Sudan - Demographic and Health Survey -1991

Publication date: 1991

Sudan Sudan Demographic and Health Survey 1989/1990 Department of Statistics Minist~, of Economic and National Planning ~I)HS Demographic and Health Sur~,eys Institute for Resource Development/Macro International, Inc. REPUBLIC OF THE SUDAN Sudan Demographic and Health Survey 1989/1990 Department of Statistics Ministry of Economic and National Planning Khartoum, Sudan Institute for Resource Development/Macro International, Inc. Columbia, Maryland USA May 1991 This report presents the findings of the Sudan Demographic and Health Survey (SDHS). The survey was a collaborative effort between the Department of Statistics, Ministry of Economic and National Planning, the Republic of the Sudan, and the Institute for Resource Development/Macro International, Inc. (IRD). The survey is part of the worldwide Demographic and Health Surveys programme, which is designed to collect data on fertility, family planning, and maternal and child health. Funding for the survey was provided by the government of the Republic of Sudan, United States Agency for International Development (Contract No. DPE-3023-C-00-4083-00), and UNICEF. Additional information about the SDHS can be obtained from the Population Census Office, Department of Statistics, Ministry of Economic and National Planning, P.O. Box 700, Khartoum, Sudan. Additional information about the DHS programme can be obtained by writing to: DHS Programme, IRD/Macro International, Inc., 8850 Stanford Boulevard, Suite 4000, Columbia, MD 21045, USA (Telephone: 301- 290-2800; Telex: 87775; Fax: 301- 290-2999). CONTENTS CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii F IGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv i i MAP OF SUDAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi i CHAPTER 1 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Geography, History, Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Population and Family Planning Policies and Pmgrammes . . . . . . . . . . . . . . . . . . . . 3 1.4 Health Priorities and Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5 Education System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.6 Objectives of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.7 Organisation of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 CHAPTER 2 BACKGROUND CHARACTERIST ICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.1 Household Population by Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.2 Educational Level and Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.3 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.4 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.5 Presence of Durable Goods in the Household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.6 Background Characteristics of Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.7 Characteristics of Husbands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 CHAPTER 3 FERT IL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.1 Levels and Differentials in Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.2 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.3 Current Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 3.4 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.5 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 i i i CHAPTER 4 FERT IL ITY REGULAT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 4.1 Knowledge of Family Planning Methods and Sources . . . . . . . . . . . . . . . . . . . . . . 33 4.2 Knowledge of Fertility Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.3 Knowledge of Sources for Specific Contraceptive Methods . . . . . . . . . . . . . . . . . . 37 4.4 Problems Perceived with Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . 38 4.5 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.6 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 4.7 Number of Children at First Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.8 Source of Current Contraceptive Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 4.9 Dissatisfaction with Current Providers of Contraception . . . . . . . . . . . . . . . . . . . . . 46 4.10 Attitude Toward Next Pregnancy and Reason for Nonuse of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 4.11 Intention to Use Contraception in the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.12 Approval and Acceptability of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 CHAPTER 5 NUPTIAL ITY AND EXPOSURE TO THE R ISK OF PREGNANCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.1 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.2 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 5.3 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.4 Breastfeeding, Postpartum Amenorrhoea, and Abstinence . . . . . . . . . . . . . . . . . . . 60 CHAPTER 6 FERT IL ITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 6.1 Desire for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 6.2 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 6.3 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 6.4 Need for Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 CHAPTER 7 CHILDHOOD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 7.1 Childhood Mortality Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 7.2 Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 7.3 Levels and Trends in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 7.4 Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 CHAPTER 8 MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 8.1 Maternal Care Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 8.2 Utilisation of Child Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 8.3 Child Morbidity and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 8.4 Knowledge and Use of ORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 iv CHAPTER 9 MATERNAL MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 9.2 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 9.3 Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 9A Direct Estimates of Adult Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 9.5 Direct Estimates of Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 9.6 Indirect Estimates of Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 9.7 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 CHAPTER 10 FEMALE C IRCUMCIS ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 10.1 Practice of Female Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 10.2 Attitudes Toward Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 10.3 Reasons for Attitudes Toward Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 10.4 Eradication of Female Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 10.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 REFERENCES APPENDIX A APPENDIX B APPENDIX C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 TABLES CHAPTER CHAPTER CHAPTER CHAPTER 1 Table 1.1 Table 1.2 Table 1.3 2 Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 4 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Population size and growth rate . . . . . . . . . . . . . . . . . . . . . . . . 2 Age-specific fertility rates and total fertility rates . . . . . . . . . . . . . 3 Sample results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Distribution of the household population by age . . . . . . . . . . . . . 10 Distribution of the household population by education and marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Type of household and household size . . . . . . . . . . . . . . . . . . 13 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Durable goods in the household . . . . . . . . . . . . . . . . . . . . . . . 15 Background characteristics of respondents . . . . . . . . . . . . . . . . . 17 Women's level of education . . . . . . . . . . . . . . . . . . . . . . . . . 18 Type of migration and reasons for migration . . . . . . . . . . . . . . . 19 Exposure to radio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Background characteristics of husbands of respondents . . . . . . . . 21 Total fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Age-specific fertility rates for five-year periods . . . . . . . . . . . . . 26 Comparison of age-specific fertility rates, SFS and SDHS . . . . . . 27 Currently pregnant women . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Children ever born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Children ever born by age at first marriage . . . . . . . . . . . . . . . 31 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Median age at first birth by background characteristics . . . . . . . . 32 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . 34 Knowledge of modem contraceptive methods . . . . . . . . . . . . . . 35 Knowledge of the fertile period . . . . . . . . . . . . . . . . . . . . . . . 36 Knowledge of source of supply for specific methods . . . . . . . . . . 37 Problems perceived in using specific methods . . . . . . . . . . . . . . 38 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . 42 Number of children at first use of contraception . . . . . . . . . . . . 44 Sources of contraceptive services . . . . . . . . . . . . . . . . . . . . . . 45 Dissatisfaction with source of contraceptive services . . . . . . . . . . 46 Attitude toward becoming pregnant among nonusers . . . . . . . . . . 47 Reasons for nonuse of contraception . . . . . . . . . . . . . . . . . . . . 48 vii Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 CHAPTER 5 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 CHAPTER 6 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 CHAPTER 7 Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 7.6 CHAPTER 8 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Intention to use contraception in the future . . . . . . . . . . . . . . . . 49 Preferred method for future use . . . . . . . . . . . . . . . . . . . . . . . 49 Attitudes of husbands and wives toward family planning . . . . . . . 50 Approval of family planning by wives and their husbands . . . . . . 51 Frequency of discussion of family planning by couples . . . . . . . . 52 Approval of the use of mass media for disseminating family planning information . . . . . . . . . . . . . . . . . . . . . . . . . 53 Marital status of women 15-49 . . . . . . . . . . . . . . . . . . . . . . . 55 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Differentials in the median age at first marriage . . . . . . . . . . . . 60 Breastfeeding and exposure to the risk of pregnancy . . . . . . . . . . 61 Differentials in breastfeeding and in exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Future reproductive intentions according to number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Future reproductive intentions according to age . . . . . . . . . . . . . 68 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Mean ideal number of children, by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Planning status of births in the preceding year . . . . . . . . . . . . . 73 Unmet need for family planning . . . . . . . . . . . . . . . . . . . . . . 74 Underreporting of early infant deaths . . . . . . . . . . . . . . . . . . . 76 Heaping of reported age at death . . . . . . . . . . . . . . . . . . . . . . 77 Mean number of children ever born, surviving, and dead . . . . . . . 78 Infant and child mortality rates by five-year calendar periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Childhood mortality rates by background characteristics . . . . . . . . 81 Childhood mortality by demographic characteristics . . . . . . . . . . . 82 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Tetanus toxoid immunisation . . . . . . . . . . . . . . . . . . . . . . . . . 86 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Immunisation coverage among children under five . . . . . . . . . . . 91 Immunisation coverage among children 12-23 months . . . . . . . . . 93 viii Table 8.6 Table 8.7 Table 8.8 Table 8.9 Table 8.10 CHAPTER 9 Table 9.1 Table 9.2 Table 9.3 Table 9.4 CHAPTER 10 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 10.6 Table 10.7 Table 10.8 Table 10.9 APPENDIX A Table A.1 APPENDIX B Table B.1 Table B.2 Table B.3 Table B.4 Prevalence of cough and use of health care providers for trealment of cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Treatment for cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Prevalence of diarrhoea among children under five . . . . . . . . . . 101 Treatment practices for children with diarrhoea . . . . . . . . . . . . 102 Use of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Siblings of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Estimates of age-specific mortality . . . . . . . . . . . . . . . . . . . . 111 Direct estimates of maternal mortality . . . . . . . . . . . . . . . . . . 112 Indirect estimates of maternal mortality . . . . . . . . . . . . . . . . . 114 Prevalence and types of female circumcision . . . . . . . . . . . . . . 118 Persons who perform female circumcision . . . . . . . . . . . . . . . 119 Preferred type of female circumcision according to circumcision status of respondents and respondents' daughters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Preferred type of female circumcision according to selected background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Husband's attitude toward female circumcision . . . . . . . . . . . . . 125 Reasons for favouring continuation of female circumcision . . . . . 126 Reasons for favouring discontinuation of female circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Reasons female circumcision continues . . . . . . . . . . . . . . . . . 128 Women's opinions of the best way to abolish female circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Clusters points by province . . . . . . . . . . . . . . . . . . . . . . . . . 136 List of selected variables with sampling errors . . . . . . . . . . . . . 141 Sampling errors - entire sample . . . . . . . . . . . . . . . . . . . . . . 142 Sampling errors - urban area . . . . . . . . . . . . . . . . . . . . . . . . 143 Sampling errors - rural area . . . . . . . . . . . . . . . . . . . . . . . . 144 ix FIGURES CHAPTER 2 Figure 2.1 Figure 2.2 Distribution of the population by age, SFS, 1983 census, and SDHS . . . . . . . . . . . . . . . . . . . . . . . 10 Percent distribution of ever-married women by current age, SFS and SDHS . . . . . . . . . . . . . . . . . 16 CHAPTER 3 Figure 3.1 Figure 3.2 Total fertility rate (TFR) and mean number of children ever bom (CEB) . . . . . . . . . . . . . . . . . . 25 Age-specific fertility rates, SFS and SDHS . . . . . . . . . . . . . . 28 CHAPTER 4 Figure 4.1 Figure 4.2 Figure 4.3 Current use of contraception by residence and region among currently married women 15J,9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Trends in contraceptive use among currently married women 15-49, SFS and SDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Source of contraceptive methods for current users of modem methods . . . . . . . . . . . . . . . . . . . . . 45 CHAPTER 5 Figure 5.1 Figure 5.2 Figure 5.3 Distribution of never-married women by age, SFS and SDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Median age at first marriage, SFS and SDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Mean duration of breastfeeding, amenorrhoea, and postpartum abstinence . . . . . . . . . . . . . . . . 63 CHAPTER 6 Figure 6.1 Figure 6.2 Fertility preferences among currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Fertility preferences among currently married women 15-49 by number of living xi CHAPTER 7 Figure 7.1 Trends in Infant (No) and under-five (sq0) mortality, SFS and SDHS . . . . . . . . . . . . . . . . . . . . . . . . . 80 CHAPTER 8 Figure 8.1 Antenatal care received from trained personnel by residence and region . . . . . . . . . . . . . . . . . . . . 85 Figure 8.2 Tetanus toxoid immunisation (antenatal) by residence and region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Figure 8.3 Children under 5 with a health card and immunisation coverage for all children under 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Figure 8.4 Percentage of children 12-23 months fully immunised by their first birthday . . . . . . . . . . . . . . . . . . . . . 94 Figure 8.5 Drop-out rates between DPT1 and DPT3 among children 12-23 months . . . . . . . . . . . . . . . . . . . . . . . 95 Figure 8.6 Source of immunisation services for children under 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Figure 8.7 Knowledge of source of immunisation services among mothers with children under 5 who were not immunised . . . . . . . . . . . . . . . . . . . . 96 Figure 8.8 Treatment for diarrhoea (other than ORT) among children under 5 years with diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Figure 8.9 Sources of treatment for diarrhoea among children under 5 years with diarrhoea . . . . . . . . . . . . . . . . . 103 Figure 8.10 Feeding practices during diarrhoea among children under 5 with diarrhoea . . . . . . . . . . . . . . . . . . . . . 104 Figure 8.11 Quantity of water used to prepare ORT solution from (UNICEF) ORS packets . . . . . . . . . . . . . . . . 106 CHAPTER 9 Figure 9.1 Percent distribution of dead sisters of respondents by time of death . . . . . . . . . . . . . . . . . . . . . . 109 xii Figure 10.2 Figure 10.3 Ever-married women who favour continuation of female circumcision by religion and husband's occupation . . . . . . . . . . . . . . . . . . . 121 Wife's perception of husband's attitude toward female circumcision by attitude of wife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 xiii FOREWORD The Sudan Demographic and Health Survey (SDHS) was conducted as part of worldwide Demographic and Health Surveys programme (DHS) of the Institute for Resource Development flRD)/Macro International, Inc. Sudan is one of fiRcen African countries that participated in the first phase of the programme. The survey is a welcome addition to demographic and health data in the country. It provides detailed information on various demographic components such as marriage, fertility, family planning, and on the socioeconomic factors associated with these variables. Knowledge of these components of population dynamics is considered an integral part of effective development planning in Sudan. The survey was conducted in two phases in 1989 and 1990 by the Department of Statistics. It was limited to nortbem Sudan due to civil unrest in the South. The survey was conducted with financial support from USAID and UNICEF and technical assistance from IRD. The successful implementation of the SDHS would not have been possible without the active and dedicated efforts of a large number of people. In particular, I would like to thank Mr. Abdel Wahab Modawi, the project director, Mr. Ibrahim Abbas Saif Elnasr, deputy project director, Ms. Elnalem S. Abbas, sampling coordinator, Mr. Mohamed A. Yousif, field coordinator, Mr. Abdeen Frahat, assistant field coordinator, and Mr. Ahmed Suliman and Mr. Salah A. Rahman, data processing coordinators. My thanks also go to the directors and staff of the regional statistical offices. Special thanks to Ms. Suzan Wesley of the Ministry of Health for her valuable participation in training field staff and also to the interviewers, who carried out the fieldwork under difficult conditions, and all the other people who took part in the survey, in particular the drivers, editors, coders, and data entry personnel. Thanks are also due to the regional governors and their staff in the regional departments who helped very much in making life easier for the interviewers and other field staff. I would also like to express special thanks to the DHS staff for their dedicated efforts throughout the various stages of the project. In particular, I would like to thank Dr. Jeremiah Sullivan, Dr. Mohamed Ayad, and Ms. Naomi Rutenberg for their roles in ensuring Sudan's participation in the DHS programme. I would like to thank Dr. Alfredo Aliaga, Ms. Thanh Le, and Mr. Sushil Kumar for their valuable assistance and hard work during the survey design. Special thanks to Ms. Jeanne Cushing for her valuable assistance and hard work in data processing activities and in training the data processing staff. Also our thanks to Ms. Elizabeth Britton for her important role in solving computer problems that faced the operators at the beginning of the data entry. My thanks to Ms. Annie Cross for reviewing the report, Dr. Sidney Moore for editing the report, Dr. George T. Bicego and Dr. Fred Amold, and other staff who participated in this work for their efforts. I also wish to record my special thanks to Mr. Sushil Kumar, the monitor for the Sudan Demographic and Health Survey for his efforts throughout the various stages of the survey, especially for travelling with the field staff to the different parts of the country and for his contributions to this report. XV Last but not least, I gratefully acknowledge the help of those people who made this report available in such a short period of time as the first study based on survey data to be used by planners and policymakers. Dr. Omer A. El Tay Director General Department of Statistics Khartoum xvi SUMMARY The Sudan Demographic and Health Survey (SDHS) was conducted in two phases between November 15, 1989 and May 21, 1990 by the Department of Statistics of the Ministry of Economic and National Planning. The survey collected information on fertility levels, marriage patterns, reproductive intentions, knowledge and use of contraception, maternal and child health, maternal mortality, and female circumcision. The survey findings provide the National Population Committee and the Ministry of Health with valuable information for use in evaluating population policy and planning public health programmes. A total of 5860 ever-married women age 15-49 were interviewed in six regions in northem Sudan; three regions in southern Sudan could not be included in the survey because of civil unrest in that part of the country. The SDHS provides data on fertility and mortality comparable to the 1978-79 Sudan Fertility Survey (SFS) and complements the information collected in the 1983 census. Fertility levels and trends Fertility has declined sharply in Sudan, from an average of six children per women in the Sudan Fertility Survey (TFR 6.0) to five children in the Sudan DHS survey flTR 5.0). Women living in urban areas have lower fertility (TFR 4.1) than those in rural areas (5.6), and fertility is lower in the Khartoum and Nortbem regions than in other regions. The difference in fertility by education is particularly striking; at current rates, women who have attained secondary school education will have an average of 3.3 children compared with 5.9 children for women with no education, a difference of almost three children. Although fertih'ty in Sudan is low compared with most sub-Saharan countries, the desire for children is strong. One in three currently married women wants to have another child within two years and the same proportion want another child in two or more years; only one in four married women wants to stop childbearing. The proportion of women who want no more children increases with family size and age. The average ideal family size, 5.9 children, exceeds the total fertility rate (5.0) by approximately one child. Older women are more likely to want large families than younger women, and women just beghming their families say they want to have about five children. Marriage Almost all Sudanese women marry during their lifetime. At the time of the survey, 55 percent of women 15-49 were currently married and 5 percent were widowed or divorced. Nearly one in five currently married women lives in a polygynous union (i.e., is married to a man who has more than one wife). The prevalence of polygyny is about the same in the SDHS as it was in the Sudan Fertility Survey. Marriage occurs at a fairly young age, although there is a trend toward later marriage among younger women (especially those with junior secondary or higher level of