Rwanda - Demographic and Health Survey - 2009

Publication date: 2009

Rwanda Interim Demographic and Health Survey 2007-08 R w anda Interim D em ographic and H ealth Survey 2007-08 REPUBLIQUE OF RWANDA Rwanda Interim Demographic and Health Survey 2007-08 Ministry of Health of Rwanda Kigali, Rwanda National Institute of Statistics of Rwanda Kigali, Rwanda ICF Macro Calverton, Maryland, USA April 2009 Investing in our future The Global Fund To Fight AIDS, Tuberculosis and Malaria The following people participated in data analysis and the preparation of this report: • Jean Philippe Gatarayiha (Director of RCB Unit/NISR) • Alphonse Rukundo ( In charge of Capacity Building RCB Unit/NISR) • Dr. Corine Karema (Director of Malaria Unit/TRACPlus) • Dr. Emilien Nkusi (In charge of HMIS/M&E/MoH) • Dr. Fidele Ngabo (MCH Task Force Coordinator/MoH) • Dr. Denise Ilibagiza (In Charge of IMCI/MoH) • Dr. Camille Munyangabe (In charge of Gender Based Violence and Adolescent Reproductive Health/MCH Task Force/MoH) • Dr. Ferdinand Bikorimana (In charge of Family Planning/MCH Task Force/MoH) • Dr. Solange Hakiba ( In charge of Maternal Health/MCH Task Force/MoH) • Dr. Mohamed Ayad (Regional Coordinator and Technical Director/ICF Macro) • Dr. Rathavuth Hong (In Charge of RIDHS and Country Manager/ICF Macro) This report presents the findings of the 2007-08Rwanda Interim Demographic and Health Survey (RIDHS), carried out from December 15, 2007 to April 29, 2008 by the National Institute of Statistics of Rwanda. Technical assistance was provided by ICF Macro as part of the Demographic and Health Surveys project (MEASURE DHS). Funding for the RIDHS was provided by the Government of Rwanda, USAID, the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNDP, European Commission, and DFID through the Basket Fund of the NISR. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID or other cooperating organizations. Additional information about the survey can be obtained from the National Institute of Statistics of Rwanda (NISR), P.O. Box 6139, Kigali, Rwanda; E-mail: info@statistics.gov.rw; Internet: www.statistics.gov.rw. Additional information about the MEASURE DHS project can be obtained from ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@macrointernational.com, Internet: http://www.measuredhs.com. Cover photo: cc Fanny Schertzer, licensed under Creative Commons Attribution-ShareAlike 2.5 <http://creativecommons.org/licenses/by-sa/2.5/>. Recommended citation: Ministry of Health (MOH) [Rwanda], National Institute of Statistics of Rwanda (NISR), and ICF Macro. 2009. Rwanda Interim Demographic and Health Survey 2007-08. Calverton, Maryland, U.S.A.: MOH, NISR, and ICF Macro. Contents | iii CONTENTS Page Tables and figures . vii Foreword.xi Acknowledgments . xiii Abbreviations. xv Summary of Findings . xvii Map of Rwanda . xx CHAPTER 1 COUNTRY PROFILE, OBJECTIVES, AND METHODOLOGY OF THE SURVEY 1.1 Country Profile .1 1.1.1 Geography .1 1.1.2 Economy .2 1.1.3 Population.3 1.1.4 Population Policy.3 1.1.5 Public Health Policy .4 1.2 Objectives and Methodology of the Survey.5 1.2.1 Sample Design.5 1.2.2 Questionnaires .6 1.2.3 Hemoglobin and Malaria Diagnostic Testing .7 1.2.4 Hemoglobin Test .7 1.2.5 Malaria Diagnostic Test.7 1.2.6 Training and Data Collection .8 1.2.7 Data Processing .8 CHAPTER 2 HOUSEHOLD CHARACTERISTICS 2.1 Household Population by Age and Sex .9 2.2 Household Size and Composition.10 2.2.1 Sex of the Head of Household.10 2.2.2 Household Size .11 2.3 Housing Characteristics.11 2.4 Ownership of Durable Goods .13 2.5 Wealth Quintiles .14 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Background Characteristics of Respondents .17 3.2 Educational Attainment.19 3.3 Marital Status.21 3.4 Polygyny.22 iv | Contents CHAPTER 4 FERTILITY 4.1 Fertility Levels and Differentials .23 4.2 Fertility Trends.26 4.3 Parity and Primary Infertility.28 4.4 Birth Intervals .30 4.5 Age at First Birth .32 4.6 Teenage Fertility .33 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraception .36 5.2 Knowledge of Contraceptive Methods by Background Characteristics .37 5.3 Use of Contraception.39 5.3.1 Ever Use of Contraception.39 5.3.2 Current Use of Contraception.41 5.4 Future Use of Contraception.46 5.5 Reasons for Not Using Contraception .46 5.6 Preferred Future Contraceptive Methods .47 CHAPTER 6 FERTILITY PREFERENCES 6.1 Desire to Have More Children .49 6.2 Ideal Number of Children .52 6.3 Fertility Planning Status .53 CHAPTER 7 MATERNAL AND CHILD HEALTH 7.1 Antenatal Care .55 7.1.1 Components of ANC.57 7.1.2 Tetanus Vaccinations .60 7.2 Delivery Care .61 7.2.1 Place of Delivery.61 7.2.2 Assistance during Delivery.63 7.3 Vaccination of Children.65 7.3.1 Vaccination Coverage by Type of Vaccine (Children Age 12-23 Months) .66 7.4 Childhood Illnesses .68 7.4.1 Acute Respiratory Infections.68 7.4.2 Fever .70 7.4.3 Diarrhea .72 7.5 Initial Breastfeeding.75 7.6 Micronutrient Intake .77 CHAPTER 8 MALARIA AND ANEMIA 8.1 Malaria Prevention.81 8.1.1 Household Possession of Mosquito Nets .81 8.1.2 Use of Mosquito Nets by Children .84 Contents | v 8.1.3 Use of Mosquito Nets by Women .85 8.1.4 Intermittent Preventive Treatment during Pregnancy.87 8.2 Treatment of Fever in Children under the Age of Five .88 8.3 Malaria Diagnostic Testing.90 8.4 Prevalence of Anemia .91 8.4.1 Prevalence of Anemia in Children.92 8.4.2 Prevalence of Anemia in Women.93 CHAPTER 9 INFANT AND CHILD MORTALITY 9.1 Definition, Methodology and Data Quality.95 9.2 Levels and Trends .96 9,3 Differentials In Infant and Child Mortality.98 9.4 High-Risk Fertility Behavior . 101 CHAPTER 10 CIRCUMCISION 10.1 Practice of Male Circumcision . 105 10.2 Reasons for Male Circumcision. 108 REFERENCES .111 APPENDIX A SAMPLING DESIGN A.1 Introduction . 113 A.2 Survey Result . 113 A.3 Sample design of the 2005 Rwanda Demographic and Health Survey . 116 A.3.1 Introduction. 116 A.3.2 Sampling Frame . 116 A.3.3 Sample Selection . 117 A.3.4 Sampling Probability . 117 APPENDIX B ESTIMATES OF SAMPLING ERRORS.119 APPENDIX C DATA QUALITY TABLES . 131 APPENDIX D SURVEY PERSONNEL .137 APPENDIX E QUESTIONNAIRES. 141 Tables and Figures | vii TABLES AND FIGURES Page CHAPTER 1 COUNTRY PROFILE, OBJECTIVES, AND METHODOLOGY OF THE SURVEY Table 1.1 Results of the household and individual interviews. 6 CHAPTER 2 HOUSEHOLD CHARACTERISTICS Table 2.1 Household population by age, sex, and residence.10 Table 2.2 Household composition.11 Table 2.3 Household characteristics .12 Table 2.4 Household durable goods .14 Table 2.5.1 Wealth quintiles: Households .15 Table 2.5.2 Wealth quintiles: Population.15 Table 2.6 Health insurance.16 Figure 2.1 Population Pyramid .10 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Distribution by age of the respondents .17 Table 3.2 Background characteristics of respondents .18 Table 3.3.1 Educational attainment: Women.19 Table 3.3.2 Educational attainment: Men .20 Table 3.4 Current marital status .21 Table 3.5 Number of men's wives.22 CHAPTER 4 FERTILITY Table 4.1 Current fertility .25 Table 4.2 Fertility by background characteristics .25 Table 4.3 Trends in age-specific fertility rates by four sources .27 Table 4.4 Trends in age-specific fertility rates.28 Table 4.5 Children ever born and living.29 Table 4.6 Birth intervals.31 Table 4.7 Age at first birth .32 Table 4.8 Median age at first birth .33 Table 4.9 Teenage pregnancy and motherhood.34 Figure 4.1 Age-Specific Fertility Rates, by Residence.24 viii | Tables and Figures Figure 4.2 Total Fertility Rate and Mean Number of Children Ever Born to Women Age 40-49.26 Figure 4.3 Trends in Age-Specific Fertility Rates, Rwanda 1992, 2000, 2005, and 2007-08.27 Figure 4.4 Age-Specific Fertility Rates for Five-Year Periods Preceding the Survey .28 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods .37 Table 5.2 Knowledge of contraceptive methods by background characteristics .38 Table 5.3.1 Ever use of contraception: Women .40 Table 5.3.2 Ever use of contraception: Men .41 Table 5.4 Current use of contraception by age .42 Table 5.5 Current use of contraception by background characteristics .45 Table 5.6 Future use of contraception .46 Table 5.7 Reason for not intending to use contraception in the future .46 Table 5.8 Preferred method of contraception for future use.47 Figure 5.1 Contraceptive Use among Currently Married Women Age 15-49.43 Figure 5.2 Trends in Use of Modern Methods among Currently Married Women .44 CHAPTER 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children .50 Table 6.2. Desire to limit childbearing .51 Table 6.3 Ideal number of children .52 Table 6.4 Mean ideal number of children.53 Table 6.5 Fertility planning status.54 Table 6.6 Wanted fertility rates.54 Figure 6.1 Proportion of Currently Married Women Who Want No More Children, by Number of Living Children.50 CHAPTER 7 MATERNAL AND CHILD HEALTH Table 7.1 Antenatal care.56 Table 7.2 Number of antenatal care visits and timing of first visit .57 Table 7.3 Components of antenatal care .58 Table 7.4 Micronutrient intake among mothers .59 Table 7.5 Tetanus toxoid injections .61 Table 7.6 Place of delivery .62 Table 7.7 Assistance during delivery .63 Table 7.8 Vaccinations by source of information.65 Table 7.9 Vaccinations by background characteristics .67 Table 7.10 Vaccinations in first year of life.68 Table 7.11 Prevalence and treatment of symptoms of ARI .69 Table 7.12 Prevalence and treatment of fever.71 Tables and Figures | ix Table 7.13 Prevalence of diarrhea .73 Table 7.14 Diarrhea treatment .74 Table 7.15 Feeding practices during diarrhea .75 Table 7.16 Initial breastfeeding.76 Table 7.17 Micronutrient intake among children .78 Figure 7.1 Trends in Antenatal Care and Delivery, Rwanda 1992, 2000, 2005, and 2007-08.64 CHAPTER 8 MALARIA AND ANEMIA Table 8.1 Ownership of mosquito nets .82 Table 8.2 Sources of mosquito nets .83 Table 8.3 Use of mosquito nets by children.84 Table 8.4 Use of mosquito nets by women and pregnant women.86 Table 8.5 Prophylactic use of SP/Fansidar and use of Intermittent Preventive Treatment (IPT) by women during pregnancy.88 Table 8.6 Prevalence and prompt treatment of fever .89 Table 8.7 Malaria prevalence among women and children.91 Table 8.8 Prevalence of anemia in children .93 Table 8.9 Prevalence of anemia in women .94 Figure 8.1 Household Ownership of Long-Lasting Insecticidal Nets (LLINs) by Province, According to 2005 RDHS and 2007-08 RIDHS.83 Figure 8.2 Use of LLINs by Children Under Age Five by Province, According to 2005 RDHS and 2007-08 RIDHS .85 Figure 8.3 Use of LLINs by Pregnant Women by Province, According to 2005 RDHS and 2007-08 RIDHS .87 CHAPTER 9 INFANT AND CHILD MORTALITY Table 9.1 Early childhood mortality rates .96 Table 9.2 Early childhood mortality rates by socioeconomic characteristics.98 Table 9.3 Early childhood mortality rates by demographic characteristics. 100 Table 9.4 High-risk fertility behavior . 102 Figure 9.1 Trends in Infant and Under-five Mortality, Rwanda 1992, 2000, 2005, and 2007-08 .97 Figure 9.2 Trends in Infant and Under-five Mortality from 1992 RDHS-I, 2000 RDHS-II, 2005 RDHS-III, and 2007-08 RIDHS .98 Figure 9.3 Infant Mortality by Mother's Background Characteristics.99 Figure 9.4 Infant Mortality by Mother's Reproductive Behavior . 101 CHAPTER 10 CIRCUMCISION Table 10.1 Practice of circumcision . 106 Table 10.2 Age at the time of circumcision . 108 x | Tables and Figures Table 10.3 Reason for circumcision . 109 Figure 10.1 Proportion of Circumcised Men by Age and by Wealth Quintile . 106 Figure 10.2 Practice of Circumcision . 107 APPENDIX A SAMPLING DESIGN Table A.1 Distribution of clusters and households by province and according to residence) . 113 Table A.2 Survey results . 114 Table A.3 Results of the interviews. 115 Table A.4 Distribution of households and enumeration areas (EAs) by old province and according to residence (RGPH, 2002) . 116 Table A.5 Sample allocation by old province and according to residence. 117 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 121 Table B.2 Sampling errors for national sample . 122 Table B.3 Sampling errors for urban sample. 123 Table B.4 Sampling errors for rural sample. 124 Table B.5 Sampling errors for Kigali City sample . 125 Table B.6 Sampling errors for South Province sample. 126 Table B.7 Sampling errors for West Province sample. 127 Table B.8 Sampling errors for North Province sample . 128 Table B.9 Sampling errors for East Province sample . 129 APPENDIX C DATA QUALITY TABLES Table C.1 Age distribution of household population. 131 Table C.2.1 Age distribution of eligible and interviewed women . 132 Table C.2.2 Age distribution of eligible and interviewed men. 132 Table C.3 Completeness of reporting . 133 Table C.4 Births by calendar years . 133 Table C.5 Reporting of age at death in days . 134 Table C.6 Reporting of age at death in months. 135 Foreword | xi FOREWORD The Government of Rwanda has just completed the 2007-2008 Rwanda Interim Demographic and Health Survey (RIDHS) to obtain a database designed to provide reliable indicators to monitor and assess the implementation of the country’s sector programs and policies, the Poverty Reduction Strategy, Vision 2020 and the commitments it has undertaken at the international level, in particular the Millennium Development Goals. RIDHS follows the Demographic and Health Surveys (RDHS) that were successfully conducted in 1992, 2000, and 2005, and is part of a broad, worldwide program of socio-demographic and health surveys conducted in developing countries since the mid-1980s. RIDHS collected the indicators on fertility, family planning and maternal and child health which the survey normally provides. In addition, RIDHS integrated a malaria module and tests for the prevalence of malaria and anemia among women and children, thus determining the prevalence of malaria and anemia for women and children at the national level. Using this report, the reader will be able to delineate better the improvements in socio- demographic status that the Government of Rwanda has achieved including a decrease in infant mortality rate compared to that of 2005, an increase in prenatal care visits and utilization of delivery and post natal services, an increase in utilization of modern contraceptives and immunization coverage for children 12- 23 months. Although improvement has occurred, readers should also be alerted to the fact that the total fertility rate remains high, continuing to be a burden on social welfare and slowing down the progress of development. A majority of indicators have improved due to government investments as well as financial and technical support from partners. The results of RIDHS 2007-2008 are thus of considerable importance because they allow assessment of progress made in meeting the challenges mentioned above. These results also make it possible to readjust intermediate objectives, identify areas requiring priority attention, and even make projections for future socio-demographic development. These same results also represent a daunting challenge to entities providing development funding and call for integrated financing approaches involving multiple sectors of socio-economic life. Accordingly, the Government of Rwanda, in particular the Ministry of Health, is pleased to provide reliable results to policymakers, planners, and other users in both the public and private sectors, based on current conditions in the country. May this document be a source of valuable and useful information to all those individuals and organizations active in development who will use it to contribute to an improved quality of life for Rwanda’s population. Acknowledgments | xiii ACKNOWLEDGMENTS This report would not have been completed without the participation of a large number of individuals and organizations. We would like to express our profound thanks to them. First, we extend our thanks to the women and men who generously agreed to answer all the questions that were asked to them. The response rate was high for both men (95.4 percent) and women (97.5 percent). We would like to express our sincere thanks to the various ministries for facilitating the implementation of the survey. We offer our profound gratitude to the Ministry of Health for its cooperation during the preparation and completion of the survey. We also offer our sincere appreciation to the Ministry of Local Administration (MINALOC) as well as to all provincial and district authorities for their assistance and contribution to the smooth implementation of the survey. Certainly, without the ongoing support of these various authorities, the 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS) could not have been achieved. We also express our gratitude to the International Organizations for their indispensable financial assistance. Financial contributions from the United States Agency for International Development (USAID/Rwanda), the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFTAM), the Department for International Development of The United Kingdom (DfID), the United Nations Development Program (UNDP), and the European Commission (EC) through the Basket Fund were of immense significance to the effective accomplishment of the survey. We hereby express our profound gratitude to the team from Macro International, in particular Dr. Mohamed Ayad who formulated and coordinated the project, Dr. Rathavuth Hong who was responsible for technical coordination of the 2007-08 RIDHS, Mrs. Monique Barrère and Mrs. Carole Ayad, who analyzed and edited the report and the other Macro International officers who contributed to the success of the 2007-08 RIDHS for their much appreciated technical assistance. The high quality of the analyses presented in this report is evidence of their support. We deeply appreciate the specific technical support of the Programme National Intégré Contre le Paludisme (PNILP) (National Malaria Control Program) for their active participation throughout the conduct of the survey that demonstrated the effectiveness of the close collaboration between the country’s various institutions. The 2007-08 RIDHS could not have been accomplished without the unfailing participation of the staff of the National Institute of Statistics of Rwanda (NISR) who were continuously involved, in particular Mr. Jean Philippe GATARAYIHA, Technical Director of the 2007-08 RIDHS, and Mr. Alphonse RUKUNDO, Deputy Technical Director, who, in cooperation with supervisors and administrative support personnel, supplied pertinent technical supervision and contributed to the analysis of the results. We would like to express our sincere thanks to the staff of the Management Information System Unit of NISR for their work on data processing and editing, and the staff of the Ministry of Health, in particular Dr. Emilien NKUSI, and those of NISR, in particular Mr. Abdon Baudouin RUTERANA for their insightful review of the final version of the survey report. xiv | Acknowledgments We warmly congratulate the cartographers, team leaders, monitors, and the women and men who conducted the surveys, as well as the drivers who were able to overcome the challenges and fatigue inherent in this type of operation. We wish to reiterate our sincere thanks to all those, far and wide, who contributed to the completion of this Survey. Lastly, we offer our profound appreciation to the men and women who will use this document, as they have understood the ultimate aim of the production of this valuable report. Abbreviations | xv ABBREVIATIONS AD Age at death AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care AQ Amodiaquine ARI Acute Respiratory Infection ASFR Age-specific Fertility Rate BCG Bacillus of Calmette and Guérin (vaccine against tuberculosis) CBR Crude Birth Rate CDC Centers for Disease Control and Prevention CNLS Commission Nationale de Lutte contre le Sida CSPro Census and Survey Processing DFID Department for International Development DHS Demographic and Health Surveys DPT Diphtheria-Pertussis-Tetanus vaccine EA Enumeration area ENF Enquête Nationale sur la Fécondité (National Fertility Survey) EPI Expanded Program on Immunization ESD Enquête sociodémographique (Sociodemographic Survey) FP Family Planning FRW Rwandan Franc GAR Gross Attendance Ratio GDP Gross Domestic Product GFR General Fertility Rate GPI Gender Parity Index GTZ German Technical Cooperation HIV Human Immunodeficiency Virus IEC Information/Education/Communication INSR Institut National de la Statistique du Rwanda IPT Intermittent Preventive Treatment ITN Insecticide-Treated Net IUD Intra Uterine Device LAM Lactational Amenorrhea Method LNR National Reference Laboratory LLIN Long-Lasting Insecticidal Net MDG Millennium Development Goals xvi | Abbreviations NAR Net Attendance Ratio NCHS National Center for Health Statistics ORS Oral Rehydration Salts ORT Oral Rehydration Therapy PNILP Programme National Intégré de Lutte contre le Paludisme (National Malaria Control Program) PRSP Poverty Reduction Strategy Papers PSU Primary Sampling Units RBM Roll Back Malaria RDHS-I First Rwanda Demographic and Health Survey, 1992 RDHS-II Second Rwanda Demographic and Health Survey, 2000 RDHS-III Third Rwanda Demographic and Health Survey, 2005 RGPH Recensement Général de la Population et de l’Habitat (General Population and Housing Census), 2002 RHF Recommended Home Fluids RIDHS Rwanda Interim Demographic and Health Survey, 2007-08 SDM Standard Days Method SP Sulfadoxine-Pyrimethamine STI Sexually Transmitted Infection TFR Total Fertility Rate TRAC Treatment and Research AIDS Center TWFR Total Wanted Fertility Rate UNFPA United Nations Population Fund UNDP United Nations Development Programme UNICEF United Nations Children’s Fund USAID United States Agency for International Development USD United States Dollars VIP Ventilated Improved Pit Latrine WHO World Health Organization YSD Years since death Summary of Findings | xvii SUMMARY OF FINDINGS The 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS) carried out from De- cember 15, 2007 to April 20, 2008 is a follow-up to the three previous Demographic and Health Surveys undertaken in 1992, 2000, and 2005. A total of 7,377 households were successfully inter- viewed for this interim survey. In the households surveyed, 7,528 women age 15-49 were eligible for the individual interview and 7,313 were suc- cessfully interviewed. Thus, the response rate for women was 97 percent. The male survey was con- ducted in all of the households surveyed. A total of 7,168 men age 15-59 were eligible for the individ- ual interview. Of these men, 6,837 were success- fully interviewed, for a response rate of 95 percent for men. The population of Rwanda is young; 40 per- cent of women and 44 percent of men interviewed were age 15-24. Slightly more than one in three women and about one in two men have never been married. There continues to be a gap in education between women and men. The proportion with no formal education is higher among women (22 per- cent) than men (15 percent), and the proportion who have attained secondary or higher education is higher among men (16 percent) than women (12 percent). These differentials are also seen by ur- ban-rural residence: 24 percent of women in rural areas have no education, compared with 17 percent of men. In urban areas, 13 percent of women have no education, compared with 9 percent of men. Nevertheless, comparing the results of the 2007-08 RIDHS with those of the RDHS surveys carried out since 1992 indicates a net improvement in the educational status of the Rwandan population. Few Rwandan households have electricity (6 percent). In rural areas less than 2 percent of households have electricity, compared with 28 per- cent in urban areas. Thus, access to electricity re- mains largely unchanged from previous surveys. Results regarding drinking water show that only 41 percent of households have safe, potable drinking water. About three in five households (56 percent) have improved latrines; 3 percent have no toilet facilities. FERTILITY Analysis of the 2007-08 RIDHS data indicates that the fertility rate for Rwandan women remains high. The Total Fertility Rate (TFR) is 5.5 children per woman, 4.7 per woman in urban area and 5.7 per woman in rural area. However, when these re- sults are compared with those from previous RDHS surveys in Rwanda, there is a trend toward a decline in fertility. The mean number of children per woman decreased from 6.2 in 1992 to 5.8 in 2000, and finally to 5.5 in 2007-08. The survey results show that the mean number of children per woman drops as women’s level of education increases and household wealth in- creases. Among the provinces, the East and West provinces show higher fertility rates than other provinces. FAMILY PLANNING Contraceptive Prevalence. At the time of the survey, 36 percent of currently married women were using a contraceptive method and 27 percent were using modern methods, mainly injectables and the pill. The proportion of married women us- ing contraception has increased since 2000, with prevalence rising from 13 to 36 percent for all me- thods and from 4 to 27 percent for modern meth- ods. Results from the survey show that modern contraceptive prevalence increases with women’s level of education, varying from 19 percent among women with no education, to 29 percent among those with a primary education, and to 43 percent among women with secondary or higher education. In addition, contraceptive use increases as house- hold wealth increases. FERTILITY PREFERENCES Regarding fertility preferences, 48 percent of women reported that they did not wish to have any more children, while 44 percent wanted more. Among the latter group, the majority want to space the next birth by two or more years while 7 percent xviii | Summary of Findings want to have the next child in the near future (with- in two years). The average ideal family size for all women is 3.3 children, and for married women it is 3.6 chil- dren, both substantially less than the TFR of 5.5. MATERNAL AND CHILD HEALTH Antenatal Care. The vast majority of expec- tant mothers consulted a health professional during their most recent pregnancy (96 percent). How- ever, only 24 percent had at least four antenatal care (ANC) visits, as recommended by the World Health Organization and the Rwandan government. For 33 percent of women, the first ANC visit did not occur until the sixth or seventh month of preg- nancy, which is considered late. According to rec- ommendations, the first antenatal care visit should take place when a woman is less than 4 months pregnant. The median time of the first ANC visit is 5.4 months into the pregnancy; the median is lower in rural areas than in urban areas (5.0 and 5.4 months, respectively). The survey results indicate that during these ANC consultations women are rarely informed of the signs of complications that can occur during pregnancy (8 percent). Most often, women were weighed (98 percent) and their blood pressure was measured (87 percent). Seven of ten women (71 percent) had blood samples taken during their ANC consultations (for routine testing). However, only 18 percent of preg- nant women were given a urine test. Just over one in two women (54 percent) took antimalarial medi- cines, and 18 percent took medication for intestinal parasites. The percentage of women who received iron supplements was 41 percent. Delivery Care. About one in two Rwandan women gave birth at home (49 percent), and 12 percent gave birth with no professional assistance during delivery. However, 40 percent of women gave birth with the assistance of a nurse or mid- wife. Among the most educated women and those in the highest (richest) wealth quintile, this propor- tion reached 59 and 52 percent, respectively. Vaccination Coverage. The objective of Rwanda’s Expanded Program on Immunization (EPI)—to vaccinate all children within the first 12 months of life—has not yet been met. About 80 percent of children age 12-23 months had received all the recommended vaccinations. Among these children, only 74 percent received all vaccinations before the age of one year. Vaccination coverage is lowest among children of women with no educa- tion (77 percent). However, the results show an improvement in vaccination coverage for all chil- dren, with the proportion increasing from 76 per- cent in the 2000 RDHS to 80 percent in the 2007- 08 RIDHS. Childhood Illness. During the two weeks pre- ceding the survey, 15 percent of children under 5 years of age had an acute respiratory infection (ARI), 21 percent had a fever, and 14 percent had experienced diarrhea. Medical treatment or advice was sought for 28 percent of children with a cough accompanied by short, rapid breathing (ARI). More than a third of children with a fever were brought to a health fa- cility (35 percent). For those who had experienced diarrhea, one-third received medical treatment; 31 percent were treated with ORS or recommended home fluids (RHF); and nearly two in five children with diarrhea were treated with ORT or increased fluids (39 percent). However, 42 percent of chil- dren with diarrhea were given no treatment, and among children in the poorest households, the per- centage was 54 percent. NUTRITION Breastfeeding Practices. In Rwanda breast- feeding is nearly universal, with 98 percent of all children born in the five years preceding the survey having been breastfed. However, among those who were ever breastfed, only 68 percent began breast- feeding within one hour of birth, and 21 percent were given supplementary food (prelacteal feed) before their first breastfeeding. Micronutrient Supplements. Nearly three- quarters of children age 6 to 59 months had re- ceived vitamin A supplements in the six months preceding the survey. Almost seven in ten children received deworming medicines during the same Summary of Findings | xix period. Only 8 percent of children received iron supplements in the past seven days. Anemia. In Rwanda, slightly more than one in four women have anemia (27 percent): 15 percent have a mild form, 8 percent are moderately ane- mic, and 4 percent are severely anemic. The preva- lence of anemia is highest in the City of Kigali (40 percent). Nearly one in two children have anemia (48 percent); 21 percent have a mild form, 18 percent are moderately anemic, and 8 percent are severely anemic. As with women, the proportion of children who are anemic is highest in the City of Kigali (56 percent). MALARIA Possession of Mosquito Nets. In Rwanda, 59 percent of households own at least one mosquito net. Households in urban areas (69 percent), those in the City of Kigali (71 percent), and those in the highest (richest) wealth quintile (72 percent) have a higher proportion with at least one net than oth- ers households. Compared with the 2005 RDHS- III, the proportion of households with mosquito nets has increased substantially; in 2005 only 18 percent of households owned at least one mosquito net. The results of the 2007-08 RIDHS indicate that 57 percent of all households have at least one insecticide-treated mosquito net (ITN), and 56 per- cent of households own a long-lasting insecticidal net (LLIN). Use of Mosquito Nets. Three in five children (60 percent) under the age of five slept under a mosquito net the night preceding the survey. The proportion who slept under an LLIN is 56 percent. Results show that 49 percent of women age 15-49 slept under a mosquito net on the night pre- ceding the survey; the proportion is higher for pregnant women (65 percent). In addition, 55 per- cent of women were protected against malaria dur- ing their pregnancy by taking antimalarial drugs. Fifty-six percent of women with at least a secon- dary education slept under a mosquito net, com- pared with 49 percent of women with no educa- tion. The results show that 51 percent of women had received Intermittent Preventive Treatment (IPT); 17 percent of women were given at least two doses of IPT during antenatal visits. Fever and Early Treatment of Children. Among children under five who had a fever in the two weeks preceding the survey, only 6 percent were given antimalarial drugs and only a small proportion were treated the same day as the fever occurred (less than 1 percent). Malaria Diagnostic Testing. Among children age 6-59 months who were tested for malaria, only 2.6 percent tested positive for at least one form of malaria parasite. The proportion is highest in the East province (5.3 percent). Women (1.4 percent) are less likely to have malaria than children; rural women are more frequently infected than women in urban areas (1.5 and 1.1 percent, respectively). As with children, women in the East province are more often infected with malaria (2.9 percent) than those in other provinces or in the City of Kigali. INFANT AND CHILD MORTALITY Childhood mortality remains high in the nation as a whole. For the most recent period (0-4 years before the survey), results show that for every one thousand live births, 62 children die before reach- ing their first birthday (28 per thousand between birth and 1 month and 34 per thousand between 1 month and 12 months), while for every one thou- sand children who survive to age one, 43 do not reach their fifth birthday. Overall, the risk of dying between birth and the fifth birthday is 103 per thousand live births. However, childhood mortality has dropped since the genocide, and the decline has accelerated in recent years. CIRCUMCISION Only 12 percent of men age 15-59 in Rwanda have been circumcised. However, the survey re- sults show that the practice is occurring more fre- quently among younger age groups. The propor- tion of circumcised men has risen from 6 percent among men age 55-59 to 15 percent among those age 25-29. About seven in ten men (70 percent) said they were circumcised by a health profes- sional. Nearly two-thirds of men (64 percent) re- ported that the procedure was carried out for rea- sons of health and hygiene. xx | Map of Rwanda Country Profile, Objectives, and Methodology of the Survey | 1 COUNTRY PROFILE, OBJECTIVES, AND METHODOLOGY OF THE SURVEY 1 1.1 COUNTRY PROFILE 1.1.1 Geography The country of Rwanda is situated in central Africa immediately south of the equator between 1°4' and 2°51' south latitude and 28°63' and 30°54' east longitude. Its total area of 26,338 square kilometers is bordered by Uganda to the north, Tanzania to the east, the Democratic Republic of the Congo to the west, and Burundi to the south. Landlocked, Rwanda lies 1,200 kilometers from the Indian Ocean and 2,000 kilometers from the Atlantic Ocean. Rwanda forms part of the highlands of eastern and central Africa, with mountainous relief and an average elevation of 1,700 meters. However, there are three distinct geographical regions. Western and north-central Rwanda is made up of the mountains and foothills of the Congo-Nile Divide, the Virunga volcano range, and the northern highlands. This region is characterized by rugged mountains intercut by steep valleys, with elevations generally exceeding 2,000 meters. The Divide itself rises to 3,000 meters at its highest point but is dwarfed by the volcano range, whose highest peak, Kalisimbi, reaches 4,507 meters. The Congo-Nile Divide slopes westward to Lake Kivu, which lies 1,460 meters above sea level in the Rift Valley trough. In Rwanda’s center, mountainous terrain gives way to the rolling hills that give the country its nickname, “Land of a Thousand Hills.” Here the average elevation varies between 1,500 and 2,000 meters. This area is also referred to as the central plateau. Further east lies a vast region known as the “eastern plateaus,” where the hills level gradually into flat lowlands interspersed with a few hills and lake-filled valleys. The elevation of this region generally falls below 1,500 meters. Because of its elevation, Rwanda enjoys a temperate, sub-equatorial climate with average yearly temperatures of around 18.5°C. The average annual rainfall is 1,250 millimeters and occurs in two rainy seasons of differing lengths, alternating with one long and one short dry season. The climate varies somewhat from region to region, depending on the altitude, the volcano range and northern highlands being generally cooler and wetter, with average temperatures of 16°C, and average rainfall of above 1,300 millimeters. The maximum rainfall is 1,600 millimeters, above the Divide and the volcanic range. The hilly central region receives an average of between 1,000 and 1,300 millimeters of rain per year, while rainfall on the eastern plateau, whose climate is relatively warmer and drier, generally falls below 1,000 millimeters and can be as low as 800 millimeters. Although Rwanda enjoys more or less constant temperatures, the climate is known to vary from year to year, with extreme variations in rainfall sometimes resulting in flooding or, more often, drought. These extremes have a profound impact on agricultural production, which sometimes falls into recession. Rwanda has a dense network of rivers and streams, draining into the Congo River on the western slope of the Congo-Nile Divide, and into the Nile in the rest of the country via the Akagera River, which receives all the streams of this watershed. Water resources also include several lakes surrounded by wetlands. 2 | Country Profile, Objectives, and Methodology of the Survey Deforestation due primarily to land clearing for agricultural expansion has resulted in mostly anthropic vegetation with only a few small areas of natural forestland (representing 7 percent of the country) remaining on the Congo-Nile Divide and the slopes of the volcanic range. There are now four geographically-based provinces (North, South, East, and West) and the City of Kigali, these being further subdivided into 30 districts, 415 sectors, cells and, finally, villages (Imidugudu). This report is based on the new administrative divisions (four provinces and the City of Kigali). 1.1.2 Economy Although regular efforts have been made to develop the service sector and stimulate investment in the industrial sector, the Rwandan economy remains dominated by agriculture. According to the 2002 General Population and Housing Census (RGPH), more than 8 out of 10 people are employed in agriculture, including 81 percent of men and 93 percent of women (SNR, 2005). However, the agricultural sector is facing major problems: a production system dominated by small farming operations of less than one hectare, rudimentary techniques, and a low rate of investment. Agrarian reforms are being gradually introduced to address these problems, in particular through population resettlement and labor quality improvements focusing on specialized training mainly for women. Efforts are also underway to regionalize crops and fully expand the use of farm inputs (MAAR, 2004). Over the past two years the service sector has accounted for the largest share of Rwanda’s Gross Domestic Product (GDP), roughly 45 percent in 2007, followed by agriculture with 36 percent and industry with 14 percent at current prices. Nevertheless, agricultural production rose slightly by 1 percent in 2007 in relation to 2006. This rise is due to the increase in production of food crops (+2 percent), including legumes (+12 percent), and bananas (+2 percent) but reduced by the drop in grains (-1 percent) and tubers (-4 percent) from that in 2006. Among the export crops, coffee production dropped by 45 percent compared with 2006. In 2007, industry value added grew by 10 percent, while mining and quarries registered a significant increase of 38 percent over 2006. At the same time, services value added increased by 13 percent in 2007. Wholesale and retail trade, restaurants and hotels, transportation, storage and communications, finance and insurance, education, health and other personnel services were the main contributors to the increase in value added. The per capita GDP at constant 2001 prices was FRW 201,000 in 2007 compared with FRW 173,000 in 2006. The value added of final consumption expenditure increased by 6 percent in relation to 2006. Private consumption expenditure, increased by 7 percent while government consumption expenditure declined 1 percent in 2007 in relation to 2006. The Demographic and Health Survey showed that 86 percent of women were working in agriculture compared with 62 percent of men. In addition, 14 percent of men compared with 6 percent of women worked in unskilled labor. Results from the 2007-08 RIDHS showed that in urban areas, 59 percent of households are in the highest wealth quintile compared with only 12 percent of households in rural areas. By comparison, in urban areas only 9 percent of households are in the lowest (poorest) wealth quintile, compared with 18 percent in rural areas. Country Profile, Objectives, and Methodology of the Survey | 3 Finally, because of the failure of most development strategies based on structural adjustment programs focused on growth measured in terms of per capita GDP, the overwhelming majority of development partners are recognizing the need to incorporate social factors into development strategies. Therefore, new initiatives are geared toward pro-poor economic growth and poverty reduction to revive the economies of developing nations (MFEP, 2007). Rwanda has adopted this new orientation. 1.1.3 Population The population of Rwanda is estimated to be 9,309,619. Although Rwanda suffered a major loss of human life (more than one million people) in the 1994 genocide, the population remains essentially the same because more than one million former refugees who had been living for years in exile returned at the end of the war and genocide. Population density is high across the country; in 2007 density was estimated at 368 inhabitants per square kilometer. The population is essentially young, with 67 percent of all Rwandans under the age of 20. In terms of gender, the 2002 RGPH shows females to be in the majority (52 percent) while males make up 48 percent of the population (SNR, 2005). The illiteracy rate in Rwanda declined between 2000 and 2005. Between the two surveys the rate went from 34 percent to 29 percent among women and from 24 percent to 22 percent among men. By contrast 70 percent of women compared with 78 percent of men know how to read and write and are considered literate. The education level of Rwandans age 6 years and above is also low. According to the 2005 Demographic and Health Survey (2005 RDHS-III), 23 percent of women and 17 percent of men had no education while nearly 67 percent of women and 70 percent of men had at least a primary school education. About 11 percent of men and 9 percent of women had reached the secondary school level, while those with education beyond the secondary level made up about 1 percent of the population. Results by religious affiliation show that 96 percent of women and 95 percent of men identify themselves as Christian compared with 1.8 and 2 percent, respectively, who identify as Muslim. Nearly all Rwandans speak the same language, Kinyarwanda (spoken by over 99 percent of the population), which is the country’s first official language, followed by French and English. Kiswahili, the third relatively common foreign language, is generally spoken in urban areas and in the provinces bordering on countries where this language is widely spoken (Democratic Republic of the Congo, Tanzania). 1.1.4 Population Policy Out of concern for improving the country’s quality of life, the Rwandan government has developed various strategies over the years to ensure an acceptable balance between demographic growth and available resources, particularly since the 1980s. A family planning initiative developed in 1982 provided for training, improved access to family planning services and, in particular, the promotion of family planning through trained communicators known as Abakangurambaga (“Awakeners of the People”). A subsequent policy was adopted in 1990 aimed at curbing demographic growth and reducing fertility through family planning. To create an environment favorable to behavioral changes that result in lower fertility rates, other elements were included in the plan such as increased production, public health improvements, land use planning, training of communicators, the promotion of education and school attendance, and the employment and advancement of women (MOH, 2008). 4 | Country Profile, Objectives, and Methodology of the Survey Following the 1994 genocide, the government of Rwanda became aware of the links between population dynamics and socioeconomic development, specifically the necessity of taking into account demographic variables in plans and programs for social and economic development. Within this context the Government of Rwanda adopted a population policy in 2003 (SNR, 2005). The main goal of this policy is improvement in the quality of life of the population by emphasizing objectives such as slowing demographic growth, managing sustainability of natural resources, food safety, access to primary and secondary education for all children—with a focus on technical and vocational instruction and information technologies—good governance, equal opportunity, and participation in development by both men and women. 1.1.5 Public Health Policy To improve the health of the population the Ministry of Health has developed a community health policy to create health care services at the community level. All socio-demographic aspects of the population have been taken into account to guarantee equal access to health services and delivery of quality health services for all. By instituting this policy, the government is recommending the active participation of the population in the planning, execution, follow-up, and evaluation of programs and projects; it strongly encourages the community to share its recommendations and make its points of view known. In March 2005, the government of Rwanda adopted the health sector’s Policy (Ministry of Health 2005a) and its 2005-2009 strategic Plan (Ministry of Health 2005b), thus achieving its overall vision for a project guaranteeing access to health and wellbeing to the entire population, and in addition, increasing production and reducing poverty. The health sector is dedicated to improving and ensuring optimal health conditions for the population by putting both quality preventive services and curative care services within an effective health care system. In order to accomplish this mission, the Ministry of Health has targeted the following objectives/programs: • Guarantee the availability of human resources for health; • Guarantee the availability of medications, vaccines and other quality medical provisions; • Guarantee the accessibility to healthcare services by the population; • Provide care and services at a reasonable cost; • Improve the quality and control of services for preventive illness as well as the demand for such services; • Improve national hospitals and research institutes; • Reinforce the institutional capabilities of national programs and institutions. One of the major problems confronting the health care system in Rwanda is solving two financial challenges within a context of poverty: improving financial access and equal access to the health care system plus mobilization of internal resources to increase financial viability of the health care services. The Rwandan government has instituted a system of mutual health insurance to respond to three specific objectives: 1) improve financial access to health care, 2) improve the financial situation of health establishments, and 3) improve the overall health of the population. A system of mutual insurance should facilitate the use of health care services by the population. The Government of Rwanda has specifically emphasized the priority components of reproductive health: lower risk maternity and child health, family planning, sexually transmitted infections (STIs), Country Profile, Objectives, and Methodology of the Survey | 5 HIV/AIDS, adolescent health and reproduction, prevention and control of sexual violence, and social changes for increasing the decisionmaking power of women. Government budget allocations for health care have increased substantially—by 304 percent between 2002 and 2007. In 2007, the government allocated 8.8 percent of its budget to health care in the Health Public Expenditure Review 2006-2007 (MOH, 2009). 1.2 OBJECTIVES AND METHODOLOGY OF THE SURVEY The 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS) is the first of its kind, following three surveys conducted in 1992, 2000 and 2005. The RIDHS is part of the international Demographic and Health Surveys program. Sponsored by the Ministry of Health with collaboration with the Ministry of Finance and Economic Planning, it was carried out by the National Institute of Statistics of Rwanda with the technical assistance of ICF Macro. Financial support for the survey was provided by the Government of Rwanda through the Ministry of Health and Global Fund to Fight AIDS, Tuberculosis, and Malaria, the United States Agency for International Development (USAID/Rwanda), and the Basket Funds of NISR (DFID, EC, and UNDP). The survey covered a representative sample of women between the ages of 15 and 49 and men between the ages of 15 and 59. The main objectives of the RIDHS were: • At the national level, gather data to determine demographic rates, particularly fertility and infant and child mortality rates, and analyze the direct and indirect factors that determine fertility and child mortality rates and trends. • Evaluate the level of knowledge and use of contraceptives among women and men. • Gather data concerning family health: vaccinations; prevalence and treatment of diarrhea, acute respiratory infections (ARI), and fever in children under the age of five; antenatal care visits; and assistance during childbirth. • Gather data concerning the prevention and treatment of malaria, particularly the possession and use of mosquito nets, and the prevention of malaria in pregnant women. • Gather data concerning child feeding practices, including breastfeeding. • Gather data concerning circumcision among men between the ages of 15 and 59. • Collect blood samples in all of the households surveyed for anemia testing of women age 15- 49, pregnant women and children under age five. • Collect blood samples in all of the households surveyed for hemoglobin and malaria diagnostic testing of women age 15 to 49, pregnant women and children under age five. 1.2.1 Sample Design The sample for the RIDHS is a two-stage stratified area sample. Clusters are the primary sampling units and are constituted from enumeration areas (EA). The EA were defined in the 2002 General Population and Housing Census (RGPH) (SNR, 2005). These enumeration areas provided the master frame for the drawing of 250 clusters (187 rural and 63 urban), selected with a representative probability proportional to their size. Only 249 of these clusters were surveyed, because one cluster located in a refugee camp had to be eliminated from the sample. A strictly proportional sample allocation would have resulted in a very low number of urban households in 6 | Country Profile, Objectives, and Methodology of the Survey certain provinces. It was therefore necessary to slightly over-sample urban areas in order to survey a sufficient number of households to produce reliable estimates for urban areas. The second stage involved selecting a sample of households in these enumeration areas. In order to adequately guarantee the accuracy of the indicators, the total number drawn was limited to 30 households per cluster. Because of the nonproportional distribution of the sample among the different strata and the fact that the number of households was set for each cluster, weighting was used to ensure the validity of the sample at both national and provincial levels. All women age 15-49 years who were either usual residents of the selected household or visitors present in the household on the night before the survey were eligible to be interviewed (7,528 women). In addition, a sample of men age 15-59 who were either usual residents of the selected household or visitors present in the household on the night before the survey were eligible for the survey (7,168 men). Finally, all women age 15-49 and all children under the age of five were eligible for the anemia and malaria diagnostic tests. The sample for the 2007-08 RIDHS covered the population residing in ordinary households across the country. A national sam- ple of 7,469 households (1,863 in urban areas and 5,606 in rural areas) was selected. The sample was first stratified to provide adequate representation from urban and rural areas as well as all the four provinces and the city of Kigali, the nation’s capital, 1.2.2 Questionnaires Three questionnaires were used in the 2007-08 RIDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. The content of these questionnaires was based on model questionnaires developed by the MEASURE DHS project. Initial technical meetings that were held beginning in September 2007 allowed a wide range of government agencies as well as local and international organizations to contribute to the development of the questionnaires. Based on these discussions, the DHS model questionnaires were modified to reflect the needs of users and relevant issues in population, family planning, anemia, malaria and other health concerns in Rwanda. The questionnaires were then translated from French into Kinyarwanda. These questionnaires were finalized in December 2007 before the training of male and female interviewers. The Household Questionnaire was used to list all of the usual members and visitors in the selected households. In addition, some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit such as the main source of drinking water, type of toilet facilities, materials used for the floor of the house, the main energy source used for cooking and ownership of various durable goods. Finally, the Household Questionnaire was also used to identify women and children eligible for the hemoglobin (anemia) and malaria diagnostic tests. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Rwanda 2007-08 Residence Result Urban Rural Total Household interviews Households selected 1,863 5,606 7,469 Households occupied 1,839 5,576 7,415 Households interviewed 1,821 5,556 7,377 Household response rate 99.0 99.6 99.5 Interviews with women age 15-49 Number of eligible women 2,046 5,482 7,528 Number of eligible women interviewed 1,974 5,339 7,313 Eligible women response rate 96.5 97.4 97.1 Interviews with men age 15-59 Number of eligible men 2,056 5,112 7,168 Number of eligible men interviewed 1,946 4,891 6,837 Eligible men response rate 94.6 95.7 95.4 Country Profile, Objectives, and Methodology of the Survey | 7 The Women’s Questionnaire was used to collect information on women of reproductive age (15- 49 years) and covered questions on the following topics: • Background characteristics • Marital status • Birth history • Knowledge and use of family planning methods • Fertility preferences • Antenatal and delivery care • Breastfeeding practices • Vaccinations and childhood illnesses The Men’s Questionnaire was administered to all men age 15-59 years living in the selected households. The Men’s Questionnaire collected information similar to that of the Women’s Questionnaire, with the only difference being that it did not include birth history or questions on maternal and child health or nutrition. In addition, the Men’s Questionnaire also collected information on circumcision. Data collection for the 2007-08 RIDHS, including the blood sample collection for the anemia and malaria diagnostic tests, took place from December 15, 2007 to April 20, 2008. 1.2.3 Hemoglobin and Malaria Diagnostic Testing All eligible women age 15-49 years and children under the age of five were eligible for the anemia and malaria tests. The anemia and malaria test protocols were approved by the ICF Macro Institutional Review Board in Calverton, Maryland USA and the National Ethics Committee of Rwanda. 