Tajikistan Demographic and Health Survey 2012

Publication date: 2013

Tajikistan Demographic and Health Survey 2012 Tajikistan 2012 D em ographic and H ealth Survey TAJIKISTAN DEMOGRAPHIC AND HEALTH SURVEY 2012 Statistical Agency under the President of the Republic of Tajikistan Dushanbe, Tajikistan Ministry of Health Dushanbe, Tajikistan MEASURE DHS ICF International Calverton, Maryland, USA November 2013 Statistical Agency under the President of the Republic of Tajikistan Ministry of Health of the Republic of Tajikistan Cover motif: Ceiling fragment at Rohat’s teahouse, Dushanbe Courtesy photo ©2013 Benoit Mathivet This report summarizes the findings of 2012 Tajikistan Demographic and Health Surveys (TjDHS) conducted by the Statistical Agency under the President of the Republic of Tajikistan in collaboration with the Ministry of Health. Support for the 2012 TjDHS was provided by the United States Agency for International Development (USAID) as part of the MEASURE DHS project. Additional funding and support for the 2012 TjDHS was received from the United Nations Population Fund (UNFPA). The TjDHS is part of the worldwide Demographic and Health Surveys program, which is designed to collect data on fertility, family planning, and maternal and child health. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID, the government of Tajikistan, or donor organizations. Additional information about the 2012 TjDHS may be obtained from the Statistical Agency under the President of the Republic of Tajikistan: 17 Bokhtar Street, Dushanbe, Tajikistan; Telephone 992-372-23- 02-45, Fax: 992-372-21-43-75, E-mail: stat@tojikiston.com. Information about the MEASURE DHS project may be obtained from ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: info@measuredhs.com, Internet: http://www.measuredhs.com. Suggested citation: Statistical Agency under the President of the Republic of Tajikistan (SA), Ministry of Health [Tajikistan], and ICF International. 2013. Tajikistan Demographic and Health Survey 2012. Dushanbe, Tajikistan, and Calverton, Maryland, USA: SA, MOH, and ICF International. Contents • iii CONTENTS LIST OF TABLES AND FIGURES . ix ACKNOWLEDGEMENTS . xv MDG TABLE . xvii MAP OF COUNTRY . xviii 1 INTRODUCTION 1.1 Geography and Population . 1 1.2 History of Tajik Culture . 2 1.3 Economy . 3 1.4 Health Care System . 3 1.4.1 Facilities and Human Resources . 3 1.4.2 Health Care Reforms . 4 1.4.3 Primary and Secondary Health Care . 5 1.4.4 Maternal and Child Health Care . 5 1.4.5 Family Planning Services . 6 1.4.6 Tuberculosis DOTS Program . 7 1.4.7 HIV/AIDS Program . 7 1.5 Systems for Collecting Demographic and Health Data . 8 1.6 Objectives and Organization of the Survey . 9 1.6.1 Sample Design and Implementation . 9 1.6.2 Questionnaires . 9 1.6.3 Training of Field Staff . 10 1.6.4 Fieldwork and Data Processing. 10 1.7 Response Rates . 11 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2.1 Housing Characteristics . 14 2.1.1 Drinking Water . 14 2.1.2 Sanitation Facilities . 16 2.1.3 Other Dwelling Characteristics . 17 2.2 Household Possessions . 19 2.3 Household Wealth . 20 2.4 Hand Washing . 21 2.5 Household Population by Age and Sex . 22 2.6 Household Composition . 23 2.7 Birth Registration . 24 2.8 Children’s Living Arrangements . 25 2.9 Education of Household Members . 27 2.9.1 Educational Attainment . 27 2.9.2 School Attendance . 29 2.9.3 Early Childhood Education . 31 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3.1 Background Characteristics of Respondents . 33 3.2 Educational Attainment by Background Characteristics . 34 3.3 Media Exposure . 35 3.4 Employment . 36 iv • Contents 3.4.1 Employment Status . 37 3.4.2 Occupation . 38 3.4.3 Type of Employment . 39 3.5 Tuberculosis . 40 3.5.1 Knowledge and Attitudes about Tuberculosis . 40 3.5.2 Knowledge of Tuberculosis Symptoms . 42 3.5.3 Misconceptions about How Tuberculosis is Spread . 44 3.5.4 Knowledge about How to Prevent Tuberculosis . 44 3.6 Hypertension . 46 3.7 Smoking . 48 4 MARRIAGE AND SEXUAL ACTIVITY 4.1 Current Marital Status . 49 4.2 Age at First Marriage . 50 4.3 Age at First Intercourse . 51 4.4 Recent Sexual Activity . 52 5 FERTILITY 5.1 Current Fertility . 55 5.2 Fertility Differentials . 58 5.3 Fertility Trends . 60 5.4 Children Ever Born and Living . 60 5.5 Birth Intervals . 61 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 63 5.7 Menopause . 65 5.8 Age at First Birth . 65 5.9 Teenage Pregnancy and Motherhood . 66 6 FERTILITY PREFERENCES 6.1 Desire for More Children . 69 6.2 Desire to Limit Childbearing . 71 6.3 Ideal Family Size . 72 6.4 Fertility Planning . 73 6.5 Wanted Fertility Rates . 74 7 FAMILY PLANNING 7.1 Knowledge of Contraceptive Methods . 77 7.2 Current Use of Contraception . 78 7.3 Current Contraceptive Use by Background Characteristics . 80 7.4 Trends in Current Contraceptive Use . 82 7.5 Source of Modern Contraceptive Methods . 83 7.6 Informed Choice . 84 7.7 Contraceptive Discontinuation . 85 7.8 Knowledge of the Fertile Period . 87 7.9 Unmet Need for Family Planning . 88 7.10 Future Use of Family Planning . 90 7.11 Exposure to Family Planning Messages . 91 7.12 Family Planning Discussion with Health Providers . 92 8 ABORTION 8.1 Collection of Abortion Data . 93 8.2 Pregnancies Ending in Induced Abortion . 93 8.3 Lifetime Experience with Induced Abortion . 94 8.4 Rates of Induced Abortion . 96 8.4.1 Abortion Level . 96 8.4.2 Abortion Differentials . 97 8.4.3 Abortion Trends . 98 8.5 Use of Contraception before Abortion . 98 Contents • v 9 INFANT AND CHILD MORTALITY 9.1 Source and Assessment of Mortality Data . 101 9.1.1 Source of the Data . 101 9.1.2 Data Quality . 102 9.2 Levels and Trends in Childhood Mortality . 103 9.3 Socioeconomic Differentials in Childhood Mortality . 104 9.4 Demographic Differentials in Childhood Mortality . 105 9.5 Perinatal Mortality . 106 9.6 High-risk Fertility Behavior . 108 9.7 Registration of Child Deaths . 109 10 MATERNAL HEALTH 10.1 Antenatal Care . 112 10.1.1 Antenatal Care Coverage . 112 10.1.2 Number of Antenatal Visits . 114 10.1.3 Components of Antenatal Care . 114 10.2 Delivery Care . 116 10.2.1 Place of Delivery. 116 10.2.2 Assistance during Delivery . 118 10.2.3 Cesarean Section . 120 10.3 Postnatal Care for Mothers and Children . 120 10.3.1 Postnatal Checkup for Mother . 120 10.3.2 Postnatal Checkup for the Newborn . 123 10.4 Breast Cancer Awareness and Testing . 124 10.5 Awareness of Cervical Cancer . 126 10.6 Visits to Family Doctor . 127 10.7 Problems in Accessing Health Care . 129 11 CHILD HEALTH 11.1 Child’s Size at Birth . 131 11.2 Vaccination of Children . 133 11.2.1 Vaccination Coverage . 133 11.2.2 Differentials in Vaccination Coverage . 135 11.2.3 Trends in Vaccination Coverage . 136 11.3 Childhood Illness and Treatment . 136 11.3.1 Acute Respiratory Infections (ARI) . 136 11.3.2 Fever . 138 11.3.3 Diarrhea . 139 11.3.4 Knowledge of ORS . 143 11.4 Stool Disposal . 144 12 NUTRITION OF CHILDREN AND WOMEN 12.1 Nutritional Status of Children . 147 12.1.1 Measurement of Nutritional Status among Young Children . 148 12.1.2 Levels of Child Malnutrition . 149 12.1.3 Trends in Children’s Nutritional Status . 151 12.2 Breastfeeding and Complementary Feeding . 153 12.2.1 Initiation of Breastfeeding . 153 12.3 Breastfeeding Status by Age . 155 12.4 Duration of Breastfeeding . 157 12.5 Types of Complementary Foods . 158 12.6 Infant and Young Child Feeding Practices . 160 12.7 Micronutrient Intake among Children . 162 12.7.1 Consumption of Micronutrient-rich Foods . 164 12.7.2 Micronutrient Supplementation . 164 12.7.3 Deworming . 165 vi • Contents 12.8 Household Iodized Salt Consumption . 165 12.9 Nutritional Status of Women . 166 12.10 Micronutrient Intake among Mothers . 168 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13.1 Knowledge of HIV/AIDS and Transmission and Prevention Methods . 172 13.1.1 Knowledge of AIDS . 172 13.1.2 Knowledge of HIV Prevention Methods . 173 13.1.3 Comprehensive Knowledge about AIDS . 174 13.2 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 176 13.3 Attitudes towards People Living with HIV . 177 13.4 Attitudes toward Negotiating Safe Sexual Relations with Husbands . 179 13.5 Attitudes towards Condom Education for Youth . 180 13.6 Multiple Sexual Partners . 181 13.7 Coverage of HIV Counseling and Testing . 182 13.8 Self-reported Prevalence of Sexually Transmitted Infections (STIs) and STI Symptoms . 184 13.9 Prevalence of Medical Injections. 186 13.10 HIV/AIDS Knowledge and Sexual Behavior Among Youth . 187 13.10.1 HIV/AIDS-Related Knowledge among Young Adults . 188 13.10.2 Age at First Sexual Intercourse among Young Adults . 189 13.10.3 Cross-Generational Sexual Partners . 190 13.10.4 Voluntary HIV Counseling and Testing among Young Adults . 190 14 DOMESTIC VIOLENCE 14.1 Measurement of Violence . 193 14.1.1 Use of Valid Measures of Violence . 193 14.1.2 Ethical Considerations in Measuring Violence . 195 14.2 Experience of Physical Violence . 195 14.3 Experience of Sexual Violence . 197 14.4 Experience of Different Forms of Violence . 199 14.5 Violence during Pregnancy . 200 14.6 Marital Control by Husband . 200 14.7 Forms of Spousal Violence . 202 14.8 Differentials in Spousal Violence . 204 14.9 Recent Experience of Spousal Violence . 207 14.10 Onset of Spousal Violence . 209 14.11 Physical Consequences of Spousal Violence . 209 14.12 Violence by Women against Their Spouse . 210 14.13 Help-seeking Behavior by Women Who Experience Violence . 212 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Employment and Form of Earnings . 216 15.2 Women’s Control over Their Own Earnings . 216 15.3 Women’s Control over their Husband’s Earnings . 218 15.4 Ownership of Assets . 219 15.5 Women’s Empowerment . 221 15.6 Attitudes toward Wife Beating . 223 15.7 Indicators of Women’s Empowerment . 225 15.8 Current Use of Contraception by Women’s Empowerment . 226 15.9 Ideal Family Size and Unmet Need by Women’s Empowerment . 227 15.10 Reproductive Health Care by Women’s Empowerment . 228 15.11 Infant and Child Mortality and Women’s Empowerment . 229 REFERENCES . 231 Contents • vii APPENDIX A A.1 Introduction . 237 A.2 Sample Frame . 237 A.3 Sampling Procedures and Sample Allocation . 238 A.4 Sample Probabilities and sampling weights . 238 A.5 Survey Results . 239 APPENDIX B . 241 APPENDIX C . 253 APPENDIX D . 259 APPENDIX E . 263 Tables and Figures • ix TABLES AND FIGURES 1 INTRODUCTION Table 1.1 Basic demographic indicators . 2 Table 1.2 Results of the household and individual interviews . 11 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION Table 2.1 Household drinking water . 14 Table 2.2 Household sanitation facilities . 16 Table 2.3 Household characteristics . 17 Table 2.4 Household possessions . 19 Table 2.5 Wealth quintiles . 21 Table 2.6 Hand washing . 22 Table 2.7 Household population by age, sex, and residence . 22 Table 2.8 Household composition . 24 Table 2.9 Birth registration of children under age 5 . 25 Table 2.10 Children's living arrangements and orphanhood . 26 Table 2.11.1 Educational attainment of the female household population . 28 Table 2.11.2 Educational attainment of the male household population . 28 Table 2.12 School attendance ratios . 29 Table 2.13 Early childhood education . 32 Figure 2.1 Trends in use of improved drinking water sources, Tajikistan 2000, 2005, and 2012 . 15 Figure 2.2 Population pyramid . 23 Figure 2.3 Age-specific attendance rates of the de facto population 7 to 24 years . 31 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 34 Table 3.2 Educational attainment . 35 Table 3.3 Exposure to mass media . 36 Table 3.4 Employment status . 37 Table 3.5 Occupation . 39 Table 3.6 Type of employment . 40 Table 3.7 Knowledge and attitude concerning tuberculosis . 41 Table 3.8 Knowledge of symptoms of tuberculosis . 43 Table 3.9 Misconceptions about tuberculosis transmission . 44 Table 3.10 Women's report on how to prevent spreading of tuberculosis . 45 Table 3.11 Knowledge and treatment of high blood pressure . 47 Figure 3.1 Women's employment status in the past 12 months. 38 Figure 3.2 Women ever told they had hypertension by Body Mass Index . 48 4 MARRIAGE AND SEXUAL ACTIVITY Table 4.1 Current marital status . 49 Table 4.2 Age at first marriage . 50 Table 4.3 Median age at first marriage by background characteristics . 51 Table 4.4 Age at first sexual intercourse . 51 Table 4.5 Median age at first sexual intercourse by background characteristics . 52 Table 4.6 Recent sexual activity: Women . 53 x • Tables and Figures 5 FERTILITY Table 5.1 Current fertility . 56 Table 5.2 Fertility by background characteristics . 59 Table 5.3 Trends in age-specific fertility rates . 60 Table 5.4 Children ever born and living . 61 Table 5.5 Birth intervals . 62 Table 5.6 Postpartum amenorrhea, abstinence and insusceptibility . 63 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 64 Table 5.8 Menopause . 65 Table 5.9 Age at first birth . 65 Table 5.10 Median age at first birth . 66 Table 5.11 Teenage pregnancy and motherhood . 67 Figure 5.1 Age-specific fertility rates by urban-rural residence . 57 Figure 5.2 Comparison of TFR in Tajikistan with other countries in the region . 58 Figure 5.3 Fertility differentials . 58 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . 70 Table 6.2 Desire to limit childbearing . 71 Table 6.3 Ideal number of children by number of living children . 72 Table 6.4 Mean ideal number of children, by background characteristics . 73 Table 6.5 Fertility planning status . 74 Table 6.6 Wanted fertility rates . 75 Figure 6.1 Fertility preferences among currently married women age 15-49 . 70 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods . 78 Table 7.2 Current use of contraception by age . 79 Table 7.3 Current use of contraception by background characteristics . 81 Table 7.4 Trends in current use of contraception . 82 Table 7.5 Source of modern contraception methods . 84 Table 7.6 Informed choice . 85 Table 7.7 Twelve-month contraceptive discontinuation rates . 86 Table 7.8 Reasons for discontinuation . 87 Table 7.9 Need and demand for family planning among currently married women . 90 Table 7.10 Future use of contraception . 91 Table 7.11 Exposure to family planning messages . 91 Table 7.12 Contact of nonusers with family planning providers . 92 Figure 7.1 Current contraceptive use among currently married women age 15-49 . 80 Figure 7.2 Trends in current contraceptive use among currently married women, Tajikistan 2000, 2005, and 2012 . 83 Figure 7.3 Perceived fertile period among all women age 15-49 . 88 8 ABORTION Table 8.1 Pregnancy outcome by background characteristics . 94 Table 8.2 Lifetime experience with induced abortion . 95 Table 8.3 Induced abortion rates . 96 Table 8.4 Induced abortion rates by background characteristics . 97 Table 8.5 Trends in age-specific abortion rates . 98 Table 8.6 Use of contraception before pregnancy . 99 Figure 8.1 Age-specific fertility rates and induced abortion rates. 97 Tables and Figures • xi 9 INFANT AND CHILD MORTALITY Table 9.1 Early childhood mortality rates . 103 Table 9.2 Early childhood mortality rates by socioeconomic characteristics . 105 Table 9.3 Early childhood mortality rates by demographic characteristics . 106 Table 9.4 Perinatal mortality . 107 Table 9.5 High-risk fertility behavior . 108 Figure 9.1 Trends in Infant and Child Mortality, Tajikistan 1998-2012 . 104 Figure 9.2 Registration of deaths of children born in the five years prior to the 2012 Tajikistan DHS . 109 10 MATERNAL HEALTH Table 10.1 Antenatal care . 112 Table 10.2 Number of antenatal care visits and timing of first visit . 114 Table 10.3 Components of antenatal care . 115 Table 10.4 Place of delivery . 116 Table 10.5 Assistance during delivery . 119 Table 10.6 Timing of first postnatal checkup for the mother . 121 Table 10.7 Type of provider of first postnatal checkup for the mother . 122 Table 10.8 Timing of first postnatal checkup for the newborn . 123 Table 10.9 Type of provider of first postnatal checkup for the newborn . 124 Table 10.10 Knowledge about breast cancer and symptoms of breast cancer . 125 Table 10.11 Breast examinations . 126 Table 10.12 Knowledge about cervical cancer and Pap smear testing . 127 Table 10.13 Family doctor . 128 Table 10.14 Problems in accessing health care . 130 Figure 10.1 Differentials in coverage of antenatal care from a skilled provider, Tajikistan, 2012 . 113 Figure 10.2 Differentials in percentage of births delivered in health facilities, Tajikistan, 2012 . 117 Figure 10.3 Duration of mother's stay in health facility after giving birth . 118 11 CHILD HEALTH Table 11.1 Child's size and weight at birth . 132 Table 11.2 Vaccinations by source of information . 134 Table 11.3 Vaccinations by background characteristics . 135 Table 11.4 Prevalence and treatment of symptoms of ARI . 137 Table 11.5 Prevalence and treatment of fever . 138 Table 11.6 Prevalence of diarrhea . 139 Table 11.7 Diarrhea treatment . 141 Table 11.8 Feeding practices during diarrhea . 142 Table 11.9 Knowledge of ORS packets . 143 Table 11.10 Disposal of children's stools . 144 Figure 11.1 Percentage of children age 18-29 months with specific vaccinations, Tajikistan 2012 . 134 Figure 11.2 Differentials in vaccination coverage, Tajikistan 2012 . 136 12 NUTRITION OF CHILDREN AND WOMEN Table 12.1 Nutritional status of children . 149 Table 12.2 Initial breastfeeding . 154 Table 12.3 Breastfeeding status by age . 155 Table 12.4 Median duration of breastfeeding . 158 Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview . 159 xii • Tables and Figures Table 12.6 Infant and young child feeding (IYCF) practices . 161 Table 12.7 Micronutrient intake among children . 163 Table 12.8 Presence of iodized salt in household . 166 Table 12.9 Nutritional status of women . 167 Table 12.10 Micronutrient intake among mothers . 169 Figure 12.1 Nutritional status of children by age . 150 Figure 12.2 Trends in nutritional status of children under age 5, Tajikistan 2012 . 152 Figure 12.3 Infant feeding practices by age, Tajikistan 2012 . 156 Figure 12.4 Infant and young child feeding indicators on breastfeeding status, Tajikistan 2012 . 157 Figure 12.5 IYCF indicators on minimum acceptable diet, Tajikistan 2012 . 162 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 13.1 Knowledge of AIDS . 172 Table 13.2 Knowledge of HIV prevention methods . 173 Table 13.3 Comprehensive knowledge about AIDS . 175 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 177 Table 13.5 Accepting attitudes toward those living with HIV/AIDS . 178 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 179 Table 13.7 Adult support of education about condom use to prevent AIDS . 180 Table 13.8 Multiple sexual partners . 181 Table 13.9 Coverage of prior HIV testing . 182 Table 13.10 Pregnant women counseled and tested for HIV . 184 Table 13.11 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms . 185 Table 13.12 Prevalence of medical injections . 187 Table 13.13 Comprehensive knowledge about AIDS and of a source of condoms among young women . 188 Table 13.14 Age at first sexual intercourse among young women . 189 Table 13.15 Age-mixing in sexual relationships among women age 15-19 . 190 Table 13.16 Recent HIV tests among young women . 191 Figure 13.1 Knowledge about AIDS and HIV prevention methods among women age 15-49, Tajikistan 2012 . 174 Figure 13.2 Knowledge about AIDS transmission, Tajikistan 2012 . 176 Figure 13.3 Treatment seeking for STI symptoms among women age 15-49, Tajikistan 2012 . 186 14 DOMESTIC VIOLENCE Table 14.1 Experience of physical violence . 196 Table 14.2 Persons committing physical violence . 197 Table 14.3 Experience of sexual violence. 198 Table 14.4 Persons committing sexual violence . 199 Table 14.5 Experience of different forms of violence . 199 Table 14.6 Experience of violence during pregnancy . 200 Table 14.7 Marital control exercised by husbands . 201 Table 14.8 Forms of spousal violence . 203 Table 14.9 Spousal violence by background characteristics . 205 Table 14.10 Spousal violence by husband's characteristics and empowerment indicators . 206 Table 14.11 Physical or sexual violence in the past 12 months by any husband/ partner . 208 Table 14.12 Experience of spousal violence by duration of marriage . 209 Table 14.13 Injuries to women due to spousal violence . 209 Table 14.14 Violence by women against their spouse . 210 Table 14.15 Women's violence against their husband by husband's characteristics and empowerment indicators . 211 Tables and Figures • xiii Table 14.16 Help seeking to stop violence . 212 Table 14.17 Sources for help to stop the violence . 213 Figure 14.1 Percentage of ever-married women age 15-49 who have experienced specific types of violence from current or most recent husband, ever and in the last 12 months, Tajikistan 2012 . 203 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women . 216 Table 15.2.1 Control over women's cash earnings and relative magnitude of women's cash earnings . 217 Table 15.2.2 Control over men's cash earnings . 218 Table 15.3 Women's control over their earnings and over those of their husbands . 219 Table 15.4 Ownership of assets . 220 Table 15.5 Participation in decision making . 221 Table 15.6 Women's participation in decision making by background characteristics . 222 Table 15.7 Attitude toward wife beating . 224 Table 15.8 Indicators of women's empowerment . 226 Table 15.9 Current use of contraception by women's empowerment . 226 Table 15.10 Ideal number of children and unmet need for family planning, by women's empowerment . 227 Table 15.11 Reproductive health care by women's empowerment . 228 Table 15.12 Early childhood mortality rates by women's status . 229 Figure 15.1 Number of decisions in which currently married women participate, Tajikistan 2012 . 223 APPENDIX A Table A.1 Households . 237 Table A.2 Sample allocation of clusters and households . 238 Table A.3 Sample implementation: Women . 240 APPENDIX B Table B.1 List of selected variables for sampling errors, Tajikistan DHS 2012 . 243 Table B.2 Sampling errors: National sample, Tajikistan 2012 . 244 Table B.3 Sampling errors: Urban sample, Tajikistan 2012 . 245 Table B.4 Sampling errors: Rural sample, Tajikistan 2012 . 246 Table B.5 Sampling errors: Dushanbe sample, Tajikistan 2012 . 247 Table B.6 Sampling errors: GBAO sample, Tajikistan 2012 . 248 Table B.7 Sampling errors: Sughd sample, Tajikistan 2012 . 249 Table B.8 Sampling errors: DRS sample, Tajikistan 2012 . 250 Table B.9 Sampling errors: Khatlon sample, Tajikistan 2012 . 251 APPENDIX C Table C.1 Household age distribution . 253 Table C.2 Age distribution of eligible and interviewed women . 254 Table C.3 Completeness of reporting . 254 Table C.4 Births by calendar years . 254 Table C.5 Reporting of age at death in days . 255 Table C.6 Reporting of age at death in months . 255 Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 256 Acknowledgments • xv ACKNOWLEDGMENTS he Statistical Agency under the President of the Republic of Tajikistan is pleased to present the results of the 2012 Tajikistan Demographic and Health Survey (TjDHS). This survey was sponsored by the United States Agency for International Development (USAID). Additional funding was provided by the United Nations Population Fund (UNFPA) in Tajikistan. The 2012 TjDHS is the first DHS survey to be undertaken in the country. The Statistical Agency wishes to express its appreciation to the Ministry of Health of the Republic of Tajikistan, ICF International, and the TjDHS Steering Committee for their technical assistance and timely support in implementation of this work. The Statistical Agency, in particular, expresses appreciation to the following MEASURE DHS project staff and consultants for their technical support during all stages of survey design and implementation: Dr. Gulnara Semenov, regional coordinator for Europe and Eurasia and the 2012 TjDHS country manager; Alfredo Aliaga, senior sampling specialist; Shawna Kelly, data processing specialist; and Dr. Saida Ismayilova, consultant survey specialist. We also wish to acknowledge the employees of the statistical system of the Republic of Tajikistan for their active participation in and contribution to this work. Over 200 staff members from the Statistical Agency under the President of the Republic of Tajikistan, working in regional, city, and rayon branches of the agency as well as in the State Leading Information Centre, participated in the survey. We hereby extend our gratitude to the government of Tajikistan and to the representatives of local authorities for their support and assistance during the survey process. Above all, we appreciate the co-operation of all the survey respondents who have made the 2012 TjDHS a success. This report was prepared as a joint effort of the Statistical Agency under the President of the Republic of Tajikistan and ICF International staff. Mrs. Bakhtya Muhammadieva Director, Statistical Agency under the President of the Republic of Tajikistan, and National Coordinator, 2012 TjDHS T Millennium Development Goal Indicators • xvii MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators Tajikistan, 2012 Indicator Sex Total Male Female 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under 5 years of age 12.3 11.9 12.1 2. Achieve universal primary education 2.1 Net attendance ratio in primary education1 94.0 93.5 93.8 3. Promote gender equality and empower women 3.1 Ratio of girls to boys in primary, secondary and tertiary education 3.1a Ratio of girls to boys in primary education2 na na 1.0 3.1b Ratio of girls to boys in secondary education2 na na 1.0 3.1c Ratio of girls to boys in tertiary education2 na na 0.3 4. Reduce child mortality 4.1 Under five mortality rate3 51 46 43 4.2 Infant mortality rate3 41 36 34 4.3 Percentage of 1 year old children immunized against measles4 95.0 95.5 95.2 5. Improve maternal health 5.2 Percentage of births attended by skilled health personnel5 na na 87.4 5.3 Contraceptive prevalence rate6 na 27.9 na 5.4 Adolescent birth rate7 na 53.6 na 5.5 Antenatal care coverage 5.5a At least one visit8 na 78.8 na 5.5b Four or more visits9 na 52.5 na 5.6 Unmet need for family planning10 na 22.9 na 6. Combat HIV/AIDS, malaria and other diseases 6.3 Percentage of the population age 15-24 years with comprehensive correct knowledge of HIV/AIDS11 na 8.7 na 6.4 Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years 0.96 0.65 0.81 Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved water source12 94.1 70.6 76.2 7.9 Percentage of population using an improved sanitation facility13 92.9 94.6 94.2 na = Not applicable 1 This is a proxy for MDG indicator 2.1, Net enrollment ratio. The ratio is based on reported attendance, not enrollment, in primary education among primary school age children (7-10 year-olds). The rate also includes children of primary school age enrolled in secondary education and therefore is different from the Net Attendance Ratio (NAR) for primary school presented in this report in Table 2.12. 2 Based on reported net attendance, not gross enrollment, among 7-10 year-olds for primary, 11-17 year-olds for secondary and 18-22 year-olds for tertiary education. 3 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the 5-year period preceding the survey. 4 In Tajikistan, measles vaccinations are given at the age of 12 months (unlike the standard 9 months in many countries). The values presented in the MDG table are for children age 18-29 months who have been vaccinated against measles or MR at any time before the survey. 5 Among births in the five years preceding the survey. 6 Percentage of currently married women age 15-49 using any method of contraception. 7 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19. 8 With a skilled provider. 9 With any healthcare provider. 10 Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 11 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission or prevention of the AIDS virus. 12 Percentage of de jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, protected spring, rainwater collection, or bottled water. 13 Percentage of de jure population whose household has a flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share this facility with other households. xviii • Map of Tajikistan Introduction • 1 INTRODUCTION 1 1.1 GEOGRAPHY AND POPULATION he republic of Tajikistan is a small, landlocked country located in the southeastern region of Central Asia. The territory of Tajikistan covers 142,600 square kilometers and is bordered by Uzbekistan and Kyrgyzstan to the west and north, China to the east, and Afghanistan to the south. The country’s border is about 3,000 kilometers long. The capital city of Tajikistan is Dushanbe. Nearly all of Tajikistan is mountainous, with 93 percent of the country covered by the massive mountain systems of Central Asia—the Trans-Alay range in the North and the Pamir Mountains in the Southeast. Somoni Peak, formerly Communism Peak, is the tallest mountain in Tajikistan and in the former Soviet Union (7,495 meters). Tajikistan’s climate is mainly continental, with mild winters and hot summers, but it varies with the altitude. The climate is arid in the subtropical, southwestern lowlands, which have the highest temperatures, and it changes from semi-arid to polar in the Pamir Mountains in the southeast (Curtis, 1997). Tajikistan’s wealth is in its hydropower resources. Among the countries of the former Soviet Union, Tajikistan is second only to Russia in its water resources and has a greater hydroelectric power capacity than any other country in Central Asia. Tajikistan's glaciers and rivers provide an estimated four percent of the world's hydropower resources. The main rivers are the Syr-Darya, Amu-Darya, and Zarafshan. The majority of Tajikistan's hydroelectric energy is produced by hydroelectric stations, including the Varzob, Kayrakkum, Sarband, Nurek, Baipasi, and Sangtuda. The country’s flora and fauna are wonderfully rich and diverse, and include rare species such as the snow leopard, the Macro Polo sheep, the bar-headed migrating goose, the Bukhara red deer, the desert antelope, and the Siberian ibex. The country is rich in mineral resources; there are many deposits of rare and precious metals such as zinc, lead, bismuth, molybdenum, tungsten, gold, silver, aluminum, antimony, mercury, and fluorspar, as well as coal, gas, oil, and other natural resources. Tajikistan is a sovereign, democratic, secular, and unitary state. It is also a presidential democracy. The president is elected by the citizens of Tajikistan on the basis of a universal, equal, and direct vote for a seven-year term. The last election was held on November 6, 2007; the president of Tajikistan is the head of state and head of the executive branch of government. Tajikistan consists of the two administrative regions (oblasts) of Khatlon and Sughd, the Gorno- Badakhshan Autonomous Oblast (GBAO), the Districts of Republican Subordination (DRS), and Dushanbe City. Each region is further broken down into administrative areas called rayons. There are 58 rayons and 74 towns and urban settlements in Tajikistan. With a population of 8 million in 2013, Tajikistan is the seventh most populous country of the former Soviet Union, following in order, Russia, Ukraine, Uzbekistan, Kazakhstan, Belarus, and Azerbaijan. Approximately 73 percent of the population resides in rural areas. The country is characterized by a high rate of population growth, mainly due to the high (although declining) birth rate (28 per 1,000 population in 2012 as opposed to 39 per 1,000 in 1991) and relatively low death rate (4.3 per 1,000 population in 2012) (SA, 2013b). The size of the resident population enumerated in the 2010 census increased by 24 percent or 1.5 million persons compared with the 2000 census (Table 1.1). As a result of T 2 • Introduction high fertility and population growth rates, Tajikistan has a young population: 35 percent of the population is under age 15, and the percentage over age 65 is relatively small at 3 percent (SA, 2013b). Life expectancy in Tajikistan steadily declined after the collapse of the Soviet Union, especially among men during the civil war (1991-1997). In 1993, life expectancy was 68.0 years for women and 56.4 years for men, a difference of nearly 12 years. By 2012, however, life expectancy had increased to 74.6 years for women and 71.1 years for men, a difference between the sexes of only three and a half years. Tajikistan has a double burden of disease, with the majority of deaths being due to cardiovascular diseases (50 percent of all causes), and with malignant neoplasms (cancers) and respiratory, digestive, infectious, and parasitic diseases also being prevalent. A rapid increase in multidrug-resistant tuberculosis and injection drug use is of particular concern. The population density of Tajikistan is 56 persons per square kilometer. However, the population is unevenly distributed among the regions. The population is mainly concentrated in the cultivated lands and in the industrialized urban areas. The capital of Tajikistan, Dushanbe, with a population of more than 764,000, is the largest city in Tajikistan. Tajikistan is a multinational country. According to the 2010 Population Census, people of more than 100 nationalities live in Tajikistan. The majority are Tajik, constituting more than 85 percent of the population. Other major ethnic groups are the Uzbek, Kyrgyz, Russian, and Turkmen. The official state language is Tajik. Russian is widely spoken as the language of “inter-ethnic” communication. Any nationality or ethnic group living in Tajikistan has the right to freely use its own language. The Tajik language belongs to the Persian group of languages. 1.2 HISTORY OF TAJIK CULTURE Tajikistan is one of the world’s most ancient civilizations. Around the 6-4 centuries B.C., much of what is today Tajikistan was part of the Achaemenid Empire, founded by the Persians. The Bactrians and the Sogdians, ancient inhabitants of Central Asia and ancestors of modern Tajik, were involved in agriculture, trade, and craftsmanship. The formation of the Tajik nation was completed under the Samanids. In the eighteenth century, the territory of what is today modern Tajikistan was home for the Kulab, Gissar, Karategin, Darvaz, Vahan, and Shugnan principalities. Throughout its history, the territory inhabited by the Tajiks was under control of many different states and khanates. In the second half of the nineteenth century, the Russian Empire annexed multiple territories in the Central Asia principalities and established the Governorate-General of Turkestan, which included territories in the northern parts of modern Tajikistan and Pamir, while the central and southern parts, the so-called Eastern Bukhara, came under control of the Bukhara Khanate, also subordinate to Russian Empire. The October 1917 Russian Revolution ended the tsarist autocracy, and the Soviets took power in Russia and Central Asia. In 1918, the newly proclaimed Turkestan Autonomous Soviet Socialist Republic (ASSR) became a part of the Russian Federation. In 1924, after the dissolution of the Turkestan ASSR, the Tajikistan Autonomous Soviet Socialist Republic was created as a part of Uzbekistan. In 1929, the Soviet government granted Tajikistan the status of Soviet Socialist Republic, thereby incorporating the republic into the Soviet Union. With the collapse of the Soviet Union in 1991, Tajikistan became a sovereign republic and joined the United Nations. A civil war began almost immediately, resulting in a serious loss of human lives and enormous damage to Tajikistan’s economy. Table 1.1 Basic demographic indicators Demographic indicators from selected sources, Tajikistan Indicators Tajikistan Census 2000 Tajikistan Census 2010 Population (millions) 6.1 7.6 Intercensal growth rate (percent) 20.3 23.5 Density (population/km2) 43 53 Percent urban 26.5 26.5 Life expectancy (years) 68.2 72.5 Male 66.1 70.8 Female 70.3 74.4 Source: SA, 2012a. Demographic year book of the Republic of Tajikistan Introduction • 3 1.3 ECONOMY The economy deteriorated rapidly from 1992 to1996. By 1996 the GDP was about one-third of the level of the early 1990s (World Bank, 2005). Under such dire circumstances, the government of Tajikistan initiated the development, adoption, and then implementation of a comprehensive program of economic reforms, leading to gradual economic recovery. By World Bank estimates, economic growth averaged 8 percent during the 2000-2008 period, fell to 3.4 percent in 2009 during the world economic crisis, and rose again to 6.5 - 7.4 percent in 2010 and 2011. A similar rate of economic growth (7.5 percent) in 2012 was attributed to higher growth in retail trade, services, and agriculture. In spite of the gradual economic growth in recent years, the country’s economy still relies on foreign investment, targeted grants, and support from Tajik citizens working abroad. In search of working opportunities and higher income, approximately 10 percent of the Tajik population is working abroad, mostly in Russia (SA, 2012b). According to the World Bank estimates, remittances from relatives working abroad in 2012 were equivalent to 47 percent of the GDP (World Bank, 2013). The main economic activities in Tajikistan are aluminum and cotton production. Both resources are highly vulnerable to world market fluctuation. Efforts to diversify agricultural production resulted in strong growth in the agricultural sector in 2009 and in 2012. Tajikistan is rich in minerals and other natural resources, including large deposits of coal, and has substantial hydropwer potential. There are many hydroelectic plants in Tajikistan that produce electricity, and the largest among them, the Nurek hydroelectric facility, is the tallest dam in the world. The government of Tajikistan is planning to build a new Roghun dam that will significantly increase electricity output, if implemented. Over the past decade, the government of Tajikistan has embarked on various economic and poverty-reduction programs with the aim of improving the living conditions of its citizenry. As a result of this poverty reduction strategy, the poverty rate declined from 72 percent in 2003 to 47 percent in 2009. Decline was more rapid in urban areas than in rural ones. In spite of these marked improvements, in 2012 almost 40 percent of the Tajikistani population still lived below the poverty level (World Bank, 2013). The National Development Strategy for the current period (by 2015) and the third Poverty Reduction Strategy for the preceding period (2010-2012) have identified priorities and general areas of state policy that aim at sustainable economic growth, better access to social services, and less poverty (IMF, 2012). In March 2013, Tajikistan joined the World Trade Organization (WTO). 1.4 HEALTH CARE SYSTEM The government of Tajikistan is committed to improving access and equity of access to essential health care services. The priority problem areas are maternal and child health, reproductive health, noncommunicable diseases, malaria, tuberculosis, HIV/AIDS, and other sexually transmitted infections (STIs). The government of Tajikistan has established a regulatory framework for the health sector that includes 9 laws, 18 government decrees, and about 40 orders of the Ministry of Health. The National Health Council of Tajikistan was established by government decree to coordinate efforts to improve population health. The Ministry of Health is responsible for “the development, implementation, monitoring, evaluation, and coordination of a unified state policy in the health sector, and for controlling the quality, safety and effectiveness of health services, pharmaceuticals, and medical equipment” (Khodjamurodov and Rechel, 2010). 1.4.1 Facilities and Human Resources A nationwide network of more than 3,748 health care facilities existed in Tajikistan in 2012 (SA, 2013a). The health care system in Tajikistan is almost all state-owned and administered; however, health financing is decentralized. The allocation of money to the health budget of Tajikistan is handled centrally by the Ministry of Finance, which distributes funds to the finance departments of oblast authorities. The oblasts determine how their own health budgets are spent, and the Ministry of Health controls only the 4 • Introduction functioning of health facilities. The republican hospitals, the State Medical University, and public health services operate under the control of the Ministry of Health, while regional and district facilities are managed by local authorities. External funds, mainly in the form of grants from international donors and bilateral agencies, are important sources of revenue to the health sector (Khodjamurodov and Rechel, 2010). In 2010, there were 163 facilities in the parastatal (parallel) health sector that were not directly subordinate to the Ministry of Health. They are under the control of the institutions that provide health care for their employees, such as the Ministries of Defense, Internal Affairs, Justice, Light Industry, and Transport and Communication (Khodjamurodov and Rechel, 2010). From an operational and a financial perspective, the parastatals are each governed by their own set of rules and regulations, have separate budgets funded directly by their ministries or companies, and exercise more autonomy in daily operations. The Ministry of Health has a coordinating share of the decision-making in parastatal organizations, at least in regards to health care protocols and standards of care. There is a small, slow-growing private sector in Tajikistan. Pharmacies and dental services are mostly privately owned. Since 2007, a number of private diagnostic centers have opened in cities to compete with the state run outpatient facilities, and about 14 private hospitals were operating in the country in 2010; however, due to the low purchasing power of the population, the share of services provided by the private sector is still low (Khodjamurodov and Rechel, 2010). According to the legislation of the Republic of Tajikistan, emergency and ambulance care, pediatric services for children under age 1, vaccinations, the initial health examination, and consultation are free of charge. A package of guaranteed health services has been implemented on a pilot basis since 2008, and a fee-for-services program was introduced by the government in 2009. In 2012, there were 16,268 physicians and 38,635 midlevel health professionals working in Tajikistan, or 20.4 physicians and 48.4 midlevel health professionals per 10,000 population (SA, 2013a). The distribution of medical staff is uneven between urban and rural areas, with the highest proportion of physicians residing in urban areas and Dushanbe (Khodjamurodov and Rechel, 2010). In Tajikistan, almost all health professionals are government employees and are paid on a salary basis. Every year the government increases wages, but the average salary is still low, which is the cause of informal payments made by patients, although there is no reliable data on this practice. In 2012, the average monthly salary for employees working in medical and social services was US$94 compared with the workforce average of US$116.60 (SA, 2013b). Over the past 20 years, the number of health professionals in Tajikistan has declined from 242 physicians, 618 nurses, and 122 midwives per 100,000 population in 1991 to 190 physicians, 447 nurses, and 60 midwives per 100,000 population in 2011 (WHO EURO, 2013). It is estimated that between 1990 and 1999, about 10,000 physicians and 39,000 midlevel health professionals left the state health care system (World Bank, 2005). 1.4.2 Health Care Reforms Tajikistan inherited a planned Soviet health system, characterized by a pronounced centralization, disproportionally high levels of funding of inpatient care facilities, and an excessive number of hospital beds and medical staff. Economic problems and financial cuts during the transition led to a serious deterioration of the health care system, including maternal and child health care. Since 1991, Tajikistan has undertaken systemic reforms of its health sector. The 1991-1998 reform priorities focused on the development of national policies, health care financing, resource allocation, and improvement of maternal and child health care services, including family planning. Introduction • 5 The 1998-2005 reform priorities included establishment of a national network of emergency medical care centers; reorganization and restructuring of outpatient and inpatient health facilities; and establishment and further development of family medicine. In 2002, the new concept of health sector reform was approved by the government. In 2005, the government approved the strategy of health care financing in Tajikistan for the period 2005–2015. In addition, in 2008 the concept of reform of medical and pharmaceutical education was approved by the government. Over the past 20 years, Tajikistan has introduced fundamental changes to the provision of maternal and child care services. Many important documents and guidelines, including the national plan on safe pregnancy, have been developed and implemented, and these have radically changed approaches to the assessment of quality care. The Ministry of Health developed and implemented the evidence-based approach of care during pregnancy, labor, and delivery, and of essential neonatal care, in accordance with the international standards of care. 1.4.3 Primary and Secondary Health Care Primary (ambulatory) health care in Tajikistan is provided through health houses and rural health centers in rural areas and through rayon and urban health centers in urban areas. In 2011, there were 1,689 health houses and 1,404 health centers (SA, 2012c). The main focus of rural health houses, staffed by nurses and midwives, is to provide basic first aid, home visits, basic antenatal care services, immunizations, and medical referrals. The rural health centers, staffed by physicians and midlevel health professionals, provide the next level of primary care, including basic blood and urine diagnostics, basic treatment, and surgeries. Rural health centers are subordinate to central rayon hospitals. The main focus of rayon and urban health centers is to provide preventive, diagnostic, and rehabilitative services. On the secondary level, health services are provided by rural hospitals, central rayon and city hospitals, oblast hospitals, and specialized hospitals. National level and specialized hospitals (cardiology, pediatrics, obstetrics and gynecology, tuberculosis, and others) provide advanced levels of diagnostics and medical care; they are also home for clinical research and teaching institutions. Some hospitals offer day care. Emergency care is provided through emergency hospitals and ambulance services (Khodjamurodov and Rechel, 2010). Outreach services, though not always sustained, are available for remote areas, especially for immunization and emergency care. 1.4.4 Maternal and Child Health Care The problems of maternal and child health are among the priority areas identified by the government of Tajikistan, which has ratified a number of international documents, including the Convention on the Elimination of All Forms of Discrimination against Women and the Convention on the Rights of the Child. Legal aspects of protection of the population’s health, including that of the mother and child, are reflected in the principal documents of the Republic: the constitution of Tajikistan, the law on health protection, and the law on reproductive health and reproductive rights, among others. The government pays special attention to gender issues, with a focus on improving the status and role of women in society. Tajikistan is also committed to achievement of the Millennium Development Goals, where three of eight goals relate to the health of women and children. In 2008, the government of Tajikistan approved a “National strategy for health care of children and adolescents until 2015.” 6 • Introduction In rural areas, antenatal care is provided by midwives at rural health houses or by doctors and midwives at rural health centres. In urban areas, antenatal care is provided by family physicians at rayon and urban health centers; however, the initial examination during the first visit is usually conducted with an obstetrician-gynecologist. One family doctor provides care for approximately 1,500 people in a catchment area. Obstetrician-gynecologists serve family doctors as consultants, and they provide care for pregnant women with obstetric complications. The ratio of family doctors to obstetrician-gynecologists is 1:4. Antenatal care starts early in pregnancy (usually during the first trimester) and continues on a regular basis throughout the pregnancy; a standard recommendation is that all pregnant women should have at least four routine antenatal visits during pregnancy; follow-up visits may be required for certain conditions, problems, or complications. According to special decree of the Ministry of Health, since 2008, inpatient health services in Tajikistan are provided at three levels. At the first level, care for women with normal (physiological) deliveries at full term and care for newborn children whose birth weight is 2.5 kilograms or more is provided by midwives. Delivery hospitals/gynecological wards at the secondary-level facilities provide skilled obstetric and neonatal care, including care for abnormal (pathological) deliveries, deliveries by cesarean section, and care for newborn children whose birth weight is less than 2.5 kilograms, as well as diagnostic, treatment, and rehabilitation services for women with gynecologic pathologies. Tertiary health services, including perinatal centers, are planned to carry out all types of high-tech diagnostic, treatment, and rehabilitative care for women and children. Currently, tertiary-level health facilities do not meet all of the requirements of the Ministry of Health. The organization of tertiary-level health facilities at the national level will be implemented in full starting in 2013. In spite of a sufficient number of delivery facilities, about 10 percent of births take place at home without the assistance of a skilled health provider. The main reasons for this are difficulties in accessing a health facility (roads, means of transportation), low social status of women, and in some cases, out-of- pocket payments for delivery in hospitals, a lack of trust in medical personnel, or absence of a specialist in remote settlements. Child health care is provided immediately following delivery while a woman and her newborn are in the delivery hospital. After discharge from the delivery hospital, child care services are mainly provided by primary health care facilities, including family doctors and nurses who provide counseling on child care and nutrition to the mother. Family doctors ensure that the child is vaccinated according to a schedule. They also can refer children for pediatric care and for hospitalization, as necessary. Currently, mandatory childhood vaccinations in Tajikistan include vaccination against hepatitis B, poliomyelitis, tuberculosis, diphtheria, pertussis, tetanus, haemophilus influenzae type b, measles and rubella. The child vaccination schedule in Tajikistan requires that Bacillus Calmette-Guérin (BCG), hepatitis B, and oral polio vaccines be given at birth. A high rate of home births jeopardizes the health of newborns because vaccinations may be delayed. 1.4.5 Family Planning Services The Ministry of Health is responsible for providing family planning services throughout the country. The main goals of family planning policy are to ensure low-risk pregnancy and safe motherhood and to reduce complications caused by closely-spaced pregnancies and pathological conditions among women of reproductive age. Currently, five groups of women at high risk for maternal and perinatal morbidity and mortality have been selected for provision of family planning services upon request. Introduction • 7 The Ministry of Health considers family planning to be an important component of reproductive health care. In 2004, the Strategic Plan for Reproductive Health in 2005-2014 was adopted by government resolution. The Ministry of Health manages a broad spectrum of activities, including extensive family planning education of the population, training of health providers, and supply of contraceptives throughout the country. The private sector is also involved in marketing contraceptives. Regional, district, and city centers on reproductive health work at the primary health care level under the management of the National Centre on Reproductive Health (NCRH). Obstetrician-gynecologists working at the NCRH serve family doctors as consultants; family doctors provide counseling on the selection and use of contraceptive methods to the general population. Induced abortion is legal in Tajikistan. These procedures are typically performed by an obstetrician-gynecologist, either at outpatient clinics by the vacuum aspiration technique during the first five weeks of pregnancy or in state and private health clinics by dilation and curettage during the first 12 weeks of pregnancy. In some cases, induced abortion can be performed after 12 weeks and up to 22 weeks if certain medical or social conditions exist and upon permission from a medical-control commission of the outpatient and inpatient care levels of facilities. These cases require careful supervision of qualified medical personnel in a hospital setting. 1.4.6 Tuberculosis DOTS Program The 2006 law on protection of the population from tuberculosis established the basis for a state- regulated policy on combatting tuberculosis, for defining organizational and legislative regulations of activities aimed to protect the population from tuberculosis, and for regulation of the rights, responsibilities, and social guarantees of population with tuberculosis. To improve the epidemiological situation, the government adopted the National Tuberculosis Control Program of 2011-2015, based on the directly observed treatment, short-course (DOTS) approach. The DOTS approach covers all rayons of the country. Tuberculosis services are available at primary health facilities, at republican, city, and central rayon hospitals, and at tuberculosis hospitals. 1.4.7 HIV/AIDS Program Prevention of HIV/AIDS is high on the political agenda of the government of Tajikistan. It declared its commitment to addressing the HIV/AIDS crisis as outlined in the Declaration of Commitment on HIV/AIDS at the UN General Assembly Special Session on HIV/AIDS (United Nations, 2001). Tajikistan was among the first countries to develop a National Development Strategy by 2015. Issues for combatting the HIV/AIDS epidemic were reflected in the Millennium Development Goals to halt and reverse the spread of HIV/AIDS. In 2008, on the government’s initiative, Dushanbe hosted the third Inter- Parliamentary Conference in Central Asia and Azerbaijan on HIV/AIDS. The government of Tajikistan, with the objective of ensuring effective management and a unified response to the HIV and AIDS epidemic, adopted a multi-sectoral approach. This addressed the developmental challenges of the epidemic and integrated HIV/AIDS issues in the 2010-2012 Poverty Reduction Strategy. Included in the 2010-2020 Health Sector Strategy as high priority issues were prevention, treatment, care, and support activities as well as targeting of the general population, vulnerable groups, and groups at high risk. The HIV and AIDS response in Tajikistan is guided by the National Strategic Framework of 2010-2015 (GOT, 2012). The National Coordination Committee (NCC) to combat HIV/AIDS, Tuberculosis, and Malaria is a single coordinating body for HIV/AIDS activities. It is chaired by the deputy prime minister of Tajikistan. NCC works on a multisectoral approach with 22 organizations, which include representatives from key ministries, international organizations, and local non-governmental organizations as well as individuals living with HIV/AIDS and a religious leader of all Muslims in Tajikistan (GOT, 2012). 8 • Introduction In Tajikistan, HIV prevalence is still low, with only 0.3 percent of the population age 15-49 estimated to be HIV-positive in 2011 (UNAIDS, 2013). The HIV epidemic in Tajikistan is currently concentrated among injection drug users. In 2011, the needle and syringe exchange program was started in 21 drop-in health facilities (trust posts) supported by UNDP grants; this program is also scheduled for implementation in prisons on a pilot basis. In June 2010, the opioid substitution therapy program started on a pilot basis, and 296 patients were covered by the program by the end of 2011 (GOT, 2012). Although the majority of new HIV infections in Tajikistan are contracted through injection drug use, heterosexual transmission is growing quickly, especially among women. Women and men have equal access to HIV/AIDS services as guaranteed by the national law on gender equality. Staff of 26 crisis centers for vulnerable women received information about preventing violence and discrimination against women with HIV/AIDS, and they learned how to provide social and psychological support to HIV-infected women and children (GOT, 2012). All aspects of civil society, including religious institutions, are involved in combatting the HIV/AIDS epidemic in Tajikistan. The Islamic Institute of Tajikistan published the book HIV/AIDS from the Perspective of Islam. Forty-eight religious leaders have been trained at a national seminar, and over 250 religious leaders have been trained about HIV/AIDS issues countrywide (GOT, 2012). There are 35 HIV/AIDS prevention and treatment centers in Tajikistan: 1 republican, 4 regional, and 30 urban and rural centers. The main tasks of these centers are HIV testing and counseling services, treatment and care of HIV-infected persons, technical support of health facilities on HIV/AIDS- related issues, HIV surveillance, HIV prevention among specific population groups, education of the general population on HIV/AIDS prevention, prevention of transmission from mother to child, and implementation, monitoring, and evaluation of the national program on combatting HIV/AIDS. 1.5 SYSTEMS FOR COLLECTING DEMOGRAPHIC AND HEALTH DATA The Statistical Agency is the government agency responsible for collection, processing, analysis, aggregation, dissemination, accumulation, storage, and maintenance of official statistical information. It conducts censuses. Births, deaths, marriages, and divorces are registered in the departments of civil registry (so-called ZAGS) of the Ministry of Justice and in local administrations (jamoats) of rural settlements, where the records are made and certificates of birth, death, marriage, and divorce are issued. Second copies of these records are forwarded on a monthly basis through the rayon and oblast statistical offices to the Statistical Agency for aggregation and processing. The last two censuses in Tajikistan were conducted in 2000 and 2010. Collection of health data is primarily the responsibility of the Statistical and Information Center of the Ministry of Health. Health information is generated by staff at the facilities delivering service. It is then sent to the Statistical and Information Center through the rayon and oblast health statistic departments, then forwarded on to the Ministry of Health and the Statistical Agency under the President of the Republic of Tajikistan. The Statistical and Information Center of the MOH compiles and analyzes these data and issues annual reports entitled Population Health and Health Services in the Republic of Tajikistan. The annual report covers many aspects of health area registration statistics related to morbidity by type of disease; mortality by cause of death; infant deaths, including perinatal and early neonatal deaths; maternal mortality; data on maternal and child health services; the number of health facilities, medical personnel, hospital beds, and length of the average hospital stay; and family medicine, emergency medicine, and funding of health care services. These data are tabulated at the national and oblast levels. These data, at the national level, are also available at the World Health Organization’s European Health-for-All database (HFA-DB). Introduction • 9 1.6 OBJECTIVES AND ORGANIZATION OF THE SURVEY The 2012 TjDHS is a nationally representative sample survey designed to provide information on population and health issues in Tajikistan. The 2012 survey, the first of its kind in the country, was conducted by the Statistical Agency and the Ministry of Health (MOH) from July 2012 through September 2012. Support for the 2012 TjDHS was provided by the United States Agency for International Development (USAID) as part of the MEASURE DHS project. MEASURE DHS is a USAID-funded program through which ICF International provides funding and technical assistance in the implementation of population and health surveys in countries worldwide. The United Nations Population Fund (UNFPA)/Tajikistan provided additional funds for the survey. The purpose of the 2012 TjDHS was to collect national and regional data on fertility and contraceptive use, maternal and child health, childhood mortality, domestic violence against women, and knowledge and behavior regarding tuberculosis, HIV infection, and other sexually-transmitted infections. The survey obtained detailed information on these issues from women of reproductive age. Data are presented by region (oblast) when sample size permits. The 2012 TjDHS results are intended to provide the information needed to evaluate existing social programs and to design new strategies for improving health and health services for women and children in Tajikistan. The 2012 TjDHS also contributes to the growing international database on demographic and health-related indicators. 1.6.1 Sample Design and Implementation The 2012 TjDHS sample was designed to permit detailed analysis, including the estimation of rates of fertility, infant/child mortality, and abortion at the national level and for total urban and rural areas separately. Many indicators can also be estimated at the regional (oblast) level. In addition, in the Khatlon region, the sample is sufficient to provide separate estimates of the nutritional status of children for the 12 districts included in the Feed the Future Initiative (FTF) pilot areas. A representative probability sample of 6,674 households was selected for the 2012 TjDHS sample. The sample was selected in two stages. In the first stage, 356 clusters were selected from a list of enumeration areas that were part of a master sample designed from the 2010 Population Census. In the second stage, a complete listing of households was made for each selected cluster. Households were then systematically selected for participation in the survey. All women age 15-49 who were either permanent residents of the households in the 2012 TjDHS sample or visitors present in the household on the night before the survey were eligible to be interviewed. Interviews were completed with 9,656 women. Appendix A provides additional information on the sample design of the 2012 TjDHS. 1.6.2 Questionnaires Two questionnaires were used in the TjDHS: a Household Questionnaire and a Woman’s Questionnaire. The Household Questionnaire and the Woman’s Questionnaire were based on model survey instruments developed in the MEASURE DHS program. The DHS model questionnaires were adapted for use in Tajikistan by experts from the Statistical Agency (SA) and the Ministry of Health (MOH). Suggestions were also sought from USAID; a number of the UN agencies, including the United Nations Development Program (UNDP), UNFPA, and UNICEF; and other international and nongovernmental organizations (NGOs). The questionnaires were developed in English and translated into Russian and Tajik. The Household Questionnaire and the Woman’s Questionnaire were pretested in March 2012. 10 • Introduction The Household Questionnaire was used to list all usual members of and visitors to the selected households and to collect information on the socioeconomic status of the households. The first part of the Household Questionnaire collected, for each household member or visitor, information on their age, sex, educational attainment, and relationship to the head of household. This information provided basic demographic data for Tajikistan households. It also was used to identify the women who were eligible for the individual interview (i.e., women age 15-49). The first section of the Household Questionnaire also obtained information on other characteristics of household members, including information on each child’s birth registration. Other questions addressed housing characteristics (e.g., the flooring material, the source of water, and the type of toilet facilities), ownership of consumer goods, and other aspects of the socioeconomic status of the household. Results of testing of household salt for the presence of iodine and results of taking height and weight measurements of children under age 5 and of women age 15-49 also were recorded in the Household Questionnaire. The Woman’s Questionnaire obtained information from women age 15-49 on the following topics: • Background characteristics • Pregnancy history • Antenatal, delivery, and postnatal care • Knowledge, attitudes, and use of contraception • Reproductive health • Childhood mortality • Health care utilization • Vaccinations of children under age 5 • Episodes of diarrhea and respiratory illness of children under age 5 • Breastfeeding and weaning practices • Marriage and recent sexual activity • Fertility preferences • Knowledge of and attitudes toward AIDS and other sexually transmitted diseases • Knowledge of and attitudes toward tuberculosis • Woman’s work and husband’s background characteristics • Other women’s health issues • Domestic violence 1.6.3 Training of Field Staff The main survey training, which was conducted by the SA, MOH, and ICF International staff, was held during a three-week period in June and was attended by 100 people (78 females and 22 males), including supervisors, field editors, interviewers, and quality control personnel. The training included lectures, demonstrations, practice interviews, and examinations. All field staff received training in anthropometric measurement and participated in two days of field practice. 1.6.4 Fieldwork and Data Processing Fourteen teams collected the survey data; each team consisted of four female interviewers, a field editor, and a team supervisor. Fieldwork began in early July 2012 and concluded in late September 2012. Senior TjDHS technical staff visited teams regularly to review the work and monitor data quality. MEASURE DHS also assisted with field supervision. In addition, UNFPA/Tajikistan representatives visited teams to monitor data collection and to observe the height and weight measurements of women and children under age 5. Introduction • 11 The processing of the TjDHS results began shortly after fieldwork commenced. Completed questionnaires were returned regularly from the field to SA headquarters in Dushanbe, where they were entered and edited by data processing personnel specially trained for this task. The data processing personnel included a supervisor, a questionnaire administrator (who ensured that the expected number of questionnaires from all clusters was received), several office editors, 11 data entry operators, and a secondary editor. The concurrent processing of the data was an advantage because the senior DHS technical staff were able to advise field teams of problems detected during the data entry. In particular, tables were generated to check various data quality parameters, and the results were used to provide specific feedback to the teams to improve performance. The data entry and editing phase of the survey was completed in November 2012. 1.7 RESPONSE RATES Table 1.2 shows response rates for the 2012 TjDHS. A total of 6,674 households were selected in the sample, of which 6,512 were occupied at the time of the fieldwork. The main reason for the difference is that some of the dwelling units that were occupied during the household listing operation were either vacant or the household was away for an extended period at the time of interviewing. The number of occupied households successfully interviewed was 6,432, yielding a household response rate of 99 percent. The household response rate in urban areas (98 percent) was slightly lower than in rural areas (99 percent). In these households, a total of 9,794 eligible women were identified; interviews were completed with 9,656 of these women, yielding a response rate of 99 percent. Response rates are slightly higher in urban areas (99 percent) than in rural areas (98 percent). Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Tajikistan 2012 Result Residence Total Urban Rural Household interviews Households selected 2,835 3,839 6,674 Households occupied 2,732 3,780 6,512 Households interviewed 2,675 3,757 6,432 Household response rate1 97.9 99.4 98.8 Interviews with women age 15-49 Number of eligible women 3,443 6,351 9,794 Number of eligible women interviewed 3,408 6,248 9,656 Eligible women response rate2 99.0 98.4 98.6 1 Households interviewed/households occupied. 2 Respondents interviewed/eligible respondents. Housing Characteristics and Household Population • 13 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 his chapter presents information on housing facilities (sources of water supply, sanitation facilities, and dwelling characteristics), household possessions, and household arrangements (headship and size). The data on the dwelling and household characteristics and assets is used to produce the wealth index, an indicator of the household’s economic status. The chapter also provides information on general characteristics of the population such as age-sex structure and education. The description of the household environment and survey population in the chapter is useful for understanding the many social and demographic phenomena presented later in the report. In reviewing this chapter, it is helpful to understand the definitions of a household and of the de jure and de facto populations used in the 2012 TjDHS. A household consists of a person or group of persons, related or unrelated, who live together in the same dwelling unit, acknowledge one adult male or female as the head of household, share the same living arrangements, and are considered as one unit. For each household, information was obtained on usual household members as well as visitors present in the household on the night before the survey. The de jure population includes all usual household residents whether or not they were present at the time of the TjDHS interview. The de facto population includes household members and visitors who were present in the household on the night before survey. The difference between the de jure and de facto populations is small, and most results are presented for the de facto population unless otherwise noted. T Key Findings • The average Tajik household has 6.3 members. • Nearly all households (97 percent) use improved sanitation facilities. • Access among the population to improved drinking water sources increased from 57 percent in 2000 to 76 percent in 2012. • Among households where the hand washing place was observed, around eight in ten households have soap and water available at the place household members use for hand washing. • Three in ten households, mainly in rural areas, reside in dwellings with earth or sand floors. • Forty-one percent of rural households use solid fuels for cooking compared with 3 percent of urban households. • Possession of cell phones has increased rapidly, from 11 percent of households in 2005 to 93 percent in 2012. Computer ownership also has expanded, from 1 percent in 2005 to 12 percent in 2012. • The median completed years of schooling is 8.6 years among females and 9.3 years among males. • Attendance among the school-age population is widespread but not universal; 87 percent of the primary school-age population and 83 percent of the secondary school-age population are attending school. • There is almost no gender gap in primary school attendance, but males are slightly more likely to attend secondary school than females. • Most young children are not involved in any early childhood education program; only 6 percent of children age 3-6 attend pre-school education. 14 • Housing Characteristics and Household Population 2.1 HOUSING CHARACTERISTICS The 2012 TjDHS collected data on a range of housing characteristics that affect the health of household residents and also reflect the household’s socioeconomic status. Housing characteristics include sources of drinking water, type of sanitation facilities, dwelling materials (roof, walls, and floor), access to electricity, and cooking arrangements. These results are presented for households and for the de jure household population by urban-rural residence. 