schooling). The proportion of women 15-49 who have never married is 12 percentage points higher in the SDHS than in the Sudan Feltih'ty Survey. There has been a substantial increase in the average age at first marriage in Sudan. Among xvii SDHS. Since age at first marriage is closely associated with fertility, it is likely that fertility will decrease in the future. With marriages occurring later, women am having their first birth at a later age. While one in three women age 45-49 had her first birth before age 18, only one in six women age 20-24 began childbearing prior to age 18. The women most likely to postpone marriage and childbearing are those who live in urban areas ur in the Khartoum and Northern regions, and women with pest-primary education. Breastfeeding and postpartum abstinence Breastfeeding and postpartum abstinence provide substantial protection from pregnancy after the birth uf a child. In addition to the health benefits to the child, breasffeeding prolongs the length of postpartum amenorrhoea. In Sudan, almost all women breasffeed their children; 93 percent of children are still being breasffed 10-11 months after birth, and 41 percent continue breasffeeding for 20-21 months. Postpamma abstinence is traditional in Sudan and in the first two months following the birth of a child 90 percent of women were abstaining; this decreases to 32 percent after two months, and to 5 percent at~er one year. The survey results indicate that the combined effects of breastfeeding and postpartum abstinence protect women from pregnancy for an average of 15 months after the birth of a child. Knuwledge and use of contraception Most currently married women (71 percent) know at least one method of family planning, and 59 percent know a source for a method. The pill (70 percent) is the most widely known method, followed by injection, female sterilisation, and the IUD. Only 39 percent of women knew a traditional method of family planning. Despite widespread knowledge of family planning, only about one-fourth of ever-married women have ever used a contraceptive method, and among currently married women, only 9 percent were using a method at the time of the survey (6 percent modem methods and 3 percent traditional methods). The level of contraceptive use while still low, has increased from less than 5 percent reported in the Sudan Fertility Survey. Use of family planning varies by age, residence, and level of education. Current use is less than 4 percent among women 15-19, increases to 10 percent for women 30-44, then decreases to 6 percent for women 45-49. Seventeen percent of urban women practice family planning compared with only 4 percent of rural women; and women with senior secondary education are more likely to practice family planning (26 percent) than women with no education (3 percent). There is widespread approval of family planning in Sudan. Almost two-thirds of currently married women who know a family planning method approve uf the use of contraception. Husbands generally share their wives's views on family planning. Three-fourths of married women who were not using a contraceptive method at the time of the survey said they did not intend to use a method in the future. Communication between husbands and wives is important for successful family planning. Less than half of currently married women who know a contraceptive method said they had talked about xviii family planning with their husbands in the year before the survey; one in four women discussed it once or twice; and one in five discussed it more than twice. Younger women and older women were less likely to discuss family planning than those age 20 to 39. Mortality among children The neonatal mortality rate in Sudan remained virtually unchanged in the decade between the SDHS and the SFS (44 deaths per 1000 births), but under-five mortality decreased by 14 percent (from 143 deaths per 1000 births to 123 per thousand). Under-five mortality is 19 percent lower in urban areas (117 per 1000 births) than in rural areas (144 per 10(30 births). The level of mother's education and the length of the preceding birth interval play important roles in child survival. Children of mothers with no education experience nearly twice the level of under-five mortality as children whose mother had attained senior secondary or nigher education. Mortality among children under five is 2.7 times higher among children born after an interval of less than 24 months than among children born after interval of 48 months or more. Maternal mortality The maternal mortality rate (maternal deaths per 1000 women years of exposure) has remained nearly constant over the twenty years preceding the survey, while the maternal mortality ratio (number of maternal deaths per 100,000 births), has increased (despite declining fertility). Using the direct method of estimation, the maternal mortality ratio is 352 maternal deaths per 100,000 births for the period 1976-82, and 552 per 100,000 births for the period 1983-89. The indirect estimate for the maternal mortality ratio is 537. The latter estimate is an average of women's experience over an extended period before the survey centred on 1977. Maternal health care The health care mothers receive during pregnancy and delivery is important to the survival and well-being of both children and mothers. The SDHS results indicate that most women in Sudan made at least one antenatal visit to a doctor or trained health worker/midwife. Eighty-seven percent of births benefitted from professional antenatal care in urban areas compared with 62 percent in rural areas. Although the proportion of pregnant mothers seen by trained health workers/midwives are similar in urban and rural areas, doctors provided antenatal care for 42 percent and 19 percent of births in urban and rural areas, respectively. Neonatal tetanus, a major cause of infant deaths in developing countries, can be prevented if mothers receive tetanus toxoid vaccinations. One-tnird of Sudanese mothers received two doses of tetanus toxoid during their pregnancy, while an additional one-tenth received one dose. The proportion of births whose mothers received two doses of tetanus toxoid is substantially nigher in urban areas than in rural. For births occurring in the five years preceding the survey, 18 percent of urban mothers were attended by doctors, 68 percent by trained health workers/midwives, and 11 percent by traditional birth attendants; for rural mothers these percentages were 4 percent, 56 percent, and 34 percent, respectively, indicating that rural women still depend on the traditional attendants more than doctors for assistance at delivery. xix Sudan's Expanded Programme of Immunisation (EPI) recommends that all children receive immunisations in the first year of life against common childhood diseases. In the SDHS mothers of 46 percent of children age 12-23 months were able to show interviewers the health card documenting their child's immunisations. For 33 percent of children the health card was not available but their mothers reported that they had received at least one immunisation. The SDHS results indicate that immunisation coverage for children 12-23 months is moderate: 76 percent of children had been immunised against BCG, 60 percent had received three doses of DPT, 61 percent had received three doses of polio, 61 percent were vaccinated against measles, and 52 percent had had all primary immunisations, lmmunisation coverage is higher for urban children than for rural children; it is higher in the Khartoum and Nortbem regions than in other regions; and it increases sharply with the mother's level of education. Diarrhoea, a common illness among infants and young children, can cause severe dehydration and if left untreated, can lead to death. The SDHS results show that 30 percent of children under five had had diarrhoea in the two weeks preceding the survey, and 18 percent in the 24 hours preceding the survey. Prevalence was highest among children between the ages of 6 and 23 months. Dehydration caused by diarrhoea can be treated effectively and inexpensively using oral rehydration therapy (ORT). In Sudan 29 percent of children with diarrhoea were treated with a solution prepared from ORS packets (salts), and 8 percent with a homemade salt and sugar solution. About half of the children with diarrhoea were taken to a medical facility; however, 30 percent neither visited a health facility nor received any treatment. Coughing together with difficult breathing is symptom of lower respiratory tract infection particularly pneumonia. Of all children under five, 48 percent had had a cough and 19 percent had had both a cough and difficult breathing during the two weeks before the survey. About 50 percent of the children suffering from cough were taken for treatment to a government health facility, 11 percent went to private doctors or hospitals and 4 percent consulted pharmacies. Children having cough in urban areas were more likely to be taken to private doctors (25 percent) than children in rural areas (3 percent). Female circumcision The SDHS collected data on the prevalence of female circumcision and the attitudes of women and men toward the practice. Eighty-nine percent of ever-married women in Sudan have been circumcised, representing a slight drop from 96 percent reported by the SFS. The majority of women received Pharaonic circumcision (82 percent); 15 percent received Sunna, and 3 percent had an intermediate type of circumcision. More than three-quarters of ever-married women support continuation of the practice of female circumcision. Support for circumcising their own daughters is even stronger than for circumcision in general. Among those wanting to retain the practice, Sunna circumcision (the least severe type) is preferred by 48 percent of the ever-married women; 46 percent prefer Pharaonic circumcision and 5 percent prefer the intermediate type. Those who oppose continuation of female circumcision said they believe the best way to aboUsh the practice is through education campaigns and the enforcement of laws against female circumcision. XX SUDAN EGYPT LIBYA NORTHERN RED SEA EASTERN CHAD DARFUR KARDOFAN CENTRAL ETHIOPIA CENTRAL AFRICAN REPUBLIC ZAIRE UGANDA KENYA ~T~ Not Surveyed xxii CHAPTER 1 BACKGROUND 1.1 GEOGRAPHY, H~TORY, ECONOMY Sudan is the largest country in Africa and covers an area of about 2.5 million square kilometres or nearly one-tenth of the total area of Africa. It is located in the northeastern part of the continent and extends from about latitude 3 degrees to 23 degrees north and from longitude 22 degrees to 39 degrees east. It is 2100 kilometres from nonla to south and about 1800 kilometres from east to west. Sudan shares borders with eight countries: Egypt and Libya to the north; the Central African Republic, Chad, and Zaire to the west; Kenya and Uganda to the south; and Ethiopia to the east. The Red Sea forms part of the eastern border. The country is located in the tropics and features Saharan conditions in the North and equatorial conditions in the South. With minor variations, northern Sudan is dry and characterised by high temperatures and little rainfall; southern Sudan is humid with milder temperatures and heavy rains. The soil composition varies, depending on the rainfall, being generally fertile in the Central region and in parts of the Eastern region. Due to the variation in climatic conditions, Sudan has rain forest vegetation in the South and savanna woodland, semi-desert, and desert vegetation in the North. The population of Sudan is characterised by two distinct cultural traditions, one in the North and one in the South; regional divisions reflect this ethnic division. Northem Sudan consists of six regions: Khartoum, the national capital, Northern region (Northern and Nile provinces), Eastern region (Kassala and Red Sea provinces), Central region (Blue Nile, White Nile and Gezeira provinces), Kordofan (North Kordofan and South Kordofan provinees), and Darfur (North Darfur and South Darfur provinces). The majority of people in northern Sudan are Muslims, although there are some Christians and practitioners of traditional religion. Arabic is commonly spoken in the North in addition to local languages. Southern Sudan, consisting of three regions: Equatoria (Eastern Equatoria and Western Equatoria provinces), Upper Nile (Upper Nile and Jonglei provinces), and Bahr E1 Ghazal (Bahar E1 Ghazal and E1 Buheyrat provinces). The majority of people in southern Sudan practice traditional religion and speak local African languages. In general, they are more closely linked to population groups further south than to those in northern Sudan. Sudan became independent in 1956 after a long period of British role. Just prior to independence, a British-type of democratic system was hurriedly put in place. People were unfamiliar with the new system, and the country soon experienced political instability and economic deterioration. A mutiny broke out in the southern provinces and later turned into civil war. Although the war ended by 1972, it started up again in late 1980s. During this period of civil strife the country experienced widespread unrest with resulting destruction of the social infrastructure and disruption of the economy. Although the entire country has suffered the effects of the civil war, the greatest impact has been in the South. For this reason, the DHS survey did not include the southern regions. 1.2 POPULATION The first census, which was undertaken in 1955-56, reported a population of 10.3 million. The 1973 census reported 14.1 million, and the 1983 census 20.6 million. In a period of 27 years the population had doubled in size, with a fourfold increase in the urban areas (Table 1.1). A recent projection done by the Census Office estimated the population of Sudan in 1989 to be 24.5 million (Population Census Office, 1991). Population size and growth rate Table 1.1 Population size and growth rate by residence pattern, Sudan Census, 1956, 1973, and 1983 Population Growth Rate (%) Residence 1956- 1973- 1956- pattern 1956 1973 1983 1973 1983 1983 Urban 903,973 2,605,896 4,219,826 6.3 5.0 5.9 Rural 8,002,712 9,877,984 14,109,541 1.2 3.7 2.1 Nomadic 1,405,951 1,629,710 2,264,830 0.9 3.4 1.8 Total 10,262,536 14,113,590 20,594,197 1.9 3.9 2.7 The intercensal growth rate was 1.9 percent per annum for 1956-1973, 3.9 percent per annum for 1973-1983 and 2.7 percent per annum for 1956-1983. Because of coverage problems in the South during the 1973 census, the growth rate based on the 1956-1983 census data is probably the most plausible. Fertility The age-specific and total fertility rates for the census data were estimated using the United Nations MORTPAK package (FERTPF Programme). The results are presented in Table 1.2 together with estimates obtained from the Sudan Fertility Survey 1978-79. The table shows rates for the 12 months preceding the census or survey and gives both reported and adjusted fertility rates. The adjusted fertility rates show a consistent pattern of decline. Fertility rates based on data collected in the Sudan Demographic and Health Survey are discussed in Chapter 3. Mortality Indirect estimates of life expectancy at birth obtained from 1973 census data were 46 years for males, 50 years for females and 48 years for both sexes. By 1983, these levels had risen to about 53 years for males, 55 years for females and 54 years for both sexes, indicating a decline in mortality. The trend does not appear to have continued during the period 1983 to 1988. On the contrary, the level of mortality may have risen due to the civil war in the South and the drought in most parts of the country. 2 Age-specif ic ferti l i ty rates and total ferti l i ty rates Table 1.2 Reported and adjusted age-specif ic ferti l ity rates and total ferti l i ty rates (TFR), from selected sources, Sudan 1973-1983 Age-specif ic ferti l ity rate Sudan Fert i l i ty 1973 census Survey 1978-79 1983 census Age Reported Adjusted I Reported Adjusted I Reported Adjusted I 15-19 0.i09 0.142 0.090 0.I00 0.067 0.113 20-24 0.259 0.337 0.275 0.304 0.187 0.279 25-29 0.273 0.955 0.325 0.360 0.236 0.355 30-34 0.213 0.277 0.272 0.301 0.209 0.289 35-39 0.150 0.195 0.155 0.172 0.161 0.216 40-44 0.055 0.072 0.II0 0.122 0.062 0.080 45-49 0.028 0.036 0.018 0.020 0.041 0.050 TFR 5.4 7.1 6.2 6.9 4.8 6.8 Note: Regions in the South are excluded. iBased on P/F ratios for age groups 20-24, 25-29, and 30-34. Source: Population Census Office, 1991 1.3 POPULATION AND FAMILY PLANNING POLICIES AND PROGRAMMES Family planning activities in Sudan started in 1965 with the establishment of the Sudan Family Planning Association (SFPA), an affiliate of the International Planned Parenthood Federation (IPPF). In the beginning, family planning services were limited primarily to urban centres, despite the fact that about 80 percent of the population is rural. With increased acceptance of family planning on the part of Islamic leaders and with the introduction of primary health care, the Government has integrated family planning into the overall maternal and child health programme as a mean of reducing matemal morbidity and mortality. The main aim of the SFPA is to encourage women to space births so that they and their children increase their chances for survival. Another goal of the family planning programme is to reduce the high rate of natural population increase and to improve the health of mothers and their children under the age of five years. 3 1.4 HEALTH PRIORITIES AND PROGRAMMES Health services in Sudan are provided by the Ministry of Health and by local (regional) governmental and nongovernmental organisations. The Ministry of Health is responsible for developing health policies and for providing health care in government hospitals and health centres. The regional governments am in charge of health care delivery at the district level (within provinces) and coordinating the services of nongovernmental organisations. The goals and objectives of the Ministry of Health are: • reduction of infant mortality to 50 deaths per 1000 live births by the year 2000, • reduction of child (under five years) mortality to 70 deaths per 1000 live births by the year 2000, • reduction of maternal mortality by one-third of the level in 1990 by the year 2000, • reduction of severe malnutrition among children under five years by the year 1995, • elimination of iodine deficiency by 1995, • reduction of vitamin A deficiency by 50 percent by 1995, • reduction of child mortality due to acute respiratory infection by 25 percent of the 1990 level by 1995, and • reduction of mortality due to diarrhoeal disease in children under five by 40 percent of the preprogramme level by 1995. 1.5 EDUCATION SYSTEM The education system in Sudan consists of four levels: primary, junior secondary, senior secondary, and higher institute and university. Primary school covers the first six years of education, while junior and senior secondary each cover three years) In the following chapters secondary education refers to post-primary education or junior secondary and higher. In addition to formal education, there are schools called Khalwas, where children of all ages am accepted. The curriculum in these centres is mainly religious with the objective of teaching children to memorize the Koran. The government has a goal of achieving universal basic education for all Sudanese children by the year 2000. 1.6 OBJECT IVES OF THE SURVEY The primary objective of the SDHS was to provide data on fertility, nuptiality, family planning, fertility preferences, childhood mortality, indicators of maternal health care, and utilization of child health services. Additional information was coUected on educational level, literacy, source of household water, and other housing conditions. The SDHS is intended to serve as a source of demographic data for comparison with the 1983 census and the Sudan Fertility Survey (SFS) 1978-79, and to provide population and health data for policymakers and researchers. The objectives of the survey are to: Before the educational system was reorganized in the early 1970s, primary, intermediate, and secondary schooling were for four years each. • assess the overall demographic situation in Sudan, • assist in the evaluation of population and health programmes, • assist the Department of Statistics in strengthening and improving its technical skills for conducting demographic and health surveys, • enable the National Population Committee (NPC) to develop a population policy for the country, and • measure changes in fertility and contraceptive prevalence, and study the factors which affect these changes, and • examine the basic indicators of maternal and child health in Sudan. 1.7 ORGANISAT ION OF THE SURVEY The SDHS was carried out by the Census Office of the Department of Statistics, Ministry of Finance and Economic Planning, with financial support from the United States Agency for International Development (USAID). The Institute for Resource Development (IRD), a Macro Systems Company, provided technical assistance for the survey through the Demographic and Health Surveys Programme. UNICEF also provided financial support to complete the survey. Sample Design The SDHS was conducted in the northem regions of Sudan, covering 12 provinces. The three regions in the South (6 provinces) were not included in the survey due to civil unrest and security problems. The SDHS covered approximately 80 percent of the total population of the country. The sample was designed to obtain 5000 completed interviews with eligible women, i.e. ever-married women 15-49 years of age who slept in the selected household the night before the interview. It was a multistage, stratified, self-weighting probability sample, representing the settled but excluding the nomad population in urban and rural areas of the 12 northern provinces. The 1983 census formed the sampling frame. In addition, a special sample design was followed in the major cities to ensure the inclusion of recently settled areas in and around these cities. The sample design is described in more detail in Appendix A. The estimates of sampling errors are given in Appendix B. Questionnaires Two questionnaires in Arabic were used for the SDHS: the Household Questionnaire and the Individual Questionnaire. Both were adapted from the DHS Model "B" Questionnaire, designed for use in countries with low contraceptive prevalence. The questionnaires were finalised after a pretest was carried out in June and July 1989. The Household Questionnaire was used to list information including name, age, sex, and residence status for all usual members of the household and any visitors. For those ten years and older, information on marital status and level and grade of education was also recorded. The major purpose of the Household Questionnaire was to identify those women who were eligible for the Individual Questionnaire. The Individual Questionnaire was used to collect data from ever-married women 15-49 years who were present in a sampled household the night prior to the household interview. The questionnaire collected information on the following topics: 5 Respondent's background Reproductive history and female circumcision Knowledge and use of family planning Maternal and child health, and breasffeeding Marriage Fertility preferences Husband's background Maternal mortality Pretest In order to check the content and translation of the questionnaires, a pretest was conducted. Twelve female employees from the statistics section of the Ministry of Health were selected to participate as interviewers in the pretest. All interviewers bad at least secondary education and some had interviewing experience. A two-week training course for the pretest interviewers was conducted in June 1989. Staff from the Ministry of Health, IRD/Macro, and the Census Office conducted the training. On completion of the training, interviews were conducted from June 25 to July 4, 1989 in both urban (El Zihaour and A1 Hilla El Gadieda) and rural lid Babikir) areas. A total of 162 individual questionnaires were completed, 82 in urban, and 80 in rural areas. The average time required to complete the individual questionnaire was 48 minutes in urban areas and 43 minutes in rural areas. After the pretest, modifications were made in the questionnaires and manuals. An English translation of the f'mal version of the household and individual questionnaires is included in Appendix C. Fieldwork and Training The training of the field staff for the main survey began on October 16 and lasted until November 14, 1989. Sixty-two women were recruited to undergo the training; most of them were university graduates and not affiliated with the government. The special training programme for six supervisors started one week later and was conducted simultaneously. The interviewers' training included five hours of classroom sessions per day, as well as a few days of field practice. In addition to those involved in conducting the pretest training, the staff from the National Population Committee also participated in training field staff. The training programme included: • general lectures related to fertility, family planning and public health, • specific sessions on how to fill out the questionnaires, • role playing and mock interviews, • four days of field practice in areas not covered in the survey, and • periodic tests. Trainees who failed to show interest, did not attend on a regular basis, did not agree to work in all provinces or failed the first three tests were disqualified. At the beginning of the third week of training, 14 of the best trainees were selected to be the field editors. They were thoroughly trained to undertake their responsibilities. 