1.2.4 Hemoglobin Test Checking hemoglobin levels is the primary way of diagnosing anemia. This test is performed with the HemoCue system. An informed consent form is read to the eligible person or parent/responsible adult of the child or teenager between the ages of 15 and 17. This consent form asks, first of all, for the authorization of the person before undertaking the test and then explains the objectives of the test, informs the individual taking the test or those responsible for children that the results will be communicated immediately after the test. Before collecting the blood, the finger is cleaned with a swab dipped in alcohol and allowed to air dry. Then the tip of the finger (or heel, for children under 6 months, or those under one year who are small since the skin in this location is particularly thin) is pricked with a sterile, single-use retractable blood lancet. One drop of blood is collected in a microcuvette and then introduced into the HemoCue photometer, which indicates the level of hemoglobin. These results are then recorded on the Household Questionnaire and communicated to the person tested, or to the parent/responsible adult, with an explanation of their meaning. For each person whose test result indicates severe anemia (hemoglobin below 7 g/dl, or 9 g/dl for pregnant women), a referral is given for receiving care at local health centers. 1.2.5 Malaria Diagnostic Test A malaria diagnostic test was included in the 2007-08 RIDHS. The test was given to the same group of women and children who were tested for anemia. The informed consent was presented separately for the malaria test and was obtained in the same way for the different age groups as for the anemia test. For each person interviewed, a slide with a thick blood smear was prepared, transmitted, and stored at the PNILP laboratory for microscopic examination of malaria parasites. 8 | Country Profile, Objectives, and Methodology of the Survey For the rapid diagnostic test for malaria, a drop of blood was obtained from the same prick used for the anemia test. Using a small tube pipette (provided in the test kit) 10 µL of blood were drawn and placed in the test well containing antibody. The blood and antibody were mixed with the paddle at the top of the pipette. The strip slide was then placed in the slots positioned on either side of the well, which holds it vertically and allows the end to dip into the solution in the well. After 10 minutes, the slide was transferred to the wash well for a further 10 minutes to make the strip clearly visible, following which the result could be assessed. A cap was provided to seal the used well, which was then snapped off the cassette and discarded. The exposed strip was slipped into the base of the cassette, rendering it both safe to handle and preserved as a permanent record. The results of the malaria test were recorded in the Household Questionnaire, which allows them to be linked with the characteristics of the respondents. The National Institute of Statistics of Rwanda, in collaboration with the National Malaria Control Program (PNILP) and other concerned services from the Ministry of Health, prepared an information brochure on malaria and provided treatment to respondents whose test results were positive. These brochures were distributed to participants, whether or not they agreed to undergo the malaria diagnostic test. 1.2.6 Training and Data Collection Staff responsible for the survey at the National Institute of Statistics, in collaboration with the technical team, recruited 70 people to participate in data collection. Training included two phases, theoretical and practical. Three weeks of training were provided, from November 20 to December 11, 2007, including three days of field practicum in urban and rural areas not selected for the survey. After the training, the field staff were divided into 13 teams, each with a team leader, a supervisor, and three interviewers. A laboratory technician from the National Malaria Control Program was included on each team for the anemia and malaria diagnostic tests. The laboratory technicians were medically qualified to take blood samples and conduct the anemia and malaria test under the supervision of the PNILP technical team with assistance from ICF Macro. Data collection began on December 15, 2007 in the area of the city of Kigali. This location made it possible to closely monitor the teams before they were dispatched to more distant areas. After two weeks, all teams except one that was needed remaining to complete the work in Kigali were deployed to their respective work zones. Data collection was completed on April 20, 2008. 1.2.7 Data Processing Data entry began on January 7, 2008, three weeks after the beginning of data collection activities in the field. Data were entered by a team of five data processing personnel recruited and trained by staff from ICF Macro. The data entry team was reinforced during this work with an additional staffer. Completed questionnaires were periodically brought in from the field to the National Institute of Statistics in Kigali, where assigned staff checked them and coded the open-ended questions. Next, the questionnaires were sent to the data entry staff. Data were entered using CSPro, a program developed jointly by the United States Census Bureau, the ICF Macro MEASURE DHS program, and Serpro S.A. All questionnaires were entered twice to eliminate as many data entry errors as possible from the files. In addition, a quality control program was used to detect data collection errors for each team. This information was shared with field teams during supervisory visits to improve data quality. The data entry and internal consistency verification phase of the survey was completed on May 14, 2008. Household Characteristics | 9 HOUSEHOLD CHARACTERISTICS 2 This chapter presents information on the social, economic, and demographic characteristics of the households sampled in the 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS); it also covers household living conditions. All the usual residents of each household selected and visitors present in the household on the night before the survey were listed in the Household Questionnaire. Baseline information such as age, sex, marital status, and education were collected for each person. This method of data collection allows for analysis of the results of the survey either for the de jure population (usual residents) or the de facto population (persons present in the household at the time of the survey). 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.1 presents the distribution of the de facto household population by five-year age groups, according to sex and urban-rural residence. For the 7,377 households successfully surveyed (99.5 percent response rate), the total population was 31,501 (16,583 women and 14,918 men). Thus, there are more women than men in Rwanda: 53 percent, compared with 47 percent, or a sex ratio of 90 males per 100 females. This gap has narrowed somewhat since the 2005 survey when the ratio was 88 males per 100 females. The predominance of females is seen particularly in rural areas, where the sex ratio is 89 males per 100 females. Between age 0 and 19 years there is an over-representation of males compared with females. Beginning with age group 20-24 the situation reverses, although the pattern is less clear. In urban areas, for age group 0-14, the proportion of males is higher than the proportion of females; this trend is reversed in age group 20-24. Between age 25 and 39, males are the largest group; then beginning with age 40, the proportion of women again becomes slightly greater than that of men. Overall, the results indicate that 86 percent of the Rwandan population resides in rural areas compared with 14 percent in urban areas. The age pyramid (Figure 2.1) is wide at the base, narrowing rapidly as it reaches the upper age limits, an indication of a population with high fertility and even higher mortality; 65 percent of the population is under age 25 while 73 percent is under age 30. There are certain irregularities in the age structure for both males and females however these are more prominent among females than males. First, there is an underestimation of the number of women age 15-19. In part this is due to some women being moved into the 20-24 age group. In addition, there is an increase in the number of women in age group 50-54 who were not counted in the 45-49 age group. A more detailed analysis shows some aspects of the population structure specific to Rwanda: there is an abnormal shrinkage in the pyramid for age groups 30-34 and 45-49 for both sexes, but especially for men. The lower numbers for these groups are due to the high adult mortality resulting from the genocide. 10 | Household Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Rwanda 2007-08 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 17.0 14.6 15.8 18.4 16.7 17.5 18.2 16.3 17.2 5-9 14.2 13.0 13.6 16.0 14.3 15.1 15.7 14.1 14.9 10-14 12.4 12.4 12.4 15.1 13.7 14.4 14.7 13.5 14.1 15-19 10.5 11.1 10.8 10.2 8.2 9.2 10.2 8.7 9.4 20-24 11.4 11.9 11.6 8.1 9.1 8.6 8.6 9.5 9.1 25-29 10.0 9.3 9.6 7.3 8.1 7.8 7.8 8.3 8.1 30-34 6.6 6.4 6.5 5.0 5.5 5.3 5.3 5.6 5.5 35-39 4.7 4.0 4.4 4.2 4.7 4.5 4.3 4.6 4.4 40-44 3.0 4.1 3.6 3.7 4.1 3.9 3.6 4.1 3.8 45-49 3.0 3.1 3.0 3.0 3.8 3.4 3.0 3.7 3.4 50-54 2.3 3.7 3.0 2.7 3.7 3.2 2.6 3.7 3.2 55-59 1.1 2.0 1.6 1.9 2.5 2.2 1.7 2.4 2.1 60-64 1.8 1.3 1.5 1.5 1.7 1.6 1.5 1.6 1.6 65-69 0.8 1.3 1.0 0.9 1.3 1.1 0.9 1.3 1.1 70-74 0.8 0.8 0.8 0.9 1.0 1.0 0.9 1.0 0.9 75-79 0.3 0.4 0.3 0.7 0.8 0.7 0.6 0.7 0.7 80 + 0.2 0.6 0.4 0.4 0.8 0.6 0.4 0.7 0.6 Don't know/missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,427 2,495 4,923 12,491 14,088 26,579 14,918 16,583 31,501 2.2 HOUSEHOLD SIZE AND COMPOSITION 2.2.1 Sex of the Head of Household Table 2.2 shows the distribution of households by sex of the head of household and mean household size. Results are presented by urban-rural residence. Overall, 69 percent of households are 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 02468101214161820 0 2 4 6 8 10 12 14 16 18 20 RIDHS 2007-08 Male Percent Female Age Household Characteristics | 11 headed by a man while women head 31 percent of household; there is little variation by residence. Since the 2005 survey the percentage of households headed by a man has increased from 66 to 69 percent. In rural areas, the proportion of households headed by a woman has dropped slightly from 34 to 32 percent. 2.2.2 Household Size As shown in Table 2.2, a Rwandan household has, on average, 4.3 persons (4.3 persons in rural areas and 4.4 persons in urban areas). These proportions have dropped slightly compared with the result of the 2005 RDHS-III survey in which the mean household size was 4.6 persons (4.5 in rural areas and 4.8 in urban areas). About half of households have between 3 and 5 persons (51 percent). One-person households make up only 10 percent of urban households and 8 percent of rural households. In 16 percent of cases, households are large and have between 7 and 9 members (16 percent of house- holds in rural area and 18 percent of households in urban areas. 2.3 HOUSING CHARACTERISTICS The household survey collected information on certain housing characteristics such as source of drinking water, access to electricity, type of toilet and flooring materials. The survey also collected information on the ownership of certain durable goods including a radio, television, refrigerator, bicycle, motorcycle, and car. These characteristics are used to evaluate the socio- economic conditions in the household. Table 2.3 shows that at the national level only 6 percent of households have electricity and there are important disparities by urban-rural residence. Thirty-one percent of households have access to electricity in urban areas, compared with only 2 percent in rural areas. With regard to the source of drinking water for home consumption, nationally 32 percent of households use water obtained from a public tap (43 percent in urban areas and 30 percent in rural areas); 26 percent use spring water (13 percent urban areas, compared with 28 percent rural areas). Only a small proportion of households (3 percent) have a faucet in their home or courtyard, and most of these are in urban areas (17 percent in urban areas, compared with less than 1 percent in rural areas). In addition, 18 percent of households draw water from open public wells, while 6 percent drink water from covered public wells. In 14 percent of homes, household drinking water comes from rivers and streams (9 percent) and from ponds/lakes (4 percent). These results show that in Rwanda nearly one-third of households consume unsafe water from unprotected sources and are therefore exposed to the risk of preventable illnesses such as diseases transmitted by worms, dysentery, and cholera, that are all associated with unhealthy hygiene. Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size (usual members); and mean size of household, according to residence, Rwanda 2007-08 Residence Characteristic Urban Rural Total Sex of head of household Male 70.0 68.3 68.6 Female 30.0 31.7 31.4 Total 100.0 100.0 100.0 Number of usual members 0 0.1 0.0 0.0 1 10.1 7.9 8.3 2 13.3 12.6 12.7 3 16.8 18.4 18.2 4 15.6 17.5 17.2 5 15.1 16.2 16.0 6 10.7 11.5 11.4 7 8.2 7.8 7.9 8 4.7 4.3 4.4 9+ 5.4 3.7 4.0 Total 100.0 100.0 100.0 Mean size of households 4.4 4.3 4.3 Number of households 1,148 6,229 7,377 Note: Table is based on de jure household members, i.e., usual residents. 12 | Household Characteristics Table 2.3 Household characteristics Percent distribution of households by certain characteristics of the household, by urban-rural residence, Rwanda 2007-08 Residence Characteristic Urban Rural Total Electricity Yes 28.1 2.0 6.0 No 71.8 97.8 93.7 Don’t know 0.2 0.2 0.2 Total 100.0 100.0 100.0 Sources of drinking water Piped into dwelling/compound/plot 17.0 0.9 3.4 Public tap 42.6 30.3 32.2 Open well in compound/plot 0.2 0.1 0.1 Open public well 13.7 19.3 18.4 Covered well in compound/plot 0.0 0.2 0.1 Covered public well 4.2 6.0 5.7 Spring 13.4 27.9 25.6 River/stream 6.5 9.8 9.3 Pond, lake 1.6 4.8 4.3 Dam 0.1 0.5 0.4 Rain water 0.1 0.1 0.1 Tanker truck 0.0 0.0 0.0 Bottled water 0.0 0.0 0.0 Other/don’t know 0.7 0.3 0.4 Total 100.0 100.0 100.0 Time to the water source Percentage <15 minutes 53.6 27.4 31.5 Median time to source (in minutes) 8.8 29.1 24.5 Sanitation facility Flush toilet 3.2 0.4 0.8 Traditional pit toilet/latrine 53.4 37.6 40.1 Ventilated improved pit latrine 40.9 58.2 55.5 No facility, bush, field 1.8 3.1 2.9 Other/don’t know 0.7 0.7 0.7 Total 100.0 100.0 100.0 Flooring material Earth, mud, sand 51.1 90.5 84.4 Dung 0.7 0.9 0.9 Ceramic tiles/cement 47.4 8.3 14.2 Carpet 0.9 0.2 0.3 Other/don’t know 0.1 0.3 0.2 Total 100.0 100.0 100.0 Number of households 1,148 6,229 7,377 In urban areas, 22 percent of households consume water that is either unsafe or questionable (open public wells, rivers, ponds, and lakes) while in rural areas the proportion is 34 percent. These results indicate that rural households run a greater risk of contracting preventable diseases linked to unsafe water than urban households. Comparing these results with those from the 2005 RDHS-III survey indicates that there has been no substantial improvement in the proportion of households with safe drinking water; in 2005, 18 percent of urban households and 34 percent of rural households had unsafe or questionable drinking water. Household Characteristics | 13 Concerning the time necessary to obtain water, the survey results show that a wide difference exists between urban and rural areas. In urban areas, 54 percent of households are within 15 minutes of their water source, compared with only 27 percent in rural areas. The median time to a drinking water source is estimated to be 24.5 minutes for the country as a whole, 8.8 minutes in urban areas and 29.1 minutes in rural areas, illustrating again the precariousness of the situation for rural households. Compared with the 2005 RDHS-III, the proportion of urban households within 15 minutes of their water source increased almost 6 percentage points from 48 percent, while in rural areas the situation has remained essentially the same (27 percent). Overall, the change between the two surveys has been negligible; the median time to the source of water was 24.4 minutes in 2005 and 24.5 in 2007-08. Table 2.3 presents data on type of toilet facilities used by the household. This information evaluates the health situation associated with access to safe drinking water and shows the potential risks faced by households regarding diseases linked to lack of sanitary conditions. Nationally, more than one in two households (56 percent) has a ventilated improved pit (VIP) latrine. The proportion is higher in rural areas than in urban areas: 58 percent, compared with 41 percent. In addition, 40 percent of households use unimproved pit latrines/rudimentary pit toilets (53 percent in urban areas, compared with 38 percent in rural areas). Results from the survey show a definite improvement in the overall health situation because the proportion of households using improved latrines rose from 28 percent in 2005 to 56 percent in 2007- 08. The increase was seen particularly in rural areas (from 24 to 58 percent). In contrast, very few households in Rwanda have access to a flush toilet (0.8 percent); the gap by urban-rural residence is large: 3.2 percent of households in urban areas have a flush toilet, compared with 0.4 percent in rural areas. The proportion of households with no toilet facilities at all is 3 percent nationally (2 percent in urban areas and 3 percent in rural areas). This proportion has dropped slightly from the 2005 RDHS-III survey (5 percent nationally) but still remains high. The results on the type of flooring in the household dwellings show that, overall, 84 percent of household dwellings have floors made of earth or sand (51 percent in urban areas, compared with 91 percent in rural areas), and 14 percent of household dwellings have cement or tile floors (47 percent in urban areas and 8 percent in rural areas). Less than 1 percent of households live in a dwelling with a dung floor. When these results are compared with those from the 2005 survey, it is apparent that there has been no substantial improvement in the flooring used in household dwellings. This information is important because flooring material used in dwellings is not only an indicator of household wealth status, but also an indicator of the quality of the health environment in which the household lives because certain rudimentary materials like earth, sand, and cow dung are propagation vectors for disease causing parasites and germs. These rudimentary materials are, in addition, a source of dust and are difficult to clean. 2.4 OWNERSHIP OF DURABLE GOODS The 2007-08 Rwanda Interim Demographic and Health Survey collected information about household ownership of certain durable goods considered indicative of wealth. Table 2.4 shows that the most commonly owned household durable item is a radio (58 percent), with a notable urban-rural disparity (72 percent in urban areas, compared with 56 percent in rural areas). Comparison with results from the 2005 RDHS-III survey shows substantial improvement, with the overall proportion increasing from 46 to 58 percent (from 65 to 72 percent in urban areas, and from 43 to 56 percent in rural areas). However, only 3 percent of households have a television, with urban households owning the largest proportion (16 percent, compared with only 1 percent in rural areas). 14 | Household Characteristics Overall, there has been almost no change since 2005. Nevertheless, it should be noted that in urban areas the proportion of households possessing a television has increased from 14 to 16 percent. Importantly, there has been a large increase in the proportion of households owning a cellular phone since the 2005 RDHS-III: from 5 percent, the proportion has risen to 13 percent for the country as a whole. The increase has been greatest in urban areas, increasing from 24 to 42 percent, while in rural areas it increased from 1 percent in 2005 to 8 percent. Very few households have a fixed landline telephone or a refrigerator, and it is mainly urban households that have this equipment. Bicycles are the means of transportation used by 12 percent of households (10 percent in urban areas and 13 percent in rural areas). Slightly less than 1 percent of households own a car/truck. 2.5 WEALTH QUINTILES Table 2.5.1 shows the percent distribution of households by wealth quintile (according to the wealth index). The wealth index (for households interviewed) was developed on the basis of household goods data and certain housing characteristics presented in the preceding tables. The index was developed as follows: • Each durable goods item or housing characteristic is assigned a weight (score or coefficient) generated by principal components analysis. • The resulting scores for durable goods are standardized according to a normal distribution assuming a mean of 0 and a standard deviation of 1 (Gwatkin et al., 2000). • Each household is assigned a score for each durable goods item and these scores are added together to obtain a total for each household. • The households are classified in increasing order of total score and divided into 5 equal categories, or quintiles. This yields a scale from 1 (lowest or poorest quintile) to 5 (highest or richest quintile). • The score for each household is assigned to the individuals in that household. The individuals are thus distributed among the categories. The results show that the wealthiest households are found in urban areas, where 59 percent of households fall into the highest wealth quintile; in rural areas, only 9 percent of households fall into this quintile. Three-quarters of the richest households are concentrated in the City of Kigali (75 percent), while only 3 percent of the poorest households are there. In rural areas, nearly one household in two falls into the two poorest quintiles (49 percent). There is little variation between the provinces outside the City of Kigali. The proportion of households in the richest quintile varies from 12 to 16 percent by province while households in the two poorest quintiles vary from 45 percent in the South province to 52 percent in the North province. Table 2.4 Household durable goods Percentage of households and de jure population possessing various household durable goods, means of transportation, by residence, Rwanda 2007-08 Residence Durable goods/ means of transport Urban Rural Total Radio 72.1 55.6 58.1 Television 16.2 1.0 3.3 Mobile telephone 42.4 7.7 13.1 Non-mobile telephone 5.0 0.4 1.1 Refrigerator 5.0 0.2 0.9 Bicycle 10.2 12.5 12.2 Motorcycle/scooter 2.6 0.6 0.9 Car/truck 3.7 0.2 0.8 Number 1,148 6,229 7,377 Household Characteristics | 15 Table 2.5.1 Wealth quintiles: Households Percent distribution of households by wealth quintiles, according to residence and region, Rwanda 2007-08 Wealth quintile Residence/ province Lowest Second Middle Fourth Highest Total Number Residence Urban 8.5 11.1 11.7 9.7 59.0 100.0 1,148 Rural 17.9 30.8 20.5 19.2 11.6 100.0 6,229 Province Kigali 3.0 8.4 6.6 7.0 75.0 100.0 638 South 17.7 27.2 20.2 19.4 15.5 100.0 1,880 West 20.4 27.5 21.6 19.0 11.5 100.0 1,890 North 18.0 33.7 18.2 15.6 14.4 100.0 1,315 East 14.4 31.2 20.6 20.3 13.6 100.0 1,654 Total 16.5 27.7 19.1 17.8 19.0 100.0 7,377 Table 2.5.2 shows the percent distribution of the household population by wealth quintiles. The results are similar to those in Table 2.5.1, with the wealthiest proportion of the population (70 percent of the two richest quintiles) living in urban areas, particularly Kigali (82 percent of the two richest quintiles). In contrast, the poorest proportion of the population is in rural areas: 46 percent of the populations in the two poorest quintiles live in rural areas, compared with 19 percent that live in urban areas. The results are also shown by province. With the exception of Kigali, the results are similar to those observed for households. Table 2.5.2 Wealth quintiles; Population Percent distribution of the population by wealth quintiles, according to residence and region, Rwanda 2007-08 Wealth quintile Residence/ province Lowest Second Middle Fourth Highest Total Number of population Residence Urban 7.4 11.3 11.8 9.7 59.8 100.0 5,023 Rural 15.9 30.5 21.0 20.3 12.3 100.0 27,015 Province Kigali 2.5 8.8 6.8 7.2 74.7 100.0 2,700 South 16.2 27.0 19.7 20.1 16.9 100.0 8,177 West 18.5 27.4 22.0 20.1 12.0 100.0 8,258 North 15.5 32.6 19.3 16.9 15.6 100.0 5,746 East 12.0 31.0 21.7 20.9 14.4 100.0 7,157 Total 14.6 27.5 19.6 18.6 19.7 100.0 32,038 Information on health insurance coverage of household members was collected during the Household Survey. The results are shown in Table 2.6 by type of health insurance, according to urban- rural residence and province. 16 | Household Characteristics Overall, 68 percent of Rwandan households have health insurance. There is almost no variation by residence (68 percent in both urban and rural areas). Results by province do show differences, with proportions varying from 58 percent in the South province to 76 percent in the West and North provinces. Concerning the type of health insurance used by households, nearly all households are affiliated with a mutual insurance organization (96 percent). Another 4 percent of households have health insurance through state agencies. The proportions of other types of insurance are very low (less than 1 percent). Table 2.6 Health insurance Percentage of households in which at least one member is covered by health insurance, and percentage of households with specific types of health insurance, according to residence and province, Rwanda 2007-08 Type of health insurance Residence/ province Percentage of households in which at least one member is covered by health insurance Number of households Mutual RAMA1 MMA2 Private Other Number of households in which at least one member is covered by health insurance Residence Urban 68.4 1 148 89.1 10.5 2.4 1.3 1.3 785 Rural 68.1 6 229 97.4 2.7 0.3 0.1 0.4 4,242 Province Kigali 67.5 638 89.4 10.3 2.4 1.1 1.9 431 South 57.8 1 880 97.5 3.0 0.1 0.2 0.1 1,086 West 75.6 1 890 96.3 3.3 0.4 0.3 0.8 1,428 North 76.1 1 315 96.6 4.3 0.4 0.0 0.0 1,001 East 65.3 1 654 96.6 2.7 1.0 0.2 0.7 1,081 Total 68.1 7 377 96.1 3.9 0.6 0.3 0.6 5,027 Note: The total may exceed 100 percent because in each household, members may be covered by different types of health insurance. 1 State Agency Health Insurance 2 Military Health Insurance Characteristics of Survey Respondents | 17 CHARACTERISTICS OF SURVEY RESPONDENTS 3 The purpose of this chapter is to provide a socio-demographic profile of the women and men who responded to this survey including age, residence, marital status, education, and well-being. The results concern women age 15-49 and men age 15-59. These characteristics are used as variables for interpreting findings in the rest of the report and are important for understanding the factors affecting behavior of the population with respect to reproduction and health. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Age is a fundamental variable in analyzing demographic phenomena, but it is one of the most difficult to obtain when written records of events (especially civil status data) are far from exact. Special efforts were made in the individual questionnaire to record respondents’ correct age. Respondents were asked for both their date of birth and their age. The interviewer then checked the two pieces of information for consistency. In cases where the respondent did not know her birth date or her age, the interviewer sought to obtain the information by looking at an official document (identity card, etc.) or by calculating the date of birth. If no official documents were available, the interviewer confirmed the age information provided by the respondent by referring to major life events (age at marriage, age of first child, etc.) or well-known national or regional events. Table 3.1 shows no major differentials in the distribution of women age 15-49 and men age 15-59 by five-year age groups. The proportions decline regularly with increasing age; for women, the decline is from 19 percent for women age 15-19 to 9 percent for those age 45-49 for men, the decline is from 24 percent for men age 15-19 to 7 percent for those age 55-59. Table 3.1 Distribution by age of the respondents Percent distribution of women and men age 15-49 by age group, Rwanda 2007-08 Women Men Age Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted 15-19 19.0 1,387 1,434 23.6 1,461 1,446 20-24 21.2 1,548 1,557 20.1 1,245 1,266 25-29 18.8 1,374 1,373 18.7 1,156 1,157 30-34 12.8 937 931 12.4 769 796 35-39 10.5 769 760 9.9 616 624 40-44 9.3 678 667 8.4 522 514 45-49 8.5 620 591 6.9 428 422 Total 15-49 100.0 7,313 7,313 100.0 6,197 6,225 Total men 15-59 na na na na 6,837 6,837 na = Not applicable Table 3.2 shows the percent distribution of all women and men who were interviewed in the survey, according to certain socio-demographic variables. For the RIDHS, all women and men were considered “married” if they were in union with a partner, whether the union was formal (legally married) or informal (“living together”). By this definition, Table 3.2 shows that at the time of the survey, 18 | Characteristics of Survey Respondents 35 percent of women had never been married while more than half (53 percent) were married (38 percent formally married and 16 percent living in a consensual union). This compares with about one in two men (49 percent) who had never been married, and about the same proportion who were either married (39 percent) or in union (11 percent). An additional 12 percent of women were no longer in union at the time of the survey (5 percent divorced or separated and 7 percent widowed); only 2 percent of men were no longer in union. The distribution of respondents by residence indicates that the majority of Rwandans live in rural areas (83 percent of women and 81 percent of men); 17 percent of women and 19 percent of men live in urban areas. Similarly, the data by province show a relatively uniform distribution of the population, with no substantial differences between men and women, except for the City of Kigali and the North province, which have slightly smaller proportions of the population (both men and women). Table 3.2 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Rwanda 2007-08 Women Men Background characteristic Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Marital status Never married 35.2 2,573 2,698 48.7 3,019 3,125 Married 37.6 2,747 2,677 38.9 2,408 2,352 Living together 15.6 1,140 1,082 10.6 657 633 Divorced/separated 5.1 377 386 1.3 79 81 Widowed 6.5 476 470 0.5 32 33 Missing 0.0 0 0 0.0 2 1 Residence Urban 17.0 1,240 1,974 18.8 1,167 1,820 Rural 83.0 6,073 5,339 81.2 5,030 4,405 Province Kigali 9.4 685 970 11.8 730 1,004 South 26.6 1,946 1,824 25.1 1,557 1,421 West 23.8 1,738 1,862 24.9 1,540 1,629 North 17.3 1,265 1,036 16.4 1,015 851 East 23.0 1,680 1,621 21.9 1,354 1,320 Education No education 22.2 1,624 1,510 15.4 957 888 Primary 66.2 4,842 4,803 68.8 4,261 4,187 Secondary or higher 11.6 847 1,000 15.8 979 1,150 Wealth quintile Lowest 15.1 1,108 1,067 12.2 757 716 Second 27.0 1,974 1,818 25.0 1,551 1,423 Middle 18.7 1,367 1,285 19.4 1,203 1,143 Fourth 17.9 1,306 1,240 19.0 1,178 1,101 Highest 21.3 1,558 1,903 24.4 1,509 1,842 Religion Catholic 44.7 3,266 3,159 50.6 3,138 3,112 Protestant 40.3 2,950 3,040 32.7 2,029 2,050 Adventist 13.0 952 936 11.2 696 697 Muslim 1.5 107 137 2.5 155 183 Traditional 0.0 2 2 0.0 3 3 Other 0.1 6 5 1.1 67 76 None 0.3 23 26 1.6 102 96 Missing 0.1 9 8 0.1 8 8 Total 15-49 100.0 7,313 7,313 100.0 6,197 6,225 Characteristics of Survey Respondents | 19 Table 3.2 provides general information on the educational attainment of respondents. A higher proportion of women than men have no education (22 and 15 percent, respectively), but the educational gap between women and men is smaller for those with a primary or secondary education. There are small differences in household wealth status between women and men; 24 percent of men are in the richest (highest) wealth quintile, compared with 21 percent of women. In the lowest (poorest) wealth quintile, the proportions are 15 percent for women and 12 percent for men. The tabulation of respondents by religion indicates a majority of the Rwandan population is Catholic (45 percent of women and 51 percent of men) with Protestants second (40 percent of women and 33 percent of men). The Adventist faith is the next most common religion (13 percent of women and 11 percent of men), followed by the Muslim faith (2 percent of women and 3 percent of men). 3.2 EDUCATIONAL ATTAINMENT Tables 3.3.1 and 3.3.2 show the distribution of respondents by highest level of education attained according to background characteristics; the results for women are presented in Table 3.3.1 and those for men are presented in Table 3.3.2. The proportion of women who have never gone to school is higher than that for men (22 percent and 15 percent, respectively). At the primary level, the differential is smaller, 68 percent of men, compared with 66 percent of women. At the secondary level, the proportions are 15 percent for men and 12 percent for women. Table 3.3.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median number of hears of schooling completed, according to background characteristics, Rwanda 2007-08 Highest level of schooling attended or completed Background characteristic No education Primary Secondary More than secondary Total Median years completed Number of women Age 15-24 12.0 73.4 13.9 0.6 100.0 3.9 2,935 15-19 7.5 77.6 14.9 0.1 100.0 4.1 1,387 20-24 16.1 69.6 13.1 1.2 100.0 3.7 1,548 25-29 18.2 71.6 8.9 1.3 100.0 3.9 1,374 30-34 21.0 66.9 10.8 1.3 100.0 4.4 937 35-39 29.2 60.6 8.9 1.2 100.0 3.5 769 40-44 42.1 49.6 7.6 0.8 100.0 2.0 678 45-49 50.7 44.4 4.5 0.4 100.0 - 620 Residence Urban 13.0 58.7 24.3 4.0 100.0 4.9 1,240 Rural 24.1 67.8 7.9 0.3 100.0 3.4 6,073 Province Kigali 11.7 54.7 28.9 4.7 100.0 5.3 685 South 20.6 70.4 8.2 0.7 100.0 3.7 1,946 West 26.0 65.1 8.3 0.6 100.0 3.2 1,738 North 23.4 65.4 10.6 0.6 100.0 3.7 1,265 East 23.5 67.7 8.6 0.2 100.0 3.4 1,680 Wealth quintile Lowest 32.4 65.9 1.7 0.0 100.0 2.3 1,108 Second 25.9 70.4 3.8 0.0 100.0 3.1 1,974 Middle 23.3 69.6 7.0 0.1 100.0 3.5 1,367 Fourth 22.3 70.3 7.3 0.0 100.0 3.8 1,306 Highest 9.2 54.8 31.8 4.1 100.0 5.4 1,558 Total 22.2 66.2 10.7 0.9 100.0 3.6 7,313 20 | Characteristics of Survey Respondents Educational attainment for both sexes is partly associated with age, generally increasing from the oldest age groups to the youngest. For women with no education, the proportion has dropped from 51 percent in age group 45-49 to 8 percent in age group 15-19; on the other hand, the proportion with primary education has increased from 44 percent for age group 45-49, to 78 percent for age group 15-19. For men, similar differentials are seen between age groups, with the proportion having no education declining from 27 percent in age group 45-49, to 9 percent in age group 15-19. The proportion of men who attained primary education increased from 63 percent among men age 45-49, to 77 percent among men age 15-19. Comparison of education data from the 2007-08 RIDHS with data from previous surveys shows the improvement in education among Rwandans. In the second DHS survey, the 2000 RDHS-III, in 2000, 13 percent of girls age 15-19 had never been to school; this proportion fell to 9 percent in the 2005 RDHS-III and finally to 8 percent in 2007-08. For men, the same comparison shows a drop since 2000 in the percentage of those with no education. In 2000, 11 percent of men age 15-19 had never been to school, while in 2005 it had dropped to 7 percent. However, this trend appears to have slowed between 2005 and 2007 because there was a slight increase in the proportion of men age 15-19 with no education from 7 percent in 2005 to 9 percent in 2007-08. The educational attainment of respondents varies by residence. The proportion of men with education is higher in urban areas (91 percent) than in rural areas (83 percent). The proportion of women who have gone to school is 87 percent in urban areas and 76 percent in rural areas. Table 3.3.2 Educational attainment: Men Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median number of years of schooling completed, according to background characteristics, Rwanda 2007-08 Highest level of schooling attended or completed Background characteristic No education Primary Secondary More than secondary Total Median years completed Number of men Age 15-24 10.6 73.2 15.6 0.6 100.0 4.1 2,705 15-19 9.2 77.1 13.7 0.0 100.0 4.0 1,461 20-24 12.2 68.7 17.9 1.2 100.0 4.2 1,245 25-29 16.1 68.9 12.1 2.9 100.0 4.4 1,156 30-34 15.8 66.5 14.2 3.5 100.0 5.1 769 35-39 20.3 60.7 16.3 2.8 100.0 5.0 616 40-44 23.9 62.7 11.8 1.6 100.0 4.2 522 45-49 26.5 63.2 8.5 1.8 100.0 3.4 428 Residence Urban 9.1 55.1 29.8 6.1 100.0 5.4 1,167 Rural 16.9 71.9 10.4 0.8 100.0 4.0 5,030 Province Kigali 6.7 53.3 33.6 6.4 100.0 5.6 730 South 19.5 68.6 10.7 1.1 100.0 3.7 1,557 West 13.6 72.6 12.2 1.5 100.0 4.4 1,540 North 15.2 70.2 13.2 1.4 100.0 4.4 1,015 East 17.7 71.8 10.0 0.5 100.0 3.8 1,354 Wealth quintile Lowest 23.9 72.4 3.7 0.0 100.0 3.2 757 Second 18.3 75.2 6.6 0.0 100.0 3.8 1,551 Middle 16.2 74.7 8.7 0.4 100.0 4.0 1,203 Fourth 15.8 73.7 10.1 0.4 100.0 4.2 1,178 Highest 7.5 51.7 34.2 6.6 100.0 5.6 1,509 Total 15.4 68.8 14.0 1.8 100.0 4.3 6,197 Total men 15-59 17.5 67.6 13.2 1.6 100.0 4.1 6,837 Characteristics of Survey Respondents | 21 Education results by province show a wide gap between the City of Kigali and the other provinces. In the City of Kigali, 12 percent of women and 7 percent of men have no education compared with at least one in five women and one in seven men in the other provinces. The highest proportion of men with no education (20 percent) is in the South province, while the highest proportion of women with no education is in the West province (26 percent). Tables 3.3.1 and 3.3.2 show a positive relationship between educational attainment and household wealth; the proportion of women and men with no education decreases as household wealth increases. The decrease for women is from 32 percent in the lowest (poorest) wealth quintile to 9 percent in the highest (richest) wealth quintile; for men, the decrease is from 24 to 8 percent. 3.3 MARITAL STATUS In the RIDHS, the term “in union” applies to all persons, both women and men who were either married or living together with a partner at the time of the survey. Therefore, all persons considered “married” were counted whether the union was civil, religious or by traditional custom as well as consensual or de jure unions. Table 3.4 shows the percent distribution of women and men age 15-49 by marital status at the time of the survey. The data show that more than one woman in two (53 percent), and about one man in two (50 percent) are in union. Single women and men account for 35 percent and 49 percent of the population, respectively. In addition, 12 percent of women are no longer in union, mainly because of widowhood (7 percent), while the proportion of men who are no longer in union (2 percent) is much lower. Table 3.4 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Rwanda 2007-08 Marital status Age group Never married Married Living together Divorced Separated Widowed Missing Total Percentage of respondents currently in union Number of respondents WOMEN 15-19 97.0 0.5 2.1 0.1 0.3 0.0 0.0 100.0 2.6 1,387 20-24 53.0 24.1 19.1 1.0 2.2 0.6 0.0 100.0 43.2 1,548 25-29 19.7 51.5 22.2 1.1 4.3 1.1 0.0 100.0 73.7 1,374 30-34 6.5 59.4 20.5 1.6 7.1 4.9 0.0 100.0 79.9 937 35-39 5.2 58.6 16.1 2.1 6.7 11.4 0.0 100.0 74.7 769 40-44 2.0 54.0 16.1 1.0 6.9 20.1 0.0 100.0 70.0 678 45-49 3.4 46.2 13.7 0.6 6.8 29.3 0.0 100.0 59.9 620 Total 15-49 35.2 37.6 15.6 1.0 4.1 6.5 0.0 100.0 53.2 7,313 MEN 15-19 99.3 0.1 0.4 0.0 0.0 0.0 0.1 100.0 0.5 1,461 20-24 76.3 13.0 9.7 0.1 0.9 0.1 0.0 100.0 22.7 1,245 25-29 36.9 46.6 15.2 0.6 0.7 0.0 0.0 100.0 61.8 1,156 30-34 15.3 67.0 15.6 0.8 1.0 0.4 0.0 100.0 82.5 769 35-39 8.2 73.5 15.2 0.4 1.6 1.1 0.0 100.0 88.6 616 40-44 2.0 77.8 15.3 1.1 2.7 1.2 0.0 100.0 93.0 522 45-49 2.9 77.3 14.5 0.7 1.0 3.6 0.0 100.0 91.8 428 Total 15-49 48.7 38.9 10.6 0.4 0.9 0.5 0.0 100.0 49.5 6,197 Total 15-59 44.3 42.7 10.8 0.4 0.9 0.9 0.1 100.0 53.5 6,837 22 | Characteristics of Survey Respondents The proportion of single women drops sharply with age from 97 percent among women age 15- 19 to 53 percent among those age 20-24, and then to 20 percent for those age 25-29. Among men, 99 percent are single at age 15-19. The proportion drops to 37 percent for those age 25-29 and to 8 percent at age 35-39. Only 3 percent of women age 45-49 and 3 percent of men age 45-49 have never married. 3.4 POLYGYNY Table 3.5 shows the distribution of currently married men by the number of wives they have. Polygyny, the practice of having more than one spouse, is not widely practiced in Rwanda; only 4 percent of men have more than one wife. The differentials by background characteristics are small, however, the proportion of men in polygynous unions is slightly higher in East province (6 percent) than in other provinces. Table 3.5 Number of men's wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Rwanda 2007-08 Number of wives Background characteristic 1 2 3+ Missing Total Number of men Age 15-19 100.0 0.0 0.0 0.0 100.0 8 20-24 98.9 0.9 0.2 0.0 100.0 282 25-29 98.3 1.1 0.0 0.6 100.0 714 30-34 96.6 3.3 0.1 0.0 100.0 635 35-39 95.1 4.2 0.2 0.5 100.0 546 40-44 95.8 2.9 0.2 1.2 100.0 486 45-49 93.0 5.9 0.4 0.7 100.0 393 Residence Urban 98.9 0.4 0.3 0.4 100.0 453 Rural 95.9 3.4 0.1 0.5 100.0 2,612 Province Kigali 98.1 1.2 0.0 0.7 100.0 267 South 96.7 2.7 0.3 0.3 100.0 745 West 97.0 2.6 0.1 0.2 100.0 768 North 96.6 3.0 0.0 0.4 100.0 578 East 94.4 4.3 0.2 1.1 100.0 707 Education No education 94.6 4.5 0.4 0.5 100.0 611 Primary 96.7 2.7 0.1 0.5 100.0 2,091 Secondary or higher 97.5 2.1 0.0 0.4 100.0 363 Wealth quintile Lowest 95.5 2.7 1.1 0.7 100.0 371 Second 95.8 3.5 0.0 0.7 100.0 836 Middle 96.9 2.6 0.0 0.5 100.0 631 Fourth 95.6 3.6 0.1 0.7 100.0 649 Highest 97.9 2.7 1.1 0.1 100.0 578 Total 15-49 96.4 3.0 0.2 0.5 100.0 3,065 Total 15-59 95.6 3.5 0.4 0.5 100.0 3,656 Fertility | 23 FERTILITY 4 Information was collected on the birth history of women interviewed in the 2007-08 RIDHS to estimate fertility levels, ascertain trends, and evaluate differentials according to background character- istics. Fertility data were obtained by asking a series of questions to all eligible women respondents. For each woman, interviewers recorded the number of children ever born, the gender of each child, the number of children currently living with the mother, the number of children living elsewhere, the number of children who had died, and the number still living. A complete birth history was compiled, from the earliest to the most recent birth. In addition, the following information was gathered for each birth: type of birth (single or multiple), sex of child, date of birth, and survival status. For living children, respondents were asked the current age of the child and whether the child was living with its mother or elsewhere. For children who had died, respondents were asked the age at the time of death. At the end of the interview, the interviewer verified that the number of children reported by the mother initially (for each category: living and dead) was consistent with the number of children reported in the birth history. Because this is a retrospective survey, the data can be used to estimate not only current fertility levels, but also trends in fertility over the past 20 years. However, limits inherent in all retrospective surveys should be noted, including: • Underreporting of births, in particular, the omission of very young children, those not living with their mother, and children who died very young (a few hours or days after birth), which can result in underestimation of fertility levels. • Misreporting of date of birth and/or age, in particular, the tendency to round off ages or year of birth, which can result in under- or overestimation of fertility at certain ages and/or for certain periods. • Selective survival bias or selectivity effect: the women surveyed are those who have sur- vived. Assuming that the fertility of women who died prior to the survey differs from that of surviving women, the fertility levels obtained by the survey may be slightly biased. Information can also be affected by inaccurate recording of birth dates for children born in the past five years (since 2002 in the case of Rwanda), particularly when birth dates are moved backward in time to an earlier year. These birth year shifts, common to most DHS-type surveys, are sometimes made by interviewers to avoid asking questions about the health of children born in the past five years (sections 4 and 5 of the questionnaire). Some shifting of birth dates1 from 2002 to 2001 did occur in the RIDHS; however, the changes were not important enough to significantly affect current fertility levels. 4.1 FERTILITY LEVELS AND DIFFERENTIALS Current fertility levels are measured in terms of age-specific fertility rates (ASFRs) and the total fertility rate (TFR). ASFRs are calculated by dividing the number of births in each age group into the total number of women for that age group. The TFR, a common measurement of current fertility, is the average of all of the ASFRs. It corresponds to the average number of children a woman would bear in her lifetime 1 The percent distribution of births by calendar year of birth is show in Appendix C, Table C.4. The ratio of annual births (ratio of births for year x to the half sum of births from the preceding and following years, or NJ[(Nx-i+Nx+J/2)], computes the shifting of birth years. The ratio indicates a shortage of births in 2001 (ratio = 84 < 100) and a surplus in 2000 (ratio = 133 > 100). 24 | Fertility if fertility rates were to remain constant at the level prevailing during the period under consideration. In Rwanda, current fertility rates and the TFR were calculated for the three years preceding the survey. This three-year reference period was chosen to provide the most recent fertility indicators possible with sufficient cases to reduce sampling errors. The total fertility rate for Rwandan women remains high: at the end of her reproductive years a woman has an average of 5.5 children. Adolescents age 15-19 contribute only 4 percent of the total fertility while women age 25-29 contribute 25 percent. For all age groups, fertility is higher among women in rural areas (5.7) than among women in urban areas (4.7) (Figure 4.1). The fertility curves for urban and rural areas follow the same trajectory: increasing rapidly, reaching a maximum at age 25-29 before declining steadily with age. The maximum rate is 277 births per thousand women in rural areas and 245 births per thousand women in urban areas. Table 4.1 shows the General Fertility Rate (GFR), that is, the average number of live births annually in the total population of women of reproductive age; the estimated GFR for Rwanda is 178 births per thousand women. Like the TFR, this indicator varies substantially by residence. Urban areas have a GFR of 150 per thousand, compared with 184 per thousand in rural areas. Figure 4.1 Age-Specific Fertility Rates, by Residence RIDHS 2007-08 * * * * * * * ) ) ) ) ) ) ) # # # # # # # 15 20 25 30 35 40 45 Woman's age 0 50 100 150 200 250 300 Births per 1,000 women Urban Rural Total# ) * Fertility | 25 Table 4.1 Current fertility Age-specific and total rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Rwanda 2007-08 Residence Age group Urban Rural Total 15-19 46 39 40 20-24 173 219 211 25-29 245 277 272 30-34 205 254 246 35-39 175 214 209 40-44 91 107 105 45-49 8 22 20 TFR 4.7 5.7 5.5 GFR 150 184 178 CBR 36.8 39.6 39.2 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate for age 15-49 expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Table 4.2 presents the TFR by background characteristics. With the exception of the City of Kigali (4.4 children per woman) the TFR varies little by province, ranging from a low of 5.4 children per woman in the North province and 5.5 in the South province to a high of 5.8 in the West and East prov- inces. In addition, the TFR is strongly correlated with level of educational attainment, varying from a low of 3.8 children per woman for those with secondary edu- cation or higher, to 5.7 for women with primary edu- cation, and 6.1 for those with no education. By wealth quintile, the TFR varies little among the first four quintiles (5.7 to 6.0 children). Only women in the richest quintile have markedly lower fertility (4.4 children). Table 4.2 shows the mean number of children ever born to women age 40-49. This figure is an indicator of completed or cumulative fertility. Unlike the TFR, which measures the current fertility of women age 15-49, cumulative fertility shows the past fertility of respondents at the end of their childbearing years. In a population whose fertility does not change, the cumulative fertility rate generally coincides with Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Rwanda 2007-08 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 4.7 7.7 5.6 Rural 5.7 9.7 6.1 Province Kigali 4.4 10.3 5.3 South 5.5 9.0 5.6 West 5.8 9.3 6.3 North 5.4 9.2 6.4 East 5.8 9.7 6.2 Education No education 6.1 8.8 6.2 Primary 5.7 9.9 6.1 Secondary or higher 3.8 7.8 4.6 Wealth quintile Lowest 5.8 8.2 5.6 Second 5.7 10.2 6.4 Middle 6.0 10.2 6.0 Fourth 5.8 10.5 6.5 Highest 4.4 7.5 5.4 Total 5.5 9.4 6.0 26 | Fertility the TFR. When the cumulative fertility rate is higher than the TFR, a downward trend in fertility is indicated. In Rwanda, the cumulative fertility rate, estimated at 6.0 children, is higher than the TFR (5.5). This important difference of 0.5 children suggests a decline in fertility (Figure 4.2). The largest differences between the two measures are seen for urban women (0.9 children), women with secondary education or higher (0.8), women in the North province (1.0) and the City of Kigali (0.9), and women in the highest (richest) wealth quintile (1.0 children). Fertility among these women, therefore, would be the most likely to drop. Table 4.2 shows the percentage of women who reported being pregnant at the time of the survey. Overall, more than 9 percent of women reported being pregnant. This is likely to be an underestimate because women in the early stages of pregnancy may be unaware or unsure of their pregnancy status. However, the differentials in pregnancy rates by background characteristics show patterns similar to those of the TFRs, with the exception of women living in the City of Kigali, women with primary education, and women in the poorest wealth quintile. 4.2 FERTILITY TRENDS Rwanda has conducted three Demographic and Health Surveys and one Interim Demographic and Health Survey over the past 15 years, and estimating fertility levels has been one of the main objectives of these surveys. Fertility trends can be observed from these four data sources (Table 4.3 and Figure 4.3). The four ASFR curves follow a similar pattern: they increase beginning at age 15-19 and reach their peak between age 25 and 29, then taper off steadily as they move toward age group 45-49. At all ages, except for age group 35-39, the curve for the RIDHS is clearly below the curves from preceding surveys, while that for the 2005 RDHS-III is above the curve of the 2000 RDHS-II for women age 25-39 and above the 1992 RDHS-I for women age 25-34. Figure 4.2 Total Fertility Rate and Mean Number of Children Ever Born to Women Age 40-49 RIDHS 2007-08 5.5 4.7 5.7 6.1 5.7 3.8 6 5.6 6.1 6.2 6.1 4.6 RWANDA RESIDENCE Urban Rural EDUCATION No education Primary Secondary or higher 0 1 2 3 4 5 6 7 8 Number of children per woman TFR Mean number of children ever born 6.0 Fertility | 27 Over the past 15 years, the TFR has gone from 6.2 children per woman in 1992 to 5.8 in 2000, 6.0 in 2005, and 5.5 in 2007-08 (Table 4.3 and Figure 4.3). It should be noted that the TFR dropped slightly following the 1994 genocide but rose again in the early years after 2000. However, results from this survey show a definite drop in fertility. Table 4.3 Trends in age-specific fertility rates by four sources Age-specific fertility rates (per 1,000 women) and total fertility rates, 1992 RDHS-I, 2000 RDHS-II, 2005 RDHS-III, and 2007-08 RIDHS Age group 1992 RDHSI 2000 RDHS-II 2005 RDHS-III 2007-08 RIDHS 15-19 60 52 42 40 20-24 227 240 235 211 25-29 294 272 305 272 30-34 270 257 273 246 35-39 214 190 211 209 40-44 135 123 117 105 45-49 46 33 32 20 TFR 15-49 years 6.2 5.8 6.0 5.5 Note: Age-specific fertility rates per 1,000 women. The data collected in the RIDHS were used to track fertility trends by women’s age-specific fertility rates, by the five-year periods preceding the survey (Table 4.4 and Figure 4.4). In all age groups the fertility rates have dropped steadily from the earliest periods to the most recent. For example, in the 20-24 age group, the fertility rate estimated at 256 per thousand 10 to 14 years ago, had dropped to 235 per thousand by 5-9 years before the survey, and has now been 214 per thousand over the past five years. These results confirm the trend toward a drop in fertility. Figure 4.3 Trends in Age-Specific Fertility Rates, Rwanda 1992, 2000, 2005, and 2007-08 ( ( ( ( ( ( ( " " " " " " " # # # # # # # $ $ $ $ $ $ $ 15 20 25 30 35 40 45 Woman's age 0 50 100 150 200 250 300 350 Births per 1,000 women 1992 RDHS-I 2000 RDHS-II 2005 RDHS-III 2007-08 RIDHS$ # " ( 28 | Fertility Table 4.4 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Rwanda 2007-08 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 43 55 67 20-24 214 235 256 25-29 279 283 302 30-34 251 269 281 35-39 208 225 [229] 40-44 106 [140] - 45-49 [25] - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 4.3 PARITY AND PRIMARY INFERTILITY Women’s average parity by age group is calculated on the basis of the total number of children ever born in their lifetime. Table 4.5 presents these parities for all women and for currently married women. Overall, women have had an average of 2.6 children; among currently married women, parity is 3.8 children, or 1.2 children more than parity among all women. For all women, parity increases steadily and rapidly with age: from an average of less than 0.1 children at age 15-19, parity increases to 0.7 children at age 20-24 and to 6.4 children at age 45-49, the end of the childbearing years. The distribution of women by number of children ever born does not show Figure 4.4 Age-Specific Fertility Rates for Five-Year Periods Preceding the Survey RIDHS 2007-08 , , , , + + + + + * * * * * * # # # # # # # 15 20 25 30 35 40 45 Woman's age 0 50 100 150 200 250 300 350 Births per 1,000 women 0-4 years 5-9 yeaers 10-14 years 15-19 years# * + , Fertility | 29 early childbearing. Less than 5 percent of young women under the age of 20 have given birth to at least one child, but after age 20, fertility levels accelerate rapidly because 45 percent of women age 20-24 have given birth to at least one child. More than six women in ten (64 percent) age 25-29 have at least two children. Finally, at age 45-49, the end of the childbearing years, more than one woman in eight (12 percent) has given birth to 10 or more children. Compared with all women, parity among currently married women is higher for every age group. This illustrates the fact that fertility in Rwanda takes place within union (marital or consensual). Among currently married women, parity increases steadily with age: at age 20-24, 80 percent of women have had at least one child, and at age 25-29, this proportion has reached 94 percent. Among all women, the proportion with at least one child in age group 25-29 is smaller, 81 percent. Women who voluntarily remain childless are relatively rare in Rwanda, where the population is still strongly pronatal. For this reason, zero parity among married women age 35-49 would be an indicator of total or primary infertility. In Rwanda, only 1.3 percent of married women age 35-49 have never had a child and can be considered infertile. This number is consistent with the results from previous surveys: 1.3 percent in both the 2000 RDHS-II and 2005 RDHS-III. Among women age 45-49, the level of primary sterility is 0.4 percent, Finally, Table 4.5 shows the mean number of children ever born and the mean number of living children. Overall, women have an average of 2.2 living children, but among married women the number is 3.3, or 85 percent of children ever born. In other words, 15 percent of children ever born have died, which gives a general idea about the level of mortality. Table 4.5 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, Rwanda 2007-08 Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number of women Mean number of children ever born Mean number of living children ALL WOMEN 15-19 95.5 3.8 0.6 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,387 0.05 0.05 20-24 55.1 25.7 13.5 4.8 0.9 0.1 0.0 0.0 0.0 0.0 0.0 100.0 1,548 0.71 0.65 25-29 18.5 17.5 23.9 20.7 13.6 4.0 1.6 0.0 0.1 0.0 0.0 100.0 1,374 2.13 1.88 30-34 4.4 8.7 15.7 19.3 20.5 17.7 8.7 2.8 1.4 0.7 0.1 100.0 937 3.59 3.08 35-39 4.2 3.7 6.8 12.5 15.2 20.1 16.7 10.8 5.7 3.2 1.1 100.0 769 4.77 3.99 40-44 2.0 2.3 5.2 8.6 12.8 13.2 17.2 15.9 9.4 7.8 5.7 100.0 678 5.75 4.72 45-49 1.5 2.3 3.1 7.9 10.5 11.2 13.5 15.3 14.2 8.9 11.6 100.0 620 6.36 4.99 Total 34.6 11.4 10.9 10.2 9.0 7.3 5.9 4.3 2.9 1.9 1.6 100.0 7,313 2.59 2.17 CURRENTLY MARRIED WOMEN 15-19 (39.2) (43.2) (17.6) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 100.0 36 0.78 0.75 20-24 20.0 43.0 26.0 9.0 1.8 0.1 0.0 0.0 0.0 0.0 0.0 100.0 669 1.30 1.17 25-29 5.9 16.9 27.4 24.9 17.6 5.0 2.2 0.1 0.1 0.0 0.0 100.0 1,013 2.56 2.27 30-34 1.3 6.0 15.6 19.5 22.0 20.0 10.2 3.3 1.4 0.5 0.2 100.0 749 3.85 3.35 35-39 1.6 2.5 4.4 9.8 15.8 21.2 20.0 13.0 6.7 3.9 1.2 100.0 574 5.21 4.43 40-44 1.7 1.6 3.6 6.1 10.2 12.5 17.8 17.8 11.3 10.2 7.2 100.0 475 6.19 5.16 45-49 0.4 1.2 3.7 7.1 5.7 9.8 11.9 16.7 18.6 9.8 15.0 100.0 371 6.88 5.55 Total 6.1 14.0 16.2 14.7 13.3 10.8 8.8 6.3 4.4 2.9 2.5 100.0 3,888 3.82 3.26 Note: Figures in parentheses are based on 25-49 unweighted cases. 