2.1.1 Drinking Water The source of drinking water is an indicator of whether it is suitable for drinking. Table 2.1 uses the categorization of improved and non-improved sources proposed by the WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation (UNICEF and WHO, 2012) in presenting the 2012 TjDHS drinking water information. The table also shows the time spent in obtaining drinking water and the practices that Tajik households employ in treating the water they use for drinking. Table 2.1 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Tajikistan 2012 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 94.6 70.7 78.1 94.1 70.6 76.2 Piped water into dwelling/yard/plot 78.2 22.1 39.3 76.5 22.9 35.7 Public tap/standpipe 12.9 29.8 24.6 13.4 28.9 25.2 Tube well/borehole 1.4 10.6 7.7 1.7 10.8 8.6 Protected dug well 1.4 4.4 3.5 1.5 4.1 3.5 Protected spring 0.4 3.6 2.6 0.5 3.6 2.8 Rain water 0.4 0.3 0.3 0.5 0.3 0.3 Bottled water 0.0 0.0 0.0 0.0 0.0 0.0 Non-improved source 3.7 28.2 20.7 4.1 28.4 22.5 Unprotected dug well 0.2 0.6 0.5 0.3 0.7 0.6 Unprotected spring 0.8 2.3 1.9 0.6 2.3 1.9 Tanker truck/cart with small tank 0.8 6.1 4.5 0.9 6.0 4.8 Surface water 1.9 19.2 13.9 2.4 19.4 15.3 Other source 1.5 0.9 1.1 1.6 0.9 1.1 Missing 0.1 0.2 0.2 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 81.5 39.8 52.6 80.7 41.0 50.5 Less than 30 minutes 15.1 44.7 35.6 14.7 43.3 36.5 30 minutes or longer 2.7 14.0 10.5 3.8 14.2 11.7 Don't know/missing 0.7 1.5 1.2 0.8 1.4 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 87.7 83.3 84.6 87.4 83.3 84.3 Bleach/chlorine added 0.3 0.3 0.3 0.4 0.2 0.3 Strained through cloth 0.1 0.4 0.3 0.1 0.4 0.3 Ceramic, sand or other filter 0.6 0.1 0.3 0.5 0.1 0.2 Solar disinfection 0.3 0.5 0.4 0.3 0.5 0.5 Other 24.5 26.1 25.6 22.5 25.3 24.6 No treatment 11.1 15.2 14.0 11.4 15.2 14.3 Percentage using an appropriate treatment method2 87.9 83.5 84.8 87.6 83.5 84.5 Number 1,976 4,456 6,432 9,715 30,753 40,468 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. More than three-quarters of households in Tajikistan obtain drinking water from an improved source. Most of these households either have piped water available in the dwelling, yard, or plot (39 percent) or get water from a public tap or standpipe (25 percent). The most common non-improved Housing Characteristics and Household Population • 15 water source is surface water (14 percent), i.e., water from rivers, dams, lakes, ponds, or similar sources. Around nine in ten households obtain drinking water from a source on premises (53 percent) or spend less than 30 minutes obtaining water (36 percent). Eighty-five percent of households use an appropriate water treatment method, with almost all boiling the water used for drinking. Urban households are much more likely than rural households to have access to an improved drinking water source (95 percent versus 71 percent), and they are twice as likely as rural households to have the drinking water source on the premises (82 percent versus 40 percent). On the other hand, the proportion using an appropriate water treatment method is only slightly higher among urban households (88 percent) than rural households (83 percent). Figure 2.1 compares the results of the 2012 TjDHS with the findings from the Multiple Indicator Cluster Survey conducted in 2000 (UNICEF, 2000) and 2005 (SCS, 2007). Access among the population to improved drinking water sources increased in Tajikistan from 57 percent in 2000 to 76 percent in 2012. The increase was largely concentrated in rural areas. The percentage of the rural population obtaining drinking water from an improved source rose from 47 percent in 2000 to 71 percent in 2012, while in urban areas where access to an improved source was already widespread in 2000, the percentage increased from 93 percent to 94 percent. Figure 2.1 Trends in use of improved drinking water sources, Tajikistan 2000, 2005, and 2012 93 47 57 93 61 70 94 71 76 Urban Rural Total 2000 MICS 2005 MICS 2012 TjDHS Percent 16 • Housing Characteristics and Household Population 2.1.2 Sanitation Facilities The availability of hygienic sanitation facilities is important in reducing the risk of transmitting diarrhea and other diseases within a household. According to the standards set by the WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation, the hygienic status of sanitation facilities is determined on the basis of type of facility used and whether or not it is a shared facility (UNICEF and WHO, 2012). A household’s toilet/latrine facility is classified as hygienic if it is used only by household members (i.e., not shared) and if the type of facility effectively separates human waste from human contact. The types of facilities that are most likely to accomplish this are flush or pour flush toilets emptying into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrines; pit latrines with a slab; and composting toilets. Table 2.2 shows that the vast majority of the TjDHS households and household population use improved sanitation facilities (97 percent each), which is an increase over the 94 percent of the household population reported in the 2005 MICS (SCS, 2007). Most households using an improved facility do not share the facility; only 3 percent of Tajik households use an improved facility that is shared with other households. Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Tajikistan 2012 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 91.8 94.1 93.4 92.9 94.6 94.2 Flush/pour flush to piped sewer system 52.0 0.1 16.0 45.2 0.1 10.9 Flush/pour flush to septic tank 0.3 0.0 0.1 0.3 0.0 0.1 Flush/pour flush to pit latrine 1.0 0.3 0.5 1.0 0.4 0.5 Ventilated improved pit (VIP) latrine 11.3 23.8 20.0 12.4 23.0 20.4 Pit latrine with slab 27.2 69.8 56.7 34.0 71.1 62.2 Composting toilet 0.0 0.1 0.1 0.0 0.1 0.1 Shared facility1 6.4 1.7 3.2 5.2 1.5 2.4 Flush/pour flush to piped sewer system 3.2 0.0 1.0 2.3 0.0 0.5 Flush/pour flush to septic tank 0.0 0.0 0.0 0.0 0.0 0.0 Flush/pour flush to pit latrine 0.5 0.0 0.2 0.3 0.0 0.1 Ventilated improved pit (VIP) latrine 0.9 0.6 0.7 0.9 0.4 0.5 Pit latrine with slab 1.8 1.2 1.4 1.8 1.1 1.2 Non-improved facility 1.4 4.0 3.2 1.6 3.8 3.3 Flush/pour flush not to sewer/septic tank/pit latrine 0.7 0.2 0.3 0.9 0.1 0.3 Pit latrine without slab/open pit 0.6 3.5 2.7 0.7 3.4 2.8 No facility/bush/field 0.1 0.4 0.3 0.1 0.3 0.2 Other 0.1 0.0 0.0 0.0 0.0 0.0 Missing 0.2 0.1 0.2 0.3 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,976 4,456 6,432 9,715 30,753 40,468 1 Facilities that would be considered improved if they were not shared by two or more households. Pit latrines with slab (58 percent) are the most common type of toilet, followed by VIP latrines (21 percent). One in six households uses a toilet connected to a piped sewer system. More than half of urban households have flush toilets, while they are virtually nonexistent in rural areas. Housing Characteristics and Household Population • 17 2.1.3 Other Dwelling Characteristics Table 2.3 shows the distribution of households and the de jure population by other dwelling characteristics that reflect the socioeconomic status and also may directly affect the health of household members. Table 2.3 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Tajikistan 2012 Housing characteristic Residence Total Urban Rural Electricity Yes 99.8 98.8 99.1 No 0.2 1.2 0.9 Total 100.0 100.0 100.0 Flooring material Earth/sand 5.3 39.8 29.2 Wood/planks 31.6 18.6 22.6 Parquet or polished wood 43.3 22.0 28.5 Vinyl or linoleum 9.9 3.6 5.5 Ceramic tiles 0.4 0.4 0.4 Cement 8.8 14.8 13.0 Carpet 0.5 0.2 0.3 Other 0.0 0.4 0.3 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Roof material No roof 0.1 1.2 0.8 Thatch 0.9 5.8 4.3 Sod 0.1 0.0 0.1 Wood planks 0.2 0.1 0.2 Cardboard 0.0 0.1 0.1 Metal 4.6 3.0 3.5 Wood 0.1 0.0 0.1 Calamine/cement fiber 4.0 0.0 1.2 Ceramic tiles 0.3 0.0 0.1 Cement/concrete blocks 15.9 0.2 5.0 Roofing shingles/shifer 62.2 88.5 80.4 Taule (tarred rough paper) 11.3 0.6 3.9 Other 0.2 0.3 0.3 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Wall material No walls 0.1 0.2 0.2 Cane/trunks 0.1 0.3 0.2 Dirt 4.6 13.2 10.5 Stone with mud 3.2 5.3 4.7 Uncovered adobe 6.8 28.0 21.5 Plywood 0.3 0.1 0.2 Reused wood 0.1 0.0 0.0 Cement 33.3 5.6 14.1 Stone with lime/cement 5.2 8.8 7.7 Bricks 32.8 9.0 16.3 Cement blocks 8.5 2.3 4.2 Covered adobe 4.8 27.2 20.3 Wood planks/shingles 0.0 0.0 0.0 Other 0.0 0.0 0.0 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Rooms used for sleeping One 22.8 11.9 15.2 Two 42.4 39.4 40.3 Three or more 34.0 47.9 43.6 Missing 0.8 0.8 0.8 Total 100.0 100.0 100.0 Continued… 18 • Housing Characteristics and Household Population Table 2.3—Continued Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Tajikistan 2012 Housing characteristic Residence Total Urban Rural Place for cooking In the house 51.5 14.2 25.7 In a separate building 47.0 81.0 70.6 Outdoors 1.1 4.7 3.6 No food cooked in household 0.2 0.1 0.1 Other 0.1 0.0 0.1 Total 100.0 100.0 100.0 Cooking fuel Electricity 75.1 42.3 52.3 LPG/natural gas/biogas 21.3 16.8 18.2 Kerosene 0.0 0.0 0.0 Charcoal 0.0 0.1 0.0 Wood 2.6 29.2 21.0 Straw/shrubs/grass 0.1 1.2 0.9 Agricultural crop 0.1 2.8 2.0 Animal dung 0.6 7.4 5.3 Other 0.0 0.2 0.1 No food cooked in household 0.2 0.1 0.1 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 3.4 40.7 29.2 Frequency of smoking in the home Daily 10.4 5.5 7.0 Weekly 3.5 2.8 3.0 Monthly 0.7 0.3 0.4 Less than monthly 1.4 1.1 1.2 Never 83.8 90.2 88.2 Missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Number 1,976 4,456 6,432 LPG = Liquid petroleum gas 1 Includes charcoal, wood, straw/shrubs/grass, agricultural crops, and animal dung. Almost all Tajik households (99 percent) have electricity. With regard to the construction of the dwelling, while most dwellings have some type of flooring, 29 percent of households reside in dwellings with earth or sand floors. Earth/sand floors are much more common in rural than in urban areas (40 percent versus 5 percent). Shingles are the most widely used roofing material, found in around nine in ten rural and six in ten urban dwellings. Cement (33 percent) and bricks (33 percent) are the most common wall materials in urban dwellings, while rural dwellings are most often built with covered or uncovered adobe (27 percent and 28 percent, respectively). More than eight in ten Tajik households have at least two rooms in the dwelling used for sleeping, and 44 percent have three or more rooms. Urban households are almost twice as likely as rural households to have only one room for sleeping (23 percent versus 12 percent). Indoor air pollution from the use of solid (biomass) fuels is related to increased morbidity and mortality (WHO, 2006a). Table 2.3 shows that, while the majority of Tajik households use electricity (52 percent) or LPG/natural gas/biogas (18 percent) for cooking, around three in ten households burn solid fuels (e.g., wood, charcoal, straw, shrubs, grass, agricultural crops or animal dung). Rural households are much more likely than urban households to cook with solid fuels. Among rural households, the practice of cooking in a building separate from the dwelling or outdoors may reduce the exposure to pollutants generated by the burning of solid fuels; more than eight in ten rural households report cooking takes place in a separate building or outside. There is also evidence that the use of solid fuels for cooking is declining in Tajikistan; overall, 35 percent of households reported use of solid fuels for cooking in the 2005 MICS Housing Characteristics and Household Population • 19 (SCS, 2007) compared with 29 percent in the TjDHS. The percentage using solid fuels for cooking declined among urban households from 8 percent in 2005 to 3 percent in 2012 and among rural households from 48 percent to 41 percent. The information on smoking inside the home is included in Table 2.3 to assess the percentage of households in which there is exposure to secondhand smoke. Secondhand smoke (SHS) causes health risks in children and adults who do not smoke. For example, research has shown that children who are exposed to SHS are at increased risk for respiratory and ear infections and poor lung development (US Department of Health and Human Services, 2006) and that pregnant women exposed to SHS have a higher risk of giving birth to a low-birth weight baby (Windham et al., 1999). Overall, around one in nine Tajik households report that smoking occurs in the home, with 7 percent saying smoking takes place in the home on a daily basis and 3 percent saying that it occurs on a weekly basis. Smoking in the home is more frequent in urban households than rural households (16 percent versus 10 percent). 2.2 HOUSEHOLD POSSESSIONS The availability of durable consumer goods is a useful indicator of household socioeconomic level. Moreover, particular goods have specific benefits. Having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs the wholesomeness of foods; and a means of transport allows greater access to services located away from the local area. Table 2.4 shows the availability of selected household possessions by residence. Almost all Tajik households (96 percent) own some type of television, primarily a color television, eight in ten have a DVD player, and four in ten own a satellite dish. The vast majority of households (94 percent) have a telephone, with mobile phones much more common than fixed phones. A comparison of the TjDHS and 2005 MICS (SCS, 2007) results documents both a very rapid expansion of mobile phone ownership from 11 percent of households in 2005 to 93 percent in 2012 and a decline in fixed phone ownership from 20 percent in 2005 to 11 percent in 2012. Although the change was not as rapid as the increase in cell phone ownership, computer ownership has also expanded, from 1 percent of households at the time of the 2005 MICS (SCS, 2007) to 12 percent in 2012. Four percent of TjDHS households reported that they could access the Internet in the home. There is considerable variability in the percentages of households possessing other household effects, with households least Table 2.4 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, livestock/farm animals, watch, or bank account by residence, Tajikistan 2012 Possession Residence Total Urban Rural Household effects Radio 19.3 25.6 23.7 Any television 97.9 95.8 96.4 Black and white television 6.0 11.7 9.9 Color television 95.7 90.3 91.9 DVD 86.4 77.8 80.5 Dish/satellite antenna 53.6 37.2 42.3 Computer 25.0 6.9 12.4 Internet connection 8.3 1.3 3.5 Any phone 96.6 92.9 94.1 Mobile telephone 95.2 92.5 93.3 Non-mobile telephone 28.9 3.6 11.4 Camera 12.8 5.4 7.7 Video camera 7.3 2.2 3.8 Carpet 97.4 95.7 96.2 Table 52.3 31.8 38.1 Chair 43.0 14.0 22.9 Sofa 58.1 32.0 40.0 Bed 38.3 47.6 44.8 Buffet 58.1 34.7 41.9 Refrigerator 77.3 35.0 48.0 Freezer 6.1 2.1 3.3 Fan 54.0 39.8 44.2 Air conditioner 26.7 5.2 11.8 Washing machine 39.6 10.9 19.7 Vacuum cleaner 48.1 13.1 23.8 Sewing machine 49.7 63.3 59.1 In-door heater (burzhuika) 36.4 87.0 71.4 Mini-generator (dvizhok) 8.8 16.4 14.1 Wood/fuel stock 36.9 93.3 76.0 Means of transport Bicycle 18.6 29.8 26.3 Animal drawn cart 1.0 6.1 4.6 Motorcycle/scooter 0.6 1.6 1.3 Car/truck 28.0 33.0 31.4 Ownership of agricultural land 27.0 92.9 72.7 Ownership of farm animals1 13.4 72.0 54.0 Watch 43.5 33.1 36.3 Bank account 2.9 1.9 2.2 Number 1,976 4,456 6,432 1 Livestock, herds, other farm animals, beehives, or poultry 20 • Housing Characteristics and Household Population likely to have a freezer (3 percent) and most likely to have a stock of wood or other fuel (76 percent) and an indoor heater (71 percent). Urban households are more likely to have most but not all of the household effects in Table 2.4. One of the most notable differences is in the percentage owning a refrigerator; 77 percent of urban households have a refrigerator compared with 35 percent of rural households. On the other hand, rural households are more likely than urban households to have a stock of wood or other fuel and to own an indoor heater. Table 2.4 also presents information on household ownership of a means of transport. Twenty-six percent of Tajik households report they own a bicycle, and 31 percent have a car or truck. Household ownership of cars/trucks has almost doubled since the 2005 MICS survey (SCS, 2007) when 17 percent of households reported owning a car or truck. Rural households are more likely to have a car/truck than urban households (33 percent versus 28 percent) and also to own a bicycle (30 percent versus 19 percent). The majority of Tajik households own agricultural land1 (73 percent), and a large proportion also owns farm animals (54 percent). As expected, rural households are much more likely than urban households to own agricultural land (93 percent versus 27 percent) or farm animals (72 percent versus 13 percent). Few Tajik households have a bank account. Three percent of urban households and 2 percent of rural households report they have an account. 2.3 HOUSEHOLD WEALTH The TjDHS survey did not include direct questions on household consumption or income. However, the detailed data on dwelling and household characteristics and household assets obtained in the survey have been used to construct the wealth index presented in Table 2.5. The wealth index has been shown to be consistent with other expenditure and income measures and to provide a useful measure in assessing inequalities in the use of health and other services and in health outcomes (Rutstein and Johnson, 2004). The process of constructing the wealth index, which takes into account urban-rural differences in the household characteristics, involved three steps. In the first step, a subset of indicators common to both urban and rural areas was used to create wealth scores for households in both areas. To create the scores, categorical variables were transformed into separate dichotomous (0-1) indicators. These variables and other continuous measures were then analyzed using principal components analysis to produce a common factor score for each household. In a second step, separate factor scores were produced for households in urban areas and rural areas using area-specific indicators (Rutstein, 2008). The third step combined the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting the area-specific score through regression on the common factor scores. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index was computed, national-level wealth quintiles were formed by assigning the household score to each de jure household member, ranking each person in the population by their score, and then dividing the ranking into five equal categories, each including approximately 20 percent of the population. 1 According to the Land Code of the Republic of Tajikistan, land in the Republic of Tajikistan is exclusively owned by the State (GOT, 2008). However, upon appropriate State registration, use of a land plot can be given for perpetual use to natural persons and legal entities of the Republic of Tajikistan (Articles 11-15). Land suitable for agricultural needs can be allocated to natural persons and legal entities for agricultural production (Articles 65-71). Housing Characteristics and Household Population • 21 Table 2.5 shows the distribution of the population across the five wealth quintiles according to urban-rural residence and region. These distributions indicate the degree to which wealth is evenly (or unevenly) distributed by geographic areas. The distribution of households by quintiles is not exactly 20 percent due to the fact that members of the households, not the households themselves, are divided into the quintiles. Table 2.5 Wealth quintiles Percent distribution of the de jure population by wealth quintiles and the Gini Coefficient, according to residence and region, Tajikistan 2012 Residence/region Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 2.4 5.0 10.9 20.7 61.1 100.0 9,715 0.27 Rural 25.6 24.8 22.9 19.8 6.9 100.0 30,753 0.19 Region Dushanbe 0.6 0.7 3.4 15.2 80.1 100.0 3,526 0.24 GBAO 33.0 21.4 19.0 15.9 10.7 100.0 894 0.28 Sughd 17.1 13.3 19.7 29.3 20.5 100.0 11,790 0.29 DRS 11.2 18.6 29.7 24.3 16.3 100.0 9,966 0.28 Khatlon 32.5 31.3 17.7 10.8 7.7 100.0 14,291 0.30 Total 20.0 20.0 20.0 20.0 19.9 100.0 40,468 0.33 The results in Table 2.5 show that wealth is not evenly distributed by residence or region. For example, more than 60 percent of the urban population is in the highest quintile. In contrast, 50 percent of the rural population is found in the two lowest quintiles. Similar disparities are observed across the regions. For example, 80 percent of Dushanbe’s population is in the highest wealth quintile, while almost two- thirds of Khatlon’s population and more than half of the population in the GBAO region are in the two lowest quintiles. Table 2.5 also presents the Gini coefficient, which indicates the level of concentration of wealth, 0 being an equal distribution and 1 a totally unequal distribution. The Gini coefficient is higher in urban areas (0.27) than rural areas (0.19), indicating a somewhat more inequitable distribution of wealth in the urban population than in the rural population. Regional differences in Gini coefficients are generally not large; the highest coefficient is observed in the Khatlon region (0.30), indicating that this region has the most inequitable wealth distribution. 2.4 HAND WASHING Washing hands with soap and water is the ideal hygienic practice. Research shows the substantial potential that hand washing with water and soap (or a non-soap cleansing agent such as ash or sand) has for reducing the transmission of diarrhea, respiratory infections, and other illnesses (Ensink, 2008; Luby et al., 2005). To obtain information on hand washing, the TjDHS interviewer asked to see the place where household members most often washed their hands and recorded information on the availability of water and soap and/or other cleansing agents at that place. Table 2.6 shows that the place for hand washing was observed in 93 percent of households. The main reason that interviewers were not able to observe the place where household members washed their hands was because the place was not in the dwelling (data not shown). 22 • Housing Characteristics and Household Population Table 2.6 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap, and other cleansing agents, Tajikistan 2012 Background characteristic Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed, percentage with: Number of households with place for hand washing observed Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Missing Total Residence Urban 97.7 1,976 90.0 0.0 6.1 1.0 0.0 2.7 0.1 100.0 1,931 Rural 90.2 4,456 73.0 0.6 18.2 1.5 0.0 6.5 0.2 100.0 4,019 Region Dushanbe 98.0 756 93.1 0.1 3.6 0.6 0.0 2.6 0.0 100.0 741 GBAO 93.5 160 85.5 1.3 12.7 0.0 0.0 0.5 0.0 100.0 149 Sughd 92.4 2,069 71.7 0.2 18.7 0.6 0.0 8.7 0.2 100.0 1,911 DRS 91.3 1,433 83.9 0.6 10.6 1.4 0.1 3.3 0.1 100.0 1,309 Khatlon 91.4 2,014 75.2 0.6 16.8 2.6 0.0 4.7 0.1 100.0 1,840 Wealth quintile Lowest 85.7 1,207 60.3 0.7 29.6 2.2 0.0 6.8 0.4 100.0 1,034 Second 86.6 1,132 73.3 0.6 18.9 1.8 0.1 5.3 0.0 100.0 980 Middle 92.5 1,158 75.7 0.6 14.9 1.2 0.0 7.6 0.1 100.0 1,071 Fourth 96.4 1,271 81.2 0.4 10.4 1.3 0.0 6.6 0.1 100.0 1,226 Highest 98.6 1,664 92.9 0.0 4.4 0.8 0.0 1.8 0.1 100.0 1,640 Total 92.5 6,432 78.5 0.4 14.3 1.4 0.0 5.3 0.2 100.0 5,951 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only as well as those with soap and another cleansing agent Among households where the hand washing place was observed, 79 percent had soap and water available. Most other households had water only available. Only 5 percent of households had no water, soap, or other cleaning agent available at the location. Urban households were more likely to have soap and water available at the usual hand washing place than rural households (90 percent versus 73 percent). The likelihood of having soap and water available was highest in Dushanbe (93 percent) and lowest in Sughd (72 percent) and increased with the wealth quintile, from 60 percent of households in the lowest quintile to more than 90 percent in the highest quintile. 2.5 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.7 gives the distribution of the 2012 TjDHS de facto household population by age, according to sex and residence. A total of 37,779 persons were found in the 6,432 households interviewed in the TjDHS. Table 2.7 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Tajikistan 2012 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 13.7 11.9 12.8 16.3 13.9 15.0 15.7 13.4 14.5 5-9 12.6 9.4 10.9 13.2 11.4 12.2 13.0 10.9 11.9 10-14 11.1 10.7 10.9 13.3 11.0 12.1 12.8 10.9 11.8 15-19 11.4 10.5 10.9 10.9 10.8 10.9 11.1 10.7 10.9 20-24 9.1 10.1 9.6 7.7 10.4 9.1 8.0 10.3 9.2 25-29 7.1 7.7 7.4 7.0 8.8 7.9 7.0 8.5 7.8 30-34 6.0 6.7 6.4 5.1 6.2 5.7 5.3 6.3 5.8 35-39 5.2 6.4 5.8 4.4 5.1 4.8 4.6 5.4 5.0 40-44 5.7 6.5 6.1 4.0 4.9 4.5 4.4 5.3 4.9 45-49 4.9 5.5 5.2 4.2 4.3 4.2 4.4 4.6 4.5 50-54 4.5 5.5 5.0 4.4 4.5 4.5 4.5 4.7 4.6 55-59 3.3 3.1 3.2 2.9 3.1 3.0 3.0 3.1 3.1 60-64 2.0 2.1 2.1 2.1 2.2 2.2 2.1 2.2 2.1 65-69 0.9 1.3 1.1 1.3 1.0 1.2 1.2 1.1 1.2 70-74 1.0 1.0 1.0 1.4 1.0 1.1 1.3 1.0 1.1 75-79 0.7 0.8 0.8 1.0 0.7 0.8 0.9 0.7 0.8 80 + 0.8 0.6 0.7 0.9 0.8 0.8 0.8 0.7 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,394 4,807 9,202 13,285 15,292 28,577 17,679 20,099 37,779 Housing Characteristics and Household Population • 23 The age structure of the household population shows the effects of past demographic trends in Tajikistan, particularly the country’s moderately high fertility. The majority of the household population is under age 25 (58 percent), and 38 percent is less than age 15. The proportion of the population under age 25 is higher in rural areas (59 percent) than in urban areas (55 percent). The population pyramid shown in Figure 2.2 was constructed using the age and sex distribution of the TjDHS household population. The pyramid has a wide base, which is typical of populations that have experienced high fertility in the recent past. Figure 2.2 Population pyramid 2.6 HOUSEHOLD COMPOSITION Table 2.8 looks at aspects of the composition of households that may affect the allocation of resources (financial, emotional, etc.) available to household members. For example, in cases where women are heads of households, financial resources are often limited. Similarly, the size of the household affects the wellbeing of its members. Where the size of the household is large, crowding can lead to health problems. The presence of orphans and foster children may also strain household resources. 8 6 4 2 0 2 4 6 8 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Percentage Age Male Tajikistan DHS 2012 Female 24 • Housing Characteristics and Household Population Table 2.8 shows that the head of most Tajik households is male; the head is female in only 21 percent of households. Female- headed households are more common in urban areas than in rural areas (28 percent versus 18 percent). The average TjDHS household has 6.3 members. One-quarter of the households have 8 or more members, while just 7 percent have 1 to 2 members. Residence is strongly related to household size; on average, rural households have 6.9 members, two more than the average urban household (4.9 members). Information was collected in the TjDHS on the living arrangements and survival status of the parents of children under age 18. This information is used in Table 2.8 to identify the percentage of households that include: (1) children who were fostered, that is, children whose parents were both alive but not living in the household with the child and (2) children who were orphans, that is, children whose father or mother or both parents were dead. Eight percent of Tajik households are caring for foster children and/or orphans. Additional detail on the prevalence of fosterhood and orphanhood among children under age 18 is presented later in this chapter. 2.7 BIRTH REGISTRATION The registration of a child’s birth is a critical step to ensuring that a child may claim full legal rights and protections and services in a society (UNICEF, 2012). Table 2.9 provides information collected in the TjDHS Household Questionnaire on birth registration and possession of a birth certificate for the de jure children under age 5. The registration of births is the inscription of the facts of the birth into an official log kept at the registrar’s office. A birth certificate is typically issued at the time of registration or later as proof of the registration of the birth. Not all children who are registered may have a birth certificate because some certificates may have been lost or were never issued. However, all children with a certificate have been registered. Table 2.8 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under age 18, according to residence, Tajikistan 2012 Characteristic Residence Total Urban Rural Household headship Male 71.7 81.7 78.6 Female 28.3 18.3 21.4 Total 100.0 100.0 100.0 Number of usual members 0 0.9 0.1 0.3 1 7.0 0.9 2.8 2 8.4 2.7 4.5 3 12.3 4.9 7.2 4 18.5 9.5 12.3 5 17.8 16.0 16.6 6 14.3 18.4 17.2 7 8.5 16.1 13.8 8 4.7 8.8 7.6 9+ 7.5 22.5 17.9 Total 100.0 100.0 100.0 Mean size of households 4.9 6.9 6.3 Percentage of households with orphans and foster children under age 18 Foster children1 3.5 3.9 3.8 Double orphans 0.4 0.3 0.3 Single orphans2 4.0 5.0 4.7 Foster and/or orphan children 7.0 8.3 7.9 Number of households 1,976 4,456 6,432 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2 Single orphans include children with one dead parent and an unknown survival status of the other parent. Housing Characteristics and Household Population • 25 Table 2.9 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with civil authorities, according to background characteristics, Tajikistan 2012 Background characteristic Percentage of children whose births are registered Percentage of children whose births are registered and who have Percentage of children who are not registered or who are registered but do not have a birth certificate Number of children Birth certificate No birth certificate Age <2 84.3 73.5 10.8 26.5 2,356 2-4 91.5 87.7 3.7 12.3 3,181 Sex Male 89.0 82.9 6.2 17.1 2,803 Female 87.8 80.4 7.4 19.6 2,734 Residence Urban 87.8 82.7 5.1 17.3 1,193 Rural 88.6 81.4 7.2 18.6 4,343 Region Dushanbe 86.5 80.8 5.7 19.2 441 GBAO 89.2 79.2 10.0 20.8 102 Sughd 92.2 91.6 0.6 8.4 1,490 DRS 86.4 76.9 9.5 23.1 1,428 Khatlon 87.4 78.1 9.3 21.9 2,076 Wealth quintile Lowest 86.1 76.5 9.6 23.5 1,088 Second 86.8 80.8 6.0 19.2 1,182 Middle 88.7 81.2 7.5 18.8 1,163 Fourth 91.2 85.2 5.9 14.8 1,112 Highest 89.6 85.0 4.6 15.0 991 Total 88.4 81.7 6.8 18.3 5,536 The TjDHS results indicate that almost one in five young children in Tajikistan is potentially at risk of being unable to claim full legal rights and services because their birth is not registered or they lack a birth certificate as proof that the birth was registered. Children under age 2 are more than twice as likely as older children not to be registered or to be without a birth certificate (27 percent versus 12 percent). Only 8 percent of children in the Sughd region are not registered or lack a birth certificate. The percentage of children not registered or lacking a birth certificate is much higher in other regions, ranging from 19 percent in Dushanbe to 23 percent in the DRS region. The likelihood that a child’s birth is not registered or a birth certificate is not available decreases as the wealth quintile increases, from 24 percent in the lowest quintile to 15 percent in the fourth and highest quintiles. 2.8 CHILDREN’S LIVING ARRANGEMENTS The 2012 TjDHS included a series of questions on the living arrangements and the survival status of the parents of all children under age 18. These data were used earlier in this chapter to show the percentage of households in Tajikistan that are caring for foster or orphan children. Table 2.10 employs that information to look at the living arrangements among children under age 18 and to assess the extent of fosterhood and orphanhood among children in Tajikistan. The table shows that 88 percent of de jure children under age 18 live with both parents, 9 percent are living with their mother only, 1 percent are living with their father only, and 2 percent are not living with either parent. One percent of children under age 18 are defined as foster children, that is, their parents are both alive but are not living in the same household as the child. Three percent of children under age 18 are orphans, that is, one or both parents are dead. Among orphaned children, most have lost their fathers, less than 1 percent have lost their mothers, and very few children have lost both parents (0.1 percent). Children who are not living with a biological parent include foster children and double orphans (children who have lost both parents); less than 2 percent of Tajik children fall into this category. 26 • H ou si ng C ha ra ct er is tic s an d H ou se ho ld P op ul at io n Ta bl e 2. 10 C hi ld re n' s liv in g ar ra ng em en ts a nd o rp ha nh oo d Pe rc en t d is tri bu tio n of d e ju re c hi ld re n un de r a ge 1 8 by li vi ng a rra ng em en ts a nd s ur vi va l s ta tu s of p ar en ts , t he p er ce nt ag e of c hi ld re n no t l iv in g w ith a b io lo gi ca l p ar en t, an d th e pe rc en ta ge o f c hi ld re n w ith o ne o r bo th p ar en ts d ea d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T aj ik is ta n 20 12 Ba ck gr ou nd ch ar ac te ris tic Li vi ng w ith bo th p ar en ts Li vi ng w ith m ot he r bu t n ot w ith fa th er Li vi ng w ith fa th er bu t n ot w ith m ot he r N ot li vi ng w ith e ith er p ar en t To ta l Pe rc en ta ge no t l iv in g w ith a bi ol og ic al pa re nt Pe rc en ta ge w ith o ne o r bo th p ar en ts de ad 1 N um be r o f ch ild re n Fa th er al iv e Fa th er de ad M ot he r al iv e M ot he r de ad Bo th al iv e O nl y fa th er a liv e O nl y m ot he r a liv e Bo th de ad M is si ng in fo rm at io n on fa th er / m ot he r A ge 0- 4 91 .1 7. 0 0. 7 0. 1 0. 2 0. 6 0. 0 0. 0 0. 1 0. 2 10 0. 0 0. 7 0. 9 5, 53 6 <2 92 .1 6. 6 0. 5 0. 1 0. 2 0. 4 0. 0 0. 0 0. 0 0. 2 10 0. 0 0. 4 0. 6 2, 35 6 2- 4 90 .5 7. 4 0. 8 0. 2 0. 2 0. 7 0. 0 0. 0 0. 2 0. 2 10 0. 0 0. 9 1. 1 3, 18 1 5- 9 89 .6 6. 2 1. 9 0. 4 0. 2 1. 2 0. 1 0. 1 0. 2 0. 1 10 0. 0 1. 5 2. 4 4, 52 8 10 -1 4 86 .8 5. 9 3. 4 0. 7 0. 6 1. 8 0. 1 0. 3 0. 2 0. 3 10 0. 0 2. 4 4. 6 4, 48 7 15 -1 7 82 .2 5. 5 5. 2 1. 1 1. 1 2. 7 0. 3 0. 6 0. 1 1. 1 10 0. 0 3. 7 7. 3 2, 70 0 Se x M al e 88 .1 6. 3 2. 4 0. 6 0. 5 1. 4 0. 1 0. 1 0. 1 0. 3 10 0. 0 1. 8 3. 3 8, 79 4 Fe m al e 88 .3 6. 3 2. 4 0. 4 0. 4 1. 4 0. 1 0. 2 0. 2 0. 4 10 0. 0 1. 8 3. 3 8, 45 7 R es id en ce U rb an 84 .8 8. 6 3. 1 0. 6 0. 2 2. 0 0. 1 0. 2 0. 3 0. 1 10 0. 0 2. 5 3. 9 3, 88 8 R ur al 89 .2 5. 6 2. 2 0. 5 0. 5 1. 2 0. 1 0. 2 0. 1 0. 4 10 0. 0 1. 6 3. 1 13 ,3 63 R eg io n D us ha nb e 84 .5 8. 0 3. 2 0. 6 0. 2 2. 2 0. 1 0. 3 0. 5 0. 2 10 0. 0 3. 2 4. 4 1, 46 8 G BA O 77 .5 9. 6 2. 2 1. 3 0. 1 8. 0 0. 1 0. 6 0. 1 0. 5 10 0. 0 8. 7 3. 1 34 3 Su gh d 87 .9 7. 2 1. 4 0. 6 0. 6 1. 6 0. 0 0. 0 0. 1 0. 5 10 0. 0 1. 8 2. 2 4, 64 6 D R S 89 .9 5. 0 2. 9 0. 5 0. 4 0. 9 0. 2 0. 1 0. 0 0. 3 10 0. 0 1. 1 3. 4 4, 30 3 Kh at lo n 88 .7 6. 0 2. 6 0. 4 0. 5 1. 0 0. 1 0. 3 0. 2 0. 2 10 0. 0 1. 6 3. 7 6, 49 2 W ea lth q ui nt ile Lo w es t 91 .6 4. 2 2. 1 0. 1 0. 5 0. 8 0. 1 0. 2 0. 0 0. 3 10 0. 0 1. 1 3. 0 3, 84 4 Se co nd 88 .7 5. 6 2. 7 0. 5 0. 7 1. 0 0. 0 0. 1 0. 2 0. 5 10 0. 0 1. 3 3. 8 3, 56 2 M id dl e 87 .5 6. 5 2. 1 0. 9 0. 4 1. 5 0. 3 0. 3 0. 2 0. 4 10 0. 0 2. 3 3. 3 3, 36 1 Fo ur th 87 .8 6. 8 2. 3 0. 4 0. 3 2. 0 0. 0 0. 0 0. 2 0. 2 10 0. 0 2. 2 2. 8 3, 22 8 H ig he st 84 .9 8. 8 2. 7 0. 7 0. 3 1. 9 0. 2 0. 2 0. 1 0. 3 10 0. 0 2. 3 3. 5 3, 25 6 To ta l < 15 89 .3 6. 4 1. 9 0. 4 0. 3 1. 1 0. 1 0. 1 0. 1 0. 2 10 0. 0 1. 5 2. 5 14 ,5 52 To ta l < 18 88 .2 6. 3 2. 4 0. 5 0. 5 1. 4 0. 1 0. 2 0. 1 0. 3 10 0. 0 1. 8 3. 3 17 ,2 52 N ot e: T ab le is b as ed o n de ju re m em be rs , i .e ., us ua l r es id en ts . 1 I nc lu de s ch ild re n w ith fa th er d ea d, m ot he r d ea d, b ot h de ad , a nd o ne p ar en t d ea d bu t m is si ng in fo rm at io n on s ur vi va l s ta tu s of th e ot he r p ar en t. 26 • Housing Characteristics and Household Population Housing Characteristics and Household Population • 27 Table 2.10 shows that, as expected, the percentage of orphaned children rises with age, from 1 percent among children age 0-4 to 7 percent among children age 15-17. Similarly, the proportion of children who are not living with a biological parent increases with age, from less than 1 percent among children age 0-4 to 4 percent among children age 15-17. The proportion of children who are not living with a biological parent is 9 percent in GBAO compared with 3 percent or less in the other regions. The difference is mainly due to the much higher level of fostered children in GBAO (8 percent) than in the other regions (2 percent or less). 2.9 EDUCATION OF HOUSEHOLD MEMBERS Many phenomena such as reproductive behavior, use of contraception, health of children, and proper hygienic habits are affected by the education of household members. During the household interview, questions on the highest level of schooling completed were included for all household members and visitors age three and over and on recent school attendance for persons age 3-24 years. This information is used in this section to examine several aspects of the educational experience of the TjDHS household population, including the overall educational attainment of household members, school attendance among the primary- and secondary-school age populations, and participation in early childhood education programs. 2.9.1 Educational Attainment Tables 2.11.1 and 2.11.2 present information on the educational attainment of the de facto female and male household population age six and over, respectively. Within the Tajikistan system, education levels are as follows: primary (Grades 1-4); general basic, also known as stage I of secondary education (Grades 5-92); general secondary, also known as stage II of secondary education (Grades 10-11); professional primary/middle (specialized technical or vocational school programs involving two or three grades each); and higher (university or post-graduate programs). Individuals who attended or completed the general basic level (Grades 5-9) and those who attended but did not complete the general secondary level (Grades 10-11) are combined into the some secondary category. The completed secondary category includes individuals who completed grade 11 and those who completed grade 10 and were awarded a general education school diploma (“attestat” in the older Soviet education system terminology). Overall, most of the female population age six and older has attained at least some secondary education; only one in five never attended school (7 percent) or attended only the primary level (14 percent). One in three women completed secondary school but did not pursue professional or higher education. Ten percent of women attended or completed professional school or have a university or higher education. The median completed years of schooling among females is 8.6 years. Similar to the female population, only one in five males age six and over never attended school or attained only the primary level. On the other hand, males are more likely than females to have post- secondary education; 8 percent of men have attended or completed the professional level, and 15 percent have higher education. The median completed years of schooling among males is 9.3 years. 2 It should be noted that Tajikistan’s educational system has undergone several stages of restructuring over the past several decades. The current system of formal education was introduced in September 1990. In the new system, primary education consists of Grades 1-4, general basic education consists of Grades 5-9 instead of Grades 5-8 as in the previous system, and general secondary (high school) consists of Grades 10-11 instead of Grades 9-10. For purposes of categorizing educational level in the 2012 TjDHS, individuals who in 1989 were age 15 or older and reported attending or completing grade 9 were included in the general secondary education category because they attained grade 9 before the current educational system change took effect. Individuals who reported at the time of interview that they had attended or completed grade 9 and were age 14 or younger in 1989 were included in the general basic education category, in accordance with the new system. 28 • Housing Characteristics and Household Population Table 2.11.1 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Tajikistan 2012 Background characteristic No education Some primary Completed primary1 Some secondary2 Completed secondary3 Profes- sional primary Profes- sional middle Higher Don't know/ missing Total Number Median years completed Age 6-9 39.8 58.0 1.3 0.4 0.0 0.0 0.0 0.0 0.5 100.0 1,831 0.4 10-14 1.8 11.5 18.9 67.7 0.0 0.0 0.0 0.0 0.1 100.0 2,190 5.0 15-19 2.1 1.0 2.6 60.0 29.1 1.3 1.5 2.4 0.0 100.0 2,154 8.8 20-24 3.5 3.4 3.4 38.8 36.1 1.6 5.5 7.7 0.0 100.0 2,073 9.5 25-29 3.1 3.1 3.6 42.0 34.0 2.4 3.9 7.8 0.1 100.0 1,709 9.0 30-34 1.6 0.7 1.5 45.1 38.4 2.3 4.7 5.6 0.1 100.0 1,269 9.2 35-39 2.0 0.5 0.5 21.2 58.7 4.5 5.3 7.3 0.0 100.0 1,088 9.8 40-44 1.3 0.9 0.3 11.9 64.4 6.8 4.7 9.8 0.0 100.0 1,064 9.6 45-49 1.2 0.5 0.2 12.3 70.7 3.0 5.5 6.5 0.0 100.0 924 9.5 50-54 1.3 0.9 1.3 19.8 62.1 3.9 3.7 6.9 0.1 100.0 954 9.4 55-59 2.4 1.3 1.7 27.8 50.8 2.6 3.5 9.7 0.1 100.0 624 9.4 60-64 4.6 2.7 2.5 39.1 39.4 1.8 3.0 6.9 0.0 100.0 443 9.1 65+ 14.7 11.9 10.9 40.1 14.3 1.1 2.1 4.7 0.2 100.0 714 6.2 Residence Urban 4.8 7.7 3.8 31.7 31.2 3.2 5.3 12.2 0.1 100.0 4,159 9.2 Rural 7.4 9.9 4.7 37.7 33.5 1.7 2.3 2.7 0.1 100.0 12,879 8.4 Region Dushanbe 4.5 9.2 4.4 33.3 25.1 2.2 4.2 17.0 0.1 100.0 1,503 9.0 GBAO 3.3 6.1 2.7 22.0 40.0 3.0 7.6 15.2 0.0 100.0 401 9.7 Sughd 5.7 7.8 2.9 32.0 38.2 3.2 4.3 5.9 0.0 100.0 5,059 9.2 DRS 7.4 9.9 5.7 43.1 26.7 1.4 2.8 2.9 0.2 100.0 4,033 8.1 Khatlon 8.1 10.6 5.2 36.8 34.2 1.4 1.5 2.0 0.1 100.0 6,042 8.2 Wealth quintile Lowest 9.4 12.2 6.0 39.8 29.7 1.2 0.6 0.8 0.3 100.0 3,488 7.6 Second 7.9 10.6 5.2 39.3 33.0 1.1 1.5 1.3 0.1 100.0 3,359 8.2 Middle 7.0 9.8 4.8 37.9 34.2 1.8 2.1 2.4 0.0 100.0 3,395 8.5 Fourth 5.3 7.2 3.1 34.3 38.7 2.7 4.4 4.4 0.0 100.0 3,390 9.1 Highest 4.2 7.2 3.4 29.8 29.1 3.4 6.6 16.1 0.1 100.0 3,406 9.4 Total 6.8 9.4 4.5 36.2 32.9 2.1 3.0 5.0 0.1 100.0 17,038 8.6 1 Completed Grade four at the primary level 2 Attended or completed the general basic level (Grades 5-9) and attended but did not complete the general secondary level (Grades 10-11) 3 Completed Grade 11 at the secondary level or completed Grade 10 at the secondary level and has a general education school diploma ("attestat" as in older Soviet educational system terminology) Table 2.11.2 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Tajikistan 2012 Background characteristic No education Some primary Completed primary1 Some secondary2 Completed secondary3 Profes- sional primary Profes- sional middle Higher Don't know/ missing Total Number Median years completed Age 6-9 41.0 58.0 0.7 0.1 0.0 0.0 0.0 0.0 0.2 100.0 1,886 0.4 10-14 0.9 11.6 17.4 70.0 0.0 0.0 0.0 0.0 0.1 100.0 2,258 5.0 15-19 1.0 0.7 0.2 51.9 36.2 1.7 1.7 6.5 0.1 100.0 1,957 9.3 20-24 1.7 0.9 1.1 19.3 39.5 3.4 3.7 30.3 0.0 100.0 1,417 10.6 25-29 1.5 1.2 1.2 19.8 41.6 3.6 3.2 27.8 0.0 100.0 1,241 10.6 30-34 0.9 0.8 1.3 16.5 46.8 3.6 3.8 26.4 0.0 100.0 940 10.5 35-39 0.4 0.2 0.5 9.6 52.8 9.1 6.1 21.4 0.0 100.0 814 10.3 40-44 1.2 0.3 0.0 5.5 52.7 11.5 8.1 20.7 0.0 100.0 777 9.9 45-49 0.4 0.8 0.3 7.0 46.1 15.4 7.2 22.6 0.0 100.0 771 9.9 50-54 0.4 0.6 0.2 7.7 50.4 11.9 7.7 21.2 0.0 100.0 789 9.8 55-59 1.2 0.4 0.4 9.4 41.4 10.0 12.3 24.6 0.2 100.0 531 10.0 60-64 1.4 0.4 1.4 15.7 38.5 6.2 10.4 25.5 0.4 100.0 368 9.8 65+ 6.3 5.1 7.1 29.0 26.5 6.3 3.9 15.6 0.2 100.0 746 9.1 Residence Urban 5.3 9.8 3.1 22.1 25.7 3.8 4.3 25.9 0.0 100.0 3,704 9.8 Rural 6.9 10.2 3.8 27.9 31.7 4.8 3.4 11.2 0.1 100.0 10,791 9.2 Region Dushanbe 5.9 10.2 3.5 20.6 20.3 2.7 3.5 33.3 0.1 100.0 1,391 9.9 GBAO 4.2 7.6 2.5 19.0 29.0 6.8 9.9 21.0 0.1 100.0 344 10.2 Sughd 7.0 9.3 3.3 26.8 31.5 5.0 3.6 13.3 0.1 100.0 4,095 9.3 DRS 6.2 10.2 3.2 31.0 30.1 3.4 3.7 12.1 0.1 100.0 3,377 9.1 Khatlon 6.6 10.7 4.2 25.2 31.9 5.2 3.2 12.8 0.1 100.0 5,289 9.3 Wealth quintile Lowest 7.9 11.7 4.6 31.9 30.9 4.8 2.6 5.6 0.1 100.0 2,928 8.4 Second 6.7 10.5 4.1 27.5 33.4 4.9 3.4 9.4 0.1 100.0 2,880 9.2 Middle 6.9 9.7 3.1 27.7 32.4 5.3 3.4 11.4 0.2 100.0 2,748 9.2 Fourth 5.7 8.5 3.4 25.9 32.4 4.1 4.7 15.1 0.1 100.0 2,855 9.4 Highest 5.4 10.0 2.8 19.6 22.5 3.7 4.1 32.0 0.1 100.0 3,084 10.0 Total 6.5 10.1 3.6 26.4 30.2 4.5 3.6 14.9 0.1 100.0 14,496 9.3 1 Completed Grade four at the primary level. 2 Attended or completed the general basic level (Grades 5-9) and attended but did not complete the general secondary level (Grades 10-11). 3 Completed Grade 11 at the secondary level or completed Grade 10 at the secondary level and has a general education school diploma ("attestat" as in older Soviet educational system terminology). Housing Characteristics and Household Population • 29 Tables 12.11.1 and 12.11.2 also show differentials in educational attainment by age, residence, region, and wealth quintile. The majority of both females and males in every subgroup have at least some secondary education, except children age 6-9, who are, as expected, concentrated at the primary level or have not yet entered school. The median completed years of schooling is higher in urban areas than in rural areas among both females (9.2 years versus 8.4 years) and males (9.8 years versus 9.2 years). On average, educational attainment is highest in the GBAO region and lowest in the DRS region. Among females, there is a difference of 1.6 years in the median years of schooling between GBAO and DRS while the difference among males is 1.1 years. Dushanbe lags behind GBAO in the median completed years of schooling among both males and females; however, the percentage attaining at least some higher education is higher in Dushanbe than in any of the regions, especially among males. Wealth has a strong positive relationship with education. Among females, the median years of schooling varies from 7.6 in the lowest quintile to 9.4 years in the highest quintile, and, among males, the median ranges from 8.4 years in the lowest quintile to 10.0 years in the highest quintile. 2.9.2 School Attendance Table 2.12 provides information on net and gross attendance ratios and the gender parity index by school level, sex, residence, and region, and Figure 2.3 presents age-specific attendance rates. For purposes of calculating these indicators, children were considered to be currently attending if they had attended school at the given level at any time during the current school year. Table 2.12 School attendance ratios Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Tajikistan 2012 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 88.0 88.0 88.0 1.00 100.9 102.4 101.5 1.01 Rural 86.4 87.6 87.0 1.01 103.3 99.1 101.1 0.96 Region Dushanbe 84.4 88.5 86.3 1.05 97.1 100.6 98.7 1.04 GBAO 87.9 82.2 85.1 0.94 100.4 93.1 96.8 0.93 Sughd 86.2 87.7 86.9 1.02 103.7 103.1 103.4 0.99 DRS 87.5 88.6 88.1 1.01 105.4 98.4 101.7 0.93 Khatlon 87.4 87.1 87.3 1.00 102.0 98.5 100.2 0.97 Wealth quintile Lowest 88.6 87.5 88.0 0.99 101.7 99.5 100.5 0.98 Second 86.2 87.7 87.0 1.02 102.8 99.2 101.0 0.97 Middle 83.8 89.5 86.9 1.07 106.0 102.6 104.2 0.97 Fourth 87.9 84.1 86.1 0.96 102.2 95.8 99.2 0.94 Highest 86.8 89.0 87.8 1.03 101.4 101.2 101.3 1.00 Total 86.8 87.6 87.2 1.01 102.7 99.7 101.2 0.97 SECONDARY SCHOOL Residence Urban 87.6 82.2 84.9 0.94 95.0 88.3 91.6 0.93 Rural 88.4 78.3 83.4 0.89 94.9 84.5 89.8 0.89 Region Dushanbe 87.5 77.0 82.0 0.88 99.8 83.2 91.1 0.83 GBAO 93.0 91.1 92.0 0.98 99.5 100.3 99.9 1.01 Sughd 86.4 80.9 83.6 0.94 92.7 86.8 89.7 0.94 DRS 88.3 78.0 83.3 0.88 93.4 83.4 88.6 0.89 Khatlon 89.3 78.7 84.1 0.88 96.0 85.2 90.7 0.89 Wealth quintile Lowest 90.4 76.5 83.7 0.85 94.6 81.3 88.2 0.86 Second 86.7 79.2 83.0 0.91 93.1 83.8 88.6 0.90 Middle 87.5 78.9 83.3 0.90 92.8 87.1 90.0 0.94 Fourth 88.2 79.4 83.8 0.90 96.4 87.2 91.9 0.91 Highest 88.2 82.4 85.1 0.93 98.1 88.1 92.7 0.90 Total 88.3 79.2 83.8 0.90 94.9 85.4 90.2 0.90 1 The NAR for primary school is the percentage of the primary-school age (7-10) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (11-17) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the primary school NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. 30 • Housing Characteristics and Household Population The net attendance ratio (NAR) is an indicator of participation in schooling among those of official school age, that is, children age 7-10 for the primary level and children age 11-17 for the secondary level. A NAR of 100 would indicate that all children in the official age range for the level are attending school at that level. The gross attendance ratio (GAR) is an indicator of participation in schooling among those of any age between 5 and 24 years, expressed as a percentage of the official school age population. The GAR can exceed 100 percent if children who are overage or underage for the given level are attending school at the level.3 The results in Table 2.12 show school attendance among the school-age population is high but not universal. Among children age 7-10 who should be attending the primary level, 87 percent are doing so. A comparison of primary level NAR and GAR indicates that 14 percent of students attending primary school are underage or over-age for the level. Differentials in the NAR and GAR at the primary level are generally minor. The secondary school NAR indicates that 84 percent of children who should be attending the secondary level are doing so. The comparison of the secondary school NAR and GAR shows the proportion of secondary school students who are outside of the official school age is 6 percent. There are only minor differences in the NAR and GAR across subgroups. Table 2.12 also includes the Gender Parity Index (GPI), or the ratio of the female to the male GAR at the primary and secondary levels. The GPI indicates the magnitude of the gender gap in attendance ratios. If there is no gender difference, the GPI will equal 1.0, whereas the wider the disparity in favor of males, the closer the GPI will be to 0. If the gender gap favors females, the GPI will exceed 1.0. Table 2.12 shows that, at the primary level, the NAR GPI is 1.01 and the GAR GPI is 0.97, indicating there is almost no gender gap in primary school attendance. At the secondary level, the NAR and GAR GPIs are identical at 0.90, evidence of a modest but clear gender gap in secondary attendance favoring males. The secondary school NAR and GAR GPIs are lowest in rural areas, in the Dushanbe, DRS, and Khatlon regions, and in the lowest quintile, indicating that males have the greatest advantage over females in school attendance in these subgroups. Figure 2.3 presents information on age-specific school attendance rates for the population age 7-24. Attendance levels are low among children under age 7, and only about half of children age 7, which is the age at which children are expected to enter school, are currently attending school; the low attendance rate may in part reflect the fact that some of the children were not 7 at the start of the school year and, thus, were not eligible to start school. Among children age 8-14, attendance rates exceed 95 percent, with the rates generally slightly higher among boys than girls. Among the population age 15-24, attendance rates decline rapidly, and the gender gap increases with age. For example, among the population age 18, 61 percent of males are attending school compared with 38 percent of girls. 3 Students who are overage for a given level of schooling may have started school overage, may have repeated one or more grades at school, or may have dropped out of school and later returned. Children who are underage for the level may have started school underage or skipped one or more grades. Housing Characteristics and Household Population • 31 Figure 2.3 Age-specific attendance rates of the de facto population 7 to 24 years 2.9.3 Early Childhood Education Participation in pre-school is important in preparing children to attend school. Table 2.13 shows the percentage of children age 3-6 who were reported to be currently attending pre-school. Interviewers were instructed to record a child as attending pre-school if they were enrolled in a nursery school, a kindergarten, or any other type of separate structured session conducted by some educational center on a regular basis. 0 10 20 30 40 50 60 70 80 90 100 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age Male Female Percentage Tajikistan DHS 2012 32 • Housing Characteristics and Household Population Most young children in Tajikistan are not involved in any type of early childhood educational program; only 6 percent of children age 3-6 are attending pre-school. The highest rates of pre-school attendance are observed among children whose mothers have a professional school or higher education (23 percent and 29 percent, respectively) and children in the highest wealth quintile (20 percent). Urban residence is strongly related to pre-school attendance; 17 percent of children in urban areas are attending pre-school compared with 3 percent in rural areas. Pre-school attendance is markedly higher in Dushanbe (17 percent), GBAO (15 percent), and Sughd (12 percent) than in DRS and Khatlon (2 percent each). Table 2.13 Early childhood education Percentage of children 36-83 months attending a pre-school education program, a kindergarten, or any other organized early child education program, Tajikistan 2012 Background Characteristic Percentage of children attending early child educational program Number of children Age (months) 36-59 6.1 1,967 60-71 8.2 781 72-83 5.4 1,068 Sex Male 7.0 1,962 Female 5.6 1,855 Residence Urban 17.2 844 Rural 3.2 2,973 Region Dushanbe 17.3 314 GBAO 14.9 68 Sughd 12.0 1,117 DRS 1.7 1,003 Khatlon 2.0 1,315 Mother's education None/primary 2.0 246 General basic 2.8 1,337 General secondary 4.5 1,721 Professional primary/middle 22.8 257 Higher 29.0 197 Missing 9.7 59 Wealth quintile Lowest 0.1 807 Second 2.2 749 Middle 3.1 772 Fourth 6.8 751 Highest 20.3 738 Total 6.3 3,817 Background Characteristics of Respondents • 33 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3 his chapter first presents distributions of TjDHS respondents by basic demographic and socioeconomic characteristics including age at the time of the survey, marital status, broad education levels, urban/rural residence, region, and the wealth quintile to which they belong. A number of these characteristics are used in tables throughout the report to provide insights into demographic and social phenomena influencing the health situation of women and children in Tajikistan. The chapter also provides information on respondents’ exposure to mass media and their employment status and earnings. In addition, the chapter covers several important health issues, including respondents’ knowledge of tuberculosis, history of hypertension, and use of tobacco. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 shows the distribution of the 9,656 women age 15-49 interviewed in the 2012 TjDHS by various demographic and socioeconomic characteristics. Two in five of the TjDHS respondents were under 25, and one in five was age 40 or older. More than two-thirds of respondents were married (67 percent) or living together with a partner (0.2 percent); 27 percent were never-married; and 5 percent were divorced, separated, or widowed. Three-quarters of respondents lived in rural areas. More than one in three respondents was from Khalton (36 percent), 30 percent resided in Sughd, and 23 percent were from DRS. Dushanbe was home to 9 percent of the TjDHS respondents, and 2 percent lived in the GBAO region. Six in ten respondents had at least a general secondary education, or higher, and an additional 35 percent had attended or completed the general basic level. Relatively few respondents never went to school or attended only the primary level (6 percent). T Key Findings • The majority of Tajik women are exposed to some form of media at least once per week; television reaches the largest number of women (84 percent). • One in three women is currently working or was employed during the past 12 months; one in four working women is not paid or receives only in-kind payment. • Seven in ten women have heard about tuberculosis. • Three quarters of the women who knew about tuberculosis correctly identified that the disease is spread through the air when a person with tuberculosis coughs or sneezes, and nearly half mentioned the DOT approach as a way to prevent the spread of tuberculosis. • One in eight women age 15-49 have ever been told by a health provider they had high blood pressure; women who were overweight or obese were much more likely to be hypertensive than other women. • The majority of women told they had high blood pressure (82 percent) were taking prescribed medication to control hypertension; however, less than half of the women were taking other actions to lower their blood pressure such as cutting down on salt intake (46 percent), controlling their weight (39 percent), or exercising (28 percent). 34 • Background Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women age 15-49 by selected background characteristics, Tajikistan 2012 Background characteristic Women Weighted percent Weighted number Unweighted number Age 15-19 20.8 2,013 2,001 20-24 20.2 1,950 1,900 25-29 16.7 1,609 1,566 30-34 12.3 1,188 1,173 35-39 10.7 1,030 1,084 40-44 10.3 991 1,018 45-49 9.1 875 914 Marital status Never married 27.4 2,648 2,723 Married 67.1 6,483 6,364 Living together 0.2 21 24 Divorced/separated 2.9 275 301 Widowed 2.4 229 244 Residence Urban 25.0 2,413 3,408 Rural 75.0 7,243 6,248 Region Dushanbe 9.1 881 1,733 GBAO 2.3 220 1,069 Sughd 29.7 2,872 2,084 DRS 23.2 2,240 2,334 Khatlon 35.7 3,444 2,436 Education None 2.0 195 155 Primary 3.9 372 330 General basic 34.7 3,349 3,095 General secondary 46.3 4,474 4,373 Professional primary 2.6 252 276 Professional middle 4.1 394 481 Higher 6.4 620 946 Wealth quintile Lowest 19.5 1,878 1,616 Second 19.8 1,913 1,625 Middle 19.7 1,904 1,736 Fourth 20.4 1,971 1,930 Highest 20.6 1,989 2,749 Total 100.0 9,656 9,656 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Education categories are described in chapter 2, section 2.9.1. 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Education is a key determinant of health care knowledge, attitudes, and behavior. To gain further insight into how educational attainment varies among TjDHS respondents, Table 3.2 presents the distribution of TjDHS respondents by educational level1, according to other demographic and socioeconomic background characteristics used throughout the report. The results show that Tajik women who are of the reproductive ages 15-49 have completed an average of 9.4 years of schooling. Although the gap is not large, educational attainment tends to be somewhat lower among younger women than among older women, with the median years of schooling exceeding the national average among women age 35 and over and falling below the average among women age 15-24. The lower educational attainment among women age 15-24 is mainly due to the fact that some women in the age group are still in school. The somewhat lower median number of years of schooling among women age 25-34 likely reflects the adverse effects of the civil war in the 1990s on Tajikistan’s educational system (Shemyakina, 2011). 1 Education categories are described in chapter 2, section 2.9.1. Background Characteristics of Respondents • 35 Table 3.2 Educational attainment Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Tajikistan 2012 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary2 Completed secondary3 Profes- sional primary Profes- sional middle Higher Age 15-24 2.5 2.2 2.9 51.1 31.4 1.4 3.4 5.0 100.0 8.9 3,963 15-19 1.7 0.9 2.5 62.3 27.4 1.3 1.3 2.4 100.0 8.8 2,013 20-24 3.4 3.4 3.4 39.6 35.5 1.5 5.6 7.7 100.0 9.4 1,950 25-29 2.5 3.2 3.8 42.9 34.0 2.1 3.9 7.7 100.0 9.0 1,609 30-34 1.4 0.9 1.6 46.0 38.3 2.3 4.1 5.6 100.0 9.2 1,188 35-39 1.6 0.7 0.6 21.0 59.0 3.8 5.6 7.6 100.0 9.8 1,030 40-44 0.8 0.8 0.1 11.8 65.5 7.0 4.4 9.6 100.0 9.6 991 45-49 1.4 0.6 0.3 12.6 70.1 3.0 5.3 6.7 100.0 9.5 875 Residence Urban 0.7 1.6 1.1 32.1 39.4 3.6 6.3 15.2 100.0 9.8 2,413 Rural 2.5 1.8 2.5 40.5 43.7 2.3 3.3 3.5 100.0 9.3 7,243 Region Dushanbe 0.9 2.2 1.6 33.9 32.8 2.3 4.9 21.4 100.0 9.7 881 GBAO 0.2 0.3 0.2 16.0 46.5 5.0 10.4 21.4 100.0 10.6 220 Sughd 0.5 0.4 0.6 33.9 47.6 4.1 5.8 7.1 100.0 9.7 2,872 DRS 1.8 2.2 3.2 48.1 35.1 1.9 3.8 3.9 100.0 8.9 2,240 Khatlon 3.9 2.5 3.0 38.4 45.7 1.7 2.2 2.7 100.0 9.2 3,444 Wealth quintile Lowest 4.6 2.4 3.2 43.6 42.2 1.6 1.2 1.2 100.0 9.0 1,878 Second 3.3 1.7 3.1 41.8 44.4 1.5 2.6 1.7 100.0 9.1 1,913 Middle 1.6 2.6 2.4 41.6 43.3 2.4 2.6 3.5 100.0 9.2 1,904 Fourth 0.4 0.9 1.0 35.8 47.7 3.3 5.8 5.3 100.0 9.6 1,971 Highest 0.4 1.2 0.9 29.7 35.7 4.2 8.0 19.9 100.0 10.1 1,989 Total 2.0 1.7 2.1 38.4 42.6 2.6 4.1 6.4 100.0 9.4 9,656 Note: Education categories are described in chapter 2, section 2.9.1. 1 Completed Grade four at the primary level. 2 Attended or completed the general basic level, also known as stage I, of secondary education (Grades 5-9) and attended but did not complete the general secondary level, also known as stage II of secondary education (Grades 10-11). 3 Completed Grade 11 at the secondary level or completed Grade 10 at the secondary level and has a general education school diploma ("attestat" in the old Soviet educational system terminology). Urban women are notably more likely to have attended or completed professional school or higher levels of education than rural women (25 percent versus 9 percent). The median number of years of schooling among women is highest in GBAO (10.6 years), followed by Dushanbe and Sughd (9.7 years each). As expected, education is directly related to the wealth quintile, with the median number of years completed increasing from 9.0 among women in the lowest quintile to 10.1 years among women in the highest quintile. 3.3 MEDIA EXPOSURE The 2012 TjDHS included questions to assess the frequency with which respondents were exposed to print and broadcast media. This information is useful for understanding which women are likely to be reached by media campaigns disseminating family planning, health, and other information. Table 3.3 shows the percentages of women age 15-49 exposed to three specific media (newspaper/magazine, radio, or television) at least once per week. The table also includes information on the percentage of women who are exposed to all three media at least once per week and the percentage not regularly exposed to any of the media. Overall, television reaches the largest number of women; 84 percent of women watch television at least once per week. Three in ten women read a newspaper or magazine, and 26 percent listen to the radio weekly. Only 17 percent of women access all three media at least once per week, while 15 percent are not regularly exposed to any of the three media. 36 • Background Characteristics of Respondents Table 3.3 Exposure to mass media Percentage of women age 15-49 who are exposed to specific media on a weekly basis by background characteristics, Tajikistan 2012 Background characteristic Reads a newspaper/ magazine at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 37.9 86.7 29.3 20.8 11.0 2,013 20-24 26.0 82.5 26.3 15.2 15.8 1,950 25-29 22.9 82.6 23.7 12.3 15.7 1,609 30-34 25.3 82.6 23.0 13.4 15.3 1,188 35-39 34.3 82.8 25.4 17.8 15.5 1,030 40-44 33.0 84.2 26.8 18.7 13.4 991 45-49 32.4 81.4 26.2 18.6 16.9 875 Residence Urban 43.9 89.5 30.4 22.5 8.2 2,413 Rural 25.4 81.5 24.6 14.6 16.7 7,243 Region Dushanbe 43.0 87.3 28.6 21.2 9.3 881 GBAO 50.4 78.4 8.0 4.0 14.4 220 Sughd 39.4 85.8 31.7 22.3 12.8 2,872 DRS 29.6 79.8 32.1 22.7 19.3 2,240 Khatlon 18.0 83.4 17.9 7.5 14.3 3,444 Education None/primary 5.0 69.9 14.5 3.0 28.4 567 General basic 20.7 81.0 22.3 11.8 17.4 3,349 General secondary 30.2 84.8 25.1 16.0 13.2 4,474 Professional primary/middle 56.3 90.8 36.1 28.8 7.1 645 Higher 75.3 93.1 53.0 46.7 3.5 620 Wealth quintile Lowest 15.0 75.6 16.4 7.4 21.6 1,878 Second 17.7 78.5 19.4 9.3 19.6 1,913 Middle 27.9 84.9 26.4 15.9 14.0 1,904 Fourth 38.7 87.1 32.4 22.1 11.3 1,971 Highest 49.7 91.0 34.8 27.5 6.6 1,989 Total 30.1 83.5 26.0 16.6 14.5 9,656 Looking at media exposure rates among subgroups in Table 3.3, the percentage watching television at least once per week exceeds 90 percent among women with a professional or higher education and women in the highest wealth quintile; women with no or only a primary education have the lowest rate of regular exposure to television (70 percent). The percentage listening to the radio regularly is lowest in the GBAO region (8 percent) and highest among women with higher education (53 percent). Only 5 percent of women with no or only a primary education read a newspaper/magazine weekly. In contrast, three-quarters of women with higher education are exposed to newspapers/magazines at least weekly. 3.4 EMPLOYMENT Like education, employment can be a source of empowerment for women, especially if it puts them in control of income. The measurement of women’s employment, however, is difficult. The difficulty arises largely because some of the work that women do, especially work on family farms, family businesses, or in the informal sector is often not perceived by women themselves as employment, and hence not reported as such. To avoid underestimating women’s employment, the TjDHS asked respondents several questions to probe for their employment status and to ensure complete coverage of employment in both the formal or informal sectors. Additional information was obtained from employed women on the type of work they were doing, whether they worked continuously throughout the year, whom they worked for, and whether they received their earnings in cash or in kind. Background Characteristics of Respondents • 37 3.4.1 Employment Status Table 3.4 presents the percent distribution of TjDHS respondents by current employment status, according to background characteristics. Respondents are defined as employed if they were working at the time of the survey or had worked at any time in the 12 months prior to the survey. They were considered to be currently employed if they had done any work in the seven days before the TjDHS interview or if they were regularly employed but had been absent from work during the week before the survey because they were ill, on vacation, or took leave for some other reason. Table 3.4 Employment status Percent distribution of women age 15-49 by employment status, according to background characteristics, Tajikistan 2012 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don't know Total Number of women Currently employed1 Not currently employed Age 15-19 18.0 3.9 78.1 0.0 100.0 2,013 20-24 21.3 6.3 72.3 0.1 100.0 1,950 25-29 26.5 5.3 68.1 0.1 100.0 1,609 30-34 29.5 4.0 66.5 0.0 100.0 1,188 35-39 36.2 4.9 58.8 0.0 100.0 1,030 40-44 41.4 5.3 53.2 0.1 100.0 991 45-49 34.6 5.7 59.6 0.1 100.0 875 Marital status Never married 25.8 4.7 69.6 0.0 100.0 2,648 Married or living together 26.6 5.1 68.1 0.1 100.0 6,504 Divorced/separated/widowed 45.1 5.5 49.4 0.0 100.0 504 Number of living children 0 24.3 5.4 70.3 0.1 100.0 3,483 1-2 25.6 4.5 69.9 0.1 100.0 2,588 3-4 30.4 4.6 65.0 0.0 100.0 2,385 5+ 33.9 6.1 59.9 0.1 100.0 1,200 Residence Urban 25.5 3.8 70.7 0.0 100.0 2,413 Rural 28.0 5.5 66.5 0.1 100.0 7,243 Region Dushanbe 24.8 3.2 72.0 0.0 100.0 881 GBAO 20.1 5.6 74.3 0.0 100.0 220 Sughd 28.3 4.2 67.4 0.0 100.0 2,872 DRS 11.5 0.4 88.0 0.2 100.0 2,240 Khatlon 37.9 9.2 52.9 0.0 100.0 3,444 Education None/primary 25.8 7.0 67.1 0.0 100.0 567 General basic 19.9 4.4 75.5 0.1 100.0 3,349 General secondary 27.1 4.8 68.1 0.1 100.0 4,474 Professional primary/middle 46.6 5.7 47.7 0.0 100.0 645 Higher 50.6 7.5 41.9 0.0 100.0 620 Wealth quintile Lowest 35.3 7.5 57.1 0.2 100.0 1,878 Second 31.0 6.6 62.4 0.1 100.0 1,913 Middle 21.4 3.3 75.2 0.0 100.0 1,904 Fourth 21.6 4.4 74.0 0.0 100.0 1,971 Highest 27.7 3.5 68.7 0.0 100.0 1,989 Total 27.3 5.0 67.6 0.1 100.0 9,656 1 "Currently employed" is defined as having done work in the past seven days. Included are persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 38 • Background Characteristics of Respondents The TjDHS results indicate that more than one in four women age 15-49 in Tajikistan is currently employed, and 5 percent are not currently employed but have worked in the past 12 months (Figure 3.1). The current employment rate generally increases with age and with the number of living children. More than four in ten women who are divorced, separated, or widowed are currently working compared with around one-quarter each of never-married and married women. Rural women are slightly more likely than urban women to be currently employed. The current employment rate is highest in Khalton (38 percent) and lowest in the DRS region (12 percent). Women with higher education are almost twice as likely to be currently employed as women with no or only primary education (51 percent versus 26 percent). Women in the lowest wealth quintile have the highest current employment rate (35 percent) and women in the middle quintile have the lowest (21 percent). Figure 3.1 Women's employment status in the past 12 months Tajikistan DHS 2012 3.4.2 Occupation TjDHS respondents who reported that they were currently employed or had worked in the past 12 months were asked about their occupation. Their responses were recorded verbatim and then coded into major occupation groups after the questionnaires were sent to the central office. Table 3.5 shows the distribution of employed women by occupation group, according to background characteristics. The largest group is employed in unskilled manual labor jobs (45 percent), 21 percent work in sales and services, 20 percent are in professional, technical, or managerial positions, and 10 percent work in agriculture. Urban women, women from the GBAO and Dushanbe regions, women with a professional or higher education, and women in the highest wealth quintile are most likely to be employed in professional, technical, or managerial occupations. One-third or more of employed women in urban areas, in Dushanbe, and in the fourth and highest wealth quintiles work in sales and services. More than six in ten employed women in the lowest two wealth quintiles and in the Khalton region and more than seven in ten employed women who have no or only a primary education are working as unskilled manual laborers. As expected, women in rural areas are much more likely to work in agricultural occupations than women in urban areas (12 percent versus 1 percent). Agricultural employment is also much more common among women in Khalton (12 percent) and Sughd (10 percent) than in other regions (2 percent or less). Currently employed 27% Not currently employed, but worked in past 12 months 5% Did not work in past 12 months 68% Background Characteristics of Respondents • 39 Table 3.5 Occupation Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Tajikistan 2012 Background characteristic Profes- sional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Other Missing Total Number of women Age 15-19 1.9 0.0 26.1 1.6 58.6 0.3 10.5 0.0 1.0 100.0 441 20-24 16.2 1.4 23.2 2.0 48.2 0.0 7.9 0.9 0.2 100.0 538 25-29 20.7 1.2 16.6 1.1 47.4 0.1 11.8 0.6 0.6 100.0 512 30-34 21.4 1.2 22.4 1.5 42.9 0.5 9.2 0.0 0.8 100.0 397 35-39 27.5 1.0 22.2 2.3 38.0 0.4 7.9 0.0 0.7 100.0 424 40-44 27.1 1.2 18.4 3.4 40.0 0.6 8.8 0.0 0.4 100.0 462 45-49 25.0 1.4 20.8 1.3 39.3 0.0 11.2 0.4 0.6 100.0 352 Marital status Never married 10.9 1.0 24.3 1.5 52.2 0.1 8.8 0.5 0.7 100.0 806 Married or living together 22.3 1.0 18.9 1.7 44.7 0.3 10.5 0.2 0.4 100.0 2,066 Divorced/separated/widowed 26.5 2.0 31.8 4.5 28.1 0.4 4.6 0.6 1.5 100.0 255 Number of living children 0 11.8 0.9 23.6 1.6 51.3 0.1 9.6 0.6 0.5 100.0 1,032 1-2 28.1 1.7 21.1 2.8 38.4 0.6 6.2 0.1 1.1 100.0 779 3-4 26.8 1.1 23.9 2.3 37.8 0.1 7.7 0.1 0.3 100.0 835 5+ 11.0 0.5 12.4 0.4 56.4 0.3 18.3 0.3 0.4 100.0 480 Residence Urban 38.8 3.2 36.6 5.6 12.6 0.7 1.1 0.4 1.0 100.0 707 Rural 14.2 0.5 16.9 0.8 54.8 0.1 12.0 0.3 0.4 100.0 2,420 Region Dushanbe 44.6 2.5 33.4 7.2 10.1 0.9 0.0 0.6 0.6 100.0 247 GBAO 66.2 2.4 18.8 1.1 10.9 0.0 0.5 0.0 0.0 100.0 57 Sughd 25.7 1.1 27.1 1.5 32.3 0.5 10.4 0.6 0.8 100.0 936 DRS 34.9 2.5 30.4 2.3 27.4 0.0 1.6 0.0 1.0 100.0 266 Khatlon 8.4 0.6 14.8 1.3 62.2 0.1 12.2 0.1 0.4 100.0 1,622 Education None/primary 2.9 0.9 11.3 0.6 72.0 0.0 11.5 0.8 0.0 100.0 186 General basic 1.8 0.3 23.2 1.8 58.1 0.2 13.5 0.2 0.9 100.0 816 General secondary 4.4 0.7 25.8 2.3 54.5 0.5 11.4 0.0 0.5 100.0 1,426 Professional primary/middle 72.4 1.1 16.6 1.5 6.9 0.0 0.9 0.1 0.4 100.0 337 Higher 80.1 4.6 9.0 1.7 1.6 0.0 0.7 1.6 0.6 100.0 361 Wealth quintile Lowest 4.9 0.0 11.4 0.7 64.4 0.0 18.1 0.2 0.4 100.0 803 Second 8.4 0.1 14.0 0.5 62.7 0.2 13.9 0.0 0.2 100.0 718 Middle 20.1 1.6 17.1 1.3 50.0 0.5 7.6 0.9 1.0 100.0 472 Fourth 25.7 1.7 33.4 2.9 32.0 0.1 3.4 0.0 0.7 100.0 512 Highest 46.8 2.6 35.9 4.6 7.8 0.6 0.2 0.5 0.9 100.0 622 Total 19.7 1.1 21.3 1.9 45.3 0.3 9.6 0.3 0.6 100.0 3,127 3.4.3 Type of Employment Table 3.6 shows the percent distribution of women who worked at any time during the 12 months preceding the survey by the type of earnings women received (cash, in-kind, or both), the type of employer, and the continuity of employment, according to the type of work (agricultural or non- agricultural). Slightly more than half (53 percent) of employed women are paid in cash only, and 20 percent are paid in cash and in-kind. Around one in four women either is not paid (19 percent) or receives only in-kind payments (8 percent). As expected, women who work in nonagricultural jobs are much more likely to be paid in cash for the work they do. Six in ten women working in agriculture are not paid at all for their work. Around half of women (51 percent) are employed by a nonrelative, slightly more than one-third work for a family member, and 12 percent are self-employed. Women who work in agriculture are mainly employed by family members (83 percent), which is likely the reason a large proportion are not paid. Women in nonagricultural jobs are more likely to be employed by a nonfamily member (55 percent) than to work for a relative (32 percent) or to be self-employed (13 percent). 40 • Background Characteristics of Respondents Table 3.6 Type of employment Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Tajikistan 2012 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 4.7 58.6 53.4 Cash and in-kind 24.0 19.7 20.1 In-kind only 12.7 7.1 7.6 Not paid 58.7 14.5 18.8 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Type of employer Employed by family member 82.9 31.9 36.9 Employed by nonfamily member 16.6 55.0 51.2 Self-employed 0.4 12.9 11.7 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Continuity of employment All year 10.7 47.2 43.6 Seasonal 83.9 43.3 47.1 Occasional 5.0 9.2 8.9 Missing 0.5 0.3 0.3 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 300 2,809 3,127 Note: Total includes women with missing information on type of employment who are not shown separately. Women’s employment in agricultural jobs is more often seasonal than year-round (84 percent versus 11 percent). Women in nonagricultural jobs are much more likely to be employed throughout the year, but even among these women, only 47 percent report that they work year-round. 3.5 TUBERCULOSIS Tuberculosis is a serious health concern in Tajikistan, which is among 27 nations worldwide identified by WHO as high multi-drug resistant tuberculosis (MDR-TB) countries (WHO, 2012a). In 2010, the prevalence of tuberculosis in Tajikistan was estimated at 332 cases per 100,000 population, and the incidence rate was 206 per 100,000, with 17 percent of new cases being MDR-TB (WHO/EURO, 2012). TjDHS respondents were asked a series of questions to assess the level of tuberculosis awareness, attitudes about the disease, and knowledge about modes of transmission, tuberculosis symptoms, and ways to prevent the spread of the disease. The information they provided is useful for designing communications strategies to improve awareness of the disease. 