6 At the end of the training, 48 of the 62 trainees were selected to work as interviewers and editors during the main survey fieldwork. An additional three were asked to stand by as back-up. The fieldwork was carried out in two phases: from November 15, 1989 to January 31, 1990 and from March 19 to May 21, 1990. Phase I of the fieldwork involved interviewing in Khartoum and in the Central and Eastem regions and was carried out by seven teams. Each team consisted of a supervisor, two field editors and five interviewers. The field editors also worked as interviewers when time permitted. Phase II of the fieldwork in Kordofan and Darfur regions was initially planned to start February 10, 1990 but was delayed until mid-Mareh because of problems obtaining survey vehicles. Since one solution was to reduce the number of teams, the survey director selected 27 of the 45 interviewers to complete the fieldwork: (a) one team (seven interviewers, a supervisor and a fieldwork coordinator from the Central office) was assigned to complete the remaining rural clusters in Khartoum and to cover the entire Nor.hem region, and (b) four teams (20 interviewers/editors and four supervisors) worked in two groups in Kordofan and Darfur regions. Data Entry, Editing and Tabulation The central office of the SDHS in Khartoum was responsible for collecting the completed questionnaires from supervisors as soon as a sufficient number of clusters was completed in a province. The field coordinator from the central office, or staff from the regional census offices, hand-carried the batches of questionnaires to Khartoum for data entry and editing. At the central office, the questionnaires were coded and reviewed for consistency and completeness by office editors who also carried out the data entry. To provide feedback for the field teams, the office editors were instructed to report any problems detected while editing the questionnaires. These reports were reviewed by the senior staff and, when warranted, team supervisors were contacted in order to inform them of the steps to be taken to avoid these problems in the future. The data entry and editing phase began soon after the start of the fieldwork. The data from the questionnaires were entered and edited on microcomputers using the Integrated System for Survey Analysis (ISSA), a package developed especially for the Demographic and Health Survey programme. Eight data entry personnel used three IBM-compatible microcomputers to process the SDHS survey. The data entry and editing were completed one month after the end of the fieldwork. All data processing, including preliminary tabulations, was completed by July 1990. Coverage of the Survey In the Sudan Demographic and Health Survey, 7,280 households were selected for the sample; 6,945 of these were identified (Table 1.3). Household interviews were completed in 6,891 identified households, which represents a response rate of 99 percent. A total of 6,131 eligible women were identified and 5,860 were successfully interviewed. The response rate at the individual level was 96 percent. 7 Sample results Table 1.3 Sample Results, Sudan DHS 1989-90 Result Number Percent Boulehold l me leot~ 7280 I00.0 Completed 6891 94.7 Household present, but no competent respondent 34 0.5 Household absent 113 1.6 Refused 3 0.0 Dwel l ing vacant 187 2.6 Dwel l ing destroyed 1 0.0 Dwel l ing not found 17 0.2 Other 34 0.5 Households ident i f ied 6945 I00.0 Interviewed 6891 99.2 Not interviewed 54 0.8 E l ig ib le women ident i f ied 6131 I00.0 Completed 5860 95.6 Not at home 169 2.8 Refused 15 0.2 Part ly completed 5 0.i Other 82 1.3 8 CHAPTER 2 BACKGROUND CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Throughout this report, nuptiality, fertility, contraceptive behaviour, mortality and health of children, etc. are viewed in terms of the different subgroups of the population. One purpose of this chapter is to profile these subgroups and to describe the environment in which women and children live. The general characteristics of the population are presented, including: the age-sex structure, literacy and education, household arrangements (headship, size) and housing facilities (such as water supply, sani- tation, and electricity). The distinction between urban and rural settings is an important indicator of household differences. The second purpose of the chapter is to provide a summary of the respondents' characteristics. This is intended to highlight important features of the women included in the SDHS. For the full sample, percent distributions are shown for various demographic and socioeconomic characteristics, such as age, marital status, residence, and education level. 2.1 HOUSEHOLD POPULAT ION BY AGE In many developing countries data on age are affected by errors such as misstatement and preference for or avoidance of certain digits. In order to improve age reporting in cases where age is not given, interviewers were instructed to estimate ages using a specially designed historical calendar, with reference to other members of the household whose ages might be reasonably guessed, or based on physiological or sociological factors. Table 2.1 shows the percent distribution of the household population by five-year age groups, according to urban-rural residence and sex. The table indicates that the age distribution of the household population in the SDHS is similar to that of the 1983 census population and the population surveyed by the Sudan Fertility Survey 1978-79. Proportionally, in the SDHS there are more people age 15-49 and fewer children and older people in urban areas; this is due to the migration of young adults from rural areas to the cities. Figure 2.1 shows the population distribution of the three data sources--the SFS, the 1983 census, and the SDHS--by broad age categories. It is apparent that the proportion of the population under age 15 has declined, while the proportion age 15-64 has increased. This pattern is characteristic of populations that are experiencing declining fertility. 2.2 EDUCATIONAL LEVEL AND MARRIAGE In the SDHS, for all household members ten years and older, questions were asked to determine what level of education they had completed and whether they had ever been married. Table 2.2 shows the percent distribution of the population age 10 and over by level of education and the percentage ever married according to sex, age, residence, and region. The table shows that 33 percent of men in the SDHS household sample have never attended school, 25 percent attended but did not complete primary school, 10 percent completed primary school, 9 Distribution of the household population by age Table 2.1 Percent distribution of the household population by five-year age groups according to urban- rural residence and sex, Sudan DHS 1989-90, and percent distribution of population according to the 1983 census and the Sudan Fertility Survey ($F6) 1978-79 SDHS 1989-90 Urban Rural Total 1983 SFS Age group Male Female Total Male Female Total Male Female Total Census 1978-79 0-4 12.2 12.3 12.3 16.3 15.2 15.7 14.6 14.1 14.3 13.9 16.0 5--9 12.2 13.1 12.6 16.8 16.1 16.5 14.9 14.9 18.9 16.4 17.8 10-14 12.1 12.5 12.3 14.5 14.0 14.3 13.5 13.4 13.5 13.7 14.3 15-19 12.0 12.6 12.3 10.3 11.4 10.9 II.0 11.9 11.5 11.4 10.4 20-24 12.5 11.5 12.0 6.8 8.7 7.8 9,2 9.8 9.5 7.8 6.7 25-29 9.3 9.7 9.5 6.0 8.3 7.2 7.8 8.8 8.1 7.8 7.2 30-34 6.I 5.7 5.9 4.7 4.8 4.8 5.3 5.2 5.2 5,6 4.8 35-59 8.0 5.3 5.7 4.5 5.4 5.0 5.1 5.3 5.2 6,2 5.9 40-44 3.9 3.4 3.7 3.8 3.0 3.4 3.9 3,1 3.5 4.3 3.7 85-49 3.5 2.7 3.1 3.6 2.8 3.0 3.6 2.5 3.1 3.7 3.4 50-54 2.2 3.3 2.7 2.8 2.6 2.7 2.5 2.9 2.7 2.8 2.7 55-59 2.1 2.8 2.4 2.2 3.0 2.6 2.1 2.9 2.5 1.6 2.1 60-64 1.9 1.9 1.9 2.6 1.9 2.2 2.3 1.9 2.1 1.7 1.8 65-69 1.5 1.0 1.2 1.8 1.0 1.4 1.6 1.0 1.3 1.0 1.2 70-74 1.0 1.0 1.0 1.6 1.0 1.3 1.4 1.0 1.2 0.9 1.2 75-79 0.5 0.4 0.5 0.7 0.4 0.5 0.6 8.4 0.5 1.0 1.3 80 + 0.9 0.6 0.8 1.0 8.7 0.9 0.9 0.7 0.8 0.2 0.I T~ml I00.0 IO0.O I00.0 lO0.O lO0,O 100.0 lOO.O lO0.O IOO.O IOO.O 100.0 Numbgr o£ personJ 9170 8485 17655 12616 13298 25914 21786 21783 43569 a 63211 Note: Figures are based on the de facto population, i.e., persons who slept in the household the night before the interview. aThe total population (excluding nomadic groups) was 18,329,327. Figure 2.1 Distribution of the Population by Age 8F8, 1983 Census and SDHS Percent 70 60 80 40 30 20 10 0 c15 years 15-64 years 65. years I ~SFS 1977-78. • Umlted to six region| ~n Northern Sudan m~1983 Census m SDHS 1989-90* / Ruder1 DH8 1889-80 ]0 Distribution of the household population by education and marriage Table 2.2 Percent distribution of household population by level of education+ and the percentage ever married according to sex, age, residence and region, Sudan DNS 1989-90 Level of education Percentage Number No Primary Primary Junior Senior Total ever of Characteristic education incomplete complete secondary secondary+ percent married persons MALES ~m 10-14 13.4 62.0 14.0 9.9 0.7 100.0 0.7 2919 15-19 14.3 16.1 14.7 34.4 20.5 i00.0 1.7 2391 20-24 13.4 13.3 14.0 17.0 42.4 i00.0 9.7 1999 25-29 21.0 14.5 12.5 16.6 35.4 100.0 37.7 1608 30-34 32.8 14.8 10.3 12.2 29.9 100.0 68.3 1140 35-39 38.5 21.8 7.9 10.7 21.0 i00.0 85.8 1117 40-44 49.2 23.5 4.0 9.5 13.9 100.0 94.4 835 45-49 55.6 22.1 3.1 7.5 11.8 I00.0 96.3 774 50-54 69.7 16.7 2.4 4.8 6.4 I00.0 97.2 545 55-59 68.5 18.6 1.7 3.2 8.0 I00.0 97.8 463 60-84 82.7 10.9 1.0 2.6 2.8 i00.0 98.0 503 65 or more 87.7 7.2 1.2 1.5 2.4 I00.0 98.8 990 Urban 20.5 21.2 10.3 17.7 30.6 I00.0 38.1 6893 Rural 42.5 27.6 9.9 11.5 8.5 i00.0 47.2 6391 Khartoum 17.8 18.5 10.3 17.8 35.7 i00.0 38.4 4010 Northern 22.3 27.0 10.9 20.5 19.3 100.0 40.7 940 Eastern 48.0 22.2 9.2 9.5 11.2 100.0 47.3 1632 Central 30.8 28.1 10.8 15.8 14.5 i00.0 41.5 4386 Kordofan 38.8 31.3 10.3 10.4 9.3 100.0 46.3 2032 Darfur 49.1 24.0 8.5 9.5 8.8 100.0 49.4 2284 Total 32.5 24.7 i0.i 14.3 18.4 I00.0 43.1 15264 FEMALES ~e 10-14 22.1 55.8 12.0 9.8 0.4 I00.0 1.5 2911 15-19 23.5 18.1 14.6 27.2 16.6 I00.0 15.8 2580 20-24 29.1 15.5 12.3 12.3 30.8 i00.0 46.7 2136 25-29 42.6 17.0 9.8 8.3 22.3 100.0 73.7 1923 30-34 53.1 21.6 6.8 6.0 12.4 I00.0 88.2 1126 35-39 66.2 23.5 2.4 3.2 4.7 100.0 95.0 1161 40-44 75.9 17.3 0.6 2.9 3.4 100.0 97.4 684 45-49 86.3 10.3 0.5 1.8 i.i 100.0 98.7 554 50-54 91.2 6.4 0.3 I.I 1.0 100.0 98.9 627 55-59 94.7 4.1 0.0 0.6 0.6 100.0 99.1 640 60-69 96.3 3.2 0.0 0.2 0.2 i00.0 99.0 410 65 or more 98.2 0.9 0.i 0.4 0.3 I00.0 97.8 672 Re l i~n~ Urban 33.3 21.9 8.9 14.1 21.8 i00.0 51.5 6319 Rural 56.9 23.5 8.0 7.3 4.2 100.0 57.5 9205 Khartoum 27.8 21.3 9.6 15.3 26.1 100.0 52.1 3479 Northern 94.8 28.0 10.7 14.4 12.2 100.0 54.4 1066 Eastern 64.1 17.7 6.3 6.3 5.7 i00.0 63.8 1488 Central 45.0 26.7 8.7 10.2 9.3 I00.0 53.0 4400 Kordofan 54.3 25.0 8.0 7.3 5.3 100.0 53.2 2497 Darfur 66.5 16.9 6.7 5.9 3.9 i00.0 59.6 2494 T~a~ 47.2 22.8 8.4 I0.I 11.4 100.0 55.1 15424 Note: Figures are based on the de facto population, i.e. t persons who slept in the household the night before the interview; 84 males and 43 females were excluded because of missing information on education. 11 14 percent have a junior secondary education and 18 percent attained senior secondary school or higher. The substantial improvement in educational attainmem over time can be seen in the fact that younger men have attained higher levels than older men. The proportion of men with no education increases with age and the proportion with secondary school decreases with age. As expected, urban men tend to be more highly educated than their rural counterparts. The regions show considerable variation in education: in Khartoum more than 50 percent of the men have attained post-primary education; this decreases to 40 percent in the Northem region, 30 percent in the Central region, and 20 percent in the Eastern, Kordofan, and Darfur regions. Women in Sudan are less educated than men. About 47 percent of women age ten and over in the SDHS household sample have never attended school, 23 percent have not completed primary school, 8 percent have completed primary education, 10 percent have a junior secondary education, and about the same proportion (11 percent) attended secondary school or higher. As with men, there has been a steady improvement in women's educational attainment over time. Women have advanced in education at all levels, but the gains are most marked at the higher levels. For example, among women age 60 and over, only three in 1,000 women got as far as secondary level. Among women who were age 20-24 at the time of the survey, however, nearly one-third had attained the secondary level of schooling. Women who reside in urban areas have considerably more education than those living in rural areas. Fifty-seven percent of rural women have never attended school compared with 33 percent of urban women, and the proportion who have post-primary education is three times as high in urban areas as in rural. Educational attainment for women is the highest in Khartoum where four in ten women have post-primary education. Women in the Darfur region have the least education. Table 2.2 shows that marriage is almost universal among Sudanese men and women. By the time they reach their late 40s, all but 4 percent of men and 1 percent of women have married. However, women marry much earlier in life than men. For example, while almost half of women aged 20-24 have married, only 10 percent of men in this age group have married. The proportion of both men and women who have ever married is lower in urban areas than in rural and lower in Khartoum than in other regions. 2.3 HOUSEHOLD COMPOSIT ION Table 2.3 presents information on household composition according to urban-rural residence for the de jure population (i.e., usual residents). Eighty-seven percent of the households in Sudan are headed by men, while 13 percent have female heads. There is a slight difference between urban and rural areas in the proportion of households headed by men and women. Large households are common in Sudan. The average number of household members is 6.6 for the country as a whole, with urban households larger than rural households (7.5 and 6.2, respectively). One-third of urban households are composed of nine or more members, compared with one-fifth of rural households. 12 Type of household and household size Table 2.3 Percent d istr ibut ion of households (HH) by sex of head of household and house- hold size according to urban-rural residence, Sudan DHS 1989-90 Residence Household head/size Urban Rural Total Household head Male 86.7 87.9 87.4 Female 13.3 12.1 12.6 Numbor of household mambere 1 1.9 2.8 2.5 2 4.4 7.4 6.3 3 6.6 10.8 9.3 4 8.2 12.2 10.8 5 11.2 12.7 12.2 6 10.9 12.5 ii .9 7 11.7 11.3 11.4 8 10.4 9.7 i0.0 9+ 34.7 20.6 25.6 Total percent I00.0 i00.0 I00.0 Mean HH size 7.5 6.2 6.6 N%1~ber of HH 2451 4440 6891 Note: Figures are based on the de Jure (usual resident) household population. 2.4 HOUSING CHARACTERIST ICS It should be noted that the data on housing characteristics were collected in the individual questionnaire and not in the household questionnaire. Thus, a selected household is represented as many times as the number of eligible woman interviewed in the household. The households with no individual interviews are therefore not included in this analysis. Table 2.4 shows the percent distribution of respondents by housing characteristics according to urban-rural residence. Overall, one-third of respondents live in households that have electricity, though this varies widely by residence; two-thirds of urban women live in households with electricity, compared with 13 percent of rural women. As for the source of drinking water, 40 percent of respondents live in households with water piped into the residence, while 15 percent use an outside water pipe, another 20 percent use public wells, 9 percent depend on rivers and other surface water, and 8 percent buy water from vendors. The table also indicates that 57 percent of respondents live in households equipped with pit latrines, while 35 percent have no facility. Six percent have flush toilets and 1 percent use buckets. Urban residents are much more likely to have piped water and toilet facilities than rural residents. 13 Eousinq characteristics Table 2.4 Percent distribution of respondents by housing character ist ics according to urban-rural resi- dence, Sudan DHS 1989-90 Residence Housing character ist ic Urban Rural Total PeE~nt with electricity 66.1 13.2 32.8 Source of wateE Piped into residence 75.9 18.7 40.0 Piped outside 6.1 20.3 15.0 Publ ic well 4.6 28.6 19.7 River/surface water 2.8 12.8 9.1 Vendor 9.5 7.7 8.4 Rainwater 0.0 1.9 1.2 Other 1.0 10.0 6,7 Total percent lOO.O I00.0 I00.0 Sa~nlt&tion facility Pit latr ine 70.7 48.7 56.9 Flush 16.1 0.3 6.2 Bucket 1.7 0.7 1.0 Other 0.4 0.5 0.4 No faci l i ty II.i 49.8 35.4 Total percent I00.0 I00.0 I00.0 Floorimg ~ter ia l Earth/sand 66.6 96.4 85.3 Ceramic 19.8 1.5 8.3 Cement 6.8 1.3 3.3 Brick 6.6 0.8 2.9 Other 0.2 0.0 0.I Total per~nt i00.0 I00.0 100.0 Wall material Straw 11.5 55.5 39.1 Mud 35.6 32.4 33.6 Brick 46.0 I0.I 23.5 Cement/concrete 5.2 0.2 2.0 Wood i.i 0.9 0.9 Other 0.6 0.9 0.8 Total percent I00.0 100.O I00.0 N%mber of re~pondentm 2181 3679 5860 As far as construction materials of homes are concerned, 85 percent of respondents have earth or sand floors in their houses, while 8 percent have ceramic floors, 3 percent have cement, and the same proportion have brick floors. In urban areas, ceramic, cement and brick flooring is more common, though a majority (two-thirds) of women live in houses with earthen flooring. In contrast, almost all rural respondents (96 percent) have earth/sand flooring. Houses with straw walls are most common, followed 14 by those with mud or brick walls. Around one-third of respondents in urban and rural areas live in homes with mud walls, while almost half of urban respondents (46 percent) and one in ten rural respondents (or one-quarter for the whole country) have brick walls. 2.5 PRESENCE OF DURABLE GOODS IN THE HOUSEHOLD Table 2.5 shows the percentage of respondents who live in households with spe- cific durable consumer goods by residence. Overall, 56 percent of women live in house- holds that have a radio, 25 percent have a television and 20 percent have a refrigerator. Regarding ownership of a means of transpor- tation, only 15 percent of women live in households with a bicycle, 11 percent with a car, and only 1 percent with a motorcycle. The question on tractor ownership was asked only of rural respondents, 2 percent of whom live in households that have a tractor. Ownership of durable consumer goods varies greatly by residence. As expect- ed, the proportion of women who live in households where the specific items are pres- ent is much lower in rural areas than in urban areas. This urban-rural difference is particu- larly strong for televisions and refrigerators, and reflects the fact that urban respondents are five times as likely to have electricity as rural respondents. Durable qoods in the household Table 2.5 Percentage of ever-marr ied women in households with specif ic durable consumer goods by urban-rural residence, Sudan DHS 1989-90 Residence Durable consumer good Urban Rural Total Radio 76.2 43.4 55.6 Televis ion 51.8 9.9 25.5 Refr igerator 44.4 6.0 20.3 Bicycle 25.2 9.4 15.3 Motorcycle 2.2 0.4 I.I Car 21.0 5.2 II.I Tractor a 1.7 a N%uJ~ez of women 2181 3679 5860 aQuest ion not asked in urban areas. 2.6 BACKGROUND CHARACTERISTICS OF WOMEN Age The low level individual awareness of exact age in Sudan increases the probability of age misreporting. In some cases, age was not known at all and the interviewers had to estimate it by various means. Figure 2.2 compares the age distributions of female respondents in the SFS and the SDHS as reported by the respondents. Both distributions show appreciable heaping at ages ending in zero and five and corresponding troughs at ages ending in one and nine. Less pronounced heaping is found at ages ending in even numbers such as two and eight. The very sharp peaks and troughs in the SFS are reduced somewhat in the SDHS, suggesting that progress has been made in the quality of age reporting. However, this improvement may be due to the higher educational level of respondents as well as improved data collection procedures. 15 Figure 2,2 Percent Dis t r ibut ion of Ever -marr ied Women by Cur rent Age, SFS and SDHS Percent '4 I ~2 10 8 0 15 20 25 30 36 40 45 Current Age - "~-- SFS 1978"79 - - SDHS 1989"90 m Sudsn DH8 1989-90 Table 2.6 shows the percent distribution of respondents by age group and other background characteristics. As expected, the distribution of ever-married and currently married women increases from age 15-19 to age 25-29, then declines as age increases. The distribution of ever-married and currently married women is similar for all background characteristics. Place of Residence A little more than one-third (37 percent) of the women in the sample reside in urban areas with the remainder (63 percent) living in rural areas. About half of the respondents live in two regions: 27 percent in the Central region and 21 percent in Khartoum; the region with the smallest proportion of respondents is the Northern region (7 percent). The other regions in order of size are Darfur (18 percent), Kordofan (15 percent) and the Eastern region (11 percent). Almost all the women interviewed in the survey are Muslim (98 percent); only 2 percent are Christian. Level of Education As can be seen in Table 2.6, the majority of women in Sudan have received no formal education. Among ever-married women, six in ten (58 percent) have never been to school, and only 15 percent have received education beyond primary school. More than six in ten ever-married women cannot read and only one in four can read easily. 16 Backqround character ist ics of respondents Table 2.6 Percent distr ibut ion of ever-marr led women and current ly marr ied women by selected background characterist ics, Sudan DHS 1989-90 Ever-marr ied Current ly women marr ied women Number Number Background of of character ist ic Percent women Percent women 15-19 6.5 380 6.8 367 20-24 16.0 938 16.7 900 25-29 23.1 1355 23.6 1276 30-34 16.6 970 16.8 906 35-39 17.9 1047 17.7 955 40-44 10.8 630 i0.i 543 45-49 9.2 540 8.4 453 Resi4~noe Urban 37.2 2181 36.6 1979 Rural 62.8 3679 63.4 3421 Region Khartoum 21.3 1249 21.0 1136 Northern 6.7 394 6.8 365 Eastern 11.4 667 11.4 616 Central 27.3 1599 27.4 1480 Kordofan 15,5 908 15.3 828 Darfur 17.8 1043 18.1 975 Edu~t lon No educat ion 58.4 3425 58.0 3130 Pr imary incomplete 19.5 1142 19.6 1061 Pr imary complete 6.8 401 6.9 374 Junior secondary 7.3 427 7.5 405 Senior secondary+ 7.9 465 8.0 430 Li ter&a M Reads easi ly 25.8 1509 25.8 1395 Reads with di f f iculty 12.6 737 12.8 693 Cannot read 61.6 3607 61.2 5305 Miss ing 0.I 7 0.i 7 Religion Musl im 98.0 5745 98.0 5293 Chr ist ian 1.9 111 1.9 103 Other 0.I 4 0.i 4 Total 100.0 5860 i00.0 5400 Table 2.7 examines variations in educational attainment of ever-married women by age, residence, and region. Education is inversely related to age; that is, older women are generally less educated than younger women. For example, whereas about two-fifths of women age 20-24 have no education, more than four-fifths of the women age 45-49 have no schooling. 