Rwanda Demographic and Health Survey 2014-2015

Publication date: 2016

Rwanda Demographic and Health Survey 2014-15 ANNIVERSAR YCELE BRATING2005 2015 NIS R’S 10 YE ARS OF PO LIC Y S UPP ORT Republic of Rwanda Rwanda Demographic and Health Survey 2014-15 Final Report National Institute of Statistics of Rwanda Kigali, Rwanda Ministry of Finance and Economic Planning Kigali, Rwanda Ministry of Health Kigali, Rwanda The DHS Program ICF International Rockville, Maryland, USA March 2016 The Rwanda Demographic and Health Survey 2014-15 (2014-15 RDHS) was implemented by the National Institute of Statistics of Rwanda (NISR) from November 9, 2014, to April 8, 2015. The funding for the RDHS was provided by the government of Rwanda, the United States Agency for International Development (USAID), the One United Nations (One UN), the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), World Vison International, the Swiss Agency for Development and Cooperation (SDC), and the Partners in Health (PIH). ICF International provided technical assistance through The DHS Program, a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. Additional information about the 2014-15 RDHS may be obtained from the National Institute of Statistics of Rwanda, 6139 Kigali, Rwanda; Telephone: +250 252 571035; Fax: +250 252 570705; Email: info@statistics.gov.rw; Website: www.statistics.gov.rw. Information about The DHS Program may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; Telephone: +1-301-407-6500; Fax: +1-301-407-6501; Email: info@DHSprogram.com; Website: www.DHSprogram.com. ISBN: 978-99977-43-09-1 Recommended citation: National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda], and ICF International. 2015. Rwanda Demographic and Health Survey 2014-15. Rockville, Maryland, USA: NISR, MOH, and ICF International. Contents • iii CONTENTS TABLES AND FIGURES .ix FOREWORD . xix ACKNOWLEDGMENTS . xxi MAP OF RWANDA . xxii 1 INTRODUCTION . 1 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 . 4 1.1.5 Health Policy . 4 1.2 Objectives and Methodology of the Survey . 5 1.2.1 Objectives of the Survey . 6 1.2.2 Questionnaires . 7 1.2.3 Sample Design . 7 1.2.4 Sample Coverage . 8 1.2.5 Anthropometry Measurements, Anemia, Malaria, and HIV Testing . 9 1.3 Pretest . 11 1.4 Training of Field Staff . 11 1.5 Fieldwork . 12 1.6 Data Processing . 12 2 HOUSEHOLD CHARACTERISTICS . 13 2.1 Household Population by Age and Sex . 13 2.2 Household Composition . 15 2.3 Educational Attainment . 16 2.4 School Attendance . 18 2.5 Household Conditions . 20 2.5.1 Household Drinking Water . 20 2.5.2 Household Sanitation Facilities . 21 2.5.3 Household Hand Washing Places . 22 2.5.4 Household Characteristics . 23 2.5.5 Household Possession of Durable Goods . 25 2.5.6 Household Wealth . 26 2.6 Birth Registration . 27 2.7 Children’s Living Arrangements and Orphanhood . 28 2.8 School Attendance by Survivorship of Parents . 29 2.9 Health Insurance Coverage and Bank Accounts . 30 3 RESPONDENT CHARACTERISTICS . 35 3.1 Background Characteristics of Respondents . 35 3.2 Educational Attainment . 37 3.3 Literacy . 38 3.4 Exposure to Mass Media . 40 3.5 Employment . 43 3.6 Use of Tobacco . 48 4 PROXIMATE DETERMINANTS OF FERTILITY . 51 4.1 Marital Status . 51 4.2 Polygamy . 52 iv • Contents 4.3 Age at First Union . 54 4.4 Age at First Sexual Intercourse . 56 4.5 Recent Sexual Activity . 58 5 FERTILITY . 61 5.1 Fertility Levels and Differentials . 62 5.2 Fertility Trends . 65 5.3 Children Ever Born and Living . 67 5.4 Birth Intervals . 68 5.5 Exposure to the Risk of Pregnancy . 70 5.6 Menopause . 71 5.7 Age at First Birth . 72 5.8 Teenage Fertility . 73 6 FERTILITY PREFERENCES . 75 6.1 Desire for Children. 75 6.2 Ideal Number of Children . 78 6.3 Fertility Planning Status . 80 7 FAMILY PLANNING . 83 7.1 Knowledge of Contraceptive Methods . 83 7.2 Current Use of Contraceptive Methods . 85 7.2.1 Current Use of Contraception by Age . 85 7.2.2 Current Use of Contraception by Background Characteristics . 87 7.2.3 Trends in Current Use of Family Planning . 89 7.3 Timing of Sterilization . 89 7.4 Source of Supply . 89 7.5 Use of Social Marketing Brands of Pills and Condoms . 90 7.6 Informed Choice . 91 7.7 Contraceptive Discontinuation . 92 7.8 Reasons for Discontinuation of Contraceptive Use . 93 7.9 Knowledge of Fertile Period . 94 7.10 Need and Demand for Family Planning Services . 95 7.10.1 Need and Demand for Family Planning among Currently Married Women . 95 7.10.2 Need and Demand for Family Planning among All Women and Women Who Are Not Currently Married . 97 7.11 Future Use of Contraception . 98 7.12 Exposure to Family Planning Messages . 99 7.13 Contact of Nonusers with Family Planning Providers . 100 8 INFANT AND CHILD MORTALITY . 103 8.1 Assessment of Data Quality . 104 8.2 Levels and Trends in Childhood Mortality . 105 8.3 Socioeconomic Differentials in Childhood Mortality . 106 8.4 Demographic Differentials in Mortality . 107 8.5 Perinatal Mortality . 108 8.6 High-Risk Fertility Behavior. 110 9 MATERNAL HEALTH . 113 9.1 Antenatal Care . 113 9.1.1 Components of Antenatal Care . 115 9.1.2 Tetanus Vaccinations . 117 9.2 Delivery Care . 118 9.2.1 Place of Delivery . 118 9.2.2 Assistance during Delivery . 120 Contents • v 9.3 Postnatal Care . 122 9.3.1 Maternal Postnatal Care . 122 9.3.2 Newborn Postnatal Care . 124 9.4 Problems in Accessing Health Care . 126 10 CHILD HEALTH . 129 10.1 Child’s Size at Birth . 130 10.2 Vaccination of Children . 131 10.3 Trends in Vaccination Coverage . 133 10.4 Childhood Illnesses . 134 10.4.1 Acute Respiratory Infections . 134 10.4.2 Fever . 135 10.5 Diarrheal Disease . 137 10.5.1 Prevalence of Diarrhea. 137 10.5.2 Treatment of Diarrhea . 138 10.5.3 Feeding Practices during Diarrhea . 140 10.6 Knowledge of ORS Packets . 142 10.7 Stool Disposal . 142 11 NUTRITION OF CHILDREN AND ADULTS . 145 11.1 Nutritional Status of Children . 146 11.1.1 Measurement of Nutritional Status among Young Children . 146 11.1.2 Measures of Child Nutritional Status . 147 11.1.3 Trends in Children’s Nutritional Status . 150 11.2 Initiation of Breastfeeding . 151 11.3 Breastfeeding Status by Age . 152 11.4 Duration of Breastfeeding . 154 11.5 Types of Complementary Foods . 156 11.6 Infant and Young Child Feeding (IYCF) Practices . 157 11.7 Prevalence of Anemia in Children . 160 11.8 Micronutrient Intake among Children . 162 11.9 Iodization of Household Salt . 165 11.10 Nutritional Status of Women . 165 11.11 Prevalence of Anemia in Women . 167 11.12 Micronutrient Intake among Mothers . 169 11.13 Nutritional Status of Men . 170 12 MALARIA . 173 12.1 Mosquito Nets . 175 12.1.1 Ownership of Mosquito Nets . 175 12.1.2 Use of Mosquito Nets by Persons in the Household . 177 12.1.3 Use of Mosquito Nets by Children under Age 5 . 178 12.1.4 Use of Mosquito Nets by Pregnant Women . 179 12.2 Prevalence and Prompt Treatment of Fever . 180 12.3 Prevalence of Anemia and Malaria in Children and Women . 182 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 189 13.1 Knowledge of HIV and AIDS and of Transmission and Prevention Methods . 190 13.1.1 Awareness of AIDS . 190 13.1.2 HIV Prevention Methods . 190 13.1.3 Knowledge about Transmission . 192 13.1.4 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 195 13.2 Stigma Associated with AIDS and Attitudes Related to HIV and AIDS . 196 13.3 Attitudes toward Negotiating Safer Sex . 198 13.4 Attitudes toward Condom Education for Youth . 200 vi • Contents 13.5 Multiple and Concurrent Partnerships and Paying for Sex . 201 13.5.1 Multiple Sexual Partnerships . 201 13.5.2 Concurrent Sexual Partners . 204 13.5.3 Payment for Sex . 206 13.6 Prior Testing for HIV . 207 13.7 HIV Testing during Antenatal Care . 209 13.8 Reports of Recent Sexually Transmitted Infections . 211 13.9 Needle and Syringe Injection . 213 13.10 HIV- and AIDS-related Knowledge and Behavior among Youth . 214 13.10.1 Knowledge about HIV and AIDS and Sources for Condoms . 215 13.10.2 Age at First Sex and Condom Use at First Sexual Intercourse . 216 13.10.3 Premarital Sexual Activity . 217 13.10.4 Multiple Sexual Partnerships . 218 13.10.5 Age-mixing in Sexual Relationships . 218 13.10.6 Recent HIV Testing among Youth . 219 13.11 Male Circumcision . 220 14 HIV PREVALENCE . 225 14.1 Coverage Rates for HIV Testing among Adults . 226 14.2 HIV Prevalence among Adults . 228 14.2.1 HIV Prevalence by Age and Sex . 228 14.2.2 Trends in HIV Prevalence . 229 14.2.3 HIV Prevalence by Socioeconomic Characteristics . 230 14.2.4 HIV Prevalence by Demographic Characteristics. 231 14.2.5 HIV Prevalence by Sexual Risk Behavior . 233 14.3 HIV Prevalence among Youth . 234 14.3.1 Overall HIV Prevalence among Youth . 234 14.3.2 HIV Prevalence among Youth by Condom Use at Last Sex . 235 14.4 HIV Prevalence by Other Characteristics . 236 14.4.1 HIV Prevalence and STIs . 236 14.4.2 HIV Prevalence by Male Circumcision . 237 14.4.3 Prior HIV Testing by Current HIV Status . 238 14.5 HIV Prevalence among Cohabiting Couples . 239 14.6 HIV Prevalence among Children . 241 15 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES . 243 15.1 Women’s and Men’s Employment . 243 15.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s Earnings . 244 15.3 Women’s and Men’s Ownership of Selected Assets . 248 15.4 Women’s Participation in Decision-making . 250 15.5 Attitudes toward Wife Beating . 253 15.6 Women’s Empowerment Indicators . 256 15.7 Current Use of Contraception by Women’s Empowerment Status . 256 15.8 Ideal Family Size and Unmet Need by Women’s Status . 257 15.9 Women’s Status and Reproductive Health Care . 258 16 ADULT AND MATERNAL MORTALITY . 261 16.1 Data Quality Issues . 261 16.2 Adult Mortality . 263 16.3 Maternal Mortality . 263 17 DOMESTIC VIOLENCE . 267 17.1 Measurement of Violence . 267 17.1.1 Use of Valid Measures of Violence . 267 17.1.2 Ethical Considerations in the 2014-15 RDHS . 269 17.1.3 Subsample for the Violence Module . 269 17.2 Experience of Physical Violence . 269 17.3 Perpetrators of Physical Violence . 272 Contents • vii 17.4 Experience of Sexual Violence . 273 17.5 Perpetrators of Sexual Violence . 275 17.6 Age at First Experience of Sexual Violence . 275 17.7 Experience of Different Forms of Violence . 276 17.8 Violence during Pregnancy . 277 17.9 Marital Control by Spouse . 278 17.10 Forms of Spousal Violence . 281 17.11 Spousal Violence by Background Characteristics . 284 17.12 Violence by Spousal Characteristics and Empowerment Indicators . 286 17.13 Recent Spousal Violence . 289 17.14 Onset of Spousal Violence . 291 17.15 Physical Consequences of Spousal Violence . 291 17.16 Violence by Women and Men against Their Spouse . 293 17.17 Help-seeking Behavior by Those Who Experience Violence . 297 18 EARLY CHILDHOOD EDUCATION AND DEVELOPMENT . 301 18.1 Prevalence of Early Childhood Education . 301 18.2 Adult Involvement in Early Learning Activities . 302 18.3 Children’s Books and Playthings . 304 18.4 Adequate Care for Young Children . 305 18.5 Early Childhood Development . 306 REFERENCES . 309 APPENDIX A SAMPLE IMPLEMENTATION . 313 A.1 Introduction . 313 A.2 Sampling Frame . 313 A.3 Structure of the Sample and the Sampling Procedure . 316 A.4 Selection Probability and Sampling Weight . 318 A.5 Survey Results . 320 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 327 APPENDIX C DATA QUALITY TABLES . 349 APPENDIX D DISTRICT TABLES. 365 APPENDIX E SURVEY PERSONNEL . 471 APPENDIX F QUESTIONNAIRES . 477 Tables and Figures • ix TABLES AND FIGURES 1 INTRODUCTION . 1 Table 1.1 Results of the household and individual interviews . 9 2 HOUSEHOLD CHARACTERISTICS . 13 Table 2.1 Household population by age, sex, and residence . 14 Table 2.2 Household composition . 15 Table 2.3.1 Educational attainment of the female household population . 16 Table 2.3.2 Educational attainment of the male household population . 17 Table 2.4 School attendance ratios . 19 Table 2.5 Household drinking water . 21 Table 2.6 Household sanitation facilities . 22 Table 2.7 Hand washing . 23 Table 2.8 Household characteristics . 24 Table 2.9 Household possessions . 26 Table 2.10 Wealth quintiles . 27 Table 2.11 Birth registration of children under age 5 . 28 Table 2.12 Children’s living arrangements and orphanhood . 29 Table 2.13 School attendance by survivorship of parents . 30 Table 2.14 Household bank account and health insurance . 31 Table 2.15 Health insurance among adult women and men . 32 Figure 2.1 Population pyramid . 14 Figure 2.2 Age-specific attendance rates . 20 3 RESPONDENT CHARACTERISTICS . 35 Table 3.1 Background characteristics of respondents . 36 Table 3.2.1 Educational attainment: Women . 37 Table 3.2.2 Educational attainment: Men . 38 Table 3.3.1 Literacy: Women . 39 Table 3.3.2 Literacy: Men . 40 Table 3.4.1 Exposure to mass media: Women . 41 Table 3.4.2 Exposure to mass media: Men . 42 Table 3.5.1 Employment status: Women . 43 Table 3.5.2 Employment status: Men . 45 Table 3.6.1 Occupation: Women . 46 Table 3.6.2 Occupation: Men . 47 Table 3.7 Type of employment: Women . 48 Table 3.8.1 Use of tobacco: Women . 49 Table 3.8.2 Use of tobacco: Men . 50 4 PROXIMATE DETERMINANTS OF FERTILITY . 51 Table 4.1 Current marital status . 52 Table 4.2.1 Number of women’s co-wives . 53 Table 4.2.2 Number of men’s wives . 54 Table 4.3 Age at first marriage . 55 Table 4.4 Median age at first marriage by background characteristics . 56 Table 4.5 Age at first sexual intercourse . 57 Table 4.6 Median age at first sexual intercourse by background characteristics . 58 x • Tables and Figures Table 4.7.1 Recent sexual activity: Women . 59 Table 4.7.2 Recent sexual activity: Men . 60 5 FERTILITY . 61 Table 5.1 Current fertility . 63 Table 5.2 Fertility by background characteristics. 64 Table 5.3.1 Trends in age-specific fertility rates . 65 Table 5.3.2 Trends in fertility . 66 Table 5.4 Children ever born and living . 68 Table 5.5 Birth intervals . 69 Table 5.6 Postpartum amenorrhea, abstinence, and insusceptibility . 70 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 71 Table 5.8 Menopause . 72 Table 5.9 Age at first birth . 72 Table 5.10 Median age at first birth . 73 Table 5.11 Teenage pregnancy and motherhood . 74 Figure 5.1 Age-specific fertility rates for five-year periods preceding the survey . 66 Figure 5.2 Trends in age-specific fertility rates, various sources . 67 6 FERTILITY PREFERENCES . 75 Table 6.1 Fertility preferences by number of living children . 76 Table 6.2.1 Desire to limit childbearing: Women . 77 Table 6.2.2 Desire to limit childbearing: Men . 78 Table 6.3 Ideal number of children by number of living children . 79 Table 6.4 Mean ideal number of children . 80 Table 6.5 Fertility planning status . 81 Table 6.6 Wanted fertility rates . 81 7 FAMILY PLANNING . 83 Table 7.1 Knowledge of contraceptive methods . 84 Table 7.2 Knowledge of contraceptive methods by background characteristics . 84 Table 7.3 Current use of contraception by age . 86 Table 7.4 Current use of contraception by background characteristics . 88 Table 7.5 Timing of sterilization . 89 Table 7.6 Source of modern contraception methods . 90 Table 7.7 Use of social marketing brand pills and condoms . 91 Table 7.8 Informed choice . 92 Table 7.9 Twelve-month contraceptive discontinuation rates . 93 Table 7.10 Reasons for discontinuation . 93 Table 7.11 Knowledge of fertile period . 94 Table 7.12.1 Need and demand for family planning among currently married women . 96 Table 7.12.2 Need and demand for family planning for all women and for women who are not currently married . 97 Table 7.13 Future use of contraception . 99 Table 7.14 Exposure to family planning messages . 100 Table 7.15 Contact of nonusers with family planning providers . 101 Figure 7.1 Trends in contraceptive use among currently married women . 89 Tables and Figures • xi 8 INFANT AND CHILD MORTALITY . 103 Table 8.1 Early childhood mortality rates . 105 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 106 Table 8.3 Early childhood mortality rates by demographic characteristics . 108 Table 8.4 Perinatal mortality . 109 Table 8.5 High-risk fertility behavior . 110 Figure 8.1 Trends in childhood mortality rates . 105 Figure 8.2 Under-5 mortality rates by socioeconomic characteristics . 107 Figure 8.3 Infant mortality rates by demographic characteristics . 108 9 MATERNAL HEALTH . 113 Table 9.1 Antenatal care . 114 Table 9.2 Number of antenatal care visits and timing of first visit. 115 Table 9.3 Components of antenatal care . 116 Table 9.4 Tetanus toxoid injections . 118 Table 9.5 Place of delivery . 119 Table 9.6 Assistance during delivery . 120 Table 9.7 Timing of first postnatal checkup . 123 Table 9.8 Type of provider of first postnatal checkup for the mother . 124 Table 9.9 Timing of first postnatal checkup for the newborn . 125 Table 9.10 Type of provider of first postnatal checkup for the newborn . 126 Table 9.11 Problems in accessing health care . 127 Figure 9.1 Trends in antenatal care and delivery, Rwanda 2005 to 2014-15 . 121 Figure 9.2 Births delivered by a skilled provider . 122 10 CHILD HEALTH . 129 Table 10.1 Child’s weight and size at birth . 130 Table 10.2 Vaccinations by source of information . 132 Table 10.3 Vaccinations by background characteristics . 132 Table 10.4 Vaccinations in first year of life . 133 Table 10.5 Prevalence and treatment of symptoms of ARI . 134 Table 10.6 Prevalence and treatment of fever . 136 Table 10.7 Prevalence of diarrhea . 137 Table 10.8 Diarrhea treatment . 139 Table 10.9 Feeding practices during diarrhea . 141 Table 10.10 Knowledge of ORS packets . 142 Table 10.11 Disposal of children’s stools . 143 Figure 10.1 Trends in vaccination coverage among children age 12-23 months . 133 11 NUTRITION OF CHILDREN AND ADULTS . 145 Table 11.1 Nutritional status of children . 149 Table 11.2 Initial breastfeeding . 152 Table 11.3 Breastfeeding status by age . 153 Table 11.4 Median duration of breastfeeding . 155 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 157 Table 11.6 Infant and young child feeding (IYCF) practices . 159 Table 11.7 Prevalence of anemia in children . 161 Table 11.8 Micronutrient intake among children . 164 Table 11.9 Presence of iodized salt in household . 165 Table 11.10 Nutritional status of women . 166 xii • Tables and Figures Table 11.11 Prevalence of anemia in women . 168 Table 11.12 Micronutrient intake among mothers . 170 Table 11.13 Nutritional status of men . 171 Figure 11.1 Nutritional status of children by age . 150 Figure 11.2 Trends in nutritional status of children under age 5 . 151 Figure 11.3 Infant feeding practices by age . 154 Figure 11.4 IYCF indicators on breastfeeding status . 156 Figure 11.5 Trends in the percentage of children age 6-23 months fed according to all three infant and young child feeding (IYCF) practices . 160 Figure 11.6 Trends in anemia status among children age 6-59 months . 162 Figure 11.7 Trends in nutritional status among women age 15-49 . 167 Figure 11.8 Trends in anemia status among women age 15-49 . 169 12 MALARIA . 173 Table 12.1 Household possession of mosquito nets . 176 Table 12.2 Access to an insecticide-treated net (ITN) . 177 Table 12.3 Use of mosquito nets by persons in the household . 178 Table 12.4 Use of existing ITNs . 178 Table 12.5 Use of mosquito nets by children . 179 Table 12.6 Use of mosquito nets by pregnant women . 180 Table 12.7 Prevalence, diagnosis, and prompt treatment of children with fever . 181 Table 12.8 Source of advice or treatment for children with fever . 182 Table 12.9 Type of antimalarial drugs taken by children who took antimalarial drugs . 182 Table 12.10 Hemoglobin <8.0 g/dl in children . 183 Table 12.11 Coverage of malaria testing among children . 184 Table 12.12 Prevalence of malaria in children . 185 Table 12.13 Coverage of malaria testing among women . 186 Table 12.14 Prevalence of malaria in women . 187 Figure 12.1 Percentage of de facto population with access to an ITN in the household. 176 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 189 Table 13.1 Knowledge of AIDS . 190 Table 13.2 Knowledge of HIV prevention methods . 191 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 193 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 194 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV. 196 Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 197 Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 198 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 199 Table 13.7 Adult support of education about condom use to prevent AIDS . 200 Table 13.8.1 Multiple sexual partners: Women . 202 Table 13.8.2 Multiple sexual partners: Men . 203 Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners . 205 Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse . 206 Table 13.11.1 Coverage of prior HIV testing: Women . 208 Table 13.11.2 Coverage of prior HIV testing: Men . 209 Table 13.12 Pregnant women counseled and tested for HIV . 210 Table 13.13 HIV testing for prenuptial purposes and as a couple . 211 Table 13.14 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 212 Table 13.15 Prevalence of medical injections . 214 Tables and Figures • xiii Table 13.16 Comprehensive knowledge about AIDS and of a source of condoms among youth . 215 Table 13.17 Age at first sexual intercourse among young people . 216 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 217 Table 13.19 Multiple sexual partners in the past 12 months among young people . 218 Table 13.20 Age-mixing in sexual relationships among women and men age 15-19 . 219 Table 13.21 Recent HIV tests among youth . 220 Table 13.22 Practice of circumcision . 221 Table 13.23 Place of circumcision . 222 Table 13.24 Age at circumcision . 223 Figure 13.1 Women and men seeking treatment for STIs . 213 14 HIV PREVALENCE . 225 Table 14.1 Coverage of HIV testing by residence and province . 227 Table 14.2 Coverage of HIV testing by selected background characteristics . 228 Table 14.3 HIV prevalence among adults . 229 Table 14.4 Trends in HIV prevalence by age . 230 Table 14.5 HIV prevalence by socioeconomic characteristics . 231 Table 14.6 HIV prevalence by demographic characteristics . 232 Table 14.7 HIV prevalence by sexual behavior . 233 Table 14.8 HIV prevalence among young people by background characteristics . 235 Table 14.9 HIV prevalence among young people by sexual behavior . 236 Table 14.10 HIV prevalence by other characteristics . 237 Table 14.11 HIV prevalence by male circumcision . 238 Table 14.12 Prior HIV testing by current HIV status . 239 Table 14.13 HIV prevalence among couples. 240 Table 14.14 HIV prevalence among children age 0-14 . 241 Figure 14.1 HIV prevalence by sex and age . 229 15 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES . 243 Table 15.1 Employment and cash earnings of currently married women and men . 244 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 245 Table 15.2.2 Control over men’s cash earnings . 247 Table 15.3 Women’s control over their own earnings and over those of their husbands . 248 Table 15.4.1 Ownership of assets: Women . 249 Table 15.4.2 Ownership of assets: Men . 250 Table 15.5 Participation in decision-making . 251 Table 15.6.1 Women’s participation in decision-making by background characteristics . 252 Table 15.6.2 Men’s participation in decision-making by background characteristics . 253 Table 15.7.1 Attitudes toward wife beating: Women . 254 Table 15.7.2 Attitudes toward wife beating: Men . 255 Table 15.8 Indicators of women’s empowerment . 256 Table 15.9 Current use of contraception by women’s empowerment . 257 Table 15.10 Ideal number of children and unmet need for family planning by women’s empowerment . 258 Table 15.11 Reproductive health care by women’s empowerment . 259 xiv • Tables and Figures 16 ADULT AND MATERNAL MORTALITY . 261 Table 16.1 Completeness of information on siblings . 262 Table 16.2 Sibship size and sex ratio of siblings . 262 Table 16.3 Adult mortality rates . 263 Table 16.4 Maternal mortality . 264 Figure 16.1 Maternal mortality ratios for the period 0-4 years prior to the 2000, 2005, 2010, and 2014-15 RDHS surveys . 265 17 DOMESTIC VIOLENCE . 267 Table 17.1.1 Experience of physical violence: Women . 270 Table 17.1.2 Experience of physical violence: Men . 271 Table 17.2.1 Persons committing physical violence: Women . 272 Table 17.2.2 Persons committing physical violence: Men . 272 Table 17.3.1 Experience of sexual violence: Women . 273 Table 17.3.2 Experience of sexual violence: Men . 274 Table 17.4.1 Persons committing sexual violence: Women . 275 Table 17.4.2 Persons committing sexual violence: Men . 275 Table 17.5.1 Age at first experience of sexual violence among women . 276 Table 17.5.2 Age at first experience of sexual violence: Men . 276 Table 17.6.1 Experience of different forms of violence: Women . 276 Table 17.6.2 Experience of different forms of violence: Men. 277 Table 17.7 Experience of violence during pregnancy . 278 Table 17.8.1 Marital control exercised by husbands . 279 Table 17.8.2 Marital control exercised by wives . 280 Table 17.9.1 Forms of spousal violence: Women . 282 Table 17.9.2 Forms of spousal violence: Men . 283 Table 17.10.1 Spousal violence by background characteristics: Women . 284 Table 17.10.2 Spousal violence by background characteristics: Men . 285 Table 17.11.1 Spousal violence by husband’s characteristics and empowerment indicators . 287 Table 17.11.2 Spousal violence by wife’s characteristics and empowerment indicators . 288 Table 17.12.1 Physical or sexual violence in the past 12 months by any husband/partner . 290 Table 17.12.2 Physical or sexual violence in the past 12 months by any wife/partner . 290 Table 17.13.1 Experience of spousal violence by duration of marriage: Women . 291 Table 17.13.2 Experience of spousal violence by duration of marriage: Men . 291 Table 17.14.1 Injuries due to spousal violence: Women . 292 Table 17.14.2 Injuries due to spousal violence: Men . 292 Table 17.15.1 Women’s violence against their spouse. 294 Table 17.15.2 Men’s violence against their spouse . 294 Table 17.16.1 Women’s violence against their spouse by spouse’s characteristics and empowerment indicators . 295 Table 17.16.2 Men’s violence against their spouse by spouse’s characteristics and empowerment indicators . 297 Table 17.17.1 Help seeking to stop violence: Women . 298 Table 17.17.2 Help seeking to stop violence: Men . 299 Table 17.18.1 Sources for help to stop the violence: Women . 300 Table 17.18.2 Sources for help to stop the violence: Men . 300 18 EARLY CHILDHOOD EDUCATION AND DEVELOPMENT . 301 Table 18.1 Early childhood education . 302 Table 18.2 Support for learning . 303 Table 18.3 Learning materials . 305 Tables and Figures • xv Table 18.4 Inadequate care . 306 Table 18.5 Early Child Development Index . 308 APPENDIX A SAMPLE IMPLEMENTATION . 313 Table A.1 Population by province and by district within province according to type of residence . 314 Table A.2 Distribution of residential households by province and by district within province according to type of residence . 315 Table A.3 Distribution of EAs and their average size in number of households by province and by district, according to type of residence . 316 Table A.4 Sample allocation of EAs and households by province and by district within province according to type of residence . 317 Table A.5 Sample allocation of expected number of interviews by province and by district within province according to type of residence . 318 Table A.6 Sample implementation: Women . 320 Table A.7 Sample implementation: Men . 321 Table A.8 Coverage of HIV testing by social and demographic characteristics: Women . 322 Table A.9 Coverage of HIV testing by social and demographic characteristics: Men . 323 Table A.10 Coverage of HIV testing by sexual behavior characteristics: Women . 324 Table A.11 Coverage of HIV testing by sexual behavior characteristics: Men . 325 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 327 Table B.1 List of selected variables for sampling errors, Rwanda 2014-15 . 329 Table B.2 Sampling errors: Total sample, Rwanda 2014-15 . 331 Table B.3 Sampling errors: Urban sample, Rwanda 2014-15 . 333 Table B.4 Sampling errors: Rural sample, Rwanda 2014-15 . 335 Table B.5 Sampling errors: Kigali City sample, Rwanda 2014-15 . 337 Table B.6 Sampling errors: South sample, Rwanda 2014-15 . 339 Table B.7 Sampling errors: West sample, Rwanda 2014-15 . 341 Table B.8 Sampling errors: North sample, Rwanda 2014-15 . 343 Table B.9 Sampling errors: East sample, Rwanda 2014-15 . 345 Table B.10 Sampling errors for adult and maternal mortality probability and rates in last 0-4 years, Rwanda 2014-15 . 347 APPENDIX C DATA QUALITY TABLES . 349 Table C.1 Household age distribution . 349 Table C.2.1 Age distribution of eligible and interviewed women . 350 Table C.2.2 Age distribution of eligible and interviewed men . 350 Table C.3 Completeness of reporting . 351 Table C.4 Births by calendar years . 351 Table C.5 Reporting of age at death in days . 352 Table C.6 Reporting of age at death in months . 353 Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 354 Table C.8 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 355 Table C.9 Prevalence of anemia in children in 2005 . 356 Table C.10 Prevalence of anemia in women in 2005 . 357 Table C.11 Prevalence of anemia in children in 2007-08 . 358 Table C.12 Prevalence of anemia in women in 2007-08 . 359 Table C.13 Rotavirus and pneumococcal vaccinations by source of information . 360 Table C.14 Rotavirus and pneumococcal vaccinations by background characteristics . 360 Table C.15 Support for learning . 361 xvi • Tables and Figures Table C.16 Adult mortality rates . 362 Table C.17 Smoking . 363 APPENDIX D DISTRICT TABLES. 365 Table D2.3.1 Educational attainment of the female household population . 365 Table D2.3.2 Educational attainment of the male household population . 366 Table D2.4 School attendance ratios . 367 Table D2.7 Hand washing . 368 Table D2.11 Birth registration of children under age 5 . 369 Table D2.12 Children’s living arrangements and orphanhood . 370 Table D2.14 Household bank account and health insurance . 371 Table D2.15 Health insurance among adult women and men . 372 Table D3.1 Distribution of respondents by district . 373 Table D3.2.1 Educational attainment: Women . 374 Table D3.2.2 Educational attainment: Men . 375 Table D3.3.1 Literacy: Women . 376 Table D3.3.2 Literacy: Men . 377 Table D3.4.1 Exposure to mass media: Women . 378 Table D3.4.2 Exposure to mass media: Men . 379 Table D3.5.1 Employment status: Women . 380 Table D3.5.2 Employment status: Men . 381 Table D3.6.1 Occupation: Women . 382 Table D3.6.2 Occupation: Men . 383 Table D3.8.1 Use of tobacco: Women . 384 Table D3.8.2 Use of tobacco: Men . 385 Table D4.1 Current marital status . 386 Table D4.2.1 Number of women’s co-wives . 387 Table D4.2.2 Number of men’s wives . 388 Table D4.4 Median age at first marriage by background characteristics . 389 Table D4.6 Median age at first intercourse by background characteristics . 390 Table D4.7.1 Recent sexual activity: Women . 391 Table D4.7.2 Recent sexual activity: Men . 392 Table D5.2 Fertility by background characteristics . 393 Table D5.5 Birth intervals . 394 Table D5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 395 Table D5.10 Median age at first birth . 396 Table D5.11 Teenage pregnancy and motherhood . 397 Table D6.2.1 Desire to limit childbearing: Women . 398 Table D6.2.2 Desire to limit childbearing: Men . 399 Table D6.4 Mean ideal number of children . 400 Table D6.6 Wanted fertility rates . 401 Table D7.2 Knowledge of contraceptive methods by background characteristics . 402 Table D7.4 Current use of contraception by background characteristics . 403 Table D7.12.1 Need and demand for family planning among currently married women . 404 Table D7.12.2 Need and demand for family planning for all women . 405 Table D7.14 Exposure to family planning messages . 406 Table D7.15 Contact of nonusers with family planning providers . 407 Table D8.2 Early childhood mortality rates . 408 Table D9.1 Antenatal care . 409 Table D9.3 Components of antenatal care . 410 Tables and Figures • xvii Table D9.4 Tetanus toxoid injections . 411 Table D9.5 Place of delivery . 412 Table D9.6 Assistance during delivery . 413 Table D9.7 Timing of first postnatal checkup . 414 Table D9.8 Type of provider of first postnatal checkup for the mother . 415 Table D9.9 Timing of first postnatal checkup for the newborn . 416 Table D9.10 Type of provider of first postnatal checkup for the newborn . 417 Table D9.11 Problems in accessing health care . 418 Table D10.1 Child’s weight and size at birth . 419 Table D10.5 Prevalence of ARI . 420 Table D10.6 Prevalence of fever . 421 Table D10.7 Prevalence of diarrhea . 422 Table D10.10 Knowledge of ORS packets or pre-packaged liquids . 423 Table D10.11 Disposal of children’s stools . 424 Table D11.1 Nutritional status of children . 425 Table D11.2 Initial breastfeeding . 426 Table D11.4 Median duration of breastfeeding . 427 Table D11.7 Prevalence of anemia in children . 428 Table D11.8 Micronutrient intake among children . 429 Table D11.9 Presence of iodized salt in household . 430 Table D11.10 Nutritional status of women . 431 Table D11.11 Prevalence of anemia in women . 432 Table D11.12 Micronutrient intake among mothers . 433 Table D12.1 Household possession of mosquito nets . 434 Table D12.3 Use of mosquito nets by persons in the household . 435 Table D12.4 Use of existing ITNs . 436 Table D12.5 Use of mosquito nets by children. 437 Table D12.7 Prevalence, diagnosis, and prompt treatment of children with fever . 438 Table D12.10 Hemoglobin <8.0 g/dl in children . 439 Table D12.12 Prevalence of malaria in children . 440 Table D12.14 Prevalence of malaria in women . 441 Table D13.1 Knowledge of AIDS . 442 Table D13.2 Knowledge of HIV prevention methods . 443 Table D13.3.1 Comprehensive knowledge about AIDS: Women . 444 Table D13.3.2 Comprehensive knowledge about AIDS: Men . 445 Table D13.4 Knowledge of prevention of mother-to-child transmission of HIV . 446 Table D13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 447 Table D13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 448 Table D13.6 Attitudes toward negotiating safer sexual relations with husband . 449 Table D13.7 Adult support of education about condom use to prevent AIDS . 450 Table D13.8.1 Multiple sexual partners: Women . 451 Table D13.8.2 Multiple sexual partners: Men . 452 Table D13.9 Point prevalence and cumulative prevalence of concurrent sexual partners . 453 Table D13.10 Payment for sexual intercourse . 454 Table D13.11.1 Coverage of prior HIV testing: Women . 455 Table D13.11.2 Coverage of prior HIV testing: Men . 456 Table D13.12 Pregnant women counseled and tested for HIV . 457 Table D13.14 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 458 Table D13.15 Prevalence of medical injections . 459 Table D13.16 Comprehensive knowledge about AIDS and of a source of condoms among youth . 460 xviii • Tables and Figures Table D13.22 Practice of circumcision. 461 Table D14.5 HIV prevalence . 462 Table D14.8 HIV prevalence among young people . 463 Table D14.13 HIV prevalence among couples . 464 Table D15.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 465 Table D15.2.2 Control over men’s cash earnings . 466 Table D15.6.1 Women’s participation in decision-making by background characteristics . 467 Table D15.7.1 Attitude toward wife beating: Women . 468 Table D15.7.2 Attitudes toward wife beating: Men . 469 Foreword • xix FOREWORD rom 2014 to 2015, with the aim of collecting data to monitor progress across Rwanda’s health programs and policies, the Government of Rwanda (GOR) conducted the most recent Rwanda Demographic and Health Survey (RDHS) through the Ministry of Health (MOH) and the National Institute of Statistics of Rwanda (NISR) with the members of the national steering committee to the DHS and the technical assistance of ICF International. As a member of the steering committee, ICF International provided technical assistance in implementing the 2014-15 RDHS. The RDHS was sponsored by the GOR, the United States’ Agency for International Development (USAID), One United Nations (ONE UN), the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF), World Vision International (WVI), Partners in Health (PIH), and the Suisse Development Cooperation (SDC). This most recent RDHS builds on the assessments and findings of the 1992, 2000, 2005, and 2010 RDHS surveys, as well as the 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS). The main objective of the 2014-15 RDHS was to obtain current information on demographic and health indicators, including family planning; maternal mortality; infant and child mortality; nutrition status of mothers and children; prenatal care, delivery, and postnatal care; childhood diseases; and pediatric immunization. In addition, the survey was designed to measure indicators such as domestic violence, the prevalence of anemia and malaria among women and children, and the prevalence of HIV infection in Rwanda. For the first time, this 2014-15 RDHS also includes indicators to monitor HIV testing among children age 0-14 as well as domestic violence for males age 15-59. The 2014-15 RDHS targeted women age 15-49 and men age 15-59 from randomly selected households across the country. Information about children under 5 was also collected. RDHS data collection fieldwork was conducted from November 9, 2014, to April 8, 2015. The data entry, editing, and cleaning was completed by May 15, 2015, and the final survey report was completed in March 2016. Compared with the 2005 and 2010 RDHS, the 2014-15 survey shows promising results across multiple areas of health over the past 10 years. Such achievements include a decrease in maternal and infant mortality rates, an increase in prenatal care visits and utilization of delivery services, a steady decline in the total fertility rate, and relative stability in malaria and HIV prevalence. Compared with the 2010 RDHS, the 2014-15 survey also shows a slight increase in the utilization of modern contraceptives and higher immunization rates regarding coverage of children 12-23 months. Despite these improvements, the 2014-15 RDHS shows that there is still work to be done in the health sector, most notably in the area of pediatric and maternal nutrition, which remains a challenge in Rwanda. With this most recent data on nutrition across the country, Rwanda can now target health interventions and policies to tackle nutrition, with the hope of improving the nutritional status of the Rwandan people. The Ministry of Health and the National Institute of Statistics of Rwanda invite policy makers, program managers, and all users to play an important role in using the valuable data showcased in the 2014-15 RDHS to contribute to enhancing Rwandans’ quality of life. We hope that the RDHS datasets will be used efficiently and analyzed further by researchers so that the findings’ potential impact on the health sector can be maximized. F Acknowledgments • xxi ACKNOWLEDGMENTS he National Institute of Statistics of Rwanda (NISR) wishes to acknowledge the efforts of a number of organizations and individuals who contributed substantially to the success of the fifth Rwanda Demographic and Health Survey (2014-15 RDHS). First, we would like to acknowledge the financial assistance from the government of Rwanda (GOR), the United States Agency for International Development (USAID), One United Nations (ONE UN), the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF), World Vision International (WVI), Partners in Health (PIH), and the Suisse Development Cooperation (SDC). We express our gratitude to the Ministry of Health (MOH) for its close collaboration and to ICF International for its technical assistance throughout the survey. We gratefully acknowledge the support of the Steering Committee (SC) and Technical Advisory Committee (TAC) members, who contributed to the successful preparation and implementation of the survey. We wish to express great appreciation for the work carried out by the Technical Committee (TC) staff, namely coordinators, supervisors, cartographers, and data processors from NISR, MOH, and RBC Divisions, especially Malaria & OPD, HIV, Maternal and Child Health (MCH), and the National Reference Laboratory (NRL) that worked with dedication and enthusiasm to make the survey a success. We recognize the valuable support provided by NISR departments, especially administration, finance and procurement services; their interventions allowed this survey to run smoothly, safely, and in good conditions. We would like to express our special thanks to the Ministry of Local Government and to the local authorities as well as community health workers for their assistance and contribution to the smooth implementation of the survey. Special thanks goes to the team leaders, field and office editors, enumerators, drivers, and data entry staffs for their valuable time that made this survey possible. Finally, we are grateful to the survey respondents who generously gave their time to provide the information that forms the basis of this report. T xxii • Map of Rwanda Introduction • 1 INTRODUCTION 1 Key Findings • The 2014-15 Rwanda Demographic and Health Survey (RDHS) is a nationally representative survey of 12,699 households, 13,497 women age 15-49, and 6,217 men age 15-59. • The 2014-15 RDHS is the fifth standard DHS conducted in Rwanda as part of the worldwide DHS Program. • The primary purpose of the RDHS is to provide policymakers and planners with detailed information on fertility and family planning; infant, child, adult, and maternal mortality; maternal and child health; nutrition; malaria; knowledge of HIV/AIDS and other sexually transmitted infections; and domestic violence, among others. • Anthropometry measurements and anemia and malaria testing were carried out among women and children in a subsample of 50 percent of households. HIV testing was carried out among adults in another 50 percent of households and children under age 15 in 15 percent of the households. 1.1 COUNTRY PROFILE 1.1.1 Geography wanda is located 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 and 2,000 meters. The area is also referred to as the central plateau (Randall Baker, 1970). 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. R 2 • Introduction 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, occurring 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 per year. 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 of 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. Rwanda is divided into four geographically based provinces North, South, East, and West and the City of Kigali. The lower administrative areas consist of 30 districts, 416 sectors, 2,148 cells, and 14,837 villages. 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 to the economy than the agricultural sector in recent years. Rwanda’s economy has been growing steadily at about 8 percent per year since 2001, with gross domestic product (GDP) per capita more than tripling from $211 in 2001 to $719 in 2014. The rate of growth in food crop production was more than twice the population growth rate between 2007 and 2014. In fact, in fiscal year 2014-2015, GDP at current market prices was estimated to be Rwf 5,605 billion, up from Rwf 5,136 billion in 2013-2014. The service sector contributed 48 percent of GDP in 2014, and in this sector, the share of trade and transport represented 15 percent, and other services (e.g., information, communication, real estate activities, education, hotels and restaurants) represented 32 percent. The agriculture sector contributed 33 percent of GDP, with food crops representing 23 percent of this total. The industrial sector contributed 14 percent of GDP, with different types of manufacturing representing 5 percent, mining and quarrying representing 2 percent, and approximately 5 percent attributable to adjustment for taxes less subsidies on products. In fiscal year 2014-2015, estimates calculated at constant 2011 prices showed that GDP was 7.3 percent higher in real terms than in 2013-2014. In this period, the agriculture sector grew by 5 percent and contributed 1.6 percentage points to overall GDP growth. Activities in the industry sector grew by 7 percent and contributed 1 percentage point to GDP growth. The service sector increased by 8 percent and contributed 4 percentage points (NISR 2014-15). Introduction • 3 Although the agricultural sector appears to have been overtaken by the service sector, it remains the backbone of Rwanda’s economy and still employs many Rwandans. The Fourth Household Living Conditions Survey (EICV4) shows that the percentage of farmers whose main job is farming is 71 percent, with 61 percent of them independent famers and 10 percent wage farmers. 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 gradually being introduced to address these problems; in particular, over recent years, land consolidation and regionalization of crops have been a focus of agricultural policies, as has protection of land from erosion. The results of the EICV4 show that 85 percent of crop-producing households in Rwanda have at least one of their plots protected from erosion, and 13 percent have at least one of their plots irrigated. The EICV4 calculated an indicator of the incidence of poverty, which is the share of the population whose total consumption is below the poverty line (Rwf 159,375 in January 2014 prices), or the share of the population that cannot afford to buy a basic basket of goods (food and non-food).Thirty-nine percent of the population was identified as poor in 2013-2014, as compared with 45 percent in the Third Household Living Conditions Survey in 2010-2011. 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 are geared toward pro-poor economic growth and poverty reduction to revive the economies of developing nations. Rwanda has adopted this new orientation, and the economic development and poverty reduction strategies developed every five years through this framework serve as a guide for elaborating different plans as well as an instrument for monitoring and evaluating the development progress made. 1.1.3 Population The fourth population and housing census (RPHC4) in 2012 showed that the Rwandan population was 10,515,973 from which 5,451,105 (52 percent) of the country’s residents were female, and 5,064,867 (48 percent) were male. According to projections, Rwanda’s population would grow to 11,274,221 in 2015. The population increased from 4,831,527 in 1978 to 7,157,551 in 1991 and 8,128,553 in 2002 before reaching the 2012 total of 10,515,973. Thus, the population more than doubled between 1978 and 2012. The increase was essentially due to rapid population growth, which remains high despite the progressive decreases in the natural growth rate and the total fertility rate. In fact, according to census estimates, the natural growth rate was 2.6 percent between 2002 and 2012 and 3.1 percent between 1978 and 1991. The low natural growth rate of 1.2 percent between 1991 and 2002 is due to the high number of deaths caused by the genocide of 1994. Based on Rwanda Demographic and Health Surveys (RDHS) data, the total fertility rate is estimated to have declined from 6.1 in 2005 to 4.6 in 2010. Population density is high across the country and has increased steadily over the years, from 183 inhabitants per square kilometer in 1978 to 272 in 1991, 321 in 2002, and 415 in 2012. The population is largely rural: according to the RPHC4, almost 84 percent of the country’s residents live in rural areas. Among the total urban population, 49 percent live in City of Kigali, the capital of the country. Also, the population is essentially young, with 43.4 percent of all Rwandans under age 15 according to the RPHC4. 4 • Introduction The illiteracy rate in Rwanda declined between 2005 and 2010. Between the two RDHS surveys, the rate decreased from 29 percent to 23 percent among women age 15-49 and from 22 percent to 19 percent among men age 15-59. This means that 77 percent of women are considered literate, as compared with 80 percent of men. The educational level of Rwandans is still low. The 2010 RDHS results showed that 22 percent of women and 16 percent of men had no education, while 68 percent of women and 72 percent of men had attended primary school only. Nine percent of women and 11 percent of men had reached the secondary school level, while those with education beyond the secondary level made up only 1 percent of the female population and 2 percent of the male population. Although numerous religions are practiced in Rwanda, the 2012 census showed that Christianity is by far the dominant faith, practiced in some form by 93 percent of the population (44 percent are Catholic, 38 percent are Protestant, and 12 percent are Adventist). The number of Muslim adherents remained at 2 percent of the population from 2002 to 2012. Only 0.4 percent of the population profess to have no religion. 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 other countries 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, 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 (ONAPO, 1990a, 1990b, and 199c). To create an environment favorable to behavioral change that would result in lower fertility rates, other elements were included in the plan, such as increased production, public health improvements, land use planning, training of communicators, promotion of education and school attendance, and employment and advancement of women. Following the 1994 genocide, population problems were seen in a new light, with an 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 Health Policy Rwanda’s Health Sector Policy translates the Government’s overall vision of development in the health sector, as set out in Vision 2020 and the Economic Development and Poverty Reduction Strategy (EDPRS 2, 2013-2018). Since the adoption of the previous Health Sector Policy in 2005, much has changed in terms of national socio-economic development policy and more specifically in the health sector policy. The new Health Sector Policy thus takes into account new orientations in the national development agenda and changes in the socio-economic and epidemiologic situation of the Rwandan population and in the institutional environment of the country and specifically in the health sector. Introduction • 5 The health sector has a crucial role to play in the achievement of the national mid-term (EDPRS 2) goal of 11.5% economic growth rate. Continuous progress in the coverage and quality of promotive, preventive, curative and rehabilitative health interventions and in the health seeking behavior of the population ensure improvements in the health status and productivity of the Rwandan population. The health sector also has an influence on enabling environment for economic and social transformation as envisioned by the EDPRS 2. It aims to contribute among others, to a reduction in the fertility rate. Availability of high quality health services, as an important element of the service sector, contributes to the generation of collective wealth and is crucial to attracting investors and tourists. The overall objective of the health sector policy is to ensure universal accessibility (in geographical and financial terms) of equitable and affordable quality health services (preventative, curative, rehabilitative and promotional services) for all Rwandans. This objective will be attained through the full implementation of (1) the various programs, while strengthening (2) the various systems that will support them at (3) all levels of service delivery together with (4) the governance of the sector. To achieve the above objective health policy will require different directions such as: • Improve demand, access and quality of essential health services • Strengthen policies, resources and management mechanisms of health support systems to ensure optimal performance of the health programs • Strengthen policies, resources and management mechanisms of health services delivery systems • Strengthen the Health Sector Governance mechanisms The implementation of this policy would not be a reality without involving different stakeholders and existing structures ensure the involvement of all of them. • The Health Sector Working Group (HSWG comprises representatives of the MOH, development partners, and civil society. • Technical working groups (TWGs) are operational entities where technical and policy issues are discussed by staff of the MOH with representatives of development partners, NGOs, FBOs, and CSOs. TWGs operate under the authority of the HSWG. • The Single Project Implementation Unit (SPIU) aims at reducing the number of separate projects and the administrative burden of the MOH in managing and reporting on the various projects with off-budget resources. The 2015 Health Policy will help the Government of Rwanda to sustain the achievements made through previous policies and existing strategies. Health sector has contributed in achieving objectives of EDPRS I (2008-2012) and the Millennium Development Goals (MDGs). Ministry of Health through its implementing agency (RBC) and health facilities at different levels will continue to be an integral part of implementing strategies aiming to achieve Vision 2020 and Sustainable Development Goals (SDGs). 1.2 OBJECTIVES AND METHODOLOGY OF THE SURVEY The government of Rwanda planned the 2014-15 RDHS with the support of its development partners and institutions interested in population and health issues. The 2014-15 RDHS is the fifth survey of its kind, 6 • Introduction following standard DHS surveys conducted in 1992, 2000, 2005, and 2010. In addition in Rwanda interim RDHS was conducted in 2007-08. The 2014-15 RDHS was implemented by the National Institute of Statistics of Rwanda (NISR) in collaboration with the Ministry of Health (MOH) and the Rwanda Biomedical Center (RBC) under the guidance of a steering committee. The Demographic and Health Survey (DHS) Program of ICF International provided technical assistance through its contract with the United States Agency for International Development (USAID). Funding for the 2014-15 RDHS was provided by the Government of Rwanda and by development partners including USAID; United Nations agencies (One UN); the Global Fund to Fight AIDS, Tuberculosis, and Malaria; World Vision International; Partners in Health and Suisse Agency for Development and Cooperation. 1.2.1 Objectives of the Survey The main objectives of the 2014-15 RDHS were to: • Collect data at the national level to calculate essential demographic indicators, especially fertility and infant and child mortality, and analyze the direct and indirect factors that relate to levels and trends in fertility and child mortality • Measure levels of knowledge and use of contraceptive methods among women and men • Collect data on family health, including immunization practices; prevalence and treatment of diarrhea, acute upper respiratory infections, and fever among children under age 5; antenatal care visits; assistance at delivery; and postnatal care • Collect data on knowledge, prevention, and treatment of malaria, in particular the possession and use of treated mosquito nets among household members, especially children under age 5 and pregnant women • Collect data on feeding practices for children, including breastfeeding • Collect data on the knowledge and attitudes of women and men regarding sexually transmitted infections (STIs) and HIV and evaluate recent behavioral changes with respect to condom use • Collect data for estimation of adult mortality and maternal mortality at the national level • Take anthropometric measurements to evaluate the nutritional status of children, men, and women • Assess the prevalence of malaria infection among children under age 5 and pregnant women using rapid diagnostic tests and blood smears • Estimate the prevalence of HIV among children age 0-14 and adults of reproductive age • Estimate the prevalence of anemia among children age 6-59 months and adult women of reproductive age • Collect information on early childhood development • Collect information on domestic violence Introduction • 7 1.2.2 Questionnaires Three types of questionnaires were used in the 2014-15 RDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. They are based on questionnaires developed by the worldwide DHS Program and on questionnaires used during the 2010 RDHS. 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, nongovernmental organizations, and international donors. The questionnaires were translated from English into Kinyarwanda. The Household Questionnaire was used to list all of 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 relationship to the head of the household, sex, residence status, age, and marital status along with survival status of children’s parents, education, birth registration, health insurance coverage, and tobacco use. The Household Questionnaire also collected information on the following: (1) dwelling characteristics; (2) possession of iodized salt; (3) possession and utilization of mosquito nets; (4) height and weight of women age 15-49, men age 15-59, and children age 0-5; (5) hemoglobin measurement of women and children; (6) blood collection from women and children for rapid and laboratory testing for malaria; and (7) blood collection from women, men, and children for laboratory testing for HIV. The Woman’s Questionnaire was administered to all women age 15-49 living in the sampled households. It was used to collect information on (1) background characteristics; (2) reproduction; (3) contraception; (4) pregnancy and postnatal care, including breastfeeding and feeding practices; (5) immunization, health, and nutrition of children(including early child development); (6) marriage and sexual activity; (7) fertility preferences; (8) husbands’ characteristics and women’s employment activity; (9) HIV/AIDS and other sexually transmitted infections; (10) other health issues; (11) adult and maternal mortality; and (12) domestic violence. The Man’s Questionnaire was administered to all men age 15-59 living in every second household in the sample. It was similar to the Woman’s Questionnaire but did not include questions on use of contraceptive methods or birth history; pregnancy and postnatal care; child immunization, health, and nutrition; or adult and maternal mortality. A detailed interviewers’ manual was also developed, as well as other instructional manuals including one focusing on biomarkers such as HIV, anemia, and anthropometric measurements. Instruction manuals were available and used during the pretest from August 25 to September 22, 2014; the training for the main survey from October 5 to November 2, 2014; and data collection from November 9 to April 8, 2015. 1.2.3 Sample Design The sampling frame used for the 2014-15 RDHS was the 2012 Rwanda Population and Housing Census (RPHC). The sampling frame consisted of a list of enumeration areas (EAs) covering the entire country, provided by the National Institute of Statistics of Rwanda, the implementing agency for the RDHS. An EA is a natural village or part of a village created for the 2012 RPHC; these areas served as counting units for the census. The 2014-15 RDHS followed a two-stage sample design and was intended to allow estimates of key indicators at the national level as well as for urban and rural areas, five provinces, and each of Rwanda’s 30 districts (for some limited indicators). The first stage involved selecting sample points (clusters) consisting of 8 • Introduction EAs delineated for the 2012 RPHC. A total of 492 clusters were selected, 113 in urban areas and 379 in rural areas. The second stage involved systematic sampling of households. A household listing operation was undertaken in all of the selected EAs from July 7 to September 6, 2014, and households to be included in the survey were randomly selected from these lists. Twenty-six households were selected from each sample point, for a total sample size of 12,792 households. However, during data collection, one of the households was found to actually be two households, which increased the total sample to 12,793. Because of the approximately equal sample sizes in each district, the sample is not self-weighting at the national level, and weighting factors have been added to the data file so that the results will be proportional at the national level. All women age 15-49 who were either permanent residents of the household or visitors who stayed in the household the night before the survey were eligible to be interviewed. In half of the households, all men age 15-59 who either were permanent household residents or were visiting the night before the survey were eligible to be interviewed. In the subsample of households not selected for the male survey, anemia and malaria testing were performed among eligible women who consented to being tested. With the parent’s or guardian’s consent, children aged 6-59 months were tested for anemia and malaria in this subsample. Height and weight information was collected from eligible women, and children (age 0-5) in the same subsample. In the subsample of households selected for male survey, blood spot samples were collected for laboratory testing of HIV from eligible women and men who consented. Height and weight information was collected from eligible men. In one-third of the same subsample (or 15 percent of the entire sample), blood spot samples were collected for laboratory testing of children age 0-14 for HIV. The domestic violence module was implemented in the households selected for the male survey: The domestic violence module for men was implemented in 50 percent of the household selected for male survey and domestic violence for women was conducted in the remaining 50 percent of household selected for male survey (or 25 percent of the entire sample, each). 1.2.4 Sample Coverage All 492 enumeration areas selected for the sample were surveyed for the 2014-15 RDHS. A total of 12,793 households were selected, of which 12,717 were occupied at the time of the survey. Among these households, 12,699 completed the Household Questionnaire, yielding a response rate of 99.9 percent (Table 1.1). There was little variation in response rates by urban-rural residence. In the 12,699 households surveyed, 13,564 women age 15-49 were identified as being eligible for the individual interview; interviews were completed with 13,497 of these women, yielding a response rate of 99.5 percent. Male interviews were conducted in every second household. A total of 6,249 men age 15-59 were identified in this subsample of households. Of these men, 6,217 completed individual interviews, yielding a response rate of 99.5 percent. Response rates among men were slightly higher in rural areas, while rates among women were almost the same in rural and urban areas. Introduction • 9 Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Rwanda 2014-15 Residence Total Result Urban Rural Household interviews Households selected 2,939 9,854 12,793 Households occupied 2,911 9,806 12,717 Households interviewed 2,895 9,804 12,699 Household response rate1 99.5 100.0 99.9 Interviews with women age 15-49 Number of eligible women 3,446 10,118 13,564 Number of eligible women interviewed 3,427 10,070 13,497 Eligible women response rate2 99.4 99.5 99.5 Interviews with men age 15-59 Number of eligible men 1,619 4,630 6,249 Number of eligible men interviewed 1,607 4,610 6,217 Eligible men response rate2 99.3 99.6 99.5 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents 1.2.5 Anthropometry Measurements, Anemia, Malaria, and HIV Testing In the subsample of households not selected for the male survey, blood specimens were collected from women age 15-49 and children age 6-59 months for measurement of anemia in the field. Blood specimens were collected and tested for malaria in the field using a rapid diagnostic test (RDT) and blood smears were collected dried and stained and later tested in the laboratory using a microscope. Additionally, in the household selected for male survey; one-half of households, blood specimens for HIV testing were collected from all women age 15-49 and men age 15-59 who consented to the test. HIV testing among children age 0-14 was implemented in 15 percent of the households with the consent of the child’s parent or responsible guardian. Sterile, non-reusable, self-retractable lancets were used to collect blood specimens for anemia, malaria, and HIV testing. The protocol for blood specimen collection and HIV testing 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. Anthropometry In the all of the households not selected for the male survey, height and weight measurements were recorded for children age 0-5, women age 15-49, and men age 15-59. Height and weight information was collected from eligible men in half of households selected for male survey. Anemia testing Blood specimens for hemoglobin measurement were collected from women age 15-49 and from all children age 6-59 months for whom consent was obtained from their parents or the adult responsible for them. Consent was also obtained from parents or responsible adults for young unmarried women age 15-17. The consent statement explained the purpose of the test, the procedures to be followed, the confidentiality of the results, and the voluntary nature of the test. It also indicated that the results would be made available as soon as the test was completed. Blood samples were drawn from a drop of blood taken from a finger prick (or a heel prick in the case of children age 6-11 months) and collected in a microcuvette. Hemoglobin analysis was carried out on-site 10 • Introduction using a battery-operated portable HemoCue analyzer. Results were provided verbally and in writing. Parents of children with a hemoglobin level under 7 g/dl were instructed to take the child to a health facility for follow-up care. Likewise, non-pregnant women and pregnant women were referred for follow-up care if their hemoglobin levels were below 7 g/dl and 9 g/dl, respectively. Malaria testing Malaria diagnostic tests, including rapid diagnostic tests and tests using thick and thin blood smears, were conducted among eligible women and children. In the case of RDTs, a drop of blood was obtained by pricking the end of the finger, usually at the same time as anemia testing. RDT results were used to diagnose malaria and guide treatment of parasitic children during the survey. The parent or guardian of a child with a positive RDT result was provided with written results and the child was given artemisinin-based combination therapy (ACT) for treatment, according to the current malaria treatment guidelines. Women with a positive result were treated with ACT, while women with severe malaria were referred to the nearest health center for treatment. Thin and thick blood smears were also collected from eligible women (age 15-49) and children (age 6-59 months) who agreed to malaria testing. An informed consent statement was read to the eligible person or to the parent or adult responsible for a child or an unmarried young adult age 15-17. A slide with a thick and thin blood smears was prepared, stained for all eligible women and children. These samples were collected two or three times weekly by survey supervisors, transmitted, to NISR for verification and stored at Parasitology and Entomology Laboratory for microscopic examination of malaria parasites, then referred to the National Reference Laboratory/RBC (NRL) for quality assurance and quality control. The RBC Malaria and Other Parasitic Diseases Division were in charge of internal and external quality control of malaria testing. HIV testing Interviewers collected finger-prick dried blood spot (DBS) specimens for laboratory testing of HIV from women age 15-49 and men age 15-59 who consented to be tested. Also, DBS specimens were collected from children age 0-14 with the consent of their parent or another responsible guardian. The protocol for DBS collection and analysis was based on the anonymous linked protocol developed for the DHS Program. This protocol allows for merging of HIV test results with background characteristics and other data collected in the individual questionnaires after removal of all information that could potentially identify an individual. Interviewers explained the procedure, the confidentiality of the data, and the fact that the test results would not be made available to the respondent. If consent was given for HIV testing, four to five blood spots from the finger prick were collected on a filter paper card to which a barcode label unique to the respondent was affixed. A duplicate label was attached to the biomarker data collection form. A third copy of the barcode was affixed to the DBS transmittal sheet to track the blood samples from the field to the laboratory. Blood samples were dried overnight and packaged for storage the following morning. Samples were periodically collected from the field and transported to the NRL in Kigali. Upon arrival at the NRL, each blood sample was logged into the CSPro HIV Test Tracking System database and stored at -80˚C until tested. The HIV testing protocol stipulated that blood could be tested only after questionnaire data collection had been completed, data had been verified and cleaned, and all unique identifiers other than the anonymous barcode number had been removed from the data file. The testing algorithm calls for testing all samples on the first assay, the Vironostika® HIV Ag/Ab (Biomérieux) enzyme-linked immunoassay (ELISA I). A random 10 percent of samples deemed negative on Introduction • 11 the ELISA I are subjected to a second ELISA (ELISA II),the Murex HIV Ag/Ab combination (DiaSorin); the other 90 percent are recorded as negative. All samples deemed positive on the ELISA I are subjected to the ELISA II. Concordant positive and negative results on the ELISA I and ELISA II are recorded as positive and negative, respectively. If the results of the first and second tests are discordant, a third confirmatory test, the HIV 2.2 western blot (DiaSorin), is administered. The final result is recorded as positive if the western blot confirms it to be positive and negative if the western blot confirms it to be negative. If the western blot results are indeterminate, the sample is recorded as indeterminate. Polymerase chain reaction (PCR) was used in testing the specimens of children age 0-23 months. After HIV testing had been completed, the test results for the 2014-15 RDHS were entered into a spreadsheet with a barcode as the unique identifier. The barcode was used to link the HIV test results with the data from the individual interviews. All households, whether or not they were part of anthropometry, anemia, malaria, or HIV testing, were given a brochure explaining the causes and prevention of anemia, malaria, and HIV. Each respondent (whether providing consent or not) was given an informational brochure on HIV and a list of nearby sites providing HIV voluntary counseling and testing (VCT) services. Respondents who consented to HIV testing were given a voucher for transportation and a meal if they wished to receive free VCT services. 1.3 PRETEST A pretest was conducted from August 25 to September 22, 2014. Thirty-four individuals (17 women and 17 men) participated in the four-week pretest training and fieldwork practice for the 2014-15 RDHS. The majority of participants had worked in previous RDHS surveys. Training was conducted by representatives from the NISR, the MOH, the RBC Malaria and Other Parasitic Diseases Division, the RBC HIV division, and the RBC NRL, with technical assistance from ICF International. UNICEF provided training on the early childhood development module. Classroom instruction was provided during the first three weeks, and pretest fieldwork took place over five days in three rural villages and two urban villages. After the fieldwork, a debriefing session was held with the pretest field staff, and modifications to the questionnaires were made based on lessons drawn from the exercise. 1.4 TRAINING OF FIELD STAFF The main training for the 2014-15 RDHS started on October 5, 2014, and ended on November 2, 2014. A total of 136 participants from across the country were invited to participate in the training. They were selected based on merit. Eighty-eight of the participants were female, and 48 were male. From October 6-25, the training focused on the questionnaires. These sessions were conducted by NISR trainers with support from ICF International. Class presentations by trainers were followed by mock interviews, group practice, and role playing among participants in the classroom. Guest speakers and experts (e.g., from the MOH, the RBC, and UNICEF) made brief presentation son the national health strategies related to nutrition, contraception, malaria, maternal and child health, the HIV voluntary counseling and testing component, and early childhood development before the questionnaire training session corresponding to each of these topics. This led to an understanding among fieldworkers that items included in the questionnaire would be useful in evaluating these health topics. All participants were trained on the questionnaires through October 26. From October 27-30, 34 participants identified as health technicians were separated and trained on biomarkers. Meanwhile, the remaining participants continued to be trained on the questionnaires. Training on biomarkers was provided by representatives from the NRL with support from ICF International. Health technicians learned how to 12 • Introduction withdrawal blood samples for HIV testing, how to prepare blood slides for malaria testing, and how to conduct anemia and rapid malaria testing. In addition, procedures for handling and packaging dried blood spots and slides were reviewed and demonstrated. Training on taking anthropometry measurements (weight and height) was also covered in detail. Training included PowerPoint presentations to illustrate procedures and emphasized practice among lab technicians in order to ensure accuracy. At the end of the main training, 17 teams were formed, each consisting of a team leader, a field editor, a health technician, a male interviewer, and three female interviewers. Team leaders received additional training on how to identify the selected households and different subsamples, data quality control procedures, and fieldwork coordination. Field editors received additional training on how to edit the questionnaires and on data quality control procedures. 1.5 FIELDWORK Data collection for the 2014-15 RDHS was carried out by 17 field teams from November 9, 2014, to April 8, 2015. Each team was provided a vehicle with a driver. All questionnaires and blood specimens were transferred to the NISR office every 3-4 days by 10 supervisors from the NISR and NRL/RBC who also coordinated and supervised fieldwork activities. ICF International provided technical assistance during the entire five months of data collection period. 1.6 DATA PROCESSING The processing of the 2014-15 RDHS data began as soon as questionnaires were received from the field. Completed questionnaires were returned to NISR headquarters. The numbers of questionnaires and blood samples (DBS and malaria slides) were verified by two receptionists. Questionnaires were then checked, and open-ended questions were coded by four editors who had been trained for this task and who had also attended the questionnaire training sessions for the field staff. Blood samples (DBS and malaria slides) with transmittal sheets were sent respectively to the RBC/NRL and Parasitological and Entomology Laboratory to be screened for HIV and tested for malaria. Questionnaire data were entered via the CSPro computer program by 17 data processing personnel who were specially trained to execute this activity. Data processing was coordinated by the NISR data processing officer. ICF International provided technical assistance during the entire data processing period. Processing the data concurrently with data collection allowed for regular monitoring of team performance and data quality. Field check tables were generated regularly during data processing to check various data quality parameters. As a result, feedback was given on a regular basis, encouraging teams to continue in areas of high quality and to correct areas of needed improvement. Feedback was individually tailored to each team. Data entry, which included 100 percent double entry to minimize keying errors, and data editing were completed on April 26, 2015. Data cleaning and finalization were completed on May 15, 2015. Household Characteristics • 13 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; it is often a domestic unit consisting of the members of a family who live together, with or without nonrelatives such as servants. This chapter summarizes demographic and socioeconomic characteristics of the people who live in the households in Rwanda that were sampled during the 2014-15 RDHS. The Household Questionnaire collected 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 53,844 respondents, of whom 44,780 (83 percent) lived in rural areas and 9,064 (17 percent) lived in urban areas. The distribution of the household population by age and sex is further depicted by the population pyramid in Figure 2.1. The pyramid is wide at the base, narrowing rapidly as it reaches the upper age limits, an indication of a population with high fertility. Although the base of the pyramid (age 0-4) remains large, it is narrower than the bars for the age group 5-9. This pattern reflects a recent decline in fertility. In addition, there A Key Findings • The mean size of a Rwandan household is 4.3 persons. • Thirty-one percent of households are headed by women. • Seventy-three percent of households use an improved source of drinking water. • More than four in 10 households (44 percent) use an appropriate method to treat drinking water, primarily boiling (38 percent). • Fifty-four percent of households have an improved, not shared sanitation facility. • Almost one in four households (23 percent) have electricity. • Three in five (60 percent) Rwandan households own a mobile phone. • Fifty-six percent of children under age 5 have had their births registered. • Nine percent of children under age 18 are orphan with one or both parent dead. • Almost three-quarters of Rwandan adults are covered by health insurance. 14 • Household Characteristics 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, both the male and female populations drop significantly from 10-14, to 15-19 and 30-34 to 35-39 age groups. The fall in the population at age 10-14 might relate to child mortality in previous years. The drop in the age 15-19 group can be directly attributed to the low birth rate during 1994-1999, while the fall observed in the 35-39 age group might be the effect of the genocide in 1994. The shape of the pyramid gradually evolves over time based on fertility, mortality, and international migration trends. 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 2014-15 Urban Rural Rwanda Age Male Female Total Male Female Total Male Female Total <5 14.6 13.8 14.2 15.9 13.9 14.9 15.7 13.9 14.8 5-9 13.8 12.0 12.9 16.7 14.6 15.6 16.2 14.2 15.1 10-14 11.6 10.4 11.0 14.8 13.0 13.8 14.2 12.5 13.3 15-19 9.4 12.1 10.8 10.6 9.2 9.9 10.4 9.7 10.0 20-24 10.9 11.9 11.4 7.2 8.1 7.6 7.8 8.7 8.3 25-29 10.5 10.7 10.6 6.9 7.5 7.2 7.5 8.1 7.8 30-34 9.5 9.0 9.3 6.9 7.3 7.1 7.4 7.6 7.5 35-39 5.7 6.1 5.9 4.4 5.4 4.9 4.6 5.5 5.1 40-44 4.4 4.2 4.3 3.5 4.5 4.0 3.7 4.4 4.1 45-49 3.0 2.7 2.8 3.0 3.6 3.3 3.0 3.4 3.2 50-54 2.2 1.9 2.1 2.9 3.3 3.1 2.7 3.1 2.9 55-59 1.3 1.7 1.5 2.4 3.0 2.7 2.2 2.8 2.5 60-64 1.1 1.1 1.1 1.7 2.2 2.0 1.6 2.0 1.8 65-69 0.7 0.6 0.7 1.1 1.3 1.2 1.0 1.2 1.1 70-74 0.4 0.8 0.6 0.8 1.3 1.1 0.8 1.2 1.0 75-79 0.3 0.5 0.4 0.5 0.8 0.6 0.4 0.7 0.6 80+ 0.3 0.6 0.4 0.8 1.0 0.9 0.7 0.9 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,430 4,634 9,064 20,985 23,793 44,780 25,415 28,427 53,844 Figure 2.1 Population pyramid 10 8 6 4 2 0 2 4 6 8 10 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Percent Male Female RDHS 2014-15 Age Household Characteristics • 15 2.2 HOUSEHOLD COMPOSITION Table 2.2 shows that the mean size of a Rwandan household is 4.3 persons. It has decreased slightly from the mean household size of 4.6 found in the 2005 RDHS and the mean of 4.4 found in the 2010 RDHS. Mean household size varies somewhat by residence, with 4.1 members in urban areas and 4.3 in rural areas. In addition, Table 2.2 shows that 69 percent of Rwandan households are headed by men and 31 percent by women. By residence, female-headed households represent 32 percent of all households in rural areas and 27 percent in urban areas. After increasing significantly from 21 percent to 36 percent between 1992 and 2000, the percentage of female-headed households has dropped in ensuing years, from 34 percent in 2005 and 33 percent in 2010 to 31 percent in 2014-15. More than half of all households (53 percent) contain three to five people, 23 percent have six to eight people, and 3 percent have nine or more people. One-person households make up only 8 percent of all households. Table 2.2 also shows that 25 percent of households have foster and/or orphaned children; 20 percent have foster children, 11 percent have single orphans, and 2 percent have 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 age 18, according to residence, Rwanda 2014-15 Residence Total Characteristic Urban Rural Household headship Male 72.7 68.2 69.0 Female 27.3 31.8 31.0 Total 100.0 100.0 100.0 Number of usual members 1 12.4 7.3 8.2 2 14.3 11.9 12.3 3 16.6 18.8 18.5 4 17.8 19.6 19.3 5 13.9 15.9 15.6 6 9.9 12.6 12.1 7 7.3 7.4 7.4 8 3.7 3.7 3.7 9+ 4.2 2.7 3.0 Total 100.0 100.0 100.0 Mean size of households 4.1 4.3 4.3 Percentage of households with orphans and foster children under age 18 Foster children1 19.9 19.5 19.6 Double orphans 1.9 1.7 1.7 Single orphans2 9.8 11.1 10.9 Foster and/or orphan children 23.9 25.5 25.3 Number of households 2,188 10,511 12,699 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 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 16 • Household Characteristics 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, 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 19 percent of women and 13 percent of men have never attended school. A comparison of these proportions with those of the previous survey shows improvement: at the time of the 2010 survey, 22 percent of women and 16 percent of men had no education at all. The percentage of women and men who have completed only primary school is nearly identical (14 percent for women and 14 percent for men). As educational attainment increases, the percentage of both women and men in these categories decreases: only 3 percent of women and men have completed a secondary-level education, and 2 percent of women and 3 percent of men have attended any schooling beyond the secondary level. Table 2.3.1 Educational attainment of the female household population Percent distribution of the de facto female household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Rwanda 2014-15 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 22.6 77.3 0.0 0.0 0.0 0.0 0.1 100.0 3,279 0.2 10-14 1.7 89.1 2.0 7.2 0.0 0.0 0.0 100.0 3,567 2.7 15-19 1.4 42.0 16.3 39.2 1.1 0.1 0.0 100.0 2,756 5.3 20-24 4.8 41.6 14.6 25.3 11.2 2.4 0.0 100.0 2,466 5.2 25-29 10.7 52.6 16.7 6.7 7.9 5.4 0.0 100.0 2,292 3.9 30-34 16.4 50.0 20.6 5.1 3.8 4.1 0.0 100.0 2,147 3.7 35-39 17.5 36.9 33.4 6.5 3.3 2.4 0.1 100.0 1,575 4.5 40-44 24.2 32.0 35.1 3.5 2.2 2.9 0.0 100.0 1,257 4.1 45-49 35.6 26.7 31.6 3.7 0.6 1.8 0.0 100.0 980 2.7 50-54 46.4 31.8 16.7 2.7 1.5 0.9 0.2 100.0 869 0.6 55-59 50.1 30.7 16.8 0.5 1.6 0.3 0.1 100.0 790 0.0 60-64 61.2 26.2 9.7 2.0 0.7 0.2 0.0 100.0 577 0.0 65+ 75.1 20.7 3.0 0.8 0.1 0.0 0.3 100.0 1,153 0.0 Residence Urban 9.7 41.5 14.9 17.7 8.6 7.5 0.0 100.0 3,890 4.9 Rural 20.8 54.1 14.0 8.9 1.8 0.4 0.0 100.0 19,818 2.6 Province City of Kigali 9.8 41.4 16.8 16.0 8.7 7.2 0.1 100.0 2,562 4.9 South 19.1 53.5 15.0 9.1 2.2 1.1 0.1 100.0 5,867 2.8 West 21.0 53.5 11.7 10.1 2.7 1.0 0.0 100.0 5,386 2.6 North 19.4 50.8 15.4 11.4 2.2 0.8 0.0 100.0 3,971 3.0 East 20.7 54.6 13.5 8.8 1.7 0.7 0.0 100.0 5,923 2.5 Wealth quintile Lowest 30.2 57.1 8.5 3.8 0.4 0.0 0.0 100.0 4,806 1.3 Second 23.0 57.1 12.7 6.8 0.4 0.0 0.0 100.0 4,785 2.2 Middle 19.5 55.1 15.6 8.4 1.4 0.1 0.1 100.0 4,697 2.8 Fourth 14.3 51.3 17.7 13.5 2.7 0.5 0.0 100.0 4,720 3.5 Highest 7.8 39.3 16.3 19.5 9.7 7.4 0.0 100.0 4,701 5.2 Total 19.0 52.0 14.1 10.3 2.9 1.6 0.0 100.0 23,709 2.9 Note: Total includes one woman with age missing. 1 Completed 6th grade (for 6-grade system) and 8th grade (for 8-grade system) at the primary level or were in vocational school. 2 Completed 6th grade at the secondary level The percentage of women and men who have completed primary school or higher has increased since 2010, from 19 percent to 29 percent among women and from 22 percent to 30 percent among men. The figures for 2014-15 also show significant gains across generations. For example, among females, the proportion with Household Characteristics • 17 no education drops from 75 percent for women age 65 and over to 2 percent for girls between age 10 and age 14. The percentage among males in these age groups drops from 41 percent to 3 percent. In addition, the gap in educational attainment between the sexes has narrowed in the younger age groups. For example, among those age 25-29, only 37 percent of women have completed primary school or higher, as compared with 44 percent of men. However, among those age 20-24, the proportions are almost identical: 54 percent of women and 55 percent of men. The gender gap reverses among those age 15-19, with 57 percent of women and only 46 percent of men have completed primary school or higher. Table 2.3.2 Educational attainment of the male household population Percent distribution of the de facto male household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Rwanda 2014-15 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 23.7 76.2 0.0 0.0 0.0 0.0 0.1 100.0 3,316 0.1 10-14 2.9 90.2 1.5 5.4 0.0 0.0 0.1 100.0 3,619 2.4 15-19 2.2 51.4 12.1 33.4 0.9 0.0 0.0 100.0 2,639 4.8 20-24 4.3 40.3 15.4 24.5 10.8 4.6 0.0 100.0 1,990 5.3 25-29 8.2 48.1 17.5 8.5 9.3 8.2 0.1 100.0 1,912 4.5 30-34 14.1 46.9 22.9 5.6 4.5 6.0 0.0 100.0 1,879 4.2 35-39 15.9 33.0 36.2 5.8 3.6 5.5 0.0 100.0 1,175 5.0 40-44 16.0 34.5 33.6 7.5 3.6 4.5 0.3 100.0 933 4.9 45-49 22.8 28.9 36.2 5.4 2.6 4.0 0.0 100.0 767 4.7 50-54 27.9 37.1 25.4 3.4 3.3 2.5 0.4 100.0 698 2.9 55-59 28.0 40.1 24.6 2.9 2.3 2.1 0.0 100.0 570 2.9 60-64 33.0 41.2 18.3 3.7 1.8 2.1 0.0 100.0 402 2.4 65+ 40.5 40.0 14.0 2.8 1.3 1.1 0.3 100.0 739 1.6 Residence Urban 7.0 42.3 16.5 15.8 8.3 10.0 0.1 100.0 3,663 5.0 Rural 14.7 59.4 13.8 8.9 2.0 1.1 0.1 100.0 16,978 2.7 Province City of Kigali 7.1 42.2 18.8 13.7 8.3 9.7 0.2 100.0 2,415 5.0 South 14.6 58.8 13.7 8.7 2.1 1.8 0.2 100.0 4,986 2.6 West 15.1 56.9 12.7 10.3 3.2 1.8 0.1 100.0 4,651 2.9 North 12.8 57.7 15.6 9.5 2.6 1.8 0.0 100.0 3,384 3.0 East 13.9 59.1 13.4 10.0 2.1 1.4 0.0 100.0 5,205 2.8 Wealth quintile Lowest 23.9 64.2 7.4 4.2 0.3 0.0 0.0 100.0 3,613 1.3 Second 16.5 62.1 13.2 7.0 1.0 0.1 0.2 100.0 3,896 2.4 Middle 13.4 60.4 15.3 8.6 1.9 0.3 0.1 100.0 4,175 2.8 Fourth 9.7 57.1 17.4 11.5 2.8 1.4 0.1 100.0 4,372 3.4 Highest 5.8 40.9 16.9 17.5 8.8 10.1 0.0 100.0 4,585 5.2 Total 13.4 56.3 14.3 10.1 3.1 2.6 0.1 100.0 20,641 3.0 Note: Total includes two men with age missing. 1 Completed 6th grade (for 6-grade system) and 8th grade (for 8-grade system) at the primary level or were in vocational school. 2 Completed 6th grade at the secondary level By residence, the data show significant gaps in educational attainment. In rural areas, 21 percent of women and 15 percent of men have no education, as compared with 10 percent of women and 7 percent of men in urban areas. There are also variations among provinces. The City of Kigali has the lowest percentage of residents with no education (10 percent of women and 7 percent of men). Conversely, the West province has the highest proportion of women and men with no education (21 percent and 15 percent, respectively). As level of educational attainment increases, the gaps between the provinces widen: in the City of Kigali, 16 percent of women have completed secondary school or higher, as compared with 2 percent to 4 percent in other provinces; among men, 18 percent have completed secondary school or higher, compared with 4 percent to 5 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: 17 percent of women and 19 percent of men in the highest quintile have completed secondary school or higher, as compared with less than 1 percent of women and men in the lowest quintile. In 18 • Household Characteristics households in the highest wealth quintile, there is practically no gap in educational attainment between women and men up to 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 2014-15 RDHS asked questions concerning school attendance of all respondents between age 3 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 measure school attendance among 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 attends primary school. Table 2.4 shows that the primary-level NAR is 92 percent, which means that slightly more than 9 in 10 children in Rwanda between age 7 and 12 attend primary school. The ratio is the same in urban and rural areas (92 percent). In the provinces, the ratio ranges from a high of 93 percent in North to a low of 91 percent in South. Household wealth also affects the NAR, which is 86 percent among children in the lowest wealth quintile and 95 percent and 94 percent among children in the middle and fourth quintiles, respectively. The NAR is slightly higher for female children (92 percent) than for male children (91 percent). At the secondary level, where children are age 13-18, the NAR is much lower, at 29 percent; that is, only 29 percent of the official secondary school age population actually attends school. There are notable disparities between the sexes (32 percent for females versus 27 percent for males). The NAR is higher in urban areas than in rural areas (39 percent and 27 percent, respectively). By province, there is a gap between West, with an NAR of 33 percent, and the other provinces, whose NARs are between 25 percent (East) and 31 percent (City of Kigali). NARs clearly increase with increasing wealth, from 15 percent in the lowest quintile to 43 percent in the highest quintile. Table 2.4 also shows gross school attendance ratios. Unlike the NAR, the GAR measures school attendance among young people regardless of age. The GAR for primary school is the total number of students of any age attending primary school, expressed as a percentage of the official primary school age population (age 7-12). Unless there are significant numbers of overage and underage 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 at the primary level is 136 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 2010, the GAR was higher for girls than for boys (146 percent versus 141 percent); in 2014-15, by contrast, the GAR was slightly higher for boys than girls (137 percent versus 135 percent). At the secondary level, the GAR is low (40 percent). The reason is either that official secondary school age children are still in primary school or that they have dropped out of secondary school or never attended at all. The ratio is different for girls (43 percent) and boys (37 percent), and it is higher in urban areas than in rural areas (54 percent versus 37 percent). In 2010, City of Kigali had by far the highest secondary school GAR. In 2014-15, however, West had the highest GAR (47 percent), followed by City of Kigali and North (42 percent each).East had the lowest GAR (34 percent). The GAR increases with increasing wealth, from 20 percent in the lowest quintile to 59 percent in the highest quintile. Household Characteristics • 19 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 2014-15 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender parity index3 Male Female Total Gender parity index3 PRIMARY SCHOOL Residence Urban 93.3 90.1 91.7 0.97 141.0 133.6 137.4 0.95 Rural 90.9 92.8 91.8 1.02 136.6 135.7 136.2 0.99 Province City of Kigali 91.8 91.9 91.8 1.00 142.3 139.9 141.2 0.98 South 90.4 90.7 90.6 1.00 135.2 134.2 134.7 0.99 West 91.1 92.8 92.0 1.02 139.3 132.7 135.9 0.95 North 91.3 94.2 92.7 1.03 136.1 136.8 136.5 1.01 East 91.8 92.6 92.2 1.01 136.5 136.7 136.6 1.00 Wealth quintile Lowest 84.5 86.6 85.5 1.02 122.3 122.9 122.6 1.00 Second 90.1 93.7 91.9 1.04 131.6 139.1 135.4 1.06 Middle 94.1 95.3 94.7 1.01 145.2 138.1 141.5 0.95 Fourth 94.1 94.7 94.4 1.01 148.2 139.4 143.8 0.94 Highest 93.5 91.6 92.6 0.98 138.9 137.9 138.4 0.99 Total 91.2 92.4 91.8 1.01 137.2 135.4 136.3 0.99 SECONDARY SCHOOL Residence Urban 40.2 38.7 39.4 0.96 57.7 50.7 53.9 0.88 Rural 24.1 29.9 26.9 1.24 33.7 40.8 37.2 1.21 Province City of Kigali 32.5 29.2 30.7 0.90 48.4 36.6 41.8 0.76 South 24.3 29.1 26.7 1.20 33.4 40.7 37.0 1.22 West 28.6 38.0 33.1 1.33 42.2 52.6 47.2 1.25 North 26.4 36.2 31.6 1.37 36.4 46.7 41.8 1.28 East 24.9 25.3 25.1 1.01 33.8 34.7 34.3 1.03 Wealth quintile Lowest 13.6 15.5 14.6 1.14 19.2 20.9 20.1 1.09 Second 20.5 23.2 21.9 1.14 27.0 29.3 28.2 1.08 Middle 22.7 29.6 26.0 1.30 33.5 39.9 36.6 1.19 Fourth 27.4 39.3 33.0 1.43 38.9 55.3 46.6 1.42 Highest 42.9 43.1 43.0 1.00 60.3 57.9 59.0 0.96 Total 26.5 31.5 29.0 1.19 37.4 42.6 40.0 1.14 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. The table also includes a third school attendance indicator: the gender parity index (GPI), which is the ratio of the NAR/GAR for females to the NAR/GAR for males. The narrower the gap between the sexes, the closer the index is to 1. The NAR GPI for primary school is 1.01, and there are only minimal variations according to residence, province, or wealth quintile. This indicates an absence of disparity between the sexes. The NAR GPI for secondary school is 1.19; this indicates that boys are somewhat educationally disadvantaged at this level. The inequality is greater in rural areas, which have a GPI of 1.24 compared with 0.96 in urban areas. 