3.5.1 Knowledge and Attitudes about Tuberculosis Table 3.7 shows the percentage of women age 15-49 who had heard about tuberculosis, and, among women who know about tuberculosis, the percentages who are aware that tuberculosis is spread through the air by coughing or sneezing, who believe that tuberculosis can be cured and who would want to keep it a secret if a family member had tuberculosis. Seventy percent of women say they have heard of tuberculosis, showing that awareness of the disease is widespread in Tajikistan but not yet universal. Women in the 15-19 age group, women living in the DRS region, and women with no or only a primary education are least likely to have heard of tuberculosis (54 percent, 58 percent, and 50 percent, respectively). The level of knowledge reaches 90 percent only among women with professional or higher education. Background Characteristics of Respondents • 41 Table 3.7 Knowledge and attitude concerning tuberculosis Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentage who report that TB is spread through the air when an infected person coughs or sneezes, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who have heard of TB Number of women Among women who have heard of TB, percentage who: Number of women who have heard of tuberculosis Report that TB is spread through the air when an infected person coughs or sneezes Believe that TB can be cured Would want a family member's TB kept secret Age 15-19 54.3 2,013 66.7 73.6 24.2 1,092 20-24 65.4 1,950 75.3 79.7 24.4 1,275 25-29 72.0 1,609 77.2 79.0 27.4 1,159 30-34 75.4 1,188 79.1 82.3 25.3 896 35-39 81.8 1,030 81.9 86.9 24.0 842 40-44 82.5 991 81.1 84.1 21.3 817 45-49 81.8 875 80.4 85.4 23.5 716 Residence Urban 77.7 2,413 80.7 82.3 27.0 1,875 Rural 68.0 7,243 75.3 80.4 23.5 4,922 Region Dushanbe 73.6 881 76.7 76.2 29.5 649 GBAO 79.0 220 72.1 95.7 22.9 173 Sughd 78.5 2,872 85.1 82.7 35.7 2,255 DRS 57.5 2,240 75.0 80.9 20.4 1,288 Khatlon 70.6 3,444 70.4 79.6 15.0 2,432 Education None/primary 49.7 567 66.3 71.2 21.6 282 General basic 61.1 3,349 72.6 76.8 22.7 2,046 General secondary 74.2 4,474 76.9 82.0 24.6 3,321 Professional primary/middle 90.3 645 86.2 86.9 25.3 583 Higher 91.1 620 86.7 88.8 30.5 565 Wealth quintile Lowest 68.8 1,878 71.8 80.5 17.4 1,293 Second 66.0 1,913 71.9 79.9 19.4 1,262 Middle 65.4 1,904 76.8 80.3 22.1 1,245 Fourth 73.9 1,971 81.8 82.0 31.8 1,457 Highest 77.4 1,989 80.2 81.8 29.5 1,540 Total 70.4 9,656 76.8 81.0 24.5 6,797 Around three in four of the women who have heard about tuberculosis correctly believe that the disease is spread through the air when an infected individual coughs or sneezes. The percentage of women identifying coughing and sneezing as a way in which the disease may be transmitted is lowest among women age 15-19 (67 percent) and women with no or only a primary education (66 percent) and highest among women with professional (86 percent) or higher (87 percent) education. The majority (81 percent) of women who know about tuberculosis believe that the disease can be cured. Women who never attended school or only attended primary school are least likely to agree that tuberculosis can be cured (71 percent). One in four women would want to keep a family member’s tuberculosis secret, suggesting there is stigma attached to the disease for these women. The percentages wanting to keep a family member’s tuberculosis diagnosis secret are highest among women in Sughd (36 percent), women with higher education (31 percent), and women in the fourth and in the highest wealth quintiles (32 percent and 30 percent, respectively). 42 • Background Characteristics of Respondents 3.5.2 Knowledge of Tuberculosis Symptoms Table 3.8 presents information on the level of awareness of the symptoms of tuberculosis among women who report knowing about the disease. More than eight in ten of the women identified some form of coughing as a symptom that would lead them to think a person has tuberculosis; 62 percent cited coughing alone, 37 percent mentioned coughing with sputum, and 10 percent cited coughing that lasted for several weeks. Weight loss was mentioned by 24 percent as a tuberculosis symptom, 20 percent cited tiredness/fatigue, and 19 percent said fever was a symptom. Fewer women (11 percent or less) mentioned other symptoms including blood in sputum, loss of appetite, night sweating, and pain in the chest. One in ten women who had heard about tuberculosis was not able to name any symptom that would lead women to think a person had the disease. In general, women with a professional or higher education were more likely than other women to identify the various symptoms of tuberculosis shown in Table 3.8. B ac kg ro un d C ha ra ct er is tic s of R es po nd en ts • 4 3 Ta bl e 3. 8. K no w le dg e of s ym pt om s of tu be rc ul os is Am on g w om en w ho h av e he ar d of tu be rc ul os is (T B) , t he p er ce nt ag e id en tif yi ng s pe ci fic s ym pt om s as s ig ns th at w ou ld le ad th em to th in k a pe rs on h as tu be rc ul os is , b y ba ck gr ou nd c ha ra ct er is tic s, T aj ik is ta n 20 12 Ba ck gr ou nd ch ar ac te ris tic N on - sp ec ifi c co ug hi ng C ou gh in g w ith sp ut um C ou gh in g fo r s ev er al w ee ks An y co ug hi ng Fe ve r Bl oo d in sp ut um Lo ss o f ap pe tit e N ig ht sw ea tin g Pa in in ch es t Ti re dn es s/ fa tig ue W ei gh t lo ss Le th ar gy O th er D on 't kn ow N um be r o f w om en w ho h ea rd of T B A ge 15 -1 9 56 .7 32 .2 9. 8 78 .5 13 .1 6. 1 7. 2 5. 4 9. 3 16 .8 20 .7 0. 2 0. 4 17 .3 1, 09 2 20 -2 4 62 .9 35 .1 8. 6 83 .0 16 .9 8. 2 7. 6 6. 7 10 .3 19 .8 22 .5 0. 3 0. 6 12 .4 1, 27 5 25 -2 9 60 .0 36 .2 10 .8 84 .3 18 .2 7. 2 8. 4 5. 3 9. 9 17 .9 20 .5 0. 5 0. 3 10 .7 1, 15 9 30 -3 4 64 .9 38 .6 10 .9 87 .6 21 .0 8. 0 7. 6 5. 8 11 .1 21 .1 26 .9 0. 7 0. 7 7. 4 89 6 35 -3 9 63 .2 40 .6 10 .0 89 .3 25 .2 7. 9 7. 7 8. 3 10 .2 22 .8 27 .1 0. 8 0. 5 6. 2 84 2 40 -4 4 67 .3 40 .5 11 .6 89 .2 21 .2 8. 7 11 .3 7. 0 12 .3 20 .2 29 .3 0. 3 0. 9 6. 4 81 7 45 -4 9 64 .1 41 .7 9. 1 86 .8 20 .3 7. 8 6. 8 7. 8 11 .1 21 .1 24 .6 0. 7 0. 2 9. 0 71 6 R es id en ce U rb an 66 .8 40 .5 8. 1 88 .4 23 .6 7. 8 9. 2 8. 2 9. 7 19 .9 24 .6 0. 4 0. 7 8. 3 1, 87 5 R ur al 60 .7 36 .1 10 .8 83 .7 17 .2 7. 6 7. 6 5. 8 10 .8 19 .6 23 .8 0. 5 0. 4 11 .2 4, 92 2 R eg io n D us ha nb e 75 .7 37 .6 7. 9 86 .8 23 .7 4. 3 9. 8 4. 6 7. 1 18 .7 18 .7 0. 1 1. 0 10 .2 64 9 G BA O 59 .6 19 .0 8. 8 79 .0 23 .7 6. 9 7. 8 13 .9 2. 4 16 .8 14 .6 1. 2 0. 4 9. 7 17 3 Su gh d 63 .6 42 .9 11 .9 88 .8 29 .9 8. 3 7. 9 9. 9 15 .3 28 .2 24 .3 0. 5 1. 2 8. 2 2, 25 5 D R S 63 .0 33 .6 12 .3 81 .4 11 .4 2. 5 8. 6 3. 7 6. 9 15 .0 21 .2 1. 0 0. 1 11 .1 1, 28 8 Kh at lo n 57 .6 35 .3 7. 8 83 .4 11 .2 10 .7 7. 4 4. 7 9. 4 14 .8 27 .4 0. 2 0. 0 12 .1 2, 43 2 Ed uc at io n N on e/ pr im ar y 61 .9 30 .5 4. 9 78 .6 11 .2 8. 2 3. 4 3. 9 10 .5 10 .5 20 .1 0. 6 0. 2 17 .5 28 2 G en er al b as ic 63 .5 33 .4 9. 1 82 .0 15 .7 6. 3 7. 1 4. 9 9. 0 17 .9 21 .7 0. 5 0. 3 12 .7 2, 04 6 G en er al s ec on da ry 60 .4 38 .4 10 .4 85 .4 18 .4 7. 7 7. 7 6. 3 10 .3 20 .0 24 .2 0. 6 0. 3 10 .2 3, 32 1 Pr of es si on al p rim ar y/ m id dl e 66 .1 45 .7 12 .2 90 .9 30 .6 9. 2 12 .2 7. 8 12 .1 22 .5 24 .6 0. 2 2. 2 5. 4 58 3 H ig he r 66 .3 40 .2 11 .9 90 .8 25 .8 10 .1 11 .5 13 .2 15 .3 26 .0 33 .0 0. 1 1. 3 4. 4 56 5 W ea lth q ui nt ile Lo w es t 66 .7 31 .0 10 .6 84 .3 14 .9 6. 6 7. 5 5. 6 8. 3 21 .1 23 .2 0. 9 0. 0 10 .2 1, 29 3 Se co nd 59 .9 34 .3 10 .0 81 .8 14 .8 9. 3 6. 8 5. 3 11 .1 18 .0 25 .7 0. 6 0. 2 12 .6 1, 26 2 M id dl e 58 .6 39 .3 11 .2 84 .1 17 .0 8. 3 8. 0 5. 8 9. 1 17 .8 23 .5 0. 4 0. 3 11 .9 1, 24 5 Fo ur th 59 .2 41 .5 10 .1 86 .3 21 .9 6. 8 8. 1 6. 2 12 .2 23 .7 24 .9 0. 3 0. 8 9. 1 1, 45 7 H ig he st 66 .7 39 .6 8. 8 87 .8 24 .6 7. 4 9. 5 9. 1 11 .4 17 .6 23 .0 0. 2 1. 0 8. 6 1, 54 0 To ta l 62 .4 37 .3 10 .1 85 .0 18 .9 7. 6 8. 1 6. 5 10 .5 19 .7 24 .0 0. 5 0. 5 10 .4 6, 79 7 Background Characteristics of Respondents • 43 44 • Background Characteristics of Respondents 3.5.3 Misconceptions about How Tuberculosis is Spread Women who had heard about tuberculosis were asked to identify ways in which the disease is spread from one person to another; all of the modes of transmission that women mentioned in response to the question were recorded. As shown in Table 3.7, around three-quarters of women who knew about tuberculosis correctly identified that the disease is spread through the air when an individual with the disease coughs or sneezes. Although the majority of women knew the correct mode by which tuberculosis is spread, Table 3.9 shows that substantial minorities of women share misconceptions about other ways the disease may be spread. For example, three in ten women falsely think that the disease may be spread through food, and 26 percent incorrectly believe that it may be spread by sharing utensils with a person with tuberculosis. Fewer women have other misconceptions including believing that tuberculosis may be spread through sexual contact with a person who has tuberculosis (9 percent) or touching a person who has the disease (6 percent). Only 2 percent of women think tuberculosis is spread through mosquito bites. Table 3.9 Misconceptions about tuberculosis transmission Among women who have heard of tuberculosis (TB), the percentage who report various misconceptions about ways tuberculosis is spread, by background characteristics, Tajikistan 2012 Background characteristic Through sharing utensils Through touching a person with TB Through food Through sexual contact Through mosquito bites Other Don't know Number of women who heard of TB Age 15-19 24.8 6.7 28.0 5.9 2.7 0.2 18.0 1,092 20-24 25.2 6.3 25.7 10.0 2.2 0.4 13.6 1,275 25-29 23.4 4.5 28.1 9.4 1.9 0.2 11.9 1,159 30-34 27.0 7.2 29.8 8.1 3.1 0.5 10.1 896 35-39 28.6 6.1 31.1 8.2 1.2 0.6 6.8 842 40-44 28.2 8.5 31.9 10.6 1.9 0.7 8.1 817 45-49 28.1 6.6 31.1 7.1 1.4 0.5 9.5 716 Residence Urban 26.8 6.4 26.5 8.2 2.2 0.6 10.1 1,875 Rural 25.9 6.4 29.9 8.7 2.1 0.4 12.2 4,922 Region Dushanbe 26.8 6.2 19.7 8.5 3.0 0.9 12.9 649 GBAO 13.0 4.5 39.0 9.0 1.1 0.1 12.7 173 Sughd 32.6 8.8 35.2 6.5 1.2 0.4 9.3 2,255 DRS 30.5 3.0 18.9 3.7 0.2 0.1 11.7 1,288 Khatlon 18.6 6.2 30.3 12.9 3.8 0.5 13.3 2,432 Education None/primary 21.1 1.9 36.0 8.7 1.1 0.9 16.3 282 General basic 25.2 5.6 26.0 8.8 1.9 0.3 14.8 2,046 General secondary 25.0 7.1 29.0 8.5 2.4 0.3 11.4 3,321 Professional primary/middle 34.7 6.1 31.0 8.6 2.0 0.6 5.9 583 Higher 29.8 7.8 34.2 7.8 1.6 1.1 5.0 565 Wealth quintile Lowest 25.7 6.3 36.3 8.9 3.0 0.1 12.6 1,293 Second 26.1 9.2 30.7 12.2 2.7 0.0 13.4 1,262 Middle 26.6 5.5 27.0 6.9 1.8 0.9 12.3 1,245 Fourth 27.6 5.9 26.5 8.3 1.4 0.4 9.2 1,457 Highest 24.8 5.6 25.5 6.8 1.7 0.6 11.1 1,540 Total 26.1 6.4 29.0 8.5 2.1 0.4 11.6 6,797 3.5.4 Knowledge about How to Prevent Tuberculosis Women who knew about tuberculosis were asked how they would prevent the spread of the disease if a member of their family became sick with tuberculosis, and all of the actions they mentioned were recorded in the questionnaire. Table 3.10 presents the percentages of women reporting specific actions to prevent the spread of tuberculosis among family members. B ac kg ro un d C ha ra ct er is tic s of R es po nd en ts • 4 5 Background Characteristics of Respondents • 45 Ta bl e 3. 10 W om en 's re po rt on h ow to p re ve nt s pr ea di ng o f t ub er cu lo si s A m on g w om en w ho h av e he ar d of tu be rc ul os is (T B ), th e pe rc en ta ge w ho re po rt va rio us w ay s to p re ve nt s pr ea di ng o f t ub er cu lo si s, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic S ic k pe rs on tre at ed ap pr o- pr ia te ly S ic k pe rs on fo llo w s D O TS tre at m en t S ic k pe rs on is ol at ed S ic k pe rs on as ke d to di sp os e of sp ut um sa fe ly S ic k pe rs on av oi ds co ug hi ng or sn ee zi ng in o pe n ai r Fa m ily m em be rs ge t va cc in a- tio n/ bo os te r Fa m ily m em be rs ta ke p re - ve nt at iv e tre at m en t Fa m ily m em be rs se ek do ct or ’s ad vi ce if ha ve fe ve r Fa m ily m em be rs se ek do ct or ’s ad vi ce if ha ve pr ol on ge d co ug h C le an ho us e da ily D on 't sh ar e fo od a nd ut en si ls w ith in fe ct ed pe rs on s Li m it se xu al co nt ac t w ith in fe ct ed pe rs on D o no th in g S m ok e ho us e w ith he rb P ra y O th er D on 't kn ow N um be r o f w om en w ho h ea rd of T B A ge 15 -1 9 46 .2 45 .2 18 .5 3. 2 10 .1 1. 5 2. 9 7. 7 5. 5 12 .2 17 .7 1. 9 0. 3 1. 2 4. 1 0. 0 7. 7 1, 09 2 20 -2 4 47 .6 45 .5 20 .6 5. 2 9. 7 2. 1 2. 9 8. 5 5. 6 10 .4 18 .1 2. 8 0. 4 1. 3 5. 7 0. 1 6. 0 1, 27 5 25 -2 9 49 .0 45 .6 22 .7 2. 8 9. 2 1. 4 3. 4 6. 8 6. 1 7. 4 18 .3 1. 3 0. 4 0. 8 4. 2 0. 0 4. 9 1, 15 9 30 -3 4 51 .6 49 .5 23 .1 4. 9 10 .3 1. 8 3. 3 7. 5 7. 0 10 .5 21 .3 2. 9 0. 1 1. 0 6. 3 0. 0 2. 4 89 6 35 -3 9 53 .6 47 .8 26 .1 4. 3 10 .9 1. 9 5. 2 5. 8 4. 7 10 .4 18 .8 1. 0 0. 2 0. 7 5. 1 0. 1 1. 9 84 2 40 -4 4 52 .9 49 .7 23 .4 4. 8 9. 9 3. 1 5. 1 9. 3 7. 6 10 .8 21 .0 1. 9 0. 1 1. 2 5. 7 0. 2 3. 5 81 7 45 -4 9 51 .7 50 .6 22 .7 5. 0 8. 7 2. 3 3. 7 9. 8 7. 2 11 .6 19 .9 1. 9 0. 2 0. 9 6. 5 0. 0 2. 1 71 6 R es id en ce U rb an 55 .8 47 .0 23 .3 5. 6 11 .4 2. 7 4. 5 7. 5 6. 8 12 .2 17 .1 2. 2 0. 2 1. 2 6. 2 0. 1 3. 3 1, 87 5 R ur al 47 .7 47 .5 21 .8 3. 8 9. 3 1. 7 3. 4 8. 0 5. 9 9. 6 19 .9 1. 9 0. 3 0. 9 4. 9 0. 0 4. 8 4, 92 2 R eg io n D us ha nb e 57 .7 48 .8 20 .4 2. 9 10 .7 3. 7 4. 9 7. 6 6. 4 15 .7 11 .5 1. 3 0. 4 2. 1 9. 9 0. 1 4. 9 64 9 G B A O 47 .2 46 .9 14 .7 9. 3 6. 2 4. 0 1. 6 2. 3 2. 2 2. 3 2. 4 0. 5 0. 2 0. 3 0. 6 0. 0 1. 1 17 3 S ug hd 63 .2 34 .2 40 .5 5. 7 15 .2 1. 7 4. 8 6. 4 7. 5 10 .0 27 .6 1. 9 0. 2 1. 4 10 .3 0. 1 5. 1 2, 25 5 D R S 47 .4 46 .7 10 .6 1. 7 4. 9 1. 4 2. 1 11 .3 5. 8 6. 6 16 .8 0. 9 0. 0 0. 7 0. 4 0. 0 3. 9 1, 28 8 K ha tlo n 37 .2 59 .5 12 .4 4. 3 7. 6 1. 8 3. 3 7. 8 5. 2 11 .9 15 .7 2. 9 0. 5 0. 7 2. 3 0. 1 4. 1 2, 43 2 Ed uc at io n N on e/ pr im ar y 37 .7 50 .3 10 .2 3. 2 9. 0 2. 3 1. 3 8. 1 3. 7 9. 4 15 .2 3. 0 0. 0 0. 2 1. 6 0. 0 6. 7 28 2 G en er al b as ic 46 .5 48 .6 19 .0 2. 8 8. 6 2. 0 2. 4 8. 5 5. 6 9. 2 18 .9 2. 2 0. 4 0. 8 3. 9 0. 0 5. 5 2, 04 6 G en er al s ec on da ry 50 .5 47 .0 22 .5 4. 5 9. 5 1. 6 3. 9 7. 5 6. 6 10 .6 19 .2 1. 9 0. 3 1. 1 6. 3 0. 1 4. 3 3, 32 1 P ro fe ss io na l pr im ar y/ m id dl e 55 .3 46 .1 29 .5 5. 3 11 .4 2. 1 4. 6 7. 4 5. 3 9. 9 20 .4 1. 1 0. 0 1. 2 3. 0 0. 0 2. 5 58 3 H ig he r 60 .1 44 .7 30 .6 7. 4 15 .5 3. 6 7. 1 7. 6 7. 2 13 .8 20 .4 2. 3 0. 3 2. 0 7. 9 0. 0 1. 5 56 5 W ea lth q ui nt ile Lo w es t 41 .9 56 .5 16 .6 2. 9 6. 0 1. 8 2. 3 8. 7 6. 2 8. 0 19 .0 2. 0 0. 5 0. 6 2. 6 0. 0 4. 6 1, 29 3 S ec on d 44 .4 52 .9 17 .8 4. 1 6. 9 1. 9 2. 9 9. 1 5. 6 9. 6 20 .3 2. 8 0. 3 1. 3 2. 7 0. 1 5. 0 1, 26 2 M id dl e 49 .6 45 .9 23 .5 4. 7 10 .1 1. 4 2. 9 8. 8 6. 4 10 .1 19 .6 2. 1 0. 1 0. 7 5. 3 0. 0 5. 1 1, 24 5 Fo ur th 51 .9 42 .8 28 .8 4. 0 12 .1 2. 0 4. 3 6. 8 6. 4 10 .7 19 .9 1. 4 0. 2 1. 0 7. 7 0. 0 3. 8 1, 45 7 H ig he st 59 .7 40 .6 23 .1 5. 4 13 .2 2. 6 5. 5 6. 3 6. 1 12 .8 17 .1 1. 7 0. 2 1. 4 7. 2 0. 2 3. 8 1, 54 0 To ta l 50 .0 47 .3 22 .2 4. 3 9. 8 1. 9 3. 7 7. 8 6. 1 10 .3 19 .1 2. 0 0. 3 1. 0 5. 3 0. 1 4. 4 6, 79 7 46 • Background Characteristics of Respondents The most common preventative action women reported was to seek appropriate treatment for a family member with tuberculosis (50 percent). Around half of women (47 percent) mentioned that a family member with tuberculosis should be observed by a health worker to ensure the treatment regime is being followed. Tajikistan’s tuberculosis treatment regime is built around the directly observed therapy (DOT) approach recommended by WHO in which a health worker observes that a person with TB takes each dose of the medications prescribed to treat the disease (Zaleskis et al., 2009). Other less frequently mentioned actions that women mention to avoid the spread of tuberculosis include isolating the infected person (22 percent), not sharing food and utensils with the infected person (19 percent), cleaning the house daily (10 percent), and having the infected person avoid coughing or sneezing into the open air (10 percent). Only 4 percent of the women reported that they did not know of any way to avoid the spread of tuberculosis, and virtually no women believed there was nothing a family could do to prevent the spread of tuberculosis. 3.6 HYPERTENSION Cardiovascular diseases, including heart attacks and strokes, accounts for 39 percent of all deaths annually in Tajikistan (WHO, 2011). High blood pressure or hypertension is among the major risk factors for cardiovascular disease. In the 2012 TjDHS, respondents were asked several questions to determine their history of hypertension, including whether they had ever been told by a doctor or other health worker that they had high blood pressure and, if so, whether they had been told that on two or more occasions. If they reported being told one or more times that they had high blood pressure, they were asked additional questions about actions they were taking at the time of the survey to lower their blood pressure. Table 3.11 summarizes the results of the questions relating to hypertension. In reviewing the findings, it is important to remember that they apply only to women who were advised by a health care provider that they had high blood pressure. Many Tajik women may suffer from hypertension but do not know it; hypertension is often termed the ‘silent killer’ because of the lack of warning signs or symptoms. Overall, the TjDHS results indicate 12 percent of women age 15-49 report having ever been told by a doctor or other health worker that their blood pressure was high. A diagnosis of hypertension is usually only made after blood pressure readings are found to be high on several occasions. Table 3.11 shows that the majority of women (78 percent) told they had high blood pressure were advised they were hypertensive on two or more occasions. It is encouraging that more than eight in ten of the women told they had high blood pressure were taking medication to control their blood pressure. Women were much less likely to be taking other measures to lower their blood pressure. For example, less than half were cutting back on salt in their diet (46 percent), 39 percent were controlling or losing weight, and 29 percent were exercising. Background Characteristics of Respondents • 47 Table 3.11 Knowledge and treatment of high blood pressure Percentage of women age 15-49 who were ever told by a health professional that they have high blood pressure, and among women who were ever told that they have hypertension, the percentage who were told on two or more different occasions by a health professional that they have hypertension, and the percentages taking specific actions to lower blood pressure, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women ever told by a health professional they had hypertension or high blood pressure Number of women Among women ever told by a health professional they have hypertension percentage: Number of women ever told they had hyper- tension Told on two or more different occasions that they had high blood pressure Taking prescribed medication Controlling or losing weight Cutting down salt in their diet Exercising to control hyper- tension Cutting down on alcohol intake Stopped smoking Age 15-19 2.6 2,013 42.0 72.4 31.3 41.4 21.6 16.0 15.9 52 20-24 6.6 1,950 69.6 66.8 32.4 36.7 22.3 2.4 2.4 130 25-29 9.9 1,609 75.7 76.7 34.7 33.5 22.2 3.3 5.7 159 30-34 12.7 1,188 79.1 82.8 34.7 42.5 23.6 5.3 5.0 150 35-39 18.4 1,030 78.5 80.6 32.9 48.9 28.1 8.6 8.9 189 40-44 23.3 991 82.7 84.5 47.0 53.0 36.1 10.2 8.2 230 45-49 29.1 875 86.8 92.3 47.9 53.8 34.1 8.7 7.9 254 Body Mass Index 1 <18.5 (thin) 6.4 942 72.5 67.0 20.7 34.0 27.0 11.2 11.4 61 18.5 - 24.9 (normal) 8.4 5,788 71.9 76.7 31.1 41.8 23.7 5.4 6.0 483 25.0-29.9 (overweight) 17.7 2,013 82.4 85.9 45.7 52.3 34.7 9.1 8.3 357 >=30.0 (obese) 29.0 895 85.3 88.7 50.2 48.0 30.5 8.1 7.0 260 Residence Urban 15.0 2,413 80.0 81.3 42.7 47.0 30.4 10.8 9.9 361 Rural 11.1 7,243 77.4 82.0 37.8 45.8 27.9 5.9 6.0 804 Region Dushanbe 12.6 881 85.4 77.2 42.4 42.4 28.4 12.4 11.9 111 GBAO 17.6 220 92.1 89.2 52.0 59.8 45.5 55.7 55.7 39 Sughd 9.8 2,872 76.3 71.9 48.7 56.9 23.3 7.6 6.1 281 DRS 10.6 2,240 82.0 91.0 46.1 41.4 31.6 4.7 4.8 237 Khatlon 14.4 3,444 74.8 83.4 29.1 42.1 29.1 3.8 4.2 497 Education None/primary 9.1 567 (70.6) (74.2) (17.7) (30.3) (21.4) (3.9) (4.3) 52 General basic 7.6 3,349 72.9 83.3 37.5 43.1 22.7 5.7 6.6 253 General secondary 14.5 4,474 81.5 82.6 39.3 47.4 28.3 6.7 6.0 648 Professional primary/ middle 19.3 645 77.6 80.3 47.9 49.6 37.3 10.6 11.4 125 Higher 14.2 620 75.2 77.8 44.9 50.3 40.6 15.2 13.4 88 Wealth quintile Lowest 10.5 1,878 80.8 83.7 30.2 39.6 32.0 6.0 6.1 196 Second 11.6 1,913 73.5 82.7 36.0 48.4 31.0 7.7 8.6 223 Middle 11.6 1,904 71.0 77.1 37.4 49.0 23.1 4.4 3.6 220 Fourth 13.4 1,971 84.9 84.2 42.6 44.9 25.9 6.5 5.9 264 Highest 13.2 1,989 79.6 81.0 47.2 48.0 31.7 11.8 11.2 262 Total 12.1 9,656 78.2 81.8 39.3 46.2 28.7 7.4 7.2 1,165 Note: Total includes women with missing information on Body Mass Index who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). Table 3.11 also presents the variation in the percentage of women told they had high blood pressure and the percentages of these women taking various actions to control hypertension by background characteristics. As expected, the percentage told that they had high blood pressure increases directly with age, from 3 percent of women age 15-19 to 29 percent among women age 45-49. Also as expected, being overweight is strongly related to high blood pressure. As shown in Figure 3.2, the percentage of women ever told they had high blood pressure is much higher among women classified as obese (29 percent) or overweight (18 percent) based on body mass2 than women considered normal-weight (8 percent) or thin (6 percent). The percentage told they had high blood pressure is slightly higher among urban women than rural women, and it ranges from 10 percent in Sughd to 18 percent in the GBAO region. Women with general secondary or higher education are more likely to report having been told they had high blood pressure than less educated women. The percentage told they had high blood pressure generally increases with the wealth quintile, but the differences between quintiles are small. 2 The 2012 TjDHS obtained data on the height and weight of women age 15-49. This information was used to calculate each woman’s Body Mass Index (BMI), a commonly used measure of nutritional status obtained by dividing weight in kilograms by height in meters squared (kg/m2). More information on BMI levels among TjDHS respondents is presented in Chapter 12 of this report. 48 • Background Characteristics of Respondents Figure 3.2 Women ever told they had hypertension by Body Mass Index Although the pattern is not uniform, groups where the percentages of women told they had high blood pressure are highest tend to be the groups most often taking actions intended to lower blood pressure. For example, among women told they had high blood pressure, those who are obese and overweight women are more likely to say they are taking medication, losing weight, cutting down on salt, and exercising than normal-weight or thin women. 3.7 SMOKING Tobacco use is associated with increased risks of respiratory, cardiovascular, and other diseases among adults who smoke, and the effects of second-hand smoke pose increased morbidity and mortality risks among adults and children who do not use tobacco (WHO, 2012b). The 2012 TjDHS included questions designed to assess the prevalence of smoking among the women interviewed in the survey. Smoking is rare among Tajik women, overall. Only 0.3 percent of women age 15-49 interviewed in the TjDHS reported that they currently smoke (data nor shown). While few women themselves smoke, a substantial number of women are regularly exposed to the harmful effects of second-hand smoke. As reported in Chapter 2, one in ten households reports that smoking takes place in the home daily or weekly. Marriage and Sexual Activity • 49 MARRIAGE AND SEXUAL ACTIVITY 4 his chapter addresses age at first marriage. Marriage is a primary indication of the exposure of women to the risk of pregnancy and, therefore, is important for the understanding of fertility. Populations in which age at marriage is young tend to be populations with early childbearing and high fertility. For this reason, there is an interest in trends in age at marriage. The chapter also includes information on two other direct measures of exposure to pregnancy: the age at first sexual intercourse and the frequency of intercourse. 4.1 CURRENT MARITAL STATUS Table 4.1 presents the distribution of all TjDHS respondents by current marital status and age. The term married in the table refers to legal or formal unions while living together refers to informal unions. In subsequent tables, the two categories are combined into the proportion currently in either type of union, and the new category is referred to as currently married. Table 4.1 shows that more than two-thirds of Tajik women age 15-49 (67 percent) are currently married. Reflecting the traditional character of Tajik society, almost all of these women are in formal unions; less than 1 percent report they are living together with a partner. Just over one-quarter of women are currently never-married, while 5 percent are divorced, separated, or widowed. Table 4.1 Current marital status Percent distribution of women age 15-49 by current marital status, according to age, Tajikistan 2012 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed 15-19 86.7 13.2 0.0 0.1 0.0 0.0 100.0 13.2 2,013 20-24 29.4 67.4 0.3 1.8 0.0 1.1 100.0 67.7 1,950 25-29 12.8 82.6 0.2 3.2 0.1 1.1 100.0 82.8 1,609 30-34 6.8 85.2 0.2 5.2 0.3 2.3 100.0 85.4 1,188 35-39 2.6 89.5 0.1 4.3 0.2 3.2 100.0 89.6 1,030 40-44 1.1 88.2 0.5 4.3 0.2 5.7 100.0 88.7 991 45-49 0.5 87.5 0.5 3.0 0.3 8.3 100.0 88.0 875 Total 27.4 67.1 0.2 2.7 0.1 2.4 100.0 67.4 9,656 T Key Findings • More than two-thirds of Tajik women age 15-49 (67 percent) are currently married, just over one-quarter are never-married, and 5 percent are divorced, separated, or widowed. • Most Tajik women marry at least once during their lifetime, with the proportion never-married decreasing rapidly with age to less than 1 percent among women age 45-49. • Less than one percent of women age 25-49 married for the first time before age 15, and only 15 percent married before age 18. The median age at first marriage is 20.2 years. 50 • Marriage and Sexual Activity The results in Table 4.1 also suggest that most Tajik women marry at least once during their lifetime, with the proportion never-married decreasing rapidly with age. Among women age 30-34, only 7 percent have never married, and the proportion never married declines to 1 percent or less among women age 40 and older. The proportion divorced or separated peaks at 6 percent among women age 30-34, while the proportion widowed increases directly with age to 8 percent among women age 45-49. 4.2 AGE AT FIRST MARRIAGE First marriage is an important social and demographic indicator since, in most societies, it represents the point in life when childbearing first becomes welcome. The information presented in Table 4.2 on the age at which women first marry was obtained by asking all ever-married TjDHS respondents about the month and year in which they married their first partner. Respondents who were not able to provide the date of their first marriage were asked about their age when they first married. Trends in age at marriage in Tajikistan can be examined in Table 4.2 by comparing changes in the proportions married at specific exact ages across age groups. In addition, the median age at marriage is presented to provide a measure of the average age at which women married. The median is defined as the age by which half of the cohort has married. In drawing conclusions concerning trends in the age at first marriage, the data for the oldest age cohorts should be interpreted cautiously since respondents may not recall dates or ages at marriage with accuracy. Table 4.2 Age at first marriage Percentage of women age 15-49 who were first married, by specific exact ages, and median age at first marriage, according to current age, Tajikistan 2012 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 15-19 0.1 na na na na 86.7 2,013 a 20-24 0.1 11.6 44.3 na na 29.4 1,950 a 25-29 0.4 10.9 34.5 61.2 80.6 12.8 1,609 21.1 30-34 1.1 18.8 45.9 63.4 81.6 6.8 1,188 20.4 35-39 0.3 23.8 60.4 78.3 88.5 2.6 1,030 19.3 40-44 1.0 11.6 52.9 78.4 89.6 1.1 991 19.8 45-49 0.3 12.1 49.5 76.0 91.3 0.5 875 20.0 25-49 0.6 15.2 47.1 70.0 85.5 5.8 5,693 20.2 Note: The age at first marriage is defined as the age at which the respondent began living with her first spouse/partner. na = Not applicable due to censoring. a = Omitted because less than 50 percent of the women began living with their spouse or partner for the first time before reaching the beginning of the age group. Table 4.2 shows that, among women age 25-49, the median age at first marriage was 20.2 years. Less than one percent of women age 25-49 married for the first time before age 15, and only 15 percent married before age 18. The rate at which the women marry clearly accelerates after age 18, with nearly half of women reporting they married for the first time by age 20 and 86 percent by age 25. An examination of the trend in the median age at marriage indicates that women age 25-29 married for the first time more than one year later on average than women age 35 and older. Table 4.3 presents differentials in the median age at first marriage by background characteristics. In general, differences in age at first marriage are not large, with the median age at marriage for most subgroups falling within half a year of the national median (20.2 years). The median age at first marriage is highest among women in the GBAO region (22.6 years) and women with higher education (22.3 years). Marriage and Sexual Activity • 51 Table 4.3 Median age at first marriage by background characteristics Median age at first marriage among women age 25-49, according to background characteristics, Tajikistan 2012 Background characteristic Women age 25-49 Residence Urban 20.5 Rural 20.1 Region Dushanbe 20.5 GBAO 22.6 Sughd 20.1 DRS 20.1 Khalton 20.2 Education None/primary 20.6 General basic 20.2 General secondary 19.8 Professional primary/middle 20.9 Higher 22.3 Wealth quintile Lowest 20.4 Second 20.0 Middle 20.4 Fourth 20.0 Highest 20.3 Total 20.2 Note: The age at first marriage is defined as the age at which the respondent began living with her first spouse/partner. 4.3 AGE AT FIRST INTERCOURSE Age at first marriage has long been used as a proxy for a woman’s first exposure to sexual intercourse and, thus, to the risk of pregnancy. However, a woman may initiate sexual intercourse before (or in a few cases after) she begins living together or is formally married to her first spouse/partner. In the 2012 TjDHS, women were asked about how old they were when they first had intercourse. Table 4.4 shows the ages at which women start having sexual intercourse and the trend in this indicator across age cohorts. Table 4.5 shows the variation in the median age at first intercourse among women 25-49 by background characteristics. Table 4.4 Age at first sexual intercourse Percentage of women age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had sexual intercourse, and median age at first sexual intercourse, according to current age, Tajikistan 2012 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse 15 18 20 22 25 15-19 0.1 na na na na 86.6 2,013 a 20-24 0.1 11.3 43.3 na na 29.4 1,950 a 25-29 0.3 10.1 32.6 59.1 77.1 12.8 1,609 21.3 30-34 1.1 18.9 45.7 62.7 79.6 6.8 1,188 20.5 35-39 0.2 23.1 59.3 76.2 85.3 2.6 1,030 19.4 40-44 1.0 11.2 52.0 77.1 87.8 1.1 991 19.9 45-49 0.2 11.3 48.7 75.0 89.2 0.5 875 20.1 25-49 0.6 14.7 46.0 68.5 82.8 5.8 5,693 20.3 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group. 52 • Marriage and Sexual Activity Tajikistan is a traditional society. In such settings, women are unlikely to have many opportunities to engage in sexual intercourse before marriage. Moreover, those women who initiated intercourse before marriage may be very reluctant to admit that in a survey interview. Thus, it is not surprising that the findings with respect to the age at first intercourse in Table 4.4 correspond almost exactly with the results presented for the age at first marriage in Table 4.2. The median age at first intercourse among women age 25-49 is in fact slightly higher than the age at first marriage (20.3 years versus 20.2 years), and the percentages reporting they initiated sexual intercourse by exact ages 18, 20, 22, and 25 years are uniformly slightly lower than the percentages reporting they were first married at those exact ages. Similarly, the median ages at first intercourse for each of the age cohorts in Table 4.4 are higher than the median ages at first marriage reported for those cohorts in Table 4.2. A comparison of the medians in Table 4.5 with similar information on the median age at first marriage in Table 4.3 indicates that the pattern of a slightly later average age at intercourse than first marriage is apparent in almost all socioeconomic groups. The pattern of a slightly later age at first intercourse than first marriage in the TjDHS results may reflect a tendency for some couples in Tajikistan to delay cohabitation and the initiation of sexual intercourse for a period after they formally marry. However, much of the pattern is likely owed to errors in the reporting of the age at first marriage and, particularly, first intercourse. In particular, TjDHS respondents were asked to provide the exact month and year they first married and only to provide the age at which they married if they could not provide the date. In contrast, respondents were asked to provide information only on their age at first intercourse, which may have resulted in a greater number of reporting errors. 4.4 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the regularity of sexual intercourse. Thus, information on intercourse is important for refinement of the measurement of exposure to pregnancy. Table 4.6 is based on responses to a question on time since last intercourse and, considered together with information on whether the woman has ever had sex, allows an assessment of the overall level of sexual activity among all women age 15-49 in Tajikistan. More than seven in ten women had ever had sexual intercourse, and 45 percent of women were recently sexually active, that is, they had sex during the four weeks before the survey. Nineteen percent of women had sexual intercourse within the year before the survey, but not during the four weeks immediately before the survey, and 9 percent reported they last had intercourse a year or more ago. The percentage recently sexually active increases with age, peaking at 62 percent among women age 40-44. As expected, marital status is related to the recent sexual activity. Between 60 and 70 percent of currently married women report having recently had intercourse, regardless of the length of time they have been married. The proportion recently sexually active is substantially lower among women who have a husband/partner who lives elsewhere (10 percent) compared with 71 percent among currently married women who report that a husband lives with them. Sixty-three percent of women who have a husband/partner who lives elsewhere had sexual intercourse within the year before the survey, but not during the four weeks immediately before the survey, and 27 percent reported they last had intercourse a year or more ago. Overall, 7 percent of currently married women have a husband/partner who lives elsewhere (data not shown). Table 4.5 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 25-49, according to background characteristics, Tajikistan 2012 Background characteristic Women age 25-49 Residence Urban 20.6 Rural 20.2 Region Dushanbe 20.6 GBAO 22.9 Sughd 20.2 DRS 20.2 Khalton 20.3 Education None/primary 20.7 General basic 20.3 General secondary 19.9 Professional primary/middle 21.0 Higher 22.4 Wealth quintile Lowest 20.4 Second 20.2 Middle 20.4 Fourth 20.1 Highest 20.3 Total 20.3 Marriage and Sexual Activity • 53 Not unexpectedly, nine in ten of the women who are divorced, separated, or widowed reported that it had been one year or more since they last had intercourse. Sexual activity is nonexistent (or underreported) among never-married women. The proportions recently sexually active do not vary much with other background characteristics in Table 4.6. Table 4.6 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Tajikistan 2012 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 8.7 4.3 0.3 0.1 86.6 100.0 2,013 20-24 42.1 22.3 6.0 0.3 29.4 100.0 1,950 25-29 55.4 23.3 8.3 0.3 12.8 100.0 1,609 30-34 57.4 23.7 11.8 0.3 6.8 100.0 1,188 35-39 61.2 24.0 12.0 0.2 2.6 100.0 1,030 40-44 61.9 20.2 16.5 0.3 1.1 100.0 991 45-49 57.5 23.4 18.5 0.1 0.5 100.0 875 Marital status Never married 0.0 0.0 0.0 0.1 99.9 100.0 2,648 Married or living together 66.3 27.5 6.0 0.2 0.0 100.0 6,504 Husband/partner lives with her 70.5 24.9 4.4 0.2 0.0 100.0 6,040 Husband/partner lives elsewhere 9.9 62.7 26.8 0.7 0.0 100.0 455 Divorced/separated/widowed 0.9 8.7 90.2 0.1 0.0 100.0 504 Marital duration2 0-4 years 63.6 31.8 4.2 0.4 0.0 100.0 1,873 5-9 years 64.9 28.1 7.0 0.1 0.0 100.0 1,215 10-14 years 70.1 23.7 5.7 0.5 0.0 100.0 808 15-19 years 67.1 27.3 5.6 0.1 0.0 100.0 852 20-24 years 68.0 23.5 8.3 0.3 0.0 100.0 850 25+ years 67.2 26.0 6.8 0.0 0.0 100.0 698 Married more than once 70.2 22.7 6.8 0.3 0.0 100.0 208 Residence Urban 47.2 14.7 10.9 0.4 26.8 100.0 2,413 Rural 43.9 20.4 8.0 0.2 27.6 100.0 7,243 Region Dushanbe 47.6 14.0 10.1 0.4 28.0 100.0 881 GBAO 39.9 13.2 9.8 0.6 36.5 100.0 220 Sughd 43.1 22.6 8.8 0.2 25.3 100.0 2,872 DRS 41.8 23.6 9.2 0.1 25.3 100.0 2,240 Khalton 47.5 14.5 7.9 0.3 29.7 100.0 3,444 Education None/primary 42.1 17.9 8.3 0.7 31.0 100.0 567 General basic 38.1 19.3 6.9 0.0 35.8 100.0 3,349 General secondary 49.2 19.2 9.8 0.2 21.6 100.0 4,474 Professional primary/middle 48.3 20.6 11.1 0.6 19.3 100.0 645 Higher 47.1 14.6 9.0 0.5 28.9 100.0 620 Wealth quintile Lowest 44.6 16.7 7.8 0.1 30.7 100.0 1,878 Second 43.9 19.6 8.0 0.2 28.3 100.0 1,913 Middle 42.8 22.3 8.4 0.1 26.4 100.0 1,904 Fourth 43.8 21.3 9.3 0.3 25.3 100.0 1,971 Highest 48.3 15.0 10.1 0.3 26.4 100.0 1,989 Total 44.7 19.0 8.7 0.2 27.4 100.0 9,656 Note: Table excludes 10 married women with missing information on whether a husband/partner lives with her or elsewhere. 1 Excludes women who had sexual intercourse within the last 4 weeks. 2 Excludes women who are not currently married. Fertility • 55 FERTILITY 5 major objective of the 2012 TjDHS was to examine fertility levels, trends, and differentials in Tajikistan. This chapter describes current and past fertility, birth intervals, age at first birth, and the reproductive behavior of adolescents. The data on birth intervals are important because short intervals are strongly associated with childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the mother and the child. All women who were interviewed in the 2012 TjDHS were asked to give a complete reproductive history. To encourage complete reporting, each woman was asked about the number of sons and daughters living with her, the number living elsewhere, and the number who had died. In addition to information on live births, all women were then asked questions on all pregnancies that did not result in a live birth to obtain the number of induced abortions, the number of miscarriages, and the number of stillbirths that women had experienced in their lifetime. After obtaining these aggregate data, an event-by-event pregnancy history was collected. Information was collected about all the pregnancies the respondent had in the order in which they occurred, starting with her first pregnancy. For each pregnancy that resulted in a live birth, information was collected on the child’s sex, survival status, and current age (for surviving children) or age at death (for deceased children). For all pregnancies that did not result in a live birth, information was collected on the month and year the pregnancy ended. For births and terminations that occurred during the five years preceding the survey (i.e., in January 2007 or later), the pregnancy duration was recorded in the 5-year calendar of events. Women were also asked questions about current pregnancies. 5.1 CURRENT FERTILITY Several measures of current fertility are derived from the pregnancy history data. Age-specific fertility rates (ASFRs) refer to the average number of live births per 1,000 women in a certain age group.1 They are a valuable measure to assess the current age pattern of childbearing. The total fertility rate (TFR) is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed ASFRs. The TFR is obtained by summing the ASFRs and multiplying by five. The general fertility rate (GFR) is expressed as the annual number of live births per 1,000 women age 15-44, and the crude birth rate (CBR) is expressed as the annual number of live births per 1,000 population. 1 Numerators for age-specific fertility rates are calculated by summing the number of live births that occurred in the period 1-36 months preceding the survey (determined by the date of interview and the date of birth of the child) and classifying them by the age of the mother (in five-year groups) at the time of birth (determined by the mother’s date of birth). The denominators for the rates are the number of woman-years lived in each specific five-year age group during the period 1 to 36 months preceding the survey. A Key Findings • The total fertility rate in Tajikistan is 3.8 births per woman. • Rural women have higher fertility than urban women (3.9 versus 3.3). • The total fertility rate is highest in Khatlon (4.2). • Childbearing begins relatively late in Tajikistan, with less than one- quarter of women giving birth by age 20. • The median age at first birth is 22. 56 • Fertility The various measures of current fertility are calculated for the three-year period preceding the survey, which roughly corresponds to mid-2009 to mid-2012. A three-year period was chosen because it reflects the current situation without unduly increasing sampling error. Birth data from the TjDHS are subject to the same types of errors that are inherent in all retrospective sample surveys: the possibility of omitting some births (especially births of children who died at a very young age) and the difficulty of accurately determining each child’s date of birth. These errors can bias estimates of fertility trends, which therefore have to be interpreted within the context of data quality and sample sizes. A summary of the quality of the TjDHS birth history data appears in Appendix Table C.4. It shows that there might have been some transference of births from 2007 to 2006 in order to reduce the interviewer’s workload; however, the differences are small and could also be due to real fluctuations in fertility. Both month and year of birth were given for all but a tiny fraction of births, and sex ratios at birth—while fluctuating considerably across time—do not show any evidence of omission by sex of the birth. Table 5.1 shows, that the TFR for the three-year period before the survey is 3.8 children per woman. The TFR for rural areas (3.9 births per woman) is higher than that for urban areas (3.3 births). Table 5.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Tajikistan 2012 Age group Residence Total Urban Rural 15-19 52 54 54 20-24 230 259 253 25-29 190 224 216 30-34 116 148 139 35-39 58 73 69 40-44 7 24 19 45-49 1 3 2 TFR (15-49) 3.3 3.9 3.8 GFR 113 141 134 CBR 28.9 35.6 33.9 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women age 15-44 CBR: Crude birth rate, expressed per 1,000 population Table 5.1 and Figure 5.1 show that age-specific fertility rates are low among women age 15-19 (54 per 1,000 at the national level), rise to a peak among women 20-24 (253 per 1,000), remain high for women 25-29 (216 per 1,000), and decline rapidly at older ages. Age-specific fertility rates are higher among rural than urban women throughout the childbearing years, but the difference is more pronounced among women under age 30 than among older women: the greatest absolute urban-rural difference in ASFR (34 births per 1,000 woman) is in the 25-29 age group. Fertility • 57 Figure 5.1 Age-specific fertility rates by urban-rural residence Rate per 1,000 women Tajikistan DHS 2012 As shown in Figure 5.2, compared with recent fertility estimates from Demographic and Health Surveys conducted in other countries, the TFR of 3.8 births per woman in Tajikistan in 2012 is lower than in Afghanistan (5.1 births per woman in 2010) and Pakistan (4.1 births per woman in 2006-07), but higher than in Azerbaijan (2.0 births per woman in 2006) and Armenia (1.7 births per woman in 2010). (APHI/MoPH [Afghanistan] et al., 2011; NIPS [Pakistan] and Macro International Inc., 2008; SSC [Azerbaijan] and Macro International Inc., 2008; NSS [Armenia] at al., 2012). 0 50 100 150 200 250 300 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Mother's age at birth Urban Rural Total 58 • Fertility Figure 5.2 Comparison of TFR in Tajikistan with other countries in the region Source: Afghan Public Health Institute et al., 2011; National Institute of Population Studies and Macro International Inc., 2008; State Statistical Committee and Macro International Inc., 2008; National Statistical Service at al., 2012 5.2 FERTILITY DIFFERENTIALS In addition to urban-rural residence, fertility also varies by region (Table 5.2 and Figure 5.3). The TFR is lowest in GBAO and Sughd (3.3 births per woman), followed by Dushanbe at 3.4 births per woman, and highest in Khatlon (4.2 births per woman) and DRS (3.9 births per women). Women’s education is strongly associated with fertility. The TFR decreases from 4.2 births for women with no education or only primary schooling to 2.7 births for women with higher education. Fertility is also negatively associated with wealth; the difference in fertility between women in the lowest and highest wealth quintiles amounts to almost one child per woman. Figure 5.3 Fertility differentials Tajikistan DHS 2012 Fertility • 59 The percentage of women who reported being pregnant at the time of the survey is also presented in Table 5.2. This percentage may be underreported because some women may not be aware of a pregnancy, especially at the early stages, and some women who are early in their pregnancy may not want to reveal that they are pregnant. At the time of the survey, 8 percent of women age 15-49 reportedly were pregnant. Rural women are slightly more likely to be currently pregnant than urban women (8 percent and 6 percent, respectively). Table 5.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Tajikistan 2012 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 3.3 6.3 3.8 Rural 3.9 8.0 4.8 Region Dushanbe 3.4 5.5 3.6 GBAO 3.3 6.0 4.0 Sughd 3.3 6.8 3.7 DRS 3.9 8.0 4.8 Khatlon 4.2 8.6 5.4 Education None/primary 4.2 9.9 (5.2) General basic 4.1 9.4 5.0 General secondary 3.8 6.2 4.7 Professional primary/middle 3.1 7.3 3.8 Higher 2.7 6.2 3.2 Wealth quintile Lowest 4.1 6.5 5.5 Second 4.1 9.2 5.1 Middle 3.9 8.0 4.5 Fourth 3.5 8.5 4.2 Highest 3.2 5.9 3.6 Total 3.8 7.6 4.5 Note: Total fertility rates are for the period 1-36 months prior to interview. Numbers in parentheses are based on 25-49 unweighted cases. Among the regions, the proportion of women who are currently pregnant is highest in Khatlon (9 percent) and DRS (8 percent) and lowest in Dushanbe and GBAO (6 percent each). The relationship between the percentage currently pregnant and education is not uniform, but generally decreases as education increases. Women in the highest wealth quintile are less likely to be currently pregnant (6 percent) than women in other quintiles (7 to 9 percent). Table 5.2 also presents data on the mean number of children ever born to women age 40-49, which allows for a crude assessment of trends in fertility. The TFR is a measure of current fertility, while the mean number of children ever born is a measure of past or completed fertility. Although comparing completed fertility among women age 40-49 with the TFR can provide an indication of fertility change, this change is subject to bias resulting from an understatement of parity by older women. Unless there is evidence of increased age at marriage and/or increased use of contraception, it is unlikely that fertility would decline. The comparison of past and current fertility indicators suggests a decline of almost one child per woman, from 4.5 to 3.8 children. There has been a decline in fertility in both urban and rural areas, in all regions, at all educational levels, and for all wealth quintiles. The difference between current and completed fertility is highest in rural areas (0.9 births), in Khatlon region (1.2 births), and among women in the lowest wealth quintile (1.4 births). 60 • Fertility 5.3 FERTILITY TRENDS In addition to the comparison of current and completed fertility, trends in fertility can be assessed in two other ways. First, fertility trends can be investigated using retrospective data from birth histories collected in the 2012 TjDHS. Second, the TFR from the 2012 TjDHS can be compared with estimates obtained in earlier surveys. Trends in fertility over time can be examined by comparing age-specific fertility rates from the 2012 TjDHS for successive five-year periods preceding the survey, as presented in Table 5.3. The rates for older age groups become progressively more truncated for periods more distant from the survey date, because women age 50 and older were not interviewed in the survey. For example, rates cannot be calculated for women age 35-39 during the period 15-19 years before the survey because these women would have been over age 50 at the time of the survey and therefore not eligible to be interviewed. Nonetheless, the results in Table 5.3 show that fertility has dropped among all age groups over the past two decades. The decline is steepest among the cohort age 30-34, with a 27 percent decline between the period 10 to 14 years before the survey and the period 0 to 4 years before the survey. According to the results of the Survey on Infant, Child, and Maternal Mortality in the Republic of Tajikistan conducted by the Statistical Agency in 2010, the TFR in Tajikistan declined from 5.1 children per woman in 1989 to 3.6 children per woman in 2006-2010 (SA, 2010). The TFR of 3.6 for the four-year period (2006-2010) reported in the 2010 survey is slightly lower than the TFR of 3.8 children per woman in the 2012 Tajik DHS calculated for the three-year period before the survey (2010-2012). This difference could be due to differences in survey methods or to a slight increase in fertility in the recent period. 5.4 CHILDREN EVER BORN AND LIVING Table 5.4 shows the distribution of all women and currently married women by age and number of children ever born. It also shows the mean number of children ever born to women in each five-year age group, an indicator of the momentum of childbearing, as well as the mean number of living children. Overall, more than one-third of all women age 15-49 in Tajikistan have never given birth. This proportion is far higher among younger women; 96 percent of women age 15-19 and 47 percent of those age 20-24 have never given birth. However, this proportion rapidly decreases with age. The percentage of women age 45-49 who have never given birth is quite low (2 percent), indicating that childbearing among Tajik women is nearly universal. The percentage of women in their forties who have never had children is a crude indicator of the level of primary infertility—that is, the proportion of women who are unable to bear children at all. Because voluntary childlessness is rare in Tajikistan, it is likely that married women with no births are unable to have children. Primary infertility is relatively low in Tajikistan at less than 2 percent. Table 5.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Tajikistan 2012 Mother's age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 47 36 49 83 20-24 243 226 251 298 25-29 212 220 234 262 30-34 133 141 181 [181] 35-39 67 87 [107] 40-44 20 [39] 45-49 [2] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. Fertility • 61 Table 5.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Tajikistan 2012 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN Age 15-19 96.1 3.6 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,013 0.04 0.04 20-24 47.3 29.4 19.1 3.7 0.4 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,950 0.81 0.77 25-29 21.8 14.1 30.7 23.4 7.6 2.1 0.3 0.0 0.0 0.0 0.0 100.0 1,609 1.88 1.82 30-34 11.5 7.4 17.1 27.3 20.6 10.7 3.9 1.1 0.4 0.0 0.0 100.0 1,188 2.94 2.80 35-39 4.5 5.5 11.9 22.2 25.2 16.2 7.9 5.0 1.2 0.3 0.0 100.0 1,030 3.73 3.49 40-44 3.0 4.4 10.6 18.2 20.5 17.5 11.9 8.7 3.0 1.5 0.6 100.0 991 4.26 3.90 45-49 2.4 3.3 7.0 15.3 18.3 17.0 14.0 11.8 5.1 3.1 2.6 100.0 875 4.86 4.30 Total 35.6 11.3 14.1 13.6 10.3 6.7 3.9 2.6 1.0 0.5 0.3 100.0 9,656 2.12 1.97 CURRENTLY MARRIED WOMEN Age 15-19 71.4 26.7 1.7 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 266 0.31 0.28 20-24 25.0 40.7 28.1 5.5 0.6 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,320 1.16 1.11 25-29 8.8 15.1 36.1 28.1 8.9 2.6 0.3 0.0 0.0 0.0 0.0 100.0 1,332 2.22 2.15 30-34 3.5 5.9 18.2 30.3 23.3 12.4 4.6 1.3 0.5 0.0 0.0 100.0 1,014 3.29 3.13 35-39 1.7 3.7 10.7 23.1 27.1 17.8 8.8 5.5 1.2 0.4 0.0 100.0 923 3.96 3.71 40-44 1.3 2.8 9.4 18.2 21.4 18.4 13.1 9.5 3.4 1.7 0.7 100.0 879 4.49 4.12 45-49 1.9 2.2 5.0 15.3 18.7 17.9 15.0 12.2 5.5 3.4 3.0 100.0 770 5.04 4.45 Total 11.0 14.5 19.4 19.2 14.5 9.6 5.6 3.7 1.4 0.7 0.4 100.0 6,504 2.98 2.78 As expected, older women have much higher parities than younger women. For example, over half (54 percent) of all women age 45-49 have given birth to five or more children. The mean number of children ever born increases with age from almost zero among women age 15-19 to 4.9 among women age 45-49. Patterns are similar for currently married women, except that only 11 percent of currently married women age 15-49 have never given birth. These differences in childbearing can be explained by the presence of many young and unmarried women in the all women category who are less exposed to the risk of conception than married women. 5.5 BIRTH INTERVALS Birth interval is the length of time between two successive live births. Information on birth intervals provides insight into birth spacing patterns, which affect fertility as well as maternal, infant, and childhood mortality. Studies have shown that short birth intervals are associated with increased risk of death for mother and baby, particularly when the birth interval is less than 24 months. Table 5.5 shows the percent distribution of non-first births that occurred in the five years preceding the survey by the number of months since the previous birth, according to background characteristics. 62 • Fertility Table 5.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Tajikistan 2012 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 * * * * * * 100.0 4 * 20-29 21.2 26.1 31.8 12.7 5.2 3.0 100.0 1,848 24.6 30-39 6.9 11.3 22.4 19.6 12.5 27.2 100.0 1,387 41.1 40-49 4.3 2.7 12.8 11.5 14.6 54.2 100.0 229 63.5 Sex of preceding birth Male 14.0 18.3 25.6 15.1 9.1 17.8 100.0 1,733 31.5 Female 14.9 18.9 27.9 15.7 8.3 14.4 100.0 1,735 29.9 Survival of preceding birth Living 13.2 18.6 27.2 15.6 8.9 16.5 100.0 3,300 31.3 Dead 39.1 18.2 17.7 11.2 5.7 8.1 100.0 167 22.1 Birth order 2-3 18.4 21.8 29.2 13.5 6.8 10.3 100.0 2,256 26.8 4-6 7.3 13.4 22.8 18.4 12.2 25.8 100.0 1,044 40.5 7+ 6.2 7.3 17.9 21.6 13.4 33.5 100.0 167 46.2 Residence Urban 14.5 17.5 23.2 13.1 11.9 19.8 100.0 723 33.0 Rural 14.5 18.9 27.7 16.0 7.9 15.1 100.0 2,745 30.1 Region Dushanbe 16.6 13.3 23.2 12.4 13.1 21.4 100.0 279 35.1 GBAO 14.4 16.3 21.1 11.9 11.6 24.7 100.0 55 34.5 Sughd 10.9 19.6 28.3 16.3 8.6 16.3 100.0 879 31.3 DRS 16.3 18.7 28.0 15.0 7.1 14.9 100.0 885 29.8 Khatlon 15.2 19.0 25.9 15.8 8.9 15.2 100.0 1,371 30.1 Education None/primary 19.1 26.6 29.6 11.3 5.4 8.0 100.0 277 24.8 General basic 15.8 19.1 28.7 15.6 7.9 13.0 100.0 1,332 29.1 General secondary 12.3 16.8 25.1 16.6 9.6 19.5 100.0 1,501 33.8 Professional primary/middle 11.9 17.8 25.6 15.3 8.5 20.9 100.0 200 31.3 Higher 18.7 18.6 22.7 9.4 13.3 17.4 100.0 157 29.9 Wealth quintile Lowest 13.4 20.3 24.5 16.5 8.9 16.4 100.0 754 31.2 Second 13.4 18.5 28.9 15.2 7.4 16.6 100.0 757 30.3 Middle 16.9 17.5 26.8 17.0 8.5 13.3 100.0 711 30.7 Fourth 13.9 18.6 29.8 14.8 7.9 15.2 100.0 652 30.1 Highest 15.0 18.1 23.4 12.8 11.4 19.3 100.0 594 32.4 Total 14.5 18.6 26.7 15.4 8.7 16.1 100.0 3,468 30.8 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Birth intervals are generally moderately long in Tajikistan, with a median interval of 31 months. Nevertheless, one-third of births take place less than 24 months after a previous birth. The length of the birth interval is closely associated with the survival status of the previous sibling. The median birth interval is 9 months shorter when the previous sibling has died than when the previous sibling is still alive (22 and 31 months, respectively). The percentage of births occurring within a very short interval (less than 18 months) is three times higher for children whose previous sibling died than for children whose previous sibling survived (39 and 13 percent, respectively). The shorter interval following the death of a child is partly due to a shortened period of breastfeeding (or no breastfeeding) for the preceding child, which leads to an earlier return of ovulation and hence increased chance of pregnancy. Minimal use of contraception, presumably because of a desire to have another child as soon as possible, could also be partly responsible for the shorter birth interval in these cases. Fertility • 63 The median number of months since a preceding birth increases considerably with age, from 25 months among mothers age 20-29 to 64 months among mothers age 40-49. The median birth interval also increases with birth order. There is a small difference in the length of the median birth interval by sex of the preceding birth, from 30 months when the preceding child was a girl to 32 months when the preceding child was a boy. Birth intervals are slightly longer in urban (33 months) than in rural (30 months) areas. The median birth interval is longest in Dushanbe and GBAO (35 months) and shortest in DRS and Khatlon (30 months). The median number of months since the preceding birth increases and then decreases as mother’s education increases. It varies little by wealth quintile. 5.6 POSTPARTUM AMENORRHEA, ABSTINENCE, AND INSUSCEPTIBILITY Two factors influence birth intervals during the period immediately following a birth: postpartum amenorrhea and postpartum abstinence. Postpartum amenorrhea is the interval between the birth of a child and the resumption of menstruation, during which the risk of pregnancy is very low. Postpartum amenorrhea is affected by the intensity and duration of breastfeeding. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. Delaying the resumption of sexual relations after a birth prolongs the period of postpartum protection. A woman is considered insusceptible to pregnancy if she is not exposed to the risk of pregnancy either because she is amenorrheic or because she is abstaining from sexual intercourse following a birth. The duration of amenorrhea and sexual abstinence following birth jointly determine the length of insusceptibility. Table 5.6 shows the proportion of mothers who are still amenorrheic, abstaining, and insusceptible by number of months since birth for all births occurring in the three years before the survey. Table 5.6 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Tajikistan 2012 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 < 2 79.0 81.6 93.7 108 2-3 55.0 27.4 62.6 179 4-5 42.0 15.2 46.0 163 6-7 23.8 13.2 32.3 204 8-9 25.5 10.3 32.9 192 10-11 15.6 8.3 23.8 207 12-13 9.5 10.4 17.7 215 14-15 9.7 2.2 11.5 171 16-17 7.6 5.9 12.9 167 18-19 10.1 6.7 12.5 181 20-21 7.2 3.4 9.1 170 22-23 2.6 5.7 6.4 197 24-25 3.5 4.4 7.0 229 26-27 8.8 4.4 12.9 207 28-29 2.7 4.5 6.8 193 30-31 3.3 3.7 7.0 160 32-33 1.8 3.7 5.3 173 34-35 3.7 3.5 5.2 212 Total 15.5 10.2 20.5 3,328 Median 3.2 2.0 4.1 na Mean 6.6 4.6 8.4 na Note: Estimates are based on status at the time of the survey. na = Not applicable. 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth. 64 • Fertility The data indicate that mothers in Tajikistan are amenorrheic for a median of 3 months, abstain for a median of 2 months, and are insusceptible to pregnancy for a median of 4 months. The proportion of women who are amenorrheic drops rapidly from 79 percent in the first two months after birth to a low of 2 percent at 32-33 months. The majority (82 percent) of Tajik women abstain from sex during the first two months following a birth. The proportion abstaining drops sharply to 27 percent at 2 to 3 months and then drops to 15 percent at 4 to 5 months. The period of postpartum amenorrhea is longer than the period of postpartum abstinence and is the more important determinant of the length of postpartum insusceptibility to pregnancy. At 8 to 9 months after birth, one-quarter of all women are still amenorrheic, but only 10 percent are abstaining. Table 5.7 shows the median duration of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics. In general, differences in these three variables by background characteristics are small. Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 3.0 2.0 4.0 30-49 3.8 2.0 4.5 Residence Urban (1.9) 1.3 3.0 Rural 3.6 2.1 4.3 Region Dushanbe (0.7) (0.7) (2.1) GBAO (2.8) (2.4) 5.8 Sughd (2.4) (1.6) 3.1 DRS 4.2 1.9 5.0 Khatlon 3.5 2.2 4.2 Education None/primary (4.7) (2.6) (6.4) General basic 3.7 1.9 4.4 General secondary 2.9 2.0 3.6 Professional primary/middle * * * Higher (2.3) * * Wealth quintile Lowest 2.9 (2.0) 3.5 Second 4.2 2.5 4.9 Middle 3.7 2.0 4.5 Fourth 3.4 1.6 4.3 Highest 1.1 1.1 2.4 Total 3.2 2.0 4.1 Note: Medians are based on the status at the time of the survey (current status). Medians in parentheses are based on 25-49 unweighted births, while an asterisk denotes that a median is based on fewer than 25 unweighted births and has been suppressed. 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth. Fertility • 65 5.7 MENOPAUSE The risk of becoming pregnant declines with age. After age 30, women’s susceptibility to pregnancy declines as an increasing proportion of women become infecund. The term infecundity denotes a process rather than a well-defined event. Although the onset of infecundity is difficult to determine for an individual woman, one indicator of infecundity is menopause. Menopause is the culmination of a gradual decline in fecundity with increasing age. The 2012 TjDHS defines menopausal women as those who are neither pregnant nor postpartum amenorrheic but who have not had a menstrual period in the six months preceding the survey. Women who report that they have had a hysterectomy are also defined as menopausal. Table 5.8 presents data on menopause for women age 30 and older. Ten percent of women age 30-49 are estimated to be menopausal. The proportion menopausal increases with age, from 1 percent among women age 30-34 to 49 percent among women age 48-49. 5.8 AGE AT FIRST BIRTH Age at first birth has a direct effect on fertility. The onset of childbearing at an early age has a major effect on both the mother’s and the child’s health. Early initiation of childbearing lengthens the reproductive period and subsequently increases fertility. In many countries, postponement of first births— reflecting an increase in the age at marriage—has contributed greatly to overall fertility decline. Moreover, bearing children at a young age involves substantial risks to the health of both the mother and child. Early childbearing also tends to restrict educational and economic opportunities for women. Table 5.9 presents by age cohort the percentage of all women who had given birth by specific ages. The median age at first birth is not shown for women under age 24, because a majority had not become mothers before age 20. Overall, the median age at first birth is about 22 years. This median fluctuates between 21 and 23 across age groups and shows a slight tendency to rise among the younger age groups. Just under one-quarter of women in Tajikistan give birth before reaching age 20, while over half (52 percent) give birth by age 22, and about three-quarters give birth by age 25. Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Tajikistan 2012 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 Age 15-19 0.1 na na na na 96.1 2,013 a 20-24 0.1 2.2 20.0 na na 47.3 1,950 a 25-29 0.0 2.7 18.0 41.1 68.6 21.8 1,609 22.8 30-34 0.0 6.1 24.6 48.9 71.6 11.5 1,188 22.1 35-39 0.0 3.7 33.0 64.7 81.5 4.5 1,030 20.8 40-44 0.1 1.0 22.8 58.6 84.3 3.0 991 21.5 45-49 0.0 1.3 19.7 56.7 82.7 2.4 875 21.6 20-49 0.0 2.9 22.4 na na 19.7 7,643 a 25-49 0.0 3.1 23.2 52.4 76.4 10.3 5,693 21.8 na = Not applicable due to censoring. a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group. Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Tajikistan 2012 Age Percentage menopausal1 Number of women Age 30-34 1.1 1,188 35-39 2.7 1,030 40-41 4.4 404 42-43 8.0 374 44-45 13.1 407 46-47 32.0 375 48-49 49.1 305 Total 10.1 4,084 1 Percentage of all women who are not pregnant and not postpartum amenorrheic whose last menstrual period occurred six or more months preceding the survey. 66 • Fertility Table 5.10 shows the median age at first birth by background characteristics for women currently age 25-49. Women in GBAO have a slightly higher median age at first birth then women in other regions. Differences by other characteristics are very small. Table 5.10 Median age at first birth Median age at first birth among women age 25-49 years, according to background characteristics, Tajikistan 2012 Background characteristic Women age 25-49 Residence Urban 22.0 Rural 21.7 Region Dushanbe 22.2 GBAO 24.1 Sughd 21.7 DRS 21.6 Khatlon 21.9 Education None/primary 22.6 General basic 21.9 General secondary 21.5 Professional primary/middle 22.4 Higher 23.5 Wealth quintile Lowest 22.1 Second 21.9 Middle 22.0 Fourth 21.5 Highest 21.7 Total 21.8 5.9 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy and motherhood is a major social and health concern. Early teenage pregnancy can cause health problems for both the mother and the child. Teenage mothers are more likely to suffer from severe complications during delivery, which result in higher morbidity and mortality for both themselves and their children. In addition, young mothers may not be sufficiently emotionally mature to bear the burden of childbearing and rearing. Moreover, an early start to childbearing often reduces women’s educational and employment opportunities and is associated with higher levels of fertility. Table 5.11 shows that 7 percent of adolescents age 15-19 in Tajikistan have begun childbearing. Four percent of teenagers have given birth, and another 4 percent are pregnant with their first child. As expected, the proportion of women age 15-19 who have begun childbearing rises with age, from almost zero percent among women age 15 and age 16 to 27 percent of women age 19. Early childbearing among teenagers is slightly more common in DRS (9 percent) than in other regions, especially GBAO (3 percent). It is also somewhat more common among women with no or only primary education and among women in the fourth wealth quintile. Fertility • 67 Table 5.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 0.3 0.0 0.3 342 16 0.0 0.0 0.0 443 17 0.0 0.7 0.7 422 18 3.7 5.7 9.5 415 19 15.7 11.4 27.1 391 Residence Urban 4.6 2.6 7.2 476 Rural 3.7 3.8 7.5 1,537 Region Dushanbe 4.4 2.0 6.5 183 GBAO 1.4 1.4 2.8 43 Sughd 3.4 2.9 6.3 580 DRS 4.9 4.2 9.0 461 Khatlon 3.7 4.1 7.8 746 Education None/primary 7.0 4.0 10.9 104 General basic 4.9 3.0 7.9 1,029 General secondary 2.5 4.1 6.6 777 Professional primary/middle 2.5 2.5 5.0 54 Higher 0.0 6.7 6.7 48 Wealth quintile Lowest 1.4 2.1 3.4 394 Second 3.6 4.5 8.1 398 Middle 4.3 4.1 8.3 380 Fourth 5.2 4.8 9.9 420 Highest 4.8 2.4 7.2 421 Total 3.9 3.5 7.4 2,013 Fertility Preferences • 69 FERTILITY PREFERENCES 6 nformation on fertility preferences is of considerable importance to family planning programs because it allows planners to assess not only the desire for children but also the extent of unwanted and mistimed pregnancies. Data on fertility preferences also indicate the direction that future fertility efforts of a country’s citizens may take. In the 2012 TjDHS, women were asked a series of questions to ascertain their fertility preferences. The resulting data were used to quantify fertility preferences—whether women wanted to cease childbearing altogether or merely delay the next pregnancy, for example. Data can also be used to determine the demand for family planning—in combination with data on contraceptive use—to estimate unmet need for family planning, including the need for spacing and limiting births. The ideal number of children is another important indicator of fertility preferences that shows the number of children a woman would want in total if she could start afresh. The information on ideal family size provides two measures. First, for women who have not yet started a family the data provide an idea of future fertility (to the extent that women are able to realize their fertility desires). Second, the excess of past fertility over ideal family size provides a measure of unwanted fertility. Other topics discussed in this chapter are fertility planning and the effect of unwanted births on fertility rates. The interpretation of data on fertility preferences is often difficult since it is understood that respondents’ reported preferences are, in a sense, hypothetical and thus subject to change and rationalization. Still, data on fertility preferences indicate the direction of future fertility to the extent that individuals and couples will act to achieve their preferred family sizes. 6.1 DESIRE FOR MORE CHILDREN Information about the desire for more children is important for understanding future reproductive behavior. The provision of adequate and accessible family planning services depends on the availability of such information. In the 2012 TjDHS, women were asked if they wanted to have another child or not and, if so, how soon they wanted the child. The question was phrased differently in the case of pregnant women to ask about desire for a subsequent child after completion of the current pregnancy. Sterilized women were considered to want no more children, and therefore they were not asked questions about their desire for more children. I Key Findings • Forty-four percent of currently married women in Tajikistan want to limit childbearing—43 percent want no more children, and 1 percent of the women have been sterilized. • Women prefer to have moderate family sizes (3.6 children). The most commonly reported ideal family size is four children (cited by 45 percent of women). • Women in Tajikistan have an average of half a child more than their desired number of children. This implies that the total fertility rate would be 3.3 if unwanted births were avoided, instead of the actual rate of 3.8. • Nevertheless, 93 percent of recent births were reported as being wanted at the time they occurred. 70 • Fertility Preferences Table 6.1 and Figure 6.1 show that there is widespread desire among women to control the timing and number of births they have. Overall, 44 percent of currently married women in Tajikistan want to limit childbearing—43 percent say they want no more children, and less than 1 percent have been sterilized. Thirty-seven percent of married women want to have a child at some time in the future, but only 17 percent of married women want a child within two years, and 19 percent would prefer to wait two or more years Thus, the majority of married women want to either space their next birth or cease childbearing altogether. A sizeable proportion of married women in Tajikistan are undecided about their fertility preferences (14 percent), either because they are unsure if they want another child or they want another child but are not sure when. Table 6.1 Fertility preferences by number of living children Percent distribution of currently married women age 15-49 by desire for children, according to number of living children, Tajikistan 2012 Desire for children Number of living children1 Total 0 1 2 3 4 5 6+ Have another soon2 77.7 32.5 16.6 7.0 3.5 2.3 1.4 16.9 Have another later3 3.2 46.8 32.1 13.9 4.2 4.2 2.4 18.9 Have another, undecided when 2.9 3.1 2.3 0.7 0.3 0.9 0.5 1.5 Undecided 1.5 9.8 18.5 16.6 11.3 6.9 6.0 12.2 Want no more 0.7 2.1 26.7 54.7 73.3 77.2 80.7 43.4 Sterilized4 0.0 0.3 0.1 0.9 1.2 0.3 1.3 0.6 Declared infecund 13.5 5.1 3.8 5.9 6.1 8.3 7.7 6.3 Missing 0.5 0.1 0.0 0.2 0.2 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 479 1,044 1,410 1,388 1,004 650 529 6,504 1 The number of living children includes the current pregnancy. 2 Wants next birth within two years. 3 Wants to delay next birth for two or more years. 4 Includes both female and male sterilization. Figure 6.1 Fertility preferences among currently married women age 15-49 The desire to limit fertility increases rapidly with the number of living children (Table 6.1). For example, most childless women want to have a child soon (78 percent); fewer than 1 percent say they do not want any children. However, more than one-fourth of married women with two children say they want no more or are already sterilized. This proportion increases to more than half of women with three children and almost three-quarters of those with four children. Wants soon* 17% Wants later** 19% Undecided*** 14% Infecund 6% Wants no more/sterilized 44% * Within the next 2 years ** After 2 years *** Wants more, undecided when or undecided if wants more Tajikistan DHS 2012 Fertility Preferences • 71 6.2 DESIRE TO LIMIT CHILDBEARING The proportion of women who want no more children is an important and easily understood measure of fertility preference. Table 6.2 shows the percentage of currently married women who want to stop childbearing by the number of children they already have and by urban-rural residence, region, education, and wealth quintile. Differences by urban-rural residence are very small. Overall, by region, differences among women in their desire to limit childbearing are relatively small, with married women in GBAO being the most likely to want no more children. However, the desire to limit childbearing varies more among currently married women with two or three children. The proportion of women with two or three children who want no more children is lowest in Khatlon and Dushanbe and highest in Sughd. Generally speaking, the more education a woman has, the more likely she is to want no more children. For example, among married women with two children, the proportion who want no more increases from 18 percent among those with no education or only primary to 32 percent among those with professional primary/middle schooling and then decreases to 31 percent among women with higher education. Differences in the desire to limit childbearing by household wealth are not straightforward. Overall, the desire to have no more children first declines with wealth and then increases; women in the lowest wealth quintile are most likely to want no more children (51 percent), while women in the middle wealth quintile are least likely to want no more children (39 percent). This U-shaped pattern generally holds, regardless of the number of children women already have. Table 6.2 Desire to limit childbearing Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Tajikistan 2012 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 1.3 3.7 28.9 53.0 76.2 78.4 80.0 42.7 Rural 0.5 2.1 25.9 56.5 73.9 77.3 82.3 44.5 Region Dushanbe 0.8 5.8 23.8 41.6 70.1 81.7 (79.4) 39.6 GBAO (3.3) 6.0 27.6 60.7 85.6 (83.7) (81.9) 46.5 Sughd 0.7 2.5 33.1 66.7 78.3 77.0 (83.8) 45.6 DRS 1.4 2.1 24.4 50.7 67.6 68.3 77.4 41.0 Khatlon 0.0 1.8 20.8 47.2 77.4 82.1 83.9 45.7 Education None/primary (0.0) 0.0 17.9 48.8 (67.3) * * 32.2 General basic 0.9 1.3 20.9 47.4 68.8 75.5 75.4 33.3 General secondary 0.0 2.8 30.6 57.9 76.1 77.0 83.5 50.8 Professional primary/middle (1.0) 4.7 32.4 70.8 79.4 (81.7) * 52.6 Higher (6.2) 8.7 31.1 58.4 83.3 (84.1) * 43.5 Wealth quintile Lowest 0.0 1.7 26.6 57.7 74.1 79.8 86.0 51.0 Second 0.0 1.9 26.9 57.4 80.3 74.3 82.9 45.2 Middle 1.6 1.5 22.9 52.6 70.6 74.6 72.1 39.1 Fourth 0.2 2.3 27.0 55.2 73.9 79.0 83.5 41.5 Highest 1.7 5.3 29.8 55.8 73.9 80.4 79.2 44.1 Total 0.7 2.5 26.8 55.6 74.5 77.5 82.0 44.0 Note: Women who have been sterilized are considered to want no more children. Figures in parentheses are based on 25-49 unweighted women; an asterisk denotes a figure based on fewer than 25 unweighted women that has been suppressed. 