Rwanda - Demographic and Health Survey - 2012

Publication date: 2012

Demographic and Health Survey 2010 Rwanda Republic of Rwanda Rwanda Demographic and Health Survey 2010 Final Report National Institute of Statistics of Rwanda Ministry of Finance and Economic Planning Kigali, Rwanda Ministry of Health Kigali, Rwanda MEASURE DHS ICF International Calverton, Maryland, USA February 2012 Investing in our future The Global Fund To Fight AIDS, Tuberculosis and Malaria The 2010 Rwanda Demographic and Health Survey (2010 RDHS) was implemented by the National Institute of Statistics of Rwanda (NISR) in collaboration with the Ministry of Health (MOH), and the field work was conducted from September 26, 2010, to March 10, 2011. The funding for the RDHS was provided by the United States Agency for International Development (USAID), the United Nations Children’s Fund (UNICEF), the Centers for Disease Control and Prevention/Global AIDS Program (CDC/GAP), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United Nations Population Fund (UNFPA), World Vision, and the Government of Rwanda. ICF International provided technical assistance to the project through the MEASURE DHS project, a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. Additional information about the 2010 RDHS may be obtained from the NISR, P.O. Box 6139, Kigali, Rwanda; Telephone: (250) 571 035; E-mail: info@statistics.gov.rw; Internet: http://www.statistics.gov.rw. Information about the MEASURE DHS project may be obtained from ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200; Fax: 301-572-0999; E-mail: info@measuredhs.com; Internet: http://www.measuredhs.com. Recommended citation: National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda], and ICF International. 2012. Rwanda Demographic and Health Survey 2010. Calverton, Maryland, USA: NISR, MOH, and ICF International. Contents • iii CONTENTS TABLES AND FIGURES . ix FOREWORD . xvii ACKNOWLEDGMENTS . xix SUMMARY OF FINDINGS . xxi MAP OF RWANDA . xxvi CHAPTER 1 INTRODUCTION 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 . 4 1.2.1 Objectives of the Survey . 5 1.2.2 Questionnaires . 5 1.2.3 Sample Design . 7 1.2.4 Sample Coverage . 7 1.2.5 Hemoglobin, Malaria, and HIV Testing . 8 1.2.6 Training and Fieldwork Data Collection . 9 1.2.7 Data Processing . 9 CHAPTER 2 HOUSEHOLD CHARACTERISTICS 2.1 Household Population By Age and Sex . 11 2.2 Household Composition . 12 2.3 Educational Attainment . 13 2.4 School Attendance . 15 2.5 Household Conditions . 18 2.5.1 Household Drinking Water . 18 2.5.2 Household Sanitation Facilities . 20 2.5.3 Households with Hand Washing Places . 20 2.5.4 Household Characteristics . 21 2.5.5 Household Possession of Durable Goods . 23 2.5.6 Household Wealth Quintile . 24 2.6 Birth Registration with Civil Authorities . 25 2.7 Children’s Living Arrangements and Orphanhood . 26 2.8 School Attendance by Survivorship of Parents . 27 2.9 Child Labor . 28 2.10 Health Insurance Coverage . 31 2.11 Utilization of Health Services and Out-of-Pocket Expenditure for Health Care . 33 iv • Contents CHAPTER 3 RESPONDENT CHARACTERISTICS 3.1 Background Characteristics of Respondents . 37 3.2 Educational Attainment . 38 3.3 Literacy . 40 3.4 Exposure to Mass Media. 42 3.5 Employment . 44 3.6 Use of Tobacco . 50 CHAPTER 4 PROXIMATE DETERMINANTS OF FERTILITY 4.1 Marital Status . 53 4.2 Polygamy . 54 4.3 Age at First Union . 55 4.4 Age at First Sexual Intercourse . 57 4.5 Recent Sexual Activity . 59 CHAPTER 5 FERTILITY 5.1 Fertility Levels and Differentials . 63 5.2 Fertility Trends . 66 5.4 Children Ever Born and Living . 69 5.5 Birth Intervals . 69 5.6 Exposure to the Risk of Pregnancy . 71 5.7 Menopause . 73 5.8 Age at First Birth . 73 5.9 Teenage Fertility . 74 CHAPTER 6 FERTILITY PREFERENCES 6.1 Desire for Children . 77 6.2 Ideal Number of Children . 80 6.3 Fertility Planning Status . 82 CHAPTER 7 FAMILY PLANNING 7.1 Knowledge of Contraceptive Methods . 85 7.2 Current Use of Contraceptive Methods . 87 7.2.1 Current Use of Contraception by Age . 87 7.2.2 Current Use of Contraception by Background Characteristics . 89 7.3 Timing of Sterilization . 90 7.4 Source of Supply . 90 7.5 Informed Choice . 91 7.6 Contraceptive Discontinuation . 92 7.7 Knowledge of Fertile Period . 93 7.8 Need and Demand for Family Planning Services . 94 7.8.1 Need and Demand for Family Planning among Currently Married Women . 94 7.8.2 Need and Demand for Family Planning among All Women and Women Who Are Not Currently Married . 95 7.9 Future Use of Contraception . 97 7.10 Exposure to Family Planning Messages . 97 7.11 Contact of Nonusers with Family Planning Providers . 98 Contents • v CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Assessment of Data Quality . 101 8.2 Levels and Trends in Childhood Mortality . 102 8.3 Socioeconomic Differentials in Childhood Mortality . 103 8.4 Demographic Differentials in Mortality . 105 8.5 High-Risk Fertility Behavior . 106 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care . 109 9.1.1 Components of Antenatal Care . 112 9.1.2 Tetanus Vaccinations . 114 9.2 Delivery Care . 115 9.2.1 Place of Delivery . 115 9.2.2 Assistance during Delivery . 116 9.3 Postnatal Care . 118 9.3.1 Maternal Postnatal Care . 118 9.3.2 Newborn Postnatal Care . 120 9.4 Problems in Accessing Health Care . 122 CHAPTER 10 CHILD HEALTH 10.1 Child’s Size at Birth . 125 10.2 Vaccination of Children . 126 10.3 Trends in Vaccination Coverage . 128 10.4 Childhood Illnesses . 129 10.4.1 Acute Respiratory Infections . 129 10.4.2 Fever . 130 10.5 Diarrheal Disease . 132 10.5.1 Prevalence of Diarrhea . 132 10.5.2 Treatment of Diarrhea . 133 10.5.3 Feeding Practices during Diarrhea . 135 10.6 Knowledge of ORS Packets . 137 10.7 Stool Disposal . 137 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 139 11.1.1 Measurement of Nutritional Status among Young Children . 139 11.1.2 Measures of Child Nutritional Status . 141 11.1.3 Trends in Children’s Nutritional Status . 143 11.2 Initiation of Breastfeeding . 144 11.3 Breastfeeding Status by Age . 146 11.4 Duration of Breastfeeding . 147 11.5 Types of Complementary Foods . 149 vi • Contents 11.6 Infant and Young Child Feeding (IYCF) Practices . 151 11.7 Prevalence of Anemia in Children . 154 11.8 Micronutrient Intake among Children . 156 11.9 Use of Iodized Salt . 158 11.10 Nutritional Status of Women . 158 11.11 Prevalence of Anemia in Women . 160 11.12 Micronutrient Intake among Mothers . 162 11.13 Nutritional Status of Men . 163 CHAPTER 12 MALARIA 12.1 Introduction . 165 12.2 Mosquito Nets . 165 12.2.1 Ownership of Mosquito Nets . 166 12.2.2 Use of Mosquito Nets by Persons in the Household . 167 12.2.3 Use of Mosquito Nets by Children Under 5 . 167 12.2.4 Use of Mosquito Nets by Pregnant Women . 168 12.3 Prevalence and Prompt Treatment of Fever . 169 12.4 Prevalence of Anemia and Malaria in Children and Women . 172 CHAPTER 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13.1 Knowledge of HIV and AIDS and of Transmission and Prevention Methods . 177 13.1.1 Awareness of AIDS . 177 13.1.2 HIV Prevention Methods . 178 13.1.3 Knowledge about Transmission . 179 13.1.4 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 182 13.2 Stigma Associated with AIDS and Attitudes Related to HIV and AIDS . 183 13.3 Attitudes towards Negotiating Safer Sex . 185 13.4 Attitudes towards Condom Education for Youth . 187 13.5 Multiple and Concurrent Partnerships, and Paying for Sex . 188 13.5.1 Multiple Sexual Partnerships . 188 13.5.2 Concurrent Sexual Partners . 190 13.5.3 Payment for Sex . 192 13.6 Testing for HIV . 193 13.7 Reports of Recent Sexually Transmitted Infections . 197 13.8 Needle and Syringe Injection . 199 13.9 HIV- and AIDS-Related Knowledge and Behavior among Youth . 200 13.9.1 Knowledge about HIV and AIDS and Source for Condoms . 201 13.9.2 Age at First Sex and Condom Use at First Sexual Intercourse . 202 13.9.3 Recent Sexual Activity . 202 13.9.4 Multiple Sexual Partnerships . 203 13.9.5 HIV Testing . 204 13.10 Male Circumcision . 205 CHAPTER 14 HIV PREVALENCE 14.1 Coverage Rates for HIV Testing . 209 14.2 HIV Prevalence . 211 Contents • vii 14.2.1 HIV Prevalence by Age and Sex . 211 14.2.2 Trends in HIV Prevalence: 2005 RDHS and 2010 RDHS . 212 14.2.3 HIV Prevalence by Socioeconomic Characteristics . 213 14.2.4 HIV Prevalence by Demographic Characteristics . 214 14.2.5 HIV Prevalence by Sexual Risk Behavior . 215 14.3 HIV Prevalence among Youth . 216 14.3.1 HIV Prevalence by Condom Use at Last Sex in Past 12 Months among Youth . 218 14.4 HIV Prevalence by Other Characteristics . 218 14.4.1 HIV Prevalence and STIs . 218 14.4.2 HIV Prevalence by Male Circumcision . 219 14.4.3 Prior HIV Testing by Current HIV Status. 221 14.5 HIV Prevalence among Cohabiting Couples . 221 CHAPTER 15 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Women’s and Men’s Employment . 223 15.1.1 Employment Status . 223 15.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s Earnings . 224 15.3 Women’s Participation in Decision-making . 227 15.4 Attitudes towards Wife Beating . 229 15.5 Women’s Empowerment Indicators . 231 15.6 Current Use of Contraception by Women’s Empowerment Status . 232 15.7 Ideal Family Size and Unmet Need by Women’s Status . 232 15.8 Women’s Status and Reproductive Health Care . 233 CHAPTER 16 ADULT AND MATERNAL MORTALITY 16.1 Data Quality Issues . 235 16.2 Adult Mortality . 236 16.3 Maternal Mortality . 237 CHAPTER 17 DOMESTIC VIOLENCE 17.1 Measurement of Violence . 239 17.1.1 The Use of Valid Measures of Violence . 239 17.1.2 Ethical Considerations . 240 17.1.3 Special Training for Implementing the Domestic Violence Module . 241 17.2 Sub-Sample for the Violence Module . 242 17.3 Experience of Physical Violence and Perpetrators of Physical Violence . 242 17.4 Experience of Sexual Violence and Perpetrators of Sexual Violence . 243 17.5 Experience of Different Types of Violence . 246 17.6 Types of Spousal Violence . 246 17.7 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 249 17.8 Frequency of Spousal Violence by Husbands . 250 17.9 Help-seeking to Stop Violence . 251 REFERENCES . 253 viii • Contents APPENDIX A SAMPLE IMPLEMENTATION A.1 Introduction . 255 A.2 Sampling Frame . 255 A.3 Structure of the Sample and the Sampling Procedure . 257 A.4 Selection of Probability and Sampling Weight . 260 APPENDIX B SAMPLING ERRORS . 269 APPENDIX C DATA QUALITY TABLES . 281 APPENDIX D DISTRICT TABLES . 293 APPENDIX E SURVEY PERSONNEL. . 405 APPENDIX F QUESTIONNAIRES . 411 Tables and Figures • ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 7 CHAPTER 2 HOUSEHOLD CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 12 Table 2.2 Household composition . 13 Table 2.3.1 Educational attainment of the female household population . 14 Table 2.3.2 Educational attainment of the male household population . 15 Table 2.4 School attendance ratios . 16 Table 2.5 Household drinking water . 19 Table 2.6 Household sanitation facilities . 20 Table 2.7 Hand washing . 21 Table 2.8 Household characteristics . 22 Table 2.9 Household possessions . 24 Table 2.10 Wealth quintiles . 25 Table 2.11 Birth registration of children under age 5 . 26 Table 2.12 Children’s living arrangements and orphanhood . 27 Table 2.13 School attendance by survivorship of parents . 28 Table 2.14 Child labor . 30 Table 2.15 Health insurance . 31 Table 2.16 Health insurance . 32 Table 2.17 Annual outpatient visits and inpatient admissions for de facto population . 33 Table 2.18 Annual per capita expenditure (in US $) on outpatient visits and inpatient admissions for de facto population . 34 Figure 2.1 Population Pyramid . 12 Figure 2.2 Age-Specific Attendance Rates of the De Facto Population Age 5-24 . 18 CHAPTER 3 RESPONDENT CHARACTERISTICS Table 3.1 Background characteristics of respondents . 37 Table 3.2.1 Educational attainment: Women . 39 Table 3.2.2 Educational attainment: Men . 39 Table 3.3.1 Literacy: Women . 41 Table 3.3.2 Literacy: Men . 41 Table 3.4.1 Exposure to mass media: Women . 42 Table 3.4.2 Exposure to mass media: Men . 43 Table 3.5.1 Employment status: Women . 44 Table 3.5.2 Employment status: Men . 46 Table 3.6.1 Occupation: Women. 48 Table 3.6.2 Occupation: Men . 48 Table 3.7 Type of employment: Women . 50 Table 3.8.1 Use of tobacco: Women . 51 Table 3.8.2 Use of tobacco: Men . 51 x • Tables and Figures CHAPTER 4 PROXIMATE DETERMINANTS OF FERTILITY Table 4.1 Current marital status . 53 Table 4.2.1 Number of women’s co-wives . 54 Table 4.2.2 Number of men’s wives . 55 Table 4.3 Age at first marriage . 56 Table 4.4 Median age at first marriage by background characteristics . 57 Table 4.5 Age at first sexual intercourse . 58 Table 4.6 Median age at first intercourse by background characteristics . 59 Table 4.7.1 Recent sexual activity: Women . 60 Table 4.7.2 Recent sexual activity: Men . 61 CHAPTER 5 FERTILITY Table 5.1 Current fertility . 64 Table 5.2 Fertility by background characteristics . 65 Table 5.3.1 Trends in age-specific fertility rates . 67 Table 5.3.2 Trends in fertility . 68 Table 5.4 Children ever born and living . 69 Table 5.5 Birth intervals . 70 Table 5.6 Postpartum amenorrhea, abstinence, and insusceptibility . 71 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 72 Table 5.8 Menopause . 73 Table 5.9 Age at first birth . 74 Table 5.10 Median age at first birth . 75 Table 5.11 Teenage pregnancy and motherhood . 76 Figure 5.1 Age-Specific Fertility Rates for Five-Year Periods Preceding the Survey . 67 Figure 5.2 Trends in Age-Specific and Total Fertility Rates, Various Sources . 68 CHAPTER 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . 78 Table 6.2.1 Desire to limit childbearing: Women . 79 Table 6.2.2 Desire to limit childbearing: Men . 80 Table 6.3 Ideal number of children . 81 Table 6.4 Mean ideal number of children . 82 Table 6.5 Fertility planning status . 83 Table 6.6 Wanted fertility rates . 84 CHAPTER 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods . 86 Table 7.2 Knowledge of contraceptive methods by background characteristics . 88 Table 7.3 Current use of contraception by age . 88 Table 7.4 Current use of contraception by background characteristics . 90 Table 7.5 Timing of sterilization . 90 Table 7.6 Source of modern contraception methods . 91 Table 7.7 Informed choice . 92 Table 7.8 Reasons for discontinuation . 93 Table 7.9 Knowledge of fertile period . 94 Table 7.10.1 Need and demand for family planning among currently married women . 95 Table 7.10.2 Need and demand for family planning among all women and women who are not currently married . 96 Table 7.11 Future use of contraception . 97 Table 7.12 Exposure to family planning messages . 98 Table 7.13 Contact of nonusers with family planning providers . 99 Tables and Figures • xi CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 102 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 104 Table 8.3 Early childhood mortality rates by demographic characteristics . 105 Table 8.4 High-risk fertility behavior . 107 Figure 8.1 Trend in Childhood Mortality Rates . 103 Figure 8.2 Under-5 Mortality Rates by Socioeconomic Characteristics . 104 Figure 8.3 Infant Mortality Rates by Demographic Characteristics . 106 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 110 Table 9.2 Number of antenatal care visits and timing of first visit . 112 Table 9.3 Components of antenatal care . 113 Table 9.4 Tetanus toxoid injections . 114 Table 9.5 Place of delivery . 115 Table 9.6 Assistance during delivery . 117 Table 9.7 Timing of first postnatal checkup . 118 Table 9.8 Type of provider of first postnatal checkup . 119 Table 9.9 Timing of newborn’s first postnatal checkup . 120 Table 9.10 Type of provider of newborn’s first postnatal checkup . 121 Table 9.11 Problems in accessing health care . 123 Figure 9.1 Trends in Antenatal Care and Delivery, Rwanda 2005, 2007-08, and 2010 . 111 Figure 9.2 Children Whose Delivery Was Assisted by Trained Personnel . 117 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth. 126 Table 10.2 Vaccinations by source of information . 127 Table 10.3 Vaccinations by background characteristics . 128 Table 10.4 Vaccinations in first year of life . 128 Table 10.5 Prevalence and treatment of symptoms of ARI . 129 Table 10.6 Prevalence and treatment of fever . 131 Table 10.7 Prevalence of diarrhea . 133 Table 10.8 Diarrhea treatment . 134 Table 10.9 Feeding practices during diarrhea . 136 Table 10.10 Knowledge of ORS packets or pre-packaged liquids . 137 Table 10.11 Disposal of children's stools . 138 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 142 Table 11.2 Initial breastfeeding . 145 Table 11.3 Breastfeeding status by age . 146 Table 11.4 Median duration of breastfeeding . 148 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 150 Table 11.6 Infant and young child feeding (IYCF) practices . 153 Table 11.7 Prevalence of anemia in children . 154 Table 11.8 Micronutrient intake among children . 157 Table 11.9 Presence of iodized salt in household . 158 Table 11.10 Nutritional status of women . 159 Table 11.11 Prevalence of anemia in women . 161 Table 11.12 Micronutrient intake among mothers . 163 Table 11.13 Nutritional status of men . 164 xii • Tables and Figures Figure 11.1 Nutritional Status of Children by Age . 143 Figure 11.2 Trends in Nutritional Status of Children under 5 Years . 144 Figure 11.3 Infant Feeding Practices by Age . 147 Figure 11.4 IYCF Indicators on Breastfeeding Status . 149 CHAPTER 12 MALARIA Table 12.1 Household possession of mosquito nets . 166 Table 12.2 Use of mosquito nets by persons in the household . 167 Table 12.3 Use of mosquito nets by children . 168 Table 12.4 Use of mosquito nets by pregnant women . 169 Table 12.5 Prevalence, diagnosis, and prompt treatment of children with fever . 170 Table 12.6.1 Type of antimalarial drugs taken by children who took antimalarial drugs . 171 Table 12.6.2 Type and timing of antimalarial drugs taken by children with fever . 171 Table 12.7 Hemoglobin <8.0 g/dl in children . 173 Table 12.8 Malaria among children . 174 Table 12.9 Malaria among women . 175 CHAPTER 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 13.1 Knowledge of AIDS . 177 Table 13.2 Knowledge of HIV prevention methods. 179 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 180 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 181 Table 13.4 Knowledge of prevention of mother to child transmission of HIV . 182 Table 13.5.1 Accepting attitudes toward those living with HIV and AIDS: Women . 184 Table 13.5.2 Accepting attitudes toward those living with HIV and AIDS: Men . 185 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 186 Table 13.7 Adult support of youth education about condom use to prevent AIDS . 187 Table 13.8.1 Multiple sexual partners: Women . 189 Table 13.8.2 Multiple sexual partners: Men . 190 Table 13.9.1 Point prevalence and cumulative prevalence of concurrent sexual partners . 191 Table 13.9.2 Payment for sexual intercourse and condom use at last paid sexual intercourse . 193 Table 13.10.1 Coverage of prior HIV testing: Women . 194 Table 13.10.2 Coverage of prior HIV testing: Men . 195 Table 13.11.1 Pregnant women counseled and tested for HIV . 196 Table 13.11.2 HIV testing for prenuptial purposes and as a couple . 197 Table 13.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 198 Table 13.13 Prevalence of medical injections . 200 Table 13.14 Comprehensive knowledge about AIDS and of a source of condoms among youth . 201 Table 13.15 Age at first sexual intercourse among youth . 202 Table 13.16 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 203 Table 13.17 Multiple sexual partners in the past 12 months among young people . 204 Table 13.18 Recent HIV tests among youth . 205 Table 13.19 Practice of circumcision . 206 Table 13.20 Place of circumcision . 207 Table 13.21 Age at circumcision . 208 Figure 13.1 Women and Men Seeking Treatment for STIs . 199 CHAPTER 14 HIV PREVALENCE Table 14.1 Coverage of HIV testing by residence and province . 209 Table 14.2 Coverage of HIV testing by selected background characteristics . 210 Table 14.3 HIV prevalence by age . 211 Tables and Figures • xiii Table 14.4 Trends in HIV prevalence by age . 212 Table 14.5 HIV prevalence by socioeconomic characteristics . 213 Table 14.6 HIV prevalence by demographic characteristics . 215 Table 14.7 HIV prevalence by sexual behavior . 216 Table 14.8 HIV prevalence among young people, by background characteristics . 217 Table 14.9 HIV prevalence among young people by condom use at last sex . 218 Table 14.10 HIV prevalence by sexually transmitted infections . 219 Table 14.11 HIV prevalence by male circumcision . 220 Table 14.12 Prior HIV testing by current HIV status . 221 Table 14.13 HIV prevalence among couples . 222 Figure 14.1 HIV Prevalence by Sex and Age . 212 CHAPTER 15 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women and men . 224 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 225 Table 15.2.2 Control over men’s cash earnings . 226 Table 15.3 Women’s control over their own earnings and over those of their husband . 227 Table 15.4 Participation in decision-making . 228 Table 15.5 Women’s participation in decision-making by background characteristics . 228 Table 15.6.1 Attitude toward wife beating: Women . 229 Table 15.6.2 Attitude toward wife beating: Men . 230 Table 15.7 Indicators of women’s empowerment . 231 Table 15.8 Current use of contraception by women’s empowerment. 232 Table 15.9 Women’s empowerment and ideal number of children and unmet need for family planning . 233 Table 15.10 Reproductive health care by women’s empowerment . 234 CHAPTER 16 ADULT AND MATERNAL MORTALITY Table 16.1 Data on siblings . 235 Table 16.2 Sibship size and sex ratio of siblings . 236 Table 16.3 Adult mortality rates . 237 Table 16.4 Direct estimates of maternal mortality . 238 Figure 16.1 Trend in Maternal Mortality Ratios for the Periods of 1995-2000 (2000 RDHS), 2000-2005 (2005 RDHS), and 2005-2010 (2010 RDHS) . 238 CHAPTER 17 DOMESTIC VIOLENCE Table 17.1 Experience of physical violence . 241 Table 17.2 Persons committing physical violence . 243 Table 17.3 Experience of sexual violence . 244 Table 17.4 Age at first experience of sexual violence . 245 Table 17.5 Person committing sexual violence at first experience of sexual violence . 245 Table 17.6 Experience of different forms of violence . 246 Table 17.7 Forms of spousal violence . 246 Table 17.8 Spousal violence by background characteristics . 248 Table 17.9 Spousal violence by husband's characteristics and empowerment indicators . 249 Table 17.10 Frequency of spousal violence among those who report violence . 250 Table 17.11 Help seeking to stop violence . 251 Table 17.12 Sources from where help was sought . 252 xiv • Tables and Figures APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Distribution of village and population by province and by district within province . 256 Table A.2 Average village size and population distribution by district. 257 Table A.3 Sample allocation of clusters, households and expected number of women’s interviews by district . 258 Table A.4 Sample allocation of clusters, households and expected number of men’s interviews by district . 259 Table A.5 Expected number of eligible individuals for HIV testing and expected number of completed HIV tests by sex and by district . 260 Table A.6 Sample implementation: Women . 262 Table A.7 Sample implementation: Men . 263 Table A.8 Coverage of HIV testing by social and demographic characteristics: Women . 264 Table A.9 Coverage of HIV testing by social and demographic characteristics: Men . 265 Table A.10 Coverage of HIV testing by sexual behavior characteristics: Women . 266 Table A.11 Coverage of HIV testing by sexual behavior characteristics: Men . 267 APPENDIX B SAMPLING ERRORS Table B.1. List of selected variables for sampling errors, Rwanda DHS 2010 . 271 Table B.2 Sampling errors: Total sample, Rwanda DHS 2010 . 272 Table B.3 Sampling errors: Urban sample, Rwanda DHS 2010 . 273 Table B.4 Sampling errors: Rural sample, Rwanda DHS 2010 . 274 Table B.5 Sampling errors: City of Kigali sample, Rwanda DHS 2010 . 275 Table B.6 Sampling errors: South sample, Rwanda DHS 2010 . 276 Table B.7 Sampling errors: West sample, Rwanda DHS 2010 . 277 Table B.8 Sampling errors: North sample, Rwanda DHS 2010 . 278 Table B.9 Sampling errors: East sample, Rwanda DHS 2010 . 279 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 281 Table C.2.1 Age distribution of eligible and interviewed women . 282 Table C.2.2 Age distribution of eligible and interviewed men . 282 Table C.3 Completeness of reporting . 283 Table C.4 Births by calendar years . 284 Table C.5 Reporting of age at death in days . 285 Table C.6 Reporting of age at death in months . 286 Table C.7 Nutritional status of children . 287 Table C.8 Prevalence of anemia in children in 2005 . 288 Table C.9 Prevalence of anemia in women in 2005 . 289 Table C.10 Prevalence of anemia in children in 2007-08 . 290 Table C.11 Prevalence of anemia in women in 2007-08 . 291 APPENDIX D DISTRICT TABLES Table D.1 Hand washing . 293 Table D.2. Birth registration of children under age five . 294 Table D.3 Children's living arrangements and orphanhood . 295 Table D.4.1 Educational attainment of the household population: Female . 296 Table D.4.2 Educational attainment of the household population: Men . 297 Table D.5 School attendance ratios . 298 Table D.6 Child labor . 299 Table D.7 Annual outpatient visits and inpatient admissions for de facto population . 300 Table D.8 Annual per capita expenditure (in US $) on outpatient visits and inpatient admissions for de facto population . 301 Table D.9 Health insurance . 302 Tables and Figures • xv Table D.10 Health insurance . 303 Table D.11.1 Educational attainment: Women . 304 Table D.11.2 Educational attainment: Men . 305 Table D.12.1 Literacy: Women . 306 Table D.12.2 Literacy: Men . 307 Table D.13.1 Exposure to mass media: Women . 308 Table D.13.2 Exposure to mass media: Men . 309 Table D.14.1 Employment status: Women . 310 Table D.14.2 Employment status: Men . 311 Table D.15.1 Occupation: Women. 312 Table D.15.2 Occupation: Men . 313 Table D.16.1 Use of tobacco: Women . 314 Table D.16.2 Use of tobacco: Men . 315 Table D.17 Current marital status . 316 Table D.18 Number of women's co-wives . 317 Table D.19 Number of men's wives . 318 Table D.20 Median age at first marriage . 319 Table D.21 Median age at first intercourse . 320 Table D.22.1 Recent sexual activity: Women . 321 Table D.22.2 Recent sexual activity: Men . 322 Table D.23 Fertility by district . 323 Table D.24 Birth intervals . 324 Table D.25 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 325 Table D.26 Median age at first birth . 326 Table D.27 Teenage pregnancy and motherhood . 327 Table D.28.1 Desire to limit childbearing: Women . 328 Table D.28.2 Desire to limit childbearing: Men . 329 Table D.29 Mean ideal number of children . 330 Table D.30 Wanted fertility rates . 331 Table D.31 Knowledge of contraceptive methods . 332 Table D.32 Current use of contraception . 333 Table D.33 Need and demand for family planning among currently married women . 334 Table D.34 Exposure to family planning messages . 335 Table D.35 Contact of nonusers with family planning providers . 336 Table D.36 Youth who could get a male condom . 337 Table D.37 Early childhood mortality rates . 338 Table D.38 Antenatal care . 339 Table D.39 Components of antenatal care . 340 Table D.40 Tetanus toxoid injections . 341 Table D.41 Place of delivery . 342 Table D.42 Assistance during delivery . 343 Table D.43 Timing of first postnatal checkup . 344 Table D.44 Type of provider of first postnatal checkup . 345 Table D.45 Timing of first postnatal checkup for the newborn . 346 Table D.46 Type of provider of first postnatal checkup for the newborn . 347 Table D.47 Problems in accessing health care . 348 Table D.48 Child's weight and size at birth. 349 Table D.49 Vaccinations . 350 Table D.50 Prevalence of symptoms of ARI, of fever, and of diarrhea . 351 Table D.51 Knowledge of ORS packets or pre-packaged liquids . 352 Table D.52 Disposal of children's stools . 353 Table D.53 Nutritional status of children . 354 Table D.54 Initial breastfeeding . 355 Table D.55 Median duration of breastfeeding . 356 Table D.56 Infant and young child feeding (IYCF) practices . 357 xvi • Tables and Figures Table D.57 Prevalence of anemia in children . 358 Table D.58 Micronutrient intake among children . 359 Table D.59 Presence of iodized salt in household . 360 Table D.60 Nutritional status of women . 361 Table D.61 Nutritional status of men . 362 Table D.62 Prevalence of anemia in women . 363 Table D.63 Micronutrient intake among mothers . 364 Table D.64 Household possession of mosquito nets . 365 Table D.65 Use of mosquito nets by persons in the household . 366 Table D.66 Use of mosquito nets by children . 367 Table D.67 Malaria among children . 368 Table D.68 Malaria among women . 369 Table D.69 Knowledge of AIDS . 370 Table D.70 Knowledge of HIV prevention methods. 371 Table D.71.1 Comprehensive knowledge about AIDS: Women . 372 Table D.71.2 Comprehensive knowledge about AIDS: Men . 373 Table D.72 Knowledge of prevention of mother to child transmission of HIV . 374 Table D.73 Information given about AIDS during antenatal visits . 375 Table D.74.1 Accepting attitudes toward those living with HIV/AIDS: Women . 376 Table D.74.2 Accepting attitudes toward those living with HIV/AIDS: Men . 377 Table D.75 Attitudes toward negotiating safer sexual relations with husband . 378 Table D.76 Adult support of education about condom use to prevent AIDS . 379 Table D.77.1 Multiple sexual partners: Women . 380 Table D.77.2 Multiple sexual partners: Men . 381 Table D.78 Point prevalence and cumulative prevalence of concurrent sexual partners . 382 Table D.79 Payment for sexual intercourse and condom use at last paid sexual intercourse . 383 Table D.80.1 Coverage of prior HIV testing: Women . 384 Table D.80.2 Coverage of prior HIV testing: Men . 385 Table D.81 Pregnant women counseled and tested for HIV . 386 Table D.82 HIV testing for prenuptial purposes . 387 Table D.83 HIV testing as a couple . 388 Table D.84 Male circumcision . 389 Table D.85 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 390 Table D.86 Prevalence of medical injections . 391 Table D.87 Comprehensive knowledge about AIDS and of a source of condoms among youth . 392 Table D.88 Age at first sexual intercourse among youth . 393 Table D.89 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 394 Table D.90.1 Multiple sexual partners in the past 12 months among young people: Women . 395 Table D.90.2 Multiple sexual partners in the past 12 months among young people: Men . 396 Table D.91 HIV prevalence . 397 Table D.92 HIV prevalence among young people . 398 Table D.93 HIV prevalence among couples . 399 Table D.94 Control over women's cash earnings and relative magnitude of women's cash earnings . 400 Table D.95 Control over men's cash earnings . 401 Table D.96 Women's participation in decision making by background characteristics . 402 Table D.97.1 Attitude toward wife beating: Women . 403 Table D.97.2 Attitude toward wife beating: Men . 404 Foreword • xvii FOREWORD The government of Rwanda conducted the 2010 Rwanda Demographic and Health Survey (RDHS) to gather up-to-date information for monitoring progress on healthcare programs and policies in Rwanda, including the Economic Development and Poverty Reduction Strategy (EDPRS), the Millennium Development Goals (MDGs), and Vision 2020. The 2010 RDHS is a follow-up to the 1992, 2000, 2005, and 2007-08 RDHS surveys. Each survey provides data on background characteristics of the respondents, demographic and health indicators, household health expenditures, and domestic violence. The target groups in these surveys were women age 15-49 and men age 15-59 who were randomly selected from households across the country. Information about children age 5 and under also was collected, including the weight and height of the children. The 2010 RDHS was implemented by the National Institute of Statistics of Rwanda (NISR) in partnership with the Ministry of Health (MOH). The Rwanda Biomedical Centre, through its Institute of HIV/AIDS, Disease Prevention and Control (RBC-IHDPC), and in particular the HIV, malaria, and National Reference Laboratory (NRL) divisions, collaborated on several aspects of the survey, especially the biomarkers. ICF International provided technical assistance in implementation of the survey. Funding for the 2010 RDHS was provided by the government of Rwanda, the United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), World Vision, and the Global Fund (through the malaria division of RBC-IHDPC), Results of the 2010 RDHS indicate key changes have occurred in the demographic and health indicators. The survey shows a decrease in maternal and infant mortality rates compared with the surveys of 2005 and 2007-08, an increase in prenatal care visits and utilization of delivery services, an increase in utilization of modern contraceptives, and higher immunization coverage for children age 12-23 months. The total fertility rate has steadily declined. Despite these improvements, the nutritional status of children and mothers remains a big challenge as it has decreased slightly. This report is therefore an important tool that addresses health concerns and informs policy makers and other stakeholders of priority areas for intervention. It provides only a snapshot, however, and it is our sincere hope that researchers will deepen our understanding of the topics covered in the survey by undertaking further analysis of the RDHS datasets. Last but not least, we urge all stakeholders, both individuals and organizations, to play an active role in using this valuable information to contribute to a better quality of life for the Rwandan population. Dr. Agnes BINAGWAHO Minister of Health Acknowledgments • xix ACKNOWLEDGMENTS This report has been prepared with the participation of a large number of individuals and organizations. We would like to express our gratitude to all of them. First, we sincerely acknowledge the men and women who generously agreed to respond to all questions they were asked. The response rate was high, both for men (98.7 percent) and women (99.1 percent). We also present our sincere thanks to the Ministry of Local Government and to the local government authorities for their assistance and contributions to the smooth implementation of the survey. We would like to express our sincere appreciation to the Ministry of Health for close collaboration with the National Institute of Statistics of Rwanda (NISR) during preparation and implementation of the survey. The orientation and directives given by the steering committee members are appreciated. We also express our gratitude to many international organizations for their vital financial assistance. Contributions from the United States Agency for International Development (USAID), United Nations Children’s Fund (UNICEF), Centers for Disease Control and Prevention/Global AIDS Program (CDC/GAP) (through the Rwanda Biomedical Center/Institute of HIV/AIDS Disease Prevention and Control (RBC/IHDPC)/Malaria division), Global Fund, United Nations Population Fund (UNFPA), and World Vision were of immense importance to the effective accomplishment of the survey. We express our profound gratitude to the team from ICF International, and in particular to Dr. Rathavuth Hong and his colleagues. Their technical assistance contributed to the success of the survey. We thank the technical staff from the Ministry of Health (MOH), RBC-IHDPC, and NISR, for their unfailing participation in all activities of the survey, which were coordinated by RUTERANA Baudouin and his assistants, MUKANYONGA Apolline and MUCHOCHORI Kanobana. We congratulate the supervisors, cartographers, team leaders, field editors, enumerators, and office editors for their valuable efforts, and also the drivers who were able to overcome the fatigue and other challenges inherent in this type of operation. We also thank the data processing team led by TWAGIRAMUKIZA Augustin for its contribution to the completion of the survey. We appreciate the valuable support provided by administrative and financial departments of the NISR. Their interventions allowed this RDHS to be carried out smoothly and under good conditions. Summary of Findings • xxi SUMMARY OF FINDINGS The 2010 Rwanda Demographic and Health Survey (RDHS) is designed to provide data for monitoring the population and health situation in Rwanda. The 2010 RDHS is the fifth Demographic and Health Survey to be conducted in Rwanda. The objective of the survey is to provide up-to-date information on fertility, family planning, childhood mortality, nutrition, maternal and child health, domestic violence, malaria, maternal mortality, awareness and behavior regarding HIV/AIDS, HIV prevalence, malaria prevalence, and anemia prevalence. A nationally representative sample of 13,671 women, age 15–49 from 12,540 surveyed households, and 6,329 men, age 15–59 from half of these households, were interviewed. This represents a response rate of 99 percent for women and 99 percent for men. The sample provides estimates at the national and provincial levels. Household composition: The survey results show that Rwandan households consist of an average of 4.4 people. Forty-five percent of the household members are children under age 15. Housing conditions: Housing conditions vary greatly based on residence. Nearly half (45 percent) of urban households have electricity compared with only 4 percent of rural households. Almost all (90 percent) households in urban areas have access to an improved water source; this compares with 71 percent of households in rural areas. Overall, 58 percent of households use an improved, unshared toilet facility. One in four households has a non-improved toilet facility. Ownership of goods: Currently, 63 percent of Rwandan households own a radio, and 40 percent have a mobile phone. Nearly one-third of urban households have a television compared with 2 percent of rural households. Fifteen percent of households own a bicycle, but only 1 percent of households own a car or truck. Rural households are most likely to own agricultural land (82 percent). Education of survey respondents: Sixteen percent of Rwandan women and 10 percent of Rwandan men have had no formal education; 16 percent of women and 21 percent of men have gone to secondary school or beyond. Urban residents and those living in the City of Kigali have the highest level of education. Overall, 77 percent of women and 82 percent of men are literate. FERTILITY AND ITS DETERMINANTS Total Fertility Rate: Fertility in Rwanda has declined over the past two decades. Currently, women in Rwanda have an average of 4.6 children, down from 6.1 in 2005. Fertility varies by residence. Women in urban areas have 3.4 children on average, compared with 4.8 children per woman in rural areas. Fertility also varies with mother’s education and economic status. Women who have no education have nearly twice as many children as women with secondary or higher education (5.4 versus 3.0 children per woman). Fertility increases as the wealth of the respondent’s household decreases. The poorest women, on average, have two children more than women who live in the wealthiest households (5.4 versus 3.4 children per woman). Teenage fertility: According to the 2010 RDHS, 6 percent of young women age 15–19 have already begun childbearing: 5 percent are mothers, and an additional 1 percent of them are pregnant with their first child. Young motherhood is slightly more common in rural areas than in urban areas. Young women with no education are more than six times as likely to have started childbearing by age 19 compared with those who have secondary and higher education (25 percent versus 4 percent). Age at first birth: The median age at first birth for all women age 25–49 is 22.4. Women living in urban areas have their first birth slightly later than women living in rural areas. Age at first birth increases with education and wealth. xxii • Summary of Findings Age at first marriage: Seventeen percent of women in Rwanda are married by age 18, compared with just 3 percent of men. The median age at first marriage is 21.4 for women age 25–49; men age 25–59 marry later, at a median age of 24.9. Age at marriage greatly increases with education; women with more than secondary education get married three and a half years later than those with no education (median age of 23.6 years versus 20.1 years for women age 25–49). Age at first sexual intercourse: Twenty-one percent of women and 16 percent of men age 25–49 were sexually active by age 18. Three percent of women and men have had sex by age 15. Women start sexual activity about a year earlier than men (median age of 20.7 years for women age 25–49 and 21.6 years for men age 25–59). Desired family size: Rwandan women and men want about three children, on average. Women’s ideal family size is similar regardless of residence, province, or wealth. Women with secondary education and higher desire fewer children than women with no education (2.9 percent versus 3.8 percent). FAMILY PLANNING Knowledge of family planning: Knowledge of family planning methods in Rwanda is universal; all women and men age 15–49 know at least one modern method of family planning. The most commonly known methods are injectables, male condoms, and the pill. Current use of family planning: More than four in ten married women (45 percent) currently use a modern method of family planning. Another 6 percent are using a traditional method. Injectables (26 percent), the pill (7 percent), and implants (6 percent) are the most commonly used methods. Similarly, sexually- active unmarried women are equally as likely to use family planning—four in ten (40 percent) are using a modern method, with 18 percent using injectables and 12 percent using male condoms. Use of modern family planning varies little by residence. However, use does vary by province. Modern contraceptive use ranges from a low of 36 percent among married women in West province to a high of 57 percent in North province. Modern contraceptive use increases with education and wealth. Over half (52 percent) of married women with secondary education and higher use modern methods compared with 37 percent of women with no education. NEED FOR FAMILY PLANNING Desire to delay or stop childbearing: Fifty-two percent of currently married Rwandan women want no more children. Another 36 percent want to wait at least two years before their next birth. These women are potential users of family planning. Unmet need for family planning: Unmet need for family planning is defined as the percentage of married women who want to space their next birth or stop childbearing entirely but who are not currently using contraception. The 2010 RDHS reveals that 19 percent of married women have an unmet need for family planning—10 percent of women have a need for spacing births and 9 percent have a need for limiting births. Unmet need is highest among the poorest women and those with no education. West and East provinces have the highest unmet need for family planning: 25 percent and 20 percent, respectively. MATERNAL HEALTH Antenatal care: Almost all (98 percent) Rwandan women receive some antenatal care (ANC) from a skilled provider, most commonly from a nurse or medical assistant (94 percent). Thirty-eight percent of women had an antenatal care visit by the time of their fourth month of pregnancy, as recommended. Thirty- five percent received the recommended four or more ANC visits. Seventy-three percent of women took iron supplements during pregnancy; 39 percent took intestinal parasite drugs. Seven in ten women were informed of signs of pregnancy complications during an ANC visit. Seventy-nine percent of women’s most recent births were protected against neonatal tetanus. Delivery and postnatal care: Over two-thirds (69 percent) of Rwandan births occur in health facilities, primarily in public sector facilities. Home births are twice as common in rural areas (31 percent) as in urban areas (16 percent). Summary of Findings • xxiii Sixty-nine percent of births are assisted by a skilled provider (doctor, clinical officer, nurse, or midwife). Another 16 percent are assisted by untrained relatives or friends and another 10 percent are unassisted. Postnatal care helps prevent complications after childbirth. Only 18 percent of women received a postnatal checkup within two days of delivery. The majority of women (80 percent) did not have a postnatal checkup. CHILD HEALTH Vaccination coverage: Ninety percent of Rwandan children age 12–23 months have received all recommended vaccines—one dose each of BCG and measles, and three doses each of pentavalent (DPT- HepB-Hib) and polio. Less than 1 percent of children did not receive any of the recommended vaccines. Vaccination coverage is slightly higher in urban areas than in rural areas (93 percent versus 90 percent). There is some variation in vaccination coverage by province, ranging from only 81 percent in West province to 96 percent in City of Kigali province. Coverage increases with a mother’s education; 97 percent of children whose mothers have secondary education and higher were fully vaccinated compared with 87 percent of children whose mothers have no education. Vaccination coverage has continued to increase gradually in the past five years. Childhood illnesses: In the two weeks before the survey, four percent of children under 5 were ill with cough and rapid breathing, symptoms of an acute respiratory infection (ARI). Of these children, 50 percent were taken to a health facility or provider. During the two weeks before the survey, 13 percent of Rwandan children under age 5 had diarrhea. The rate was highest among children 12–23 months (25 percent) and 6–11 months (22 percent). Thirty-seven percent of children with diarrhea were taken to a health provider. Children with diarrhea should drink more fluids, particularly through oral rehydration salts (ORS). Nearly one in two children with diarrhea was treated with ORS or increased fluids. However, one in four children received no treatment (from a medical professional or at home) at all. NUTRITION STATUS Breastfeeding and complementary feeding: Breastfeeding is very common in Rwanda, with 99 percent of children having been breastfed at some point in time. The World Health Organization (WHO) recommends that children receive nothing but breast milk (exclusive breastfeeding) for the first six months of life. Over eight in ten children under 6 months in Rwanda are being exclusively breastfed. Infants should not be given water, juices, other milks, or complementary foods until age 6 months, yet 11 percent of Rwandan infants under 6 months receive complementary foods. On average, children breastfeed until age 29 months and are exclusively breastfed for 5.3 months. Complementary foods should be introduced when a child is 6 months old to reduce the risk of malnutrition. In Rwanda, 61 percent of children age 6–8 months begin eating complementary foods. Anemia: About four in ten children are classified as having anemia, most of whom have mild anemia. Anemia has decreased from 52 percent of children in the 2005 RDHS to 38 percent of children in 2010. Seventeen percent of women are anemic, most of whom are mildly anemic. Anemia is higher among pregnant women (20 percent) than among nonpregnant women (17 percent). Mild anemia is the most common form of anemia among both groups of women. Children’s nutritional status: According to the survey, 44 percent of children under age 5 are stunted or too short for their age. This indicates chronic malnutrition. Stunting is most common among children age 18–23 months (55 percent). Stunting is least common among children of more educated mothers and those from wealthier families. Wasting (too thin for height), which is a sign of acute malnutrition, is far less common (only 3 percent). Eleven percent of Rwandan children are underweight or too thin for their age. Women’s nutritional status: Few Rwandan women are too thin (7 percent), and 16 percent of women are overweight or obese. Overweight and obesity is higher in urban areas than in rural areas (25 percent compared with 15 percent) and increases with age, education, and wealth. Women in the City of Kigali are most likely to be overweight or obese (30 percent). xxiv • Summary of Findings Vitamin A and iron supplementation: In the 24 hours before the survey, 73 percent of children age 6–23 months ate food, fruits, and vegetables rich in vitamin A. Ninety-three percent of children age 6–59 months received a vitamin A supplement in the six months prior to the survey. Over half (52 percent) of women received a vitamin A supplement postpartum. Vitamin A supplementation has increased since 2005, when 84 percent of children age 6–59 months received a vitamin A supplement in the six months prior to the survey and 34 percent of pregnant women received a vitamin A supplement postpartum. Only 1 percent of women took iron tablets or syrup for at least 90 days during their last pregnancy to prevent anemia and other complications. MALARIA Malaria prevalence: There has been remarkable progress in the decline of malaria prevalence in Rwanda, which has decreased by half since 2007–08; from 2.6 percent to 1.4 percent among children age 6–59 months and from 1.4 percent to 0.7 percent among women age 15–49. Household ownership of mosquito nets: In Rwanda, 82 percent of households have at least one long lasting, insecticide-treated mosquito net (LLIN). LLIN ownership is highest in East province (90 percent) and lowest in North province (70 percent). LLIN ownership in Rwanda has increased by nearly 50 percent in the past few years. Use of mosquito nets by children and women: Overall, 70 percent of children under 5 and 72 percent of pregnant women slept under an LLIN the night before the survey. This LLIN use shows about a 25 percent increase from use reported in the 2007–08 RDHS. INFANT AND CHILD MORTALITY Childhood mortality levels are decreasing in Rwanda. Currently, infant mortality is 50 deaths per 1,000 live births for the five-year period before the survey compared with 73 deaths for the five-to-nine- year period before the survey. Under 5 mortality levels have also decreased from 133 deaths per 1,000 live births to 76. Mortality rates differ slightly by province. The under 5 mortality rate for the ten-year period before the survey ranges from 79 deaths per 1,000 live births in the City of Kigali to 125 deaths in the East province. Under-5 mortality differs dramatically by a mother’s level of education. Children born to a mother who has a secondary education or higher are markedly less likely to die before their fifth birthday than children whose mothers have received no education (63 and 125 deaths per 1,000 live births, respectively). MATERNAL MORTALITY The maternal mortality ratio (MMR) remains high in Rwanda. According to the 2010 RDHS, the MMR is 476 deaths per 100,000 live births. The 95 percent confidence interval for the 2010 maternal mortality ratio ranges from 393 to 581 deaths per 100,000 live births. This rate has declined considerably in the past 10 years, from 1,071 deaths per 100,000 live births in the 2000 RDHS and 750 deaths per 100,000 live births in the 2005 RDHS. DOMESTIC VIOLENCE Two in five women (41 percent) reported that they have suffered from physical violence at least once since they were 15 years old. One in five women (22 percent) had suffered from sexual violence sometime in the past. Most often, it is the husband or partner who is responsible for the violence, whether physical or sexual. STI AND HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIORS Knowledge: Seventy-nine percent of women and 74 percent of men age 15–49 know that the risk of HIV infection can be reduced by using condoms and limiting sex to one faithful, uninfected partner. This knowledge varies by province, from 68 percent of women in the West province to 89 percent of women in the City of Kigali. Eighty-nine percent of women and 84 percent of men know that HIV can be transmitted by breastfeeding and that the risk of mother-to-child transmission can be reduced by taking drugs during pregnancy. Multiple and concurrent sexual partners: Less than 1 percent of women and 4 percent of men age Summary of Findings • xxv 15–49 report that they had sex with two or more partners in the past 12 months. Over one in four of these women and men report using a condom at last sexual intercourse. Among the women who had two or more partners in the past 12 months, almost two-thirds (63 percent) had overlapping (concurrent) sexual partnerships. Concurrent sexual partnerships may increase the risk of HIV transmission because they allow the virus to pass quickly through multiple individuals. Nearly 8 in 10 men who had two or more partners in the past 12 months had concurrent sexual partnerships. HIV testing: HIV testing is increasing rapidly in Rwanda. Currently, 76 percent of women and 69 percent of men have ever been tested and received their test results. Among young women and men age 15–24, 59 percent of women and 49 percent of men have ever been tested and received the results. Nearly 9 in 10 women (88 percent) who were pregnant in the two years before the survey received HIV counseling, were offered and accepted an HIV test, and received their test results. HIV testing during antenatal care is slightly more common in urban areas (93 percent) than in rural areas (88 percent). HIV PREVALENCE HIV prevalence: The 2010 RDHS included HIV testing of over 6,900 women age 15–49 and over 6,300 men age 15–59. Ninety-nine percent of women and 98 percent of men agreed to be tested for HIV. There has been essentially no change in Rwanda’s HIV prevalence since 2005. According to the 2010 RDHS, HIV prevalence is 3.0 percent for women and men age 15–49, compared with 3.0 percent in the 2005 RDHS. In Rwanda, HIV prevalence is 3.7 percent for women and 2.2 percent for men. HIV prevalence is three times as high in urban areas (7.1 percent) as in rural areas (2.3 percent). HIV estimates vary by age, with HIV prevalence highest among women age 35–39 and men age 40–44. HIV prevalence is highest in the City of Kigali where 7.3 percent of adults age 15–49 are HIV-positive. HIV prevalence is fairly uniform throughout the rest of Rwanda and ranges from 2.1 percent to 2.5 percent. HIV prevalence is particularly high among widows and those who are divorced or separated; 16.6 percent of widows are HIV-positive. CHILD LABOR Nearly 9 of 10 children (88 percent) age 5–14 in households worked in a week prior to the survey, either for their own household or for somebody else. Nearly 8 percent of children worked for someone who was not a member of the household: 2 percent for paid work and 5 percent for unpaid work. Eighty-three percent of children age 5–14 fetched water or collected fire wood for household use, 10 percent performed other family work, and 63 percent helped with household chores for 28 or more hours in a week. HEALTH INSURANCE On average, 78 percent of households have health insurance, an increase from 68 percent in 2007–08. Nearly all insured households (98 percent) are with Mutual Health Insurance. Other insurors are La Rwandaise d’Assurance Maladie (RAMA), Military Medical Insurance (MMI), and private insurance, which are commonly reported by households in urban areas, in the city of Kigali, and in the highest wealth quintile. At the individual level, 67 percent of women and 71 percent of men are insured. The majority of those insured individuals are covered by Mutual Health Insurance. xxvi • Map of Rwanda Introduction • 1 INTRODUCTION 1 1.1 COUNTRY PROFILE 1.1.1 Geography he country of Rwanda is situated in central Africa, immediately south of the equator between latitude 1°4' and 2°51' S and longitude 28°63' and 30°54' E. It has a surface area of 26,338 square kilometers and 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, where the highest peak, Mount Karisimbi, 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 1,500-2,000 meters. The 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 is below 1,500 meters. Because of its elevation, Rwanda enjoys a temperate, sub-equatorial climate with average yearly temperatures around 18.5°C. The average annual rainfall is 1,250 millimeters, which occurs over two rainy seasons of differing lengths that alternate 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 are generally cooler and wetter, with an average temperature of 16°C and an average rainfall 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 1,000 to 1,300 millimeters of rain per year, while rainfall on the eastern plateau, where the 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. Rwanda has a dense network of rivers and streams, which drain into the Congo River on the western slope of the Congo-Nile Divide, and into the Nile River 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. Deforestation caused mainly by 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. T 2 • Introduction Rwanda is divided into 4 geographically-based provinces—North, South, East, and West—and the City of Kigali, with the provinces being further subdivided into 30 districts, 416 sectors, 2,148 cells, and 14,837 villages (Imidugudu). 1.1.2 Economy In Rwanda, regular efforts have been made to develop the service sector and to stimulate investment in the industrial sector. These efforts are now bearing positive results, as the service sector has contributed more than the agricultural sector to the economy in recent years. Although the agricultural sector appears to have been overtaken by the service sector, it still employs many Rwandans. According to the 2002 General Population and Housing Census (RGPH) more than 8 of 10 people are employed in agriculture, including 81 percent of men and 93 percent of women (NISR, 2005). However, the agricultural sector faces major problems, including production 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, population resettlement and labor quality improvements focus on specialized training, mainly for women. Efforts are also under way to regionalize crops and to fully expand the use of farming techniques (MAAR, 2004). In 2010, the tertiary sector accounted for the largest share of Rwanda’s gross domestic product (GDP) at 47 percent, followed by the primary sector at 32 percent, the secondary sector at 15 percent, and the reminder at 6 percent were from Financial Intermediation Services Indirectly Measured (FISIM) and taxes. Nevertheless, agricultural production rose by 5 percent from 2009, to 2010. This rise is due to the increase in production of food crops (5 percent) and export crops (14 percent), which recovered from a decrease of 15 percent in 2009. In 2010, industry value added grew by 8 percent, while mining exports registered a decrease for the second consecutive year—11 percent in 2010, compared with 18 percent in 2009. Manufacturing increased by 9 percent; electricity, gas, and water increased by 15 percent; and construction grew by 9 percent. At the same time, services value added increased by 10 percent in 2010 as a result of 9 percent growth in transport, storage, and communication; 8 percent growth in wholesale and retail trade; and 24 percent growth in finance and insurance, after a recovery from a decrease of 4 percent in 2009. In 2010, the private final consumption expenditure was 83 percent of GDP, and the government final consumption expenditure was 15.8 percent of GDP. The level of investment (gross capital formation) was estimated at 21 percent of GDP, reflecting high levels of construction activity and imports of capital equipment. The imports were provisionally estimated to have increased by 12 percent at constant prices. These figures imply an increase of 8 percent in private final consumption expenditure compared to that in 2009. Exports grew by 20 percent after a decrease of 25 percent in 2009. The per capita GDP at constant 2001 prices was FRW 326,160 in 2010, compared with FRW 314,080 in 2009. Data from the 2005 Rwanda Demographic and Health Survey (RDHS) showed that 86 percent of women were working in agriculture, compared with 62 percent of men. In addition, 14 percent of men and 4 percent of women worked as unskilled labor. Results from the 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS) showed that in urban areas, 59 percent of the households fell 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 fell in the lowest (poorest) wealth quintile, compared with 18 percent in rural areas. Finally, because of the failure of most development strategies that had been 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 Introduction • 3 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 According to a 2009 population projection, the country would grow to 10,412,820 inhabitants in 2010. The population of Rwanda increased steadily and rapidly, from 4,831,527 to 7,157,551 in 1991 and to 8,128,553 inhabitants in 2002. The increase was, essentially, due to rapid population growth. The 2002 RGPH census estimated the natural growth rate at 2.6 percent and the fertility rate at 5.9. The rate of increase declined significantly, to 1.2 percent, between 1991 and 2002. The decline, which resulted from the deaths of more than one million people in the Genocide of the Tutsis, compares with a 3.1 percent decline between 1978 and 1991. Population density is high across the country and has increased steadily to 395 inhabitants per square kilometer in 2010, as compared with 321 in 2002, 283 in 1991, and 191 in 1978. The population is essentially young, with 42.3 percent of all Rwandans under the age of 15. In sex-disaggregated terms, the 2009 population projections show women to be in the majority (51.7 percent), while men make up 48.3 percent of the population. The illiteracy rate in Rwanda declined between 2000 and 2005. Between the two RDHS surveys, the rate decreased from 34 percent to 30 percent of women, and from 24 percent to 23 percent of men. This means that 70 percent of women know how to read and write and are considered literate compared with 77percent of men. The educational level of Rwandans is also low. Twenty-three percent of women and 17 percent of men have had no education, while nearly 67 percent of women and 70 percent of men have only a primary school education. About 11 percent of men and 9 percent of women have reached the secondary school level, while those with education beyond the secondary level make up only 1 percent of the population. Under Article 33 of Rwanda’s current constitution (adopted in 2003), “Freedom of thought, opinion, conscience, religion, worship, and the public manifestation thereof is guaranteed by the State in accordance with conditions determined by law.” Although numerous religions are practiced in Rwanda, Christianity is by far the dominant faith, practiced in some form by 93 percent of the resident population, the majority of whom are Catholic. In the 1991 census, 90 percent of the resident population identified themselves as Christian. Their number has increased at the expense of those who profess no religion, who have declined from 6.8 percent in 1991 to 3.6 percent in 2002. The number of Muslim adherents has risen slightly, from 1.2 percent of the population in the 1991 census to 1.8 percent in 2002. Nearly all Rwandans speak the same language, Kinyarwanda, which is the country’s official first language, followed by English and French. Kiswahili, the third most common foreign language, is generally spoken in urban areas and in the provinces bordering othercountries where this language is widely spoken, such as the Democratic Republic of the Congo and Tanzania. 1.1.4 Population Policy Out of concern for improving the country’s quality of life, the Rwandan government has developed strategies 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 change that would result in lower fertility rates, other elements were included in the plan, such as 4 • Introduction 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. Following the 1994 genocide, population problems were seen in a new light, with emphasis on both quality of life and population growth. A new national population policy was developed and issued to all development partners in 2003. This policy emphasizes quality of life by providing objectives and strategies to affect both demographic (fertility, mortality) and socioeconomic factors. The policy advocates slow population growth, managed sustainability of natural resources, food safety, access to primary and secondary education for all children (with a focus on technical and vocational instruction as well as information technology), good governance, equal opportunity, and participation in development by both men and women. 1.1.5 Public Health Policy Since the 1980s, the Government of Rwanda has implemented primary health care as the key strategy for improving the health of the population. In February 1995, the Ministry of Health began making reforms in the health sector in accord with the Lusaka declaration; these reforms were later adopted by the Government of National Unity in March 1996. The new policy was based upon three main strategies: (1) the decentralization of the health system using the health district as the basic operational unit; (2) the development of the primary health care system through its eight core components; and (3) the reinforcement of community participation in the management and financing of services. The Ministry of Health has laid down seven major policy objectives for the health sector: (1) to improve the availability of human resources; (2) to improve the availability of quality drugs, vaccines, and consumables; (3) to expand geographical accessibility to health services; (4) to improve financial accessibility to health services; (5) to improve the quality of services in the control of disease; (6) to strengthen national referral hospitals and research and treatment institutions; and (7) to strengthen institutional capacity. Characteristics of Rwandan health care services include decentralization, continuous provision, flexibility, and efficiency. The health system consists of three levels of provision: central, intermediary, and peripheral. The central level includes the central directorates and programs of the Ministry of Health and the national referral hospitals. It elaborates policies and strategies, ensures monitoring and evaluation, and regulates the health sector. It organizes and coordinates the intermediary (at the provincial level) and peripheral (at the health district level) levels of the health system and provides them with administrative, technical, and logistical support. 1.2 OBJECTIVES AND METHODOLOGY OF THE SURVEY The 2010 Rwanda Demographic and Health Survey (RDHS) is the fifth of its kind, following surveys conducted in 1992, 2000, 2005, and the 2007-08 Rwanda Interim DHS (RIDHS). The 2010 RDHS was carried out by the National Institute of Statistics of Rwanda (NISR) and the Ministry of Health (MoH). ICF International provided technical assistance to the project through the MEASURE Demographic and Health Surveys program (MEASURE DHS). The survey was funded by the Government of Rwanda, the United States Agency for International Development (USAID), the United Nations Children’s Fund (UNICEF), the Centers for Disease Control and Prevention/Global AIDS Program (CDC/GAP), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United Nations Population Fund (UNFPA), and World Vision. The survey was conducted on a representative sample of women age 15-49 and men age 15-59. Introduction • 5 1.2.1 Objectives of the Survey The main objectives of the 2010 RDHS were to: • Collect data at the national level to facilitate calculation of essential demographic rates, especially rates for fertility and infant and child mortality, and to analyze the direct and indirect factors that determine levels and trends in fertility and child mortality • Measure the levels of knowledge of contraceptive practices among women • Collect data on family health, including immunization practices; prevalence and treatment of diarrhea, acute upper respiratory infections, fever and/or convulsions among children under age 5; antenatal visits; and assistance at delivery • Collect data on the prevention and treatment of malaria, in particular the possession and use of bed nets among children under 5 and among women and pregnant women • Collect data on nutritional practices of children, including breastfeeding • Collect data on the knowledge and attitudes of men and women concerning sexually transmitted infections (STIs) and acquired immune deficiency syndrome (AIDS) and evaluate recent behavioral changes with regard to condom use • Collect data for the estimation of adult mortality and maternal mortality at the national level • Take anthropometric measurements in half of surveyed households in order to evaluate the nutritional status of children, men, and women • Conduct confidential testing for malaria parasitemia using Rapid Diagnostic Testing in half of the surveyed households and anonymous blood smear testing at the National Reference Laboratory • Collect dried blood spots (from finger pricks) for anonymous HIV testing at the National Reference Laboratory in half of surveyed households • Measure hemoglobin level (by finger prick) for anemia of surveyed respondents in half of surveyed households. 1.2.2 Questionnaires Three questionnaires were used for the 2010 RDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. They are based on questionnaires developed by the worldwide Demographic and Health Surveys (DHS) program and on questionnaires used during the 2005 RDHS and 2007-08 RIDHS surveys. To reflect relevant issues in population and health in Rwanda, the questionnaires were adapted during a series of technical meetings with various stakeholders from government ministries and agencies, non- governmental organizations, and international donors. The questionnaires were translated from English and French into Kinyarwanda. The Household Questionnaire was used to list all the usual members and visitors in the selected households as well as to identify women and men eligible for individual interviews. Basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of household. For children under 18, survival status of the parents was determined. The Household Questionnaire also collected information on the following: 6 • Introduction • Dwelling characteristics • Utilization of health services and health expenditures for recent illness and injury • Possession of iodized salt • Possession and utilization of mosquito nets • Height and weight of women and children • Hemoglobin measurement of women and children • Blood collection from women and children for rapid test and laboratory testing of malaria • Blood collection from women and men for laboratory testing for HIV The Woman’s Questionnaire was used to collect information from all women age 15-49 and was organized by the following sections: • Respondent background characteristics • Reproduction, including a complete birth and death history of respondents’ children and information on abortion • Contraception • Pregnancy and postnatal care • Child’s immunization, health, and nutrition • Marriage and sexual activity • Fertility preferences • Husband’s background and woman’s work • HIV/AIDS and other sexually transmitted infections • Other health issues • Adult mortality • Relationship in the household The Man’s Questionnaire was administered to all men age 15-59 living in every other household in the RDHS sample. The Man’s Questionnaire collected much of the same information as the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health or nutrition. An instruction manual was also developed to support standardized data collection. All data collection instruments were pretested in June-July 2010. The observations and experiences gathered from the pretest were used to improve the instruments for the main survey data collection. Introduction • 7 1.2.3 Sample Design The sample for the 2010 RDHS was designed to provide population and health indicator estimates for the country as a whole and for urban and rural areas in particular. Survey estimates are also reported for the provinces (South, West, North, and East) and for the City of Kigali. The results presented in this report show key indicators that correspond to these provinces and the City of Kigali. A representative sample of 12,792 households was selected for the 2010 RDHS. The sample was selected in two stages. In the first stage, 492 villages (also known as clusters or enumeration areas) were selected with probability proportional to the village size. The village size is the number of households residing in the village. Then, a complete mapping and listing of all households existing in the selected villages was conducted. The resulting lists of households served as the sampling frame for the second stage of sample selection. Households were systematically selected from those lists for participation in the survey. All women age 15-49 who were either permanent residents of the household or visitors present in the household on the night before the survey were eligible to be interviewed. In addition, in a subsample of half of all households selected for the survey, all men age 15-59 were eligible to be interviewed if they were either permanent residents or visitors present in the household on the night before the survey. 1.2.4 Sample Coverage All of the 492 clusters selected for the sample were surveyed for the 2010 RDHS. A total of 12,792 households were selected, of which 12,570 households were identified and occupied at the time of the survey. Among these households, 12,540 completed the Household Questionnaire, yielding a response rate of nearly 100 percent (Table 1.1). In the 12,540 households surveyed, 13,790 women age 15-49 were identified as being eligible for the individual interview; interviews were completed with 13,671 of these women, yielding a response rate of 99.1 percent. Male interviews were conducted in every second household. A total of 6,414 men age 15-59 were identified in the subsample of households. Of these 6,414 men, 6,329 completed the individual interviews, yielding a response rate of 98.7 percent. The response rates were slightly higher in rural areas for men, while for women they were almost the same in rural and urban areas. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Rwanda 2010 Result Residence Total Urban Rural Household interviews Households selected 2,054 10,738 12,792 Households occupied 2,014 10,556 12,570 Households interviewed 2,009 10,531 12,540 Household response rate1 99.8 99.8 99.8 Interviews with women age 15-49 Number of eligible women 2,386 11,404 13,790 Number of eligible women interviewed 2,367 11,304 13,671 Eligible women response rate2 99.2 99.1 99.1 Interviews with men age 15-59 Number of eligible men 1,178 5,236 6,414 Number of eligible men interviewed 1,156 5,173 6,329 Eligible men response rate2 98.1 98.8 98.7 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents 8 • Introduction 1.2.5 Hemoglobin, Malaria and HIV Testing In a subsample of one-half of all households selected for the Man’s Questionnaire, blood specimens were collected from women age 15-49 and children age 6-59 months for measurement of hemoglobin in the field. The specimens were tested for malaria in the field using the Rapid Diagnostic Test (RDT) and tested for malaria in the lab using the microscopic method. Additionally, in the same one-half of all households, blood specimens for HIV testing were collected from all women age 15-49 and men age 15-59 who consented to the test. The protocol for the blood specimen collection and testing for HIV was reviewed and approved by the Rwanda National Ethics Committee, the Institutional Review Board of ICF International, and the Centers for Disease Control and Prevention (CDC) in Atlanta. Hemoglobin testing The 2010 RDHS included anemia testing of children age 6 to 59 months and women age 15-49 in the same one-half of households that were selected for interviews of men. A consent statement was read to the eligible respondent or to the parent or responsible adult for children and young women age 15-17. This statement explained the purpose of the test, informed respondents that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Anemia levels were determined by measuring the level of hemoglobin in the blood (a decreased concentration of hemoglobin characterizes anemia). The concentration of hemoglobin in the blood was measured in the field using the HemoCue system. A special-purpose photometer is used to determine hemoglobin levels. A capillary blood sample is taken from the palm side of the end of a finger, punctured with a sterile, non-reusable, self- retractable lancet. The blood drop is collected in a HemoCue microcuvette, which serves as a measuring tool, and placed in the HemoCue photometer to determine the level of hemoglobin in the blood. A pamphlet was given to each respondent, explaining symptoms of anemia, prevention methods, and the individual results of the hemoglobin measurement of the respondent and any children for whom the respondent gave permission to be measured. Each person whose hemoglobin level was lower than the recommended cutoff point (testing severely anemic) was advised to visit a health facility for follow-up with a health professional. Malaria testing Malaria diagnostic tests, including a rapid diagnostic test (RDT) and a test using thick and thin blood smears, were given to eligible women and children in the 2010 RDHS. For the RDT for malaria, a drop of blood was obtained by a prick at the end of the finger, usually at the same time as anemia testing. First Response test kits were used according to manufacturer recommendations. The results of the malaria RDT were recorded in the Household Questionnaire, which allows linking with the characteristics of the respondents. Results from the RDTs were used to diagnose malaria and guide treatment of parasitemic children during the survey. The parent or guardian of children with a positive RDT was provided with written results, and children were given Coartem® for treatment, according to the current malaria treatment guidelines. Women with a positive RDT were referred to the nearest health center for treatment. Thin and thick blood smears were also collected from participants who agreed to malaria testing. Blood slides were stained with Giemsa stain prepared by the laboratory in advance of the fieldwork. Parasite densities were calculated by counting the number of asexual stage parasites/200 white blood cells (WBCs), assuming 6,000 WBCs/dl of blood. Blood smears were considered negative if no parasites were found after counting 200 fields. An informed consent form was read to the eligible person or parent/responsible adult of the child or teenager age 15-18 . 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, informing the individual taking the test or those responsible for children that the results would be communicated immediately after the test. For each eligible woman and child, a Introduction • 9 slide with thick and thin blood smears was prepared, transmitted, and stored for microscopic examination of malaria parasites at the NRL. HIV testing Women and men who were interviewed in the subsample of households selected for the men’s survey of the 2010 RDHS were asked to voluntarily provide blood for HIV testing. The HIV test is anonymous; that is, the results of the test were not linked to survey data until the individual respondent’s identifying information was destroyed by NISR. Therefore, the respondents’ HIV test results can never be linked to identifying data. For women and men willing to be tested, drops of blood were drawn and dried on filter paper. Only an identification number (barcode) drawn at random was assigned to each specimen. Since no information containing personal identification accompanied the samples, it was not possible to inform the respondents of the result of their test. Analysis of the samples for HIV was carried out at the NRL. Information and educational brochures about HIV/AIDS prevention and the existing Voluntary Counseling and Testing (VCT) and Prevention of Mother-To-Child Transmission (PMTCT) sites were distributed to all households selected for the survey, whether these households were selected for testing or not. These brochures were prepared by TRAC-Plus and the Commission Nationale de Lutte contre le Sida (CNLS) or National AIDS Control Commission in close collaboration with NISR and were adapted to the population surveyed. 1.2.6 Training and Fieldwork Data Collection Thirty-eight women and men were trained from June 14-July 2, 2010, in the administration of the RDHS survey instruments, anthropometric measurement, hemoglobin testing, malaria testing, and blood drawing for HIV testing. Seven days of fieldwork were followed by one day of interviewer debriefing and examination. Pre-test fieldwork was conducted in 230 households in two rural and two urban villages outside of City of Kigali. The majority of pretest participants attended the main training and served as field editors and team leaders for the main survey. NISR recruited and trained 117 participants, and at the end of the training it retained 105 to work as field personnel. The main training was conducted from August 16-September 14, 2010. The training consisted of instruction regarding interviewing techniques and field procedures, a detailed review of items on the questionnaires followed by tests, instruction and practice in weighing and measuring children, and mock interviews and role plays among participants in the classroom. Each of the fifteen data collection teams included a team leader, a field editor, three female interviewers, one male interviewer, and one biomarker staff member. The main fieldwork was launched immediately upon the conclusion of field staff training. Each of the 15 teams was assigned to 2 of the 30 districts. Fieldwork supervision was conducted by NISR, NRL, and ICF International through regular visits to teams to review their work and monitor data quality. The UNICEF team also regularly visited the teams in the field. Additional contact between the central office and the teams was maintained through cell phones. Fieldwork was conducted from September 26, 2010, to March 10, 2011. Questionnaires and blood samples were regularly delivered to NISR headquarters. 1.2.7 Data Processing Data entry began on November 1, 2010, almost one month after the survey was launched in the field. Data were entered by a team of 15 data processing personnel recruited and trained for this task. They were assisted during these operations by 4 data verification and codification officers and 2 receptionists. Completed questionnaires were periodically brought in from the field to the National Institute of Statistics headquarters, where assigned agents checked them and coded the open-ended questions. Next, the questionnaires were sent to the data entry facility and the blood samples (DBS and malaria slides) were sent to the NRL to be screened for HIV. Data were entered using 10 • Introduction CSPro, a program developed jointly by the United States Census Bureau, the ORC Macro MEASURE DHS+ program, and Serpro S.A. Processing the data concurrently with data collection allowed for regular monitoring of teams’ performance and data quality. Field check tables were regularly generated during data processing to check various data quality parameters. As a result, feedback was given on a regular basis, encouraging teams to continue their high quality work and to correct areas in need of improvement. Feedback was individually tailored to each team. Data entry, which included 100 percent double entry to minimize keying error and data editing, was completed on April 21, 2011. Data cleaning and finalization was completed on May 27, 2011. Household Characteristics • 11 HOUSEHOLD CHARACTERISTICS 2 household is a person or a group of persons, related or unrelated, who live together and share common cooking and eating arrangements. This chapter summarizes demographic and socioeconomic characteristics of the people who live in the households of Rwanda, which were sampled during the 2010 RDHS. Characteristics of the housing structure were also provided by responses to the survey. The Household Questionnaire collected the basic demographic and socioeconomic information (e.g., age, sex, educational attainment, and current school attendance) for all usual residents and visitors who slept in the household the night preceding the interview. This method of data collection allowed for analysis of the results for either the de jure population (usual residents) or the de facto population (persons in the household at the time of the survey). The Household Questionnaire also collected information on housing facilities, including dwelling characteristics, source of water supply, sanitation facilities, and household assets. The information in this chapter is intended to facilitate interpretation of key demographic, socioeconomic, and health indices presented later in the report. It will also assist in the assessment of the representativeness of the survey sample. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.1 shows the distribution by age and sex of the household population surveyed, according to urban- rural residence. The household survey involved 55,292 respondents, of which 47,868, or 87 percent, live in rural areas and 7,424, or 13 percent, live in urban areas. Table 2.1 shows the distribution by age and sex of the household population, which is further depicted by the age pyramid in Figure 2.1. The age pyramid 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. Although the base of the pyramid (age 0-4 years) remains large, the figure shows a decline in fertility as well as an decrease in mortality between age group 0-4 and age group 5-9. In addition, there is a notable gender imbalance: there are 89 males for every 100 females in the total population. Further analysis reveals structural elements peculiar to the Rwandan population. First, the number of men drops off significantly in age groups 10-14, 15-19, 20-24, 30-34, and 35-39. The same trend occurs among females in age groups 10-14, 15-19, and 30-34. The fall in the population at age 10-14 might relate to high child mortality in previous years. And the drop in the age 15-19 group can be directly attributed to the low birth rate during 1994 and the adjacent years, while the fall observed at age group 30-39 might be the effect of Tutsi genocide in 1994. The overrepresentation of women overall is noted in both urban and rural areas. In rural areas, males predominate among those age 0 to 19. From age 20-24 on, however, the situation begins to reverse, and the gap narrows. In urban areas, males age 0 to 14 and 25 to 34 outnumber females, but beginning at age group 35-39, the proportion of females exceeds that of males. A 12 • 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 2010 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 15.2 13.2 14.2 17.9 15.3 16.5 17.5 15.0 16.2 5-9 13.1 12.7 12.9 17.1 14.6 15.8 16.6 14.3 15.4 10-14 11.5 10.8 11.1 14.1 12.7 13.3 13.7 12.4 13.0 15-19 11.3 11.8 11.6 10.9 9.9 10.4 10.9 10.1 10.5 20-24 11.2 12.1 11.7 8.3 8.7 8.5 8.7 9.2 9.0 25-29 12.3 10.5 11.4 7.3 8.3 7.8 8.0 8.5 8.3 30-34 7.9 7.1 7.5 5.3 6.1 5.7 5.6 6.2 6.0 35-39 4.6 5.7 5.2 3.9 4.9 4.4 4.0 5.0 4.5 40-44 3.8 3.7 3.7 3.2 4.0 3.7 3.3 4.0 3.7 45-49 3.1 3.4 3.2 3.0 3.9 3.5 3.0 3.8 3.4 50-54 2.2 2.9 2.6 3.0 3.5 3.3 2.9 3.4 3.2 55-59 1.4 2.2 1.8 2.1 2.6 2.3 2.0 2.5 2.3 60-64 0.8 1.2 1.0 1.3 1.7 1.5 1.2 1.7 1.5 65-69 0.5 0.7 0.6 0.8 1.3 1.1 0.8 1.2 1.0 70-74 0.5 0.8 0.7 0.8 1.1 1.0 0.7 1.1 0.9 75-79 0.2 0.6 0.4 0.4 0.7 0.5 0.4 0.7 0.5 80 + 0.4 0.5 0.4 0.6 0.9 0.7 0.6 0.8 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,628 3,796 7,424 22,400 25,468 47,868 26,029 29,264 55,292 Figure 2.1 Population Pyramid Rwanda 2010 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 <5 A ge g ro u p 0246810 0 2 4 6 8 10 Percent MaleFemale 2.2 HOUSEHOLD COMPOSITION Table 2.2 shows that the mean size of a Rwandan household is 4.4 persons. It has decreased slightly compared with the mean household size of 4.6 found in the 2005 RDHS. This mean size varies somewhat by residence: 4.5 in rural areas compares with 4.2 in urban areas. In addition, Table 2.2 shows that 67 percent of Rwandan households are headed by men. Female-headed households represent 33 percent of households, 34 percent in rural areas and nearly the same percentage in urban areas (31 percent). The percentage of female-headed Household Characteristics • 13 households increased significantly between 1992 and 2000, from 21 percent to 36 percent, but dropped slightly again in 2005 (to 34 percent) and in 2010 (to 33 percent). Approximately half of all households contain three to five people, 26 percent hold six to eight people, and 4 percent have nine or more people. One-person households make up only 7 percent of the population. Table 2.2 shows also that 30 percent of households at the national level are lived in by foster and/or orphaned children. The data show that 22 percent of households are lived in by foster children, 16 percent are lived in by single orphans, and 3 percent are lived in by double orphans. No significant variation exists between rural and urban areas. Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18 years of age, according to residence, Rwanda 2010 Characteristic Residence Total Urban Rural Household headship Male 69.5 66.3 66.7 Female 30.5 33.7 33.3 Total 100.0 100.0 100.0 Number of usual members 0 0.0 0.0 0.0 1 10.4 6.1 6.7 2 14.6 11.5 11.9 3 17.4 18.3 18.2 4 17.6 18.4 18.3 5 13.3 16.3 15.8 6 11.0 12.5 12.3 7 7.9 8.5 8.4 8 3.6 5.0 4.8 9+ 4.3 3.5 3.6 Total 100.0 100.0 100.0 Mean size of households 4.2 4.5 4.4 Percentage of households with orphans and foster children under 18 years of age Foster children1 22.1 21.8 21.9 Double orphans 3.8 3.2 3.3 Single orphans2 16.1 15.7 15.8 Foster and/or orphan children 29.5 30.3 30.2 Number of households 1,759 10,781 12,540 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 years of age living in households with neither their mother nor their father present. 2 Includes children with one dead parent and an unknown survival status of the other parent. 2.3 EDUCATIONAL ATTAINMENT Tables 2.3.1 and 2.3.2 show the percent distribution of the female and male household populations according to highest level of education attained, by age, residence, province, and household wealth quintile. Educational attainment is important; it contributes to improved living conditions not only for the individual household but for society as a whole. Reproductive behavior, the use of contraception, health habits, school attendance of household members, and habits relating to hygiene and nutrition are all influenced by educational attainment. The data in these two tables show that 22 percent of women and 16 percent of men have never attended school. A comparison of these proportions to those of the previous survey shows slight improvement: at the time of 14 • Household Characteristics the previous survey, 29 percent of women and 22 percent of men had no education at all. The percentage of men and women who have completed primary school is nearly identical (9 percent for women and 10 percent for men,). As educational attainment increases, the percentage of both women and men in these categories decreases: only 2 percent of women and men have completed secondary level education; about 1 percent of women and 2 percent of men have attended any education beyond the secondary level. The percentage of men and women who have completed primary school has increased, from 7 percent to 9 percent for women and from 8 percent to 10 percent for men. However, when compared with previous generations, the figures show significant gains. The proportion of women with no education at all has dropped from 79 percent for women age 65 and over to 2 percent for girls between the ages of 10 and 14. The percentage for males in these age groups has dropped from 43 percent to 2 percent. In addition, the gap in educational attainment between the sexes seems to be narrowing in the younger age groups. The percentage of women who have completed primary school is the same or close to that of men for all ages up to age 34: 14 percent of women between the ages of 15 and 19, compared with 12 percent of men said they had completed primary school. This narrowing of the gap in educational attainment between the sexes is also seen at the secondary level: between the ages of 20 and 24, 5 percent of women and 6 percent of men and have completed secondary school. This contrasts with the common situation of previous generations, when the proportion of women between the ages of 55 and 59 who had completed primary school was 5 percent, while that of men was 17 percent. Table 2.3.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Rwanda 2010 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 28.4 71.4 0.1 0.1 0.0 0.0 0.0 100.0 3,328 0.0 10-14 1.8 94.2 2.6 1.4 0.0 0.0 0.0 100.0 3,637 2.3 15-19 3.3 59.2 13.5 23.3 0.6 0.1 0.0 100.0 2,966 4.4 20-24 9.5 55.6 13.0 14.5 5.4 1.8 0.1 100.0 2,687 3.9 25-29 14.4 57.8 16.9 4.4 3.8 2.5 0.1 100.0 2,502 3.4 30-34 16.5 50.1 21.6 5.9 3.3 2.4 0.1 100.0 1,827 4.2 35-39 20.9 55.8 8.9 9.2 2.8 2.2 0.2 100.0 1,458 4.2 40-44 32.7 46.1 9.1 9.2 1.4 1.2 0.3 100.0 1,168 3.0 45-49 39.9 41.2 11.6 5.4 1.0 0.7 0.2 100.0 1,111 1.4 50-54 49.6 33.4 12.6 3.1 0.6 0.3 0.5 100.0 996 0.0 55-59 61.4 29.7 4.5 2.7 0.5 0.4 0.9 100.0 737 0.0 60-64 63.3 28.4 5.5 1.7 0.6 0.0 0.4 100.0 485 0.0 65+ 79.4 18.0 1.0 0.8 0.0 0.0 0.7 100.0 1,104 0.0 Residence Urban 12.3 51.3 10.0 16.0 5.6 4.6 0.2 100.0 3,178 4.0 Rural 23.5 59.9 9.2 5.8 1.1 0.3 0.2 100.0 20,834 2.1 Province Kigali City 10.6 47.5 10.3 17.7 7.6 6.2 0.1 100.0 2,281 4.5 South 20.9 61.3 9.5 6.7 1.0 0.2 0.3 100.0 5,841 2.3 West 25.5 59.4 8.0 5.5 0.9 0.6 0.2 100.0 5,979 1.9 North 23.6 58.0 11.1 6.0 1.1 0.2 0.1 100.0 4,239 2.1 East 23.0 60.6 8.6 6.1 1.3 0.3 0.1 100.0 5,672 2.0 Wealth quintile Lowest 32.2 60.1 5.3 2.0 0.0 0.0 0.4 100.0 4,876 1.0 Second 27.2 61.1 8.1 3.5 0.1 0.0 0.0 100.0 4,884 1.5 Middle 22.5 62.1 10.1 4.9 0.3 0.0 0.1 100.0 4,756 2.2 Fourth 17.8 61.4 12.1 7.8 0.8 0.0 0.1 100.0 4,775 2.8 Highest 10.0 49.0 10.9 18.1 7.2 4.5 0.2 100.0 4,719 4.4 Total 22.0 58.8 9.3 7.2 1.7 0.9 0.2 100.0 24,012 2.3 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level By residence, the data show significant gaps in educational attainment. In rural areas, 24 percent of women and 17 percent of men have no education at all, compared with 9 percent of men and 12 percent of women in urban areas. Household Characteristics • 15 There are also variations among provinces. The City of Kigali has the lowest percentage of residents with no education (11 percent of women and 7 percent of men). Conversely, the West province has the highest percentage of women and men with no education (26 percent and 17 percent, respectively). As the level of educational attainment increases, the gaps between the provinces widen: in the City of Kigali, 8 percent of women have completed secondary school compared with 1 percent in other provinces; among men, 7 percent have completed secondary school, compared with 1 to 2 percent in other provinces. Results by wealth quintile show that the proportions of both women and men with no education decrease as the household standard of living increases. Conversely, educational level increases with household wealth. In households in the highest wealth quintile, there is practically no gap in educational attainment between women and men up to the secondary level. Table 2.3.2 Educational attainment of the male household population Percent distribution of the de facto male household populations, age 6 and over, by highest level of schooling attended or completed and median years completed, according to background characteristics, Rwanda 2010 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 31.1 68.6 0.1 0.1 0.0 0.0 0.1 100.0 3,456 0.0 10-14 2.3 94.0 2.2 1.5 0.0 0.0 0.0 100.0 3,572 2.1 15-19 3.4 62.1 11.6 22.4 0.3 0.2 0.1 100.0 2,850 4.2 20-24 7.2 54.2 12.4 17.8 5.8 2.6 0.1 100.0 2,271 4.3 25-29 11.9 53.8 18.7 6.5 4.8 4.2 0.0 100.0 2,085 3.9 30-34 12.0 48.4 21.5 10.0 3.8 4.2 0.2 100.0 1,468 4.8 35-39 18.8 52.1 10.3 11.2 4.1 3.5 0.1 100.0 1,032 4.5 40-44 19.2 50.6 10.3 13.6 2.3 3.8 0.1 100.0 861 4.7 45-49 30.5 43.8 13.4 8.5 2.2 1.5 0.1 100.0 786 2.5 50-54 28.8 44.0 18.2 4.4 2.4 1.3 0.9 100.0 759 2.5 55-59 29.5 45.9 16.5 5.1 1.7 1.3 0.0 100.0 519 2.4 60-64 37.1 40.5 14.0 5.0 1.8 0.6 0.9 100.0 318 2.0 65+ 43.4 47.1 5.9 2.2 0.6 0.6 0.2 100.0 632 0.7 Residence Urban 9.0 52.2 11.5 15.7 5.4 6.1 0.1 100.0 2,988 4.2 Rural 16.7 64.2 9.4 7.4 1.4 0.8 0.1 100.0 17,622 2.3 Province Kigali City 6.6 49.7 12.1 17.8 6.8 7.0 0.0 100.0 2,197 4.7 South 17.0 64.9 9.0 6.9 1.3 0.5 0.4 100.0 4,977 2.2 West 17.3 64.5 7.6 7.6 1.7 1.3 0.1 100.0 4,889 2.3 North 15.4 62.0 11.9 8.2 1.2 1.1 0.1 100.0 3,469 2.6 East 16.4 64.1 10.0 7.4 1.3 0.7 0.0 100.0 5,078 2.3 Wealth quintile Lowest 25.0 66.1 5.3 3.0 0.1 0.1 0.4 100.0 3,640 1.2 Second 20.0 67.6 7.4 4.6 0.3 0.1 0.1 100.0 3,883 1.8 Middle 15.9 67.0 10.5 5.9 0.5 0.2 0.1 100.0 4,150 2.3 Fourth 12.3 63.1 12.5 10.1 1.6 0.4 0.0 100.0 4,317 3.0 Highest 7.0 50.8 12.0 17.3 6.6 6.1 0.2 100.0 4,621 4.5 Total 15.5 62.5 9.7 8.6 2.0 1.5 0.1 100.0 20,610 2.6 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level 2.4 SCHOOL ATTENDANCE The level of school attendance of children is the primary indicator of a population’s access to education and, indirectly, its socioeconomic development. The 2010 RDHS asked questions concerning school attendance of all respondents between age 5 and age 24. Table 2.4 shows net attendance ratios (NARs) and gross attendance ratios (GARs) by sex and level of schooling, according to background characteristics. Net school attendance ratios (NARs) measure school attendance in children who have reached the official school age. At the primary school level, the NAR is the percentage of the primary-school-age population (age 7-12 in Rwanda) that actually attend primary school. Table 2.4 shows that the primary level NAR is 87 percent for 16 • Household Characteristics Rwanda, which means that almost 9 in 10 children between the ages of 7 and 12 attend primary school. The ratio is higher for urban areas than for rural areas (92 percent compared with 87 percent). In the provinces, the ratio ranges from a high of 92 percent in the City of Kigali to a low of 85 percent in West province. Household wealth also affects the NAR, which is 80 percent at the lowest wealth quintile compared with 94 percent at the highest one. The NAR is also higher for female children (88 percent) than for male children (86 percent), regardless of urban/rural residence, and household wealth quintile. At the secondary level, where children are age 13-18, the NAR is much lower (15 percent), which means that only 15 percent of the official secondary-school-age population actually attends school. There is practically no gap between the sexes (16 percent for women compared with 15 percent for men). However, the NAR is much higher in urban areas than in rural areas (27 percent compared with 13 percent), which may explain the major gap between the City of Kigali, with a NAR of 27 percent, and the other provinces, whose NARs are between 12 percent (East) and 15 percent (North, West, South provinces). Table 2.4 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Rwanda 2010 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 90.3 93.6 91.9 1.04 138.1 140.1 139.1 1.01 Rural 85.7 87.7 86.7 1.02 141.1 146.4 143.7 1.04 Province Kigali City 91.4 92.8 92.1 1.01 133.7 138.2 135.7 1.03 South 85.0 88.9 86.8 1.05 141.8 151.0 146.3 1.06 West 84.8 85.5 85.2 1.01 138.0 141.7 139.9 1.03 North 90.6 91.5 91.1 1.01 144.5 148.6 146.6 1.03 East 84.3 87.4 85.8 1.04 142.3 144.6 143.4 1.02 Wealth quintile Lowest 78.0 81.3 79.7 1.04 126.6 134.4 130.5 1.06 Second 84.5 86.9 85.7 1.03 141.0 144.5 142.8 1.02 Middle 87.3 88.5 87.9 1.01 143.3 153.2 148.0 1.07 Fourth 88.5 91.3 90.0 1.03 147.9 150.6 149.3 1.02 Highest 93.4 94.6 94.0 1.01 145.1 145.9 145.5 1.01 Total 86.3 88.4 87.3 1.02 140.7 145.6 143.2 1.03 SECONDARY SCHOOL Residence Urban 23.7 29.0 26.5 1.23 47.8 48.8 48.3 1.02 Rural 13.3 13.6 13.4 1.02 24.7 22.0 23.3 0.89 Province Kigali City 25.4 28.1 26.9 1.10 55.0 53.1 53.9 0.96 South 13.1 15.8 14.5 1.20 24.1 24.4 24.3 1.02 West 15.2 14.4 14.8 0.95 27.0 22.3 24.5 0.82 North 14.6 14.9 14.8 1.02 28.1 23.8 25.9 0.85 East 12.1 12.2 12.2 1.01 23.1 20.7 21.9 0.90 Wealth quintile Lowest 7.3 5.8 6.5 0.80 13.0 8.8 10.8 0.68 Second 10.0 8.8 9.3 0.88 17.6 14.0 15.8 0.80 Middle 11.7 11.3 11.5 0.97 22.1 18.0 20.0 0.81 Fourth 15.7 18.0 16.8 1.15 32.0 28.4 30.2 0.89 Highest 25.6 32.2 28.9 1.26 47.8 55.0 51.4 1.15 Total 14.6 15.6 15.1 1.07 27.6 25.5 26.5 0.93 1 The NAR for primary school is the percentage of the primary-school-age (7-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (13-18 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. Table 2.4 also shows gross school attendance ratios (GARs). Unlike a NAR, a GAR measures school attendance in young people regardless of age. The GAR for primary school is the total number of students of any Household Characteristics • 17 age attending primary school, expressed as a percentage of the official primary-school-age population, which is 7 to 12 years in Rwanda. Unless there are significant numbers of over-age and under-age students at a given level of schooling, the GAR is always higher than the NAR and can, in some cases, exceed 100 percent. In Rwanda, the GAR is 143 percent, which means that a significant proportion of children who do not fall into the official primary- school-age category are attending school at the primary level. These are likely to be children over age 12 or under age 7 who are attending primary school; in fact, a program exists to reintegrate children who drop out of primary school for any reason. In addition, the GAR is higher for girls than for boys (146 percent for girls compared with 141 percent for boys). Moreover, there is practically no difference by residence. At the secondary level, the GAR is low. Slightly more than one-quarter (27) percent of all children of official secondary school age actually attend school. The GAR is low either because official secondary-school-age children are still in primary school or because they have dropped out of secondary school or have never attended at all. The ratio is nearly the same for girls (26) and boys (28). However, it is higher in urban areas than in rural areas (48 percent compared with 23 percent). Similarly, there is a pronounced difference by province: at 54 percent, the GAR for the City of Kigali stands out from the other provinces, while the GAR varies from a maximum of 22 percent in the East province to 26 percent in the North province. The GAR increases with wealth; 11 percent of the potential student population from the lowest quintile actually attends secondary school while this proportion is 51 percent for students in the highest quintile. The table also includes a third school attendance indicator: the gender parity index (GPI), which is the ratio of the GAR for females to the GAR for males. The narrower the gap between the sexes, the closer the index is to 1. The GPI for primary school is just above 1, and this situation doesn’t change with residence, province, or wealth quintile. This indicates an absence of disparity between the sexes. The GPI for secondary school is below one (0.93); this indicates that girls are educationally disadvantaged at this level. The inequality is more pronounced in rural areas, which have a GPI of only 0.89 compared with 1.02 in urban areas. South province, has the highest GPI (1.02) while in other provinces it varies from 0.96 (City of Kigali) to 0.85 (North province). The GPI changes with the wealth quintile, rising from 0.68 percent at the lowest quintile to 1.15 at the highest quintile. 