30 | Fertility 4.4 BIRTH INTERVALS Examination of birth intervals, defined as the length of time between two successive live births, is important not only for their impact on the health status of both mother and child, but for their role in fertility analysis. Currently, short birth intervals (less than 24 months) are considered harmful to the health and nutritional status of children, increasing the risk of death to both mother and child. Short birth intervals diminish a woman’s physiological capacity, exposing her to a greater risk of complications during and after pregnancy (miscarriage, eclampsia). Table 4.6 shows the distribution of non-first births in the five years preceding the survey by number of months since the preceding birth, according to background characteristics. Table 4.6 shows that a relatively low 9 percent of births occur less than 18 months after the preceding birth and that 13 percent of children are born 18 to 24 months after the birth of the preceding sibling, or a total of 22 percent of births with a birth interval of less than 24 months. However, a large proportion of births (38 percent) occur between 24 and 36 months after the preceding birth, and about 41 percent occur 36 or more months after the birth of the older sibling. The median duration of the birth intervals in Rwanda is nearly three years (32.5 months), which means that half of all births take place after an interval of nearly three years. The RIDHS median birth interval is close to the one estimated in the 2005 RDHS-III (31 months); likewise, the proportion of births that occurred after an interval of less than 24 months in the RIDHS (22 percent) is similar to that from the 2005 RDHS-III (23 percent). Mother’s age is related to the length of birth intervals. Birth intervals are shorter for younger women than for older women: the median duration is 29.4 months at age 20-29, 33.6 months at age 30-39 and 39.0 months among mothers age 40-49. This correlation between mother’s age and the length of the birth interval must be qualified by the fact that young women, who often have fewer children, are less inclined to delay the arrival of the next birth.2 This is confirmed in the percent distribution of births by length of birth interval, according to birth order. The results show a slight increase in the length of birth intervals according to birth order, from 31.9 months for birth orders 2-3, to 32.9 months for birth orders 4-6, and 33.5 months for birth order 7 and higher. Regarding differentials in the length of birth intervals, there are no significant differences by gender. However, when the preceding sibling has died, the birth interval is shorter—a median of 27.0 months, compared with 33.1 months when the preceding sibling is living. In addition, while only 6 percent of births occur within 18 months when the preceding sibling is living, more than 24 percent of births take place within 18 months when the preceding sibling has died. The median length of the birth interval differs slightly by urban-rural residence; it is lower in rural areas (32.4 months) than urban areas (33.3 months). By province, there is little variation in the length of birth intervals, which range from 32.0 months in the City of Kigali to 32.9 months in the West province. The survey results show that mother’s level of education has little effect on the length of birth intervals: the median birth interval for mothers who have never gone to school and for mothers who have secondary or higher education is the same (33.5 months); the birth interval for mothers with primary education is 32.1 months. 2 Only 0.7 percent of women age 15-19 and 19.3 percent of women age 20-24 have two or more children. Fertility | 31 Finally, there is no clear association between household wealth status (wealth quintile) and length of birth interval: the lowest (poorest) quintile has a median birth interval of 34.8 months, compared with durations between 31.6 and 32.8 months for the other quintiles. Table 4.6 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, Rwanda 2007-08 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48-59 60+ Total Number of non-first births Median number of months since preceding birth Age 15-19 * * * * * * * 11 23.9 20-29 11.5 16.2 43.3 17.9 6.6 4.4 100.0 1,669 29.4 30-39 6.8 12.6 36.7 23.4 9.8 10.8 100.0 2,034 33.6 40-49 6.8 7.8 27.2 26.6 12.0 19.6 100.0 720 39.0 Birth order 2-3 9.6 14.4 36.7 19.4 9.2 10.7 100.0 1,938 31.9 4-6 7.2 12.3 39.8 23.1 8.4 9.3 100.0 1,771 32.9 7+ 9.6 12.3 34.8 25.1 9.8 8.4 100.0 726 33.2 Sex of preceding birth Male 9.3 13.1 37.9 21.6 9.0 9.2 100.0 2,220 32.5 Female 8.0 13.3 37.4 22.0 8.9 10.4 100.0 2,214 32.6 Survival of preceding birth Living 6.2 12.7 39.1 23.2 9.1 9.8 100.0 3,833 33.1 Dead 23.8 16.5 28.2 13.1 8.4 9.9 100.0 601 27.0 Residence Urban 8.3 14.5 33.7 22.7 9.0 11.7 100.0 588 33.3 Rural 8.7 13.0 38.2 21.7 9.0 9.5 100.0 3,846 32.4 Province Kigali 10.8 15.9 32.0 19.5 9.2 12.6 100.0 307 32.0 South 6.7 14.9 35.5 21.3 10.1 11.4 100.0 1,123 32.8 West 8.7 14.1 36.3 22.6 8.9 9.4 100.0 1,106 32.9 North 8.3 12.4 40.2 23.8 7.0 8.3 100.0 807 32.4 East 10.2 10.3 40.8 20.7 9.2 8.8 100.0 1,091 32.3 Education No education 9.4 12.9 34.7 22.7 9.1 11.2 100.0 1,257 33.5 Primary 8.5 13.1 39.6 21.3 8.5 9.0 100.0 2,886 32.1 Secondary or higher 6.4 15.7 31.0 22.6 12.8 11.4 100.0 292 33.5 Wealth quintile Lowest 6.5 12.4 34.3 20.5 13.4 13.0 100.0 673 34.8 Second 8.2 10.3 41.9 22.6 7.9 9.1 100.0 1,317 32.8 Middle 10.6 12.5 39.3 20.6 9.1 7.9 100.0 873 31.7 Fourth 7.5 14.5 36.2 24.3 7.6 9.9 100.0 870 32.3 Highest 10.4 18.5 32.4 20.1 8.3 10.3 100.0 701 31.6 Total 8.6 13.2 37.6 21.8 9.0 9.8 100.0 4,434 32.5 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. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed 32 | Fertility 4.5 AGE AT FIRST BIRTH The age at which childbearing begins has a direct impact on a woman’s cumulative fertility and can have important effects on a woman’s health as well as that of her children. Table 4.7 shows the percentage of women who first gave birth by exact ages, and the median age at first birth, according to current age. The results show that the median age at first birth has remained largely unchanged from one generation to the next (from a low of 22.0 years to a high of 22.5 years); no trends could be seen indicating a rise or fall in the median age at first birth. Table 4.7 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, Rwanda 2007-08 Percentage who gave birth by exact age Current age 15 18 20 22 25 Percentage who have never given birth Number of women Median age at first birth 15-19 0.3 na na na na 95.5 1,387 a 20-24 1.1 6.7 19.0 na na 55.1 1,548 a 25-29 1.1 10.0 26.8 47.9 71.7 18.5 1,374 22.2 30-34 1.5 9.8 25.4 50.6 76.7 4.4 937 22.0 35-39 2.1 8.6 22.4 44.3 74.4 4.2 769 22.5 40-44 1.7 9.4 26.4 44.6 72.3 2.0 678 22.5 45-49 1.8 8.7 25.2 46.9 72.1 1.5 620 22.3 25-49 1.6 9.4 25.4 47.2 73.4 8.0 4,378 22.3 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.8 shows that the median age at first birth among women age 25-49 in Rwanda is 22.3 years; this is nearly the same as the median age at first birth observed for women age 25-49 in the 2005 RDHS-III (22.0 months). The table also provides differentials in age at first birth according to various socioeconomic characteristics. The first child arrives at a slightly younger age among women in rural areas (22.2 years) than among those in urban areas (22.5 years). The South province has the highest median age at first birth (23.0 years), followed by the City of Kigali (22.8 years). In the other provinces, median age at first birth varies from a low of 21.6 years in the East province to a high of 22.1 years in the West province. Women’s level of education affects the median age at first birth: women with no education (21.6 years) and women with primary education (22.3 years) have a lower median age at first birth than women with secondary or higher education (24.7 years). The results by household wealth show that the first birth occurs later among women in the highest (richest) quintile (22.8 years) than among those in the lowest (poorest) quintile (21.9 years). Fertility | 33 Table 4.8 Median age at first birth Median age at first birth among women age 25-49 years, according to background characteristics, Rwanda 2007-08 Age Background characteristic 25-29 30-34 35-39 40-44 45-49 Women age 25-49 Residence Urban 22.6 22.2 23.1 22.5 22.3 22.5 Rural 22.2 21.9 22.4 22.4 22.3 22.2 Province Kigali 22.8 22.7 24.0 22.1 22.9 22.8 South 23.3 22.8 23.0 23.2 22.7 23.0 West 22.3 21.9 22.1 22.3 22.0 22.1 North 21.6 22.1 22.1 22.1 22.2 22.0 East 21.4 21.1 22.1 22.2 21.7 21.6 Education No education 21.0 21.4 21.4 21.9 22.1 21.6 Primary 22.3 21.8 22.7 22.5 22.2 22.3 Secondary or higher na 23.9 24.7 24.5 25.0 24.7 Wealth quintile Lowest 21.7 21.5 21.8 22.0 22.4 21.9 Second 22.0 21.9 22.6 22.0 22.0 22.1 Middle 22.0 21.7 22.4 22.5 22.5 22.2 Fourth 22.1 22.3 22.7 22.9 21.9 22.4 Highest 23.0 22.4 22.9 23.0 22.9 22.8 Total 22.2 22.0 22.5 22.5 22.3 22.3 na = Not applicable 4.6 TEENAGE FERTILITY Teenage fertility is an important demographic factor for many reasons. First, children born to very young mothers run a greater risk of illness and death. Second, teenage mothers are more likely to suffer complications during pregnancy and less likely to treat them, exposing them to a greater risk of complica- tions during delivery and greater risk of dying for reasons related to childbearing. Third, early childbearing seriously affects a woman’s ability to pursue an education, find employment, and become independent. In Rwanda, teenagers make up 19 percent of all women of childbearing age, but comprise less than 4 percent of the total fertility for all women. Table 4.9 shows the percentage of young women age 15-19 who have had one or more children and the percentage who are currently in their first pregnancy. Together, these two groups constitute the proportion of teenagers who have begun childbearing (6 percent); of these, 5 percent have begun child- bearing and 1 percent are pregnant for the first time. By age 16-17, 2.5 percent of young women have begun childbearing. The percentage increases rapidly with age: at age 18, 9 percent of women have had at least one child or are pregnant for the first time, and by age 19, this proportion reaches 14 percent, with 11 percent having already had at least one child. 34 | Fertility Table 4.9 shows that teenagers in rural areas (6 percent) are slightly more likely to have begun childbearing than those in urban areas (5 percent), but the difference is small (0.5 percent). Similar differences are seen between provinces: the proportion of teenagers who have begun childbearing varies from 5 percent in the East province to 9 percent in the City of Kigali. Early childbearing occurs more frequently among teenagers with primary education (6 percent) and no education (5 percent) than among those with secondary or higher education (3 percent). The differentials by wealth quintile are small, ranging from 4 percent in the highest (richest) quintile to 7 percent in the second and middle quintiles. These narrow differentials mean that standard of living has little impact on the behavior of Rwandan teenagers regarding procreation. Finally, it should be noted that the proportion of teenagers who have begun childbearing has changed little since 2000, from 7 percent in 2000 to 4 percent in 2005 and to 6 percent in 2007-08. Table 4.9 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, Rwanda 2007-08 Percentage who: Background characteristic Have had a live birth Are pregnant with first child Percentage who have begun childbearing Number of women Age 15 0.0 0.0 0.0 265 16 1.9 0.7 2.6 274 17 1.2 1.2 2.4 267 18 7.3 1.3 8.6 293 19 11.3 2.8 14.1 288 Residence Urban 4.2 1.1 5.3 275 Rural 4.6 1.3 5.8 1,112 Province Kigali 6.4 2.7 9.1 155 South 4.5 1.1 5.6 371 West 3.4 1.7 5.2 320 North 5.0 1.1 6.0 234 East 4.2 0.2 4.5 308 Education No education 5.1 0.0 5.1 104 Primary 4.8 1.5 6.3 1,076 Secondary or higher 2.5 0.4 2.9 207 Wealth quintile Lowest 4.3 1.1 5.4 197 Second 5.6 1.5 7.1 356 Middle 4.3 2.6 6.9 244 Fourth 5.2 0.0 5.2 207 Highest 3.3 0.8 4.1 383 Total 4.5 1.2 5.7 1,387 Family Planning | 35 FAMILY PLANNING 5 Family planning activities in Rwanda initially began in 1982. However, following the inter- national conference on population and development that took place in Cairo in 1994, developing countries broadened their population and development policies and integrated family planning services within the overall scope of health and reproduction, Rwanda redefined its reproductive health policy to promote the inclusion of family planning services into all the country’s health services. By 1992 results from the RDHS-I had already shown that only 21 percent of currently married women were using any contraceptive method; 13 percent were using a modern method and 8 percent a traditional method (ONAPO and Macro International, 1994). Results from the 2000 RDHS-II revealed a drop in contraceptive prevalence among married women. The proportion using any method in 2000 was about 13 percent; 4 percent were using a modern method and 9 percent were using a traditional method. This drop was, to a large extent, a consequence of the social unrest in 1994 that derailed the health system and forced the population to rely more on traditional methods of family planning. In 2005, the proportion of currently married women using a modern contraceptive method had increased to 10 percent (2005 RDHS-III)—21 percent in urban areas and 9 percent in rural areas (INSR and ORC Macro, 2006). Nearly all women (95 percent) and all men (98 percent) know of at least one contraceptive method. As the previous discussion makes clear, contraceptive methods are underused in Rwanda. Fer- tility levels have remained high because of the low level of contraceptive use. A woman has an average of 5.5 children, a figure that has not changed appreciably since 1992 (6.2 children per woman). In the 2005 RDHS-III, 43 percent of married women wanted no more children and 59 percent wanted to use a family planning method in the future. In addition, nearly two married women in five (38 percent) had an unmet need for family planning: they wanted either to space their births or to limit the number of children but were not currently using a contraceptive method. A majority of these women wanted to use some method of birth spacing (25 percent), but 13 percent wanted to limit the size of their families. The 2005 RDHS-III showed a high frequency of lost opportunities for promoting family planning, such as encouraging advice and/or quality services. For example, nearly one in five women went to a health facility, but had not been asked by a health caregiver to discuss family planning. Implementation of the family planning and reproductive health program is coordinated by a task force on Maternal and Child Health (MCH) in the Ministry of Health. The Directorate of the Health Sector of the Government of Rwanda has adopted a new reproductive health policy that decentralizes the delivery of family planning services at all levels of the country’s health care system (FOSACOM, Health Center, District Hospital, Referral Hospital, private clinics, pharmaceutical outlets), and encourages the use of modern family planning methods. The new policy includes free health care services in state run facilities for women of childbearing age, sex education in the schools and improvement in access to basic reproductive health care. During the 2007-08 RIDHS, women were asked questions about use of family planning. Responses to these questions have provided an estimate of contraceptive prevalence in Rwanda. In addition, women who were not using contraception were asked if they intended to use it in the future. When the answer was affirmative, they were also asked which method they would choose. These results evaluated current activity and reconsidered, if necessary, the strategies that had already been put in place. 36 | Family Planning 5.1 KNOWLEDGE OF CONTRACEPTION The use of contraception presupposes prior knowledge of a least one contraceptive method. The different methods covered by the questionnaire fell into two categories: • Modern methods. These include voluntary surgical contraceptions (female sterilization, male sterilization), hormonal contraception methods (pill, injectables, implants), IUD (intrauterine device), barrier methods (male condom, female condom, diaphragm), vaginal methods (spermicides, foams and jellies), emergency contraception method (morning after pill), the lactational amenorrhea method (LAM), and the standard days method (SDM)/cycle beads. • Traditional methods. These include the rhythm or periodic abstinence method, withdrawal, and so-called “folk” methods such as herbs, amulets, tea infusions, and other methods of this type. Information concerning knowledge of contraceptive methods was gathered in two ways: first each respondent was asked to spontaneously name the contraceptive method(s) he or she knew about. Then, if a respondent failed to mention all the methods covered by the questionnaire, the interviewer briefly described the method and recorded whether or not the respondent had heard of it. A method was considered to be known by a respondent if she or he mentioned it spontaneously or recognized it after it was described. The results in Table 5.1 show that knowledge of family planning is nearly universal in Rwanda: 97 percent of all women reported having knowledge of at least one method of contraception and 99 percent of currently married women. Women are more familiar with modern methods than traditional methods, whether they are married or not: all women (97 percent know of modern methods and 79 percent know of traditional method), and currently married women (99 percent know of modern methods and 87 percent know of traditional methods). The average number of methods known by all women is 8.5 while among married women it is slightly higher (9.7). With respect to specific methods, results show that the most well known methods of family planning, whether for all women or for married women are the pill (88 percent and 95 percent respectively), injectables (90 percent and 96 percent, respectively), the male condom (93 percent and 95 percent, respectively), followed by female sterilization (65 percent and 72 percent, respectively), implants (60 percent and 74 percent, respectively) and the female condom (58 percent and 63 percent, respectively). The least familiar methods include the IUD (53 percent and 64 percent, respectively), the standard days method (52 percent and 64 percent, respectively), LAM (50 percent and 62 percent, respectively), and male sterilization (43 percent and 50 percent, respectively). With respect to traditional methods, 81 percent of married women reported knowing about the rhythm or periodic abstinence method, and 75 percent had heard of withdrawal. Comparing the results of the 2007-08 RIDHS with those of the 2005 RDHS-III shows an improvement in knowledge of contraceptive methods. The proportion of women who know at least one contraceptive method went from 95 percent in 2005 to 97 percent in 2007-08. In particular, the percentage of women who reported knowing about the IUD and the female condom increased between the two surveys. Family Planning | 37 Men were also asked about knowledge of family planning methods. Table 5.1 shows that almost all men (98 percent) know at least one contraceptive method. Modern methods are known by 98 percent of men and a smaller proportion (79 percent) reported knowing at least one traditional method. Thus, knowledge of modern contraceptive methods is almost as high among women as it is among men (97 and 98 percent, respectively), and knowledge of a traditional contraceptive methods is the same (79 percent for both). Table 5.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who know any contraceptive method, by specific method, Rwanda 2007-08 Women Men Method All women Currently married women All men Currently married men Any method 97.4 99.0 97.7 99.5 Any modern method 97.1 98.8 97.6 99.4 Female sterilization 65.3 71.9 66.4 77.0 Male sterilization 42.8 50.1 45.8 56.0 Pill 88.4 94.9 79.2 89.1 IUD 52.5 63.6 41.5 54.4 Injectables 89.7 96.2 82.0 91.3 Implants 60.0 73.8 42.4 57.8 Male condom 92.5 94.8 96.4 98.4 Female condom 57.7 63.1 53.6 60.2 Lactational amenorrhea (LAM) 49.5 61.5 31.9 44.2 Standard Days Methods (SDM) 51.9 64.1 0.0 0.0 Any traditional method 78.7 87.4 78.7 91.1 Rhythm 73.2 80.5 86.7 81.8 Withdrawal 58.9 74.5 62.1 80.0 Folk method 0.5 0.6 36.5 49.1 Mean number of methods known by respondents 15-49 8.0 9.1 7.6 9.1 Number of respondents 7,313 3,888 6,197 3,065 Mean number of methods known by respondents 15-59 na na 7.7 9.0 Number of respondents na na 6,837 3,656 na = Not applicable 5.2 KNOWLEDGE OF CONTRACEPTIVE METHODS BY BACKGROUND CHARACTERISTICS Table 5.2 shows the percentage of currently married women and men who know at least one modern contraceptive method, by background characteristics. The results for women do not show any important differences, either by age or other background characteristics, whether for any method or for any modern method. Knowledge of contraceptive methods is high for all subgroups of women, although the level for women age 15-19 is slightly lower (93 percent). Men’s knowledge of contraceptive methods by background characteristics is high for all subgroups, except for men age 15-19, who have the lowest level of knowledge of contraceptive methods, both for any method and for any modern method (88 percent for both). 38 | Family Planning Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men 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, Rwanda 2007-08 Women Men Background characteristic Heard of any method Heard of any modern method Number Heard of any method Heard of any modern method Number Age 15-19 92.6 92.6 36 88.1 88.1 8 20-24 99.1 98.9 669 99.7 99.7 282 25-29 99.2 98.7 1,013 99.2 99.2 714 30-34 99.5 99.4 749 99.6 99.4 635 35-39 99.6 99.5 574 99.9 99.9 546 40-44 98.1 97.8 475 99.6 99.6 486 45-49 97.9 97.9 371 99.0 98.6 393 Residence Urban 98.8 98.8 566 99.6 99.6 453 Rural 99.0 98.7 3,322 99.4 99.3 2,612 Province Kigali city 98.1 98.1 309 99.0 99.0 267 South 98.6 98.2 985 99.4 99.0 745 West 99.3 99.3 943 99.9 99.9 768 North 99.3 99.0 727 99.4 99.4 578 East 99.0 98.8 923 99.3 99.3 707 Education No education 97.8 97.3 1,011 98.5 98.1 611 Primary 99.5 99.3 2,539 99.7 99.7 2,091 Secondary or higher 98.9 98.9 338 99.6 99.6 363 Wealth quintile Lowest 98.8 98.8 528 99.3 99.3 371 Second 98.9 98.8 1,072 99.6 99.4 836 Middle 99.3 99.2 776 99.5 99.5 631 Fourth 99.2 98.7 795 99.2 98.9 649 Highest 98.6 98.4 716 99.7 99.7 578 Total 15-49 99.0 98.8 3,888 99.5 99.4 3,065 Total 15-59 na na 0 99.0 98.9 3,656 Family Planning | 39 5.3 USE OF CONTRACEPTION Data from the 2007-08 RIDHS are used to estimate levels of ever use of contraception as well as current use of contraception. 5.3.1 Ever Use of Contraception Women and men who said that they had heard of any contraceptive method(s) were asked if they had ever used the method(s). This information is used to measure past use of contraceptive methods (ever use). Table 5.3.1 shows the results for ever use of contraception by all women: almost two in five women (39 percent) have used a method of contraception at some time. Traditional methods (19 percent) have been used less frequently than modern methods (29 percent). Above age 20, the percentage of all women who have ever used any method or any modern method is higher for the most commonly used modern methods: injectables (17 percent), the pill (10 percent), male condoms (5 percent), and LAM (4 percent). With respect to other modern methods, the proportions are very small; only 0.5 percent of women have been sterilized. This method of family planning has been used most frequently by women age 45-45 (about 1 percent). Among traditional methods, periodic abstinence (14 percent) and withdrawal (10 percent) were used the most commonly used methods. Table 5.3.1 shows that ever use of contraception is much higher among married women than all women: about one in two (56 percent) married women has used a method of contraception at some time, compared with 39 percent of all women. Likewise, married women are more likely to have used a modern method (44 percent) than all women (29 percent), and more likely to have used a traditional method (25 percent) than all women (19 percent). As with all women, married women are most likely to have used injectables (26 percent) and the pill (15 percent) at some time in the past. Only 6 percent of married women have ever used the male condom. Periodic abstinence (17 percent) and withdrawal (16 percent) are the traditional methods most commonly used by married women at some time in the past. Table 5.3.2 presents the same results for men. Among all men, almost two in five age 15-49 (38 percent) have used a contraceptive method at some time in their life. Traditional methods have been used more often than modern methods (28 percent, compared to 18 percent). Ever use of modern methods of contraception is highest among men age 25 to 39 (25 percent for men age 25-29 and 30-34, and 26 percent for men age 35-39). The male condom (18 percent) is the most commonly used modern method while periodic abstinence (23 percent) is the most commonly used traditional method. Among married men age 15-49, more than half (54 percent) reported that they had used a method of contraception at some time in the past, which is higher than the percentage reported by all men (38 percent) (Table 5.3.2). The level of ever use of contraception among married men is similar to that for married women (54 and 56 percent, respectively). On the other hand, married men have used the male condom more often than married women (21 and 6 percent, respectively), and married men are more than twice as likely as married women to have used periodic abstinence (39 and 17 percent, respectively). T ab le 5 .3 .1 E ve r u se o f c on tra ce pt io n: W om en P er ce nt ag e of a ll w om en a nd c ur re nt ly m ar rie d w om en a ge 1 5- 49 w ho h av e ev er u se d an y co nt ra ce pt iv e m et ho d by m et ho d, a cc or di ng to a ge , R w an da 2 00 7- 08 M od er n m et ho d Tr ad iti on al m et ho d A ge An y m et ho d An y m od er n m et ho d Fe m al e st er ili za tio n M al e st er ili za tio n Pi ll IU D I nj ec ta bl es Im pl an ts M al e co nd om Fe m al e co nd om LA M SD M An y tra di tio na l m et ho d Pe rio di c ab st in en ce / rh yt hm W ith dr aw al Fo lk m et ho d N um be r of w om en AL L W O M EN 1 5- 19 10 .5 3. 1 0. 0 0. 0 0. 5 0. 0 0. 8 0. 1 1. 5 0. 0 0. 0 0. 6 8. 3 7. 9 0. 6 0. 0 1, 38 7 2 0- 24 28 .1 18 .5 0. 1 0. 1 5. 6 0. 4 8. 9 0. 5 4. 9 0. 3 2. 0 0. 7 14 .3 11 .7 5. 9 0. 0 1, 54 8 2 5- 29 46 .8 36 .4 0. 3 0. 0 12 .0 0. 8 21 .0 2. 4 5. 8 0. 1 3. 7 1. 2 19 .1 14 .2 10 .5 0. 1 1, 37 4 3 0- 34 58 .0 45 .7 0. 6 0. 2 14 .5 0. 6 28 .5 2. 2 8. 8 0. 0 6. 6 2. 1 24 .9 17 .3 15 .7 0. 0 93 7 3 5- 39 58 .1 44 .8 0. 8 0. 1 16 .2 0. 6 26 .3 1. 9 7. 4 0. 0 6. 7 0. 7 26 .6 18 .8 17 .4 0. 1 76 9 4 0- 44 55 .3 40 .1 1. 4 0. 3 16 .6 1. 2 25 .0 0. 9 5. 1 0. 1 5. 4 0. 8 28 .7 21 .1 15 .4 0. 1 67 8 4 5- 49 44 .8 33 .3 1. 1 0. 0 12 .1 0. 5 20 .6 1. 4 1. 2 0. 3 5. 5 1. 3 22 .5 16 .5 13 .6 0. 0 62 0 T ot al 39 .2 28 .5 0. 5 0. 1 9. 7 0. 5 16 .5 1. 2 4. 9 0. 1 3. 6 1. 0 18 .7 14 .2 9. 7 0. 0 7, 31 3 C U RR EN TL Y M A RR IE D W O M EN 1 5- 19 36 .4 29 .2 0. 0 0. 0 13 .1 0. 0 12 .4 0. 0 6. 6 0. 0 0. 0 0. 0 16 .6 9. 2 9. 3 0. 0 36 2 0- 24 42 .4 32 .7 0. 1 0. 2 11 .9 0. 8 16 .7 0. 9 5. 8 0. 4 3. 7 0. 9 17 .4 12 .3 10 .5 0. 0 66 9 2 5- 29 54 .1 43 .2 0. 4 0. 0 14 .2 1. 0 25 .8 3. 0 5. 2 0. 1 4. 6 1. 5 21 .3 14 .9 13 .2 0. 1 1, 01 3 3 0- 34 64 .0 50 .6 0. 4 0. 2 15 .6 0. 7 32 .3 2. 6 8. 5 0. 0 7. 3 2. 5 27 .5 18 .8 17 .9 0. 1 74 9 3 5- 39 64 .6 49 .7 0. 8 0. 2 18 .2 0. 7 29 .6 2. 2 8. 0 0. 0 7. 8 0. 9 30 .3 21 .7 20 .1 0. 1 57 4 4 0- 44 61 .1 45 .5 1. 7 0. 5 19 .1 1. 1 28 .1 1. 2 4. 6 0. 2 6. 7 1. 1 31 .6 21 .7 19 .5 0. 1 47 5 4 5- 49 51 .4 39 .3 1. 5 0. 0 14 .0 0. 3 25 .2 2. 1 0. 9 0. 5 7. 1 1. 6 26 .2 18 .6 17 .7 0. 0 37 1 T ot al 56 .0 43 .6 0. 7 0. 2 15 .2 0. 8 26 .1 2. 1 5. 9 0. 2 5. 9 1. 4 24 .8 17 .4 15 .8 0. 1 3, 88 8 L A M = L ac ta tio na l a m en or rh ea m et ho d SD M = S ta nd ar d D ay s M et ho ds 40 | Family Planning Family Planning | 41 Table 5.3.2 Ever use of contraception: Men Percentage of all men and currently married men age 15-49 who have ever used any contraceptive method by method, according to age, Rwanda 2007-08 Modern method Traditional method Age Any method Any modern method Male sterilization Male condom Any traditional method Periodic abstinence/ rhythm With- drawal Number of men ALL MEN 15-19 9.8 4.7 0.2 4.5 6.0 5.4 1.0 1,461 20-24 29.8 18.9 0.3 18.7 16.6 13.2 6.8 1,245 25-29 47.4 25.4 0.4 25.1 32.3 25.9 17.1 1,156 30-34 52.9 24.9 0.1 24.9 40.5 33.5 24.1 769 35-39 59.2 26.1 0.5 25.8 47.9 39.5 27.0 616 40-44 57.1 22.3 0.5 21.9 49.8 40.8 30.0 522 45-49 52.8 16.3 0.4 16.0 46.1 38.7 25.3 428 Total 15-49 38.0 18.3 0.3 18.1 28.0 22.9 14.7 6,197 Total men 15-59 38.7 17.5 0.4 17.2 29.3 24.0 15.7 6,837 CURRENTLY MARRIED MEN 15-19 17.1 0.0 0.0 0.0 17.1 17.1 0.0 8 20-24 47.3 20.2 0.0 20.2 40.1 30.3 21.0 282 25-29 52.6 21.3 0.4 20.9 43.4 36.0 23.6 714 30-34 52.2 20.2 0.1 20.2 43.8 38.3 25.6 635 35-39 60.5 24.3 0.5 23.9 51.7 43.0 29.3 546 40-44 58.3 21.6 0.5 21.2 52.3 42.8 31.5 486 45-49 53.4 15.4 0.5 15.0 47.8 39.9 26.5 393 Total 15-49 54.3 20.7 0.3 20.5 46.6 38.7 26.3 3,065 Total men 15-59 53.0 18.9 0.4 18.6 46.0 38.1 26.2 3,656 5.3.2 Current Use of Contraception Contraceptive prevalence is a measure of current use of contraceptive methods by women of childbearing age. Table 5.4 shows that for all women, nearly one in four women (24 percent) is currently using a contraceptive method; 16 percent are using a modern method while 8 percent are using a tradi- tional method. Women are mainly using two methods, just as they have in the past: injectables (9 percent) and the pill (4 percent). Other methods have low prevalence (less than 1 percent of all women), except for the male condom, which is used by 1.4 percent of women. Contraceptive prevalence among married women at the time of the survey was 36 percent for any method and 27 percent for any modern method; 9 percent of married women reported using a traditional method at the time of the survey. The most frequently used modern methods were injectables (15 percent) and the pill (6 percent). Periodic abstinence (6 percent) and withdrawal (3 percent) were the most frequently used traditional methods. The results for married women by age show that contraceptive prevalence, whether for any method or any modern method, increases up to age 30-34, and then drops off in the older age groups. Prevalence among married women rises from 24 percent among those age 15-19 to 45 percent among those age 30-34. Beyond this age group, prevalence tends to drop even though the proportion of users remains relatively high. Two in five married women age 35 to 44 are using a method of contraception, and at least one-quarter are using a modern method. Results by type of method show that modern methods are used more often than traditional methods (27 percent, compared with 9 percent). Among young married women age 20-24, in particular, 22 percent are using a modern method compared with only 5 percent who are using a traditional method . T ab le 5 .4 C ur re nt u se o f c on tra ce pt io n by a ge P er ce nt d ist rib ut io n of a ll w om en a nd c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to a ge , R w an da 2 00 7- 08 M od er n m et ho d Tr ad iti on al m et ho d A ge An y m et ho d An y m od er n m et ho d Fe m al e st er ili - za tio n M al e st er ili - za tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M SD M An y tra di - tio na l m et ho d Pe rio di c ab st i- ne nc e/ rh yt hm W ith - dr aw al Fo lk m et ho d N ot cu rr en tly us in g m et ho d To ta l N um be r of w om en AL L W O M EN 1 5- 19 7. 3 1. 5 0. 0 0. 0 0. 3 0. 0 0. 7 0. 1 0. 3 0. 0 0. 0 0. 1 5. 8 5. 7 0. 1 0. 0 92 .7 10 0. 0 1, 38 7 2 0- 24 16 .7 11 .0 0. 1 0. 0 2. 4 0. 0 6. 2 0. 5 1. 5 0. 0 0. 3 0. 1 5. 7 4. 9 0. 8 0. 0 83 .3 10 0. 0 1, 54 8 2 5- 29 30 .5 24 .5 0. 3 0. 0 5. 7 0. 1 13 .6 2. 0 1. 4 0. 1 1. 0 0. 3 6. 0 5. 1 0. 9 0. 0 69 .5 10 0. 0 1, 37 4 3 0- 34 39 .5 29 .5 0. 6 0. 2 5. 7 0. 1 16 .8 1. 5 2. 9 0. 0 1. 4 0. 3 10 .0 6. 2 3. 8 0. 0 60 .5 10 0. 0 93 7 3 5- 39 35 .2 25 .2 0. 8 0. 1 5. 9 0. 2 13 .3 1. 4 2. 3 0. 0 0. 9 0. 4 10 .0 7. 3 2. 8 0. 0 64 .8 10 0. 0 76 9 4 0- 44 32 .7 19 .1 1. 4 0. 1 4. 1 0. 1 10 .9 0. 6 1. 2 0. 0 0. 7 0. 2 13 .6 10 .0 3. 6 0. 1 67 .3 10 0. 0 67 8 4 5- 49 17 .5 10 .0 1. 1 0. 0 2. 6 0. 1 5. 1 0. 4 0. 3 0. 0 0. 2 0. 2 7. 5 5. 4 2. 1 0. 0 82 .5 10 0. 0 62 0 T ot al 23 .9 16 .3 0. 5 0. 0 3. 6 0. 1 9. 0 0. 9 1. 4 0. 0 0. 6 0. 2 7. 7 6. 0 1. 7 0. 0 76 .1 10 0. 0 7, 31 3 C U RR EN TL Y M A RR IE D W O M EN 1 5- 19 23 .7 23 .7 0. 0 0. 0 11 .2 0. 0 10 .5 0. 0 2. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 76 .3 10 0. 0 36 2 0- 24 26 .0 21 .6 0. 1 0. 0 5. 5 0. 1 12 .5 0. 9 2. 1 0. 0 0. 4 0. 0 4. 5 2. 6 1. 9 0. 0 74 .0 10 0. 0 66 9 2 5- 29 36 .3 30 .6 0. 4 0. 0 7. 4 0. 2 17 .0 2. 6 1. 2 0. 1 1. 3 0. 4 5. 6 4. 4 1. 2 0. 0 63 .7 10 0. 0 1, 01 3 3 0- 34 45 .1 34 .1 0. 4 0. 2 6. 6 0. 2 19 .6 1. 7 3. 2 0. 0 1. 8 0. 4 10 .9 6. 4 4. 6 0. 0 54 .9 10 0. 0 74 9 3 5- 39 42 .5 30 .4 0. 8 0. 2 7. 4 0. 2 16 .0 1. 7 2. 6 0. 0 1. 0 0. 5 12 .2 8. 7 3. 5 0. 0 57 .5 10 0. 0 57 4 4 0- 44 40 .8 25 .2 1. 7 0. 2 5. 7 0. 1 14 .1 0. 7 1. 5 0. 0 1. 0 0. 3 15 .6 10 .5 5. 0 0. 1 59 .2 10 0. 0 47 5 4 5- 49 23 .8 14 .3 1. 5 0. 0 3. 9 0. 1 7. 1 0. 7 0. 2 0. 0 0. 3 0. 4 9. 5 6. 0 3. 5 0. 0 76 .2 10 0. 0 37 1 T ot al 36 .4 27 .4 0. 7 0. 1 6. 4 0. 2 15 .2 1. 6 1. 9 0. 0 1. 0 0. 3 8. 9 6. 0 3. 0 0. 0 63 .6 10 0. 0 3, 8 88 N ot e: If a w om an is u sin g m or e th an o ne m et ho d, o nl y th e m os t e ffe ct iv e m et ho d is in cl ud ed in th is ta bu la tio n. LA M = L ac ta tio na l a m en or rh ea m et ho d SD M = S ta nd ar d D ay s M et ho ds 42 | Family Planning Family Planning | 43 Comparing the 2007-08 RIDHS results with those of previous surveys shows that use of contra- ceptive methods by married women has varied substantially over time. The proportion of married women using any method rose from 17 percent in the 2005 RDHS-III to 36 percent in the 2007-08 RIDHS. At the same time, use of modern methods rose from 10 to 27 percent. If the 2007-08 RIDHS results are compared with those from the 2000 RDHS-II, the level of contraceptive prevalence rose from 13 to 36 percent, nearly tripling the number of users in less than ten years. The increase is even greater for use of modern methods: from 4 percent among married women in 2000 to 27 percent in 2007-08. Figure 5.1 Contraceptive Use among Currently Married Women Age 15-49 RIDHS 2007-08 36 27 15 6 2 2 1 9 6 3 Any method Modern method Injectables Pill Male condom Implants LAM Tradi- tional method Periodic abstinence With- drawal 0 10 20 30 40 50 Percent 44 | Family Planning Table 5.5 shows the percent distribution of currently married women by use of contraceptive methods, according to background characteristics. Contraceptive prevalence among married women varies considerably by background characteristics, beginning with geographical differences. Use of modern methods is highest in urban areas (36 percent), in the City of Kigali (35 percent), and in the North province (33 percent). In rural areas, only 26 percent of married women are using a modern method and in the South province, only 23 percent use a modern contraception. Contraceptive prevalence increases with level of education, from 19 percent among those with no education to 29 percent among those who have gone to primary school, to 43 percent for the most educated women. Results by number of children ever born show that contraceptive prevalence increases with the number of children, from 1 percent among woman with no children to 33 percent among women with 3-4 children, and then to 30 percent among women who have 5 or more children. Contraceptive prevalence by specific methods does not show these patterns. Finally, contraceptive prevalence increases with household wealth status (wealth quintile), from 22 percent in the lowest (poorest) quintile, to 27 percent in the middle and fourth quintiles, to 39 percent in the highest (richest) quintile. Figure 5.2 Trends in Use of Modern Methods among Currently Married Women 20 13 13 14 3 4 20 9 10 36 26 27 Urban Rural Total 0 10 20 30 40 50 Percent 1992 RDHS-I 2000 RDHS-II 2005 RDHS-III 2007-08 RIDHS T ab le 5 .5 C ur re nt u se o f c on tra ce pt io n by b ac kg ro un d ch ar ac te ris tic s P er ce nt d ist rib ut io n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, R w an da 2 00 7- 08 M od er n m et ho d Tr ad iti on al m et ho d B ac kg ro un d ch ar ac te ris tic An y m et ho d An y m od er n m et ho d Fe m al e st er ili - za tio n M al e st er ili - za tio n Pi ll IU D I nj ec t- ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M SD M An y tra di tio na l m et ho d Pe rio di c ab st in en ce / rh yt hm W ith - dr aw al Fo lk m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en R es id en ce U rb an 44 .6 36 .1 1. 8 0. 0 8. 8 1. 0 17 .6 1. 9 3. 6 0. 0 1. 0 0. 4 8. 5 6. 1 2. 4 0. 1 55 .4 10 0. 0 56 6 Ru ra l 35 .0 25 .9 0. 5 0. 1 6. 0 0. 0 14 .8 1. 5 1. 6 0. 0 1. 0 0. 3 9. 0 5. 9 3. 1 0. 0 65 .0 10 0. 0 3, 32 2 P ro vi nc e Ki ga li ci ty 41 .8 34 .5 1. 9 0. 0 8. 8 0. 9 16 .6 1. 2 3. 9 0. 0 0. 9 0. 3 7. 3 5. 1 2. 2 0. 0 58 .2 10 0. 0 30 9 So ut h 33 .5 22 .9 0. 4 0. 0 4. 8 0. 1 12 .5 1. 9 1. 5 0. 0 1. 3 0. 5 10 .5 6. 9 3. 6 0. 0 66 .5 10 0. 0 98 5 W es t 33 .9 26 .3 1. 0 0. 3 6. 2 0. 2 14 .0 1. 1 1. 9 0. 1 1. 0 0. 6 7. 5 4. 9 2. 6 0. 0 66 .1 10 0. 0 94 3 N or th 44 .0 33 .3 0. 3 0. 1 8. 9 0. 0 19 .7 2. 4 1. 5 0. 0 0. 4 0. 0 10 .6 7. 5 3. 1 0. 0 56 .0 10 0. 0 72 7 Ea st 34 .2 26 .3 0. 5 0. 0 5. 5 0. 1 15 .5 1. 2 1. 9 0. 0 1. 4 0. 2 7. 9 5. 1 2. 8 0. 0 65 .8 10 0. 0 92 3 E du ca tio n N o ed uc at io n 27 .3 19 .0 0. 5 0. 0 3. 8 0. 0 11 .8 0. 7 1. 0 0. 0 1. 2 0. 0 8. 3 6. 1 2. 2 0. 0 72 .7 10 0. 0 1, 01 1 Pr im ar y 37 .4 28 .7 0. 7 0. 1 7. 0 0. 1 16 .2 1. 5 1. 9 0. 0 0. 9 0. 3 8. 6 5. 5 3. 2 0. 0 62 .6 10 0. 0 2, 53 9 Se co nd ar y or h ig he r 55 .8 42 .7 1. 2 0. 0 9. 5 1. 3 18 .2 4. 7 4. 5 0. 0 1. 4 2. 0 13 .1 9. 3 3. 9 0. 0 44 .2 10 0. 0 33 8 N um be r of li vi ng c hi ld re n 0 2. 5 0. 7 0. 0 0. 0 0. 0 0. 0 0. 5 0. 0 0. 0 0. 0 0. 0 0. 3 1. 7 1. 4 0. 3 0. 0 97 .5 10 0. 0 26 6 1- 2 33 .0 25 .9 0. 2 0. 0 7. 2 0. 1 13 .1 1. 4 2. 4 0. 1 1. 2 0. 2 7. 1 5. 1 2. 0 0. 0 67 .0 10 0. 0 1, 36 4 3- 4 40 .7 32 .5 0. 9 0. 1 6. 9 0. 4 18 .8 1. 8 1. 8 0. 0 1. 4 0. 4 8. 2 5. 3 2. 9 0. 0 59 .3 10 0. 0 1, 22 2 5+ 44 .4 30 .2 1. 2 0. 2 6. 5 0. 0 17 .6 1. 9 1. 8 0. 0 0. 7 0. 4 14 .2 9. 1 5. 1 0. 0 55 .6 10 0. 0 1, 03 7 W ea lth q ui nt ile Lo w es t 27 .6 21 .7 0. 4 0. 1 6. 1 0. 1 12 .0 0. 7 1. 1 0. 0 1. 2 0. 0 5. 9 3. 7 2. 3 0. 0 72 .4 10 0. 0 52 8 Se co nd 30 .3 23 .2 0. 4 0. 3 5. 2 0. 0 14 .1 0. 9 1. 3 0. 0 1. 0 0. 1 7. 0 4. 3 2. 7 0. 0 69 .7 10 0. 0 1, 07 2 M id dl e 36 .1 26 .8 0. 3 0. 0 6. 2 0. 0 16 .1 1. 0 1. 8 0. 0 1. 0 0. 4 9. 3 7. 2 2. 1 0. 0 63 .9 10 0. 0 77 6 Fo ur th 38 .8 27 .4 0. 4 0. 0 6. 1 0. 1 15 .6 2. 4 1. 4 0. 1 1. 0 0. 4 11 .4 7. 4 4. 0 0. 0 61 .2 10 0. 0 79 5 H ig he st 49 .6 38 .6 2. 0 0. 0 8. 9 0. 7 18 .0 3. 0 4. 0 0. 0 1. 1 0. 9 10 .9 7. 2 3. 7 0. 0 50 .4 10 0. 0 71 6 T ot al 36 .4 27 .4 0. 7 0. 1 6. 4 0. 2 15 .2 1. 6 1. 9 0. 0 1. 0 0. 3 8. 9 6. 0 3. 0 0. 0 63 .6 10 0. 0 3, 88 8 N ot e: If a w om an is u sin g m or e th an o ne m et ho d, o nl y th e m os t e ffe ct iv e m et ho d is in cl ud ed in th is ta bu la tio n. LA M = L ac ta tio na l a m en or rh ea m et ho d SD M = S ta nd ar d D ay s M et ho ds Family Planning | 45 46 | Family Planning 5.4 FUTURE USE OF CONTRACEPTION Married women who were not using a contraceptive method at the time of the survey were asked whether they planned to use one in the future. Table 5.6 shows the percent distribution of these women by intention to use a method in the future, according to number of living children. Table 5.6 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use a method in the future, according to number of living children, Rwanda 2007-2008 Number of living children1 Intention 0 1 2 3 4+ Total Intends to use 75.3 83.9 79.4 73.8 59.7 71.2 Unsure 5.0 2.2 2.1 1.7 1.3 1.9 Does not intend to use 18.1 13.0 18.0 23.6 38.2 26.2 Missing 1.7 0.9 0.4 0.8 0.8 0.8 Total2 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 110 462 498 409 995 2,474 1 Includes current pregnancy 2 Include missing or don't know Nearly three in four women (71 percent) reported that they plan to use a contraceptive meth- od in the future. By comparison, more than a quar- ter of women (26 percent) said that they did not intend to use contraception in the future while 2 percent were not sure. More than three women in four (75 percent) with no children intend to use a method of family planning in the future. This pro- portion is highest (84 percent) among women hav- ing one child. 5.5 REASONS FOR NOT USING CONTRACEPTION Women who were not using contraception and do not plan to use it in the future were asked to give their reason. Table 5.7 shows that 69 percent of women gave reasons relating to fertility: in par- ticular, menopause or hysterectomy (28 percent); 12 percent of women said they were opposed to the use of contraception: whether it was opposition of the husband/partner (2 percent), opposition of the woman herself (6 percent), or opposition motivated by religious prohibitions (4 percent); and 13 percent of women gave method-related reasons for not in- tending to use a contraceptive method. These rea- sons included health concerns (3 percent) and fear Table 5.7 Reason for not intending to use contraception in the future Percent distribution of currently married women age 15-49 who are not using contraception and who do not intend to use a method in the future by main reason for not intending to use a method, Rwanda 2007-08 Age Reason 15-29 30-49 Total Fertility-related reasons Infrequent sex/no sex 2.8 16.5 14.4 Menopausal/had hysterectomy 0.7 32.9 27.9 Subfecund/infecund 35.7 23.2 25.1 Wants as many children as possible 1.2 2.2 2.0 Opposition to use Respondent opposed 11.2 4.7 5.7 Husband/partner opposed 3.4 1.2 1.5 Others opposed 0.3 0.0 0.1 Religious prohibition 8.5 3.4 4.2 Lack of knowledge Knows no method 4.2 0.4 1.0 Knows no source 0.0 0.3 0.2 Method-related reasons Health concerns 2.6 3.3 3.2 Fear of side effects 21.8 6.0 8.5 Inconvenient to use 0.0 0.4 0.4 Interferes with body's normal process 0.8 0.8 0.8 Other 4.7 3.9 4.0 Don't know 1.1 0.5 0.6 Missing 1.1 0.5 0.6 Total 100.0 100.0 100.0 Number of women 100 547 647 Family Planning | 47 of side effects from contraceptive methods (9 percent). Very few women gave reasons related to lack of knowledge about contraceptive methods or lack of knowledge of where to obtain family planning services (1 percent). Results by broad age groups show that biological reasons were cited more frequently by older women (age 30-49) than by younger women (15-29). On the other hand, it was the younger women who most often reported opposition to contraception (11 percent, compared with 5 percent), and the younger women who most often cited lack of knowledge as their reason for not using contraception (4 percent, compared with 0.4 percent). 5.6 PREFERRED FUTURE CONTRACEPTIVE METHODS To assess the potential demand for specific contracep- tive methods, married women who reported intending to use contraception in the future were asked to state their preferred method. Table 5.8 shows that most women prefer modern methods regardless of their age; in particular, injectables for both those age 15-29 (48 percent) and age 30-49 (45 percent), followed by the pill (25 and 19 percent, respectively), and implants (7 and 8 percent, respectively). Other modern methods were rarely cited, except for female sterilization (3 percent for women age 15-29 and 7 percent for women age 30-49), the IUD (4 percent for women in both age groups), and periodic abstinence (4 and 6 percent, respec- tively). Table 5.8 Preferred method of contraception for future use Percent distribution of currently married women age 15-49 who are not using a contraceptive method but who intend to use a method in the future by preferred method, Rwanda 2007-08 Age Method 15-29 30-49 Total Female sterilization 2.6 6.6 4.2 Male sterilization 0.0 0.2 0.1 Pill 25.0 19.2 22.6 IUD 4.0 4.0 4.0 Injectables 48.1 45.2 46.9 Implants 6.5 8.2 7.2 Condom 2.8 2.3 2.6 Female condom 0.1 0.2 0.2 Lactation amenorrhea 0.4 0.5 0.5 Periodic abstinence 4.2 6.3 5.0 Withdrawal 0.9 1.5 1.2 Other 0.0 0.4 0.2 Unsure 2.9 3.0 2.9 Missing 0.0 0.2 0.1 Total 100.0 100.0 100.0 Number of women 1,036 726 1,762 Fertility Preferences | 49 FERTILITY PREFERENCES 6 Data on fertility preferences are used to evaluate the effectiveness of couples’ efforts to control their own fertility and to assess future contraceptive needs not only for birth spacing, but to limit the total number of births. To obtain information about fertility preferences, the 2007-08 RIDHS asked women how many additional children they wanted to have in the future, how long they wanted to wait before having their next child, and the total number of children desired. Data on attitudes and opinions about procreation have always been somewhat controversial. Some researchers think responses to questions about fertility preferences represent viewpoints that are subject to change rather than firm convictions, or that responses do not take into account the effects of social pressure and the attitudes of other family members, particularly the husband, who may have considerable influence over reproductive decisions. In addition, the data are obtained from a sample of women of different ages with different birth histories. Responses relate to medium- or long-term goals that may change over time or may be of limited predictive value for young and/or recently married women. The responses of older women and/or women at the end of their childbearing years are inevitably influenced by their birth histories. This chapter discusses the following issues: desire to have more children, family planning needs, ideal number of children, and fertility planning. 6.1 DESIRE TO HAVE MORE CHILDREN The desire to have more children in the future generally correlates with a woman’s age and the number of living children she and/or her husband have. The 2007-08 RIDHS asked currently married women a series of questions designed to obtain information on their desire to delay the next birth or to stop having children. The results presented in Table 6.1 and Figure 6.1 show that nearly one in two women (48 percent) reported wanting no more children, while 44 percent wanted to have another child. Among the women who wanted more children in the future, 7 percent wanted another child within two years. This proportion was 12 percent in the 2005 RDHS-III. Table 6.1 also shows that among the women who wanted more children in the future, a majority (36 percent) want to delay the next birth by two or more years. So, overall, 84 percent of women either want no more children (48 percent) or want to delay the next birth for two years or more (36 percent). This means that more than four of five married women can be considered potentially favorable toward family planning. The percentage of women who want no more children has increased with each successive survey, from 33 percent in the 2000 RDHS-II, to 42 percent in the 2005 RDHS-III, and to 48 percent in the 2007- 08 RIDHS. Additionally, the proportion of married women who want no more children increases with the number of living children the woman has, from 1 percent among women with no children, to 56 percent among women with three children, to 83 percent among women with six children or more. Likewise, nearly all nulliparous women (93 percent) want to have a child, and a majority (81 percent) wants to have a birth soon (within the next two years). Women with one child, like those with no children, want to have another birth (93 percent), but unlike the nulliparous women, a majority of these parity 1 women want to wait at least two years before the next birth (79 percent). 50 | Fertility Preferences As parity increases, the proportion of women who want another child drops rapidly and the proportion of women who do not want another child increases. The percentage of women who want another child drops from 93 percent among those with no children, to 37 percent among those with three children, and to 5 percent among women with six children or more. Table 6.1 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, Rwanda 2007-08 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total 15-49 Have another soon2 81.3 11.9 8.1 3.9 1.5 1.6 0.5 7.2 Have another later3 4.0 78.5 64.0 32.3 16.3 9.7 4.5 35.7 Have another, undecided when 7.7 2.5 1.3 0.5 1.2 1.1 0.3 1.3 Undecided 3.2 0.3 0.6 0.7 1.1 0.6 0.2 0.6 Want no more 1.2 5.3 22.6 55.5 71.3 77.2 82.5 48.4 Sterilized4 0.0 0.1 0.3 1.2 0.8 1.1 1.4 0.8 Declared infecund 1.7 1.4 3.1 5.8 7.6 8.7 10.5 5.8 Missing 0.9 0.0 0.1 0.1 0.2 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 116 651 759 686 573 445 656 3,888 1 Includes 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 Figure 6.1 Proportion of Currently Married Women Who Want No More Children, by Number of Living Children 0 1 2 3 4 5 6+ Number of living children 0 20 40 60 80 100 Percent RIDHS 2007-08 Fertility Preferences | 51 The results in Table 6.2 show that the percentage of women who do not want another child increases steadily with the number of surviving children, increasing from 5.4 percent among those with only one child to 84 percent among those with six children or more. This same trend is seen in urban and rural areas: the percentage of women in urban areas who do not want another child increases from 6 percent at parity one to 89 percent at parity six or more; in rural areas the increase is from 5 percent at parity one to 83 percent at parity six or more. The proportion of women who want to limit births differs slightly by province, ranging from 44 percent in the West province to 56 percent in the North province. The results by level of education show that women who have never gone to school (57 percent) are more likely to want to limit births than women who have primary school education (46 percent) or women with secondary of higher education (51 percent). Regarding household wealth status (wealth index), only the second and highest (richest) quintiles stand out with a higher proportion of women wanting no more children (51 percent for both), compared with 47 percent and 48 percent in the other quintiles. Table 6.2. 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, Rwanda 2007-08 Number of living children1 Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban * 5.8 29.2 62.1 78.5 80.7 88.9 50.4 Rural (1.4) 5.3 21.7 55.7 71.1 77.9 83.3 49.0 Province Kigali City * 5.1 30.4 62.8 77.1 75.2 89.4 47.7 South (4.3) 4.9 25.9 61.8 74.8 84.6 80.1 50.2 West * 3.8 13.8 45.0 60.5 74.9 79.3 43.6 North * 7.1 26.3 64.2 75.8 78.5 92.7 56.0 East * 6.5 24.8 53.9 73.8 75.4 84.1 49.0 Education No education (5.2) 13.7 22.4 55.0 68.3 83.6 82.5 57.2 Primary * 3.2 23.0 55.3 72.1 75.8 84.7 45.7 Secondary or higher * 8.3 22.5 69.8 83.3 74.8 86.2 51.3 Wealth quintile Lowest * 6.8 28.1 58.2 73.3 76.8 76.3 48.3 Second (3.9) 6.0 22.1 56.2 66.2 81.0 88.7 51.3 Middle * 5.4 18.3 54.1 70.5 76.7 85.7 47.4 Fourth * 1.8 21.7 51.9 71.3 78.2 78.8 46.7 Highest * 8.0 25.0 63.4 83.4 76.2 88.4 51.3 Total (1.2) 5.4 22.9 56.7 72.1 78.3 84.0 49.2 Note: Women who have been sterilized are considered to want no more children. An asterisk indicates that the figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes current pregnancy 52 | Fertility Preferences 6.2 IDEAL NUMBER OF CHILDREN Women’s reproductive behavior can be influenced by the ideal number of children they would like to have and the ideal number their husband/partner would like to have. To determine the ideal number of children, all women surveyed were asked one of the following two questions, according to their situation at the time of the survey: • To women with no living children: If you could choose the exact number of children you would like to have in your lifetime, how many would you have? • To women with living children: If you could go back to the time to when you had no children and choose the exact number of children you would like to have in your lifetime, how many would you have chosen? These seemingly simple questions may be awkward, particularly for women with living children who may specify an ideal number that differs from the number of children they already have. It may also be difficult for respondents to specify an ideal number that is lower than their current family size. The responses to these questions are presented in Table 6.3. Three percent of women were not able to give a numeric response, giving instead a general answer such as “However many God gives me,” “I don’t know,” or “any number.” Overall, the average ideal number of children reported by all Rwandan women is 3.3. Among married women this number has decreased from 4.5 in the 2005 RDHS-III to 3.6 in the 2007-08 RIDHS. There is a positive correlation between current family size and ideal family size. The mean ideal family size ranges from 2.9 children for all women with no children, to 4.1 for those with 6 children or more. Among women who were married at the time of the survey, ideal family size is not very different from that for all women (3.6), varying from 3.1 children for women with one child to 4.2 children for women with 6 or more children. Table 6.3 Ideal number of children Percent distribution of women age 15-49 by ideal number of children, and mean ideal number of children for all women and for currently married women, according to number of living children, Rwanda 2007-08 Number of living children1 Ideal number of children 0 1 2 3 4 5 6+ Total 0 3.7 1.0 0.7 0.9 0.4 0.1 0.7 1.7 1 1.1 3.8 1.2 0.8 0.1 0.7 0.7 1.3 2 27.4 25.6 21.1 10.8 17.1 11.7 11.5 20.5 3 38.6 41.9 40.1 34.0 20.1 29.0 20.2 34.2 4 22.9 20.6 29.8 38.6 43.7 32.9 38.3 29.9 5 3.2 3.3 3.5 8.6 9.6 11.5 9.2 5.8 6+ 1.1 1.9 1.7 3.3 6.9 11.4 13.4 4.2 Non-numeric responses 2.0 1.9 1.9 2.9 2.1 2.7 6.0 2.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,412 986 990 879 734 523 789 7,313 Mean ideal number children for:2 All women 2.9 3.0 3.2 3.6 3.7 3.9 4.1 3.3 Currently married women 3.0 3.1 3.3 3.6 3.7 3.9 4.2 3.6 1 Includes current pregnancy . 