH SHARING FOOD . . . . . . . . D THROUGH SEXUAL CONTACT . . . . . E RECORD ALL MENTIONED. THROUGH MOSQUITO BITES . . . . . . . . F OTHER X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . . . Z 903 Can tuberculosis be cured? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 905 904 What is the duration of treatment of TB now a days? MONTHS . . . . . . . . . . . . . . . . . . . . IF MORE THAN 7 MONTHS, RECORD 7 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 905 Have you ever been told by a doctor or nurse or LHV that God YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 forbid you have/had tuberculosis? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . 8 906 CHECK 212: ONE OR MORE NO LIVE LIVE BIRTH BIRTHS 911 907 Sometimes a woman can have a problem, usually after a YES, DRIBBLING OF URINE . . . . . . . . 1 difficult childbirth, such that she continuously dribbles urine even during sleep that wets her clothes too and/or leaks stool YES, STOOL COMING FROM from her vagina. Have you ever experienced this problem? VAGINA . . . . . . . . . . . . . . . . . . . . . . 2 YES, BOTH . . . . . . . . . . . . . . . . . . . . . . 3 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 911 DON’T KNOW . . . . . . . . . . . . . . . . . . . . 8 908 Do you still have this problem? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 909 Please tell me how did this problem start: AFTER A DIFFICULT CHILDBIRTH 1 AFTER A RAPE/SEXUAL ASSAULT 2 OTHER 6 (SPECIFY) 910 What happened to baby? LIVE BIRTH: . . . . . . . . 1 . . . . . . . . 2 . . . . . . . . 3 STILL BIRTH . . . . . . . . . . . . . . . . . . . . 4 DIED IN SEVEN DAYS DIED AFTER SEVEN DAYS STILL LIVING . . . . . . . . . . 294 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 911 Now I would like to ask you some questions relating to other health matters. Have you had an injection for any reason in the last 12 months? NUMBER OF INJECTIONS . . . IF YES: NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 915 How many injections have you had? IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. 912 Among these injections, how many were given by a doctor, nurse, pharmacist, dentist, LHV or any other health worker? NUMBER OF INJECTIONS . . . IF NUMBER OF INJECTIONS IS GREATER THAN 90, NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 915 OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. 913 The last time you had an injection from where did you PUBLIC SECTOR obtain the syringe? GOVT. HOSPITAL/RHSC . . . . . . . . 11 RHC/MCH . . . . . . . . . . . . . . . . . 12 BHU/FWC . . . . . . . . . . . . . . . . . . 13 MOBILE SERVICE CAMP . . . . . . . . 14 LADY HEALTH WORKER (LHW) HEALTH HOUSE . . . . . . . . . . . . 15 OTHER PUBLIC 16 (SPECIFY) IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, PRIVATE MED. SECTOR WRITE THE NAME OF THE SOURCE. PRIVATE HOSPITAL/CLINIC/ PROBE TO IDENTIFY THE TYPE OF SOURCE AND PRIVATE DOCTOR . . . . . . . . . . 21 CIRCLE THE APPROPRIATE CODE. DENTAL CLINIC/OFFICE . . . . . . . . 22 IF SYRINGE WAS PURCHASED FROM A CHEMIST CHEMIST . . . . . . . . . . . . . . . . . . . . . 23 CODE "23". OFFICE OR HOME OF NURSE/ HEALTH WORKER . . . . . . . . . . . . 24 DISPENSER / COMPOUNDER . . . . . 25 OTHER PRIVATE (NAME OF PLACE) MEDICAL 26 (SPECIFY) OTHER PLACE AT HOME . . . . . . . . . . . . . . . . . . . . 31 OTHER 96 (SPECIFY) 914 Did the person who gave you that injection take the syringe and YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 needle from a new, unopened package? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 295Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 915 Do you think that one can protect herself/himself from getting Hepatitise B,C, and HIV AIDS if: YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 915A A syringe and needle from a new unopened packet is used while giving an injection? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 915B If need be , blood tested for Hepatitise B,C and HIV AIDS YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 virus is transfused? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 916 RECORD THE TIME. HOUR . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . . 296 | Appendix F INTERVIEWER'S OBSERVATIONS TO BE FILLED IN AFTER COMPLETING INTERVIEW COMMENTS ABOUT RESPONDENT: COMMENTS ON SPECIFIC QUESTIONS: ANY OTHER COMMENTS: SUPERVISOR'S OBSERVATIONS NAME OF SUPERVISOR: DATE: EDITOR'S OBSERVATIONS NAME OF EDITOR: DATE: 297Appendix F | NATIONAL INSTITUTE OF POPULATION STUDIES PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY DECEASED CHILD'S IDENTIFICATION IDENTIFICATION PROVINCE (PUNJAB=1; SINDH=2; NWFP=3; BALOCHISTAN=4; FATA=5) . . . . . . . . . . . . . . . . DISTRICT . . . . . . . . . . . . . . . . TEHSIL/TALUKA CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME OF HOUSEHOLD HEAD NAME OF CHILD WHO DIED (IF NO NAME GIVEN OR STILL BIRTH WRITE BABY) INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. NUMBER RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: 1 COMPLETED 4 REFUSED 2 NOT AT HOME 5 PARTLY COMPLETED 7 OTHER 3 POSTPONED 6 INCAPACITATED (SPECIFY) LANGUAGE OF QUESTIONNAIRE: URDU SUPERVISOR FIELD EDITOR OFFICE EDITOR NAME NAME DATE DATE Introduction and Consent Assalamo Alaikum. My name is ______ and I am working with (NIPS, Islamabad). We are conducting a national survey about various he issues. We would very much appreciate your participation in this survey. As part of this survey, we are interested in the illness that le death. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If I ask any question you do not to answer just let me know and I will go to the next question; or you can stop the interview at any time. However, we hope you will participa the survey since your views are important At this time, do you want to ask me anything about the survey? May I begin the interview now? Signature of interviewer: Date: RESPONDENT AGREES TO BE INTERVIEWED . . . . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . . 2 END 1 2 3 KEYED BY 2 0 0 299Appendix F | INTERVIEWER: ASK TO TALK TO THOSE WHO KNOW THE MOST ABOUT THE CHILD'S LAST ILLNESS AND DEATH,IF A NEIGHBOR, FRIEND, OR DAI WAS PRESENT DURING HIS/HER ILLNESS OR DEATH, ASK THEM TO COME AND JOIN IN FOR INTERVIEW GET ALL THE RESPONDENTS TOGETHER FOR THE INTERVIEW AND FILL THE TABLE BELOW. First, I have a few questions about each of you. Please tell me: NO. What is your name? Sex of How old What was What is Were Were you Were you CIRCLE respondent ? are you? your your you present present LINE relationship educa- present when when NO. to (NAME) tion? at (NAME) (NAME) OF i.e deceased SEE the was ill? died? MAIN child? CODES delivery RES- BELOW of POND- COMPLETED (CLASSES (NAME)? ENT YEARS RELATION PASSED) 1 MALE. . . . 1 YES . . 1 YES . . . . 1 YES . . 1 1 FEMALE . 2 NO . . . 2 NO . . . . . 2 NO . . . 2 2 MALE. . . . 1 YES . . 1 YES . . . . 1 YES . . 1 2 FEMALE . 2 NO . . . 2 NO . . . . . 2 NO . . . 2 3 MALE. . . . 1 YES . . 1 YES . . . . 1 YES . . 1 3 FEMALE . 2 NO . . . 2 NO . . . . . 2 NO . . . 2 4 MALE. . . . 1 YES . . 1 YES . . . . 1 YES . . 1 4 FEMALE . 2 NO . . . 2 NO . . . . . 2 NO . . . 2 5 MALE. . . . 1 YES . . 1 YES . . . . 1 YES . . 1 5 FEMALE . 2 NO . . . 2 NO . . . . . 2 NO . . . 2 6 MALE. . . . 1 YES . . 1 YES . . . . 1 YES . . 1 6 FEMALE . 2 NO . . . 2 NO . . . . . 2 NO . . . 2 RELATIONSHIP TO DECEASED CHILD: EDUCATION CLASS: 01 = PARENT 00 = LESS THAN 1 YEAR COMPLETED 02 = BROTHER / SISTER 01 = CLASS 1; 03 = GRAND PARENTS 02 = CLASS 2 04 = GRAND MATERNAL PARENTS . . . 05 = ANTS / UNCLE 10 = MATRIC, CLASS 10 06 = OTHERRELATIVE 11 = CLASS 11 07 = STEP PARENTS . . . . 08 = NOT RELATED 16 = MASTER'S DEGREE OR MBBS, PhD, 09 = DOMESTIC SERVANT MPhil, BSc (4 YEARS) 107 108 SECTION 1. INFORMATION ABOUT RESPONDENTS 109101 110102 103 104 105 106 300 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 111 RECORD THE TIME AT BEGINNING OF INTERVIEW HOUR . . . . . . . . . . . . . . . . . . MINUTES 112 CHECK 105: MOTHER NOT PRESENT MOTHER PRESENT 114 113 Is (NAME)'s mother still alive? ALIVE AND IN THE IF YES: HOUSEHOLD . . . . . . . . . . . . . . . . 1 Where is she living now? ALIVE BUT LIVING ELSEWHERE . 2 DEAD . . . . . . . . . . . . . . . . . . . . . . 3 114 Name of the mother of deceased child: LINE NUMBER . . . . . . . . . . (WRITE THE LINE NO. OF THE MOTHER FROM HOUSEHOLD SCHEDULE OR '00' IF NOT IN THE HOUSEHOLD) 115 Name of the father of deceased child: LINE NUMBER . . . . . . . . . . (WRITE THE LINE NO. OF THE FATHER FROM HOUSEHOLD SCHEDULE OR '00' IF NOT IN THE HOUSEHOLD) 116 In what month and year did you/mother was born? MONTH . . . . . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . 98 YEAR . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . 9998 117 In what month and year did you/mother start living with your/her (first) husband? MONTH . . . . . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . 98 YEAR . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . 9998 301Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 118 How many times have you/mother been pregnant ? TIMES . . . . . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . 98 119 What was the date of delivery or birth of the deceased child? DAY . . . . . . . . . . . . . . MONTH . . . . . . . . . . . . . . YEAR . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . 9998 120 Was the child born alive or dead ? ALIVE . . . . . . . . . . . . . . . . . . . . . . 1 124 DEAD . . . . . . . . . . . . . . . . . . . . . . 2 121 Did the baby ever cry, even a little ? YES . . . . . . . . . . . . . . . . . . . . . . . . 1 124 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . 8 122 Did the baby ever show movement, even a little bit ? YES . . . . . . . . . . . . . . . . . . . . . . . . 1 124 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . 8 123 Did the baby ever breathe, even for a short while ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . 8 124 When did (NAME) die ? DAY . . . . . . . . . . . . . . . IF NOT IN THE YEARS 2005 OR 2006, END MONTH . . . . . . . . . . . . . . INTERVIEW. CHANGE DATE ON THE HOUSEHOLD QUESTIONNARE YEAR . . . . . . . . . . H101 125 How old was (NAME) when he/she died ? STILLBIRTH . . . . . . . . . . . . . . . . 000 MINUTES . . . . . . . . . . 1 IF < 1 HOUR, WRITE MINUTES HOURS . . . . . . . . . . . . 2 IF < 1 DAY, WRITE HOURS IF < 1 MONTH, WRITE DAYS DAY . . . . . . . . . . . . 3 IF < 2 YEARS, WRITE MONTHS IF > = 2 YEARS, WRITE YEARS MONTH . . . . . . . . . . . . 4 YEAR . . . . . . . . . . . . 5 126 Was (NAME) a boy or girl ? BOY . . . . . . . . . . . . . . . . . . . . . . . . 1 GIRL . . . . . . . . . . . . . . . . . . . . . . . . 2 UNCERTAIN . . . . . . . . . . . . . . . . . . 3 302 | Appendix F SECTION 2. OPEN HISTORY OPEN HISTORY INSTRUCTIONS TO INTERVIEWER: ALLOW THE RESPONDENT TO TELL YOU ABOUT THE PREGNANCY, DELIVERY AND THE BABY’S ILLNESS IN HER OWN WORDS. WRITE DOWN WHAT THE RESPONDENT TELLS YOU IN HER OWN WORDS. DO NOT PROMPT EXCEPT FOR ASKING WHETHER THERE WAS ANYTHING ELSE FOR STILLBIRTHS (I.E., NO CRY, NO BREATHING, NO MOVEMENT AT BIRTH), ASK: COULD YOU TELL ME ABOUT THE PREGNANCY FOR THIS BABY, LABOUR AND DELIVERY, WHAT THE BABY WAS LIKE AT BIRTH AND WHAT HAPPENED AFTER THE DELIVERY? FOR NEONATAL DEATHS (LIVE BIRTH THAT DIED AT LESS THAN 28 DAYS OLD), ASK: COULD YOU TELL ME ABOUT THE PREGNANCY FOR THIS BABY, LABOUR AND BIRTH, WHAT HAPPENED IMMEDIATELY AFTER BIRTH AND ABOUT THE BABY’S ILLNESS THAT LED TO DEATH? FOR POST NEONATAL AND CHILD DEATHS (LIVE BIRTH THAT DIED AT MORE THAN 28 DAYS OLD), PLEASE DESCRIBE THE SYMPTOMS IN ORDER OF APPEARANCE, CARE PROVIDER CONSULTED OR HOSPITALIZATION, HISTORY OF SIMILAR EPISODES, ENTER THE RESULTS FROM REPORTS OF INVESTIGATION 303Appendix F | CONTD. OPEN HISTORY 304 | Appendix F INVERVIEWER: USE THE FOLLOWING CHECLIST TO MARK ALL COMPLICATIONS REPORTED SPONTANEOUSLY IN THE WRITTEN OPEN HISTORY. IF NOT MENTIONED IN OPEN HISTORY, ASK ABOUT EACH ONE. ALL MORBIDITIES TO BE MARKED. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 201 What were the compilcations/ problems that occcurred COMPLICATIONS YES NO DK during pregnancy but before labor and delivery ? VAGINAL BLEEDING? . . . . . . 1 2 8 HIGH BLOOD PRESSURE? . 1 2 8 CRAMPS AND ABDOMINAL PAIN. . . . . . . . 1 2 8 CONVULSIONS/ FITS? . . . 1 2 8 SEVERE HEADACHE? . . . . . . 1 2 8 HAND, FEET AND FACIAL SWELLING? . . . . . . 1 2 8 ANEMIA? . . . . . . . . . . . . . . . . . 1 2 8 Did you/ the mother have: SEVERE ANEMIA? . . . . . . . . 1 2 8 DIABETES? . . . . . . . . . . . . . . . 1 2 8 URINARY COMPLAINTS? . 1 2 8 GENITAL ULCER? . . . . . . . . 1 2 8 BABY STOPPED MOVING? . 1 2 8 OTHER (SPECIFY) . . . . . . . . 1 2 8 202 What were the complications/ problems that occurred COMPLICATIONS YES NO DK during labour and/ or delivery ? HAND, FEET AND FACIAL SWELLING . . . . . . 1 2 8 HIGH BLOOD PRESSURE . 1 2 8 ANEMIA . . . . . . . . . . . . . . . . . 1 2 8 SEVERE ANEMIA . . . . . . . . 1 2 8 CONVULSIONS . . . . . . . . . . 1 2 8 BABY STOPPED MOVING . 1 2 8 VAGINAL BLEEDING LIKE A PERIOD . . . . . . . . . . . . . . . 1 2 8 Did you/ the mother have: WATER BAG BROKE MORE THAN ONE DAY BEFORE LABOR BEGAN . 1 2 8 LIQUOR (WATER) WAS YELLOW MECONIUM STAINED . . . . . . . . . . . . . . . 1 2 8 LIQUOR (WATER) WAS GREEN . . . . . . . . . . . . . . . . . 1 2 8 VERY SMELLY LIQUOR (WATER) . . . . . . 1 2 8 MULTIPLE PREGNANCY . . . 1 2 8 BABY VERY SMALL AT BIRTH . . . . . . . . . . . . . . . . . 1 2 8 BORN EARLY . . . . . . . . . . . . 1 2 8 BREECH DELIVERY . . . . . . 1 2 8 PROLONGED/ DIFFICULT LABOR . . . . . . . . . . . . . . . . . 1 2 8 INSTRUMENTAL DELIVERY (FORCEPS AND VACUUM) 1 2 8 C – SECTION (OPERATIVE DELIVERY) . . . . . . . . . . . . 1 2 8 OTHERS 1 2 8 (SPECIFY) 203 CHECK 126: LIVE BIRTH STILL BIRTH 301 305Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 204 What were the complications that occurred to the baby, COMPLICATIONS YES NO DK during the illness that led to death? BABY WAS VERY SMALL 1 2 8 PREMATURE (BABY WAS BORN BEFORE 38 WEEKS OF GESTATIONAL AGE) . 1 2 8 BRUISES OR MARKS OF INJURY ON HEAD/BODY 1 2 8 HAD A PHYSICAL MALFORMATION . . . . . . 1 2 8 DID NOT HAVE STRONG SUCK . . . . . . . . . . . . . . . 1 2 8 COULD NOT GET FEED . 1 2 8 HAD A STRONG SUCK, BUT THEN STOPPED SUCKING WELL . . . . . . 1 2 8 DID NOT HAVE STRONG CRY . . . . . . . . . . . . . . . 1 2 8 HAD A STRONG CRY BUT THEN STOPPED CRYING . . . . . . . . . . . . 1 2 8 HAD A SPASM OR CONVULSION . . . . . . . . 1 2 8 HAD TETANUS . . . . . . . . 1 2 8 AREAS OF SKIN THAT WERE RED AND HOT . 1 2 8 HAD A BULGING FONTANEL . . . . . . . . . . 1 2 8 BECOME UNRESPONSIVE/ UNCONSCIOUS. . . . . . . . 1 2 8 HANDS OR FEET WERE COLD . . . . . . . . . . . . . . . 1 2 8 HAD FEVER . . . . . . . . . . 1 2 8 HAD REDNESS OR DRAINAGE FROM UMBILICAL STUMP . . . 1 2 8 BABY WAS VERY PALE . 1 2 8 HAD YELLOW EYES AND BODY . . . . . . . . . . 1 2 8 HAD CYANOSIS (BLUE COLOR) . . . . . . . . . . . . 1 2 8 HAD DIFFICULTY BREATHING . . . . . . . . . . 1 2 8 BABY WAS NOT ABLE TO BREATHE . . . . . . . . 1 2 8 HAD CHEST IN-DRAWING 1 2 8 WAS BREATHING VERY FAST . . . . . . . . . . . . . . . 1 2 8 COUGH . . . . . . . . . . . . . . . 1 2 8 HAD PERSISTENT VOMITING. . . . . . . . . . . . 1 2 8 FREQUENT, LIQUID OR WATERY STOOLS . . . 1 2 8 ABDOMINAL DISTENSION 1 2 8 OTHER 1 2 8 (SPECIFY) 306 | Appendix F SECTION 3. DETAILS OF THE LAST (DECEASED CHILD) PREGNANCY LABOUR AND DELIVERY (FOR ALL DEATHS) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 301 Did any of illiness (problem) Duration Stage of occur to the child's mother of illness pregnancy * during pregnancy ? (Weeks) BLEEDING FROM THE VAGINA . . . . . A . SMELLY OR EXCESSIVE VAGINAL DISCHARGE. . . . . . . . . . . . . . . . . . . . B . SEVERE OR PERSISTENT ABDOMINAL OR BACK PAIN THAT (CIRCLE ALL MENTIONED) WAS NOT LABOUR PAIN . . . . . . . . . . C . HAND OR FACE SWELLING OR RAPID LEG SWELLING. . . . . . . . . . . . . . . . . . D . BLURRING OF VISION AND SEVERE HEADACHE . . . . . . . . . . . . . . . . . . . . E . * (GESTATIONAL AGE) IN MONTHS WHEN DISEASE CONVULSIONS. . . . . . . . . . . . . . . . . . F . STARTED) HIGH BLOOD PRESSURE . . . . . . . . . . G . LESS BLOOD OR WAS ANEMIC . . . H . MALARIA . . . . . . . . . . . . . . . . . . . . I . DIABETES . . . . . . . . . . . . . . . . . . . . J . JAUNDICE . . . . . . . . . . . . . . . . . . . . K . POSITIVE HIV TEST . . . . . . . . . . . . . . L . OTHER X . (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . Z 302 CHECK 301: AT LEAST ONE ILLNESS NOT A SINGLE ILLNESS 305 303 In case of illness or problem, was health care sought YES . . . . . . . . . . . . . . . . . . . . . . . . . . 1 from a health care provider/ facility for any illness (problem)? NO . . . . . . . . . . . . . . . . . . . . . . . . . . 