18 • Household Characteristics Figure 2.2 Age-Specific Attendance Rates of the De Facto Population Age 5-24 RDHS 2010 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Female Male Note: Figure shows percentage of the de facto household population age 5-24 attending school Figure 2.2 shows that the rate of school attendance, which is low at age 5, begins to increase at age 6, and reaches a high level between age 10 and age 13. This period corresponds to the primary school years for children in classes four, five, and six in the normal primary cycle and to the first year of the secondary school. After age 13, the age at the beginning of the secondary cycle, the curve declines steadily, reaching its lowest point at age 24. It should also be noted that the proportion of women who attend is higher than the proportion of men who attend between age 5 and age 11 while the situation balances at ages 12-14 before reversing itself up to age 24. The only exception to this pattern is at age 15 paradoxically, where we observe an imbalance in favor of female students. 2.5 HOUSEHOLD CONDITIONS The household survey gathered information on certain household characteristics: access to electricity, source of drinking water, type of toilet facilities, and type of roofing and flooring materials. Information was also sought concerning ownership of various modern durable goods, including a radio, television, mobile phone, refrigerator, bicycle, motorcycle/scooter, and car/truck. Household characteristics and ownership of durable goods were used to evaluate the socioeconomic conditions of the household. 2.5.1 Household Drinking Water With respect to drinking water, Table 2.5 shows, at the national level, that 74 percent of households have access to an improved source of drinking water. The most common source of drinking water used by the households is protected spring water, which accounts for 38 percent of usage, followed by public tap/standpipe (26 percent). Only 5 percent of the households have running water in their dwelling or courtyard. Overall, 25 percent of households use unimproved sources of water, which is considered unhealthy. For example, 14 percent of the households use an unprotected spring as a water source, which increases the household members’ risk of contracting diarrhea and other waterborne diseases. Household Characteristics • 19 With respect to residence, it appears that the urban households are more likely than rural households to use improved drinking water (90 percent versus 71 percent). In contrast, 28 percent of the households in rural areas use unsafe drinking water compared with 7 percent of those in urban areas. In fact, 16 percent of these households collect their water from an unprotected spring, 10 percent collect it from surface water, and 2 percent retrieve it from an unprotected dug well. Regarding the time spent in roundtrip travel to obtain drinking water, Table 2.5 shows that slightly more than half of the households (53 percent) spend 30 minutes or longer to get to the water source, and only two in five (42 percent) spend fewer than 30 minutes. Only 5 percent of the households have water on their premises. In rural areas, 57 percent of the households take 30 minutes or longer to get to the source of water compared with 29 percent in urban areas. The proportions of households who spend fewer than 30 minutes to get to a source of water vary slightly between rural areas (41 percent) and urban areas (45 percent). With respect to the treatment of water prior to drinking, 49 percent of the households use an appropriate treatment method prior to drinking, while the other 51 percent of the households do not treat their water prior to drinking. Table 2.5 Household drinking water Percent distribution of households and de jure population by source, time to collect, and treatment of drinking water, according to residence, Rwanda 2010 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 89.6 71.2 73.8 89.1 71.2 73.6 Piped water into dwelling/yard/plot 23.7 1.4 4.5 26.7 1.6 5.0 Public tap/standpipe 40.9 23.4 25.8 38.1 23.6 25.5 Tubewell/borehole 1.6 2.4 2.3 1.5 2.3 2.2 Protected dug well 2.1 2.5 2.5 2.1 2.4 2.4 Protected spring 20.3 41.0 38.1 20.0 40.8 38.0 Rainwater 0.2 0.4 0.4 0.0 0.4 0.4 Bottled water 0.8 0.0 0.1 0.7 0.0 0.1 Nonimproved source 7.0 27.9 25.0 7.4 27.9 25.2 Unprotected dug well 0.5 2.2 1.9 0.6 2.1 1.9 Unprotected spring 5.4 15.7 14.2 5.6 15.9 14.5 Tanker truck/cart with drum 0.0 0.0 0.0 0.0 0.0 0.0 Surface water 1.1 10.0 8.8 1.2 10.0 8.8 Other 3.4 0.9 1.2 3.4 0.8 1.2 Missing 0.0 0.1 0.0 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 89.6 71.2 73.8 89.1 71.2 73.6 Time to obtain drinking water (round trip) Water on premises 25.7 2.1 5.4 28.9 2.2 5.8 Less than 30 minutes 45.4 40.9 41.5 42.7 40.0 40.4 30 minutes or longer 28.7 56.7 52.8 28.1 57.6 53.6 Don’t know/missing 0.3 0.3 0.3 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 58.5 38.4 41.2 61.8 39.1 42.2 Bleach/chlorine added 10.3 13.7 13.2 11.2 14.6 14.2 Strained through cloth 1.5 0.5 0.6 1.6 0.5 0.6 Ceramic, sand or other filter 0.8 0.2 0.3 1.2 0.2 0.3 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 Other 1.4 1.3 1.4 1.1 1.3 1.3 No treatment 34.7 53.1 50.5 31.2 51.9 49.1 Percentage using an appropriate treatment method2 64.4 46.1 48.7 68.1 47.3 50.1 Number 1,759 10,781 12,540 7,444 48,142 55,585 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 20 • Household Characteristics The most common method to treat water prior to drinking is boiling (41 percent), followed by adding bleach/chlorine (13 percent). Households in rural areas are more likely to drink untreated water (53 percent) than those in urban areas (35 percent). 2.5.2 Household Sanitation Facilities With respect to type of toilet facilities, Table 2.6 shows 55 percent of households have access to an improved/not shared pit latrine with slab (57 percent in rural areas compared with 42 percent in urban areas). Less than 1 percent of households have flush/pour flush to piped sewer system. Data show also that 2 percent of households use a ventilated improved pit (VIP) latrine. However, 16 percent of households use an improved pit latrine with slab but share the latrine with other households (37 percent in urban areas compared with 13 percent in rural areas). One in four households (26 percent) uses an unimproved facility, with the majority (23 percent) using a pit latrine without a slab/open pit. Twenty-five percent of rural households and 11 percent of urban households use this type of facility. It should be noted that, about 1 percent of households in Rwanda have no sanitation facility at all (1 percent in urban areas and 2 percent in rural areas). The number of households with no facility has decreased from 5 percent since 2005. The pit latrine with or without a slab is the most common sanitation facility in Rwanda. Table 2.6 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Rwanda 2010 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 3.1 0.1 0.6 3.6 0.2 0.6 Flush/pour flush to septic tank 0.3 0.0 0.1 0.3 0.0 0.1 Flush/pour flush to pit latrine 1.7 0.1 0.4 2.1 0.2 0.4 Ventilated improved pit (VIP) latrine 1.8 1.4 1.5 2.3 1.5 1.6 Pit latrine with slab 42.2 56.8 54.8 47.9 60.5 58.8 Composting toilet 0.1 0.4 0.4 0.1 0.4 0.3 Shared facility1 Flush/pour flush to piped sewer system 0.1 0.0 0.0 0.1 0.0 0.0 Flush/pour flush to septic tank 0.0 0.0 0.0 0.0 0.0 0.0 Flush/pour flush to pit latrine 0.0 0.0 0.0 0.0 0.0 0.0 Ventilated improved pit (VIP) latrine 1.2 0.3 0.4 1.0 0.2 0.3 Pit latrine with slab 36.7 12.8 16.1 30.5 10.3 13.0 Composting toilet 0.1 0.1 0.1 0.1 0.1 0.1 Nonimproved facility Flush/pour flush not to sewer/septic tank/pit latrine 0.3 0.4 0.4 0.4 0.4 0.4 Pit latrine without slab/open pit 10.7 25.1 23.0 10.1 24.4 22.5 Bucket 0.0 0.0 0.0 0.0 0.0 0.0 No facility/bush/field 0.9 1.5 1.4 0.8 1.2 1.1 Other 0.5 0.8 0.8 0.5 0.6 0.6 Missing 0.2 0.0 0.1 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,759 10,781 12,540 7,444 48,142 55,585 1 Shared facility of an otherwise improved type. 2.5.3 Households with Hand Washing Places Washing hands with water and soap before eating, while preparing food, and after leaving the toilet is a simple and inexpensive good practice that protects against many diseases. During the survey, the interviewers asked and observed each household to see if there were a place used for hand washing and if water and soap or some other cleansing agent was available. Table 2.7 shows that only 10 percent of the households have a place for hand washing. Among those households, one in five (21 percent) has water and soap for hand washing. Nearly one in four of them (23 percent) has water only, and in 3 percent of the households there is soap but no water. In urban areas, 13 percent of the households have a place for hand washing compared with 10 percent of the households in rural areas. In urban areas, 47 percent of households have soap and water available at a hand washing place, but only 15 percent of the rural Household Characteristics • 21 households have it available. A higher percentage of households in rural areas have no water, no soap, and no other cleansing agent available than do those in urban areas (58 percent compared with 26 percent). Among the provinces, 17 percent of the households in East province and 11 percent of the households in South province have a place for hand washing; however, in West province, only 4 percent of the households have such a place. Among households where a place for hand washing was observed, a high proportion of households in Kigali City (69 percent) have soap and water compared with only 9 percent of households in South province. A large proportion of the households in the other provinces have no water, soap, or other cleansing agent at a place for hand washing (68 percent in the South, 57 percent in the East, and 53 percent in North province) compared with the Kigali City (7 percent). The proportion of households with a place for hand washing increases with the level of wealth index; it rises from 8 percent among households in the lowest and second quintiles to 16 percent among those in the highest quintile. More than three quarters of households in the lowest wealth quintile (77 percent) have no water, soap, or other cleansing agent available at a place for hand washing. This same finding was observed in only 26 percent of the households in the highest quintile. Table 2.7 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap and other cleansing agents, Rwanda 2010 Background characteristics Among households where place for hand washing was observed Percentage of households where place for washing hands was observed Number of households Soap and water1 Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Missing Total Number of households with place for hand washing observed Residence Urban 12.7 1,759 47.3 22.0 4.2 0.5 25.7 0.4 100.0 224 Rural 10.0 10,781 14.9 23.5 2.8 0.1 58.0 0.7 100.0 1,083 Province Kigali City 9.7 1,284 69.0 20.2 3.0 0.0 7.0 0.7 100.0 125 South 10.6 3,136 9.1 18.2 4.9 0.0 67.5 0.3 100.0 334 West 4.2 2,967 20.6 35.7 2.3 0.0 39.9 1.6 100.0 126 North 9.3 2,120 18.6 22.6 4.6 1.0 53.2 0.0 100.0 197 East 17.3 3,033 16.8 24.4 1.4 0.0 56.5 0.9 100.0 525 Wealth quintile Lowest 7.9 2,838 5.0 13.4 2.7 0.5 77.1 1.3 100.0 224 Second 7.7 2,600 6.0 17.9 3.9 0.0 71.4 0.7 100.0 200 Middle 9.9 2,448 10.2 28.3 3.3 0.0 56.8 1.4 100.0 242 Fourth 11.9 2,287 14.7 30.6 3.3 0.3 51.0 0.0 100.0 271 Highest 15.6 2,367 48.6 23.4 2.2 0.0 25.5 0.2 100.0 370 Total 10.4 12,540 20.5 23.2 3.0 0.2 52.5 0.7 100.0 1,307 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only as well as those with soap and another cleansing agent 2.5.4 Household Characteristics The survey collected household information on access to electricity, type of flooring materials, number of sleeping rooms, places for cooking, types of cooking fuel, and presence of tobacco smoking inside the house. These characteristics and others are used to evaluate the socioeconomic and living conditions of the household. Table 2.8 shows that only 1 in 10 households in Rwanda has access to electricity. The situation has improved since 2005 when only 5 percent, or 1 in 20 households, had access to electricity. The results show large disparities between urban and rural areas. In rural areas, only 4 percent of households have electricity; which compares with 45 percent of households in urban areas. The type of material used for flooring is extremely important. Some materials propagate disease-causing germs and parasites. The large majority (81 percent) of floors in Rwandan houses are earth or sand. This proportion is higher in rural areas (87 percent) than in urban areas (43 percent). Sixteen percent of households have cement floors. However, this type of flooring is more commonly observed in urban than in rural areas (53 percent compared 22 • Household Characteristics with 11 percent). In 2005, 86 percent of the surveyed households’ floors were earth/sand and 13 percent were cement. Table 2.8 shows that 43 percent of households have two rooms for sleeping (44 percent in urban areas compared with 36 percent in rural areas). It should be noted that in about 1 in 4 households (26 percent) all household members sleep together in a single room. This proportion is more or less the same in both rural areas and urban areas (26 percent compared with 29 percent). More than half (52 percent) of the households cook their meals in a separate building. There is no significant difference between rural and urban areas (52 percent and 51 percent respectively). Nevertheless, 27 percent of the households cook in the same house that is used for sleeping (29 percent of rural households and 14 percent of urban households). Table 2.8 shows that, 77 percent of households use wood as cooking fuel. More rural households than urban households use wood as cooking fuel (83 percent compared with 36 percent). The second most common cooking fuel is straw/shrubs/grass, which is used by 12 percent. One in 10 households in Rwanda uses charcoal for cooking, including 50 percent of those in urban areas but only 3 percent in rural areas. Most of the households use a solid fuel such as coal/lignite, charcoal, wood, straw, shrubs, grass, agricultural crops, or animal dung for cooking (98 percent). There is no significant difference between rural and urban areas. Twenty-two percent of the households report that someone has smoked inside the house; in 20 percent of all households, this happens on a daily basis (21 percent in rural areas compared with 16 percent in urban areas). Table 2.8 Household characteristics Percent distribution of households by housing characteristics and percentage using solid fuel for cooking; and percentage distribution by frequency of smoking in the home, according to residence, Rwanda 2010 Housing characteristic Residence Urban Rural Total Electricity Yes 44.5 4.0 9.7 No 55.5 95.9 90.3 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Flooring material Earth, sand 42.5 87.3 81.0 Dung 0.5 0.8 0.8 Wood/planks 0.0 0.0 0.0 Ceramic tiles 2.9 0.1 0.5 Cement 52.8 10.5 16.4 Other 1.2 1.3 1.3 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Rooms used for sleeping One 29.2 25.8 26.2 Two 36.4 43.7 42.7 Three or more 34.1 30.0 30.6 Missing 0.3 0.5 0.4 Total 100.0 100.0 100.0 Place for cooking In the house 14.0 28.9 26.8 In a separate building 50.7 52.2 52.0 Outdoors 32.0 18.0 20.0 Other 0.2 0.0 0.1 Missing 3.1 0.9 1.2 Total 100.0 100.0 100.0 Continued… Household Characteristics • 23 Table 2.8—Continued Housing characteristic Residence Urban Rural Total Cooking fuel Electricity 0.1 0.0 0.0 LPG/natural gas/biogas 0.2 0.0 0.1 Kerosene 0.5 0.0 0.1 Charcoal 50.1 3.0 9.6 Wood 36.4 83.3 76.7 Straw/shrubs/grass 9.1 12.4 12.0 Agricultural crop 0.0 0.2 0.2 Animal dung 0.0 0.0 0.0 Other 0.4 0.1 0.2 No food cooked in household 3.1 0.9 1.2 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 95.6 98.9 98.4 Frequency of smoking in the home Daily 16.1 20.7 20.0 Weekly 1.4 2.0 1.9 Monthly 0.3 0.3 0.3 Less than monthly 0.2 0.1 0.1 Never 82.1 76.9 77.6 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Number 1,759 10,781 12,540 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 2.5.5 Household Possession of Durable Goods To evaluate households’ socioeconomic level, the survey gathered information on the possession of various household durable goods, the means of transportation used by household members, and ownership of agricultural land and livestock/farm animals. Table 2.9 shows that, overall, the most frequently owned household good is the radio (63 percent), which is more often reported by households in urban areas than in rural areas (76 percent compared with 60 percent). The proportion of households owning radios has increased significantly since 2005, when only 46 percent of households owned a radio. The second household effect is the mobile telephone (40 percent), which is found more often in urban households than in rural households (72 percent compared to 35 percent). Also the proportion of households owning a mobile telephone has significantly increased since 2005 when it was only 5 percent. In addition, in urban areas, 28 percent of households own a television, and 7 percent own a refrigerator; in rural areas, these goods are more or less nonexistent. Bicycles are used as a means of transportation in 16 percent of households in rural areas and in 11 percent of households in urban areas. Overall, 82 percent of households own agricultural land. The proportion varies significantly by urban-rural residence: 87 percent of rural households own agricultural land compared with 49 percent of urban households. Fifty-seven percent of households possess farm animals (61 percent of households in rural areas compared with 38 percent of those in urban areas). 24 • Household Characteristics Table 2.9 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Rwanda 2010 Possession Residence Urban Rural Total Household effects Radio 75.9 60.4 62.6 Television 27.6 1.6 5.3 Mobile telephone 71.8 35.1 40.3 Non-mobile telephone 1.4 0.1 0.3 Refrigerator 7.0 0.3 1.2 Means of transport Bicycle 11.0 15.9 15.2 Animal drawn cart 0.1 0.0 0.0 Motorcycle/scooter 2.6 0.9 1.1 Car/truck 4.8 0.2 0.8 Boat with a motor 0.0 0.0 0.0 Ownership of agricultural land 48.6 86.8 81.5 Ownership of farm animals1 37.7 60.6 57.4 Number 1,759 10,781 12,540 1 Cattle, cows, bulls, horses, donkeys, goats, sheep, or chickens 2.5.6 Household Wealth Quintile Table 2.10 shows the percent distribution of the de jure population by wealth quintile and Gini coefficient. The wealth index was developed on the basis of de jure population goods data, using principal components analysis. The information on household goods comes from responses to questions about ownership of certain durable goods (television, radio, car, mobile telephone, etc.) and questions about certain housing characteristics (access to electricity, source of drinking water, type of toilet facilities, type of flooring material, number of rooms used for sleeping, and type of cooking fuel. The index was developed using the following steps: • Each durable goods or housing characteristic was assigned a weight (score or coefficient) generated by principal components analysis. • The resulting scores for durable goods are standardized according to a normal distribution that assumes a mean of 0 and a standard deviation of 1 (Gwatkin et al., 2000). • Each household is assigned a score for each durable good, 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 (the poorest quintile) to 5 (the 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 in urban areas, 68 percent of the de jure population falls into the richest quintile, while in rural areas only 13 percent falls into this quintile. The proportion of rich households is highest in Kigali City (80 percent). Conversely, in urban areas, only 15 percent of households fall into the poorest quintile. In fact, the preceding tables showing ownership of durable goods, housing characteristics, and source of drinking water have already established that the population of Rwanda is generally poor. Table 2.6 confirms the previous results and explains the relative lack of variation among provinces. Household Characteristics • 25 Table 2.10 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini Coefficient, according to residence and province, Rwanda 2010 Residence/Province Wealth quintile Lowest Second Middle Fourth Highest Total Number of population Gini coefficient Residence Urban 15.0 2.7 3.7 11.0 67.6 100.0 7,444 18.8 Rural 20.8 22.7 22.5 21.4 12.6 100.0 48,142 5.2 Province Kigali City 2.2 2.1 5.9 9.6 80.2 100.0 5,459 12.7 South 32.5 21.9 18.3 15.3 12.1 100.0 13,534 8.1 West 23.2 25.5 21.6 17.1 12.7 100.0 13,624 6.0 North 18.5 23.2 25.0 21.6 11.7 100.0 9,413 4.1 East 12.6 17.6 22.4 30.7 16.8 100.0 13,555 5.6 Total 20.0 20.0 20.0 20.0 20.0 100.0 55,585 12.4 2.6 BIRTH REGISTRATION WITH CIVIL AUTHORITIES Registering a child with civil authorities establishes the child’s legal family ties and his or her right to a name and nationality prior to the age of majority. It confers on the child the right to be recognized by his or her parents and the right to state protection if his or her rights are abused by parents. It gives the child access to social assistance through the parents, including health insurance, and establishes family lineage. Registration is therefore an essential formality. Registration of a child with civil authorities, if performed correctly, also provides a reliable source of socio- demographic statistics. For this reason, the survey asked all children in each household whether the children had been registered with the civil authorities. Table 2.11 shows that 63 percent of the children have been registered with the civil authorities and 37 percent have not been registered. The percentage registered has dropped significantly since the 2005 survey when 82 percent were registered. Of those children who were registered with the civil authorities at the time of the survey, only 7 percent possess birth certificates. Those children who are age 2-4 are registered more often than those who are younger than age 2 (71 percent compared with 49 percent, respectively). Gender has little to do with whether or not the children are registered with the civil authorities. Also, level of household wealth does not seem to influence the prevalence of birth registration. Children in the fourth and middle wealth quintiles showed the highest levels of registration (67 percent and 65 percent respectively). There is some discrepancy by urban/rural residence because the rural areas show a higher percentage of birth registrations (64 percent compared with 60 percent in urban areas). Results by province show that households in the North and South provinces are the most likely to have declared their children with the civil authorities (79 percent and 66 percent, respectively). 26 • Household Characteristics Table 2.11 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Rwanda 2010 Background characteristic Children whose births are registered Percentage who had birth certificate Percentage who did not have birth certificate Percentage registered Number of children Age <2 6.2 43.1 49.3 3,210 2-4 6.8 64.2 71.0 5,760 Sex Male 6.8 56.8 63.6 4,578 Female 6.4 56.5 62.9 4,393 Residence Urban 8.2 52.2 60.4 1,052 Rural 6.4 57.2 63.6 7,918 Province Kigali City 5.5 52.9 58.5 826 South 8.0 57.5 65.5 2,185 West 8.4 52.6 60.9 2,239 North 7.7 71.4 79.2 1,386 East 3.3 52.2 55.6 2,335 Wealth quintile Lowest 5.6 52.8 58.4 2,086 Second 5.2 57.2 62.3 1,924 Middle 6.6 58.8 65.4 1,800 Fourth 6.8 60.3 67.1 1,668 Highest 9.5 54.7 64.2 1,492 Total 6.6 56.6 63.2 8,971 2.7 CHILDREN’S LIVING ARRANGEMENTS AND ORPHANHOOD Because the family is the primary safety net for children, any strategy aimed at protecting children must place a high priority on strengthening the family’s capacities to care for children. It is therefore essential to identify orphaned children and find out whether those who have one or both parents alive are living with either or both surviving parents. Table 2.12 presents these two types of information for children under age 18, according to background characteristics. The data show that 61 percent of Rwandan children under the age of 18 live with both their parents. This proportion declines steadily with age, from a high of 76 percent under age 2 and 70 percent at age 2 to age 4 years, to a low of 40 percent at age 15 to 17. The results show practically no difference, according to the child’s sex. The proportion of children living with their parents is higher in rural areas (62 percent) than in urban areas (57 percent). The lowest proportion of children living with both parents is in the South province (56 percent); the highest proportion is in the North province (64 percent). Twenty-three percent of children under age 18 live with their mother only, whether their father is alive (16 percent) or deceased (7 percent) and 2 percent live with their father only. Thirteen percent (13 percent) do not live with either parent. Overall, 13 percent of children under age 18 have lost one or both parents: 2 percent have lost both parents, 9 percent have lost their father, and 3 percent have lost their mother. Because a parent’s risk of dying increases with time, the proportion of children who have lost their father and/or mother increases significantly with the age of the child, from 1 percent at age less than 2 years, to 3 percent at age 2 to 4 years, and to 9 percent at age 5 to 9 years. This proportion jumps very high level among children age 10 to 14 (21 percent) and 15 to 17 (35 percent), largely due to the effects of the 1994 genocide. Household Characteristics • 27 Table 2.12 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Rwanda 2010 Background characteristic Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Percent- age not living with a biological parent Percent- age with one or both parents dead1 Number of children Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing information on father/ mother Age 0-4 72.3 19.0 1.9 0.8 0.2 4.4 0.2 0.2 0.1 0.9 100.0 4.9 2.6 8,971 <2 75.8 21.5 1.2 0.2 0.1 0.6 0.0 0.0 0.0 0.5 100.0 0.7 1.4 3,210 2-4 70.4 17.6 2.2 1.2 0.3 6.6 0.3 0.2 0.2 1.1 100.0 7.3 3.3 5,760 5-9 64.2 15.4 5.1 1.6 0.9 8.9 1.0 1.1 0.9 0.9 100.0 11.9 9.1 8,549 10-14 53.7 13.6 11.6 1.6 1.9 9.1 1.7 2.9 2.7 1.2 100.0 16.4 20.9 7,244 15-17 40.2 10.6 18.3 1.4 2.2 10.2 3.1 5.6 6.1 2.4 100.0 25.0 35.4 3,670 Sex Male 61.4 15.4 7.2 1.5 1.1 7.2 1.3 1.7 1.9 1.2 100.0 12.1 13.4 14,311 Female 60.6 15.5 7.6 1.1 1.1 8.3 1.0 2.0 1.7 1.2 100.0 13.0 13.5 14,121 Residence Urban 57.0 15.8 8.0 2.1 1.0 7.7 1.7 2.9 2.2 1.7 100.0 14.5 16.0 3,336 Rural 61.5 15.4 7.4 1.2 1.1 7.7 1.1 1.7 1.7 1.1 100.0 12.3 13.1 25,097 Province Kigali City 58.6 16.6 6.1 2.0 1.5 6.9 1.7 2.9 2.1 1.7 100.0 13.5 14.5 2,336 South 56.1 18.8 7.6 1.3 1.0 8.7 1.2 1.8 1.9 1.6 100.0 13.6 13.7 6,957 West 63.1 14.2 8.2 1.0 1.1 6.9 1.1 1.7 2.0 0.7 100.0 11.7 14.1 7,223 North 64.4 13.3 6.7 0.8 0.8 8.4 1.4 1.4 1.6 1.1 100.0 12.9 12.2 4,856 East 62.2 14.6 7.4 1.9 1.2 7.5 0.9 1.9 1.5 1.0 100.0 11.8 12.9 7,061 Wealth quintile Lowest 51.3 21.9 11.1 1.5 1.1 7.8 1.2 1.1 1.4 1.5 100.0 11.6 16.0 5,995 Second 58.4 17.5 8.7 0.9 1.2 7.5 1.1 1.5 2.1 1.1 100.0 12.2 14.6 5,913 Middle 66.0 12.8 6.8 1.2 1.1 7.2 1.1 1.4 1.3 1.1 100.0 11.0 11.8 5,635 Fourth 69.5 11.0 5.5 1.0 0.9 6.7 1.1 1.8 1.7 0.8 100.0 11.3 11.1 5,704 Highest 60.5 13.4 4.7 2.1 1.1 9.5 1.5 3.4 2.5 1.3 100.0 16.9 13.3 5,185 Total <15 64.1 16.2 5.8 1.3 0.9 7.4 0.9 1.3 1.1 1.0 100.0 10.7 10.2 24,763 Total <18 61.0 15.5 7.4 1.3 1.1 7.7 1.2 1.8 1.8 1.2 100.0 12.5 13.4 28,433 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both dead, and one parent dead but missing information on survival status of the other parent. 2.8 SCHOOL ATTENDANCE BY SURVIVORSHIP OF PARENTS Access to education is considered an “essential service” and is included among the key components of national responses to guarantee orphans access to services on an equal basis with other children. To assess whether orphans are educationally disadvantaged in relation to other children, an indicator was devised to compare school attendance among orphans and non-orphans. The results are presented in Table 2.13 for children age 10 to 14, the age group in which school attendance is generally assumed for all children. The data show a clear relationship between parent survivorship and school attendance of children age 10 to 14. Although 96 percent of children whose parents are both alive and who are living with one of their parents attend school, only 88 percent of children who have lost both parents attend school. The ratio of school attendance for orphaned and non-orphaned children is less than 1 (0.91), indicating an educational disadvantage for orphans. By sex, results on parent survivorship and school attendance of children age 10 to 14 show that female children with deceased parents are disadvantaged compared with their male counterparts (84 percent compared with 91 percent), which explains the low ratio for females (0.87 compared with 0.95 for males). By residence, surprisingly, the ratio of school attendance by survivorship shows a disadvantage for urban area children (0.80) compared with their rural counterparts (0.93). This is reflected also by province results, with the City of Kigali showing the lowest school attendance ratio for vulnerable children (0.79) compared with the other provinces. The vulnerable children in the lowest-wealth-quintile household are surprisingly advantaged, with a ratio of 1.04 compared with those in upper wealth quintiles with, for example, a ratio of 0.87 for the highest wealth quintile. 28 • Household Characteristics Table 2.13 School attendance by survivorship of parents For de jure children age 10-14, the percentage attending school, by parental survival, and the ratio of the percentage attending school, by parental survival, according to background characteristics, Rwanda 2010 Background characteristic Percentage attending school by survivorship of parents Both parents deceased Number Both parents alive and living with at least one parent Number Ratio1 Sex Male 91.2 101 96.2 2,502 0.95 Female 83.8 92 96.0 2,491 0.87 Residence Urban * 21 97.3 544 0.80 Rural 88.8 172 96.0 4,449 0.93 Province City of Kigali * 16 96.8 374 0.79 South 83.8 51 96.5 1,210 0.87 West (95.5) 51 96.2 1,257 0.99 North (96.3) 31 96.7 942 1.00 East (81.0) 44 95.0 1,209 0.85 Wealth quintile Lowest (96.9) 34 92.9 922 1.04 Second 81.6 55 95.7 935 0.85 Middle (95.5) 29 96.2 1,038 0.99 Fourth (84.8) 31 97.0 1,124 0.87 Highest (85.1) 44 98.3 974 0.87 Total 87.7 193 96.1 4,993 0.91 Note: Table is based only on children who usually live in the household. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent 2.9 CHILD LABOR The government of Rwanda has actively tackled the problem of child labor. Article 32 of the UN Convention on the Rights of the Child recognizes the right of children to be protected from economic exploitation and from performing any work that is hazardous, interferes with their education, or is harmful to their health or physical, mental, spiritual, moral, or social development. To assess how much children are working in Rwanda, the 2010 RDHS included a set of questions on participation by each child age 5-14 years in household work. The types of work asked about included work for persons other than members of the household, work in a household business, and work doing household chores. The number of hours worked in the seven days preceding the survey was recorded for all children engaged in any type of work. For work that was done for any person who was not a member of the household, a question was also asked to determine whether the child was paid or not paid for the work. Table 2.14 presents the percentage of de jure children age 5-14 years, who were engaged in different activities in the seven days preceding the interview, by background characteristics. A child worker is defined by UNICEF as any child, age 5-11, who, in the seven days preceding the survey, (1) worked for someone who was not a member of the household, with or without pay, (2) did household chores for 28 or more hours, or (3) engaged in any family business. A child worker is also any child, age 12-14, who, in the seven days preceding the survey (1) worked for someone who was not a member of the household, with or without pay, for 14 or more hours, (2) did household chores for 28 or more hours, or (3) engaged in any other family work for 14 or more hours. Table 2.14 shows that 88 percent of children age 5-14 in households worked in a week prior to the survey, either for their own household or for somebody else. Nearly 8 percent of children age 5-14 worked for someone who was not member of the household; among them 2 percent are engaged in paid work, 5 percent are engaged in unpaid Household Characteristics • 29 work. The results also show that 83 percent of children age 5-14 are engaged in fetching water or collecting fire wood for household use, 10 percent perform any other family work, and 63 percent are helping with household chores for 28 or more hours in a week. The work participation rate for children who are working for someone who is not member of their household is the same for boys and girls (8 percent for both). The age-specific work participation rate shows an increasing trend in work participation with age, from 6 percent among children age 5-9 years to 11 percent among boys age 10-14 years. The work participation rate is slightly higher in rural areas compared with urban areas (8 percent and 6 percent respectively), while by province it is highest in the South province (14 percent) and the lowest in Kigali City (2 percent). According to wealth quintile, children in the lowest quintile have the highest work participation rate at 12 percent, which compares with the highest wealth quintile at 4 percent. Children who are orphans experience the highest work participation rate at 10 percent, which compares with 8 percent of those who are not orphans. 30 • H ou se ho ld C ha ra ct er is tic s Ta bl e 2. 14 C hi ld la bo r P er ce nt ag e of c hi ld re n 5- 14 y ea rs o ld w ho w or ke d in th e w ee k pr io r t o th e su rv ey fo r s om eo ne w ho w as n ot a m em be r o f t hi s ho us eh ol d, w ho fe tc he d w at er o r c ol le ct ed fi re w oo d fo r h ou se ho ld u se , w ho d id a ny o th er fa m ily w or k, o r h el pe d w ith h ou se ho ld c ho re s su ch a s sh op pi ng , c le an in g, w as hi ng c lo th es , c oo ki ng , o r c ar in g fo r c hi ld re n or s ic k pe op le , a cc or di ng to th e nu m be r o f h ou rs , b y se le ct ed b ac kg ro un d ch ar ac te ris tic , R w an da 2 01 0 W or ke d fo r s om eo ne w ho is n ot m em be r o f t he h ou se ho ld Fe tc he d w at er o r c ol le ct ed fi re w oo d fo r ho us eh ol d us e D id a ny o th er fa m ily w or k H el p w ith h ou se ho ld c ho re s To ta l P ai d, le ss th an 4 ho ur s pe r d ay P ai d 4+ ho ur s pe r d ay U np ai d le ss th an 4 ho ur s pe r d ay U np ai d 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l N o. o f ch ild re n A ge 5- 9 0. 7 0. 0 4. 2 0. 1 0. 8 5. 8 72 .5 2. 4 0. 1 75 .0 3. 0 0. 1 0. 0 3. 2 44 .4 3. 3 0. 1 47 .7 65 .2 14 .7 0. 1 80 .0 8, 65 3 10 -1 4 2. 7 0. 5 6. 1 0. 2 0. 9 10 .5 81 .8 9. 7 0. 1 91 .7 15 .2 2. 1 0. 0 17 .3 73 .2 8. 0 0. 1 81 .2 55 .7 40 .4 0. 5 96 .6 7, 37 5 Se x M al e 1. 9 0. 3 5. 0 0. 1 0. 9 8. 1 76 .3 5. 7 0. 1 82 .1 8. 1 0. 9 0. 0 9. 0 51 .9 4. 2 0. 0 56 .2 61 .8 24 .3 0. 3 86 .4 8, 03 5 Fe m al e 1. 3 0. 2 5. 2 0. 2 0. 8 7. 8 77 .3 5. 8 0. 1 83 .2 9. 2 1. 2 0. 0 10 .4 63 .4 6. 7 0. 1 70 .2 59 .8 28 .9 0. 3 88 .9 7, 99 3 R es id en ce U rb an 1. 6 0. 0 3. 4 0. 2 0. 6 5. 9 59 .0 3. 7 0. 0 62 .8 6. 0 0. 4 0. 1 6. 4 54 .7 3. 8 0. 2 58 .7 58 .6 17 .6 0. 1 76 .4 1, 81 5 R ur al 1. 6 0. 3 5. 3 0. 2 0. 9 8. 2 79 .0 6. 0 0. 1 85 .2 9. 0 1. 1 0. 0 10 .1 58 .0 5. 6 0. 0 63 .7 61 .1 27 .7 0. 3 89 .1 14 ,2 13 Pr ov in ce K i g al i C ity 0. 6 0. 1 1. 0 0. 0 0. 0 1. 7 51 .5 2. 6 0. 1 54 .1 2. 0 0. 3 0. 1 2. 4 52 .7 3. 6 0. 0 56 .2 57 .8 12 .9 0. 1 70 .8 1, 21 6 S ou th 2. 5 0. 2 9. 3 0. 3 2. 1 14 .4 85 .5 5. 4 0. 0 90 .9 10 .2 0. 6 0. 0 10 .9 59 .7 5. 2 0. 0 64 .9 68 .0 25 .1 0. 3 93 .3 3, 96 7 W es t 1. 6 0. 2 4. 1 0. 2 0. 4 6. 6 78 .8 6. 0 0. 2 85 .0 11 .0 1. 2 0. 0 12 .1 57 .9 3. 8 0. 0 61 .7 60 .0 27 .8 0. 3 88 .2 4, 06 4 N or th 1. 4 0. 5 5. 4 0. 1 0. 3 7. 7 76 .1 7. 4 0. 2 83 .8 8. 9 1. 1 0. 0 10 .1 57 .1 8. 6 0. 2 65 .9 56 .3 32 .1 0. 6 88 .9 2, 87 1 E as t 1. 2 0. 1 3. 0 0. 1 0. 7 5. 0 74 .1 5. 7 0. 1 80 .0 6. 4 1. 4 0. 1 7. 9 57 .2 5. 7 0. 0 62 .9 58 .5 27 .0 0. 1 85 .6 3, 91 0 W ea lth q ui nt ile Lo w es t 3. 1 0. 4 7. 2 0. 3 1. 2 12 .3 80 .9 7. 1 0. 0 88 .0 9. 3 1. 0 0. 0 10 .3 58 .7 6. 4 0. 0 65 .1 59 .4 30 .9 0. 4 90 .6 3, 31 4 S ec on d 1. 9 0. 4 6. 2 0. 2 0. 9 9. 5 79 .9 6. 9 0. 3 87 .1 9. 9 0. 9 0. 0 10 .8 58 .9 6. 3 0. 0 65 .2 60 .7 29 .0 0. 3 90 .0 3, 32 8 M id dl e 1. 2 0. 1 4. 7 0. 2 0. 8 7. 0 81 .6 5. 7 0. 1 87 .4 9. 6 1. 4 0. 0 11 .0 59 .2 4. 8 0. 1 64 .0 63 .7 27 .3 0. 2 91 .1 3, 14 9 Fo ur th 1. 2 0. 2 4. 3 0. 1 0. 5 6. 3 79 .0 6. 0 0. 0 85 .0 8. 6 1. 2 0. 1 10 .0 57 .1 5. 5 0. 1 62 .7 60 .7 27 .5 0. 1 88 .4 3, 31 8 H ig he st 0. 4 0. 0 2. 9 0. 0 0. 7 4. 1 60 .7 3. 0 0. 1 63 .8 5. 4 0. 6 0. 0 6. 0 53 .9 4. 1 0. 2 58 .1 59 .5 17 .0 0. 3 76 .8 2, 92 0 O rp ha ns Ye s 3. 1 0. 4 5. 7 0. 3 0. 9 10 .4 80 .2 7. 9 0. 3 88 .4 11 .5 1. 7 0. 0 13 .2 64 .1 6. 7 0. 0 70 .8 58 .2 34 .0 0. 5 92 .6 2, 33 5 N o 1. 3 0. 2 5. 0 0. 1 0. 8 7. 5 76 .2 5. 4 0. 1 81 .7 8. 1 0. 9 0. 0 9. 1 56 .6 5. 2 0. 1 61 .8 61 .3 25 .3 0. 2 86 .8 13 ,5 45 M is si ng 0. 6 0. 8 5. 2 0. 0 1. 4 8. 0 77 .7 5. 8 0. 0 83 .5 9. 0 0. 0 0. 0 9. 0 53 .4 8. 4 0. 0 61 .8 56 .2 30 .4 0. 0 86 .6 14 8 To ta l 1. 6 0. 2 5. 1 0. 2 0. 8 8. 0 76 .8 5. 8 0. 1 82 .7 8. 6 1. 0 0. 0 9. 7 57 .6 5. 4 0. 1 63 .1 60 .8 26 .6 0. 3 87 .6 16 ,0 28 30 • Household Characteristics Household Characteristics • 31 2.10 HEALTH INSURANCE COVERAGE Information on health insurance coverage of household members was collected during the survey. The household coverage is shown in Table 2.15 by type of health insurance, urban-rural residence, province, and household wealth quintile. Overall, 78 percent of Rwandan households have health insurance. This proportion is higher than that in the RIDHS 2007-08 (68 percent). There is almost no variation by residence (78 percent in both urban and rural areas). There is significant difference by province, with proportions varying from the low of 71 percent in the East province to the high of 86 percent in the North province. Households in the higher wealth quintiles are generally better insured than those in the lower wealth quintiles. Concerning the type of health insurance used by households, nearly all households with a least one member insured are insured by Mutual Health Insurance (98 percent). Other types of insurances reported by households are La Rwandaise d’Assurance Maladie (RAMA), Military Medical Insurance (MMI), and private insurance. These insurances are commonly reported by households in urban areas, in the city of Kigali, and in the highest wealth quintile. Table 2.15 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 2010 Background characteristics Percentage of households with at least one member covered by health insurance Number of households Type of insurance Mutual RAMA MMI Private Number of households with at least one member covered by health insurance Residence Urban 78.4 1,759 93.9 9.7 1.9 2.5 1,379 Rural 77.7 10,781 98.3 2.7 0.3 0.1 8,377 Province Kigali City 71.7 1,284 91.8 13.0 2.5 4.0 921 South 77.2 3,136 98.4 2.2 0.2 0.0 2,420 West 82.7 2,967 98.7 3.0 0.4 0.0 2,454 North 85.6 2,120 98.3 2.5 0.5 0.1 1,815 East 70.8 3,033 97.7 3.0 0.5 0.1 2,146 Wealth quintile Lowest 67.8 2,838 99.4 0.1 0.0 0.0 1,924 Second 76.1 2,600 99.6 0.0 0.1 0.0 1,978 Middle 79.8 2,448 98.6 0.6 0.1 0.0 1,954 Fourth 84.5 2,287 98.5 1.9 0.6 0.0 1,932 Highest 83.1 2,367 92.2 15.5 2.0 2.1 1,968 Total 77.8 12,540 97.7 3.7 0.6 0.4 9,756 Individual health insurance coverage is presented in Table 2.16 by type of health insurance, according to selected background characteristics. Overall, 71 percent of women and 66 percent of men are insured. Young women age 15-19 (64 percent) and young men age 15-19 (62 percent) are less likely to be insured than the older women and men (70 percent or higher and 67 percent or higher, respectively). According to marital status, currently married women and men are better insured than those in other categories. Women and men in the North province have higher coverage than those in the other provinces. However, there is no variation by urban-rural residence for women or men. The proportion of coverage among women increases as the level of education increases; from 66 percent among those who have no education to 80 percent for secondary education or higher. Among men, these figures are 59 percent and 75 percent respectively. Women and men in the higher wealth quintiles are generally better insured than those in the lower wealth quintiles. Concerning the type of health insurance used by households, nearly all insured household members are insured by Mutual Health Insurance (95 percent for women and 96 percent for men). Other types of insurances are RAMA, MMI, and private insurance. These insurances are commonly reported by women and men who are currently married, live in urban areas, reside in the city of Kigali, have secondary education and higher, and are in the highest wealth quintile. 32 • Household Characteristics Table 2.16 Health insurance Percentage of respondents covered by health insurance, and percent distribution of respondents with specific types of health insurance, according to selected background characteristics, Rwanda 2010 Background characteristic Percentage of respondents covered by health insurance Number of respondents Type of insurance Mutual RAMA MMI Private Don’t know/missing Total Number of respondents covered by health insurance WOMEN Age 15-19 64.4 2,945 97.2 1.3 0.1 0.3 1.1 100.0 1,897 20-24 73.1 2,683 96.8 1.8 0.3 0.3 0.8 100.0 1,961 25-29 75.3 2,494 95.1 3.1 0.6 0.4 0.8 100.0 1,877 30-34 75.0 1,822 92.7 5.7 0.5 0.5 0.6 100.0 1,366 35-39 73.2 1,447 91.7 5.2 1.4 0.5 1.2 100.0 1,058 40-44 70.2 1,168 95.2 3.2 0.1 0.8 0.6 100.0 820 45-49 70.2 1,112 96.3 2.1 0.1 0.5 1.0 100.0 781 Marital status Never married 68.1 5,285 96.3 2.2 0.1 0.3 1.1 100.0 3,597 Married 80.3 4,799 92.7 4.9 1.0 0.7 0.7 100.0 3,854 Living together 65.6 2,098 98.3 1.0 0.0 0.1 0.5 100.0 1,377 Divorced/separated 58.7 746 97.5 1.2 0.0 0.1 1.1 100.0 438 Widowed 66.5 743 97.3 1.4 0.0 0.2 1.1 100.0 494 Residence Urban 71.4 2,057 86.7 8.3 1.2 2.4 1.5 100.0 1,469 Rural 71.4 11,614 96.8 2.1 0.3 0.1 0.8 100.0 8,291 Province Kigali City 65.6 1,596 83.3 9.5 1.4 3.7 2.1 100.0 1,047 South 70.1 3,212 96.9 1.9 0.2 0.0 1.1 100.0 2,251 West 76.1 3,305 96.6 2.5 0.2 0.0 0.7 100.0 2,515 North 80.5 2,278 96.9 1.9 0.5 0.1 0.6 100.0 1,834 East 64.4 3,280 96.5 2.5 0.5 0.0 0.5 100.0 2,113 Education No education 66.2 2,119 98.9 0.2 0.1 0.0 0.8 100.0 1,402 Primary 70.5 9,337 98.6 0.5 0.2 0.1 0.7 100.0 6,583 Secondary and higher 80.1 2,216 80.1 14.6 1.5 2.1 1.6 100.0 1,776 Wealth quintile Lowest 59.8 2,622 99.4 0.1 0.0 0.0 0.6 100.0 1,568 Second 68.8 2,661 99.4 0.0 0.1 0.0 0.5 100.0 1,829 Middle 73.4 2,736 98.7 0.3 0.1 0.0 0.9 100.0 2,008 Fourth 77.6 2,677 97.8 1.0 0.4 0.0 0.8 100.0 2,076 Highest 76.6 2,976 83.8 11.6 1.4 1.8 1.4 100.0 2,279 Total 15-49 71.4 13,671 95.3 3.0 0.4 0.4 0.9 100.0 9,761 MEN Age 15-19 62.1 1,449 98.9 0.2 0.1 0.2 0.4 100.0 899 20-24 61.7 1,159 97.0 1.8 0.0 0.2 1.0 100.0 715 25-29 70.2 1,038 95.6 2.8 0.4 0.4 0.9 100.0 729 30-34 73.5 710 94.3 4.5 0.2 0.7 0.2 100.0 522 35-39 67.3 490 91.4 5.9 0.8 0.9 1.1 100.0 330 40-44 70.3 430 91.8 5.0 1.6 0.6 1.1 100.0 302 45-49 67.0 412 95.5 2.4 0.2 0.6 1.3 100.0 276 Marital status Never married 62.3 2,873 96.6 2.0 0.2 0.2 0.9 100.0 1,790 Married 76.2 1,938 94.1 4.0 0.5 0.6 0.7 100.0 1,478 Living together 60.7 761 97.7 0.9 0.3 0.5 0.6 100.0 462 Divorced/separated 35.2 92 97.7 2.3 0.0 0.0 0.0 100.0 32 Widowed 46.0 22 100.0 0.0 0.0 0.0 0.0 100.0 10 Residence Urban 66.1 939 88.8 6.4 1.1 1.5 2.2 100.0 621 Rural 66.4 4,748 97.2 1.9 0.2 0.2 0.5 100.0 3,152 Province Kigali City 58.4 739 85.2 8.4 1.6 2.5 2.2 100.0 432 South 64.4 1,308 97.7 1.5 0.2 0.0 0.6 100.0 842 West 73.9 1,307 96.8 1.9 0.2 0.3 0.8 100.0 966 North 77.7 899 97.5 2.1 0.2 0.2 0.2 100.0 698 East 58.2 1,435 96.8 2.3 0.1 0.1 0.7 100.0 836 Continued… Household Characteristics • 33 Table 2.16─Continued Background characteristic Percentage of respondents covered by health insurance Number of respondents Type of insurance Mutual RAMA MMI Private Don’t know/missing Total Number of respondents covered by health insurance Education No education 58.8 583 99.8 0.2 0.0 0.0 0.0 100.0 343 Primary 65.0 3,916 99.1 0.2 0.2 0.0 0.6 100.0 2,544 Secondary and higher 74.6 1,189 84.9 10.8 1.0 1.8 1.5 100.0 887 Wealth quintile Lowest 54.4 854 99.8 0.0 0.0 0.0 0.2 100.0 464 Second 64.2 986 99.2 0.0 0.0 0.0 0.8 100.0 633 Middle 65.8 1,139 99.3 0.4 0.0 0.0 0.3 100.0 749 Fourth 72.8 1,235 97.4 1.7 0.2 0.0 0.7 100.0 899 Highest 69.7 1,474 87.9 8.0 1.1 1.6 1.4 100.0 1,028 Total 15-49 66.3 5,687 95.8 2.7 0.3 0.4 0.8 100.0 3,773 50-59 69.7 642 96.0 2.9 0.1 0.3 0.7 100.0 447 Total 15-59 66.7 6,329 95.8 2.7 0.3 0.4 0.8 100.0 4,220 2.11 UTILIZATION OF HEALTH SERVICES AND OUT-OF-POCKET EXPENDITURE FOR HEALTH CARE The 2010 RDHS collected data on the utilization of health services by household members. Information on outpatient visits by each household member to a health care facility, provider, pharmacy, or traditional healer four weeks preceding the interview and information on inpatient admissions 6 months preceding the interview was collected. The survey also collected all out-of-pocket expenditures for visits and admissions during those reference periods. Utilization of health services was assessed in the Household Questionnaire. The questions were asked of all households in the sample. The analysis was carried out to estimate the number of annual outpatient visits (per capita) and inpatient admissions (per 1,000 population), with separate data for women and men. Table 2.17 Annual outpatient visits and inpatient admissions for de facto population Average number of annual outpatient visits and inpatient admissions to health facilities for women and men by background characteristics, Rwanda 2010 Background characteristic Women Men Outpatient visits (per capita) Inpatient admissions (per 1,000 population) De facto population Outpatient visits (per capita) Inpatient admissions (per 1,000 population) De facto population Age <5 2.7 68 4,390 2.9 88 4,561 5-14 0.9 17 7,827 0.9 23 7,885 15-49 1.8 159 13,719 1.1 43 11,353 50-64 2.5 90 2,218 1.7 59 1,595 65+ 2.7 118 1,104 2.6 92 632 Don’t know/missing 0.0 0 5 5.3 0 2 Residence Urban 2.2 95 3,796 1.7 38 3,628 Rural 1.8 102 25,468 1.4 48 22,400 Province Kigali City 2.2 108 2,743 1.9 33 2,713 South 2.1 91 7,127 1.9 43 6,273 West 1.7 131 7,276 1.3 58 6,246 North 1.7 81 5,069 1.2 55 4,305 East 1.6 90 7,049 1.2 40 6,491 Total 1.8 101 29,264 1.5 47 26,029 34 • Household Characteristics Table 2.17 shows that in Rwanda the number of annual outpatient visits in 2010 is 1.8 visits per capita for women and 1.5 visits per capita for men. The number of visits is higher among children under 5 (2.7 visits for girls and 2.9 visits for boys) and among the elderly age 65 and older (2.7 visits for women and 2.6 visits for men). In both populations, the number of visits is higher in urban areas than in rural areas and higher in the city of Kigali and in South province than in other provinces. On average, the annual number of inpatient admissions is 101 admissions (per 1,000 population) for women and 47 admissions (per 1,000 population) for men. For men, the number of annual admissions is higher among young children and the elderly. Among women, the number of annual admission peaks among three age groups: young children (under age 5), women of reproductive age (age 15-49), and the elderly (age 65 and older). For both women and men, the number of inpatient admissions is higher in rural areas than in urban areas. Table 2.18 indicates that the total annual out-of-pocket expenditure for the female population is US$4.14 per capita; that includes US$3.36 in outpatient expenditure and US$0.79 in inpatient expenditure. For the male population, the total annual out-of-pocket expenditure is US$4.37 per capita; that includes US$3.79 in outpatient expenditure and US$0.58 in inpatient expenditure. The total expenditure has a U-shape in relation to age. In the female population, the annual expense is US$3.46 among children under age 5, drops to US$1.40 among girls age 5- 14, then shapely increases to US$4.82 among those age 15-49, and reaches the highest level of US$10.01 among those age 65 or older. A similar pattern is observed among men, except the highest level for men is US$12.74 among those age 50-64. Table 2.18 Annual per capita expenditure (in US $) on outpatient visits and inpatient admissions for de facto population Average annual per capita expenditure for outpatient visits and inpatient admissions for women and men by background characteristics, Rwanda 2010 Background characteristic Women Men Per capita expenditure for outpatient Per capita expenditure for inpatient Total per capita expenditure De facto population Per capita expenditure for outpatient Per capita expenditure for inpatient Total per capita expenditure De facto population Age <5 3.05 0.41 3.46 4,390 5.32 0.38 5.70 4,561 5-14 1.23 0.17 1.40 7,827 1.54 0.28 1.82 7,885 15-49 3.82 1.00 4.82 13,719 3.61 0.67 4.28 11,353 50-64 6.14 1.96 8.10 2,218 10.70 2.04 12.74 1,595 65+ 8.29 1.72 10.01 1,104 6.47 0.49 6.96 632 Don’t know/missing 0.00 0.00 0.00 5 2.68 0.00 2.68 2 Residence Urban 10.90 2.74 13.64 3,796 8.19 0.68 8.87 3,628 Rural 2.23 0.50 2.73 25,468 3.07 0.56 3.64 22,400 Province Kigali City 12.27 3.75 16.03 2,743 13.56 0.73 14.29 2,713 South 2.19 0.44 2.62 7,127 2.55 0.67 3.22 6,273 West 2.35 0.59 2.93 7,276 2.52 0.54 3.06 6,246 North 1.57 0.36 1.92 5,069 1.53 0.28 1.82 4,305 East 3.39 0.51 3.91 7,049 3.61 0.66 4.27 6,491 Education No education 2.98 0.46 3.44 10,433 3.75 0.33 4.08 8,523 Primary 2.87 0.61 3.48 16,426 3.23 0.58 3.81 14,949 Secondary and higher 8.45 3.51 11.96 2,344 7.24 1.46 8.70 2,493 Missing 3.50 0.00 3.50 60 3.37 0.06 3.43 63 Wealth quintile Lowest 2.07 0.38 2.45 6,119 1.60 0.45 2.05 4,861 Second 2.01 0.46 2.47 5,984 2.42 0.31 2.72 5,081 Middle 1.61 0.43 2.04 5,806 2.34 0.42 2.76 5,212 Fourth 1.95 0.58 2.53 5,776 3.05 0.26 3.32 5,311 Highest 9.48 2.18 11.66 5,578 9.00 1.39 10.39 5,563 Total 3.36 0.79 4.14 29,264 3.79 0.58 4.37 26,029 The total out-of- pocket expenditure is higher in urban areas than in rural areas (US$13.64 versus US$2.73 for women and US$8.87 versus US$3.64 for men. The expenditure is significantly higher in the city of Kigali (US$16.03 for women and US$14.29 for men) than in other provinces (US$3.91 or less for women and US$4.27 or Household Characteristics • 35 less for men). On average, people with secondary education and higher spend more for health care than people with primary education or lower. Similarly, out-of-pocket spending of people in the highest wealth quintile (US$11.66 for women and US$10.39 for men) is significantly higher than for those in others quintiles (US$2.53 or less for women and US$3.32 or less for men). Respondent Characteristics • 37 RESPONDENT CHARACTERISTICS 3 his chapter provides a sociodemographic profile of women age 15-49 and men age 15-59 who responded to the survey questions. The information that the women and men provided is important for understanding the behavior of the population with respect to contraception, sexually transmitted infections (STIs), HIV/AIDS, and fertility preferences. Like the Household Questionnaire, the individual questionnaire gathered information concerning respondents’ age, place of residence, marital status, and educational attainment. This chapter also presents level of literacy, exposure to mass media, employment and occupation, and tobacco use of the men and women interviewed. These characteristics are used to interpret findings elsewhere in the report. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Given the importance of age in analyzing demographic characteristics, special attention was paid to making sure this statistic was accurately recorded in the survey. Prior to recording any information, the interviewer asked respondents to gather all official documents with information about themselves and other members of the household. If no official documents were available, the interviewer confirmed the age provided by the respondent through reference to major life events (age at the time of marriage, age of first child, etc.) or well-known national or regional events. Table 3.1 shows no major disparities in the distribution of women and men age 15-49 grouped by five-year age increments. Proportions in each age group decline with increasing age. For women, the percentages range from 22 percent for the age group 15-19 to 8 percent for the age group 45-49. For men, the percentages range from 26 percent for age group 15-19 to 7 percent for age group 45-49. Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Rwanda 2010 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 21.5 2,945 2,963 25.5 1,449 1,436 20-24 19.6 2,683 2,692 20.4 1,159 1,159 25-29 18.2 2,494 2,495 18.3 1,038 1,046 30-34 13.3 1,822 1,822 12.5 710 726 35-39 10.6 1,447 1,442 8.6 490 488 40-44 8.5 1,168 1,155 7.6 430 434 45-49 8.1 1,112 1,102 7.2 412 406 Religion Catholic 42.7 5,842 5,854 47.7 2,710 2,727 Protestant 41.2 5,627 5,586 35.9 2,044 2,031 Adventist 13.0 1,781 1,792 11.9 680 682 Muslim 1.3 179 197 1.9 106 111 Traditional 0.0 0 0 0.0 1 1 Other 0.9 129 131 0.9 50 50 No religion 0.7 92 91 1.7 96 93 Missing 0.2 21 20 0.0 0 0 Marital status Never married 38.7 5,285 5,362 50.5 2,873 2,900 Married 35.1 4,799 4,757 34.1 1,938 1,930 Living together 15.3 2,098 2,077 13.4 761 751 Divorced/separated 5.5 746 746 1.6 92 93 Widowed 5.4 743 729 0.4 22 21 Residence Urban 15.0 2,057 2,367 16.5 939 1,082 Rural 85.0 11,614 11,304 83.5 4,748 4,613 Continued… T 38 • Respondent Characteristics Table 3.1─Continued Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Province City of Kigali 11.7 1,596 1,890 13.0 739 876 South 23.5 3,212 3,340 23.0 1,308 1,373 West 24.2 3,305 3,138 23.0 1,307 1,243 North 16.7 2,278 2,199 15.8 899 859 East 24.0 3,280 3,104 25.2 1,435 1,344 Education No education 15.5 2,119 2,061 10.3 583 580 Primary 68.3 9,337 9,277 68.8 3,916 3,884 Secondary 14.7 2,008 2,090 18.7 1,064 1,089 More than secondary 1.5 207 243 2.2 125 142 Wealth quintile Lowest 19.2 2,622 2,569 15.0 854 850 Second 19.5 2,661 2,603 17.3 986 968 Middle 20.0 2,736 2,663 20.0 1,139 1,102 Fourth 19.6 2,677 2,621 21.7 1,235 1,203 Highest 21.8 2,976 3,215 25.9 1,474 1,572 Total 15-49 100.0 13,671 13,671 100.0 5,687 5,695 50-59 na na na na 642 634 Total 15-59 na na na na 6,329 6,329 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable All men and women in the sample were asked their marital status. For the 2010 RDHS, all men and women were considered married if they were in union with a partner, whether the union was formal (legally married) or informal (living together). According to this definition, Table 3.1 shows that nearly 2 in 5 women (39 percent) had never been married at the time of the survey, while half of the women were married (35 percent were legally married and 15 percent were living together with a man). In addition, 6 percent of women were divorced or separated and 5 percent were widowed at the time of the survey. About half of the men age 15-49 (51 percent) were single, 47 percent were married (34 percent were legally married, and 13 percent were living with a woman). Slightly under 2 percent were separated or divorced, and less than 1 percent were widowed. The distribution of respondents by residence shows that the majority of the Rwandan population is living in rural areas (85 percent of women and 84 percent of men). Similarly, distribution of respondents by province shows no significant disparities between men and women. The City of Kigali, with 12 percent of women and 13 percent of men, has the lowest proportion of respondents; next is North province with 17 percent of women and 16 percent of men. The tabulation of respondents by religion indicates a majority of Catholic adherents (43 percent of women and 48 percent of men), with Protestant religions coming in second in popularity (41 percent of women and 36 percent of men). The Adventist faith is the next most common religion (13 percent of women and 12 percent of men), followed by the Muslim faith (1 percent of women and 2 percent of men). Table 3.1 also shows the distribution of men and women according to household wealth quintile. The development of this index is explained in Chapter 2. Table 3.1 provides educational attainment data for the respondents. The proportion of women with no education is significantly higher than that of men (16 percent of women, 10 percent of men). Inversely, the proportion of women with secondary education is lower than that of men (15 percent of women, 19 percent of men). The gap between men and women is not very wide at the primary and tertiary levels, however. 3.2 EDUCATIONAL ATTAINMENT Tables 3.2.1 and 3.2.2 show the distributions of female and male respondents by highest level of education attained. The proportion of men who received completed primary education or received some primary education is equal to that of women: 68 percent each. At the secondary level, the proportions are 15 percent for women and Respondent Characteristics • 39 18 percent for men. It is noteworthy that proportions for both men and women drop significantly from primary to secondary and from secondary to postsecondary levels. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Rwanda 2010 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 6.1 57.5 13.1 19.6 2.9 0.9 100.0 4.2 5,628 ,,.15-19 2.9 59.0 13.4 24.1 0.6 0.0 100.0 4.4 2,945 …20-24 9.5 55.9 12.9 14.6 5.4 1.8 100.0 3.9 2,683 25-29 14.0 58.5 16.8 4.6 3.6 2.5 100.0 3.4 2,494 30-34 16.4 50.9 21.0 6.1 3.1 2.4 100.0 4.2 1,822 35-39 21.1 56.0 8.9 9.0 2.8 2.2 100.0 4.0 1,447 40-44 32.7 46.8 8.4 9.7 1.4 1.0 100.0 2.9 1,168 45-49 39.8 41.5 11.6 5.4 1.0 0.7 100.0 1.4 1,112 Residence Urban 6.7 42.8 13.0 22.9 8.0 6.6 100.0 5.4 2,057 Rural 17.1 56.5 14.0 10.0 1.8 0.6 100.0 3.6 11,614 Province City of Kigali 6.2 39.3 12.5 23.5 10.2 8.3 100.0 5.7 1,596 South 13.4 58.6 14.3 11.7 1.6 0.4 100.0 3.8 3,212 West 19.9 55.4 12.6 9.5 1.5 1.1 100.0 3.4 3,305 North 16.3 53.9 17.3 10.2 1.8 0.4 100.0 3.8 2,278 East 17.1 57.2 12.9 10.2 2.1 0.5 100.0 3.4 3,280 Wealth quintile Lowest 26.1 61.5 8.5 3.7 0.1 0.0 100.0 2.3 2,622 Second 20.4 60.4 13.2 6.0 0.1 0.0 100.0 3.0 2,661 Middle 16.2 59.9 15.1 8.3 0.5 0.0 100.0 3.6 2,736 Fourth 11.2 56.2 17.6 13.4 1.5 0.1 100.0 4.3 2,677 Highest 5.0 36.2 14.7 26.5 10.7 6.9 100.0 5.8 2,976 Total 15.5 54.4 13.9 11.9 2.8 1.5 100.0 3.8 13,671 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Rwanda 2010 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 3.8 59.3 11.3 22.0 2.6 1.1 100.0 4.3 2,607 …15-19 2.5 62.1 11.1 24.2 0.2 0.0 100.0 4.3 1,449 …20-24 5.3 55.9 11.5 19.3 5.6 2.4 100.0 4.2 1,159 25-29 11.6 55.4 17.5 6.7 4.9 3.9 100.0 3.6 1,038 30-34 10.7 52.4 18.3 11.3 3.6 3.8 100.0 4.6 710 35-39 17.5 53.6 9.9 12.1 4.0 2.9 100.0 4.5 490 40-44 18.8 51.8 10.2 12.9 3.4 2.8 100.0 4.8 430 45-49 29.5 43.2 15.0 9.4 2.0 0.9 100.0 2.7 412 Residence Urban 5.6 43.4 12.7 23.0 8.2 7.0 100.0 5.3 939 Rural 11.2 57.9 13.5 13.9 2.3 1.2 100.0 3.9 4,748 Province City of Kigali 3.9 38.3 14.3 26.2 9.8 7.6 100.0 5.8 739 South 11.2 61.0 12.6 12.1 2.3 0.8 100.0 3.7 1,308 West 11.8 58.9 9.7 14.5 2.8 2.3 100.0 3.9 1,307 North 9.7 51.9 17.8 16.3 2.6 1.7 100.0 4.3 899 East 11.6 58.5 14.1 13.2 1.8 0.9 100.0 3.8 1,435 Wealth quintile Lowest 18.5 67.1 8.3 5.8 0.2 0.0 100.0 2.5 854 Second 15.0 62.4 12.1 9.7 0.5 0.3 100.0 3.2 986 Middle 10.7 62.0 13.8 12.0 0.8 0.6 100.0 3.7 1,139 Fourth 6.8 55.3 17.0 17.4 2.5 0.9 100.0 4.5 1,235 Highest 4.8 39.3 13.7 25.7 9.5 7.1 100.0 5.7 1,474 Total 15-49 10.3 55.5 13.3 15.4 3.3 2.2 100.0 4.1 5,687 50-59 27.2 46.6 16.9 6.3 1.9 1.3 100.0 2.4 642 Total 15-59 12.0 54.6 13.7 14.5 3.1 2.1 100.0 4.0 6,329 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level 40 • Respondent Characteristics The data by age show that the proportions of men and women with no education have decreased significantly in the younger generation. For men, the proportion with no education is 30 percent in the 45-49 age group but only 4 percent in the 15-24 age group. For women, the proportions for these age groups are 40 percent and 6 percent, respectively. The gap between men and women in the previous generations has narrowed significantly: Among women and men age 45 to 49 years, the gap is about 10 percent; for those age 15-19 years, the gap is about 2 percent. Similarly, in the 15-24 age group, the proportion of girls who have attended or completed primary school is exactly equal to that of boys (71 percent for girls and boys). In addition, 25 percent of young women age 15-19 have attended or completed secondary school compared with 24 percent of young men. The educational attainment of respondents varies by residence. The proportion of men and women with no education is higher in rural areas (17 percent for women, 11 percent for men) than in urban areas (7 percent for women, 6 percent for men). Urban areas also have the highest proportions of men and women at every level of education except primary. Results by province show a wide gap between the City of Kigali and the rest of the country. In the City of Kigali, 6 percent of women and 4 percent of men have no education; in the other provinces the proportions vary from 13 percent (South) to 20 percent (West) for women and from 10 percent (North) to 12 percent (West and East) for men. The data in this table show a positive relationship between educational attainment and household wealth: the proportions of men and women with no education decrease as household wealth increases. 3.3 LITERACY For this survey, literacy was established by asking respondents who reported not having attended school or having attended only primary school to read a sentence that was presented to them. Respondents were then classified into one of the following three levels: cannot read at all, can read part of a sentence, and can read a whole sentence. The test was given only to men and women who had less than a secondary education; those with secondary or postsecondary educations (16 percent of women and 21 percent of men) were considered literate and not in need of testing. Tables 3.3.1 and 3.3.2 show that the proportion of men and women who cannot read at all has decreased from previous generations, especially among women. For women, this proportion drops from 46 percent in the 45- 49 age group to 10 percent in the 15-19 age group. For men, the proportions for these age groups are 28 percent and 18 percent, respectively. The data show also that a higher proportion of women than men cannot read (23 percent of women; 18 percent of men). Conversely, 77 percent of women and 82 percent of men are considered literate; that is, they have attended secondary school or, if they have attended only primary school, they are able to read all or part of a sentence. The level of illiteracy varies appreciably by residence. Illiteracy is higher in rural areas than in urban areas (11 percent in urban areas versus 25 percent in rural areas, for women, and 11 percent in urban areas versus 19 percent in rural areas, for men). The results by province show a gap between the City of Kigali and the rest of the country: in Kigali, 91 percent of women and 92 percent of men are literate. In other provinces, the proportion varies from 73 percent (West) to 78 percent (South) for women and from 79 percent (East) to 84 percent (North) for men. In addition, results by wealth quintile show that the level of illiteracy decreases considerably from the poorest to the richest quintile, dropping for women from 38 percent in the lowest quintile to 8 percent in the highest quintile and for men from 33 percent in the lowest quintile to 9 percent in the highest quintile. Respondent Characteristics • 41 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Rwanda 2010 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 23.3 54.2 7.4 14.9 0.0 0.0 0.1 100.0 85.0 5,628 …15-19 24.7 58.3 6.5 10.4 0.0 0.0 0.1 100.0 89.5 2,945 …20-24 21.8 49.8 8.5 19.8 0.0 0.1 0.0 100.0 80.1 2,683 25-29 10.8 56.3 9.8 23.0 0.0 0.1 0.0 100.0 76.9 2,494 30-34 11.6 57.7 8.7 21.6 0.0 0.2 0.2 100.0 78.1 1,822 35-39 14.0 50.8 9.1 25.7 0.0 0.1 0.2 100.0 73.9 1,447 40-44 12.2 43.2 8.6 35.3 0.0 0.7 0.1 100.0 63.9 1,168 45-49 7.2 35.4 9.5 46.2 0.1 1.4 0.2 100.0 52.1 1,112 Residence Urban 37.5 45.3 5.9 11.0 0.0 0.2 0.1 100.0 88.8 2,057 Rural 12.4 53.5 9.0 24.8 0.0 0.3 0.1 100.0 74.8 11,614 Province City of Kigali 42.0 42.8 5.5 9.3 0.0 0.3 0.0 100.0 90.4 1,596 South 13.7 56.4 8.2 21.2 0.0 0.4 0.1 100.0 78.3 3,212 West 12.1 50.9 9.7 27.1 0.0 0.1 0.1 100.0 72.7 3,305 North 12.5 54.3 8.9 23.9 0.0 0.2 0.2 100.0 75.7 2,278 East 12.8 52.6 8.8 25.4 0.0 0.4 0.0 100.0 74.2 3,280 Wealth quintile Lowest 3.8 45.9 11.7 38.1 0.0 0.3 0.1 100.0 61.4 2,622 Second 6.1 53.4 10.4 29.9 0.0 0.1 0.1 100.0 69.9 2,661 Middle 8.8 57.7 9.1 23.8 0.0 0.4 0.1 100.0 75.7 2,736 Fourth 15.0 61.6 6.9 16.2 0.0 0.2 0.1 100.0 83.5 2,677 Highest 44.1 43.3 4.8 7.5 0.0 0.2 0.0 100.0 92.2 2,976 Total 16.2 52.2 8.5 22.7 0.0 0.3 0.1 100.0 76.9 13,671 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Rwanda 2010 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 25.6 50.8 8.8 14.5 0.0 0.0 0.2 100.0 85.3 2,607 …15-19 21.7 52.7 8.8 13.9 0.0 0.0 0.3 100.0 85.9 1,449 …20-24 27.3 48.5 8.9 15.4 0.0 0.0 0.0 100.0 84.6 1,159 25-29 15.5 54.4 8.0 21.8 0.0 0.1 0.2 100.0 78.0 1,038 30-34 18.7 56.0 7.9 17.1 0.2 0.0 0.1 100.0 82.6 710 35-39 19.1 53.5 6.9 20.5 0.0 0.0 0.0 100.0 79.5 490 40-44 19.1 56.1 7.7 17.1 0.0 0.0 0.0 100.0 82.9 430 45-49 12.3 51.2 7.7 27.6 0.0 1.2 0.0 100.0 71.2 412 Residence Urban 38.3 44.3 6.3 11.0 0.0 0.0 0.2 100.0 88.9 939 Rural 17.5 54.5 8.6 19.2 0.0 0.1 0.1 100.0 80.6 4,748 Province City of Kigali 43.6 44.1 4.3 7.8 0.0 0.0 0.2 100.0 92.0 739 South 15.2 52.2 12.0 20.3 0.0 0.2 0.1 100.0 79.4 1,308 West 19.6 54.5 6.9 18.7 0.0 0.2 0.0 100.0 81.1 1,307 North 20.6 56.2 7.2 16.0 0.0 0.0 0.1 100.0 83.9 899 East 15.8 54.1 8.7 21.0 0.1 0.1 0.2 100.0 78.6 1,435 Wealth quintile Lowest 6.1 50.6 10.5 32.6 0.0 0.3 0.0 100.0 67.1 854 Second 10.5 53.8 10.8 24.7 0.0 0.2 0.1 100.0 75.0 986 Middle 13.5 60.0 8.2 18.3 0.0 0.0 0.0 100.0 81.7 1,139 Fourth 20.8 58.4 8.5 11.9 0.1 0.1 0.3 100.0 87.7 1,235 Highest 42.3 43.2 5.0 9.2 0.0 0.0 0.2 100.0 90.6 1,474 Total 15-49 20.9 52.8 8.2 17.8 0.0 0.1 0.1 100.0 81.9 5,687 50-59 9.4 48.8 8.7 31.1 0.0 1.7 0.3 100.0 66.9 642 Total 15-59 19.7 52.4 8.3 19.2 0.0 0.3 0.1 100.0 80.4 6,329 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 42 • Respondent Characteristics 3.4 EXPOSURE TO MASS MEDIA Data on the exposure of men and women to mass media are especially important to the development of education programs and the dissemination of all types of information, particularly information about health and family planning. Tables 3.4.1 and 3.4.2 present data on the exposure of men and women to mass media (print or broadcast). It should be stated at the outset that it is not necessary for a household to own a radio or television or to buy a newspaper to have access to these media because many people listen to the radio or watch television at the homes of friends and neighbors. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Rwanda 2010 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 4.4 11.9 70.6 1.1 27.1 2,945 20-24 3.7 11.8 70.8 1.5 27.7 2,683 25-29 3.1 9.1 67.6 1.4 31.1 2,494 30-34 3.3 8.9 66.0 1.4 32.8 1,822 35-39 3.0 8.5 64.8 1.5 34.2 1,447 40-44 2.6 5.3 66.3 0.8 33.0 1,168 45-49 2.7 4.5 66.4 0.9 33.2 1,112 Residence Urban 7.8 41.0 80.0 5.5 15.5 2,057 Rural 2.7 3.8 66.1 0.5 33.1 11,614 Province City of Kigali 9.0 50.8 82.6 7.0 11.7 1,596 South 2.3 3.2 66.3 0.4 33.1 3,212 West 2.3 4.8 55.1 0.5 43.9 3,305 North 3.5 4.0 75.9 0.8 23.5 2,278 East 3.1 3.7 70.8 0.5 28.3 3,280 Education No education 0.0 2.0 52.0 0.0 47.8 2,119 Primary 2.0 6.0 67.6 0.4 31.2 9,337 Secondary and higher 12.7 30.8 85.9 6.3 10.9 2,216 Wealth quintile Lowest 1.3 1.2 36.4 0.1 62.6 2,622 Second 1.6 1.2 57.4 0.2 42.0 2,661 Middle 2.3 1.8 73.3 0.2 26.0 2,736 Fourth 2.9 2.8 82.8 0.3 16.7 2,677 Highest 8.5 37.0 87.9 5.1 8.4 2,976 Total 3.4 9.4 68.2 1.3 30.5 13,671 Table 3.4.1 shows that, at the national level, 31 percent of women and approximately 12 percent of men are not exposed to any media. However, improvement has occurred since the 2005 RDHS, which reported that 44 percent of women and 19 percent of men were not exposed to any media. Radio is the most common form of media exposure: 68 percent of women and 87 percent of men report listening to the radio at least once a week. Men watch television more frequently than women: Almost one in ten women (9 percent) and one quarter of men (24 percent) watch television at least once a week. Only 3 percent of women, compared with 8 percent of men, report reading a newspaper at least once a week, however. The proportions of men and women who are exposed to all three media are very low: only 1 percent of women and 5 percent of men. The data by age show that the younger women receive relatively more exposure to mass media than older women. In fact, the proportions of women who are not exposed to any media vary from 27 percent for women age 15-19 to 33 percent for women age 45-49. For men, the age differences are narrow and uneven. Respondent Characteristics • 43 Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Rwanda 2010 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of men Age 15-19 6.9 25.7 86.5 3.1 12.5 1,449 20-24 8.3 30.3 90.5 4.8 8.2 1,159 25-29 7.6 28.0 86.0 4.9 12.7 1,038 30-34 7.3 24.0 87.6 5.1 11.0 710 35-39 8.1 18.5 84.2 5.8 14.1 490 40-44 10.4 19.9 88.6 6.6 11.2 430 45-49 7.7 15.2 86.5 5.4 12.8 412 Residence Urban 16.8 58.7 93.7 14.6 4.8 939 Rural 6.0 18.4 86.1 2.7 12.9 4,748 Province City of Kigali 19.5 67.1 95.2 17.3 2.8 739 South 5.0 15.2 85.5 1.5 13.8 1,308 West 5.2 24.8 83.2 3.5 14.5 1,307 North 9.8 16.9 89.4 3.9 9.9 899 East 5.4 17.6 87.3 2.6 12.2 1,435 Education No education 0.3 9.6 76.5 0.0 23.0 583 Primary 4.0 21.2 86.6 1.6 12.2 3,916 Secondary and higher 24.0 45.1 95.0 17.1 3.8 1,189 Wealth quintile Lowest 2.2 11.1 67.1 0.8 30.5 854 Second 3.1 13.4 81.9 1.1 17.3 986 Middle 5.3 17.5 88.3 1.8 10.5 1,139 Fourth 6.8 19.1 94.3 2.4 5.2 1,235 Highest 16.9 51.8 96.1 13.4 2.7 1,474 Total 15-49 7.8 25.0 87.3 4.7 11.5 5,687 50-59 4.7 13.1 84.9 2.9 14.5 642 Total 15-59 7.5 23.8 87.1 4.5 11.8 6,329 Results by residence reveal significant differentials: in urban areas, 16 percent of women are not exposed to any media compared with 33 percent in rural areas. The differential is also wide for men: the proportion of men not exposed to any media varies from 5 percent in urban areas to 13 percent in rural areas. Results by province show significant differences between the City of Kigali and other provinces: the percentage of women who are not exposed to any media is estimated to be 12 percent in the City of Kigali, while in other provinces this proportion varies from 44 percent (West) to 24 percent (North). For men, the proportion is 3 percent in the City of Kigali, while in other provinces it varies from 15 percent (West) to 10 percent (North). Educational attainment has a significant impact on the level of media exposure. For both men and women, those who have secondary education and higher are the most likely to be exposed to all three media: 6 percent of women who have secondary education and higher compared with less than 1 percent of women who have primary education and none of those who have no education. Similarly, 17 percent of men who have secondary education and higher are exposed to all three media compared with 2 percent of men who have primary education and none of those who have no education. The results show that 48 percent of women with no education are not exposed to any media compared with 11 percent of women with secondary education or higher. For men, 23 percent of those with no education are unexposed to any media, compared with only 4 percent of those with secondary or higher education. As in the case of educational attainment, there is a positive relationship between household wealth and media exposure. Men and women in the richest households have the highest levels of exposure to all three media: 5 percent of women and 13 percent of men, compared with less than 1 percent of women and men in the poorest households. 44 • Respondent Characteristics 3.5 EMPLOYMENT The 2010 RDHS asked both men and women whether they were employed at the time of the survey. Respondents who reported having held a job, paid or unpaid, in any sector during the 12 months preceding the survey were considered employed. Table 3.5.1 shows that, at the national level, 11 percent of women were not working at the time of the survey even if they reported working in the preceding 12 months. More than three in five women (73 percent) were employed at the time of the survey. The percentage of women working at the time of the survey increases steadily with age, rising from 52 percent at age 15-19 to 80-83 percent at age 30 and older. Women who were separated, divorced, or widowed (81 percent) and married women (80 percent) were more likely than women never married to be working at the time of the survey. The number of children also affects a woman’s level of employment. As the number of children increases, the proportion of women who work also increases, from 60 percent among women with no children, to 78 percent among women with one or two children, to 82 percent among women with three children or more. Data by residence show that rural areas had the highest proportion of women working at the time of the survey (74 percent compared with 65 percent in urban areas). North province followed by the City of Kigali had the lowest percentages of women working (60 percent and 61 percent, respectively). In other provinces, the proportion of employed women ranged from 72 percent in West province, to 79 percent in East province, to a maximum of 81 percent in South province. Results by educational attainment show that women with no education (80 percent) are proportionally more likely to be employed than women who have primary education (75 percent) and women who have secondary education and higher (55 percent). Finally, women in households in the two poorest wealth quintiles are more likely to be employed (76 percent and 77 percent) than women in the richest households (63 percent). The results for men show that 91 percent of men had some form of employment at the time of the survey. As with women, the percentage of men working at the time of the survey increases with age, from 73 percent for those age 15-19 to 91 percent or more for those age 20 to 49. With respect to marital status, the results show that currently married men are proportionally more likely to be working (99 percent) than separated, divorced, or widowed men (97 percent) and those who have never been married (81 percent respectively). With respect to residence, rural areas had the highest proportion of men working at the time of the survey: 91 percent, compared with 85 percent in rural areas. Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Rwanda 2010 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 52.2 11.7 36.2 100.0 2,945 20-24 70.8 13.0 16.2 100.0 2,683 25-29 78.3 11.7 10.0 100.0 2,494 30-34 80.0 10.8 9.2 100.0 1,822 35-39 83.1 9.1 7.8 100.0 1,447 40-44 80.4 10.3 9.3 100.0 1,168 45-49 82.9 9.0 8.2 100.0 1,112 Marital status Never married 60.6 12.1 27.3 100.0 5,285 Married or living together 79.8 10.5 9.7 100.0 6,897 Divorced/separated/widowed 81.0 11.2 7.8 100.0 1,489 Continued… Respondent Characteristics • 45 Table 3.5.1─Continued Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Number of living children 0 60.0 12.2 27.8 100.0 5,207 1-2 77.7 11.7 10.5 100.0 3,552 3-4 82.0 10.1 7.9 100.0 2,704 5+ 81.7 9.6 8.6 100.0 2,209 Residence Urban 64.6 12.6 22.8 100.0 2,057 Rural 73.9 11.0 15.1 100.0 11,614 Province City of Kigali 61.3 17.6 21.1 100.0 1,596 South 80.6 7.3 12.1 100.0 3,212 West 72.1 5.6 22.3 100.0 3,305 North 60.1 27.1 12.8 100.0 2,278 East 79.0 6.5 14.4 100.0 3,280 Education No education 79.6 10.0 10.4 100.0 2,119 Primary 75.0 10.8 14.2 100.0 9,337 Secondary and higher 55.1 14.1 30.9 100.0 2,216 Wealth quintile Lowest 76.3 10.0 13.7 100.0 2,622 Second 77.0 10.0 13.0 100.0 2,661 Middle 75.1 10.9 14.0 100.0 2,736 Fourth 72.6 11.0 16.4 100.0 2,677 Highest 62.7 13.8 23.5 100.0 2,976 Total 72.5 11.2 16.3 100.0 13,671 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 46 • Respondent Characteristics Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Rwanda 2010 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 72.5 2.9 24.6 100.0 1,449 20-24 90.7 2.9 6.4 100.0 1,159 25-29 97.4 1.3 1.3 100.0 1,038 30-34 97.9 1.4 0.6 100.0 710 35-39 98.5 1.1 0.4 100.0 490 40-44 98.1 1.4 0.5 100.0 430 45-49 98.4 0.6 1.0 100.0 412 Marital status Never married 81.3 3.2 15.5 100.0 2,873 Married or living together 98.9 0.8 0.3 100.0 2,699 Divorced/separated/widowed 97.3 0.0 2.7 100.0 115 Number of living children 0 82.2 2.9 14.9 100.0 2,987 1-2 98.0 1.5 0.5 100.0 1,177 3-4 99.0 0.6 0.4 100.0 841 5+ 99.2 0.5 0.3 100.0 683 Residence Urban 85.3 7.5 7.2 100.0 939 Rural 90.9 0.9 8.2 100.0 4,748 Province Kigali City 85.1 9.4 5.5 100.0 739 South 92.0 2.0 6.0 100.0 1,308 West 93.8 1.0 5.3 100.0 1,307 North 90.1 0.2 9.6 100.0 899 East 87.1 0.2 12.7 100.0 1,435 Education No education 98.5 1.0 0.5 100.0 583 Primary 92.0 1.0 6.9 100.0 3,916 Secondary and higher 79.1 5.6 15.3 100.0 1,189 Wealth quintile Lowest 93.3 1.2 5.5 100.0 854 Second 91.9 0.6 7.5 100.0 986 Middle 91.6 0.4 8.0 100.0 1,139 Fourth 90.0 0.9 9.1 100.0 1,235 Highest 85.5 5.5 9.0 100.0 1,474 Total 15-49 90.0 2.0 8.0 100.0 5,687 50-59 96.5 0.6 3.0 100.0 642 Total 15-59 90.6 1.8 7.5 100.0 6,329 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. With respect to educational attainment, the results show men with no education (99 percent) being proportionally more likely to be employed than men with primary education (92 percent) and men with secondary education and higher (79 percent). By province, the data show that the City of Kigali had the lowest proportion of the population that was working at the time of the survey (85 percent); the highest proportion was located in West province (94 percent). Finally, similar to findings for women, the proportion of men working was lower in the richest households than in the poorest households (86 percent compared with 93 percent). Also, the proportion of men who were working at the time of the survey exceeded the proportion of women who were working at any level of background characteristics. Compared with the previous survey, the proportion of women and men who worked at the time of the survey has increased from 64 percent to 73 percent among women and from 52 percent to 91 percent among men. Similarly, we see that during the 2005 RDHS, women were more likely than men to work at the time of the survey (64 percent of women compared with 52 percent of men in 2005), while today the situation is reversed in favor of men (73 percent of women compared with 91 percent of men). Respondent Characteristics • 47 Table 3.6.1 shows women’s occupations. The majority of women who were employed at the time of the survey, or who had worked during the 12 months preceding it, were employed in agriculture (77 percent compared with 86 percent in 2005). Among those working in other occupations (23 percent), 8 percent performed unskilled manual labor, 7 percent worked in sales and services, 3 percent worked in domestic services, and 2 percent performed skilled manual labor. Only 2 percent reported working in a technical, professional, or managerial occupation. Results by age show that the older women are more likely to work in agriculture than the younger ones (89 percent at age group 45-49, 59 percent at age group 15-19). As expected, the data by residence show that the proportion of women working in agriculture is higher in rural areas (85 percent, 32 percent in urban areas). This proportion is much lower in the City of Kigali (24 percent) than in other provinces where the proportion of women working in agriculture varies from 80 percent (South) to 89 percent (East). With respect to educational attainment, 92 percent of women with no education and 82 percent of women with primary education work in agriculture compared with 35 percent of women with secondary education and higher. Table 3.6.2 shows men’s occupations. Like women, the majority of men work in agriculture (60 percent compared with 62 percent in 2005). Almost one in seven men performs unskilled manual labor (14 percent), and 11 percent perform skilled manual labor. Those proportions have remained stable since 2005. As for women, results by age show that the old men are more likely to work in agriculture than the young ones (72 percent at age group 45- 49, 51 percent at age group 15-19). The results by province show that more than one quarter (28 percent) of men in the City of Kigali work in skilled manual sectors, 19 percent work in sales and services sectors, 18 percent in unskilled manual sectors, and only 15 percent in agriculture. In other provinces, the agricultural occupations dominate. As expected, the proportion of men working in agriculture is higher in the rural areas (68 percent compared with 20 percent in urban areas). Conversely, it appears that men with other occupations are more likely to work in urban areas than in rural areas. In particular, the proportion of men performing skilled manual labor and sales and services is significantly higher in urban areas than in rural areas (25 percent compared with 9 percent in rural areas for skilled manual labor, and 18 percent compared with 5 percent in rural areas for sales and services). For unskilled manual labor, the difference is not big (18 percent in urban areas, 13 percent in rural areas). With respect to educational attainment, the results show that, like women, the majority of men with no education work in agriculture (80 percent compared with 27 percent of those with secondary education and higher). However, of those with secondary education or higher, 14 percent work in professional/technical/managerial occupations. Results by wealth quintile show that a majority of men in the poorest households work in agriculture (77 percent). Twenty- eight percent of men in the richest quintile work in agriculture, and 20 percent work in skilled manual labor capacities. 48 • Respondent Characteristics Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Rwanda 2010 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of women Age 15-19 0.4 0.1 5.7 1.6 26.6 6.9 58.5 0.3 100.0 1,880 20-24 1.9 0.9 7.4 3.5 8.3 3.9 74.0 0.1 100.0 2,250 25-29 2.6 0.6 7.9 2.8 4.1 1.6 80.0 0.3 100.0 2,245 30-34 3.5 0.7 7.8 2.1 3.0 0.8 82.0 0.1 100.0 1,654 35-39 3.3 0.3 7.6 2.7 2.9 0.8 82.2 0.2 100.0 1,334 40-44 2.3 0.2 4.8 1.3 2.3 1.2 87.7 0.2 100.0 1,059 45-49 1.5 0.2 5.2 1.2 2.1 0.9 88.9 0.0 100.0 1,022 Marital status Never married 2.2 0.8 6.7 3.3 18.1 6.4 62.3 0.3 100.0 3,840 Married or living together 2.3 0.3 6.9 1.9 2.8 0.4 85.2 0.2 100.0 6,231 Divorced/separated/widowed 1.5 0.2 7.1 2.0 3.4 2.2 83.7 0.0 100.0 1,373 Number of living children 0 2.5 0.7 6.7 3.4 18.0 6.1 62.3 0.3 100.0 3,759 1-2 2.5 0.6 8.0 2.4 4.0 1.5 80.9 0.1 100.0 3,177 3-4 2.2 0.3 6.5 1.7 2.5 0.7 85.9 0.1 100.0 2,490 5+ 1.2 0.0 5.8 1.1 2.5 0.2 88.9 0.2 100.0 2,018 Residence Urban 7.0 2.6 21.9 6.1 16.5 13.8 31.6 0.6 100.0 1,588 Rural 1.4 0.1 4.4 1.8 6.6 0.8 84.7 0.1 100.0 9,857 Province Kigali City 8.0 3.4 25.2 6.5 15.3 17.5 23.7 0.4 100.0 1,259 South 1.5 0.1 3.5 2.2 11.3 1.1 80.2 0.1 100.0 2,824 West 1.3 0.1 7.8 1.2 5.3 0.4 83.6 0.3 100.0 2,569 North 1.8 0.1 3.9 2.3 8.2 0.7 83.1 0.1 100.0 1,986 East 1.4 0.2 3.3 1.8 3.7 0.8 88.7 0.1 100.0 2,807 Education No education 0.1 0.0 3.6 0.7 2.5 0.7 92.2 0.1 100.0 1,899 Primary 0.2 0.0 6.3 2.4 5.9 3.2 81.8 0.1 100.0 8,014 Secondary and higher 15.2 3.3 13.8 4.2 25.7 2.1 35.2 0.5 100.0 1,532 Wealth quintile Lowest 0.2 0.0 2.4 1.2 7.1 0.2 88.9 0.2 100.0 2,263 Second 0.1 0.0 3.0 1.1 5.8 0.5 89.4 0.0 100.0 2,314 Middle 0.4 0.0 3.9 1.5 6.2 0.4 87.4 0.1 100.0 2,352 Fourth 0.7 0.1 5.1 2.7 6.1 0.4 84.7 0.1 100.0 2,237 Highest 9.6 2.2 20.0 5.3 14.9 11.7 35.9 0.5 100.0 2,278 Total 2.2 0.5 6.9 2.4 8.0 2.6 77.3 0.2 100.0 11,444 Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Rwanda 2010 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of men Age 15-19 0.0 0.1 4.7 3.9 32.4 8.1 50.6 0.3 100.0 1,092 20-24 3.5 0.4 8.4 12.5 16.7 3.8 54.7 0.0 100.0 1,084 25-29 3.2 0.9 8.9 13.7 9.4 1.2 62.6 0.1 100.0 1,024 30-34 4.4 0.7 10.2 17.1 5.6 0.5 61.2 0.4 100.0 706 35-39 5.6 0.5 6.1 8.8 5.5 0.2 73.0 0.4 100.0 488 40-44 4.8 1.0 8.9 12.6 4.4 0.4 67.7 0.2 100.0 428 45-49 3.2 0.7 5.0 13.2 5.0 0.3 72.1 0.4 100.0 408 Marital status Never married 3.0 0.4 7.2 10.5 22.8 5.8 50.0 0.3 100.0 2,427 Married or living together 3.3 0.7 7.8 11.7 6.4 0.2 69.6 0.2 100.0 2,692 Divorced/separated/widowed 0.6 0.0 6.2 18.0 7.9 1.7 65.6 0.0 100.0 112 Number of living children 0 3.0 0.5 7.2 9.9 22.3 5.5 51.4 0.2 100.0 2,541 1-2 3.0 0.8 8.3 14.5 9.0 0.6 63.7 0.1 100.0 1,171 3-4 3.1 0.7 8.3 12.0 3.6 0.2 71.6 0.5 100.0 837 5+ 3.8 0.3 6.2 10.0 4.9 0.2 74.5 0.2 100.0 681 Residence Urban 7.1 2.3 17.8 25.0 18.4 8.4 20.1 0.9 100.0 872 Rural 2.3 0.2 5.4 8.5 13.2 1.7 68.4 0.1 100.0 4,359 Continued… Respondent Characteristics • 49 Table 3.6.2─Continued Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of men Province City of Kigali 7.1 2.6 19.2 27.8 18.1 8.7 15.4 1.0 100.0 698 South 2.3 0.1 5.1 8.1 11.5 3.7 68.9 0.2 100.0 1,229 West 2.9 0.5 7.0 9.1 18.4 1.9 60.2 0.1 100.0 1,238 North 2.7 0.6 5.3 9.9 16.7 0.4 64.2 0.2 100.0 812 East 2.1 0.0 5.2 8.2 8.3 1.3 74.8 0.1 100.0 1,252 Education No education 0.2 0.3 4.0 5.9 7.8 2.1 79.5 0.2 100.0 580 Primary 0.6 0.2 7.5 9.9 11.9 3.2 66.5 0.1 100.0 3,644 Secondary and higher 13.9 2.0 9.5 19.3 25.5 2.0 27.2 0.7 100.0 1,007 Wealth quintile Lowest 0.2 0.0 2.3 5.4 13.1 1.1 77.4 0.4 100.0 807 Second 0.6 0.2 3.0 7.0 13.9 0.7 74.6 0.0 100.0 912 Middle 1.1 0.1 3.6 8.4 12.3 0.7 73.8 0.0 100.0 1,048 Fourth 1.9 0.4 7.5 11.5 13.6 1.5 63.4 0.1 100.0 1,122 Highest 9.1 1.6 16.7 19.8 16.5 8.2 27.5 0.6 100.0 1,341 Total 15-49 3.1 0.6 7.5 11.3 14.1 2.9 60.4 0.2 100.0 5,230 50-59 3.0 0.4 2.3 10.0 4.8 0.3 79.0 0.1 100.0 622 Total 15-59 3.1 0.5 7.0 11.1 13.1 2.6 62.4 0.2 100.0 5,853 Table 3.7 shows the distribution of women employed during the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment. Overall, 55 percent of women in agricultural occupations were paid in cash and in-kind, 18 percent were paid in-kind only, 16 were not paid for their work, and only 11 percent were paid in cash only. Women in nonagricultural occupations were more likely to be paid in cash (63 percent) than those working in agriculture (11 percent). Slightly more than one quarter (27 percent) of women in nonagricultural occupations were not paid for their work. In the majority of cases, women are self-employed, regardless of their occupations (68 percent of women in agricultural occupations, 66 percent of those in nonagricultural occupations). Women who work in agriculture are more likely to work for a family member than women in nonagricultural occupations (16 percent compared with 4 percent). Note also that about a third (30 percent) of women working in nonagricultural occupations are employed by a nonfamily member, while this proportion is about 17 percent for women working in agricultural occupations. Finally, 73 percent of all women work all year, and about one in five (20 percent in nonagricultural, 19 percent in agricultural occupations) works occasionally. 50 • Respondent Characteristics Table 3.7 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Rwanda 2010 Employment Characteristic Agricultural work Nonagricultural work Missing Total Type of earnings Cash only 10.9 62.5 52.7 22.6 Cash and in-kind 54.8 8.5 9.2 44.3 In-kind only 18.2 1.5 5.6 14.4 Not paid 15.9 26.5 27.2 18.3 Missing 0.1 1.0 5.3 0.3 Total 100.0 100.0 100.0 100.0 Type of employer Employed by family member 15.5 3.7 0.0 12.8 Employed by nonfamily member 16.5 29.6 33.5 19.5 Self-employed 68.0 65.6 61.2 67.4 Missing 0.0 1.0 5.3 0.3 Total 100.0 100.0 100.0 100.0 Continuity of employment All year 72.6 72.0 80.9 72.5 Seasonal 8.6 7.0 0.0 8.2 Occasional 18.8 20.0 13.7 19.0 Missing 0.1 1.0 5.3 0.3 Total 100.0 100.0 100.0 100.0 Number of women employed during the last 12 months 8,849 2,574 21 11,444 Note: Total includes women with missing information on type of employment who are not shown separately. 3.6 USE OF TOBACCO The consumption of tobacco has a negative impact on children’s health, because it affects not only the health of those who consume it but also the health of those in proximity to people who consume it. For this reason, the 2010 RDHS asked questions to determine the level of tobacco consumption among the women surveyed. Table 3.8.1 shows percentages of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, according to their background characteristics and maternity status. The results show that the vast majority of women in Rwanda do not smoke tobacco (96 percent). The proportion of women who smoke cigarettes or a pipe is very low: less than 1 percent reported smoking cigarettes or a pipe, although 3 percent consume other tobacco products. Although the proportion of women who smoke tobacco is low, it appears that the oldest women age 45-49 are more likely to use other tobacco products (9 percent) or to smoke a pipe (4 percent). Four percent of breastfeeding women reported using other tobacco products, and this proportion was 2 percent for pregnant women. Women in rural areas consume other tobacco products more frequently than those in urban areas (3 percent, 1 percent in rural areas). By province we find that the women in South province are most likely to consume other tobacco products (5 percent), followed by East province (4 percent), and other provinces (2 percent in North and in City of Kigali and less than 1 percent in West). Finally, women with no education and those who are in the lowest wealth quintile are proportionally more likely than other women to smoke other tobacco products (7 percent and 6 percent, respectively). Respondent Characteristics • 51 Table 3.8.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, according to background characteristics and maternity status, Rwanda 2010 Background characteristic Uses tobacco Does not use tobacco Number of women Cigarettes Pipe Other tobacco Age 15-19 0.0 0.0 0.1 99.8 2,945 20-24 0.2 0.0 0.8 99.0 2,683 25-29 0.3 0.0 1.9 97.8 2,494 30-34 0.5 0.5 2.6 96.5 1,822 35-39 0.3 1.3 5.1 93.5 1,447 40-44 1.2 1.6 6.7 91.2 1,168 45-49 0.8 3.7 9.3 87.4 1,112 Maternity status Pregnant 0.1 0.2 2.0 97.8 956 Breastfeeding (not pregnant) 0.4 0.5 3.7 95.6 4,178 Neither 0.4 0.7 2.4 96.7 8,536 Residence Urban 0.8 0.2 1.2 97.8 2,057 Rural 0.3 0.7 3.0 96.2 11,614 Province City of Kigali 0.7 0.1 1.5 97.7 1,596 South 0.6 0.1 4.8 94.7 3,212 West 0.1 0.3 0.7 99.1 3,305 North 0.3 2.4 2.2 95.5 2,278 East 0.3 0.6 3.8 95.5 3,280 Education No education 0.6 2.5 7.2 90.3 2,119 Primary 0.3 0.4 2.3 97.1 9,337 Secondary and higher 0.4 0.0 0.2 99.3 2,216 Wealth quintile Lowest 0.7 0.9 6.0 93.0 2,622 Second 0.2 0.8 3.4 95.6 2,661 Middle 0.2 1.0 2.5 96.4 2,736 Fourth 0.2 0.5 1.6 97.8 2,677 Highest 0.5 0.1 0.5 99.0 2,976 Total 0.4 0.6 2.8 96.4 13,671 Table 3.8.2 shows the percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics. The results show that 86 percent of men in Rwanda do not smoke tobacco. Eleven percent of men reported smoking cigarettes, and 5 percent reported consuming other tobacco products. Table 3.8.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Rwanda 2010 Background characteristic Uses tobacco Does not use tobacco Number of men Number of cigarettes in the last 24 hours Total Number of cigarette smokersCigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Don't know/ missing Age 15-19 1.7 0.0 0.5 98.2 1,449 8.5 31.2 45.7 10.4 4.2 0.0 100.0 25 20-24 10.3 0.2 1.8 89.1 1,159 9.7 27.6 41.6 11.4 9.6 0.0 100.0 119 25-29 14.7 0.1 3.6 83.9 1,038 8.5 24.4 40.3 11.8 13.6 1.5 100.0 153 30-34 15.2 0.1 3.7 82.6 710 5.4 33.1 30.7 9.8 21.0 0.0 100.0 108 35-39 16.5 0.4 8.5 78.6 490 10.6 35.4 26.6 13.8 11.8 1.9 100.0 81 40-44 14.9 1.0 12.5 76.3 430 14.7 23.2 36.4 12.3 13.5 0.0 100.0 64 45-49 20.6 2.2 18.2 67.3 412 19.7 34.7 27.9 9.3 6.9 1.5 100.0 85 Residence Urban 13.2 0.2 2.1 85.9 939 9.9 18.7 30.3 15.7 24.8 0.6 100.0 124 Rural 10.7 0.4 5.1 86.3 4,748 10.7 32.0 36.6 10.2 9.7 0.8 100.0 510 Continued… 52 • Respondent Characteristics Table 3.8.2─Continued Background characteristic Uses tobacco Does not use tobacco Number of men Number of cigarettes in the last 24 hours Total Number of cigarette smokersCigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Don't know/ missing Province Kigali City 13.6 0.0 2.0 85.8 739 7.0 19.0 31.2 16.9 25.1 0.7 100.0 100 South 14.9 0.0 7.7 81.1 1,308 17.6 24.0 32.5 11.2 14.3 0.4 100.0 195 West 6.7 0.0 1.9 92.7 1,307 10.2 28.6 38.6 11.5 11.2 0.0 100.0 88 North 8.9 1.6 4.9 87.4 899 12.2 37.0 36.3 6.7 6.5 1.4 100.0 80 East 11.9 0.3 5.4 84.3 1,435 4.2 38.5 38.8 10.1 7.0 1.4 100.0 171 Education No education 20.3 1.2 15.1 69.5 583 15.9 28.9 34.4 10.1 10.7 0.0 100.0 118 Primary 11.6 0.3 4.2 86.1 3,916 9.5 30.1 36.6 10.5 12.4 0.9 100.0 455 Secondary and higher 5.1 0.0 0.8 94.7 1,189 8.6 25.1 27.9 19.4 17.6 1.3 100.0 61 Wealth quintile Lowest 16.5 0.7 11.4 77.0 854 18.0 29.4 37.8 7.7 7.2 0.0 100.0 141 Second 11.0 0.2 5.5 84.9 986 9.5 35.7 35.9 5.9 12.9 0.0 100.0 108 Middle 11.6 0.7 5.2 85.8 1,139 6.1 34.1 38.2 10.6 9.1 1.8 100.0 132 Fourth 8.8 0.1 2.7 89.7 1,235 11.5 33.5 29.0 12.9 12.1 1.0 100.0 108 Highest 9.9 0.1 1.3 89.8 1,474 7.5 17.4 34.6 18.3 21.2 1.0 100.0 145 Total 15-49 11.2 0.3 4.6 86.2 5,687 10.6 29.4 35.3 11.3 12.6 0.8 100.0 634 50-59 19.5 6.7 19.2 63.4 642 13.9 29.0 35.8 13.0 5.0 3.2 100.0 125 Total 15-59 12.0 1.0 6.1 83.9 6,329 11.1 29.3 35.4 11.6 11.4 1.2 100.0 760 The proportion of men who smoke cigarettes increases as age increases (from 2 percent at age 15-19 to 10 percent at age 20-24 and to 21 percent at age group 45-49). The proportion of men who use other tobacco products follows a similar pattern (from 2 percent at age group 20-24 to 18 percent at age group 45-49). There is no big difference between urban areas and rural areas concerning consumption of cigarettes or other tobacco products among men: 13 percent in urban areas and 11 percent in rural areas smoke cigarettes. By province, we find that the men in South province, the City of Kigali, and East province are likely to smoke cigarettes (15 percent, 14 percent, and 12 percent, respectively). The proportions in the West and North provinces are only 7 percent and 9 percent, respectively. As for women, men with no education (20 percent) and those classified in the lowest wealth quintile (17 percent) are more likely to smoke cigarettes and other tobacco products than others. Among the men who smoke cigarettes, 35 percent reported smoking from 3 to 5 cigarettes in the 24 hours preceding the survey, 29 percent smoked from 1 to 2 cigarettes, 13 percent smoked 10 or more cigarettes, and 11 percent smoked from 6 to 9 cigarettes. Note also that 11 percent of the men who smoke did not smoke a cigarette 24 hours before the interview. Proximate Determinants of Fertility • 53 PROXIMATE DETERMINANTS OF FERTILITY 4 his chapter addresses the key factors that define the risk of becoming pregnant. These include age at first marriage, age at first sexual intercourse, sexual activity, and postpartum abstinence and amenorrhea. 4.1 MARITAL STATUS In Rwanda, formal unions (married) or informal unions (living together) between men and women are the sole socially permissible context for sexual activity. Marital status can therefore be considered the primary factor initiating exposure to the risk of pregnancy. In the data discussed in this section, the term married refers to men and women bound together legally, while living together refers to couples cohabiting in informal unions. People are considered never married if they are not currently married, living together, widowed, separated, or divorced. Table 4.1 shows the distribution of men and women by marital status and according to age at the time of the survey. Of the 13,671 women interviewed, 51 percent were in union. This proportion has remained relatively stable since the 2005 RDHS when the proportion was 49 percent. The proportion of women in formal marriages, however, has increased from 29 percent to 35 percent during this period, while the proportion of women in informal union has declined from 20 percent in 2005 to 15 percent in 2010. Similarly, the proportion of divorced women has increased since the 2005 RDHS, rising from 1 percent to 5 percent, while the proportion of separated women has decreased since the 2005 RDHS, from 9 percent to 1 percent. The proportion of widows has remained relatively stable since the last survey at 5 percent. The proportion of never-married women makes up 39 percent, a percentage that has remained stable since 2005 when it was 38 percent. The largest proportion of never-married women is observed in the age group 15 to 19, of whom 96 percent had never been married in 2010. This proportion was 90 percent in 1992, 93 percent in 2000, and 97 percent in 2005. Table 4.1 Current marital status Percent distribution of women and men age 15-49 , by current marital status, according to age, Rwanda 2010 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed WOMEN Age 15-19 96.4 0.4 2.7 0.4 0.2 0.0 100.0 3.0 2,945 20-24 58.8 15.8 21.4 2.4 1.2 0.4 100.0 37.2 2,683 25-29 22.1 48.5 22.6 4.9 1.0 1.0 100.0 71.1 2,494 30-34 8.7 62.4 17.7 6.7 1.2 3.4 100.0 80.0 1,822 35-39 5.3 59.0 17.9 9.1 0.4 8.4 100.0 76.9 1,447 40-44 5.3 51.4 15.3 8.2 0.8 19.0 100.0 66.8 1,168 45-49 1.9 50.8 11.0 8.0 1.0 27.3 100.0 61.8 1,112 Total 15-49 38.7 35.1 15.3 4.7 0.8 5.4 100.0 50.5 13,671 MEN Age 15-19 99.8 0.0 0.2 0.0 0.0 0.0 100.0 0.2 1,449 20-24 79.9 6.5 12.7 0.8 0.2 0.0 100.0 19.1 1,159 25-29 35.3 40.0 22.2 1.6 0.7 0.2 100.0 62.2 1,038 30-34 11.0 64.6 21.7 1.5 0.9 0.3 100.0 86.3 710 35-39 6.2 69.1 20.5 2.7 0.8 0.7 100.0 89.6 490 40-44 4.3 75.0 17.3 1.7 0.6 1.1 100.0 92.3 430 45-49 2.2 79.7 12.6 1.9 1.0 2.5 100.0 92.4 412 Total 15-49 50.5 34.1 13.4 1.1 0.5 0.4 100.0 47.5 5,687 50-59 0.9 77.1 14.5 1.4 1.0 4.9 100.0 91.7 642 Total 15-59 45.5 38.4 13.5 1.2 0.5 0.9 100.0 51.9 6,329 T 54 • Proximate Determinants Of Fertility Among the 5,687 men surveyed, 51 percent were never married compared with 46 percent in 2005, 48 percent were in union compared with 52 percent in 2005, and 34 percent were in formal marriages, the same as in 2005. Thirteen percent were living together, compared with 18 percent in 2005. In addition, 1 percent was either separated or divorced (0.5 percent separated, 1.1 percent divorced). This status was relatively the same in 2005. Less than 1 percent of the men were widowed (0.4). A comparison of these data with the results of the previous survey shows no change in proportions of separated or divorced men, while there is a decrease in the proportion of men living together and the proportion of men that never married. 