2 Means are calculated excluding respondents who gave non-numeric responses. Fertility Preferences | 53 Table 6.4 shows the mean ideal number of children for all women according to current age and background characteristics. The mean ideal number of children increases with women’s age, from 2.9 children among women age 15-19 to 3.8 children among women age 40-49. These data suggest that if the wishes of younger women are realized, there would be a substantial drop in fertility. The mean ideal number of children does not vary much by residence, province, level of education, or household wealth status. There is almost no difference between urban and rural areas: 3.2 children in urban areas, compared with 3.3 children in rural areas. With respect to province, there are slight differences in the mean ideal number of children ranging from 3.1 the City of Kigali and 3.2 in the South province, to 3.6 in the West province. The mean ideal number of children shows the greatest variation according to the level of education. The higher the level of education, the lower the mean ideal number of children: 3.6 for women with no education, compared with 2.9 children for women with a secondary or higher education. There is almost no difference by wealth quintile; only women in the highest (richest) quintile want a slightly lower mean ideal number of children (3.1), compared with other women (3.4). 6.3 FERTILITY PLANNING STATUS During the 2007-08 RIDHS, questions were asked concerning each child born in the five years preceding the survey, and the current pregnancy (if the respondent was pregnant). The purpose of these questions was to determine if, at the time she became pregnant, the woman wanted to be pregnant at that moment, if she would have preferred to be pregnant later, or if she had not wanted to become pregnant at all. The responses to these questions are used to measure couples’ effectiveness in controlling their fertility. Such questions require a woman to concentrate in order to remember her desires accurately at one or more specific times in the past five years. The data can be subject to rationalization because an unwanted pregnancy may have resulted in the birth of a child to which the mother has become attached. Table 6.5 shows that more than three in five births (64 per- cent) in the five years preceding the survey were wanted. Most of these births (52 percent) were planned and occurred at the desired time; 12 percent occurred earlier than the women would have liked; and 22 percent of births were associated with unwanted pregnancies. The majority of births were wanted and arrived according to desired timing, regardless of birth order. However, the results suggest that earlier births are better planned. The proportion of births that arrived according to desired timing declines steadily with increasing birth order, from 69 percent for first births to 40 percent for births of parity 4 or higher. Table 6.4 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Rwanda 2007-08 Background characteristic Mean ideal number of children Number of women Age 15-19 2.9 1,368 20-24 3.1 1,530 25-29 3.3 1,343 30-34 3.6 910 35-39 3.6 741 40-44 3.7 642 45-49 3.8 591 Residence Urban 3.2 1,207 Rural 3.3 5,918 Province Kigali 3.1 663 South 3.2 1,897 West 3.6 1,684 North 3.2 1,236 East 3.3 1,646 Education No education 3.6 1,558 Primary 3.3 4,733 Secondary or higher 2.9 835 Wealth quintile Lowest 3.3 1,083 Second 3.4 1,908 Middle 3.4 1,338 Fourth 3.4 1,275 Highest 3.1 1,521 Total 3.3 7,125 54 | Fertility Preferences Table 6.5 Fertility planning status Percent distribution of births to women 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, Rwanda 2007-08 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 69.2 2.0 12.2 16.5 100.0 1,374 2 56.1 15.9 13.3 14.6 100.0 1,165 3 54.6 17.0 14.8 13.6 100.0 1,040 4+ 39.9 14.5 32.9 12.6 100.0 2,764 Mother's age at birth <20 62.8 5.0 22.1 10.0 100.0 333 20-24 61.5 10.2 13.4 15.0 100.0 1,821 25-29 51.2 16.6 16.5 15.7 100.0 1,779 30-34 47.0 14.8 24.7 13.5 100.0 1,159 35-39 42.9 11.3 34.3 11.4 100.0 823 40-44 32.4 6.6 49.1 11.9 100.0 386 45-49 28.0 6.5 46.4 19.1 100.0 42 Total 51.6 12.5 21.9 14.0 100.0 6,343 With respect to age of the mother, the most planned births (wanted then) occurred among women age 20-24. This age group also had the lowest proportion (13 percent) of unplanned births (wanted no more). Conversely, births among older women age 40- 44 appear to be less planned: while 32 percent of women age 40-44 wanted the birth at that time, 7 percent wanted the birth later (mistimed), and 49 percent reported that the birth was unplanned. Table 6.6 compares the total wanted fertility rate (TWFR) with the total fertility rate (TFR). Calculation of the TWFR is the same as for the TFR, except that unwanted births are omitted from the numerator. Comparing the TFR (5.5) with the TWFR (3.7) shows the potential demographic impact of preventing unwanted births. Theoretically, the TWFR should be a better indicator of wanted fertility than the responses to the question on the ideal number of children. The TWFR index is closer to reality because the answers given by women probably take into account the sex of the living children and survival considerations. Answers to the question on the total number of wanted children, on the other hand, refer to children who are still living and assume an ideal distri- bution of the two sexes. Another difference between the two meas- ures is that the TWFR uses observed fertility as its departure point; consequently, it can never be higher than the TFR, unlike the ideal number of wanted children, which can be higher than the number of children who have already been born. If all unwanted births were eliminated, the total fertility rate for Rwandan women would be 3.7 children instead of 5.5 children, and fertility would be 33 percent lower than reported in the 2007-08 RIDHS. The greatest disparity between the TFR and the TWFR is seen among women in rural areas, those in the second wealth quintile, and among those who have never been to school. Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Rwanda 2007-08 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 3.3 4.7 Rural 3.8 5.7 Province Kigali 3.1 4.4 South 3.8 5.5 West 4.1 5.8 North 3.2 5.4 East 3.8 5.8 Education No education 4.1 6.1 Primary 3.8 5.7 Secondary or higher 2.7 3.8 Wealth quintile Lowest 4.0 5.8 Second 3.8 5.7 Middle 4.0 6.0 Fourth 3.8 5.8 Highest 3.0 4.4 Total 3.7 5.5 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. Maternal and Child Health | 55 MATERNAL AND CHILD HEALTH 7 The 2007-08 Rwanda Interim Demographic and Health Survey provides detailed information about the health of mothers and their children. Information presented in this chapter evaluates coverage of antenatal care and delivery care, as well as childhood vaccination coverage for children under age five and the prevalence of common childhood illnesses, specifically, respiratory infections, fever, and diarrhea. Comparison of the results with those of previous surveys shows not only that progress has been made but also identifies the problems that still remain in maternal and child health and reproductive health. 7.1 ANTENATAL CARE Monitoring of pregnant women through antenatal care visits helps reduce risks and complications during pregnancy and delivery. For this reason, the RIDHS asked women who had had a live birth in the five years preceding the survey if they had received antenatal care (ANC). Table 7.1 shows the distribution of the women’s most recent live births in the past five years according to type of medical personnel consulted by the mother during the pregnancy and the mother’s background characteristics. During the RIDHS, all categories of ANC providers consulted by the mother were recorded; however, if more than one provider was mentioned, only the provider with the highest qualifications was included in the tabulations. Nearly all of these women, more than nine in ten (96 percent), received antenatal care from trained health personnel including doctors, nurses and trained midwives. ANC consultations were mainly provided by midwives or nurses (92 percent) but, in some cases, also by doctors (3 percent). Just over 3 percent of the women reported receiving no antenatal care. The data do not vary much by background characteristics: the proportion of mothers who received antenatal care is greater than 90 percent for all variables. There is no difference by urban-rural residence (96 percent for both), and the data by province are similar with the proportion of women who received antenatal care ranging from 95 percent in the South and East provinces to 97 percent in the West and North provinces. The results according to the age of the mother at the child’s birth do not show any major differences, however a smaller proportion of women under age 20 received antenatal care (94 percent). There are no substantial differences by birth order. The largest differentials in antenatal care are found by mother’s level of education (although the proportions are high for all levels). Antenatal care coverage ranges from 94 percent among women who have never gone to school to 99 percent among those with the most education (Table 7.1). Finally, the proportion of women who received antenatal care is not affected by household wealth status (wealth index). 56 | Maternal and Child Health Differentials are seen in the health personnel consulted for antenatal care. The proportion of women who received antenatal care from a doctor is higher in urban areas than in rural areas (8 and 3 percent, respectively), higher in the City of Kigali, compared to the other provinces (10 percent, compared with 2 and 3 percent), and higher among women with secondary education or higher (14 percent, compared with 2 percent among women with no education and 3 percent among women with primary education). Likewise, women who live in households in the highest (richest) wealth quintile are more likely to visit a doctor for ANC consultations than women in households in the lower wealth quintiles (9 percent, compared with 2 percent for women in the lowest [poorest] quintile and 3 percent for women in the middle quintile). Table 7.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Rwanda 2007-08 Background characteristic Doctor Nurse/ midwife Traditional birth attendant Other No one Missing Total Percentage receiving antenatal care from a skilled provider1 Number of women Mother's age at birth <20 3.1 90.5 0.9 0.0 4.8 0.8 100.0 93.6 174 20-34 3.5 92.7 0.4 0.1 2.3 1.1 100.0 96.2 2,625 35-49 2.9 92.1 0.2 0.0 3.6 1.2 100.0 95.0 859 Birth order 1 4.3 93.0 0.5 0.0 1.3 1.0 100.0 97.2 690 2-3 3.2 92.7 0.4 0.0 3.2 0.5 100.0 95.9 1,240 4-5 4.0 91.9 0.3 0.2 2.0 1.6 100.0 95.9 878 6+ 2.2 92.1 0.3 0.0 3.9 1.4 100.0 94.3 850 Residence Urban 7.7 88.2 0.5 0.0 3.5 0.1 100.0 95.9 544 Rural 2.6 93.2 0.4 0.0 2.6 1.3 100.0 95.8 3,114 Province Kigali city 10.1 85.7 0.0 0.0 4.2 0.0 100.0 95.8 287 South 2.7 92.6 0.6 0.0 3.0 1.1 100.0 95.3 930 West 2.0 94.6 0.1 0.1 2.3 0.9 100.0 96.6 913 North 3.4 93.1 0.0 0.0 2.0 1.4 100.0 96.6 641 East 3.2 91.8 0.8 0.0 2.9 1.4 100.0 95.0 888 Mother's education No education 2.2 91.6 0.4 0.0 4.5 1.3 100.0 93.8 923 Primary 2.5 93.7 0.4 0.1 2.2 1.1 100.0 96.2 2,452 Secondary or higher 14.3 84.6 0.0 0.0 1.1 0.0 100.0 98.8 282 Wealth quintile Lowest 2.1 92.0 0.4 0.0 4.5 1.0 100.0 94.1 572 Second 1.9 92.8 0.4 0.1 3.1 1.7 100.0 94.7 1,034 Middle 3.0 94.1 0.3 0.0 1.7 0.9 100.0 97.2 705 Fourth 2.0 94.0 0.6 0.0 2.0 1.3 100.0 96.0 708 Highest 8.8 88.6 0.1 0.0 2.4 0.1 100.0 97.3 639 Total 3.4 92.4 0.4 0.0 2.7 1.1 100.0 95.8 3,658 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications was used in this tabulation. 1 Skilled provider includes doctor, nurse and midwife. Maternal and Child Health | 57 To be effective, antenatal care must be sought early in pregnancy and, more importantly, must con- tinue regularly through delivery. The World Health Organization (WHO) recommends at least four ANC visits at regular intervals throughout the pregnancy. Table 7.2 shows the number of ANC visits and the timing of the first visit. Slightly less than one in four women (24 percent) had the four recommended visits. Two-thirds of the women had 2 or 3 ANC visits (66 percent), and 6 percent had a single visit. With regard to the stage of pregnancy when the first ANC visit took place; 22 percent of respondents had their first visit when they were less than four months pregnant. In 37 percent of cases, the first antenatal visit took place between 4 and 5 months of pregnancy and 33 percent of first visits occurred relatively late, between 6 and 7 months of pregnancy. Only 3 percent of women waited until the final stage of pregnancy to have their first ANC visit. The median number of months of pregnancy at the first ANC visit is 5.4 months; the median in urban areas is 5.0 months while in rural areas—where women tend to have their first antenatal care consultation later than women in urban areas—it is 5.4 months. The lateness of the first ANC visit can be explained by a Rwandan tradition whereby women do not speak of their pregnancy until it is visible. Current policy in Rwanda encourages women to go for an antenatal consultation, which allows them to benefit from the distribution of bednets and to receive a tetanus vaccination. 7.1.1 Components of ANC The effectiveness of antenatal care depends not only on the type of examinations performed during the ANC visit, but also on the counseling and preventive measures provided to avoid miscarriage and other pregnancy complications. The 2007-08 RIDHS collected data on this important aspect of prenatal monitoring by asking women if, during their ANC visits for the most recent birth: they were told about the danger signs of pregnancy complications, they received specific medical examinations (weight, height, and blood pressure measurements), and they were given blood and urine tests. Women were also asked if they had received iron supplements, medications for intestinal parasites, and antimalarial drugs. The results are presented in Table 7.3 by background characteristics. Only 8 percent of women were informed of the signs of pregnancy complications, with little variation by background characteristics. The proportion of women who received this information was slightly higher among women age 35-49 (11 percent), among those with birth order 6 or above (11 percent), and among those who have secondary education or more (10 percent). During the ANC visit, other services (measurements and tests) were carried out by health care professionals (Table 7.3). The most commonly reported ANC services were: weight measurement (98 percent), blood pressure measurement (87 percent), and blood sample taken (71 percent). Eighteen percent of women seeking ANC services had a urine sample taken. Results by mother’s background characteristics show that overall, women in rural areas, those who have never been to school, and women Table 7.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Rwanda 2007-08 Residence Number and timing of ANC visits Urban Rural Total Number of ANC visits None 3.5 2.6 2.7 1 6.0 5.8 5.9 2-3 63.2 66.5 66.0 4+ 26.4 23.5 23.9 Don't know/missing 0.8 1.7 1.5 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 3.5 2.6 2.7 <4 26.2 21.3 22.0 4-5 36.7 37.2 37.1 6-7 30.0 33.3 32.8 8+ 2.7 3.6 3.4 Don't know/missing 0.8 2.1 1.9 Total 100.0 100.0 100.0 Number of women 544 3,114 3,658 Median months pregnant at first visit (for those with ANC) 5.0 5.4 5.4 Number of women with ANC 525 2,994 3,519 58 | Maternal and Child Health in the poorest households are the least likely to receive these basic components as part of their ANC visits. Four in ten women (41 percent) took iron supplements during pregnancy, whether in pill form or a syrup; 54 percent received antimalarial medication to protect against malaria during pregnancy, and about two in ten (18 percent) were given medication for intestinal parasites. Table 7.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who received iron tablets or syrup, drugs for intestinal parasites, and antimalarial drugs during the pregnancy for the most recent birth, and among women who received antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Rwanda 2007-08 Among women with a live birth in the past five years, the percentage who during the pregnancy for their last birth received: Among women who received antenatal care for their most recent birth in the past five years, the percentage who received specific services Background characteristic Iron tablets or syrup Intestinal parasite drugs Anti- malarial drugs Number of women with a live birth in the past five years Informed of signs of pregnancy complications Weighed Blood pressure measured Urine sample taken Blood sample taken Number of women with ANC for their most recent birth Mother's age at birth <20 39.7 18.4 56.4 174 7.8 97.1 84.2 17.7 75.6 164 20-34 40.4 19.1 52.1 2,625 6.8 97.5 87.5 18.5 72.3 2,537 35-49 43.1 14.1 61.0 859 10.5 97.4 85.8 16.3 65.2 818 Birth order 1 42.9 21.5 48.1 690 6.1 97.2 85.5 23.7 78.5 674 2-3 41.6 18.3 54.3 1,240 7.0 97.2 87.3 18.0 72.8 1,194 4-5 40.4 17.0 55.9 878 7.2 97.9 88.6 17.0 67.8 846 6+ 39.3 15.2 58.0 850 10.7 97.9 85.7 14.1 64.6 805 Residence Urban 42.9 20.0 54.9 544 7.9 98.2 94.3 34.4 84.8 525 Rural 40.7 17.5 54.3 3,114 7.7 97.4 85.6 15.1 68.4 2,994 Province Kigali city 42.3 18.9 56.9 287 8.7 96.9 93.0 44.5 84.5 275 South 42.0 16.4 55.4 930 8.1 97.2 88.6 16.4 68.1 892 West 53.2 23.1 52.5 913 6.9 98.2 88.1 16.3 77.5 884 North 33.6 15.6 58.3 641 7.0 98.0 86.9 17.1 60.5 619 East 32.4 15.4 51.6 888 8.3 96.9 82.0 13.5 69.8 850 Mother's education No education 39.0 15.8 59.8 923 7.5 97.3 85.2 13.5 66.6 869 Primary 40.5 18.3 53.1 2,452 7.6 97.4 86.5 17.0 70.5 2,370 Secondary or higher 52.5 20.9 47.6 282 9.5 98.5 95.8 40.1 86.9 279 Wealth quintile Lowest 39.7 16.0 55.9 572 7.9 96.3 83.1 16.3 66.8 541 Second 37.0 14.7 56.8 1,034 7.9 98.0 84.6 14.0 66.3 984 Middle 43.2 17.1 55.6 705 7.8 98.0 88.5 17.1 73.5 687 Fourth 43.2 22.6 47.8 708 7.2 97.7 87.3 15.4 69.7 684 Highest 43.8 20.4 54.9 639 7.6 96.9 91.7 29.5 79.7 623 Total 41.0 17.9 54.4 3,658 7.7 97.5 86.9 18.0 70.8 3,519 Vitamin A deficiency among pregnant women must be addressed to prevent night blindness. Night blindness is often caused by a lack of vitamin A. The condition can occur as a result of a lack of variety in foods and insufficient consumption of foods rich in vitamin A. Vitamin A deficiency has a negative impact on women’s health. Maternal and Child Health | 59 In the RIDHS, women were asked whether they had experienced night blindness during their pregnancy (i.e., difficulty seeing at nightfall or during the night). Table 7.4 indicates that nearly 6 percent of women who gave birth in past five years reported experiencing problems seeing at nightfall during their pregnancies. At the same time, some of these women reported that they also had difficulty seeing during the day. It is likely that these women have sight problems, but not necessarily night blindness. Thus, an “adjusted” prevalence for night blindness was calculated by removing women who reported having daytime sight problems from the “reported” night blindness total. The adjusted prevalence of night blindness is 3 percent. There are small differential in the prevalence of night blindness by background characteristics. The condition is less common among younger women (2 percent among women age 15-19) than older women (4 percent among women age 45-49). Night blindness is more common in rural areas (3 percent) than in urban areas (1 percent). By province, the proportion of women with this condition is slightly higher in the South, North, and East provinces (3 percent each) than in the City of Kigali (1 percent) or the West province (2 percent). The proportion of women with night blindness is two times higher among those in the lowest (poorest) wealth quintile (4 percent) than among those in the highest (richest) wealth quintile (2 percent). With regard to education, women who have never gone to school have the highest proportion of night blindness (4 percent, compared with 2 percent for women with education). Table 7.4 Micronutrient intake among mothers Among women who had a birth in the five years preceding the survey, percentage who experienced night blindness during pregnancy (reported and adjusted), percentage who (for last birth) took iron tablets or syrup for specific numbers of days, and percentage who (for last birth) took deworming medication, by background characteristics, Rwanda 2007-08 Percentage of women who experienced night blindness Number of days women took iron tablets or syrup during pregnancy for last birth Background characteristic Reported prevalence Adjusted prevalence None <60 60-89 90+ Don't know/ missing Percentage of women who took deworming medication during pregnancy for last birth Number of women Age 15-19 3.0 1.9 54.9 42.3 0.0 0.0 2.9 23.9 62 20-29 3.9 1.9 57.8 34.9 0.2 0.0 7.0 19.7 1,743 30-39 6.8 3.1 56.1 36.0 0.5 0.1 7.4 18.0 1,314 40-49 10.7 4.3 56.3 35.5 0.0 0.2 8.0 10.9 540 Residence Urban 3.2 1.2 56.2 36.5 1.0 0.3 5.9 20.0 544 Rural 6.4 2.9 57.0 35.3 0.2 0.0 7.4 17.5 3,114 Province Kigali city 2.1 1.4 56.0 35.1 1.4 0.5 6.9 18.9 287 South 7.7 3.3 56.5 37.2 0.3 0.1 5.9 16.4 930 West 4.9 1.7 44.7 48.2 0.1 0.0 6.9 23.1 913 North 6.6 2.9 63.8 26.9 0.4 0.0 8.8 15.6 641 East 5.9 3.3 65.2 27.1 0.0 0.0 7.7 15.4 888 Education No education 7.9 4.1 58.6 34.3 0.3 0.0 6.8 15.8 923 Primary 5.5 2.2 57.4 35.2 0.3 0.0 7.1 18.3 2,452 Secondary or higher 3.3 2.3 46.9 42.4 0.4 0.7 9.6 20.9 282 Wealth quintile Lowest 8.9 4.3 58.6 34.1 0.3 0.0 7.0 16.0 572 Second 5.6 2.8 60.0 32.2 0.1 0.0 7.7 14.7 1,034 Middle 6.1 1.7 55.1 37.5 0.6 0.0 6.9 17.1 705 Fourth 5.9 3.3 54.6 38.1 0.2 0.0 7.1 22.6 708 Highest 3.6 1.5 55.0 37.1 0.5 0.4 7.1 20.4 639 Total 5.9 2.7 56.9 35.5 0.3 0.1 7.2 17.9 3,658 60 | Maternal and Child Health Table 7.4 shows the proportion of women who took iron pills or syrup during pregnancy. Overall, about six in ten women (57 percent) reported that they had not taken any iron supplements during their last pregnancy in the past five years; 36 percent of the women took the supplements for less than 60 days, and less than 1 percent of the women took the supplements for 60 or more days. Nearly two-thirds of women in the East and North provinces (64 percent and 65 percent, respectively) did not receive iron supplements, while in the West province, 48 percent of women took the supplements for at least 60 days. Table 7.4 also shows that 18 percent of women said they had taken deworming medication during the last pregnancy. Use of deworming treatment is higher among younger women than older women: 24 percent among women age 15-19, compared with 11 percent among women age 40-49. The proportion of women who took deworming during pregnancy is highest among those in urban areas (20 percent), those in the City of Kigali (19 percent) and the West province (23 percent), among women who have at least a secondary education (21 percent), and among women in the two highest (richest) wealth quintiles (23 percent for the fourth quintile and 20 percent for the highest quintile). 7.1.2 Tetanus Vaccinations Neonatal tetanus is a major cause of death among newborns in most developing countries. Tetanus toxoid (TT) injections given to mothers during pregnancy protect both the mother and child against this disease. To be fully protected, a pregnant woman should receive two doses of the vaccine during her pregnancy; however, if she has already been vaccinated, for example during a previous pregnancy, one more dose is sufficient. It is important to note that the information presented here does not take into account the woman’s “vaccination history”; some women may have received the vaccine prior to the period under consideration. If the TT vaccination was received within the past 10 years, the woman will retain some immunity. Table 7.5 shows that while only 31 percent of women with a live birth in the five years preceding the survey received at least two doses of tetanus toxoid vaccine for their most recent pregnancy, 72 percent of mothers were fully protected against neonatal tetanus because of immunity accumulated from past tetanus toxoid immunizations. Some differentials by background characteristics are large. Mother’s age is an important factor in tetanus coverage: the proportion of women completely protected against neonatal tetanus increases from 49 percent among women under age 20, to 69 percent among women age 35-49. Similarly, intermediate order births are better protected than first births or higher order births: 81 percent coverage for birth orders 2-3, and 78 percent coverage for birth orders 4-5, compared with 54 percent for first births and 70 percent for birth orders 6 and above. Differences in TT coverage by rural-urban residence are not large: 71 percent of mothers in rural areas, compared with 73 percent in urban areas. Differences are more marked among provinces. The proportion of women who are completely vaccinated against neonatal tetanus is lowest in the City of Kigali (67 percent) and highest in the West province (78 percent). Other results presented in Table 7.5 show slight variations in TT coverage by level of education: 77 percent of women who have secondary education are completely protected against neonatal tetanus, compared with 72 percent of both those who have never been to school and those who have gone to primary school. The differences by wealth quintile show no major variations with respect to vaccination coverage. The lowest proportions of women who are completely protected against neonatal tetanus are in the lowest (poorest) wealth quintile and the highest (richest) wealth quintile (69 percent each). In the intermediate quintiles the TT coverage is between 73 and 75 percent. Maternal and Child Health | 61 Table 7.5 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid 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, Rwanda 2007-08 Background characteristic Percentage who received 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 36.4 48.7 174 20-34 35.6 75.0 2,625 35-49 14.8 69.4 859 Birth order 1 52.4 53.9 690 2-3 36.9 80.6 1,240 4-5 23.3 78.1 878 6+ 11.7 69.7 850 Residence Urban 31.5 70.5 544 Rural 30.6 72.8 3,114 Province Kigali city 32.2 67.3 287 South 33.1 70.0 930 West 25.6 77.6 913 North 33.1 71.4 641 East 31.3 72.2 888 Mother's education No education 27.3 71.9 923 Primary 31.3 72.1 2,452 Secondary or higher 36.9 77.2 282 Wealth quintile Lowest 29.6 68.6 572 Second 30.6 73.4 1,034 Middle 29.4 75.2 705 Fourth 32.0 74.3 708 Highest 31.8 69.2 639 Total 30.7 72.4 3,658 1 Includes mothers with two injections during the pregnancy for 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. 7.2 DELIVERY CARE 7.2.1 Place of Delivery Table 7.6 shows that 49 percent of the births in the five years preceding the survey took place at home and 45 percent were delivered at a health facility, mainly one in the public sector. However, among some groups of women, the proportion giving birth at home is higher than the national average. In rural areas the proportion is 52 percent, compared with 33 percent in urban areas. Among women who have never attended school, 61 percent give birth at home. The incidence of home births is highest among women who received no antenatal care (88 percent) and among women in households in the three lowest (poorest) wealth quintiles (more than 52 percent). However, in the capital, more than three in ten women 62 | Maternal and Child Health give birth at home (35 percent). In urban areas, about seven in ten births take place in a health facility (65 percent). Similar results are seen for births among women who have secondary education or higher (74 percent in a public facility and 5 percent are in a private facility), and births among women in the highest (richest) wealth quintile (62 percent in the public sector and 4 percent in the private sector). The place of delivery varies considerably by age of the mother. The incidence of home births increases with the mother’s age: 35 percent among women under the age of 20, 48 percent among those age 20-34, and 59 percent among women age 35-49. Child’s birth order is also related to the place of delivery. Sixty- six percent of first births take place in a public sector health facility, compared with 44 percent for birth orders 2-3, and 34 percent for orders 6 or more. Table 7.6 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, Rwanda 2007-08 Health facility Background characteristic Public sector Private sector Home Other Missing Total Percentage delivered in a health facility Number of births Mother's age at birth <20 58.8 1.2 35.2 0.5 4.3 100.0 60.0 314 20-34 45.6 0.9 47.7 1.7 4.1 100.0 46.5 4,214 35-49 35.4 0.8 58.9 1.6 3.3 100.0 36.2 1,129 Birth order 1 66.0 1.2 26.6 1.2 5.0 100.0 67.2 1,203 2-3 44.1 1.0 49.5 2.0 3.4 100.0 45.1 1,957 4-5 34.2 0.8 59.3 1.5 4.1 100.0 35.0 1,339 6+ 33.9 0.5 60.6 1.6 3.4 100.0 34.4 1,157 Residence Urban 60.9 3.5 32.8 0.8 1.9 100.0 64.5 804 Rural 41.6 0.4 52.0 1.8 4.3 100.0 42.0 4,852 Province Kigali city 55.2 5.6 35.4 0.4 3.5 100.0 60.8 425 South 40.9 0.6 53.3 1.7 3.6 100.0 41.4 1,442 West 47.3 0.5 47.8 1.2 3.2 100.0 47.8 1,408 North 43.7 0.6 48.5 2.9 4.4 100.0 44.3 991 East 42.1 0.4 51.2 1.4 4.9 100.0 42.5 1,390 Mother's education No education 31.3 0.3 61.3 1.6 5.6 100.0 31.6 1,453 Primary 46.1 0.6 48.0 1.7 3.5 100.0 46.7 3,793 Secondary or higher 73.9 5.3 18.3 0.9 1.6 100.0 79.2 410 Antenatal care visits None 8.6 0.0 88.0 2.7 0.7 100.0 8.6 99 1-3 45.8 1.0 51.2 1.6 0.4 100.0 46.8 2,628 4+ 63.8 0.9 32.5 2.3 0.5 100.0 64.7 875 Don't know/missing 17.2 0.0 19.0 0.0 63.8 100.0 17.2 56 Wealth quintile Lowest 36.3 0.1 57.8 2.3 3.5 100.0 36.4 851 Second 37.8 0.6 55.1 1.2 5.2 100.0 38.4 1,634 Middle 42.9 0.4 51.7 1.8 3.3 100.0 43.2 1,112 Fourth 46.5 0.2 47.3 1.9 4.1 100.0 46.7 1,106 Highest 61.8 3.5 30.9 1.2 2.6 100.0 65.3 954 Total1 44.3 0.9 49.2 1.6 3.9 100.0 45.2 5,656 1 Includes only the most recent birth in the five years preceding the survey Maternal and Child Health | 63 7.2.2 Assistance during Delivery Analysis of data in Table 7.7 shows that 52 percent of births in the five years preceding the survey were assisted by trained personnel (mainly midwives, nurses, and nurse’s aides); doctors assisted in 6 percent of deliveries. Two percent of deliveries were assisted by traditional birth attendants; relatives provided childbirth assistance in 30 percent of deliveries; and in 12 percent of deliveries, women received no assistance. Table 7.7 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider, according to background characteristics, Rwanda 2007-08 Person providing assistance during delivery Background characteristic Doctor Nurse/ midwife Auxiliary nurse/ midwife Traditional birth attendant Relative/ other No one Don't know/ missing Total Percentage delivered by a skilled provider1 Number of births Mother's age at birth <20 7.9 51.9 7.5 1.1 22.5 5.5 3.7 100.0 67.3 314 20-34 5.9 41.0 6.3 1.7 29.9 11.1 4.1 100.0 53.3 4,214 35-49 4.6 32.6 6.2 1.0 34.4 18.1 3.0 100.0 43.4 1,129 Birth order 1 10.0 57.7 6.1 1.3 16.1 4.3 4.5 100.0 73.8 1,203 2-3 5.8 39.7 6.5 1.8 32.2 10.5 3.5 100.0 52.0 1,957 4-5 3.5 32.2 7.1 1.7 33.9 17.4 4.3 100.0 42.7 1,339 6+ 3.9 30.9 5.7 1.1 38.2 17.0 3.2 100.0 40.5 1,157 Place of delivery Health facility 12.5 86.7 0.1 0.0 0.3 0.0 0.3 100.0 99.4 2,557 Elsewhere 0.1 0.9 12.4 3.0 59.3 23.9 0.4 100.0 13.4 2,877 Missing 1.1 6.4 0.0 0.0 2.7 0.0 89.8 100.0 7.5 222 Residence Urban 14.4 51.0 4.3 1.7 20.4 6.7 1.4 100.0 69.8 804 Rural 4.3 38.1 6.7 1.5 32.1 13.1 4.2 100.0 49.1 4,852 Province Kigali 16.1 46.2 3.2 2.3 22.3 6.9 3.0 100.0 65.5 425 South 5.1 36.8 8.8 1.7 32.1 12.0 3.5 100.0 50.7 1,442 West 4.1 44.1 3.7 0.5 33.4 11.2 3.0 100.0 51.9 1,408 North 5.2 39.4 3.1 1.0 29.1 17.5 4.7 100.0 47.7 991 East 5.4 37.5 9.9 2.5 29.0 11.2 4.7 100.0 52.7 1,390 Mother's education No education 2.5 29.4 7.1 2.0 36.4 17.2 5.4 100.0 39.0 1,453 Primary 5.5 41.9 6.5 1.4 30.2 11.0 3.5 100.0 53.9 3,793 Secondary or higher 20.0 59.4 2.6 1.1 11.0 4.5 1.5 100.0 82.0 410 Wealth quintile Lowest 2.9 33.9 5.9 1.4 38.0 14.4 3.6 100.0 42.7 851 Second 4.0 34.8 7.0 1.4 34.2 13.4 5.1 100.0 45.8 1,634 Middle 4.1 39.5 7.2 1.4 31.7 12.8 3.3 100.0 50.7 1,112 Fourth 4.9 42.5 6.5 2.5 25.5 14.6 3.6 100.0 53.9 1,106 Highest 14.3 51.7 4.6 0.8 21.3 4.5 2.8 100.0 70.6 954 Total 5.8 39.9 6.4 1.5 30.4 12.2 3.8 100.0 52.1 5,656 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person was included in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, and auxiliary nurse/midwife. 64 | Maternal and Child Health Births assisted by trained personnel show substantial differences by background characteristics. The proportion of women who received assistance at delivery from a skilled provider is highest among women under age 20 (67 percent) and lowest among women age 35-49 (43 percent); the proportion of women who received assistance from a skilled provider declines as birth order increases, from 74 percent among first births to 41 percent among birth orders six or more. The results by place of delivery show, as expected, that almost all births that take place in a health facility are assisted by trained personnel (99 percent). Births among urban women (70 percent) and those in the City of Kigali (66 percent) are more likely to be assisted by trained personnel than those in rural areas and the other provinces. Finally, a woman’s level of education and her household wealth status are important variables regarding assistance at delivery: women with at least a secondary education are more than twice as likely to be assisted at delivery by a skilled provider as women with no education (82 and 39 percent, respectively); likewise, 71 percent of women in the highest (richest) wealth quintile received assistance from trained personnel—14 percent were assisted by a doctor—compared with 43 percent of those in the lowest (poorest) wealth quintile. Trends Figure 7.1 shows changes in antenatal care and delivery care in Rwanda based on the results of the four DHS surveys between 1992 and 2007-08. Since 1992, nearly all women have received antenatal care: 94 percent in 1992, 92 percent in 2000, 94 percent in 2005, and 96 percent in the 2007-08 RIDHS survey. Childbirth conditions have improved noticeably: the proportion of women assisted at delivery by trained health personnel has increased from 26 percent in 1992, to 31 percent in 2000, then to 39 percent in 2005, and reaching 52 percent in 2007-08. Regarding delivery in a health facility, there were small improvements between 1992 and 2005, when the proportion of women giving birth in a health facility rose from 25 to 28 percent, then between 2005 and 2007-2008 the proportion increased dramatically from 28 to 45 percent. Figure 7.1 Trends in Antenatal Care and Delivery, Rwanda 1992, 2000, 2005, and 2007-08 94 26 25 92 31 26 94 39 28 96 52 45 Antenatal care Delivery assisted by trained personnel Delivery at a health facility 0 20 40 60 80 100 Percent 1992 RDHS-I 2000 RDHS-II 2005 RDHS-III 2007-08 RIDHS Maternal and Child Health | 65 7.3 VACCINATION OF CHILDREN To assess Rwanda’s Expanded Program on Immunization (EPI), the 2007-08 RIDHS gathered information on vaccination coverage for all children born in the five years preceding the survey. According to the World Health Organization’s (WHO) guidelines, a child is completely vaccinated when he or she has received a BCG vaccination (against tuberculosis), a measles vaccination, and three doses each of polio vaccine and DPT (against diphtheria, pertussis, and tetanus). WHO recommends that all these vaccinations be given before age one year. Information on childhood vaccinations was obtained from two sources: the child’s vaccination card and the mother’s reports when the card was not available or there was no card. Table 7.8 presents the results on vaccination coverage by source of information for children age 12 to 23 months, thereby including only children who had reached the age by which they should be fully immunized, according to the recommended schedule. The data from the two sources of information indicate that four in five children (80 percent) age 12 to 23 months are fully immunized. Table 7.8 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, Rwanda 2007-08 DPT or Pentavalent Polio Source of information BCG 1 2 3 01 1 2 3 Measles All basic vacci- nations2 No vacci- nation Number of children Vaccinated at any time before survey Vaccination card 66.8 66.8 66.4 66.1 62.8 66.9 66.3 65.8 64.1 63.5 0.0 821 Mother's report 28.7 28.1 26.2 23.7 22.4 28.7 26.6 19.7 26.3 16.9 3.8 405 Either source 95.5 94.8 92.6 89.8 85.2 95.6 92.9 85.5 90.4 80.4 3.8 1,226 Vaccinated by 12 months of age 95.2 94.3 91.9 88.5 84.9 94.9 92.2 84.5 82.9 73.8 4.2 1,226 Note: 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. 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) When information from both sources is considered, the percentage of children age 12-23 months who received BCG (normally given at birth) was 96 percent, with 95 percent having received the vaccine before the age of 12 months. For DPT, more than nine in ten children (95 percent) received the first dose, but coverage drops with successive doses, to 93 percent for the second dose, and to 90 percent for the third dose. For this vaccine, then, the dropout rate of loss between the first and second dose is 2 percent and the dropout rate between the first and third dose is 5 percent. Similar declines in coverage by dose are seen for polio vaccine: 96 percent received the first dose of polio vaccine, but coverage drops to 93 percent for the second dose, and to 86 percent for the third dose. The dropout rate of loss between the first and third dose of polio vaccine is about 10 percent. An additional 85 percent of children were given polio 0 at birth. Ninety percent of children age 12-23 months received the measles vaccination; however, only 83 percent received it before the age of 12 months. Of the children who were fully immunized, 74 percent received all their vaccinations before their first birthday (according to the recommended schedule). Only 4 percent of children age 12-23 months had not received any of the EPI vaccinations before the age of 12 months. 66 | Maternal and Child Health Trends One way of evaluating the changes that have occurred in vaccination coverage is to compare results from the current survey with those from the two most recent surveys. Results from the 2005 survey did not show any substantial changes in vaccination coverage when compared with the 2000 survey. The proportion of children fully immunized against the EPI target diseases was 76 percent in 2000 and 75 percent in 2005. Vaccination coverage of Rwandan children has, nevertheless, generally improved since 2000, with the proportion fully immunized rising from 76 to 80 percent currently. However, comparison of results from the current 2007-08 survey results with those from the initial survey in 1992 does not show an improvement in vaccination coverage. In fact, in 1992, 87 percent of children were reported as fully immunized. Vaccination coverage, therefore, has still not risen to the level prevailing in 1992. The proportion of children who have never been immunized has essentially remained stable at around 4 percent since 1992. 7.3.1 Vaccination Coverage by Type of Vaccine (Children Age 12-23 Months) Table 7.9 shows vaccination coverage among children age 12-23 months by background characteristics of the mother and child. There is almost no difference in coverage by sex (80 percent for boys and 81 percent for girls). By birth order, the results indicate that vaccination coverage for first births and for birth orders six and above is slightly higher than coverage for birth orders 2-3 and 4-5. There is almost no difference in coverage by urban-rural residence (81 percent in urban areas and 80 percent in rural areas). There are some differentials in the proportion fully immunized by province, with the highest coverage in the West and North provinces (85 percent for both). By comparison, coverage is 77 percent in the South and East provinces and 78 percent in the City of Kigali. Mother’s level of education is closely related to vaccination coverage. The proportion of children who are fully immunized ranges from 77 percent among children whose mothers have never gone to school, to 81 percent among children whose mothers have primary education, to 84 percent among children whose mothers have secondary education or higher. No trends were identified by household wealth status: there is almost no variation in immunization coverage between children in households in the lowest (poorest) wealth quintile (82 percent) and children in households in the highest (richest) wealth quintile (83 percent), although the proportion of children fully vaccinated is lowest in the middle wealth quintile (78 percent). The proportion of children who have not received any vaccinations is highest in the two lowest (poorest) wealth quintiles (5 percent for each), while in the three highest (richest) wealth quintiles, only 3 percent of children have not received any vaccinations. Maternal and Child Health | 67 Table 7.9 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, Rwanda 2007-08 DPT or Pentavalent Polio Background characteristic BCG 1 2 3 0 1 2 3 Measles All basic vaccinations2 No vaccination Percentage with a vaccination card seen Number of children Sex Male 95.9 95.3 93.1 90.1 84.6 95.6 93.7 86.2 90.1 80.2 3.9 65.4 613 Female 95.1 94.4 92.1 89.5 85.8 95.5 92.1 84.8 90.7 80.6 3.7 68.6 613 Birth order 1 96.8 96.1 93.3 89.5 87.2 96.8 92.9 85.7 92.7 82.6 3.2 66.6 240 2-3 94.1 93.9 91.2 87.8 83.9 93.9 91.7 85.4 89.5 79.0 5.0 64.4 447 4-5 96.1 96.2 95.0 92.7 86.3 96.4 94.7 86.8 88.3 79.3 2.9 69.4 283 6+ 96.0 93.7 91.8 90.3 84.4 96.5 92.9 84.1 92.2 82.0 3.3 69.1 256 Residence Urban 98.4 96.7 95.1 91.7 91.2 98.3 95.6 87.2 91.8 80.5 1.3 63.5 168 Rural 95.0 94.5 92.2 89.5 84.3 95.1 92.5 85.3 90.2 80.4 4.2 67.5 1,058 Province Kigali city 94.6 93.9 90.3 85.6 89.3 96.3 91.6 84.2 90.8 77.8 2.5 64.8 95 South 94.7 94.2 91.4 87.5 83.9 94.7 90.9 83.5 87.7 77.1 5.3 67.5 322 West 97.2 97.1 95.0 93.9 90.4 96.8 94.4 87.7 92.4 85.3 2.8 73.4 318 North 94.1 92.2 91.4 91.0 87.8 94.0 93.3 88.6 92.9 84.5 3.9 69.3 204 East 95.8 95.2 93.1 88.2 77.6 96.1 93.5 83.6 89.2 76.7 3.6 58.3 287 Mother's education No education 95.6 93.6 91.0 88.2 86.6 95.1 90.9 82.1 86.1 77.0 4.0 71.1 303 Primary 95.1 94.8 92.6 89.8 84.3 95.4 93.1 86.4 91.4 81.3 4.0 65.3 825 Secondary or higher 98.7 98.7 97.6 94.9 88.4 98.7 97.0 88.8 95.3 84.0 1.3 68.7 98 Wealth quintile Lowest 94.9 93.6 92.9 90.7 86.7 94.9 92.8 86.2 89.4 81.5 5.1 66.4 199 Second 94.1 94.4 92.1 88.7 84.8 94.7 90.7 83.5 88.2 79.0 5.1 67.6 323 Middle 97.3 95.4 93.9 90.9 87.2 96.9 93.2 84.2 90.2 78.2 2.7 70.2 254 Fourth 94.8 94.1 91.9 89.7 82.9 94.6 93.7 85.5 92.8 81.2 2.9 67.1 245 Highest 96.9 96.9 92.5 89.3 84.8 97.2 95.0 89.9 92.3 83.4 2.8 62.3 204 Total 95.5 94.8 92.6 89.8 85.2 95.6 92.9 85.5 90.4 80.4 3.8 67.0 1,226 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) Data on childhood vaccinations were collected for all children under age five. Trends in vaccination coverage can be evaluated retrospectively before the age of 12 months for the four years preceding the survey, beginning with data for children ages 12-23, 24-35, 36-47 and 48-59 months. Table 7.10 presents the vaccination coverage rates as seen on the vaccination card or as reported by the mothers for children in these age groups. The proportion of children in each age group who had a vaccination card that was seen by the interviewer is also shown. Vaccination cards were seen by interviewers for 56 percent of all children age 1-4 years. The highest proportion of children with vaccination cards is in age group 12-23 months (67 percent). Thereafter, the proportion declines steadily with increasing age, to 46 percent in the oldest age group (48- 59 months). The decline in vaccination cards seen is partly the result of the cards being lost as the child gets older. Overall, 65 percent of children age 1-4 were fully immunized before the age of one year: 91 percent of the children had received BCG, 84 percent had received the third dose of DPT, 78 percent 68 | Maternal and Child Health had received the third dose of polio, and 76 percent had been vaccinated against measles. Nine percent of children age 1-4 had not received any EPI vaccinations before the age of one year. Because these vaccinations were given before the age of 12 months, the differentials in vaccination rates by child’s current age reflect differences in vaccination coverage during the four years preceding the survey, or the period 2004-05 to 2007-08. The proportion of children who received BCG and three doses each of DPT and polio vaccine appears to show improvement over this period, with coverage increasing from 85 to 95 percent for BCG, from 78 to 89 percent for DPT, and from 71 to 85 percent for polio. There has been a drop in loss rates between the first and third doses of polio, from 13 percent in 2004-05 to 10 percent in 2007-08. The improvement in measles vaccination coverage is also substantial, increasing from 70 to 83 percent over the past four years. The measles vaccination is given late in the first 12 months, as is the third dose of DPT and polio. The proportion of children under age five who received all the recommended vaccines during the last four years has increased considerably: from 58 percent in 2004-05 to 74 percent in 2007-08. Table 7.10 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Rwanda 2007-08 DPT or Pentavalent Polio Age in months BCG 1 2 3 01 1 2 3 Measles All basic vacci- nations2 No vacci- nations Percentage with a vaccination card seen Number of children 12-23 95.2 94.3 91.9 88.5 84.9 94.9 92.2 84.5 82.9 73.8 4.2 67.0 1,226 24-35 92.3 90.8 87.5 84.8 80.4 91.8 88.6 79.2 75.4 64.1 7.3 59.0 959 36-47 88.7 87.8 84.8 81.4 75.2 88.3 85.7 76.0 72.8 61.2 10.2 51.3 1,066 48-59 84.5 83.0 80.7 78.0 71.6 84.0 81.1 70.7 69.5 57.5 14.4 45.7 963 Total 90.7 89.5 86.8 83.7 78.5 90.3 87.5 78.2 76.0 64.9 8.6 56.3 4,213 Note: Information was obtained from the vaccination card or if there was no written record, from the mother. 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 vaccinations. 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) 7.4 CHILDHOOD ILLNESSES 7.4.1 Acute Respiratory Infections Acute Respiratory Infections (ARI), particularly pneumonia, are one of the main causes of death among children under age five in developing countries. To assess the prevalence of these infections, mothers were asked if their children under five years had been ill with a cough during the two weeks preceding the survey. If the answer was yes, they were asked if the cough had been accompanied by short, rapid breathing. Although insufficient for establishing a true diagnosis, the presence of these two symptoms is, in many cases, an indicator of acute respiratory infection, and even pneumonia. For children reported by the mother as having symptoms of ARI, information was gathered on whether or not treatment had been sought. Maternal and Child Health | 69 Table 7.11 shows the prevalence and treatment of symptoms of acute respiratory infection among children under age five: 15 percent of the children had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. Respiratory infections were reported most frequently for children age 6-11 months (22 percent). There is no notable difference in ARI prevalence between boys and girls (16 percent for boys and 15 percent for girls). The prevalence of ARI is 15 percent in both urban and rural areas, and differentials by wealth quintile are minor. Results according to mother’s level of education vary only slightly, with ARI prevalence slightly lower among children of mothers with no education (16 percent) than among children of mothers with secondary or higher education (18 percent). Table 7.11 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 for whom advice or treatment was sought from a health facility or provider, and percentage who received antibiotics as treatment, according to background characteristics, Rwanda 2007-08 Children under five with symptoms of ARI Children under five Background characteristic Percentage with symptoms of ARI1 Number of children Percentage for whom advice or treatment was sought from a health facility or provider2 Percentage who received antibiotics Number of children Age in months <6 16.7 500 25.4 15.3 84 6-11 21.6 528 32.5 10.7 114 12-23 16.7 1,226 29.3 14.1 205 24-35 14.4 959 26.2 10.8 139 36-47 13.9 1,066 30.8 16.5 148 48-59 11.1 963 21.5 8.0 107 Sex Male 15.9 2,623 31.1 13.0 417 Female 14.5 2,618 24.7 12.5 379 Residence Urban 15.4 764 38.1 14.1 117 Rural 15.2 4,478 26.3 12.6 679 Province Kigali city 13.8 400 42.4 11.8 55 South 16.0 1,340 21.0 9.1 215 West 17.1 1,312 30.1 12.2 225 North 11.5 925 32.3 26.7 107 East 15.4 1,263 27.1 10.2 195 Mother's education No education 15.8 1,321 18.7 7.8 209 Primary 14.6 3,523 28.6 14.1 514 Secondary or higher 18.4 397 50.7 18.2 73 Wealth quintile Lowest 15.5 778 15.8 7.9 120 Second 16.5 1,501 22.8 12.5 247 Middle 14.9 1,040 25.2 10.6 155 Fourth 14.2 1,016 37.1 19.9 145 Highest 14.2 907 42.9 12.6 129 Total 15.2 5,241 28.0 12.8 796 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related) are considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 70 | Maternal and Child Health Results by province show the highest prevalence of ARI in the West province (17 percent), followed by the South province (16 percent), and the East province (15 percent). The prevalence of ARI is lowest in the North province (12 percent). Table 7.11 shows that treatment was sought from a health facility or provider for 28 percent of children under five with symptoms of ARI. Treatment was sought most often for children age 6-11 months (33 percent)—which is the age group with the highest prevalence of ARI—and least often for children age 48-59 months (22 percent). The differentials in treatment-seeking indicate that children with ARI are more likely to be taken for treatment if they are boys (31 percent, compared with 25 percent for girls) and if they live in urban areas (38 percent, compared with 26 percent in rural areas). The greater likelihood of a child being taken for treatment in urban areas is related to the greater availability of health facilities and the greater accessibility of the health infrastructure in urban areas than in rural areas. Among the provinces, children in the City of Kigali (42 percent) are the most likely to be taken to a health facility or provider for treatment of ARI; only 21 percent of sick children in the South province received care. The likelihood of a child being taken for treatment of ARI increases with mother’s level of education: 19 percent among children whose mothers have no education, 29 percent among children whose mothers have primary education, and 51 percent among children whose mothers have secondary or higher education. Treatment for ARI was sought for 43 percent of children in households in the highest (richest) wealth quintile, compared to 25 percent of children in the middle wealth quintile, and 16 percent of children in the lowest (poorest) wealth quintile. Table 7.11 shows the proportion of children with ARI symptoms who were treated with antibiotics. The results by child’s age show that children under age six months (15 percent) and those age 36-47 months (17 percent) were most likely to be treated with antibiotics. No variation was seen by gender of the child. There is almost no difference by urban-rural residence in treatment of ARI with antibiotics: 14 percent in urban areas and 13 percent in rural areas. There are large differences by province, ranging from 9 percent in the South province to 27 percent in the North province. A trend can be seen in the treatment of ARI with antibiotics by mother’s level of education. The proportion of children treated with antibiotics increases as the mother’s education increases, from 8 percent among children whose mothers have no education, to 14 percent among children whose mothers have primary education, and to 18 percent among children whose mothers have attained at least secondary education. No trend in the use of antibiotics was seen by wealth quintile; however, in the lowest (poorest) wealth quintile only 8 percent of children with ARI were treated with antibiotics, compared with 20 percent in the fourth quintile. 7.4.2 Fever Fever is the primary symptom of many illnesses including malaria and measles, which cause numerous deaths in developing countries. For this reason, mothers were asked whether their children under age five years had experienced a fever in the two weeks preceding the survey. For the children who had experienced a fever, information was gathered on whether the child was taken to a health facility or provider for a consultation, and the treatment that was received. Table 7.12 shows the results on the prevalence and treatment of fever among children under five in the two weeks preceding the survey. About one in five children (21 percent) were reported by their mothers as having a fever in the two weeks preceding the survey. Differentials are shown by child’s age, Maternal and Child Health | 71 province, mother’s level of education, and wealth quintile. Age is an important factor in the prevalence of fever because children age 6-23 months are the most likely to have a fever. The prevalence of fever among children age 6-11 months is 32 percent and among children age 12-23 months, 26 percent had a fever in the two weeks preceding the survey. The prevalence of fever varies by province; it is highest in the West province (24 percent), followed by the East province (23 percent), the North province (19 percent), and the City of Kigali (18 percent). Mother’s level of education is related to the prevalence of fever in children. Children whose mothers have no education are most likely to have fever (23 percent), followed by children of mothers with primary education (21 percent), with children of mothers with secondary or higher education being the least likely to have fever (19 percent). Table 7.12 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage for whom treatment was sought from a health facility or provider, the percentage who received antimalarial drugs, and the percentage who received antibiotic drugs, by background characteristics, Rwanda 2007-08 Children under five with fever Children under five Background characteristic Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who received antimalarial drugs Percentage who received antibiotic drugs Number of children Age in months <6 14.6 500 35.8 3.3 23.8 73 6-11 31.7 528 39.3 6.4 17.1 167 12-23 25.5 1,226 36.4 7.2 19.1 313 24-35 23.1 959 36.9 6.3 14.8 222 36-47 18.8 1,066 33.3 2.2 15.1 201 48-59 15.4 963 25.6 6.4 10.3 149 Sex Male 21.7 2,623 36.4 5.8 16.4 568 Female 21.2 2,618 33.4 5.5 16.4 556 Residence Urban 19.0 764 34.7 5.3 17.9 145 Rural 21.9 4,478 35.0 5.7 16.2 978 Province Kigali city 17.7 400 41.2 3.6 18.6 71 South 20.6 1,340 27.3 3.9 9.6 276 West 23.5 1,312 35.8 5.0 14.7 309 North 18.7 925 38.4 4.6 24.9 173 East 23.4 1,263 37.5 9.0 19.0 296 Mother's education No education 22.7 1,321 27.1 7.0 12.8 300 Primary 21.2 3,523 35.2 4.8 16.2 748 Secondary or higher 19.2 397 63.2 9.1 33.0 76 Wealth quintile Lowest 24.7 778 28.2 7.0 10.0 192 Second 21.0 1,501 29.7 4.1 16.3 316 Middle 21.9 1,040 30.7 1.1 13.8 228 Fourth 22.5 1,016 40.2 8.9 21.0 229 Highest 17.6 907 51.8 9.0 21.3 160 Total 21.4 5,241 34.9 5.6 16.4 1,124 1 Excludes pharmacy, shop, and traditional practitioner 72 | Maternal and Child Health Among children with fever, 35 percent were taken to a health facility or provider for treatment. As in the case of treatment of ARI, the differentials in treatment of children with fever indicate that they are more likely to be taken for treatment if they are age 6-11 months (39 percent), boys (36 percent, compared with 33 percent for girls), children whose mothers have secondary education or higher (63 percent), and children in the highest (richest) wealth quintile (52 percent). Table 7.12 also shows the percentage of children with fever who received antimalarial drugs (6 percent) and the percentage who received antibiotics (16 percent). Use of these drugs is limited, but children under the age of 6 months (24 percent) are more likely to be treated with antibiotics than other children. Likewise, children are more likely to receive modern medicines if their mothers have secondary or more education (9 percent for antimalarial drugs and 33 percent for antibiotics) or if they live in households in the highest (richest) wealth quintile (9 percent for antimalarial drugs and 21 percent for antibiotics). 