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 9 and age 12. This period corresponds to the primary school years for 20 • Household Characteristics children in classes three, four, five, and six in the normal primary cycle. After age 12, 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 females who attend school is higher than the proportion of males at age 5, age 6, and age 8-15, while the situation generally reverses beginning at age 16. Figure 2.2 Age-specific attendance rates 2.5 HOUSEHOLD CONDITIONS The Household Questionnaire 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 73 percent of households have access to an improved source of drinking water. Protected springs are the most common improved source of drinking water used by households (32 percent), followed by public taps/standpipes (27 percent). Only 10 percent of households have running water in their dwelling, yard, or plot. Overall, 27 percent of households use unimproved sources of water, which are considered unhealthy. For example, 14 percent of households use an unprotected spring as a water source, which increases household members’ risk of contracting diarrhea and other waterborne diseases. With respect to residence, it appears that urban households are more likely than rural households to use improved drinking water (91 percent versus 69 percent). In contrast, 31 percent of households in rural areas use unsafe drinking water, as compared with 9 percent of those in urban areas. In fact, 16 percent of rural households collect their water from an unprotected spring, 13 percent collect it from surface water, and 2 percent retrieve it from an unprotected well. Regarding the time spent in round-trip travel to obtain drinking water, Table 2.5 shows that slightly less than half of households (49 percent) spend 30 minutes or longer to get to the water source and return, and 41 percent spend fewer than 30 minutes. Only 11 percent of households have water on their premises. Fifty- 0 10 20 30 40 50 60 70 80 90 100 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percent Age Male Female RDHS 2014-15Note: Figure shows percentage of the de jure household population age 5-24 years attending school Household Characteristics • 21 five percent of households in rural areas take 30 minutes or longer to obtain drinking water, as compared with 19 percent of households in urban areas. The proportions of households that spend less than 30 minutes to obtain drinking water vary slightly between rural areas (41 percent) and urban areas (38 percent). With respect to treatment of water prior to drinking, 44 percent of households use an appropriate treatment method prior to drinking, while the other 56 percent do not treat their water prior to drinking. Table 2.5 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Rwanda 2014-15 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 90.9 69.2 72.9 90.4 68.7 72.3 Piped into dwelling/yard/plot 42.1 2.7 9.5 43.6 2.8 9.6 Public tap/standpipe 39.3 24.8 27.3 37.7 24.2 26.5 Tube well or borehole 0.8 1.6 1.4 0.9 1.7 1.6 Protected well 0.5 2.3 2.0 0.5 2.2 1.9 Protected spring 7.8 37.0 32.0 7.4 37.0 32.0 Rain water 0.3 0.8 0.7 0.4 0.9 0.8 Non-improved source 8.9 30.8 27.0 9.5 31.2 27.6 Unprotected well 0.5 1.9 1.7 0.6 2.0 1.7 Unprotected spring 3.6 15.8 13.7 3.9 15.9 13.9 Tanker truck/cart with tank 0.0 0.1 0.1 0.0 0.1 0.1 Surface water 4.8 13.0 11.6 5.0 13.3 11.9 Other 0.1 0.0 0.0 0.1 0.0 0.0 Missing 0.0 0.0 0.0 0.0 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 43.2 3.7 10.5 44.5 3.9 10.7 Less than 30 minutes 37.7 41.3 40.7 36.0 40.7 39.9 30 minutes or longer 19.0 54.8 48.7 19.5 55.3 49.3 Don’t know/missing 0.0 0.2 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 62.4 33.2 38.3 64.9 33.5 38.7 Bleach/chlorine added 4.6 4.8 4.8 5.0 5.2 5.2 Strained through cloth 0.1 0.1 0.1 0.1 0.2 0.2 Ceramic, sand, or other filter 2.2 3.8 3.5 2.4 4.1 3.8 Solar disinfection 0.2 0.0 0.0 0.2 0.0 0.0 Let it stand 0.3 0.5 0.4 0.2 0.4 0.4 Other 0.4 0.1 0.1 0.4 0.1 0.1 No treatment 32.8 60.2 55.5 30.2 59.4 54.5 Percentage using an appropriate treatment method2 66.6 39.4 44.1 69.3 40.2 45.0 Number 2,188 10,511 12,699 9,033 45,052 54,085 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, filtering, and solar disinfecting. The most common method to treat water prior to drinking is boiling (38 percent), followed by adding bleach/chlorine (5 percent) and using ceramic/sand or another filter (4 percent). Households in rural areas are more likely to drink untreated water (60 percent) than those in urban areas (33 percent). 2.5.2 Household Sanitation Facilities With respect to type of toilet facilities, Table 2.6 shows that 54 percent of households have access to an improved, unshared toilet facility (57 percent in rural areas and 42 percent in urban areas). Only 1 percent of households have toilets that flush to a piped sewer system, while 4 percent use a ventilated improved pit (VIP) latrine. However, almost half of households (48 percent) use unshared pit latrines with a slab. These 22 • Household Characteristics toilets are considerably more common in rural households than urban households (52 percent and 30 percent, respectively). Seventeen percent of Rwandan households use a toilet facility that would be considered improved except that it is shared with other households; most of these facilities are pit latrines with slabs (15 percent). Twenty-nine percent of households use an unimproved facility, with the majority (24 percent) using a pit latrine without a slab or an open pit. Twenty-seven percent of rural households and 11 percent of urban households use this type of facility. It should be noted that 4 percent of households in Rwanda have no sanitation facility at all (1 percent in urban areas and 4 percent in rural areas). It is interesting to note that rural households are more likely to have improved and not shared facilities. Although urban households have more improved facilities, they are mostly shared with other households. Table 2.6 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Rwanda 2014-15 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 5.7 0.2 1.1 6.6 0.2 1.3 Flush/pour flush to septic tank 1.3 0.0 0.2 1.5 0.0 0.3 Flush/pour flush to pit latrine 1.2 0.1 0.3 1.4 0.1 0.3 Ventilated improved pit (VIP) latrine 4.1 3.8 3.8 5.3 4.1 4.3 Pit latrine with slab 29.7 51.9 48.0 34.6 55.0 51.6 Composting toilet 0.2 0.6 0.6 0.1 0.6 0.5 Total 42.1 56.6 54.1 49.5 60.0 58.3 Shared facility1 Flush/pour flush to piped sewer system 0.7 0.0 0.1 0.6 0.0 0.1 Flush/pour flush to septic tank 0.0 0.0 0.0 0.0 0.0 0.0 Flush/pour flush to pit latrine 0.4 0.0 0.1 0.4 0.0 0.1 Ventilated improved pit (VIP) latrine 4.4 0.7 1.4 3.8 0.6 1.1 Pit latrine with slab 38.5 10.6 15.4 31.9 8.5 12.4 Composting toilet 0.2 0.1 0.1 0.1 0.1 0.1 Total 44.2 11.5 17.1 36.9 9.2 13.8 Non-improved facility Flush/pour flush not to sewer/septic tank/pit latrine 0.8 0.2 0.3 0.8 0.2 0.3 Pit latrine without slab/open pit 11.2 27.1 24.3 11.4 27.0 24.4 Bucket 0.0 0.0 0.0 0.0 0.0 0.0 No facility/bush/field 1.4 4.4 3.9 1.1 3.4 3.0 Other 0.2 0.1 0.1 0.3 0.1 0.1 Missing 0.0 0.1 0.1 0.0 0.1 0.1 Total 13.7 32.0 28.8 13.6 30.8 27.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,188 10,511 12,699 9,033 45,052 54,085 1 Facilities that would be considered improved if they were not shared by two or more households 2.5.3 Household Hand Washing Places Washing hands with water and soap before eating, while preparing food, and after leaving the toilet is a simple, inexpensive, and good practice that protects against many diseases. During the survey, the interviewers asked each household if there was a place used for hand washing, and, if so, they asked if they could observe the place to see if water and soap or some other cleansing agent was available. Table 2.7 shows that only 12 percent of households had a place for hand washing that was observed by an interviewer. Among households where there was a place for hand washing, over one third (37 percent) had water and soap. Nearly one in seven households had water only, and the same proportion had soap but no water. In urban areas, 20 percent of households had a place for hand washing, as compared with 10 percent of Household Characteristics • 23 households in rural areas. Among households where place for hand washing was observed sixty-seven percent had soap and water available in urban area compared with only 25 percent in rural area. A higher percentage of rural than urban households had no water, no soap, and no other cleansing agent available (39 percent versus 12 percent among household where a place for hand washing was observed). Among the provinces, households in North and East are least likely to have a place for hand washing (7 percent and 8 percent, respectively). In contrast, 13 percent of households in West, 14 percent in South, and 17 percent in City of Kigali have a place for hand washing. Among households where a place for hand washing was observed, households the highest percentage of household with soap and water is in City of Kigali 83 percent) while the lowest is in West (11 percent). The proportion of households with a place for hand washing increases with increasing wealth, from 9 percent among households in the lowest three quintiles to 20 percent of those in the highest quintile. Half of households in the lowest wealth quintile (50 percent) had no water, soap, or other cleansing agent available, as compared with only 9 percent of 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, according to residence, province, and wealth quintile, Rwanda 2014-15 Percentage of house- holds where place for washing hands was observed Number of house- holds Among households where place for hand washing was observed, percentage with: Number of house- holds with place for hand washing observed Background characteristic Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Missing Total Residence Urban 19.5 2,188 66.9 0.3 10.3 8.9 0.0 11.9 1.8 100.0 426 Rural 9.8 10,511 25.1 0.2 17.1 17.4 0.2 38.5 1.4 100.0 1,028 Province City of Kigali 16.8 1,496 83.3 0.0 6.9 1.2 0.0 5.8 2.8 100.0 251 South 13.8 3,103 25.2 0.5 21.8 4.3 0.3 46.3 1.6 100.0 427 West 13.1 2,789 11.1 0.3 5.5 49.9 0.0 32.9 0.3 100.0 367 North 7.0 2,090 24.8 0.0 27.0 7.3 0.9 37.9 2.1 100.0 147 East 8.1 3,221 57.1 0.0 18.7 0.9 0.0 22.0 1.4 100.0 262 Wealth quintile Lowest 9.0 2,920 9.3 0.0 18.1 21.3 0.0 50.3 1.0 100.0 262 Second 8.8 2,636 15.0 0.0 11.3 24.7 1.0 47.6 0.5 100.0 233 Middle 9.4 2,441 24.9 0.4 16.4 20.5 0.0 36.8 0.9 100.0 230 Fourth 10.4 2,290 34.2 0.4 19.9 13.0 0.0 31.7 0.8 100.0 238 Highest 20.4 2,412 70.4 0.2 12.4 5.3 0.0 8.9 2.8 100.0 492 Total 11.5 12,699 37.4 0.2 15.1 14.9 0.2 30.7 1.5 100.0 1,455 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 housing materials, number of rooms used for sleeping, the place used for cooking, types of cooking fuel, and presence of tobacco smoking inside the house. These characteristics and others were used to evaluate the socioeconomic and living conditions of the household. Table 2.8 shows that only 23 percent of households in Rwanda have access to electricity. The situation has improved since 2010, when only 10 percent of households had electricity. The results show large 24 • Household Characteristics disparities between urban and rural areas. Only 12 percent of rural households have electricity, as compared with 73 percent of urban households. Table 2.8 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Rwanda 2014-15 Residence Total Housing characteristic Urban Rural Electricity Yes 72.9 12.4 22.8 No 27.1 87.5 77.1 Total 100.0 100.0 100.0 Roofing material Metal/iron sheets 89.7 57.6 63.1 Ceramic tiles 8.4 41.6 35.9 Other 1.9 0.8 1.0 Total 100.0 100.0 100.0 Flooring material Earth, sand 29.1 84.2 74.7 Dung 0.1 0.9 0.7 Ceramic tiles 4.7 0.6 1.3 Cement 65.7 14.1 23.0 Carpet 0.2 0.0 0.1 Other 0.2 0.1 0.1 Total 100.0 100.0 100.0 Rooms used for sleeping One 32.1 26.4 27.4 Two 32.7 45.4 43.2 Three or more 34.8 28.0 29.2 Missing 0.3 0.1 0.2 Total 100.0 100.0 100.0 Place for cooking In the house 14.4 26.4 24.3 In a separate building 44.8 55.1 53.3 Outdoors 37.7 17.5 20.9 No food cooked in household 2.9 1.0 1.4 Missing 0.1 0.0 0.0 Total 100.0 100.0 100.0 Cooking fuel Electricity 0.3 0.0 0.1 LPG/natural gas/biogas 1.5 0.1 0.3 Kerosene 0.6 0.0 0.1 Charcoal 65.5 4.8 15.3 Wood 26.1 76.7 68.0 Straw/shrubs/grass 2.9 16.7 14.4 Agricultural crop 0.0 0.6 0.5 No food cooked in household 2.9 1.0 1.4 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 94.6 98.9 98.1 Frequency of smoking in the home Daily 9.5 15.6 14.6 Weekly 2.4 4.0 3.7 Monthly 0.9 1.0 1.0 Less than monthly 0.4 0.4 0.4 Never 86.9 78.9 80.3 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Number 2,188 10,511 12,699 LPG = Liquid petroleum gas 1 Includes charcoal, wood/straw/shrubs/grass, and agricultural crops Household Characteristics • 25 The type of material used for flooring is extremely important. Some materials propagate diseases causing germs and parasites. The large majority (75 percent) of floors in Rwandan houses are earth or sand. This proportion is higher in rural areas (84 percent) than in urban areas (29 percent). Twenty-three percent of households have cement floors. This type of flooring is more commonly observed in urban than in rural areas (66 percent versus 14 percent). The results indicate an improvement in flooring materials since 2010, when 81 percent of floors were earth/sand and 16 percent were cement. Table 2.8 shows that 43 percent of households have two rooms for sleeping (33 percent of urban households and 45 percent of rural households). It should be noted that, in 27 percent of households, all household members sleep in a single room. This proportion is higher in urban areas (32 percent) than in rural areas (26 percent). More than half (53 percent) of households cook their meals in a separate building, while 21 percent cook outdoors. Twenty-four percent of households cook in the same structure that is used for sleeping (14 percent of urban and 26 percent of rural households). Table 2.8 shows that 68 percent of households use wood as cooking fuel. More rural households than urban households use wood as cooking fuel (77 percent versus 26 percent). The second and third most common cooking fuels are charcoal (used by 15 percent of households) and straw/shrubs/grass (used by 14 percent of households). Sixty-six percent of households in urban areas use charcoal for cooking, as compared with only 5 percent of those in rural areas. Electricity is rarely used for cooking in Rwanda. Most households use a solid fuel for cooking (98 percent), with no significant difference between rural and urban areas. Fifteen percent of households report that someone smokes inside the house on a daily basis (16 percent in rural areas and 10 percent in urban areas).Four in five households (80 percent) report that no one smokes in the house. 2.5.5 Household Possession of Durable Goods To evaluate households’ socioeconomic level, the survey gathered information on 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, mobile telephones (60 percent) are the most frequently owned household good. More urban (86 percent) than rural (54 percent) households reported owning a mobile telephone. The proportion of households owning a mobile telephone has increased significantly since 2010, when only 40 percent of households owned a mobile telephone. The second most common household asset is a radio, owned by 55 percent of households. The proportion of households owning a radio is much higher in urban areas (67 percent) than in rural areas (52 percent). Ten percent of households own a television, twice as high as the proportion in 2010 (5 percent). There is a significant difference in television ownership between urban (39 percent) and rural (4 percent) households. Only 2 percent of households own a refrigerator (8 percent in urban areas and less than 1 percent in rural areas). Three percent of households own a computer, again with disparities between urban (14 percent) and rural (1 percent) areas. Bicycles are used as a means of transportation in 15 percent of households (16 percent of households in rural areas and 10 percent of households in urban areas). Only 1 percent of Rwandan households own a car or truck, while 2 percent own a motorcycle or scooter. Overall, 72 percent of households own agricultural land. The proportion varies significantly by urban- rural residence: 80 percent of rural households own agricultural land, as compared with 36 percent of urban 26 • Household Characteristics households. Fifty-three percent of households possess farm animals (58 percent of households in rural areas and 26 percent of households in urban areas). Table 2.9 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, Rwanda 2014-15 Residence Total Possession Urban Rural Household effects Radio 67.1 51.9 54.5 Television 38.6 3.6 9.6 Mobile telephone 86.4 54.2 59.8 Non-mobile telephone 1.0 0.1 0.2 Refrigerator 8.4 0.2 1.6 Computer 13.9 1.0 3.2 Means of transport Bicycle 10.0 15.9 14.9 Animal-drawn cart 0.2 0.0 0.0 Motorcycle/scooter 4.4 1.3 1.8 Car/truck 5.9 0.2 1.2 Boat without a motor 0.0 0.2 0.2 Boat with a motor 0.0 0.0 0.0 Ownership of agricultural land 36.3 79.9 72.4 Ownership of farm animals1 26.4 58.1 52.6 Number 2,188 10,511 12,699 1 Cows, milk cows, bulls, goats, sheep, chickens, pigs, rabbits, or horses/donkeys/mules 2.5.6 Household Wealth 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 data and was generated via a principal components analysis. Information on household goods was derived from responses to questions about ownership of certain durable goods (e.g., television, radio, car, mobile telephone) 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). In its current form, which takes better account of urban-rural differences in scores and indicators of wealth, the wealth index is created in three steps. In the first step, a subset of indicators common to both urban and rural areas is used to create wealth scores for households in both areas. Categorical variables to be used are transformed into separate dichotomous (0-1) indicators. These indicators and those that are continuous are then analyzed using a principal components analysis to produce a common factor score for each household. In a second step, separate factor scores are produced for households in urban and rural areas using area-specific indicators. The third step combines the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting area-specific scores through a regression on the common factor scores. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index is computed, national-level wealth quintiles (from lowest to highest) are obtained by assigning household scores to each de jure household member, ranking each person in the population by his or her score, and then dividing the ranking into five equal categories, each comprising 20 percent of the population. The results show that, in urban areas, 75 percent of the de jure population falls into the richest quintile, as compared with only 9 percent in rural areas. City of Kigali has the largest percentage of households in the highest wealth quintile (73 percent). Twenty-three percent of households in rural areas fall into the poorest quintile. Household Characteristics • 27 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 2014-15 Wealth quintile Total Number of persons Gini coefficient Residence/region Lowest Second Middle Fourth Highest Residence Urban 5.8 4.7 4.8 9.6 75.2 100.0 9,033 0.20 Rural 22.9 23.1 23.0 22.1 8.9 100.0 45,052 0.25 Province City of Kigali 5.3 4.9 6.0 10.9 72.9 100.0 6,023 0.25 South 25.7 20.9 19.3 20.6 13.6 100.0 13,132 0.22 West 25.6 24.0 20.6 17.1 12.7 100.0 12,398 0.21 North 19.3 22.4 23.0 22.3 13.0 100.0 8,858 0.16 East 16.4 20.7 24.3 24.6 14.1 100.0 13,674 0.26 Total 20.0 20.0 20.0 20.0 20.0 100.0 54,085 0.24 2.6 BIRTH REGISTRATION Registering a child’s birth 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, for all children age 0 to 4 in each household, whether the child had a birth certificate or whether the child’s birth had been registered with the civil authorities. Table 2.11 shows that 56 percent of children have been registered with the civil authorities. The percentage has dropped significantly since 2010, when 63 percent of births were registered. Only 3 percent of children under age 5 possess birth certificates. Children age 2-4 are more likely to be registered than those younger than age 2 (60 percent and 50 percent, respectively). There is no difference regarding to gender whether or not children are registered with the civil authorities. Children in the poorest households are less likely to be registered (43 percent) than children in households in the other wealth quintiles (53 to 66 percent). There is no discrepancy by urban/rural residence. Results by province show that children in North and City of Kigali are most likely to be registered with the civil authorities (67 percent and 59 percent, respectively). 28 • 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 2014-15 Children whose births are registered Number of children Background characteristic Percentage who had a birth certificate Percentage who did not have a birth certificate Percentage registered Age <2 2.9 47.2 50.1 3,244 2-4 2.5 57.6 60.0 4,671 Sex Male 2.7 53.3 56.0 3,972 Female 2.6 53.4 55.9 3,942 Residence Urban 4.7 50.7 55.4 1,271 Rural 2.3 53.8 56.1 6,643 Province City of Kigali 2.6 56.8 59.4 900 South 2.4 47.6 50.0 1,808 West 3.3 51.7 55.0 1,902 North 4.3 62.7 66.9 1,149 East 1.5 53.1 54.6 2,156 Wealth quintile Lowest 1.0 42.2 43.3 1,916 Second 1.8 50.7 52.5 1,728 Middle 2.5 56.9 59.4 1,579 Fourth 2.5 63.9 66.4 1,383 Highest 6.6 57.6 64.2 1,310 Total 2.7 53.3 56.0 7,915 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 capacity to care for children. It is therefore essential to identify orphaned children and to determine 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 63 percent of Rwandan children under age 18 live with both of their parents. This proportion declines steadily with age, from 74 percent among children under age 2 and 68 percent among those age 2 to 4 to 49 percent among those age 15 to 17. The results show practically no difference according to child’s sex. The proportion of children living with both of their parents is higher in rural areas (64 percent) than in urban areas (59 percent). The lowest proportion of children living with both parents is in the South province (59 percent), while the highest proportion is in the North and West provinces (66 percent each). Twenty-two percent of children under age 18 live with their mother only, whether their father is alive (17 percent) or deceased (5 percent); and 2 percent live with their father only. Twelve percent do not live with either parent. Overall, 9 percent of children under age 18 have lost one or both parents: 8 percent have lost their fathers, 3 percent have lost their mothers, and 1 percent have lost both parents. 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 age, from 1 percent among those less than age 2 and 3 percent among those age 2 to 4 to 7 percent among those age 5 to 9. The proportion increases further among children age 10 to 14 (13 percent) and age 15 to 17 (23 percent). Household Characteristics • 29 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 2014-15 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 Background characteristic 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 70.5 21.8 1.4 0.6 0.2 4.2 0.3 0.2 0.1 0.7 100.0 4.8 2.1 7,915 <2 73.7 23.6 0.8 0.1 0.0 0.9 0.2 0.0 0.0 0.5 100.0 1.2 1.1 3,244 2-4 68.3 20.6 1.8 1.0 0.3 6.5 0.3 0.3 0.2 0.8 100.0 7.2 2.8 4,671 5-9 66.6 15.8 3.9 1.7 0.7 8.3 0.8 0.9 0.5 0.7 100.0 10.5 6.8 8,189 10-14 57.9 14.5 7.6 2.4 1.0 11.4 1.1 2.2 1.2 0.7 100.0 15.9 13.2 7,224 15-17 48.8 11.5 12.0 1.4 1.2 13.6 2.0 4.6 3.4 1.4 100.0 23.6 23.4 3,361 Sex Male 63.6 17.0 5.0 1.8 0.7 7.9 0.9 1.4 1.0 0.8 100.0 11.1 9.1 13,363 Female 62.8 16.4 5.3 1.3 0.7 9.3 0.9 1.5 1.0 0.9 100.0 12.7 9.4 13,324 Residence Urban 59.1 19.1 4.3 2.6 0.8 8.8 0.9 2.2 1.2 0.9 100.0 13.1 9.5 3,996 Rural 63.9 16.3 5.3 1.3 0.7 8.5 0.9 1.4 0.9 0.8 100.0 11.7 9.2 22,692 Province City of Kigali 63.7 17.3 3.9 2.5 0.7 7.8 0.6 2.0 0.9 0.6 100.0 11.3 8.1 2,566 South 59.4 18.9 5.5 1.6 0.7 9.3 1.1 1.5 1.2 0.9 100.0 13.1 10.1 6,442 West 66.4 15.1 5.3 1.0 0.9 7.3 0.8 1.4 1.0 0.9 100.0 10.6 9.5 6,280 North 66.0 14.1 5.4 0.9 0.7 9.4 0.7 1.2 1.0 0.7 100.0 12.2 8.9 4,439 East 61.7 17.6 5.2 2.1 0.5 8.8 0.9 1.5 0.7 0.9 100.0 12.0 9.0 6,961 Wealth quintile Lowest 51.4 26.3 8.4 1.6 0.7 7.8 0.8 1.1 1.0 1.0 100.0 10.6 12.1 5,653 Second 63.4 16.6 5.7 1.3 0.5 8.3 1.0 1.2 1.1 0.9 100.0 11.6 9.5 5,486 Middle 69.3 13.2 5.1 1.2 0.7 7.2 0.6 1.2 0.8 0.8 100.0 9.8 8.4 5,379 Fourth 70.1 11.9 3.2 1.4 0.7 9.0 0.9 1.4 0.7 0.6 100.0 12.0 7.0 5,384 Highest 62.2 14.8 3.0 2.3 0.9 10.9 1.1 2.8 1.3 0.8 100.0 16.1 9.2 4,786 Total <15 65.3 17.5 4.2 1.5 0.6 7.9 0.7 1.0 0.6 0.7 100.0 10.2 7.2 23,327 Total <18 63.2 16.7 5.2 1.5 0.7 8.6 0.9 1.5 1.0 0.8 100.0 11.9 9.3 26,688 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 among children age 10 to 14. Although 95 percent of children whose parents are both alive and who are living with one of their parents attend school, only 83 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 (0.88), indicating an educational disadvantage for orphans. 30 • 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, by parental survival, according to background characteristics, Rwanda 2014-15 Percentage attending school by survivorship of parents Background characteristic Both parents deceased Number Both parents alive and living with at least one parent Number Ratio1 Sex Male 77.1 47 93.8 2,763 0.82 Female (90.5) 42 95.8 2,637 (0.95) Residence Urban * 12 97.8 750 * Rural 81.0 78 94.3 4,649 0.86 Province City of Kigali * 5 97.0 436 * South (79.0) 30 94.5 1,280 (0.84) West * 22 95.8 1,314 * North * 19 95.5 1,010 * East * 13 92.8 1,360 * Wealth quintile Lowest (87.0) 24 89.0 970 (0.98) Second (87.3) 26 92.7 1,000 (0.94) Middle * 12 95.3 1,190 * Fourth * 13 97.0 1,254 * Highest * 15 99.2 985 * Total 83.4 89 94.8 5,400 0.88 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 HEALTH INSURANCE COVERAGE AND BANK ACCOUNTS Information on bank accounts and health insurance coverage was collected during the survey. The proportion of households in which at least one person has a bank account and health insurance coverage is shown in Table 2.14 by type of health insurance, urban-rural residence, province, and household wealth quintile. Forty-six percent of Rwandan households have at least one member with a bank account. This proportion is higher among households in urban areas (67 percent), City of Kigali (64 percent), and the highest wealth quintile (81 percent) than other households. Overall, 79 percent of Rwandan households have at least one member covered by health insurance. This proportion is similar to that found in the 2010 RDHS (78 percent). There is slight variation by residence (81 percent in urban areas and 78 percent in rural areas). There are considerable differences by province, with proportions varying from a low of 76 percent in South to a high of 84 percent in North. Households in the higher wealth quintiles are generally more likely to have at least one member insured than those in the lower wealth quintiles. With respect to type of health insurance coverage, nearly all households with at least one member insured are insured by Mutual Health Insurance (97 percent). Other types of coverage reported by households include La Rwandaise d’Assurance Maladie (RAMA; now the Rwanda Social Security Board, or RSSB) (6 percent), Military Medical Insurance (MMI) (1 percent), and private insurance (1 percent). These other types Household Characteristics • 31 of insurance are more commonly reported by households in urban areas, the City of Kigali, and the highest wealth quintile. Table 2.14 Household bank account and health insurance Percentage of households in which at least one member has a bank account and is covered by health insurance, and percentage of households with specific types of health insurance, according to residence, province, and wealth quintile, Rwanda 2014-15 Percentage of households with at least one member who has a bank account Percentage of households with at least one member covered by health insurance Number of households Type of insurance Residence/region Mutual/ community RAMA (RSSB) MMI Private/ commercial Other Number of households with at least one member covered by health insurance Residence Urban 66.5 81.4 2,188 93.1 14.1 2.5 4.2 1.5 1,780 Rural 41.8 78.2 10,511 97.9 3.7 0.5 0.2 0.1 8,218 Province City of Kigali 64.2 77.4 1,496 93.5 11.2 2.7 5.0 1.5 1,158 South 45.6 76.2 3,103 98.0 5.0 0.5 0.6 0.2 2,365 West 41.2 78.1 2,789 96.9 5.4 0.7 0.3 0.1 2,179 North 41.7 84.4 2,090 97.5 5.0 0.6 0.4 0.3 1,764 East 45.2 78.6 3,221 97.7 3.9 0.8 0.2 0.1 2,532 Wealth quintile Lowest 11.7 63.5 2,920 99.3 0.1 0.0 0.0 0.1 1,855 Second 32.4 75.0 2,636 99.5 0.5 0.1 0.0 0.0 1,978 Middle 48.0 82.4 2,441 98.6 1.8 0.4 0.1 0.1 2,010 Fourth 66.7 87.8 2,290 96.7 5.2 1.2 0.4 0.1 2,010 Highest 81.2 88.9 2,412 91.8 18.7 2.7 3.8 1.3 2,145 Total 46.1 78.7 12,699 97.1 5.5 0.9 0.9 0.3 9,998 Information about individual health insurance coverage is presented in Table 2.15 by type of insurance, according to selected background characteristics. Overall, 74 percent of women and 73 percent of men age 15-49 are insured. Women age 15-19 (72 percent) and 45-49 (71 percent) and men age 15-19 (70 percent) are slightly less likely to be insured than other women and men. According to marital status, currently married women (79 percent) and men (80 percent) are more likely to be insured than women and men in other categories, particularly those who are divorced or separated. Women and men in North have higher levels of coverage than those in the other provinces. There is no variation by urban-rural residence among men. However, urban women are more likely to have coverage than rural women (78 percent versus 73 percent). Among women, the proportion with insurance increases with increasing education; from 66 percent among those who have no education to 85 percent among those who have a secondary education or higher. The corresponding figures among men are 62 percent and 85 percent. Women and men in the higher wealth quintiles are more likely to have health insurance than those in the lower wealth quintiles. For example 85 percent of women in the highest quintile are covered by health insurance as compared to 57 percent of those in the lowest quintile. In terms of type of health insurance coverage, 94 percent of both women and men are insured by Mutual Health Insurance. Other types of coverage reported are RAMA, MMI, and private insurance. These other types of insurance are more commonly reported by women and men who are married, live in urban areas, reside in the City of Kigali, have a secondary education or higher, and are in the highest wealth quintile. 32 • Household Characteristics Table 2.15 Health insurance among adult women and men Percentage of women age 15-49 and men age 15-59 covered by health insurance, and percent distribution of respondents with specific types of health insurance, according to selected background characteristics, Rwanda 2014-15 Percentage of respondents covered by health insurance Number of respondents Type of insurance Background characteristic Mutual/ community RAMA (RSSB) MMI Private/co mmercial Other Don’t know/missing Total Number of respondents covered by health insurance WOMEN Age 15-19 71.5 2,768 96.2 3.0 0.1 0.3 0.2 0.2 100.0 1,980 20-24 75.5 2,457 97.3 1.8 0.2 0.3 0.1 0.3 100.0 1,856 25-29 76.0 2,300 92.9 5.0 1.2 0.6 0.3 0.1 100.0 1,749 30-34 74.0 2,151 90.9 6.0 1.6 0.9 0.4 0.2 100.0 1,592 35-39 74.0 1,575 91.2 6.0 1.2 1.3 0.2 0.1 100.0 1,165 40-44 75.3 1,269 93.5 5.2 0.4 0.6 0.3 0.0 100.0 956 45-49 71.0 977 95.4 3.0 0.7 0.6 0.4 0.0 100.0 694 Marital status Never married 74.0 5,100 95.9 3.1 0.1 0.5 0.3 0.2 100.0 3,775 Married 79.2 4,655 89.3 7.5 1.7 1.1 0.3 0.0 100.0 3,688 Living together 67.5 2,327 98.5 0.6 0.3 0.1 0.2 0.3 100.0 1,571 Divorced/separated 64.2 842 98.7 0.6 0.2 0.2 0.0 0.3 100.0 541 Widowed 73.0 572 97.4 2.2 0.4 0.0 0.0 0.0 100.0 418 Residence Urban 77.6 2,626 85.2 9.8 1.7 2.3 0.9 0.1 100.0 2,037 Rural 73.2 10,871 96.3 2.7 0.5 0.2 0.1 0.2 100.0 7,955 Province City of Kigali 73.9 1,799 87.5 7.3 1.7 2.6 0.8 0.1 100.0 1,329 South 70.9 3,214 94.4 3.9 0.6 0.6 0.3 0.3 100.0 2,280 West 71.5 2,965 94.4 4.5 0.7 0.3 0.1 0.1 100.0 2,120 North 80.7 2,211 95.5 3.4 0.5 0.2 0.3 0.1 100.0 1,783 East 75.0 3,308 96.1 2.9 0.7 0.2 0.0 0.2 100.0 2,480 Education No education 66.2 1,665 99.4 0.1 0.1 0.1 0.2 0.0 100.0 1,102 Primary 71.6 8,678 98.4 0.6 0.6 0.2 0.1 0.2 100.0 6,215 Secondary and higher 84.8 3,154 81.8 14.0 1.4 1.9 0.7 0.2 100.0 2,676 Wealth quintile Lowest 57.2 2,561 99.5 0.0 0.0 0.0 0.2 0.2 100.0 1,465 Second 67.7 2,631 99.5 0.2 0.1 0.0 0.0 0.2 100.0 1,782 Middle 75.8 2,597 98.3 1.3 0.2 0.0 0.0 0.2 100.0 1,968 Fourth 82.4 2,634 95.7 2.8 1.1 0.3 0.0 0.1 100.0 2,172 Highest 84.8 3,073 82.8 12.5 1.8 2.1 0.8 0.1 100.0 2,605 Total 15-49 74.0 13,497 94.1 4.2 0.7 0.6 0.2 0.2 100.0 9,992 Continued… Household Characteristics • 33 Table 2.15—Continued Percentage of respondents covered by health insurance Number of respondents Type of insurance Background characteristic Mutual/ community RAMA (RSSB) MMI Private/co mmercial Other Don’t know/missing Total Number of respondents covered by health insurance MEN Age 15-19 70.3 1,282 96.8 2.6 0.3 0.1 0.2 0.0 100.0 901 20-24 71.5 994 97.0 0.9 0.3 0.5 1.1 0.3 100.0 711 25-29 75.7 946 92.1 6.8 0.0 0.7 0.2 0.2 100.0 716 30-34 75.0 930 92.2 6.4 0.5 0.9 0.0 0.1 100.0 697 35-39 73.6 567 90.4 6.2 1.1 1.9 0.5 0.0 100.0 418 40-44 72.1 473 89.7 7.1 1.0 1.6 0.7 0.0 100.0 341 45-49 72.5 385 92.8 5.3 0.3 1.1 0.4 0.0 100.0 279 Marital status Never married 72.1 2,691 94.2 4.2 0.2 0.7 0.5 0.2 100.0 1,941 Married 80.1 1,833 91.0 6.8 0.7 1.2 0.3 0.1 100.0 1,469 Living together 63.4 959 98.4 0.8 0.5 0.2 0.2 0.0 100.0 608 Divorced/separated 42.1 79 93.1 3.8 0.0 3.1 0.0 0.0 100.0 33 Widowed 70.4 16 100.0 0.0 0.0 0.0 0.0 0.0 100.0 11 Residence Urban 73.1 1,169 84.6 9.0 1.4 3.1 1.7 0.1 100.0 855 Rural 72.8 4,408 96.1 3.4 0.1 0.2 0.0 0.1 100.0 3,208 Province City of Kigali 68.8 804 84.9 7.1 1.6 4.1 2.1 0.2 100.0 554 South 70.7 1,327 94.2 4.9 0.0 0.4 0.2 0.3 100.0 939 West 73.2 1,182 95.3 4.0 0.5 0.2 0.0 0.0 100.0 865 North 79.4 851 95.7 3.5 0.1 0.4 0.4 0.0 100.0 676 East 72.8 1,413 95.2 4.3 0.3 0.2 0.0 0.0 100.0 1,029 Education No education 61.9 496 99.6 0.0 0.0 0.0 0.4 0.0 100.0 307 Primary 69.7 3,636 99.2 0.3 0.1 0.2 0.2 0.1 100.0 2,534 Secondary and higher 84.5 1,445 80.8 14.6 1.2 2.3 0.9 0.2 100.0 1,222 Wealth quintile Lowest 53.5 819 99.5 0.0 0.0 0.0 0.3 0.2 100.0 438 Second 67.6 991 99.7 0.2 0.1 0.0 0.0 0.0 100.0 670 Middle 75.3 1,097 98.7 1.1 0.0 0.1 0.0 0.1 100.0 826 Fourth 78.5 1,234 95.9 3.4 0.1 0.4 0.0 0.1 100.0 969 Highest 80.8 1,436 82.6 12.5 1.2 2.4 1.3 0.1 100.0 1,159 Total 15-49 72.8 5,577 93.7 4.6 0.4 0.8 0.4 0.1 100.0 4,062 50-59 73.2 640 96.3 2.7 0.1 0.7 0.2 0.0 100.0 468 Total 15-59 72.9 6,217 94.0 4.4 0.4 0.8 0.4 0.1 100.0 4,531 Respondent Characteristics • 35 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. As with the Household Questionnaire, the individual questionnaire gathered information concerning the respondent’s age, place of residence, marital status, and educational attainment. In addition, the individual questionnaire collected data on literacy, exposure to mass media, employment and occupation, and on tobacco use. 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 ensuring that 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 (e.g., age at time of marriage, age of first child) or well-known national or regional events. Table 3.1 shows the distribution of women and men age 15-49 grouped by five-year age increments. The proportions in each age group decline with increasing age. Among women, the percentages range from a high of 21 percent for the 15-19 age group to a low of 7 percent for the 45-49 age group. The corresponding percentages among men are 23 percent and 7 percent. All women and men in the sample were asked their marital status. In the 2014-15 RDHS, all women and men were considered married if they were in a 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 (38 percent) had never been married at the time of the survey, while slightly more than half of women were married (35 percent were legally married and 17 percent were living together with a man). In addition, 6 percent of women were divorced or separated, and 4 percent were widowed. Just under half (48 percent) of men age T Key Findings • Twelve percent of women and 9 percent of men age 15-49 have no education, while 23 percent and 26 percent, respectively, have at least some secondary education. • Eighty percent of women and 84 percent of men are literate. • Sixty-four percent of women and 81 percent of men age 15-49 are exposed to at least one source of mass media once a week. • Eighty-six percent of women and 87 percent of men were employed in the 12 months preceding the survey, with the majority (76 percent of women and 58 percent of men) employed in the agricultural sector. • Three in five working women are self-employed. • Only 2 percent of women and 10 percent of men age 15-49 use tobacco. products 36 • Respondent Characteristics 15-49 were single, while half were married (33 percent were legally married and 17 percent were living with a woman). One percent of men were separated or divorced, and less than 1 percent were widowed. The distribution of respondents by residence shows that the majority of women (81 percent) and men (79 percent) live in rural areas. Similarly, the distribution of respondents by province shows no significant disparities between women and men. The City of Kigali has the lowest proportion of respondents (13 percent of women and 14 percent of men), followed by North (16 percent of women and 15 percent of men). One-quarter of women and men live in East. Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Rwanda 2014-15 Women Men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 20.5 2,768 2,779 23.0 1,282 1,281 20-24 18.2 2,457 2,473 17.8 994 999 25-29 17.0 2,300 2,319 17.0 946 964 30-34 15.9 2,151 2,155 16.7 930 932 35-39 11.7 1,575 1,570 10.2 567 559 40-44 9.4 1,269 1,249 8.5 473 469 45-49 7.2 977 952 6.9 385 381 Religion Catholic 39.8 5,377 5,426 44.6 2,488 2,503 Protestant 45.1 6,084 5,971 38.3 2,135 2,107 Adventist 11.9 1,601 1,626 11.5 641 656 Muslim 2.0 267 303 3.0 168 180 Jehovah’s Witness 0.7 97 99 0.8 46 46 Traditional 0.0 5 3 0.0 0 0 Other 0.0 5 5 0.0 1 1 No religion 0.3 46 49 1.7 94 88 Missing 0.1 16 15 0.1 5 4 Marital status Never married 37.8 5,100 5,205 48.2 2,691 2,736 Married 34.5 4,655 4,611 32.9 1,833 1,817 Living together 17.2 2,327 2,279 17.2 959 937 Divorced/separated 6.2 842 838 1.4 79 80 Widowed 4.2 572 564 0.3 16 15 Residence Urban 19.5 2,626 3,427 21.0 1,169 1,507 Rural 80.5 10,871 10,070 79.0 4,408 4,078 Province City of Kigali 13.3 1,799 1,876 14.4 804 823 South 23.8 3,214 3,435 23.8 1,327 1,441 West 22.0 2,965 3,060 21.2 1,182 1,209 North 16.4 2,211 2,170 15.3 851 830 East 24.5 3,308 2,956 25.3 1,413 1,282 Education No education 12.3 1,665 1,600 8.9 496 487 Primary 64.3 8,678 8,509 65.2 3,636 3,565 Secondary and higher 23.4 3,154 3,388 25.9 1,445 1,533 Wealth quintile Lowest 19.0 2,561 2,523 14.7 819 807 Second 19.5 2,631 2,516 17.8 991 956 Middle 19.2 2,597 2,461 19.7 1,097 1,034 Fourth 19.5 2,634 2,523 22.1 1,234 1,188 Highest 22.8 3,073 3,474 25.7 1,436 1,600 Total 15-49 100.0 13,497 13,497 100.0 5,577 5,585 50-59 na na na na 640 632 Total 15-59 na na na na 6,217 6,217 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Respondent Characteristics • 37 The distribution of respondents by religion indicates that almost half of women are Protestant (45 percent), while 40 percent are Catholic. Among men, 45 percent are Catholic and 38 percent are Protestant. The Adventist faith is the next most common religion among both sexes (12 percent), followed by Muslim (2 percent of women and 3 percent of men). Table 3.1 also shows the distribution of women and men according to household wealth quintile. The development of the wealth index is explained in Chapter 2. Table 3.1 also provides data on educational attainment. Women are more likely than men to have no education (12 percent versus 9 percent) and less likely to have a secondary education or higher (23 percent versus 26 percent). However, the gap between women and men is not wide at the primary level. 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 women who either attended some primary schooling or completed primary school only is almost equal to that of men (64 percent and 65 percent, respectively). At the secondary level or higher, the proportions are 23 percent among women and 26 percent among men. The proportions for both women and men drop significantly from the primary to secondary and the secondary to postsecondary levels. The data by age show that the proportions of women and men with no education have decreased significantly in the younger generation. Among men, the proportion with no education is 21 percent in the 45-49 age group but only 2 percent in the 15-24 age group. The corresponding proportions among women are 36 percent and 3 percent. The gap between women and men with no education has narrowed significantly: among women and men age 45 to 49, the gap is about 15 percentage points, while among those age 15-19 the gap is so small as to be insignificant. 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 2014-15 Highest level of schooling Total Median years completed Number of women Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 2.6 42.0 16.0 32.1 5.9 1.3 100.0 5.3 5,225 15-19 1.1 41.7 17.2 38.6 1.2 0.1 100.0 5.3 2,768 20-24 4.4 42.3 14.7 24.7 11.2 2.7 100.0 5.2 2,457 25-29 10.6 53.1 16.4 6.8 7.8 5.3 100.0 3.9 2,300 30-34 16.5 50.5 20.1 5.1 3.8 4.0 100.0 3.6 2,151 35-39 17.2 37.4 33.1 7.1 3.2 2.2 100.0 4.5 1,575 40-44 24.3 32.0 35.2 3.6 2.2 2.7 100.0 4.1 1,269 45-49 35.8 26.9 30.8 3.9 0.6 1.9 100.0 2.6 977 Residence Urban 5.3 29.7 19.1 23.8 11.6 10.6 100.0 5.9 2,626 Rural 14.0 45.8 22.2 13.9 3.2 0.8 100.0 4.2 10,871 Province City of Kigali 4.3 30.6 21.9 22.1 11.3 9.7 100.0 5.8 1,799 South 11.5 45.0 23.0 14.8 3.8 1.9 100.0 4.5 3,214 West 15.1 44.4 18.9 15.3 4.5 1.8 100.0 4.3 2,965 North 11.4 43.3 23.6 16.3 4.0 1.5 100.0 4.6 2,211 East 15.7 45.1 21.2 13.5 3.3 1.3 100.0 4.1 3,308 Wealth quintile Lowest 23.2 55.6 14.5 5.9 0.8 0.0 100.0 2.7 2,561 Second 15.6 52.2 20.4 11.0 0.7 0.1 100.0 3.8 2,631 Middle 13.2 46.4 24.3 13.5 2.4 0.1 100.0 4.3 2,597 Fourth 7.5 38.0 27.8 21.0 4.8 0.9 100.0 5.2 2,634 Highest 3.9 24.6 21.0 25.7 13.9 10.9 100.0 6.6 3,073 Total 12.3 42.7 21.6 15.8 4.9 2.7 100.0 4.6 13,497 1 Completed 6th grade (for 6-grade system) and 8th grade (for 8-grade system) at the primary level or were in vocational school. 2 Completed 6th grade at the secondary level 38 • Respondent Characteristics In the 15-24 age group, the median number of years of school completed for young women and young men is about the same. In addition, 40 percent of young women age 15-19 have attended or completed secondary school, as compared with 35 percent of young men. Educational attainment varies by residence. The proportion of women and men with no education is higher in rural areas (14 percent for women and 10 percent for men) than in urban areas (5 percent for women and 4 percent for men). Results by province show a wide gap between the city of Kigali and the rest of the country. In Kigali, only 4 percent of women and men age 15-49 have no education, while the proportions in the other provinces vary from 11 percent (North) to 16 percent (East) among women and from 9 percent (North) to 11 percent (West) among men. The data show a positive relationship between educational attainment and household wealth: the proportions of women and men with no education decrease as household wealth increases. 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 2014-15 Highest level of schooling Total Median years completed Number of men Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 2.4 46.2 13.4 29.9 5.8 2.2 100.0 5.1 2,276 15-19 1.5 51.2 12.1 34.2 1.0 0.1 100.0 4.8 1,282 20-24 3.7 39.7 15.1 24.3 12.1 5.1 100.0 5.4 994 25-29 8.1 49.0 15.9 8.5 9.8 8.6 100.0 4.5 946 30-34 14.3 50.2 21.2 4.5 3.7 6.1 100.0 4.0 930 35-39 12.9 35.6 38.4 4.6 3.9 4.6 100.0 5.1 567 40-44 16.1 34.9 33.5 8.0 3.7 3.7 100.0 4.9 473 45-49 21.2 27.0 40.1 4.7 3.2 3.9 100.0 5.1 385 Residence Urban 4.2 30.2 19.2 20.9 12.2 13.3 100.0 5.9 1,169 Rural 10.1 47.6 21.8 14.5 3.8 2.1 100.0 4.4 4,408 Province City of Kigali 4.1 31.9 23.2 16.1 12.2 12.5 100.0 5.7 804 South 9.1 46.7 21.7 14.9 4.1 3.5 100.0 4.5 1,327 West 11.3 44.4 18.8 17.3 5.3 2.9 100.0 4.6 1,182 North 8.6 44.0 25.6 14.5 4.5 2.8 100.0 4.8 851 East 9.6 48.0 19.0 16.3 4.1 3.1 100.0 4.4 1,413 Wealth quintile Lowest 19.7 60.2 12.0 7.5 0.6 0.0 100.0 2.8 819 Second 12.1 54.3 21.8 10.3 1.4 0.1 100.0 3.9 991 Middle 8.7 48.3 24.5 14.4 3.5 0.6 100.0 4.5 1,097 Fourth 5.7 42.4 24.5 18.9 5.2 3.4 100.0 5.1 1,234 Highest 3.4 25.7 20.8 23.1 13.2 13.9 100.0 6.3 1,436 Total 15-49 8.9 44.0 21.2 15.9 5.6 4.5 100.0 4.8 5,577 50-59 28.1 39.4 25.5 3.1 2.1 1.8 100.0 2.7 640 Total 15-59 10.9 43.5 21.7 14.6 5.2 4.2 100.0 4.6 6,217 1 Completed 6th grade (for 6-grade system) and 8th grade (for 8-grade system) at the primary level or were in vocational school. 2 Completed 6th grade at the secondary level 3.3 LITERACY In this survey, literacy was established by asking respondents who reported not having attended school or having attended only primary school to read a sentence in any language of his/her choice (Kinyarwanda, French, English and Swahili) 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, or can read a whole sentence. The test was Respondent Characteristics • 39 given only to women and men who had less than a secondary education; those with a secondary or postsecondary education (23 percent of women and 26 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 women and men who cannot read at all has decreased from previous generations, especially among women. For women, this proportion drops from 39 percent in the 45-49 age group to 9 percent in the 15-19 age group. For men, the proportion decreases from 19 percent to 12 percent. The data show also that a higher proportion of women than men cannot read (20 percent of women and 16 percent of men). Eighty percent of women and 84 percent of men are considered literate; that is, they have attended secondary school or, if they have attended only primary school or not attended school, they are able to read all or part of a sentence. The level of literacy varies appreciably by residence. Literacy is higher in urban areas than in rural areas (91 percent versus 78 percent among women and 91 percent versus 82 percent among men). The results by province show a gap between the City of Kigali and the rest of the country: in Kigali, 92 percent of women and men are literate. In the other provinces, the proportion varies from 76 percent (East) to 80 percent (North and South) among women and from 81 percent (South and West) to 85 percent (North and East) among men. Results according to wealth show that literacy levels increase considerably from the poorest to the richest quintile (from 62 percent to 93 percent among women and from 68 percent to 93 percent among men). 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 2014-15 Secondary school or higher No schooling or primary school Total Percent- age literate1 Number of women Background characteristic 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 39.3 43.7 5.9 10.8 0.0 0.0 0.2 100.0 88.9 5,225 15-19 40.0 44.9 5.8 9.2 0.0 0.0 0.1 100.0 90.7 2,768 20-24 38.6 42.4 6.0 12.7 0.0 0.0 0.3 100.0 86.9 2,457 25-29 19.8 50.9 8.8 20.3 0.1 0.0 0.1 100.0 79.5 2,300 30-34 12.9 53.5 8.5 25.0 0.0 0.0 0.1 100.0 74.9 2,151 35-39 12.4 57.8 8.7 21.0 0.0 0.0 0.1 100.0 78.9 1,575 40-44 8.5 56.0 7.3 27.9 0.0 0.3 0.0 100.0 71.8 1,269 45-49 6.4 44.4 9.3 39.3 0.0 0.5 0.1 100.0 60.1 977 Residence Urban 45.9 40.6 4.6 8.8 0.0 0.0 0.1 100.0 91.1 2,626 Rural 17.9 51.5 8.2 22.2 0.0 0.1 0.1 100.0 77.6 10,871 Province City of Kigali 43.2 44.9 4.1 7.7 0.0 0.0 0.1 100.0 92.1 1,799 South 20.4 53.4 6.1 19.9 0.0 0.1 0.0 100.0 79.9 3,214 West 21.7 48.4 7.8 22.0 0.0 0.0 0.1 100.0 77.9 2,965 North 21.8 47.4 10.7 19.6 0.2 0.2 0.2 100.0 79.9 2,211 East 18.0 50.0 8.3 23.5 0.0 0.1 0.2 100.0 76.3 3,308 Wealth quintile Lowest 6.8 45.2 10.4 37.4 0.1 0.1 0.1 100.0 62.4 2,561 Second 11.8 54.2 9.0 24.8 0.0 0.1 0.1 100.0 75.0 2,631 Middle 16.0 56.4 7.7 19.5 0.0 0.2 0.2 100.0 80.1 2,597 Fourth 26.7 53.6 7.4 12.0 0.0 0.1 0.1 100.0 87.7 2,634 Highest 50.5 39.1 3.6 6.7 0.0 0.0 0.1 100.0 93.2 3,073 Total 23.4 49.3 7.5 19.6 0.0 0.1 0.1 100.0 80.2 13,497 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 40 • Respondent Characteristics 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 2014-15 Secondary school or higher No schooling or primary school Total Percent- age literate1 Number of men Background characteristic 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 38.0 42.1 7.6 12.0 0.0 0.0 0.3 100.0 87.7 2,276 15-19 35.2 44.0 8.3 12.1 0.0 0.0 0.3 100.0 87.6 1,282 20-24 41.5 39.7 6.6 11.9 0.0 0.0 0.2 100.0 87.8 994 25-29 27.0 48.3 8.3 16.4 0.0 0.0 0.0 100.0 83.6 946 30-34 14.3 54.7 9.4 21.5 0.0 0.0 0.1 100.0 78.4 930 35-39 13.1 62.7 7.2 16.6 0.1 0.0 0.3 100.0 83.0 567 40-44 15.5 59.5 7.8 17.2 0.0 0.0 0.0 100.0 82.8 473 45-49 11.7 60.9 8.2 19.0 0.0 0.2 0.0 100.0 80.8 385 Residence Urban 46.5 38.1 6.4 8.8 0.1 0.1 0.1 100.0 91.0 1,169 Rural 20.5 53.3 8.4 17.6 0.0 0.0 0.2 100.0 82.3 4,408 Province City of Kigali 40.8 44.7 6.8 7.1 0.1 0.1 0.3 100.0 92.4 804 South 22.5 49.8 8.2 19.4 0.0 0.0 0.1 100.0 80.5 1,327 West 25.5 45.4 10.1 18.9 0.0 0.0 0.2 100.0 80.9 1,182 North 21.8 54.5 8.4 15.1 0.0 0.0 0.1 100.0 84.8 851 East 23.5 54.9 6.5 15.0 0.0 0.0 0.1 100.0 84.9 1,413 Wealth quintile Lowest 8.1 44.9 14.6 32.3 0.0 0.0 0.0 100.0 67.7 819 Second 11.8 58.5 9.7 19.9 0.0 0.0 0.1 100.0 80.0 991 Middle 18.5 58.5 6.9 16.0 0.0 0.0 0.1 100.0 84.0 1,097 Fourth 27.5 54.2 6.6 11.5 0.0 0.0 0.2 100.0 88.3 1,234 Highest 50.1 37.5 5.1 6.9 0.0 0.1 0.2 100.0 92.7 1,436 Total 15-49 25.9 50.1 8.0 15.7 0.0 0.0 0.1 100.0 84.1 5,577 50-59 7.0 53.9 7.3 31.1 0.0 0.5 0.1 100.0 68.2 640 Total 15-59 24.0 50.5 8.0 17.3 0.0 0.1 0.1 100.0 82.4 6,217 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 3.4 EXPOSURE TO MASS MEDIA Data on the exposure of women and men 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 women and men 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. Respondent Characteristics • 41 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 2014-15 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 9.6 21.3 67.4 3.4 29.1 2,768 20-24 6.5 19.9 66.3 3.0 31.3 2,457 25-29 4.9 14.6 61.1 2.1 36.7 2,300 30-34 4.4 14.9 59.2 2.1 38.9 2,151 35-39 5.1 12.6 57.4 2.3 41.3 1,575 40-44 4.7 10.9 56.0 1.3 42.3 1,269 45-49 4.1 8.8 53.5 1.7 44.9 977 Residence Urban 10.4 51.0 76.9 7.6 17.8 2,626 Rural 5.0 7.5 57.9 1.2 40.6 10,871 Province City of Kigali 9.8 52.1 80.6 7.1 14.4 1,799 South 6.1 10.8 63.5 2.0 35.2 3,214 West 4.6 9.5 52.3 1.2 45.3 2,965 North 5.6 12.0 62.9 2.2 35.5 2,211 East 5.4 9.9 56.8 1.6 41.2 3,308 Education No education 0.3 3.0 40.9 0.0 58.3 1,665 Primary 3.6 10.8 58.5 0.6 39.5 8,678 Secondary and higher 15.6 37.1 81.1 8.8 15.2 3,154 Wealth quintile Lowest 2.8 3.4 28.5 0.4 69.4 2,561 Second 3.2 3.2 50.1 0.3 48.6 2,631 Middle 4.3 3.9 62.9 0.5 35.5 2,597 Fourth 6.5 8.7 78.0 1.2 21.1 2,634 Highest 12.2 53.9 83.7 8.8 11.3 3,073 Total 6.0 16.0 61.6 2.4 36.2 13,497 Tables 3.4.1 and 3.4.2 show that, at the national level, 36 percent of women and 20 percent of men are not exposed to any media, a moderate increase from the 2010 RDHS figures of 31 percent and 12 percent, respectively. Radio is the most common form of media exposure: 62 percent of women and 79 percent of men report listening to the radio at least once a week. Men watch television more frequently than women: 16 percent of women and 30 percent of men watch television at least once a week. Only 6 percent of women, as compared with 14 percent of men, report reading a newspaper at least once a week. The proportions of women and men who are exposed to all three media are very low (2 percent and 10 percent, respectively). The data by age show that younger women receive relatively more exposure to mass media than older women. The proportions of women who are not exposed to any media vary from 29 percent among those age 15-19 to 45 percent among those age 45-49. Among men, age differences are narrow and uneven. 42 • Respondent Characteristics 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 2014-15 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 9.9 28.9 75.8 6.4 22.1 1,282 20-24 18.1 37.1 83.9 12.9 14.2 994 25-29 17.2 33.9 83.0 12.2 15.6 946 30-34 13.9 27.3 76.7 9.3 21.9 930 35-39 14.4 27.5 77.3 10.3 21.6 567 40-44 16.6 24.7 80.8 10.5 18.3 473 45-49 11.9 24.1 77.9 7.8 20.9 385 Residence Urban 32.1 61.7 88.4 26.5 8.9 1,169 Rural 9.7 21.7 76.9 5.5 21.8 4,408 Province City of Kigali 38.0 65.2 90.1 32.4 7.1 804 South 6.2 15.7 70.9 3.8 27.9 1,327 West 8.6 21.5 73.5 4.4 24.8 1,182 North 8.2 24.2 83.1 3.9 16.3 851 East 17.3 34.5 83.7 10.9 14.6 1,413 Education No education 0.0 12.9 62.2 0.0 36.8 496 Primary 8.9 24.8 77.5 5.7 21.2 3,636 Secondary and higher 33.4 49.3 89.8 23.8 7.9 1,445 Wealth quintile Lowest 3.9 14.9 55.4 1.9 43.0 819 Second 5.1 15.3 70.6 2.3 28.3 991 Middle 8.3 16.9 78.6 4.2 20.1 1,097 Fourth 15.3 28.1 87.8 9.1 10.9 1,234 Highest 30.8 60.8 92.3 24.6 5.4 1,436 Total 15-49 14.4 30.1 79.3 9.9 19.1 5,577 50-59 9.0 17.3 75.7 4.8 23.2 640 Total 15-59 13.9 28.8 79.0 9.3 19.5 6,217 Results by residence reveal significant differentials. In urban areas, 18 percent of women are not exposed to any media, as compared with 41 percent in rural areas. The differential is also wide among men: the proportion of men not exposed to any media varies from 9 percent in urban areas to 22 percent in rural areas. Results by province show significant differences between City of Kigali and other provinces: the percentage of women who are not exposed to any media is 14 percent in City of Kigali; while in other provinces this proportion varies from 35 percent (South) to 45 percent (West). Among men, the proportion is 7 percent in the city of Kigali, while it varies from 15 percent (East) to 28 percent (South) in other provinces. Educational attainment has a considerable correlation with level of media exposure. Among both women and men, those who have no education are least likely to be exposed to all three media. The results show that 58 percent of women with no education are not exposed to any media, as compared with 15 percent of women with a secondary education or higher. Among men, 37 percent of those with no education are not exposed to any media, compared with only 8 percent of those with a secondary education or higher. As in the case of educational attainment, there is a positive relationship between household wealth and media exposure. Women and men in the richest households have the highest levels of exposure to all three media: 9 percent of women and 25 percent of men. In contrast, less than 1 percent of women and 2 percent of men in the poorest households have access to all three media. Respondent Characteristics • 43 3.5 EMPLOYMENT The 2014-15 RDHS asked both women and men 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 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Rwanda 2014-15 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of women Background characteristic Currently employed1 Not currently employed Age 15-19 52.5 9.2 38.0 0.2 100.0 2,768 20-24 73.1 9.5 17.4 0.0 100.0 2,457 25-29 85.3 7.4 7.3 0.0 100.0 2,300 30-34 87.6 7.1 5.3 0.0 100.0 2,151 35-39 88.8 7.2 4.0 0.0 100.0 1,575 40-44 88.9 6.9 4.2 0.0 100.0 1,269 45-49 88.0 7.6 4.4 0.0 100.0 977 Marital status Never married 62.3 8.9 28.6 0.1 100.0 5,100 Married or living together 86.7 7.5 5.8 0.0 100.0 6,982 Divorced/separated/widowed 88.2 7.6 4.2 0.0 100.0 1,415 Number of living children 0 60.8 8.9 30.1 0.1 100.0 4,754 1-2 84.8 8.0 7.2 0.0 100.0 4,007 3-4 88.4 7.6 4.1 0.0 100.0 2,894 5+ 88.7 6.6 4.8 0.0 100.0 1,842 Residence Urban 63.7 8.9 27.3 0.1 100.0 2,626 Rural 81.0 7.8 11.1 0.0 100.0 10,871 Province City of Kigali 64.9 10.3 24.8 0.0 100.0 1,799 South 81.8 7.0 11.1 0.1 100.0 3,214 West 76.9 4.6 18.5 0.0 100.0 2,965 North 80.2 8.9 10.9 0.0 100.0 2,211 East 79.6 10.3 10.0 0.0 100.0 3,308 Education No education 86.3 7.2 6.5 0.0 100.0 1,665 Primary 83.1 8.0 8.9 0.0 100.0 8,678 Secondary and higher 58.2 8.5 33.1 0.1 100.0 3,154 Wealth quintile Lowest 82.8 8.2 9.1 0.0 100.0 2,561 Second 84.0 6.5 9.5 0.0 100.0 2,631 Middle 81.1 8.5 10.4 0.0 100.0 2,597 Fourth 78.6 7.5 13.9 0.1 100.0 2,634 Highest 64.3 9.4 26.2 0.1 100.0 3,073 Total 77.7 8.0 14.2 0.0 100.0 13,497 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. Table 3.5.1 shows that 78 percent of women were employed in the seven days before the survey, while 8 percent were not currently employed but had worked sometime in the previous 12 months and 14 percent had not been employed in the preceding 12 months. The percentage of women working at the time of the survey increases steadily with age, from 53 percent at age 15-19 to 73 percent at age 20-24, 85 percent at age 25-29, and 88-89 percent at age 30-49. Women who were separated, divorced, or widowed (88 percent) and married women (87 percent) were more likely to be employed at the time of the survey than women who had never been married (62 percent). Number of children is also related to a woman’s employment status. As number of children 44 • Respondent Characteristics increases, the proportion of women who work also increases, from 61 percent among those with no children to 89 percent for those with five children or more. Data by residence show that rural women were more likely to be working at the time of the survey (81 percent) than urban women (64 percent). The city of Kigali has the lowest percentage of women who are working (65 percent). In other provinces, the proportion of currently employed women ranges from 77 percent in West to 82 percent in South. Results by educational attainment show that women with no education (86 percent) are more likely to be employed than women with a primary education only (83 percent) and those with a secondary education or higher (58 percent). Finally, women in households in the two poorest wealth quintiles are more likely to be employed (83-84 percent) than women in the richest households (64 percent). Table 3.5.2 shows that 85 percent of men age 15-49 were employed in the seven days before the survey, while 2 percent were not currently employed but had worked sometime in the last 12 months and 13 percent had not been employed in the preceding 12 months As with women, the percentage of men working at the time of the survey increases with age, from 57 percent among those age 15-19 to 96-98 percent among those age 25 to 49. Currently married men are more likely to be working (98 percent) than separated, divorced, or widowed men (96 percent) and those who have never been married (71 percent). With respect to residence, men in rural areas (86 percent) were more likely to have been working at the time of the survey than men in urban areas (80 percent). By province, the data show that City of Kigali had the lowest proportion of men who were working at the time of the survey (82 percent); the highest proportions were reported in North and South (87 percent each). Men with no education (97 percent) were more likely to be employed than men with a primary education (91 percent) and men with a secondary education or higher (65 percent). Finally, similar to findings among women, the proportion of men who were working was lower in the richest households than in the poorest households (80 percent versus 90 percent). The proportion of men who were working at the time of the survey exceeded the proportion of women who were working in all categories of background characteristics. Since 2010, the proportion of women working at the time of the survey has increased from 73 percent to 78 percent, while the proportion among men has slightly decreased from 90 percent to 85 percent. As can be seen, in both 2010 and 2014-15, women were less likely than men to be working at the time of the survey. Respondent Characteristics • 45 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Rwanda 2014-15 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of men Background characteristic Currently employed1 Not currently employed Age 15-19 56.8 1.7 41.0 0.5 100.0 1,282 20-24 80.7 2.2 16.9 0.2 100.0 994 25-29 96.1 1.2 2.7 0.0 100.0 946 30-34 97.2 1.3 1.5 0.0 100.0 930 35-39 98.3 1.1 0.6 0.0 100.0 567 40-44 98.1 1.5 0.3 0.0 100.0 473 45-49 97.2 2.2 0.6 0.0 100.0 385 Marital status Never married 70.7 1.9 27.0 0.3 100.0 2,691 Married or living together 98.3 1.3 0.4 0.0 100.0 2,792 Divorced/separated/widowed 95.5 2.4 2.2 0.0 100.0 94 Number of living children 0 71.7 1.9 26.2 0.3 100.0 2,760 1-2 97.7 1.2 1.2 0.0 100.0 1,288 3-4 98.3 1.6 0.1 0.0 100.0 912 5+ 98.2 1.5 0.3 0.0 100.0 617 Residence Urban 79.7 1.8 18.4 0.1 100.0 1,169 Rural 86.4 1.6 11.9 0.1 100.0 4,408 Province City of Kigali 81.8 1.2 16.9 0.0 100.0 804 South 86.6 1.0 11.9 0.5 100.0 1,327 West 83.6 2.2 14.2 0.0 100.0 1,182 North 86.9 1.1 12.0 0.0 100.0 851 East 85.2 2.2 12.5 0.1 100.0 1,413 Education No education 96.8 2.2 1.1 0.0 100.0 496 Primary 91.2 1.4 7.3 0.1 100.0 3,636 Secondary and higher 65.2 2.0 32.4 0.4 100.0 1,445 Wealth quintile Lowest 89.9 2.1 7.9 0.0 100.0 819 Second 90.9 0.7 8.2 0.2 100.0 991 Middle 85.6 2.9 11.4 0.2 100.0 1,097 Fourth 82.5 1.1 16.3 0.1 100.0 1,234 Highest 79.8 1.4 18.7 0.1 100.0 1,436 Total 15-49 85.0 1.6 13.3 0.1 100.0 5,577 50-59 95.7 1.7 2.6 0.0 100.0 640 Total 15-59 86.1 1.6 12.2 0.1 100.0 6,217 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. Table 3.6.1 shows information on women’s occupations. The majority of women who were employed at the time of the survey or who had worked during the preceding 12 months were employed in agriculture (76 percent, as compared with 77 percent in 2010). In terms of other occupations, 11 percent of working women worked in sales and services, 4 percent worked in domestic services, 3 percent performed skilled manual labor and 2 percent performed unskilled manual labor. Only 3 percent reported working in a technical, professional, or managerial occupation. Results by age show that older women are more likely to work in agriculture than younger women (87 percent of those age 45-49 and 72 percent of those age 15-19). As expected, data by residence show that the proportion of women working in agriculture is higher in rural areas (87 percent) than in urban areas (23 percent). Also, this proportion is much lower in the city of Kigali (24 percent) than in other provinces, where the proportion of employed women working in agriculture varies from 80 percent (West) to 87 percent (East). With respect to educational attainment, 91 percent of women with no education and 81 percent of women with only a primary education work in agriculture, as compared with 45 percent of women with a 46 • Respondent Characteristics secondary education or higher. The proportion of employed women who work in agriculture also decreases with increasing wealth and is especially low among those in the highest quintile (28 percent). 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 2014-15 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agri- culture Missing Total Number of women Age 15-19 0.4 0.1 8.7 1.4 3.3 13.0 71.7 1.3 100.0 1,709 20-24 2.0 0.7 14.0 3.4 2.2 5.8 71.3 0.5 100.0 2,028 25-29 4.3 1.0 13.7 3.7 2.5 2.7 72.0 0.2 100.0 2,133 30-34 3.8 0.5 11.8 2.8 1.7 1.5 77.8 0.2 100.0 2,037 35-39 4.0 0.2 11.1 2.9 1.4 1.2 79.2 0.0 100.0 1,511 40-44 3.2 0.4 10.5 1.7 1.3 0.6 82.2 0.2 100.0 1,215 45-49 2.0 0.1 6.1 2.2 1.4 0.9 87.3 0.0 100.0 934 Marital status Never married 2.7 0.8 12.0 3.6 3.0 10.3 66.4 1.1 100.0 3,634 Married or living together 3.3 0.3 11.2 2.4 1.5 0.8 80.5 0.1 100.0 6,579 Divorced/separated/widowed 1.4 0.3 10.6 2.2 2.2 2.5 80.8 0.0 100.0 1,355 Number of living children 0 3.1 1.0 11.6 3.7 3.0 10.2 66.3 1.1 100.0 3,318 1-2 3.7 0.4 12.9 2.9 1.8 2.3 75.8 0.1 100.0 3,720 3-4 2.6 0.2 10.3 2.3 1.7 0.9 81.9 0.0 100.0 2,776 5+ 1.2 0.1 9.4 1.1 1.4 0.7 86.1 0.0 100.0 1,754 Residence Urban 8.5 2.4 37.5 5.9 5.3 16.9 23.2 0.4 100.0 1,907 Rural 1.8 0.1 6.2 2.1 1.4 1.4 86.5 0.4 100.0 9,661 Province City of Kigali 6.7 2.2 34.9 7.3 6.0 18.8 23.7 0.2 100.0 1,353 South 2.9 0.3 7.9 2.6 1.1 2.6 82.2 0.4 100.0 2,853 West 2.4 0.4 11.4 1.5 2.0 2.1 79.7 0.4 100.0 2,416 North 2.3 0.2 8.7 2.3 1.9 1.5 82.5 0.7 100.0 1,971 East 1.9 0.1 5.7 2.0 1.3 1.7 86.9 0.2 100.0 2,975 Education No education 0.1 0.0 4.6 1.0 1.7 1.5 91.0 0.0 100.0 1,556 Primary 0.2 0.0 9.3 2.6 2.1 4.2 81.4 0.2 100.0 7,907 Secondary and higher 15.2 2.5 24.2 4.6 2.2 4.9 45.2 1.2 100.0 2,105 Wealth quintile Lowest 0.1 0.0 4.2 1.5 1.3 0.7 92.0 0.3 100.0 2,329 Second 0.1 0.0 5.7 1.4 1.4 1.0 90.1 0.3 100.0 2,381 Middle 1.0 0.0 5.4 2.4 1.9 0.6 88.5 0.1 100.0 2,327 Fourth 2.0 0.2 9.6 3.1 2.3 1.9 80.6 0.4 100.0 2,267 Highest 11.5 2.2 32.6 5.4 3.5 16.1 27.8 0.8 100.0 2,265 Total 2.9 0.5 11.4 2.7 2.1 4.0 76.1 0.4 100.0 11,568 Table 3.6.2 shows similar data for men’s occupations. As with women, the majority of men work in agriculture (58 percent, as compared with 60 percent in 2010). Twelve percent of working men perform skilled manual labor, 11 percent are employed in sales and services and 10 percent of perform unskilled manual labor. Only 5 percent reported working in a technical, professional, or managerial occupation. These proportions have remained similar since 2010. As is the case with women, results by age show that older men are somewhat more likely to work in agriculture than younger ones. Results by province show that 30 percent of men in City of Kigali work in skilled manual jobs, 22 percent work in sales and services, 15 percent work in the unskilled manual sector, and only 15 percent work in agriculture. In other provinces, agricultural occupations dominate. As expected, the proportion of men working in agriculture is higher in rural areas than in urban areas (69 percent versus 13 percent). Conversely, it appears that urban men are more likely than rural men to work in other occupations. In particular, urban men are significantly more likely than rural men to perform skilled manual labor (28 percent versus 8 percent) and to be employed in sales and services (23 percent versus 8 percent). The difference is not large for unskilled manual labor (15 percent in urban areas and 9 percent in rural areas). With respect to educational attainment, the results show that, as with women, the majority of men who have no Respondent Characteristics • 47 education work in agriculture (74 percent, as compared with 30 percent of those with a secondary education or higher). Among those with a secondary education or higher, 23 percent work in professional/ technical/managerial occupations. Results according to wealth show that a majority of men in the poorest households work in agriculture (77 percent). Only 21 percent of men in the richest quintile work in agriculture, and 23 percent are engaged in skilled manual labor. 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 2014-15 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agri- culture Missing Total Number of men Age 15-19 0.8 0.0 7.9 7.4 15.6 7.5 60.4 0.4 100.0 751 20-24 3.4 0.5 13.9 9.9 14.3 4.9 53.0 0.1 100.0 824 25-29 9.1 0.3 12.9 13.6 11.7 2.0 50.4 0.0 100.0 921 30-34 6.0 0.4 11.8 14.7 7.4 1.2 58.4 0.0 100.0 916 35-39 4.8 0.2 9.3 14.1 7.3 1.0 63.2 0.0 100.0 564 40-44 6.0 0.6 11.4 11.9 4.2 0.6 65.3 0.0 100.0 472 45-49 5.1 0.4 8.6 15.4 2.9 0.3 67.3 0.0 100.0 383 Marital status Never married 5.7 0.4 12.3 10.3 13.8 5.8 51.5 0.2 100.0 1,955 Married or living together 4.8 0.3 10.4 13.5 7.2 0.7 63.0 0.0 100.0 2,781 Divorced/separated/widowed 2.2 0.0 10.4 15.3 16.3 0.8 55.0 0.0 100.0 92 Number of living children 0 5.9 0.4 11.4 10.5 13.6 5.6 52.4 0.2 100.0 2,030 1-2 6.4 0.6 11.9 14.0 9.9 0.8 56.4 0.0 100.0 1,273 3-4 3.3 0.2 12.0 12.1 6.0 0.9 65.6 0.0 100.0 911 5+ 2.6 0.0 7.8 14.7 4.3 0.4 70.2 0.0 100.0 615 Residence Urban 11.8 1.2 22.5 28.0 15.1 7.8 13.3 0.2 100.0 953 Rural 3.5 0.1 8.4 8.4 8.7 1.6 69.3 0.1 100.0 3,876 Province City of Kigali 10.2 1.2 22.0 30.0 14.6 7.3 14.7 0.0 100.0 668 South 4.3 0.1 7.6 7.9 7.2 2.7 69.9 0.4 100.0 1,163 West 4.5 0.2 9.4 10.9 10.8 1.7 62.5 0.0 100.0 1,014 North 3.5 0.5 8.8 10.0 12.2 1.2 63.9 0.0 100.0 749 East 4.6 0.1 11.7 9.3 8.3 2.4 63.8 0.0 100.0 1,235 Education No education 0.0 0.0 6.5 7.4 10.3 2.1 73.6 0.0 100.0 490 Primary 0.6 0.1 9.8 11.6 10.8 2.8 64.1 0.0 100.0 3,367 Secondary and higher 23.2 1.3 18.2 16.9 7.1 3.1 30.0 0.3 100.0 972 Wealth quintile Lowest 0.1 0.0 4.0 7.0 11.2 0.6 76.9 0.2 100.0 754 Second 0.4 0.1 6.3 9.1 10.6 0.3 73.1 0.0 100.0 908 Middle 1.0 0.0 8.9 9.0 9.1 1.2 70.9 0.0 100.0 970 Fourth 4.5 0.3 11.1 10.1 9.4 2.3 62.1 0.1 100.0 1,031 Highest 15.9 1.1 21.6 22.7 10.0 8.0 20.5 0.2 100.0 1,166 Total 15-49 5.1 0.3 11.2 12.3 10.0 2.8 58.2 0.1 100.0 4,829 50-59 3.1 0.6 5.0 8.6 3.1 0.5 79.1 0.0 100.0 623 Total 15-59 4.9 0.4 10.5 11.8 9.2 2.5 60.6 0.1 100.0 5,452 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, 44 percent of women in agricultural occupations were paid in cash and in-kind, 14 percent were paid in-kind only, 30 percent were not paid for their work, and only 13 percent were paid in cash only. Women in nonagricultural occupations were more likely to be paid in cash only (81 percent) than those working in agriculture (13 percent). Only 4 percent of women in nonagricultural occupations were not paid for their work. In the majority of cases, women are self-employed, regardless of their occupation (60 percent of women in agricultural occupations and 54 percent of those in nonagricultural occupations). Women who work in 48 • Respondent Characteristics agriculture are more likely to work for a family member than women in nonagricultural occupations (17 percent versus 4 percent). Slightly more than 2 in 5 women (42 percent) working in nonagricultural occupations are employed by a non-family member, while this proportion is about 22 percent among women working in agricultural occupations. Finally, 62 percent of employed women work all year, whereas about 3 in 10 work occasionally. 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 2014-15 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 13.0 81.2 29.0 Cash and in-kind 43.6 13.4 36.4 In-kind only 13.5 1.0 10.5 Not paid 29.8 4.3 24.0 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Type of employer Employed by family member 17.3 4.3 14.4 Employed by non-family member 22.4 41.5 26.8 Self-employed 60.2 54.1 58.6 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Continuity of employment All year 60.9 66.9 62.2 Seasonal 8.2 5.1 7.5 Occasional 30.9 28.0 30.3 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 8,804 2,720 11,568 Note: Total includes 44 weighted 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 2014-15 RDHS asked questions to determine the level of tobacco consumption among survey respondents. Table 3.8.1 shows the 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 use tobacco (98 percent). The proportion of women who smoke cigarettes or a pipe is very low, at less than 1 percent; however, 1 percent consume other tobacco products. Although the proportion of women who smoke tobacco is low, it appears that the oldest women age 45-49 (5 percent), those in South Province (3 percent), those with no education (4 percent) and those in the lowest wealth quintile (3 percent) are more likely to use other tobacco products. Respondent Characteristics • 49 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 2014-15 Uses tobacco Does not use tobacco Number of women Background characteristic Cigarettes Pipe Other tobacco Age 15-19 0.1 0.0 0.0 99.9 2,768 20-24 0.1 0.1 0.2 99.7 2,457 25-29 0.4 0.3 0.8 98.6 2,300 30-34 0.3 0.4 1.3 98.1 2,151 35-39 0.7 1.2 1.3 96.9 1,575 40-44 0.6 2.5 3.3 94.0 1,269 45-49 1.3 3.2 4.8 91.5 977 Maternity status Pregnant 0.2 0.2 1.2 98.6 984 Breastfeeding (not pregnant) 0.4 0.6 1.2 97.8 3,850 Neither 0.4 0.9 1.2 97.7 8,663 Residence Urban 0.6 0.1 0.4 98.9 2,626 Rural 0.3 0.9 1.4 97.5 10,871 Province City of Kigali 0.6 0.1 0.5 98.8 1,799 South 0.7 0.5 3.1 96.0 3,214 West 0.1 0.1 0.2 99.6 2,965 North 0.3 1.3 0.8 97.9 2,211 East 0.4 1.4 0.9 97.5 3,308 Education No education 0.7 2.3 3.8 93.7 1,665 Primary 0.4 0.7 1.1 97.9 8,678 Secondary and higher 0.3 0.0 0.0 99.6 3,154 Wealth quintile Lowest 0.5 1.6 3.1 95.1 2,561 Second 0.4 0.8 1.5 97.4 2,631 Middle 0.4 0.8 1.0 97.9 2,597 Fourth 0.3 0.6 0.4 98.9 2,634 Highest 0.3 0.1 0.1 99.5 3,073 Total 0.4 0.7 1.2 97.8 13,497 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 the preceding 24 hours, according to background characteristics. The results show that 90 percent of men age 15-49 in Rwanda do not use tobacco. Nine percent of men reported smoking cigarettes and 2 percent reported smoking pipes, while approximately 1 percent reported consuming other tobacco products. The proportion of men who smoke cigarettes increases with increasing age, from 1 percent among those age 15-19 to 16 percent among those age 40-44, before declining slightly to 14 percent among those age 45-49. The proportion of men who smoke pipes follows a similar pattern (from 0 percent at age 15-19 to 9 percent at age 45-49). There are only minimal differences between urban and rural men in consumption of cigarettes or other tobacco products; about 9 percent in urban and rural areas smoke cigarettes. By province, men in South and East are more likely to smoke cigarettes (12 percent and 11 percent, respectively) than men in Kigali City and North (9 percent); men in West are least likely to smoke cigarettes (4 percent). As with women, men who have no education (18 percent) and those in the lowest wealth quintile (17 percent) are more likely to smoke cigarettes than their counterparts; they are also more likely to smoke pipes. 50 • Respondent Characteristics 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 2014-15 Uses tobacco Does not use tobacco Number of men Percent distribution of men who smoke cigarettes by number of cigarettes smoked in the past 24 hours Total Number of cigarette smokers Background characteristic Cigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 1.2 0.0 0.2 98.7 1,282 * * * * * * 100.0 16 20-24 4.8 0.1 0.6 95.1 994 (5.8) (30.4) (41.0) (15.1) (5.5) (2.2) 100.0 47 25-29 11.8 0.9 1.0 87.8 946 3.3 28.9 42.6 12.6 7.5 5.2 100.0 112 30-34 12.5 2.5 1.3 86.2 930 3.5 28.3 44.1 7.0 15.9 1.3 100.0 116 35-39 15.4 2.9 0.4 83.8 567 4.0 25.7 51.2 9.5 7.2 2.4 100.0 88 40-44 16.0 6.3 1.0 80.3 473 8.2 31.0 37.0 3.4 16.6 3.8 100.0 76 45-49 14.2 9.0 0.8 80.4 385 8.7 27.2 43.8 12.8 5.4 2.2 100.0 55 Residence Urban 8.6 0.4 0.7 91.2 1,169 3.1 15.4 48.1 16.2 11.5 5.7 100.0 100 Rural 9.3 2.5 0.7 89.4 4,408 5.6 31.0 42.4 8.4 9.8 2.7 100.0 408 Province City of Kigali 8.7 0.8 0.8 90.7 804 4.2 15.8 50.6 13.5 13.8 2.2 100.0 70 South 12.2 2.9 1.0 86.3 1,327 8.3 41.3 34.6 5.6 7.0 3.3 100.0 162 West 4.4 0.4 0.3 95.3 1,182 4.3 26.0 41.7 7.8 11.4 8.9 100.0 51 North 8.7 2.5 0.4 90.4 851 1.7 22.9 53.7 8.4 8.8 4.6 100.0 74 East 10.7 3.0 0.8 87.6 1,413 4.0 22.5 45.6 14.5 12.2 1.1 100.0 152 Education No education 17.7 6.4 1.6 77.5 496 6.5 35.8 36.2 10.0 8.9 2.6 100.0 87 Primary 10.2 2.1 0.8 88.8 3,636 4.8 27.3 46.6 9.3 9.5 2.5 100.0 372 Secondary and higher 3.4 0.3 0.1 96.5 1,445 4.9 18.9 33.5 15.0 17.8 10.0 100.0 50 Wealth quintile Lowest 16.5 5.3 1.0 80.4 819 2.9 40.8 43.8 6.9 5.1 0.6 100.0 135 Second 10.2 3.2 0.8 88.2 991 5.2 23.2 47.0 13.0 7.3 4.3 100.0 101 Middle 9.8 1.7 1.0 89.2 1,097 8.2 30.3 37.1 3.5 14.8 6.2 100.0 108 Fourth 6.6 1.0 0.3 93.1 1,234 6.7 23.7 47.2 13.0 9.4 0.0 100.0 81 Highest 5.8 0.5 0.5 93.9 1,436 3.1 14.3 43.8 16.6 16.6 5.7 100.0 84 Total 15-49 9.1 2.0 0.7 89.8 5,577 5.1 28.0 43.5 10.0 10.2 3.2 100.0 509 50-59 19.1 16.0 3.8 69.5 640 13.1 31.8 36.0 10.3 7.0 1.7 100.0 123 Total 15-59 10.2 3.5 1.0 87.7 6,217 6.7 28.7 42.1 10.0 9.6 3.0 100.0 631 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figures is based on fewer than 25 unweighted cases. Among men who smoke cigarettes, 44 percent reported smoking from 3 to 5 cigarettes in the 24 hours preceding the survey, 28 percent smoked from 1 to 2 cigarettes, 10 percent smoked 6-9 cigarettes, and 10 percent smoked 10 or more cigarettes. Notably, 5 percent of men who reported that they smoke did not smoke a cigarette in the 24 hours before the interview. Proximate Determinants of Fertility • 51 PROXIMATE DETERMINANTS OF FERTILITY 4 Key Findings • The median age at first marriage among women age 25-49 is 22 years, • The median age at first marriage among men age 30-49 is 26 years. • Median age at first marriage among women has increased slightly since 2010, from 21 years to 22 years. • The percentage of never-married women (38 percent versus 39 percent in RDHS 2010) and men (48 percent versus 51 percent for RDHS 2010) has decreased slightly in the past five years. • Two percent of currently married men age 15-49 are in polygamous unions; 7 percent of currently married women have co-wives. • Only 2 percent of women and men age 30-49 reported having had sex before age 15. • Twelve percent of men reported that they had sex by age 18, as compared with 20 percent of women. his chapter addresses the key factors that define the risk of becoming pregnant. These factors include age at first marriage, age at first sexual intercourse, sexual activity, 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 culturally permissible contexts 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 have never been married or lived together with a partner. Ever-married people include those who are currently married as well as those who are living with a partner, widowed, separated, or divorced. Table 4.1 shows the distribution of women and men by marital status, according to age at the time of the survey. Of the 13,497 women interviewed, 52 percent were in a union. This proportion has remained relatively stable since the 2010 RDHS, when the figure was 50 percent. T 52 • Proximate Determinants of Fertility Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Rwanda 2014-15 Marital status Total Percentage of respondents currently in union Number of respondentsAge Never married Married Living together Divorced Separated Widowed WOMEN Age 15-19 96.2 0.1 2.9 0.2 0.6 0.0 100.0 3.1 2,768 20-24 58.8 11.3 24.7 1.3 3.7 0.3 100.0 35.9 2,457 25-29 24.0 39.7 28.9 2.5 4.2 0.8 100.0 68.6 2,300 30-34 11.4 58.7 20.0 3.6 4.0 2.2 100.0 78.7 2,151 35-39 7.1 62.5 16.3 4.6 4.0 5.6 100.0 78.7 1,575 40-44 4.1 55.7 15.0 5.3 5.9 14.2 100.0 70.6 1,269 45-49 3.5 52.1 10.0 6.7 3.8 23.8 100.0 62.1 977 Total 15-49 37.8 34.5 17.2 2.8 3.4 4.2 100.0 51.7 13,497 MEN Age 15-19 99.8 0.0 0.2 0.0 0.0 0.0 100.0 0.2 1,282 20-24 82.1 4.1 12.9 0.1 0.8 0.0 100.0 17.0 994 25-29 41.4 26.3 29.7 1.0 1.4 0.2 100.0 56.0 946 30-34 14.1 55.0 28.3 1.1 1.4 0.1 100.0 83.3 930 35-39 8.2 68.5 21.7 0.4 1.0 0.2 100.0 90.2 567 40-44 3.2 74.4 19.6 0.7 1.2 0.8 100.0 94.0 473 45-49 2.8 75.5 17.7 0.9 1.1 2.1 100.0 93.2 385 Total 15-49 48.2 32.9 17.2 0.5 0.9 0.3 100.0 50.1 5,577 50-59 1.9 73.9 16.6 2.2 2.5 2.9 100.0 90.5 640 Total 15-59 43.5 37.1 17.1 0.7 1.1 0.5 100.0 54.2 6,217 Thirty-five percent of women are in formal marriages, the same percentage as in 2010, while the proportion of women in informal unions has increased from 15 percent to 17 percent. The proportion of women who are divorced has declined from 5 percent to 3 percent, while the proportion of women who are separated has increased from 1 percent to 3 percent. The proportion of widows has declined slightly, from 5 percent to 4 percent. Thirty-eight percent of women have never been married, similar to the figure in 2010 (39 percent). Young women in the 15 to 19 age group (96 percent) are most likely to have never been married. Among men age 15-49, 48 percent have never been married, 50 percent are in a union, 2 percent are either separated, divorced, or widowed. Thirty-three percent of those in a union are in a formal marriage, while 17 percent are in an informal marriage (living together with a partner). These figures are slightly different from those found in the 2010 RDHS, with an increase in the proportion of married men and a decrease in the proportion of men who have never been married. There has been no change in the proportion of men who are separated or divorced. 4.2 POLYGAMY The survey asked currently married women (in formal or informal marriages) 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. Although polygamy is illegal in Rwanda and is not very common, it affects 7 percent of women who are in a union. The proportion of women in polygamous unions is slightly lower than the proportion in 2010 (8 percent). The percentage of women with only one co-wife has decreased (from 7 percent to 6 percent), while the percentage with more than one co-wife has remained the same (1 percent). Proximate Determinants of Fertility • 53 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 2014-15 Number of co-wives Total Number of women Background characteristic 0 1 2+ Don’t know Missing Age 15-19 95.5 3.4 0.0 1.2 0.0 100.0 85 20-24 96.2 2.6 0.6 0.5 0.0 100.0 883 25-29 93.9 3.8 1.1 1.1 0.1 100.0 1,577 30-34 92.0 5.7 1.4 0.7 0.1 100.0 1,693 35-39 91.0 6.5 1.1 1.2 0.2 100.0 1,240 40-44 88.1 8.8 2.0 1.1 0.0 100.0 896 45-49 86.7 9.6 2.3 1.2 0.2 100.0 607 Residence Urban 93.2 4.4 1.2 1.2 0.0 100.0 1,194 Rural 91.6 6.0 1.4 0.9 0.1 100.0 5,788 Province City of Kigali 94.3 3.7 0.8 1.2 0.0 100.0 842 South 92.7 4.8 1.4 0.8 0.3 100.0 1,606 West 90.3 6.8 1.3 1.6 0.0 100.0 1,542 North 94.2 4.2 0.8 0.6 0.1 100.0 1,130 East 89.9 7.5 1.8 0.7 0.1 100.0 1,863 Education No education 87.0 9.9 2.2 0.7 0.3 100.0 1,154 Primary 92.2 5.4 1.2 1.1 0.1 100.0 4,921 Secondary and higher 96.4 1.9 0.8 0.8 0.1 100.0 907 Wealth quintile Lowest 87.2 9.3 1.6 1.7 0.3 100.0 1,313 Second 90.4 6.5 2.1 0.9 0.2 100.0 1,472 Middle 92.9 5.3 1.3 0.4 0.0 100.0 1,453 Fourth 93.4 4.5 1.1 0.9 0.1 100.0 1,380 Highest 95.3 3.0 0.6 1.0 0.0 100.0 1,365 Total 91.9 5.7 1.3 1.0 0.1 100.0 6,982 The proportion of women with one or more co-wives increases steadily with age, from 3 percent among those age 15-19 to 12 percent among those age 45-49. The extent of polygamy differs by residence; the percentage of married women living in polygamous unions is 6 percent in urban areas and 7 percent in rural areas. There is also variation between the provinces, from a low of 5 percent in Kigali and North to a high of 9 percent in East. Women’s level of education is related to polygamy: the percentage of married women with one or more co-wives is four times higher among those with no education (12 percent) than among those with a secondary education or higher (3 percent). The proportion of women in polygamous unions decreases with increasing wealth, from 11 percent among those in the lowest wealth quintile to 4 percent among those in the highest quintile. Table 4.2.2 shows information on polygamy for men. The proportion of married men in polygamous unions is very low (2 percent, identical to the figure in 2010). The percentage of men in such unions increases with age, from less than 1 percent among those less than age 30 to 5 percent among those age 45-49. 54 • Proximate Determinants of Fertility 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 2014-15 Number of wives Total Number of men Background characteristic 1 2+ Age 15-19 * * 100.0 3 20-24 100.0 0.0 100.0 169 25-29 99.6 0.4 100.0 530 30-34 98.2 1.8 100.0 775 35-39 97.5 2.5 100.0 512 40-44 96.5 3.5 100.0 445 45-49 95.3 4.7 100.0 359 Residence Urban 97.5 2.5 100.0 494 Rural 97.9 2.1 100.0 2,298 Province City of Kigali 98.4 1.6 100.0 361 South 98.8 1.2 100.0 605 West 97.2 2.8 100.0 627 North 98.8 1.2 100.0 472 East 96.5 3.5 100.0 727 Education No education 95.8 4.2 100.0 392 Primary 98.1 1.9 100.0 2,050 Secondary and higher 98.0 2.0 100.0 350 Wealth quintile Lowest 97.0 3.0 100.0 492 Second 97.6 2.4 100.0 601 Middle 98.3 1.7 100.0 585 Fourth 98.2 1.8 100.0 554 Highest 97.8 2.2 100.0 560 Total 15-49 97.8 2.2 100.0 2,792 50-59 93.8 6.2 100.0 579 Total 15-59 97.1 2.9 100.0 3,371 Note: An asterisk indicates that a 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 age at first union is very important. Table 4.3 shows the percentage of currently married women and men by current age, according to their age at first marriage. Only 2 percent of women reported being married by age 15. At age 18, the proportion is significantly higher (14 percent). Thirty-one percent of women are married by age 20, 51 percent by age 22, and 73 percent by age 25. The median age at first union is 21.9 years, which is relatively late. This figure has changed only minimally since 2010 (21.4 years). According to the data, men marry at a later age than women. Less than half of men age 30-49 were married by age 25 (46 percent), as compared with three-quarters of women (76 percent) in the same age group. The median age at first union among men age 30-59 is 25.4 years. Proximate Determinants of Fertility • 55 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 2014-15 Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage Current age 15 18 20 22 25 WOMEN Age 15-19 0.0 na na na na 96.2 2,768 a 20-24 0.4 6.8 20.8 na na 58.8 2,457 a 25-29 1.1 8.2 21.2 42.7 66.5 24.0 2,300 22.8 30-34 1.1 13.6 29.9 46.9 69.1 11.4 2,151 22.4 35-39 1.2 15.8 38.6 58.6 75.3 7.1 1,575 21.0 40-44 2.0 18.1 36.2 61.3 82.3 4.1 1,269 21.1 45-49 3.0 17.8 36.1 56.2 81.0 3.5 977 21.5 25-49 1.5 13.7 30.8 51.3 73.0 12.0 8,272 21.9 30-49 1.7 15.8 34.6 54.6 75.5 7.4 5,972 21.5 MEN Age 15-19 0.0 na na na na 99.8 1,282 a 20-24 0.0 0.6 5.2 na na 82.1 994 a 25-29 0.0 1.1 4.6 13.2 41.3 41.4 946 a 30-34 0.0 3.0 10.8 23.1 45.8 14.1 930 25.5 35-39 0.0 2.7 9.9 24.1 48.6 8.2 567 25.2 40-44 0.0 2.0 5.8 18.8 46.7 3.2 473 25.4 45-49 0.0 1.9 8.7 19.3 39.0 2.8 385 26.3 30-49 0.0 2.6 9.3 21.9 45.6 8.7 2,355 25.6 30-59 0.0 2.7 9.5 22.9 47.2 7.2 2,995 25.4 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 among women and men according to background characteristics. The median age at first marriage is slightly lower among rural women than among urban women (21.7 years versus 23.2 years). The data show variations by province: among women, East and North have the earliest age at first union (21.2 years), while South and City of Kigali have the latest (22.6 years and 23.7 years, respectively). Level of education is also related to age at first union. The median age at first union is 20.3 years among women with no education and 21.8 years among those with a primary education (age at marriage was not computed for those with a secondary education because less than 50 percent of the respondents began living with their spouse/partner for the first time before reaching age 25). Results according to wealth quintile show little difference among the four lowest quintiles; however, women in the richest quintile (23.5 years) enter into their first union later than women in the other quintiles (21.4 to 21.9 years). Differentials in age at first marriage are more observed among men than women in all background characteristics. 56 • Proximate Determinants of Fertility 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 30-59, according to background characteristics, Rwanda 2014-15 Background Women age Men age characteristic 25-49 30-59 Residence Urban 23.2 28.2 Rural 21.7 24.8 Province City of Kigali 23.7 28.5 South 22.6 26.0 West 21.5 24.1 North 21.2 24.3 East 21.2 25.2 Education No education 20.3 24.4 Primary 21.8 25.0 Secondary and higher a 29.6 Wealth quintile Lowest 21.4 25.7 Second 21.6 24.6 Middle 21.4 24.5 Fourth 21.9 24.6 Highest 23.5 27.8 Total 21.9 25.4 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 or partner 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, along with the median age at first intercourse. Very few women reported having had sexual intercourse before age 15 (2 percent). Approximately one in five women (19 percent) had sexual intercourse by age 18. At age 20, two in five women (39 percent) have had sexual intercourse. The median age at first sexual intercourse is 21.8 years, an increase of approximately one year since 2010 (20.7 years). It appears that the median age at first intercourse is nearly identical to the median age at first union, which implies that the majority of Rwandan women have their first sexual intercourse at the time of their first union. Very few men age 30-49 reported that they have had sexual intercourse prior to age 15 (2 percent). Among men in that age group, the median age at first sexual intercourse is 22.5 years. Unlike women, men’s age at first sexual intercourse is about three years younger than their age at first union. This difference in age at first sexual intercourse and age at first union is the same as that found in 2010. Proximate Determinants of Fertility • 57 Table 4.5 Age at first sexual intercourse Percentage of women age 15-49 and men age 15-59 who had first sexual intercourse by specific exact ages, percentage who never had sexual intercourse, and median age at first sexual intercourse, according to current age, Rwanda 2014-15 Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse Current age 15 18 20 22 25 WOMEN Age 15-19 6.8 na na na na 79.9 2,768 a 20-24 3.0 18.1 40.2 na na 35.5 2,457 a 25-29 2.5 15.3 32.3 55.7 79.0 11.9 2,300 21.5 30-34 2.1 18.3 37.6 55.9 76.1 4.5 2,151 21.3 35-39 1.8 20.6 44.7 66.0 80.7 2.7 1,575 20.4 40-44 2.6 21.2 42.4 67.2 85.7 1.8 1,269 20.6 45-49 3.5 21.3 41.6 60.5 83.9 2.0 977 21.0 25-49 2.4 18.7 38.7 na na 5.5 8,272 21.8 30-49 2.4 20.0 41.1 61.7 80.6 3.0 5,972 21.0 MEN Age 15-19 13.4 na na na na 76.5 1,282 a 20-24 7.0 20.5 37.9 na na 42.2 994 a 25-29 4.5 17.4 30.0 46.0 72.1 12.9 946 22.5 30-34 2.3 12.7 30.6 45.8 67.7 4.0 930 22.6 35-39 1.7 11.4 25.5 44.2 69.4 1.8 567 22.6 40-44 1.6 10.2 27.6 45.1 66.4 1.1 473 22.5 45-49 2.7 15.4 31.7 51.0 69.2 1.0 385 21.8 25-49 2.8 13.8 29.2 na na 5.4 3,301 22.4 30-49 2.1 12.3 28.9 46.1 68.1 2.4 2,355 22.5 25-59 2.6 14.2 29.9 na na 4.7 3,941 22.3 30-59 1.9 13.1 29.8 47.1 68.2 2.1 2,995 22.4 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Table 4.6 shows women’s and men’s median age at first sexual intercourse according to background characteristics. Neither area of residence nor wealth quintile is related to median age at first sexual intercourse among either women or men. The greatest variation among women is by level of education: the higher the level of education, the higher the median age at first sexual intercourse. Median age ranges from 19.6 years among women with no education to 23.6 years among those with a secondary education or higher. Among men the difference is small, with a corresponding range of 22.2 years to 23.0 years. Median age at first intercourse among women varies slightly across the provinces, from 20.5 years in East to 21.7 years in South. Among men, it varies from 21.9 years in West to 23.0 years in South. 58 • Proximate Determinants of Fertility Table 4.6 Median age at first sexual 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 30-59, according to background characteristics, Rwanda 2014-15 Background Women age Men age characteristic 25-49 30-59 Residence Urban 21.1 22.4 Rural 21.0 22.3 Province City of Kigali 21.2 22.5 South 21.7 23.0 West 21.0 21.9 North 20.7 22.0 East 20.5 22.2 Education No education 19.6 22.2 Primary 21.0 22.3 Secondary and higher 23.6 23.0 Wealth quintile Lowest 20.4 22.7 Second 21.1 22.5 Middle 20.9 22.2 Fourth 21.3 22.0 Highest 21.7 22.6 Total 21.0 22.3 4.5 RECENT SEXUAL ACTIVITY Frequency of sexual intercourse is a direct determinant of fertility. Therefore, the survey asked all women and men, 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 among women, according to background characteristics. Half of all women age 15-49 had sexual intercourse in the four weeks preceding the survey. Recent sexual activity was most common among women in their 30s, about three-quarters of whom reported being sexually active in the previous four weeks. The results also show that married women are most likely to have been sexually active in the past four weeks (92 percent). Recent sexual activity decreases with marital duration, from a high of 94 percent among women who have been married less than five years to a low of 88 percent among women who have been married 20 years or more. Women in rural areas reported a higher level of sexual activity in the past four weeks (51 percent) than women in urban areas (45 percent). The percentage of women who had sexual intercourse in the four weeks before the survey decreases as level of education increases, from 65 percent among those with no education to 28 percent among those with a secondary education or higher. Proximate Determinants of Fertility • 59 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 2014-15 Timing of last sexual intercourse Never had sexual intercourse Total Number of women Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 5.3 5.5 9.3 0.0 79.9 100.0 2,768 20-24 36.7 13.6 14.2 0.0 35.5 100.0 2,457 25-29 66.2 12.3 9.5 0.1 11.9 100.0 2,300 30-34 74.9 10.3 10.1 0.2 4.5 100.0 2,151 35-39 73.6 10.0 13.6 0.1 2.7 100.0 1,575 40-44 64.1 10.5 23.5 0.1 1.8 100.0 1,269 45-49 55.9 6.6 34.2 1.3 2.0 100.0 977 Marital status Never married 3.5 10.0 17.2 0.0 69.4 100.0 5,100 Married or living together 91.5 6.7 1.7 0.1 0.0 100.0 6,982 Divorced/separated/widowed 9.3 26.3 63.2 1.2 0.0 100.0 1,415 Marital duration2 0-4 years 93.8 6.0 0.3 0.0 0.0 100.0 1,680 5-9 years 92.4 7.1 0.6 0.0 0.0 100.0 1,537 10-14 years 91.4 6.9 1.7 0.0 0.0 100.0 1,078 15-19 years 91.8 5.7 2.3 0.1 0.0 100.0 962 20-24 years 88.0 8.5 3.4 0.2 0.0 100.0 619 25+ years 87.8 5.8 6.1 0.2 0.0 100.0 410 Married more than once 89.6 7.5 2.7 0.2 0.0 100.0 696 Residence Urban 45.0 13.6 15.0 0.0 26.5 100.0 2,626 Rural 50.8 9.1 13.8 0.2 26.2 100.0 10,871 Province City of Kigali 47.1 12.7 15.0 0.0 25.2 100.0 1,799 South 48.3 10.0 14.2 0.1 27.4 100.0 3,214 West 49.6 8.7 13.7 0.0 27.9 100.0 2,965 North 48.1 8.3 13.0 0.2 30.3 100.0 2,211 East 53.4 10.7 14.1 0.4 21.4 100.0 3,308 Education No education 64.7 10.2 20.3 0.6 4.2 100.0 1,665 Primary 54.7 9.9 13.7 0.1 21.6 100.0 8,678 Secondary and higher 27.9 10.1 11.5 0.0 50.5 100.0 3,154 Wealth quintile Lowest 47.8 13.5 20.4 0.2 18.2 100.0 2,561 Second 53.2 9.0 13.5 0.2 24.1 100.0 2,631 Middle 54.5 7.7 11.9 0.2 25.6 100.0 2,597 Fourth 50.5 7.7 10.6 0.1 31.1 100.0 2,634 Highest 43.3 11.7 13.8 0.2 31.0 100.0 3,073 Total 49.6 10.0 14.0 0.2 26.2 100.0 13,497 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married Table 4.7.2 presents information on recent sexual activity among men according to background characteristics. The data indicate that 50 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 reaches its peak at age 40-44 (91 percent). As with women, married men are more likely to be sexually active (95 percent) than unmarried men. The results show similar levels of sexual activity at all marital durations, with a decrease observed only among men married for 25 years or more (88 percent). 