4.2 POLYGAMY The survey asked currently married women (in formal or informal union) whether their partners had other wives. Table 4.2.1 shows the percent distribution of married women by number of co-wives, according to background characteristics. Polygamy is not very common in Rwanda. However, although it’s illegal, it affects 8 percent of women in union. This proportion has decreased since 2005 when it was 12 percent. However, the proportion of women with only one co-wife has increased at the expense of women with more than one co-wife (0.1 percent in 2005 compared with 7.1 percent in 2010 for those whose husbands had only one co-wife and 11.5 percent in 2005 compared with 1.2 percent for those whose husbands had more than one co-wife). The proportion of women with one co-wife increases steadily with age, from 4 percent at age 15-19, to 12 percent at age 45-49. The extent of polygamy differs by residence; the percentage of married women living in polygamous unions with one co-wife is 4 percent in urban areas compared with 8 percent in rural areas. Variations between the provinces are few except in City of Kigali where the proportion of women with one co-wife falls to 4 percent. However, women’s level of education does affect the frequency of this practice: the percentage of married women with one co-wife is four times higher among women with no education (12 percent) than among women with a secondary education or higher (3 percent). The proportion of women with one co-wife decreases with wealth quintile, going from 8 percent for the lowest quintile to 4 percent for the highest quintile. Table 4.2.1 Number of women's co-wives Percent distribution of currently married women age 15-49 by number of co-wives, according to background characteristics, Rwanda 2010 Background characteristic Number of co-wives Total Number of women 0 1 2+ DK Age 15-19 95.2 3.5 1.4 0.0 100.0 89 20-24 96.5 3.1 0.3 0.1 100.0 998 25-29 94.0 5.0 0.7 0.4 100.0 1,773 30-34 92.2 6.4 1.1 0.2 100.0 1,458 35-39 88.7 9.5 1.0 0.8 100.0 1,112 40-44 85.1 10.9 3.0 1.1 100.0 780 45-49 85.2 11.8 2.5 0.5 100.0 688 Residence Urban 94.8 4.2 0.8 0.2 100.0 926 Rural 90.7 7.5 1.3 0.5 100.0 5,971 Province City of Kigali 95.8 3.8 0.2 0.2 100.0 726 South 91.2 7.2 1.1 0.5 100.0 1,614 West 89.4 8.2 1.6 0.7 100.0 1,675 North 92.9 5.7 0.9 0.6 100.0 1,151 East 90.2 8.1 1.6 0.2 100.0 1,731 Education No education 85.4 11.9 2.1 0.7 100.0 1,355 Primary 92.1 6.3 1.1 0.4 100.0 4,816 Secondary and higher 96.6 3.0 0.1 0.2 100.0 727 Wealth quintile Lowest 89.2 8.3 1.6 0.8 100.0 1,352 Second 89.3 9.0 0.9 0.8 100.0 1,388 Middle 90.8 7.6 1.4 0.3 100.0 1,394 Fourth 91.9 6.7 1.3 0.1 100.0 1,415 Highest 95.2 3.7 0.8 0.2 100.0 1,348 Total 91.3 7.1 1.2 0.5 100.0 6,897 Proximate Determinants of Fertility • 55 Table 4.2.2 shows polygamy for men. The proportion of polygamous married men is very low (2 percent compared with 5 percent in 2005). Results by age show that the proportion of polygamous married men increases with age, climbing from 0 percent at age 20-24 to 4 percent at age 45-49. Also, polygamy is more common in rural areas than in urban areas (respectively, 2.3 and 0.6 percent). The influence of education on polygamy is also visible. Men without education are more likely to be polygamous than those with primary or higher education (3.1 percent for men with no education compared with 1.4 percent for those with a secondary or higher level of education). West and East provinces have the highest proportions of polygamous married men (3 percent). There is no steady trend of polygamous by wealth quintile for men in one direction but it is twice as high than average (4 percent) for men in middle quintile. Table 4.2.2 Number of men's wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Rwanda 2010 Background characteristic Number of wives Total Number of men 1 2+ Age 15-19 * * * 3 20-24 100.0 0.0 100.0 222 25-29 99.1 0.9 100.0 646 30-34 97.8 2.2 100.0 613 35-39 97.4 2.6 100.0 439 40-44 97.4 2.6 100.0 397 45-49 96.1 3.9 100.0 380 Residence Urban 99.4 0.6 100.0 391 Rural 97.7 2.3 100.0 2,308 Province City of Kigali 98.8 1.2 100.0 307 South 98.2 1.8 100.0 624 West 97.2 2.8 100.0 623 North 99.0 1.0 100.0 430 East 97.3 2.7 100.0 715 Education No education 96.9 3.1 100.0 438 Primary 98.0 2.0 100.0 1,893 Secondary and higher 98.6 1.4 100.0 368 Wealth quintile Lowest 98.5 1.5 100.0 467 Second 98.1 1.9 100.0 523 Middle 96.1 3.9 100.0 558 Fourth 98.1 1.9 100.0 580 Highest 98.9 1.1 100.0 572 Total 15-49 97.9 2.1 100.0 2,699 50-59 94.5 5.5 100.0 588 Total 15-59 97.3 2.7 100.0 3,287 Note: An asterisk indicates that the figure is based on fewer than 25 unweighted cases and has been suppressed. 4.3 AGE AT FIRST UNION Marriage remains the legally sanctioned context for sexual intercourse in Rwanda. Therefore, despite the existence of prenuptial intercourse, age at first marriage constitutes the beginning of exposure to the risk of pregnancy. For this reason, analysis of the age at first union is very important. Table 4.3 and Table 4.4 show the percentage of currently married men and women by age at first marriage, according to current age. The proportion of women who were age 25-49 during the survey and who reported being married at age 15 is very low (2 percent). At age 18, the proportion is significantly higher (17 percent). At age 20, more than three in ten women (36 percent) are married; at age 22, slightly more than half of women are married (56 percent); at age 25, three quarters of women have already celebrated their first marriage (76 percent). The median 56 • Proximate Determinants Of Fertility age at first union is 21.4 years, which is relatively late. This has remained more or less unchanged since 2005, when the median age at first union was 20.7. Based on the 2005 RDHS, it appears that women are marrying progressively later: 82 percent of women were married at age 25 in 2005, while this proportion has fallen to 76 percent in the current survey. According to the data, men marry at a later age than women. At age 25, half of men are in union (51 percent). The median age at first union is 24.9 years for men age 25-59 and is nearly identical to the estimate from the preceding survey (24.6 years). Table 4.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Rwanda 2010 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN Age 15-19 0.2 na na na na 96.4 2,945 a 20-24 0.8 8.1 20.1 na na 58.8 2,683 a 25-29 1.7 12.9 27.7 47.1 69.0 22.1 2,494 22.3 30-34 1.5 18.8 40.9 59.1 75.2 8.7 1,822 20.9 35-39 2.2 17.1 37.2 61.7 83.7 5.3 1,447 20.9 40-44 3.0 18.6 35.5 56.3 78.3 5.3 1,168 21.4 45-49 3.2 20.9 42.8 64.4 83.9 1.9 1,112 20.6 20-49 1.8 14.7 31.8 na na 22.8 10,726 a 25-49 2.1 16.9 35.6 56.2 76.4 10.8 8,043 21.4 MEN Age 15-19 0.0 na na na na 99.8 1,449 a 20-24 0.0 1.5 5.1 - na 79.9 1,159 a 25-29 0.0 2.3 9.4 20.8 47.6 35.3 1,038 a 30-34 0.3 3.9 13.3 28.4 51.4 11.0 710 24.8 35-39 0.5 2.9 7.9 22.3 53.1 6.2 490 24.6 40-44 0.0 2.5 7.2 14.4 38.7 4.3 430 25.8 25-49 0.2 2.9 10.1 22.4 48.1 16.3 3,080 a 25-59 0.2 3.4 11.9 25.7 50.8 13.7 3,722 24.9 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner na = Not applicable due to censoring a = Omitted because less than 50 percent of the women or men began living with their spouse or partner for the first time before reaching the beginning of the age group Table 4.4 shows the median age at first union for men and women, according to background characteristics. In rural areas, the median age at first marriage for women is slightly lower than in urban areas: age 21.2 compared with age 23.0 in urban areas. The data show variations by province: among women, the East province has the earliest age at first union (20.4 years), and the South province and City of Kigali have the latest ages (22.3 years and 23.3 years, respectively). The level of education is the variable that most affects age at first union: among women with no education, the median age is 20.1 years; it is 21.4 years for those with a primary education and 23.6 years for those with a secondary education. This indicates that remaining in the school system allows women to delay marriage. Results according to wealth quintile show virtually no differences among the four lowest quintiles; however, women in the richest quintile enter into first union later than women in the other quintiles (22.8 years compared with 21 years for the poorest quintile). Proximate Determinants of Fertility • 57 Table 4.4 Median age at first marriage by background characteristics Median age at first marriage among women age 25-49, and median age at first marriage among men age 25-59, according to background characteristics, Rwanda 2010 Background characteristic Women age Men age 25-49 25-59 Residence Urban 23.0 a Rural 21.2 24.8 Province City of Kigali 23.3 a South 22.3 a West 21.1 24.4 North 20.9 24.2 East 20.4 24.5 Education No education 20.1 24.1 Primary 21.4 24.8 Secondary and higher 23.6 a Wealth quintile Lowest 21.0 24.7 Second 21.1 24.7 Middle 21.1 24.4 Fourth 21.2 24.7 Highest 22.8 a Total 21.4 24.9 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner a = Omitted because less than 50 percent of the respondents began living with their spouse/partners for the first time before reaching the beginning of the age group 4.4 AGE AT FIRST SEXUAL INTERCOURSE Although marriage is still considered the only socially sanctioned context for sexual activity, prenuptial sex is increasingly common. For this reason, the survey asked respondents their age at the time they first had sexual intercourse. Table 4.5 shows percentages for both women and men according to age at first sexual intercourse, and the median age at first intercourse for both sexes. In Rwanda very few women have sexual intercourse at an early age (2.7 percent by exact age 15). Approximately one in five women (20.8 percent) first had sexual intercourse by age 18. At age 20, two in five (41.4 percent) women have had sexual intercourse. The median age at first sexual intercourse is estimated at 20.7 years. There has been virtually no change since the 2005 survey where median age at first sexual intercourse was 20.3 years. It appears that the median age at first intercourse is nearly identical to the median age at first union, which seems to confirm that the majority of Rwandan women have their first sexual intercourse at the time of their first union. With respect to men, there are also very few who have sexual intercourse for the first time prior to age 15 (3.2 percent). However, nearly three-quarters of men have had sexual intercourse by age 25 (73.1 percent). The median age at first sexual intercourse is 21.6 years for men age 25-59. Unlike women, men’s age at first sexual intercourse is 3.3 years younger than their age at first union. The finding was similar to the previous survey where the range between the age at first sexual intercourse and the age at first union was 3.7 years. 58 • Proximate Determinants Of Fertility Table 4.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first intercourse, according to current age, Rwanda 2010 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse 15 18 20 22 25 WOMEN Age 15-19 4.8 na na na na 85.3 2,945 a 20-24 2.8 16.0 34.2 na na 42.2 2,683 a 25-29 2.4 18.2 36.3 57.3 78.2 12.5 2,494 21.3 30-34 2.1 22.3 45.6 65.0 80.2 4.5 1,822 20.4 35-39 2.8 21.4 43.9 67.7 87.0 2.1 1,447 20.4 40-44 3.7 22.1 40.0 60.9 81.1 1.8 1,168 20.9 45-49 2.9 21.9 44.5 65.9 84.3 0.4 1,112 20.5 20-49 2.7 19.6 39.6 na na 14.8 10,726 a 25-49 2.7 20.8 41.4 62.6 81.5 5.6 8,043 20.7 MEN Age 15-19 13.3 na na na na 78.5 1,449 a 20-24 8.8 26.4 41.3 na na 39.4 1,159 a 25-29 4.3 17.2 32.5 49.7 74.5 11.3 1,038 22.0 30-34 2.5 15.7 33.6 52.2 71.3 1.5 710 21.7 35-39 1.9 12.0 32.8 51.1 72.3 1.0 490 21.8 40-44 2.0 13.8 29.6 45.4 67.4 1.5 430 22.8 45-49 3.0 17.0 35.3 53.4 69.4 0.4 412 21.2 25-49 3.0 15.5 32.8 50.4 71.7 4.6 3,080 21.9 25-59 3.2 16.4 34.6 52.6 73.1 3.8 3,722 21.6 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Table 4.6 shows the median age at first sexual intercourse, according to background characteristics, for both men and women. Neither the area of residence nor the wealth quintile affects the age at first sexual intercourse among women and men. The greatest variation in median age at first intercourse is by level of education: for women and men alike, the higher the level of education, the later the median age at first sexual intercourse. Among women, this median age ranges from 19.8 years for those with no education to 22.6 years for those with secondary education or higher. Among men, it ranges from 21.2 to 22.3 years, respectively. In the provinces, the median age at first intercourse for women varies slightly, from 20.0 years in East province to 21.5 years in South province; for men it varies from 20.8 years in East province to 22.6 years in South province. Proximate Determinants of Fertility • 59 Table 4.6 Median age at first intercourse by background characteristics Median age at first sexual intercourse among women age 25-49, and median age at first sexual intercourse among men age 25-59, according to background characteristics, Rwanda 2010 Background characteristic Women age Men age 25-49 25-59 Residence Urban 21.0 21.3 Rural 20.7 21.7 Province Kigali City 21.3 21.2 South 21.5 22.6 West 20.7 21.8 North 20.5 21.6 East 20.0 20.8 Education No education 19.8 21.2 Primary 20.8 21.5 Secondary and higher 22.6 22.3 Wealth quintile Lowest 20.5 22.2 Second 20.6 21.6 Middle 20.6 21.7 Fourth 20.7 21.4 Highest 21.3 21.4 Total 20.7 21.6 4.5 RECENT SEXUAL ACTIVITY Frequency of sexual intercourse is a direct determinant of fertility. Therefore, the survey asked all men and women, regardless of marital status, how long it had been since they last had sexual intercourse. Table 4.7.1 shows the data on most recent sexual activity for women, according to background characteristics. Forty-eight percent of all women age 15-49 had sexual intercourse in the four weeks preceding the survey. Recent sexual activity was most common among women age 30-34, three quarters (75 percent) of them reported being sexually active in the past four weeks. The results also show that married women are most likely to have been sexually active in the past four weeks (90.6 percent). Recent sexual activity decreases with marital duration, from a high of 95 percent for marital durations of 0-4 years, to a low of 82 percent for marital durations of 25 years or more. Women in rural areas reported a higher level of sexual activity in the past four weeks (48 percent) than women in urban areas (44 percent). 60 • Proximate Determinants Of Fertility Table 4.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Rwanda 2010 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 4.3 3.5 6.8 0.0 85.3 100.0 2,945 20-24 37.6 8.4 11.8 0.0 42.2 100.0 2,683 25-29 68.9 9.2 9.4 0.0 12.5 100.0 2,494 30-34 75.2 9.4 10.9 0.0 4.5 100.0 1,822 35-39 68.5 11.2 18.1 0.1 2.1 100.0 1,447 40-44 59.4 10.2 28.6 0.0 1.8 100.0 1,168 45-49 52.7 9.7 36.9 0.2 0.4 100.0 1,112 Marital status Never married 2.6 6.1 13.8 0.0 77.5 100.0 5,285 Married or living together 90.6 6.7 2.7 0.0 0.0 100.0 6,897 Divorced/separated/widowed 7.1 22.5 70.3 0.1 0.0 100.0 1,489 Marital duration2 0-4 years 95.0 4.5 0.4 0.0 0.0 100.0 1,686 5-9 years 92.6 5.7 1.7 0.0 0.0 100.0 1,410 10-14 years 90.3 7.5 2.2 0.0 0.0 100.0 1,117 15-19 years 86.6 9.0 4.3 0.1 0.0 100.0 922 20-24 years 89.2 5.6 5.0 0.2 0.0 100.0 505 25+ years 82.2 9.6 8.2 0.0 0.0 100.0 494 Married more than once 88.8 8.0 3.1 0.0 0.0 100.0 764 Residence Urban 43.5 9.2 16.1 0.1 31.0 100.0 2,057 Rural 48.2 8.0 14.0 0.0 29.8 100.0 11,614 Province City of Kigali 43.2 9.3 16.6 0.1 30.8 100.0 1,596 South 46.1 8.5 15.9 0.0 29.4 100.0 3,212 West 47.7 7.4 12.6 0.1 32.2 100.0 3,305 North 47.8 8.0 12.5 0.0 31.7 100.0 2,278 East 50.6 8.2 14.6 0.0 26.6 100.0 3,280 Education No education 58.0 10.0 24.1 0.0 7.8 100.0 2,119 Primary 49.1 8.0 12.6 0.0 30.3 100.0 9,337 Secondary and higher 30.7 7.1 12.4 0.1 49.7 100.0 2,216 Wealth quintile Lowest 46.8 10.2 19.6 0.1 23.3 100.0 2,622 Second 48.5 8.9 14.7 0.0 27.9 100.0 2,661 Middle 48.7 7.1 13.0 0.0 31.2 100.0 2,736 Fourth 51.1 6.2 10.8 0.0 31.9 100.0 2,677 Highest 42.9 8.6 13.7 0.1 34.8 100.0 2,976 Total 47.5 8.2 14.3 0.0 30.0 100.0 13,671 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married The percentage of women who had sexual intercourse during the past four weeks decreases as level of education increases (58 percent for those with no education, 49 percent for those with primary education, and 31 percent for those with secondary education or higher). Table 4.7.2 presents information on recent sexual activity among men, according to background characteristics. The data indicate that 47 percent of men age 15-49 had sexual intercourse in the four weeks preceding the survey. The proportion of men who are sexually active increases with age and then begins to decline at age 45. Sexual activity peaks between age 30 and 44 (86 percent to 87 percent). Like women, married men are more sexually active (95 percent) than unmarried men. Results by marital duration show a slow increase of sexual activity between marital durations of 0 to 4 years (95 percent) and 10 to 14 years (96 percent) and then a decrease from durations of 15 to 19 years (94 percent) to durations of 25 years or more (89 percent). Proximate Determinants of Fertility • 61 Table 4.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Rwanda 2010 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 1.0 4.4 16.1 0.0 78.5 100.0 1,449 20-24 21.6 14.1 24.8 0.1 39.4 100.0 1,159 25-29 63.1 11.7 13.9 0.1 11.3 100.0 1,038 30-34 85.7 6.6 5.8 0.3 1.5 100.0 710 35-39 86.6 7.7 4.8 0.0 1.0 100.0 490 40-44 87.4 7.6 3.3 0.2 1.5 100.0 430 45-49 83.9 10.1 5.5 0.0 0.4 100.0 412 Marital status Never married 3.4 11.3 25.0 0.0 60.3 100.0 2,873 Married or living together 94.8 4.8 0.2 0.2 0.0 100.0 2,699 Divorced/separated/widowed 16.1 45.9 38.0 0.0 0.0 100.0 115 Marital duration2 0-4 years 95.0 4.8 0.1 0.0 0.2 100.0 772 5-9 years 95.7 3.8 0.2 0.4 0.0 100.0 586 10-14 years 96.2 3.5 0.3 0.0 0.0 100.0 444 15-19 years 94.4 5.6 0.0 0.0 0.0 100.0 340 20-24 years 92.0 8.0 0.0 0.0 0.0 100.0 162 25+ years 88.8 11.2 0.0 0.0 0.0 100.0 100 Married more than once 94.3 4.4 0.6 0.7 0.0 100.0 295 Residence Urban 42.6 15.0 14.5 0.3 27.7 100.0 939 Rural 47.9 7.7 13.3 0.1 31.1 100.0 4,748 Province City of Kigali 42.5 15.2 16.0 0.4 25.8 100.0 739 South 46.5 8.5 11.2 0.1 33.7 100.0 1,308 West 47.4 6.2 12.8 0.0 33.7 100.0 1,307 North 48.0 7.0 15.6 0.1 29.3 100.0 899 East 48.9 9.7 13.6 0.0 27.8 100.0 1,435 Education No education 71.7 8.3 7.7 0.0 12.3 100.0 583 Primary 47.8 8.8 12.8 0.1 30.4 100.0 3,916 Secondary and higher 32.3 9.5 18.5 0.1 39.6 100.0 1,189 Wealth quintile Lowest 52.9 7.7 11.8 0.1 27.5 100.0 854 Second 51.8 5.6 11.0 0.1 31.6 100.0 986 Middle 48.7 8.4 12.9 0.0 29.9 100.0 1,139 Fourth 46.4 8.0 12.4 0.0 33.3 100.0 1,235 Highest 39.7 13.1 17.4 0.2 29.6 100.0 1,474 Total 15-49 47.0 8.9 13.5 0.1 30.5 100.0 5,687 50-59 81.6 10.1 8.2 0.0 0.2 100.0 642 Total 15-59 50.5 9.0 12.9 0.1 27.4 100.0 6,329 1 Excludes men who had sexual intercourse within the last 4 weeks 2 Excludes men who are not currently married Results by residence show a small differential in the proportion of sexual activity between rural (48 percent) and urban (43 percent) areas. By province, City of Kigali has the lowest proportion of men who had sexual intercourse in the four weeks before the survey (43 percent), while East province registers the largest proportion (49 percent). As for women, although in different proportions, the percentage of men who had sexual intercourse during the four weeks before the survey decreases as the level of education increases (72 percent for those with no education, 48 percent for those with primary education, and 32 percent for those with secondary education or higher). The data indicates also that the proportion of men who are sexually active decreases with wealth quintile. Fifty-three percent are active at the lowest wealth quintile, and 40 percent are active at the highest quintile. Fertility • 63 FERTILITY 5 or more than 25 years, Rwanda has collected socio-demographic data to evaluate fertility levels and other general characteristics of its population. These efforts include the following surveys: the 1978 Rwanda General Population and Housing Census (RGPH), the 1983 Enquête National sur la Fécondité (ENF) or National Fertility Survey, the 1991 Rwanda General Population and Housing Census (RGPH), the 1992 Rwanda Demographic and Health Survey (RDHS), the 1996 Enquête Socio-Démographique (ESD) or Socio-demographic Survey, the 2000 Rwanda Demographic and Health Survey (RDHS), the 2002 Rwanda Demographic and Health Survey (RGPH), the 2005 Rwanda Demographic and Health Survey, the 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS), and the current survey, the 2010 Rwanda Demographic and Health Survey (RDHS). Information on fertility obtained by the 2010 RDHS is used to estimate fertility levels, determine the timing of births, and describe the impact of variables, such as residence and educational attainment, on fertility. This information provides recent indicators of fertility rates and birth spacing not only at the national level but also by province and residence. Fertility is one of the three principal components of population dynamics, the other two being mortality and migration (United Nations, 1973). The collection of data on fertility levels, trends, and differentials has been a prime objective of the Demographic and Health Surveys (DHS) program since its inception. The DHS surveys have contributed to the development of population policies in Rwanda and therefore have played an important role in the country’s overall population growth. This chapter analyzes the fertility data gathered by the 2010 RDHS, presents data on age at first birth and at birth intervals, and concludes with an analysis of teenage fertility. Teenage fertility is a special emphasis of Rwanda’s National Reproductive Health Policy (MOH 2003). Fertility data were obtained by posing a series of questions to all eligible female respondents. During the interview, interviewers recorded the total number of children born to each woman who had given birth, 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 of children still living. A complete birth history for each woman 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 age at the time of death. At the end of the interview, the interviewer verified that the number of living and dead children reported by the mother initially was consistent with the number of children obtained from the birth history. Because the DHS survey is a retrospective survey, the data can be used to estimate not only current fertility levels but also fertility trends over the past 25 years. Despite the organization and controls established to ensure the achievement of survey objectives (including training, instructions to field and data processing personnel, and quality controls at all levels), the data obtained may be subject to various types of errors, primarily errors inherent in all retrospective surveys, including: • Underreporting of births, in particular, the omission of children living elsewhere and children who died very young (a few days or hours after birth), which can result in underestimation of fertility levels. F 64 • Fertility • Misreporting of date of birth and/or age and, in particular, the tendency to round off age 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 because the women surveyed are those who have survived. Assuming that the fertility of women who died prior to the survey differs from the fertility of the survivors, the fertility levels obtained by the survey may be slightly biased. Finally, for the men’s survey, as for the women’s survey, information was gathered concerning total fertility by asking men a series of questions, including the number of children they had, the gender of each child, the number of children living with them, the number of children living elsewhere, the number of children who had died, and the number still living. The men were not asked to provide a complete birth history, however. 5.1 FERTILITY LEVELS AND DIFFERENTIALS Current fertility levels are measured in terms of age-specific fertility rates (ASFRs) and total fertility rate (TFR). ASFRs are calculated by dividing the number of births to women in each specific age group by the number of women-years of exposure in that age group. The TFR, a common measurement of current fertility, is the average of all ASFRs. It indicates the average number of children a woman would bear in her lifetime if fertility rates were to remain constant at the level prevailing during the period under consideration, in this case, the three years preceding the survey. Table 5.1 Current fertility Age-specific and total fertility rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Rwanda 2010 Age group Residence Total Urban Rural 15-19 40 41 41 20-24 143 198 189 25-29 180 235 226 30-34 137 211 200 35-39 113 153 148 40-44 58 92 88 45-49 16 21 20 TFR(15-49) 3.4 4.8 4.6 GFR 115 157 151 CBR 30.6 35.0 34.4 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 is expressed per woman. GFR: General fertility rate is expressed per 1,000 women, age 15-44. CBR: Crude birth rate is expressed per 1,000 population. Table 5.1, indicates that, at the national level, age-specific fertility rates (ASFRs) follow the classic pattern of countries with high fertility. This pattern is characterized by relatively high early fertility (41 births per 1,000 for women age 15-19), followed by a rapid increase to higher levels for women age 20-24 (189 per 1,000), age 25-29 (226 per 1,000), and age 30-34 (200 per 1,000). This high fertility is sustained over a long period (148 per 1,000 even at age 35-39) before declining precipitously at the very end of the childbearing years (20 per 1,000 at age 45- 49). At the end of her childbearing years, a Rwandan woman has had an average of 4.6 children. Even though the current TFR is high, it has declined from an estimated TFR of 6.1 in the 2005 RDHS. The data in Table 5.1 also show clear differentials in fertility by residence: women in urban areas have lower fertility (3.4) than those in rural areas (4.8). This means that, if current fertility levels were to remain constant, by the end of her childbearing years a woman living in a rural area would have an average of 1.4 children more than a woman living in an urban area. Fertility • 65 Table 5.1 also shows the crude birth rate (CBR), or average number of live births annually in the total population, estimated at 34 per 1,000 for the country as a whole, and shows the general fertility rate (GFR), or the average number of live births per 1,000 women of reproductive age (age 15-44), estimated here at 151 per 1,000. Like the TFR, these two indicators vary significantly by residence. Rural areas have a GFR of 157 per 1,000, which means that 1,000 women in rural areas are giving birth to an average of 42 more children annually than their urban counterparts (GFR of 115 per 1,000). Similarly, the CBR for rural areas (35 per 1,000) is four points higher than the CBR for urban areas (31 per 1,000). Table 5.2 presents fertility rates by background characteristic. The TFR varies by province, ranging from a high of 5.0 children per woman in the West province to a low of 3.5 children per woman in the City of Kigali. In other words, women in the West province have an average of 1.5 more children than women in the City of Kigali. The TFR relates to educational attainment, varying from a low of 3.0 children for women with secondary education and higher, to a high of 5.4 for women with no education. On average a woman with no education (TFR of 5.4) has 0.6 children more than a woman who has attended primary school (TFR of 4.8) and 2.4 more children than a woman who has attended secondary school and higher (3.0). Table 5.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Rwanda 2010 Background characteristic Total fertility rate Percentage women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 3.4 7.3 5.1 Rural 4.8 6.9 6.0 Province City of Kigali 3.5 7.2 5.1 South 4.6 6.2 5.3 West 5.0 7.4 6.4 North 4.1 6.5 6.2 East 4.9 7.7 6.3 Education No education 5.4 7.4 6.4 Primary 4.8 7.5 5.8 Secondary and higher 3.0 4.3 4.7 Wealth quintile Lowest 5.4 7.5 5.7 Second 5.2 7.3 5.9 Middle 4.5 7.3 6.1 Fourth 4.4 7.0 6.4 Highest 3.4 6.0 5.3 Total 4.6 7.0 5.9 Note: Total fertility rates are for the period 1-36 months prior to interview. Table 5.2 shows the mean number of live births for women age 40 to 49. This figure is an indicator of completed, or cumulative, fertility. Unlike the TFR, which measures the current or recent fertility of women age 15 to 49, cumulative fertility shows the past fertility of women surveyed at the end of their childbearing years. In a population whose fertility does not change, the cumulative fertility rate more or less coincides with the TFR. But TFRs that are lower than the mean number of children ever born to women at the end of their childbearing years indicate a downward trend in fertility. 66 • Fertility In Rwanda, the total cumulative fertility rate is estimated at 5.9 children. This is higher than the TFR (4.6). The difference, though small (1.3), suggests a substantial decline in fertility. In the 1992 RDHS, the difference be- tween the two rates was 1.5 children; in the 2000 RDHS, it was 1 child, and in 2005 RDHS, it was 0.5. The fertility results by background characteristics show cumulative fertility rates above the TFR for all categories, indicating that fertility is declining for all women. However, the difference between the cumulative fertility (number of children ever born) and the TFR is greatest in the North province (2.1 children) and in the wealthiest households (1.9 children). Table 5.2 shows the percentage of women who reported being pregnant at the time of the survey. At the national level, 7 percent of women age 15-49 reported being pregnant. This is likely an underestimate because women in the early stages of pregnancy may be unaware or unsure of their pregnancy status. Age, residence, culture, and/or beliefs may also affect a woman’s willingness to report her condition. In Rwanda, women generally declare their pregnancies only when their condition becomes visible. For these reasons, the differentials in pregnancy rates shown here must be interpreted with a great deal of caution. It should be noted, however, that the findings are generally consistent with current fertility levels. In fact, the lowest pregnancy rates are observed for women with a secondary education and higher (4.3 percent), for women living in the wealthiest households (6.0 percent), and for women living in South province (6.2 percent). These groups also have among the lowest fertility levels, except for South province. 5.2 FERTILITY TRENDS Two national demographic data collection efforts are conducted regularly in Rwanda: the General Population and Housing Census and the Demographic and Health Survey (DHS). The censuses of 1978, 1991, and 2002 gathered information on natural population dynamics and were used to estimate fertility levels for those years by asking questions about births that occurred in the 12 months preceding the survey. This method generally results in underestimates of fertility levels. The DHS surveys employ a more accurate method (women’s birth histories), which yields more reliable results. Yet the various RDHS surveys (1992, 2000, 2005, and 2007-08) and the censuses of 1991 and 2002 have produced more or less similar results with respect to the TFR, which fluctuates around 6. This means that fertility during the period 1992-2008 remained relatively stable in Rwanda. Since 2007-08 the fertility level has declined considerably, and in 2010 the rate reached 4.6 children per woman. Fertility • 67 Figure 5.1 Age-Specific Fertility Rates for Five-Year Periods Preceding the Survey                      15-19 20-24 25-29 30-34 35-39 40-44 45-49 0 50 100 150 200 250 300 350 Bi rth s pe r 1 00 0 w om en 0-4 5-9 10-14 15-19    2010 RDHS The data collected in the RDHS were used to track fert ility trends over the course of five-year periods up to 20 years prio r to the survey (Table 5.3.1 and Figure 5.1). Among young women, age 15-19, the ASFR declined progressively by age group. These women had an ASFR of 60 per thousand in the period 15-19 years before the survey. The ASFR for the same age group dropped to 41 per thousand in the period 0-4 years prior to the survey. For women age 20-49 at birth of their child, fertility rates have also declined over time. For instance, among mothers in age group 20-24 at birth, the ASFR fell from 254 per thousand during the 10-14 years preceding the survey to 195 per thousand during years 0-4 before the survey. The ASFR increased only briefly from 233 per thousand to 254 per thousand prior to the survey and then dropped again. Table 5.3.1 Trends in age-specif ic f ertility rates Age-specif ic f ertility rates f or f ive-y ear periods preceding the surv ey , by mother's age at the time of the birth, Rwanda 2010 Mother's age at birth Number of y ears preceding surv ey 0-4 5-9 10-14 15-19 15-19 41 47 59 60 20-24 195 217 254 233 25-29 248 286 307 301 30-34 217 264 277 [297] 35-39 164 211 [255] - 40-44 98 [133] - - 45-49 [21] - - - Note: Age-specif ic f ertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interv iew. 68 • Fertility Table 5.3.2 shows age-specific fertility rates (ASFRs) for the five DHS surveys. Figure 5.2 examines past fertility trends based on the results of the 2005 RDHS, the 2007-2008 RIDHS, and the 2010 RDHS. The most recent three ASFR curves follow a similar pattern: they increase rapidly with age, peak between age 25 and age 29, and then taper off steadily as they move toward the age group 45 to 49. Table 5.3.2 Trends in fertility Age-specific fertility rates (per 1,000 women) and total fertility rates, 1992 RDHS, 2000 RDHS, 2005 RDHS, 2007-08 RIDHS, and 2010 RDHS. Age group 1992 RDHS 2000 RDHS 2005 RDHS 2007-08 RIDHS 2010 RDHS 15-19 60 52 42 40 41 20-24 227 240 235 211 195 25-29 294 272 305 272 248 30-34 270 257 273 246 217 35-39 214 190 211 209 164 40-44 135 123 117 105 98 45-49 46 33 32 20 21 Total 6.2 5.8 6.1 5.5 4.6 Note: Age-specific fertility rates are per 1,000 women. It should be emphasized that the ASFR at age group 45-49 declines slowly over time, demonstrating high levels of late fertility. However, the curve for the current survey (2010 RDHS) drops lower after age 40 than the other three curves, indicating a trend toward declining fertility in women of these generations. Figure 5.2 Trends in Age-Specific and Total Fertility Rates, Various Sources ) ) ) ) ) ) ) , , , , , , , ' ' ' ' ' ' ' 15-19 20-24 25-29 30-34 35-39 40-44 45-49 0 50 100 150 200 250 300 350 Bi rth s pe r 1 ,0 0 0 w om e n 2000 RDHS 2007-08 RIDHS 2010 RDHS' , ) 2010 RDHS Fertility • 69 5.4 CHILDREN EVER BORN AND LIVING Table 5.4 presents by age group the 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. Data on the number of children ever born reflect the accumulation of births to women over their entire reproductive lifespan and therefore have limited reference to current fertility levels, particularly when a country has experienced a decline in fertility. However, the information on children ever born is useful for observing how average family size varies across age groups and also for observing the level of primary infertility. The results show that 95 percent of women age 15-19 have never given birth. This proportion declines to 19 percent for women age 25-29 and to 8 percent or lower for women age 30 and older. On average, Rwandan women attain a parity of 6.4 children per woman by the end of their childbearing years. This number is relatively higher than the TFR of 4.6 per woman, a discrepancy that is attributable to the gradual decrease in fertility. As expected, women age 40 or older have much higher parities, with substantial proportions having 10 or more births each by the end of their childbearing years. For example, 35 percent of women age 45-49 have given birth to eight or more children. The same pattern is shown by currently married women, except that the mean number of children ever born is higher for currently married women (3.8 children) than for all women (2.4 children). The difference in the mean number of children ever born between all women and currently married women is because a substantial proportion of young, unmarried women in the former category exhibit lower fertility. Table 5.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Rwanda 2010 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN Age 15-19 95.3 4.4 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,945 0.05 0.05 20-24 57.1 27.7 11.5 3.2 0.5 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,683 0.62 0.58 25-29 19.1 21.9 27.9 19.0 9.2 2.3 0.5 0.1 0.0 0.0 0.0 100.0 2,494 1.86 1.69 30-34 8.4 7.3 13.8 19.3 22.2 16.5 8.2 3.5 0.5 0.3 0.0 100.0 1,822 3.44 3.06 35-39 4.3 3.3 7.9 12.3 17.7 17.8 16.4 10.9 6.2 2.2 0.9 100.0 1,447 4.70 3.98 40-44 4.2 4.2 4.7 8.2 10.9 14.8 16.8 14.3 11.0 6.3 4.6 100.0 1,168 5.50 4.48 45-49 2.0 3.2 3.8 5.4 9.6 11.8 13.6 15.5 13.5 10.1 11.6 100.0 1,112 6.37 4.99 Total 37.3 12.3 10.8 9.1 8.3 6.7 5.5 4.1 2.8 1.6 1.4 100.0 13,671 2.42 2.05 CURRENTLY MARRIED WOMEN Age 15-19 44.1 50.9 5.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 89 0.61 0.59 20-24 16.6 49.0 26.1 7.2 1.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 998 1.27 1.18 25-29 5.1 21.3 34.2 24.1 11.8 2.7 0.7 0.1 0.0 0.0 0.0 100.0 1,773 2.28 2.07 30-34 2.3 6.2 13.0 20.5 24.5 18.8 9.8 4.0 0.6 0.3 0.0 100.0 1,458 3.80 3.40 35-39 1.8 2.0 4.9 10.5 17.4 19.9 18.8 13.3 7.6 2.7 1.1 100.0 1,112 5.15 4.39 40-44 1.7 1.9 2.3 6.9 9.8 14.3 18.3 16.9 13.5 8.1 6.5 100.0 780 6.14 5.08 45-49 1.5 1.6 2.3 3.2 6.0 10.3 13.0 17.3 15.9 12.7 16.1 100.0 688 7.04 5.60 Total 5.4 15.2 16.7 14.4 12.9 10.5 8.6 6.7 4.5 2.7 2.5 100.0 6,897 3.81 3.27 5.5 BIRTH INTERVALS Birth intervals, or the length of time between two successive live births, are important not only because they influence the health status of both mother and child but also because they play a role in fertility analysis and in design of reproductive health programs. Currently, short birth intervals (less than 24 months) are considered harmful to the health and nutritional status of children and increase their risk of death. In addition, short birth intervals expose a woman to a greater risk of complications during and after pregnancy (miscarriage or eclampsia, for 70 • Fertility example) and are associated with high cumulative fertility. Table 5.5 shows the distribution of nonfirst births across the five years preceding the survey by the number of months since the preceding birth. Table 5.5 shows that 7 percent of births occur less than 18 months after the preceding birth and that 13 percent of children are born between 18 and 24 months after the birth of their immediately older sibling. Thus, in almost 20 percent of all cases, the birth interval is less than two years. However, a large proportion of births (39 percent) occurs between two and three years after the preceding birth. About two in five children (41 percent) are born three or more years after the birth of their next oldest sibling. The mean duration of the birth interval is slightly more than two and a half years (32.7 months), which means that half of all births take place 32.7 months after the preceding birth. With respect to age, birth intervals are shorter for younger women; that is, the younger the woman, the shorter the birth interval. The mean duration increases from 29.3 months at age 20 to 29 to 39.9 months at age 40 to 49. Differentials by gender are not significant (33.0 months for boys and 32.4 months for girls). The results also show an increase in the length of birth intervals associated with birth order, from 31.3 months for birth orders 2-3 to Table 5.5 Birth intervals Percent distribution of nonfirst births in the five years preceding the survey by number of months since preceding birth and by median number of months since preceding birth, according to background characteristics, Rwanda 2010 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 * * * * * * 100.0 12 * 20-29 11.5 17.4 41.2 19.7 6.1 4.0 100.0 2,421 29.3 30-39 5.4 10.8 40.6 21.9 10.6 10.9 100.0 3,316 33.7 40-49 3.7 7.6 30.4 23.6 14.6 20.1 100.0 1,079 39.9 Sex of preceding birth Male 7.2 12.4 38.5 21.8 10.1 10.0 100.0 3,410 33.0 Female 7.4 12.9 39.9 20.9 9.1 9.8 100.0 3,419 32.4 Survival of preceding birth Living 5.2 12.0 40.5 22.3 10.0 9.8 100.0 6,136 33.2 Dead 25.7 18.0 27.3 12.6 6.2 10.2 100.0 693 25.6 Birth order 2-3 10.2 14.4 38.6 19.4 7.8 9.5 100.0 3,092 31.3 4-6 5.0 10.9 39.2 23.1 11.3 10.5 100.0 2,642 34.1 7+ 4.8 11.7 40.9 22.6 10.6 9.3 100.0 1,095 33.4 Residence Urban 12.5 13.2 29.8 18.1 11.6 14.8 100.0 715 34.0 Rural 6.7 12.6 40.3 21.7 9.4 9.3 100.0 6,114 32.6 Province City of Kigali 12.9 13.4 30.6 18.1 9.7 15.3 100.0 560 33.2 South 5.8 12.9 38.5 22.1 9.5 11.1 100.0 1,635 32.7 West 6.7 11.7 43.6 21.2 9.3 7.6 100.0 1,729 32.2 North 5.7 12.0 41.4 21.9 9.9 9.1 100.0 1,080 33.0 East 8.4 13.5 37.0 21.5 9.9 9.8 100.0 1,825 32.8 Education No education 5.9 12.8 37.1 24.4 10.1 9.6 100.0 1,461 33.8 Primary 7.3 12.7 41.1 20.5 9.2 9.2 100.0 4,856 32.2 Secondary and higher 11.3 11.9 26.9 20.8 12.1 17.0 100.0 512 35.9 Wealth quintile Lowest 6.2 11.1 38.6 24.5 9.1 10.5 100.0 1,625 33.7 Second 5.4 11.1 44.3 20.7 9.9 8.6 100.0 1,483 32.7 Middle 7.4 13.7 40.7 21.1 10.0 7.1 100.0 1,361 31.8 Fourth 8.3 14.1 37.5 21.5 8.5 10.1 100.0 1,305 32.2 Highest 10.4 13.9 33.1 17.7 10.8 14.0 100.0 1,055 33.1 Total 7.3 12.6 39.2 21.4 9.6 9.9 100.0 6,829 32.7 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. Fertility • 71 33.4 months for birth orders 7 and higher. Survival of the preceding child is an important factor. When the preceding child has died, the birth interval between that birth and the next birth is a median of 25.6 months. When the preceding child is alive, the birth interval is a median of 33.2 months, or approximately eight months later than the birth following the death of the preceding sibling. The median interval between births is slightly lower in rural areas (32.6 months) than in urban areas (34.0 months). In 2010, the differential between rural and urban areas was 1.4 months; in 2005, it was 1.5 months; in 2000, it was 3.2 months. With respect to provinces, the birth interval varies from a low of 32.2 months in the West province to a high of 33.2 months in the City of Kigali. Regarding mother’s level of educational attainment, birth intervals for women with a secondary education or higher are longer (35.9 months) than birth intervals for women with primary education (32.2 months). Apparently, wealth does not influence the length of birth intervals: the lowest birth interval is located at the middle wealth quintile, and the highest is at the first, or lowest, wealth quintile followed closely by the fourth quintile. 5.6 EXPOSURE TO THE RISK OF PREGNANCY Women are not exposed to the risk of another pregnancy for a period following childbirth. Exposure to the risk of pregnancy depends on several factors, including the duration of postpartum amenorrhea—the period between childbirth and the return of ovulation—and the period when a woman abstains from sexual intercourse (postpartum abstinence). These two factors jointly determine which women are insusceptible to becoming pregnant and the length of the period of insusceptibility. Women are considered insusceptible if they abstain from intercourse following childbirth and/or are amenorrheic. In the latter case, the risk of pregnancy is negligible even if sexual activity is resumed without contraceptive protection. Table 5.6 shows the percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible. It also shows median and mean durations for these indicators. Table 5.6 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Rwanda 2010 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 < 2 96.8 40.8 98.3 195 2-3 84.0 14.8 85.9 250 4-5 75.5 12.0 79.1 288 6-7 65.3 12.9 69.9 298 8-9 59.3 9.4 61.6 275 10-11 49.7 11.7 54.3 287 12-13 42.2 7.9 46.9 275 14-15 32.4 6.8 37.3 277 16-17 33.1 7.5 37.8 258 18-19 25.5 9.9 33.1 288 20-21 14.6 6.8 19.3 287 22-23 12.5 9.1 18.5 309 24-25 9.4 4.2 12.5 304 26-27 7.0 7.0 12.8 322 28-29 3.7 7.9 11.5 334 30-31 5.6 8.4 12.8 351 32-33 3.0 5.0 7.7 315 34-35 2.6 4.5 6.1 292 Total 31.9 9.7 36.7 5,206 Median 10.6 0.6 11.6 - Mean 12.7 4.3 14.4 - Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth 72 • Fertility In Rwanda, about 32 percent of women who gave birth during the three years preceding the survey were amenorrheic, and another 10 percent were abstinent. About 37 percent were insusceptible, meaning that they were either amenorrheic, abstinent, or both. The median duration of postpartum amenorrhea is 11 months, and the mean is 13 months. The duration, intensity, and frequency of exclusive breastfeeding affects the return of ovulation (see Chapter 10 on nutrition) and is partly responsible for these relatively long durations. However, the median duration of postpartum amenorrhea (10.6 months) has declined by 3.7 months compared with what it was in the 2005 RDHS (14.3 months). The median and mean durations for postpartum abstinence are very short (0.6 months and 4.3 months, respectively). Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Rwanda 2010 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 8.7 0.7 10.5 30-49 12.3 0.6 12.8 Residence Urban 6.4 0.7 7.4 Rural 11.0 0.6 12.0 Province City of Kigali 7.3 0.8 7.9 South 11.5 0.6 13.0 West 12.0 0.6 13.2 North 10.7 0.6 11.4 East 9.7 0.9 10.4 Education No education 13.8 0.6 15.6 Primary 10.5 0.6 11.2 Secondary and higher 7.3 0.9 8.7 Wealth quintile Lowest 12.9 0.7 15.0 Second 11.9 0.6 13.6 Middle 10.2 0.6 10.8 Fourth 9.1 0.5 10.4 Highest 7.6 1.0 8.2 Total 10.6 0.6 11.6 Note: Medians are based on the status at the time of the survey (current status) 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth As expected, the amenorrheic status for women who gave birth during the three years preceding the survey decreases with duration since birth: almost all the women (97 percent) remained amenorrheic for less than 2 months since the birth; three quarters (76 percent) remained amenorrheic for 4 or 5 months; approximately three in five women (59 percent) were still amenorrheic at 8-9 months; but only 7 percent remained so at 26 to 27 months. Beyond 28 months, the proportion of women for whom ovulation had not yet returned varied between 6 percent and 3 percent. Postpartum abstinence decreases quickly over time, affecting 41 percent of women fewer than 2 months and only 15 percent of women for 2 to 3 months. The percentage of women who abstain for 4 months or longer varies from a high of 13 percent to a low of 4 percent. Table 5.7 shows the median duration of postpartum amenorrhea, abstinence, and insusceptibility following births in the three years preceding the survey. The duration of amenorrhea varies with age: women age 15-29 have shorter periods of amenorrhea (8.7 months) than women age 30-49 (12.3 months). The duration of postpartum amenorrhea is 6.4 months in urban areas compared with 11.0 months in rural areas. By province, women in the City Fertility • 73 of Kigali have the shortest period of amenorrhea (7.3 months), while those in the West province have the longest period (12 months). Results differ according to the level of education: women with secondary education and higher have the shortest periods of amenorrhea (7.3 months), while women with no education have the longest periods of amenorrhea (13.8 months). The duration of the postpartum amenorrhea decreases also with the level of the wealth quintile: 12.9 months for the women in the lowest quintile compared with 7.6 months for those in the highest quintile. The duration of postpartum insusceptibility follows the same pattern as that of postpartum amenorrhea. 5.7 MENOPAUSE Women cease being exposed to the risk of pregnancy when they reach menopause. For the survey, women were considered menopausal if they were neither pregnant nor had postpartum amenorrhea and had not had a menstrual period in the six months preceding the survey, or if they reported themselves as having entered menopause. Table 5.8 shows the percentage of women age 30-49 who are menopausal. Overall, 9 percent of women age 30-49 reported being menopausal. The proportion increases with age, rising from 5 percent for women age 30-34, to 9 percent at age 44-45, and to 29 percent at age 48-49. Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Rwanda 2010 Age Percentage menopausal1 Number of women Age 30-34 4.9 1,822 35-39 6.2 1,447 40-41 6.0 472 42-43 6.7 452 44-45 8.7 442 46-47 16.0 466 48-49 28.8 449 Total 8.7 5,549 1 Percentage of all women who are not pregnant and not postpartum amenorrheic whose last menstrual period occurred six or more months preceding the survey 5.8 AGE AT FIRST BIRTH The age at which childbearing begins is an important demographic indicator because it has a direct bearing on a women’s cumulative fertility, particularly when there is little or no contraceptive use. The younger a woman begins childbearing, the greater is her likelihood of having many children. At the same time, having children at too young an age can have negative repercussions on the mother’s health and can put her children at risk. Table 5.9 shows the distribution of women by age at first birth and median age at first birth by age at the time of the survey. 74 • Fertility The results show that median age at first birth has remained practically unchanged from one generation to the next (from a low of 21.9 to a high of 22.9), and no trends indicate a rise or fall in this median age. Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by specific exact ages, percentage who have never given birth, and median age at first birth, according to current age, Rwanda 2010 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 0.1 na na na na 95.3 2,945 a 20-24 0.3 5.2 18.3 na na 57.1 2,683 a 25-29 0.4 6.3 20.3 40.5 68.6 19.1 2,494 22.9 30-34 0.7 8.8 27.8 50.9 73.2 8.4 1,822 21.9 35-39 0.5 8.2 24.8 49.8 78.7 4.3 1,447 22.0 40-44 0.6 10.2 25.0 45.4 72.3 4.2 1,168 22.5 45-49 1.0 9.8 25.6 47.9 75.4 2.0 1,112 22.2 20-49 0.5 7.5 22.8 na na 21.4 10,726 a 25-49 0.6 8.3 24.2 46.3 72.9 9.5 8,043 22.4 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 5.9 shows a median age at first birth of 22.4 years for women age 25-49; this is 0.4 years higher than the median age at first birth observed for women of the same age in the 2005 RDHS. Table 5.10 shows median age at first birth according to various socioeconomic characteristics. The first child arrives at a younger age for women in rural areas (22.3 years) than for those in urban areas (23.3 years). The City of Kigali has the highest median age at first birth (23.5 years), which is followed by the South province (23.2 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 22.2 years in the West province. Women’s level of educational attainment affects the median age at first birth: women with no education (21.5 years) and women with primary education (22.4 years) have a lower median age at first birth than women with secondary and higher education (24.5 years). Fertility • 75 Results by household wealth show that the first birth occurs later among women in the highest wealth quintile (23.3 years) compared with those in the lowest quintile (22.0 years). Table 5.10 Median age at first birth Median age at first birth among women age 20- 49 (25-49) years, according to background characteristics, Rwanda 2010 Background characteristic Women age 25-49 Residence Urban 23.3 Rural 22.3 Province City of Kigali 23.5 South 23.2 West 22.2 North 21.9 East 21.6 Education No education 21.5 Primary 22.4 Secondary and higher 24.5 Wealth quintile Lowest 22.0 Second 22.2 Middle 22.1 Fourth 22.3 Highest 23.3 Total 22.4 5.9 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 greater risk of complications 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, thereby limiting her job opportunities. Table 5.11 shows the proportion of teenagers who have already had one or more children, as well as those currently in their first pregnancy; together these two subgroups make up the proportion of teenagers who have already begun childbearing. About 6 percent of young women between the ages of 15 and 19 have already begun childbearing (5 percent are already mothers; 1 percent are pregnant for the first time). At age 15, none of the teenagers has begun childbearing, but the percentage increases steadily and rapidly with age: 3 percent of the teenagers at age 17 have already had at least one child or are pregnant for the first time. At age 19, this proportion reaches 20 percent, 16 percent of whom have already had at least one child. 76 • Fertility Table 5.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Rwanda 2010 Background characteristic Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 0.0 0.0 0.0 677 16 0.5 0.3 0.8 655 17 2.3 1.0 3.3 530 18 7.6 2.1 9.7 605 19 16.3 4.0 20.3 478 Residence Urban 4.2 1.2 5.4 447 Rural 4.8 1.4 6.2 2,499 Province Kigali City 5.6 0.9 6.6 332 South 3.8 1.2 4.9 642 West 4.3 1.1 5.4 762 North 4.6 1.1 5.7 503 East 5.8 2.0 7.9 707 Education No education 20.0 4.9 24.9 87 Primary 4.6 1.5 6.1 2,132 Secondary 3.2 0.4 3.6 727 Wealth quintile Lowest 6.9 2.0 8.9 481 Second 5.5 1.5 7.0 570 Middle 3.8 1.7 5.5 607 Fourth 5.0 1.1 6.1 598 Highest 3.3 0.6 3.9 690 Total 4.7 1.3 6.1 2,945 The results show also that teenagers residing in rural areas begin childbearing slightly earlier than their urban counterparts. In fact, 6 percent of teenagers in rural areas have begun childbearing compared with 5 percent in urban areas. Differences are also observed among provinces: the proportion of teenagers who have begun childbearing varies from a low of 5 percent in the South province to a high of 8 percent in the East province. Early childbearing occurs more frequently among teenagers with no education (25 percent) than among those who are educated (6 percent for those have primary education and 4 percent for those with secondary education and higher). Differentials by wealth quintile are also observed: the proportion of teenagers who have begun childbearing varies from 9 percent in the lowest wealth quintile to 4 percent in the highest quintile. These differentials indicate that the standard of living affects childbearing behavior of Rwandan teenagers. Also, the proportion of teenagers who have begun childbearing has decreased from 11 percent in 1992, to 7 percent in 2000, and to 4 percent in 2005, finally increasing slightly to 6 percent in 2010. Fertility Preferences • 77 FERTILITY PREFERENCES 6 ata on fertility preferences is used to evaluate the effectiveness of couples’ efforts to control their own fertility and to assess Rwanda’s future contraceptive needs not only for spacing but also for limiting the total number of births. To obtain information about fertility preferences, the 2010 RDHS asked women how many additional children they wanted to have, how long they wanted to wait before having their next child, and the total number of children they desired. Analysis of the data covered only men and women who were married at the time of the survey. Data on attitudes and opinions about procreation have always been somewhat controversial. Some researchers believe responses to questions about fertility preferences are subject to three potential flaws: first, they represent viewpoints, which are subject to change, rather than firm convictions; second, they do not take into account the effects of social pressure and the attitudes of other family members, particularly the husband, who can exert enormous influence over reproductive health decisions; and third, they are obtained from a sample of women of differing ages with differing birth histories. Their responses relate to medium- or long-term goals that may change over time or are of limited predictive value for the young or recently-married women who respond. The responses of older women and women at the end of their childbearing years are inevitably influenced by their birth histories. Despite possible problems with interpretation, the data on fertility preferences can improve understanding of the factors affecting fertility in Rwanda, a country where contraceptive prevalence is increasing and fertility is starting to decline. 6.1 DESIRE FOR CHILDREN The desire to have children in the future generally correlates with a woman’s age and the number of living children she and her husband currently have. The 2010 RDHS asked currently married women a series of questions designed to discern their desire to delay the next birth or to stop having children altogether. The results are presented in Table 6.1 by number of living children (including any current pregnancy) at the time of the survey. More than half of the respondents (52 percent) reported wanting no more children, while slightly more than two in five women (44 percent) wanted to have another child. The proportion of women who do not want more children has increased since 2005, when 42 percent of women reported not wanting additional children. As a result of this increase, the proportion of women wanting children has decreased from 2005 when 52 percent of women reported that they wanted more children. Among the women who wanted more children in the future, 8 percent wanted another child within two years, 36 percent wanted to delay the next birth by two or more years, and 0.5 percent wanted to have another child but were uncertain when. In general, more than four in five women in Rwanda (88 percent) can be considered potential candidates for family planning: those who do not want any more children (52 percent) and those who want to delay their next birth (36 percent). The results show that the proportion of women who want more children soon decreases as parity increases. In fact, the percentage of women who want more children but who want them later in life ranges from 80 percent among those with one child, to 16 percent among those with four children, and to 3 percent among those who have six children or more. On the other hand, the proportion of women who want no more children increases considerably with the number of living children, from 1 percent for women with no children, to 76 percent for women with four children, and to 92 percent for those with six children or more (Table 6.1). Women who want no more children have presumably reached their desired family size, or cumulative fertility, and should be using a D 78 • Fertility Preferences contraceptive method to avoid unwanted pregnancies. Finally, the data show that 94 percent of women with no children would like to have a child, and the majority of these women (89 percent) would like to have one soon. Table 6.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Rwanda 2010 Desire for children Number of living children1 Total 15-49 Total 15-59 0 1 2 3 4 5 6+ WOMEN Have another soon2 88.5 15.0 8.1 4.6 2.5 1.1 0.5 8.3 na Have another later3 5.1 79.5 61.7 35.0 15.9 8.3 3.0 35.6 na Have another, undecided when 0.5 0.8 1.0 0.4 0.5 0.0 0.3 0.5 na Undecided 0.0 0.8 1.6 2.6 2.3 1.4 1.5 1.6 na Want no more 1.4 3.4 26.9 56.2 76.0 86.1 91.7 52.0 na Sterilised4 0.0 0.1 0.1 1.0 1.6 2.3 0.9 0.9 na Declared infecund 4.1 0.4 0.5 0.3 1.0 0.8 1.7 0.8 na Missing 0.5 0.1 0.1 0.0 0.3 0.0 0.4 0.2 na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 na Number 220 1,159 1,366 1,183 1,045 811 1,112 6,897 na MEN5 Have another soon2 79.0 11.7 7.1 2.8 2.0 1.0 0.4 7.2 6.4 Have another later3 19.6 82.0 59.4 32.3 13.6 6.5 5.0 37.4 31.3 Have another, undecided when 0.0 0.3 0.2 0.2 0.0 0.2 0.3 0.2 0.2 Undecided 0.0 0.0 1.2 0.8 0.2 0.4 0.8 0.6 0.5 Want no more 0.0 5.2 32.0 63.5 83.2 90.9 92.3 53.9 60.3 Sterilised4 0.0 0.0 0.0 0.4 0.0 0.0 0.7 0.2 0.2 Declared infecund 0.0 0.4 0.0 0.0 0.3 0.0 0.2 0.2 0.7 Missing 1.3 0.3 0.2 0.0 0.6 0.9 0.5 0.4 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 88 515 553 465 383 277 419 2,699 3,287 na = Not applicable 1 The number of living children includes current pregnancy for women. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilisation 5 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). Unlike most countries in sub-Saharan Africa, the proportion of men in Rwanda who want no more children (54 percent) is similar to that among women. The same is true for the proportion of men who want more children later (37 percent). As with women, the proportion of men who want more children decreases as parity increases, and the proportion of men who want no more children increases as parity increases. The percentage of men who want more children ranges from a high of 82 percent among those with one child, to 14 percent among those with four children, and to 5 percent among those who have six or more children. It should be noted that, at each parity level, the differences between men and women who want more children are minimal. Fertility Preferences • 79 Table 6.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Rwanda 2010 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 1.6 6.5 37.7 67.8 82.5 85.5 90.7 49.8 Rural 1.3 2.8 25.0 55.7 76.8 88.8 92.9 53.4 Province City of Kigali 2.0 6.8 37.4 65.0 84.6 91.3 90.2 48.6 South 0.0 2.3 29.6 62.1 80.6 91.5 95.6 55.4 West 0.0 3.1 18.3 49.5 66.7 80.0 91.3 48.8 North 3.6 3.7 20.5 52.9 78.0 88.4 88.4 52.2 East 2.1 2.8 30.8 59.2 81.7 92.4 95.7 56.8 Education No education 3.3 6.3 31.0 61.7 75.5 88.9 91.9 64.5 Primary 1.2 2.8 25.5 54.6 77.4 87.5 93.1 49.9 Secondary and higher 0.0 4.7 31.8 68.8 82.1 94.3 93.0 50.8 Wealth quintile Lowest 0.0 3.0 27.3 55.3 76.9 90.1 93.9 51.7 Second 3.2 3.2 29.2 59.4 75.6 88.0 92.8 53.9 Middle 2.4 1.7 17.6 55.4 75.7 87.0 93.4 49.6 Fourth 1.6 4.6 28.3 54.2 77.0 90.2 92.5 56.9 Highest 0.0 4.9 32.5 62.4 82.8 86.2 91.0 52.3 Total 1.4 3.5 27.0 57.2 77.5 88.4 92.7 52.9 Note: Women who have been sterilised are considered to want no more children. 1 The number of living children includes the current pregnancy. Tables 6.2.1and 6.2.2 show by background characteristics the percentages of women and men who want no more children. Results by residence show that the proportions of women and men who want no more children are somewhat higher in rural areas (53 percent for women; 55 percent for men) than in urban areas (50 percent for women; 49 percent for men). The situation is the reverse of the previous survey where women and men of urban areas were more likely to want to limit births (49 percent for women; 48 percent for men) than those of rural areas (42 percent for women; 43 percent for men). By province, the proportion of women who want no more children ranges from a low of 49 percent in the City of Kigali to a high of 57 percent in East province. Results by level of education show that women with no education are more likely to want to limit births (65 percent) than women with primary (50 percent) or secondary education (51 percent). The effect of wealth on the desire to limit the births is not remarkable: the highest proportion is located at the fourth quintile (57 percent) and the lowest at the middle wealth quintile (50 percent). Married women who do not use contraception and who report not wanting any more children (desiring, therefore, to limit births) or who report wanting to wait two or more years before their next birth (desiring, therefore, to space births) are considered to have an unmet family planning need. Women who report having unmet need and women currently using contraception make up the total potential demand for family planning. As for women, men with no education are more likely to want to limit births (62 percent) than men with primary (52 percent) or secondary education (54 percent). The results for men, according to province, are similar to those for women: City of Kigali has the lowest proportion of men who have reached their desired number of children (48 percent), and North province has the highest (58 percent). 80 • Fertility Preferences Table 6.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Rwanda 2010 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 0.0 8.3 36.5 65.3 87.8 93.2 93.5 48.7 Rural 0.0 4.5 31.1 63.7 82.4 90.7 92.9 55.0 Province City of Kigali 0.0 9.2 39.9 63.6 92.0 96.6 100.0 48.0 South 0.0 3.5 25.4 66.8 80.9 95.6 95.2 55.2 West 0.0 5.7 29.0 59.6 72.3 84.6 86.1 51.3 North 0.0 4.9 36.8 55.5 86.8 95.9 97.3 57.7 East 0.0 4.1 33.5 69.7 89.5 87.6 93.7 56.2 Education No education 0.0 5.1 27.6 64.3 82.5 90.5 90.9 62.3 Primary 0.0 4.7 32.2 64.4 82.5 91.3 92.8 52.2 Secondary and higher 0.0 7.7 35.3 61.4 87.1 89.6 98.3 54.2 Wealth quintile Lowest 0.0 3.3 28.2 68.7 79.3 93.8 93.4 52.2 Second 0.0 3.4 35.6 63.7 84.6 87.2 88.9 53.3 Middle 0.0 5.9 31.5 60.0 84.5 89.9 92.9 53.4 Fourth 0.0 4.5 35.6 64.6 83.9 93.0 92.0 59.1 Highest 0.0 8.1 29.8 63.4 83.7 89.9 98.4 52.0 Total 15-49 0.0 5.2 32.0 64.0 83.2 90.9 92.9 54.1 50-59 27.8 41.5 71.1 84.0 88.1 93.9 93.0 89.8 Total 15-59 1.1 5.9 33.6 65.5 83.9 91.6 92.9 60.5 Note: Men who have been sterilised or who state in response to the question about desire for children that their wife has been sterilised are considered to want no more children. 1 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). The proportion of men who want no more children increases slowly from the poorest quintile (52 percent) to the fourth quintile (59 percent); surprisingly, at the richest quintile, this proportion drops to the lowest proportion of men who want no more children (52 percent). 6.2 IDEAL NUMBER OF CHILDREN Women’s reproductive behaviour can be influenced by the ideal number of children they would like to have and the ideal number their husband or partner would like to have. To determine this ideal number, the 2010 RDHS asked all women surveyed one of the following two questions: • 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 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 embarrassing, particularly for women with living children who may wish to specify an ideal number that differs from the number of children they already have. It may also be difficult for a woman to specify an ideal number that is lower than her current cumulative fertility. Fertility Preferences • 81 The ideal number of children reported in Table 6.3 by all women is 3.3 and the ideal number reported by married women is 3.6. In both cases, the ideal is lower than the TFR of 4.6, which means that women desire a lower cumulative fertility. An examination of the distribution of reported ideal family size shows that, for 85 percent of women, the ideal number of children ranges from 2 to 4. For 36 percent of the women, the ideal number of children is 3; for about one quarter (26 percent), it is 2; and for more than two in four women (23 percent), it is 4. For 6 percent of women, the ideal number of children is either 5 or 6. The proportion of women who visualize the ideal number of children fewer than 2 is very low—only 2 percent. Table 6.3 Ideal number of children Percent distribution of women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to the number of living children, Rwanda 2010 Ideal number of children Number of living children1 Total 0 1 2 3 4 5 6+ WOMEN 0 1.5 0.2 0.3 0.2 0.1 0.0 0.4 0.7 1 2.0 3.4 0.9 1.5 1.1 1.2 0.8 1.7 2 37.4 33.5 22.2 11.6 14.5 14.8 11.2 25.8 3 41.6 46.0 41.6 35.5 21.4 22.7 19.9 36.2 4 13.7 13.3 26.8 34.8 38.3 32.7 31.7 23.1 5 2.1 1.9 5.0 9.3 12.8 11.5 12.7 5.9 6+ 0.8 1.1 2.6 6.0 10.2 15.6 21.1 5.5 Non-numeric responses 0.9 0.5 0.7 1.1 1.7 1.5 2.3 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,926 1,894 1,762 1,504 1,306 984 1,295 13,671 Mean ideal number children for:2 All women 2.8 2.8 3.2 3.7 3.9 4.1 4.5 3.3 Number 4,882 1,884 1,751 1,487 1,284 969 1,266 13,523 Women currently in union 2.9 2.9 3.2 3.7 3.9 4.1 4.5 3.6 Number 217 1,154 1,357 1,175 1,028 800 1,087 6,817 MEN 0 0.3 0.5 0.5 0.2 0.7 0.8 1.2 0.4 1 2.3 3.0 3.0 3.7 1.8 2.4 3.6 2.6 2 40.4 37.4 24.6 24.3 28.2 29.1 23.4 34.4 3 43.4 48.4 52.2 44.4 31.1 35.0 39.2 43.3 4 11.7 8.8 16.5 22.2 29.2 20.7 24.0 15.3 5 1.5 0.8 1.7 3.6 6.9 7.1 3.6 2.4 6+ 0.5 1.2 1.5 1.7 1.8 4.2 4.9 1.4 Non-numeric responses 0.0 0.0 0.0 0.0 0.3 0.8 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,898 626 583 476 390 282 432 5,687 Mean ideal number children for:2 All men 2.7 2.7 2.9 3.0 3.1 3.2 3.2 2.8 Number 2,898 626 583 476 389 280 431 5,683 Men currently in union 2.6 2.7 2.9 3.0 3.1 3.2 3.2 3.0 Number 88 515 553 465 382 275 418 2,695 Mean ideal number children for men 15-59:2 All men 2.7 2.7 2.9 3.0 3.1 3.1 3.1 2.9 Number 2,912 639 612 520 458 371 810 6,323 Men currently in union 2.6 2.7 2.9 3.0 3.1 3.1 3.2 3.0 Number 91 525 576 503 444 357 787 3,283 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent’s wife is pregnant (or if any wife is pregnant for men with more than one current wife). The results also show that the mean ideal family size increases from 2.8 children for all women with no children to 4.5 children for those with 6 children or more. The finding is almost the same for women who were married at the time of the survey. The ideal number of children for men is approximately 2.8 for all men and 3.0 for married men. As with the women, the men reported an ideal number of children that was lower than the TFR. For 93 percent the ideal number 82 • Fertility Preferences of children ranges from 2 to 4: for 43 percent, the ideal number of children is 3, for 34 percent it is 2, and for 15 percent it is 4. Only 2 percent would like to have 5 children, and 1 percent desires 6 children. Only 3 percent would like to have fewer than 2 children. Table 6.4 shows the mean ideal number of children for all women, according to current age and background characteristics. The ideal number of children does not vary much by age: for women age 15 to 19, the ideal is 2.7 children, for those age 25-29, the ideal is 3.2, and for those age 45 to 49 it is 4.3 children. Table 6.4 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Rwanda 2010 Background characteristic Mean Number of women1 Age 15-19 2.7 2,924 20-24 2.8 2,668 25-29 3.2 2,481 30-34 3.6 1,796 35-39 3.8 1,429 40-44 4.0 1,147 45-49 4.3 1,078 Residence Urban 3.1 2,045 Rural 3.3 11,477 Province City of Kigali 3.0 1,587 South 3.2 3,155 West 3.5 3,272 North 3.2 2,262 East 3.4 3,247 Education No education 3.8 2,080 Primary 3.3 9,242 Secondary and higher 2.9 2,200 Wealth quintile Lowest 3.4 2,579 Second 3.4 2,637 Middle 3.3 2,699 Fourth 3.4 2,659 Highest 3.1 2,947 Total 3.3 13,523 1 Number of women who gave a numeric response This ideal number is the same in urban and in rural areas (3.1 and 3.3); similarly, in all provinces, the ideal number of children is not very different. The highest number is located in West province (3.5) and the lowest number is in the City of Kigali (3 percent). Also, the higher the level of education, the lower is the mean ideal number of children: 3.8 for women with no education compared with 2.9 for women with a secondary education and higher. The desired cumulative fertility does not vary much with household wealth, ranging from 3.4 children in the lowest, second, and fourth wealth quintiles to 3.3 children in the middle wealth quintile and to 3.1 in the highest quintile. 6.3 FERTILITY PLANNING STATUS For each child born in the five years preceding the survey and for the current pregnancy (if the respondent was pregnant), each mother was asked if she had wanted to be pregnant at that time, 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 were 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 during the past five years. The data may be subject Fertility Preferences • 83 to rationalisation, as an undesired pregnancy often results in the birth of a child to which the mother later becomes attached. Table 6.5 shows that more than four in five births (87 percent) were wanted, either at the time they occurred or later. Most of these births (62 percent) occurred at the desired time; 25 percent occurred earlier than the women would have liked. Unwanted pregnancies represented approximately 13 percent of the births. Table 6.5 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Rwanda 2010 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 79.8 18.8 1.1 0.3 100.0 2,534 2 64.1 33.5 2.1 0.2 100.0 1,990 3 61.5 33.3 5.1 0.0 100.0 1,503 4+ 50.7 21.7 27.4 0.2 100.0 4,067 Mother’s age at birth <20 59.5 37.1 3.1 0.3 100.0 593 20-24 71.7 25.6 2.4 0.3 100.0 2,806 25-29 64.5 29.5 6.0 0.1 100.0 2,978 30-34 59.6 24.0 16.3 0.1 100.0 1,928 35-39 51.6 17.6 30.7 0.1 100.0 1,139 40-44 41.9 8.4 49.4 0.3 100.0 585 45-49 27.2 1.7 71.1 0.0 100.0 66 Total 62.3 25.1 12.5 0.2 100.0 10,093 The great majority of births are desired and arrive according to the desired timing, regardless of birth order. However, the percentage of women reporting that a birth was unplanned increased regularly starting with the birth of the first child (1 percent), increased slightly with the third child (5 percent), and finally peaked up at four or more children when more than one quarter of the women (27 percent) reported that the birth was unplanned. In fact, the results show that 80 percent of first births arrived at the desired time compared with 64 percent of second births and 51 percent of fourth or higher order births. Beginning at age 20, the percentage of planned births decreases with the age of the mother: dropping from 72 percent for women age 20-24 to 27 percent for women age 45-49. In fact, births among women who had children when they were older (age 45 to 49) seem to be less well planned: 71 percent of births were not wanted at this age. It must be noted also that for women less than age 20 at the time of birth, only 60 percent of the births were planned, 37 percent of the births were wanted later in life, and 3 percent were unwanted. 84 • Fertility Preferences Table 6.6 compares the total wanted fertility rate (TWFR) with the current total fertility rate (TFR) for the five years preceding the survey. Calculation of the TWFR is the same as for the TFR, except that unwanted births are omitted. If all unwanted births were eliminated, the TFR for Rwandan women would be 3.1 children rather than 4.6 children. 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 2010 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 2.6 3.4 Rural 3.2 4.8 Province City of Kigali 2.6 3.5 South 3.2 4.6 West 3.4 5.0 North 2.7 4.1 East 3.4 4.9 Education No education 3.8 5.4 Primary 3.3 4.8 Secondary and higher 2.2 3.0 Wealth quintile Lowest 3.7 5.4 Second 3.6 5.2 Middle 3.1 4.5 Fourth 3.0 4.4 Highest 2.4 3.4 Total 3.1 4.6 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 5.2. The TWFR is higher in rural areas (3.2) than in urban areas (2.6). It is lowest in the City of Kigali (2.6) and highest in West and East provinces (3.4). It decreases as the level of education increases, from 3.8 percent for women with no education to 2.2 percent for women with a secondary level of education. It also decreases with the increase of the wealth quintile: the lowest TWFRs are found among women with the greatest household wealth (2.4 percent), and the highest TWFRs are found among women with the lowest household wealth (3.7). Family Planning • 85 FAMILY PLANNING 7 his chapter presents the 2010 Rwanda Demographic and Health Survey (RDHS) results on contraceptive prevalence, knowledge, attitudes, and behaviour. Although the focus is on women, some results from the men’s survey are also presented because men play an important role in the realisation of reproductive health goals. Comparisons are also made, where feasible, with findings from previous surveys to evaluate trends occurring in Rwanda over the past decade. 7.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Acquiring knowledge about fertility control is an important step toward gaining access to and then using a suitable contraceptive method in a timely and effective manner. The interviewer collected data on knowledge of contraception by describing the method and asking whether the respondent recognised it. Information was collected on 11 modern family planning methods: female and male sterilisation, pills, intrauterine devices (IUDs), injectables, implants, male and female condoms, lactational amenorrhoea method (LAM), emergency contraception, and Standard Days Method (SDM). Information was also collected on two traditional methods: rhythm and withdrawal. Any other traditional method mentioned spontaneously by the respondent was recorded on the questionnaire. Prompted and unprompted knowledge are combined in this report. Table 7.1 shows that knowledge of at least one method of contraception is universal among both women and men in Rwanda regardless of marital status and sexual experience. Men are slightly more likely than women to have heard of a modern method (100 and 99 percent, respectively) and a traditional method (91 and 90 percent, respectively). The mean number of methods known is a rough indicator of the breadth of knowledge of family planning methods. All women and men age 15-49 know an average of 9.8 contraceptive methods. Currently married women and men are more likely than sexually active unmarried women and men to know about family planning methods. Modern methods are more widely known than traditional methods. More than 9 in 10 women have heard about the male condom, injectables, and the pill. Emergency contraception is the least known modern method among women and men. The most well-known contraceptive methods among men are the male condom and injectables. T 86 • Family Planning Table 7.1 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 2010 Method Women Men All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 99.3 99.9 99.6 99.5 100.0 100.0 Any modern method 99.3 99.9 99.6 99.5 100.0 100.0 Female sterilisation 71.9 78.1 76.0 77.4 85.9 82.8 Male sterilisation 59.9 71.0 58.7 69.0 82.0 66.6 Pill 95.0 99.0 98.7 88.6 96.5 92.5 IUD 69.1 79.1 72.6 67.8 80.1 65.5 Injectables 95.4 99.2 96.1 90.0 97.8 95.5 Implants 88.1 96.9 91.7 75.4 91.1 74.9 Male condom 98.1 99.0 99.6 99.0 99.8 100.0 Female condom 82.4 87.1 85.4 79.5 84.7 86.3 Lactational amenorrhoea (LAM) 66.3 79.2 68.6 54.5 70.5 40.4 Emergency contraception 23.0 25.5 23.8 39.2 45.8 47.5 Standard Days Method 77.7 88.2 76.8 71.8 82.4 64.1 Any traditional method 89.6 95.4 91.3 90.7 98.1 93.4 Rhythm 85.6 90.2 84.8 87.5 96.0 89.0 Withdrawal 70.8 88.2 79.7 75.3 91.4 80.9 Other 0.5 0.8 0.3 0.7 0.8 0.0 Mean number of methods known by respondents 15-49 9.8 10.8 10.1 9.8 11.0 9.9 Number of respondents 13,671 6,897 246 5,687 2,699 117 Mean number of methods known by respondents 15-59 na na na 9.9 11.1 9.8 Number of respondents na na na 6,329 3,287 118 na = Not applicable 1 Had sexual intercourse within 30 days preceding the survey Table 7.2 shows little variation in knowledge of contraceptive methods by background characteristics. Regardless of their background, nearly all currently married women and men have heard of at least one contraceptive method or at least one modern method, with the proportion ranging from over 99 percent to universal. Table 7.2 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 2010 Background characteristic Women Men Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number Age 15-19 98.5 98.5 89 100.0 100.0 3 20-24 100.0 100.0 998 100.0 100.0 222 25-29 99.8 99.8 1,773 99.8 99.8 646 30-34 100.0 99.9 1,458 100.0 100.0 613 35-39 99.9 99.9 1,112 100.0 100.0 439 40-44 100.0 100.0 780 100.0 100.0 397 45-49 100.0 99.9 688 100.0 100.0 380 Residence Urban 100.0 100.0 926 100.0 100.0 391 Rural 99.9 99.9 5,971 100.0 100.0 2,308 Province City of Kigali 100.0 100.0 726 100.0 100.0 307 South 100.0 99.9 1,614 100.0 100.0 624 West 100.0 100.0 1,675 100.0 100.0 623 North 100.0 100.0 1,151 99.8 99.8 430 East 99.7 99.6 1,731 100.0 100.0 715 Education No education 99.9 99.8 1,355 99.8 99.8 438 Primary 99.9 99.9 4,816 100.0 100.0 1,893 Secondary and higher 100.0 100.0 727 100.0 100.0 368 Continued. Family Planning • 87 Table 7.2—Continued Background characteristic Women Men Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number Wealth quintile Lowest 99.7 99.6 1,352 99.8 99.8 467 Second 100.0 100.0 1,388 100.0 100.0 523 Middle 99.9 99.8 1,394 100.0 100.0 558 Fourth 100.0 100.0 1,415 100.0 100.0 580 Highest 100.0 100.0 1,348 100.0 100.0 572 Total 15-49 99.9 99.9 6,897 100.0 100.0 2,699 50-59 na na na 99.7 99.5 588 Total 15-59 na na na 99.9 99.9 3,287 na = Not applicable 1 Female sterilisation, male sterilisation, pill, IUD, injectables, implants, male condom, female condom, diaphragm, foam or jelly, lactational amenorrhoea method (LAM), and emergency contraception 7.2 CURRENT USE OF CONTRACEPTIVE METHODS The level of current use of contraceptive methods is one of the indicators most frequently used to assess the success of family planning programme activities and one of the determinants of fertility. This section focuses on levels, trends, and differentials in current use of family planning. 7.2.1 Current Use of Contraception by Age Table 7.3 shows that 29 percent of all women, 52 percent of currently married women, and 41 percent of sexually active unmarried women age 15-49 are using a contraceptive method. The majority of women who are using a contraceptive method use a modern method (25 percent). Three percent of women use traditional methods. The most commonly used modern methods are injectables (15 percent), the pill (4 percent), and implants (4 percent). More than one in two currently married women (52 percent) are currently using contraception; 45 percent use modern methods and 6 percent use traditional methods. The most commonly used methods among currently married women are injectables (26 percent), the pill (7 percent), and implants (6 percent). The use of modern contraceptive methods among currently married women varies by age, gradually rising from 31 percent among women age 15-19, peaking at 52 percent among women age 35 to 39, and dropping to 21 percent among women age 45-49. Most of the women who have been sterilised are age 35 or older, while younger women are more likely to use other nonpermanent methods of contraception such as injectables and pills. The high level of current use of any contraception among sexually active unmarried women (41 percent) is driven by the high prevalence of injectables and condoms (18 percent and 12 percent, respectively). 88 • F am ily P la nn in g Ta bl e 7. 3 C ur re nt u se o f c on tra ce pt io n by a ge P er ce nt d is tri bu tio n of a ll w om en , c ur re nt ly m ar rie d w om en , a nd s ex ua lly a ct iv e un 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 rre nt ly u se d, a cc or di ng to a ge , R w an da 2 01 0 A ge A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tr ad i- tio na l m et ho d Tr ad iti on al m et ho d N ot cu rre nt ly us in g To ta l N um be r o f w om en Fe m al e st er ili- sa tio n M al e st er ili- sa tio n P ill IU D In je ct ab le s Im pl an ts M al e co nd om D ia ph ra gm LA M S ta nd ar d D ay s M et ho d R hy th m W ith dr aw al O th er A LL W O M E N 15 -1 9 2. 1 1. 9 0. 0 0. 0 0. 3 0. 0 1. 0 0. 1 0. 5 0. 0 0. 0 0. 0 0. 1 0. 1 0. 0 0. 0 97 .9 10 0. 0 2, 94 5 20 -2 4 19 .5 18 .5 0. 0 0. 0 2. 9 0. 0 12 .6 1. 4 1. 2 0. 0 0. 3 0. 1 1. 0 0. 5 0. 5 0. 0 80 .5 10 0. 0 2, 68 3 25 -2 9 42 .1 38 .8 0. 1 0. 0 6. 3 0. 1 24 .0 4. 8 2. 7 0. 0 0. 5 0. 4 3. 3 1. 2 2. 0 0. 0 57 .9 10 0. 0 2, 49 4 30 -3 4 47 .8 42 .9 0. 4 0. 0 7. 0 0. 5 23 .8 7. 3 2. 8 0. 0 0. 4 0. 6 4. 9 2. 2 2. 7 0. 1 52 .2 10 0. 0 1, 82 2 35 -3 9 48 .5 42 .9 1. 7 0. 2 5. 4 0. 9 22 .5 7. 7 3. 6 0. 0 0. 2 0. 7 5. 6 2. 6 3. 0 0. 0 51 .5 10 0. 0 1, 44 7 40 -4 4 37 .1 30 .9 0. 9 0. 0 5. 5 0. 4 15 .6 5. 1 2. 2 0. 0 0. 4 0. 9 6. 2 3. 2 2. 8 0. 2 62 .9 10 0. 0 1, 16 8 45 -4 9 24 .4 14 .8 1. 7 0. 0 1. 7 0. 1 7. 6 2. 5 1. 1 0. 0 0. 1 0. 1 9. 6 5. 0 4. 6 0. 0 75 .6 10 0. 0 1, 11 2 To ta l 28 .6 25 .2 0. 5 0. 0 3. 9 0. 2 14 .6 3. 6 1. 8 0. 0 0. 3 0. 3 3. 4 1. 6 1. 8 0. 0 71 .4 10 0. 0 13 ,6 71 C U R R E N TL Y M A R R IE D W O M E N 15 -1 9 32 .9 30 .6 0. 0 0. 0 6. 7 1. 4 19 .9 0. 0 1. 5 0. 0 1. 2 0. 0 2. 2 1. 2 1. 0 0. 0 67 .1 10 0. 0 89 20 -2 4 44 .5 42 .1 0. 1 0. 0 6. 9 0. 1 28 .9 2. 9 2. 2 0. 0 0. 6 0. 3 2. 4 1. 0 1. 4 0. 0 55 .5 10 0. 0 99 8 25 -2 9 54 .3 49 .8 0. 1 0. 0 8. 1 0. 2 31 .1 6. 0 3. 1 0. 0 0. 7 0. 6 4. 5 1. 6 2. 8 0. 0 45 .7 10 0. 0 1, 77 3 30 -3 4 56 .3 50 .2 0. 4 0. 0 8. 4 0. 6 28 .0 8. 3 3. 2 0. 1 0. 5 0. 7 6. 1 2. 7 3. 3 0. 1 43 .7 10 0. 0 1, 45 8 35 -3 9 58 .6 51 .8 2. 1 0. 3 6. 5 1. 2 27 .3 9. 2 4. 1 0. 0 0. 3 0. 9 6. 8 3. 0 3. 9 0. 0 41 .4 10 0. 0 1, 11 2 40 -4 4 50 .9 42 .1 1. 3 0. 0 7. 8 0. 6 21 .2 6. 9 2. 6 0. 0 0. 4 1. 3 8. 9 4. 5 4. 1 0. 3 49 .1 10 0. 0 78 0 45 -4 9 36 .5 21 .4 2. 3 0. 0 2. 6 0. 0 11 .2 3. 4 1. 6 0. 0 0. 2 0. 1 15 .1 7. 7 7. 5 0. 0 63 .5 10 0. 0 68 8 To ta l 51 .6 45 .1 0. 8 0. 0 7. 1 0. 5 26 .3 6. 3 2. 9 0. 0 0. 5 0. 6 6. 4 2. 9 3. 5 0. 1 48 .4 10 0. 0 6, 89 7 S E XU A LL Y A C TI V E U N M A R R IE D W O M E N 1 15 -1 9 (2 7. 3) (2 7. 3) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (7 .1 ) (0 .0 ) (2 0. 2) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (7 2. 7) (1 00 .0 ) 42 20 -2 4 38 .3 38 .3 0. 0 0. 0 2. 5 0. 0 21 .5 7. 9 6. 5 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 61 .7 10 0. 0 53 25 -2 9 46 .4 46 .4 0. 0 0. 0 9. 1 0. 0 24 .4 2. 0 10 .9 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 53 .6 10 0. 0 61 30 -3 4 (4 8. 9) (4 8. 9) (0 .0 ) (0 .0 ) (6 .2 ) (0 .0 ) (2 2. 9) (1 1. 0) (8 .8 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (5 1. 1) (1 00 .0 ) 34 35 -3 9 (4 6. 2) (4 1. 9) (0 .0 ) (0 .0 (7 .2 ) (0 .0 ) (1 2. 5) (9 .7 ) (1 2. 5) (0 .0 ) (0 .0 ) (0 .0 ) (4 .3 ) (4 .3 ) (0 .0 ) (0 .0 ) (5 3. 8) (1 00 .0 ) 25 40 -4 4 * * * * * * * * * * * * * * * * * * 23 45 -4 9 * * * * * * * * * * * * * * * * * * 7 To ta l 41 .2 40 .3 0. 0 0. 0 4. 4 0. 0 18 .4 5. 9 11 .7 0. 0 0. 0 0. 0 0. 8 0. 4 0. 4 0. 0 58 .8 10 0. 0 24 6 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. LA M = L ac ta tio na l a m en or rh oe a m et ho d 1 W om en w ho h av e ha d se xu al in te rc ou rs e w ith in 3 0 da ys p re ce di ng th e su rv ey 88 • Family Planning Family Planning • 89 7.2.2 Current Use of Contraception by Background Characteristics Table 7.4 shows no substantial variation by background characteristics in the current use of contraceptive methods. Currently married women in urban areas and their rural counterparts slightly differ in terms of use of a contraceptive method (53 and 51 percent, respectively). There is also little difference between urban women and rural women in the use of a modern method (47 percent and 45 percent, respectively). By province, the North province shows the highest proportion of married women who are using a contraceptive method (57 percent); the lowest proportion (43 percent) is in the West province. Women in the North province are more likely to rely on injectables (36 percent) than their counterparts in other regions, while pills are equally popular among women in the City of Kigali and the South, North, and East provinces (8 percent). The male condom, IUDs, and female sterilisation are most popular among women in the City of Kigali (5 percent, 3 percent, and 2 percent, respectively), while implants are most popular among currently married women in the South province (8 percent). Use of any contraceptive method among currently married women increases with educational attainment, from 43 percent among women with no education to 60 percent among women with a secondary education or higher. Contraceptive use also increases rapidly as the number of living children increases, peaking at 58 percent for women with three to four children. Use of any contraceptive method increases with wealth quintile as well, from 43 percent of women in the lowest quintile to 57 percent of women in the highest quintile. 90 • Family Planning Table 7.4 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Rwanda 2010 Background characteristic Any method Any modern method Modern method Any tradi- tional method Traditional method Not current- ly using Total Number of women Female sterili- sation Male sterili- sation Pill IUD Inject- ables Im- plants Male condom Dia- phragm LAM Stan- dard Days Method Rhythm With- drawal Other Number of living children 0 1.5 1.3 0.0 0.0 0.0 0.0 0.5 0.5 0.3 0.0 0.0 0.0 0.2 0.0 0.2 0.0 98.5 100.0 429 1-2 53.1 48.3 0.1 0.0 8.2 0.5 30.5 4.7 3.1 0.0 0.5 0.7 4.8 2.2 2.6 0.0 46.9 100.0 2,478 3-4 58.2 52.0 1.3 0.1 8.3 0.6 28.8 8.3 3.5 0.0 0.7 0.5 6.2 2.8 3.4 0.0 41.8 100.0 2,133 5+ 53.5 43.2 1.5 0.1 6.0 0.5 23.7 7.6 2.6 0.0 0.3 0.8 10.3 4.6 5.5 0.1 46.5 100.0 1,858 Residence Urban 53.1 47.0 2.0 0.0 7.9 2.4 22.3 6.1 4.3 0.0 0.2 1.9 6.0 2.5 3.3 0.2 46.9 100.0 926 Rural 51.4 44.9 0.7 0.0 7.0 0.2 26.9 6.4 2.7 0.0 0.5 0.4 6.5 3.0 3.5 0.0 48.6 100.0 5,971 Province City of Kigali 53.6 47.5 2.2 0.0 8.2 2.6 20.9 5.9 5.0 0.0 0.1 2.6 6.1 2.8 3.0 0.3 46.4 100.0 726 South 55.3 48.3 0.6 0.0 7.5 0.4 27.7 8.3 2.5 0.0 0.6 0.7 6.9 2.4 4.4 0.1 44.7 100.0 1,614 West 42.7 35.5 1.2 0.1 5.0 0.2 19.3 5.5 2.6 0.0 1.2 0.5 7.3 3.7 3.5 0.1 57.3 100.0 1,675 North 56.9 52.0 0.3 0.2 8.0 0.2 36.0 4.5 2.6 0.0 0.0 0.3 4.9 3.0 1.9 0.0 43.1 100.0 1,151 East 52.3 45.9 0.5 0.0 7.8 0.1 27.5 6.6 2.9 0.1 0.2 0.2 6.4 2.6 3.7 0.0 47.7 100.0 1,731 Education No education 43.3 37.3 0.5 0.2 5.1 0.1 22.7 6.0 1.6 0.1 1.0 0.1 6.0 3.0 2.9 0.1 56.7 100.0 1,355 Primary 52.6 46.3 0.7 0.0 7.3 0.2 28.2 6.0 3.0 0.0 0.3 0.6 6.3 2.6 3.7 0.1 47.4 100.0 4,816 Secondary and higher 60.3 52.3 2.3 0.0 10.1 3.0 20.5 8.9 4.9 0.0 0.6 2.0 8.0 4.9 3.1 0.0 39.7 100.0 727 Wealth quintile Lowest 43.1 38.5 0.2 0.0 4.9 0.1 27.0 3.8 1.2 0.0 0.8 0.4 4.6 1.8 2.7 0.1 56.9 100.0 1,352 Second 47.4 41.2 0.7 0.2 6.5 0.0 25.8 4.7 2.0 0.0 1.0 0.3 6.2 2.4 3.7 0.1 52.6 100.0 1,388 Middle 52.8 47.1 0.6 0.0 7.5 0.1 28.4 6.7 2.9 0.1 0.4 0.3 5.7 3.0 2.7 0.0 47.2 100.0 1,394 Fourth 57.2 49.2 0.8 0.1 8.3 0.2 28.2 7.8 3.4 0.0 0.0 0.3 8.0 3.5 4.5 0.0 42.8 100.0 1,415 Highest 57.1 49.6 1.8 0.0 8.4 2.0 21.7 8.5 5.1 0.0 0.2 1.8 7.6 3.8 3.6 0.1 42.9 100.0 1,348 Total 51.6 45.1 0.8 0.0 7.1 0.5 26.3 6.3 2.9 0.0 0.5 0.6 6.4 2.9 3.5 0.1 48.4 100.0 6,897 Note: If more than one method is used, only the most effective method is considered in this tabulation. LAM = Lactational amenorrhoea method 7.3 TIMING OF STERILISATION Table 7.5 shows the distribution of women age 15-49 by age group at the time of sterilisation and median age at sterilisation. Forty-six percent of Rwandan women who adopted sterilisation as their contraceptive method have done so at age 35-39, 28 percent at age 30-34. The median age at sterilisation is 35.1. Table 7.5 Timing of sterilisation Percent distribution of sterilised women age 15-49 by age at the time of sterilisation and median age at sterilisation, Rwanda 2010 Age at time of sterilisation Total Number of women Median age1 <25 25-29 30-34 35-39 40-44 45-49 Total 3.1 10.4 28.2 45.7 11.4 1.0 100.0 63 35.1 1 Median age at sterilisation is calculated only for women sterilised before age 40 to avoid problems due to censoring. 7.4 SOURCE OF SUPPLY To assess the contribution of public and private medical service providers to the sale or distribution of the various modern methods of contraception, the women surveyed were asked where they obtained the method they use. They were also asked where they had most recently obtained the contraceptive methods they were using at the time of the survey. Table 7.6 shows that the majority of women in Rwanda obtain modern methods of contraception from the public sector (92 percent, compared with 73 percent in 2005) and that 77 percent of women obtain their method from a health centre. Other sources are health posts, outreach, and the private medical sector (4 percent). The nonmedical private sector (kiosks, friends, relatives, and other sources) supplies about 2 percent of contraceptive needs, while community health workers provide only 1 percent (mainly the male condom, at 8 percent). Family Planning • 91 7.5 INFORMED CHOICE Informed choice is an important aspect of the delivery of family planning services. It is required that all family planning providers inform method users of potential side effects and what they should do if they encounter such side effects. This information is designed to assist users in coping with side effects and, thus, to decrease discontinuation of temporary methods. Contraceptive users should also be informed of the choices they have with respect to other methods. Table 7.7 shows the percentage of current users of modern methods who were informed about side effects or problems with the method used and informed of other methods they could use at the time they first began using the method. Figures are broken down by method type, initial source, and background characteristics. A majority of users were given information about each of the three issues considered to be essential parts of informed choice: 64 percent were informed about potential side effects of their method, 68 percent were told what to do if they experienced side effects, and 78 percent were given information about other contraception method options. Table 7.6 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Rwanda 2010 Source Female sterilisation Male sterilisation Pill IUD1 Injectables Implants1 Male condom Diaphragm Total Public sector 89.1 * 93.6 (50.4) 97.0 93.9 51.2 * 92.0 Referral hospital 26.2 * 0.0 (22.7) 0.1 0.8 0.4 * 1.0 District hospital 57.4 * 2.9 (16.9) 2.1 4.3 2.1 * 3.8 Health centre 2.1 * 77.4 (10.8) 84.2 84.2 37.5 * 77.3 Health post 0.0 * 5.1 (0.0) 5.5 0.9 2.2 * 4.3 Outreach 0.0 * 6.1 (0.0) 4.4 3.5 1.0 * 4.2 Community health worker 0.0 * 2.0 (0.0) 0.2 0.0 7.9 * 1.0 Other public 3.4 * 0.2 (0.0) 0.4 0.2 0.0 * 0.3 Private medical sector 5.5 * 5.5 (34.5) 2.8 3.4 8.9 * 4.2 Polyclinic 0.7 * 0.0 (20.7) 0.1 1.9 0.0 * 0.6 Clinic 3.3 * 0.9 (4.5) 0.3 0.0 0.0 * 0.4 Dispensary 0.0 * 1.1 (3.6) 1.7 0.6 1.0 * 1.4 Pharmacy 0.0 * 2.6 (0.0) 0.4 0.0 7.1 * 1.2 Family planning clinic 0.0 * 0.8 (5.7) 0.2 0.9 0.4 * 0.5 Other private 1.5 * 0.0 (0.0) 0.1 0.0 0.4 * 0.1 Other source 0.0 * 0.0 (0.0) 0.0 0.2 31.8 * 2.4 Kiosk 0.0 * 0.0 (0.0) 0.0 0.0 30.0 * 2.2 Friend/relative 0.0 * 0.0 (0.0) 0.0 0.2 1.8 * 0.2 Other 0.7 * 0.3 (4.7) 0.0 1.1 6.1 * 0.7 Don’t know 0.0 * 0.0 (0.0) 0.1 0.0 1.5 * 0.1 Missing 4.7 * 0.7 (10.4) 0.1 1.4 0.6 * 0.6 Total 100.0 * 100.0 (100.0) 100.0 100.0 100.0 * 100.0 Number of women 63 3 531 34 1,993 491 252 1 3,367 Note: Total includes other modern methods but excludes lactational amenorrhoea method (LAM). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For users of IUDs and implants, the source is where the respondent obtained the method when she started the current episode of use. Source of method is missing for IUD and implant users if they began using the method more than five years before the survey. 92 • Family Planning Table 7.7 Informed choice Among current users of modern methods age 15-49 who started the most recent episode of use within the five years preceding the survey, the percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods they could use, by method and initial source, Rwanda 2010 Method/source Among women who started last episode of modern contraceptive method within five years preceding the survey: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experiencing side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilisation (37.5) (36.9) (22.6) 38 Pill 60.4 64.3 81.4 507 IUD (72.0) (80.7) (75.5) 28 Injectables 64.5 68.5 78.3 1,914 Implants 66.5 69.8 76.4 484 Initial source of method1 Public sector 64.0 67.8 78.2 2,828 Referral hospital (62.6) (62.3) (56.4) 23 District hospital 56.7 60.9 65.3 121 Health centre 65.2 69.0 79.4 2,446 Health post 54.2 56.5 71.6 105 Outreach 53.2 59.3 75.0 121 Community health worker * * * 1 Other public * * * 10 Private medical sector 61.6 68.3 71.9 121 Polyclinic (69.3) (69.3) (75.9) 20 Clinic * * * 16 Dispensary 59.0 68.8 76.9 42 Pharmacy * * * 18 Family planning clinic (72.8) (83.7) (69.4) 20 Other private * * * 6 Other source * * * 1 Friend/relative * * * 1 Other * * * 10 Don’t know * * * 1 Total 63.8 67.7 77.8 2,970 Note: Table includes users of only the methods listed individually. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Source at start of current episode of use 7.6 CONTRACEPTIVE DISCONTINUATION Couples can realise their reproductive goals only when they use contraceptive methods continuously. A prominent concern for managers of family planning programmes is discontinuation of contraceptive use. In the 2010 RDHS ‘calendar’ section, all periods of contraceptive use between January 2005 and the date of the interview were recorded, along with reasons for any discontinuation. One-year contraceptive discontinuation rates based on the calendar data are presented in Table 7.8. The results show that a variety of reasons were given for discontinuation. Thirty-five percent of women gave reasons relating to side effects/health concerns, 19 percent wanted to become pregnant, 13 percent became pregnant while using, and 11 percent wanted a more effective method. The frequency with which reasons were reported varied according to method. Women using implants were most likely to discontinue use due to side effects/health concerns (67 percent), followed by those using injectables (45 percent) and pills (37 percent). Family Planning • 93 Table 7.8 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method, Rwanda 2010 Reason Pill IUD Injectables Implants Male condom LAM Rhythm Withdrawal Other All methods Became pregnant while using 11.7 * 5.1 1.6 16.7 35.9 44.3 38.9 (48.9) 12.9 Wanted to become pregnant 13.7 * 20.7 11.2 21.5 10.4 26.4 24.9 (28.2) 19.3 Husband disapproved 1.1 * 1.4 1.2 11.9 0.0 1.1 1.7 (2.0) 1.7 Wanted a more effective method 12.4 * 9.0 4.1 16.8 38.1 11.9 14.6 (5.6) 11.1 Side effects/health concerns 37.1 * 44.6 66.5 0.9 0.0 0.7 0.0 (0.0) 34.5 Lack of access/too far 1.1 * 0.9 0.0 1.1 0.0 0.0 0.0 (0.0) 0.8 Cost too much 0.0 * 0.0 0.0 0.0 0.0 0.0 0.0 (0.0) 0.0 Inconvenient to use 8.7 * 1.7 1.1 5.2 1.5 4.2 7.0 (6.1) 4.1 Up to God/fatalistic 0.8 * 0.3 0.0 0.0 0.0 0.0 0.0 (0.0) 0.4 Difficult to get pregnant/menopausal 0.2 * 0.2 0.0 1.0 0.0 0.0 0.5 (0.0) 0.2 Infrequent sex/husband away 2.9 * 3.5 1.4 7.2 0.0 1.2 2.7 (1.0) 3.1 Marital dissolution/separation 1.0 * 1.9 1.5 1.1 0.0 0.5 0.5 (0.0) 1.4 Other 5.2 * 5.7 1.3 6.2 1.5 3.8 1.4 (0.0) 4.9 Don’t know 0.0 * 0.0 0.0 2.5 0.0 0.0 0.0 (0.0) 0.1 Missing 4.2 * 4.9 10.1 7.9 12.6 5.9 7.8 (8.3) 5.5 Total 100.0 * 100.0 100.0 100.0 100.0 100.0 100.0 (100.0) 100.0 Number of discontinuations 710 10 1,533 86 105 59 171 207 43 2,923 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. LAM = Lactational amenorrhoea method 7.7 KNOWLEDGE OF FERTILE PERIOD Successful use of natural family planning methods depends largely on an understanding of when during the menstrual cycle a woman is most likely to conceive. An elementary knowledge of reproductive physiology provides background for the successful practice of coitus-associated methods such as withdrawal. Such knowledge is especially critical for the practice of rhythm/periodic abstinence (the calendar method). To assess this understanding, the survey asked all women whether there were certain days during the menstrual cycle when they were more likely to become pregnant if they had sexual intercourse. Those who answered yes were asked when those days occurred during the cycle. The question provided four explicit responses: ‘just before her period begins’, ‘right after her period has ended’, ‘during her period’, and ‘halfway between two periods’. Respondents could also give a different response or state that they did not know when this occurred. These responses can be grouped into three categories of decreasing knowledge: • Correct knowledge: ‘halfway between two periods’; the middle of the cycle. • Possibly correct knowledge: ‘just before her period begins’ and ‘right after her period has ended’. These responses are too vague to be considered accurate but, depending on how a woman views ‘right after her period has ended’ or ‘just before her period begins’, these answers could indicate the fertile period. • Incorrect knowledge: ‘during her period’, ‘no specific time’, ‘other’, and ‘don’t know’. Table 7.9 provides the results for all women users and nonusers of the rhythmic method. Overall, only 12 percent of women reported the correct timing of the fertile period, that is, halfway through the woman’s menstrual cycle. This is a slight decline compared with the results of the 2005 RDHS, where 13 percent of women reported the correct timing of the fertile period. The data also show that 29 percent of women have possibly correct knowledge and that 59 percent have incorrect knowledge or don’t know that there is a time during the menstrual cycle when a woman is more likely to conceive. Knowledge of the fertile period is considerably higher among users of rhythm/periodic abstinence (38 percent) than among nonusers (12 percent). However, 40 percent of rhythm/periodic abstinence users have only 94 • Family Planning possibly correct knowledge of the fertile period, and 22 percent do not know when a woman should stop having sexual intercourse in order to avoid becoming pregnant or do not know that such a time exists. Nonetheless, these results show an improvement since 2005, when 67 percent of rhythm/periodic abstinence users did not know how to use the method correctly because they had only possibly correct knowledge of the fertile period or because they had incorrect knowledge. This is a result of government efforts to make contraceptive methods available and accessible to the population, as reflected by the current prevalence of use of modern methods (45 percent). Table 7.9 Knowledge of fertile period Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Rwanda 2010 Perceived fertile period Users of rhythm method Nonusers of rhythm method All women Just before her menstrual period begins 2.3 4.6 4.6 During her menstrual period 1.5 1.4 1.4 Right after her menstrual period has ended 37.9 23.7 24.0 Halfway between two menstrual periods 37.8 11.9 12.3 Other 2.4 0.7 0.7 No specific time 16.1 48.9 48.4 Don’t know 2.1 8.6 8.5 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of women 217 13,454 13,671 7.8 NEED AND DEMAND FOR FAMILY PLANNING SERVICES 7.8.1 Need and Demand for Family Planning among Currently Married Women Women who do not want any more children or want to wait two or more years before having another child, but are not using contraception, are considered to have an unmet need for family planning. Women who are using family planning methods are said to have a met need for family planning. Women with unmet need and women with met need together constitute the total demand for family planning, which can be categorised according to whether the need is for spacing or limiting births. Table 7.10.1 presents estimates for unmet need, met need, and total demand for family planning among currently married Rwandan women. Nineteen percent of currently married women have an unmet need for family planning (an improvement since 2005, when the figure was 38 percent): 10 percent have an unmet need for spacing, and 9 percent have an unmet need for limiting. The total demand for family planning among currently married women is 72 percent, and almost three quarters of that demand (74 percent) is satisfied. The demand for limiting needs is slightly higher than the demand for spacing needs (39 and 34 percent, respectively). Unmet need does not vary much by age except for the youngest and oldest women, who have the lowest percentage of unmet need. Up to age 34, most unmet need for family planning involves spacing. From age 35, most unmet need for family planning is for limiting childbearing. Total unmet need for family planning is higher in rural areas (20 percent) than in urban areas (16 percent). At regional levels, total unmet need is highest in the West province (25 percent) and lowest in the City of Kigali (15 percent). There are notable differences in percentage of demand satisfied by women’s characteristics. As expected, a high percentage of demand is satisfied among urban women, those living in wealthier households, and those with more education. There has been a significant improvement in unmet need since the 2005 RDHS (when, as mentioned above, the figure was 38 percent); also, there has been a significant increase in the total demand for family planning among currently married women (from 55 percent in the 2005 RDHS to 72 percent in the 2010 RDHS). In this same interval, the percentage of demand satisfied has more than doubled, increasing from 31 percent to 74 percent. Family Planning • 95 Table 7.10.1 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Rwanda 2010 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Percentage of demand satisfied by modern methods Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 6.4 0.0 6.4 30.2 2.7 32.9 36.5 2.7 39.2 83.8 78.1 89 20-24 14.3 0.9 15.2 38.4 6.1 44.5 54.7 7.0 61.8 75.4 68.2 998 25-29 14.0 3.0 17.0 39.3 15.0 54.3 55.2 18.3 73.5 76.9 67.8 1,773 30-34 11.7 8.1 19.8 21.7 34.6 56.3 35.4 43.7 79.1 75.0 63.4 1,458 35-39 6.4 15.2 21.6 9.0 49.6 58.6 15.7 65.7 81.4 73.5 63.6 1,112 40-44 3.2 21.2 24.4 4.0 47.0 50.9 7.3 69.3 76.6 68.1 54.9 780 45-49 0.9 17.8 18.7 1.2 35.3 36.5 2.1 53.5 55.5 66.3 38.5 688 Residence Urban 8.7 6.8 15.5 23.6 29.5 53.1 33.8 37.1 70.8 78.2 66.4 926 Rural 9.9 9.6 19.5 22.5 28.8 51.4 33.6 39.0 72.6 73.2 61.8 5,971 Province City of Kigali 7.5 7.5 15.0 25.7 27.9 53.6 34.8 36.1 71.0 78.9 67.0 726 South 7.6 8.6 16.1 23.0 32.3 55.3 32.0 41.8 73.8 78.1 65.5 1,614 West 14.6 10.3 25.0 20.2 22.5 42.7 36.0 33.3 69.4 64.0 51.2 1,675 North 7.8 7.8 15.6 25.2 31.7 56.9 33.9 40.1 74.0 78.9 70.3 1,151 East 9.1 10.5 19.6 21.8 30.5 52.3 32.2 41.4 73.5 73.3 62.5 1,731 Education No education 8.9 14.9 23.8 13.8 29.5 43.3 23.1 45.0 68.2 65.1 54.8 1,355 Primary 10.4 8.2 18.6 24.6 28.0 52.6 36.6 36.7 73.3 74.6 63.1 4,816 Secondary and higher 6.4 5.5 11.9 26.3 34.0 60.3 33.8 40.4 74.2 84.0 70.5 727 Wealth quintile Lowest 12.9 11.1 24.0 19.3 23.8 43.1 33.4 35.4 68.8 65.1 55.9 1,352 Second 11.7 10.0 21.7 21.4 26.0 47.4 34.6 36.8 71.4 69.6 57.7 1,388 Middle 9.0 8.8 17.8 25.0 27.8 52.8 35.0 36.9 71.9 75.2 65.5 1,394 Fourth 7.8 8.4 16.2 23.1 34.1 57.2 32.3 43.5 75.8 78.6 64.9 1,415 Highest 7.2 7.9 15.0 24.6 32.6 57.1 32.8 41.0 73.9 79.6 67.1 1,348 Total 9.7 9.2 18.9 22.7 28.9 51.6 33.6 38.7 72.4 73.8 62.4 6,897 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 7.8.2 Need and Demand for Family Planning among All Women and Women Who Are Not Currently Married Table 7.10.2 presents estimates for unmet need, met need, and total demand for family planning among all women and among women who are not currently married. Ten percent of all women and about 1 percent of women not currently married have an unmet need for family planning. The total demand for family planning is 40 percent among all women and 7 percent among women not currently married; the corresponding proportions of demand satisfied among these women are 74 percent and 80 percent. The demand for limiting is slightly higher than the demand for spacing (21 and 19 percent, respectively) among all women, while the demand for spacing and limiting is almost the same among women not currently married. Unmet need does not vary extensively by age with the exception of the youngest and oldest women, who have the lowest percentages of unmet need. Up to age 34, most unmet need for family planning involves spacing. From age 35, most unmet need for family planning is for limiting childbearing. Total unmet need for family planning among all women is higher in rural areas (11 percent) than in urban areas (8 percent), while the reverse is true among women not currently married. At the regional level, total unmet need is highest in the West province and lowest in the City of Kigali among all women; proportions of unmarried women with unmet need are lowest in the South and highest in the City of Kigali. 