1 The number of living children includes the current pregnancy. 72 • Fertility Preferences 6.3 IDEAL FAMILY SIZE Women who were interviewed in the 2012 TjDHS were asked two questions for determining ideal family size. Those who did not have any living children were asked, “If you could choose exactly the number of children to have in your lifetime, how many would that be?” For respondents who had living children, the question was rephrased as follows, “If you could go back to the time you did not have any children and could choose exactly the number of children to have in your lifetime, how many would that be?” The results are presented in Table 6.3. Table 6.3 Ideal number of children by number of living children Percent distribution of women age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to the number of living children, Tajikistan 2012 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ 0 2.2 0.1 0.1 0.3 0.8 0.3 0.0 0.9 1 2.3 1.4 0.3 0.5 0.0 0.4 0.0 1.1 2 39.7 32.3 28.3 13.1 7.3 3.5 3.7 24.9 3 11.1 15.3 17.2 22.3 3.3 3.1 2.3 12.4 4 31.9 42.6 48.2 53.8 73.8 42.5 33.8 44.5 5 2.1 2.0 2.6 4.3 4.1 21.2 5.0 4.2 6+ 3.8 4.5 2.8 5.0 9.6 26.2 50.2 8.8 Non-numeric responses 6.9 1.7 0.5 0.9 1.0 2.8 5.1 3.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,215 1,188 1,521 1,462 1,047 672 550 9,656 Mean ideal number children for:2 All women 3.0 3.3 3.4 3.7 4.1 4.7 5.4 3.6 Number of women 2,995 1,168 1,513 1,449 1,037 653 522 9,336 Currently married women 3.4 3.3 3.4 3.7 4.1 4.7 5.4 3.8 Number of currently married women 463 1,029 1,404 1,376 993 631 504 6,401 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. Women in Tajikistan generally prefer moderate family sizes (3.6 children on average). More than two in five women (45 percent) want to have four children, while one-quarter (25 percent) want to have two children. Twelve percent of women prefer a three-child family. The ideal number of children increases with the number of living children. Women with six or more living children have an ideal family size of 5.4, compared with 3.0 for those with no children. The positive association between actual and ideal number of children is due to two factors. First, to the extent that women are able to implement their fertility desires, women who want smaller families will tend to achieve smaller families. Second, some women may have difficulty admitting their desire for fewer children if they could begin childbearing again and may in fact report their actual number as their preferred number. Despite this tendency to rationalize, the data provide evidence of unwanted fertility, with about half of women with five or more children reporting an ideal family size of fewer than their actual number of children. Table 6.4 shows the mean ideal number of children for women age 15-49, by background characteristics. The ideal family size for women increases with age, from 2.9 children in the youngest age group (15-19 years) to 4.6 children in the oldest age group (45-49 years). Ideal family size is slightly higher in rural areas than urban areas, and it is inversely related to household wealth. Regional variations in ideal family size range from 3.2 children among women in GBAO and Sughd to 3.9 among women in Khatlon. The relationship between ideal family size and education is erratic. Fertility Preferences • 73 Table 6.4 Mean ideal number of children, by background characteristics Mean ideal number of children for all women age 15-49 by background characteristics, Tajikistan 2012 Background characteristic Mean Number of women1 Age 15-19 2.9 1,860 20-24 3.3 1,889 25-29 3.5 1,589 30-34 3.7 1,170 35-39 4.0 1,019 40-44 4.2 968 45-49 4.6 841 Residence Urban 3.4 2,339 Rural 3.6 6,997 Region Dushanbe 3.4 851 GBAO 3.2 218 Sughd 3.2 2,812 DRS 3.7 2,141 Khatlon 3.9 3,314 Education None/primary 3.5 536 General basic 3.4 3,186 General secondary 3.8 4,377 Professional primary/middle 3.5 633 Higher 3.3 605 Wealth quintile Lowest 3.8 1,800 Second 3.7 1,844 Middle 3.5 1,834 Fourth 3.4 1,913 Highest 3.4 1,945 Total 3.6 9,336 1 Number of women who gave a numeric response. 6.4 FERTILITY PLANNING Information collected in the 2012 TjDHS can be used to estimate levels of unwanted fertility. This information provides some insight into the degree to which couples are able to control fertility. Women age 15-49 were asked a series of questions about each child born to them in the preceding five years, as well as any current pregnancy, to determine whether the birth or pregnancy was wanted then (planned), wanted later (mistimed), or not wanted at all (unplanned) at the time of conception. In assessing these results, it is important to recognize that women may declare a previously unwanted birth or current pregnancy as wanted, and this rationalization results in an underestimate of the true extent of unwanted births. Table 6.5 shows that the vast majority of births in the five years preceding the survey were wanted at the time they occurred (93 percent). Only 2 percent were mistimed (wanted later) and 3 percent were unwanted. The proportion of wanted births decreases and the proportion of unwanted births increases with increasing birth order. Ninety-seven percent of first births are wanted then, compared with only 86 percent of fourth and higher-order births. The proportion of unwanted births increases from a tiny fraction of first births to 11 percent of fourth and higher births. 74 • Fertility Preferences Table 6.5 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother's age at birth, Tajikistan 2012 Birth order and mother's age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 96.8 0.7 0.1 2.3 100.0 2,023 2 92.5 4.9 0.7 1.9 100.0 1,561 3 93.1 2.7 2.2 2.0 100.0 1,061 4+ 86.1 1.5 10.7 1.7 100.0 1,323 Mother's age at birth <20 95.3 1.0 0.3 3.3 100.0 546 20-24 95.0 2.8 0.5 1.7 100.0 2,497 25-29 92.6 2.8 2.2 2.4 100.0 1,672 30-34 90.1 1.8 6.8 1.3 100.0 785 35-39 83.6 0.4 13.8 2.1 100.0 359 40-44 76.7 2.0 20.5 0.9 100.0 105 45-49 * * * * 100.0 4 Total 92.7 2.3 3.0 2.0 100.0 5,968 Note: an asterisk denotes a figure based on fewer than 25 unweighted births that has been suppressed. A similar pattern is observed for the mother’s age at birth. The proportion of planned births is highest (95 percent) among mothers in the youngest age groups (<25) and then decreases with mother’s age. The percentage of unwanted births increases with mother’s age at birth, rising from less than 1 percent among mothers below age 25 to 21 percent of births to mothers age 40-44. 6.5 WANTED FERTILITY RATES The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. It is calculated in the same manner as the total fertility rate but excludes unwanted births from the numerator. A birth is considered wanted if the number of living children at the time of conception is lower than the ideal number of children reported by the respondent. The gap between wanted and actual fertility shows how successful women are in achieving their reproductive intentions. This measure also may be an underestimate to the extent that women may not report an ideal family size lower than their actual family size. The total wanted fertility rates in Table 6.6 represent the levels of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been avoided. Overall, the total wanted fertility rate for Tajikistan is 3.3 children, half a child lower than the actual total fertility rate (TFR) of 3.8. This implies that women have 0.5 children more than their wanted number of children and the TFR would be 13 percent lower if unwanted births were avoided. Fertility Preferences • 75 The gap between wanted and observed fertility rates is not uniform across characteristics of women. It is higher among women in Khatlon region than among women in other regions. The gap decreases as education and wealth of the woman increases. For example, the difference between wanted and actual fertility rates is 0.8 children among women in the lowest wealth quintile, compared with only 0.3 among women in the highest wealth quintile. Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 2.9 3.3 Rural 3.4 3.9 Region Dushanbe 3.0 3.4 GBAO 3.0 3.3 Sughd 2.9 3.3 DRS 3.4 3.9 Khatlon 3.6 4.2 Education None/primary 3.6 4.2 General basic 3.5 4.1 General secondary 3.3 3.8 Professional primary/middle 2.8 3.1 Higher 2.5 2.7 Wealth quintile Lowest 3.3 4.1 Second 3.5 4.1 Middle 3.4 3.9 Fourth 3.2 3.5 Highest 2.9 3.2 Total 3.3 3.8 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 5.2. Family Planning • 77 FAMILY PLANNING 7 his chapter first assesses contraceptive knowledge among TjDHS respondents and then moves on to consider the current practice of family planning. Special attention is focused on the source of contraception, informed choice, nonuse, reasons for discontinuation, unmet need for family planning, and intention to use in the future. The chapter concludes with information collected in the TjDHS on exposure to media coverage about family planning and on contact with family planning providers. These topics are of practical use to the reproductive health program in several ways. The discussion of women’s knowledge of family planning methods provides insight into one of the main pre-conditions to adoption of contraception. Levels of use of contraceptives provide the most obvious and widely accepted criterion of success of the program. The examination of use in relation to need pinpoints segments of the population for whom intensified efforts at service provision are most needed. Since most women have tried at least one method, practical problems with particular methods or in obtaining supplies may be important obstacles to further advances in the program. The 2012 TjDHS findings on these topics can provide important guidance for improving family planning services. 7.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Acquiring knowledge of contraceptive methods is a critical first step in the process of deciding to use family planning. Awareness of a wide range of methods improves a woman’s chances of finding an appropriate method to use. To obtain information on contraceptive knowledge in the TjDHS, the names and/or descriptions of 12 contraceptive methods were read aloud, and respondents were asked if they had heard of each method. In addition, respondents were asked about other ways to avoid pregnancy that they may have heard about. Table 7.1 shows the percentages of respondents reporting they had heard of specific T Key Findings • More than nine in ten women have heard about at least one family planning method. • Over one-quarter (28 percent) of married women are currently using contraception, primarily the IUD (19 percent). • Around one-third of married urban women are using family planning compared with slightly more than one-quarter of rural women. Use levels are highest in in the GBAO and Sughd regions (35 percent each) and lowest in the DRS and Khatlon regions (22 and 24 percent, respectively). • Current use of contraceptives among married women is much lower than the rate reported in the 2005 MICS survey (38 percent). • Public sector providers are the principal source for contraceptive methods, serving nine in ten users. • Most current users were provided information essential to making an informed choice at the time they adopted their method; almost 80 percent were told about potential side effects or problems, 73 percent were advised what to do if they experienced side effects or problems, and 70 percent were informed about other methods. • More than one in five married women is considered to have an unmet need for family planning, 12 percent because they want to delay the next pregnancy and 11 percent because they want no more children. 78 • Family Planning methods of contraception. For analytical purposes, contraceptive methods are grouped into two types: modern and traditional. Modern methods include female sterilization, male sterilization, the pill, IUD, injectables, implants, male condom, foam/jelly, diaphragm, and lactational amenorrhea method (LAM). Traditional methods include the rhythm (calendar) method, withdrawal, and other traditional methods. Contraceptive knowledge is widespread among women in Tajikistan. More than nine in ten currently married women, who are most immediately faced with the need to plan their families, know about at least one contraceptive method. Almost all of these women are aware of a modern method, and more than half of married women recognize at least one traditional method. Considering knowledge of specific methods, the most widely known modern method among married women is the IUD (93 percent), followed by the pill (83 percent), the male condom (71 percent), and injectables (67 percent). Other modern methods are less well-known; around three in ten married women have heard of female sterilization, implants, and the lactational amenorrhea method (LAM), and 22 percent know about emergency contraception. Very few married women know about male sterilization (12 percent) or the female condom (8 percent). With respect to traditional methods, almost half of married women know about withdrawal, and one-third are aware of the rhythm method. The mean number of methods known is a rough indicator of the breadth of knowledge of family planning methods. Table 7.1 shows that, on average, currently married women in Tajikistan are aware of more than five methods. 7.2 CURRENT USE OF CONTRACEPTION The level of current use is the most widely used and valuable measure of the success of a reproductive health planning program. Furthermore, it can be used to estimate the reduction in fertility attributable to contraception. To obtain information on current use of contraception, all TjDHS respondents not pregnant at the time of the survey were asked if they (or their partners) were currently using a method. Table 7.2 shows the level in the current use of contraception by method for all women and currently married women, according to age. The 2012 TjDHS found that over one-quarter (28 percent) of currently married women are using some method of contraception. Most currently married women rely on a modern method (26 percent), with only 2 percent relying on a traditional method. By far, the most popular method is the IUD, used by 19 percent of married women (Figure 7.1); more than six in ten women practicing family planning use the IUD. The pill, the male condom, injectables, and withdrawal are each used by 2 percent of married women. Less than 1 percent of women report using female sterilization. Table 7.1 Knowledge of contraceptive methods Percentage of all women and currently married women age 15-49 who know any contraceptive method, by specific method, Tajikistan 2012 Method All women Currently married women Any method 83.2 95.1 Any modern method 83.2 95.0 Female sterilization 24.6 29.9 Male sterilization 9.9 11.6 Pill 70.5 83.2 IUD 81.1 93.4 Injectables 55.9 67.1 Implants 26.0 31.3 Male condom 59.7 70.7 Female condom 7.2 8.0 Lactational amenorrhea (LAM) 26.5 34.6 Emergency contraception 16.5 21.5 Any traditional method 41.5 53.5 Rhythm (Calendar) method 27.3 34.9 Withdrawal 36.1 47.5 Folk method 0.8 1.0 Mean number of methods known by women 4.4 5.3 Number of women 9,656 6,504 Fa m ily P la nn in g • 7 9 Ta bl e 7. 2 C ur re nt u se o f c on tra ce pt io n by a ge Pe rc en t d is tri bu tio n of a ll w om en a nd c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rre nt ly u se d, a cc or di ng to a ge , T aj ik is ta n 20 12 Ag e An y m et ho d An y m od er n m et ho d M od er n m et ho d An y tra di tio na l m et ho d Tr ad iti on al m et ho d N ot cu rre nt ly us in g To ta l N um be r of w om en Fe m al e st er ili- za tio n P ill IU D In je ct - ab le s Im pl an ts M al e co nd om Fo am / je lly / di ap hr ag m LA M O th er R hy th m (C al en da r) m et ho d W ith - dr aw al O th er AL L W O M EN A ge 15 -1 9 0. 3 0. 2 0. 0 0. 0 0. 1 0. 0 0. 0 0. 1 0. 0 0. 1 0. 0 0. 1 0. 0 0. 1 0. 0 99 .7 10 0. 0 2, 01 3 20 -2 4 6. 8 6. 5 0. 0 0. 6 4. 6 0. 3 0. 1 0. 8 0. 0 0. 1 0. 0 0. 3 0. 0 0. 3 0. 0 93 .2 10 0. 0 1, 95 0 25 -2 9 22 .0 20 .6 0. 2 1. 5 16 .2 0. 4 0. 1 2. 0 0. 0 0. 1 0. 0 1. 4 0. 0 1. 4 0. 1 78 .0 10 0. 0 1, 60 9 30 -3 4 35 .2 32 .2 0. 7 3. 7 21 .7 2. 5 0. 0 3. 5 0. 0 0. 0 0. 1 3. 0 0. 0 2. 9 0. 0 64 .8 10 0. 0 1, 18 8 35 -3 9 42 .0 39 .6 1. 0 4. 2 27 .4 3. 7 0. 0 3. 2 0. 1 0. 0 0. 1 2. 4 0. 5 1. 9 0. 0 58 .0 10 0. 0 1, 03 0 40 -4 4 33 .6 30 .8 0. 9 2. 3 22 .2 3. 4 0. 0 2. 1 0. 0 0. 0 0. 0 2. 8 0. 1 2. 6 0. 1 66 .4 10 0. 0 99 1 45 -4 9 17 .4 15 .4 1. 1 0. 4 11 .5 1. 9 0. 0 0. 5 0. 0 0. 0 0. 0 2. 1 0. 2 1. 8 0. 1 82 .6 10 0. 0 87 5 To ta l 18 .9 17 .5 0. 4 1. 5 12 .6 1. 3 0. 0 1. 5 0. 0 0. 1 0. 0 1. 4 0. 1 1. 3 0. 0 81 .1 10 0. 0 9, 65 6 C U R R E N TL Y M A R R IE D W O M EN A ge 15 -1 9 2. 4 1. 8 0. 0 0. 0 0. 9 0. 0 0. 0 0. 4 0. 0 0. 5 0. 0 0. 6 0. 0 0. 6 0. 0 97 .6 10 0. 0 26 6 20 -2 4 9. 9 9. 5 0. 0 0. 9 6. 8 0. 3 0. 1 1. 2 0. 0 0. 2 0. 0 0. 4 0. 0 0. 4 0. 0 90 .1 10 0. 0 1, 32 0 25 -2 9 26 .6 24 .8 0. 3 1. 8 19 .6 0. 5 0. 1 2. 4 0. 0 0. 1 0. 0 1. 8 0. 0 1. 7 0. 1 73 .4 10 0. 0 1, 33 2 30 -3 4 40 .9 37 .4 0. 8 4. 4 25 .2 2. 9 0. 0 4. 0 0. 0 0. 0 0. 1 3. 5 0. 1 3. 4 0. 0 59 .1 10 0. 0 1, 01 4 35 -3 9 46 .5 43 .9 1. 1 4. 6 30 .3 4. 1 0. 0 3. 6 0. 1 0. 0 0. 0 2. 7 0. 5 2. 1 0. 0 53 .5 10 0. 0 92 3 40 -4 4 37 .8 34 .6 1. 0 2. 6 25 .0 3. 8 0. 0 2. 3 0. 0 0. 0 0. 0 3. 1 0. 1 2. 9 0. 1 62 .2 10 0. 0 87 9 45 -4 9 19 .4 17 .0 1. 0 0. 5 12 .9 2. 1 0. 0 0. 5 0. 0 0. 0 0. 0 2. 4 0. 2 2. 1 0. 1 80 .6 10 0. 0 77 0 To ta l 27 .9 25 .8 0. 6 2. 3 18 .5 2. 0 0. 0 2. 2 0. 0 0. 1 0. 0 2. 1 0. 1 1. 9 0. 0 72 .1 10 0. 0 6, 50 4 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. LA M = L ac ta tio na l a m en or rh ea m et ho d. Family Planning • 79 80 • Family Planning Figure 7.1 Current contraceptive use among currently married women age 15-49 Tajikistan DHS 2012 Note: The category ‘other modern’ includes female sterilization, LAM and other modern methods. Table 7.2 also shows how the current use of contraception varies with age. The results conform to the inverted U-shaped pattern of prevalence by age typically observed for currently married women. Use is lower among young women (because they are in an early stage of family building) and among older women (some of whom are no longer fecund) than among those at intermediate ages. Contraceptive use levels are quite low among married women under age 25 but rise rapidly with age, peaking at 47 percent among women age 35-39, and then declining to 19 percent among women age 45-49. The IUD is the most frequently used method in all age groups. 7.3 CURRENT CONTRACEPTIVE USE BY BACKGROUND CHARACTERISTICS Table 7.3 presents information on the current use of contraception among currently married women, by background characteristics. The table allows the comparison of levels of current contraceptive use among major groups of the population. It also permits an examination of differences in the method mix among current users in the various subgroups. An examination of the variation in contraceptive use levels with the number of children confirms that very few women in Tajikistan begin using contraception before they have had at least one child. Use levels remain relatively low until women have more than two children; current use among women with 3-4 children is 42 percent, more than twice the level among women with 1-2 children (20 percent). The use level drops off slightly, to 35 percent, among women with 5 or more children. IUD 19% Pill 2% Injectables 2% Male condom 2% Other modern 1%Any traditional method 2% Not currently using 72% Fa m ily P la nn in g • 8 1 Ta bl e 7. 3 C ur re nt u se o f c on tra ce pt io n by b ac kg ro un d ch ar ac te ris tic s P er ce nt d is tri bu tio n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rre nt ly u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tr ad i- tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en Fe m al e st er ili - za tio n P ill IU D In je ct - ab le s Im pl an ts M al e co nd om Fo am / je lly d ia - ph ra gm LA M O th er R hy th m (C al en - da r) m et ho d W ith - dr aw al O th er N um be r o f l iv in g ch ild re n 0 0. 1 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 99 .9 10 0. 0 74 6 1- 2 19 .5 17 .7 0. 2 1. 7 12 .8 0. 6 0. 1 2. 0 0. 0 0. 3 0. 0 1. 8 0. 1 1. 7 0. 0 80 .5 10 0. 0 2, 33 3 3- 4 41 .9 38 .7 1. 1 3. 6 29 .0 2. 0 0. 0 3. 0 0. 0 0. 0 0. 1 3. 2 0. 3 2. 8 0. 1 58 .1 10 0. 0 2, 26 8 5+ 35 .4 33 .6 0. 7 2. 6 21 .6 5. 8 0. 0 2. 7 0. 1 0. 0 0. 0 1. 9 0. 0 1. 9 0. 0 64 .6 10 0. 0 1, 15 7 R es id en ce o f a hu sb an d/ pa rt ne r H us ba nd /p ar tn er li ve s w ith h er 28 .8 26 .6 0. 6 2. 4 19 .1 2. 0 0. 1 2. 3 0. 0 0. 1 0. 0 2. 2 0. 1 2. 0 0. 0 71 .2 10 0. 0 6, 04 0 H us ba nd /p ar tn er li ve s el se w he re 16 .6 15 .6 0. 3 0. 9 12 .0 1. 3 0. 0 1. 1 0. 0 0. 0 0. 0 1. 0 0. 0 1. 0 0. 0 83 .4 10 0. 0 45 5 R es id en ce U rb an 31 .5 29 .0 0. 6 3. 3 20 .5 1. 1 0. 0 3. 2 0. 0 0. 0 0. 1 2. 5 0. 2 2. 1 0. 2 68 .5 10 0. 0 1, 57 1 R ur al 26 .8 24 .8 0. 6 2. 0 17 .9 2. 3 0. 1 1. 9 0. 0 0. 1 0. 0 1. 9 0. 1 1. 9 0. 0 73 .2 10 0. 0 4, 93 3 R eg io n D us ha nb e 31 .7 28 .7 0. 5 2. 7 19 .6 0. 1 0. 0 5. 2 0. 1 0. 1 0. 4 3. 0 0. 5 2. 0 0. 5 68 .3 10 0. 0 55 9 G B A O 35 .0 34 .9 0. 0 2. 5 23 .8 5. 6 0. 0 3. 0 0. 0 0. 0 0. 0 0. 2 0. 0 0. 2 0. 0 65 .0 10 0. 0 12 9 S ug hd 35 .3 30 .7 0. 7 2. 0 22 .9 2. 2 0. 0 2. 6 0. 0 0. 3 0. 0 4. 6 0. 2 4. 4 0. 0 64 .7 10 0. 0 2, 02 2 D R S 22 .3 22 .0 0. 7 2. 2 16 .6 0. 8 0. 0 1. 7 0. 0 0. 0 0. 0 0. 4 0. 0 0. 4 0. 0 77 .7 10 0. 0 1, 54 6 K ha tlo n 23 .8 22 .9 0. 4 2. 5 15 .4 2. 9 0. 1 1. 5 0. 0 0. 0 0. 0 0. 9 0. 0 0. 9 0. 0 76 .2 10 0. 0 2, 24 9 Ed uc at io n N on e/ pr im ar y 20 .5 19 .9 0. 0 0. 5 15 .4 2. 8 0. 4 0. 9 0. 0 0. 0 0. 0 0. 6 0. 0 0. 6 0. 0 79 .5 10 0. 0 35 6 G en er al b as ic 21 .8 20 .0 0. 4 1. 9 14 .4 1. 3 0. 0 1. 9 0. 0 0. 1 0. 0 1. 8 0. 0 1. 7 0. 0 78 .2 10 0. 0 2, 01 6 G en er al s ec on da ry 30 .0 28 .0 0. 8 2. 7 20 .0 2. 5 0. 0 1. 9 0. 0 0. 1 0. 0 2. 0 0. 1 1. 9 0. 0 70 .0 10 0. 0 3, 26 0 P ro fe ss io na l p rim ar y/ m id dl e 34 .1 30 .2 0. 3 2. 5 22 .9 2. 0 0. 3 2. 1 0. 0 0. 0 0. 1 3. 9 0. 5 3. 4 0. 0 65 .9 10 0. 0 47 5 H ig he r 40 .7 37 .4 0. 5 2. 8 25 .1 0. 5 0. 0 8. 0 0. 1 0. 1 0. 1 3. 3 0. 4 2. 6 0. 2 59 .3 10 0. 0 39 7 W ea lth q ui nt ile Lo w es t 24 .9 23 .3 0. 1 1. 3 15 .6 4. 4 0. 1 1. 7 0. 0 0. 0 0. 0 1. 6 0. 0 1. 6 0. 0 75 .1 10 0. 0 1, 21 0 S ec on d 24 .5 22 .7 0. 7 2. 1 16 .6 2. 4 0. 0 1. 0 0. 0 0. 0 0. 0 1. 8 0. 0 1. 8 0. 0 75 .5 10 0. 0 1, 28 7 M id dl e 25 .2 23 .7 0. 7 1. 9 18 .2 1. 3 0. 1 1. 3 0. 0 0. 2 0. 0 1. 4 0. 0 1. 4 0. 0 74 .8 10 0. 0 1, 30 7 Fo ur th 28 .8 25 .8 0. 7 2. 7 18 .3 1. 3 0. 0 2. 7 0. 0 0. 2 0. 0 2. 9 0. 3 2. 7 0. 0 71 .2 10 0. 0 1, 37 9 H ig he st 35 .9 33 .3 0. 8 3. 5 23 .7 0. 7 0. 0 4. 4 0. 0 0. 0 0. 2 2. 5 0. 3 2. 0 0. 2 64 .1 10 0. 0 1, 32 0 To ta l 27 .9 25 .8 0. 6 2. 3 18 .5 2. 0 0. 0 2. 2 0. 0 0. 1 0. 0 2. 1 0. 1 1. 9 0. 0 72 .1 10 0. 0 6, 50 4 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. T ab le e xc lu de s 10 w om en w ith m is si ng in fo rm at io n on w he th er a h us ba nd /p ar tn er li ve s w ith h er o r e ls ew he re . LA M = L ac ta tio na l a m en or rh ea m et ho d. Family Planning • 81 82 • Family Planning There are differences in the current use of contraception by husband’s residence. Currently married women who report a husband/partner lives elsewhere are less likely to report using any method or any modern method of contraception (17 and 16 percent, respectively) compared with women whose husbands live with them (29 and 27 percent, respectively). Around three in ten married women in urban areas are using contraception compared with slightly more than one-quarter of rural married women. There is considerable variation in contraceptive use by region. Women from the DRS and Khatlon regions are the least likely to use any method of contraception (22 and 24 percent, respectively). The GBAO and Sughd regions have the highest rates of use of any method (35 percent each). As expected, contraceptive use increases with educational attainment. Women with higher level of education are nearly twice as likely to use a method as women with primary only or no education (41 percent compared with 21 percent). The IUD dominates the method mix in all subgroups; whatever their background, two-thirds of current users rely on an IUD to prevent pregnancy. Injectables are most popular among users with five or more children, users in the GBAO region, and users in the lowest wealth quintile. Users in Dushanbe, users with higher education, and users in the highest wealth quintile are most likely to report relying on the male condom. 7.4 TRENDS IN CURRENT CONTRACEPTIVE USE Table 7.4 compares the level of contraceptive use in the 2012 TjDHS with the levels reported in the 2000 and 2005 MICS surveys (UNICEF, 2000 and SCS, 2007). The survey results indicate that contraceptive use rose modestly in Tajikistan during the first half of the last decade, from 34 percent in 2000 to 38 percent in 2005, before declining sharply to 28 percent in 2012. Much of the decline in contraceptive use was due to decreased use of the IUD; around one in four married women was reported to be using an IUD in both the 2000 and 2005 MICS surveys compared with less than one in five women in the 2012 TjDHS. Table 7.4 Trends in current use of contraception Percent distribution of currently married women by contraceptive method currently used, Tajikistan 2000-2012 Method 2000 MICS 2005 MICS 2012 TjDHS Any method 33.9 37.9 27.9 Any modern method 28.3 36.1 25.8 Female sterilization 0.2 0.4 0.6 Male sterilization 0.1 0.4 0.0 Pill 0.6 2.1 2.3 IUD 25.1 26.3 18.5 Injectables 0.9 2.4 2.0 Implants na 0.0 0.0 Male condom 0.4 1.4 2.2 Female condom na 0.0 0.0 Foam/jelly 0.0 0.0 0.0 Lactational amenorrhea (LAM)1 1.0 3.1 0.1 Any traditional method 5.6 1.8 2.1 Rhythm (Calendar) method2 2.5 0.3 0.1 Withdrawal 3.0 1.4 1.9 Other 0.1 0.1 0.0 Not using 66.1 62.1 72.1 Total percent 100.0 100.0 100.0 Number of women 3,945 6,245 6,504 na=Not applicable 1 LAM was considered a traditional method in the 2000 and 2005 MICS surveys. 2 Periodic abstinence in the 2000 and 2005 MICS surveys. Family Planning • 83 Figure 7.2 shows that the decrease in the current use of contraception was evident in both urban and rural areas. The urban use rate fell from a peak of 42 percent in 2005 to 32 percent in 2012, while the rural use rate declined from 36 percent to 27 percent. Figure 7.2 Trends in current contraceptive use among currently married women, Tajikistan 2000, 2005, and 2012 The reason for such a difference between surveys in contraceptive use, and in IUD use in particular, is not clear. One factor that is sometimes cited as a possible explanation is an increase in the outmigration of men from Tajikistan in search of work. Women whose husbands are away for an extended period because of work may be much less likely to adopt contraception or, if they are using contraception, more likely to discontinue use, because they are not exposed to the risk of pregnancy while their husbands are away. As shown in Table 7.3, currently married women who report a husband/partner lives elsewhere are somewhat less likely to report using any method or any modern method of contraception (17 and 16 percent, respectively) compared with women whose husbands live with them (29 and 27 percent, respectively). However, the overall number of women whose husbands live elsewhere is small—only 7 percent of all currently married women report their husbands live away—so the behavior of this group is unlikely to have had a very major effect on the trend in contraceptive use. A more indepth analysis than is possible in this report is needed to understand the role outmigration and other factors have played in the decline in contraceptive use in Tajikistan. 7.5 SOURCE OF MODERN CONTRACEPTIVE METHODS Table 7.5 documents the main sources of contraception for users of different contraceptive methods. This information is useful for reproductive health program managers, particularly those responsible for program logistics. The results in Table 7.5 show that public sector providers are the principal source for most of the contraceptive methods used in Tajikistan. Around nine in ten current users of modern methods obtain their method from a public sector provider. The principal public sector sources for contraceptives are polyclinics serving 28 percent of current users, health centers serving 26 percent of users, and maternity homes serving 23 percent of users. Pharmacies, the principal private sector provider for contraceptives, serve 9 percent of users. 34 39 32 38 42 36 28 32 27 Total Urban Rural 2000 MICS 2005 MICS 2012 TjDHS Percentage 84 • Family Planning Considering specific methods, almost all IUD and injectable users obtain their methods from a public sector provider (97 percent and 96 percent, respectively). IUD users most often obtain the method from polyclinics (31 percent), followed closely by maternity homes (28 percent) and health centers (27 percent). Nearly half of injectable users obtain the method at health centers. Polyclinics (18 percent) and health houses (15 percent) are the other sources most often relied on by injectable users. The majority of pill users rely on public sector providers, principally polyclinics (22 percent) and health centers (20 percent), for their method. More than one-third of pill users obtain their method from pharmacies. Table 7.5 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Tajikistan 2012 Source Pill IUD Injectables Male condom Total Public Sector 60.7 96.9 96.4 40.0 88.5 Government hospital 4.6 7.0 6.1 1.3 6.6 Maternity home 5.2 28.1 8.0 2.3 23.0 Health center (urban/rural) 19.8 26.5 47.8 11.6 25.8 Reproductive health center 1.3 1.5 2.3 2.3 1.6 Health house 6.4 2.1 14.7 0.8 3.3 Polyclinics 21.9 31.2 17.5 20.7 27.6 Integrated management of childhood illness center 0.0 0.1 0.0 0.0 0.1 Healthy lifestyle center 0.5 0.1 0.0 0.0 0.1 Family medicine center 1.0 0.3 0.0 0.0 0.5 Private Sector 37.4 1.5 0.6 57.4 9.5 Private hospital clinic 0.0 0.2 0.2 0.0 0.1 Private doctor's office 0.0 0.0 0.0 0.5 0.1 Pharmacy 37.4 1.3 0.5 56.9 9.3 Other Source 0.3 0.0 0.0 0.0 0.0 Missing 0.7 1.5 3.0 2.6 1.8 Total 100.0 100.0 100.0 100.0 100.0 Number of women 149 1,213 129 147 1,683 Note: Total includes other modern methods not shown separately but excludes lactational amenorrhea method (LAM). Total and public sector, private sector, and other source subtotals include sources not shown separately. 7.6 INFORMED CHOICE Informed choice is a key component of effective reproductive health programs. Family planning providers should inform all method users of the potential side effects and what they should do if they encounter any of the effects. Users should also be informed of the range of methods available. This information both assists the user in coping with side effects and decreases unnecessary discontinuation of temporary methods. Current users of modern methods were asked a series of questions in the TjDHS to assess if family planning providers are giving women the information they need to make an informed choice. Users were asked if the provider had informed them about (1) possible side effects or problems with the method, (2) what to do if they experienced side effects, and (3) other methods that could be used. The questions were directed to the user’s experience at the provider that they consulted at the beginning of the current segment of use. Table 7.6 presents information on these three aspects of informed choice obtained from current users who adopted their method within the five-year period prior to the survey. The majority of women adopting the contraceptive methods shown in the table were provided information essential to making an informed choice. Almost 80 percent of users were told about side effects or problems they might have using the method, 73 percent were advised what to do if they experienced side effects, and 70 percent were informed about other methods. The likelihood that a user received information to make an informed choice generally did not vary markedly by the method the user chose. Private sector providers (mainly pharmacies serving pill users) were somewhat less likely than public sector providers to discuss side effects or other problems of the method (72 percent versus 81 Family Planning • 85 percent) or to advise what to do if the user experienced side effects (67 percent versus 76 percent). On the other hand, private sector providers were more likely to provide information about other methods than public sector providers (78 percent versus 71 percent). Table 7.6 Informed choice Among current users of modern methods age 15-49 who started the current episode of use within the five years preceding the survey, the percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods they could use, by method and initial source, Tajikistan 2012 Method/source Among women who started current episode of modern contraceptive method within five years preceding the survey: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Pill 75.6 69.5 71.9 130 IUD 79.5 74.2 68.9 788 Injectables 73.8 70.6 76.9 111 Initial source of method1 Public Sector 81.3 75.6 71.4 963 Government hospital 78.6 71.3 63.2 70 Maternity home 82.6 77.6 76.9 252 Health center (urban/rural) 82.4 79.3 75.4 287 Health house (88.9) (82.8) (80.0) 45 Polyclinics 78.6 70.6 64.1 282 Private Sector 72.1 66.9 78.1 57 Pharmacy 71.0 68.3 77.2 55 Missing 8.6 8.6 8.6 33 Total 78.5 73.0 69.9 1,054 Note: Table includes users of female sterilization and implants not shown separately. Figures in parentheses based on 25-49 unweighted cases. Sources used by fewer than 25 unweighted cases are included in the total and in the public sector and private sector subtotals but not shown separately. 1 Source at start of current episode of use. 7.7 CONTRACEPTIVE DISCONTINUATION A key concern for reproductive health programs is the extent to which women discontinue use due to problems with their method, leaving many at risk of an unintended pregnancy. Data on discontinuation was obtained in the 2012 TjDHS by asking respondents for information on all episodes of use between January 2007 and the interview. For each episode of use that a respondent reported, information was obtained and recorded in the calendar included in the TjDHS questionnaire on the contraceptive method used, the date (month and year) the episode began, and, if applicable, the date when the episode ended and the reason for the discontinuation. Information from the calendar was used to calculate 12-month discontinuation rates presented in Table 7.7 by method and reason for discontinuation. The rates represent the proportion of users discontinuing a method within 12 months after the start of use. The rates refer only to episodes of contraceptive use that began during the period of time covered by the calendar, not all episodes that occurred during this period. For purposes of calculating the rates, the month of interview and the 2 months prior are ignored in order to avoid the bias that may be introduced by unrecognized pregnancies. The various reasons for discontinuation were treated as competing risks and, thus, the rates are additive across reasons for discontinuing. 86 • Family Planning Table 7.7 Twelve-month contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months, by reason for discontinuation and specific method, Tajikistan 2012 Method Method failure Desire to become pregnant Other fertility related reasons2 Side effects/ health concerns Wanted more effective method Other method related reasons3 Other reasons Any reason4 Switched to another method5 Number of episodes of use6 Pill 5.3 4.4 6.2 2.9 2.5 4.9 9.8 36.0 7.2 237 IUD 0.4 2.2 0.8 2.7 0.2 1.8 1.2 9.4 1.1 1,054 Injectables 0.0 1.5 9.7 13.0 2.9 10.7 3.3 41.2 8.7 190 Male condom 5.3 8.8 0.0 0.4 1.0 7.9 7.9 31.3 5.3 241 Withdrawal 6.1 2.6 2.6 0.0 4.8 0.4 14.3 30.8 8.6 168 All methods1 2.2 3.4 2.4 3.0 1.6 3.5 8.1 24.3 4.7 2,022 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months preceding the survey. 1 LAM, female sterilization, implants, rhythm (calendar), and other methods are included in the discontinuation rate for all methods, but are not listed separately. 2 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation. 3 Includes lack of access/too far, costs too much, and inconvenient to use. 4 Reasons for discontinuation are mutually exclusive and add to the total given in this column. 5 The episodes of use included in this column are a subset of the discontinued episodes included in the discontinuation rate. A woman is considered to have switched to another method if she used a different method in the month following discontinuation or if she gave "wanted a more effective method" as the reason for discontinuation and started another method within two months of discontinuation. 6 Number of episodes of use includes both episodes of use that were discontinued during the period of observation and episodes of use that were not discontinued during the period of observation. Table 7.7 shows that one in four contraceptive users who started using within a five-year period before the TjDHS discontinued use within 12 months of the time they began using a method. Women who adopted the IUD were least likely to discontinue use; 9 percent of IUD users stopped using within 12 months of adopting the method. Discontinuation rates were much higher for other methods; more than four in ten injectable users and more than three in ten users of the pill, the male condom, and withdrawal, stopped using within 12 months of starting use of the method. What happens after a user discontinues use of a method is important; a woman may simply stop all contraceptive use, leaving her potentially vulnerable to an unintended pregnancy, or she may switch to another method. Table 7.7 provides information on switching behavior during the five-year period before the TjDHS among users discontinuing use within 12 months of adopting their method. The episodes of discontinuation used in calculating the rate at which users switched to another method are a subset of all episodes of discontinuation. They include episodes in which a different method was used in the month following discontinuation and episodes in which the user “wanted a more effective method” and started another method within 2 months of discontinuing (i.e., there was only one month with no use following the discontinuation). If the woman restarted the same method after the one month of non-use, she was not considered in the switching rate. IUD users were least likely to switch to another method immediately after stopping use. The switching rate among IUD users was 1 percent. Comparing that rate to the overall IUD discontinuation rate of 9 percent shows that around one in nine users who discontinued the IUD adopted another method very shortly after they discontinued use of the IUD. Withdrawal users were most likely to switch to another method after they discontinued use; comparing the switching rate among withdrawal users (9 percent) to the overall discontinuation rate for the method (31 percent) shows that more than one in four users discontinuing withdrawal adopted another method shortly after they stopped use of withdrawal. Table 7.8 presents the distributions of all discontinued episodes of use in the five years preceding the survey by the reason for the discontinuation, according to the method used. Overall, the most frequent reason for discontinuation was the desire to become pregnant (25 percent). Unintended pregnancies due to method failure, i.e., the woman became pregnant while still using the method, were cited as the reason in 10 percent of discontinuations. An additional ten percent of discontinuations were due to changes in a woman’s situation that reduced the risk of pregnancy, including perceived difficulties in becoming pregnant/menopause, infrequent sex, and marital dissolution or separation. Dissatisfaction with the method Family Planning • 87 was a factor in more than one in four discontinuations, with women most frequently mentioning side effects or health concerns or the fact that the method was inconvenient to use. Table 7.8 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method, Tajikistan 2012 Reason Pill IUD Injectables Male condom Lactation amenorrhea Withdrawal All methods Became pregnant while using 15.4 4.3 2.8 14.0 5.6 28.7 9.7 Wanted to become pregnant 16.6 33.1 12.4 35.9 5.5 17.5 25.0 Husband disapproved 2.8 2.0 1.2 9.7 0.0 9.2 3.6 Wanted a more effective method 6.9 1.7 3.7 3.7 8.8 6.8 4.1 Side effects/health concerns 11.1 27.9 28.3 1.0 0.0 0.0 16.6 Lack of access/too far 2.8 0.2 0.0 3.6 0.0 0.0 1.0 Cost too much 1.6 0.0 2.7 2.4 0.0 0.0 0.8 Inconvenient to use 8.3 9.4 21.0 6.9 1.0 1.4 8.6 Difficult to get pregnant/menopausal 1.6 1.1 0.3 0.8 0.0 0.0 0.9 Infrequent sex/husband away 9.1 6.1 14.4 8.9 2.9 12.6 8.2 Marital dissolution/separation 0.0 0.4 0.0 0.9 0.0 0.0 0.3 Other 0.0 1.7 0.0 0.0 18.4 0.0 2.2 Missing 23.8 12.2 13.1 12.1 57.6 23.7 19.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 168 484 123 152 92 122 1,149 Note: All methods includes female sterilization, implants, rhythm (calendar), and other methods in addition to methods shown in table. LAM = Lactational amenorrhea method Looking at the reasons for discontinuing specific methods, IUD users most often stopped using because they were ready to have another child (33 percent) or because of side effects/health concerns (28 percent). Around one in two of all discontinuations of injectables was the result of side effects/health concerns (28 percent) or because the method was perceived as inconvenient to use (21 percent). Discontinuation due to method failure was most common among users of withdrawal (29 percent), the pill (15 percent), and the male condom (14 percent). 7.8 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for successful practice of coitus-associated methods such as withdrawal, condoms, and vaginal methods. Knowledge is particularly critical in the case of the rhythm method. In the TjDHS, respondents were asked two questions to ascertain their level of understanding of the ovulatory cycle. The first question determined if respondents had a general understanding that there are certain days during a woman’s menstrual cycle when she is more likely to become pregnant. Respondents who indicated that there were certain days a woman was more likely to become pregnant were then asked if that time was just before the woman’s period begins, during her period, right after her period has ended, or halfway between two periods. Figure 7.3 shows that Tajik women generally have a poor understanding of the ovulatory cycle. More than six in ten women either believe that there is no specific time during the menstrual cycle when a woman is more likely to become pregnant (22 percent) or they do not know when a woman is more at risk of becoming pregnant (39 percent). Only one in six women (16 percent) is aware that a woman is most at risk of pregnancy if she has intercourse halfway between two periods. 88 • Family Planning Figure 7.3 Perceived fertile period among all women age 15-49 Tajikistan DHS 2012 7.9 UNMET NEED FOR FAMILY PLANNING Women with an unmet need for family planning include fecund women who are not using contraception but who wish to postpone the next birth (spacing) or stop childbearing altogether (limiting). An estimate of the size and composition of the population of women who have an unmet need for family planning services is useful for planning purposes in reproductive health programs. The criteria used within the DHS program to identify women with unmet need for family planning has recently been revised (Bradley et al., 2012).1 The revised definition was employed for determining the women who have an unmet need for family planning in Table 7.9. Specifically, women are considered to have unmet need for spacing if they are: • At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years, or are unsure if or when they want to become pregnant. • Pregnant with a mistimed pregnancy. • Postpartum amenorrheic for up to two years following a mistimed birth and not using contraception. Women are considered to have unmet need for limiting if they are: • At risk of becoming pregnant, not using contraception, and want no (more) children. • Pregnant with an unwanted pregnancy. • Postpartum amenorrheic for up to two years following an unwanted birth and not using contraception. 1 Because of differences in the way in which unmet need is defined, the estimates of need presented in Table 7.9 are not comparable to the unmet results from the 2005 MICS survey. Just before menstrual period begins 1% During her menstrual period 1% Right after her menstrual period has ended 21% Halfway between two menstrual periods 16% No specific time 22% Don't know/missing 39% Family Planning • 89 Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Women using contraception are considered to have met need. Women using contraception who say they want no (more) children are considered to have met need for limiting, and women who are using contraception and say they want to delay having a child, or are unsure if or when they want a/another child, are considered to have met need for spacing. Finally, in Table 7.9, the total demand, percentage of demand satisfied, and percentage of demand satisfied by modern methods are defined as follows: • Total demand for family planning: the sum of unmet need (for spacing and limiting ) plus total contraceptive use • Percentage of demand satisfied: total contraceptive use divided by the sum of unmet need plus total contraceptive use • Percentage of demand satisfied by modern methods: use of modern contraceptive methods divided by the sum of unmet need plus total contraceptive use Table 7.9 shows that more than one in five currently married women are in need of family planning, 12 percent to delay a wanted birth and 11 percent because they want no more children. Total unmet need rises rapidly with age, peaking at 28 percent among women age 20-29. As expected, the level of unmet need for spacing is higher among younger women than older women. The level of unmet need for limiting peaks at 17 percent among women age 40-44 years. Total unmet need is slightly higher among rural than urban women (23 percent versus 21 percent), and it is highest in DRS (28 percent) and lowest in Sughd (20 percent). Women with a general basic education or less and women in the lowest wealth quintile have higher unmet need than other women. Table 7.9 also shows that the total demand for family planning among married women in Tajikistan is 51 percent. Fifty-five percent of that demand is satisfied, primarily through use of modern contraceptive methods. Demand for family planning is less than 50 percent among women age 15-24 and women age 45-49. The level of satisfied demand is markedly lower among women age 15-19 (16 percent) and 20-24 (26 percent) than among other women. 90 • Family Planning Table 7.9 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Tajikistan 2012 Background characteristic Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percent- age of demand satisfied2 Percent- age of demand satisfied by modern methods3 Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 12.8 0.0 12.8 2.4 0.0 2.4 15.2 0.0 15.2 15.6 12.0 266 20-24 25.5 2.7 28.2 8.1 1.8 9.9 33.6 4.5 38.2 26.1 25.0 1,320 25-29 18.2 10.1 28.3 14.3 12.3 26.6 32.5 22.3 54.9 48.4 45.2 1,332 30-34 10.6 15.5 26.0 15.3 25.5 40.9 25.9 41.0 66.9 61.1 55.9 1,014 35-39 4.1 16.0 20.1 8.2 38.3 46.5 12.3 54.3 66.6 69.8 65.8 923 40-44 1.1 17.1 18.1 4.0 33.7 37.8 5.1 50.8 55.9 67.6 62.0 879 45-49 0.2 12.1 12.3 1.0 18.4 19.4 1.2 30.5 31.7 61.2 53.8 770 Residence Urban 12.1 8.9 21.0 12.6 19.0 31.5 24.7 27.9 52.6 60.0 55.2 1,571 Rural 11.8 11.7 23.4 7.7 19.1 26.8 19.5 30.8 50.2 53.3 49.4 4,933 Region Dushanbe 14.6 9.7 24.3 15.1 16.6 31.7 29.7 26.3 56.1 56.6 51.3 559 GBAO 12.6 10.5 23.1 12.0 23.0 35.0 24.6 33.5 58.1 60.3 60.1 129 Sughd 10.5 9.5 20.0 11.1 24.2 35.3 21.6 33.7 55.3 63.8 55.5 2,022 DRS 15.8 11.8 27.6 7.7 14.6 22.3 23.5 26.4 49.9 44.7 44.0 1,546 Khatlon 9.6 12.2 21.8 5.9 17.9 23.8 15.5 30.0 45.6 52.1 50.2 2,249 Education None/primary 17.6 10.1 27.7 9.0 11.5 20.5 26.5 21.6 48.2 42.6 41.4 356 General basic 14.8 11.1 25.9 8.4 13.4 21.8 23.2 24.6 47.8 45.7 41.9 2,016 General secondary 9.4 11.4 20.9 8.2 21.8 30.0 17.7 33.2 50.9 59.0 55.1 3,260 Professional primary/ middle 9.6 12.4 22.0 8.9 25.2 34.1 18.5 37.6 56.1 60.8 53.9 475 Higher 14.0 6.4 20.4 16.6 24.2 40.7 30.6 30.6 61.1 66.6 61.2 397 Wealth quintile Lowest 10.2 16.6 26.8 5.2 19.8 24.9 15.4 36.3 51.7 48.2 45.1 1,210 Second 9.4 12.2 21.7 6.2 18.3 24.5 15.6 30.5 46.2 53.1 49.2 1,287 Middle 12.7 9.7 22.4 8.8 16.4 25.2 21.5 26.1 47.6 52.9 49.9 1,307 Fourth 14.9 9.3 24.2 9.8 18.9 28.8 24.8 28.2 52.9 54.3 48.8 1,379 Highest 11.6 7.9 19.5 14.1 21.8 35.9 25.6 29.8 55.4 64.8 60.2 1,320 Total 11.8 11.0 22.9 8.9 19.0 27.9 20.7 30.1 50.8 55.0 50.9 6,504 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, and lactational amenorrhea method (LAM). 7.10 FUTURE USE OF FAMILY PLANNING Intention to use contraception in the future provides a forecast of potential demand for services and acts as a convenient summary indicator of disposition toward contraception among current nonusers. To obtain information on the intent to use family planning in the future, TjDHS respondents who were not using contraception were asked if they thought they would use a method to delay or avoid pregnancy at any time in the future. It should be realized that respondents may or may not adhere to the intentions for future use they professed at the time of the interview. Table 7.10 presents information on plans to use family planning among currently married nonusers. Around one in four married women who are not using contraception now intends to use a family planning method in the future. An additional 29 percent are unsure if they will use family planning, and 42 percent say they do not think they will use at any time in the future. The percentage indicating that they plan to adopt contraception is highest among nonusers with two children; one-third of married nonusers in that group intend to use family planning. Family Planning • 91 Table 7.10 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Tajikistan 2012 Intention Number of living children1 Total 0 1 2 3 4+ Intends to use 12.4 29.0 33.8 29.6 19.6 25.7 Unsure 39.8 37.4 29.4 22.0 23.6 29.1 Does not intend to use 45.1 31.5 33.9 45.5 53.8 42.4 Missing 2.7 2.0 2.9 2.9 2.9 2.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 478 989 1,010 852 1,359 4,688 1 Includes current pregnancy. 7.11 EXPOSURE TO FAMILY PLANNING MESSAGES Data on the media through subgroups of the population that typically receive family planning messages is useful for assessing the coverage of current information, education, and communication efforts and for planning future media campaigns. To assess the extent to which women receive family planning information through mass media, TjDHS respondents were asked if they had heard about family planning on the radio, seen anything about family planning on television, or read about family planning in a newspaper or magazine in the last few months. Table 7.11 shows that televised messages about family planning reach the largest audience of women (45 percent). Around one in five women recently read about family planning in a newspaper or magazine, and 16 percent heard about family planning on the radio. Slightly more than half of women did not receive family planning information from any of the three sources in the last few months. Women in their teens, women from Dushanbe, women with no or only a primary education, and women in the lowest wealth quintile are most likely not to have been recently exposed to family planning messages through any of the media. Table 7.11 Exposure to family planning messages Percentage of women age 15-49 who heard or saw a family planning message on radio, on television, or in a newspaper or magazine in the past few months, according to background characteristics, Tajikistan 2012 Background characteristic Radio Television Newspaper/ magazine None of these three media sources Number of women Age 15-19 15.2 37.2 19.8 59.1 2,013 20-24 14.3 43.9 19.6 53.5 1,950 25-29 13.9 45.2 18.0 51.4 1,609 30-34 15.9 46.8 21.7 50.1 1,188 35-39 18.2 51.2 29.1 45.0 1,030 40-44 20.0 52.8 28.6 44.9 991 45-49 15.6 48.4 22.9 49.7 875 Residence Urban 17.2 45.1 27.0 51.0 2,413 Rural 15.2 45.2 20.2 52.0 7,243 Region Dushanbe 11.9 33.7 18.7 63.5 881 GBAO 7.2 56.1 46.7 41.1 220 Sughd 24.1 54.4 33.3 41.0 2,872 DRS 13.2 46.0 15.3 52.5 2,240 Khatlon 11.9 39.2 15.8 57.9 3,444 Education None/primary 7.5 33.5 4.9 64.1 567 General basic 11.5 39.6 14.5 57.1 3,349 General secondary 17.0 46.8 22.9 50.6 4,474 Professional primary/middle 24.3 61.1 44.9 33.7 645 Higher 27.7 57.2 45.4 38.3 620 Wealth quintile Lowest 9.8 38.5 12.3 59.0 1,878 Second 12.1 43.4 15.4 54.3 1,913 Middle 16.1 47.6 21.3 49.8 1,904 Fourth 20.8 50.8 29.1 45.8 1,971 Highest 19.4 45.2 30.5 50.2 1,989 Total 15.7 45.2 21.9 51.8 9,656 92 • Family Planning 7.12 FAMILY PLANNING DISCUSSION WITH HEALTH PROVIDERS Health providers are a very important source of family planning information for nonusers who may be in need of family planning. The 2012 TjDHS included several questions to determine if nonusers had any contacts with health providers in the year before the survey and, if they had had contact with a health provider, whether they had received any information about family planning from the provider. Table 7.12 shows that 18 percent of nonusers were visited in the home by a health worker who discussed family planning and that 18 percent had discussed family planning during a visit they had made to a health facility in the past 12 months. The results also show that some potential opportunities for discussing family planning with nonusers are missed; around one in four nonusers had visited a health facility in the past year without receiving any information on family planning. Overall, three in four nonusers had not discussed family planning with a fieldworker or at a health facility in the past year. This percentage was markedly lower in the GBAO region (49 percent) compared with other groups (66 percent or higher). Table 7.12 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the past 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who did not discuss family planning either with a fieldworker or at a health facility, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who were visited by fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who did not discuss family planning either with fieldworker or at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 8.9 5.7 15.6 88.9 2,007 20-24 21.9 22.7 27.1 70.1 1,818 25-29 24.8 25.1 29.1 66.2 1,255 30-34 21.8 23.1 28.8 69.0 770 35-39 22.4 22.1 26.6 71.2 598 40-44 18.5 15.4 28.9 76.5 658 45-49 16.3 15.7 27.0 76.2 722 Region Dushanbe 18.6 10.9 39.2 77.6 700 GBAO 46.6 32.8 21.3 48.9 174 Sughd 19.2 22.5 25.0 71.3 2,153 DRS 17.9 15.1 23.0 77.1 1,895 Khatlon 16.1 16.0 22.4 78.4 2,906 Education None/primary 17.9 15.3 25.3 76.0 494 General basic 17.4 16.0 24.3 76.8 2,906 General secondary 17.2 17.3 23.8 76.4 3,488 Professional primary/middle 24.6 25.6 29.1 65.5 484 Higher 25.4 22.1 30.0 67.8 456 Wealth quintile Lowest 17.7 16.5 17.6 77.3 1,577 Second 16.6 15.7 20.8 78.2 1,598 Middle 17.8 17.7 26.4 75.0 1,573 Fourth 20.5 20.4 27.8 72.3 1,572 Highest 18.7 17.0 31.5 74.0 1,509 Total 18.3 17.5 24.7 75.4 7,828 Abortion • 93 ABORTION 8 bortion is legally available as a means of fertility regulation in Tajikistan. In addition to providing information on live births, the pregnancy history in the 2012 TjDHS obtained information on any other pregnancies respondents may have had that ended in a miscarriage, induced abortion, or still birth. The information on induced abortion collected in the pregnancy histories is employed in this chapter to look at women’s lifetime experience with abortion and to investigate the current levels and trends in abortion in Tajikistan. In addition, the chapter explores the relationship between contraceptive use and abortion. 8.1 COLLECTION OF ABORTION DATA The TjDHS pregnancy history was structured to ensure complete reporting of all reproductive events including abortion. To obtain the pregnancy history data, each respondent was first asked questions to determine the total numbers of live births, abortions, miscarriages, and still births she had had during her life. Then she was asked to list in order all the pregnancies she had had, beginning with her first pregnancy, and to provide information on the outcome of each pregnancy. For all pregnancies that did not result in a live birth, information was collected on the month and year the pregnancy ended. At the end of the pregnancy history, the aggregate data collected at the outset of the reproductive event section was compared with the number of various events recorded in the pregnancy history and any discrepancies were reconciled. The 2012 TjDHS also included a calendar in which information was recorded on the duration and outcome of all pregnancies and periods of contraceptive use that occurred between January 2007 and the interview. The calendar data can be used to explore the role contraceptive method failure plays in abortion. 8.2 PREGNANCIES ENDING IN INDUCED ABORTION Table 8.1 shows the percent distribution of the pregnancies occurring during the three-year period prior to the TjDHS (approximately August 2009 to August 2012) by outcome according to background characteristics. More than eight in ten pregnancies occurring during the period resulted in a live birth, and 9 percent ended in an abortion, 8 percent in a miscarriage, and less than 1 percent in a stillbirth. The proportion of pregnancies ending in an induced abortion rises sharply with woman’s age at the time of the abortion. Less than 1 percent of teenage pregnancies ended in induced abortion compared with 26 percent of pregnancies among women age 35-44. The proportion of pregnancies ending in induced abortion also rises steadily with the pregnancy order, from 1 percent of first-order pregnancies to 25 percent of fifth- or higher-order pregnancies. A Key Findings • The total abortion rate is 0.5 abortions per woman. • Abortion rates vary minimally by residence, region, education, and wealth, with Dushanbe having the highest rate (0.7). • Abortion levels appear to have been stable over the past several decades. • The vast majority of induced abortions occur among women who are not using contraception at the time of conception; 17 percent of induced abortions appear to result from contraceptive failure. 94 • Abortion Table 8.1 Pregnancy outcome by background characteristics Percent distribution of pregnancies ending in the three years preceding the survey by type of outcome, according to background characteristics, Tajikistan 2012 Background characteristic Pregnancy outcome Total Number Live birth Induced abortion Miscarriage Stillbirth Age at pregnancy outcome <20 85.8 1.1 13.0 0.1 100.0 385 20-24 89.2 3.9 6.5 0.4 100.0 1,549 25-34 81.9 10.2 7.2 0.6 100.0 1,689 35-44 64.1 26.2 8.0 1.6 100.0 404 45-49 * * * * 100.0 12 Pregnancy order First 91.0 1.1 7.5 0.4 100.0 1,116 Second 90.0 2.7 6.7 0.6 100.0 980 Third 85.6 6.6 7.1 0.7 100.0 690 Fourth 77.5 14.4 7.2 1.0 100.0 460 Fifth or higher 64.8 25.0 9.5 0.7 100.0 792 Residence Urban 77.6 12.3 9.3 0.8 100.0 912 Rural 84.8 7.6 7.1 0.5 100.0 3,127 Region Dushanbe 77.0 13.9 8.5 0.6 100.0 336 GBAO 80.5 10.3 8.0 1.2 100.0 74 Sughd 82.8 9.4 7.4 0.3 100.0 1,071 DRS 84.8 7.3 7.6 0.3 100.0 987 Khatlon 83.8 7.7 7.5 1.0 100.0 1,570 Education None/primary 89.0 2.7 7.9 0.4 100.0 329 General basic 84.3 7.9 7.2 0.6 100.0 1,627 General secondary 82.0 9.5 7.9 0.6 100.0 1,652 Professional primary/middle 77.8 11.1 10.2 1.0 100.0 229 Higher 79.7 14.3 5.2 0.8 100.0 201 Wealth quintile Lowest 83.4 6.8 8.8 0.9 100.0 812 Second 87.8 6.2 5.2 0.8 100.0 843 Middle 84.6 7.1 7.6 0.7 100.0 849 Fourth 80.9 11.1 8.0 0.0 100.0 814 Highest 78.3 12.6 8.5 0.6 100.0 720 Total 83.2 8.6 7.6 0.6 100.0 4,038 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Pregnancies among urban women were somewhat more likely to have ended in an induced abortion than pregnancies among rural women (12 percent versus 8 percent). Among the regions, Dushanbe had the highest proportion of pregnancies ending in induced abortion (14 percent), and DRS and Khatlon had the lowest proportions (7 percent and 8 percent, respectively). The likelihood that a pregnancy ended in an induced abortion increased directly with education, from 3 percent of pregnancies among women who never attended school or had only a primary education to 14 percent of pregnancies among women with higher education. Considering wealth status, the percentage of pregnancies ending in induced abortion was highest among women in the fourth and fifth quintiles (11 percent and 13 percent, respectively). 8.3 LIFETIME EXPERIENCE WITH INDUCED ABORTION Table 8.2 presents several indicators from the perspective of women’s lifetime experience with abortion, including the percentage of all women reporting they ever had an induced abortion, the percent distribution of women who ever had an abortion by the number of abortions, and the mean number of abortions among women who had an abortion. Abortion • 95 Table 8.2 Lifetime experience with induced abortion Percentage of women age 15-49 who have had at least one induced abortion, and among these women, percent distribution by number of abortions, and the mean number of abortions, according to background characteristics, Tajikistan 2012 Background characteristic Percentage of women with an induced abortion Number of women Among women who had an abortion, percent distribution by number of abortions Total Mean number of abortions Number of women with abortions 1 2-3 4-5 6+ Age <20 0.2 2,013 * * * * 100.0 * 3 20-24 2.1 1,950 (84.2) (15.8) (0.0) (0.0) 100.0 (1.2) 42 25-34 9.6 2,797 71.1 27.7 1.1 0.1 100.0 1.4 269 35+ 21.0 2,896 58.4 36.4 4.4 0.9 100.0 1.6 608 Number of living children 0 0.3 3,483 * * * * 100.0 * 10 1 3.8 1,142 (78.5) (20.8) (0.7) (0.0) 100.0 (1.3) 44 2 14.7 2,820 66.0 31.8 1.9 0.3 100.0 1.5 413 3 20.6 2,211 59.6 34.7 4.7 0.9 100.0 1.6 455 Marital status Currently married 13.5 6,504 62.9 33.3 3.2 0.6 100.0 1.5 878 Formerly married 8.8 504 74.0 23.2 2.8 0.0 100.0 1.3 45 Residence Urban 12.6 2,413 59.8 34.8 4.4 1.0 100.0 1.6 305 Rural 8.5 7,243 65.2 31.8 2.6 0.4 100.0 1.5 618 Region Dushanbe 11.6 881 56.1 38.6 4.5 0.8 100.0 1.6 102 GBAO 9.5 220 70.2 24.5 5.3 0.0 100.0 1.5 21 Sughd 11.9 2,872 65.2 30.6 3.7 0.4 100.0 1.5 341 DRS 7.5 2,240 62.2 34.7 2.6 0.6 100.0 1.5 168 Khatlon 8.5 3,444 64.1 32.8 2.4 0.8 100.0 1.5 291 Education None/primary 3.5 567 100.0 * 20 General basic 6.2 3,349 72.5 24.0 3.3 0.2 100.0 1.4 209 General secondary 11.5 4,474 61.8 34.7 2.6 1.0 100.0 1.6 512 Professional primary/ middle 15.6 645 52.7 40.2 7.1 0.0 100.0 1.7 100 Higher 13.1 620 59.5 37.5 3.1 0.0 100.0 1.5 81 Wealth quintile Lowest 7.3 1,878 69.8 28.1 0.9 1.1 100.0 1.4 137 Second 7.3 1,913 58.5 38.7 2.8 0.0 100.0 1.6 139 Middle 8.1 1,904 63.9 33.8 2.3 0.0 100.0 1.5 154 Fourth 11.8 1,971 64.7 30.1 5.2 0.0 100.0 1.5 232 Highest 13.1 1,989 61.2 33.8 3.4 1.5 100.0 1.6 260 Total 9.6 9,656 63.4 32.8 3.2 0.6 100.0 1.5 923 Note: Currently married includes respondents in consensual union (living together). Formerly married includes divorced, separated, and widowed respondents. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Overall, one in ten Tajik women age 15-49 has ever had an induced abortion. The majority of these women (63 percent) have had only one induced abortion. Around one-third of the women have had two to three abortions, 3 percent have had 4 to 5 abortions, and less than 1 percent has had 6 or more abortions. Among women who have had an abortion, the mean number of abortions per woman is 1.5. Lifetime experience with abortion increases with the woman’s age and number of living children. For example, women age 35 and older are more than twice as likely to have ever had an induced abortion as women age 25-34 (21 percent versus 10 percent). Not surprisingly, marital disruptions are associated with a slightly lower level of induced abortion; 14 percent of currently married women have ever had an abortion compared with 9 percent of women who were divorced, separated, or widowed. Urban women are more likely to have ever had an induced abortion than rural women, and Sughd and Dushanbe have slightly higher percentages of women ever having had an abortion compared with other regions. Generally, the better educated or better off financially that a woman is, the more likely she is to have had an induced abortion. For example, the percentage ever having had an abortion rises from 4 96 • Abortion percent among women with no or only primary education to a peak of 16 percent among women with professional education before declining to 13 percent among women with higher education. In general, the number of abortions reported among women ever having had an abortion does not vary markedly with the background characteristics shown in Table 8.2. The largest differences are observed by the woman’s age and number of living children. 8.4 RATES OF INDUCED ABORTION 8.4.1 Abortion Level Table 8.3 shows the rates of induced abortion for the three-year period prior to the 2012 TjDHS (approximately August 2009 to August 2012). Three types of rates are presented: age-specific abortion rates (ASARs), the total abortion rates (TARs), and the general abortion rate (GAR). These rates are calculated in a manner analogous to the calculation of age-specific fertility rates, total fertility rates, and general fertility rates. Age-specific abortion rates, shown per 1,000 women, express the number of abortions among women of a given age, divided by the total number of women in the age group. The TAR, expressed per woman, is a summary measure across all age groups. The TAR is interpreted as the number of induced abortions a woman would have in her lifetime if she experienced the currently observed age-specific induced abortion rates during her childbearing years. The general abortion rate is the number of abortions divided by the number of women age 15-44 and is expressed per 1,000 women. The TAR (15-49) for all of Tajikistan is 0.5 induced abortions per woman. The urban TAR is 0.6 abortions per woman, slightly higher than the rural TAR (0.4 abortions per woman). Age-specific abortion rates are low among women in age groups 15-19 and 20-24, rise to a broad peak among women in age groups 25-29, 30-34, and 35-39 (21, 23, and 26 per 1,000, respectively), and decline in the older age groups. A comparison of the ASARs with the age-specific fertility rates shows that abortion rates are much lower than fertility rates except among women age 40-49 (Figure 8.1). Among women age 45-49, the ASAR (3 per 1,000) is slightly higher than the fertility rate (2 per 1,000). The urban ASARs are higher than rural rates among women under age 40; among older women, although the differences are very small, the rural rates exceed the urban rates. Table 8.3 Induced abortion rates Age-specific induced abortion rates (ASARs) (per 1,000 women), total abortion rates (TARs), and general abortion rates (GARs), for the three-year period preceding the survey, by residence, Tajikistan 2012 Age group Residence Total Urban Rural 15-19 1 1 1 20-24 17 9 11 25-29 28 20 21 30-34 30 20 23 35-39 30 25 26 40-44 8 9 9 45-49 2 4 3 TAR(15-49)1 0.6 0.4 0.5 TAR(15-44) 0.6 0.4 0.5 GAR2 18.0 12.0 14.0 1Total abortion rate (TAR) expressed per woman. 2 General abortion rate (GAR) = number of abortions divided by number of women (15-44), expressed per 1,000 women. Abortion • 97 Figure 8.1 Age-specific fertility rates and induced abortion rates Rate per 1,000 women Tajikistan DHS 2012 The TAR for induced abortions in Tajikistan is lower than estimates reported in recent DHS surveys in other parts of the former Soviet Union, including Armenia (0.8) in 2010, Azerbaijan (2.3) in 2006, Moldova (1.1) in 2005, and Uzbekistan (0.95) in 2002, but is similar to the TAR for Ukraine (0.4) in 2007) (NSS [Armenia] et al., 2012; SSC [Azerbaijan] and Macro International Inc., 2008; (NCPM) [Moldova] and ORC Macro. 2006; Analytical and Information Centre [Uzbekistan] et al., 2004; UCSR [Ukraine] et al., 2008 ). 8.4.2 Abortion Differentials Table 8.4 presents differentials in the total induced abortion rate for the three-year period prior to the survey and in the mean number of abortions ever performed among women age 40-49. The latter is an indicator of cumulative terminations over the lifetime of women who are nearing the end of their reproductive period. When compared to the TAR, it allows for an assessment of the trend in abortion levels over the past 30 years. In general, differences in the TARs in Table 8.4 are minor. Dushanbe has the highest TAR (0.7 abortions per woman) and GBAO and Sughd the lowest rates (0.4 abortions per woman each). The TAR does not vary in a consistent fashion with education. It generally increases with the wealth quintile, from 0.4 abortions per woman in the two lowest quintiles to 0.6 abortions per woman in the two highest quintiles. 0 50 100 150 200 250 300 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group Abortion rates Fertility rates Table 8.4 Induced abortion rates by background characteristics Total induced abortion rates for the three years preceding the survey and mean number of abortions among women age 40-49, by background characteristics, Tajikistan 2012 Background characteristic Total abortion rate 15-49 Mean number of abortions among women age 40-49 Residence Urban 0.6 0.4 Rural 0.4 0.3 Region Dushanbe 0.7 0.3 GBAO 0.4 0.4 Sughd 0.4 0.4 DRS 0.5 0.2 Khatlon 0.5 0.3 Education None/primary 0.4 0.3 General basic 0.5 0.2 General secondary 0.5 0.3 Professional primary/middle 0.4 0.5 Higher 0.5 0.4 Wealth quintile Lowest 0.4 0.2 Second 0.4 0.3 Middle 0.5 0.3 Fourth 0.6 0.4 Highest 0.6 0.4 Total 0.5 0.3 98 • Abortion The TAR for the three years preceding the survey (0.5 abortions per woman) is only slightly higher than the mean number of abortions ever performed among women age 40-49 (0.3 abortions per woman), suggesting that abortion levels over the past 30 years in Tajikistan have remained relatively stable. The pattern is found in most subgroups, with the greatest difference observed in Dushanbe. 8.4.3 Abortion Trends Using the TjDHS pregnancy history data, trends in abortion rates can be explored by examining changes in age-specific abortion rates over time. Table 8.5 shows the age-specific abortion rates for four five-year periods prior to the TjDHS. Because women age 50 and older were not interviewed in the survey, the rates are successively more truncated across the periods shown in the table. In general, the changes in the age-specific rates across the time periods shown in Table 8.5 are minor and do not exhibit a consistent trend. This is further evidence that abortion levels in Tajikistan have remained relatively stable over an extended. 8.5 USE OF CONTRACEPTION BEFORE ABORTION Table 8.6 uses information from the reproductive event calendar in the TjDHS to look at the use of contraception at the time of conception for all pregnancies in the three-year period prior to the survey. The information contributes to an understanding of the extent to which contraceptive method failures are contributing to abortions and of the role that efforts to increase use of contraception might play in reducing abortions. Table 8.6 shows that women were using contraception at the time of conception in the case of 17 percent of all pregnancies ending in induced abortion during the three-year period prior to the survey. This implies that around one in six induced abortions resulted from contraceptive failures. Looking at specific methods, women were using the pill at the time of conception in the case of 5 percent of the pregnancies ending in induced abortions, while the IUD, male condom, and withdrawal each were used prior to 4 percent of pregnancies ending in induced abortions. These results suggest that improvement in the counseling provided to contraceptive users is an important avenue in efforts to reduce the incidence of abortion. Although contraceptive failures contribute to abortion, the TjDHS results clearly show the vast majority (83 percent) of induced abortions in the three-year period prior to the survey occurred among women who were not using contraception. Improving access to contraception for women who want to delay or limit childbearing is, thus, a very important step in efforts to reduce the number of abortions. Table 8.5 Trends in age-specific abortion rates Age-specific abortion rates for five-year periods preceding the survey, by women's age at the time of the abortion, Tajikistan 2012 Woman's age at the time of the abortion Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 1 0 1 2 20-24 11 7 6 7 25-29 20 19 20 14 30-34 22 25 21 [18] 35-39 23 20 [24] 40-44 7 [9] 45-49 [4] Note: Age-specific induced abortion rates are per 1,000 women. Estimates in brackets are truncated. Abortion • 99 Table 8.6 Use of contraception before pregnancy Percent distribution of pregnancy outcomes in the three years preceding the survey by contraceptive method used at the time of conception, Tajikistan 2012 Result of the pregnancy All pregnancies Live birth Induced abortion Miscarriage No method used 96.9 82.7 95.5 95.6 Any method 3.1 17.3 4.5 4.4 Any modern method 2.3 13.1 4.0 3.4 Pill 0.3 5.4 0.4 0.8 IUD 1.2 3.5 0.8 1.4 Injectables 0.4 0.5 0.0 0.3 Male condom 0.3 3.6 2.4 0.7 Lactational amenorrhea (LAM) 0.1 0.0 0.4 0.1 Other 0.0 0.0 0.0 0.0 Any traditional method 0.8 4.2 0.5 1.1 Rhythm 0.0 0.4 0.0 0.1 Withdrawal 0.8 3.9 0.5 1.0 Total 100.0 100.0 100.0 100.0 All pregnancies 3,359 349 306 4,038 Note: Total includes pregnancies ending in still births. Infant and Child Mortality • 101 INFANT AND CHILD MORTALITY 9 ne important objective of the 2012 TjDHS was to measure the level of and trends in mortality among children under age 5. Information on levels and trends in mortality in this age group is central to an assessment of the demographic situation in Tajikistan. The TjDHS mortality data also are useful in identifying subgroups of children at increased risk of dying who should be targeted in programs designed to improve child survival in Tajikistan. In addition to infant and child mortality rates, the chapter presents the distribution of children according to fertility behavior that place children at an elevated risk of mortality. The chapter also considers information obtained in the TjDHS on the registration of child deaths. 