7.4.3 Diarrhea Prevalence of diarrhea Diarrheal diseases constitute one of the main causes of death among young children in developing countries because of associated dehydration and malnutrition. To combat the effects of dehydration, WHO promotes the use of oral rehydration therapy (ORT), which includes a prepared solution of oral rehydration salts (ORS) from packets, or a solution prepared at home using water, sugar, and salt (recommended home fluids, or RHF). To assess the prevalence of diarrheal diseases in children under the age of five, mothers interviewed in the 2007-08 RIDHS were asked whether their children had diarrhea in the two weeks preceding the survey. Table 7.13 shows that more than one in six children under age five (14 percent) had one or more episodes of diarrhea in the two weeks preceding the survey. The prevalence of diarrhea is especially high among children age 6-11 months (23 percent) and age 12-23 months (22 percent). These high-prevalence ages are when children begin to be weaned and to consume foods other than breast milk. They also correspond to the ages at which children begin to explore their environment, resulting in greater exposure to pathogens. While diarrhea prevalence varies little by gender and urban-rural residence, there are differences by province: children in the City of Kigali and the South province have the highest prevalence of diarrhea (15 percent) while those in the North province have the lowest prevalence (11 percent). Mother’s level of education is closely related to the prevalence of diarrhea. Children whose mothers have no education are most likely to have diarrhea (16 percent), followed by children whose mothers have primary education (13 percent). Children whose mothers have secondary education are least likely to have diarrhea (12 percent). The results on diarrhea prevalence by wealth quintile are variable, but children in the lowest (poorest) wealth quintile have the highest prevalence of diarrhea (16 percent). Maternal and Child Health | 73 Table 7.13 Prevalence of diarrhea Percentage of children under age five who had diarrhea in the two weeks preceding the survey, by background characteristics, Rwanda 2007-08 Diarrhea in the two weeks preceding the survey Background characteristic All diarrhea Diarrhea with blood Number of children Age in months <6 5.6 0.5 500 6-11 23.1 3.3 528 12-23 22.0 2.3 1,226 24-35 15.4 2.7 959 36-47 9.5 1.3 1,066 48-59 5.3 1.0 963 Sex Male 14.1 2.1 2,623 Female 13.4 1.6 2,618 Source of drinking water Improved1 12.2 1.6 3,254 Not improved 14.5 2.2 739 Other/missing 17.1 2.4 1,248 Toilet facility Improved, not shared2 12.9 1.7 4,357 Non-improved or shared 18.6 3.1 805 Missing 9.8 0.5 80 Residence Urban 13.9 1.4 764 Rural 13.7 1.9 4,478 Province Kigali city 14.9 1.1 400 South 14.8 1.6 1,340 West 13.6 1.5 1,312 North 11.4 1.9 925 East 14.0 2.7 1,263 Mother's education No education 15.7 2.8 1,321 Primary 13.2 1.6 3,523 Secondary or higher 12.0 0.9 397 Wealth quintile Lowest 15.8 2.1 778 Second 11.9 1.4 1,501 Middle 14.7 3.1 1,040 Fourth 14.0 1.6 1,016 Highest 13.4 1.2 907 Total 13.7 1.9 5,241 1 Improved sources of drinking water include piped into dwelling/ compound/plot, public tap, protected well in compound/plot, protected public well, and bottle water. 2 Improved toilet facilities include flush toilet and ventilated improved pit (VIP) latrine, not share with other household. Treatment of diarrhea Table 7.14 shows that treatment was sought for one-third (33 percent) of children with diarrhea in the two weeks preceding the survey. Treatment was most often sought for children age 12-47 months (33 to 35 percent), those in urban areas (38 percent), those in the City of Kigali (49 percent), those in the highest (richest) wealth quintile (51 percent), and those whose mothers have secondary education or higher (59 percent). Treatment was also sought more frequently when blood was present in the feces than when it was not (41 and 32 percent, respectively). 74 | Maternal and Child Health Table 7.14 Diarrhea treatment Among children under age five who had diarrhea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration 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, Rwanda 2007-08 Oral rehydration therapy (ORT) Other treatments Background characteristic Percentage taken to a health provider1 ORS packets RHF Either ORS or RHF Increased fluids ORS, RHF or increased fluids Anti- biotic Anti- motility Zinc supple- ments Intra- venous solution Home remedy /other Missing No treat- ment Number of children Age in months <6 25.5 15.5 1.4 15.5 6.7 15.5 5.1 0.0 0.0 0.0 3.3 9.0 67.2 28 6-11 28.6 19.4 9.4 28.8 9.4 32.0 15.6 3.4 0.0 0.0 25.7 0.0 47.0 122 12-23 34.8 21.8 10.4 30.8 15.1 40.3 11.1 2.2 0.4 0.3 25.2 2.0 40.4 270 24-35 32.9 22.5 10.1 30.9 19.3 42.8 11.1 1.0 0.0 0.0 27.2 0.9 37.1 148 36-47 35.3 26.0 10.3 35.5 17.4 44.9 10.3 3.0 0.0 0.0 21.3 1.9 37.7 101 48-59 28.2 12.9 21.3 34.2 14.7 40.1 6.8 0.0 0.0 0.0 27.4 0.0 41.9 51 Sex Male 30.7 20.9 9.5 30.0 15.3 37.4 11.6 3.0 0.3 0.0 23.1 1.1 42.9 369 Female 34.5 21.6 11.7 31.5 14.6 40.8 10.8 1.0 0.0 0.3 25.9 2.0 40.2 350 Type of diarrhea Non-bloody 31.6 21.5 11.0 31.1 15.9 39.8 10.1 2.2 0.2 0.2 23.7 1.4 42.4 552 Bloody 41.1 29.9 5.6 35.5 10.0 42.1 18.1 2.4 0.0 0.0 32.2 0.0 32.8 97 Missing 28.1 7.2 14.3 21.5 14.2 28.9 10.2 0.0 0.0 0.0 19.7 5.0 48.0 70 Residence Urban 37.9 30.3 13.2 42.3 15.4 46.6 16.7 3.2 0.0 0.8 14.4 0.8 41.8 106 Rural 31.7 19.7 10.1 28.8 14.9 37.7 10.3 1.8 0.2 0.0 26.2 1.7 41.6 613 Province Kigali city 49.0 43.9 12.3 56.2 20.1 59.5 21.9 3.1 0.0 1.5 14.7 1.9 25.1 60 South 21.1 8.4 13.5 21.0 15.7 32.3 7.0 2.9 0.0 0.0 26.6 3.1 44.3 198 West 38.8 30.9 10.7 40.4 13.7 45.3 15.2 2.4 0.0 0.0 27.6 1.1 34.6 179 North 39.9 25.9 7.6 33.5 12.3 42.5 9.8 0.0 1.1 0.0 17.8 0.9 42.3 105 East 29.4 15.6 8.3 21.8 15.3 31.5 9.2 1.6 0.0 0.0 26.1 0.6 50.7 177 Mother's education No education 27.5 19.1 8.3 26.9 10.0 34.0 6.8 1.2 0.0 0.0 28.5 0.8 48.6 208 Primary 32.2 20.5 11.1 30.5 16.1 39.7 11.8 2.1 0.2 0.0 24.0 1.9 39.6 463 Secondary or higher 58.8 38.5 14.8 50.6 25.2 54.7 24.9 5.3 0.0 1.8 11.2 1.6 30.6 48 Wealth quintile Lowest 29.9 18.1 5.9 24.0 14.0 31.6 5.0 2.3 0.9 0.0 20.6 1.4 53.9 123 Second 24.0 13.9 10.7 22.7 13.3 33.8 10.8 0.7 0.0 0.0 25.4 1.9 45.0 179 Middle 23.9 15.5 12.6 26.7 14.7 36.1 10.3 1.9 0.0 0.0 23.4 2.5 42.0 153 Fourth 39.1 30.8 10.3 39.6 15.8 46.6 10.9 1.5 0.0 0.0 27.1 1.6 34.7 143 Highest 51.2 31.4 12.8 44.2 17.8 49.3 19.6 4.7 0.0 0.7 25.2 0.0 31.9 122 Total 32.6 21.3 10.6 30.8 15.0 39.1 11.2 2.0 0.2 0.1 24.4 1.6 41.6 719 Note: ORT includes solution prepared from oral rehydration salts (ORS), pre-packaged ORS packets, and recommended home fluids (RHF) 1 Excludes pharmacy, shop and traditional practitioner More than one in five (21 percent) children under five with diarrhea were treated with ORS, 11 percent received recommended home fluids, and 15 percent were given increased fluids. Overall, nearly two in five children were treated with ORT (39 percent). Use of ORT to treat diarrhea in children under five increases with age, from 16 percent among children under six months, to 32 percent among children age 6-11 months, to more than 40 percent among children 12 months and older. Treatment of diarrhea with ORT is higher among girls than boys (41 and 37 percent, respectively) and higher among children in urban areas than those in rural areas (47 and 38 percent, respectively). There are substantial differences in ORT treatment by province, with 60 percent of children in the City of Kigali receiving ORT, compared with 32 percent of those in the South and East provinces. Treatment with ORT is also related to mother’s level of education and household wealth status: 55 percent of children whose mothers have secondary or higher education received ORT, compared with 34 percent for those whose mothers had never been to school; likewise, the proportion treated with ORT ranges from 32 percent in households in the lowest (poorest) wealth quintile to 49 percent in households in the highest (richest) wealth quintile. Maternal and Child Health | 75 Antimotility medications (2 percent), zinc supplements (0.2 percent), and intravenous solutions (0.1 percent) account for only a small portion of diarrhea treatment; however, a large proportion of children were given home remedies and other treatments (24 percent) and antibiotics (11 percent). About 42 percent of children did not receive any treatment for their diarrhea. Feeding practices during diarrhea Regarding feeding practices during diarrhea for children under five, Table 7.15 shows that 42 percent of children were given increased liquids, 15 percent were given the same amount of liquids as usual, and 25 percent of children were given a smaller amount of liquids. Concerning food intake, 39 percent of children were given more food, 6 percent were given the same amount of food as usual, 46 percent were given less food, and 2 percent of children were given no food at all. 7.5 INITIAL BREASTFEEDING Knowledge of feeding practices is crucial to determining children’s nutritional status, which in turn is linked directly to levels of morbidity and mortality. Breastfeeding plays a pivotal role in the first six months of a child’s life. Breast milk has many beneficial properties—it is sterile, transmits antibodies from mother to child, and contains all of the nutrients children need during the first six months of life. Thus, breastfeeding prevents nutritional deficiencies and limits the presence of diarrhea and other diseases. In addition, prolonged and frequent breastfeeding extends the mother’s period of postpartum amenorrhea, thereby lengthening the interval between births and influencing fertility. Because of the importance of breastfeeding practices, mothers were asked whether they had breastfed those of their children who were born in the five years preceding the survey, how old their children were when they initiated breastfeeding, how long they had breastfed, how frequently, the children’s age when they were introduced to supplementary foods, the type of supplementary foods they were given and, finally, how frequently the different types of foods were given to the child. Nearly all children (98 percent) born in the five years preceding the survey were breastfed for at least some period of time, regardless of background characteristics. Among children who were breastfed, 68 percent began breastfeeding within one hour of birth and 92 percent began within one day of birth. Although breastfeeding is widespread, about one in three children (32 percent) did not begin breastfeeding within one hour of birth and 8 percent of children did not receive breast milk within one day of birth. About one in five children (21 percent) is fed a supplement before the start of breastfeeding (prelacteal feed). This practice can have negative consequences for children, even affecting their chances of survival. This is because the breast milk that is produced in the first 24 hours following birth contains colostrum, which transmits the mother’s antibodies to the child, providing crucial resistance to numerous diseases. In addition, newborns who are not breastfed within 24 hours of birth are usually given other liquids in place of breast milk, and these may carry pathogens. Overall, these results indicate that a major effort is needed to inform mothers of the benefits of breastfeeding in the first hours of a child’s life. Table 7.15 Feeding practices during diarrhea Percent distribution of children under five years who had diarrhea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, Rwanda 2007-08 Liquid/food offered Percentage Amount of liquids offered More 41.6 Same as usual 15.0 Somewhat less 24.5 Much less 15.0 None 3.2 Don't know/missing 0.7 Total 100.0 Amount of food offered More 38.5 Same as usual 5.5 Somewhat less 30.1 Much less 16.2 None 1.9 Never gave food 7.2 Don't know/missing 0.6 Total 100.0 Number of children 719 76 | Maternal and Child Health Table 7.16 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and for last-born children ever breastfed, the percentage who started breastfeeding within one hour and within one day of birth, and the percentage who received a pre-lacteal feed, by background characteristics, Rwanda 2007-08 Last-born children ever breastfed Children born in past five years Background characteristic Percentage ever breastfed Number of children Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a pre-lacteal feed2 Number of children Sex Male 97.7 2,860 67.2 90.3 22.1 1,818 Female 98.3 2,796 68.8 92.7 19.8 1,788 Residence Urban 97.2 804 73.3 94.3 18.4 534 Rural 98.1 4,852 67.1 91.0 21.5 3,071 Province Kigali city 96.8 425 71.2 91.6 22.8 281 South 97.7 1,442 67.3 92.0 20.6 919 West 98.7 1,408 70.8 90.5 18.3 900 North 98.6 991 62.8 90.9 24.1 636 East 97.4 1,390 68.5 92.3 21.3 869 Mother's education No education 98.1 1,453 65.1 90.3 24.1 907 Primary 98.1 3,793 68.5 91.7 19.8 2,421 Secondary or higher 96.3 410 72.8 92.9 21.7 278 Assistance at delivery Health professional3 97.4 2,945 72.3 94.0 15.8 2,010 Traditional birth attendant 96.3 86 80.2 100.0 29.0 48 Other 98.5 1,720 63.2 90.4 28.8 1,045 No one 98.7 688 64.0 89.7 26.9 461 Missing 100.0 217 9.7 9.7 0.0 42 Place of delivery Health facility 97.5 2,557 73.7 94.1 14.6 1,780 At home 98.2 2,785 63.9 90.6 28.1 1,710 Other 100.0 92 58.1 96.4 17.8 66 Missing 99.7 222 16.6 21.7 7.2 50 Wealth quintile Lowest 97.3 851 60.2 88.8 21.8 561 Second 98.4 1,634 66.4 90.4 22.2 1,022 Middle 98.4 1,112 70.6 92.8 18.4 695 Fourth 98.2 1,106 70.6 92.9 21.2 699 Highest 97.3 954 71.8 92.7 20.9 628 Total4 98.0 5,656 68.0 91.5 21.0 3,605 Note: Table is based on births in the last five years whether the children are living or dead at the time of interview. 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 Include doctor, nurse, midwife and auxiliary nurse/midwife 4 Total includes 42 cases where assistance at delivery and place of delivery is unknown Although breastfeeding is widely practices across all subgroups of women, the timing of initial breastfeeding varies by background characteristics. The proportion of children breastfed within one hour of birth varies according to the type of assistance received by the mother during childbirth. Among children whose birth was assisted by a traditional birth assistant, 80 percent began breastfeeding in the first hour of life; the proportion is 72 percent if the birth was assisted by a health professional, and 64 percent if no one assisted the mother during delivery. By province, the lowest proportion of children breastfed within one hour of birth occurs in the North province (63 percent); the City of Kigali and the West province have the highest proportions (71 percent for both). Maternal and Child Health | 77 Mother’s level of education shows a positive relationship with breastfeeding in the first hour after the birth. While only 65 percent of mothers with no education began breastfeeding in the first hour, 69 percent of mothers with primary education began breastfeeding then, and 72 percent of mothers with secondary or higher education began breastfeeding in the first hour. 7.6 MICRONUTRIENT INTAKE Vitamin and mineral deficiencies are the cause of some illnesses. For example, vitamin A deficiency can cause night blindness, and insufficient iron causes anemia. These deficiencies also have less visible effects, in particular the weakening of the immune system. Vitamin A is necessary for the development and maintenance of epithelial tissue as well as the digestive and respiratory systems, and is essential for good retinal health. It also maintains the body’s immune defenses. Vitamin A is stored in the liver, but when quantities are too low or used up, the consequences of the deficiency become apparent. Vitamin A deficiency (VAD) affects a child’s immune system and increases the chances of death from infectious diseases. VAD also affects the health of pregnant and breastfeeding women (including causing night blindness). Vitamin A deficiency can be avoided by taking vitamin A supplements or eating foods rich in vitamin A. UNICEF and WHO recommend that a program monitoring vitamin A be instituted in all countries with an under-five mortality rate higher than 70 deaths per 1,000 live births, and where vitamin A deficiency is a public health problem. Table 7.17 shows the percentage of last-born children age 6-59 months who received vitamin A supplements in the six months preceding the survey. Nearly three in four children age 6-59 months (72 percent) received a vitamin A supplement in the past six months. Children age 24-35 months (76 percent) were the most likely to receive the supplements, while those age 6-8 months (49 percent) were the least likely to receive vitamin A supplements. The proportion of children age 6-59 months who received vitamin A supplements varies by background characteristics. Children in urban areas received vitamin A supplements more often (75 percent) than those in rural areas (72 percent). Among the provinces, vitamin A supplementation ranges from 68 percent in the South province to 74 percent in both the East and West provinces. Mother’s level of education influences whether a child receives vitamin A supplements; among children whose mothers have no education, 69 percent received the supplements, compared with 76 percent of children whose mothers have secondary or higher education. A similar pattern is seen by household wealth status; 68 percent of children in the lowest (poorest) wealth quintile received vitamin A supplements, compared with 74 percent of children in the highest (richest) wealth quintile. Table 7.17 shows the proportion of children who were given iron supplements in the seven days preceding the survey. Overall, nearly one in ten children (8 percent) received iron supplements in the past seven days. Children age 12-23 months were the most likely to receive iron supplements (9 percent). There is little difference in the prevalence of iron supplements by other background characteristics, however, it is should be noted that the proportion of children receiving iron supplementation is very low in the South and North provinces (4 percent each), compared with the West province (13 percent). 78 | Maternal and Child Health Table 7.17 Micronutrient intake among children Percentage of children age 6-59 months who received vitamin A supplements in the past six months, percentage who received iron supplements in the past seven days, and percentage who received deworming medication in past six months, by background characteristics, Rwanda 2007-08 Background characteristic Percentage who received vitamin A supplement in past 6 months Percentage who received iron supplement in past 7 days Percentage who received deworming medication in past 6 months Number of children Age in months 6-8 48.6 4.5 19.8 269 9-11 63.5 6.2 29.7 259 12-17 72.4 9.4 64.6 608 18-23 73.1 8.7 75.1 618 24-35 76.2 7.8 77.6 959 36-47 74.7 6.9 77.8 1,066 48-59 72.8 7.8 76.3 963 Sex Male 72.2 6.8 70.4 2,369 Female 71.8 8.5 68.5 2,372 Breastfeeding status Breastfeeding 68.4 7.8 61.5 2,179 Not breastfeeding 77.1 8.0 78.2 2,017 Missing 67.9 5.8 69.1 545 Residence Urban 74.9 8.1 71.0 679 Rural 71.6 7.6 69.2 4,062 Province Kigali 72.3 8.4 69.2 360 South 67.6 3.6 69.6 1,226 West 73.7 13.1 68.4 1,183 North 73.0 3.5 74.7 846 East 74.3 9.2 66.7 1,126 Mother's education No education 68.9 9.0 66.3 1,209 Primary 72.8 7.3 70.7 3,175 Secondary or higher 75.6 5.9 69.1 357 Mother's age at birth 15-19 67.3 4.5 63.4 55 20-29 72.4 7.6 67.2 2,226 30-39 71.9 7.8 72.3 1,830 40-49 71.5 7.7 70.1 632 Wealth quintile Lowest 68.0 7.1 65.5 696 Second 69.9 6.5 68.6 1,353 Middle 73.8 8.4 67.9 950 Fourth 74.9 8.4 71.9 916 Highest 73.9 8.3 73.3 827 Total 72.0 7.7 69.5 4,742 Maternal and Child Health | 79 Table 7.17 also shows the percentage of children who were given deworming medicines in the six months preceding the survey. Overall, 70 percent of children under age five received deworming medi- cines in the past six months. Deworming treatment increases with children’s age, from 20 percent among children age 6-8 months to 78 percent among those age 36-47 months. There is no substantial difference in the prevalence of deworming treatment by urban-rural residence (71 and 69 percent, respectively). Differences by province are small (67 to 70 percent) except for the North province, which stands out with 75 percent of children receiving deworming treatment. As in the case of vitamin A supplementation, children whose mothers are educated and those who live in households in the higher wealth quintiles are the most likely to be treated with deworming medicines. Malaria and Anemia | 81 MALARIA AND ANEMIA 8 Malaria has been the main cause of morbidity and mortality in Rwanda for several years with periodic epidemics in high altitude areas. The Government of Rwanda established the National Malaria Control Program, as a national strategy to roll back malaria and reach the goals for 2010 set by the Abuja summit of African Heads of State. To achieve these objectives, the country has adopted a strategy based on the availability of services in communities, with the goal of increasing accessibility to health care. This plan would contribute to the achievement of the millennium development goals (MDG) as set forth in the Vision 2020 strategic plan for the national health sector. With the commitment of the country’s highest authorities, Rwanda has adopted prevention as its main strategy for controlling malaria, through use of long-lasting insecticidal [mosquito] nets (LLINs) as well as appropriate and timely treatment of malaria cases with antimalarial drugs. While insecticide-treated [mosquito] nets (ITNs) have been known for years as an effective preventive measure in combating malaria—when they are used often and with extensive coverage in the community—Rwanda (like other African countries) was never able to achieve extensive coverage with ITNs. Since 2005, with funding from the Global Funds to Fight AIDS, Malaria and Tuberculosis, Rwanda has been able to distribute about 3 million LLINs to pregnant women and children under five; 1,364,897 of these LLINs were distributed to children under five during an integrated vaccination campaign against measles in September 2006. 8.1 MALARIA PREVENTION Each household in the 2007-08 RIDHS was asked whether it had a mosquito net, the number of mosquito nets, the type of mosquito net, and how long the household had owned each net. For mosquito nets acquired in the six months preceding the survey, the household was asked where and how each net was obtained. The definitions of the various types of mosquito nets are given in the notes at the bottom of Table 8.1. 8.1.1 Household Possession of Mosquito Nets Table 8.1 shows that about six in ten households (59 percent) own at least one mosquito net; in the 2005 RDHS-III, only 18 percent of households had a mosquito net. The percentage of households with at least one mosquito net varies by residence, province, and household wealth status: 69 percent of households in urban areas have a mosquito net compared with 57 percent of those in rural areas. Mosquito net ownership is highest in the City of Kigali (71 percent) and lowest in the West province (51 percent). Households in the highest (richest) wealth quintile (72 percent) are the most likely to own at least one mosquito net; only 41 percent of households in the lowest (poorest) wealth quintile own at least one mosquito net. While a majority of households have at least one mosquito net, 27 percent of households have two or more nets. The highest proportion of households with more than one mosquito net is found in the City of Kigali (39 percent) and, to a lesser extent, in the East province (33 percent). Between the households with one mosquito net and the households with more than one net, the average number of mosquito nets per household in Rwanda is 1.0, compared with 0.3 in the 2005 RDHS-III. 82 | Malaria and Anemia Table 8.1 Ownership of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), percentage with at least one and more than one ever-treated mosquito net, and percentage with at least one and more than one long-lasting insecticidal net (LLIN), and the average number of nets per household, by background characteristics, Rwanda 2007-08 Any mosquito net Ever-treated mosquito net1 Long-lasting insecticidal net2 (LLIN) Background characteristic Percentage with at least one net Percentage with more than one net Average number of nets per household Percentage with at least one net Percentage with more than one net Average number of ever-treated nets per household Percentage with at least one net Percentage with more than one net Average number of LLINs per household Number of households Residence Urban 68.5 37.6 1.3 67.1 36.1 1.2 65.3 33.8 1.2 1,148 Rural 57.4 24.5 0.9 55.4 23.0 0.9 53.8 21.9 0.8 6,229 Province Kigali 70.6 38.5 1.3 67.6 36.8 1.3 66.8 33.6 1.2 638 South 61.1 27.3 1.0 59.2 25.6 0.9 57.1 24.4 0.9 1,880 West 50.5 20.2 0.8 49.2 19.5 0.8 48.5 19.2 0.7 1,890 North 52.7 20.7 0.8 50.6 19.1 0.8 49.0 18.3 0.7 1,315 East 67.3 33.1 1.1 65.3 31.1 1.1 62.9 28.6 1.0 1,654 Wealth quintile Lowest 41.9 12.6 0.6 40.4 11.5 0.5 39.2 11.1 0.5 1,215 Second 54.2 20.8 0.8 52.3 19.7 0.8 51.2 18.7 0.7 2,043 Middle 60.2 26.0 0.9 58.7 24.5 0.9 56.9 23.5 0.9 1,410 Fourth 68.0 30.1 1.1 66.0 29.2 1.0 64.7 28.1 1.0 1,310 Highest 71.8 44.3 1.4 69.2 41.4 1.4 66.3 38.1 1.3 1,400 Total 59.1 26.6 1.0 57.2 25.1 0.9 55.6 23.7 0.9 7,377 1 An ever-treated net is a pretreated net or a non-pretreated that has subsequently been soaked with insecticide at any time. 2 LLIN is a factory-made, long-lasting, insecticidal net. In Rwanda, LLIN brands include Tuzanet and MamaNet. Possession of ever-treated mosquito nets is relatively high: 57 percent, compared with 18 percent in the 2005 RDHS-III. The proportion of households having at least one ever-treated mosquito net is higher in urban areas than in rural areas (67 percent, compared with 55 percent). By province, the proportion of households with at least one ever-treated mosquito net is highest in the City of Kigali (68 percent) and lowest in the West province (49 percent). By wealth quintile, the largest proportion of households with at least one ever-treated mosquito net is in the highest (richest) wealth quintile (69 percent) while the smallest proportion is in the lowest (poorest) wealth quintile (40 percent). The percentage of households owning at least one LLIN is about the same as the percentage owning at least one ever-treated mosquito net (56 percent, compared with 57 percent). It appears therefore that almost all mosquito nets owned by Rwandan households are LLINs. Results from the RDHS-III indicate that only 15 percent of households had an LLIN in 2005. The proportion of households possessing an LLIN reaches 65 percent in urban households, compared with 54 percent in rural households; likewise, 66 percent of households in the highest (richest) wealth quintile have a LLIN, compared with 39 percent in the lowest (poorest) wealth quintile. By province, the City of Kigali has the highest proportion of households with an LLIN (67 percent), followed by the East province (63 percent); the North and East provinces have the lowest proportion of households with an LLIN (49 percent for both). Figure 8.1 shows the proportion of households with an LLIN by province based on the results from the 2005 RDHS-III and the 2007-08 RIDHS. Malaria and Anemia | 83 Table 8.2 presents the results on sources of mosquito nets. The results are categorized by type and brand of mosquito net. With regard to permanent mosquito nets, which are referred to as long-lasting insecticidal nets (LLINs), one-third are the Mamanet brand and were obtained during vaccination campaigns (36 percent); 28 percent were received during antenatal care visits. One-quarter of the Tuzanet brand mosquito nets were obtained during vaccination campaigns, while 17 percent came from a store. Regarding the Origine ever-treated mosquito nets, 24 percent came from a store and 17 percent were obtained during vaccination campaigns. These results show the important role of vaccination campaigns in the distribution of mosquito nets to the population in Rwanda. Table 8.2 Sources of mosquito nets Percent distribution of observed mosquito nets obtained in the past six months by sources of nets, according to type of net (permanent/LLIN or treated net) and brand of net, Rwanda 2007-08 Long-lasting insecticidal net (LLIN) Ever-treated net Source of net Tuzanet Mamanet Origine Other Don’t know/ not sure Total Vaccination campaign 25.5 31.6 16.7 * 19.8 27.6 Special vaccination campaign in 2006 2.1 4.0 0.0 * 0.0 2.8 ANC visit 10.6 27.7 6.8 * 8.0 17.9 Shop 17.3 6.4 23.6 * 10.1 12.5 Volunteer from malaria program 5.9 6.3 2.4 * 23.4 6.4 Other 28.6 15.0 16.7 * 12.6 21.5 Don’t know/missing 9.9 9.1 33.7 * 26.2 11.3 Total 100.0 100.0 100.0 * 100.0 100.0 Number of mosquito nets 613 587 69 5 36 1,310 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. LLIN = Long-lasting insecticidal net Figure 8.1 Household Ownership of Long-Lasting Insecticidal Nets (LLINs) by Province, According to 2005 RDHS-III and 2007-08 RIDHS 32 16 14 8 13 15 67 57 49 49 63 56 Kigali City South West North East RWANDA 0 20 40 60 80 Percent 2005 RDHS-III 2007-08 RIDHS 84 | Malaria and Anemia 8.1.2 Use of Mosquito Nets by Children One of the major strategies used to combat malaria is individual protection through use of mosquito nets treated with insecticide. Households that reported owning at least one mosquito net were asked who had slept under the net the night before the survey. The two most vulnerable groups are children under five and pregnant women. Table 8.3 shows the proportion of children under age five who slept under a mosquito net the night before the survey. Overall, six in ten children under five (60 percent) slept under a net the night before the survey; the corresponding figure in the 2005 RDHS-III was only 16 percent. Table 8.3 Use of mosquito nets by children Percentage of children under five years of age who slept under a mosquito net (treated or untreated), an ever-treated mosquito net,1 and a long-lasting insecticidal net2 (LLIN) the night before the survey, by background characteristics, Rwanda 2007-08 Background characteristic Percentage who slept under any net the past night Percentage who slept under an ever- treated net1 the past night Percentage who slept under an LLIN2 the past night Number of children Age in months <12 64.7 63.1 62.1 1,033 12-23 67.6 65.1 61.9 1,232 24-35 60.8 57.8 55.2 981 36-47 56.8 54.2 51.6 1,130 48-59 50.0 48.8 47.0 1,037 Sex Male 61.1 59.0 56.8 2,706 Female 59.3 57.0 54.7 2,708 Residence Urban 65.6 64.1 61.6 774 Rural 59.3 57.0 54.7 4,640 Province Kigali 64.6 62.3 61.0 407 South 61.3 58.7 56.0 1,386 West 58.6 57.4 57.1 1,350 North 56.7 54.7 52.1 952 East 61.9 59.0 55.1 1,319 Wealth quintile Lowest 49.1 46.9 44.6 796 Second 56.8 54.7 53.0 1,566 Middle 61.1 59.1 57.0 1,068 Fourth 65.7 63.7 61.6 1,054 Highest 68.1 65.3 61.8 930 Total 60.2 58.0 55.7 5,414 1 An ever-treated net is a pretreated net or a non-pretreated that has subsequently been soaked with insecticide at any time. 2 LLIN is a factory-made, long-lasting, insecticidal net. In Rwanda LLINs include Tuzanet and MamaNet. Malaria and Anemia | 85 The results by age group show that younger children are more likely to have slept under a mosquito net the night preceding the survey than older children: 68 percent for children age 12-23 months, compared with 50 percent for children age 48-59 months. There is a very small difference by gender (61 percent for boys and 59 percent for girls), and children in urban areas are more likely to have slept under a net than those in rural areas (66 percent, compared with 59 percent). Differences by province are small: the City of Kigali (65 percent) and the East province (62 percent) have the highest proportions of children sleeping under mosquito nets; the North province (57 percent) has the lowest proportion. The results by household wealth status show that the proportion of children who slept under a mosquito net the past night is highest in the highest (richest) wealth quintile (68 percent), and lowest (poorest) in the lowest wealth quintile (49 percent). The proportions of children under five who slept under an ever-treated mosquito net (58 percent) or a LLIN (56 percent) the night preceding the survey are slightly lower than the proportion of children who slept under any mosquito net (60 percent). Variations by background characteristics for these two types of mosquito nets are similar to those observed for all mosquito nets. For example, use of LLINs is highest in the City of Kigali (61 percent) and lowest in the North province (52 percent). Figure 8.2 shows the use of LLINs among children under five by province in the 2005 RDHS-III and the 2007-08 RIDHS. 8.1.3 Use of Mosquito Nets by Women Table 8.4 shows the percentage of all women and pregnant women age 15-49 that slept under a mosquito net the night before the survey by type of mosquito net and background characteristics. Overall, 50 percent of all women age 15-49 slept under a mosquito net the night before the survey. This proportion is slightly lower in rural areas (48 percent) than in urban areas (54 percent) and is highest among women with secondary or higher education (56 percent), those in the City of Kigali (56 percent), and women in the highest (richest) wealth quintile (57 percent). Forty-seven percent of all women slept under an ever- treated mosquito net, and 45 percent slept under an LLIN. Figure 8.2 Use of LLINs by Children Under Age Five by Province, According to 2005 RDHS-III and 2007-08 RIDHS 24 16 13 8 12 13 61 56 57 52 55 56 Kigali City South West North East RWANDA 0 20 40 60 80 Percent 2005 RDHS-III 2007-08 RIDHS 86 | Malaria and Anemia Table 8.4 Use of mosquito nets by women and pregnant women Percentage of all women age 15-49 and pregnant women age 15-49 who, the night before the survey, slept under a mosquito net (treated or untreated), slept under an ever-treated mosquito net,1 and slept under a long-lasting insecticidal net2 (LLIN), by background characteristics, Rwanda 2007-08 Percentage of all women age 15-49 who, the night before the survey: Percentage of pregnant women age 15-49 who, the night before the survey: Background characteristic Slept under any mosquito net Slept under an ever- treated mosquito net1 Slept under an LLIN2 Number of women Slept under any mosquito net Slept under an ever- treated mosquito net1 Slept under an LLIN2 Number of women Residence Urban 54.2 52.4 49.5 1,245 68.3 67.6 63.1 93 Rural 48.1 46.1 44.3 6,124 64.1 61.5 59.9 580 Province Kigali 55.6 52.9 49.8 690 66.5 64.1 61.8 68 South 47.8 46.2 44.2 1,959 58.1 55.8 53.3 172 West 45.3 44.2 43.8 1,756 67.4 64.4 63.6 161 North 45.7 43.4 41.5 1,282 64.1 61.5 59.2 113 East 54.6 51.7 48.5 1,681 68.7 67.0 64.9 159 Education No education 48.7 47.5 46.5 1,518 59.2 55.9 54.9 165 Primary 48.4 46.4 44.4 5,149 66.2 63.9 61.7 451 Secondary or higher 55.7 52.0 48.2 702 68.7 67.7 64.8 57 Wealth quintile Lowest 37.1 35.8 34.4 1,107 50.1 47.4 47.4 90 Second 45.5 43.6 42.5 1,994 65.9 64.7 62.3 197 Middle 49.7 48.0 46.2 1,374 67.3 62.5 60.6 137 Fourth 55.0 53.2 51.4 1,330 66.3 65.3 63.1 135 Highest 56.9 53.6 50.0 1,565 68.9 66.2 63.5 114 Total 49.1 47.1 45.2 7,370 64.7 62.3 60.3 673 1 An ever-treated net is a pretreated net or a non-pretreated net that has subsequently been soaked with insecticide at some time. 2 LLIN is a factory-made, long-lasting insecticidal net. In Rwanda LLINs include Tuzanet and MamaNet. The proportions of pregnant women age 15-49 years who slept under a mosquito net the night before the survey are much higher than those for all women. This shows the special interest given to pregnant women with respect to protecting them against malaria. The proportion of pregnant women who slept under an LLIN was 17 percent in the 2005 RDHS-III, compared with 60 percent in the 2007-08 RIDHS. Malaria and Anemia | 87 8.1.4 Intermittent Preventive Treatment during Pregnancy At the end of 2005, Rwanda adopted Intermittent Preventive Treatment as one of the strategies for preventing malaria during pregnancy. However, based on evidence of resistance to Sulfadoxine- pyrimethamine (SP), a decrease in the transmission of malaria, and the high prevalence of gene mutations for resistance to SP (Dhfr, Dhps), at the beginning of 2008, Rwanda suspended supplying this medication during antenatal consultations. Table 8.5 shows that 55 percent of pregnant women received antimalarial drugs preventively during their most recent pregnancy in the two years preceding the survey. The proportion is almost the same in urban and rural areas: 56 and 55 percent, respectively. There is slight variation by province, ranging from 52 percent in the City of Kigali to 57 percent in the East province. Women with secondary or higher education benefit most from these medications (63 percent), while women with no schooling benefit least (49 percent). The differentials by wealth quintile are small with no clear pattern, except that the proportions are highest in the fourth and fifth quintiles (63 and 58 percent, respectively). The percentage of women who received SP/Fansidar is shown in Table 8.5. More than half of all women (53 percent) were given SP/Fansidar during their last pregnancy; about 51 percent received Intermittent Preventive Treatment (IPT) with SP/Fansidar during a routine antenatal care visit; only 17 percent of the women received two doses or more of the recommended IPT. The results indicate that urban women, women in the South province, those with primary education, and those in the wealthiest households, are most likely to receive at least two doses of SP/Fansidar as IPT during antenatal care—the proportions range from 19 to 25 percent. The North province has the lowest rate (9 percent). Figure 8.3 Use of LLINs by Pregnant Women by Province, According to 2005 RDHS and 2007-08 RIDHS 23 19 16 12 18 17 62 53 64 59 65 60 Kigali City South West North East RWANDA 0 20 40 60 80 Percent 2005 RDHS-III 2007-08 RIDHS 88 | Malaria and Anemia Table 8.5 Prophylactic use of SP/Fansidar and use of Intermittent Preventive Treatment (IPT) by women during pregnancy Percentages of women who, during the pregnancy for their last live birth in the two years preceding the survey, received any antimalarial drugs for prevention, received SP/Fansidar, and received Intermittent Preventive Treatment (IPT), by background characteristics, Rwanda 2007-08 SP/Fansidar Intermittent Preventive Treatment1 Background characteristic Percentage who received any antimalarial drug Percentage who received any SP/Fansidar Percentage who received 2+ doses Percentage who received any SP/Fansidar during an ANC visit Percentage who received 2+ doses, at least one during an ANC visit Number of women Residence Urban 56.2 52.9 21.5 49.1 20.1 319 Rural 55.2 53.0 17.1 51.7 16.7 1,948 Province Kigali 52.3 47.9 19.9 42.4 18.4 173 South 54.4 50.9 21.9 48.9 21.0 580 West 55.8 55.0 18.4 53.5 17.9 581 North 55.4 53.6 9.3 52.2 9.3 374 East 56.6 54.3 17.7 53.8 17.3 559 Education No education 48.5 46.9 12.5 45.0 12.1 544 Primary 56.8 54.4 19.7 52.9 19.1 1,541 Secondary or higher 62.8 59.1 16.9 56.8 16.4 182 Wealth quintile Lowest 53.2 51.3 13.9 50.7 13.6 360 Second 51.5 49.8 12.9 48.2 12.2 625 Middle 52.1 49.4 15.6 47.6 15.0 458 Fourth 62.7 60.2 26.0 58.0 25.3 446 Highest 58.7 55.7 22.3 53.9 21.9 379 Total 55.3 53.0 17.7 51.3 17.2 2,267 1 Intermittent Preventive Treatment (IPT) during pregnancy is preventive treatment with SP/Fansidar during an antenatal care (ANC) visit. Compared with the results from the 2005 RDHS-III, there has been a substantial increase in the use of SP/Fansidar to treat pregnant women: from 31 percent in 2005 to 53 percent in 2007-08. This gain is particularly evident in rural areas and among educated women. 8.2 TREATMENT OF FEVER IN CHILDREN UNDER THE AGE OF FIVE In addition to questions on the availability of mosquito nets and preventive antimalarial treatment in pregnant women, the RIDHS asked whether children under the age of five had had a fever in the two weeks preceding the survey. If the answer was affirmative, the respondent was asked questions about how the fever was treated, including whether the child received antimalarial drugs and when they were given for the first time. The results are shown in Table 8.6. Malaria and Anemia | 89 Table 8.6 shows that one in five children under the age of five (21 percent) had a fever in the two weeks preceding the survey. By age group, fever prevalence is highest among children age 12-23 months (26 percent) and lowest among those age 48-59 months (15 percent). However, analysis by residence shows little difference between urban and rural areas (19 and 22 percent, respectively). In the provinces, the highest prevalence of fever is in the West and East provinces (24 and 23 percent, respectively); while the lowest rates are in the City of Kigali and the North province (18 and 19 percent, respectively). By level of education and wealth quintile, the highest prevalence of fever in children under five is among children whose mothers have no education, and children in the lowest (poorest) wealth quintile (23 and 25 percent, respectively). Table 8.6 Prevalence and prompt treatment of fever Percentage of children under five with fever in the two weeks preceding the survey, and among children with fever, the percentage who received antimalarial drugs, the percentage who received Coartem, and the percentage who received the drugs the same day as the onset of the fever or the next day, by background characteristics, Rwanda 2007-08 Children under five Children under five with fever Background characteristic Percentage with fever in the past two weeks Number of children Percentage who received antimalarial drugs Percentage who received Coartem Percentage who received antimalarial drugs the same or next day Number of children Age (in months) <12 23.4 1,028 5.5 4.6 0.0 240 12-23 25.5 1,226 7.2 6.4 0.4 313 24-35 23.1 959 6.3 5.0 0.4 222 36-47 18.8 1,066 2.2 2.2 0.0 201 48-59 15.4 963 6.4 5.3 0.3 149 Residence Urban 19.0 764 5.3 4.0 0.4 145 Rural 21.9 4,478 5.7 5.0 0.2 978 Province Kigali 17.7 400 3.6 1.6 0.7 71 South 20.6 1,340 3.9 3.3 0.5 276 West 23.5 1,312 5.0 4.6 0.3 309 North 18.7 925 4.6 3.9 0.0 173 East 23.4 1,263 9.0 7.9 0.0 296 Mother's education No education 22.7 1,321 7.0 6.2 0.0 300 Primary 21.2 3,523 4.8 4.1 0.3 748 Secondary or higher 19.2 397 9.1 7.3 0.7 76 Wealth quintile Lowest 24.7 778 7.0 5.7 0.7 192 Second 21.0 1,501 4.1 3.8 0.0 316 Middle 21.9 1,040 1.1 0.9 0.0 228 Fourth 22.5 1,016 8.9 8.3 0.0 229 Highest 17.6 907 9.0 6.7 0.9 160 Total 21.4 5,241 5.6 4.9 0.2 1,124 90 | Malaria and Anemia Regarding treatment of fever in children, the results show that less than 6 percent received antimalarial drugs, and 5 percent received Coartem. In addition, only 0.2 percent of the children with fever who were treated with antimalarials received the medication early, i.e., the same day as the onset of the fever or the next day. This means that, in Rwanda, only a very small proportion of children with fever received effective treatment. 8.3 MALARIA DIAGNOSTIC TESTING Malaria diagnostic testing was included in the 2007-08 RIDHS. The testing was carried out by laboratory technicians recruited by the National Malaria Control Program (PNILP). The same group of women and children who took part in the anemia testing were tested for malaria. For each person interviewed, in addition to the rapid diagnostic test, a slide with a thick blood smear was prepared, transmitted and stored at the PNILP laboratory for microscopic examination of malarial parasites. For diagnosing malaria in the field, the individual rapid OptiMAL-IT™ diagnostic test was used. The testing method is described below: 1) First the cap on the vial of buffer solution (provided in the test kit) was unsealed, and a drop of buffer solution was placed in the first test well (reactive well, designated by a red line) and four drops in the second test well (wash well), followed by a one minute wait. 2) Then a drop of blood was obtained from the same blood sample as the one used for the anemia testing. The blood was collected by using a single use micropipette provided in the test kit. The total volume of blood drawn with the small tube pipette was placed in the first reactive test well while stirring gently. A one minute rest period ensued, and then the pipette was put into a special waste bin. 3) The strip slide or dipstick (with the sticker) was placed into the first reactive test well. At the end of a ten minutes wait, the entire blood and reactive well mixture had moved along the reactive part of the strip slide. 4) The strip slide was next placed in the wash well for another ten minutes. 5) The strip slide was then taken out of the wash well and put back into the plastic support slots. The two wells were sealed with the plastic cover. The supports were broken off and discarded in the waste bin. The reaction was read and the result recorded. The tested strip slide must be kept in case of need. In this survey, the results of the malaria diagnostic testing, like those in the anemia testing, were recorded in the household questionnaire so they could be linked to the respondent’s background characteristics. The results of the microscopic assessment are presented in the remainder of this chapter. Results from the malaria rapid diagnostic testing were used to treat the respondents (children under five years of age and pregnant women) who tested positive. Table 8.7 shows the results of the malaria rapid diagnostic test for women and children. Nationally, 2.6 percent of children age 6-59 months are infected with at least one form of malarial parasites. Overall, the proportion of children with malaria is higher in rural areas than urban areas (2.7 percent compared with 1.9 percent). In addition, the results show that children in the East province (5.3 percent) are more likely to be infected with malaria than those from the other provinces and the City of Kigali. Malaria and Anemia | 91 Table 8.7 Malaria prevalence among women and children Among children age 6-59 months and women age 15-49, percentage for whom the results of the laboratory test for malaria were positives, by background characteristics, Rwanda 2007-08 Results of the laboratory text Background characteristic Positive Negative Total Number CHILDREN Residence Urban 1.9 98.1 100.0 640 Rural 2.7 97.3 100.0 4,021 Province Kigali 1.9 98.1 100.0 323 South 3.0 97.0 100.0 1,225 West 0.6 99.4 100.0 1,181 North 1.2 98.8 100.0 813 East 5.3 94.7 100.0 1,121 Total 2.6 97.4 100.0 4,662 WOMEN Residence Urban 1.1 98.9 100.0 1,134 Rural 1.5 98.5 100.0 5,634 Province Kigali 1.2 98.8 100.0 570 South 1.0 99.0 100.0 1,763 West 0.5 99.5 100.0 1,687 North 1.3 98.7 100.0 1,165 East 2.9 97.1 100.0 1,583 Pregnant Pregnant 0.9 99.1 100.0 642 Not pregnant/not sure 1.4 98.6 100.0 6,126 Total 1.4 98.6 100.0 6,768 Women are less likely to be infected with malaria than children. In the country as a whole, only 1.4 percent of women have malaria. There is almost no difference by urban-rural residence (1.1 and 1.5 percent, respectively). By province, women in the East province are more affected by malaria (2.9 percent) than those in the other provinces and in the City of Kigali. In addition, women who are not pregnant are more likely to be infected than those who are pregnant (1.4 percent, compared with 0.9 percent). 8.4 PREVALENCE OF ANEMIA Anemia is the most widespread micronutrient deficiency in the world, affecting more than 3.5 billion people in developing countries (ACC/SCN, 2000). Anemia is characterized by a reduced number of red blood cells and lower concentrations of hemoglobin in the blood. It is generally the result of a deficiency in iron, which is an essential element in the making of red blood cells. Iron deficiency is the root cause of many problems, especially among children and women. Iron deficiency in children increases the risk of impaired coordination and motor development, learning disabilities, and reduced physical activity. Anemia in women can cause lowered resistance to infection, fatigue, and, particularly for pregnant women, increased risk of maternal and fetal morbidity and mortality, and low-birth-weight babies. 92 | Malaria and Anemia During the survey, women and children in all the households surveyed were asked to give blood samples to assess hemoglobin content. Samples were collected in the following manner: a) capillary blood was taken by pricking the finger with a retractable blade (Tenderlette); b) a drop of blood was dropped into a microcuvette, which was then introduced into a portable hemoglobin reader (HemoCue), that produced a hemoglobin value in grams per deciliter of blood (g/dl) in less than one minute; c) the value given was then recorded on the questionnaire. There is a three-level classification system for anemia based on blood hemoglobin content that was developed by researchers at the World Health Organization (DeMaeyer, 1989). For children over the age of five and non-pregnant women, anemia is considered severe if the hemoglobin content per deciliter of blood is less than 7.0 g/dl; it is considered moderate if the value is between 7.0 and 9.9 g/dl; and it is considered mild if the value is between 10.0 and 10.9 g/dl. The amount of hemoglobin in the blood increases with altitude. This is because the partial pressure of oxygen decreases at high altitudes, as does the blood oxygen saturation. There is also a compensation factor that causes increased production of red blood cells to ensure adequate oxygen carrying capacity in the blood (CDC, 1998). In other words, the higher the altitude, the more hemoglobin needed by the blood. Because a part of Rwanda’s population lives at high altitudes, the hemoglobin values were adjusted for altitude. 8.4.1 Prevalence of Anemia in Children Table 8.8 shows that more than half (48 percent) of Rwandan children age 6 to 59 months have anemia: 21 percent are mildly anemic, 18 percent are moderately anemic, and 8 percent are severely anemic. In 2005, the prevalence rate for anemia in children under the age of five was 56 percent: 20 percent were mildly anemic, 27 percent were moderately anemic, and 9 percent were severely anemic. More than three-quarters (78 percent) of children age 6-8 months are anemic. The prevalence drops with the child’s age and is only 34 percent at 48-59 months. The results show little variation by gender or urban-rural residence, although the proportion of children who are moderately or severely anemic is slightly higher in urban areas (19 and 9 percent, respectively) than in rural areas (18 and 8 percent, respectively). There are variations by province, with the City of Kigali having the highest proportion of anemic children (56 percent) and the South province having the lowest proportion (41 percent). These data confirm similar results from the 2005 RDHS-III. In addition, 20 percent of children in the City of Kigali are severely anemic, and the level is almost as high for children in the North province (19 percent). In 2005 the prevalence of severe anemia was 25 percent in Kigali and 14 percent in the North province. The prevalence of anemia varies somewhat by mother’s level of education; it is slightly lower among children whose mothers have a secondary or higher education (46 percent) than among children whose mothers have primary education (48 percent) or no education (50 percent). However, children whose mothers have secondary or more education have the highest prevalence of severe anemia (9 percent). The majority of children who are anemic are mildly so, and they share almost the same background characteristics as all anemic children. Paradoxically, children living in the City of Kigali (20 percent) and in the North province (19 percent), those in urban areas (9 percent), those whose mothers have secondary or higher education (9 percent), and those living in households in the two highest (richest) wealth quintiles are more affected by severe anemia than other children. Malaria and Anemia | 93 Table 8.8 Prevalence of anemia in children Percentage of children age 6-59 months classified as having anemia, by anemia status (level of hemoglobin) and background characteristics, Rwanda 2007-08 Anemia status by hemoglobin level Background characteristic Any anemia (<11.0 g/dl) Mild (10.0-10.9 g/dl) Moderate (7.0-9.9 g/dl) Severe (<7.0 g/dl) Number of children Age in months 6-8 77.7 28.7 38.4 10.6 260 9-11 70.6 25.9 36.0 8.7 254 12-17 61.2 28.1 24.1 9.0 591 18-23 52.3 24.3 18.9 9.1 608 24-35 44.1 20.1 16.3 7.6 953 36-47 40.0 19.5 11.4 9.1 1 084 48-59 34.3 16.0 11.6 6.7 1 001 Sex Male 47.8 21.1 18.6 8.1 2 373 Female 47.2 21.7 16.9 8.6 2 379 Residence Urban 47.9 20.0 18.6 9.3 666 Rural 47.4 21.6 17.6 8.2 4 086 Province Kigali 56.0 15.7 20.6 19.7 340 South 40.7 23.0 17.1 0.6 1 243 West 46.4 24.8 16.8 4.8 1 191 North 51.1 19.2 13.3 18.6 835 East 50.9 19.5 21.8 9.6 1 143 Mother’s education1 No education 49.5 20.3 21.0 8.2 1 124 Primary 48.0 22.7 16.9 8.4 2 913 Secondary or higher 46.1 17.3 19.4 9.4 324 Don’t know/missing 39.7 18.6 13.3 7.8 391 Wealth quintile Lowest 47.0 20.7 21.0 5.3 693 Second 46.8 22.2 16.4 8.2 1 373 Middle 49.0 23.4 18.2 7.4 949 Fourth 48.5 20.8 17.1 10.6 928 Highest 46.2 19.1 17.5 9.6 809 Total 47.5 21.4 17.7 8.3 4 752 Note: Table is based on children who slept in the household the night before the interview. Prevalence of anemia is based on hemoglobin levels and is adjusted for altitude using CDC formulas (CDC, 1998). Hemoglobin is measured in grams per deciliter (g/dl). Children with <7.0 g/dl of hemoglobin have severe anemia, children with 7.0-9.9 g/dl have moderate anemia, and children with 10.0-10.9 g/dl have mild anemia. 1 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 8.4.2 Prevalence of Anemia in Women Table 8.9 shows the results of anemia tests among women. More than one-quarter (27 percent) of women have anemia: 15 percent are mildly anemic, 8 percent are moderately anemic, and less than 4 percent are severely anemic. The prevalence of anemia in the 2005 RDHS-III was 33 percent. There are few differences in the prevalence of anemia by woman’s age and the number of children ever born. Also, neither breastfeeding nor pregnancy is significantly associated with an increased risk of anemia. 