96 • Family Planning There are notable differences according to women’s characteristics in the percentage of demand satisfied. As expected, among all women a high percentage of demand is satisfied for those residing in urban areas, those living in wealthier households, and those with more education. In general, the same tendency is seen among women not currently married except in terms of residence; the percentage of demand satisfied is higher in rural areas than in urban areas. Table 7.10.2 Need and demand for family planning among all women and women who are not currently married Percentage of all women and women not currently married age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Rwanda 2010 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Percentage of demand satisfied by modern methods Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total ALL WOMEN Age 15-19 1.0 0.0 1.0 1.9 0.2 2.1 3.0 0.2 3.2 67.1 61.6 2,945 20-24 6.2 0.5 6.6 16.8 2.7 19.5 23.8 3.2 27.0 75.4 68.7 2,683 25-29 10.5 2.3 12.9 29.5 12.6 42.1 41.4 15.2 56.6 77.3 68.6 2,494 30-34 9.6 6.8 16.3 18.1 29.8 47.8 29.2 37.4 66.6 75.5 64.4 1,822 35-39 5.0 12.0 17.0 7.3 41.2 48.5 12.6 53.9 66.5 74.5 64.5 1,447 40-44 2.1 14.4 16.6 3.0 34.1 37.1 5.2 49.3 54.5 69.6 56.6 1,168 45-49 0.6 11.1 11.7 0.8 23.6 24.4 1.4 34.9 36.3 67.9 40.8 1,112 Residence Urban 4.8 3.2 8.0 12.4 14.5 26.9 17.9 18.2 36.1 77.9 66.8 2,057 Rural 5.5 5.1 10.6 12.6 16.3 28.9 18.8 21.7 40.5 73.8 62.8 11,614 Province City of Kigali 4.4 3.5 7.9 12.8 13.7 26.6 18.0 17.7 35.7 77.8 66.7 1,596 South 4.1 4.5 8.6 13.1 18.1 31.3 18.1 23.1 41.2 79.2 66.9 3,212 West 8.1 5.4 13.5 11.2 12.6 23.7 19.9 18.2 38.0 64.6 52.2 3,305 North 4.3 4.1 8.4 13.6 17.4 31.0 18.4 21.8 40.2 79.1 70.6 2,278 East 5.2 5.7 10.9 12.6 17.7 30.3 18.5 23.7 42.1 74.1 63.9 3,280 Education No education 6.3 9.7 16.0 9.3 20.4 29.7 16.0 30.5 46.5 65.6 55.5 2,119 Primary 5.8 4.4 10.2 14.0 16.0 29.9 20.6 20.7 41.3 75.2 64.3 9,337 Secondary and higher 2.6 1.9 4.6 10.0 12.1 22.0 12.9 14.3 27.2 83.3 70.2 2,216 Wealth quintile Lowest 7.2 6.1 13.3 11.0 14.6 25.7 19.0 21.0 40.0 66.7 58.0 2,622 Second 6.6 5.4 11.9 12.3 15.2 27.5 19.7 20.9 40.6 70.6 58.9 2,661 Middle 4.8 4.5 9.4 13.8 15.4 29.1 19.3 20.0 39.3 76.1 66.4 2,736 Fourth 4.4 4.6 9.0 13.2 19.2 32.4 18.3 24.3 42.7 78.9 65.8 2,677 Highest 4.1 3.7 7.8 12.6 15.8 28.4 17.2 19.8 36.9 79.0 67.3 2,976 Total 5.4 4.8 10.2 12.6 16.0 28.6 18.6 21.2 39.8 74.4 63.4 13,671 WOMEN NOT CURRENTLY MARRIED Age 15-19 0.9 0.0 0.9 1.0 0.1 1.1 1.9 0.1 2.0 57.1 51.7 2,857 20-24 1.3 0.2 1.5 4.0 0.7 4.7 5.4 1.0 6.3 75.8 71.5 1,685 25-29 1.9 0.8 2.8 5.2 6.8 12.1 7.5 7.7 15.1 81.7 78.0 721 30-34 1.1 1.3 2.4 3.4 10.5 13.9 4.5 12.0 16.5 85.3 82.4 364 35-39 0.4 1.2 1.6 1.4 13.4 14.8 2.0 14.8 16.9 90.8 78.4 335 40-44 0.0 0.8 0.8 1.1 8.1 9.2 1.1 9.1 10.2 92.6 82.6 388 45-49 0.0 0.3 0.3 0.2 4.7 4.9 0.2 5.0 5.1 94.8 80.3 425 Residence Urban 1.6 0.2 1.8 3.2 2.2 5.4 4.9 2.7 7.6 76.0 70.1 1,130 Rural 0.9 0.3 1.2 2.1 3.1 5.2 3.1 3.4 6.5 81.3 75.2 5,643 Province City of Kigali 1.9 0.1 2.0 2.1 1.9 4.0 3.9 2.3 6.2 67.4 63.8 870 South 0.6 0.3 0.9 3.2 3.8 7.0 4.0 4.2 8.2 88.9 80.1 1,598 West 1.3 0.3 1.7 1.8 2.3 4.2 3.2 2.6 5.9 71.9 65.4 1,630 North 0.6 0.4 1.0 1.8 2.7 4.5 2.5 3.1 5.6 81.3 74.4 1,126 East 0.8 0.4 1.2 2.3 3.4 5.8 3.2 3.9 7.1 83.3 80.0 1,550 Education No education 1.8 0.4 2.2 1.3 4.2 5.5 3.2 4.9 8.1 72.7 66.4 764 Primary 0.9 0.4 1.3 2.6 3.2 5.8 3.6 3.6 7.2 82.3 77.0 4,521 Secondary and higher 0.8 0.2 1.0 2.0 1.4 3.4 2.7 1.6 4.3 77.7 67.4 1,489 Wealth quintile Lowest 1.2 0.8 2.0 2.2 4.8 7.1 3.5 5.8 9.3 78.7 74.5 1,270 Second 0.9 0.3 1.3 2.4 3.4 5.7 3.4 3.7 7.1 82.2 71.7 1,273 Middle 0.5 0.1 0.6 2.1 2.4 4.5 2.9 2.5 5.4 88.8 79.3 1,341 Fourth 0.7 0.3 0.9 2.0 2.5 4.5 2.6 2.8 5.5 83.4 79.2 1,262 Highest 1.5 0.3 1.7 2.7 1.9 4.6 4.2 2.2 6.4 72.7 69.3 1,628 Total 1.0 0.3 1.3 2.3 2.9 5.2 3.4 3.3 6.7 80.3 74.2 6,774 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. Family Planning • 97 7.9 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 a method in the future. The reasons given by those who do not plan to use contraception in the future are useful in developing family planning marketing strategies. Also, the methods preferred by those who plan to use contraception in the future are useful in assessing the demand for family planning. Table 7.11 shows that more than 7 in 10 currently married women (74 percent) reported that they intend to use a contraceptive method in the future, 2 percent were not sure, and 24 percent reported that they did not intend to use contraception. The number of children a woman has affects her decision on whether to use contraception in the future. Almost 7 in 10 currently married women (69 percent) who do not have any children reported intending to use a family planning method in the future. The percentages are 86 percent among women with one child and 84 percent among women with two children; among those with three children and those with four or more children, the proportions are a bit lower (77 percent and 63 percent, respectively). Table 7.11 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Rwanda 2010 Intention Number of living children1 Total 0 1 2 3 4+ Intends to use 68.6 85.5 84.1 76.8 63.2 73.5 Unsure 6.3 1.2 1.6 1.9 1.3 1.8 Does not intend to use 24.6 12.9 14.1 21.0 34.7 24.2 Missing 0.6 0.4 0.1 0.3 0.8 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 213 599 611 533 1,384 3,339 1 Includes current pregnancy 7.10 EXPOSURE TO FAMILY PLANNING MESSAGES Information on the level of exposure to sources of information about family planning can be very important to those managing family planning programmes. This information allows them to design strategies to reach specific target populations and to effectively disseminate information about contraceptive use. For this reason, the survey asked women age 15 to 49 and men age 15 to 59 whether they had heard or seen anything about family planning on the radio or on television, from newspapers/magazines, or from posters/ brochures during the past 12 months. Table 7.12 shows that 33 percent of women did not see or hear a family planning message in newspapers/magazines or on radio or television. However, 66 percent of women heard a family planning message on the radio, and 5 percent saw one on television. Only 4 percent of women had seen a family planning message in a newspaper or magazine in the past 12 months. Exposure to family planning messages in the media varied by background characteristics. Women age 15 to 19 were least likely to see family planning messages in the media during the 12 months preceding the survey (40 percent). The results also showed disparities by residence, with women in rural areas having higher rates of nonexposure than women in urban areas (34 percent and 30 percent, respectively). Similarly, women with no education were less exposed (43 percent with no exposure) than those with a secondary education or higher (21 percent with no exposure), and women in the poorest households were less exposed (50 percent with no exposure) than women in the wealthiest households (24 percent with no exposure). With respect to province, the West (39 percent) and South (37 percent) provinces had the highest levels of nonexposure to family planning messages. 98 • Family Planning Among men, the data show that 16 percent—a smaller proportion than for women (33 percent)—had no exposure to a family planning message in the past few months through any of the various media (radio, television, newspapers/magazines). However, 83 percent of men reported having heard a family planning message on the radio, 13 percent had seen one on television, and 12 percent had seen one in a newspaper or magazine. Younger men (age 15-19) were more exposed to family planning messages than men age 20 or older, regardless of the media source. As was the case among women, men in rural areas were more likely to report not having been exposed to family planning messages, regardless of the source (17 percent among rural men and 13 percent among urban men). Similarly, men with no education (21 percent) were more likely than those with a secondary education or higher (7 percent) to have had no exposure, and men in the poorest households (25 percent) were more likely to have had no exposure than those in the richest households (12 percent). Results by province showed that 20 percent of men in the East province had no exposure to family planning messages, as compared with 11 percent in the City of Kigali. Table 7.12 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on radio, television, or in a newspaper/magazine in the past few months, according to background characteristics, Rwanda 2010 Background characteristic Women Men Radio Television Newspaper/ magazine None of these three media sources Number of women Radio Television Newspaper/ magazine None of these three media sources Number of men Age 15-19 59.4 4.8 4.9 39.6 2,945 74.4 7.6 9.5 25.0 1,449 20-24 66.4 6.7 5.5 32.8 2,683 83.3 15.0 12.7 16.0 1,159 25-29 68.2 5.4 3.7 31.1 2,494 84.0 13.5 11.3 15.0 1,038 30-34 68.5 5.8 3.7 30.8 1,822 87.1 15.7 14.6 11.7 710 35-39 68.0 6.2 3.9 31.4 1,447 85.7 13.5 12.9 12.7 490 40-44 69.6 4.5 3.8 30.2 1,168 90.5 16.0 16.0 9.5 430 45-49 65.8 3.6 2.1 33.8 1,112 89.2 11.0 13.7 10.1 412 Residence Urban 67.3 21.9 8.5 29.8 2,057 85.1 33.7 20.5 12.5 939 Rural 65.6 2.5 3.5 34.0 11,614 82.4 8.4 10.5 17.1 4,748 Province City of Kigali 68.1 26.5 9.4 28.3 1,596 85.7 39.5 21.0 11.4 739 South 63.1 2.3 2.8 36.6 3,212 87.1 8.7 10.0 12.4 1,308 West 60.8 3.3 3.9 39.0 3,305 79.8 8.7 8.5 19.8 1,307 North 67.5 2.5 4.9 32.0 2,278 84.0 7.0 18.5 15.1 899 East 71.6 2.4 3.0 28.1 3,280 79.5 9.3 9.0 20.2 1,435 Education No education 57.1 1.3 0.1 42.7 2,119 78.9 6.5 0.9 20.9 583 Primary 65.3 3.1 2.4 34.3 9,337 80.9 9.7 8.3 18.5 3,916 Secondary and higher 76.7 19.2 16.1 20.5 2,216 91.0 25.1 30.7 7.1 1,189 Wealth quintile Lowest 50.2 1.1 1.8 49.5 2,622 74.3 5.0 4.4 24.8 854 Second 61.1 0.9 2.0 38.8 2,661 78.7 6.7 7.1 21.1 986 Middle 67.0 1.5 3.0 32.6 2,736 84.5 7.4 9.2 15.4 1,139 Fourth 76.2 1.7 3.6 23.6 2,677 86.6 8.9 12.2 12.8 1,235 Highest 73.6 20.3 10.0 24.0 2,976 86.1 28.1 22.4 12.1 1,474 Total 15-49 65.9 5.4 4.2 33.4 13,671 82.8 12.6 12.2 16.4 5,687 50-59 na na na na na 89.3 8.4 9.7 10.5 642 Total 15-59 na na na na na 83.5 12.2 11.9 15.8 6,329 na = Not applicable 7.11 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS Information on contact with family planning service providers among women who do not use contraception is important in determining effective family planning outreach activities. For this reason, the 2010 RDHS asked women whether they had been visited in the past 12 months by a community health worker who spoke to them about Family Planning • 99 family planning. Women who had visited a health facility in the past 12 months were also asked whether medical personnel had spoken to them about family planning methods. Table 7.13 shows that in the 12 months preceding the survey, more than 7 of 10 women who did not use contraception (73 percent) had not discussed family planning with a community health worker or at a health facility. Nearly 3 in 10 women (29 percent) had visited a health facility but had not discussed family planning issues. Only 15 percent had been visited by a community health worker who discussed family planning with them, and only 20 percent had discussed family planning at a health facility. There were differences according to residence: 79 percent of women in urban areas and 71 percent in rural areas had not discussed family planning with a community health worker or at a health facility. The results show surprisingly significant differentials by level of education; 63 percent of those with no education had not discussed family planning with a community health worker or at a health facility, as compared with 83 percent of those with a secondary education or higher. Table 7.13 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the last 12 months were visited by a community health worker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who neither discussed family planning with a fieldworker nor at a health facility, by background characteristics, Rwanda 2010 Background characteristic Percentage of women who were visited by community health worker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who neither discussed family planning with community health worker nor at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 4.2 4.2 23.3 92.4 2,884 20-24 11.0 19.0 32.1 75.5 2,159 25-29 19.8 31.7 31.2 59.8 1,444 30-34 31.6 38.2 29.3 49.2 950 35-39 25.7 33.9 28.7 54.9 745 40-44 24.2 28.4 29.0 59.1 735 45-49 15.8 20.1 33.7 71.3 841 Residence Urban 8.1 17.3 35.4 78.8 1,504 Rural 16.1 20.9 27.5 71.3 8,255 Province City of Kigali 5.9 14.0 38.2 82.3 1,172 South 13.4 19.5 30.3 73.4 2,208 West 14.8 23.8 26.6 70.2 2,521 North 21.8 18.4 29.2 68.8 1,571 East 16.0 21.9 24.4 71.5 2,285 Education No education 20.7 26.6 26.7 63.1 1,490 Primary 15.2 20.9 27.4 71.9 6,541 Secondary and higher 8.4 12.7 35.4 82.5 1,727 Wealth quintile Lowest 19.5 22.7 26.4 67.9 1,949 Second 16.0 22.0 26.1 70.4 1,930 Middle 16.1 21.5 25.5 70.7 1,939 Fourth 14.2 20.6 29.0 73.1 1,810 Highest 9.0 15.4 35.9 79.6 2,131 Total 14.8 20.3 28.7 72.5 9,758 Infant and Child Mortality • 101 INFANT AND CHILD MORTALITY 8 his chapter describes levels and trends of neonatal, postneonatal, infant, and child mortality in Rwanda. Infant and child mortality rates reflect a country’s socioeconomic situation as well as the quality of life of the population under study. Childhood mortality is affected by socioeconomic conditions and can vary according to the demographic characteristics of children and their mothers. Therefore, differentials in infant and child mortality are presented by socioeconomic and demographic characteristics in this chapter. Disaggregation of mortality indicators by economic, social, and demographic categories helps to identify population groups at risk. Preparation, implementation, monitoring, and evaluation of socioeconomic programs and policies depend to a large extent on identification of a target population. The data presented here can help identify at-risk populations and indicate their current mortality status, which can be compared with previously collected data to determine whether improvements in health and quality of life have occurred over time. The data used to compute the childhood mortality rates presented in this chapter were derived from the birth history section of the Woman’s Questionnaire. Each woman age 15-49 was asked whether she had ever given birth, and, if she had, she was asked to report the number of sons and daughters who live with her, the number who live elsewhere, and the number who have died. In addition, she was asked to provide a detailed birth history of her children in chronological order starting with the first child. Women were asked whether a birth was single or multiple, the sex of the child, the date of birth (month and year, according to either the Gregorian or the Khmer calendar system), survival status, age of the child on the date of the interview if alive, and, if not alive, the age at death of each live birth. Childhood mortality rates, expressed as deaths per 1,000 live births, are defined as follows: • Neonatal mortality: the probability of dying within the first month of life • Postneonatal mortality: the probability of dying between the first month of life and first birthday (computed as the difference between infant and neonatal mortality) • Infant mortality: the probability of dying between birth and the first birthday • Child mortality: the probability of dying between the first and fifth birthday • Under-5 mortality: the probability of dying between birth and the fifth birthday 8.1 ASSESSMENT OF DATA QUALITY The reliability of mortality estimates depends on sampling errors and nonsampling errors. Sampling errors are discussed in detail in Appendix B. Nonsampling errors depend on the extent to which the date of birth and age at death are accurately reported and recorded and the completeness with which child deaths are reported. Omission of births and deaths affects mortality estimates, displacement of dates of births and of deaths affects mortality trends, and misreporting of age at death may alter the age pattern of mortality. Typically, the most serious source of nonsampling errors in a survey that collects retrospective information on births and deaths is underreporting of both births and deaths of children who are not alive at the time of the survey. It may be that mothers are generally reluctant to talk about their dead children because of the sorrow associated with any death, or they may live in a culture that discourages discussing the dead. Underreporting of births and deaths is generally more severe the further back in time an event has occurred. Table C.3 in Appendix C shows a negligible proportion of missing information for birth dates (births in the past 15 years), age at death, age at first union, and mother’s education. T 102 • Infant and Child Mortality An unusual pattern in the distribution of births by calendar years is an indication of omission of children or age displacement. However, Table C.4 in Appendix C shows that the percentage of all births for which a month and year of birth were reported remains stable over time, ranging from 100 percent of births in 2011 to 98.0 percent of births prior to 1992. There is little difference in reporting by whether or not the child is alive (99.6 percent of births) or dead (98.0 percent of births). Table C.5 in Appendix C shows the distribution of reported deaths under age 1 month by age at death in days and the percentage of neonatal deaths reported to occur at age 0-6 days, for five-year periods preceding the survey. For all infant deaths reported in days for the period 0-4 years preceding the survey, 67 percent were neonatal deaths occurring in the first week of life. For all infant deaths reported in days for the 20 years preceding the survey, 65 percent were neonatal deaths. These rates are reasonable, suggesting that there has not been severe underreporting of early infant deaths in the 2010 RDHS. Another issue affecting childhood mortality estimates is the quality of reporting of age at death. If age at death is misreported, estimates may be biased, especially if the net effect of age misreporting results in the transfer of deaths from one childhood mortality category to another. To minimize this error, interviewers were instructed to record the age at death in days for deaths under age 1 month, and in months for deaths under age 2. They were also asked to probe for deaths reported at one year to determine a more precise age at death in terms of months. Table C.6 in Appendix C shows that there may have been death transfers or heaping of deaths at age 12 months because the number of deaths at this age is four times the number of deaths at age 11 months. Reporting of infant deaths at 12 months is less accurate for 15-19 years prior to the survey than for the other earlier five-year periods. It is possible that some of these deaths may have occurred before age 1 but are not included in the infant mortality rate. However, the excess deaths reported at 12 months would have no effect on estimates of under-5 mortality rates. 8.2 LEVELS AND TRENDS IN CHILDHOOD MORTALITY Table 8.1 presents neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey. Neonatal mortality in the most recent period is 27 deaths per 1,000 live births. This rate is higher than the postneonatal mortality rate (23 deaths per 1,000 live births) during the same period; that is, the risk of dying for any child who survives the first month of life decreases during the period of the next 11 months. Fifty of every 1,000 babies born in Rwanda do not survive to their first birthday. Under-5 mortality in Rwanda is 76 deaths per 1,000 live births. Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Rwanda 2010 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 27 23 50 27 76 5-9 32 41 73 64 133 10-14 48 61 109 99 197 1 Computed as the difference between the infant and neonatal mortality rates Trends in the childhood mortality rate can be established by comparing the results of the 2010 RDHS with the findings from the 2005 RDHS and 2007-08 Rwanda Interim Demographic Health Survey (RIDHS), in which data were collected using the same techniques and estimates were calculated using the same methodology. Figure 8.1 shows that infant mortality has declined substantially in the past 5 years, from 86 deaths per 1,000 live births in 2005 to 62 per 1,000 in 2007-08 and to 50 per 1,000 in 2010. Under-5 mortality also declined during this period, from 152 deaths per 1,000 live births in 2005 to 103 per 1,000 in 2007-08 and to 76 per 1,000 in 2010. The decrease Infant and Child Mortality • 103 in infant mortality and under-5 mortality result mainly from the implementation of integrated management of childhood illness in health facilities and communities and also the introduction of new vaccines. Figure 8.1 Trend in Childhood Mortality Rates 37 49 86 72 152 28 34 62 43 103 27 23 50 27 76 Neonatal mortality Postneonatal mortality Infant mortality Child mortality Under-5 mortality 0 20 40 60 80 100 120 140 160 180 Deaths per 1,000 live births 2005 RDHS 2007-08 RIDHS 2010 RDHS RDHS 2010 8.3 SOCIOECONOMIC DIFFERENTIALS IN CHILDHOOD MORTALITY Results presented in Table 8.2 and Figure 8.2 show that childhood mortality in Rwanda varies significantly by the socioeconomic characteristics of households and mothers.1 Mortality in urban areas is generally lower than in rural areas. For example, infant mortality in urban areas is 55 deaths per 1,000 live births compared with 62 deaths per 1,000 live births in rural areas. The urban-rural gap is wider for neonatal mortality (21 deaths versus 31 deaths per 1,000). Differentials in mortality by province are also substantial, particularly in the under-5 mortality rates. The City of Kigali has the lowest rates of neonatal mortality (21 deaths per 1,000 live births) and under-5 mortality (79 deaths per 1,000 live births). The highest neonatal mortality and infant mortality rates are found in the North province (39 deaths and 71 deaths per 1,000 live births respectively), whereas the East province has the highest rate of under-5 mortality (125 deaths per 1,000 live births). 1 To have a sufficient number of cases to ensure statistically reliable mortality estimates, rates presented in Tables 8.2 and 8.3 are calculated for a 10-year period. 104 • Infant and Child Mortality Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by background characteristic, Rwanda 2010 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 21 34 55 27 81 Rural 31 31 62 46 105 Province City of Kigali 21 34 55 26 79 South 31 28 60 39 96 West 27 29 56 34 88 North 39 33 71 39 107 East 27 35 63 66 125 Mother’s education No education 32 42 75 54 125 Primary 30 29 59 43 99 Secondary and higher 22 23 46 19 63 Wealth quintile Lowest 33 37 70 53 119 Second 32 25 57 49 103 Middle 25 35 61 46 104 Fourth 31 35 66 41 104 Highest 24 26 50 27 75 1 Computed as the difference between the infant and neonatal mortality rates Figure 8.2 Under-5 Mortality Rates by Socioeconomic Characteristics RDHS 2010 81 105 125 99 63 119 103 104 104 75 RESIDENCE Urban Rural EDUCATION No schooling Primary Secondary and higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 20 40 60 80 100 120 140 Deaths per 1,000 live births As expected, mortality declines markedly as mother’s education increases. Children born to mothers with no schooling have the highest mortality rates. According to the survey results in Table 8.2, the infant mortality rate Infant and Child Mortality • 105 among children of mothers with a secondary education or higher is 46 deaths per 1,000 live births, much lower than the rate of 75 deaths per 1,000 live births among children of mothers with no schooling. In addition, mortality declines markedly as the wealth of the household increases. Children born in poorer households suffer higher mortality than those born in wealthier households. For example, infant and under-5 mortality rates are about one and a half times higher among children living in the poorest households compared with rates among those living in the wealthiest households. 8.4 DEMOGRAPHIC DIFFERENTIALS IN MORTALITY Infant and child mortality varies substantially by the demographic characteristics of mothers and children. Table 8.3 and Figure 8.3 show childhood mortality rates by different demographic variables. With the exception of child mortality, mortality rates are higher among male children than among female children during all periods of life before age 5. This excess mortality among boys is observed not only in Rwanda but also in other countries and is in fact a universal phenomenon. Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by demographic characteristics, Rwanda 2010 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child’s sex Male 32 35 67 43 107 Female 27 28 55 44 97 Mother’s age at birth <20 42 36 78 64 137 20-29 28 31 59 46 102 30-39 29 32 61 38 96 40-49 31 36 66 25 89 Birth order 1 32 30 62 47 107 2-3 30 29 59 47 103 4-6 25 32 56 40 94 7+ 35 42 78 36 111 Previous birth interval2 <2 years 52 52 104 57 156 2 years 20 29 50 39 87 3 years 20 21 41 37 76 4+ years 21 23 44 36 78 Birth size3 Small/very small 42 26 69 na na Average or larger 23 22 45 na na 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey na = Not applicable The distribution of infant mortality by maternal age at birth is a U-shaped curve, being relatively higher among children born to mothers under age 20 and over age 40 than among children born to mothers in age groups 20-29 and 30-39. Relationships between infant mortality and specific demographic characteristics are illustrated in Figure 8.3. First-order births appear to be at the same risk of mortality as second- to sixth-order births. Significant increases in risk are most apparent for births of order seven and higher. 106 • Infant and Child Mortality Figure 8.3 Infant Mortality Rates by Demographic Characteristics RDHS 2010 78 59 61 66 62 59 56 78 104 50 41 44 MOTHER’S AGE <20 20-29 30-39 40-49 BIRTH ORDER 1 2-3 4-6 7+ PREVIOUS BIRTH INTERVAL <2 years 2 years 3 years 4+ years 0 20 40 60 80 100 120 Deaths per 1,000 live births Short birth interval is one of the risk factors for childhood mortality. For example, Table 8.3 shows that children born less than two years after a preceding birth are more than twice as likely to die within the first month of life as children born after a two-year interval (52 deaths per 1,000 live births versus 20 per 1,000 live births). The relationship between short birth interval and infant mortality is also evident; a child born less than two years after a preceding birth is more than twice as likely to die before his or her first birthday compared with a child born four or more years after a preceding birth (104 deaths per 1,000 live births versus 44 per 1,000). Studies have demonstrated that children’s weight at birth is an important determinant of their chances of survival. Actual birth weights were unavailable for most children; instead, mothers were asked whether their child was very large, larger than average, average, smaller than average, or small at birth, because this has been found to be a good proxy for a child’s weight at birth. Those children reported by their mothers to be small or very small were almost twice as likely to die before age 1 month as those reported to be average or larger than average. 8.5 HIGH-RISK FERTILITY BEHAVIOR The survival of infants and children depends in part on the demographic and biological characteristics of their mothers. Typically, the probability of dying in infancy is much greater among children born to mothers who are too young (under age 18) or too old (over age 34), children born after a short birth interval (less than 24 months after the preceding birth), and children born to mothers of high parity (more than three children). The risk is elevated when a child is born to a mother who has a combination of these risk characteristics. Table 8.4 shows the percent distribution of children born to currently married women in the five years before the survey by these risk factors. One quarter of births (25 percent) were not in any high-risk category. Twenty-four percent were first births to women between age 18 and age 34—considered an unavoidable risk category—whereas 30 percent of births were in a single high-risk category and 21 percent were in a multiple high- Infant and Child Mortality • 107 risk category. The most common single high-risk category was births of order three and above (20 percent), and the most common multiple high-risk category was births to mothers older than 34 years and of birth order three and above (15 percent). Table 8.4 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Rwanda 2010 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high risk category 24.7 1.00 20.0 Unavoidable risk category First order births between ages 18 and 34 years 23.6 1.08 4.7 Single high-risk category Mother’s age <18 1.3 1.37 0.0 Mother’s age >34 1.2 0.91 2.7 Birth interval <24 months 8.2 1.27 10.5 Birth order >3 19.6 0.68 16.7 Subtotal 30.3 0.87 29.9 Multiple high-risk category Age <18 and birth interval <24 months2 0.0 * 0.0 Age >34 and birth interval <24 months 0.1 * 0.2 Age >34 and birth order >3 14.7 1.06 31.8 Age >34 and birth interval <24 months and birth order >3 1.9 2.65 4.7 Birth interval <24 months and birth order >3 4.6 1.92 8.8 Subtotal 21.4 1.40 45.4 In any avoidable high-risk category 51.7 1.09 75.3 Total 100.0 - 100.0 Number of births/women 9,137 - 6,897 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women The risk ratios displayed in the second column of Table 8.4 denote the relationship between risk factors and mortality. For example, the risk of dying for a child who falls into any of the avoidable high-risk categories is 1.1 times higher than for a child not in any high-risk category. In general, risk ratios are higher for children in a multiple high-risk category than for children in a single high-risk category. Most vulnerable are children born to a mother older than age 34, born less than 24 months after a preceding birth, and born with a birth order greater than 3; they are nearly 2.65 times as likely to die as children who are not in any high-risk category. However, only 2 percent of births fall into this category. Among the single high-risk categories, having a mother less than 18 years old results in a child having a risk of dying that is 1.4 times the risk of a child not in any high-risk category. The final column of Table 8.4 illustrates the potential for currently married women to experience a high- risk birth. A woman’s status at the time of the survey with regard to her age, time elapsed since the last birth, and parity are used to classify her into a potential risk category that would apply if she were to become pregnant at the time of the survey. For example, if a respondent who is age 40, has had four births, and has had her last birth 12 months ago were to become pregnant, she would fall into the multiple high-risk category of being too old, too high in parity (four or more births), and giving birth too soon (less than 24 months) after a previous birth. 108 • Infant and Child Mortality Overall, approximately three in four currently married women (75 percent) have the potential to give birth to a child at elevated risk of mortality. Thirty percent of women have the potential for having a birth in a single high- risk category, and 45 percent of women have the potential for having a birth in a multiple high-risk category (mainly older maternal age and higher birth order). Maternal Health • 109 MATERNAL HEALTH 9 he 2010 Rwanda Demographic and Health Survey (RDHS) collected information about the health of mothers and their children born in the five years preceding the survey. This chapter covers antenatal, postnatal, and delivery care and describes problems in accessing health care. The findings in this chapter help identify the most important problems in maternal and child health and reproductive health. A comparison of the results with those of previous surveys can assist in the planning and evaluation of national health policies and programmes. 9.1 ANTENATAL CARE Monitoring of pregnant women through antenatal care visits helps reduce risks and complications during pregnancy and delivery and the postpartum period. For this reason, the 2010 RDHS asked women who had had a live birth in the five years preceding the survey whether they had received antenatal care (ANC). Table 9.1 shows the distribution of women’s most recent live births in the past five years according to the type of medical personnel consulted by the women during the pregnancy and the women’s background characteristics. 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 considered in the tabulations (e.g., if a doctor and nurse were mentioned, the doctor is considered in the tabulation). For their most recent live births in the five years preceding the survey, nearly all of the mothers (98 percent) received antenatal care from trained personnel. This proportion represented an increase from the previous survey, where 94 percent of births benefited from antenatal care (Figure 9.1). ANC was mainly provided by nurses or medical assistants (94 percent) and, in very low percentages, by doctors (4 percent). In the current Rwandan health system, ANC at public or private health facilities is almost always provided by nurses (doctors intervene only if complications are noted during the mother’s ANC visit). The data do not vary substantially by background characteristics: the proportion of mothers who received antenatal care is greater than or nearly equal to 97 percent regardless of age, birth order, area of residence, level of education, or household wealth. However, the proportion of women who consulted with a doctor during these visits is higher in urban areas (9 percent, as compared with 3 percent in rural areas), among those in the City of Kigali (8 percent, as compared with 1 to 5 percent in the other provinces), and among those with a secondary education or higher (11 percent, as compared with 4 percent among mothers with no education). The proportion of women who consulted with a doctor is also higher among those in the richest quintile (9 percent, as compared with 2 or 3 percent in the other quintiles). T 110 • Maternal Health Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Rwanda 2010 Background characteristic Antenatal care provider Total Percentage receiving antenatal care from a skilled provider1 Number of women Doctor Nurse/ medical assistant Midwife Traditional birth attendant Other No one Missing Mother’s age at birth <20 2.1 95.0 0.0 0.0 0.0 2.9 0.0 100.0 97.1 373 20-34 4.1 94.2 0.2 0.0 0.0 1.4 0.1 100.0 98.4 4,679 35-49 3.7 93.2 0.1 0.0 0.1 2.7 0.2 100.0 97.0 1,353 Birth order 1 4.4 93.7 0.2 0.1 0.0 1.5 0.1 100.0 98.3 1,436 2-3 4.0 94.4 0.0 0.0 0.0 1.4 0.1 100.0 98.5 2,190 4-5 4.0 93.6 0.3 0.0 0.1 1.7 0.3 100.0 97.9 1,406 6+ 3.0 94.1 0.0 0.0 0.0 2.7 0.1 100.0 97.1 1,373 Residence Urban 8.5 89.6 0.2 0.0 0.0 1.5 0.1 100.0 98.3 819 Rural 3.2 94.6 0.1 0.0 0.0 1.8 0.2 100.0 98.0 5,586 Region City of Kigali 7.7 91.2 0.1 0.0 0.0 0.9 0.2 100.0 99.0 635 South 4.4 93.1 0.1 0.0 0.0 2.3 0.0 100.0 97.6 1,532 West 5.3 92.6 0.0 0.0 0.0 1.8 0.3 100.0 97.9 1,545 North 1.1 96.8 0.4 0.0 0.1 1.4 0.2 100.0 98.3 1,035 East 2.3 95.5 0.1 0.1 0.0 1.9 0.1 100.0 98.0 1,658 Mother’s education No education 3.5 92.8 0.1 0.1 0.0 3.2 0.3 100.0 96.4 1,211 Primary 3.0 95.3 0.1 0.0 0.0 1.5 0.1 100.0 98.4 4,571 Secondary and higher 11.3 86.9 0.4 0.0 0.0 1.0 0.3 100.0 98.7 623 Wealth quintile Lowest 3.3 93.2 0.1 0.1 0.0 3.2 0.2 100.0 96.6 1,475 Second 2.9 94.5 0.0 0.0 0.0 2.3 0.3 100.0 97.4 1,369 Middle 2.6 95.8 0.2 0.0 0.0 1.3 0.1 100.0 98.6 1,250 Fourth 2.4 96.6 0.1 0.0 0.1 0.8 0.0 100.0 99.1 1,188 Highest 8.8 89.8 0.3 0.0 0.0 0.9 0.2 100.0 98.9 1,122 Total 3.9 94.0 0.1 0.0 0.0 1.8 0.1 100.0 98.0 6,405 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, medical assistant, and midwife. These results can be explained by the concentration of doctors in urban areas, particularly the City of Kigali. It should be noted that almost 2 percent of women received no antenatal care during their pregnancy. The youngest and oldest women, those in the sixth or higher birth order category, those with no education, and those in the poorest wealth quintile were least likely to receive antenatal care (3 percent in each group). To be effective, antenatal care must be sought early in the pregnancy, preferably in the first semester; more important, it must continue regularly through to delivery. The World Health Organization (WHO) recommends at least four ANC visits at regular intervals throughout the pregnancy, as does the Rwandan health system. Maternal Health • 111 Figure 9.1 Trends in Antenatal Care and Delivery, Rwanda 2005, 2007-08, and 2010 RDHS 2010 94 39 28 96 52 45 98 69 69 Antenata Care by a Skilled Provider Delivery Assisted by a Skilled Provider Delivery at a Health Facility 0 20 40 60 80 100 Percent 2005 RDHS 2007-08 RIDHS 2010 RDHS Table 9.2 shows the number of ANC visits and the timing of the first visit. Although the great majority of Rwandan mothers sought antenatal care, the number of visits was below the standard set by WHO and Rwanda Ministry of Health. About 35 percent of women who had a live birth in the five years preceding the survey met the standard of at least four ANC visits. This proportion was only 13 percent in 2005. More than half of the women (58 percent) had two or three ANC visits. It should also be noted that 4 percent of mothers had only one ANC visit and that 2 percent had no visits, as compared with 13 percent and 5 percent, respectively, in 2005. Results by residence show that the proportion of women who had at least four ANC visits was slightly higher in urban areas (40 percent) than in rural areas (35 percent). It should be noted that Rwandan women seek their first prenatal visit late in pregnancy. In fact, only 38 percent of women made their first visit before the fourth month of pregnancy, and this proportion was higher in urban areas (43 percent) than in rural areas (38 percent). The results also show that 38 percent of women had their first visit at the fourth or fifth month of pregnancy; 19 percent began at the sixth or seventh month, and 2 percent began at the eighth month or after. The median number of months pregnant at the first ANC visit was 4.5 for the country as a whole (4.3 and 4.5 for urban and rural areas, respectively); this represents a decline from the previous survey (2005 RDHS), when the figure was 6.4 (6.2 in urban areas and 6.5 in rural areas). 112 • Maternal Health Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Rwanda 2010 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 1.5 1.9 1.8 1 5.4 4.2 4.3 2-3 52.5 59.1 58.3 4+ 40.4 34.7 35.4 Don’t know/missing 0.3 0.2 0.2 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.5 1.9 1.8 <4 43.4 37.5 38.2 4-5 35.1 38.8 38.3 6-7 16.8 19.6 19.2 8+ 3.2 2.2 2.3 Don’t know/missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of women 819 5,586 6,405 Median months pregnant at first visit (for those with ANC) 4.3 4.5 4.5 Number of women with ANC 806 5,482 6,289 9.1.1 Components of Antenatal Care The effectiveness of antenatal care depends not only on the types of examinations performed at the visit but also on the counselling and preventive measures administered to avoid the risk of miscarriage and other pregnancy complications. The 2010 RDHS collected data on this important aspect of prenatal monitoring by asking women whether, during their ANC visits for their most recent birth, they were told about the danger signs of pregnancy complications, they received specific medical examinations (blood pressure measurements), and they were given blood and urine tests. In addition, women were asked whether they had received iron supplements. The results from these questions are presented in Table 9.3 by background characteristics. Almost three quarters of women (73 percent, as compared with 28 percent in 2005) took iron tablets or syrup during the pregnancy of their last birth, but only 39 percent took intestinal parasite drugs. Ninety-one percent of women had a blood sample taken (as compared with 25 percent in 2005), 86 percent had their blood pressure measured (71 percent in 2005), and 72 percent were informed of signs of pregnancy complications (6 percent in 2005); however, only 31 percent had a urine sample taken (7 percent in 2005). The results reveal the possible effects of birth order and education on use of iron tablets or syrup by pregnant mothers. Seventy-five percent of women in the first birth order category took iron, as compared with 72 percent in the fourth and fifth birth order category. Similarly, 69 percent of women with no education took iron, as compared with 74 percent of those with a secondary education or higher. By province, the East province had the lowest proportion (69 percent) of women who took iron during their pregnancy, while the North province had the highest proportion (78 percent). Maternal Health • 113 Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Rwanda 2010 Background characteristic Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Among women who received antenatal care for their most recent birth in the past five years, the percentage with selected services: Took iron tablets or syrup Took intestinal parasite drugs Number of women with a live birth in the past five years Informed of signs of pregnancy complica- tions 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 73.8 40.2 373 72.7 79.7 35.6 92.5 362 20-34 72.9 40.1 4,679 72.3 85.6 32.0 91.2 4,610 35-49 72.9 35.4 1,353 72.0 88.1 25.1 88.0 1,316 Birth order 1 74.9 39.4 1,436 72.5 83.4 39.8 94.5 1,414 2-3 73.0 40.9 2,190 72.3 85.0 32.0 91.5 2,160 4-5 72.3 38.1 1,406 71.7 88.4 26.9 89.1 1,380 6+ 71.6 36.9 1,373 72.4 86.8 23.0 86.7 1,335 Residence Urban 72.5 35.5 819 74.5 93.0 51.9 94.7 806 Rural 73.1 39.6 5,586 71.9 84.7 27.6 90.0 5,482 Region City of Kigali 72.0 33.2 635 73.4 95.0 60.0 96.1 629 South 75.9 32.7 1,532 77.4 90.8 33.7 91.3 1,497 West 71.9 42.4 1,545 64.7 80.2 33.5 88.7 1,517 North 77.8 44.8 1,035 74.4 89.3 32.4 87.2 1,019 East 68.7 40.7 1,658 72.8 80.5 13.1 91.9 1,626 Mother’s education No education 68.7 37.3 1,211 71.2 84.3 23.6 88.1 1,172 Primary 73.9 39.4 4,571 71.8 85.4 29.6 90.9 4,501 Secondary and higher 74.4 40.1 623 77.3 91.4 52.8 93.6 616 Wealth quintile Lowest 71.3 37.0 1,475 72.0 84.2 26.5 88.7 1,427 Second 72.0 38.0 1,369 69.9 83.2 25.2 89.8 1,337 Middle 75.2 39.6 1,250 72.0 84.3 26.3 89.3 1,234 Fourth 74.0 43.2 1,188 73.9 86.4 29.0 92.4 1,178 Highest 72.8 38.4 1,122 73.9 91.7 49.7 93.8 1,112 Total 73.0 39.1 6,405 72.3 85.8 30.8 90.6 6,289 Consumption of intestinal drugs varied by age, area of residence, and education. Two in five pregnant women less than age 35 took intestinal drugs, as compared with 35 percent of those age 35-49. Thirty-six percent of pregnant women in urban areas took intestinal drugs, as compared with 40 percent in rural areas, and 37 percent with education took intestinal drugs, as compared with 40 percent with a secondary education or higher. By province, the City of Kigali and the South province had the lowest proportions of women who took intestinal drugs during their pregnancy (33 percent), while the North province had the highest proportion (45 percent). Overall, the proportion of pregnant women informed of the signs of pregnancy complications was higher in urban areas (75 percent) than in rural areas (72 percent). It was also higher among mothers with a secondary education or more (77 percent) than among those with no education (71 percent). The West province had the lowest proportion of pregnant women informed of the signs of pregnancy complications (65 percent), while the South province had the highest (77 percent). The oldest women were more likely to have their blood pressure measured than the youngest ones (88 percent and 80 percent, respectively). Similarly, mothers in the fourth or fifth birth order category (88 percent) were more likely to have their blood pressure measured than those in the first birth order category (83 percent). Ninety- three percent of women in urban areas had their blood pressure measured, as compared with 85 percent in rural areas. Mothers with a secondary education or higher (91 percent) were more likely than those with no education (84 percent) to have their blood pressure checked. By province, the proportion varied from a low of 80 percent in the West province to a high of 95 percent in the City of Kigali. 114 • Maternal Health Young women (36 percent), those in the first birth order category (40 percent), those living in urban areas (52 percent), those living in the City of Kigali (60 percent), those with the highest level of education (53 percent), and those in the highest wealth quintile (50 percent) were most likely to have a urine test. 9.1.2 Tetanus Vaccinations Neonatal tetanus is a major cause of death among newborns in most developing countries. Tetanus toxoid injections given to the mother during pregnancy protect both mother and child against this disease. To be fully protected, a woman should receive five doses of the vaccine during her life; however, if she has already been vaccinated, for example during a previous pregnancy, one additional dose is sufficient. It is important to note that the information presented here does not take into account women’s vaccination history; some women may have received the vaccine prior to the period under consideration. If the vaccination was received within the past 10 years, the woman will retain some immunity. Table 9.4 shows that 34 percent of women who had a live birth in the five years preceding the survey received two or more doses of anti-tetanus vaccine during their most recent pregnancy, as compared with 63 percent in 2005. If we take into account the mothers who had previous protection against tetanus and were immunised during the survey, the proportion increases to 79 percent. This means that 21 percent of pregnant women were not protected against tetanus. The age of the mother seemed to be an important factor in tetanus coverage: the proportion whose last birth was protected against neonatal tetanus was higher among mothers in the oldest group (82 percent) than among mothers in the youngest group (65 percent). Similarly, higher order births were better protected than first births (85 percent for births order six and above and 62 percent for first births). In addition, mothers in rural areas (79 percent), mothers in the East province (81 percent), and mothers with a primary education or a secondary education or higher (79 percent) were more likely to be protected against tetanus. The data by wealth quintile showed no major variations with respect to vaccination coverage. Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Rwanda 2010 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 58.7 65.0 373 20-34 37.0 78.6 4,679 35-49 17.2 82.4 1,353 Birth order 1 60.3 61.8 1,436 2-3 37.8 80.0 2,190 4-5 23.5 86.9 1,406 6+ 11.7 85.4 1,373 Residence Urban 36.5 76.7 819 Rural 33.7 78.9 5,586 Region City of Kigali 36.9 73.2 635 South 38.0 79.4 1,532 West 35.2 76.0 1,545 North 29.4 80.7 1,035 East 31.3 81.0 1,658 Mother’s education No education 27.9 77.4 1,211 Primary 35.0 78.9 4,571 Secondary and higher 40.0 78.9 623 Wealth quintile Lowest 33.4 74.1 1,475 Second 33.5 78.9 1,369 Middle 36.8 81.1 1,250 Fourth 30.8 81.0 1,188 Highest 36.4 78.7 1,122 Total 34.1 78.6 6,405 1 Includes mothers with two injections during the pregnancy of their last birth or two or more injections (the last within three years of the last live birth), three or more injections (the last within five years of the last birth), four or more injections (the last within 10 years of the last live birth), or five or more injections prior to the last birth Maternal Health • 115 9.2 DELIVERY CARE 9.2.1 Place of Delivery Because every pregnancy may be subject to complications, women are advised to deliver their babies in a health facility so they have access to emergency services if needed during labour, delivery, and postdelivery. For this reason, the 2010 RDHS asked women where they had given birth and who had assisted in the delivery. Table 9.5 shows that 69 percent of women delivered their babies at a health facility (compared with 28 percent in 2005). Among these deliveries, 68 percent took place in a public health facility (compared with 27 percent in 2005) and only 1 percent took place in a private facility (compared with 1.3 percent in 2005). It should also be noted that 29 percent of deliveries in the five years preceding the survey took place at home (compared with 70 percent in 2005). Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Rwanda 2010 Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector Mother’s age at birth <20 82.5 0.2 15.4 1.8 0.1 100.0 82.7 556 20-34 69.5 1.1 27.4 1.8 0.2 100.0 70.6 6,938 35-49 56.0 1.1 40.3 2.6 0.1 100.0 57.0 1,643 Birth order 1 86.8 1.2 11.0 0.9 0.2 100.0 88.0 2,277 2-3 68.6 1.2 27.9 2.1 0.2 100.0 69.8 3,123 4-5 58.5 1.0 38.1 2.3 0.1 100.0 59.5 1,960 6+ 52.7 0.6 44.1 2.4 0.2 100.0 53.3 1,777 Antenatal care visits1 None 16.0 0.0 83.0 0.0 1.0 100.0 16.0 116 1-3 67.2 0.8 29.9 2.1 0.1 100.0 68.0 4,009 4+ 79.6 2.0 16.3 2.1 0.0 100.0 81.6 2,268 Residence Urban 77.5 4.6 16.2 1.8 0.0 100.0 82.0 1,094 Rural 66.6 0.5 30.8 1.9 0.2 100.0 67.1 8,043 Region City of Kigali 77.1 5.9 16.0 1.0 0.0 100.0 83.0 872 South 65.5 1.1 30.6 2.4 0.3 100.0 66.6 2,169 West 70.4 0.2 27.4 1.9 0.1 100.0 70.6 2,284 North 63.1 0.3 33.6 2.6 0.4 100.0 63.4 1,437 East 67.1 0.4 31.1 1.4 0.1 100.0 67.5 2,376 Mother’s education No education 56.3 0.5 41.1 1.6 0.5 100.0 56.7 1,756 Primary 69.4 0.5 28.0 2.0 0.1 100.0 69.9 6,578 Secondary and higher 80.9 6.4 11.1 1.4 0.3 100.0 87.3 803 Wealth quintile Lowest 60.6 0.4 36.1 2.6 0.3 100.0 61.0 2,134 Second 62.9 0.4 34.5 2.0 0.2 100.0 63.3 1,964 Middle 66.0 0.4 31.6 1.7 0.2 100.0 66.5 1,815 Fourth 72.4 0.4 25.7 1.5 0.1 100.0 72.7 1,698 Highest 81.7 4.0 12.7 1.4 0.1 100.0 85.7 1,525 Total 67.9 1.0 29.0 1.9 0.2 100.0 68.9 9,137 1 Includes only the most recent birth in the five years preceding the survey The incidence of home births increased with the age of the mother (15 percent among mothers under the age of 20 and 40 percent among mothers age 35 to 49) and with the child’s birth order (11 percent of first births took place at home, as compared with 44 percent of births order six and above). Mothers who had not received ANC were more likely to give birth at home (83 percent, compared with 16 percent among women who had four or more ANC visits). In addition, home births were more frequent in rural areas (31 percent, as compared with 16 percent in urban areas) and among women with no education or only a primary education (41 percent and 28 percent, respectively, as compared with 11 percent among women with a secondary education or higher). By province, with 116 • Maternal Health the exception of the City of Kigali (where only 16 percent of births took place at home), the proportion of home births ranged from a low of 27 percent in the West province to a high of 34 percent in the North province. Finally, the proportion of women who delivered at home decreased as household wealth increased, from 36 percent among women in the poorest households to 13 percent among those in the richest households. The youngest mothers were more likely to deliver in a health facility (83 percent) than the oldest mothers (57 percent). Similarly, the proportion of mothers who delivered at a health facility decreased with increasing birth order (88 percent for first births, as compared with 53 percent for births order six and above). Mothers who had four or more ANC visits were more likely than mothers with no visits to deliver at a health facility (82 percent and 16 percent, respectively). In urban areas 82 percent of births took place at a health facility, and in the City of Kigali this proportion was 83 percent. Similarly, 87 percent of women with a secondary education or higher delivered their babies at a health facility, as did 86 percent of women in the highest wealth quintile. It should be noted that these results represent a substantial change from the 2005 RDHS with respect to place of delivery. 9.2.2 Assistance during Delivery To avoid the risk of complications or maternal death, women should be assisted during delivery by personnel who have received training in normal childbirth and who are able, if needed, to diagnose, treat, and refer complications. Table 9.6 presents the distribution of births in the five years preceding the survey according to the person providing assistance during the delivery. The results show that almost 7 in 10 births (69 percent) were assisted by a skilled provider (a substantial improvement since the previous survey, where only 39 percent were assisted by a skilled provider); 10 percent were assisted by doctors, 59 percent by nurses or medical assistants, and 0.3 percent by midwives. However, it should be noted that 10 percent of births received no assistance during their delivery and that 21 percent were assisted by untrained persons (2 percent by nonqualified health workers, 3 percent by traditional birth attendants, and 16 percent by relatives or other persons). Seven percent of births delivered by caesarean. The proportion of deliveries that received no assistance increased with mother’s age at birth (3 percent among mothers under age 20 and 17 percent among mothers age 35-49) and with birth order (2 percent for first births and 19 percent for births order six and above). Unassisted deliveries were more frequent in rural areas (11 percent) than in urban areas (5 percent). In the provinces, the proportion of unassisted deliveries ranged from a low of 6 percent in the City of Kigali to a high of 12 percent in the East province. Level of education was related to delivery conditions: 15 percent of deliveries that mothers having no education delivered without assistance, as compared with 9 percent of deliveries that mothers having a primary education and 4 percent of deliveries that mothers having a secondary education or higher. Results by household wealth quintile showed a higher proportion of unassisted deliveries in the poorest quintile (13 percent) than in the richest one (5 percent). Deliveries assisted by skilled personnel were more frequent among the youngest mothers (83 percent); those in the first birth order category (88 percent); those who delivered in health facilities (100 percent); those in urban areas (82 percent), particularly the City of Kigali (83 percent); those with a secondary education or higher (88 percent); and those in the richest wealth quintile (86 percent) (Table 9.6 and Figure 9.2). Maternal Health • 117 Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider, and percentage delivered by caesarean section, according to background characteristics, Rwanda 2010 Background characteristic Person providing assistance during delivery Percentage delivered by a skilled provider1 Percentage delivered by C-section Number of births Doctor Nurse/ medical assistant Midwife Other health worker Traditional birth attendant Relative/ other No one Don’t know/ missing Total Mother’s age at birth <20 12.2 70.5 0.4 1.5 1.9 10.2 3.1 0.1 100.0 83.1 9.3 556 20-34 10.3 60.0 0.3 2.0 2.5 15.7 8.8 0.4 100.0 70.6 7.4 6,938 35-49 7.0 50.2 0.2 2.9 2.5 19.6 17.3 0.3 100.0 57.4 5.0 1,643 Birth order 1 16.0 71.3 0.6 1.0 1.1 7.7 2.0 0.3 100.0 88.0 13.1 2,277 2-3 10.1 59.4 0.3 2.2 2.8 16.5 8.4 0.3 100.0 69.8 7.0 3,123 4-5 6.9 52.6 0.2 2.7 3.2 20.5 13.5 0.4 100.0 59.7 3.7 1,960 6+ 4.6 48.8 0.2 2.8 2.9 21.2 19.0 0.4 100.0 53.7 3.2 1,777 Place of delivery Health facility 14.1 85.1 0.3 0.1 0.0 0.1 0.1 0.2 100.0 99.5 10.3 6,295 Elsewhere 0.4 0.7 0.3 6.7 7.9 51.9 32.0 0.2 100.0 1.3 0.0 2,825 Residence Urban 20.3 61.5 0.5 1.2 1.1 9.4 5.4 0.5 100.0 82.4 15.9 1,094 Rural 8.4 58.5 0.3 2.2 2.6 17.0 10.6 0.3 100.0 67.2 5.9 8,043 Region City of Kigali 19.9 62.8 0.4 1.2 1.2 8.1 5.9 0.5 100.0 83.1 15.9 872 South 9.2 56.8 0.4 2.3 2.9 17.9 9.8 0.6 100.0 66.4 7.1 2,169 West 9.0 61.7 0.2 1.6 0.9 17.3 9.2 0.1 100.0 71.0 5.9 2,284 North 7.2 56.3 0.3 1.5 1.5 22.6 10.2 0.4 100.0 63.8 5.1 1,437 East 9.0 58.2 0.3 3.2 4.6 12.3 12.2 0.2 100.0 67.5 6.3 2,376 Mother’s education No education 6.5 50.4 0.2 1.9 3.1 23.0 14.5 0.3 100.0 57.1 4.7 1,756 Primary 9.0 60.7 0.3 2.2 2.5 15.5 9.4 0.4 100.0 69.9 6.3 6,578 Secondary and higher 24.2 62.6 0.9 1.4 0.8 5.7 4.2 0.2 100.0 87.7 18.6 803 Wealth quintile Lowest 7.0 53.9 0.3 2.7 2.9 20.3 12.5 0.5 100.0 61.2 4.9 2,134 Second 7.1 56.2 0.2 2.2 2.4 19.7 11.9 0.3 100.0 63.5 5.2 1,964 Middle 8.7 57.6 0.3 2.0 3.3 17.8 10.0 0.2 100.0 66.7 7.0 1,815 Fourth 9.0 63.3 0.2 2.1 2.7 13.2 9.2 0.2 100.0 72.6 5.7 1,698 Highest 19.4 65.8 0.6 1.3 0.8 6.9 4.6 0.5 100.0 85.9 14.4 1,525 Total 9.8 58.9 0.3 2.1 2.5 16.1 10.0 0.3 100.0 69.0 7.1 9,137 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. 1 Skilled provider includes doctor, nurse, medical assistant, and midwife. Figure 9.2 Children Whose Delivery was Assisted by Trained Personnel RDHS 2010 69 82 67 57 70 88 61 64 67 73 86 RWANDA RESIDENCE Urban Rural MOTHER'S EDUCATION No Education Primary Secondary and Higher WEALTH QUINTILE Lowest Second Middle Fourth Highest 0 20 40 60 80 100 Percent 118 • Maternal Health 9.3 POSTNATAL CARE A significant proportion of maternal and newborn deaths in the neonatal period take place within the 48 hours following delivery. For this reason, safe motherhood programmes have recently placed special emphasis on the importance of postnatal checkups, recommending that all women have a postnatal visit within two to seven days following the delivery. During the survey, therefore, women age 15-49 who had given birth in the two years preceding the survey were asked whether they had received a postnatal checkup and about the timing of this checkup. 9.3.1 Maternal Postnatal Care Table 9.7 shows that slightly fewer than one woman in five (18 percent) had a postnatal checkup in the first two days after delivery. Among these women, 12 percent had a checkup within 4 hours, 3 percent within 4 to 23 hours, and 3 percent within 1 to 2 days. Eighty percent of women did not have a postnatal checkup, and this proportion was very high in each of the background characteristic categories. However, the proportion of women who did not have a postnatal checkup decreased relative to 2005, when it was 95 percent. Table 9.7 Timing of first postnatal checkup Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution of the mother’s first postnatal checkup for the last live birth by time after delivery, and the percentage of women with a live birth in the two years preceding the survey who had a postnatal checkup in the first two days after giving birth, according to background characteristics, Rwanda 2010 Background characteristic Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Mother’s age at birth <20 16.9 3.4 3.8 0.9 2.5 0.0 72.4 100.0 24.2 214 20-34 11.5 3.1 2.7 1.1 1.1 0.7 79.9 100.0 17.2 2,454 35-49 9.7 4.5 2.2 0.0 1.0 0.2 82.4 100.0 16.5 540 Birth order 1 13.8 3.9 4.2 1.8 2.2 0.9 73.2 100.0 21.8 881 2-3 13.4 2.8 2.4 0.7 0.8 0.6 79.3 100.0 18.6 1,104 4-5 8.3 3.4 1.7 0.6 1.1 0.4 84.5 100.0 13.4 658 6+ 8.3 3.5 2.0 0.0 0.4 0.2 85.6 100.0 13.8 566 Place of delivery Health facility 12.8 4.0 3.2 1.0 1.3 0.7 76.9 100.0 20.0 2,576 Elsewhere 6.4 0.8 0.5 0.3 0.5 0.0 91.5 100.0 7.7 630 Residence Urban 13.3 6.0 3.8 1.6 1.9 1.1 72.2 100.0 23.1 381 Rural 11.3 3.0 2.5 0.8 1.1 0.5 80.8 100.0 16.8 2,827 Region City of Kigali 15.2 5.7 3.9 1.0 1.3 1.8 71.1 100.0 24.8 297 South 14.7 6.0 3.1 0.7 1.4 1.3 72.7 100.0 23.8 759 West 8.6 2.5 2.2 0.8 1.2 0.0 84.9 100.0 13.2 874 North 13.9 2.0 2.0 1.2 1.3 0.4 79.2 100.0 17.9 478 East 9.1 1.7 2.7 0.9 0.8 0.1 84.6 100.0 13.6 800 Education No education 9.7 2.6 3.1 0.9 0.8 0.2 82.8 100.0 15.4 550 Primary 11.7 3.3 2.5 0.8 1.3 0.7 79.8 100.0 17.4 2,364 Secondary and higher 13.8 5.3 3.5 1.2 1.1 0.4 74.7 100.0 22.7 294 Wealth quintile Lowest 10.9 3.0 2.4 0.7 1.1 1.0 80.9 100.0 16.3 776 Second 10.5 2.8 3.3 1.2 0.9 0.2 81.0 100.0 16.6 736 Middle 11.7 3.3 2.6 0.3 1.7 0.4 79.9 100.0 17.6 595 Fourth 11.6 2.6 1.8 0.8 1.4 0.4 81.5 100.0 16.0 578 Highest 13.9 5.4 3.2 1.3 0.8 0.9 74.5 100.0 22.5 523 Total 11.6 3.3 2.7 0.9 1.2 0.6 79.8 100.0 17.6 3,208 1 Includes women who had a checkup after 41 days Maternal Health • 119 The proportion of women who had no postnatal checkup increased with age (72 percent among women under age 20 and 82 percent among women age 35-49) and with birth order (73 percent for first births and 86 percent for births order six and above). Lack of a postnatal checkup was more frequent in rural areas (81 percent) than in urban areas (72 percent). By province, the proportion of women who had no postnatal checkup ranged from a low of 71 percent in the City of Kigali to a high of 85 percent in the West and East provinces. A woman’s level of education was related to whether or not she had a postnatal checkup: 83 percent of women with no education did not have a postnatal checkup, as compared with 80 percent of women with a primary education and 75 percent of women with a secondary education or higher. Results by household wealth quintile showed that the proportion of women with no postnatal checkup was higher in the poorest quintile (81 percent) than in the richest one (75 percent). It is important that postnatal care be carried out by skilled health providers who can detect and intervene in time to counter any problems related to the delivery and postpartum period. Table 9.8 shows the type of provider of the mother’s first postnatal health checkup in the two days after the last live birth. Only 17 percent of women’s first postnatal health checkups were carried out by doctors, nurses, or midwives. For 82 percent of women, there was no postnatal checkup in the first two days after the last live birth. Absence of postnatal care, high in each of the background characteristic categories, increased with age (76 percent among women under age 20 and 84 percent among women age 35-49) and with birth order (78 percent for first births and 87 percent for birth order four or five). Table 9.8 Type of provider of first postnatal checkup Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal health check in the two days after the last live birth, according to background characteristics, Rwanda 2010 Background characteristic Type of health provider of mother’s first postnatal checkup No postnatal checkup in the first two days after birth1 Total Number of women Doctor/nurse/ midwife Auxiliary nurse/midwife Community health worker Mother’s age at birth <20 24.2 0.0 0.0 75.8 100.0 214 20-34 17.0 0.2 0.0 82.8 100.0 2,454 35-49 16.3 0.2 0.0 83.5 100.0 540 Birth order 1 21.8 0.0 0.0 78.2 100.0 881 2-3 18.5 0.1 0.0 81.4 100.0 1,104 4-5 13.1 0.3 0.0 86.6 100.0 658 6+ 13.1 0.6 0.2 86.2 100.0 566 Place of delivery Health facility 19.8 0.2 0.0 80.0 100.0 2,576 Elsewhere 7.3 0.3 0.1 92.3 100.0 630 Missing 0.0 0.0 0.0 100.0 100.0 2 Residence Urban 22.8 0.0 0.2 76.9 100.0 381 Rural 16.6 0.2 0.0 83.2 100.0 2,827 Region City of Kigali 24.8 0.0 0.0 75.2 100.0 297 South 23.5 0.3 0.0 76.2 100.0 759 West 13.2 0.0 0.0 86.8 100.0 874 North 17.5 0.4 0.0 82.1 100.0 478 East 13.2 0.3 0.1 86.4 100.0 800 Education No education 15.0 0.2 0.2 84.6 100.0 550 Primary 17.3 0.2 0.0 82.6 100.0 2,364 Secondary and higher 22.3 0.3 0.0 77.3 100.0 294 Wealth quintile Lowest 16.0 0.1 0.1 83.7 100.0 776 Second 16.5 0.1 0.0 83.4 100.0 736 Middle 17.3 0.3 0.0 82.4 100.0 595 Fourth 16.0 0.0 0.0 84.0 100.0 578 Highest 22.0 0.5 0.0 77.5 100.0 523 Total 17.3 0.2 0.0 82.4 100.0 3,208 1 Includes women who had a checkup after 41 days 120 • Maternal Health Mothers who had not given birth in health facilities (92 percent, compared with 80 percent of women who delivered in health facilities), those living in rural areas (83 percent, compared with 77 percent in urban areas), those with no education (85 percent, compared with 77 percent of women with a secondary education or higher), and those in the lowest wealth quintile (84 percent, compared with 78 percent for women in the highest wealth quintile) were most likely not to have had a postnatal health checkup. By contrast, although proportions were low, young women (24 percent), those in the first birth order category (22 percent), those who delivered in a health facility (20 percent), those living in urban areas (23 percent), those with a high level of education (22 percent), and those in the highest wealth quintile (22 percent) were more likely to receive postnatal care from a skilled provider. 9.3.2 Newborn Postnatal Care Postnatal checkups for newborns should also be carried out within two days after the birth to evaluate their health status and intervene rapidly if necessary. Table 9.9 shows the distribution of births according to the time after birth of the first postnatal checkup and the percentage of births with a postnatal checkup in the first two days. Table 9.9 Timing of newborn’s first postnatal checkup Percent distribution of births in the two years preceding the survey by time after birth of first postnatal checkup, and the percentage of births with a postnatal checkup in the two days after birth, according to background characteristics, Rwanda 2010 Background characteristic Time after birth of newborn’s first postnatal checkup No postnatal checkup1 Total Percentage of births with a postnatal checkup in the first two days after birth Number of births Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don’t know/ missing Mother’s age at birth <20 1.4 4.2 0.8 2.3 0.0 0.0 91.3 100.0 8.7 214 20-34 1.6 1.5 0.6 0.7 0.3 0.2 95.1 100.0 4.4 2,454 35-49 1.3 1.9 1.0 0.2 0.1 0.0 95.5 100.0 4.4 540 Birth order 1 1.8 1.6 0.6 1.1 0.3 0.0 94.5 100.0 5.2 881 2-3 1.9 2.0 0.6 0.9 0.1 0.3 94.2 100.0 5.4 1,104 4-5 0.9 1.6 0.9 0.4 0.5 0.1 95.6 100.0 3.7 658 6+ 1.3 1.6 0.6 0.2 0.1 0.0 96.1 100.0 3.7 566 Place of delivery Health facility 1.7 1.5 0.5 0.7 0.1 0.2 95.3 100.0 4.4 2,576 Elsewhere 1.0 2.7 1.2 0.9 0.7 0.0 93.5 100.0 5.8 630 Residence Urban 2.5 1.8 1.3 1.7 0.3 0.0 92.3 100.0 7.4 381 Rural 1.4 1.7 0.6 0.6 0.2 0.1 95.3 100.0 4.3 2,827 Region City of Kigali 3.0 2.4 1.0 1.9 0.4 0.0 91.4 100.0 8.2 297 South 1.8 1.9 1.6 0.4 0.5 0.3 93.5 100.0 5.7 759 West 0.6 1.3 0.1 0.7 0.0 0.0 97.3 100.0 2.7 874 North 3.0 2.3 0.6 0.9 0.4 0.2 92.6 100.0 6.8 478 East 1.0 1.5 0.3 0.6 0.2 0.2 96.3 100.0 3.4 800 Mother’s education No education 0.9 1.2 0.4 0.7 0.2 0.0 96.7 100.0 3.2 550 Primary 1.7 1.8 0.7 0.6 0.3 0.2 94.7 100.0 4.8 2,364 Secondary and higher 1.6 2.2 0.8 1.9 0.0 0.0 93.5 100.0 6.5 294 Wealth quintile Lowest 1.0 1.0 0.8 0.7 0.1 0.2 96.2 100.0 3.5 776 Second 1.5 2.2 0.1 0.7 0.3 0.0 95.1 100.0 4.6 736 Middle 1.6 1.3 0.8 0.5 0.2 0.0 95.6 100.0 4.2 595 Fourth 1.8 1.5 0.8 0.3 0.4 0.2 95.0 100.0 4.4 578 Highest 2.1 2.9 0.9 1.7 0.4 0.2 91.8 100.0 7.6 523 Total 1.6 1.7 0.7 0.7 0.3 0.1 94.9 100.0 4.7 3,208 1 Includes newborns who had a checkup after the first six days Maternal Health • 121 Ninety-five percent of newborns did not receive postnatal care in the first two days after birth, and this proportion was higher than 91 percent in each of the background characteristic categories. Among the 5 percent of newborns who received postnatal care, 2 percent received it either in less than 1 hour or in 1 to 3 hours, and 1 percent received it in 4 to 23 hours or 1 to 2 days. The proportion of newborns who received postnatal care in 3 to 6 days was very low (0.3 percent). The proportion of newborns receiving care was not related to mother’s age or birth order but was related to place of delivery and mother’s area of residence, level of education, and wealth quintile. Table 9.10 shows the proportion of newborns who received postnatal care from skilled providers. Almost all children who received postnatal care (5 percent) were cared for by doctors, nurses, or midwives. Newborns whose mothers were less than age 20 were twice as likely to have a postnatal checkup (9 percent) as newborns whose mothers were age 20-34 or 35-49 (4 percent for each age group). Paradoxically, newborns not delivered in a health facility were slightly more likely to have a postnatal checkup (6 percent) than those delivered in a health facility (4 percent). By province, the proportion of newborns who received postnatal care varied from a low of 3 percent in the East and West provinces to a high of 8 percent in the City of Kigali. By other background characteristics, newborns whose mothers lived in urban areas (7 percent, as compared with 4 percent in rural areas), had a secondary education or higher (7 percent, as compared with 3 percent of those with no education), and were in the highest wealth quintile (7 percent, as compared with 3 percent of those in the lowest wealth quintile) were most likely to have had a postnatal checkup. Table 9.10 Type of provider of newborn’s first postnatal checkup Percent distribution of births in the two years preceding the survey by type of provider of the newborn’s first postnatal health check during the two days after the last live birth, according to background characteristics, Rwanda 2010 Background characteristic Type of health provider of newborn’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of births Doctor/nurse/ midwife Auxiliary nurse/midwife Community health worker Mother’s age at birth <20 8.7 0.0 0.0 91.3 100.0 214 20-34 4.3 0.1 0.1 95.6 100.0 2,454 35-49 4.4 0.0 0.0 95.6 100.0 540 Birth order 1 5.2 0.0 0.0 94.8 100.0 881 2-3 5.3 0.1 0.0 94.6 100.0 1,104 4-5 3.6 0.0 0.1 96.3 100.0 658 6+ 3.3 0.2 0.2 96.3 100.0 566 Place of delivery Health facility 4.3 0.1 0.0 95.6 100.0 2,576 Elsewhere 5.6 0.0 0.3 94.2 100.0 630 Missing 0.0 0.0 0.0 100.0 100.0 2 Residence Urban 7.1 0.0 0.2 92.6 100.0 381 Rural 4.2 0.1 0.0 95.7 100.0 2,827 Region City of Kigali 8.2 0.0 0.0 91.8 100.0 297 South 5.5 0.1 0.0 94.3 100.0 759 West 2.7 0.0 0.0 97.3 100.0 874 North 6.8 0.0 0.0 93.2 100.0 478 East 3.0 0.2 0.2 96.6 100.0 800 Mother’s education No education 3.0 0.0 0.2 96.8 100.0 550 Primary 4.7 0.1 0.0 95.2 100.0 2,364 Secondary and higher 6.5 0.0 0.0 93.5 100.0 294 Wealth quintile Lowest 3.3 0.0 0.1 96.5 100.0 776 Second 4.6 0.0 0.0 95.4 100.0 736 Middle 4.2 0.0 0.0 95.8 100.0 595 Fourth 4.3 0.0 0.1 95.6 100.0 578 Highest 7.2 0.5 0.0 92.4 100.0 523 Total 4.6 0.1 0.1 95.3 100.0 3,208 122 • Maternal Health 9.4 PROBLEMS IN ACCESSING HEALTH CARE Access to health care is a key priority for improving a country’s overall health status. Therefore, the survey asked women about perceived barriers to accessing health care. The results are presented in Table 9.11. Three in five women (61 percent) reported at least one problem in accessing health care. Slightly more than half of women (53 percent) reported that lack of money for treatment was the primary barrier. The extent of this problem increased with age; 49 percent of women age 15-19 reported difficulties in getting money for treatment, as compared with 60 percent of women age 40-49. Divorced, separated, and widowed women (74 percent) reported having this problem more frequently than married women (51 percent) and never- married women (50 percent). Lack of money was more of a barrier for women in rural areas (55 percent) than for women in urban areas (41 percent). With respect to provinces, women in the South province were more likely (64 percent) than those in other provinces to mention this problem. Similarly, women with no education mentioned this problem more often (68 percent) than women with a secondary education or higher (36 percent), and women in the poorest wealth quintile were more affected by lack of money (74 percent) than women in the richest quintile (32 percent). Twenty-six percent of women mentioned distance to the health facility as a problem. This problem was much more frequent among women age 35-49 (28 percent); women with five or more children (28 percent); divorced, separated, and widowed women (31 percent); women employed not for cash (27 percent); women in rural areas (28 percent); women with no education (30 percent); and women in poorer households (31 percent). Less than one in five women (17 percent) mentioned ‘not wanting to go alone’ as a serious problem in accessing health care. The youngest women (18 percent); those with no living children (19 percent); those who were divorced, separated, or widowed (20 percent); those employed not for cash (19 percent); those living in rural areas (18 percent); those with no education (19 percent); those in the North province (20 percent); and those in the poorest households (22 percent) were most likely to consider not wanting to go alone as a barrier to accessing health care. Getting permission was a serious problem for only 3 percent of women. Young women (4 percent), those with no living children (3 percent), those who had never been married (3 percent), those living in urban areas (4 percent), those with a high level of education (3 percent), and those in the highest wealth quintile (4 percent) most frequently reported this problem. Maternal Health • 123 Table 9.11 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Rwanda 2010 Background characteristic Problems in accessing health care Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone At least one problem accessing health care Number of women Age 15-19 3.7 48.5 23.5 18.4 57.1 2,945 20-34 2.5 51.0 26.1 17.0 60.0 6,999 35-49 1.7 60.3 28.3 16.3 67.4 3,727 Number of living children 0 3.1 47.7 24.4 18.9 56.5 5,207 1-2 2.3 54.3 26.5 16.2 62.1 3,552 3-4 2.6 56.9 27.2 16.2 65.1 2,704 5+ 1.7 58.8 28.3 15.4 67.3 2,209 Marital status Never married 3.1 49.6 24.4 19.1 58.0 5,285 Married or living together 2.2 51.1 26.4 14.8 60.4 6,897 Divorced/separated/widowed 2.4 73.9 30.9 20.4 78.1 1,489 Employed last 12 months Not employed 3.1 50.3 22.8 16.9 58.1 2,227 Employed for cash 2.5 53.4 26.6 16.0 61.6 7,660 Employed not for cash 2.5 53.8 27.3 19.4 63.0 3,751 Missing 0.0 44.6 8.4 5.7 47.1 33 Residence Urban 4.2 41.4 14.9 12.7 48.1 2,057 Rural 2.3 55.1 28.1 17.9 63.8 11,614 Region City of Kigali 4.4 38.8 15.2 11.1 45.4 1,596 South 3.3 64.4 30.8 19.5 74.0 3,212 West 1.3 50.5 20.7 12.8 57.5 3,305 North 3.3 46.1 21.5 20.4 55.1 2,278 East 1.8 56.0 35.6 19.7 65.1 3,280 Education No education 2.4 68.1 30.2 18.5 73.8 2,119 Primary 2.5 53.6 26.5 17.5 62.2 9,337 Secondary and higher 2.9 36.2 20.8 14.2 46.3 2,216 Wealth quintile Lowest 3.2 74.3 31.3 22.1 79.6 2,622 Second 2.6 61.4 28.2 18.3 68.6 2,661 Middle 2.0 55.2 28.6 18.6 64.3 2,736 Fourth 1.4 45.1 27.8 15.6 55.9 2,677 Highest 3.6 31.9 15.9 11.6 41.2 2,976 Total 2.6 53.0 26.1 17.1 61.4 13,671 Child Health • 125 CHILD HEALTH 10 his chapter presents findings from several areas of importance relating to child health and survival, including infant birth weight and size, the vaccination status of children, and childhood illnesses and their treatment. The information on birth weight and size is intended to assist monitoring programs in their efforts to decrease neonatal and infant mortality by reducing the incidence of low birth weight. Immunizing children against vaccine-preventable diseases can greatly reduce childhood morbidity and mortality. In the 2010 RDHS, data on immunization were collected for all living children born in 2005 or later. Information on vaccination coverage was collected in two ways: from the child’s health card and by direct report from the mother. If a health card was presented, the interviewer would copy the immunization dates directly onto the questionnaire. If the mother was not able to present a card for her child, she was asked to recall the specific vaccines given to her child and the number of times the child received each vaccine. Ensuring that children receive prompt and appropriate treatment when they become ill is also important to improving child health. Information on treatment practices and contact with health services for children with three childhood illnesses (acute respiratory infection, fever, and diarrhea) help in the assessment of national programs aimed at reducing child mortality. The 2010 RDHS collected data on the prevalence and treatment of acute respiratory infection (ARI), fever, and diarrhea. The extent to which diarrheal disease is treated with oral rehydration therapy (including increased fluid intake) is used to assess programs that recommend such treatment. Because appropriate sanitary practices can help prevent and reduce the severity of diarrheal disease, information is provided on how children’s fecal matter is disposed. 10.1 Child’s Size at Birth A child’s birth weight is an important determinant of infant and child health and mortality. A birth weight less than 2.5 kilograms (kg) is considered low. For all births during the five-year period preceding the survey, mothers were asked their perception of their child’s size at birth. Although such information is subjective, it can be a useful proxy for the weight of the child. The mothers were also asked to report the actual weight in kilograms (based on either a written record or on their own recall) if the child had been weighed after delivery. Table 10.1 shows that 68 percent of newborns were weighed at birth. Among births with known birth weight, only 6 percent were classified as having low birth weight (i.e., weighing less than 2.5 kg at birth). According to the respondent’s own assessment of her infant’s size, the majority of infants (84 percent) were classified as average or larger than average. More than one in ten births was either smaller than average (13 percent) or very small (2 percent). Although the differences are not large, children born in rural areas are more likely than those born in urban areas to weigh less than 2.5 kg or to be described as very small in size. Data also show that, in general, there is a positive relationship between the mother’s education and wealth quintile and the weight and size of the newborn. Children whose mothers have at least some secondary and higher education, or who are in the highest wealth quintile, are less likely to weigh under 2.5 kg or to be described as very small at birth compared with other children. Variations in weight and size at birth are also seen among regions; the prevalence of children born with a weight below 2.5 kg ranges from 5.2 percent in West province to 7.5 percent in South province. T 126 • Child Health Table 10.1 Child's weight and size at birth Percentage of live births in the five years preceding the survey with a reported birth weight; among live births in the five years preceding the survey with a reported birth weight, percent distribution by birth weight; percent distribution of all live births in the five years preceding the survey by mother's estimate of baby's size at birth, according to background characteristics, Rwanda 2010 Background characteristic Percentage of all births with a reported birth weight1 Percent distribution of births with a reported birth weight1 Percent distribution of all live births by size of child at birth Total Number of births Less than 2.5 kg 2.5 kg or more Total Number of births Very small Smaller than average Average or larger Don't know/ missing Mother's age at birth <20 80.2 8.4 91.6 100.0 446 2.3 16.2 81.3 0.1 100.0 556 20-34 68.9 5.9 94.1 100.0 4,783 2.2 12.9 84.2 0.7 100.0 6,938 35-49 58.9 7.0 93.0 100.0 967 2.9 12.4 84.5 0.2 100.0 1,643 Birth order 1 81.8 7.6 92.4 100.0 1,862 2.3 16.9 80.1 0.7 100.0 2,277 2-3 69.3 5.9 94.1 100.0 2,163 2.1 12.5 84.8 0.6 100.0 3,123 4-5 60.3 5.2 94.8 100.0 1,181 2.4 11.4 86.0 0.3 100.0 1,960 6+ 55.7 5.6 94.4 100.0 990 2.6 10.8 85.9 0.7 100.0 1,777 Mother's smoking status Smokes cigarettes/tobacco 49.0 2.2 97.8 100.0 46 2.2 11.5 85.4 1.0 100.0 95 Does not smoke 68.0 6.3 93.7 100.0 6,150 2.3 13.0 84.1 0.6 100.0 9,041 Residence Urban 81.2 5.9 94.1 100.0 888 1.4 13.9 84.5 0.3 100.0 1,094 Rural 66.0 6.3 93.7 100.0 5,308 2.4 12.9 84.0 0.6 100.0 8,043 Province Kigali City 81.7 6.5 93.5 100.0 712 1.9 14.7 83.3 0.1 100.0 872 South 66.4 7.5 92.5 100.0 1,441 2.0 15.6 81.5 0.8 100.0 2,169 West 66.8 5.2 94.8 100.0 1,526 1.9 12.4 85.3 0.4 100.0 2,284 North 65.1 5.9 94.1 100.0 935 3.0 10.8 84.9 1.2 100.0 1,437 East 66.6 6.2 93.8 100.0 1,582 2.7 12.0 85.0 0.3 100.0 2,376 Education No education 57.0 7.1 92.9 100.0 1,001 2.1 13.8 83.1 1.0 100.0 1,756 Primary 68.3 6.3 93.7 100.0 4,495 2.5 12.7 84.3 0.5 100.0 6,578 Secondary and higher 87.2 4.7 95.3 100.0 701 1.5 13.7 84.6 0.2 100.0 803 Wealth quintile Lowest 60.1 9.0 91.0 100.0 1,283 2.5 13.2 83.2 1.1 100.0 2,134 Second 61.5 6.9 93.1 100.0 1,208 2.3 14.5 82.7 0.5 100.0 1,964 Middle 65.5 5.8 94.2 100.0 1,189 2.7 13.0 84.0 0.4 100.0 1,815 Fourth 71.8 5.5 94.5 100.0 1,220 2.7 12.6 84.3 0.4 100.0 1,698 Highest 84.9 4.0 96.0 100.0 1,295 1.3 11.5 86.9 0.3 100.0 1,525 Total 67.8 6.2 93.8 100.0 6,196 2.3 13.0 84.1 0.6 100.0 9,137 1 Based on either a written record or the mother's recall 10.2 VACCINATION OF CHILDREN To assess Rwanda’s Expanded Program on Immunization (EPI), the 2010 RDHS gathered information on vaccinations for all children born in the five years preceding the survey. The EPI generally follows the World Health Organization (WHO) guidelines for vaccinating children. These guidelines stipulate that, to be considered fully immunized, children should receive the following vaccines by the age of 12 months: one dose of BCG (against tuberculosis), three doses of DPT (against diphtheria, pertussis, and tetanus), three doses of oral polio vaccine, and one dose of measles vaccine. Vaccines against Haemophilus influenzae type B and hepatitis B were introduced in Rwanda in February 2002 and pneumococcal vaccine in April 2009. Each child who is vaccinated receives an immunization card on which all of the vaccines received are recorded. The information on vaccinations was gathered from two sources: (1) where vaccination cards were available, the interviewer copied the information directly onto the questionnaire; and (2) where cards were not available because the mother never had one, or the card was unavailable at the time of the survey, or the mother had lost the card, mothers were asked to recall whether or not the child had received each of the vaccines covered by the survey. Table 10.2 presents vaccination coverage results by source of information for children age 12 to 23 months, thereby including only children who had reached the age by which they should be fully immunized. According to the vaccination cards, 78 percent of children age 12-23 months are fully immunized. When information from both Child Health • 127 information sources is considered, the percentage of children fully immunized reaches 90 percent. Vaccination coverage based solely on the mother’s report occurred in only 12 percent of cases. Of the fully immunized children, 85 percent received their vaccinations before their first birthday as recommended by WHO and the Rwanda EPI. Less than one percent of children age 12 to 23 months had not received any vaccinations at the time of the survey. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by 12 months of age, Rwanda 2010 Source of information BCG Pentavalent Polio1 Measles All basic vaccinations2 No vaccinations Number of children 1 2 3 0 1 2 3 Vaccinated at any time before survey Vaccination card 82.1 82.2 81.9 80.9 74.7 82.2 81.9 81.0 79.0 78.4 0.0 1,329 Mother's report 17.0 16.7 16.4 15.9 14.8 17.0 16.6 12.3 16.0 11.7 0.5 287 Either source 99.1 98.8 98.3 96.8 89.6 99.2 98.5 93.3 95.0 90.1 0.5 1,616 Vaccinated by 12 months of age3 98.9 98.5 98.0 96.3 89.4 98.9 98.2 92.8 90.3 85.4 0.8 1,616 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of pentavalent and polio vaccine excluding polio vaccine given at birth 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. Table 10.3 shows the results for vaccination coverage among children age 12 to 23 months, according to background characteristics of mother and child. The data show practically no disparity by sex (90 percent for males and females). However, complete coverage first increases slightly, from 90 percent for the first birth order to 93 percent with children’s birth orders two to three, before it declines to 89 percent with children’s birth orders four to five; and declines further to 86 percent for children of birth orders six and above. By residence, complete vaccination coverage is higher in urban areas (93 percent) than in rural areas (90 percent), primarily because the City of Kigali has the highest vaccination coverage in the country (96 percent). The West province has the lowest coverage rate (81 percent). This low proportion in the West province is due in part to the high dropout rate between polio doses (12 percentage points between the second and the third doses). Complete vaccination coverage increases steadily with the mother’s level of education, although the differentials are not great: 87 percent for children whose mothers have no education; 90 percent for children whose mothers have a primary education; and 97 percent for children whose mothers have a secondary education or higher. Household wealth quintile has a positive relationship with the vaccination coverage. The proportion of vaccinated children varies from 87 percent for the lowest quintile to 96 percent for the highest quintile. 128 • Child Health Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Rwanda 2010 Background characteristic BCG Pentavalent Polio Measles All basic vaccinations2 No vaccinations Percentage with a vaccination card seen Number of children 1 2 3 01 1 2 3 Sex Male 99.5 99.2 98.5 97.1 90.3 99.3 98.5 93.3 95.0 90.2 0.4 82.1 786 Female 98.8 98.5 98.1 96.5 88.9 99.1 98.4 93.3 95.0 90.0 0.7 82.3 831 Birth order 1 99.0 99.3 98.6 96.8 94.9 99.7 98.5 92.5 96.2 90.3 0.0 81.2 437 2-3 99.4 99.3 98.6 97.5 87.4 99.5 98.8 94.8 96.2 92.6 0.4 85.1 542 4-5 98.5 97.8 97.3 96.1 86.8 98.2 97.9 93.2 94.3 89.4 1.5 81.1 336 6+ 99.5 98.5 98.5 96.4 88.9 99.2 98.5 91.8 92.1 86.1 0.5 79.8 301 Residence Urban 99.7 99.4 99.0 95.7 94.3 99.4 99.0 94.1 97.3 93.3 0.3 77.8 181 Rural 99.1 98.8 98.2 97.0 89.0 99.2 98.4 93.2 94.8 89.7 0.6 82.8 1,436 Province City of Kigali 99.6 99.2 98.8 98.5 94.5 99.2 98.8 96.6 98.2 96.3 0.4 77.0 142 South 99.0 98.7 98.4 96.8 89.0 99.2 99.0 94.4 97.6 92.8 0.8 82.4 383 West 98.3 98.3 97.3 94.5 89.7 98.8 97.7 86.3 91.1 80.9 1.0 82.9 426 North 100.0 100.0 100.0 99.2 96.1 100.0 100.0 97.0 97.4 93.6 0.0 86.8 251 East 99.5 98.7 98.0 97.2 84.4 99.2 97.7 96.2 94.2 92.8 0.2 80.5 414 Education No education 98.5 98.0 97.7 95.0 87.6 99.2 98.1 92.3 90.8 87.0 0.8 85.1 271 Primary 99.2 98.9 98.3 97.0 89.8 99.2 98.4 93.1 95.6 90.1 0.5 82.1 1,217 Secondary and higher 99.5 99.5 99.5 98.3 91.4 99.5 99.5 97.5 98.5 96.8 0.5 77.1 128 Wealth quintile Lowest 98.5 98.5 98.0 95.6 86.6 98.7 98.3 90.5 94.0 86.6 1.3 82.8 398 Second 98.6 97.6 97.1 95.7 91.1 98.5 97.9 91.6 93.0 87.2 0.9 80.2 359 Middle 99.3 99.0 97.8 97.1 89.4 100.0 97.9 94.7 94.9 91.7 0.0 85.6 303 Fourth 100.0 100.0 99.6 97.9 89.6 99.6 99.2 94.3 97.0 92.1 0.0 84.4 301 Highest 99.8 99.6 99.3 98.7 92.2 99.6 99.3 97.3 97.4 95.5 0.2 77.7 254 Total 99.1 98.8 98.3 96.8 89.6 99.2 98.5 93.3 95.0 90.1 0.5 82.2 1,616 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of pentavalent and polio vaccine (excluding polio vaccine given at birth) 10.3 TRENDS IN VACCINATION COVERAGE Table 10.4 shows, by age cohort, the percentages of children age 12-59 months who received specific vaccinations during the first year of life. The data indicate that the proportion of children fully vaccinated by 12 months of age has increased over the past few years, from 78 percent of children age 48-59 months to 85 percent of children age 12-23 months. Table 10.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Rwanda 2010 Age in months BCG Pentavalent Polio Measles All basic vaccinations2 No vaccinations Percentage with a vaccination card seen Number of children 1 2 3 01 1 2 3 FINAL TABLE 12-23 98.9 98.5 98.0 96.3 89.4 98.9 98.2 92.8 90.3 85.4 0.8 82.2 1,616 24-35 99.3 99.2 98.8 97.0 88.8 99.0 98.2 92.4 91.1 84.9 0.5 75.9 1,824 36-47 98.9 98.2 98.0 96.1 88.3 98.8 98.0 90.9 90.7 82.7 0.7 68.1 1,741 48-59 98.6 98.2 97.0 94.1 85.6 98.6 96.8 87.5 88.3 77.8 0.9 61.1 1,850 Total 98.9 98.5 97.9 95.9 88.0 98.8 97.8 90.9 90.2 82.7 0.7 71.5 7,032 Note: Information was obtained from the vaccination card or, if there was no written record, from the mother. For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of tetravalent/pentavalent and polio vaccine (excluding polio vaccine given at birth) Child Health • 129 10.4 CHILDHOOD ILLNESSES 10.4.1 Acute Respiratory Infections Acute respiratory infections (ARIs), particularly pneumonia, constitute one of the main causes of child deaths in developing countries. To assess the prevalence of these infections, mothers were asked if their children under age 5 had been ill with a cough during the two weeks preceding the survey. If the answer was yes, they were asked if the cough had been accompanied by short, rapid breathing. It should be borne in mind that these data are subjective (i.e., based on the mother’s perception of illness) and not validated by a medical examination. Table 10.5 shows that, among children under age 5, 4 percent had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These respiratory infections were the most frequent among children age 6-11 months (6 percent) and 12-23 months (5 percent). There is little difference in ARI prevalence between boys and girls (4 percent and 3 percent, respectively). The prevalence of ARI is, surprisingly, slightly higher in urban areas (5 percent) compared with rural areas (4 percent). Results according to province show a higher prevalence of ARIs in the West province (6 percent), the City of Kigali (5 percent), and South province (4 percent) than elsewhere. Results according to mother’s level of education vary somewhat: from a high of 5 percent for children of mothers with secondary and higher education, to a low of 4 percent for children of mothers with primary education. In general, results show that ARI prevalence does not vary much by wealth quintile. Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age 5, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, and among children with symptoms of ARI, and the percentage for whom advice or treatment was sought from a health facility or provider, according to background characteristics, Rwanda 2010 Background characteristic Among children under age 5: Among children under age 5 with symptoms of ARI: Percentage with symptoms of ARI1 Number of children Percentage for whom advice or treatment was sought from a health facility or provider2 Percentage for whom advice or treatment was sought from a community health worker Number of children Age in months <6 4.0 732 (39.0) (16.5) 29 6-11 6.3 841 62.7 9.3 53 12-23 5.1 1,616 57.8 15.7 82 24-35 3.1 1,824 50.7 15.3 56 36-47 3.4 1,741 35.1 6.1 60 48-59 2.2 1,850 (48.4) (16.6) 41 Sex Male 4.1 4,364 50.1 14.6 179 Female 3.4 4,241 50.5 10.9 143 Residence Urban 5.2 1,033 75.8 9.8 54 Rural 3.5 7,572 45.1 13.6 269 Province Kigali City 4.6 830 (74.2) (1.8) 38 South 3.5 2,049 46.7 24.7 71 West 6.1 2,159 45.3 11.7 131 North 2.9 1,342 (47.1) (4.6 39 East 1.9 2,225 (52.4) (15.1) 43 Education No education 4.1 1,629 40.6 14.2 66 Primary 3.5 6,214 49.2 13.1 219 Secondary and higher 4.9 762 (73.3) (9.8) 37 Wealth quintile Lowest 5.1 1,992 40.3 12.4 101 Second 3.4 1,852 49.6 15.2 64 Middle 3.2 1,709 48.7 16.6 54 Fourth 3.1 1,598 (46.6) (9.4) 50 Highest 3.7 1,454 74.8 11.1 53 Total 3.7 8,605 50.2 13.0 322 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Symptoms of ARI (cough accompanied by short, rapid breathing that was chest-related and/or by difficult breathing that was chest-related) is considered a proxy for pneumonia 2 Excludes pharmacy, shop, and traditional practitioner 130 • Child Health Table 10.5 also shows the proportion of children for whom treatment was sought. Half (50 percent) of children with the symptoms of acute respiratory infection sought treatment or advice from a health facility or health provider, including 13 percent who sought help from a community health worker. Treatment was sought most often for children age 6-11 months (63 percent) and 12-23 months (58 percent), who, as seen above, have the highest prevalence of ARI. Whether treatment for an ARI is sought from a health facility is influenced by residence, mother’s level of education, and wealth quintile. In urban areas, treatment was sought for 76 percent of children, compared with 45 percent in rural areas. Similarly, treatment or advice was sought for 49 percent of children whose mothers have a primary education, compared with 41 percent of children whose mothers have no education. Finally, treatment was sought for 75 percent of children in the richest households; in the poorest households, this proportion was only 40 percent. The treatment data show no significant variation by sex of child. The results, according to province, show that seeking treatment is not necessarily linked to prevalence of ARI. Treatment was less often sought in the West province (45 percent), which has the highest prevalence of ARIs. 10.4.2 Fever Fever is the primary symptom of many illnesses, including malaria and measles, which cause numerous deaths in developing countries. For this reason, mothers were asked whether their children had suffered from a fever during the two weeks preceding the survey. Table 10.6 shows that during this time period 16 percent of the children had a fever. As with ARI, age seems to be the most important factor affecting fever prevalence: children age 6-11 months (25 percent) and 12-23 months (22 percent) were the most likely to have had a fever. Fever prevalence does not vary much by sex of the child (17 percent for boys; 15 percent for girls) or residence (17 percent for urban; 16 percent for rural). There are in general slight variations among the provinces, with the highest prevalence in the South and West provinces (almost 18 percent for both). Similarly, children whose mothers have some education (16 percent) are more likely to have suffered from fever than those whose mothers have no education (14 percent). In general, household wealth does not significantly affect the prevalence of fever in children under age 5. Child Health • 131 Table 10.6 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, and the percentage of children for whom treatment was sought from a health facility or provider, by background characteristics, Rwanda 2010 Background characteristic Among children under age 5: Among children under age 5 with fever Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage for whom advice or treatment was sought from a community health worker Number of children Age in months <6 12.6 732 27.4 4.7 92 6-11 24.7 841 46.5 17.2 208 12-23 21.9 1,616 47.7 15.7 353 24-35 15.4 1,824 45.5 16.8 282 36-47 13.6 1,741 36.5 15.8 237 48-59 9.9 1,850 40.3 17.2 184 Sex Male 16.5 4,364 43.2 15.5 722 Female 14.9 4,241 42.2 15.7 634 Residence Urban 16.7 1,033 55.9 13.5 172 Rural 15.6 7,572 40.8 15.9 1,183 Province Kigali City 17.4 830 51.9 7.8 144 South 17.9 2,049 46.8 26.1 367 West 17.5 2,159 42.3 12.6 378 North 17.1 1,342 30.8 5.4 229 East 10.7 2,225 43.2 18.8 237 Education No education 14.0 1,629 34.0 13.1 228 Primary 16.2 6,214 42.8 17.3 1,008 Secondary and higher 15.6 762 59.1 6.4 119 Wealth quintile Lowest 17.8 1,992 35.1 15.6 355 Second 16.9 1,852 35.9 17.3 313 Middle 15.4 1,709 42.3 16.4 264 Fourth 11.9 1,598 50.2 17.5 190 Highest 16.1 1,454 57.9 11.1 234 Total 15.8 8,605 42.7 15.6 1,355 1 Excludes pharmacy, shop, and traditional practitioner Table 10.6 also shows the proportion of children for whom treatment for fever was sought. Treatment or advice was sought from a health facility or provider for 43 percent of children with the symptoms of fever; including 16 percent who sought help from a community health worker. Treatment was sought most often for children age 12-23 months (48 percent) and 6-11 months (47 percent), who, as seen above, have the highest prevalence of fever. Whether or not treatment is sought from a health facility for fever is influenced by residence, mother’s level of education, and wealth quintile. In urban areas, treatment was sought for 56 percent of children, compared with 41 percent in rural areas. Similarly, treatment or advice was sought for 59 percent of children whose mothers have a secondary education or higher, compared with 43 percent of children whose mothers have a primary education, and only 34 percent of those whose mothers have no education. Finally, treatment was sought for 58 percent of children in the richest households, while in the poorest households, this proportion was only 35 percent. The data for treatment seeking show no significant variation by sex of the child. 132 • Child Health The results according to province show that seeking treatment is not necessarily linked to prevalence of fever. Treatment was less often sought in the North province (31 percent), which has a higher prevalence of fever compared with other provinces. 