17 Women's level of education Table 2.7 Percent distribution of ever-married women by age, urban-rural residence, and region, according to level of education, Sudan DHS 1989-90 Background No Primary Primary Junior Senior Total Number of characteristic education incomplete complete secondary secondary+ percent women A~Q 15-19 43.4 22.1 16.3 15.5 2.6 10O.0 380 20-24 41.8 18.7 12.5 14.8 12.3 i00.0 938 25-29 50.4 18.1 10.1 8.5 12.9 100.0 1355 30-34 56.9 21.2 5.6 6.1 10.2 100.0 970 35-39 66.0 24.5 2.3 3.2 4.0 100.0 1047 40-44 75.6 18.3 0.8 2.4 3.0 100.0 630 45-49 86.3 11.3 0.4 i.I 0.9 100.0 540 llelldence Urban 39.5 23.9 8.1 11.8 17.0 100.0 2181 Rural 69.7 16.9 6.1 4.8 2.6 100.0 3679 l~gion Khar toum 32.2 24.9 8.4 12.6 21.9 i00.0 1249 Northern 41.1 29.7 10.7 10.4 9.I I00.0 394 Eastern 71 . 4 14.1 5.2 4.5 4.8 I00.0 667 Central 56.0 24.1 7.4 7.1 5.4 100.0 1599 Kordofan 72.9 14.6 5.5 4.5 2,4 I00.0 908 Darfur 79.4 9.8 4.8 4.3 1.7 i00.0 1043 Total 58.4 19.5 6.8 7.3 7.9 i00.0 5860 Women who reside in urban areas have a higher level of education than those living in rural areas. The proportion of ever-married women who have no education is much higher in rural areas (70 percent) than in urban areas (40 percent). Conversely, the percentage who have senior secondary or higher education is more than six times higher in urban areas than in rural areas. Regarding differentials by region, educational attainment is higher in Khartoum than in any other region, with 13 percent having junior secondary schooling and 22 percent having attained senior secondary or higher education. The Northern region shows the next highest level of educational achievement (10 percent of women have attained junior secondary education and 8 percent senior secondary or higher). The proportion of women who have attended senior secondary or higher education in the other four regions ranges from 2 to 5 percent. Women in the Darfur region appear to be the most educationally disadvantaged. Migration The SDHS questionnaire provides information on the migration of respondents and the reasons for migration. Respondents were asked how long they had been living continuously in the place where they were interviewed. Those who had not always lived in that place were asked in which province they had lived just before moving to their current residence. Of the 5860 respondents interviewed, 2104 (36 percent) had moved either within the same province (intra-regional migration) or from one province to another (inter-provincial migration). It should be noted that migration refers to the most recent move to the current place of residence, and therefore does not necessarily reflect migration since birth or since the beginning of civil unrest. The results summarized in Table 2.8 indicate that most migration in northern Sudan was intemal, that is, intra-provincial (53 percen0 or inter-provincial (40 percent). Only a small 18 proportion of the migrants came from southern Sudan or from outside Sudan, mostly from neighbouring countries. Overall, about half of the migrants moved because of marriage, one-third moved for reasons related to employment, and one in ten moved in order to own or live in a better home. Reasons for migration varied by type of migration, although marriage and employment were important in all types of migration. Almost half the immigration from other countries and more than one-quarter of out-migration from the South was due to security problems. The other major reasons for out-migration from the South were employment (36 percent) and marriage (30 percent); among immigrants from other countries, marriage (26 percent) was more often cited as a reason for migrating thar, employment (20 percen0. About three percent of migrants in northern Sudan mentioned drought/desertification as the reason for moving. Type of migrat ion and reasons for migrat ion Table 2.8 Among ever-marr ied women who have migrated, the percent distr ibut ion by type and reason for migrat ion according to type of migration, Sudan DHS 1989-90 Within North South From Type of migrat ion/ Intra- Inter- to other All reason for migrat ion province province North countries migrants T~ of migrat ion 53.0 40.5 3.2 3.3 I00.0 Reason for migrat ion Marr iage 51.7 45.4 29.9 25.7 47.6 Employment 25.7 40.1 35.8 20.0 31.7 Living in own/ better home 12.6 5.4 6.0 1.4 9.1 Drought/desert i f icat ion 3.8 2.2 0.0 0.0 2.9 Security 2.7 i.i 28.4 47.1 4.3 Famine 0.2 0.4 0.0 0.0 0.2 Other/missing 3.5 5.4 0.0 5.7 4.2 Total percent i00.0 I00.0 I00.0 I00.0 i00.0 Number of women 1115 852 67 70 2104 Note: A migrant is def ined as a person who has not always l ived in the vil lage, town, or city in which she currently resides. Exposure to Radio Table 2.9 shows the percentage of ever-married women who are exposed to radio at least once a week, according to selected background characteristics. Slightly more than two-thirds of women in the sample listen to radio once a week, with only minor differences by age. Women 20-24 years old were most likely to listen to the radio (72 percent); those 45-49 years were least likely (64 percent). 19 Exposure to radio Table 2.9 Percentage of ever-marr ied women who l isten to radio at least once a week by background character- istics, Sudan DHS 1989-90 Listens Number Background to of character ist ic radio women a4m 15-19 67.9 380 20-24 72.1 938 25-29 67.9 1355 30-34 67.7 970 35-39 67.5 1047 40-44 65.2 630 45-49 64.4 540 Rel idenae Urban 84.2 2181 Rural 58.2 9679 Region Khartoum 86.9 1249 Northern 83.5 394 Eastern 61.5 667 Central 71.2 1599 Kordofan 61.1 908 Darfur 44.0 1043 Educat ion No educat ion 53.5 3425 Pr imary incomplete 84.1 1142 Pr imary complete 86.5 401 Junior secondary 91.1 427 Senior secondary+ 96.1 465 TotJd. 67.9 5860 The SDHS data indicate a positive relationship between education and exposure to radio. Ninety- six percent of women with senior secondary school or higher education listen to radio once a week compared with 54 percent of women who have never been to school. As expected, exposure to radio is related to residence; 84 percent of urban women listen to radio regularly compared with 58 percent of rural women. There are also substantial regional differences: approximately 90 percent of women who live in Khartoum listen to radio once a week compared with less than half of those in Darfur region. 2.7 CHARACTERIST ICS OF HUSBANDS The SDHS questionnaire included questions about the characteristics of husbands of respondents. For women who wen: no longer married (divorced or widowed), the questions referred to their most recent husband. Table 2.10 shows the percent distribution of ever-married women by husbands' background characteristics. About half of the respondents' husbands have no education, 19 percent have 20 Background character ist ics of husbands of respondents Table 2.10 Percent distr ibut ion of ever-marr ied women by husband's background charac- teristics, Sudan DHS 1989-90 Percent Husband's of ever- Number background marr ied of character ist ic women women Education No education 47.5 2782 Primary incomplete 19.2 1125 Primary complete 6.5 381 Junior secondary 9.6 563 Senior secondary+ 15.6 914 Don't know, Miss ing 1.6 95 L i termoy Reads easi ly 55.6 3260 Reads with di f f iculty 12.1 710 Cannot read 32.1 1881 Miss ing 0.2 9 Oooupatlon Professional, technical, or manageria l 8.6 504 Clerical 6.3 372 Sales 15.7 919 Agriculture: self- employed 24.4 1432 Agriculture: employee 8.6 503 Household domest ic 0.i 7 Services 16.8 982 Ski l led manual 12.3 719 Unski l led manual 6.1 357 Current ly not working 0.5 28 Miss ing 0.6 37 Couple'm literacy Both l iterate 35.4 2073 Husband literate, not wife 32.3 1894 Wife literate, not husband 2.9 172 Both i l l i terate 29.1 1705 Information incomplete 0.3 16 Total 1O0.0 5860 not completed primary, 7 percent have completed primary, 10 percent have junior secondary schooling and 16 percent have senior secondary or higher education. More than two-thirds of the husbands can read, although 12 percent read with difficulty. The level of education and literacy for husbands has improved since the Sudan Fertility Survey. According ~ the SFS, only 36 percent of husbands had attended school and 52 percent could read. It is interesting that both surveys reported a higher proportion of husbands who could read than the proportion who attended school (about 15 percent highe0 which suggests that some husbands acquired literacy 21 outside the formal educational system, probably in Khalwas, the religious schools. Regarding the joint literacy of spouses, couples are about equally divided into three groups: both the husband and the wife are literate (35 percent); the husband is literate and the wife is not (32 percent); and both the husband and the wife are illiterate (29 percent). Only 3 percent of couples are in the fourth possible category, that is, the wife is literate and the husband is not. Generally, husbands have more education than their wives and are more likely to be literate (see Table 2.6). The distribution of husbands by occupation reflects the fact that Sudan is mainly a country of subsistence farmers. Table 2.10 shows that self-employed agriculture is the most common single enterprise (24 percent), followed by service workers (17 percent), sales workers (16 percent) and skilled manual workers (12 percent). Nine percent of husbands were in the professional, technical and managerial category and the same proportion were in the agricultural employee category. Less than one percent of women reported that their husbands were unemployed. 22 CHAPTER 3 FERTILITY This chapter examines a number of issues related to fertility and childbearing, including fertility levels and trends, and the age at which women initiate childbearing. In the SDHS, a series of questions about live births was asked to obtain data on fertility. The wording and the sequence of the questions were designed so as to reduce errors commonly found in such surveys. First, the respondents were asked to report their total number of live births, the number of surviving children, and the number living at home and elsewhere. Second, a full birth history was collected from each woman, including the name, sex and date (year and month or season) of each live biRh, age at death for children who died, and for living children, whether or not they were residing with their mother. As an indicator of future fertility, all currently married women were also asked if they were pregnant. It has been observed that the estimation of fertility levels from birth histories can be affected by underreporting of the number of children ever bom, while errors of recall in reporting children's dates of birth can distort trends in fertility over time. Evidence from previous censuses and similar surveys in Sudan shows that female children are always underreported as compared with male children. The underreporting is due mainly to the omission of female children who died in infancy and those who married and left the parental home. Finally, some women with no surviving children are enumerated as childless. However, misreporting and misdating are less likely to be serious for time periods close to the date of the survey, which are the main focus of the analysis of the levels, trends, and differentials in fertility presented in this chapter. Despite efforts to eliminate the problems of misreporting of date of birth, there is evidence from the SDHS that births occurring five or six years prior to the survey were shifted to seven years prior to the survey, presumably to avoid asking an extensive series of questions in the health section for those children. In order to obtain data for all children under age five, questions related to health status were asked for all respondents' children bern since January 1, 1984. SDHS data on births indicate that 25 percent more births were reported as occurring in 1983 than in 1984. Displacement of this type has occurred in many of the DHS surveys (Arnold, 1990). For the purpose of this report data on trends in fertility that involve the year 1983 or 1984 should be regarded with caution. However, this problem most likely does not affect the rates for the five-year period prior to the survey. Finally, although the SDHS collected birth histories only from ever-married women, it is possible to calculate measures relating to all women regardless of marital status by assuming that women who were reported as having never married bad no children. While some births undoubtedly occur outside of marital unions, most observers agree that the level of nonmarital fertility is likely to be quite low in northem Sudan. 3.1 LEVELS AND DIFFERENTIALS IN FERT IL ITY Table 3.1 presents the total fertility rate (TFR) and the mean number of children ever bom (CEB) according to background characteristics of women. The TFR, which is an indicator of current fertility, is defined as the number of children a woman would give birth to by the end of her reproductive life if current age-specific rates were to stay constant. The first two columns of the table show the total fertility rates for two calendar year periods, 1987-90 and 1984-86 respectively, while the third column presents 23 Total fert i l i ty rates Table 3.1 Total fert i l i ty rates for women 15-49 for calendar year periods and the five years preceding the survey, and the mean number of chi ldren ever born to women 40-49, by background characterist ics, Sudan DHS 1989-1990 Total fert i l i ty rates Mean number of 0-4 chi ldren years ever born Background 1987- 1984- before to women character ist ic 1990 a 1986 survey age 40-49 Residence Urban 3.9 4.4 4.1 6.8 Rural 5.2 6.4 5.6 7.6 Region Khartoum 3.6 4.2 3.9 6.4 Northern 4.3 4.4 4.3 6.5 Eastern 5.0 6.0 5.5 7.5 Central 4.6 6.2 5.0 7.9 Kordofan 4.9 6.5 5.5 7,8 Darfur 5.7 5.9 5.9 7.0 Educat ion No educat ion 5.5 6.5 5.9 7.4 Pr imary 4.7 5.3 4.9 6.9 Secondary+ 3.3 3.1 3.3 4.8 Total 4.6 5.6 5.0 7.3 Note: Figures are calculated for all women (ever-married and never-married) 15-49 us ing information on women's age and marita l status from the household quest ionnaire and on the number of births from the woman's quest ionnaire. The pro- cedure assumes no births occur to never-marr ied women. alncludes exposure in 1990 up to the time of the interview. the total fertility rates for the five-year period before the survey. The last column of the table presents the mean number of children ever born to women 40-49 years old. The average number of children ever born is an indicator of cumulative fertility and reflects past fertility performance for these older women who are nearing the end of their reproductive lives. If no change in fertility has taken place, the two fertility measures (l't'g. and CEB) for women aged 40-49 would either be equal or very close to each other. Comparison of the TFR in the five years preceding the survey with the completed family size for older women (the last column in Table 3.1) suggests that fertility has been declining in the Sudan. The mean number of children ever born to women 40-49 is 7.3 while the TFR for the five years before the survey is 5.0 children per woman. The evidence of fertility decline can also be seen by comparing total fertility rates for the two calendar periods. The "l'rR of 4.6 per woman for the period 1987-1990 is 18 percent lower than the rate of 5.6 for the period 1984-1986. 24 Regarding fertility differentials, Table 3.1 shows that rural fertility is higher than urban fertility for all time periods, although the differential has narrowed in the most recent period. Based on births in the five years preceding the survey, rural women have on average 1.5 more births than women in urban areas (Figure 3.1). Women in the Khartoum and Northern regions have the lowest fertility. This is true whether the indicator is I1-K or the mean number of children ever born to women 40-49 years. For the five years preceding the survey, the lt-K in the Khartoum region was 3.9 compared with 5.9 in the Darfur region. Similarly, the mean number of children ever born is 6.4 and 6.5 for the Khartoum and Northern regions respectively, compared with 7.8 and 7.9 for the Kordofan and Central regions respectively. The decline in fertility is evident in all the regions. The sharpest decline is reported in the Kordofan and Central regions. F igure 3.1 Total Fertility Rate (TFR) and Mean Number of Children Ever Born (CEB) flESIUENCE Urban Rur l l REGION Khartoum Northern E&|terN CeNtral Kordoten Dertur EDUCATION NO Education Primary Secondary* IfFHIII I • 0-4 ye|ra brecadlng the survey 2 4 6 8 Number of B i r ths I ~TFf l . lOEB(Women40-49) i 10 8udan DHS 1989-90 The largest fertility differentials are associated with educational background. The "I'I~R in the five years preceding the survey was 5.9 for women with no education and 3.3 for those with junior secondary education and higher, a difference of 2.6 births. Similar differences are also observed when completed fertility is considered. Generally, differences are less significant between women with no education and those with primary education, than between women with primary education and those with junior secondary and higher education. Previous studies based on censuses and national surveys have shown that female education, specifically secondary and higher education, is negatively correlated with fertility. Women with higher education tend to delay marriage and have fewer children (see chapters 5 and 6). 3.2 FERT IL ITY TRENDS The fertility indicators in Table 3.1 suggest a substantial decline in fertility in recent years. Data from the birth histories eoRected in the SDHS make it possible to analyze fertility trends over a long period of time. 25 Table 3.2 shows age-specific fertility rates for successive five-year periods preceding the survey. Note that fertility rates are truncated due to the fact that the SDHS covered only women who were under 50 years of age at the time of the survey. Partially truncated rates are shown in brackets. Information in this table should be treated with caution due to the possible omission of or incorrect dating of events, especially by older women, for the more distant time periods. Age-speci f ic fert i l i ty rates for f ive-year per iods Table 3.2 Age-speci f ic fert i l i ty rates (per thousand women) for f ive-year per iods preceding the survey, by age of mother at the time of the birth, Sudan DHS 1989-1990 Number of years preceding survey Age at b i r th 0-4 5-9 10-14 15-19 20-24 25-29 30-34 15-19 69 112 134 188 218 203 20-24 183 246 303 329 314 [347] 25-29 240 310 339 326 [409] 30-34 236 277 296 [327] 35-39 157 199 [237] 40-44 82 [97] 45-49 [25] Total fert i l l ty rata 15-34 3.6 4.7 5.4 [5.9] Note: F igures in square brackets are part ia l ly truncated rates. [1561 Table 3.2 indicates that fertility has been declining gradually during the 20 to 25 years preceding the survey. The decline is most pronounced in the ten-year period preceding the survey, particularly for women 15-34. For example, women would have had an average of 5.9 children by the age of 35 during the period 15-19 years preceding the survey, the rate was 5.4 for the period 10-14 years preceding the survey, and 4.7 for the period 5-9 years preceding the survey. The decline accelerated between the periods 5-9 and 0-4 years prior to the survey, when fertility dropped from 4.7 to 3.6 children, a decrease of 23 percent. Another approach in considering fertility trends is to compare the SDHS rates with those obtained from the Sudan Fertility Survey (SFS) conducted in 1978-79 (Sudan, 1982). Table 3.3 presents the age- specific and total fertility rates for both surveys. Note that the SFS and SDHS rates are both based on information derived from complete birth histories and refer to the five years preceding the surveys. Comparison of data from the two surveys further supports a major decline in fertility during the last ten years. The "I'I-R has declined by one birth in the inter-survey period, dropping from 6.0 children per woman in the SFS to 5.0 children in the SDHS. Figure 3.2 also shows that for every age group except women 35-39, the age-specific fertility rates from the SDHS are lower than those from the SFS. The fertility decline is most evident among women 15-24. 26 Comparison of age-speci f ic fert i l i ty rates r SFS and SDHS Table 3.3 Age-specl f ic fert i l i ty rates (per thousand women) and total fert i l i ty rate for women 15-49, Sudan Fer- t i l i ty Survey (SFS) 1978-79 and Sudan DHS 1989-90 SFS SDHS Age 1978-79 a 1989-90 15-19 114 69 20-24 264 183 25-29 283 240 30-34 251 236 35-39 149 157 40-44 108 82 45-49 35 25 Total fert i l i ty rate 6.02 4.96 Note: Figures are calculated for all women (ever-married and never married) 15-49 using information on women's age and marita l status from the household quest ionnaire and on the number of b ir ths from the woman's quest ion- naire. The procedure assumes no births occurred for never-marr led women. Rates refer to the five years preceding the survey. asudan (1982) Ministry of Nat ional Planning, Department of Statistics, The Sudan Fert i l i ty Survey 1979, Principal Report, Vol. I, Table 5.18 The rapid decline in the 'I'I~R in Sudan is due to many factors, but can be attributed mainly to major changes in the marriage patterns: increasing age at first marriage, a sharp drop in the proportion ever married among women 20-29, and a slight increase in polygyny since the SFS, especially among women over 40 (see chapter 5). Among all of the countries in Africa that conducted DHS surveys, the rise in the median age at first marriage between women age 35-39 and 25-29 was sharpest in Sudan. The age at first birth has also increased substantially since the SFS (see section 3.5 below). Although contraceptive use has almost doubled in the last ten years (see chapter 4), use of modem contraceptive methods among married women is still low; therefore, changes in contraceptive use have not had much impact on fertility. It cannot be ruled out that fertility control among couples may be more prevalent than reported in the SDHS, but there is no evidence to support this argument. Other factors which may have had an impact on the fert'tiity decline in Sudan are: an increase in urbanization, a rapid increase in male and female education, and the temporary migration of husbands to work in Saudi Arabia and the Gulf states. Despite remittances from labour migrants, Sudan has experienced severe economic conditions for more than five years (partly due to drought). It is known that economic factors can affect fertility desires and behaviour, thus, it is possible that economic conditions have contributed to the fertility decline. Further investigation is needed to clearly delineate the causes of fertility decline in Sudan. 27 Figure 3.2 Age-Specific Fertility Rates SFS and SDHS Births per 1000 women 300 250 200 150 100 50 0 15-19 ; , : 6.0) (TFR: 6.0) 20-24 25-29 30-34 35-39 40-44 45-49 ~e I *- $FS 1978-79 - - SOHS 1989-90 m 8udlln OH8 19119-90 3.3 CURRENTPREGNANCY Another measure of current fertility is the proportion of women who are pregnant. This represents, in a sense, the most current level of fertility since it actually anticipates fertility during the next few months. However, this measure of current fertility should be treated with caution because it is an underestimate. Some women in the early stages of pregnancy may be unaware or uncertain that they are pregnant; others may deliberately avoid mentioning their status due to local customs and tradition. Table 3.4 shows the percentage of all women and currently married women reporting a current pregnancy by age. Overall, 16 percent of currently married women and 9 percent of all women reported being pregnant. There was no change in the proportion pregnant among married women between the SFS and the SDHS; however, the proportion pregnant among all women has declined slightly (from 10 to 9 percent). 