9.1 SOURCE AND ASSESSMENT OF MORTALITY DATA 9.1.1 Source of the Data As described in Chapter 5, the 2012 TjDHS questionnaire included a reproductive history in which respondents were asked to report the outcome of each pregnancy, i.e., to report if the pregnancy ended in a live birth, stillbirth, miscarriage, or abortion. A live birth was defined for respondents as any birth that cried or showed any sign of life. For each live birth reported in the pregnancy history, information was collected on the date of birth (month and year), sex, survivorship, and current age (for surviving children) or age at death (for deceased children). In this chapter, TjDHS birth history data are used to produce the following five direct measures of mortality: Neonatal mortality (NN): probability of dying within the first month of life Postneonatal mortality (PNN): difference between infant and neonatal mortality Infant mortality (1q0): probability of dying between birth and exact age 1 Child mortality (4q1): probability of dying between exact ages 1 and 5 Under-5 mortality (5q0): probability of dying between birth and exact age 5 O Key Findings • The under-5 mortality rate is 43 deaths per 1,000 births. At this rate, one in every 23 children born in Tajikistan dies before reaching their fifth birthday. • The infant mortality rate is 34 deaths per 1,000 births, and the neonatal mortality rate is 19 deaths per 1,000 births. Thus, almost 80 percent of the deaths of young children take place before the child’s first birthday, with more than half occurring during the first month of life. • The Khatlon region has the highest under-5 mortality level; it is followed by the DRS region, and Dushanbe has the lowest level. • Infant and under-5 mortality rates decline with the birth interval. For example, under-5 mortality among children born less than two years after a previous birth is more than twice the level among children born four or more years after a previous birth (71 versus 30 per 1,000). 102 • Infant and Child Mortality All rates are expressed as deaths per 1,000 live births, except for child mortality, which is expressed as deaths per 1,000 children surviving to age 1. 9.1.2 Data Quality As with all the indicators in the TjDHS, the accuracy of the early childhood mortality estimates is influenced by two factors: sampling error and nonsampling error. Sampling error is inherent in the fact that the sample for the TjDHS was only one of a number of samples that could have been selected for the survey. As described further in Appendix B, the sampling error associated with the TjDHS mortality data can be evaluated statistically in order to provide an estimate of the range within which the actual mortality rates in Tajikistan lie. Nonsampling error arises from problems occurring during the collection or processing of mortality data. Specifically, the reliability of the mortality estimates depends upon full reporting of children who die, the absence of differential displacement of birth dates of surviving and dead children, and accurate information on ages at death. Although the nonsampling error associated with the TjDHS mortality data cannot be evaluated statistically, Appendix C includes several tables that can be used to assess the extent to which the TjDHS mortality data may be subject to common reporting errors. Omission, or the failure to report births that did not survive, can lead to a serious underestimation of mortality levels, if severe. Omission, which can be difficult to detect, is assumed to occur more often for deaths in early infancy and to increase for time periods more remote from the survey. One approach in looking for evidence of omission is to compare the ratio of neonatal deaths to all infant deaths before the survey and the ratio of early neonatal deaths (deaths in the first week of life) to all neonatal deaths to see if these measures fall within expected ranges. The proportion of neonatal to infant deaths ranges from 58 percent in the period 0 to 4 years prior to the survey to 33 percent during the period 15 to19 years before the survey (Table C.6). This pattern conforms to the expectation that, as mortality levels decline, a larger proportion of infant deaths takes place during the early neonatal period. Early neonatal deaths also do not appear to be severely underreported; the ratio of early neonatal deaths to all neonatal deaths exceeds 70 percent in the period 0 to 14 years prior to the survey (Table C.5). Another potential data quality problem is heaping of the age of death. Errors in the reporting of the age at death may result in the transference of deaths from one age bracket for which mortality rates are being calculated to another; for example, heaping on age 1 year or 12 months can result in an underestimate of the infant mortality rate and an overestimate of the child mortality level. Several steps were taken in the training of the TjDHS interviewers and in the structure of the TjDHS birth history to reduce errors in the reporting of the age at death. Interviewers were instructed to record information on the age at death in days if the child died during the first month of life and in months if the child died in the first two years of life. Because heaping on “1 year” or “12 months” is very common, interviewers were asked specifically to probe when the mothers gave these responses. Despite these measures, there is evidence of some heaping of deaths on age 12 months, with the heaping most noticeable for the periods 5 to 9 and 10 to 14 years before the survey; however, the effect on the infant mortality rate is quite small, about 3 percent in the periods 5 to 9 years and 10 to 14 years before the survey (Table C.6). A third data quality problem may arise from errors in the reporting of birth dates. Displacement of births can affect the accuracy of mortality trends if they result in deaths being transferred from one time period to another, e.g., from the period 0 to 4 years to the period 5 to 9 years before the survey. Displacement may be a result of problems with the mothers’ recall. However, it also may reflect deliberate transference of births from one period to another by interviewers interested in reducing their workload by avoiding the detailed set of maternal and child health questions included in DHS surveys for births occurring in 2007 or later. An examination of the distribution of TjDHS birth history data by calendar year shows some evidence of transference of births from 2007 to 2006, with the transference more evident for living children (Table C.4). While the transference has implications for recent mortality trends, it is not Infant and Child Mortality • 103 overly severe. Moreover, the effects are mitigated by the fact that the TjDHS data are calculated for five- year periods before the survey and not for specific calendar year periods. Because the TjDHS fieldwork started in July 2012, only part of the transference of births from calendar year 2007 to 2006 influenced the mortality estimates for the periods 0 to 4 years and 5 to 9 years before the survey. Births of dead children, however, appear to have been shifted from 2007 and 2006 to 2005, perhaps because of emphasis during training on the tendency of interviewers to transfer dead children, thus causing interviewers to attempt to avoid this error. The sex ratio also may indicate a greater tendency to transfer deaths of boys than girls. However, there are very few deaths for each sex, so the sex ratios can fluctuate greatly. 9.2 LEVELS AND TRENDS IN CHILDHOOD MORTALITY Table 9.1 shows childhood mortality estimates based on data from the 2012 TjDHS. For the five years preceding the survey (approximate calendar years 2008-2012), the under-5 mortality rate was 43 per 1,000. At this rate, one in every 23 children born in Tajikistan will die before reaching their fifth birthday. The infant mortality rate was 34 per 1,000 live births, and the child mortality (age 1 to age 4) is 9 per 1,000; thus, almost 80 percent of deaths among children under age 5 during the period occurred during the first year of life. The estimates of neonatal and postneonatal mortality were 19 and 15 per 1,000, respectively, indicating that more than half of infant deaths took place in the first month of life. Table 9.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Tajikistan 2012 Years preceding the survey Approximate calendar period Neonatal mortality (NN) Postneonatal mortality (PNN) 1 Infant mortality (1q0) Child Mortality (4q1) Under-5 mortality (5q0) 0-4 2008-2012 19 15 34 9 43 5-9 2003-2007 20 23 43 12 54 10-14 1998-2002 25 31 56 21 76 1 Computed as the difference between the infant and neonatal mortality rates. Trends in mortality over the 15-year period prior to the survey are also presented in Table 9.1. The data suggest that mortality has substantially decreased over the last 15 years. For example, the infant mortality rate was 56 per 1,000 during the period 10 to 14 years before the survey and 43 per 1,000 during the period 5 to 9 years before the survey compared with the estimate for the five years before the survey of 34 per 1,000 (Figure 9.1). Because of differences in methodology, it is difficult to directly compare the TjDHS with results from the 2000 and 2005 MICS surveys1 or the 2010 Tajikistan Infant, Child, and Maternal Mortality Surveys.2 However, these surveys, like the 2012 TjDHS, provide evidence of a continuous decline in mortality over the past several decades in Tajikistan.3 1 The techniques used to derive the mortality estimates differ between the MICS and the TjDHS surveys. The mortality rates from the MICS surveys are derived from the responses to the questions on the number of children ever born and surviving using indirect estimation techniques (UNICEF, 2000; SCS, 2007). The TjDHS rates are direct estimates using birth history data. 2 The mortality rates from the 2010 Infant, Child and Maternal Mortality Survey are direct estimates based on birth history data (SA, 2010). However, differences in the calculation approach, including the fact that the published estimates from the 2010 survey are annual rather than period rates, as well as the comparatively low response rate (71 percent) make comparisons with the 2012 TjDHS results difficult. 3 The 2000 MICS survey found that under-5 mortality was 126 per 1,000 and infant mortality was 89 per 1,000 in 1993, while the 2005 MICS survey estimated under-5 mortality at 79 per 1,000 and infant mortality at 65 per 1,000 ten years later in 2003 (UNICEF, 2008). The 2010 Tajikistan Infant, Child and Maternal Mortality Survey (SA, 2010) also reported a decline in mortality over the past two decades, with under-5 mortality dropping from 77 deaths per 1,000 in 1989 to 34 per 1,000 in 2009. 104 • Infant and Child Mortality Figure 9.1 Trends in Infant and Child Mortality, Tajikistan 1998-2012 Tajikistan DHS 2012 Childhood mortality rates in Tajikistan are relatively high when compared with the levels reported in recent DHS surveys in several neighboring countries; for example, infant mortality for the five-year period prior to the survey was 13 and 14 per 1,000 live births in the 2010 Armenia DHS and 2007 Ukraine DHS, respectively, considerably lower than the rate reported in the TjDHS (NSS [Armenia] et al., 2012; UCSR [Ukraine] et al., 2008). On the other hand, survival probabilities for children under age one in Tajikistan are better than those reported in the 2010 Afghanistan Maternal Mortality Survey (55 per 1,000 births), the 2006 Azerbaijan DHS (43 per 1,000 births), and the 2006-07 Pakistan DHS (78 per 1,000 live births) (SSC [Azerbaijan] and Macro International Inc., 2008; APHI/MoPH [Afghanistan] et al., 2011; NIPS [Pakistan] and Macro International Inc., 2008). 9.3 SOCIOECONOMIC DIFFERENTIALS IN CHILDHOOD MORTALITY Table 9.2 presents infant and child mortality estimates for the 10-year period prior to the survey (approximate calendar years of 2003 through 2012) by socioeconomic characteristics. The rates were calculated for a period of ten rather than five years as was used in Table 9.1 to reduce sampling variability. Despite the longer period, the number of deaths in some categories is still small and, thus, minor differences in mortality between subgroups of the population should be interpreted cautiously. Rural mortality rates are higher than urban rates although the differences are not large. For example, infant mortality is 39 per 1,000 in rural areas compared with 35 per 1,000 in urban areas. The Khatlon region has the highest childhood mortality levels and Dushanbe has the lowest. The infant and under-5 mortality rates in Khatlon are double the level in Dushanbe. Infant mortality in the DRS region is more than 70 percent higher than in Dushanbe, and under-5 mortality is nearly 60 percent higher. Mortality levels among children in the lowest three wealth quintiles are generally higher than the levels among children in the fourth and highest quintile. 56 43 34 76 54 43 1998-2002 2003-2007 2008-2012 Infant mortality Under-5 mortality Infant and Child Mortality • 105 Table 9.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 18 17 35 8 42 Rural 20 19 39 11 50 Region Dushanbe 11 11 22 7 29 GBAO 13 16 29 8 36 Sughd 18 13 31 9 40 DRS 20 18 38 8 46 Khatlon 23 25 48 13 61 Mother's education None/primary 17 (19) (36) (20) (55) General basic 22 18 40 11 50 General secondary 19 20 39 9 47 Higher/professional primary/middle 18 18 34 10 44 Wealth quintile Lowest 18 27 45 13 58 Second 25 19 43 13 56 Middle 22 18 40 11 50 Fourth 18 12 30 6 36 Highest 15 16 30 8 38 Note: Rates in parentheses are based on 250-499 unweighted person-years of exposure. 1 Computed as the difference between the infant and neonatal mortality rates. 9.4 DEMOGRAPHIC DIFFERENTIALS IN CHILDHOOD MORTALITY Table 9.3 presents differentials in childhood mortality by several demographic variables known to be associated with a child’s probability of dying, including the child’s sex, the mother’s age at the birth, the birth order, the child’s size at birth, and, for second and higher order births, the interval between the birth of the previous child and the child who died. As was the case with the socioeconomic differentials, mortality rates in Table 9.3 are shown for the ten-year period prior to the survey to reduce sampling variability except in the case of birth size where information is available to calculate rates only for the five- year period before the survey. Under-5 mortality is slightly higher for males than females, with the difference largely due to the expected higher mortality experienced among males in early infancy compared with females (Naeye, et al., 1971). Mortality levels exhibit the expected relationship with the mother’s age at the time of the birth, with mortality levels highest for births to mothers under age 20 and rising with age among older mothers. First-order births have a somewhat higher risk of dying than second-order births. Otherwise, mortality levels generally rise with birth order. Infant and under-5 mortality levels decline as the birth interval increases. For example, the under- 5 mortality rate among children born less than two years after a previous birth is 71 per 1,000, more than twice the level among children born four or more years after a previous birth (30 per 1,000). Research has shown that small size at birth is related to an elevated risk of dying in infancy. To obtain information on birth size for births during the five-year period before the TjDHS interview, mothers were asked if at the time of the birth the baby was very large, larger than average, average, smaller than average, or very small.4 Mortality during the neonatal period conformed to the expected pattern, with the rate more than three times higher for babies whom the mother considered to be very small or small 4 For additional details on the birth size measure, see Chapter 11 in this report. 106 • Infant and Child Mortality compared with average or larger babies. However, the pattern is reversed in the postneonatal period, where mortality for very small or small babies is lower than among average or larger babies. Table 9.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by demographic characteristics, Tajikistan 2012 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child's sex Male 21 19 41 10 51 Female 18 18 36 10 46 Mother's age at birth <20 38 27 65 13 77 20-29 17 15 32 9 40 30-39 19 24 43 11 53 40-49 * * * * * Birth order 1 25 15 39 8 47 2-3 16 15 31 9 40 4-6 20 24 44 10 54 7+ (20) (46) (66) (35) (99) Previous birth interval2 <2 years 28 32 59 12 71 2 years 11 19 30 15 45 3 years 19 9 28 10 38 4+ years 11 14 24 6 30 Birth size3 Small/very small 39 6 45 na na Average or larger 12 13 25 na na Note: Rates in parentheses are based on 250-499 unweighted person-years of exposure. An asterisk indicates that a rate is based on fewer than 250 uweighted person-years of exposure and has been suppressed. na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rate. 2 Excludes first-order births. 3 Rates for the five-year period before the survey. 9.5 PERINATAL MORTALITY Perinatal mortality takes into account fetal deaths occurring late in pregnancy in addition to early neonatal deaths. Examining the perinatal mortality level is important because it is recognized that the distinction between a stillbirth and an early neonatal death is often a fine one, depending on the mother’s observing and recalling sometimes-faint signs of life following delivery. The causes of stillbirths and early neonatal deaths are also closely linked, and just examining one or the other can understate the true level of mortality around delivery. In the TjDHS survey, as in other DHS surveys, perinatal deaths are defined to include any deaths of live births within the first seven days of life (early neonatal deaths) and any pregnancies reported by mothers as having ended in stillbirths after seven or more months of gestation. DHS asks and records pregnancy duration in months; the definition of seven months used for the purpose of calculating perinatal mortality in DHS is the equivalent of 28 weeks of pregnancy (Rutstein, S. O., and G. Rojas, 2006). The information on the durations of pregnancies ending in stillbirth is obtained in the detailed reproductive events calendars completed in the survey for the period after January 2007. The perinatal rate is calculated by dividing the total number of perinatal deaths by the total number of pregnancies reported in the calendar as having lasted 7 or more months (i.e., number of pregnancies of seven or more months that terminated in a fetal death plus pregnancies that ended with a live birth). Table 9.4 presents the number of stillbirths, the number of early neonatal deaths, and the perinatal mortality for the five-year period preceding the survey by selected demographic and socioeconomic characteristics. In considering the results, it should be remembered that both stillbirths and early neonatal deaths are subject to underreporting. The total number of events is also small (45 stillbirths and 80 early Infant and Child Mortality • 107 neonatal deaths); as a result, perinatal mortality rates for a number of the subgroups are based on very few events. Overall, the perinatal mortality rate is 24 per 1,000.5 In general, differences in the perinatal rates across subgroups are similar to those observed in childhood mortality rates, although the patterns are not identical. Table 9.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five- year period preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 1 15 32 481 20-29 27 48 21 3,637 30-39 12 12 23 1,054 40-49 5 6 101 105 Previous pregnancy interval in months4 First pregnancy 11 44 33 1,646 <15 8 11 43 458 15-26 16 10 19 1,354 27-38 5 8 17 757 39+ 5 7 10 1,062 Residence Urban 10 15 22 1,129 Rural 35 65 24 4,148 Region Dushanbe 3 6 21 417 GBAO 1 1 23 92 Sughd 5 16 15 1,388 DRS 9 19 21 1,325 Khatlon 27 38 32 2,055 Mother's education None/primary 3 5 18 455 General basic 18 40 28 2,081 General secondary 18 24 19 2,178 Professional primary/middle 4 7 37 306 Higher 3 3 21 258 Wealth quintile Lowest 11 22 30 1,073 Second 12 20 28 1,145 Middle 12 16 25 1,102 Fourth 5 14 18 1,042 Highest 5 9 15 914 Total 45 80 24 5,277 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months (the equivalent of 28 or more weeks of pregnancy duration). 2 Early neonatal deaths are deaths at age 0 to 6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths is divided by the number of pregnancies of seven or more months' duration, expressed per 1,000. 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. 5 The TjDHS classification of perinatal deaths differs somewhat from that used by the Tajik Republic Ministry of Health. In calculating perinatal mortality, the current Tajik MOH approach includes early neonatal deaths and stillbirths occurring after 22 weeks of pregnancy in the numerator of the rate and all births (stillbirths and live births) in the denominator. DHS asks for and records pregnancy duration only in months; thus, it is not possible to exactly match the MOH definition. However, it is possible to closely approximate the MOH approach by using a cut-off of 6 months or the equivalent of 24 weeks of pregnancy for the purpose of re-calculating perinatal mortality. When the 2012 TjDHS perinatal mortality rate is re-calculated using this cut-off, the estimate of the perinatal mortality rate is 27 per 1,000 (data not shown). 108 • Infant and Child Mortality 9.6 HIGH-RISK FERTILITY BEHAVIOR Research suggests there is a strong relationship between several aspects of women’s fertility behavior and children’s survival risks. The risk of death in early childhood is higher among children whose mothers are young or old at birth, children of too high a parity, or children born after too short a preceding birth interval. The category “young” refers to mothers less than 18 years old while “old” includes mothers over age 34 at the time of the birth. A “short birth interval” is defined as a birth occurring less than 24 months after a previous birth. A child is of “too high a birth order” if the mother had previously given birth to three or more children. Taking into account the four risk factors, Table 9.5 presents the distribution of births during the five-year period before the survey and of currently married women6 by whether they are in a single high risk category, a multiple high-risk category, or not in any high-risk category. Although often at increased risk, first births between ages 18 and 34 are assigned to a separate category because the risk is “unavoidable.” Table 9.5 also presents risk ratios that represent an increased risk of dying among births in the category relative to births with no risk factors. Table 9.5 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Tajikistan 2012 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high risk category 25.0 1.00 17.3a Unavoidable risk category First order births between ages 18 and 34 years 32.3 1.58 10.3 Single high-risk category Mother's age <18 0.8 3.16 0.0 Mother's age >34 1.5 2.44 5.2 Birth interval <24 months 17.2 1.53 12.4 Birth order >3 12.3 1.25 12.7 Subtotal 31.8 1.51 30.3 Multiple high-risk category Age <18 and birth interval <24 months2 0.0 0.00 0.0 Age >34 and birth interval <24 months 0.1 10.54 0.3 Age >34 and birth order >3 6.1 1.32 34.1 Age >34 and birth interval <24 months and birth order >3 0.5 9.24 1.6 Birth interval <24 months and birth order >3 4.0 1.79 6.1 Subtotal 10.8 2.00 42.1 In any avoidable high-risk category 42.7 1.63 72.4 Total 100.0 na 100.0 Number of births/women 5,233 na 6,504 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3. a Includes sterilized women. 6 The criteria for placing women into specific risk categories are adjusted to take into account the gestation time for an additional birth. Infant and Child Mortality • 109 Overall, looking at the first column of the table, more than four in ten babies were in some avoidable risk category at the time they were born; 32 percent were in a single risk category, and 11 percent were in a multiple risk category. The most common avoidable risk factors were short birth intervals and high birth order. As the second column of Table 9.5 shows, the overall risk of dying was 1.63 times higher among births that fell into any high-risk category compared with births not in any high-risk category. The risk ratio for first births is similar to that for births in any high-risk category. The final column of Table 9.5 shows that 72 percent of currently married women have the potential to give birth to a child at elevated risk of dying. Three in ten women have the potential for a birth in a single high-risk category (mainly too short a birth interval and too high a birth order), and four in ten women have the potential to give birth to a child in a multiple high-risk category (mainly, too old and too high in birth order). 9.7 REGISTRATION OF CHILD DEATHS Vital registration systems are a key instrument for tracking mortality trends in a country. To obtain information on the extent to which child deaths are being registered in Tajikistan7, the TjDHS birth history included a question for each child reported as having ever died on whether a death certificate was available for the child. If a death certificate was not available, an additional question was asked about whether the death had ever been registered in the State Office for Registration of Civil Status (ZAGS). Using this information, Figure 9.2 shows that fewer than four of the ten deaths that occurred among children born in the five years prior to the survey were registered with civil authorities. Moreover, mothers reported having a death certificate available for only 18 percent of the children who died during the five-year period before the survey. Figure 9.2 Registration of deaths of children born in the five years prior to the 2012 Tajikistan DHS Tajikistan DHS 2012 7 Information on birth registration is included in Chapter 2. Don't know 12% Missing 6% Registered, has certificate 18% Registered, no certificate 20% Not registered 44% Maternal Health • 111 MATERNAL HEALTH 10 he health care that a woman receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and the child. In 2004, the government of Tajikistan adopted a Strategic Plan for Reproductive Health in 2005–2014 that identifies several priorities for improving maternal health: improving access to antenatal care (ANC) and safe delivery services and decreasing mortality and morbidity during pregnancy (Khodjamurodov and Rechel, 2010). Among the targets set in the document were the increase of ANC coverage from 54 percent in 2002 to 80 percent in 2014 and the increase in skilled attendance at home deliveries from 44 to 75 percent over the same time period. This chapter provides information from the 2012 Tajikistan DHS on several aspects of maternal health, including ANC, delivery, postnatal care, and newborn care. The chapter also covers issues related to breast cancer examinations, awareness of cervical cancer, and coverage of tests for cervical cancer. Finally, information is also presented on problems women face in accessing health care when they are sick. In the 2012 TjDHS, women who had given birth in the five years preceding the survey were asked a number of questions about maternal and child health care. For the last live birth in that period, mothers were asked whether they had received ANC during pregnancy and whether they had sought postnatal care for themselves and their children. Information was also collected on the place of delivery and on attendance at birth for all births in the five years preceding the survey. T Key Findings • Seventy-nine percent of women in Tajikistan received antenatal care from a skilled provider. • Over half of women have four or more antenatal care visits during the course of their pregnancy, and over half get care in the first trimester of pregnancy, as recommended. • More than three-quarters of births in Tajikistan take place in a health facility, and 87 percent are assisted by a skilled provider. • The vast majority of women (80 percent) receive postnatal care from a skilled provider within two days after delivery. • Knowledge of and testing for breast cancer and cervical cancer are not widespread in Tajikistan. Only 3 percent of women have ever had a breast exam from a health provider, and only 6 percent know how to perform a breast self-exam. Only 8 percent of women have ever had a Pap/cervical cytology smear test for cervical cancer. • Forty-five percent of women report that getting money for treatment is a serious problem in accessing health care when they are sick. 112 • Maternal Health 10.1 ANTENATAL CARE Antenatal care (ANC) from a medically-trained provider is important to monitor the status of a pregnancy, identify the complications associated with the pregnancy, and prevent adverse pregnancy outcomes. To be most effective, there should be regular ANC throughout a pregnancy. Information on ANC was assessed for women who gave birth in the five years preceding the survey. Among women with two or more live births during the five-year period, data refer to the most recent live birth only. 10.1.1 Antenatal Care Coverage Table 10.1 shows the percent distribution of mothers with a live birth, by source of ANC received during pregnancy. Women were asked to report on all persons they saw for antenatal care for their last birth. However, if a woman saw more than one provider, only the provider with the highest qualifications was considered in the tabulation of results. In Tajikistan, skilled providers trained to assist during pregnancy and delivery include doctors, nurses, midwives, and feldshers.1 Table 10.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving ANC from a skilled provider for the most recent birth, according to background characteristics, Tajikistan 2012 Background characteristic Antenatal care provider No ANC Total Percent- age receiving ANC from a skilled provider2 Number of women Family doctor Other doctor Nurse/ midwife Feldsher1 Commu- nity health worker Tradi- tional birth attendant Other Missing Mother's age at birth <20 14.3 58.0 13.7 0.0 0.0 0.6 0.0 0.3 13.1 100.0 86.0 258 20-34 17.1 47.7 15.0 0.2 0.1 0.3 0.3 0.6 18.7 100.0 80.0 2,945 35-49 10.5 38.8 15.9 0.1 0.0 0.4 0.0 0.9 33.3 100.0 65.3 398 Birth order 1 18.7 49.9 15.2 0.2 0.1 0.4 0.1 0.6 14.8 100.0 84.0 922 2-3 16.9 50.8 13.7 0.2 0.1 0.2 0.3 0.5 17.3 100.0 81.5 1,672 4-5 13.9 41.1 17.6 0.2 0.0 0.6 0.5 0.7 25.5 100.0 72.8 728 6+ 9.3 36.3 15.4 0.0 0.0 0.0 0.0 1.1 37.9 100.0 61.0 279 Residence Urban 21.2 52.6 8.6 0.3 0.0 0.0 0.0 0.7 16.6 100.0 82.7 802 Rural 14.8 46.0 16.8 0.1 0.1 0.4 0.3 0.6 20.8 100.0 77.7 2,799 Region Dushanbe 20.4 56.1 4.3 0.0 0.0 0.0 0.0 0.5 18.7 100.0 80.8 295 GBAO 5.5 33.9 42.8 3.0 0.0 0.3 0.0 0.6 14.0 100.0 85.1 67 Sughd 25.4 50.7 17.9 0.0 0.0 0.0 0.0 0.3 5.7 100.0 94.1 1,000 DRS 9.9 58.3 10.0 0.4 0.4 0.3 0.3 0.4 19.9 100.0 78.7 887 Khatlon 13.1 36.7 17.0 0.0 0.0 0.6 0.6 1.0 31.0 100.0 66.8 1,351 Education None/primary 12.9 44.5 12.0 0.0 0.3 0.0 0.3 0.5 29.5 100.0 69.4 272 General basic 12.5 49.9 15.5 0.2 0.1 0.5 0.6 0.5 20.2 100.0 78.0 1,400 General secondary 18.5 44.2 15.5 0.1 0.0 0.3 0.0 0.9 20.4 100.0 78.4 1,530 Professional primary/ middle 23.4 50.1 13.6 0.3 0.4 0.0 0.0 0.0 12.2 100.0 87.4 210 Higher 21.3 57.3 12.7 0.7 0.0 0.1 0.0 0.0 7.9 100.0 92.0 189 Wealth quintile Lowest 10.5 30.8 24.8 0.2 0.0 1.0 0.6 0.7 31.4 100.0 66.3 731 Second 11.2 40.8 18.5 0.4 0.0 0.3 0.2 1.1 27.5 100.0 70.9 757 Middle 18.2 51.0 12.5 0.1 0.2 0.3 0.2 0.7 16.9 100.0 81.7 743 Fourth 22.0 57.3 10.3 0.2 0.1 0.0 0.4 0.4 9.4 100.0 89.7 718 Highest 19.7 59.0 8.0 0.0 0.1 0.0 0.0 0.1 13.1 100.0 86.7 652 Total 16.2 47.5 15.0 0.2 0.1 0.3 0.3 0.6 19.9 100.0 78.8 3,601 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Feldsher is a mid-level health professional that provides medical care beyond the scope of a nurse but less than that of a physician. 2 Skilled provider includes doctor, nurse, midwife, and feldsher. 1 A feldsher is a mid-level health professional (equivalent of a paramedical practitioner). A feldsher provides care that is beyond the scope of a nurse but less than that of a physician. A feldsher oversees work at a feldhser-accoucher post (FAP) with no assigned doctor, while in larger facilities a feldsher works under a physician. Maternal Health • 113 Table 10.1 shows that 79 percent of mothers reported seeing a skilled health professional at least once for ANC for the most recent birth in the five-year period before the survey. This is very close to the target of 80 percent set in the strategic plan for 2014. Almost two-thirds (64 percent) saw a doctor—either their family doctor or another doctor. Fifteen percent of mothers saw a nurse or midwife for ANC. However, one in five mothers in Tajikistan did not have any ANC at all for their most recent birth. There are substantial variations in ANC coverage by background characteristics of the mother. The likelihood of receiving ANC from a medically-trained provider declines rapidly with increasing age and birth order. For example, 86 percent of women who were younger than age 20 at their last birth received ANC from a skilled provider compared with 65 percent of women age 35 or older. ANC coverage is also much higher for first births (84 percent) than for women delivering their sixth or higher birth (61 percent). The urban-rural differential in ANC coverage is not large: 83 percent of urban mothers receive ANC from a skilled provider compared with 78 percent of rural mothers (see also Figure 10.1). Coverage is markedly higher among mothers from Sughd (94 percent) and GBAO (85 percent) regions and is lowest among women in Khatlon (67 percent). The likelihood of receiving ANC from a medically- trained provider increases with the mother’s education level and wealth status (Table 10.1). Sixty-nine percent of mothers with no education or only primary education received ANC from a trained provider compared with 92 percent of mothers with higher than secondary education. Similarly, the proportion of women who received ANC from a medically-trained provider is lowest among those in the lowest wealth quintile (66 percent) and increases to a high of 90 percent among women in the fourth wealth quintile. Figure 10.1 Differentials in coverage of antenatal care from a skilled provider, Tajikistan, 2012* Tajikistan DHS 2012 Overall, ANC coverage from a skilled provider has barely changed since 2005, increasing from 77 percent as reported in the 2005 Multiple Indicator Cluster Survey (2005 MICS) to 80 percent in the 2012 TjDHS (SCS, 2007)2. Compared with estimates from recent Demographic and Health Surveys conducted in other countries in the region, coverage of ANC by a skilled provider in Tajikistan (79 percent) is higher than in Pakistan (61 percent) or Afghanistan (63 percent), but similar to that in Azerbaijan (77 percent), and substantially lower than in Armenia and Ukraine (99 percent each) (NIPS [Pakistan] and Macro International Inc., 2008; APHI/MoH [Afghanistan] et al., 2011; SSC [Azerbaijan] and Macro International Inc., 2008; NSS[Armenia] at al., 2012; UCSR [Ukraine] and Macro International, 2008). 2 The 2005 Tajikistan MICS collected information on ANC during the pregnancy for the most recent birth in the two years before the survey, while the 2012 TjDHS collected it for the most recent birth in the five years before the survey. Thus, in order to obtain estimates comparable to the MICS, the 2012 TjDHS ANC indicators have been re- calculated based on information for the most recent birth in the two years before the survey. 114 • Maternal Health 10.1.2 Number of Antenatal Visits Under normal circumstances, the World Health Organization (WHO) recommends that a pregnant woman should have at least four ANC visits (WHO, 2007). Since 2008, the Ministry of Health of the Republic of Tajikistan recommends seven ANC visits. Table 10.2 presents information on the number of ANC visits and the timing of the first visit for the most recent live birth in the five years preceding the survey. Over half of women in Tajikistan (53 percent) have four or more ANC visits during their pregnancy. Urban women are more likely than rural women to have made four or more visits (64 percent versus 49 percent). Also, over half of women (52 percent) have their first ANC visit in the first trimester of pregnancy, as recommended. Urban women are only slightly more likely than rural women to have their first ANC visit in the first trimester. The median number of months of pregnancy at the first visit is 3.5. 10.1.3 Components of Antenatal Care The content of ANC is important in assessing the quality of services. Pregnancy complications are an important source of maternal and child morbidity and mortality, and thus teaching pregnant women about the danger signs associated with pregnancy and administering appropriate tests are essential components of ANC. Being accompanied to an ANC visit by a family member or friend can facilitate better care. Table 10.3 presents information on the percentage of women who took iron supplements during the pregnancy that resulted in their most recent birth in the five years preceding the survey. The table also shows the percentage of women receiving ANC who were informed about the signs of pregnancy complications and the percentage who received specific routine ANC services. Finally, it shows the proportion of women with ANC who were accompanied to at least one visit by a family member or friend and the proportion who were admitted to a health facility during the pregnancy. Among women with a live birth in the past five years, one-third took iron tablets or syrup while pregnant with the last birth. Variations in iron supplementation by background characteristics are moderate. The strongest differences occur by region and education. Mothers in GBAO are more than twice as likely to take iron tablets or syrup as those in DRS (57 percent versus 24 percent). Similarly, iron supplementation increases with education of the mother, from a low of 26 percent among those with no education or only primary to a high of 54 percent among those with higher than secondary education. Those who are more likely to take iron supplements include younger women and those in the upper wealth quintiles. Interestingly, there is no difference in iron supplementation by urban-rural residence. Among women who received ANC during their most recent pregnancy, 76 percent reported that they were told about the signs of pregnancy complications during at least one of their ANC visits. As for tests, 94 percent of mothers had their blood pressure taken, while 90 percent gave a urine sample and 92 percent gave a blood sample for testing. Table 10.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Tajikistan 2012 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 17.2 21.1 20.2 1 3.4 8.5 7.4 2-3 14.2 20.5 19.1 4+ 64.0 49.1 52.5 Don't know/missing 1.2 0.8 0.9 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 17.2 21.1 20.2 <4 57.5 50.3 51.9 4-5 19.1 19.2 19.2 6-7 4.5 6.5 6.0 8+ 1.2 2.1 1.9 Don't know/missing 0.5 0.9 0.8 Total 100.0 100.0 100.0 Number of women 802 2,799 3,601 Median months pregnant at first visit (for those with ANC) 3.4 3.6 3.5 Number of women with ANC 664 2,208 2,872 Maternal Health • 115 Table 10.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Tajikistan 2012 Background characteristic Among women with a live birth in the past five years Among women who received ANC for their most recent birth in the past five years, the percentage with selected services Percentage who took iron tablets or syrup during pregnancy of their last birth Number of women with a live birth in the past five years Informed of signs of pregnancy complications Blood pressure measured Urine sample taken Blood sample taken Accompanied to any ANC visit by husband/ partner, family member, or friend Admitted to a health facility (including day-bed) Number of women with ANC for their most recent birth Mother's age at birth <20 38.0 258 75.1 96.3 94.5 94.8 70.1 12.0 223 20-34 33.1 2,945 76.2 93.9 90.3 92.5 63.3 11.0 2,388 35-49 25.7 398 74.5 92.4 87.5 89.0 51.9 7.4 262 Birth order 1 35.2 922 74.1 94.2 91.5 93.0 71.7 15.7 784 2-3 33.5 1,672 78.2 94.6 91.0 93.1 60.2 9.4 1,379 4-5 31.6 728 72.8 92.6 89.1 91.7 59.3 8.8 539 6+ 22.0 279 77.0 90.8 84.0 85.0 53.5 4.1 170 Residence Urban 32.2 802 74.6 96.7 95.8 96.7 61.6 10.6 664 Rural 32.8 2,799 76.4 93.1 88.8 91.0 63.1 10.7 2,208 Region Dushanbe 29.8 295 72.5 98.7 99.2 99.0 63.0 8.4 239 GBAO 56.5 67 78.7 97.5 92.9 96.1 70.2 31.4 58 Sughd 38.1 1,000 81.3 99.5 97.8 98.4 53.3 14.3 942 DRS 23.7 887 60.1 95.2 94.7 94.8 70.2 6.1 708 Khatlon 33.9 1,351 83.4 85.9 77.1 82.4 66.3 9.9 926 Education None/primary 26.2 272 71.0 88.8 81.1 87.8 77.0 6.8 190 General basic 30.5 1,400 72.6 93.9 90.7 92.0 64.2 11.6 1,114 General secondary 31.3 1,530 79.2 93.2 89.4 91.4 59.0 9.7 1,210 Professional primary/ middle 46.4 210 76.6 99.0 96.4 98.2 56.3 15.8 185 Higher 53.6 189 79.9 99.5 99.5 100.0 71.1 11.6 174 Wealth quintile Lowest 25.8 731 77.5 88.4 77.4 83.6 64.3 7.4 498 Second 29.3 757 75.7 90.9 86.5 88.4 65.2 10.1 543 Middle 34.3 743 74.6 93.6 91.2 92.9 64.8 11.8 617 Fourth 40.5 718 79.2 96.9 96.1 96.7 61.8 13.2 648 Highest 33.8 652 72.6 98.6 98.1 98.3 58.0 10.2 567 Total 32.7 3,601 76.0 93.9 90.4 92.3 62.8 10.7 2,872 There are remarkably few differences in the content of ANC by background characteristics of women. For example, the proportions of women who were informed of the signs of pregnancy complications during an ANC visit are similar across age, birth order, and residence. The only large variation occurs by region, with mothers in Khatlon region (83 percent) being more likely to be informed about pregnancy complications than those in DRS region (60 percent). The likelihood of receiving blood pressure, urine, and blood tests during pregnancy increases with education and wealth quintile and is also slightly higher among urban than rural women. Almost two in three women (63 percent) said they were accompanied on at least one ANC visit by either a husband/partner, a family member, or a friend. Those more likely to be accompanied include younger mothers and those who are pregnant with their first child. Women in Sughd region are the least likely to report that they were accompanied to an ANC visit by their husband/partner, a family member, or friend. Differences by residence are minimal, while differences by education and wealth do not follow any clear pattern. Only 11 percent of women said they were admitted to a health facility (including day-bed occupancy) during their most recent pregnancy. Hospital admission is considerably more common for pregnant women in GBAO (31 percent), than for women in other regions. Younger women and those pregnant with their first births are also more likely to be admitted to a health facility during pregnancy. Among those admitted to a health facility, three-quarters were admitted only once or twice, while 9 percent 116 • Maternal Health were admitted three to five times, and 15 percent were admitted six of more times during the pregnancy (data not shown). The major reasons for admission were anemia (40 percent), threat of miscarriage (38 percent), threat of pre-term labor (20 percent), and bleeding (9 percent) (data not shown). 10.2 DELIVERY CARE Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that can cause death or serious illness for the mother or the newborn. Hence, it is important to increase the proportion of births delivered in a safe, clean environment and under the supervision of health professionals. Women interviewed in the 2012 TjDHS reported on the place and type of assistance during delivery of all children born in the five years before the survey. 10.2.1 Place of Delivery Table 10.4 shows the percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. Over three-quarters of births in Tajikistan (77 percent) are delivered at a health facility, while 23 percent are delivered at home. Table 10.4 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Tajikistan 2012 Background characteristic Health facility Home Missing Total Percentage delivered in a health facility Number of births Public sector Private sector Mother's age at birth <20 80.1 0.0 18.0 1.8 100.0 80.1 480 20-34 77.6 0.0 21.6 0.8 100.0 77.7 4,321 35-49 61.1 0.0 37.0 1.8 100.0 61.1 433 Birth order 1 85.8 0.1 12.9 1.2 100.0 85.9 1,765 2-3 76.1 0.0 23.2 0.7 100.0 76.1 2,256 4-5 68.2 0.0 31.5 0.3 100.0 68.2 889 6+ 51.4 0.0 45.8 2.8 100.0 51.4 323 Antenatal care visits1 None 52.8 0.0 45.3 2.0 100.0 52.8 729 1-3 68.8 0.0 31.1 0.1 100.0 68.8 953 4+ 91.1 0.1 8.8 0.1 100.0 91.1 1,889 Residence Urban 87.3 0.1 11.7 0.8 100.0 87.4 1,119 Rural 73.6 0.0 25.5 1.0 100.0 73.6 4,114 Region Dushanbe 88.1 0.2 10.6 1.0 100.0 88.4 414 GBAO 65.4 0.0 33.8 0.9 100.0 65.4 91 Sughd 93.3 0.0 6.1 0.7 100.0 93.3 1,383 DRS 70.0 0.0 29.1 0.9 100.0 70.0 1,316 Khatlon 67.4 0.0 31.4 1.2 100.0 67.4 2,029 Mother's education None/primary 69.1 0.0 30.4 0.5 100.0 69.1 452 General basic 73.3 0.0 25.7 1.0 100.0 73.3 2,063 General secondary 77.3 0.0 21.6 1.1 100.0 77.3 2,161 Professional primary/middle 89.1 0.0 10.3 0.6 100.0 89.1 302 Higher 93.5 0.4 5.8 0.3 100.0 93.9 255 Wealth quintile Lowest 58.5 0.0 40.5 1.1 100.0 58.5 1,062 Second 68.8 0.0 29.3 1.9 100.0 68.8 1,132 Middle 77.1 0.0 21.9 0.9 100.0 77.1 1,092 Fourth 89.8 0.0 9.9 0.3 100.0 89.8 1,037 Highest 91.2 0.1 8.3 0.3 100.0 91.4 909 Total 76.5 0.0 22.5 0.9 100.0 76.5 5,233 Note: Table excludes 31 births, for which the number of ANC visits is missing. 1 Includes only the most recent birth in the five years preceding the survey. Maternal Health • 117 There are considerable variations in delivery care by mother’s age at birth and residence. Younger women and women delivering their first births are more likely to deliver in a health facility than older women and those who are having their second or higher birth; 80 percent of births to women age 20 or younger are delivered in a health facility compared with 61 percent of births to women age 35 or older. Similarly, 86 percent of first births are delivered in a health facility compared with only 51 percent of sixth and higher births. As expected, women who have ANC care are also more likely to deliver in a health facility than those who do not. The proportion of births that take place in a health facility increases from 53 percent of those to women who had no ANC to 91 percent of those with four or more ANC visits. As shown in Figure 10.2, births in urban areas are more likely to take place in a health facility than those in rural areas (87 percent versus 74 percent). About 88-93 percent of births in the Sughd region and Dushanbe take place in a health facility compared with only 65-67 percent of those in GBAO and Khatlon regions. Figure 10.2 Differentials in percentage of births delivered in health facilities, Tajikistan, 2012* Tajikistan DHS 2012 Mother’s level of education is directly related to the likelihood that a birth is delivered in a health facility. Only 69 percent of births to women with no education or only a primary education take place in a health facility compared with 94 percent of those to women with higher than a secondary education. Place of delivery is also highly correlated with wealth quintile; fewer than 6 in 10 births to women in the lowest quintile take place in a health facility compared with over 9 in 10 births to women in the highest quintile. There is some evidence that institutional deliveries may be increasing in Tajikistan. Data from the 2005 Multiple Indicator Cluster Survey (MICS) show that only 62 percent of births in the two years before the survey took place in a health facility (SCS, 2007) compared with 78 percent of births in the two years before the 2012 TjDHS3. The proportion of births in Tajikistan that take place in a health facility (77 percent) is substantially higher than in Afghanistan (32 percent) or Pakistan (34 percent), similar to Azerbaijan (78 percent), and lower than in Armenia and Ukraine (99 percent each) (APHI/MoH [Afghanistan] et al., 2011; NIPS [Pakistan] and Macro International Inc. 2008; SSC [Azerbaijan] and Macro International Inc., 2008; NSS[Armenia] at al., 2012; UCSR [Ukraine] and Macro International, 2008). 3 The 2005 Tajikistan MICS collected information on delivery care for the last live birth in the two years before the survey, while the 2012 TjDHS collected it for live births in the five years before the survey. Thus, in order to obtain estimates comparable to the MICS, the 2012 TjDHS ANC indicators have been re-calculated based on information for the last birth in the two years before the survey. 118 • Maternal Health As shown in Figure 10.3, a large majority of women who deliver in a health facility stay for at least three days in the facility after delivery. Among those with a vaginal birth, 64 percent stay three or more days in the facility, while 27 percent stay 1-2 days and 8 percent are released within 24 hours after delivering. As expected, the duration of stay in health facilities is longer for those who deliver by Caesarian section. For these births, 85 percent of mothers stay for three or more days. Figure 10.3 Duration of mother's stay in health facility after giving birth*, Tajikistan Tajikistan DHS 2012 10.2.2 Assistance during Delivery Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that can cause the death or serious illness of the mother, infant, or both. Table 10.5 shows the percent distribution of all live births in the five years preceding the survey by type of assistance during delivery, according to background characteristics. A large majority of births in Tajikistan (87 percent) are assisted by a medical professional, mainly doctors (64 percent) and nurses or midwives (22 percent). Nine percent of births are assisted by traditional birth attendants. The proportion of births delivered with the assistance of a skilled provider is higher among younger mothers and for first births than for other births. As expected, births that take place in a health facility are also much more likely to be assisted by a skilled professional than births that take place at home. Also more likely to be assisted by a health professional are births to urban women, births to women in Dushanbe, and births to women with more education and in higher wealth quintiles. The proportion of births delivered with the assistance of a health professional ranges from 80 percent in DRS region to 96 percent in Dushanbe. Although only two-thirds of births in GBAO are delivered in a health facility (65 percent), nearly all births are delivered by a skilled provider (93 percent), in part because the region has the highest use of feldshers as assistants at delivery. 8 3 27 12 64 85 Vaginal birth Caesarian section Percentage Less than 24 hours 1-2 days 3+ days * Percentage among women whose last birth in the last 5 years was delivered in a health facility. Maternal Health • 119 Table 10.5 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of birth assisted by a skilled provider, and percentage delivered by cesarean-section, according to background characteristics, Tajikistan 2012 Background characteristic Person providing assistance during delivery Percent- age delivered by a skilled provider2 Percent- age delivered by C- section Number of births Family doctor Other doctor Nurse/ midwife Feldsher1 Tradi- tional birth attendant Relative/ other No one Don't know/ missing Total Mother's age at birth <20 1.5 63.2 25.5 0.9 5.6 1.0 0.0 2.2 100.0 91.2 3.2 480 20-34 3.5 61.6 22.0 0.9 8.9 2.1 0.1 0.9 100.0 88.0 4.0 4,321 35-49 5.9 51.5 17.8 1.2 14.6 6.6 0.9 1.6 100.0 76.3 5.5 433 Birth order 1 3.0 66.9 22.6 1.1 4.4 0.4 0.1 1.4 100.0 93.7 5.8 1,765 2-3 3.2 61.0 22.0 0.8 9.8 2.2 0.1 0.9 100.0 87.0 3.4 2,256 4-5 4.4 56.0 20.9 1.3 13.5 3.2 0.5 0.4 100.0 82.5 3.0 889 6+ 6.5 40.5 21.3 0.6 17.1 11.3 0.6 2.2 100.0 68.9 1.3 323 Place of delivery Health facility 1.9 75.7 21.0 1.1 0.2 0.0 0.0 0.2 100.0 99.5 5.3 4,005 Elsewhere 9.4 13.2 26.3 0.6 39.6 10.2 0.5 0.4 100.0 49.4 0.0 1,179 Residence Urban 1.3 69.7 21.9 0.5 4.5 1.0 0.1 1.0 100.0 93.4 6.1 1,119 Rural 4.2 58.5 22.0 1.1 10.3 2.7 0.2 1.1 100.0 85.7 3.5 4,114 Region Dushanbe 1.4 67.7 26.1 0.4 2.7 0.6 0.0 1.1 100.0 95.6 9.7 414 GBAO 1.1 46.0 38.7 6.7 3.1 4.0 0.0 0.4 100.0 92.5 6.0 91 Sughd 1.0 74.1 19.1 1.0 1.8 2.0 0.0 1.0 100.0 95.2 4.7 1,383 DRS 1.2 56.1 22.0 1.2 17.0 1.6 0.0 1.0 100.0 80.4 3.3 1,316 Khatlon 7.4 54.3 22.3 0.7 10.5 3.3 0.4 1.2 100.0 84.6 2.8 2,029 Mother's education None/primary 4.7 53.6 19.2 1.1 15.0 5.2 0.4 0.8 100.0 78.5 2.8 452 General basic 3.1 58.1 23.1 0.5 11.0 2.8 0.1 1.4 100.0 84.7 4.1 2,063 General secondary 4.1 62.5 21.3 1.3 7.9 1.7 0.2 1.0 100.0 89.2 3.7 2,161 Professional primary/ middle 1.9 72.8 21.4 1.3 2.0 0.3 0.3 0.0 100.0 97.4 5.0 302 Higher 2.7 69.1 24.6 0.7 1.4 0.8 0.0 0.7 100.0 97.1 6.7 255 Wealth quintile Lowest 7.6 43.6 21.8 0.9 17.2 7.0 0.5 1.3 100.0 73.9 2.7 1,062 Second 4.7 57.0 22.7 0.6 11.6 1.6 0.2 1.7 100.0 84.9 2.4 1,132 Middle 2.3 62.4 23.9 1.1 7.9 1.3 0.1 1.0 100.0 89.7 4.2 1,092 Fourth 1.6 70.3 20.4 1.5 5.0 0.5 0.0 0.8 100.0 93.6 5.1 1,037 Highest 1.1 73.5 20.7 0.8 2.5 1.1 0.0 0.4 100.0 96.1 6.2 909 Total 3.5 60.9 22.0 1.0 9.1 2.3 0.2 1.1 100.0 87.4 4.0 5,233 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Table excludes 49 births for which information on place of delivery is missing. 1 Feldsher is a mid-level health professional that provides medical care beyond the scope of a nurse but less than that of a physician. 2 Skilled provider includes doctor, nurse, midwife, and feldsher. There has been a modest increase in delivery care by health professionals since 2005. The proportion of births assisted by skilled providers increased from 83 percent in 2005 (SCS, 2007) to 89 percent in 20124. The proportion of births in Tajikistan assisted by a health professional (87 percent) is higher than in Afghanistan (34 percent) or Pakistan (39 percent), similar to Azerbaijan (89 percent) and lower than in Ukraine (99 percent) and Armenia (almost 100 percent) (APHI/MoH [Afghanistan] et al., 2011; NIPS [Pakistan] and Macro International Inc. 2008; SSC [Azerbaijan] and Macro International Inc., 2008; UCSR [Ukraine] and Macro International, 2008; NSS [Armenia] at al., 2012). 4 The 2005 Tajikistan MICS collected information on delivery care for the last live birth in the two years before the survey, while the 2012 TjDHS collected it for live births in the five years before the survey. Thus, in order to obtain estimates comparable to the MICS, the 2012 TjDHS ANC indicators have been re-calculated based on information for the last birth in the two years before the survey. 120 • Maternal Health 10.2.3 Cesarean Section Table 10.5 also shows the percentage of live births delivered by Cesarean section during the five years preceding the survey. The percentage of C-section births is sometimes considered to be a proxy indicator of women’s access to skilled care for complicated deliveries. According to the 2012 TjDHS, 4 percent of births are delivered by C-section. Delivery by Caesarean section is highest among births to mothers who live in Dushanbe (10 percent), who have higher than secondary education (7 percent), and who are in the highest wealth quintile (6 percent). 10.3 POSTNATAL CARE FOR MOTHERS AND CHILDREN Postnatal care is a crucial component of safe motherhood. Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their babies. A large proportion of maternal and neonatal deaths occur during the 24 hours following delivery. In addition, the first two days following delivery are critical for monitoring complications arising from the delivery. To assess the extent of postnatal care utilization, women interviewed in the 2012 TjDHS were asked about checkups for their last birth in the five years preceding the survey. Specifically, they were asked if they, their child, or both had received a health checkup after the delivery, the timing of the first checkup, and the type of health provider. 10.3.1 Postnatal Checkup for Mother Table 10.6 shows the percent distribution of last births in the two years preceding the survey for which the mothers received postnatal care. Overall, 80 percent of mothers receive postnatal care within the crucial first two days of delivery. About two-thirds of women received a checkup within the first four hours after delivering, 5 percent received a checkup within 4 to 23 hours, and 8 percent were seen 1 to 2 days following delivery. On the other hand, 13 percent of mothers do not receive any postnatal checkup at all. The proportion of mothers receiving a postnatal checkup within two days of delivery decreases with age of the mother and birth order. It is higher among urban mothers than rural mothers. Women who deliver in a health facility are more than twice as likely to receive timely postnatal checkups as women who deliver elsewhere (92 percent versus 40 percent). Over 90 percent of women in Sughd and Dushanbe regions receive postnatal care within the first two days after delivery, compared with only 73-74 percent of women in DRS and Khatlon regions. The proportion of women who receive a postnatal checkup within two days of delivering increases steadily with the education level and the wealth quintile of the mother. Maternal Health • 121 Table 10.6 Timing of first postnatal checkup for the mother Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution of the mother's first postnatal check-up for the last live birth by time after delivery, and the percentage of women with a live birth in the two years preceding the survey who received a postnatal checkup in the first two days after giving birth, according to background characteristics, Tajikistan 2012 Background characteristic Time after delivery of mother's first postnatal checkup No postnatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don't know/ missing Mother's age at birth <20 72.8 5.7 5.9 3.0 1.3 1.8 9.4 100.0 84.5 186 20-34 67.7 5.6 7.6 3.2 1.6 1.3 12.9 100.0 80.9 1,708 35-49 53.2 3.1 11.6 7.0 1.0 1.4 22.7 100.0 67.8 151 Birth order 1 74.0 4.8 7.9 1.4 1.7 1.4 8.8 100.0 86.7 664 2-3 66.9 5.9 6.7 4.1 1.5 1.2 13.8 100.0 79.5 933 4-5 64.3 5.7 7.3 3.9 1.6 2.0 15.2 100.0 77.4 325 6+ 39.1 4.3 16.1 9.4 1.2 0.9 29.1 100.0 59.4 123 Place of delivery Health facility 80.4 5.6 5.8 1.9 1.0 1.2 4.1 100.0 91.7 1,595 Elsewhere 20.6 4.7 15.1 9.2 3.5 1.9 45.0 100.0 40.4 442 Residence Urban 76.1 5.6 6.8 1.8 0.5 1.1 8.3 100.0 88.4 431 Rural 64.7 5.4 8.0 4.0 1.9 1.4 14.7 100.0 78.1 1,615 Region Dushanbe 82.5 3.6 5.6 0.7 0.0 0.6 7.0 100.0 91.7 154 GBAO 57.8 4.6 20.9 4.1 1.8 1.1 9.6 100.0 83.4 34 Sughd 83.3 3.6 6.9 1.2 0.0 0.3 4.8 100.0 93.8 539 DRS 62.6 5.4 4.8 5.0 1.0 1.7 19.5 100.0 72.8 519 Khatlon 56.6 7.0 10.1 4.6 3.3 2.0 16.4 100.0 73.7 798 Education None/primary 55.8 5.5 8.2 4.6 2.6 2.9 20.4 100.0 69.5 177 General basic 62.6 4.8 8.0 4.1 1.7 1.3 17.6 100.0 75.4 850 General secondary 71.9 5.8 7.6 3.3 1.2 0.9 9.3 100.0 85.3 810 Professional primary/middle 75.0 7.2 6.3 0.0 1.4 1.3 8.8 100.0 88.5 107 Higher 77.7 5.7 7.9 2.5 1.1 3.2 1.8 100.0 91.4 100 Wealth quintile Lowest 52.2 3.5 11.6 5.2 1.3 0.7 25.5 100.0 67.3 393 Second 62.9 5.4 8.5 4.1 1.8 1.3 16.0 100.0 76.9 454 Middle 66.4 8.0 7.0 3.0 2.6 2.0 11.0 100.0 81.3 451 Fourth 79.1 4.6 4.4 2.3 1.1 1.3 7.2 100.0 88.1 425 Highest 76.4 5.1 7.4 2.9 0.7 1.4 6.0 100.0 89.0 323 Total 67.1 5.4 7.8 3.5 1.6 1.4 13.3 100.0 80.3 2,045 Note: Table excludes nine women for whom information on place of delivery is missing. 1 Includes women who received a checkup after 41 days. 122 • Maternal Health The skill of the provider who performs the first postnatal checkup has important implications for maternal and neonatal health. Table 10.7 shows that among women who gave birth in the two years before the survey, 60 percent of women received care from a doctor and 20 percent received care from a nurse or midwife within two days after birth. Twenty percent of women received no postnatal checkup within two days of birth. Table 10.7 Type of provider of first postnatal checkup for the mother Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution by type of provider of the mother's first postnatal health check in the two days after the last live birth, according to background characteristics, Tajikistan 2012 Background characteristic Type of health provider of mother's first postnatal checkup No postnatal checkup in the first two days after birth Total Number of women Family doctor Other doctor Nurse/ midwife Feldsher1 Community health worker Traditional birth attendant Mother's age at birth <20 1.5 58.3 23.9 0.7 0.0 0.0 15.5 100.0 186 20-34 3.0 57.5 19.6 0.4 0.1 0.4 19.1 100.0 1,708 35-49 5.1 44.0 17.3 0.0 0.0 1.3 32.2 100.0 151 Birth order 1 2.4 63.9 19.7 0.4 0.1 0.3 13.3 100.0 664 2-3 3.7 55.0 20.0 0.3 0.1 0.4 20.5 100.0 933 4-5 2.1 52.6 21.2 0.7 0.1 0.6 22.6 100.0 325 6+ 3.6 38.7 15.4 0.0 0.0 1.6 40.6 100.0 123 Place of delivery Health facility 1.5 69.3 20.7 0.2 0.1 0.0 8.3 100.0 1,595 Elsewhere 8.5 11.6 17.2 1.0 0.0 2.1 59.6 100.0 442 Residence Urban 1.8 66.3 19.7 0.0 0.1 0.4 11.6 100.0 431 Rural 3.3 53.9 19.9 0.5 0.1 0.5 21.9 100.0 1,615 Region Dushanbe 1.6 73.6 15.8 0.0 0.3 0.4 8.3 100.0 154 GBAO 1.8 34.8 41.5 3.6 1.1 0.6 16.6 100.0 34 Sughd 2.2 69.8 21.3 0.5 0.0 0.0 6.2 100.0 539 DRS 1.1 51.2 18.5 0.7 0.2 1.2 27.2 100.0 519 Khatlon 5.1 48.7 19.6 0.0 0.0 0.3 26.3 100.0 798 Education None/primary 2.6 51.3 15.2 0.0 0.0 0.4 30.5 100.0 177 General basic 2.1 50.8 21.3 0.5 0.1 0.6 24.6 100.0 850 General secondary 4.4 61.2 19.0 0.3 0.1 0.4 14.7 100.0 810 Professional primary/ middle 3.1 59.0 26.0 0.4 0.0 0.0 11.5 100.0 107 Higher 0.4 74.4 16.1 0.4 0.0 0.0 8.6 100.0 100 Wealth quintile Lowest 4.3 41.5 20.1 0.7 0.0 0.7 32.7 100.0 393 Second 3.6 52.8 19.9 0.3 0.0 0.3 23.1 100.0 454 Middle 1.9 56.0 22.0 0.7 0.3 0.4 18.7 100.0 451 Fourth 2.8 65.8 19.3 0.0 0.0 0.2 11.9 100.0 425 Highest 2.5 68.7 17.1 0.0 0.1 0.6 11.0 100.0 323 Total 3.0 56.5 19.8 0.4 0.1 0.5 19.7 100.0 2,045 Note: Table excludes 9 women for whom information on place of delivery is missing. 1 Feldsher is a mid-level health professional that provides medical care beyond the scope of a nurse but less than that of a physician. Younger mothers are more likely than older mothers to receive a postnatal checkup within two days of delivery from a doctor or from a nurse/midwife. Similarly, the proportion of mothers who receive a postnatal checkup from a doctor decreases as birth order increases. It is also higher among women in urban areas than in rural areas and among women in Dushanbe than among those in other regions. This is especially true in GBAO, where a sizeable proportion of mothers receive postnatal care from nurses and midwives (42 percent). Timely postnatal care coverage from doctors increases with both education level and wealth quintile of the mother. Maternal Health • 123 10.3.2 Postnatal Checkup for the Newborn Table 10.8 shows that more than half (54 percent) of last births in the two years preceding the survey received a postnatal checkup within the first two days after birth. Table 10.8 Timing of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by time after birth of first postnatal checkup, and the percentage of births with a postnatal checkup in the first two days after birth, according to background characteristics, Tajikistan 2012 Background characteristic Time after birth of newborn's first postnatal checkup No postnatal checkup1 Total Percentage of births with a postnatal checkup in the first two days after birth Number of births Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don't know/ missing Mother's age at birth <20 1.7 34.5 5.1 12.4 6.5 0.0 39.6 100.0 53.8 186 20-34 1.4 36.3 4.2 13.3 7.2 0.8 36.7 100.0 55.2 1,708 35-49 1.7 22.0 2.0 15.3 8.3 0.9 50.0 100.0 40.9 151 Birth order 1 1.4 41.0 3.7 14.0 4.1 0.0 35.7 100.0 60.1 664 2-3 2.1 34.4 4.4 13.0 8.5 1.0 36.7 100.0 53.9 933 4-5 0.5 30.1 4.8 11.6 8.6 0.9 43.6 100.0 47.0 325 6+ 0.0 21.4 1.7 18.2 11.5 1.9 45.4 100.0 41.3 123 Place of delivery Health facility 1.8 42.5 4.1 11.6 5.7 0.7 33.6 100.0 59.9 1,595 Elsewhere 0.3 8.9 4.1 20.3 12.9 0.8 52.6 100.0 33.6 442 Residence Urban 1.6 42.0 4.3 10.2 5.8 0.7 35.4 100.0 58.2 431 Rural 1.4 33.2 4.0 14.2 7.6 0.7 38.7 100.0 53.0 1,615 Region Dushanbe 0.4 45.4 2.9 6.2 4.2 0.9 40.0 100.0 54.9 154 GBAO 0.6 37.1 0.7 22.5 8.4 0.0 30.7 100.0 60.9 34 Sughd 4.6 43.1 3.7 15.4 9.4 0.7 23.1 100.0 66.8 539 DRS 0.2 32.8 1.7 6.1 7.4 1.0 50.7 100.0 40.9 519 Khatlon 0.5 29.0 6.2 17.8 6.3 0.6 39.7 100.0 53.5 798 Mother's education None/primary 0.9 27.1 3.5 13.5 7.3 2.1 45.5 100.0 45.1 177 General basic 1.3 33.9 4.1 11.0 7.0 0.6 42.1 100.0 50.3 850 General secondary 1.7 36.1 4.4 15.9 7.8 0.6 33.5 100.0 58.1 810 Professional primary/ middle 2.6 40.0 2.0 10.0 6.7 1.3 37.5 100.0 54.6 107 Higher 1.2 45.6 4.8 16.6 5.7 0.0 26.1 100.0 68.2 100 Wealth quintile Lowest 0.3 29.6 3.7 19.2 7.7 0.9 38.5 100.0 52.9 393 Second 1.0 31.9 5.2 16.6 5.9 0.7 38.8 100.0 54.6 454 Middle 1.9 33.2 3.6 9.5 9.0 0.6 42.2 100.0 48.2 451 Fourth 2.0 41.0 4.0 10.3 6.1 0.7 35.9 100.0 57.3 425 Highest 2.4 41.0 3.8 11.3 7.7 0.7 33.1 100.0 58.5 323 Total 1.5 35.1 4.1 13.4 7.3 0.7 38.0 100.0 54.1 2,045 Note: Table excludes 9 births for which information on place of delivery is missing. 1 Includes newborns who received a checkup after the first week. Less than two percent of newborns receive a postnatal checkup within one hour after birth; however, 35 percent receive a checkup one to three hours after birth. Thirty-eight percent of babies do not receive any checkup at all in the first week after birth. Differences in postnatal care for newborns by background characteristics are similar to patterns discussed for mothers’ postnatal checkups. 124 • Maternal Health Table 10.9 presents the percent distribution of last births in the two years preceding the survey by type of provider of postnatal care during the first two days after delivery, according to background characteristics. Among all newborns, 45 percent receive a checkup from a doctor and 8 percent receive a checkup from a nurse or midwife within the first two days after birth. Almost half of newborns (46 percent) receive no postnatal checkup in the first two days after birth. Table 10.9 Type of provider of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by type of provider of the newborn's first postnatal health check during the two days after the last live birth, according to background characteristics, Tajikistan 2012 Background characteristic Type of health provider of newborn's first postnatal checkup No postnatal checkup in the first two days after birth Total Number of births Family doctor Other doctor Feldsher1 Nurse/ midwife Traditional birth attendant Mother's age at birth <20 3.2 41.5 0.5 7.3 1.3 46.2 100.0 186 20-34 3.6 42.3 0.1 8.7 0.6 44.8 100.0 1,708 35-49 4.2 30.3 0.0 4.5 2.0 59.1 100.0 151 Birth order 1 3.3 48.8 0.3 7.1 0.7 39.9 100.0 664 2-3 4.2 39.4 0.1 9.6 0.5 46.1 100.0 933 4-5 2.7 35.8 0.0 7.8 0.8 53.0 100.0 325 6+ 3.2 30.1 0.0 5.6 2.4 58.7 100.0 123 Place of delivery Health facility 2.5 49.6 0.1 7.6 0.2 40.1 100.0 1,595 Elsewhere 7.8 12.0 0.3 10.8 2.7 66.4 100.0 442 Residence Urban 3.9 48.1 0.0 5.7 0.5 41.8 100.0 431 Rural 3.5 39.5 0.2 8.9 0.8 47.0 100.0 1,615 Region Dushanbe 2.1 47.5 0.0 4.8 0.4 45.1 100.0 154 GBAO 2.2 29.1 0.0 29.0 0.6 39.1 100.0 34 Sughd 4.6 54.0 0.2 7.7 0.3 33.2 100.0 539 DRS 1.2 31.0 0.4 7.5 1.0 59.1 100.0 519 Khatlon 4.9 38.8 0.0 8.9 1.0 46.5 100.0 798 Mother's education None/primary 2.2 32.1 0.0 9.4 1.4 54.9 100.0 177 General basic 2.5 38.8 0.4 8.3 0.4 49.7 100.0 850 General secondary 5.3 43.5 0.0 8.3 1.0 41.9 100.0 810 Professional primary/middle 2.8 44.7 0.0 6.2 0.9 45.4 100.0 107 Higher 2.9 57.7 0.0 7.6 0.0 31.8 100.0 100 Wealth quintile Lowest 4.7 36.6 0.3 9.3 2.0 47.1 100.0 393 Second 3.1 41.3 0.0 9.8 0.4 45.4 100.0 454 Middle 2.4 35.5 0.2 9.4 0.7 51.8 100.0 451 Fourth 4.8 45.5 0.2 6.7 0.0 42.7 100.0 425 Highest 3.2 49.5 0.0 5.2 0.7 41.5 100.0 323 Total 3.6 41.3 0.2 8.2 0.7 45.9 100.0 2,045 Note: Table excludes 9 births for which information on place of delivery is missing. 1 Feldsher is a mid-level health professional that provides medical care beyond the scope of a nurse but less than that of a physician. 10.4 BREAST CANCER AWARENESS AND TESTING In order to assess the level of awareness about breast cancer, women who were interviewed in the 2012 TjDHS were asked a series of questions. First they were asked if they had ever heard of breast cancer and if so, what signs or symptoms would lead them to think a woman had breast cancer. They were also asked if they knew how to give themselves a breast examination and, if so, when they most recently performed a self-exam. Finally, they were asked if a health provider had ever given them a breast examination—either a manual exam, an ultrasound, or a mammogram—and if so, when the most recent exam was performed. Maternal Health • 125 As shown in Table 10.10, less than half of all women reported that they had heard of breast cancer. Awareness of breast cancer is higher among older women, women in urban areas, women in Dushanbe and Sughd regions, women with more education, and those in the higher wealth quintiles. Table 10.10 Knowledge about breast cancer and symptoms of breast cancer Percentage of women age 15-49 who have heard of breast cancer, and among women who have heard of breast cancer, the percentage who reported knowing of specific symptoms of breast cancer, by background characteristics, Tajikistan 2012 Background characteristic Among all women Among women who have heard of breast cancer, percentage who report knowing of specific symptoms of breast cancer Percentage who have heard of breast cancer Number of women Lump in breasts Lump in lymph nodes Discharge from nipples Pain in breasts Inverted nipple Fatigue Weight loss Other Don't know Number of women Age 15-19 22.9 2,013 34.3 9.6 3.3 1.1 38.4 10.1 6.1 0.3 37.0 461 20-24 43.0 1,950 40.1 14.7 4.2 2.7 46.4 10.1 9.4 0.5 27.8 839 25-29 49.8 1,609 40.5 17.2 3.3 2.1 45.8 9.9 6.3 0.2 24.4 801 30-34 58.3 1,188 45.7 16.9 5.8 3.7 50.6 11.3 10.9 0.5 19.7 693 35-39 61.7 1,030 46.9 16.3 6.6 2.0 52.6 11.1 9.1 1.1 18.1 636 40-44 64.5 991 50.3 21.4 7.0 2.5 55.3 12.4 11.9 1.9 14.6 639 45-49 62.8 875 43.4 16.0 5.1 2.1 53.7 10.3 8.2 0.9 21.1 549 Residence Urban 57.4 2,413 50.0 17.3 5.9 3.0 44.0 10.7 8.8 0.9 21.2 1,385 Rural 44.6 7,243 40.2 15.9 4.6 2.1 51.3 10.8 9.0 0.7 23.7 3,233 Region Dushanbe 54.3 881 63.3 13.8 5.7 2.5 35.6 13.8 8.2 0.9 19.5 479 GBAO 44.2 220 44.5 17.0 7.0 4.1 42.8 5.1 2.2 0.0 23.6 97 Sughd 55.3 2,872 49.4 21.1 6.2 2.7 50.5 14.4 13.4 1.3 19.9 1,588 DRS 37.0 2,240 39.6 13.9 2.0 1.1 54.7 11.3 6.3 0.2 20.3 828 Khatlon 47.2 3,444 32.9 13.5 5.1 2.6 49.2 6.3 6.5 0.5 28.2 1,626 Education None/primary 29.9 567 26.1 9.4 6.2 1.3 47.2 9.0 12.4 0.8 35.0 170 General basic 37.1 3,349 35.6 12.6 3.7 2.3 48.7 10.9 5.5 0.4 27.8 1,241 General secondary 50.6 4,474 42.8 15.7 4.3 1.9 48.4 9.8 10.3 0.6 23.1 2,264 Professional primary/middle 75.1 645 56.2 22.0 8.2 2.7 50.4 10.7 9.6 2.6 15.4 485 Higher 73.9 620 57.8 25.6 8.3 5.0 52.8 15.7 9.5 0.7 12.2 459 Wealth quintile Lowest 40.3 1,878 30.7 10.2 3.7 2.1 52.5 9.8 7.2 0.9 29.7 757 Second 40.1 1,913 32.6 14.0 3.6 2.6 51.4 7.7 5.8 0.3 29.2 767 Middle 45.3 1,904 41.6 16.0 4.9 2.5 53.3 11.7 9.1 1.0 22.2 862 Fourth 53.7 1,971 48.0 19.5 6.0 2.0 47.1 11.4 11.2 0.7 20.5 1,058 Highest 59.0 1,989 54.9 19.0 6.0 2.7 44.2 12.1 9.8 0.7 17.2 1,174 Total 47.8 9,656 43.2 16.3 5.0 2.4 49.1 10.7 8.9 0.8 22.9 4,618 Among women who had heard of breast cancer, the most commonly reported signs or symptoms of breast cancer are inverted nipples (49 percent), breast lumps (43 percent), lumps in lymph nodes (16 percent), and fatigue (11 percent). With regard to breast examinations, only 3 percent of women have ever had any kind of breast exam from a health care provider—a manual exam, an ultrasound, or a mammogram (Table 10.11). Those more likely to have had such an exam include older women, those with living children, those in GBAO region and Dushanbe, and those with more education. 126 • Maternal Health Table 10.11 Breast examinations Among women age 15-49, percentage who have ever had a breast examination given by a health professional and percentage who know how to give breast self-examination and among them, the percent distribution by time since last breast self-examination, according to background characteristics, Tajikistan 2012 Background characteristic Percentage of women who ever had breast exam given by health provider Percentage of women who know how to give self-exam Number of women Among women who know how to give self-examination, percent distribution by last time performed breast self-examination Never Within past 3 months 3+ months ago Missing Total Number Age 15-19 0.3 0.5 2,013 * * * * 100.0 10 20-24 2.6 4.3 1,950 53.9 28.4 15.4 2.4 100.0 84 25-29 3.1 4.6 1,609 64.5 27.9 6.5 1.2 100.0 75 30-34 3.7 7.7 1,188 58.5 18.3 20.1 3.1 100.0 91 35-39 5.4 10.3 1,030 49.6 27.0 23.4 0.0 100.0 107 40-44 7.2 12.7 991 57.3 27.4 14.1 1.2 100.0 126 45-49 5.4 10.8 875 61.8 20.7 15.6 2.0 100.0 95 Number of living children 0 0.8 1.5 3,483 65.3 22.7 8.8 3.2 100.0 53 1-2 4.6 8.2 2,588 58.9 26.5 12.3 2.3 100.0 212 3-4 5.4 9.4 2,385 51.7 30.3 17.1 0.9 100.0 225 5+ 4.1 8.1 1,200 64.2 9.5 25.7 0.6 100.0 97 Marital status Never married 0.5 1.1 2,648 70.2 18.7 5.9 5.2 100.0 30 Married or living together 4.4 7.9 6,504 57.0 25.5 16.4 1.1 100.0 517 Divorced/separated/ widowed 4.9 8.1 504 56.3 19.6 19.4 4.6 100.0 41 Residence Urban 4.5 9.6 2,413 57.8 25.6 14.8 1.9 100.0 232 Rural 3.0 4.9 7,243 57.4 24.3 16.9 1.4 100.0 355 Region Dushanbe 5.8 9.2 881 52.8 25.6 19.7 1.9 100.0 81 GBAO 7.1 11.0 220 72.7 12.9 13.7 0.8 100.0 24 Sughd 5.4 7.7 2,872 55.4 26.9 17.1 0.6 100.0 220 DRS 2.3 3.3 2,240 35.2 55.3 9.5 0.0 100.0 73 Khatlon 1.5 5.5 3,444 69.0 11.6 16.1 3.2 100.0 189 Education None/primary 1.2 3.9 567 * * * * 100.0 22 General basic 2.2 3.2 3,349 58.1 24.6 15.7 1.6 100.0 109 General secondary 2.5 5.1 4,474 64.5 17.4 17.2 0.9 100.0 227 Professional primary/ middle 11.1 19.4 645 53.5 31.8 13.2 1.5 100.0 125 Higher 9.9 16.6 620 46.2 35.3 17.5 1.0 100.0 103 Wealth quintile Lowest 2.8 3.4 1,878 68.5 9.0 18.5 4.1 100.0 64 Second 2.5 3.4 1,913 56.7 17.1 22.1 4.1 100.0 65 Middle 2.0 4.8 1,904 64.6 20.8 14.6 0.0 100.0 91 Fourth 4.1 8.0 1,971 58.0 28.3 12.2 1.4 100.0 157 Highest 5.5 10.5 1,989 51.2 31.1 16.9 0.7 100.0 210 Total 3.4 6.1 9,656 57.6 24.8 16.1 1.6 100.0 587 Note: An asterisk denotes a figure based on fewer than 25 unweighted women and has been suppressed. Only 6 percent of women say they know how to give themselves a breast exam. Knowledge about breast self-examination is higher among older women, those who have living children, those who have ever been married, and those with more education and in the higher wealth quintiles. Even among women who know how to examine their own breasts, almost 6 in 10 say they have never performed a self-exam and only one-quarter have performed a self-exam in the three months before the survey. 