10.5 DIARRHEAL DISEASE 10.5.1 Prevalence of Diarrhea Diarrheal diseases constitute one of the main causes of death among young children in developing countries because of associated dehydration and malnutrition. To combat the effects of dehydration, WHO promotes the use of oral rehydration therapy (ORT), which includes a prepared solution of oral rehydration salts (ORS) made from packets; a solution prepared at home using clean water, sugar, and salt (recommended home fluids, or RHF); or simply increased intake of fluids. To assess the prevalence of diarrheal diseases in children under age 5, mothers were asked whether their children had suffered from diarrhea during the two weeks preceding the survey (Table 10.7). Information was also gathered on the percentage of mothers who had heard of ORS packets (Table 10.8), the percentage of children for whom treatment or advice was sought, and the type of treatment used to treat the diarrhea. Regarding treatment, mothers were asked whether they had used ORS packets, RHF, or other treatments during the diarrheal episodes (Table 10.9). Table 10.7 shows that, according to mothers’ reports, 13 percent of children had suffered from diarrhea in the two weeks preceding the survey. The prevalence of diarrhea is especially high among children age 12-23 months and 6-11 months (25 percent and 22 percent respectively). These high-prevalence ages are also the ages at which children begin to be weaned and consume foods other than breast milk. They also correspond to the ages at which children begin to explore their environment, resulting in greater exposure to pathogens. Diarrhea prevalence seems to bear little relation to a child’s sex or residence: 14 percent of male children suffered from diarrhea, compared with 12 percent of female children, and 14 percent of children in urban areas were affected by diarrhea, compared with 13 percent in rural areas. By province, the East and City of Kigali have the lowest prevalence of diarrhea (11 percent); variations are small among the other provinces, with the proportion of children with diarrhea ranging between 13 percent in the West province and 16 percent in the South province. However, mother’s level of education seems to play no great role, with prevalence being higher among children whose mothers have a primary education than among those whose mothers have no education (14 percent, compared with 11 percent). Moreover, children who drink from an improved water source have the lower prevalence of diarrhea (13 percent) compared with those who drink from a nonimproved water source (15 percent). There is an apparent strong link between diarrhea prevalence and household wealth. Prevalence varies from 16 percent of children in the poorest quintile to 11 percent of children in the richest quintile. Child Health • 133 Table 10.7 Prevalence of diarrhea Percentage of children under age 5 who had diarrhea in the two weeks preceding the survey, by background characteristics, Rwanda 2010 Background characteristic Diarrhea in the two weeks preceding the survey Number of children All diarrhea Diarrhea with blood Age in months <6 6.6 0.7 732 6-11 21.8 3.3 841 12-23 25.0 3.2 1,616 24-35 13.3 2.6 1,824 36-47 8.7 1.4 1,741 48-59 5.6 0.8 1,850 Sex Male 14.0 2.2 4,364 Female 12.3 1.8 4,241 Source of drinking water1 Improved 12.7 1.9 6,190 Not improved 14.5 2.3 2,408 Toilet facility2 Improved, not shared 11.7 2.0 5,000 Non-improved 15.1 2.1 3,597 Residence Urban 13.6 2.0 1,033 Rural 13.1 2.0 7,572 Province Kigali City 11.4 1.5 830 South 15.6 2.3 2,049 West 13.4 2.6 2,159 North 13.7 1.5 1,342 East 11.0 1.7 2,225 Education No education 11.2 2.0 1,629 Primary 13.9 2.1 6,214 Secondary and higher 11.6 1.5 762 Wealth quintile Lowest 16.1 2.4 1,992 Second 13.6 2.0 1,852 Middle 12.2 2.0 1,709 Fourth 11.8 1.5 1,598 Highest 11.3 2.0 1,454 Total 13.2 2.0 8,605 1 See Table 2.1 for definition of categories. 2 See Table 2.2 for definition of categories. 10.5.2 Treatment of Diarrhea Table 10.8 shows that advice or treatment was sought for 37 percent of children with diarrhea; including 13 percent who sought help from a community health worker. Treatment was most often sought for children age 12-23 months (47 percent). Forty-three percent of children age 6-11 months—who have one of the highest prevalence rates of diarrhea—received treatment. Boys (40 percent) were more likely to be taken to health facilities for treatment than girls (34 percent). There is little difference in treatment seeking for diarrhea between urban (33 percent) and rural (38 percent) areas. However, there are major differences with respect to provinces: the proportion of children taken to a health facility ranges from a high of 46 percent in the West province to a low of 32 percent in the North province. Children whose mothers have a secondary education or higher (47 percent, compared with 28 percent for those whose mothers have no education) and those living in the richest households (50 percent, compared with 27 percent in the poorest quintile) received treatment more frequently than other children. 13 4 • C hi ld H ea lth Ta bl e 10 .8 D ia rrh ea tr ea tm en t A m on g ch ild re n un de r ag e 5 w ho h ad d ia rrh ea in th e tw o w ee ks p re ce di ng th e su rv ey , t he p er ce nt ag e fo r w ho m a dv ic e or tr ea tm en t w as s ou gh t f ro m a h ea lth fa ci lit y or p ro vi de r, th e pe rc en ta ge g iv en o ra l r eh yd ra tio n th er ap y (O R T) , t he p er ce nt ag e gi ve n in cr ea se d flu id s, th e pe rc en ta ge g iv en O R T or in cr ea se d flu id s, a nd th e pe rc en ta ge w ho w er e gi ve n ot he r t re at m en ts o r n o tre at m en t, by b ac kg ro un d ch ar ac te ris tic s, R w an da 2 01 0 B ac kg ro un d ch ar ac te ris tic P er ce nt ag e of ch ild re n w ith di ar rh ea fo r w ho m ad vi ce o r t re at m en t w as s ou gh t f ro m a he al th fa ci lit y or pr ov id er 1 P er ce nt ag e fo r w ho m a dv ic e or tre at m en t w as so ug ht fr om a co m m un ity h ea lth w or ke r O ra l r eh yd ra tio n th er ap y (O R T) In cr ea se d flu id s O R T or in cr ea se d flu id s O th er tr ea tm en ts M is si ng N o tre at m en t N um be r o f ch ild re n w ith di ar rh ea Fl ui d fro m O R S p ac ke t o r pr e- pa ck ag ed O R S fl ui d R ec om m en de d ho m e flu id s (R H F) E ith er O R S o r R H F A nt ib io tic dr ug s A nt i- m ot ili ty dr ug s In tra ve no us so lu tio n H om e re m ed y/ ot he r A ge in m on th s <6 15 .8 4. 7 9. 0 2. 0 11 .0 10 .9 20 .0 6. 1 2. 4 0. 0 21 .8 0. 0 54 .0 48 6- 11 42 .9 15 .4 29 .4 6. 0 33 .8 18 .9 45 .2 12 .0 0. 6 0. 6 51 .0 0. 0 25 .9 18 4 12 -2 3 46 .5 16 .4 38 .4 9. 2 44 .4 20 .9 54 .3 10 .3 3. 0 0. 2 44 .6 1. 6 19 .9 40 4 24 -3 5 35 .5 13 .2 25 .1 7. 5 30 .9 25 .5 47 .3 8. 0 0. 6 0. 4 51 .2 0. 8 22 .4 24 2 36 -4 7 22 .3 10 .1 22 .3 4. 7 26 .3 28 .6 45 .7 7. 4 4. 4 0. 0 45 .4 1. 4 28 .2 15 2 48 -5 9 27 .0 2. 0 21 .1 8. 8 28 .9 34 .1 47 .7 6. 4 1. 1 0. 0 48 .2 0. 0 24 .0 10 3 Se x M al e 40 .0 14 .2 31 .3 7. 6 36 .5 23 .8 50 .2 10 .6 2. 6 0. 3 46 .4 0. 6 22 .6 61 0 Fe m al e 33 .9 11 .3 26 .6 7. 0 32 .2 22 .9 45 .7 7. 4 1. 5 0. 2 46 .7 1. 4 26 .4 52 2 Ty pe o f di ar rh ea N on -b lo od y 34 .9 12 .3 26 .9 6. 6 31 .9 22 .9 46 .0 8. 2 2. 3 0. 1 45 .2 1. 0 26 .3 92 1 B lo od y 52 .0 16 .2 41 .3 10 .2 48 .5 25 .2 59 .2 15 .4 1. 2 0. 7 54 .3 0. 0 13 .9 17 3 M is si n g (2 8. 1) (1 1. 8) (2 7. 9) (1 1. 8) (3 6. 4) (2 8. 5) (5 0. 7) (4 .5 ) (0 .0 ) (2 .5 ) (4 3. 4) (2 .8 ) (2 3. 2) 36 R es id en ce U rb an 33 .0 6. 1 26 .3 7. 7 32 .1 18 .5 46 .0 8. 8 2. 8 0. 0 46 .5 0. 0 30 .2 14 0 R ur al 37 .8 13 .9 29 .5 7. 3 34 .9 24 .1 48 .4 9. 2 2. 0 0. 3 46 .5 1. 1 23 .5 99 2 Pr ov in ce K i g al i C ity 33 .1 4. 6 32 .5 10 .0 40 .9 6. 3 47 .2 8. 0 2. 7 0. 0 56 .1 0. 0 28 .0 95 S ou th 33 .0 15 .9 27 .1 8. 7 34 .2 32 .4 51 .1 6. 5 0. 8 0. 3 47 .0 0. 7 23 .6 31 9 W es t 45 .5 16 .2 29 .4 8. 5 34 .8 24 .3 50 .9 10 .8 2. 3 0. 0 43 .9 0. 0 22 .7 29 0 N or th 31 .5 4. 4 25 .5 2. 9 27 .3 12 .5 34 .0 5. 2 2. 7 0. 0 42 .1 1. 9 36 .2 18 3 E as t 38 .9 14 .6 32 .8 6. 5 37 .5 25 .3 51 .9 14 .1 2. 8 0. 8 48 .6 2. 1 17 .0 24 5 Ed uc at io n N o ed uc at io n 28 .4 10 .7 21 .3 8. 6 28 .1 23 .6 41 .2 2. 9 1. 2 0. 0 46 .7 0. 5 26 .8 18 2 P rim ar y 38 .1 13 .6 30 .1 6. 8 35 .0 23 .2 49 .2 10 .0 2. 5 0. 4 46 .7 1. 1 24 .1 86 2 S ec on da ry an d hi gh er 47 .1 10 .4 35 .4 10 .0 43 .3 24 .9 52 .3 13 .8 0. 0 0. 0 44 .1 0. 0 21 .5 88 W ea lth q ui nt ile Lo w es t 26 .5 11 .4 21 .9 6. 0 26 .7 23 .8 42 .7 6. 1 2. 0 0. 0 42 .9 1. 0 29 .4 32 1 S ec on d 38 .2 15 .8 30 .4 6. 7 34 .5 24 .1 47 .1 8. 8 1. 5 0. 8 47 .3 0. 4 23 .7 25 1 M id dl e 40 .5 14 .1 32 .0 7. 9 36 .7 31 .0 56 .5 9. 4 1. 5 0. 0 50 .4 0. 5 18 .0 20 8 Fo ur th 39 .1 15 .4 29 .6 8. 5 37 .0 16 .3 45 .2 9. 5 3. 1 0. 0 46 .3 0. 6 27 .0 18 8 H i g he st 50 .4 7. 0 37 .0 8. 8 44 .2 19 .9 52 .9 14 .9 2. 8 0. 7 47 .7 2. 5 20 .5 16 5 To ta l 37 .2 12 .9 29 .1 7. 4 34 .5 23 .4 48 .1 9. 2 2. 1 0. 3 46 .5 0. 9 24 .3 1, 13 2 N ot e: F ig ur es in th e pa re nt he se s ar e ba se d on 2 5- 49 u nw ei gh te d ca se s. O R T in cl ud es fl ui d pr ep ar ed fr om o ra l r eh yd ra tio n sa lt (O R S ) p ac ke ts , p re -p ac ka ge d O R S fl ui d, a nd re co m m en de d ho m e flu id s (R H F) . 1 E xc lu de s ph ar m ac y, s ho p, a nd tr ad iti on al p ra ct iti on er 134 • Child Health Child Health • 135 During diarrheal episodes, only 29 percent of children received ORS, 7 percent received RHF, and 35 percent received either ORS or RHF. In addition, 23 percent of children received increased fluids. Almost half, 48 percent of children, were treated with some form of oral rehydration (ORT) or increased fluids. In addition, 9 percent of children received antibiotic drugs, and a very small proportion of children (2 percent) received anti- motility drugs. The proportion of children treated with a home remedy/other is high (47 percent), and nearly identical to that of children who received ORT or increased fluid (48 percent). Almost one quarter of the children (24 percent) received no treatment at all. This proportion is particularly high among children younger than 6 months (54 percent). 10.5.3 Feeding Practices during Diarrhea Mothers are encouraged to continue feeding children normally when they suffer from diarrheal illnesses and to increase the fluids that children receive. These practices help to reduce the likelihood that the child will become dehydrated. They also minimize the adverse consequences of diarrhea on the child’s nutritional status. Mothers were specifically asked whether they gave the child more or less fluid and food than usual when their child had diarrhea. Table 10.9 shows that 26 percent of children who had diarrhea were offered the same amount of liquid as usual while they were sick; 21 percent were offered somewhat less than usual, and 24 percent were offered much less than usual. Only 23 percent of children were offered more liquids than usual. Five percent of children were offered no liquid at all. Regarding food intake, 23 percent of children with diarrhea were offered the same amount of food as usual, 22 percent were offered somewhat less than usual, and 39 percent were offered much less than usual. Only 4 percent of children were offered more food than usual. Finally, 6 percent were never given any food. 13 6 • C hi ld H ea lth Ta bl e 10 .9 F ee di ng p ra ct ic es d ur in g di ar rh ea P er ce nt d is tri bu tio n of c hi ld re n un de r ag e 5 w ho h ad d ia rrh ea in th e tw o w ee ks p re ce di ng th e su rv ey b y am ou nt o f l iq ui ds a nd fo od o ffe re d co m pa re d w ith n or m al p ra ct ic e, th e pe rc en ta ge o f c hi ld re n gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g du rin g th e di ar rh ea e pi so de , a nd th e pe rc en ta ge o f c hi ld re n w ho c on tin ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s du rin g th e ep is od e of d ia rrh ea , b y ba ck gr ou nd c ha ra ct er is tic s, R w an da 2 01 0 B ac kg ro un d ch ar ac te ris tic A m ou nt o f l iq ui ds g iv en A m ou nt o f f oo d gi ve n P er ce nt ag e gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g1 P er ce nt ag e w ho co nt in ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s1 N um be r of ch ild re n w ith di ar rh ea M or e S am e as us ua l S om ew ha t le ss M uc h le ss N on e To ta l M or e S am e as us ua l S om ew ha t le ss M uc h le ss N on e N ev er ga ve fo od D on 't kn ow / m is si ng To ta l A ge in m on th s <6 10 .9 33 .1 10 .3 13 .3 32 .4 10 0. 0 0. 0 3. 6 0. 0 2. 4 1. 8 92 .1 0. 0 10 0. 0 0. 0 0. 0 48 6- 11 18 .9 24 .7 14 .9 35 .0 6. 5 10 0. 0 3. 2 17 .6 17 .1 41 .7 9. 5 10 .3 0. 5 10 0. 0 8. 3 16 .5 18 4 12 -2 3 20 .9 24 .1 24 .9 25 .7 4. 3 10 0. 0 3. 4 24 .8 20 .5 44 .4 6. 0 0. 8 0. 0 10 0. 0 6. 9 22 .1 40 4 24 -3 5 25 .5 26 .6 22 .1 23 .7 2. 0 10 0. 0 5. 5 24 .8 24 .6 40 .8 4. 3 0. 0 0. 0 10 0. 0 9. 8 22 .1 24 2 36 -4 7 28 .6 28 .8 19 .9 16 .0 6. 6 10 0. 0 4. 0 30 .2 29 .6 31 .7 4. 5 0. 0 0. 0 10 0. 0 15 .7 26 .6 15 2 48 -5 9 34 .1 26 .1 22 .3 16 .6 0. 9 10 0. 0 3. 9 22 .8 31 .7 38 .1 3. 5 0. 0 0. 0 10 0. 0 14 .3 21 .5 10 3 Se x M al e 23 .8 26 .5 19 .5 24 .8 5. 5 10 0. 0 3. 8 22 .6 20 .4 41 .5 5. 2 6. 6 0. 0 10 0. 0 10 .0 21 .1 61 0 Fe m al e 22 .9 25 .3 23 .2 23 .4 5. 2 10 0. 0 3. 8 24 .0 24 .4 36 .4 6. 1 5. 1 0. 2 10 0. 0 8. 5 20 .4 52 2 Ty pe o f d ia rr he a N on -b lo od y 22 .9 28 .7 21 .2 22 .4 4. 7 10 0. 0 4. 0 24 .7 23 .2 36 .4 5. 3 6. 3 0. 1 10 0. 0 9. 4 21 .0 92 1 B lo od y 25 .2 10 .4 21 .4 35 .4 7. 6 10 0. 0 2. 1 12 .6 18 .6 55 .8 7. 5 3. 5 0. 0 10 0. 0 7. 4 17 .6 17 3 M is si ng (2 8. 5) (3 0. 5) (1 5. 8) (1 4. 7) (1 0. 4) (1 00 .0 ) (7 .7 ) (3 8. 8) (1 2. 9) (3 0. 8) (3 .6 ) (6 .2 ) (0 .0 ) (1 00 .0 ) (1 7. 3) (3 1. 3) 36 R es id en ce U rb an 18 .5 34 .2 16 .0 27 .5 3. 7 10 0. 0 1. 6 30 .1 19 .1 36 .0 5. 8 7. 4 0. 0 10 0. 0 6. 0 20 .3 14 0 R ur al 24 .1 24 .8 21 .9 23 .7 5. 6 10 0. 0 4. 1 22 .3 22 .6 39 .6 5. 6 5. 7 0. 1 10 0. 0 9. 8 20 .9 99 2 Pr ov in ce K ig al i C ity 6. 3 43 .6 12 .6 29 .0 8. 4 10 0. 0 1. 0 33 .6 16 .3 28 .3 7. 4 13 .4 0. 0 10 0. 0 2. 3 23 .6 95 S ou th 32 .4 29 .7 18 .0 15 .7 4. 2 10 0. 0 4. 6 24 .0 20 .5 35 .1 10 .5 5. 2 0. 0 10 0. 0 12 .1 21 .9 31 9 W es t 24 .3 13 .7 18 .6 36 .3 7. 0 10 0. 0 1. 7 12 .4 20 .5 54 .9 4. 3 6. 1 0. 0 10 0. 0 7. 8 16 .0 29 0 N or th 12 .5 30 .3 32 .7 19 .7 4. 8 10 0. 0 3. 3 31 .7 30 .8 25 .6 2. 9 5. 7 0. 0 10 0. 0 7. 0 20 .6 18 3 E as t 25 .3 25 .3 23 .0 22 .1 4. 2 10 0. 0 6. 7 24 .8 22 .2 40 .2 2. 1 3. 7 0. 4 10 0. 0 12 .0 24 .1 24 5 Ed uc at io n N o ed uc at io n 23 .6 24 .1 22 .6 25 .5 4. 2 10 0. 0 6. 2 21 .0 23 .3 38 .0 4. 6 6. 8 0. 0 10 0. 0 9. 5 18 .1 18 2 P rim ar y 23 .2 26 .4 21 .0 23 .8 5. 7 10 0. 0 3. 6 23 .6 22 .4 38 .9 5. 8 5. 6 0. 1 10 0. 0 9. 5 21 .4 86 2 S ec on da ry a nd h ig he r 24 .9 25 .6 20 .3 24 .5 4. 7 10 0. 0 1. 2 25 .0 17 .7 43 .6 5. 9 6. 5 0. 0 10 0. 0 7. 3 20 .7 88 W ea lth q ui nt ile Lo w es t 23 .8 28 .7 22 .5 19 .0 6. 0 10 0. 0 3. 2 27 .0 22 .8 35 .3 6. 5 5. 1 0. 0 10 0. 0 9. 9 21 .8 32 1 S ec on d 24 .1 24 .6 21 .4 25 .0 4. 9 10 0. 0 5. 9 20 .5 24 .3 39 .5 4. 7 4. 8 0. 4 10 0. 0 10 .2 21 .0 25 1 M id dl e 31 .0 21 .7 21 .2 21 .8 4. 3 10 0. 0 3. 8 20 .0 23 .6 41 .0 4. 3 7. 3 0. 0 10 0. 0 11 .6 20 .4 20 8 Fo ur th 16 .3 28 .5 22 .9 26 .3 6. 1 10 0. 0 4. 2 24 .6 19 .8 39 .6 5. 3 6. 4 0. 0 10 0. 0 7. 4 18 .1 18 8 H ig he st 19 .9 25 .2 16 .2 33 .4 5. 3 10 0. 0 1. 4 22 .9 18 .7 43 .3 7. 1 6. 6 0. 0 10 0. 0 6. 3 22 .0 16 5 To ta l 23 .4 25 .9 21 .2 24 .1 5. 4 10 0. 0 3. 8 23 .3 22 .2 39 .2 5. 6 5. 9 0. 1 10 0. 0 9. 3 20 .8 1, 13 2 N ot e: It is re co m m en de d th at c hi ld re n sh ou ld b e gi ve n m or e liq ui ds to d rin k du rin g di ar rh ea a nd fo od s ho ul d no t b e re du ce d. Fi gu re s in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 1 C on tin ue d fe ed in g pr ac tic es in cl ud e ch ild re n w ho w er e gi ve n m or e, s am e as u su al , o r s om ew ha t l es s fo od d ur in g th e di ar rh ea e pi so de . 136 • Child Health Child Health • 137 10.6 KNOWLEDGE OF ORS PACKETS A simple and effective response to dehydration caused by diarrhea is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy (ORT). ORT may include the use of a solution prepared from commercially produced packets of oral rehydration salts (ORS), a homemade mixture usually prepared from sugar, salt, and water; any kind of thin, nutritious fluids such as rice water, coconut milk, or watery soup; or simply increased fluids. Table 10.10 shows that almost all women with children under age 5 know about ORS packets (92 percent). With respect to age, the data show that the proportion of women with children under 5 who know about ORS packets or ORS pre-packaged liquids varies from a high of 94 percent for those age 35-49 to a low of 85 percent for those age 15-19. In the City of Kigali 95 percent of women with children under age 5 know of ORS packets compared with 88 percent of those living in the West province. However, by educational level, the proportion of women with children under 5 who know of ORS varies from a low of 89 percent for those with no education to a high of 97 percent for those with secondary or higher education. There are only small variations by other background characteristics. Table 10.10 Knowledge of ORS packets or pre-packaged liquids Percentage of women age 15-49 with a live birth in the five years preceding the survey who know about ORS packets or ORS pre-packaged liquids for treatment of diarrhea by background characteristics, Rwanda 2010 Background characteristic Percentage of women who know about ORS packets or ORS pre- packaged liquids Number of women Age 15-19 84.8 139 20-24 86.1 1,133 25-34 93.0 3,293 35-49 93.9 1,839 Residence Urban 93.5 819 Rural 91.6 5,586 Province City of Kigali 94.9 635 South 94.2 1,532 West 87.9 1,545 North 90.9 1,035 East 92.9 1,658 Education No education 89.1 1,211 Primary 91.9 4,571 Secondary and higher 96.8 623 Wealth quintile Lowest 88.6 1,475 Second 90.8 1,369 Middle 90.8 1,250 Fourth 95.1 1,188 Highest 95.3 1,122 Total 91.9 6,405 ORS = Oral rehydration salts 10.7 STOOL DISPOSAL The proper disposal of children’s feces is extremely important in preventing the spread of disease. If feces are left uncontained, disease may spread by direct contact or through animal contact. Table 10.11 presents information on the disposal of fecal matter from children under age 5, by background characteristics. Almost nine of 138 • Child Health ten (87 percent) of children’s stools are usually contained. Children’s stools are more likely to be contained in urban than in rural areas (91 and 86 percent, respectively). Regional differentials are also observed. For example, in the City of Kigali, 94 percent of children’s stools were disposed of safely compared with only 83 percent in the North province. There is a positive relationship between containment of children’s stools and mother’s educational level and wealth quintile. Table 10.11 Disposal of children's stools Percent distribution of youngest children under age 5 living with the mother by the manner of disposal of the child's last fecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Rwanda 2010 Background characteristic Manner of disposal of children's stools Total Percentage of children whose stools are disposed of safely1 Number of children Child used toilet or latrine Put/ rinsed into toilet or latrine Buried Put/ rinsed into drain or ditch Thrown into garbage Left in the open Other Missing Age in months <6 0.7 42.3 0.5 16.7 9.7 5.3 24.7 0.2 100.0 43.5 718 6-11 0.9 71.5 3.0 6.6 4.1 2.5 11.1 0.3 100.0 75.5 833 12-23 2.1 89.3 1.6 1.7 1.0 1.9 2.2 0.1 100.0 93.0 1,539 24-35 14.4 79.9 1.2 0.9 0.8 1.3 1.3 0.2 100.0 95.5 1,404 36-47 51.2 46.0 0.6 0.1 0.2 0.6 1.0 0.4 100.0 97.8 968 48-59 74.5 22.4 0.1 0.3 0.1 1.4 0.7 0.5 100.0 97.0 725 Toilet facility Improved, not shared2 23.8 64.4 1.0 3.4 1.6 1.3 4.2 0.3 100.0 89.2 3,614 Non-improved or shared 16.5 65.1 1.6 3.6 3.0 2.9 7.2 0.2 100.0 83.2 2,569 Residence Urban 19.6 71.4 0.3 2.5 1.3 0.8 4.1 0.0 100.0 91.2 765 Rural 20.9 63.7 1.4 3.6 2.3 2.1 5.6 0.3 100.0 86.0 5,423 Province Kigali City 18.4 74.8 0.5 2.2 1.9 0.6 1.6 0.0 100.0 93.7 593 South 22.4 60.7 1.4 2.8 2.9 3.1 6.5 0.1 100.0 84.6 1,495 West 17.7 64.4 1.6 4.1 1.3 2.3 8.2 0.4 100.0 83.7 1,504 North 25.2 57.3 0.5 7.4 1.7 2.5 5.0 0.4 100.0 83.0 996 East 20.2 69.5 1.5 1.6 2.7 0.8 3.6 0.2 100.0 91.1 1,600 Education No education 22.8 61.3 1.2 3.3 2.2 2.5 6.5 0.2 100.0 85.3 1,165 Primary 19.8 65.4 1.3 3.7 2.3 2.0 5.2 0.3 100.0 86.5 4,426 Secondary and higher 24.1 66.3 0.5 2.3 0.8 0.5 5.3 0.2 100.0 90.9 596 Wealth quintile Lowest 16.8 63.5 2.1 3.5 2.8 3.4 7.5 0.4 100.0 82.4 1,422 Second 19.3 63.6 1.5 4.5 2.9 2.5 5.6 0.2 100.0 84.4 1,332 Middle 21.0 64.8 1.4 3.4 1.8 1.7 5.8 0.1 100.0 87.2 1,220 Fourth 24.4 64.5 0.5 3.9 1.7 0.9 3.8 0.3 100.0 89.4 1,151 Highest 23.5 67.8 0.4 2.0 1.2 1.0 3.9 0.2 100.0 91.6 1,064 Total 20.7 64.7 1.2 3.5 2.1 2.0 5.5 0.2 100.0 86.7 6,188 1 Children's stools are considered to be disposed of safely if the child used a toilet or latrine, if the fecal matter was put/rinsed into a toilet or latrine, or if it was buried. 2 Non-shared facilities that are of the types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; pit latrine with a slab; and a composting toilet. Nutrition of Children and Adults • 139 NUTRITION OF CHILDREN AND ADULTS 11 utritional status is the result of complex interactions between food consumption and the overall status of health and care practices. Numerous socioeconomic and cultural factors influence decisions on patterns of feeding and nutritional status. Adequate nutrition is critical to child growth, health, and development, especially during the period from conception to 2 years of age. During this period, children who do not receive adequate nutrition can be susceptible to growth faltering, micronutrient deficiencies, and common childhood illnesses such as diarrhea and acute respiratory infections. Among women, malnutrition can result in reduced productivity, an increased susceptibility to infections, slow recovery from illness, and a heightened risk of adverse pregnancy outcomes. A woman who has poor nutritional status, as indicated by a low body mass index (BMI), short stature, anemia, or other micronutrient deficiency, has a greater risk of obstructed labour, of having a baby with a low birth weight, of producing lower quality breast milk, of mortality due to postpartum haemorrhage, and of morbidity for both herself and her baby. Nutrition continues to be a public health concern in Rwanda. However, there is a strong commitment from the Government of Rwanda, together with its development partners and educational institutions, to find solutions. Under the leadership of the Ministry of Health, multisectoral initiatives and interventions have been put into place over the past decade aimed at accelerating improvement of the nation’s nutritional status. These efforts include the promulgation of the National Nutrition Policy in 2007, adoption of the National Protocol on Management of Malnutrition at the facility and community levels in 2009, and the 2010 National Multisectoral Strategy to Eliminate Malnutrition. The National Multisectoral Strategy for the Elimination of Malnutrition seeks to create a more coherent institutional approach to solving the problem of both acute and chronic childhood malnutrition by extending nutrition interventions throughout all communities. The 2010 Rwanda Demographic and Health Survey (RDHS) asked questions about early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding until at least age 2, time of introducing complementary foods (with increasing frequency of feeding solid and semisolid foods), and diet diversity. The height and weight of all children under age 5 and women age 15-49 were measured. This chapter presents findings on infant feeding practices, maternal eating patterns, household testing of salt for adequate levels of iodine, and the nutritional status of women and children. 11.1 NUTRITIONAL STATUS OF CHILDREN Nutritional status of children under age 5 is an important measure of children’s health. The anthropometric data on height and weight collected in the 2010 RDHS permit the measurement and evaluation of the nutritional status of young children in Rwanda. 11.1.1 Measurement of Nutritional Status among Young Children In addition to questions on feeding practices of infants and young children, the 2010 RDHS included an anthropometric component in which children under age 5 in a subsample of 50 percent of the households were measured for height and weight. Weight measurements were taken using a lightweight electronic SECA scale designed and manufactured under the guidance of the United Nations Children’s Fund (UNICEF). The scale allowed for the weighing of very young children through an automatic mother-child adjustment that eliminated the mother’s weight while she was standing on the scale with her baby. Height measurements were carried out using a Shorr measuring board also produced under the guidance of UNICEF. Children younger than 24 months were measured lying down (recumbent length) on the board, whereas standing height was measured for older children. Based on N 140 • Nutrition of Children and Adults these measurements, three internationally accepted indices were constructed and are used to reflect the nutritional status of children. These are: • Height-for-age (stunting) • Weight-for-height (wasting) • Weight-for-age (underweight) In the 2005 RDHS, children’s anthropometric measurements were compared with an international reference population defined by the U.S. National Center for Health Statistics (NCHS) and accepted by the U.S. Centers for Disease Control and Prevention (CDC). In the 2010 RDHS, as recommended by the World Health Organization (WHO), the nutritional status of children in the survey population was compared with the 2006 WHO Child Growth Standards (WHO, 2006), which are based on an international sample (from Brazil, Ghana, India, Norway, Oman, and the United States) of ethnically, culturally, and genetically diverse healthy children living under optimum conditions conducive to achieving a child’s full genetic growth potential. The 1977 NCHS/CDC/WHO reference was replaced with the 2006 WHO Child Growth Standards because of the prescriptive rather than descriptive nature of the WHO standards versus the NCHS reference. Also, the 2006 WHO Child Growth Standards identify the breastfed child as the normative model for growth and development and document how children should grow under optimum conditions and infant feeding and child health practices. The use of the 2006 WHO Child Growth Standards is based on the finding that well-nourished children in all population groups for which data exist follow very similar growth patterns before puberty. The internationally based standard population serves as a point of comparison, facilitating examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the mean of the reference population are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the mean of the reference population are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and does not vary according to recent dietary intake. The weight-for-height index measures body mass in relation to body height and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) from the mean of the reference population are considered thin (wasted) for their height and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) from the mean of the reference population are considered severely wasted. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the mean of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the mean of the reference population are considered severely underweight. A total of 4,356 children under age 5 were eligible to be measured for weight and height and had complete and valid anthropometric data collected. Nutrition of Children and Adults • 141 11.1.2 Measures of Child Nutritional Status Nationally, 44 percent of children under age 5 are stunted, and 17 percent are severely stunted (Table 11.1 and Figure 11.1). Analysis by age group indicates that stunting is apparent even among children less than 6 months of age (17 percent). Stunting increases with the age of the child, rising from 26 percent among children age 9-11 months to the highest level of 55 percent among children age 18-23 months, with little change from 24 months to 59 months. There is a difference in the level of stunting by gender (47 percent among boys and 41 percent among girls). Stunting is highest when the birth interval is less than 24 months (47 percent) or between 24 and 47 months (48 percent). The disparity in stunting prevalence between rural and urban children is substantial: 47 percent of rural children are stunted, as compared with 27 percent of urban children. Variation in nutritional status of children by province is quite evident, with stunting being highest in the North (51 percent) and West (50 percent) provinces and lowest in the City of Kigali (24 percent). Mother’s level of education and wealth quintile have a clear inverse relationship with prevalence of stunting. For example, the prevalence of stunting is higher among children living in the poorest households (54 percent) than among children in the richest households (26 percent) and higher among children whose mothers have no education (52 percent) than among those whose mother has a secondary education or higher (23 percent). Three percent of children under age 5 are wasted, and 1 percent are severely wasted. The wasting prevalence is highest among children age 9-11 months (8 percent) and begins to decline only after 11 months of age. The proportions of children less than 6 months and 6-8 months who are wasted are 5 percent and 6 percent, respectively. Wasting varies slightly by sex and by area of residence. Boys are more likely to be wasted than girls (3 percent and 2 percent, respectively), and urban children are slightly more likely to be wasted than rural children (4 percent and 3 percent). Wasting is more than twice as frequent among children born to malnourished mothers (BMI below 18.5 kg/m2) as among children whose mothers have a normal BMI (18.5-24.9 kg/m2). Wasting is highest in the City of Kigali and the South province (4 percent) and lowest in the North province (1 percent). Overweight and obesity are other forms of malnutrition that may be on the rise among children in Rwanda. Overall, 7 percent of children below age 5 are overweight or obese (weight-for-height more than +2 SD). There are no substantial differences by sex or area of residence, but overweight and obesity increase with increasing BMI of the mother. Variation by province is small. Eleven percent of children under 5 are underweight (low weight-for-age), and 2 percent are severely underweight. Figure 11.1 shows that the percentage of children underweight increases steadily from 6 percent among children under age 6 months to 10 percent among children age 6-8 months and 15 percent among children age 18-23 months, decreasing slightly to 14 percent among children age 48-59 months. This may be due to inappropriate and/or inadequate feeding practices because the percentage of underweight children begins to increase at the age when normal complementary feeding starts. Rural children are twice as likely to be underweight as urban children (12 percent versus 6 percent) (Table 11.1). Three of the five provinces in Rwanda (South, West, and East) have percentages of underweight children above the national average. The prevalence of underweight children is 7 percent in the City of Kigali and 10 percent in the North province. A mother’s wealth status and educational level are negatively associated with the likelihood that her child is underweight. Children born to mothers in the lowest wealth quintile are more than three times as likely to be underweight as children born to mothers in the highest wealth quintile (16 percent versus 5 percent). Also, children born to undernourished mothers (BMI <18.5 kg/m2) are twice as likely to be underweight as children whose mothers have a normal BMI (18.5-24.9 kg/m2) (24 percent versus 12 percent). 14 2 • N ut rit io n of C hi ld re n an d W om en Ta bl e 11 .1 N ut rit io na l s ta tu s of c hi ld re n P er ce nt ag e of c hi ld re n un de r 5 y ea rs c la ss ifi ed a s m al no ur is he d ac co rd in g to th re e an th ro po m et ric in di ce s of n ut rit io na l s ta tu s: h ei gh t-f or -a ge , w ei gh t-f or -h ei gh t, an d w ei gh t-f or -a ge , b y ba ck gr ou nd c ha ra ct er is tic s, R w an da 20 10 B ac kg ro un d ch ar ac te ris tic H ei gh t-f or -a ge 1 W ei gh t-f or -h ei gh t W ei gh t-f or -a ge N um be r o f ch ild re n P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 M ea n Z- sc or e (S D ) P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) A ge in m on th s <6 4. 4 16 .7 -0 .6 2. 8 5. 4 16 .2 0. 5 1. 9 6. 4 1. 4 -0 .2 35 4 6- 8 6. 2 18 .9 -0 .8 2. 9 6. 4 10 .3 0. 1 1. 9 9. 7 1. 8 -0 .5 20 1 9- 11 9. 9 25 .6 -1 .2 3. 4 8. 2 3. 8 -0 .1 4. 8 12 .2 1. 2 -0 .7 21 6 12 -1 7 15 .6 42 .5 -1 .7 0. 8 3. 8 5. 0 0. 1 3. 3 11 .2 0. 8 -0 .7 38 3 18 -2 3 24 .6 55 .1 -2 .1 0. 4 3. 3 6. 4 0. 3 2. 7 14 .7 1. 1 -0 .8 41 8 24 -3 5 22 .6 51 .8 -2 .0 0. 3 1. 6 6. 5 0. 5 1. 9 11 .9 0. 7 -0 .8 93 5 36 -4 7 17 .6 50 .9 -2 .0 0. 3 1. 0 6. 7 0. 5 1. 1 9. 4 0. 3 -0 .8 92 6 48 -5 9 16 .9 46 .1 -1 .9 0. 4 2. 2 4. 1 0. 3 3. 0 13 .8 0. 2 -1 .0 92 3 Se x M al e 19 .5 47 .4 -1 .9 1. 0 3. 3 6. 6 0. 3 2. 6 12 .7 0. 7 -0 .8 2, 18 7 Fe m al e 14 .5 41 .1 -1 .7 0. 6 2. 4 6. 8 0. 4 2. 0 10 .2 0. 7 -0 .7 2, 16 9 B irt h in te rv al in m on th s3 Fi rs t b irt h4 12 .3 36 .3 -1 .6 1. 1 2. 3 8. 0 0. 4 1. 0 7. 2 0. 7 -0 .6 1, 00 5 <2 4 16 .6 46 .8 -1 .9 0. 5 1. 7 8. 1 0. 5 1. 5 8. 5 0. 6 -0 .7 62 1 24 -4 7 19 .4 47 .9 -1 .9 0. 8 3. 1 6. 5 0. 3 2. 8 14 .3 0. 5 -0 .9 1, 86 4 48 + 17 .4 42 .5 -1 .7 1. 2 4. 5 5. 2 0. 2 3. 3 12 .8 1. 2 -0 .8 58 0 M ot he r's in te rv ie w s ta tu s In te rv ie w ed 16 .9 44 .1 -1 .8 0. 9 2. 9 6. 9 0. 3 2. 2 11 .4 0. 7 -0 .8 4, 07 0 N ot in te rv ie w ed b ut in h ou se ho ld (2 3. 7) (5 1. 0) (- 1. 9) (0 .0 ) (0 .0 ) (4 .0 ) (0 .2 ) (3 .2 ) (1 5. 3) (0 .0 ) (- 1. 0) 34 N ot in te rv ie w ed a nd n ot in ho us eh ol d5 18 .1 45 .8 -1 .8 0. 4 2. 1 4. 3 0. 5 3. 6 10 .8 1. 1 -0 .8 25 2 M ot he r's n ut rit io na l s ta tu s6 Th in (B M I < 18 .5 ) 14 .3 47 .9 -1 .9 2. 3 6. 5 2. 6 -0 .2 4. 4 24 .1 0. 0 -1 .2 18 6 N or m al (B M I 1 8. 5- 24 .9 ) 18 .1 45 .9 -1 .8 0. 8 2. 8 6. 3 0. 3 2. 3 11 .6 0. 5 -0 .8 3, 17 6 O ve rw ei gh t/ ob es e (B M I ≥ 25 ) 12 .5 35 .7 -1 .5 0. 6 2. 2 10 .2 0. 6 1. 3 7. 6 1. 7 -0 .4 72 5 M is si n g (2 7. 1) (2 7. 1) (- 1. 8) (0 .0 ) (0 .0 ) (9 .8 ) (0 .7 ) (1 0. 1) (1 9. 8) (0 .0 ) (- 0. 5) 11 R es id en ce U rb an 7. 7 27 .3 -1 .1 1. 7 3. 5 7. 0 0. 3 0. 8 6. 3 1. 1 -0 .4 51 7 R ur al 18 .3 46 .5 -1 .8 0. 7 2. 7 6. 7 0. 4 2. 5 12 .1 0. 6 -0 .8 3, 83 9 Pr ov in ce C it y o f K ig al i 7. 8 23 .5 -1 .1 1. 4 4. 4 7. 5 0. 3 1. 1 7. 4 1. 5 -0 .4 39 7 S ou th 14 .6 42 .3 -1 .7 1. 1 3. 8 5. 7 0. 2 2. 8 12 .4 0. 7 -0 .8 1, 05 0 W es t 20 .4 49 .9 -1 .9 0. 4 2. 0 6. 5 0. 4 2. 1 12 .6 0. 3 -0 .8 1, 08 6 N or th 19 .3 50 .7 -2 .0 0. 4 1. 2 6. 8 0. 6 1. 8 10 .4 0. 6 -0 .8 71 0 E as t 18 .0 43 .9 -1 .7 1. 1 3. 2 7. 6 0. 4 2. 7 11 .5 0. 8 -0 .8 1, 11 2 M ot he r’s e du ca tio n7 N o ed uc at io n 22 .2 52 .0 -2 .0 0. 5 2. 3 6. 3 0. 4 3. 0 14 .7 0. 4 -0 .9 80 6 P rim ar y 16 .7 44 .5 -1 .8 0. 9 2. 9 7. 0 0. 3 2. 1 11 .6 0. 6 -0 .8 2, 94 7 S ec on da r y a nd h ig he r 7. 3 22 .9 -0 .9 1. 7 3. 8 7. 5 0. 3 1. 4 2. 8 1. 8 -0 .3 35 1 W ea lth q ui nt ile Lo w es t 23 .5 54 .0 -2 .1 0. 9 3. 5 7. 3 0. 4 3. 2 15 .5 0. 4 -0 .9 96 0 S ec on d 20 .4 51 .1 -1 .9 1. 0 3. 2 6. 2 0. 3 2. 5 13 .8 0. 6 -0 .9 96 5 M id dl e 17 .9 45 .7 -1 .9 0. 3 2. 0 6. 9 0. 4 2. 6 11 .4 0. 5 -0 .8 87 8 Fo ur th 12 .8 39 .2 -1 .7 0. 9 2. 4 6. 0 0. 4 2. 0 9. 2 0. 9 -0 .7 84 5 H i g he st 7. 8 25 .8 -1 .1 1. 0 2. 8 7. 3 0. 4 0. 8 5. 2 1. 3 -0 .4 70 7 To ta l 17 .0 44 .2 -1 .8 0. 8 2. 8 6. 7 0. 4 2. 3 11 .4 0. 7 -0 .8 4, 35 6 N ot e: T ab le is b as ed o n ch ild re n w ho s ta ye d in th e ho us eh ol d on th e ni gh t b ef or e th e in te rv ie w . E ac h of th e in di ce s is e xp re ss ed in s ta nd ar d de vi at io n un its (S D ) f ro m th e m ed ia n of th e W H O C hi ld G ro w th S ta nd ar ds ad op te d in 2 00 6. T he in di ce s in th is ta bl e ar e N O T co m pa ra bl e to th os e ba se d on th e pr ev io us ly u se d N C H S /C D C /W H O re fe re nc e. F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. T ab le is b as ed o n ch ild re n w ith v al id d at es o f b irt h (m on th a nd y ea r) an d va lid m ea su re m en t o f b ot h he ig ht a nd w ei gh t. 1 R ec um be nt le ng th is m ea su re d fo r c hi ld re n un de r a ge 2 a nd le ss th an 8 5 cm ; s ta nd in g he ig ht is m ea su re d fo r a ll ot he r c hi ld re n. 2 In cl ud es c hi ld re n w ho a re b el ow -3 s ta nd ar d de vi at io ns (S D ) f ro m th e W H O C hi ld G ro w th S ta nd ar ds p op ul at io n m ed ia n 3 E xc lu de s ch ild re n w ho se m ot he rs w er e no t i nt er vi ew ed 4 Fi rs t-b or n tw in s (tr ip le ts , e tc .) ar e co un te d as fi rs t b irt hs b ec au se th ey d o no t h av e a pr ev io us b irt h in te rv al . 5 In cl ud es c hi ld re n w ho se m ot he rs a re d ec ea se d 6 E xc lu de s ch ild re n w ho se m ot he rs w er e no t w ei gh ed a nd m ea su re d. M ot he r's n ut rit io na l s ta tu s in te rm s of B M I ( bo dy m as s in de x) is p re se nt ed in T ab le 1 1. 10 . 7 F or w om en w ho w er e no t i nt er vi ew ed , i nf or m at io n is ta ke n fro m th e H ou se ho ld Q ue st io nn ai re . E xc lu de s ch ild re n w ho se m ot he rs a re n ot li st ed in th e H ou se ho ld Q ue st io nn ai re . 142 • Nutrition of Children and Adults Nutrition of Children and Adults • 143 Figure 11.1 Nutritional Status of Children by Age ) ) ))))))) ))))))))) )))))))))))))))))))))))))))) )))) )))))))))) ' ' ''''''' ''''''''''''''''''''''''''''''''''''''''''''''''''' & & &&&&&& && & && & & &&& &&& &&&&&&&&&&&& &&&&&&&&&&&& &&&&&&&&&&&& && & 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 Age in m onths 0 10 20 30 40 50 60 Percent Stunted Wasted Underw eight& ' ) RDHS 2010 11.1.3 Trends in Children’s Nutritional Status Trends in the nutritional status of children under age 5 for the period 2005 to 2010 are shown in Figure 11.2. To allow assessment of trends, the data for 2005 were recalculated using the 2006 WHO Child Growth Standards. Results indicate that there have been improvements in the nutritional status of children in the past five years. The percentage of stunted children fell from 51 percent in 2005 to 44 percent in 2010. The percentage of children wasted declined from 5 percent in 2005 to 3 percent in 2010. Underweight declined from 18 percent in 2005 to 11 percent in 2010. These improvements are attributed to the National Plan to Eliminate Malnutrition, which includes active nutrition screening of children by community health workers (since 2009). Children who are determined to be at risk of malnourishment are referred to a health facility for appropriate treatment using therapeutic milks (F100 and F75), ready-to-use therapeutic food for severe cases, and corn-soy blend for moderate cases. Other sustainable approaches have been initiated and include infant and young child feeding, community- based nutrition programs, behaviour change communication (mainly using media), and home food fortification (using micronutrient powders). Although there have been improvements in the nutritional status of Rwandan children in the past decade, there is still a need for more intensive interventions as the prevalence of malnutrition is still unacceptably high. 144 • Nutrition of Children and Adults Figure 11.2 Trends in Nutritional Status of Children Under 5 years RDHS 2010 51 5 18 44 3 11 Stunted Wasted Underweight 0 20 40 60 80 100 Percent RDHS 2005 RDHS 2010 11.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the uterus contract and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 11.2 shows the percentage of all children born in the two years preceding the survey by breastfeeding status and the timing of initial breastfeeding, according to background characteristics. In the 2005 RDHS initial breastfeeding data were collected for all children less than age 5, and thus caution should be exercised in comparing the results of the 2010 RDHS with previous survey results. Practically all of the children (99 percent) born in the two years preceding the survey were breastfed at some point of time. Because breastfeeding is nearly universal, variations according to background characteristics are minimal. However, young children living in rural areas at the time of the survey were slightly more likely to be breastfed than children living in urban areas. Seventy-one percent of children are breastfed within one hour of birth, and 94 percent are breastfed within one day of birth. Only 14 percent of children receive a prelacteal feed, that is, something other than breast milk during the first three days of life. Nutrition of Children and Adults • 145 Table 11.2 Initial breastfeeding Among last-born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth; and among last-born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, Rwanda 2010 Background characteristic Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 98.3 70.8 92.5 1,581 13.9 1,554 Female 99.1 71.8 94.4 1,628 14.3 1,613 Assistance at delivery Health professional3 98.7 73.3 94.3 2,582 11.6 2,547 Traditional birth attendant * * * * * 21 Other 98.2 58.8 88.1 397 25.0 390 No one 100.0 69.6 92.8 204 22.9 204 Place of delivery Health facility 98.7 73.4 94.3 2,576 11.6 2,543 At home 98.8 64.7 90.4 569 23.8 562 Other 98.4 44.5 86.0 60 29.7 60 Residence Urban 97.1 66.5 92.4 381 16.6 370 Rural 98.9 71.9 93.7 2,827 13.7 2,797 Province City of Kigali 97.4 64.1 89.1 297 17.2 289 South 98.5 69.1 93.1 759 16.5 747 West 98.9 73.9 94.1 874 12.2 864 North 99.3 67.7 92.2 478 12.6 475 East 98.8 75.4 95.7 800 13.6 791 Education No education 98.7 68.8 91.7 550 17.9 543 Primary 98.8 72.4 94.0 2,364 12.9 2,336 Secondary and higher 97.8 67.4 92.6 294 16.1 288 Wealth quintile Lowest 99.1 70.3 93.1 776 13.9 769 Second 98.3 68.4 91.9 736 16.1 724 Middle 99.1 72.2 96.7 595 12.7 589 Fourth 98.8 77.9 93.4 578 12.1 571 Highest 98.3 68.6 92.8 523 15.4 514 Total 98.7 71.3 93.5 3,208 14.1 3,167 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children were living or dead at the time of the interview. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse/midwife, or auxiliary midwife There is a small difference in the timing of initial breastfeeding by sex of the child; slightly more female than male children are breastfed within one hour and one day. Other background characteristics have important influences on early breastfeeding practices. Early initiation of breastfeeding is more common among children whose mothers were assisted at delivery by a health professional and at a health facility than among children delivered with the assistance of a nonprofessional and at home. In addition, children born in the City of Kigali are slightly less likely to be breastfed within one hour and one day of birth than children born in other provinces. Differences in early breastfeeding by mother’s education and wealth are small. The proportions of children who receive a prelacteal feed in the first three days of life are higher among those delivered by a nonprofessional (25 percent), those delivered without assistance (23 percent), and those delivered at home (24 percent) or other places (30 percent) than among those attended by a health professional (12 percent) and delivered in a health facility (12 percent). Children residing in urban areas are more likely than children residing in rural areas to receive a prelacteal feed (17 percent versus 14 percent). The proportions of children who 146 • Nutrition of Children and Adults receive a prelacteal feed are higher in the City of Kigali and the South province than in the other provinces. In addition, the percentage of children who receive a prelacteal feed is lower among those whose mothers have a primary education (13 percent) than among those whose mothers have no education (18 percent) or a secondary education or higher (16 percent). There is no clear association between prelacteal feeding and wealth quintile. 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first six months of life and that children be given solid or semisolid complementary food in addition to continued breastfeeding from six months to 24 months. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all of the nutrients necessary for children in the first six months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease. Early supplementation is discouraged for several reasons: First, it exposes infants to pathogens and increases their risk of infection, especially disease. Second, it decreases infants’ intake of breast milk and therefore suckling, which reduces breast milk production. Third, in a harsh socioeconomic environment, supplementary food is often nutritionally inferior. Information on complementary feeding was obtained by asking mothers about the current breastfeeding status of all children under age 2 and food (liquids or solids) given to the child the day and night before the survey. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under 2 years who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under 2 years using a bottle with a nipple, according to age in months, Rwanda 2010 Age in months Not breastfeeding Breastfeeding and consuming: Total Percentage currently breastfeeding Number of youngest child under 2 years Percentage using a bottle with a nipple Number of children Exclusively breastfed Breastfeeding and consuming plain water only Breastfeeding and consuming non-milk liquids1 Breastfeeding and consuming other milk Breastfeeding and consuming complementary foods 0-1 0.6 91.4 1.8 5.5 0.7 0.0 100.0 99.4 192 0.5 196 2-3 0.4 90.4 1.6 5.6 1.4 0.4 100.0 99.6 245 1.9 251 4-5 0.7 75.7 2.1 8.4 6.8 6.3 100.0 99.3 281 4.2 284 6-8 1.5 19.5 2.0 8.7 7.2 61.2 100.0 98.5 417 5.7 420 9-11 3.0 2.9 0.1 1.8 1.0 91.2 100.0 97.0 416 6.6 421 12-17 5.6 0.3 0.0 0.8 0.0 93.3 100.0 94.4 756 2.7 772 18-23 14.1 0.6 0.1 0.1 0.0 85.0 100.0 85.9 783 1.3 844 0-3 0.5 90.9 1.7 5.6 1.1 0.2 100.0 99.5 437 1.3 447 0-5 0.6 84.9 1.9 6.7 3.3 2.6 100.0 99.4 718 2.4 732 6-9 1.5 15.5 1.6 6.7 5.9 68.9 100.0 98.5 553 6.2 558 12-15 5.0 0.2 0.0 1.0 0.0 93.8 100.0 95.0 515 3.0 527 12-23 9.9 0.4 0.1 0.4 0.0 89.1 100.0 90.1 1,539 2.0 1,616 20-23 16.5 0.5 0.0 0.0 0.0 82.9 100.0 83.5 519 1.1 566 Note: Breastfeeding status refers to a ‘24-hour’ period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semisolids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus, children who receive breast milk and non-milk liquids and who do not receive other milk and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Non-milk liquids include juice, juice drinks, clear broth, or other liquids. Table 11.3 shows the percent distribution of youngest children under 2 years living with their mother by breastfeeding status and the percentage of all children under 2 years using a bottle with a nipple, according to age in months. The data presented in Table 11.3 and Figure 11.3 show that, contrary to WHO’s recommendations, not all children under 6 months are exclusively breastfed. Seventy-six percent of Rwandan children age 4-5 months are exclusively breastfed, which is slightly lower than the exclusive breastfeeding prevalence observed in the 2005 RDHS (80 percent). Eighty-five percent of children under age 6 months are exclusively breastfed, 2 percent consume breast milk and plain water, 7 percent consume breast milk and non-milk liquids, and 3 percent consume other milk in addition to breast milk. Although 61 percent of children begin eating complementary foods at 6-8 months, 20 percent of children continue to be exclusively breastfed and 2 percent receive just plain water in addition to breast milk. Eighty-six percent of Rwandan children continue to breastfeed until age 2 (Table 11.3), and thus one in seven Nutrition of Children and Adults • 147 children are deprived of valuable nutrients during this period. Exclusive breastfeeding quickly declines from birth to age 6-8 months. However, a few infants are still exclusively breastfed beyond this age, which is not recommended. Although other liquids are not needed before 6 months, 9 percent of infants under 6 months receive water or other non milk liquids. The prevalence of bottle feeding among Rwandan children age 0-5 months is about 2 percent, similar to that in 2005 (3 percent). Six percent of children 6-9 months of age were fed with a bottle in 2010, as compared with 8 percent in 2005. In Rwanda, the bottle is used for feeding breast milk substitutes (which are most often formula or sweetened condensed milk or other canned milk usually thinned out with water) or very watery gruel made from cereal flour, both of which are contraindicated. Figure 11.3 Infant Feeding Practices by Age <2 2- 3 4 - 5 6 - 7 8- 9 10 -1 1 1 2 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 Age group in months 0% 20% 40% 60% 80% 100% Percentage Exclusively Breastfed Breastfeeding and Consuming Plain Water Only Breastfeeding and Consuming Non-milk Liquids Breastfeeding and Consuming Other Milk Breastfeeding and Consuming Complementary Foods Not Breastfeeding RDHS 2010 11.4 DURATION OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding by selected background characteristics. The estimates of median and mean durations of breastfeeding are based on current status data, that is, the proportion of last-born children in the three years preceding the survey who were being breastfed at the time of the survey. 148 • Nutrition of Children and Adults Table 11.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, by background characteristics, Rwanda 2010 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 29.8 5.1 5.9 Female 29.1 5.4 6.1 Residence Urban 26.4 4.6 5.5 Rural 30.1 5.3 6.0 Province City of Kigali 25.0 4.9 5.4 South 32.5 4.8 5.4 West 27.9 4.8 6.1 North 31.5 6.2 6.6 East 28.1 5.5 6.2 Education No education 29.8 5.5 6.4 Primary 30.1 5.3 6.0 Secondary and higher 26.0 4.5 4.7 Wealth quintile Lowest 31.2 5.1 5.8 Second 31.0 5.3 6.0 Middle 29.9 5.9 6.7 Fourth 28.6 5.2 5.9 Highest 25.5 4.7 5.3 Total 29.4 5.3 6.0 Mean for all children 27.2 5.9 6.8 Note: Median and mean durations are based on the distribution at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water and/or non-milk liquids only The median duration of any breastfeeding is 29.4 months, and the mean duration is 27.2 months. There is little difference in duration of breastfeeding by sex of the child. Rural children are breastfed for a slightly longer duration than urban children (30.1 months versus 26.4 months). Highly educated mothers breastfeed their children for a duration of 4 months less than mothers with a primary or no education; mothers from the highest wealth quintile breastfeed their children for 25.5 months, as compared with 31.2 months among mothers in the lowest wealth quintile. Children in the South province are breastfed for 32.5 months, whereas children in the City of Kigali are breastfed for 25.0 months. The median duration of exclusive breastfeeding among Rwandan children is 5.3 months, and the mean duration is 5.9 months. In comparison with data from the 2005 RDHS, the median duration of any breastfeeding has increased by 4.2 months, whereas exclusive breastfeeding has decreased by 0.3 months. Breastfeeding status is part of the current set of infant and young child feeding (IYCF) indicators proposed by WHO. Figure 11.4 presents selected IYCF indicators on breastfeeding status in 2010. Nutrition of Children and Adults • 149 Figure 11.4 IYCF Indicators on Breastfeeding Status RDHS 2010 84.9 75.7 95 79.1 83.5 84.9 93.5 3.2 IYCF 2: Exclusive breastfeeding under 6 months Exclusive breastfeeding at 4-5 months IYCF 3: Continued breastfeeding at 1 year IYCF 4: Introduction of solid, semi-solid, or soft IYCF 10: Continued breastfeeding at 2 years IYCF 11: Age-appropriate breastfeeding IYCF 12: Predominant breastfeeding IYCF 14: Bottle feeding 0 20 40 60 80 100 95.0 11.5 TYPES OF COMPLEMENTARY FOODS UNICEF and WHO recommend the introduction of solid food to infants at approximately age 6 months because by that age breast milk alone is no longer sufficient to maintain a child’s optimal growth. In the transition to eating the family diet, children age 6 months and older should be fed small quantities of solid and semisolid foods throughout the day. During this transition period (age 6-23 months), the prevalence of malnutrition increases substantially in many countries because of increased infections and poor feeding practices. Table 11.5 provides information on the types of food given to the youngest child under age 2 living with the mother on the day and night preceding the survey, according to breastfeeding status. The data show that few breastfeeding infants receive infant formula or any other kinds of milk (1 percent and 14 percent, respectively). 150 • Nutrition of Children and Adults Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age 2 who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Rwanda 2010 Age in months Liquids Solid or semisolid foods Any solid or semi- solid food Number of children Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vegetables rich in vitamin A4 Other fruits and vegetables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry Eggs Cheese, yogurt, other milk product BREASTFEEDING CHILDREN 0-1 0.2 0.7 5.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 191 2-3 0.4 1.0 5.7 0.0 0.0 0.0 0.0 0.4 0.0 0.0 0.0 0.0 0.4 244 4-5 0.6 7.1 12.7 1.4 1.9 3.3 0.7 0.3 0.7 0.7 0.3 0.0 6.3 279 6-8 1.1 19.4 47.9 3.9 22.8 39.5 17.8 13.2 26.2 8.1 3.3 1.0 62.1 411 9-11 1.7 20.4 71.0 1.3 35.3 69.3 22.2 39.0 64.3 19.4 8.4 2.1 94.1 404 12-17 0.1 15.7 71.8 1.1 34.0 76.0 24.4 51.3 75.9 17.6 3.4 1.9 98.9 714 18-23 0.6 16.2 70.5 0.9 30.5 77.5 27.6 60.7 81.8 18.8 3.7 1.3 99.0 672 6-23 0.7 17.4 66.8 1.6 31.1 68.4 23.7 44.8 66.3 16.5 4.4 1.6 91.2 2,200 Total 0.7 14.0 52.5 1.3 23.6 52.0 18.0 33.9 50.1 12.6 3.4 1.2 69.5 2,914 NONBREASTFEEDING CHILDREN 0-1 * * * * * * * * * * * * * 1 2-3 * * * * * * * * * * * * * 1 4-5 * * * * * * * * * * * * * 2 6-8 * * * * * * * * * * * * * 6 9-11 * * * * * * * * * * * * * 12 12-17 (1.1) (36.1) (77.7) (1.1) (43.8) (74.9) (29.9) (56.5) (81.9) (30.2) (4.8) (4.6) (95.3) 42 18-23 1.6 24.6 71.5 1.3 35.4 82.6 24.3 51.5 80.1 18.2 7.3 1.8 99.3 111 6-23 2.6 31.1 73.7 2.5 37.1 79.2 26.8 51.2 77.4 20.1 6.4 2.3 97.7 172 Total 2.5 31.0 72.4 2.9 36.2 77.2 26.1 49.9 75.5 19.6 6.2 2.2 95.8 176 Note: Breastfeeding status and food consumed refer to a ‘24-hour’ period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Other milk includes fresh, tinned, and powdered cow or other animal milk. 2 Does not include plain water. 3 Includes fortified baby food. 4 Includes pumpkin, carrots, squash and sweet potatoes (that are yellow or orange inside), dark green leafy vegetables, mangoes, papayas, and other locally grown fruits and vegetables that are rich in vitamin A. Nutrition of Children and Adults • 151 Overall, 91 percent of breastfed children age 6-23 months receive solid or semisolid complementary foods in addition to breast milk. Consumption of foods made from legumes and nuts (66 percent), fruits and vegetables rich in vitamin A (68 percent), food made from roots and tubers (45 percent), and food made from grains (31 percent) is high. Consumption of food made from animal sources (meat, fish, and poultry) is low (17 percent). Comparing dietary intake of children by their breastfeeding status, a higher proportion of solid and semisolid foods are being consumed by nonbreastfed children. Approximately 3 percent of nonbreastfeeding children receive infant formula, and 31 percent receive other types of milk in addition to solid foods, both of which are essential because these children are not benefiting from breast milk. A larger percentage of nonbreastfed children age 6-23 months than breastfed children in the same age group are receiving grains, fruits and vegetables rich in vitamin A, and meat, fish, poultry, and eggs. 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Appropriate infant and young child feeding (IYCF) practices include timely initiation of feeding solid and semisolid foods at age 6 months and increasing the amount and variety of foods and frequency of feeding as the child gets older while maintaining frequent breastfeeding (WHO, 2008). The age ranges of various indicators of IYCF practices presented in this chapter have been updated based on the most recent definitions of breastfeeding and complementary feeding indicators (WHO, 2010). Therefore, to compare results with those of the 2005 RDHS, one needs to first check that indicator definitions and age ranges of sampled children are the same across surveys. Table 11.6 presents a summary indicator of IYCF practices. The indicator takes into account the percentages of children for whom feeding practices meet minimum standards with respect to food diversity (i.e., the number of food groups consumed), feeding frequency (i.e., the number of times the child is fed), and consumption of breast milk or other types of milk or milk products (accounting for number of milk feedings for nonbreastfed children). Breastfed children are considered to be fed within the minimum standards if they consume at least four food groups and receive food other than breast milk two to three times per day in the case of infants 6-8 months and three to four times per day in the case of children 9-23 months (Arimond and Ruel, 2003). Nonbreastfed children are considered to be fed in accordance with the minimum standards if they consume milk or milk products at least twice a day, are fed four food groups each day, and are fed at least four to five times per day (including milk feeds). Meal frequency is considered a proxy for energy intake from foods other than breast milk; therefore, the feeding frequency indicator for nonbreastfed children includes both milks and solid and semisolid foods (WHO, 2008). According to the results presented in Table 11.6, 25 percent of breastfed children age 6-23 months were given foods from four or more food groups in the 24 hours preceding the survey, and 51 percent were fed the minimum number of times in the preceding 24 hours. Almost one in five (17 percent) breastfed children fell into both categories; that is, their feeding practices met minimum standards with respect to food diversity as well as feeding frequency. The proportion of breastfed children receiving the recommended variety of food the minimum number of times a day increased with age, from 9 percent among children age 6-8 months to 24 percent among those age 18-23 months. The proportion of breastfed children who met both criteria was more than twice as high in urban areas as in rural areas. This proportion did not vary by sex of the child. There were large regional differences in feeding practices. Children residing in the West province were more than three times less likely than children in the City of Kigali to be fed from four or more food groups the minimum number of times a day. The proportions of breastfed children meeting the IYCF criteria were highest among children of mothers with a secondary education or higher (36 percent) and those in the highest wealth quintile (38 percent). Among nonbreastfed children age 6-23 months, 24 percent were given milk or milk products, 34 percent were given food from at least four food groups, and 45 percent were fed four or more times per day. However, only 152 • Nutrition of Children and Adults 10 percent were fed in accordance with all three IYCF practices. Appropriate feeding practices were more common among breastfed children than nonbreastfed children. Overall, 17 percent of Rwandan children age 6-23 months met the minimum standard with respect to all three IYCF feeding practices (Table 11.6). The most common problem with feeding practices was an inadequate number of food groups. Ninety-five percent of all children age 6-23 months received breast milk or other milk or milk products during the 24-hour period preceding the survey, and 51 percent were fed the minimum number of times in the preceding 24 hours. However, only 26 percent had been fed foods from the minimum number of food groups for their age. N ut rit io n of C hi ld re n an d W om en • 1 53 Ta bl e 11 .6 In fa nt a nd y ou ng c hi ld fe ed in g (IY C F) p ra ct ic es P er ce nt ag e of y ou ng es t c hi ld re n ag e 6- 23 m on th s liv in g w ith th ei r m ot he r w ho a re fe d ac co rd in g to th re e IY C F fe ed in g pr ac tic es b as ed o n br ea st fe ed in g st at us , n um be r o f f oo d gr ou ps , a nd ti m es th ey a re fe d du rin g th e da y or n ig ht p re ce di ng th e su rv ey , b y ba ck gr ou nd c ha ra ct er is tic s, R w an da 2 01 0 B ac kg ro un d ch ar ac te ris tic A m on g br ea st fe d ch ild re n 6- 23 m on th s, pe rc en ta ge fe d: A m on g no nb re as tfe d ch ild re n 6- 23 m on th s, p er ce nt ag e fe d: A m on g al l c hi ld re n 6- 23 m on th s, p er ce nt ag e fe d: 4+ fo od gr ou ps 1 M in im um m ea l fre qu en cy 2 B ot h 4+ fo od gr ou ps an d m in im um m ea l fre qu en cy N um be r o f br ea st fe d ch ild re n 6- 23 m on th s M ilk o r m ilk pr od uc ts 3 4+ fo od gr ou ps 1 M in im um m ea l fre qu en cy 4 W ith 3 IY C F pr ac tic es 5 N um be r o f no n- br ea st fe d ch ild re n 6- 23 m on th s B re as t m ilk o r m ilk pr od uc ts 6 4+ fo od gr ou ps M in im um m ea l fre qu en cy 7 W ith a ll 3 IY C F pr ac tic es N um be r o f al l c hi ld re n 6- 23 m on th s A ge in m on th 6- 8 9. 5 45 .7 9. 3 41 1 * * * * 6 99 .2 9. 4 45 .7 9. 2 41 7 9- 11 25 .3 38 .0 12 .8 40 4 * * * * 12 98 .4 25 .9 38 .6 13 .1 41 6 12 -1 7 27 .2 51 .4 18 .2 71 4 (3 3. 8) (4 7. 9) (5 2. 0) (1 5. 2) 42 96 .3 28 .4 51 .5 18 .0 75 6 18 -2 3 32 .4 62 .4 24 .0 67 2 17 .1 28 .4 40 .5 7. 8 11 1 88 .3 31 .9 59 .3 21 .7 78 3 Se x M al e 24 .4 50 .2 17 .5 1, 08 8 17 .8 29 .1 44 .9 10 .9 81 94 .3 24 .7 49 .9 17 .1 1, 16 8 Fe m al e 25 .9 52 .2 17 .1 1, 11 2 30 .1 37 .5 44 .7 9. 9 91 94 .7 26 .8 51 .7 16 .6 1, 20 4 R es id en ce U rb an 46 .5 57 .3 34 .0 23 1 (3 6. 2) (5 3. 7) (5 8. 5) (1 7. 3) 30 92 .7 47 .4 57 .4 32 .1 26 0 R ur al 22 .6 50 .5 15 .4 1, 97 0 21 .9 29 .3 41 .9 8. 9 14 2 94 .7 23 .1 50 .0 15 .0 2, 11 2 Pr ov in ce C ity o f K ig al i 45 .8 56 .6 33 .5 18 2 (3 7. 8) (6 6. 1) (6 5. 7) (2 3. 9) 32 90 .7 48 .8 58 .0 32 .1 21 3 S ou th 32 .0 55 .7 22 .2 54 5 (2 8. 6) (3 9. 3) (3 9. 9) (1 2. 0) 25 96 .9 32 .3 55 .0 21 .8 57 0 W es t 14 .6 41 .9 9. 5 60 5 (1 5. 4) (1 5. 5) (2 9. 5) (2 .9 ) 40 94 .8 14 .6 41 .1 9. 1 64 5 N or th 26 .8 55 .4 18 .1 32 2 * * * * 26 94 .0 26 .8 54 .7 17 .4 34 8 E as t 22 .1 52 .9 15 .3 54 6 (2 2. 6) (2 7. 9) (4 5. 1) (7 .8 ) 49 93 .6 22 .6 52 .3 14 .7 59 5 Ed uc at io n N o ed uc at io n 15 .0 42 .4 10 .4 38 3 (2 8. 1) (2 7. 9) (4 6. 2) (2 .8 ) 29 95 .0 15 .9 42 .7 9. 9 41 2 P rim ar y 24 .8 51 .6 16 .9 1, 63 5 17 .1 25 .8 37 .7 8. 3 11 8 94 .4 24 .9 50 .7 16 .3 1, 75 3 S ec on da ry a nd h ig he r 49 .5 66 .4 36 .2 18 2 (5 3. 9) (7 6. 0) (7 6. 0) (2 8. 7) 25 94 .4 52 .7 67 .6 35 .3 20 7 W ea lth q ui nt ile Lo w es t 17 .1 46 .8 11 .5 57 2 * * * * 22 96 .5 17 .1 45 .7 11 .3 59 4 S ec on d 20 .6 47 .9 12 .4 51 1 (1 7. 0) (2 0. 7) (3 5. 2) (8 .2 ) 27 95 .9 20 .6 47 .3 12 .2 53 7 M id dl e 23 .3 48 .1 14 .2 39 3 (1 4. 6) (2 7. 0) (2 9. 6) (1 1. 7) 37 92 .6 23 .6 46 .5 14 .0 43 0 Fo ur th 24 .9 57 .4 18 .7 40 3 (1 9. 6) (2 5. 1) (4 5. 8) (3 .8 ) 35 93 .6 24 .9 56 .5 17 .5 43 7 H ig he st 49 .1 60 .6 37 .6 32 2 46 .5 58 .6 71 .5 17 .0 51 92 .6 50 .5 62 .1 34 .8 37 4 To ta l 25 .1 51 .2 17 .3 2, 20 0 24 .4 33 .6 44 .8 10 .4 17 2 94 .5 25 .8 50 .8 16 .8 2, 37 2 N ot e: F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. A n as te ris k in di ca te s th at a fi gu re is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. 1 F oo d gr ou ps : a . i nf an t f or m ul a, m ilk o th er th an b re as t m ilk , c he es e or y og ur t o r o th er m ilk p ro du ct s; b . f oo ds m ad e fro m g ra in s, ro ot s, a nd tu be rs , i nc lu di ng p or rid ge a nd fo rti fie d ba by fo od fr om g ra in s; c . v ita m in A -ri ch fru its a nd v eg et ab le s (a nd re d pa lm o il) ; d . o th er fr ui ts a nd v eg et ab le s; e . e gg s; f. m ea t, po ul try , f is h, a nd s he llf is h (a nd o rg an m ea ts ); g. le gu m es a nd n ut s. 2 F or b re as tfe d ch ild re n, m in im um m ea l f re qu en cy is re ce iv in g so lid o r s em is ol id fo od a t l ea st tw ic e a da y fo r i nf an ts 6 -8 m on th s an d at le as t t hr ee ti m es a d ay fo r c hi ld re n 9- 23 m on th s. 3 I nc lu de s tw o or m or e fe ed in gs o f c om m er ci al in fa nt fo rm ul a; fr es h, ti nn ed , a nd p ow de re d an im al m ilk ; a nd y og ur t 4 F or n on br ea st fe d ch ild re n ag e 6- 23 m on th s, m in im um m ea l f re qu en cy is re ce iv in g so lid o r s em is ol id fo od o r m ilk fe ed s at le as t f ou r t im es a d ay . 5 N on br ea st fe d ch ild re n ag e 6- 23 m on th s ar e co ns id er ed to b e fe d w ith a m in im um s ta nd ar d of th re e in fa nt a nd y ou ng c hi ld fe ed in g pr ac tic es if th ey re ce iv e ot he r m ilk o r m ilk p ro du ct s at le as t t w ic e a da y, re ce iv e th e m in im um m ea l f re qu en cy , a nd re ce iv e so lid o r s em is ol id fo od s fro m a t l ea st fo ur fo od g ro up s no t i nc lu di ng th e m ilk /m ilk p ro du ct g ro up . 6 B re as tfe ed in g, o r n ot b re as tfe ed in g an d re ce iv in g tw o or m or e fe ed in gs o f c om m er ci al in fa nt fo rm ul a; fr es h, ti nn ed , a nd p ow de re d an im al m ilk ; a nd y og ur t 7 C hi ld re n ar e fe d th e m in im um re co m m en de d nu m be r o f t im es p er d ay a cc or di ng to th ei r a ge a nd b re as tfe ed in g st at us a s de sc rib ed in n ot es 2 a nd 4 . • 153Nutrition of Children and Adults 154 • Nutrition of Children and Adults 11.7 PREVALENCE OF ANEMIA IN CHILDREN Common causes of anemia, characterized by a low level of hemoglobin in the blood, include inadequate intake of iron, folate, vitamin B12, and other nutrients. Anemia can also result from thalassemia, sickle cell disease, malaria, and intestinal worm infestation. Anemia may be an underlying cause of maternal mortality, spontaneous abortion, premature birth, and low birth weight. Iron and folic acid supplementation and antimalarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bednets by pregnant women and children under 5, and six-month deworming for children are some of common measures used to reduce anemia prevalence among vulnerable groups. Home (point-of-use) fortification using micronutrient powders is another measure for combating anemia, especially among children age 6 to 23 months. Table 11.7 shows the prevalence of anemia among children age 6 to 59 months, according to selected background characteristics. Unadjusted (i.e., measured) values of hemoglobin were obtained using the HemoCue instrument. Given that hemoglobin requirements differ substantially depending on altitude, an adjustment to sea- level equivalents is typically made before classifying children by level of anemia. Based on the altitude information derived from the clusters surveyed for the 2010 RDHS, adjustment was required in the measured hemoglobin values. Anemia is a critical public health problem in Rwanda, where more than one third (38 percent) of children age 6-59 months are anaemic, with 24 percent mildly anaemic, 14 percent moderately anaemic, and less than 1 percent severely anaemic. Anemia is highest among children less than 12 months of age (69-70 percent) and declines with increasing age (the prevalence is 25 percent among children age 48-59 months). The prevalence of anemia is higher among boys (41 percent) than girls (35 percent) but does not vary substantially between urban and rural areas. Children residing in the East province are more likely (43 percent) to be anaemic than children residing in the other provinces (31 to 38 percent). Children of uneducated mothers and those residing in the poorest households are more likely than other children to be anaemic. For example, 43 percent of children in the lowest wealth quintile are anaemic, as compared with 36 percent in each of the three highest wealth quintiles. Table 11.7 Prevalence of anemia in children Percentage of children age 6-59 months classified as having anemia, by background characteristics, Rwanda 2010 Background characteristic Anemia status by hemoglobin level Any anemia (<11.0 g/dl) Mild anemia (10.0-10.9 g/dl) Moderate anemia (7.0-9.9 g/dl) Severe anemia (<7.0 g/dl) Number of children1 Age in months 6-8 70.2 26.2 41.4 2.6 188 9-11 69.2 36.7 30.8 1.7 219 12-17 56.7 32.3 23.9 0.5 391 18-23 44.6 29.1 15.3 0.2 423 24-35 36.1 24.0 11.7 0.4 944 36-47 29.0 21.0 7.8 0.2 943 48-59 24.8 18.8 5.9 0.1 929 Sex Male 41.2 25.3 15.3 0.6 2,037 Female 35.0 23.1 11.6 0.3 1,999 Mother's interview status Interviewed 38.7 24.5 13.7 0.4 3,731 Not interviewed but in household (25.9) (20.0) (3.4) (2.5) 31 Not interviewed and not in household2 32.3 20.5 11.4 0.4 275 Residence Urban 35.7 22.3 12.3 1.2 475 Rural 38.4 24.5 13.6 0.4 3,562 Continued… Nutrition of Children and Adults • 155 Table 11.7─Continued Background characteristic Anemia status by hemoglobin level Any anemia (<11.0 g/dl) Mild anemia (10.0-10.9 g/dl) Moderate anemia (7.0-9.9 g/dl) Severe anemia (<7.0 g/dl) Number of children1 Province City of Kigali 38.1 23.2 13.3 1.6 365 South 37.5 24.1 13.0 0.4 986 West 38.4 24.5 13.9 0.1 1,003 North 30.6 21.6 8.7 0.3 656 East 43.2 26.1 16.6 0.6 1,027 Education No education 41.7 26.7 14.7 0.4 740 Primary 38.1 24.0 13.7 0.4 2,707 Secondary and higher 35.2 23.7 10.2 1.3 316 Wealth quintile Lowest 43.2 28.1 14.7 0.4 901 Second 38.3 24.7 13.3 0.2 881 Middle 36.2 23.5 12.6 0.1 812 Fourth 35.8 22.3 12.9 0.7 788 Highest 36.0 21.3 13.7 1.0 655 Total 38.1 24.2 13.5 0.5 4,037 Note: Table is based on children who stayed in the household on the night before the interview. Prevalence of anemia, based on hemoglobin levels, is adjusted for altitude using formulas in CDC (1998). Hemoglobin in grams per decilitre (g/dl). Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children whose mothers are deceased 2 For women who were not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. A comparison with the 2005 RDHS shows that the prevalence of anemia has dropped by 14 percentage points in the past five years, from 52 percent to 38 percent (Figure 11.5 and Appendix C, Table C.8). The most noticeable drop has been in the prevalence of moderate anemia, by 13 percentage points (27 percent in 2005 versus 14 percent in 2010). Severe anemia has also declined in the past five years, but mild anemia has increased slightly. 156 • Nutrition of Children and Adults Figure 11.5 Trend in Anemia Status Among Children Under 5 Years 51.5 21.9 27.4 2.2 39.7 23.1 16.3 0.4 38.1 24.2 13.5 0.5 Total Mild Moderate Severe 0 10 20 30 40 50 60 2005 RDHS 2007-08 RIDH 2010 RDHS RDHS 2010 11.8 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is an important contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, food fortification, and direct supplementation. Table 11.8 looks at measures relating to intake of several key micronutrients among children. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency (VAD) can cause blindness. VAD can also increase the severity of infections such as measles and diarrheal diseases in children and slows recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of vitamin A for four to six months. Periodic dosing (usually every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD. Rwanda, through campaigns and twice-yearly Mother and Child Health Week events, has been providing Vitamin A supplementation and deworming tablets to children age 6-59 months and iron/acid folic tablets to mothers. There is not yet an iron supplementation program targeting children. The RDHS collected information on the consumption of foods rich in vitamin A and on the coverage of supplements. Table 11.8 shows that 73 percent of last-born children age 6-23 months living with their mother consumed foods rich in vitamin A in the 24-hour period preceding the survey. Consumption of foods rich in vitamin A increases from 42 percent among children age 6-8 months to 82 percent among children age 18-23 months. There is no significant difference between boys and girls in the consumption of foods rich in vitamin A. Breastfeeding children are slightly less likely to consume foods rich in vitamin A than nonbreastfeeding children (72 percent versus 82 percent). Children in urban areas and in the City of Kigali were more likely to consume foods rich in vitamin A the day and night preceding the survey than were children in rural areas and in the other provinces. Nutrition of Children and Adults • 157 Vitamin A consumption was lowest among children of uneducated mothers and those residing in the poorest households. Twenty percent of children consume foods rich in iron. The differences in consumption of iron-rich foods by background characteristics are similar to those seen for consumption of foods rich in vitamin A. Table 11.8 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey; among all children 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey and who were given deworming medication in the six months preceding the survey; and among all children age 6- 59 months who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Rwanda 2010 Background characteristic Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Among children age 6-59 months living in households tested for iodized salt Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supplements in last 6 months Percentage given deworming medication in last 6 months3 Number of children Percentage living in households with iodized salt4 Number of children Age in months 6-8 42.2 10.7 417 67.2 27.3 420 98.0 392 9-11 74.0 25.5 416 85.3 42.4 421 99.7 390 12-17 79.2 21.0 756 93.2 77.2 772 99.2 714 18-23 81.7 21.3 783 95.1 92.0 844 99.1 787 24-35 na na na 95.5 95.0 1,824 99.6 1,689 36-47 na na na 95.4 94.6 1,741 99.4 1,639 48-59 na na na 94.6 93.8 1,850 99.3 1,708 Sex Male 71.1 19.1 1,168 93.4 86.9 4,009 99.2 3,704 Female 74.2 21.0 1,204 92.4 85.2 3,864 99.4 3,614 Breastfeeding status5 Breastfeeding 71.9 19.8 2,200 90.4 76.6 3,529 99.3 3,268 Not breastfeeding 81.5 24.4 172 95.1 93.9 4,319 99.3 4,028 Mother's age at birth 15-19 73.3 19.9 65 91.4 63.6 97 100.0 92 20-29 70.0 20.6 1,311 91.7 84.0 3,697 99.5 3,451 30-39 75.3 19.9 809 93.8 88.0 3,113 99.1 2,896 40-49 79.3 18.0 187 95.0 90.6 966 99.4 880 Residence Urban 81.6 39.4 260 95.4 89.2 936 99.3 894 Rural 71.5 17.7 2,112 92.6 85.7 6,937 99.3 6,425 Province City of Kigali 79.3 38.4 213 96.9 89.6 759 99.3 731 South 71.2 21.1 570 91.0 84.0 1,884 99.2 1,730 West 72.3 17.2 645 93.6 86.2 1,959 99.4 1,778 North 74.8 13.1 348 94.9 88.7 1,225 99.6 1,138 East 70.7 19.8 595 91.4 85.2 2,045 99.1 1,941 Education No education 65.2 13.3 412 92.8 86.0 1,507 99.6 1,343 Primary 73.3 19.8 1,753 92.8 85.7 5,681 99.2 5,310 Secondary and higher 82.0 36.0 207 93.9 89.5 685 99.4 666 Wealth quintile Lowest 66.9 15.1 594 91.5 83.7 1,838 98.4 1,606 Second 70.8 13.8 537 91.7 84.2 1,677 99.3 1,554 Middle 72.5 18.3 430 92.3 86.6 1,557 99.6 1,463 Fourth 74.0 19.6 437 95.2 87.8 1,480 99.7 1,417 Highest 83.0 39.8 374 94.6 89.3 1,321 99.6 1,279 Total 72.6 20.1 2,372 92.9 86.1 7,873 99.3 7,319 Note: Information on vitamin A is based on both mother's recall and the immunization card (where available). Information on iron supplements and deworming medication is based on the mother's recall. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mangos, papayas, and other locally grown fruits and vegetables that are rich in vitamin A, 2 Includes meat (including organ meat) 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 4 Salt containing 15 parts per million of iodine or more. Excludes children in households in which salt was not tested. 5 Does not include missing data Ninety-three percent of children age 6-59 months received a vitamin A supplement in the six months before the survey, 9 percent higher than the figure observed in the 2005 RDHS (84 percent). Differences in the 158 • Nutrition of Children and Adults consumption of vitamin A supplements by sex, area of residence, and wealth quintile were small. Children who were not breastfed were more likely to receive vitamin A supplements (95 percent) than children who were breastfed (90 percent). Ninety-one percent of children residing in the South and East provinces received vitamin A supplements, as compared with 97 percent of children in the City of Kigali. Nearly 9 in 10 children (86 percent) children received deworming medication in the six months preceding the survey. 11.9 USE OF IODIZED SALT Iodine is an important micronutrient for mental development. Dietary iodine deficiencies are a major public health concern worldwide. A lack of sufficient iodine is known to cause goitre, cretinism (a severe form of neurological defect), spontaneous abortion, premature birth, infertility, stillbirth, and increased child mortality. Iodine deficiency disorder is the most common cause of preventable mental retardation and brain damage in the world. Inadequate amounts of iodine in the diet are related to serious health risks for young children. In the 2010 RDHS, a rapid test was used to determine the presence or absence of iodine in the salt used for cooking in the household. Table 11.9 shows the percentage of households using iodized salt. Practically all (99 percent) households used salt with iodine. Table 11.9 Presence of iodized salt in household Among all households, percentage of households tested for iodine content and percentage of households without salt; and among households with salt tested, the percentage with iodine present in salt, according to background characteristics, Rwanda 2010 Background characteristic Among all households, percentage: Among households with tested salt: With salt tested Without salt Number of households Percentage iodized salt Number of households Residence Urban 90.6 9.4 1,759 99.1 1,595 Rural 90.9 9.1 10,781 99.3 9,797 Province City of Kigali 91.2 8.8 1,284 99.3 1,171 South 88.8 11.2 3,136 99.3 2,786 West 90.7 9.3 2,967 99.3 2,691 North 91.9 8.1 2,120 99.5 1,947 East 92.2 7.8 3,033 99.2 2,797 Wealth quintile Lowest 85.3 14.7 2,838 98.6 2,420 Second 91.1 8.9 2,600 99.4 2,369 Middle 92.0 8.0 2,448 99.6 2,251 Fourth 94.3 5.7 2,287 99.5 2,156 Highest 92.8 7.2 2,367 99.4 2,196 Total 90.8 9.2 12,540 99.3 11,392 11.10 NUTRITIONAL STATUS OF WOMEN The height and weight of women age 15-49 were measured among a 50 percent subsample of households selected in the 2010 RDHS. In this report, two indicators of nutritional status are presented: height and body mass index (BMI). The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. A woman’s height is used to predict the risk of difficulty in delivery because small stature is often associated with small pelvis size and the potential for obstructed labor. The risk of giving birth to a low birth weight baby is influenced by the mother’s nutritional status. The cutoff point for the height at which mothers can be Nutrition of Children and Adults • 159 considered at risk varies between populations but normally falls between 140 and 150 centimeters. As in other DHS surveys, a cutoff point of 145 cm was used for the 2010 RDHS. The index used to measure thinness or obesity is known as the body mass index or the Quetelet index. BMI is defined as weight in kilograms divided by height in meters squared (kg/m2). A BMI lower than 18.5 kg/m2 indicates thinness or acute undernutrition, a BMI of 18.5-24.9 kg/m2 is indicative of normal nutritional status, a BMI of 25.0-29.9 kg/m2 indicates overweight, and a BMI of 30.0 kg/m2 or higher indicates obesity. Table 11.10 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Rwanda 2010 Background characteristic Height Body mass index1 Percentage below 145 cm Number of women Mean BMI 18.5- 24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moderately and severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Number of women Age 15-19 7.2 1,538 21.5 76.3 12.6 9.0 3.6 11.1 10.8 0.3 1,511 20-29 2.9 2,653 22.6 78.0 4.7 3.9 0.8 17.3 15.8 1.5 2,293 30-39 2.0 1,603 22.7 76.1 5.0 3.9 1.0 19.0 15.2 3.8 1,440 40-49 1.4 1,150 22.4 73.6 8.4 6.6 1.8 18.0 13.9 4.1 1,122 Residence Urban 2.8 1,052 23.2 67.9 6.9 5.4 1.5 25.2 19.1 6.1 973 Rural 3.5 5,892 22.2 77.9 7.4 5.6 1.8 14.7 13.2 1.5 5,393 Province City of Kigali 3.6 808 23.7 63.9 6.4 5.0 1.4 29.7 22.0 7.7 743 South 4.0 1,597 21.6 78.4 10.6 8.3 2.3 11.0 10.0 1.0 1,490 West 3.8 1,696 22.3 78.6 6.1 4.8 1.2 15.3 13.8 1.5 1,556 North 2.2 1,174 22.5 80.5 4.8 3.4 1.3 14.7 13.5 1.3 1,082 East 3.1 1,669 22.3 75.2 7.7 5.5 2.1 17.1 15.1 2.0 1,495 Education No education 3.9 1,059 22.3 77.9 7.5 5.8 1.7 14.6 13.0 1.6 958 Primary 3.6 4,761 22.2 77.3 7.7 5.8 1.8 15.0 13.3 1.7 4,338 Secondary and higher 2.0 1,124 23.0 71.4 5.7 4.3 1.4 22.9 18.4 4.5 1,071 Wealth quintile Lowest 4.4 1,255 21.8 79.0 10.0 8.1 1.9 10.9 10.4 0.6 1,148 Second 3.6 1,398 21.7 81.7 8.6 6.0 2.5 9.7 9.4 0.4 1,274 Middle 3.9 1,382 22.1 79.9 6.6 4.6 2.0 13.5 12.5 1.1 1,267 Fourth 2.8 1,389 22.4 75.3 7.0 5.8 1.3 17.7 15.4 2.3 1,259 Highest 2.5 1,520 23.5 67.4 4.9 3.9 1.0 27.8 21.8 6.0 1,418 Total 3.4 6,944 22.3 76.4 7.3 5.6 1.7 16.3 14.1 2.2 6,367 Note: Body mass index is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding two months Table 11.10 presents the mean values of the two indicators of nutritional status and the proportions of women falling into high-risk categories, according to background characteristics. Women for whom there was no information on height and/or weight and for whom a BMI could not be estimated are excluded from this analysis. The data analysis on BMI is based on 6,367 women, whereas the height analysis is based on 6,944 women. Overall, 3 percent of women are shorter than 145 cm. Women living in rural areas are more likely than women living in urban areas to be below 145 cm. A smaller percentage of women in the North province are below 145 cm (2 percent) than women in other provinces. As expected, women with no schooling and those in the lowest wealth quintile are more likely to be shorter than 145 cm. Table 11.10 shows that there are large differentials across background characteristics in the percentage of women assessed as underweight or thin (BMI less than 18.5 kg/m2) and overweight (BMI 25.0 kg/m2 or higher). Seven percent of women are underweight, and 16 percent are overweight or obese. Thirteen percent of women age 15-19 are underweight. There is no substantial difference in underweight between urban and rural women. However, as would be expected, the percentage of overweight or obese women is higher in urban areas (25 percent) than in 160 • Nutrition of Children and Adults rural areas (15 percent). Comparisons across provinces show that the South province (11 percent) has the highest percentage of undernourished women, whereas the lowest proportion of undernourished women is found in the North province (5 percent). The percentage of overweight or obese women in the highest wealth quintile is nearly three times higher than that of the lowest quintile (28 percent versus 11 percent). A comparison with the 2005 RDHS shows that the proportion of undernourished women in the reproductive age group has declined and that the proportion of overweight or obese women in this group has increased slightly (Figure 11.6). Figure 11.6 Trend in Nutritional Status Among Women 14-49 10 12 7 16 Thin/Underweight Overweight or obese 0 5 10 15 20 2005 RDHS 2010 RDHS RDHS 2010 11.11 PREVALENCE OF ANEMIA IN WOMEN Table 11.11 shows the prevalence of anemia among women age 15-49, adjusted for smoking status. Seventeen percent of Rwandan women are anaemic, including 14 percent with mild anemia and 3 percent with moderate anemia. Less than 1 percent of women suffer from a severe form of anemia. Anemia is more prevalent among women who are of high parity (more than four children), have no education, are pregnant, and live in poor households. Prevalence of anemia does not vary significantly between the rural and urban areas. Women residing in the North province have the lowest prevalence of anemia (12 percent), and women residing in the East province have the highest prevalence (23 percent). Anemia prevalence is higher among women who smoke (25 percent) than among women who do not smoke (17 percent). Nutrition of Children and Adults • 161 Table 11.11 Prevalence of anemia in women Percentage of women age 15-49 with anemia, by background characteristics, Rwanda 2010 Background characteristic Anemia status by hemoglobin level Any anemia Mild anemia Moderate anemia Severe anemia Number of women Age 15-19 15.0 12.8 2.1 0.2 1,539 20-29 16.1 13.1 2.7 0.2 2,654 30-39 18.4 15.2 2.9 0.3 1,603 40-49 21.4 16.9 4.1 0.4 1,150 Number of children ever born 0 15.0 12.6 2.2 0.2 2,642 1 17.2 14.4 2.7 0.2 865 2-3 17.3 13.3 3.7 0.2 1,375 4-5 20.8 16.6 3.8 0.4 997 6+ 19.5 16.7 2.7 0.2 1,066 Maternity status Pregnant 19.5 12.4 6.7 0.4 487 Breastfeeding 18.0 15.3 2.6 0.1 2,088 Neither 16.6 13.8 2.5 0.3 4,369 Smoking status Smokes cigarettes/tobacco 25.3 19.7 5.6 0.0 254 Does not smoke 16.9 13.9 2.8 0.2 6,691 Residence Urban 16.2 13.1 2.9 0.2 1,050 Rural 17.4 14.4 2.9 0.2 5,895 Province City of Kigali 18.0 13.8 4.0 0.2 807 South 17.4 14.4 2.8 0.1 1,593 West 15.3 13.7 1.5 0.1 1,698 North 11.6 10.2 1.3 0.1 1,178 East 22.8 17.3 4.8 0.6 1,668 Education No education 21.0 17.2 3.4 0.4 1,060 Primary 16.6 13.7 2.7 0.2 4,762 Secondary and higher 16.5 13.3 3.0 0.2 1,124 Wealth quintile Lowest 19.2 15.1 3.9 0.2 1,258 Second 19.3 16.6 2.4 0.3 1,399 Middle 16.5 13.8 2.5 0.2 1,382 Fourth 16.1 13.2 2.5 0.4 1,387 Highest 15.5 12.3 3.1 0.2 1,518 Total 17.3 14.2 2.9 0.2 6,945 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC (1998). Women with <7.0 g/dl of hemoglobin have severe anemia, women with 7.0-9.9 g/dl have moderate anemia, and pregnant women with 10.0-10.9 g/dl and nonpregnant women with 10.0-11.9 g/dl have mild anemia. 162 • Nutrition of Children and Adults Figure 11.7 Trend in Anemia Status Among Women 15-49 26 19 6 1 18 15 2 0 17 14 3 0 Total Mild Moderate Severe 0 5 10 15 20 25 30 2005 RDHS 2007-08 RIDHS 2010 RDHS RDHS 2010 Figure 11.7 indicates that the overall prevalence of anemia has decreased by 8 percentage points since the 2005 RDHS. The proportion of mildly anaemic women decreased from 19 percent in 2005 to 14 percent in 2010. Moderate anemia has also declined by half since 2005 (Appendix C, Table C.9). 11.12 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects mother and infant against anemia. It is estimated that one fifth of perinatal mortality and one tenth of maternal mortality are attributable to iron deficiency anemia. Anemia results in an increased risk of premature delivery and low birth weight as well. Finally, iodine deficiency is also related to a number of adverse pregnancy outcomes. VAD can be prevented through the provision of a high-dose (200,000 IU) vitamin A capsule in the first six to eight weeks after delivery (when women are considered not at risk of being pregnant). Due to possible adverse effects (birth defects) resulting from high doses of vitamin A, a high-dose vitamin A supplement should not be given to pregnant women. Table 11.12 shows the extent to which women receive vitamin A following delivery. Fifty-two percent of women reported that they had received vitamin A within the two-month period following the delivery of their last- born child. Table 11.12 also shows the proportion of women who took iron tablets during pregnancy. Overall, one quarter of women (27 percent) took no iron during pregnancy. Among those who did take iron, 67 percent took it for fewer than 60 days, 2 percent took it for two to three months, and 1 percent took it for three months or more. There Nutrition of Children and Adults • 163 was no significant difference in iron consumption by residence. The proportion of women who reported taking iron for fewer than 60 days varied only minimally by province, level of education, and wealth quintile. As was the case among children, practically all women live in households with iodized salt. Table 11.12 Micronutrient intake among mothers Among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child, and the percentages who, during the pregnancy of the last child born in the five years prior to the survey, took iron tablets or syrup for specific numbers of days and took deworming medication; and among women age 15-49 with a child born in the past five years and who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Rwanda 2010 Background characteristic Percentage who received vitamin A dose postpartum1 Number of days women took iron tablets or syrup during pregnancy of last birth Percentage who took deworming medication during pregnancy of last birth Number of women Among women with a child born in the last five years who live in households that were tested for iodized salt None <60 60-89 90+ Don't know/ missing Percentage living in households with iodized salt2 Number of women Age 15-19 46.8 26.5 68.5 2.1 2.2 0.7 39.4 139 100.0 133 20-29 50.8 25.6 68.3 2.5 1.3 2.3 41.3 3,012 99.4 2,818 30-39 53.6 27.9 65.8 1.8 1.6 2.9 38.3 2,380 99.1 2,217 40-49 54.2 27.3 66.6 1.6 1.0 3.5 33.5 874 99.2 790 Residence Urban 55.1 26.9 66.8 1.2 1.2 3.8 35.5 819 99.1 778 Rural 51.8 26.7 67.2 2.3 1.4 2.5 39.6 5,586 99.3 5,180 Province City of Kigali 53.1 27.6 64.4 1.9 1.4 4.7 33.2 635 99.1 613 South 54.7 23.9 67.1 2.9 1.5 4.6 32.7 1,532 99.1 1,404 West 48.2 28.0 67.4 2.4 1.4 0.7 42.4 1,545 99.4 1,413 North 53.0 21.4 70.4 2.5 2.6 3.2 44.8 1,035 99.7 959 East 52.9 31.0 65.9 1.0 0.6 1.5 40.7 1,658 99.1 1,569 Education No education 49.6 30.9 63.2 2.1 1.3 2.5 37.3 1,211 99.4 1,072 Primary 52.2 25.8 68.3 2.0 1.3 2.6 39.4 4,571 99.3 4,280 Secondary and higher 57.8 25.4 66.5 2.9 2.1 3.1 40.1 623 99.3 606 Wealth quintile Lowest 52.6 28.5 65.4 1.9 1.2 3.1 37.0 1,475 98.6 1,282 Second 48.7 27.7 66.6 1.8 1.8 2.0 38.0 1,369 99.4 1,268 Middle 51.3 24.5 69.3 2.9 1.2 2.1 39.6 1,250 99.6 1,182 Fourth 54.2 25.8 68.7 1.8 1.5 2.2 43.2 1,188 99.5 1,137 Highest 55.0 26.6 66.0 2.3 1.3 3.7 38.4 1,122 99.4 1,090 Total 52.2 26.7 67.1 2.1 1.4 2.6 39.1 6,405 99.3 5,958 1 In the first two months after delivery 2 Excludes women in households where salt was not tested 11.13 NUTRITIONAL STATUS OF MEN Table 11.13 presents the nutritional status of men according to background characteristics. Men for whom there was no information on height and/or weight and for whom a BMI could not be estimated are excluded from this analysis. The analysis of BMI is based on 5,667 men age 15-49 and 6,304 men age 15-59. Overall, 16 percent of men 15-49 are underweight or thin (BMI less than 18.5 kg/m2), more than twice the percentage among women (7 percent). Only 4 percent of men are overweight or obese (BMI 25.0 kg/m2 or higher), which is one fourth the proportion observed among women (16 percent). Thirty-five percent of men age 15-19 are underweight. There is no substantial difference in underweight between urban and rural men. As would be expected, the percentage of overweight or obese men is higher in urban areas (9 percent) than in rural areas (3 percent). Comparisons across provinces show that the South province has the highest percentage of undernourished men (22 percent), whereas the North Province has the lowest (12 percent). 164 • Nutrition of Children and Adults The percentage of overweight or obese men in the highest wealth quintile is more than five times that in the lowest quintile. Table 11.13 Nutritional status of men Among men age 15-49, mean body mass index (BMI) and the percentage with specific BMI levels, by background characteristics, Rwanda 2010 Background characteristic Body mass index Mean BMI 18.5-24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moderately and severely thin) ≥25.0 (total over- weight or obese) 25.0-29.9 (over- weight) ≥30.0 (obese) Number of men Age 15-19 19.3 64.5 35.2 21.7 13.6 0.3 0.3 0.0 1,444 20-29 21.3 89.0 7.3 6.2 1.2 3.7 3.6 0.1 2,188 30-39 21.3 84.4 9.6 7.8 1.7 6.1 5.7 0.4 1,195 40-49 21.0 82.2 12.1 8.7 3.4 5.7 5.2 0.6 840 Residence Urban 21.1 75.4 15.6 11.5 4.2 9.0 8.0 1.0 931 Rural 20.7 81.8 15.6 10.7 4.9 2.6 2.5 0.1 4,735 Province City of Kigali 21.3 75.9 13.5 10.6 2.8 10.6 9.8 0.8 732 South 20.0 76.4 22.1 14.0 8.1 1.5 1.5 0.0 1,304 West 21.1 83.0 12.6 8.1 4.5 4.4 4.1 0.3 1,299 North 21.0 85.8 11.5 9.7 1.9 2.7 2.7 0.0 897 East 20.6 82.0 16.1 11.3 4.8 1.9 1.7 0.2 1,435 Education No education 20.9 86.5 11.1 8.0 3.0 2.5 2.0 0.5 581 Primary 20.6 80.5 16.5 11.2 5.3 2.9 2.8 0.1 3,904 Secondary and higher 20.9 78.6 14.9 10.9 3.9 6.5 6.1 0.4 1,182 Wealth quintile Lowest 20.2 77.6 20.9 13.3 7.6 1.6 1.6 0.0 852 Second 20.4 81.7 17.0 11.8 5.2 1.3 1.3 0.0 985 Middle 20.6 83.4 14.7 10.1 4.6 1.9 1.9 0.0 1,136 Fourth 20.7 83.5 14.3 10.4 4.0 2.2 2.0 0.2 1,230 Highest 21.3 77.6 13.4 9.7 3.7 8.9 8.3 0.7 1,463 Total 15-49 20.7 80.8 15.6 10.8 4.8 3.6 3.4 0.2 5,667 50-59 20.5 71.7 22.2 14.3 7.9 6.1 4.4 1.7 638 Total 15-59 20.7 79.8 16.3 11.2 5.1 3.9 3.5 0.4 6,304 Note: Body mass index is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). Malaria • 165 MALARIA 12 12.1 INTRODUCTION alaria has been the main cause of morbidity and mortality in Rwanda for several years, with periodic epidemics in high-altitude areas. The Government of Rwanda established the National Malaria Control Program as a national strategy to combat malaria and reach the goals for 2010 set by the Abuja summit of African heads of state. To achieve these objectives, the country has adopted a strategy based on the availability of services in communities, with the goal of increasing accessibility to health care. This plan would contribute to the achievement of the millennium development goals as set forth in the Vision 2020 strategic plan for the national health sector. With the commitment of the government, Rwanda launched an aggressive nationwide campaign in 2006 to scale up malaria control tools and adopted prevention as its main strategy for controlling malaria, through use of long-lasting insecticidal mosquito nets (LLINs) as well as appropriate and timely treatment of malaria cases with efficacious antimalarial drugs. Over the past few years, malaria has also been the focus of the country’s comprehensive poverty reduction strategy, health policy reforms, and overall investment on health. While insecticide-treated mosquito nets (ITNs) have been shown for years to be an effective preventive measure in combating malaria, used often and with extensive coverage in the community, Rwanda (similar to other African countries) has benefited from massive distribution of LLINs and scale-up of artemisinin combination therapy (ACT). In 2006, following the mass distribution of 1.96 million LLINs to children under 5 during the integrated measles vaccination campaign and the introduction of ACT throughout the country in all public and faith- based health facilities (with the support of the Global Fund to Fight AIDS, Malaria and Tuberculosis), malaria declines were seen countrywide. Comparing 2007 figures against the average figures from 2001 to 2006, inpatient malaria cases and deaths among children under 5 in Rwanda fell by 55 percent and 67 percent, respectively, and there was a decrease of 58 percent in outpatient laboratory-confirmed cases. Since 2005, more than 9.3 million LLINs have been distributed, including 6.1 million since December 2009 with the support of the Global Fund to Fight AIDS, Malaria and Tuberculosis (80 percent of all LLINs distributed), the President’s Malaria Initiative, and UNICEF. Most of LLINs were distributed to children under 5 during integrated measles vaccination campaigns in September 2006 (1.4 million) and April 2010 (1.6 million), through EPI for under 5 children and antenatal care (ANC) clinics for pregnant women (2.4 million distributed from 2005 onward), and through a massive household distribution campaign in 2010 (2.2 million). Other groups receiving LLINs included people living with HIV, the poorest segments of the population, and boarding school students. 12.2 MOSQUITO NETS The ownership and use of treated mosquito nets is the primary prevention strategy for reducing malaria transmission in Rwanda. Since 2006, the ITN policy has included free distribution of LLINs to all children under 5 years every three years during vaccination campaigns or maternal and child health weeks, free distribution of ITNs to pregnant women at their first visit to an ANC clinic, and free distribution of ITNs to children during their final visit under the Expanded Program of Immunization for measles immunization; in addition, there has been universal coverage of LLINs since 2010, with free distribution of one LLINs per 2 persons through household campaigns. To increase coverage, timely mass ITN distribution campaigns are conducted. Since 2005, Rwanda has been moving to M 166 • Malaria the use of LLINs, which are heavy duty and pretreated. In the past five years, more than 9.3 million ITNs have been distributed country-wide in Rwanda. This chapter presents the 2010 Rwanda Demographic and Health Survey (RDHS) household-level findings on ownership and use of mosquito nets, particularly among children under 5 and pregnant women. 12.2.1 Ownership of Mosquito Nets All household respondents in the 2010 RDHS were asked whether their household owned any mosquito nets and, if so, how many and what type. Interviewers were instructed to look at the nets whenever possible. Table 12.1 shows that 83 percent of all households owned at least one net, 82 percent owned at least one ITN, and 82 percent owned at least one LLIN. About 55 percent of households had more than one ITN, and 54 percent had more than one LLIN. Average numbers of any type of mosquito net, ITNs, and LLINs per household were 1.7, 1.6, and 1.6, respectively. This indicates that practically all of the mosquito nets own by households in Rwanda are LLINs. Table 12.1 Household possession of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), insecticide-treated net (ITN), and long-lasting insecticidal net (LLIN), and the average number of nets per household, by background characteristics, Rwanda 2010 Background characteristic Any type of mosquito net Insecticide treated mosquito nets (ITN)1 Long-lasting insecticide net (LLIN) Number of households Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Percentage with at least one Percentage with more than one Average number of LLINs per household Residence Urban 85.4 59.0 1.9 84.5 57.8 1.9 84.0 57.1 1.8 1,759 Rural 82.2 54.8 1.6 81.6 54.0 1.6 81.1 53.4 1.6 10,781 Province City of Kigali 87.0 63.3 2.1 86.5 62.1 2.0 86.1 61.5 2.0 1,284 South 83.7 54.9 1.6 82.9 53.6 1.6 82.2 52.8 1.6 3,136 West 79.6 51.0 1.5 79.0 50.5 1.5 78.7 50.3 1.5 2,967 North 71.1 38.8 1.3 70.2 37.7 1.2 69.7 37.1 1.2 2,120 East 90.8 68.6 2.0 90.4 67.9 1.9 89.8 67.3 1.9 3,033 Wealth quintile Lowest 73.6 39.3 1.2 73.0 38.8 1.2 72.5 38.2 1.2 2,838 Second 79.7 48.4 1.4 78.9 47.5 1.4 78.7 47.3 1.4 2,600 Middle 85.0 58.3 1.7 84.4 57.3 1.7 83.8 56.8 1.6 2,448 Fourth 88.8 65.9 1.9 88.1 65.1 1.9 87.7 64.6 1.9 2,287 Highest 88.5 69.3 2.2 87.8 68.0 2.2 87.0 66.9 2.1 2,367 Total 82.7 55.4 1.7 82.0 54.5 1.6 81.5 53.9 1.6 12,540 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. The proportion of households owning at least one net did not vary by area of residence (85 percent in urban areas versus 82 percent in rural areas). Eighty-five percent of households in urban areas reported having at least one ITN, as compared with 82 percent of households in rural areas. By province, household ownership of ITNs and LLINs was highest in the East province (90 percent for each) and lowest in the North province (70 percent for each). Ownership of any type of mosquito net was also highest in the East province and lowest in the North province. Wealthier households were slightly more likely to own mosquito nets. Eighty-nine percent of the households in the highest wealth quintile owned any type of mosquito net, 88 percent owned an ITN, and 87 percent owned an LLIN. Seventy-three percent of the households in the lowest wealth quintile owned at least one ITN. There has been remarkable progress in net ownership, which has increased from 59 percent in the 2007-08 RIDHS to 83 percent in the 2010 RDHS. However, data on the final round of the LLIN distribution mass campaign Malaria • 167 were not completely captured by the 2010 RDHS because the campaign was organized after the RDHS fieldwork started. 12.2.2 Use of Mosquito Nets by Persons in the Household Table 12.2 shows that 59 percent of the household population slept under any net the night before the survey. The same percentage of the household population (58 percent) slept under an ITN and under an LLIN. Table 12.2 Use of mosquito nets by persons in the household Percentage of the de facto household population who slept the night before the survey under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months; and among the de facto household population in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Rwanda 2010 Background characteristic Household population Household population in households with at least one ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Number Percentage who slept under an ITN1 last night Number Age <5 70.3 69.6 70.2 8,942 75.1 8,288 5-14 48.7 47.9 48.5 15,724 55.3 13,618 15-34 57.4 56.8 57.3 18,657 67.0 15,823 35-39 71.1 69.7 70.8 6,414 80.3 5,566 50+ 57.1 55.9 56.9 5,548 74.3 4,174 Sex Male 57.2 56.4 57.0 26,029 65.7 22,372 Female 59.8 58.9 59.7 29,264 68.7 25,100 Residence Urban 64.0 62.8 63.8 7,424 70.5 6,618 Rural 57.7 56.9 57.6 47,868 66.7 40,854 Province City of Kigali 65.0 64.3 64.9 5,456 70.6 4,972 South 58.7 57.6 58.5 13,400 66.7 11,564 West 57.1 56.5 57.0 13,522 67.7 11,294 North 45.1 44.2 44.9 9,375 58.6 7,070 East 66.6 65.8 66.5 13,540 70.9 12,571 Wealth quintile Lowest 49.6 49.0 49.5 10,980 62.8 8,568 Second 54.3 53.4 54.0 11,065 64.7 9,134 Middle 58.9 58.3 58.8 11,018 67.5 9,509 Fourth 63.1 62.2 63.0 11,088 68.6 10,050 Highest 66.8 65.7 66.6 11,141 71.7 10,211 Total 58.6 57.7 58.4 55,292 67.2 47,472 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 12.2.3 Use of Mosquito Nets by Children Under 5 Children under age 5 are most vulnerable to severe complications of malarial infection due to their reduced immunity. Table 12.3 shows the use of mosquito nets by children under age 5. Seventy percent of children under age 5 slept under a mosquito net the night before the survey. However, in households with at least one ITN, 75 percent of children slept under an ITN the night before the survey. 