94 | Malaria and Anemia By residence, women in urban areas are proportionally more likely to have anemia than those in rural areas (30 percent, compared with 26 percent). The prevalence of anemia varies substantially by province. The highest prevalence is in the City of Kigali (40 percent), just as it is for children. High prevalence is also observed in the East (32 percent) and North (30 percent) provinces, while prevalence in the South province (19 percent) is lower than elsewhere. Anemia prevalence varies slightly by level of education, from 26 percent among women with primary education to 29 percent among women with no education. The data show no major differentials by household wealth status: the proportion of women with anemia varies from 26 percent in the lowest (poorest) wealth quintile to 29 percent in the fourth quintile. Table 8.9 Prevalence of anemia in women Percentage of women age 15-49 with anemia, by anemia status and background characteristics, Rwanda 2007-08 Anemia status Background characteristic Any anemia Mild Moderate Severe Number of women Age 15-19 25.0 14.5 7.8 2.8 1 325 20-29 27.5 15.0 8.7 3.9 2 851 30-39 27.9 16.4 7.5 4.0 1 678 40-49 27.4 16.1 7.4 3.9 1 284 Number of children ever born 0 26.8 14.3 8.6 3.8 2 427 1 26.6 15.5 8.1 3.0 817 2-3 27.0 16.3 7.8 2.9 1 515 4-5 29.4 15.3 8.9 5.2 1 182 6+ 26.2 16.7 6.1 3.4 1 196 Maternity status Pregnant 28.8 13.1 10.0 5.7 682 Breastfeeding 26.5 16.0 7.3 3.1 2 530 Neither 27.3 15.4 8.1 3.7 3 925 Residence Urban 30.2 15.1 12.1 3.0 1 201 Rural 26.5 15.5 7.2 3.8 5 936 Province Kigali 40.3 14.1 18.9 7.3 642 South 18.8 15.5 3.1 0.1 1 901 West 24.8 16.9 5.5 2.5 1 727 North 30.1 12.1 8.9 9.1 1 228 East 31.8 16.8 11.4 3.7 1 638 Education No education 29.3 17.0 8.5 3.8 1 599 Primary 26.3 15.5 7.4 3.4 4 730 Secondary or higher 27.8 12.0 10.5 5.4 808 Wealth quintile Lowest 25.9 17.3 6.9 1.7 1 085 Second 27.7 15.8 7.5 4.4 1 931 Middle 25.1 14.6 7.6 2.9 1 340 Fourth 28.6 16.0 7.6 5.0 1 288 Highest 27.9 13.8 10.3 3.8 1 492 Total 27.1 15.4 8.0 3.7 7 137 Note: Table is based on women who stayed in the household the night before the interview. Prevalence is adjusted for altitude using CDC formulas (CDC, 1998). Women with <7.0 g/dl of hemoglobin have severe anemia, women with 7.0-9.9 g/dl have moderate anemia, and pregnant women with 10.0-10.9 g/dl and nonpregnant women with 10.0-11.9 g/dl have mild anemia. Infant and Child Mortality | 95 INFANT AND CHILD MORTALITY 9 This chapter presents information on levels, trends, and differentials in neonatal, postneonatal, infant, child and under-five mortality The information provides mortality statistics to policymakers, program managers and researchers for use in assessing the impact of health policies and programs, and to identify sectors of the population that are at high risk. Estimates of infant and child mortality also serve as necessary parameters for population projections, particularly if the level of adult mortality can be inferred with reasonable confidence. Finally, indices of childhood mortality are widely accepted as indicators of the overall living conditions of a population. 9.1 DEFINITION, METHODOLOGY AND DATA QUALITY The mortality indicators presented in this chapter are calculated from birth history information collected for all women age 15-49 who were interviewed during the 2007-08 RIDHS. The interviewer records on the Woman’s Questionnaire all the live births ever experienced by the respondent, noting the gender, age, survival status, and, for children who died, age at death: number of days (for children who died at less than one month of age), the number of months (for children who died at less than two years of age), and in years (for children who died at age two or over). There are several methods that can be used for the direct calculation of infant and child mortality rates, e.g., the period approach, the true cohort approach, and the synthetic cohort approach. It is beyond the scope of this report to describe the differences between the main approaches, but a technical explanation can be found in the Guide to DHS Statistics (Rutstein and Rojas, 2003). The Demographic and Health Surveys uses the synthetic cohort approach, which calculates mortality probabilities for small age segments, and then combines these component probabilities for the full age segment of interest. The advantage to this method is that mortality rates can be calculated for periods close to the survey date while still respecting the principle of correspondence. The data needed for the calculations are in the birth history section of the Woman’s Questionnaire and include the month and year of birth for all of a woman’s children, the children’s gender and survival status, and the current age at the time of the interview if the child is living, or age at death if the child is dead. The following age-specific mortality measures are calculated from information collected in the birth history data: Neonatal mortality (NN): the probability of dying within the first month of life; Postneonatal mortality (PNN): the probability of dying after the first month of life but before exact age one year; Infant mortality (1q0): the probability of dying between birth and exact age one year; Child mortality (4q1): the probability of dying between exact age one and exact age five; Under-five mortality (5q0): the probability of dying between birth and exact age five. All measures are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to 12 months of age. 96 | Infant and Child Mortality The quality of mortality estimates calculated from retrospective birth histories depends on 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 history 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 age at death, which may distort the age pattern of mortality. When selective omission of childhood deaths occurs, the impact 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 in the first seven days to all neonatal deaths, and an unusually low ratio of neonatal to infant deaths. The ratio between the first seven days to all neonatal deaths should be about 70 percent (Sullivan et al., 1990). Underreporting of early infant deaths is most commonly seen 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 C.5 and C.6) shows that a very low number of early infant deaths were omitted in the 2007-08 RIDHS. The proportion of neonatal deaths occurring in the first week of life (70 percent) is close to the proportions reported in the 2005 RDHS-III (71 percent) and the 2000 RDHS-II (72 percent). Moreover, the proportions are roughly constant over the 20 years preceding the survey (varying from 65 to 72 percent). The proportion of infant deaths that occurred during the first month of life (49 percent) is entirely plausible; it is almost the same as the proportion reported in the 2005 RDHS-III (47 percent) and the 2000 RDHS-II (43 percent). The proportions are also stable over the 20 years preceding the survey (varying from 39 to 46 percent). This examination of the mortality data shows no evidence of selective underreporting or misreporting of age at death that would significantly compromise the quality of the RIDHS rates for childhood mortality. 9.2 LEVELS AND TRENDS Table 9.1 shows the variations in neonatal, postneonatal, infant, child, and under-five mortality rates for three successive five-year periods preceding the survey. For the most recent five-year period, infant mortality was 62 deaths per 1,000 live births, and under-five mortality was 103 deaths per 1,000 live births. This means that about one in sixteen children born in Rwanda dies before the first birthday, and one in ten children dies before attaining the fifth birthday. Neonatal mortality was 28 deaths per 1,000 live births in the most recent five-year period, while postneonatal mortality was 34 deaths per 1,000. This pattern shows that about 45 percent of deaths among children under one year occur in the neonatal period, and neonatal deaths are responsible for about one-quarter of deaths among children under five years. Table 9.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Rwanda 2007-08 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) 0-4 28 34 62 43 103 5-9 36 59 95 86 173 10-14 39 56 95 92 178 1 Computed as the difference between the infant and neonatal mortality rates Infant and Child Mortality | 97 Figure 9.1 compares infant mortality and under-five child mortality for the four five-year periods preceding the 1992 RDHS-I, the 2000 RDHS-II, the 2005 RDHS-III, and the 2007-08 RIDHS. Results from the RIDHS show that the trend toward declining mortality that began before the 1990s and was interrupted by the genocide in 1994 has since continued. The rate of infant mortality, which was estimated at 85 per 1,000 for the period 1987-1991, increased to 107 per 1,000 for the period 1995-1999. This uninterrupted increase during the genocide was followed by a renewed drop in mortality, with infant mortality returning to the level prior to the genocide by around 2002 (86 per 1,000) and reaching 62 per 1,000 by 2005. Under-five mortality shows a similar pattern. These trends suggest that, after the tragic events of 1994, which had negative repercussions on childhood mortality in the mid- and late 1990s, the situation for young children in Rwanda has improved substantially. Figure 9.2 shows in more detail the trends in infant and under-five mortality over several five- year periods preceding the 1992 RDHS-I, the 2000 RDHS-II, the 2005 RDHS-III, and the 2007-08 RIDHS. Under-five mortality rates, and to a lesser extent infant mortality rates, decreased from the mid- to late 1970s into the mid- to late 1980s. In the 1990s, there was a pronounced increase in deaths among young children, with mortality levels at or above levels in the 1970s. This increase in mortality corresponds to periods of civil unrest in the early 1990s, especially the culmination of this unrest in the 1994 genocide. The genocide resulted in widespread disintegration of the social and health infrastructure, with an increase in deaths of young children. Since the genocide, infant and child mortality have dropped considerably, and the decline has been accelerating in recent years. 85 151 107 196 86 152 62 103 Infant mortality Under-five mortality 0 25 50 75 100 125 150 175 200 225 Deaths per 1,000 live births 1992 RDHS-I 2000 RDHS-II 2005 RDHS-III 2007-08 RIDHS Figure 9.1 Trends in Infant and Under-five Mortality, Rwanda 1992, 2000, 2005, and 2007-08 98 | Infant and Child Mortality 9,3 DIFFERENTIALS IN INFANT AND CHILD MORTALITY Mortality differentials by residence, province, mother’s education, and wealth quintile are presented in Table 9.2 and Figure 9.3. To have sufficient numbers of births to analyze mortality differentials across population subgroups, period-specific rates are presented for the ten-year period preceding the survey (mid-1998 to mid-2008). Table 9.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristic, Rwanda 2007-08 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 19 28 47 43 87 Rural 34 48 82 65 142 Province Kigali city 28 33 60 44 102 South 32 46 79 53 127 West 31 47 79 55 129 North 35 36 71 47 115 East 30 54 84 98 174 Mother's education No education 42 58 100 83 174 Primary 29 45 73 57 127 Secondary or higher 16 6 23 21 43 Wealth quintile Lowest 40 59 99 69 161 Second 32 49 82 73 149 Middle 34 40 74 62 132 Fourth 32 54 85 60 141 Highest 20 24 45 41 84 1 Computed as the difference between the infant and neonatal mortality rates Figure 9.2 Trends in Infant and Under-five Mortality from 1992 RDHS-I, 2000 RDHS-II, 2005 RDHS-III, and 2007-08 RIDHS ( (' ' & & & % % % $ $ $ $ $ # # # # # " " " ! !! 1975(77)- 1979(81) 1980(82)- 1984(86) 1985(87)- 1989(91) 1990-94 1995-99 1998(00)- 2002(04) 2003-07 Years on which estimates are centered 0 50 100 150 200 250 Deaths per 1,000 live births RDHS-I infant mortality RDHS-I under-five mortality RDHS-II infant mortality RDHS-II under-five mortality RDHS-III infant mortality RDHS-III under-five mortality RIDHS infant mortality RIDHS under-five mortality ! " # $ % & ' ( 225 233 176 167 151 141 219 198 196 217 173 103107 110 95 84 129 85 86 121 118 152 107 86 95 62 Infant and Child Mortality | 99 Childhood mortality is higher in rural areas than in urban areas: the under-five mortality rate in rural areas (142 per 1,000) is 63 percent higher than the rate in urban areas (87 per 1,000). There are large differentials by province. The highest levels of mortality are found in the East province, which has an infant mortality rate of 84 per 1,000 and an under-five mortality rate of 174 per 1,000. The lowest levels are found in the City of Kigali (60 per 1,000 for infant mortality and 102 per 1,000 for under-five mortality). Variations in mortality by province should be interpreted with caution because of the relatively large sampling errors when the sample is stratified by province or other background characteristics (see Appendix B). Mother’s level of education is inversely related to a child’s risk of dying. There are substantial differences between the mortality rates for children of women who have secondary or higher education and the rates for children whose mothers have primary education or no education. In Figure 9.3, the under-five mortality rates for children of mothers with no education are the highest (174 deaths per 1,000 live births), followed by children of mothers with primary education (127 per 1,000 live births), and finally, children of mothers with secondary or higher education (43 deaths per 1,000 live births). The same trend is seen for infant mortality rates. Under-five mortality rates by wealth quintile generally show the expected direction, with children in poorer households having a higher probability of dying than children in the richest households. Children in the three middle quintile households, however, have an irregular pattern with differing rates of dying. This result merits deeper analysis. Childhood mortality rates by sex of child, age of mother at birth, birth order, previous birth interval, and size at birth are presented in Table 9.3. Differences in mortality at birth between males and females are observed in nearly all populations. The results for Rwanda indicate that female mortality is lower than male mortality at all ages up to five years. 47 82 100 73 22 99 82 74 85 45 RESIDENCE Urban Rural EDUCATION No education Primary Secondary or higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 20 40 60 80 100 Deaths per 1,000 live births Figure 9.3 Infant Mortality by Mother's Background Characteristics RIDHS 2007-08 100 | Infant and Child Mortality Table 9.3 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, Rwanda 2007-08 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 34 49 83 69 146 Female 29 42 71 55 123 Mother's age at birth <20 38 59 96 88 176 20-29 29 43 71 64 131 30-39 36 47 83 57 135 40-49 26 47 73 21 93 Birth order 1 32 44 77 73 144 2-3 28 40 68 62 125 4-6 31 46 78 57 130 7+ 41 61 102 59 155 Previous birth interval 2 <2 years 56 76 132 90 210 2 years 24 37 61 56 114 3 years 15 31 46 46 90 4+ years 28 35 62 34 95 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births The relationship between mother’s age at birth and infant mortality shows that children born to the youngest women (under age 20) have the greatest risk of dying in the first year (96 per 1,000), followed by children of women age 30-39 (83 per 1,000) (Figure 9.4). The risk of dying in the first year is lowest for children of women age 20-29 (71 per 1,000) and women age 40-49 (73 per 1,000). Neonatal mortality shows similar trends. Under-five mortality rates show a less defined pattern by mother’s age at birth; however, children of mothers under age 20 still have the greatest risk of dying (176 per 1,000), followed by children of mothers age 30-39 (135 per 1,000), and children of mothers age 20-29 (131 per 1,000). However, the lowest under-five mortality rates by mother’s age at birth are for women age 40-49 (93 per 1,000). It appears that these children have a better chance of survival than the children of younger mothers. The length of the birth interval has a significant impact on a child’s chances of survival, with short birth intervals increasing the risk of dying (Figure 9.4). As the birth interval gets longer, mortality risk is reduced considerably. Children born less than two years after a prior sibling have substantially greater risk of dying than children born after an interval of two or more years. For example, the infant mortality rate is 132 deaths per 1,000 live births for children born after an interval of less than two years, compared with 46 deaths per 1,000 for children born after an interval of three years. Infant and Child Mortality | 101 9.4 HIGH-RISK FERTILITY BEHAVIOR Research has shown that there is a strong relationship between children’s chances of dying and certain fertility behaviors of the mother. 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, and 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. In this analysis, a mother is classified as “too young” if she is less than 18 years of age and “too old” if she is over 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 four or higher). First order 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 Table 9.4 because it is not considered avoidable fertility behavior. Also, for the short birth interval category, only children with a preceding interval of less than 24 months are included. Table 9.4 presents the distribution of children born in the five years preceding the survey by corresponding categories of increased risk of dying: • First order births that present a high risk of dying but are unavoidable, except for births to mothers under age 18. First order births and those to mothers over age 18 years were therefore separated. • Births to mothers in a single high-risk category: early fertility (under age 18) or late fertility (age 35 or more), short birth interval (less than 24 months), and high birth order (greater than 3). • Births combining multiple high-risk factors according to mother’s age at birth, birth interval, and birth order. • Finally, births not in any high-risk category defined above. 96 71 83 73 77 68 78 102 132 61 46 62 MOTHER'S AGE <20 20-29 30-39 40-49 BIRTH ORDER 1 2-3 4-6 7+ PREVIOUS BIRTH INTERVAL <2 years 2 years 3 years 4+ years 0 20 40 60 80 100 120 140 Deaths per 1,000 live births Figure 9.4 Infant Mortality by Mother's Reproductive Behavior RIDHS 2007-08 102 | Infant and Child Mortality Table 9.4 shows that 25 percent of births in the five years preceding the survey do not come under any of the high-risk categories identified; 20 percent are at high risk because they are first births and unavoidable; 31 percent fall into a single high-risk category, and 24 percent fall into multiple high- risk categories. To assess the increased risk of dying for children whose mothers show certain fertility behaviors, “risk ratios” were calculated by taking as a reference point births that do not belong in any high-risk category. The risk ratio is therefore the ratio of the proportion dead among children in each high-risk category to the proportion dead among children not in any high-risk category. Births with unavoidable risks include first-order births that do not occur too early or too late (i.e., before age 18 or after age 34); they appear here as births at risk. In Rwanda, these births present a risk of dying 1.32 times higher than the reference category made up of children who have none of the risks considered. Table 9.4 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Rwanda 2007-08 Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women1 Not in any high-risk category 24.8 1.00 17.3a Unavoidable risk category First-order births between ages 18 and 34 19.9 1.32 5.5 Single high-risk category Mother's age <18 1.4 1.93 0.1 Mother's age >34 1.6 0.70 2.6 Birth interval <24 months 8.0 1.46 11.0 Birth order >3 19.9 1.04 16.6 Subtotal 30.9 1.17 30.4 Multiple high-risk category Age <18 and birth interval <24 months2 0.1 * 0.0 Age >34 and birth interval <24 months 0.1 * 0.4 Age >34 and birth order >3 15.4 0.92 28.5 Age >34 and birth interval <24 months and birth order >3 3.0 2.74 6.8 Birth interval <24 months and birth order >3 5.9 1.77 11.0 Subtotal 24.4 1.37 46.8 In any avoidable high-risk category 55.3 1.26 77.2 Total 100.0 na 100.0 Number of births/women 5,656 na 3,888 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category.An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Women were 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 Infant and Child Mortality | 103 A child belonging to any single high-risk category (not including children who are first-order births and whose mothers are age 18-34) run a risk of dying 1.17 times higher than a child who is not in any high-risk category. A short birth interval is a high-risk factor because a child born less than 24 months after the previous birth runs a risk of dying 1.46 times greater than the reference category. This is also the case for early fertility, because children born to teenage mothers run a risk of dying 1.93 times greater than children in the reference group. Children in multiple high-risk categories are at greatest risk because their risk of dying is 1.37 times that for children who are not in any high-risk category. Children whose mothers are older than 34 years, who were born after an interval of less than 24 months, and whose birth order is greater than 3, are particularly exposed, with a risk of dying 2.74 times higher than the reference group. An analysis of high-risk fertility behavior was made to determine the percentage of currently married women who have the potential for a high-risk birth. This was obtained by simulating the distribution of currently married women according to the risk category in which a birth would fall if a woman were to conceive at the time of the survey. The high-risk potential was calculated from a woman’s current age, from the interval since her most recent birth, and from the birth order of her last birth. It appears that only 17 percent of births would be children who are not in any high-risk category. Overall, 77 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 47 percent falling into a multiple high-risk category. Circumcision | 105 CIRCUMCISION 10 Circumcision is a practice involving removal of the foreskin and is primarily based on religion. It is mentioned in the Bible and practiced by Jews, Muslims, as well as some Christian groups. About one in every six men in the world is circumcised (Williams and Kapila, 1993). In addition to the religious and cultural reasons, circumcision is also practiced based on hygienic and medical reasons. According to current medical opinion, circumcision may provide protection against HIV infection. At the beginning of 2008, the Rwandan Health Ministry (MINISANTÉ) announced that it planned to include circumcision in its national programs for combating HIV/AIDS, and indicated that a voluntary circumcision program in Rwanda would start in August 2008. The 2007-08 RIDHS collected data on the prevalence of circumcision among male respondents, including age at circumcision and type of practitioner who performed the procedure. Circumcised men were also asked the main reason for their circumcision. 10.1 PRACTICE OF MALE CIRCUMCISION In Rwanda, only 12 percent of men age 15-59 have been circumcised (Table 10.1). The rate varies according to their background characteristics. Results by age group show that the prevalence of circumcision is higher in the younger age groups, going from 6 percent among men age 55-59 to 15 percent among men age 25-29 and 30-34 (Figure 10.1). There are also large geographic differentials, with the practice occurring more frequently in urban areas (31 percent) than in rural areas (8 percent). By province, the proportion of men who are circumcised is highest in the City of Kigali (35 percent) and the West province (18 percent), while it does not exceed 7 percent in the other provinces. There are also socioeconomic differences in the prevalence of circumcision, with the highest proportions among men who have secondary or higher education (38 percent) and those in the highest (richest) wealth quintile (31 percent). Finally, differentials by religion show that a large proportion of Muslim men are circumcised (82 percent). Men who were circumcised were asked who had performed the procedure. About seven in ten men (70 percent) said they were circumcised by a health professional. This proportion remains high irrespective of background characteristics (Figure 10.2). In urban areas (78 percent), in the City of Kigali (74 percent), in the South province (75 percent), among the most educated men (82 percent), and among men in the highest (richest) wealth quintile (77 percent), at least three-quarters of circumcisions were performed by a health professional. The lowest rate is seen among Muslims (47 percent), who were almost as likely to be circumcised by a traditional practitioner (46 percent). 106 | Circumcision Table 10.1 Practice of circumcision Percentage of men age 15-59 who are circumcised, and percent distribution of circumcised men by type of practitioner who performed the circumcision, according to background characteristics, Rwanda 2007-08 Person who performed circumcision Background characteristic Percentage of circumcised men Number of men Health professional Traditional practitioner Don’t know Total Number of circumcised men Age 15-19 9.2 1,461 64.8 22.9 12.3 100.0 135 20-24 13.1 1,245 74.6 17.3 8.1 100.0 163 25-29 15.1 1,156 76.0 18.8 5.1 100.0 174 30-34 15.2 769 69.0 24.2 6.8 100.0 117 35-39 14.3 616 64.7 23.7 11.6 100.0 88 40-44 13.2 522 62.3 26.2 11.5 100.0 69 45-49 10.3 428 75.8 17.5 6.7 100.0 44 50-54 9.1 383 70.8 28.2 1.0 100.0 35 55-59 5.6 257 63.4 36.6 0.0 100.0 15 Residence Urban 31.3 1,248 77.5 16.0 6.6 100.0 391 Rural 8.0 5,589 63.9 26.7 9.5 100.0 448 Province Kigali city 35.3 763 73.7 18.2 8.1 100.0 270 South 6.9 1,743 74.8 18.8 6.5 100.0 120 West 17.7 1,688 67.7 25.7 6.5 100.0 299 North 4.6 1,149 65.2 17.1 17.6 100.0 53 East 6.5 1,494 65.2 25.0 9.8 100.0 97 Education No education 6.0 1,194 58.5 30.9 10.6 100.0 72 Primary 8.2 4,625 60.1 31.2 8.8 100.0 381 Secondary or higher 37.9 1,018 82.4 10.6 7.0 100.0 386 Religion Catholic 9.7 3,517 76.2 16.1 7.7 100.0 341 Protestant 11.4 2,205 71.0 18.7 10.4 100.0 253 Adventist 12.0 754 81.1 13.4 5.5 100.0 91 Muslim 82.4 164 47.3 45.8 6.9 100.0 135 Other 12.4 76 68.3 30.7 1.0 100.0 10 No religion/missing 8.4 121 56.7 29.7 13.6 100.0 10 Wealth quintile Lowest 5.9 833 57.2 32.2 10.6 100.0 49 Second 6.5 1,737 60.8 29.8 9.5 100.0 113 Middle 6.1 1,342 61.6 29.4 9.0 100.0 82 Fourth 6.9 1,313 59.9 31.3 8.8 100.0 91 Highest 31.3 1,612 76.9 15.8 7.3 100.0 504 Total 12.3 6,837 70.2 21.7 8.1 100.0 839 9 13 15 15 14 13 10 9 6 6 7 6 7 31 AGE 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 10 20 30 40 Percent Figure 10.1 Proportion of Circumcised Men by Age and by Wealth Quintile RIDHS 2007-08 Circumcision | 107 Men who said they had been circumcised were asked how old they were at the time of circum- cision. The results are presented in Table 10.2. Slightly more than two in five circumcisions (44 percent) took place before the age of 13, and over one-third of cases (35 percent) were performed between the ages of 13 and 19. However, one out of five men (20 percent) was circumcised relatively late, at the age 20 or later. Only 1 percent of the men were not certain when they were circumcised, perhaps because they were circumcised at a very young age and do not remember the event. No specific trends in age at circumcision can be seen with respect to the different age groups. However, in subgroups with high prevalence of circumcision, such as Muslims, men living in urban areas, men who have secondary or higher education, and men in the wealthiest households, circumcision was performed before the age of 13 in half of the case (50 to 53 percent). Among Muslims this rate is slightly higher, reaching 59 percent. 70 22 8 44 35 20 27 64 9 PERSON THAT PERFORMED CIRCUMCISION Health professional Traditional Other/don't know AGE WHEN CIRCUMCISED <13 years 13-19 years >20 years REASON FOR CIRCUMCISON Tradition/religion Health/hygiene Other/don't know 0 10 20 30 40 50 60 70 80 Percent Figure 10.2 Practice of Circumcision RIDHS 2007-08 >20 years 108 | Circumcision Table 10.2 Age at circumcision Percent distribution of circumcised men age 15-59 by age at circumcision, according to background characteristics, Rwanda 2007-08 Age at circumcision Background characteristic <13 years 13-19 years ≥20 years Don’t know/ missing Total Number of circumcised men Age 15-19 69.5 27.0 1.4 2.1 100.0 135 20-24 42.4 45.4 12.2 0.0 100.0 163 25-29 35.1 37.8 26.8 0.3 100.0 174 30-34 37.3 39.3 22.7 0.7 100.0 117 35-39 45.6 25.8 28.5 0.0 100.0 88 40-44 34.0 33.5 30.1 2.4 100.0 69 45-49 47.4 19.9 30.5 2.1 100.0 44 50-54 29.5 46.2 24.3 0.0 100.0 35 55-59 50.2 27.9 22.0 0.0 100.0 15 Residence Urban 52.5 30.7 16.4 0.5 100.0 391 Rural 36.7 39.5 22.7 1.1 100.0 448 Province Ville de Kigali 48.9 34.1 16.5 0.5 100.0 270 South 27.6 34.9 36.1 1.4 100.0 120 West 51.1 38.2 10.7 0.0 100.0 299 North 35.3 29.8 31.3 3.6 100.0 53 East 33.8 33.9 30.4 1.9 100.0 97 Education No education 39.7 33.7 24.3 2.3 100.0 72 Primary 37.3 42.3 19.0 1.3 100.0 381 Secondary or higher 51.5 28.8 19.6 0.0 100.0 386 Religion Catholic 37.4 40.2 21.5 1.0 100.0 341 Protestant 44.3 36.9 18.1 0.7 100.0 253 Adventist 42.6 32.6 23.8 1.0 100.0 91 Muslim 59.3 23.4 16.7 0.6 100.0 135 Other 48.9 22.7 28.5 0.0 100.0 10 No religion/missing 66.5 33.5 0.0 0.0 100.0 10 Wealth quintile Lowest 40.7 46.5 12.8 0.0 100.0 49 Second 38.5 35.9 22.4 3.1 100.0 113 Middle 33.0 38.3 28.7 0.0 100.0 82 Fourth 28.6 48.1 20.4 3.0 100.0 91 Highest 50.2 31.4 18.3 0.1 100.0 504 Total 44.1 35.4 19.8 0.8 100.0 839 10.2 REASONS FOR MALE CIRCUMCISION Men who reported being circumcised were asked the main reason they had undergone the procedure. The results are shown in Table 10.3. Nearly two-thirds of men (64 percent) said they had been circumcised for health or hygienic reasons. A little over one-quarter (27 percent) of the men mentioned tradition or religion as the main reason they were circumcised. Nine percent of men did not provide an answer to the question. Over three-quarters of Muslims (76 percent) were circumcised for religious or traditional reasons. Among men who have secondary education or higher (71 percent), and those in the highest (richest) wealth quintile, circumcision is more frequently carried out for reasons related to health or hygiene (71 and 68 percent, respectively) than to conform to traditional or religious practices (23 and 27 percent, respectively). Circumcision | 109 Table 10.3 Reason for circumcision Percent distribution of circumcised men age 15-59 by reason for circumcision, according to background characteristics, Rwanda 2007-08 Reason for circumcision Background characteristic Tradition/ religion Health/ hygiene Other/ don’t know/ missing Total Number of circumcised men Age 15-19 27.3 58.0 14.6 100.0 135 20-24 17.6 73.7 8.7 100.0 163 25-29 26.5 65.0 8.5 100.0 174 30-34 30.3 64.2 5.5 100.0 117 35-39 29.2 61.5 9.2 100.0 88 40-44 26.8 63.1 10.0 100.0 69 45-49 31.1 55.8 13.0 100.0 44 50-54 22.6 75.3 2.1 100.0 35 55-59 67.2 32.8 0.0 100.0 15 Residence Urban 31.4 63.8 4.8 100.0 391 Rural 22.3 64.8 12.9 100.0 448 Province Kigali City 30.7 61.6 7.7 100.0 270 South 24.8 66.4 8.8 100.0 120 West 21.4 67.8 10.9 100.0 299 North 24.7 67.5 7.8 100.0 53 East 34.2 56.9 8.9 100.0 97 Education No education 32.5 63.3 4.3 100.0 72 Primary 29.1 58.3 12.6 100.0 381 Secondary or higher 22.9 70.5 6.6 100.0 386 Religion Catholic 16.7 73.0 10.3 100.0 341 Protestant 15.8 71.3 13.0 100.0 253 Adventist 19.6 75.1 5.3 100.0 91 Muslim 75.8 23.3 0.9 100.0 135 Other/missing 41.3 54.0 4.7 100.0 20 Wealth quintile Lowest 30.0 56.8 13.2 100.0 49 Second 28.8 52.0 19.1 100.0 113 Middle 27.1 66.5 6.4 100.0 82 Fourth 20.6 61.7 17.6 100.0 91 Highest 26.6 67.9 5.4 100.0 504 Total 26.5 64.3 9.1 100.0 839 References | 111 REFERENCES ACC/SCN. 2000. Fourth report on the world nutrition situation. Geneva: ACC/SCN in collaboration with IFPRI. Centers for Disease Control and Prevention (CDC). 1998. Recommendations to prevent and control iron deficiency in the United States. Morbidity and Mortality Weekly Report 47 (RR-3): 1-29. DeMaeyer, E.M. 1989. Preventing and controlling iron deficiency anemia through primary health care: A guide for health administrators and programme managers. E.M. DeMaeyer with the collaboration of P. Dallman et al. Geneva: World Health Organization. Gwatkin, D.R., S.Rutstein, K. Johnson, R.P. Pande and A.Wagstaff. 2000. Socio-economic differences in health, nutrition and poverty. HNP/Poverty Thematic Group of the World Bank, Washington, D.C.: The World Bank. Institut National de la Statistique du Rwanda (INSR) and ORC Macro. 2006. Enquête Démographique et de Santé 2005. Calverton, Maryland, USA: INSR and ORC Macro. Ministry of Agriculture and Animal Resources (MAAR) [Rwanda]. 2004. Strategic plan for agricultural transformation in Rwanda. Kigali, Rwanda: Ministry of Agriculture and Animal Resources. Ministry of Finance and Economic Planning (MFEP) [Rwanda]. 2007. Economic development and poverty reduction strategy, 2008-2012. Kigali, Rwanda: Ministry of Finance and Economic Planning. Ministry of Health (MOH) [Rwanda]. 2005a. Politique du secteur de la santé. Kigali, Rwanda: Ministry of Health. Ministry of Health (MOH) [Rwanda]. 2005b. Plan stratégique du secteur de la santé 2005-2009. Kigali, Rwanda: Ministry of Health. Ministry of Health (MOH) [Rwanda]. 2008. Formation des formateurs en planification familiale : Manuel de référence. Kigali, Rwanda: Ministry of Health. Ministry of Health (MOH) [Rwanda]. 2009. Health public expenditure review 2006-2007. Kigali, Rwanda: Ministry of Health. Office National de la Population [Rwanda] and Macro International. 1994. Enquête Démographique et de Santé du Rwanda 1992. Calverton, Maryland, USA: Office National de la Population and Macro International. Office National de la Population [Rwanda] and ORC Macro. 2001. Enquête Démographique et de Santé du Rwanda 2000. Calverton, Maryland, USA: Office National de la Population and ORC Macro. Rutstein, S.O., and G. Rojas. 2003. Guide to DHS statistics. Calverton, Maryland, USA: ORC Macro. 112 | References Service National de Recensement (SNR) [Rwanda]. 2005. 3ème Recensement Général de la Population et de l’Habitat du Rwanda au 15 Août 2002. Kigali, Rwanda: Service National de Recensement. Sullivan, J.M., S.O. Rutstein, and G.T. Bicego. 1994. Infant and child mortality. DHS Comparative Studies No. 15. Calverton, Maryland, USA: ORC Macro. Williams, N., and L. Kapila. 1993. Complications of circumcision. (Nottingham, UK). British Journal of Surgery 80: 1231-1236. Appendix A | 113 SAMPLING DESIGN APPENDIX A A.1 INTRODUCTION The 2007-08 Rwanda Interim Demographic and Health Survey (2007-08 RIDHS) followed the third standard DHS (2005 RDHS-III), which was conducted in 2005. It is composed of a nationally representative sample of approximately 7,500 households selected from 250 clusters. All women age 15- 49 and all men age 15-59 who were usual residents of the households or who were present in the sampled households on the night before the survey were eligible to be interviewed. The primary goal of the survey was to collect data on demographic and health indicators of women, men, and children. The data were representative at the national level, for urban and rural areas separately, and for each of the five provinces. To obtain results that would be compared with the results from the 2005 RDHS-III, the 2007-08 RIDHS selected a subsample of 250 clusters from the 462 clusters of the 2005 RDHS-III, where the households in each cluster were independently selected. The survey methodology of the 2007-08 RIDHS is the same as that of the 2005 RDHS-III, which is presented in section A.3. The survey interviewed 30 households per cluster; the distribution of the sample is presented in the Table A.1. Table A.1 Distribution of clusters and households by urban-rural residence and province, Rwanda 2007-08 Number of clusters selected Number of households selected Province Urban Rural Subtotal Urban Rural Subtotal Kigali City 25 0 25 750 0 750 Kigali Ngali 3 18 21 90 540 630 Gitarama 5 16 21 150 480 630 Butare 6 15 21 180 450 630 Gikongoro 3 17 20 90 510 600 Cyangugu 3 17 20 90 510 600 Kibuye 3 17 20 90 510 600 Gisenyi 3 18 21 90 540 630 Ruhengeri 3 18 21 90 540 630 Byumba 3 17 20 90 510 600 Umutara 2 18 20 60 540 600 Kibungo 4 16 20 120 480 600 Total 63 187 250 1,890 5,610 7,500 A.2 SURVEY RESULT Tables A.2 and A.3 present the detailed results from the interviewed households, women, and men by urban-rural residence and province. 114 | Appendix A Table A.2 Sample implementation: Women Percent distribution of households and eligible women by the result of the household and individual interviews, and household, eligible women, and overall response rates by urban-rural residence and province, Rwanda 2007-08 Residence Province Result of the interviews Urban Rural Kigali City South West North East Total Households selected Completed (a) 97.7 99.1 96.3 98.8 99.0 99.3 99.4 98.8 Household present but no respondent at home (b) 0.8 0.3 1.4 0.5 0.2 0.3 0.1 0.4 Postponed (c) 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Refused (d) 0.1 0.0 0.2 0.0 0.1 0.0 0.0 0.1 Dwelling not found (e) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Household absence (f) 0.8 0.5 1.1 0.5 0.5 0.4 0.4 0.5 Dwelling vacant/address not a dwelling (g) 0.2 0.1 0.4 0.0 0.1 0.0 0.1 0.1 Dwelling destroyed (h) 0.1 0.0 0.1 0.0 0.1 0.0 0.0 0.0 Other (i) 0.2 0.0 0.4 0.1 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of household selected 1,632 5,837 929 1,830 1,950 1,140 1,620 7,469 Household response rate (HRR) 99.1 99.6 98.4 99.4 99.6 99.7 99.9 99.5 Eligible women Completed (1) 96.2 97.4 95.4 96.4 99.0 95.8 97.9 97.1 Not at home (2) 2.7 1.7 3.5 2.5 0.6 2.7 1.4 2.0 Postponed (3) 0.1 0.1 0.0 0.2 0.0 0.0 0.0 0.1 Refuse (4) 0.3 0.2 0.4 0.3 0.2 0.6 0.0 0.3 Partially competed (5) 0.1 0.1 0.3 0.1 0.0 0.1 0.0 0.1 Incapacitated (6) 0.6 0.4 0.2 0.6 0.2 0.6 0.5 0.4 Other (7) 0.1 0.1 0.2 0.1 0.0 0.2 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,809 5,719 1,017 1,893 1,881 1,081 1,656 7,528 Eligible women response rate (EWRR) 96.2 97.4 95.4 96.4 99.0 95.8 97.9 97.1 Overall response rate (ORR) 95.3 97.1 93.8 95.8 98.6 95.6 97.8 96.6 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * (a) ——————————— (a) + (b) + (c) + (d) + (e) 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * (1) —————————————— (1) + (2) + (4) + (5) + (6) + (7) 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 Appendix A | 115 Table A.3 Sample implementation: Men Percent distribution of households and eligible men by the result of the household and individual interviews, and household, eligible men, and overall response rates by residence and province, Rwanda 2007-08 Residence Province Result of the interviews Urban Rural Kigali City South West North East Total Households selected Completed (a) 97.7 99.1 96.3 98.8 99.0 99.3 99.4 98.8 Household present but no respondent at home (b) 0.8 0.3 1.4 0.5 0.2 0.3 0.1 0.4 Postponed (c) 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Refused (d) 0.1 0.0 0.2 0.0 0.1 0.0 0.0 0.1 Dwelling not found (e) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Household absence (f) 0.8 0.5 1.1 0.5 0.5 0.4 0.4 0.5 Dwelling vacant/address not a dwelling (g) 0.2 0.1 0.4 0.0 0.1 0.0 0.1 0.1 Dwelling destroyed (h) 0.1 0.0 0.1 0.0 0.1 0.0 0.0 0.0 Other (i) 0.2 0.0 0.4 0.1 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of household selected 1,632 5,837 929 1,830 1,950 1,140 1,620 7,469 Household response rate (HRR) 99.1 99.6 98.4 99.4 99.6 99.7 99.9 99.5 Eligible men Completed (1) 94.9 95.6 93.3 92.9 98.2 95.8 96.0 95.4 Not at home (2) 4.3 3.5 5.6 6.2 1.1 3.6 2.5 3.7 Postponed (3) 0.1 0.1 0.2 0.1 0.1 0.2 0.2 0.1 Refuse (4) 0.0 0.2 0.2 0.1 0.2 0.2 0.1 0.2 Partially competed (5) 0.3 0.2 0.2 0.4 0.2 0.1 0.4 0.3 Incapacitated (6) 0.4 0.4 0.5 0.3 0.3 0.1 0.7 0.4 Other (7) Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,829 5,339 1,120 1,716 1,819 1,004 1,509 7,168 Eligible men response rate (EMRR) 94.9 95.6 93.3 92.9 98.2 95.8 96.0 95.4 Overall response rate (ORR) 94.0 95.2 91.8 92.3 97.9 95.6 95.9 94.9 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * (a) ——————————— (a) + (b) + (c) + (d) + (e) 2 Using the number of eligible men falling into specific response categories, the eligible man response rate (EMRR) is calculated as: 100 * (1) —————————————— (1) + (2) + (4) + (5) + (6) + (7) 3 The overall response rate (ORR) is calculated as: ORR = HRR * EMRR/100 116 | Appendix A A.3 SAMPLE DESIGN OF THE 2005 RWANDA DEMOGRAPHIC AND HEALTH SURVEY A.3.1 Introduction The third Demographic and Health Survey in Rwanda (2005 RDHS-III) followed those conducted in 1992 and 2000. It is composed of a nationally representative sample of approximately 10,500 households. All women age 15-49 who were usual residents of the household or who were present in the sampled households on the night before the survey, were eligible to be interviewed. In addition, a subsample of 50 percent of all households selected for the women’s questionnaire was selected for the men’s questionnaire. In this subsample of households, all men age 15-59 were eligible to be interviewed and, in addition, all eligible men and women were asked to consent to an HIV test. As with the prior two surveys, the primary goal of the survey was to collect data on fertility, knowledge and use of contraception, maternal and childhood mortality, and sexually transmitted infections and HIV/AIDS. The data were representative at the national level, for urban and rural areas separately, and for each of the five provinces. The sample was designed to be representative for each of the 12 old provinces, and is therefore representative at the level of the five new provinces, because these represent a regrouping of the 12 old provinces. A.3.2 Sampling Frame The Service National de Recensement (SNR) [National Census Service] has a computer file of 7,727 enumeration areas (EAs) created for the 2002 General Population and Housing Census (SNR, 2005). In that file, each EA is listed with all of its identifiers (province, district, and identification code), its population size, number of households, and urban-rural classification. The boundaries for each EA are clearly identifiable on the cartographic maps created for the 2002 GPHC. The distribution of EAs and of households among the 12 old provinces and according to urban-rural residence is shown in Table A.4. Table A.4 Distribution of households and enumeration areas (EAs) by old province and according to residence (RGPH, 2002) Number of households Number of EAs Old province Urban Rural Total Urban Rural Total Kigali City 124,964 0 124,964 565 0 565 Kigali Ngali 11,513 160,967 172,480 41 694 735 Gitarama 27,205 157,108 184,313 116 698 814 Butare 27,117 137,526 164,643 113 568 681 Gikongoro 6,258 100,833 107,091 28 465 493 Cyangugu 9,284 111,267 120,551 42 559 601 Kibuye 9,654 92,747 102,401 40 432 472 Gisenyi 12,360 174,853 187,213 51 761 812 Ruhengeri 14,474 178 ,86 193,160 61 779 840 Byumba 12,294 139,645 151,939 50 615 665 Umutara 1,843 89,817 91,660 7 393 400 Kibungo 16,015 140,996 157,011 64 585 649 Total 272,981 1,484,445 1,757,426 1,178 6,549 7,727 Appendix A | 117 A.3.3 Sample Selection The sample for the 2005 RDHS-III used a stratified, two-stage cluster selection. The primary sampling unit is the EA as defined in the 2002 census. Each province is separated into urban and rural areas to create the sampling strata and the sample was drawn independently in each stratum. There were therefore 23 strata in total, because the City of Kigali had no rural areas. In the first stage, 462 EAs were selected with probability proportional to size, the size being the number of households in the EA. An updating operation listed all the households in each selected EA and this list was used to select the households for the second stage. Before this updating of the households, the larger EAs were divided into segments, of which only one was selected for the survey. In the second stage, in each EA selected in the first stage, a fixed number of households (20 households in each urban cluster, 24 households in each rural cluster) were selected using a systematic selection based on the new list of households created during the household listing. In all, 10,644 households were selected for the women’s interview. All members of each selected household were listed in the Household Questionnaire. Every woman age 15-49 in the household was interviewed using the Women’s Questionnaire. Half of the households selected for the women’s interview were also selected for the men’s interview. In this subsample of households all men age 15-59 were interviewed. All men age 15-59 and all women age 15- 49 in this subsample of households were also asked to consent to an HIV test. Table A.5 shows the sample allocation by old province and according to urban-rural residence. In all, 462 EAs were selected (111 in urban areas and 351 in rural areas), and 10,644 households were selected (2,220 in urban areas and 8,424 in rural areas). Table A.5 Sample allocation by old province and according to residence Number of households Number of EAs Old province Urban Rural Total Urban Rural Total Expected number of interviewed women Kigali City 880 0 880 44 0 44 899 Kigali Ngali 100 792 892 5 33 38 911 Gitarama 180 696 876 9 29 38 894 Butare 200 672 872 10 28 38 890 Gikongoro 100 792 892 5 33 38 911 Cyangugu 120 768 888 6 32 38 907 Kibuye 120 768 888 6 32 38 907 Gisenyi 100 792 892 5 33 38 911 Ruhengeri 120 768 888 6 32 38 907 Byumba 120 768 888 6 32 38 907 Umutara 40 864 904 2 36 38 923 Kibungo 140 744 884 7 31 38 903 Total 2,220 8,424 10,644 111 351 462 10,868 A.3.4 Sampling Probability The sampling probabilities were calculated separately for each sampling stage and for each stratum. For each stratum h, the following notations are used: P1hi : first-stage’s sampling probability of EA i. P2hi : second-stage’s sampling probability of households in stratum h, EA i. 118 | Appendix A Let ah be the number of clusters selected in stratum h, Mhi the number of households of the ith EA in stratum h, and Mh the total number of households in stratum h. In the first stage, the probability of inclusion of the ith EA in the sample is calculated as follows: h hih hi M Ma P ×=1 In the second stage, a number of bhi households is selected from the number Lhi households found during the household listing in the ith EA. We then have: hi hi hi L bP =2 Because of the nonproportional distribution of the sample between strata, sampling weights are used to insure that the sample is representative at the national level. Sampling weights for individuals of cluster i in strata h are calculated as follows: hihi hi PP W 21 1= with a correction for non-response and normalization. Appendix B | 119 ESTIMATES OF SAMPLING ERRORS APPENDIX B 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, misunder- standing 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 2007-08 RIDHS 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 2007-08 RIDHS 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 2007-08 RIDHS sample is the result of a multistage stratified design, and, consequently, it was necessary to use more complex formula. The computer software used to calculate sampling errors for the 2007-08 RIDHS is a macro SAS procedure. This procedure 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 zz m m x frvarrSE h 1 2 1 2 2 2 1 1)()( in which hihihi rxyz −= , et hhh rxyz −= 120 | Appendix B 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 cluster in the calculation of the estimates. Pseudoindependent replications are thus created. In the 2007-08 RIDHS, there were 250 non-empty clusters. Hence, 250 subsamples were created. The variance of a rate r is calculated as follows: ∑ = −−== k i i rrkk rvarrSE 1 22 )( )1( 1)()( in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 250 clusters, r(i) is the estimate computed from the reduced sample of 251 clusters (ith cluster excluded), k is the total number of clusters. In addition to the standard error, the procedure computes the design effect (DEFT) or cluster effect 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. The procedure also computes the relative error and confidence limits for the estimates. Sampling errors for the 2007-08 RIDHS are calculated for selected variables considered to be of primary interest for woman’s survey and for man’s surveys, respectively. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the five provinces. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.9 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 because there is no known unweighted value for woman-years of exposure to childbearing. The confidence interval (e.g., as calculated for children surviving) can be interpreted as follows: the 2007-08 RIDHS provides the overall average from the national sample is 2.593 and its standard error is 0.046. Therefore, the 95 percent confidence limits, the true average number of children surviving per women age 15-49, is obtained by adding and subtracting twice the standard error to the sample estimate, i.e., 2.593-2×0.046 and 2.593+2×0.046, that is, between 2.500 and 2.686. Appendix B | 121 For the total sample of women, the value of the design effect (DEFT), averaged over all variables, is 1.42, which means that because of multistage clustering of the sample, the average standard error is increased by a factor of 1.42 over that in an equivalent simple random sample. However in the practical situation of the survey, it would not be possible to select a simple random sample of women age 15-49 because it requires a list of all women age 15-49 in the whole country, which is not available. Table B.1 List of selected variables for sampling errors, Rwanda 2007-08 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Variable Estimation Base population –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion All women 15-49 No education Proportion All women 15-49 Secondary education or higher Proportion All women 15-49 Never married/in union Proportion All women 15-49 Currently married/in union Proportion All women 15-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women 40-49 Mean Women 40-49 Know any contraceptive method Proportion Currently married women 15-49 Ever used any contraceptive method Proportion Currently married women 15-49 Currently use any contraceptive method Proportion Currently married women 15-49 Currently use pill Proportion Currently married women 15-49 Currently use condom Proportion Currently married women 15-49 Currently use female sterilization Proportion Currently married women 15-49 Currently use periodic abstinence Proportion Currently married women 15-49 Want no more children Proportion Currently married women 15-49 Want to delay births at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean All women 15-49 Mother received tetanus injection for last birth Proportion Most recent births in the last 5 years Mother received medical assistance at delivery Proportion Birth in the last 5 years Children with diarrhea 2 weeks preceding survey Proportion Children under 5 Treated with oral rehydration salt (ORS) Proportion Children with diarrhea in 2 weeks before interview Taken to the health provider Proportion Children with diarrhea in 2 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 immunized Proportion Children age 12-23 months Total fertility rate (0-3 years) Rate All women Neonatal mortality¹ Rate Number of births in past 5(10) years Postneonatal mortality¹ Rate Number of births in past 5(10) years Infant mortality¹ Rate Number of births in past 5(10) years Child mortality¹ Rate Number of births in past 5(10) years Under-five mortality¹ Rate Number of births in past 5(10) years –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence Proportion All men 15-49 No education Proportion All men 15-49 Secondary education or higher Proportion All men 15-49 Never married/in union Proportion All men 15-49 Currently married/in union Proportion All men 15-49 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ¹ Past 5 years for national-level rate, and past 10 years for urban-rural and provincial rates 122 | Appendix B Table B.2 Sampling errors for national sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.170 0.010 7,313 7,313 2.209 0.057 0.150 0.189 No education 0.222 0.009 7,313 7,313 1.823 0.040 0.204 0.240 Secondary education or higher 0.116 0.008 7,313 7,313 2.252 0.073 0.099 0.133 Never married/in union 0.352 0.009 7,313 7,313 1.597 0.025 0.334 0.370 Currently married/in union 0.532 0.009 7,313 7,313 1.546 0.017 0.514 0.550 Currently pregnant 0.094 0.004 7,313 7,313 1.262 0.046 0.085 0.102 Children ever born 2.593 0.046 7,313 7,313 1.453 0.018 2.500 2.686 Children surviving 2.174 0.038 7,313 7,313 1.442 0.018 2.097 2.251 Children ever born to women 40-49 6.041 0.089 1,258 1,297 1.242 0.015 5.863 6.219 Know any contraceptive method 0.990 0.002 3,759 3,888 1.469 0.002 0.985 0.995 Ever used any contraceptive method 0.560 0.013 3,759 3,888 1.554 0.022 0.534 0.585 Currently use any contraceptive method 0.364 0.012 3,759 3,888 1.514 0.033 0.340 0.387 Currently use pill 0.064 0.005 3,759 3,888 1.279 0.080 0.054 0.074 Currently use condom 0.019 0.002 3,759 3,888 1.113 0.131 0.014 0.024 Currently use female sterilization 0.007 0.001 3,759 3,888 1.001 0.198 0.004 0.009 Currently use periodic abstinence 0.060 0.005 3,759 3,888 1.374 0.089 0.049 0.070 Want no more children 0.492 0.011 3,759 3,888 1.321 0.022 0.470 0.513 Want to delay births at least 2 years 0.357 0.010 3,759 3,888 1.295 0.028 0.337 0.378 Ideal number of children 3.317 0.028 7,123 7,125 1.798 0.009 3.260 3.373 Mother received tetanus injection for last birth 0.724 0.011 3,568 3,658 1.455 0.015 0.703 0.746 Mother received medical assistance at delivery 0.521 0.014 5,489 5,656 1.719 0.026 0.493 0.548 Children with diarrhea 2 weeks preceding survey 0.137 0.006 5,094 5,241 1.207 0.046 0.125 0.150 Treated with oral rehydration salt (ORS) 0.213 0.021 689 719 1.248 0.100 0.170 0.255 Taken to the health provider 0.326 0.023 689 719 1.179 0.069 0.281 0.371 Vaccination card seen 0.670 0.020 1,174 1,226 1.476 0.030 0.629 0.710 Received BCG 0.955 0.007 1,174 1,226 1.233 0.008 0.940 0.970 Received DPT (3 doses) 0.898 0.011 1,174 1,226 1.273 0.013 0.875 0.921 Received polio (3 doses) 0.855 0.014 1,174 1,226 1.344 0.016 0.827 0.883 Received measles 0.904 0.011 1,174 1,226 1.225 0.012 0.883 0.925 Fully immunized 0.804 0.016 1,174 1,226 1.358 0.020 0.772 0.836 Total fertility rate (0-3 years) 5.514 0.113 na 20,691 1.428 0.021 5.288 5.741 Neonatal mortality (5 years) 28.011 2.761 5,528 5,691 1.157 0.099 22.488 33.533 Postneonatal mortality (5 years) 34.283 3.065 5,514 5,673 1.195 0.089 28.152 40.413 Infant mortality (5 years) 62.293 4.409 5,541 5,705 1.263 0.071 53.475 71.111 Child mortality (5 years) 43.023 4.416 5,473 5,626 1.434 0.103 34.191 51.856 Under-five mortality (5 years) 102.636 6.564 5,631 5,801 1.416 0.064 89.508 115.765 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.188 0.011 6,225 6,197 2.238 0.059 0.166 0.211 No education 0.154 0.007 6,225 6,197 1.519 0.045 0.140 0.168 Secondary education or higher 0.158 0.010 6,225 6,197 2.206 0.065 0.138 0.178 Never married/in union 0.487 0.009 6,225 6,197 1.499 0.019 0.468 0.506 Currently married/in union 0.495 0.009 6,225 6,197 1.486 0.019 0.476 0.513 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 123 Table B.3 Sampling errors for urban sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 1,974 1,240 na na 1.000 1.000 No education 0.130 0.011 1,974 1,240 1.397 0.081 0.108 0.151 Secondary education or higher 0.284 0.026 1,974 1,240 2.571 0.092 0.231 0.336 Never married/in union 0.428 0.018 1,974 1,240 1.575 0.041 0.393 0.463 Currently married/in union 0.456 0.017 1,974 1,240 1.532 0.038 0.422 0.491 Currently pregnant 0.077 0.008 1,974 1,240 1.279 0.100 0.061 0.092 Children ever born 2.065 0.082 1,974 1,240 1.505 0.040 1.900 2.229 Children surviving 1.822 0.067 1,974 1,240 1.407 0.037 1.688 1.956 Children ever born to women 40-49 5.595 0.170 282 181 1.162 0.030 5.255 5.936 Know any contraceptive method 0.988 0.006 872 566 1.682 0.006 0.976 1.001 Ever used any contraceptive method 0.641 0.024 872 566 1.466 0.037 0.594 0.689 Currently use any contraceptive method 0.446 0.024 872 566 1.444 0.055 0.397 0.494 Currently use pill 0.088 0.012 872 566 1.244 0.136 0.064 0.112 Currently use condom 0.036 0.008 872 566 1.285 0.226 0.020 0.052 Currently use female sterilization 0.018 0.006 872 566 1.270 0.320 0.006 0.029 Currently use periodic abstinence 0.061 0.010 872 566 1.288 0.172 0.040 0.081 Want no more children 0.504 0.023 872 566 1.376 0.046 0.457 0.550 Want to delay births at least 2 years 0.337 0.017 872 566 1.050 0.050 0.304 0.371 Ideal number of children 3.162 0.050 1,929 1,207 1.698 0.016 3.063 3.261 Mother received tetanus injection for last birth 0.705 0.023 851 544 1.443 0.032 0.660 0.750 Mother received medical assistance at delivery 0.698 0.024 1,268 804 1.553 0.034 0.650 0.745 Children with diarrhea 2 weeks preceding survey 0.139 0.013 1,200 764 1.203 0.096 0.112 0.166 Treated with oral rehydration salt (ORS) 0.303 0.047 156 106 1.167 0.155 0.209 0.396 Taken to the health provider 0.379 0.047 156 106 1.123 0.123 0.286 0.472 Vaccination card seen 0.635 0.042 258 168 1.423 0.067 0.550 0.720 Received BCG 