60 • Proximate Determinants of Fertility 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 2014-15 Timing of last sexual intercourse Never had sexual intercourse Total Number of men Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 1.8 6.1 15.5 0.1 76.5 100.0 1,282 20-24 20.8 14.6 22.4 0.0 42.2 100.0 994 25-29 57.4 12.8 16.7 0.1 12.9 100.0 946 30-34 82.2 7.3 6.4 0.0 4.0 100.0 930 35-39 85.8 8.9 3.6 0.0 1.8 100.0 567 40-44 90.9 5.8 1.9 0.3 1.1 100.0 473 45-49 84.7 10.2 3.9 0.2 1.0 100.0 385 Marital status Never married 4.5 12.9 23.8 0.1 58.7 100.0 2,691 Married or living together 94.9 4.9 0.2 0.1 0.0 100.0 2,792 Divorced/separated/widowed 13.7 47.7 38.6 0.0 0.0 100.0 94 Marital duration2 0-4 years 95.4 4.2 0.4 0.0 0.0 100.0 775 5-9 years 94.6 5.1 0.1 0.2 0.0 100.0 647 10-14 years 95.6 4.4 0.0 0.0 0.0 100.0 455 15-19 years 95.5 4.3 0.3 0.0 0.0 100.0 369 20-24 years 93.7 5.5 0.0 0.8 0.0 100.0 170 25+ years 88.0 12.0 0.0 0.0 0.0 100.0 59 Married more than once 94.2 5.8 0.0 0.0 0.0 100.0 317 Residence Urban 44.2 15.0 15.8 0.1 24.9 100.0 1,169 Rural 51.4 8.0 11.3 0.1 29.2 100.0 4,408 Province City of Kigali 45.7 14.7 13.6 0.1 25.9 100.0 804 South 44.4 9.4 15.5 0.1 30.6 100.0 1,327 West 52.9 7.4 9.8 0.0 29.9 100.0 1,182 North 55.6 6.2 10.4 0.3 27.4 100.0 851 East 51.4 10.3 11.5 0.0 26.8 100.0 1,413 Education No education 74.9 8.8 6.6 0.0 9.6 100.0 496 Primary 55.4 8.8 10.5 0.1 25.2 100.0 3,636 Secondary and higher 27.4 11.5 18.5 0.0 42.6 100.0 1,445 Wealth quintile Lowest 56.3 9.7 9.6 0.0 24.4 100.0 819 Second 58.5 6.0 8.7 0.0 26.8 100.0 991 Middle 53.5 7.5 12.6 0.0 26.5 100.0 1,097 Fourth 44.9 8.2 12.6 0.3 34.0 100.0 1,234 Highest 41.8 14.5 15.5 0.1 28.2 100.0 1,436 Total 15-49 49.9 9.5 12.2 0.1 28.3 100.0 5,577 50-59 78.1 14.3 6.7 0.0 0.9 100.0 640 Total 15-59 52.8 10.0 11.7 0.1 25.5 100.0 6,217 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 difference between rural (51 percent) and urban (44 percent) areas in the proportion of men who are sexually active. By province, South has the lowest proportion of men who had sexual intercourse in the four weeks before the survey (44 percent), while North has the highest proportion (56 percent). As with women, the percentage of men who had sexual intercourse during the four weeks before the survey decreases as level of education increases, from 75 percent among those with no education to 27 percent among those with a secondary education or higher. The data also indicate that the proportion of men who are sexually active generally decreases with increasing wealth. Fertility • 61 FERTILITY 5 Key Findings • The total fertility rate for the three years preceding the survey is 4.2 births per woman, with rural women having almost one child more than urban women (4.3 and 3.6 respectively). • Fertility has decreased from 6.1 births per woman in 2005 to 4.6 in 2010 and to 4.2 in 2014-15, a two-child decline in the past 10 years. • Forty-five percent of births occur within three years of a previous birth, with 14 percent occurring within 24 months. • Childbearing begins rather late in Rwanda, with 7 percent of women giving birth by age 18 and 43 percent by age 22. • Seven percent of adolescent women age 15-19 are already mothers or pregnant with their first child. or more than 30 years, Rwanda has collected socio demographic data to evaluate fertility levels, patterns, trends, and other general characteristics of its population. These efforts include the following surveys: • The 1978 Rwanda General Population and Housing Census, • The 1983 National Fertility Survey, • The 1991 Rwanda General Population and Housing Census, • The 1992 Rwanda Demographic and Health Survey (RDHS), • The 1996 Socio-demographic Survey, • The 2000 RDHS, • The 2002 Rwanda General Population and Housing Census, • The 2005 RDHS, the 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS), the 2010 RDHS, • The 2012 Rwanda General Population and Housing Census, and • The current survey, 2014-15 RDHS. Information from women’s birth histories obtained in the 2014-15 RDHS is used to estimate fertility levels, determine the timing of births, and describe the relationship of variables such as residence and educational attainment with fertility. This information provides recent indicators of fertility rates and birth spacing not only at the national level but also by province and residence. F 62 • Fertility 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 Survey (DHS) Program since its inception. The DHS surveys have contributed to the development of different policies in Rwanda and therefore have played an important role in providing evidence on the country’s overall population dynamics. This chapter analyzes the fertility data gathered in the 2014-15 RDHS, presents data on age at first birth and birth intervals, and concludes with an analysis of teenage fertility. Fertility data were obtained by asking a series of questions to all female respondents. Interviewers recorded the total number of children born to each woman, the number of children currently living with their mother, the number of children living elsewhere, and the number of children who had died. A complete birth history for each woman was then compiled, from the earliest to the most recent birth. 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 his or her mother or elsewhere. For children who had died, respondents were asked age at the time of death. 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 is a retrospective survey, the data can be used to estimate not only current fertility levels but also fertility trends over the past 30 years. Despite the organization and controls established to ensure achievement of the 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. • 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 (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 in the survey may be slightly biased. Finally, for the men’s survey, as for the women’s survey, information was gathered concerning total number of children born 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, and the number of children who had died. However, men were not asked to provide a complete birth history. 5.1 FERTILITY LEVELS AND DIFFERENTIALS Current fertility levels are commonly measured in terms of age-specific fertility rates (ASFRs). ASFRs are calculated by dividing the number of births to women in each specific five-year age group by the number of woman-years of exposure in that age group during the reference period. The total fertility rate (TFR), another common measurement of current fertility, is 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. A three-year rate was chosen to allow reporting Fertility • 63 of the most current information, to reduce sampling errors, and to avoid problems with possible intentional displacement of births from five to six years before the survey as a means of reducing the workload of collecting information for children under age 5. Table 5.1 indicates that, at the national level, ASFRs follow the classic pattern of countries with high fertility. This pattern is characterized by relatively high early fertility (45 births per 1,000 among women age 15-19) followed by a rapid increase to higher levels among women age 20-29 (179 to 213 per 1,000). Fertility is still high at age 30-34 (186 per 1,000) and 35-39 (134 per 1,000) before declining precipitously at the end of the childbearing years (12 per 1,000 at age 45-49). By the end of her childbearing years, a Rwandan woman has had an average of 4.2 births. Even though the current TFR is high, it has declined overtime from 6.1 in 2005 and 4.6 in 2010. The data in Table 5.1 also show clear differentials in fertility by residence: women in urban areas have lower fertility (3.6) than those in rural areas (4.3). 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 0.7 children more than a woman living in an urban area. Table 5.1 also shows the crude birth rate (CBR), or the average number of live births annually in the total population, estimated at 33 per 1,000 for the country as a whole, and the general fertility rate (GFR), or the average number of live births per 1,000 women of reproductive age (age 15-44), estimated at 142 per 1,000. Similar to the TFR, these two indicators vary significantly by residence. Rural areas have a GFR of 146 per 1,000, as compared with 124 per 1,000 in urban areas. Conversely, the CBR for rural areas (32 per 1,000) is two points less than the CBR for urban areas (34 per 1,000). This might be explained by the increasing number of youths migrating from rural to urban areas. This leads to a larger proportion of the urban population being made up of younger adults, those in the prime fertility ages. Thus, even though the fertility rate per woman is lower in urban areas than in rural areas, the fact that there are proportionally more women in urban areas means that the crude birth rate per population is higher. Table 5.2 presents fertility rates by background characteristics. The TFR varies by province, ranging from a high of 4.6 children per woman in West and East to a low of 3.6 children per woman in the city of Kigali, 3.7 in North, and 4.0 in South. In other words, women in the West and East provinces have an average of one more child than women in City of Kigali. The TFR is associated with educational attainment, varying from 3.0 children among women with a secondary education or higher to 5.1 children among women with no education. There is a similar relationship between fertility and wealth; the TFR is almost two children lower among women in the highest wealth quintile than among those in the lowest quintile. Table 5.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Rwanda 2014-15 Residence Total Age group Urban Rural 15-19 41 46 45 20-24 143 190 179 25-29 185 220 213 30-34 185 187 186 35-39 107 139 134 40-44 52 67 65 45-49 1 13 12 TFR(15-49) 3.6 4.3 4.2 GFR 124 146 142 CBR 34.3 32.3 32.6 Notes: Age-specific fertility rates are per 1,000 women. Rates for the 45-49 age group may be slightly biased due to truncation. Rates are for the period 1-36 months prior to the interview. TFR: Total fertility rate, expressed per woman GFR: General fertility rate, expressed per 1,000 women age 15-44 CBR: Crude birth rate, expressed per 1,000 population 64 • Fertility 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, by background characteristics, Rwanda 2014-15 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 3.6 6.6 4.8 Rural 4.3 7.5 5.6 Province City of Kigali 3.6 6.9 4.6 South 4.0 6.9 5.0 West 4.6 7.4 5.9 North 3.7 6.3 5.6 East 4.6 8.4 5.9 Education No education 5.1 6.6 6.1 Primary 4.5 8.0 5.4 Secondary and higher 3.0 5.8 3.9 Wealth quintile Lowest 5.1 7.7 5.3 Second 4.6 7.7 5.6 Middle 4.1 8.0 5.8 Fourth 3.9 7.1 5.7 Highest 3.3 6.2 4.9 Total 4.2 7.3 5.5 Note: Total fertility rates are for the period 1-36 months prior to the interview. Table 5.2 also shows the mean number of lifetime live births (children ever born) among women age 40 to 49. This figure is an indicator of completed, or cumulative, fertility. Unlike the TFR, which measures current or recent fertility among 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. However, 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. In Rwanda, the total cumulative fertility rate is 5.5 children, considerably higher than the TFR (4.2). The difference (1.3) suggests a substantial decline in fertility. The difference between the two rates was 0.5 children in 2005 and 1.3 children in 2010. The fertility results by background characteristics show cumulative fertility rates above the TFR for all categories, indicating that fertility is declining among all women. However, the difference between cumulative fertility (number of children ever born) and the TFR is greatest in the North province (1.9 children) and in the three highest wealth quintiles (1.6 to 1.8 children).In the lowest wealth quintile, the difference is negligible (0.2 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. The lowest pregnancy rates are observed among women with a secondary education or higher, those living in the wealthiest households, and Fertility • 65 those living in the North province (6 percent for each category). These groups also tend to have the lowest current fertility levels. 5.2 FERTILITY TRENDS Trends in fertility can be examined in two ways. One is to utilize data from the 2014-15 RDHS alone, examining the information on births over time gathered in the birth histories. A second way to examine trends is to compare the data from the 2014-15 survey with data from previous surveys. Both indicate that there has been a decline in fertility in Rwanda. The data collected in the 2014-15 RDHS were used to track fertility trends over the course of five-year periods up to 20 years prior to the survey (Table 5.3.1 and Figure 5.1). To calculate these rates, births were classified according to the period of time in which the birth occurred and the mother’s age at the time of the birth. Because women age 50 and above were not interviewed in the survey, the rates are successively truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 35-39 for a period of 15 to 19 years before the survey because these women would have been over age 50 at the time of the 2014-15 RDHS and would not have been interviewed. ASFR shave declined over time among young women age 15-19, from 58 per 1,000 in the period 15-19 years before the survey to 44 per 1,000 in the five years preceding the survey. Among women age 20-24, the ASFR fell from 242 during the 15-19 years preceding the survey to 179 during years 0-4 before the survey. Finally, among women age 25-29, the ASFR fell from 299 in the 15-19 years preceding the survey to 207 during the five years before the survey. Table 5.3.1 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Rwanda 2014-15 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 44 40 50 58 20-24 179 199 218 242 25-29 207 264 289 299 30-34 182 231 276 [270] 35-39 131 188 [228] - 40-44 66 [112] - - 45-49 [14] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of the interview. As mentioned above, trends can also be assessed by comparing results across surveys and censuses. Two national demographic data collection efforts are conducted regularly in Rwanda: the General Population and Housing Census and the RDHS. The censuses of 1978, 1991, 2002, and 2012 gathered information on 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) that yields more reliable results. Yet, the various RDHS surveys (1992, 2000, 2005, 2007-08, and 2010) and the censuses of 1991, 2002, and 2012 have produced more or less similar results with respect to TFRs. 66 • Fertility Figure 5.1 Age-specific fertility rates for five-year periods preceding the survey Table 5.3.2 shows ASFRs for the six DHS surveys (including the interim DHS), and Figure 5.2 presents past fertility trends based on the results of the 2000, 2005, 2010, and 2014-15 RDHS surveys and the 2007-2008 RIDHS. Fertility during the period 1992-2005 remained relatively stable at around six children per woman. The total fertility rate then dropped to 5.5 in 2007-08 and declined considerably thereafter, to 4.6 in 2010 and 4.2 in 2014-15. The ASFR curves follow a similar pattern, increasing rapidly with age, peaking between age 25-29, and then tapering off steadily up to age 45 to 49. Table 5.3.2 Trends in fertility Age-specific fertility rates (per 1,000 women) and total fertility rates, Rwanda 1992 to 2014-15 Mother's age at birth 1992 2000 2005 2007-08 2010 2014-15 15-19 60 52 42 40 41 44 20-24 227 240 235 211 195 179 25-29 294 272 305 272 248 207 30-34 270 257 273 246 217 182 35-39 214 190 211 209 164 131 40-44 135 123 117 105 98 66 45-49 46 33 32 20 21 14 Total 6.2 5.8 6.1 5.5 4.6 4.2 Note: Age-specific fertility rates are per 1,000 women. It should be noted that the ASFRs in the 40-44 and 45-49 age groups have declined relatively slowly over time. However, the curve for the 2014-15 RDHS is below the other four ASFR curves at all ages and drops lower after age 25 than the other four curves, indicating a trend toward declining fertility among women in these generations. 0 50 100 150 200 250 300 350 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Births per 1,000 women Woman's age 0-4 years 5-9 years 10-14 years 15-19 years RDHS 2014-15 Fertility • 67 Figure 5.2 Trends in age-specific fertility rates, various sources 5.3 CHILDREN EVER BORN AND LIVING Table 5.4 presents the distribution of all women and currently married women by age group and according to: 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, this information is useful for observing how average family size varies across age groups and for observing levels of primary infertility. On average, Rwandan women attain a parity of 5.8 children by the end of their childbearing years. This number is considerably higher than the TFR of 4.2 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, 27 percent of women age 45-49 have given birth to eight or more children. The same pattern is observed among currently married women, except that the mean number of children ever born is higher in this group (3.5 children) than among all women (2.3 children). The difference in mean number of children ever born between all women and currently married women can be attributed to the substantial proportion of young, unmarried women in the former category. The results show that 95 percent of young women age 15-19 have never given birth. This proportion declines steadily to 20 percent among women age 25-29, 8 percent or lower among women age 30-49. 0 50 100 150 200 250 300 350 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Births per 1,000 women RDHS 2000 RDHS 2005 RDHS 2007-08 RDHS 2010 RDHS 2014-15 68 • 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 2014-15 Number of children ever born Total Number of women Mean number of children ever born Mean number of living children Age 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN Age 15-19 94.5 5.2 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,768 0.06 0.05 20-24 52.5 33.6 11.5 2.1 0.3 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,457 0.64 0.61 25-29 19.5 25.6 32.7 15.5 5.4 1.1 0.2 0.1 0.0 0.0 0.0 100.0 2,300 1.66 1.57 30-34 8.1 10.6 22.3 25.6 18.6 9.2 3.9 1.2 0.4 0.1 0.0 100.0 2,151 2.89 2.67 35-39 4.2 5.3 9.5 15.3 20.4 20.6 12.3 7.6 3.4 1.2 0.2 100.0 1,575 4.22 3.74 40-44 3.0 3.9 5.3 9.3 15.0 17.4 15.3 15.0 8.2 5.0 2.4 100.0 1,269 5.23 4.36 45-49 3.8 2.6 4.4 7.8 11.2 15.1 15.2 13.3 11.4 7.2 7.9 100.0 977 5.81 4.60 Total 34.6 14.4 13.2 10.3 8.5 6.8 4.6 3.5 2.1 1.2 0.8 100.0 13,497 2.28 1.99 CURRENTLY MARRIED WOMEN Age 15-19 42.4 51.2 6.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 85 0.64 0.59 20-24 15.3 55.1 24.8 4.2 0.6 0.0 0.0 0.0 0.0 0.0 0.0 100.0 883 1.20 1.13 25-29 4.8 26.3 41.2 18.8 7.0 1.3 0.3 0.2 0.0 0.0 0.0 100.0 1,577 2.03 1.92 30-34 2.6 8.1 22.8 27.7 21.6 10.4 4.8 1.5 0.4 0.1 0.0 100.0 1,693 3.18 2.95 35-39 0.8 2.9 8.9 14.9 21.3 22.9 13.7 8.8 4.0 1.5 0.3 100.0 1,240 4.57 4.07 40-44 0.9 1.8 3.4 6.9 14.1 16.7 17.9 18.5 10.5 6.5 2.6 100.0 896 5.77 4.88 45-49 1.9 1.6 3.7 5.0 9.1 11.6 15.5 16.5 14.2 9.3 11.5 100.0 607 6.49 5.22 Total 4.6 16.4 20.4 15.5 13.3 10.0 7.3 5.8 3.4 1.9 1.4 100.0 6,982 3.51 3.10 5.4 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 the design of reproductive health programs. Short birth intervals (less than 24 months) are considered harmful to the health and nutritional status of children and increase their risk of premature death. In addition, short birth intervals expose a woman to a greater risk of complications during and after pregnancy (miscarriage or eclampsia, for example) and are associated with high cumulative fertility. Table 5.5 shows the distribution of non-first births in the five years preceding the survey by the number of months since the preceding birth. The results show that 5 percent of births occur less than 18 months apart and that 9 percent occur between 18 and 23 months after the preceding birth. Thus, 14 percent of births occur less than two years after a prior birth. However, a relatively large proportion of births (30 percent) occur between two and three years after the preceding birth, and over half (56 percent) occur three or more years apart. The median birth interval is slightly more than three years (38.5 months), which means that half of all non-first births take place 38.5 months after the preceding birth. Fertility • 69 Table 5.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Rwanda 2014-15 Months since preceding birth Total Number of non-first births Median number of months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 * * * * * * 100.0 6 * 20-29 8.9 12.8 32.9 24.3 12.4 8.7 100.0 1,861 34.0 30-39 3.4 7.9 29.9 20.8 15.5 22.5 100.0 2,985 40.8 40-49 2.4 6.0 23.9 20.2 14.2 33.3 100.0 766 46.1 Sex of preceding birth Male 4.9 9.4 29.6 21.9 15.5 18.7 100.0 2,803 38.8 Female 5.3 9.1 30.6 21.8 13.1 20.1 100.0 2,816 38.3 Survival of preceding birth Living 4.0 9.2 30.2 22.4 14.5 19.6 100.0 5,265 38.9 Dead 21.2 10.1 27.8 13.5 11.7 15.8 100.0 354 30.9 Birth order 2-3 6.6 10.4 29.1 24.0 14.0 15.8 100.0 3,037 37.2 4-6 3.3 7.6 30.5 18.0 15.1 25.4 100.0 1,932 41.6 7+ 3.6 8.7 33.3 23.1 13.0 18.4 100.0 651 38.0 Residence Urban 6.9 10.6 30.4 17.8 11.3 23.0 100.0 866 37.3 Rural 4.8 9.0 30.0 22.6 14.8 18.7 100.0 4,753 38.7 Province City of Kigali 6.6 10.6 26.5 21.1 12.0 23.3 100.0 613 38.9 South 4.5 7.6 31.5 21.8 14.1 20.5 100.0 1,283 39.1 West 6.6 10.2 36.7 22.0 10.9 13.6 100.0 1,392 34.2 North 2.8 9.2 26.3 20.3 17.7 23.7 100.0 782 42.2 East 4.9 9.2 26.3 22.8 16.7 20.1 100.0 1,548 40.3 Education No education 4.9 7.4 31.6 20.5 14.9 20.6 100.0 1,018 39.1 Primary 4.8 9.6 30.2 22.3 14.3 18.7 100.0 4,107 38.3 Secondary and higher 7.9 9.9 25.8 20.7 13.3 22.4 100.0 494 39.8 Wealth quintile Lowest 5.1 8.0 32.4 22.7 14.6 17.1 100.0 1,403 38.1 Second 4.7 8.5 32.0 20.9 15.8 18.1 100.0 1,225 38.1 Middle 5.0 8.8 31.2 23.4 12.7 18.9 100.0 1,130 37.8 Fourth 3.7 10.6 27.0 23.4 15.2 20.1 100.0 965 40.2 Highest 7.4 11.2 25.7 18.1 12.8 24.7 100.0 897 39.1 Total 5.1 9.3 30.1 21.8 14.3 19.4 100.0 5,619 38.5 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. With respect to age, birth intervals are shorter for younger women than for older women. The median duration increases from 34 months at age 20 to 29 to 46 months at age 40 to 49. Differentials by gender are not significant (39 months for boys and 38 months for girls). Birth intervals vary with birth order, from 37 months for birth orders 2-3 to 42 months for birth orders 4-6 and 38 months for birth order 7 or above. Survival of the preceding child is an important factor related to birth interval. When the preceding child has died, the median interval between that birth and the next birth is 31 months; when the preceding child is alive, the median interval is 39 months, or approximately eight months longer. The median interval between births is slightly higher in rural areas (39 months) than in urban areas (37 months). By province, the birth interval varies from a low of 34 months in West to a high of 42 months in North. Median birth intervals are longer among birth whose mother with a secondary education or higher (40 months) than among those with no education (39 months) and those whose mother with a primary education 70 • Fertility (38 months). Similarly, birth intervals are slightly longer among women in the fourth and highest wealth quintiles (40 months and 39 months, respectively) than among those in the three lowest quintiles (38 months). 5.5 EXPOSURE TO THE RISK OF PREGNANCY 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 largely 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 low 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 were 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 2014-15 Percentage of births for which the mother is: Number of births Months since birth Amenorrheic Abstaining Insusceptible1 <2 95.5 52.7 96.5 207 2-3 84.3 19.5 86.1 240 4-5 74.1 14.5 76.0 276 6-7 66.0 13.3 69.0 348 8-9 61.8 17.3 66.7 324 10-11 47.6 17.0 56.0 263 12-13 38.8 8.7 45.3 273 14-15 33.1 6.8 37.3 266 16-17 33.3 11.0 39.8 293 18-19 20.8 11.3 29.6 286 20-21 16.3 7.8 22.2 267 22-23 16.0 5.9 19.8 256 24-25 8.7 7.1 14.5 287 26-27 8.0 7.8 13.8 249 28-29 4.9 11.3 15.0 278 30-31 7.8 6.5 13.3 259 32-33 5.3 4.4 9.3 257 34-35 6.4 8.5 13.3 252 Total 34.9 12.4 40.2 4,883 Median 10.5 0.9 11.8 na Mean 12.8 5.1 14.7 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth In Rwanda, 35 percent of women who gave birth during the three years preceding the survey were amenorrheic, and another 12 percent were abstinent. Forty 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. Duration, intensity, and frequency of exclusive breastfeeding affect the return of ovulation (see Chapter 10 on nutrition) and are partly responsible for these relatively long durations. However, the median duration of postpartum amenorrhea has remained unchanged since 2010 (11 months). The median and mean durations of postpartum abstinence are very short (1 month and 5 months, respectively). As expected, the amenorrheic status of women who gave birth during the three years preceding the survey decreases with increasing duration since birth: almost all of the women (96 percent) who gave birth less than 2 months before the survey remained amenorrheic, around three-quarters (74 percent) remained amenorrheic for 4 or 5 months, approximately three in five (62 percent) were still amenorrheic at 8-9 months, Fertility • 71 and only 8 percent remained so at 26-27 months. Beyond 28 months, the proportion of women for whom menstruation had not yet returned varied between 5 percent and 8 percent. Postpartum abstinence decreases quickly over time, from 53 percent at less than 2 months postpartum to only 20 percent at 2-3 months postpartum. The percentage of women who abstain for 4 months or longer varies from a high of 17 percent to a low of 4 percent. 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 2014-15 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 9.1 0.9 10.8 30-49 12.4 1.0 13.2 Residence Urban 7.8 0.7 9.9 Rural 10.8 1.0 12.0 Province City of Kigali 6.3 0.7 10.5 South 11.8 0.8 13.2 West 11.7 0.7 13.0 North 10.0 0.7 11.5 East 9.0 1.6 10.2 Education No education 15.9 0.7 16.0 Primary 10.7 0.9 11.6 Secondary and higher 6.1 1.4 7.5 Wealth quintile Lowest 13.0 0.6 17.4 Second 10.3 0.7 10.8 Middle 10.6 0.9 12.7 Fourth 9.8 1.3 12.2 Highest 6.9 1.4 8.0 Total 10.5 0.9 11.8 Note: Medians are based on 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 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 (9 months) than women age 30-49 (12 months). The duration of postpartum amenorrhea is 8 months in urban areas, as compared with 11 months in rural areas. By province, women in City of Kigali have the shortest period of amenorrhea (6 months), while those in South and West have the longest periods (12 months). Results differ according to level of education: the median duration of amenorrhea is shortest among women with a secondary education or higher (6 months) and longest among women with no education (16 months). Duration of postpartum amenorrhea decreases with increasing wealth, from 13 months among women in the lowest wealth quintile to 7 months among those in the highest quintile. Duration of postpartum insusceptibility follows the same pattern as that of postpartum amenorrhea. 5.6 MENOPAUSE Women cease being exposed to the risk of pregnancy when they reach menopause. Women were considered menopausal if they were neither pregnant nor postpartum amenorrheic and had not had a menstrual period in the six months preceding the survey or if they reported themselves as having entered menopause. 72 • Fertility Table 5.8 shows the percentage of women age 30-49 who are menopausal. Overall, 8 percent of women reported being menopausal. The proportion increases with age, from 5 percent among women age 30-34 and 35-39 to 13 percent among those age 44-45 and 31 percent among those age 48-49. 5.7 AGE AT FIRST BIRTH The age at which childbearing begins is an important demographic indicator because it has a direct bearing on a woman’s cumulative fertility, particularly when there is little or no contraceptive use. The earlier a woman begins childbearing, the greater her likelihood of having many children. Also, having children at too young an age can have negative repercussions for 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 the median age at first birth according to age at the time of the survey. The median age at first birth among women age 25-49 is 22.7 years. There is no clear trend across age groups. Median age at first birth has increased slightly since 2010 (22.4 years). Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Rwanda 2014-15 Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth Current age 15 18 20 22 25 Age 15-19 0.2 na na na na 94.5 2,768 a 20-24 0.1 6.1 20.5 na na 52.5 2,457 a 25-29 0.3 5.9 18.1 37.7 68.2 19.5 2,300 23.0 30-34 0.2 6.1 21.4 40.5 67.0 8.1 2,151 23.0 35-39 0.4 6.9 26.0 49.0 72.9 4.2 1,575 22.1 40-44 0.7 8.7 24.6 47.5 78.3 3.0 1,269 22.2 45-49 1.0 7.9 24.2 43.4 72.5 3.8 977 22.7 25-49 0.4 6.8 22.2 42.8 70.9 9.2 8,272 22.7 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 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Rwanda 2014-15 Age Percentage menopausal1 Number of women Age 30-34 5.1 2,151 35-39 5.0 1,575 40-41 7.7 552 42-43 6.2 487 44-45 13.4 430 46-47 15.4 400 48-49 30.8 378 Total 8.3 5,972 1 Percentage of all women who are not pregnant and not postpartum amenorrheic, not currently using contraceptive method, whose last menstrual period occurred six or more months preceding the survey, and report that they are in menopausal. Fertility • 73 Table 5.10 shows median age at first birth according to various socioeconomic characteristics. Women in rural areas (22.6 years) have a lower median age at first birth than those in urban areas (23.3 years). The city of Kigali and the South province have the highest median age at first birth (23.5 years). In the other provinces, median age at first birth varies from a low of 22.1 years in East to a high of 23.5 years in South. Women’s level of educational attainment is related to their median age at first birth: age at first birth rises as women’s educational level increases. Results by household wealth show that median age at first birth varies from a high among women in the highest wealth quintile (23.6 years) to a low among those in the lowest quintile (22.1 years). For women age 30-49, the median age at first birth is 21.4 for women with no education and 24.8 for the women with secondary and higher education. 5.8 TEENAGE FERTILITY Teenage fertility is an important demographic factor for several reasons. First, children born to very young mothers are at greater risk of illness and death. Second, teenage mothers are more likely to suffer complications during pregnancy and less likely to treat them, exposing them to a greater risk of complications during delivery and a 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 young women age 15-19 who have already had one or more children as well as those currently in their first pregnancy. Seven percent of young women between age 15 and age 19 have already begun childbearing (6 percent are already mothers and 2 percent are pregnant for the first time). At age 15, 1 percent of young women have begun childbearing. The percentage increases steadily and rapidly with age: 4 percent of young women age 17 have already had at least one child or are pregnant for the first time. At age 19, 21 percent of young women have begun childbearing (16 percent have already had at least one child and 5 percent are pregnant for the first time). Table 5.10 Median age at first birth Median age at first birth among women age 25-49 and 30-49, according to background characteristics, Rwanda 2014-15 Background Women age Women age characteristic 25-49 30-49 Residence Urban 23.3 23.1 Rural 22.6 22.4 Province City of Kigali 23.5 23.4 South 23.5 23.6 West 22.5 22.2 North 22.2 21.8 East 22.1 21.8 Education No education 21.4 21.4 Primary 22.6 22.6 Secondary and higher a 24.8 Wealth quintile Lowest 22.1 22.2 Second 22.5 22.5 Middle 22.4 22.1 Fourth 22.9 22.7 Highest 23.6 23.3 Total 22.7 22.5 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 74 • 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 2014-15 Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Background characteristic Have had a live birth Are pregnant with first child Age 15 0.9 0.1 1.0 666 16 1.7 0.3 2.0 559 17 2.9 1.4 4.3 518 18 8.4 3.1 11.5 557 19 15.9 4.9 20.8 468 Residence Urban 5.6 2.3 7.9 564 Rural 5.4 1.7 7.1 2,204 Province City of Kigali 6.5 3.7 10.2 357 South 4.1 1.5 5.6 665 West 4.8 0.9 5.8 592 North 4.0 0.9 4.9 525 East 8.1 2.6 10.7 628 Education No education (12.7) (0.0) (12.7) 30 Primary 6.9 2.3 9.2 1,632 Secondary and higher 3.2 1.1 4.3 1,106 Wealth quintile Lowest 9.0 2.1 11.1 433 Second 6.1 2.0 8.2 509 Middle 5.4 1.9 7.3 501 Fourth 4.0 1.4 5.5 599 Highest 4.1 1.7 5.8 726 Total 5.5 1.8 7.3 2,768 Note: Figures in parentheses are based on 25-49 unweighted cases. There are differences in teenage pregnancy across the provinces: the proportion of young women who have begun childbearing varies from a low of 5 percent in North to a high of 11 percent in East. Early childbearing occurs more frequently among young women with a primary education (9 percent) than among those with a secondary education or higher (4 percent). There are also differentials by wealth quintile: the proportion of young women who have begun childbearing varies from 6 percent in the richest two quintiles to 11 percent in the lowest quintile. After decreasing from 11 percent in 1992 to 7 percent in 2000 and 4 percent in 2005, the proportion of young women who have begun childbearing has shown slight increase from 6 percent in 2010 to 7 percent in 2014-15. Fertility Preferences • 75 FERTILITY PREFERENCES 6 Key Findings • About half of currently married women (47 percent) and men (49 percent) age 15-49 want no more children or are sterilized. • The mean ideal number of children is 3.4 among women and 3.0 among men. Mean ideal number of children among women has remained stable in the last five years. • The gap between the total fertility rate (TFR) and the total wanted fertility rate (TWFR) has narrowed marginally within the last five years, from 1.5 children in the 2010 RDHS to 1.1 children in 2014-15. ata on fertility preferences are 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 2014-15 RDHS asked women and men whether they wanted another child (more children), how long they wanted to wait before having their next child, and the total number of children they considered to be ideal. Some of the data focus on only women and men who were married at the time of the survey. Data on attitudes and opinions about procreation have always been somewhat controversial. Some researchers believe that 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 spouse, who can exert enormous influence over reproductive health decisions; and, third, they are obtained from a sample of respondents 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 individuals who respond. The responses of older women and men who are at the end of their childbearing years are inevitably influenced by their birth histories. Despite possible problems with interpretation, data on fertility preferences can improve understanding 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 2014-15 RDHS asked women and men a series of questions designed to discern their desire to delay their 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. Data are shown for currently married women and men only. Forty-seven percent of married women reported wanting no more children, while about half (49 percent) wanted to have another child. The proportion of women who do not want more children increased D 76 • Fertility Preferences between 2005 and 2010 (from 42 percent to 52 percent) before the decline to 47 percent in the current survey. As a result of this decline, the proportion of women wanting more children has increased from 44 percent in 2010 to 49 percent in 2014-15. Among the women in this group, 10 percent want another child within two years, 39 percent want to delay their next birth by two or more years, and less than 1 percent want to have another child but are uncertain when. In general, 87 percent of married women in Rwanda can be considered potential candidates for family planning: those who do not want any more children (47 percent) and those who want to delay their next birth (39 percent). The proportion of women who want more children decreases as parity increases. For example, the percentage of women who want to delay their next birth declines from 78 percent among those with one child to 17 percent among those with four children and 5 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 number of living children, from 1 percent among those with no children to 73 percent among those with four children and 89 percent among those with six children or more (Table 6.1). Women who want no more children have presumably reached their desired family size and should be using a contraceptive method to avoid unwanted pregnancies. Finally, the data show that 93 percent of married 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 2014-15 Number of living children Total 15-49 Total 15-59 Desire for children 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 89.0 17.9 10.3 6.2 4.6 1.8 1.2 9.7 na Have another later3 3.7 78.0 64.1 37.1 17.0 10.7 4.8 39.3 na Have another, undecided when 0.0 0.4 0.3 0.1 0.1 0.0 0.1 0.2 na Undecided 0.8 0.3 1.3 2.3 2.0 0.8 1.1 1.3 na Want no more 0.7 2.7 22.9 52.4 73.3 82.5 88.7 47.2 na Sterilized4 0.6 0.2 0.5 1.4 1.9 3.1 3.1 1.5 na Declared infecund 5.2 0.4 0.6 0.5 0.9 0.4 0.9 0.7 na Missing 0.0 0.1 0.1 0.1 0.2 0.6 0.2 0.2 na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 na Number 158 1,224 1,564 1,257 1,126 746 907 6,982 na MEN5 Have another soon2 88.6 12.3 8.6 4.0 3.9 2.1 0.3 8.1 7.0 Have another later3 6.2 84.0 59.6 39.0 18.0 11.3 7.3 40.9 34.4 Have another, undecided when 0.0 0.0 0.5 0.2 0.2 0.3 0.3 0.3 0.2 Undecided 1.3 0.7 0.7 0.9 2.0 0.3 0.7 0.9 0.8 Want no more 1.5 2.7 30.2 55.4 74.2 85.3 90.7 49.1 55.7 Sterilized4 0.0 0.0 0.2 0.4 1.7 0.4 0.8 0.5 0.6 Declared infecund 2.3 0.4 0.0 0.1 0.0 0.0 0.0 0.2 1.1 Missing 0.0 0.0 0.2 0.0 0.0 0.3 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 72 526 617 491 437 292 356 2,792 3,371 na=Not applicable 1 The number of living children includes the current pregnancy. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 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 married men in Rwanda who want no more children (49 percent) is about the same as that among women. The same is true for the proportion of men who want more children later (41 percent). As it is the case 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 Fertility Preferences • 77 with increasing parity. The percentage of men who want to delay their next child ranges from a high of 84 percent among those with one child to a low of 7 percent among those who have six or more children. It should be noted that, at each parity level, the differences between married men and women who want more children are minimal. 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 2014-15 Number of living children1 Total Background characteristic 0 1 2 3 4 5 6+ Residence Urban (0.0) 2.2 26.7 59.4 74.3 83.4 90.5 44.4 Rural 1.6 3.2 22.5 52.5 75.3 85.9 91.9 49.5 Province City of Kigali * 1.5 24.2 58.0 77.2 88.4 89.5 43.8 South (0.0) 4.3 28.5 57.0 82.7 88.7 94.2 52.6 West (2.9) 2.0 23.6 47.9 62.2 77.1 89.5 46.9 North (4.2) 5.9 20.8 60.7 79.6 83.5 92.9 50.9 East (0.0) 1.7 19.2 48.9 75.6 90.4 92.1 47.5 Education No education * 9.2 28.5 52.8 73.5 85.6 93.8 63.6 Primary 2.0 2.2 22.2 53.6 74.4 85.8 91.2 47.8 Secondary and higher (0.0) 2.9 25.7 56.1 84.2 83.5 (85.2) 34.1 Wealth quintile Lowest (0.0) 3.0 29.6 54.2 82.0 89.7 94.9 49.8 Second (3.4) 3.4 21.5 54.7 72.2 89.2 91.8 46.6 Middle * 3.2 18.7 53.8 73.2 81.8 91.6 49.3 Fourth (2.7) 3.0 21.2 48.6 75.0 85.4 92.6 51.2 Highest (0.0) 2.2 25.3 56.4 73.5 82.7 88.2 46.5 Total 1.3 3.0 23.4 53.8 75.1 85.6 91.8 48.7 Note: Women who have been sterilized are considered to want no more children. 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 The number of living children includes the current pregnancy. Tables 6.2.1 and 6.2.2 show the percentages of currently married women and men who want no more children according to background characteristics. In these tables, respondents who have been sterilized or whose spouse has been sterilized are considered to 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 (50 percent for women and 51 percent for men) than in urban areas (44 percent for women and 45 percent for men). The situation is the same as in 2010, when women and men in rural areas were more likely to want to limit births than those in urban areas. By province, the proportion of married women who want no more children ranges from a low of 44 percent in the City of Kigali to a high of 53 percent in South. Results by level of education show that women with no education are more likely wanting to limit births (64 percent) than women with a primary (48 percent) or secondary (34 percent) education. There are no substantial differences by wealth quintile in the desire to limit births: women in the fourth quintile are most likely to want to stop childbearing (51 percent), while women in the second and highest quintiles are least likely to want to do so (47 percent). By province, the results for men differ from those for women: West has the lowest proportion of men who have reached their desired number of children (46 percent), and South has the highest (55 percent). As with women, married men with no education are more likely to want to limit births (61 percent) than men with a primary (49 percent) or secondary (38 percent) education. The proportion of men who want no more children does not vary consistently with wealth quintile. 78 • 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 2014-15 Number of living children1 Total Background characteristic 0 1 2 3 4 5 6+ Residence Urban * 0.7 28.5 67.5 67.7 (85.3) 86.0 44.8 Rural 1.9 3.2 30.9 53.0 77.2 85.7 92.3 50.6 Province City of Kigali * 4.2 37.2 64.9 78.9 (86.4) (91.5) 50.2 South * 1.9 38.1 62.7 84.8 93.9 92.2 54.9 West * 3.3 29.7 45.1 61.5 80.2 90.9 46.4 North * 1.4 23.0 54.6 72.9 (88.2) 94.4 48.6 East * 2.7 24.7 53.2 79.6 81.8 89.7 48.3 Education No education * 5.7 39.9 65.3 72.3 87.3 89.2 60.5 Primary 0.0 2.4 29.4 52.7 76.2 86.4 92.6 49.4 Secondary and higher * 2.1 28.5 62.5 (77.7) (77.5) (86.2) 38.3 Wealth quintile Lowest * 3.9 41.7 59.5 78.7 (90.1) (93.2) 50.3 Second * 3.2 26.4 52.3 74.5 90.9 87.0 47.0 Middle * 1.1 26.1 53.1 81.0 85.2 91.6 50.2 Fourth * 2.0 33.4 55.9 74.7 72.3 98.8 51.5 Highest * 3.1 26.6 59.4 70.5 91.0 86.7 49.2 Total 15-49 1.5 2.7 30.4 55.8 75.8 85.7 91.4 49.6 50-59 * * (59.8) * 84.8 87.2 94.5 88.8 Total 15-59 1.4 4.4 31.7 57.2 77.0 86.0 93.0 56.3 Note: Men who have been sterilized or who state in response to the question about desire for children that their wife has been sterilized are considered to want no more children. 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 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). 6.2 IDEAL NUMBER OF CHILDREN Women’s reproductive behavior can be influenced by the ideal number of children they would like to have and the ideal number their husband or partner would like to have. Two questions were used to determine this ideal number. Women with no living children were asked: If you could choose the exact number of children you would like to have in your lifetime, how many would you have? Women with living children were asked: 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. Also, it might be difficult for some women to think in terms of a total number of children to have. The ideal numbers of children reported by all women and married women are 3.4 and 3.6, respectively (Table 6.3). In both cases, the ideal is lower than the total fertility rate (TFR) of 4.2, which means that women’s ideal family size is smaller than actual fertility. An examination of the distribution of reported ideal family size shows that, among 85 percent of women, the ideal number of children ranges from two to four. Thirty-six percent of women prefer three children, 26 percent prefer four and 23 percent prefer two. For 12 percent of women, the ideal family size is five children or more. Only 2 percent of women have an ideal number of children below two. Fertility Preferences • 79 Table 6.3 Ideal number of children by number of living 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 2014-15 Number of living children Total Ideal number of children 0 1 2 3 4 5 6+ WOMEN1 0 1.1 0.3 0.2 0.3 0.2 0.3 0.3 0.5 1 1.1 3.1 1.3 2.4 1.4 1.1 0.3 1.6 2 31.4 30.7 21.1 13.3 14.7 12.7 10.4 23.1 3 41.5 47.4 42.1 29.9 22.6 23.8 17.6 36.2 4 19.1 14.3 28.3 39.9 34.2 30.8 32.6 25.5 5 3.7 2.5 3.6 8.2 15.2 11.0 14.7 6.5 6+ 1.7 1.5 2.4 5.0 10.7 18.5 20.4 5.6 Non-numeric responses 0.4 0.3 0.9 1.0 1.0 1.7 3.7 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,487 2,103 1,989 1,608 1,373 916 1,020 13,497 Mean ideal number of children for:2 All 3.0 2.9 3.2 3.6 3.9 4.2 4.5 3.4 Number 4,469 2,097 1,971 1,592 1,360 900 982 13,372 Currently married 3.1 2.9 3.3 3.7 3.9 4.3 4.6 3.6 Number of currently married 154 1,221 1,549 1,244 1,114 733 875 6,890 MEN3 0 0.2 0.0 0.3 0.1 0.7 0.0 0.7 0.3 1 1.2 1.3 2.6 3.9 2.1 3.0 1.4 1.8 2 38.6 37.4 23.4 17.4 24.1 29.7 22.9 32.1 3 41.8 49.8 50.6 43.2 26.6 36.8 34.8 41.9 4 14.5 8.9 18.4 29.7 33.4 20.2 25.0 18.2 5 2.2 1.5 3.8 4.9 7.9 5.4 4.3 3.3 6+ 1.4 1.1 0.8 0.8 4.5 4.8 10.6 2.3 Non-numeric responses 0.1 0.0 0.1 0.0 0.7 0.0 0.3 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,673 641 649 508 451 296 357 5,577 Mean ideal number of children for:2 All 2.8 2.8 3.0 3.2 3.3 3.1 3.5 3.0 Number 2,670 641 648 508 448 296 356 5,569 Currently married 3.0 2.8 3.0 3.2 3.3 3.1 3.5 3.1 Number of currently married 72 526 616 491 434 292 355 2,787 Mean ideal number of children for men 15-59:2 All men 2.8 2.8 3.0 3.2 3.3 3.1 3.3 3.0 Number of men 2,690 658 683 536 522 387 733 6,209 Currently married men 2.9 2.7 3.0 3.1 3.3 3.1 3.3 3.1 Number of currently married men 79 539 645 511 502 379 711 3,366 1 The number of living children includes the current pregnancy. 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 mean ideal family size for women in general increases from 3.0 children among those with no children to 4.5 children among those with six children or more. A similar finding was observed among women who were married at the time of the survey. The results indicate that many women would ideally want to have fewer children than they already have. For example, three-quarters of women with six or more children say that if they could start over, they would have preferred fewer than six. Similarly, more than two-thirds of women with five children say they would ideally like to have fewer. Among all women, mean ideal family size decreased from 4.3 in 2005 to 3.3 in 2010 and more or less stabilizing at 3.4 in 2014-15. 80 • Fertility Preferences In the case of men, ideal numbers of children are 3.0 for all men and 3.1 for married men. As with women, men reported an ideal number of children that was lower than the TFR. Among 92 percent of men, the ideal number of children ranges from two to four, with 42 percent preferring three children, 32 percent preferring two, and 18 percent preferring four. Only 3 percent would like to have five children, and 2 percent want six children or more. However 2 percent of men would like to have fewer than two children. Table 6.4 shows the mean ideal number of children for all women, according to current age and background characteristics. Ideal number of children tends to increase gradually with age, from 3.0 children among women age 15-19 to 3.2 among those age 25-29 and 4.3 among those age 45-49. Ideal number of children is almost the same in urban and rural areas (3.3 and 3.4, respectively), and there is only minimal variation by province. In terms of education, the higher the educational level, the lower the mean ideal number of children: 3.9 among women with no education versus 3.0 among women with a secondary education or higher. Ideal number of children is almost constant across household wealth quintiles. 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), the 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 to rationalization, as an undesired pregnancy often results in the birth of a child to whom the mother later becomes attached. Table 6.5 shows that 64 percent of births were wanted at the time they occurred, while 25 percent occurred earlier than women would have liked. Unwanted births represented approximately 11 percent of births overall. Table 6.4 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Rwanda 2014-15 Background characteristic Mean Number of women1 Age 15-19 3.0 2,762 20-24 2.9 2,450 25-29 3.2 2,287 30-34 3.5 2,131 35-39 3.8 1,555 40-44 4.0 1,239 45-49 4.3 949 Residence Urban 3.3 2,611 Rural 3.4 10,761 Province City of Kigali 3.2 1,786 South 3.2 3,193 West 3.5 2,925 North 3.5 2,201 East 3.4 3,266 Education No education 3.9 1,633 Primary 3.4 8,593 Secondary and higher 3.0 3,146 Wealth quintile Lowest 3.4 2,536 Second 3.4 2,600 Middle 3.4 2,575 Fourth 3.4 2,606 Highest 3.3 3,056 Total 3.4 13,372 1 Number of women who gave a numeric response Fertility Preferences • 81 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 2014-15 Planning status of birth Total Number of births Birth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Birth order 1 76.4 21.3 2.3 0.0 100.0 2,630 2 67.1 30.1 2.7 0.0 100.0 2,043 3 63.6 29.3 6.9 0.2 100.0 1,399 4+ 51.2 21.1 27.6 0.1 100.0 2,916 Mother's age at birth <20 52.3 42.4 5.3 0.0 100.0 611 20-24 70.9 26.4 2.6 0.1 100.0 2,330 25-29 68.9 25.0 6.0 0.1 100.0 2,584 30-34 62.4 24.0 13.5 0.0 100.0 1,971 35-39 55.3 16.6 27.9 0.2 100.0 1,055 40-44 45.2 7.7 47.1 0.0 100.0 399 45-49 (42.4) (2.4) (55.2) (0.0) 100.0 39 Total 64.1 24.5 11.3 0.1 100.0 8,988 Note: Figures in parentheses are based on 25-49 unweighted cases. A majority of births are desired and arrive according to the desired timing, regardless of birth order. In fact, the results show that 76 percent of first births arrived at the desired time, as compared with 67 percent of second births and 51 percent of fourth- or higher-order births. However, the percentage of unwanted births increases steadily with birth order, from 2 percent of first births to 7 percent of third births and more than one- quarter of fourth-and higher-order births. Beginning at age 20, the percentage of planned births decreases with age, dropping from 71 percent among women age 20-24 to 45 percent among those age 40-44. In fact, births to older women (age 40-44) generally seem to be less well planned: 47 percent of births in this age group were not wanted. It must also be noted that, among women less than age 20 at the time of the birth, only 52 percent of births were planned, 42 percent were wanted later in life, and 5 percent were unwanted. Table 6.6 compares the total wanted fertility rate (TWFR) with the current 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 4.2 children. The TWFR is higher in rural areas (3.2) than in urban areas (2.7). It is lowest in City of Kigali (2.7) and highest in the East province (3.5). The TWFR decreases with increasing education, from 3.8 among women with no education to 2.5 among women with a secondary education or higher. It also decreases with increasing wealth, from 3.7 among women in the lowest quintile to 2.5 among those in the highest quintile. 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 2014-15 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 2.7 3.6 Rural 3.2 4.3 Province City of Kigali 2.7 3.6 South 3.0 4.0 West 3.1 4.6 North 2.8 3.7 East 3.5 4.6 Education No education 3.8 5.1 Primary 3.3 4.5 Secondary and higher 2.5 3.0 Wealth quintile Lowest 3.7 5.1 Second 3.4 4.6 Middle 3.0 4.1 Fourth 2.8 3.9 Highest 2.5 3.3 Total 3.1 4.2 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. Family Planning • 83 FAMILY PLANNING 7 Key Findings • Knowledge of at least one contraceptive method among women and men age 15-49 is nearly universal in Rwanda. • More than half of currently married women are using a contraceptive method (53 percent), with most women using a modern method (48 percent). • The contraceptive methods most commonly used by married women are injectables (24 percent), the pills (8 percent), and implants (8 percent). • Use of modern methods has increased from 45 percent in 2010 to 48 percent in 2014-15. • The public health sector remains the major provider of contraceptive methods; 91 percent of modern contraceptive users obtain their contraception from a government source. • Twenty-eight percent of family planning users discontinue use of a method within 12 months of starting its use. Side effects and health concerns (34 percent) are the main reason for discontinuation. • Thirty-one percent of users of the rhythm method know when the fertile period occurs. • Nineteen percent of currently married women have an unmet need for family planning services, with 11 percent in need of spacing and 8 percent in need of limiting. his chapter presents 2014-15 RDHS results related to contraceptive prevalence, knowledge, attitudes, and behavior. Although the focus is on women, some of the results from the men’s survey are also presented because men play an important role in the realization of reproductive health goals. In addition, comparisons are made, where feasible, with findings from previous surveys to evaluate trends 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 interviewers collected data on knowledge of contraception by describing the method and asking whether the respondent recognized it. Information was collected on 11 modern family planning methods: female and male sterilization, pills, intrauterine devices (IUDs), injectables, implants, male and female condoms, the Lactational Amenorrhea Method (LAM), emergency contraception, and the standard days method. Information was also collected on two traditional methods: rhythm and withdrawal. Any other method mentioned spontaneously by the respondent was recorded on the questionnaire. Table 7.1 shows that knowledge of at least one method of contraception is nearly universal among both women and men in Rwanda regardless of marital status or sexual experience. Modern methods are more widely known than traditional methods. The most widely known methods among both women and men are the male condom (98 percent and 100 percent, respectively), injectables (97 percent and 94 percent), and the pill (97 percent and 93 percent), while emergency contraception is the least known method (35 percent and 45 percent). T 84 • Family Planning In the case of each method, knowledge is highest among currently married women and men with the exception of emergency contraception (most likely to be known by sexually active unmarried respondents) and the male condom (equally likely to be known by married and unmarried men). On average, women and men have heard of 11 to 12 methods out of all methods. Table 7.1 Knowledge of contraceptive methods Percentage of all women and men, currently married women and men, and sexually active unmarried women and men age 15-49 who know any contraceptive method, by specific method, Rwanda 2014-15 Women Men Method All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 99.5 100.0 99.4 99.8 100.0 100.0 Any modern method 99.4 100.0 99.4 99.8 100.0 100.0 Female sterilization 80.9 85.9 82.8 85.2 91.1 83.5 Male sterilization 77.2 86.3 78.3 83.0 91.8 77.3 Pill 97.1 99.4 98.1 93.2 98.3 92.9 IUD 81.9 90.6 82.1 80.4 89.1 77.1 Injectables 97.2 99.6 97.7 94.2 99.1 93.4 Implants 93.8 98.6 94.4 88.1 97.2 88.5 Male condom 98.0 99.1 97.9 99.5 99.9 100.0 Female condom 83.5 87.6 84.6 80.7 87.0 80.1 Lactational amenorrhea (LAM) 79.2 89.4 80.5 69.5 82.2 60.1 Emergency contraception 35.2 35.4 43.5 45.3 51.2 54.5 Standard days method 82.3 92.0 83.7 78.3 89.7 70.2 Any traditional method 93.9 98.0 94.4 92.8 97.9 93.6 Rhythm 91.6 95.1 91.4 90.7 96.6 86.5 Withdrawal 74.1 88.9 79.6 80.1 92.7 83.3 Other 0.5 0.6 0.4 0.7 0.9 0.5 Mean number of methods known by respondents 15-49 10.7 11.5 10.9 10.7 11.7 10.5 Number of respondents 13,497 6,982 313 5,577 2,792 134 Mean number of methods known by respondents 15-59 na na na 10.8 11.7 10.5 Number of respondents na na na 6,217 3,371 140 na = Not applicable 1 Had last sexual intercourse within 30 days preceding the survey Table 7.2 shows that there is little variation in knowledge of contraceptive methods by background characteristics. Regardless of their background, over 99 percent of currently married women and men have heard of at least one contraceptive method and at least one modern method. 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 2014-15 Women Men Background characteristic Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number Age 15-19 99.1 99.1 85 * * 3 20-24 100.0 100.0 883 100.0 100.0 169 25-29 100.0 100.0 1,577 100.0 100.0 530 30-34 100.0 100.0 1,693 100.0 100.0 775 35-39 100.0 100.0 1,240 100.0 100.0 512 40-44 100.0 100.0 896 100.0 100.0 445 45-49 99.7 99.7 607 100.0 100.0 359 Residence Urban 99.9 99.9 1,194 100.0 100.0 494 Rural 100.0 100.0 5,788 100.0 100.0 2,298 Province Kigali City 100.0 100.0 842 100.0 100.0 361 South 100.0 100.0 1,606 100.0 100.0 605 West 100.0 100.0 1,542 100.0 100.0 627 North 100.0 100.0 1,130 100.0 100.0 472 East 99.8 99.8 1,863 100.0 100.0 727 (Continued…) Family Planning • 85 Table 7.2—Continued Women Men Background characteristic Heard of any method Heard of any modern method1 Number Heard of any method Heard of any modern method1 Number Education No education 99.8 99.8 1,154 100.0 100.0 392 Primary 100.0 100.0 4,921 100.0 100.0 2,050 Secondary and higher 100.0 100.0 907 100.0 100.0 350 Wealth quintile Lowest 99.9 99.9 1,313 100.0 100.0 492 Second 100.0 100.0 1,472 100.0 100.0 601 Middle 100.0 100.0 1,453 100.0 100.0 585 Fourth 100.0 100.0 1,380 100.0 100.0 554 Highest 99.8 99.8 1,365 100.0 100.0 560 Total 15-49 100.0 100.0 6,982 100.0 100.0 2,792 50-59 na na na 100.0 100.0 579 Total 15-59 na na na 100.0 100.0 3,371 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, lactational amenorrhea method (LAM), emergency contraception, and standard days method 7.2 CURRENT USE OF CONTRACEPTIVE METHODS This section presents information on the prevalence of current contraceptive use among women age 15-49 at the time of the survey. Level of current use of contraceptives is one of the indicators most frequently used to assess the success of family planning program 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 31 percent of all women, 53 percent of currently married women, and 36 percent of sexually active unmarried women are using a contraceptive method. The majority of women who are using a contraceptive method use a modern method (28 percent of all women). The most commonly used methods among all women are injectables (14 percent), the pills (5 percent), and implants (5 percent). Three percent of women use traditional methods. More than half of currently married women (53 percent) are currently using contraception: 48 percent use modern methods and 6 percent use traditional methods. The most commonly used methods among currently married women are injectables (24 percent), the pills (8 percent), and implants (8 percent). The use of contraception among currently married women varies by age, gradually rising from 35 percent among women age 15-19 to a peak of 58 percent among women age 35 to 39 before dropping to 42 percent among women age 45-49. Most women who have been sterilized are age 35 or older, while younger women are more likely to use non-permanent methods of contraception such as injectables and pills. The high level of contraceptive use among sexually active unmarried women (36 percent) is driven by the high prevalence of injectables, implants, and male condom (16 percent, 8 percent and 6 percent, respectively). 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 rr en tly u se d, a cc or di ng to a ge , R w an da 2 01 4- 15 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 tra di tio na l m et ho d Tr ad iti on al m et ho d To ta l N um be r of w om en A ge Fe m al e st er ili - za tio n M al e st er ili - za tio n P ill IU D In je c- ta bl es Im - pl an ts M al e co nd om Fe m al e co nd om LA M S ta nd ar d da ys m et ho d R hy th m W ith - dr aw al O th er N ot cu rr en tly us in g A LL W O M E N A ge 15 -1 9 2. 3 2. 0 0. 0 0. 0 0. 2 0. 0 1. 1 0. 5 0. 2 0. 0 0. 0 0. 0 0. 3 0. 3 0. 0 0. 0 97 .7 10 0. 0 2, 76 8 20 -2 4 21 .3 20 .1 0. 0 0. 0 3. 3 0. 2 12 .9 2. 4 1. 1 0. 0 0. 1 0. 1 1. 2 0. 3 0. 8 0. 0 78 .7 10 0. 0 2, 45 7 25 -2 9 41 .9 39 .2 0. 1 0. 1 7. 5 0. 7 21 .5 6. 3 2. 3 0. 0 0. 1 0. 6 2. 7 1. 2 1. 4 0. 0 58 .1 10 0. 0 2, 30 0 30 -3 4 47 .6 44 .4 0. 3 0. 2 7. 7 1. 3 22 .9 8. 0 3. 3 0. 0 0. 2 0. 5 3. 2 1. 4 1. 7 0. 0 52 .4 10 0. 0 2, 15 1 35 -3 9 48 .6 43 .3 1. 9 0. 2 7. 5 1. 4 19 .2 7. 6 4. 1 0. 0 0. 2 1. 1 5. 4 2. 4 2. 9 0. 0 51 .4 10 0. 0 1, 57 5 40 -4 4 44 .1 36 .6 3. 1 0. 5 5. 6 1. 0 15 .0 6. 7 3. 7 0. 0 0. 1 0. 9 7. 4 4. 2 3. 3 0. 0 55 .9 10 0. 0 1, 26 9 45 -4 9 27 .8 20 .0 1. 8 0. 1 1. 8 0. 8 8. 0 4. 4 2. 5 0. 0 0. 0 0. 5 7. 7 3. 9 3. 8 0. 0 72 .2 10 0. 0 97 7 To ta l 30 .9 27 .8 0. 7 0. 1 4. 7 0. 7 14 .1 4. 7 2. 2 0. 0 0. 1 0. 4 3. 1 1. 5 1. 6 0. 0 69 .1 10 0. 0 13 ,4 97 C U R R EN TL Y M AR R IE D W O M EN A ge 15 -1 9 35 .3 32 .8 0. 0 0. 0 4. 9 0. 0 18 .7 6. 0 3. 2 0. 0 0. 0 0. 0 2. 5 1. 2 1. 2 0. 0 64 .7 10 0. 0 85 20 -2 4 47 .4 44 .3 0. 0 0. 0 8. 2 0. 4 27 .7 4. 9 2. 7 0. 0 0. 3 0. 1 3. 1 0. 7 2. 3 0. 0 52 .6 10 0. 0 88 3 25 -2 9 54 .7 50 .9 0. 1 0. 1 10 .1 0. 8 28 .0 7. 6 3. 2 0. 0 0. 2 0. 9 3. 8 1. 7 2. 1 0. 0 45 .3 10 0. 0 1, 57 7 30 -3 4 54 .9 51 .1 0. 3 0. 2 9. 1 1. 2 26 .7 8. 9 3. 9 0. 0 0. 2 0. 6 3. 8 1. 6 2. 1 0. 0 45 .1 10 0. 0 1, 69 3 35 -3 9 57 .7 51 .0 2. 4 0. 3 9. 0 1. 8 22 .6 8. 4 4. 8 0. 0 0. 2 1. 4 6. 7 3. 0 3. 7 0. 0 42 .3 10 0. 0 1, 24 0 40 -4 4 56 .9 46 .6 3. 9 0. 6 7. 6 1. 2 19 .0 8. 4 4. 5 0. 0 0. 2 1. 2 10 .3 5. 7 4. 6 0. 0 43 .1 10 0. 0 89 6 45 -4 9 41 .6 29 .5 2. 5 0. 2 2. 5 1. 2 11 .9 6. 4 4. 0 0. 0 0. 0 0. 8 12 .1 5. 9 6. 2 0. 0 58 .4 10 0. 0 60 7 To ta l 53 .2 47 .5 1. 2 0. 2 8. 4 1. 1 24 .0 7. 7 3. 8 0. 0 0. 2 0. 8 5. 8 2. 7 3. 1 0. 0 46 .8 10 0. 0 6, 98 2 S EX U A LL Y A C TI VE U N M A R R IE D W O M E N 1 A ge 15 -1 9 11 .6 11 .6 0. 0 0. 0 1. 6 0. 0 2. 0 2. 2 5. 7 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 88 .4 10 0. 0 66 20 -2 4 34 .3 34 .3 0. 0 0. 0 5. 4 0. 0 21 .5 3. 6 3. 7 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 65 .7 10 0. 0 65 25 -2 9 51 .3 51 .3 0. 0 0. 0 8. 0 1. 2 19 .8 20 .6 1. 6 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 48 .7 10 0. 0 56 30 -3 4 42 .5 40 .6 0. 0 0. 0 2. 6 1. 4 23 .0 6. 0 7. 6 0. 0 0. 0 0. 0 1. 9 0. 0 1. 9 0. 0 57 .5 10 0. 0 60 35 -3 9 (5 2. 1) (5 2. 1) (0 .0 ) (0 .0 ) (3 .3 ) (0 .0 ) (2 3. 9) (1 7. 0) (7 .8 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (4 7. 9) 10 0. 0 30 40 -4 4 * * * * * * * * * * * * * * * * * 10 0. 0 22 45 -4 9 * * * * * * * * * * * * * * * * * 10 0. 0 14 To ta l 35 .6 34 .9 0. 3 0. 0 4. 0 0. 8 16 .0 8. 3 5. 6 0. 0 0. 0 0. 0 0. 6 0. 3 0. 4 0. 0 64 .4 10 0. 0 31 3 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 on 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. na = N ot a pp lic ab le LA M = L ac ta tio na l a m en or rh ea 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 86 • Family Planning Family Planning • 87 7.2.2 Current Use of Contraception by Background Characteristics There is modest variation by background characteristics in current use of contraceptive methods (Table 7.4). Currently married women in urban areas and their rural counterparts differ slightly in terms of use of a contraceptive method (57 percent and 53 percent, respectively). Discrepancies are also observed between urban women and rural women in use of modern methods (51 percent and 47 percent, respectively). By province, North has the highest proportion of married women using a contraceptive method (61 percent), while West has the lowest proportion (47 percent). There is a direct association between women’s use of family planning methods and the number of children they have. The majority of women do not begin to use contraception until they have had at least one child. Only 2 percent of married women with no living children use contraception; the percentage increases to 54 percent among women with one or two children and 58 percent among those with three to four children. Use of any contraceptive method increases with increasing education, from 48 percent among women with no education to 55 percent among women with a secondary education or higher. Use of any contraception increases with increasing wealth as well, from 48 percent among women in the lowest wealth quintile to 57 percent among those in the highest quintile. Ta bl e 7. 4 C ur re nt u se o f c on tra ce pt io n by b ac kg ro un d ch ar ac te ris tic s P er ce nt d is tri bu tio n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rre nt ly u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, R w an da 2 01 4- 15 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 rr en tly us in g To ta l N um be r o f w om en B ac kg ro un d ch ar ac te ris tic Fe m al e st er ili - za tio n M al e st er ili - za tio n P ill IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M S ta nd ar d da ys m et ho d R hy th m W ith - dr aw al N um be r o f l iv in g ch ild re n 0 1. 8 1. 8 0. 3 0. 0 0. 2 0. 3 0. 2 0. 6 0. 3 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 98 .2 10 0. 0 35 8 1- 2 54 .3 50 .4 0. 3 0. 1 10 .2 0. 8 27 .2 7. 5 3. 2 0. 0 0. 2 0. 9 4. 0 1. 6 2. 4 45 .7 10 0. 0 2, 75 7 3- 4 58 .1 52 .8 1. 6 0. 1 9. 4 1. 5 26 .0 8. 6 4. 5 0. 0 0. 2 0. 9 5. 3 2. 6 2. 7 41 .9 10 0. 0 2, 30 2 5+ 56 .0 45 .1 2. 6 0. 6 5. 4 1. 2 21 .0 8. 5 4. 7 0. 0 0. 2 1. 0 10 .9 5. 3 5. 6 44 .0 10 0. 0 1, 56 4 R es id en ce U rb an 56 .5 51 .1 2. 0 0. 1 9. 7 3. 5 18 .0 10 .6 5. 2 0. 1 0. 3 1. 7 5. 4 2. 9 2. 5 43 .5 10 0. 0 1, 19 4 R ur al 52 .6 46 .7 1. 1 0. 3 8. 1 0. 6 25 .3 7. 1 3. 5 0. 0 0. 2 0. 7 5. 8 2. 6 3. 2 47 .4 10 0. 0 5, 78 8 Pr ov in ce K ig al i C ity 54 .5 49 .7 1. 6 0. 0 9. 8 3. 8 16 .6 10 .6 4. 8 0. 1 0. 6 1. 9 4. 8 2. 3 2. 5 45 .5 10 0. 0 84 2 S ou th 52 .7 48 .2 0. 9 0. 3 8. 3 1. 3 25 .5 8. 4 3. 1 0. 0 0. 0 0. 6 4. 5 2. 2 2. 4 47 .3 10 0. 0 1, 60 6 W es t 47 .1 41 .2 2. 0 0. 1 5. 6 0. 3 22 .7 6. 2 3. 3 0. 0 0. 3 0. 7 5. 9 3. 1 2. 8 52 .9 10 0. 0 1, 54 2 N or th 60 .8 55 .0 1. 0 0. 2 9. 3 0. 7 29 .5 8. 9 3. 9 0. 0 0. 3 1. 2 5. 8 2. 7 3. 1 39 .2 10 0. 0 1, 13 0 E as t 53 .6 46 .5 0. 8 0. 4 9. 5 0. 7 24 .0 6. 3 4. 4 0. 0 0. 0 0. 5 7. 1 2. 9 4. 2 46 .4 10 0. 0 1, 86 3 Ed uc at io n N o ed uc at io n 48 .1 40 .7 1. 1 0. 5 5. 4 0. 4 23 .8 6. 2 3. 1 0. 0 0. 1 0. 2 7. 3 3. 8 3. 6 51 .9 10 0. 0 1, 15 4 P rim ar y 54 .2 48 .8 1. 3 0. 2 8. 8 0. 8 25 .5 7. 6 3. 7 0. 0 0. 2 0. 6 5. 4 2. 4 3. 1 45 .8 10 0. 0 4, 92 1 S ec on da ry a nd hi gh er 54 .7 49 .1 1. 1 0. 3 9. 4 3. 6 16 .3 9. 9 5. 1 0. 1 0. 4 2. 8 5. 6 3. 0 2. 6 45 .3 10 0. 0 90 7 W ea lth q ui nt ile Lo w es t 48 .4 44 .9 0. 6 0. 2 6. 0 0. 1 29 .0 6. 3 2. 3 0. 0 0. 2 0. 2 3. 5 1. 5 2. 0 51 .6 10 0. 0 1, 31 3 S ec on d 50 .0 45 .8 0. 8 0. 2 8. 5 0. 2 25 .6 6. 7 3. 2 0. 0 0. 2 0. 4 4. 2 1. 9 2. 3 50 .0 10 0. 0 1, 47 2 M id dl e 54 .6 48 .1 1. 0 0. 3 8. 0 0. 6 25 .3 7. 8 4. 4 0. 0 0. 1 0. 5 6. 5 2. 9 3. 6 45 .4 10 0. 0 1, 45 3 Fo ur th 56 .4 48 .7 0. 9 0. 4 9. 2 0. 8 24 .5 7. 4 3. 8 0. 0 0. 2 1. 4 7. 7 3. 6 4. 1 43 .6 10 0. 0 1, 38 0 H ig he st 56 .8 50 .0 2. 8 0. 0 10 .0 3. 8 15 .7 10 .2 5. 4 0. 1 0. 2 1. 8 6. 9 3. 5 3. 4 43 .2 10 0. 0 1, 36 5 To ta l 53 .2 47 .5 1. 2 0. 2 8. 4 1. 1 24 .0 7. 7 3. 8 0. 0 0. 2 0. 8 5. 8 2. 7 3. 1 46 .8 10 0. 0 6, 98 2 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. LA M = L ac ta tio na l a m en or rh ea m et ho d 88 • Family Planning Family Planning • 89 7.2.3 Trends in Current Use of Family Planning Figure 7.1 shows trends in contraceptive use among currently married women since 2005. After increasing from 17 percent in 2005 to 52 percent in 2010, the use of any method changed only slightly in 2014-15 (53 percent). One of the Ministry of Health’s targets in its Health Sector Strategic Plan (HSSP III, 2012-18) was an increase in the contraceptive prevalence rate among married women from 52 percent in 2010 to 62 percent in 2015. Use of any modern method also increased dramatically between 2005 and 2010 (from 10 percent to 45 percent) and then rose slightly in 2014-15 (48 percent) (Figure 7.1). Figure 7.1 Trends in contraceptive use among currently married women 7.3 TIMING OF STERILIZATION Table 7.5 shows the distribution of women age 15-49 by age group at the time of sterilization and median age at sterilization. Thirty-seven percent of Rwandan women who have been sterilized had the operation at age 35-39, while 30 percent did so at age 30-34. Few women are sterilized at young ages (e.g., only 3 percent of women under age 25 have been sterilized). The median age at sterilization is 34 years. Table 7.5 Timing of sterilization Percent distribution of sterilized women age 15-49 by age at the time of sterilization and median age at sterilization, Rwanda 2014-15 Age at time of sterilization Total Number of women Median age1 <25 25-29 30-34 35-39 40-44 45-49 Total 2.8 10.1 30.0 36.8 19.2 1.2 100.0 96 34.4 1 Median age at sterilization is calculated only for women sterilized before age 40 to avoid problems of 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 first obtained the method they use. They were also asked where they had most recently obtained the contraceptive method they were using at the time of the survey. 17 10 36 27 52 45 53 48 Any method Any modern method Percent 2005 RDHS 2007-08 RIDHS 2010 RDHS 2014-15 RDHS 90 • Family Planning Table 7.6 shows that the majority of women in Rwanda obtain modern methods of contraception from the public health sector (91 percent, as compared with 92 percent in 2010). The most common source where contraception is obtained is from a health center, while 25 percent obtain it from a community health worker. Other sources are the private medical sector (4 percent) and the non-medical private sector (kiosks, friends, relatives) (3 percent). Public health sector sources supply over 90 percent of users of female sterilization, the pills, injectables, and implants, with community health workers servicing about one-third of pills and injectables users. This is mainly a result of government of Rwanda through creation of health posts in cells and the secondary health post nearest faith based health facilities, and the contribution of community health workers. As expected, more than one-third of users of male condoms obtain their method from a private source, mainly kiosks and pharmacies. 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 2014-15 Source Female sterilization Pill IUD Injectables Implants Male condom Total Public sector 96.5 93.3 71.4 96.0 91.3 59.8 90.8 Referral hospital 23.0 0.0 7.2 0.2 1.3 0.1 1.1 District hospital 65.7 0.6 17.4 0.3 3.2 0.5 3.1 Health center 7.7 50.9 43.1 51.6 81.8 41.3 54.7 Health post 0.0 3.9 1.3 6.0 3.1 0.9 4.3 Outreach 0.0 4.7 2.3 3.2 2.0 0.4 2.8 Community health worker 0.0 33.2 0.0 34.7 0.0 16.6 24.6 Other public 0.0 0.0 0.0 0.0 0.0 0.1 0.0 Private medical sector 2.6 6.5 18.8 3.3 2.5 6.4 4.4 Polyclinic 1.2 0.2 9.3 0.1 0.4 0.4 0.4 Clinic 1.4 0.0 5.9 0.6 0.6 0.0 0.6 Dispensary 0.0 1.9 0.0 1.8 0.6 0.5 1.4 Pharmacy 0.0 4.3 0.0 0.3 0.2 5.2 1.3 Family planning clinic 0.0 0.1 3.5 0.5 0.7 0.4 0.6 Other private 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Other source 0.0 0.1 0.0 0.0 0.0 30.1 2.6 Kiosk 0.0 0.0 0.0 0.0 0.0 29.7 2.4 Church 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Friend/relative 0.0 0.1 0.0 0.0 0.0 0.4 0.2 Other 0.0 0.1 0.0 0.0 0.0 2.2 0.2 Don't know 0.0 0.0 0.0 0.0 0.0 0.9 0.1 Missing 0.9 0.0 9.1 0.6 6.1 0.6 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 96 632 91 1,905 638 295 3,734 Note: Total includes other modern methods but excludes lactational amenorrhea method (LAM). 7.5 USE OF SOCIAL MARKETING BRANDS OF PILLS AND CONDOMS Women who said they were currently using pills or condoms as a method of contraception were asked which brands of pills and condoms they used. Interviewers presented a brochure with photographs of different brands of pills and condoms to assist respondents in identification of the brand. At the time of the 2014-15 RDHS, Microgynon, Lofemenal, and Ovrette/Microlut were the socially marketed brands of contraceptive pills. Microlut was introduced in 2012-2013. Generic condoms, Prudence Plus, and Plaisir were the socially marketed condom brands. Table 7.7 shows that more than 9 in 10 pill users (94 percent) use Microgynon, and 3 percent use Ovrette/Microlut. Forty-five percent of condom users use Prudence Plus and 38 percent use generic condoms. There is almost no variation in the use of socially marketed brands of pills and condoms by residence or province. Also, there are no significant differences in use of socially marketed brands according to education or wealth. Family Planning • 91 Table 7.7 Use of social marketing brand pills and condoms Percentage of pill and condom users age 15-49 using a social marketing brand, by background characteristics, Rwanda 2014-15 Among pill users Among condom users1 Background characteristic Percent- age using Microgynon Percent- age using Lofemenal Percent- age using Ovrette/ Microlut Percent- age using other Don't know/ missing Number of women using the pill Percent- age using Prudence Plus Percent- age using Plaisir Percent- age using generic Percent- age using other Don't know/ missing Number of women using condoms Age 15-19 * * * * * 6 * * * * * 6 20-24 92.3 0.0 6.5 0.0 1.2 81 (36.7) (15.2) (40.7) (0.0) (7.4) 27 25-29 91.3 0.5 5.7 0.6 1.8 173 49.0 14.9 32.0 2.0 2.1 54 30-34 94.7 2.8 0.2 0.0 2.3 165 36.8 14.1 48.1 0.0 1.0 72 35-39 97.1 1.8 0.7 0.0 0.4 117 46.5 15.8 32.5 0.0 5.3 64 40-44 95.9 1.4 0.0 1.4 1.3 72 (54.9) (15.0) (30.2) (0.0) (0.0) 47 45-49 * * * * * 18 (47.4) (8.5) (41.3) (0.0) (2.8) 25 Residence Urban 94.0 1.2 2.7 0.4 1.8 593 45.4 13.4 38.2 0.4 2.6 272 Rural 94.4 1.0 2.4 0.4 1.9 501 46.5 10.3 39.9 0.5 2.8 228 Province Kigali City 91.9 2.3 4.6 0.0 1.2 92 (40.0) (29.3) (29.2) (0.0) (1.6) 44 South 94.6 0.5 4.3 0.0 0.6 150 47.6 10.4 42.0 0.0 0.0 52 West 91.0 4.4 0.3 2.2 2.0 94 43.1 13.9 38.3 0.0 4.7 59 North 94.1 0.8 3.2 0.0 1.9 112 (61.7) (18.9) (16.9) (0.0) (2.5) 48 East 96.2 0.4 1.0 0.0 2.4 184 38.4 8.0 48.9 1.1 3.5 93 Education No education 91.0 0.0 3.8 0.0 5.2 66 (35.0) (8.3) (54.8) (0.0) (1.8) 40 Primary 94.8 1.7 2.2 0.4 0.9 470 50.1 10.5 36.3 0.5 2.6 201 Secondary and higher 92.3 0.9 3.9 0.0 2.9 96 33.4 33.7 29.1 0.0 3.8 55 Wealth quintile Lowest 90.8 0.9 3.9 1.1 3.3 94 (46.4) (4.8) (41.1) (0.0) (7.7) 36 Second 97.1 1.5 1.4 0.0 0.0 133 54.8 5.9 35.8 0.0 3.6 54 Middle 93.0 0.0 2.8 0.0 4.1 123 46.8 5.5 44.1 1.6 2.0 65 Fourth 95.5 1.5 2.2 0.0 0.8 133 44.5 13.8 38.5 0.0 3.1 61 Highest 92.9 2.6 3.0 0.7 0.7 149 36.4 32.8 30.8 0.0 0.0 79 Total 94.0 1.4 2.6 0.3 1.7 632 45.0 14.5 37.5 0.4 2.7 295 Note: Condom use is based on women's reports. 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 Among condom users not also using the pill 7.6 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 problems. 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 7.8 shows the percentage of current users of modern methods who were informed about side effects or problems associated with the method used and informed of other methods they could use. Data are grouped according to method, initial source, and background characteristics. A majority of users were given information about each of the three topics considered to be essential parts of informed choice: 70 percent were informed about potential side effects of their method, 68 percent were told what to do if they experienced side effects, and 87 percent were given information about other contraception options. Although their numbers are relatively small, it is nevertheless of concern that women who have been sterilized appear to be least likely to be informed about side effects; only slightly more than half said they were told of other methods they could use. The data show that public and private medical sources appear to be about equally likely to inform women about side effects and other methods. 92 • Family Planning Table 7.8 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, 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 2014-15 Among women who started last episode of modern contraceptive method within five years preceding the survey: Method/source Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if side effects experienced Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilization 58.3 43.5 54.6 55 Pill 65.7 63.7 89.9 557 IUD 78.8 76.9 84.8 79 Injectables 69.9 67.5 87.7 1,686 Implants 76.4 74.7 85.5 561 Initial source of method1 Public sector 70.6 68.3 87.5 2,821 Referral hospital (77.4) (65.2) (60.1) 30 District hospital 66.4 61.5 74.8 92 Health center 70.9 69.1 88.5 2,413 Health post 69.3 64.2 84.8 132 Outreach 71.9 68.9 89.9 106 Community health worker (58.1) (51.8) (79.9) 47 Private medical sector 69.9 64.7 80.7 107 Polyclinic * * * 16 Clinic * * * 19 Dispensary (73.8) (68.6) (86.5) 39 Pharmacy * * * 16 Family planning clinic * * * 17 Missing * * * 9 Total 70.3 68.0 87.0 2,937 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 7.7 CONTRACEPTIVE DISCONTINUATION Couples can realize their reproductive goals only when they use contraceptive methods correctly and consistently. Discontinuation of a method is a major concern for managers of family planning programs. All segments of contraceptive use since January 2009 were recorded in the “calendar” section of the Woman’s Questionnaire. In analyses of the data, the month of the interview and the two months prior to the survey are excluded to avoid any bias that might be introduced by unrecognized pregnancies. One-year contraceptive discontinuation rates based on calendar data are presented in Table 7.9. Twenty-eight percent of women who started using family planning method discontinued using it within 12 months. Discontinuation rates are highest among pill users (42 percent) and lowest among users of implants (3 percent). Eleven percent of episodes of use were discontinued due to the fear of side effects or health concerns, 10 percent because women switched to another method, while 5 percent were discontinued because of the desire for a more effective method, 4 percent due to the woman wanted to become pregnant, and 3 percent because the method failed. Family Planning • 93 Table 7.9 Twelve-month contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months, by reason for discontinuation and specific method, Rwanda 2014-15 Method Method failure Desire to become pregnant Other fertility- related reasons2 Side effects/ health concerns Wanted more effective method Other method- related reasons3 Other reasons Any reason4 Switched to another method5 Number of episodes of use6 Pill 4.2 4.4 2.7 16.9 9.0 2.0 2.3 41.5 20.6 1,402 Injectables 1.7 4.3 2.4 13.7 3.2 0.5 1.6 27.5 8.4 3,548 Implants 0.3 0.6 0.0 2.1 0.0 0.0 0.1 3.1 0.7 758 Male condom 5.8 4.6 3.8 0.4 9.4 2.8 10.6 37.3 14.7 391 Other1 (12.4) (4.8) (0.0) (0.0) (4.8) (1.3) (1.8) (25.1) (6.4) 267 Standard days method 13.2 5.1 1.0 0.0 5.9 1.9 2.4 29.4 7.2 310 All methods 3.2 3.9 2.0 11.0 4.5 0.9 2.1 27.7 10.1 6,878 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months preceding the survey. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes IUD, LAM, rhythm, and withdrawal 2 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation 3 Includes lack of access/too far, costs too much, and inconvenient to use 4 Reasons for discontinuation are mutually exclusive and add to the total given in this column. 5 The episodes of use included in this column are a subset of the discontinued episodes included in the discontinuation rate. A woman is considered to have switched to another method if she used a different method in the month following discontinuation or if she gave "wanted a more effective method" as the reason for discontinuation and started another method within two months of discontinuation. 6 Number of episodes of use includes both episodes of use that were discontinued during the period of observation and episodes of use that were not discontinued during the period of observation. 7.8 REASONS FOR DISCONTINUATION OF CONTRACEPTIVE USE Table 7.10 shows the percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by reasons for discontinuation of method. The most common reason for discontinuing a method is health concerns or side effects (34 percent), followed by desire to become pregnant (28 percent), desire for a more effective method , and become pregnant while using it (11 percent each). The frequency with which reasons were reported varied according to the method. Discontinuations of rhythm and withdrawal were most often due to failure (i.e., becoming pregnant while using; (48 percent and 47 percent, respectively). The main reason for discontinuation of the pill, IUDs, injectables, and implants was side effects or health concerns. Table 7.10 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 2014-15 Reason Pill IUD Injectables Implants Male condom Rhythm Withdrawal Other/ missing All methods Became pregnant while using 12.8 11.7 5.5 3.2 17.3 47.8 46.7 45.7 11.1 Wanted to become pregnant 21.6 22.6 31.4 23.2 23.5 35.4 28.0 33.8 28.2 Husband disapproved 0.4 4.5 1.0 1.7 16.2 0.0 1.8 0.0 1.6 Wanted a more effective method 15.2 1.3 9.1 9.5 18.9 9.5 11.5 9.1 10.9 Side effects/health concerns 34.7 46.5 39.6 44.7 1.1 0.0 0.0 1.2 33.9 Lack of access/too far 1.2 0.0 1.0 0.6 2.4 0.0 0.0 0.0 1.0 Cost too much 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 Inconvenient to use 2.6 0.0 0.9 0.0 5.1 2.2 3.9 5.3 1.6 Up to God/fatalistic 0.1 0.0 0.3 0.7 0.6 0.0 0.0 0.0 0.2 Difficult to get pregnant/menopausal 0.6 0.0 0.3 0.4 0.5 0.0 0.0 0.0 0.3 Infrequent sex/husband away 5.8 3.0 5.4 2.7 5.1 0.0 2.3 1.2 4.9 Marital dissolution/separation 0.5 0.5 0.8 0.8 0.4 0.0 0.0 1.1 0.7 Other 1.6 7.5 2.3 9.7 3.7 2.0 2.3 1.1 2.8 Missing 3.0 2.3 2.3 2.9 5.4 3.2 3.5 1.5 2.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 1,075 47 2,714 394 219 140 182 98 4,869 94 • Family Planning 7.9 KNOWLEDGE OF FERTILE PERIOD A basic understanding of the physiology of human reproduction is useful for the successful practice of contraception. Successful use of some methods depends in large part on understanding when during the menstrual cycle a woman is most likely to conceive. Such knowledge is especially critical for the practice of rhythm/periodic abstinence. To assess this understanding, women were asked whether there were certain days during the menstrual cycle when a woman is more likely to become pregnant if she has 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,” “during her period,” “right after her period has ended,” and “halfway between two periods.” Respondents could also provide 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 7.11 provides the results for all women, for women using the rhythm method, and for women not using the rhythm method. Overall, only 20 percent of women reported the correct timing of the fertile period, that is, halfway through the menstrual cycle. This proportion represents an increase from 2010, when only 12 percent of women reported the correct timing of the fertile period. The data also show that 59 percent of women have possibly correct knowledge and that 21 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 (31 percent) than among nonusers (19 percent). However, 58 percent of rhythm/periodic abstinence users have only possibly correct knowledge of the fertile period, and 11 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. The proportion of women using rhythm/periodic abstinence who have correct knowledge of the fertile period has declined slightly relative to the figure reported in 2010 (38 percent). Table 7.11 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 2014-15 Perceived fertile period Users of rhythm method Nonusers of rhythm method All women Just before her menstrual period begins 11.8 13.7 13.7 During her menstrual period 1.6 2.7 2.7 Right after her menstrual period has ended 45.9 45.3 45.3 Halfway between two menstrual periods 30.9 19.4 19.6 Other 0.0 0.1 0.1 No specific time 7.4 13.1 13.0 Don't know 2.4 5.5 5.5 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of women 204 13,293 13,497 Family Planning • 95 7.10 NEED AND DEMAND FOR FAMILY PLANNING SERVICES 7.10.1 Need and Demand for Family Planning among Currently Married Women This section provides information on the extent of need and potential demand for family planning services in Rwanda. Unmet need for family planning refers to fecund women who are not using contraception but who wish to postpone their next birth (spacing) or stop childbearing altogether (limiting). Specifically, women are considered to have an unmet need for spacing if they are: • At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years or are unsure if or when they want to become pregnant. • Pregnant with a mistimed pregnancy. • Postpartum amenorrheic for up to two years following a mistimed birth and not using contraception. Women are considered to have an unmet need for limiting if they are: • At risk of becoming pregnant, not using contraception, and want no (more) children. • Pregnant with an unwanted pregnancy. • Postpartum amenorrheic for up to two years following an unwanted birth and not using contraception. Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Women using contraception are considered to have a met need. Women using contraception who say they want no (more) children are considered to have a met need for limiting, and women who are using contraception and say they want to delay having a child, or are unsure if or when they want a (another) child, are considered to have a met need for spacing. Unmet need, total demand, percentage of demand satisfied, and percentage of demand satisfied by modern methods are defined as follows: Unmet need: The sum of unmet need for spacing plus unmet need for limiting Total demand for family planning: The sum of unmet need plus total contraceptive use Percentage of demand satisfied: Total contraceptive use divided by the sum of unmet need plus total contraceptive use Percentage of demand satisfied by modern methods: Use of modern contraceptive methods divided by the sum of unmet need plus total contraceptive use In the past, the definition of unmet need used information from the contraceptive calendar and other questions that were not included in every survey, which led to unmet need being calculated inconsistently. The revised definition uses only information that has been collected in every survey so that unmet need can be measured in the same way over time (Bradley et al., 2012). 96 • Family Planning Table 7.12.1 presents estimates of 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 (the same proportion as in 2010); 11 percent have an unmet need for spacing, and 8 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 is the same as the demand for spacing (36 percent each). Table 7.12.1 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 2014-15 Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 2.7 1.0 3.6 33.4 1.9 35.3 36.1 2.8 38.9 90.7 84.3 85 20-24 14.2 0.7 14.8 43.1 4.3 47.4 57.3 5.0 62.2 76.1 71.2 883 25-29 15.6 2.6 18.1 42.3 12.4 54.7 57.9 14.9 72.8 75.1 69.9 1,577 30-34 14.4 7.5 21.9 29.3 25.6 54.9 43.7 33.1 76.8 71.5 66.6 1,693 35-39 8.3 13.7 22.0 14.6 43.1 57.7 22.8 56.8 79.6 72.4 64.0 1,240 40-44 2.9 16.8 19.7 4.8 52.2 56.9 7.7 69.0 76.7 74.3 60.8 896 45-49 0.0 13.8 13.8 0.0 41.6 41.6 0.0 55.3 55.3 75.1 53.2 607 Residence Urban 10.6 6.7 17.3 29.5 27.0 56.5 40.1 33.6 73.8 76.6 69.3 1,194 Rural 10.7 8.6 19.3 24.9 27.6 52.6 35.6 36.3 71.9 73.2 65.0 5,788 Province Kigali City 10.5 7.1 17.7 28.9 25.5 54.5 39.5 32.7 72.2 75.5 68.9 842 South 9.7 9.6 19.2 23.1 29.6 52.7 32.8 39.1 71.9 73.3 67.0 1,606 West 14.5 8.2 22.8 23.1 24.0 47.1 37.6 32.3 69.9 67.4 58.9 1,542 North 8.0 6.9 14.9 27.6 33.3 60.8 35.6 40.2 75.8 80.3 72.6 1,130 East 10.0 8.6 18.6 27.6 26.0 53.6 37.6 34.6 72.2 74.3 64.5 1,863 Education No education 10.5 12.2 22.7 14.4 33.7 48.1 24.9 45.9 70.8 67.9 57.5 1,154 Primary 10.8 8.1 19.0 26.9 27.3 54.2 37.7 35.5 73.2 74.1 66.7 4,921 Secondary and higher 9.8 4.1 14.0 34.0 20.7 54.7 43.8 24.8 68.6 79.6 71.5 907 Wealth quintile Lowest 12.8 9.4 22.2 23.2 25.2 48.4 36.0 34.6 70.6 68.6 63.6 1,313 Second 11.6 9.7 21.3 25.7 24.2 50.0 37.3 34.0 71.3 70.1 64.2 1,472 Middle 10.1 7.4 17.5 26.3 28.3 54.6 36.3 35.8 72.1 75.7 66.7 1,453 Fourth 9.0 8.6 17.6 25.5 31.0 56.4 34.5 39.5 74.0 76.2 65.8 1,380 Highest 9.9 6.3 16.1 27.8 29.0 56.8 37.7 35.3 73.0 77.9 68.5 1,365 Total 10.7 8.3 18.9 25.7 27.5 53.2 36.4 35.8 72.2 73.8 65.8 6,982 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, standard days method, and lactational amenorrhea method (LAM). There is minimal variance in unmet need by age except for the youngest and oldest women, who have the lowest percentages of unmet need. Up through age 34, most unmet need for family planning involves spacing. At age 35 and thereafter, most unmet need is associated with limiting childbearing. Total unmet need for family planning is higher in rural areas (19 percent) than in urban areas (17 percent). By province, total unmet need is highest in West (23 percent) and lowest in North (15 percent). Unmet need decreases with increasing education and wealth. There are notable differences by women’s characteristics in percentage of demand satisfied. As expected, percentages of demand satisfied are higher among urban women (77 percent), those living in wealthier households (78 percent), and those with more education (80 percent) and North province (80 percent). Family Planning • 97 Total demand for family planning did not change between 2010 and 2014-15 (72 percent). However, over that period, the percentage of total demand satisfied by modern methods increased from 62 percent to 66 percent. 7.10.2 Need and Demand for Family Planning among All Women and Women Who Are Not Currently Married Table 7.12.2 presents estimates of unmet need, met need, and total demand for family planning among all women and among women who are not currently married. Thirteen percent of all women and 6 percent of women not currently married have an unmet need for family planning. Total demand for family planning is 43 percent among all women and 13 percent among women not currently married; the corresponding proportions of demand satisfied among these women are 71 percent and 55 percent. The demand for spacing is slightly higher than the demand for limiting among all women (22 percent and 21 percent, respectively) as well as among women who are not currently married (7 percent and 6 percent, respectively). Table 7.12.2 Need and demand for family planning for all women and for 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 2014-15 Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total ALL WOMEN Age 15-19 3.3 0.2 3.4 2.1 0.2 2.3 5.4 0.3 5.7 39.6 34.6 2,768 20-24 9.3 0.7 10.0 18.7 2.5 21.3 28.0 3.2 31.2 68.1 64.3 2,457 25-29 12.6 2.5 15.2 31.3 10.7 41.9 43.9 13.2 57.1 73.4 68.7 2,300 30-34 12.3 6.9 19.1 24.3 23.3 47.6 36.6 30.1 66.7 71.3 66.6 2,151 35-39 6.8 12.1 18.9 11.6 37.0 48.6 18.4 49.1 67.6 72.0 64.0 1,575 40-44 2.4 13.7 16.1 3.5 40.5 44.1 6.0 54.2 60.2 73.2 60.9 1,269 45-49 0.0 9.4 9.4 0.0 27.8 27.8 0.0 37.2 37.2 74.7 53.8 977 Residence Urban 7.1 3.7 10.8 15.3 14.2 29.5 22.4 17.9 40.4 73.2 66.6 2,626 Rural 7.6 5.4 13.0 14.6 16.6 31.2 22.2 22.0 44.2 70.6 63.3 10,871 Province Kigali City 6.8 4.0 10.8 15.8 13.6 29.4 22.7 17.6 40.3 73.1 67.6 1,799 South 6.9 6.2 13.1 12.7 17.1 29.8 19.6 23.2 42.8 69.5 63.9 3,214 West 9.3 4.8 14.2 12.9 14.5 27.4 22.2 19.3 41.5 65.9 58.1 2,965 North 5.4 4.2 9.6 14.9 18.7 33.6 20.3 22.8 43.2 77.8 70.6 2,211 East 8.2 5.4 13.6 17.6 16.5 34.1 25.8 21.9 47.7 71.5 62.7 3,308 Education No education 8.0 10.0 18.0 10.7 26.5 37.2 18.7 36.5 55.1 67.4 57.9 1,665 Primary 8.2 5.5 13.7 16.6 17.6 34.2 24.8 23.1 47.9 71.4 64.8 8,678 Secondary and higher 5.2 1.3 6.5 11.6 6.8 18.4 16.9 8.0 24.9 73.8 66.4 3,154 Wealth quintile Lowest 9.0 7.0 16.0 13.3 16.6 29.9 22.3 23.6 45.9 65.1 60.9 2,561 Second 8.1 6.1 14.2 15.8 15.7 31.5 23.9 21.8 45.7 68.8 63.2 2,631 Middle 7.7 4.6 12.3 16.1 17.1 33.2 23.8 21.7 45.5 73.0 64.7 2,597 Fourth 6.2 5.1 11.3 14.9 17.4 32.3 21.1 22.5 43.6 74.1 64.5 2,634 Highest 6.5 3.0 9.5 13.7 14.3 28.0 20.3 17.2 37.5 74.6 66.3 3,073 Total 7.5 5.1 12.6 14.7 16.2 30.9 22.2 21.2 43.4 71.1 63.9 13,497 (Continued…) 98 • Family Planning Table 7.12.2—Continued Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total WOMEN NOT CURRENTLY MARRIED Age 15-19 3.3 0.2 3.4 1.1 0.1 1.2 4.4 0.3 4.7 26.1 21.4 2,683 20-24 6.5 0.7 7.2 5.1 1.5 6.6 11.6 2.2 13.8 47.7 46.8 1,574 25-29 6.2 2.5 8.7 7.2 6.9 14.1 13.3 9.4 22.7 61.9 60.8 723 30-34 4.5 4.5 9.0 5.8 14.6 20.5 10.4 19.2 29.5 69.4 66.6 457 35-39 1.6 6.2 7.8 0.5 14.7 15.2 2.1 20.9 23.0 66.0 64.1 335 40-44 1.2 6.3 7.4 0.6 12.5 13.1 1.7 18.8 20.5 63.7 61.3 372 45-49 0.0 2.3 2.3 0.0 5.1 5.1 0.0 7.3 7.3 69.2 61.2 370 Residence Urban 4.3 1.2 5.4 3.4 3.6 7.1 7.7 4.8 12.5 56.5 53.5 1,432 Rural 4.0 1.8 5.8 2.8 4.1 6.9 6.8 5.8 12.7 54.2 52.1 5,083 Province Kigali City 3.6 1.2 4.8 4.3 3.1 7.4 7.9 4.3 12.2 60.7 60.7 957 South 4.1 2.8 6.9 2.3 4.5 6.8 6.4 7.4 13.8 49.7 47.5 1,608 West 3.6 1.2 4.8 1.9 4.1 6.0 5.5 5.3 10.8 55.5 52.7 1,423 North 2.7 1.3 4.0 1.7 3.4 5.1 4.4 4.7 9.1 55.8 53.3 1,081 East 5.8 1.3 7.1 4.8 4.1 8.9 10.6 5.4 16.1 55.5 52.4 1,445 Education No education 2.3 4.9 7.2 2.3 10.3 12.6 4.6 15.2 19.8 63.7 61.2 511 Primary 4.7 2.1 6.8 3.2 4.8 8.0 8.0 6.9 14.9 54.0 52.5 3,758 Secondary and higher 3.4 0.1 3.5 2.6 1.1 3.7 6.0 1.3 7.3 51.6 46.7 2,247 Wealth quintile Lowest 5.1 4.5 9.6 2.8 7.6 10.4 7.9 12.1 20.0 52.1 50.7 1,248 Second 3.7 1.5 5.2 3.2 4.8 8.0 6.9 6.3 13.2 60.5 56.4 1,159 Middle 4.6 1.0 5.7 3.3 2.9 6.1 7.9 3.9 11.8 52.0 49.5 1,144 Fourth 3.2 1.2 4.4 3.2 2.6 5.8 6.4 3.8 10.2 56.6 54.4 1,255 Highest 3.9 0.4 4.2 2.5 2.5 5.0 6.3 2.8 9.2 54.1 52.2 1,709 Total 4.1 1.6 5.7 2.9 4.0 6.9 7.0 5.6 12.6 54.7 52.4 6,515 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, standard days method, and lactational amenorrhea method (LAM). 