168 • Malaria Table 12.3 Use of mosquito nets by children Percentage of children under age 5 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes in the past 12 months; and among children under age 5 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Rwanda 2010. Background characteristic Children under age 5 in all households Children under age 5 in households with at least one ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Number of children Percentage who slept under an ITN1 last night Number of children Age (in months) <12 72.6 72.1 72.4 1,577 78.9 1,440 12-23 76.9 76.2 76.7 1,632 80.5 1,544 24-35 72.9 71.9 72.7 1,881 77.4 1,748 36-47 66.8 66.1 66.7 1,861 71.4 1,721 48-59 64.1 63.4 64.0 1,991 68.8 1,835 Sex Male 69.3 68.6 69.1 4,563 74.0 4,233 Female 71.5 70.6 71.4 4,379 76.3 4,055 Residence Urban 76.0 75.3 75.9 1,060 79.3 1,007 Rural 69.6 68.8 69.4 7,882 74.5 7,281 Province City of Kigali 76.1 75.9 76.1 826 78.6 797 South 69.5 68.6 69.4 2,171 74.6 1,997 West 70.2 69.8 70.1 2,235 76.8 2,033 North 66.4 65.3 66.1 1,388 71.7 1,264 East 71.6 70.7 71.4 2,323 74.7 2,197 Wealth quintile Lowest 62.8 62.4 62.7 2,069 71.4 1,809 Second 66.2 65.4 66.0 1,925 71.4 1,762 Middle 72.3 71.6 72.1 1,775 76.6 1,660 Fourth 75.2 74.3 75.2 1,673 77.1 1,612 Highest 78.3 77.5 78.2 1,499 80.4 1,445 Total 70.3 69.6 70.2 8,942 75.1 8,288 Note: Table is based on children who stayed in the household the night before the interview. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. There is no variation by sex in the use of mosquito nets in Rwanda. Children in urban areas are more likely to use ITNs (75 percent) than those in rural areas (69 percent); children in urban areas are also more likely to use LLINs. Additionally, children under age 3 are slightly more likely to use a mosquito net for sleeping than children age 3 and older. Net usage among children under age 5 was higher in the 2010 RDHS (70.3 percent) than in the 2007-08 RIDHS (60.2 percent). 12.2.4 Use of Mosquito Nets by Pregnant Women To prevent complications from malaria during pregnancy, such as anemia, low birth weight, and trans- placental parasitaemia, all pregnant women are encouraged to sleep under ITNs. Table 12.4 shows that 73 percent of all pregnant women age 15 to 49 years slept under any net the night before the survey. Since practically all of the mosquito nets in Rwanda are LLINs, the percentages of pregnant women who slept under ITNs and LLINs were similar to the percentage of women who slept under any net. Use of any net was higher among urban pregnant women (81 percent) than rural women (71 percent). Among pregnant Malaria • 169 women in households with at least one ITN, 81 percent slept under an ITN the night preceding the survey; in these households, more urban women slept under an ITN (87 percent) than their rural counterparts (80 percent). Women without a formal education were less likely to have slept under a mosquito net the night before the survey (62 percent) than those with a primary education or a secondary education or higher (75 percent). Women in the highest three wealth quintiles were more likely to have slept under an ITN than those in the lowest two quintiles. Table 12.4 Use of mosquito nets by pregnant women Percentages of pregnant women age 15-49 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes in the past 12 months; and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Rwanda 2010 Background characteristic Among pregnant women age 15-49 in all households Among pregnant women age 15-49 in households with at least one ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Number of women Percentage who slept under an ITN1 last night Number of women Residence Urban 80.9 80.2 80.9 149 86.7 138 Rural 71.0 70.8 71.0 803 79.9 712 Province City of Kigali 80.3 80.3 80.3 114 85.7 107 South 74.6 74.1 74.6 198 83.7 176 West 68.0 67.6 68.0 241 77.7 210 North 66.6 66.6 66.6 148 74.7 131 East 75.2 74.8 75.2 251 83.3 226 Education No education 62.1 62.1 62.1 157 73.3 133 Primary 74.6 74.2 74.6 700 82.4 630 Secondary and higher 74.6 74.6 74.6 95 82.4 86 Wealth quintile Lowest 67.1 67.1 67.1 197 77.8 169 Second 66.6 65.5 66.6 194 75.7 168 Middle 76.6 76.6 76.6 200 86.7 176 Fourth 75.9 75.9 75.9 186 82.6 170 Highest 77.0 76.4 77.0 176 81.8 165 Total 72.5 72.2 72.5 952 81.0 849 Note: Table is based on women who stayed in the household the night before the interview. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), or (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 12.3 PREVALENCE AND PROMPT TREATMENT OF FEVER Malaria case management, including the detection, diagnosis, and rapid treatment of all malaria cases with appropriate and effective antimalarial drugs, is one of the key strategic areas for malaria control in Rwanda. Since 2006, ACTs have been widely available in public health and faith-based facilities, as well as in the community via community health workers and private pharmacies. In December 2009, the National Malaria Control Program revised its malaria treatment guidelines requiring that laboratory diagnostic results be confirmed via either microscopy or rapid diagnostic test before any treatment is initiated. In 2010, Rwanda achieved one of the highest parasitological diagnosis rates in Africa, with an estimated 94 percent of suspected malaria cases being parasitologically diagnosed (Malaria Program Review, 2011). Table 12.5 shows that 16 percent of children under age 5 had a fever during the two weeks preceding the survey; the proportion was higher among children age 12-23 months (22 percent) than among other children. 170 • Malaria Children in the East province were slightly less likely to have experienced fever (11 percent) than those in the other provinces (17 percent or higher). Table 12.5 Prevalence, diagnosis, and prompt treatment of children with fever Percentage of children under age 5 with fever in the two weeks preceding the survey, and among children under age 5 with fever, the percentage who had blood taken from a finger or heel, the percentage who took antimalarial drugs, and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, Rwanda 2010 Background characteristic Among children under age 5: Among children under age 5 with fever: Percentage with fever in the two weeks preceding the survey Number of children Percentage who had blood taken from a finger or heel for testing Percentage who took antimalarial drugs Percentage who took antimalarial drugs same or next day Number of children Age (in months) <12 19.1 1,573 18.8 6.7 3.6 300 12-23 21.9 1,616 26.9 11.8 9.0 353 24-35 15.4 1,824 21.5 11.5 7.3 282 36-47 13.6 1,741 15.8 11.4 8.7 237 48-59 9.9 1,850 19.0 13.9 11.1 184 Sex Male 16.5 4,364 22.8 10.7 7.4 722 Female 14.9 4,241 18.9 11.0 8.0 634 Residence Urban 16.7 1,033 39.3 7.9 7.1 172 Rural 15.6 7,572 18.3 11.3 7.8 1,183 Province City of Kigali 17.4 830 42.0 6.7 5.0 144 South 17.9 2,049 19.7 17.6 12.0 367 West 17.5 2,159 17.4 8.0 5.8 378 North 17.1 1,342 11.8 1.8 1.8 229 East 10.7 2,225 24.8 16.1 11.1 237 Mother's education No education 14.0 1,629 14.9 11.1 7.8 228 Primary 16.2 6,214 19.4 11.2 8.1 1,008 Secondary and higher 15.6 762 46.3 7.4 4.2 119 Wealth quintile Lowest 17.8 1,992 13.6 12.2 8.5 355 Second 16.9 1,852 13.2 8.9 4.6 313 Middle 15.4 1,709 17.8 12.3 9.4 264 Fourth 11.9 1,598 26.8 9.1 7.2 190 Highest 16.1 1,454 41.5 11.1 9.0 234 Total 15.8 8,605 21.0 10.8 7.7 1,355 Among children under age 5 with fever, 21 percent had blood taken from a finger or heel for testing. The percentage of children with fever who had blood taken from a finger or heel for testing was highest in urban areas, in the City of Kigali, in the highest wealth quintile, and among those whose mother had a secondary education or higher. Eleven percent of children under age 5 with fever took antimalarial drugs. However, only 8 percent of children under age 5 took antimalarial drugs the same day or the day after the fever started. There were substantial differences among children under age 5 who took antimalarial drugs the same or next day by mothers’ educational level and region. Children under age 12 months were less likely than older children to take antimalarial drugs or to take them the same day or the day after the fever started. Malaria • 171 Table 12.6.1 Type of antimalarial drugs taken by children who took antimalarial drugs Among children under age 5 who had a fever and took any antimalarial medication in the two weeks preceding the survey, the percentage who took specific antimalarial drugs by background characteristics, Rwanda 2010 Antimalarial drug Percent Quinine 3.5 Coartem1 37.2 Primo1 60.1 Other 1.3 Number of children who took any antimalarial drug 147 1 Artemisinin combination therapy (ACT) In line with the malaria treatment policy of the National Malaria Control Program, antimalarial medicines (Table 12.6.1) are given to children only after the presence of malaria parasites is confirmed by microscope or the rapid diagnostic test. Table 12.6.2 shows that 11 percent of children under age 5 with fever took an antimalarial medicine, about half the percentage of children who had blood taken from a finger or heel for testing (21 percent). Almost all of these children were treated with ACT (120 mg Lumefantrine and 20 mg Artemether, commonly known as Primo or Coartem). Less than 1 percent of children took quinine or other antimalarial medicines (Tables 12.6.1 and 12.6.2). On the same or the next day following the onset of fever, 8 percent of children took an antimalarial medicine, with most children treated with a type of ACT. There were substantial differences in the use of ACT for treatment of fever by residence and province. Rural children with fever (11 percent) were more likely than their urban counterparts (7 percent) to be treated with ACT. The percentages of children treated with ACT were highest in the South (17 percent) and East (15 percent) provinces. Only 1 percent of children in the North province were treated with ACT. Table 12.6.2 Type and timing of antimalarial drugs taken by children with fever Among children under age 5 with fever in the two weeks preceding the survey, the percentage who took specific antimalarial drugs and the percentage who took each type of drug the same or next day after developing fever, by background characteristics, Rwanda 2010 Background characteristic Percentage of children who took drug: Percentage of children who took drug the same or next day: Number of children with feverQuinine Coartem1 Primo1 Other antimalarial Quinine Coartem Primo Other antimalarial Age (in months) <12 0.7 2.3 3.3 0.3 0.4 1.4 1.4 0.3 300 12-23 0.3 5.4 6.4 0.0 0.0 3.6 5.4 0.0 353 24-35 0.6 3.3 8.2 0.0 0.3 1.8 5.6 0.0 282 36-47 0.0 2.6 8.9 0.0 0.0 2.1 6.6 0.0 237 48-59 0.0 7.2 6.2 0.5 0.0 4.8 6.2 0.0 184 Sex Male 0.1 3.5 6.8 0.3 0.0 2.5 4.7 0.1 722 Female 0.7 4.6 6.2 0.0 0.3 2.8 5.0 0.0 634 Residence Urban 0.0 4.2 3.1 0.6 0.0 3.4 3.1 0.6 172 Rural 0.4 4.0 7.0 0.1 0.2 2.5 5.1 0.0 1,183 Province City of Kigali 0.0 2.9 3.8 0.0 0.0 2.0 3.0 0.0 144 South 0.8 6.4 10.9 0.0 0.2 4.0 8.1 0.0 367 West 0.0 3.3 4.7 0.2 0.0 2.5 3.4 0.0 378 North 0.0 0.5 0.9 0.4 0.0 0.5 0.9 0.4 229 East 0.9 5.6 9.6 0.0 0.5 3.4 7.3 0.0 237 Continued… 172 • Malaria Table 12.6.2—Continued Background characteristic Percentage of children who took drug: Percentage of children who took drug the same or next day: Number of children with feverQuinine Coartem1 Primo1 Other antimalarial Quinine Coartem Primo Other antimalarial Mother's education No education 0.3 4.2 6.5 0.4 0.3 2.3 5.1 0.4 228 Primary 0.4 3.9 6.9 0.1 0.1 2.8 5.2 0.0 1,008 Secondary and higher 0.0 4.5 2.9 0.0 0.0 2.4 1.9 0.0 119 Wealth quintile Lowest 0.2 4.4 7.5 0.3 0.2 2.9 5.4 0.3 355 Second 0.7 3.1 4.8 0.3 0.0 1.4 3.2 0.0 313 Middle 0.4 4.4 7.9 0.0 0.4 3.3 5.6 0.0 264 Fourth 0.0 2.3 6.7 0.0 0.0 1.6 5.5 0.0 190 Highest 0.5 5.6 5.5 0.0 0.0 4.0 5.0 0.0 234 Total 0.4 4.0 6.5 0.1 0.1 2.6 4.9 0.1 1,355 1 Artemisinin combination therapy (ACT) In the past five years, Rwanda has made extraordinary progress in the fight against malaria. Data from the National Malaria Control Program show that malaria incidence declined by 70 percent between 2005 and 2010. During this period, malaria cases reported in outpatient visits declined 60 percent, and mortality due to malaria in inpatient admissions declined 54 percent. Between 2001 and 2010, the test positivity rate declined 66 percent (Malaria Program Review, 2011). In Rwanda, due to low malaria transmission, fever cases are not recommended for antimalarial treatments as they are in high-transmission countries. Treatments are given in cases in which malaria infection is confirmed. This could explain the differences in the use of ACT for treatment of fever by residence and province, with a higher percentage of children using ACT in the East and South provinces, where the prevalence of malaria is higher, than in the North province (where only 1 percent of children have received ACT). 12.4 PREVALENCE OF ANEMIA AND MALARIA IN CHILDREN AND WOMEN One of the objectives of the 2010 RDHS was to assess anemia prevalence in children age 6-59 months. Table 11.7 in the previous chapter presents the percentage of children with anemia according to the cutoffs of 11.0 g/dl for any anemia and 7.0 g/dl for severe anemia. In addition to poor dietary intake of iron, malaria infection can also result in anemia. A hemoglobin concentration of less than 8.0 g/dl is considered an indication that an individual may have malaria, according to the National Guidelines for the management of malaria in Rwanda. Table 12.7 shows that 1 percent of children age 6-59 months have hemoglobin lower than 8.0 g/dl. Children under 18 months have higher levels of anemia, ranging from 6 percent among children age 6-8 months to 3 percent among children age 9-17 months. Boys are slightly more anaemic than girls (2 percent versus 1 percent). The proportions of children with a hemoglobin level below 8 g/dl are higher in urban areas, the City of Kigali, and the East province (2 percent each) than in rural areas and the other provinces. Malaria • 173 Table 12.7 Hemoglobin <8.0 g/dl in children Percentage of children age 6-59 months with hemoglobin lower than 8.0 g/dl, by background characteristics, Rwanda 2010 Background characteristic Hemoglobin < 8.0 g/dl Number of children Age (in months) 6-8 5.5 188 9-11 3.0 219 12-17 3.0 391 18-23 0.7 423 24-35 1.2 944 36-47 0.3 943 48-59 0.6 929 Sex Male 1.5 2,037 Female 1.0 1,999 Mother's interview status Interviewed 1.3 3,731 Not interviewed but in household (2.5) 31 Not interviewed and not in household1 0.7 275 Residence Urban 1.9 475 Rural 1.2 3,562 Province City of Kigali 2.1 365 South 1.4 986 West 0.4 1,003 North 0.7 656 East 2.0 1,027 Mother's education2 No education 1.0 740 Primary 1.3 2,707 Secondary and higher 2.3 316 Wealth quintile Lowest 1.3 901 Second 1.1 881 Middle 0.9 812 Fourth 1.3 788 Highest 1.9 655 Total 1.3 4,037 Note: Table is based on children who stayed in the household the night before the interview. Prevalence of anemia is based on hemoglobin levels and is adjusted for altitude using CDC formulas (CDC, 1998). Hemoglobin is measured in grams per decilitere (g/dl). Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. Table 12.8 shows the results of microscopic diagnostic test (blood smear) among children who had a malaria test. Nationally, 1.4 percent of children 6 to 59 months are infected with at least one form of malarial parasites. Children 6-11 months are less likely to be infected with malaria than children 12 months or older. The prevalence in boys and girls is not substantially different. Overall, the proportion of children with malaria is higher in rural areas than urban areas (1.4 percent versus 0.8 percent). In addition, children in the East province (3.4 percent) and the South province (1.4 percent) are more likely to be infected than those in other provinces. Children whose mothers never attended school are more likely to be infected than children whose mothers attended some school. Children in the lowest wealth quintile are twice as likely to be infected as children in the highest wealth quintile. The prevalence of malaria among children who were not with their mothers at the time of interview (mothers were not interviewed and not in household) is more than four times higher than the national average (Table 12.8). 174 • Malaria Table 12.8 Malaria among children Percentage of children age 6-59 months classified as having malaria, by background characteristics, Rwanda 2010 Background characteristic Malaria Number of children Age (in months) 6-8 0.6 191 9-11 0.5 219 12-17 1.0 391 18-23 1.3 425 24-35 1.4 945 36-47 1.8 944 48-59 1.5 931 Sex Male 1.5 2,045 Female 1.2 2,001 Mother's interview status Interviewed 1.1 3,739 Not interviewed but in household (0.0) 32 Not interviewed and not in household1 4.7 275 Residence Urban 0.8 475 Rural 1.4 3,571 Province City of Kigali 0.2 365 South 1.4 986 West 0.5 1,009 North 0.0 656 East 3.4 1,031 Education2 No education 1.6 742 Primary 1.0 2,714 Secondary and higher 1.1 316 Wealth quintile Lowest 2.1 902 Second 1.7 884 Middle 0.7 817 Fourth 1.2 788 Highest 1.0 656 Total 1.4 4,046 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. Women are less likely to be infected with malaria than children. In the country as a whole, only 0.7 percent of women have malaria (Table 12.9). There is no clear relationship between malaria infection and the age of a woman. Similar to children, rural women are more likely to be infected than urban women, and malaria prevalence among women is higher in the East (1.6 percent) and South (1.0 percent) provinces than in other provinces. Malaria prevalence is negatively associated with a woman’s education and wealth quintile. Malaria • 175 Table 12.9 Malaria among women Percentage of women age 15-49 years classified as having malaria, by background characteristics, Rwanda 2010 Background characteristic Malaria Number of women Age 15-19 1.0 1,540 20-24 0.8 1,372 25-29 0.6 1,270 30-34 0.6 883 35-39 0.9 715 40-44 0.5 614 45-49 0.0 532 Pregnancy status Currently pregnant 0.5 486 Not pregnant/not sure 0.7 6,441 Residence Urban 0.2 1,048 Rural 0.8 5,880 Province City of Kigali 0.1 802 South 1.0 1,599 West 0.2 1,684 North 0.1 1,174 East 1.6 1,668 Education No education 1.0 1,062 Primary 0.7 4,746 Secondary and higher 0.5 1,119 Wealth quintile Lowest 1.4 1,253 Second 0.8 1,395 Middle 0.5 1,378 Fourth 0.7 1,386 Highest 0.2 1,516 Total 0.7 6,927 There have been remarkable improvements in malaria prevalence since the 2007-08 RIDHS, with malaria in children under 5 declining from 2.6 to 1.4 percent and malaria in women declining from 1.4 to 0.7 percent. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 177 HIV AND AIDS RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13 IV infection is a major public health concern in Rwanda, where it is a primary cause of mortality with negative social and economic consequences that affect everyone in the country. Since the initiation of the 2005-2009 National Multi-sector Strategic Plan (NMSP), Rwanda has made significant progress towards the goal of creating universal access to HIV and AIDS services. To continue this progress, Rwanda decided to develop and implement a 2009-2012 National Strategic Plan (NSP) against HIV and AIDS. The NSP sets out the overarching goals for the country’s response to HIV and AIDS and affirms Rwanda's commitment to a multi-sector response. It is based on the most up–to-date understanding of the epidemic and the strengths and weaknesses of the systems and mechanisms that are used to respond. To assess the impact of Rwanda’s anti-AIDS program, the 2010 RDHS has devoted its efforts, in large part, to gathering data on HIV and AIDS and other sexually transmitted infections (STIs). The aim of this chapter is to present knowledge, attitudes, and behaviors at the national and provincial levels and among certain subgroups of the population. The chapter also provides information on male circumcision in Rwanda. Survey data were collected about how HIV infection is prevented and transmitted, the stigmatization of those who have the disease, and risk factors, particularly those relating to sexual behavior. The information gathered is essential for adjusting current programs and setting up new AIDS information, education, and communication campaigns. In addition, the 2010 Rwanda Demographic and Health Survey (RDHS) tested for HIV to determine the prevalence of HIV infection and factors associated with HIV infection (see Chapter 14). 13.1 KNOWLEDGE OF HIV AND AIDS AND OF TRANSMISSION AND PREVENTION METHODS 13.1.1 Awareness of AIDS Practically all women and men age 15-49 have heard of AIDS (Table 13.1). Because of the universal awareness of AIDS, the variation by background characteristics, such as marital status, residence, province, education, and wealth, is minimal. Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Rwanda 2010 Background characteristic Women Men Has heard of AIDS Number of respondents Has heard of AIDS Number of respondents Age 15-24 99.9 5,628 99.9 2,607 …15-19 99.9 2,945 99.9 1,449 …20-24 100.0 2,683 100.0 1,159 25-29 100.0 2,494 100.0 1,038 30-39 100.0 3,269 100.0 1,201 40-49 100.0 2,280 100.0 842 Marital status Never married 99.9 5,285 99.9 2,873 Ever had sex 100.0 1,188 100.0 1,140 Never had sex 99.9 4,097 99.9 1,733 Married/Living together 100.0 6,897 100.0 2,699 Divorced/Separated/Widowed 100.0 1,489 100.0 115 Residence Urban 100.0 2,057 100.0 939 Rural 100.0 11,614 100.0 4,748 Continued… H 178 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.1—Continued Background characteristic Women Men Has heard of AIDS Number of respondents Has heard of AIDS Number of respondents Province City of Kigali 100.0 1,596 100.0 739 South 100.0 3,212 99.9 1,308 West 100.0 3,305 100.0 1,307 North 100.0 2,278 99.9 899 East 100.0 3,280 100.0 1,435 Education No education 100.0 2,119 100.0 583 Primary 100.0 9,337 100.0 3,916 Secondary and higher 100.0 2,216 99.9 1,189 Wealth quintile Lowest 99.9 2,622 99.9 854 Second 100.0 2,661 100.0 986 Middle 100.0 2,736 99.9 1,139 Fourth 100.0 2,677 100.0 1,235 Highest 100.0 2,976 100.0 1,474 Total 15-49 100.0 13,671 100.0 5,687 50-59 na na 100.0 642 Total 15-59 na na 100.0 6,329 na = Not applicable 13.1.2 HIV Prevention Methods The 2010 Rwanda Demographic and Health Survey (RDHS) prompted respondents to answer specific questions about HIV and AIDS prevention methods, which include limiting sexual intercourse to one uninfected, faithful sexual partner and using condoms. Table 13.2 presents knowledge of these HIV and AIDS prevention methods among women and men age 15-49, by background characteristics. Eighty-five percent of women and 79 percent of men are aware that the risks of contracting the AIDS virus can be reduced by limiting sex to one uninfected partner who has no other partners; women (91 percent) and men (92 percent) are somewhat more likely to know that using condoms also can prevent transmission of the AIDS virus. Approximately 79 percent of women and 74 percent of men have knowledge of both HIV prevention methods. Knowledge of both HIV prevention methods among women age 15-19 and age 40-49 is lower than among women in the middle age group (20-39). Younger men age 15-19 are somewhat less likely to have knowledge about prevention of HIV and AIDS than older men. Women and men who are not married, particularly those who have never had sex, are slightly less likely to know the two HIV prevention methods than those who are currently married or who have ever had sex. Knowledge about prevention of HIV and AIDS is also low among men who are divorced, separated, or widowed. Knowledge of HIV prevention methods is higher among women in urban areas than in rural areas, whereas it does not differ among men. There is considerable variability across provinces in knowledge of prevention methods. Among women, knowledge of the two HIV prevention methods is highest in the City of Kigali (89 percent) and lowest in the West province (68 percent). Among men, knowledge of the two methods is highest in the City of Kigali (77 percent) and lowest in the South province (71 percent). The level of educational attainment positively relates to a respondent’s knowledge of HIV prevention methods. Women and men with higher levels of schooling are more likely than those with less schooling to be aware of various preventive methods. The data also show that women and men in higher wealth quintiles are more likely than those in lower quintiles to be aware of ways to prevent the transmission of HIV. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 179 Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, and by having one sex partner who is not infected and has no other partners, by background characteristics, Rwanda 2010 Background characteristic Women Men Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner2 Number of men Age 15-24 89.7 82.9 76.3 5,628 90.3 76.9 71.2 2,607 …15-19 87.8 81.1 73.4 2,945 88.2 74.1 67.7 1,449 …20-24 91.7 84.9 79.4 2,683 92.8 80.4 75.6 1,159 25-29 92.4 88.6 82.8 2,494 93.9 81.0 77.1 1,038 30-39 92.0 86.5 80.8 3,269 94.1 79.7 75.9 1,201 40-49 89.6 84.8 77.5 2,280 93.8 81.9 77.3 842 Marital status Never married 89.4 82.1 75.3 5,285 90.4 76.0 70.4 2,873 Ever had sex 92.6 85.2 79.7 1,188 93.2 81.0 76.5 1,140 Never had sex 88.5 81.1 74.1 4,097 88.5 72.7 66.4 1,733 Married/Living together 91.8 87.5 81.3 6,897 94.3 82.4 78.4 2,699 Divorced/Separated/Widowed 90.3 85.1 79.0 1,489 91.8 71.7 68.5 115 Residence Urban 93.7 89.9 84.9 2,057 95.4 78.1 75.6 939 Rural 90.2 84.3 77.6 11,614 91.6 79.1 73.9 4,748 Province City of Kigali 94.7 92.8 88.8 1,596 95.5 79.4 76.6 739 South 89.9 90.1 82.5 3,212 93.3 74.6 70.5 1,308 West 87.7 76.2 67.6 3,305 89.2 83.0 76.0 1,307 North 92.8 87.5 82.2 2,278 90.3 81.5 75.5 899 East 91.1 83.9 78.9 3,280 93.6 77.4 73.7 1,435 Education No education 87.6 81.4 73.3 2,119 90.7 76.4 70.1 583 Primary 90.5 85.9 79.2 9,337 91.4 79.1 73.9 3,916 Secondary and higher 94.5 85.6 81.8 2,216 95.7 79.8 77.2 1,189 Wealth quintile Lowest 88.1 84.2 75.7 2,622 89.0 78.7 71.4 854 Second 88.9 84.2 76.9 2,661 90.7 76.8 71.3 986 Middle 90.6 85.5 79.0 2,736 91.7 79.0 73.8 1,139 Fourth 91.8 84.0 78.8 2,677 93.8 79.9 76.4 1,235 Highest 93.7 87.4 82.7 2,976 94.3 79.8 76.1 1,474 Total 15-49 90.7 85.1 78.7 13,671 92.3 79.0 74.2 5,687 50-59 na na na na 91.2 80.0 73.5 642 Total 15-59 na na na na 92.1 79.1 74.1 6,329 na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 13.1.3 Knowledge about Transmission The 2010 RDHS included questions on common misconceptions about AIDS and HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have the AIDS virus and whether a person can contract the AIDS virus from mosquito bites, by supernatural means, or by sharing food with a person who has AIDS. The results in Tables 13.3.1 and 13.3.2 indicate that some Rwandan adults lack accurate knowledge about the ways in which HIV can and cannot be transmitted. In fact, 12 percent of women and 10 percent of men don’t know that a healthy-looking person can have (and thus transmit) the virus that causes AIDS. Large percentages of women and men also erroneously believe that the AIDS virus can be transmitted by mosquito bites (21 percent and 22 percent, respectively). Larger proportions of women and men are aware that the AIDS virus cannot be 180 • HIV and AIDS Related Knowledge, Attitudes, and Behavior transmitted by supernatural means (92 percent and 93 percent, respectively) or by sharing food with a person who has AIDS (90 percent each, for women and for men). Overall, two-thirds of women and men (68 percent, each) are able to reject two of the more common misconceptions about AIDS—that the AIDS virus can be transmitted by mosquito bites and that a person can become infected with the AIDS virus by sharing food with someone who is infected—and they also know that a healthy-looking person can have the AIDS virus. Table 13.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Rwanda 2010 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of women A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 82.8 81.4 92.1 90.0 65.8 52.6 5,628 …15-19 78.0 82.7 91.7 89.3 63.0 49.3 2,945 …20-24 88.2 80.1 92.6 90.9 68.9 56.3 2,683 25-29 91.9 76.7 92.1 89.4 69.4 58.9 2,494 30-39 91.5 77.7 92.4 90.5 69.7 57.8 3,269 40-49 90.1 77.1 91.3 88.3 68.2 55.4 2,280 Marital status Never married 82.9 82.1 92.5 90.4 66.7 53.0 5,285 Ever had sex 87.1 77.3 91.3 89.6 66.5 55.2 1,188 Never had sex 81.7 83.5 92.9 90.6 66.8 52.3 4,097 Married/Living together 91.0 77.3 92.1 89.8 69.1 57.8 6,897 Divorced/Separated/Widowed 90.0 75.8 90.0 87.1 65.9 53.5 1,489 Residence Urban 92.9 86.2 95.3 92.9 78.5 67.8 2,057 Rural 86.8 77.7 91.5 89.2 65.9 53.3 11,614 Province City of Kigali 94.6 87.6 96.1 94.4 80.9 72.7 1,596 South 90.0 81.9 95.8 91.1 72.7 61.7 3,212 West 82.1 76.6 89.5 85.9 62.5 45.4 3,305 North 85.9 72.4 86.3 87.3 58.4 48.3 2,278 East 89.2 78.9 93.0 91.8 68.6 56.1 3,280 Education No education 84.7 67.6 84.8 80.8 54.8 43.3 2,119 Primary 87.3 78.3 92.2 89.9 66.6 54.7 9,337 Secondary and higher 92.9 92.6 98.3 97.7 85.3 70.5 2,216 Wealth quintile Lowest 84.0 72.2 88.9 84.7 58.9 46.8 2,622 Second 85.4 74.7 89.8 86.4 62.4 50.5 2,661 Middle 87.2 76.6 90.7 88.8 64.7 53.2 2,736 Fourth 88.5 82.4 93.8 93.1 71.0 57.7 2,677 Highest 93.0 87.8 96.6 95.0 80.4 67.7 2,976 Total 15-49 87.8 79.0 92.1 89.8 67.8 55.5 13,671 1 Two most common local misconceptions: HIV transmission by mosquito bites and sharing food 2 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 181 Table 13.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Rwanda 2010 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of men A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites AIDS cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 83.3 79.4 91.6 89.6 64.1 47.4 2,607 …15-19 77.6 80.7 90.2 88.8 60.8 43.5 1,449 …20-24 90.4 77.7 93.2 90.7 68.3 52.4 1,159 25-29 94.0 75.4 93.1 90.7 69.5 54.6 1,038 30-39 96.0 77.3 94.7 92.0 73.1 55.0 1,201 40-49 93.9 76.4 92.8 90.2 70.0 56.1 842 Marital status Never married 84.3 79.7 92.4 90.4 65.4 47.9 2,873 Ever had sex 89.1 77.8 93.1 90.8 67.6 52.3 1,140 Never had sex 81.1 80.9 92.0 90.1 64.0 45.0 1,733 Married/Living together 94.9 76.0 92.9 90.6 70.7 55.8 2,699 Divorced/Separated/Widowed 93.8 69.4 93.6 87.6 62.9 46.9 115 Residence Urban 93.4 86.3 96.6 94.0 79.7 59.7 939 Rural 88.7 76.1 91.9 89.7 65.6 50.0 4,748 Province City of Kigali 94.7 87.2 97.0 94.1 81.5 63.0 739 South 90.3 77.3 94.6 90.9 68.3 48.8 1,308 West 85.7 70.2 85.5 85.7 56.7 44.7 1,307 North 87.5 77.4 93.5 90.9 66.7 52.0 899 East 90.9 80.5 94.9 92.1 71.4 54.3 1,435 Education No education 90.0 63.4 84.6 83.2 54.6 40.1 583 Primary 88.5 75.2 92.2 89.4 64.6 48.7 3,916 Secondary and higher 92.5 93.3 98.4 97.5 85.3 66.6 1,189 Wealth quintile Lowest 87.0 68.9 87.6 83.5 58.4 42.2 854 Second 86.8 72.0 89.8 86.5 58.9 42.9 986 Middle 88.9 77.8 92.5 91.4 66.7 51.2 1,139 Fourth 89.9 79.2 94.1 92.6 70.2 54.7 1,235 Highest 92.9 85.4 96.6 94.4 78.4 60.6 1,474 Total 15-49 89.5 77.7 92.7 90.4 67.9 51.6 5,687 50-59 90.7 66.6 88.3 85.8 58.3 43.0 642 Total 15-59 89.6 76.6 92.2 89.9 66.9 50.7 6,329 1 Two most common local misconceptions: mosquito bites and sharing food 2 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. Tables 13.3.1 and 13.3.2 also provide an assessment of the level of comprehensive knowledge of HIV and AIDS prevention and transmission. People are considered to have comprehensive knowledge about AIDS when they know that both condom use and limiting sex partners to one uninfected person are HIV and AIDS prevention methods, they are aware that a healthy-looking person can have HIV, and they reject the two most common local misconceptions, HIV transmission by mosquito bite and by sharing food. In Rwanda, 56 percent of women and 52 percent of men age 15-49 have comprehensive knowledge of HIV and AIDS prevention and transmission. These tables also show that there is considerable variation in HIV and AIDS knowledge by background characteristics. Married man and sexually active never-married men tend to be more knowledgeable than men in other marital status categories. For all indicators, the proportion of women and men with correct knowledge about HIV and AIDS prevention and transmission is higher in urban than in rural areas and among women and men with 182 • HIV and AIDS Related Knowledge, Attitudes, and Behavior higher levels of schooling. Similarly, men and women in higher wealth quintiles are more likely than those in lower quintiles to have comprehensive knowledge about HIV and AIDS. Variations in knowledge levels by province are marked among both women and men, with the highest levels of comprehensive knowledge about AIDS observed among residents of the City of Kigali (73 percent for women and 63 percent for men) and the lowest levels observed among residents of the West province (45 percent for each group). Comprehensive knowledge about AIDS has varied little since the 2005 RDHS. 13.1.4 Knowledge of Prevention of Mother-to-Child Transmission of HIV Educating people about the ways in which HIV can be transmitted from mother to child during pregnancy, delivery, and breastfeeding is critical to reducing mother-to-child transmission (MTCT) of HIV. To obtain information on these issues, respondents were asked whether the virus that causes AIDS can be transmitted from a mother to a child during pregnancy, delivery, or breastfeeding and whether a mother who is infected with HIV can reduce the risk of transmission of the virus to the baby by taking certain drugs (antiretrovirals) during pregnancy. Table 13.4 shows that, overall, 94 percent of women and 91 percent of men know that HIV can be transmitted by breastfeeding. Proportions of women who know that HIV can be transmitted during pregnancy and delivery are 64 percent and 95 percent respectively. In men these proportions are 62 percent and 92 percent respectively (data not shown). Ninety-four percent of women and 91 percent of men know that the risk of MTCT can be reduced through the use of certain drugs during pregnancy. Eighty-nine percent of women and 84 percent of men know that HIV can be transmitted by breastfeeding and the risk of MTCT can be reduced through the use of certain drugs during pregnancy. There are no marked differences in MTCT knowledge among women and men by background characteristics in Rwanda. Table 13.4 Knowledge of prevention of mother to child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother to child transmission (MTCT) of HIV can be reduced by mother taking special drugs during pregnancy, by background characteristics, Rwanda 2010 Background characteristic Women Men HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 93.1 91.1 87.1 5,628 90.2 87.4 81.1 2,607 …15-19 92.2 88.5 84.6 2,945 89.1 85.7 79.1 1,449 …20-24 94.1 93.9 90.0 2,683 91.5 89.4 83.6 1,159 25-29 94.7 95.1 91.0 2,494 92.4 92.5 86.7 1,038 30-39 94.8 96.3 92.1 3,269 89.9 93.9 85.8 1,201 40-49 94.0 93.7 89.2 2,280 89.8 93.1 85.0 842 Marital status Never married 92.5 90.0 85.9 5,285 89.6 87.9 81.0 2,873 Ever had sex 94.1 93.9 89.8 1,188 91.1 91.7 85.4 1,140 Never had sex 92.1 88.9 84.8 4,097 88.6 85.3 78.2 1,733 Married/Living together 94.9 96.1 92.0 6,897 91.5 93.3 86.5 2,699 Divorced/Separated/Widowed 94.7 93.9 89.4 1,489 87.9 92.9 84.1 115 Pregnant Currently pregnant 95.8 96.7 93.4 956 na na na na Not pregnant or not sure 93.8 93.3 89.1 12,715 na na na na Residence Urban 95.9 95.6 92.4 2,057 90.9 92.8 85.6 939 Rural 93.6 93.1 88.8 11,614 90.4 90.1 83.3 4,748 Continued… HIV and AIDS Related Knowledge, Attitudes, and Behavior • 183 Table 13.4—Continued Background characteristic Women Men HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Province City of Kigali 96.2 96.2 93.3 1,596 90.3 94.2 86.3 739 South 94.2 92.2 88.4 3,212 92.5 90.5 85.0 1,308 West 91.1 93.2 87.4 3,305 90.2 90.9 83.9 1,307 North 95.4 93.0 90.1 2,278 90.3 89.9 83.0 899 East 94.6 94.0 89.8 3,280 89.0 88.7 81.4 1,435 Education No education 92.6 92.3 86.9 2,119 87.8 86.7 78.1 583 Primary 93.8 93.1 89.1 9,337 90.7 90.3 83.8 3,916 Secondary and higher 96.0 96.3 92.9 2,216 91.1 93.2 86.1 1,189 Wealth quintile Lowest 93.0 91.7 87.1 2,622 90.3 87.9 82.1 854 Second 93.1 92.3 87.8 2,661 89.3 88.4 80.8 986 Middle 93.0 92.8 88.2 2,736 89.2 91.8 83.8 1,139 Fourth 94.6 94.8 90.9 2,677 92.1 90.0 84.7 1,235 Highest 95.9 95.5 92.3 2,976 91.0 92.9 85.7 1,474 Total 15-49 93.9 93.5 89.4 13,671 90.5 90.5 83.7 5,687 50-59 na na na na 87.2 92.4 83.3 642 Total 15-59 na na na na 90.1 90.7 83.7 6,329 na = Not applicable 13.2 STIGMA ASSOCIATED WITH AIDS AND ATTITUDES RELATED TO HIV AND AIDS Knowledge and beliefs about HIV infection affect how people treat those they know to be living with HIV or AIDS. In the 2010 RDHS, a number of questions were posed to respondents to measure their attitudes towards HIV-infected people. These questions concerned their willingness to buy vegetables from an infected vegetable seller, to let others know the HIV status of family members, and to take care of relatives who have the AIDS virus in their own household. They were also asked whether an HIV-positive female teacher who is not sick should be allowed to continue teaching. Tables 13.5.1 and 13.5.2 show the percentages of women and men who have heard of HIV and AIDS and who express positive attitudes towards people with HIV, by background characteristics. 184 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.5.1 Accepting attitudes toward those living with HIV&AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with AIDS, by background characteristics, Rwanda 2010 Background characteristic Percentage of respondents who: Percentage expressing acceptance attitudes on all four indicators Number of respondents who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 95.1 80.6 84.4 63.1 47.6 5,625 …15-19 93.5 76.4 80.9 59.8 41.3 2,942 …20-24 96.9 85.2 88.3 66.8 54.5 2,683 25-29 97.0 86.7 89.9 68.6 56.8 2,494 30-39 97.4 86.8 91.1 70.2 58.8 3,269 40-49 97.5 82.3 86.8 68.1 53.6 2,280 Marital status Never married 95.4 80.9 84.8 64.0 48.7 5,281 Ever had sex 96.4 81.5 87.1 64.5 50.9 1,188 Never had sex 95.1 80.8 84.2 63.9 48.0 4,094 Married/Living together 97.1 85.4 89.6 68.7 56.4 6,897 Divorced/Separated/Widowed 97.3 84.0 86.6 66.4 52.0 1,489 Residence Urban 98.0 90.4 93.0 65.0 57.0 2,056 Rural 96.2 82.3 86.5 66.9 52.2 11,611 Province City of Kigali 98.7 92.6 94.8 63.1 56.6 1,596 South 97.8 85.8 89.6 77.3 62.8 3,212 West 93.4 76.8 83.0 58.1 42.6 3,304 North 96.7 80.1 86.5 59.8 44.2 2,278 East 96.9 85.9 86.9 71.3 58.0 3,279 Education No education 93.4 72.9 79.6 62.7 43.1 2,119 Primary 96.5 83.2 87.2 66.9 52.3 9,333 Secondary and higher 98.9 94.8 96.1 69.4 65.1 2,215 Wealth quintile Lowest 94.7 76.6 82.3 66.8 47.9 2,620 Second 95.0 78.6 84.4 64.8 46.9 2,661 Middle 96.8 83.1 86.0 66.1 52.1 2,736 Fourth 97.2 86.6 90.4 69.7 58.4 2,675 Highest 98.3 91.5 93.3 65.8 58.7 2,975 Total 15-49 96.4 83.5 87.4 66.6 53.0 13,667 Almost the same proportion of women and men reported that they would be willing to take care of a family member with HIV at home (96 and 97 percent, respectively). However, men are slightly more likely than women to say that they would buy fresh vegetables from a shopkeeper who has HIV (90 percent versus 84 percent) and to think that a female teacher with HIV should be allowed to continue teaching (89 percent versus 87 percent). Men are also more likely than women not to want to keep secret a family member’s infection with HIV (78 percent versus 67 percent). Overall, men are more likely to express accepting attitudes regarding all four situations when compared with women (64 percent compared with 53 percent, respectively). In general, better educated respondents, those in the higher wealth quintiles, and those living in urban areas have more accepting attitudes towards nonrelatives who are HIV positive and who are more willing to care for family members with AIDS in their own home. There is no marked difference among women and men who said that they would not want to keep secret the knowledge that a family member is HIV positive by wealth and by area of residence. Accepting attitudes on all four indicators are generally more common among respondents in urban areas than among those in rural areas, and they increase with the level of education. Residents of the City of Kigali, and of HIV and AIDS Related Knowledge, Attitudes, and Behavior • 185 the South and East provinces, are more likely to express accepting attitudes towards people living with HIV or AIDS (57 percent or more for women and 71 percent or more for men) than residents of the North and West provinces (44 percent and 43 percent, respectively, for women and 55 percent and 54 percent, respectively, for men). Stigmatization against HIV and AIDS in Rwanda remains high, especially in the West province. Table 13.5.2 Accepting attitudes toward those living with HIV&AIDS: Men Among men age 15-49 who have heard of HIV&AIDS, percentage expressing specific accepting attitudes toward people with HIV&AIDS, by background characteristics, Rwanda 2010 Background characteristic Percentage of respondents who: Percentage expressing acceptance attitudes on all four indicators Number of respondents who have heard of AIDS Are willing to care for a family member with the AIDS virus in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 95.6 85.8 84.3 74.1 56.9 2,605 …15-19 93.7 82.2 79.8 72.1 50.7 1,447 …20-24 98.0 90.3 89.9 76.5 64.8 1,159 25-29 97.9 93.4 90.4 82.3 70.2 1,038 30-39 98.9 93.8 93.8 80.8 72.1 1,201 40-49 99.0 92.7 91.5 79.3 69.5 842 Marital status Never married 95.9 86.8 85.4 75.6 59.4 2,872 Ever had sex 97.8 89.3 88.4 77.5 63.7 1,140 Never had sex 94.6 85.1 83.5 74.4 56.6 1,731 Married/Living together 98.6 93.3 91.9 80.0 70.0 2,699 Divorced/Separated/Widowed 99.1 87.7 82.9 79.5 59.6 115 Residence Urban 98.3 94.0 93.2 79.1 70.6 939 Rural 97.0 89.1 87.5 77.5 63.2 4,746 Province City of Kigali 99.0 94.3 93.8 78.1 70.9 739 South 97.4 90.9 90.8 83.8 71.6 1,307 West 95.0 84.6 81.7 73.0 53.9 1,307 North 97.4 89.5 90.4 66.3 54.8 898 East 98.0 91.7 88.5 83.6 70.1 1,435 Education No education 95.2 84.9 82.4 80.0 59.4 583 Primary 97.0 88.4 87.1 77.1 62.1 3,915 Secondary and higher 99.0 97.4 96.0 78.8 74.6 1,188 Wealth quintile Lowest 94.9 84.1 82.4 81.4 60.3 853 Second 97.1 86.9 87.4 73.7 58.0 986 Middle 97.6 90.2 88.9 76.4 63.3 1,138 Fourth 97.7 92.0 88.2 78.0 66.2 1,235 Highest 97.9 93.2 92.6 79.3 70.5 1,474 Total 15-49 97.2 89.9 88.5 77.8 64.4 5,686 50-59 96.4 86.3 86.5 82.4 64.8 642 Total 15-59 97.1 89.5 88.3 78.2 64.5 6,327 13.3 ATTITUDES TOWARDS NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent it is not useful if people are not able to negotiate safer sex practices with their partners. To gauge attitudes towards safer sex, respondents in the 2010 RDHS were asked whether they think a woman is justified in refusing to have sex with her husband if she knows he has sex with other women. They were also asked whether they think that a woman in the same circumstances is justified in asking her husband to use a condom if she knows that her husband has a sexually transmitted infection (STI). The results from these questions are shown in Table 13.6. 186 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with other women, and percentage who believe that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI), by background characteristics, Rwanda 2010 Background characteristic Women Men Refusing to have sexual intercourse with husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of women Refusing to have sexual intercourse with husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Number of men Age 15-24 78.4 95.6 5,628 81.0 95.9 2,607 …15-19 76.2 94.4 2,945 77.4 94.7 1,449 …20-24 80.7 96.8 2,683 85.5 97.5 1,159 25-29 82.7 96.9 2,494 89.6 97.4 1,038 30-39 83.2 95.7 3,269 89.2 96.2 1,201 40-49 82.8 95.0 2,280 91.7 96.5 842 Marital status Never married 78.3 94.8 5,285 81.8 95.9 2,873 Ever had sex 79.5 96.8 1,188 86.5 97.2 1,140 Never had sex 78.0 94.2 4,097 78.7 95.1 1,733 Married/Living together 82.9 96.7 6,897 90.5 96.9 2,699 Divorced/Separated/Widowed 82.3 94.4 1,489 79.4 94.4 115 Residence Urban 83.0 97.2 2,057 87.9 98.0 939 Rural 80.7 95.5 11,614 85.5 96.0 4,748 Province City of Kigali 85.8 97.6 1,596 89.2 97.9 739 South 82.7 95.4 3,212 85.7 97.4 1,308 West 76.1 95.1 3,305 82.5 95.3 1,307 North 84.5 95.7 2,278 86.9 97.8 899 East 79.7 95.8 3,280 86.7 94.6 1,435 Education No education 80.9 93.9 2,119 86.0 94.1 583 Primary 80.2 95.7 9,337 85.4 96.0 3,916 Secondary and higher 84.7 97.8 2,216 87.3 98.4 1,189 Wealth quintile Lowest 80.0 94.2 2,622 83.8 95.3 854 Second 80.1 95.7 2,661 85.5 95.8 986 Middle 80.2 94.7 2,736 84.1 95.9 1,139 Fourth 80.6 96.4 2,677 86.3 96.8 1,235 Highest 84.0 97.4 2,976 88.3 97.2 1,474 Total 15-49 81.0 95.7 13,671 85.9 96.3 5,687 50-59 na na 0 88.6 93.8 642 Total 15-59 na na 0 86.2 96.1 6,329 na = Not applicable Eighty-one percent of women and 86 percent of men believe that a woman is justified in refusing to have sex with her husband if she knows he has sex with other women, and 96 percent of women and men believe that a woman is justified in asking her husband to use a condom if he has an STI. The majority of respondents in all groups support a woman’s right to refuse to have sex with her husband if she knows he has sex with other women or to propose using a condom if she knows that her husband has an STI. However, there are small differences by background characteristics in the percentages of respondents holding this opinion. For example, the higher a respondent’s educational attainment and wealth quintile, the more likely he or she is to say that a woman can refuse to have sex with her husband or propose using a condom. The percentage that agrees with a woman’s right to refuse to have sex with her husband ranges from a low of 76 percent (women) and 83 percent (men) in the West province to a high of 86 percent (women) and 89 percent (men) in the City of Kigali. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 187 13.4 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH Condom use is one of the most effective strategies for combating the spread of HIV. However, educating youth about condoms is sometimes controversial because some people believe it promotes early sexual initiation. To evaluate attitudes toward condom education for youth, the 2010 RDHS asked respondents if they thought that young people age 12-14 should be taught about using a condom to avoid AIDS. Because the table focuses on adult opinions, results are tabulated for respondents age 18-49. Table 13.7 shows that about 9 in 10 respondents (89 percent of women and 91 percent of men) agree that young people age 12-14 should be taught about using condoms for AIDS prevention. Among women, support for condom education for youth is lowest in the 40-49 age group, while among men there is no substantial variation in agreement with condom education by age group. Respondents who have higher education, have never been married, live in urban areas, and are in higher wealth quintiles are most likely to agree with condom education for youth. Table 13.7 Adult support of youth education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that adolescents age 12-14 years should be taught about using a condom to avoid AIDS, by background characteristics, Rwanda 2010 Background characteristic Women Men Percentage who agree Number Percentage who agree Number Age 18-24 90.7 3,766 92.2 1,678 …18-19 89.2 1,083 92.2 519 …20-24 91.3 2,683 92.1 1,159 25-29 90.7 2,494 90.1 1,038 30-39 88.6 3,269 92.1 1,201 40-49 85.5 2,280 89.7 842 Marital status Never married 90.3 3,428 92.0 1,944 Married or living together 89.0 6,893 90.8 2,699 Divorced/separated/widowed 87.0 1,488 88.5 115 Residence Urban 91.8 1,793 92.8 833 Rural 88.6 10,015 90.9 3,926 Province City of Kigali 93.4 1,420 93.5 664 South 88.7 2,784 89.1 1,098 West 85.5 2,823 91.5 1,049 North 90.6 1,947 90.2 741 East 89.9 2,836 92.5 1,207 Education No education 82.4 2,079 86.0 563 Primary 89.8 7,884 91.4 3,184 Secondary and higher 93.8 1,845 93.8 1,011 Wealth quintile Lowest 86.9 2,313 89.5 714 Second 87.3 2,290 89.0 799 Middle 88.2 2,361 91.5 968 Fourth 90.0 2,289 92.2 1,030 Highest 92.7 2,555 92.7 1,248 Total 18-49 89.1 11,809 91.3 4,758 50-59 na na 84.8 642 Total 18-59 na na 90.5 5,400 na = Not applicable 188 • HIV and AIDS Related Knowledge, Attitudes, and Behavior 13.5 MULTIPLE AND CONCURRENT PARTNERSHIPS, AND PAYING FOR SEX 13.5.1 Multiple Sexual Partnerships Given that most HIV infections are contracted through heterosexual contact, information on sexual behavior is important when designing and monitoring intervention programs to control the spread of the epidemic. In the context of HIV and AIDS prevention, limiting the number of sexual partners and encouraging protected sex are crucial to combating the epidemic. The 2010 RDHS included questions on respondents’ lifetime sexual partners as well as partners in the 12 months preceding the survey. Male respondents were also asked whether they had paid for sex in the 12 months preceding the interview. Information on use of condoms during the last sexual encounter with each of these types of partners was collected from both women and men. Given that questions about sexual activity are sensitive, it is important to remember when interpreting the results in this section that respondents’ answers are likely subject to at least some reporting bias. Tables 13.8.1 and 13.8.2 show the percentages of women and men age 15-49 years who had engaged in sexual intercourse with more than one partner in the past 12 months. They also show the women’s and men’s mean number of lifetime sexual partners and their condom use during their most recent intercourse. Because the number of respondents reporting more than one partner in the past 12 months is very small, condom use by background characteristics is not noteworthy. The data show that less than 1 percent of women and 4 percent of men reportedly had two or more sexual partners during the 12 months preceding the survey. There is little variation by background characteristics in the percentage of women with two or more sexual partners in the past 12 months. The percentage of women with multiple partners is highest among women with no education, women living in the City of Kigali and urban areas, and women who are divorced, widowed, or separated. The results of the question on condom use show that 29 percent of the women who had two or more sexual partners in the past 12 months used a condom during their last sex. Compared with other male respondents, men age 25 and older, those who are currently married and formerly married (divorced, separated, or widowed), those in polygynous unions, those living in urban areas, and those in the City of Kigali and in the West province are more likely than other respondents to have had multiple partners over the past year. Among men with two or more partners in the past 12 months, 28 percent report having used a condom during their last encounter. Condom use is more pronounced among urban than rural men (52 and 20 percent, respectively). Because the total number of men who have had multiple sexual partners in the past 12 months is small, the variation in condom use by background characteristics is not noteworthy. On average, men age 15-49 report having 2.7 lifetime sexual partners, about twice the average reported by women (1.4 partners). Among women, variation according to background characteristics is minimal. Women who live in urban areas and in the City of Kigali have slightly more lifetime partners than other women. The mean number of lifetime sexual partners reported by men age 40-49 (3.4) and those who are divorced, separated, or widowed (3.5) is higher than the number reported by all men (2.7). The number of lifetime sexual partners is also higher among urban men than among rural men (3.9 versus 2.4). More educated and well-off men are more likely to report a higher number of sexual partners. Men with no schooling report an average of 2.5 partners, compared with 3.6 partners among men with a secondary education or higher. The average number of partners ranges from 2.4 or less in the lowest two wealth quintiles to 3.6 in the highest quintile. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 189 Table 13.8.1 Multiple sexual partners: Women Among all women age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for women who ever had sexual intercourse, by background characteristics, Rwanda 2010 Background characteristic All women Among women who had 2+ partners in the past 12 months: Among women who ever had sexual intercourse1: Percentage who had 2+ partners in the past 12 months Number of women Percentage who reported using a condom during last sexual intercourse Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 0.6 5,628 (29.1) 33 1.4 1,981 …15-19 0.3 2,945 * 9 1.3 432 …20-24 0.9 2,683 * 24 1.4 1,549 25-29 0.7 2,494 * 17 1.3 2,178 30-39 0.5 3,269 * 16 1.5 3,153 40-49 0.7 2,280 * 16 1.6 2,248 Marital status Never married 0.5 5,285 (38.7) 26 1.7 1,184 Married or living together 0.4 6,897 * 25 1.3 6,892 Divorced/separated/widowed 2.0 1,489 (38.1) 30 1.9 1,483 Residence Urban 1.0 2,057 * 20 1.8 1,411 Rural 0.5 11,614 21.9 62 1.4 8,148 Province City of Kigali 1.1 1,596 * 17 1.8 1,099 South 0.4 3,212 * 11 1.4 2,262 West 0.6 3,305 * 19 1.3 2,237 North 0.4 2,278 * 10 1.4 1,553 East 0.8 3,280 * 25 1.4 2,408 Education No education 0.9 2,119 * 19 1.5 1,951 Primary 0.6 9,337 30.4 60 1.4 6,499 Secondary and higher 0.1 2,216 * 3 1.5 1,109 Wealth quintile Lowest 0.6 2,622 * 16 1.5 2,008 Second 0.8 2,661 * 22 1.4 1,916 Middle 0.5 2,736 * 14 1.4 1,881 Fourth 0.3 2,677 * 7 1.3 1,821 Highest 0.7 2,976 (40.3) 22 1.6 1,932 Total 15-49 0.6 13,671 28.9 82 1.4 9,559 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses. 190 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.8.2 Multiple sexual partners: Men Among all men age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for men who ever had sexual intercourse, by background characteristics, Rwanda 2010 Background characteristic All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 1.7 2,607 (58.0) 43 2.1 1,008 …15-19 0.4 1,449 * 7 1.7 311 …20-24 3.2 1,159 (53.0) 37 2.2 697 25-29 5.6 1,038 32.5 58 2.5 914 30-39 6.3 1,201 17.2 75 2.8 1,182 40-49 5.5 842 (9.5) 46 3.4 829 Marital status Never married 2.0 2,873 77.8 58 2.7 1,128 Married or living together 5.7 2,699 7.4 153 2.6 2,691 Divorced/separated/widowed 10.6 115 * 12 3.5 115 Type of union In polygynous union 85.3 56 (11.2) 48 3.2 56 Not in polygynous union 4.0 2,643 5.6 105 2.6 2,635 Not currently in union 2.4 2,988 71.2 70 2.7 1,242 Residence Urban 5.6 939 51.5 52 3.9 677 Rural 3.6 4,748 20.1 171 2.4 3,257 Province City of Kigali 5.8 739 (50.1) 43 4.1 545 South 2.4 1,308 (21.6) 32 2.1 855 West 5.2 1,307 20.6 68 2.6 866 North 2.7 899 (27.6) 25 2.1 634 East 3.9 1,435 21.8 56 2.8 1,033 Education No education 3.8 583 * 22 2.5 509 Primary 4.0 3,916 27.1 156 2.5 2,711 Secondary and higher 3.7 1,189 35.2 44 3.6 713 Wealth quintile Lowest 3.6 854 (28.2) 31 2.4 615 Second 3.2 986 (3.2) 32 2.2 670 Middle 5.1 1,139 22.3 58 2.4 796 Fourth 3.2 1,235 (25.8) 39 2.5 823 Highest 4.3 1,474 45.1 63 3.6 1,030 Total 15-49 3.9 5,687 27.5 223 2.7 3,933 50-59 6.0 642 (14.3) 39 4.0 636 Total 15-59 4.1 6,329 25.5 262 2.9 4,569 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses. 13.5.2 Concurrent Sexual Partners Concurrent sexual partnerships are defined as “overlapping sexual partnerships where intercourse with one partner occurs between two acts of intercourse with another partner” (UNAIDS, 2009). If an individual has multiple sexual partners in the same year, it is important to know whether those partnerships are serial or concurrent. Concurrent sexual partnerships are theoretically more risky than serial sexual partnerships because concurrent partnerships can create large interconnected sexual networks whose members are at heightened risk of infection. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 191 The 2010 RDHS collected information on the time since the first and most recent sexual intercourse with each sexual partner in the past 12 months. This information was used to determine if sexual intercourse with one partner occurred between two acts of intercourse with another partner, i.e., whether two partnerships were concurrent. There are two indicators to measure concurrent sexual partnerships. Point prevalence of concurrent sexual partnerships is defined as the proportion of women and men age 15-49 with more than one ongoing sexual partnership at the point in time six months before the survey. Cumulative prevalence of concurrent sexual partnerships is defined as the proportion of women and men age 15-49 who have had any overlapping sexual partnerships in the past 12 months (UNAIDS, 2009). A partnership that consists of a single sexual encounter is considered overlapping if it occurs during another ongoing partnership. The point prevalence is generally lower than the cumulative prevalence because the point prevalence only includes relationships ongoing on a particular day rather than over an entire year. For men, overlapping polygynous unions are considered concurrent partnerships in both the point prevalence and cumulative prevalence concurrency indicators. Table 13.9.1 shows that less than 1 percent of women age 15-49 had concurrent sexual partnerships by either the point prevalence or cumulative prevalence definition. Among women who had two or more sexual partnerships in the past 12 months, 63 percent had sexual partnerships that were concurrent. Table 13.9.1 Point prevalence and cumulative prevalence of concurrent sexual partners Percentage of all women and men age 15-49 who had concurrent sexual partners six months before the survey (point prevalence1), and percentage of all women and all men age 15-49 who had concurrent sexual partners during the 12 months before the survey (cumulative prevalence2), and among women and men age 15-49 who had multiple sexual partners during the 12 months before the survey, percentage who had concurrent sexual partners, Rwanda 2010 Background characteristic Among all respondents Among all respondents who had multiple partners during the 12 months before the survey Point of prevalence of concurrent sexual partners1 Cumulative prevalence of concurrent sexual partners2 Number of respondents Percentage who had concurrent sexual partners2 Number of respondents WOMEN Age 15-24 0.1 0.3 5,628 (46.4) 33 …15-19 0.1 0.2 2,945 * 9 …20-24 0.0 0.4 2,683 * 24 25-29 0.2 0.5 2,494 * 17 30-39 0.2 0.4 3,269 * 16 40-49 0.2 0.5 2,280 * 16 Marital status Never married 0.1 0.3 5,285 (61.2) 26 Married or living together 0.1 0.3 6,897 * 25 Divorced/separated/widowed 0.2 1.2 1,489 (59.2) 30 Residence Urban 0.2 0.4 2,057 * 20 Rural 0.1 0.4 11,614 69.5 62 Total 15-49 0.1 0.4 13,671 62.9 82 MEN Age 15-24 0.2 0.7 2,607 (43.8) 43 …15-19 0.1 0.2 1,449 * 7 …20-24 0.3 1.4 1,159 (45.1) 37 25-29 1.5 4.2 1,038 75.6 58 30-39 2.9 5.7 1,201 91.0 75 40-49 3.6 5.2 842 (94.3) 46 Continued… 192 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.9.1—Continued Background characteristic Among all respondents Among all respondents who had multiple partners during the 12 months before the survey Point of prevalence of concurrent sexual partners1 Cumulative prevalence of concurrent sexual partners2 Number of respondents Percentage who had concurrent sexual partners2 Number of respondents Marital status Never married 0.2 0.8 2,873 40.0 58 Married or living together 2.8 5.4 2,699 94.7 153 Divorced/separated/widowed 4.0 6.3 115 * 12 Residence Urban 1.0 3.3 939 58.9 52 Rural 1.6 3.0 4,748 84.5 171 Total 15-49 1.5 3.1 5,687 78.5 223 50-59 4.5 5.7 642 (95.2) 39 Total 15-59 1.8 3.3 6,329 81.0 262 Note: Two sexual partners are considered to be concurrent if the date of the most recent sexual intercourse with the earlier partner is after the date of the first sexual intercourse with the later partner. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 8 men with information missing on type of union. 1 The percentage of respondents who had two (or more) sexual partners that were concurrent at the point in time six months before the survey 2 The percentage of respondents who had two (or more) sexual partners that were concurrent anytime during the 12 months preceding the survey Table 13.9.1 also shows that 2 percent of men had concurrent sexual partnerships, according to the point prevalence indicator, while 3 percent of men had concurrent sexual partnerships, according to the cumulative prevalence indicator. The percentage of men with concurrent sexual partnerships, according to the cumulative prevalence indicator, increases with age from less than 1 percent of men age 15-19 to 5 percent of men age 40-49. Differences in the cumulative prevalence of concurrent sexual partnerships by urban or rural residence are small. Men who are currently married (3 percent) or who are divorced, widowed, or separated (4 percent) are more likely than men who have never been married (less than 1 percent) to report concurrent sexual partnerships in the past 6 months. Among men with two or more partners in the past 12 months, 79 percent had concurrent partners. 13.5.3 Payment for Sex Male respondents in the 2010 RDHS who had had sex in the past 12 months were asked whether they had paid anyone in exchange for sex in the past 12 months or ever in their lifetime and whether any of their last three partners in the past 12 months was a commercial sex worker. The results in Table 13.9.2 show that only 3 percent of men age 15-49 have ever paid for sexual intercourse and that less than 1 percent had done so in the 12 months before the survey. Men age 30 and older (6 percent); men who are divorced, separated, or widowed (6 percent); men living in urban areas (7 percent) and in City of Kigali (8 percent); and those in the highest wealth quintile (6 percent) are most likely to have ever paid for sexual intercourse. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 193 Table 13.9.2 Payment for sexual intercourse and condom use at last paid sexual intercourse Percentage of men age 15-49 who ever paid for sexual intercourse and percentage reporting payment for sexual intercourse in the past 12 months, and among them, the percentage reporting that a condom was used the last time they paid for sexual intercourse, by background characteristics, Rwanda 2010 Background characteristic Among all men Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Age 15-24 1.2 0.3 2,607 …15-19 0.3 0.2 1,449 …20-24 2.2 0.5 1,159 25-29 3.7 0.6 1,038 30-39 5.8 0.4 1,201 40-49 5.9 0.2 842 Marital status Never married 1.7 0.5 2,873 Married or living together 4.9 0.1 2,699 Divorced/separated/widowed 6.2 2.6 115 Residence Urban 6.8 0.8 939 Rural 2.6 0.3 4,748 Province City of Kigali 7.9 0.7 739 South 2.2 0.2 1,308 West 2.4 0.3 1,307 North 2.9 0.6 899 East 3.0 0.3 1,435 Education No education 3.0 0.3 583 Primary 3.2 0.4 3,916 Secondary and higher 3.7 0.4 1,189 Wealth quintile Lowest 2.4 0.2 854 Second 1.8 0.0 986 Middle 2.3 0.7 1,139 Fourth 3.1 0.4 1,235 Highest 5.8 0.4 1,474 Total 15-49 3.3 0.4 5,687 50-59 9.0 0.1 642 Total 15-59 3.9 0.3 6,329 13.6 TESTING FOR HIV Knowledge of HIV status helps HIV-negative individuals make specific decisions to reduce risk and increase safer sex practices so they can remain disease free. For those who are HIV infected, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. Testing of pregnant women is especially important so that action can be taken to prevent mother-to-child transmission. To obtain information on the prevalence of HIV testing, all respondents were asked whether they had ever been tested for HIV. If they said that they had been tested, they were asked whether they had received the results of their last test. Women giving birth in the two-year period before the survey were asked additional questions regarding testing that may have occurred as part of any antenatal care they received prior to the birth. Tables 13.10.1 and 13.10.2 show that, among the adult population age 15-49, 77 percent of women and 73 percent of men have been tested for HIV at some time. The majority of women and men who were tested indicated that they had received the results of their test. Thirty-nine percent of women and 38 percent of men said that they had received results from an HIV test taken during the 12 months prior to the survey. However, many women and 194 • HIV and AIDS Related Knowledge, Attitudes, and Behavior men who were tested did not receive the results, which should have been made available to all tested individuals. The proportions of both women and men ever tested were higher among those age 20 and older than among those younger than age 20. Testing rates were highest among currently married respondents (93 percent of women and 92 percent of men) and among widowed, divorced, and separated persons (82 percent for women and 83 percent for men). Women who had never married and were sexually active had a higher testing rate than their male counterparts (82 percent versus 68 percent). Urban residents, residents of the City of Kigali, those with a secondary education or higher, and those in the highest wealth quintile had slightly higher testing rates than other respondents. Table 13.10.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Rwanda 2010 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested and received results from last HIV test taken in the past 12 months Number of women Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 97.7 59.4 2.8 37.8 100.0 62.2 36.8 5,628 …15-19 96.0 43.5 4.3 52.2 100.0 47.8 27.3 2,945 …20-24 99.5 76.9 1.0 22.0 100.0 78.0 47.2 2,683 25-29 99.7 90.3 0.8 8.9 100.0 91.1 47.0 2,494 30-39 99.6 91.2 0.8 8.1 100.0 91.9 41.2 3,269 40-49 99.3 76.8 1.2 22.0 100.0 78.0 30.3 2,280 Marital status Never married 97.3 52.2 3.2 44.6 100.0 55.4 31.1 5,285 …Ever had sex 98.6 79.1 2.4 18.5 100.0 81.5 46.6 1,188 …Never had sex 96.9 44.4 3.4 52.1 100.0 47.9 26.6 4,097 Married/Living together 99.8 92.4 0.6 7.1 100.0 92.9 44.9 6,897 Divorced/Separated/Widowed 99.3 80.2 1.4 18.3 100.0 81.7 36.3 1,489 Residence Urban 99.0 79.4 1.5 19.2 100.0 80.8 38.1 2,057 Rural 98.7 74.9 1.7 23.4 100.0 76.6 38.7 11,614 Province City of Kigali 99.0 81.4 1.3 17.3 100.0 82.7 37.8 1,596 South 99.2 73.3 2.0 24.7 100.0 75.3 35.1 3,212 West 97.6 72.8 1.8 25.4 100.0 74.6 39.0 3,305 North 99.2 75.8 2.0 22.1 100.0 77.9 42.9 2,278 East 99.1 77.4 1.1 21.5 100.0 78.5 39.1 3,280 Education No education 98.5 78.4 1.1 20.4 100.0 79.6 35.6 2,119 Primary 98.6 74.2 1.7 24.1 100.0 75.9 38.0 9,337 Secondary and higher 99.8 78.5 2.1 19.4 100.0 80.6 44.3 2,216 Wealth quintile Lowest 98.1 74.8 1.9 23.3 100.0 76.7 37.2 2,622 Second 98.4 73.8 1.7 24.5 100.0 75.5 37.2 2,661 Middle 98.9 73.3 2.3 24.4 100.0 75.6 38.3 2,736 Fourth 99.3 76.5 1.2 22.3 100.0 77.7 39.9 2,677 Highest 99.1 78.9 1.3 19.8 100.0 80.2 40.2 2,976 Total 15-49 98.8 75.5 1.7 22.8 100.0 77.2 38.6 13,671 1 Includes “don't know/missing” HIV and AIDS Related Knowledge, Attitudes, and Behavior • 195 Table 13.10.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who received their test results the last time they were tested for HIV in the past 12 months, according to background characteristics, Rwanda 2010 Background characteristic Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who received results from last HIV test taken in the past 12 months Number of men Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 95.5 49.3 4.9 45.8 100.0 54.2 31.8 2,607 …15-19 93.1 37.1 5.7 57.2 100.0 42.8 23.9 1,449 …20-24 98.6 64.5 4.0 31.5 100.0 68.5 41.7 1,159 25-29 99.6 86.4 1.8 11.7 100.0 88.3 47.4 1,038 30-39 99.5 88.4 2.8 8.8 100.0 91.2 42.5 1,201 40-49 99.5 82.9 2.3 14.9 100.0 85.1 36.9 842 Marital status Never married 95.8 49.2 4.8 46.0 100.0 54.0 30.4 2,873 …Ever had sex 98.1 63.2 4.5 32.4 100.0 67.6 38.6 1,140 …Never had sex 94.2 40.0 5.0 55.0 100.0 45.0 25.0 1,733 Married/Living together 99.7 90.1 2.3 7.6 100.0 92.4 45.1 2,699 Divorced/Separated/Widowed 98.5 81.1 1.7 17.2 100.0 82.8 46.2 115 Residence Urban 98.4 73.1 2.3 24.6 100.0 75.4 37.4 939 Rural 97.5 68.5 3.8 27.7 100.0 72.3 37.7 4,748 Province City of Kigali 99.0 76.2 2.2 21.7 100.0 78.3 36.5 739 South 97.0 64.0 4.5 31.6 100.0 68.4 32.4 1,308 West 97.2 68.8 4.3 26.9 100.0 73.1 39.6 1,307 North 97.7 70.4 3.4 26.1 100.0 73.9 40.6 899 East 98.1 70.3 2.7 27.0 100.0 73.0 39.5 1,435 Education No education 96.8 74.2 3.4 22.4 100.0 77.6 38.1 583 Primary 97.3 67.1 3.3 29.6 100.0 70.4 36.5 3,916 Secondary and higher 99.5 74.1 4.3 21.5 100.0 78.5 41.2 1,189 Wealth quintile Lowest 96.4 65.2 4.8 30.0 100.0 70.0 35.7 854 Second 97.1 66.6 5.2 28.2 100.0 71.8 36.2 986 Middle 98.2 69.5 4.1 26.4 100.0 73.6 39.0 1,139 Fourth 97.6 69.5 2.5 27.9 100.0 72.1 38.5 1,235 Highest 98.5 73.1 2.1 24.8 100.0 75.2 38.1 1,474 Total 15-49 97.7 69.3 3.5 27.2 100.0 72.8 37.7 5,687 50-59 98.3 62.8 3.1 34.1 100.0 65.9 27.2 642 Total 15-59 97.8 68.6 3.5 27.9 100.0 72.1 36.6 6,329 1 Includes “don't know/missing” Nearly all of the women (99 percent) and men (98 percent) in Rwanda know where to get an HIV test. Table 13.11.1 presents data on HIV and AIDS information and counseling during antenatal care. Among women who had given birth in the past two years, 91 percent received information and counseling about HIV and AIDS during antenatal care for their most recent birth. Ninety-five percent of the women reported that they were tested for HIV during antenatal care; most of them also received the test results and posttest counseling (87 percent). Taking these occurrences into account, the 2010 RDHS results indicate that 88 percent of women giving birth during the two-year period prior to the survey were counseled about HIV, were tested for HIV, and received the test results. Women living in urban areas were more likely than those living in rural areas to have received comprehensive HIV and AIDS counseling and testing services during antenatal care. According to province, pregnant women living in the City of Kigali (92 percent) were slightly more likely to have received HIV and AIDS counseling and testing services. Women with a secondary education or higher were more likely than those with no education to receive full counseling and testing services during pregnancy. Eighty-five percent of women in the lowest wealth quintile received HIV and AIDS counseling and testing services during pregnancy, whereas 93 percent of women in the fourth wealth quintile and 92 percent of those in the highest wealth quintile did. 196 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.11.1 Pregnant women counseled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received HIV pretest counseling, the percentage who received an HIV test during antenatal care for their most recent birth by whether they received their results and post-test counseling, and percentage who received an HIV test at the time of delivery for their most recent birth by whether they received their test results, according to background characteristics, Rwanda 2010 Background characteristic Percentage who received HIV counseling during antenatal care1 Percentage who were tested for HIV during antenatal care and who: Percentage who received pretest counseling, had an HIV test, and who received results Percentage who had an HIV test during labor and who: Number of women who gave birth in the past two years2 Received results and received post-test counseling Received results and did not receive post-test counseling Did not receive results Received results Did not receive results Age 15-24 90.5 88.3 7.1 0.4 88.9 0.5 0.0 882 …15-19 82.7 79.1 10.3 0.9 80.8 2.6 0.0 116 …20-24 91.7 89.7 6.6 0.3 90.1 0.1 0.0 766 25-29 91.8 87.0 7.2 0.8 89.1 0.0 0.1 1,005 30-39 90.8 87.8 6.3 0.9 88.3 0.0 0.1 1,080 40-49 85.4 84.3 6.7 1.2 83.4 0.5 0.0 241 Marital status Never married 86.5 83.4 6.4 1.1 83.5 0.7 0.0 271 …Ever had sex 86.5 83.4 6.4 1.1 83.5 0.7 0.0 271 Married/Living together 91.3 88.5 6.6 0.6 89.1 0.1 0.1 2,682 Divorced/Separated/Widowed 87.6 80.2 9.5 1.8 85.1 0.5 0.0 255 Residence Urban 94.0 91.9 4.3 0.8 92.7 0.0 0.2 381 Rural 90.2 86.8 7.2 0.7 87.8 0.2 0.0 2,827 Province City of Kigali 93.5 90.9 6.1 0.4 92.3 0.0 0.2 297 South 89.3 86.1 6.7 1.6 85.6 0.6 0.1 759 West 91.7 88.7 5.5 0.3 89.6 0.1 0.0 874 North 89.0 86.0 7.6 0.4 85.9 0.0 0.0 478 East 90.6 86.9 8.3 0.8 89.5 0.0 0.0 800 Education No education 87.9 83.4 6.8 1.6 84.0 0.2 0.1 550 Primary 90.9 88.0 6.8 0.6 88.8 0.1 0.0 2,364 Secondary and higher 93.6 90.3 7.1 0.6 92.3 0.4 0.3 294 Wealth quintile Lowest 88.4 83.9 7.0 1.2 84.6 0.5 0.0 776 Second 88.2 86.3 7.5 1.3 85.9 0.2 0.0 736 Middle 90.8 85.6 8.5 0.2 88.3 0.0 0.2 595 Fourth 94.5 92.1 5.5 0.3 93.2 0.0 0.0 578 Highest 92.8 91.3 5.2 0.5 92.0 0.0 0.1 523 Total 15-49 90.6 87.4 6.8 0.7 88.3 0.2 0.1 3,208 1 In this context, "counseled" means that someone talked with the respondent about all three of the following topics: 1) babies getting the AIDS virus from their mother, 2) preventing the virus, and 3) getting tested for the virus. 2 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. Table 13.11.2 shows that, among the adult population age 15-49, 27 percent of women and 28 percent of men have been tested for HIV for prenuptial purposes. The percentages of women and men who were tested vary significantly by age and marital status. As one would expect, testing rates were highest among currently-married respondents (42 percent of women and 52 percent of men). Respondents age 25-29 have the highest proportion of testing for HIV for prenuptial purposes (54 percent each, for women and for men). The proportion of respondents that is tested for prenuptial purposes is lowest in North province (22 percent for women and 25 percent for men). This proportion is highest for women in East province (32 percent) and for men in the City of Kigali (31 percent). Variation of testing for prenuptial purposes by area of residence is small, and that by wealth quintile is not linear. Table 13.11.2 also indicates that the large majority of ever-married women and men age 15-49 have been tested as a couple sometime in the past (72 percent for women and 84 percent for men). Older women and men (40- 49) are the least likely to have ever been tested as a couple sometime in the past (45 percent for women and 76 percent for men). Respondents who are formerly married and those who have no education are less likely to be HIV and AIDS Related Knowledge, Attitudes, and Behavior • 197 tested as a couple than those who are currently in union and those who have at least primary education. Variations of testing as a couple by other background characteristics are small. Table 13.11.2 HIV testing for prenuptial purposes and as a couple Percentage of women and men age 15-49 who were ever tested for the HIV virus for prenuptial purposes and percentage of ever married women and men age 15-49 who were ever tested for the HIV virus as a couple, by background characteristics, Rwanda 2010 Background characteristic Percentage of all women and men age 15-49 who were ever tested for prenuptial purposes Percentage of ever married women and men age 15-49 who were ever tested for the HIV virus as a couple Percentage of women Number of women Percentage of men Number of men Percentage of women Number of women Percentage of men Number of men Age 15-24 20.9 5,628 10.2 2,607 88.6 1,212 87.3 236 .15-19 7.0 2,945 1.5 1,449 79.1 106 * 3 .20-24 36.2 2,683 21.1 1,159 89.5 1,106 87.6 233 25-29 54.1 2,494 54.2 1,038 88.3 1,943 90.0 672 30-39 28.5 3,269 50.5 1,201 73.7 3,034 84.2 1,092 40-49 9.0 2,280 19.6 842 45.3 2,197 76.3 814 Marital status Never married 8.6 5,285 5.0 2,873 na na na na …Ever had sex 11.5 1,188 7.8 1,140 na na na na …Never had sex 7.7 4,097 3.1 1,733 na na na na Married/Living together 42.3 6,897 52.2 2,699 79.3 6,897 84.3 2,699 Divorced/Separated/Widowed 19.4 1,489 41.7 115 37.1 1,489 65.9 115 Residence Urban 28.9 2,057 29.1 939 74.1 1,145 83.8 411 Rural 26.4 11,614 27.9 4,748 71.4 7,241 83.5 2,403 Province City of Kigali 30.3 1,596 30.5 739 77.8 877 82.6 323 South 27.8 3,212 29.7 1,308 67.5 1,990 83.3 647 West 22.6 3,305 25.8 1,307 69.6 1,996 83.8 637 North 21.5 2,278 25.2 899 74.3 1,380 85.9 444 East 32.0 3,280 29.6 1,435 73.8 2,142 82.7 762 Education No education 19.0 2,119 30.1 583 58.8 1,825 76.9 460 Primary 29.4 9,337 30.0 3,916 75.3 5,710 84.7 1,979 Secondary and higher 23.1 2,216 21.1 1,189 76.5 851 85.9 375 Wealth quintile Lowest 26.4 2,622 31.9 854 67.3 1,808 82.8 491 Second 24.7 2,661 29.5 986 69.7 1,733 83.5 537 Middle 26.7 2,736 29.0 1,139 72.6 1,664 83.1 584 Fourth 27.7 2,677 25.3 1,235 73.9 1,625 85.0 600 Highest 28.3 2,976 26.8 1,474 76.2 1,556 83.3 602 Total 15-49 26.8 13,671 28.1 5,687 71.8 8,386 83.6 2,814 50-59 na na 9.4 642 na na 51.1 635 Total 15-59 na na 26.2 6,329 na na 77.6 3,450 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 13.7 REPORTS OF RECENT SEXUALLY TRANSMITTED INFECTIONS Information about the incidence of sexually transmitted infections is useful not only as a marker of unprotected sexual intercourse but also as a cofactor for HIV transmission. The 2010 RDHS asked respondents who had ever had sex whether they had had an STI in the past 12 months. They were also asked whether, in the past year, they had experienced a genital sore or ulcer and whether they had any genital discharge. These symptoms have been shown to be useful in identifying STIs in men. They are less easily interpreted in women because women are likely to experience more non-STI conditions of the reproductive tract that produce a discharge. Table 13.12 shows the self-reported prevalence of STIs and STI symptoms among women and men age 15- 49 who have ever had sexual intercourse. Three percent of women and 2 percent of men who have ever had sex reported having had an STI in the 12 months before the survey. Six percent of women and 5 percent of men reported having had an abnormal genital discharge. Furthermore, 4 percent each of women and men reported having had a 198 • HIV and AIDS Related Knowledge, Attitudes, and Behavior genital sore or ulcer in the past 12 months. Overall, 8 percent each of women and men had either an STI or symptoms of an STI in the 12 months preceding the survey. Table 13.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Rwanda 2010 Background characteristic Women Men STI Bad smelling/ abnormal genital discharge Genital sore/ ulcer STI/ genital discharge/ sore or ulcer Number of respondents who ever had sexual intercourse STI Bad smelling/ abnormal genital discharge Genital sore/ ulcer STI/ genital discharge/ sore or ulcer Number of respondents who ever had sexual intercourse Age 15-24 3.1 6.1 3.8 7.9 1,979 2.1 7.9 3.8 10.7 1,011 …15-19 2.5 5.5 3.0 6.9 429 1.4 9.2 3.6 11.5 310 …20-24 3.2 6.3 4.1 8.1 1,550 2.4 7.3 4.0 10.3 701 25-29 3.1 5.6 4.0 7.9 2,181 3.1 5.7 4.3 9.1 921 30-39 3.4 6.5 4.5 9.0 3,154 2.3 2.7 4.2 7.1 1,185 40-49 3.2 6.6 4.7 8.5 2,254 2.0 1.7 3.4 6.3 833 Marital status Never married 3.0 6.5 4.4 8.4 1,184 2.1 8.0 3.6 10.7 1,137 Married/Living together 3.1 5.9 4.2 8.0 6,895 2.4 3.1 4.0 7.2 2,698 Divorced/Separated/Widowed 3.8 7.6 5.0 10.4 1,489 4.4 3.2 7.0 12.1 115 Male circumcision Circumcised na na na na 0 2.8 2.4 2.4 5.9 609 Not circumcised na na na na 0 2.3 4.9 4.2 8.8 3,339 DK/Missing na na na na 0 * * * * 2 Residence Urban 4.2 7.3 4.3 10.0 1,418 3.8 5.8 5.3 10.6 679 Rural 3.0 6.1 4.3 8.1 8,150 2.1 4.3 3.7 7.9 3,272 Province City of Kigali 3.6 6.3 4.2 9.1 1,103 3.5 4.3 4.4 9.4 547 South 2.6 7.4 5.0 10.0 2,265 1.6 5.6 4.4 9.4 865 West 3.5 6.8 4.4 7.9 2,239 2.7 4.9 5.1 9.5 867 North 1.7 4.5 2.0 6.1 1,555 1.7 4.6 2.5 6.5 635 East 4.3 5.8 5.1 8.5 2,407 2.6 3.4 3.4 6.9 1,036 Education No education 3.4 5.9 4.0 7.5 1,951 1.4 2.4 3.8 6.4 511 Primary 3.2 6.6 4.5 8.9 6,503 2.6 5.3 4.1 9.1 2,722 Secondary and higher 2.8 5.1 3.6 7.0 1,114 2.4 2.9 3.6 6.8 716 Wealth quintile Lowest 3.4 6.2 4.6 8.7 2,010 2.4 5.4 5.5 9.5 619 Second 3.3 7.0 4.6 9.0 1,916 2.0 3.7 3.7 7.6 674 Middle 2.2 5.0 3.8 7.2 1,880 2.1 5.5 4.3 9.4 798 Fourth 3.4 6.3 4.1 8.0 1,823 2.5 4.6 3.8 8.2 824 Highest 3.8 6.8 4.4 9.1 1,938 2.7 3.8 3.1 7.3 1,036 Total 15-49 3.2 6.3 4.3 8.4 9,568 2.4 4.5 4.0 8.3 3,950 50-59 na na na na 0 2.2 2.5 2.6 5.8 640 Total 15-59 na na na na 0 2.3 4.2 3.8 8.0 4,591 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable The results presented in Table 13.12 indicate that the proportion of respondents who reported having had an STI or an STI symptom varied slightly across provinces. Among women, self-reported prevalence of STIs and STI symptoms ranged from a low of 6 percent in the North province to a high of 10 percent in the South province. Among men, 10 percent reported STIs or symptoms of STIs in the West province, as compared with 7 percent in the North and East provinces. Figure 13.1 shows that, among those reporting a sexually transmitted infection or symptom thereof in the past year, women were more likely to seek treatment from various sources than men (60 percent versus 42 percent). Moreover, among those who sought treatment, women were more likely than men to seek treatment from a health professional (54 percent versus 35 percent). HIV and AIDS Related Knowledge, Attitudes, and Behavior • 199 Figure 13.1 Women and Men Seeking Treatment for STIs 54 1 5 39 35 3 4 54 Clinic/hospital/private Advice or medicine from Advice or treatment No advice or treatment 0 10 20 30 40 50 60 70 Women Men RDHS 2010 doctor/other health professional shop/pharmacy from any other source 13.8 NEEDLE AND SYRINGE INJECTION Injection overuse in a health care setting can contribute to the transmission of blood-borne pathogens because it amplifies the effects of unsafe practices such as reuse of injection equipment. As a consequence, the proportion of injections given with reused injection equipment is an important prevention indicator in initiatives designed to control the spread of HIV and AIDS. Table 13.13 presents data on the prevalence of injections among respondents. Respondents were asked whether they had had any injections given by a health worker in the 12 months preceding the survey and, if so, the number of injections they had received and whether their last injection was given with a syringe from a new, unopened package. Women were more likely than men to report having received at least one injection from a health provider in the past 12 months (56 percent and 45 percent, respectively). On average, women had received 1.5 injections, and men had received 0.8 injections. The variations in injection prevalence were observed across provinces. Among both women and men, the percentage reporting that they had received at least one injection from a health worker during the 12 months prior to the survey is lowest in the South province (48 percent in women and 39 percent in men). The prevalence of medical injection among women is highest in the City of Kigali and in the North province (62 percent and 63 percent respectively). Among men, the South province has the lowest proportion of men who received a medical injections in the past 12 months, while the likelihood of having received an injection in four other provinces is about the same (46-48 percent). The urban versus rural difference for receiving at least one injection from a health provider is small. Receiving at least one injection increases as the levels of education and wealth increase. Women and men who are currently married, formerly married, or never married but sexually active are more likely to have received at least one injection from a health provider than those who have never married and have never had sex. 200 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.13 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the last 12 months, the average number of medical injections per person in the last 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Rwanda 2010 Background characteristic Women Men Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respondents For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respondents For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months Age 15-24 49.2 1.2 5,628 98.7 2,769 39.9 0.7 2,607 99.3 1,039 …15-19 37.4 0.7 2,945 98.4 1,101 33.8 0.6 1,449 99.1 490 …20-24 62.2 1.7 2,683 98.9 1,668 47.4 0.9 1,159 99.4 549 25-29 70.0 2.1 2,494 98.8 1,745 53.6 0.9 1,038 99.4 556 30-39 63.1 1.9 3,269 98.8 2,063 48.1 1.0 1,201 99.2 578 40-49 45.9 1.3 2,280 98.9 1,047 44.4 0.9 842 98.9 373 Marital status Never married 41.6 0.8 5,285 98.3 2,197 38.9 0.7 2,873 99.2 1,117 Ever had sex 59.8 1.4 1,188 98.8 710 47.6 0.9 1,140 99.2 543 Never had sex 36.3 0.7 4,097 98.1 1,487 33.1 0.6 1,733 99.3 575 Married/Living together 68.0 2.1 6,897 99.0 4,693 51.0 0.9 2,699 99.2 1,377 Divorced/Separated/Widowed 49.3 1.3 1,489 98.7 734 46.3 1.4 115 100.0 53 Residence Urban 58.2 1.8 2,057 98.4 1,197 46.6 1.0 939 99.8 438 Rural 55.3 1.5 11,614 98.8 6,426 44.4 0.8 4,748 99.1 2,109 Province City of Kigali 61.5 1.9 1,596 98.7 981 46.3 0.9 739 99.4 342 South 47.7 1.4 3,212 98.8 1,532 39.2 0.9 1,308 99.7 512 West 52.4 1.3 3,305 98.3 1,732 45.9 0.9 1,307 99.0 600 North 62.6 1.6 2,278 98.5 1,425 45.5 0.9 899 98.1 409 East 59.6 1.6 3,280 99.4 1,953 47.7 0.7 1,435 99.7 684 Education No education 51.2 1.4 2,119 98.9 1,084 41.9 0.7 583 98.8 244 Primary 55.8 1.6 9,337 98.7 5,207 43.8 0.8 3,916 99.2 1,713 Secondary and higher 60.1 1.6 2,216 98.9 1,332 49.6 0.9 1,189 99.4 590 Wealth quintile Lowest 51.9 1.4 2,622 98.7 1,361 42.3 1.1 854 99.8 361 Second 54.0 1.4 2,661 98.8 1,437 45.0 0.7 986 99.1 444 Middle 56.2 1.6 2,736 98.6 1,538 43.7 0.7 1,139 99.2 497 Fourth 58.0 1.6 2,677 99.1 1,552 45.0 0.8 1,235 98.5 555 Highest 58.3 1.7 2,976 98.7 1,736 46.8 0.9 1,474 99.6 690 Total 15-49 55.8 1.5 13,671 98.8 7,623 44.8 0.8 5,687 99.2 2,547 50-59 na na na na na 34.3 0.8 642 98.5 220 Total 15-59 na na na na na 43.7 0.8 6,329 99.2 2,767 Note : Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker na = Not applicable Practically all injections (99 percent among both women and men) were administered with a needle and syringe taken from a newly opened package. 13.9 HIV AND AIDS RELATED KNOWLEDGE AND BEHAVIOR AMONG YOUTH Knowledge of HIV and AIDS issues and related sexual behavior among youth age 15-24 is of particular interest because the period between sexual initiation and marriage is, for many young people, a time of sexual experimentation that may involve high-risk behaviors. This section considers a number of issues that relate to both transmission and prevention of HIV and AIDS among youth, including the extent to which youth have comprehensive knowledge of HIV and AIDS transmission and prevention modes and knowledge of a source where they can obtain condoms. Issues such as abstinence, age at sexual debut, and condom use are also covered in this section. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 201 13.9.1 Knowledge about HIV and AIDS and Source for Condoms Knowledge of how HIV is transmitted is crucial to help young people avoid AIDS. Young people are often at greater risk because they may have shorter relationships with more partners or engage in other risky behaviors. As discussed earlier, comprehensive knowledge is defined as knowing that people can reduce their risk of getting the AIDS virus by having sex with only one uninfected faithful partner and by using condoms consistently, that a healthy-looking person can have the AIDS virus, and that HIV cannot be transmitted by mosquito bites or by sharing food with a person who has AIDS. Table 13.14 shows that about half of women and men age 15-24 (53 percent of women, 47 percent of men) know all of these facts about HIV and AIDS. The level of comprehensive knowledge about HIV and AIDS slightly increases with age in the youth population, but is not associated with marital status. Table 13.14 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Rwanda 2010 Background characteristic Women Men Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of respondents Age 15-19 49.3 81.4 2,945 43.5 87.0 1,449 …15-17 46.2 77.5 1,862 41.2 83.7 929 …18-19 54.5 88.2 1,083 47.6 93.0 519 20-24 56.3 90.2 2,683 52.4 95.4 1,159 20-22 54.9 89.5 1,616 50.4 95.6 704 23-24 58.4 91.3 1,067 55.5 95.0 454 Marital status Never married 52.1 83.9 4,416 46.7 90.1 2,371 Ever had sex 52.4 90.7 769 51.1 96.6 778 Never had sex 52.0 82.4 3,647 44.6 86.9 1,593 Ever married 54.5 92.0 1,212 54.5 97.3 236 Residence Urban 66.0 91.5 909 53.4 95.4 388 Rural 50.1 84.5 4,720 46.4 89.9 2,219 Education No education 39.9 82.5 341 39.1 84.4 98 Primary 48.5 82.5 3,976 42.4 88.9 1,840 Secondary and higher 68.5 96.0 1,312 62.4 96.8 669 Total 52.6 85.6 5,628 47.4 90.7 2,607 1 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2 2 For this table, the following responses are not considered sources for condoms: friends, family members and home As expected, comprehensive HIV and AIDS knowledge is much more common among urban than rural youth. Young adults age 15-24 with a secondary education or higher are far more likely to have comprehensive knowledge of HIV and AIDS than those with no schooling. Because condoms play an important role in combating the transmission of HIV, young women were asked whether they knew where condoms could be obtained. Only “formal” sources of condoms were counted; friends and family and other similar sources were not included. As shown in Table 13.14, 86 percent of young women and 91 percent of young men know where to obtain a condom. Knowledge of a condom source among young women tends to increase with age. Ever-married young women and those who ever had sex are more likely to know about a source for condoms than those who have never been married or never had sex. Women in urban areas are more likely than those in rural areas to know of a condom 202 • HIV and AIDS Related Knowledge, Attitudes, and Behavior source. Consistent with the patterns observed for other indicators, young women who are better educated are more likely than their counterparts to know a source of condoms. A similar association between knowledge of a condom source and age, marital status, residence, and level of education was also observed among young men 15-24. 13.9.2 Age at First Sex and Condom Use at First Sexual Intercourse Information from the 2010 RDHS can be used to look at several important issues related to the initiation of sexual activity among youth, such as age at first sex and condom use at first sexual intercourse. Table 13.15 shows the proportion of women and men in the age 15-24 cohort who had sex before age 15 and before age 18. Approximately 4 percent of young women and 11 percent of young men had sex before age 15, whereas 17 percent of young women and 27 percent of young men had sex by age 18. Given that the median age at first marriage among Rwandan women is 21.4 years (see Chapter 5), few women report that they have had sex before the age of 15. Young adults age 15-19 are more likely to have sexual intercourse before age 15 than those age 20-24. Level of education showed a negative association with early initiation of sexual activity among women: as level of education increased, the proportion of women reporting sex before age 15 or 18 decreased. This association is not observed among men. Married women age 15-24 are more likely to have their first sex before age 18 than those who had never married (29 percent versus 11 percent). However, in an opposite trend, married men age 15-24 are less likely to have their first sex before the age of 15 or 18 than those who had never married. Young women and men who know a source of condoms are more likely to have sexual intercourse before age 18 than other women. Table 13.15 Age at first sexual intercourse among youth Percentage of young women and of young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and of young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Rwanda 2010 Background characteristic Women Men Percentage who had sexual intercourse before age 15 Number of respondents (15-24) Percentage who had sexual intercourse before age 18 Number of respondents (18-24) Percentage who had sexual intercourse before age 15 Number of respondents (15-24) Percentage who had sexual intercourse before age 18 Number of respondents (18-24) Age 15-19 4.8 2,945 na na 13.3 1,449 na na …15-17 4.5 1,862 na na 12.0 929 na na …18-19 5.1 1,083 18.7 1,083 15.7 519 27.7 519 20-24 2.8 2,683 16.0 2,683 8.8 1,159 26.4 1,159 20-22 2.9 1,616 16.2 1,616 9.6 704 28.6 704 23-24 2.7 1,067 15.7 1,067 7.7 454 22.8 454 Marital status Never married 3.8 4,416 11.2 2,559 12.1 2,371 27.6 1,442 Ever married 4.1 1,212 28.7 1,207 3.4 236 21.8 236 Knows condom source1 Yes 3.7 4,819 17.5 3,376 11.7 2,366 27.4 1,588 No 4.3 809 10.5 390 7.6 241 15.5 90 Residence Urban 4.2 909 20.6 645 8.4 388 27.4 281 Rural 3.8 4,720 16.0 3,121 11.8 2,219 26.7 1,397 Education No education 7.2 341 31.4 301 10.4 98 26.9 78 Primary 4.1 3,976 17.4 2,524 11.4 1,840 27.6 1,108 Secondary and higher 2.2 1,312 10.5 941 11.1 669 24.9 491 Total 3.8 5,628 16.8 3,766 11.3 2,607 26.8 1,678 na = Not available 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home 13.9.3 Recent Sexual Activity The period between age at first sex and age at marriage is often a time of sexual experimentation. Unfortunately, for those who may be exposed to HIV and AIDS, it can also be a risky time. Table 13.16 presents HIV and AIDS Related Knowledge, Attitudes, and Behavior • 203 data on the percentage of never-married young women and men age 15-24 who have never had sexual intercourse, the percentage who had sex in the 12 months preceding the survey, and, among youth who have had sexual intercourse in the past 12 months, the percentage who used condoms during their most recent sexual intercourse. Table 13.16 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Rwanda 2010 Background characteristic Women Men Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never married respondents Percentage who used a condom at last sexual intercourse Number of respondents who had sexual intercourse in the past 12 months Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never married respondents Percentage who used a condom at last sexual intercourse Number of respondents who had sexual intercourse in the past 12 months Age 15-19 88.5 4.6 2,840 41.9 132 78.6 5.2 1,446 57.5 75 …15-17 92.2 2.8 1,857 40.5 51 83.9 2.8 929 (37.9) 26 …18-19 81.6 8.2 982 42.7 80 69.1 9.4 516 (68.1) 49 20-24 71.9 11.0 1,577 42.1 173 49.4 19.7 925 69.8 182 20-22 74.5 10.5 1,109 39.9 116 52.4 18.2 619 66.7 112 23-24 65.8 12.2 468 46.7 57 43.2 22.8 306 74.8 70 Knows condom source1 Yes 81.2 7.7 3,704 44.4 286 64.8 11.9 2,136 66.7 254 No 90.0 2.6 712 * 19 88.8 1.5 235 * 4 Residence Urban 77.0 11.2 727 52.6 82 61.1 18.8 370 76.3 70 Rural 83.7 6.0 3,689 38.1 223 68.3 9.4 2,001 62.5 188 Education No education 68.2 12.9 173 * 22 61.7 16.3 75 * 12 Primary 82.7 7.0 3,052 35.1 214 67.8 11.0 1,643 62.3 180 Secondary and higher 84.4 5.7 1,191 65.8 68 66.3 9.9 653 76.3 65 Total 82.6 6.9 4,416 42.0 305 67.2 10.8 2,371 66.2 257 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home Eighty-three percent of never-married young women and 67 percent of never-married men reported that they had never had sex, and as a result the proportions reporting recent sexual activity (i.e., within the 12-month period before the survey) are low (7 percent among young women and 11 percent among young men). Among never-married, sexually active young women, condom use at last sexual intercourse was 42 percent. Condom use is higher in the urban areas and among those with secondary education and higher than in the rural areas and among those with a lower level of education. Among never-married, sexually active young men, condom use at last sexual intercourse was 66 percent. Similar to women, condom use is higher in the urban areas than in the rural areas and increases with level of education. For example, 76 percent of sexually active, never-married young men who have more than a secondary education used a condom the last time they had sexual intercourse, compared with 62 percent of those with a primary education. 13.9.4 Multiple Sexual Partnerships The most common mode of HIV transmission in Rwanda is through unprotected sex with an infected person. To prevent HIV and AIDS transmission, it is important for young people to be faithful to one uninfected partner. Table 13.17 shows the percentage of all young women and men age 15-24 who had had sexual intercourse with more than one partner in the past 12 months, by background characteristics. 204 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.17 Multiple sexual partners in the past 12 months among young people Percentage of young adults age 15-24 who had sexual intercourse with more than one sexual partner in the past 12 months by background characteristics, Rwanda 2010 Background characteristic Among all women age 15-24 Among all men age 15-24 Percentage who had 2+ partners in the past 12 months Number of women Percentage who had 2+ partners in the past 12 months Number of men Age 15-19 0.3 2,945 0.4 1,449 …15-17 0.1 1,862 0.1 929 …18-19 0.7 1,083 1.1 519 20-24 0.9 2,683 3.2 1,159 20-22 1.2 1,616 2.7 704 23-24 0.4 1,067 3.9 454 Marital status Never married 0.4 4,416 1.3 2,371 Ever married 1.2 1,212 5.7 236 Knows condom source1 Yes 0.6 4,819 1.8 2,366 No 0.2 809 0.0 241 Residence Urban 1.1 909 2.6 388 Rural 0.5 4,720 1.5 2,219 Education No education 1.6 341 2.1 98 Primary 0.6 3,976 1.7 1,840 Secondary or higher 0.2 1,312 1.4 669 Total 15-24 0.6 5,628 1.7 2,607 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home Overall, only less than 1 percent of young women and less than 2 percent of young men who had sexual intercourse reported having had two or more sexual partners in the past 12 months. Women age 20-22, those who had ever been married, and those who live in urban areas reported having had two or more sexual partners in the past 12 months—more than other women. Young women with no education are more likely than other women to have had two or more sexual partners in the past 12 months. Overall, 29 percent of young women who had high-risk sexual intercourse used a condom the last time they had high-risk sexual intercourse (data not shown). Among men, those age 23-24 (4 percent), those who had ever been married (6 percent), and those who live in urban areas (3 percent) are more likely than other men to have had two or more sexual partners in the past 12 months. Young men who had high-risk sexual intercourse are twice as likely as young women to use a condom the last time they had high-risk sexual intercourse (58 percent versus 29 percent, data not shown). 