2 305 304 From where the care was sought ? GOVERNMENT SECTOR GOVT. DHQ/THQ/CIVIL HOSPITAL. A RURAL HEALTH CENTER . . . . . . . . B BASIC HEALTH UNIT . . . . . . . . . . C DISPENSARY . . . . . . . . . . . . . . . . . D CIRCLE ALL MENTIONED LADY HEALTH WORKER . . . . . . . . E OTHER GOV’T . F (SPECIFY) PRIVATE SECTOR HOSPITAL /NURSING HOME. . . . . . G LADY HEALTH VISITER . . . . . . . . H MIDWIFE . . . . . . . . . . . . . . . . . . . . . I COMPOUNDER/ DISPENSER. . . . . . J DAI . . . . . . . . . . . . . . . . . . . . . . . . . . K HAKEEM/ HOMEOPATH . . . . . . . . L OTHER PRIVATE . M (SPECIFY) 307Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 305 Did you/ mother have vaginal bleeding before delivery for YES . . . . . . . . . . . . . . . . . . . . . . . . . . 1 any previous pregnancy (APH)? NO . . . . . . . . . . . . . . . . . . . . . . . . . . 2 308 306 Was healthcare sought during this problem? YES . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . 2 308 307 From where did you/ mother seek care GOVERNMENT SECTOR GOVT. DHQ/THQ/CIVIL HOSPITAL A RURAL HEALTH CENTER . . . . . . . . B BASIC HEALTH UNIT . . . . . . . . . . C DISPENSARY . . . . . . . . . . . . . . . . . D LADY HEALTH WORKER . . . . . . . . E OTHER GOV’T_____________ . . . F (SPECIFY) CIRCLE ALL MENTIONED PRIVATE SECTOR HOSPITAL /NURSING HOME. . . . . . G LADY HEALTH VISITER . . . . . . . . H MIDWIFE . . . . . . . . . . . . . . . . . . . . . I COMPOUNDER/ DISPENSER. . . . . . J DAI . . . . . . . . . . . . . . . . . . . . . . . . . . K HAKEEM/ HOMEOPATH . . . . . . . . L OTHER PRIVATE . X (SPECIFY) 308 Was this child a single or multiple birth ? SINGLE BIRTH . . . . . . . . . . . . . . . . . 1 FIRST OF TWINS . . . . . . . . . . . . . . 2 SECOND OF TWINS . . . . . . . . . . . . 3 OTHERS 4 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . 8 309 Was he/ she born after full term or pre-term or after FULL TERM . . . . . . . . . . . . . . . . . . . 1 term ? PRE-TERM . . . . . . . . . . . . . . . . . . . 2 AFTER-TERM . . . . . . . . . . . . . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . 8 310 How many months of pregnancy were completed ? MONTHS . . . . . . . . . . . . . . 311 Where was he/she born ? AT HOME . . . . . . . . . . . . . . . . . . . 1 GOVT. HEALTH FACILITY . . . . . . 2 PRIVATE HEALTH FACILITY . . . 3 ON THE WAY TO HEALTH FACILITY . . . . . . . . . . . . 4 OTHER GOV'T . 5 (SPECIFY) 312 Who attended the delivery ? DOCTOR . . . . . . . . . . . . . . . . . . . . . A MIDWIFE / NURSE / LHV . . . . . . . . B TRAINED TBA . . . . . . . . . . . . . . . . . C DAI . . . . . . . . . . . . . . . . . . . . . . . . . . D LADY HEALTH WORKER . . . . . . . . E (CIRCLE ALL MENTIONED) HOMEOPATH . . . . . . . . . . . . . . . . . F HAKEEM . . . . . . . . . . . . . . . . . . . . . G FAMILY ELDER WOMAN . . . . . . . . H HERSELF . . . . . . . . . . . . . . . . . . . . . I OTHERS X (SPECIFY) NO ONE . . . . . . . . . . . . . . . . . . . . . Y 308 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 313 How long did the labor take, from the time contractions began and before the baby came out ? HOURS . . . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . . 98 IF < 1 HOUR WRITE '00' 314 Was any intervention or procedure done during the YES . . . . . . . . . . . . . . . . . . . . . . . . . . 1 labor / delivery ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . 2 316 315 Which types of interventions or procedure were done ? MANIPULATION WITH HANDS . . . A AUGMENTATION . . . . . . . . . . . . . . B FORCEP ASSISTED . . . . . . . . . . . . C (CIRCLE ALL MENTIONED) VACUUM . . . . . . . . . . . . . . . . . . . . . D C-SECTION . . . . . . . . . . . . . . . . . . . E DON’T KNOW . . . . . . . . . . . . . . . . . Z 316 How much time did the delivery take ? MINUTES . . . . . . . . . . 1 IF < 1 HOUR WRITE MINUTES HOURS . . . . . . . . . . 2 IF >= 1 HOUR WRITE HOURS DON’T KNOW . . . . . . . . . . . . . . . . . 998 317 CHECK 126: LIVE BIRTH STILL BIRTH 321 318 What was the weight of the baby at birth ? 320 Kg. Gm. DON’T KNOW . . . . . . . . . . . . 98 998 319 What was the size of the baby at birth ? (SHOW PHOTOS AND RECORD ITS NUMBER) PHOTO NO. . . . . . . . . . . . . . . . . . 320 Did child receive any vaccinations to prevent him/ her VACCINATION YES NO DK from getting diseases, including vaccinations received in BCG . . . . . . . . . . . . . . 1 2 8 a national immunization compaign ? POLIO 0 . . . . . . . . . . . 1 2 8 POLIO 1 . . . . . . . . . . . . 1 2 8 POLIO 2 . . . . . . . . . . . . 1 2 8 POLIO 3 . . . . . . . . . . . . 1 2 8 DPT 1 . . . . . . . . . . . . . . 1 2 8 DPT 2 . . . . . . . . . . . . . . 1 2 8 DPT 3 . . . . . . . . . . . . . . 1 2 8 HBV 1 . . . . . . . . . . . . . . 1 2 8 HBV 2 . . . . . . . . . . . . . . 1 2 8 HBV 3 . . . . . . . . . . . . . . 1 2 8 MEASLES. . . . . . . . . . . . 1 2 8 321 During this pregnancy, were you/mother given an YES . . . . . . . . . . . . . . . . . . . . . . . . . . 1 injection in the buttocks or arm to prevent you/mother and the baby from getting tetanus ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . 8 323 322 How many times did you/ mother get this tetanus injection ? NO. OF DOSES . . . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . . 98 323 CHECK 124: CHILD WAS BORN DEAD STILL BIRTH . . . . . . . . . . . . . . 1 401 CHILD HAD DIED AT AGE LESS THAN 28 DAYS NEONATAL DEATH . . . . . . . . . . 2 CHILD HAD DIED AFTER 28 COMPLETED DAYS OF BIRTH POST NEONATAL & CHILD DEATH . . . . . . . . . . . . . . 3 501 309Appendix F | SECTION 4. STILL BIRTH (BORN DEAD) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 401 Was the baby moving in the last few days before the YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 delivery? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 402 When did you/ mother last feel the movements of the baby before the delivery ? MINUTES . . . . . . . . . . . . 1 HOURS . . . . . . . . . . . . 2 IF < 1 HOUR WRITE MINUTES IF < 1 DAY WRITE HOURS DAYS . . . . . . . . . . . . . . 3 IF > = 1 DAY WRITE DAYS DON’T KNOW . . . . . . . . . . . . . . . . 998 403 Was you/ mother having excess fluid in the womb YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (Ployhydramnios) ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 404 What was the color of liquor (water) during delivery ? GREENISH . . . . . . . . . . . . . . . . . . . . 1 BROWNISH . . . . . . . . . . . . . . . . . . . . 2 NORMAL . . . . . . . . . . . . . . . . . . . . . . 3 DON'T KNOW . . . . . . . . . . . . . . . . . . 8 405 Was the liquor foul smelling ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 406 Which part of the baby came out first HEAD . . . . . . . . . . . . . . . . . . . . . . . . 1 BOTTOM . . . . . . . . . . . . . . . . . . . . . . 2 FEET . . . . . . . . . . . . . . . . . . . . . . . . 3 HANDS AND ARMS . . . . . . . . . . . . 4 C-SECTION . . . . . . . . . . . . . . . . . . . . 5 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 407 Was the cord around the neck of the dead baby ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 408 Was there any gross physical deformity in the dead baby ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 409 Was the head not properly formed or skull vault and YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 forebrain absent at the time to birth (Anencephaly) ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SHOW PHOTO) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 410 Was there a mass or defect on the back YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (Meningomyelocele) ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SHOW PHOTO) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 411 Was there any cleft lip or cleft palate in the dead baby ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (SHOW PHOTO) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 412 Was dead baby macerated (skin and tissue was YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pulpy)? (SHOW PHOTO) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 H101 310 | Appendix F SECTION 5. DEATH FROM INJURY OR ACCIDENT ( For Neonatal, Post Neonatal child deaths) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 501 Did he/she die from an injury or accident ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 503 502 IF YES: ROAD TRAFFICE ACCIDENT . . . . . 01 What kind of injury or accident ? FALL DOWN . . . . . . . . . . . . . . . . . . 02 SOMETHING FELL ON THE CHILD . 03 BURN . . . . . . . . . . . . . . . . . . . . . . . . 04 DROWNING . . . . . . . . . . . . . . . . . . . . 05 POISONING . . . . . . . . . . . . . . . . . . . . 06 H101 BITE/STING . . . . . . . . . . . . . . . . . . . . 07 NATURAL DISASTER . . . . . . . . . . . . 08 HOMICIDE/ ASSAULT . . . . . . . . . . . . 