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. Beginning at age 35, most unmet need is for limiting childbearing. Total unmet need for family planning among all women is slightly higher in rural areas (13 percent) than in urban areas (11 percent). At the provincial level, total unmet need is highest in West and East (14 percent ) and lowest in North (10 percent) among all women; the proportions of unmarried women with unmet need are lowest in North (4 percent) and highest in East and South (7 percent for each). 7.11 FUTURE USE OF CONTRACEPTION Future demand for specific methods of family planning can be assessed from the survey results. In the 2014-15 RDHS, women who were not currently using a method of contraception were asked about their intention to use family planning in the future. Those who intended to use contraception in the future were asked which methods they prefer to use. This is an important indicator of how demand for family planning may change in the future. The results are presented in Table 7.13. Seven in 10 (71 percent) currently married women who are non-users intend to use family planning in the future, while 28 percent do not intend to do so. The proportion of women intending to use contraception increases from 64 percent among those with no children to a peak of 79 percent among those with one child before decreasing slightly among those with two (78 percent) or three (77 percent) children. The proportion Family Planning • 99 among women with four or more children is 63 percent. The proportion of women intending to use family planning in the future is slightly lower than the figure reported in the 2010 RDHS (74 percent). Table 7.13 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 2014-15 Number of living children1 Total Intention 0 1 2 3 4+ Intends to use 63.5 78.7 78.3 76.8 62.8 71.4 Unsure 0.4 1.6 0.0 0.4 0.7 0.7 Does not intend to use 36.2 19.7 21.0 22.2 35.8 27.5 Missing 0.0 0.0 0.7 0.6 0.6 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 152 603 686 543 1,279 3,264 1 Includes current pregnancy 7.12 EXPOSURE TO FAMILY PLANNING MESSAGES The mass media play an important role in communicating messages about family planning. Data on levels of exposure to radio, television, and printed materials are important for program managers and planners to effectively target population subgroups for information, education, and communication campaigns. To assess the effectiveness of family planning information disseminated through various media, interviewers asked respondents if they had been exposed to family planning messages on the radio or television, in video or films, and in print (newspapers and magazines) in the few months preceding the survey. Table 7.14 shows that radio is by far the most widely accessed source of family planning messages in Rwanda, with 52 percent of women and 64 percent of men age 15-49 having heard a family planning message on the radio in the past few months. Eight percent each of women reported having seen a family planning message on television or in a newspaper/magazine; while 10 percent each of men reported having seen a family planning message from these two media. It is also important to note that, 47 percent of women and 34 percent of men have not been exposed to any family planning messages in any of the three specified media sources. These proportions represent a considerable increase since 2010 (33 percent for women and 16 percent for men). Women in rural areas (48 percent) were more likely to report not having been exposed to family planning messages than those in urban areas (40 percent). Women with no education (59 percent) were more likely to have had no exposure than those with a primary education (49 percent) or a secondary education or higher (34 percent). The same pattern is observed in women in the lowest wealth quintile (67 percent) compared to the higher quintiles (36-53 percent). Results by province showed that the highest percentage of women who had no exposure to family planning messages is observed in West (58 percent), while the lowest percentage is observed in North (39 percent). Similar patterns were observed among men. 100 • Family Planning Table 7.14 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on radio, on television, or in a newspaper or magazine in the past few months, according to background characteristics, Rwanda 2014-15 Women Men Background characteristic 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 44.4 6.5 9.0 52.8 2,768 50.6 6.2 6.2 48.0 1,282 20-24 53.9 9.8 10.8 44.3 2,457 66.4 11.0 12.4 32.0 994 25-29 53.1 7.8 6.5 45.3 2,300 68.5 10.3 11.5 30.8 946 30-34 52.5 7.7 6.9 46.4 2,151 67.6 9.4 7.8 31.4 930 35-39 53.8 7.4 7.1 45.4 1,575 68.3 12.0 8.2 30.2 567 40-44 53.6 6.8 5.8 45.7 1,269 73.1 10.8 12.9 25.8 473 45-49 54.1 5.9 3.5 45.0 977 70.7 10.9 11.8 28.3 385 Residence Urban 55.5 21.8 12.6 40.4 2,626 71.2 23.2 18.7 26.3 1,169 Rural 50.6 4.2 6.5 48.4 10,871 62.6 6.0 7.2 36.5 4,408 Province Kigali City 53.5 20.2 9.3 41.7 1,799 69.1 20.6 15.2 29.1 804 South 52.2 7.0 7.9 46.6 3,214 65.7 5.8 6.4 33.2 1,327 West 40.9 3.6 5.3 58.1 2,965 56.3 8.1 8.6 42.8 1,182 North 59.8 7.9 12.5 38.8 2,211 66.8 7.6 11.6 32.4 851 East 53.8 4.7 5.3 45.3 3,308 65.8 9.2 9.2 32.7 1,413 Education No education 41.0 2.7 0.4 58.8 1,665 56.0 4.2 0.3 43.5 496 Primary 49.9 4.7 4.7 49.2 8,678 62.0 6.5 4.8 37.2 3,636 Secondary and higher 61.7 18.3 19.7 34.1 3,154 73.4 19.1 24.9 24.1 1,445 Wealth quintile Lowest 32.7 2.0 2.2 67.0 2,561 49.7 3.2 3.2 49.7 819 Second 45.7 2.8 4.3 53.4 2,631 58.5 4.4 4.2 40.6 991 Middle 55.5 3.4 6.2 43.7 2,597 64.0 3.6 4.4 35.5 1,097 Fourth 61.5 4.6 9.6 37.1 2,634 67.3 8.7 10.6 31.5 1,234 Highest 60.3 22.7 14.6 35.6 3,073 74.7 22.0 20.2 23.0 1,436 Total 15-49 51.6 7.6 7.6 46.9 13,497 64.4 9.6 9.6 34.4 5,577 50-59 na na na na na 71.6 8.5 6.1 27.8 640 Total 15-59 na na na na na 65.1 9.4 9.3 33.7 6,217 na = Not applicable 7.13 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS To gain insight into the level of contact between nonusers and family planning providers, interviewers in the 2014-15 RDHS asked women who were not using contraception whether a fieldworker or health worker had visited them during the 12 months preceding the survey and discussed family planning. In addition, women were asked whether they had visited a health facility in the 12 months preceding the survey for any reason and whether anyone at the facility had discussed family planning with them during the visit. This information is important to determine whether family planning initiatives in Rwanda are reaching nonusers of family planning. Table 7.15 shows that 14 percent of non-users during the 12 months preceding the survey had been visited by fieldworkers who discussed family planning. Among women who were not using contraception, only 17 percent had visited a health facility and discussed family planning at the facility in the past 12 months, while 38 percent had visited a health facility but did not discuss family planning. Overall, 75 percent of non-users did not discuss family planning either with a fieldworker or at a health facility. There were differences according to residence: 82 percent of women in urban areas and 74 percent in rural areas had not discussed family planning with a community health worker or at a health facility. By province, the highest percentage of women who did not discuss family planning is found in Kigali City (83 percent) while the lowest is observed in East (68 percent) Family Planning • 101 Percentage of women who did not discuss family planning either with fieldworker or at a health facility increases as level of education increases; 68 percent of women with no education had not discussed family planning with a community health worker or at a health facility, as compared to 86 percent of those with a secondary or higher education. Similar relationship is observed for wealth quintile. Table 7.15 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the past 12 months were visited by a fieldworker 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 did not discuss family planning either with a fieldworker or at a health facility, by background characteristics, Rwanda 2014-15 Percentage of women who were visited by fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who did not discuss family planning either with fieldworker or at a health facility Number of women Background characteristic Discussed family planning Did not discuss family planning Age 15-19 4.2 3.9 30.8 92.8 2,705 20-24 10.9 15.0 44.2 78.5 1,935 25-29 16.7 24.9 42.4 67.3 1,336 30-34 25.0 31.3 38.4 57.0 1,127 35-39 25.0 31.0 38.6 57.1 809 40-44 24.5 21.9 39.9 62.8 710 45-49 14.8 14.2 37.9 76.3 706 Residence Urban 8.3 12.3 42.3 82.3 1,850 Rural 15.4 18.2 37.0 73.5 7,479 Province Kigali City 8.5 10.9 42.2 83.3 1,269 South 14.1 17.1 42.1 74.7 2,257 West 12.5 15.7 36.6 77.4 2,153 North 16.2 13.8 34.7 76.5 1,469 East 17.2 24.0 35.2 68.1 2,180 Education No education 18.4 22.4 35.0 67.8 1,046 Primary 16.0 19.7 35.2 71.9 5,710 Secondary and higher 8.0 8.9 45.7 85.6 2,574 Wealth quintile Lowest 17.4 19.5 33.1 70.5 1,795 Second 16.7 19.4 34.8 71.8 1,804 Middle 15.7 19.2 37.1 73.0 1,734 Fourth 13.5 17.1 39.8 76.0 1,783 Highest 8.3 11.3 44.1 83.0 2,213 Total 14.0 17.0 38.1 75.2 9,329 Infant and Child Mortality • 103 INFANT AND CHILD MORTALITY 8 his chapter describes levels and trends in 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 to identify populations at-risk 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 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 the first birthday (computed as the difference between infant and neonatal mortality) • Infant mortality: the probability of dying between birth and the first birthday T Key Findings • Infant mortality rate in Rwanda in 2014-15 is 32 per 1,000 live birth; and under 5 mortality rate is 50 per 1,000 live births. • Infant mortality declined from 50 deaths to 32 deaths per 1,000 live births between the 2010 RDHS and the 2014-15 RDHS. • Under-5 mortality has declined from 76 deaths in 2010 RDHS to 50 deaths per 1,000 live births in 2014-15 RDHS • Neonatal and postneonatal mortality rates are 20 deaths per 1,000 live births and 13 deaths per 1,000 live births, respectively. • The perinatal mortality rate is 29 deaths per 1,000 pregnancies. • Childhood mortality is higher in rural areas than in urban areas. Mortality rates are lowest among households in the highest wealth quintile. 104 • Infant and Child Mortality • Child mortality: the probability of dying between the first and the fifth birthday • Under-5 mortality: the probability of dying between birth and the fifth birthday • Perinatal mortality rate: is the sum of stillbirths and early neonatal deaths divided by the sum of all stillbirths and live births. All rates are expressed as deaths per 1,000 live births with the exception of child mortality, which is expressed as deaths per 1,000 children surviving to their first birthday. 8.1 ASSESSMENT OF DATA QUALITY The reliability of mortality estimates depends on sampling errors and non-sampling errors. Sampling errors are discussed in detail in Appendix B. Non-sampling 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. The omission of births and deaths affects mortality estimates, displacement of dates of births and deaths affects mortality trends, and misreporting of age at death may alter the age pattern of mortality. Typically, the most serious source of non-sampling 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 that there is a negligible proportion of missing information on birth dates (births in the past 15 years), age at death, age at first union, and mother’s education. An unusual pattern in the distribution of births by calendar years is an indication of possible 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 99 to 100 percent of births. There is little difference in reporting by whether or not the child is alive (100 percent of births) or dead (99 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. Among all infant deaths reported in days during the period 0-4 years preceding the survey, 73 percent were neonatal deaths occurring in the first week of life. Among all infant deaths reported in days during the 20 years preceding the survey, 69 percent were neonatal deaths. These rates are reasonable, suggesting that early infant deaths are not severely underreported in the 2014-15 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 nearly five times the number of deaths at age 11 months. Reporting of infant deaths at 12 months is much more common for the earlier periods prior to the survey (5 years or earlier) than for the most recent periods (0-4 years). It is possible that some of these deaths occurred before Infant and Child Mortality • 105 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 to get sufficient observations because deaths are rare events. Neonatal mortality in the most recent period is 20 deaths per 1,000 live births. This rate is higher than the postneonatal mortality rate (13 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. Thirty-two of every 1,000 babies born in Rwanda do not survive to their first birthday. The child mortality is 19 deaths per 1000 live births. Under-5 mortality in Rwanda is 50 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 2014-15 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 20 13 32 19 50 5-9 25 26 51 35 84 10-14 37 46 83 73 150 1 Computed as the difference between the infant and neonatal mortality rates Figure 8.1 Trends in childhood mortality rates Trends in childhood mortality rates can be established by comparing the results of the 2014-15 RDHS with the findings from the 2005 and 2010 RDHS surveys and the 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 10 years, from 86 deaths per 1,000 live births in 2005 to 62 per 1,000 live births in 2007-08, 50 per 1,000 live births in 2010, and 32 per 1,000 live births in 2014-15. Under-5 mortality also declined during this period, from 152 deaths per 1,000 live births in 2005 to 103 per 1,000 live births in 2007-08, 76 per 1,000 live births in 2010, and 37 49 86 72 152 28 34 62 43 103 27 23 50 27 76 20 13 32 19 50 Neonatal mortality Postneonatal mortality Infant mortality Child mortality Under-5 mortality Deaths per 1,000 live births RDHS 2005 RDHS 2007-08 RDHS 2010 RDHS 2014-15 RDHS 2014-15 106 • Infant and Child Mortality 50 per 1,000 live births in 2014-15. The decreases in infant and under-5 mortality are likely due to the implementation of integrated management of childhood illnesses in all health facilities and in community health services and the introduction of new vaccines among others. 8.3 SOCIOECONOMIC DIFFERENTIALS IN CHILDHOOD MORTALITY The results presented in Table 8.2 and Figure 8.2 show that childhood mortality in Rwanda varies considerably 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 32 deaths per 1,000 live births, as compared with 44 deaths per 1,000 live births in rural areas. The urban-rural gap is wider for neonatal mortality (15 deaths versus 24 deaths per 1,000 livebirths). Differentials in mortality by province, particularly under-5 mortality, are also substantial. The city of Kigali has the lowest rates of neonatal mortality (12 deaths per 1,000 live births) and under-5 mortality (42 deaths per 1,000 live births). The highest neonatal mortality rates are found in West and South (25 deaths per 1,000 live births), while the highest infant mortality rates are found in East and West (51 deaths and 41 deaths per 1000 live births, respectively).The East province has the highest under-5 mortality rate (86 deaths per 1,000 live births). 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 characteristics, Rwanda 2014-15 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 15 17 32 19 51 Rural 24 20 44 28 70 Province Kigali City 12 17 29 14 42 South 25 16 40 27 66 West 25 17 41 22 62 North 23 15 38 23 60 East 22 30 51 37 86 Mother’s education No education 24 28 52 39 89 Primary 23 19 42 24 65 Secondary and higher 16 13 29 14 43 Wealth quintile Lowest 23 26 50 36 84 Second 26 18 44 34 77 Middle 22 24 47 23 68 Fourth 24 15 39 20 58 Highest 13 12 25 15 40 1 Computed as the difference between the infant and neonatal mortality rates 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 neonatal mortality rate among children of mothers with a secondary education or higher is 16 deaths per 1,000 live births, much lower than the rate of 24 deaths per 1,000 live births among children of mothers with no education. In addition, mortality declines markedly as the wealth of the household increases. For example, infant and under-5 mortality rates are about twice as high among children living in the poorest households than among those living in the wealthiest households. 1 To have a sufficient number of cases to ensure statistically reliable mortality estimates by background characteristics, the rates presented in Tables 8.2 and 8.3 are calculated for a 10-year period. Infant and Child Mortality • 107 Figure 8.2 Under-5 mortality rates by socioeconomic characteristics 8.4 DEMOGRAPHIC DIFFERENTIALS IN MORTALITY Infant and child mortality rates vary substantially by the demographic characteristics of mothers and children. Table 8.3 and Figure 8.3 show childhood mortality rates by different demographic variables. 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. In general, the distribution of childhood mortality by maternal age at birth is a U-shaped curve, with mortality relatively higher among children born to mothers under age 20 and over age 40 than among children born to mothers in the 20-29 and 30-39 age groups. The only exception is postneonatal mortality. Relationships between infant mortality and specific demographic characteristics are illustrated in Figure 8.3. First-order births appear to be at a somewhat higher risk of mortality than second- to sixth-order births. Substantial increases in risk are most apparent for births of order seven and higher. 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 almost twice as likely to die within the first month of life as children born after a four-year interval (33 deaths per 1,000 live births versus 17 deaths 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 almost twice as likely to die before his or her first birthday as a child born four or more years after a preceding birth (60 deaths per 1,000 live births versus 32 deaths 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 very 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 four times as likely to die before age 1 month as those reported to be average or larger. 40 58 68 77 84 43 65 89 70 51 0 20 40 60 80 100 120 140 Highest Fourth Middle Second Lowest WEALTH QUINTILE Secondary and higher Primary No education EDUCATION Rural Urban RESIDENCE Deaths per 1,000 live births RDHS 2014-15 108 • Infant and Child Mortality 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 2014-15 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 25 20 45 27 70 Female 20 19 39 26 64 Mother’s age at birth <20 40 14 54 31 83 20-29 21 18 39 24 62 30-39 19 23 43 30 71 40-49 33 18 52 (31) (80) Birth order 1 29 17 46 21 66 2-3 19 18 37 26 62 4-6 19 21 41 30 70 7+ 26 26 52 30 80 Previous birth interval2 <2 years 33 27 60 41 99 2 years 19 23 41 30 70 3 years 12 17 29 21 49 4+ years 17 15 32 18 49 Birth size3 Small/very small 47 19 66 na na Average or larger 13 12 25 na na Note: Figures in parentheses are based on 250-499 unweighted person-years of exposure to the risk of death. na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey Figure 8.3 Infant mortality rates by demographic characteristics 8.5 PERINATAL MORTALITY The 2014-15 RDHS asked women to report on any pregnancy losses that had occurred in the five years preceding the survey. For each pregnancy that did not end in a live birth, the duration of pregnancy was recorded. In this report, perinatal deaths include pregnancy losses of at least seven months’ gestation (stillbirths) and 32 29 41 60 52 41 37 46 52 43 39 54 0 20 40 60 80 4+ years 3 years 2 years <2 years PREVIOUS BIRTH INTERVAL 7+ 4-6 2-3 1 BIRTH ORDER 40-49 30-39 20-29 <20 MOTHER'S AGE Deaths per 1,000 live births RDHS 2014-15 Infant and Child Mortality • 109 deaths to live births within the first seven days of life (early neonatal deaths). The perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the sum of all stillbirths and live births. Information on stillbirths and infant deaths within the first week of life is highly susceptible to omission and misreporting. Nevertheless, retrospective surveys in most developing countries provide more representative and accurate perinatal death rates than do vital registration systems and hospital-based studies. Table 8.4 shows that of the 8,129 reported pregnancies of at least seven months’ gestation in the five years preceding the survey, 125 were stillbirths and 114 were early neonatal deaths, yielding an overall perinatal mortality rate of 29 per 1,000 pregnancies. Because the rate is subject to a high degree of sampling variation, differences by background characteristics should be interpreted with caution. Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Rwanda 2014-15 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months’ duration Mother’s age at birth <20 7 16 40 570 20-29 62 57 26 4,481 30-39 54 32 32 2,685 40-49 3 9 31 392 Previous pregnancy interval in months4 First pregnancy 30 42 32 2,252 <15 27 17 42 1,036 15-26 16 18 23 1,444 27-38 12 11 19 1,212 39+ 41 26 31 2,185 Residence Urban 22 17 28 1,368 Rural 104 97 30 6,761 Province Kigali City 16 9 26 960 South 29 31 32 1,866 West 26 31 29 1,945 North 15 16 28 1,123 East 39 27 30 2,235 Mother’s education No education 30 16 38 1,227 Primary 83 89 29 5,883 Secondary and higher 12 9 25 855 Wealth quintile Lowest 42 29 36 1,978 Second 27 21 27 1,764 Middle 18 22 25 1,597 Fourth 17 29 33 1,401 Highest 21 13 25 1,388 Total 125 114 29 8,129 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration, expressed per 1,000 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. The perinatal mortality rate is highest among mothers less than age 20 (40 deaths per 1,000 pregnancies) and among births that occur less than 15 months after the previous birth (42 deaths per 1,000 pregnancies). It is lowest among births that occur 27-38 months after the previous birth (19 deaths per 1,000 live births). Perinatal mortality differs little by urban-rural residence or by province. By maternal educational and wealth status, perinatal mortality is highest among women with no education (38 deaths per 1,000 live births) and those in the lowest wealth quintile (36 deaths per 1,000 live births). 110 • Infant and Child Mortality 8.6 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 augmented when a child is born to a mother who has a combination of these risk characteristics. Table 8.5 shows the percent distribution of children born to currently married women in the five years before the survey by these risk factors. Thirty percent of births were not in any high-risk category. Twenty-eight percent were first births to women between age 18 and age 34 (considered an unavoidable risk category).Slightly more than a quarter (26 percent) of births were in a single high-risk category, and 17 percent were in a multiple high-risk category. The most common single high-risk category was birth order higher than three (16 percent), and the most common multiple high-risk category was births to mothers older than age 34 and of birth order higher than three (13 percent). Table 8.5 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 2014-15 Births in the 5 years preceding the survey Percentage of currently married women1 Risk category Percentage of births Risk ratio Not in any high-risk category 29.8 1.00 23.4a Unavoidable risk category First-order births between age 18 and age 34 27.6 1.39 4.1 Single high-risk category Mother’s age <18 1.9 2.01 0.0 Mother’s age >34 2.0 0.39 3.7 Birth interval <24 months 6.3 0.94 10.8 Birth order >3 15.7 1.11 12.9 Subtotal 25.9 1.08 27.4 Multiple high-risk category Age <18 and birth interval <24 months2 0.0 * 0.0 Age >34 and birth interval <24 months 0.2 * 0.4 Age >34 and birth order >3 12.9 1.65 31.8 Age >34 and birth interval <24 months and birth order >3 1.3 1.78 5.6 Birth interval <24 months and birth order >3 2.4 1.77 7.1 Subtotal 16.7 1.66 45.0 In any avoidable high-risk category 42.6 1.31 72.5 Total 100.0 na 100.0 Number of births/women 8,004 na 6,982 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 (RRs), displayed in the second column of Table 8.5, 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 1.3 times higher than that 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. Children born to a mother younger than age 18 are most vulnerable; they are twice as likely to die as children who are not in any Infant and Child Mortality • 111 high-risk category. However, only about 2 percent of births fall into this category. The risk of dying is also high among births to mothers older than age 34, with a birth interval of less than 24 months, and of a birth order higher than three (RR of 1.78); births with a birth interval of less than 24 months and of a birth order higher than three (RR of 1.77); and births to mothers older than age 34 and of a birth order higher than three (RR of 1.65). The last column of Table 8.5 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 her 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 had her last birth 12 months ago were to become pregnant, she would fall into the multiple high-risk category of being too old, being too high in parity (four or more births), and giving birth too soon (less than 24 months) after a previous birth. Overall, approximately three in four currently married women (73 percent) have the potential to give birth to a child at elevated risk of mortality. Twenty-seven percent of women have the potential for having a birth in a single high-risk category, and 45 percent have the potential for having a birth in a multiple high-risk category (mainly older maternal age and higher birth order). Maternal Health • 113 MATERNAL HEALTH 9 he 2014-15 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 outlined help to 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, monitoring and evaluation of national health policies and programs. 9.1 ANTENATAL CARE Monitoring of pregnant women through antenatal care visits helps to reduce risks and complications during pregnancy, delivery, and the postpartum periods. For this reason, the 2014-15 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 who had a live birth in the five years before the survey according to the category of medical personnel they consulted during the pregnancy for their most recent birth and their 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 tabulation of results (e.g., if a doctor and nurse were mentioned, the doctor is considered in the tabulation). Nearly all mothers (99 percent) received at least one antenatal care from skilled personnel for their most recent live birth in the five years preceding the survey. Universal ANC from skilled personnel has remained stable since 2010 (98 percent). The data do not vary substantially by background characteristics; 98-99 percent of mothers received antenatal care from a skilled health provider regardless of age at birth, birth order, residence, province, level of education, or household wealth. However, the proportion of women who consulted a medical doctor during these visits is higher in urban areas (11 percent) as compared to in rural areas (3 percent), among those residing in the City of Kigali (12 percent) as compared to other provinces (2 to 8 percent), and among those with a secondary T Key Findings • Ninety-nine percent of women with a live birth in the five years preceding the survey received at least one antenatal care from a skilled health provider, almost the same level found in the 2010 RDHS (98 percent). • Forty-four percent of women make the recommended four or more antenatal care visits during their pregnancy, an increase of 9 percentage points since 2010 (35 percent). • Ninety-one percent of live births in the five years preceding the survey were delivered in a health facility; 91 percent were assisted by a skilled health provider. • More than 4 in 10 (43 percent) women who gave birth in the two years preceding the survey received a postnatal care checkup in the first two days after delivery. • Only 19 percent of newborns in the two years preceding the survey had a postnatal checkup within the first two days after birth; nearly all of these children received care from skilled personnel. 114 • Maternal Health education or higher (15 percent) as compared to those with no education (4 percent). The proportion of women who consulted with a doctor is also higher among those in the richest quintile (13 percent) as compared to other quintiles (2 to 4 percent). These results can be explained by the concentration of doctors in urban areas, particularly the City of Kigali. 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 2014-15 Antenatal care provider No ANC Total Percentage receiving antenatal care from a skilled provider1 Number of women Background characteristic Doctor Nurse/ medical assistant Midwife Traditional birth attendant Other Missing Mother’s age at birth <20 3.5 95.7 0.6 0.0 0.0 0.0 0.2 100.0 99.8 429 20-34 4.6 93.8 0.6 0.0 0.0 0.1 0.8 100.0 99.0 4,523 35-49 5.4 92.6 0.6 0.0 0.0 0.3 1.1 100.0 98.6 1,109 Birth order 1 4.6 94.2 0.5 0.0 0.0 0.0 0.6 100.0 99.4 1,656 2-3 5.1 93.3 0.6 0.1 0.0 0.2 0.7 100.0 99.0 2,350 4-5 4.9 93.9 0.4 0.0 0.0 0.3 0.5 100.0 99.1 1,171 6+ 3.3 93.8 1.1 0.0 0.2 0.1 1.6 100.0 98.1 884 Residence Urban 11.4 86.6 0.8 0.0 0.0 0.0 1.1 100.0 98.9 1,025 Rural 3.3 95.2 0.6 0.0 0.0 0.2 0.7 100.0 99.0 5,035 Province City of Kigali 11.7 85.7 1.1 0.0 0.0 0.1 1.4 100.0 98.5 723 South 8.0 91.0 0.1 0.0 0.0 0.1 0.7 100.0 99.1 1,406 West 1.8 95.9 1.3 0.0 0.0 0.1 0.9 100.0 99.0 1,365 North 3.4 95.3 0.6 0.0 0.0 0.4 0.3 100.0 99.3 885 East 1.8 96.9 0.3 0.1 0.1 0.2 0.7 100.0 98.9 1,682 Education No education 3.9 93.5 0.7 0.0 0.2 0.0 1.7 100.0 98.2 881 Primary 2.9 95.6 0.6 0.0 0.0 0.2 0.6 100.0 99.1 4,360 Secondary and higher 14.5 84.0 0.7 0.0 0.0 0.1 0.7 100.0 99.2 819 Wealth quintile Lowest 2.9 94.9 0.8 0.1 0.0 0.1 1.2 100.0 98.6 1,432 Second 2.7 95.9 0.3 0.0 0.1 0.3 0.6 100.0 98.9 1,306 Middle 2.2 96.4 0.5 0.0 0.0 0.1 0.8 100.0 99.1 1,195 Fourth 3.7 95.3 0.7 0.0 0.0 0.1 0.3 100.0 99.6 1,072 Highest 13.1 84.9 0.8 0.0 0.0 0.2 1.0 100.0 98.8 1,055 Total 4.6 93.7 0.6 0.0 0.0 0.2 0.8 100.0 99.0 6,060 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. It should be noted that women with sixth or higher birth order category and those with no education were most likely to have received no antenatal care (2 percent in each group). To be effective, antenatal care must be sought early during 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. Table 9.2 shows the number of ANC visits and the timing of the first visit. Although 99 percent of Rwandan mothers received antenatal care, the number of visits was below the standard set by WHO and the Rwanda Ministry of Health. Only 44 percent of women who had a live birth in the five years preceding the survey met the standard of at least four ANC visits. Nevertheless, this proportion represents an increase from 13 percent in 2005 and 35 percent in 2010. More than half of women (52 percent) had two or three ANC visits. It Maternal Health • 115 should also be noted that 3 percent of mothers had only one ANC visit, and 1 percent had no visits. Results by residence show no variation in the proportion of women who had at least four ANC visits (44 percent in both urban and rural areas). It should be noted that most Rwandan women obtain antenatal care during their early pregnancy. Fifty-six percent of women made their first visit before the fourth month of pregnancy. This proportion was only 38 percent in 2010. There is no variation in this proportion between urban and rural women. The results also show that 31 percent of women had their first visit at the fourth or fifth month of pregnancy; 11 percent began at the sixth or seventh month, and 1 percent began at the eighth month or after. The median duration of pregnancy at the first ANC visit was 3.9 months for the country as a whole (3.8 months and 3.9 months in urban and rural areas, respectively).This represents an improvement from 2010, when the median duration was 4.5 months. 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 2014-15 Residence Total Number and timing of ANC visits Urban Rural Number of ANC visits None 1.1 0.8 0.8 1 3.7 3.0 3.1 2-3 50.8 52.4 52.1 4+ 44.3 43.9 43.9 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 1.1 0.8 0.8 <4 56.3 56.1 56.1 4-5 28.2 31.5 31.0 6-7 12.5 10.2 10.6 8+ 1.8 1.4 1.4 Don’t know/missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Number of women 1,025 5,035 6,060 Median months pregnant at first visit (for those with ANC) 3.8 3.9 3.9 Number of women with ANC 1,013 4,997 6,011 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 counseling and preventive measures administered to avoid the risk of miscarriage and other pregnancy complications. The 2014-15 RDHS collected data on these important aspects of antenatal 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 like blood pressure measurements, 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. Four out of five women (80 percent) took iron tablets or syrup during the pregnancy of their last birth. About half of women (49 percent) took deworming drugs. Ninety-seven percent of women had a blood sample taken, 84 percent had their blood pressure measured, 79 percent were informed of signs of pregnancy complications, and 58 percent had a urine sample taken. Overall, these figures represent improvements from those reported in the 2010 RDHS. 116 • Maternal Health The results reveal only minor differences in the use of iron tablets or syrup by pregnant mothers. Younger mothers (less than age 20) and those with their first birth were slightly less likely to take iron supplements during pregnancy than other mothers. Looking at provincial level East had the lowest proportion (73 percent) of women who took iron during their pregnancy, while North had the highest proportion (90 percent). 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 2014-15 Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Number of women with a live birth in the past five years Among women who received antenatal care for their most recent birth in the past five years, the percentage with selected services Number of women with ANC for their most recent birth Background characteristic Took iron tablets or syrup Took intestinal parasite drugs Informed of signs of pregnancy complications Blood pressure measured Urine sample taken Blood sample taken Mother’s age at birth <20 72.2 42.9 429 80.9 83.2 61.4 97.3 428 20-34 80.2 49.7 4,523 78.6 83.0 58.7 96.8 4,487 35-49 79.9 50.0 1,109 79.6 88.6 55.2 96.2 1,096 Birth order 1 76.1 47.6 1,656 80.6 81.6 65.8 97.6 1,645 2-3 81.6 49.8 2,350 78.0 84.2 57.9 97.3 2,331 4-5 80.4 51.9 1,171 78.6 84.9 54.1 95.3 1,164 6+ 79.8 47.8 884 78.9 87.1 50.6 95.4 870 Residence Urban 80.4 51.3 1,025 81.7 91.4 74.8 98.0 1,013 Rural 79.5 48.9 5,035 78.4 82.6 54.9 96.5 4,997 Province City of Kigali 79.7 51.2 723 84.1 95.5 77.1 99.1 713 South 83.8 53.1 1,406 82.0 90.5 57.2 98.5 1,396 West 77.1 51.1 1,365 68.8 83.3 65.4 93.5 1,352 North 90.0 51.2 885 86.0 83.7 70.8 95.3 882 East 72.7 42.9 1,682 78.8 74.5 38.7 97.7 1,668 Education No education 79.9 46.8 881 73.9 83.0 50.1 93.8 867 Primary 79.9 49.8 4,360 79.1 83.1 56.9 97.0 4,330 Secondary and higher 77.7 49.1 819 83.5 90.1 74.4 98.3 814 Wealth quintile Lowest 78.7 47.7 1,432 75.3 83.6 54.8 95.6 1,414 Second 79.5 49.5 1,306 77.4 81.7 53.0 95.8 1,297 Middle 81.1 47.3 1,195 80.1 80.8 55.3 97.0 1,186 Fourth 79.0 50.2 1,072 80.4 82.6 56.5 97.3 1,069 Highest 79.9 52.6 1,055 83.0 92.7 74.8 98.6 1,045 Total 79.6 49.3 6,060 79.0 84.1 58.3 96.7 6,011 Use of deworming drugs also varies little by background characteristics. Half of women age 20 or older took intestinal parasite drugs during their pregnancy, as compared with only 43 percent of those less than age 20. By province, East had the lowest proportion of women who took deworming drugs during their pregnancy (43 percent), while South had the highest proportion (53 percent). Overall, the proportion of pregnant women informed of the signs of pregnancy complications was higher in urban areas (82 percent) than in rural areas (78 percent). It was also higher among mothers with a secondary education or more (84 percent) than among those with no education (74 percent). The West province had the lowest proportion of pregnant women informed of the signs of pregnancy complications (69 percent), while the North province had the highest (86 percent). Maternal Health • 117 The older mothers were more likely to have their blood pressure measured than the younger ones (89 percent and 83 percent, respectively). Similarly, women having a child of birth order six or higher were more likely to have their blood pressure measured (87 percent) than women pregnant with their first birth (82 percent). Ninety-one percent of women in urban areas had their blood pressure measured, as compared with 83 percent in rural areas. Mothers with a secondary education or higher (90 percent) were more likely to have their blood pressure checked than those with no education or only a primary education (83 percent each). By province, the proportion varied from a low of 75 percent in East to a high of 96 percent in City of Kigali. Younger women (61 percent), women giving their first birth (66 percent), those living in urban areas (75 percent), those living in the City of Kigali (77 percent), those with the highest level of education (74 percent), and those in the highest wealth quintile (75 percent) were most likely to have a urine test during antenatal care. Almost all women who received ANC for their most recent birth in the five years before the survey had their blood tested. Differences by background characteristics are small and follow patterns similar to those observed for urine testing. 9.1.2 Tetanus Vaccinations Neonatal tetanus is a major cause of death among newborns in 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 time; however, if she has already been vaccinated, for example during a previous pregnancy, one additional dose may be sufficient. 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. This figure has not changed since 2010. Taking into account mothers who had previous protection against tetanus, the proportion protected against tetanus rises to 82 percent, an increase from 79 percent in 2010. This means that 18 percent of pregnant women were not protected against tetanus. The age of the mother seems to be an important factor in tetanus coverage: the proportion whose last birth was protected against neonatal tetanus was higher among mothers age 20-34 (83 percent) and 35-49 (88 percent) than among mothers less than age 20 (64 percent). Similarly, higher-order births were better protected than first births (87-92 percent for second-and higher-order births and 63 percent for first births). In addition, mothers in the South province (85 percent), mothers with no education (84 percent) or a primary education (83 percent), and mothers in the fourth and highest wealth quintiles (84 percent each) were slightly more likely to be protected against tetanus than their counterparts. There is no variation in vaccination coverage by residence. 118 • Maternal Health 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 2014-15 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 60.6 63.5 429 20-34 36.0 82.9 4,523 35-49 13.6 87.5 1,109 Birth order 1 61.7 63.4 1,656 2-3 31.0 89.3 2,350 4-5 17.8 92.1 1,171 6+ 9.0 86.8 884 Residence Urban 40.5 82.5 1,025 Rural 32.2 82.4 5,035 Province City of Kigali 39.0 83.9 723 South 32.9 85.1 1,406 West 36.9 80.3 1,365 North 32.2 81.4 885 East 30.0 81.7 1,682 Education No education 27.9 84.0 881 Primary 32.4 82.8 4,360 Secondary and higher 46.5 78.8 819 Wealth quintile Lowest 35.3 81.7 1,432 Second 32.6 81.1 1,306 Middle 31.4 81.8 1,195 Fourth 30.1 83.7 1,072 Highest 38.6 84.4 1,055 Total 33.6 82.4 6,060 1 Includes mothers with two injections during the pregnancy of their last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within 10 years of the last live birth), or five or more injections at any time prior to the last birth 9.2 DELIVERY CARE 9.2.1 Place of Delivery Since every pregnancy may be subject to complications, women are advised to deliver their babies in a health facility so that they access emergency services if needed during labor, delivery, and post-delivery. For this reason, the 2014-15 RDHS asked women where they had given birth and who had assisted them during the delivery. Table 9.5 shows that 91 percent of births in the five years before the survey were delivered at a health facility, a sharp increase from the 69 percent in 2010. Among these deliveries, 90 percent took place in a public health facility, and only 1 percent took place in a private facility. It should also be noted that 8 percent of deliveries in the five years preceding the survey took place at home (compared with 29 percent in 2010). These achievements are partly due to the government commitment to support maternal and neonatal programs; new infrastructure for delivery and neonatal services, using mobile phone for monitoring of mothers and new born by community health workers (RapidSMS system), and continuous capacity building for providers through Human Resource for Health (HRH) program. Maternal Health • 119 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 2014-15 Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Background characteristic Public sector Private sector Mother’s age at birth <20 94.4 0.1 5.3 0.2 0.0 100.0 94.5 564 20-34 90.6 0.8 7.2 1.3 0.1 100.0 91.4 6,130 35-49 84.8 0.8 11.9 2.5 0.0 100.0 85.6 1,310 Birth order 1 95.8 0.9 2.8 0.6 0.0 100.0 96.6 2,384 2-3 90.6 1.0 7.0 1.3 0.1 100.0 91.6 3,037 4-5 85.7 0.5 11.4 2.3 0.1 100.0 86.2 1,469 6+ 80.9 0.2 16.3 2.6 0.0 100.0 81.1 1,114 Antenatal care visits1 None 47.2 0.0 45.7 4.5 2.6 100.0 47.2 50 1-3 88.3 0.4 9.7 1.7 0.0 100.0 88.7 3,347 4+ 92.9 1.2 4.5 1.4 0.0 100.0 94.1 2,663 Residence Urban 93.1 3.6 2.6 0.6 0.0 100.0 96.8 1,347 Rural 89.2 0.2 8.9 1.6 0.1 100.0 89.4 6,657 Province City of Kigali 90.9 3.3 4.9 0.8 0.0 100.0 94.2 944 South 89.6 0.3 8.3 1.8 0.0 100.0 89.9 1,837 West 90.3 0.3 8.6 0.7 0.1 100.0 90.7 1,920 North 91.9 0.5 5.5 2.1 0.0 100.0 92.4 1,108 East 88.3 0.5 9.3 1.7 0.1 100.0 88.8 2,196 Mother’s education No education 82.1 0.0 15.8 2.0 0.1 100.0 82.1 1,196 Primary 91.2 0.1 7.2 1.4 0.0 100.0 91.3 5,800 Secondary and higher 91.8 5.3 2.2 0.7 0.0 100.0 97.0 1,007 Wealth quintile Lowest 84.1 0.0 13.5 2.2 0.1 100.0 84.1 1,936 Second 90.6 0.1 7.9 1.3 0.1 100.0 90.8 1,737 Middle 90.9 0.0 7.5 1.5 0.0 100.0 90.9 1,579 Fourth 92.6 0.3 5.7 1.4 0.0 100.0 92.9 1,384 Highest 93.3 3.8 2.5 0.4 0.0 100.0 97.1 1,367 Total 89.9 0.8 7.9 1.4 0.0 100.0 90.7 8,004 1 Includes only the most recent birth in the five years preceding the survey The proportion of home deliveries increases with mother’s age (from 5 percent among mothers under age 20 to 12 percent among mothers age 35-49) and child’s birth order (from 3 percent of first births to 16 percent of sixth-order births and above). Mothers who had not received ANC (46 percent) were more likely to give birth at home than mothers who had four or more ANC visits (5 percent). In addition, home deliveries were more frequent in rural areas (9 percent, as compared with 3 percent in urban areas) and among women with no education or only a primary education (16 percent and 7 percent, respectively, as compared with 2 percent among women with a secondary education or higher). By province, the proportion of home deliveries ranged from a low of 5 percent in City of Kigali to a high of 9 percent in East. Finally, the proportion of women who delivered at home decreased as household wealth increased, from 14 percent among those in the poorest households to 3 percent among those in the richest households. The younger mothers (95 percent) were more likely to deliver in a health facility than the older mothers (86 percent). The proportion of births delivered in a health facility decreased with increasing birth order, from 97 percent for first births to 81 percent for births of order six and above. Mothers who had four or more ANC visits were more likely to deliver in a health facility than mothers with no visits (94 percent and 47 percent, respectively). Births in urban areas and in the city of Kigali were more likely to be delivered in a health facility than other births. Women with a secondary education or higher and women in the highest wealth quintile were most likely to deliver their babies in a health facility (97 percent each). 120 • Maternal Health It should be noted that these results represent a substantial change over time with respect to place of delivery. The proportion of births taking place in a health facility has increased from 28 percent in 2005 and 69 percent in 2010 to 91 percent in 2014-15. 9.2.2 Assistance during Delivery To avoid the risk of complications and maternal deaths, women should be assisted during delivery by personnel who have received training in childbirth and who are able, if needed, to diagnose, treat, and refer complications on time. Table 9.6 presents the distribution of births in the five years preceding the survey according to the person providing assistance during the delivery. 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 cesarean section, according to background characteristics, Rwanda 2014-15 Person providing assistance during delivery Percentage delivered by a skilled provider1 Percentage delivered by C-section Number of births Background characteristic 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 18.4 73.4 2.7 0.7 0.5 2.9 1.4 0.0 100.0 94.5 13.5 564 20-34 19.0 69.6 2.8 1.7 0.2 4.6 2.1 0.1 100.0 91.4 13.5 6,130 35-49 15.1 68.2 2.5 2.6 0.2 6.1 5.3 0.1 100.0 85.7 10.4 1,310 Birth order 1 25.8 67.7 3.1 0.6 0.2 1.7 0.8 0.0 100.0 96.7 19.0 2,384 2-3 18.0 71.1 2.5 2.1 0.2 4.0 2.0 0.2 100.0 91.6 13.6 3,037 4-5 12.5 71.4 2.4 1.9 0.3 7.6 3.7 0.2 100.0 86.3 7.1 1,469 6+ 10.8 67.3 2.9 3.1 0.3 9.2 6.4 0.1 100.0 81.0 6.1 1,114 Antenatal care visits1 None 8.9 38.3 0.0 4.4 0.0 26.8 19.1 2.6 100.0 47.2 7.3 50 1-3 15.6 70.4 2.7 1.9 0.4 6.2 2.7 0.1 100.0 88.7 11.0 3,347 4+ 22.7 68.5 2.8 1.8 0.0 2.2 1.8 0.1 100.0 94.0 15.8 2,663 Place of delivery Health facility 20.2 76.7 3.0 0.1 0.0 0.0 0.0 0.0 100.0 99.9 14.3 7,255 Elsewhere 0.2 1.2 0.3 18.1 2.3 50.3 27.0 0.5 100.0 1.7 0.0 745 Residence Urban 28.1 63.7 5.2 0.4 0.1 1.7 0.9 0.0 100.0 96.9 22.0 1,347 Rural 16.4 70.8 2.2 2.0 0.3 5.3 2.9 0.1 100.0 89.4 11.1 6,657 Province City of Kigali 26.5 61.5 6.4 0.7 0.2 3.5 0.9 0.2 100.0 94.5 21.0 944 South 23.4 65.1 1.6 1.8 0.4 5.0 2.6 0.0 100.0 90.1 14.2 1,837 West 13.8 73.8 2.9 1.4 0.0 3.9 4.0 0.1 100.0 90.5 11.7 1,920 North 15.3 73.9 2.9 1.9 0.0 3.6 2.1 0.1 100.0 92.2 9.3 1,108 East 16.1 71.1 1.8 2.3 0.4 6.1 2.1 0.2 100.0 88.9 11.4 2,196 Mother’s education No education 12.1 68.6 1.8 2.1 0.3 8.9 6.0 0.3 100.0 82.5 8.5 1,196 Primary 17.1 71.3 2.8 1.9 0.2 4.4 2.1 0.1 100.0 91.2 12.3 5,800 Secondary and higher 32.8 61.0 3.3 0.7 0.2 1.2 0.8 0.0 100.0 97.2 22.3 1,007 Wealth quintile Lowest 14.1 68.0 2.1 2.2 0.4 8.0 5.0 0.2 100.0 84.2 9.9 1,936 Second 14.0 74.8 2.1 2.1 0.3 4.3 2.3 0.2 100.0 90.8 9.1 1,737 Middle 15.1 74.4 1.5 1.7 0.2 5.3 1.8 0.1 100.0 91.0 10.3 1,579 Fourth 21.4 68.1 3.3 1.8 0.0 3.5 1.9 0.0 100.0 92.8 14.7 1,384 Highest 30.5 61.5 5.2 0.6 0.2 1.1 0.8 0.0 100.0 97.2 23.5 1,367 Total 18.3 69.6 2.7 1.7 0.2 4.7 2.5 0.1 100.0 90.7 13.0 8,004 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Total includes 4 cases in which information on place of delivery is missing. 1 Skilled provider includes doctor, nurse/medical assistant, and midwife. 2 Includes only the most recent birth in the five years preceding the survey Maternal Health • 121 The results show that 9 in 10 births (91 percent) were assisted by a skilled health provider; a substantial improvement since 2010, when only 69 percent were assisted by a skilled provider. Eighteen percent of births were assisted by doctors, 70 percent by nurses or medical assistants, and 3 percent by midwives. This is partly due to the availability of nurses in health facilities, and limited number of doctors and midwives in Rwanda. However, it should be noted that 3 percent of births received no assistance and that 7 percent were assisted by untrained persons (2 percent by nonqualified health workers, less than 1 percent by traditional birth attendants, and 5 percent by relatives or other persons). Thirteen percent of births were delivered by cesarean sections. Figure 9.1 Trends in antenatal care and delivery, Rwanda 2005 to 2014-15 Deliveries assisted by skilled health personnel were more common among the youngest mothers (95 percent), first births (97 percent),births in health facilities (100 percent),and births in urban areas (97 percent), particularly the city of Kigali (95 percent) (Table 9.6 and Figure 9.2). Also, mothers with a secondary education or higher and those in the richest wealth quintile (97 percent each) were most likely to receive assistance from skilled personnel. 94 39 28 96 52 45 98 69 69 99 91 91 Antenatal care by a skilled provider Delivery assisted by a skilled provider Delivery at a health facility RDHS 2005 RDHS 2007-08 RDHS 2010 RDHS 2014-15 RDHS 2014-15 Percent 122 • Maternal Health Figure 9.2 Births delivered by a skilled provider 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 programs 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 43 percent of women had a postnatal checkup in the first two days after delivery; 30 percent had a checkup within 4 hours, 8 percent within 4-23 hours, and 5 percent within 1-2 days. The proportion of women who received a postnatal checkup has increased significantly since 2010, when only 18 percent of women had a postnatal checkup in the first two days after delivery. Overall, 55 percent of women did not have a postnatal checkup, and this proportion was very high in each of the background characteristic categories. 97 93 91 91 84 97 91 83 89 97 91 0 20 40 60 80 100 Highest Fourth Middle Second Lowest WEALTH QUINTILE Secondary and higher Primary No schooling EDUCATION Rural Urban RESIDENCE RWANDA Percent RDHS 2014-15 Maternal Health • 123 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 received a postnatal checkup in the first two days after giving birth, according to background characteristics, Rwanda 2014-15 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 Background characteristic 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 29.8 6.5 7.0 2.0 2.0 0.0 52.5 100.0 43.4 229 20-34 29.9 8.7 4.6 0.7 1.3 0.1 54.7 100.0 43.3 2,432 35-49 30.9 7.7 3.2 1.1 1.7 0.3 55.1 100.0 41.8 575 Birth order 1 32.2 10.0 5.8 1.5 1.8 0.0 48.7 100.0 48.0 914 2-3 30.4 8.4 4.2 0.5 1.0 0.3 55.2 100.0 43.0 1,262 4-5 26.6 7.1 4.2 0.9 1.8 0.2 59.3 100.0 37.9 618 6+ 29.7 6.8 3.3 0.5 1.1 0.0 58.5 100.0 39.9 442 Place of delivery Health facility 30.7 8.7 4.8 0.9 1.4 0.1 53.3 100.0 44.2 2,966 Elsewhere 23.5 5.0 2.0 0.0 1.0 0.0 68.4 100.0 30.6 269 Residence Urban 33.3 9.2 5.3 1.0 1.4 0.2 49.5 100.0 47.8 561 Rural 29.4 8.2 4.4 0.8 1.4 0.1 55.7 100.0 42.0 2,675 Province City of Kigali 32.9 8.4 5.5 0.0 1.5 0.0 51.8 100.0 46.7 395 South 34.7 10.7 3.8 0.8 0.6 0.4 49.1 100.0 49.2 730 West 28.8 7.4 3.3 1.2 2.0 0.1 57.1 100.0 39.5 763 North 29.3 5.4 8.0 1.3 2.3 0.1 53.6 100.0 42.6 453 East 26.7 8.8 4.0 0.7 1.1 0.0 58.6 100.0 39.6 896 Education No education 22.5 8.2 2.4 0.8 0.7 0.2 65.2 100.0 33.1 439 Primary 30.7 7.8 4.7 0.8 1.5 0.1 54.4 100.0 43.1 2,316 Secondary and higher 34.2 11.5 5.9 1.0 1.6 0.1 45.7 100.0 51.6 481 Wealth quintile Lowest 28.5 6.6 4.5 0.6 1.4 0.0 58.4 100.0 39.6 792 Second 28.1 7.7 3.9 0.8 0.9 0.1 58.6 100.0 39.6 672 Middle 30.2 7.9 4.8 0.7 1.4 0.0 54.9 100.0 43.0 622 Fourth 30.4 9.7 4.4 1.7 1.6 0.5 51.8 100.0 44.4 573 Highest 34.2 10.9 5.3 0.4 1.9 0.1 47.2 100.0 50.4 576 Total 30.1 8.4 4.5 0.8 1.4 0.1 54.6 100.0 43.0 3,236 Note: Total includes 1 case in which information on place of delivery is missing. 1 Includes women who received a checkup after 41 days The proportion of women who had no postnatal checkup increased with birth order, from 49 percent for first births to 59 percent for fourth- and higher-order births. Lack of a postnatal checkup was more frequent in rural areas (56 percent) than in urban areas (50 percent). By province, the proportion of women who did not have a postnatal checkup ranged from 49 percent in South to 57 percent in West and 59 percent in East. A woman’s level of education was related to whether or not she had a postnatal checkup: 65 percent of women with no education did not have a postnatal checkup, as compared with 54 percent of women with a primary education and 46 percent of women with a secondary education or higher. Results by household wealth showed that the proportion of women with no postnatal checkup was higher in the lowest and second quintiles (58 percent and 59 percent, respectively) than in the highest quintile (47 percent). It is important that postnatal checkups be performed by skilled health providers who can detect and intervene in time to counter any problems related to the delivery and the 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. Forty-three percent of women’s first postnatal health checkups were carried out by doctors, nurses, medical assistant, midwives, or community health workers. Fifty-seven percent of women did not receive a postnatal checkup from 124 • Maternal Health a skilled provider in the first two days after their last live birth. Lack of a postnatal checkup increased with increasing birth order, from 52 percent for first births to 60-62 percent for fourth- and higher-order births. Table 9.8 Type of provider of first postnatal checkup for the mother 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 2014-15 Type of health provider of mother’s first postnatal checkup No postnatal checkup in the first two days after birth1 Total Number of women Background characteristic Doctor/nurse/ medical assistant Midwife Community health worker Mother’s age at birth <20 40.9 2.5 0.0 56.6 100.0 229 20-34 41.2 1.8 0.2 56.7 100.0 2,432 35-49 40.7 0.9 0.2 58.2 100.0 575 Birth order 1 45.8 2.1 0.0 52.0 100.0 914 2-3 41.0 1.8 0.3 57.0 100.0 1,262 4-5 36.1 1.7 0.2 62.1 100.0 618 6+ 38.7 0.7 0.5 60.1 100.0 442 Place of delivery Health facility 42.4 1.8 0.0 55.8 100.0 2,966 Elsewhere 27.1 0.8 2.6 69.4 100.0 269 Residence Urban 45.2 2.5 0.1 52.2 100.0 561 Rural 40.2 1.5 0.2 58.0 100.0 2,675 Province City of Kigali 42.1 4.6 0.0 53.3 100.0 395 South 48.3 0.4 0.5 50.8 100.0 730 West 37.1 2.2 0.3 60.5 100.0 763 North 41.3 1.1 0.2 57.4 100.0 453 East 38.2 1.4 0.0 60.4 100.0 896 Education No education 31.9 0.9 0.3 66.9 100.0 439 Primary 41.3 1.6 0.2 56.9 100.0 2,316 Secondary and higher 48.4 3.1 0.2 48.4 100.0 481 Wealth quintile Lowest 38.1 1.2 0.3 60.4 100.0 792 Second 37.4 1.9 0.3 60.4 100.0 672 Middle 42.1 0.6 0.4 57.0 100.0 622 Fourth 42.5 1.9 0.0 55.6 100.0 573 Highest 47.0 3.2 0.1 49.6 100.0 576 Total 41.1 1.7 0.2 57.0 100.0 3,236 Note: Total includes 1 case in which information on place of delivery is missing. 1 Includes women who received a checkup after 41 days Mothers who did not give birth in a health facility, those living in rural areas, those with no education, and those in the lowest wealth quintile were most likely not to have a postnatal checkup. 9.3.2 Newborn Postnatal Care Postnatal checkup 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 in the two years before the survey according to the time after birth of the first postnatal checkup and the percentage of newborns with a postnatal checkup in the first two days. Maternal Health • 125 Table 9.9 Timing of first postnatal checkup for the newborn Percent distribution of last 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 first two days after birth, according to background characteristics, Rwanda 2014-15 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 Background characteristic 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 10.0 5.9 1.1 2.9 0.9 0.0 79.2 100.0 19.9 229 20-34 9.5 5.1 2.7 1.4 0.5 0.0 80.8 100.0 18.7 2,432 35-49 8.5 7.2 3.8 1.8 0.8 0.2 77.7 100.0 21.4 575 Birth order 1 10.6 5.4 2.3 1.9 0.5 0.0 79.2 100.0 20.2 914 2-3 9.5 5.9 3.2 0.7 0.4 0.1 80.3 100.0 19.3 1,262 4-5 8.3 4.6 2.3 2.4 0.7 0.2 81.5 100.0 17.6 618 6+ 8.1 6.1 3.2 2.0 0.9 0.0 79.7 100.0 19.4 442 Place of delivery Health facility 9.8 5.3 2.7 1.4 0.4 0.1 80.3 100.0 19.3 2,966 Elsewhere 5.1 7.5 3.5 2.9 2.5 0.0 78.5 100.0 19.0 269 Residence Urban 6.0 5.6 2.2 1.2 0.4 0.0 84.5 100.0 15.1 561 Rural 10.1 5.5 2.9 1.6 0.6 0.1 79.2 100.0 20.1 2,675 Province City of Kigali 2.9 4.5 1.1 1.7 0.0 0.0 89.7 100.0 10.3 395 South 17.0 6.0 3.9 1.0 0.7 0.1 71.3 100.0 27.8 730 West 3.7 6.4 2.4 1.6 0.4 0.1 85.3 100.0 14.1 763 North 6.8 3.8 1.7 2.0 0.7 0.0 85.0 100.0 14.3 453 East 12.2 5.7 3.4 1.7 0.6 0.0 76.4 100.0 23.0 896 Mother’s education No education 6.5 5.3 4.3 1.0 0.5 0.2 82.2 100.0 17.1 439 Primary 9.7 5.5 2.4 1.5 0.6 0.0 80.2 100.0 19.2 2,316 Secondary and higher 10.6 5.8 3.0 2.1 0.3 0.0 78.1 100.0 21.6 481 Wealth quintile Lowest 9.1 5.6 2.8 1.3 0.7 0.0 80.5 100.0 18.8 792 Second 8.8 5.1 2.4 0.8 0.6 0.1 82.0 100.0 17.2 672 Middle 11.8 4.8 2.8 1.8 0.7 0.0 78.1 100.0 21.2 622 Fourth 9.5 6.2 3.3 2.4 0.3 0.2 78.1 100.0 21.5 573 Highest 7.8 5.9 2.6 1.6 0.3 0.0 81.8 100.0 17.9 576 Total 9.4 5.5 2.8 1.6 0.5 0.1 80.2 100.0 19.2 3,236 Note: Total includes 1 case in which information on place of delivery is missing. 1 Includes newborns who received a checkup after the first week Only 19 percent of newborns received postnatal care in the first two days after birth. However, this proportion was higher than that reported in the 2010 RDHS (5 percent). Nine percent of newborns received postnatal care less than 1 hour after birth, 6 percent received care in 1-3 hours, 3 percent received care in 4-23 hours, and 2 percent received care 1-2 days after birth. The proportion of newborns who received postnatal care in 3-6 days was very low (less than 1 percent). The proportion of newborns receiving postnatal care within two days varies slightly by age of the mother, birth order, place of delivery, or wealth quintile. This proportion is lowest among births in urban areas (15 percent), births in City of Kigali (10 percent), and births to mothers with no education (17 percent). Table 9.10 shows the proportion of newborns who received postnatal care from skilled providers. Virtually all children who received postnatal care received it from doctors, nurses, medical assistants, midwives, or community health workers. The proportion of newborns receiving postnatal checkups from skilled health providers did not vary significantly by mother’s age, birth other, place of delivery, or residence. By province, the proportion of newborns who received postnatal care varied from a low of 10 percent in the City of Kigali to a high of 28 percent in South. Newborns whose mothers had a secondary education or higher (22 percent) were more likely 126 • Maternal Health than those whose mothers had only a primary education (19 percent) or no education (17 percent) to have received postnatal care from skilled providers. Table 9.10 Type of provider of first postnatal checkup for the newborn Percent distribution of last 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 birth, according to background characteristics, Rwanda 2014-15 Type of health provider of newborn’s first postnatal checkup No postnatal checkup in the first two days after birth Total Number of births Background characteristic Doctor/nurse/ medical assistant Midwife Community health worker Traditional birth attendant Mother’s age at birth <20 19.4 0.4 0.0 0.0 80.1 100.0 229 20-34 17.6 0.8 0.2 0.0 81.3 100.0 2,432 35-49 20.3 0.9 0.2 0.0 78.6 100.0 575 Birth order 1 19.1 1.1 0.0 0.0 79.8 100.0 914 2-3 18.1 0.8 0.3 0.1 80.7 100.0 1,262 4-5 17.1 0.5 0.0 0.0 82.4 100.0 618 6+ 18.2 0.7 0.5 0.0 80.6 100.0 442 Place of delivery Health facility 18.4 0.9 0.0 0.0 80.7 100.0 2,966 Elsewhere 16.8 0.0 2.2 0.0 81.0 100.0 269 Residence Urban 14.8 0.1 0.1 0.0 84.9 100.0 561 Rural 18.9 0.9 0.2 0.0 79.9 100.0 2,675 Province City of Kigali 9.9 0.2 0.0 0.2 89.7 100.0 395 South 27.2 0.1 0.5 0.0 72.2 100.0 730 West 13.1 0.9 0.1 0.0 85.9 100.0 763 North 13.8 0.2 0.2 0.0 85.7 100.0 453 East 21.2 1.8 0.0 0.0 77.0 100.0 896 Mother’s education No education 16.2 0.9 0.0 0.0 82.9 100.0 439 Primary 18.2 0.8 0.2 0.0 80.8 100.0 2,316 Secondary and higher 20.4 0.9 0.2 0.2 78.4 100.0 481 Wealth quintile Lowest 18.2 0.5 0.1 0.0 81.2 100.0 792 Second 15.9 1.0 0.3 0.0 82.8 100.0 672 Middle 20.3 0.8 0.2 0.0 78.8 100.0 622 Fourth 20.1 1.1 0.2 0.1 78.5 100.0 573 Highest 17.1 0.7 0.1 0.0 82.1 100.0 576 Total 18.2 0.8 0.2 0.0 80.8 100.0 3,236 Note: Total includes 1 case in which information on place of delivery is missing. 9.4 PROBLEMS IN ACCESSING HEALTH CARE Access to health care is a key priority for improving a country’s overall health status. It has been assessed through the power of taking decision, financial or economic accessibility, and geographical access. Therefore, women were asked about perceived barriers to accessing health care. The results are presented in Table 9.11. Fifty nine percent of women reported at least one problem in accessing health care, this figure is similar to that reported in 2010 (61 percent). Forty-nine percent of women reported that lack of money for treatment was a serious problem. The extent of this problem increased with age; 43 percent of women age 15-19 reported difficulty in obtaining money for treatment, as compared with 57 percent of women age 35-49. Divorced, separated, and widowed women (70 percent) were more likely to report this problem than married women (49 percent) and never-married women (44 percent). Lack of money was more commonly reported as a barrier by women in rural areas (53 percent) than by women in urban areas (33 percent). By province, women in South (57 percent) and West (55 percent) were more likely to mention this problem than those in the other provinces (34-47 percent). Similarly, women with no Maternal Health • 127 education mentioned lack of money more often (68 percent) than women with a secondary education or higher (29 percent), and women in the poorest wealth quintile reported this problem more frequently (77 percent) than women in the richest quintile (24 percent). 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 2014-15 Problems in accessing health care Background characteristic 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 43.2 17.5 20.4 54.6 2,768 20-34 2.6 47.7 22.2 17.3 57.2 6,908 35-49 2.1 56.6 23.3 16.2 64.0 3,821 Number of living children 0 3.5 41.2 19.3 20.0 52.4 4,754 1-2 2.3 49.7 21.4 15.9 58.1 4,007 3-4 2.0 56.3 23.7 17.0 64.7 2,894 5+ 2.3 58.5 24.2 16.5 66.0 1,842 Marital status Never married 3.5 43.7 19.6 19.6 54.3 5,100 Married or living together 2.2 49.3 22.3 15.8 58.6 6,982 Divorced/separated/widowed 2.2 69.7 25.2 19.8 74.2 1,415 Employed last 12 months Not employed 2.1 39.1 15.0 15.5 48.6 1,929 Employed for cash 2.4 50.7 21.8 17.8 59.6 7,562 Employed not for cash 3.5 51.6 24.2 18.4 61.4 3,995 Residence Urban 2.5 33.1 7.7 9.7 39.0 2,626 Rural 2.7 53.3 24.9 19.6 63.3 10,871 Province City of Kigali 1.7 33.6 10.2 9.2 40.9 1,799 South 2.4 57.4 23.8 17.0 66.5 3,214 West 3.7 55.4 26.3 26.2 66.3 2,965 North 4.2 46.7 18.4 16.8 56.7 2,211 East 1.5 46.4 23.4 15.8 54.8 3,308 Education No education 3.0 67.7 27.2 17.1 73.1 1,665 Primary 2.7 53.3 22.9 18.9 62.6 8,678 Secondary and higher 2.3 28.8 15.0 14.5 39.8 3,154 Wealth quintile Lowest 4.0 77.4 29.5 23.4 82.2 2,561 Second 2.7 63.0 28.3 20.7 72.1 2,631 Middle 2.4 51.0 22.9 19.3 60.9 2,597 Fourth 2.6 36.2 21.9 16.7 50.6 2,634 Highest 1.8 24.1 7.7 9.6 32.2 3,073 Total 2.7 49.3 21.6 17.6 58.6 13,497 Note: Total includes 12 cases in which information on employment is missing. Twenty-two percent of women mentioned distance to a health facility as a serious problem in accessing health care. This problem was most frequently reported by women age 35-49 (23 percent); women with three or more children (24 percent); divorced, separated, and widowed women (25 percent); women employed but not for cash (24 percent); women in rural areas (25 percent); women with no education (27 percent); and women in the lowest wealth quintile (30 percent). Less than one in five women (18 percent) cited not wanting to go alone as a serious problem in accessing health care. The youngest women (20 percent); those with no living children (20 percent); those who had never been married or were divorced, separated, or widowed (20 percent each); those employed for cash or employed but not for cash (18 percent each); those living in rural areas (20 percent); those with a primary education (19 128 • Maternal Health percent); those in the West province (26 percent); and those in the poorest households (23 percent) were most likely to report not wanting to go alone as a barrier to accessing health care. Only 3 percent of women reported that getting permission was a serious problem, and differentials by background characteristics are minor. Child Health • 129 CHILD HEALTH 10 Key Findings • Six percent of newborns were of low birth weight (less than 2.5 kg). • Ninety-three percent of children age 12-23 months have received all basic vaccines, slightly higher than the figure of 90 percent reported in the 2010 RDHS. • Six percent of children under age 5 had symptoms of acute respiratory infection in the two weeks before the survey; 54 percent of these children were taken to a health facility or provider for advice or treatment. • Nineteen percent of children under age 5 had a fever in the two weeks before the survey, of whom 49 percent were taken to a health facility or provider for advice or treatment. • Twelve percent of children under age 5 had diarrhea in the two weeks before the survey. • The proportion of children with diarrhea taken to a health provider for advice or treatment has increased from 37 percent in 2010 to 44 percent in 2014-15. • Forty-three percent of children with diarrhea were given oral rehydration therapy (ORT) or increased fluids. • Eighty-nine percent of women have heard of ORS to treat diarrhea. • The stools of 88 percent of children under age 5 are disposed of safely. his chapter presents findings on 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 2014-15 RDHS, data on immunizations were collected for all living children born in 2009 or later. Information on vaccination coverage was collected in two ways: from the child’s vaccination card and through direct reports from the mother. If a vaccination card was presented, the interviewer copied the immunization dates directly onto the questionnaire. If the mother was not able to present a vaccination 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 in improving child health. Information on treatment practices and contact with health services among children with common childhood illnesses helps in the assessment of national programs aimed at reducing child mortality. The 2014-15 RDHS collected data on the prevalence and treatment of Acute Respiratory Infection (ARI), fever, and diarrhea among children under age 5. Prevalence of ARI, fever, and diarrhea may not be appropriately used for trend analysis due the seasonal variation of these illnesses. The extent to which diarrheal disease is treated with oral rehydration therapy (including increased fluid intake) is used to assess programs that recommend such treatments. Because appropriate sanitary practices can help prevent and reduce the severity of diarrheal disease, information is provided on disposal of children’s fecal matter. T 130 • Child Health 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 of less than 2.5 kilograms 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. Mothers were also asked to report the actual weight in kilograms (based on either a written record or their own recall) if the child had been weighed after delivery. Table 10.1 shows that 92 percent of newborns had a birth weight reported. Among these infants, only 6 percent were classified as having a low birth weight (i.e., less than 2.5 kg). According to the mother’s own assessment of her infant’s size, the majority of infants (84 percent) were classified as average or larger than average. Sixteen percent of newborns were either smaller than average (13 percent) or very small (3 percent). 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; and 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 2014-15 Percentage of all births with a reported birth weight1 Births with a reported birth weight1 Total Number of births Percent distribution of all live births by size of child at birth Total Number of births Background characteristic Less than 2.5 kg 2.5 kg or more Very small Smaller than average Average or larger Don’t know/ missing Mother’s age at birth <20 93.9 8.4 91.6 100.0 529 4.7 14.7 79.9 0.7 100.0 564 20-34 92.4 6.1 93.9 100.0 5,664 2.9 12.5 84.0 0.6 100.0 6,130 35-49 90.7 6.4 93.6 100.0 1,188 2.8 14.0 83.0 0.2 100.0 1,310 Birth order 1 95.7 7.9 92.1 100.0 2,283 3.8 16.5 79.2 0.5 100.0 2,384 2-3 92.4 5.8 94.2 100.0 2,807 2.7 11.7 84.9 0.7 100.0 3,037 4-5 90.0 5.9 94.1 100.0 1,322 2.6 10.5 86.6 0.3 100.0 1,469 6+ 87.1 4.5 95.5 100.0 970 2.4 11.9 85.4 0.4 100.0 1,114 Mother’s smoking status Smokes cigarettes/ tobacco 84.8 15.8 84.2 100.0 63 8.0 20.8 70.3 0.9 100.0 74 Does not smoke 92.3 6.2 93.8 100.0 7,319 2.9 12.8 83.7 0.5 100.0 7,929 Residence Urban 97.0 3.7 96.3 100.0 1,307 2.1 11.1 86.5 0.3 100.0 1,347 Rural 91.3 6.9 93.1 100.0 6,075 3.2 13.3 83.0 0.6 100.0 6,657 Region City of Kigali 95.5 4.2 95.8 100.0 901 2.2 11.1 86.1 0.6 100.0 944 South 92.8 8.3 91.7 100.0 1,705 4.3 14.9 79.9 0.8 100.0 1,837 West 89.4 5.5 94.5 100.0 1,716 2.6 13.6 83.4 0.4 100.0 1,920 North 94.7 5.4 94.6 100.0 1,049 3.4 10.9 84.8 0.9 100.0 1,108 East 91.6 6.7 93.3 100.0 2,011 2.3 12.5 85.0 0.2 100.0 2,196 Education No education 83.8 7.0 93.0 100.0 1,002 3.1 13.1 83.1 0.7 100.0 1,196 Primary 93.1 6.5 93.5 100.0 5,397 3.1 13.1 83.2 0.6 100.0 5,800 Secondary and higher 97.6 4.7 95.3 100.0 982 1.9 11.7 86.1 0.3 100.0 1,007 Wealth quintile Lowest 87.1 8.1 91.9 100.0 1,687 4.2 14.6 80.0 1.2 100.0 1,936 Second 92.3 7.2 92.8 100.0 1,603 3.2 12.8 83.4 0.7 100.0 1,737 Middle 92.3 6.7 93.3 100.0 1,457 2.4 14.0 83.5 0.1 100.0 1,579 Fourth 94.2 5.3 94.7 100.0 1,304 2.6 12.9 84.2 0.3 100.0 1,384 Highest 97.4 3.5 96.5 100.0 1,331 2.0 9.5 88.4 0.2 100.0 1,367 Total 92.2 6.3 93.7 100.0 7,382 3.0 12.9 83.6 0.5 100.0 8,004 1 Based on either a written record or the mother’s recall Child Health • 131 Although the differences are not large, children born in rural areas are more likely to weigh less than 2.5 kg than those born in urban area, and to be described as very small or smaller than average in size. The data also show that, in general, there is a positive relationship between mother’s education and wealth quintile and the weight and size of the newborn. Children whose mothers have a secondary education or higher or who are in the highest wealth quintile are less likely to weigh below 2.5 kg or to be described as very small at birth than other children (Table 10.1). Variations in weight and size at birth are also seen by province; for example, the proportion of children with a birth weight below 2.5 kg ranges from 4 percent in City of Kigali to 8 percent in South. Although the number of women who smoke tobacco is very small, there seems to be a negative association between smoking and birth weight; women who smoke are more likely to deliver low birth weight babies. 10.2 VACCINATION OF CHILDREN To assess vaccination status in children, the 2014-15 RDHS gathered information on vaccination for all children under 5 from eligible interviewed women. In addition to traditional vaccines (BCG, OPV, DPT and measles) that have been using since the beginning of vaccination program in Rwanda; six new vaccines have been introduced in routine immunization. Hepatitis B and Haemophilus Influenza type B vaccines in combination with DPT (pentavalent vaccine) was introduced in 2002, pneumococcal vaccine was introduced in 2009, rotavirus vaccine was introduced in 2012 and combined measles and rubella vaccine introduced in 2013. Rwanda Vaccination program generally follows the World Health Organization (WHO, February 2015) recommended vaccines for routine immunization, and all required vaccines now are given in routine immunization. A child is considered fully immunized when he/she has received all recommended vaccines by age 12 months: one dose of BCG (against tuberculosis), three doses of combined vaccine (Pentavalent) against diphtheria, pertussis, Tetanus, hepatitis B and Haemophilus Influenza Type B (DPT-HepB-Hib), three doses of oral polio vaccine and one dose of measles vaccine. Each child who is vaccinated receives an immunization card on which all of the vaccines received are recorded. As noted, information on vaccination coverage was obtained in two ways: from child health cards and from mothers’ verbal reports. For all children born since January 2009, mothers were asked to show the interviewer the child health cards in which immunization dates were recorded. If a card was available, the interviewer recorded onto the questionnaire the dates of each vaccination received by the child. If a card indicated that the child was not fully vaccinated, the mother was then asked whether the child had received other vaccinations that were not recorded on the card, and they too were noted on the questionnaire. When cards were not available because the mother never had one, 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 in the survey. Questions were asked for each vaccine type. Mothers were asked to recall whether the child had received BCG, polio, pentavalent, and measles vaccinations. If the mother indicated that the child had received the polio or pentavalent vaccine, she was asked about the number of doses that the child received. The results presented here are based on both vaccination card information and, for children without a card, information provided by the mother. Information from cards was available for 94 percent of children (Table 10.3), a sizeable improvement from 2010 (82 percent). 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. Overall (according to both vaccination cards and mothers’ reports), 93 percent of children age 12-23 months are fully immunized. Almost 9 in 10 (87 percent) children received all of their basic vaccinations before their first birthday, as recommended by WHO and the Rwanda EPI. Less than 1 percent of children had not received any vaccinations at the time of the survey. Vaccination coverage for pneumococcal and rotavirus is available in Appendix C. 132 • Child Health 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 age 12 months, Rwanda 2014-15 Source of information BCG Pentavalent Polio1 Measles2 All basic vaccina- tions3 No vaccina- tions Number of children 1 2 3 0 1 2 3 Vaccinated at any time before survey Vaccination card 93.6 93.8 93.5 93.2 86.6 93.9 93.7 93.2 90.1 89.4 0.0 1,485 Mother’s report 5.3 5.3 5.3 5.0 4.7 5.2 4.9 3.4 5.1 3.2 0.7 96 Either source 98.9 99.1 98.8 98.1 91.3 99.1 98.6 96.6 95.2 92.6 0.7 1,581 Vaccinated by age 12 months4 98.9 98.9 98.8 98.1 91.3 99.0 98.6 96.6 88.7 86.6 0.8 1,581 Note: Pentavalent includes diphtheria, pertussis, tetanus, Haemophilus influenzae type B, and hepatitis B. 1 Polio 0 is the polio vaccination given at birth. 2 Including children who received a combined measles and rubella vaccine 3 BCG, measles, and three doses each of pentavalent and polio vaccine (excluding polio vaccine given at birth) 4 For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccination. Table 10.3 shows vaccination coverage according to background characteristics of mother and child. The data show practically no variation by sex (93 percent for male children and 92 percent for female children). However, complete coverage decreases slightly as birth order increases, from 94 percent for birth orders one to three to 91 percent for birth orders four to five and 90 percent for birth orders six and above. Complete vaccination coverage is the same in urban and rural areas (93 percent). The city of Kigali has the highest vaccination coverage in the country (96 percent), while the West province has the lowest coverage (90 percent). 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 2014-15 Background characteristic BCG Pentavalent Polio1 Measles2 All basic vaccina- tions3 No vaccina- tions Percentage with a vaccination card seen Number of children 1 2 3 0 1 2 3 Sex Male 99.1 99.5 99.0 98.5 90.9 99.5 98.9 97.2 95.7 93.0 0.3 93.9 814 Female 98.6 98.6 98.6 97.8 91.6 98.7 98.4 96.0 94.7 92.3 1.1 94.1 766 Birth order 1 98.8 99.1 99.1 98.4 90.7 99.3 99.2 96.7 96.5 93.6 0.4 93.7 447 2-3 99.3 99.1 99.0 98.2 91.3 99.1 98.6 97.3 95.5 94.0 0.7 94.2 593 4-5 98.4 98.8 98.2 97.8 92.9 98.8 97.5 96.6 92.7 90.5 1.0 94.2 306 6+ 98.3 99.2 98.7 97.8 90.1 99.2 99.2 94.8 95.4 90.1 0.8 93.6 234 Residence Urban 99.2 98.7 98.7 98.7 97.5 99.3 98.5 96.7 96.4 93.4 0.3 93.5 278 Rural 98.8 99.2 98.8 98.0 89.9 99.1 98.7 96.6 94.9 92.5 0.8 94.0 1,303 Province City of Kigali 99.6 99.1 99.1 99.1 97.7 99.6 99.6 98.7 97.4 96.1 0.4 93.7 204 South 98.8 98.6 98.6 98.6 87.5 98.5 98.5 98.2 94.9 94.5 1.2 95.4 331 West 98.8 99.1 98.5 96.3 88.5 99.1 98.6 95.6 93.1 89.8 0.3 94.9 372 North 100.0 100.0 100.0 100.0 98.2 100.0 99.2 97.5 97.4 94.8 0.0 94.9 220 East 98.0 98.9 98.5 98.0 90.0 98.9 98.1 95.0 95.1 91.0 1.1 91.8 453 Mother’s education No education 97.1 98.0 97.6 95.4 89.3 98.0 97.1 93.4 89.7 85.9 2.0 91.0 233 Primary 99.0 99.3 99.0 98.5 91.1 99.2 98.7 96.8 95.7 93.0 0.5 94.4 1,124 Secondary and higher 100.0 99.1 99.1 99.1 94.3 100.0 100.0 99.0 98.7 97.9 0.0 95.0 223 Wealth quintile Lowest 97.2 98.1 97.0 95.7 86.0 98.1 96.7 93.5 91.3 86.7 1.5 92.6 384 Second 99.6 99.6 99.6 98.2 88.8 99.6 99.3 97.4 94.9 93.4 0.4 94.4 316 Middle 98.8 99.1 99.1 98.7 94.2 98.7 98.7 97.3 95.1 93.0 0.9 94.4 323 Fourth 100.0 100.0 100.0 100.0 92.1 99.8 99.5 97.7 99.3 97.0 0.0 95.6 273 Highest 99.3 98.9 98.9 98.9 97.0 99.7 99.5 98.2 97.0 95.2 0.3 93.2 285 Total 98.9 99.1 98.8 98.1 91.3 99.1 98.6 96.6 95.2 92.6 0.7 94.0 1,581 1 Polio 0 is the polio vaccination given at birth. 2 Including children who received a combined measles and rubella vaccine 3 BCG, measles, and three doses each of pentavalent and polio vaccine (excluding polio vaccine given at birth) Child Health • 133 Complete vaccination coverage increases steadily with mother’s level of education, from 86 percent among children whose mothers have no education to 98 percent among children whose mothers have a secondary education or higher. The proportion of children fully vaccinated generally increases with increasing wealth but falls slightly at the highest quintile. 10.3 TRENDS IN VACCINATION COVERAGE Figure 10.1 shows that vaccination coverage among children age 12-23 months has continued to improve steadily over the past 10 years. Figure 10.1 Trends in vaccination coverage among children age 12-23 months Table 10.4 shows, by age cohort, the percentages of children age 12-59 months who received specific vaccinations during their first year of life. The data indicate that the proportion of children fully vaccinated by age 12 months has increased over the past five years, from 84 percent among those age 48-59 months to be stabilized at 87 percent among those age 12-47 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 age 12 months, and percentage with a vaccination card, by current age of child, Rwanda 2014-15 Age in months BCG Pentavalent Polio1 Measles2 All basic vaccinations3 No vaccinations Percentage with a vaccination card seen Number of children 1 2 3 0 1 2 3 12-23 98.9 98.9 98.8 98.1 91.3 99.0 98.6 96.6 88.7 86.6 0.8 94.0 1,581 24-35 98.6 98.5 98.4 97.6 90.1 98.6 97.9 94.5 91.6 87.3 0.9 89.2 1,555 36-47 98.3 98.7 98.3 97.3 90.4 98.6 97.8 94.2 90.7 86.6 1.3 86.5 1,602 48-59 98.1 98.0 97.7 96.5 89.7 98.0 96.6 91.0 90.1 83.7 1.6 81.7 1,314 Total 98.5 98.6 98.3 97.4 90.4 98.6 97.8 94.2 90.2 86.1 1.1 88.1 6,053 Note: Information was obtained from the vaccination card or, if there was no written record, from the mother. For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccination. 1 Polio 0 is the polio vaccination given at birth. 2 Including children who received a combined measles and rubella vaccine 3 BCG, measles, and three doses each of pentavalent and polio vaccine (excluding polio vaccine given at birth) 97 87 84 86 75 96 90 86 90 80 99 97 93 95 90 99 98 97 95 93 BCG Pentavalent 3 Polio 3 Measles All vaccines RDHS 2005 RDHS 2007-08 RDHS 2010 RDHS 2014-15 Note: All vaccines includes BCG, measles and three doses each of pentavalent and polio vaccine 134 • Child Health 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 and, if so, whether 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 6 percent of children under age 5 had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These respiratory infections were more frequently reported among children age 6-23 months (8 percent) than among other children. There is no difference in ARI prevalence between boys and girls and only a minimal difference by residence. Results according to province show a slightly higher prevalence of ARIs in South (8 percent) and North (6 percent) than elsewhere. In general, there is no clear pattern in ARI prevalence by mother’s education or wealth. 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, the percentage for whom advice or treatment was sought from a health facility or provider and the percentage who received antibiotics as treatment, according to background characteristics, Rwanda 2014-15 Among children under age 5: Among children under age 5 with symptoms of ARI: Background characteristic Percentage with symptoms of ARI1 Number of children Percentage for whom advice or treatment was sought from a community health worker Percentage for whom advice or treatment was sought from a health facility or provider2 Percentage who received antibiotics Number of children Age in months <6 4.3 725 (10.5) (46.9) (49.3) 31 6-11 7.8 916 14.4 50.4 51.7 72 12-23 7.6 1,581 11.2 54.2 54.0 120 24-35 5.5 1,555 19.5 61.7 49.8 85 36-47 4.4 1,602 11.8 52.6 42.2 71 48-59 3.8 1,314 17.9 51.4 43.0 50 Sex Male 5.6 3,857 14.4 58.6 52.8 216 Female 5.6 3,837 14.1 49.3 45.6 213 Residence Urban 5.0 1,303 8.1 60.0 61.1 65 Rural 5.7 6,391 15.3 52.9 47.1 364 Province City of Kigali 4.4 921 (0.0) (61.4) (62.7) 40 South 7.5 1,756 13.1 48.4 42.2 131 West 5.3 1,842 15.2 52.4 42.3 98 North 5.8 1,071 10.5 50.5 49.8 62 East 4.6 2,103 23.0 62.0 59.6 98 Mother’s education No education 4.2 1,125 (16.0) (53.8) (39.4) 48 Primary 6.0 5,583 13.9 51.5 48.6 337 Secondary and higher 4.5 985 14.5 72.3 64.7 44 Wealth quintile Lowest 6.4 1,834 11.2 44.8 36.7 118 Second 6.6 1,670 19.6 55.1 49.4 111 Middle 5.9 1,524 12.3 57.5 56.5 90 Fourth 4.4 1,331 21.0 54.9 51.2 58 Highest 3.9 1,335 5.6 64.7 62.2 53 Total 5.6 7,694 14.2 53.9 49.2 429 Note: Figures in the parentheses are based on 25-49 unweighted cases. 1 Symptoms of ARI (cough accompanied by short, rapid breathing that is chest-related and/or by difficult breathing that is chest-related) are considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner Child Health • 135 Table 10.5 also shows the proportion of children for whom treatment was sought. Fifty-four percent of children with ARI symptoms received treatment or advice from a health facility or health provider, including 14 percent who sought help from a community health worker. Treatment from a medical provider was sought most often for children age 12-23 months (54 percent) and 24-35 months (62 percent). Even though boys and girls were equally likely to have ARI symptoms, boys were more likely to have been taken to a health facility or provider for advice or treatment than girls (59 percent versus 49 percent). Residence and mother’s level of education are associated with whether ARI treatment is sought. In urban areas, treatment from a health facility or provider was sought for 60 percent of children with ARI symptoms, as compared with 53 percent in rural areas. Similarly, treatment or advice was sought from a health facility or provider for 52 percent of children whose mothers had a primary education, compared with 72 percent of children whose mothers had a secondary education or higher. The results according to province show that treatment seeking is not necessarily linked to ARI prevalence. Treatment from a health facility or provider was less often sought in South (48 percent), where the prevalence of ARIs is 8 percent, than in East (62 percent), where the prevalence is 5 percent. Finally, treatment was sought for 65 percent of children in the richest households, as compared with only 45 percent in the poorest households. Almost half of children with ARI symptoms were reported to have received antibiotics. Boys, urban children, and children whose mothers had a secondary education or higher and were in the highest wealth quintile were more likely to receive this treatment. 10.4.2 Fever Fever is the primary symptom of many illnesses such as ARI, malaria and measles among others, 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, 19 percent of children had a fever. As with ARIs, age seems to be the most important factor related to fever prevalence; children age 6-11 months (25 percent) and 12-23 months (24 percent) were most likely to have had a fever. Fever prevalence varies only slightly by sex of the child (18 percent for boys and 19 percent for girls) and residence (17 percent in urban areas and 19 percent in rural areas). There are variations among the provinces, with the highest prevalence in East (22 percent) and South (21 percent) and the lowest in North (14 percent). Differences in the prevalence of childhood fever by mother’s education and wealth are not large. 136 • Child Health 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 a fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who received antibiotics as treatment, by background characteristics, Rwanda 2014-15 Among children under age 5: Among children under age 5 with fever: Background characteristic Percentage with fever Number of children Percentage for whom advice or treatment was sought from a community health worker Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 8.5 725 8.7 48.9 0.0 48.1 62 6-11 24.5 916 8.4 51.3 5.9 43.8 225 12-23 24.0 1,581 13.1 48.4 8.3 40.9 380 24-35 20.2 1,555 16.9 51.6 11.9 40.9 313 36-47 17.3 1,602 11.3 48.0 17.9 34.6 277 48-59 14.1 1,314 12.4 46.0 17.3 28.8 186 Sex Male 18.1 3,857 12.9 52.1 10.9 41.0 698 Female 19.4 3,837 12.3 46.4 11.7 36.9 744 Residence Urban 16.8 1,303 6.9 57.1 6.2 52.7 218 Rural 19.1 6,391 13.6 47.8 12.3 36.5 1,223 Province City of Kigali 16.4 921 4.1 59.8 6.6 57.5 151 South 21.2 1,756 13.9 41.7 12.6 30.7 372 West 17.0 1,842 13.2 45.1 6.0 35.8 314 North 14.2 1,071 7.5 48.4 0.9 43.6 152 East 21.5 2,103 15.6 54.8 19.2 40.0 453 Mother’s education No education 16.9 1,125 12.5 44.0 11.6 30.6 190 Primary 19.6 5,583 13.3 47.6 11.9 38.7 1,095 Secondary and higher 16.0 985 8.0 66.4 7.4 50.1 157 Wealth quintile Lowest 20.0 1,834 11.9 38.6 11.0 29.3 366 Second 19.1 1,670 16.0 48.4 13.2 36.7 318 Middle 20.1 1,524 13.3 48.2 15.1 35.3 306 Fourth 17.8 1,331 14.2 55.9 9.2 47.5 237 Highest 16.0 1,335 5.8 62.4 6.1 54.2 214 Total 18.7 7,694 12.6 49.2 11.4 38.9 1,442 1 Excludes pharmacy, shop, market, 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 49 percent of children with a fever, including 13 percent who sought help from a community health worker. Treatment from a health facility or provider was sought most often for boys and for children in urban areas. The proportion of children with a fever for whom treatment or advice was sought increased with increasing mother’s education, from 44 percent among those whose mothers had no education to 66 percent among those whose mothers had a secondary education or higher. Treatment was sought from a health facility or provider for 62 percent of children in the richest households, as compared with only 39 percent of those in the poorest households. The results according to province again show that treatment seeking is not necessarily linked to fever prevalence. Facility-based treatment was more often sought for children in City of Kigali (60 percent), where the prevalence of fever is 16 percent, than for children in South (42 percent), where the prevalence is 21 percent. Child Health • 137 10.5 DIARRHEAL DISEASE Diarrheal diseases constitute one of the main causes of death among young children in developing countries as they are associated with dehydration and malnutrition. To combat the effects of dehydration, WHO recommends the use of oral rehydration therapy (ORT), which includes a prepared solution of oral rehydration salts (ORS) made from packets or a solution prepared at home using clean water, sugar, and salt (recommended home fluids, or RHF). To assess the prevalence of diarrheal diseases among 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 with diarrhea for whom treatment or advice was sought, and the type of treatment used. Regarding treatment, mothers were asked whether they had used ORS packets, RHF, or other treatments (Table 10.9). 10.5.1 Prevalence of Diarrhea Table 10.7 shows that, according to mothers’ reports, 12 percent of children had diarrhea in the two weeks preceding the survey. Only 2 percent of children had diarrhea with blood, a symptom of dysentery. The prevalence of diarrhea is especially high among children age 12-23 months and 6-11 months (22 percent and 18 percent, respectively). These high-prevalence age groups are also the ages at which children begin to be weaned and consume foods other than breast milk. Moreover, they correspond to the ages at which children begin to explore their environment, resulting in greater exposure to pathogens. Diarrhea prevalence seems to bear some association with residence: 10 percent of children in urban areas were affected by diarrhea, as compared with 13 percent in rural areas. Variations by sex of the child and source of drinking water are small. Diarrhea prevalence varies by province, from a low of 8 percent in City of Kigali to a high of 15 percent in West. Mother’s level of education is negatively associated with the prevalence of diarrhea. The prevalence is higher among children whose mothers have no education (14 percent) or a primary education (12 percent) than among those whose mothers have a secondary education or higher (9 percent). Children in households with 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 2014-15 Diarrhea in the two weeks preceding the survey Number of children Background characteristic All diarrhea Diarrhea with blood Age in months <6 5.1 0.8 725 6-11 17.9 1.6 916 12-23 21.7 2.9 1,581 24-35 12.2 2.2 1,555 36-47 8.5 1.1 1,602 48-59 4.5 0.9 1,314 Sex Male 12.5 1.7 3,857 Female 11.7 1.7 3,837 Source of drinking water1 Improved 11.9 1.6 5,455 Not improved 12.5 1.9 2,236 Toilet facility2 Improved, not shared 10.3 1.1 4,151 Shared3 12.4 2.1 1,266 Non-improved 15.2 2.5 2,269 Residence Urban 9.8 1.4 1,303 Rural 12.6 1.7 6,391 Province City of Kigali 8.1 1.8 921 South 12.3 2.0 1,756 West 14.8 1.7 1,842 North 11.0 1.6 1,071 East 11.9 1.4 2,103 Mother’s education No education 13.9 2.0 1,125 Primary 12.3 1.8 5,583 Secondary and higher 8.7 0.5 985 Wealth quintile Lowest 14.8 2.5 1,834 Second 14.3 2.3 1,670 Middle 11.6 1.3 1,524 Fourth 10.4 0.8 1,331 Highest 8.0 1.0 1,335 Total 12.1 1.7 7,694 Note: Total includes cases for which information on sources of drinking water (3) and toilet facility (8) is missing. 1 See Table 2.5 for definition of categories. 2 See Table 2.6 for definition of categories. 3 Facilities that would be considered improved if they were not shared by two or more households 138 • Child Health shared and non-improved toilet facilities are more likely to have had diarrhea than those who live in households with improved, not shared toilets. There is an apparent association between diarrhea prevalence and household wealth. The prevalence varies from a high of 15 percent among children in the lowest quintile to a low of 8 percent among children in the highest quintile. 