13.9.5 HIV Testing Young people may believe there are barriers to accessing and using many health services and facilities, and this is particularly true for sensitive concerns relating to sexual health, such as HIV and AIDS and other STIs. Table 13.18 presents data on the percentage of sexually active youth who had been tested and received their results within the past year. More than half of young women and young men who had had sexual intercourse in the past 12 months had been tested for HIV and received their test results (59 percent and 55 percent, respectively). HIV and AIDS Related Knowledge, Attitudes, and Behavior • 205 Table 13.18 Recent HIV tests among youth Among young women and young men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who have had an HIV test in the past 12 months and received the results of the test, by background characteristics, Rwanda 2010 Background characteristic Among women age 15-24 who have had sexual intercourse in the past 12 months: Among men age 15-24 who have had sexual intercourse in the past 12 months: Percentage who have been tested for HIV and received results in the past 12 months Number of women Percentage who have been tested for HIV and received results in the past 12 months Number of men Age 15-19 59.4 229 37.4 78 …15-17 46.5 56 (26.2) 26 …18-19 63.6 173 43.1 52 20-24 59.4 1,233 57.8 414 20-22 63.3 604 58.9 197 23-24 55.5 628 56.8 217 Marital status Never married 57.8 305 47.1 257 Ever married 59.8 1,157 62.7 235 Knows condom source1 Yes 59.8 1,355 54.6 482 No 53.3 106 * 10 Residence Urban 61.4 252 54.2 88 Rural 58.9 1,209 54.7 404 Education No education 60.2 181 (68.3) 34 Primary 58.2 1,101 54.2 377 Secondary and higher 65.6 180 50.5 80 Total 59.4 1,461 54.6 492 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home 13.10 MALE CIRCUMCISION According to current medical opinion, circumcision may provide protection against HIV infection. Male circumcision is recommended by WHO as one of the HIV prevention methods. Since 2008, the Rwandan Health Ministry (MINISANTÉ) had adopted this program and it is now part of 2009-2012 National Strategic Plan against HIV and AIDS. The 2010 RDHS collected data on the prevalence of circumcision among male respondents, including age at circumcision and type of practitioner who performed the procedure. Circumcised men were also asked the main reason for their circumcision. In Rwanda, only 13 percent of men age 15-59 have been circumcised (Table 13.19). The rate varies according to their background characteristics. Results by age group show that the prevalence of circumcision among men age 15-19 is 10 percent. The prevalence increases sharply from the age of 20 and reaches the highest point (18 percent) among men age 30-34. It drops gradually from age 35-39 (13 percent) and is only 6 percent among men age 55-59. There are also large geographic differentials, with the practice occurring more frequently in urban areas (32 percent) than in rural areas (10 percent). By province, the proportion of men who are circumcised is highest in the City of Kigali (34 percent) and the West province (20 percent), while it does not exceed 10 percent in the other provinces. There are also socioeconomic differences in the prevalence of circumcision, with the highest proportions among men who have secondary or higher education (30 percent) and those in the highest (richest) wealth quintile 206 • HIV and AIDS Related Knowledge, Attitudes, and Behavior (29 percent). Finally, differentials by religion show that a large proportion of Muslim men are circumcised (73 percent) compared with men of other religious categories (15 percent or less). Men who were circumcised were asked who had performed the procedure. About eight in ten men (78 percent) said they were circumcised by a health professional. This proportion remains high irrespective of background characteristics. In urban areas (83 percent), in the City of Kigali (83 percent), in the South and North provinces (86 percent, each), among the most educated men (84 percent), and among men in the highest wealth quintile (83 percent), at least four of five circumcisions were performed by a health professional. The lowest rate is seen among men in the lowest wealth quintile (60 percent), who were almost as likely to be circumcised by a traditional practitioner (29 percent). Seven of 10 circumcisions were carried at a health facility, whereas about 1 in 10 was carried out at ritual site (Table 13.20). About 5 percent of circumcisions were carried out at the home of the health care providers and 6 percent were at the home of the respondents. Table 13.19 Practice of circumcision Percentage of men age 15-59 who are circumcised, and percent distribution of circumcised men by type of practitioner who performed the circumcision, according to background characteristics, Rwanda 2010 Background characteristic Percentage circumcised Number of men Who performed the circumcision Traditional practitioner/ family friend Health worker/ professional Other Don't know Missing Total Number of circumcised men Age 15-19 10.0 1,448 11.3 76.2 7.8 3.8 1.0 100.0 146 20-24 16.1 1,157 11.0 72.7 9.3 5.9 1.1 100.0 187 25-29 17.2 1,037 8.2 78.0 5.2 8.0 0.6 100.0 178 30-34 17.7 710 11.4 81.2 2.4 3.4 1.6 100.0 126 35-39 12.8 494 8.8 75.5 11.1 4.6 0.0 100.0 63 40-44 12.4 429 12.9 80.6 6.5 0.0 0.0 100.0 53 45-49 10.0 412 (6.1) (93.9) (0.0) (0.0) (0.0) 100.0 41 50-54 8.9 383 (12.9) (76.7) (10.4) (0.0) (0.0) 100.0 34 55-59 6.0 258 * * * * * 100.0 16 Residence Urban 31.6 1,005 5.8 82.8 6.9 4.0 0.5 100.0 317 Rural 9.9 5,324 12.7 75.1 6.5 4.8 0.9 100.0 526 Province City of Kigali 33.9 789 6.4 82.7 7.8 2.9 0.2 100.0 268 South 4.5 1,444 6.6 85.7 4.5 0.0 3.2 100.0 65 West 20.4 1,488 17.3 70.9 5.1 5.7 0.9 100.0 303 North 5.2 1,014 (3.9) (85.9) (2.0) (6.3) (1.9) 100.0 53 East 9.7 1,594 6.1 77.7 10.2 6.1 0.0 100.0 154 Education No education 7.4 757 13.1 79.0 5.3 2.6 0.0 100.0 56 Primary 9.4 4,323 14.2 72.6 9.0 3.0 1.2 100.0 407 Secondary and higher 30.4 1,249 5.3 83.5 4.4 6.4 0.4 100.0 380 Religion Catholic 9.7 3,068 11.7 77.7 4.7 5.2 0.8 100.0 298 Protestant 14.9 2,227 10.6 78.3 6.8 3.7 0.6 100.0 332 Adventist 13.7 747 6.6 84.0 2.8 5.6 1.0 100.0 102 Muslim 72.6 120 6.3 70.5 17.0 4.9 1.3 100.0 87 Traditional/Other/No religion 14.4 166 12.2 79.4 8.4 0.0 0.0 100.0 24 Wealth quintile Lowest 6.3 937 28.8 60.0 11.2 0.0 0.0 100.0 59 Second 6.8 1,108 12.3 72.4 9.3 4.7 1.3 100.0 75 Middle 8.1 1,306 14.8 71.0 9.4 2.2 2.7 100.0 106 Fourth 10.2 1,391 8.1 78.3 6.4 6.4 0.7 100.0 142 Highest 29.0 1,586 6.9 82.7 5.1 5.0 0.4 100.0 460 Total 13.3 6,329 10.1 78.0 6.7 4.5 0.8 100.0 843 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. HIV and AIDS Related Knowledge, Attitudes, and Behavior • 207 Table 13.20 Place of circumcision Percent distribution of circumcised men age 15-59 by place of circumcision, according to background characteristics, Rwanda 2010 Background characteristic Place of circumcision Health facility Home of a health worker/ professional Circumcision done at home Ritual site Other home/ place Don't know/ missing Total Number of circumcised men Age 15-19 66.8 5.0 10.4 9.6 3.5 4.7 100.0 146 20-24 66.6 5.7 4.1 12.1 5.0 6.5 100.0 187 25-29 69.3 5.1 3.4 9.7 6.1 6.3 100.0 178 30-34 72.2 6.0 5.3 5.8 5.8 4.9 100.0 126 35-39 68.0 5.5 4.8 11.9 7.4 2.3 100.0 63 40-44 80.5 3.0 3.9 10.0 2.6 0.0 100.0 53 45-49 (77.1) (3.0) (10.2) (9.6) (0.0) (0.0) 100.0 41 50-54 (73.7) (2.8) (3.4) (6.7) (13.5) (0.0) 100.0 34 55-59 * * * * * * 100.0 16 Residence Urban 78.3 2.3 7.3 3.6 4.6 3.9 100.0 317 Rural 65.5 6.6 4.3 13.3 5.5 4.8 100.0 526 Province City of Kigali 79.3 1.7 7.1 3.2 5.5 3.3 100.0 268 South 79.3 3.1 3.8 6.1 6.3 1.5 100.0 65 West 60.2 9.3 4.8 16.3 3.8 5.5 100.0 303 North (79.2) (4.0) (2.5) (3.9) (4.2) (6.3) 100.0 53 East 67.8 3.3 5.6 11.4 6.8 5.2 100.0 154 Education No education 59.9 13.8 7.1 9.7 9.5 0.0 100.0 56 Primary 62.5 5.6 5.3 14.5 8.0 4.2 100.0 407 Secondary and higher 80.2 3.0 5.4 4.5 1.4 5.5 100.0 380 Religion Catholic 70.5 4.1 5.0 9.3 5.1 6.0 100.0 298 Protestant 72.3 6.2 3.8 10.8 3.5 3.4 100.0 332 Adventist 75.8 3.7 4.4 5.8 5.9 4.4 100.0 102 Muslim 55.6 5.4 13.7 10.0 10.4 4.9 100.0 87 Traditional/Other/No religion 71.4 2.5 8.4 13.4 4.3 0.0 100.0 24 Wealth quintile Lowest 50.2 7.6 4.1 28.6 9.5 0.0 100.0 59 Second 59.1 8.7 2.2 17.7 8.1 4.1 100.0 75 Middle 62.7 6.1 3.4 15.8 7.2 4.8 100.0 106 Fourth 66.8 8.7 4.9 10.1 3.1 6.4 100.0 142 Highest 77.5 2.6 6.8 4.4 4.2 4.4 100.0 460 Total 70.3 5.0 5.5 9.7 5.1 4.5 100.0 843 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Men who said they had been circumcised were asked how old they were at the time of circumcision. The results are presented in Table 13.21. About one-third of circumcisions (34 percent) took place before the age of 13, and over one-third of cases (35 percent) were performed between the ages of 13 and 19. Twenty-nine percent of circumcised men did that relatively late, at age 20 or later. Only 2 percent of the men were not certain when they were circumcised, perhaps because they were circumcised at a very young age and do not remember the event. No specific trends in age at circumcision can be seen with respect to the different age groups. However, a large proportion of subgroups of men with a high prevalence of circumcision, such as men living in urban areas (47 percent), men in the City of Kigali (50 percent), men who have secondary or higher education (43 percent), and men in the wealthiest households (44 percent), circumcision was performed before the age of 13 (43 percent or higher). However, only 38 percent of Muslim men were circumcised before age 13. 208 • HIV and AIDS Related Knowledge, Attitudes, and Behavior Table 13.21 Age at circumcision Percent distribution of circumcised men age 15-59 by age at circumcision, according to background characteristics, Rwanda 2010 Background characteristic Age at circumcision < 13 13-19 > 20 Don't know/ missing Total Number of circumcised men Age 15-19 45.0 53.6 0.0 1.4 100.0 146 20-24 35.2 43.3 18.9 2.6 100.0 187 25-29 29.6 22.7 46.7 1.0 100.0 178 30-34 27.9 28.3 41.5 2.3 100.0 126 35-39 44.8 26.9 28.3 0.0 100.0 63 40-44 34.3 22.2 43.6 0.0 100.0 53 45-49 (31.8) (32.9) (35.3) (0.0) 100.0 41 50-54 (17.7) (36.1) (40.5) (5.7) 100.0 34 55-59 * * * * 100.0 16 Residence Urban 47.2 22.1 30.2 0.5 100.0 317 Rural 26.4 42.7 28.5 2.4 100.0 526 Province City of Kigali 50.0 21.0 28.4 0.6 100.0 268 South 25.6 25.6 47.3 1.5 100.0 65 West 25.1 48.9 24.2 1.9 100.0 303 North (31.0) (33.4) (31.9) (3.7) 100.0 53 East 29.4 36.4 31.5 2.8 100.0 154 Education No education 26.8 32.8 35.4 4.9 100.0 56 Primary 26.6 42.2 29.5 1.7 100.0 407 Secondary and higher 43.4 27.6 27.8 1.3 100.0 380 Religion Catholic 30.1 36.9 31.0 2.0 100.0 298 Protestant 35.7 33.0 29.8 1.4 100.0 332 Adventist 35.5 39.5 23.1 1.9 100.0 102 Muslim 38.0 36.7 23.3 2.1 100.0 87 Traditional/Other/No religion 44.3 13.0 42.7 0.0 100.0 24 Wealth quintile Lowest 25.3 54.8 19.9 0.0 100.0 59 Second 19.9 44.6 33.1 2.4 100.0 75 Middle 26.8 43.5 24.2 5.5 100.0 106 Fourth 20.2 45.7 31.1 2.9 100.0 142 Highest 43.7 25.6 30.1 0.6 100.0 460 Total 34.2 35.0 29.1 1.7 100.0 843 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. HIV Prevalence • 209 HIV PREVALENCE 14 n Rwanda, much of the information on the national HIV prevalence estimates is derived from sentinel surveillance. Although surveillance data do not provide estimates of HIV prevalence for the general population, they do provide results specific to women attending antenatal clinics. The inclusion of HIV testing in the 2005 and 2010 RDHS offers the opportunity to better understand the magnitude and patterns of infection in the general population of reproductive age, including men age 15-59 who are not tested as part of antenatal (ANC) sentinel surveillance. The 2010 RDHS is the second RDHS survey to anonymously link HIV testing results with key behavioral and sociodemographic characteristics of both male and female respondents. The first survey to include HIV testing was the 2005 RDHS. These surveys provide national, population-based trend data for HIV prevalence estimates among women and men. This chapter presents information on the HIV testing coverage rates among eligible survey respondents, the prevalence of HIV infection among those tested, and the factors associated with HIV infection in the population. HIV specimen collection and testing methodologies used in the 2010 RDHS are described in Chapter 1. 14.1 COVERAGE RATES FOR HIV TESTING Table 14.1 shows the distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status. Ninety-nine percent of all RDHS respondents who were eligible for testing were interviewed and consented to HIV testing. The percentages of respondents who refused to be tested for HIV or were absent at the time of blood collection for the test and therefore did not provide a blood sample is very small. Coverage rates were slightly higher for women than for men (99 and 98 percent, respectively). The proportion of respondents who consented to the HIV test was slightly higher in rural areas than in urban areas for both women and men. Ninety- nine percent of women in rural areas consented to HIV testing, compared with 98 percent in urban areas. Among men, 98 percent consented to testing in rural areas, compared with 96 percent in urban areas. Table 14.1 Coverage of HIV testing by residence and province Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to residence and province (unweighted), Rwanda 2010 Background characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed WOMEN Residence Urban 97.8 0.0 0.6 0.2 0.1 0.1 0.8 0.5 100.0 1,243 Rural 99.1 0.1 0.1 0.1 0.0 0.1 0.1 0.5 100.0 5,789 Province City of Kigali 97.9 0.0 0.5 0.2 0.0 0.1 0.9 0.4 100.0 982 South 99.1 0.2 0.1 0.0 0.0 0.0 0.1 0.5 100.0 1,677 West 98.5 0.0 0.2 0.2 0.1 0.2 0.1 0.7 100.0 1,632 North 99.5 0.0 0.1 0.1 0.0 0.0 0.1 0.3 100.0 1,144 East 99.1 0.2 0.1 0.0 0.0 0.1 0.1 0.4 100.0 1,597 Total 98.9 0.1 0.2 0.1 0.0 0.1 0.2 0.5 100.0 7,032 MEN Residence Urban 96.2 0.1 1.0 0.3 0.1 0.4 0.8 1.0 100.0 1,178 Rural 98.6 0.0 0.1 0.1 0.0 0.2 0.1 0.9 100.0 5,236 Continued… I 210 • HIV Prevalence Table 14.1—Continued Background characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed MEN Province City of Kigali 96.0 0.0 1.3 0.3 0.1 0.5 0.9 0.8 100.0 948 South 99.0 0.1 0.1 0.0 0.0 0.1 0.1 0.7 100.0 1,529 West 97.8 0.1 0.3 0.3 0.0 0.2 0.2 1.0 100.0 1,437 North 98.4 0.1 0.0 0.0 0.0 0.2 0.0 1.3 100.0 987 East 98.8 0.0 0.1 0.1 0.0 0.1 0.0 0.9 100.0 1,513 Total 98.2 0.0 0.3 0.2 0.0 0.2 0.2 0.9 100.0 6,414 TOTAL Residence Urban 97.0 0.0 0.8 0.2 0.1 0.2 0.8 0.7 100.0 2,421 Rural 98.9 0.1 0.1 0.1 0.0 0.1 0.1 0.7 100.0 11,025 Province Kigali City 96.9 0.0 0.9 0.3 0.1 0.3 0.9 0.6 100.0 1,930 South 99.1 0.1 0.1 0.0 0.0 0.0 0.1 0.6 100.0 3,206 West 98.2 0.0 0.3 0.3 0.0 0.2 0.2 0.8 100.0 3,069 North 99.0 0.0 0.0 0.0 0.0 0.1 0.0 0.8 100.0 2,131 East 99.0 0.1 0.1 0.1 0.0 0.1 0.1 0.6 100.0 3,110 Total 98.5 0.1 0.2 0.1 0.0 0.1 0.2 0.7 100.0 13,446 1 Includes all Dried Blood Samples (DBS) tested at the lab and for which there is a result, i.e. positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes: 1) other results of blood collection (e.g. technical problem in the field), 2) lost specimens, 3) non corresponding bar codes, and 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. Table 14.2 shows HIV testing coverage rates for women age 15-49 and men age 15-59 by age, level of education, and wealth quintile. Because HIV testing coverage rates are nearly 100 percent, for women and men, variation by background characteristics is negligible. Additional tables describing the relationship between participation in the HIV testing and characteristics related to HIV risks are presented in Appendix A. Table 14.2 Coverage of HIV testing by selected background characteristics Percent distribution of women age 15-49 and men age 15-59 eligible for HIV testing by testing status, according to selected background characteristics (unweighted), Rwanda 2010 Background characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed WOMEN 15-19 98.9 0.1 0.0 0.1 0.0 0.1 0.3 0.5 100.0 1,572 20-24 98.7 0.1 0.2 0.0 0.0 0.1 0.4 0.5 100.0 1,408 25-29 98.6 0.2 0.2 0.2 0.1 0.1 0.1 0.6 100.0 1,286 30-34 99.2 0.1 0.1 0.1 0.0 0.0 0.2 0.2 100.0 898 25-39 98.6 0.0 0.6 0.1 0.0 0.1 0.1 0.4 100.0 723 40-44 99.2 0.0 0.2 0.0 0.0 0.0 0.0 0.7 100.0 609 45-49 99.3 0.0 0.4 0.0 0.0 0.0 0.2 0.2 100.0 536 Education No education 97.9 0.6 0.1 0.0 0.0 0.0 0.1 1.3 100.0 1,049 Primary 99.2 0.0 0.1 0.1 0.0 0.0 0.1 0.3 100.0 4,779 Secondary and higher 98.6 0.0 0.4 0.0 0.0 0.2 0.5 0.4 100.0 1,083 Wealth quintile Lowest 99.4 0.1 0.1 0.0 0.0 0.1 0.0 0.3 100.0 1,242 Second 99.1 0.1 0.1 0.0 0.0 0.0 0.1 0.6 100.0 1,380 Middle 99.2 0.1 0.1 0.1 0.0 0.1 0.1 0.3 100.0 1,350 Fourth 98.9 0.1 0.3 0.1 0.1 0.0 0.0 0.6 100.0 1,380 Highest 97.9 0.1 0.4 0.2 0.0 0.2 0.7 0.5 100.0 1,680 Total 98.9 0.1 0.2 0.1 0.0 0.1 0.2 0.5 100.0 7,032 Continued. HIV Prevalence • 211 Table 14.2—Continued Background characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed Interviewed Not interviewed MEN 15-19 98.9 0.0 0.3 0.1 0.0 0.2 0.1 0.3 100.0 1,446 20-24 97.4 0.0 0.3 0.4 0.0 0.0 0.2 1.7 100.0 1,184 25-29 98.0 0.2 0.1 0.2 0.1 0.1 0.6 0.8 100.0 1,059 30-34 97.6 0.0 0.5 0.0 0.0 0.4 0.3 1.2 100.0 738 25-39 98.8 0.0 0.0 0.0 0.0 0.2 0.0 1.0 100.0 494 40-44 98.4 0.0 0.5 0.0 0.0 0.7 0.0 0.5 100.0 439 45-49 98.5 0.2 0.2 0.0 0.0 0.0 0.0 1.0 100.0 411 50-54 97.7 0.0 0.5 0.0 0.0 0.5 0.3 1.0 100.0 385 55-59 98.4 0.0 0.0 0.4 0.0 0.0 0.4 0.8 100.0 258 Education No education 96.6 0.1 0.0 0.4 0.0 0.3 0.3 2.3 100.0 775 Primary 98.9 0.0 0.1 0.1 0.0 0.1 0.1 0.6 100.0 4,320 Secondary and higher 97.6 0.2 0.8 0.1 0.0 0.2 0.4 0.8 100.0 1,154 Missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 100.0 3 Wealth quintile Lowest 98.7 0.0 0.1 0.0 0.0 0.1 0.0 1.1 100.0 941 Second 97.7 0.2 0.1 0.2 0.0 0.1 0.1 1.6 100.0 1,111 Middle 99.1 0.0 0.1 0.1 0.0 0.2 0.1 0.5 100.0 1,273 Fourth 98.9 0.0 0.1 0.1 0.0 0.0 0.1 0.9 100.0 1,370 Highest 96.8 0.1 0.8 0.3 0.1 0.5 0.6 0.8 100.0 1,719 Total 98.2 0.0 0.3 0.2 0.0 0.2 0.2 0.9 100.0 6,414 1 Includes all Dried Blood Samples (DBS) tested at the lab and for which there is a result, i.e. positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes: 1) other results of blood collection (e.g. technical problem in the field), 2) lost specimens, 3) noncorresponding bar codes, and 4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 14.2 HIV PREVALENCE 14.2.1 HIV Prevalence by Age and Sex Table 14.3 shows that 3 percent of adults age 15-49 in Rwanda are infected with HIV. Among women age 15-49, the HIV prevalence rate is 4 percent, while among men age 15-49 the HIV prevalence rate is 2 percent. HIV prevalence increases with age for both women and men up to age 35- 39 for women and age 40-44 for men. For women, HIV prevalence among women age 35-39 is 8 percent, which is much higher than the rate among women age 15-19 (1 percent). For men, the prevalence increases sharply from less than 1 percent among men age 15-19 to 8 percent among those age 40-44, and drops to 6 percent among those age 45-49, and to 4 percent among those age 50-59. Figure 14.1 illustrates the age pattern of HIV prevalence for women and men. Table 14.3 HIV prevalence by age Among the de facto women age 15-49 and men age 15-59 who were interviewed and tested, the percentage HIV-1 positive, by age, Rwanda 2010 Women Men Total Age Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 0.8 1,532 0.3 1,450 0.5 2,982 20-24 2.4 1,372 0.5 1,158 1.5 2,531 25-29 3.9 1,270 1.7 1,037 2.9 2,307 30-34 4.2 880 3.5 710 3.9 1,590 35-39 7.9 715 3.8 493 6.3 1,208 40-44 6.1 612 7.5 430 6.7 1,042 45-49 5.8 534 5.6 413 5.7 947 Total 15-49 3.7 6,917 2.2 5,690 3.0 12,607 50-59 na na 4.0 641 na na Total 15-59 na na 2.4 6,331 na na na=Not applicable 212 • HIV Prevalence Figure 14.1 HIV Prevalence by Sex and Age % % % % % % % 0.3 0.5 1.7 3.5 3.9 7.3 5.8 + + + + + + + 0.8 2.4 3.9 4.2 7.9 6.1 5.6 15-19 20-24 25-29 30-34 35-39 40-44 45-49 0 1 2 3 4 5 6 7 8 9 Pe rc en t Women Men+ % 2010 RDHS 14.2.2 Trends in HIV Prevalence: 2005 RDHS and 2010 RDHS Table 14.4 shows trends in HIV prevalence over time, by age. In Rwanda, adult HIV prevalence is unchanged between the 2005 RDHS and the 2010 RDHS: 3 percent for each survey. HIV prevalence among women and men remained at 4 percent and 2 percent, respectively, over the five-year period. Table 14.4 Trends in HIV prevalence by age Among de facto women age 15-49 and men age 15-54 who were interviewed and tested, the percentage HIV positive, by age, Rwanda 2005 and 2010 Age Women Men Total RDHS 2005 RDHS 2010 RDHS 2005 RDHS 2010 RDHS 2005 RDHS 2010 Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 0.6 1,316 0.8 1,532 0.4 1,087 0.3 1,450 0.5 2,403 0.5 2,982 20-24 2.5 1,142 2.4 1,372 0.5 939 0.5 1,158 1.6 2,080 1.5 2,531 25-29 3.4 833 3.9 1,270 2.1 628 1.7 1,037 2.9 1,461 2.9 2,307 30-34 5.9 806 4.2 880 4.2 497 3.5 710 5.2 1,303 3.9 1,590 35-39 6.9 540 7.9 715 2.3 432 3.9 493 4.8 972 6.3 1,208 40-44 6.3 554 6.1 612 7.1 401 7.3 430 6.6 955 6.6 1,042 45-49 4.1 464 5.8 534 5.3 378 5.6 413 4.6 842 5.7 947 Total 15-49 3.6 5,656 3.7 6,917 2.3 4,361 2.2 5,690 3.0 10,016 3.0 12,607 Total men15-59 na na na na 2.2 4,763 2.4 6,331 na na na na na = Not applicable HIV Prevalence • 213 14.2.3 HIV Prevalence by Socioeconomic Characteristics Table 14.5 shows the variation in HIV prevalence by various socioeconomic characteristics, including residence, province, religion, education, employment, and wealth quintile. HIV prevalence in urban areas is more than three times that in rural areas: 7 percent of women and men age 15-49 in urban areas are infected with HIV compared with 2 percent in rural areas. The City of Kigali has the highest HIV prevalence at 7 percent, which is more than twice as high as that of the other provinces (2 percent to 3 percent). Table 14.5 HIV prevalence by socioeconomic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by socioeconomic characteristics, Rwanda 2010 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Religion Catholic 3.5 2,947 2.1 2,713 2.8 5,660 Protestant 3.5 2,825 2.4 2,040 3.0 4,865 Adventist 3.7 943 1.9 683 3.0 1,626 Muslim 11.9 77 4.2 107 7.4 184 Traditional/Other/No religion 7.4 111 3.2 147 5.0 258 Missing * 13 na na * 13 Employment (last 12 months ) Not employed 3.3 1,154 0.7 455 2.5 1,610 Employed 3.8 5,762 2.4 5,235 3.1 10,997 Residence Urban 8.7 1,049 5.4 938 7.1 1,987 Rural 2.8 5,867 1.6 4,752 2.3 10,619 Province City of Kigali 9.4 808 5.1 741 7.3 1,548 South 3.0 1,593 1.8 1,308 2.4 2,901 West 3.2 1,688 2.0 1,307 2.7 2,995 North 3.1 1,168 1.8 899 2.5 2,067 East 2.5 1,660 1.6 1,435 2.1 3,095 Education No education 4.2 1,055 2.9 583 3.7 1,638 Primary 3.4 4,742 2.1 3,922 2.8 8,664 Secondary and higher 4.5 1,023 2.3 1,062 3.4 2,085 Wealth quintile Lowest 3.3 1,252 1.9 855 2.7 2,107 Second 3.1 1,392 1.9 986 2.6 2,378 Middle 2.6 1,374 1.5 1,140 2.1 2,514 Fourth 2.5 1,384 2.2 1,236 2.3 2,621 Highest 6.8 1,515 3.3 1,472 5.1 2,987 Total 15-49 3.7 6,917 2.2 5,690 3.0 12,607 50-59 na na 4.0 641 na na Total 15-59 na na 2.4 6,331 na na Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable HIV prevalence varies from 7 percent among Muslims to 3 percent among Christians (Catholic, Protestant, or Adventist). Variation in HIV prevalence by religion is greater among women than among men. Among women, HIV prevalence ranges from 4 percent among Catholics, Protestants and Adventists to 12 percent among Muslims. Among men, HIV prevalence ranges from 2 percent among Catholics, Protestants, and Adventists to 4 percent among Muslims. By education, HIV prevalence in Rwanda is higher among respondents with no education (4 percent) than among those with primary education or higher (3 percent). The same pattern is seen among men; 3 percent of men with no education are infected with HIV compared with 2 percent of men with primary education or higher. However, among women, the pattern differs. Women with some secondary education or higher have the highest 214 • HIV Prevalence HIV prevalence (5 percent), followed by women with no education (4 percent) and those with primary education (3 percent). HIV prevalence is three times higher among men who are employed (2 percent) than among men who are not employed (less than 1 percent). Among women, the difference by employment status is less pronounced. HIV prevalence is highest among men and women in the highest wealth quintile (5 percent compared with 3 percent or less in the lower wealth quintiles). However, the relationship between HIV prevalence and wealth is not linear. Among both women and men, those in the middle wealth quintile have slightly lower HIV prevalence than those in the lowest and second wealth quintiles. 14.2.4 HIV Prevalence by Demographic Characteristics Table 14.6 shows HIV prevalence among women and men by various demographic characteristics. HIV prevalence is closely related to marital status among both women and men. Seventeen percent of widowed and 7 percent of divorced or separated respondents are HIV positive. Four percent of respondents who are currently married are HIV positive. Among respondents who have never been married, the HIV prevalence is 3 percent for those who have had sex and less than1 percent for those who have never had sex. This suggests that some women and men incorrectly reported that they were not sexually active, or that there is some degree of nonsexual HIV transmission occurring (e.g., through blood transfusions, non-sterile injections, or mother-to-child transmission). HIV prevalence is the same for women and men who are currently married/living together (4 percent each), and not very different for women and men who are divorced/separated (7 and 8 percent, respectively). However, the HIV prevalence among unmarried women who have ever had sex is much higher than among their male counterparts (6 percent compared with 1 percent). HIV prevalence is 6 percent among respondents who reported being in a polygynous union, compared with 3 percent of respondents who are in a nonpolygynous union or who are not currently in union. The pattern is similar when observing the data disaggregated for women and men. Among women, 6 percent of those in polygynous union are HIV positive, compared with 3 percent of women in nonpolygynous union and 4 percent of those who are not currently in union. Among men, HIV prevalence is 9 percent among those in polygynous union, compared with 4 percent among those in nonpolygynous union and 1 percent among those not currently in union. The 2010 RDHS measured time away from home in two different ways: (1) number of times the respondent slept away from home in the past 12 months, and (2) whether or not the respondent was away for more than 1 month at a time. Looking at times away from home, HIV prevalence is highest among respondents who slept away from home the most often. Four percent of men and women who slept away from home five or more times in the past 12 months are HIV positive (6 percent among women and 4 percent among men). However, for both women and men, those who slept away from home three to four times had a lower HIV prevalence than those who did not sleep away from home at all. With respect to the duration of time away from home over the past year, HIV prevalence is lower among women who spent more than one month away from home (2 percent) than among women who were away from home for less than one month and those who had not traveled away from home (4 percent each). The differences in HIV prevalence by duration of stay away from home among men are small. Women who were pregnant at the time of the survey are less likely to be HIV positive than women who were not pregnant or who were unsure of their pregnancy status (2 and 4 percent, respectively). Most women who received ANC went to a public sector source. There is little difference in HIV prevalence among women who did not receive ANC and those who received ANC from a public sector facility. HIV Prevalence • 215 Table 14.6 HIV prevalence by demographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by demographic characteristics, Rwanda 2010 Demographic characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive1 Number Marital status Never married 1.7 2,735 0.6 2,874 1.2 5,609 …Ever had sexual intercourse 6.0 629 1.0 1,139 2.8 1,768 …Never had sexual intercourse 0.5 2,106 0.3 1,736 0.4 3,842 Married/living together 3.6 3,453 3.6 2,701 3.6 6,154 Divorced or separated 6.8 366 7.5 92 7.0 458 Widowed 16.5 362 * 22 16.6 385 Type of union In polygynous union 5.7 275 9.3 56 6.3 332 In nonpolygynous union 3.4 3,164 3.5 2,645 3.4 5,809 Not currently in union 3.8 3,464 0.9 2,989 2.5 6,452 DK/missing * 14 na 0 * 14 Times slept away from home in past 12 months None 3.6 3,698 2.2 3,034 3.0 6,731 1-2 3.8 2,428 1.9 1,610 3.0 4,038 3-4 3.2 545 1.8 533 2.5 1,078 5+ 5.5 246 3.7 513 4.3 759 Time away in past 12 months Away for more than 1 month 2.3 444 2.4 678 2.4 1,123 Away for less than 1 month 4.1 2,773 2.1 1,974 3.3 4,746 No away 3.6 3,698 2.2 3,034 3.0 6,731 Missing * 2 * 4 * 7 Pregnant Currently pregnant 2.4 484 na na na na Not pregnant or not sure 3.8 6,433 na na na na ANC for last birth in the last 3 years ANC provided by the public sector 3.3 2,287 na na na na ANC provided by other than the public sector (5.2) 28 na na na na No ANC/No birth in last 3 years 3.9 4,600 na na na na Missing * 3 na na na na Male circumcision Circumcised na na 2.5 786 na na Not circumcised na na 2.2 4,897 na na DK/Missing na na * 7 na na Total 15-49 3.7 6,917 2.2 5,690 3.0 12,607 50-59 na na 4.0 641 na na Total 15-59 na na 2.4 6,331 na na Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 14.2.5 HIV Prevalence by Sexual Risk Behavior Table 14.7 presents HIV prevalence rates among respondents who have ever had sexual intercourse by sexual behavior indicators. In reviewing these results, it is important to note that responses to questions about sexual risk behaviors may be subject to reporting bias. Also, sexual behavior in the 12 months preceding the survey may not adequately reflect lifetime sexual risk, nor is it possible to know the sequence of events, e.g., whether any reported condom use occurred before or after HIV infection. Among respondents age 15-49 who have ever had sex and were tested for HIV, 4 percent are HIV positive: 5 percent of women and 3 percent of men. Among women whose sexual debut was before the age of 18, 6 percent are HIV positive, a figure that decreases to 5 percent among women whose sexual debut was at age 18 or older. By contrast, HIV prevalence is highest for men whose sexual debut was at age 20 or older (4 percent) and lowest for men whose sexual debut was before age 16 (1 percent). 216 • HIV Prevalence Table 14.7 HIV prevalence by sexual behavior Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by sexual behavior characteristics, Rwanda 2010 Sexual behavior characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sexual intercourse <16 6.0 471 1.4 657 3.4 1,128 16-17 6.2 795 2.7 419 5.0 1,214 18-19 5.2 1,099 3.0 720 4.3 1,819 20+ 4.5 2,343 3.7 2,068 4.1 4,412 Missing 6.9 103 1.0 88 4.2 191 Condom use at last sexual intercourse in past 12 months Used condom 20.5 300 10.7 472 14.5 772 Did not use condom 2.8 3,539 2.3 2,712 2.6 6,251 No sexual intercourse in last 12 months 8.8 971 1.0 769 5.3 1,739 DK/Missing * 1 na na * 1 Number of lifetime partners 1 3.1 3,451 0.6 1,725 2.3 5,176 2 8.3 997 3.4 1,085 5.7 2,082 3-4 14.0 318 4.6 728 7.4 1,046 5-9 31.0 32 8.8 276 11.1 308 10+ * 10 13.4 122 14.3 132 Missing * 3 * 17 * 19 Paid for sexual intercourse in past 12 motnhs1 Yes na na 8.9 77 na na Used condom na na 9.8 58 na na Did not use condom na na * 19 na na No (No paid sexual intercourse/no sexual intercourse in last 12 months) na na 2.9 3,876 na na Total 15-49 5.1 4,811 3.1 3,953 4.2 8,764 50-59 na na 4.1 640 na na Total 15-59 na na 3.2 4,593 na na na = Not applicable Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes men who report having a prostitute for at least one of their last three sexual partners in the past 12 months Use of a condom at last sexual intercourse in the past 12 months is positively correlated with HIV prevalence among both women and men. HIV prevalence is higher among women who used a condom at last sex (21 percent) than among those who did not (3 percent). Similarly, men who used a condom at last sexual intercourse in the past 12 months have a prevalence rate of 11 percent compared with 2 percent among those who did not use a condom. HIV prevalence among women and men who did not have sexual intercourse in the past 12 months is 9 percent and 1 percent, respectively. HIV prevalence increases as the number of lifetime sexual partners increases for both women and men. Prevalence among women increases from 3 percent among women with one lifetime partner to 8 percent among women with two lifetime partners, to 14 percent for three to four lifetime partners, and to 31 percent for five to nine lifetime partners. Among men, HIV prevalence ranges from less than 1 percent among men with one lifetime partner to 13 percent among men with ten or more lifetime partners. Men who paid for sexual intercourse in the past 12 months have a higher prevalence of HIV than men who did not report paying for sex or who did not have sexual intercourse in the past 12 months (9 percent versus 3 percent). 14.3 HIV PREVALENCE AMONG YOUTH Table 14.8 shows HIV prevalence among women and men age 15-24. Overall, 1 percent of youth age 15- 24 tested positive for HIV, and prevalence is higher among young women (2 percent) than among young men (less HIV Prevalence • 217 than 1 percent). Among young women, HIV prevalence increases steadily with age. For young men, the increase in HIV prevalence is not linear. The low overall prevalence among men makes it very difficult to analyze differentials by age or other background characteristics. Young respondents who have never been married have a lower HIV prevalence (1 percent) than those who are married or living together (2 percent), and a much lower prevalence than youth who are separated, divorced, or widowed (8 percent). Among youth who have never been married, those who have never had sex have a lower prevalence (less than 1 percent) than those who have had sex (2 percent). Among young women, those who have never married but have ever had sex are more likely to have HIV than those who are currently married, but the reverse is true of young men. Among young women, HIV prevalence is 3 percent among those who are pregnant and 2 percent among women who are not pregnant or are not sure. Table 14.8 HIV prevalence among young people, by background characteristics Percentage HIV-positive among women and men age 15-24 who were tested for HIV, by background characteristics, Rwanda 2010 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 0.8 1,532 0.3 1,450 0.5 2,982 .15-17 0.6 976 0.4 931 0.5 1,907 .18-19 1.0 556 0.1 519 0.5 1,075 20-24 2.4 1,372 0.5 1,158 1.5 2,531 20-22 1.9 853 0.4 704 1.2 1,557 23-24 3.3 520 0.5 454 2.0 974 Marital status Never married 1.1 2,296 0.3 2,372 0.7 4,668 .Ever had sex 3.8 406 0.3 775 1.5 1,181 .Never had sex 0.5 1,890 0.3 1,597 0.4 3,487 Married/Living together 2.6 537 1.1 225 2.1 762 Divorced/Separated/Widowed 8.7 71 * 12 7.5 83 Currently pregnant Pregnant 2.5 166 na na na na Not pregnant or not sure 1.5 2,739 na na na na Residence Urban 3.7 472 1.5 389 2.7 861 Rural 1.1 2,432 0.2 2,219 0.7 4,651 Province City of Kigali 3.8 372 1.2 288 2.7 660 South 1.6 623 0.4 570 1.0 1,193 West 1.0 741 0.2 644 0.6 1,385 North 1.1 488 0.3 441 0.7 929 East 1.2 680 0.1 665 0.7 1,345 Education No education 2.9 174 0.0 99 1.9 273 Primary 1.3 2,047 0.3 1,842 0.8 3,888 Secondary and higher 1.8 658 0.5 639 1.2 1,298 Wealth quintile Lowest 1.7 463 0.4 369 1.1 832 Second 0.9 580 0.0 433 0.5 1,013 Middle 0.6 577 0.2 544 0.4 1,121 Fourth 1.1 577 0.4 581 0.7 1,158 Highest 3.1 707 0.6 681 1.9 1,388 Total 1.5 2,904 0.4 2,608 1.0 5,512 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable As observed for adults age 15-49, HIV prevalence among youth age 15-24 is higher in urban areas than in rural areas, and the same urban-rural pattern is observed for young women and men. Four percent of young women living in urban areas are infected with HIV compared with 1 percent of their rural counterparts. Among young men, prevalence is 2 percent in urban areas and less than 1 percent in rural areas. By province, HIV prevalence is higher 218 • HIV Prevalence in the City of Kigali (3 percent) than in other provinces. HIV prevalence is highest in the City of Kigali for both young women and young men. Among youth, the HIV prevalence varies by educational attainment. Young women with no education have an HIV prevalence of 3 percent, compared with 2 percent of women with some secondary education or higher and 1 percent for women with primary education. Among young men, HIV prevalence and level of education share the same pattern. By wealth, HIV prevalence is highest among both young women and young men in the highest wealth quintile. However, the relationship of HIV prevalence and household wealth quintile is not linear. 14.3.1 HIV Prevalence by Condom Use at Last Sex in Past 12 Months among Youth The 2010 RDHS collected data on behaviors that correlate with sexually transmitted infection (STI) rates. Information on sexual behavioral characteristics is important in designing, targeting, and monitoring HIV prevention interventions for the young adult population. This section examines data on condom use at last sexual intercourse in the past 12 months and the prevalence of HIV infections among young respondents who have ever had sexual intercourse. Table 14.9 shows HIV prevalence among youth by condom use at last sexual intercourse in past 12 months. Overall, 2 percent of respondents age 15-24 who have ever had sex and were tested for HIV in the 2010 RDHS are HIV positive: 4 percent of young women and less than 1 percent of young men tested positive. Table 14.9 HIV prevalence among young people by condom use at last sex Percentage HIV-positive among women and men age 15-24 who have ever had sex and were tested for HIV, by condom use at last sex in the past 12 months, Rwanda 2010 Condom use at last sexual intercourse in past 12 months Women Men Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Used condom 13.8 81 1.1 182 5.1 263 Did not use condom 2.6 644 0.8 309 2.0 953 No sexual intercourse in last 12 months 2.6 289 0.0 520 0.9 809 Total 3.5 1,014 0.4 1,011 2.0 2,025 Youth who used a condom at last sexual intercourse in the past 12 months are more likely to be HIV positive than those who did not use a condom at last sex (5 percent versus 2 percent). The association between HIV infection and condom use at last sexual intercourse is stronger among young women than among young men: 14 percent of young women who used a condom at last sex are HIV positive, compared with 3 percent of those who did not use a condom. The association observed among young men is weak. Three percent of young women who have had sex but not in the past 12 months are infected with HIV. Less than 1 percent of young men who have had sex but not in the past 12 months tested positive for HIV. 14.4 HIV PREVALENCE BY OTHER CHARACTERISTICS 14.4.1 HIV Prevalence and STIs A strong link exists between sexually transmitted infections and the sexual transmission of HIV. Many studies have demonstrated that sexually transmitted infections are a co-factor for HIV transmission. Management and treatment of STIs may play an important role in the reduction of HIV transmission. Respondents in the 2010 RDHS who had ever had sex were asked if they had contracted a disease through sexual contact in the past 12 months or if they had had any symptoms associated with STIs (a bad-smelling, abnormal discharge from the vagina or penis, or a genital sore or ulcer). Table 14.10 shows HIV prevalence among women and men age 15-49 who have HIV Prevalence • 219 ever had sex by whether respondents reported an STI in the 12 months preceding the survey. The data show that respondents with a history of STIs or STI symptoms have a higher HIV prevalence than those with no history of STIs or STI symptoms (13 percent compared with 3 percent). Women who had an STI or STI symptoms in the past 12 months are more than three times as likely to be HIV positive (15 percent) as women who did not have an STI or STI symptoms (4 percent). Similarly, men who reported having an STI or STI symptoms in the past 12 months (10 percent) are more than three as likely to be HIV positive as men who did not report an STI or STI symptoms (3 percent). Table 14.10 HIV prevalence by sexually transmitted infections Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by whether they had an STI in the past 12 months, Rwanda 2010 Characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Sexually transmitted infection in past 12 months Had STI or STI symptoms 15.0 428 9.5 329 12.6 756 No STI, no symptoms 4.2 4,367 2.5 3,605 3.4 7,971 DK/missing * 17 * 20 (0.0) 37 Total 15-49 5.1 4,811 3.1 3,953 4.2 8,764 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 14.4.2 HIV Prevalence by Male Circumcision In the recent past, several studies in sub-Saharan Africa—including clinical trials conducted in South Africa, Kenya, and Uganda (Auvert et al., 2005; and Gray et al., 2007)—have documented that male circumcision is associated with a lower risk of acquiring HIV. Although the research supporting circumcision’s protective effects is compelling, it is important to emphasize that circumcised men can still become infected with HIV and can infect their sexual partners. To investigate the relationship between male circumcision and HIV status in the 2010 RDHS, men were asked whether they were circumcised. The majority of men reported that they are not circumcised (87 percent).1 For those men who reported that they are circumcised, 78 percent reported that a health professional performed the circumcision. Sixty-nine percent of circumcised men report that their circumcision occurred before age 20.2 Table 14.11 presents data on HIV prevalence by male circumcision status. In Rwanda, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men age 15-49 have a higher HIV prevalence than men who have not been circumcised, though the difference is small (3 percent compared with 2 percent). However, for men age 15-29, HIV prevalence is higher among uncircumcised men than among circumcised men. In the 30-39 age group, circumcised and uncircumcised men are roughly equally likely to be HIV positive (4 percent). Among men age 44-59, HIV prevalence is higher among circumcised men than among uncircumcised men. HIV prevalence is higher in urban areas among both circumcised and uncircumcised men. HIV prevalence among circumcised men is 4 percent in urban areas and 1 percent in rural areas. For uncircumcised men, the prevalence is 6 percent in urban areas and 2 percent in rural areas. The pattern of HIV prevalence by province is not the same for circumcised and uncircumcised men. Among both circumcised and uncircumcised men, HIV 1 See Table 13.19 in Chapter 13. 2 See Table 13.21 in Chapter 13. 220 • HIV Prevalence prevalence is highest in the City of Kigali (4 percent among circumcised and 6 percent among uncircumcised). In the other provinces, HIV prevalence among circumcised men is lowest in West province and highest in South province, whereas among uncircumcised men, the prevalence is lowest in East province and highest in West province. Circumcised men in the West province have the lowest HIV rate compared with other provinces (1 percent compared with 3 percent). Patterns in HIV prevalence by education also differ by circumcision status. Circumcised men who have a primary education (3 percent) are more likely to be HIV positive than those with no education (2 percent) and those with secondary and higher education (2 percent). However, among uncircumcised men, men with primary education are slightly less likely to be HIV positive (2 percent) than those with no education and secondary and higher education (3 percent each). Association of HIV prevalence with wealth quintiles among both circumcised and uncircumcised men is not linear and does not follow a clear pattern. Among religious groups, HIV prevalence is highest in Muslims among both circumcised and uncircumcised men. Table 14.11 HIV prevalence by male circumcision Among men age 15-49 who were tested for HIV, the percentage HIV positive by whether circumcised, according to background characteristics, Rwanda 2010 Background characteristic Circumcised Not circumcised Percentage HIV positive Number Percentage HIV positive Number Age 15-19 0.0 143 0.3 1,299 20-24 0.0 187 0.6 972 25-29 0.4 176 2.0 861 30-34 3.7 124 3.5 586 35-39 3.7 64 3.8 429 40-44 10.5 52 7.1 378 45-49 (16.3) 41 4.4 372 Religion Catholic 2.1 273 2.1 2,435 Protestant 2.7 315 2.3 1,723 Adventist 0.0 100 2.2 583 Muslim 4.5 75 3.6 32 Traditional/Other/No religion 7.9 24 2.3 123 Residence Urban 4.4 296 5.9 640 Rural 1.4 490 1.6 4,256 Province City of Kigali 3.6 247 5.8 491 South 3.3 58 1.7 1,248 West 1.2 286 2.2 1,021 North (2.6) 52 1.8 848 East 2.8 143 1.5 1,289 Education No education (1.8) 46 3.0 537 Primary 3.4 384 2.0 3,532 Secondary and higher 2.1 286 2.5 775 Wealth quintile Lowest 0.0 57 2.1 796 Second 3.1 71 1.8 916 Middle 3.1 98 1.3 1,041 Fourth 1.7 130 2.2 1,106 Highest 2.8 431 3.5 1,037 Total 15-49 2.5 786 2.2 4,897 50-59 6.8 49 3.8 592 Total 15-59 2.8 836 2.4 5,488 Note: Table excludes 7 men with information missing on circumcision status. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable HIV Prevalence • 221 14.4.3 Prior HIV Testing by Current HIV Status Knowing one’s HIV status through testing helps individuals make decisions to reduce infection risks and increase safer sex practices. Additionally, knowledge of one’s HIV status provides an important link to HIV/AIDS treatment and care, and other support services including clinical management of related illness, access to antiretroviral therapy (ART), and psychological support for HIV-positive persons. To assess the coverage of HIV testing services, 2010 RDHS respondents were asked whether they had ever been tested for HIV. Those respondents who had been tested were further asked whether they had received the results of their last HIV test and where they had been tested. Table 14.12 shows that respondents who are HIV-positive are more likely than those who are HIV-negative to have ever received an HIV test (92 percent compared with 75 percent). Ninety percent of HIV-positive people had been tested previously and received the results of their last test. Only 8 percent of HIV-positive women and 10 percent of HIV-positive men had never been tested for HIV. Table 14.12 Prior HIV testing by current HIV status Percent distribution of women and men age 15-49 who tested HIV positive and who tested HIV negative by HIV testing status prior to the survey, Rwanda 2010 HIV testing prior to the survey Women Men Total HIV positive HIV negative HIV positive HIV negative HIV positive HIV negative Previously tested Received result of last test 91.3 74.4 87.1 68.9 89.9 71.9 Did not receive result of last test 1.1 1.9 3.3 3.5 1.9 2.7 Not previously tested 7.5 23.5 9.6 27.6 8.2 25.4 Missing 0.0 0.2 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 257 6,660 127 5,563 383 12,223 14.5 HIV PREVALENCE AMONG COHABITING COUPLES In the 2010 RDHS, 2,841 cohabiting couples were interviewed and tested for HIV. Table 14.13 shows that in 95 percent of cohabiting couples, both partners are HIV negative, while in more than 2 percent of cohabiting couples, both partners are HIV positive. Two percent of cohabiting couples are discordant; that is, one partner is infected and the other is not. Among discordant partners, 1 percent represent cases where the male partner is HIV positive and the female partner is HIV negative, while another 1 percent represent cases where the female partner is HIV positive and the male partner is HIV negative. 222 • HIV Prevalence Table 14.13 HIV prevalence among couples Percent distribution of couples living in the same household, both of whom were tested for HIV, by HIV status, according to background characteristics, Rwanda 2010 Background characteristic Both HIV positive Man HIV positive, woman HIV negative Woman HIV positive, man HIV negative Both HIV negative Total Number Woman's Age 15-19 (0.0) (0.0) (0.0) (100.0) 100.0 44 20-29 2.2 1.1 1.1 95.6 100.0 1,196 30-39 2.7 2.0 0.8 94.5 100.0 1,018 40-49 2.3 0.7 0.8 96.2 100.0 584 Man's Age 15-19 * * * * 100.0 3 20-29 1.0 0.7 0.7 97.7 100.0 814 30-39 2.1 1.1 1.2 95.6 100.0 1,003 40-49 3.8 2.3 0.5 93.4 100.0 708 50-59 3.6 1.5 1.1 93.8 100.0 313 Age difference between partners Woman older 0.7 1.5 1.9 96.0 100.0 405 Same age/man older by 0-4 years 1.9 0.5 0.5 97.1 100.0 1,302 Man older by 5-9 years 2.8 1.4 1.0 94.8 100.0 758 Man older by 10-14 years 3.6 2.7 1.2 92.5 100.0 245 Man older by 15+ years 7.5 6.1 0.9 85.5 100.0 131 Type of union Monogamous 2.2 1.3 0.9 95.6 100.0 2,683 Polygynous 3.9 1.6 1.7 92.7 100.0 152 DK/missing * * * * 100.0 7 Multiple partners in past 12 months1 Both no 2.0 1.2 0.8 95.9 100.0 2,666 Man yes, woman no 8.0 1.8 2.6 87.7 100.0 163 Woman yes, man no 9.3 13.8 0.0 76.9 100.0 10 Both yes * * * * 100.0 1 Either missing * * * * 100.0 1 Residence Urban 7.8 2.4 2.9 86.9 100.0 368 Rural 1.6 1.2 0.6 96.7 100.0 2,473 Province City of Kigali 8.5 1.6 4.5 85.4 100.0 292 South 0.9 1.6 0.0 97.5 100.0 645 West 2.7 1.0 0.6 95.7 100.0 679 North 1.8 1.5 0.0 96.7 100.0 466 East 1.4 1.2 1.1 96.3 100.0 760 Woman's education No education 2.2 1.4 0.9 95.5 100.0 549 Primary 2.0 1.3 0.7 96.1 100.0 2,018 Secondary 6.2 1.5 2.6 89.6 100.0 242 More than secondary (0.0) (0.0) (4.1) (95.9) 100.0 32 Man's education No education 2.2 1.7 0.8 95.4 100.0 503 Primary 2.0 1.2 0.8 96.0 100.0 1,980 Secondary 4.6 1.3 1.5 92.6 100.0 314 More than secondary 6.3 2.0 4.0 87.6 100.0 45 Wealth quintile Lowest 1.5 1.0 0.4 97.0 100.0 486 Second 1.8 1.9 0.3 95.9 100.0 559 Middle 1.5 1.0 0.7 96.9 100.0 609 Fourth 1.9 1.2 0.5 96.4 100.0 643 Highest 5.3 1.4 2.6 90.6 100.0 545 Total 2.4 1.3 0.9 95.4 100.0 2,841 Note: The table is based on couples for which a valid test result (positive or negative) is available for both partners. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 A respondent is considered to have had multiple sexual partners in the past 12 months if he or she had sexual intercourse with two or more people during this time period. (Respondents with multiple partners include polygynous men who had sexual intercourse with two or more wives.) Women’s Status and Demographic and Health Outcomes • 223 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 he status of women is an important factor in development, poverty reduction, and improvement in the standard of living. This chapter presents information on factors that affect the status of women in society: employment, type of earnings, control over cash earnings, earnings relative to those of a husband, and participation in decision-making. This chapter also defines two summary indices of women’s empowerment derived from women’s responses. The indices are based on the number of household decisions in which the respondent participates and her agreement with reasons for which wife beating is justified. The ranking of women on these indices is then related to select demographic and health outcomes, including contraceptive use and the receipt of health care services during pregnancy, childbirth, and the postpartum period. 15.1 WOMEN’S AND MEN’S EMPLOYMENT The 2010 Rwanda Demographic and Health Survey (RDHS) collected information related to women’s and men’s employment. Women’s employment includes formal employment as well as work in the home, on family farms, in family businesses, and in other informal sectors. It is important to be cautious while collecting data on women’s employment because some activities are not perceived by women themselves as employment and hence may not be reported as such. To avoid underestimating women’s employment, the 2010 RDHS asked female respondents several questions to ascertain their employment status. First, they were asked whether they had done any work in the past seven days aside from their own housework. Women who answered ‘no’ to this question were asked, ‘As you know, some women take up jobs for which they are paid in cash or in kind. Others sell things, have a small business, or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?’ 15.1.1 Employment Status Table 15.1 shows the percent distribution of currently married women and men age 15-49, by employment and cash earnings. Overall, 90 percent of currently married women and over 99 percent of currently married men were employed in the 12 months preceding the survey. The proportion of employed women increases with age, from 81 percent among women age 15-19 to 91 to 92 percent among women age 25-49. Comparing married women and men age 15-49, 19 percent of women and 38 percent of men receive payment in cash only. About the same proportion of married women as married men are not paid for their work (12 percent versus 14 percent). Married women are four times as likely as men to receive in- kind-only payment for their employment (17 percent and 4 percent, respectively). T 224 • Women’s Status and Demographic and Health Outcomes Table 15.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Rwanda 2010 Age Among currently married respondents: Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Total Number of women Percentage employed Number of respondents Cash only Cash and in-kind In-kind only Not paid Missing/ don’t know WOMEN Age 15-19 80.5 89 21.7 41.9 19.3 17.0 0.0 100.0 71 20-24 86.8 998 21.7 49.4 17.3 11.7 0.0 100.0 866 25-29 90.6 1,773 18.9 54.4 15.0 11.6 0.0 100.0 1,605 30-34 90.8 1,458 19.1 51.5 16.8 12.6 0.0 100.0 1,324 35-39 91.4 1,112 21.3 50.5 17.0 11.2 0.0 100.0 1,017 40-44 91.9 780 14.4 53.4 19.0 13.2 0.0 100.0 716 45-49 91.8 688 14.8 54.1 19.1 11.8 0.2 100.0 631 Total 15-49 90.3 6,897 18.8 52.2 16.9 12.0 0.0 100.0 6,231 MEN Age 15-19 * 3 * * * * * 100.0 3 20-24 99.5 222 36.6 42.5 5.8 15.1 0.0 100.0 221 25-29 100.0 646 37.7 42.3 3.5 16.3 0.2 100.0 646 30-34 99.5 613 42.1 41.4 3.6 13.0 0.0 100.0 610 35-39 100.0 439 35.8 43.7 4.3 16.2 0.0 100.0 439 40-44 99.5 397 37.0 45.1 4.2 13.7 0.0 100.0 395 45-49 99.6 380 34.9 48.8 4.5 11.5 0.3 100.0 379 Total 15-49 99.7 2,699 37.8 43.6 4.1 14.4 0.1 100.0 2,692 50-59 97.2 588 28.7 50.0 5.1 16.2 0.0 100.0 572 Total 15-59 99.3 3,287 36.2 44.8 4.3 14.7 0.1 100.0 3,264 Note: An asterisk indicates that a figure is based on less than 25 unweighted cases and has been suppressed. 15.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS To assess women’s autonomy, currently married women who earned cash for their work in the 12 months preceding the survey were asked who usually decides how their earnings are spent. Women who earned cash for their work were also asked the relative magnitude of their earnings compared with those of their husband. This information assesses women’s control over their own earnings, as it is expected that employment and earnings are more likely to empower women if women themselves control their own earnings and perceive them as significant relative to those of their husband. Table 15.2.1 shows the percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey, by the person who decides how the cash earnings are to be used and by the relative magnitude of their earnings compared with those of their husbands, according to background characteristics. Only 18 percent of women decide for themselves how their earnings are used, and 66 percent of women make joint decisions with their husbands. Fifteen percent of the married women responded that decisions regarding how their earnings are spent are made mainly by their husbands. The percentage of women who decide how their earnings are spent generally increases with age, from 6 percent among women age 15-19 to 28 percent among women age 45-49. Women in urban areas are more likely to make decisions on how their earnings are used than their counterparts in rural areas (29 percent versus 17 percent). Sixteen percent of currently married women in rural areas report that their husbands mainly decide how to spend their earnings, as compared with 8 percent of currently married women residing in urban areas. Decision-making on earnings also varies by province. Thirty percent of currently married women in the City of Kigali decide how to spend their earnings, as compared with 14 percent in the East province and 15 percent in the West province. The West province has the highest proportion of women (70 Women’s Status and Demographic and Health Outcomes • 225 percent) who report joint decision-making with their husbands regarding their earnings. Women in the East province are more likely than women in the other regions to report that their husbands mainly decide how to spend their earnings (22 percent). Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife’s cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Rwanda 2010 Background characteristic Person who decides how the wife’s cash earnings are used: Total Wife’s cash earnings compared with husband’s cash earnings: Total Number of women Mainly wife Wife and husband jointly Mainly husband Missing More Less About the same Husband has no earnings Don’t know/ missing Age 15-19 6.4 74.1 19.5 0.0 100.0 4.5 83.2 12.2 0.0 0.0 100.0 45 20-24 14.5 67.2 17.3 0.9 100.0 5.9 75.8 15.5 0.9 1.9 100.0 616 25-29 11.8 71.1 16.2 0.9 100.0 7.3 70.7 19.1 1.6 1.4 100.0 1,178 30-34 18.4 67.7 13.2 0.6 100.0 7.3 69.8 19.9 1.9 1.2 100.0 935 35-39 22.9 62.1 14.1 0.8 100.0 13.5 60.6 18.7 5.2 2.0 100.0 730 40-44 24.1 58.4 16.3 1.2 100.0 13.9 57.1 22.5 4.7 1.9 100.0 486 45-49 28.0 61.3 9.0 1.6 100.0 15.2 55.1 19.8 5.9 4.0 100.0 435 Number of living children 0 11.1 72.0 14.9 2.0 100.0 7.6 70.4 18.7 1.2 2.0 100.0 246 1-2 14.7 69.9 14.6 0.9 100.0 7.5 72.1 17.0 1.9 1.5 100.0 1,615 3-4 20.1 63.6 15.7 0.6 100.0 10.2 63.9 20.6 3.8 1.5 100.0 1,407 5+ 22.7 62.4 13.7 1.1 100.0 12.3 61.6 20.2 3.5 2.4 100.0 1,157 Residence Urban 28.5 62.4 8.4 0.6 100.0 13.9 64.2 18.2 2.4 1.3 100.0 628 Rural 16.6 66.6 15.8 1.0 100.0 8.9 67.0 19.2 3.0 1.9 100.0 3,796 Region City of Kigali 29.8 60.5 9.2 0.5 100.0 15.3 70.5 11.8 1.6 0.8 100.0 529 South 21.4 67.4 9.9 1.3 100.0 9.1 50.5 34.0 4.6 1.8 100.0 900 West 15.2 70.2 13.7 0.9 100.0 10.2 69.3 14.9 3.5 2.1 100.0 1,042 North 18.0 67.0 13.7 1.2 100.0 9.4 69.2 15.3 2.8 3.3 100.0 765 East 13.7 63.3 22.4 0.6 100.0 7.0 73.2 17.0 1.7 1.0 100.0 1,188 Education No education 21.7 60.1 16.6 1.5 100.0 10.3 66.5 17.6 3.2 2.4 100.0 850 Primary 16.9 67.1 15.3 0.7 100.0 8.5 66.7 20.3 2.9 1.6 100.0 3,065 Secondary and higher 21.0 69.9 8.2 1.0 100.0 15.0 66.7 14.0 2.7 1.6 100.0 509 Wealth quintile Lowest 24.1 57.9 16.4 1.6 100.0 9.2 58.8 23.2 5.9 2.9 100.0 815 Second 17.3 65.0 16.7 1.1 100.0 7.6 67.3 20.2 3.2 1.6 100.0 888 Middle 15.5 69.2 14.2 1.0 100.0 8.0 70.8 17.3 2.3 1.6 100.0 889 Fourth 13.0 69.3 17.2 0.5 100.0 9.8 67.1 19.5 1.8 1.8 100.0 918 Highest 22.1 68.0 9.4 0.5 100.0 13.2 68.5 15.5 1.7 1.2 100.0 914 Total 18.3 66.0 14.7 0.9 100.0 9.6 66.6 19.1 2.9 1.8 100.0 4,424 There is wide variation in decision-making about spending women’s earnings by level of education. Women with no education are the least likely to decide jointly with their husbands how to spend their earnings (60 percent), and the proportion increases with each level of education to 70 percent of women with a secondary education or higher. There is a negative association between decision-making by mainly the husband and women’s education. Seventeen percent of women with no education report that their husband mainly decides how their earnings are spent, as compared with 8 percent of women with a secondary education or higher. There is no linear relationship between level of education and the proportion of women who are the main decision-makers about spending their earnings. In addition, there is no clear pattern of association between wealth and decision-making on how women’s cash earnings are used. However, women in the highest wealth quintile are least likely to report that their husband is the main decision-maker. Only 9 percent of women in the highest wealth quintile report that their husband mainly decides how their cash earnings are used, as compared with 14 to 17 percent of women in the other wealth quintiles. Fifty-eight percent of women in the lowest quintile report that they make decisions jointly with their husband about how to spend their earnings, as compared with 68 percent of women in the highest quintile. 226 • Women’s Status and Demographic and Health Outcomes Table 15.2.1 also shows women’s earnings relative to their husbands’ earnings during the 12 months preceding the survey. Two thirds of women report that they earn less than their husband, 10 percent report that they earn more than their husband, and 19 percent earn about the same as their husband. The proportion of women who earn more than their husband increases with age, from 5 percent among women age 15-19 to 15 percent of women age 45-49. Fourteen percent of women in urban areas earn more than their husband, as compared with 9 percent of women in rural areas. Similar proportions of women in urban and rural areas earn the same as their husband (18 percent and 19 percent, respectively). The South province has the highest proportion of women (34 percent) reporting that they earn the same as their husband. Regarding education, women with a secondary education or higher are more likely than other women to report that they earn more than their husband (15 percent versus 10 percent or less). Table 15.2.2 shows the percent distributions of currently married men age 15-49 who receive cash earnings, and of currently married women age 15-49 whose husbands receive cash earnings, by the person who decides how men’s cash earnings are used, according to background characteristics. Table 15.2.2 Control over men’s cash earnings Percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women 15-49 whose husbands receive cash earnings, by person who decides how husband’s cash earnings are used, according to background characteristics, Rwanda 2010 Background characteristic Men Women Mainly wife Husband and wife jointly Mainly husband Missing Total Number Mainly wife Husband and wife jointly Mainly husband Other Missing Total Number Age 15-19 * * * * 100.0 3 1.8 70.0 28.2 0.0 0.0 100.0 89 20-24 2.9 71.8 25.2 0.0 100.0 174 2.6 66.4 30.6 0.0 0.4 100.0 993 25-29 2.7 72.0 25.2 0.0 100.0 516 3.1 67.9 28.6 0.0 0.4 100.0 1,754 30-34 2.3 73.0 24.8 0.0 100.0 509 4.2 67.6 27.6 0.0 0.6 100.0 1,440 35-39 3.0 75.2 21.8 0.0 100.0 349 5.1 64.3 29.4 0.1 1.1 100.0 1,074 40-44 2.3 75.6 22.1 0.0 100.0 324 6.2 58.9 33.7 0.5 0.6 100.0 757 45-49 2.5 74.2 22.7 0.6 100.0 317 6.4 58.7 32.2 0.6 2.0 100.0 662 Number of living children 0 3.7 70.6 25.7 0.0 100.0 148 2.9 71.5 24.7 0.0 0.9 100.0 425 1-2 2.7 74.0 23.3 0.0 100.0 842 3.7 67.6 27.9 0.1 0.7 100.0 2,446 3-4 2.4 76.5 21.1 0.0 100.0 660 4.5 63.2 31.5 0.1 0.6 100.0 2,079 5+ 2.3 70.4 26.9 0.3 100.0 544 4.9 62.7 31.3 0.2 0.9 100.0 1,818 Residence Urban 2.3 70.8 26.9 0.0 100.0 361 6.1 68.6 24.4 0.1 0.7 100.0 911 Rural 2.6 74.2 23.1 0.1 100.0 1,833 3.9 64.6 30.5 0.1 0.8 100.0 5,857 Region City of Kigali 1.7 71.2 27.2 0.0 100.0 304 7.9 66.9 24.6 0.0 0.7 100.0 717 South 4.2 75.8 20.0 0.0 100.0 473 6.4 61.8 30.3 0.4 1.0 100.0 1,573 West 2.0 79.2 18.8 0.0 100.0 566 3.0 66.9 29.1 0.1 0.9 100.0 1,638 North 1.5 80.0 18.4 0.0 100.0 337 2.3 70.2 26.8 0.0 0.8 100.0 1,130 East 2.9 62.7 34.0 0.4 100.0 514 3.1 62.5 33.8 0.1 0.4 100.0 1,710 Education No education 2.2 73.5 24.3 0.0 100.0 336 5.1 58.2 35.0 0.2 1.5 100.0 1,327 Primary 2.8 72.6 24.5 0.1 100.0 1,531 3.9 65.8 29.7 0.1 0.6 100.0 4,728 Secondary and higher 1.8 78.7 19.4 0.0 100.0 327 5.1 73.8 20.1 0.3 0.7 100.0 713 Wealth quintile Lowest 4.6 74.0 21.3 0.0 100.0 342 6.7 56.8 34.8 0.3 1.4 100.0 1,304 Second 2.5 74.9 22.5 0.0 100.0 403 4.0 62.5 32.5 0.2 0.8 100.0 1,359 Middle 2.0 74.4 23.2 0.4 100.0 443 2.4 65.1 31.4 0.1 0.9 100.0 1,374 Fourth 3.2 72.8 24.0 0.0 100.0 479 3.1 68.5 28.0 0.1 0.4 100.0 1,398 Highest 1.2 72.4 26.3 0.0 100.0 527 5.0 72.7 22.0 0.0 0.3 100.0 1,333 Total 15-49 2.6 73.6 23.7 0.1 100.0 2,194 4.2 65.2 29.7 0.1 0.8 100.0 6,769 50-59 3.6 77.3 19.1 0.0 100.0 450 na na na na na na na Total 15-59 2.7 74.2 22.9 0.1 100.0 2,644 na na na na na na na Note: An asterisk indicates that a figure is based on less than 25 unweighted cases and has been suppressed. na = Not applicable Twenty-four percent of men age 15-49 report that they mainly decide how their cash earnings are used. Seventy-four percent state that they make these decisions jointly with their wife, and 3 percent state that these decisions are made mainly by their wives. There is little variation by age and number of living children in the percentage of men who are the main decision-makers regarding how to spend their cash earnings. Men who are Women’s Status and Demographic and Health Outcomes • 227 living in urban areas are more likely than men who are living in rural areas to be the main decision-makers regarding how to use their cash earnings (27 percent versus 23 percent). The East province (34 percent) and the City of Kigali (27 percent) have a higher proportion of men who are the main decision-makers regarding their own earnings than other provinces. Men with a secondary education or higher are less likely than other men to be the main decision- maker regarding how to spend their earnings (19 percent versus 24 percent or more) and more likely to make the decision jointly with their wives. Women’s reports on who makes decisions about how their husband’s earnings are spent somewhat comparable to men’s reports. Thirty percent of women whose husbands have cash earnings report that their husband mainly decides how his cash earnings are used. This is only slightly higher than the 24 percent reported by men themselves. Sixty-five percent of women report that the decisions are made jointly, as compared with 74 percent of men, and 4 percent of women report that they mainly decide how to use their husband’s earnings. The proportion of women reporting that they mainly decide how to spend their husband’s earnings increases by age of the woman and number of living children. The proportion of women who are the main decision-makers on how to use their husband’s earnings is higher in urban areas and in the City of Kigali. Joint decision-making is more commonly reported by women with a secondary education or higher and those in the higher wealth quintiles. In contrast, women are more likely to report that their husband is the main decision-maker if they have no education or are in the lower wealth quintiles. Table 15.3 shows who controls the wife’s and husband’s earnings by the amount of the wife’s earnings relative to her husband’s. Currently married women who earn more than their husbands are more likely to decide mainly by themselves (37 percent) or jointly with their husbands (54 percent) on how their earnings are spent. Likewise, 15 percent of the same group of women mainly decide how their husbands’ earnings are spent, and an additional 54 percent make these decisions jointly with their husbands. Women who earn less than their husbands are more likely to make decisions on their own earnings (16 percent) than women who earn the same as their husbands (8 percent). However, women who earn the same as their husbands are more likely than other women to decide how to use their earnings jointly with their husbands (80 percent). Table 15.3 Women’s control over their own earnings and over those of their husband Percent distributions of currently married women age 15-49 with cash earnings in the last 12 months by person who decides how the wife’s cash earnings are used and of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband’s cash earnings are used, according to the relation between wife’s and husband’s cash earnings, Rwanda 2010 Women’s earnings relative to husband’s earnings Person who decides how the wife’s cash earnings are used: Total Number of women Person who decides how husband’s cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Missing Mainly wife Wife and husband jointly Mainly husband Other Missing More than husband 37.1 54.4 8.5 0.0 100.0 425 15.4 54.4 29.4 0.5 0.3 100.0 425 Less than husband 16.2 66.6 17.1 0.0 100.0 2,948 2.6 65.2 32.1 0.0 0.1 100.0 2,948 Same as husband 8.4 80.0 11.7 0.0 100.0 843 2.2 78.7 18.6 0.0 0.5 100.0 843 Husband has no cash earnings or did not work 65.0 29.3 5.7 0.0 100.0 129 na na na na na na 0 Woman worked but has no cash earnings na na na na na 0 5.2 64.9 28.8 0.3 0.8 100.0 1,807 Woman did not work na na na na na 0 4.0 59.6 35.8 0.0 0.5 100.0 666 Don’t know/missing 24.3 18.3 6.8 50.6 100.0 79 6.6 31.6 28.3 2.6 30.9 100.0 79 Total 18.3 66.0 14.7 0.9 100.0 4,424 4.2 65.2 29.7 0.1 0.8 100.0 6,769 na = Not applicable 15.3 WOMEN’S PARTICIPATION IN DECISION-MAKING The ability of women to make decisions that affect their personal circumstances is essential for their empowerment and serves as an important factor in national development. To assess women’s decision-making autonomy, the 2010 RDHS collected information on women’s participation in three types of decisions: the respondent’s own health care, making major household purchases, and visits to family or relatives. Women are 228 • Women’s Status and Demographic and Health Outcomes considered to participate in decision-making if they make decisions alone or jointly with their husband or someone else. Table 15.4 shows the percent distribution of currently married women by the person who usually makes decisions, as reported by women. Twenty-five percent of currently married women report that their husbands mainly make the decisions regarding their health care, and 28 percent report that their husbands decide on major household purchases. With respect to visits to their own family or relatives, 18 percent of women report that their husbands make the decision. Table 15.4 Participation in decision-making Percent distribution of currently married women age 15-49 by person who usually makes decisions about various issues, Rwanda 2010 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women WOMEN Own health care 19.1 54.6 25.4 0.1 0.1 0.6 100.0 6,897 Major household purchases 7.1 64.1 28.2 0.0 0.0 0.6 100.0 6,897 Visits to her family or relatives 14.8 66.5 18.1 0.0 0.0 0.6 100.0 6,897 Table 15.5 shows how women’s participation in decision-making varies by background characteristics such as age and residence. The table presents results on three specific topics in which a married woman makes decisions either by herself or jointly with her husband: her own health care, making major household purchases, and visits to her own family or relatives. In addition, the table includes two summary indicators: the proportion of women involved in all three decisions and the proportion of women not involved in making any of the decisions. Table 15.5 shows that 59 percent of women report taking part in all three decisions, while 11 percent have no say in any of the three decisions. The percentage of women participating in all three decisions increases with levels of education and wealth; 70 percent of women with a secondary education or higher participate in all three decisions, as compared with 55 percent of women with no education. Sixty-one percent of women who are employed for cash take part in all three decisions, as compared with 53 percent of women who are not employed and 56 percent of women who are employed but are not paid in cash. Women in urban areas (68 percent) are more likely than women in rural areas (57 percent) to participate in all three decisions. Table 15.5 Women’s participation in decision-making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Rwanda 2010 Background Characteristic Specific decisions Percentage who participate in all three decisions Percentage who participate in none of the three decisions Number of women Woman’s own health care Making major household purchases Visits to her family or relatives Age 15-19 69.8 68.5 73.1 54.8 15.7 89 20-24 68.8 68.2 79.3 54.3 11.9 998 25-29 71.3 69.3 79.3 54.9 11.5 1,773 30-34 76.6 72.2 81.7 61.1 10.5 1,458 35-39 73.3 72.1 84.0 59.4 9.8 1,112 40-44 78.2 75.3 81.6 65.6 10.3 780 45-49 77.2 72.5 84.2 61.9 9.4 688 Employment (last 12 months) Not employed 63.7 62.9 70.6 53.4 22.5 666 Employed for cash 75.4 73.4 82.5 60.7 9.6 4,424 Employed not for cash 73.5 68.9 82.0 56.1 9.2 1,806 Missing 0.0 0.0 100.0 0.0 0.0 1 Number of living children 0 70.4 76.1 83.7 59.1 7.9 429 1-2 72.2 71.3 81.0 57.5 10.6 2,478 3-4 74.1 69.6 80.0 57.6 11.3 2,133 5+ 76.2 71.8 82.4 61.7 11.1 1,858 Residence Urban 80.8 79.1 88.2 67.8 5.8 926 Rural 72.7 70.0 80.2 57.3 11.5 5,971 Region City of Kigali 78.9 78.6 87.8 66.6 6.7 726 South 71.5 73.2 82.1 56.5 8.0 1,614 West 75.9 68.7 80.2 60.4 13.3 1,675 North 70.5 69.3 81.6 54.5 10.1 1,151 East 73.7 69.8 78.4 58.8 13.1 1,731 Education No education 69.2 67.9 78.3 55.4 14.5 1,355 Primary 73.6 70.8 80.8 58.0 10.6 4,816 Secondary and higher 83.3 80.0 89.3 69.6 4.9 727 Wealth quintile Lowest 68.3 67.4 75.9 52.7 14.5 1,352 Second 71.8 68.2 79.9 56.5 11.8 1,388 Middle 71.3 69.9 80.7 56.0 11.7 1,394 Fourth 76.0 71.8 82.5 60.7 9.8 1,415 Highest 81.4 78.9 87.1 67.9 6.0 1,348 Total 73.7 71.2 81.2 58.7 10.8 6,897 Women’s Status and Demographic and Health Outcomes • 229 15.4 ATTITUDES TOWARDS WIFE BEATING The 2010 RDHS collected information on the degree of acceptance of wife beating by asking whether a husband is justified in beating his wife in five situations: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual intercourse with him. Tables 15.6.1 and 15.6.2 show the percentages of women and men who agree that a husband is justified in hitting or beating his wife for these specific reasons. The tables also show the summary percentages (of women or men) who feel that wife beating is justified for at least one of the specified reasons. Agreement of a high proportion of women that wife beating is acceptable is an indication that women generally accept the right of a man to control his wife’s behaviour even by means of violence. If a low proportion of women agree that wife beating is acceptable, then the majority of women reject beliefs and behaviours that place them at a low status relative to men. Table 15.6.1 shows that 56 percent of women believe that wife beating is justified for at least one of the specified reasons. Women are least likely to agree that a man is justified in beating his wife for burning the food (19 percent). Women are most likely to agree that a man is justified in beating his wife if she neglects the children (44 percent), refuses to have sexual intercourse with him (37 percent), or goes out without telling him (36 percent). Women who have never married (54 percent) are less likely than women who are currently married (57 percent) or formerly married (60 percent) to agree that wife beating is justified for any of the reasons. Women in urban areas are less likely to agree with at least one of the specified reasons than those in rural areas (40 percent and 59 percent, respectively). The North and West provinces have the highest proportions of women who say that wife beating is justified for at least one of the reasons (63 percent each), while the City of Kigali has the lowest proportion (39 Table 15.6.1 Attitude toward wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Rwanda 2010 Background Characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 17.7 30.3 32.8 43.8 33.6 55.7 2,945 20-24 19.9 32.7 37.9 44.2 35.6 55.5 2,683 25-29 18.9 34.9 37.8 44.7 37.4 57.3 2,494 30-34 19.2 33.5 36.4 42.7 39.9 57.3 1,822 35-39 18.6 32.5 34.6 41.2 36.2 53.6 1,447 40-44 19.6 32.9 34.0 43.2 39.9 58.3 1,168 45-49 18.0 32.5 36.6 44.5 37.2 56.1 1,112 Employment (last 12 months) Not employed 20.2 32.9 34.5 42.4 38.6 55.2 2,227 Employed for cash 18.6 33.3 36.4 44.0 37.9 56.5 7,660 Employed not for cash 18.7 31.3 35.6 43.9 33.0 56.3 3,751 Missing 11.8 17.1 17.1 29.8 20.5 36.3 33 Number of living children 0 17.2 29.8 33.5 42.6 32.9 53.6 5,207 1-2 19.7 34.3 37.3 43.6 38.1 56.8 3,552 3-4 20.0 35.6 38.5 45.1 39.8 58.7 2,704 5+ 19.9 33.4 35.6 44.6 39.2 58.3 2,209 Marital status Never married 17.3 29.6 33.1 42.5 32.5 53.8 5,285 Married or living together 19.1 34.2 36.8 43.6 38.3 57.3 6,897 Divorced/separated/widowed 23.0 36.6 40.8 47.7 43.6 60.0 1,489 Residence Urban 12.5 23.2 26.6 30.2 24.5 40.3 2,057 Rural 20.0 34.4 37.4 46.0 38.8 59.0 11,614 Region City of Kigali 14.2 24.0 25.5 30.9 23.8 38.7 1,596 South 12.7 27.2 33.5 40.4 28.1 54.0 3,212 West 20.5 34.5 40.8 48.0 45.2 62.8 3,305 North 27.0 44.7 42.5 51.7 43.8 62.7 2,278 East 19.7 32.2 33.4 43.1 37.7 55.8 3,280 Education No education 26.6 42.5 44.5 52.5 48.2 66.1 2,119 Primary 19.7 34.6 38.3 46.3 38.7 59.8 9,337 Secondary and higher 7.8 15.2 17.0 23.9 16.8 31.7 2,216 Wealth quintile Lowest 25.3 41.5 45.3 51.4 46.8 66.3 2,622 Second 21.4 36.7 39.9 48.7 41.9 62.8 2,661 Middle 19.5 33.4 36.9 46.5 37.0 58.5 2,736 Fourth 17.2 31.4 33.6 42.5 35.3 55.5 2,677 Highest 11.8 21.8 24.7 30.6 23.8 39.9 2,976 Total 18.8 32.7 35.8 43.6 36.6 56.2 13,671 230 • Women’s Status and Demographic and Health Outcomes percent). Women with no education (66 percent) or a primary education (60 percent) are more likely than women with a secondary education or higher (32 percent) to agree that wife beating is justified for at least one reason. Agreement with at least one reason that justifies wife beating decreases with wealth quintile, from 66 percent in the lowest quintile to 40 percent in the highest quintile. Table 15.6.2 shows that the proportion of men age 15-49 who agree with at least one of the reasons justifying wife beating is lower than that observed among women (25 percent versus 56 percent). However, as was observed for women, men are most likely to agree that a husband is justified in beating his wife if she neglects the children (19 percent) and least likely to agree that a husband is justified in beating his wife if she burns the food (5 percent). Men age 15-19 (35 percent), men who are employed not for cash (29 percent), and formerly married men (36 percent) are more likely than other men to agree with at least one reason justifying wife beating. Rural men are more likely to agree with at least one reason for hitting or beating a wife than urban men (26 percent and 20 percent, respectively). By province, the City of Kigali has the lowest proportion of men who agree with at least one reason for hitting or beating a wife (12 percent). Table 15.6.2 Attitude toward wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Rwanda 2010 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 6.1 15.5 16.1 26.4 14.6 34.6 1,449 20-24 4.5 10.0 10.4 19.3 10.9 25.1 1,159 25-29 5.1 10.0 13.1 18.7 9.6 25.1 1,038 30-34 2.8 8.1 8.9 14.6 7.5 20.5 710 35-39 2.6 7.6 8.1 12.7 5.8 17.9 490 40-44 3.7 7.4 6.8 12.5 6.8 18.7 430 45-49 3.0 6.9 7.2 11.3 7.3 15.3 412 Employment (last 12 months) Not employed 2.1 8.0 8.9 16.7 9.6 25.0 457 Employed for cash 4.8 10.3 11.3 17.2 9.7 23.4 3,728 Employed not for cash 4.3 12.0 12.9 23.0 11.8 29.4 1,491 Number of living children 0 5.3 12.5 13.4 22.0 12.6 29.2 2,987 1-2 3.9 9.5 10.4 17.2 8.7 23.1 1,177 3-4 3.5 7.9 8.6 14.7 6.4 19.7 841 5+ 3.0 6.8 8.2 12.3 7.0 17.5 683 Marital status Never married 5.3 12.8 13.8 22.6 12.7 30.0 2,873 Married or living together 3.5 7.8 8.5 14.3 7.2 19.5 2,699 Divorced/separated/widowed 7.5 18.5 22.1 28.1 16.0 36.0 115 Residence Urban 2.0 7.1 7.9 13.5 7.7 19.5 939 Rural 5.0 11.2 12.2 19.8 10.7 26.2 4,748 Region City of Kigali 0.5 4.2 5.5 8.6 2.6 12.3 739 South 3.0 10.9 11.4 19.7 9.2 26.3 1,308 West 9.2 17.2 17.5 27.2 16.8 33.7 1,307 North 3.4 7.7 7.5 13.4 8.4 21.9 899 East 4.2 9.2 11.5 18.7 10.2 24.9 1,435 Education No education 4.7 12.9 12.8 19.5 11.0 26.1 583 Primary 5.4 12.1 13.3 20.9 11.5 28.0 3,916 Secondary and higher 1.2 4.1 4.6 11.3 5.3 15.2 1,189 Wealth quintile Lowest 7.5 15.1 16.4 25.4 15.3 34.2 854 Second 5.9 14.2 14.9 22.7 13.3 30.6 986 Middle 4.9 11.1 11.7 20.6 10.5 26.3 1,139 Fourth 3.9 8.9 9.7 17.7 9.3 23.6 1,235 Highest 1.9 6.4 7.6 11.7 5.6 16.6 1,474 Total 15-49 4.5 10.5 11.5 18.8 10.2 25.1 5,687 50-59 4.2 9.1 8.4 12.6 10.5 21.3 642 Total 15-59 4.4 10.4 11.2 18.1 10.2 24.7 6,329 Women’s Status and Demographic and Health Outcomes • 231 The proportion of men who agree that a husband is justified in beating his wife for at least one reason is lower among men with a secondary education or higher (15 percent) than among men with a primary education (28 percent) or no education (26 percent). The proportion of men who agree that a husband is justified in beating his wife for at least one reason decreases as wealth quintile increases. Thirty-four percent of men in the lowest quintile agree with at least one reason for hitting or beating a wife, as compared with 17 percent of men in the highest quintile. 15.5 WOMEN’S EMPOWERMENT INDICATORS Two sets of empowerment indicators, namely women’s participation in making household decisions and women’s attitudes towards wife beating, can be summarised in two indices. The first index shows the number of decisions (see Table 15.5 for the list of decisions) in which women participate either alone or jointly with their husband or partner. This index ranges from 0 to 3 and reflects the degree of decision-making control that women are able to exercise in areas that affect their own lives and the level of women’s empowerment in a society. The second index, which ranges from 0 to 5, is the number of reasons (see Table 15.6.1 for a list of reasons) for which a woman thinks that a husband is justified in beating his wife. A lower score on this indicator is interpreted as reflecting a higher status of women in the household and society. Table 15.7 shows how these indices relate to each other. There are clear relationships between the two indices. The percentage of women who disagree with all reasons justifying wife beating increases as the number of household decisions in which the women participate increases, from 25 percent among women who participate in none of the household decisions to 48 percent among women who participate in all three household decisions. The percentage of women who participate in all three household decisions decreases as the number of reasons for which wife beating is justified increases, from 66 percent among women who agree with none of the reasons justifying wife beating to 46 percent among women who agree with all five reasons justifying wife beating. Table 15.7 Indicators of women’s empowerment Percentage of currently married women age 15-49 who participate in all decision- making and the percentage who disagree with all of the reasons justifying wife beating, by value on each of the indicators of women’s empowerment, Rwanda 2010 Empowerment indicator Percentage who participate in all decision- making Percentage who disagree with all reasons justifying wife beating Number of women Number of decisions in which women participate1 0 na 24.7 743 1-2 na 38.7 2,103 3 na 48.2 4,052 Number of reasons for which wife beating is justified2 0 66.2 na 2,948 1-2 57.3 na 1,680 3-4 53.2 na 1,270 5 46.2 na 999 na = Not applicable 1 See Table 15.5 for the list of decisions. 2 See Table 15.6.1 for the list of reasons. 232 • Women’s Status and Demographic and Health Outcomes 15.6 CURRENT USE OF CONTRACEPTION BY WOMEN’S EMPOWERMENT STATUS A woman’s desire and ability to control her fertility and her choice of contraceptive methods are affected by her status in the household and her own sense of empowerment. A woman who is unable to control other aspects of her life may be less able to make decisions regarding her fertility. She may also feel the need to choose contraceptive methods that are less obvious or do not need the approval or knowledge of her husband. Table 15.8 shows the relationship of each of the empowerment indicators with current use of contraceptive methods by currently married women. As expected, contraceptive use is positively associated with participation in household decisions, although the relationship is not linear. Use of any contraceptive method is lower among women who do not participate in any household decisions (45 percent) than among women who participate in at least one household decision. Fifty-four percent of women who participate in one or two household decisions are currently using a method of family planning, as are 51 percent of women who participate in all three household decisions. Results are similar for use of a modern method. Use of any contraceptive method and use of any modern method are slightly lower among women who agree will all five reasons justifying wife beating (47 percent and 43 percent, respectively) than among women who agree with none of the reasons (51 percent and 45 percent, respectively). Table 15.8 Current use of contraception by women’s empowerment Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women’s status, Rwanda 2010 Empowerment indicator Any method Any modern method Modern methods Any traditional method Not currently using Total Number of women Female sterilization Male steriliszation Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 45.4 39.6 0.5 0.0 36.5 2.5 5.8 54.3 99.7 743 1-2 53.8 46.6 0.7 0.0 43.1 2.8 7.2 45.7 99.5 2,103 3 50.5 44.3 1.0 0.1 40.3 3.0 6.2 48.8 99.3 4,052 Number of reasons for which wife beating is justified3 0 51.2 44.5 0.9 0.0 40.4 3.2 6.7 47.8 99.0 2,948 1-2 51.5 43.9 1.0 0.1 39.7 3.1 7.7 47.9 99.4 1,680 3-4 52.7 46.8 0.8 0.1 43.5 2.5 5.9 46.8 99.5 1,270 5 46.8 42.6 0.3 0.1 40.0 2.2 4.2 53.2 100.0 999 Total 50.9 44.5 0.8 0.0 40.7 2.9 6.4 48.4 99.4 6,897 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly, and lactational amenorrhoea method 2 See Table 15.5 for the list of decisions. 3 See Table 15.6.1 for the list of reasons. 15.7 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS Women’s fertility preferences, for example the ideal number of children, are typically lower than those of their husband. As a woman becomes more empowered to negotiate fertility decision-making, she has more control over her ability to access and use contraceptives to space and limit her family size. Women who have a desire to space or limit their births but who are not using family planning are defined as having an unmet need for family planning. Table 15.9 shows how women’s ideal family size and their unmet need for family planning vary by the two indicators of women’s status. Women’s Status and Demographic and Health Outcomes • 233 Women who participate in none of the household decisions have a higher desired family size than women who participate in one or more decisions (3.7 children versus 3.6 children). Women who participate in three decisions have a lower total unmet need for family planning (19 percent) than women who do not participate in any decisions (25 percent). Women who participate in three decisions also have a lower unmet need for spacing and for limiting than women who do not participate in any decision-making. Desired family size increases with the number of reasons a woman thinks that wife beating is justified, from 3.2 children among women who do not agree with any of the reasons justifying wife beating to 3.4 children among women who agree with all five reasons. However, there is no strong association between unmet need for family planning and the number of reasons justifying wife beating. Table 15.9 Women’s empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women’s empowerment, Rwanda 2010 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of women For spacing For limiting Total Number of decisions in which women participate3 0 3.7 732 14.3 10.3 24.6 743 1-2 3.6 2,083 9.7 7.6 17.3 2,103 3 3.6 4,003 8.8 9.9 18.7 4,052 Number of reasons for which wife- beating is justified4 0 3.2 5,953 9.1 9.6 18.7 2,948 1-2 3.3 3,281 10.3 10.1 20.4 1,680 3-4 3.4 2,399 8.7 7.9 16.6 1,270 5 3.4 1,890 11.8 8.4 20.2 999 Total 3.3 13,523 9.7 9.2 18.9 6,897 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.10.1 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 15.5 for the list of decisions. 4 See Table 15.6.1 for the list of reasons. 15.8 WOMEN’S STATUS AND REPRODUCTIVE HEALTH CARE Table 15.10 shows women’s use of antenatal, delivery, and postnatal care services from health care workers by level of empowerment, as measured by the two indicators of women’s status. Women’s empowerment affects their ability to access reproductive health services. Increased empowerment of women is likely to increase their ability to seek out and use health services to better meet their reproductive health goals, including safe motherhood. The results in Table 15.10 show that, overall, there is not much variation in use of maternal health care services by indicators of women’s empowerment. Women who participate in none of the decisions are slightly less likely to receive antenatal care from a skilled provider, to receive delivery assistance from a skilled provider, and to receive postnatal care from a skilled provider within the first two days after delivery than women who participate in one or more household decisions. The percentage of women who receive delivery assistance from a skilled provider increases from 71 percent among those who participate in no decisions to 73 percent among those who participate in three decisions. Women who agree with all five reasons justifying wife beating were less likely to receive postnatal care from a skilled provider within the first two days following delivery than women who agree with four or fewer reasons. Eleven percent of women who agree with all five reasons justifying wife beating received postnatal care 234 • Women’s Status and Demographic and Health Outcomes within two days following the birth, as compared with 15 to 16 percent of women who agree with four or fewer reasons justifying wife beating. Table 15.10 Reproductive health care by women’s empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance, and postnatal care from health personnel for the most recent birth, by indicators of women’s empowerment, Rwanda 2010 Empowerment indicator Received antenatal care from health personnel Received delivery assistance from health personnel Received postnatal care from health personnel within the first two days since delivery1 Number of women with a child born in the last five years Number of decisions in which women participate2 0 97.3 70.5 13.2 602 1-2 99.1 71.7 15.9 1,641 3 98.6 73.2 15.0 3,063 Number of reasons for which wife- beating is justified3 0 98.4 74.5 15.9 2,607 1-2 97.8 69.9 15.4 1,573 3-4 97.6 68.8 15.5 1,217 5 97.9 73.3 11.4 1,007 Total 98.0 72.1 15.0 6,405 Note: ‘Health personnel’ includes doctor, nurse, midwife, or auxiliary nurse or auxiliary midwife. 1 Includes women who gave birth in a health facility and those who did not give birth in a health facility 2 Restricted to currently married women. See Table 15.5 for the list of decisions. 3 See Table 15.6.1 for the list of reasons. Adult and Maternal Mortality • 235 ADULT AND MATERNAL MORTALITY 16 stimates of maternal mortality require comprehensive and accurate reporting of maternal deaths. Such reporting can be obtained through vital registration, longitudinal studies of pregnant women, or repeated household surveys. The 2010 Rwanda Demographic and Health Survey (RDHS) is the third population- based national survey (after the 2000 RDHS and 2005 RDHS) to incorporate questions on maternal mortality. The RDHS asked female respondents a series of questions designed to elicit the information needed to make direct estimates of maternal mortality. To avoid seriously misinterpreting the results of the survey, users of the information must understand the problems inherent in measuring maternal mortality. Direct estimates of maternal mortality rely on data such as the ages of surviving sisters of survey respondents, the ages at death of sisters who have died, and the number of years that have passed since the death of the sisters. RDHS interviewers had to list all brothers and sisters born to the natural mother of female respondents, in chronological order, starting with the first born. Information was then obtained on the survivorship of each of the siblings, the ages of surviving siblings, the year of death or years since death of deceased siblings, and the age at death of deceased siblings. For each sister who died at age 12 or older, the respondent was asked additional questions to determine whether the death was maternity related. The interviews asked whether the sister was pregnant when she died, and if so, whether she died during childbirth, and if not, whether she died within two months of the termination of a pregnancy or childbirth. Listing all siblings in chronological order of their birth may improve the completeness of reporting. Collecting data on both male and female siblings also allows direct estimation of adult male and adult female mortality. 16.1 DATA QUALITY ISSUES Estimation of adult and maternal mortality requires reasonably accurate reporting of the number of sisters and brothers of the respondent, the number who have died, and the number of sisters who died of maternity-related causes. There is no definitive procedure for establishing the completeness or accuracy of retrospective data on sibling survivorship. Table 16.1 shows the number of siblings reported by female respondents and the completeness of the reported data on current age, age at death, and years since death. Table 16.1 Data on siblings Number of siblings reported by female survey respondents and completeness of reported data on sibling age, age at death (AD), and years since death (YSD), Rwanda 2010 Sibling Sisters Brothers All siblings Number Percent Number Percent Number Percent All siblings 41,562 100.0 42,048 100.0 83,609 100.0 Surviving 31,581 76.0 29,224 69.5 60,805 72.7 Dead 9,875 23.8 12,535 29.8 22,410 26.8 Missing survival information 105 0.3 289 0.7 395 0.5 Living siblings 31,581 100.0 29,224 100.0 60,805 100.0 Age reported 31,556 99.9 29,207 99.9 60,763 99.9 Age missing 25 0.1 16 0.1 42 0.1 Dead siblings 9,875 100.0 12,535 100.0 22,410 100.0 AD and YSD reported 9,811 99.3 12,461 99.4 22,271 99.4 AD missing 22 0.2 23 0.2 45 0.2 YSD missing 20 0.2 14 0.1 34 0.2 Both AD and YSD missing 22 0.2 37 0.3 59 0.3 E 236 • Adult and Maternal Mortality As a group, 2010 RDHS female respondents were able to report the survival status of more than 99 percent of their siblings; whether or not a brother or sister was alive or dead was unknown for 0.5 percent of siblings. Sex ratio is defined as the number of males per 100 females. The sex ratio of siblings who have died is calculated as the number of brothers per 100 sisters (12,535 brothers who died compared with 9,875 sisters who died). The sex ratio of siblings who have died was 127, which is very high and may be the consequence of the high male mortality during the period of genocide. Overall, the data on siblings are nearly complete, with age reported for 99.9 percent of living siblings and age at death and years since death reported for 99.4 percent of siblings who have died, with little difference between brothers and sisters. Rather than excluding siblings with missing information from the analysis, the information on the birth order of siblings, in conjunction with other information, is used to impute the missing data.1 Another crude measure of data quality is the mean number of siblings, or the mean sibship size (Table 16.2). Sibship size is expected to decline as fertility declines over time. The monotonic decline in sibship size that would be expected to accompany declining fertility is supportive of more complete reporting of older siblings. Sex ratios at birth are near the internationally accepted range of 103 to 105, suggesting that there is no serious underreporting or overreporting of brothers or sisters. However, it should be borne in mind that any information that relies on recall will suffer from some degree of misreporting, especially if it pertains to deceased persons and involves events that occurred a long time before the survey. 16.2 ADULT MORTALITY Because maternal mortality is a subset of adult mortality, estimates of overall adult mortality are calculated before estimates of maternal mortality. If overall adult mortality estimates display a general, stable, and plausible pattern, then credence is given to the maternal mortality estimates derived thereafter. Direct estimates of male and female adult mortality are obtained from information collected in the sibling history. Age-specific death rates are computed by dividing the number of deaths in each age group by the total person-years of exposure in that age group during a specified reference period. In total, female respondents reported 83,609 siblings, of whom 41,562 were sisters and 42,048 were brothers (Table 16.1). Direct estimates of age- specific mortality rates for men and women are shown in Table 16.3. Direct estimates are presented for the period 0 to 4 years before the survey, which roughly corresponds2 to September 2006 to March 2011. Aggregating the data over the age range 15-49 will reduce the effects of sampling variability. There are more male than female deaths in the seven years preceding the survey (406 versus 373). The male mortality rate is 3.6 deaths per 1,000 population, a figure higher than the female mortality rate of 3.1 deaths per 1,000 population. 1 The imputation procedure is based on the assumption that the reported birth ordering of the siblings in the birth history is correct. The first step is to calculate birth dates. For each living sibling with a reported age and for each dead sibling with complete information on both age at death and year of death, the birth date is calculated. For a sibling missing these data, a birth date is imputed within the range defined by the birth dates of the bracketing siblings. In the case of living siblings, an age is calculated from the imputed birth date. In the case of dead siblings, if either age at death or year of death is reported, that information is combined with the birth date to provide missing information. If both pieces of information are missing, the age at death is imputed. This imputation is based on the distribution of the ages at death for those whose year of death is unreported but age at death is reported. 2 The time period is not exact because, as with all DHS calculations of exposure time, exposure is calculated separately for each respondent, counting back in time from the date of the interview, and dates of interview in the 2010 RDHS spanned a period of six months. Table 16.2 Sibship size and sex ratio of siblings Mean sibship size and sex ratio of births, Rwanda 2010 Respondent’s year of birth Mean sibship size Sex ratio at birth of siblings 1960-64 7.4 100.3 1965-69 7.6 103.0 1970-74 7.6 105.4 1975-79 7.6 99.8 1980-84 7.2 101.8 1985-89 7.0 100.6 1990-94 6.6 99.6 1995 or 1996 7.4 100.3 Total 7.1 101.2 Adult and Maternal Mortality • 237 Table 16.3 Adult mortality rates Estimated adult mortality rates for women and men for the period 0 to 4 years prior to the survey, Rwanda 2010 Age Deaths Exposure Mortality rate1 WOMEN 15-19 29 21,511 1.4 20-24 49 26,065 1.9 25-29 69 24,195 2.9 30-34 84 18,732 4.5 35-39 61 13,943 4.4 40-44 58 9,888 5.9 45-49 23 6,566 3.4 15-49 373 120,900 3.1 a MEN 15-19 50 20,509 2.4 20-24 37 25,361 1.5 25-29 64 22,817 2.8 30-34 76 16,423 4.6 35-39 71 12,160 5.9 40-44 57 8,745 6.5 45-49 51 5,631 9.1 15-49 406 111,646 3.6 a Note: Exposure years are calculated using a life table technique; here, they represent the number of person-years that men or women are exposed to the probability of dying. 1 Expressed per 1,000 population a Age-adjusted rate 16.3 MATERNAL MORTALITY Estimates of maternal mortality for the period 0 to 4 years before the survey are shown in Table 16.4. This period of time was chosen to produce estimate that is comparable to the previous surveys. Age-specific mortality rates are calculated by dividing the number of maternal deaths by years of exposure. To remove the effect of truncation bias (the upper boundary for eligibility in the 2010 RDHS is 49 years), the overall rate for women age 15- 49 is standardized by the age distribution of the survey respondents. Maternal deaths are defined as any death that occurred during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy. This time- specific definition includes all deaths occurring during the specified period even if the death is due to causes that are not pregnancy related. However, this definition is unlikely to result in overreporting of maternal deaths because most deaths to women in the specified period are due to maternal causes, and maternal deaths in general are more likely to be underreported than overreported. For any given age group, maternal deaths are a relatively rare occurrence, and as such the age-specific pattern should be interpreted with caution. There were 91 maternal deaths (in the survey sample) in the period 0 to 4 years preceding the survey. During the period 2006-2010, the maternal mortality rate, which is the annual number of maternal deaths per 1,000 women age 15-49, was 0.80. Maternal deaths accounted for 24 percent of all deaths to women age 15-49; in other words, about 1 in 4 Rwandan women who died in the seven years preceding the survey died as a result of pregnancy or pregnancy-related causes. Maternal deaths accounted for a higher proportion of overall deaths than they had in the past; in the 2000 RDHS and 2005 RDHS, respectively, maternal deaths accounted for 16 percent and 20 percent of all female deaths in the seven years prior to each survey. The maternal mortality ratio, obtained by dividing the age-standardized maternal mortality rate by the age- standardized general fertility rate, is often considered a more useful measure of maternal mortality because it measures the obstetric risk associated with each live birth. Table 16.4 shows that the maternal mortality ratio for 238 • Adult and Maternal Mortality Rwanda for the period 2004-2010 was 476 deaths per 100,000 live births (or, alternatively, 4.76 deaths per 1,000 live births). The maternal mortality ratio can be converted to an estimate of the lifetime risk of dying from maternal causes: 0.023 or, in other words, a risk of dying of 1 in 43. Table 16.4 Direct estimates of maternal mortality Direct estimates of maternal mortality for the period 0 to 4 years prior to the survey, Rwanda 2010 Age Maternal deaths Exposure years Maternal mortality rate1 Proportion of maternal deaths to all women deaths 15-19 4 21,511 0.2 13.9 20-24 16 26,065 0.6 33.2 25-29 20 24,195 0.8 28.3 30-34 23 18,732 1.2 27.9 35-39 17 13,943 1.2 27.5 40-44 8 9,888 0.8 13.3 45-49 3 6,566 0.5 13.8 Total 91 165,352 0.8a 24.3 General fertility rate (GFR) 149a Maternal mortality ratio (MMR)2 476 Lifetime risk of maternal death3 0.023 1 Expressed per 1,000 woman-years of exposure 2 Expressed per 100,000 live births; calculated as the maternal mortality rate divided by the general fertility rate 3 Lifetime risk of maternal death = 1 – (1 – MMR/100,000)TFR where TFR represents the total fertility rate for the period 0 to 4 years prior to the survey (= 4.9) a Age-adjusted rate In the 2000 RDHS and 2005 RDHS, the maternal mortality ratios were 1,051 deaths per 100,000 live births and 750 deaths per 100,000 live births respectively. A comparison of the maternal mortality ratio from these three surveys shows no reason to doubt that there has been a steady decline in the maternal mortality ratio between 2000 and 2010. Nevertheless, the level of decline should be interpreted with caution and with consideration of the sampling error of the estimates. Figure 16.1 Maternal Mortality Ratio with Confidence Interval for the Period of 0-4 years Prior to the Survey, 2000 RDHS, 2005 RDHS and 2010 RDHS RDHS 2010 1267 908 584 875 592 368 2000 RDHS 2005 RDHS 2010 RDHS 0 200 400 600 800 1000 1200 1400 Maternal deaths per 100,000 live births 1071 750 476 Domestic Violence • 239 DOMESTIC VIOLENCE 17 n the words of former United Nations Secretary General Kofi Annan, “Violence against women is perhaps the most shameful human rights violation, and it is perhaps the most pervasive. It knows no boundaries of geography, culture or wealth. As long as it continues, we cannot claim to be making real progress towards equality, development, and peace” (UNIFEM, 2003). The World Health Organization defines domestic violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation” (Krug et al., 2002). Domestic violence is defined here as any act of violence resulting in physical, sexual, or psychological harm or suffering to women, girls, and also men, including threats of such acts, coercion, or arbitrary deprivation of liberty. The 2010 RDHS included a series of questions that focused on specific aspects of domestic and interpersonal violence. These questions addressed women’s experience of interpersonal violence, including acts of physical and sexual violence. Information was collected on both domestic violence (also known as spousal violence or intimate partner violence) and violence by other family members or unrelated individuals. Specifically, this chapter presents the findings on women who have experienced interpersonal violence—physical violence since the age of 15 and sexual violence at any age. It also presents findings on women who have experienced spousal violence, ever and in the past 12 months. Detailed information is presented on the physical consequences of partner violence, and when partner violence began. 17.1 MEASUREMENT OF VIOLENCE Collecting valid, reliable, and ethical data on intimate partner violence poses particular challenges because (1) what constitutes violence or abuse varies across cultures and individuals; (2) a culture of silence usually surrounds domestic violence and can affect reporting; and (3) the topic is a sensitive one. Assuring the safety of respondents and interviewers and protecting women who disclose violence, when asking about domestic violence in a familial setting, are responsibilities that raise specific ethical concerns. The responses to these challenges by the 2010 RDHS respondents and interviewers are described in the paragraphs that follow. 