0.984 0.008 258 168 1.055 0.008 0.967 1.000 Received DPT (3 doses) 0.917 0.026 258 168 1.514 0.028 0.866 0.969 Received polio (3 doses) 0.872 0.029 258 168 1.382 0.033 0.815 0.929 Received measles 0.918 0.020 258 168 1.199 0.022 0.878 0.959 Fully immunized 0.805 0.037 258 168 1.494 0.045 0.732 0.878 Total fertility rate (0-3 years) 4.714 0.204 na 3,476 1.273 0.043 4.307 5.121 Neonatal mortality (10 years) 18.722 2.809 2,317 1,465 0.923 0.150 13.104 24.340 Postneonatal mortality (10 years) 27.802 4.332 2,315 1,463 1.234 0.156 19.138 36.467 Infant mortality (10 years) 46.524 5.462 2,319 1,467 1.177 0.117 35.600 57.449 Child mortality (10 years) 42.504 5.081 2,252 1,425 1.065 0.120 32.342 52.666 Under-five mortality (10 years) 87.051 8.186 2,340 1,480 1.260 0.094 70.678 103.424 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 1.000 0.000 1,820 1,167 na na 1.000 1.000 No education 0.091 0.010 1,820 1,167 1.415 0.105 0.072 0.110 Secondary education or higher 0.358 0.027 1,820 1,167 2.382 0.075 0.305 0.412 Never married/in union 0.596 0.017 1,820 1,167 1.509 0.029 0.561 0.631 Currently married/in union 0.388 0.017 1,820 1,167 1.526 0.045 0.353 0.423 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 124 | Appendix B Table B.4 Sampling errors for rural sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 5,339 6,073 na na 0.000 0.000 No education 0.241 0.010 5,339 6,073 1.772 0.043 0.220 0.262 Secondary education or higher 0.081 0.008 5,339 6,073 2.195 0.101 0.065 0.098 Never married/in union 0.336 0.010 5,339 6,073 1.571 0.030 0.316 0.357 Currently married/in union 0.547 0.010 5,339 6,073 1.518 0.019 0.526 0.568 Currently pregnant 0.097 0.005 5,339 6,073 1.226 0.051 0.087 0.107 Children ever born 2.701 0.053 5,339 6,073 1.405 0.020 2.594 2.808 Children surviving 2.245 0.044 5,339 6,073 1.406 0.020 2.157 2.334 Children ever born to women 40-49 6.113 0.100 976 1,116 1.229 0.016 5.913 6.314 Know any contraceptive method 0.990 0.003 2,887 3,322 1.416 0.003 0.985 0.995 Ever used any contraceptive method 0.546 0.014 2,887 3,322 1.524 0.026 0.517 0.574 Currently use any contraceptive method 0.350 0.013 2,887 3,322 1.498 0.038 0.323 0.376 Currently use pill 0.060 0.006 2,887 3,322 1.272 0.094 0.049 0.071 Currently use condom 0.016 0.002 2,887 3,322 1.068 0.156 0.011 0.021 Currently use female sterilization 0.005 0.001 2,887 3,322 0.940 0.250 0.002 0.007 Currently use periodic abstinence 0.059 0.006 2,887 3,322 1.353 0.100 0.048 0.071 Want no more children 0.490 0.012 2,887 3,322 1.287 0.024 0.466 0.514 Want to delay births at least 2 years 0.361 0.012 2,887 3,322 1.287 0.032 0.338 0.384 Ideal number of children 3.349 0.033 5,194 5,918 1.759 0.010 3.283 3.414 Mother received tetanus injection for last birth 0.728 0.012 2,717 3,114 1.420 0.017 0.704 0.752 Mother received medical assistance at delivery 0.491 0.015 4,221 4,852 1.677 0.031 0.461 0.522 Children with diarrhea 2 weeks preceding survey 0.137 0.007 3,894 4,478 1.178 0.051 0.123 0.151 Treated with oral rehydration salt (ORS) 0.197 0.023 533 613 1.240 0.119 0.150 0.244 Taken to the health provider 0.317 0.025 533 613 1.156 0.080 0.266 0.367 Vaccination card seen 0.675 0.022 916 1,058 1.436 0.033 0.630 0.720 Received BCG 0.950 0.009 916 1,058 1.176 0.009 0.933 0.967 Received DPT (3 doses) 0.895 0.012 916 1,058 1.208 0.014 0.870 0.920 Received polio (3 doses) 0.853 0.015 916 1,058 1.297 0.018 0.822 0.883 Received measles 0.902 0.012 916 1,058 1.187 0.013 0.878 0.925 Fully immunized 0.804 0.017 916 1,058 1.305 0.022 0.769 0.839 Total fertility rate (0-3 years) 5.663 0.126 na 17,215 1.393 0.022 5.410 5.916 Neonatal mortality (10 years) 33.713 2.667 7,941 9,071 1.175 0.079 28.378 39.047 Postneonatal mortality (10 years) 48.445 3.251 7,940 9,072 1.226 0.067 41.942 54.948 Infant mortality (10 years) 82.158 4.421 7,961 9,096 1.271 0.054 73.316 91.000 Child mortality (10 years) 65.478 4.898 7,834 8,931 1.399 0.075 55.682 75.274 Under-five mortality (10 years) 142.257 7.161 8,069 9,221 1.472 0.050 127.935 156.578 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.000 0.000 4,405 5,030 na na 0.000 0.000 No education 0.169 0.008 4,405 5,030 1.456 0.049 0.153 0.186 Secondary education or higher 0.111 0.010 4,405 5,030 2.166 0.092 0.091 0.132 Never married/in union 0.462 0.011 4,405 5,030 1.450 0.024 0.440 0.484 Currently married/in union 0.519 0.011 4,405 5,030 1.433 0.021 0.498 0.541 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 125 Table B.5 Sampling errors for Kigali City sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.874 0.014 970 685 1.333 0.016 0.846 0.903 No education 0.117 0.014 970 685 1.319 0.116 0.090 0.145 Secondary education or higher 0.336 0.027 970 685 1.807 0.082 0.281 0.390 Never married/in union 0.451 0.026 970 685 1.656 0.059 0.398 0.504 Currently married/in union 0.451 0.026 970 685 1.615 0.057 0.400 0.503 Currently pregnant 0.103 0.012 970 685 1.189 0.113 0.080 0.127 Children ever born 1.818 0.108 970 685 1.485 0.059 1.603 2.033 Children surviving 1.597 0.087 970 685 1.432 0.055 1.422 1.771 Children ever born to women 40-49 5.316 0.224 113 83 0.929 0.042 4.869 5.763 Know any contraceptive method 0.981 0.011 416 309 1.597 0.011 0.960 1.003 Ever used any contraceptive method 0.644 0.026 416 309 1.101 0.040 0.592 0.695 Currently use any contraceptive method 0.418 0.026 416 309 1.073 0.062 0.366 0.470 Currently use pill 0.088 0.017 416 309 1.254 0.198 0.053 0.123 Currently use condom 0.039 0.012 416 309 1.299 0.316 0.014 0.064 Currently use female sterilization 0.019 0.009 416 309 1.387 0.489 0.000 0.038 Currently use periodic abstinence 0.051 0.013 416 309 1.186 0.252 0.025 0.076 Want no more children 0.477 0.030 416 309 1.236 0.064 0.416 0.537 Want to delay births at least 2 years 0.361 0.022 416 309 0.935 0.061 0.317 0.406 Ideal number of children 3.061 0.064 943 663 1.570 0.021 2.932 3.190 Mother received tetanus injection for last birth 0.673 0.040 386 287 1.666 0.059 0.594 0.752 Mother received medical assistance at delivery 0.655 0.040 567 425 1.657 0.061 0.575 0.734 Children with diarrhea 2 weeks preceding survey 0.149 0.022 533 400 1.223 0.145 0.106 0.192 Treated with oral rehydration salt (ORS) 0.439 0.056 71 60 0.861 0.127 0.328 0.551 Taken to the health provider 0.490 0.060 71 60 0.940 0.122 0.371 0.610 Vaccination card seen 0.648 0.059 124 95 1.399 0.091 0.530 0.766 Received BCG 0.946 0.013 124 95 0.658 0.014 0.919 0.972 Received DPT (3 doses) 0.856 0.031 124 95 1.021 0.037 0.794 0.919 Received polio (3 doses) 0.842 0.034 124 95 1.065 0.040 0.774 0.911 Received measles 0.908 0.032 124 95 1.254 0.035 0.845 0.972 Fully immunized 0.778 0.052 124 95 1.427 0.067 0.674 0.883 Total fertility rate (0-3 years) 4.369 0.388 na 1,936 1.285 0.089 3.592 5.145 Neonatal mortality (10 years) 27.520 7.499 1,015 746 1.253 0.272 12.523 42.518 Postneonatal mortality (10 years) 32.931 4.748 1,021 748 0.619 0.144 23.434 42.428 Infant mortality (10 years) 60.452 10.027 1,016 746 0.969 0.166 40.398 80.505 Child mortality (10 years) 43.804 11.641 981 720 1.406 0.266 20.523 67.085 Under-five mortality (10 years) 101.607 19.423 1,021 751 1.437 0.191 62.762 140.453 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.873 0.029 1,004 730 2.729 0.033 0.816 0.931 No education 0.067 0.011 1,004 730 1.343 0.158 0.046 0.088 Secondary education or higher 0.400 0.030 1,004 730 1.945 0.075 0.339 0.460 Never married/in union 0.620 0.024 1,004 730 1.542 0.038 0.572 0.667 Currently married/in union 0.366 0.024 1,004 730 1.602 0.067 0.317 0.414 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 126 | Appendix B Table B.6 Sampling errors for South Province sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.140 0.013 1,824 1,946 1.615 0.094 0.113 0.166 No education 0.206 0.017 1,824 1,946 1.770 0.081 0.173 0.240 Secondary education or higher 0.089 0.014 1,824 1,946 2.140 0.160 0.061 0.118 Never married/in union 0.378 0.016 1,824 1,946 1.384 0.042 0.346 0.409 Currently married/in union 0.506 0.014 1,824 1,946 1.200 0.028 0.478 0.535 Currently pregnant 0.090 0.008 1,824 1,946 1.127 0.084 0.075 0.105 Children ever born 2.404 0.085 1,824 1,946 1.402 0.036 2.234 2.575 Children surviving 2.029 0.071 1,824 1,946 1.374 0.035 1.887 2.171 Children ever born to women 40-49 5.608 0.154 343 365 1.124 0.027 5.300 5.916 Know any contraceptive method 0.986 0.006 915 985 1.491 0.006 0.974 0.998 Ever used any contraceptive method 0.546 0.025 915 985 1.517 0.046 0.496 0.596 Currently use any contraceptive method 0.335 0.020 915 985 1.307 0.061 0.294 0.376 Currently use pill 0.048 0.008 915 985 1.085 0.160 0.033 0.063 Currently use condom 0.015 0.004 915 985 1.110 0.295 0.006 0.024 Currently use female sterilization 0.004 0.002 915 985 0.904 0.454 0.000 0.008 Currently use periodic abstinence 0.069 0.012 915 985 1.415 0.172 0.045 0.093 Want no more children 0.502 0.020 915 985 1.184 0.039 0.463 0.541 Want to delay births at least 2 years 0.332 0.021 915 985 1.354 0.064 0.290 0.374 Ideal number of children 3.245 0.043 1,777 1,897 1.459 0.013 3.159 3.331 Mother received tetanus injection for last birth 0.700 0.023 863 930 1.465 0.032 0.654 0.745 Mother received medical assistance at delivery 0.507 0.026 1,331 1,442 1.641 0.052 0.454 0.560 Children with diarrhea 2 weeks preceding survey 0.148 0.013 1,240 1,340 1.231 0.090 0.121 0.174 Treated with oral rehydration salt (ORS) 0.084 0.021 177 198 1.026 0.251 0.042 0.126 Taken to the health provider 0.211 0.041 177 198 1.276 0.193 0.129 0.292 Vaccination card seen 0.675 0.037 299 322 1.329 0.054 0.602 0.748 Received BCG 0.947 0.014 299 322 1.028 0.015 0.919 0.974 Received DPT (3 doses) 0.875 0.023 299 322 1.206 0.027 0.829 0.922 Received polio (3 doses) 0.835 0.030 299 322 1.359 0.036 0.775 0.895 Received measles 0.877 0.019 299 322 0.967 0.021 0.840 0.914 Fully immunized 0.771 0.034 299 322 1.363 0.044 0.704 0.839 Total fertility rate (0-3 years) 5.507 0.198 na 5,522 1.265 0.036 5.111 5.903 Neonatal mortality (10 years) 32.215 4.404 2,416 2,584 1.084 0.137 23.407 41.024 Postneonatal mortality (10 years) 46.388 6.116 2,404 2,573 1.263 0.132 34.155 58.620 Infant mortality (10 years) 78.603 8.620 2,419 2,588 1.329 0.110 61.363 95.843 Child mortality (10 years) 52.614 8.215 2,374 2,526 1.509 0.156 36.183 69.045 Under-five mortality (10 years) 127.081 12.182 2,446 2,618 1.404 0.096 102.718 151.445 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.134 0.012 1,421 1,557 1.352 0.091 0.110 0.159 No education 0.195 0.017 1,421 1,557 1.608 0.087 0.161 0.229 Secondary education or higher 0.118 0.015 1,421 1,557 1.702 0.123 0.089 0.148 Never married/in union 0.501 0.020 1,421 1,557 1.475 0.039 0.462 0.540 Currently married/in union 0.479 0.019 1421 1557 1.407 0.039 0.441 0.516 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 127 Table B.7 Sampling errors for West Province sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.091 0.011 1,862 1,738 1.669 0.122 0.069 0.114 No education 0.260 0.021 1,862 1,738 2.091 0.082 0.218 0.303 Secondary education or higher 0.089 0.013 1,862 1,738 1.962 0.146 0.063 0.114 Never married/in union 0.330 0.018 1,862 1,738 1.623 0.054 0.295 0.366 Currently married/in union 0.543 0.018 1,862 1,738 1.591 0.034 0.506 0.580 Currently pregnant 0.093 0.008 1,862 1,738 1.193 0.086 0.077 0.109 Children ever born 2.782 0.093 1,862 1,738 1.407 0.033 2.597 2.967 Children surviving 2.373 0.078 1,862 1,738 1.403 0.033 2.217 2.529 Children ever born to women 40-49 6.295 0.141 349 334 1.044 0.022 6.013 6.577 Know any contraceptive method 0.993 0.003 958 943 1.135 0.003 0.987 0.999 Ever used any contraceptive method 0.539 0.025 958 943 1.532 0.046 0.490 0.588 Currently use any contraceptive method 0.339 0.024 958 943 1.543 0.070 0.291 0.386 Currently use pill 0.062 0.010 958 943 1.342 0.168 0.041 0.083 Currently use condom 0.019 0.004 958 943 1.008 0.237 0.010 0.027 Currently use female sterilization 0.010 0.003 958 943 0.942 0.304 0.004 0.016 Currently use periodic abstinence 0.049 0.010 958 943 1.385 0.198 0.029 0.068 Want no more children 0.436 0.021 958 943 1.329 0.049 0.393 0.478 Want to delay births at least 2 years 0.427 0.021 958 943 1.322 0.050 0.385 0.469 Ideal number of children 3.583 0.067 1,811 1,684 1.970 0.019 3.449 3.717 Mother received tetanus injection for last birth 0.776 0.019 941 913 1.420 0.025 0.737 0.814 Mother received medical assistance at delivery 0.519 0.031 1,439 1,408 2.014 0.060 0.457 0.581 Children with diarrhea 2 weeks preceding survey 0.136 0.012 1,345 1,312 1.186 0.087 0.112 0.160 Treated with oral rehydration salt (ORS) 0.309 0.055 180 179 1.464 0.178 0.199 0.419 Taken to the health provider 0.388 0.051 180 179 1.307 0.131 0.286 0.489 Vaccination card seen 0.734 0.035 316 318 1.406 0.047 0.664 0.803 Received BCG 0.972 0.012 316 318 1.278 0.012 0.949 0.995 Received DPT (3 doses) 0.939 0.017 316 318 1.176 0.018 0.906 0.972 Received polio (3 doses) 0.877 0.022 316 318 1.202 0.026 0.832 0.922 Received measles 0.924 0.017 316 318 1.077 0.018 0.891 0.957 Fully immunized 0.853 0.024 316 318 1.203 0.028 0.805 0.901 Total fertility rate (0-3 years) 5.751 0.229 na 4,895 1.533 0.040 5.293 6.208 Neonatal mortality (10 years) 31.251 4.830 2,731 2,663 1.268 0.155 21.591 40.910 Postneonatal mortality (10 years) 47.331 5.255 2,730 2,663 1.174 0.111 36.820 57.841 Infant mortality (10 years) 78.581 7.510 2,738 2,672 1.272 0.096 63.562 93.600 Child mortality (10 years) 54.981 6.046 2,701 2,641 1.096 0.110 42.889 67.074 Under-five mortality (10 years) 129.242 11.089 2,773 2,706 1.467 0.086 107.064 151.420 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.096 0.016 1,629 1,540 2.167 0.165 0.064 0.128 No education 0.136 0.012 1,629 1,540 1.356 0.085 0.113 0.159 Secondary education or higher 0.137 0.020 1,629 1,540 2.352 0.146 0.097 0.178 Never married/in union 0.485 0.015 1,629 1,540 1.188 0.030 0.456 0.515 Currently married/in union 0.498 0.014 1,629 1,540 1.139 0.028 0.470 0.527 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable 128 | Appendix B Table B.8 Sampling errors for North Province sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.081 0.018 1,036 1,265 2.173 0.228 0.044 0.118 No education 0.234 0.020 1,036 1,265 1.526 0.086 0.194 0.275 Secondary education or higher 0.111 0.029 1,036 1,265 2.924 0.258 0.054 0.169 Never married/in union 0.313 0.028 1,036 1,265 1.922 0.089 0.257 0.368 Currently married/in union 0.575 0.027 1,036 1,265 1.778 0.048 0.520 0.629 Currently pregnant 0.092 0.012 1,036 1,265 1.327 0.130 0.068 0.115 Children ever born 2.840 0.140 1,036 1,265 1.565 0.049 2.561 3.119 Children surviving 2.407 0.118 1,036 1,265 1.553 0.049 2.172 2.642 Children ever born to women 40-49 6.382 0.237 186 224 1.288 0.037 5.907 6.856 Know any contraceptive method 0.993 0.003 594 727 0.927 0.003 0.987 0.999 Ever used any contraceptive method 0.581 0.036 594 727 1.786 0.062 0.509 0.654 Currently use any contraceptive method 0.440 0.036 594 727 1.739 0.081 0.369 0.511 Currently use pill 0.089 0.015 594 727 1.272 0.167 0.059 0.119 Currently use condom 0.015 0.005 594 727 0.937 0.316 0.005 0.024 Currently use female sterilization 0.003 0.002 594 727 0.933 0.706 0.000 0.007 Currently use periodic abstinence 0.075 0.014 594 727 1.279 0.184 0.048 0.103 Want no more children 0.560 0.031 594 727 1.513 0.055 0.499 0.622 Want to delay births at least 2 years 0.296 0.027 594 727 1.434 0.091 0.242 0.350 Ideal number of children 3.203 0.068 1,012 1,236 1.865 0.021 3.067 3.339 Mother received tetanus injection for last birth 0.714 0.028 530 641 1.421 0.039 0.658 0.770 Mother received medical assistance at delivery 0.477 0.027 815 991 1.324 0.058 0.422 0.532 Children with diarrhea 2 weeks preceding survey 0.114 0.017 759 925 1.356 0.148 0.080 0.147 Treated with oral rehydration salt (ORS) 0.259 0.048 83 105 0.905 0.185 0.164 0.355 Taken to the health provider 0.399 0.044 83 105 0.747 0.109 0.312 0.486 Vaccination card seen 0.693 0.056 166 204 1.559 0.080 0.582 0.805 Received BCG 0.941 0.025 166 204 1.389 0.027 0.891 0.992 Received DPT (3 doses) 0.910 0.027 166 204 1.223 0.030 0.856 0.964 Received polio (3 doses) 0.886 0.027 166 204 1.089 0.030 0.832 0.939 Received measles 0.929 0.031 166 204 1.587 0.034 0.866 0.992 Fully immunized 0.845 0.031 166 204 1.122 0.037 0.782 0.908 Total fertility rate (0-3 years) 5.352 0.371 na 3,601 1.708 0.069 4.610 6.094 Neonatal mortality (10 years) 35.456 6.648 1,631 1,979 1.241 0.188 22.160 48.753 Postneonatal mortality (10 years) 35.941 7.168 1,638 1,987 1.514 0.199 21.606 50.276 Infant mortality (10 years) 71.397 10.837 1,636 1,986 1.538 0.152 49.723 93.072 Child mortality (10 years) 46.724 7.389 1,633 1,988 1.086 0.158 31.947 61.502 Under-five mortality (10 years) 114.786 15.562 1,655 2,010 1.584 0.136 83.661 145.910 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.075 0.014 851 1,015 1.589 0.192 0.046 0.104 No education 0.152 0.017 851 1,015 1.370 0.111 0.118 0.186 Secondary education or higher 0.146 0.038 851 1,015 3.134 0.261 0.070 0.222 Never married/in union 0.423 0.027 851 1,015 1.564 0.063 0.370 0.476 Currently married/in union 0.569 0.026 851 1,015 1.535 0.046 0.517 0.621 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix B | 129 Table B.9 Sampling errors for East Province sample, Rwanda 2007-08 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Number of cases –––––––––––––––– Standard Un- Weight- Design Relative Confidence limits Value error weighted ed effect error –––––––––––––––– Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– WOMEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.065 0.017 1,621 1,680 2.750 0.260 0.031 0.098 No education 0.235 0.018 1,621 1,680 1.716 0.077 0.198 0.271 Secondary education or higher 0.088 0.013 1,621 1,680 1.900 0.152 0.061 0.115 Never married/in union 0.333 0.017 1,621 1,680 1.452 0.051 0.299 0.367 Currently married/in union 0.550 0.019 1,621 1,680 1.569 0.035 0.511 0.588 Currently pregnant 0.097 0.010 1,621 1,680 1.366 0.104 0.077 0.117 Children ever born 2.747 0.091 1,621 1,680 1.321 0.033 2.565 2.929 Children surviving 2.194 0.072 1,621 1,680 1.305 0.033 2.051 2.338 Children ever born to women 40-49 6.236 0.239 267 291 1.550 0.038 5.759 6.714 Know any contraceptive method 0.990 0.006 876 923 1.823 0.006 0.978 1.002 Ever used any contraceptive method 0.549 0.024 876 923 1.439 0.044 0.501 0.598 Currently use any contraceptive method 0.342 0.024 876 923 1.472 0.069 0.295 0.390 Currently use pill 0.055 0.010 876 923 1.351 0.189 0.034 0.076 Currently use condom 0.019 0.006 876 923 1.182 0.285 0.008 0.030 Currently use female sterilization 0.005 0.002 876 923 0.982 0.469 0.000 0.010 Currently use periodic abstinence 0.051 0.010 876 923 1.298 0.189 0.032 0.070 Want no more children 0.490 0.020 876 923 1.173 0.040 0.450 0.530 Want to delay births at least 2 years 0.360 0.015 876 923 0.907 0.041 0.331 0.390 Ideal number of children 3.316 0.059 1,580 1,646 1.699 0.018 3.197 3.435 Mother received tetanus injection for last birth 0.722 0.021 848 888 1.376 0.029 0.679 0.764 Mother received medical assistance at delivery 0.527 0.028 1,337 1,390 1.751 0.054 0.470 0.584 Children with diarrhea 2 weeks preceding survey 0.140 0.012 1,217 1,263 1.111 0.085 0.117 0.164 Treated with oral rehydration salt (ORS) 0.156 0.037 178 177 1.273 0.240 0.081 0.230 Taken to the health provider 0.294 0.044 178 177 1.197 0.148 0.207 0.381 Vaccination card seen 0.583 0.046 269 287 1.527 0.079 0.491 0.675 Received BCG 0.958 0.016 269 287 1.318 0.017 0.926 0.990 Received DPT (3 doses) 0.882 0.029 269 287 1.460 0.033 0.824 0.940 Received polio (3 doses) 0.836 0.035 269 287 1.554 0.042 0.766 0.906 Received measles 0.892 0.025 269 287 1.316 0.028 0.843 0.941 Fully immunized 0.767 0.038 269 287 1.479 0.050 0.690 0.843 Total fertility rate (0-3 years) 5.836 0.196 na 4,737 1.149 0.034 5.443 6.228 Neonatal mortality (10 years) 29.666 4.375 2,465 2,565 1.187 0.147 20.916 38.415 Postneonatal mortality (10 years) 54.236 6.188 2,462 2,562 1.200 0.114 41.860 66.612 Infant mortality (10 years) 83.901 7.281 2,471 2,570 1.170 0.087 69.339 98.464 Child mortality (10 years) 98.312 11.346 2,397 2,481 1.617 0.115 75.620 121.004 Under-five mortality (10 years) 173.965 14.058 2,514 2,616 1.563 0.081 145.849 202.082 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MEN ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Urban residence 0.071 0.022 1,320 1,354 3.120 0.311 0.027 0.116 No education 0.177 0.016 1,320 1,354 1.502 0.089 0.146 0.209 Secondary education or higher 0.105 0.013 1,320 1,354 1.496 0.120 0.080 0.131 Never married/in union 0.450 0.022 1,320 1,354 1.597 0.049 0.406 0.493 Currently married/in union 0.522 0.023 1,320 1,354 1.652 0.044 0.477 0.568 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– na = Not applicable Appendix C | 131 DATA QUALITY TABLES APPENDIX C Table C.1 Age distribution of household population Single-year age distribution of the de facto household population by sex (weighted), Rwanda 2007-08 Women Men Women Men Age Number Percent Number Percent Age Number Percent Number Percent 0 549 3.3 500 3.4 36 137 0.8 94 0.6 1 616 3.7 623 4.2 37 148 0.9 130 0.9 2 489 3.0 493 3.3 38 147 0.9 130 0.9 3 554 3.3 564 3.8 39 139 0.8 106 0.7 4 502 3.0 535 3.6 40 169 1.0 123 0.8 5 432 2.6 488 3.3 41 116 0.7 85 0.6 6 465 2.8 431 2.9 42 142 0.9 118 0.8 7 555 3.3 569 3.8 43 121 0.7 109 0.7 8 519 3.1 504 3.4 44 125 0.8 96 0.6 9 368 2.2 356 2.4 45 161 1.0 127 0.9 10 478 2.9 470 3.2 46 126 0.8 78 0.5 11 400 2.4 413 2.8 47 112 0.7 77 0.5 12 518 3.1 506 3.4 48 121 0.7 90 0.6 13 521 3.1 449 3.0 49 94 0.6 76 0.5 14 328 2.0 354 2.4 50 128 0.8 114 0.8 15 272 1.6 322 2.2 51 145 0.9 76 0.5 16 289 1.7 328 2.2 52 136 0.8 69 0.5 17 283 1.7 330 2.2 53 97 0.6 74 0.5 18 311 1.9 289 1.9 54 111 0.7 56 0.4 19 284 1.7 258 1.7 55 104 0.6 87 0.6 20 337 2.0 294 2.0 56 96 0.6 54 0.4 21 320 1.9 231 1.6 57 74 0.4 46 0.3 22 297 1.8 254 1.7 58 70 0.4 48 0.3 23 306 1.8 283 1.9 59 53 0.3 24 0.2 24 313 1.9 225 1.5 60 97 0.6 79 0.5 25 375 2.3 277 1.9 61 40 0.2 43 0.3 26 253 1.5 231 1.5 62 51 0.3 45 0.3 27 289 1.7 250 1.7 63 47 0.3 36 0.2 28 229 1.4 224 1.5 64 35 0.2 26 0.2 29 232 1.4 175 1.2 65 61 0.4 44 0.3 30 234 1.4 216 1.5 66 33 0.2 29 0.2 31 177 1.1 128 0.9 67 51 0.3 27 0.2 32 184 1.1 165 1.1 68 49 0.3 17 0.1 33 172 1.0 151 1.0 69 25 0.2 13 0.1 34 162 1.0 130 0.9 70+ 407 2.5 278 1.9 35 193 1.2 176 1.2 Don’t know/ 7 0.0 3 0.0 missing Total 16,583 100.0 14,918 100.0 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. 132 | Appendix C Table C.2.1 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, Rwanda 2007-08 Interviewed women age 15-49 Age group Household population of women age 10-54 Number Percent Percentage of eligible women interviewed 10-14 2,245 na na na 15-19 1,438 1,356 18.9 94.3 20-24 1,573 1,515 21.2 96.3 25-29 1,379 1,350 18.9 97.9 30-34 929 912 12.7 98.1 35-39 764 753 10.5 98.5 40-44 674 665 9.3 98.6 45-49 614 606 8.5 98.8 50-54 618 na na na 15-49 7,371 7,157 100.0 97.1 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 C.2.2 Age distribution of eligible and interviewed men De facto household population of men age 10-64, interviewed men age 15-59, and percentage of eligible men who were interviewed (weighted), by five-year age groups, Rwanda 2007-08 Interviewed men age 15-59 Age group Household population of men age 10-64 Number Percent Percentage of eligible men interviewed 10-14 2,192 na na na 15-19 1,526 1,433 21.4 93.9 20-24 1,287 1,224 18.3 95.1 25-29 1,157 1,122 16.7 96.9 30-34 789 760 11.3 96.3 35-39 636 601 9.0 94.5 40-44 531 508 7.6 95.8 45-49 447 425 6.3 95.0 50-54 390 375 5.6 96.2 55-59 260 251 3.8 96.8 60-64 229 na na na 15-59 7,022 6,699 100.0 95.4 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 men and interviewed men are household weights. Age is based on the household schedule. na = Not applicable Appendix C | 133 Table C.3 Completeness of reporting Percentage of observations with information missing for selected demographic and health questions (weighted), Rwanda 2007-08 Subject Reference group Percentage with information missing Number of cases Birth date Births in the past 15 years Month only 1.29 14,339 Month and year 0.04 14,339 Age at death Deceased children born in past 15 years 0.00 1,948 Respondent's education All women age 15-49 0.05 7,313 Diarrhea in past 2 weeks Living children age 0-59 months 1.62 5,241 Blood collection for anemia and malaria testing 1 Children Living children age 6-59 months (from the household questionnaire) 3.13 4,906 Women All women age 15-49 (from the household questionnaire) 4.81 7,371 1 Not tested Table C.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), Rwanda 2007-08 Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 Year L D T L D T L D T L D T 2007 1,075 54 1,129 99.6 100.0 99.7 91.1 105.7 91.8 na na na 2006 1,212 55 1,267 99.6 97.7 99.5 98.3 178.6 100.9 na na na 2005 977 91 1,068 99.6 100.0 99.6 106.9 121.5 108.1 86.5 113.1 88.3 2004 1,047 106 1,153 99.2 97.2 99.0 105.1 116.4 106.0 108.9 97.8 107.8 2003 946 126 1,072 99.7 95.4 99.2 99.5 147.6 104.2 94.7 107.1 96.0 2002 950 129 1,079 99.3 97.2 99.1 100.5 142.8 104.8 109.2 93.0 107.0 2001 794 151 945 98.8 98.5 98.8 105.9 109.1 106.4 81.4 96.5 83.5 2000 1,001 185 1,186 98.7 97.9 98.6 93.7 120.7 97.5 133.0 131.7 132.8 1999 711 129 841 98.3 95.9 98.0 103.3 111.3 104.5 87.5 68.4 83.9 1998 624 193 817 98.8 96.6 98.3 90.2 124.7 97.4 91.7 142.6 100.2 2003-2007 5,256 433 5,689 99.6 97.7 99.4 99.9 131.1 101.9 na na na 1998-2002 4,080 787 4,868 98.8 97.3 98.6 98.6 121.0 101.9 na na na 1993-1997 2,971 753 3,724 98.2 95.1 97.5 101.3 103.1 101.7 na na na 1988-1992 1,917 564 2,481 97.8 95.6 97.3 102.6 108.9 104.0 na na na <1988 1,503 523 2,026 97.4 94.4 96.6 98.6 114.0 102.3 na na na Ensemble 15,727 3,061 18,788 98.7 96.0 98.2 100.0 114.2 102.2 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 134 | Appendix C Table C.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 age 0-6 days, for five-year periods preceding the survey (weighted), Rwanda 2007-08 Number of years preceding the survey Age at death in days 0-4 5-9 10-14 15-19 Total 0-19 <1 46 36 42 24 148 1 38 34 34 18 124 2 10 21 6 10 47 3 13 11 10 7 41 4 2 6 1 2 10 5 2 4 6 1 14 6 0 0 2 3 5 7 17 30 17 12 76 8 0 6 3 1 9 9 1 0 1 0 2 10 0 1 0 0 1 12 3 2 2 3 10 14 9 12 10 4 34 15 3 0 1 1 5 17 1 1 0 0 2 18 0 0 1 0 1 20 1 1 2 0 4 21 7 3 4 1 14 22 1 0 0 0 1 24 0 1 0 0 1 25 1 0 1 0 2 27 2 0 0 0 2 28 0 1 1 1 3 30 3 4 4 3 14 ND 0 0 0 0 0 Total 0-30 160 172 148 91 571 Percent early neonatal1 69.5 64.8 68.5 71.7 68.2 1 0-6 days /0-30 days Appendix C | 135 Table C.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months, and the percentage of infant deaths reported to occur at age under one month, for five-year periods preceding the survey, Rwanda 2007-08 Number of years preceding the survey Age at death in months 0-4 5-9 10-14 15-19 Total 0-19 <1a 160 172 148 91 571 1 22 22 22 11 77 2 27 40 31 23 121 3 20 23 19 14 75 4 13 29 20 7 68 5 3 28 10 7 49 6 13 41 26 17 97 7 19 21 24 6 71 8 11 17 23 7 58 9 25 37 33 13 109 10 6 8 5 0 18 11 6 2 5 2 15 12 38 90 52 17 197 13 0 6 3 1 9 14 3 6 6 5 19 15 6 7 3 2 18 16 0 3 2 3 8 17 0 2 4 0 5 18 5 20 18 6 50 19 3 5 0 2 10 20 3 0 3 1 7 21 0 1 1 0 1 22 0 1 1 0 2 23 2 1 2 0 5 Total 0-11 324 440 365 198 1,327 Percent neonatal1 49.3 39.2 40.5 46.0 43.0 a Includes under one month reported in days 1 Under one month/under one year Appendix D | 137 SURVEY PERSONNEL APPENDIX D NATIONAL COORDINATOR Louis MUNYAKAZI Yusuf MURANGWA SURVEY DIRECTOR Jean Philippe GATARAYIHA Baudouin A. RUTERANA TECHNICAL DIRECTORS Alphonse RUKUNDO Corine KAREMA OTHER MEMBERS OF THE TECHNICAL TEAM Tharcisse MUNYANEZA Appolinaire MUNYALIBANJE COORDONNATOR - ANALYSIS TEAM Jean Philippe GATARAYIHA AUTRES MEMBRES DE L’ÉQUIPE D’ANALYSE Alphonse RUKUNDO Corine KAREMA André HABIMANA OTHER MEMBERS OF THE ANALYSIS TEAM Emilien NKUSI Vianney NIZEYIMANA Fidele NGABO Claude SEKABARAGA MAIN SURVEY Supervisors Alphonse RUKUNDO Emilien NKUSI Appolinaire MUNYALIBANJE Tharcisse MUNYANEZA Team Leaders and Field Editors Béata AKAYEZU Immaculée NGIRUWONSANGA Egide KABANDAHO Marie Thérese NIYOMWUNGERI Etienne KWIZERA Geofrey NKURUNZIZA Gerard MIGAMBI Moise NSENGIMANA Clotilde MUHIMPUNDU Olive NYIRABAGOYI Janvier MUKAMA Medard RUTAYISIRE Illuminée MUKAMWIZA Stella UMUGWANEZA Claudine MUKANDORI Rédempta UMUTANGUHA Francoise MUKASEKURU Hassina UMUTESI Issa MUSABEMUNGU Vestine UWAMAHORO Michel MUTANGUHA Nathalie UWAMALIYA Déo Maxim NDAMUKUNDA Therese UWANYIRIGIRA Yvette NDENGEYINGOMA Jeanne Claudine UWERA 138 | Appendix D Laboratory Technicians Patrick AGAHUNGU Placide MUNEZA Emmanuel HABYARIMANA Claude NGABONZIZA SEMUTO Alida KAMALIZA Venuste NIYONSABA Vincent KAYIGIRE Felicite NYINAWABALI Etienne MPABUKA Gilberte NYIRABALITONDA Jean de Dieu MUGENZI Josianne TUYISENGE Julienne MUKASHEMA Interviewers Marie Josée BANANEZA Josée MUKAGATERA Sarah GAHONGAYIRE Dorothée MUKANDEKEZI Lucie GAJU Faina MUKANTWARI Jacqueline GAKOBWA Quesie MUKESHIMANA Aurélie INGABIRE Genevieve MUKUNDUHIRWE Aulea IRANKUNDA Christine MUTAMURIZA Blandine ISHIMWE Pélagie NIWEMFURA Donata IYATOBOYISARO Josephine NYAMBIBI Winifred KABEGA Patricie NYIRAMINANI Angelique KABERA Justine NYIRAMURAVA Sandra KAGARAMA Clémence TUGIRAMAHORO Grace KAMAYUGI Alice UGIRINEMA Alice KANEZA Livia UMUTONI KAYITESI Jeanine Vestine UMWARI Frida MBABAZI NTWAZA Sabine UWAMBAYIKIREZI Asmeen MBUGUJE Rachel UWIMANA Esperance MUGOREWERA Annick UWINEZA Gaudence MUJAWIMANA Jeannette UWINEZA Jeanne d'Arc MUKAGATERA Elyse UWIZEYE DATA PROCESSING Data Processing Supervisor Augustin TWAGIRUMUKIZA Assistant Supervisor Pascal SEMUCYO Office Editors Data Entry Omar MURENGEZI Antoine BAZIZERIMANA Fides KAYITESI Beata BENIMANA Illuminée MUKAMWIZA Vestine KWERERE Sandra KAGARAMA Sylvie NIYONGORE Jeanne UWIMANA ADMINISTRATION Didier GAKUBA Theodore HAKIZIMANA Malik NTASHAMAJE Eric BUGINGO Jean Pierre UWIMANA Appendix D | 139 SECRETARIAT Ninette UWIZEYE DRIVERS Oscar NDAHIMANA Ramadhan NTARISA Protais RUTAGARAMA MACRO INTERNATIONAL STAFF Mohamed AYAD (Regional Coordinator) Rathavuth HONG (Country Manager) Ruilin REN (Sampling) Harouna KOCHÉ (Data Processing) Amadou SOW (Data Processing) Sidney MOORE (Editing) Kaye MITCHELL (Report Production) Christopher GRAMER (Cover) Hannah GUEDENET (Dissemination) QUESTIONNAIRES APPENDIX E 141Appendix E | RWANDA INTERIM DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE National Institute of Statistics of Rwanda Republic of Rwanda IDENTIFICATION LOCALITY NAME NAME OF HOUSEHOLD HEAD PROVINCE. DISTRICT. CLUSTER NUMBER . STRUCTURE NUMBER. HOUSEHOLD NUMBER . URBAN/RURAL (URBAN=1, RURAL=2) . CITY/LARGE TOWN/SMALL TOWN/VILLAGE . (CITY OF KIGALI=1, OTHER CITY=2, RURAL=3) INTERVIEWER VISITS 1 2 3 FINAL VISIT DATE INTERVIEWER’S NAME RESULT* ┌──┬──┐ DAY │░░│░░│ ├──┼──┤ MONTH │░░│░░│ ┌──┬──┼──┼──┤ YEAR │ 2│ 0│00│-░│ └──┼──┼──┼──┤ NAME │ │░░│░░│ └──┴──┼──┤ RESULT │░░│ └──┘ NEXT VISIT: DATE TIME TOTAL NO. OF VISITS ┌──┐ │░░│ └──┘ TOTAL PERSONS IN HOUSEHOLD ┌──┬──┐ │░░│░░│ └──┴──┘ TOTAL ELIGIBLE WOMEN ┌──┬──┐ │░░│░░│ └──┴──┘ TOTAL ELIGIBLE MEN ┌──┬──┐ │░░│░░│ └──┴──┘ *RESULT CODES: 1 COMPLETED 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 4 POSTPONED 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER (SPECIFY) LINE NO. OF RESP. TO HOUSEHOLD QUEST. ┌──┬──┐ │░░│░░│ └──┴──┘ SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY NAME NAME DATE ┌──┬──┐ │░░│░░│ └──┴──┘ DATE ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ 143Appendix E | INFORMED CONSENT Hello. My name is and I am working with the National Institute of Statistics. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete. In this survey, I would like to first ask you some questions about your household. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this 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 144 | Appendix E HOUSEHOLD SCHEDULE IF 15 + YEARS LINE NO. USUAL RESIDENTS AND VISITORS RELATIONSHI P TO HEAD OF HOUSEHOLD SEX RESIDENCE AGE MARITAL STATUS ELIGIBILITY Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household?* Is (NAME) male or female? Does (NAME) usually live here? Did (NAME) stay here last night? What is the current marital status of (NAME) What is the current marital status of (NAME) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 (1) (2) (3) (4) (5) (6) (8) (8) (9) (11) M F YES NO YES NO IN YEAR 01 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 01 01 01 02 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 02 02 02 03 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 03 03 03 04 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 04 04 04 05 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 05 05 05 06 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 06 06 06 07 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 07 07 07 08 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 08 08 08 09 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 09 09 09 10 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 10 10 10 * CODES FOR Q.3: RELATIONSHIP TO HEAD OF HOUSEHOLD 01 = HEAD; 02 = WIFE OR HUSBAND; 03 = SON OR DAUGHTER; 04 = SON-IN-LAW OR DAUGHTER-IN-LAW; 05 = GRANDCHILD; 06 = PARENT; 07 = PARENT-IN-LAW; 08 = BROTHER OR SISTER; 09 = CO-WIFE; 10 = OTHER RELATIVE; 11 = ADOPTED/FOSTER/STEPCHILD; 12 = NOT RELATED; 98 = DON’T KNOW 145Appendix E | IF 15 + YEARS LINE NO. USUAL RESIDENTS AND VISITORS RELATIONSHI P TO HEAD OF HOUSEHOLD SEX RESIDENCE AGE MARITAL STATUS ELIGIBILITY Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household?* Is (NAME) male or female? Does (NAME) usually live here? Did (NAME) stay here last night? How old is (NAME)? What is the current marital status of (NAME) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) M F YES NO YES NO IN YEARS 11 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 11 11 11 12 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 12 12 12 13 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 13 13 13 14 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 14 14 14 15 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 15 15 15 16 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 16 16 16 17 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 17 17 17 18 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 18 18 18 19 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 19 19 19 20 ┌──┬──┐ │░░│░░│ └──┴──┘ 1 2 1 2 1 2 ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┐ │░░│ └──┘ 20 20 20 * CODES FOR Q.3: RELATIONSHIP TO HEAD OF HOUSEHOLD 01 = HEAD; 02 = WIFE OR HUSBAND; 03 = SON OR DAUGHTER; 04 = SON-IN-LAW OR DAUGHTER-IN-LAW; 05 = GRANDCHILD; 06 = PARENT; 07 = PARENT-IN-LAW; 08 = BROTHER OR SISTER; 09 = CO-WIFE; 10 = OTHER RELATIVE; 11 = ADOPTED/FOSTER/STEPCHILD; 12 = NOT RELATED; 98 = DON’T KNOW TICK HERE IF CONTINUATION SHEET USED ┌──┐ └──┘ Just to make sure that I have a complete listing: 1) Are there any other persons such as small children or infants that we have not listed? YES ┌──┐ └──┴──> ENTER EACH IN TABLE NO ┌──┐ └──┘ 2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here? YES ┌──┐ └──┴──> ENTER EACH IN TABLE NO ┌──┐ └──┘ 3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed? YES ┌──┐ └──┴──> ENTER EACH IN TABLE NO ┌──┐ └──┘ 146 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 What is the main source of drinking water for members of your household? PIPED WATER PIPED INTO DWELLING .11 PIPED INTO YARD/PLOT.12 PUBLIC TAP.13 WATER FROM OPEN WELL OPEN WELL IN DWELLING .21 OPEN WELL IN YARD/PLOT.22 OPEN PUBLIC WELL.23 WATER FROM COVERED WELL OR BOREHOLE PROTECTED WELL IN DWELLING.31 PROTECTED WELL IN YARD/PLOT .32 PROTECTED PUBLIC WELL.33 SURFACE WATER SPRING.41 RIVER/STREAM.42 POND/LAKE.43 DAM.44 RAINWATER .51 TANKER TRUCK.61 BOTTLED WATER .71 OTHER 96 (SPECIFY) ──> 203 ──> 103 ──> 103 ──> 103 ──> 22A ──> 22A ──> 103 ──> 103 ──> 103 ──> 103 102 How long does it take you to go there, get water, and come back? ┌──┬──┬──┐ MINUTES .│░░│░░│░░│ └──┴──┴──┘ ON PREMISES.996 103 What kind of toilet facilities does your household have? FLUSH TOILET .11 PIT TOILET/LATRINE TRADITIONAL PIT TOILET.21 VENTILATED IMPROVED PIT (VIP) LATRINE .22 NO FACILITY/BUSH/FIELD/BEACH.31 OTHER 96 (SPECIFY) ──> 105 104 Do you share these facilities with other households? YES .1 NO .2 105 Does your household have: Electricity? A radio? A television? A land line telephone? A refrigerator? YES NO ELECTRICITY .1 2 RADIO .1 2 TELEVISION .1 2 TELEPHONE.1 2 REFRIGERATOR .1 2 106 What type of fuel does your household mainly use for cooking? ELECTRICITY .01 LPG/NATURAL GAS .02 BIOGAS.03 KEROSENE.04 COAL, LIGNITE.05 CHARCOAL.06 FIREWOOD, STRAW.07 DUNG .08 OTHER 96 (SPECIFY) 147Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 107 MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION. NATURAL FLOOR EARTH/SAND/MUD .11 MUD MIXED WITH DUNG .12 RUDIMENTARY FLOOR WOOD PLANKS.21 PALM/BAMBOO.22 FINISHED FLOOR PARQUET OR POLISHED WOOD.31 LINOLEUM .32 CERAMIC TILES.33 CEMENT .34 CARPET.35 OTHER 96 (SPECIFY) 108 Does any member of your household own: A bicycle? A motorcycle or motor scooter? A car or truck? A mobile phone YES NO BICYCLE .1 2 MOTORCYCLE/SCOOTER .1 2 CAR/TRUCK.1 2 MOBILE PHONE .1 2 108A Are your household members covered by health insurance? YES .1 NO .2 ──> 108D 108B What type of health insurance do you have? MUTUELLE DE SANTÉ . A RAMA . B MMI.C PRIVATE INSSURANCE.D OTHER . X (SPECIFY) ─┐ ─│ ─├►108D ─│ ─┘ 108C How many of your household members are covered by MUTUELLE DE SANTÉ? ┌──┬──┐ TOTAL HH MEMBERS │░░│░░│ └──┴──┘ ┌──┬──┐ NO OF CHILDREN<5 │░░│░░│ └──┴──┘ 108D CHECK IF PROVINCE IS ‘KIGALI’┌──┐ NO ┌──┐ └──┘ └──┴─---------------------------- ↓ --Æ109 108E Between August and October 2007, did someone come to spray the walls of your home against mosquitoes? YES .1 NO .2 DON’T KNOW .8 109 Does your household have any mosquito bed nets that can be used while sleeping? YES .1 NO .2 ÆSKIP TO TABLE FOR MALARIA 109A How many mosquito bed nets does your household have? IF THERE IS 7 OR MORE RECORD '7' ┌──┐ NUMBER.│░░│ └──┘ 148 | Appendix E NET # 1 NET # 2 NET #3 110 ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. PERMANET. 1 OLYSET. 2 DK. 3 NOT OBSERVED . 4 PERMANET. 1 OLYSET. 2 DK. 3 NOT OBSERVED . 4 PERMANET .1 OLYSET .2 DK .3 NOT OBSERVED.4 111 How long ago did your household obtain the mosquito bed net? ┌──┬──┐ MONTHS AGO │░░│░░│ └──┴──┘ MORE THAN 3 YEARS AGO. 96 DK. 98 ┌──┬──┐ MONTHS AGO │░░│░░│ └──┴──┘ MORE THAN 3 YEARS AGO. 96 DK. 98 ┌──┬──┐ MONTHS AGO │░░│░░│ └──┴──┘ MORE THAN 3 YEARS AGO .96 DK .98 111A VERIFY Q. 111 IF MORE THAN 6 MONRHS AGO YES……………………….1 NO……………………….2 SKIP TO 112 YES……………………….1 NO……………………….2 SKIP TO 112 YES……………………….1 NO……………………….2 SKIP TO 112 111B Where did you obtain the net? SECTOR PUBLIC HEALTH CENTER.….12 COMMUNITY HW.….13 OTHER 16 (SPECIFY) SECTOR PRIVÉ HOSPITAL….………….21 PHARMACY………….22 PRIVATE DOC……….23 DISPENSARY……….25 OTHER 26 (SPECIFY) OTHER SOURCE MARKET…….…………31 CHURCH…………….32 PARENT/FRIEND.….33 OTHER 96 (SPECIFY) SECTOR PUBLIC HEALTH CENTER.….12 COMMUNITY HW.….13 OTHER 16 (SPECIFY) SECTOR PRIVÉ HOSPITAL….……….…21 PHARMACY………….22 PRIVATE DOC……….23 DISPENSARY…….….25 OTHER 26 (SPECIFY) OTHER SOURCE MARKET…….……….…31 CHURCH…………….32 PARENT/FRIEND…….33 OTHER 96 (SPECIFY) SECTOR PUBLIC HEALTH CENTER.….12 COMMUNITY HW.….13 OTHER 16 (SPECIFY) SECTOR PRIVÉ HOSPITAL….……….…21 PHARMACY………….22 PRIVATE DOC……….23 DISPENSARY…….….25 OTHER 26 (SPECIFY) OTHER SOURCE MARKET…….…….……31 CHURCH………….….32 PARENT/FRIEND…….33 OTHER 96 (SPECIFY) 111BB How did you obtain the net? DURING IMMUNIZATION CAMPAIGN. 1 DURING SCPECIAL IMMUNIZATION CAMPAIGN IN 2006. 2 DURING ANC VISITS. 3 MARKET/STORE . 4 VOLUNTEER OF THE MALARIA PROGRAM . 5 OTHER 6 (SPECIFY) DURING IMMUNIZATION CAMPAIGN.1 DURING SCPECIAL IMMUNIZATION CAMPAIGN IN 2006.2 DURING ANC VISITS.3 MARKET/STORE .4 VOLUNTEER OF THE MALARIA PROGRAM .5 OTHER 6 (SPECIFY) DURING IMMUNIZATION CAMPAIGN .1 DURING SCPECIAL IMMUNIZATION CAMPAIGN IN 2006.2 DURING ANC VISITS .3 MARKET/STORE .4 VOLUNTEER OF THE MALARIA PROGRAM .5 OTHER 6 (SPECIFY) 111C How much did you pay for the net COST ┌──┬──┬──┬──┐ │░░│░░│░░│░░│ └──┴──┴──┴──┘ FREE……………….…9996 DON’T KNOW……….9998 COST ┌──┬──┬──┬──┐ │░░│░░│░░│░░│ └──┴──┴──┴──┘ FREE………………….…9996 DON’T KNOW……….….9998 COST ┌──┬──┬──┬──┐ │░░│░░│░░│░░│ └──┴──┴──┴──┘ FREE……………….…9996 DON’T KNOW…….….9998 112 OBSERVE OR ASK FOR THE BRAND OF MOSQUITO NET PERMANENT TUZANET . 1 MAMANET. 2 TREATED ORGINAL.3 OTHER . 4 DK/NOT SURE . 5 PERMANENT TUZANET .1 MAMANET.2 TREATED ORGINAL.3 OTHER .4 DK/NOT SURE .5 PERMANENT TUZANET.1 MAMANET .2 TREATED ORGINAL . 3 OTHER.4 DK/NOT SURE.5 112D Did anyone sleep under this mosquito bed net last night? YES.1 NO . 2 (SKIP TO 112F)<───┤ DON’T KNOW. 8 YES. .1 NO .2 (SKIP TO 112F)<───┤ DON’T KNOW.8 YES .1 NO .2 (SKIP TO 112F)<───┤ DON’T KNOW .8 112DD Did anyone sleep under this mosquito bed net the night before last night? YES.1 NO . 2 (SKIP TO 112F)<───┤ DON’T KNOW. 8 YES.1 NO .2 (SKIP TO 112F)<───┤ DON’T KNOW.8 YES .1 NO .2 (SKIP TO 112F)<───┤ DON’T KNOW .8 149Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 112E Who slept under this mosquito bed net last night? RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ NAME ┌──┬──┐ LINE NO │░░│░░│ └──┴──┘ 112F GO BACK TO 111 IN THE FIRST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE NETS, GO TO MALARIA TABLE GO BACK TO 111 IN THE FIRST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE NETS, GO TO MALARIA TABLE GO BACK TO 111 IN THE FIRST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE NETS, GO TO MALARIA TABLE 150 | Appendix E TA B LE F O R M A LA R IA D IA G N O SI S FO R C H IL D R EN IN FO R M A ED C O N S EN T ST AT EM EN T FO R M A N EM IA F O R C H IL D R EN In th e su rv ey w e m ea su re th e le ve l o f a ne m ia in w om en a nd c hi ld re n ag ed le ss th an 5 y ea rs . W e as k th e w om en a nd th e ch ild re n to p ar tic ip at e in th e m al ar ia a nd a ne m ia te st in g pa rt of th is s ur ve y by g iv in g a fe w dr op s of b lo od fr om a fi ng er . T he te st s us e di sp os ab le s te ril e in st ru m en ts th at a re c le an a nd c om pl et el y sa fe . T he b lo od w ill b e ta ke n w ith n ew e qu ip m en t a nd th e re su lts o f t he te st w ill b e gi ve n to y ou im m ed ia te ly af te r. Th es e re su lts w ill b e ke pt c on fid en tia l. N ow I w ou ld li ke to a sk th at y ou a nd (N AM E O F C H IL D R EN ]) ag re e to p ar tic ip at e in th e an em ia te st . H ow ev er , i f y ou d ec id e no t t o ha ve th e te st d on e, it is y ou r r ig ht a nd w e w ill re sp ec t y ou r d ec is io n. N ow p le as e te ll m e if yo u ag re e to h av e th e te st d on e. D o yo u ha ve a ny q ue st io n? N ow p le as e te ll m e if yo u ag re e to h av e th e te st d on e. S KI P TO C O LU M N 1 13 A N D C IR C LE A PP R O PR IA TE C O D E S LI N E N O . FR O M C O L. (9 ) N AM E FR O M C O L. (2 ) AG E FR O M C O L. (7 ) W ha t i s (N AM E) ’s d at e of b irt h? * LI N E N O . O F PA R EN T/ R ES P O N S IB LE AD U LT . R EC O R D ‘0 0' IF N O T LI ST ED IN H O U SE H O LD SC H E D U LE R EA D C O N S EN T ST AT E M E N T TO PA R EN T/ R ES PO N SI B LE A D U LT * C IR C LE C O D E (A N D S IG N ) R ES U LT O F TH E R AP ID T ES T R ES U LT 1 R A PI D T ES T 2 TH IC K S M E AR 3 A BS E N C E 4 R E FU S ED 5 TE A C H /P R O B 6 O TH ER (S P EC IF Y) PL A C E BA R C O D ES PU T 1S T BA R C O D E H E R E PU T 2N D B AR C O D E O N R AP ID T E ST F O R M AL A R IA PU T 3R D B AR C O D E O N TH E S LI D E 11 3 11 4 11 5 11 6 11 7 11 8 11 9 12 0 12 1 G R AN TE D R EF U S ED ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N O R N O T R EA D 2 │ SK IP T O 1 20 < ─ ─ ┘ PO SI TI VE … … … … 1 N E G AT IV E … .… . .2 IN D ET ER M IN … .… 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ SK IP T O 1 20 < ─ ─ ┘ PO SI TI VE … … … … 1 N E G AT IV E … .… . .2 IN D ET ER M IN … .… 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ SK IP T O 1 20 < ─ ─ ┘ PO SI TI VE … … … … 1 N E G AT IV E … .… . .2 IN D ET ER M IN … .… 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ SK IP T O 1 20 < ─ ─ ┘ PO SI TI VE … … … … 1 N E G AT IV E … .… . .2 IN D ET ER M IN … .… 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ SK IP T O 1 20 < ─ ─ ┘ PO SI TI VE … … … … 1 N E G AT IV E … .… . .2 IN D ET ER M IN … .… 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ SK IP T O 1 20 < ─ ─ ┘ PO SI TI VE … … … … 1 N E G AT IV E … .… . .2 IN D ET ER M IN … .… 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E 151Appendix E | TA B LE F O R M A LA R IA D IA G N O SI S FO R W O M EN IN FO R M A ED C O N S EN T ST AT E M EN T FO R M A N EM IA F O R W O M EN W e re qu es t t ha t y ou a nd a ll ch ild re n ag ed le ss th an 5 y ea rs p ar tic ip at e in th e an em ia te st in g pa rt of th is s ur ve y by g iv in g a fe w d ro ps o f b lo od fr om a fi ng er . T he te st u se s di sp os ab le s te ril e in st ru m en ts th at a re c le an a nd c om pl et el y sa fe . T he b lo od w ill b e ta ke n w ith n ew e qu ip m en t a nd th e re su lts o f t he te st w ill b e gi ve n to y ou im m ed ia te ly a fte r. Th es e re su lts w ill b e ke pt c on fid en tia l. D o yo u ha ve a ny q ue st io n? N ow p le as e te ll m e if yo u ag re e to h av e th e te st d on e. IF W O M EN A G ED 1 5- 17 , A SK T H E C O N SE N T S TA TE M EN T FR O M T H E R E S PO N SI BL E P AR E N T/ G U A R D IE N N ow p le as e te ll m e if yo u ag re e to h av e th e te st d on e fo r ( N AM E O F TH E W O M A N 1 5- 17 ). SK IP T O C O LU M N 1 22 A N D C IR C LE A PP R O P R IA TE C O D E S L IN E N O . FR O M C O L. (9 ) N AM E FR O M C O L. (2 ) AG E FR O M C O L. (7 ) V ER IF Y A G E IN C O LU M N 12 3 R EA D C O N S EN T ST AT E M EN T TO P AR E N T/ R ES P O N S IB LE A D U LT * C IR C LE C O D E (A N D SI G N ) R E AD C O N SE N T ST AT EM E N T TO TH E W O M EN C IR C LE C O D E (A N D S IG N ) R ES U LT O F TH E R A PI D TE ST P R EG N AN T W O M E N R ES U LT 1 R AP ID T ES T 2 TH IC K S M EA R 3 AB SE N C E 4 R EF U S ED 5 TE A C H /P R O B 6 O TH E R (S PE C IF Y) PL AC E B AR C O D ES P U T 1S T BA R C O D E H E R E P U T 2N D B AR C O D E O N R A PI D TE ST F O R M AL AR IA P U T 3R D B AR C O D E O N T H E S LI D E 12 2 12 3 12 4 12 5 12 6 12 7 12 8 12 9 13 0 13 1 AG E A G E 15 -1 7 18 + ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ SK IP T O 1 27 A G R E E … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ A G R E E … … … … … .1 R EF U S E… … … … … 2 D ID N O T R EA D … … 3 SI G N __ __ __ __ __ __ _ I F 12 7 N O T EQ U AL 1 → 1 30 PO SI TI V E… … … … … … .… .1 N E G AT IV E… … … … … … . .2 IN D E TE R M IN … … … … … … .8 Y E S … … … … … … … . .1 N O … … … … … … … … .2 D O N ’T K N O W … … … … 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ S K IP T O 1 27 A G R E E … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ A G R E E … … … … … .1 R EF U S E… … … … … 2 D ID N O T R EA D … … 3 SI G N __ __ __ __ __ __ _ IF 1 27 N O T EQ U AL 1 → 1 30 PO SI TI V E… … … … … … .… .1 N E G AT IV E… … … … … … . .2 IN D ET E R M IN … … … … … … .8 Y E S … … … … … … … . .1 N O … … … … … … … … .2 D O N ’T K N O W … … … … 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ S K IP T O 1 27 A G R E E … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ A G R E E … … … … … .1 R EF U S E… … … … … 2 D ID N O T R EA D … … 3 SI G N __ __ __ __ __ __ _ IF 1 27 N O T EQ U AL 1 → 1 30 PO SI TI V E… … … … … … .… .1 N E G AT IV E… … … … … … . .2 IN D ET E R M IN … … … … … … .8 Y E S … … … … … … … . .1 N O … … … … … … … … .2 D O N ’T K N O W … … … … 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ S K IP T O 1 27 A G R E E … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ A G R E E … … … … … .1 R EF U S E… … … … … 2 D ID N O T R EA D … … 3 SI G N __ __ __ __ __ __ _ IF 1 27 N O T EQ U AL 1 → 1 30 PO SI TI V E… … … … … … .… .1 N E G AT IV E… … … … … … . .2 IN D ET E R M IN … … … … … … .8 Y E S … … … … … … … . .1 N O … … … … … … … … .2 D O N ’T K N O W … … … … 3 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ S K IP T O 1 27 A G R E E … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ A G R E E … … … … … .1 R EF U S E… … … … … 2 D ID N O T R EA D … … 3 SI G N __ __ __ __ __ __ _ IF 1 27 N O T EQ U AL 1 → 1 30 PO SI TI V E… … … … … … .… .1 N E G AT IV E… … … … … … . .2 IN D ET E R M IN … … … … … … .8 Y E S … … … … … … … . .1 N O … … … … … … … … .2 D O N ’T K N O W … … … … 3 IF 1 27 N O T EQ U AL 1 → 1 30 PO SI TI V E… … … … … … .… .1 N E G AT IV E… … … … … … . .2 IN D ET E R M IN … … … … … … .8 ┌ ─ ─ ─ ┬ │ ░ ░ │ ├ ─ ─ ─ ┼ │ ░ ░ │ └ ─ ─ ─ ┴ PU T 1S T BA R C O D E H E R E ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ S K IP T O 1 27 A G R E E … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ A G R E E … … … … … .1 R EF U S E… … … … … 2 D ID N O T R EA D … … 3 SI G N __ __ __ __ __ __ _ Y E S … … … … … … … . .1 N O … … … … … … … … .2 D O N ’T K N O W … … … … 3 152 | Appendix E TA B LE F O R H EM O G LO B IN F O R C H IL D R EN G O T O C O LU M N 1 32 A N D C IR C LE A P PR O PR IA TE C O D ES L IN E N O . FR O M C O L. (1 1) N AM E FR O M C O L. (2 ) A G E FR O M C O L. (7 ) W ha t i s (N AM E) ’s d at e of b irt h? * L IN E N O . O F P AR EN T/ R E SP O N SI B LE AD U LT . R E C O R D ‘0 0' IF N O T LI ST ED IN H O U S EH O LD S C H ED U LE ** R EA D C O N SE N T ST AT EM E N T TO PA R E N T/ R ES P O N SI BL E AD U LT C IR C LE C O D E (A N D S IG N ) H EM O G LO B IN L EV EL (G /D L) R E SU LT 1 R A PI D T E ST 2 A BS EN C E 3 R E FU SE D 4 TE AC H /P R O B 6 O TH ER (S P EC IF Y) 13 2 13 3 13 4 13 5 13 6 13 7 13 8 13 9 D A Y M O N TH YE A R G R AN TE D R EF U SE D ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ S KI P TO 1 39 < ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ S KI P TO 1 39 < ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ S KI P TO 1 39 < ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ S KI P TO 1 39 < ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ S KI P TO 1 39 < ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┬ ─ ─ ┬ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ │ ░ ░ │ ░ ░ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┘ └ ─ ─ ┴ ─ ─ ┴ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 ↓ SI G N 2 │ S KI P TO 1 39 < ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ * FO R C H IL D R EN N O T IN C LU D ED IN A N Y BI R TH H IS TO R Y (S E C TI O N 2 ), S U C H A S O R P H AN , A D O PT ED C H IL D R E N E TC , A SK D A Y, M O N TH ,A N D Y E AR O F BI R TH . F O R A LL O TH ER C H IL D R EN C O PY M O N TH A N D Y EA R F R O M Q . 2 15 IN M O TH ER 'S B IR TH H IS TO R Y (S E C TI O N 2 ) A N D A S K D A Y O F B IR TH . ** R EC O R D '0 0' IF N O T LI ST ED IN T H E H O U S EH O LD Q U ES TI O N AI R E 153Appendix E | TA B LE F O R H EM O G LO B IN F O R W O M EN S KI P TO C O LU M N 1 21 A N D C IR C LE A PP R O P R IA TE C O D ES L IN E N O . FR O M C O L. (9 ) N AM E FR O M C O L. (2 ) A G E FR O M C O L. (7 ) V ER IF Y AG E IN C O LU M N 14 2 R E AD C O N SE N T ST AT EM EN T TO P AR EN T/ R ES PO N S IB LE A D U LT * C IR C LE C O D E (A N D SI G N ) R EA D C O N SE N T ST AT EM E N T TO TH E W O M EN C IR C LE C O D E (A N D S IG N ) LE VE L O F H E M O G LO BI N E (G /D L) P R EG N AN T W O M E N R E SU LT 1 R A PI D T ES T 2 A BS E N C E 3 R E FU SE D 4 TE A C H /P R O B 6 O TH ER (S P EC IF Y) 14 0 14 1 14 2 14 3 14 4 14 5 14 6 14 7 14 8 AG E A G E 15 -1 7 18 + IF 1 45 N O T EQ U AL 1 S KI P TO 1 48 ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ SK IP T O 1 45 A G R E E… … … … … .1 R E FU SE … … … … … 2 D ID N O T R EA D … … 3 S IG N __ __ __ __ __ __ _ AG R EE … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ Y E S … … … … … … . 1 N O … … … … … … … .2 D O N ’T K N O W … … .8 ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ IF 1 45 N O T EQ U AL 1 S KI P TO 1 48 ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ SK IP T O 1 45 A G R E E… … … … … .1 R E FU SE … … … … … 2 D ID N O T R EA D … … 3 S IG N __ __ __ __ __ __ _ AG R EE … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ Y E S … … … … … … . 1 N O … … … … … … … .2 D O N ’T K N O W … … .8 ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ IF 1 45 N O T EQ U AL 1 S KI P TO 1 48 ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ SK IP T O 1 45 A G R E E… … … … … .1 R E FU SE … … … … … 2 D ID N O T R EA D … … 3 S IG N __ __ __ __ __ __ _ AG R EE … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ Y E S … … … … … … . 1 N O … … … … … … … .2 D O N ’T K N O W … … .8 ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ IF 1 45 N O T EQ U AL 1 S KI P TO 1 48 ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ SK IP T O 1 45 A G R E E… … … … … .1 R E FU SE … … … … … 2 D ID N O T R EA D … … 3 S IG N __ __ __ __ __ __ _ AG R EE … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ Y E S … … … … … … . 1 N O … … … … … … … .2 D O N ’T K N O W … … .8 ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ IF 1 26 N O T EQ U AL 1 S KI P TO 1 48 ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ SK IP T O 1 45 A G R E E… … … … … .1 R E FU SE … … … … … 2 D ID N O T R EA D … … 3 S IG N __ __ __ __ __ __ _ AG R EE … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ Y E S … … … … … … . 1 N O … … … … … … … .2 D O N ’T K N O W … … .8 ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ IF 1 45 N O T EQ U AL 1 SK IP T O 1 48 ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ ┌ ─ ─ ┬ ─ ─ ┐ │ ░ ░ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ 1 2 ↓ SK IP T O 1 45 A G R E E… … … … … .1 R E FU SE … … … … … 2 D ID N O T R EA D … … 3 S IG N __ __ __ __ __ __ _ AG R EE … … … … … .1 R EF U SE … … … … … 2 D ID N O T R E AD … … 3 SI G N __ __ __ __ __ __ _ ┌ ─ ─ ┬ ─ ─ ┐ ┌ ─ ─ ┐ │ ░ ░ │ ░ ░ │ │ ░ ░ │ └ ─ ─ ┴ ─ ─ ┘ .└ ─ ─ ┘ Y E S … … … … … … . 1 N O … … … … … … … .2 D O N ’T K N O W … … .8 ┌ ─ ─ ┐ │ ░ ░ │ └ ─ ─ ┘ 154 | Appendix E 14 9 C H EC K Q U E ST IO N S 4 6 (F O R C H IL D R EN ) A N D 5 6/ 57 (F O R A D U LT S) : N U M BE R O F H O U S EH O LD M E M B ER S FO R W H IC H T H E LE V EL O F H EM O G LO BI N IS B EL O W T H E C U T- O FF P O IN TS : LE SS T H AN 7G /D L FO R C H IL D R EN , F O R M EN , A N D F O R W O M EN W H O A R E N O T PR EG N A N T (O R W H O D O N O T KN O W IF T H E Y AR E PR E G N AN T) ; L E SS T H AN 9 G /D L FO R P R EG N AN T W O M EN . O N E O R M O R E ┌ ─ ─ ┐ ├ ─ ─ ┘ ↓ G IV E E AC H W O M AN , M A N O R R E SP O N SI BL E AD U LT T H E R E SU LT S O F TH E H EM O G LO B IN T E ST . R E A D T H E D EC LA R AT IO N B EL O W (Q .1 50 ) T O T H E S E P ER S O N S W IT H H EM O G LO BI N L EV EL S B EL O W C U T- O FF P O IN TS . N O N E ┌ ─ ─ ┐ ├ ─ ─ ┘ ↓ G IV E E AC H W O M AN , M A N O R R E SP O N SI BL E AD U LT T H E R E SU LT S O F TH E H EM O G LO BI N T E S T. 15 0 Th e re su lts o f t he te st s ho w th at (y ou r b lo od /th e bl oo d of N AM E O F C H IL D /C H IL D R EN ) h as a v er y lo w le ve l o f h em og lo bi n. T hi s in di ca te s th at (y ou /N AM E O F C H IL D /C H IL D R E N ) a re s ev er el y an em ic ,w hi ch is a s er io us h ea lth p ro bl em . W e re co m m en d th at y ou v is it a he al th fa ci lit y as s oo n as p os si bl e to b e ex am in ed a nd o bt ai n th e pr op er tr ea tm en t. G IV E TH E A D U LT T H E R EF ER EN C E FO R M F O R A N EM IA . 155Appendix E | RWANDA INTERIM DEMOGRAPHIC AND HEALTH SURVEYS WOMAN'S QUESTIONNAIRE National Institute of Statistics of Rwanda REPUBLIC OF RWANDA IDENTIFICATION VILLAGE NAME NAME OF HOUSEHOLD HEAD CLUSTER NUMBER STRUCTURE NUMBER HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URBIN/RURAL (URBAN=1, RURAL=2) CITY OF KIGALI/OTHER CITY/RURAL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (CITY OF KIGALI=1, OTHER CITY=2, RURAL=3) NAME AND LINE NUMBER OF WOMAN INTERVIEWER VISITES FINAL VISIT DATE DAY MONTH YEAR NAME OF THE INTERVIEWER CODE RESULT* RESULT NEXT DATE VISITE TOTAL NUMBER OF HOURS VISITS *RESULT CODES 1 COMPLETED 4 REFUSED 2 NOT AT HOME 5 PARTIALLY COMPLETED 7 OTHER 3 POSTPONED 6 INCAPACITATED (SPECIFY) LANGUAGE OF INTERVIEW KINYARWANDA 1 OTHER LANGUAGE 2 (SPECIFY) WAS A TRANSLATOR USED? YES 1 NO 2 SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY MANE NAME DATE DATE 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISTRICT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PROVINCE 2 0 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 157Appendix E | SECTION 1. RESPONDENT'S BACKGROUND INTRODUCTION AND CONSENT INFORMED CONSENT Hello. My name is ___________________________________ and I am working with the National Institute of Statistics of Rwanda. We are conducting a national survey that asks women and men about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 10 and 15 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. Participation in this survey is voluntary, and if we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important. I should add that in the coming few months someone from our office will probably come back to ask aditional questions on the health of children. 