10.5.2 Treatment of Diarrhea Table 10.8 shows that advice or treatment was sought from a health facility or provider for 44 percent of children with diarrhea; help from a community health worker was sought for 10 percent of children with diarrhea. Treatment from a health facility or provider was most often sought for children age 12-23 months (49 percent). Forty-four percent of children age 6-11 months a group with one of the highest diarrhea prevalence rates received treatment. Girls (46 percent) were slightly more likely than boys (42 percent) to be taken to a health facility or provider for treatment. Differences by residence and province in the proportion of children taken to a health facility or provider for treatment are only minor. Children whose mothers have a secondary education or higher (57 percent) and those living in the richest households (53 percent) are more likely than other children to receive treatment for diarrhea from a health facility or provider. 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 a ge 5 w ho h ad d ia rr he a 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 , b y ba ck gr ou nd c ha ra ct er is tic s, R w an da 2 01 4- 15 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 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 co m m un ity he al th 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 of c hi ld re n w ith di ar rh ea B ac kg ro un d ch ar ac te ris tic Fl ui d fro m O R S pa ck et s R ec om m en - de d ho m e flu id s (R H F) E ith er O R S or R H F (O R T) A nt i- bi ot ic dr ug s A nt i- m ot ili ty dr ug s O th er (In cl ud in g Zi nc ) 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 (2 8. 1) (6 .1 ) (2 1. 9) (2 .8 ) (2 4. 7) (1 1. 8) (3 0. 7) (6 .2 ) (3 .0 ) (6 .6 ) (0 .0 ) 15 .7 (0 .0 ) (4 8. 1) 37 6- 11 44 .3 11 .4 22 .6 14 .0 32 .5 18 .1 42 .5 9. 9 3. 3 17 .0 0. 4 18 .4 0. 0 28 .5 16 4 12 -2 3 49 .3 11 .9 30 .9 6. 2 35 .4 12 .1 40 .8 13 .0 2. 3 15 .2 0. 8 16 .3 0. 3 26 .7 34 3 24 -3 5 40 .9 11 .1 31 .5 9. 9 37 .2 18 .5 49 .0 8. 2 1. 6 11 .9 0. 5 20 .1 0. 0 26 .4 19 0 36 -4 7 40 .7 6. 9 21 .6 7. 3 25 .3 22 .0 41 .8 6. 9 1. 6 16 .8 0. 0 31 .3 0. 0 18 .0 13 7 48 -5 9 32 .9 7. 1 24 .8 12 .0 33 .6 20 .6 44 .6 7. 3 3. 4 8. 2 0. 0 20 .3 0. 0 29 .5 59 Se x M al e 41 .6 10 .5 26 .3 6. 4 30 .8 16 .0 39 .8 10 .6 2. 1 14 .6 0. 9 21 .2 0. 0 28 .2 48 4 Fe m al e 45 .7 10 .3 28 .7 11 .3 35 .8 17 .0 46 .0 9. 2 2. 6 14 .0 0. 0 18 .4 0. 2 25 .1 44 7 Ty pe o f d ia rr he a N on -b lo od y 41 .1 10 .0 25 .3 8. 1 30 .5 16 .7 40 .3 9. 2 1. 5 14 .6 0. 4 20 .3 0. 1 28 .6 77 0 B lo od y 55 .4 10 .7 40 .2 12 .4 48 .5 16 .0 55 .7 15 .1 3. 1 16 .2 0. 9 18 .4 0. 0 16 .3 12 9 R es id en ce U rb an 46 .6 5. 3 33 .4 9. 6 40 .2 14 .3 47 .1 12 .0 3. 5 15 .4 0. 1 15 .2 0. 0 24 .7 12 7 R ur al 43 .1 11 .2 26 .5 8. 6 32 .1 16 .8 42 .1 9. 6 2. 1 14 .1 0. 5 20 .6 0. 1 27 .0 80 4 Pr ov in ce C ity o f K ig al i 44 .7 6. 7 30 .7 5. 8 35 .0 12 .0 38 .9 13 .5 4. 4 16 .3 1. 8 28 .3 0. 0 24 .6 75 S ou th 43 .4 15 .0 25 .7 5. 1 29 .5 16 .4 39 .8 9. 9 1. 8 17 .3 0. 0 22 .2 0. 5 25 .7 21 6 W es t 41 .9 9. 9 28 .9 11 .1 35 .1 17 .2 44 .6 10 .9 1. 4 7. 1 0. 1 13 .2 0. 0 30 .7 27 3 N or th 44 .4 9. 7 29 .3 16 .5 42 .1 17 .9 50 .2 11 .3 0. 8 8. 8 1. 8 16 .2 0. 0 31 .1 11 7 E as t 44 .7 8. 4 25 .5 6. 5 29 .8 16 .3 41 .0 7. 2 4. 0 21 .5 0. 3 24 .4 0. 0 21 .8 25 1 M ot he r’s e du ca tio n N o ed uc at io n 39 .8 9. 3 26 .1 10 .0 33 .3 17 .5 44 .1 9. 3 0. 0 11 .0 0. 7 18 .2 0. 0 31 .8 15 6 P rim ar y 42 .7 10 .6 27 .1 8. 5 33 .0 16 .5 42 .5 9. 3 2. 8 14 .3 0. 4 20 .9 0. 2 26 .4 68 9 S ec on da ry a nd h ig he r 56 .9 10 .8 32 .9 8. 1 35 .2 14 .6 42 .5 16 .3 2. 7 20 .5 0. 8 15 .0 0. 0 19 .8 86 W ea lth q ui nt ile Lo w es t 35 .4 11 .3 21 .7 7. 4 26 .9 18 .1 37 .8 5. 5 2. 4 9. 1 0. 4 28 .6 0. 4 28 .7 27 0 S ec on d 42 .8 9. 3 28 .9 9. 2 35 .4 14 .5 42 .7 12 .3 0. 0 11 .5 0. 6 16 .0 0. 0 27 .7 23 9 M id dl e 50 .7 15 .4 26 .3 11 .3 35 .0 15 .8 44 .1 11 .4 3. 6 21 .9 0. 0 16 .1 0. 0 25 .6 17 6 Fo ur th 44 .5 8. 5 30 .4 8. 1 34 .8 16 .8 46 .1 5. 5 2. 9 14 .5 0. 8 19 .8 0. 0 25 .8 13 8 H ig he st 53 .0 4. 8 36 .7 7. 5 39 .5 17 .7 48 .8 19 .4 4. 4 20 .7 0. 6 12 .9 0. 0 22 .5 10 7 To ta l 43 .6 10 .4 27 .5 8. 7 33 .2 16 .5 42 .8 9. 9 2. 3 14 .3 0. 5 19 .9 0. 1 26 .7 93 1 N ot e: 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 flu id , a nd re co m m en de d ho m e flu id s (R H F) . 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. To ta l i nc lu de s 32 ch ild re n w ith m is si ng in fo rm at io n on ty pe o f d ia rr he a. 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 Child Health • 139 140 • Child Health One-third of children with diarrhea received oral rehydration therapy (ORT); 28 percent received oral rehydration salts (ORS), and 9 percent received a recommended homemade fluid (RHF). Seventeen percent of children with diarrhea received increased fluids. Overall, 43 percent of children were treated with some form of ORT or increased fluids. In addition, 10 percent of children received antibiotic drugs, and a very small proportion (2 percent) received anti-motility drugs. One in five children was treated with a home remedy or other treatment (20 percent). It is notable that 27 percent of children with diarrhea received no treatment at all. 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 risk of dehydration among diarrheic children. They also minimize the adverse consequences of diarrhea for the child’s nutritional status. Mothers were specifically asked whether they gave their child more or less fluid and food than usual when the child had diarrhea. Table 10.9 shows that 27 percent of children who had diarrhea were offered the same amount of liquid as usual while they were sick; 27 percent were offered somewhat less than usual, and 25 percent were offered much less than usual. Only 17 percent of children were offered more liquids than usual. Five percent of children were offered no liquid at all. Regarding food intake, 20 percent of children with diarrhea were offered the same amount of food as usual, 25 percent were offered somewhat less than usual, and 38 percent were offered much less than usual. Only 3 percent of children were offered more food than usual. Eight percent were given no food at all during the episode and 6 percent had never been given any food, presumably because they were too young to eat. Overall, only 20 percent of children with diarrhea were given ORT or increased fluids and also given the same, more, or slightly less to eat than usual. Variations in this proportion by background characteristics are not large. Ta bl e 10 .9 Fe ed in g pr ac tic 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 a ge 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 , an d th e pe rc en ta ge o f ch ild 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 i nc re as ed f lu id s du rin g th e ep is od e of d ia rrh ea , by b ac kg ro un d ch ar ac te ris tic s, R w an da 2 01 4- 15 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 B ac kg ro un d ch ar ac te ris tic M or e S am e as us ua l S om e- w ha t l es s M uc h le ss N on e D on ’t kn ow / m is si ng To ta l M or e S am e as us ua l S om e- w ha t l es s M uc h le ss N on e N ev er ga ve fo od To ta l A ge in m on th s <6 (1 1. 8) (4 8. 5) (1 1. 0) (1 7. 4) (1 1. 4) (0 .0 ) 10 0. 0 (3 .1 ) (3 .3 ) (5 .5 ) (3 .9 ) (2 .9 ) (8 1. 3) 10 0. 0 (3 .1 ) (5 .8 ) 37 6- 11 18 .1 24 .7 23 .7 25 .4 8. 1 0. 0 10 0. 0 1. 3 9. 2 20 .8 40 .8 11 .5 16 .4 10 0. 0 4. 6 16 .1 16 4 12 -2 3 12 .1 28 .5 28 .9 25 .3 5. 2 0. 0 10 0. 0 2. 7 21 .5 24 .5 40 .2 11 .0 0. 0 10 0. 0 6. 4 16 .9 34 3 24 -3 5 18 .5 24 .6 28 .1 25 .9 2. 8 0. 0 10 0. 0 2. 7 23 .7 29 .2 39 .3 4. 7 0. 4 10 0. 0 12 .5 24 .6 19 0 36 -4 7 22 .0 23 .6 27 .6 24 .4 0. 8 1. 6 10 0. 0 1. 6 26 .1 30 .2 37 .5 4. 7 0. 0 10 0. 0 12 .4 25 .2 13 7 48 -5 9 20 .6 22 .3 32 .2 18 .9 5. 9 0. 0 10 0. 0 5. 9 21 .0 29 .5 36 .5 7. 0 0. 0 10 0. 0 10 .8 22 .6 59 Se x M al e 16 .0 28 .5 26 .8 23 .6 4. 9 0. 2 10 0. 0 3. 0 20 .7 24 .0 36 .4 8. 8 7. 1 10 0. 0 7. 4 19 .2 48 4 Fe m al e 17 .0 24 .8 27 .5 25 .7 4. 8 0. 2 10 0. 0 2. 1 18 .6 26 .5 39 .8 7. 8 5. 2 10 0. 0 9. 4 19 .7 44 7 Ty pe o f d ia rr he a N on -b lo od y 16 .7 28 .5 27 .7 22 .6 4. 2 0. 3 10 0. 0 2. 3 21 .5 26 .2 36 .6 7. 2 6. 3 10 0. 0 8. 8 20 .0 77 0 B lo od y 16 .0 13 .2 26 .8 35 .3 8. 7 0. 0 10 0. 0 4. 4 10 .3 20 .1 44 .9 15 .6 4. 8 10 0. 0 6. 5 15 .0 12 9 R es id en ce U rb an 14 .3 24 .0 29 .4 25 .3 7. 0 0. 0 10 0. 0 0. 8 19 .5 31 .9 32 .5 9. 2 6. 0 10 0. 0 7. 0 22 .4 12 7 R ur al 16 .8 27 .2 26 .8 24 .5 4. 5 0. 3 10 0. 0 2. 8 19 .7 24 .1 38 .9 8. 2 6. 2 10 0. 0 8. 6 19 .0 80 4 Pr ov in ce C ity o f K ig al i 12 .0 22 .8 40 .1 21 .1 4. 0 0. 0 10 0. 0 2. 2 15 .5 38 .7 22 .3 16 .3 4. 9 10 0. 0 4. 9 17 .5 75 S ou th 16 .4 24 .1 29 .3 25 .7 4. 5 0. 0 10 0. 0 1. 0 18 .9 23 .4 39 .9 12 .1 4. 7 10 0. 0 6. 0 17 .1 21 6 W es t 17 .2 30 .1 17 .0 25 .5 9. 3 0. 8 10 0. 0 3. 4 20 .0 21 .2 37 .8 11 .2 6. 3 10 0. 0 9. 0 18 .3 27 3 N or th 17 .9 23 .3 27 .8 28 .2 2. 8 0. 0 10 0. 0 5. 5 13 .3 26 .0 43 .4 3. 9 7. 9 10 0. 0 11 .3 21 .8 11 7 E as t 16 .3 28 .1 32 .0 22 .0 1. 5 0. 0 10 0. 0 1. 6 24 .3 26 .7 38 .9 1. 6 6. 9 10 0. 0 9. 4 22 .3 25 1 M ot he r’s ed uc at io n N o ed uc at io n 17 .5 26 .2 25 .0 27 .8 3. 4 0. 0 10 0. 0 1. 3 23 .8 21 .4 39 .3 9. 8 4. 3 10 0. 0 8. 5 21 .3 15 6 P rim ar y 16 .5 27 .4 27 .7 22 .7 5. 4 0. 3 10 0. 0 2. 9 19 .2 25 .8 37 .0 7. 8 7. 3 10 0. 0 8. 8 19 .5 68 9 S ec on da ry a nd hi gh er 14 .6 22 .4 26 .4 33 .5 3. 1 0. 0 10 0. 0 1. 3 16 .3 27 .1 44 .5 9. 9 0. 8 10 0. 0 4. 7 16 .2 86 W ea lth q ui nt ile Lo w es t 18 .1 25 .2 28 .5 22 .1 6. 2 0. 0 10 0. 0 1. 6 16 .3 28 .7 38 .9 9. 2 5. 3 10 0. 0 9. 4 18 .5 27 0 S ec on d 14 .5 27 .8 26 .2 25 .8 4. 9 0. 9 10 0. 0 3. 5 22 .2 22 .0 37 .2 10 .5 4. 7 10 0. 0 6. 8 17 .6 23 9 M id dl e 15 .8 27 .1 28 .3 24 .5 4. 4 0. 0 10 0. 0 3. 8 21 .8 19 .2 38 .5 7. 0 9. 7 10 0. 0 8. 7 20 .1 17 6 Fo ur th 16 .8 33 .9 20 .7 24 .5 4. 1 0. 0 10 0. 0 0. 8 24 .2 26 .3 39 .9 3. 7 5. 1 10 0. 0 9. 0 23 .0 13 8 H ig he st 17 .7 18 .6 32 .1 28 .6 3. 1 0. 0 10 0. 0 2. 9 13 .7 32 .0 34 .7 9. 3 7. 4 10 0. 0 7. 7 20 .3 10 7 To ta l 16 .5 26 .7 27 .1 24 .6 4. 9 0. 2 10 0. 0 2. 5 19 .7 25 .2 38 .1 8. 3 6. 2 10 0. 0 8. 4 19 .5 93 1 N ot e: It is re co m m en de d th at c hi ld re n be g iv en m or e liq ui ds to d rin k du rin g di ar rh ea a nd th at fo od n ot b e re du ce d. 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 ot al in cl ud es 3 2 ca se s w ith m is si ng in fo rm at io n on ty pe o f d ia rrh ea . 1 C on tin ue d fe ed in g pr ac tic es in cl ud es c hi ld re n w ho w er e gi ve n m or e, th e sa m 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 . Child Health • 141 142 • Child Health 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 eighty nine percent of women who gave birth in the five years before the survey know about ORS packets. The proportion of women with children under age 5 who have heard about ORS packets increases as age increases, from 79 percent among those age 15-19 to 94 percent among those age 35-49. Knowledge of ORS packets among women with recent births varies by province, from a high of 95 percent in City of Kigali to a low of 84 percent in West. According to educational level, the proportion of women who know of ORS increases from 86 percent among those with no education to 91 percent among those with a secondary education or higher. Women in the highest wealth quintile are more likely to have heard about ORS packets than other women. 10.7 STOOL DISPOSAL 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 of children under age 5, by background characteristics. The stools of 88 percent of children are disposed of safely. Variations in safe disposal of children’s fecal matter by background characteristics are generally small. The only exceptions are that, as expected, the stools of younger children are less likely to be disposed of safely than those of older children, and children living in households with improved, private toilet facilities are more likely to have their stools disposed of safely than children in households with non-improved or shared toilets. Table 10.10 Knowledge of ORS packets Percentage of women age 15-49 with a live birth in the five years preceding the survey who know about ORS packets for treatment of diarrhea, by background characteristics, Rwanda 2014-15 Background characteristic Percentage of women who know about ORS packets Number of women Age 15-19 78.7 151 20-24 80.8 1,142 25-34 89.4 3,196 35-49 93.9 1,570 Residence Urban 93.6 1,025 Rural 87.7 5,035 Province City of Kigali 94.5 723 South 89.3 1,406 West 84.2 1,365 North 86.1 885 East 90.7 1,682 Education No education 86.3 881 Primary 88.7 4,360 Secondary and higher 91.4 819 Wealth quintile Lowest 85.8 1,432 Second 85.4 1,306 Middle 89.2 1,195 Fourth 90.3 1,072 Highest 94.5 1,055 Total 88.7 6,060 ORS = Oral rehydration salts Child Health • 143 Table 10.11 Disposal of children’s stools Percent distribution of youngest children under age 5 living with their 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 2014-15 Manner of disposal of children’s stools Total Percent- age of children whose stools are disposed of safely1 Number of children Background characteristic 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 1.1 43.8 1.0 29.2 8.0 15.7 0.8 0.5 100.0 45.8 714 6-11 1.6 76.0 2.6 12.0 2.6 4.8 0.2 0.1 100.0 80.3 900 12-23 2.5 90.7 1.0 3.0 1.1 1.5 0.1 0.2 100.0 94.3 1,509 24-35 10.0 86.6 1.4 0.9 0.4 0.4 0.2 0.1 100.0 98.0 1,228 36-47 35.7 61.7 0.7 0.8 0.0 0.9 0.2 0.0 100.0 98.1 929 48-59 65.1 33.0 0.2 0.5 0.0 0.7 0.2 0.3 100.0 98.3 557 Toilet facility2 Improved, not shared 16.3 73.2 0.8 5.2 1.5 2.6 0.2 0.2 100.0 90.3 3,157 Shared2 11.9 73.5 1.5 8.0 1.7 3.0 0.3 0.1 100.0 86.8 943 Non-improved or shared 14.3 68.2 1.9 8.2 2.2 4.8 0.4 0.1 100.0 84.4 1,729 Residence Urban 13.7 75.3 0.5 7.2 1.9 1.3 0.1 0.0 100.0 89.5 953 Rural 15.3 71.0 1.4 6.4 1.7 3.7 0.3 0.2 100.0 87.7 4,883 Province City of Kigali 15.1 72.0 0.0 9.0 1.7 2.1 0.0 0.0 100.0 87.1 674 South 15.0 72.2 0.9 7.0 1.3 3.4 0.2 0.1 100.0 88.0 1,354 West 14.6 71.3 1.5 5.5 2.9 3.5 0.6 0.1 100.0 87.4 1,339 North 13.0 70.9 3.6 5.9 1.4 4.7 0.1 0.5 100.0 87.4 855 East 16.6 72.1 0.5 6.3 1.4 2.9 0.1 0.2 100.0 89.1 1,613 Mother’s education No education 14.3 73.2 1.4 4.8 1.4 4.4 0.5 0.1 100.0 88.9 855 Primary 15.5 70.9 1.3 6.9 1.8 3.4 0.2 0.2 100.0 87.6 4,205 Secondary and higher 13.5 74.6 0.7 6.7 2.1 2.0 0.2 0.2 100.0 88.8 776 Wealth quintile Lowest 12.4 71.2 2.1 5.6 2.1 6.0 0.4 0.2 100.0 85.6 1,388 Second 13.7 73.3 1.9 5.3 1.8 3.7 0.1 0.2 100.0 88.9 1,264 Middle 18.0 70.6 0.6 7.3 1.2 2.0 0.3 0.1 100.0 89.2 1,167 Fourth 16.8 70.2 0.7 7.3 1.5 3.1 0.3 0.1 100.0 87.7 1,035 Highest 15.1 73.5 0.4 7.9 2.0 0.9 0.1 0.1 100.0 89.0 983 Total 15.0 71.7 1.2 6.5 1.7 3.3 0.2 0.2 100.0 88.0 5,836 Note: Total includes 6 cases for which information on toilet facility is missing. 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 or rinsed into a toilet or latrine, or if it was buried. 2 See Table 2.6 for definition of categories. 3 Facilities that would be considered improved if they were not shared by two or more households Nutrition of Children and Adults • 145 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 age 2. 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 (ARIs). 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 deficiencies, has a greater risk of obstructed labor, of having a baby with a low birth weight, of producing lower quality breast milk, of mortality due to postpartum hemorrhage, 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, together with its development partners and educational institutions, to find solutions. Under the leadership of the government of Rwanda, multisectoral initiatives and interventions have been put into place over the past decade aimed at improving of the nation’s nutritional status. These efforts include the Presidential Initiative that inspired nationwide emergency action to find and manage all cases of acute malnutrition in children (2009). Other efforts included: • The multisector participation and consensus around Rwanda’s First National Nutrition Summit (2009), and Second National Nutrition Summit (2011), N Key Findings • Thirty eight percent of children under age 5 are short for their age or stunted; however, this represents a decline from the figure of 44 percent reported in 2010. • Rwanda is among the leading countries globally adhere to the recommended practices regarding breastfeeding: 99 percent of children are breastfed for at least some time, the median duration of breastfeeding is 28 months, and almost 9 in 10 children under age 6 months are being exclusively breastfed. • Sixty-four percent of children age 6-9 months started receiving complementary foods. • Eighteen children age 6-23 months are fed in accordance with infant and young child feeding (IYCF) practices. • Seventy-four percent of children age 6-59 months consumed food rich in vitamin A in the 24 hours before the survey. • Thirty-seven percent of children age 6-59 months are anemic, a slight decline from 38 percent in 2010. • Nineteen percent of women age 15-49 are anemic. • Seven percent of women are thin, 17 percent are overweight and 4 percent are obese. • Almost all households in Rwanda use iodized salt. 146 • Nutrition of Children and Adults • Completion of health facility and community level tools to more effectively promote and counsel on Maternal, Infant and Young Child Nutrition (MIYCN), • Development of the National multisector Strategy to Eliminate Malnutrition (NmSEM) (2010), • A national Joint Action Plan (2012) to Eliminate Malnutrition (JAPEM) and District Plans to Eliminate Malnutrition (DPEM) in every district (2011). • Adoption of National Protocol on Management of Malnutrition at the health Facility and Community levels in 2013, • Establishment of the 2013-2018 National Food and Nutrition Policy and National Food and Nutrition Strategic Plan; • Promotion of the first 1000 Days Community Based Food and Nutrition program linked with the wide range of key services and practices that helped to enhance household food security; • Protection of maternal health and fetal growth during pregnancy and prevent stunting during a child’s first two years. The 2014-15 RDHS included questions about 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 dietary diversity. The height and weight of all children under age 5 and women age 15-49 were measured. This chapter also presents findings on infant feeding practices, maternal eating patterns, household testing of salt for adequate levels of iodine, and the nutritional status of women, men, and children. 11.1 NUTRITIONAL STATUS OF CHILDREN Nutritional status of children under age 5 is an important measure of children’s health and growth. The anthropometric data on height and weight collected in the 2014-15 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 2014-15 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 age 24 months were measured lying down (recumbent length) on the board, whereas standing height was measured for older children. Based on these measurements, three internationally accepted indices were constructed and are used to reflect the nutritional status of children: • Height-for-age (stunting) • Weight-for-height (wasting) • Weight-for-age (underweight) Nutrition of Children and Adults • 147 For this report, indicators of the nutritional status of children were calculated using growth standards published by the World Health Organization (WHO) in 2006. These growth standards were generated through data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). The findings of that study, based on a sample of 8,440 children in six countries (Brazil, Ghana, India, Norway, Oman, and the United States), demonstrated how children should grow under optimal conditions. Therefore, the WHO child growth standards can be used to assess children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. The standards replaced the previously used reference standards of the U.S. National Center for Health Statistics, accepted by the U.S. Centers for Disease Control and Prevention (NCHS/CDC/WHO) in 1977. 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.1 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 reference population mean 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 reference population mean are considered severely underweight. A total of 3,884 children under age 5 were eligible to be measured for weight and height, and 3,813 (97 percent) had complete and valid anthropometric data collected. 11.1.2 Measures of Child Nutritional Status Nationally, 38 percent of children under age 5 are stunted, and 14 percent are severely stunted (Table 11.1). Analysis by age group indicates that stunting is apparent even among children less than age 6 months (11 percent). Stunting increases with the age of the child, rising from 18 percent among children age 6-8 months to a 1 The WHO child growth standards reference population used for the 2010 and 2014-15 RDHS surveys differed from that used in past RDHS surveys. When the WHO child growth standards are used in place of the previous reference standards, the following changes are observed: (1) the level of stunting is usually greater, but not for all age groups; (2) the level of wasting in infancy is substantially higher, particularly in the first six months of life; (3) the level of underweight is substantially higher during the first half of infancy (age 0-6 months) and decreases thereafter; and (4) the level of overweight/obesity is higher. 148 • Nutrition of Children and Adults peak of 49 percent among children age 18-23 months before gradually declining to 37 percent among children age 48-59 months (Figure 11.1). There is a difference in level of stunting by sex (43 percent among boys and 33 percent among girls). Stunting shows only small differences by interval between births. Stunting is more prevalent among children born very small (61 percent) compared to children born with average size (35 percent). Forty-nine percent of children born to undernourished mothers (BMI below 18.5 kg/m2) are stunted compared to 40 percent of children whose mothers have a normal BMI (18.5-24.9 kg/m2) and 29 percent of children whose mother is overweight-obese. The disparity in stunting prevalence between rural and urban children is substantial: 41 percent of rural children are stunted, as compared with 24 percent of urban children. Variation in children’s nutritional status by province is quite evident, with stunting being highest in West (45 percent) and lowest in the City of Kigali (23 percent). Mother’s level of education and wealth quintile both have a clear inverse relationship with prevalence of stunting. For example, the prevalence of stunting is higher among children living in the poorest households (49 percent) than among children in the richest households (21 percent) and higher among children whose mothers have no education (47 percent) than among those whose mothers have a secondary education or higher (19 percent). In generally, stunting among children under age 5 has declined, and this may be due to the efforts made by the government to reduce malnutrition in Rwanda. Two percent of children under age 5 are wasted, and less than 1 percent are severely wasted. The wasting prevalence is highest among children less than age 8 months (5 percent) and begins to decline only after age 8 months. Wasting is about four times as common 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). There are no differences in wasting by province. Two other forms of malnutrition, overweight and obesity may be on the rise among children in Rwanda. Overall, 8 percent of children below age 5 are overweight or obese (weight-for-height more than +2 SD). There are no substantial differences by sex, but differences are observed by area of residence (11 percent in urban areas and 7 percent in rural areas). In addition, the proportion of children who are overweight increases with increasing mother’s BMI. Variations by province are small. Table 11.1 shows that nine percent of children under age 5 are underweight (low weight-for-age), and 2 percent are severely underweight. Overall, 1 percent of children below age 5 have weight-for-age more than +2 SD. The percentage of children who are underweight increases steadily from 4 percent among those less than age 6 months to 9 percent among those age 6-11 months and 11 percent among those age 12-17 months, after which it decreases slightly to 9 percent among children age 18-23 months before once again increasing to 11 percent among children age 24-35 months. Being underweight is more prevalent among children born very small (22 percent) compared to children born of average size (7 percent). There is no clear relationship between the age of the children and being underweight. Rural children are almost twice as likely to be underweight as urban children (10 percent versus 6 percent). Two of the five provinces in Rwanda South and West (11 and 10 percent, respectively) have percentages of underweight children above the national average. The prevalence of underweight children is 5 percent in the city of Kigali and 9 percent in the North and East provinces. A mother’s wealth status and educational level are negatively associated with the likelihood that her child is underweight. For example, 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 (13 percent versus 3 percent). Also, children born to undernourished mothers (BMI below 18.5 kg/m2) are two and a half times more likely than children whose mothers have a normal BMI (18.5-24.9 kg/m2) to be underweight (25 percent versus 10 percent). Nutrition of Children and Adults • 149 Table 11.1 Nutritional status of children Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Rwanda 2014-15 Height-for-age1 Weight-for-height Weight-for-age Number of children Background characteristic Percent- age below -3 SD Percent- age below -2 SD2 Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Age in months <6 3.7 10.5 -0.5 1.7 5.4 18.3 0.7 1.4 4.3 4.2 0.1 331 6-8 8.8 18.2 -0.7 1.1 4.5 11.0 0.3 2.6 9.0 2.4 -0.3 214 9-11 7.6 21.3 -1.0 1.5 3.8 10.6 0.4 1.6 9.1 0.9 -0.3 214 12-17 16.1 41.6 -1.6 0.8 3.8 9.2 0.4 2.9 11.4 0.6 -0.5 402 18-23 15.2 49.4 -1.8 0.4 2.6 7.2 0.3 2.0 9.2 1.1 -0.7 365 24-35 18.5 47.1 -1.9 0.5 1.3 7.1 0.5 2.4 11.3 0.8 -0.7 797 36-47 13.8 42.7 -1.8 0.0 0.7 5.7 0.5 1.2 7.9 0.5 -0.7 831 48-59 12.7 37.4 -1.7 0.4 1.2 2.9 0.3 3.3 10.3 0.5 -0.8 657 Sex Male 15.6 42.7 -1.7 0.9 2.4 8.1 0.5 2.8 9.3 1.1 -0.6 1,924 Female 11.3 32.9 -1.4 0.3 2.0 7.3 0.4 1.6 9.3 1.0 -0.5 1,889 Birth interval in months3 First birth4 11.7 34.7 -1.5 0.6 1.8 8.1 0.5 2.3 7.6 1.5 -0.5 986 <24 13.9 38.7 -1.6 0.3 3.1 8.5 0.4 5.6 11.6 0.6 -0.6 353 24-47 14.0 40.3 -1.6 0.6 2.0 7.5 0.4 1.5 9.7 0.5 -0.6 1,358 48+ 12.7 36.8 -1.4 0.8 2.9 8.2 0.4 1.2 8.9 1.6 -0.5 853 Size at birth3 Very small 20.6 60.6 -2.2 2.3 3.0 8.4 0.2 7.2 21.8 0.8 -1.2 88 Small 19.8 50.1 -2.0 0.4 4.6 4.3 0.1 6.5 19.1 0.1 -1.1 431 Average or larger 11.9 35.2 -1.5 0.6 1.9 8.4 0.5 1.3 7.3 1.2 -0.5 3,020 Mother's interview status Interviewed 13.1 37.8 -1.6 0.6 2.3 7.9 0.4 2.1 9.1 1.1 -0.6 3,550 Not interviewed but in household (10.7) (29.3) 1.6 (0.0) (0.0) (6.1) -0.4 (3.6) (6.7) (0.0) 0.6 30 Not interviewed and not in the household5 20.0 40.5 -1.7 0.0 1.6 4.0 0.4 4.1 13.0 1.0 -0.7 232 Mother's nutritional status6 Thin (BMI < 18.5) 21.5 48.8 -1.9 1.3 7.6 1.5 -0.2 4.9 25.1 0.0 -1.3 152 Normal (BMI 18.5-24.9) 13.9 40.2 -1.6 0.6 2.2 6.5 0.4 2.3 9.7 0.8 -0.6 2,245 Overweight/obese (BMI ≥ 25) 7.9 28.8 -1.3 0.4 0.9 12.4 0.7 0.9 4.5 1.6 -0.2 690 Residence Urban 7.0 23.7 -1.0 0.6 1.8 10.9 0.5 1.6 5.9 2.9 -0.2 612 Rural 14.7 40.6 -1.7 0.6 2.3 7.1 0.4 2.3 10.0 0.7 -0.7 3,200 Province City of Kigali 5.2 22.7 -0.9 0.7 2.3 9.9 0.5 1.9 5.3 2.8 -0.2 419 South 13.9 40.5 -1.6 0.3 2.4 6.8 0.4 2.3 10.5 0.9 -0.6 910 West 18.6 44.9 -1.8 0.7 2.3 7.6 0.4 2.7 10.1 0.9 -0.7 894 North 13.3 39.2 -1.6 0.1 1.8 9.7 0.6 1.7 9.3 0.7 -0.5 541 East 12.1 34.8 -1.5 0.9 2.2 6.7 0.4 2.1 9.2 0.8 -0.6 1,049 Mother's education7 No education 17.9 47.0 -1.9 0.9 3.0 7.3 0.5 3.4 11.7 0.8 -0.8 530 Primary 13.2 39.1 -1.6 0.5 2.1 7.7 0.4 2.0 9.2 0.7 -0.6 2,589 Secondary and higher 6.4 19.3 -0.8 1.0 2.3 10.1 0.5 1.1 5.6 3.2 -0.1 462 Wealth quintile Lowest 19.2 48.6 -1.9 0.5 2.3 6.9 0.4 3.1 13.2 0.7 -0.8 959 Second 16.3 44.7 -1.8 0.7 2.2 7.2 0.4 2.6 12.1 0.5 -0.8 829 Middle 13.6 37.5 -1.6 0.6 2.9 6.1 0.4 2.5 8.3 0.1 -0.6 740 Fourth 8.8 30.2 -1.4 0.3 1.8 8.7 0.5 1.6 6.8 1.3 -0.4 650 Highest 5.7 20.9 -0.9 0.7 1.8 10.3 0.5 0.8 3.4 3.2 -0.1 633 Total 13.5 37.9 -1.6 0.6 2.2 7.7 0.4 2.2 9.3 1.1 -0.6 3,813 Note: Table is based on children who stayed in the household on the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO child growth standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 12 cases in which information on size at birth is missing. Figures in parentheses are based on 25-49 unweighted cases. 1 Recumbent length was measured for children under age 2, or in the few cases when the age of the child was unknown and the child was less than 85 cm; standing height was measured for all other children. 2 Includes children who are below -3 standard deviations (SD) from the WHO child growth standards population median 3 Excludes children whose mothers were not interviewed 4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 5 Includes children whose mothers are deceased 6 Excludes children whose mothers were not weighed and measured, children whose mothers were not interviewed, and children whose mothers are pregnant or gave birth within the preceding 2 months. Mother's nutritional status in terms of BMI (body mass index) is presented in Table 11.10. 7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 150 • Nutrition of Children and Adults Figure 11.1 Nutritional status of children by age 11.1.3 Trends in Children’s Nutritional Status Trends in the nutritional status of children under age 5 between 2005 and 2014-15 are shown in Figure 11.2. To allow assessment of trends, the data for 2005 were recalculated using the 2006 WHO child growth standards. The results indicate that there have been improvements in the nutritional status of children over the past decade. The percentage of stunted children fell from 51 percent in 2005 to 44 percent in 2010 and 38 percent in 2014-15. The percentage of children who are wasted declined from 5 percent in 2005 to 3 percent in 2010 and 2 percent in 2014-15, and the proportion of children who are underweight declined from 18 percent in 2005 to 11 percent in 2010 and 9 percent in 2014-15. These improvements may be attributable to the National Plan to Eliminate Malnutrition, which, since 2009, has included active nutrition screening of children by community health workers. Children who are determined to be at risk of malnourishment are referred to a health facility for appropriate treatment using therapeutic milks, ready-to-use therapeutic food for severe cases, and a corn-soy blend for moderate cases. Other sustainable approaches have been initiated and include infant and young child feeding, community-based nutrition programs, behavior change communication (including mass media), and home food fortification (using micronutrient powders). Although there have been improvements in the nutritional status of Rwandan children in the past several years, the prevalence of malnutrition (stunting) is still high, and there remains a need for more intensive interventions. 0 10 20 30 40 50 60 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 Age (months) Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a 5-month moving average. Stunted RDHS 2014-15 Underweight Wasted Percent Nutrition of Children and Adults • 151 Figure 11.2 Trends in nutritional status of children under age 5 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 last-born children born in the two years preceding the survey by breastfeeding status and timing of initial breastfeeding, according to background characteristics. Practically all of the children (99 percent) born in the two years preceding the survey were breastfed at some point in time. Because breastfeeding is nearly universal, variations according to background characteristics are minimal. Eighty-one percent of children are breastfed within one hour of birth, an increase from the figure of 71 percent reported in the 2010 RDHS. Ninety-six percent are breastfed within one day of birth. About 5 percent of children receive a prelacteal feed, that is, something other than breast milk during the first three days of life. 51 5 18 44 3 11 38 2 9 Stunted Wasted Underweight RDHS 2005 RDHS 2010 RDHS 2014-15 152 • Nutrition of Children and Adults 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 2014-15 Among last-born children born in the past 2 years: Among last-born children born in the past 2 years who were ever breastfed: Background characteristic 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 98.6 80.3 95.2 1,623 4.6 1,600 Female 98.9 80.7 96.2 1,612 4.3 1,595 Assistance at delivery Health professional3 98.8 81.4 95.7 2,971 4.3 2,936 Traditional birth attendant * * * 4 * 4 Other 98.3 71.9 95.0 181 6.5 178 No one 98.6 68.8 97.2 75 4.2 74 Place of delivery Health facility 98.8 81.4 95.7 2,966 4.3 2,931 At home 98.1 70.2 96.1 218 7.0 214 Other (100.0) (74.3) (94.7) 51 (5.6) 51 Residence Urban 98.8 78.3 95.5 561 5.8 554 Rural 98.8 80.9 95.7 2,675 4.2 2,642 Province City of Kigali 99.2 74.3 95.8 395 7.8 391 South 98.7 81.6 95.7 730 2.8 720 West 98.9 78.6 95.6 763 4.2 754 North 98.0 79.3 93.4 453 3.3 444 East 99.0 84.4 96.8 896 5.1 886 Mother's education No education 99.3 84.2 96.8 439 4.0 436 Primary 98.7 80.4 95.6 2,316 4.3 2,285 Secondary and higher 98.8 77.3 95.0 481 5.5 475 Wealth quintile Lowest 98.9 79.4 96.2 792 4.6 784 Second 98.8 80.6 94.9 672 5.0 663 Middle 99.2 85.6 97.1 622 3.2 617 Fourth 98.0 78.4 94.2 573 3.7 562 Highest 98.9 78.4 95.8 576 5.7 570 Total 98.8 80.5 95.7 3,236 4.5 3,196 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children are living or dead at the time of the interview. Total includes 3 cases in which information on assistance at delivery is missing and 1 case in which place of delivery is missing. 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 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/medical assistant, or midwife 11.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first six months of life and that they be given solid or semisolid complementary food in addition to continued breastfeeding from age 6 months until age 24 months or more, when the child is fully weaned. Use of bottles with nipples is not recommended at any age. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all of the nutrients necessary in the first few months of life. In addition, the mother’s antibodies in breast milk provide the infant with immunity to disease. Early supplementation is discouraged for several reasons. First, it exposes infants to pathogens and thus increases their risk of infection, especially diarrheal disease. Second, it decreases infants’ intake of breast milk and therefore suckling, which in turn reduces breast milk production. Third, in low-resource settings, supplementary food often has poor or inadequate nutrients. Nutrition of Children and Adults • 153 Interviewers obtained information on complementary feeding by asking mothers about the current breastfeeding status of the youngest child born in the five-year period before the survey and, for the youngest child born in the two-year period before the survey and living with the mother, foods and liquids given to the child the day and night before the survey. Table 11.3 shows the percent distribution of youngest children under age 2 living with their mother by breastfeeding status and the percentage of children under age 2 using a bottle with a nipple, according to age in months. The data presented in Table 11.3 and Figure 11.3 show that exclusive breastfeeding during the first six months after birth is widely practiced in Rwanda. Currently, mothers exclusively breastfeed 87 percent of children younger than age 6 months. The percentage of young children who are exclusively breastfed decreases sharply from 94 percent among infants age 0-1 month to 90 percent among those age 2-3 months and 81 percent among those age 4-5 months. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under age 2 who are living with their mother by breastfeeding status and the percentage currently breastfeeding, and the percentage of all children under age 2 using a bottle with a nipple, according to age in months, Rwanda 2014-15 Not breast- feeding Breastfeeding status Total Percent- age currently breast- feeding Number of youngest children under age 2 living with their mother Percent- age using a bottle with a nipple Number of all children under age 2 Age in months Exclusively breastfed Breast- feeding and consuming plain water only Breast- feeding and consuming non-milk liquids1 Breast- feeding and consuming other milk Breast- feeding and consuming complement ary foods 0-1 0.7 93.5 0.0 5.5 0.0 0.4 100.0 99.3 202 1.1 206 2-3 0.7 89.5 0.7 6.7 2.5 0.0 100.0 99.3 238 3.4 242 4-5 0.4 80.8 1.1 5.9 6.6 5.3 100.0 99.6 274 4.9 278 6-8 1.5 23.2 0.5 10.6 8.4 55.8 100.0 98.5 474 11.3 482 9-11 1.3 2.6 0.0 3.3 1.5 91.4 100.0 98.7 425 8.8 434 12-17 5.8 0.7 0.4 0.6 0.3 92.2 100.0 94.2 793 4.2 811 18-23 12.4 0.4 0.1 0.2 0.0 87.0 100.0 87.6 716 3.0 769 0-3 0.7 91.3 0.4 6.1 1.3 0.2 100.0 99.3 440 2.3 448 0-5 0.5 87.3 0.7 6.0 3.3 2.2 100.0 99.5 714 3.3 725 6-9 1.5 18.1 0.4 9.0 6.6 64.4 100.0 98.5 651 11.4 663 12-15 4.4 1.0 0.2 0.6 0.4 93.4 100.0 95.6 519 5.5 526 12-23 8.9 0.5 0.3 0.4 0.1 89.7 100.0 91.1 1,509 3.6 1,581 20-23 12.8 0.0 0.2 0.0 0.0 86.9 100.0 87.2 456 2.6 496 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. In addition to breast milk, 2 percent of infants under age 6 months are given complementary foods, 3 percent are given other milk, 1 percent are given plain water only, and 6 percent are given non-milk liquids and juice (Figure 11.3 and Table 11.3). Complementary feeding increases rapidly from 5 percent among children age 4-5 months to 56 percent among those age 6-8 months. Three percent of infants under age 6 months are fed using a bottle with a nipple, a practice that is discouraged because it increases the child’s risk of illness and reduces the child’s interest in breastfeeding, with consequent potential declines in milk production. The duration of breastfeeding in Rwanda is long. The proportion of children who are currently breastfeeding is 99 percent for children up to age 9-11 months. This proportion subsequently declines to 94 percent among children age 12-17 months and 88 percent among those age 18-23 months. 154 • Nutrition of Children and Adults Figure 11.3 Infant feeding practices by age 11.4 DURATION OF BREASTFEEDING Table 11.4 shows the median duration of breastfeeding by selected background characteristics. Estimates of breastfeeding durations are based on current status data, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The median duration of any breastfeeding is 28.3 months, and the mean duration is 27.2 months. There is little difference in duration of breastfeeding by sex of the child (27.3 months and 29.3 months for male and female children, respectively). Rural children are breastfed for a slightly longer duration than urban children (29.0 months versus 25.1 months). Mothers with a primary education or no education breastfeed their children four months longer than highly educated mothers. Similarly, mothers from the highest wealth quintile breastfeed their children for a median duration of 25.4 months, as compared with 28.8 months among mothers in the lowest wealth quintile. Children in the East province are breastfed for 28.0 months, whereas children in City of Kigali are breastfed for 26.2 months. The median duration of exclusive breastfeeding among Rwandan children is five months, and the mean duration is six months. The median duration of any breastfeeding has declined by one month since 2010, whereas exclusive breastfeeding has remained stable. 0% 20% 40% 60% 80% 100% <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Not breastfeeding Breastfeeding and consuming complementary foods Breastfeeding and consuming other milk Breastfeeding and consuming nonmilk liquids Breastfeeding and consuming plain water only Exclusively breastfed RDHS 2014-15Age in months Nutrition of Children and Adults • 155 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 2014-15 Median duration (months) of breastfeeding among children born in the past 3 years1 Background characteristic Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 27.3 5.5 6.1 Female 29.3 5.3 6.0 Residence Urban 25.1 5.1 5.6 Rural 29.0 5.4 6.1 Province City of Kigali 26.2 5.1 5.4 South a 5.4 5.9 West 26.2 5.1 6.3 North 27.0 5.7 6.1 East 28.0 5.5 6.2 Mother's education No education 29.2 5.5 6.4 Primary 29.0 5.4 6.1 Secondary and higher 24.9 5.2 5.6 Wealth quintile Lowest 28.8 5.7 6.3 Second 29.4 5.3 6.3 Middle 29.5 5.7 6.5 Fourth 27.8 5.1 5.6 Highest 25.4 5.0 5.4 Total 28.3 5.4 6.0 Mean for all children 27.2 6.1 7.0 Note: Median and mean durations are based on the distributions 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. a = Omitted because more than 50 percent of the children continued to breastfeed after reaching 36 months 1 It is assumed that non-last-born children and last-born children not currently living with their mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only Figure 11.4 shows several Infant and Young Child Feeding (IYCF) indicators of breastfeeding status. As mentioned above, 87 percent of children under age 6 months and 81 percent of children age 4-5 months are exclusively breastfed, and 94 percent of children under age 6 months are predominantly breastfed. Close to 6 in 10 children age 6-8 months (57 percent) consume solid, semisolid, or soft foods. Eighty-four percent of children under age 2 receive age-appropriate breastfeeding, while about 5 percent use a bottle with a nipple. Ninety-six percent of children continue breastfeeding at age 1 and 87 percent at age 2. 156 • Nutrition of Children and Adults Figure 11.4 IYCF indicators on breastfeeding status 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. The 2014-15 RDHS collected data on the types of foods given on the day and night preceding the survey to the youngest children under age 2 living with their mothers. These data are presented in Table 11.5 according to breastfeeding status. Infant formula supplementation and consumption of fortified baby foods are uncommon in Rwanda. Among breastfeeding children under age 2, only 1 percent consume infant formula and only 2 percent are given fortified (commercial) baby food. However, a much higher proportion of children receive other milk (17 percent). For a small number of children, the introduction of other liquids, such as water, juice, and formula, takes place earlier than the recommended age of 6 months. Among the youngest breastfeeding children (0-1 month), only 6 percent consume liquids other than water and breast milk. As expected, consumption of other milk and other liquids increases substantially among children over age 6 months. Among children age 6-23 months, foods rich in vitamin A and foods made from legumes and nuts are consumed more often than foods from other food groups. Among breastfeeding children in this age group, 70 percent ate fruits and vegetables rich in vitamin A and 65 percent ate foods made from legumes and nuts during the day or night preceding the interview. Meat, fish, poultry, and eggs have bodybuilding substances essential to good health. They are important for balanced physical and mental development. Overall, 17 percent of breastfeeding children age 6-23 months consume meat, fish, or poultry, and 4 percent consume eggs. Only 1 percent of children in this age group consumed cheese, yogurt, or other dairy products in the 24 hours preceding the survey. Overall, almost 9 in 10 breastfeeding children age 6-23 months (89 percent) consumed solid or semisolid food during the day or night preceding the survey. 5 94 84 87 57 96 81 87 IYCF 14: Bottle feeding (0-23 months) IYCF 12: Predominant breastfeeding (0-5 months) IYCF 11: Age-appropriate breastfeeding (0-23 months) IYCF 10: Continued breastfeeding at 2 years IYCF 4: Introduction of solid, semisolid, or soft foods (6-8 months) IYCF 3: Continued breastfeeding at 1 year Exclusive breastfeeding at 4-5 months IYCF 2: Exclusive breastfeeding under 6 months RDHS 2014-15 Nutrition of Children and Adults • 157 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 their mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Rwanda 2014-15 Liquids Solid or semisolid foods Any solid or semi solid food Number of children Age in months Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry Eggs Cheese, yogurt, other milk products BREASTFEEDING CHILDREN 0-1 0.0 0.0 5.9 0.0 0.4 0.4 0.0 0.0 0.4 0.0 0.0 0.0 0.4 201 2-3 0.3 2.3 6.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 236 4-5 1.4 6.8 7.5 1.8 0.0 2.8 1.5 0.8 0.8 0.4 0.4 0.4 5.4 273 6-8 1.6 24.2 51.0 4.1 14.1 40.6 22.3 20.3 23.6 7.1 2.9 2.0 56.7 467 9-11 2.1 21.5 70.1 2.3 35.8 70.9 26.6 56.8 69.6 19.3 5.2 1.6 92.5 420 12-17 0.7 19.9 74.2 1.9 33.9 79.5 24.0 65.0 74.5 20.4 4.1 0.9 97.9 748 18-23 0.6 19.4 69.5 1.9 35.5 81.4 25.1 70.3 82.4 19.0 3.8 0.9 99.2 627 6-23 1.1 20.9 67.3 2.4 30.6 70.4 24.4 55.7 65.3 17.1 4.0 1.3 88.8 2,262 Total 1.0 16.7 52.9 2.0 23.3 53.9 18.8 42.5 49.8 13.0 3.1 1.0 68.1 2,972 NONBREASTFEEDING CHILDREN 0-11 * * * * * * * * * * * * * 16 12-17 (0.0) (60.1) (72.1) (4.4) (48.6) (64.4) (28.7) (52.6) (67.8) (22.4) (12.9) (2.7) (92.9) 46 18-23 3.8 39.4 80.6 4.8 49.0 79.6 30.3 62.6 86.5 32.5 9.6 3.2 100.0 88 6-23 2.8 45.0 76.0 5.4 47.6 73.8 29.4 58.1 74.9 27.9 9.8 2.8 97.3 147 Total 2.8 44.4 74.7 5.2 46.3 71.9 28.6 56.6 73.0 27.2 9.6 2.7 94.7 151 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, squash, carrots, sweet potatoes, dark green leafy vegetables, mangoes, and papayas A comparison of the dietary intake of children age 6-23 months by breastfeeding status shows that a higher proportion of nonbreastfeeding children (97 percent) than breastfeeding children (89 percent) are consuming solid and semisolid foods. Consumption of all groups of liquids and solid or semisolid foods is more common among nonbreastfeeding children than among those who are still breastfeeding. 11.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Appropriate infant and young child feeding (IYCF) practices include initiation of 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 et al, 2008). WHO has established guidelines with respect to IYCF practices for children age 6-23 months. Breastfed children in this age group should receive animal-source foods and vitamin A-rich fruits and vegetables daily (PAHO/WHO, 2003). Since first foods almost universally include a grain- or tuber-based staple, it is unlikely that young children who eat two or fewer food groups will receive both an animal-source food and a vitamin A-rich fruit or vegetable. Therefore, four food groups are considered the minimum acceptable number of food groups for breastfed infants (Arimond and Ruel, 2004). Breastfed infants age 6-8 months should be fed meals of complementary foods two or three times per day, with one to two snacks as desired; breastfed children age 9-23 months should be fed meals three or four times per day, with one to two snacks (WHO et al, 2008). Nonbreastfed children age 6-23 months should receive milk products at least twice a day to ensure that their calcium needs are met. In addition, they need animal-source foods and vitamin A-rich fruits and vegetables. 158 • Nutrition of Children and Adults Therefore, for nonbreastfed young children, four food groups are considered the minimum acceptable number. Nonbreastfed children should be fed meals four or five times per day, with one to two snacks as desired (WHO, 2005). Meal frequency is considered a proxy for energy intake from foods other than breast milk. Therefore, feeding frequency indicators for nonbreastfed children include both milk feeds and solid or semisolid feeds (WHO et al, 2008). Table 11.6 presents summary indicators of IYCF practices. Among all children age 6-23 months, 96 percent received breast milk or milk products during the 24-hour period before the survey, and nearly half (47 percent) were fed at least the minimum number of times. Only 30 percent were fed according to minimum standards with respect to food diversity (four or more food groups). Overall, only 18 percent of children age 6-23 months living with their mothers are fed in accordance with all three IYCF practices. Older children, children in urban areas, and those residing in City of Kigali are more likely to be fed according to the IYCF practices than younger children, rural children, and children in other provinces. Feeding practices improve as the wealth quintile and educational level of the mother increase. Among breastfed children age 6-23 months, 29 percent receive foods from at least four food groups, while 47 percent are fed the minimum number of times or more. In total, 19 percent of breastfed children are given foods from four or more groups and also are fed at least the minimum number of times per day. Among nonbreastfed children in the same age group, 35 percent receive milk or milk products, 53 percent receive foods from at least four food groups, and 45 percent are fed the minimum number of times or more. Only 10 percent of nonbreastfed children are fed in accordance with IYCF practices. Overall, feeding standards among children age 6-23 months have improved slightly in the last five years, with the proportion of children fed in accordance with all three IYCF practices increasing by 1 percent since 2010 (from 17 percent to 18 percent) (Figure 11.5). Nutrition of Children and Adults • 159 Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night preceding the survey, by background characteristics, Rwanda 2014-15 Among breastfed children 6-23 months, percentage fed: Among non-breastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: Background characteristic 4+ food groups1 Minimum meal fre- quency2 Both 4+ food groups and minimum meal frequency Number of breastfed children 6-23 months Milk or milk products3 4+ food groups1 Minimum meal fre- quency4 With 3 IYCF practices5 Number of non- breastfed children 6-23 months Breast milk, milk, or milk products6 4+ food groups1 Minimum meal fre- quency7 With 3 IYCF practices Number of all children 6-23 months Age in months 6-8 14.1 41.7 11.8 467 * * * * 7 99.1 13.9 41.9 11.6 474 9-11 30.0 37.8 15.9 420 * * * * 5 98.9 30.1 37.5 15.7 425 12-17 32.3 49.7 20.4 748 (47.2) (51.8) (51.7) (14.7) 46 96.9 33.5 49.8 20.0 793 18-23 34.0 55.0 23.5 627 29.2 58.5 42.6 8.5 88 91.2 37.0 53.5 21.6 716 Sex Male 27.3 49.8 18.2 1,122 38.3 50.5 51.9 12.3 75 96.2 28.7 50.0 17.9 1,196 Female 29.8 44.8 19.0 1,140 31.2 55.3 37.7 7.0 72 95.9 31.4 44.4 18.3 1,212 Residence Urban 45.6 53.3 31.7 355 34.4 63.6 46.9 14.8 45 92.6 47.7 52.5 29.8 400 Rural 25.4 46.2 16.2 1,907 35.0 48.1 44.0 7.4 102 96.7 26.6 46.1 15.7 2,009 Province City of Kigali 45.7 54.4 32.0 246 (34.2) (66.2) (42.6) (13.1) 35 91.9 48.3 53.0 29.7 281 South 27.1 48.2 18.0 510 (53.8) (46.9) (65.2) (16.6) 22 98.1 27.9 48.9 17.9 532 West 21.0 39.0 11.1 559 (15.9) (32.2) (20.3) (8.7) 24 96.5 21.4 38.2 11.0 583 North 32.6 53.9 22.7 323 * * * * 20 96.3 34.0 53.5 21.8 344 East 27.7 47.9 18.4 624 (34.7) (55.6) (48.4) (5.1) 45 95.6 29.6 47.9 17.5 669 Mother's education No education 18.6 36.3 10.1 328 * * * * 12 97.5 19.4 36.5 9.8 340 Primary 26.9 47.1 17.0 1,630 31.2 46.9 41.9 9.2 101 96.0 28.1 46.8 16.5 1,731 Secondary and higher 48.4 60.1 36.5 304 (47.0) (75.4) (55.8) (15.1) 33 94.9 51.0 59.7 34.4 337 Wealth quintile Lowest 15.4 37.0 7.8 575 (40.4) (33.0) (48.2) (4.0) 26 97.5 16.1 37.5 7.6 601 Second 21.6 45.7 13.9 485 * * * * 20 97.1 22.6 45.4 13.7 505 Middle 25.2 45.3 16.5 440 (19.4) (48.7) (37.3) (3.4) 29 95.1 26.6 44.8 15.7 469 Fourth 41.7 56.4 28.6 400 * * * * 20 96.6 42.2 55.3 28.1 420 Highest 48.5 58.3 33.7 362 45.4 67.1 53.7 12.7 53 93.1 50.9 57.7 31.0 414 Total 28.6 47.3 18.6 2,262 34.8 52.9 44.9 9.7 147 96.0 30.1 47.2 18.1 2,409 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 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c. vitamin A-rich fruits and vegetables and red palm oil; d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, shellfish and organ meats; g. legumes and nuts. 2 For breastfed children, minimum meal frequency is receiving solid or semisolid food at least twice a day for infants age 6-8 months and at least three times a day for children age 9-23 months. 3 Includes two or more feedings of commercial infant formula, fresh, tinned, and powdered animal milk, and yogurt 4 For nonbreastfed children age 6-23 months, minimum meal frequency is receiving solid or semisolid food or milk feeds at least four times a day. 5 Nonbreastfed children age 6-23 months are considered to be fed with a minimum standard of three infant and young child feeding practices if they receive other milk or milk products at least twice a day, receive the minimum meal frequency, and receive solid or semisolid foods from at least four food groups not including the milk or milk products food group. 6 Breastfeeding, or not breastfeeding and receiving two or more feedings of commercial infant formula, fresh, tinned, and powdered animal milk, and yogurt 7 Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in footnotes 2 and 4. 160 • Nutrition of Children and Adults Figure 11.5 Trends in the percentage of children age 6-23 months fed according to all three infant and young child feeding (IYCF) practices 11.7 PREVALENCE OF ANEMIA IN CHILDREN Anemia is a condition characterized by a reduction in red blood cell volume and a decrease in the concentration of hemoglobin in the blood. Hemoglobin is necessary for transporting oxygen to tissues and organs in the body. About half of the global burden of anemia is due to iron deficiency. Iron deficiency, in turn, is largely due to an inadequate dietary intake of bio-available iron, increased iron requirements during rapid growth periods (such as pregnancy and infancy), and increased blood loss due to hookworm or schistosomiasis infestation. Nutritional anemia includes the anemia burden due to deficiency in iron along with deficiencies in folate, vitamins B and B12, and certain trace elements involved in red blood cell production. Anemia in children is associated with impaired mental and physical development and with increased morbidity and mortality. Anemia can be a particularly serious problem for pregnant women, leading to premature delivery and low birth weight. The most common causes of anemia in Rwanda are inadequate dietary intake of iron, malaria, and intestinal worm infection. Iron and folic acid supplementation and anti-malarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bed nets by pregnant women and children under age 5, and six-month deworming for children age 2 to 5 are some of the important measures to reduce the anemia burden among vulnerable groups. Hemoglobin levels were successfully measured for 96 percent of the children eligible for testing, along with 98 percent of eligible women. Hemoglobin levels for children and women were adjusted for altitude and, among women only, smoking status. Table 11.7 presents anemia prevalence for children age 6-59 months. The results are based on tests of 3,524 (de facto) children living in the one-half of households selected for the men’s survey who were present at the time of testing, whose parents consented to their being tested, and whose hemoglobin results were plausible. Children with hemoglobin level of 11.0 g/dl are not anemic. Children are classified into three groups according to the level of hemoglobin (after adjustment) in their blood2: • Mild: hemoglobin concentration of 10.0-10.9 g/dl • Moderate: hemoglobin concentration of 7.0-9.9 g/dl • Severe: hemoglobin concentration below 7.0 g/dl 2 The classification is based on criteria developed by WHO (DeMaeyer et al., 1989). Because hemoglobin levels vary by altitude, each child’s result should be adjusted based on altitude measurements taken in the sample cluster where the testing was conducted. However, in the 2014-15 RDHS, adjustments for altitude were not made because none of the children were living above 1,000 meters. 17 10 1719 10 18 Breastfed Nonbreastfed All 6-23 months RDHS 2010 RDHS 2014-15 Nutrition of Children and Adults • 161 Overall, 37 percent of children age 6-59 months in Rwanda have some level of anemia, including 21 percent who are mildly anemic, 15 percent who are moderately anemic, and 1 percent with severe anemia. The prevalence of any anemia decreases as the age of the child increases, from 72 percent among children age 6-8 months to 21 percent among children age 48-59 months. Children in rural areas (38 percent) are more likely than children in urban areas (30 percent) to be anemic. By province, children in East and South (40 percent and 39 percent, respectively) are most likely to be anemic, while children in the city of Kigali are least likely to be anemic (31 percent). Children of mothers with no education are more likely than children of mothers with either a primary or a secondary education to be anemic (40 percent versus 36 percent). Similarly, the prevalence of anemia decreases with increasing wealth, from 41 percent among children in the lowest wealth quintile to 29 percent among those in the highest quintile. Table 11.7 Prevalence of anemia in children Percentage of children age 6-59 months classified as having anemia, by background characteristics, Rwanda 2014-15 Anemia status by hemoglobin level Background characteristic 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 children Age in months 6-8 71.7 33.4 34.2 4.1 204 9-11 61.3 24.9 36.2 0.2 212 12-17 53.3 31.1 21.3 0.9 415 18-23 35.7 20.3 14.8 0.7 371 24-35 35.2 21.6 12.9 0.7 809 36-47 27.2 16.8 9.9 0.4 840 48-59 21.4 13.4 7.7 0.4 673 Sex Male 37.3 20.7 15.7 0.9 1,779 Female 35.8 20.9 14.3 0.6 1,745 Mother's interview status Interviewed 36.7 20.6 15.4 0.7 3,242 Not interviewed but in household (36.8) (27.7) (4.9) (4.1) 29 Not interviewed and not in the household 33.8 21.8 11.5 0.5 253 Residence Urban 30.2 20.6 9.3 0.3 552 Rural 37.7 20.8 16.1 0.8 2,972 Province City of Kigali 30.6 21.0 9.3 0.4 381 South 39.3 20.3 18.0 1.0 842 West 34.5 22.0 11.5 1.0 829 North 33.6 20.9 12.4 0.2 502 East 39.7 19.9 19.0 0.8 970 Mother's education2 No education 40.2 21.8 17.3 1.1 495 Primary 36.1 19.8 15.6 0.7 2,379 Secondary and higher 36.2 24.4 11.0 0.8 396 Wealth quintile Lowest 40.8 20.9 18.5 1.3 885 Second 39.1 21.5 16.5 1.1 783 Middle 37.2 20.0 16.8 0.4 696 Fourth 32.9 20.5 12.0 0.4 596 Highest 29.4 20.8 8.5 0.1 565 Total 36.5 20.8 15.0 0.7 3,524 Note: Table is based on children who stayed in the household on the night before the interview and who were tested for anemia. Prevalence of anemia, based on hemoglobin levels, is adjusted for altitude using formulas in CDC, 1998. Hemoglobin is in grams per deciliter (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. 162 • Nutrition of Children and Adults A comparison with the 2005 RDHS shows that the prevalence of anemia has dropped by 15 percentage points in the last decade, from 52 percent to 37 percent, but the decrease between 2010 RDHS and 2014-15 RDHS was minimal (Figure 11.6 and Appendix C). The most noticeable drop has been in the prevalence of moderate anemia, with a decrease of 12 percentage points (27 percent in 2005 versus 15 percent in 2014-15). This figure was 14 percent in 2010. There have been only minimal changes in the prevalence of mild and severe anemia. Figure 11.6 Trends in anemia status among children age 6-59 months 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. In Rwanda, the provision of vitamin A supplementation and deworming tablets to children age 6-59 months and iron/folic acid tablets to mothers has been organized though campaigns; twice-yearly Mother and Child Health Week events. There is not yet an iron supplementation program targeting children. Table 11.8 shows that 74 percent of the youngest children age 6-23 months living with their mothers consumed foods rich in vitamin A the day or night preceding the interview. The proportion of children consuming vitamin A-rich foods increases with age (from 42 percent at 6-8 months to 85 percent at 18-23 months). Nonbreastfeeding children are more likely than breastfeeding children to consume foods rich in vitamin A (80 percent versus 73 percent). Consumption of foods rich in vitamin A increases with increasing mother’s age at birth, from 69 percent among children whose mothers were age 15-19 at the time they gave birth 52 22 27 2 40 23 16 <1 38 24 14 <1 37 21 15 <1 Total Mild Moderate Severe RDHS 2005 RIDHS 2007-08 RDHS 2010 RDHS 2014-15 Nutrition of Children and Adults • 163 to 78 percent among those whose mothers were age 40-49. There are also differences by area of residence; urban children are more likely to consume food rich in vitamin A (79 percent) than children living in rural areas (73 percent). With regard to provinces, children living in City of Kigali and North are most likely to consume foods rich in vitamin A (80 percent each), while those in West are least likely to do so (68 percent). As mothers’ educational level and wealth quintile increase, consumption of food rich in vitamin A among their children age 6-23 months also increases. As noted, low iron intake can contribute to anemia. Also, iron is essential for cognitive development. Iron requirements are greatest at age 6-11 months, when growth is extremely rapid. As Table 11.8 shows, 20 percent of children age 6-23 months consumed iron-rich foods in the 24 hours preceding the survey. Consumption of foods rich in iron increases from 9 percent at age 6-8 months to 24 percent at age 18-23 months. Nonbreastfeeding children are more likely than breastfeeding children to consume iron-rich foods (33 percent versus 19 percent). Furthermore, consumption of iron-rich foods is more common in urban areas (33 percent) than in rural areas (18 percent). Children in the North province are least likely to consume iron-rich foods (13 percent), while those living in City of Kigali are most likely to consume such foods (37 percent). Children whose mothers have a secondary education or higher are more likely to consume iron-rich foods (33 percent) than those whose mothers have no education (13 percent). Similarly, wealth status is directly related to consumption of foods rich in iron, with 13 percent of children in the lowest wealth quintile and 37 percent of children in the highest quintile consuming foods rich in iron in the 24 hours before the survey. The 2014-15 RDHS also collected data on vitamin A supplementation among children age 6-59 months. Table 11.8 shows that 86 percent of children age 6-59 months received vitamin A supplements in the six months preceding the survey. Infants under age 11 months are less likely than older children to have received a vitamin A supplement in the previous six months. Vitamin A supplementation does not show a clear pattern by gender, urban-rural residence, mother’s education, or wealth. Vitamin A supplementation is higher among nonbreastfeeding than breastfeeding children (89 percent versus 84 percent). At the provincial level, the proportion of children receiving vitamin A supplements is lowest in East (83 percent) and highest in North (90 percent). Infection with helminths or intestinal worms has an adverse impact on the physical development of children and is associated with high levels of iron deficiency anemia and other nutritional deficiencies. Regular treatment with deworming medication is a simple, cost-effective measure to address these infections. As Table 11.8 shows, 8 in 10 children age 6-59 months (80 percent) received deworming medication during the six months preceding the survey. The likelihood of receiving deworming medication increases with the child’s age, from 19 percent among children age 6-8 months to 90 percent or more among those age 18-59 months. It is lower among breastfeeding children (69 percent) and children whose mothers were age 15-19 at childbirth (60 percent) than among other children, and it is the same in urban and rural areas (80 percent). The proportion of children receiving deworming medication shows little variation by province, mother’s education, or household wealth. 164 • Nutrition of Children and Adults 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, and among all children age 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 2014-15 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 Background characteristic 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 42.0 9.1 474 50.1 18.5 482 99.3 440 9-11 75.1 21.9 425 75.2 38.5 434 99.7 398 12-17 81.6 23.0 793 90.3 73.3 811 99.9 721 18-23 84.6 23.7 716 92.1 90.1 769 100.0 728 24-35 na na na 90.3 90.5 1,555 99.6 1,422 36-47 na na na 89.2 90.1 1,602 99.8 1,486 48-59 na na na 89.7 90.0 1,314 99.8 1,207 Sex Male 73.4 20.7 1,196 86.5 80.5 3,487 99.7 3,204 Female 73.6 19.8 1,212 86.4 79.6 3,481 99.8 3,196 Breastfeeding status Breastfeeding 73.1 19.4 2,262 83.6 69.1 3,235 99.8 2,963 Not breastfeeding 79.5 33.3 147 88.9 89.6 3,713 99.8 3,418 Mother's age at birth 15-19 68.5 17.8 88 73.6 60.0 112 100.0 105 20-29 72.1 21.5 1,192 84.8 78.0 3,227 99.8 2,963 30-39 74.9 19.5 949 87.9 81.4 2,943 99.7 2,711 40-49 77.6 17.0 180 89.7 87.2 686 99.7 621 Residence Urban 78.7 33.4 400 83.9 80.0 1,162 99.8 1,081 Rural 72.5 17.7 2,009 86.9 80.1 5,807 99.7 5,319 Province City of Kigali 80.4 36.9 281 85.1 81.9 820 99.8 770 South 73.9 15.5 532 87.0 80.5 1,583 99.8 1,462 West 68.3 18.7 583 88.6 81.3 1,680 99.5 1,489 North 79.7 12.9 344 89.8 79.5 978 99.7 907 East 71.7 22.2 669 82.8 78.1 1,907 100.0 1,773 Mother's education No education 67.9 13.0 340 86.0 80.7 1,049 99.8 921 Primary 73.4 19.2 1,731 87.0 80.0 5,064 99.7 4,649 Secondary and higher 79.5 33.0 337 83.2 79.4 856 99.9 830 Wealth quintile Lowest 65.6 12.7 601 86.4 79.4 1,674 99.6 1,423 Second 70.8 16.0 505 85.8 78.3 1,518 99.6 1,385 Middle 74.8 18.1 469 87.8 82.1 1,390 99.9 1,287 Fourth 80.9 22.4 420 88.2 79.8 1,196 99.7 1,153 Highest 79.3 36.8 414 83.7 81.0 1,190 99.8 1,153 Total 73.5 20.3 2,409 86.4 80.1 6,969 99.7 6,400 Note: Information on vitamin A supplementation is based on both mother's recall and the immunization card (where available). Information on deworming medication is based on the mother's recall. Total includes 20 cases in which information on breastfeeding status is missing. 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, mango, papaya, and other locally grown fruits and vegetables that are rich in vitamin A, and red palm oil 2 Includes meat (and organ meat), fish, poultry, and eggs 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 4 Excludes children in households in which salt was not tested Iodine deficiency has serious effects on body growth and mental development. The principal cause of iodine deficiency is inadequate iodine in foods. Fortification of salt with iodine is the most common method of preventing iodine deficiency. According to WHO, a country’s salt iodization program is considered to be on a Nutrition of Children and Adults • 165 good track (poised to attain the goal of eliminating iodine deficiency) when 90 percent of households are using iodized salt. To assess the use of iodized salt in Rwanda, interviewers in the 2014-15 RDHS asked households to provide a teaspoon of salt used for cooking. The salt was tested for iodine using a rapid test kit. As Table 11.8 shows, nearly all children live in households that use iodized salt. 11.9 IODIZATION OF HOUSEHOLD SALT Table 11.9 shows the percentage of households with salt tested for iodine content, the percentage of households without salt, and, among households with tested salt, the percentage with iodine present in the salt. Ninety percent of households had salt tested for iodine at the time of the interview. Of these households, almost all were using iodized salt. Because the presence of iodized salt in households is almost universal, there is no major variation by background characteristics. Table 11.9 Presence of iodized salt in household Among all households, the percentage with salt tested for iodine content and the percentage with no salt in the household, and among households with salt tested, the percentage with iodized salt, according to background characteristics, Rwanda 2014-15 Among all households, the percentage Among households with tested salt: Background characteristic With salt tested With no salt in the household Number of households Percentage with iodized salt Number of households Residence Urban 90.4 9.6 2,188 99.8 1,977 Rural 90.4 9.6 10,511 99.7 9,501 Province City of Kigali 91.4 8.6 1,496 99.7 1,368 South 91.3 8.7 3,103 99.8 2,832 West 87.4 12.6 2,789 99.5 2,438 North 91.2 8.8 2,090 99.4 1,905 East 91.1 8.9 3,221 99.9 2,935 Wealth quintile Lowest 84.0 16.0 2,920 99.6 2,453 Second 90.6 9.4 2,636 99.6 2,389 Middle 92.4 7.6 2,441 99.8 2,254 Fourth 93.7 6.3 2,290 99.8 2,145 Highest 92.7 7.3 2,412 99.8 2,236 Total 90.4 9.6 12,699 99.7 11,478 11.10 NUTRITIONAL STATUS OF WOMEN Anthropometric data on height and weight were collected for interviewed women age 15-49 living in the households not selected for the men’s survey. Two indicators of nutritional status based on these data are presented in this report: body mass index (BMI) and the percentage of women of very short stature (less than 145 cm). BMI, also referred to as the Quetelet index, is used to measure thinness or obesity. BMI is defined as weight in kilograms divided by height squared in meters (kg/m2). A cutoff point of 18.5 is used to define thinness or acute undernutrition, and a BMI of 25.0 or above usually indicates overweight or obesity. The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. Low pre-pregnancy BMI and short stature are risk factors for poor birth outcomes and obstetric complications. In developing countries, maternal underweight is a leading risk factor for preventable death and diseases. A total of 6,858 women were eligible for anthropometric measurements. Table 11.10 presents the mean values for the two indicators of nutritional status and the proportions of women falling into high-risk categories, according to background characteristics. Respondents 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 height is based on 6,682 women, and the analysis of BMI is based on 6,088 women. 166 • Nutrition of Children and Adults The data show that only 3 percent of women age 15-49 in Rwanda are less than 145 cm in height. There are variations by background characteristics. Younger women are slightly more likely to be short than older women. Mothers’ educational level and wealth quintile are related to their height. Less educated women are slightly more likely to be short than educated women, and short stature decreases with increasing wealth. The mean BMI among women in Rwanda is 22.8. Analysis by background characteristics shows that the mean BMI falls in the normal range (18.5-24.9) in all background categories. At the national level, 7 percent of women are considered to be thin (BMI below 18.5); however, only 1 percent of women are considered to be moderately or severely thin (BMI below 17). The highest proportions of women with a BMI below 18.5 are observed among those age 15-19 (11 percent), those living in rural areas (7 percent), and those residing in the South (9 percent) and East (7 percent) provinces. The percentage of thin women tends to decrease with increasing education and wealth. 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 2014-15 Height Body mass index1 Background characteristic Percent- age below 145 cm Number of women Mean body mass index (BMI) 18.5-24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moder- ately 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 4.7 1,388 21.9 75.6 10.9 7.9 3.0 13.5 12.8 0.7 1,350 20-29 2.7 2,382 22.9 75.4 4.0 3.1 0.9 20.6 18.1 2.5 2,079 30-39 2.3 1,818 23.3 68.6 5.7 4.7 1.0 25.7 19.3 6.5 1,597 40-49 1.8 1,093 22.9 69.4 7.5 6.5 1.0 23.1 17.2 5.9 1,061 Residence Urban 1.8 1,325 24.2 57.7 5.5 4.2 1.3 36.8 26.4 10.4 1,218 Rural 3.2 5,357 22.4 76.3 6.8 5.4 1.4 16.8 14.8 2.1 4,870 Province City of Kigali 1.4 899 24.0 60.6 5.4 4.0 1.4 34.0 24.1 9.9 819 South 3.8 1,602 22.2 74.8 9.3 7.1 2.2 15.9 13.1 2.7 1,462 West 3.0 1,445 22.8 75.7 4.9 4.2 0.7 19.4 17.2 2.2 1,316 North 2.1 1,089 22.9 74.8 4.5 4.2 0.3 20.7 18.2 2.5 1,016 East 3.1 1,646 22.6 72.8 7.4 5.5 1.9 19.8 16.2 3.6 1,474 Education No education 3.9 800 22.5 76.1 7.8 6.9 0.8 16.1 13.6 2.6 726 Primary 3.2 4,315 22.6 74.0 6.4 5.0 1.4 19.6 16.7 2.9 3,909 Secondary and higher 1.5 1,567 23.3 67.1 6.4 4.7 1.7 26.5 20.0 6.5 1,453 Wealth quintile Lowest 5.5 1,307 21.8 79.1 10.2 7.9 2.3 10.7 10.4 0.3 1,177 Second 2.8 1,315 22.3 78.4 6.7 5.4 1.3 14.9 12.8 2.1 1,194 Middle 2.8 1,253 22.4 77.2 6.8 5.6 1.1 16.0 14.6 1.4 1,141 Fourth 2.1 1,253 22.8 72.8 4.6 3.7 0.9 22.7 20.7 2.0 1,140 Highest 1.5 1,554 24.2 58.7 5.0 3.6 1.3 36.4 25.3 11.1 1,435 Total 2.9 6,682 22.8 72.6 6.6 5.2 1.4 20.8 17.1 3.7 6,088 Note: The body mass index (BMI) 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 2 months The proportion of overweight women stands at 17 percent, and 4 percent of women are considered to be obese (BMI of 30.0 or above). The proportion of overweight or obese women is somewhat positively correlated with women’s age, increasing from 14 percent among women age 15-19 to 26 percent among women age 30-39 before declining to 23 percent among women age 40-49. Urban women are twice as likely to be overweight or obese (37 percent) as rural women (17 percent). A provincial comparison shows that the South province has the lowest proportion of overweight or obese women (16 percent), while City of Kigali has the highest proportion (34 percent).The proportion of women who are overweight or obese increases with increasing education and wealth. Nutrition of Children and Adults • 167 In terms of trends in women’s nutritional status over the past 10 years, the proportion of thin women decreased from 10 percent in 2005 to 7 percent in 2010 and 2014-15, while the proportion of overweight or obese women increased from 12 percent in 2005 to 16 percent in 2010 and 21 percent in 2014-15 (Figure 11.7). Figure 11.7 Trends in nutritional status among women age 15-49 11.11 PREVALENCE OF ANEMIA IN WOMEN The same equipment and procedures used to measure anemia in children were used to measure anemia among women in the same subsample of households. Three levels of anemia severity are distinguished: mild anemia (10.0-10.9 g/dl for pregnant women and 10.0-11.9 g/dl for non-pregnant women), moderate anemia (7.0-9.9 g/dl), and severe anemia (less than 7.0 g/dl). Table 11.11 presents anemia prevalence among women age 15-49 based on hemoglobin levels, according to selected background characteristics. Raw measured values of hemoglobin were obtained using the HemoCue instrument and adjusted for altitude and smoking status. The data show that anemia is less prevalent among women than children; 19 percent of women in Rwanda have some level of anemia, as compared with 37 percent of children. The great majority of women with anemia are mildly anemic (16 percent); 3 percent are moderately anemic, and almost none are severely anemic. As expected, the prevalence of anemia is higher among pregnant women (23 percent) than among those who are breastfeeding or neither pregnant nor breastfeeding (19 percent each). Anemia is much more prevalent among women using an IUD than among women not using this method (29 percent and 19 percent, respectively). It is also more common among the small group of women who smoke (28 percent) than among nonsmokers (19 percent). The prevalence of any anemia is slightly higher among women in rural areas (20 percent) than women in urban areas (16 percent). By province, the prevalence of anemia among women ranges from 15 percent in the city of Kigali to 23 percent in South. Anemia declines as education and wealth increase. Overall, the prevalence of anemia among women age 15-49 in Rwanda has decreased over the last decade, dropping from 26 percent in 2005 to 17 percent in 2010 before increasing slightly to 19 percent in 2014-15. This trend is observed for all three anemia severity levels (Figure 11.8 and Appendix C). 10 127 16 7 21 Thin/underweight Overweight or obese RDHS 2005 RDHS 2010 RDHS 2014-15 168 • Nutrition of Children and Adults Table 11.11 Prevalence of anemia in women Percentage of women age 15-49 with anemia, by background characteristics, Rwanda 2014-15 Anemia status by hemoglobin level Background characteristic Any anemia Mild anemia Moderate anemia Severe anemia Number of women Age 15-19 18.8 16.4 2.2 0.1 1,386 20-29 18.9 15.1 3.5 0.2 2,378 30-39 18.6 14.9 3.6 0.2 1,820 40-49 21.6 17.2 4.0 0.4 1,097 Number of children ever born 0 19.6 16.5 3.0 0.1 2,327 1 17.9 14.5 3.3 0.1 948 2-3 19.1 15.6 3.3 0.2 1,584 4-5 19.4 15.0 4.3 0.1 1,032 6+ 19.9 15.9 3.4 0.6 789 Maternity status Pregnant 23.4 14.6 8.8 0.0 491 Breastfeeding 19.3 16.0 3.1 0.2 1,858 Neither 18.7 15.7 2.9 0.2 4,331 Using IUD Yes 29.1 24.9 4.2 0.0 52 No 19.2 15.6 3.3 0.2 6,628 Smoking status Smokes cigarettes/tobacco 28.4 21.6 6.2 0.7 144 Does not smoke 19.0 15.6 3.3 0.2 6,535 Residence Urban 16.3 13.2 3.0 0.2 1,325 Rural 19.9 16.3 3.5 0.2 5,355 Province City of Kigali 14.8 11.9 2.7 0.2 900 South 22.9 17.7 5.0 0.2 1,605 West 17.9 15.7 1.9 0.3 1,442 North 15.4 13.5 1.9 0.0 1,088 East 21.8 17.2 4.3 0.2 1,646 Education No education 22.5 16.4 5.6 0.5 798 Primary 19.1 15.8 3.1 0.2 4,315 Secondary and higher 17.9 15.0 2.9 0.1 1,567 Wealth quintile Lowest 24.8 18.9 5.7 0.2 1,306 Second 20.1 16.4 3.3 0.4 1,316 Middle 18.8 16.1 2.7 0.1 1,249 Fourth 16.1 14.0 2.1 0.0 1,253 Highest 16.6 13.4 3.0 0.2 1,556 Total 19.2 15.7 3.4 0.2 6,680 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC, 1998. Women with a hemoglobin level below 7.0 g/dl have severe anemia, women with a level of 7.0-9.9 g/dl have moderate anemia, and pregnant women with a level of 10.0-10.9 g/dl and nonpregnant women with a level of 10.0-11.9 g/dl have mild anemia. Nutrition of Children and Adults • 169 Figure 11.8 Trends in anemia status among women age 15-49 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 the 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. Finally, iodine deficiency is also related to a number of adverse pregnancy outcomes. Table 11.12 includes a number of measures that are useful in assessing the extent to which women are receiving adequate intake of vitamin A and iron and the proportion of women who take deworming medication during pregnancy. Around one in two mothers (49 percent) who gave birth in the five years preceding the survey received postpartum vitamin A supplements. The proportion of mothers who received vitamin A supplements increases with age. Vitamin A supplements are slightly less common in urban areas than in rural areas (46 percent and 50 percent, respectively). More than 6 in 10 women (64 percent) residing in the North province received vitamin A supplements, as compared with about 4 in 10 women (43 and 44 percent, respectively) in the West and East provinces. Vitamin A supplementation is not related to women’s level of education or wealth. With regard to iron supplementation during pregnancy, 20 percent of women did not take iron tablets or syrup during pregnancy. Although about 8 in 10 women said they took iron tablets, 68 percent of women took iron for fewer than 60 days, Seven percent of women took iron for a period between 60-89 days and only 3 percent took iron tablets or syrup for the recommended 90 or more days. Iron intake does not vary substantially by background characteristics, although women in the East province appear to be less likely to have taken iron supplements during pregnancy than other women. Table 11.12 also shows that 49 percent of women took deworming medication during the pregnancy for their last birth. Variations by background characteristics are minor. Finally, virtually all women live in households with iodized salt, with variations by background characteristics almost nonexistent. 26 19 6 1 18 15 2 <1 17 14 3 <1 19 16 3 <1 Total Mild Moderate Severe RDHS 2005 RIDHS 2007-08 RDHS 2010 RDHS 2014-15 170 • Nutrition of Children and Adults 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, the percent distribution by number of days they took iron tablets or syrup during the pregnancy of the last child, and the percentage who took deworming medication during the pregnancy of the last child, 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 2014-15 Percentage who received vitamin A dose postpartum1 Number of days women took iron tablets or syrup during pregnancy of last birth Percentage of women 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 Background characteristic None <60 60-89 90+ Don't know/ missing Total Percentage living in households with iodized salt2 Number of women Age 15-19 38.2 30.0 61.1 6.6 2.3 0.0 100.0 40.3 151 100.0 143 20-29 45.6 21.7 66.4 7.1 3.7 1.1 100.0 48.5 2,812 99.8 2,597 30-39 52.2 18.1 70.4 7.1 3.4 1.0 100.0 51.2 2,464 99.6 2,274 40-49 58.2 20.3 67.5 8.3 2.6 1.3 100.0 47.4 633 99.7 571 Residence Urban 46.4 19.6 70.8 5.9 2.5 1.2 100.0 51.3 1,025 99.8 959 Rural 50.0 20.5 67.4 7.5 3.6 1.0 100.0 48.9 5,035 99.7 4,627 Province City of Kigali 48.9 20.3 69.3 7.4 2.1 0.9 100.0 51.2 723 99.7 683 South 53.4 16.1 70.5 8.1 4.5 0.8 100.0 53.1 1,406 99.8 1,297 West 43.4 22.9 68.3 4.6 2.6 1.7 100.0 51.1 1,365 99.5 1,214 North 63.7 9.9 70.8 11.7 6.6 0.9 100.0 51.2 885 99.5 823 East 43.6 27.2 63.5 6.2 2.2 0.9 100.0 42.9 1,682 99.9 1,569 Education No education 49.2 20.1 68.9 7.2 3.1 0.6 100.0 46.8 881 99.5 782 Primary 49.9 20.0 68.0 7.5 3.4 1.1 100.0 49.8 4,360 99.7 4,013 Secondary and higher 47.0 22.3 67.0 5.5 3.9 1.3 100.0 49.1 819 99.9 791 Wealth quintile Lowest 49.0 21.3 68.0 6.6 3.1 1.0 100.0 47.7 1,432 99.5 1,227 Second 48.1 20.3 67.0 7.9 3.6 1.2 100.0 49.5 1,306 99.7 1,196 Middle 51.2 18.9 70.9 6.1 3.1 1.0 100.0 47.3 1,195 99.9 1,115 Fourth 50.8 20.8 64.9 9.0 4.2 1.1 100.0 50.2 1,072 99.8 1,029 Highest 48.2 20.1 69.0 6.7 3.3 0.9 100.0 52.6 1,055 99.8 1,019 Total 49.4 20.3 68.0 7.2 3.4 1.0 100.0 49.3 6,060 99.7 5,586 1 In the first two months after delivery of last birth 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 6,180 men age 15-59. Overall, 13 percent of men 15-49 are underweight or thin (BMI less than 18.5 kg/m2), about twice the percentage of underweight women (7 percent). Six percent of men are overweight (BMI 25.0 kg/m2 or higher) and less than one percent are obese (BMI ≥ 30.0). Obesity in women is more than 9 times higher than in men . The highest proportions of men with a BMI below 18.5 are observed among those age 15-19 (30 percent), those living in rural areas (14 percent), and those residing in the South province (20 percent) and those with secondary and higher education (15 percent). The percentage of thin men tends to decrease with increasing wealth. As would be expected, the percentage of overweight is higher among men in urban areas (10 percent) than among those in rural areas (5 percent). Comparisons across provinces show that the City of Kigali has the highest percentage of overweight men (10 percent), whereas the South has the lowest (3 percent). The Nutrition of Children and Adults • 171 percentage of overweight increases progressively with wealth quintile from 2 percent in the lowest quintile to 5 percent in the fourth quintile and peaks to 12 percent in the highest wealth 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 2014-15 Body Mass Index Background characteristic Mean Body Mass Index (BMI) 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17 (Moder- ately 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 19.7 68.9 30.1 20.7 9.4 1.0 1.0 0.0 1,277 20-29 21.5 89.2 5.6 4.9 0.7 5.2 5.0 0.2 1,928 30-39 21.6 81.7 8.4 7.4 1.1 9.8 8.9 0.9 1,481 40-49 21.3 78.6 11.6 9.1 2.5 9.8 9.2 0.7 856 Residence Urban 21.7 77.8 10.8 7.8 3.0 11.4 10.1 1.4 1,157 Rural 20.9 81.7 13.5 10.4 3.1 4.8 4.6 0.1 4,385 Province City of Kigali 21.5 76.6 12.4 9.1 3.3 11.0 9.6 1.4 794 South 20.4 77.3 19.7 14.7 5.0 3.0 2.9 0.1 1,321 West 21.6 84.3 8.2 6.2 2.0 7.5 7.3 0.3 1,171 North 21.4 83.8 9.6 7.8 1.7 6.6 6.2 0.4 848 East 20.8 82.0 12.9 10.0 2.9 5.1 4.8 0.3 1,408 Education No education 21.2 86.6 8.7 6.2 2.4 4.7 4.7 0.0 492 Primary 21.0 81.9 12.8 9.7 3.1 5.3 4.9 0.4 3,618 Secondary and higher 21.2 76.2 14.8 11.4 3.4 9.0 8.3 0.7 1,431 Wealth quintile Lowest 20.7 83.6 14.2 11.2 3.0 2.2 2.1 0.1 812 Second 20.8 82.4 13.8 10.2 3.6 3.8 3.6 0.2 989 Middle 20.8 82.5 13.6 10.5 3.1 3.9 3.9 0.0 1,092 Fourth 20.9 81.3 13.7 9.8 3.9 5.0 4.8 0.2 1,228 Highest 21.8 76.7 10.4 8.4 2.1 12.9 11.7 1.2 1,421 Total 15-49 21.1 80.9 12.9 9.8 3.1 6.2 5.8 0.4 5,542 50-59 20.8 74.8 18.3 13.2 5.1 6.9 6.2 0.7 638 Total 15-59 21.1 80.3 13.5 10.2 3.3 6.3 5.8 0.4 6,180 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). Malaria • 173 MALARIA 12 alaria has been a major cause of morbidity and mortality in Rwanda for several years, with periodic epidemics in high-altitude areas. Rwanda has achieved significant reductions in the burden of malaria over the past decade (Otten M. et al. 2009 and Karema C. et al. 2012). Evidence of progress in malaria control provided by Rwanda Health Information Management System (HMIS) include an 86 percent decline in malaria incidence between 2005 and 2011; 87 percent decline in outpatient malaria cases between 2005 and 2011; 74 percent decline in inpatient malaria deaths between 2005 and 2011; and 71 percent decline in malaria test positivity rate (TPR) between 2005 and 2011 (Rwanda HMIS, 2012). According to the 2010 RDHS, malaria prevalence has decreased from 2.6 percent in 2008 to 1.4 percent in 2010 in children < 5 years and a decline from 1.4 percent in 2008 to 0.7 percent in 2010 of malaria prevalence in pregnant women. The success of malaria control in Rwanda has been acknowledged internationally as a result of the country’s strong leadership and vision, evidence-based implementation of malaria control interventions, and coordinated partnerships through the government’s malaria control strategy. For the past years, Rwanda has continued to implement key malaria control interventions based on evidence, which included: • Early diagnosis and prompt and effective treatment reaching universal malaria parasitological diagnosis and treatment coverage both at health facility level and community level using 30,000 CHWs. As a result in 2015, 99 percent of all suspected malaria cases were tested before treatment as compared to 56 M Key Findings • Eighty-one percent of households own at least one insecticide-treated mosquito net (ITN). • Forty-three percent of households have at least one ITN for every two people staying in the same house in the night preceding the survey. • Sixty-two percent of the household population slept under ITN the night before the survey. • Sixty-eight percent of children under age 5 slept under ITN the night before the survey; while 73 percent of pregnant women slept under ITN the night before the survey. • Nineteen percent of children who had fever in the two weeks preceding the survey; among them 57 percent sought for advice or treatment. • Thirty-six percent of children with a fever had blood taken for testing • Ninety nine percent of children who received antimalarial drugs for fever were given ACT. • Among children with a fever and took antimalarial drugs, two-thirds took antimalarial drugs the same day or the day after the fever started. • Malaria prevalence is 2 percent among children age 6-59 months and 0.6 percent among women age 15-49. • Two percent of children age 6-59 months has hemoglobin lower than 8.0 g/dl. 174 • Malaria percent in 2009 and 96 percent of children under with malaria were tested using RDTs and treated with ACTs within 24 hours while only 62 percent were treated in 2008 (Ministry of Health, 2016). • Prevention using LLINs distribution: The mainstay of vector control in Rwanda is universal coverage with long-lasting insecticidal nets (LLINs) targeting the entire population in the country Rwanda has achieved universal coverage of LLINs in 2010 resulting with over 75 percent decline in malaria cases, inpatients and deaths. Thus since 2012 more than 10 million LLINs were distributed. The 2014-2015 DHS shows 83 percent of household ownership of at least one LLIN while the RMIS 2013 showed an ownership of 84 percent. Sixty-eight percent of children under 5 and 70 percent and pregnant women slept under a mosquito net the night before the survey. Only, 61.5 percent of household population slept under a mosquito net. • Prevention using IRS: Indoor residual spraying (IRS) was initiated in 2007 in high transmission areas located in 3 districts: Gisagara, Bugesera and Nyagatare. The latest IRS campaign conducted in 2015 and resulted with an estimated coverage of 97.8 percent (243,952 structures targeted). Rwanda is also implementing integrated vector management (IVM) and insecticide resistance mitigation strategy that will improve ecological soundness and cost-effectiveness of interventions for rational decision. • Behavior Change communication (BCC): several interventions have been implemented in Rwanda including radio, TV shows and several community mobilizations. This has resulted in a significant increase of the knowledge and practice of malaria related behavior. This strategy contributed to the achievement of the Millennium Development Goals as set forth in the Vision 2020 strategic plan for the national health sector. However, since 2012 Rwanda is facing an increase of malaria cases reaching more than 2 million with a malaria morbidity of 18.3 percent in 2015 (Ministry of Health, 2016). Although malaria cases has been increasing, malaria mortality trends have not been at the same path given mortality remained constant with 5 percent in 2015 (Ministry of Health, 2016). which may be attributed to efficacious antimalarial drug in use in Rwanda malaria treatment guidelines as well as increased access to health care including prompt malaria testing and treatment. The increase of malaria burden is attributable to several factors such as vectors densities, parasites, climate (temperature, rainfall), environmental modification, human behavior and health system and effective interventions coverage. It also important to note that malaria has been increasing in the eastern region, thus it will be challenging for Rwanda to control malaria while trans-border exchanges are intense. While it is difficult to nail down specifics causes of malaria increase, analysis are showing that main contributing factors to malaria increase in Rwanda may be: Significant drop of effective LLINs coverage at community level given that since 2010-2011 Rwanda has not been able to maintain that level of population coverage of effective LLINs because there has not been a countrywide LLINs distribution given that replacement were only done in targeted districts located in high malaria burden districts based on LLINs availability. LLINs replacement were not done based on LLINs needs and LLINs efficacy duration of 2 years as seen in the monitoring of LLINs durability and efficacy due to significant delay in procurement and gap in malaria funding (Hakizimana et al. 2014). Mosquitos resistance to pyrethroids (insecticide): Vector control in Rwanda is highly dependent on the use of pyrethroids, which are the only class of insecticides currently recommended for ITNs or LLINs. In most of the sentinel site monitoring insecticide resistance, resistance to insecticides of pyrethroid family used for public health has been detected. The Malaria & OPD Division in RBC-Ministry of Health has made the monitoring and Malaria • 175 prevention of the spread of insecticide resistance as a priority. The level pyrethroid resistance in 14 sites that have been tracked for the past 5 years and shown 77 percent resistance to pyrethroid insecticide (Ministry of Health 2015). Climatic anomalies: The most important climatic factors that directly affect malaria transmission are temperature, rainfall. Trends of temperature increase and rainfall anomalies in Rwanda have indicated similar patterns with increase of malaria cases showing that there may be a correlation. In order to overcome this malaria increase, the government of Rwanda is currently implementing the Rwanda Malaria Contingency Strategy containing key malaria control intervention and multisectorial approach to fight against malaria. 12.1 MOSQUITO NETS Use of Long Lasting Insectsidal treated Nets (LLINs) is the primary prevention strategy for reducing malaria transmission in Rwanda. Since 2006, the insecticide-treated mosquito net policy has included free distribution of treated nets to all children under age 5 every three years during vaccination campaigns or maternal and child health weeks, to pregnant women at their first visit to an antenatal care (ANC) clinic, and 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 LLIN per two persons through household campaigns. To increase coverage, timely mass net distribution campaigns are conducted. Since 2005, Rwanda has been moving to the use of LLINs, which are heavy duty and pretreated and are longer lasting than the older insecticide-treated nets (ITNs). This section presents the 2014-15 RDHS household-level findings on ownership and use of mosquito nets, particularly among children under age 5 and pregnant women. 