09 OTHERS . . . 10 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . 98 503 CHECK 126: NEONATAL DEATH . . . . . . . . . . . . 1 601 CIRCLE THE APPROPRIATE CODE FOR TYPE OF POST NEONATAL DEATH . . . . . . . . 2 701 DEATH. 311Appendix F | SECTION 6. NEONATAL DEATHS (INFANT DIED WITH IN 28 DAYS AFTER BIRTH) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 601 Did the water bag rupture before or after start of BEFORE . . . . . . . . . . . . . . . . . . . . . . 1 labor pains or water bag never broke ? AFTER . . . . . . . . . . . . . . . . . . . . . . 2 WATER BAG NEVER BROKE . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 603 602 How much time before labor started did the water bag rupture ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY WRITE HOURS IF >= 1 DAY WRITE DAYS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 603 What was the color of liquor (amniotic fluid) ? GREENISH . . . . . . . . . . . . . . . . . . . . 1 BROWNISH . . . . . . . . . . . . . . . . . . . . 2 NORMAL . . . . . . . . . . . . . . . . . . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 604 What was the color of child at birth ? PINK . . . . . . . . . . . . . . . . . . . . . . 1 PALE . . . . . . . . . . . . . . . . . . . . . . . . 2 BLUE . . . . . . . . . . . . . . . . . . . . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 605 What was the color of child after 5 minutes of birth ? PINK . . . . . . . . . . . . . . . . . . . . . . 1 PALE . . . . . . . . . . . . . . . . . . . . . . . . 2 BLUE . . . . . . . . . . . . . . . . . . . . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 606 Did the baby breathe immediately after birth ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (THIS DOES NOT INCLUDE GASPS OR VERY BRIEF DON’T KNOW . . . . . . . . . . . . . . . . . . 8 EFFORTS TO BREATHE) 607 Did the child cry after birth ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 609 608 Was the cry feeble or strong ? FEEBLE . . . . . . . . . . . . . . . . . . . . . . 1 STRONG . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 609 Were there any green marks of meconium on the YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 child's body ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 610 Were there any bruises or marks of injury on the child's YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 body ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 611 Did the newborn have swelling(s) over the skull ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 612 Was there any physical deformity in the baby ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 312 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 613 Was the head size not properly formed or skull vault NOT PROPERLY FORMED . . . . . . . . 1 and forebrain absent, very small, small, normal SMALL . . . . . . . . . . . . . . . . . . . . . . 2 or very large? NORMAL . . . . . . . . . . . . . . . . . . . . . . 3 (Anencephaly, Microcephaly, Hydrocephaly) LARGE . . . . . . . . . . . . . . . . . . . . . . 4 VERY LARGE . . . . . . . . . . . . . . . . . . 5 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 (SHOW PHOTO) 614 Was there a mass or defect on the back of head or spine? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (Meningomyelocele) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 (SHOW PHOTO) 615 Was there any cleft lip or cleft palate ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SHOW PHOTO) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 616 Was there any limp defect ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (SHOW PHOTO) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 617 Was the child limp/ flaccid during first 72 hours ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 618 When did the child start sucking on the breast or feed IMMEDIATELY . . . . . . . . . . . . . . . . . . 000 bottle after birth ? MINUTES . . . . . . . . . . . . 1 HOURS . . . . . . . . . . . . 2 IF < 1 HOUR WRITE MINUTES DAYS . . . . . . . . . . . . . . 3 IF > 1 HOUR BUT > 1 DAY WRITE HOURS NEVER FED . . . . . . . . . . . . . . . . . . . . 995 621 IF >= 1 DAY WRITE DAYS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 619 When did child stop sucking or bottle-feeding before death ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . 2 IF < 1 DAY WRITE HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY WRITE DAYS 620 How long before death, did the infant stop crying? HOURS . . . . . . . . . . . . 1 IF < 1 DAY RECORD HOURS MINUTES . . . . . . . . . . . . 2 IF >= 1 DAY RECORD DAYS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 621 Did body of the child become stiff with the back arched? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 313Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 622 Did the newborn have convulsions (Fits/seizure) during YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 first 24 hours after birth ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 623 Was a safe delivery kit used during this delivery ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 624 What was used to TIE the umbilical cord ? UNBOILED THREAD . . . . . . . . . . . . 1 BOILED THREAD . . . . . . . . . . . . . . . . 2 WASHED CLAMPS . . . . . . . . . . . . . . 3 UNWASHED CLAMPS . . . . . . . . . . . . 4 HAIR . . . . . . . . . . . . . . . . . . . . . . . . 5 OTHER 6 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 625 What was used to cut the umbilical cord ? NEW RAZOR BLADE . . . . . . . . . . 1 OLD RAZOR BLADE . . . . . . . . . . . . 2 SCISSOR . . . . . . . . . . . . . . . . . . . . . . 3 KNIFE . . . . . . . . . . . . . . . . . . . . . . . . 4 TOKA / CHOPPER . . . . . . . . . . . . . . 5 OTHER 6 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 627 626 Were the instruments boiled before using or not boiled ? BOILED . . . . . . . . . . . . . . . . . . . . . . 1 NOT BOILED . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 627 Did child have "Tetanus" (local words)? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (EXPLAIN DESCRIPTION OF DISEASE) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 628 Did child become unresponsive / unconscious during the YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 illness ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 629 Did child have a bulging fontanelle during the illness ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 630 Did child have jaundice or yellow discoloration of skin ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 631 Did child have redness or pus oozing from the umbilical YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 cord ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 632 Did child have areas of skin that were red and hot ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 633 Did child have skin rash with pus ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 635 314 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 634 Did the skin peel off after the rash started ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 635 Did child have ear discharge ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 636 Did Child become lethargic at any stage of the illness ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 637 Did the child have a fever at any stage of the illness ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 639 638 For how long did fever last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY RECORD HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY RECORD DAYS 639 Did child have frequent loose or watery stools / diarrhea ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 645 640 For how long did the diarrhea last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF < 1 DAY RECORD HOURS IF >= 1 DAY RECORD DAYS 641 Was there visible blood in the stools at any stage of YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 diarrhea ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 642 Did child have abdominal distension at any stage of YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 diarrhea ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 643 Did the child take any liquids during loose or watery YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 stools ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 644 Did the child take ORS during loose or watery stools ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 645 Did child have cough ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 647 646 For how long did cough last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY RECORD HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY RECORD DAYS 647 Did child have difficult breathing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 649 315Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 648 For how long did difficult breathing last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY RECORD HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY RECORD DAYS 649 Did child have fast breathing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 651 650 For how long did fast breathing last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY RECORD HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY RECORD DAYS 651 Did child ever stop breathing for a long time, and start YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 again ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 652 Did child have chest in-drawing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 653 Did child have noisy breathing (Stridor)? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (DEMONSTRATE SOUND) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 # 654 Did child have noisy breathing (Grunting) ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (DEMONSTRATE SOUND) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 655 Did child have noisy breathing (Wheezing) > YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (DEMONSTRATE SOUND) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 656 Did child's nostrils flare with breathing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 657 Did child have pneumonia (local term) ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 658 Did child become cold at the beginning/ during of illness ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 801 316 | Appendix F SECTION 7. POST NEONATAL AND CHILD DEATHS (CHILD DIED AFTER 28 DAYS UP TO 5 YEARS) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 701 Did child have a fever ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 703 702 For how long did fever last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY WRITE HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY WRITE DAYS 703 Did child become unresponsive / unconscious ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 704 Did child have "Tetanus" (local words) ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (EXPLAIN DESCRIPTION OF DISEASE) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 705 Did child have a bulging fontanlle ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 706 Did the child have a stiff neck ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (DEMONSTRATE) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 707 Did the child have convulsions (Fits/ seizure) ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 708 Did child have frequent loose or watery stools / diarrhea ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 713 709 For how long did diarrhea last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY WRITE HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY WRITE DAYS 710 Was there visible blood in stools during diarrhea ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 711 Did child have abdominal distention during diarrhea ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 712 Did the child drink anything during loose or watery stools ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 712A Did the child take ORS during loose or watery stools ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 317Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 713 Did child have a cough ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 716 714 For how long did cough last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY RECORD HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY RECORD DAYS 715 How severe was the cough ? MILD . . . . . . . . . . . . . . . . . . . . 1 SEVERE . . . . . . . . . . . . . . . . . . . . . . 2 VERY SEVERE . . . . . . . . . . . . . . . . 3 716 Did child have difficult breathing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 718 717 For how long did difficult breathing last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY RECORD HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY RECORD DAYS 718 Did child have fast breathing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 720 719 For how long did fast breathing last ? HOURS . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY RECORD HOURS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF >= 1 DAY RECORD DAYS 720 Did child ever stop breathing for a long time and YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 start again ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 720 721 Did child have chest indrawing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 720 722 Did child have noisy breathing (Stridor)? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (DEMONSTRATE SOUND) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 723 Did child have noisy breathing (Grunting) ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (DEMONSTRATE SOUND) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 724 Did child have noisy breathing (Wheezing) > YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (DEMONSTRATE SOUND) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 318 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 725 Did child's nostrils flare with breathing ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 726 Did child have pneumonia (local term) ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 727 Did child become cold at the beginning of illness ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 728 Did child become cold during the illness ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 729 Did child have yellow eyes ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 730 Did child have jaundice or yellow coloured skin ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 731 Did the child have skin rash ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 737 732 Was the rash all over child's body ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 733 Was the rash also on child's face ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 734 For how many days did the rash last ? IF < 1 DAY RECORD '00' DAYS . . . . . . . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . . . 98 735 Did rash contain clear fluid ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 736 Did the skin crack or peel off after the rash started ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 737 Did the child have "measles" ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 738 Did child become very thin ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 739 Did child become very weak ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 319Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 740 Did child have swelling on legs or feet ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 742 741 For how long did the swelling last ? IF < 1 DAY RECORD '00' DAYS . . . . . . . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . . . 98 742 Did child's skin flake off in patches ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 743 Did Child's hair colour change to reddish (or yellowish) ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 744 Did child have "kwashiorkor" ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 745 Did child have "marasmus" ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 746 Did child suffer from "lack of blood" or "pallor" ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 747 Did child have pale palms ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 748 Did child have white nails ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 749 Did child have swellings in the armpits ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 750 Did child have swellings in the groin ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 751 Did child have a whitish rash inside the mouth or on YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 the tongue ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 320 | Appendix F SECTION 8. TREATMENT AND RECORDS (FOR NEONATAL AND POST NEONATAL DEATH) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 801 I would like to ask a few questions about any medicines/ drugs child might have received during the illness. Did child receive any of the following medicine/ drugs during illness? (PROMPT ALL BELOW) YES NO DK Antibiotics ANTIBIOTICS . . . . . . . . . . . 