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 t

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