12.1.1 Ownership of Mosquito Nets All household respondents in the 2014-15 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 8 in 10 households (81 percent) owned at least one mosquito net, at least one ITN, or at least one LLIN (81 percent each). More than 4 in 10 households (43 percent) had at least one LLIN for every two household members. Overall, the average number of ITNs and LLINs per household was 1.6, as was the average number of any type of mosquito net. This indicates that practically all of the mosquito nets owned by households in Rwanda are LLINs. The proportion of households owning at least one ITN varied only slightly by area of residence (82 percent in urban areas versus 80 percent in rural areas). By province, household ownership of ITNs was highest in City of Kigali (86 percent) and lowest in West (69 percent). Wealthier households are slightly more likely to own mosquito nets. Eighty-nine percent of households in the two highest wealth quintiles owned an ITN, as compared with 66 percent of households in the lowest quintile. A comparison of the data from the 2010 and 2014-15 RDHS surveys shows no real change in ITN ownership (82 percent in 2010 and 81 percent in 2014-15). Although there have been some changes by province, ownership of mosquito nets continues to be highest in City of Kigali, East, and South, given that for the past LLIN have been prioritized high malaria burden district located in East and South province. 176 • Malaria Table 12.1 Household possession of mosquito nets Percentage of households with at least one mosquito net (treated or untreated), insecticide-treated net (ITN), and long-lasting insecticidal net (LLIN); average number of nets, ITNs, and LLINs per household; and percentage of households with at least one net, ITN, and LLIN per two persons who stayed in the household last night, by background characteristics, Rwanda 2014-15 Percentage of households with at least one mosquito net Average number of nets per household Number of households Percentage of households with at least one net for every two persons who stayed in the household last night1 Number of households with at least one person who stayed in the household last night Background characteristic Any mosquito net Insecticide- treated mosquito net (ITN)2 Long- lasting insecti- cidal net (LLIN) Any mosquito net Insecticide- treated mosquito net (ITN)2 Long- lasting insecti- cidal net (LLIN) Any mosquito net Insecticide- treated mosquito net (ITN)2 Long- lasting insecti- cidal net (LLIN) Residence Urban 82.3 81.9 81.8 1.9 1.9 1.9 2,188 53.8 53.4 53.3 2,184 Rural 80.5 80.3 80.3 1.6 1.6 1.5 10,511 40.5 40.3 40.3 10,494 Province City of Kigali 86.4 86.0 85.9 1.9 1.9 1.9 1,496 55.4 55.0 54.8 1,495 South 85.2 85.2 85.2 1.7 1.7 1.7 3,103 45.4 45.1 45.1 3,097 West 69.0 68.8 68.6 1.3 1.3 1.3 2,789 33.0 32.8 32.8 2,787 North 79.3 78.9 78.8 1.6 1.6 1.6 2,090 43.6 43.2 43.2 2,081 East 85.1 85.1 85.1 1.6 1.6 1.6 3,221 42.4 42.4 42.4 3,219 Wealth quintile Lowest 65.6 65.5 65.4 1.0 1.0 1.0 2,920 30.7 30.7 30.6 2,911 Second 78.4 78.2 78.2 1.4 1.4 1.4 2,636 37.4 37.1 37.1 2,635 Middle 85.3 85.2 85.1 1.7 1.7 1.7 2,441 43.1 42.9 42.9 2,440 Fourth 89.4 89.2 89.2 1.9 1.9 1.9 2,290 45.5 45.3 45.3 2,287 Highest 89.1 88.8 88.6 2.2 2.2 2.2 2,412 60.4 60.1 59.9 2,405 Total 80.8 80.6 80.6 1.6 1.6 1.6 12,699 42.8 42.6 42.5 12,678 1 De facto household members 2 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. Figure 12.1 shows the percentage of the de facto population with access to an ITN in the household. Overall, 64 percent of the population could sleep under an ITN if each ITN were used by up to two people. Access to a mosquito net is higher in urban areas (71 percent) than in rural areas (62 percent). By province, those in City of Kigali are most likely to have access to an ITN. Access to an ITN increases with increasing wealth quintiles. Figure 12.1 Percentage of de facto population with access to an ITN in the household 71 62 75 67 52 63 66 48 58 65 70 78 64 1Residence Urban Rural Province Kigali City South West North East Wealth quintile Lowest Second Middle Fourth Highest Total 0 10 20 30 40 50 60 70 80 90 100 Malaria • 177 Table 12.2 presents the distribution of the de facto household population by the number of ITNs the household owns. Seventeen percent of households did not have a mosquito net. Almost one third of households had two mosquito nets (32 percent), 23 percent had one net and 20 percent had 3 mosquito nets. In total, 64 percent of the de facto population has access to an ITN. Table 12.2 Access to an insecticide-treated net (ITN) Percent distribution of the de facto household population by number of ITNs the household owns, according to number of persons who stayed in the household the night before the survey, Rwanda 2014-15 Number of persons who stayed in the household the night before the survey Total Number of ITNs 1 2 3 4 5 6 7 8+ 0 35.8 26.1 18.4 17.3 16.7 15.9 14.2 12.8 17.0 1 49.2 41.9 39.3 27.1 19.6 15.9 17.2 10.8 23.3 2 12.7 26.9 31.2 38.5 40.3 34.4 26.6 20.7 32.1 3 1.6 4.0 9.5 13.7 17.5 24.7 29.8 33.6 19.6 4 0.6 0.8 1.2 2.7 4.8 6.3 8.3 13.7 5.5 5 0.2 0.2 0.2 0.5 1.0 1.9 2.8 5.9 1.8 6 0.0 0.0 0.1 0.2 0.1 0.8 1.0 2.2 0.6 7+ 0.0 0.0 0.0 0.0 0.0 0.1 0.2 0.4 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,043 3,188 7,069 9,719 9,855 8,971 6,565 7,432 53,844 Percent with access to an ITN1 64.2 73.9 68.5 69.1 63.5 62.0 57.9 56.0 63.8 1 Percentage of the de facto household population who could sleep under an ITN if each ITN in the household were used by up to two people 12.1.2 Use of Mosquito Nets by Persons in the Household Table 12.3 shows that 62 percent of the household population slept under any net the night before the survey, while 61 percent slept under an ITN. Seventy-four percent of members of households with at least one ITN slept under an ITN the night before the survey. Children age 5-14, rural residents, and those in the lower wealth quintiles were somewhat less likely than their counterparts to sleep under a mosquito net. Also, the proportion of the population that slept under an ITN the night before the survey is relatively low in the West province (50 percent). 178 • Malaria Table 12.3 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), 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 2014-15 Household population Household population in households with at least one ITN1 Background characteristic 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 (in years) <5 67.9 67.7 67.7 7,932 80.3 6,692 5-14 51.5 51.3 51.2 15,338 62.1 12,672 15-34 61.5 61.4 61.3 18,093 74.1 14,979 35-49 72.4 72.1 72.0 6,683 85.9 5,607 50+ 67.8 67.5 67.5 5,795 82.5 4,745 Sex Male 59.5 59.3 59.3 25,415 72.0 20,951 Female 63.5 63.3 63.2 28,427 75.8 23,744 Residence Urban 69.5 69.2 69.1 9,064 80.7 7,773 Rural 60.0 59.8 59.8 44,780 72.6 36,923 Province City of Kigali 75.0 74.6 74.5 6,038 82.1 5,489 South 66.3 66.2 66.2 13,075 76.3 11,343 West 50.2 50.1 50.0 12,316 70.5 8,755 North 56.0 55.8 55.7 8,724 68.4 7,114 East 64.9 64.8 64.8 13,690 74.0 11,995 Wealth quintile Lowest 47.3 47.2 47.2 10,737 70.0 7,250 Second 55.8 55.7 55.7 10,758 70.7 8,472 Middle 62.7 62.5 62.5 10,743 72.6 9,248 Fourth 68.1 68.0 68.0 10,757 74.9 9,765 Highest 73.9 73.6 73.5 10,849 80.1 9,960 Total 61.6 61.4 61.4 53,844 74.0 44,696 Note: Total includes cases where information on age (4 cases) and on sex (1 case) of the household member is missing. 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. Table 12.4 presents data on the use of existing ITNs. The results show that 77 percent of the ITNs owned by households were used the night before the survey. This proportion was higher in urban areas (81 percent) than in rural areas (76 percent). By province, City of Kigali has the highest level of ITN use (82 percent), while North has the lowest (71 percent). ITN use increases slightly with increasing wealth. 12.1.3 Use of Mosquito Nets by Children under Age 5 Children under age 5 are most vulnerable to severe complications of malarial infection due to their low immunity. Table 12.5 shows the use of mosquito nets by children under age 5. Sixty-eight percent of children under age 5 slept under a mosquito net the night before the survey. However, in households with at least one ITN, 80 percent of children slept under an ITN the night before the survey. The percentage of children Table 12.4 Use of existing ITNs Percentage of insecticide-treated nets (ITNs) that were used by anyone the night before the survey, by background characteristics, Rwanda 2014-15 Background characteristic Percentage of existing ITNs1 used last night Number of ITNs1 Residence Urban 81.4 4,097 Rural 76.4 16,292 Province City of Kigali 82.3 2,852 South 78.7 5,209 West 75.6 3,746 North 70.9 3,355 East 78.9 5,227 Wealth quintile Lowest 74.7 2,979 Second 75.2 3,576 Middle 76.9 4,055 Fourth 78.6 4,400 Highest 79.7 5,380 Total 77.4 20,389 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. Malaria • 179 who slept under any net, an ITN, or an LLIN decreases with age, from 72 percent among those less than age 1 to 60 percent among those age 4. Table 12.5 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), and under a long-lasting insecticidal net (LLIN), 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 2014-15 Children under age 5 in all households Children under age 5 in households with at least one ITN1 Background characteristic 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 years) <1 72.2 72.0 72.0 1,647 84.7 1,401 1 71.6 71.5 71.5 1,602 83.8 1,367 2 69.1 69.0 69.0 1,596 82.7 1,331 3 65.5 65.4 65.4 1,668 77.3 1,411 4 59.9 59.8 59.8 1,418 71.8 1,181 Sex Male 67.7 67.5 67.5 3,977 80.1 3,351 Female 68.0 67.9 67.9 3,954 80.4 3,339 Residence Urban 77.9 77.9 77.9 1,283 87.3 1,145 Rural 65.9 65.8 65.8 6,648 78.8 5,547 Province City of Kigali 81.4 81.4 81.4 906 86.7 851 South 72.0 71.8 71.8 1,821 82.2 1,590 West 57.2 57.2 57.1 1,903 77.6 1,403 North 62.2 61.8 61.8 1,123 74.9 926 East 71.0 71.0 71.0 2,177 80.4 1,921 Wealth quintile Lowest 53.5 53.4 53.4 1,907 75.9 1,341 Second 62.6 62.5 62.5 1,733 77.2 1,403 Middle 70.6 70.5 70.5 1,578 80.0 1,392 Fourth 76.4 76.2 76.2 1,389 81.8 1,294 Highest 83.1 83.0 83.0 1,325 87.2 1,262 Total 67.9 67.7 67.7 7,932 80.3 6,692 Note: Table is based on children who stayed in the household the night before the interview. Total includes 1 case where information on sex is missing. 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 use of mosquito nets among children. Children in urban areas are more likely to use ITNs (78 percent) than those in rural areas (66 percent). Additionally, mosquito net use among children increases strongly with increasing wealth from 53 percent in the lowest quintile to 83 percent in the highest wealth quintile. Mosquito net usage among children under age 5 was slightly higher in the 2010 RDHS (70 percent) than in the 2014-15 RDHS (68 percent). 12.1.4 Use of Mosquito Nets by Pregnant Women To prevent complications from malaria during pregnancy, such as anemia, low birth weight, and transplacental parasitemia, all pregnant women are encouraged to sleep under ITNs. Table 12.6 shows that 73 percent of pregnant women age 15 to 49 slept under any net the night before the survey; there is no change as compared with 2010 RDHS. 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 who slept under any net. Use of any net was higher among pregnant women in urban (78 percent) than rural (72 percent) areas. Among pregnant women in households with at least one ITN, 88 percent slept 180 • Malaria under an ITN the night preceding the survey; in these households, more urban (92 percent) than rural (87 percent) women slept under an ITN. Pregnant women with no education were less likely to have slept under a mosquito net the night before the survey (62 percent) than those with a primary education (72 percent) or a secondary education or higher (85 percent). Women in the highest three wealth quintiles were more likely to have slept under an ITN (81 to 87 percent) than those in the lowest two quintiles (52 to 62 percent). Table 12.6 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 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 2014-15 Among pregnant women age 15-49 in all households Among pregnant women age 15-49 in households with at least one ITN1 Background characteristic 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 78.3 77.5 77.5 172 91.7 145 Rural 71.9 71.9 71.9 806 86.8 667 Province City of Kigali 84.1 82.9 82.9 123 91.8 112 South 74.4 74.4 74.4 222 86.6 190 West 67.2 67.2 67.2 219 86.8 169 North 64.6 64.6 64.6 138 83.2 107 East 75.8 75.8 75.8 276 89.5 234 Education No education 62.4 62.4 62.4 109 85.7 79 Primary 71.7 71.7 71.7 687 86.9 567 Secondary and higher 84.6 83.8 83.8 181 91.4 166 Wealth quintile Lowest 52.2 52.2 52.2 197 77.5 133 Second 62.0 62.0 62.0 202 81.2 154 Middle 80.6 80.6 80.6 206 92.0 181 Fourth 87.0 87.0 87.0 185 92.6 174 Highest 84.7 83.9 83.9 188 92.0 171 Total 73.0 72.9 72.9 977 87.7 812 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. 12.2 PREVALENCE AND PROMPT TREATMENT OF FEVER Malaria case management, including 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, ACT (commonly known as Coartem) has been widely available in public health and faith-based facilities, as well as in the community (Primo) via community health workers and private pharmacies. In December 2009, the National Malaria Control Program (currently Malaria and OPD Division-RBC) 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) and have reached 99 percent in 2014 (Rwanda HMIS, 2014). Table 12.7 shows that 19 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 (24 percent) than among other children. Malaria • 181 Children in the North province were slightly less likely to have experienced fever (14 percent) than those in the other provinces (16 percent or higher). Table 12.7 Prevalence, diagnosis, and prompt treatment of children with fever Percentage of children under age 5 with a fever in the two weeks preceding the survey, and among children under age 5 with a fever, the percentage for whom advice or treatment was sought, the percentage who had blood taken from a finger or heel, the percentage who took any artemisinin-based combination therapy (ACT), the percentage who took ACT the same or next day following the onset of fever, the percentage who took antimalarial drugs, and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, Rwanda 2014-15 Among children under age 5: Among children under age 5 with fever: Background characteristic Percentage with fever in the two weeks preceding the survey Number of children Percentage for whom advice or treatment was sought1 Percentage who had blood taken from a finger or heel for testing Percentage who took any ACT Percentage who took any ACT same or next day Percentage who took antimalarial drugs Percentage who took antimalarial drugs same or next day Number of children Age (in months) <12 17.4 1,641 57.6 32.5 4.6 3.6 4.6 3.6 286 12-23 24.0 1,581 55.8 36.6 8.3 5.0 8.3 5.0 380 24-35 20.2 1,555 59.7 35.9 11.6 7.6 11.9 7.6 313 36-47 17.3 1,602 55.4 37.9 17.9 12.5 17.9 12.7 277 48-59 14.1 1,314 54.3 37.9 16.7 10.4 17.3 10.4 186 Sex Male 18.1 3,857 58.8 36.9 10.6 6.6 10.9 6.8 698 Female 19.4 3,837 54.7 35.2 11.7 8.1 11.7 8.1 744 Residence Urban 16.8 1,303 66.3 43.2 6.2 5.4 6.2 5.4 218 Rural 19.1 6,391 55.0 34.8 12.1 7.8 12.3 7.8 1,223 Province City of Kigali 16.4 921 70.3 48.7 6.6 5.6 6.6 5.6 151 South 21.2 1,756 49.3 34.7 12.0 6.9 12.6 7.1 372 West 17.0 1,842 47.8 28.6 6.0 3.3 6.0 3.3 314 North 14.2 1,071 57.8 22.5 0.9 0.9 0.9 0.9 152 East 21.5 2,103 64.1 42.7 19.2 13.4 19.2 13.4 453 Mother’s education No education 16.9 1,125 48.8 34.6 11.6 6.1 11.6 6.1 190 Primary 19.6 5,583 55.9 35.2 11.7 8.0 11.9 8.1 1,095 Secondary and higher 16.0 985 72.1 43.7 7.4 5.0 7.4 5.0 157 Wealth quintile Lowest 20.0 1,834 45.6 27.8 11.0 5.2 11.0 5.2 366 Second 19.1 1,670 54.4 34.3 13.2 8.9 13.2 9.2 318 Middle 20.1 1,524 58.1 38.1 14.4 10.6 15.1 10.6 306 Fourth 17.8 1,331 63.1 38.9 9.2 7.6 9.2 7.6 237 Highest 16.0 1,335 70.2 46.7 6.1 4.1 6.1 4.1 214 Total 18.7 7,694 56.7 36.1 11.2 7.4 11.4 7.5 1,442 1 Excludes market and traditional practitioner Among children under age 5 with a fever, 57 percent were taken for advice or treatment. Treatment seeking was more common for urban children, especially those in the City of Kigali. The proportion of children with a fever for whom advice or treatment is sought increases with increasing mother’s education and wealth. Thirty-six percent of children with a fever had blood taken from a finger or heel for testing. The percentage of children who had blood taken from a finger or heel for testing was highest among those in urban areas (43 percent) and the City of Kigali, and those in the highest wealth quintile (49 percent each) , and those whose mothers had a secondary education or higher (44 percent). 182 • Malaria Eleven percent of children under age 5 with a fever took antimalarial drugs, while 8 percent of children with fever took antimalarial drugs the same day or the day after the fever started. Among children who took antimalarial drugs, almost all of them took ACT. 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. There are large differences in fever treatment by province; children in North are far less likely to take antimalarial drugs than children in East (1 percent and 19 percent, respectively). Table 12.8 shows the source of advice or treatment for children with fever. Children with a fever are most likely to be taken to public health facility sources for advice or treatment (46 percent), followed by private health facility (10 percent) and other (4 percent) sources. Health centers serve almost one-third of children with a fever (31 percent), while community health workers receive 13 percent of cases. In the private sector, 7 percent of children with a fever are treated in a pharmacy (presumably to buy medicine). Looking only at children who received treatment for their fever, the distribution is similar, with a majority receiving help from a health center. In line with the malaria treatment policy of the National Malaria Control Program, antimalarial medicines are given to children only after the presence of malaria parasites is confirmed by microscopy or a rapid diagnostic test. As shown in Table 12.9, Coartem is the most common antimalarial drug taken by children under age 5 with a fever (50 percent). It is closely followed by Primo, taken by 48 percent of children who were given an antimalarial drug. Quinine was taken by only 1 percent of children given an antimalarial drug. Thus, 99 percent of children who received antimalarial drugs for fever were given ACT. 12.3 PREVALENCE OF ANEMIA AND MALARIA IN CHILDREN AND WOMEN One of the objectives of the 2014-15 RDHS was to assess anemia prevalence in children age 6-59 months and women age 15-49. Table 11.7 in Chapter 11 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 result in anemia. According to the national guidelines for the management of malaria in Rwanda, a hemoglobin concentration of less than 8.0 g/dl is considered an indication that an individual may have malaria. Table 12.8 Source of advice or treatment for children with fever Percentage of children under age 5 with a fever in the two weeks preceding the survey for whom advice or treatment was sought from specific sources, and among children under age 5 with a fever in the two weeks preceding the survey for whom advice or treatment was sought, the percentage for whom advice or treatment was sought from specific sources, by background characteristics, Rwanda 2014-15 Percentage for whom advice or treatment was sought from each source: Background characteristic Among children with fever Among children with fever for whom advice or treatment was sought Any public sector source 46.0 79.3 Referral hospital 0.0 0.1 Provincial/district hospital 1.4 2.4 Health center 30.7 52.8 Health post 3.3 5.8 Community health worker 12.6 21.7 Any private sector source 10.0 17.3 Clinic 0.8 1.4 Pharmacy 6.8 11.8 Polyclinic 0.4 0.7 Dispensary 2.0 3.5 Any other source 3.5 6.1 Kiosk/shop 0.2 0.4 Traditional practitioner 1.6 2.8 Church 0.1 0.1 Friend/relative 1.3 2.2 Other 0.4 0.7 Number of children 1,442 837 Table 12.9 Type of antimalarial drugs taken by children who took antimalarial drugs Among children under age 5 with a fever in the two weeks preceding the survey who took any antimalarial medication, the percentage who took specific antimalarial drugs, Rwanda 2014-15 Antimalarial drug Percent Quinine 1.2 Coartem1 50.4 Primo1 48.3 Other 1.8 Number of children who took any antimalarial drug 164 1 Artemisinin combination therapy (ACT) Malaria • 183 Table 12.10 shows that only 2 percent of children age 6-59 months have a hemoglobin level lower than 8.0 g/dl. Children under age 18 months have higher levels of anemia, ranging from 4 percent among those age 9-17 months to 8 percent among those age 6-8 months. The proportion of children with a hemoglobin level below 8 g/dl decreases with increasing wealth. Table 12.10 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 2014-15 Background characteristic Percentage with Hemoglobin <8.0 g/dl Number of children Age (in months) 6-8 7.7 204 9-11 3.8 212 12-17 4.0 415 18-23 1.6 371 24-35 1.7 809 36-47 1.8 840 48-59 1.1 673 Sex Male 2.9 1,779 Female 1.7 1,745 Mother’s interview status Interviewed 2.3 3,242 Not interviewed but in household (4.1) 29 Not interviewed and not in the household1 2.0 253 Residence Urban 0.6 552 Rural 2.7 2,972 Province City of Kigali 0.7 381 South 4.0 842 West 2.0 829 North 0.8 502 East 2.6 970 Mother’s education2 No education 3.4 495 Primary 2.1 2,379 Secondary and higher 2.9 330 Wealth quintile Lowest 4.4 885 Second 2.4 783 Middle 1.7 696 Fourth 1.1 596 Highest 1.1 565 Total 2.3 3,524 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 deciliter (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. As part of the survey, a malaria microscopy test was performed among children age 6-59 months whose parent or guardian provided consent, with the aim of estimating the prevalence of malaria in this age group. A rapid diagnostic test (First Response Malaria Ag pLDH/HRP2) was also conducted among the same children. For the Rapid Diagnostic Test (RDT), a drop of blood was obtained by a prick at the end of the finger (except for infants, for whom the sample was taken from under the heel). The test was done according to manufacturer recommendations. Because the Ministry of Health has instituted a policy expanding the use of malaria rapid diagnostic tests in conjunction with the use of ACT (a fixed-dose combination antimalarial treatment) for 184 • Malaria primary treatment of uncomplicated malaria, the results from the RDTs were used to diagnose malaria and guide treatment of parasitemic children during the survey. Parents or guardians of children with a positive RDT were told the results and asked about current treatment; they were also asked to provide their consent for malaria treatment. If consent was provided, the children were immediately given artemisinin-based combination antimalarial treatment (Coartem or Primo) according to the malaria treatment guidelines. Table 12.11 shows that 99 percent of children eligible for malaria testing were tested using a thick blood smear that was examined in the parasitology and entomology laboratory (microscopy). Only children age 6-8 months had relatively low coverage rates, presumably because parents are reluctant to allow a blood sample to be taken from such young children. Table 12.11 Coverage of malaria testing among children Percentage of children age 6-59 months eligible for microscopic tests, according to background characteristics (unweighted), Rwanda 2014-15 Background characteristic Blood smear tested Number of children Age (in months) 6-8 92.9 212 9-11 100.0 215 12-17 99.8 409 18-23 99.7 370 24-35 99.9 806 36-47 99.3 842 48-59 100.0 675 Sex Male 99.5 1,795 Female 99.1 1,734 Mother’s interview status Interviewed 99.7 3,102 Not interviewed but in household 96.5 426 Not interviewed and not in the household1 100.0 1 Residence Urban 98.8 737 Rural 99.5 2,792 Province City of Kigali 98.7 397 South 99.2 906 West 99.5 858 North 98.8 500 East 99.8 868 Mother’s education2 No education 100.0 481 Primary 99.4 2,360 Secondary and higher 98.1 431 Missing 99.6 256 Wealth quintile Lowest 99.3 879 Second 99.9 742 Middle 99.3 668 Fourth 99.5 587 Highest 98.6 653 Total 99.3 3,529 Note: Table is based on children who stayed in the household the night before the interview. 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 12.12 shows the results of the microscopic diagnostic test (blood smear) among children who were tested. Nationally, 2 percent of children age 6-59 months are infected with at least one form of malarial parasites. Children age 48-59 months are most likely to have malaria (3 percent), while those age 9-11 months are least likely. The proportion of children with malaria is higher in rural areas than in urban areas (3 percent versus less than 1 percent). In addition, children in South and East (4 percent each) are more likely to have malaria than those in other provinces. No children who live in the sampled households in City of Kigali or North Malaria • 185 were tested positive for malaria. Children of mothers with no education are more likely to be infected than children of mothers with at least primary education. The proportion of children who test positive for malaria decreases with increasing wealth. Table 12.12 Prevalence of malaria in children Percentage of children age 6-59 months classified as having malaria by microscopic tests, according to background characteristics, Rwanda 2014-15 Background characteristic Percentage positive Number Age (in months) 6-8 1.0 205 9-11 0.4 214 12-17 1.7 416 18-23 0.9 371 24-35 2.9 812 36-47 2.3 840 48-59 3.4 676 Sex Male 2.5 1,786 Female 1.9 1,748 Mother’s interview status Interviewed 2.4 3,115 Not interviewed but in household 0.7 418 Residence Urban 0.3 554 Rural 2.6 2,980 Province City of Kigali 0.0 382 South 4.4 844 West 0.5 830 North 0.0 506 East 3.9 972 Mother’s education1 No education 3.0 499 Primary 2.2 2,385 Secondary and higher 1.0 395 Wealth quintile Lowest 4.7 890 Second 2.4 785 Middle 1.5 693 Fourth 1.1 596 Highest 0.2 570 Total 2.2 3,534 Note: Total includes 1 case in which information on mother’s interview status was missing. 1 For women who are not interviewed, information is taken from the Household Questionnaire. Excluding children whose mothers are not listed in the Household Questionnaire. Women age 15-49 were also offered malaria testing as part of the 2014-15 RDHS. Among all women who were eligible for testing, 99 percent of them were tested (Table 12.13). Also, RDTs were done to provide women with immediate results and, among those with a positive test were provided treatment, severe cases of malaria were referred to the health facility for treatment. The distribution by background characteristics shows no differences among women in testing coverage. 186 • Malaria Table 12.13 Coverage of malaria testing among women Percentage of women age 15-49 eligible for microscopic tests, according to background characteristics (unweighted), Rwanda 2014-15 Background characteristic Blood smear tested Number of women Age 15-19 98.9 1,410 20-24 98.9 1,249 25-29 99.3 1,181 30-34 99.1 1,041 35-39 99.2 797 40-44 98.9 613 45-49 99.8 475 Currently pregnant Pregnant 100.0 481 Not pregnant or not sure 99.5 6,255 Residence Urban 98.6 1,752 Rural 99.3 5,014 Province City of Kigali 98.1 960 South 99.3 1,722 West 99.2 1,499 North 99.4 1,084 East 99.2 1,501 Education No education 97.4 793 Primary 99.5 4,279 Secondary and higher 99.0 1,694 Wealth quintile Lowest 99.2 1,299 Second 99.4 1,255 Middle 99.3 1,209 Fourth 99.6 1,203 Highest 98.4 1,800 Total 99.1 6,766 Note: Total includes 30 women with missing information on current pregnancy. Women are less likely to be infected with malaria than children. In the country as a whole, less than one percent of women have malaria (Table 12.14). There are no meaningful differences in malaria prevalence by women’s background characteristics. Malaria • 187 Table 12.14 Prevalence of malaria in women Percentage of women age 15-49 classified as having malaria by microscopic tests, according to background characteristics, Rwanda 2014-15 Background characteristic Percentage positive Number Age 15-19 0.5 1,382 20-24 1.3 1,220 25-29 0.5 1,146 30-34 0.0 1,018 35-39 0.3 790 40-44 0.7 612 45-49 0.4 479 Currently pregnant Pregnant 0.7 488 Not pregnant or not sure 0.5 6,158 Residence Urban 0.1 1,314 Rural 0.7 5,331 Province City of Kigali 0.1 891 South 0.9 1,595 West 0.4 1,438 North 0.1 1,088 East 0.9 1,634 Education No education 1.0 795 Primary 0.5 4,293 Secondary and higher 0.4 1,558 Wealth quintile Lowest 1.0 1,302 Second 0.4 1,308 Middle 0.7 1,246 Fourth 0.4 1,247 Highest 0.2 1,542 Total 0.6 6,646 Since the 2010 RDHS, the prevalence of malaria among children age 6-59 months has increased slightly, from 1 percent to 2 percent, while the prevalence among women has remained the same at about 1 percent. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 189 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13 IV infection is a major public health concern in Rwanda, where it is among cause of mortality with negative social and economic consequences that affect people and the country. Since the initiation of the 2005-2009 National Multi-sector Strategic Plan (NMSP), Rwanda has made significant progress toward the goal of creating universal access to HIV and AIDS services. To continue this progress, Rwanda developed and implemented the 2009-2012 followed by 2013-2018 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 2014-15 RDHS devoted considerable effort to gather data on HIV/AIDS and other sexually transmitted infections (STIs). The aim of this chapter is to present data concerning HIV-related 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 on beliefs regarding how HIV infection is prevented and transmitted, on stigmatization of those who have the disease, and on 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 2014-15 RDHS included an HIV testing component to determine the prevalence of HIV infection and factors associated with infection (see Chapter 14). H Key Findings • Virtually all Rwandan adults have heard of HIV/AIDS, • Sixty-seven percent of women and 69 percent of men have comprehensive knowledge of HIV/AIDS prevention and transmission • Nine in 10 adult respondents (90 percent of women and 92 percent of men) agreed that young people age 12-14 should be taught about using condoms to avoid getting AIDS. • Among those who had more than one sexual partner in the past 12 months, 48 percent of women and 31 percent of men reported using a condom during their last sexual intercourse. • HIV testing has risen since 2010. The proportion of women who have ever been tested and received their results has increased from 76 percent in 2010 to 84 percent in 2014-15, and the proportion among men has increased from 69 percent to 78 percent during the same period. • Seventy-five percent of never-married young women age 15-24 and 67 percent of their male counterparts reported that they had never had sex. • Overall, 10 percent of young women age 15-19 who had sexual intercourse in the 12 months before the survey had sex with someone 10 or more years older than they were. • Half of women (50 percent) and two-thirds of men (63 percent) express accepting attitudes in four situations related to stigmatization toward people with HIV. 190 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior 13.1 KNOWLEDGE OF HIV AND AIDS AND OF TRANSMISSION AND PREVENTION METHODS 13.1.1 Awareness of AIDS Table 13.1 shows that almost all women and men age 15-49 have heard of AIDS. Because of the universal awareness of AIDS, variations by background characteristics, such as marital status, residence, province, education, and wealth, are negligible. Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Rwanda 2014-15 Women Men Background characteristic Has heard of AIDS Number of respondents Has heard of AIDS Number of respondents Age 15-24 99.9 5,225 99.9 2,276 15-19 99.8 2,768 99.8 1,282 20-24 99.9 2,457 100.0 994 25-29 99.9 2,300 100.0 946 30-39 99.9 3,726 99.9 1,497 40-49 100.0 2,246 100.0 858 Marital status Never married 99.8 5,100 99.9 2,691 Ever had sex 99.9 1,562 100.0 1,110 Never had sex 99.8 3,539 99.9 1,581 Married/living together 100.0 6,982 100.0 2,792 Divorced/separated/widowed 99.9 1,415 100.0 94 Residence Urban 100.0 2,626 100.0 1,169 Rural 99.9 10,871 99.9 4,408 Province City of Kigali 100.0 1,799 100.0 804 South 99.9 3,214 99.9 1,327 West 99.8 2,965 99.9 1,182 North 99.9 2,211 99.9 851 East 100.0 3,308 100.0 1,413 Education No education 99.8 1,665 100.0 496 Primary 99.9 8,678 99.9 3,636 Secondary and higher 100.0 3,154 100.0 1,445 Wealth quintile Lowest 99.9 2,561 99.9 819 Second 99.9 2,631 99.9 991 Middle 99.9 2,597 99.9 1,097 Fourth 99.9 2,634 100.0 1,234 Highest 100.0 3,073 100.0 1,436 Total 15-49 99.9 13,497 99.9 5,577 50-59 na na 100.0 640 Total 15-59 na na 100.0 6,217 na = Not applicable 13.1.2 HIV Prevention Methods The 2014-15 RDHS asked respondents specific questions about HIV and AIDS prevention methods, including 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-nine percent of women and 92 percent of men are aware that the risk of contracting the AIDS virus can be reduced by limiting sex to one uninfected partner who has no other partners. 91 percent of women and 95 percent of men know that using condoms also can prevent transmission of HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 191 the AIDS virus. Eighty-three percent of women and 88 percent of men have knowledge of both HIV prevention methods. 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 2014-15 Women Men Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of men Age 15-24 90.9 87.7 81.6 5,225 94.7 89.4 85.7 2,276 15-19 89.3 86.5 79.6 2,768 93.5 87.4 82.8 1,282 20-24 92.7 89.1 83.9 2,457 96.1 92.1 89.4 994 25-29 90.9 90.1 83.4 2,300 95.0 92.6 88.8 946 30-39 92.0 90.4 84.4 3,726 95.7 93.6 90.0 1,497 40-49 91.9 88.8 82.9 2,246 96.5 93.7 90.8 858 Marital status Never married 90.9 86.9 81.0 5,100 94.6 89.2 85.4 2,691 Ever had sex 92.1 89.5 83.4 1,562 96.4 92.3 89.2 1,110 Never had sex 90.3 85.8 80.0 3,539 93.3 87.0 82.8 1,581 Married/living together 91.6 90.7 84.2 6,982 96.0 94.2 90.8 2,792 Divorced/separated/widowed 92.0 88.6 83.3 1,415 92.6 94.9 89.2 94 Residence Urban 94.7 89.7 85.8 2,626 96.7 93.3 90.7 1,169 Rural 90.6 88.9 82.2 10,871 94.9 91.3 87.5 4,408 Province City of Kigali 95.3 93.8 89.9 1,799 98.3 95.0 93.6 804 South 91.7 92.5 86.5 3,214 96.2 92.0 89.2 1,327 West 85.8 80.8 71.9 2,965 93.4 91.6 87.1 1,182 North 94.9 89.3 85.7 2,211 89.6 88.1 79.0 851 East 91.6 90.3 83.7 3,308 97.6 92.0 90.4 1,413 Education No education 89.7 88.2 81.1 1,665 94.4 91.3 86.1 496 Primary 90.7 89.5 82.7 8,678 94.8 92.1 88.2 3,636 Secondary and higher 94.2 88.2 84.4 3,154 96.8 91.0 88.6 1,445 Wealth quintile Lowest 87.9 88.3 80.0 2,561 93.9 91.6 86.9 819 Second 90.7 88.1 81.4 2,631 94.5 91.5 87.5 991 Middle 91.5 90.2 84.1 2,597 95.7 92.2 88.8 1,097 Fourth 91.9 88.9 83.1 2,634 95.1 90.1 86.8 1,234 Highest 94.3 89.7 85.5 3,073 96.4 93.1 89.9 1,436 Total 15-49 91.4 89.0 82.9 13,497 95.3 91.8 88.1 5,577 50-59 na na na na 93.8 92.2 86.7 640 Total 15-59 na na na na 95.1 91.8 88.0 6,217 na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners Knowledge of both prevention methods is slightly lower among women and men age 15-19 than among older women and men. Women and men who have never been married, particularly those who have never had sex, are slightly less likely to know of these two HIV prevention methods than those who have ever been married or who have ever had sex. Knowledge of HIV prevention methods is slightly higher among women and men in urban areas than among those in rural areas. There is considerable variability across provinces in knowledge of prevention methods. Among women, knowledge of the two HIV prevention methods is highest in City of Kigali (90 192 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior percent) and lowest in the West province (72 percent). Among men, knowledge is highest in the City of Kigali (94 percent) and lowest in North (79 percent). Level of educational attainment is positively related to a respondent’s knowledge of HIV prevention methods. Women and men with higher levels of education are more likely to be aware of these two preventive methods than those with no education. Eighty-four percent of women with secondary or higher versus 81 with no education and 89 percent of men with secondary or higher education versus 86 percent are aware of HIV prevention method. The data also show that women and men in the higher wealth quintiles are more likely to be aware of ways to prevent the transmission of HIV than those in the lower quintiles (85 percent in the highest quintile versus 80 percent in lowest quintile among women, and 90 percent in the highest quintile versus to 87 percent in the lowest quintile among men). 13.1.3 Knowledge about Transmission The 2014-15 RDHS included questions on common misconceptions about transmission of AIDS and HIV. 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. Nevertheless, more than 90 percent of respondents know that a healthy-looking person can have the AIDS virus (91 percent of women and 92 percent of men) and are aware that the virus cannot be transmitted by supernatural means (96 percent of women and 95 percent of men) or by sharing food with a person who has AIDS (94 percent of women and 93 percent of men). Eighty-nine percent of women and 86 percent of men know that the AIDS virus cannot be transmitted by mosquito bites. Overall, 78 percent of women and 77 percent of men are able to reject the two most common misconceptions about AIDS—that the AIDS virus can be transmitted by mosquito bites and that a person can become infected with the virus by sharing food with someone who has AIDS—and also know that a healthy-looking person can have the AIDS virus. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 193 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 transmission or prevention of the AIDS virus, and the percentage with comprehensive knowledge about AIDS, by background characteristics, Rwanda 2014-15 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 mis- conceptions1 Percentage with compre- hensive knowledge about AIDS2 Number of women Background characteristic A healthy-looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 86.6 90.2 95.4 93.6 75.8 64.6 5,225 15-19 83.1 90.7 94.7 92.7 73.1 61.6 2,768 20-24 90.5 89.6 96.3 94.6 78.9 68.1 2,457 25-29 93.4 88.9 96.4 95.1 80.6 68.5 2,300 30-39 93.4 87.8 95.5 94.4 80.4 68.9 3,726 40-49 93.5 86.9 95.4 93.8 78.8 67.5 2,246 Marital status Never married 86.3 90.4 95.8 93.7 75.8 64.1 5,100 Ever had sex 88.5 89.5 96.0 94.3 77.6 66.9 1,562 Never had sex 85.3 90.8 95.7 93.4 75.0 62.8 3,539 Married/living together 93.7 88.1 95.7 94.6 80.4 69.2 6,982 Divorced/separated/widowed 92.6 86.1 94.6 93.0 77.8 66.2 1,415 Residence Urban 94.3 93.7 97.6 96.7 86.7 75.7 2,626 Rural 89.9 87.5 95.1 93.5 76.4 64.8 10,871 Province City of Kigali 95.2 95.1 97.8 97.2 89.1 81.8 1,799 South 92.7 89.9 96.4 94.4 81.0 71.8 3,214 West 85.6 84.1 93.0 91.3 68.8 50.9 2,965 North 92.9 88.6 96.2 94.5 80.1 69.4 2,211 East 89.7 88.4 95.6 94.3 77.5 66.9 3,308 Education No education 91.2 82.0 92.1 89.7 72.1 60.5 1,665 Primary 90.6 88.0 95.2 93.6 77.3 66.0 8,678 Secondary and higher 91.1 94.3 98.6 97.8 84.8 73.0 3,154 Wealth quintile Lowest 88.1 85.3 93.0 91.0 71.9 59.4 2,561 Second 90.0 86.4 95.0 92.9 75.2 63.1 2,631 Middle 90.5 88.3 95.7 94.7 78.1 67.8 2,597 Fourth 90.7 89.6 96.5 95.2 79.4 67.7 2,634 Highest 93.9 93.3 97.4 96.3 85.9 75.1 3,073 Total 15-49 90.8 88.7 95.6 94.1 78.4 66.9 13,497 1 Two most common local misconceptions: the AIDS virus can be transmitted by mosquito bites and a person can become infected by sharing food with a person who has the AIDS virus. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 194 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior 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 transmission or prevention of the AIDS virus, and the percentage with comprehensive knowledge about AIDS, by background characteristics, Rwanda 2014-15 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 compre- hensive knowledge about AIDS2 Number of men Background characteristic A healthy-looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 86.2 87.1 94.1 92.0 72.7 64.3 2,276 15-19 82.6 86.6 93.1 91.1 69.5 59.5 1,282 20-24 90.9 87.8 95.5 93.3 76.8 70.6 994 25-29 93.9 85.4 96.4 94.9 78.1 71.2 946 30-39 95.4 84.3 96.3 94.2 78.5 70.8 1,497 40-49 96.2 87.2 96.2 94.2 82.1 74.8 858 Marital status Never married 87.4 87.8 94.6 92.9 74.5 65.7 2,691 Ever had sex 90.9 86.1 94.9 93.4 74.8 67.7 1,110 Never had sex 85.0 88.9 94.4 92.6 74.2 64.2 1,581 Married/living together 95.5 84.8 96.2 94.0 79.0 72.2 2,792 Divorced/separated/widowed 91.1 76.8 95.5 91.6 67.8 61.6 94 Residence Urban 94.8 91.0 96.9 95.9 84.6 77.3 1,169 Rural 90.7 84.8 95.0 92.8 74.5 66.6 4,408 Province City of Kigali 97.8 94.6 97.2 97.0 90.9 85.1 804 South 93.4 89.3 96.5 95.5 81.1 73.2 1,327 West 86.8 80.7 93.3 90.2 66.2 59.6 1,182 North 85.2 82.2 93.8 92.4 68.6 56.1 851 East 93.9 85.0 96.1 92.8 77.9 70.8 1,413 Education No education 92.4 73.9 91.1 89.4 65.6 56.7 496 Primary 91.3 84.3 94.9 92.3 74.6 67.3 3,636 Secondary and higher 91.9 94.7 98.2 97.6 85.5 76.9 1,445 Wealth quintile Lowest 90.2 78.1 92.3 87.9 67.5 60.2 819 Second 88.9 83.5 95.6 93.4 72.1 65.0 991 Middle 90.5 83.9 95.0 93.1 73.7 67.3 1,097 Fourth 92.1 88.8 95.9 94.3 79.5 69.3 1,234 Highest 94.4 91.8 97.0 96.1 84.8 77.2 1,436 Total 15-49 91.5 86.1 95.4 93.4 76.6 68.8 5,577 50-59 95.4 83.2 94.6 90.4 75.6 68.3 640 Total 15-59 91.9 85.8 95.3 93.1 76.5 68.8 6,217 1 Two most common local misconceptions: the AIDS virus can be transmitted by mosquito bites and a person can become infected by sharing food with a person who has the AIDS virus. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 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 to one uninfected partner are HIV and AIDS prevention methods, they are also aware that a healthy-looking person can have HIV, and they reject the two most common local misconceptions (that HIV can be transmitted by mosquito bites and by sharing food). The data show that 67 percent of women and 69 percent of men age 15-49 have comprehensive knowledge of HIV and AIDS prevention and transmission. There is considerable variation in comprehensive HIV and AIDS knowledge by background characteristics. Comprehensive knowledge increases with age; for women from 62 percent for those age 15-19 to HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 195 69 percent for those age 30-39, and for men from 60 percent for those age 15-19 to 75 percent for those age 40-49. Married women and men and sexually active never-married men tend to be more knowledgeable than women and men in other marital status categories. The proportion of women and men with correct knowledge about HIV and AIDS prevention and transmission is higher in urban (76 percent for women and 77 percent for men) than in rural areas (65 percent for women and 74 percent for men). This figure is higher among women and men with secondary or higher education represent (73 percent and 77 percent) than those with primary or less education. Similarly, men and women in the higher wealth quintiles (77 percent and 75 percent, respectively) are more likely to have comprehensive knowledge about HIV and AIDS than those in the lower quintiles (59 percent and 60 percent, respectively). Variations in comprehensive knowledge by province are marked, with the highest levels of knowledge observed among women and men in the City of Kigali (82 percent and 85 percent, respectively) and the lowest levels observed among women in West (51 percent) and men in North (56 percent). Comprehensive knowledge about AIDS has increased since the 2010 RDHS, from 56 percent in 2010 to 67 percent in 2014-15 among women and from 52 percent to 69 percent among men during the same period. 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 Rwandan women are more knowledgeable than Rwandan men about MTCT. Ninety-four percent of women and 89 percent of men age 15-49 know that HIV can be transmitted to a baby through breastfeeding, while 95 percent of women and 93 percent of men are aware that the risk of transmission can be reduced if the mother takes special drugs during pregnancy. Overall, 90 percent of women and 84 percent of men are aware that HIV can be transmitted through breastfeeding and that the risk of MTCT can be reduced by taking special drugs during pregnancy. MTCT knowledge has not changed over the past five years. There are no marked differences in MTCT knowledge among women and men by background characteristics. 196 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior 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 the mother taking special drugs during pregnancy, by background characteristics, Rwanda 2014-15 Women Men Background characteristic HIV can be transmitted by breast- feeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breast- feeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of women HIV can be transmitted by breast- feeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breast- feeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Number of men Age 15-24 93.5 92.4 88.2 5,225 88.3 89.3 81.3 2,276 15-19 92.2 89.8 85.3 2,768 87.3 87.1 78.5 1,282 20-24 94.9 95.3 91.3 2,457 89.6 92.1 85.0 994 25-29 95.0 96.2 92.3 2,300 90.4 94.8 87.0 946 30-39 93.8 96.9 91.7 3,726 89.6 94.1 85.6 1,497 40-49 92.1 95.3 89.5 2,246 88.4 96.2 85.9 858 Marital status Never married 92.6 91.9 87.1 5,100 88.8 90.1 82.2 2,691 Ever had sex 92.9 94.3 89.3 1,562 90.6 92.1 85.0 1,110 Never had sex 92.5 90.8 86.1 3,539 87.5 88.6 80.3 1,581 Married/living together 94.3 96.7 92.0 6,982 89.2 94.9 85.8 2,792 Divorced/separated/widowed 93.6 95.7 91.3 1,415 90.9 94.5 86.5 94 Currently pregnant Pregnant 94.6 96.2 91.8 984 na na na na Not pregnant or not sure 93.5 94.6 89.9 12,513 na na na na Residence Urban 95.1 96.0 92.4 2,626 90.8 94.7 86.8 1,169 Rural 93.2 94.5 89.5 10,871 88.6 92.0 83.4 4,408 Province City of Kigali 95.6 96.1 92.9 1,799 93.0 96.0 90.2 804 South 94.3 95.9 91.2 3,214 90.4 96.0 88.0 1,327 West 92.8 92.5 87.5 2,965 90.6 89.1 83.3 1,182 North 92.9 96.4 91.0 2,211 81.6 90.2 75.5 851 East 93.1 93.9 89.0 3,308 88.6 91.7 82.8 1,413 Education No education 93.3 94.7 90.3 1,665 88.8 92.0 83.3 496 Primary 93.2 94.6 89.6 8,678 88.1 92.4 83.5 3,636 Secondary and higher 94.9 95.3 91.0 3,154 91.4 93.2 86.0 1,445 Wealth quintile Lowest 92.7 93.9 88.8 2,561 89.5 92.5 85.2 819 Second 93.8 94.9 90.4 2,631 87.1 92.2 82.1 991 Middle 93.3 94.2 89.2 2,597 89.5 91.0 83.3 1,097 Fourth 93.6 95.2 90.3 2,634 87.6 92.5 82.8 1,234 Highest 94.5 95.5 91.2 3,073 90.9 94.2 86.7 1,436 Total 15-49 93.6 94.8 90.0 13,497 89.0 92.6 84.1 5,577 50-59 na na na na 87.1 93.5 82.6 640 Total 15-59 na na na na 88.8 92.7 84.0 6,217 na = Not applicable 13.2 STIGMA ASSOCIATED WITH AIDS AND ATTITUDES RELATED TO HIV AND AIDS Widespread stigma and discrimination toward those living with HIV can adversely affect both people’s willingness to be tested for HIV and their adherence to antiretroviral therapy. Thus, reduction of stigma and discrimination against people living with AIDS is an important indicator of the success of programs aimed at preventing and controlling infection. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 197 In the 2014-15 RDHS, respondents were asked a number of questions to measure their attitudes toward HIV-positive people. These questions concerned their willingness to buy fresh vegetables from an infected shopkeeper, to let others know of an infected family member, and to take care of relatives who have AIDS 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 express positive attitudes toward people with HIV, by background characteristics. 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 HIV/AIDS, by background characteristics, Rwanda 2014-15 Percentage of respondents who: Percentage expressing accepting attitudes on all four indicators Number of respondents who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but 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 95.3 85.5 86.3 58.2 44.0 5,218 15-19 93.6 82.0 82.9 56.3 39.0 2,763 20-24 97.2 89.5 90.2 60.4 49.7 2,455 25-29 97.2 92.0 91.2 62.9 52.3 2,298 30-39 97.0 92.4 92.0 64.1 55.2 3,723 40-49 98.0 89.2 90.7 65.4 54.4 2,246 Marital status Never married 95.3 86.7 87.0 59.4 45.8 5,092 Ever had sex 96.6 89.0 89.7 60.4 49.0 1,560 Never had sex 94.7 85.6 85.8 59.0 44.4 3,532 Married/living together 97.3 91.0 91.4 63.3 53.5 6,981 Divorced/separated/widowed 97.4 88.9 88.5 63.2 50.6 1,413 Residence Urban 97.8 94.9 94.9 53.4 48.6 2,625 Rural 96.2 87.8 88.1 63.9 50.7 10,861 Province City of Kigali 98.4 95.8 95.8 50.9 47.0 1,799 South 96.8 89.5 90.6 70.3 58.1 3,211 West 94.8 84.6 85.5 61.9 45.6 2,960 North 95.9 87.9 89.1 50.6 40.2 2,208 East 97.2 90.1 88.6 66.9 55.4 3,308 Education No education 94.8 82.7 84.6 61.4 43.9 1,662 Primary 96.1 88.0 88.3 63.2 50.4 8,670 Secondary and higher 98.7 95.7 95.1 58.2 53.2 3,154 Wealth quintile Lowest 93.9 83.1 83.7 64.6 45.9 2,558 Second 95.9 87.6 87.9 62.7 49.4 2,630 Middle 97.2 88.3 88.9 63.4 51.5 2,594 Fourth 97.4 91.2 90.9 64.4 54.3 2,632 Highest 98.1 94.5 94.7 55.3 50.2 3,073 Total 15-49 96.5 89.2 89.4 61.8 50.3 13,486 Almost all women and men say that they would be willing to take care of a family member with AIDS at home (97 percent and 98 percent, respectively). Women are less likely to say that they would buy fresh vegetables from a shopkeeper who has HIV than men (89 percent versus 92 percent). Approximately 9 in 10 respondents feel that a female teacher with HIV who is not sick should be allowed to continue teaching (89 percent of women and 90 percent of men). Sixty-two percent of women and 74 percent of men say that they would not want to keep secret that a family member is infected with the AIDS virus. Accepting attitudes on all four indicators are more common among men (63 percent) than women (50 percent). Among both women and men, acceptance tends to increase with age, from 39 percent among women age 15-19 years to 55 percent among women age 40-49, and from 49 percent among men 15-19 to 71 percent 198 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior among men at 40-49. Urban and rural women are more or less equally likely to express accepting attitudes, whereas urban men are somewhat more accepting than rural men. The proportion of women who report accepting attitudes on all four indicators increases with increasing education from 44 percent among those with no education to 53 percent among those with secondary education or higher; the relationship is less clear among men, although those with a secondary education or higher (69 percent) are most likely to have accepting attitudes on all four indicators. Women and men in the North province are less likely to express accepting attitudes toward people living with HIV or AIDS (40 percent and 45 percent, respectively) than residents of the other provinces. Men in City of Kigali have a particularly high level of acceptance (74 percent). 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 2014-15 Percentage of respondents who: Percentage expressing accepting attitudes on all four indicators Number of respondents who have heard of AIDS Background characteristic Are willing to care for a family member with AIDS in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but 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 96.4 86.9 85.7 70.4 54.3 2,274 15-19 95.1 82.6 81.6 69.4 48.8 1,280 20-24 98.1 92.4 90.8 71.6 61.3 994 25-29 99.0 95.3 91.3 75.2 66.4 946 30-39 98.5 95.9 93.6 77.9 71.1 1,496 40-49 98.8 95.9 95.7 77.2 71.1 858 Marital status Never married 96.9 88.5 87.2 71.8 57.5 2,689 Ever had sex 97.9 92.1 90.2 73.6 62.8 1,110 Never had sex 96.2 86.0 85.1 70.5 53.7 1,579 Married/living together 98.7 95.8 93.4 76.5 69.2 2,791 Divorced/separated/widowed 95.0 87.4 88.1 78.7 61.8 94 Residence Urban 98.3 95.6 95.6 74.8 68.9 1,169 Rural 97.6 91.2 88.9 74.1 62.0 4,405 Province City of Kigali 98.6 97.8 98.1 77.3 73.8 804 South 98.4 93.2 89.1 79.4 68.7 1,327 West 96.9 89.4 88.4 74.5 61.6 1,181 North 97.2 89.7 88.4 57.2 44.5 850 East 97.7 91.6 89.8 77.8 65.5 1,413 Education No education 95.1 90.3 88.1 77.2 62.3 496 Primary 97.6 90.5 88.1 74.3 61.4 3,633 Secondary and higher 99.0 96.9 96.7 73.3 68.9 1,445 Wealth quintile Lowest 95.8 89.4 83.6 75.8 59.3 818 Second 98.1 90.9 88.0 76.3 63.1 990 Middle 98.0 91.7 89.1 73.0 61.3 1,096 Fourth 98.0 92.6 91.5 74.6 64.8 1,234 Highest 98.2 94.5 95.6 72.7 66.4 1,436 Total 15-49 97.8 92.1 90.3 74.3 63.4 5,574 50-59 98.4 90.8 93.8 76.0 66.6 640 Total 15-59 97.8 92.0 90.7 74.4 63.8 6,214 13.3 ATTITUDES TOWARD NEGOTIATING SAFER SEX Knowledge about HIV transmission and ways to prevent transmission is not useful if people are not able to negotiate safer sex practices with their partners. To gauge attitudes toward safer sex, respondents in the 2014-15 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 is justified in HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 199 asking her husband to use a condom if she knows that he has a sexually transmitted infection (STI). The results are shown in Table 13.6. 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 2014-15 Women Men Background characteristic Refusing to have sexual intercourse with her 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 her 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 76.1 96.6 5,225 80.5 97.8 2,276 15-19 74.2 95.2 2,768 76.6 96.6 1,282 20-24 78.4 98.1 2,457 85.5 99.5 994 25-29 80.9 98.2 2,300 89.1 99.5 946 30-39 81.7 98.0 3,726 90.7 98.5 1,497 40-49 82.2 97.1 2,246 90.8 99.0 858 Marital status Never married 76.1 96.2 5,100 81.9 97.8 2,691 Ever had sex 77.5 97.9 1,562 85.0 98.8 1,110 Never had sex 75.5 95.4 3,539 79.8 97.2 1,581 Married/living together 81.5 98.0 6,982 90.5 99.1 2,792 Divorced/separated/widowed 81.9 98.1 1,415 84.6 97.7 94 Residence Urban 83.8 99.1 2,626 89.2 99.2 1,169 Rural 78.4 96.9 10,871 85.5 98.3 4,408 Province City of Kigali 87.0 99.3 1,799 92.1 99.5 804 South 81.4 97.3 3,214 88.4 98.4 1,327 West 80.4 96.4 2,965 86.8 98.5 1,182 North 74.3 96.3 2,211 81.2 96.5 851 East 76.2 97.8 3,308 83.6 99.1 1,413 Education No education 79.9 96.5 1,665 90.3 97.9 496 Primary 79.0 97.0 8,678 86.4 98.3 3,636 Secondary and higher 80.5 98.7 3,154 84.5 99.1 1,445 Wealth quintile Lowest 79.6 96.2 2,561 88.0 97.6 819 Second 78.8 97.3 2,631 87.2 97.8 991 Middle 79.2 97.3 2,597 85.2 98.4 1,097 Fourth 77.6 97.4 2,634 84.9 98.9 1,234 Highest 81.8 98.3 3,073 86.7 99.1 1,436 Total 15-49 79.5 97.3 13,497 86.3 98.5 5,577 50-59 na na na 90.4 98.4 640 Total 15-59 na na na 86.7 98.5 6,217 na = Not applicable Eighty 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 97 percent of women and 99 percent of men believe that a woman is justified in asking her husband to use a condom if he has an STI. There are small differences by background characteristics in the percentages of respondents who support a woman’s right to refuse to have sex with her husband if she knows he had sex with other women or to propose using a condom if he has an STI. Both indicators tend to increase slightly with the age of the respondent. For example; the percentage of respondent who think that it is justified for a wife refusing to have sex with her husband if she knows he has sex with other women increases from 74 percent among women age 15-19 to 82 percent among those age 40-49 and from 77 percent among men 15-19 to 91 among men age 40-49. Urban 200 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior women and men, especially those in City of Kigali, are more likely to agree with both indicators than rural respondents. 13.4 ATTITUDES TOWARD 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, the 2014-15 RDHS asked respondents if they thought that young people age 12-14 should be taught about using a condom to avoid AIDS. Because the data focus on adult opinions, results are tabulated for respondents age 18-49. Table 13.7 shows that about 9 in 10 respondents (90 percent of women and 92 percent of men) agree that young people age 12-14 should be taught about using condoms for AIDS prevention. There is minimal variation in support for condom education by background characteristics. Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 should be taught about using a condom to avoid AIDS, by background characteristics, Rwanda 2014-15 Women Men Background characteristic Percentage who agree Number Percentage who agree Number Age 18-24 91.6 3,482 90.3 1,468 18-19 89.8 1,025 89.1 474 20-24 92.3 2,457 90.9 994 25-29 91.8 2,300 93.4 946 30-39 90.0 3,726 92.2 1,497 40-49 87.6 2,246 91.0 858 Marital status Never married 90.3 3,369 90.4 1,883 Married/living together 90.4 6,973 92.5 2,792 Divorced/separated/widowed 90.3 1,412 93.1 94 Residence Urban 92.9 2,281 90.4 1,063 Rural 89.7 9,473 92.0 3,707 Province City of Kigali 94.3 1,583 93.0 743 South 90.4 2,782 90.6 1,100 West 88.3 2,615 92.7 1,005 North 88.0 1,871 88.3 717 East 91.5 2,903 92.9 1,204 Education No education 85.9 1,652 93.4 480 Primary 90.5 7,592 91.4 3,092 Secondary and higher 92.9 2,511 91.5 1,197 Wealth quintile Lowest 88.2 2,287 92.7 712 Second 89.9 2,308 93.7 856 Middle 90.8 2,288 91.6 928 Fourth 90.1 2,256 90.0 1,006 Highest 92.5 2,616 91.1 1,267 Total 18-49 90.4 11,754 91.7 4,769 50-59 na na 87.0 640 Total 18-59 na na 91.1 5,409 na = Not applicable HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 201 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 in designing and monitoring intervention programs to control the spread of the disease. In the context of HIV and AIDS prevention, limiting the number of sexual partners, encouraging protected sex and delaying first sexual intercourse for youth are crucial to combating the epidemic,. The 2014-15 RDHS included questions on respondents’ sexual partners during their lifetime as well as 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. In addition, information was collected on women’s and men’s use of condoms during their last sexual encounter with each type of partner. 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 who had sexual intercourse with more than one partner in the 12 months before the survey. They also show mean numbers of lifetime sexual partners and condom use during most recent intercourse. Less than 1 percent of women 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. Forty-eight percent of women who had two or more sexual partners in the 12 months before the survey used a condom during their last sex. Because the number of respondents reporting more than one partner in the past 12 months is very small, differences in condom use by background characteristics are not noteworthy. Table 13.8.2 shows that 5 percent of men had two or more sexual partners during the 12 months preceding the survey. Men age 25 and older; those who are divorced, separated, or widowed; those in polygynous unions; and those living in urban areas and the City of Kigali are more likely to have had multiple partners over the past 12 months than other respondents. Among men with two or more partners in the past 12 months, 31 percent report having used a condom during their last encounter. Condom use is more pronounced among urban than rural men (58 percent and 18 percent, respectively). It is also higher among men who have never been married or are not currently married. Because the total number of men who have had multiple sexual partners in the past 12 months is small, variations in condom use by other background characteristics are not meaningful. On average, men age 15-49 report having 2.6 lifetime sexual partners, almost twice the average reported by women (1.5 partners). Among women, variation according to background characteristics is minimal. Women who live in urban areas and City of Kigali have had slightly more lifetime partners than other women, and women who have never been married or who are widowed, divorced, or separated have had more lifetime partners than women who are currently married. Mean number of lifetime sexual partners among men increases with age, from 1.8 among those age 15-19 to 3.3 among those age 40-49. It also varies according to marital status. Men who are divorced, separated, or widowed report a mean of 4.6 lifetime partners, as compared with 2.6 among other category of men. Mean number of lifetime sexual partners is higher among urban men than among rural men (3.4 versus 2.4). More educated and well-off men are more likely to report a higher number of sexual partners. The average number of partners among men with no level of education is 2.0, as compared with 3.2 among men with a secondary education or higher. Average number of partners ranges from 2.1 to 2.3 among men in the lowest three wealth quintiles to 3.5 among those in the highest quintile. 202 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior 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 2014-15 All women Among women who had 2+ partners in the past 12 months: Among women who ever had sexual intercourse1: Background characteristic 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 0.7 5,225 (61.2) 38 1.5 2,140 15-19 0.5 2,768 * 15 1.5 556 20-24 0.9 2,457 * 23 1.5 1,584 25-29 0.9 2,300 * 20 1.4 2,026 30-39 0.7 3,726 (38.5) 27 1.5 3,583 40-49 0.5 2,246 * 10 1.6 2,202 Marital status Never married 0.8 5,100 (74.3) 40 1.9 1,560 Married/living together 0.3 6,982 (7.1) 23 1.3 6,977 Divorced/separated/widowed 2.3 1,415 (46.1) 33 2.0 1,415 Residence Urban 1.4 2,626 (64.4) 37 1.8 1,930 Rural 0.5 10,871 38.1 58 1.4 8,022 Province City of Kigali 1.7 1,799 (69.9) 31 1.9 1,344 South 0.7 3,214 (35.6) 22 1.5 2,334 West 0.5 2,965 * 15 1.4 2,137 North 0.4 2,211 * 9 1.3 1,541 East 0.6 3,308 * 19 1.5 2,596 Education No education 0.6 1,665 * 10 1.5 1,591 Primary 0.8 8,678 49.3 68 1.5 6,802 Secondary and higher 0.5 3,154 * 17 1.6 1,558 Wealth quintile Lowest 1.0 2,561 (37.7) 25 1.5 2,095 Second 0.5 2,631 * 12 1.4 1,994 Middle 0.5 2,597 * 14 1.4 1,931 Fourth 0.6 2,634 * 15 1.4 1,811 Highest 1.0 3,073 (64.1) 29 1.7 2,120 Total 15-49 0.7 13,497 48.4 95 1.5 9,951 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. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 203 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 2014-15 All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Background characteristic Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual inter- course Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 1.9 2,276 (75.0) 43 2.1 875 15-19 0.7 1,282 * 9 1.8 301 20-24 3.5 994 (71.5) 34 2.2 574 25-29 6.2 946 33.2 59 2.4 822 30-39 6.4 1,497 19.0 97 2.6 1,447 40-49 6.5 858 14.9 56 3.3 846 Marital status Never married 2.7 2,691 80.9 72 2.6 1,110 Married/living together 6.2 2,792 9.3 172 2.6 2,787 Divorced/separated/widowed 10.6 94 * 10 4.6 93 Type of union In polygynous union 75.7 62 (8.4) 47 3.9 62 In non-polygynous union 4.6 2,730 9.7 125 2.5 2,725 Not currently in union 3.0 2,785 75.8 82 2.7 1,203 Residence Urban 7.1 1,169 57.7 83 3.4 877 Rural 3.9 4,408 17.9 171 2.4 3,113 Province City of Kigali 6.8 804 59.5 55 3.7 596 South 2.9 1,327 (36.7) 39 2.3 921 West 5.8 1,182 18.3 69 2.5 827 North 3.0 851 (19.1) 25 2.2 615 East 4.7 1,413 21.4 67 2.6 1,030 Education No education 5.0 496 * 25 2.0 446 Primary 4.9 3,636 22.2 177 2.5 2,714 Secondary and higher 3.7 1,445 69.2 53 3.2 829 Wealth quintile Lowest 5.0 819 (13.9) 41 2.2 618 Second 4.8 991 (10.7) 47 2.3 726 Middle 3.1 1,097 (21.1) 34 2.1 807 Fourth 2.8 1,234 (18.2) 34 2.5 809 Highest 6.8 1,436 55.5 98 3.5 1,031 Total 15-49 4.6 5,577 30.9 254 2.6 3,990 50-59 6.5 640 (10.8) 42 3.5 633 Total 15-59 4.8 6,217 28.0 296 2.7 4,623 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. 204 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior 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 partnerships because they can create large interconnected sexual networks whose members are at heightened risk of HIV infection. The 2014-15 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). Two indicators are used to measure concurrent sexual partnerships. The 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. The 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 includes only relationships ongoing on a particular day rather than over an entire year. In the case of men, overlapping polygynous unions are considered concurrent partnerships in both the point prevalence and cumulative prevalence concurrency indicators. Table 13.9 shows the point prevalence of current sexual partners among all respondents during the 12 months before the survey. It also shows, among respondents who had multiple sexual partners during the 12 months preceding the survey, the percentage who had concurrent sexual partners. Among women, both the point prevalence and the cumulative prevalence of concurrent sexual partners are less than 1 percent. The point prevalence among men is 2 percent, and the cumulative prevalence is 4 percent. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 205 Table 13.9 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), percentage of all women and all men age 15-49 who had any 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, by background characteristics, Rwanda 2014-15 Among all respondents: Among all respondents who had multiple partners during the 12 months before the survey: Background characteristic Point 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 0.0 0.4 5,225 (57.3) 38 15-19 0.0 0.3 2,768 * 15 20-24 0.1 0.5 2,457 * 23 25-29 0.2 0.6 2,300 * 20 30-39 0.2 0.5 3,726 (63.7) 27 40-49 0.1 0.3 2,246 * 10 Marital status Never married 0.1 0.5 5,100 (61.5) 40 Married/living together 0.1 0.3 6,982 (80.4) 23 Divorced/separated/widowed 0.4 1.2 1,415 (52.5) 33 Residence Urban 0.3 1.0 2,626 (73.2) 37 Rural 0.1 0.3 10,871 56.4 58 Total 15-49 0.1 0.4 13,497 63.0 95 MEN Age 15-24 0.3 0.8 2,276 (43.3) 43 15-19 0.1 0.3 1,282 * 9 20-24 0.5 1.6 994 (44.9) 34 25-29 0.9 4.3 946 69.2 59 30-39 2.7 5.8 1,497 89.7 97 40-49 3.8 6.4 858 98.0 56 Marital status Never married 0.2 1.2 2,691 44.1 72 Married/living together 2.9 5.9 2,792 95.2 172 Divorced/separated/widowed 1.1 5.5 94 * 10 Type of union In polygynous union 63.4 75.7 62 (100.0) 47 In non-polygynous union 1.5 4.3 2,730 93.4 125 Not currently in union 0.3 1.3 2,785 45.0 82 Residence Urban 1.3 4.9 1,169 68.6 83 Rural 1.6 3.3 4,408 83.9 171 Total 15-49 1.6 3.6 5,577 78.9 254 50-59 4.7 6.2 640 (94.9) 42 Total 15-59 1.9 3.9 6,217 81.2 296 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. 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 There are few variations according to background characteristics. The percentage of men with concurrent sexual partnerships (according to the cumulative prevalence indicator) increases with age, from less than 1 percent among those age 15-19 to 6 percent among those age 40-49. Men who are married or who are divorced, widowed, or separated (6 percent each) are more likely to report concurrent sexual partnerships in the 206 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior past 12 months than men who have never been married (1 percent). It is probable that men who are in polygynous unions are more likely than those who are not to have concurrent sexual partnerships. 13.5.3 Payment for Sex Male respondents in the 2014-15 RDHS who had had sex in the 12 months before the survey were asked whether they had ever paid anyone in exchange for sex and whether they had done so in the past 12 months or if any of their last three partners in the past 12 months was a commercial sex worker. They were also asked whether they used a condom the last time they paid for sex. The results in Table 13.10 show that only 7 percent of men age 15-49 have ever paid for sexual intercourse, and only 2 percent had done so in the 12 months before the survey. Among those men who paid for sexual intercourse in the last 12 months, 65 percent reported that they used a condom the last time they paid for sex. Men who are divorced, separated, or widowed (24 percent); men living in urban areas (12 percent) and in the City of Kigali (13 percent); and men in the highest wealth quintile (12 percent) are most likely to have ever paid for sexual intercourse. Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse Among men age 15-49 who had sexual intercourse in the 12 months before the survey, the percentage who ever paid for sexual intercourse and the 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 2014-15 Among men who had sex in the past 12 months: Among men who paid for sex in the past 12 months: Background characteristic Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Percentage reporting condom use at last paid sexual intercourse Number of men Age 15-24 7.7 4.4 453 * 20 15-19 4.5 3.3 102 * 3 20-24 8.6 4.7 352 * 17 25-29 7.2 3.2 665 * 21 30-39 6.3 1.5 1370 * 21 40-49 8.4 1.5 823 * 12 Marital status Never married 13.2 8.4 468 (66.4) 39 Married/living together 5.9 1.0 2785 (63.0) 28 Divorced/separated/widowed 24.1 11.0 58 * 6 Residence Urban 12.1 4.6 692 (80.4) 32 Rural 5.9 1.6 2619 (53.8) 42 Province City of Kigali 12.5 4.9 486 * 24 South 5.8 1.6 714 * 11 West 6.3 2.4 712 * 17 North 5.2 1.7 527 * 9 East 7.4 1.5 872 * 13 Education No education 2.2 0.3 415 * 1 Primary 7.5 2.4 2333 69.9 57 Secondary and higher 9.6 2.8 562 * 16 Wealth quintile Lowest 5.2 2.6 540 * 14 Second 5.5 1.4 639 * 9 Middle 4.6 1.2 668 * 8 Fourth 7.8 0.8 655 * 5 Highest 11.6 4.7 808 (73.9) 38 Total 15-49 7.2 2.2 3,310 65.2 74 50-59 7.4 0.0 591 * 0 Total 15-59 7.2 1.9 3,901 65.2 74 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 13.6 PRIOR TESTING FOR HIV People’s knowledge of their HIV status is considered a key motivating factor for behavior change and a critical linkage to care, treatment, and support services for infected individuals. Knowledge of HIV status helps HIV-negative individuals make specific decisions to reduce risk and increase safer sex practices so that they can remain free of disease. For those who are infected with HIV, knowledge of their status allows them to take action to protect their sexual partners, to seek treatment, and to plan for the future. The HIV/AIDS program in Rwanda has been engaged in increasing coverage of HIV counseling and testing services based on a multiple-intervention approach. In the 2014-15 RDHS, respondents were asked if they knew a place where they could go to be tested and, furthermore, if they had ever undergone an HIV test and received the results of the test. Tables 13.11.1 and 13.11.2 show that knowledge of a place to get an HIV test is universal among both women and men (99 percent each). Among the adult population age 15-49, 86 percent of women and 81 percent of men have ever been tested for HIV. The majority of women (82 percent) and men (78 percent) who were ever tested indicated that they had received the results of their test. However, a small proportion of women (3 percent) and men (3 percent) who were tested did not receive the results. Thirty-eight percent of women and 37 percent of men said that they had been tested during the 12 months prior to the survey and had received the results. Respondents age 20 and above are more likely to have received the results than younger respondents to have ever had an HIV test and. Among both women and men, urban residents are more likely than rural residents to have ever had an HIV test and received the results. Married respondents (95 percent of women and 96 percent of men) are more likely to have taken the test and received the results than never-married respondents. By province, the percentage of women who have ever been tested for HIV and received the results ranges from a low of 80 percent among those in South and North to a high of 87 percent among those in City of Kigali. Among men, the percentage ranges from 74 percent in South to 82 percent in City of Kigali. The proportion of women and men who have ever been tested for HIV and received the results is highest among those with no education. There is no consistent relationship with wealth quintile. HIV testing has increased since 2010. The proportion of women who have ever been tested for HIV and received their results has risen from 76 percent in 2010 to 82 percent in 2014-15, while the proportion among men has increased from 69 percent to 78 percent during the same period. 208 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior Table 13.11.1 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 were tested in the past 12 months and received the results of the last test, according to background characteristics, Rwanda 2014-15 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 for HIV in the past 12 months and received the results of the last test Number of women Background characteristic Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 98.6 68.0 4.0 28.0 100.0 72.0 36.8 5,225 15-19 97.9 52.5 5.3 42.2 100.0 57.8 27.4 2,768 20-24 99.3 85.5 2.6 11.9 100.0 88.1 47.4 2,457 25-29 99.3 92.5 2.5 5.0 100.0 95.0 46.0 2,300 30-39 99.7 94.0 2.4 3.7 100.0 96.3 41.4 3,726 40-49 99.4 86.3 3.1 10.6 100.0 89.4 29.3 2,246 Marital status Never married 98.4 64.0 4.4 31.6 100.0 68.4 32.2 5,100 Ever had sex 99.6 83.7 3.0 13.4 100.0 86.6 46.5 1,562 Never had sex 97.9 55.3 5.1 39.7 100.0 60.3 25.9 3,539 Married/living together 99.7 94.8 2.2 2.9 100.0 97.1 43.2 6,982 Divorced/separated/widowed 99.5 87.4 3.2 9.4 100.0 90.6 36.6 1,415 Residence Urban 99.5 86.5 2.2 11.3 100.0 88.7 42.8 2,626 Rural 99.1 81.4 3.4 15.2 100.0 84.8 37.3 10,871 Province City of Kigali 99.8 86.8 1.8 11.5 100.0 88.5 42.2 1,799 South 99.4 80.4 3.4 16.2 100.0 83.8 37.0 3,214 West 98.4 82.0 3.2 14.7 100.0 85.3 38.4 2,965 North 98.8 80.3 4.1 15.6 100.0 84.4 39.0 2,211 East 99.5 83.6 3.0 13.4 100.0 86.6 37.2 3,308 Education No education 99.4 86.5 3.3 10.2 100.0 89.8 33.5 1,665 Primary 98.9 81.7 2.7 15.6 100.0 84.4 37.4 8,678 Secondary and higher 99.7 82.1 4.4 13.5 100.0 86.5 43.5 3,154 Wealth quintile Lowest 98.5 81.8 3.3 14.9 100.0 85.1 37.7 2,561 Second 99.1 80.8 3.4 15.8 100.0 84.2 37.4 2,631 Middle 99.1 82.9 3.0 14.1 100.0 85.9 38.0 2,597 Fourth 99.3 81.7 3.1 15.2 100.0 84.8 37.5 2,634 Highest 99.6 84.4 3.0 12.7 100.0 87.3 40.8 3,073 Total 15-49 99.2 82.4 3.2 14.5 100.0 85.5 38.4 13,497 1 Includes “don’t know/missing” HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 209 Table 13.11.2 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 were tested in the past 12 months and received the results of the last test, according to background characteristics, Rwanda 2014-15 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 have been tested for HIV in the past 12 months and received the results of the last test Number of men Background characteristic Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 96.9 55.9 5.2 38.8 100.0 61.2 30.3 2,276 15-19 95.1 41.5 6.9 51.7 100.0 48.3 21.9 1,282 20-24 99.3 74.6 3.2 22.2 100.0 77.8 41.1 994 25-29 100.0 90.0 1.7 8.2 100.0 91.8 46.9 946 30-39 99.9 93.9 2.1 4.0 100.0 96.0 41.9 1,497 40-49 99.8 92.3 1.8 5.9 100.0 94.1 33.6 858 Marital status Never married 97.3 58.3 4.5 37.2 100.0 62.8 30.2 2,691 Ever had sex 98.6 69.5 3.6 27.0 100.0 73.0 36.7 1,110 Never had sex 96.5 50.4 5.2 44.4 100.0 55.6 25.7 1,581 Married/living together 100.0 95.6 2.1 2.3 100.0 97.7 42.8 2,792 Divorced/separated/widowed 100.0 89.6 3.4 7.0 100.0 93.0 43.4 94 Residence Urban 99.1 82.6 1.5 16.0 100.0 84.0 40.9 1,169 Rural 98.6 76.2 3.8 20.1 100.0 79.9 35.6 4,408 Province City of Kigali 99.2 81.5 1.8 16.7 100.0 83.3 38.5 804 South 99.0 73.9 3.9 22.2 100.0 77.8 33.8 1,327 West 97.8 78.4 3.1 18.6 100.0 81.4 41.1 1,182 North 98.6 78.2 3.8 18.1 100.0 81.9 35.9 851 East 98.9 77.5 3.4 19.1 100.0 80.9 35.2 1,413 Education No education 99.0 85.8 1.9 12.3 100.0 87.7 35.7 496 Primary 98.3 75.9 3.2 20.9 100.0 79.1 35.4 3,636 Secondary and higher 99.5 78.8 3.9 17.3 100.0 82.7 40.4 1,445 Wealth quintile Lowest 97.9 78.3 2.5 19.2 100.0 80.8 39.2 819 Second 98.8 78.1 3.7 18.2 100.0 81.8 37.3 991 Middle 98.9 77.3 4.3 18.4 100.0 81.6 35.1 1,097 Fourth 98.3 74.3 4.1 21.6 100.0 78.4 35.0 1,234 Highest 99.3 79.5 1.9 18.6 100.0 81.4 37.7 1,436 Total 15-49 98.7 77.5 3.3 19.2 100.0 80.8 36.7 5,577 50-59 98.8 78.8 3.1 18.1 100.0 81.9 24.6 640 Total 15-59 98.7 77.6 3.3 19.1 100.0 80.9 35.5 6,217 1 Includes “don’t know/missing” 13.7 HIV TESTING DURING ANTENATAL CARE Table 13.12 presents information on HIV screening of pregnant women age 15-49 who gave birth in the two years preceding the survey. The screening process is a key tool in reducing mother-to-child transmission of HIV. Ninety-three percent of women who gave birth in the two years before the survey received HIV counseling during antenatal care (ANC). More than 9 in 10 women (92 percent) were tested for HIV during antenatal care and received the test results and post-test counseling, while only 6 percent received results but did not receive post-test counseling. Less than 1 percent of women were tested for HIV during an ANC visit but did not receive the test results. 210 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior Overall, 92 percent of women received HIV counseling, an HIV test, and the results during ANC for their most recent birth in the two years preceding the survey. Women’s likelihood of receiving HIV counseling and testing during ANC is similar across all background characteristics. Table 13.12 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 the percentage who received an HIV test at the time of ANC or labor for their most recent birth by whether they received their test results, according to background characteristics, Rwanda 2014-15 Percentage who received counseling on HIV during antenatal care1 Percentage who were tested for HIV during antenatal care and who: Percentage who received counseling on HIV and an HIV test during ANC, and the results Percentage who had an HIV test during ANC or labor and who:2 Number of women who gave birth in the past 2 years3 Background characteristic 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 91.7 90.1 7.5 0.7 90.6 97.8 0.7 871 15-19 91.0 87.5 10.4 0.9 89.3 97.9 0.9 133 20-24 91.8 90.6 7.0 0.7 90.9 97.8 0.7 738 25-29 92.7 91.3 6.1 0.2 92.0 97.5 0.3 899 30-39 94.4 93.0 5.3 0.1 93.9 98.5 0.1 1,228 40-49 92.1 92.0 3.5 1.0 89.7 96.1 1.0 237 Marital status Never married 89.9 88.8 8.1 0.9 89.0 96.9 0.9 349 Married/living together 93.4 92.2 5.7 0.4 92.6 98.1 0.4 2,643 Divorced/separated/widowed 93.1 90.2 5.7 0.0 92.0 96.4 0.0 244 Residence Urban 92.9 91.5 7.0 0.1 92.8 98.8 0.2 561 Rural 93.0 91.7 5.8 0.4 92.0 97.7 0.4 2,675 Province City of Kigali 94.7 90.7 7.5 0.0 94.5 98.6 0.0 395 South 94.2 94.6 3.6 0.6 93.4 98.2 0.6 730 West 91.0 89.5 7.4 0.5 89.7 97.0 0.6 763 North 92.2 90.8 7.9 0.0 91.9 99.0 0.0 453 East 93.4 92.1 5.1 0.4 92.3 97.4 0.4 896 Education No education 93.2 90.3 4.4 0.6 91.3 94.9 0.6 439 Primary 93.2 91.9 6.2 0.3 92.4 98.3 0.3 2,316 Secondary and higher 92.1 91.9 6.5 0.5 91.6 98.5 0.5 481 Wealth quintile Lowest 91.2 89.1 7.1 0.5 90.3 96.5 0.5 792 Second 93.9 91.5 6.1 0.3 92.5 97.8 0.3 672 Middle 92.8 92.7 5.4 0.7 91.9 98.4 0.7 622 Fourth 93.5 93.7 4.8 0.3 92.7 98.5 0.3 573 Highest 94.3 92.3 6.1 0.2 94.1 98.7 0.3 576 Total 15-49 93.0 91.7 6.0 0.4 92.2 97.9 0.4 3,236 1 In this context, "pretest counseling" 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 Women are asked whether they received an HIV test during labor only if they were not tested for HIV during ANC. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. Table 13.13 shows that 43 percent of women and 45 percent of men have ever had an HIV test as part of a prenuptial arrangement. The table also indicates that the large majority of ever-married women (86 percent) and men (93 percent) have been tested as a couple at some point. Older women and men (age 40-49) are least likely to have ever been tested as a couple (68 percent of women and 87 percent of men). Formerly married respondents and those with no education are less likely to have been tested as a couple than those who are currently in a union and those with at least a primary education. Variations in testing as a couple by other background characteristics are small. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 211 Table 13.13 HIV testing for prenuptial purposes and as a couple Percentage of all 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 2014-15 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 34.8 5,225 24.4 2,276 92.4 1,118 90.7 181 15-19 20.6 2,768 15.5 1,282 81.9 106 * 3 20-24 50.9 2,457 36.0 994 93.5 1012 90.6 178 25-29 66.6 2,300 62.2 946 95.1 1,749 96.6 554 30-39 54.6 3,726 67.2 1,497 89.7 3,369 94.5 1,319 40-49 19.7 2,246 40.0 858 67.6 2,160 87.0 832 Marital status Never married 24.8 5,100 22.3 2,691 na na na na Ever had sex 22.9 3,539 17.6 1,580 na na na na Never had sex 29.0 1,562 29.1 1,111 na na na na Married/living together 57.7 6,982 65.8 2,792 90.8 6,982 93.1 2,792 Divorced/separated/widowed 37.8 1,415 60.4 94 59.4 1,415 74.2 94 Residence Urban 45.3 2,626 50.6 1,169 89.0 1,456 93.1 517 Rural 42.7 10,871 43.2 4,408 84.8 6,940 92.3 2369 Province City of Kigali 40.3 1,799 48.6 804 90.0 1,013 94.6 369 South 46.7 3,214 41.1 1,327 82.1 1,972 93.2 624 West 42.2 2,965 51.8 1,182 86.2 1,817 94.8 646 North 47.8 2,211 46.6 851 85.6 1,332 87.5 484 East 39.0 3,308 38.8 1,413 85.9 2,263 92.1 764 Education No education 32.8 1,665 45.4 496 76.5 1,501 90.5 412 Primary 44.7 8,678 46.2 3,636 86.7 5,873 92.7 2116 Secondary and higher 44.5 3,154 40.8 1,445 92.0 1,023 93.6 358 Wealth quintile Lowest 41.0 2,561 48.3 819 81.6 1,809 90.7 516 Second 43.8 2,631 48.9 991 83.3 1,762 93.3 614 Middle 42.1 2,597 43.7 1,097 86.2 1,684 93.0 606 Fourth 44.5 2,634 39.8 1,234 87.7 1,553 92.7 571 Highest 44.1 3,073 44.8 1,436 89.4 1,588 92.5 580 Total 15-49 43.2 13,497 44.7 5,577 85.5 8,397 92.5 2,886 50-59 na na 12.6 640 na na 66.3 628 Total 15-59 na na 41.4 6,217 na na 87.8 3,514 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 13.8 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 2014-15 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, however, because women are likely to experience non-STI conditions of the reproductive tract that produce a discharge. Table 13.14 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. Nine percent of women and 2 percent of men reported having had an abnormal genital discharge in the past 12 months, and 11 percent of women and 4 percent 212 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior of men reported having had a genital sore or ulcer. Overall, 15 percent of women and 5 percent of men had either an STI or symptoms of an STI in the 12 months preceding the survey. Table 13.14 Self-reported prevalence of sexually transmitted infections (STIs) and STI 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 2014-15 Percentage of women who reported having in the past 12 months: Percentage of men who reported having in the past 12 months: Background characteristic STI Bad- smelling/ abnormal genital discharge Genital sore/ulcer STI/ genital discharge/ sore or ulcer Number of women who ever had sexual intercourse STI Bad- smelling/ abnormal discharge from penis Genital sore/ulcer STI/ abnormal discharge from penis/ sore or ulcer Number of men who ever had sexual intercourse Age 15-24 2.7 8.0 8.4 12.5 2,141 1.3 2.4 2.6 3.9 874 15-19 1.3 9.8 8.4 14.2 557 0.9 2.7 2.5 4.3 301 20-24 3.1 7.4 8.4 11.9 1,584 1.5 2.2 2.7 3.8 573 25-29 3.0 8.2 9.1 12.8 2,027 2.0 2.2 4.1 4.8 823 30-39 4.1 9.5 12.4 16.3 3,583 2.3 1.5 4.1 4.8 1,449 40-49 3.4 9.1 12.3 15.2 2,204 2.1 0.5 4.9 5.6 848 Marital status Never married 2.7 9.0 8.9 12.9 1,562 1.8 2.6 2.5 3.9 1,110 Ever had sex 2.7 9.0 8.9 12.9 1,562 1.8 2.6 2.5 3.9 1,110 Married/living together 3.6 8.2 11.1 14.6 6,980 1.9 1.1 4.3 4.9 2,789 Divorced/separated/widowed 3.3 11.4 11.6 15.8 1,413 4.7 4.2 10.1 11.5 94 Male circumcision Circumcised na na na na na 1.8 1.3 3.6 4.5 1,153 Not circumcised na na na na na 2.0 1.7 4.1 4.9 2,839 Residence Urban 3.4 8.6 10.7 14.5 1,931 2.4 2.1 3.6 5.1 877 Rural 3.4 8.9 10.9 14.6 8,024 1.8 1.5 4.1 4.7 3,117 Province City of Kigali 3.1 8.3 9.5 13.2 1,345 1.9 1.4 3.2 4.0 596 South 3.0 6.5 9.9 12.5 2,334 1.1 1.5 3.9 4.3 921 West 2.5 10.8 11.6 16.3 2,137 1.8 1.3 3.5 4.4 828 North 3.8 11.0 10.9 16.8 1,539 2.1 2.1 2.2 3.6 614 East 4.4 8.2 11.7 14.2 2,600 2.9 1.9 5.9 6.7 1,034 Education No education 4.2 8.1 10.7 13.7 1,593 3.0 2.0 5.5 6.7 447 Primary 3.4 9.5 11.4 15.5 6,802 2.0 1.7 4.4 5.1 2,718 Secondary and higher 2.7 6.6 8.5 11.4 1,560 1.1 1.0 1.9 2.7 829 Wealth quintile Lowest 3.2 9.9 10.4 14.9 2,095 2.8 2.8 6.9 7.3 619 Second 3.2 8.7 11.0 14.7 1,995 2.4 1.4 4.0 4.9 726 Middle 3.7 8.9 10.9 14.8 1,931 1.6 1.2 3.3 4.1 807 Fourth 3.4 8.7 11.1 14.2 1,813 1.7 1.0 3.6 4.2 812 Highest 3.4 7.8 10.8 14.1 2,120 1.7 1.9 3.0 4.1 1,030 Total 15-49 3.4 8.8 10.8 14.5 9,955 2.0 1.6 4.0 4.8 3,994 50-59 na na na na na 1.2 0.7 2.8 3.7 634 Total 15-59 na na na na na 1.9 1.5 3.8 4.6 4,628 Note: Total includes 1 case in which information on male circumcision is missing. na = Not applicable The proportion of respondents who reported having had an STI or STI symptoms varied minimally across background characteristics. An exception is that men who are divorced, separated, or widowed (12 percent) were more likely to have had an STI or STI symptoms than men in other marital status categories (4-5 percent). Figure 13.1 shows that, among those reporting a sexually transmitted infection or symptom thereof in the 12 months before the survey, men were more likely to seek treatment from various sources than women (64 percent versus 58 percent). HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 213 Figure 13.1 Women and men seeking treatment for STIs 13.9 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. 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. Table 13.15 presents data on the prevalence of injections. Women were more likely than men to report having received at least one injection from a health provider in the past 12 months (60 percent and 47 percent, respectively). On average, women had received 1.7 injections, and men had received 0.8 injections. The proportion of respondents who received a medical injection in the 12 months before the survey peaks at age 25-29 among both women and men. Currently married women and men are most likely to have received at least one injection from a health provider, followed closely by women and men who have never been married but have had sex. Variations in injection prevalence across provinces are not large. The percentage of women and men reporting that they received at least one injection from a health worker during the 12 months prior to the survey is lowest in North (57 percent and 43 percent, respectively). The prevalence of medical injections among women is highest in the City of Kigali and in East (63 percent and 62 percent, respectively), while the prevalence among men is highest in West (51 percent). Urban-rural differences in receipt of at least one injection from a health provider are small. The proportion of women and men receiving at least one injection increases with increasing education. 51 2 5 42 57 5 2 37 Clinic/hospital/private doctor/other health professional Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment Women Men RDHS 2014-15 214 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior Table 13.15 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 2014-15 Women Men Background characteristic Percent- age who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respon- dents For last injection, syringe and needle taken from a new, unopened package Number of respon- dents receiving medical injections in the last 12 months Percent- age who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of respon- dents For last injection, syringe and needle taken from a new, unopened package Number of respon- dents receiving medical injections in the last 12 months Age 15-24 58.4 1.4 5,225 99.0 3,053 44.3 0.8 2,276 99.0 1,008 15-19 52.2 1.1 2,768 98.8 1,445 40.4 0.8 1,282 98.4 518 20-24 65.4 1.7 2,457 99.2 1,608 49.3 0.9 994 99.8 490 25-29 70.1 2.1 2,300 99.5 1,614 55.2 0.8 946 98.8 522 30-39 64.2 2.0 3,726 99.2 2,392 48.4 0.8 1,497 99.6 724 40-49 48.9 1.5 2,246 99.1 1,098 41.2 0.9 858 99.4 353 Marital status Never married 52.8 1.2 5,100 98.9 2,694 43.2 0.8 2,691 99.1 1,164 Ever had sex 61.9 1.6 1,562 98.7 966 49.0 0.9 1,110 99.5 544 Never had sex 48.8 1.0 3,539 99.1 1,727 39.2 0.8 1,581 98.7 620 Married/living together 67.6 2.1 6,982 99.3 4,721 50.1 0.8 2,792 99.3 1,400 Divorced/separated/widowed 52.5 1.4 1,415 98.9 742 46.8 1.5 94 (100.0) 44 Residence Urban 62.5 1.7 2,626 99.3 1,640 48.4 0.9 1,169 99.3 566 Rural 59.9 1.7 10,871 99.1 6,516 46.3 0.8 4,408 99.2 2,041 Province City of Kigali 63.3 1.6 1,799 99.4 1,139 45.7 0.9 804 100.0 368 South 61.5 1.8 3,214 99.2 1,978 44.1 0.6 1,327 98.2 585 West 57.8 1.7 2,965 99.2 1,714 51.4 1.0 1,182 99.4 607 North 57.4 1.6 2,211 99.0 1,269 42.5 0.7 851 99.4 361 East 62.2 1.8 3,308 99.0 2,057 48.6 1.0 1,413 99.4 686 Education No education 54.5 1.6 1,665 98.9 908 42.9 0.6 496 98.6 212 Primary 60.6 1.8 8,678 99.2 5,256 45.4 0.8 3,636 99.0 1,651 Secondary and higher 63.2 1.6 3,154 99.2 1,992 51.5 1.0 1,445 99.7 744 Wealth quintile Lowest 59.3 1.7 2,561 99.0 1,519 44.4 0.9 819 99.2 363 Second 60.1 1.7 2,631 99.1 1,582 49.1 0.7 991 99.8 487 Middle 59.4 1.8 2,597 98.9 1,543 47.5 0.7 1,097 98.8 521 Fourth 60.7 1.7 2,634 99.2 1,600 46.2 0.9 1,234 98.9 570 Highest 62.2 1.7 3,073 99.5 1,913 46.4 1.0 1,436 99.4 667 Total 15-49 60.4 1.7 13,497 99.2 8,157 46.8 0.8 5,577 99.2 2,607 50-59 na na na na na 33.3 1.0 640 98.4 213 Total 15-59 na na na na na 45.4 0.9 6,217 99.1 2,820 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable Practically all injections (99 percent among both women and men) were reported to have been administered with a needle and syringe taken from a newly opened package. 13.10 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 HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 215 where they can obtain condoms. Issues such as abstinence, age at sexual debut, and condom use are also addressed. 13.10.1 Knowledge about HIV and AIDS and Sources for Condoms Knowledge of how HIV is transmitted is crucial to help young people avoid HIV/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 of HIV and AIDS 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 13.16 shows that 65 percent of young women and 64 percent of young men age 15-24 have comprehensive knowledge of HIV and AIDS. Young people’s level of comprehensive knowledge about HIV and AIDS increases slightly with age and much more so by education. As expected, comprehensive HIV and AIDS knowledge is much more common among young women and men in urban areas (74 percent and 75 percent, respectively) than among those in rural areas (62 percent each). Table 13.16 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 2014-15 Women Men Background characteristic Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source1 Number of respondents Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source1 Number of respondents Age 15-19 61.6 84.6 2,768 59.5 93.6 1,282 15-17 59.7 81.5 1,743 55.7 91.0 808 18-19 64.7 89.8 1,025 65.9 97.9 474 20-24 68.1 91.4 2,457 70.6 98.3 994 20-22 68.5 91.1 1,545 68.4 97.8 624 23-24 67.4 92.1 913 74.3 99.0 370 Marital status Never married 63.2 86.7 4,107 64.2 95.3 2,095 Ever had sex 65.0 91.4 1,023 65.6 98.3 693 Never had sex 62.6 85.1 3,084 63.6 93.8 1,401 Ever married 69.8 92.0 1,118 65.2 99.5 181 Residence Urban 73.6 94.3 1,115 74.7 98.6 451 Rural 62.2 86.1 4,110 61.8 94.9 1,825 Education No education 45.9 79.7 138 36.2 91.2 55 Primary 61.6 83.7 3,033 58.9 94.2 1,356 Secondary and higher 70.3 94.5 2,054 74.7 98.1 864 Total 64.6 87.8 5,225 64.3 95.6 2,276 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 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 a source for condoms: friends, family members, and home. Because condoms play an important role in fighting the transmission of HIV, young women and men were asked whether they knew of a source for condoms. Only “formal” sources of condoms were considered; friends and family and other similar sources were not included. Table 13.16 shows that, 88 percent of young women and 96 percent of young men know where to obtain a condom. Knowledge of a condom source tends to increase slightly with age. Ever-married youth and those who 216 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior have never been married but have had sex are more likely to know about a source for condoms than those who have never been married and never had sex. Young women (94 percent) and men (97 percent) in urban areas are more likely to know a source of condom than those in rural areas (62 percent of young women compared to 62 percent of young men). Consistent with the patterns observed for other indicators, youth who are better educated (95 percent of women and 98 percent of men) are more likely than their counterparts to know a source of condoms (80 percent and 91 percent among women and men, respectively, with no education). 