1 2 8 Antimalarial medicines ANTI-MALARIAL . . . . . 1 2 8 Fever medicines FEVER . . . . . . . . . . . . . . . . 1 2 8 Diarrhea medicines DIARRHEA . . . . . . . . . . . . 1 2 8 Other medicines OTHER MEDICINES . . . . . 1 2 8 (SPECIFY) 802 Do you have any health records that belong to your YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 child ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 804 803 Are these records available at this time ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 804 RECORD THE MOST RECENT TWO WEIGHTS OF THE WEIGHTS 1 CHILD (IF AVAILABLE) Kg. Gm. RECORD THE DATES OF THE MOST RECENT WEIGHTS DATE RECORD MOST RECENT IN WEIGHT 1 IF CARD IS NOT AVAILABLE THEN SKIP TO 805 WEIGHTS 2 Kg. Gm. DATE DON’T KNOW . . . . . . . . . . . . . . . . . . 8 805 Was a death certificate sought for the deceased child ? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 901 806 RECORD THE IMMEDIATE CAUSE OF DEATH FROM THE CERTIFICATE (IF AVAILABLE) - - - - 321Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 807 RECORD THE OTHER CAUSES FROM DEATH CERTIFICATE RECOR THE FIRST UNDERLYING CAUSE OF DEATH FROM THE CERTIFICATE RECORD THE SECOND UNDERLYING CAUSES OF DEATH FROM THE CERTIFICATE RECORD THE CONTRIBUTING CAUSES OF DEATH FROM THE CERTIFICATE 322 | Appendix F SECTION 9. SOCIAL AUDIT AND OTHER ASPECTS Please ask about any maternal complication during the last trimester of pregnancy and response of family/provider to the complication. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 901 Did you/mother have any complaints or problems during YES . . . . . . . . . . . . . . . . . . . . . . . . 1 the last trimester (last 3 months) of pregnancy? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 906 902 Please describe the nature of illness which you/mother faced during the last 3-months of pregnancy? . . . . . . . . . . . . . . . . . . . . . . . . 903 Did you/mother seek advice or treatment for the problem(s)? YES . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 905 904 Whom did you/mother see? DOCTOR . . . . . . . . . . . . . . . . . . . . A HAKIM . . . . . . . . . . . . . . . . . . . . . . . . . B HOMEOPATH . . . . . . . . . . . . . . . . . . C PHARMACY . . . . . . . . . . . . . . . . . . D GOVERNMENT HOSPITAL . . . . . . . . E 906 PRIVATE HOSPITAL . . . . . . . . . . . . F NGO CLINIC . . . . . . . . . . . . . . . . . . . . G OTHERS . . . X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . Z 905 Why did'nt you/mother see anyone for this problem? DISEASE WAS TOO SERIOUS BUT NO USE OF SEEKING CARE . 1 DISEASE WAS NOT TOO SERIOUS TOO SEEK CARE. . . . . . . . 2 HAD NO MONEY TO SEEK CARE . 3 TRANSPORT WAS NOT AVAILABLE . . . . . . . . . . . . . . . . . . 4 HAD NO PERMISSION TO GO 914 OUT ON MY OWN . . . . . . . . . . . . . . 5 MALE MEMBER/ HUSBAND WAS NOT AVAILABLE AT HOME TO ACCOMPANY ME TO HOSPITAL . . . . . . . . . . . . . . . . . . . . 6 OTHER . 7 (SPECIFY) 906 Where was the baby delivered? GOVT HEALTH FACILITY . . . . . . . . 1 PRIVATE HEALTH FACILITY . . . . . 2 ON ROUTE TO THE HEALTH FACILITY . . . . . . . . . . . . . . . . . . . . 3 908 AT HOME . . . . . . . . . . . . . . . . . . . . 4 OTHERS . . . 6 (SPECIFY) 323Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 907 Why did'nt you/mother deliver baby in a health facility? COST TOO MUCH . . . . . . . . . . . . . . A FACILITY NOT OPENED . . . . . . . . . . B POOR SERVICES AT FACILITY . . . C NO PERMISSION FROM FAMILY . D FACILITY TOO FAR . . . . . . . . . . . . . . E NO TRANSPORTATION . . . . . . . . . . F ALWAYS A DAI ASSIST IN FAMILY . . . . . . . . . . . . . . . . . . . . . . G OTHERS . . . X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . Z 908 What was the age of the baby/child when you/ mother first noticed that he/ she is not well ? HOURS . . . . . . . . . . . . . . 1 DAYS . . . . . . . . . . . . . . 2 IF < 1 DAY WRITE HOURS MONTHS. . . . . . . . . . . . . . 3 IF > = 1 DAY BUT < 1 MONTH WRITE DAYS IF >1 MONTH BUT < 1 YEAR WRITE MONTHS YEARS . . . . . . . . . . . . . . 4 IF >= 1 YEAR WRITE YEARS DON’T KNOW . . . . . . . . . . . . . . . . . . 998 909 What signs and symptoms did you/ mother notice ? DAY ONE OF ILLNESS 910 What did you/ mother/ family do first day of illness ? NOTHING . . . . . . . . . . . . . . . . . . . . 1 HOME CARE . . . . . . . . . . . . . . . . . . 2 912 SOUGHT CARE OUTSIDE . . . . . . . . 3 913 911 Why did you do nothing ? DISEASE WAS TOO SERIOUS BUT NO USE OF SEEKING CARE . 1 DISEASE WAS NOT TOO SERIOUS TO SEEK CARE . . . . . 2 HAD NO MONEY TO SEEK CARE . 3 TRANSPORT WAS NOT AVAILABLE . . . . . . . . . . . . . . . . . . 4 HAD NO PERMISSION TO GO 915 OUT ON MY OWN . . . . . . . . . . . . . . 5 MALE MEMBER/ HUSBAND WAS NOT AVAILABLE AT HOME TO ACCOMPANY ME TO HOSPITAL . . . . . . . . . . . . . . . . . . . . 6 OTHER . 7 (SPECIFY) BABY DIED SAME DAY . . . . . . . . . . 8 933 912 Why did you seek home care ? FAMILY ADVISED FOR HOME CARE 1 ILLNESS WAS NOT SERIOUS . . . . . 2 OTHERS . . . 3 915 (SPECIFY) 324 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 913 From whom did you seek care ? DOCTOR . . . . . . . . . . . . . . . . . . . . A HAKIM . . . . . . . . . . . . . . . . . . . . . . . . . B HOMEOPATH . . . . . . . . . . . . . . . . . . C PHARMACY . . . . . . . . . . . . . . . . . . D GOVERNMENT HOSPITAL . . . . . . . . E PRIVATE HOSPITAL . . . . . . . . . . . . F CIRCLE ALL MENTIONED NGO CLINIC . . . . . . . . . . . . . . . . . . . . G OTHERS . . . X (SPECIFY) NO ANSWER . . . . . . . . . . . . . . . . . . . Y 918 914 What did care provider do ? GAVE MEDICINE . . . . . . . . . . . . . . . . A REFERRED TO ANOTHER HOSPITAL B ADMITTED IN HOSPITAL . . . . . . . . . . C CIRCLE ALL MENTIONED OTHERS . . . X (SPECIFY) DAY TWO AND THREE OF ILLNESS 915 How was child on second and third day of illness? WITH SAME CONDITION . . . . . . . . . . 1 WORSENED . . . . . . . . . . . . . . . . . . 2 IMPROVED . . . . . . . . . . . . . . . . . . . . 3 WAS HOSPITALIZED . . . . . . . . . . . . 4 OTHERS . . . 6 (SPECIFY) HAD DIED DURING THIS PERIOD . . . . . . . . . . . . . . . . . . 5 933 916 What did you/ family do ? NOTHING . . . . . . . . . . . . . . . . . . . . 1 HOME CARE . . . . . . . . . . . . . . . . . . 2 918 SOUGHT CARE OUTSIDE . . . . . . . . 3 919 917 Why did you do nothing ? DISEASE WAS TOO SERIOUS BUT NO USE OF SEEKING CARE 1 DISEASE WAS NOT TOO SERIOUS TOO SEEK CARE . . . 2 HAD NO MONEY TO SEEK CARE . 3 TRANSPORT WAS NOT AVAILABLE . . . . . . . . . . . . . . . . . . 4 HAD NO PERMISSION TO GO 921 OUT ON MY OWN . . . . . . . . . . . . 5 MALE MEMBER/ HUSBAND WAS NOT AVAILABLE AT HOME TO ACCOMPANY ME TO HOSPITAL . . . . . . . . . . . . . . . . . . . . 6 OTHER . 7 (SPECIFY) 918 Why was home care sought ? FAMILY ADVISED FOR HOME CARE 1 ILLNESS WAS NOT SERIOUS . . . 2 OTHERS . . . 3 921 (SPECIFY) 325Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 919 From whom did you/ mother seek care ? DOCTOR . . . . . . . . . . . . . . . . . . . . A HAKIM . . . . . . . . . . . . . . . . . . . . . . . . . B HOMEOPATH . . . . . . . . . . . . . . . . . . C PHARMACY . . . . . . . . . . . . . . . . . . D GOVERNMENT HOSPITAL . . . . . . . . E PRIVATE HOSPITAL . . . . . . . . . . . . F CIRCLE ALL MENTIONED NGO CLINIC . . . . . . . . . . . . . . . . . . . . G OTHERS . . . X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . Z 921 920 What did the care provider do ? GAVE MEDICINE . . . . . . . . . . . . . . . . A REFERRED TO ANOTHER HOSPITAL B ADMITTED IN HOSPITAL . . . . . . . . . . C CIRCLE ALL MENTIONED OTHERS . . . X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . Z DAY 4 -8 OF ILLNESS 921 How was (NAME) baby/ child between days 4-8 of WITH SAME CONDITION . . . . . . . . . . 1 illness? WORSENED . . . . . . . . . . . . . . . . . . 2 IMPROVED . . . . . . . . . . . . . . . . . . . . 3 WAS HOSPITALIZED . . . . . . . . . . . . 4 OTHERS . . . 6 (SPECIFY) HAD DIED DURING THIS PERIOD . . . . . . . . . . . . . . . . 5 933 922 What did you/ mother/ family do ? NOTHING . . . . . . . . . . . . . . . . . . . . 1 HOME CARE . . . . . . . . . . . . . . . . . . 2 924 SOUGHT CARE OUTSIDE . . . . . . . . 3 925 923 Why did you/ mother/family do nothing ? DISEASE WAS TOO SERIOUS BUT NO USE OF SEEKING CARE . 1 DISEASE WAS NOT TOO SERIOUS TOO SEEK CARE . . . 2 HAD NO MONEY TO SEEK CARE . 3 TRANSPORT WAS NOT AVAILABLE . . . . . . . . . . . . . . . . . . 