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 100 RECORD THE TIME. HOUR . . . . . . . . . . . . . . MINUTES. . . . . . . . . . . . . . . . 101 In what month and year were you born? MONTH . . . . . . . . . . . . . . . . . . DON'T KNOW MONTH . . . . . . . . . . . . 98 YEAR . . . . . . . . . . . . DON'T KNOW YEAR . . . . . . . . . . . . 9998 102 How old were you at your last birthday? AGE IN COMPLETED YEARS COMPARE AND CORRECT 101 AND/OR 102 IF INCONSISTENT. 103 Have you ever attended school? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 106 104 What is the highest level of school you attended: PRIMARY . . . . . . . . . . . . . . . . . . . . . . 1 primary, secondary, or higher? SECONDARY . . . . . . . . . . . . . . . . . . . . 2 HIGHER . . . . . . . . . . . . . . . . . . . . . . . . . 3 105 What is the highest grade/year you completed at that level? GRADE/YEAR . . . . . . . . 106 What is your religion? CATHOLIC 1 PROTESTANT 2 ADVENTIST 3 MOSLEM 4 TRADITIONAL RELIGION 5 OTHER 6 (SPECIFY) NONE . 7 107 Are you currently married or living together with a man as if YES, CURRENTLY MARRIED 1 married? YES, LIVING WITH A MAN . . . . . . . . . . 2 110 NO, NOT IN UNION . . . . . . . . . . . . . . . . 3 108 Have you ever been married or lived together with a man as if YES, FORMERLY MARRIED . . . . . . . . 1 married? YES, LIVED WITH A MAN . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 201 109 What is your marital status now: are you widowed, WIDOWED . . . . . . . . . . . . . . . . . . . . . . 1 divorced, or separated? DIVORCED 2 201 SEPARATED 3 110 Is your husband/partner living with you now or is he staying LIVING WITH HER . . . . . . . . . . . . . . . . 1 elsewhere? STAYING ELSEWHERE . . . . . . . . . . . . 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 | Appendix E 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 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 of life but NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 208 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, AND 207, AND 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 225 159Appendix E | 211 Now I would like to record the names of all your births, whether still alive or not, starting with the first 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 SECOND ROW). IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD: What name Were Is In what month Is How old was Is (NAME) RECORD How old was (NAME) Were there was given to any of (NAME) and year was (NAME) (NAME) at living with HOUSE- when he/she died? any other your these a boy or (NAME) born? still his/her last you? HOLD LINE live births (first/next) births a girl? alive? birthday? NUMBER OF IF '1 YR', PROBE: between baby? twins? PROBE: CHILD How many months old (NAME OF What is his/her RECORD (RECORD '00' was (NAME)? PREVIOUS birthday? AGE IN IF CHILD NOT RECORD DAYS IF BIRTH) and COM- LISTED IN LESS THAN 1 (NAME), PLETED HOUSE- MONTH; MONTHS IF including YEARS. HOLD). LESS THAN TWO any children YEARS; OR YEARS. who died after birth? 01 MONTH LINE NUMBER DAYS . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 YEAR MONTHS 2 MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 (NEXT BIRTH) YEARS . . 3 220 02 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 03 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 04 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 05 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 06 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 07 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 220 221216 217 218 (NAME) 212 213 214 215 YEARS AGE IN YEARS AGE IN AGE IN 219 YEARS AGE IN YEARS AGE IN YEARS AGE IN YEARS AGE IN YEARS 160 | Appendix E IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD: What name Were Is In what month Is How old was Is (NAME) RECORD How old was (NAME) Were there was given to any of (NAME) and year was (NAME) (NAME) at living with HOUSE- when he/she died? any other your next these a boy or (NAME) born? still his/her last you? HOLD LINE live births baby? births a girl? alive? birthday? NUMBER OF IF '1 YR', PROBE: between twins? PROBE: CHILD How many months old (NAME OF What is his/her RECORD (RECORD '00' was (NAME)? PREVIOUS birthday? AGE IN IF CHILD NOT RECORD DAYS IF BIRTH) and COM- LISTED IN LESS THAN 1 (NAME), PLETED HOUSE- MONTH; MONTHS IF including YEARS. HOLD). LESS THAN TWO any children YEARS; OR YEARS. who died after birth? 08 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 09 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 10 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 11 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 12 MONTH LINE NUMBER DAYS . . . 1 YES . . . . 1 SING 1 BOY 1 YES . . 1 YES . . . 1 ADD YEAR MONTHS 2 BIRTH MULT 2 GIRL 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 (GO TO 221) YEARS . . 3 NEXT 220 BIRTH 222 Have you had any live births since the birth of (NAME OF LAST YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE. NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 223 COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK: NUMBERS NUMBERS ARE ARE SAME DIFFERENT (PROBE AND RECONCILE) CHECK: FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED. FOR EACH BIRTH SINCE JANUARY 2002: MONTH AND YEAR OF BIRTH ARE RECORDED. FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED. FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED. 224 CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2002 OR LATER. IF NONE, RECORD '0' AND SKIP TO 226. 220 221212 213 214 215 216 217 218 (NAME) AGE IN YEARS AGE IN 219 YEARS AGE IN YEARS YEARS AGE IN YEARS AGE IN 161Appendix E | NO. QUESTIONS AND FILTERS CATEGORIES SKP 225 Are you pregnant now? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 UNSURE . . . . . . . . . . . . . . . . . . . . . . . . 8 301 226 How many months pregnant are you? MONTHS . . . . . . . . . . . . . . . . . . 162 | Appendix E 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? (1) 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 STERILIZATION Women can have an operation to avoid YES . . . . . . . . . . . . . . 1 Have you ever had an operation to having any more children. NO . . . . . . . . . . . . . . 2 avoid having any more children? YES . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . 2 02 MALE STERILIZATION Men can have an operation to avoid having YES . . . . . . . . . . . . . . 1 Have you ever had a partner who had any more children. NO . . . . . . . . . . . . . . 2 an operation to avoid having any more children? YES . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . 2 03 PILL Women can take a pill every day to avoid becoming pregnant. YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 04 IUD Women can have a loop or coil placed inside them by a doctor or YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 a nurse. NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 05 INJECTABLES Women can have an injection by a health provider YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 that stops them from becoming pregnant for one or more months. NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 06 IMPLANTS Women can have several small rods placed in their upper YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 arm by a doctor or nurse which can prevent pregnancy for one or more NO . . . . . . . . . . . . . . 2 years. NO . . . . . . . . . . . . . . . . . . 2 07 CONDOM Men can put a rubber sheath on their penis before sexua YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 intercourse. NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 08 FEMALE CONDOM Women can place a sheath in their vagina before YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 sexual intercourse. NO . . . . . . . . . . . . . . 2 NON . . . . . . . . . . . . . . . . . . 2 09 LACTATIONAL AMENORRHEA METHOD (LAM) YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 NON . . . . . . . . . . . . . . . . . . 2 10 RHYTHM METHOD Every month that a woman is sexually active YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 she can avoid pregnancy by not having sexual intercourse NO . . . . . . . . . . . . . . 2 on the days of the month she is most likely to get pregnant NO . . . . . . . . . . . . . . . . . . 2 11 WITHDRAWAL Men can be careful and pull out before climax. YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . . 2 12 EMERGENCY CONTRACEPTION As an emergency measure after YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . . 1 unprotected sexual intercourse, women can take special pills at any NO . . . . . . . . . . . . . . 2 time within five days to prevent pregnancy. NO . . . . . . . . . . . . . . . . . . 2 13 OUI . . . . . . . . . . . . . . 1 OUI . . . . . . . . . . . . . . . . . . 1 NON . . . . . . . . . . . . . . 2 NON . . . . . . . . . . . . . . . . . . 2 16 Have you heard of any other ways or methods that women or men can YES . . . . . . . . . . . . . . 1 use to avoid pregnancy? YES . . . . . . . . . . . . . . . . . . 1 (SPECIFY) NO . . . . . . . . . . . . . . . . . . 2 YES . . . . . . . . . . . . . . . . . . 1 (SPECIFY) NO . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 303 CHECK 302: NOT A SINGLE AT LEAST ONE "YES" "YES" 306 (NEVER USED) (EVER USED) STANDARD DAYS METHODS USING CYCLE BEADS: Woman can know better the days of the months that she would have a greater chance of being pregnant by using cycle beads or calendar. 163Appendix E | NO QUESTIONS AND FILTERS CODES SKIP 304 Have you ever used anything or tried in any way to delay or avoid YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 getting pregnant? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 306 305 What have you used or done? CORRECT 302 AND 303 (AND 301 IF NECESSARY). 306 CHECK 302 (01): WOMAN NOT WOMAN STERILIZED STERILIZED 309A 307 CHECK 225: NOT PREGNANT PREGNANT OR UNSURE 314 308 Are you currently doing something or using any method to delay YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 or avoid getting pregnant? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 314 309 Which method are you using? FEMALE STERILIZATION . . . . . . . . . . A MALE STERILIZATION . . . . . . . . . . . . B CIRCLE ALL MENTIONED. PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INJECTABLES . . . . . . . . . . . . . . . . . . E INSTRUCTION FOR HIGHEST METHOD IN LIST. IMPLANTS . . . . . . . . . . . . . . . . . . . . . . F CONDOM . . . . . . . . . . . . . . . . . . . . . . G FEMALE CONDOM . . . . . . . . . . . . . . H 309A CIRCLE 'A' FOR FEMALE STERILIZATION. LACTATIONAL AMEN. METHOD . . . . . I RHYTHM . . . . . . . . . . . . . . . . . . . . . . J 311 WITHDRAWAL . . . . . . . . . . . . . . . . . . K EMRGENCY PILL . . . . . . . . . . . . . . L SDM CYCLESBEADS . . . . . . . . . . . . . . M FOAM/JELLY . . . . . . . . . . . . . . . . . . N DIAPHRAGM . . . . . . . . . . . . . . . . . . O OTHER ______________________ X (SPECIFY) 310 In what facility did the sterilization take place? SECTEUR PUBLIC REFERRAL HOSPITAL . . . . . . 11 PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE DISTRICT HOSIPTAL . . . . . . . . . . 12 THE APPROPRIATE CODE. HEALTH CENTER . . . . . . . . . . . . 13 OTHER PUBLIC 16 IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER (SPECIFY) OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. PRIVATE MEDICAL SECTOR PRIVATE CLINIC/HOSPITAL . . . 21 PRIVATE DOCTOR . . . . . . . . . . . . 23 (NAME OF PLACE) OTHER PRIVATE MEDICAL 26 (SPECIFY) OTHER ______________________ 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . 98 164 | Appendix E NO QUESTIONS AND FILTERS CODES SKIP 311 CHECK 309/309A : NO CODE CIRCLED . . . . . . . . . . . . 00 313 FEMALE STERILIZATION . . . . . . . . . . 01 313 CIRCLE METHOD CODE: MALE STERILIZATION . . . . . . . . . . . . 02 313 PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 IF MORE THAN ONE METHOD CODE CIRCLED IN 309/309A, IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 CIRCLE CODE FOR HIGHEST METHOD IN LIST. INJECTABLES . . . . . . . . . . . . . . . . . . 05 IMPLANTS . . . . . . . . . . . . . . . . . . . . . . 06 CONDOM . . . . . . . . . . . . . . . . . . . . . . 07 FEMALE CONDOM . . . . . . . . . . . . . . 08 LACTATIONAL AMEN. METHOD . . . . . 09 312A RHYTHM 10 312A WITHDRAWAL . . . . . . . . . . . . . . . . . . 11 313 EMRGENCY PILL . . . . . . . . . . . . . . 12 SDM CYCLESBEADS . . . . . . . . . . . . . . 13 FOAM/JELLY . . . . . . . . . . . . . . . . . . 14 DIAPHRAGM . . . . . . . . . . . . . . . . . . 15 OTHER METHOD . . . . . . . . . . . . . . 16 313 312 Where did you obtain (CURRENT METHOD) when you started PUBLIC SECTOR using it? REFERENCE HOSPITAL . . . . . . 11 DISTRICT HOSIPTAL . . . . . . . . . . 12 HEALTH CENTER . . . . . . . . . . . . 13 HEALTH WORKER . . . . . . . . 14 OTHER PUBLIC ________________ 16 (PRÉCISER) 312A PRIVATE MEDICAL SECTOR PRIVATE CLINIC/HOSPITAL . . . 21 Where did you learn how to use the rhythm/lactational PHARMACY 22 amenorhea method? PRIVATE DOCTOR . . . . . . . . . . . . 23 ARBEF CLINIC 24 IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR NURSE 25 CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF OTHER PRIVATE THE PLACE. MEDICAL 26 (PRÉCISER) OTHER SOURCE (NAME OF PLACE) SHOP . . . . . . . . . . . . . . . . . . . . . . 31 CHURCH . . . . . . . . . . . . . . . . . . . . 32 FRIEND/RELATIVE . . . . . . . . . . . . 33 OTHER ______________________ 96 (SPECIFY) 313 CHECK 309/309A : NEITHER HE OR SHE STERILIZED STERILIZED 325 314 CHECK 225 NOT PREGNANT PREGNANT OR UNSURE Now I have some questions Now I have some questions HAVE (A/ANOTHER) CHILD . . . . . . . . 1 about the future. about the future. NO MORE/NONE . . . . . . . . . . . . . . . . 2 316 Would you like to have After the child you are SAYS SHE CAN'T GET PREGNANT . 3 325 (a/another) child, or would you expecting now, would you like UNDECIDED/DON'T KNOW AND prefer not to have any (more) to have another child, or would PREGNANT . . . . . . . . . . . . . . . . . . 4 321 children? you prefer not to have any UNDECIDED/DON'T KNOW more children? AND NOT PREGNANT OR UNSURE . . . . . . . . . . . . . . . . 5 320 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165Appendix E | NO QUESTIONS AND FILTERS CODES SKIP 315 CHECK 225: 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 . . . . . . . . . . . . . . . . . . 993 320 from now before the birth of are expecting now, how long SAYS SHE CAN'T GET PREGNANT 994 325 (a/another) child? would you like to wait before AFTER MARRIAGE . . . . . . . . . . . . . . 995 the birth of another child? OTHER ______________________ 996 320 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . 998 316 CHECK 225: NOT PREGNANT PREGNANT OR UNSURE 321 317 CHECK 308: USING A CONTRACEPTIVE METHOD? NOT NOT CURRENTLY ASKED CURRENTLY USING 325 USING 318 CHECK 315: NOT 24 OR MORE MONTHS 00-23 MONTHS ASKED OR 02 OR MORE YEARS OR 00-01 YEAR 321 319 CHECK 314: NOT MARRIED . . . . . . . . . . . . . . . . . . A WANTS TO HAVE WANTS NO MORE/ FERTILITY-RELATED REASONS A/ANOTHER CHILD NONE NOT HAVING SEX . . . . . . . . . . . . . . B INFREQUENT SEX . . . . . . . . . . . . . . C MENOPAUSAL/HYSTERECTOMY . D You have said that you do not You have said that you do not SUBFECUND/INFECUND . . . . . . . . E want (a/another) child soon, but want any (more) children, but POSTPARTUM AMENORRHEIC . . . F you are not using any method to you are not using any method to BREASTFEEDING . . . . . . . . . . . . . . G avoid pregnancy. avoid pregnancy. FATALISTIC . . . . . . . . . . . . . . . . . . H Can you tell me why you are Can you tell me why you are OPPOSITION TO USE not using a method? not using a method? RESPONDENT OPPOSED . . . . . . . . I HUSBAND/PARTNER OPPOSED . J Any other reason? Any other reason? OTHERS OPPOSED . . . . . . . . . . . . K RELIGIOUS PROHIBITION . . . . . . . . L RECORD ALL REASONS MENTIONED. LACK OF KNOWLEDGE KNOWS NO METHOD . . . . . . . . . . . . M KNOWS NO SOURCE . . . . . . . . . . . . N METHOD-RELATED REASONS HEALTH CONCERNS . . . . . . . . . . . . O FEAR OF SIDE EFFECTS . . . . . . . . P LACK OF ACCESS/TOO FAR . . . . . Q COSTS TOO MUCH . . . . . . . . . . . . R INCONVENIENT TO USE . . . . . . . . S INTERFERES WITH BODY'S NORMAL PROCESSES . . . . . . . . T OTHER ______________________ X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . Z 166 | Appendix E NO QUESTIONS AND FILTERS CODES SKIP 320 CHECK 309: USING A CONTRACEPTIVE METHOD? NOT NO, YES, ASKED NOT CURRENTLY USING CURRENTLY USING 325 321 Do you think you will use a contraceptive method to delay or avoid YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pregnancy at any time in the future? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 323 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 323 322 Quelle méthode préféreriez-vous utiliser ? FEMALE STERILIZATION . . . . . . . . . . 01 MALE STERILIZATION . . . . . . . . . . . . 02 PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 INJECTABLES . . . . . . . . . . . . . . . . . . 05 IMPLANTS . . . . . . . . . . . . . . . . . . . . . . 06 CONDOM . . . . . . . . . . . . . . . . . . . . . . 07 FEMALE CONDOM . . . . . . . . . . . . . . 08 325 LACTATIONAL AMEN. METHOD . . . . . 09 RHYTHM 10 WITHDRAWAL . . . . . . . . . . . . . . . . . . 11 EMRGENCY PILL . . . . . . . . . . . . . . 12 SDM CYCLESBEADS . . . . . . . . . . . . . . 13 FOAM/JELLY . . . . . . . . . . . . . . . . . . 14 DIAPHRAGM . . . . . . . . . . . . . . . . . . 15 OTHER ______________________ 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 323 What is the main reason that you think you will not use a NOT MARRIED . . . . . . . . . . . . . . . . 11 contraceptive method at any time in the future? FERTILITY-RELATED REASONS INFREQUENT SEX/NO SEX . . . 22 MENOPAUSAL/HYSTERECTOMY 23 SUBFECUND/INFECUND . . . . . 24 WANTS AS MANY CHILDREN AS POSSIBLE . . . . . . . . . . . . . . . . 26 OPPOSITION TO USE RESPONDENT OPPOSED . . . . . 31 HUSBAND/PARTNER OPPOSED 32 OTHERS OPPOSED . . . . . . . . . . 33 RELIGIOUS PROHIBITION . . . . . 34 LACK OF KNOWLEDGE KNOWS NO METHOD . . . . . . . . . . 41 325 KNOWS NO SOURCE . . . . . . . . . . 42 METHOD-RELATED REASONS HEALTH CONCERNS . . . . . . . . . . 51 FEAR OF SIDE EFFECTS . . . . . 52 LACK OF ACCESS/TOO FAR . . . 53 COSTS TOO MUCH . . . . . . . . . . 54 INCONVENIENT TO USE . . . . . . . . 55 INTERFERES WITH BODY'S NORMAL PROCESSES . . . . . 56 OTHER ______________________ 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . 98 324 Would you ever use a contraceptive method if you were married? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 . . . . . . . . . . . . . . . . . . 167Appendix E | NO QUESTIONS AND FILTERS CODES SKIP 325 CHECK 216: HAS LIVING CHILDREN NO LIVING CHILDREN NONE . . . . . . . . . . . . . . . . . . . . . . . . . 00 401 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? 401 your whole life, how many OTHER ______________________ 96 would that be? (SPECIFY) PROBE FOR A NUMERIC RESPONSE. 326 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) 168 | Appendix E SECTION 4. PREGNANCY AND POSTNATAL CARE 401 CHECK 224: ONE OR MORE NO GO TO 574 BIRTHS BIRTHS IN 2002 IN 2002 OR LATER OR LATER 402 CHECK 215: ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 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 in the last five years. (We will talk about each separately.) 403 LINE NUMBER FROM 212 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH LINE NO. LINE NO. LINE 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 435) (SKIP TO 435) 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 435) (SKIP TO 435) 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 PROF. DE LA SANTÉ care for this pregnancy? DOCTOR . . . . . . . A NURSE/MIDWIFE AUXILIARY IF YES: Whom did you see? MIDWIFE . . . . . B Anyone else? OTHER PERSON TRAINED TRAD.BIRTH PROBE TO IDENTIFY EACH TYPE ATTENDANT . C OF PERSON AND RECORD ALL NON TRAINED TRAD. MENTIONED. BIRTH ATTENDANT. . . D OTHER X (SPECIFY) NO ONE . . . . . . . . . . Y (SKIP TO 414) . .1 . .2 . .1 . .2 . .1 . .2 169Appendix E | 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 Anywhere else? PUBLIC SECTOR PROBE TO IDENTIFY TYPE(S) GOV. HOSPITAL. C OF SOURCE(S) AND CIRCLE HEALTH CENTER. . D THE APPROPRIATE CODE(S). OTHER PUBLIC E IF UNABLE TO DETERMINE (SPECIFY) IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PRIV. MEDICAL SECTOR PUBLIC OR PRIVATE PRIVATE HOSP./ MEDICAL, WRITE THE CLINIC . . . . . . . F THE NAME OF THE PLACE. PRIV. DOCTOR . G ARBEF CLINIC . H NURSE . . . . . . . I (NAME OF PLACE(S)) OTHER MEDICAL PRIVATE J (SPECIFY) OTHER (SPECIFY) X 409 How many months pregnant were you when you first received MONTHS . . . antenatal care for this pregnancy? DON'T KNOW . . . . . 98 410 How many times did you receive NUMBER antenatal care during this OF TIMES . pregnancy? DON'T KNOW . . . . . 98 411 As part of your antenatal care during this pregnancy, were any of the following done at least once? YES NO Were you weighed? WEIGHT . . . 1 2 Was your blood pressure measured? BP . . . . . . . 1 2 Did you give a urine sample? URINE . . . . . 1 2 Did you give a blood sample? BLOOD . . . 1 2 412 During (any of) your antenatal YES . . . . . . . . . . . . . . 1 care visit(s), were you told about NO . . . . . . . . . . . . . . 2 the signs of pregnancy (SKIP TO 414) complications? DON'T KNOW . . . . . 8 413 Were you told where to go if you YES . . . . . . . . . . . . . . 1 had any of these complications? NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 414 During this pregnancy, were you YES . . . . . . . . . . . . . . 1 given an injection in the arm to prevent the baby from getting NO . . . . . . . . . . . . . . 2 tetanus, that is, convulsions (SKIP TO 417) after birth? DON'T KNOW . . . . . 8 415 During this pregnancy, how many times did you get this tetanus TIMES . . . . . . . . . . injection? DON'T KNOW . . . 8 416 CHECK 415: 2 OR MORE OTHER TIMES (SKIP TO 421) 170 | Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME ________________ 417 At any time before this pregnancy, YES . . . . . . . . . . . . . . 1 did you receive any tetanus NO . . . . . . . . . . . . . . 2 injections, either to protect (SKIP TO 421) yourself or another baby? DON'T KNOW . . . . . 8 418 Before this pregnancy, how many other times did you receive a TIMES . . . . . . . . . . tetanus injection? IF 7 OR MORE TIMES, RECORD '7'. DON'T KNOW . . . 8 RECORD '7'. 421 During this pregnancy, were you YES . . . . . . . . . . . . . . 1 given or did you buy any iron tablets or iron syrup? NO . . . . . . . . . . . . . . 2 (SKIP TO 423) SHOW TABLETS/SYRUP. DON'T KNOW . . . . . 8 MONTRER COMPRIMÉS/SIROP 422 During the whole pregnancy, for how many days did you take the DAYS . tablets or syrup? DON'T KNOW . . . 998 IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS. During this pregnancy, did you YES . . . . . . . . . . . . . . 1 423 take any drug for intestinal NO . . . . . . . . . . . . . . 2 worms? DON'T KNOW . . . . . 8 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 424 have difficulty with your vision NO . . . . . . . . . . . . . . 2 during daylight? DON'T KNOW . . . . . 8 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 425 suffer from night blindness NO . . . . . . . . . . . . . . 2 [USE LOCAL TERM]? DON'T KNOW . . . . . 8 425A During this pregnancy, did you YES . . . . . . . . . . . . . . 1 have the fever? NO . . . . . . . . . . . . . . 2 (SKIP TO 426) DON'T KNOW . . . . . 8 425B In which trimester did you have FIRST TRIMES. . . . . 1 the fever? SECOND TRIMES. . . 2 THIRD TRIMES. . . . . 3 DON'T KNOW . . . . . . 8 426 During this pregnancy, did you YES . . . . . . . . . . . . . . 1 take any drugs to keep you from getting malaria? NO . . . . . . . . . . . . . . 2 (SKIP TO 435) DON'T KNOW . . . . . 8 427 What drugs did you take? SP/FANSIDAR . . . . . A QUARTEM . . . . . . . B RECORD ALL MENTIONED. QUININE . . . . . . . . . . C IF TYPE OF DRUG IS NOT OTHER X DETERMINED, SHOW TYPICAL (SPECIFY) ANTIMALARIAL DRUGS TO DON'T KNOW . . . . . . Z RESPONDENT. 428 CHECK 427: CODE 'A' CODE CIRCLED A' NOT DRUGS TAKEN FOR MALARIA CIRCLED PREVENTION. (SKIP TO 435) 171Appendix E | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME ________________ 429 How many times did you take (SP/Fansidar) during this TIMES . . . . . pregnancy? 430 CHECK 407: CODE 'A', OTHER B' OR 'C' ANTENATAL CARE FROM CIRCLED HEALTH PERSONNEL DURING THIS PREGNANCY (SKIP TO 435) 431 Did you get the (SP/Fansidar) ANTENATAL VISIT . . 1 during any antenatal care visit, ANOTHER FACILITY during another visit to a health VISIT . . . . . . . . . . 2 facility or from another source? OTHER SOURCE . . . 6 435 Who assisted with the delivery HEALTH PERSONNEL HEALTH PERSONNEL HEALTH PERSONNEL of (NAME)? DOCTOR . . . . . A DOCTOR . . . . . A DOCTOR . . . . . A NURSE/MIDWIFE. B NURSE/MIDWIFE . B NURSE/MIDWIFE. B Anyone else? AUXILIARY AUXILIARY AUXILIARY MIDWIFE . . . . . . C MIDWIFE . . . . . . C MIDWIFE . . . . . . C PROBE FOR THE TYPE(S) OF OTHER PERSON OTHER PERSON OTHER PERSON PERSON(S) AND RECORD ALL TRADITIONAL BIRTH TRADITIONAL BIRTH TRADITIONAL BIRTH MENTIONED. ATTENDANT . . D ATTENDANT . . D ATTENDANT . . D RELATIVE/FRIEND E RELATIVE/FRIEND . E RELATIVE/FRIEND E IF RESPONDENT SAYS NO ONE OTHER OTHER OTHER ASSISTED, PROBE TO X X X DETERMINE WHETHER ANY (SPECIFY) (SPECIFY) (SPECIFY) ADULTS WERE PRESENT AT NO ONE . . . . . . . . . . Y NO ONE . . . . . . . . . . Y NO ONE . . . . . . . . . . Y THE DELIVERY. 436 Where did you give birth to HOME HOME HOME (NAME)? (2) YOUR HOME . . . 11 YOUR HOME . . . 11 YOUR HOME . . . 11 (SKIP TO 460) (SKIP TO 460) (SKIP TO 460) PROBE TO IDENTIFY THE TYPE OTHER HOME . . . 12 OTHER HOME . . . 12 OTHER HOME . . . 12 OF SOURCE AND CIRCLE THE APPROPRIATE CODE. PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR REFER. HOSPITAL 21 REFER. HOSPITAL 21 REFER. HOSPITAL 21 IF UNABLE TO DETERMINE DISTRICT DISTRICT DISTRICT IF A HOSPITAL, HEALTH HOSPITAL 22 HOSPITAL 22 HOSPITAL 22 CENTER, OR CLINIC IS HEALTH HEALTH HEALTH PUBLIC OR PRIVATE CENTER 23 CENTER 23 CENTER 23 MEDICAL, WRITE THE OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC THE NAME OF THE PLACE. 26 26 26 (SPECIFY) (SPECIFY) (SPECIFY) (NAME OF PLACE) PRIV. MEDICAL SECTOR PRIV. MEDICAL SECTOR PRIV. MEDICAL SECTOR PRIVATE HOSP./ PRIVATE HOSP./ PRIVATE HOSP./ CLINIC . . . . . . . 31 CLINIC . . . . . . . 31 CLINIC . . . . . . . 31 OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL PRIVATE 36 PRIVATE 36 PRIVATE 36 (SPECIFY) (SPECIFY) (SPECIFY) OTHER 96 OTHER 96 OTHER 96 (SPECIFY) (SPECIFY) (SPECIFY) (SKIP TO 460) (SKIP TO 460) (SKIP TO 460) 437 Did the mutuelle pay for the YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 delivery of (NAME) ? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 460 Did you ever breastfeed (NAME)? YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 501) (SKIP TO 501) (SKIP TO 501) 172 | Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME ________________ 461 How long after birth did you first put (NAME) to the breast? IMMEDIATELY . . . 000 IF LESS THAN 1 HOUR, RECORD ‘00' HOURS. IF LESS THAN 24 HOURS, HOURS 1 RECORD HOURS. OTHERWISE, RECORD DAYS. DAYS 2 462 In the first three days after YES . . . . . . . . . . . . . . 1 delivery, was (NAME) given NO . . . . . . . . . . . . . . 2 anything to drink other than (SKIP TO 464) breast milk? 463 What was (NAME) given to drink? MILK (OTHER THAN BREAST MILK ) . A Anything else? PLAIN WATER . . . B SUGAR OR GLU- RECORD ALL LIQUIDS COSE WATER . . . C MENTIONED. GRIPE WATER . . . D SUGAR-SALT-WATER SOLUTION . . . . . E FRUIT JUICE . . . . . F INFANT FORMULA . G TEA/INFUSIONS . . . H HONEY . . . . . . . . . . I OTHER X (SPECIFY) 464 CHECK 404: LIVING DEAD IS CHILD LIVING? (SKIP TO 466) 465 Are you still breastfeeding YES . . . . . . . . . . . . . . 1 (NAME)? (SKIP TO 501) NO . . . . . . . . . . . . . . 2 466 For how many months did you breastfeed (NAME)? MONTHS . . . MONTHS . . . MONTHS . . . STILL BF . . . . . . . 95 STILL BF . . . . . . . 95 STILL BF . . . . . . . 95 DON'T KNOW . . . 98 DON'T KNOW . . . 98 DON'T KNOW . . . 98 173Appendix E | SECTION 5. VACCINATION OF CHILDREN AND HEALTH AND NUTRITION OF WOMEN AND CHILDREN 501 ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 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 LINE NUMBER LINE LINE LINE 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 573) BIRTHS, GO TO 573) OR IF NO MORE BIRTHS, GO TO 573) 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) (SKIP TO 506) written down? (2) YES, NOT SEEN . . . . . . . . 2 YES, NOT SEEN . . . . . . . . 2 YES, NOT SEEN . . . . . . . 2 IF YES: (SKIP TO 508) (SKIP TO 508) (SKIP TO 508) May I see it please? NO CARD . . . . . . . . . . . . . . 3 NO CARD . . . . . . . . . . . . . . 3 NO CARD . . . . . . . . . . . . 3 505 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 VACCINATION DATE FOR EACH VACCINE FROM THE CARD. (2) WRITE ‘44' IN ‘DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED. (3) IF MORE THAN TWO VITAMIN 'A' DOSES, RECORD DATES FOR MOST RECENT AND SECOND MOST RECENT DOSES. LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH DAY MONTH YEAR DAY MONTH YEAR DAY MONTH YEAR POLIO 2 POLIO 3 D1 P1 P2 P3 BCG P3 P0 BCG BCG P0 P1 P2 POLIO 0 (POLIO GIVEN AT BIRTH) POLIO 1 MOST RECENT) VITAMIN A (MOST RECENT) VITAMIN A (2nd VIT A D2 D3 MEA VIT A VIT A VIT A D3 D2 MEAMEASLES/MMR DTP/Pentavalent 3 D1DTP/Pentavalent 1 DTP/Pentavalent 2 174 | Appendix E 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) RECORD ‘YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, AND/OR NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 MEASLES VACCINES. (SKIP TO 512) (SKIP TO 512) (SKIP TO 512) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 508 Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 vaccinations received in a NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 national immunization (SKIP TO 512) (SKIP TO 512) (SKIP TO 512) campaign? 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 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 in the arm or shoulder that usually DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 causes a scar? 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 polio vaccine FIRST 2 WEEKS . . . 1 FIRST 2 WEEKS . . . 1 FIRST 2 WEEKS . . . 1 received in the first two weeks LATER . . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 after birth or later? 509D How many times was the polio NUMBER NUMBER NUMBER vaccine received? OF TIMES . . . . . OF TIMES . . . . . OF TIMES . . . . . 509E A DPT vaccination, that is, an YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 injection given in the thigh or NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 buttocks, sometimes at the (SKIP TO 509G) (SKIP TO 509G) (SKIP TO 509G) same time as polio drops? 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 measles injection or an MMR YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 injection - that is, a shot in the NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 arm at the age of 9 months or DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 older - to prevent him/her from getting measles? 512 CHECK 506: DATE DATE DATE FOR OTHER FOR OTHER FOR OTHER DATE SHOWN FOR VITAMIN MOST MOST MOST A DOSE RECENT RECENT RECENT VITAMIN VITAMIN VITAMIN A DOSE A DOSE A DOSE (SKIP TO (SKIP TO (SKIP TO 514) 514) 514) 175Appendix E | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 513 According to (NAME)'s health card, he/she received a vitamin A dose (like this/any of these) in (MONTH AND YEAR OF MOST RECENT DOSE FROM CARD). YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 Has (NAME) received another (SKIP TO 515) (SKIP TO 515) (SKIP TO 515) vitamin A dose since then? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 SHOW COMMON TYPES OF (SKIP TO 516) (SKIP TO 516) (SKIP TO 516) AMPULES/CAPSULES/SYRUPS. DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 514 HAS (NAME) ever received a vitamin A dose (like this/ YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 any of these)? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 SHOW COMMON TYPES OF (SKIP TO 516) (SKIP TO 516) (SKIP TO 516) AMPULES/CAPSULES/SYRUPS. DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 515 Did (NAME) receive a vitamin A YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 dose within the last six months? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 516 In the last seven days, did (NAME) take iron pills, sprinkles with iron, or iron syrup (like this/any of these)? SHOW COMMON TYPES OF YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 PILLS/SPRINKLES/ NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 SYRUPS. DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 517 Has (NAME) taken any drug for YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 intestinal worms in the last six NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 months? DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 518 Has (NAME) had diarrhea in the YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 last 2 weeks? (6) NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 533) (SKIP TO 533) (SKIP TO 533) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 519 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 . . . . . 8 520 Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). Was he/she given less than usual to drink, about the same MUCH LESS . . . . . 1 MUCH LESS . . . . . 1 MUCH LESS . . . . . 1 amount, or more than usual to SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 drink? ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 IF LESS, PROBE: Was he/she MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 given much less than usual to NOTHING TO DRINK 5 NOTHING TO DRINK 5 NOTHING TO DRINK 5 drink or somewhat less? DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 521 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 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 than usual, or nothing to eat? ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 IF LESS, PROBE: Was he/she STOPPED FOOD . 5 STOPPED FOOD . 5 STOPPED FOOD . 5 given much less than usual to NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 eat or somewhat less? DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 522 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 527) (SKIP TO 527) (SKIP TO 527) 176 | Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 523 Where did you seek advice or PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR treatment? REF. HOSPITAL A REF. HOSPITAL A REF. HOSPITAL A DISTRICT HOSP. B DISTRICT HOSP. B DISTRICT HOSP. B Anywhere else? HEALTH CENT. . . . C HEALTH CENT. . . . C HEALTH CENT. . . . C HEALTH . HEALTH . HEALTH . PROBE TO IDENTIFY EACH WORKER . . . . . D WORKER . . . . . D WORKER . . . . . D TYPE OF SOURCE AND OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC CIRCLE THE APPROPRIATE E E E CODE(S). (SPECIFY) (SPECIFY) (SPECIFY) IF UNABLE TO DETERMINE OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE IF A HOSPITAL, HEALTH MEDICAL MEDICAL MEDICAL CENTER, OR CLINIC IS PRIVATE CLINIC/ PRIVATE CLINIC/ PRIVATE CLINIC/ PUBLIC OR PRIVATE HOSPIT. . . . . . . . F HOSPIT. . . . . . . . F HOSPIT. . . . . . . . F MEDICAL, WRITE THE PHARMACY . . . G PHARMACY . . . G PHARMACY . . . G THE NAME OF THE PLACE. PRIV. DOCTOR . H PRIV. DOCTOR . H PRIV. DOCTOR . H ARBEF CLINIC I ARBEF CLINIC I ARBEF CLINIC I NURSE J NURSE J NURSE J (NAME OF PLACE(S)) OTHER PRIVATEE OTHER PRIVATEE OTHER PRIVATEE MEDICAL K MEDICAL K MEDICAL K (SPECIFY) (SPECIFY) (SPECIFY) OTHER SOURCE OTHER SOURCE OTHER SOURCE SHOP/KIOSQUE. L SHOP/KIOSQUE. L SHOP/KIOSQUE. L TRAD. HEALER M TRAD. HEALER M TRAD. HEALER M OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) 524 CHECK 523: TWO OR ONLY TWO OR ONLY TWO OR ONLY MORE ONE MORE ONE MORE ONE CODES CODE CODES CODE CODES CODE CIRCLED CIRCLED CIRCLED CIRCLED CIRCLED CIRCLED (SKIP TO 526) (SKIP TO 526) (SKIP TO 526) 525 Where did you first seek advice or treatment? FIRST PLACE . . . FIRST PLACE . . . FIRST PLACE . . . USE LETTER CODE FROM 523. 526 How many days after the diarrhea began did you first seek advice or treatment for (NAME)? DAYS . . . . . DAYS . . . . . DAYS . . . . . IF THE SAME DAY, RECORD '00'. 527 Does (NAME) still have diarrhea? YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 528 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 A fluid made from a special packet called [LOCAL NAME FLUID FROM FLUID FROM FLUID FROM FOR ORS PACKET]? ORS PKT . . 1 2 8 ORS PKT . . 1 2 8 ORS PKT . . 1 2 8 A pre-packaged ORS liquid? ORS LQD . . 1 2 8 ORS LQD . . 1 2 8 ORS LQD . . 1 2 8 A government-recommended HOMEMADE HOMEMADE HOMEMADE homemade fluid? FLUID . . . 1 2 8 FLUID . . . 1 2 8 FLUID . . . 1 2 8 a) b) c) 177Appendix E | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 529 Was anything (else) given to YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 treat the diarrhea? NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 533) (SKIP TO 533) (SKIP TO 533) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 530 What (else) was given to treat PILL OR SYRUP PILL OR SYRUP PILL OR SYRUP the diarrhea? ANTIBIOTIC . . . . . A ANTIBIOTIC . . . . . A ANTIBIOTIC . . . . . A ANTIMOTILITY . B ANTIMOTILITY . B ANTIMOTILITY . B Anything else? ZINC . . . . . . . . . . C ZINC . . . . . . . . . . C ZINC . . . . . . . . . . C OTHER (NOT ANTI- OTHER (NOT ANTI- OTHER (NOT ANTI- RECORD ALL TREATMENTS BIOTIC, ANTI- BIOTIC, ANTI- BIOTIC, ANTI- GIVEN. MOTILITY, OR MOTILITY, OR MOTILITY, OR ZINC) . . . . . . . . D ZINC) . . . . . . . . D ZINC) . . . . . . . . D UNKNOWN PILL UNKNOWN PILL UNKNOWN PILL OR SYRUP . . . E OR SYRUP . . . E OR SYRUP . . . E INJECTION INJECTION INJECTION ANTIBIOTIC . . . . . F ANTIBIOTIC . . . . . F ANTIBIOTIC . . . . . F NON-ANTIBIOTIC. G NON-ANTIBIOTIC. G NON-ANTIBIOTIC. G UNKNOWN UNKNOWN UNKNOWN INJECTION . . . H INJECTION . . . H INJECTION . . . H (IV) INTRAVENOUS . I (IV) INTRAVENOUS . I (IV) INTRAVENOUS . I HOME REMEDY/ HOME REMEDY/ HOME REMEDY/ HERBAL MED- HERBAL MED- HERBAL MED- ICINE . . . . . . . . . . J ICINE . . . . . . . . . . J ICINE . . . . . . . . . . J OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) 531 CHECK 530: CODE "C" CODE "C" CODE "C" CODE "C" CODE "C" CODE "C" CIRCLED NOT CIRCLED NOT CIRCLED NOT CIRCLED CIRCLED CIRCLED GIVEN ZINC? (SKIP TO 533) (SKIP TO 533) (SKIP TO 533) 532 How many times was (NAME) given zinc? TIMES . . . . . TIMES . . . . . TIMES . . . . . DON'T KNOW . . . . . . 98 DON'T KNOW . . . . . . 98 DON'T KNOW . . . . . . 98 533 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 . . . . . 8 534 Has (NAME) had an illness with YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 a cough at any time in the NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 last 2 weeks? (SKIP TO 537) (SKIP TO 537) (SKIP TO 537) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 535 When (NAME) had an illness with YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 a cough, did he/she breathe faster NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 than usual with short, rapid breaths (SKIP TO 538) (SKIP TO 538) (SKIP TO 538) or have difficulty breathing? DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 536 Was the fast or difficult breathing 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 538) (SKIP TO 538) (SKIP TO 538) 178 | Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 537 CHECK 533: YES NO OR DK YES NO OR DK YES NO OR DK HAD FEVER OR COUGH? (GO TO 572) (GO TO 572) (GO TO 572) 538 Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same MUCH LESS . . . . . 1 MUCH LESS . . . . . 1 MUCH LESS . . . . . 1 amount, or more than usual to SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 drink? ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 IF LESS, PROBE: Was he/she MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 given much less than usual to NOTHING TO DRINK 5 NOTHING TO DRINK 5 NOTHING TO DRINK 5 drink or somewhat less? DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 539 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, SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 SOMEWHAT LESS . 2 or nothing to eat? ABOUT THE SAME . 3 ABOUT THE SAME . 3 ABOUT THE SAME . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 IF LESS, PROBE: Was he/she STOPPED FOOD . 5 STOPPED FOOD . 5 STOPPED FOOD . 5 given much less than usual to NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 NEVER GAVE FOOD 6 eat or somewhat less? DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 540 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 545) (SKIP TO 545) (SKIP TO 545) 541 Where did you seek advice or PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR treatment? REF. HOSPITAL A REF. HOSPITAL A REF. HOSPITAL A DISTRICT HOSP. B DISTRICT HOSP. B DISTRICT HOSP. B Anywhere else? HEALTH CENT. . . . C HEALTH CENT. . . . C HEALTH CENT. . . . C HEALTH . HEALTH . HEALTH . PROBE TO IDENTIFY EACH WORKER . . . . . D WORKER . . . . . D WORKER . . . . . D TYPE OF SOURCE AND OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC CIRCLE THE APPROPRIATE E E E CODE(S). (SPECIFY) (SPECIFY) (SPECIFY) IF UNABLE TO DETERMINE OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE IF A HOSPITAL, HEALTH MEDICAL MEDICAL MEDICAL CENTER, OR CLINIC IS PRIVATE CLINIC/ PRIVATE CLINIC/ PRIVATE CLINIC/ PUBLIC OR PRIVATE HOSPITAL . . . F HOSPIT. . . . . . . . F HOSPIT. . . . . . . . F MEDICAL, WRITE THE PHARMACY . . . G PHARMACY . . . G PHARMACY . . . G THE NAME OF THE PLACE. PRIV. DOCTOR . H PRIV. DOCTOR . H PRIV. DOCTOR . H NURSE I NURSE I NURSE I OTHER PRIVATEE OTHER PRIVATEE OTHER PRIVATEE (NAME OF PLACE(S)) MEDICAL J MEDICAL J MEDICAL J (SPECIFY) (SPECIFY) (SPECIFY) OTHER SOURCE OTHER SOURCE OTHER SOURCE SHOP/KIOSQUE. K SHOP/KIOSQUE. K SHOP/KIOSQUE. K TRAD. HEALER L TRAD. HEALER L TRAD. HEALER L OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) 542 CHECK 541: TWO OR ONLY TWO OR ONLY TWO OR ONLY MORE ONE MORE ONE MORE ONE CODES CODE CODES CODE CODES CODE CIRCLED CIRCLED CIRCLED CIRCLED CIRCLED CIRCLED (SKIP TO 544) (SKIP TO 544) (SKIP TO 544) 179Appendix E | LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 543 Where did you first seek advice or treatment? FIRST PLACE . . . FIRST PLACE . . . FIRST PLACE . . . USE LETTER CODE FROM 541. 544 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'. 545 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 . . . 8 546 At any time during the illness, did YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 (NAME) take any drugs for the NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 illness? (GO TO 572) (GO TO 572) (GO TO 572) DON'T KNOW 8 DON'T KNOW 8 DON'T KNOW 8 547 What drugs did (NAME) take? ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS SP/FANSIDAR . . . A SP/FANSIDAR . . . A SP/FANSIDAR . . . A QUININE . . . . . . . . B QUININE . . . . . . . . B QUININE . . . . . . . . B Any other drugs? QUARTEM . . . . . C QUARTEM . . . . . C QUARTEM . . . . . C PRIMO . . . . . . . . D PRIMO . . . . . . . . D PRIMO . . . . . . . . D OTHER ANTI- OTHER ANTI- OTHER ANTI- RECORD ALL MENTIONED. MALARIAL MALARIAL MALARIAL . . . E . . . E . . . E ANTIBIOTIC DRUGS ANTIBIOTIC DRUGS ANTIBIOTIC DRUGS PILL/SYRUP . . . F PILL/SYRUP . . . F PILL/SYRUP . . . F INJECTION . . . G INJECTION . . . G INJECTION . . . G ASPIRIN . . . . . . . . . . H ASPIRIN . . . . . . . . . . H ASPIRIN . . . . . . . . . . H ACETA- ACETA- ACETA- MINOPHEN . . . . . I MINOPHEN . . . . . I MINOPHEN . . . . . I IBUPROFEN . . . . . J IBUPROFEN . . . . . J IBUPROFEN . . . . . J OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) DON'T KNOW . . . . . Z DON'T KNOW . . . . . Z DON'T KNOW . . . . . Z 548 CHECK 547: YES NO YES NO YES NO ANY CODE A-E CIRCLED? (GO TO 572) (GO TO 572) (GO TO 572) ; , ; , 549 Did you already have (NAME OF ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS DRUG FROM 547) at home when SP/FANSIDAR . . . A SP/FANSIDAR . . . A SP/FANSIDAR . . . A the child became ill? (10) QUININE . . . . . . . . B QUININE . . . . . . . . B QUININE . . . . . . . . B QUARTEM . . . . . C QUARTEM . . . . . C QUARTEM . . . . . C PRIMO . . . . . . . . D PRIMO . . . . . . . . D PRIMO . . . . . . . . ASK SEPARATELY FOR EACH OTHER ANTI- OTHER ANTI- OTHER ANTI- OF THE DRUGS 'A' THROUGH MALARIAL MALARIAL MALARIAL 'E' THAT THE CHILD IS . . . E . . . E . . . E RECORDED AS HAVING (SPECIFY) (SPECIFY) (SPECIFY) TAKEN IN 547. ANTIBIOTIC DRUGS ANTIBIOTIC DRUGS ANTIBIOTIC DRUGS IF YES FOR ANY DRUG, PILL/SYRUP . . . F PILL/SYRUP . . . F PILL/SYRUP . . . F CIRCLE CODE FOR THAT DRUG. NO DRUG AT HOME . Y NO DRUG AT HOME . Y NO DRUG AT HOME . Y IF NO FOR ALL DRUGS, CIRCLE 'Y'. 180 | Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 569 CHECK 547: CODE 'D' CODE 'D' CODE 'D' CODE 'D' CODE 'D' CODE 'D' CIRCLED NOT CIRCLED NOT CIRCLED NOT OTHER ANTIMALARIAL ('D') CIRCLED CIRCLED CIRCLED GIVEN (GO TO 572) (GO TO 572) (GO TO 572) 570 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 (OTHER ANTIMALARIAL)? 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 . . . 8 571 For how many days did (NAME) take the (OTHER ANTIMALARIAL)? DAYS . . . . . . . . . . DAYS . . . . . . . . . . DAYS . . . . . . . . . . IF 7 DAYS OR MORE, RECORD 7. DON'T KNOW . . . 8 DON'T KNOW . . . 8 DON'T KNOW . . . 8 572 Is (NAME) covered by the YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 mutuelle when he is sick NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 and you have to take him DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 to a health facility for for traitement? 573 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, END NO MORE BIRTHS, END COLUMN OF NEW OF INTERVIEW AND GO OF INTERVIEW AND GO QUESTIONNAIRE; OR, TO 574 TO 574 IF NO MORE BIRTHS, END OF INTERVIEW AND GO TO 574 574 RECORD THE TIME. HOUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181Appendix E | 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: 182 | Appendix E RWANDA INTERIM DEMOGRAPHIC AND HEALTH SURVEYS MAN’S QUESTIONNAIRE National Institute of Statistics of Rwanda Republic of Rwanda IDENTIFICATION LOCALITY NAME NAME OF HOUSEHOLD HEAD PROVINCE. DISTRICT. CLUSTER NUMBER . STRUCTURE NUMBER. HOUSEHOLD NUMBER . URBAN/RURAL (URBAN=1, RURAL=2) . CITY/LARGE TOWN/SMALL TOWN/VILLAGE . (CITY OF KIGALY=1, OTHER CITY=2, RURAL=3) NAME AND LINE NUMBER OF MAN 1 2 3 FINAL VISIT DATE INTERVIEWER’S NAME RESULT* ┌──┬──┐ DAY │░░│░░│ ├──┼──┤ MONTH │░░│░░│ ┌──┬──┼──┼──┤ YEAR │ 2│ 0│00│ ░│ └──┼──┼──┼──┤ NAME │ │░░│░░│ └──┴──┼──┤ RESULT │░░│ └──┘ NEXT VISIT: DATE TIME TOTAL NO. OF VISITS ┌──┐ │░░│ └──┘ *RESULT CODES: 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER __________________________ (SPECIFY) LANGUAGE OF INTERVIEW KINYA-RWANDA. 1 OTHER LANGUAGE. 2 (SPECIFY) WAS A TRANSLATOR USED? YES. 1 NO . 2 SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY NAME NAME DATE DATE 183Appendix E | SECTION 1. RESPONDENT’S BACKGROUND INFORMED CONSENT Hello. My name is and I am working with the National Institute of Statistics. We are conducting a national survey about the health of women, men and children. We would very much appreciate your participation in this survey. I would like to ask you some questions about yourself and your family. This information will help the government to plan health services. The survey usually takes between 10 and 15 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this 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 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 100 RECORD THE TIME. HOUR……………………………. MINUTES………………………… MONTH.░ DOES NOT KNOW MONTH.98 YEAR……………………. . 101 In what month and year were you born? DON’T KNOW YEAR.9998 102 How old were you at your last birthday? COMPARE AND CORRECT 101 AND/OR 102 IF INCONSISTENT. AGE IN COMPLETED YEARS 103 Have you ever attended school? YES.1 NO .2 ──>106 104 What is the highest level of school you attended: primary, middle/JSS, secondary/SSS, or higher? PRIMARY .1 SECONDARY.2 HIGHER.3 105 What is the highest grade you completed at that level? GRADE………………………. 106 What is your religion? CATHOLIC.1 PROTETANT.2 ADVENTIST.3 MOSLEM .4 TRADITINAL.5 OTHER 6 (SPECIFY) NO RELIGION .7 107 Are you currently married or living with a woman? YES, CURRENTLY MARRIED. 1 YES, LIVING WITH A WOMAN. 2 NO, NOT IN UNION . 3 ──>110 ──>110 108 Have you ever been married or lived with a woman? YES, USED TO BE MARRIED. 1 YES, LIVED WITH A WOMAN . 2 NO . 3 ──>201 109 What is your marital status now: are you widowed, divorced, or separated? WIDOWED . 1 DIVORCED . 2 SEPARATED. 3 ─┐ ├>201 ─┘ 184 | Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 110 Is your wife/partner living with you or elsewhere? WITH HIM. 1 ELSEWHERE. 2 111 Are there any other women with whom you live as if married? YES . 1 NO . 2 ─>201 112 In total, how many women are you living with as if you were married? NUMBER OF LIVE-IN ┌ PARTNERS.│ 185Appendix E | SECTION 2. REPRODUCTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 201 Now I would like to ask about any children you have had. I am interested only in the children that are biologically yours. Have you ever fathered any children with any woman? YES.1 NO .2 DON’T KNOW.8 ─┐ ─┴>206 202 Do you have any sons or daughters that you have fathered who are now livings with you? YES.1 NO .2 ──>204 203 How many sons live with you? And how many daughters live with you? IF NONE, WRITE ‘00'. SONS AT HOME…………………… DAUGHTERS AT HOME…………. 204 Do you have any sons or daughters you have fathered who are alive but do not live with you? YES.1 NO .2 ──>206 205 How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? IF NONE, WRITE ‘00'. SONS ELSEWHERE. DAUGHTERS ELSEWHERE. 206 Have you ever fathered a boy or girl who was born alive but later died? IF NO, PROBE: Any baby who cried or showed signs of life but did not survive? YES.1 NO .2 DON’T KNOW.8 ─┐ ─┴>208 207 How many boys have died? And how many girls have died? IF NONE, WRITE ‘00'. BOYS DEAD. GIRLS DEAD. 208 SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, WRITE ‘00'. TOTAL . 209 CHECK 208: HAS HAD ┌──┬─────────────────────────────────────────────────── ONLY ONE └──┘ HAS HAD ┌──┐ CHILD MORE THAN ├──┘ ONE CHILD ↓ HAS NOT HAD ┌──┐ ANY CHILDREN └──┴───────────────────────────────── ──>301 ──>301 210 Do the children that you have fathered all have the same biological mother? YES .1 NO.2 ──>301 211 In all how many women have you fathered children with? NUMBER OF WOMEN. 186 | Appendix E SECTION 3. CONTRACEPTION Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. 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 RECOGNISED, AND CODE 2 IF NOT RECOGNISED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302. 301 Which ways or methods have you heard about? FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)? 302 Have you ever used (METHOD)? 01 FEMALE STERILIZATION Women can have an operation to avoid having any more children. YES.1 NO . 2 ─┐ ↓ 02 MALE STERILIZATION Men can have an operation to avoid having any more children. YES.1 NO . 2 ─┐ ↓ Have you ever had an operation to avoid having any more children? YES . 1 NO . 2 03 PILL Women can take a pill every day to stop them from becoming pregnant. YES.1 NO . 2 ─┐ ↓ 04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse. YES.1 NO . 2 ─┐ ↓ 05 INJECTABLES Women can have an injection by a health provider which stops them from becoming pregnant for one or more months. YES.1 NO . 2 ─┐ ↓ 06 IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years. YES.1 NO . 2 ─┐ ↓ 07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse. YES.1 NO . 2 ─┐ ↓ YES . 1 NO . 2 08 FEMALE CONDOM Women can place a sheath in their vagina before sexual intercourse. YES.1 NO . 2 ─┐ ↓ 09 LACTATIONAL AMENORRHEA METHOD (LAM) Up to 6 months after childbirth, a woman can use a method that requires that she breastfeeds frequently, day and night, and that her menstrual period has not returned. YES.1 NO . 2 ─┐ ↓ 10 RHYTHM OR PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant. YES.1 NO . 2 ─┐ ↓ YES . 1 NO . 2 11 WITHDRAWAL Men can be careful and pull out before climax. YES.1 NO . 2 ─┐ ↓ YES . 1 NO . 2 12 EMERGENCY CONTRACEPTION Women can take pills up to five days after sexual intercourse to avoid becoming pregnant. YES.1 NO . 2 ─┐ ↓ 12A STANDARD DAYS METHODS USING CYCLE BEADS: Woman can know better the days of the months that she would have a greater chance of being pregnant by using cycle beads or calendar. YES.1 NO . 2 ─┐ ↓ 13 Have you heard of any other ways or methods that women or men can use to avoid pregnancy? YES.1 (SPECIFY) (SPECIFY) NO . 2 ─┐ ↓ 187Appendix E | NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 303 CHECK 301(07), KNOWLEDGE OF MALE CONDOM YES ┌──┐ NO ┌──┐ ├──┘ └──┴──────────────────────── ↓ ──>401 304 Do you know of a place where a person can get male condoms? YES . 1 NO. 2 ──>401 305 Where is that? IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. (NAME OF PLACE) Any other place? RECORD ALL SOURCES MENTIONED. PUBLIC SECTOR REFERRAL HOSPITAL .A DISTRICT HOSPITAL.B HEALTH CENTER .C FIELDWORKER.D OTHER PUBLIC E (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . F PHARMACY. G PRIVATE DOCTOR .H ARBEF CLINIC . I NURSE. J OTHER PRIVATE MEDICAL K (SPECIFY) OTHER SOURCE SHOP. L CHURCH. M FRIENDS/RELATIVES.N OTHER X (SPECIFY) 188 | Appendix E SECTION 4. CIRCUMCISION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 401 Some men are circumcised. Are you circumcised? YES.1 NO .2 ──>405 402 How old were you when you were circumcised? LESS THAN 13 YEARS OLD .1 13-19 YEARS OLD .2 20 YEARS OR OLDER.3 403 Who performed your circumcision? TRADITIONAL .1 HEALTH PROFESSIONAL.2 DON’T KNOW.3 404 What is the main reason for your circumcision? TRADITION/RELOGION.1 HEALTH/HYGIENE.2 SEXUAL SATISFACTION .3 EASIER TO PUT ON CONDOM.4 OTHER X (SPECIFY) DON’T KNOW.8 ─┐ │ │ │ ├>408 │ │ │ ─┘ 405 Would you like to be circumcised? YES.1 NO .2 DON’T KNOW.8 ──>407 ──>408 406 What is the main reason that you would like to be circumcised? TRADITION/RELOGION.1 HEALTH/HYGIENE.2 SEXUAL SATISFACTION .3 EASIER TO PUT ON CONDOM.4 OTHER X (SPECIFY) DON’T KNOW.8 ─┐ │ │ │ ├>408 │ │ │ ─┘ 407 What is the main reason that you would not like to be circumcised? TRADITION/RELOGION.01 HEALTH/HYGIENE.02 SEXUAL SATISFACTION .03 COST.04 PAIN .05 OTHER 96 (SPECIFY) DON’T KNOW.98 408 RECORD THE TIME HOURS. MINUTES. 189Appendix E | 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 THE SUPERVISOR:______________________________________ DATE: ___________________________________ EDITOR’S OBSERVATIONS NAME OF EDITOR:_______________________________________________ DATE: ___________________________________ 190 | Appendix E Front Matter Title Page Information and Citation Page Table of Contents Tables and Figures Foreword Acknowledgments Abbreviations Summary of Findings Map of Rwanda Chapter 01 - Country Profile, Objectives, and Methodology of the Survey Chapter 02 - Household Characteristics Chapter 03 - Characteristics of Survey Respondents Chapter 04 - Fertility Chapter 05 - Family Planning Chapter 06 - Fertility Preferences Chapter 07 - Maternal and Child Health Chapter 08 - Malaria and Anemia Chapter 09 - Infant and Child Mortality Chapter 10 - Circumcision References Appendix A - Sampling Design Appendix B - Estimates of Sampling Errors Appendix C - Data Quality Tables Appendix D - Survey Personnel Appendix E - Questionnaires Household Questionnaire Woman's Questionnaire Man's Questionnaire << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /None /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel 1.4 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.0000 /ColorConversionStrategy /CMYK /DoThumbnails false /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 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