13.10.2 Age at First Sex and Condom Use at First Sexual Intercourse Information from the 2014-15 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 13.17 shows the proportion of young women and men age 15-24 who had sex before age 15 and before age 18. Five percent of young women and 11 percent of young men had sex before age 15, whereas 20 percent of young women and 23 percent of young men had sex by age 18. Young adults women age 15-19 (7 percent) are more likely to have had sexual intercourse before age 15 than those age 20-24 (3 percent). Similarly, youth men age 18-19 (28 percent) are more likely than those age 20-24 (21 percent) to have had sex before age 18. Table 13.17 Age at first sexual intercourse among young people Percentage of young women and young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Rwanda 2014-15 Women Men Background characteristic 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 6.8 2,768 na na 13.4 1,282 na na 15-17 7.5 1,743 na na 12.9 808 na na 18-19 5.5 1,025 23.6 1,025 14.2 474 28.1 474 20-24 3.0 2,457 18.1 2,457 7.0 994 20.5 994 20-22 3.1 1,545 19.8 1,545 7.6 624 21.3 624 23-24 2.9 913 15.3 913 6.0 370 19.0 370 Marital status Never married 5.6 4,107 15.8 2,375 11.5 2,095 23.7 1,287 Ever married 3.0 1,118 28.2 1,107 0.6 181 17.5 181 Knows condom source1 Yes 4.8 4,588 19.8 3,168 10.7 2,176 23.2 1,441 No 6.5 637 19.3 315 9.1 100 (8.3) 27 Residence Urban 5.2 1,115 23.7 770 8.1 451 23.3 345 Rural 5.0 4,110 18.6 2,712 11.2 1,825 22.8 1,123 Education No education 10.1 138 26.4 125 9.5 55 (31.3) 40 Primary 5.7 3,033 24.3 1,947 11.0 1,356 23.3 812 Secondary and higher 3.7 2,054 12.9 1,411 10.1 864 21.9 616 Total 5.0 5,225 19.7 3,482 10.6 2,276 22.9 1,468 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not available 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Among young women, there is a negative association between level of education and early initiation of sexual activity: the proportion of women reporting sex before age 15 or age 18 decreases as education increases. This association is not observed among young men. Ever-married women are more likely than never-married HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 217 women to have had sex before age 18 (28 percent versus 16 percent). The opposite pattern is observed among men, however, with those who have ever been married being less likely to have had sex before age 18 than those who have never been married. 13.10.3 Premarital Sexual Activity Table 13.18 presents 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 those who had sex in the past 12 months, the percentage who used condoms during their most recent sexual intercourse. Table 13.18 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 2014-15 Women Men Background characteristic 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 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 Age 15-19 83.1 7.2 2,661 52.3 193 76.7 7.7 1,279 66.7 99 15-17 87.7 4.3 1,731 52.6 75 83.2 3.3 808 (47.7) 27 18-19 74.4 12.6 930 52.0 117 65.5 15.3 472 73.7 72 20-24 60.4 18.8 1,445 50.3 272 51.6 21.6 816 72.2 176 20-22 62.7 17.8 1,043 50.6 186 54.5 19.8 554 69.5 110 23-24 54.4 21.3 403 49.5 86 45.3 25.2 262 76.7 66 Knows condom source1 Yes 73.8 12.1 3,560 54.4 432 65.9 13.6 1,996 70.8 272 No 83.8 6.0 547 (8.0) 33 87.8 2.4 99 * 2 Residence Urban 65.8 17.2 913 66.9 157 57.1 21.3 431 83.5 92 Rural 77.8 9.6 3,193 43.0 307 69.5 11.0 1,664 63.6 183 Education No education 54.4 19.1 60 * 12 (75.9) (12.8) 39 * 5 Primary 72.7 11.9 2,208 45.1 264 68.3 12.4 1,214 71.3 150 Secondary and higher 78.6 10.3 1,838 60.6 189 64.5 14.2 842 69.5 119 Total 75.1 11.3 4,107 51.1 464 66.9 13.1 2,095 70.2 275 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. Seventy-five percent of never-married young women and 67 percent of never-married men reported that they had never had sex. Consequently, the proportions of young adults reporting recent sexual activity (i.e., within the 12-month period before the survey) are low (11 percent among young women and 13 percent among young men). Among never-married, sexually active young women, 51 percent used a condom during their most recent sexual intercourse. Condom use among women is higher in urban than rural areas (67 percent versus 43 percent) and higher among those with a secondary education or more than among those with only a primary education. Seventy percent of never-married, sexually active young men reported using a condom during their last sexual intercourse. Similar to women, condom use among men is higher in urban areas (84 percent) than in rural areas (64 percent); however, it is not associated with educational level. 218 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior 13.10.4 Multiple Sexual Partnerships The most common mode of HIV transmission is through unprotected sex with an infected partner. To prevent HIV and AIDS transmission, it is important for young people to be faithful to one uninfected partner. Table 13.19 shows the percentage of young women and men age 15-24 who had sexual intercourse with more than one partner in the 12 months before the survey, by background characteristics. Table 13.19 Multiple sexual partners in the past 12 months among young people Among all women and men age 15-24, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months, by background characteristics, Rwanda 2014-15 Women age 15-24 Men age 15-24 Background characteristic 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 0.5 2,768 0.7 1,282 15-17 0.0 1,743 0.2 808 18-19 1.4 1,025 1.5 474 20-24 0.9 2,457 3.5 994 20-22 1.0 1,545 2.2 624 23-24 0.8 913 5.6 370 Marital status Never married 0.6 4,107 1.6 2,095 Ever married 1.3 1,118 4.9 181 Knows condom source1 Yes 0.8 4,588 2.0 2,176 No 0.1 637 0.0 100 Residence Urban 2.1 1,115 4.8 451 Rural 0.4 4,110 1.2 1,825 Education No education 0.6 138 3.1 55 Primary 0.8 3,033 2.0 1,356 Secondary and higher 0.6 2,054 1.7 864 Total 15-24 0.7 5,225 1.9 2,276 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Overall, one percent of young women and only 2 percent of young men reported having had two or more sexual partners in the past 12 months. Differences by background characteristics among women are very slight. Among men, those age 23-24 (6 percent), those who have ever been married (5 percent), and those who live in urban areas (5 percent) are more likely to have had two or more sexual partners in the past 12 months than their counterparts. 13.10.5 Age-mixing in Sexual Relationships In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the spread of HIV and other STIs because older men are more likely to have been exposed to these diseases. Also, using preventive strategies such as negotiating safer sex is more difficult when a woman’s partner is much older. To examine age-mixing, the 2014-15 RDHS asked respondents who had had sex in the 12 months preceding the survey to provide the age of their partner(s). The results are presented in Table 13.20 for young women and men age 15-19. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 219 Table 13.20 Age-mixing in sexual relationships among women and men age 15-19 Among women and men age 15-19 who had sexual intercourse in the past 12 months, percentage who had sexual intercourse with a partner who was 10 or more years older than themselves, by background characteristics, Rwanda 2014-15 Women age 15-19 who had sexual intercourse in the past 12 months Men age 15-19 who had sexual intercourse in the past 12 months Background characteristic Percentage who had sexual intercourse with a partner 10+ years older Number of women Percentage who had sexual intercourse with a partner 10+ years older Number of men Age 15-17 13.5 87 (2.8) 27 18-19 8.4 212 1.5 75 Residence Urban 8.7 87 (3.3) 23 Rural 10.4 212 1.4 79 Education No education * 9 * 2 Primary 9.3 200 2.0 57 Secondary and higher 10.7 89 (1.8) 43 Total 9.9 298 1.9 102 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. Overall, 10 percent of young women and 2 percent of young men age 15-19 who had sexual intercourse in the 12 months before the survey, had sex with a partner who was 10 or more years older than they were. Women age 15-17 are more likely to have had sex with someone 10 or more years older than they are, than those age 18-19. 13.10.6 Recent HIV Testing among Youth People’s knowledge of their HIV serostatus can motivate them to practice safer sexual behavior to avoid transmitting the virus to others. It is particularly important to measure coverage of HIV testing among youth, not only because of their vulnerability but also because they may encounter obstacles to counseling and testing. The 2014-15 RDHS asked respondents age 15-24 who had had sexual intercourse in the 12 months before the survey whether they had been tested for HIV in the past 12 months and received their test results. The results are shown in Table 13.21. 220 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior Table 13.21 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 were tested for HIV in the past 12 months and received the results of the last test, by background characteristics, Rwanda 2014-15 Women age 15-24 who have had sexual intercourse in the past 12 months: Men age 15-24 who have had sexual intercourse in the past 12 months: Background characteristic Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Age 15-19 61.3 298 29.4 102 15-17 43.4 87 (29.6) 27 18-19 68.6 212 29.3 75 20-24 59.0 1,235 54.5 352 20-22 62.8 662 52.5 179 23-24 54.7 572 56.6 173 Marital status Never married 56.2 464 38.3 275 Ever married 60.9 1,069 65.2 179 Knows condom source1 Yes 60.1 1,417 49.0 450 No 52.2 116 * 3 Residence Urban 61.2 350 46.1 111 Rural 58.9 1,183 49.8 343 Education No education 49.3 86 * 22 Primary 59.3 1,049 49.2 290 Secondary and higher 62.1 398 47.1 142 Total 59.5 1,533 48.9 453 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. Sixty percent of young women and 49 percent of young men who had had sexual intercourse in the year before the survey had been tested for HIV in the past 12 months and received the results of the test. Among women, those age 18-19 (69 percent), those who know a source for condoms (60 percent), and those with a secondary education or higher (62 percent) are more likely to have been tested for HIV and received the results in the past 12 months than their counterparts. The percentage of young women and men who were tested for HIV in the last 12 months and received the results is higher among those who have ever been married (61 percent for men and 65 percent for men) than among those who have never been married (56 percent for women and 38 percent for men). 13.11 MALE CIRCUMCISION Studies have shown that male circumcision, which involves the removal of the foreskin of the penis, is associated with lower susceptibility to transmission of STIs, including HIV. Consequently, WHO recommends male circumcision as an HIV prevention method. Since 2009, the Ministry of Health of Rwanda has included male circumcision in the National Strategic Plans against HIV and AIDS. The 2014-15 RDHS collected data on the prevalence of circumcision among male respondents, including age at circumcision and type of practitioner who performed the procedure. In Rwanda, 30 percent of men age 15-49 have been circumcised (Table 13.22). The rate varies according to background characteristics. Results by age group show that the prevalence of circumcision is HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 221 highest at age 20-24 (44 percent), after which it drops gradually to a low of 18 percent at age 45-49. There are large geographic differentials, with the practice occurring more frequently in urban areas (58 percent) than in rural areas (22 percent). By province, the proportion of men who are circumcised is highest in City of Kigali (50 percent) and West (40 percent) and lowest in South (17 percent). There are also socioeconomic differences in the prevalence of circumcision, with the highest proportions among men who have a secondary education or higher (59 percent) and those in the richest wealth quintile (55 percent). Finally, differentials by religion show that Muslim men are much more likely to be circumcised (85 percent) than men of other religions (32 percent or less). Men who were circumcised were asked who had performed the procedure. The majority of men (86 percent) said they were circumcised by a health professional. This proportion remains high irrespective of background characteristics but is highest among circumcised men in the city of Kigali (93 percent), those in the South province (94 percent), those with a secondary education or higher (90 percent), and those in the highest wealth quintile (89 percent). Eight percent of circumcisions were performed by a traditional practitioner or family friend. Table 13.22 Practice of circumcision Percentage of men age 15-49 who are circumcised, and percent distribution of circumcised men by type of practitioner who performed the circumcision, according to background characteristics, Rwanda 2014-15 Percentage circumcised Number of men Who performed the circumcision Background characteristic Traditional practitioner/ family friend Health professional Other Don’t know Missing Total Number of circumcised men Age 15-19 26.5 1,282 6.3 87.0 3.7 2.8 0.3 100.0 340 20-24 44.2 994 7.0 88.6 2.9 1.3 0.3 100.0 439 25-29 35.3 946 7.2 86.0 4.1 2.8 0.0 100.0 334 30-34 27.7 930 8.7 84.6 1.6 4.7 0.5 100.0 257 35-39 22.0 567 7.4 81.8 7.8 2.5 0.6 100.0 125 40-44 18.9 473 13.1 79.2 3.8 2.8 1.1 100.0 89 45-49 17.5 385 12.6 82.7 2.6 2.0 0.2 100.0 67 Residence Urban 58.2 1,169 4.5 89.5 1.8 3.9 0.3 100.0 680 Rural 22.0 4,408 10.0 83.3 4.7 1.7 0.3 100.0 972 Province City of Kigali 50.2 804 2.7 92.9 0.8 3.3 0.4 100.0 403 South 17.3 1,327 2.0 94.1 1.6 1.9 0.4 100.0 230 West 40.3 1,182 16.3 78.2 2.7 2.5 0.3 100.0 476 North 19.1 851 2.3 77.1 19.6 1.0 0.0 100.0 162 East 26.9 1,413 8.2 86.7 1.6 3.2 0.3 100.0 380 Education No education 11.9 496 15.6 73.8 7.0 3.6 0.0 100.0 59 Primary 20.4 3,636 10.3 82.2 4.6 2.4 0.5 100.0 742 Secondary and higher 58.8 1,445 5.0 89.8 2.3 2.7 0.2 100.0 850 Religion Catholic 24.7 2,488 8.3 87.3 2.0 2.3 0.2 100.0 615 Protestant 31.5 2,135 8.4 85.2 3.2 2.9 0.3 100.0 673 Adventist 28.7 641 2.5 89.4 6.5 0.6 1.0 100.0 184 Muslim 84.7 168 9.8 78.1 7.5 4.6 0.0 100.0 142 Traditional/other/no religion 26.7 140 5.3 85.8 3.0 5.9 0.0 100.0 37 Wealth quintile Lowest 12.6 819 7.9 80.7 8.9 2.5 0.0 100.0 104 Second 17.6 991 11.3 82.6 5.3 0.8 0.0 100.0 174 Middle 23.0 1,097 9.2 82.0 4.9 3.0 0.8 100.0 253 Fourth 27.0 1,234 9.1 85.4 4.2 0.9 0.4 100.0 333 Highest 54.9 1,436 5.9 88.6 1.6 3.6 0.2 100.0 788 Total 15-49 29.6 5,577 7.7 85.8 3.5 2.6 0.3 100.0 1,652 50-59 11.8 640 26.1 69.0 4.9 0.0 0.0 100.0 75 Total 15-59 27.8 6,217 8.5 85.1 3.6 2.5 0.3 100.0 1,727 Note: Total includes 5 cases in which information on religion is missing. 222 • HIV- and AIDS-Related Knowledge, Attitudes, and Behavior Table 13.23 shows that 80 percent of circumcisions were performed at a health facility, whereas 6 percent were carried out at the home of a health care provider and 3 percent at the respondent’s home. Four percent of men were circumcised at a ritual site. The proportion of men who were circumcised at a health facility increases with increasing education; 50 percent for those with no education level represent and 84 percent for those with secondary or higher education. Muslim men are most likely to have been circumcised at a ritual site or at home compared to other religions. Table 13.23 Place of circumcision Percent distribution of circumcised men age 15-49 by place of circumcision, according to background characteristics, Rwanda 2014-15 Place of circumcision Background characteristic 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 80.9 6.2 4.3 3.2 3.5 1.9 100.0 340 20-24 82.3 5.4 3.5 2.5 5.4 0.9 100.0 439 25-29 80.1 6.7 2.0 5.0 4.5 1.7 100.0 334 30-34 81.2 4.3 1.8 2.7 4.9 5.2 100.0 257 35-39 77.0 4.8 1.8 6.5 7.6 2.2 100.0 125 40-44 70.9 5.9 8.6 4.3 7.5 2.8 100.0 89 45-49 66.6 7.4 2.9 4.5 16.5 2.1 100.0 67 Residence Urban 79.7 6.2 4.2 3.5 2.9 3.3 100.0 680 Rural 79.7 5.4 2.5 3.7 7.3 1.3 100.0 972 Province City of Kigali 85.1 5.0 2.9 3.1 0.8 3.0 100.0 403 South 85.8 3.9 2.7 4.6 1.9 1.0 100.0 230 West 71.0 10.1 4.5 0.3 11.5 2.6 100.0 476 North 85.7 2.2 2.2 5.0 3.8 1.0 100.0 162 East 78.7 3.5 2.8 7.3 5.8 1.9 100.0 380 Education No education 57.2 18.2 1.2 10.7 10.3 2.4 100.0 59 Primary 76.7 5.6 3.1 4.6 8.0 2.0 100.0 742 Secondary and higher 84.0 4.9 3.5 2.3 2.9 2.3 100.0 850 Religion Catholic 82.9 5.0 2.1 2.0 6.0 1.9 100.0 615 Protestant 79.5 6.9 3.3 2.5 5.3 2.5 100.0 673 Adventist 86.9 4.3 0.9 2.4 3.9 1.6 100.0 184 Muslim 56.6 6.4 10.6 18.9 5.9 1.5 100.0 142 Traditional/other/no religion 85.6 0.0 3.1 0.0 5.4 5.9 100.0 37 Wealth quintile Lowest 72.6 7.6 2.9 7.0 9.1 0.9 100.0 104 Second 77.3 7.3 2.9 2.2 9.8 0.4 100.0 174 Middle 81.4 4.4 1.4 2.7 8.5 1.6 100.0 253 Fourth 81.6 5.5 2.6 3.6 5.5 1.2 100.0 333 Highest 79.9 5.7 4.2 3.8 3.1 3.3 100.0 788 Total 15-49 79.7 5.7 3.2 3.7 5.5 2.2 100.0 1,652 50-59 63.0 6.4 6.5 8.7 14.4 0.9 100.0 75 Total 15-59 79.0 5.8 3.4 3.9 5.9 2.1 100.0 1,727 Men who said they had been circumcised were asked how old they were at the time of circumcision. The results are presented in Table 13.24. One-quarter of circumcisions took place before age 13, and over one-third (35 percent) were performed between age 13 and age 19. However, the largest proportion of circumcised men (39 percent) said that the procedure took place when they were age 20 or older. Only 2 percent of men were not certain when they were circumcised, perhaps because they were circumcised at a very young age and do not remember the event. HIV- and AIDS-Related Knowledge, Attitudes, and Behavior • 223 There are no specific patterns in age at circumcision with respect to current age group. However, the proportion of men who were circumcised before age 13 is highest among those living in urban areas (33 percent), those in the West province and City of Kigali (31 percent and 30 percent, respectively), those with no education (40 percent), and those in the wealthiest households (32 percent). Also, about half of Muslim men (51 percent) were circumcised before age 13. Table 13.24 Age at circumcision Percent distribution of circumcised men age 15-49 by age at circumcision, according to background characteristics, Rwanda 2014-15 Age at circumcision Background characteristic <13 13-19 ≥20 Don’t know/ missing Total Number of circumcised men Age 15-19 34.2 64.1 0.2 1.4 100.0 340 20-24 20.5 39.5 38.2 1.8 100.0 439 25-29 21.0 21.9 56.4 0.7 100.0 334 30-34 23.8 17.7 56.9 1.6 100.0 257 35-39 27.1 21.8 48.5 2.6 100.0 125 40-44 33.0 19.9 45.9 1.2 100.0 89 45-49 18.0 27.4 53.8 0.9 100.0 67 Residence Urban 33.4 27.2 37.7 1.6 100.0 680 Rural 19.1 40.0 39.5 1.3 100.0 972 Province City of Kigali 29.8 24.7 43.0 2.5 100.0 403 South 19.2 30.6 49.3 0.9 100.0 230 West 30.5 43.4 25.1 1.0 100.0 476 North 14.6 45.2 40.2 0.0 100.0 162 East 21.0 32.6 44.5 1.9 100.0 380 Education No education 40.4 28.7 29.9 1.0 100.0 59 Primary 21.0 33.7 44.0 1.3 100.0 742 Secondary and higher 27.4 36.1 34.9 1.6 100.0 850 Religion Catholic 20.5 35.6 42.3 1.6 100.0 615 Protestant 24.2 35.3 39.1 1.4 100.0 673 Adventist 22.3 37.3 40.4 0.0 100.0 184 Muslim 50.8 23.6 22.3 3.2 100.0 142 Traditional/other/no religion 29.2 40.4 30.4 0.0 100.0 37 Wealth quintile Lowest 25.2 43.7 29.1 1.9 100.0 104 Second 20.3 43.2 35.9 0.6 100.0 174 Middle 18.0 40.5 40.3 1.2 100.0 253 Fourth 16.3 38.8 43.8 1.1 100.0 333 Highest 31.9 28.2 38.1 1.8 100.0 788 Total 15-49 25.0 34.7 38.8 1.5 100.0 1,652 50-59 35.6 35.8 27.0 1.6 100.0 75 Total 15-59 25.5 34.8 38.3 1.5 100.0 1,727 HIV Prevalence • 225 HIV PREVALENCE 14 n Rwanda, much of the information on national HIV prevalence is derived from the antenatal care (ANC) sentinel surveillance system. 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, 2010, and 2014-15 RDHS surveys 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 sentinel surveillance. The 2014-15 RDHS is the third RDHS survey to anonymously link HIV testing results with key behavioral and sociodemographic characteristics of both male and female respondents, the first being the 2005 RDHS. These surveys provide national, population-based trend data on HIV prevalence among women age 15-49 and men age 15-59. In addition, for the first time, the 2014-15 RDHS included HIV testing of children age 0-14. This chapter presents information on 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. Blood samples were collected from all eligible respondents who provided informed consent. Drops of blood were drawn and dried on filter paper. Dried blood spot (DBS) specimens on filter paper and transfer forms for the samples from each cluster were returned to the National Institute of Statistics of Rwanda (NISR), where they were verified, resolved for any discrepancies, and registered. Samples were then transferred by lot to the National Reference Laboratory (NRL). The NRL registered each lot of samples it received and indicated the date and number of samples received for each cluster. Any discrepancies between the samples received by the laboratory and the number of samples recorded at the central NISR office were resolved immediately. Each blood sample provided to the NRL is identified only via a barcode. For respondents between the age of 2 and 59, specimens were tested according to the following protocol. DBS specimens were first tested via Vironostika® Ag/Ab, fourth generation, and MUREX® Ag/Ab combination. Specimens that were reactive to the EIA were confirmed through the Pepti-LAV HIV-1 western blot (WB). Each round of testing included positive and negative control specimens to aid in the interpretation of results. I Key Findings • HIV prevalence has been stable since 2005 and remains at 3 percent among adults age 15-49 (4 percent among women and 2 percent among men). • HIV prevalence is higher in urban areas than in rural areas (6 percent and 2 percent, respectively). • HIV prevalence increases with age and is highest among women age 40-44 (8 percent) and men age 45-49 (9 percent). • HIV prevalence is highest in the City of Kigali (6 percent) and is relatively uniform throughout the other provinces (2 percent to 3 percent). • HIV prevalence is particularly high among widows and those who are divorced or separated; 14 percent of widows are HIV positive. • Only a very small proportion of children age 0-14 are living with HIV (less than 1 percent). 226 • HIV Prevalence The NRL processed the samples according to the following algorithm: Screening: The Vironostika Ag/Ab is used in this step. If the test is negative, the result is recorded as negative. Confirmation: Positive samples are tested with the highly specific Murex HIV Ag/Ab combination. • If a sample is positive (concordance), the result is recorded as positive. • If a sample is negative (discordance), it is confirmed with the WB. The final result is recorded as positive if the WB result is positive and negative if the WB result is negative. If the WB result is indeterminate, the final result is recorded as indeterminate. Polymerase chain reaction (PCR) was used in testing the specimens of children age 0-23 months. 14.1 COVERAGE RATES FOR HIV TESTING AMONG ADULTS 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 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 and therefore did not provide a blood sample was very small (less than 1 percent). The coverage rate was the same for women and men (99 percent each). HIV Prevalence • 227 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 2014-15 Testing status Total Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Residence/province Inter- viewed Not inter- viewed Inter- viewed Not inter- iewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed WOMEN Residence Urban 98.6 0.0 1.0 0.1 0.0 0.0 0.1 0.2 100.0 1,695 Rural 99.5 0.0 0.2 0.1 0.0 0.0 0.0 0.2 100.0 5,105 Province City of Kigali 98.6 0.0 1.1 0.0 0.0 0.0 0.1 0.2 100.0 929 South 99.0 0.1 0.5 0.2 0.0 0.0 0.1 0.2 100.0 1,732 West 99.6 0.0 0.2 0.1 0.0 0.0 0.0 0.2 100.0 1,573 North 99.6 0.0 0.3 0.0 0.0 0.0 0.0 0.1 100.0 1,092 East 99.4 0.0 0.1 0.2 0.0 0.0 0.0 0.3 100.0 1,474 Total 99.3 0.0 0.4 0.1 0.0 0.0 0.0 0.2 100.0 6,800 MEN Residence Urban 98.3 0.1 0.9 0.2 0.0 0.2 0.0 0.2 100.0 1,619 Rural 99.3 0.0 0.2 0.1 0.0 0.0 0.0 0.3 100.0 4,630 Province City of Kigali 98.5 0.0 1.0 0.2 0.0 0.0 0.0 0.2 100.0 886 South 99.2 0.1 0.1 0.2 0.0 0.1 0.1 0.3 100.0 1,658 West 99.2 0.1 0.4 0.1 0.0 0.0 0.0 0.2 100.0 1,358 North 99.0 0.1 0.2 0.0 0.0 0.2 0.0 0.4 100.0 932 East 99.2 0.0 0.3 0.0 0.1 0.0 0.1 0.4 100.0 1,415 Total 15-49 99.0 0.1 0.4 0.1 0.0 0.1 0.0 0.3 100.0 5,917 Total 99.1 0.0 0.4 0.1 0.0 0.0 0.0 0.3 100.0 6,249 TOTAL Residence Urban 98.5 0.0 1.0 0.2 0.0 0.1 0.0 0.2 100.0 3,314 Rural 99.4 0.0 0.2 0.1 0.0 0.0 0.0 0.3 100.0 9,735 Province City of Kigali 98.6 0.0 1.0 0.1 0.0 0.0 0.1 0.2 100.0 1,815 South 99.1 0.1 0.3 0.2 0.0 0.0 0.1 0.3 100.0 3,390 West 99.4 0.0 0.3 0.1 0.0 0.0 0.0 0.2 100.0 2,931 North 99.4 0.0 0.2 0.0 0.0 0.1 0.0 0.2 100.0 2,024 East 99.3 0.0 0.2 0.1 0.0 0.0 0.0 0.3 100.0 2,889 Total 99.2 0.0 0.4 0.1 0.0 0.0 0.0 0.3 100.0 13,049 1 Includes all dried blood spot (DBS) samples 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 coverage rates were nearly 100 percent among both women and men, variation by background characteristics was negligible. Additional tables describing the relationship between participation in HIV testing and characteristics related to HIV risk are presented in Appendix A. 228 • HIV Prevalence 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 2014-15 Testing status Total Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Background characteristic Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed WOMEN Age 15-19 99.2 0.1 0.4 0.0 0.0 0.0 0.0 0.4 100.0 1,386 20-24 99.3 0.0 0.3 0.2 0.0 0.0 0.0 0.2 100.0 1,237 25-29 99.1 0.0 0.3 0.1 0.0 0.0 0.1 0.3 100.0 1,148 30-34 99.2 0.0 0.4 0.2 0.0 0.0 0.1 0.2 100.0 1,127 35-39 99.0 0.0 0.8 0.0 0.0 0.0 0.0 0.3 100.0 780 40-44 99.7 0.0 0.3 0.0 0.0 0.0 0.0 0.0 100.0 640 45-49 99.6 0.0 0.2 0.2 0.0 0.0 0.0 0.0 100.0 479 Education No education 97.6 0.1 0.2 0.6 0.0 0.0 0.0 1.4 100.0 843 Primary 99.7 0.0 0.2 0.0 0.0 0.0 0.0 0.0 100.0 4,249 Secondary and higher 98.8 0.0 0.9 0.1 0.0 0.0 0.1 0.1 100.0 1,708 Wealth quintile Lowest 99.4 0.0 0.0 0.1 0.0 0.0 0.1 0.5 100.0 1,240 Second 99.5 0.1 0.3 0.1 0.0 0.0 0.0 0.0 100.0 1,270 Middle 99.3 0.0 0.3 0.3 0.0 0.0 0.0 0.1 100.0 1,264 Fourth 99.8 0.0 0.1 0.0 0.0 0.0 0.0 0.2 100.0 1,327 Highest 98.5 0.0 1.0 0.1 0.0 0.0 0.1 0.4 100.0 1,699 Total 99.3 0.0 0.4 0.1 0.0 0.0 0.0 0.2 100.0 6,800 MEN Age 15-19 99.5 0.0 0.0 0.1 0.0 0.0 0.0 0.4 100.0 1,290 20-24 99.1 0.0 0.3 0.2 0.1 0.1 0.0 0.2 100.0 1,001 25-29 99.0 0.0 0.6 0.1 0.0 0.0 0.0 0.3 100.0 968 30-34 98.6 0.0 0.7 0.0 0.0 0.2 0.1 0.3 100.0 938 35-39 98.9 0.0 0.5 0.2 0.0 0.0 0.2 0.2 100.0 560 40-44 98.7 0.4 0.2 0.2 0.0 0.0 0.0 0.4 100.0 474 45-49 99.2 0.3 0.5 0.0 0.0 0.0 0.0 0.0 100.0 382 50-59 99.2 0.0 0.2 0.2 0.0 0.0 0.0 0.5 100.0 636 Education No education 98.1 0.3 0.1 0.3 0.0 0.0 0.0 1.2 100.0 671 Primary 99.3 0.0 0.2 0.1 0.0 0.1 0.1 0.3 100.0 3,987 Secondary and higher 98.9 0.1 0.8 0.1 0.1 0.1 0.0 0.1 100.0 1,591 Wealth quintile Lowest 98.7 0.1 0.1 0.2 0.0 0.0 0.0 0.9 100.0 909 Second 99.3 0.1 0.0 0.2 0.0 0.0 0.0 0.4 100.0 1,076 Middle 99.7 0.0 0.1 0.0 0.1 0.1 0.0 0.1 100.0 1,181 Fourth 99.3 0.0 0.3 0.1 0.0 0.0 0.1 0.2 100.0 1,362 Highest 98.5 0.1 1.0 0.1 0.0 0.1 0.1 0.2 100.0 1,721 Total 99.1 0.0 0.4 0.1 0.0 0.0 0.0 0.3 100.0 6,249 1 Includes all dried blood spot (DBS) samples 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. 14.2 HIV PREVALENCE AMONG ADULTS 14.2.1 HIV Prevalence by Age and Sex Table 14.3 shows that 3 percent of adults age 15-49 in Rwanda are living with HIV. The HIV prevalence rate is 4 percent among women and 2 percent among men. Figure 14.1 illustrates age patterns in HIV prevalence among women and men. In general, HIV prevalence rises with age. Among women, the HIV prevalence increases from 1 percent at age 15-19 to 8 percent at age 40-44 before decreasing rapidly to 6 percent at age HIV Prevalence • 229 45-49. Among men, the prevalence increases from less than 1 percent at age 15-19 to 4 percent at age 40-44 and 9 percent at age 45-49. Table 14.3 HIV prevalence among adults Among de facto women age 15-49 and men age 15-59 who were interviewed and tested, the percentage HIV positive, by age, Rwanda 2014-15 Women Men Total Age Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number 15-19 0.9 1,366 0.3 1,280 0.6 2,646 20-24 1.8 1,218 1.0 989 1.5 2,207 25-29 4.2 1,139 1.7 941 3.1 2,080 30-34 4.2 1,119 2.1 920 3.2 2,039 35-39 5.0 772 3.3 564 4.3 1,335 40-44 7.8 646 3.7 473 6.1 1,119 45-49 5.5 494 9.3 383 7.1 877 50-54 na na 5.6 349 na na 55-59 na na 4.3 289 na na Total 15-49 3.6 6,752 2.2 5,551 3.0 12,302 50-59 na na 5.0 638 na na Total 15-59 na na 2.5 6,188 na na na = Not applicable Figure 14.1 HIV prevalence by sex and age 14.2.2 Trends in HIV Prevalence Table 14.4 shows trends in HIV prevalence over the last 5 years, by age. In Rwanda, the overall HIV prevalence among adults did not change between the 2010 and 2014-15 RDHS surveys (3 percent). HIV prevalence among women held steady at 4 percent over the five-year period, while the prevalence among men remained at 2 percent. 0.9 1.8 4.2 4.2 5.0 7.8 5.5 0.3 1.0 1.7 2.1 3.3 3.7 9.3 0 1 2 3 4 5 6 7 8 9 10 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Women Men RDHS 2014-15 Age Percentage 230 • HIV Prevalence Table 14.4 Trends in HIV prevalence by age Among de facto women age 15-49 and men age 15-59 who were interviewed and tested, the percentage HIV positive, by age, Rwanda 2010 and 2014-15 Age Women Men Total 2010 RDHS 2014-15 RDHS 2010 RDHS 2014-15 RDHS 2010 RDHS 2014-15 RDHS 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 0.8 1,532 0.9 1,366 0.3 1,450 0.3 1,280 0.5 2,982 0.6 2,646 20-24 2.4 1,372 1.8 1,218 0.5 1,158 1.0 989 1.5 2,531 1.5 2,207 25-29 3.9 1,270 4.2 1,139 1.7 1,037 1.7 941 2.9 2,307 3.1 2,080 30-34 4.2 880 4.2 1,119 3.5 710 2.1 920 3.9 1,590 3.2 2,039 35-39 7.9 715 5.0 772 3.9 493 3.3 564 6.3 1,208 4.3 1,335 40-44 6.1 612 7.8 646 7.3 430 3.7 473 6.6 1,042 6.1 1,119 45-49 5.8 534 5.5 494 5.6 413 9.3 383 5.7 947 7.1 877 Total 15-49 3.7 6,917 3.6 6,752 2.2 5,690 2.2 5,551 3.0 12,607 3.0 12,302 Total men 15-59 na na na na 2.4 6,331 2.5 6,188 na na na na na = Not applicable 14.2.3 HIV Prevalence by Socioeconomic Characteristics Table 14.5 shows variations in HIV prevalence by various socioeconomic characteristics, including residence, province, religion, education, employment, and wealth quintile. HIV prevalence is slightly higher among respondents who are employed (3 percent) than among those who are not employed (2 percent). HIV prevalence in urban areas (6 percent) is three times that in rural areas (2 percent). By sex, 8 percent of women and 5 percent of men in urban areas are infected with HIV, as compared with 3 percent of women and 2 percent of men in rural areas. The City of Kigali has a higher HIV prevalence (6 percent) than the other provinces (3 percent in South and 2 percent each of the remaining Provinces). Overall, HIV prevalence in Rwanda is higher among respondents with no education (4 percent) than among those with a primary education (3 percent) and those with a secondary education or higher (2 percent). Five percent of women with no education, 4 percent of women with a primary education, and 3 percent of women with a secondary education or higher are living with HIV. The pattern differs among men, with the HIV prevalence rate being the same at all levels of education (2 percent). HIV Prevalence • 231 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 2014-15 Women Men Total Background characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Religion Catholic 3.1 2,724 2.1 2,478 2.6 5,202 Protestant 3.6 2,996 2.0 2,125 3.0 5,121 Adventist 4.8 809 2.8 637 3.9 1,446 Muslim 6.2 130 1.9 167 3.8 297 Jehovah’s Witness 5.7 53 (0.0) 46 3.1 99 Traditional * 3 * 0 * 3 Other (9.8) 24 4.2 92 5.4 116 Employment (last 12 months) Not employed 2.0 953 0.7 737 1.5 1,690 Employed 3.9 5,795 2.4 4,806 3.2 10,600 Residence Urban 7.8 1,277 4.6 1,164 6.2 2,440 Rural 2.7 5,475 1.5 4,387 2.2 9,862 Province City of Kigali 8.0 881 4.4 800 6.3 1,681 South 3.2 1,601 2.0 1,321 2.6 2,922 West 3.2 1,508 1.3 1,177 2.4 2,684 North 2.5 1,109 2.1 847 2.3 1,956 East 2.9 1,653 1.9 1,406 2.4 3,058 Education No education 5.3 860 2.0 494 4.1 1,354 Primary 3.6 4,329 2.3 3,621 3.0 7,950 Secondary and higher 2.8 1,394 2.0 1,191 2.4 2,585 Wealth quintile Lowest 4.0 1,246 2.2 816 3.3 2,062 Second 2.6 1,309 1.5 990 2.1 2,299 Middle 3.7 1,334 2.1 1,092 3.0 2,426 Fourth 1.8 1,375 1.3 1,227 1.6 2,602 Highest 5.8 1,488 3.5 1,425 4.7 2,913 Total 15-49 3.6 6,752 2.2 5,551 3.0 12,302 50-59 na na 5.0 638 5.0 638 Total 15-59 na na 2.5 6,188 2.5 6,188 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. Total includes 8 women and 5 men with missing information on religion and 4 women and 8 men with missing information on employment. na = Not applicable HIV prevalence is highest among women and men in the highest wealth quintile. However, the relationship between HIV prevalence and wealth is not linear. Among both women and men, those in the fourth wealth quintile have the lowest HIV prevalence. 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. Fifteen percent of widowed respondents and 8 percent of divorced or separated respondents are HIV positive, as compared with only 3 percent of respondents who are currently married. Among respondents who have never been married, the HIV prevalence is 3 percent for those who have had sex and less than 1 percent for those who have never had sex. The latter statistics suggest that some women and men incorrectly reported that they were not sexually active or that some degree of nonsexual HIV transmission is occurring (e.g., through blood transfusions, non-sterile injections, or mother-to-child transmission). 232 • HIV Prevalence Currently married women or living together with a partner, are slightly more likely to be infected with HIV than their men counterparts (4 percent and 3 percent, respectively). The same pattern is observed among women and men who are divorced or separated (8 percent and 7 percent, respectively). Unmarried adult who ever had sex are more likely to be infected with HIV than those who never had sex. HIV prevalence among unmarried women who have ever had sex is much higher than the prevalence among their male counterparts (5 percent versus 2 percent). HIV prevalence is higher (7 percent) among respondents who are in a polygynous union, than among respondents who are in a non-polygynous union or are not currently in a union (3 percent). The pattern is similar when the data are disaggregated by sex. The 2014-15 RDHS measured time away from home in two different ways: (1) the 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 one month at a time. In terms of the number of times respondents slept away from home, there is no relationship in HIV prevalence among either women or men. Similarly, there are no meaningful differences in HIV prevalence with respect to the duration of time away from home over the past year. 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 2014-15 Women Men Total Demographic characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Never married 1.8 2,521 0.9 2,681 1.3 5,202 Ever had sexual intercourse 4.7 779 1.5 1,105 2.8 1,884 Never had sexual intercourse 0.5 1,741 0.5 1,576 0.5 3,318 Married/living together 3.6 3,524 3.1 2,776 3.4 6,300 Divorced or separated 8.1 415 6.6 78 7.9 492 Widowed 13.7 292 * 16 14.8 308 Type of union In polygynous union 6.5 258 6.7 61 6.5 318 In non-polygynous union 3.4 3,226 3.0 2,716 3.2 5,941 Not currently in union 3.7 3,228 1.3 2,774 2.6 6,002 Times slept away from home in past 12 months None 3.9 3,560 2.2 3,391 3.1 6,951 1-2 3.4 2,309 2.2 1,280 3.0 3,589 3-4 2.9 559 2.3 427 2.6 986 5+ 3.6 313 1.9 448 2.6 761 Time away in past 12 months Away for more than 1 month 3.3 547 2.0 576 2.7 1,123 Away for less than 1 month 3.3 2,642 2.2 1,577 2.9 4,219 Not away 3.9 3,562 2.2 3,391 3.1 6,953 Currently pregnant Pregnant 2.5 492 na na na na Not pregnant or not sure 3.7 6,260 na na na na ANC for last birth in the last 3 years ANC provided by the public sector 3.3 2,243 na na na na ANC provided by other than the public sector * 19 na na na na No ANC/no birth in last 3 years 3.8 4,487 na na na na Male circumcision Circumcised na na 1.9 1,639 na na Not circumcised na na 2.3 3,907 na na Total 15-49 3.6 6,752 2.2 5,551 3.0 12,302 50-59 na na 5.0 638 na na Total 15-59 na na 2.5 6,188 na na Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 40 women with missing information on type of union, 11 women and 5 men with missing information on times slept away from home, 7 men with missing information on time away, 2 women with missing information on ANC, and 4 men with missing information on circumcision status. na = Not applicable HIV Prevalence • 233 Women who were pregnant at the time of the survey are slightly less likely to be HIV positive than women who were not pregnant or who were unsure of their pregnancy status (3 percent and 4 percent, respectively). Male circumcision has been shown to somewhat reduce transmission of HIV (see Table 14.7). 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). The results show that 4 percent of respondents age 15-49 who had ever had sex and were tested for HIV are HIV positive (5 percent of women and 3 percent of men). 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 2014-15 Women Men Total Sexual behavior characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sexual intercourse <16 6.7 457 0.9 538 3.6 995 16-17 7.8 742 3.3 387 6.2 1,129 18-19 5.1 1,146 3.6 708 4.5 1,854 20+ 3.4 2,578 3.0 2,256 3.2 4,833 Missing 4.7 86 3.1 83 3.9 169 Multiple sexual partners and partner concurrency in past 12 months 0 6.5 970 2.7 678 4.9 1,648 1 4.2 3,981 2.7 3,041 3.5 7,022 2+ 14.9 55 4.5 253 6.3 308 Had concurrent partners1 * 10 3.9 86 8.4 96 None of the partners were concurrent (7.7) 45 4.8 167 5.4 212 Condom use at last sexual intercourse in past 12 months Used condom 12.8 442 8.8 543 10.6 986 Did not use condom 3.3 3,592 1.7 2,750 2.6 6,342 No sexual intercourse in last 12 months 6.5 972 2.7 678 4.9 1,649 Number of lifetime partners 1 2.5 3,520 1.1 1,661 2.0 5,181 2 8.7 1,038 2.7 1,167 5.5 2,206 3-4 12.8 404 4.1 764 7.1 1,168 5-9 (16.7) 34 6.7 269 7.8 303 10+ * 9 12.7 105 14.1 114 Paid for sexual intercourse in past 12 months Yes na na 4.7 74 na na Used condom na na (6.6) 48 na na Did not use condom na na (1.2) 26 na na No (No paid sexual intercourse/no sexual intercourse in last 12 months) na na 2.8 3,898 na na Total 15-49 4.7 5,008 2.8 3,972 3.9 8,980 50-59 na na 5.0 632 na na Total 15-59 na na 3.1 4,604 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. Total includes 2 women with missing information on number of partners, 2 women and 1 man with missing information on condom use at last sexual intercourse, and 3 women and 5 men with missing information on number of lifetime partners. na = Not applicable 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives.) 234 • HIV Prevalence Among women whose age at sexual debut was 17 and younger, 7 percent to 8 percent are HIV positive, a figure that decreases to 3 percent among women whose sexual debut was at age 20 or older. By contrast, HIV prevalence is highest among men whose sexual debut was at age 18-19 (4 percent) and lowest among those whose sexual debut was before age 16 (less than 1 percent). HIV prevalence is higher among respondents with multiple sexual partners; 6 percent of respondents who had two or more partners in the 12 months before the survey and 8 percent who had concurrent partners in the past 12 months are living with HIV. The pattern is similar when the data are disaggregated by sex, especially for the small number of women who reported having more than one partner (15 percent of these women tested HIV positive). Thirteen percent of women who used a condom during their most recent sexual intercourse in the 12 months preceding the survey were tested HIV positive. Three percent of those who did not use a condom during their most recent sexual intercourse in the 12 months preceding the survey were tested HIV positive. Nine percent of men who used a condom during their most recent sexual intercourse and 2 percent of those who did not use a condom are infected with HIV. However this cross-sectional study did not determine the cause and effect. HIV prevalence rates among women and men who did not have sexual intercourse in the 12 months before the survey are 7 percent and 3 percent, respectively. HIV prevalence increases with increasing number of lifetime sexual partners among both women and men. The prevalence among women increases from 3 percent among those with one lifetime partner to 13 percent among those with three to four lifetime partners. Among men, the prevalence ranges from 1 percent among those with one lifetime partner to 13 percent among those with 10 or more partners. HIV prevalence is slightly higher among men who paid for sexual intercourse in the 12 months before the survey than among men who did not report paying for sex or who did not have sexual intercourse in the past 12 months (5 percent versus 3 percent). 14.3 HIV PREVALENCE AMONG YOUTH 14.3.1 Overall HIV Prevalence among Youth Table 14.8 shows HIV prevalence among young women and men age 15-24. Overall, 1 percent of youth in this age group tested positive for HIV, with the prevalence being marginally higher among young women (1 percent) than among young men (less than 1 percent). HIV prevalence among young people increases very slightly but steadily with age. Young respondents who have never been married are less likely to be living with HIV (1 percent) than those who are married or living together with a partner (2 percent) and much less likely than those who are separated, divorced, or widowed (6 percent). Among youth who have never been married, HIV prevalence is higher among those who have had sex (2 percent) than among those who have never had sex (less than 1 percent). Among young women, HIV prevalence is 1 percent among both those who are pregnant and those who are not pregnant or not sure. As observed for adults age 15-49, HIV prevalence among youth age 15-24 is higher in urban areas than in rural areas. By province, HIV prevalence is higher in the City of Kigali (3 percent) than in other provinces. HIV prevalence among youth varies by educational attainment. Five percent of young women with no education are living with HIV, as compared with 2 percent of young women with a primary education and HIV Prevalence • 235 1 percent with a secondary education or higher. Among young men, HIV prevalence is higher among those with any education than among those with none. By wealth, HIV prevalence is highest among both young women and young men in the highest wealth quintile. However, the relationship between HIV prevalence and household wealth quintile is not linear. 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 2014-15 Women Men Total Background characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 0.9 1,366 0.3 1,280 0.6 2,646 15-17 0.5 876 0.2 806 0.4 1,682 18-19 1.6 490 0.3 474 0.9 964 20-24 1.8 1,218 1.0 989 1.5 2,207 20-22 1.7 763 0.8 620 1.3 1,383 23-24 2.1 454 1.5 369 1.8 823 Marital status Never married 0.8 2,036 0.5 2,089 0.7 4,126 Ever had sex 2.3 513 0.8 691 1.5 1,204 Never had sex 0.3 1,523 0.4 1,399 0.4 2,922 Married/living together 2.6 479 1.7 171 2.4 650 Divorced/separated/widowed 7.0 68 * 9 6.2 77 Currently pregnant Pregnant 1.0 140 na na na na Not pregnant or not sure 1.4 2,443 na na na na Residence Urban 2.7 521 1.3 452 2.1 973 Rural 1.0 2,062 0.4 1,817 0.7 3,880 Province City of Kigali 3.5 348 1.7 300 2.6 647 South 1.4 592 0.4 554 0.9 1,146 West 0.4 607 0.0 515 0.2 1,122 North 0.8 430 0.7 342 0.7 772 East 1.4 607 0.8 559 1.1 1,165 Education No education 4.8 65 0.0 55 2.6 121 Primary 1.5 1,483 0.6 1,354 1.1 2,837 Secondary and higher 0.9 1,006 0.6 808 0.7 1,814 Wealth quintile Lowest 1.3 411 0.3 292 0.9 702 Second 0.8 483 0.3 371 0.6 853 Middle 1.0 479 0.4 445 0.7 924 Fourth 0.9 562 0.7 564 0.8 1,125 Highest 2.3 649 1.0 599 1.7 1,247 Total 1.3 2,583 0.6 2,269 1.0 4,853 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 14.3.2 HIV Prevalence among Youth by Condom Use at Last Sex The 2014-15 RDHS collected data on behaviors that correlate with HIV infection rates. Information on sexual behaviors is important in designing and monitoring HIV prevention interventions aimed at the young adult population. This section examines data on HIV prevalence by number of sexual partners in the 12 months before the survey and condom use during last sexual intercourse in the past 12 months among young respondents who have ever had sexual intercourse. Table 14.9 shows that, overall, 2 percent of respondents age 15-24 who have ever had sex and were tested for HIV in the 2014-15 RDHS are HIV positive (3 percent of young women and 1 percent of young men). 236 • HIV Prevalence HIV prevalence among youth increases with increasing number of partners, from 1 percent among those who did not have any sexual partners in the 12 months before the survey to 5 percent among those with two or more sexual partners. Table 14.9 HIV prevalence among young people by sexual behavior Percentage HIV positive among women and men age 15-24 who have ever had sex and were tested for HIV, by sexual behavior, Rwanda 2014-15 Women Men Total Sexual behavior characteristic Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Multiple sexual partners in past 12 months 0 1.8 319 0.9 418 1.3 737 1 2.9 721 1.2 410 2.3 1,130 2+ * 20 (0.0) 43 4.6 63 Condom use at last sexual intercourse in past 12 months Used condom 6.2 139 1.5 209 3.4 348 Did not use condom 2.5 601 0.8 244 2.0 845 No sexual intercourse in last 12 months 1.8 320 0.9 418 1.3 738 Total 2.8 1,060 1.0 870 2.0 1,931 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. Total includes 1 case for which information on multiple sexual partners in past 12 months is missing. Three percent of youth who used a condom during their most recent sexual intercourse in the 12 months preceding the survey were tested positive for HIV. Two percent of those who did not use a condom during their most recent sexual intercourse were HIV positive. Six percent of young women who used a condom during their most recent sexual intercourse were HIV positive, and 3 percent of those who did not use a condom were tested positive. The corresponding figures among young men are 2 percent and 1 percent respectively. 14.4 HIV PREVALENCE BY OTHER CHARACTERISTICS 14.4.1 HIV Prevalence and STIs A strong link exists between HIV infection and sexually transmitted infections (STIs). Many studies have demonstrated that sexually transmitted infections are a co-factor for HIV transmission. Management and treatment of STIs can play an important role in the reduction of HIV transmission. Respondents in the 2014-15 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 ever had sex by whether they reported an STI in the 12 months preceding the survey. The data show that HIV prevalence is higher among respondents with a recent history of STIs or STI symptoms than among those with no recent STIs or STI symptoms (7 percent versus 4 percent). Four percent of respondent who ever had sex reported that they have been tested for HIV and received the results were HIV positive. Two percent of those who have been tested for HIV and did not receive results were HIV positive. One percent who reported that they have never been tested in twelve months preceding the survey were HIV positive. HIV Prevalence • 237 Table 14.10 HIV prevalence by other characteristics 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 and by prior testing for HIV, Rwanda 2014-15 Women Men Total Characteristic Percentage HIV positive1 Number Percentage HIV positive1 Number Percentage HIV positive1 Number Sexually transmitted infection (STI) in past 12 months Had STI or STI symptoms 7.1 729 8.4 190 7.3 919 No STI, no symptoms 4.3 4,264 2.6 3,767 3.5 8,031 Don’t know/missing * 14 * 14 (4.3) 29 Prior HIV testing Ever tested 4.9 4,791 3.0 3,604 4.1 8,394 Received results 4.9 4,700 3.0 3,504 4.1 8,204 Did not receive results 2.4 91 2.2 100 2.2 191 Never tested 1.6 216 1.3 368 1.4 585 Total 15-49 4.7 5,008 2.8 3,972 3.9 8,980 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. Total includes 1 case for which information on prior HIV testing is missing. 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; 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 2014-15 RDHS, men were asked whether they were circumcised. Table 14.11 shows that, overall, there is no meaningful difference in HIV prevalence by circumcision status (2 percent among both circumcised and uncircumcised men). In some subgroups (age, residence, province, wealth), circumcised men are less likely to be living with HIV than uncircumcised men. However, the pattern is reversed in other groups with HIV prevalence being higher among circumcised men. 238 • HIV Prevalence 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 2014-15 Circumcised Not circumcised Background characteristic Percentage HIV positive Number Percentage HIV positive Number Age 15-19 0.3 340 0.2 938 20-24 1.0 435 1.1 554 25-29 1.7 333 1.7 608 30-34 0.6 253 2.7 666 35-39 4.7 121 2.9 442 40-44 5.7 89 3.2 384 45-49 12.5 67 8.6 316 Religion Catholic 2.1 611 2.1 1,863 Protestant 1.8 667 2.2 1,457 Adventist 1.8 182 3.2 456 Muslim 1.3 141 (4.8) 26 Jehovah’s Witness * 24 * 22 Other * 13 2.7 79 Missing * 0 * 5 Residence Urban 3.0 676 6.8 488 Rural 1.2 963 1.6 3,420 Province City of Kigali 3.4 400 5.4 400 South 2.6 229 1.8 1,088 West 0.4 475 2.0 702 North 2.0 160 2.1 687 East 1.9 375 1.9 1,031 Education No education 1.5 59 2.1 435 Primary 2.0 739 2.4 2,879 Secondary and higher 2.1 655 1.8 535 Wealth quintile Lowest 0.7 103 2.4 712 Second 0.0 174 1.8 815 Middle 1.8 251 2.2 841 Fourth 1.8 331 1.1 897 Highest 2.6 780 4.5 643 Total 15-49 1.9 1,639 2.3 3,907 50-59 10.3 74 4.3 564 Total 15-59 2.3 1,713 2.5 4,471 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. 14.4.3 Prior HIV Testing by Current HIV Status Knowing their HIV status through testing helps individuals make decisions to reduce infection risks and increase safer sex practices. Additionally, knowledge of 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. To assess coverage of HIV testing services, 2014-15 RDHS respondents were asked whether they had ever been tested for HIV. 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 to have ever had an HIV test and received the results than those who are negative (95 percent versus 80 percent). HIV-positive women are somewhat more likely to have been tested and to have received the results than HIV-positive men. HIV Prevalence • 239 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 2014-15 Women Men Total HIV testing prior to the survey HIV positive HIV negative HIV positive HIV negative HIV positive HIV negative Previously tested Received result of last test 95.9 82.2 91.8 77.2 94.6 79.9 Did not receive result of last test 1.3 3.5 2.3 3.3 1.6 3.4 Not previously tested 2.8 14.2 5.9 19.5 3.8 16.6 Missing 0.0 0.1 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 244 6,507 121 5,430 365 11,937 14.5 HIV PREVALENCE AMONG COHABITING COUPLES In the 2014-15 RDHS, 2,947 cohabiting couples were interviewed and tested for HIV. Table 14.13 shows that, in 95 percent of couples in union, both partners are HIV negative; in 2 percent of couples, both partners are HIV positive. About 3 percent of couples in union are discordant (i.e., one partner is infected and the other is not). Discordant couples are almost evenly divided between those in which the male partner is infected and the female partner is not and those in which the female partner is infected and the male partner is not. Table 14.13 shows HIV prevalence among couples by background characteristics. The percentage of couples in which both partners are HIV positive is higher in couples in which women age 30-39 (3 percent) and men age 50-59 (4 percent). The percentage of couples in which both partners are HIV positive is also higher (7 percent) when men is 10-14 years older than women as compared to 1 percent when couples are for the same age/man older 0-4 years. This is true when the male partner is infected and female partner is not. The percentage of couples in which both partners are HIV positive is high in urban (6 percent) areas, especially in the City of Kigali (5 percent) and in the highest wealth quintile (5 percent). 240 • 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 2014-15 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 (4.3) (0.0) (8.0) (87.7) 100.0 33 20-29 1.2 0.8 1.2 96.8 100.0 1,055 30-39 2.7 1.9 0.9 94.5 100.0 1,241 40-49 2.2 1.7 2.1 94.1 100.0 619 Man’s age 15-19 * * * * 100.0 3 20-29 0.6 0.8 1.6 97.0 100.0 666 30-39 1.9 0.6 1.0 96.5 100.0 1,208 40-49 3.0 2.8 1.5 92.6 100.0 750 50-59 3.5 3.0 1.6 91.9 100.0 321 Age difference between partners Woman older 1.7 0.3 1.5 96.6 100.0 446 Same age/man older by 0-4 years 0.8 0.8 1.3 97.0 100.0 1,378 Man older by 5-9 years 2.4 1.8 1.1 94.7 100.0 744 Man older by 10-14 years 6.9 3.5 2.1 87.5 100.0 259 Man older by 15+ years 4.9 6.4 1.5 87.3 100.0 121 Type of union Non-polygynous 1.9 1.4 1.2 95.5 100.0 2,763 Polygynous 5.0 2.1 3.4 89.5 100.0 165 Don’t know/missing * * * * 100.0 20 Multiple partners in past 12 months1 Both no 1.8 1.4 1.1 95.7 100.0 2,749 Man yes, woman no 5.2 2.2 4.5 88.2 100.0 182 Woman yes, man no * * * * 100.0 11 Both yes * * * * 100.0 1 Either missing * * * * 100.0 5 Concurrent sexual partners in past 12 months2 Both no 1.9 1.5 1.3 95.3 100.0 2,850 Man yes, woman no 4.4 1.5 3.6 90.4 100.0 94 Woman yes, man no * * * * 100.0 3 Residence Urban 5.9 3.0 3.5 87.7 100.0 478 Rural 1.3 1.2 0.9 96.6 100.0 2,469 Province City of Kigali 4.6 3.2 5.1 87.0 100.0 352 South 1.5 1.2 0.9 96.4 100.0 664 West 2.0 1.3 0.8 95.9 100.0 657 North 1.8 1.4 0.7 96.2 100.0 504 East 1.6 1.1 0.9 96.4 100.0 770 Woman’s education No education 2.4 2.2 2.2 93.1 100.0 488 Primary 1.8 1.3 1.2 95.7 100.0 2,129 Secondary 2.9 1.4 1.0 94.7 100.0 330 Man’s education No education 1.9 1.5 1.0 95.7 100.0 473 Primary 1.9 1.2 1.3 95.5 100.0 2,142 Secondary 3.0 3.1 1.9 92.0 100.0 333 Wealth quintile Lowest 2.6 0.9 1.3 95.2 100.0 519 Second 0.9 1.3 1.2 96.6 100.0 622 Middle 1.5 2.0 0.8 95.8 100.0 657 Fourth 0.9 1.0 1.0 97.1 100.0 610 Highest 4.9 2.1 2.6 90.4 100.0 539 Total 2.1 1.5 1.3 95.1 100.0 2,947 Note: 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 2 or more people during this time period. (Respondents with multiple partners include polygynous men who had sexual intercourse with 2 or more wives.) 2 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives.) HIV Prevalence • 241 14.6 HIV PREVALENCE AMONG CHILDREN Nearly all parents or guardians of children age 0-14 eligible for HIV testing provided informed consent for testing. Table 14.14 shows HIV prevalence among children age 0-14. Overall, only 0.2 percent of children tested positive for HIV. HIV prevalence in children does not show any linear pattern with age. Table 14.14 HIV prevalence among children age 0-14 Among de facto children age 0-14, the percentage HIV positive, by age, Rwanda 2014-15 Female Male Total Age Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number <2 0.7 273 0.0 259 0.4 532 2-4 0.0 347 0.0 348 0.0 695 5-9 0.2 644 0.0 610 0.1 1,254 10-14 0.2 623 0.8 533 0.4 1,156 Total 0.2 1,887 0.2 1,750 0.2 3,637 Women’s Status and Demographic and Health Outcomes • 243 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 he status of women is an important factor in development, poverty reduction, and improvements 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 their 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 2014-15 RDHS collected information related to women’s and men’s employment. 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 that caution be exercised in 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 2014-15 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 the following: “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?” Table 15.1 shows the percent distribution of currently married women and men age 15-49, by employment and cash earnings. Overall, 94 percent of currently married women and almost all currently married men were employed in the 12 months preceding the survey. The proportion of employed women increases with age, from 84 percent among those age 15-19 to 96 percent among those age 35-49. Working women are half as likely to be paid in cash only as working men (25 percent versus 49 percent, respectively); 19 percent of women and 8 percent of men are not paid for their work. T Key Findings • Twenty percent of currently married employed women who earn cash make independent decisions about how to spend their earnings, while 68 percent make joint decisions with their husbands. • Sixty-five percent of currently married women participate in household decisions pertaining to their own health care, major household purchases, and visits to their family or relatives. • Eighty-three percent of married women participate in decisions about their own health care. • Forty-one percent of all women believe that wife beating is justified for at least one of five specified reasons, as compared with only 18 percent of men. 244 • Women’s Status and Demographic and Health Outcomes Women are almost three times as likely as men to receive only in-kind payment (13 percent and 5 percent, respectively). 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 2014-15 Among currently married respondents: Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Total Number of women Age Percentage employed in past 12 months Number of respondents Cash only Cash and in-kind In-kind only Not paid Missing/ don’t know WOMEN 15-19 84.3 85 29.0 38.6 21.3 11.1 0.0 100.0 72 20-24 90.2 883 22.2 41.7 15.4 20.7 0.0 100.0 797 25-29 93.8 1,577 28.7 40.8 9.9 20.5 0.1 100.0 1,479 30-34 94.4 1,693 26.5 41.4 13.0 19.0 0.1 100.0 1,598 35-39 96.2 1,240 25.4 43.2 12.5 18.7 0.2 100.0 1,193 40-44 95.6 896 23.3 46.3 11.9 18.4 0.0 100.0 857 45-49 96.1 607 17.5 49.1 13.3 19.9 0.2 100.0 584 Total 15-49 94.2 6,982 25.1 42.9 12.5 19.4 0.1 100.0 6,579 MEN 15-19 100.0 3 * * * * * * 3 20-24 100.0 169 54.7 34.2 4.0 7.1 0.0 100.0 169 25-29 99.5 530 51.7 38.0 3.0 7.3 0.0 100.0 528 30-34 99.2 775 50.7 37.0 5.0 7.1 0.3 100.0 768 35-39 99.8 512 46.4 40.9 3.5 9.3 0.0 100.0 511 40-44 100.0 445 45.1 42.1 5.7 7.0 0.0 100.0 445 45-49 99.8 359 43.4 40.6 5.8 10.2 0.0 100.0 358 Total 15-49 99.6 2,792 48.5 39.0 4.5 7.9 0.1 100.0 2,781 50-59 97.9 579 31.1 50.1 6.1 12.7 0.0 100.0 567 Total 15-59 99.3 3,371 45.6 40.9 4.8 8.7 0.1 100.0 3,348 Note: An asterisk indicates that a figure is based on fewer 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 is an indicator of 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 used and by the relative magnitude of women’s earnings compared with those of their husbands, according to background characteristics. Only 20 percent of women mainly decide for themselves how their earnings are used, whereas 68 percent of women say they make joint decisions with their husbands. Twelve percent of women reported that decisions regarding how their earnings are spent are made mainly by their husbands. The percentage of women who mainly decide themselves how their earnings are spent generally increases with age. Women in urban areas are more likely to make decisions themselves on how their cash earnings are used than their counterparts Women’s Status and Demographic and Health Outcomes • 245 in rural areas (23 percent versus 19 percent). Fourteen percent of women in rural areas report that their husbands mainly decide how to spend their earnings, as compared with 8 percent of women in urban areas. Decision-making on earnings also varies by province. Twenty-six percent of women in North mainly decide themselves how to spend their earnings, as compared with 15 percent in West and 18 percent in South. The West province has the highest proportion of women (74 percent) who report joint decision-making with their husbands regarding their earnings. Women in East and South are more likely to report that their husbands mainly decide how to spend their earnings than women in the other provinces (14 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 2014-15 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 Background characteristic 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 (17.1) (64.5) (18.4) (0.0) (100.0) (6.4) (79.6) (14.0) (0.0) (0.0) 100.0 48 20-24 15.9 67.2 16.6 0.4 100.0 4.9 74.0 19.9 0.5 0.7 100.0 509 25-29 15.5 71.6 12.5 0.3 100.0 7.2 70.0 21.4 0.9 0.5 100.0 1,028 30-34 18.6 69.6 11.4 0.4 100.0 9.3 65.5 23.4 1.2 0.5 100.0 1,085 35-39 21.9 64.7 12.1 1.3 100.0 11.2 60.9 23.6 2.9 1.5 100.0 818 40-44 24.8 63.7 10.7 0.7 100.0 13.0 55.9 25.6 4.1 1.3 100.0 597 45-49 24.4 62.6 11.6 1.4 100.0 13.7 53.0 26.8 4.3 2.2 100.0 389 Number of living children 0 16.2 74.4 9.4 0.0 100.0 8.1 69.6 21.3 0.5 0.5 100.0 220 1-2 16.3 69.9 13.2 0.6 100.0 8.2 67.9 22.1 1.2 0.7 100.0 1,750 3-4 20.8 66.2 12.2 0.8 100.0 9.9 63.8 22.6 2.6 1.0 100.0 1,529 5+ 23.9 63.5 11.7 0.9 100.0 11.5 58.1 26.0 2.9 1.4 100.0 975 Residence Urban 23.3 68.7 7.7 0.3 100.0 12.9 68.0 16.2 1.4 1.4 100.0 852 Rural 18.6 67.2 13.5 0.7 100.0 8.7 63.6 24.7 2.1 0.8 100.0 3,622 Province Kigali City 19.4 73.0 7.3 0.2 100.0 12.5 69.5 16.0 1.3 0.8 100.0 634 South 18.4 66.5 14.3 0.8 100.0 13.9 59.0 24.4 1.6 1.1 100.0 994 West 15.1 74.3 10.1 0.6 100.0 6.9 68.5 20.9 2.7 1.0 100.0 938 North 25.5 59.6 13.8 1.1 100.0 7.8 64.9 22.8 3.2 1.3 100.0 716 East 20.4 64.7 14.4 0.6 100.0 7.3 62.8 27.6 1.5 0.7 100.0 1,192 Education No education 25.0 61.1 13.4 0.4 100.0 8.1 59.9 27.8 3.5 0.7 100.0 714 Primary 19.4 66.5 13.2 0.8 100.0 8.1 66.1 22.9 1.9 1.0 100.0 3,095 Secondary and higher 13.9 78.7 7.2 0.2 100.0 17.5 61.6 18.8 1.1 1.0 100.0 665 Wealth quintile Lowest 27.0 58.6 13.1 1.3 100.0 8.8 60.3 25.9 3.5 1.5 100.0 881 Second 21.4 64.2 13.9 0.5 100.0 8.3 63.8 24.9 2.4 0.6 100.0 893 Middle 17.5 69.6 12.2 0.6 100.0 7.4 65.6 24.2 2.0 0.8 100.0 873 Fourth 13.7 72.0 13.7 0.7 100.0 9.7 66.3 21.7 1.3 0.9 100.0 846 Highest 17.8 72.6 9.4 0.2 100.0 13.0 66.2 19.0 1.0 0.9 100.0 980 Total 19.5 67.5 12.4 0.7 100.0 9.5 64.5 23.1 2.0 0.9 100.0 4,474 Note: Figures in parentheses are based on 25-49 unweighted cases. There are wide variations by level of education in who makes decisions about how women’s earnings are spent. The proportion of women who say they mainly decide themselves on how to spend their earnings decreases as education increases, whereas the proportion who make joint decisions with their husbands increases with increasing education. There is a negative association between educational level and decision- making mainly by the husband. Thirteen percent of women with no education or a primary education report that their husband mainly decides how their earnings are spent, as compared with only 7 percent of women with a secondary education or higher. 246 • Women’s Status and Demographic and Health Outcomes Wealth is also related to decision-making on how women’s cash earnings are used. Joint decision- making between spouses increases with increasing wealth: 59 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 73 percent of women in the highest quintile. Only 9 percent of women in the highest wealth quintile report that their husband mainly decides on how their cash earnings are used, compared with 12-14 percent of women in the other wealth quintiles. Table 15.2.1 also shows women’s earnings relative to their husbands’ earnings during the 12 months preceding the survey. Almost two-thirds (65 percent) of women report that they earn less than their husband, 10 percent report that they earn more than their husband, and 23 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 those age 20-24 to 14 percent among those age 45-49. Thirteen percent of urban women and 9 percent of rural women earn more than their husband, while 16 percent of women in urban areas and 25 percent of women in rural areas earn the same as their husband. Women in the East province (28 percent) are most likely to report that they earn the same as their husband. Women with a secondary education or higher (18 percent) are more likely than women with no education or a primary education (8 percent each) to report that they earn more than their husband. Table 15.2.2 shows the percent distributions of currently married men age 15-49 who receive cash earnings and 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. Nineteen percent of men report that they mainly decide on how their cash earnings are used. Seventy- eight percent state that they make these decisions jointly with their wife, and 2 percent state that these decisions are made mainly by their wives. There is little variation by age, number of living children, or residence in the percentage of men who are the main decision-makers regarding how to spend their cash earnings. Men in North (25 percent) and East (24 percent) are more likely to be the main decision-makers regarding their own earnings than men in other provinces. Men with a secondary education or higher are less likely to be the main decision-maker than other men regarding how to spend their earnings (14 percent) and more likely to make decisions jointly with their wives (85 percent). In general, women’s reports on who makes decisions about how their husband’s earnings are spent are comparable to men’s reports. Twenty-five percent of women whose husbands have cash earnings report that their husband mainly decides how his cash earnings are used, a figure slightly higher than the 19 percent reported by men themselves. Seventy percent of women report that decisions are made jointly, as compared with 78 percent of men, and 4 percent of women report that they mainly decide how to use their husband’s earnings. 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 with no education and those in the lower wealth quintiles are more likely to report that their husband is the main decision-maker. Women’s Status and Demographic and Health Outcomes • 247 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 age 15-49 whose husbands receive cash earnings, by person who decides how husband’s cash earnings are used, according to background characteristics, Rwanda 2014-15 Men Women Background characteristic Mainly wife Husband and wife jointly Mainly husband Missing Total Number Mainly wife Husband and wife jointly Mainly husband Missing Total Number Age 15-19 * * * * 100.0 3 4.3 68.4 27.3 0.0 100.0 85 20-24 3.1 72.0 24.9 0.0 100.0 151 3.4 72.3 23.9 0.5 100.0 881 25-29 2.5 79.2 18.0 0.3 100.0 473 3.0 71.9 24.6 0.5 100.0 1,568 30-34 2.4 77.3 20.2 0.1 100.0 673 4.0 69.9 25.3 0.8 100.0 1,680 35-39 1.5 80.0 18.0 0.5 100.0 446 5.7 69.4 24.4 0.5 100.0 1,217 40-44 2.1 78.1 19.8 0.0 100.0 388 6.7 68.0 24.5 0.7 100.0 871 45-49 1.8 81.1 17.0 0.0 100.0 300 5.1 66.3 27.0 1.6 100.0 589 Number of living children 0 3.3 80.1 16.6 0.0 100.0 146 2.2 81.4 16.2 0.2 100.0 357 1-2 2.2 79.6 18.1 0.1 100.0 1,000 3.8 71.3 24.3 0.6 100.0 2,737 3-4 1.9 75.4 22.7 0.1 100.0 766 4.5 68.0 26.8 0.7 100.0 2,263 5+ 2.1 80.4 17.0 0.4 100.0 522 5.9 68.1 25.0 0.9 100.0 1,535 Residence Urban 1.7 79.7 18.4 0.1 100.0 482 5.4 73.1 21.2 0.3 100.0 1,182 Rural 2.3 78.1 19.4 0.2 100.0 1,952 4.2 69.4 25.6 0.8 100.0 5,709 Province Kigali City 1.0 79.9 19.1 0.0 100.0 349 4.1 73.7 21.8 0.4 100.0 834 South 1.3 81.6 17.1 0.0 100.0 509 6.1 65.8 27.4 0.7 100.0 1,590 West 3.8 83.8 12.0 0.4 100.0 558 2.9 74.6 21.8 0.7 100.0 1,517 North 3.1 72.2 24.7 0.0 100.0 373 4.3 68.5 26.5 0.6 100.0 1,106 East 1.5 74.2 24.0 0.3 100.0 646 4.5 69.2 25.5 0.8 100.0 1,845 Education No education 3.4 74.3 22.2 0.0 100.0 328 5.2 66.9 27.5 0.4 100.0 1,129 Primary 2.1 78.0 19.6 0.3 100.0 1,776 4.3 69.2 25.6 0.8 100.0 4,862 Secondary and higher 1.2 84.7 14.1 0.0 100.0 330 4.1 78.1 17.3 0.5 100.0 900 Wealth quintile Lowest 2.8 76.0 21.2 0.0 100.0 424 6.0 61.5 31.2 1.3 100.0 1,282 Second 3.5 77.2 19.1 0.2 100.0 503 5.4 64.9 29.1 0.6 100.0 1,451 Middle 2.1 76.5 21.1 0.2 100.0 478 3.6 72.6 23.2 0.6 100.0 1,434 Fourth 1.7 79.5 18.7 0.1 100.0 488 3.1 74.8 21.4 0.7 100.0 1,369 Highest 0.9 82.3 16.5 0.3 100.0 541 4.1 75.9 19.6 0.4 100.0 1,355 Total 15-49 2.2 78.4 19.2 0.2 100.0 2,434 4.4 70.0 24.9 0.7 100.0 6,891 50-59 3.2 76.8 20.0 0.0 100.0 460 na na na na na na Total 15-59 2.3 78.2 19.3 0.2 100.0 2,894 na na na na na na Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 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, especially those whose husbands have no cash earnings, are more likely to decide mainly by themselves on how their earnings are spent than women who earn the same as or less than their husbands. Interestingly, women who earn more than their husband are also more likely than other women to be the main decision-maker as to how the husband’s earnings are used. Women who earn the same as their husband are more likely to jointly decide with their husband how to use both their own earnings and their husband’s earnings than other women (82 percent). 248 • Women’s Status and Demographic and Health Outcomes Table 15.3 Women’s control over their own earnings and over those of their husbands Percent distribution 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 percent distribution 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 2014-15 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 Women’s earnings relative to husband’s earnings Mainly wife Wife and husband jointly Mainly husband Missing Mainly wife Wife and husband jointly Mainly husband Missing More than husband 31.4 59.9 8.7 0.0 100.0 425 11.7 62.0 25.7 0.6 100.0 425 Less than husband 19.7 65.5 14.8 0.0 100.0 2,884 3.9 68.6 27.4 0.1 100.0 2,884 Same as husband 9.7 82.1 8.2 0.0 100.0 1,033 2.1 82.4 15.3 0.1 100.0 1,033 Husband has no cash earnings or did not work 66.4 25.7 6.6 1.2 100.0 90 na na na na na 0 Woman worked but has no cash earnings na na na na na 0 5.1 66.6 27.3 1.0 100.0 2,104 Woman did not work na na na na na 0 2.4 79.4 17.9 0.3 100.0 403 Don’t know/missing (28.2) (6.1) (0.0) (65.7) 100.0 42 (11.4) (25.1) (19.3) (44.2) 100.0 42 Total 19.5 67.5 12.4 0.7 100.0 4,474 4.4 70.0 24.9 0.7 100.0 6,891 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 15.3 WOMEN’S AND MEN’S OWNERSHIP OF SELECTED ASSETS Ownership of assets, particularly high-value assets, has many beneficial effects for households, including protection against financial ruin. Women’s individual ownership of assets enables their economic empowerment and provides protection in the case of marital dissolution or abandonment. The 2014-15 RDHS collected information on women’s and men’s ownership (alone, jointly, and both alone and jointly) of two high-value assets, namely land and a house. Table 15.4.1 shows that 51 percent of women age 15-49 do not own a house and 54 percent do not own any land. Eight percent of women own a house alone, and 10 percent own land alone. Notably, women who own either of these assets appear to own them mostly jointly, as opposed to other types of ownership. Women’s ownership of a house or land increases with age but decreases with education. Rural women are more likely to own a house and land than urban women. More women in the North province own a house (13 percent) and land (14 percent) by themselves than women from the other provinces. Women in the highest wealth quintile are least likely to own either a house or land. Women’s Status and Demographic and Health Outcomes • 249 Table 15.4.1 Ownership of assets: Women Percent distribution of women age 15-49 by ownership of housing and land, according to background characteristics, Rwanda 2014-15 Percentage who own a house: Total Percentage who own land: Total Number Background characteristic Alone Jointly Alone and jointly Percentage who do not own a house Missing Alone Jointly Alone and jointly Percentage who do not own land Missing Age 15-19 0.5 3.2 0.0 96.3 0.0 100.0 4.0 3.9 0.1 91.9 0.0 100.0 2,768 20-24 2.0 23.4 0.2 74.4 0.0 100.0 6.5 21.1 0.3 72.2 0.0 100.0 2,457 25-29 4.2 49.0 0.1 46.7 0.0 100.0 7.2 41.4 0.2 51.2 0.0 100.0 2,300 30-34 8.2 61.8 0.6 29.5 0.0 100.0 10.0 53.2 0.1 36.6 0.1 100.0 2,151 35-39 12.0 66.0 0.4 21.6 0.0 100.0 12.6 58.0 0.6 28.7 0.0 100.0 1,575 40-44 21.3 63.3 0.1 15.3 0.0 100.0 18.6 55.8 0.1 25.4 0.1 100.0 1,269 45-49 28.9 58.7 0.3 12.1 0.0 100.0 25.5 54.4 0.6 19.5 0.0 100.0 977 Residence Urban 4.8 25.1 0.3 69.8 0.0 100.0 7.0 19.2 0.1 73.7 0.0 100.0 2,626 Rural 8.8 44.9 0.2 46.2 0.0 100.0 10.6 40.2 0.3 48.9 0.0 100.0 10,871 Province Kigali City 5.8 23.9 0.2 70.1 0.0 100.0 8.1 19.0 0.1 72.8 0.0 100.0 1,799 South 6.0 43.9 0.2 50.0 0.0 100.0 9.1 41.8 0.3 48.7 0.0 100.0 3,214 West 9.6 40.3 0.1 49.9 0.0 100.0 9.0 33.6 0.2 57.2 0.0 100.0 2,965 North 12.8 42.3 0.3 44.5 0.1 100.0 14.3 38.9 0.3 46.4 0.1 100.0 2,211 East 6.4 47.3 0.2 46.0 0.0 100.0 9.4 40.3 0.3 49.9 0.0 100.0 3,308 Education No education 16.5 59.2 0.2 24.1 0.0 100.0 15.8 50.5 0.4 33.2 0.0 100.0 1,665 Primary 8.3 45.4 0.3 46.1 0.0 100.0 10.2 40.0 0.2 49.5 0.0 100.0 8,678 Secondary and higher 2.7 19.4 0.1 77.7 0.0 100.0 6.1 17.7 0.3 76.0 0.0 100.0 3,154 Wealth quintile Lowest 14.1 38.8 0.2 47.0 0.0 100.0 13.5 31.9 0.3 54.3 0.0 100.0 2,561 Second 10.3 45.4 0.0 44.2 0.0 100.0 12.4 39.6 0.2 47.7 0.1 100.0 2,631 Middle 7.6 48.9 0.4 43.1 0.0 100.0 9.4 44.8 0.4 45.4 0.0 100.0 2,597 Fourth 4.7 45.2 0.3 49.8 0.1 100.0 7.6 41.8 0.3 50.2 0.1 100.0 2,634 Highest 4.0 28.9 0.2 66.9 0.0 100.0 7.1 24.4 0.2 68.3 0.0 100.0 3,073 Total 8.0 41.0 0.2 50.8 0.0 100.0 9.9 36.1 0.3 53.7 0.0 100.0 13,497 Table 15.4.2 shows that 52 percent of men age 15-49 do not own a house and 53 percent do not own land. Twenty-two percent of men own a house alone, and the same proportion own land alone, as compared with 8 percent and 10 percent of women, respectively. As with women, men’s ownership of land and a house increases with age. Men’s sole ownership of a house declines sharply with increasing education, from 32 percent among those with no education to 11 percent among those with a secondary education or higher. Sole ownership of land is also highest among men with no education (29 percent). Men in the highest quintile are least likely to own either a house or land. Men in the South province are more likely than men in other provinces to own a house or land alone (30 percent and 28 percent, respectively). Women’s disadvantage relative to men in terms of sole ownership of a house and land is evident across demographic and socioeconomic categories. A higher proportion of men own a house or land alone (22 percent, each) than their female counterparts (8 percent for house and 10 percent for land), while a higher proportion of women than men own a house or land jointly (41 percent and 36 percent, for house and land respectively among women, as compared to 26 percent and 25 percent for house and land, among men). 250 • Women’s Status and Demographic and Health Outcomes Table 15.4.2 Ownership of assets: Men Percent distribution of men age 15-49 by ownership of housing and land, according to background characteristics, Rwanda 2014-15 Percentage who own a house: Total Percentage who own land: Total Number Background characteristic Alone Jointly Alone and jointly Percentage who do not own a house Alone Jointly Alone and jointly Percentage who do not own land Missing Age 15-19 1.6 1.4 0.0 97.0 100.0 6.9 0.9 0.2 92.0 0.0 100.0 1,282 20-24 12.5 7.7 0.3 79.5 100.0 18.1 7.8 0.3 73.6 0.1 100.0 994 25-29 29.4 24.8 0.1 45.7 100.0 28.2 25.5 0.2 46.0 0.0 100.0 946 30-34 34.5 39.7 0.2 25.6 100.0 32.4 37.4 0.8 29.4 0.0 100.0 930 35-39 31.0 47.2 1.0 20.8 100.0 26.5 48.4 1.3 23.9 0.0 100.0 567 40-44 34.7 52.2 0.3 12.8 100.0 27.0 50.3 0.4 22.3 0.0 100.0 473 45-49 34.0 55.6 0.2 10.2 100.0 26.6 55.5 0.4 17.4 0.0 100.0 385 Residence Urban 15.1 14.4 0.1 70.3 100.0 18.3 13.3 0.1 68.3 0.0 100.0 1,169 Rural 23.5 28.5 0.3 47.6 100.0 22.7 28.3 0.6 48.3 0.0 100.0 4,408 Province Kigali City 18.0 11.9 0.2 69.9 100.0 20.9 12.4 0.1 66.6 0.0 100.0 804 South 30.4 15.8 0.0 53.8 100.0 27.7 19.7 0.2 52.4 0.0 100.0 1,327 West 18.1 32.6 0.2 49.1 100.0 17.1 28.4 0.3 54.1 0.1 100.0 1,182 North 28.3 28.7 0.9 42.1 100.0 27.3 29.9 0.9 41.9 0.0 100.0 851 East 15.0 34.9 0.2 49.8 100.0 17.4 32.1 0.9 49.7 0.0 100.0 1,413 Education No education 32.2 39.9 0.8 27.1 100.0 28.9 37.6 0.2 33.3 0.0 100.0 496 Primary 24.8 29.2 0.2 45.7 100.0 23.1 28.9 0.6 47.3 0.0 100.0 3,636 Secondary and higher 10.5 11.5 0.2 77.7 100.0 16.1 11.6 0.2 72.1 0.0 100.0 1,445 Wealth quintile Lowest 29.0 25.4 0.1 45.5 100.0 23.3 23.6 0.1 52.9 0.1 100.0 819 Second 25.5 31.3 0.4 42.8 100.0 23.2 29.8 0.6 46.4 0.0 100.0 991 Middle 23.8 31.2 0.3 44.7 100.0 23.4 31.6 0.7 44.3 0.0 100.0 1,097 Fourth 20.4 26.0 0.1 53.5 100.0 21.0 27.0 0.5 51.5 0.0 100.0 1,234 Highest 14.8 17.2 0.3 67.7 100.0 19.6 16.5 0.4 63.6 0.0 100.0 1,436 Total 15-49 21.8 25.6 0.3 52.4 100.0 21.8 25.2 0.5 52.5 0.0 100.0 5,577 50-59 39.0 53.5 0.2 7.3 100.0 30.7 55.4 0.9 13.0 0.0 100.0 640 Total 15-59 23.6 28.5 0.2 47.7 100.0 22.7 28.3 0.5 48.4 0.0 100.0 6,217 15.4 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 2014-15 RDHS collected information on married women’s participation in three types of decisions: their own health care, major household purchases, and visits to family, relatives, or friends. Also, to provide an understanding of gender differences in household decision-making, currently married men were asked about their participation in decisions about their own health care and major household purchases. Table 15.5 shows the percent distribution of currently married women and men according to the person in the household who usually makes decisions concerning these matters. Women are considered to participate in decision-making if they make decisions alone or jointly with their husbands. The results show that although 83 percent of women participate in making decisions about their own health care, only 23 percent of them decide solely about their health care, and 60 percent decide jointly with their husband. A higher proportion of men (97 percent) are involved in decisions about their own health care: 43 percent usually make decisions on their own while 54 percent decide jointly with their wives. Married men are also more likely than women to be involved in decisions regarding major household purchases (96 percent and 73 percent, respectively); over one-quarter of women (26 percent) and men (29 percent) say that such decisions are usually made by the husband alone. Seventeen percent of women decide themselves on visits to their family or relatives, while over two-thirds say they decide jointly with their husbands. Women’s Status and Demographic and Health Outcomes • 251 Table 15.5 Participation in decision-making Percent distribution of currently married women and currently married men age 15-49 by person who usually makes decisions about various issues, Rwanda 2014-15 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Missing Total Number of women/ men WOMEN Own health care 23.2 60.1 16.0 0.1 0.5 100.0 6,982 Major household purchases 12.4 60.8 26.2 0.1 0.5 100.0 6,982 Visits to her family or relatives 16.9 68.4 14.2 0.0 0.4 100.0 6,982 MEN Own health care 3.1 53.7 43.0 0.0 0.1 100.0 2,792 Major household purchases 3.9 67.4 28.5 0.0 0.1 100.0 2,792 Table 15.6.1 shows how women’s participation in decision-making varies by background characteristics such as age and residence. Sixty-five percent of married women report taking part in all three decisions, while 7 percent have no say in any of the three decisions. In general, the percentage of women participating in all three decisions increases with age, education, and wealth; for example, 78 percent of women with a secondary education or higher participate in all three decisions, as compared with 65 percent of women with no education. Sixty-eight percent of women who are employed for cash take part in all three decisions, compared with 66 percent of women who are not employed and 59 percent who are employed but are not paid in cash. Women in urban areas (70 percent) are more likely than women in rural areas (64 percent) to participate in all three decisions. Women’s participation in all three decisions ranges from a low of 61 percent in the South province to a high of 71 percent in the City of Kigali. 252 • Women’s Status and Demographic and Health Outcomes Table 15.6.1 Women’s participation in decision-making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either alone or jointly with their husband, by background characteristics, Rwanda 2014-15 Specific decisions All three decisions None of the three decisions Number of women Background characteristic Woman’s own health care Making major household purchases Visits to her family or relatives Age 15-19 73.6 61.9 76.9 51.3 11.6 85 20-24 82.7 69.5 83.6 61.2 8.3 883 25-29 82.4 73.2 84.7 63.7 6.2 1,577 30-34 82.9 72.2 84.5 64.9 7.4 1,693 35-39 85.1 74.8 87.0 67.5 5.5 1,240 40-44 84.4 74.5 87.0 68.1 6.8 896 45-49 84.4 77.8 86.9 70.5 7.5 607 Employment (last 12 months) Not employed 86.4 71.7 88.1 65.8 5.2 403 Employed for cash 84.9 75.9 86.6 68.1 6.0 4,474 Employed not for cash 79.5 67.8 82.1 59.4 9.1 2,099 Number of living children 0 79.8 77.4 87.6 65.9 6.5 358 1-2 83.8 72.5 84.3 64.9 7.3 2,757 3-4 83.4 72.2 85.5 64.4 6.4 2,302 5+ 83.4 75.0 86.3 67.4 7.0 1,564 Residence Urban 87.9 77.8 89.2 70.3 3.8 1,194 Rural 82.5 72.2 84.5 64.3 7.5 5,788 Province Kigali City 89.3 79.0 88.7 71.4 3.2 842 South 81.0 68.9 82.8 61.0 8.5 1,606 West 78.9 72.3 86.0 62.9 7.9 1,542 North 83.6 73.1 85.3 67.1 8.2 1,130 East 86.3 75.1 85.4 67.4 5.5 1,863 Education No education 80.9 73.7 84.9 64.8 7.8 1,154 Primary 82.5 71.2 84.3 63.2 7.3 4,921 Secondary and higher 91.5 83.2 91.2 78.0 3.6 907 Wealth quintile Lowest 79.4 67.6 80.3 58.5 10.0 1,313 Second 80.1 71.4 83.3 62.6 8.6 1,472 Middle 84.3 75.1 86.6 66.7 5.9 1,453 Fourth 84.2 72.8 86.2 65.5 5.8 1,380 Highest 89.0 78.9 90.1 73.2 4.1 1,365 Total 83.4 73.2 85.3 65.4 6.9 6,982 Note: Total includes 6 cases with missing information on employment. Table 15.6.2 presents data on currently married men’s participation (alone or jointly) in decision- making by background characteristics. The table shows that 97 percent of men age 15-49 participate in decisions about their own health care, and 96 percent participate in decisions about major household purchases. Overall, 93 percent of currently married men participate in both of these decisions, and only 1 percent do not participate in either. The proportion of men participating in both decisions varies only slightly by background characteristics. Women’s Status and Demographic and Health Outcomes • 253 Table 15.6.2 Men’s participation in decision-making by background characteristics Percentage of currently married men age 15-49 who usually make specific decisions either alone or jointly with their wife, by background characteristics, Rwanda 2014-15 Specific decisions Both decisions Neither of the two decisions Number of men Background characteristic Man’s own health Making major household purchases Age 15-19 * * * * 3 20-24 95.5 92.4 89.8 2.0 169 25-29 95.1 96.4 92.3 0.9 530 30-34 98.9 96.0 95.1 0.2 775 35-39 96.2 95.8 92.8 0.8 512 40-44 95.9 97.0 93.3 0.4 445 45-49 96.7 96.1 93.1 0.3 359 Employment (last 12 months) Not employed * * * * 11 Employed for cash 96.5 95.9 93.0 0.5 2,434 Employed not for cash 98.2 97.1 95.8 0.6 345 Number of living children 0 96.7 94.6 92.0 0.8 158 1-2 96.4 96.1 93.3 0.7 1,141 3-4 97.6 96.5 94.2 0.2 881 5+ 96.0 95.4 92.2 0.8 612 Residence Urban 97.9 95.6 94.1 0.6 494 Rural 96.5 96.1 93.1 0.6 2,298 Province Kigali City 98.7 96.5 95.6 0.4 361 South 97.3 96.8 94.6 0.5 605 West 96.7 94.3 92.0 1.0 627 North 98.0 95.6 93.8 0.2 472 East 94.4 96.8 91.8 0.6 727 Education No education 95.4 93.9 90.1 0.8 392 Primary 96.9 96.4 93.9 0.6 2,050 Secondary and higher 96.9 96.1 93.4 0.5 350 Wealth quintile Lowest 96.7 93.6 91.0 0.6 492 Second 95.5 95.8 91.8 0.5 601 Middle 96.9 96.7 94.5 0.9 585 Fourth 96.6 97.5 94.5 0.3 554 Highest 97.8 96.1 94.5 0.5 560 Total 15-49 96.7 96.0 93.3 0.6 2,792 50-59 95.2 95.4 92.2 1.6 579 Total 15-59 96.5 95.9 93.1 0.7 3,371 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 2 cases with missing information on employment. 15.5 ATTITUDES TOWARD WIFE BEATING The 2014-15 RDHS collected information on the degree of acceptance of wife beating by asking all women and men whether they believe that 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 15.7.1 and 15.7.2 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 and men who feel that wife beating is justified for at least one of the specified reasons. Agreement of a high proportion of respondents that wife beating is acceptable is an indication that they generally accept the right of a man to control his wife’s behavior even by means of violence. 254 • Women’s Status and Demographic and Health Outcomes Table 15.7.1 shows that 41 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 (9 percent). They are most likely to agree that a man is justified in beating his wife if she neglects the children (29 percent), refuses to have sexual intercourse with him (24 percent), or goes out without telling him (22 percent). One in five women (20 percent) believes that wife beating is justified if the woman argues with her husband. Table 15.7.1 Attitudes 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 2014-15 Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 10.6 22.0 24.5 33.2 24.8 45.1 2,768 20-24 9.0 20.8 23.6 30.8 24.5 42.6 2,457 25-29 8.1 19.6 20.8 28.9 23.4 40.1 2,300 30-34 8.2 19.6 21.6 27.4 24.2 39.8 2,151 35-39 8.0 18.2 19.7 26.0 23.5 38.1 1,575 40-44 7.8 20.2 20.7 27.1 25.1 39.6 1,269 45-49 9.5 22.7 24.0 29.4 26.5 42.1 977 Employment (last 12 months) Not employed 6.6 16.9 17.4 24.8 20.1 35.6 1,922 Employed for cash 8.5 19.8 21.6 27.7 24.6 40.4 7,562 Employed not for cash 10.7 23.3 26.0 35.0 26.1 46.1 3,995 Number of living children 0 9.5 20.3 23.7 30.9 23.5 42.5 4,754 1-2 8.5 20.6 22.1 29.5 24.7 41.3 4,007 3-4 9.2 20.1 21.0 27.9 25.0 40.2 2,894 5+ 7.6 20.8 21.1 27.7 25.1 40.6 1,842 Marital status Never married 10.0 20.9 23.6 31.0 24.3 42.9 5,100 Married or living together 7.2 19.4 20.5 27.8 23.4 39.8 6,982 Divorced/separated/widowed 13.1 23.6 26.4 31.8 29.7 43.8 1,415 Residence Urban 3.9 12.0 12.7 15.8 13.1 23.1 2,626 Rural 10.1 22.5 24.6 32.7 27.1 45.8 10,871 Province Kigali City 0.7 4.2 5.9 7.6 5.1 11.7 1,799 South 12.0 26.3 32.2 37.8 29.1 50.6 3,214 West 13.8 30.0 28.4 37.3 35.3 51.7 2,965 North 10.9 25.8 28.9 37.8 29.4 52.8 2,211 East 4.5 11.4 11.8 20.4 17.3 31.8 3,308 Education No education 11.0 24.9 25.0 31.3 31.4 46.1 1,665 Primary 9.7 21.8 23.7 30.9 26.0 43.8 8,678 Secondary and higher 5.5 14.3 17.0 24.4 16.3 32.3 3,154 Wealth quintile Lowest 13.8 27.3 28.1 36.5 32.6 50.5 2,561 Second 10.2 23.9 25.6 34.1 29.4 48.4 2,631 Middle 9.8 21.7 23.9 31.2 26.8 45.1 2,597 Fourth 8.2 20.1 22.8 30.7 23.4 42.3 2,634 Highest 3.4 11.0 12.9 16.9 12.2 24.0 3,073 Total 8.9 20.4 22.3 29.4 24.4 41.4 13,497 Note: Total includes 18 cases with missing information on employment. Women in rural areas are twice as likely to agree with at least one of the specified reasons as women in urban areas (46 percent and 23 percent, respectively). Differences by province are large. More than half of women in North, West, and South provinces believe that wife beating is justified for at least one of the reasons, as compared with only 12 percent of women in the city of Kigali and about one-third of those in East (32 percent). Women with no education (46 percent) or a primary education (44 percent) are more likely to agree that wife beating is justified for at least one reason than women with a secondary education or higher (32 Women’s Status and Demographic and Health Outcomes • 255 percent). Agreement with at least one reason justifying wife beating decreases with increasing wealth, from 51 percent of women in the lowest quintile to 24 percent of those in the highest quintile. Table 15.7.2 shows that the proportion of men age 15-49 who agree with at least one of the reasons justifying wife beating is far lower than that observed among women (18 percent versus 41 percent). However, as with women, men are most likely to agree that a husband is justified in beating his wife if she neglects the children (12 percent) and least likely to agree that a husband is justified in beating his wife if she burns the food (2 percent). Men age 15-19 (24 percent), men who are not employed (20 percent), and men with no children and never-married men (21 percent, each) are most likely to agree with at least one reason justifying wife beating. Rural men are more likely than urban men to agree that wife beating is justified for at least one of the specified reasons (19 percent and 13 percent, respectively). By province, Kigali City has the lowest proportion of men who agree with at least one reason justifying wife beating (6 percent). As with women, the proportion of men who agree with at least one reason justifying wife beating decreases with increasing education and wealth. Table 15.7.2 Attitudes 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 2014-15 Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 2.4 7.7 8.6 16.8 9.7 24.4 1,282 20-24 2.9 5.9 8.6 14.7 8.8 20.9 994 25-29 1.4 5.3 7.7 11.5 7.0 17.2 946 30-34 0.6 4.6 5.6 9.3 4.9 13.8 930 35-39 1.1 4.5 5.3 9.2 3.6 14.8 567 40-44 0.8 3.7 5.8 9.0 4.3 12.7 473 45-49 1.5 2.3 2.9 7.2 2.3 10.4 385 Employment (last 12 months) Not employed 2.1 6.3 7.6 13.7 8.8 20.1 740 Employed for cash 1.6 5.3 6.8 11.8 6.4 17.2 4,042 Employed not for cash 1.8 5.3 7.1 12.8 6.1 19.1 783 Number of living children 0 2.4 6.4 7.8 14.3 8.7 20.7 2,760 1-2 0.9 4.5 6.9 11.0 4.7 15.4 1,288 3-4 1.3 3.8 4.6 7.7 4.9 13.2 912 5+ 0.7 5.2 6.8 12.0 4.5 17.0 617 Marital status Never married 2.3 6.3 7.9 14.4 8.6 21.0 2,691 Married or living together 1.0 4.4 6.0 10.0 4.7 14.8 2,792 Divorced/separated/widowed 3.2 9.1 8.4 14.3 10.3 19.1 94 Residence Urban 1.4 3.8 5.4 10.2 3.5 13.0 1,169 Rural 1.7 5.8 7.4 12.7 7.5 19.1 4,408 Province Kigali City 0.2 1.3 3.0 4.8 0.5 6.2 804 South 1.4 5.7 9.0 12.7 5.5 17.2 1,327 West 3.0 6.9 9.2 17.7 7.6 23.4 1,182 North 3.3 10.8 9.0 15.3 13.6 27.2 851 East 0.7 3.0 4.2 9.4 6.4 14.8 1,413 Education No education 1.2 7.5 8.6 14.9 8.0 21.1 496 Primary 1.7 5.6 7.1 12.3 7.0 18.4 3,636 Secondary and higher 1.9 4.2 6.0 10.9 5.4 15.4 1,445 Wealth quintile Lowest 2.1 8.2 9.7 16.7 8.9 23.9 819 Second 2.3 5.6 6.3 13.6 7.1 18.9 991 Middle 1.7 5.3 8.1 12.4 7.3 18.7 1,097 Fourth 1.6 6.3 7.1 12.2 7.1 18.6 1,234 Highest 1.1 3.0 4.9 8.4 4.3 12.5 1,436 Total 15-49 1.7 5.4 7.0 12.2 6.7 17.9 5,577 50-59 1.3 2.8 3.0 5.8 4.4 10.8 640 Total 15-59 1.6 5.1 6.6 11.5 6.5 17.1 6,217 Note: Total includes 12 cases with missing information on employment. 256 • Women’s Status and Demographic and Health Outcomes 15.6 WOMEN’S EMPOWERMENT INDICATORS The two sets of empowerment indicators—women’s participation in making household decisions and their attitudes toward wife beating—can be summarized in two indices. The first index is the number of decisions (see Table 15.6.1 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. A higher score on this indicator is interpreted as reflecting a higher degree of empowerment of women. The second index ranges from 0 to 5 and corresponds with the number of reasons (see Table 15.7.1 for the 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 15.8 shows how these indices relate to each other among currently married women. There are clear relationships between the two indices. The percentage of women who disagree with all reasons justifying wife beating increases when the number of decisions in which they participate increases, from 48 percent among those who participate in none of the decisions to 64 percent among those who participate in all three decisions. The percentage of women who participate in all three decisions decreases as the number of reasons for which wife beating is justified increases, from 70 percent among those who agree with none of the reasons justifying wife beating to 53 percent among those who agree with all five reasons. Table 15.8 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 2014-15 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 48.0 480 1-2 na 53.9 1,939 3 na 64.1 4,563 Number of reasons for which wife beating is justified2 0 69.6 na 4,200 1-2 60.8 na 1,572 3-4 57.7 na 894 5 52.5 na 316 1 See Table 15.6.1 for the list of decisions. 2 See Table 15.7.1 for the list of reasons. na = Not applicable 15.7 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 15.9 shows the relationship of each of the empowerment indicators with current use of contraceptive methods by currently married women. Women’s Status and Demographic and Health Outcomes • 257 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 one or more decisions (53-56 percent). The pattern is similar for use of modern methods. Surprisingly, use of any contraceptive method and use of any modern method are slightly higher among women who agree with all five reasons justifying wife beating (59 percent and 53 percent, respectively) than among women who agree with none of the reasons (54 percent and 48 percent, respectively). Table 15.9 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 2014-15 Any method Any modern method Modern methods Any traditional method Not currently using Total Number of women Empowerment indicator Female sterili- zation Male sterili- zation Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 45.0 42.1 1.3 0.0 37.2 3.5 2.9 55.0 100.0 480 1-2 55.7 49.4 1.1 0.0 44.9 3.3 6.3 44.3 100.0 1,939 3 53.1 47.2 1.3 0.3 41.6 4.1 5.8 46.9 100.0 4,563 Number of reasons for which wife beating is justified3 0 53.7 47.9 1.5 0.2 42.0 4.2 5.8 46.3 100.0 4,200 1-2 50.9 45.5 1.0 0.3 40.3 3.9 5.4 49.1 100.0 1,572 3-4 53.1 47.2 0.5 0.2 44.8 1.7 5.9 46.9 100.0 894 5 59.2 53.1 1.0 0.0 47.9 4.2 6.1 40.8 100.0 316 Total 53.2 47.5 1.2 0.2 42.2 3.8 5.8 46.8 100.0 6,982 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 amenorrhea method 2 See Table 15.6.1 for the list of decisions. 3 See Table 15.7.1 for the list of reasons. 15.8 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS Women’s ideal number of children is typically lower than that 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 are not using family planning are defined as having an unmet need for family planning. Table 15.10 shows how women’s ideal family size and their unmet need for family planning vary by the two indicators of women’s status. Women who participate in none of the household decisions have almost the same desired family size as women who participate in one or more decisions (3.7 children versus 3.6 children). Women who participate in any of the three decisions have a lower total unmet need for family planning (19 percent) than women who do not participate in any decisions (24 percent). In general, there is no strong association between number of reasons justifying wife beating and either mean ideal number of children or unmet need for family planning. 