4 HAD NO PERMISSION TO GO 927 OUT ON MY OWN . . . . . . . . . . . . . . 5 MALE MEMBER/ HUSBAND WAS NOT AVAILABLE AT HOME TO ACCOMPANY ME TO HOSPITAL . . . . . . . . . . . . . . . . . . . . 6 OTHER . 7 (SPECIFY) 924 Why did you seek home care ? FAMILY ADVISED FOR HOME CARE 1 ILLNESS WAS NOT SERIOUS . . . . . 2 OTHERS . . . 3 927 (SPECIFY) 326 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 925 From whom did you/ mother seek care ? DOCTOR . . . . . . . . . . . . . . . . . . . . A HAKIM . . . . . . . . . . . . . . . . . . . . . . . . . B HOMEOPATH . . . . . . . . . . . . . . . . . . C PHARMACY . . . . . . . . . . . . . . . . . . D (CIRCLE ALL MENTIONED) GOVERNMENT HOSPITAL . . . . . . . . E PRIVATE HOSPITAL . . . . . . . . . . . . F NGO CLINIC . . . . . . . . . . . . . . . . . . . . G OTHERS . . . X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . . Z 927 926 What did the care provider do ? GAVE MEDICINE . . . . . . . . . . . . . . . . A REFERRED TO ANOTHER HOSPITAL B ADMITTED IN HOSPITAL . . . . . . . . . . C (CIRCLE ALL MENTIONED) OTHERS . . . X (SPECIFY) LAST DAY OF ILLNESS 927 How was (NAME) baby/ child on last day of illness ? WITH SAME CONDITION . . . . . . . . . . 1 WORSENED . . . . . . . . . . . . . . . . . . 2 IMPROVED . . . . . . . . . . . . . . . . . . . . 3 WAS HOSPITALIZED . . . . . . . . . . . . 4 OTHERS 6 (SPECIFY) HAD DIED DURING THIS PERIOD . . . . . . . . . . . . . . . . 5 933 928 What did you/mother/family do ? NOTHING . . . . . . . . . . . . . . . . . . . . 1 HOME CARE . . . . . . . . . . . . . . . . . . 2 930 SOUGHT CARE OUTSIDE . . . . . . . . 3 931 929 Why did you do nothing ? DISEASE WAS TOO SERIOUS BUT NO USE OF SEEKING CARE . 1 DISEASE WAS NOT TOO SERIOUS TOO SEEK CARE . . . 2 HAD NO MONEY TO SEEK CARE . 3 TRANSPORT WAS NOT AVAILABLE . . . . . . . . . . . . . . . . . . 4 HAD NO PERMISSION TO GO 933 OUT ON MY OWN . . . . . . . . . . . . . . 5 MALE MEMBER/ HUSBAND WAS NOT AVAILABLE AT HOME TO ACCOMPANY ME TO HOSPITAL . . . . . . . . . . . . . . . . . . . . 6 OTHER 7 (SPECIFY) 930 Why did you/ mother seek home care ? FAMILY ADVISED FOR HOME CARE 1 ILLNESS WAS NOT SERIOUS . . . . . 2 OTHERS 3 933 (SPECIFY) 327Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 931 From whom did you seek care ? DOCTOR . . . . . . . . . . . . . . . . . . . . A HAKIM . . . . . . . . . . . . . . . . . . . . . . . . . B HOMEOPATH . . . . . . . . . . . . . . . . . . C PHARMACY . . . . . . . . . . . . . . . . . . D GOVERNMENT HOSPITAL . . . . . . . . E PRIVATE HOSPITAL . . . . . . . . . . . . F (CIRCLE ALL MENTIONED) NGO CLINIC . . . . . . . . . . . . . . . . . . . . G OTHERS . . . X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . . Z 933 932 What did care provider do ? GAVE MEDICINE . . . . . . . . . . . . . . . . A REFERRED TO ANOTHER HOSPITAL B ADMITTED IN HOSPITAL . . . . . . . . . . C (CIRCLE ALL MENTIONED) OTHERS X (SPECIFY) DECISION MAKING MECHANISM AND HELP SEEKING 933 When did you/ mother tell your spouse about the illness AT THE START OF THE ILLNESS . 1 of baby ? DURING THE ILLNESS . . . . . . . . . . . . 2 TOWARDS THE END OF THE ILLNESS(WHEN IT BECAME SEVERE) . . . . . . . . . . . . . . . . . . . . 3 OTHER . . . 6 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 935 934 What was the reaction of your spouse ? 935 Who mainly takes the care seeking (& other) HUSBAND . . . . . . . . . . . . . . . . . . . . 1 decisions in the household ? MOTHER/MOTHER IN LAW . . . . . 2 FATHER/FATHER IN LAW . . . . . . . . 3 GRANDMOTHER . . . . . . . . . . . . . . . . 4 GRANDFATHER . . . . . . . . . . . . . . . . 5 UNCLE . . . . . . . . . . . . . . . . . . . . . . . . . 6 OTHER . 7 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 937 936 Why does he/ she take the decisions ? 937 Who took the child for seeking care ? MOTHER . . . . . . . . . . . . . . . . . . . . A FATHER . . . . . . . . . . . . . . . . . . . . B GRANDMOTHER . . . . . . . . . . . . . . . . C GRANDFATHER . . . . . . . . . . . . . . . . D UNCLE . . . . . . . . . . . . . . . . . . . . . . . . . E OTHER . X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . Z 939 938 Why did the above mentioned person go ? 328 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 939 Who decided the care should be sought outside home ? MOTHER . . . . . . . . . . . . . . . . . . . . 1 FATHER . . . . . . . . . . . . . . . . . . . . 2 GRANDMOTHER . . . . . . . . . . . . . . . . 3 GRANDFATHER . . . . . . . . . . . . . . . . 4 UNCLE . . . . . . . . . . . . . . . . . . . . . . . . . 5 OTHER . 6 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 940 In your opinion, what was the illness; MILD/ DID NOT REQUIRE IMMEDIATE ATTENTION/ TREATABLE WITH HOME REMEDIES . . . . . . . . . . . . 1 MODERATE/ ILLNESS PERSISTING YET TREATABLE/ NOT SEVERE (PLEASE READ THE RESPONSES) ENOUGH TO CAUSE DEATH . . . 2 SEVERE/ DEATH WAS POSSIBLE . . . . . . . . . . . . . . . . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 SOURCES OF CARE 941 Where did you usually go to receive health care ? HAKIM/ MATAB . . . . . . . . . . . . . . . . 1 HOMEOPATH CLINIC/ HOSPITAL . . 2 PHARMACY . . . . . . . . . . . . . . . . . . 3 GOVERNMENT HOSPITAL . . . . . . . . 4 PRIVATE HOSPITAL . . . . . . . . . . . . 5 NGO CLINIC . . . . . . . . . . . . . . . . . . . . 6 OTHERS . . . 7 (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . 8 942 How far is the nearest health facility from your house ? KILOMETER: . . . . . . . . . . . . DON’T KNOW . . . . . . . . . . . . . . . . . . 98 943 How do you commute to the nearest health facility ? TAXI . . . . . . . . . . . . . . . . . . . . . . . . . A BUS . . . . . . . . . . . . . . . . . . . . . . . . . B RICKSHAW . . . . . . . . . . . . . . . . . . . . C MOTORBIKE . . . . . . . . . . . . . . . . . . D WALKING . . . . . . . . . . . . . . . . . . . . E (CIRCLE ALL MENTIONED) OTHER X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . Z 944 How much is the transportation cost to reach the nearest health facility? RUPEES . . . . . . . 945 When did you or your household member last time visit a health care facility ? DAYS . . . . . . . . . . . . . . 1 MONTHS. . . . . . . . . . . . . . 2 YEARS . . . . . . . . . . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 998 IF < 1 MONTH WRITE DAYS IF < 1 YEAR, WRITE MONTHS IF > = 1 YEAR WRITE YEARS 329Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 946 CHECK 916, 922, 928: HEALTH CARE OTHERS H101 SOUGHT OUTSIDE SATISFACTION WITH THE HEALTH SYSTEM 947 How easy was it to see a health care provider VERY EASY/ DID NOT HAVE TO regarding your child ? WAIT AT ALL/ RECEIVED IMMEDIATE HELP. . . . . . . . . . . . . . . . 1 SOMEWHAT EASY/ HAD TO WAIT A SHORT WHILE . . . . . . . . 2 DIFFICULT/ HAD TO WAIT A LONG WHILE . . . . . . . . . . . . . . . . . . 3 EXTREMELY DIFFICULT/ NOBODY WAS AVAILABLE . . . . . . . . . . . . . . 4 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 948 How was the conduct of the physician (who saw the UNHELPFUL/ DID NOT EXPLAIN child towards the baby) ? ILLNESS TO OR REASSURE CARETAKER . . . . . . . . . . . . . . . . 1 SOMEWHAT HELPFUL/ GAVE LITTLE INFORMATION . . . . . . . . . . 2 VERY HELPFUL/ EXPLAINED EVERYTHING VERY WELL . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 949 How was the conduct of the physician (who saw the UNHELPFUL/ DID NOT EXPLAIN child towards the caretaker of the baby) ? ILLNESS TO OR REASSURE CARETAKER . . . . . . . . . . . . . . . . . . 1 SOMEWHAT HELPFUL/ GAVE LITTLE INFORMATION . . . . . . . . . . . . 2 VERY HELPFUL/ EXPLAINED EVERYTHING VERY WELL . . . . . . . . 3 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 950 Were you easily able to purchase/ accquire the drugs YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 952 needed for the child ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 951 Why you were not able to purchase/ acquire the drugs ? EXPENSIVE . . . . . . . . . . . . . . . . . . . . A NOT EASILY AVAILABLE . . . . . . . . B TOO MANY WERE PRESCRIBED . . . C (CIRCLE ALL MENTIONED) OTHER X (SPECIFY) DON’T KNOW . . . . . . . . . . . . . . . . . . Z 952 Were you overall satisfied with the quality of care YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 provied at the health facility ? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON’T KNOW . . . . . . . . . . . . . . . . . . 8 H101 953 What are the reasons of your satisfaction ? 330 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP H101 What is the main source of drinking water for members of your PIPED WATER household? PIPED INTO DWELLING . . . . . . . . 