28 Current ly pregnant women Table 3.4 Percentage of all women and currently marr ied women 15-49 who reported a current pregnancy by age, Sudan Fert i l i ty Survey (SFS) 1978-79 and Sudan DHS 1969-90 Current ly All women I marr ied women SFS SDHS SFS SDHS Age 1978-792 1989-90 1978-792 1989-90 15-19 5.1 3.8 25.1 24.5 20-24 ii.I i0.0 18.5 22,4 25-29 11.2 14.0 18.1 20.3 30-34 15.9 12.1 18.0 14.9 35-39 14.4 11.4 16.5 13.0 40-44 6.7 5.8 8.0 7.0 45-49 1.8 2.6 2.3 3.1 Total 10.4 9.0 16.3 16.0 1Assumes no pregnanc ies among n6ver -~ar r ied women, 2Sudan (1982) Ministry of Nat ional Planning, Department of Statistics, The Sudan Fert i l i ty Survey, 1979, Pr incipal Report, Vol. I, Table 5.15 3.4 CHILDREN EVER BORN Information on the number of children ever bom is presented in Table 3.5 for all women and for currently married women. (Note: For all women, it is assumed that never-married women had no births.) These data, which reflect the cumulation of births over time, show that on average, all women have had 2.7 children, while currently married women have had 4.5. The difference in fertility between the two groups is mainly due to the large proportion of never-married women in the younger age groups. The mean number of children ever born increases with age, reflecting the natural family building process. For example, among all women, the average number of live births for the age group 25-29 was 2.2, while women 35-39 reported an average of 6.0 live births. At the end of their reproductive life at age 45-49, the mean number of children ever bom for all women was 7.5. The results show that early childbearing is relatively rare since fewer than 10 percent of teenagers (15-19) have had a child, compared to 37 percent of women 20-24. The proportion of women who have never given birth can be taken as a measure of primary sterility. Only 2 percent of currently married women 45-49 have never given birth. This is down from 8 percent reported in the SIS 1978-79. The difference in the proportion of childless women between the two surveys may be explained by a possible reduction in primary sterility because of improved health conditions. 29 Chi ldren ever born Table 3.5 Percent distr ibut ion of all women and currently marr ied women 15-49 by number of chi ldren ever born (CEB), according to age, Sudan DHS 1989-1990 Number of chi ldren ever born Mean Number Total number of Age None 1 2 3 4 5 6 7 8 9 1O+ percent CEB women ALL WOMEN 15-19 91.3 6.1 2.1 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.I 2386 20-24 62.9 14.0 11.2 6.7 3.8 I.i 0.2 0,O 0,0 0.0 O.0 i00.0 0.8 2049 25-29 84.2 11.6 12.4 19.9 11.5 9.2 4.2 2.2 0.7 8.i 0.i 100.0 2.2 ]878 30-34 17.1 6.2 7.6 i0.5 12.8 12.9 11.9 10.3 5.4 3.0 2.3 1O0.0 4.1 ]117 35-39 7.9 3.3 4.0 6.8 8.6 11.5 II.0 11.8 13.5 9.5 12.3 100.0 6.0 ]106 40-44 7.0 2.6 3.2 4.6 6.3 6.6 8.3 ii.i 11.4 12.8 26.0 I00.0 7.0 650 45-49 4.4 2.4 2,6 4.0 3.8 7.3 9.9 9.0 12.6 15.8 29.1 100.0 7.5 547 Total 45.8 8.1 6.9 6.7 6.1 5.7 4.6 4.2 3.8 3.2 5.8 I00.0 2.7 9732 CURRENTLY MARRIED WOMEN 15-19 45.0 38.4 13.6 2.7 0.0 0.3 0.0 0.O 0.0 0.0 0.0 100.0 0.8 367 20-24 19.1 30.I 23.9 15.3 8.4 2.3 0.6 0.0 0.I 0.I 0.0 100.0 1.7 900 25-29 8.1 14.6 17.2 19.4 16.8 13.2 6.2 3.2 i.I 8.2 0.I i00.0 3.1 ]276 30-34 3.9 6.5 8.3 11.4 14.8 15.2 14.5 12.5 6,5 3.8 2.8 i00.0 4.8 906 35-39 1.7 3.1 3.5 6.4 8.7 12.6 11.8 13.0 14.9 10.6 13.8 100.0 6.5 955 40-44 3.3 2.2 2.4 4.1 5.5 6.6 7.9 11.8 12.0 14.2 30.0 100.0 7.6 543 45-49 2.0 1.5 2.2 3.3 3.3 7.3 9.7 8.2 13.7 15.7 33.1 180.0 8.0 453 Total 9.6 13.1 11.4 ii.I I0.2 9.6 7.7 7.0 6.4 5.3 8.7 i00.0 4.5 ,5400 Table 3.6 presents the mean number of children ever bom to ever-married women by age at first marriage and duration of marriage. Since use of contraception is limited and premarital conception is negligible, the number of children a woman bears depends largely on the age at which she marries and the duration of her marriage. Therefore, women who marry at a young age will give birth to more children than women who marry later because they are exposed to the risk of pregnancy for a longer time. The data show that, overall, women married before age 15 have more children (an average of 5.8) than women married between age 20 and 21 (3.2 children). However, the pattern is not present when controlling for duration since first marriage. For marriage durations less than 15 years, age at marriage has no effect on the number of children ever born, except for women married at age 25 or over. Among women with longer marriage durations, marrying at a later age has only a small negative effect on fertility. 3.5 AGE AT F IRST B IRTH The age at which women start childbearing is an important demographic and health indicator and in most countries is closely associated with age at first marriage. The data on age at first birth are affected by reporting errors, such as misreporting the woman's age, underreporting of first births, and misreporting the first child's date of birth. Such errors are usually more pronounced among older women. 30 Chi ldren ever born by age at first marr iage Table 3.6 Mean number of chi ldren ever born to ever-marr ied women, by age at first marr iage and years since first marriage, Sudan DHS 1989-1990 Years since first marr iage Age at first marr iage <15 15-17 18-19 20-21 22-24 25+ Total 0-4 0.9 0.9 0.8 0.9 1.0 0.8 0.9 5-9 2.5 2.7 2.7 2.5 2.5 2.5 2.6 10-14 4.2 4.6 4.4 4.4 4.5 3.0 4.3 15-19 5.7 6.0 5.7 5.7 5.3 4.1 5.7 20-24 6.9 7.3 7.5 5.7 5.1 5.7 7.0 25-29 8.0 7.7 7.6 6.7 8.7 NA 7.8 30+ 8.4 8.1 10.2 NA NA NA 8.3 Total 5.8 4.6 3.8 3.2 2.6 2.0 4.4 NA = Not applicable; by def in i t ion these women would be age 50 or over. Table 3.7 shows the percent distribution of women by age at first birth according to their current age. The median age at first birth is presented for all cohorts in which at least 50 percent of the women had a first birth (i.e., age groups 25-29 and above). Overall, one-third of women had their first child before age 20, and slightly less than one-quarter had their first birth before reaching age 18. These proportions measure the magnitude of teenage pregnancy, which is a major concem of health profes- sionals. Women are at greater risk of dying from the complications of pregnancy and delivery below the age of 20 and above the age of 34. Also, early childbearing usually results in women having larger families, which can have a negative effect on socioeconomic status and the participation of women in the labour force. However, there is evidence of a trend toward delayed childbearing in Sudan. For example, while more than half of the women 45-49 (53 percent) had given bi~h before reaching age 20, only one- quarter of those 20-24 (26 percent) had done so. Overall, the median age at first birth is 20.5 years. The trend across age cohorts suggests a substantial increase from the oldest to the youngest cohorts. Indeed, the median age at first birth rose from 18.9 years for women age 40-44 to 22.8 years for those age 25-29. Table 3.8 shows the median age at first birth among women age 25-49 years by current age and background characteristics. Urban women begin childbearing much later (21.5 years) than rural women (20 years). With respect to regional differences, the Northern (22.8 years) and Khartoum (21.3 years) regions have the highest median age at first birth, and the Eastern region (19.6 years) has the lowest. In the three other regions, the median age at first birth is slightly below the overall median. Differences in median age at first birth are particularly large with respect to educational level. Women with no education have the lowest median age at first birth (19.2 years); women with primary and secondary education have the highest (20.4 and 28.2 years, respectively). The association is most evident for women age 25 to 39. 31 Age at first b i r th Table 3.7 Percent d ist r ibut ion of women 15-49 by age at first birth, according to current age, Sudan DHS 1989-1990 Women Age at first birth Median with Number age at Current no Total of first age births <15 15-17 18-19 20-21 22-24 25+ percent women birth a 15-19 91.3 1.5 5.5 1.7 0.0 0.0 0.0 10O.0 2386 b 20-24 62.9 4.8 12.2 9.2 7.4 3.6 0.0 100.0 2049 b 25-29 34.2 6.9 16.6 12.8 10.3 13.3 6.0 I00.0 1878 22.8 30-34 17.1 10.3 23.8 10.7 12.7 13.9 11.5 100.0 1117 20.8 35-39 7.9 13.4 24.3 15.9 13.5 13.0 12,0 i00.0 1106 19.5 40-44 7.0 14.2 28.8 17.5 10.5 11.5 10.5 100.0 650 18.9 45-49 4.4 12.6 22.1 18.1 14.1 11.9 16.8 100.0 547 19.8 TotAl 45.8 7.1 15.8 10.0 8.0 7.8 5.5 100.0 9732 20.5 c aDef ined as the exact age by which 50 percent of women hays had a birth. b (~i t ted for age-groups 15-19 and 20-24 because less than 50 percent of the wom~n in these age groups have had a birth. eBased on data for women 25-49 years. Median age at first b i r th by background character ist ics Table 3.8 Median age at first birth among women 25-49, by current age and background characterist ics, Sudan DHS 1989-1990 Current age Background character ist ics 25-29 30-34 35-39 40-44 45-49 Total Rmmiaen~ Urban 25.6 21.8 28.1 18.6 19.1 21.5 Rural 21.2 19.9 19,2 19.1 20.1 20.0 P, gqion Khartoum 25.4 21.7 28.0 18.6 19.1 21.3 Northern 24.9 23.1 21.2 20.8 20.1 22.8 Eastern 20.8 18.9 17.8 17.2 19.8 19.6 Central 22.9 20.3 19.2 18.2 18.7 20.1 Kordofan 23.0 20.9 18.6 18.7 19.8 20.4 Darfur 20.3 20.3 20.2 19.6 20.8 20.3 ZduaAt lon NO educat ion 19.6 19.0 19.0 18.8 19.7 19.2 Pr imary 21.3 20.5 19.7 18.8 20.1 20.4 Secondary+ a 27.0 24.2 21.8 (19.9) 28.2 Total 22.8 20,8 19.5 18.9 19.8 20.5 Note: Median is def ined as the exact age by which 50 percent of the women have had a birth. Numbers in parentheses are based on fewer than 20 cases cases. aLess than 50 percenf of the women have had a birth. 32 CHAPTER 4 FERTILITY REGULATION Information on contraceptive use is of particular interest to policymakers, programme managers, and researchers in population and family planning. This chapter describes women's knowledge of family planning methods and sources where they can be obtained, women's perceptions of problems with particular methods, and use or contraception. Differentials in knowledge and use are also discussed. 4.1 KNOWLEDGE OF FAMILY PLANNING METHODS AND SOURCES Familiarity with contraceptive methods and sources for methods are among the prerequisites for the adoption of fertility regulation. The Sudan Demographic and Health Survey (SDHS) provides information on the level of knowledge of family planning methods and providers of family planning services. Data on knowledge of contraceptive methods were collected by asking a series of questions in the individual questionnaire. The respondent was asked to name the methods or ways a couple could use to avoid or postpone pregnancy. The interviewer then read a brief description of specific methods, omitting those that the respondent had already mentioned, and asked whether the respondent had ever heard of the method. The questionnaire included seven specific modem methods: the pill, IUD, injection, vaginal methods (jelly, diaphragm or foam), condom, female sterilisation and male sterilisation. Two traditional methods, rhythm or periodic abstinence and withdrawal, were included. Any other methods mentioned by respondents, such as herbs or breastfeeding, were also recorded. To determine knowledge of sources of contraceptive methods, for each modem method the respondent recognized, she was asked where she would go to obtain the method if she wanted to use it. Women who reported knowing about rhythm were asked, "Where would you go to obtain advice on periodic abstinence?" Table 4.1 indicates that 71 percent of currently married women 1 have heard of at least one family planning method. The most widely known method is the pill; almost all women who knew of a method had heard about the pill. Less than half of the women knew about any of the other methods. About 45 percent had heard of female sterilisation and injection, and 39 percent know about the IUD. Knowledge of other modem methods was low: condom (18 percent), vaginal methods (8 percent) and male sterilisation (5 percent). Four in ten women knew a traditional method, mainly periodic abstinence (36 percent), while less than one in five (19 percent) reported knowledge of withdrawal. In the last ten years, contraceptive knowledge has increased substantially. Since the Sudan Fertility Survey 1978-79, the level of knowledge (of at least one method of family planning) has risen from 51 percent to 71 percent among currently married women. The proportion of women who have heard of the pill has increased from less than 50 percent in the late seventies to 70 percent in 1990. Knowledge of other methods also increased substantially: the proportion knowing about injection, vaginal methods, and male and female sterilisation doubled, and awareness of the condom, IUD, periodic abstinence, and withdrawal tripled. 1 The results for ever-married and currently married women are almost identical. 33 Knowledge of contraceptive methods Table 4.1 Percentage of currently married women who know a specific contraceptive method, Sudan Fer- tility Survey 1978-79 and Sudan DHS 1989-90, and the percentage who know a source for specific methods, Sudan DHS 1989-90 Know method Method of SFS I SDHS Know contraception 1978-79 1989-90 source Any method 50.8 71.4 60.5 An~ modern method 49.8 70.8 59.2 Pill 47.9 69.9 54.5 IUD 13.9 39.0 33.0 Injection 25.0 45.6 36.0 Vaginal methods 3.0 7.8 5.9 Condom 6.0 17.8 13.4 Female sterilisation 23.8 44.1 40.1 Male sterilisation 2.7 5.i 4.2 Any trlditional method 14.4 38.7 34.5 Periodic abstinence 9.5 36.0 34.5 Withdrawal 5.1 19.3 NA Other methods 1.8 4.1 NA N~r of women 2859 5400 5400 Iunited Nations (1987). Department of International Economic and Social Affairs. Population Division. Fertility Behaviour in the Context of Development, Table 80 The results presented in Table 4.1 also show that 60 percent of married women know where to go to get a modem method of contraception. In the SFS only 23 percent of currently married women reported knowing a source of family planning. (SFS respondents were not asked to name a source for vaginal methods or male sterilisation.) Knowledge of sources for specific methods shows substantial improvements between the SFS and the SDHS. For example, the overwhelming majority of women in the SDHS who had heard of female sterilisation also knew where to go to get the operation (44 percent knew the method and 40 percent knew a source). For other modem methods, around three-quarters of the women who knew a particular method also knew where to obtain it. Almost everyone who recognized periodic abstinence (36 percent) mentioned someone or some place where they could seek information about the method (35 percent). In contrast, the SFS results indicated that less than half of those who knew about the pill, and only 28-30 percent of those aware of female sterilisation, injection, the IUD or the condom could name a source for the method (not shown in the table). 34 The percentage of married women who knew at least one modem contraceptive method and a source is presented in Table 4.2 by background characteristics. There were only small differences in knowledge of modem methods by age: 67 percent of the youngest women knew a modem method, 75 percent of those 20-24, and 65 percent of women 45-49. Knowledqe of modern contraceptive methods Table 4.2 Percentage of currently married women who know at least one modern method and the percentage who know a source for a modern method, by background characteristics, Sudan DHS 1989-90 Know Number Background modern Know of characteristic method source women A~Q 15-19 67.3 54.5 367 20-24 75.0 64.6 908 25-29 72.5 61.5 1276 30-34 72.7 58.8 906 35-39 69.1 57.8 955 40-44 67.2 55.2 543 45-49 64.9 53.9 453 Residence Urban 91.3 83.4 1979 Rural 59.0 45.1 3421 Region Khartoum 96.3 91.6 1136 Northern 97.8 88.5 365 Eastern 60.2 46.9 616 Central 88.2 69.9 1480 Kordofan 62.7 41.2 828 Darfur 30.5 17.0 975 Eduo&tion No education 54.2 38.8 3130 Primary incomplete 90.8 82.1 1061 Primary complete 91.7 84.8 374 Junior secondary 97.0 91.6 405 Senior secondary+ 99.5 97.9 430 Total 70.8 59.2 5400 There was greater variability in the level of contraceptive knowledge by residence and region. Nine in ten urban women knew at least one modem family planning method, compared with six in ten rural women. Knowledge of a modem method was almost universal in the Khartoum (96 percent) and Northern regions (98 percent), high in the Central region (80 percent), below the national average in the Eastern and Kordofan regions (60 and 63 percent, respectively), and lowest in the Darfur region (31 percent). Differentials in knowledge by education were also striking. Among women with no schooling, only 54 percent knew a modem method, compared with over 90 percent of women with primary education, and almost all women with higher education. In fact, the differences in knowledge by 35 education may account, in large part, for the differences in knowledge by residence and region, since the more educated women tend to live in urban areas, especially Khartoum. Differentials in knowledge of service providers follow the patterns noted above for knowledge of modem methods. Between 54 and 65 percent of married women knew a source for a modern contraceptive method. Urban women were more likely to know a source (83 percent) than rural women (45 percent). The Khartoum (92 percent) and Northern regions (89 percent) bad the highest proportion of women knowing at least one family planning source, and the Darfur region (17 percent), the lowest. It should be noted that knowledge of service providers depends to a large extent on the existence of service points and access to them in an area. Therefore, the small proportion of women in Darfur who knew a source for contraception may be partly due to the paucity of sources and the difficulty in reaching those sources. 4.2 KNOWLEDGE OF FERTILE PERIOD A basic understanding of the ovulatory cycle and an awareness of the fertile period is important for practising certain family planning methods, especially periodic abstinence or "the safe period." Periodic abstinence, as noted above, is one of the better-known methods in Sudan, with more than one- third of ever-married women having heard of it. To obtain data on knowledge of the safe period, all respondents were asked when in the monthly cycle women have the greatest chance of becoming pregnant. Table 4.3 presents the dis- tribution of all ever-married wom- en and women who have ever used periodic abstinence by their knowledge of the fertile period. The most common response, giv- en by 43 percent of all ever-mar- ried women, was "don't know." Only 29 percent of ever-married women correctly identified the middle of the cycle as the time a woman is most likely to get preg- nant and one in four believes that the most fertile time in the ovula- tory cycle occurs just after the pe- riod ends. Knowledge of the fertile period is much more accurate a- mong ever-users of periodic absti- nence. Almost three of every four ever-users correctly identified the fertile period as falling in the mid- die of the ovulatory cycle, while only 3 percent of ever-users re- ported that they did not know Knowledge of the fert i le period Table 4.3 Percent distr ibut ion of ever-marr ied women and wo~e~ who have ever used per iodic abst inence by knowledge of the fert i le per iod during the ovulatory cycle, Sudan DHS 1989-90 Fert i le per iod EveK- Ever- users of marr ied per iodic women abst inence Correct knowl~e of fert i le per iod Middle of the cycle 29.2 72.1 Doubtful knowle4h~e After per iod ends 24.5 22.3 Before per iod begins 2.0 1.9 Zr=oneouB knowledge During per iod 0.4 0.3 At any t ime 0.6 0.I Other 0.2 0.I Don't kDow 43.1 3.1 Tota l peraent I00.0 I00.0 Number of womon 5860 678 36 when the fertile period occurs. As the response, "afar the period ends" is not very specific, some women who answered, "a few days after the period ends" or something similar, may actually have accurate knowledge; therefore in Table 4.3, this category is shown as "doubtful knowledge." About one percent of ever-married women and ever-users had completely erroneous knowledge of the fertile period and gave responses such as "during her period" or "at any time." 4.3 KNOWLEDGE OF SOURCES FOR SPECIF IC CONTRACEPT IVE METHODS Table 4.4 presents the percent distribution of women who knew specific contraceptive methods by the service provider mentioned as a source for each method. For the pill, IUD and injection, the proportion of women mentioning private and public sources was about equal. Public sources were cited more frequently than private for female and male sterilisation. The majority of women who knew about vaginal methods and the condom mentioned providers in the private sector. Knowledge of source of supply for specif ic methods Table 4.4 Percent distr ibution of women knowing a contraceptive method by supply source they say they would use, according to specif ic methods, Sudan DHS 1989-90 Vagi- Female Male Periodic Injec- hal Con- steri l i- steri l i - absti- Supply source Pill IUD tion methods dom sation sation hence 1 Publ ic 37.8 42.8 39.6 20.7 18.I 63.2 48.7 7.0 Government hospital 15.7 30.3 22.6 4.6 3.0 61.2 46.7 1.6 Government health centre 14.4 6.6 9.9 5.7 2.2 0.7 1.3 1.2 Dispensary 1.3 0.3 0.7 0.2 0.3 0.3 0.0 0.I Mobile clinic 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.2 Other health facil ity 0.5 0.1 0.4 0.2 0.8 0.i 0.0 0.2 Family p lanning clinic 5.9 5.5 6.0 I0.0 4.3 0.7 0.7 3.7 PEiv&te 40.1 41.7 39.4 54.3 65.9 27.6 35.3 80.9 Private doctor 12.6 38.5 28.4 12.4 5.0 25.9 31.7 16.5 Private hospital 0.2 1.0 1.2 0.2 0.4 1.1 1.7 0.2 Pharmacy 26.6 2.0 9.5 40.4 59.5 0.3 0.7 0.1 Friends/relat ives 0.6 0.0 0.i 0.7 0.7 0.2 1.3 61.2 Other 0.I 0.i 0.i 0.7 0.3 0.I 0.0 2.9 ~eol f f ied mesca l fac l l i t i e | O. 0 O. 0 O. 0 O. 0 O. 0 0 .0 O. 0 8 .0 ~nQl&i mi l led 22.1 15.6 21.0 25.0 24.1 9.2 16.0 4.0 Don't know 21.9 15.4 20.4 24.6 23.3 8.3 15.3 3.5 Miss ing 0.2 0.1 0.6 0.4 0.8 1.0 0.7 0.5 Total pez~ent 100.0 100.0 100.0 100.0 100.0 100.0 I00.0 I00.0 Nu~z of women 4103 2301 2674 460 1022 2592 300 2100 IRefers to the place women say they could go to obtain advice on periodic abstinence. 37 Pharmacies were perceived as a major source for supply methods, namely, condoms (60 percent), vaginal methods (40 percent), and the pill (27 percent), while government hospitals and private doctors were the main service providers for clinical methods. Government hospitals were cited as major sources for female sterilisarion (61 percent), and male sterilisation (47 percent) and were mentioned by a substantial proportion of women for the IUD (30 percent) and injection (23 percent). Private doctors are cited more frequently for the IUD (39 percent) and injection (28 percen0 but are less popular than government hospitals for male and female sterilisation (32 percent and 26 percent, respectively). Private doctors were also mentioned as a source for information about periodic abstinence by 17 percent of women. Family planning clinics have less importance as service providers; only a small proportion of women mentioned family planning clinics as sources for supply methods (4 to 10 percent). Relatives and friends (61 percent) were the primary source for information about periodic abstinence. It should be noted that for each method a substantial minority of women did not report any source. One in seven women mentioned no service provider for the IUD and male sterilisation; one in five did not know where to obtain the pill or injection; and almost one in four did not know where condoms and vaginal methods could be obtained. 