258 • Women’s Status and Demographic and Health Outcomes Table 15.10 Ideal number of children and unmet need for family planning by women’s empowerment Mean ideal number of children for women age 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 2014-15 Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of women Empowerment indicator For spacing For limiting Total Number of decisions in which women participate3 0 3.7 477 14.8 9.6 24.4 480 1-2 3.6 1,916 11.2 7.4 18.6 1,939 3 3.6 4,497 10.0 8.5 18.5 4,563 Number of reasons for which wife beating is justified4 0 3.3 7,835 9.8 8.6 18.4 4,200 1-2 3.4 3,004 12.6 8.2 20.8 1,572 3-4 3.5 1,787 11.7 7.2 18.9 894 5 3.4 746 9.7 7.4 17.1 316 Total 3.4 13,372 10.7 8.3 18.9 6,982 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.12.1 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 15.6.1 for the list of decisions. 4 See Table 15.7.1 for the list of reasons. 15.9 WOMEN’S STATUS AND REPRODUCTIVE HEALTH CARE Women’s empowerment affects their ability to access reproductive health services. Higher levels of empowerment are likely to increase women’s ability to seek out and use health services to better meet their reproductive health goals, including safe motherhood. Table 15.11 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. The results show that, overall, there is minimal variation in use of maternal health care services by indicators of women’s empowerment. Antenatal care and delivery assistance from a health skilled provider are not different substantially by participation in household decisions and by the reason of beating wife is justified. Women who participate in none of the decisions are less likely to receive postnatal care from a skilled health provider within the first two days after delivery than those who participate at least in one or more decision. Women who agree with all five reasons justifying wife beating (38 percent) 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 (39-43 percent). Women’s Status and Demographic and Health Outcomes • 259 Table 15.11 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 2014-15 Empowerment indicator Percentage receiving antenatal care from a skilled provider1 Percentage receiving delivery care from a skilled provider1 Received postnatal care from health personnel within the first two days since delivery2 Number of women with a child born in the last five years Number of decisions in which women participate3 0 98.8 87.9 34.1 351 1-2 99.3 90.8 37.3 1,395 3 99.1 91.4 44.6 3,099 Number of reasons for which wife beating is justified4 0 99.1 91.3 43.2 3,596 1-2 99.2 90.9 40.9 1,351 3-4 98.1 88.4 38.8 790 5 98.7 89.4 37.5 323 Total 99.0 90.7 41.8 6,060 1 “Skilled provider” includes doctor, nurse, medical assistant, midwife, and community health worker. 2 Includes women who received a postnatal checkup from a doctor, nurse, medical assistant, midwife, or community health worker in the first two days after the birth and who gave birth either in a health facility or elsewhere. 3 Restricted to currently married women. See Table 15.6.1 for the list of decisions. 4 See Table 15.7.1 for the list of reasons. Adult and Maternal Mortality • 261 ADULT AND MATERNAL MORTALITY 16 stimates of maternal mortality require a 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 2014-15 RDHS is the fourth population-based national survey, following the 2000, 2005, and 2010 RDHSs, 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 serious misinterpreting of 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 interviewers 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 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 of those 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. E Key Findings • The maternal mortality ratio was 210 maternal deaths per 100,000 live births for the five-year period preceding the survey. • A comparison of the maternal mortality ratios from the 2000, 2005, 2010, and 2014-15 RDHS surveys indicates that there has been a steady decline in maternal mortality over the past 15 years (1071, 750, 476 and 210 deaths per 100,000 live births, respectively). • Maternal deaths account for 15 percent of all deaths to women age 15-49 in the past five years preceding the survey. 262 • Adult and Maternal Mortality Table 16.1 Completeness of information on siblings Completeness of data on survival status of sisters and brothers reported by interviewed women, age of living siblings, and age at death (AD) and years since death (YSD) of dead siblings (unweighted), Rwanda 2014-15 Sisters Brothers All siblings Number Percent Number Percent Number Percent All siblings 39,230 100.0 40,076 100.0 79,306 100.0 Living 30,626 78.1 28,962 72.3 59,588 75.1 Dead 8,539 21.8 10,985 27.4 19,524 24.6 Survival status unknown 65 0.2 129 0.3 194 0.2 Living siblings 30,626 100.0 28,962 100.0 59,588 100.0 Age reported 30,617 100.0 28,952 100.0 59,569 100.0 Age missing 9 0.0 10 0.0 19 0.0 Dead siblings 8,539 100.0 10,985 100.0 19,524 100.0 AD and YSD reported 8,526 99.8 10,966 99.8 19,492 99.8 Missing only AD 10 0.1 13 0.1 23 0.1 Missing only YSD 1 0.0 1 0.0 2 0.0 Missing AD and YSD 2 0.0 5 0.0 7 0.0 As a group, 2014-15 RDHS female respondents were able to report the survival status of almost 100 percent of their siblings; whether or not a brother or sister was alive or dead was unknown for less than 1 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 (10,985 brothers who died compared with 8,539 sisters who died). The sex ratio of siblings who have died is 129, which is very high and may be a consequence of the high male mortality during the genocide of 1994. Overall, the data on siblings are almost complete, with age reported for all living siblings and age at death and years since death reported for nearly all siblings who have died, with no difference between brothers and sisters. Rather than excluding siblings with missing information from the analysis, 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). The sibship size is expected to increase as the age increases. The monotonic increase in sibship size shown in Table 16.2 is supportive of more complete reporting of older siblings. Sex ratios at birth are near the internationally accepted range of 102 to 105, suggesting that there is no serious underreporting or over reporting 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 period of time before the survey. 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. Table 16.2 Sibship size and sex ratio of siblings Mean sibship size and sex ratio of siblings at birth, Rwanda 2014-15 Age of respondents Mean sibship size1 Sex ratio of siblings at birth2 15-19 6.2 100.2 20-24 6.5 104.4 25-29 6.9 99.9 30-34 7.2 103.0 35-39 7.4 98.4 40-44 7.5 101.5 45-49 7.6 109.6 Total 6.9 101.9 1 Includes the respondent 2 Excludes the respondent Adult and Maternal Mortality • 263 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 79,306 siblings, of whom 39,230 were sisters and 40,076 were brothers (Table 16.1). Direct estimates of age-specific mortality rates for women and men are shown in Table 16.3 for the five-year period before the survey, which roughly corresponds2 to the period from November 2009 to April 2015. There were more male than female deaths in the five years preceding the survey (320 versus 234). The male mortality rate is 2.96 deaths per 1,000 population, higher than the female mortality rate of 2.04 deaths per 1,000 population. Table 16.3 Adult mortality rates Direct estimates of female and male mortality rates for the five years preceding the survey, by five-year age groups, Rwanda 2014-15 Age Deaths Exposure years Mortality rates1 FEMALE 15-19 22 18,347 1.21 20-24 40 23,625 1.68 25-29 27 24,795 1.10 30-34 41 21,009 1.94 35-39 42 14,680 2.88 40-44 37 9,758 3.75 45-49 25 6,068 4.17 15-49 234 118,281 2.04a MALE 15-19 24 18,317 1.33 20-24 53 22,515 2.36 25-29 65 23,393 2.77 30-34 51 19,041 2.67 35-39 46 13,301 3.43 40-44 47 8,641 5.38 45-49 34 5,481 6.27 15-49 320 110,688 2.96a 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 estimates comparable to 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 2014-15 RDHS is 49 years), the overall rate for 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 2014-15 RDHS spanned a period of five months. 264 • Adult and Maternal Mortality 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 over reporting 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 over reported. 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 34 maternal deaths reported by women in the period 0 to 4 years preceding the survey. During this period, the maternal mortality rate, which is the annual number of maternal deaths per 1,000 women age 15-49, was 0.273. Maternal deaths accounted for 15 percent of all deaths to women age 15-49; in other words, about 1 in 6 Rwandan women who died in the five years preceding the survey died as a result of pregnancy or pregnancy-related causes. Maternal deaths accounted for a lower proportion of overall female deaths than they had in the past; in the 2005 RDHS and the 2010 RDHS, respectively, maternal deaths accounted for 20 percent and 24 percent of all female deaths in the five 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 indicator of maternal mortality because it measures the obstetric risk associated with each live birth. Table 16.4 shows that the maternal mortality ratio for Rwanda for the period 0-4 years prior to the survey was 210 deaths per 100,000 live births (or, alternatively, 2.1 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: 0.009, which is a sizeable decline relative to the figure of 0.023 reported in 2010. Table 16.4 Maternal mortality Direct estimates of maternal mortality rates for the five years preceding the survey, by five-year age groups, Rwanda 2014-15 Age Percentage of female deaths that are maternal Maternal deaths Exposure years Maternal mortality rate1 15-19 0.0 0 18,347 0.00 20-24 16.1 6 23,625 0.27 25-29 28.0 8 24,795 0.31 30-34 9.7 4 21,009 0.19 35-39 24.5 10 14,680 0.71 40-44 15.9 6 9,758 0.59 45-49 0.0 0 6,068 0.00 15-49 14.6 34 118,281 0.27a General fertility rate (GFR)2 128 Maternal mortality ratio (MMR)3 210 Lifetime risk of maternal death4 0.009 1 Expressed per 1,000 woman-years of exposure 2 Expressed per 1,000 women age 15-49 3 Expressed per 100,000 live births; calculated as the age-adjusted maternal mortality rate times 100 divided by the age-adjusted general fertility rate 4 Calculated as 1-(1-MMR)TFR, where TFR represents the total fertility rate for the five years preceding the survey a Age-adjusted rate 3 A rate is a measure of the frequency with which an event occurs in a defined population in a defined time: number of maternal deaths per thousand in five years. It has a time dimension. Ratio is the value obtained by dividing one quantity by another: i.e. the male to female ratio. A ratio often compares two rates. For example maternal mortality ratio (MMR) compares maternal mortality rates (0.27 per 1,000) and general fertility rate (GFR) (128 per 1,000), calculated as (0.27/128) x 100,000 =210 per 100,000. Adult and Maternal Mortality • 265 In the 2000, 2005, and 2010 RDHS surveys, maternal mortality ratios were 1,071, 750, and 476 deaths per 100,000 live births, respectively (Figure 16.1). A comparison of the maternal mortality ratios from these three surveys and the 2014-15 RDHS shows no reason to doubt that there has been a steady decline in the maternal mortality ratio between 2000 and 2014-15. Nevertheless, the level of decline should be interpreted with caution and with consideration of the sampling error of the estimates or confident interval4. Figure 16.1 Maternal mortality ratios for the period 0-4 years prior to the 2000, 2005, 2010, and 2014-15 RDHS surveys 4 A 95 percent confidence interval is a given realized interval calculated from sample data that there is a 95 percent probability the population parameter lies within the interval, that there is a 95 percent confidence that the interval covers the population estimate. 875 592 368 134 1,267 908 584 287 0 200 400 600 800 1000 1200 1400 RDHS 2000 RDHS 2005 RDHS 2010 RDHS 2014-15 MMR per 100,000 live births 1,071 750 476 210 Domestic Violence • 267 DOMESTIC VIOLENCE 17 omestic violence has negative health consequences for victims, especially with respect to the reproductive health of women and the physical, emotional, and mental health of their children. Acts of domestic violence may also be committed against men. The 2014-15 RDHS included a domestic violence module for both women and men, in recognition of the seriousness of the problem of domestic violence. Gender-based violence is defined as any act that results in, or is likely to result in, physical, sexual, or psychological harm or suffering among women and men, including threats of such acts and coercion or arbitrary deprivations of liberty, whether occurring in public or in private life (United Nations, 1993; United Nations, 1995). 17.1 MEASUREMENT OF VIOLENCE Collecting valid, reliable, and ethical data on domestic violence poses particular challenges because what constitutes violence or abuse varies across cultures and among individuals. Also, a culture of silence usually surrounds domestic violence and can affect reporting. The sensitivity of the topic is another issue. Assuring the safety of respondents and interviewers when asking about domestic violence in a household setting, protecting those who disclose violence, and reducing the risk of double victimization of respondents as they relive their experiences are all specific ethical concerns. The responses to these challenges by the 2014-15 RDHS are described in the sections that follow. 17.1.1 Use of Valid Measures of Violence In the 2014-15 RDHS, information was obtained from ever-married respondents on violence committed by their current and former spouses and by others. Information was collected from never-married respondents on violence committed by anyone. Since international research shows that intimate partner violence is one of the D Key Findings • Fourteen percent of women and 11 percent of men, age 15-49 have experienced physical violence within the 12 months preceding the survey. • Thirty-five percent of women and 39 percent of men age 15-49 have ever experienced physical violence at least once since age 15. • Eight percent of women and 1 percent of men age 15-49 report having experienced sexual violence at least once in the past 12 months. • Twenty-two percent of women and 5 percent of men age 15-49 report having experienced sexual violence at least once in their lifetime. • The most common perpetrators of sexual violence among ever-married women are current husbands/partners (34 percent), whereas the most common perpetrators among men are current/former girlfriends (20 percent). • Overall, 4 in 10 women and 2 in 10 men age 15-49 report having experienced emotional, physical, or sexual violence from a spouse. • Among women and men who have ever experienced spousal physical or sexual violence, 35 percent and 31 percent, respectively, reported suffering physical injuries. • Forty-eight percent of women and 45 percent of men have sought assistance to stop the violence they have experienced. 268 • Domestic Violence most common forms of violence, especially against women, information on spousal violence was measured in more detail than violence committed by other perpetrators. This was done by using a shortened, modified version of the Conflict Tactics Scale (Strauss, 1990). Specifically, violence by the current spouse/partner for currently married respondents and by the most recent spouse/partner for formerly married respondents was measured by asking all ever-married women and men the following set of questions. Does (did) your (last) spouse/partner ever: (a) Push you, shake you, or throw something at you? (b) Slap you? (c) Twist your arm or pull your hair? (d) Punch you with his/her 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/her even when you did not want to? (i) Force you to perform any sexual acts you did not want to? (j) Force you with threats or in any other way to perform sexual acts you did not want to? For every question that a respondent answered “yes,” she or he was asked about the frequency of the act in the 12 months preceding the survey. An affirmative answer to one or more of items (a) to (g) above constitutes evidence of physical violence, and an affirmative answer to one or more of items (h) to (j) constitutes evidence of sexual violence. Similarly, emotional violence among ever-married respondents was measured with the following questions. Does (did) your (last) spouse/partner ever: (a) Say or do something to humiliate you in front of others? (b) Threaten to hurt or harm you or someone close to you? (c) Insult you or make you feel bad about yourself? 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 respondents, all women and men were asked about physical violence from persons other than the current or most recent spouse/partner. Respondents who answered yes to this question were asked who committed violence against them and the frequency of such violence during the 12 months preceding the survey. Respondents who reported experiencing different forms of violence were asked for the perpetrators of the violence. Domestic Violence • 269 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 in the 2014-15 RDHS In recognition of the challenges in collecting data on violence, the interviewers in the 2014-15 RDHS were given special training. The training focused on how to ask sensitive questions, ensure privacy, and build rapport between interviewer and respondent. Rapport with the interviewer, confidentiality, and privacy are all key to building respondents’ confidence so that they can safely share their experiences with the interviewer. Also, placement of questions about violence at the end of the questionnaire provides time for the interviewer to develop a certain degree of intimacy that should further encourage respondents to share their experiences of violence, if any. In addition, the following protections were built into the survey in keeping with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001): 1. To maintain confidentiality, questions on domestic violence were asked of only one woman or man in each of the households selected for the male interview. In half of the households selected for the male survey, one man per household was randomly selected to receive the questions on domestic violence. In the remaining half of the households, one woman per household was selected for the questions on violence. The random selection of one woman or man was done through a simple selection procedure based on the Kish grid, which was built into the Household Questionnaire (Kish, 1965). 2. As a means of obtaining additional consent beyond the initial consent at the start of the interview, the respondent was informed that the questions could be sensitive and was reassured regarding the confidentiality of her/his responses. 3. The violence module was implemented only if privacy could be obtained. The interviewers were instructed to skip the module, thank the respondent, and end the interview if they could not maintain privacy. 17.1.3 Subsample for the Violence Module The domestic violence module was implemented only in the subsample of households selected for the men’s survey. Furthermore, in keeping with ethical requirements, only one woman or man per household was selected for the module, as mentioned above. As a result of these restrictions, a weighted total of 2,679 women age 15-49 (1,691 ever-married women) and 1,876 men age 15-49 (1,007 ever-married men) completed the domestic violence module. Specially constructed weights were used to adjust for the selection of only one woman or man per household and to ensure that the domestic violence subsample was nationally representative. 17.2 EXPERIENCE OF PHYSICAL VIOLENCE Tables 17.1.1 and 17.1.2 show the percentages of women and men, respectively, who have ever experienced physical violence since age 15 and the percentages of women and men experienced violence during the 12 months preceding the survey, by background characteristics. Thirty-five percent of women and 39 percent of men age 15-49 have experienced physical violence since age 15. Fourteen percent and 11 percent, respectively, experienced physical violence in the 12 months prior to the survey. Overall, 3 percent of women and 2 percent of men reported that they had experienced physical violence often in the past 12 months, and 11 percent and 9 percent, respectively, said they had experienced physical violence sometimes during the past 12 months. 270 • Domestic Violence Table 17.1.1 Experience of physical violence: Women Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced violence during the 12 months preceding the survey, by background characteristics, Rwanda 2014-15 Percentage who have ever experienced physical violence since age 151 Percentage who have experienced physical violence in the past 12 months Number of women Background characteristic Often Sometimes Often or sometimes2 Age 15-19 24.4 1.8 7.7 9.6 512 20-24 28.1 1.8 7.5 9.3 485 25-29 35.4 2.0 11.0 13.1 458 30-39 39.6 4.2 13.7 18.0 760 40-49 43.4 4.7 11.3 16.0 464 Religion Catholic 37.0 4.1 11.3 15.5 1,041 Protestant 34.2 2.4 10.3 12.8 1,231 Adventist 29.0 2.6 9.4 12.0 301 Muslim 30.6 1.2 10.1 11.3 71 Jehovah’s Witness (22.2) (0.0) (2.6) (2.6) 29 Other * * * * 4 Residence Urban 35.0 2.4 7.1 9.7 506 Rural 34.4 3.2 11.4 14.5 2,173 Province Kigali City 35.8 2.7 8.6 11.2 359 South 32.2 5.1 9.7 14.9 638 West 33.6 2.4 9.5 12.1 600 North 37.3 2.1 13.3 15.4 433 East 35.2 2.3 11.6 13.9 648 Marital status Never married 22.4 0.9 4.5 5.4 988 Married or living together 39.2 3.5 14.9 18.5 1,415 Divorced/separated/widowed 54.2 7.9 10.1 18.1 276 Number of living children 0 23.3 1.3 5.3 6.6 913 1-2 36.5 3.3 11.5 14.8 829 3-4 42.6 4.6 15.7 20.5 558 5+ 45.6 4.3 13.4 17.8 379 Employment Employed for cash 39.8 3.7 12.6 16.3 1,494 Employed not for cash 32.7 2.7 9.2 12.0 802 Not employed 17.7 1.0 5.5 6.5 382 Education No education 40.5 3.3 11.8 15.1 342 Primary 36.2 3.9 12.5 16.5 1,727 Secondary and higher 26.4 0.5 4.3 4.8 610 Wealth quintile Lowest 43.7 5.8 14.3 20.1 501 Second 34.6 2.6 12.9 15.5 510 Middle 36.6 3.8 10.7 14.5 520 Fourth 29.2 2.3 8.6 10.9 502 Highest 29.9 1.1 7.1 8.5 646 Total 15-49 34.5 3.0 10.5 13.6 2,679 Note: Total includes 1 woman for whom information on religion is missing and 1 woman for whom information on employment is missing. 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 Includes violence in the past 12 months. For women who were married before age 15 and who reported physical violence by a spouse, the violence could have occurred before age 15. 2 Includes women for whom frequency in the past 12 months is not known Domestic Violence • 271 Table 17.1.2 Experience of physical violence: Men Percentage of men age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced violence during the 12 months preceding the survey, by background characteristics, Rwanda 2014-15 Percentage who have ever experienced physical violence since age 151 Percentage who have experienced physical violence in the past 12 months Number of men Background characteristic Often Sometimes Often or sometimes2 Age 15-19 28.2 1.9 11.3 13.2 381 20-24 40.7 1.3 7.1 8.4 346 25-29 43.0 1.0 10.7 11.7 329 30-39 39.7 1.4 7.6 9.0 538 40-49 48.4 1.8 10.6 12.5 282 Religion Catholic 37.1 1.3 9.0 10.3 829 Protestant 40.8 1.4 9.6 11.0 732 Adventist 41.9 2.8 7.8 10.6 224 Muslim 46.9 0.0 9.8 9.8 41 Jehovah’s Witness * * * * 13 Other (45.2) (2.7) (16.5) (19.2) 32 Residence Urban 41.7 1.1 7.8 9.0 363 Rural 38.9 1.6 9.6 11.2 1,513 Province Kigali City 41.9 0.0 9.1 9.1 259 South 39.0 0.5 8.6 9.1 442 West 40.8 1.9 8.8 10.7 413 North 35.6 2.3 10.4 12.7 286 East 39.6 2.3 9.7 12.0 475 Marital status Never married 34.8 1.0 9.6 10.6 869 Married or living together 42.3 1.4 8.5 9.9 974 Divorced/separated/widowed (77.4) (16.0) (24.6) (40.6) 33 Number of living children 0 35.0 1.2 9.9 11.1 886 1-2 40.1 1.5 8.1 9.6 446 3-4 47.6 1.1 10.1 11.3 326 5+ 43.7 2.9 7.8 10.7 218 Employment Employed for cash 42.6 1.4 9.1 10.5 1,364 Employed not for cash 34.4 2.9 7.8 10.7 312 Not employed 26.1 0.0 12.5 12.5 200 Education No education 42.5 1.4 9.7 11.1 185 Primary 40.9 1.1 10.0 11.1 1,239 Secondary and higher 34.1 2.4 7.1 9.6 452 Wealth quintile Lowest 41.0 0.7 12.5 13.2 299 Second 41.9 1.1 10.1 11.2 355 Middle 39.1 1.3 9.7 11.0 353 Fourth 37.6 3.1 8.4 11.5 441 Highest 38.5 0.8 6.8 7.6 429 Total 15-49 39.4 1.5 9.3 10.7 1,876 50-59 48.4 1.3 10.9 12.2 242 Total 15-59 40.5 1.5 9.4 10.9 2,118 Note: Total includes 4 men for whom information on religion is missing and 1 man for whom information on employment is missing. 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 Includes violence in the past 12 months. For men who were married before age 15 and who reported physical violence by a spouse, the violence could have occurred before age 15. 2 Includes men for whom frequency in the past 12 months is not known The experience of physical violence varies by background characteristics. Older women (40-49) are more likely to have ever experienced physical violence (43 percent) than younger women (24 percent among 15-19). Similarly, women with five or more children are more likely to have experienced physical violence (46 272 • Domestic Violence percent) than women with no children (23 percent). Ever-married women are more likely to have ever experienced physical violence than those who have never been married, implying that in Rwanda violence perpetrated by spouses is more prevalent than violence perpetrated by other individuals. Fifty-four percent of women who are divorced, separated, or widowed and 39 percent of currently married women have experienced physical violence since age 15, as compared with 22 percent of never-married women. The percentage of women who have experienced physical violence decreases as educational level increases from 41 percent among those with no education to 26 percent for those with secondary or higher education and is lowest among those in the highest wealth quintile (30 percent). Variations by residence and province are minimal. The percentage of men who have experienced physical violence since age 15 is lowest among those age 15-19 (28 percent). Men living in urban areas are slightly more likely than those living in rural areas to report experiencing physical violence (42 percent and 39 percent, respectively). Married men, men with three or more children, and those who are employed for cash are more likely to have experienced physical violence than other category of men. The percentage of men who have experienced physical violence since age 15 decreases with increasing education, from 43 percent among those with no education to 34 percent among those with a secondary education or higher. There is no clear relationship between experience of physical violence and wealth quintile among men. 17.3 PERPETRATORS OF PHYSICAL VIOLENCE Tables 17.2.1 and 17.2.2 show perpetrators of physical violence, according to marital status, among women and men who have experienced physical violence since age 15. Among ever-married women, the most commonly reported perpetrator of physical violence is the current husband or partner (58 percent), followed by the former husband/partner (27 percent), indicating a high level of spousal violence. Among ever-married men, the most common perpetrators are those in the “other” category (20 percent), followed by the current wife or partner (18 percent) and police or solders (17 percent). Table 17.2.1 Persons committing physical violence: Women Among women age 15-49 who have experienced physical violence since age 15, percentage who report specific persons who committed the violence, according to the respondent’s current marital status, Rwanda 2014-15 Marital status Total Person Ever married Never married Current husband/partner 57.5 na 43.8 Former husband/partner 27.4 na 20.9 Current boyfriend 0.0 0.8 0.2 Former boyfriend 1.2 4.0 1.9 Father/stepfather 6.3 17.4 9.0 Mother/stepmother 3.3 20.3 7.3 Sister/brother 4.3 18.7 7.8 Daughter/son 0.3 0.0 0.2 Other relative 5.8 8.2 6.4 Mother-in-law 0.2 na 0.2 Other in-law 1.1 na 0.8 Teacher 2.8 21.2 7.2 Employer/someone at work 0.5 1.3 0.7 Police/soldier 1.1 0.8 1.1 Other 6.6 21.4 10.1 Number of women who have experienced physical violence since age 15 704 221 925 na = Not applicable Table 17.2.2 Persons committing physical violence: Men Among men age 15-49 who have experienced physical violence since age 15, percentage who report specific persons who committed the violence, according to the respondent’s current marital status, Rwanda 2014-15 Marital status Total Person Ever married Never married Current wife/partner 18.3 na 10.8 Former wife/partner 8.8 na 5.2 Current girlfriend 0.2 0.0 0.1 Former girlfriend 0.1 0.0 0.1 Father/stepfather 4.6 13.1 8.1 Mother/stepmother 2.9 4.3 3.4 Sister/brother 5.1 6.8 5.8 Other relative 10.3 10.8 10.5 Other in-law 1.7 na 1.0 Teacher 3.9 17.8 9.5 Employer/someone at work 6.8 2.8 5.2 Police/soldier 17.4 7.9 13.5 Other 19.9 24.5 21.8 Number of men who have experienced physical violence since age 15 437 303 740 na = Not applicable Domestic Violence • 273 Among never-married women who have experienced physical violence since age 15, the most common perpetrators are teachers and those in the “other” category (21 percent, each), followed by mothers or stepmothers (20 percent) and sisters or brothers (19 percent). Among never-married men, the most commonly reported perpetrators are those in the “other” category (25 percent), followed by teachers (18 percent) and fathers or stepfathers (13 percent). 17.4 EXPERIENCE OF SEXUAL VIOLENCE Tables 17.3.1 and 17.3.2 show the percentage of women and men, respectively, who have experienced sexual violence ever and in the past 12 months, according to background characteristics. Twenty-two percent of women age 15-49 and 5 percent of men have ever experienced sexual violence and that 8 percent of women and one percent of men experienced sexual violence in the past 12 months. There are notable variations in the experience of sexual violence by age. Younger women (age 15-19) are less likely than older women (age 40-49) to report ever having experienced sexual violence (15 percent and 26 percent, respectively). Similarly, those who have never been married and those who have no children are less likely to have experienced sexual violence. Differences by other background characteristics are not large. Urban women, those living in City of Kigali, and those who are divorced, separated, or widowed are more likely to have ever experienced sexual violence than other women. In all background characteristics, experiencing sexual violence is lower among men compared to women. Table 17.3.1 Experience of sexual violence: Women Percentage of women age 15-49 who have ever experienced sexual violence and percentage who have experienced sexual violence in the 12 months preceding the survey, by background characteristics, Rwanda 2014-15 Percentage who have experienced sexual violence: Number of women Background characteristic Ever1 In the past 12 months Age 15-19 14.5 3.8 512 20-24 25.3 7.8 485 25-29 21.8 7.6 458 30-39 23.9 9.9 760 40-49 26.3 7.5 464 Religion Catholic 21.8 7.1 1,041 Protestant 22.4 7.5 1,231 Adventist 23.5 7.2 301 Muslim 24.6 15.1 71 Jehovah’s Witness (31.7) (9.0) 29 Other * * 4 Residence Urban 28.0 9.1 506 Rural 21.1 7.2 2,173 Province Kigali City 25.6 6.9 359 South 22.2 7.1 638 West 23.2 8.3 600 North 19.7 7.4 433 East 22.1 7.7 648 Marital status Never married 19.0 4.4 988 Married or living together 23.2 9.7 1,415 Divorced/separated/widowed 30.7 8.2 276 Employment Employed for cash 25.1 8.4 1,494 Employed not for cash 19.5 7.0 802 Not employed 18.2 5.7 382 Number of living children 0 16.8 5.0 913 1-2 27.1 8.9 829 3-4 23.5 8.3 558 5+ 24.3 9.6 379 Education No education 18.2 6.8 342 Primary 22.9 8.2 1,727 Secondary and higher 23.6 6.3 610 Wealth quintile Lowest 23.0 9.3 501 Second 22.8 7.4 510 Middle 22.1 7.8 520 Fourth 18.9 5.7 502 Highest 24.7 7.6 646 Total 15-49 22.4 7.6 2,679 Note: Total includes 1 case each in which information on religion and employment is missing. 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 Includes violence in the past 12 months 274 • Domestic Violence Table 17.3.2 Experience of sexual violence: Men Percentage of men age 15-49 who have ever experienced sexual violence and percentage who have experienced sexual violence in the 12 months preceding the survey, by background characteristics, Rwanda 2014-15 Percentage who have experienced sexual violence: Number of men Background characteristic Ever1 In the past 12 months Age 15-19 2.8 0.6 381 20-24 8.3 1.7 346 25-29 6.1 1.6 329 30-39 5.0 1.2 538 40-49 3.3 0.7 282 Religion Catholic 5.0 1.0 829 Protestant 5.4 1.4 732 Adventist 4.1 1.1 224 Muslim 7.8 1.8 41 Jehovah’s Witness * * 13 Other (5.5) (0.0) 32 Residence Urban 7.9 1.3 363 Rural 4.4 1.1 1,513 Province Kigali City 6.7 1.5 259 South 4.1 0.6 442 West 5.2 1.3 413 North 5.7 1.6 286 East 4.6 1.1 475 Marital status Never married 4.7 0.5 869 Married or living together 4.9 1.3 974 Divorced/separated/widowed (20.2) (15.5) 33 Employment Employed for cash 5.8 1.5 1,364 Employed not for cash 4.0 0.0 312 Not employed 1.7 0.5 200 Number of living children 0 4.9 0.7 886 1-2 6.3 2.3 446 3-4 4.7 0.7 326 5+ 3.7 1.3 218 Education No education 3.9 1.6 185 Primary 5.0 1.2 1,239 Secondary and higher 5.8 0.8 452 Wealth quintile Lowest 4.6 1.7 299 Second 3.2 0.6 355 Middle 5.0 0.8 353 Fourth 5.7 1.8 441 Highest 6.4 0.9 429 Total 15-49 5.1 1.2 1,876 50-59 3.9 1.0 242 Total 15-59 4.9 1.1 2,118 Note: Total includes 4 cases in which information on religion is missing and 1 case in which information on employment is missing. 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 Includes violence in the past 12 months Domestic Violence • 275 17.5 PERPETRATORS OF SEXUAL VIOLENCE Tables 17.4.1 and 17.4.2 show perpetrators of sexual violence, according to marital status, among women and men who have ever experienced sexual violence. Among ever-married women, the most commonly reported perpetrators of sexual violence are current husbands/partners (34 percent), followed by former husbands/partners (22 percent). Among men, the most common perpetrators are current/former girlfriends (20 percent), current wives (18 percent), and friends/acquaintances (18 percent). Among never-married women who have experienced sexual violence, the most commonly reported perpetrators are current/former boyfriends (41 percent), friends or acquaintances (16 percent), and family friends (12 percent). Table 17.4.1 Persons committing sexual violence: Women Among women age 15-49 who have experienced sexual violence, percentage who report specific persons who committed the violence, according to the respondent’s current marital status, Rwanda 2014-15 Marital status Total Person Ever married Never married Current husband/partner 33.8 na 23.3 Former husband/partner 21.8 na 15.0 Current/former boyfriend 16.4 41.3 24.2 Father/stepfather 0.6 1.5 0.9 Brother/stepbrother 0.2 0.0 0.1 Other relative 4.9 7.4 5.6 In-law 3.0 na 2.4 Own friend/acquaintance 12.0 15.8 13.2 Family friend 9.9 11.9 10.5 Teacher 0.4 2.8 1.2 Employer/someone at work 2.5 3.5 2.8 Police/soldier 1.8 1.4 1.7 Priest/religious leader 0.2 0.0 0.2 Stranger 8.4 11.1 9.2 Other 0.6 2.1 1.0 Number of women who have experienced sexual violence 413 188 601 Note: Women can report more than one person who committed the violence. na = Not applicable Table 17.4.2 Persons committing sexual violence: Men Among men age 15-49 who have experienced sexual violence, percentage who report specific persons who committed the violence, according to the respondent’s current marital status, Rwanda 2014-15 Marital status Total Person Ever married Never married Current wife/partner 17.6 na 10.1 Former wife/partner 12.2 na 7.0 Current/former girlfriend 19.6 (13.0) 16.8 Mother/stepmother 0.0 (6.1) 2.6 Sister/stepsister 0.0 (0.0) 0.0 Other relative 2.1 (5.1) 3.4 In-law 0.7 na 1.2 Own friend/acquaintance 17.5 (28.7) 22.3 Family friend 4.7 (10.7) 7.3 Teacher 0.0 (0.0) 0.0 Employer/someone at work 15.3 (9.2) 12.7 Police/soldier 0.0 (0.0) 0.0 Priest/religious leader 0.0 (0.0) 0.0 Stranger 5.9 (14.4) 9.5 Other 0.0 (0.0) 0.0 Number of men who have experienced sexual violence 55 41 95 Note: Men can report more than one person who committed the violence. 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 17.6 AGE AT FIRST EXPERIENCE OF SEXUAL VIOLENCE Table 17.5.1 and Table17.5.2 shows the percentage of respondents age 15-49 who experienced sexual violence by specific exact ages it first happened, according to current age and current marital status. Overall, 78 percent of women and 95 percent of men have not experienced sexual violence at time of the survey. Among women, 1 percent or less experienced sexual violence by exact age 10 or 12. Four percent of women and a very insignificant proportion of men experienced sexual violence by age 15. Ten percent of women experienced sexual violence by age 18, and 16 percent experienced sexual violence by age 22. Women age 40-49 (18 percent) are more likely to have experienced sexual violence by age 22 than younger women age 25-39 (14 percent). Furthermore, a higher percentage of never-married women than ever-married women experienced sexual violence by each specific age. 276 • Domestic Violence Table 17.5.1 Age at first experience of sexual violence among women Percentage of women age 15-49 who experienced sexual violence by specific exact ages, according to current age and current marital status, Rwanda 2014-15 Percentage who first experienced sexual violence by exact age: Percentage who have not experienced sexual violence Number of women Background characteristic 10 12 15 18 22 Age 15-19 1.4 3.3 6.8 na na 85.5 512 20-24 0.8 1.1 3.1 11.0 na 74.7 485 25-29 0.0 0.6 3.4 7.9 13.8 78.2 458 30-39 0.6 0.7 2.4 7.7 13.4 76.1 760 40-49 0.5 1.1 2.6 11.7 18.2 73.7 464 Marital status Never married 1.1 2.5 5.6 12.5 17.4 81.0 988 Ever married 0.4 0.6 2.4 8.7 15.5 75.6 1,691 Total 0.7 1.3 3.6 10.1 16.2 77.6 2,679 na = Not applicable Table 17.5.2 Age at first experience of sexual violence: Men Percentage of men age 15-49 who experienced sexual violence by specific exact ages, according to current age and current marital status, Rwanda 2014-15 Percentage who first experienced sexual violence by exact age: Percentage who have not experienced sexual violence Number of men Background characteristic 15 18 22 Total 0.0 0.0 0.3 94.9 1,876 17.7 EXPERIENCE OF DIFFERENT FORMS OF VIOLENCE Tables 17.6.1 and 17.6.2 present information on the experience of various forms of violence among respondents age 15-49. Forty-four percent of women age 15-49 reported that they have ever experienced either physical or sexual violence (Table 17.6.1). Twenty-two percent have ever experienced physical violence only, 9 percent have ever experienced sexual violence only, and 13 percent have ever experienced both physical and sexual violence. The percentage of women who have ever experienced both physical and sexual violence; and the percentage who have ever experienced either physical or sexual violence increase gradually with age. Table 17.6.1 Experience of different forms of violence: Women Percentage of women age 15-49 who have ever experienced different forms of violence, by current age, Rwanda 2014-15 Age Physical violence only Sexual violence only Physical and sexual violence Physical or sexual violence Number of women 15-19 18.1 8.2 6.4 32.6 512 15-17 14.6 8.2 5.8 28.6 333 18-19 24.5 8.1 7.5 40.0 178 20-24 16.9 14.2 11.2 42.3 485 25-29 24.4 10.8 11.0 46.2 458 30-39 23.1 7.4 16.5 47.0 760 40-49 24.5 7.4 18.9 50.8 464 Total 21.5 9.4 13.1 43.9 2,679 Overall, 41 percent of men age 15-49 reported that they have ever experienced either physical or sexual violence; 36 percent have ever experienced physical violence only, 2 percent have ever experienced sexual Domestic Violence • 277 violence only, and 3 percent have ever experienced both physical and sexual violence. In general, the percentage of men who have ever experienced physical or sexual violence tends to increase with age (Table 17.6.2). Table 17.6.2 Experience of different forms of violence: Men Percentage of men age 15-49 who have ever experienced different forms of violence, by current age, Rwanda 2014-15 Age Physical violence only Sexual violence only Physical and sexual violence Physical or sexual violence Number of men 15-19 26.4 0.9 1.8 29.2 381 15-17 20.6 0.9 2.1 23.5 238 18-19 36.2 1.1 1.4 38.6 142 20-24 35.3 2.9 5.4 43.6 346 25-29 38.6 1.7 4.4 44.7 329 30-39 36.2 1.5 3.5 41.2 538 40-49 46.5 1.3 2.0 49.7 282 Total 15-49 36.0 1.7 3.4 41.1 1,876 50-59 46.0 1.5 2.4 49.9 242 Total 15-59 37.2 1.6 3.3 42.1 2,118 17.8 VIOLENCE DURING PREGNANCY Respondents who had ever been pregnant were asked specifically whether they had ever experienced physical violence while pregnant and, if so, who the perpetrators of the violence were. Table 17.7 shows that 8 percent of women who has ever been pregnant experienced physical violence during pregnancy. Differences by background characteristics are not large. The main exception is that women who are divorced, separated, or widowed were substantially more likely to have ever experienced violence during pregnancy (18 percent) than women in other marital status categories (5 to7 percent). 278 • Domestic Violence Table 17.7 Experience of violence during pregnancy Among women age 15-49 who have ever been pregnant, percentage who have ever experienced physical violence during pregnancy, by background characteristics, Rwanda 2014-15 Background characteristic Percentage who experienced violence during pregnancy Number of women who have ever been pregnant Age 15-19 (8.5) 37 20-24 6.8 276 25-29 7.1 360 30-39 7.9 711 40-49 11.3 449 Religion Catholic 8.7 696 Protestant 9.1 843 Adventist 5.9 215 Muslim 5.7 55 Jehovah’s Witness * 16 Other * 3 Residence Urban 9.0 322 Rural 8.3 1,509 Province Kigali City 10.8 231 South 8.0 429 West 6.4 394 North 8.3 294 East 9.4 483 Marital status Never married 5.0 165 Married or living together 7.0 1,393 Divorced/separated/widowed 17.6 273 Number of living children 0 4.1 65 1-2 6.7 829 3-4 9.7 558 5+ 11.0 379 Education No education 8.7 318 Primary 8.9 1,279 Secondary and higher 5.2 234 Wealth quintile Lowest 11.8 389 Second 8.1 375 Middle 6.6 362 Fourth 7.7 327 Highest 7.5 377 Total 15-49 8.4 1,831 Note: Total includes 1 case in which information on religion is missing. 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. 17.9 MARITAL CONTROL BY SPOUSE Close control and monitoring of a spouse’s behavior is known to be an important warning sign and correlate with violence in a relationship. A series of questions were included in the 2014-15 RDHS to elicit the degree of marital control exercised by husbands or wives over their spouses. Controlling behaviors most often manifest themselves in terms of extreme possessiveness, jealousy, and attempts to isolate spouses from their family and friends. To determine the degree of marital control, ever-married women and men were asked whether their current or former spouse exhibited each of the following controlling behaviors: (1) is jealous or gets angry if she/he talks to other men/women, (2) frequently accuses her/him of being unfaithful, (3) does not permit meetings with female/male friends, (4) tries to limit contact with her/his family, and (5) insists on Domestic Violence • 279 knowing where she/he is at all times. Because the concentration of such behaviors is more significant than the display of any single behavior, the proportion of respondents whose spouses display at least three of the specified behaviors is highlighted. Tables 17.8.1 and 17.8.2 present the percentage of ever-married women and men, respectively, whose spouses display each of the listed behaviors, by selected background characteristics. The main controlling behaviors women experienced from their husbands were jealousy or anger if they talked to other men (35 percent) and insisting on knowing where they are at all times (29 percent), followed by not permitting them to meet female friends (14 percent), limiting contact with family (13 percent), and frequently accusing them of being unfaithful (12 percent). Seventeen percent of ever-married women confirm that their husbands display three or more of these controlling behaviors. More than half (55 percent) say that their husbands display none of these behaviors. Women who are afraid of their husbands/partners most of the time (56 percent) and those who are divorced, separated, or widowed (34 percent) are much more likely to report that their husbands display three or more of these controlling behaviors than other women. Table 17.8.1 Marital control exercised by husbands Percentage of ever-married women age 15-49 whose husbands/partners have ever demonstrated specific types of controlling behaviors, by background characteristics, Rwanda 2014-15 Percentage of women whose husband/partner: Background characteristic Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Displays 3 or more of the specific behaviors Displays none of the specific behaviors Number of ever-married women Age 15-19 * * * * * * * 19 20-24 41.2 7.7 13.7 11.5 31.4 13.0 46.3 223 25-29 34.3 11.9 13.9 13.4 28.9 16.2 53.4 325 30-39 36.2 11.7 15.8 14.7 30.7 18.8 54.0 677 40-49 30.0 14.3 12.4 10.5 26.0 16.2 63.4 446 Religion Catholic 31.3 11.2 12.3 12.0 26.9 15.2 58.7 642 Protestant 36.5 12.9 15.6 14.4 30.5 18.6 52.7 777 Adventist 34.0 12.6 14.8 11.9 29.0 19.0 58.8 199 Muslim 66.9 11.9 23.8 13.5 45.7 14.3 29.6 51 Jehovah’s Witness * * * * * * * 18 Other * * * * * * * 3 Residence Urban 42.0 12.3 18.2 13.1 31.2 18.4 50.3 296 Rural 33.6 12.0 13.6 13.0 29.1 16.8 56.1 1,395 Province Kigali City 41.1 13.0 22.8 15.0 29.3 21.9 52.7 207 South 36.3 13.7 15.7 14.5 35.1 21.3 53.4 393 West 39.1 13.4 11.2 11.5 30.2 14.6 51.4 353 North 29.7 10.5 13.0 12.4 28.5 14.5 56.5 286 East 31.6 10.3 12.9 12.6 24.6 14.7 59.6 453 Marital status Married or living together 33.0 10.0 11.2 10.9 26.7 13.8 57.3 1,415 Divorced/separated/widowed 45.9 22.5 30.9 24.3 43.5 33.7 43.8 276 Number of living children 0 41.4 9.1 9.7 12.7 34.2 17.5 49.8 77 1-2 33.9 10.4 14.8 13.8 30.4 16.0 53.9 692 3-4 37.7 14.1 15.5 14.9 30.7 19.8 53.7 544 5+ 32.4 12.8 13.1 9.2 24.9 14.8 60.4 378 Employment Employed for cash 37.3 13.9 16.4 14.5 30.2 18.8 52.2 1,089 Employed not for cash 30.4 9.6 10.2 11.8 28.8 14.6 60.5 501 Not employed 33.9 4.7 14.1 3.4 24.6 10.0 60.0 100 (Continued…) 280 • Domestic Violence Table 17.8.1—Continued Percentage of women whose husband/partner: Background characteristic Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Displays 3 or more of the specific behaviors Displays none of the specific behaviors Number of ever-married women Education No education 32.5 16.1 14.7 11.1 25.7 16.6 57.8 305 Primary 35.5 11.8 13.9 13.1 30.4 17.3 54.8 1,187 Secondary and higher 36.6 7.8 16.9 15.8 29.5 16.2 52.6 198 Wealth quintile Lowest 42.0 19.6 20.7 16.2 34.1 25.0 48.2 359 Second 35.3 12.2 12.8 14.2 30.8 16.6 54.4 349 Middle 29.8 10.6 11.3 10.0 26.0 13.5 61.1 333 Fourth 30.6 9.2 11.5 11.4 29.5 13.4 57.8 307 Highest 36.9 8.1 15.1 13.0 26.4 16.0 54.7 342 Woman afraid of husband/partner Afraid most of the time 71.9 37.2 46.6 48.7 64.1 56.1 19.5 180 Sometimes afraid 59.1 25.0 26.5 20.0 41.6 32.0 32.4 283 Never afraid 24.1 5.4 6.9 6.3 21.6 7.9 65.6 1,223 Total 35.1 12.1 14.4 13.1 29.4 17.1 55.1 1,691 Note: Total includes 1 case in which information on religion is missing, 1 case in which information on employment is missing, and 5 cases in which information on fear of husband/partner is missing. 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. Table 17.8.2 shows that, similar to women, the main controlling behaviors men experienced from their wives were jealousy or anger if they talked to other women (39 percent) and insisting on knowing where they are at all times (24 percent). Fifteen percent of men said that their wives frequently accuse them of being unfaithful, 5 percent reported that their wives try to limit contact with family, and 4 percent said that their wives do not permit them to meet male friends. Table 17.8.2 Marital control exercised by wives Percentage of ever-married men age 15-49 whose wives/partners have ever demonstrated specific types of controlling behaviors, by background characteristics, Rwanda 2014-15 Percentage of men whose wife/partner: Background characteristic Is jealous or angry if he talks to other women Frequently accuses him of being unfaithful Does not permit him to meet his male friends Tries to limit his contact with his family Insists on knowing where he is at all times Displays 3 or more of the specific behaviors Displays none of the specific behaviors Number of ever- married men Age 15-19 * * * * * * * 1 20-24 36.3 7.1 3.2 6.2 30.9 5.7 42.7 67 25-29 39.9 16.3 7.2 7.6 25.2 13.0 50.6 188 30-39 42.7 16.2 4.4 5.0 24.8 10.4 50.4 475 40-49 32.6 13.7 2.9 3.9 18.9 5.8 57.2 276 Religion Catholic 39.1 14.9 3.8 5.6 21.6 8.0 50.8 441 Protestant 36.1 13.4 4.5 5.5 23.4 9.4 55.8 399 Adventist 43.3 19.6 4.5 4.2 29.6 13.7 46.6 122 Muslim (66.4) (17.8) (0.0) (0.0) (31.7) (7.0) (27.3) 17 Jehovah’s Witness * * * * * * * 8 Other (38.4) (16.3) (16.5) (6.8) (24.0) (6.8) (48.4) 19 Residence Urban 45.7 14.6 5.5 7.9 36.5 12.0 42.3 169 Rural 37.7 15.0 4.2 4.7 21.0 8.7 53.7 837 (Continued…) Domestic Violence • 281 Table 17.8.2—Continued Percentage of men whose wife/partner: Background characteristic Is jealous or angry if he talks to other women Frequently accuses him of being unfaithful Does not permit him to meet his male friends Tries to limit his contact with his family Insists on knowing where he is at all times Displays 3 or more of the specific behaviors Displays none of the specific behaviors Number of ever- married men Province Kigali City 33.2 13.4 5.1 4.5 32.8 9.1 54.5 123 South 37.1 13.2 5.2 5.7 23.1 11.4 52.7 215 West 46.2 13.5 4.5 7.0 28.0 7.3 42.2 239 North 36.8 11.3 5.9 8.1 24.0 11.1 54.6 167 East 38.3 20.6 2.4 2.0 15.6 8.3 56.5 263 Marital status Married or living together 38.1 13.4 3.6 4.5 22.9 8.3 52.7 974 Divorced/separated/widowed (68.2) (59.6) (28.6) (27.6) (43.8) (39.7) (23.0) 33 Number of living children 0 35.4 11.9 6.3 5.6 30.9 11.6 52.6 60 1-2 38.0 13.2 5.1 5.6 23.4 8.9 52.2 406 3-4 40.1 15.4 4.0 6.2 25.5 11.1 51.4 324 5+ 40.4 18.2 3.2 3.2 19.2 6.7 51.2 218 Employment Employed for cash 39.2 14.8 4.6 5.3 23.6 9.1 51.8 868 Employed not for cash 37.7 15.7 3.2 5.0 23.4 10.5 51.8 138 Not employed * * * * * * * 1 Education No education 37.3 16.8 7.5 7.5 26.7 10.4 49.6 163 Primary 38.6 15.5 3.8 4.8 22.6 9.2 52.6 734 Secondary and higher 44.6 8.6 3.7 5.0 25.9 8.0 49.3 110 Wealth quintile Lowest 41.9 18.0 6.4 6.2 22.3 10.5 47.7 190 Second 39.1 13.8 2.8 5.1 20.2 9.4 52.5 220 Middle 36.4 15.8 7.1 7.2 20.8 9.5 56.1 202 Fourth 40.1 14.9 1.4 2.4 23.9 6.9 49.9 219 Highest 37.6 12.1 5.0 5.7 32.2 10.5 52.4 176 Man afraid of wife/partner Afraid most of the time * * * * * * * 17 Sometimes afraid 61.8 34.2 15.9 19.1 53.6 32.7 27.8 73 Never afraid 36.6 12.7 3.1 3.6 20.5 6.7 54.3 915 Total 15-49 39.0 14.9 4.4 5.3 23.6 9.3 51.7 1,007 50-59 32.3 18.0 4.9 4.7 15.8 9.5 59.8 239 Total 15-59 37.8 15.5 4.5 5.2 22.1 9.3 53.3 1,246 Note: Total includes 1 case in which information on religion is missing, 1 case in which information on employment is missing, and 1 case in which information on fear of wife/partner is missing. Wife/partner refers to the current wife/partner for currently married men and the most recent wife/partner for divorced, separated, or widowed men. 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. Nine percent of ever-married men say that their wives display three or more of these controlling behaviors. Variations by background characteristics are minimal with the exception that men who say they are sometimes afraid of their wives (33 percent) are more likely to say their wives display three or more controlling behaviors than those who are never afraid of their wives (7 percent). Fifty-two percent of men confirmed that their wives display none of these 3 controlling behaviors. 17.10 FORMS OF SPOUSAL VIOLENCE Different types of violence are not mutually exclusive, and people may report multiple forms of violence. Tables 17.9.1 and 17.9.2 show the percentage of ever-married women and men age 15-49, respectively, who have experienced various forms of violence by their spouse over the course of the marriage and in the 12 months preceding the survey. Note that respondents who are currently married reported on violence by their current spouse, and respondents who are widowed, divorced, or separated reported on violence by their most recent spouse. 282 • Domestic Violence Table 17.9.1 shows that 31 percent of ever-married women reported that they have ever had experienced any physical violence committed by their current or most recent husband or partner, 12 percent reported any sexual violence, and 27 percent reported any emotional violence. Thirty-four percent of ever-married women have experienced any form of physical and/or sexual violence, and 4 in 10 (40 percent) have experienced any form of emotional and/or physical and/or sexual violence. Thirty-seven percent of women have experienced physical and/or sexual violence committed by their current or most recent husband or partner. The most common form of spousal violence reported by ever-married women is being slapped (28 percent). Twenty-three percent of women reported that their husbands had insulted them or made them feel bad about themselves; 15 percent said that they had been pushed, been shaken, or had something thrown at them; and 11 percent reported that they had been physically forced to have sexual intercourse when they did not want to. Table 17.9.1 Forms of spousal violence: Women 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 husband/partner, Rwanda 2014-15 Ever In the past 12 months1 Type of violence Often Sometimes Often or sometimes Physical violence Any physical violence 31.1 4.0 13.5 17.6 Pushed her, shook her, or threw something at her 14.6 2.7 6.3 8.9 Slapped her 28.1 2.7 12.7 15.4 Twisted her arm or pulled her hair 7.5 1.4 3.4 4.7 Punched her with his fist or with something that could hurt her 12.0 2.0 4.7 6.7 Kicked her, dragged her, or beat her up 11.9 2.0 4.8 6.8 Tried to choke her or burn her on purpose 3.1 0.6 1.0 1.6 Threatened her or attacked her with a knife, gun, or other weapon 4.6 0.9 2.1 3.0 Sexual violence Any sexual violence 11.6 1.7 6.5 8.3 Physically forced her to have sexual intercourse with him when she did not want to 10.7 1.5 6.1 7.6 Physically forced her to perform any other sexual acts she did not want to 6.5 1.1 3.1 4.2 Forced her with threats or in any other way to perform sexual acts she did not want to 5.2 0.9 2.3 3.3 Emotional violence Any emotional violence 26.6 5.5 13.0 18.5 Said or did something to humiliate her in front of others 16.7 3.3 7.6 10.9 Threatened to hurt or harm her or someone she cared about 13.1 3.0 5.9 9.0 Insulted her or made her feel bad about herself 23.3 4.6 11.5 16.1 Any form of physical and/or sexual violence 34.4 4.6 16.0 20.6 Any form of emotional and/or physical and/or sexual violence 40.4 6.7 19.9 26.7 Spousal violence committed by any husband/partner Physical violence 33.6 na na 17.6 Sexual violence 13.3 na na 8.4 Physical and/or sexual violence 37.1 na na 20.7 Number of ever-married women 1,691 1,691 1,691 1,691 1 For widows, estimates of spousal violence by the current or most recent spouse in the past 12 months are not known; hence, widows are excluded from the estimate of spousal violence by the current or most recent spouse in the past 12 months. However, widows are included in the estimate of spousal violence committed by any husband/partner in the past 12 months. na = Not applicable Eighteen percent of ever-married women reported having experienced physical violence in the 12 months preceding the survey. Eight percent of women reported sexual violence while 19 percent experienced Domestic Violence • 283 any emotional violence, and 21 percent has experienced physical and/or sexual in the past 12 months preceding the survey. Table 17.9.2 shows that, among ever-married men, 10 percent reported ever experiencing any physical violence by their current or most recent wife or partner, 2 percent reported any sexual violence, and 17 percent reported any emotional violence. Eleven percent of men have ever experienced physical and/or sexual violence, and 20 percent have experienced at least one of the three forms of spousal violence. Thirteen percent of men reported that their current or most recent spouse or partner insulted them or made them feel bad about themselves; 6 percent reported having been pushed with her fist or with something that could hurt him, been shaken, or had something thrown at them; and 4 percent each reported having been slapped or punched with a fist. One percent of men said that they had been physically forced to have sexual intercourse when they did not want to. Table 17.9.2 Forms of spousal violence: Men Percentage of ever-married men age 15-49 who have experienced various forms of violence ever or in the 12 months preceding the survey committed by their wife/partner, Rwanda 2014-15 Ever In the past 12 months Type of violence Often Sometimes Often or sometimes Physical violence Any physical violence 9.9 1.6 5.0 6.5 Pushed him, shook him, or threw something at him 5.6 0.6 3.2 3.8 Slapped him 4.2 0.4 2.3 2.7 Twisted his arm or pulled his hair 1.5 0.1 0.6 0.7 Punched him with her fist or with something that could hurt him 3.7 0.5 1.5 2.0 Kicked him, dragged him, or beat him up 1.4 0.2 0.6 0.8 Tried to choke him or burn him on purpose 0.6 0.0 0.3 0.3 Threatened him or attacked him with a knife, gun, or other weapon 1.6 0.6 0.4 1.0 Sexual violence Any sexual violence 1.6 0.6 0.6 1.2 Physically forced him to have sexual intercourse with her when he did not want to 0.8 0.3 0.2 0.5 Physically forced him to perform any other sexual acts he did not want to 1.0 0.5 0.2 0.7 Forced him with threats or in any other way to perform sexual acts he did not want to 0.4 0.1 0.3 0.4 Emotional violence Any emotional violence 16.7 3.3 10.8 14.0 Said or did something to humiliate him in front of others 10.9 2.0 6.7 8.7 Threatened to hurt or harm him or someone he cared about 4.9 0.7 2.9 3.6 Insulted him or made him feel bad about himself 12.6 2.6 8.0 10.6 Any form of physical and/or sexual violence 10.7 1.7 5.3 7.0 Any form of emotional and/or physical and/or sexual violence 19.8 4.1 11.7 15.8 Spousal violence committed by any wife/partner Physical violence 11.5 na na 6.5 Sexual violence 1.6 na na 1.2 Physical and/or sexual violence 12.3 na na 7.0 Number of ever-married men 1,007 1,007 1,007 1,007 na = Not applicable Seven percent of ever-married men reported experiencing spousal physical violence, 1 percent experienced sexual violence, and 14 percent experienced emotional often or sometimes in the past 12 months. 284 • Domestic Violence 17.11 SPOUSAL VIOLENCE BY BACKGROUND CHARACTERISTICS Tables 17.10.1 and 17.10.2 show the percentages of ever-married women and men age 15-49, respectively, who have ever experienced spousal emotional, physical, or sexual violence by selected background characteristics. Four in 10 ever-married women (40 percent) have ever experienced at least one form of spousal violence (emotional, physical, or sexual), and 7 percent have experienced all three forms of violence. The percentage of women who have experienced at least one form of spousal violence increases with age and number of living children. It is higher among rural women (42 percent), women in the North province (46 percent), and women who are divorced, separated, or widowed (55 percent) than among other categories of women. Women with a secondary education or higher, women who are not employed, and those in the wealthiest quintile are less likely to have ever experienced at least one form of spousal violence (27 percent each) than other women. Table 17.10.1 Spousal violence by background characteristics: Women Percentage of ever-married women age 15-49 who have ever experienced emotional, physical, or sexual violence committed by their husband/partner, by background characteristics, Rwanda 2014-15 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever-married women Age 15-19 * * * * * * * 19 20-24 22.4 22.1 9.9 5.6 5.2 26.4 32.9 223 25-29 22.1 28.7 9.6 6.1 4.8 32.2 37.5 325 30-39 28.7 32.9 12.8 9.1 8.3 36.6 42.4 677 40-49 28.3 34.5 11.9 9.9 8.1 36.5 42.7 446 Religion Catholic 28.3 34.0 12.1 8.9 7.6 37.1 43.8 642 Protestant 27.2 32.1 11.2 8.5 7.3 34.8 40.4 777 Adventist 20.6 20.1 11.1 8.1 7.7 23.1 28.3 199 Muslim 18.3 27.7 17.1 1.3 1.3 43.5 46.6 51 Jehovah’s Witness * * * * * * * 18 Other * * * * * * * 3 Residence Urban 20.6 23.2 13.4 7.7 6.4 29.0 33.1 296 Rural 27.9 32.8 11.2 8.4 7.4 35.5 42.0 1,395 Province Kigali City 23.7 28.3 11.8 9.1 6.6 30.9 35.5 207 South 27.4 29.3 10.0 7.0 6.3 32.2 38.6 393 West 26.2 28.8 12.3 7.1 5.9 34.1 40.3 353 North 25.9 37.4 11.7 8.3 7.1 40.9 46.3 286 East 28.1 31.7 12.2 9.9 9.3 34.1 40.6 453 Marital status Married or living together 22.6 28.4 9.9 6.3 5.2 32.0 37.5 1,415 Divorced/separated/widowed 47.0 45.1 20.2 18.5 17.3 46.8 55.2 276 Number of living children 0 27.2 24.7 12.4 8.8 7.8 28.3 35.4 77 1-2 23.8 27.3 11.7 7.0 6.3 32.0 37.7 692 3-4 27.1 33.2 11.2 8.7 7.7 35.8 40.5 544 5+ 30.9 36.3 11.6 9.8 7.8 38.1 46.3 378 Employment Employed for cash 29.9 33.9 11.7 8.6 7.7 36.9 43.3 1,089 Employed not for cash 21.8 29.0 10.8 8.0 6.5 31.7 36.9 501 Not employed 15.9 11.5 14.3 5.3 5.3 20.5 27.1 100 (Continued…) Domestic Violence • 285 Table 17.10.1—Continued Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever-married women Education No education 27.2 34.2 10.9 8.2 7.4 36.9 42.7 305 Primary 27.7 32.7 11.8 8.5 7.3 36.0 42.0 1,187 Secondary and higher 19.2 16.9 10.9 6.8 6.4 21.0 27.3 198 Wealth quintile Lowest 37.0 43.1 13.2 10.5 9.6 45.7 52.5 359 Second 27.2 33.3 11.6 9.6 7.9 35.3 41.8 349 Middle 26.1 28.9 10.7 8.2 6.9 31.4 39.1 333 Fourth 26.9 30.3 11.8 7.0 6.3 35.1 41.3 307 Highest 15.4 19.2 10.5 5.7 5.0 23.9 26.8 342 Total 15-49 26.6 31.1 11.6 8.3 7.2 34.4 40.4 1,691 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. Total includes 1 case in which information on religion is missing and 1 case in which information on employment is missing. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Table 17.10.2 shows that 20 percent of ever-married men have ever experienced at least one form of spousal violence (emotional, physical, or sexual), and only 1 percent have experienced all three forms of violence. There is no consistent pattern by age in the percentage of men who have experienced at least one form of spousal violence. Men in urban areas (22 percent) and those with three or four living children (23 percent) are slightly more likely to have experienced at least one form of violence than their counterparts. Men with a secondary education or higher (11 percent) and those in the fourth wealth quintile (15 percent) are less likely to have experienced at least one form of spousal violence. There are no differences between provinces. Table 17.10.2 Spousal violence by background characteristics: Men Percentage of ever-married men age 15-49 who have ever experienced emotional, physical, or sexual violence committed by their wife/partner, by background characteristics, Rwanda 2014-15 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever-married men Age 15-19 * * * * * * * 1 20-24 23.3 5.5 7.5 5.5 5.5 7.5 24.7 67 25-29 13.8 8.2 2.2 0.4 0.4 9.9 16.0 188 30-39 18.5 10.0 0.9 0.4 0.4 10.4 21.5 475 40-49 13.9 12.1 1.1 0.5 0.5 12.7 18.3 276 Religion Catholic 16.9 9.9 1.6 0.9 0.9 10.6 20.7 441 Protestant 14.6 9.6 1.7 1.0 1.0 10.3 17.4 399 Adventist 20.9 10.1 0.8 0.1 0.1 10.8 21.2 122 Muslim (16.2) (7.3) (9.5) (0.0) (0.0) (16.8) (29.5) 17 Jehovah’s Witness * * * * * * * 8 Other (20.8) (18.7) (0.0) (0.0) (0.0) (18.7) (25.5) 19 Residence Urban 19.7 9.4 1.9 0.2 0.2 11.2 22.4 169 Rural 16.0 10.0 1.6 0.9 0.9 10.7 19.3 837 Province Kigali City 16.1 8.8 0.6 0.0 0.0 9.4 20.2 123 South 16.9 7.9 1.2 0.0 0.0 9.1 19.4 215 West 16.6 10.2 1.8 1.1 1.1 10.9 19.7 239 North 17.1 12.0 2.8 2.3 2.3 12.5 20.4 167 East 16.5 10.5 1.5 0.6 0.6 11.4 19.6 263 Marital status Married or living together 15.0 8.2 1.0 0.2 0.2 9.0 17.9 974 Divorced/separated/widowed (66.6) (60.2) (20.2) (17.8) (17.8) (62.6) (74.5) 33 (Continued…) 286 • Domestic Violence Table 17.10.2—Continued Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever-married men Number of living children 0 10.2 5.6 5.5 1.9 1.9 9.2 13.2 60 1-2 17.2 8.9 1.9 1.3 1.3 9.5 19.8 406 3-4 18.5 13.2 1.0 0.0 0.0 14.1 22.7 324 5+ 14.6 8.1 0.9 0.6 0.6 8.5 17.3 218 Employment Employed for cash 16.4 9.6 1.9 0.9 0.9 10.6 19.6 868 Employed not for cash 18.6 12.0 0.0 0.0 0.0 12.0 21.5 138 Not employed 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1 Education No education 24.6 13.4 2.7 0.8 0.8 15.3 28.1 163 Primary 16.0 9.2 1.6 0.9 0.9 9.9 19.2 734 Secondary and higher 9.2 9.3 0.2 0.1 0.1 9.4 11.3 110 Wealth quintile Lowest 21.3 13.1 3.0 1.3 1.3 14.8 27.8 190 Second 13.3 9.3 0.3 0.0 0.0 9.6 17.6 220 Middle 20.9 11.6 1.4 0.6 0.6 12.4 22.5 202 Fourth 13.6 7.6 2.5 1.9 1.9 8.3 15.0 219 Highest 14.9 8.2 0.9 0.1 0.1 9.0 16.7 176 Total 15-49 16.7 9.9 1.6 0.8 0.8 10.7 19.8 1,007 50-59 19.7 16.3 1.4 0.7 0.7 17.0 23.9 239 Total 15-59 17.2 11.1 1.6 0.8 0.8 12.0 20.6 1,246 Note: Wife/partner refers to the current wife/partner for currently married men and the most recent wife/partner for divorced, separated, or widowed men. Total includes 1 case in which information on religion is missing and 1 case in which information on employment is missing. 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. 17.12 VIOLENCE BY SPOUSAL CHARACTERISTICS AND EMPOWERMENT INDICATORS Tables 17.11.1 and 17.11.2 present information on ever-married women and men age 15-49, respectively, who have ever experienced emotional, physical, or sexual violence committed by their spouse according to spousal characteristics and empowerment indicators. Table 17.11.1 shows that, among ever-married women, spousal violence is highest among those whose husbands have no education (50 percent) and, especially, those whose husbands get drunk very often (79 percent). It should be noted that spousal violence is not correlated with spousal education differences. Spousal violence increases linearly with the number of controlling behaviors displayed by the husband. Twenty-one percent of women whose husbands display none of the five controlling behaviors have experienced one or more forms of violence, as compared with 96 percent of women whose husbands display all of marital control behaviors. Women’s experience of violence decreases as the number of decisions in which they participate increases; 48 percent of women who do not participate in any decisions and 33 percent of those who participate in three decisions have experienced at least one form of violence. On the other hand, spousal violence increases as the number of reasons women give for which wife beating is justified increases; 37 percent of women who do not feel that wife beating is justified for any of the specified reasons report having experienced spousal physical, sexual, or emotional violence, as compared with 53 percent of women who agree with all five reasons justifying wife beating. Women whose fathers did not beat their mothers are less likely to experience any type of violence by their husband than women whose fathers beat their mothers (36 percent versus 47 percent). Finally, women who are never afraid of their husband or partner are much less likely to experience spousal violence than women who are afraid most of the time (26 percent versus 90 percent). Domestic Violence • 287 Table 17.11.1 Spousal violence by husband’s characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have ever experienced emotional, physical, or sexual violence committed by their husband/partner, by husband’s characteristics and empowerment indicators, Rwanda 2014-15 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever-married women Husband’s/partner’s education No education 37.3 38.1 12.8 10.3 9.8 40.7 49.8 301 Primary 24.9 32.1 11.1 8.4 7.0 34.8 39.8 1,167 Secondary 20.3 15.5 12.6 4.8 4.2 23.3 30.1 213 Don’t know/missing * * * * * * * 9 Husband’s/partner’s alcohol consumption Does not drink 13.6 16.6 7.6 3.1 2.5 21.1 25.0 595 Drinks/never gets drunk 9.3 12.8 3.3 1.0 0.0 15.0 18.6 219 Gets drunk sometimes 27.4 35.2 11.1 7.5 5.8 38.8 46.3 605 Gets drunk very often 67.8 68.3 28.6 27.6 26.9 69.2 78.7 267 DK/Missing * * * * * * * 5 Spousal education difference Husband better educated 24.5 28.7 11.1 6.9 5.9 32.9 38.4 712 Wife better educated 31.1 33.9 12.7 9.4 8.5 37.1 44.1 624 Both equally educated 17.8 28.8 8.8 7.6 6.1 29.9 33.6 222 Neither educated 32.7 34.6 14.8 11.6 10.4 37.8 46.1 116 Don’t know/missing * * * * * * * 17 Spousal age difference1 Wife older 20.5 28.1 7.1 6.0 5.5 29.3 36.1 189 Wife same age 19.5 28.2 8.2 4.4 4.4 31.9 36.3 132 Wife 1-4 years younger 20.9 28.1 11.1 6.2 5.0 33.0 37.3 560 Wife 5-9 years younger 23.9 30.0 9.8 6.2 5.0 33.6 38.5 330 Wife 10+ years younger 28.7 25.9 10.0 7.8 6.0 28.1 38.4 199 Missing * * * * * * * 5 Number of marital control behaviors displayed by husband/partner2 0 9.9 16.3 3.6 2.2 1.4 17.7 20.9 931 1-2 33.4 38.0 13.6 7.1 6.1 44.6 54.5 471 3-4 63.3 61.8 28.2 23.2 21.1 66.7 75.6 223 5 90.5 86.6 53.3 51.3 49.8 88.6 96.0 66 Number of decisions in which women participate3 0 29.2 38.3 16.3 12.2 10.0 42.4 47.9 100 1-2 30.9 32.9 13.6 9.0 7.4 37.5 45.9 387 3 18.5 25.4 7.6 4.5 3.8 28.6 32.9 928 Number of reasons for which wife beating is justified4 0 24.2 29.4 10.7 8.0 7.1 32.1 36.8 1,039 1-2 27.6 32.5 10.4 8.2 6.6 34.7 42.3 348 3-4 32.0 33.2 15.2 7.2 6.9 41.3 49.8 220 5 38.0 40.3 18.0 14.2 11.5 44.1 52.5 83 Woman’s father beat her mother Yes 30.9 37.0 13.0 9.0 7.8 41.0 47.2 656 No 23.8 26.9 10.1 7.3 6.4 29.6 35.5 951 Don’t know/missing 25.5 32.7 16.8 12.5 11.3 37.0 43.0 84 Woman afraid of husband/partner Afraid most of the time 81.9 79.9 44.0 40.7 40.0 83.1 89.5 180 Sometimes afraid 51.5 56.1 18.9 13.8 11.4 61.1 71.9 283 Never afraid 12.8 18.0 5.2 2.3 1.4 21.0 25.9 1,223 Missing * * * * * * * 5 Total 15-49 26.6 31.1 11.6 8.3 7.2 34.4 40.4 1,691 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. 1 Includes only currently married women 2 According to the wife’s report. See Table 17.8.1 for list of behaviors. 3 According to the wife’s report. Includes only currently married women. See Table 15.5 for list of decisions. 4 According to the wife’s report. See Table 15.7.1 for list of reasons. Table 17.11.2 shows similar patterns in spousal violence against ever-married men. Spousal violence against men is higher among those whose wives get drunk sometimes (54 percent) and it increases as the number of controlling behaviors displayed by the wife increases. Eight percent of men whose wife displays none of the 288 • Domestic Violence five controlling behaviors have experienced one or more forms of violence, as compared with 57 percent of men whose wife exhibits three or four controlling behaviors. The percentage of men experiencing violence increases as the number of reasons they give for which wife beating is justified increases. As with women, men whose fathers did not beat their mothers are less likely to experience any type of violence by their spouse than men whose fathers beat their mothers (14 percent versus 25 percent). Men who are never afraid of their wives are much less likely to have experienced physical, sexual, or emotional violence than men who are sometimes afraid (16 percent versus 54 percent). Table 17.11.2 Spousal violence by wife’s characteristics and empowerment indicators Percentage of ever-married men age 15-49 who have ever experienced emotional, physical, or sexual violence committed by their wife/partner, by wife’s characteristics and empowerment indicators, Rwanda 2014-15 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever-married men Wife’s/partner’s alcohol consumption Does not drink 12.6 6.3 1.4 0.7 0.7 7.0 14.8 648 Drinks/never gets drunk 14.7 9.1 1.7 1.1 1.1 9.7 18.5 262 Gets drunk sometimes 45.4 35.9 1.2 0.3 0.3 36.7 54.1 83 Gets drunk very often * * * * * * * 12 Don’t know/Missing * * * * * * * 1 Spousal age difference1 Husband older 12.9 7.7 0.8 0.2 0.2 8.3 16.0 685 Husband same age 15.7 10.2 1.7 0.0 0.0 11.9 19.5 96 Husband 1-4 years younger 20.1 6.1 1.3 0.0 0.0 7.4 21.9 134 Husband 5-9 years younger (17.2) (0.0) (0.0) (0.0) (0.0) (0.0) (17.2) 26 Husband 10+ years younger * * * * * * * 5 Number of marital control behaviors displayed by wife/partner2 0 5.2 4.4 0.3 0.0 0.0 4.8 7.9 521 1-2 21.3 12.5 2.5 1.2 1.2 13.8 25.1 392 3-4 53.7 26.2 4.9 3.1 3.1 28.0 57.2 76 5 * * * * * * * 17 Number of decisions in which men participate3 0 * * * * * * * 6 1-2 15.0 8.3 1.0 0.2 0.2 9.0 18.0 968 Number of reasons for which wife beating is justified4 0 15.1 8.9 1.6 0.9 0.9 9.6 18.2 877 1-2 30.3 13.0 2.6 0.0 0.0 15.6 31.5 67 3-4 (28.2) (24.0) (0.0) (0.0) (0.0) (24.0) (33.3) 32 5 * * * * * * * 17 Man’s father beat his mother Yes 20.9 14.9 1.8 0.9 0.9 15.8 25.4 442 No 12.0 4.5 1.2 0.3 0.3 5.4 14.0 472 Don’t know/missing 20.0 13.6 3.3 2.9 2.9 14.0 22.9 93 Man afraid of wife/partner Afraid most of the time * * * * * * * 17 Sometimes afraid 46.2 33.5 0.2 0.0 0.0 33.7 54.2 73 Never afraid 13.3 7.7 1.6 0.8 0.8 8.5 16.1 915 Missing * * * * * * * 1 Total 15-49 16.7 9.9 1.6 0.8 0.8 10.7 19.8 1,007 50-59 19.7 16.3 1.4 0.7 0.7 17.0 23.9 239 Total 15-59 17.2 11.1 1.6 0.8 0.8 12.0 20.6 1,246 Note: Wife/partner refers to the current wife/partner for currently married men and the most recent wife/partner for divorced, separated, or widowed men. 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 Includes only currently married men. 2 According to the husband’s report. See Table 17.8.2 for list of behaviors. 3 According to the husband’s report. Includes only currently married men. See Table 15.5 for list of decisions. 4 According to the husband’s report. See Table 15.7.1 for list of reasons. Domestic Violence • 289 17.13 RECENT SPOUSAL VIOLENCE Tables 17.12.1 and 17.12.2 show the percentage of ever-married women and men, respectively, who have experienced physical or sexual violence by any spouse/partner in the past 12 months, by background characteristics. Overall, 21 percent of women (Table 17.12.1) experienced physical or sexual violence by any husband or partner in the past 12 months. The percentage of women who have experienced recent physical or sexual violence is slightly higher among those who work for cash, and those in the lowest wealth quintile. The characteristic most highly correlated with recent spousal violence is women’s fear of their husband; women who say they are afraid of their husband most of the time are much more likely to have recently experienced spousal violence (56 percent) than those who say they are never afraid of their husband (12 percent). Among ever-married men (Table 17.12.2), 7 percent experienced physical or sexual violence in the past 12 months by any wife or partner. Variations by background characteristics are minimal with the exception of men’s fear of their wife. Men who are sometimes afraid of their wives are more likely to have experienced spousal violence in the previous 12 months than men who are never afraid of their wives (21 percent and 5 percent, respectively). 290 • Domestic Violence Table 17.12.1 Physical or sexual violence in the past 12 months by any husband/partner Percentage of ever-married women age 15-49 who have experienced physical or sexual violence by any husband/partner in the past 12 months, by background characteristics, Rwanda 2014-15 Background characteristic Percentage of women who have experienced physical or sexual violence in the past 12 months from any husband/partner Number of ever-married women Age 15-19 * 19 20-24 21.9 223 25-29 18.9 325 30-39 23.1 677 40-49 17.2 446 Religion Catholic 23.4 642 Protestant 19.7 777 Adventist 15.0 199 Muslim 29.7 51 Jehovah’s Witness * 18 Other * 3 Residence Urban 18.7 296 Rural 21.1 1,395 Province Kigali City 19.1 207 South 22.0 393 West 20.0 353 North 22.7 286 East 19.5 453 Marital status Married or living together 21.4 1,415 Divorced/separated/widowed 17.1 276 Number of living children 0 20.0 77 1-2 20.7 692 3-4 22.1 544 5+ 18.9 378 Employment Employed for cash 22.5 1,089 Employed not for cash 17.3 501 Not employed 18.2 100 Education No education 17.2 305 Primary 23.2 1,187 Secondary and higher 10.8 198 Wealth quintile Lowest 26.0 359 Second 22.1 349 Middle 18.3 333 Fourth 20.1 307 Highest 16.6 342 Woman afraid of husband/partner Afraid most of the time 55.5 180 Sometimes afraid 38.3 283 Never afraid 11.6 1,223 Total 15-49 20.7 1,691 Note: Total includes 1 case in which information on religion is missing, 1 case in which information on employment is missing, and 5 cases in which information on fear of husband is missing. Any husband/partner includes all current, most recent, and former husbands/partners. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Table 17.12.2 Physical or sexual violence in the past 12 months by any wife/partner Percentage of ever-married men age 15-49 who have experienced physical or sexual violence by any wife/partner in the past 12 months, by background characteristics, Rwanda 2014-15 Background characteristic Percentage of men who have experienced physical or sexual violence in the past 12 months from any wife/partner Number of ever-married men Age 15-19 * 1 20-24 6.1 67 25-29 8.4 188 30-39 5.9 475 40-49 8.3 276 Religion Catholic 7.2 441 Protestant 6.2 399 Adventist 7.4 122 Muslim (4.2) 17 Jehovah’s Witness * 8 Other (18.7) 19 Residence Urban 6.6 169 Rural 7.1 837 Province Kigali City 6.0 123 South 6.1 215 West 6.6 239 North 8.7 167 East 7.5 263 Marital status Married or living together 5.9 974 Divorced/separated/widowed (40.6) 33 Employment Employed for cash 6.6 868 Employed not for cash 9.5 138 Not employed * 1 Number of living children 0 7.7 60 1-2 6.3 406 3-4 8.4 324 5+ 6.1 218 Education No education 8.7 163 Primary 6.6 734 Secondary and higher 7.5 110 Wealth quintile Lowest 9.4 190 Second 5.0 220 Middle 8.4 202 Fourth 6.8 219 Highest 5.6 176 Man afraid of wife/partner Afraid most of the time * 17 Sometimes afraid 21.2 73 Never afraid 5.4 915 Total 15-49 7.0 1,007 50-59 10.2 239 Total 15-59 7.6 1,246 Note: Total includes 1 case in which information on religion is missing, 1 case in which information on employment is missing, and 1 case in which information on fear of wife/partner is missing. Any wife/partner includes all current, most recent, and former wives/partners. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Domestic Violence • 291 17.14 ONSET OF SPOUSAL VIOLENCE To obtain information on the onset of marital violence, the 2014-15 RDHS asked ever-married women and men how long after marriage the onset of spousal violence occurred, if ever. Tables 17.13.1 and 17.3.2 show the data for women and men, respectively. Table 17.13.1 shows that 68 percent of women have never experienced physical or sexual violence by their current or most recent husband. Twelve percent of women experienced violence in the first two years of their marriage, 20 percent first experienced it in the first five years, and 27 percent experienced it within the first 10 years. These data show that a considerable percentage of women first experienced spousal physical or sexual violence relatively early in their marriages. Table 17.13.1 Experience of spousal violence by duration of marriage: Women Among currently married women age 15-49 who have been married only once, the percentage who first experienced physical or sexual violence committed by their current husband/partner by specific exact years since marriage, according to marital duration, Rwanda 2014-15 Percentage who first experienced spousal physical or sexual violence by exact marital duration: Percentage who have not experienced spousal sexual or physical violence Number of currently married women who have been married only once Duration of marriage Before marriage 2 years 5 years 10 years Years since marriage <2 1.5 na na na 88.0 136 2-4 0.0 16.9 na na 72.3 216 5-9 0.0 11.1 23.6 na 66.7 316 10+ 0.3 9.9 17.4 27.6 63.6 606 Total 0.3 11.6 20.1 27.3 68.4 1,274 Among ever-married men, more than 9 in 10 (92 percent) have not experienced physical or sexual violence by their current or most recent wife, 2 percent first experienced violence in the first two years of marriage, 5 percent experienced it in the first five years, and 7 percent experienced it within the first 10 years of marriage (Table 17.13.2). Table 17.13.2 Experience of spousal violence by duration of marriage: Men Among currently married men age 15-49 who have been married only once, the percentage who first experienced physical or sexual violence committed by their current wife/partner by specific exact years since marriage, according to marital duration, Rwanda 2014-15 Percentage who first experienced spousal physical or sexual violence by exact marital duration: Percentage who have not experienced spousal sexual or physical violence Number of currently married men who have been married only once Duration of marriage Before marriage 2 years 5 years 10 years Years since marriage <2 0.2 na na na 95.3 103 2-4 0.4 2.7 na na 94.1 158 5-9 0.0 2.6 6.6 na 90.7 219 10+ 0.2 1.5 3.5 6.6 90.4 386 Total 0.2 2.4 4.9 6.9 91.7 866 17.15 PHYSICAL CONSEQUENCES OF SPOUSAL VIOLENCE In the 2014-15 RDHS, ever-married women and men were asked whether they had sustained some form of injury as a result of physical or sexual violence inflicted by their spouse. Thirty-three percent of women who reported ever having experienced spousal physical or sexual violence suffered from cuts, bruises, or aches; 16 percent had eye injuries, sprains, dislocations, or burns; and 7 percent had deep wounds, broken bones, broken teeth, or other serious injuries (Table 17.14.1). Overall, 35 percent of women who had ever experienced spousal physical or sexual violence suffered from cuts, bruises or aches. This proportion is slightly lower among women 292 • Domestic Violence who experienced spousal violence in the 12 months before the survey (36 percent). Thirty-eight percent and 41 percent of women suffered any type of injury as a result of experiencing spousal physical violence in the past 12 months and ever, respectively; the corresponding proportions among women who experienced sexual violence are 44 percent and 40 percent. Table 17.14.1 Injuries due to spousal violence: Women Percentage of ever-married women age 15-49 who have experienced specific types of spousal violence by types of injuries resulting from the violence, according to the type of violence and whether they experienced the violence ever and in the 12 months preceding the survey, Rwanda 2014-15 Type of violence Cuts, bruises, or aches Eye injuries, sprains, dislocations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of ever- married women who have ever experienced any physical or sexual violence Experienced physical violence1 Ever2 35.7 17.9 7.3 38.1 526 In the past 12 months 39.3 19.9 7.4 41.3 297 Experienced sexual violence Ever2 41.0 25.4 11.9 43.6 196 In the past 12 months 37.7 23.0 7.7 40.0 140 Experienced physical or sexual violence1 Ever2 32.5 16.3 6.6 34.8 582 In the past 12 months 34.4 17.6 6.4 36.2 348 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. 1 Excludes women who reported violence only in response to a direct question on violence during pregnancy 2 Includes in the past 12 months Table 17.14.2 shows that 29 percent of men who had ever experienced spousal physical or sexual violence suffered from cuts, bruises or aches; the proportion is slightly lower among men who experienced spousal violence in the 12 months before the survey (28 percent). Thirty-one percent and 30 percent of men suffered any type of injury as a result of experiencing spousal physical or sexual violence ever and in the past 12 months, respectively. Table 17.14.2 Injuries due to spousal violence: Men Percentage of ever-married men age 15-49 who have experienced specific types of spousal violence by types of injuries resulting from the violence, according to the type of violence and whether they experienced the violence ever and in the 12 months preceding the survey, Rwanda 2014-15 Type of violence Cuts, bruises, or aches Eye injuries, sprains, dislocations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of ever- married men who have ever experienced any physical or sexual violence Experienced physical violence Ever1 31.8 13.6 3.3 32.4 100 In the past 12 months 30.1 11.9 2.4 31.1 66 Experienced sexual violence Ever1 * * * * 16 In the past 12 months * * * * 12 Experienced physical or sexual violence Ever1 29.3 13.3 3.0 30.6 108 In the past 12 months 28.1 12.2 2.3 30.1 71 Note: Wife/partner refers to the current wife/partner for currently married men and the most recent wife/partner for divorced, separated, or widowed men. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes in the past 12 months Domestic Violence • 293 17.16 VIOLENCE BY WOMEN AND MEN AGAINST THEIR SPOUSE In cases of domestic violence, either person (husband or wife) can be the perpetrator of violence. In the 2014-15 RDHS, ever-married women and men were asked about instances if they were the instigator of spousal violence. Specifically, all eligible ever-married respondents were asked whether they had ever initiated physical violence against their spouse when he or she was not already beating or physically hurting them. Tables 17.15.1 and 17.15.2 show the percentage of ever-married women and men age 15-49, respectively who reported initiating physical violence against their current or most recent spouse/partner ever and in the 12 months prior to the survey, by background characteristics. Overall, only 2 percent of ever-married women reported that they had ever initiated physical violence against their husbands, and less than 1 percent had done so in the past 12 months. Women who have been physically abused by their husband/partner ever and in the past 12 months (5 percent and 6 percent, respectively) are more likely to have initiated spousal physical abuse than women who have never been abused (less than 1 percent). Differences by other background characteristics are minimal. Table 17.15.2 shows that 21 percent of ever-married men age 15-49 reported having initiated physical violence against their wives, and 8 percent had done so in the past 12 months. Men who have been physically abused by their spouse ever and in the past 12 months are much more likely to initiate physical violence against their wives (52 percent and 57 percent, respectively) than those who have never been abused (18 percent). The proportion of men who have ever initiated violence against their wives increases with age and number of living children. Men with a secondary education or higher and those in the highest wealth quintile are least likely to have initiated physical violence against their wife or partner. 294 • Domestic Violence Table 17.15.1 Women’s violence against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting them, ever and in the past 12 months, according to women’s own experience of spousal violence and background characteristics, Rwanda 2014-15 Percentage who have committed physical violence against their husband/partner Number of ever- married women Background characteristic Ever1 In the past 12 months Woman’s experience of spousal physical violence Ever1 4.9 2.0 526 In the past 12 months 6.2 3.2 297 Never 0.3 0.1 1,165 Age 15-19 * * 19 20-24 0.7 0.7 223 25-29 0.7 0.3 325 30-39 1.7 0.6 677 40-49 2.8 1.0 446 Religion Catholic 1.6 0.7 642 Protestant 2.2 1.0 777 Adventist 0.8 0.0 199 Muslim 0.0 0.0 51 Jehovah’s Witness * * 18 Other * * 3 Residence Urban 1.5 0.8 296 Rural 1.7 0.7 1,395 Province Kigali City 1.4 0.9 207 South 1.2 0.4 393 West 1.5 0.8 353 North 2.9 0.9 286 East 1.6 0.7 453 Marital status Married or living together 1.5 0.9 1,415 Divorced/separated/widowed 2.6 0.0 276 Employment Employed for cash 1.9 0.7 1,089 Employed not for cash 1.4 0.5 501 Not employed 1.7 1.7 100 Number of living children 0 0.0 0.0 77 1-2 1.5 0.7 692 3-4 1.8 0.6 544 5+ 2.3 1.0 378 Education No education 2.0 0.8 304 Primary 1.7 0.8 1187 Secondary and higher 1.5 0.0 198 Wealth quintile Lowest 2.0 1.4 359 Second 1.4 0.7 349 Middle 3.0 1.0 333 Fourth 0.6 0.2 307 Highest 1.4 0.3 342 Total 1.7 0.7 1,691 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. Total includes 2 case in which information on education is missing, 1 case in which information on religion is missing and 1 case in which information on employment is missing. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes in the past 12 months Table 17.15.2 Men’s violence against their spouse Percentage of ever-married men age 15-49 who have committed physical violence against their current or most recent wife/partner when she was not already beating or physically hurting them, ever and in the past 12 months, according to men’s own experience of spousal violence and background characteristics, Rwanda 2014-15 Percentage who have committed physical violence against their wife/partner Number of ever- married men Background characteristic Ever1 In the past 12 months Man’s experience of spousal physical violence Ever1 52.2 24.7 100 In the past 12 months 57.1 33.8 66 Never 17.7 6.1 907 Age 15-19 * * 1 20-24 10.9 9.5 67 25-29 18.3 8.8 188 30-39 22.5 8.0 475 40-49 23.3 6.9 276 Religion Catholic 20.1 7.3 441 Protestant 19.1 8.1 399 Adventist 25.9 9.9 122 Muslim (16.9) (0.0) 17 Jehovah’s Witness * * 8 Other (53.8) (15.8) 19 Residence Urban 19.1 5.7 169 Rural 21.5 8.4 837 Province Kigali City 14.9 5.1 123 South 23.0 8.2 215 West 21.5 6.2 239 North 24.7 8.9 167 East 19.9 10.0 263 Marital status Married or living together 20.5 7.4 974 Divorced/separated/widowed (39.9) (23.0) 33 Employment Employed for cash 20.9 7.9 868 Employed not for cash 22.1 8.5 138 Not employed * * 1 Number of living children 0 12.5 7.2 60 1-2 17.4 9.2 406 3-4 24.7 7.0 324 5+ 25.1 7.0 218 Education No education 26.3 10.9 163 Primary 21.5 8.0 734 Secondary and higher 10.6 2.8 110 Wealth quintile Lowest 29.1 13.4 190 Second 19.2 7.0 220 Middle 24.9 8.9 202 Fourth 19.3 7.7 219 Highest 12.9 2.3 176 Total 15-49 21.1 7.9 1,007 50-59 27.8 4.9 239 Total 15-59 22.4 7.4 1,246 Note: Wife/partner refers to the current wife/partner for currently married men and the most recent wife/partner for divorced, separated, or widowed men. Total includes 1 case in which information on religion is missing and 1 case in which information on employment is missing. 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 Includes in the past 12 months Domestic Violence • 295 Table 17.16.1 Women’s violence against their spouse by spouse’s characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting them, ever and in the past 12 months, according to the empowerment indicators and husband’s characteristics, Rwanda 2014-15 Percentage who have committed physical violence against their husband/partner Number of ever- married women Background characteristic Ever1 In the past 12 months Husband’s/partner’s education No education 2.6 1.8 301 Primary 1.5 0.5 1,167 Secondary and higher 1.7 0.4 213 Don’t know/missing * * 9 Husband’s/partner’s alcohol consumption Does not drink 1.0 0.1 595 Drinks/never gets drunk 0.4 0.4 219 Gets drunk sometimes 1.2 0.8 605 Gets drunk very often 5.5 2.1 267 Don’t know/missing * * 5 Spousal education difference Husband better educated 1.3 0.5 712 Wife better educated 1.8 0.9 624 Both equally educated 2.3 0.8 222 Neither educated 3.0 1.4 116 Don’t know/missing * * 17 Spousal age difference2 Wife older 2.2 1.4 189 Wife same age 2.6 1.5 132 Wife 1-4 years younger 1.2 0.5 560 Wife 5-9 years younger 1.0 0.8 330 Wife 10+ years younger 1.9 1.1 199 Missing * * 5 Number of marital control behaviors displayed by husband/partner3 0 0.6 0.2 931 1-2 1.8 1.0 471 3-4 3.1 1.8 223 5 12.0 1.5 66 Number of decisions in which women participate4 0 1.5 0.8 100 1-2 2.0 1.2 387 3 1.3 0.7 928 Number of reasons for which wife beating is justified5 0 1.6 0.4 1,039 1-2 2.2 1.5 348 3-4 2.3 1.1 220 5 0.0 0.0 83 Woman’s father beat her mother Yes 2.8 1.0 656 No 0.9 0.4 951 Don’t know 2.0 2.0 84 Woman afraid of husband/partner Afraid most of the time 5.5 1.8 180 Sometimes afraid 2.8 1.6 283 Never afraid 0.9 0.4 1,223 Missing * * 5 Total 1.7 0.7 1,691 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. 1 Includes in the past 12 months 2 Includes only currently married women 3 According to the wife’s report. See Table 17.8.1 for list of behaviors. 4 According to the wife’s report. Includes only currently married women. See Table 15.5 for list of decisions. 5 According to the wife’s report. See Table 15.7.1 for list of reasons. 296 • Domestic Violence Tables 17.16.1 and 17.16.2 present information on the proportion of ever-married women and men age 15-49, respectively, who have initiated physical violence against their spouse ever and in the past 12 months, according to spousal characteristics and empowerment indicators. Table 17.16.1 shows that violence against husbands is highest among women whose husband gets drunk very often (6 percent, ever) and 2 percent in the past 12 months prior the survey, women who are afraid of their husband most of the time (6 percent, ever) and 2 percent in the last 12 months preceding the survey, and both women and men are uneducated (3 percent, ever). Women’s violence against their husband increases as the number of controlling behaviors displayed by the husband increases. There is no relationship between the proportion of women who initiate violence against their spouse and the number of decisions in which women participate or the number of reasons they give for which wife beating is justified. Women whose fathers beat their mothers are only slightly more likely to commit spousal physical violence than women whose fathers did not beat their mothers (3 percent versus 1 percent). Similar patterns by background characteristics are observed in women’s