11 PIPED TO YARD/PLOT . . . . . . . . 12 H103 PUBLIC TAP/STAND PIPE . . . 13 TUBE WELL OR BOREHOLE . . . . . 21 HAND PUMP . . . . . . . . . . . . . . . . 22 DUG WELL PROTECTED WELL . . . . . . . . . . 31 UNPROTECTED WELL . . . . . . . . 32 WATER FROM SPRING ` PROTECTED SPRING/KAREZ . . . 41 UNPROTECTED SPRING . 42 RAINWATER . . . . . . . . . . . . . . . . . . 51 TANKER TRUCK . . . . . . . . . . . . . . . . 61 CART WITH SMALL TANK . . . . . . . . 71 SURFACE WATER (RIVER/DAM/LAKE/ POND/STREAM/CANAL . . . . . . 81 BOTTLED WATER . 91 OTHER ______________________ 96 (SPECIFY) H102 How long does it take to go there, get water, and come back? MINUTES . . . . . . . . . . . . . . ON PREMISES . . . . . . . . . . . . . . . . 996 DON'T KNOW . . . . . . . . . . . . . . . . . . 998 H103 Do you treat your water in any way to make it safer to drink? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 H105 H104 What do you usually do to the water to make it safer to drink? BOIL . . . . . . . . . . . . . . . . . . . . . . . . . . . A ADD BLEACH/CHLORINE . . . . . . . . . . B STRAIN THROUGH A CLOTH . . . . . . . . C Anything else? USE WATER FILTER (CERAMIC/ SAND/COMPOSITE/ETC.) . . . . . . . . D SOLAR DISINFECTION . . . . . . . . . . . . E RECORD ALL MENTIONED. LET IT STAND AND SETTLE . . . . . . . . F OTHER ______________________ X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . Z H105 What kind of toilet facility do members of your household usually FLUSH OR POUR FLUSH TOILET use? FLUSH TO SEWER SYSTEM . . . 11 FLUSH TO SEPTIC TANK . . . . . 12 FLUSH TO SOMEWHERE ELSE . . . 13 FLUSH, DON'T KNOW WHERE . . . 14 PIT LATRINE VENTILATED IMPROVED PIT LATRINE (VIP) . . . . . . . . . . 21 PIT LATRINE WITH SLAB . . . . . 22 PIT LATRINE WITHOUT SLAB/ OPEN PIT . . . . . . . . . . . . . . . . 23 BUCKET TOILET . . . . . . . . . . . . . . . . 41 HANGING TOILET/HANGING LATRINE . . . . . . . . . . . . . . . . . . . . 51 NO FACILITY/BUSH/FIELD . . . . . . . . 61 H107 OTHER ______________________ 96 (SPECIFY) SECTION 10: HOUSEHOLD CHARACTERISTICS 331Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP H106 Do you share this toilet facility with other households? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 H107 Does your household have: YES NO Electricity? ELECTRICITY . . . . . . . . . . . . . . 1 2 Radio? RADIO . . . . . . . . . . . . . . . . . . . . 1 2 Television? TELEVISION . . . . . . . . . . . . . . 1 2 Refrigerator? REFRIGERATOR . . . . . . . . . . . . 1 2 Mobile telephone or land line telephone? ANY TELEPHONE . . . . . . . . . . 1 2 Room cooler, air conditioner? ROOM COOLER, AIR COND. . 1 2 Washing machine? WASHING MACHINE . . . . . . . . 1 2 Water pump? WATER PUMP . . . . . . . . . . . . 1 2 Bed? BED . . . . . . . . . . . . . . . . . . . . 1 2 Chairs? CHAIRS . . . . . . . . . . . . . . . . . . 1 2 Almirah / cabinet? ALMIRAH/CABINET . . . . . . . . 1 2 Clock? CLOCK . . . . . . . . . . . . . . . . . . 1 2 Sofa? SOFA . . . . . . . . . . . . . . . . . . . . 1 2 Sewing machine? SEWING MACHINE . . . . . . . . . . 1 2 Camera? CAMERA . . . . . . . . . . . . . . . . . . 1 2 Personal computer? PERSONAL COMPUTER . . . 1 2 H108 What type of fuel does your household mainly use for cooking? ELECTRICITY . . . . . . . . . . . . . . . . . . 01 CYLINDER GAS . . . . . . . . . . . . . . . . 02 NATURAL GAS . . . . . . . . . . . . . . . . 03 BIOGAS . . . . . . . . . . . . . . . . . . . . . . 04 KEROSENE . . . . . . . . . . . . . . . . . . . . 05 CHARCOAL . . . . . . . . . . . . . . . . . . . . 06 WOOD . . . . . . . . . . . . . . . . . . . . . . 07 STRAW/SHRUBS/GRASS . . . . . . . . 08 AGRICULTURAL CROP . . . . . . . . . . 09 ANIMAL DUNG . . . . . . . . . . . . . . . . 10 NO FOOD COOKED IN HOUSEHOLD 95 OTHER ______________________ 96 (SPECIFY) H109 MAIN MATERIAL OF THE FLOOR: NATURAL FLOOR EARTH / SAND / MUD . . . . . . . . . . 11 RECORD OBSERVATION FINISHED FLOOR CHIPS / TERRAZZO . . . . . . . . . . 31 CERAMIC TILES . . . . . . . . . . . . . . 32 MARBLE . . . . . . . . . . . . . . . . . . . . 33 CEMENT . . . . . . . . . . . . . . . . . . . . 34 CARPET . . . . . . . . . . . . . . . . . . . . 35 BRICKS . . . . . . . . . . . . . . . . . . . . 36 MATS . . . . . . . . . . . . . . . . . . . . 37 OTHER ______________________ 96 (SPECIFY) 332 | Appendix F NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP H110 MAIN MATERIAL OF THE ROOF: NATURAL ROOFING THATCH / BAMBOO / WOOD /MUD 12 RECORD OBSERVATION RUDIMENTARY ROOFING CARDBOARD / PLASTIC . . . . . . . . 21 FINISHED ROOFING IRON SHEETS / ASBESTOS . . . 31 T-IRON / WOOD / BRICK . . . . . 32 REINFORCED BRICK CEMENT/RCC 33 OTHER ______________________ 96 (SPECIFY) H111 MAIN MATERIAL OF THE WALLS: NATURAL WALLS MUD / STONES . . . . . . . . . . . . . . 11 BAMBOO / STICKS / MUD . . . . . 12 RECORD OBSERVATION RUDIMENTARY WALLS UNBAKED BRICKS / MUD . . . . . 21 PLYWOOD SHEETS . . . . . . . . . . 22 CARTON / PLASTIC . . . . . . . . . . 23 FINISHED WALLS STONE BLOCKS . . . . . . . . . . . . . . 31 BAKED BRICKS . . . . . . . . . . . . . . 32 CEMENT BLOCKS/ CEMENT . . . 33 TENT . . . . . . . . . . . . . . . . . . . . . . 34 OTHER ______________________ 96 (SPECIFY) H112 How many rooms in this household are used for sleeping? ROOMS . . . . . . . . . . . . . . . . . . H113 Is this house rented, rent-free, mortgaged, or or owned by RENTED . . . . . . . . . . . . . . . . . . . . . . . . 1 a member of the household? RENT-FREE . . . . . . . . . . . . . . . . . . . . . . 2 MORTGAGED . . . . . . . . . . . . . . . . . . . . 3 OWNED . . . . . . . . . . . . . . . . . . . . . . . . 4 OTHER . . . . . . . . . . . . . . . . . . . . . . . . 6 H114 Does any member of this household own: YES NO A watch? WATCH . . . . . . . . . . . . . . . . . . 1 2 A bicycle? BICYCLE . . . . . . . . . . . . . . . . . . 1 2 A motorcycle or motor scooter? MOTORCYCLE/SCOOTER . . . 1 2 An animal-drawn cart? ANIMAL-DRAWN CART . . . . . 1 2 A car or truck or Tractor? CAR/TRUCK . . . . . . . . . . . . . . 1 2 A boat with a motor? BOAT WITH MOTOR . . . . . . . . 1 2 H115 Does any member of this household own any land YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 that can be used for agriculture? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 H116 Does this household own any livestock, herds, other farm YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 animals, or poultry? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 H118 333Appendix F | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP H117 How many of the following animals does this household own? Buffalo BUFFALO . . . . . . . . . . . . . . . . Milk cows or bulls? COWS/BULLS . . . . . . . . . . . . . . Camels? CAMELS . . . . . . . . . . . . . . . . . . Donkeys, or mules or horses? DONKEYS/MULES/HORSES . Goats? GOATS . . . . . . . . . . . . . . . . . . Sheep? SHEEP . . . . . . . . . . . . . . . . . . Chickens? CHICKENS . . . . . . . . . . . . . . . . IF NONE, WRITE '00'. IF > 95, WRITE '95'. IF UNKNOWN, WRITE '98' H118 Does your household have any mosquito nets that can be used YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 while sleeping? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 H126 H119 How many mosquito nets does your household have? NUMBER OF NETS . . . . . . . . . . . . . . H126 Does your household do anything (else) to avoid YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 mosquitos? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 H128 H127 What do you do? COIL . . . . . . . . . . . . . . . . . . . . . . . . A MATS . . . . . . . . . . . . . . . . . . . . . . B CIRCLE ALL MENTIONED. SPRAY . . . . . . . . . . . . . . . . . . . . . . C ELECTRIC SPRAY REPELLANT . . . D INSECT REPELLANT . . . . . . . . . . . . E OTHER X (SPECIFY) H128 Do you have any medicines for treating malaria in your YES . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 house now? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DOES NOT KNOW . . . . . . . . . . . . . . 8 334 | Appendix F NATIONAL INSTITUTE OF POPULATION STUDIES PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY, 2006 DECEASED WOMAN'S IDENTIFICATION IDENTIFICATION PROVINCE (PUNJAB=1; SINDH=2; NWFP=3; BALOCHISTAN=4; FATA=5) . . . . . . . . . . . . . . . DISTRICT . . . . . . . . . . . . . . . TEHSIL CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME OF HOUSEHOLD HEAD NAME OF DECEASED WOMAN NAME OF DECEASED WOMAN'S HUSBAND/FATHER (CIRCLE ONE) DATE OF DECEASED WOMAN'S DEATH AFTER 1 JANUARY, 2003 INTERVIEWER VISITS F