4.4 PROBLEMS PERCEIVED WITH CONTRACEPT IVE METHODS In order to understand the problems women associate with the use of family planning methods, respondents in the SDHS were asked to report the main problem, if any, with using each method that they had heard of. Table 4.5 shows the distribution of women who knew specific methods, by the main problem they perceived in using each method. From one-half to two-thirds of women who were asked the question reported either "don't know" or "none" (no problem). Problems perce ived in usin~ speci f ic methods Table 4.5 Percent d ist r ibut ion of ever-marr ied women who know a specif ic contracept ive method by the main problem perceived in using the method, Sudan DHS 1989-90 Vagi- Female Male Per iodic Main problem InJec- hal Con- steri l i - ster i l i - abst i - With- perce ived Pi l l IUD tion methods dom sation sation nence drawal None 16.6 14.6 18.9 22.0 22.1 35.6 18.0 50.4 28.7 Not effect ive 1.0 9.6 2.5 10.7 12.6 2.4 1.7 24.3 6.2 Husband disapproves 1.3 0.7 I.I 2.6 14.5 2.6 8.7 6.1 33.4 Others disapprove 0.I 0.I 0.0 0.0 0.I 0.0 0.3 0.2 0.l Health concerns 46.6 40.4 30.6 i0.0 3.8 7.9 4.3 0.4 1.2 Inaccessib i l i ty / lack of availability 0.5 0.i 0.B 0.9 0.3 0.0 0.0 0.O 0.0 High cost 0.0 0.I 0.0 0.0 0.0 0.1 0.0 0.0 0.0 Inconvenient to use 9.I 3.9 0.5 6.7 6.2 0.3 1.0 1.4 6.9 Permanent method 0.I 0.2 1.0 0.0 0.3 18.6 19.0 0.9 0.0 Rel ig ion 0.6 0.2 0.5 0.2 0.6 2.6 6.7 0.4 0.7 Other 0.2 0.1 0.I 0.0 0.2 0.I 1.0 0.0 0.4 Don't know 32.7 30.6 43.2 46.3 38.4 28.6 39.0 15.1 20.4 Miss ing 0.2 0.2 0.7 0.7 1.0 1.2 1.3 0.7 1.9 Tota l ~t~nt I00.0 I00.0 i00.0 100.0 I00.0 100.O i00.0 i00.0 i00.0 N ~ r of woman 4103 2301 2674 460 1022 2592 300 2100 1121 38 Focusing on specific responses, health concerns were the most frequently cited problem regarding the pill (47 percent), IUD (40 percent) and injection (31 percent). Irreversibility was the major problem (19 percent) reported in using female and male sterilisation. Other responses regarding sterilisation included health concerns for female sterllisatlon (8 percent), and husband's disapproval (9 percent) and religion (6 percent) for male sterilisation. Husband's disapproval was the most commonly mentioned problem with the condom (15 percent) and withdrawal (33 percent). "Not effective" was reported as a problem for the condom (13 percent) and the IUD (10 percent) and was the most frequently mentioned problem with vaginal methods (11 percent) and periodic abstinence (24 percent). Around 6 percent mentioned husband's disapproval as the major problem with periodic abstinence, and the same proportion reported inconvenience as the major problem with the condom, withdrawal, and vaginal methods. In summary, the findings in Table 4.5 suggest that the high proportion of women who reported health concerns for the pill, IUD, and injection underscores the need to provide information and assurance to current and potential users of these methods. Male methods, especially the condom and withdrawal, but also male sterilisation and periodic abstinence, were less acceptable to women because their husbands disapproved of them. 4.5 EVER USE OF CONTRACEPTION In the SDHS, all respondents were asked if they had ever used the methods they reported knowledge of. As shown in Table 4.6, almost one-fourth (24 percent) of ever-married women have used a method to regulate their fertility at some point in their lives. Eighteen percent have used a modem method and 14 percent have used a traditional method; thus, the majority of ever-users have had experience with a modem method and some have used two or more methods. Currently married women have about the same level of ever-use (25 percent) as ever-married women. Ever use of contraception among currently married women is almost twice as high in the SDHS as in the SFS (13 percent). The age differentials for ever-use show that among currently married women, the lowest rate of ever-use (9 percent) occurred among the youngest women, those age 15-19; the highest rate (31 percent) was found among women age 30-34. Except for age group 30-34, about 25 percent of currently married women between 20 and 44 years have tried some method for controlling fertility. Twenty-three percent of the women in their late forties have had some experience with family planning (the overwhelming majority of them with modem methods). Two methods, the pill (17 percent) and periodic abstinence (12 percent), are used most commonly; less than 5 percent of women have ever used any other method---withdrawal (4 percent), condom, IUD, and "other" methods (2 percent), and 1 percent injection or sterilisation. 39 4~ O Ever use of contracept ion Table 4.6 Percentage of ever-marr ied women and currently marr ied women who have ever used a contracept ive method, by specif ic method according to age, Sudan DHS 1989-90 Modern method Tradit ional method Any Vagi- Female Any Per iodic With- Any modern Injec- nal Con- steri l i - t rad' l abst i - draw- Age method method Pil l IUD tion methods dom sation method nence al Other Number of women EVER-MARRIED WOMEN 15-19 8.9 5.3 4.7 0.3 0.0 0.0 0.5 0.0 6.6 4.7 1.8 0.6 380 20-24 24.1 14.1 13.2 0.5 0.7 0.2 2.0 0.0 16.1 13.1 4.5 i.i 938 25-29 25.7 18.5 17.0 1.4 i.i 0.2 1.3 0.i 15.0 12.1 4.2 1.9 1355 30-34 30.1 23.3 21.4 2.7 1.4 0.5 3.0 1.2 18.6 15.2 6.1 2.8 970 35-39 25.3 20.2 19.6 2.2 0.8 0.4 2.3 0.7 13.5 Ii.I 3.0 2.4 1047 40-44 24.6 19.4 17.6 1.7 1.4 0.5 1.7 2.4 12.7 Ii.i 1.9 2.1 630 45-49 20.6 18.3 16.3 1.3 1.7 0.4 1.9 2.2 9.8 7.4 2.4 1.3 540 Total 24.4 18.1 16.8 1.6 i.i 0.3 1.9 0.8 14.2 11.6 3.8 1.8 5860 CURRENTLY MARRIED WOMEN T~al 25.2 18.6 17.3 1.6 I.i 0.4 2.0 0.8 14.9 12.1 4.0 1.9 5400 15-19 9.0 5.4 4.9 0.3 0.0 0.0 0.5 0.0 6.5 4.6 1.9 0.6 367 20-24 24.3 14.2 13.4 0.6 0.8 0.2 2.0 0.0 16.3 13.2 4.6 1.0 900 25-29 26.2 18.7 17.4 1.4 1.0 0.2 1.4 O.l 15.4 12.4 4.3 2.0 1276 30-34 31.1 24.0 22.2 2.5 1.5 0.6 3.1 1.3 19.5 15.9 6.5 3.0 906 35-39 26.3 20.9 20.2 2.3 0.7 0.4 2.4 0.7 14.2 11.7 3.1 2.5 955 40-44 26.0 20.3 18.4 2.0 1.5 0.6 1.7 2.6 13.8 12.0 2.0 2.5 543 45-49 22.5 20.3 17.9 1.5 1.8 0.4 2.0 2.4 10.4 8.2 2.4 1.3 453 4.6 CURRENT USE OF CONTRACEPT ION Only currently married women were asked if they were using any contraceptive method at the time of the survey. The contraceptive prevalence rate reported by the SDHS is 9 percent, which, though low in comparison with many developing countries, 2 is almost double the level reported in the SFS (5 percent) (Table 4.7). The pill, the most widely known method, is also the most widely used (4 percent), accounting for more than 40 percent of contraceptive use in Sudan. The remaining modem method users are equally divided between those relying on the IUD and female sterilisation. Periodic abstinence is the most frequently used traditional method and the second most frequently used method overall (2 percent). Less than 1 percent of married women rely on breastfeeding or traditional methods such as "seeds" and herbs. Table 4.7 shows the percent distribution of currently married women by contraceptive method currently used according to selected backgmund characteristics. The pattem of differentials by age is similar to the pat~m for ever-use of contraception, with women in their thirties and early forties having the highest levels of contraceptive use. Extremely large differences are observed in contraceptive prevalence for urban and mral areas; 17 percent of urban women were using a contraceptive method at the time of the survey compared with 4 percent of rural women (see Figure 4.1). Urban women are also more likely than mral women to use modem methods, especially the IUD. Figure 4.1 highlights the differentials in contraceptive prevalence by region. Khartoum has the highest level of contraceptive prevalence, with 22 percent of married women using a method, followed by the Northern (12 percent) and Central regions (8 percent). Less than 5 percent of women use contra- ception in the Eastern (4 percent), Kordofan (3 percent) and Darfur (1 percent) regions. Pronounced differences in current use exist by level of education. The proportion of married women using contraception increases dramatically from 3 percent among women with no schooling to 12 percent among those with primary education, and then rises to 19 and 26 percent for women with junior secondary and senior secondary or higher education, respectively. Contraceptive use also increases with the number of living children (Table 4.7); current use is negligible (1 percent) among women who have yet to start childbearing and increases to 7 percent among women with one child. The prevalence rate is about 10 percent for women with two or more children. Figure 4.2 compares contraceptive prevalence by age and number of living children for the SFS and the SDHS. Since the SFS, contraceptive use has increased substantially in the age group 20-24 (from 4 to 8 percent) and even more dramatically among women age 30 and over (almost two-and-a-half times the previous prevalence rate), but has remained unchanged for age groups 15-19 and 25-29. Except among childless women, contraceptive use has increased since the SFS among women regardless of number of children. Among women with two children, current use increased from 4 percent in the SFS to 10 percent in the SDHS; increases in the proportion using family planning were less pronounced for other family sizes. 2 For African countries where DHS surveys have been conducted, prevalence rates are higher than Sudan in: Tunisia (50 percent), Zimbabwe (43 percen0, Egypt (38 percent), Morocco (36 percent), Botswana (33 percen0, Kenya (27 percent), Ghana (13 percent) and "logo (12 percent). Six countries--Bumndi, Liberia, Mali, Nigeria, Senegal, and Uganda have contraceptive prevalence rates lower than Sudan (3-7 percent). 41 4~ to Current use of contraception Table 4.7 Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Sudan DHS 1989-90; and percent distribution of currently married women by contraceptlve method currently being used, SFS 1978-79 Contraceptive method Female Perl- Not Any steri- Any odic With- cur- Number Background Any modern InJec- Con- llsa- trad'l abstl- draw- rently Total of characteristic method method Pill IUD tlon d~m tlon method hence al Other using percent women J4m 15-19 3.8 2.2 1.9 0.3 0.0 0.0 0.0 1.6 1.4 0.0 0.3 96,2 100.0 367 20-24 7.8 4.2 3.9 0.2 0.1 0,0 0,0 3.6 2.9 0.4 0.2 92,2 100.0 900 25-29 7.1 5.0 4.4 0.4 0.1 0.i 0.i 2.0 1.2 0.2 0.7 92,9 i00.0 1276 30-34 12.4 7.9 5.3 1.0 0.0 0.3 1.3 4.4 2.8 0.4 1.2 87,6 100.0 906 35-39 9.9 5.7 3.7 1.3 O.0 0.0 0.7 4.3 2.8 0.4 1.0 90.i i00.0 955 40-44 11.4 7.7 3.5 I.I 0.2 0.4 2.6 3.7 3.3 0.0 0.4 88,6 100.0 543 45-49 5.5 4.4 1.8 0.2 0.0 0.0 2.4 i.i 0.7 0.4 0.0 94.5 100.0 453 ~idence Urban 17.0 11.3 7.6 1.6 0.1 0.3 1.6 5.7 4.2 0.8 0.7 83,0 100.0 1979 Rural 3.9 2.2 1.7 0.I 0.0 0.0 0.4 1.7 1.0 0.0 0.6 96,1 100.0 3421 ~ ion Khart oum 22.1 15.8 10.9 2.4 0.2 0.4 1.9 6.3 4.7 1.0 0.6 77,9 100.0 1136 Northern 12.1 8.2 6.6 0.0 0.0 0.3 1.4 3.8 3.0 0.0 0.8 87,9 100.0 365 Eastern 4.4 2.1 1.6 0.2 0.0 0.0 0.3 2.3 1.6 0.0 0.6 95,6 100.0 616 Central 7.6 4.1 2.6 0.5 0.1 0.0 0.9 3.4 2.2 0.2 i.I 92,4 100.0 1480 Kordo fan 3.0 1.4 i.I 0.i 0.0 0.0 0.2 1.6 0.7 0.2 0.6 97,0 100.0 828 Dar fur 0.9 0.2 0.2 0.0 0.0 0.0 0.0 0.7 0.7 0.0 0.0 99,1 100.0 975 E~t ion No education 3.2 1.9 1.0 0.2 0.0 0.I 0.6 1.3 0.6 0.0 0.7 96,8 I00.0 3130 Primary incomplete 12.7 8.0 5.4 0.9 0.2 0.0 1.5 4.7 3.2 0.6 1.0 87,3 100.0 1061 Primary complete 11.5 7.8 7.2 0.3 0.0 0.3 0.0 3.7 3.2 0.0 0.6 88,5 100.0 374 Junior secondary 19.3 13.1 10.4 1.2 0.0 0.0 1.5 6.2 4.9 0.7 0.5 80,7 I00.0 405 Senior secondary+ 26.0 16.5 11.9 3.0 0.0 0.7 0.9 9.5 8.1 1.4 0.0 74,0 100.0 430 a l s~z of living chil4h:~ None 1.2 0.2 0.2 0.0 0.0 0.0 0.0 1.0 1.0 0.0 0.0 98,8 i00.0 578 i 7.3 3.9 3.9 0.0 0.0 0.0 0.0 3.4 2.9 0.4 0.1 92,7 100.0 819 2 9.6 6.9 5.4 i.i 0.0 0.0 0.4 2.7 1.7 0.7 0.2 90,4 100.0 708 3 9.4 6.3 4.1 0.9 0.3 0.5 0.5 3.1 2.0 0.3 0.8 90,6 I00.0 651 4 or more i0.9 6.6 4.2 0.8 0.0 0.I 1.5 3.7 2.4 0.2 1.0 89.7 i00.0 2646 Total SD~ 8.7 5.5 3.9 0.7 0.1 0.I 0.8 3.1 2.2 0.3 0.6 91.3 100.0 5400 T<M: al SFS 1 4.6 3.9 3.1 0.I 0.2 0.l 0.3 0.7 0.4 0.i O.0 95.4 I08.0 2859 1United Nations (1987). Department of International Economic and Social Affairs. Population Division. Fertility Behaviour in the Context of Development, Table 81 30 25 20 16 lO 8 o Percent Urbsn Rurel REEIOENC~ F igure 4.1 Current Use of Contraception by Residence end Region among Currently Married Women 15-49 KhMtouffi Central Kordofln Northern Eeetllr n REGION Oartur 8ud ln DH8 1gEE°gO F igure 4,2 Trends in Contraceptive Use among Currently Married Women 15-49 SFS and SDHS AGE 15-19 20-24 26-ag 30-34 35-39 40-44 45-4g NO. OF CHILOREN None 1 2 3 4÷ g 4 6 8 10 Percentage Uwing Cont racept ion [m EF8 1978-7g 1 EDH8 1gEE-gO 12 Not i : ln th i 8F8 ourr int use for fi'*e or more ch l ld r inwl l § percent. 14 Sudan DHS 1gag-go 4.7 NUMBER OF CHILDREN AT FIRST USE Table 4.8 shows the percent distribution of ever-married women by the number of living children they had at the time they first used contraception. It is interesting to note that half of the women (12 percent) started using contraception before their second child. This tendency to start contraception early, probably for the purpose of spacing births, is more noticeable among younger women, i.e., women below 30 years of age. For example, 20 percent of women aged 20-24 started using before they had two children, compared with only 4 percent of those age 45-49. 43 Number of ch i ldren at f i rst use of contracept ion Table 4.8 Percent d is t r ibut ion of ever -marr ied women by number of l iv ing ch i ldren at the t ime of f irst use of contracept lon I accord ing to current age, Sudan DHS 1989-90 No. of l iv ing chi ldren at t ime of first use Number Never Total of Age used None 1 2 3 4+ Miss ing percent women 15-19 91.1 3.4 5.0 0.5 0.0 0.0 0.0 i00.0 380 20-24 75.9 4.5 15.0 3.6 0.6 0.0 0.3 i00.0 938 25-29 74.3 3,4 12.6 6.1 1.6 1.8 0.I i00.0 1355 30-34 69.9 1.3 10.7 7.0 5.4 5.6 0.1 100.0 970 35-39 74.7 0.9 5.9 5.1 4.6 8.5 0.4 100.0 1047 40-44 75.4 1.1 5.1 3.3 3.8 ii.0 0.3 100.0 630 45-49 79.4 0.2 3.9 1.7 1.7 12.8 0.4 I00.0 540 Tota l 75.6 2.2 9.4 4.6 2,7 5.2 0.2 I00.0 5860 4.8 SOURCE OF CURRENT CONTRACEPT IVE METHOD The identification of sources of contraceptive methods for current users is important in order to evaluate the role played by various providers of family planning services and supplies in the public and private sectors. Women who were using a method were asked where they obtained the method, or in the case of users of periodic abstinence, where they obtained advice the last time. The responses are summa- rized in Table 4.9. The public sector (including nongovemmental organizations) provides methods to six of ten users of modem methods (46 percent government sources, and 12 percent family planning clinics), while the private sector serves four in ten users. In the private sector, pharmacies (22 percent) and private doctors/clinics (13 percent) are the major sources of contraceptive methods (see Figure 4.3). As for sources of specific methods, government health centres (31 percent) and pharmacies (29 percent) are the major sources for pill users; family planning clinics (14 percent), government hospitals (11 percen0, private doctors (4 percent) and, friends and relatives (5 percent) are the other sources. Eighty percent of the women who chose female sterilisation, used government hospitals and 11 percent used private doctors. The majority of IUD insertions (53 percent) were done by private doctors; the rest were performed at government hospitals (14 percent), family planning clinics (11 percent), government health centres (8 percent), and private hospitals (8 percent). The majority of women who relied on periodic abstinence consulted friends and relatives (54 percent), although one in five reported private doctors as the source of information and advice on the rhythm method. 44 Sources of contracept ive services Table 4.9 Percent distr ibut ion of current users of modern methods by most recent source of supply according to speci f ic method, and percent d ist r ibut ion of users of per iodic abst inence by most recent source of information, Sudan DHS 1989-90 Supply methods I Cl inic methods Source Female Total Per iodic of supply steri l i - modern abst i - or information Pi l l Total IDD sation Total methods I hence P%~l lo 59.1 57.6 36.1 80.0 60.5 58.4 5.0 Government hospital 10.6 10.6 13.9 60.0 50.6 21.5 1.7 Govt health centre 31.3 30.0 8.3 O.O 3.7 22.8 0.8 Dispensary 1.9 1.8 0.0 0.0 0.0 1.3 0.0 Mobi le cl inic 0.5 0.5 0.0 0.0 0.0 0.3 0.0 Other health faci l i ty 0.5 0.5 2.8 0.0 1.2 0.7 0.8 Family p lanning cl inic 14.4 14.3 11.1 0.O 4.9 11.7 1.7 Pz ivate 40.4 41.9 63.9 17.8 38.3 40.9 95.0 Pr ivate doctor 3.8 3.7 52.8 11.1 29.6 10.7 19.3 Pr ivate hospital 0.5 0.9 8.3 2.2 4.9 2.0 0.0 Pharmacy 29.3 30.9 0.0 0.0 0.0 22.5 0.0 Fr iends/re lat ives 5.3 5.1 0.0 0.0 0.0 3.7 53.8 Other 1.4 1.4 2.8 4.4 3.7 2.0 21.8 Unalaall fled 0.5 0.5 0.0 2.2 1.2 0.7 0.0 Don't know 0.5 0.5 0.0 0.0 0.0 0.3 0.0 Miss ing 0.0 0.0 0.0 2.2 1.2 0.3 0.0 Tota l ]peroent I00.0 100.0 I00.0 I00.0 I00.0 i00.0 i00.0 Figure 4.3 Source of Contraceptive Methods for Current Users of Modern Methods Government 48% Other 3% Frienda/ Relatives 4% FP Clinic PrN. Doctor/ Cllnlc 13ek 'macy 22% 8udam DH8 1989-90 45 4.9 DISSATISFACTION WITH CURRENT PROVIDERS OF CONTRACEPTION Twenty percent of the currently married women using contraception reported some dissatisfaction with their most recent source of contraception (see Table 4.10). The highest proportion of dissatisfied respondents were pharmacy clients (30 percent). Eighteen percent of those using government health facilities and 13 percent of those attended by private doctors or at private hospitals were also dissatisfied with the services they received. Overall, the main complaint was unavailability of the desired method at the source (9 percent), though this complaint was more common among pharmacy clients (18 percent). Distance to the source was the second most frequently mentioned cause of dissatisfaction (6 percent): 8 percent of pharmacy clients, 6 percent of government health facilities users, and 3 percent of those receiving services at private hospitals or from private doctors. Among those who received services from private doctors or hospitals, the major dissatisfaction was cost; 5 percent of the women said these services were expensive. Only 2 percent of users mentioned waiting too long as a reason for dissatisfaction with the service. Dissat i s faot lon with source of cont racept ive serv ices Table 4.10 Percent d i s t r ibut ion of current users of cont racept ion by type of d i ssat i s fac t ion with the source of cont racept ive services, accord ing to type of source last visited, Sudan DHS 1989-90 D issat i s fac t ion with the source of contracept ive serv ices Not com- Desi red Source of Wait fortable method Ntu~ber cont racept ive Too too with Expen- not Unsure/ Total of serv ices None far long staff s lve ava i lab le Other miss ing percent users Govt. heal th fac i l i ty Pharmacy Pr ivate doctor / hospi ta l 82.1 6.4 2.3 1.2 1.2 6.4 0.0 0*6 I00.0 173 70.1 7.5 3.0 O.0 1.5 17.9 0.0 0.0 I00.0 67 87.2 2.6 0.0 0.0 5.1 2.6 2.6 0.0 I00.0 39 TOta l I 79.7 5.9 2.1 0.7 1.7 9.0 0.3 0.6 I00.0 290 I Inc ludes II women who said that they obta ined their method from fr iends or re lat ives but excludes women who d id not spec i fy the source. 4.10 ATTITUDE TOWARD NEXT PREGNANCY AND REASON FOR NONUSE OF CONTRACEPTION Table 4.11 presents the percent distribution of sexually active, nonpregnant women who were not using a contraceptive method by their attitude toward becoming pregnant in the next few weeks. Overall, one-third of these nonusers were exposed to the risk of unwanted pregnancy, that is, they said that they would be unhappy if they got pregnant in the next few weeks. Examining the attitude of these women by number of living children, the proportion at risk of an unwanted pregnancy increases with increasing family size. For example, 29 percent of mothers with one child said they would be unhappy if they became pregnant in the next few weeks, compared with 40 percent of women with four or more children. It is notable that among those with four or more children, 44 said they would be happy to become 46 pregnant again, while 16 percent said that it would not matter. This f'mding suggests that the majority of women with large families either want more children or are fatalistic about the size of their family. Att i tude toward becoming pregnant amon~ nonusers Table 4.11 Percent distr ibut ion of nonpregnant women who are sexual ly active and who are not using any contra- ceptive method by att i tude toward becoming pregnant in the next few weeks, according to number of l iving children, Sudan DHS 1989-90 Att i tude toward becoming pregnant in next few weeks Number Would Number of l iving not Miss- Total of chi ldren Happy Unhappy matter ing percent women None 93.6 3.2 2.4 0.7 I00.0 409 1 64.7 29.3 5.4 0.6 i00.0 467 2 58.4 33.4 7.1 1.2 I00.0 425 3 54.7 34.6 i0.2 0.5 I00.0 413 4 or more 43.5 48.0 15.6 0.7 100.0 1856 Total 55.1 33.0 11.2 0.7 1O0.0 3570 Women who reported that they would be unhappy if they became pregnant soon were asked why they were not using any method of family planning. The percent distribution of younger women (under 30) and older women (30 years and over) by the mason given for nonuse are shown in Table 4.12. A substantial proportion of these women (39 percent) did not feel themselves at risk of pregnancy because they were breasffeeding (24 percent), menopausal (7 percent) or were sexually active infrequently (8 percent). Another 36 percent cited reasons for nonuse that are important for family planning services: lack of knowledge (21 percent), health concerns (12 percent), inaccessibility of methods (3 percent) and high cost (1 percent). Four percent gave religion as the main reason for nonuse, 2 percent disapprove of family planning, and 6 percent report that their husband disapproved of family planning. Finally, about 7 percent of the women cited reasons that implied there was little they can do to control their fertility (fatalistic). The main difference in reasons for nonuse among younger and older women was that a higher proportion of younger women reported postpartum/breastfeeding (35 percent) and husband disapproval (7 percent). Also, older women were more likely to mention menopause and lack of knowledge as reasons for nonuse. 47 Reasons for nonuse of contracept ion Table 4.12 Percent distr ibut ion of nonpregnant women who are sexual ly active, not using any contracept ive method, and who would be unhappy if they became pregnant, by main reason for nonuse, according to age, Sudan DHS 1989-90 Main reason for not using contracept ion Age 10-29 30-49 Total Postpartum/breast feeding 34.5 16.4 24.0 Menopausal /subfecund 0.0 12.9 7.5 Infrequent sex 7.7 7.0 7.7 Lack of knowledge 17.8 22.7 20.6 Health concerns 8.1 15.1 12.1 Inaccessibi l i ty/ lack of avai labi l i ty 3.8 1.8 2.6 High cost 0.4 0.6 0.5 Rel ig ion 3.4 4,2 3.9 Husband disapproves 7.3 4.5 5.7 Oppose family planning 3.0 1.6 2.2 Fata l is t ic 6.7 7.0 6.9 Don't know 3.8 3.1 3.4 Inconvenient to use 1.2 1.0 i.I Others disapprove 0.4 0.1 0.3 Other 0.6 0.7 0.7 Miss ing 1.2 0.4 0.8 Total percent 100.0 I00.0 I00.0 4.11 INTENTION TO USE CONTRACEPT ION IN THE FUTURE Women who were not using any contraceptive method at the time of interview were asked if they thought they would use a family planning method in the future. Those who responded in the affirmative were also asked what method they would prefer to use and whether they would use that method in the next 12 months. Table 4.13 shows the distribution of currently married women who were not using contraception, by intention to use in the future, according to the number of living children (including a current pregnancy). Three-fourths of the women (77 percent) said they did not intend to use any contraceptive method. Eighteen percent said they intended to use a method--13 percent in the next 12 months, and 4 percent after 12 months (1 percent unspecified); 5 percent were unsure about future use. Differentials by number of living children were minimal, although those with no children were least likely to express an intention of using within the next 12 months. Method preferences among those who intend to use in the future are shown in Table 4.14. The pill is by far the most popular choice (61 percent), followed by periodic abstinence as a distant second (15 percent). !ajection, although used by hardly any current users, is the preferred method of 8 percent of those who'intend to use. Male methods--condom, withdrawal, and male sterilisation--were selected by almost none of those who intend to use. Method preferences were almost identical for women who intend to use contraception in the next 12 months and those who intend to use a method after 12 months. 