17.1.1 The Use of Valid Measures of Violence The 2010 RDHS measures violence committed by spouses and by other household members. Accordingly, information was obtained from ever-married women on violence by spouses and by others, and from never-married women on violence by anyone, including boyfriends. International research on violence shows that intimate partner violence is one of the most common forms of violence against women. Thus, spousal/partner violence was measured in more detail than violence by other perpetrators by using a greatly shortened and modified Conflict Tactics Scale (CTS) (Strauss, 1990). Specifically, spousal violence was measured using the following set of questions for women: (Does/did) your (last) husband/partner ever do any of the following things to you? a) Slap you? b) Twist your arm or pull your hair? c) Push you, shake you, or throw something at you? I 240 • Domestic Violence d) Punch you with his fist or with something that could hurt you? e) Kick you, drag you or beat you up? f) Try to choke you or burn you on purpose? g) Threaten or attack you with a knife, gun, or any other weapon? h) Physically force you to have sexual intercourse with him even when you did not want to? i) Force you to perform any sexual acts you did not want to? When the answer to the question was “yes,” women were asked about the frequency of the act in the 12 months preceding the survey. An affirmative answer to one or more of items (a) through (g) constitutes evidence of physical violence, while a similar answer to items (h) or (i) constitutes evidence of sexual violence. This approach of asking about specific acts to measure different forms of violence has the advantage of not being affected by different understandings of what constitutes a summary term such as violence. By including a wide range of acts, this approach has the additional advantage of giving the respondent multiple opportunities to disclose any experience of violence. In addition to these questions asked only of ever-married women, all women were asked about physical violence from persons other than the current or most recent spouse/partner with the question: From the time you were 15 years old, has anyone [other than your (current/last) husband] hit, slapped, kicked, or done anything else to hurt you physically? Respondents who answered this question in the affirmative were asked who had done this to them. Although this approach to questioning is generally considered to be optimal, the possibility of underreporting of violence, particularly sexual violence, cannot be entirely ruled out in any survey. 17.1.2 Ethical Considerations Three specific protections were built into the questionnaire, in accordance with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001b): • Only one eligible woman in each household was administered the questions on violence. The DHS protocol specifies that the domestic violence module can only be administered to one randomly selected woman per household. Therefore, in households with more than one eligible woman, the respondent for the module was randomly selected through a specially designed simple selection procedure based on the “Kish Grid”, which was built into the Household Questionnaire. Interviewing only one woman in each household using the domestic violence module provides assurance to the selected respondent that other respondents in the household will not know about the types of questions the selected respondent was asked. • Informed consent for the survey was obtained from the respondent at the beginning of the individual interview. In addition, at the beginning of the section on domestic violence, respondents were read an additional statement informing them that the subsequent questions could be sensitive, and reassuring them of the confidentiality of their responses. • The domestic violence module was implemented only if privacy could be obtained. If privacy could not be obtained, the interviewer was instructed to skip the module, thank the respondent, and end the interview. To maintain privacy, when a translator needed to conduct the interview, respondents were not asked questions from the domestic violence module. Domestic Violence • 241 17.1.3 Special Training for Implementing the Domestic Violence Module Complete privacy is essential for ensuring the security of the respondent and the interviewer. Asking about or reporting violence, especially in households where the perpetrator may be present at the time of the interview, carries the risk of further violence. Accordingly, interviewers were provided specific training for implementing the domestic violence module that would enable the field staff to collect violence data in a secure, confidential, and ethical manner. Table 17.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15, by background characteristics Rwanda 2010 Background characteristic Percentage who have ever experienced physical violence since age 151 Number of women Current age 15-19 15.8 1,115 20-24 28.9 975 25-29 49.1 909 30-39 57.4 1,154 40-49 57.9 855 Employed last 12 months Not employed 26.7 845 Employed for cash 47.3 2,745 Employed not for cash 38.3 1,401 Marital status Never married 14.4 1,966 Married or living together 56.1 2,499 Divorced/separated/widowed 69.7 542 Number of living children 0 16.6 1,918 1-2 50.8 1,315 3-4 61.6 959 5+ 59.5 816 Residence Urban 36.4 768 Rural 42.1 4,240 Province City of Kigali 34.5 587 South 42.7 1,154 West 41.1 1,215 North 37.4 852 East 45.7 1,199 Education No education 53.2 776 Primary 42.5 3,393 Secondary or higher 24.2 769 Wealth quintile Lowest 48.5 901 Second 41.9 1,012 Middle 43.4 994 Fourth 40.7 999 Highest 33.0 1,101 Total 41.2 5,008 Note: Total includes 17 women with missing information on employment. 1 Includes a few women who were married before age 15 and who reported only spousal violence. Such women could have first experienced the violence before age 15. 242 • Domestic Violence 17.2 SUB-SAMPLE FOR THE VIOLENCE MODULE The domestic violence module was implemented in half the households selected for the RDHS. Further, in keeping with the ethical requirements, only one woman per household was selected for the module. In all, 5,016 women were eligible for the module, of which 5,008 were successfully interviewed. Only 8 women were not interviewed, either because they refused or because complete privacy could not be obtained. Specially constructed weights were used to adjust for the selection of only one woman per household and to ensure that the domestic violence subsample was nationally representative. 17.3 EXPERIENCE OF PHYSICAL VIOLENCE AND PERPETRATORS OF PHYSICAL VIOLENCE The section first examines women’s experience of physical violence since age 15 and then continues with a report on lifetime experience of sexual violence. Background characteristics associated with increased risk of violence are considered. Table 17.1 shows that approximately two in five women (41 percent) have experienced physical violence since age 15.1 The proportion of women who have ever experienced physical violence increases with the age of women, from 16 percent (age 15-19) to 58 percent (age 40-49). Women who are employed for cash are more likely to report having experienced physical violence compared with women who are unemployed or employed but not paid in cash. Formerly married women (divorced, separated, or widowed) are more likely to have ever experienced physical violence since age 15 than currently married and never married women (70 percent, compared with 56 and 14 percent, respectively). Women with no living children are least likely to have experienced physical violence since age 15 (17 percent). There is little variation in the level of physical violence by urban-rural residence and by province. The percentage of women who have ever experienced physical violence ranges from 35 percent in the City of Kigali to 46 percent in the East province. The proportion of women who have ever experienced physical violence declines steeply with education, from 53 percent of women with no education to 24 percent of women with secondary and higher education. Women’s experience of physical violence is highest in the lowest wealth quintile (49 percent), and is lowest in the highest wealth quintile (33 percent); however, the relationship is not linear. Among women who have ever experienced physical violence, Table 17.2 shows, by current marital status, the percentages who reported that specific persons committed the violence. Because respondents could have experienced violence at the hands of several people, the percentages do not sum to 100. Among currently married women who have experienced physical violence since age 15, 95 percent reported that a current husband or partner committed the physical violence against them. 1 For the few women who married before age 15 and reported only spousal violence, the violence reported could have occurred before age 15. Domestic Violence • 243 Table 17.2 Persons committing physical violence Among women age 15-49 who have experienced physical violence since age 15, the percentage who report specific persons who committed the violence, according to the respondent's marital status, Rwanda 2010 Person Marital status Total Never married Currently married Formerly married Current husband/partner - 95.4 - 64.8 Former husband/partner - 0.8 94.7 17.9 Current boyfriend 1.1 0.4 0.4 0.5 Former boyfriend 0.2 0.1 0.0 0.1 Father/stepfather 15.6 2.0 1.2 3.7 Mother/stepmother 14.1 1.7 1.4 3.4 Sister/brother 16.8 2.0 3.9 4.4 Other relative 6.9 1.0 1.4 1.9 Mother-in-law 0.0 0.1 0.0 0.0 Other in-law 1.1 0.4 0.4 0.5 Teacher 13.1 0.9 0.4 2.5 Employer/someone at work 0.9 0.1 0.0 0.2 Police/soldier 1.1 0.5 1.0 0.7 Stanger 8.1 2.5 2.8 3.3 Neighbor/community member 21.9 2.9 2.8 5.5 Other 11.1 2.0 3.1 3.4 Number of women 283 1,401 378 2,062 na = Not applicable Among women who have never been married, the most common perpetrators of physical violence are neighbor/community member (22 percent), sister/brother (17 percent), father/stepfather (16 percent), and mother/stepmother (14 percent). 17.4 EXPERIENCE OF SEXUAL VIOLENCE AND PERPETRATORS OF SEXUAL VIOLENCE As shown in Table 17.3, more than one in five women have experienced sexual violence (22 percent). Women age 15-19 are less likely than other women to have experienced sexual violence. Differentials on women’s experience of sexual violence by urban-rural residence and province are small. Women who are employed for cash and those who are formerly married are more likely to have experienced sexual violence than other women. The likelihood of experiencing sexual violence decreases only marginally with women’s educational attainment—from 24 percent among women with no education to 20 percent among women with secondary and higher education. Sexual violence is also higher in prevalence among women in the lowest wealth quintile than among those in the other wealth quintiles, but the differentials are small. 244 • Domestic Violence Table 17.3 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence, by background characteristics, Rwanda 2010 Percentage who have ever experienced sexual violence Number of women Current age 15-19 12.0 1,115 20-24 23.0 975 25-29 25.6 909 30-39 27.5 1,154 40-49 24.1 855 Employed last 12 months Not employed 15.8 845 Employed for cash 26.1 2,745 Employed not for cash 18.8 1,401 Marital status Never married 17.0 1,966 Married or living together 23.1 2,499 Divorced/separated/widowed 37.4 542 Residence Urban 24.2 768 Rural 21.9 4,240 Province City of Kigali 24.3 587 South 22.3 1,154 West 21.4 1,215 North 18.3 852 East 24.9 1,199 Education No education 24.0 776 Primary 22.4 3,393 Secondary and higher 19.8 769 Wealth quintile Lowest 26.2 901 Second 21.5 1,012 Middle 21.6 994 Fourth 20.8 999 Highest 21.6 1,101 Total 22.3 5,008 Note: Total includes 17 women with missing information on employment. Table 17.4 shows the percent distribution of women who have experienced sexual violence, by age at first experience. In the RDHS questionnaire, if a respondent had experienced sexual violence committed only by the current spouse/partner (or the most recent spouse if currently divorced/separated), information was not collected on age at first experience of sexual violence. These respondents are included in the “Don’t know” column, which represents 36 percent of women. For 37 percent of women who experienced sexual violence, the first experience of such violence occurred at age 15-19; 14 percent first experienced sexual violence at age 10-14; and 2 percent first experienced sexual violence before age 10. Twelve percent of women who experienced sexual violence first experienced it at age 20-49. Domestic Violence • 245 Table 17.4 Age at first experience of sexual violence Percent distribution of women age 15-49 who have experienced sexual violence by age at first experience of sexual violence, according to current age, Rwanda 2010. Age at first experience of sexual violence Total Number of women Less than 10 years 10-14 years 15-19 years 20-49 years Don't know1 Missing Current age 15-19 4.9 41.2 50.3 na 3.0 0.5 100.0 134 20-24 4.1 12.3 50.4 12.8 19.8 0.6 100.0 225 25-29 1.9 14.0 31.1 15.8 37.2 0.0 100.0 236 30-39 1.1 7.6 36.6 10.6 44.1 0.0 100.0 321 40-49 0.0 7.0 21.2 13.9 57.6 0.3 100.0 213 Total 2.1 13.7 36.9 11.5 35.5 0.2 100.0 1,129 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed. For these women, the age at first experience of sexual violence is not known. na: Not applicable Table 17.5 shows that the main perpetrator of the first experience of sexual violence against women is a current or former husband or partner. Overall, 27 percent of women who have experienced sexual violence have experienced it at the hands of their current husband or partner, while 13 percent have experienced sexual violence committed by a former husband or partner. Other perpetrators of sexual violence reported by women are a current or former boyfriend (11 percent), a stranger (10 percent), and a neighbor or community member (10 percent, each). Among women who report experiencing sexual violence before age 15, the most frequently mentioned perpetrators are neighbours/community members, strangers, and other relatives. Table 17.5 Person committing sexual violence at first experience of sexual violence Among women age 15-49 who have experienced sexual violence, percent distribution by the person committing sexual violence at first experience of sexual violence, according to age at first experience of sexual violence and current marital status, Rwanda 2010 Person committing sexual violence Age at first experience of sexual violence Marital status < 15 years 15 years or higher Don't know1 Never married Currently married Formerly married Total Current husband/partner 0.0 5.1 68.9 0.0 51.7 na 27.0 Former husband/partner 1.3 3.0 30.9 0.0 0.6 67.5 12.6 Current/former boyfriend 5.6 20.9 0.0 19.1 9.2 3.1 11.0 Other relative 11.7 7.2 0.0 6.6 4.9 4.6 5.3 In-law 0.0 0.7 0.0 0.0 0.2 1.3 0.3 Own friend/acquaintance 3.3 5.3 0.0 4.9 2.7 1.5 3.1 Family friend 7.9 4.7 0.0 8.0 1.9 0.9 3.5 Teacher 2.2 1.2 0.0 2.0 0.5 0.4 0.9 Employer/someone at work 3.5 2.2 0.0 2.6 1.6 0.0 1.6 Police/soldier 0.5 1.5 0.0 0.5 1.0 0.8 0.8 Priest/religious leader 0.5 0.1 0.0 0.1 0.0 0.4 0.1 Stranger 16.7 15.5 0.0 17.1 7.7 5.7 10.1 Stepfather alone 0.0 0.3 0.0 0.0 0.1 0.4 0.1 Neighbor/community member 20.8 13.9 0.0 15.7 8.6 5.5 10.1 Other 23.7 17.4 0.2 22.0 8.5 7.3 12.3 Missing 2.2 1.0 0.0 1.2 0.8 0.6 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 179 547 401 334 589 206 1,129 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed. For these women, the age of first experience of sexual violence is not known. na: Not applicable 246 • Domestic Violence 17.5 EXPERIENCE OF DIFFERENT TYPES OF VIOLENCE Table 17.6 shows the percentage of respondents who have experienced different combinations of physical and sexual violence, by respondent’s current age. Overall, 26 percent of women age 15-49 have experienced only physical violence, 7 percent have experienced only sexual violence, and 16 percent have experienced both physical and sexual violence. Nearly half of all women age 15-49 (48 percent) have experienced either physical or sexual violence. The likelihood of having experienced physical or sexual violence increases with age, from 24 percent among women age 15-19 to 41 percent among women age 20-24 and then reaching a maximum of 61-62 percent among women age 30-49. Table 17.6 Experience of different forms of violence Percentage of women age 15-49 who have experienced different forms of violence by current age, Rwanda 2010 Physical violence only Sexual violence only Physical and sexual violence Physical or sexual violence Number of women Age 15-19 11.9 8.1 3.9 23.9 1,115 15-17 12.0 7.5 2.9 22.4 704 18-19 11.7 9.1 5.6 26.5 411 20-24 17.5 11.6 11.4 40.5 975 25-29 29.2 5.7 19.9 54.8 909 30-39 34.5 4.6 22.9 62.0 1,154 40-49 37.0 3.1 21.0 61.1 855 Total 25.6 6.7 15.6 47.9 5,008 17.6 TYPES OF SPOUSAL VIOLENCE This section of the chapter looks at violence perpetrated by intimate partners who are either married to the respondent or living with the respondent as if married. Because spousal or intimate partner violence is the most common form of violence for women age 15-49, the 2010 RDHS collected detailed information on the different types of spousal violence experienced by ever married women, including both physical and sexual violence. Currently married women were asked about violence perpetrated by their current husband, and formerly married women were asked about violence perpetrated by their most recent husband. Respondents were asked about seven specific acts of physical violence and two acts of sexual violence. The acts are listed in Table 17.7. Table 17.7 Forms of spousal violence Percentage of ever-married women age 15-49 who have experienced various forms of violence ever or in the 12 months preceding the survey, committed by their (former) husband/partner, Rwanda 2010 Ever In the past 12 months Often Sometimes Often or sometimes Physical violence Any 55.6 3.4 29.5 32.8 Pushed her, shook her, or threw something at her 15.6 1.0 10.2 11.2 Slapped her 29.9 1.4 17.3 18.7 Twisted her arm or pulled her hair 11.2 0.7 7.1 7.8 Punched her with his fist or with something that could hurt her 9.5 0.4 6.1 6.5 Kicked her, dragged her, or beat her up 48.9 3.8 35.0 38.8 Tried to choke her or burn her on purpose 31.9 2.3 22.4 24.7 Threatened her or attacked her with a knife, gun, or any other weapon 7.5 0.4 4.8 5.2 Sexual violence Any 17.5 1.4 11.9 13.3 Physically forced her to have sexual intercourse with him even when she did not want to 16.9 1.2 11.5 12.7 Forced her to perform any sexual acts she did not want to 6.9 0.6 4.7 5.2 Any form of physical and/or sexual violence 56.4 5.2 39.1 44.3 Any form of physical and sexual violence 16.7 0.9 11.1 11.9 Number of ever married women 3,042 3,042 3,042 3,042 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Domestic Violence • 247 Table 17.7 shows that 56 percent of ever married women have experienced physical violence at the hands of their current or most recent husband or partner, and 33 percent have experienced spousal physical violence in the past 12 months. Eighteen percent have ever experienced spousal sexual violence, and 13 percent have experienced such violence in the past 12 months. Overall, 56 percent of ever married women have experienced some kind of violence (physical or sexual) by their husband or partner, and 44 percent have experienced some form of spousal violence in the past 12 months. Among the physical acts of violence experienced by women in the past 12 months, kicking or dragging or beating was the most commonly reported act experienced by 39 percent of women. Eleven percent of women were slapped by their husband or partner, and 25 percent were choked or burned. Thirteen percent of women were forced to have sexual intercourse with their husband/partner when they did not want to, and 5 percent were forced to perform other sexual acts that they did not want to. Figure 17.1 shows the different forms of spousal violence experienced by ever married women. Figure 17.1 Percentage of ever-married women who have experienced specific forms of physical and sexual violence committed by their husband/partner, ever and during the past 12 months, Rwanda 2010 16 30 11 10 50 32 8 17 7 55 11 19 8 7 40 25 5 13 5 44 MODERATE PHYSICAL VIOLENCE Pushed/shook/thrown Slapped her Twisted arm/pulled hair SEVERE PHYSICAL VIOLENCE Punched with fist/or with something else Kicked/dragged/beat up Choked/burned Threatened/attacked with weapon SEXUAL VIOLENCE Forced to have intercourse Forced her to perform other sexual acts At least one of these acts 0 10 20 30 40 50 60 70 Percent Ever Last 12 months RDHS 2010 Table 17.8 shows the experience of spousal violence among ever married women by background characteristics. Women age 15-19 are less likely to have experienced physical or sexual violence by their spouse than those in the older age groups. Women with no children are much less likely than women with three or more children to have experienced such violence. Experience of spousal physical or sexual violence varies strongly with marital status. Women who are divorced, separated, or widowed are more likely to have experienced each type of violence than other women. This finding suggests that the experience of violence may have contributed to the termination of the relationship. Currently married women who have been married more than once are more likely to experience physical or sexual violence than currently married women married only once. Among women who have been married only once, the likelihood of having experienced violence increases with the duration of the union. 248 • Domestic Violence Rural women are more likely than urban women to experience each type of violence. Women in the City of Kigali are less likely to have experienced physical or sexual violence than their counterparts in other provinces. The proportions of women experiencing such violence decline with both education and wealth, although the relationship is not linear. Despite these variations in the prevalence of spousal physical or sexual violence by background characteristics, the most notable finding is that at least 50 percent of women in most categories have experienced spousal violence. Even among the most educated and wealthiest groups, 48 percent of women have experienced such violence. Table 17.8 Spousal violence by background characteristics Percentage of ever married women age 15-49 by whether they have ever experienced physical, or sexual violence committed by their husband/ partner, according to background characteristics, Rwanda 2010 Physical violence Sexual violence Physical or sexual violence Current age 15-19 40.9 9.4 42.9 20-24 49.7 15.3 50.3 25-29 54.7 16.1 55.6 30-39 58.5 17.8 59.1 40-49 56.3 17.6 57.2 Employed last 12 months Not employed 49.8 17.1 51.2 Employed for cash 57.0 17.6 57.5 Employed not for cash 54.5 15.1 55.7 Number of living children 0 34.7 10.4 36.2 1-2 54.3 16.2 55.2 3-4 59.7 18.9 60.3 5+ 57.5 17.1 58.2 Marital status and duration Currently married woman 53.5 14.0 54.2 Married only once 52.4 13.5 53.0 0-4 years 42.5 9.1 43.5 5-9 years 57.6 16.4 57.8 10+ years 55.4 14.5 56.1 Married more than once 62.1 18.3 63.0 Divorced/separated/widowed 65.6 30.2 66.7 Residence Urban 47.6 13.4 48.9 Rural 56.9 17.5 57.6 Province City of Kigali 45.4 11.8 46.3 South 57.0 18.2 58.2 West 54.9 17.4 55.9 North 54.1 13.1 54.9 East 59.7 19.5 59.9 Education No education 55.7 17.4 56.3 Primary 57.1 17.3 57.8 Secondary and higher 46.1 14.1 48.2 Wealth quintile Lowest 60.4 21.7 61.4 Second 56.1 18.5 57.1 Middle 59.5 17.9 60.4 Fourth 54.3 14.2 54.4 Highest 46.8 11.4 47.7 Total 55.6 16.9 56.4 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Domestic Violence • 249 17.7 VIOLENCE BY SPOUSAL CHARACTERISTICS AND WOMEN’S EMPOWERMENT INDICATORS Because the perpetrators of spousal violence are husbands or partners, it is important to understand how a woman’s experience of violence varies by the characteristics of her husbands or partner. It is also useful to examine whether spousal violence varies with indicators of women’s status. Table 17.9 shows the percentage of ever married women who have experienced different forms of spousal violence, by the current or most recent husband, by spousal characteristics, and by women’s empowerment indicators. The table shows that women whose husbands are more educated are less likely than women whose husbands have no education to have ever experienced spousal violence. Women who are at least 10 years younger than their husbands are less likely to experience spousal violence than those who are in the other categories of spousal age difference. Women in marriages in which both spouses are equally educated are the least likely to have experienced violence from their husbands, and women who are more educated than their husbands are most likely to have experienced such violence. However, these differences are quite small. As expected, women who do not participate in household decisions are more likely to experience spousal violence than women who participate in all three specific decisions. There is no clear relationship between views about wife beating and actual experience of physical abuse, although women who agree with no reasons are the least likely to have ever experienced sexual violence. Table 17.9 Spousal violence by husband's characteristics and empowerment indicators Percentage of ever married women age 15-49 who have ever suffered physical, or sexual violence committed by their husband/partner, according to his characteristics, marital characteristics, and empowerment indicators, Rwanda 2010 Physical violence Sexual violence Physical or sexual violence Number of women Husband's/partner's education No education 58.8 18.4 59.6 657 Primary 56.3 16.7 56.8 1,983 Secondary and higher 45.4 14.9 47.4 368 DK/missing (66.3) (21.8) (66.3) 33 Spousal age difference1 Wife older 54.3 16.9 55.5 342 Wife is same age 56.8 16.9 57.4 220 Wife is 1-4 years younger 52.2 12.7 53.0 889 Wife is 5-9 years younger 55.2 14.8 55.5 629 Wife is 10+ years younger 50.8 10.6 51.6 403 Missing * * * 16 Spousal education difference Husband better educated 54.1 16.6 54.8 1,306 Wife better educated 58.9 18.2 59.7 1,031 Both equally educated 50.4 13.3 51.4 366 Neither educated 54.5 17.2 55.0 272 DK/missing 69.2 21.8 69.2 67 Number of decisions in which women participate 0 63.7 17.2 65.2 278 1-2 60.3 15.4 60.8 769 3 48.0 12.7 48.6 1,453 Number of reasons given for refusing to have sexual intercourse with husband 0 57.8 15.4 59.2 518 1-2 55.2 17.2 55.8 2,524 Number of reasons for which wife-beating is justified 0 50.9 14.2 51.8 1,297 1-2 60.3 17.6 61.1 720 3-4 62.0 21.9 62.8 557 5 54.1 17.4 54.6 467 Total 55.6 16.9 56.4 3,042 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in the parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes only currently married women. 250 • Domestic Violence 17.8 FREQUENCY OF SPOUSAL VIOLENCE BY HUSBANDS Table 17.10 shows the percent distribution by frequency of violence of ever married women who reported physical or sexual violence by their current or most recent husband or partner in the 12 months preceding the survey. Seventy-eight percent of women who have experienced physical or sexual violence by their current or most recent husband have experienced such violence in the 12 months preceding the survey; this includes the 9 percent who have experienced such violence often. Table 17.10 Frequency of spousal violence among those who report violence Among ever married women age 15-49, percent distribution of those who have ever experienced physical or sexual violence committed by their husband/partner by frequency of violence in the 12 months preceding the survey, according to background characteristics, Rwanda 2010 Frequency of physical or sexual violence in the past 12 months Often Sometimes Not at all Total Number of women Current age 15-19 * * * 100.0 19 20-24 10.7 77.6 11.6 100.0 201 25-29 7.4 78.7 13.9 100.0 392 30-39 9.4 68.4 22.1 100.0 630 40-49 9.5 59.1 31.5 100.0 474 Employed last 12 months Not employed 14.0 73.5 12.5 100.0 149 Employed for cash 8.9 70.7 20.3 100.0 1,128 Employed not for cash 8.6 64.1 27.3 100.0 440 Number of living children 0 7.5 78.1 14.3 100.0 67 1-2 8.9 71.1 20.1 100.0 609 3-4 10.0 66.7 23.3 100.0 567 5+ 9.2 68.8 22.0 100.0 474 Marital status and duration Currently married woman 9.6 78.6 11.7 100.0 1,355 Married only once 9.1 78.6 12.3 100.0 1,172 0-4 years 6.7 88.0 5.3 100.0 265 5-9 years 8.8 83.4 7.8 100.0 288 10+ years 10.3 72.3 17.4 100.0 619 Married more than once 13.1 79.1 7.9 100.0 183 Divorced/separated 7.9 34.2 57.9 100.0 362 Residence Urban 7.0 64.4 28.7 100.0 200 Rural 9.6 69.9 20.5 100.0 1,517 Province City of Kigali 8.6 57.6 33.8 100.0 137 South 12.2 69.2 18.6 100.0 408 West 11.4 77.0 11.6 100.0 397 North 8.0 66.7 25.3 100.0 276 East 6.0 67.8 26.1 100.0 498 Education No education 9.9 61.6 28.5 100.0 369 Primary 8.9 72.0 19.0 100.0 1,206 Secondary and higher 11.1 65.7 23.2 100.0 126 Wealth quintile Lowest 12.4 65.0 22.5 100.0 386 Second 9.6 70.3 20.0 100.0 369 Middle 7.7 71.5 20.8 100.0 370 Fourth 8.9 74.0 17.0 100.0 332 Highest 6.7 64.8 28.4 100.0 260 Total 9.3 69.3 21.5 100.0 1,717 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Recent experience of spousal violence (i.e., within the past 12 months) varies by age. Among women who have ever experienced spousal physical or sexual violence, 88 percent of women age 20-24 have experienced such violence in the past year, compared with 68 percent of women age 40-49. Similarly, unemployed women experienced more recent spousal violence, and also experienced such violence more often than employed women. Domestic Violence • 251 The frequency of violence varies little by education. The proportion of women who have experienced spousal violence often in the past year declines more or less steadily with wealth. 17.9 HELP-SEEKING TO STOP VIOLENCE All respondents who have ever experienced physical or sexual violence by any person were asked whether and from whom they sought help to try to end the violence. This information is presented in Tables 17.11 and 17.12. Table 17.11 Help seeking to stop violence Percent distribution of women age 15-49 who have ever experienced physical or sexual violence by whether they have ever sought help from any source, according to type of violence and background characteristics, Rwanda 2010 Background characteristic Never sought help Have sought help from any source Missing/DK Total Number of women Type of violence Physical only 60.8 37.2 2.0 100.0 1,283 Sexual only 65.0 34.8 0.2 100.0 335 Both physical and sexual 45.4 54.1 0.5 100.0 779 Current age 15-19 56.1 42.9 1.0 100.0 267 20-24 55.3 43.5 1.2 100.0 395 25-29 58.2 39.8 2.0 100.0 498 30-39 56.3 42.9 0.8 100.0 715 40-49 55.9 42.8 1.3 100.0 522 Employed last 12 months Not employed 58.4 38.8 2.8 100.0 284 Employed for cash 55.9 43.1 1.1 100.0 1,479 Employed not for cash 56.9 42.1 1.0 100.0 632 Number of living children 0 54.9 44.3 0.8 100.0 508 1-2 56.7 41.6 1.6 100.0 769 3-4 56.8 42.3 0.9 100.0 613 5+ 56.8 41.6 1.6 100.0 507 Marital status and duration Never married 56.4 43.1 0.5 100.0 521 Currently married woman 60.4 38.3 1.3 100.0 1,481 Married only once 61.5 36.9 1.5 100.0 1,279 0-4 years 65.4 32.2 2.4 100.0 320 5-9 years 58.6 39.9 1.4 100.0 309 10+ years 61.0 37.8 1.2 100.0 651 Married more than once 52.9 47.1 0.0 100.0 201 Divorced/separated/widowed 41.6 56.6 1.9 100.0 396 Residence Urban 59.4 40.0 0.7 100.0 356 Rural 55.9 42.8 1.4 100.0 2,042 Province City of Kigali 59.9 40.1 0.0 100.0 264 South 58.2 41.4 0.4 100.0 565 West 58.8 38.8 2.4 100.0 569 North 54.6 43.2 2.2 100.0 383 East 52.1 47.0 0.9 100.0 616 Education No education 50.1 48.0 1.8 100.0 452 Primary 58.3 40.6 1.1 100.0 1,650 Secondary and higher 53.6 45.2 1.2 100.0 270 Wealth quintile Lowest 51.6 46.7 1.7 100.0 489 Second 53.4 45.7 0.9 100.0 485 Middle 55.4 43.5 1.1 100.0 489 Fourth 61.2 37.7 1.1 100.0 465 Highest 60.8 37.7 1.4 100.0 468 Total 56.4 42.4 1.3 100.0 2,398 Note: Total includes 2 women with missing information on employment. Slightly more than 2 in 5 women (42 percent) who have experienced any type of violence have ever sought help. Women who experience both physical and sexual violence (54 percent) are most likely to seek help, and those who have experienced only sexual violence are least likely to do so. The percentage of respondents who seek help varies little by age and by number of living children. Unemployed women are less likely to seek help than those who 252 • Domestic Violence are employed. Formerly married women and women who have been married more than once are more likely to have sought help than women who have been married only once. More women in the East province (47 percent) sought help, compared with women in the City of Kigali and the West province (40 and 39 percent, respectively). Women with primary education and those in the fourth and highest wealth quintiles are less likely to seek help than other women. Table 17.12 shows the sources of help for women who have ever experienced violence and have sought help, by type of violence. Women were most likely to have sought help from their friends or neighbours (53 percent). Women were also likely to seek help from their in-laws (25 percent) and their own family (22 percent). Only 7 percent of women sought help from the police. Table 17.12 Sources from where help was sought Percentage of women age 15-49 who have ever experienced physical or sexual violence and sought help according to source from which help was sought, by type of violence experienced, Rwanda 2010 Sources from where help was sought Type of violence Total Any physical Any sexual Own family 22.6 24.0 22.4 In-laws 28.1 23.5 25.3 Husband/partner boyfriend 0.2 0.3 0.2 Friend/neighbor 54.6 50.2 52.8 Police 6.4 7.7 6.5 Other 18.9 26.3 21.0 Number of women 899 544 1,016 References • 253 REFERENCES Auvert, B., D. Taljaard, E. Largarde, J. Sobngwi-Tambekou, R. Sitta, and A. Puren. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2(11): e298. doi:10.1371/journal.pmed.0020298. Gray, R.H., G. Kigozi, D. Serwadda, F. Makumbi, S. Watya, F. Nalugoda, N. Kiwanuka, L.H. Moulton, M.A. Chaudhary, M.Z. Chen, N.K. Sewankambo, F. Wabwire-Managen, M.C. Bacon, C.F.M. Williams, P. Opendi, S.J. Reynolds, O. Laeyendecker, T.C. Quinn, and M.J. Wawer. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomized trial. The Lancet 369(9562): 657-66. doi:10.1016/S0140-6736(07)60313-4. Gwatkin, D.R., S. Rutstein, K. Johnson, R.P. Pande and A. Wagstaff. 2000. Socio-economic differences in health, nutrition and poverty. HNP/Poverty Thematic Group of the World Bank, Washington, D.C.: The World Bank. Institut National de la Statistique du Rwanda (INSR) and ORC Macro. 2006. Rwanda Demographic and Health Survey 2005. Calverton, Maryland, U.S.A.: INSR and ORC Macro. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2009. Consultation on concurrent sexual partnerships: recommendations from a meeting of the UNAIDS Reference Group on Estimates, Modelling and Projections held in Nairobi, Kenya, April 20-21st 2009. http://www.epidem.org/Publications/Concurrency%20meeting%20recommendations_Final.pdf (accessed December 21, 2011). Krug, E.G., L.L. Dahlberg, J.A. Mercy, A.B. Zwi, and R. Lozano, eds. 2002. World report on violence and health. Geneva: World Health Organization. Ministry of Agriculture and Animal Resources (MAAR) [Rwanda]. 2004. Strategic plan for agricultural transformation in Rwanda. Kigali, Rwanda: MAAR. Ministry of Finance and Economic Planning (MFEP) [Rwanda]. 2007. Economic development and poverty reduction strategy, 2008-2012. Kigali, Rwanda: MFEP. 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. Ministry of Health (MOH) [Rwanda]. 2003. National Reproductive Health Policy. http://payson.tulane.edu/gsdl- 2.73/collect/mohnonve/archives/HASH5736.dir/doc.pdf (accessed December 21, 2011). Ministry of Health (MOH) [Rwanda]. 2010. Malaria Performance Program Review, 2011. http://www.rollbackmalaria.org/countryaction/aideMemoire/Rwanda-The-malaria-program-performance-review- 2011.pdf (accessed December 21, 2011). National AIDS Commission (Republic of Rwanda). 2005. National Multi-sectoral HIV and AIDS Strategic Plan 2005-2009. Kigali, Rwanda: National AIDS Commission. National AIDS Commission (Republic of Rwanda). 2009. Rwanda National Strategic Plan on HIV and AIDS 2009- 2012. Kigali, Rwanda: National AIDS Commission. 254 • References National Census Bureau [Rwanda], 2005. Third Rwandan General Population and Housing Census-August 15, 2002. Kigali, Rwanda: National Census Bureau. Office National de la Population (ONAPO) [Rwanda] and Macro International Inc. 2001. Enquête Démographique et de Santé Rwanda 2000. Kigali, Rwanda and Calverton, Maryland, U.S.A.: ONAPO and Macro International Inc. United Nations. 1973. The determinants and consequences of population trends. Vol. 1. New York: United Nations. United Nations Fund for Women (UNIFEM). 2003. Not a minute more; ending violence against women. New York: UNIFEM. Appendix A • 255 SAMPLE IMPLEMENTATION Appendix A A.1 INTRODUCTION The 2010 Rwanda Demographic and Health Survey (RDHS) followed surveys implemented in 1992, 2000, and 2005. A nationally representative sample, of about 12,800 households, was selected. All women age 15-49 who are usual residents of the selected households or who sleep in the households the night before the survey are eligible for the survey. A survey of men as also conducted in a subsample consisting of every second household. All men age 15-59 who are usual residents or who sleep in the subsample households the night before the survey are eligible. Altogether about 13,400 women age 15-49 and 5,700 men age 15-59 were interviewed. As with prior surveys, the main objectives of the 2010 RDHS are to provide up-to-date information on fertility and childhood mortality levels; fertility preferences; awareness, approval, and use of family planning methods; maternal and child health; knowledge and attitudes toward HIV/AIDS and other sexually transmitted infections (STIs); and prevalence of HIV among the adult population. The survey was designed to produce representative estimates for the main demographic and health indictors for the country as a whole, for the urban and rural areas, and for each of the five provinces. For some indicators, representative results may be available for each of the thirty districts. A.2 SAMPLING FRAME The sampling frame used for the 2010 RDHS is the preparatory frame for the Rwanda General Population and Housing Census (RGPH), which will be conducted in 2012. Provided by the National Institute of Statistics of Rwanda (NISR), the sampling frame is a complete list of natural villages covering the entire country. Though it is preferable to work with a frame consisting of enumeration areas (EAs) because the natural villages are too variable in size, an EA frame is not available at the time of sampling design. The sampling frame that was available is the list of 14,837 natural villages, which contains the administrative characteristics for each village and village population. The village population comes from the national ID card project carried out in 2007-08, which may be under estimated compared with the population projection conducted in 2009 by NISR. Rwanda’s administrative units were reformed in 2006, so the country is currently divided into 5 provinces; 30 districts, 417 sectors, and 14,837 villages. Table A.1 below shows the distribution of number of villages, population, and population share by province and by district within province. Table B.2 below shows the average village size and population distribution by district. The average village size is 610 residents, which is equivalent to 133 households. The sizes of the districts are quite homogeneous, varying from 2.7 percent to 4.4 percent. There is no urban-rural specification in the sampling frame because the urban-rural definition has not been released by the Ministry of Local Administration (MINALOC). It was expected that the urban-rural definition of the sampled villages will be determined during the data collection or in the office once the MINALOC releases the definition. 256 • Appendix A Table A.1 Distribution of village and population by province and by district within province Province District Number of Population Population Villages share East Bugesera 585 294,013 0.144 Gatsibo 594 350,403 0.172 Kayonza 418 255,119 0.125 Kirehe 613 278,708 0.137 Ngoma 473 277,129 0.136 Nyagatare 630 326,588 0.160 Rwamagana 472 256,147 0.126 East Total 3,785 2,038,107 0.225 Kigali City Gasabo 494 398,282 0.446 Kicukiro 327 246,664 0.277 Nyarugenge 356 247,090 0.277 Kigali City Total 1,177 892,036 0.098 North Burera 567 320,123 0.199 Gakenke 617 334,236 0.207 Gicumbi 629 360,237 0.224 Musanze 434 331,254 0.206 Rulindo 494 264,981 0.164 North Total 2,741 1,610,831 0.178 South Gisagara 524 278,367 0.123 Huye 516 288,203 0.127 Kamonyi 319 287,881 0.127 Muhanga 331 299,658 0.132 Nyamagabe 536 311,808 0.138 Nyanza 421 262,713 0.116 Nyaruguru 332 256,855 0.113 Ruhango 533 280,625 0.124 South Total 3,512 2,266,110 0.250 West Karongi 538 293,816 0.131 Ngororero 419 311,834 0.139 Nyabihu 473 298,163 0.133 Nyamasheke 586 344,222 0.153 Rubavu 525 349,224 0.155 Rusizi 596 356,823 0.159 Rutsiro 485 296,004 0.132 West Total 3,622 2,250,086 0.248 Rwanda 14,837 9,057,170 1.000 Note: Source is 2012 population census preparatory frame, Rwanda Appendix A • 257 Table A.2 Average village size and population distribution by district Province District Average village size Population distribution East Bugesera 502 0.032 Gatsibo 589 0.039 Kayonza 610 0.028 Kirehe 454 0.031 Ngoma 585 0.031 Nyagatare 518 0.036 Rwamagana 542 0.028 Gasabo 806 0.044 Kigali City Kicukiro 754 0.027 Nyarugenge 694 0.027 Burera 564 0.035 Gakenke 541 0.037 North Gicumbi 572 0.040 Musanze 763 0.037 Rulindo 536 0.029 Gisagara 531 0.031 Huye 558 0.032 Kamonyi 902 0.032 South Muhanga 905 0.033 Nyamagabe 581 0.034 Nyanza 624 0.029 Nyaruguru 773 0.028 Ruhango 526 0.031 Karongi 546 0.032 Ngororero 744 0.034 Nyabihu 630 0.033 West Nyamasheke 587 0.038 Rubavu 665 0.039 Rusizi 598 0.039 Rutsiro 610 0.033 Rwanda 610 1.000 Note: Source is 2012 population census preparatory frame, Rwanda A.3 STRUCTURE OF THE SAMPLE AND THE SAMPLING PROCEDURE The sample for the 2010 RDHS was a stratified sample selected in two stages from the 2012 census preparatory frame. Stratification was achieved by separating each province into districts; each district formed a sampling stratum. In total, 30 sampling strata had been created. Samples was selected independently in each sampling stratum, by a two-stage selection process. Implicit stratification and proportional allocation was achieved at each of the lower administrative unit levels by sorting the sampling frame according to administrative unit in different levels before sample selection and by using a probability proportional to size selection at the first stage of sampling. In the first stage, 492 villages were selected with probability proportional to the village size and with independent selection in each sampling stratum, according to the sample allocation given in Table A.3. A household listing operation was carried out in all of the selected villages before the main survey. The household listing operation consists of visiting each of the 492 selected villages (1) to draw a location map and a detailed sketch map and (2) to record on the household listing forms all residential households found in the village with the address and the name of the heads of the households. The resulting list of households was used as the sampling frame for the selection of households in the second stage. Some of the selected villages may be found to be large in size in the household listing operation. To minimize the task of household listing, the selected villages with an estimated number of households greater than 300 were segmented. Only one segment was selected for the survey, with its probability proportional to the segment size. The methodology and the detailed household listing procedure are addressed in the household listing manual. At the second stage, a fixed number of 26 households was selected from each selected village. Table A.3 shows the sample allocation of villages and households and the expected number of interviews with women by district. Table A.4 shows the sample allocation of villages and households and the expected number of interviews 258 • Appendix A with men by district. Table A.5 shows the expected number of eligible individuals for HIV testing and the expected number of completed HIV tests, by district and by sex. Because the total sample size is too small to provide representative results for some indicators, an equal size allocation was adopted, with a slightly larger sample size for the districts in the province of City of Kigali because of the low fertility level. In fact, the equal size allocation is not different from the proportional allocation, which is the best allocation, because the district sizes are quite homogeneous. On the other hand, the total sample size is already large; any substantial increase in the total sample size to provide representative results for most of the indicators at district level will compromise the data quality because of the limited implementing capability. With the current sample size, adequate survey precision at district level is obtained for women indicators above 15 percent; and for children (under 5) indicators is above 20 percent. The expected survey results were calculated based on the survey results of the 2005 RDHS: the average number of women age 15-49 per household was 1.12; the average number of men age 15-59 per household was 0.96; the household response rate was 96.5 percent; the women’s individual response rate was 98 percent; the men’s individual response rate was 97 percent; and the response rate for HIV testing was 98 percent for both men and women. Table A.3 Sample allocation of clusters, households and expected number of women’s interviews by district Province District Number of Villages Number of households Expected number of woman interviews East Bugesera 16 416 438 Gatsibo 16 416 438 Kayonza 16 416 438 Kirehe 16 416 438 Ngoma 16 416 438 Nyagatare 16 416 438 Rwamagana 16 416 438 Gasabo 20 520 548 City of Kigali Kicukiro 20 520 548 Nyarugenge 20 520 548 Burera 16 416 438 Gakenke 16 416 438 North Gicumbi 16 416 438 Musanze 16 416 438 Rulindo 16 416 438 Gisagara 16 416 438 Huye 16 416 438 Kamonyi 16 416 438 South Muhanga 16 416 438 Nyamagabe 16 416 438 Nyanza 16 416 438 Nyaruguru 16 416 438 Ruhango 16 416 438 Karongi 16 416 438 Ngororero 16 416 438 Nyabihu 16 416 438 West Nyamasheke 16 416 438 Rubavu 16 416 438 Rusizi 16 416 438 Rutsiro 16 416 438 Rwanda 492 12,792 13,470 Appendix A • 259 Table A.4 Sample allocation of clusters, households and expected number of men’s interviews by district Province District Number of Villages Number of households Expected number of men’s interviews East Bugesera 16 208 186 Gatsibo 16 208 186 Kayonza 16 208 186 Kirehe 16 208 186 Ngoma 16 208 186 Nyagatare 16 208 186 Rwamagana 16 208 186 Kigali City Gasabo 20 260 232 Kicukiro 20 260 232 Nyarugenge 20 260 232 North Burera 16 208 186 Gakenke 16 208 186 Gicumbi 16 208 186 Musanze 16 208 186 Rulindo 16 208 186 South Gisagara 16 208 186 Huye 16 208 186 Kamonyi 16 208 186 Muhanga 16 208 186 Nyamagabe 16 208 186 Nyanza 16 208 186 Nyaruguru 16 208 186 Ruhango 16 208 186 West Karongi 16 208 186 Ngororero 16 208 186 Nyabihu 16 208 186 Nyamasheke 16 208 186 Rubavu 16 208 186 Rusizi 16 208 186 Rutsiro 16 208 186 Rwanda 492 6,396 5,718 Note: Men’s survey will be carried out in one half of households selected for women’s survey. 260 • Appendix A Table A.5 Expected number of eligible individuals for HIV testing and expected number of completed HIV tests by sex and by district Province District Eligible individuals for HIV testing Expected number of HIV tests Men Women Total Men Women Total East Bugesera 192 224 416 182 215 397 Gatsibo 192 224 416 182 215 397 Kayonza 192 224 416 182 215 397 Kirehe 192 224 416 182 215 397 Ngoma 192 224 416 182 215 397 Nyagatare 192 224 416 182 215 397 Rwamagana 192 224 416 182 215 397 City of Kigali Gasabo 240 280 520 228 268 496 Kicukiro 240 280 520 228 268 496 Nyarugenge 240 280 520 228 268 496 North Burera 192 224 416 182 215 397 Gakenke 192 224 416 182 215 397 Gicumbi 192 224 416 182 215 397 Musanze 192 224 416 182 215 397 Rulindo 192 224 416 182 215 397 South Gisagara 192 224 416 182 215 397 Huye 192 224 416 182 215 397 Kamonyi 192 224 416 182 215 397 Muhanga 192 224 416 182 215 397 Nyamagabe 192 224 416 182 215 397 Nyanza 192 224 416 182 215 397 Nyaruguru 192 224 416 182 215 397 Ruhango 192 224 416 182 215 397 West Karongi 192 224 416 182 215 397 Ngororero 192 224 416 182 215 397 Nyabihu 192 224 416 182 215 397 Nyamasheke 192 224 416 182 215 397 Rubavu 192 224 416 182 215 397 Rusizi 192 224 416 182 215 397 Rutsiro 192 224 416 182 215 397 Rwanda 5,904 6,888 12,792 5,598 6,609 12,207 A.4 SELECTION PROBABILITY AND SAMPLING WEIGHT Because of the nonproportional allocation of the sample to the different provinces and to their districts and the possible differences in response rates, sampling weights is required for any analysis using 2010 RDHS data; this ensures the actual representativeness of the survey results at the national level as well as at the domain level. Because the 2010 RDHS sample is a two-stage stratified cluster sample, sampling weights was calculated based on separate sampling probabilities for each sampling stage and for each cluster. We used the following notations: P1hi: first-stage sampling probability of the ith village in stratum h P2hi: second -stage sampling probability within the ith village (household selection) Let ah be the number of villages selected in stratum h, Mhi be the total population according to the sampling frame in the ith village, and M hi be the total population in the stratum h. The probability of selecting the ith village in the 2010 RDHS sample is calculated as follows: M M a hi hih  Let hib be the proportion of households in the selected segment compared with the total number of households in the village i in stratum h if the village is segmented; otherwise 1=hib . Then the probability of selecting village i in the sample is: Appendix A • 261 hi hi hih 1hi b M M a = P × A 2010 RDHS cluster is either a village or a segment of a large village. Let hiL be the number of households listed in the household listing operation in the cluster i in stratum h, let hig be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster is calculated as follows: hi hi hi L gP =2 The overall selection probability of each household in cluster i of stratum h is therefore the production of the two stages of selection probabilities: hihihi PPP 21 ×= The design weight for each household in cluster i of stratum h is the inverse of its overall selection probability: hihi PW /1= A spreadsheet containing all sampling parameters and selection probabilities was prepared to facilitate the calculation of the design weights. Design weights was adjusted for household nonresponse as well as for individual nonresponse to get the sampling weights for women’s and men’s surveys, respectively. The differences in the household sampling weights and the individual sampling weights are introduced by individual nonresponse. The final sampling weights was normalized to give the total number of unweighted cases, equal to the total number of weighted cases at the national level, for both household weights and individual weights, respectively. The normalized weights are relative weights, which are valid for estimating means, proportions, and ratios but not valid for estimating population totals and pooled data. The sampling weights for HIV testing were calculated in a similar way, but the normalization of the individual sampling weights differs compared with the individual survey weights. The HIV testing weights were normalized for men and women together at the national level so that the HIV prevalence calculated for men and women together is valid. Sampling errors were calculated for selected indicators for the national sample, for the urban and rural areas separately, and for each of the five provinces. 262 • Appendix A Table A.6 Sample implementation: Women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall women’s response rates, according to urban-rural residence and region (unweighted), Rwanda 2010 ,Result Residence Region Urban Rural City of Kigali South West North East Total Selected households Completed (C) 97.8 98.1 97.6 98.0 97.5 98.4 98.5 98.0 Household present but no competent respondent at home (HP) 0.1 0.2 0.1 0.2 0.3 0.0 0.1 0.2 Refused (R) 0.1 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Dwelling not found (DNF) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Household absent (HA) 0.1 0.3 0.3 0.2 0.3 0.3 0.2 0.3 Dwelling vacant/address not a dwelling (DV) 1.7 1.0 1.8 1.1 1.3 0.7 0.7 1.1 Dwelling destroy (DD) 0.1 0.4 0.1 0.3 0.5 0.4 0.3 0.3 Other (O) 0.0 0.1 0.0 0.1 0.0 0.1 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 2,054 10,738 1,560 3,328 2,912 2,080 2,912 12,792 Household response rate (HRR)1 99.8 99.8 99.7 99.7 99.6 100.0 99.9 99.8 Eligible women Completed (EWC) 99.2 99.1 99.0 99.4 98.7 99.2 99.3 99.1 Not at home (EWNH) 0.3 0.3 0.5 0.2 0.7 0.2 0.2 0.3 Postponed (EWP) 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Refused (EWR) 0.2 0.0 0.3 0.0 0.0 0.0 0.0 0.1 Partly completed (EWPC) 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Incapacitated (EWI) 0.2 0.5 0.2 0.3 0.5 0.5 0.5 0.4 Other (EWO) 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,386 11,404 1,909 3,361 3,178 2,216 3,126 13,790 Eligible women response rate (EWRR)2 99.2 99.1 99.0 99.4 98.7 99.2 99.3 99.1 Overall women response rate (ORR)3 99.0 98.9 98.7 99.1 98.3 99.2 99.2 98.9 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C _______________________________ C + HP + P + R + DNF 2 The eligible women response rate (EWRR) is equivalent to the percentage of interviews completed (EWC) 3 The overall women response rate (OWRR) is calculated as: OWRR = HRR * EWRR/100 Appendix A • 263 Table A.7 Sample implementation: Men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men, and overall men’s response rates, according to urban-rural residence and region (unweighted), Rwanda 2010 Result Residence Region Total Urban Rural City of Kigali South West North East Selected households Completed (C) 98.0 98.0 97.4 97.8 97.7 98.3 98.6 98.0 Household present but no competent respondent at home (HP) 0.1 0.2 0.1 0.2 0.3 0.1 0.1 0.2 Refused (R) 0.2 0.0 0.3 0.0 0.0 0.0 0.1 0.0 Dwelling not found (DNF) 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 Household absent (HA) 0.2 0.4 0.5 0.2 0.3 0.5 0.2 0.3 Dwelling vacant/address not a dwelling (DV) 1.6 0.9 1.5 1.1 1.2 0.8 0.6 1.0 Dwelling destroy (DD) 0.0 0.4 0.1 0.4 0.4 0.3 0.3 0.3 Other (O) 0.0 0.1 0.0 0.1 0.0 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 1,027 5,369 780 1,664 1,456 1,040 1,456 6,396 Household response rate (HRR)1 99.7 99.8 99.6 99.7 99.6 99.9 99.9 99.7 Eligible men Completed (EMC) 98.1 98.8 98.3 99.2 98.3 98.4 98.9 98.7 Not at home (EMNH) 0.8 0.5 0.8 0.5 0.7 0.6 0.4 0.6 Postponed (EMP) 0.1 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Refused (EMR) 0.8 0.1 0.6 0.1 0.3 0.1 0.1 0.2 Partly completed (EMPC) 0.1 0.1 0.0 0.0 0.2 0.1 0.0 0.1 Incapacitated (EMI) 0.2 0.4 0.1 0.3 0.5 0.4 0.6 0.4 Other (EMO) 0.0 0.1 0.0 0.0 0.0 0.4 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,178 5,236 948 1,529 1,437 987 1,513 6,414 Eligible men response rate (EMRR)2 98.1 98.8 98.3 99.2 98.3 98.4 98.9 98.7 Overall men response rate (ORR)3 97.8 98.6 97.9 98.9 98.0 98.3 98.7 98.4 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C _______________________________ C + HP + P + R + DNF 2 The eligible men response rate (EMRR) is equivalent to the percentage of interviews completed (EMC) 3 The overall men response rate (OMRR) is calculated as: OMRR = HRR * EMRR/100 264 • Appendix A Table A.8 Coverage of HIV testing by social and demographic characteristics: Women Percent distribution of interviewed women age 15-49 by HIV testing status, according to social and demographic characteristics (unweighted), Rwanda 2010 Characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Marital status Never married 99.5 0.2 0.0 0.3 100.0 2,804 Ever had sexual intercourse 99.5 0.3 0.0 0.2 100.0 652 Never had sexual intercourse 99.5 0.2 0.0 0.3 100.0 2,152 Married/living together 99.7 0.1 0.0 0.2 100.0 3,446 Divorced or separated 99.2 0.3 0.3 0.3 100.0 372 Widowed 99.4 0.6 0.0 0.0 100.0 360 Type of union In polygynous union 99.3 0.4 0.0 0.4 100.0 267 In nonpolygynous union 99.7 0.1 0.0 0.2 100.0 3,166 Not currently in union 99.5 0.3 0.0 0.3 100.0 3,536 DK/missing 100.0 0.0 0.0 0.0 100.0 13 Ever had sexual intercourse Yes 99.6 0.2 0.0 0.2 100.0 4,830 No 99.5 0.2 0.0 0.3 100.0 2,149 Missing 100.0 0.0 0.0 0.0 100.0 3 Currently pregnant Pregnant 99.4 0.2 0.0 0.4 100.0 481 Not pregnant or not sure 99.6 0.2 0.0 0.2 100.0 6,501 Times slept away from home in past 12 months None 99.7 0.2 0.0 0.1 100.0 3,710 1-2 99.4 0.2 0.0 0.4 100.0 2,458 3-4 99.6 0.0 0.0 0.4 100.0 559 5+ 99.2 0.8 0.0 0.0 100.0 255 Time away in past 12 months Away for more than 1 month 99.1 0.6 0.0 0.2 100.0 466 Away for less than 1 month 99.5 0.1 0.0 0.4 100.0 2,804 No away 99.7 0.2 0.0 0.1 100.0 3,710 Missing 100.0 0.0 0.0 0.0 100.0 2 Religion Catholic 99.7 0.1 0.0 0.2 100.0 2,973 Protestant 99.4 0.2 0.0 0.3 100.0 2,840 Adventist 99.6 0.3 0.0 0.1 100.0 949 Muslim 98.9 1.1 0.0 0.0 100.0 91 Traditional/Other/No religion 99.1 0.9 0.0 0.0 100.0 117 Missing 100.0 0.0 0.0 0.0 100.0 12 Total 99.6 0.2 0.0 0.2 100.0 6,982 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, i.e., positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), ( 2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reasons, not enough blood to complete the algorithm, etc. Appendix A • 265 Table A.9 Coverage of HIV testing by social and demographic characteristics: Men Percent distribution of interviewed men age 15-59 by HIV testing status, according to social and demographic characteristics (unweighted), Rwanda 2010 Characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Marital status Never married 99.4 0.3 0.0 0.2 100.0 2,906 Ever had sexual intercourse 99.4 0.3 0.0 0.3 100.0 1,160 Never had sexual intercourse 99.5 0.3 0.0 0.2 100.0 1,746 Married/living together 99.5 0.2 0.0 0.2 100.0 3,261 Divorced or separated 99.1 0.9 0.0 0.0 100.0 110 Widowed 100.0 0.0 0.0 0.0 100.0 52 Type of union In polygynous union 100.0 0.0 0.0 0.0 100.0 83 In nonpolygynous union 99.5 0.3 0.0 0.2 100.0 3,178 Not currently in union 99.4 0.3 0.0 0.2 100.0 3,068 Ever had sexual intercourse Yes 99.5 0.3 0.0 0.2 100.0 4,582 No 99.5 0.3 0.0 0.2 100.0 1,744 Missing 66.7 33.3 0.0 0.0 100.0 3 Male circumcision Circumcised 97.9 1.4 0.1 0.6 100.0 871 Not circumcised 99.7 0.1 0.0 0.2 100.0 5,452 DK/Missing 100.0 0.0 0.0 0.0 100.0 6 Times slept away from home in past 12 months None 99.6 0.3 0.0 0.2 100.0 3,464 1-2 99.7 0.1 0.1 0.2 100.0 1,754 3-4 99.3 0.4 0.0 0.4 100.0 555 5+ 98.6 0.9 0.0 0.5 100.0 556 Time away in past 12 months Away for more than 1 month 99.3 0.3 0.0 0.4 100.0 712 Away for less than 1 month 99.4 0.3 0.0 0.2 100.0 2,148 No away 99.6 0.3 0.0 0.2 100.0 3,464 Missing 100.0 0.0 0.0 0.0 100.0 5 Religion Catholic 99.5 0.2 0.0 0.2 100.0 3,086 Protestant 99.2 0.5 0.0 0.3 100.0 2,210 Adventist 100.0 0.0 0.0 0.0 100.0 746 Muslim 100.0 0.0 0.0 0.0 100.0 123 Traditional/Other/No religion 99.4 0.6 0.0 0.0 100.0 164 Total 99.5 0.3 0.0 0.2 100.0 6,329 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, i.e., positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reasond, not enough blood to complete the algorithm, etc. 266 • Appendix A Table A.10 Coverage of HIV testing by sexual behavior characteristics: Women Percent distribution of interviewed women age 15-49 who ever had sexual intercourse by HIV test status, according to sexual behavior characteristics (unweighted), Rwanda 2010 Sexual behavior characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Age at first sexual intercourse <16 99.4 0.4 0.0 0.2 100.0 479 16-17 99.6 0.3 0.0 0.1 100.0 793 18-19 99.6 0.2 0.1 0.1 100.0 1,097 20+ 99.7 0.1 0.0 0.2 100.0 2,360 Missing 99.0 1.0 0.0 0.0 100.0 101 Multiple sexual partners and partner concurrency in past 12 months 0 99.5 0.4 0.0 0.1 100.0 985 1 99.6 0.2 0.0 0.2 100.0 3,802 2+ 100.0 0.0 0.0 0.0 100.0 43 Has concurrent partners2 100.0 0.0 0.0 0.0 100.0 11 None of the partners are concurrent 100.0 0.0 0.0 0.0 100.0 32 Condom use at last sexual intercourse in past 12 months Used condom 98.7 0.6 0.3 0.3 100.0 313 Did not use condom 99.7 0.1 0.0 0.2 100.0 3,531 No sexual intercourse in last 12 months3 99.5 0.4 0.0 0.1 100.0 985 DK/Missing 100.0 0.0 0.0 0.0 100.0 1 Number of lifetime partners 1 99.7 0.1 0.0 0.1 100.0 3,446 2 99.2 0.4 0.1 0.3 100.0 1,012 3-4 99.7 0.3 0.0 0.0 100.0 326 5-9 100.0 0.0 0.0 0.0 100.0 32 10+ 100.0 0.0 0.0 0.0 100.0 11 Missing 100.0 0.0 0.0 0.0 100.0 3 Prior HIV testing Ever tested 99.6 0.2 0.0 0.2 100.0 4,345 Received results 99.6 0.2 0.0 0.2 100.0 4,288 Did not received results 100.0 0.0 0.0 0.0 100.0 57 Never tested 99.4 0.4 0.0 0.2 100.0 473 Missing 100.0 0.0 0.0 0.0 100.0 12 Total 99.6 0.2 0.0 0.2 100.0 4,830 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, i.e., positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reasons, not enough blood to complete the algorithm, etc. 3 Overlapping sexual partnerships during the 12 months before the survey Appendix A • 267 Table A.11 Coverage of HIV testing by sexual behavior characteristics: Men Percent distribution of interviewed men age 15-59 who ever had sexual intercourse by HIV test status, according to sexual behavior characteristics (unweighted), Rwanda 2010 Sexual behavior characteristic Testing status Total Number DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Age at first sexual intercourse <16 99.7 0.0 0.0 0.3 100.0 686 16-17 99.4 0.2 0.0 0.4 100.0 500 18-19 99.5 0.2 0.0 0.2 100.0 859 20+ 99.5 0.3 0.0 0.2 100.0 2,416 Missing 98.3 1.7 0.0 0.0 100.0 121 Multiple sexual partners and partner concurrency in past 12 months 0 99.6 0.2 0.0 0.1 100.0 818 1 99.4 0.3 0.0 0.3 100.0 3,498 2+ 99.6 0.0 0.0 0.4 100.0 265 Has concurrent partners2 100.0 0.0 0.0 0.0 100.0 111 None of the partners are concurrent 99.4 0.0 0.0 0.6 100.0 154 Missing 100.0 0.0 0.0 0.0 100.0 1 Condom use at last sexual intercourse in past 12 months Used condom 99.0 0.4 0.0 0.6 100.0 522 Did not use condom 99.5 0.2 0.0 0.2 100.0 3,241 No sexual intercourse in last 12 months 99.6 0.2 0.0 0.1 100.0 819 Paid for sexual intercourse in past 12 months3 Yes 98.8 1.2 0.0 0.0 100.0 81 Used condom 98.4 1.6 0.0 0.0 100.0 64 Did not use condom 100.0 0.0 0.0 0.0 100.0 17 No (No paid sexual intercourse/no sexual intercourse in last 12 months) 99.5 0.2 0.0 0.2 100.0 4,501 Number of lifetime partners 1 99.6 0.2 0.1 0.2 100.0 1,889 2 99.6 0.4 0.0 0.0 100.0 1,246 3-4 99.5 0.1 0.0 0.3 100.0 888 5-9 99.2 0.3 0.0 0.5 100.0 367 10+ 98.2 0.6 0.0 1.2 100.0 170 Missing 95.5 0.0 0.0 4.5 100.0 22 Prior HIV testing Ever tested 99.5 0.2 0.0 0.3 100.0 3,766 Received results 99.4 0.2 0.0 0.3 100.0 3,635 Did not received results 100.0 0.0 0.0 0.0 100.0 131 Never tested 99.5 0.4 0.0 0.1 100.0 816 Total 99.5 0.3 0.0 0.2 100.0 4,582 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, i.e., positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 3 Overlapping sexual partnerships during the 12 months before the survey 4 Includes men who report having a prostitute for at least one of their last three sexual partners in the past 12 months Appendix B • 269 SAMPLING ERRORS Appendix B stimates from a sampled survey are affected by two types of errors: nonsampling errors and sampling errors. Nonsampling errors are errors made during data collection and data processing, i.e., failure to identify and interview the correct household, misunderstanding of the questions, and data entry errors. Efforts were made during the survey implementation to minimize these errors, but it is not possible to completely eliminate them. It is also difficult to evaluate nonsampling errors statistically. Sampling errors are errors made during the sample selection. The sample of clusters and households selected for the 2010 RDHS is only one of many possible samples. Estimates obtained from each of those possible samples would differ from those obtained from the selected sample. Sampling error is the measure of the variability among all possible samples. The degree of variability can be estimated from the survey results. Sampling errors can be evaluated statistically. Sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals, which include the true population parameters. For example, for any given statistic calculated from a sample survey, the true population parameters will fall within a range of plus or minus two standard errors in 95 percent of all possible samples. If the sample is selected as a simple random sample, the sampling errors can be simply calculated. However, the 2010 RDHS sample is the result of a multi-stage stratified design; consequently it requires more complex formulae. The sampling errors are calculated using the Taylor linearization method for variance estimation of survey estimates that are means or proportions. This method is programmed in SAS statistical software. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ( )  = =         − − −== H h h h m i hi h h h m zz m mf x rvarrSE h 1 2 1 2 2 2 1 11)()( in which hihihi rxyz −= , and hhh rxyz −= where h represents the stratum which varies from 1 to H mh is the total number of clusters selected in the hth stratum yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum fh is the sampling fraction of PSU in the hth stratum E 270 • Appendix B The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample and calculates standard errors for these estimates using simple formulae. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2010 RDHS, there were 492 nonempty clusters. Hence, 492 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − =  in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 492 clusters r(i) is the estimate computed from the reduced sample of 491 clusters (ith cluster excluded) k is the total number of clusters In addition to the standard error, the program computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates an increase in the sampling error due to the use of a more complex and less statistically efficient design, such as multistage and cluster selection. The program also computes the relative standard error and the confidence limits for the estimate)s. Sampling errors for the 2010 RDHS are calculated for selected variables considered to be of primary interest for women’s surveys and for men’s surveys, respectively. The results are presented in this appendix for the country as a whole, for the urban and the rural areas separately, and for each of the five provinces. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.9 present the value of the statistic (R), its standard error (SE), the number of unweighted (N-UNWE) and weighted (N-WEIG) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to child-bearing. The confidence interval (e.g., as calculated for children ever born to women over age 40) can be interpreted as follows: the overall average from the national sample is 5.921, and its standard error is 0.062. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 5.921±2×0.062. There is a high probability (95 percent) that the true average number of children ever born to all women over age 40 is between 5.797 and 6.044. For the total sample, the value of the design effect (DEFT), averaged over all variables for the womn’s survey, is 1.235 which means that, due to multistage and clustering of the sample, the average standard error is increased by a factor of 1.235 over that in an equivalent simple random sample. Appendix B • 271 Table B.1. List of selected variables for sampling errors, Rwanda DHS 2010 Variable Estimate Base Population WOMEN Urban residence Proportion All women 15-49 Literacy Proportion All women 15-49 No education Proportion All women 15-49 Secondary and higher education Proportion All women 15-49 Never married (never in union) Proportion All women 15-49 Currently married (in union) Proportion All women 15-49 Married before age 20 Proportion Women 25-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women over age 40 Mean Women age 40-49 Knowing any contraceptive method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using condom Proportion Currently married women 15-49 Currently using female sterilization Proportion Currently married women 15-49 Currently using periodic abstinence Proportion Currently married women 15-49 Used public sector sources Proportion Users of modern methods, women 15-49 Want no more children Proportion Currently married women 15-49 Want to delay at least 2 years Proportion Currently married women 15-49 Ideal family size Proportion All women 15-49 Mothers protected against tetanus for last birth Proportion Last birth in last 5 years Mothers received medical assistance at delivery Proportion Births in last 5 years Had diarrhea in last 2 weeks Proportion Children under 5 Treated with ORS packets or pre-packed liquid Proportion Children under 5 with diarrhea in last 2 weeks Consulted medical personnel for diarrhea Proportion Children under 5 with diarrhea in last 2 weeks Having health card, seen Proportion Children 12-23 months Received BCG vaccination Proportion Children 12-23 months Received DPT vaccination (3 doses) Proportion Children 12-23 months Received polio vaccination (3 doses) Proportion Children 12-23 months Received measles vaccination Proportion Children 12-23 months Fully immunized Proportion Children 12-23 months Weight-for-height (< -2 SD) Proportion Children under 5 who were measured Height-for-age (< -2 SD) Proportion Children under 5 who were measured Weight-for-age (< -2 SD) Proportion Children under 5 who were measured Prevalence of anemia (children) Proportion Children under 6-59 months who were tested Prevalence of anemia (women) Proportion Women 15-49 who were tested Body mass index (BMI) <18.5 Proportion Women 15-49 who were measured Total fertility rate (last 3 years) Rate Women-years of exposure to childbearing Neonatal mortality rate1 Rate Children-months of exposure to death Post neonatal mortality rate1 Rate Children-months of exposure to death Infant mortality rate1 Rate Children-months of exposure to death Child mortality rate1 Rate Children-months of exposure to death Under-five mortality rate1 Rate Children-months of exposure to death Maternal mortality ratio2 (last 0-6 years) Rate Women-years of exposure to pregnancy Prevalence of HIV Proportion Women 15-49 who were tested MEN Urban residence Proportion All men 15-49 No education Proportion All men 15-49 Secondary and higher education Proportion All men 15-49 Never married (never in union) Proportion All men 15-49 Currently married (in union) Proportion All men 15-49 Prevalence of HIV (men 15-49) Proportion Men 15-49 who were tested Prevalence of HIV (men 15-59) Proportion Men 15-59 who were tested MEN AND WOMEN Prevalence of HIV (men and women 15-49) Proportion Men and women 15-49 who were tested 1 The mortality rates are calculated for last 5 years for the total sample, and 10 years for the urban, rural and the regional samples. 2 The maternal mortality rate is calculated just for the total sample since the regional sample sizes are not big enough for a reliable estimation. 272 • Appendix B Table B.2 Sampling errors: Total sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.150 0.013 13,671 13,671 4.256 0.087 0.124 0.176 Literacy 0.769 0.005 13,671 13,671 1.525 0.007 0.758 0.780 No education 0.155 0.005 13,671 13,671 1.454 0.029 0.146 0.164 Secondary school or higher 0.162 0.006 13,671 13,671 2.019 0.039 0.149 0.175 Never married (in union) 0.387 0.005 13,671 13,671 1.250 0.013 0.376 0.397 Currently married (in union) 0.505 0.005 13,671 13,671 1.234 0.010 0.494 0.515 Married before age 20 0.356 0.007 8,016 8,043 1.355 0.020 0.342 0.371 Currently pregnant 0.070 0.002 13,671 13,671 1.100 0.034 0.065 0.075 Children ever born 2.417 0.026 13,671 13,671 1.141 0.011 2.364 2.469 Children surviving 2.050 0.021 13,671 13,671 1.090 0.010 2.008 2.092 Children ever born to women age 40-49 5.921 0.062 2,257 2,280 1.109 0.010 5.797 6.044 Knows any contraceptive method 0.999 0.000 6,834 6,897 1.186 0.000 0.998 1.000 Currently using any method 0.516 0.007 6,834 6,897 1.160 0.014 0.502 0.530 Currently using pill 0.071 0.004 6,834 6,897 1.199 0.052 0.064 0.079 Currently using condoms 0.029 0.002 6,834 6,897 1.022 0.071 0.025 0.033 Currently using female sterilization 0.008 0.001 6,834 6,897 1.127 0.149 0.006 0.011 Currently using periodic abstinence 0.029 0.002 6,834 6,897 0.973 0.068 0.025 0.033 Used public sector source 0.920 0.006 3,375 3,367 1.199 0.006 0.908 0.931 Want no more children 0.529 0.006 6,834 6,897 1.052 0.012 0.516 0.542 Want to delay birth at least 2 years 0.356 0.006 6,834 6,897 1.043 0.017 0.344 0.368 Ideal family size 3.289 0.016 13,527 13,523 1.296 0.005 3.256 3.321 Mothers protected against tetanus for last birth 0.786 0.006 6,328 6,405 1.156 0.008 0.774 0.798 Mothers received medical assistance at delivery 0.687 0.008 9,002 9,137 1.497 0.012 0.670 0.704 Having diarrhea in the last 2 weeks 0.132 0.004 8,484 8,605 1.193 0.034 0.123 0.141 Treated with oral rehydration salts (ORS) 0.291 0.015 1,109 1,132 1.065 0.051 0.261 0.321 Taken to a health provider 0.372 0.016 1,109 1,132 1.061 0.043 0.341 0.404 Vaccination card seen 0.822 0.012 1,596 1,616 1.216 0.014 0.799 0.846 Received BCG 0.991 0.002 1,596 1,616 0.983 0.002 0.987 0.996 Received DPT (3 doses) 0.968 0.005 1,596 1,616 1.205 0.005 0.958 0.979 Received polio (3 doses) 0.933 0.007 1,596 1,616 1.169 0.008 0.918 0.948 Received measles 0.950 0.006 1,596 1,616 1.134 0.007 0.938 0.963 Fully immunized 0.901 0.009 1,596 1,616 1.142 0.010 0.884 0.918 Height-for-age (below -2SD) 0.442 0.009 4,333 4,356 1.101 0.020 0.425 0.460 Weight-for-height (below -2SD) 0.028 0.003 4,333 4,356 1.035 0.093 0.023 0.033 Weight-for-age (below -2SD) 0.114 0.005 4,333 4,356 1.018 0.046 0.104 0.125 Anemia children 0.381 0.009 4,009 4,037 1.118 0.023 0.364 0.399 Anemia women 0.173 0.005 6,949 6,945 1.181 0.031 0.162 0.183 BMI < 18.5 0.073 0.004 6,381 6,367 1.099 0.049 0.066 0.080 Total fertility rate (last 3 years) 4.563 0.073 38,010 38,012 1.287 0.016 4.418 4.709 Neonatal mortality (last 0-4 years) 27.044 1.897 9,095 9,229 1.002 0.070 23.249 30.838 Post-neonatal mortality (last 0-4 years) 22.764 1.651 9,112 9,246 1.057 0.073 19.463 26.066 Infant mortality (last 0-4 years) 49.808 2.557 9,116 9,252 1.055 0.051 44.695 54.921 Child mortality (last 0-4 years) 27.231 1.866 9,200 9,336 1.045 0.069 23.498 30.963 Under-five mortality (last 0-4 years) 75.682 3.080 9,225 9,362 1.067 0.041 69.523 81.842 Maternal mortality ratio (last 0-6 years) 487 47 165,481 165,352 1.083 0.096 393 581 HIV prevalence (women 15-49) 0.037 0.002 6,952 6,917 1.070 0.065 0.032 0.042 MEN Urban residence 0.165 0.015 5,695 5,687 2.959 0.088 0.136 0.194 No education 0.103 0.004 5,695 5,687 1.067 0.042 0.094 0.111 Secondary school or higher 0.209 0.008 5,695 5,687 1.434 0.037 0.194 0.224 Never married (in union) 0.505 0.008 5,695 5,687 1.184 0.016 0.490 0.521 Currently married (in union) 0.475 0.008 5,695 5,687 1.166 0.016 0.459 0.490 HIV prevalence (men 15-49) 0.022 0.002 5,666 5,690 1.041 0.092 0.018 0.026 HIV prevalence (men 15-59) 0.024 0.002 6,296 6,331 1.051 0.084 0.020 0.028 MEN AND WOMEN HIV prevalence (men and women 15-49) 0.030 0.002 12,618 12,607 1.202 0.060 0.027 0.034 Appendix B • 273 Table B.3 Sampling errors: Urban sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE R+2SE WOMEN Urban residence 1.000 0.000 2,367 2,057 na 0.000 1.000 1.000 Literacy 0.888 0.008 2,367 2,057 1.207 0.009 0.872 0.903 No education 0.067 0.005 2,367 2,057 1.023 0.078 0.057 0.078 Secondary school or higher 0.375 0.019 2,367 2,057 1.899 0.050 0.338 0.413 Never married (in union) 0.443 0.014 2,367 2,057 1.397 0.032 0.415 0.472 Currently married (in union) 0.450 0.013 2,367 2,057 1.315 0.030 0.423 0.477 Married before age 20 0.264 0.017 1,308 1,148 1.395 0.064 0.230 0.298 Currently pregnant 0.073 0.006 2,367 2,057 1.160 0.085 0.060 0.085 Children ever born 1.829 0.058 2,367 2,057 1.223 0.032 1.714 1.944 Children surviving 1.607 0.047 2,367 2,057 1.149 0.029 1.513 1.700 Children ever born to women age 40-49 5.121 0.166 297 266 1.051 0.032 4.789 5.454 Knows any contraceptive method 1.000 0.000 1,046 926 na 0.000 1.000 1.000 Currently using any method 0.531 0.016 1,046 926 1.011 0.029 0.500 0.562 Currently using pill 0.079 0.011 1,046 926 1.283 0.135 0.058 0.101 Currently using condoms 0.043 0.006 1,046 926 0.965 0.141 0.031 0.055 Currently using female sterilization 0.020 0.005 1,046 926 1.111 0.242 0.010 0.029 Currently using periodic abstinence 0.025 0.005 1,046 926 1.039 0.200 0.015 0.035 Used public sector source 0.722 0.021 546 476 1.093 0.029 0.680 0.764 Want no more children 0.498 0.014 1,046 926 0.883 0.027 0.471 0.526 Want to delay birth at least 2 years 0.351 0.014 1,046 926 0.931 0.039 0.324 0.379 Ideal family size 3.120 0.034 2,353 2,045 1.213 0.011 3.053 3.187 Mothers protected against tetanus for last birth 0.767 0.015 921 819 1.060 0.019 0.737 0.796 Mothers received medical assistance at delivery 0.819 0.018 1,225 1,094 1.495 0.023 0.782 0.855 Having diarrhea in the last 2 weeks 0.136 0.013 1,161 1,033 1.249 0.094 0.110 0.161 Treated with oral rehydration salts (ORS) 0.263 0.027 155 140 0.734 0.102 0.209 0.317 Taken to a health provider 0.330 0.029 155 140 0.748 0.088 0.272 0.389 Vaccination card seen 0.778 0.030 207 181 1.023 0.038 0.718 0.837 Received BCG 0.997 0.003 207 181 0.816 0.003 0.990 1.003 Received DPT (3 doses) 0.957 0.010 207 181 0.673 0.010 0.938 0.976 Received polio (3 doses) 0.941 0.014 207 181 0.826 0.014 0.914 0.968 Received measles 0.973 0.007 207 181 0.573 0.007 0.960 0.986 Fully immunized 0.933 0.014 207 181 0.790 0.015 0.906 0.961 Height-for-age (below -2SD) 0.273 0.021 593 517 1.077 0.078 0.230 0.316 Weight-for-height (below -2SD) 0.035 0.008 593 517 1.044 0.226 0.019 0.050 Weight-for-age (below -2SD) 0.063 0.010 593 517 0.906 0.154 0.044 0.082 Anemia children 0.357 0.021 540 475 1.019 0.060 0.315 0.400 Anemia women 0.162 0.012 1,218 1,050 1.121 0.073 0.138 0.186 BMI < 18.5 0.069 0.010 1,132 973 1.290 0.142 0.049 0.088 Total fertility rate (last 3 years) 3.440 0.174 6,642 5,770 1.433 0.051 3.092 3.787 Neonatal mortality (last 0-9 years) 21.375 3.717 2,320 2,068 1.070 0.174 13.941 28.810 Post-neonatal mortality (last 0-9 years) 33.827 4.138 2,325 2,072 0.917 0.122 25.551 42.102 Infant mortality (last 0-9 years) 55.202 5.869 2,325 2,073 1.059 0.106 43.465 66.939 Child mortality (last 0-9 years) 27.132 3.747 2,321 2,065 0.851 0.138 19.639 34.625 Under-five mortality (last 0-9 years) 80.837 6.988 2,346 2,091 1.044 0.086 66.860 94.813 HIV prevalence (women 15-49) 0.087 0.008 1,216 1,049 1.007 0.094 0.070 0.103 MEN Urban residence 1.000 0.000 1,082 939 na 0.000 1.000 1.000 No education 0.056 0.008 1,082 939 1.105 0.137 0.041 0.072 Secondary school or higher 0.383 0.023 1,082 939 1.577 0.061 0.336 0.429 Never married (in union) 0.563 0.019 1,082 939 1.240 0.033 0.525 0.600 Currently married (in union) 0.416 0.017 1,082 939 1.149 0.041 0.382 0.451 HIV prevalence (men 15-49) 0.054 0.007 1,063 938 1.028 0.132 0.040 0.068 HIV prevalence (men 15-59) 0.053 0.007 1,133 1,001 1.016 0.127 0.040 0.067 MEN AND WOMEN HIV prevalence (men and women 15-49) 0.071 0.006 2,279 1,987 1.204 0.091 0.058 0.084 274 • Appendix B Table B.4 Sampling errors: Rural sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE R+2SE WOMEN Urban residence 0.000 0.000 11,304 11,614 na na 0.000 0.000 Literacy 0.748 0.006 11,304 11,614 1.498 0.008 0.736 0.761 No education 0.171 0.005 11,304 11,614 1.428 0.030 0.160 0.181 Secondary school or higher 0.124 0.006 11,304 11,614 1.870 0.047 0.113 0.136 Never married (in union) 0.377 0.005 11,304 11,614 1.204 0.015 0.366 0.388 Currently married (in union) 0.514 0.006 11,304 11,614 1.211 0.011 0.503 0.525 Married before age 20 0.372 0.008 6,708 6,895 1.303 0.021 0.356 0.387 Currently pregnant 0.069 0.003 11,304 11,614 1.091 0.038 0.064 0.075 Children ever born 2.521 0.027 11,304 11,614 1.058 0.011 2.466 2.575 Children surviving 2.128 0.022 11,304 11,614 1.023 0.010 2.085 2.172 Children ever born to women age 40-49 6.026 0.066 1,960 2,015 1.116 0.011 5.894 6.158 Knows any contraceptive method 0.999 0.000 5,788 5,971 1.169 0.000 0.998 1.000 Currently using any method 0.514 0.008 5,788 5,971 1.171 0.015 0.498 0.529 Currently using pill 0.070 0.004 5,788 5,971 1.185 0.057 0.062 0.078 Currently using condoms 0.027 0.002 5,788 5,971 1.047 0.083 0.023 0.031 Currently using female sterilization 0.007 0.001 5,788 5,971 1.126 0.183 0.004 0.009 Currently using periodic abstinence 0.030 0.002 5,788 5,971 0.958 0.072 0.025 0.034 Used public sector source 0.952 0.005 2,829 2,891 1.179 0.005 0.943 0.961 Want no more children 0.534 0.007 5,788 5,971 1.053 0.013 0.520 0.547 Want to delay birth at least 2 years 0.357 0.007 5,788 5,971 1.046 0.018 0.344 0.370 Ideal family size 3.319 0.018 11,174 11,477 1.308 0.005 3.282 3.355 Mothers protected against tetanus for last birth 0.789 0.006 5,407 5,586 1.163 0.008 0.776 0.802 Mothers received medical assistance at delivery 0.669 0.009 7,777 8,043 1.479 0.013 0.651 0.687 Having diarrhea in the last 2 weeks 0.131 0.005 7,323 7,572 1.166 0.036 0.122 0.140 Treated with oral rehydration salts (ORS) 0.295 0.016 954 992 1.077 0.055 0.263 0.328 Taken to a health provider 0.378 0.017 954 992 1.072 0.046 0.344 0.413 Vaccination card seen 0.828 0.013 1,389 1,436 1.241 0.015 0.803 0.853 Received BCG 0.991 0.003 1,389 1,436 0.980 0.003 0.986 0.996 Received DPT (3 doses) 0.970 0.005 1,389 1,436 1.159 0.006 0.959 0.980 Received polio (3 doses) 0.932 0.008 1,389 1,436 1.115 0.008 0.917 0.947 Received measles 0.948 0.007 1,389 1,436 1.127 0.007 0.934 0.961 Fully immunized 0.897 0.009 1,389 1,436 1.106 0.010 0.879 0.915 Height-for-age (below -2SD) 0.465 0.009 3,740 3,839 1.085 0.020 0.446 0.484 Weight-for-height (below -2SD) 0.027 0.003 3,740 3,839 1.034 0.102 0.022 0.033 Weight-for-age (below -2SD) 0.121 0.006 3,740 3,839 1.010 0.048 0.110 0.133 Anemia children 0.384 0.009 3,469 3,562 1.113 0.025 0.366 0.403 Anemia women 0.174 0.006 5,731 5,895 1.185 0.034 0.163 0.186 BMI < 18.5 0.074 0.004 5,249 5,393 1.073 0.052 0.066 0.082 Total fertility rate (last 3 years) 4.759 0.076 31,368 32,243 1.227 0.016 4.608 4.911 Neonatal mortality (last 0-9 years) 30.576 1.713 15,220 15,687 1.056 0.056 27.150 34.002 Post-neonatal mortality (last 0-9 years) 31.377 1.578 15,251 15,714 1.058 0.050 28.221 34.532 Infant mortality (last 0-9 years) 61.953 2.372 15,261 15,728 1.087 0.038 57.210 66.697 Child mortality (last 0-9 years) 45.775 2.090 15,366 15,824 1.056 0.046 41.595 49.955 Under-five mortality (last 0-9 years) 104.892 3.111 15,438 15,911 1.087 0.030 98.671 111.114 HIV prevalence (women 15-49) 0.028 0.002 5,736 5,867 1.060 0.082 0.024 0.033 MEN Urban residence 0.000 0.000 4,613 4,748 na na 0.000 0.000 No education 0.112 0.005 4,613 4,748 1.062 0.044 0.102 0.121 Secondary school or higher 0.175 0.008 4,613 4,748 1.363 0.044 0.159 0.190 Never married (in union) 0.494 0.009 4,613 4,748 1.169 0.017 0.477 0.511 Currently married (in union) 0.486 0.009 4,613 4,748 1.155 0.017 0.469 0.503 HIV prevalence (men 15-49) 0.016 0.002 4,603 4,752 1.026 0.119 0.012 0.020 HIV prevalence (men 15-59) 0.019 0.002 5,163 5,330 1.055 0.107 0.015 0.023 MEN AND WOMEN HIV prevalence (men and women 15-49) 0.023 0.002 10,339 10,619 1.139 0.073 0.019 0.026 Appendix B • 275 Table B.5 Sampling errors: City of Kigali sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE R+2SE WOMEN Urban residence 0.807 0.055 1,890 1,596 5.961 0.068 0.697 0.916 Literacy 0.904 0.011 1,890 1,596 1.612 0.012 0.882 0.926 No education 0.062 0.009 1,890 1,596 1.667 0.149 0.044 0.081 Secondary school or higher 0.420 0.024 1,890 1,596 2.149 0.058 0.371 0.469 Never married (in union) 0.451 0.017 1,890 1,596 1.491 0.038 0.417 0.485 Currently married (in union) 0.455 0.016 1,890 1,596 1.356 0.034 0.424 0.486 Married before age 20 0.247 0.025 1,036 882 1.828 0.099 0.198 0.296 Currently pregnant 0.072 0.007 1,890 1,596 1.181 0.097 0.058 0.086 Children ever born 1.739 0.084 1,890 1,596 1.623 0.048 1.572 1.907 Children surviving 1.528 0.064 1,890 1,596 1.443 0.042 1.401 1.656 Children ever born to women age 40-49 5.079 0.255 217 190 1.314 0.050 4.569 5.588 Knows any contraceptive method 1.000 0.000 835 726 na 0.000 1.000 1.000 Currently using any method 0.536 0.017 835 726 0.974 0.031 0.502 0.570 Currently using pill 0.082 0.012 835 726 1.309 0.152 0.057 0.107 Currently using condoms 0.050 0.007 835 726 0.867 0.130 0.037 0.063 Currently using female sterilization 0.022 0.006 835 726 1.214 0.278 0.010 0.035 Currently using periodic abstinence 0.028 0.006 835 726 1.140 0.234 0.015 0.041 Used public sector source 0.677 0.033 425 360 1.450 0.049 0.611 0.743 Want no more children 0.486 0.019 835 726 1.098 0.039 0.448 0.524 Want to delay birth at least 2 years 0.350 0.018 835 726 1.092 0.052 0.314 0.386 Ideal family size 3.010 0.033 1,878 1,587 1.145 0.011 2.945 3.076 Mothers protected against tetanus for last birth 0.732 0.021 731 635 1.262 0.028 0.690 0.773 Mothers received medical assistance at delivery 0.827 0.022 990 872 1.709 0.027 0.782 0.872 Having diarrhea in the last 2 weeks 0.114 0.014 947 830 1.269 0.123 0.086 0.142 Treated with oral rehydration salts (ORS) 0.325 0.039 108 95 0.884 0.120 0.247 0.403 Taken to a health provider 0.331 0.041 108 95 0.865 0.124 0.249 0.414 Vaccination card seen 0.770 0.041 168 142 1.245 0.053 0.688 0.851 Received BCG 0.996 0.004 168 142 0.828 0.004 0.988 1.004 Received DPT (3 doses) 0.985 0.008 168 142 0.790 0.008 0.970 1.000 Received polio (3 doses) 0.966 0.015 168 142 1.045 0.015 0.936 0.995 Received measles 0.982 0.008 168 142 0.762 0.008 0.966 0.998 Fully immunized 0.963 0.015 168 142 1.017 0.015 0.933 0.993 Height-for-age (below -2SD) 0.235 0.025 469 397 1.193 0.105 0.186 0.285 Weight-for-height (below -2SD) 0.044 0.011 469 397 1.168 0.250 0.022 0.065 Weight-for-age (below -2SD) 0.074 0.015 469 397 1.196 0.203 0.044 0.104 Anemia children 0.381 0.022 426 365 0.921 0.058 0.337 0.425 Anemia women 0.180 0.016 964 807 1.272 0.088 0.148 0.211 BMI < 18.5 0.064 0.009 892 743 1.146 0.148 0.045 0.082 Total fertility rate (last 3 years) 3.539 0.257 5,347 4,524 1.665 0.073 3.025 4.053 Neonatal mortality (last 0-9 years) 21.193 5.393 1,795 1,555 1.439 0.254 10.407 31.979 Post-neonatal mortality (last 0-9 years) 34.028 5.607 1,801 1,559 1.160 0.165 22.813 45.243 Infant mortality (last 0-9 years) 55.221 6.493 1,800 1,559 1.079 0.118 42.234 68.207 Child mortality (last 0-9 years) 25.511 5.320 1,777 1,530 1.387 0.209 14.870 36.152 Under-five mortality (last 0-9 years) 79.323 9.132 1,818 1,575 1.271 0.115 61.059 97.587 HIV prevalence (women 15-49) 0.094 0.010 961 808 1.028 0.103 0.075 0.114 MEN Urban residence 0.792 0.058 876 739 4.198 0.073 0.676 0.908 No education 0.039 0.007 876 739 1.034 0.175 0.025 0.052 Secondary school or higher 0.436 0.026 876 739 1.558 0.060 0.383 0.488 Never married (in union) 0.562 0.022 876 739 1.318 0.039 0.518 0.606 Currently married (in union) 0.416 0.020 876 739 1.225 0.049 0.375 0.457 HIV prevalence (men 15-49) 0.051 0.008 858 741 1.008 0.149 0.035 0.066 HIV prevalence (men 15-59) 0.052 0.007 910 790 0.983 0.139 0.037 0.066 MEN AND WOMEN HIV prevalence (men and women 15-49) 0.073 0.007 1,819 1,548 1.206 0.101 0.059 0.088 276 • Appendix B Table B.6 Sampling errors: South sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE R+2SE WOMEN Urban residence 0.112 0.028 3,340 3,212 5.040 0.246 0.057 0.168 Literacy 0.783 0.010 3,340 3,212 1.360 0.012 0.764 0.802 No education 0.134 0.008 3,340 3,212 1.326 0.058 0.119 0.150 Secondary school or higher 0.137 0.009 3,340 3,212 1.513 0.066 0.119 0.155 Never married (in union) 0.380 0.010 3,340 3,212 1.166 0.026 0.361 0.400 Currently married (in union) 0.503 0.010 3,340 3,212 1.129 0.019 0.483 0.522 Married before age 20 0.259 0.012 2,055 1,985 1.207 0.045 0.236 0.282 Currently pregnant 0.062 0.005 3,340 3,212 1.109 0.075 0.052 0.071 Children ever born 2.406 0.048 3,340 3,212 1.090 0.020 2.310 2.502 Children surviving 2.039 0.039 3,340 3,212 1.047 0.019 1.962 2.116 Children ever born to women age 40-49 5.295 0.111 654 635 1.133 0.021 5.073 5.517 Knows any contraceptive method 1.000 0.000 1,682 1,614 na 0.000 1.000 1.000 Currently using any method 0.553 0.015 1,682 1,614 1.204 0.026 0.523 0.582 Currently using pill 0.075 0.007 1,682 1,614 1.110 0.095 0.060 0.089 Currently using condoms 0.025 0.004 1,682 1,614 1.090 0.165 0.017 0.034 Currently using female sterilization 0.006 0.002 1,682 1,614 1.064 0.340 0.002 0.010 Currently using periodic abstinence 0.024 0.003 1,682 1,614 0.911 0.141 0.017 0.031 Used public sector source 0.938 0.009 905 863 1.153 0.010 0.919 0.956 Want no more children 0.554 0.013 1,682 1,614 1.091 0.024 0.527 0.580 Want to delay birth at least 2 years 0.335 0.012 1,682 1,614 1.047 0.036 0.311 0.359 Ideal family size 3.217 0.028 3,284 3,155 1.167 0.009 3.160 3.274 Mothers protected against tetanus for last birth 0.794 0.011 1,585 1,532 1.057 0.014 0.773 0.816 Mothers received medical assistance at delivery 0.660 0.016 2,244 2,169 1.385 0.024 0.629 0.692 Having diarrhea in the last 2 weeks 0.156 0.010 2,122 2,049 1.267 0.065 0.136 0.176 Treated with oral rehydration salts (ORS) 0.271 0.023 323 319 0.898 0.084 0.226 0.317 Taken to a health provider 0.330 0.027 323 319 1.022 0.082 0.275 0.384 Vaccination card seen 0.824 0.022 397 383 1.171 0.027 0.779 0.869 Received BCG 0.990 0.005 397 383 1.039 0.005 0.979 1.000 Received DPT (3 doses) 0.968 0.010 397 383 1.109 0.010 0.949 0.988 Received polio (3 doses) 0.944 0.014 397 383 1.241 0.015 0.915 0.973 Received measles 0.976 0.009 397 383 1.052 0.009 0.959 0.993 Fully immunized 0.928 0.016 397 383 1.221 0.017 0.896 0.960 Height-for-age (below -2SD) 0.423 0.016 1,097 1,050 1.013 0.038 0.390 0.455 Weight-for-height (below -2SD) 0.038 0.005 1,097 1,050 0.930 0.139 0.028 0.049 Weight-for-age (below -2SD) 0.124 0.010 1,097 1,050 0.934 0.082 0.104 0.144 Anemia children 0.375 0.020 1,030 986 1.280 0.052 0.336 0.414 Anemia women 0.174 0.010 1,656 1,593 1.090 0.058 0.153 0.194 BMI < 18.5 0.106 0.009 1,550 1,490 1.120 0.083 0.088 0.124 Total fertility rate (last 3 years) 4.590 0.127 9,302 8,953 1.115 0.028 4.336 4.845 Neonatal mortality (last 0-9 years) 31.408 3.235 4,408 4,263 1.047 0.103 24.938 37.877 Post-neonatal mortality (last 0-9 years) 28.319 2.618 4,413 4,267 0.966 0.092 23.083 33.556 Infant mortality (last 0-9 years) 59.727 4.291 4,420 4,275 1.053 0.072 51.145 68.310 Child mortality (last 0-9 years) 38.684 3.120 4,424 4,281 0.952 0.081 32.443 44.925 Under-five mortality (last 0-9 years) 96.101 5.285 4,460 4,314 1.006 0.055 85.531 106.671 HIV prevalence (women 15-49) 0.030 0.005 1,662 1,593 1.087 0.152 0.021 0.039 MEN Urban residence 0.123 0.030 1,373 1,308 3.356 0.243 0.063 0.183 No education 0.112 0.009 1,373 1,308 1.023 0.078 0.095 0.130 Secondary school or higher 0.152 0.012 1,373 1,308 1.240 0.079 0.128 0.176 Never married (in union) 0.505 0.014 1,373 1,308 1.046 0.028 0.477 0.533 Currently married (in union) 0.477 0.014 1,373 1,308 1.039 0.029 0.449 0.505 HIV prevalence (men 15-49) 0.018 0.004 1,370 1,308 0.988 0.198 0.011 0.025 HIV prevalence (men 15-59) 0.017 0.003 1,514 1,445 0.992 0.191 0.011 0.024 MEN AND WOMEN HIV prevalence (men and women 15-49) 0.024 0.003 3,032 2901 1.115 0.128 0.018 0.031 Appendix B • 277 Table B.7 Sampling errors: West sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE R+2SE WOMEN Urban residence 0.043 0.019 3,138 3,305 5.279 0.446 0.005 0.082 Literacy 0.727 0.014 3,138 3,305 1.707 0.019 0.700 0.755 No education 0.199 0.011 3,138 3,305 1.579 0.057 0.176 0.221 Secondary school or higher 0.121 0.015 3,138 3,305 2.515 0.121 0.092 0.151 Never married (in union) 0.396 0.011 3,138 3,305 1.303 0.029 0.373 0.419 Currently married (in union) 0.507 0.011 3,138 3,305 1.255 0.022 0.484 0.529 Married before age 20 0.366 0.015 1,786 1,878 1.297 0.040 0.336 0.395 Currently pregnant 0.074 0.005 3,138 3,305 1.116 0.071 0.063 0.084 Children ever born 2.442 0.054 3,138 3,305 1.082 0.022 2.334 2.549 Children surviving 2.117 0.043 3,138 3,305 1.017 0.020 2.031 2.204 Children ever born to women age 40-49 6.413 0.135 495 519 1.147 0.021 6.143 6.683 Knows any contraceptive method 1.000 0.000 1,591 1,675 na 0.000 1.000 1.000 Currently using any method 0.427 0.016 1,591 1,675 1.265 0.037 0.396 0.459 Currently using pill 0.050 0.007 1,591 1,675 1.292 0.141 0.036 0.065 Currently using condoms 0.026 0.004 1,591 1,675 1.088 0.169 0.017 0.034 Currently using female sterilization 0.012 0.003 1,591 1,675 1.219 0.282 0.005 0.018 Currently using periodic abstinence 0.037 0.005 1,591 1,675 0.984 0.127 0.027 0.046 Used public sector source 0.951 0.012 602 627 1.350 0.013 0.927 0.975 Want no more children 0.488 0.012 1,591 1,675 0.955 0.025 0.464 0.512 Want to delay birth at least 2 years 0.393 0.013 1,591 1,675 1.028 0.032 0.368 0.418 Ideal family size 3.469 0.037 3,109 3,272 1.412 0.011 3.394 3.543 Mothers protected against tetanus for last birth 0.760 0.013 1,467 1,545 1.162 0.017 0.734 0.786 Mothers received medical assistance at delivery 0.708 0.019 2,167 2,284 1.634 0.027 0.670 0.745 Having diarrhea in the last 2 weeks 0.134 0.010 2,048 2,159 1.241 0.073 0.115 0.154 Treated with oral rehydration salts (ORS) 0.294 0.037 270 290 1.277 0.127 0.219 0.369 Taken to a health provider 0.455 0.037 270 290 1.156 0.080 0.382 0.528 Vaccination card seen 0.829 0.021 404 426 1.107 0.025 0.787 0.871 Received BCG 0.983 0.006 404 426 0.927 0.006 0.972 0.995 Received DPT (3 doses) 0.945 0.015 404 426 1.310 0.016 0.915 0.974 Received polio (3 doses) 0.863 0.020 404 426 1.161 0.023 0.822 0.903 Received measles 0.911 0.017 404 426 1.175 0.018 0.878 0.945 Fully immunized 0.809 0.023 404 426 1.167 0.029 0.763 0.856 Height-for-age (below -2SD) 0.499 0.020 1,038 1,086 1.194 0.040 0.459 0.539 Weight-for-height (below -2SD) 0.020 0.004 1,038 1,086 0.888 0.202 0.012 0.028 Weight-for-age (below -2SD) 0.126 0.011 1,038 1,086 1.013 0.088 0.104 0.148 Anemia children 0.384 0.018 958 1,003 1.117 0.047 0.348 0.421 Anemia women 0.153 0.010 1,608 1,698 1.116 0.065 0.133 0.173 BMI < 18.5 0.061 0.007 1,475 1,556 1.125 0.115 0.047 0.075 Total fertility rate (last 3 years) 4.966 0.145 8,669 9,127 1.244 0.029 4.676 5.256 Neonatal mortality (last 0-9 years) 26.681 2.918 4,183 4,378 1.059 0.109 20.845 32.518 Post-neonatal mortality (last 0-9 years) 29.404 2.477 4,188 4,380 0.910 0.084 24.450 34.358 Infant mortality (last 0-9 years) 56.085 3.877 4,189 4,385 1.012 0.069 48.332 63.838 Child mortality (last 0-9 years) 34.212 3.475 4,176 4,361 1.146 0.102 27.262 41.162 Under-five mortality (last 0-9 years) 88.378 4.924 4,220 4,419 1.032 0.056 78.530 98.226 HIV prevalence (women 15-49) 0.032 0.005 1,608 1,688 1.147 0.156 0.022 0.043 MEN Urban residence 0.063 0.032 1,243 1,307 4.561 0.503 0.000 0.126 No education 0.118 0.010 1,243 1,307 1.124 0.087 0.097 0.138 Secondary school or higher 0.196 0.018 1,243 1,307 1.637 0.094 0.159 0.233 Never married (in union) 0.513 0.017 1,243 1,307 1.208 0.033 0.479 0.547 Currently married (in union) 0.477 0.017 1,243 1,307 1.214 0.036 0.442 0.511 HIV prevalence (men 15-49) 0.020 0.004 1,236 1,307 1.018 0.203 0.012 0.028 HIV prevalence (men 15-59) 0.026 0.005 1,406 1,489 1.088 0.177 0.017 0.036 MEN AND WOMEN HIV prevalence (men and women 15-49) 0.027 0.004 2,844 2,995 1.233 0.139 0.020 0.035 278 • Appendix B Table B.8 Sampling errors: North sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE R+2SE WOMEN Urban residence 0.056 0.027 2,199 2,278 5.521 0.486 0.002 0.111 Literacy 0.757 0.013 2,199 2,278 1.444 0.017 0.730 0.783 No education 0.163 0.011 2,199 2,278 1.347 0.065 0.142 0.184 Secondary school or higher 0.125 0.013 2,199 2,278 1.789 0.101 0.099 0.150 Never married (in union) 0.394 0.011 2,199 2,278 1.058 0.028 0.372 0.416 Currently married (in union) 0.506 0.012 2,199 2,278 1.119 0.024 0.482 0.529 Married before age 20 0.409 0.021 1,291 1,340 1.548 0.052 0.366 0.451 Currently pregnant 0.065 0.005 2,199 2,278 0.879 0.071 0.056 0.074 Children ever born 2.469 0.060 2,199 2,278 1.006 0.024 2.350 2.588 Children surviving 2.078 0.049 2,199 2,278 1.004 0.024 1.979 2.176 Children ever born to women age 40-49 6.178 0.151 361 374 1.094 0.024 5.876 6.480 Knows any contraceptive method 1.000 0.000 1,108 1,151 na 0.000 1.000 1.000 Currently using any method 0.569 0.014 1,108 1,151 0.967 0.025 0.540 0.598 Currently using pill 0.080 0.010 1,108 1,151 1.214 0.124 0.060 0.100 Currently using condoms 0.026 0.005 1,108 1,151 0.992 0.183 0.016 0.035 Currently using female sterilization 0.003 0.002 1,108 1,151 1.010 0.563 0.000 0.006 Currently using periodic abstinence 0.030 0.005 1,108 1,151 0.966 0.165 0.020 0.040 Used public sector source 0.967 0.008 617 642 1.072 0.008 0.952 0.983 Want no more children 0.522 0.016 1,108 1,151 1.095 0.031 0.489 0.555 Want to delay birth at least 2 years 0.366 0.014 1,108 1,151 0.983 0.039 0.337 0.394 Ideal family size 3.204 0.048 2,184 2,262 1.591 0.015 3.108 3.300 Mothers protected against tetanus for last birth 0.807 0.016 992 1,035 1.259 0.020 0.776 0.839 Mothers received medical assistance at delivery 0.635 0.019 1,374 1,437 1.337 0.030 0.597 0.674 Having diarrhea in the last 2 weeks 0.137 0.012 1,283 1,342 1.227 0.087 0.113 0.161 Treated with oral rehydration salts (ORS) 0.255 0.031 172 183 0.948 0.123 0.192 0.318 Taken to a health provider 0.315 0.033 172 183 0.930 0.105 0.249 0.381 Vaccination card seen 0.868 0.031 238 251 1.442 0.036 0.806 0.931 Received BCG 1.000 0.000 238 251 na 0.000 1.000 1.000 Received DPT (3 doses) 0.992 0.005 238 251 0.974 0.005 0.982 1.003 Received polio (3 doses) 0.970 0.013 238 251 1.164 0.013 0.944 0.996 Received measles 0.974 0.013 238 251 1.241 0.013 0.948 0.999 Fully immunized 0.936 0.017 238 251 1.110 0.019 0.901 0.971 Height-for-age (below -2SD) 0.507 0.022 684 710 1.114 0.044 0.462 0.552 Weight-for-height (below -2SD) 0.012 0.004 684 710 1.076 0.376 0.003 0.021 Weight-for-age (below -2SD) 0.104 0.013 684 710 1.052 0.127 0.078 0.131 Anemia children 0.306 0.020 632 656 1.018 0.064 0.267 0.345 Anemia women 0.116 0.010 1,138 1,178 1.092 0.090 0.095 0.136 BMI < 18.5 0.048 0.007 1,043 1,082 1.018 0.141 0.034 0.061 Total fertility rate (last 3 years) 4.136 0.178 6,039 6,256 1.308 0.043 3.781 4.491 Neonatal mortality (last 0-9 years) 38.654 4.796 2,794 2,915 1.169 0.124 29.062 48.246 Post-neonatal mortality (last 0-9 years) 32.797 3.788 2,814 2,936 1.006 0.115 25.221 40.372 Infant mortality (last 0-9 years) 71.451 6.431 2,801 2,922 1.194 0.090 58.588 84.313 Child mortality (last 0-9 years) 38.625 3.638 2,887 3,010 0.983 0.094 31.348 45.901 Under-five mortality (last 0-9 years) 107.315 7.402 2,834 2,956 1.166 0.069 92.511 122.120 HIV prevalence (women 15-49) 0.031 0.006 1,138 1,168 1.104 0.183 0.020 0.042 MEN Urban residence 0.071 0.035 859 899 3.981 0.498 0.000 0.141 No education 0.097 0.012 859 899 1.197 0.125 0.073 0.121 Secondary school or higher 0.206 0.020 859 899 1.458 0.098 0.166 0.246 Never married (in union) 0.506 0.021 859 899 1.250 0.042 0.463 0.548 Currently married (in union) 0.478 0.021 859 899 1.212 0.043 0.437 0.520 HIV prevalence (men 15-49) 0.018 0.005 859 899 1.195 0.302 0.007 0.029 HIV prevalence (men 15-59) 0.019 0.005 971 1,014 1.187 0.271 0.009 0.030 MEN AND WOMEN HIV prevalence (men and women 15-49) 0.025 0.004 1,997 2,067 1.250 0.173 0.017 0.034 Appendix B • 279 Table B.9 Sampling errors: East sample, Rwanda DHS 2010 Variable R SE N WN DEFT SE/R R-2SE R+2SE R+2SE WOMEN Urban residence 0.042 0.018 3,104 3,280 4.914 0.423 0.006 0.077 Literacy 0.742 0.011 3,104 3,280 1.414 0.015 0.720 0.764 No education 0.171 0.009 3,104 3,280 1.340 0.053 0.153 0.189 Secondary school or higher 0.128 0.010 3,104 3,280 1.676 0.078 0.108 0.148 Never married (in union) 0.347 0.011 3,104 3,280 1.236 0.030 0.326 0.368 Currently married (in union) 0.528 0.012 3,104 3,280 1.308 0.022 0.504 0.551 Married before age 20 0.460 0.014 1,848 1,958 1.211 0.031 0.432 0.488 Currently pregnant 0.077 0.005 3,104 3,280 1.149 0.071 0.066 0.088 Children ever born 2.695 0.053 3,104 3,280 1.046 0.020 2.589 2.800 Children surviving 2.227 0.042 3,104 3,280 1.033 0.019 2.143 2.311 Children ever born to women age 40-49 6.286 0.110 530 562 0.979 0.017 6.067 6.506 Knows any contraceptive method 0.997 0.002 1,618 1,731 1.144 0.002 0.993 1.000 Currently using any method 0.523 0.015 1,618 1,731 1.184 0.028 0.494 0.553 Currently using pill 0.078 0.008 1,618 1,731 1.154 0.098 0.063 0.094 Currently using condoms 0.029 0.004 1,618 1,731 1.018 0.146 0.021 0.038 Currently using female sterilization 0.005 0.002 1,618 1,731 0.926 0.321 0.002 0.008 Currently using periodic abstinence 0.026 0.004 1,618 1,731 0.934 0.141 0.019 0.034 Used public sector source 0.944 0.009 826 875 1.150 0.010 0.926 0.963 Want no more children 0.568 0.013 1,618 1,731 1.047 0.023 0.542 0.593 Want to delay birth at least 2 years 0.336 0.012 1,618 1,731 1.060 0.037 0.311 0.361 Ideal family size 3.372 0.031 3,072 3,247 1.073 0.009 3.311 3.433 Mothers protected against tetanus for last birth 0.810 0.011 1,553 1,658 1.107 0.014 0.788 0.832 Mothers received medical assistance at delivery 0.672 0.016 2,227 2,376 1.453 0.024 0.639 0.704 Having diarrhea in the last 2 weeks 0.110 0.007 2,084 2,225 0.940 0.060 0.097 0.123 Treated with oral rehydration salts (ORS) 0.328 0.032 236 245 1.023 0.099 0.263 0.393 Taken to a health provider 0.389 0.034 236 245 1.024 0.086 0.322 0.457 Vaccination card seen 0.805 0.025 389 414 1.216 0.030 0.756 0.854 Received BCG 0.995 0.004 389 414 1.013 0.004 0.987 1.002 Received DPT (3 doses) 0.972 0.009 389 414 1.042 0.009 0.954 0.989 Received polio (3 doses) 0.962 0.010 389 414 1.006 0.010 0.942 0.981 Received measles 0.942 0.012 389 414 1.009 0.013 0.918 0.966 Fully immunized 0.928 0.013 389 414 0.963 0.014 0.902 0.953 Height-for-age (below -2SD) 0.439 0.017 1,045 1,112 1.039 0.038 0.405 0.472 Weight-for-height (below -2SD) 0.032 0.006 1,045 1,112 1.155 0.200 0.019 0.044 Weight-for-age (below -2SD) 0.115 0.011 1,045 1,112 1.021 0.095 0.093 0.136 Anemia children 0.432 0.017 963 1,027 1.065 0.040 0.398 0.467 Anemia women 0.228 0.013 1,583 1,668 1.239 0.057 0.202 0.254 BMI < 18.5 0.077 0.008 1,421 1,495 1.085 0.100 0.061 0.092 Total fertility rate (last 3 years) 4.934 0.141 8,654 9,152 1.246 0.029 4.652 5.216 Neonatal mortality (last 0-9 years) 27.441 2.751 4,360 4