48 Intention to use contracept ion in the future Table 4.13 Percent distr ibut ion of current ly marr ied women who are not using any contracept ive method, by intention to use in the future, according to number of l iving children, Sudan DHS 1989-90 Number of chi ldren I Intention to use in future None 1 2 3 4+ Total Intend to use In next 12 months 4.6 13.6 16.4 15.0 13.0 13.1 After 12 months 12.7 5.7 4.9 3.2 2.0 4.0 Unsure when 2.2 1.6 1.8 1.6 0.9 1.3 Unlure Lbout USe 6.5 6.7 6.4 4.2 3.4 4.7 DO not intend to use 73.8 72.1 70.4 75.9 80.7 76.8 Miss ing 0.2 0.3 0.I 0.0 0.0 0.i Total pe¢cent i00.0 i00.0 I00.0 100.0 100.0 I00.0 N%~e~ of women 416 760 672 618 2476 4932 I Includes current pregnancy. Preferred method for future use Table 4.14 Percent distr ibut ion of current ly marr ied women who are not using a contracept ive method but who intend to use in the future, by preferred method, Sudan DH5 1989-90 Preferred method Intend to use In next After 12 12 months months Total Pi l l 60.8 61.3 60.9 IUD 6.5 5.0 6.2 Injections 7.3 8.0 7.5 Condom 0.5 0.5 0.5 Female ster i l isat ion 2.5 3.5 2.7 Per iodic Abst inence 14.6 14.1 14.5 Withdrawal 0.9 1.0 0.9 Other 0.9 0.5 0.8 Don't know 6.0 6.0 6.0 Total peroent 100.0 100.0 100.0 Number of wcaen 645 199 844 49 4.12 APPROVAL AND ACCEPTABILITY OF FAMILY PLANNING In the SDHS all respondents were asked whether they approved or disapproved of couples using a method to avoid or delay pregnancy. Currently married women were also asked if they thought their husbands approved or disapproved of family planning in general. Table 4.15 presents information on the attitudes of currently married women toward family planning and their perceptions of the attitudes of their husbands toward family planning. Sixty-four percent of the women said they approved of family planning. When asked about their husband's attitude toward family planning, only 37 percent of married women reported that their husbands approved; 44 percent said their husbands disapproved, and 19 percent did not know. Examining the attitudes of couples, it was found that 35 percent of couples jointly approved of family planning, 25 percent jointly disapproved; and in 19 percent of couples the wife supported family planning while the husband opposed it. Attitudes of husbands and wives toward family planninq Table 4.15 Percent distribution of currently married women who know a eontraceptlve method by the husband's attitude toward family planning (according to the wife) and the wife's attitude toward the use of family planning, Sudan DHS 1989-90 Husband's attitude toward family planning Wife's attitude Number toward Disap- Ap- Don't All of family planning proves proves know wlves I women Disapproves 25.4 2.0 8,8 36.2 1395 Approves 18.7 35.3 9.6 63.6 2454 All h ~ m 2 44.1 37.3 18,5 i00.0 3856 N%Iber of women 1701 1440 713 3856 3856 IIncludes seven cases with missing information. 2Includes two cases with missing information. The differentials in wives' and husbands' attitudes toward family planning are presented in Table 4.16 by selected background characteristics. Differences in wives' and husbands' approval of family planning by age of wife were minimal except that those in the youngest and oldest age groups were somewhat less likely to approve than those in the middle age groups. Not surprisingly, the attitude toward family planning was more favourable among women residing in urban areas (72 percent) than in rural areas (57 pement); similarly, more urban wives (46 percent) than rural wives (29 percent) thought that their husbands approved of family planning. The urban-rural differential was slightly larger for husbands than for their wives. Differentials by education were strong; approval of family planning increased dramatically from less than 50 percent among women with no schooling to over 70 percent among those with primary education and then rose to 89 percent for those having at least a secondary education. Husbands and wives had a similar pattern of family planning approval according to the wife's 50 education: 24 percent of husbands with uneducated wives approved of family planning compared with 65 percent of wives with at least secondary educa,ion. The urban-rural and educational differences were reflected in the regional differentials. Approval of family planning among married women in the Khartoum region (77 percent) and the Nonhero region (60 percent) was slightly higher than in the Central region (63 percent). On the other hand, the Central region showed a higher level of approval than the Kordofan (54 percent), Eastern (52 percent) or Darfur (45 perecnt) regions. Husbands' attitudes foUowed the same pattem as their wives by region. More than half of the husbands in Khartoum approved, compared with less than onc-fifth of thosc in the Darfur region. Approval of family planning by wives and their husbands Table 4.16 Among currently married women who know a contraceptive method, the percentage who approve of family planning and the percentage who say their husbands approve of family planning by background characteristics of women, Sudan DHS 1989-90 Background characteristics Approve of family planning Women Husbands Number of wo~en A~Q 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Remlaen~ Urban Rural P~ion Khartoum Northern Eastern Central Kordofan Darfur 53.6 31.2 66.8 37.9 66.7 41.2 64.7 39.1 65.0 34.7 59.8 37.8 54.7 30.4 250 680 934 662 666 368 296 71.6 46.3 1812 56.6 29.4 2044 77.0 54.0 1098 68.6 46.8 357 51.5 29.3 379 62.6 32.9 1195 54.3 22.7 529 44.6 18.8 298 E~uoation No education 48.0 23.5 1722 Primary incomplete 70.8 40.9 968 Primary complete 73.2 44.0 343 Junior secondary 79.2 53.3 394 Senior secondary+ 88.6 65.0 429 63.6 37.3 3856 Tota l 51 A good indication of the acceptability of family planning is the extent to which couples discuss the subject with each other. Currently married women were asked how often they had talked about family planning with their husbands in the year preceding the survey. As shown in Table 4.17, less than half of the married women have discussed family planning with their husbands in the preceding year; 27 percent discussed it once or twice and 20 percent discussed it three or more times. The differentials by wife's age in the proportion of couples who discussed family planning were similar to those observed in approval of family planning. Younger and older women were less likely to discuss family planning with their husbands than women 20 to 39 years old. Frequency of d iscussion of family p lanning by couples Table 4.17 Percent d ist r ibut ion of current ly marr ied women who know a contracept ive method by the number of times family p lanning was d iscussed with husband in the year preceding the survsy, according to current age, Sudan DHS 1989-90 Number of times discussed family p lanning Numbsr Once or Three Total of Age Never twice or more Miss ing percent women 15-19 60.0 26.8 13.2 0.0 I00.0 250 20-24 47.4 31.9 20.7 0.O i00.0 680 25-29 47.5 30.5 21.8 0.1 i00.0 934 30-34 50.0 24.6 25.2 0.2 100.0 662 35-39 55.3 24.9 19.8 0.0 i00.0 666 40-44 61.7 21.5 16.8 0.0 I00.0 368 45-49 65.2 21.6 12.5 0.7 i00.0 296 Total 52.8 27.0 20.1 O.l 1O0.0 3856 Another indicator of family planning approval is attitudes towards mass media providing information on family planning. All respondents were asked if it was acceptable to them for family planning information to be provided on radio or television. The results presented in Table 4.18 indicated that almost 75 percent of ever-married women considered it acceptable for mass media to provide family planning information. This was true for women of all ages except those age 45-49 who were less likely (67 percent) to approve of the use of radio and television to provide information on family planning. The attitudes of ever-married and currently married women were similar regarding dissemination of family planning information on the radio (not shown in the table). It is interesting to note that among currently married women, approval of the use of mass media to disseminate family planning information (over 70 percent) was higher than approval of the use of family planning (64 percent, see Table 4.16). Differentials by urban-rural residence, by education, and by region in approval of the use of mass media for disseminating family planning information follow the pattern described above for differentials in approval of family planning among currently married women. 52 Approval of the use of mass media for d isseminat ing family p lanning information Table 4.18 Percentage of ever-marr ied women who approve of provid ing family p lanning information on radio or television, by age according to selected back- ground characterist ics, Sudan DHS 1989-90 Age of woman Background character ist ic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Rel idenoe Urban 83.3 86.2 87.5 86.5 86.8 62.6 77.7 85.2 Rural 67.6 72.7 66.0 64.2 67.1 64.8 59.7 66.5 R~ion Khartoum 86.5 93.1 92.7 92.5 91.9 90.8 86.6 91.4 Northern (90.9) 92.6 83.5 97.0 98.8 94.0 77.8 91.1 Eastern 58.5 64.5 60.2 50.5 59.6 52.3 47.5 57.7 Central 71.4 76.9 81.7 75.9 79.3 74.3 70.2 77.0 Kordofan 75.9 79.1 75.2 71.1 71.6 72.0 66.7 73.2 Darfur 60.9 57.0 46.9 51.4 48.8 47.6 43.5 50.0 Education No education 58.2 61.2 57.1 58.3 66.0 64.9 63.3 61.5 Pr imary incomplete 75.0 82.9 84.5 89.8 87.5 93.9 88.5 86.3 Pr imary complete 79.0 88.0 89.8 90.7 95.8 (i00.0) (i00.0) 88.3 Junior secondary 91.5 92.6 93.9 96.6 97,1 (100.0) (100.0) 94.1 Senior secondary+ (100.0) 94.8 98.9 98.0 100.0 (94.7) (100.0) 97.6 Total 71.6 77.4 73.9 73.2 74.3 72.2 67.0 73.4 Note: Numbers in parentheses are based on fewer than 20 cases. 53 CHAPTER 5 NUPTIALITY AND EXPOSURE TO THE RISK OF PREGNANCY 53 CURRENT MARITAL STATUS Marriage, divorce, and widowhood are demographic events that influence exposure to pregnancy and thereby affect fertility. The marital composition of a population directly affects the population dynamics. Marriage and fertility are closely linked in northern Sudan because childbearing takes place within the context of marriage. Since marriage is the primary indicator of exposure to the risk of pregnancy, the study of marriage patterns is essential to the understanding of fertility in Sudan Table 5.1 presents the distribution of all women according to marital status and age. The table shows that at the time of the survey, 40 percent of the women 15-49 years of age had never been married, while 55 percent were currently married, 2 percent were widowed, and the remaining 3 percent were divorced. Marital status of women 15-49 Table 5.1 Percent distribution of all women by current marital status, according to age, Sudan DHS 1989-90, and the percentage of never-married women by age, Sudan Fertility Survey (SFS) 1978-79 Marital status Percentage of Number never-married Never Currently Total of women Age married married Widowed Divorced percent women SFS 1978-79 a 15-19 84.1 15.4 0.0 0.5 I00.0 2386 78.2 20-24 54.2 43.9 0.2 1.7 i08.0 2048 36.4 25-29 27.8 68.0 0.5 3.7 I00.0 1878 II.0 30-34 13.2 81.1 1.3 4.5 i00.0 1117 4.3 35-39 5.4 86.3 3.6 4.7 100.0 1106 2.0 40-44 3.0 83.6 9.1 4.3 10O.0 650 1.5 45-49 1.3 82.8 12.1 3.8 100.0 547 0.8 Total 39.8 55.5 2,0 2.7 100.O 9732 28.1 aSudan (1982) Ministry of National Planning, Department of Statistics, The Sudan Fertility Survey 1979, Principal Report, Vol. II, calculated from Table B2 (figures are from the household questionnaire). Nearly all women in the Sudan marry during their reproductive years. By age 45-49 only one percent of women have never entered into a marital union. The proportion currently married ranges from 15 percent among women 15-19 to 86 percent among those age 35-39, then declines slightly to 83 percent among women 45-49. The proportion widowed increases with age, reaching 12 percent for women age 45-49. Except for the youngest age groups the proportion divorced is 4 to 5 percent. Among ever- married women, 92 percent were currently married, 3 percent widowed, and 5 percent divorced. 55 Figure 5.1 shows the proportion of never-married women by age group for the Sudan Fertility Survey (SFS) and the SDHS. Overall, the proportion never married increased 12 percentage points between the two surveys (from 28 to 40 percent). As expected, the proportion of never-married women decreases with increasing current age in both surveys. In the SDHS, 84 percent of women age 15-19 were never married, declining to 54 percent among women 20-24 and 28 percent among those 25-29. The corresponding proportions were lower for the same age groups in the SFS, indicating increasing age at first marriage. Compared with the SFS, the proportion of women still single at the time of the SDHS increased slightly among the youngest group (from 78 to 84 percent) and substantially among those in their twenties (from 36 to 54 percent for women 20-24, from 11 to 28 percent for women 25-29). Percent Figure 5.1 Distribution of Never-married Women by Age, SFS and SDHS 15-19 20-24 25-29 30-34 Current Age [ mSFSt978-7g 1SDH51989-90 ~ Sudan DH$ 1989-90 5.2 POLYGYNY In order to collect information on the practice of polygyny in the Sudan, all currently married women were asked whether their husbands had other wives. Table 5.2 shows the percentage of currently married women in polygynous unions by age and selected background characteristics. At the time of the survey, one in five currently married women was living in a polygynous union and had at least one co- wife. Four percent of married women had two or more co-wives (not shown in the table). Younger women were less likely to be in a polygynous unions than older women. The proportion of currently married women who reported that their husbands had other wives increased from 11 percent among women in age group 15-19 to 26 percent among women aged 40-49 years. The prevalence of polygynous unions reported in the SDHS (20 percent) was slightly higher than in the SFS (17 percent), which suggests that the practice of polygyny has not declined over the past decade. The difference between the two surveys may be due to sampling design, variations in data collection, or possibly to factors related to the long periods of civil strife and economic hardship. 56 PolTgyny Table 5.2 Percentage of currently married women in a polygynous union, by age and selected background characteristics, Sudan DHS 1989-90; and percentage of currently married women in a polygynous union, by age, SFS 1978-79 Current age Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 9.7 13.9 12.2 16.1 16.9 22.5 23.4 16.0 Rural 12.0 13.0 20.6 28.3 28.5 28.6 27.7 22.6 Region Khartoum 4.2 11.4 9.9 16.2 13.5 17.1 24.2 13.5 Northern 0.0 1.9 3.6 11.7 15.4 8.7 19.4 9.3 Eastern 12.7 13.1 9.9 16.5 21.0 30.2 40.0 16.7 Central 8.3 9.2 11.3 18.1 19.7 20.9 20.8 15.0 Kordofan 9.6 19.4 28.2 29.9 25.0 31.0 23.3 25.1 Darfur 27.4 24.0 36.1 42.9 45.4 48.4 34.1 37.9 Education No education 13.7 20.2 24.5 31.2 29.1 28.3 27.5 26.4 Primary incomplete 13.6 10.6 14.7 19.7 16.0 18.4 16.4 15.6 Primary complete 11.5 5.6 12.4 8.3 18.2 (20.0) (0 .0 ) 10.2 Junior secondary 3.6 6.7 6.4 10.5 21.9 (6 .7 ) (25.0) 8.4 Senior secondary+ (0 .0 ) 9.9 5.6 3.2 0.0 (26.7) (25.0) 6.5 Total SDHS 11.4 13.3 17.6 23.4 24.3 26.2 26,0 20.2 Total SFH & --->i i . i< . . . . . . . . >16.6< . . . . . . . . . . >21.2b< . . . . . . . 16.8 b Note: Figures in parentheses are based on fewer than 20 cases. aSudan (1982) Ministry of National Planning, Department of Statistics, The Sudan Fertility Survey 1979, Principal Report, Vol. I, Table 4.12. bIncludes women age 50. The formation of polygynous unions is influenced by residence pattem. In urban areas 16 percent of currently married women had one or more co-wives, compared with 23 percent in rural areas. The distribution of women by five-year age group, also showed a higher proportions of polygynous unions among rural women than among urban, with the exception of women 20-24. The regional distribution of women in a polygynous union showed that the highest proportion of polygynous women was in Darfur (38 percent) and the lowest was in the Northem region (9 percent). The Khartoum and Central regions were also low (about 15 percent). These regional variations hold true for all age groups except women 35-39. There is an inverse relationship between polygyny and education. Polygyny was most prevalent among women with no education (26 percent) and declined to less than 7 percent among women with secondary education. This negative relationship generally holds true for all age groups. 57 5.3 AGE AT F IRST MARRIAGE Age at first marriage is an important indicator of exposure to the risk of conception and childbirth, especially in a society in which almost all births occur within marital unions. Table 5.3 gives the percent distribution of women by age at first marriage and the median age at first marriage according to age at the time of the survey. As can be seen from the table, the proportion of women who married before age 15 has declined from one in three women, for those age 35 years or older, to only one in twenty women age 15-19. In addition, more than three-fourths of women currently 40 years and over married before age 20, i.e., more than twice the proportion of those age 20-24 who married by the same age. Aqe at first marr iaqe Table 5.3 Percent d ist r ibut ion of al l women by age at first marr iage and median age at first marriage, by current age, Sudan DHS 1989-90, and median age at first marr iage by age, SFS 1978-79 Age at first marr iage Number Current Never- Total of age marr ied a <15 15-17 18-19 20-21 22-24 25+ percent women Median age at first marriage b SDHS SFS 15-19 84.1 4.9 9.0 2.1 8.0 0.0 0.0 100.0 2386 c c 20-24 54.2 11.5 15.4 9.7 6.5 2.7 0.0 100.0 2048 c 18.6 25-29 27.8 16.3 20.1 10.9 9.8 Ii.0 4.2 i00.0 1878 20.5 17.0 30-34 13.2 26.0 23.6 i0.i 10.3 8.4 8.4 100.0 1117 18.1 15.7 35-39 5.4 33.4 27.9 11.7 7.8 6.3 7.6 i00.0 1106 16.4 16.2 40-44 3.0 36.9 31.4 9.5 6.8 5.7 6.6 100.0 650 15.8 15.9 45-49 1.3 34.0 30.7 11.9 9.0 7.1 6.0 I00.0 547 16.3 16.2 Total 39.8 17.9 19.0 8.4 6.3 5.1 3.4 10o.0 9732 c c awomen who were reported as never-marr ied in the household quest ionnaire. bMedian age at marr iage is def ined as the exact age by which 50 percent of the women in the age category have exper ienced marriage. °The median age at marriage for women 15-19 and for women 20-24 in the SDHS have been omitted, since the major i ty of these women have not yet married; the median for all women is not shown for the s~e reason. Table 5.3 also shows that the median age at first marriage has increased substantially: it was about 16 years for women age 35 and over but increased to 18 years for those 30-34 years and to almost 21 years for women 25-29 years of age. The anomaly of a higher median age at marriage for women age 45-49 than for those 40-44 may be due to the inability of many older women, who are also the least educated, to recall their age at marriage, or to the fact that in Africa older women have a tendency to overstate their age at first marriage. Comparable information from the SFS also indicate that age at first marriage is increasing. Figure 5.2 and Table 5.3 show that the median age at marriage was virtually the same in both surveys for women 35 and over, but that it increased by more than two years for women 30- 34, and by three and one-half years for women 25-29 years old. 58 25 20 15 10 IS 0 Figure 5.2 Median Age at First Marriage 8F8 and 8DH8 Median Age (Yeerll) 25-2g a0-34 36-3g 40-44 4G-411 Current Age I m 8F8 1978-79 m 8DH$ 198g*90 Sudan DH8 lggg-go Differentials in the median age at first marriage according to selected background characteristics of women are examined in Table 5.4. Only women age 25-49 were included in this table because the majority of younger women were unmarried. The table shows that the median age at marriage for urban women (19 years) is two years greater than for rural women (17 years). Although the median age at marriage is the same for urban and rural women in the two older cohorts, the gap between urban and rural women increases substantially for the younger cohorts. It is noteworthy that the median age at marriage for women 25-29 (20.5 years) is nigher in Sudan than in any other African country except Tunisia (22.8 years), according to data from the DHS surveys. Comparing the median age at first marriage for women 35-39 and 25-29 in the African countries where DHS surveys have been carried out, it was found that Sudan has experienced the most rapid change in marriage patterns, t The increase in the median age at marriage from the older to the younger cohort was 4.1 years (5.7 years in urban areas and 3.0 years in rural areas). Pronounced regional differentials in age at marriage exist in Sudan. Women in the Khartoum and Northern regions, where the median age at first marriage is 19 and 20 years respectively, marry later than women in other regions. In the Central, Kordofan and Darfur regions, the median age at marriage is about 17 years, while women in the Eastern region marry even earlier, at about 16 years of age. The median age at marriage is closely related to the level of education. Women with a senior secondary education have the nighest median age at marriage, 26 years compared with 16 years for women with no education, an astonishing difference of ten years. As can be seen in Table 5.4, for each age group the median age at marriage increases with the level of education. Thus, the table reflects a strong positive relationship between age at marriage and education. In fact, women with at least senior Tunisia is the only other country in Africa where the median age at fLrSt marriage for age 25-29 (22.8 years) is substantially higher than the median age at first marriage for women 35-39 years (20.6 years). 59 secondary education have the highest median age at first marriage (26 years) of any African country for which DHS survey data are available) Dif ferent ia ls in the median aqe at first marr iaqe Table 5,4 Median age at first marr iage among women 25-49 years old, by current age and selected background character ist ics w Sudan DHS 1989-90 Current age Background character ist ic 25-29 30-34 35-39 40-44 45-49 Total Remldence Urban 23.2 20.0 17.5 15.8 16.3 19.1 Rural 19.0 16.8 16.0 15.9 16.3 17.1 R~ion Khartoum 23.0 19.9 17.4 16.1 16,5 19.1 Nor thern 23.5 19.B 17.8 18.5 17.5 19.9 Eastern 18.5 16.0 15.2 15.3 15.0 16.4 Central 20.5 17.0 16.2 15.5 15,4 17.5 Kordofan 20.6 18.6 15.8 15.5 16,5 17.4 Darfur 18.2 17.2 16.7 16.5 16.9 17,2 Edueat lon No educat ion 17.3 16.1 15.8 15.6 16,0 16.2 Pr imary incomplete 19.0 17.9 17.1 16.4 17,3 17.7 Pr imary complete 20.2 19.8 21.9 a a 20.1 Junior secondary 26.7 20.9 20.3 a a 22.9 Senior secondary+ 27.3 27.0 24.1 a a 26.4 Total 20.5 18.1 16.4 15.8 16.9 17.8 aFewer than 20 cases. 5.4 BREASTFEEDING, POSTPARTUM AMENORRHOEA, AND ABST INENCE In addition to marriage patterns, there are several other factors that affect exposure to the risk of pregnancy, such as breastfeeding, amenorrhoea, and postpartum sexual abstinence. The duration of amenorrhoea (the period following a birth before the retum of the menstrual cycle) is directly related to breastfeeding; that is, the longer (and more frequently) a woman breastfeeds, the longer she is likely to remain amenorrhoeic. Table 5.5 presents the percentages of births in the last three years whose mothers are still breasffeeding, amenorrhoeic, and abstaining by the number of months since birth. It is clear from the table that breastfeeding is a common practice among Sudanese women. Over 90 percent of births were 2 Burundi, Nigeria (Ondo State), Senegal, Sudan, Togo, and Zimbabwe in sub-Saharan Africa; and Egypt, Morocco, and Tunisia in North Africa. 60 still being breastfed 10-11 months after delivery and 40 percent of babies were still breastfed at 20-21 months. After that, breasffeeding diminishes rapidly and only 16 percent of children were still being breastfed 24-25 months after birth,. Breastfeedlnq and exposure to the risk of pregnanc 7 Table 5.5 Percentage of births whose mothers are sti l l breastfeeding, postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, Sudan DHS 1989-90 Number Months Breast- Amenor- Insus- of since birth feeding rhoeic Absta in ing eeptible I births Less than 2 92.9 95.2 89.6 96.7 269 2-3 93.1 80.7 32.1 84.3 274 4-5 93.1 77.5 15.6 79.8 218 6-7 90.1 68.5 10.8 69.8 222 8-9 91.6 66.4 10.2 70.4 226 i0-ii 93.1 65.5 6.9 68.4 174 12-13 79.3 47.8 5.2 50.0 270 14-15 67.1 33.3 4.1 35.2 219 16-17 61.5 32.5 2.0 33.0 200 18-19 51.0 25.8 6.2 28.4 194 20-21 41.2 22.2 8.2 27.3 194 22-23 38.4 23.8 5.5 27.4 164 24-25 16.1 6.9 1.5 8.0 261 26-27 9.2 4.4 3.9 8.3 266 28-29 9.4 5.2 3.1 7.8 192 30-31 5.8 3.7 1.6 5.3 189 32-33 10.4 6.4 2.8 9.2 249 34-35 8.5 4.3 0.4 4.7 235 Total 54.1 38.7 13.0 41.I 3956 Note: Includes bir ths 0-35 months preceding the survey. More than 80 percent of Sudanese women were amenorrboeic for at least two months al~er birth; 66 percent of women were still amenorrhoeic 10-11 months after giving birth. The duration of amenorrhoea follows a pattern similar to that for duration of breastfeeding; however, the proportion of women who were amenorrboeic decreased faster than the proportion of women who were still breasffeeding, reaching 7 percent 24-25 months after birth, compared with 16 percent among breastfeeding women. In Sudan, as in other Islamic societies, women observe a period of sexual abstinence following childbirth. Traditionally, the period of postpartum abstinence lasts forty days; a celebration is held to mark the end of the period. Table 5.5 shows that the proportion of women still abstaining declines sharply in the months following childbirth, from 90 percent less than two months following the birth to 32 percent two to three months after the birth, and 5 percent one year after the birth. This is a much sharper decline than for women still breastfeeding or still postpartum amenorrhoeic. 61 The proportion of women who are insusceptible to pregnancy due to either amenorrhoea or the practice of postpartum abstinence is given in Table 5.5. The results show that one year after giving birth, 50 percent of the women are still insusceptible. Table 5.6 presents the mean number of months s of breastfeeding, postpartum amenorrhoea, postpartum abstinence and insusceptibility by selected background characteristics of the mother. As can be seen from the table, the average duration of breastfeeding is slightly more than 19 months; the average for amenorrhoea is 14 months, and for postpartum abstinence 5 months. The mean duration of insuscepti- bility is 15 months. Dif ferent ia ls in breastfeeding and in exposure to the risk of pregnancy Table 6.6 Mean number of months of breastfeeding, postpartum amenorrhoea r postpartum abstinence, and postpartum insusceptibi l i ty, by selected background characterist ics, Sudan DHS 1989-90 Postpartum Background Breast- Postpartum Postpartum insuscepti - character ist ic feeding amenorrhoea abst inence bi l i ty I Age 15-29 19.3 13.5 5.4 14.8 30-49 19.8 14.5 4.5 15.7 P~s idence Urban 17.5 10.9 5.6 12.7 Rural 20.6 15.6 4.7 16.5 Region Khartoum 15.9 9.0 5.1 II.0 Northern 19.6 12.5 5.8 14.4 Eastern 19.9 13.1 5.8 14.4 Central 20.4 14.5 4.1 15.2 Kordofan 19.6 14.9 5.6 16.3 Darfur 21.5 18.2 5.0 16.9 Education No educat ion 20.0 16.0 5.0 17.0 Pr imary incomplete 19.7 13.0 4.9 14,3 Pr imary complete 18.2 11.7 5.1 13.7 Junior secondary 18.9 10.0 5.0 11.7 Senior secondary+ 17.8 8.8 5.6 I0.1 Total 19.5 13.9 5.0 15.2 Note: Includes births 1-36 months before the survey. Estimates are based prevalence/ inc idence method (see footnote 3 this page). IEither amenorrhoeic or absta in ing at the time of the survey. on 3 Estimates of mean duration are calculated using the prevalence/incidence method. The duration of breasffccding, for example, is defined as the prevalence (number of children whose mothers are breastfccding at the time of the survey) divided by the incidence (average number of births per month over the last 36 months). 62 There is no indication of a decline in breasffeeding among younger mothers; women under 30 years and those over 30 years breastfeed their children for almost the same length of time (Figure 5.3). Younger women are amenorrhoeic one month less than older women, but they abstain one month longer than older women. Older women seem to be insusceptible slightly longer (16 months) than younger women (15 months). Differentials by place of residence (Figure 5.3 and Table 5.6) show that rural women have longer mean durations of breastfeeding and amenorrhoea than urban women, with differences of three months and five months, respectively. As a result, rural women have a longer period of insusceptibility to pregnancy, 17 months compared with 13 months for urban women. On the other hand, the mean duration of postpartum abstinence is sightly shorter among rural women than urban. Differentials in breastfeeding and amenorrhoea in Table 5.6 show that, while women in the Khartoum region have the shortest average duration of breastfeeding (16 months) and amenorrhoea (9 months), women in the Darfur region have the longest durations of breastfeeding (22 months) and amenorrhoea (18 months). In the other regions, the mean duration of breastfeeding is 20 months, while the duration of amenorrhoea varies between 13 and 15 months. Postpartum abstinence is shorter among women in the Central region (4 months) than among women in the Darfur and Khartoum regions (5 months) and other regions (around 6 months). F lgur l 6.3 Mean Duration of Breestfeeding, Amenorrhoee end Postpartum Abstinence Mean Duration (Months) q30 30* Urbln Rural None Prl. Pri. Jr. $r. Incom. comp, lac, lee. AGE RESIDENCE EDUCATION I ~ Braa.tfa.ing I~ Amenorrhoe. m Ab.t,nance i Sudan DH8 1~89-90 Table 5.6 shows an inverse relationship between education and the mean duration of breast- feeding, amenorrhoea and insusceptibility. This may be explained by the fact that better educated women are more likely to participate in the labour force which makes breastfeeding more difficult. There are only minor differences in the duration of postpartum abstinence by education level. 63 CHAPTER 6 FERTILITY PREFERENCES Insight into the fertility desires in a population is important, both for predicting future fertility and estimating the potential unmet need for family planning. In this chapter, data on the desire for additional childrcn, preferred birth intervals, ideal family size, mistimed and unwanted pregnancies and the potential need for family planning are examined. The SDHS questionnaire included a number of questions to ascertain fertility preferences. Only currently married women were asked the question, "Would you like to have a (another) child or would you prefer not to have any (more) children?" The words in parentheses were used for women who had already given birth. For pregnant women, the question was prefixed by the wording, "After the child you are expecting . . . . " Women who wanted additional children were then asked how long they would like to wait before the birth of their next child. All ever-married women were asked how many children they would want to have if they could go back to the time when they did not have any children and choose the exact number to have in their whole life. This is called "ideal family size." Finally, women who had a birth in the five years before the survey were asked whether at the time they got pregnant with their last child, they had wanted to have that child then, later, or not at all. In interpreting the results, it should be remembered that women may tend to rationalize the births they already have and, consequently, may be reluctant to state a number that is less than their achieved family size or to report mistimed or unwanted births in the past. Interpretation of data on fertility preferences has long been the subject of controversy. Survey questions have been criticized on the grounds that answers arc misleading because: (a) they may reflect unformed, ephemeral views, which are held with weak intensity and little conviction; and (b) they may not take into account the effect of social pressures or the attitudes of other family members, particularly the husband, who may exert a considerable influence over reproductive decisions. The first objection has greater force in low contraceptive prevalence countries such as Sudan, where the idea of being able to control one's fertility is limited. The second objection may be correct in theory; however, in practice, its importance is doubtful. For instance, the evidence from surveys in which both husbands and wives are interviewed suggests that there is no substantial difference between the views of the two sexes. Considering the low contraceptive prevalence rate in Sudan, caution should be exercised in the interpreting the SDHS findings on fertility preferences. 6.1 DESIRE FOR CHILDREN Fertility Intentions by Current Family Size Table 6.1 shows future reproductive intentions among currently married women by the number of living children (including a current pregnancy). As shown in the table and in Figure 6.1, one of three currently married women wants to have a child within two years. Thirty-two percent would like to postpone the next birth for two or more years. About 25 percent of currently married women say that they do not want any more children, while 8 percent arc undecided and about 2 percent believe they cannot have any more children (i.e., they are infecund). Thus, about 57 percent of all currently married women can be considered potential users of contraception for the purpose of either spacing births or limiting family size. 65 Future reproductive intentions according to number of l iv ing chi ldren Table 6.1 Percent d istr ibut ion of current ly marr ied women by desire for future children, according to number of l iving children, Sudan DHS 1989-90 Number of l iving chi ldren % Desire for more chi ldren None 1 2 3 4 5 6+ Total W~t no more 0.7 3.3 10.9 16.2 23.3 36.5 49.3 24.9 Want more chi ldren After 2 or more years 7.3 53.0 48.6 40.4 33.1 30.0 16.3 31.9 Within 2 years 85.1 38.0 34.3 34.8 33.2 23.1 18.7 33.1 Unsure about t iming 5.0 2.0 0.3 0.1 0.2 0.4 0.3 0.9 Undea id~ 1.2 3.7 5.0 7.4 8.7 9.0 11.5 7.5 Dec la red Infeaund 0.7 0.0 0.8 1.2 1.6 I.i 3.7 1.7 Migming 0.0 0.0 0,0 0.0 0.0 0.0 0.2 0.1 Total percent I00.0 I00.0 I00.0 i00.0 100.0 I00.0 I00.0 100.0 Number of wcaen 423 810 740 679 623 554 1571 5400 I Includes current pregnancy. F igure 6.1 Fertility Preferences among Currently Married Women 15-49 W,r t | More In 2- yre 32% Note: Undeolded tnolUdel tho le who want more but ere un lur l about timing (l~k), Went No More 25% Sudan OH8 198e-90 66 The proportion of currently married women who want to stop childbearing rises with the number of living children, from less than 1 percent of childless women, to one-quarter of those with four children, to one-half of women with six or more children (see Figure 6.2). In terms of the proportion of women who want no more children, when Sudan is compared with other African countries in which DHS surveys were carried out, it is about in the middle. Figure 5.2 Fertility Preferences among Currently Married Women 15-49 by Number of Living Children Peroenl 1 O0 ~ ~ j f j f j j j j j ~ j ~ ~ s°b ~ 2 60 "m 4o 2o 0 0 1 2 3 & 5 6* Number of Living Children L ; Wtnt nomoro ~ InMound I-'~ Went to walt I Wsnt lOOn ~ Undecided 8udon DH8 lgsg-go For those who want to space (i.e., those who want another child after two years or more), the pattern is different. Seven percent of childless women want to wait at least two years to have their first child, compared with 53 percent of those with one child. Thereafter, the proportion of women who want to space declines steadily to a low of 16 percent among women with six or more children. The desire to have a child soon, that is, within two years of the time of the interview, also declines as the number of children increases. For example, while 38 percent of women with one child want to have another child soon, the proportion decreases slightly to 33 percent of women with four children, then drops sharply to 23 percent for women with five children. The proportion of mothers with at least six children who want to have another child soon (19 percent) is half that of mothers with one child. The findings presented in Table 6.1 indicate there is a strong desire for children in Sudanese society; even among women with six or more children, more than one-third (35 percent) stiU want to have more children. On the other hand, spacing of children is also strongly desired, even among women with only one or two children. Around half of mothers with one or two children want to wait at least two years for the next child. 67 Reproductive Intentions by Age Table 6.2 presents the percent distribution of currently married women by future reproductive intentions according to age. The proportion of women who want no more children is only 3 percent in the youngest age group, but increases to 15 percent among those in age group 25-29. It is interesting to note that the proportion of women who express the desire to cease childbearing increases approximately 10 percentage points with each succeeding age group, reaching 55 percent for women in age group 45-49. Future reproduct ive intent ions according to age Table 6.2 Percent d istr ibut ion of current ly marr ied women by desire for future children, according to age, Sudan DHS 1989-90 Age Desire for more chi ldren 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Want no more 3.0 7.9 15.3 24,0 36.3 46.0 55.4 24.9 Want more c}~lldren After 2 or more years 47.1 49.7 42.8 34.2 17.8 9.9 4.9 31,9 Within 2 years 41.1 36.1 34.5 31.3 32.9 29.8 24.5 33,1 Unsure about t iming 4.4 1.4 0.4 0.8 0.2 8.4 0.7 0.9 Undec ided 4.1 4.9 6.8 8.2 11.4 9.4 6.0 7.5 Dec la red £nfecund 0.3 0.0 0.2 1.4 1.4 4.4 8.2 1.7 Miss in~ 0.0 0.O 0.0 0,I 0.0 0.O 0.4 O.l Total ~roent 100.O I00.0 100.0 I00.0 100.0 I00.0 i00,0 i00,0 N%~¢ of women 367 900 1276 906 955 543 453 5400 The pattem is different for women who want to wait two or more years to have another child. With the exception of the first age-group (15-19), the proportion of women wanting another child after two or more years declines sharply with age. Almost half of the women age 20-24 want to wait two or more years for their next child, compared with one-third of those age 30-34. Among women age 45-49 only 5 percent want to postpone their next birth. The desire for additional children within two years declines as the woman's age increases (see Table 6.2). This is because younger women are likely to have fewer children, while the older women have many. The desire for another child within the next two years is greatest among women in their teens, 41 percent of whom want to have a child soon; desire is lowest among those age 45-49 (25 percent). The proportion of women who declared themselves infecund is very low in the age groups under 30 (0.3 percent or less); however, it increases to 8.2 percent among women age 45-49. 68 Other Differentials in Reproductive Intentions Table 6.3 shows the percentage of currently married women who want no more children by the number of living children they already have, according to urban-rural residence, region of residence and education. A substantial difference can be observed in the reproductive intentions of urban and rural women; 30 percent of urban women do not want to have another child, compared with 22 percent of rural dwellers. This is true despite the fact that rural women already have more children than urban women (see Table 3.1). The desire for smaller families among urban women can be seen by the fact that, among those with six or more children, 60 percent want no more children, while only 43 percent of rural women desire to stop with that family size. Desire to l imit chi ldbear ing Table 6.3 Percentage of currently married women who want no more children by number of l iving chi ldren and selected background characteristics, Sudan DHS 1989-90 Number of l iv ing chi ldren I Want no more chi ldren None 1 2 3 4 5 6+ Total Resldene* Urban 0.6 1.7 14.3 22.2 30.7 44.4 60.3 30.4 Rural 0.8 4.3 9.1 13.0 18.5 31.7 43.2 21.7 Region Khartoum 0.8 3.9 21.3 23.2 39.2 49.6 66.3 32.8 Northern 3.3 3.8 9.5 27.5 29.8 62.2 66.0 54.8 Eastern 0.0 8.2 9.7 12.5 14.8 24,2 39.3 17.5 Central 0.0 0.5 9.2 11.7 19.0 32.5 46.0 23.0 Kordofan 2.0 4.5 7.6 22.0 24.1 29.4 50.7 27.9 Darfur 0.0 2.4 5.7 8.1 14.4 29.3 34.7 16.6 Eduaation No education 1.2 5.3 9.2 12.6 17.2 31.4 44.6 25.1 Primary incomplete 0.0 4.4 11.9 22.5 27.4 36.9 60.7 31.9 Primary complete 0.0 1.1 7.3 12.1 29.8 55.6 54.8 16.0 Junior secondary 0.0 1.0 12.3 16.4 34.1 48.1 74.3 18.3 Senior secondary+ 1.4 0.7 19.8 29.2 00.0 83.3 81.3 19.3 Total 0.7 3.3 10.9 16.2 23.3 36.5 49.3 24.9 iIncludes current pregnancy. An examination of regional differences reveals that the percentage of women who want no more children is highest in the Northern region (35 percent) and Khartoum (33 percent); it is lowest in the Darfur and Eastern regions (about 17 percent). The Central (23 percent) and Kordofan (28 percent) regions fall in the middle. This pattern generally holds true regardless of the number of living children. For women with three children or less, there is no consistent relationship between mother's level of education and the desire to limit family size. However, among women with four or more children, 69 there is generally a positive relationship between education and desire to limit children, that is, women with higher levels of education are more likely to say that they want to stop having children. 6.2 IDEAL FAMILY S IZE In order to obtain greater insight into fertility preferences among Sudanese women, all ever- married women, irrespective of their current family size, were asked a hypothetical question about the number of children they would choose to have if they could start their reproductive years again. Those who gave non-numeric responses were not forced to give an exact number. Table 6.4 presents the distribution of ever-married women by ideal number of children, according to the actual number of living Ideal number of chi ldren Table 6.4 Percent d ist r ibut ion of ever-marr ied women by ideal number of chi ldren and mean ideal number of chi ldren for ever-marr ied and current ly marr ied women, according to number of l iving children, Sudan DHS 1989-90 Number of l iving chi ldren I Ideal number of chi ldren None 1 2 3 4 5 6+ Total 8 0.4 0.2 0.5 0.I 0.4 8.0 0.2 0.3 1 0.8 0.8 0.6 0.3 0.3 0.0 0.i 0.4 2 5.0 5.7 5.6 2.4 3.9 4.1 2.1 3.8 3 9.6 8.8 5.3 6.5 1,9 3.2 1.9 4.7 4 18.6 20.1 18.1 12.6 ]3,7 6.1 5.6 12.5 5 7.8 ii.i 8.9 8.7 6,7 7,7 3.3 7.2 6+ 22.6 18.9 22.6 24.6 27.5 27.3 28.9 24.0 Non-nu~er lc relporuse 35.1 35.2 38.3 44.8 45.6 51.2 61.9 47.2 As many as God sends 32.1 38.3 33.6 39.1 41.0 44.4 55.0 41.6 Dont care 0.4 8.9 8.9 0.9 1.2 0.7 1.0 8.9 Dont know 2.6 3.7 3.6 4.6 3.1 6.1 5.7 4.4 Other 0.8 8.2 8.2 0.i 0.3 8.8 0.2 8.2 Miss ing 0.8 8.0 8.1 0.0 0.0 0.3 0.2 8.1 Total percent 100.8 108.0 108.0 108.0 100.8 100.8 188.0 108.0 N~Lber of ever- mar r iea women 499 699 807 739 673 586 1657 5860 Ever -marr ied women 2 Mean 5.i 4.9 5.5 5.7 5.8 6.5 7.2 5.8 Number of women 324 583 497 408 366 288 628 3890 Current ly marr ied women 2 Mean 5.8 4.8 5.6 5.8 5.8 6.5 7.2 5.9 Number of women 280 525 456 378 338 273 605 2855 l lncludes current pregnancy. 2Excludes women giving non-numeric responses. 70 children (including current pregnancy). It should be noted that almost half of the respondents (47 percent) gave a non-numeric response to the hypothetical question on ideal family size. This failure to specify an ideal family size suggests either an absence of conscious consideration about family size, or a strong fatalistic belief that family size is determined by God. Interestingly, currently married women who were undecided about their future reproductive intentions and those who wanted to have more children but were not sure about the timing, were most likely to give non-numeric responses, 76 percent and 65 percent, respectively (not shown in the table). The overall proportion of non-numeric answers was higher in Sudan than in any other DHS survey. Only women who gave a numeric response are represented in the following discussion. Large families are much desired in Sudan. Twenty-four percent of all women interviewed (45 percent of those who gave numeric responses) consider six or more children to be the ideal family size; 13 percent think the ideal number of children is four. Overall, less than 10 percent of the women interviewed consider the ideal family size to be three children or less. The mean ideal family size based on numeric responses is 5.8 for ever-married women and 5.9 for currently married women. Ideal family size tends to increase with family size, which may reflect the fact that women who want more children actually end up having them, or that some women with large families find it difficult to admit that ideally they would like to have had fewer children. It is also possible that desired family size is declining and that younger women who are just starting their families actually want fewer children than their mothers. Table 6.5 shows the mean ideal number of children for ever-married women by age group and selected background characteristics. The table also shows the proportion of women who gave non- numeric answer by age group (last row) and by background characteristics (last column). It should be noted that level of education is inversely related to the likelihood of a non-numeric response being given. Uneducated women are more likely to give a non-numeric responses (61 percent) than those who have attended school (38 percent of women with primary incomplete schooling; 12 percent of those with senior secondary education). Older women prefer larger families than younger women. The mean ideal number of children steadily increases from 5.0 for women age 15-19 years to 7.4 for women age 45-49, although almost 60 percent of women over 40 did not give a numeric response. If younger women have only the number of children they desire, fertility rates will decline in the future. The mean ideal number of children for rural women (6.3) is one child greater than for urban women (5.3). In all age groups, rural women desire larger families than urban women, with the differences being increasingly more pronounced at the older ages. Differentials by region are even more striking. In Khartoum and the Northem region, desired family size is about 5 children, while in the Eastern and Central regions it is about 6 and in the Kordofan region it is 6.5. The highest mean ideal number of children is in Darfur, 6.9, which is two children more than the ideal expressed by women in Khartoum. t However, it should be pointed out that the mean ideal family size is calculated based on only 30 percent of the women in Darfur, compared with 75 percent of the women in Khartoum who give numeric responses. Regarding education, the mean ideal family size drops sharply from 6.8 for women with no schooling to 5.0 or less for those who have completed primary school. Women with senior secondary education have the smallest ideal family size (4.4). Smaller ideal family size for women with schooling is generally true for each age group, though some means are based on small numbers of cases. 1 The mean ideal number of children for currently married women

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