10.5 AWARENESS OF CERVICAL CANCER Women interviewed in the 2012 TjDHS were also asked if they had ever heard about cervical cancer. As shown in Table 10.12, 42 percent of women said they had heard of cervical cancer. Knowledge of the illness is more common among older women, urban women, and those in Sughd region and Dushanbe. The proportion of women who have ever heard of cervical cancer increases with education and with wealth quintile. Maternal Health • 127 Table 10.12 Knowledge about cervical cancer and Pap smear/cervical cytology smear testing Among all women age 15-49, percentage who have heard of cervical cancer and percentage who ever had a Pap smear/cervical cytology smear test, and among women who ever had a Pap smear/cervical cytology smear test, the percent distribution by timing of their last Pap smear/cervical cytology smear test, by background characteristics, Tajikistan 2012 Background characteristic Among all women Among women who ever had a Pap smear test Percentage who have heard of cervical cancer Percentage who were ever given a Pap smear/cervi- cal cytology smear test Number of women Percentage who had their last Pap smear/cervi- cal cytology smear test within the last 12 months Percentage who had their last Pap smear/cervi- cal cytology smear test 1- 3 years ago Percentage not stated/ missing Total Number of women Age 15-19 16.0 0.8 2,013 * * * 100.0 15 20-24 36.2 7.3 1,950 66.3 30.9 2.8 100.0 142 25-29 46.0 10.9 1,609 47.5 52.2 0.3 100.0 175 30-34 53.6 10.3 1,188 32.0 61.5 6.5 100.0 122 35-39 58.1 9.4 1,030 29.1 53.0 17.9 100.0 96 40-44 61.0 11.0 991 17.8 58.2 24.0 100.0 109 45-49 53.1 9.9 875 22.8 42.3 34.9 100.0 87 Residence Urban 50.7 8.2 2,413 38.5 52.1 9.4 100.0 197 Rural 39.3 7.6 7,243 40.2 47.5 12.3 100.0 550 Region Dushanbe 51.0 8.2 881 49.2 46.3 4.5 100.0 72 GBAO 38.1 9.5 220 33.8 62.3 3.9 100.0 21 Sughd 53.1 15.1 2,872 40.5 45.1 14.4 100.0 434 DRS 31.2 1.8 2,240 (51.3) (46.3) (2.4) 100.0 40 Khatlon 38.2 5.2 3,444 32.1 57.6 10.3 100.0 179 Education None/primary 22.2 3.0 567 * * * 100.0 17 General basic 32.3 6.7 3,349 48.5 45.8 5.7 100.0 224 General secondary 44.6 7.8 4,474 31.9 53.1 15.1 100.0 350 Professional primary/middle 68.2 13.2 645 32.3 50.3 17.4 100.0 85 Higher 68.8 11.4 620 53.5 38.3 8.2 100.0 71 Wealth quintile Lowest 35.7 10.6 1,878 37.4 43.6 19.0 100.0 200 Second 34.4 6.9 1,913 40.1 50.0 9.9 100.0 131 Middle 38.3 6.8 1,904 34.5 54.2 11.3 100.0 129 Fourth 49.5 7.2 1,971 37.1 54.5 8.4 100.0 142 Highest 52.1 7.3 1,989 49.8 44.2 6.0 100.0 145 Total 42.2 7.7 9,656 39.7 48.7 11.5 100.0 747 Note:: Numbers in parentheses are based on 25-49 unweighted women; an asterisk denotes a figure based on fewer than 25 unweighted women and has been suppressed. The table also shows that only 8 percent of women in Tajikistan have ever had a Papanicolau (Pap test) or a cervical cytology smear test. Women in Sughd region are the most likely to have ever had a Pap test or a cervical cytology smear test, as are those with professional and higher education and surprisingly, those in the lowest wealth quintile. Among women who have ever had a Pap test or a cervical cytology smear test, only 40 percent had one in the 12 months before the survey. Since only 8 percent of women have ever had a Pap test, this means that only 3 percent of reproductive age women in Tajikistan had a Pap test or a cervical cytology smear test in the previous 12 months. 10.6 VISITS TO FAMILY DOCTOR Having a family doctor can presumably improve health care to the extent that there is a sustained and comfortable doctor-patient relationship. Knowledge about a patient’s health history can have enormous benefits for subsequent care. Women interviewed in the 2012 TjDHS were asked if they had a family doctor and if so, whether they had visited that doctor in the 12 months before the survey and if so, how many times. Results are shown in Table 10.13 by background characteristics. 12 8 • M at er na l H ea lth Ta bl e 10 .1 3 F am ily d oc to r P er ce nt ag e of w om en a ge 1 5- 49 w ho h av e a fa m ily d oc to r, an d am on g th em , t he p er ce nt ag e w ho v is ite d th e fa m ily d oc to r i n th e pa st 1 2 m on th s fo r a ny re as on , a nd p er ce nt d is tri bu tio n of w om en w ho v is ite d th e fa m ily d oc to r i n th e pa st 1 2 m on th s by n um be r o f v is its ; a nd th e m ed ia n nu m be r o f v is its to a fa m ily d oc to r, ac co rd in g to b ac kg ro un d ch ar ac te ris tic s, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic P er ce nt ag e of w om en w ho h av e a fa m ily d oc to r N um be r o f w om en A m on g w om en w ho ha ve a fa m ily d oc to r: A m on g w om en w ho v is ite d a fa m ily d oc to r i n th e pa st 1 2 m on th s, nu m be r o f v is its to th e fa m ily d oc to r: M ed ia n nu m be r o f vi si ts P er ce nt ag e w ho v is ite d th e fa m ily do ct or in p as t 12 m on th s N um be r o f w om en 1- 2 3- 5 6- 10 11 + D on 't kn ow M is si ng To ta l N um be r o f w om en A ge 15 -1 9 40 .9 2, 01 3 32 .4 82 3 46 .8 23 .3 13 .9 5. 0 10 .8 0. 2 10 0. 0 26 7 1. 9 20 -2 4 43 .9 1, 95 0 59 .3 85 7 37 .4 34 .2 16 .4 5. 3 6. 5 0. 2 10 0. 0 50 8 2. 7 25 -2 9 45 .9 1, 60 9 61 .6 73 8 34 .0 32 .9 21 .2 5. 9 5. 9 0. 1 10 0. 0 45 5 3. 0 30 -3 4 50 .0 1, 18 8 64 .8 59 4 36 .9 33 .7 19 .2 4. 7 5. 5 0. 0 10 0. 0 38 5 2. 7 35 -3 9 46 .1 1, 03 0 60 .4 47 5 38 .8 34 .9 12 .7 5. 6 7. 4 0. 6 10 0. 0 28 6 2. 5 40 -4 4 46 .0 99 1 55 .6 45 6 37 .6 37 .7 12 .9 8. 1 3. 7 0. 0 10 0. 0 25 3 2. 6 45 -4 9 45 .5 87 5 53 .4 39 8 44 .1 24 .7 20 .6 6. 4 4. 2 0. 0 10 0. 0 21 2 2. 4 N um be r o f l iv in g ch ild re n 0 42 .1 3, 48 3 35 .1 1, 46 7 49 .3 23 .3 14 .6 4. 7 7. 8 0. 3 10 0. 0 51 6 1. 9 1- 2 48 .4 2, 58 8 65 .3 1, 25 1 34 .1 35 .8 17 .8 5. 9 6. 4 0. 0 10 0. 0 81 8 3. 0 3- 4 46 .9 2, 38 5 65 .5 1, 11 9 36 .8 35 .6 16 .8 5. 8 4. 9 0. 1 10 0. 0 73 3 2. 7 5+ 41 .9 1, 20 0 59 .8 50 2 36 .0 29 .6 19 .9 6. 9 7. 0 0. 5 10 0. 0 30 0 2. 9 C ur re nt ly p re gn an t P re gn an t 47 .3 73 4 79 .5 34 7 34 .7 35 .6 20 .4 5. 3 3. 7 0. 3 10 0. 0 27 6 2. 9 N ot p re gn an t o r n ot s ur e 44 .8 8, 92 2 52 .4 3, 99 3 39 .0 31 .8 16 .6 5. 8 6. 7 0. 1 10 0. 0 2, 09 1 2. 6 M ar ita l s ta tu s N ev er m ar rie d 41 .8 2, 64 8 27 .3 1, 10 7 55 .4 18 .3 11 .6 4. 9 9. 5 0. 2 10 0. 0 30 3 1. 6 M ar rie d or li vi ng to ge th er 46 .1 6, 50 4 64 .7 2, 99 6 36 .1 34 .2 17 .9 5. 9 5. 8 0. 2 10 0. 0 1, 93 9 2. 8 D iv or ce d/ se pa ra te d/ w id ow ed 46 .9 50 4 52 .8 23 7 34 .9 36 .3 16 .6 5. 7 6. 6 0. 0 10 0. 0 12 5 2. 8 R es id en ce U rb an 57 .4 2, 41 3 52 .8 1, 38 6 34 .9 35 .4 18 .6 8. 2 2. 8 0. 2 10 0. 0 73 2 3. 0 R ur al 40 .8 7, 24 3 55 .3 2, 95 4 40 .1 30 .8 16 .4 4. 6 7. 9 0. 1 10 0. 0 1, 63 4 2. 5 R eg io n D us ha nb e 65 .6 88 1 60 .4 57 8 30 .3 40 .6 19 .6 7. 5 1. 7 0. 3 10 0. 0 34 9 3. 1 G B A O 17 .0 22 0 37 .6 37 57 .6 26 .8 12 .8 1. 4 1. 4 0. 0 10 0. 0 14 1. 8 S ug hd 55 .3 2, 87 2 51 .9 1, 58 7 43 .9 34 .4 13 .5 3. 5 4. 8 0. 0 10 0. 0 82 3 2. 3 D R S 22 .3 2, 24 0 79 .6 49 9 20 .8 19 .3 25 .3 11 .5 22 .9 0. 2 10 0. 0 39 8 4. 7 K ha tlo n 47 .6 3, 44 4 47 .8 1, 63 8 45 .2 33 .0 15 .5 4. 5 1. 7 0. 2 10 0. 0 78 3 2. 3 Ed uc at io n N on e/ pr im ar y 36 .9 56 7 52 .8 20 9 32 .1 33 .2 20 .3 4. 9 9. 0 0. 5 10 0. 0 11 1 3. 3 G en er al b as ic 39 .0 3, 34 9 53 .0 1, 30 7 37 .3 27 .8 18 .7 6. 8 9. 5 0. 0 10 0. 0 69 3 2. 7 G en er al s ec on da ry 46 .7 4, 47 4 54 .5 2, 08 9 40 .2 33 .6 16 .1 5. 4 4. 5 0. 3 10 0. 0 1, 13 9 2. 5 P ro fe ss io na l p rim ar y/ m id dl e 56 .8 64 5 53 .4 36 7 37 .9 35 .6 17 .5 4. 4 4. 7 0. 0 10 0. 0 19 6 2. 7 H ig he r 59 .2 62 0 61 .9 36 8 37 .5 36 .0 14 .9 5. 6 6. 1 0. 0 10 0. 0 22 8 2. 8 W ea lth q ui nt ile Lo w es t 37 .4 1, 87 8 44 .9 70 2 40 .6 30 .6 19 .6 5. 8 2. 9 0. 5 10 0. 0 31 5 2. 9 S ec on d 37 .8 1, 91 3 53 .3 72 4 43 .3 33 .9 15 .3 4. 8 2. 8 0. 0 10 0. 0 38 6 2. 4 M id dl e 39 .5 1, 90 4 57 .2 75 2 36 .8 29 .3 17 .9 4. 3 11 .7 0. 0 10 0. 0 43 1 2. 6 Fo ur th 50 .5 1, 97 1 58 .3 99 6 41 .4 29 .3 16 .2 3. 7 9. 2 0. 2 10 0. 0 58 0 2. 3 H ig he st 58 .6 1, 98 9 56 .1 1, 16 6 33 .2 36 .6 17 .0 9. 0 4. 1 0. 1 10 0. 0 65 4 3. 0 To ta l 44 .9 9, 65 6 54 .5 4, 34 0 38 .5 32 .2 17 .0 5. 7 6. 3 0. 1 10 0. 0 2, 36 7 2. 6 128 • Maternal Health Maternal Health • 129 Just under half (45 percent) of women age 15-49 say they have a family doctor. Differentials by age, number of children, and pregnancy and marital status are minor. However, urban women and those in Dushanbe and Sughd are considerably more likely to have a family doctor than other women. Only about one in five women in GBAO and DRS regions say they have family doctors. The proportion of women with family doctors increases with education and wealth quintile. Among women with a family doctor, just over half (55 percent) say they have visited the doctor in the 12 months before the survey. There is a hint that many visits to family doctors may be for reproductive health reasons. Pregnant women are far more likely to have visited their family doctor in the previous 12 months than women who are not pregnant (80 percent versus 52 percent). Similarly, women in the prime reproductive ages—late twenties and early thirties—are more likely than younger and older women to have seen their family doctors in the previous 12 months, as are those women who have at least some children. Women who are married are more likely to see their family doctor than those who are divorced, widowed, or separated and those who have never married. Women in DRS region and Dushanbe are also more likely to have visited their family doctor recently than women in other regions. Among women age 15-49 who visited their family doctor in the 12 months before the survey, about four in ten made one or two visits in that time period, while about one-third visited three to five times and almost one-quarter visited six or more times. The median number of visits to a family doctor in the 12 months before the survey is 2.6. 10.7 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from getting medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers women may face in seeking care during pregnancy and at the time of delivery. In the 2012 TjDHS, women were asked whether each of the following factors would be a big problem or not a big problem in seeking medical care for themselves when they are sick: getting permission to go for treatment, getting money needed for advice or treatment, distance to a health facility, and not wanting to go alone. As shown in Table 10.14, by far the most common problem—cited by 45 percent of women in Tajikistan—is getting money for treatment. Additionally, distance to a health facility and not wanting to go alone are reported as problems by 26-29 percent of women. Seventeen percent of women perceived getting permission to go for treatment to be a very serious problem. Over half of women interviewed cited at least one of the stated factors to be a serious problem in accessing health care. The proportion of women who report at least one of the issues as a serious problem in getting health care for themselves varies most strongly by education and wealth quintile. For example, among women with no education or only primary education, the proportion who report at least one of the problems in getting health care (72 percent) is more than twice as high as it is among women with higher than professional education (32 percent). Rural women and those in Khatlon and GBAO regions are also more likely than women in urban areas or other regions to cite at least one problem. As for specific factors, getting permission to go for treatment are bigger problems for women in GBAO and Khatlon regions and for women with less education and less wealth than for other women. Getting money for treatment is more likely to be reported by women who are divorced, separated, or widowed and by women in Khatlon region. Each of the four factors is more likely to be reported as a serious problem by rural women than by urban women. Similarly, for each of the four factors, there is a steady decrease in the proportion of women who report them as serious problems in accessing health care as education and wealth quintile increase. 130 • Maternal Health Table 10.14 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Tajikistan 2012 Background characteristic Problems in accessing health care Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone At least one problem accessing health care Number of women Age 15-19 18.1 40.6 27.7 33.5 54.0 2,013 20-34 18.9 44.9 30.2 27.3 55.6 4,747 35-49 13.5 46.4 28.4 18.6 54.4 2,896 Number of living children 0 18.8 43.4 30.4 32.5 55.8 3,483 1-2 17.5 41.8 25.6 23.6 52.0 2,588 3-4 13.9 45.2 27.2 19.4 53.8 2,385 5+ 18.0 51.9 36.7 25.1 60.8 1,200 Marital status Never married 18.4 43.8 29.6 33.2 56.3 2,648 Married or living together 16.5 43.8 28.7 23.4 53.8 6,504 Divorced/separated/widowed 18.0 56.8 32.2 20.9 62.3 504 Employed last 12 months Not employed 17.3 42.2 27.6 27.1 53.7 6,529 Employed for cash 14.3 48.1 27.8 20.8 55.2 2,295 Employed not for cash 23.4 52.0 44.8 30.8 63.6 823 Residence Urban 9.6 36.5 12.4 17.4 44.7 2,413 Rural 19.7 47.1 34.7 28.8 58.3 7,243 Region Dushanbe 9.5 45.1 10.6 22.7 55.2 881 GBAO 24.6 47.0 32.6 28.7 60.3 220 Sughd 11.7 37.1 23.4 19.8 47.6 2,872 DRS 16.2 37.7 25.7 22.2 46.9 2,240 Khatlon 23.8 54.6 40.6 34.2 65.8 3,444 Education None/primary 25.4 59.3 45.4 38.9 72.3 567 General basic 20.4 47.0 33.1 32.8 59.4 3,349 General secondary 16.3 44.8 28.3 23.6 54.7 4,474 Professional primary/middle 9.4 35.5 17.1 12.4 40.6 645 Higher 5.7 23.8 10.9 8.3 31.5 620 Wealth quintile Lowest 32.3 69.1 55.6 42.6 77.9 1,878 Second 21.0 51.6 38.3 31.1 63.1 1,913 Middle 14.1 40.8 26.7 24.0 52.0 1,904 Fourth 11.8 31.4 17.5 18.8 44.1 1,971 Highest 7.2 30.8 9.1 14.3 38.9 1,989 Total 17.1 44.5 29.1 26.0 54.9 9,656 Note: Table excludes eight women for whom information on employment is missing. Child Health • 131 CHILD HEALTH 11 his chapter presents findings in several areas of importance to child health, including the mother’s estimate of her baby’s size at birth, the vaccination status of children, and the prevalence and treatment of important childhood illnesses. Information on perceived size at birth is important for the design and implementation of programs aimed at reducing neonatal and infant mortality. Information on vaccination coverage focuses on children age 18-29 months. Overall coverage levels at the time of the survey, and at age 18 months, are shown for this group. In addition, the source of the information—a written vaccination card or the mother’s recall—is shown. Knowing how vaccination coverage varies among subgroups of the population can aid in program planning. Examining treatment practices and contact with health services for children with the three most important childhood illnesses—acute respiratory infection (ARI), fever, and diarrhea—can help assess national programs aimed at reducing mortality from these illnesses. Information is provided on the prevalence of ARI, fever, and diarrhea in the two weeks before the survey and the extent to which treatment was sought from a health facility or medically trained provider. Measuring the coverage of oral rehydration therapy (ORT) and increased fluids to treat diarrheal disease can help assess the effectiveness of programs that recommend these treatments. 11.1 CHILD’S SIZE AND WEIGHT AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to the risk of childhood illness and chances of survival. Children whose birth weight is less than 2.5 kilograms, i.e., low birth weight (LBW), have a higher than average risk of early childhood death. In the 2012 TjDHS, for births in the five years before the survey, the actual birth weight was recorded in kilograms in the Woman’s Questionnaire, based on either the child’s health card or the mother’s recall. Because birth weight was likely to be unknown for some babies, particularly for those born at home, the mother’s estimate of the baby’s size was also obtained in the TjDHS. A mother’s report of a child being “very small” or “smaller than average,” even though subjective, is considered a useful proxy for LBW. T Key Findings • Almost all children age 18-29 months (89 percent) are fully vaccinated against the major childhood illnesses. • Roughly three in five children under age 5 with symptoms of acute respiratory infection or fever were taken to a health facility or provider for advice or treatment. • Fifteen percent of children under age 5 had diarrhea in the two weeks preceding the survey. Of these children, 54 percent received treatment from a health facility or health provider, and 72 percent were given oral rehydration therapy (ORT). Only one-third of the children with diarrhea were given more liquids than usual. • Over 90 percent of mothers of children under age 5 have heard about oral rehydration packets (Rehydron). • Safe disposal of young children’s stool is widespread; 90 percent of mothers report that the last time their youngest child under age 5 passed stool, they disposed of the fecal material in a safe manner. 132 • Child Health Table 11.1 shows that an actual birth weight was recorded for more than four in five children (83 percent). Of these, 7 percent were reported to have weighed less than 2.5 kg at birth. Low birth weight is slightly more common among births to women under age 20 or age 35 and older, among first births and sixth and higher births, and among births in the GBAO region. There is no clear relationship between low birth weight and maternal education; however, the likelihood of having a low-birth-weight baby decreases as wealth quintile increases. Table 11.1 Child's size and weight at birth Percent distribution of live births in the five years preceding the survey by mother’s estimate of baby’s size at birth, percentage of live births in the five years preceding the survey that have a reported birth weight, and among live births in the five years preceding the survey with a reported birth weight, percentage less than 2.5 kg, according to background characteristics, Tajikistan 2012 Background characteristic Percent distribution of all live births by size of child at birth Total Percentage of all births that have a reported birth weight1 Number of births Births with a reported birth weight1 Very small Smaller than average Average or larger Don't know/ missing Percentage less than 2.5 kg Number of births Mother's age at birth <20 4.5 11.8 73.3 10.3 100.0 82.0 480 10.2 393 20-34 2.3 10.4 78.5 8.7 100.0 84.4 4,321 6.7 3,648 35-49 3.4 11.3 73.3 12.0 100.0 72.3 433 9.3 313 Birth order 1 4.1 12.5 76.7 6.7 100.0 88.7 1,765 9.4 1,567 2-3 1.8 9.0 79.5 9.7 100.0 82.8 2,256 5.1 1,869 4-5 1.9 9.8 77.1 11.2 100.0 78.8 889 6.9 700 6+ 3.0 13.3 71.2 12.4 100.0 67.7 323 10.1 219 Residence Urban 1.9 8.7 84.5 4.9 100.0 90.8 1,119 6.1 1,016 Rural 2.8 11.1 75.8 10.3 100.0 81.1 4,114 7.5 3,339 Region Dushanbe 1.6 10.2 84.0 4.2 100.0 89.7 414 6.2 371 GBAO 7.0 12.5 78.2 2.3 100.0 89.6 91 11.9 82 Sughd 1.0 7.8 90.2 1.0 100.0 95.5 1,383 6.1 1,321 DRS 2.9 10.5 68.8 17.8 100.0 77.0 1,316 6.9 1,013 Khatlon 3.5 12.6 73.5 10.3 100.0 77.2 2,029 8.3 1,568 Mother's education None/primary 1.9 12.6 70.7 14.8 100.0 77.2 452 7.2 349 General basic 3.1 10.6 74.9 11.3 100.0 80.0 2,063 8.3 1,650 General secondary 2.3 10.3 79.6 7.8 100.0 84.2 2,161 6.2 1,822 Professional primary/middle 3.0 11.4 83.2 2.3 100.0 94.9 302 10.7 287 Higher 2.8 8.2 88.0 1.0 100.0 96.8 255 3.4 247 Wealth quintile Lowest 2.7 11.0 70.3 16.0 100.0 66.7 1,062 9.5 709 Second 2.7 11.0 72.8 13.4 100.0 77.6 1,132 7.8 879 Middle 2.9 11.9 77.5 7.8 100.0 86.4 1,092 6.8 943 Fourth 2.7 9.6 84.1 3.6 100.0 93.4 1,037 6.4 970 Highest 2.1 9.2 85.0 3.7 100.0 93.9 909 5.8 853 Total 2.6 10.6 77.6 9.1 100.0 83.2 5,233 7.2 4,354 1 Based on either a written record or the mother's recall. Table 11.1 also includes information on the mother’s estimate of the baby’s size at birth. According to their mother’s estimate, 3 percent of children were very small at birth, 11 percent were smaller than average, and 78 percent were average or larger in size. Differentials in the proportion of children reported at birth as either very small or smaller than average are generally similar to those cited above for low birth weight. The 2005 Tajikistan MICS survey collected information on the birth weight and size for the last live birth in the two years before the survey. Thus, to examine trends since the 2005 MICS, the 2012 TjDHS estimate of the percentage of children with a reported birth weight had to be re-calculated based on information for the last live birth in the two years before the survey. The proportion of births with a reported birth weight has increased from 66 percent in the 2005 MICS (SCS, 2007) to 85 percent in the 2012 TjDHS (data not shown). The 2005 Tajikistan MICS prevalence of LBW was calculated combining reported low birth weight from the card and the mother’s assessment of the child’s size at birth, and therefore cannot be compared with LBW data from the 2012 TjDHS. Child Health • 133 11.2 VACCINATION OF CHILDREN Universal immunization of children under age 1 against major vaccine-preventable diseases is one of the most cost-effective of all programs to reduce infant and child morbidity and mortality. Tajikistan’s Ministry of Health has adopted the World Health Organization (WHO) guidelines for childhood immunizations that call for all children to receive the following: a BCG vaccination against tuberculosis; three doses of DPT to prevent diphtheria, pertussis, and tetanus; three doses of polio vaccine; and a measles vaccine during the first year of life. In addition to these standard vaccinations, since 2001, the Ministry of Health has recommended that children receive three doses of the hepatitis B vaccine, with the first dose given at birth (MOH, 2001; Khodjamuradov and Rechel, 2010). Before 2008, children were given only three doses of hepatitis B vaccine; after 2008, in addition to the first dose given at birth, children receive three doses of the hepatitis B vaccine as part of the pentavalent vaccine, i.e., four times in total (MOH, 2008). The pentavalent vaccine protects against diphtheria, pertussis, and tetanus (DPT); hepatitis B; and Hemophilus influenza type B (Hib), and is given at 2-3-4 months according to the immunization schedule. Since 2009, the recommended national immunization schedule includes an MR vaccination to be given at age 12 months and 6 years to protect against measles and rubella (MOH, 2009). Information on vaccination coverage was collected in the 2012 TjDHS for all children under age 5. In Tajikistan, child health cards (MOH form 112) and vaccination forms (MOH form 63) are maintained in the local health care facilities. On rare occasions, child vaccination passports are kept at home. In this survey, data were collected from three sources when available during the survey visit. If the mother was able to show the child vaccination passport, the dates of vaccinations were transferred from the card to the questionnaire. In the event that the mother did not have a child vaccination passport, she was asked to recall her child’s immunizations. After all the interviews in a cluster were completed, the TjDHS team supervisor visited the local health facility to record information from the health cards (MOH forms 112 and 63) of the children in the sample. Health facility cards were found for 89 percent of children age 18-29 months, while 13 percent had immunization records that were seen at home (data not shown). Thus, while most of the data about immunization coverage are based on vaccination cards, in the case of children for whom a vaccination card was not located or was missing information on specific vaccines, the data are based on the mother’s recall. 11.2.1 Vaccination Coverage Table 11.2 presents information on vaccination coverage according to the source of information. Data are presented for children age 18-29 months, thereby including only those children who have reached the age by which they should be fully vaccinated. The first three rows show the proportions of these children vaccinated at any time before the survey. These results are presented according to the source of the information used to determine coverage, that is, a vaccination card—whether seen at home or at the health facility—a mother’s report, or either source. The last row shows the proportion of children who had been vaccinated by age 18 months, the age by which vaccination coverage should be complete. 134 • Child Health Table 11.2 Vaccinations by source of information Percentage of children age 18-29 months who received specific vaccines at any time before the survey, by source of information (vaccination card at home or at a health facility or mother's report), and percentage vaccinated by 18 months of age, Tajikistan 2012 Source of information BCG Hepatitis B at birth DPT/ pentavalent1 Polio 02 Polio 1 Polio 2 Polio 3 Measles or MR All basic vaccina- tions3 All basic3 plus hepatitis B at birth No vaccina- tions Number of children1 2 3 Vaccinated at any time before survey Vaccination card4 90.6 88.5 90.6 89.8 88.5 90.2 90.6 90.5 88.5 88.5 85.7 84.2 0.0 1,044 Mother's report 7.6 5.0 6.9 5.7 4.6 5.4 6.8 6.1 3.8 6.7 3.0 2.2 0.9 103 Either source 98.3 93.4 97.5 95.5 93.1 95.6 97.4 96.5 92.3 95.2 88.7 86.4 0.9 1,148 Vaccinated by 18 months of age5 98.3 93.4 97.4 95.2 91.7 95.6 97.3 96.3 91.7 91.4 84.3 82.0 0.9 1,148 1 The pentavalent vaccine contains DPT, hepatitis B, and Hemophilus influenza type B (Hib) vaccines. 2 Polio 0 is the polio vaccination given at birth. 3 BCG, measles or MR, and three doses each of DPT/pentavalent and polio vaccine (excluding polio vaccine given at birth). 4 Includes immunization cards kept by the parent/guardian and in the health facility. 5 For children whose information is based on the mother's report, the proportion of vaccinations given during the first 18 months of life is assumed to be the same as for children with a written record of vaccination. According to information from both vaccination cards and mothers’ reports, 89 percent of children age 18-29 months are fully vaccinated (Figure 11.1). A slightly lower proportion of children (86 percent) received the entire course of MOH-recommended vaccinations, which includes hepatitis B at birth (Table 11.2). Almost all children (at least 97 percent) had received vaccinations for BCG and the first doses of polio and DPT/pentavalent. Ninety-three percent received a vaccination for hepatitis B at birth. The proportions of children receiving the second and third doses of polio and DPT/pentavalent are slightly lower, as is the proportion receiving the measles or MR vaccine. For example, 98 percent of children received the first dose of DPT/pentavalent, compared with 93 percent who received the third dose. Thus, the dropout rate1 between the first and third doses of DPT/pentavalent is 5 percent. The corresponding dropout rate for polio is also 5 percent. Less than 1 percent of children age 18-29 months have not received any vaccinations. Figure 11.1 Percentage of children age 18-29 months with specific vaccinations, Tajikistan 2012* Tajikistan DHS 2012 1 Dropout rate = (Dose 1 – Dose 3) * 100/Dose 1 Child Health • 135 Vaccinations are most effective when given at the proper age. In Tajikistan, it is recommended that children complete the schedule of immunizations during the first 18 months of life. Overall, 84 percent of children age 18-29 months had received all the recommended vaccinations before reaching 18 months of age. 11.2.2 Differentials in Vaccination Coverage Table 11.3 shows that vaccination cards were seen either at home or at the health facility for 91 percent of children age 18-29 months. The table shows that differences by sex and urban-rural residence in the proportion of children who have received all the basic WHO-recommended vaccinations are very small. However, there are marked variations by region and maternal education (Figure 11.2). Children living in the Sughd and Khatlon regions are more likely than children in other regions to be fully vaccinated (93 percent and 91 percent, respectively). Children born to mothers with general secondary education are more likely to be fully vaccinated (93 percent) than children of mothers with other levels of education. Table 11.3 Vaccinations by background characteristics Percentage of children age 18-29 months who received specific vaccines at any time before the survey (according to a vaccination card at home or health facility or the mother's report), and percentage with any vaccination card, by background characteristics, Tajikistan 2012 Background characteristic BCG Hepatitis B at birth DPT/Pentavalent1 Polio 02 Polio 1 Polio 2 Polio 3 Measles or MR All basic vaccina- tions3 All basic3 plus Hepatitis B at birth No vaccina- tions Percent- age with any vaccina- tion card seen Number of children1 2 3 Sex Male 98.3 92.8 98.1 96.5 94.2 95.9 97.6 97.2 93.6 95.0 89.3 86.6 0.6 90.3 604 Female 98.2 94.1 96.8 94.4 91.9 95.3 97.2 95.8 90.8 95.5 88.1 86.2 1.2 91.7 544 Birth order 1 98.7 95.5 98.2 95.8 93.6 96.7 97.5 96.0 92.5 95.5 88.9 87.5 1.0 89.8 384 2-3 98.0 91.1 96.7 95.0 91.8 94.9 97.3 96.4 91.1 95.3 87.1 84.2 0.7 89.4 496 4-5 99.3 95.5 99.1 96.5 96.4 95.8 97.3 97.3 95.0 96.5 93.3 90.1 0.7 95.5 191 6+ 95.0 93.0 94.9 94.9 90.4 95.0 98.0 98.0 92.4 90.4 87.4 86.4 2.0 95.8 77 Residence Urban 98.5 94.3 96.4 94.0 91.8 97.2 95.9 93.9 91.2 93.7 87.7 86.1 1.1 88.9 230 Rural 98.2 93.2 97.8 95.9 93.4 95.2 97.8 97.2 92.6 95.6 89.0 86.5 0.8 91.5 918 Region Dushanbe 97.6 91.1 93.4 90.8 86.9 95.9 94.9 91.3 86.7 93.3 83.0 80.9 1.4 83.6 90 GBAO 98.8 89.3 98.9 92.6 86.8 90.7 97.6 96.4 92.9 96.4 83.1 77.2 0.0 89.3 17 Sughd 100.0 97.9 98.4 96.4 95.3 97.4 98.9 98.9 95.8 96.9 93.3 92.4 0.0 98.1 288 DRS 97.0 88.1 96.6 93.8 91.8 92.2 97.2 94.9 86.0 95.3 82.7 76.9 1.4 83.8 292 Khatlon 98.2 94.6 98.2 97.0 94.0 96.8 97.1 97.1 95.1 94.5 91.0 90.2 1.0 92.6 459 Mother's education None/primary 97.6 88.9 95.7 92.5 90.0 93.8 95.3 94.0 88.8 93.0 86.2 83.0 1.6 85.1 99 General basic 97.5 91.2 96.6 95.6 92.2 94.2 96.5 96.0 90.8 94.3 86.4 83.3 1.1 90.4 433 General secondary 98.8 95.7 98.7 97.3 95.6 97.7 99.3 98.7 95.6 96.4 92.7 90.8 0.6 93.7 494 Professional primary/ middle 99.7 97.5 99.4 93.0 92.4 92.4 93.1 91.7 88.7 96.9 87.8 87.8 0.0 91.3 67 Higher 98.5 94.1 93.9 87.0 83.7 95.1 96.5 92.7 84.6 93.8 77.7 76.8 1.5 81.3 55 Wealth quintile Lowest 95.9 90.6 97.2 96.4 92.9 92.5 96.5 96.4 94.3 92.7 88.7 86.8 1.7 90.4 231 Second 99.7 94.3 100.0 97.8 95.6 98.1 98.3 98.0 95.4 97.7 92.4 88.9 0.0 93.4 265 Middle 99.0 95.3 96.2 94.8 92.7 94.8 97.1 96.6 90.0 95.0 88.5 86.8 1.0 91.2 250 Fourth 98.5 92.6 96.7 93.7 91.9 96.1 97.7 96.2 90.1 96.0 86.3 83.7 0.7 90.0 213 Highest 98.0 94.3 96.8 94.1 91.6 96.7 97.3 95.0 90.9 94.4 86.7 85.2 1.1 89.2 189 Total 98.3 93.4 97.5 95.5 93.1 95.6 97.4 96.5 92.3 95.2 88.7 86.4 0.9 91.0 1,148 1 The pentavalent vaccine contains DPT, hepatitis B, and Hemophilus influenza type B (Hib) vaccines. 2 Polio 0 is the polio vaccination given at birth. 3 BCG, measles or MR, and three doses each of DPT/pentavalent and polio vaccine (excluding polio vaccine given at birth). 136 • Child Health Figure 11.2 Differentials in vaccination coverage, Tajikistan 2012 Tajikistan DHS 2012 11.2.3 Trends in Vaccination Coverage The results of the 2012 TjDHS indicate that vaccination coverage has increased substantially for all basic WHO-recommended vaccinations over the past seven years among children age 18-29 months. The 2005 Tajikistan MICS survey reported that only 77 percent of children age 18-29 months were fully immunized by the date of the interview; however, this percentage had increased to 89 percent in the 2012 TjDHS (SCS, 2007). The improvement is mainly due to an increase in the proportions of children receiving the second and third doses of polio and DPT/pentavalent. Vaccination coverage for measles or MR has increased slightly, from 92 percent in 2005 to 95 percent in 2012. It should be noted that in the 2012 TjDHS, immunization records from a vaccination card kept at home or in a heath facility were found for 91 percent of children age 18-29 months compared with 83 percent of children in the 2005 MICS (SCS, 2007). 11.3 CHILDHOOD ILLNESS AND TREATMENT This section discusses three illnesses that are major contributors to childhood morbidity and mortality in many countries: acute respiratory infection (ARI), fever, and diarrhea. Estimates of the prevalence of these illnesses as well as data concerning types of treatment are presented. 11.3.1 Acute Respiratory Infections (ARI) Acute respiratory infections (ARIs), primarily pneumonia, are a leading cause of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can reduce the number of deaths caused by ARIs, particularly deaths resulting from pneumonia. The 2012 TjDHS estimated the prevalence of ARIs by asking mothers whether their children under age 5 had been ill in the two weeks preceding the survey with a cough accompanied by short, rapid breathing or by difficulty in breathing that the mother considered to be chest-related. These symptoms are considered to be a proxy for pneumonia. Child Health • 137 Table 11.4 shows that less than 1 percent of children under age 5 had symptoms of an ARI, that is, cough accompanied by short, rapid breathing and/or by difficult breathing, which was chest-related, at some time in the two weeks preceding the survey. The prevalence of ARIs varies little by background characteristics, though it appears to be slightly higher among children in GBAO than among those in other regions. The prevalence of suspected ARIs has hardly changed since 2005, when the prevalence was 2 percent of children under age 5 (SCS, 2007). Sixty-three percent of the children with symptoms of ARI were taken to a health facility or a medically trained provider for treatment (data not shown). The number of children with ARI symptoms is insufficient to show data on treatment by background characteristics. The 2005 MICS also showed that 64 percent of children with a suspected ARI were taken for treatment (SCS, 2007). Table 11.4 Prevalence and treatment of symptoms of ARI Among children under age 5, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, according to background characteristics, Tajikistan 2012 Background characteristic Among children under age 5: Percentage with symptoms of ARI1 Number of children Age in months <6 0.8 442 6-11 0.7 591 12-23 1.4 1,072 24-35 0.5 1,146 36-47 0.8 930 48-59 1.0 851 Sex Male 0.7 2,566 Female 1.1 2,465 Cooking fuel Electricity or gas 1.1 3,236 Wood/straw2 0.7 1,450 Animal dung 0.1 335 Other fuel (0.0) 10 Residence Urban 1.2 1,086 Rural 0.8 3,945 Region Dushanbe 0.9 404 GBAO 3.8 88 Sughd 0.4 1,343 DRS 0.8 1,271 Khatlon 1.2 1,924 Mother's education None/primary 0.2 435 General basic 1.2 1,975 General secondary 0.6 2,083 Professional primary/middle 1.1 289 Higher 1.7 249 Wealth quintile Lowest 0.7 1,007 Second 1.4 1,081 Middle 0.6 1,045 Fourth 0.9 1,007 Highest 0.8 891 Total 0.9 5,031 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Symptoms of ARI (cough accompanied by short, rapid breathing, which was chest-related, and/or by difficult breathing, which was chest-related) are considered a proxy for pneumonia. 2 Includes grass, shrubs, crop residues. 138 • Child Health 11.3.2 Fever Table 11.5 shows that 9 percent of children under age 5 had a fever during the two weeks preceding the survey. The prevalence of fever varies by age, with children age 6-23 months being more likely to have a fever than either younger or older children. The prevalence of fever is highest among children residing in the Khatlon region (15 percent)—where the burden of malaria has been the greatest— and lowest in the Sughd (4 percent) and DRS (5 percent) regions. Fever is slightly more common among children whose mothers have no education or only primary education and among those in the lowest wealth quintile. Table 11.5 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey and, among children with fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who received antibiotics as treatment, by background characteristics, Tajikistan 2012 Background characteristic Among children under age 5: Among children under age 5 with fever Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children Age in months <6 7.0 442 (73.8) (0.0) (66.3) 31 6-11 15.7 591 56.5 2.7 50.9 93 12-23 14.8 1,072 59.1 2.7 55.7 159 24-35 9.4 1,146 52.9 1.2 47.0 108 36-47 5.0 930 (54.0) (0.0) (39.0) 46 48-59 3.3 851 (48.3) (4.8) (29.0) 28 Sex Male 10.4 2,566 57.3 2.0 49.5 266 Female 8.1 2,465 56.5 2.1 51.1 199 Residence Urban 10.9 1,086 61.3 1.9 62.4 118 Rural 8.8 3,945 55.5 2.1 46.0 347 Region Dushanbe 11.3 404 57.8 0.6 60.4 46 GBAO 11.8 88 44.2 3.8 24.5 10 Sughd 4.0 1,343 (76.7) (10.0) (63.5) 54 DRS 4.8 1,271 51.2 1.6 47.1 60 Khatlon 15.3 1,924 54.8 0.9 47.7 295 Mother's education None/primary 12.3 435 (52.7) (0.0) (49.6) 53 General basic 9.4 1,975 56.2 2.8 53.3 186 General secondary 8.7 2,083 58.6 2.4 44.2 181 Professional primary/middle 7.4 289 (68.1) (0.0) (72.4) 21 Higher 9.6 249 (50.2) (0.0) (52.2) 24 Wealth quintile Lowest 12.1 1,007 47.9 1.4 40.8 122 Second 10.2 1,081 51.6 0.9 46.3 110 Middle 7.3 1,045 62.1 1.8 55.0 76 Fourth 7.3 1,007 67.6 3.4 55.0 74 Highest 9.4 891 63.3 3.6 60.3 84 Total 9.2 5,031 57.0 2.1 50.2 465 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, traditional practitioner, and market. Nearly three in five children with fever were taken to a health facility or a medically-trained provider for treatment. Only 2 percent of children with fever were given antimalarial medicines. Half of children with fever were given antibiotics. Analysis of differences in treatment patterns by background characteristics is hampered by the small numbers of children with fever in some groups. Nevertheless, it is clear that the percentages of children with fever who are taken to a health facility or provider or who are Child Health • 139 given antibiotics increase with wealth. Urban children with fever are also more likely than rural children to receive antibiotics and to be taken to a health facility for treatment. The 2005 MICS survey reported that 7 percent of children under 5 had a fever in the two weeks before the survey, almost indistinguishable from the level of 9 percent reported in the 2012 TjDHS (SCS, 2007). The MICS also found higher levels of fever in the Khatlon region than in other regions. Only 2 percent of children with fever were treated with an antimalarial drug in the 2005 MICS, a finding identical to the proportion in the 2012 TjDHS. 11.3.3 Diarrhea Diarrhea remains a leading cause of childhood morbidity and mortality in developing countries. Dehydration caused by severe diarrhea is a major cause of illness among young children, although the condition can be easily treated with oral rehydration therapy (ORT). The child with diarrhea is given a solution that can be prepared by mixing water with a commercially-prepared packet of oral rehydration salts (ORS)—also known in Tajikistan as Rehydron—or by making a homemade mixture of sugar, salt, and water. The 2012 TjDHS asked mothers if any of their children under age 5 had experienced an episode of diarrhea in the two weeks before the survey. If the child had diarrhea during this period, the mother was asked what she did to treat the diarrhea. Because the prevalence of diarrhea varies seasonally, the survey results pertain only to the period from July through September when the fieldwork took place. Table 11.6 presents information on episodes of diarrhea among young children in the two weeks before the interview. Overall, 15 percent of children under age 5 were reported to have had diarrhea in the two-week period before the survey. The prevalence of diarrhea is highest at age 6-23 months, a period during which solid and/or semi-solid foods are first introduced into the child’s diet. This pattern is believed to be associated with increased exposure to illness as a result of both weaning and the greater mobility of the child, as well as the immature immune system of children in this age group. The prevalence of diarrhea is slightly higher among boys and children living in urban areas than among other children. It is Table 11.6 Prevalence of diarrhea Percentage of children under age 5 who had diarrhea in the two weeks preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Diarrhea in the two weeks preceding the survey Number of children All diarrhea Diarrhea with blood Age in months <6 10.4 0.0 442 6-11 23.2 1.9 591 12-23 24.3 2.1 1,072 24-35 15.3 1.6 1,146 36-47 8.9 0.8 930 48-59 6.6 0.9 851 Sex Male 16.5 1.8 2,566 Female 13.5 0.9 2,465 Source of drinking water1 Improved 15.1 1.2 3,720 Not improved 14.8 1.6 1,308 Toilet facility2 Improved, not shared 15.1 1.3 4,726 Shared3 12.7 2.7 113 Non-improved 14.7 1.2 190 Residence Urban 17.9 1.5 1,086 Rural 14.3 1.3 3,945 Region Dushanbe 17.4 1.1 404 GBAO 16.4 0.9 88 Sughd 7.5 0.3 1,343 DRS 9.3 0.5 1,271 Khatlon 23.5 2.7 1,924 Mother's education None/primary 18.7 1.7 435 General basic 16.2 1.9 1,975 General secondary 13.4 0.7 2,083 Professional primary/ middle 14.5 1.0 289 Higher 14.0 1.1 249 Wealth quintile Lowest 16.3 2.3 1,007 Second 15.7 1.0 1,081 Middle 13.7 1.2 1,045 Fourth 13.1 0.7 1,007 Highest 16.7 1.4 891 Total 15.1 1.3 5,031 Note: Total includes three children for whom source of drinking water is missing and two children for whom type of toilet facility is missing. 1 See Table 2.1 for definition of categories. 2 See Table 2.2 for definition of categories. 3 Facilities that would be considered improved if they were not shared by two or more households. 140 • Child Health considerably higher among children in the Khatlon region (24 percent) than among children in the Dushanbe and GBAO regions (16-17 percent) and especially those in the Sughd and DRS regions (8-9 percent). The relationship between diarrhea prevalence with mother’s education and wealth is not linear, but it is highest among children of mothers with no education or only primary education. Only 1 percent of children under 5 were reported to have had bloody diarrhea in the two weeks before the survey, a symptom usually associated with dysentery. There are no major differences in the prevalence of bloody diarrhea by background characteristics. Table 11.7 shows data on the treatment of recent episodes of diarrhea among children under age 5, as reported by their mothers. Overall, more than half (54 percent) of children with diarrhea were taken to a medically trained health provider for advice or treatment. Children age 12-23 months, children with bloody diarrhea, children living in the Sughd region, and children from households in the middle wealth quintile are more likely than other children to visit a health professional or a health facility to treat the diarrhea. More than four in five children with diarrhea (82 percent) were given oral rehydration therapy (ORT) or increased fluids. Sixty percent of children with diarrhea received fluid from oral rehydration salt (ORS) packets, while 29 percent received a recommended homemade fluid. Overall, 72 percent were given either ORS or a recommended homemade fluid. One in three children was given increased liquids, while half of children were given antibiotics to treat the diarrhea. Twenty-two percent of children were given home remedies to treat the diarrhea, while 4 percent of children were given nothing to treat the diarrhea. In general, differences by background characteristics in the treatment of childhood diarrhea are not large, except that almost all types of treatments reported are more prevalent among the small number of children with bloody diarrhea than among those with non-bloody diarrhea. Use of ORS packets generally increases with maternal education and is also more common in the GBAO region. Use of recommended home fluids is more widespread in DRS region than in other regions. Children in urban areas and especially those in Dushanbe are relatively more likely to be given increased fluids when they have diarrhea. Use of antibiotics is particularly high for children in the Khatlon region, while antimotility drugs are more widely used in Dushanbe than in other regions. It is interesting to note that use of antibiotics tends to decrease as wealth quintile increases. The 2005 MICS survey reported 13 percent of children under five as having diarrhea in the two weeks before the survey, almost identical to the 15 percent reported in the 2012 TjDHS (SCS, 2007). It appears that treatment with ORS packets has increased, from 48 percent of children with diarrhea in 2005 to 60 percent in 2012. Use of recommended home fluids has increased only slightly from 25 to 29 percent of children with diarrhea. Use of either ORS or recommended home fluids has increased from 58 percent to 72 percent of children with diarrhea between 2005 and 2012. Mothers are encouraged to continue feeding children with diarrhea normally and to increase the amount of fluids they offer. The 2012 TjDHS asked mothers who had a child under age 5 with a recent episode of diarrhea how much they gave the child to drink and eat during the diarrheal episode compared with usual practice. Table 11.8 shows that only one-third of children with diarrhea received more liquids than usual, while 27 percent were given the same amount of liquids as usual. Almost four in ten mothers still engage in the dangerous practice of curtailing fluid intake when their children have diarrhea; 28 percent give the child somewhat less liquids than normal, while 10 percent give the child much less, and 2 percent give the child no liquids. Urban mothers and especially those in Dushanbe seem to know the importance of increasing fluid intake when a child has diarrhea. Children in the DRS region are relatively more likely than children in other regions to receive less liquid when they have diarrhea. With regard to food intake during a diarrhea episode, only about one-third of children with diarrhea are fed according to the recommended practice of giving either more food or the same amount of food as usual. Two-thirds of children are given less food to eat than usual, with one-fifth given much less to eat than usual. C hi ld H ea lth • 1 41 Ta bl e 11 .7 D ia rr he a tre at m en t A m on g ch ild re n un de r a ge fi ve w ho h ad d ia rr he a in th e tw o w ee ks p re ce di ng th e su rv ey , t he p er ce nt ag e fo r w ho m a dv ic e or tr ea tm en t w as s ou gh t f ro m a h ea lth fa ci lit y or p ro vi de r, th e pe rc en ta ge g iv en o ra l r eh yd ra tio n th er ap y (O R T) , th e pe rc en ta ge g iv en in cr ea se d flu id s, th e pe rc en ta ge g iv en O R T or in cr ea se d flu id s, a nd th e pe rc en ta ge g iv en o th er tr ea tm en ts , b y ba ck gr ou nd c ha ra ct er is tic s, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic P er ce nt ag e of ch ild re n w ith di ar rh ea fo r w ho m a dv ic e or tr ea tm en t w as s ou gh t fro m a h ea lth fa ci lit y or pr ov id er 1 O ra l r eh yd ra tio n th er ap y (O R T) In cr ea se d flu id s O R T or in cr ea se d flu id s O th er tr ea tm en ts M is si ng N o tre at m en t N um be r o f ch ild re n w ith di ar rh ea Fl ui d fro m O R S p ac ke ts R ec om - m en de d ho m e flu id s (R H F) E ith er O R S or R H F A nt ib io tic dr ug s A nt im ot ili ty dr ug s In tra ve no us so lu tio n H om e re m ed y/ ot he r A ge in m on th s <6 (6 7. 1) (4 3. 5) (2 2. 7) (5 4. 9) (2 2. 2) (6 5. 7) (3 9. 3) (3 .4 ) (6 .7 ) (3 5. 9) (0 .0 ) (8 .4 ) 46 6- 11 59 .8 68 .8 32 .1 81 .0 29 .8 84 .6 56 .8 1. 3 3. 0 11 .5 0. 0 4. 1 13 7 12 -2 3 64 .2 65 .0 26 .7 74 .9 37 .4 87 .6 47 .5 2. 1 6. 7 27 .6 0. 1 2. 8 26 0 24 -3 5 40 .5 60 .6 35 .0 73 .7 33 .9 84 .6 52 .0 2. 0 1. 2 16 .8 0. 0 3. 0 17 5 36 -4 7 45 .9 52 .1 27 .1 67 .0 29 .6 75 .0 56 .1 5. 0 1. 8 30 .1 2. 0 5. 7 83 48 -5 9 32 .0 42 .4 14 .9 48 .2 23 .8 60 .5 46 .4 8. 4 3. 2 19 .4 0. 9 7. 3 56 Se x M al e 53 .6 62 .1 28 .7 73 .2 33 .1 82 .8 49 .7 3. 5 4. 0 21 .7 0. 4 4. 9 42 4 Fe m al e 53 .9 57 .9 28 .4 69 .7 31 .6 80 .1 51 .8 2. 0 3. 9 23 .2 0. 1 3. 0 33 4 Ty pe o f d ia rr he a N on -b lo od y 50 .5 58 .7 28 .9 71 .7 32 .9 81 .5 49 .0 3. 2 4. 1 20 .7 0. 0 4. 6 63 1 B lo od y 78 .7 75 .4 25 .6 78 .6 38 .4 93 .0 59 .1 1. 8 5. 0 34 .5 0. 0 0. 0 67 R es id en ce U rb an 50 .2 57 .8 28 .8 67 .9 40 .2 79 .0 50 .2 6. 5 4. 4 30 .2 0. 3 4. 5 19 4 R ur al 54 .9 61 .2 28 .4 72 .9 29 .8 82 .5 50 .7 1. 6 3. 8 19 .7 0. 3 3. 9 56 3 R eg io n D us ha nb e 46 .5 56 .9 24 .8 63 .7 52 .8 82 .5 35 .1 12 .2 0. 9 29 .7 0. 7 5. 7 70 G B A O 40 .8 78 .1 23 .1 79 .5 19 .4 82 .2 35 .7 0. 0 0. 0 20 .6 1. 2 5. 6 15 S ug hd 66 .0 61 .4 37 .5 79 .2 26 .1 80 .5 47 .9 1. 3 0. 0 23 .8 0. 0 5. 2 10 1 D R S 55 .8 68 .4 42 .3 82 .2 17 .6 86 .8 25 .4 1. 0 0. 0 22 .0 0. 0 4. 4 11 9 K ha tlo n 52 .0 57 .9 23 .7 68 .2 35 .0 80 .4 60 .7 2. 3 6. 5 21 .1 0. 4 3. 4 45 3 M ot he r's e du ca tio n N on e/ pr im ar y 57 .9 58 .3 34 .4 77 .0 37 .9 83 .5 57 .2 5. 8 6. 4 25 .9 0. 0 4. 7 81 G en er al b as ic 54 .0 60 .2 27 .3 70 .1 29 .5 80 .5 50 .4 2. 8 3. 0 21 .7 0. 7 4. 3 32 1 G en er al s ec on da ry 52 .4 59 .4 30 .2 71 .7 34 .5 83 .0 48 .7 0. 9 4. 8 19 .0 0. 0 3. 7 27 9 P ro fe ss io na l p rim ar y/ m id dl e 52 .0 61 .4 18 .7 66 .8 29 .3 72 .3 50 .5 10 .3 5. 0 37 .7 0. 0 6. 8 42 H ig he r 53 .4 71 .2 25 .3 78 .9 34 .3 87 .8 52 .7 2. 3 0. 0 28 .9 0. 5 0. 0 35 W ea lth q ui nt ile Lo w es t 48 .1 53 .0 27 .9 65 .7 31 .6 78 .4 56 .9 4. 6 7. 5 23 .4 0. 0 5. 2 16 4 S ec on d 45 .8 52 .2 29 .6 66 .8 33 .9 78 .4 52 .1 0. 0 2. 7 23 .0 1. 0 4. 1 17 0 M id dl e 65 .9 72 .4 26 .3 82 .4 23 .7 88 .2 51 .5 3. 0 3. 2 17 .8 0. 0 1. 2 14 3 Fo ur th 58 .5 64 .6 33 .6 76 .8 33 .7 86 .5 50 .1 4. 1 2. 7 20 .3 0. 0 4. 4 13 2 H i g he st 53 .1 62 .1 25 .6 68 .8 39 .1 78 .1 41 .6 2. 7 3. 3 26 .8 0. 5 5. 2 14 9 To ta l 53 .7 60 .3 28 .5 71 .6 32 .5 81 .6 50 .6 2. 8 4. 0 22 .4 0. 3 4. 1 75 7 N ot e: O R T in cl ud es fl ui d pr ep ar ed fr om o ra l r eh yd ra tio n sa lt (O R S) p ac ke ts a nd re co m m en de d ho m e flu id s (R H F) . T ot al in cl ud es 5 9 ch ild re n w ith in fo rm at io n on ty pe o f d ia rrh ea m is si ng . F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 1 E xc lu de s ph ar m ac y, s ho p, an d tra di tio na l p ra ct iti on er . Child Health • 141 14 2 • C hi ld H ea lth Ta bl e 11 .8 F ee di ng p ra ct ic es d ur in g di ar rh ea P er ce nt d is tri bu tio n of c hi ld re n un de r a ge fi ve w ho h ad d ia rr he a in th e tw o w ee ks p re ce di ng th e su rv ey b y am ou nt o f l iq ui ds a nd fo od o ffe re d co m pa re d w ith n or m al p ra ct ic e, th e pe rc en ta ge o f c hi ld re n gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g du rin g th e di ar rh ea e pi so de , a nd th e pe rc en ta ge o f c hi ld re n w ho c on tin ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s du rin g th e ep is od e of d ia rrh ea , b y ba ck gr ou nd c ha ra ct er is tic s, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic A m ou nt o f l iq ui ds g iv en A m ou nt o f f oo d gi ve n P er ce nt - ag e gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g1 P er ce nt - ag e w ho co nt in ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se ed flu id s1 N um be r o f ch ild re n w ith di ar rh ea M or e Sa m e as u su al S om e- w ha t l es s M uc h le ss N on e D on 't kn ow / m is si ng To ta l M or e S am e as us ua l S om e- w ha t l es s M uc h le ss N on e N ev er ga ve fo od D on 't kn ow / m is si ng To ta l A ge in m on th s <6 (2 2. 2) (3 9. 0) (2 6. 7) (1 0. 4) (1 .8 ) (0 .0 ) 10 0. 0 (7 .7 ) (4 5. 2) (2 5. 1) (1 5. 5) (0 .0 ) (6 .4 ) (0 .0 ) 10 0. 0 (1 5. 7) (4 7. 3) 46 6- 11 29 .8 28 .7 27 .3 13 .9 0. 0 0. 3 10 0. 0 6. 1 25 .1 42 .9 23 .6 1. 1 1. 1 0. 0 10 0. 0 19 .1 64 .2 13 7 12 -2 3 37 .4 19 .2 32 .1 9. 1 1. 1 1. 0 10 0. 0 4. 0 18 .4 52 .3 23 .0 1. 1 0. 6 0. 7 10 0. 0 28 .2 65 .3 26 0 24 -3 5 33 .9 27 .4 25 .3 10 .4 2. 5 0. 4 10 0. 0 8. 2 29 .3 38 .4 23 .3 0. 3 0. 0 0. 4 10 0. 0 22 .6 61 .4 17 5 36 -4 7 29 .6 29 .8 29 .1 6. 1 3. 4 2. 0 10 0. 0 5. 8 23 .6 49 .3 13 .3 4. 9 0. 0 3. 1 10 0. 0 22 .8 58 .2 83 48 -5 9 23 .8 45 .4 15 .5 10 .1 1. 1 4. 2 10 0. 0 0. 9 49 .0 29 .2 18 .8 0. 0 1. 3 0. 9 10 0. 0 19 .3 45 .0 56 Se x M al e 33 .1 25 .9 26 .3 11 .3 1. 7 1. 6 10 0. 0 4. 4 29 .1 41 .2 21 .5 2. 1 0. 7 1. 0 10 0. 0 23 .2 60 .2 42 4 Fe m al e 31 .6 28 .7 29 .7 8. 5 1. 3 0. 3 10 0. 0 7. 0 23 .4 46 .8 21 .2 0. 0 1. 2 0. 4 10 0. 0 23 .3 61 .6 33 4 Ty pe o f d ia rr he a N on -b lo od y 32 .9 27 .2 29 .3 8. 2 1. 5 0. 9 10 0. 0 5. 5 26 .8 46 .1 18 .9 1. 4 1. 1 0. 3 10 0. 0 24 .7 63 .0 63 1 B lo od y 38 .4 22 .2 25 .5 13 .9 0. 0 0. 0 10 0. 0 1. 5 20 .3 32 .7 45 .6 0. 0 0. 0 0. 0 10 0. 0 12 .6 47 .4 67 R es id en ce U rb an 40 .2 26 .6 18 .1 12 .0 0. 7 2. 3 10 0. 0 5. 7 27 .9 35 .5 28 .5 0. 3 1. 0 1. 1 10 0. 0 27 .4 54 .5 19 4 R ur al 29 .8 27 .3 31 .1 9. 4 1. 8 0. 6 10 0. 0 5. 5 26 .2 46 .5 18 .9 1. 5 0. 9 0. 6 10 0. 0 21 .8 63 .0 56 3 R eg io n D us ha nb e 52 .8 26 .1 12 .3 5. 3 0. 0 3. 5 10 0. 0 10 .4 28 .8 37 .1 20 .7 0. 7 0. 8 1. 5 10 0. 0 39 .1 63 .1 70 G B A O 19 .4 33 .2 35 .5 9. 3 0. 0 2. 5 10 0. 0 16 .5 32 .3 38 .0 10 .7 0. 0 0. 0 2. 5 10 0. 0 19 .4 72 .9 15 S ug hd 26 .1 28 .3 35 .4 6. 8 0. 0 3. 4 10 0. 0 3. 2 30 .0 43 .0 22 .5 1. 2 0. 0 0. 0 10 0. 0 17 .8 60 .9 10 1 D R S 17 .6 25 .6 38 .9 17 .2 0. 7 0. 0 10 0. 0 0. 0 17 .0 50 .3 32 .0 0. 0 0. 7 0. 0 10 0. 0 11 .6 58 .9 11 9 K ha tlo n 35 .0 27 .2 25 .4 9. 7 2. 3 0. 4 10 0. 0 6. 4 27 .8 43 .3 18 .7 1. 6 1. 2 0. 9 10 0. 0 25 .1 60 .6 45 3 M ot he r's e du ca tio n N on e/ pr im ar y 37 .9 19 .0 29 .9 6. 3 7. 0 0. 0 10 0. 0 4. 6 15 .4 48 .4 22 .7 7. 0 0. 0 1. 9 10 0. 0 23 .7 53 .2 81 G en er al b as ic 29 .5 29 .9 27 .5 11 .2 0. 5 1. 5 10 0. 0 5. 5 31 .1 41 .1 19 .1 0. 5 2. 0 0. 8 10 0. 0 22 .7 61 .7 32 1 G en er al s ec on da ry 34 .5 26 .7 28 .3 8. 4 1. 3 0. 7 10 0. 0 5. 8 23 .9 48 .1 21 .8 0. 0 0. 0 0. 4 10 0. 0 24 .9 63 .6 27 9 P ro fe ss io na l pr im ar y/ m id dl e 29 .3 28 .3 20 .4 19 .8 0. 0 2. 3 10 0. 0 3. 6 32 .2 31 .0 31 .9 0. 0 1. 3 0. 0 10 0. 0 13 .6 46 .8 42 H i g he r 34 .3 22 .9 30 .3 10 .1 1. 8 0. 5 10 0. 0 9. 2 26 .9 36 .1 22 .4 5. 0 0. 0 0. 5 10 0. 0 25 .6 65 .0 35 W ea lth q ui nt ile Lo w es t 31 .6 29 .0 32 .8 5. 3 1. 2 0. 0 10 0. 0 4. 2 28 .5 45 .9 20 .9 0. 0 0. 5 0. 0 10 0. 0 20 .0 58 .1 16 4 S ec on d 33 .9 27 .2 25 .7 8. 9 3. 3 1. 0 10 0. 0 6. 4 28 .4 39 .1 18 .5 4. 2 1. 4 1. 9 10 0. 0 24 .9 56 .2 17 0 M id dl e 23 .7 27 .6 34 .9 13 .8 0. 0 0. 0 10 0. 0 3. 7 29 .6 49 .6 17 .1 0. 0 0. 0 0. 0 10 0. 0 18 .2 73 .3 14 3 Fo ur th 33 .7 23 .8 27 .1 11 .6 1. 8 1. 9 10 0. 0 8. 5 18 .1 49 .4 21 .4 1. 3 1. 2 0. 0 10 0. 0 28 .0 66 .0 13 2 H ig he st 39 .1 27 .5 18 .3 11 .7 0. 9 2. 5 10 0. 0 5. 2 27 .1 35 .5 29 .2 0. 0 1. 3 1. 6 10 0. 0 25 .6 52 .5 14 9 To ta l 32 .5 27 .1 27 .8 10 .1 1. 5 1. 0 10 0. 0 5. 6 26 .6 43 .7 21 .3 1. 2 0. 9 0. 7 10 0. 0 23 .2 60 .8 75 7 N ot e: It is re co m m en de d th at c hi ld re n sh ou ld b e gi ve n m or e liq ui ds to d rin k du rin g di ar rh ea a nd fo od s ho ul d no t b e re du ce d. T ot al in cl ud es 5 9 ch ild re n w ith in fo rm at io n on ty pe o f d ia rrh ea m is si ng . F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 1 C on tin ue d fe ed in g pr ac tic es in cl ud es c hi ld re n w ho w er e gi ve n m or e, s am e as u su al , o r s om ew ha t l es s fo od d ur in g th e di ar rh ea e pi so de . 142 • Child Health Child Health • 143 Table 11.8 also shows that 23 percent of children with diarrhea were given increased fluids and either more, the same as usual, or somewhat less food to eat than usual. When ORT (either ORS fluid or a recommended home fluid) is also taken into account, the figure increases to 61 percent of children who are given either ORT or increased fluids and at least the same amount of food or only somewhat less food than usual. Children age 48-59 months and those with bloody diarrhea are the least likely to be given either ORT or increased fluids and continued feeding. There is no uniform relationship between the use of continued feeding and increased fluids or ORT when a child has diarrhea and either maternal education or wealth. Children in the GBAO region and children from households in the middle wealth quintile are more likely than other children to be given either ORT or increased fluids and continued feeding when they have diarrhea. Results from the TjDHS indicate considerable improvement in the handling of childhood diarrhea. The proportion of children under 5 with diarrhea who are given the same amount of food or only somewhat less food to eat and either increased fluids or ORT has almost tripled, from 22 percent in 2005 (SCS, 2007) to 61 percent in 2012. The improvement is due mostly to a large increase in the proportion of children who continue feeding during episodes of diarrhea, from 36 percent in 2005 to 76 percent in 2012. The proportion of children with diarrhea who are given increased liquids has increased less dramatically, from 22 percent in 2005 to 33 percent in 2012. As mentioned above, the use of ORT has increased from 58 to 72 percent of children with diarrhea between 2005 and 2012. 11.3.4 Knowledge of ORS A simple and effective response to dehydration caused by diarrhea is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy, which may include the use of a solution prepared from packets of oral rehydration salts (ORS). To ascertain how widespread knowledge of ORS is in Tajikistan, women interviewed in the 2012 TjDHS were asked whether they had ever heard of a special product called Rehydron (the name for ORS in Tajikistan) for the treatment of diarrhea. Results are tabulated in Table 11.9 for women who gave birth in the five years before the survey. The table shows that more than nine in ten mothers have heard of ORS packets (Rehydron). Knowledge of ORS increases with age of the mother. It is slightly lower among mothers in the Khatlon region (87 percent) than among those in the other regions (91 to 95 percent). Knowledge of ORS generally increases with education and wealth of the mother, although it declines slightly among the most highly educated women and those in the highest wealth quintile. Table 11.9 Knowledge of ORS packets Percentage of women age 15-49 with a live birth in the five years preceding the survey who know about ORS packets for treatment of diarrhea, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who know about ORS packets Number of women Age 15-19 84.0 78 20-24 90.2 1,024 25-34 90.7 1,890 35-49 91.3 608 Residence Urban 92.1 802 Rural 90.0 2,799 Region Dushanbe 92.0 295 GBAO 94.8 67 Sughd 94.3 1,000 DRS 90.8 887 Khatlon 86.9 1,351 Education None/primary 80.8 272 General basic 88.9 1,400 General secondary 92.3 1,530 Professional primary/middle 97.5 210 Higher 93.8 189 Wealth quintile Lowest 85.1 731 Second 88.4 757 Middle 92.5 743 Fourth 94.3 718 Highest 92.5 652 Total 90.5 3,601 ORS = Oral rehydration salts 144 • Child Health 11.4 STOOL DISPOSAL If human feces are left uncontained, disease may spread by direct contact or by animal contact with the feces. Hence, the proper disposal of children’s stools is extremely important in preventing the spread of disease. In the 2012 TjDHS, women were asked about stool disposal for their children under age 5. If a woman had more than one child under age 5, the questions were asked about the youngest child who was living with her. Specifically, she was asked when the child had last passed stools what was done to dispose of the stools. Table 11.10 presents results by background characteristics. Table 11.10 Disposal of children's stools Percent distribution of youngest children under age 5 living with the mother by the manner of disposal of the child's last fecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Tajikistan 2012 Background characteristic Manner of disposal of children's stools Total Percent- age of children whose stools are disposed of safely1 Number of children Child used toilet or latrine Put/rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Left in the open Other Missing Age in months <6 4.7 69.1 5.6 12.4 6.6 0.6 0.0 1.0 100.0 79.4 440 6-11 3.5 80.0 2.5 5.8 5.3 0.9 0.2 1.9 100.0 86.0 583 12-23 7.5 79.1 3.3 2.9 4.0 1.0 0.1 2.0 100.0 89.9 968 24-35 24.0 66.0 2.1 2.6 2.7 0.6 0.0 2.0 100.0 92.0 777 36-47 54.4 39.4 1.0 1.4 2.4 0.8 0.0 0.6 100.0 94.8 451 48-59 66.5 27.9 0.8 0.2 2.2 1.0 0.0 1.3 100.0 95.3 325 Toilet facility2 Improved, not shared 21.2 66.3 2.7 3.5 3.9 0.7 0.1 1.7 100.0 90.1 3,334 Shared3 23.1 61.8 1.8 8.6 1.0 3.9 0.0 0.0 100.0 86.6 82 Non-improved 27.0 45.0 3.9 16.4 5.5 1.1 0.0 1.2 100.0 75.9 126 Residence Urban 24.5 64.7 0.8 2.1 5.3 0.6 0.2 1.7 100.0 90.1 788 Rural 20.6 65.6 3.2 4.6 3.5 0.9 0.0 1.6 100.0 89.4 2,755 Region Dushanbe 21.7 67.4 0.2 1.6 7.4 0.0 0.7 1.0 100.0 89.3 291 GBAO 8.2 63.1 0.0 6.5 21.6 0.0 0.0 0.6 100.0 71.3 66 Sughd 17.0 63.4 4.6 4.4 7.1 2.8 0.0 0.7 100.0 85.0 990 DRS 22.9 69.6 0.2 4.1 1.7 0.2 0.0 1.3 100.0 92.7 873 Khatlon 24.4 63.8 3.5 4.2 1.3 0.0 0.0 2.7 100.0 91.8 1,322 Mother's education None/primary 22.8 66.1 2.8 3.8 1.9 0.0 0.0 2.7 100.0 91.7 267 General basic 19.5 66.0 2.2 5.3 4.1 1.1 0.0 1.8 100.0 87.8 1,376 General secondary 21.9 65.7 3.1 3.1 3.7 0.9 0.0 1.7 100.0 90.6 1,508 Professional primary/ middle 25.9 61.2 4.6 4.4 3.9 0.0 0.0 0.0 100.0 91.7 207 Higher 25.6 62.3 0.7 3.1 6.5 0.0 1.0 0.7 100.0 88.7 185 Wealth quintile Lowest 23.8 61.7 5.6 3.5 4.3 0.0 0.0 1.1 100.0 91.1 719 Second 18.7 68.6 1.9 5.4 2.3 0.7 0.0 2.3 100.0 89.3 748 Middle 20.7 65.7 2.3 4.0 3.9 1.0 0.0 2.5 100.0 88.7 720 Fourth 19.4 66.6 2.8 4.7 3.8 1.2 0.1 1.4 100.0 88.8 710 Highest 25.2 64.1 0.6 2.5 5.4 1.2 0.2 0.7 100.0 89.9 648 Total 21.5 65.4 2.7 4.1 3.9 0.8 0.1 1.6 100.0 89.5 3,543 1 Children's stools are considered to be disposed of safely if the child used a toilet or latrine, if the fecal matter was put/rinsed into a toilet or latrine, or if it was buried. Total includes one child for whom type of toilet facility is missing. 2 See Table 2.2 for definition of categories. 3 Shared facilities would be considered improved if they were not shared by two or more households. Child Health • 145 The table shows that the most commonly used method for disposing of young children’s stools is putting them into a toilet or latrine (65 percent). Twenty-two percent of children used the toilet or latrine themselves. Other methods of disposal include rinsing stools into a drain or ditch (4 percent), throwing them into the garbage (4 percent), and burying them (3 percent). Overall, 90 percent of children’s stools are disposed of safely. A closer look at the table shows some differentials in the disposal of stools. In the GBAO region, the stools of 71 percent of children under 5 are disposed of safely, compared with over 90 percent of children in the DRS and Khatlon regions (93 percent and 92 percent). The percentage of children whose stools are disposed of safely increases with age of the child, however, differences in safe disposal of children’s stools by urban-rural residence, education, and wealth quintile of the mother are small. A similar question was included in the 2005 Tajikistan MICS survey, but it referred to all children age 0-2, whereas the 2012 TjDHS question referred to the youngest child under age 5. In addition, the MICS indicator on children whose stools are disposed of safely did not include burying stool as safe disposal. When data from the 2012 TjDHS are restricted to the youngest child under age 3 and burying stool is considered a safe source for the 2005 MICS data, the information from the two sources becomes more comparable, although not completely so. The results imply a large improvement in the proportion of children’s stools that are disposed of safely, from around 42 percent in 2005 (SCS, 2007) to 88 percent in 2012 (data not shown). Nutrition of Children and Women • 147 NUTRITION OF CHILDREN AND WOMEN 12 ood nutrition is a prerequisite for the national development of countries and for the wellbeing of individuals. Although problems related to poor nutrition affect the entire population, women and children are especially vulnerable because of their unique physiology and socioeconomic characteristics. The period from birth to age 2 is especially important for optimal growth, health, and development. Unfortunately, this period is often marked by protein-energy and micronutrient deficiencies that interfere with optimal physical growth and cognitive development. Common illnesses such as diarrhea and acute respiratory infections are also common in young children (Black et al., 2008). Malnutrition in adults results in reduced productivity, increased susceptibility to infections, slow recovery from illness, and for women, increased risk of adverse pregnancy outcomes (Cesar et al., 2008). A woman of poor nutritional status (indicated by a low body mass index, short stature, anemia, or other micronutrient deficiencies) has a heightened risk of obstructed labor, having a baby with low birth weight, and dying from postpartum hemorrhage. Morbidity, in general, is high for both the woman and her baby. Numerous socioeconomic and cultural factors influence patterns of feeding and nutritional status. The 2012 TjDHS interviewers took height and weight measurements of all children under age 5 and all women age 15-49 in the household. Data were collected from the women on feeding practices for infants and young children, including breastfeeding, the feeding of solid and semisolid foods, diversity of foods, and frequency of feeding. In addition, they were asked about the feeding of foods rich in iron and vitamin A to children and the administration of iron and vitamin A supplements to children and women. 12.1 NUTRITIONAL STATUS OF CHILDREN The 2012 TjDHS collected data on the nutritional status of children by measuring the height and weight of all children under age 5 in the interviewed households. The nutritional status assessment helps to identify subgroups of the child population that face increased risk of faltered growth and contributes data for comparison with previous surveys in trend analyses. G Key Findings • Twenty-six percent of children under age 5 are stunted, 10 percent are wasted, and 12 percent are underweight. • Breastfeeding is nearly universal in Tajikistan: 98 percent of children are ever breastfed and three-quarters are still breastfeeding at age 1. Only one-third of children under age 6 months are exclusively breastfed as recommended. • Complementary foods are not introduced in a timely fashion for all children. Only half of children age 6-8 months receive complementary foods. • Overall, only 20 percent of children age 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices. • Three-quarters of children age 6-59 months were given a vitamin A supplement and half were given deworming medicine in the 6 months before the survey. • The vast majority of households (84 percent) have iodized salt. • Three in ten women age 15-49 are overweight or obese (BMI ≥25.0). 148 • Nutrition of Children and Women 12.1.1 Measurement of Nutritional Status among Young Children All children listed in the Household Questionnaire who were born in January 2007 or later were eligible for measurement of height and weight. Thus, height and weight measurements were collected from children whose mothers may not have been interviewed in the survey. Each interviewing team carried scales and height boards. Weight was measured using lightweight scales with digital screens manufactured by SECA. The height/length boards were specially produced by Shorr Productions for use in survey settings. Recumbent length was recorded for children under age 2. Standing height was measured for all other children. The nutritional status of children in the survey population is compared with the World Health Organization (WHO) Child Growth Standards, which are based on an international sample of ethnically, culturally, and genetically diverse healthy children living under optimum conditions that are conducive to achieving a child’s full genetic growth potential (WHO, 2006b). The WHO Child Growth Standards identify breastfed children as the normative model for growth and development and document how children should grow under optimum conditions and with optimum infant feeding and child health practices. Use of the WHO Child Growth Standards is based on the finding that well-nourished children of all population groups for which data exist follow very similar growth patterns before puberty. These standards can therefore be used to assess the nutritional status of children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. Three standard indices of physical growth that describe the nutritional status of children are: • Height-for-age (stunting) • Weight-for-height (wasting) • Weight-for-age (underweight) Each of these indices provides different information about growth and body composition that can be used to assess nutritional status. Height-for-age measures linear growth. A child who is more than two standard deviations below the median (-2 SD) of the WHO reference population in terms of height-for-age is considered short for his or her age, or stunted. This condition reflects the cumulative effect of chronic malnutrition. If a child is below three standard deviations (-3 SD) from the reference median, then he or she is considered to be severely stunted. Stunting reflects a failure to receive adequate nutrition over a long period of time and is worsened by recurrent and chronic illness. Height-for-age, therefore, reflects the long-term effects of malnutrition in a population and does not vary appreciably according to recent dietary intake. Weight-for-height describes current nutritional status. A child who is more than two standard deviations below (-2 SD) the reference median for weight-for-height is considered to be too thin for his or her height, or wasted. This condition reflects acute or recent nutritional deficit. As with stunting, wasting is considered severe if the child is more than three standard deviations below the reference median. Severe wasting is closely linked to mortality risk. Weight-for-age is a composite index of weight-for-height and height-for-age. Thus, it does not distinguish between acute malnutrition (wasting) and chronic malnutrition (stunting). A child can be underweight for his age because he or she is stunted, because he or she is wasted, or both. Children whose weight-for-age is below two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age is below three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. Weight-for-age is an overall indicator of a population’s nutritional health. Z-score means are also calculated as summary statistics representing the nutritional status of children in a population. These mean scores describe the nutritional status of the entire population without the use of a cut off. A mean Z-score of less than 0 (i.e., a negative mean value for stunting, wasting, or Nutrition of Children and Women • 149 underweight) suggests that the distribution of an index has shifted downward and that most if not all children in the population suffer from undernutrition relative to the reference population. 12.1.2 Levels of Child Malnutrition Table 12.1 shows the percentage of children under age 5 classified as malnourished according to the three anthropometric indices of nutritional status (height-for-age, weight-for-height, and weight-for- age) by various background characteristics. A total of 4,993 children (unweighted) under age 5 in the TjDHS sample households were eligible for anthropometric measurements. The following analysis focuses on the 4,664 (unweighted) children (93 percent) for whom complete and credible anthropometric and age data are available. Measurements were missing for 2 percent of the children because the child was not present, the parents refused, the child was ill, or for some other reason. Another 5 percent of the children were considered to have implausibly high or low values for their height or weight measures (data not shown). Table 12.1 Nutritional status of children Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Tajikistan 2012 Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children Percent- age below -3 SD Percent- age below -2 SD2 Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Age in months <6 5.3 15.2 0.0 10.8 23.0 5.4 -0.8 4.7 13.9 2.9 -0.6 427 6-8 13.1 22.6 -0.5 9.7 17.8 8.3 -0.5 6.2 15.0 2.1 -0.8 302 9-11 7.5 19.9 -0.7 4.9 14.2 6.7 -0.4 2.8 9.7 1.5 -0.8 288 12-17 8.1 19.8 -1.0 3.9 14.9 5.2 -0.5 4.3 14.4 0.6 -0.8 529 18-23 12.6 32.4 -1.4 1.8 7.6 5.2 -0.1 3.9 14.0 1.1 -0.8 545 24-35 11.6 33.8 -1.5 3.0 7.5 5.6 -0.0 4.4 12.5 0.7 -0.8 1,142 36-47 9.9 27.9 -1.3 1.4 4.7 7.0 0.1 2.0 10.4 0.5 -0.7 964 48-59 7.8 22.8 -1.3 3.2 6.7 5.0 -0.2 2.8 10.1 0.3 -0.9 882 Sex Male 9.8 25.5 -1.1 4.1 9.9 6.1 -0.2 3.3 12.3 1.0 -0.8 2,575 Female 9.6 26.8 -1.1 3.7 10.0 5.6 -0.2 4.0 11.9 0.9 -0.8 2,505 Birth interval in months3 First birth4 9.3 26.4 -1.1 4.2 10.1 6.4 -0.2 4.0 11.9 1.0 -0.8 1,655 <24 11.4 27.5 -1.2 3.9 9.5 4.2 -0.2 4.6 14.0 0.3 -0.8 1,076 24-47 9.9 26.0 -1.1 4.0 10.6 6.0 -0.2 3.3 12.3 1.2 -0.8 1,404 48+ 7.3 23.7 -1.1 3.6 9.2 6.5 -0.2 2.2 9.8 1.4 -0.7 823 Size at birth3 Very small 19.4 35.7 -1.5 8.0 15.6 4.0 -0.6 10.3 33.0 0.0 -1.3 128 Small 14.6 36.4 -1.4 4.7 11.6 3.4 -0.5 5.9 18.8 0.9 -1.1 517 Average or larger 9.0 24.2 -1.1 3.7 9.5 6.6 -0.2 3.0 10.4 1.0 -0.7 3,897 Mother's interview status Interviewed 9.6 26.1 -1.1 4.0 10.0 5.8 -0.2 3.6 12.1 1.0 -0.8 4,957 Not interviewed but in household 5.5 25.9 -1.3 0.0 2.6 13.8 0.1 2.6 5.9 0.0 -0.7 62 Not interviewed and not in the household5 23.6 33.9 -1.3 0.0 13.7 3.4 -0.4 7.5 20.2 0.0 -1.1 61 Mother's nutritional status6 Thin (BMI<18.5) 7.8 25.3 -1.1 5.2 15.1 3.4 -0.6 3.1 14.7 1.3 -1.0 425 Normal (BMI 18.5-24.9) 10.5 26.9 -1.2 3.8 9.4 5.9 -0.2 4.0 12.5 0.9 -0.8 3,149 Overweight/obese (BMI >= 25) 8.2 24.7 -1.0 3.7 9.4 6.5 -0.1 3.0 10.2 1.0 -0.7 1,403 Residence Urban 7.8 21.4 -0.9 3.8 9.9 5.5 -0.3 2.7 10.7 1.3 -0.7 1,092 Rural 10.2 27.4 -1.2 3.9 9.9 6.0 -0.2 3.9 12.5 0.8 -0.8 3,988 Region Dushanbe 7.4 18.9 -0.7 3.8 10.3 5.4 -0.3 3.1 9.3 1.4 -0.6 392 GBAO 9.1 24.3 -1.0 2.2 8.1 1.1 -0.4 2.5 13.0 0.2 -0.8 93 Sughd 11.7 27.2 -1.2 3.9 8.4 11.8 0.1 3.3 10.4 1.1 -0.6 1,365 DRS 8.5 26.3 -1.1 3.7 9.8 4.3 -0.3 3.5 12.7 1.3 -0.8 1,296 Khatlon 9.6 26.9 -1.2 4.1 11.1 3.0 -0.4 4.2 13.5 0.5 -0.9 1,934 FTF districts 8.1 24.6 -1.1 5.0 11.2 3.3 -0.4 5.0 13.1 0.6 -0.9 782 Mother's education7 None/primary 11.1 27.6 -1.3 5.3 13.5 3.6 -0.5 7.0 19.0 0.2 -1.1 416 General basic 9.9 27.2 -1.2 4.6 10.1 4.6 -0.3 3.9 12.5 0.6 -0.8 1,981 General secondary 9.5 26.4 -1.2 3.1 9.4 7.1 -0.1 2.8 10.9 1.3 -0.7 2,080 Professional primary/middle 6.8 21.3 -0.9 2.6 7.6 5.9 -0.2 3.0 10.3 0.5 -0.7 296 Higher 8.0 17.2 -0.7 4.4 9.3 10.4 -0.1 3.0 7.9 1.9 -0.5 245 Continued… 150 • Nutrition of Children and Women Table 12.1—Continued Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Tajikistan 2012 Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children Percent- age below -3 SD Percent- age below -2 SD2 Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Wealth quintile Lowest 12.0 32.1 -1.4 5.2 9.5 4.3 -0.3 4.5 15.8 0.7 -1.0 998 Second 10.1 29.0 -1.2 3.4 10.9 3.3 -0.3 4.8 13.7 0.5 -0.9 1,084 Middle 7.3 23.4 -1.1 3.0 9.6 7.4 -0.2 2.3 10.2 0.6 -0.7 1,060 Fourth 9.9 24.9 -1.1 4.3 10.5 8.1 -0.2 3.9 11.5 1.5 -0.7 1,032 Highest 9.2 20.9 -0.9 3.4 9.0 6.4 -0.2 2.7 9.3 1.4 -0.6 906 Total 9.7 26.2 -1.1 3.9 9.9 5.9 -0.2 3.7 12.1 0.9 -0.8 5,080 Note: Table is based on children who stayed in the household on the night before the interview and who had valid dates of birth (month and year) and valid measurement of both height and weight. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Total includes 415 children whose size at birth is missing. FTF = Feed the Future 1 Recumbent length is measured for children under age 2, or in the few cases when the age of the child is unknown and the child is less than 85 cm; standing height is measured for all other children. 2 Includes children who are below -3 standard deviations (SD) from the WHO Child Growth standards population median. 3 Excludes children whose mothers were not interviewed. 4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 5 Includes children whose mothers are deceased. 6 Excludes children whose mothers were not weighed and measured. Mother's nutritional status in terms of BMI (Body Mass Index) is presented in Table 12.9. 7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. Height-for-age (stunting) At the national level, 26 percent of children under age 5 are stunted, and 10 percent are severely stunted. Analysis by age group shows that stunting rises rapidly from 15 percent among children under 6 months to a high of one-third of children age 18-35 months (Figure 12.1). Severe stunting shows a similar pattern, with the lowest proportion of severe stunting in children under 6 months. Figure 12.1 Nutritional status of children by age Note: Stunting reflects chronic malnutrition, wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a 5-month moving average. Tajikistan DHS 2012 0 10 20 30 40 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Percentage Age in months Stunted Wasted Underweight Nutrition of Children and Women • 151 In the 2012 TjDHS, mothers were asked their perception of their child’s birth size: average or larger, small, or very small. The perceived birth size is useful as a proxy for birth weight because not all mothers can recall birth weight accurately and not all newborns are weighed at birth. Table 12.1 shows that about one-third of the children perceived by their mothers to be very small at birth are stunted and about one-third of those perceived to be small at birth are stunted (36 percent each), compared with less than one-quarter of those reported to have been average or larger in size at birth. In general, rural children and children born to mothers with less education are more likely to be stunted. There is large regional variation in the prevalence of stunting, ranging from 19 percent in Dushanbe to 27 percent each in the Sughd and Khatlon regions. Prevalence of severe stunting is especially high among children in Sughd (12 percent), Khatlon (10 percent), GBAO and DRS (9 percent each) regions. Stunting generally decreases as wealth quintile increases. Weight-for-height (wasting) Overall, 10 percent of children in Tajikistan are wasted. Analysis by age group shows that wasting is highest (23 percent) in children under 6 months and lowest (5 percent) in children age 36-47 months. Female and male children are equally likely to be wasted. Wasting is not strongly correlated with the length of the preceding birth interval. Children who are very small at birth are more likely to be wasted (16 percent) than children who are of average size or larger at birth (10 percent). Children whose mothers are thin are more likely to be wasted than children whose mothers are either normal weight or overweight (15 percent versus 9 percent). Children residing in urban areas are just as likely to be wasted as children living in rural areas. By region, wasting in children ranges from 8 percent in GBAO and Sughd to 11 percent in Khatlon. It is slightly higher than average in those districts that fall into the Feed the Future (FTF) program (11 percent). Wasting prevalence generally decreases as mother’s education increases. However, there is no uniform relationship between wasting and wealth quintile. Table 12.1 also shows the proportion of children who are more than 2 SD above the reference mean. These children are considered to be heavy for their height. Six percent of children under age 5 fall into this category. The proportion of children who are heavy for their height is highest in Sughd region (12 percent) and lowest in GBAO region (1 percent). Weight-for-age (underweight) Table 12.1 shows that 12 percent of children under age 5 are underweight and 4 percent are severely underweight. The proportion of children who are underweight varies only slightly for most background characteristics. It is slightly higher among children age 6-8 months than those age 9-11 months (15 percent and 10 percent, respectively). Children born less than 24 months after a previous birth are slightly more likely to be underweight (14 percent) than children born at least 48 months after a previous birth (10 percent). The data show a strong correlation between underweight children and their perceived birth size. Babies perceived by mothers as very small at birth are much more likely to be underweight (33 percent) than those perceived as either small (19 percent) or average or larger (10 percent) at birth. Dushanbe has the lowest proportion of underweight children (9 percent), while Khatlon has the largest (14 percent). As with wasting and stunting, mother’s education is associated with underweight, with the percentage of children who are underweight decreasing steadily as mother’s education increases. A similar negative relationship is observed between household wealth and the percentage of underweight children, though it is not as uniform. 12.1.3 Trends in Children’s Nutritional Status The 2005 MICS survey also collected height and weight measurements to assess children’s nutrition status. However, at that time, the National Center for Health Statistics (NCHS) reference standards were used to derive the levels of stunting, wasting, and underweight. Thus, in order to assess 152 • Nutrition of Children and Women trends in nutrition status, the 2012 TjDHS nutrition indicators have been re-calculated using the older NCHS reference population. Figure 12.2 shows that the proportion of children under age 5 who are stunted decreased from 27 percent in 2005 to 21 percent in 2012. The proportion of children who are wasted rose from 7 percent in 2005 to 9 percent in 2012, while the proportion of underweight children decreased just slightly, from 17 percent in 2005 to 16 percent in 2012 (SCS, 2007; UNICEF, 2008). Figure 12.2 Trends in nutritional status of children under age 5, Tajikistan 2012 Note: Based on children who spent the night before the interview in the household, had valid month and year of birth, and valid height and weight measurements, according to NCHS/CDC/WHO. Stunting reflects chronic malnutrition; Wasting reflects acute malnutrition; Underweight reflects chronic or acute malnutrition or a combination of both. Thus, it appears that there has been some improvement in the prevalence of stunting; however, the prevalence of wasting and underweight has changed little during the seven years between the surveys. The 2009 Micronutrient Status Survey in Tajikistan (MSST) also collected height and weight measurements to assess children’s nutrition status (MOH and UNICEF, 2010). The 2009 data on nutritional status are based on children age 6-59 months, while in the 2012 TjDHS, the data represent children age 0-59 months; thus, to compare the survey results, the 2012 TjDHS nutrition indicators have been re-calculated for children age 6-59 months using the older NCHS reference standards. Caution should be exercised in interpreting the trend data because there are many methodological differences between the DHS and MSST surveys. The number of children age 6-59 measured in the 2009 MSST was considerably smaller (about 2,150) than in the 2012 TjDHS sample (4,654 weighted and 4,283 unweighted cases), so differences between the surveys may simply reflect the variability inherent in estimates from sample surveys rather than true differences. When compared with the data on stunting in the 2009 MSST survey, the proportion of children 6-59 months who are stunted decreased from 29 percent in 2009 to 22 percent in 2012. The proportion of children who are wasted increased from 5 percent in 2009 to 9 percent in 2012, while the proportion of underweight children increased substantially, from 8 percent in 2009 to 17 percent in 2012 (MOH and 27 7 17 21 9 16 Stunting Wasting Underweight Percentage 2005 MICS 2012 TjDHS Nutrition of Children and Women • 153 UNICEF, 2010). Thus, it appears that although the prevalence of stunting has decreased, wasting and underweight have increased during the three years between the surveys. 12.2 BREASTFEEDING AND COMPLEMENTARY FEEDING Feeding practices play a pivotal role in determining the optimal growth and development of infants. Poor breastfeeding and infant feeding practices have adverse consequences for the health and nutritional status of children. These consequences, in turn, affect their mental and physical development. Breastfeeding also affects mothers by physiologically suppressing the return of fertility, thereby lengthening the interval between pregnancies. UNICEF and WHO recommend that children be exclusively breastfed (that is, given no other liquid or solid food or plain water) for the first six months of life and that children be given solid or semisolid complementary foods beginning in the seventh month of life. The standard indicator of exclusive breastfeeding is the percentage of children under age 6 months who are exclusively breastfeeding. The standard indicator of timely complementary feeding is the percentage of children age 6-8 months who receive solid, semisolid, or soft foods. WHO recommends that breastfeeding continue through the second year of life. Use of bottles with nipples is not recommended for feeding at any age (WHO, 2008). 12.2.1 Initiation of Breastfeeding Early initiation of breastfeeding is important for both the mother and the child. There are a number of reasons to encourage early breastfeeding. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps to contract the uterus and reduce postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and contains antibodies that protect the newborn from diseases. Early initiation of breastfeeding also encourages bonding between the mother and her newborn. Table 12.2 presents by background characteristics the breastfeeding status of all last-born children born in the two years preceding the survey. The table shows the percentage of children according to whether they were ever breastfed, when they started breastfeeding, and whether they were fed anything other than breast milk prior to the commencement of breastfeeding. Breastfeeding is almost universal in Tajikistan; 98 percent of last-born children born in the two years preceding the survey were breastfed at some point in their life. There are no marked differences by background characteristics in the proportion of children ever breastfed. Overall, half of children are breastfed within one hour after birth, and 92 percent are breastfed within one day after birth. Compared with data from the 2005 MICS, the percentage of children who were breastfed within one hour of birth has declined somewhat (from 61 percent in 2005 to 50 percent in 2012), while the percentage of children who started breastfeeding within one day of birth has increased slightly (from 87 percent in 2005 to 92 percent in 2012) (SCS, 2007). Table 12.2 indicates no marked differences in the timing of initial breastfeeding within one hour of birth, either by the sex of the child or by urban-rural residence. Notable variations, however, can be seen by region. The proportion of children breastfed within one hour of birth is highest in Sughd region (74 percent) and lowest in Khatlon region (37 percent). The timing of initiation of breastfeeding varies by other background characteristics. Less likely to begin breastfeeding within one hour of birth are children born at home, children attended by a traditional birth attendant at delivery, children of mothers with no education, and children from households in the lowest two wealth quintiles. Similar patterns were also reported in the 2005 MICS. It is encouraging to note that health facilities are apparently not obstructing early initiation of breastfeeding. 154 • Nutrition of Children and Women Table 12.2 Initial breastfeeding Among last-born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth; and among last-born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, Tajikistan 2012 Background characteristic Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 98.0 50.0 91.9 1,047 13.7 1,026 Female 98.3 49.1 91.9 999 13.6 982 Assistance at delivery Health professional3 98.4 52.2 92.2 1,814 14.1 1,785 Traditional birth attendant 99.3 27.4 94.3 167 10.2 166 Other (100.0) (37.2) (88.2) 54 (9.7) 54 No one * * * 2 * 2 Place of delivery Health facility 98.4 53.8 92.4 1,595 13.6 1,569 At home 99.0 35.4 92.0 442 13.9 437 Residence Urban 98.2 52.4 90.6 431 15.1 423 Rural 98.2 48.8 92.3 1,615 13.3 1,585 Region Dushanbe 98.1 46.6 86.5 154 26.1 151 GBAO 98.2 54.2 88.5 34 10.1 34 Sughd 98.5 74.4 92.5 539 7.0 531 DRS 98.6 43.1 94.4 519 13.4 512 Khatlon 97.7 37.4 91.1 798 16.1 780 FTF districts 97.1 46.4 91.7 301 17.8 293 Mother's education None/primary 99.1 36.1 92.8 177 16.5 176 General basic 98.6 49.7 91.5 850 12.4 838 General secondary 97.7 49.9 92.3 810 14.3 792 Professional primary/middle 95.9 59.0 90.1 107 14.1 103 Higher 99.1 58.7 92.9 100 14.2 100 Wealth quintile Lowest 98.5 44.2 91.5 393 14.8 387 Second 96.9 42.6 92.5 454 11.6 440 Middle 98.3 48.5 91.6 451 15.7 443 Fourth 98.9 58.0 92.6 425 10.8 420 Highest 98.5 56.1 91.2 323 16.1 318 Total 98.2 49.6 91.9 2,045 13.7 2,008 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children are living or dead at the time of interview. Total includes nine children for whom assistance at delivery is missing and nine children for whom place of delivery is missing. Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. FTF = Feed the Future. 1 Includes children who started breastfeeding within one hour of birth. 2 Children given something other than breast milk during the first three days of life. 3 Doctor, nurse/midwife, or feldsher. Prelacteal feeding is the practice of giving other liquids to a child during the first three days of life. The practice of prelacteal feeding is discouraged because it limits the frequency of suckling by the infant and exposes the child to the risk of gastrointestinal infection. Only 14 percent of newborns in Tajikistan receive a prelacteal feed. The likelihood of receiving a prelacteal feed is higher for births in Dushanbe and lower for births in Sughd region but, otherwise, does not vary much by other characteristics. Nutrition of Children and Women • 155 12.3 BREASTFEEDING STATUS BY AGE Breast milk contains all the nutrients needed by children in the first six months of life. It is recommended that during the first six months of life a child should not be given any complementary liquid or solid food or plain water. Exclusive breastfeeding (i.e., receiving only breast milk) is encouraged for newborns because it reduces the likelihood of contamination introduced by other feeding and thus reduces the risk of diarrhea. As an infant grows, breast milk alone no longer provides sufficient nourishment, and other liquids and foods need to be added to a child’s diet. When the child reaches age 6 months, solid or semisolid complementary foods should be added to the diet with continued breastfeeding. The 2012 TjDHS collected data on infant and young child feeding for all last-born children under age 2 living with their mothers, using a 24-hour recall method. As shown in Table 12.3 and Figure 12.3, a large majority of children in Tajikistan are breastfed during the first year of life, and breastfeeding continues through the second year for almost half of the children. However, supplementing breast milk with other liquids or foods starts at an early age. Among children under age 6 months, most are breastfed (94 percent). But contrary to recommended practices, only one-third (34 percent) of children under age 6 months are being exclusively breastfed. In addition to breast milk, 39 percent of children under age 6 months consume plain water, 2 percent consume nonmilk liquids, 14 percent consume other milk, and 5 percent consume complementary foods. Table 12.3 Breastfeeding status by age Percent distribution of youngest children under 2 who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under 2 using a bottle with a nipple, according to age in months, Tajikistan 2012 Age in months Not breast- feeding Breastfeeding status Total Percentage currently breast- feeding Number of youngest child under age 2 living with their mother Percentage using a bottle with a nipple Number of all children under age 2 Exclusively breastfed Breast- feeding and consu- ming plain water only Breast- feeding and consu- ming nonmilk liquids1 Breast- feeding and consu- ming other milk Breast- feeding and consu- ming comple- mentary foods 0-1 4.6 63.6 21.7 0.0 8.4 1.8 100.0 95.4 106 7.3 106 2-3 6.3 29.1 46.0 2.3 13.8 2.4 100.0 93.7 175 29.0 176 4-5 5.7 20.6 43.2 3.8 18.0 8.7 100.0 94.3 160 40.3 160 6-8 11.5 5.9 20.3 7.3 14.0 41.0 100.0 88.5 295 43.7 301 9-11 15.5 2.4 5.3 6.8 4.5 65.5 100.0 84.5 288 42.5 290 12-17 25.2 0.9 2.0 3.3 1.6 66.9 100.0 74.8 518 36.1 539 18-23 47.3 0.5 0.3 0.8 0.8 50.3 100.0 52.7 451 24.5 533 0-3 5.7 42.1 36.9 1.4 11.8 2.2 100.0 94.3 280 20.9 282 0-5 5.7 34.3 39.1 2.3 14.0 4.6 100.0 94.3 440 27.9 442 6-9 12.1 5.2 16.3 7.9 12.4 46.0 100.0 87.9 386 45.2 392 12-15 23.3 1.3 2.9 2.2 1.7 68.7 100.0 76.7 367 39.1 378 12-23 35.5 0.7 1.2 2.1 1.3 59.2 100.0 64.5 968 30.3 1,072 20-23 50.5 0.8 0.4 0.7 0.3 47.2 100.0 49.5 296 20.6 356 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, nonmilk liquids, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and nonmilk liquids and who do not receive other milk and who do not receive complementary foods are classified in the nonmilk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Nonmilk liquids include juice, juice drinks, clear broth, or other liquids. Comparison of the 2012 TjDHS rates of exclusive breastfeeding among children under age 6 months (34 percent) suggests an apparent increase from the 2005 MICS estimate of 25 percent (SCS, 2007). When comparing the results of the 2012 TjDHS to the MICS estimates, it should be noted that the 2012 DHS survey asked mothers about more kinds of complementary foods that could have been given to the child than were asked about in the 2005 MICS. 156 • Nutrition of Children and Women Figure 12.3 Infant feeding practices by age, Tajikistan 2012 Percentage Table 12.3 also presents the percentage of children using a bottle with a nipple. While only 7 percent of children under 2 months are being given a bottle with a nipple, bottle feeding increases rapidly to 29 percent of children age 2-3 months and 40 percent of children 4-5 months old. This is of potential concern, since bottles can transmit germs unless they are adequately sterilized. Figure 12.4 shows the 2012 TjDHS results for key infant and young child feeding (IYCF) practices on breastfeeding for youngest children under age 2 who are living with their mothers. Although 34 percent of children under age 6 months are exclusively breastfed, only 21 percent of those age 4-5 months are exclusively breastfed. Most children (77 percent) continue breastfeeding at age 1, and half continue to breastfeed until age 2. Only half of children are introduced to complementary foods at an appropriate age, and only 52 percent of children 0-23 months are breastfed appropriately for their age, i.e., exclusive breastfeeding for children 0-5 months and continued breastfeeding along with complementary foods for children age 6-23 months. Predominant breastfeeding (receiving breastmilk and only plain water or nonmilk liquids such as juice, clear broth, and other liquids) is prevalent in 76 percent of the children; 33 percent of children under age 2 are bottlefed. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months Not breastfeeding Complementary foods Other milk Non-milk liquids/juice Plain water only Exclusively breastfed Tajikistan DHS 2012 Nutrition of Children and Women • 157 Figure 12.4 Infant and young child feeding indicators on breastfeeding status, Tajikistan 2012 Tajikistan DHS 2012 12.4 DURATION OF BREASTFEEDING Table 12.4 shows the median duration of breastfeeding by selected background characteristics. The estimates of median and mean duration of breastfeeding are based on current status data, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The total median duration of any breastfeeding among children in Tajikistan in 2012 is 19 months. The total median duration of exclusive breastfeeding is two months, while the total median duration of predominant breastfeeding is five months. The median durations of any, exclusive, and predominant breastfeeding do not vary much across background characteristics. The median duration of any breastfeeding is four months shorter in Dushanbe than in Khatlon region. Durations of any breastfeeding and predominant breastfeeding tend to decrease as wealth quintile increases. Comparisons are hampered by the small number of cases. 34 21 77 49 50 52 76 33 Exclusive breastfeeding under 6 months Exclusive breastfeeding at 4-5 months Continued breastfeeding at 1 year Introduction of solid, semi-solid or soft foods (6-8 months) Continued breastfeeding at 2 years Age-appropriate breastfeeding (0-23 months) Predominant breastfeeding (0-5 months) Bottlefeeding (0-23 months) Percentage of children 158 • Nutrition of Children and Women Table 12.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 19.8 1.4 5.7 Female 18.1 1.5 5.1 Residence Urban 18.3 0.8 5.1 Rural 19.1 1.6 5.4 Region Dushanbe 15.8 (0.5) 4.6 GBAO (19.4) (2.6) 5.5 Sughd 19.4 (1.6) 4.9 DRS 18.1 0.8 5.3 Khatlon 19.6 1.8 6.1 FTF districts 18.2 (1.5) 4.8 Mother's education None/primary (20.5) (2.0) (6.3) General basic 19.2 1.5 5.3 General secondary 18.6 1.3 5.5 Professional primary/middle (18.1) * (4.3) Higher (16.1) * (4.0) Wealth quintile Lowest 22.8 (1.4) 5.8 Second 18.7 2.2 6.0 Middle 18.9 1.5 5.6 Fourth 18.1 0.7 5.2 Highest 15.8 0.7 3.9 Total 18.9 1.5 5.4 Mean for all children 18.8 3.1 6.6 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. FTF = Feed the Future. 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water, and/or nonmilk liquids only. 12.5 TYPES OF COMPLEMENTARY FOODS As mentioned above, it is recommended that complementary feeding (giving solid or semi-solid foods to infants in addition to breast milk) start at age 6 months, because at this age breast milk is no longer sufficient to maintain the child’s growth (WHO, 2008). Children should be fed small quantities of solid and semisolid foods while continuing to breastfeed. The amount of food is increased gradually from 6 to 23 months, which is the period of transition to eating the regular family diet. In the 2012 TjDHS, women who had at least one child living with them who was born in 2010 or later were asked questions about the types of liquids and foods the child had consumed during the day or night preceding the interview (e.g., fortified baby food, meat, eggs, etc.). Mothers who had more than one child born in 2010 or later were asked questions about the youngest child living with them. The results are subject to a number of limitations. The dietary data on children are subject to recall errors on the mother’s part. In addition, a mother may not be able to report fully on a child’s intake of food and liquids if the child was fed by other individuals during the period. Despite these limitations, the information collected on the types of foods and liquids consumed by young children is useful in assessing timely and appropriate complementary feeding. Nutrition of Children and Women • 159 For many breastfeeding children, liquids other than breast milk are introduced earlier than the recommended age of 6 months. As shown in Table 12.5, 11 percent of breastfeeding children age 2-3 months are given infant formula, and 7 percent receive other milk in addition to breast milk. By age 9 months, every child is expected to be receiving at least one daily feeding of solid or semi-solid foods. However, Table 12.5 indicates that only 78 percent of breastfeeding children ages 9-11 months received any solid or semi-solid food on the day before the interview. Overall, half of breastfeeding children age 6-23 months consume foods made from grains (including fortified baby foods), 25 percent consume vitamin A-rich fruits and vegetables, 24 percent have meat, fish, or poultry, and 27 percent consume eggs. In addition to being breastfed, 17 percent of these children also receive infant formula, 35 percent receive other milk, and 44 percent receive cheese, yogurt, or other milk products. As expected, nonbreastfed children age 6-23 months are more likely than breastfed children to receive the different types of liquids and solid and semisolid foods. However, caution should be exercised while interpreting these results because the number of nonbreastfed children is small compared with the number of breastfed children. Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age 2 who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Tajikistan 2012 Age in months Liquids Solid or semi-solid foods Any solid or semi- solid food Number of children Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and veget- ables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry Eggs Cheese, yogurt, other milk product BREASTFEEDING CHILDREN 0-1 1.8 7.1 2.7 1.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.9 101 2-3 10.5 7.0 4.1 0.7 0.2 0.2 0.2 1.0 0.2 0.2 0.7 1.9 2.6 164 4-5 15.6 10.4 8.9 4.5 2.0 0.1 0.3 2.7 1.0 0.0 1.0 3.7 9.3 150 6-8 16.8 23.5 43.1 10.5 20.7 6.0 6.5 28.7 2.3 7.1 6.2 18.3 46.4 261 9-11 17.7 29.6 76.6 15.9 45.0 20.7 28.2 59.9 9.9 14.0 16.4 35.1 77.5 243 12-17 16.9 39.8 83.4 11.9 61.6 29.5 44.7 69.0 19.3 28.4 35.7 56.2 89.5 387 18-23 15.2 45.0 90.7 8.1 84.5 44.4 58.8 80.4 26.6 43.8 44.3 62.0 95.4 238 6-23 16.7 34.9 74.1 11.6 53.4 25.3 35.3 60.1 14.9 23.6 26.5 44.1 78.2 1,129 Total 15.0 27.8 55.7 9.1 39.2 18.5 25.8 44.3 11.0 17.3 19.6 32.8 58.5 1,544 NONBREASTFEEDING CHILDREN 0-1 * * * * * * * * * * * * * 5 2-3 * * * * * * * * * * * * * 11 4-5 * * * * * * * * * * * * * 9 6-8 (23.8) (51.3) (59.4) (13.3) (23.4) (18.8) (33.4) (46.6) (16.3) (13.7) (20.9) (24.0) (68.9) 34 9-11 (35.4) (69.6) (83.7) (23.8) (68.4) (40.2) (33.4) (72.7) (20.4) (28.6) (24.8) (58.3) (95.9) 45 12-17 21.5 48.6 85.7 12.8 81.4 33.5 59.9 76.8 19.0 39.5 42.8 57.2 96.3 130 18-23 16.0 53.2 93.1 12.9 87.1 56.4 72.0 91.4 38.7 53.3 54.4 66.5 98.2 213 6-23 20.4 53.3 87.1 14.0 78.2 44.6 61.1 81.3 28.9 43.2 45.0 59.3 95.0 422 Total 21.0 51.6 82.8 14.0 74.0 42.7 57.7 77.2 27.3 41.2 42.9 56.4 91.0 447 Note: Breastfeeding status and food consumed refer to a 24-hour period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Other milk includes fresh, tinned, and powdered cow or other animal milk. 2 Doesn't include plain water. 3 Includes fortified baby food. 4 Includes fruits and vegetables such as pumpkin, carrots, red sweet bell peppers, dark green leafy vegetables, persimmon, and other locally grown fruits and vegetables that are rich in vitamin A. 160 • Nutrition of Children and Women 12.6 INFANT AND YOUNG CHILD FEEDING PRACTICES Infant and young child feeding (IYCF) practices include initiating timely feeding of solid or semisolid foods at age 6 months and increasing the amount and variety of foods and frequency of feeding as the child gets older, while maintaining frequent breastfeeding. Guidelines have been established for IYCF practices for children age 0-23 months (PAHO/WHO, 2003; WHO, 2005; WHO, 2008). Although breastfeeding is recommended for infants up to age 2, there are infants who have stopped breastfeeding before reaching age 2 because their mothers are HIV-positive, have died, or for some other reason do not breastfeed (WHO, 2005). Minimum dietary diversity means feeding the child food from at least four food groups. This cut- off was selected because it is associated with better-quality diets for both breastfed and nonbreastfed children. Studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients (WHO and UNICEF, 1998). Therefore it is recommended that meat, poultry, fish, or eggs be eaten daily or as often as possible. Vegetarian diets may not meet children’s nutrient requirements unless supplements or fortified products are used. Vitamin A-rich fruits and vegetables should be consumed daily. Children’s diets should include an adequate fat content, because fat provides essential fatty acids, facilitates absorption of fat-soluble vitamins (such as vitamin A), and enhances dietary energy density and palatability. Consumption of food from at least four food groups means that the child has a high likelihood of consuming at least one animal source of food and at least one fruit or vegetable in addition to a staple food (grains, roots, or tubers) (WHO, 2008). The four food groups should come from a list of seven food groups: grains, roots, and tubers; legumes and nuts; dairy products (milk yogurt, cheese); flesh foods (meat, fish, poultry, and liver/organ meat); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. The minimum dietary diversity is reported separately for breastfed and nonbreastfed children. However, diversity scores for breastfed and nonbreastfed children should not be directly compared, because breast milk is not counted in any of the above stated food groups. In addition to dietary diversity, frequency of feeding is important to ensure that children’s nutrient and caloric requirements are met. The recommended number of feedings is as follows: • Breastfed infants 6-8 months should be fed meals of complementary foods two to three times per day, with one to two snacks as desired; breastfed children 9-23 months should be fed meals three to four times per day, with one to two snacks. • Nonbreastfed children 6-23 months should receive milk products at least twice a day to ensure their calcium needs are met. In addition, they need animal-source foods and vitamin A-rich fruits and vegetables. Therefore, four food groups are considered a minimum acceptable number of food groups for nonbreastfed young children. Nonbreastfed children should be fed meals four to five times per day, with one to two snacks as desired (WHO, 2005). Meal frequency is considered a proxy for energy intake from foods other than breast milk; therefore, the feeding frequency indicator for nonbreastfed children includes both milk feeds and solid/semi-solid feeds (WHO, 2008). The minimum feeding frequencies are based on the energy needs from complementary foods estimated from age-specific total daily energy requirements. Infants with low breast milk intake would need to be fed more frequently. However, overly frequent feeding may lead to the displacement of breast milk (PAHO and WHO, 2003). Table 12.6 shows the IYCF practices for the youngest children age 6-23 months living with the mother. The recommendations take into account children for whom feeding practices meet minimum standards with respect to: • Food diversity (the number of food groups consumed) • Feeding frequency (the number of times the child is fed) • Consumption of breast milk or other types of milk or milk products Nutrition of Children and Women • 161 The results presented in Table 12.6 show that 33 percent of breastfed children age 6-23 months are fed foods from four or more food groups, and 35 percent are fed the minimum number of times. Among nonbreastfed children age 6-23 months, 58 percent are given milk or milk products, 60 percent are fed foods from four or more food groups, and 70 percent are fed the minimum number of times. Table 12.6 shows that among all children age 6-23 months, the vast majority (89 percent) are given breast milk or other milk products, but only 40 percent receive an appropriately diverse diet, and only 45 percent of children are fed the recommended number of times with solid or semisolid foods. One in five children (20 percent) complies with all three of the IYCF recommendations of consuming breastmilk or other milk products, having the minimum dietary diversity, and having the minimum meal frequency. Table 12.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Among breastfed children 6-23 months, percentage fed: Among nonbreastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: 4+ food groups1 Minimum meal fre- quency2 Both 4+ food groups and minimum meal fre- quency Number of breast- fed children 6-23 months Milk or milk pro- ducts3 4+ food groups1 Minimum meal fre- quency4 With 3 IYCF prac- tices5 Number of non- breast- fed children 6-23 months Breast milk, milk, or milk pro- ducts6 4+ food groups1 Minimum meal fre- quency7 With 3 IYCF practices Number of all children 6-23 months Age in months 6-8 4.2 24.4 1.8 261 (59.7) (27.8) (58.7) (11.1) 34 95.4 6.9 28.3 2.9 295 9-11 22.3 28.7 9.6 243 (78.5) (45.0) (77.1) (13.0) 45 96.7 25.8 36.2 10.2 288 12-17 44.2 39.0 23.5 387 56.5 52.8 60.5 21.4 130 89.0 46.4 44.4 23.0 518 18-23 55.4 47.6 29.6 238 54.9 72.0 76.6 36.4 213 78.7 63.2 61.3 32.8 451 Sex Male 32.0 35.6 17.3 584 56.2 56.0 72.0 24.0 215 88.2 38.5 45.4 19.1 799 Female 33.3 34.8 16.2 545 60.4 63.5 68.4 30.7 207 89.1 41.6 44.0 20.2 752 Residence Urban 33.1 35.3 18.4 216 64.6 55.1 72.0 30.5 116 87.6 40.8 48.1 22.7 332 Rural 32.5 35.2 16.4 913 55.9 61.4 69.6 26.0 306 88.9 39.7 43.8 18.8 1,219 Region Dushanbe 30.7 30.1 11.6 70 80.0 52.0 79.1 37.0 48 91.9 39.4 50.1 21.9 118 GBAO 31.4 32.5 12.9 19 (70.2) (29.4) (77.6) (18.5) 5 93.2 31.0 42.8 14.2 24 Sughd 29.1 45.0 18.7 323 40.1 62.3 59.4 14.5 109 84.9 37.4 48.6 17.6 431 DRS 35.5 34.0 18.7 275 68.7 62.9 74.6 34.6 125 90.2 44.1 46.7 23.7 400 Khatlon 33.7 29.7 15.2 443 55.0 58.5 71.5 27.6 135 89.5 39.5 39.5 18.1 578 FTF districts 31.3 32.1 12.6 170 (56.2) (65.5) (77.4) (31.0) 52 89.8 39.3 42.7 16.9 222 Mother's education None/primary 40.9 29.2 18.7 101 * * * * 25 94.9 41.3 36.4 18.4 126 General basic 32.1 35.8 17.0 457 61.2 61.2 71.1 27.9 168 89.5 39.9 45.3 19.9 625 General secondary 31.2 35.8 16.6 463 49.2 57.9 68.9 26.0 176 86.0 38.5 44.9 19.2 638 Professional primary/middle 28.2 41.5 15.6 56 (57.2) (65.4) (68.9) (34.8) 26 86.5 39.9 50.2 21.7 82 Higher 38.2 29.6 13.8 53 (84.7) (71.7) (79.7) (34.2) 27 94.8 49.5 46.6 20.7 80 Wealth quintile Lowest 29.4 43.0 19.8 243 (51.5) (47.1) (72.2) (13.6) 58 90.6 32.9 48.7 18.6 301 Second 28.9 34.1 13.9 247 43.5 58.6 73.0 21.0 84 85.7 36.4 43.9 15.7 331 Middle 40.1 31.9 19.8 256 67.7 65.0 79.1 37.8 83 92.1 46.2 43.4 24.2 338 Fourth 30.2 30.0 11.8 226 61.3 68.3 61.1 28.1 101 88.1 41.9 39.5 16.8 327 Highest 34.6 37.9 18.9 157 64.0 54.6 68.6 31.1 97 86.3 42.2 49.6 23.6 254 Total 32.6 35.2 16.8 1,129 58.3 59.7 70.2 27.3 422 88.6 40.0 44.7 19.6 1,551 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. FTF = Feed the Future 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c. vitamin A-rich fruits and vegetables; d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts. 2 For breastfed children, minimum meal frequency is receiving solid or semi-solid food at least twice a day for infants 6-8 months and at least three times a day for children 9-23 months. 3 Includes two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 4 For nonbreastfed children age 6-23 months, minimum meal frequency is receiving solid or semi-solid food or milk feeds at least four times a day. 5 Nonbreastfed children age 6-23 months are considered to be fed with a minimum standard of three infant and young child feeding practices if they receive other milk or milk products at least twice a day, receive the minimum meal frequency, and receive solid or semi-solid foods from at least four food groups, not including the milk/milk products group. 6 Breastfeeding, or not breastfeeding and receiving two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 7 Children are fed the minimum recommended number of times per day, according to their age and breastfeeding status, as described in footnotes 2 and 4. 162 • Nutrition of Children and Women The proportion of all children 6-23 months who are fed according to all three IYCF recommendations increases with the child’s age, from 3 percent for children 6-8 months to 33 percent for children 18-23 months. Feeding practices do not vary between boys and girls, but there are differences across other background characteristics. Children living in urban areas (23 percent) are more likely to be fed according to the recommendation than their rural counterparts (19 percent). Children living in GBAO region are the least likely to be fed according to all IYCF practices (14 percent), while children living in DRS region are the most likely (24 percent). There is a weak positive relationship between infant and child feeding practices and mother’s education, but the relationship with wealth status is not clear. Figure 12.5 shows IYCF practices according to breastfeeding status. In terms of overall feeding practices, a higher proportion of nonbreastfed children meet the minimum requirements (27 percent) than breastfed children (17 percent). Figure 12.5 IYCF indicators on minimum acceptable diet, Tajikistan 2012 Tajikistan DHS 2012 12.7 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is a major contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, fortified food, and direct supplementation. The 2012 TjDHS collected information on consumption of foods rich in vitamin A and iron, vitamin A and iron supplementation, and deworming status for children age 6-59 months. Household salt samples were also tested for iodine levels. Table 12.7 presents data regarding the intake of key micronutrients among children age 6-59 months. The table shows, by background characteristics, the percentage of youngest children age 6-23 months who are living with their mother and who consumed foods rich in vitamin A and iron in the day or night preceding the survey. In addition, the table shows the proportion of all children age 6-59 months who had received vitamin A supplements or deworming medication in the six months preceding the survey and iron supplements in the week before the survey. The table also presents information on children age 6-59 months who live in households with iodized salt. 33 35 17 60 70 27 40 45 20 Minimum dietary diversity Minimum meal frequency Minimum acceptable diet Percentage Breastfed Nonbreastfed All children 6-23 months Nutrition of Children and Women • 163 Table 12.7 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey, and among all children 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, who were given iron supplements in the past seven days, and who were given deworming medication in the six months preceding the survey, and among all children age 6-59 months who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Tajikistan 2012 Background characteristic Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Among children age 6-59 months living in households tested for iodized salt Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supple- ments in last 6 months Percentage given iron supplements in last 7 days Percentage given dewor- ming medica- tion in last 6 months3 Number of children Percentage living in households with iodized salt4 Number of children Age in months 6-8 15.6 12.6 295 56.4 15.2 17.0 301 82.2 286 9-11 39.3 28.2 288 73.6 18.3 23.0 290 81.6 279 12-17 59.6 49.9 518 76.8 22.2 35.0 539 85.7 520 18-23 74.4 65.7 451 82.9 20.1 52.0 533 81.7 527 24-35 na na na 76.3 22.2 55.2 1,146 83.6 1,111 36-47 na na na 78.7 20.2 60.0 930 79.5 892 48-59 na na na 78.4 19.3 59.6 851 84.9 827 Sex Male 50.1 41.7 799 76.8 21.4 49.9 2,346 83.1 2,271 Female 53.5 45.2 752 76.2 19.2 49.5 2,243 82.5 2,170 Breastfeeding status Breastfeeding 44.4 36.9 1,129 73.5 20.9 32.4 1,279 83.5 1,246 Not breastfeeding 71.3 60.7 420 77.8 20.1 56.5 3,282 82.5 3,172 Mother's age at birth 15-19 (45.4) (36.9) 39 (61.9) (19.0) (15.8) 46 (75.4) 46 20-29 51.7 43.9 1,103 77.1 20.6 48.5 2,960 82.6 2,864 30-39 52.7 42.0 372 75.9 20.0 54.1 1,359 83.6 1,327 40-49 (50.0) (47.6) 37 75.0 18.8 45.8 224 83.1 205 Residence Urban 51.4 44.6 332 72.9 17.6 52.7 995 87.5 963 Rural 51.8 43.0 1,219 77.5 21.1 48.9 3,595 81.5 3,478 Region Dushanbe 47.8 37.2 118 62.5 14.6 49.5 368 90.7 359 GBAO 37.9 22.7 24 79.4 34.9 39.6 79 80.3 77 Sughd 53.3 46.8 431 78.2 19.9 56.9 1,245 89.0 1,231 DRS 52.4 41.1 400 72.7 21.0 56.8 1,162 72.1 1,133 Khatlon 51.5 44.5 578 80.7 20.6 40.3 1,735 84.0 1,641 FTF districts 58.0 47.7 222 86.0 20.7 49.8 682 78.9 661 Mother's education None/primary 55.1 45.3 126 75.2 18.1 45.3 387 77.7 379 General basic 50.7 42.4 625 74.3 20.4 49.2 1,770 78.9 1,694 General secondary 51.0 43.1 638 78.6 20.1 50.0 1,935 86.8 1,878 Professional primary/ middle 52.9 43.4 82 76.7 24.8 56.4 266 80.7 262 Higher 58.9 49.7 80 78.6 19.4 51.1 231 89.7 228 Wealth quintile Lowest 43.1 34.9 301 77.9 19.6 43.1 924 81.2 895 Second 50.2 42.8 331 82.8 19.2 48.3 981 82.2 938 Middle 57.9 47.1 338 76.0 21.4 51.1 946 82.5 915 Fourth 53.3 45.4 327 76.5 22.9 56.0 915 82.6 889 Highest 53.8 46.6 254 68.1 18.3 50.1 822 85.9 805 Total 51.7 43.4 1,551 76.5 20.3 49.7 4,589 82.8 4,442 Note: Information on vitamin A is based on both mother's recall and the immunization card (where available). Information on iron supplements and deworming medication is based on the mother's recall. Total includes 29 children age 6-59 months who are missing information on breastfeeding status. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable FTF = Feed the Future 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, carrots, red sweet bell pepper, dark green leafy vegetables, persimmon, and other locally grown fruits and vegetables that are rich in vitamin A. 2 Includes meat (including organ meat), fish, poultry and eggs. 3 Deworming for intestinal parasites is commonly done for helminths. 4 Excludes children in households in which salt was not tested. 164 • Nutrition of Children and Women 12.7.1 Consumption of Micronutrient-rich Foods Table 12.7 shows that just over half (52 percent) of children age 6-23 months consumed foods rich in vitamin A in the day or night preceding the survey. The proportion of children consuming vitamin A- rich foods increases with age, from 16 percent among children age 6-8 months to 74 percent among children age 18-23 months. Similarly, consumption of vitamin A-rich foods is higher among children who are not breastfeeding, since these children also tend to be older than those who are still being breastfed. Otherwise, differences in consumption of vitamin A-rich foods by other background characteristics are not large, although the proportion of children consuming vitamin A-rich foods is relatively low in GBAO region (38 percent). At the national level, 43 percent of children age 6-23 months consumed foods rich in iron in the 24 hours before the survey. Differences in the intake of iron-rich foods by background characteristics are largely similar to those for consumption of vitamin A-rich foods. However, the differences by region are more pronounced than for vitamin A-rich foods, with children in GBAO region only about half as likely to receive iron-rich foods in the 24 hours before the survey as those in Sughd or Khatlon regions. The consumption of iron-rich foods is notably lower among children in the lowest wealth quintile. 12.7.2 Micronutrient Supplementation Survey results indicate that 77 percent of children age 6-59 months received a vitamin A supplement in the six months preceding the survey (Table 12.7). Children age 18-23 months are the most likely to have received vitamin A supplements (83 percent). Across regions, the proportion of children who received vitamin A supplements ranges from 63 percent in Dushanbe to 81 percent in Khatlon. It is also high (86 percent) in the districts that fall in the Feed the Future (FTF) program. There are no clear patterns in vitamin A supplementation by mother’s education or wealth quintile; however, it is interesting to note that children in the highest wealth quintile are the least likely to have received a vitamin A supplement in the previous six months. The 2012 TjDHS results indicate a substantial increase in vitamin A supplementation coverage. The proportion of children age 6-59 months who received supplementation in the previous six months increased from 47 percent in the 2005 MICS survey to 77 percent in 2012 (SCS, 2007). In the 2012 TjDHS, mothers were asked if their children under age 5 had taken an iron tablet in the seven days prior to the survey. Table 12.7 shows that 20 percent of children age 6-59 months received iron supplements in this period. Iron supplementation varies little by the child’s background characteristics, except that it is notably higher among children in GBAO region (35 percent) than among those in other regions. Fortified salt that contains 15 parts of iodine per million of salt (15 ppm) is considered adequate for the prevention of iodine deficiency (ICCIDD, UNICEF, and WHO, 2001). To assess the use of iodized salt in Tajikistan, the 2012 TjDHS included salt testing at the household level using the MBI rapid test kit for salt fortified with potassium iodate (in Tajikistan, salt is commonly iodized with potassium iodate). The MBI rapid test kit provides a good qualitative indication of the presence or absence of iodine. Interviewers asked households to provide a teaspoon of salt used for cooking. A recheck solution was used when the salt showed no change in color. Table 12.7 presents information about all children age 6-59 months who live in households that use iodized salt. At the national level, 83 percent of children live in households that use iodized salt: 88 percent in urban and 82 percent in rural areas. The percentage of children living in households that use iodized salt ranges from 72 percent in DRS region to 91 percent in Dushanbe. Mother’s education and household wealth are positively associated with the likelihood of children living in households that use iodized salt. Nutrition of Children and Women • 165 12.7.3 Deworming Certain types of intestinal parasites can cause anemia. Periodic deworming for organisms such as helminthes can improve children’s micronutrient status. In the 2012 TjDHS, mothers were asked if their children under age 5 had taken deworming medication in the six months prior to the survey. At the national level, 50 percent of children age 6-59 months received deworming medication in this period (Table 12.7). The percentage of children who received deworming medication increases with age, ranging from 17 percent of children age 6-8 months to 60 percent of children age 36-59 months. Breastfed children are less likely than nonbreastfed children to receive deworming medication (32 percent and 57 percent, respectively). There is little difference between urban and rural areas, but the coverage of deworming medication varies across regions, ranging from 40 percent in GBAO and Khatlon regions to 57 percent in Sughd and DRS regions. Mother’s education and household wealth have positive associations with children’s likelihood of receiving deworming medication. 12.8 HOUSEHOLD IODIZED SALT CONSUMPTION Salt used in the household is the most common vehicle for iodine fortification to prevent the public health concerns of iodine deficiency disorders (IDD). Since 1997, the government and donor community have addressed IDD through the National Programme for Elimination of IDD, which requires that salt be iodized to 45 parts per million (ppm) (SCS, 2007). A subsequent law (№ 344) regulating the production, distribution, and consumption of iodized salt in Tajikistan was adopted in 2002 (SCS, 2007). According to the World Health Organization, a country’s salt iodization program is considered to be on a good track to eliminate iodine deficiency when 90 percent of households use iodized salt. Table 12.8 shows the proportion of households with iodized salt according to background characteristics. Overall, salt was tested in 97 percent of households and 84 percent of the tested households were found to use salt with at least some iodine. However, although the presence of any iodine is most commonly accepted to define iodized salt, the test kits allow classification as to whether the salt contains at least 15 parts per million (ppm) of iodine, which constitutes the adequate amount of iodization. Using this criterion, only 39 percent of the tested households had adequately iodized salt. These results show some improvement in use of iodized salt, from 69 percent of households in 2005 to 83 percent in 2009 and to 84 percent in 2012. However, the proportion of households using adequately iodized salt has declined slightly, from 46 percent in 2005 to 39 percent in 2012 (SCS, 2007; MOH and UNICEF, 2010). The decrease is substantially larger when the 2012 TjDHS data are compared with the data from the 2009 Micronutrient Status Survey (MSST), when 62 percent of households were using salt containing 15 parts per million or more of iodine, indicating a 37 percent decrease in the proportion of households using adequately iodized during the past 3 years between the surveys (MOH and UNICEF, 2010). However, it should be noted, that in the 2012 TjDHS survey, a test kit for salt fortified with potassium iodate was used to test the salt for the presence of iodine, while in the 2009 MSST two different kits were used, one for salt fortified with potassium iodate and the second for salt fortified with potassium iodide. Looking at the proportion of households using salt with at least some iodine, urban households are more likely to consume iodized salt than rural households (88 percent and 83 percent, respectively). Dushanbe and Sughd regions have the highest proportion of households consuming iodized salt (90 percent), while DRS region has the lowest (75 percent). The percentage of households with iodized salt shows some tendency to increase with wealth. The wealthiest households are twice as likely to use adequately iodized salt as the poorest households (52 percent and 25 percent, respectively). 166 • Nutrition of Children and Women Table 12.8 Presence of iodized salt in household Among all households, percentage of households tested for iodine content and percentage of households with no salt; and among households with salt tested, the percent distribution by level of iodine in salt (parts per million or ppm) and percentage with iodized salt, according to background characteristics, Tajikistan 2012 Background characteristic Among all households, the percentage: None (0 ppm) Among households with tested salt: With salt tested With no salt in the household Number of households Inadequate (<15 ppm) Adequate (15+ ppm) Total Percentage with iodized salt Number of households Residence Urban 97.3 2.7 1,976 12.5 37.5 50.0 100.0 87.5 1,922 Rural 97.2 2.8 4,456 17.4 48.7 33.8 100.0 82.6 4,330 Region Dushanbe 96.7 3.3 756 9.8 40.3 49.8 100.0 90.2 732 GBAO 96.4 3.6 160 22.0 47.4 30.6 100.0 78.0 154 Sughd 98.6 1.4 2,069 10.5 31.3 58.2 100.0 89.5 2,039 DRS 97.8 2.2 1,433 25.1 53.5 21.4 100.0 74.9 1,402 Khatlon 95.6 4.4 2,014 16.9 55.8 27.4 100.0 83.1 1,926 FTF districts 97.4 2.6 800 21.9 55.4 22.7 100.0 78.1 779 Wealth quintile Lowest 97.1 2.9 1,207 17.5 57.8 24.7 100.0 82.5 1,172 Second 95.9 4.1 1,132 16.5 53.3 30.2 100.0 83.5 1,085 Middle 97.2 2.8 1,158 18.0 49.1 32.8 100.0 82.0 1,125 Fourth 98.1 1.9 1,271 16.3 36.0 47.7 100.0 83.7 1,247 Highest 97.6 2.4 1,664 12.7 35.3 52.0 100.0 87.3 1,624 Total 97.2 2.8 6,432 15.9 45.3 38.8 100.0 84.1 6,252 12.9 NUTRITIONAL STATUS OF WOMEN Low pre-pregnancy body mass index (BMI) and short stature of women are known risk factors for poor maternal and birth outcomes. In developing countries, maternal underweight is a leading risk factor for preventable death and diseases. The prevalence of overweight adults is also a growing concern in developing countries. Overweight individuals are predisposed to a wide range of health problems such as diabetes and heart disease as well as poor birth outcomes for women. In many countries, though, chronic energy deficiency, characterized by a BMI of less than 18.5 among adults remains the predominant problem, leading to low work productivity and reduced resistance to illness. The 2012 TjDHS included measuring the height and weight of women age 15-49. The data are used to derive two measures of nutritional status: height and body mass index (BMI). Given the relationship between maternal stature and pelvic size, women’s height can be useful in predicting the risk of difficulties in delivery. The risk of giving birth to low-weight babies is also higher among women of small stature. The cut-off point at which mothers are considered at risk because of short stature normally falls between 140 and 150 centimeters. The BMI is used to measure thinness or obesity. It is defined as weight in kilograms divided by height in meters squared (kg/m2). A BMI of less than 18.5 is used to define thinness or acute undernutrition. A BMI of 25 or above usually indicates overweight, and a BMI of 30 or above indicates obesity. Table 12.9 presents the height analysis for 9,630 women age 15-49, while the analysis of BMI is based on 8,800 women. The table excludes women for whom there was no information on height and/or weight and women for whom a BMI could not be estimated because they were pregnant or had given birth in the preceding two months. Overall, only 1 percent of women fall below the cut-off of 145 centimeters in height. The proportion below the cut-off for women’s height is only very slightly higher among women age 15-19 and among those in the lowest education group and wealth quintile. Nutrition of Children and Women • 167 Table 12.9 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean Body Mass Index (BMI), and the percentage with specific BMI levels, by background characteristics, Tajikistan 2012 Background characteristic Height Body Mass Index1 Percent- age below 145 cm Number of women Mean Body Mass Index (BMI) 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17 (Moder- ately and severely thin) >=25.0 (Total over- weight or obese) 25.0-29.9 (Over- weight) >=30.0 (Obese) Number of women Age 15-19 2.7 2,005 20.7 72.2 20.8 14.2 6.6 7.0 6.3 0.7 1,919 20-29 0.9 3,552 22.1 70.5 12.0 9.0 3.0 17.5 14.0 3.4 2,936 30-39 0.9 2,210 24.7 52.4 5.8 4.3 1.5 41.8 29.1 12.7 2,092 40-49 0.8 1,863 26.6 37.8 3.4 2.0 1.3 58.8 34.1 24.8 1,853 Residence Urban 1.3 2,404 24.1 52.1 10.2 7.1 3.1 37.7 23.8 14.0 2,233 Rural 1.2 7,226 23.1 62.3 10.8 7.7 3.1 26.9 18.9 8.0 6,567 Region Dushanbe 0.5 876 24.5 50.0 9.6 7.0 2.5 40.4 24.4 16.0 820 GBAO 1.2 218 22.2 64.8 13.3 9.1 4.2 22.0 17.2 4.8 202 Sughd 1.5 2,865 23.1 64.0 10.0 7.1 2.9 26.0 19.0 7.0 2,651 DRS 1.2 2,230 23.7 57.3 10.0 7.3 2.8 32.7 20.6 12.1 2,035 Khatlon 1.3 3,441 23.1 59.9 11.6 8.1 3.5 28.5 19.9 8.6 3,091 FTF districts 1.0 1,364 23.5 56.4 11.5 7.8 3.7 32.1 21.6 10.5 1,230 Education None/primary 3.3 566 22.9 64.9 11.4 7.8 3.7 23.7 15.9 7.9 495 General basic 1.8 3,338 22.5 63.8 14.2 10.2 4.0 22.0 16.0 6.0 2,980 General secondary 0.8 4,463 23.9 57.2 8.7 6.0 2.6 34.1 22.4 11.8 4,152 Professional primary/ middle 0.4 645 24.3 51.5 9.5 6.9 2.6 39.0 24.9 14.1 594 Higher 0.8 618 23.7 60.1 7.0 5.4 1.6 32.9 24.6 8.4 579 Wealth quintile Lowest 2.2 1,874 22.5 66.1 12.0 8.4 3.6 21.9 16.7 5.3 1,737 Second 1.1 1,909 23.2 62.6 10.2 7.9 2.3 27.2 18.3 8.9 1,703 Middle 1.0 1,900 23.4 59.8 10.1 7.0 3.1 30.1 21.1 9.0 1,726 Fourth 1.1 1,966 23.7 56.6 11.3 8.0 3.2 32.1 20.6 11.5 1,781 Highest 0.9 1,980 24.0 53.9 9.7 6.5 3.1 36.4 23.8 12.6 1,852 Total 1.3 9,630 23.4 59.7 10.6 7.5 3.1 29.7 20.2 9.5 8,800 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding 2 months. The mean BMI for women age 15-49 is 23.4 (Table 12.9), which falls in the normal BMI classification. Six in ten women have a normal BMI, 11 percent are undernourished or thin (BMI less than 18.5), and 30 percent are overweight or obese (BMI 25 or higher). Variations are apparent by background characteristics. Women age 15-19 are more likely to be thin or undernourished (21 percent) than women in other age cohorts (3-12 percent). On the other hand, the proportion of women who are overweight increases with age; almost three in ten women age 40-49 are overweight, and another one-quarter are obese. Urban women are more likely to be overweight or obese than rural women (38 percent and 27 percent, respectively). By region, the proportion of undernourished women does not vary much; however, the proportion of overweight or obese women ranges from 22 percent in GBAO region to 40 percent in Dushanbe. There is no clear relationship between women’s nutritional status and education. However, as household wealth rises, the proportion of women who are overweight increases. Compared with data from the 2009 MSST, the percentage of nonpregnant women age 15-49 who are thin (BMI <18.5) has increased from 7 percent in 2009 to 11 percent in 2012; the percentage of women who are overweight or obese (BMI >25) has increased somewhat, from 28 percent in 2009 to 30 percent in 2012 (MOH and UNICEF, 2010). 168 • Nutrition of Children and Women 12.10 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation during pregnancy can reduce the likelihood of anemia. Finally, iodine deficiency is related to a number of adverse pregnancy outcomes, including abortion and stillbirth, as well as fetal brain damage and congenital malformation. Vitamin A deficiency (VAD) can be prevented through the provision of a high-dose (200,000 IU) vitamin A capsule in the first six to eight weeks after delivery (when women are considered not at risk of being pregnant). Due to possible adverse effects (birth defects) resulting from high doses of vitamin A, pregnant women should not be given a high-dose vitamin A supplement. The 2012 TjDHS collected data on use of vitamin A supplements among women age 15-49 with a child born in the past five years. Table 12.10 presents information on the percentage of women who received a dose of vitamin A during the first two months after the birth of their most recent child in the five years before the survey. Overall, 27 percent of women age 15-49 received a postpartum vitamin A dose. This proportion tends to decline as age of the woman increases. The percentage of women who received a postpartum vitamin A dose is highest in GBAO region (55 percent) and lowest in DRS region (22 percent). Postpartum vitamin A supplementation increases steadily with women’s educational level, ranging from 17 percent of women with no education or only primary education to 39 percent of women with higher than secondary education. Vitamin A supplementation is also associated with household wealth, increasing from 20 percent among mothers in the lowest wealth quintile to 32 percent among mothers in the fourth quintile. It should be noted, that since 2008, the MOH guidelines no longer support postpartum vitamin A supplementation during the first six to eight weeks after delivery. As for iron supplementation, survey results indicate that only 30 percent of women took iron tablets or syrup during pregnancy for their most recent birth in the five years before the survey. Moreover, most of the women who did take iron supplements did so for fewer than 60 days; less than one percent of women said they took iron supplements for 90 days or more. Iron supplementation during pregnancy is more common among younger women, women in GBAO region, and those with more education and wealth. Table 12.10 also shows that 83 percent of women age 15-49 with a child born in the past five years lives in a household with iodized salt. Urban women are more likely to live in households that use iodized salt than their rural counterparts (87 percent and 82 percent, respectively). Dushanbe has the highest proportion of recent mothers living in households with iodized salt (90 percent), while DRS region has the lowest percentage (74 percent). The proportion of women living in households with iodized salt is positively related to educational level but shows little relationship with household wealth status. Nutrition of Children and Women • 169 Table 12.10 Micronutrient intake among mothers Among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child, the percent distribution by number of days they took iron tablets or syrup during the pregnancy of the last child, and among women age 15-49 with a child born in the past five years and who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Tajikistan 2012 Background characteristic Among women with a child born in the past five years: Among women with a child born in the last five years, who live in households that were tested for iodized salt: Percentage who received vitamin A dose post- partum1 Number of days women took iron tablets or syrup during pregnancy of last birth Number of women None <60 60-89 90+ Don't know/ missing Total Percentage living in households with iodized salt2 Number of women Age 15-19 32.0 57.9 31.6 1.6 0.0 8.8 100.0 78 76.1 78 20-29 26.5 64.5 29.0 1.5 0.9 4.1 100.0 2,179 83.4 2,111 30-39 27.3 64.5 27.2 0.9 1.0 6.4 100.0 1,124 83.8 1,098 40-49 25.1 74.0 21.5 0.0 0.6 3.9 100.0 221 81.6 201 Residence Urban 27.7 62.8 26.9 1.9 0.3 8.1 100.0 802 87.3 778 Rural 26.6 65.5 28.4 1.0 1.0 4.0 100.0 2,799 82.1 2,710 Region Dushanbe 26.4 66.3 24.4 0.9 0.3 8.1 100.0 295 90.4 288 GBAO 54.7 43.2 55.6 0.6 0.0 0.6 100.0 67 80.2 66 Sughd 29.4 59.1 27.9 3.7 1.4 7.9 100.0 1,000 88.2 988 DRS 21.9 73.5 22.0 0.1 0.5 3.9 100.0 887 73.6 867 Khatlon 26.8 64.4 31.6 0.2 0.9 2.9 100.0 1,351 84.5 1,279 FTF districts 31.4 69.3 26.9 0.4 1.6 1.7 100.0 518 79.3 505 Education None/primary 16.7 72.7 23.3 1.1 0.5 2.4 100.0 272 78.0 268 General basic 23.7 67.3 26.6 0.8 1.0 4.4 100.0 1,400 79.7 1,346 General secondary 29.5 66.1 26.7 1.4 0.7 5.1 100.0 1,530 86.9 1,482 Professional primary/ middle 30.2 52.2 41.3 2.1 1.4 2.9 100.0 210 81.0 207 Higher 38.6 40.4 42.3 2.7 1.4 13.3 100.0 189 90.1 186 Wealth quintile Lowest 19.5 72.7 23.3 0.0 0.4 3.7 100.0 731 82.9 708 Second 25.5 69.6 25.5 0.8 0.5 3.6 100.0 757 82.5 725 Middle 26.9 63.2 28.8 1.3 2.3 4.4 100.0 743 83.6 719 Fourth 31.5 57.0 35.3 2.1 0.5 5.1 100.0 718 82.3 699 Highest 31.3 61.5 27.7 2.0 0.6 8.2 100.0 652 85.3 638 Total 26.8 64.9 28.1 1.2 0.9 4.9 100.0 3,601 83.3 3,488 1 In the first two months after delivery of last birth. 2 Excludes women in households where salt was not tested. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 171 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13 cquired immune deficiency syndrome (AIDS) is an illness caused by the human immunodeficiency virus (HIV). AIDS was first recognized internationally in 1981. Epidemiological studies have since identified the main routes of transmission of HIV to be unsafe sexual intercourse, intravenous injections with contaminated needles, unscreened or contaminated blood transfusions, and transmission from an infected mother to her child during pregnancy, delivery, or breastfeeding. HIV cannot be transmitted through food, water, insect vectors, or casual contact. HIV infection weakens the immune system and makes the body susceptible to and unable to recover from other opportunistic diseases. Secondary infections, if not adequately treated, can lead to death. In Tajikistan, HIV prevalence is still low, with only 0.3 percent of the population age 15-49 estimated to be HIV-positive in 2011 (UNAIDS, 2013). Approximately 11,000 people in Tajikistan were living with HIV as of 2011 (UNAIDS, 2013). Nevertheless, the prevalence has been increasing, with a sharp rise in the number of injecting drug users, among whom the HIV epidemic is concentrated (AFEW, 2013). About 78 percent of HIV infection is registered among men and 22 percent among women. Although the majority of new HIV infections in Tajikistan are contracted through injection drug use (53 percent of people infected with HIV), about 30 percent of HIV infections occur from heterosexual contact (GOT, 2012). Heterosexual transmission is especially notable among women; in 2011, about 63 percent of HIV infections among women occurred via heterosexual contact. The number of women newly infected with HIV has tripled, increasing from 96 cases in 2009 to 282 cases in 2011 (GOT, 2012). High rates of migration and a high prevalence of sexually transmitted infections (STIs) also act as catalysts for the growing epidemic. Nonetheless, the government has committed to address these issues and has promoted educational programs as well as the distribution of condoms and clean injecting equipment to vulnerable groups (AFEW, 2013). The government program for 2011-2015 focuses on both HIV prevention and A Key Findings • Only 62 percent of women age 15-49 have heard of AIDS, but this percentage represents an increase since 2005 when only 42 percent of women had heard of AIDS. Slightly more than one-third of women know that using condoms can reduce the risk of getting AIDS, and 43 percent say that staying faithful to one partner can reduce the chance of getting AIDS. • Only 11 percent of women age 15-49 have comprehensive knowledge about HIV/AIDS. • Survey data show considerable stigma towards people living with HIV among women age 15-49 who have heard about AIDS. Only about one-quarter each of women would buy fresh vegetables from a shopkeeper with the AIDS virus and think that a female teacher with the AIDS virus but who is not sick should be allowed to continue teaching. A slightly higher percentage of women (42 percent) say they would be willing to care in their own households for a relative who is sick with AIDS. • Only 15 percent of women age 15-49 have ever been tested for HIV. • A majority of women think that a woman is justified in refusing to have sex with her husband if she knows he has sex with other women, and they also think a woman is justified in asking her husband to use a condom if she knows that he has a sexually transmitted infection. 172 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior reduction of stigma against those living with the disease (Central Asia Newswire, 2010). Emphasis on use of prophylaxis to reduce the spread of the disease as well as to provide access to antiretroviral treatment for those infected are featured in the program (Central Asia Newswire, 2010). This chapter presents current levels of knowledge and attitudes regarding HIV/AIDS prevention and transmission among women of reproductive age. This chapter also discusses self-reported prevalence of sexually transmitted infections (STIs) and symptoms. 13.1 KNOWLEDGE OF HIV/AIDS AND TRANSMISSION AND PREVENTION METHODS 13.1.1 Knowledge of AIDS The 2012 TjDHS included a series of questions to gauge women’s knowledge and attitudes about HIV and AIDS. All women age 15-49 were first asked if they had ever heard of AIDS. Those who had heard of AIDS were then asked about their knowledge of HIV transmission and prevention. Table 13.1 shows that 62 percent of women have heard of AIDS. Awareness of AIDS is considerably lower among the youngest women, women who have never married, women from rural areas, and those with less education and less wealth. Women living in the DRS and Khatlon regions are substantially less likely to have heard of AIDS than women from the GBAO and Sughd regions. Awareness of AIDS falls below 50 percent among women in the DRS region, women age 15-19, and women with primary or no education or only a general basic education. Table 13.1 Knowledge of AIDS Percentage of women age 15-49 who have heard of AIDS, by background characteristics, Tajikistan 2012 Background characteristic Has heard of AIDS Number of women Age 15-24 51.2 3,963 15-19 43.3 2,013 20-24 59.3 1,950 25-29 64.3 1,609 30-39 70.9 2,217 40-49 70.2 1,866 Marital status Never married 47.9 2,648 Married/living together 66.6 6,504 Divorced/separated/widowed 67.9 504 Residence Urban 72.1 2,413 Rural 58.0 7,243 Region Dushanbe 64.4 881 GBAO 77.1 220 Sughd 77.6 2,872 DRS 46.1 2,240 Khatlon 56.5 3,444 Education None/primary 34.9 567 General basic 49.5 3,349 General secondary 65.3 4,474 Professional primary/middle 91.3 645 Higher 92.8 620 Wealth quintile Lowest 53.6 1,878 Second 53.6 1,913 Middle 57.5 1,904 Fourth 68.1 1,971 Highest 74.0 1,989 Total 61.6 9,656 Note: Knowledge of AIDS among never married is not disaggregated by ever having had sex/ never having had sex because only one never married woman reported ever having had sexual intercourse. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 173 Women’s knowledge of AIDS has markedly improved during the last seven years, from 42 percent in 2005 (SCS, 2007) to 62 percent in 2012; nevertheless, it remains a concern that nearly four in ten women in Tajikistan have not heard of AIDS. 13.1.2 Knowledge of HIV Prevention Methods HIV prevention programs focus their messages and efforts on two important aspects of behavior: (1) using condoms and (2) staying faithful to one uninfected partner. To ascertain whether programs have effectively communicated these messages, respondents were asked specific questions about whether it is possible to reduce the chance of getting the AIDS virus by using a condom at every sexual encounter and by limiting sexual intercourse to one uninfected partner. Table 13.2 and Figure 13.1 show that 43 percent of women are aware that the chance of getting the AIDS virus can be reduced by limiting sex to one uninfected partner who has no other partners, 36 percent know about using condoms at every sexual intercourse, and 33 percent are aware of both of these means of reducing the risk of HIV transmission. Table 13.2 Knowledge of HIV prevention methods Percentage of women age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus (1) by using condoms every time they have sexual intercourse, (2) by having one sex partner who is not infected and who has no other partners, and (3) by both using condoms and limiting intercourse to one uninfected partner who has no other partners, by background characteristics, Tajikistan 2012 Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of women Age 15-24 28.3 33.4 25.1 3,963 15-19 21.3 25.2 18.6 2,013 20-24 35.5 41.8 31.8 1,950 25-29 40.2 46.1 36.5 1,609 30-39 44.2 50.8 40.0 2,217 40-49 41.1 51.6 37.6 1,866 Marital status Never married 24.1 29.6 21.6 2,648 Married/living together 41.1 47.9 37.2 6,504 Divorced/separated/widowed 40.1 50.7 36.4 504 Residence Urban 42.1 49.7 37.1 2,413 Rural 34.5 40.8 31.4 7,243 Region Dushanbe 37.3 43.1 33.4 881 GBAO 47.3 67.7 44.1 220 Sughd 44.9 51.5 39.4 2,872 DRS 27.7 33.0 26.3 2,240 Khatlon 34.1 40.8 30.8 3,444 Education None/primary 18.5 22.8 17.1 567 General basic 26.7 31.4 23.4 3,349 General secondary 38.1 45.4 34.6 4,474 Professional primary/middle 60.2 69.7 55.0 645 Higher 68.2 78.8 62.9 620 Wealth quintile Lowest 30.0 36.8 27.4 1,878 Second 28.7 36.4 25.7 1,913 Middle 35.1 41.1 32.1 1,904 Fourth 43.3 48.9 39.2 1,971 Highest 44.2 51.2 39.3 1,989 Total 36.4 43.0 32.9 9,656 1 Using condoms every time they have sexual intercourse. 2 Partner who has no other partners. 174 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Figure 13.1 Knowledge about AIDS and HIV prevention methods among women age 15-49, Tajikistan 2012 Younger and never-married women are less likely than older women and ever-married women to know ways to avoid getting the HIV virus. Urban women are more likely to be aware of safe sexual practices than rural women. Looking at regional patterns, knowledge about safe sex practices is generally lowest in the DRS region and highest in the GBAO region. There is a strong positive relationship between the respondent’s educational background and her knowledge of ways to prevent getting HIV. For example, 23 percent of women with general basic education say that the risk of getting the HIV virus can be reduced by using condoms and limiting sex to one uninfected partner, compared with 63 percent of women with higher education. Knowledge of ways to prevent getting HIV is also positively related to wealth quintile, although knowledge increases much less dramatically with wealth than with education. Overall, women’s knowledge of HIV prevention methods at the national level has improved substantially during the last seven years when compared with the results of the 2005 MICS, when condom use and staying faithful to one partner who had no other partners were individual behaviors cited by 21 percent and 25 percent of women, respectively (SCS, 2007). 13.1.3 Comprehensive Knowledge about AIDS As part of the effort to assess HIV and AIDS knowledge, the 2012 TjDHS collected information on common misconceptions about HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have HIV, and also whether they believe HIV can be transmitted through mosquito bites, by kissing a person who has HIV, or by sharing food with a person who has HIV. Comprehensive knowledge is defined as follows: (1) knowing that consistent condom use and having just one faithful partner can reduce the chance of getting the AIDS virus, (2) knowing that a healthy-looking person can have the AIDS virus, and (3) rejecting the two most common local misconceptions about HIV transmission in Tajikistan: that HIV can be transmitted by mosquito bites and that HIV can be transmitted by kissing a person who has HIV. The data presented in Table 13.3 indicate that many women in Tajikistan lack accurate knowledge about the ways in which the AIDS virus can and cannot be transmitted. Only 30 percent of women know that a healthy-looking person can have HIV, and 32 percent know that HIV cannot be transmitted by mosquito bites (Figure 13.2). Thirty-one percent of women know that HIV cannot be transmitted by kissing someone infected with HIV, and 36 percent correctly believe that a person cannot become infected by sharing food with a person who has HIV. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 175 Table 13.3 Comprehensive knowledge about AIDS Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of the AIDS virus, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who say that: Percentage who say that a healthy-looking person can have the AIDS virus and who reject the two most common local miscon- ceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of women A healthy- looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites The AIDS virus cannot be transmitted by kissing someone infected with the AIDS virus A person cannot become infected by sharing food with a person who has the AIDS virus Age 15-24 24.2 27.3 25.2 29.3 12.4 8.7 3,963 15-19 19.7 22.7 20.2 23.9 9.7 6.5 2,013 20-24 28.8 32.0 30.3 35.0 15.2 11.0 1,950 25-29 30.2 33.3 33.8 37.7 15.6 12.0 1,609 30-39 37.5 35.8 37.4 42.6 19.0 14.0 2,217 40-49 35.5 35.9 34.5 38.9 17.5 13.0 1,866 Marital status Never married 22.5 25.6 23.7 27.9 11.7 7.8 2,648 Married/living together 33.3 34.0 34.0 38.4 16.8 12.6 6,504 Divorced/separated/widowed 35.8 37.6 35.3 41.0 18.3 13.4 504 Residence Urban 42.0 39.9 39.8 47.2 21.8 14.3 2,413 Rural 26.6 29.3 28.3 31.8 13.3 10.3 7,243 Region Dushanbe 36.3 36.8 34.6 41.8 19.7 12.8 881 GBAO 49.2 42.4 39.0 45.4 22.3 16.7 220 Sughd 42.0 41.4 41.7 48.8 20.8 14.2 2,872 DRS 18.5 22.7 19.6 23.1 8.5 7.7 2,240 Khatlon 25.9 28.0 28.6 30.6 14.0 10.5 3,444 Education None/primary 13.9 16.6 15.8 15.0 5.6 4.4 567 General basic 20.7 22.4 21.3 24.8 9.2 6.3 3,349 General secondary 31.6 33.4 32.5 37.2 15.8 11.7 4,474 Professional primary/middle 55.3 52.8 57.3 62.4 30.6 21.3 645 Higher 64.4 64.4 62.0 73.9 40.3 31.3 620 Wealth quintile Lowest 23.2 28.1 27.3 28.9 12.3 8.5 1,878 Second 22.1 26.1 25.0 27.2 10.2 7.7 1,913 Middle 26.8 30.7 27.0 31.8 13.7 10.7 1,904 Fourth 37.0 34.6 37.2 41.3 18.9 14.2 1,971 Highest 42.4 39.6 39.0 48.2 21.8 15.1 1,989 Total 30.4 31.9 31.2 35.6 15.5 11.3 9,656 1 Two most common local misconceptions: kissing someone infected with AIDS and mosquito bites. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission or prevention of the AIDS virus. Table 13.3 also shows that only 11 percent of women have comprehensive knowledge about AIDS. Comprehensive knowledge about AIDS is slightly higher among urban women than rural women. Among regions, comprehensive AIDS knowledge is lowest in DRS region (8 percent) and highest in GBAO region (17 percent). Comprehensive knowledge about AIDS increases with education, rising from 4 percent among women with no education or only primary education to 31 percent among women with higher than secondary education. Comprehensive knowledge about AIDS also increases with household wealth, although not to the extent that it does with higher education. 176 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Figure 13.2 Knowledge about AIDS transmission, Tajikistan 2012 Tajikistan DHS 2012 Despite the low level of knowledge about AIDS and its means of transmission, there has been improvement since 2005. The proportion of women age 15-49 who know that a healthy-looking person can have the AIDS virus has increased from 17 percent in 2005 to 30 percent in 2012. Similarly, the proportion who know that the AIDS virus cannot be transmitted by mosquito bites has increased from 21 percent in 2005 to 32 percent in 2012. Also, the proportion who know that a person cannot become infected by sharing food with someone who has the AIDS virus has increased from 18 percent in 2005 to 36 percent in 2012 (SCS, 2007). 13.2 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Knowledge about how to prevent mother-to-child transmission (MTCT) of HIV and how to use antiretroviral medication before delivery to reduce transmission is critical. To assess MTCT knowledge, women age 15-49 were asked whether HIV can be transmitted from a mother to a child through breastfeeding and whether a mother can reduce the chance of transmitting HIV to her child during pregnancy and delivery by taking special drugs. Table 13.4 shows that 38 percent of women know that HIV can be transmitted through breastfeeding, and 23 percent of women know that the risk of MTCT can be reduced by taking special drugs during pregnancy; only 18 percent of women know both of these facts. Knowledge of MTCT increases with age of the woman, and is slightly higher among urban than rural women. The percentage of women who know about MTCT is highest among women in the GBAO and Sughd regions and among women in the higher wealth quintiles. It also increases with education of women. The proportion of women age 15-49 who know that HIV can be transmitted during breastfeeding has increased from 30 percent in 2005 to 38 percent in 2012 (SCS, 2007). HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 177 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Tajikistan 2012 Background characteristic Percentage who know that: Number of women HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Age 15-24 28.2 17.5 12.4 3,963 15-19 21.7 13.1 9.1 2,013 20-24 35.0 22.0 15.9 1,950 25-29 40.4 25.6 19.9 1,609 30-39 45.0 27.0 21.7 2,217 40-49 46.0 28.5 23.1 1,866 Marital status Never married 24.1 14.4 9.8 2,648 Married/living together 42.4 26.3 20.8 6,504 Divorced/separated/widowed 44.7 28.4 22.5 504 Currently pregnant Pregnant 38.2 23.4 16.9 734 Not pregnant or not sure 37.5 23.1 18.0 8,922 Residence Urban 45.5 26.2 21.7 2,413 Rural 34.9 22.1 16.6 7,243 Region Dushanbe 36.4 16.2 15.0 881 GBAO 69.5 21.6 20.4 220 Sughd 52.4 29.1 25.0 2,872 DRS 28.6 19.0 18.2 2,240 Khatlon 29.2 22.7 12.3 3,444 Education None/primary 19.4 12.8 9.3 567 General basic 27.1 18.1 13.0 3,349 General secondary 39.2 23.6 18.3 4,474 Professional primary/middle 67.5 35.2 29.2 645 Higher 66.6 44.1 37.1 620 Wealth quintile Lowest 32.4 22.7 14.6 1,878 Second 29.3 18.6 11.8 1,913 Middle 33.3 19.8 15.8 1,904 Fourth 43.5 25.3 21.5 1,971 Highest 48.5 28.9 25.2 1,989 Total 37.5 23.1 17.9 9,656 13.3 ATTITUDES TOWARDS PEOPLE LIVING WITH HIV Widespread stigma and discrimination in a population can adversely affect both people’s willingness to be tested and adherence to antiretroviral therapy. Reduction of stigma and discrimination in a population is, thus, an important indicator of the success of programs targeting HIV and AIDS prevention and control. To assess the level of stigma, women interviewed in the TjDHS who had heard of AIDS were asked if they would be willing to care for a family member sick with AIDS in their own households, if they would be willing to buy fresh vegetables from a shopkeeper who had the AIDS virus, if they thought a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching, and if they would want to keep a family member’s HIV status secret. Table 13.5 shows results. 178 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior The data indicate that there is considerable stigma among women in Tajikistan towards people who are living with HIV. Only 42 percent of women age 15-49 who have heard of AIDS say they would be willing to care in their own households for a relative who is sick with AIDS. Only about one-quarter of women would be willing to buy fresh vegetables from a shopkeeper who has the AIDS virus or believe that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching. Of the four attitudes asked about in the survey, the largest proportion of respondents expressed openness about divulging if a family member got infected with HIV; 57 percent of women said they would not want to keep this a secret. Table 13.5 Accepting attitudes toward those living with HIV/AIDS Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who: Percentage expressing acceptance attitudes on all four indicators Number of women who have heard of AIDS Are willing to care for a family member with AIDS in the respondent's home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher who has the AIDS virus but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 42.5 28.9 26.5 55.3 6.6 2,028 15-19 41.2 28.3 27.4 53.1 6.7 871 20-24 43.5 29.4 25.8 57.0 6.5 1,156 25-29 42.5 28.1 26.1 57.5 6.6 1,034 30-39 41.1 26.2 25.3 57.7 4.9 1,572 40-49 42.9 24.6 24.4 58.3 5.1 1,309 Marital status Never married 42.5 29.7 29.4 54.2 6.6 1,269 Married/living together 41.9 26.2 24.1 57.7 5.5 4,332 Divorced/separated/widowed 45.6 29.1 31.6 57.9 6.5 342 Residence Urban 44.5 32.6 35.1 53.0 6.0 1,740 Rural 41.3 24.8 21.7 58.6 5.7 4,204 Region Dushanbe 36.0 31.0 36.6 46.2 4.1 567 GBAO 54.8 26.9 28.5 54.4 10.3 169 Sughd 39.2 26.5 22.3 49.1 1.3 2,227 DRS 40.6 13.9 13.9 65.7 2.6 1,033 Khatlon 47.2 33.7 32.3 64.7 12.7 1,947 Education None/primary 38.3 21.7 20.7 57.7 6.0 198 General basic 38.4 20.9 21.3 58.3 5.6 1,658 General secondary 40.4 26.7 22.3 59.1 5.2 2,922 Professional primary/middle 48.5 31.9 34.6 51.8 6.7 589 Higher 57.2 43.8 48.0 47.3 8.6 576 Wealth quintile Lowest 40.8 27.1 22.4 60.5 7.5 1,007 Second 43.1 25.3 24.8 61.1 7.2 1,026 Middle 39.1 25.4 21.5 61.7 5.6 1,096 Fourth 44.8 26.1 24.9 54.7 5.0 1,343 Highest 42.5 30.5 32.3 50.2 4.6 1,471 Total 42.2 27.1 25.7 57.0 5.8 5,943 Higher education and urban residence are generally associated with more accepting attitudes towards non-relatives who are HIV-positive and with greater willingness to care for family members with AIDS in their own home. For instance, the percentage of women expressing accepting attitudes towards a female teacher who is HIV-positive but not sick is 35 percent among urban women compared with 22 percent among rural women; it is 21-22 percent among women with general secondary or lower levels of education, compared with 48 percent among those with higher education. On the other hand, among women residing in rural areas, those in households in the lower to middle wealth quintiles, and those with general secondary education or less are generally more likely to say that they would not want to keep secret that a family member is HIV positive. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 179 The percentage expressing acceptance on all four measures is very low—only 6 percent. Differentials in the proportion of women who express acceptance on all four indicators are small, showing almost no relationship with education and only a slightly negative relationship with wealth quintile. Women in the Sughd region are the least likely to express acceptance on all four indicators, while those in the Khatlon region are the most likely. Similar questions were asked of women in the 2005 MICS; however, data were tabulated to show negative attitudes, making comparisons with the 2012 TjDHS more difficult. Nevertheless, the data imply that attitudes have not changed much in the seven years between the surveys. In 2005, 5 percent of women disagreed with all four of the negative statements, which is roughly comparable to the 6 percent of women in 2012 who expressed acceptance of all four indicators in Table 13.5. 13.4 ATTITUDES TOWARD NEGOTIATING SAFE SEXUAL RELATIONS WITH HUSBANDS Comprehensive knowledge about HIV trans-mission and ways to prevent it are basic prerequisites for HIV prevention. Translating knowledge into behavior, however, depends on a number of individual, social, and contextual factors. One of the important determinants of practicing safer sex is control over one’s own sexuality. Knowledge about HIV transmission and ways to prevent it are of little use if women feel powerless to negotiate safer sex practices with their husbands. In an effort to assess a woman’s ability to negotiate safer sex, the 2012 TjDHS asked women if they think that a wife is justified in refusing to have sex with her husband when she knows he has sex with other women and if they think a wife is justified in asking that they use a condom if she knows her husband has a disease that can be transmitted through sexual contact. Table 13.6 shows that the majority of women agree with these statements; 57 percent agree that a woman is justified in refusing to have sex with her husband if she knows he has sex with other women, and 58 percent believe a woman is justified in asking her husband to use a condom if she knows that he has a sexually transmitted infection. Both proportions show a steady increase with age of the woman. For example, the proportion of women who believe a woman is justified in asking her husband to use a condom if she knows he has a sexually transmitted infection almost triples, from 25 percent of women age 15-19 to 73 percent of women age 40-49. There is also a steady increase in women’s support Table 13.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with other women, and percentage who believe that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI), by background characteristics, Tajikistan 2012 Background characteristic Woman is justified in: Number of women Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Age 15-24 41.1 40.1 3,963 15-19 27.5 25.3 2,013 20-24 55.0 55.4 1,950 25-29 63.5 65.9 1,609 30-39 70.1 72.2 2,217 40-49 72.0 73.3 1,866 Marital status Never married 27.5 25.9 2,648 Married/living together 69.1 70.9 6,504 Divorced/separated/widowed 63.9 64.0 504 Residence Urban 61.4 63.0 2,413 Rural 56.1 56.6 7,243 Region Dushanbe 52.2 54.0 881 GBAO 55.4 61.2 220 Sughd 70.6 72.0 2,872 DRS 39.3 42.0 2,240 Khatlon 59.8 58.1 3,444 Education None/primary 39.2 38.6 567 General basic 47.7 48.0 3,349 General secondary 61.8 62.3 4,474 Professional primary/middle 74.3 77.4 645 Higher 77.8 81.7 620 Wealth quintile Lowest 54.4 52.0 1,878 Second 51.2 51.1 1,913 Middle 55.2 56.9 1,904 Fourth 63.1 66.1 1,971 Highest 62.9 64.4 1,989 Total 57.4 58.2 9,656 180 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior for their ability to negotiate safer sex as education levels increase. Women in urban areas and those who have ever been married are more likely than rural women and never-married women to agree that women are justified in pressing for safe sex. Women in the Sughd region are the most likely to support both statements relating to negotiating safe sex, while women in the DRS region are the least likely to agree. The proportions of women who support a woman’s right to refuse sex and to ask for condom use generally increase with wealth, but the relationship is not strong. In an effort to assess a married woman’s ability to negotiate safer sex, the 2012 TjDHS asked currently married women if they can say no to their husband/partner if she does not want to have sexual intercourse; and whether she could ask her husband to use a condom if she wanted him to. The data show that nearly two-thirds of currently married women reported that they can say no to a husband/ partner if she does not want to have sexual intercourse (64 percent) but less than half of married women (45 percent) said that they could ask her husband to use a condom if she wanted him to. Currently married women in the Sughd region are the most certain that they can say no to sexual intercourse (77 percent) or ask him to use a condom (55 percent), while women living in the DRS and Khatlon regions are the least certain they can ask for either of these things (54 percent and 41 percent, respectively in DRS and 60 percent and 38 percent, respectively in the Khatlon region) (data not shown). 13.5 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUTH Condom use is one of the main strategies for combating the spread of HIV. However, educating youth about condoms is sometimes controversial, with some saying it promotes early sexual experimentation. To gauge attitudes towards condom education, women interviewed in the 2012 TjDHS were asked if they thought that children age 12-14 should be taught about using condoms to avoid getting AIDS. The results are shown in Table 13.7. Because the table focuses on adult opinion, results are tabulated for respondents age 18-49. The table shows that only 21 percent of women age 18-49 agree that children age 12-14 should be taught about using condoms to avoid AIDS. Women age 18-19 are slightly less likely than women age 20 and above to agree. Urban women are more likely than rural residents to agree about condom education for youth. Residents of the GBAO and Dushanbe regions are the most likely to agree that children age 12-14 should be taught about using condoms to avoid AIDS (35 and 32 percent, respectively), while residents of the DRS region are by far the least likely to agree (10 percent). Support for teaching children about using condoms to avoid AIDS increases with wealth quintile and especially with education; almost half of women with higher education agree that children age 12-14 should be taught about condom use; this compares with only 11 percent of those with no education or only primary education. Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women age 18-49 who agree that children age 12- 14 years should be taught about using a condom to avoid AIDS, by background characteristics, Tajikistan 2012 Background characteristic Percentage who agree Number of women Age 18-24 18.6 2,756 18-19 14.2 806 20-24 20.4 1,950 25-29 21.3 1,609 30-39 21.4 2,217 40-49 24.4 1,866 Marital status Never married 19.3 1,455 Married or living together 21.2 6,491 Divorced/separated/widowed 25.3 503 Residence Urban 28.6 2,124 Rural 18.6 6,325 Region Dushanbe 31.8 772 GBAO 34.9 191 Sughd 20.7 2,515 DRS 9.7 1,979 Khatlon 25.4 2,993 Education None/primary 10.7 515 General basic 14.5 2,614 General secondary 20.4 4,063 Professional primary/middle 35.8 639 Higher 47.3 619 Wealth quintile Lowest 16.1 1,627 Second 18.1 1,654 Middle 19.9 1,698 Fourth 23.2 1,740 Highest 27.9 1,731 Total 18-49 21.1 8,449 HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 181 13.6 MULTIPLE SEXUAL PARTNERS Given that heterosexual contact is a major means of HIV infection among women in Tajikistan, information on sexual behavior is important in designing and monitoring intervention programs to control the spread of the disease. In the context of HIV/AIDS prevention, limiting the number of sexual partners and having protected sex are crucial to combating the epidemic. The 2012 TjDHS included questions on respondents’ sexual partners during the 12 months preceding the survey. Information on the use of condoms at the last sexual encounter was also collected. Finally, sexually active women were asked about the total number of partners they had during their lifetime. These questions are of course sensitive, and respondents’ answers are likely subject to at least some reporting bias. Table 13.8 shows that almost no women reported having more than one sexual partner in the reference period. Similarly, among those who ever had sexual intercourse, almost no women reported having had more than one partner; consequently, the mean number of lifetime sexual partners is 1.0. Table 13.8 Multiple sexual partners Among all women age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months and the mean number of sexual partners during their lifetime for women who ever had sexual intercourse, by background characteristics, Tajikistan 2012 Background characteristic All women Among women who ever had sexual intercourse1: Percentage who had 2+ partners in the past 12 months Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 0.0 3,963 1.0 1,643 15-19 0.0 2,013 1.0 268 20-24 0.0 1,950 1.0 1,375 25-29 0.0 1,609 1.0 1,402 30-39 0.2 2,217 1.1 2,106 40-49 0.0 1,866 1.1 1,846 Marital status Never married 0.0 2,648 * 0 Married or living together 0.0 6,504 1.0 6,493 Divorced/separated/widowed 0.5 504 1.1 504 Residence Urban 0.1 2,413 1.1 1,755 Rural 0.0 7,243 1.0 5,241 Region Dushanbe 0.1 881 1.1 633 GBAO 0.0 220 1.0 138 Sughd 0.0 2,872 1.1 2,145 DRS 0.0 2,240 1.0 1,672 Khatlon 0.1 3,444 1.0 2,409 Education None/primary 0.0 567 1.0 391 General basic 0.0 3,349 1.0 2,150 General secondary 0.1 4,474 1.0 3,499 Professional primary/middle 0.0 645 1.0 518 Higher 0.2 620 1.1 440 Wealth quintile Lowest 0.0 1,878 1.0 1,300 Second 0.0 1,913 1.0 1,371 Middle 0.0 1,904 1.0 1,399 Fourth 0.1 1,971 1.0 1,469 Highest 0.2 1,989 1.1 1,458 Total 0.0 9,656 1.0 6,997 Note: an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses. 182 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior 13.7 COVERAGE OF HIV COUNSELING AND TESTING Knowledge of HIV status helps HIV-negative individuals make specific decisions to reduce risk and to increase safe sex practices so they can remain disease-free. For those who have HIV infection, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. To assess the awareness and coverage of HIV testing services, women interviewed in the 2012 TjDHS who had given birth in the two years before the survey were asked if they had been tested for HIV as part of their antenatal care, either just before delivery or any time afterwards. Women who did not have a birth in the previous two years were asked whether they had ever been tested for HIV and, if so, how long it had been since their most recent test. Respondents were asked whether they had received the results of their last test. If they had never been tested, they were asked if they knew a place where they could go to be tested. Table 13.9 presents the results regarding prior HIV testing. Table 13.9 Coverage of prior HIV testing Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, percentage of women ever tested, and percentage of women age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, Tajikistan 2012 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 24.5 8.7 2.0 89.3 100.0 10.7 4.5 3,963 15-19 16.6 1.8 0.3 97.9 100.0 2.1 1.1 2,013 20-24 32.7 15.7 3.8 80.5 100.0 19.5 8.0 1,950 25-29 37.8 21.8 3.6 74.7 100.0 25.3 8.2 1,609 30-39 36.6 15.8 2.5 81.7 100.0 18.3 5.1 2,217 40-49 32.4 9.0 1.8 89.2 100.0 10.8 3.0 1,866 Marital status Never married 18.6 1.7 0.2 98.2 100.0 1.8 1.1 2,648 Married/living together 35.9 17.1 3.2 79.7 100.0 20.3 6.7 6,504 Divorced/separated/widowed 32.7 10.6 2.3 87.0 100.0 13.0 3.8 504 Residence Urban 41.1 19.4 2.8 77.8 100.0 22.2 7.8 2,413 Rural 27.7 10.3 2.2 87.5 100.0 12.5 4.0 7,243 Region Dushanbe 40.0 20.7 2.8 76.5 100.0 23.5 8.0 881 GBAO 36.5 15.5 2.1 82.4 100.0 17.6 7.3 220 Sughd 44.5 18.2 2.5 79.3 100.0 20.7 7.3 2,872 DRS 14.3 7.1 1.1 91.8 100.0 8.2 3.4 2,240 Khatlon 28.0 9.1 2.9 88.0 100.0 12.0 3.1 3,444 Education None/primary 13.7 5.6 1.7 92.7 100.0 7.3 2.0 567 General basic 22.8 9.8 1.7 88.5 100.0 11.5 3.9 3,349 General secondary 30.5 10.9 2.3 86.8 100.0 13.2 3.8 4,474 Professional primary/middle 58.5 27.5 4.9 67.5 100.0 32.5 12.7 645 Higher 66.2 30.1 3.9 66.1 100.0 33.9 14.0 620 Wealth quintile Lowest 25.4 8.3 1.4 90.3 100.0 9.7 2.8 1,878 Second 23.8 8.2 2.4 89.4 100.0 10.6 3.5 1,913 Middle 27.7 11.0 2.7 86.3 100.0 13.7 4.5 1,904 Fourth 35.4 14.9 2.5 82.6 100.0 17.4 5.8 1,971 Highest 42.2 19.9 2.6 77.5 100.0 22.5 8.2 1,989 Total 31.0 12.5 2.3 85.1 100.0 14.9 5.0 9,656 1 Includes 'don't know/missing'. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 183 Only 31 percent of women have knowledge of a place to get tested for HIV, and only 15 percent have ever been tested. One in twenty women has been tested and received results in the 12 months before the survey. The percentage of women who have ever been tested for HIV increases with age up to age group 25-29 and then decreases. It is higher among currently married women than among women who are divorced, widowed, or separated or those who have never married. Urban women are more likely than rural women to have ever been tested. The percentage who have ever been tested is highest in Dushanbe and the Sughd regions and lowest in the DRS region. The likelihood that a woman has ever been tested increases with education and wealth quintile. Differentials in knowledge of a place to obtain an HIV test follow a pattern very similar to that for the percentage who have ever been tested. Although the level of HIV testing is low in Tajikistan, it has been increasing. In 2005, only 4 percent of women age 15-49 had ever been tested, compared with 15 percent in 2012. Knowledge of where to get tested has also increased, from 13 percent of women in 2005 to 31 percent in 2012 (SCS, 2007). Table 13.10 presents information on HIV screening of pregnant women age 15-49 who gave birth in the two years prior to the survey. The screening process is a key tool in reducing mother-to-child transmission (MTCT). Survey results show that 25 percent of women who gave birth in the two years before the survey received HIV counseling during antenatal care and a total of 28 percent were tested for HIV during antenatal care, although only 16 percent were counseled, tested, and received results during antenatal care. Rural women and women in DRS and Khatlon regions are less likely than other women to receive counseling and testing for HIV during antenatal care. The survey results also show that HIV counseling and testing during antenatal care increases with the level of education and with increasing wealth quintile. Comparison of survey data with results from the 2005 MICS survey shows no change in the proportion of women who received HIV counseling during antenatal care (from 24 percent in 2005 to 25 percent in 2012). However, the proportion of women who gave birth in the two years before the surveys and who were tested for HIV during an antenatal care visit increased from 11 percent in 2005 to 28 percent in 2012 (SCS, 2007). 184 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 13.10 Pregnant women counseled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received counseling for HIV during antenatal care, the percentage who received an HIV test during antenatal care for their most recent birth by whether they received their results and post-test counseling, and the percentage who received an HIV test during ANC or labor for their most recent birth by whether they received their test results, according to background characteristics, Tajikistan 2012 Background characteristic Percentage who received counseling on HIV during antenatal care1 Percentage who were tested for HIV during antenatal care and who: Percentage who received counseling and an HIV test during ANC, and the results Percentage who had an HIV test during ANC or labor and who:2 Number of women who gave birth in the past two years3 Received results and received post-test counseling Received results and did not receive post-test counseling Did not receive results Received results Did not receive results Age 15-24 24.3 17.1 4.8 4.4 15.9 23.0 5.1 868 15-19 19.4 12.9 3.8 2.0 13.4 16.7 2.0 72 20-24 24.8 17.4 4.9 4.6 16.1 23.6 5.4 796 25-29 25.9 17.1 8.3 3.9 17.8 27.5 4.3 655 30-39 25.1 18.2 7.6 3.5 15.9 26.8 4.3 473 40-49 (12.1) (8.9) (0.0) (0.0) (8.9) (8.9) (0.0) 49 Marital status Married or living together 24.9 17.3 6.5 3.8 16.6 25.2 4.4 2,008 Divorced/separated/widowed (16.1) (7.3) (7.3) (11.6) (4.4) (14.6) (11.6) 37 Residence Urban 29.0 22.8 12.7 4.2 22.0 37.9 5.5 431 Rural 23.6 15.6 4.8 3.9 14.8 21.6 4.2 1,615 Region Dushanbe 22.8 23.0 16.0 2.7 19.3 40.5 5.2 154 GBAO 27.7 20.9 6.0 0.5 20.1 28.1 0.5 34 Sughd 37.6 26.4 15.2 5.5 29.0 43.7 5.5 539 DRS 16.4 11.5 2.1 1.0 10.1 14.7 1.5 519 Khatlon 21.6 13.3 1.6 5.1 11.1 16.0 5.8 798 Education None/primary 11.4 7.5 1.9 2.6 5.2 10.4 3.1 177 General basic 21.1 15.0 4.1 2.8 14.3 20.2 3.3 850 General secondary 26.2 17.0 6.3 4.8 16.0 25.0 5.4 810 Professional primary/middle 49.2 34.6 18.7 7.1 38.9 56.2 7.1 107 Higher 40.4 34.2 22.7 5.5 31.8 58.0 7.5 100 Wealth quintile Lowest 18.3 14.2 2.5 2.9 12.9 18.3 2.9 393 Second 16.8 13.8 3.2 4.0 8.7 17.8 4.9 454 Middle 23.9 13.4 4.0 6.6 12.9 18.4 7.3 451 Fourth 32.3 22.3 9.6 2.2 23.4 33.6 2.3 425 Highest 34.6 23.9 15.1 3.8 26.8 41.3 4.9 323 Total 24.7 17.1 6.5 3.9 16.3 25.0 4.5 2,045 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 In this context, counseling means that someone talked with the respondent about all three of the following topics: (1) babies getting the AIDS virus from their mother, (2) preventing the virus, and 3) getting tested for the virus. 2 Women are asked whether they received an HIV test during labor only if they were not tested for HIV during ANC. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. 13.8 SELF-REPORTED PREVALENCE OF SEXUALLY TRANSMITTED INFECTIONS (STIS) AND STI SYMPTOMS Information about the prevalence of sexually transmitted infections (STIs) is useful not only as a marker of unprotected sexual intercourse but also as a cofactor for HIV transmission. STIs are closely associated with HIV because they increase the likelihood of contracting HIV and share similar risk factors. In the 2012 TjDHS, women who ever had sex were asked whether, in the past 12 months, they had contracted a disease through sexual contact. They were also asked whether they had experienced a genital sore or ulcer or had any abnormal genital discharge in the past year. These symptoms are useful in identifying STIs among men. However, they are less easily interpreted in women because women are likely to experience more conditions of the reproductive tract other than STIs that produce a genital discharge. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 185 Table 13.11 shows that self-reported STI prevalence among women age 15-49 in Tajikistan is negligible, with less than 1 percent of women who have ever had sex reporting having had an STI in the 12 months prior to the survey. It is likely that this figure underestimates the actual prevalence of STIs among the sexually active population, as many STI symptoms are not easily recognized, and many STIs do not have visible symptoms. Altogether, 6 percent of women report having had either an STI and/or symptoms of an STI in the 12 months prior to the survey. Women who report STI symptoms are much more likely to say they have had a bad-smelling or abnormal genital discharge (6 percent) than a genital ulcer or sore (1 percent). The percentage of women reporting an STI and/or STI symptoms is highest in the GBAO region and lowest in the DRS and Dushanbe regions. Table 13.11 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms Among women age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who reported having in the past 12 months: Number of women who ever had sexual intercourse STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/ genital discharge/ sore or ulcer Age 15-24 0.1 6.2 0.4 6.4 1,643 15-19 0.5 4.8 0.0 4.8 269 20-24 0.1 6.5 0.5 6.7 1,374 25-29 0.5 6.7 1.1 7.3 1,404 30-39 0.4 6.6 1.7 7.3 2,108 40-49 0.3 4.1 0.8 4.8 1,849 Marital status Never married * * * * 1 Married/living together 0.3 6.0 1.0 6.6 6,500 Divorced/separated/widowed 0.0 3.8 1.4 4.5 503 Residence Urban 0.3 4.0 0.5 4.4 1,762 Rural 0.3 6.5 1.2 7.1 5,242 Region Dushanbe 0.6 1.6 0.3 1.8 633 GBAO 0.6 12.4 7.4 15.5 137 Sughd 0.4 9.7 1.7 10.6 2,143 DRS 0.0 1.4 0.3 1.6 1,674 Khatlon 0.4 6.2 0.8 6.7 2,416 Education None/primary 0.0 2.6 0.3 2.7 391 General basic 0.1 5.9 1.1 6.3 2,151 General secondary 0.3 5.8 0.9 6.4 3,504 Professional primary/middle 0.8 9.3 2.2 10.3 519 Higher 1.0 5.2 1.3 5.9 439 Wealth quintile Lowest 0.0 5.0 1.2 5.7 1,299 Second 0.3 6.9 1.5 7.3 1,372 Middle 0.1 5.5 1.2 6.2 1,399 Fourth 0.6 6.0 0.8 6.7 1,469 Highest 0.5 5.7 0.7 6.1 1,464 Total 0.3 5.8 1.0 6.4 7,004 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. When women reported having an STI, STI symptoms, or both in the past 12 months, the 2012 TjDHS interviewer asked them whether they sought any advice or treatment. Figure 13.3 shows that 40 percent of women sought no advice or treatment, while 39 percent sought advice or treatment from a clinic, hospital, private doctor, or other health professional. Almost no women went anywhere else for treatment. 186 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Figure 13.3 Treatment seeking for STI symptoms among women age 15-49, Tajikistan 2012 13.9 PREVALENCE OF MEDICAL INJECTIONS Nonsterile injections can pose a risk of infection with HIV and other diseases. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2012 TjDHS were asked if they had received an injection in the past 12 months and, if so, how many. The responses presented in Table 13.12 show that almost one-third of women age 15-49 in Tajikistan received a medical injection in the 12 months preceding the survey. The average number of injections per woman is 7.1. The potential risk of transmission of HIV associated with such injections is very low because almost all women (99 percent) said they received their most recent injection from a new, unopened package. The likelihood of receiving an injection in the previous 12 months is much lower among the youngest women, age 15-19, than among older women. It is also much lower among women who have never married. Variations by other background characteristics are not large. There are no differentials in the likelihood that the injection was a safe one. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 187 Table 13.12 Prevalence of medical injections Percentage of women age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Tajikistan 2012 Background characteristic Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the past 12 months Age 15-24 23.7 5.0 3,963 98.4 941 15-19 16.7 3.2 2,013 98.0 337 20-24 30.9 6.8 1,950 98.7 604 25-29 36.2 7.9 1,609 99.4 582 30-39 34.6 8.2 2,217 98.8 766 40-49 36.1 9.4 1,866 98.5 674 Marital status Never married 17.1 3.4 2,648 97.7 452 Married/living together 36.1 8.5 6,504 98.9 2,345 Divorced/separated/widowed 33.0 8.2 504 99.1 167 Residence Urban 32.0 7.8 2,413 98.4 772 Rural 30.3 6.8 7,243 98.8 2,191 Region Dushanbe 35.8 9.1 881 99.2 316 GBAO 23.5 3.7 220 98.4 52 Sughd 25.2 5.1 2,872 99.6 724 DRS 31.5 6.8 2,240 98.5 705 Khatlon 33.9 8.5 3,444 98.1 1,167 Education None/primary 29.7 7.6 567 97.9 168 General basic 29.7 6.8 3,349 98.9 994 General secondary 30.5 7.2 4,474 98.6 1,364 Professional primary/middle 34.9 6.6 645 99.1 225 Higher 34.1 7.4 620 98.9 211 Wealth quintile Lowest 26.0 6.8 1,878 97.4 487 Second 31.0 7.2 1,913 98.8 593 Middle 29.8 6.7 1,904 99.3 567 Fourth 33.5 7.3 1,971 99.1 661 Highest 32.9 7.2 1,989 98.8 654 Total 30.7 7.1 9,656 98.7 2,963 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. 13.10 HIV/AIDS KNOWLEDGE AND SEXUAL BEHAVIOR AMONG YOUTH This section addresses HIV/AIDS-related knowledge and sexual behavior among youth age 15-24. In addition to knowledge of HIV transmission, data are presented on age at first sexual intercourse, age differences between sexual partners, and voluntary counseling and testing for HIV. Younger people are often at a higher risk of contracting STIs, as they are more likely to be experimenting with sex before marriage and more prone to risk-taking. 188 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior 13.10.1 HIV/AIDS-Related Knowledge among Young Adults Young respondents were asked the same set of questions on beliefs about HIV transmission as older respondents. Information on the level of knowledge of major methods of avoiding HIV and rejection of major misconceptions are shown in Table 13.13. Table 13.13 Comprehensive knowledge about AIDS and of a source of condoms among young women Percentage of young women age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Tajikistan 2012 Background characteristic Women age 15-24 Number of women Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Age 15-19 6.5 16.4 2,013 15-17 4.8 12.6 1,207 18-19 9.1 22.1 806 20-24 11.0 39.8 1,950 20-22 9.7 38.7 1,210 23-24 13.2 41.6 740 Marital status Never married 7.4 18.3 2,319 Ever married 10.6 41.5 1,644 Residence Urban 11.0 34.2 926 Rural 8.1 26.0 3,038 Education None/primary 3.3 19.2 302 General basic 5.6 21.5 1,778 General secondary 10.5 30.8 1,494 Professional primary/middle 17.3 52.2 191 Higher 24.2 53.9 198 Total 8.7 27.9 3,963 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention of the AIDS virus. The components of comprehensive knowledge are presented in Tables 13.2 and 13.3. 2 For this table, the following responses are not considered a source for condoms: friends, family members, and home. The data show that fewer than one in ten women age 15-24 in Tajikistan (9 percent of young women) have comprehensive knowledge of HIV/AIDS. The data further show that 28 percent of young women know a place where people can get condoms. Comprehensive knowledge about AIDS and knowledge of a source for condoms are both higher among women age 20-24 than among those age 15-19. Both indicators are also higher for young women who have married than for those who have never married. Urban women are more likely to have comprehensive knowledge about AIDS and also know a source of condoms than rural women. Both comprehensive knowledge of AIDS and knowledge of a source of condoms increase with increasing educational level. For example, the proportion of young women with comprehensive knowledge about AIDS increases from 3 percent of those with no education or primary education to 24 percent of those who have attended higher education. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 189 13.10.2 Age at First Sexual Intercourse among Young Adults Since HIV transmission among women in Tajikistan occurs predominantly through heterosexual intercourse between an infected and a non-infected person, age at first intercourse marks the time at which most individuals first risk exposure to the virus. Table 13.14 shows the percentage of young women age 15-24 who had their sexual debut before age 15 and the percentage who had sex before age 18. The data show that only a tiny fraction of young women in Tajikistan have sex before age 15. By age 18, 11 percent of women have had sexual intercourse. Table 13.14 Age at first sexual intercourse among young women Percentage of young women age 15-24 who had sexual intercourse before age 15 and percentage of young women age 18-24 who had sexual intercourse before age 18, by background characteristics, Tajikistan 2012 Background characteristic Women age 15-24 Women age 18-24 Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Age 15-19 0.1 2,013 na na 15-17 0.2 1,207 na na 18-19 0.0 806 11.2 806 20-24 0.1 1,950 11.3 1,950 20-22 0.1 1,210 13.6 1,210 23-24 0.1 740 7.4 740 Marital status Never married 0.0 2,319 0.0 1,126 Ever married 0.3 1,644 19.0 1,630 Knows condom source1 Yes 0.0 1,107 12.9 955 No 0.2 2,856 10.3 1,801 Residence Urban 0.0 926 10.6 636 Rural 0.2 3,038 11.4 2,120 Education None/primary 1.2 302 19.7 250 General basic 0.1 1,778 15.5 1,043 General secondary 0.0 1,494 8.8 1,082 Professional primary/middle 0.0 191 1.7 184 Higher 0.0 198 0.5 197 Total 0.1 3,963 11.2 2,756 na = Not applicable 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Differences by background characteristics in the proportion of young women who have had sexual intercourse by age 15 or age 18 are not large. As expected, the proportion of women age 18-24 who had sex before age 18 is higher among ever-married women (19 percent) than among never-married women, none of whom reported having had sex before age 18. The proportion of young women who had sex before age 18 decreases consistently as education of the woman increases. 190 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior 13.10.3 Cross-Generational Sexual Partners To examine age differences between sexual partners, women who had sexual intercourse in the 12 months preceding the survey were asked the age of their partners. The issue of cross-generational sex mainly affects younger women who engage with older men, because such relationships can create situations in which women are at a disadvantage. As shown in Table 13.15, only 4 percent of women age 15-19 had intercourse with a man 10 or more years older than they were. Those living in urban areas are slightly more likely than rural women to report having sex with a man 10 or more years older than they were. Table 13.15 Age-mixing in sexual relationships among women age 15-19 Among women age 15-19 who had sexual intercourse in the past 12 months, percentage who had sexual intercourse with a partner who was 10 or more years older than themselves, by background characteristics, Tajikistan 2012 Background characteristic Women age 15-19 who had sexual intercourse in the past 12 months Percentage who had sexual intercourse with a man 10+ years older Number of women Age 15-17 * 13 18-19 4.3 249 Knows condom source1 Yes 0.0 67 No 5.9 196 Residence Urban 7.6 52 Rural 3.6 211 Education None/primary * 20 General basic 3.9 138 General secondary 5.1 92 Professional primary/middle * 7 Higher * 5 Total 4.4 263 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 13.10.4 Voluntary HIV Counseling and Testing among Young Adults Knowledge of an individual’s own HIV status can motivate him or her to practice safer sexual behavior thereafter to avoid transmitting the virus to others. Table 13.16 shows the coverage of HIV counseling and testing by background characteristics for women age 15-24 years who have had sexual intercourse in the 12 months before the survey. Ten percent of young women age 15-24 have been tested for HIV and received results in the 12 months preceding the survey. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 191 The data show that urban young women are more likely to have been tested for HIV and received results in the 12 months prior to the survey than their rural counterparts. Recent HIV testing among young people increases with increased level of education. For example, among women who had sex in the 12 months before the survey, only 4 percent of those with no education or only primary education were tested and received results in the 12 months before the survey, compared with 30 percent of those with secondary and higher education. Table 13.16 Recent HIV tests among young women Among young women age 15-24 who have had sexual intercourse in the past 12 months, the percentage who were tested for HIV in the past 12 months and received the results of the last test, by background characteristics, Tajikistan 2012 Background characteristic Women age 15-24 who have had sexual intercourse in the past 12 months: Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Age 15-19 4.8 263 15-17 * 13 18-19 5.0 249 20-24 11.1 1,256 20-22 11.6 710 23-24 10.4 546 Knows condom source1 Yes 17.0 640 No 4.9 879 Residence Urban 17.0 315 Rural 8.2 1,204 Education None/primary 3.5 144 General basic 8.7 658 General secondary 9.3 592 Professional primary/middle 26.6 72 Higher 29.9 53 Total 10.0 1,519 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members and home. Domestic Violence • 193 DOMESTIC VIOLENCE 14 n recent years, there has been increasing concern about violence against women in general, and about domestic violence in particular, in both developed and developing countries. Not only has domestic violence against women been acknowledged worldwide as a violation of the basic human rights of women, but an increasing amount of research highlights the health burdens, intergenerational effects, and demographic consequences of such violence (United Nations General Assembly, 1991; Heise et al., 1994; Heise et al., 1999; and Jejeebhoy, 1998). Gender-based violence occurs across all socio- economic and cultural backgrounds, and in many societies, women are socialized to accept, tolerate, and even rationalize domestic violence and to remain silent about such experiences (Zimmerman, 1994). Violence of any kind has a serious impact on the economy of a country: because women bear the brunt of domestic violence, they bear the health and psychological burdens as well. Victims of domestic violence are abused inside what should be the most secure environment of all for them–their own homes. 14.1 MEASUREMENT OF VIOLENCE Collecting valid, reliable, and ethical data on domestic violence poses particular challenges. What constitutes violence or abuse varies across cultures and among individuals. A culture of silence usually surrounds domestic violence and can affect reporting. The sensitivity of the topic is another issue. Specific ethical concerns are assuring the safety of respondents and interviewers when asking about domestic violence in a familial setting, protecting women who disclose violence, and reducing the risk of double- victimization of respondents as they relive their experiences. The responses to these challenges posed by the 2012 TjDHS are described in the sections that follow. 14.1.1 Use of Valid Measures of Violence In the 2012 TjDHS, information was obtained from ever-married women on violence committed by their current and former spouses and/or by others. Information was collected from never-married women on violence by anyone. Since international research shows that intimate partner violence is one of the most common forms of violence, especially against women, information on spousal violence was measured in more detail than violence by other perpetrators. This was done by using a shortened, modified version of the Conflict Tactics Scale (Strauss, 1990). Specifically, violence by the current husband/partner I Key Findings • Nineteen percent of women age 15-49 have experienced physical violence at least once since age 15, and 13 percent have experienced physical violence within the 12 months prior to the survey. • Four percent of women report having experienced sexual violence at least once in their lifetime. • Overall, almost one in five ever-married women age 15-49 report having experienced emotional, physical, or sexual violence from a husband. • Among ever-married women who have ever experienced physical or sexual violence from a husband, 27 percent report experiencing physical injuries. • Only one in five women has sought assistance to try to stop the violence they have experienced. 194 • Domestic Violence for currently married respondents and by the most recent husband/partner for formerly married respondents was measured by asking ever-married women the following set of questions. Did your (last) (husband/partner) ever: • Push you, shake you, or throw something at you? • Slap you? • Twist your arm or pull your hair? • Punch you with his fist or with something that could hurt you? • Kick you, drag you, or beat you up? • Try to choke you or burn you on purpose? • Threaten or attack you with a knife, gun, or any other weapon? • Physically force you to have sexual intercourse with him when you did not want to? • Physically force you to perform any other sexual acts you did not want to? • Force you with threats or in any other way to perform sexual acts you did not want to? For every question that a respondent answered “yes,” she was asked about the frequency of the act in the 12 months preceding the survey. An affirmative answer to one or more of the first seven items constitutes evidence of physical violence, and a positive answer to any of the final three items constitutes evidence of sexual violence. Women who had been married more than once were also asked about physical and/or sexual violence from any previous husband(s). Similarly, emotional violence among ever-married respondents was measured by the following questions. Did your (last) (husband/partner) ever: • Say or do something to humiliate you in front of others? • Threaten to hurt or harm you or someone you care about? • Insult you or make you feel bad about yourself? This approach of asking about specific acts to measure different forms of violence has the advantage of not being affected by different understandings of what constitutes a summary term such as “violence.” By including a wide range of acts, this approach has the additional advantage of giving the respondent multiple opportunities to disclose any experience of violence. In addition to these questions that were asked only of ever-married women, all women were asked about physical and sexual violence from persons other than the current or most recent husband/partner. Respondents who answered yes to the question about physical violence were asked who committed the violence against them and the frequency of such violence during the 12 months preceding the survey. Respondents who reported experiencing sexual violence were asked for the perpetrators of the violence. Although this approach to questioning is generally considered to be optimal, the possibility of underreporting of violence, particularly sexual violence, cannot be entirely ruled out in any survey, and this survey is no exception. Domestic Violence • 195 14.1.2 Ethical Considerations in Measuring Violence In recognition of the challenges in collecting data on violence, the interviewers in the 2012 TjDHS were given special training. The training focused on how to ask sensitive questions, ensure privacy, and build rapport between interviewer and respondent. Rapport with the interviewer, confidentiality, and privacy are all keys to building respondents’ confidence so that they can safely share their experiences with the interviewer. Placing questions about violence at the end of the questionnaire also provides time for the interviewer to develop a certain degree of intimacy with respondents that should further encourage women to share their experiences of violence, if any. In addition, the following protections were built into the survey or the questionnaire in keeping with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001): • To maintain confidentiality, only one woman per household was administered the questions on violence. The random selection of one woman was done through a simple selection procedure using a grid that was built into the Household Questionnaire (Kish, 1965). • As a means of obtaining additional consent, beyond the initial consent at the start of the interview, the respondent was informed that the questions could be sensitive and was reassured regarding the confidentiality of her responses. • The violence module was implemented only if privacy could be obtained. The interviewers were instructed to skip the module, thank the respondent, and end the interview if they could not maintain privacy during the implementation of this module. • A brochure that included information on domestic violence and contact information for service centers across the country was provided to all interviewers. Interviewers, however, were instructed not to leave any printed or written information in the household. This was done to safeguard against identifying the respondent selected for the module to ensure the respondent’s safety and to avoid any further harm. Interviewers were instructed to provide oral information only upon request of the respondents so that they could access the services and be informed about what to do in the event of domestic violence. As mentioned previously, only one woman per household was selected for the module. These restrictions resulted in a total of 5,547 (unweighted) women age 15-49 (4,405 ever-married women) who completed the domestic violence module. Twenty-one eligible women were not interviewed because complete privacy could not be obtained. Specially constructed weights were used to adjust for the selection of only one woman per household and to ensure that the domestic violence subsample was nationally representative. 14.2 EXPERIENCE OF PHYSICAL VIOLENCE Table 14.1 shows the percentage of women who ever experienced physical violence since age 15 and the percentage who experienced violence during the 12 months preceding the survey, by background characteristics. Slightly fewer than one in five women age 15-49 have experienced physical violence since age 15 (19 percent), and 13 percent have experienced physical violence in the 12 months prior to the survey. Overall, only 2 percent of women reported that they had experienced physical violence often in the past 12 months, and 11 percent said they had experienced physical violence sometimes during the past 12 months. 196 • Domestic Violence The experience of physical violence varies by background characteristics. The percentage of women who have experienced physical violence since age 15 tends to increase with age but does not vary much by urban-rural residence or employment status. This percentage is highest among women in Sughd region and lowest among women in DRS region. Women who are divorced, separated, or widowed are far more likely to have experienced physical violence (36 percent) than women who are either currently married (22 percent) or who have never married (7 percent). Women who have children are more likely to have experienced violence than those who have no children, presumably in part because childless women are younger than those with children. The percentage of women who have experienced physical violence since age 15 increases with education level up to the professional primary/middle level, after which it falls to the lowest level (13 percent). Experience with physical violence increases from a low of 16 percent of women in the lowest wealth quintile to 22 percent of those in the second quintile, after which it declines in the upper quintiles. Table 14.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced violence during the 12 months preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Percentage who have ever experienced physical violence since age 151 Percentage who have experienced physical violence in the past 12 months Number of women Often Sometimes Often or sometimes2 Age 15-19 7.3 0.6 5.6 6.2 1,087 20-24 15.7 1.6 10.2 11.8 1,108 25-29 24.3 2.2 16.2 18.4 970 30-39 24.1 2.8 13.0 16.0 1,237 40-49 22.2 1.4 11.3 12.6 1,145 Residence Urban 20.8 1.6 12.6 14.2 1,399 Rural 18.1 1.8 10.7 12.5 4,148 Region Dushanbe 14.9 1.8 7.3 9.1 513 GBAO 14.4 1.5 8.5 10.0 126 Sughd 22.2 3.0 14.1 17.2 1,663 DRS 13.0 1.6 9.6 11.2 1,242 Khatlon 20.8 0.8 10.9 11.8 2,004 Marital status Never married 6.7 0.3 4.9 5.2 1,454 Married or living together 22.2 1.7 13.6 15.4 3,812 Divorced/separated/widowed 36.1 9.9 11.0 20.9 281 Number of living children 0 8.6 0.5 5.8 6.3 1,914 1-2 26.1 3.5 15.8 19.4 1,542 3-4 23.1 1.9 14.2 16.1 1,354 5+ 22.1 0.9 10.2 11.1 737 Employment Employed for cash 20.4 1.6 10.3 11.9 1,379 Employed not for cash 20.0 1.8 9.4 11.2 471 Not employed 18.0 1.8 11.8 13.6 3,693 Education None/primary 16.5 1.0 9.2 10.2 323 General basic 18.3 1.7 12.0 13.9 1,886 General secondary 19.5 1.4 11.4 12.8 2,585 Professional primary/middle 24.0 3.9 13.4 17.3 394 Higher 12.6 2.0 5.3 7.3 359 Wealth quintile Lowest 15.8 0.5 9.2 9.6 1,093 Second 21.5 2.0 13.0 15.0 1,100 Middle 18.3 3.0 10.5 13.6 1,074 Fourth 19.2 2.0 11.6 13.6 1,133 Highest 19.2 1.3 11.7 13.0 1,147 Total 18.8 1.7 11.2 13.0 5,547 Note: Totals include four women who are missing information as to employment status. 1 Includes violence in the past 12 months. For women who were married before age 15 and who reported physical violence, the violence could have occurred before age 15. 2 Includes women who report physical violence in the past 12 months but for whom frequency is not known. Domestic Violence • 197 The percentage of women who have experienced physical violence in the past 12 months (often or sometimes) shows variation by background characteristics similar to that of women who have ever experienced violence. Table 14.2 shows data about the perpetrators of physical violence, according to women’s marital status, among those who have experienced physical violence since age 15. Among ever-married women, the most commonly reported perpetrator of physical violence is the current husband or partner (76 percent), followed by the former husband/partner (15 percent), indicating a high concentration towards spousal violence. Among the small number of never-married women who have experienced physical violence since age 15, the most common perpetrators of violence are mothers or step-mothers (45 percent) and sisters/brothers (31 percent). Table 14.2 Persons committing physical violence Among women age 15-49 who have experienced physical violence since age 15, percentage who report specific persons who committed the violence, according to the respondent's current marital status, Tajikistan 2012 Person Marital status Total Ever married Never married Current husband/partner 76.3 na 69.2 Former husband/partner 14.6 na 13.2 Current boyfriend 0.0 0.5 0.1 Former boyfriend 0.2 0.0 0.2 Father/step-father 4.5 14.4 5.4 Mother/step-mother 9.7 45.2 13.0 Sister/brother 7.8 30.6 10.0 Daughter/son 0.6 2.4 0.7 Other relative 1.0 8.4 1.7 Mother-in-law 1.6 na 1.4 Other in-law 0.7 na 0.7 Teacher 0.5 1.8 0.6 Employer/someone at work 0.0 0.0 0.0 Other 1.2 1.0 1.1 Number of women who have experienced physical violence since age 15 946 97 1,043 Note: Women can report more than one person who committed the violence. na = Not applicable 14.3 EXPERIENCE OF SEXUAL VIOLENCE Table 14.3 shows the percentage of women who have experienced sexual violence ever and in the past 12 months, according to background characteristics. Results show that 4 percent of women age 15-49 have ever experienced sexual violence and 3 percent have experienced sexual violence in the 12 months before the survey. There are notable variations in the experience of sexual violence by age. Younger women (age 15-19) are less likely to report sexual violence ever and in the past 12 months than older women. Women in the Sughd region are more likely to experience sexual violence than those in the DRS region. Experience of sexual violence ever and in the past 12 months is lowest among never-married women and women with no living children. It is also slightly lower among women with higher education and women in the second and highest wealth quintiles, although there is no uniform pattern in experience of sexual violence by either education or wealth. 198 • Domestic Violence Table 14.3 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence and percentage who have experienced sexual violence in the 12 months preceding the survey, by background characteristics, Tajikistan 2012 Background characteristic Percentage who have experienced sexual violence: Number of women Ever1 Past 12 months Age 15-19 0.5 0.4 1,087 20-24 2.9 2.5 1,108 25-29 4.7 3.0 970 30-39 4.2 2.8 1,237 40-49 6.2 3.6 1,145 Residence Urban 3.4 2.1 1,399 Rural 3.9 2.6 4,148 Region Dushanbe 2.1 1.2 513 GBAO 2.0 1.1 126 Sughd 7.4 4.7 1,663 DRS 0.9 0.9 1,242 Khatlon 3.0 2.1 2,004 Marital status Never married 0.3 0.1 1,454 Married or living together 4.7 3.3 3,812 Divorced/separated/widowed 8.6 4.2 281 Employment Employed for cash 4.2 2.1 1,379 Employed not for cash 4.0 2.1 471 Not employed 3.5 2.7 3,693 Number of living children 0 1.1 0.7 1,914 1-2 6.1 4.1 1,542 3-4 4.1 2.6 1,354 5+ 5.0 3.6 737 Education None/primary 2.1 1.2 323 General basic 3.0 2.1 1,886 General secondary 4.2 2.7 2,585 Professional primary/middle 7.2 6.1 394 Higher 1.6 0.3 359 Wealth quintile Lowest 3.8 2.5 1,093 Second 3.4 2.0 1,100 Middle 4.5 3.7 1,074 Fourth 3.6 2.6 1,133 Highest 3.4 1.7 1,147 Total 3.7 2.5 5,547 Note: Totals include four women missing information as to employment status. 1 Includes violence in the past 12 months. Domestic Violence • 199 Table 14.4 shows information on the perpetrators of sexual violence among those who have ever experienced sexual violence, according to women’s marital status. Table 14.4 Persons committing sexual violence Among women age 15-49 who have experienced sexual violence, percentage who report specific persons who committed the violence according to the respondent's current marital status, Tajikistan 2012 Person Marital status Total Ever married1 Never married Current husband/partner 76.4 na 75.0 Former husband/partner 23.0 na 22.6 Current/former boyfriend 0.6 * 0.6 Father/step-father 0.0 * 0.7 Own friend/acquaintance 3.2 * 4.2 Other 0.1 * 0.1 Number women who have experienced sexual violence 204 4 207 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Women can report more than one person who committed the violence. na = Not applicable Among ever-married women, the most commonly reported perpetrators of sexual violence are current husbands/partners (76 percent), followed by former husbands/partners (23 percent). Data on the perpetrators of sexual violence for never married women had been suppressed because there are too few cases of never married respondents who have ever experienced sexual violence. 14.4 EXPERIENCE OF DIFFERENT FORMS OF VIOLENCE Table 14.5 presents information on the experience of various forms of violence among women age 15-49. The table shows that 19 percent of women age 15-49 reported that they have experienced either physical or sexual violence. Sixteen percent have experienced physical violence only, less than 1 percent have experienced sexual violence only, and 3 percent have experienced both physical and sexual violence. The percentage of women who have ever experienced physical or sexual violence increases with age, from 8 percent of women age 15-19 to 16 percent of women age 20-24 and then to about 25 percent of women age 25 or older. Table 14.5 Experience of different forms of violence Percentage of women age 15-49 who have ever experienced different forms of violence by current age, Tajikistan 2012 Age Physical violence only Sexual violence only Physical and sexual violence Physical or sexual violence Number of women 15-19 7.1 0.3 0.2 7.6 1,087 15-17 7.5 0.3 0.2 8.1 636 18-19 6.5 0.3 0.2 7.0 451 20-24 13.0 0.2 2.8 15.9 1,108 25-29 20.2 0.6 4.1 24.9 970 30-39 20.3 0.4 3.8 24.5 1,237 40-49 17.6 1.6 4.6 23.9 1,145 Total 15.7 0.6 3.1 19.4 5,547 200 • Domestic Violence 14.5 VIOLENCE DURING PREGNANCY Respondents who had ever been pregnant were asked specifically whether they had ever experienced physical violence while pregnant and, if so, who the perpe- trators of the violence were. Table 14.6 shows that 5 percent of women experienced physical violence during pregnancy. This percentage is somewhat lower among the youngest women age 15-19 than among older women. Physical violence during pregnancy does not vary by urban- rural residence, but it is higher among women in the Sughd and Dushanbe regions than among women in other regions. Women who are divorced, separated, or widowed are much more likely to report experiencing violence during pregnancy (19 percent) than women who are currently married (4 percent). Variations in violence during pregnancy by the number of living children are not large. The experience of violence during pregnancy is slightly higher among women with no education or only primary education than among those with at least a general basic education. Contrarily, women in the lowest wealth quintile are the least likely to have experienced violence during pregnancy compared with those in higher quintiles. 14.6 MARITAL CONTROL BY HUSBAND Close control and monitoring of their wives’ behavior by husbands is known to be an important warning sign and correlate of violence in a relationship. A series of questions were included in the 2012 TjDHS to elicit the degree of marital control exercised by husbands over their wives. Controlling behaviors most often manifest themselves in terms of extreme possessiveness, jealousy, and attempts to isolate the wife from her family and friends. To determine the degree of marital control, ever-married women were asked whether their current or former husband/partner exhibited each of the following controlling behaviors: (1) is jealous or gets angry if she talks to other men, (2) frequently accuses her of being unfaithful, (3) does not permit meetings with female friends, (4) tries to limit contact with her family, and (5) insists on knowing where she is at all times. Because the concentration of such behaviors is more significant than the display of any single behavior, the proportion of respondents whose spouses display at least three of the specified behaviors is highlighted. Table 14.7 presents the percentage of ever- married women whose husbands display each of the listed behaviors, by selected background characteristics. Table 14.6 Experience of violence during pregnancy Among women age 15-49 who have ever been pregnant, percentage who have ever experienced physical violence during pregnancy, by background characteristics, Tajikistan 2012 Background characteristic Percentage who experienced violence during pregnancy Number of women who have ever been pregnant Age 15-19 2.6 70 20-24 5.5 712 25-29 5.0 789 30-39 5.8 1,147 40-49 4.5 1,117 Residence Urban 5.2 977 Rural 5.1 2,857 Region Dushanbe 6.0 345 GBAO 2.3 80 Sughd 6.8 1,199 DRS 4.1 847 Khatlon 4.3 1,364 Marital status Married or living together 4.2 3,589 Divorced/separated/widowed 18.9 245 Number of living children 0 3.6 202 1-2 6.4 1,542 3-4 4.7 1,354 5+ 3.7 737 Education None/primary 7.3 208 General basic 5.2 1,154 General secondary 5.0 1,917 Professional primary/middle 4.5 306 Higher 5.3 248 Wealth quintile Lowest 2.8 722 Second 6.9 755 Middle 6.5 759 Fourth 4.7 790 Highest 4.8 807 Total 5.1 3,834 Domestic Violence • 201 Table 14.7 Marital control exercised by husbands Percentage of ever-married women age 15-49 whose husbands/partners have ever demonstrated specific types of controlling behaviors, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women whose husband/partner: Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Displays three or more of the specific behaviors Displays none of the specific behaviors Number of ever-married women Age 15-19 80.7 17.5 28.9 8.8 57.2 26.9 10.4 132 20-24 74.6 13.1 21.7 11.3 44.1 23.0 23.3 800 25-29 75.5 15.7 21.8 9.3 45.7 24.0 20.6 848 30-39 73.1 14.0 17.1 8.5 42.6 19.2 21.6 1,178 40-49 57.5 10.0 13.7 5.9 32.4 12.5 35.5 1,135 Residence Urban 72.6 13.1 19.5 8.0 40.2 20.2 22.9 1,023 Rural 68.9 13.2 18.0 8.7 41.5 19.1 26.0 3,070 Region Dushanbe 69.1 11.0 15.3 9.7 35.8 16.9 25.9 366 GBAO 48.6 12.8 10.3 8.3 36.4 14.5 40.0 84 Sughd 77.6 12.5 26.7 10.1 42.5 27.7 17.8 1,272 DRS 72.2 17.0 12.4 7.8 38.5 13.4 25.5 916 Khatlon 62.9 11.9 16.2 7.3 43.3 16.6 30.6 1,455 Marital status Married or living together 70.1 12.3 18.0 7.9 41.4 19.0 24.7 3,812 Divorced/separated/widowed 65.5 24.8 23.6 16.6 37.9 24.4 32.6 281 Number of living children 0 77.6 14.5 22.4 8.8 46.7 23.3 20.6 460 1-2 71.5 14.9 21.7 10.7 42.2 23.2 24.4 1,542 3-4 71.4 11.9 16.2 7.1 41.4 17.3 22.5 1,354 5+ 58.6 11.1 13.0 6.4 35.2 12.5 35.0 737 Employment Employed for cash 69.5 14.9 18.9 8.8 40.4 19.9 25.9 1,049 Employed not for cash 68.4 7.7 12.0 5.9 36.6 12.8 26.7 344 Not employed 70.2 13.2 19.1 8.7 42.0 20.0 24.8 2,696 Education None/primary 68.4 15.5 19.5 8.7 38.1 18.7 27.4 229 General basic 74.4 16.1 22.9 10.2 47.0 23.9 21.2 1,252 General secondary 66.1 11.7 15.4 7.0 37.8 16.9 28.6 2,031 Professional primary/middle 75.7 10.1 20.0 11.4 41.8 17.9 19.0 313 Higher 70.8 12.4 17.6 8.0 41.4 19.0 23.8 268 Wealth quintile Lowest 61.8 11.4 16.6 7.0 39.8 16.0 31.7 765 Second 66.1 15.4 17.8 9.5 41.3 20.0 28.9 821 Middle 69.2 16.6 20.0 9.9 40.4 21.2 25.2 818 Fourth 75.2 9.6 18.8 8.0 43.4 19.3 20.7 840 Highest 75.7 12.8 18.7 8.0 40.9 19.9 20.3 849 Woman afraid of husband Most of the time afraid 72.0 15.8 23.2 12.4 38.9 23.1 25.2 1,778 Sometimes afraid 71.1 11.5 15.0 5.7 44.9 17.3 22.4 1,939 Never afraid 53.9 10.0 12.5 5.2 32.0 11.9 38.1 293 Total 69.8 13.2 18.4 8.5 41.2 19.3 25.2 4,093 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Totals include four women for whom employment status is missing and 84 women for whom information on how often they are afraid of their husband is missing. The main controlling behaviors women experienced from their husbands were jealousy or anger if they talked to other men (70 percent) and husbands insisting on knowing where they are at all times (41 percent). The next most common behaviors were not permitting them to meet female friends (18 percent) and frequently accusing them of being unfaithful (13 percent). Only 9 percent of women said their current or most recent husband tried to limit her contact with her family. 202 • Domestic Violence Almost one in five ever-married women (19 percent) say that their husbands display three or more of these controlling behaviors. This proportion declines with the increase in age of the women. Women in the Sughd region and those who have been previously married are more likely than other women to report that their husbands display three or more of these controlling behaviors. Having a husband who displays at least three controlling behaviors is least likely among women with five or more living children and those employed not for cash. There is no clear relationship between the percentage of women whose husbands display three or more controlling behaviors and either education of the woman or wealth quintile. In the 2012 TjDHS, a question about whether (and how frequently) women are afraid of their husbands was included as part of the domestic violence module. For women who report any acts of violence perpetrated by their husbands/partners, information on whether or not women are frequently afraid of their husbands provides a context in which the experience of the reported violent acts can be interpreted. Further, despite the fact that the domestic violence module was designed to optimize the reporting of violent acts, the possibility of underreporting of violence cannot be entirely ruled out. Given that some women may be reluctant to report violence, questions about fear of husband may be a proxy indicator of violence experienced by women. The question asks all ever-married women (irrespective of their experience of spousal violence), whether they are afraid of their husband/partner most of the time, sometimes, or never. Nine in ten of all ever-married women report being afraid of their husbands/partners (data not shown). Women who are almost always afraid of their husbands are about twice as likely as women who are never afraid to report that their husbands display at least three controlling behaviors. 14.7 FORMS OF SPOUSAL VIOLENCE Different types of violence are not mutually exclusive, and women may report multiple forms of violence. Research suggests that physical violence in intimate relationships is often accompanied by psychological abuse and, in one-third to more than one-half of cases, by sexual abuse (Krug et al., 2002). Table 14.8 shows the percentage of ever-married women age 15-49, who have experienced various forms of violence by their husbands, over the course of the marriage and in the 12 months preceding the survey. Note that respondents who are currently married reported on violence by their current husband, and respondents who are widowed, divorced, or separated reported on violence by their most recent husband. Table 14.8 shows that 20 percent of ever-married women report ever experiencing physical violence committed by their current or most recent husband or partner, 4 percent report ever experiencing sexual violence, and 11 percent report ever experiencing emotional violence. One in five ever-married women (20 percent) have experienced physical and/or sexual violence, and 24 percent have experienced at least one of the three forms of spousal violence. The most common form of spousal violence ever experienced by ever-married women is being slapped (17 percent) (Figure 14.1). Eleven percent of ever-married women report having been pushed, shaken, or had something thrown at them, and 5 percent report having ever been punched by their husbands. Four percent of ever-married women say their husbands have twisted their arm or pulled their hair, kicked them or dragged them or beat them up, or physically forced them to have sexual intercourse when they did not want to. One in ten women say that their husbands have said or done something to humiliate them in front of others. Domestic Violence • 203 Table 14.8 Forms of spousal violence Percentage of ever-married women age 15-49 who have experienced various forms of violence ever or in the 12 months preceding the survey, committed by their husband/partner, ajikistan 2012 Type of violence Ever In the past 12 months Often Sometimes Often or sometimes SPOUSAL VIOLENCE COMMITTED BY CURRENT OR MOST RECENT HUSBAND/PARTNER Physical violence Any physical violence 19.5 2.0 12.5 14.5 Pushed her, shook her, or threw something at her 10.6 1.0 7.5 8.5 Slapped her 16.6 1.2 10.3 11.5 Twisted her arm or pulled her hair 4.4 0.6 3.0 3.6 Punched her with his fist or with something that could hurt her 5.0 0.8 2.9 3.7 Kicked her, dragged her, or beat her up 3.6 0.8 1.9 2.7 Tried to choke her or burn her on purpose 1.0 0.3 0.5 0.8 Threatened or attacked her with a knife, gun, or other weapon 0.4 0.2 0.1 0.3 Sexual violence Any sexual violence 4.4 0.6 2.7 3.3 Physically forced her to have sexual intercourse with him when she did not want to 3.7 0.5 2.3 2.9 Physically forced her to perform any other sexual acts she did not want to 0.7 0.2 0.3 0.5 Forced her with threats or in any other way to perform sexual acts she did not want to 0.9 0.1 0.4 0.5 Emotional violence Any emotional violence 11.3 2.6 7.8 10.3 Said or did something to humiliate her in front of others 10.4 1.9 7.5 9.4 Threatened to hurt or harm her or someone she cared about 2.9 0.7 1.7 2.4 Insulted her or made her feel bad about herself 4.0 1.0 2.4 3.4 Any form of physical and/or sexual violence 20.3 2.3 12.8 15.2 Any form of emotional and/or physical and/or sexual violence 24.4 3.9 15.6 19.5 SPOUSAL VIOLENCE COMMITTED BY ANY HUSBAND/PARTNER Physical violence 20.4 na na 14.5 Sexual violence 4.8 na na 3.3 Physical and/or sexual violence 21.2 na na 15.2 Number of ever-married women 4,093 4,093 4,093 4,093 na = Not applicable Figure 14.1 Percentage of ever-married women age 15-49 who have experienced specific types of violence from current or most recent husband, ever and in the last 12 months, Tajikistan 2012 Tajikistan DHS 2012 0.9 0.7 4 0.4 1 4 5 4 17 11 0.5 0.5 3 0.3 0.8 3 4 4 12 9 Forced her with threats or in any other way to perform sexual acts she did not want to Physically forced her to perform other sexual acts she did not want to Physically forced her to have sex with him when she did not want to Threatened or attacked her with a knife, gun, or other weapon Tried to choke her or burn her on purpose Kicked her, dragged her, or beat her up Punched her with fist or something that could hurt her Twisted her arm or pulled her hair Slapped her Pushed her, shook her, or threw something at her In last 12 months Ever 204 • Domestic Violence Fifteen percent of ever-married women report experiencing spousal physical violence in the past 12 months, with 13 percent having experienced violence sometimes and 2 percent having experienced it often. Three percent report having experienced spousal sexual violence in the past 12 months, with 3 percent having experienced such violence sometimes and less than one percent often. Additionally, 10 percent of women report spousal emotional violence in the past 12 months, 8 percent sometimes, 3 percent often. Overall, 20 percent of ever-married women have experienced at least one of the three forms of violence by their current or most recent husband or partner in the past year. The 2012 TjDHS also collected information about spousal violence committed by any husband or partner ever and in the past 12 months. As shown in Table 14.8, 20 percent of ever married women report ever experiencing physical violence committed by any husband or partner and 15 percent experienced such violence often or sometimes in the past 12 months. Five percent of ever married women report ever experiencing sexual violence committed by any husband and 3 percent experienced such violence often or sometimes in the past 12 months. Overall, one in five ever married women (21 percent) has experienced physical and/or sexual violence committed by any husband, and 15 percent have experienced such violence often or sometimes in the past year. 14.8 DIFFERENTIALS IN SPOUSAL VIOLENCE Table 14.9 shows the percentage of ever-married women age 15-49 who have experienced spousal emotional, physical, or sexual violence by selected background characteristics of the woman. As mentioned above, 20 percent of ever-married women have experienced physical and/or sexual violence and 24 percent have experienced at least one of the three forms of spousal violence. The percentage of women who have ever experienced at least one form of spousal violence tends to increase with age to a peak at ages 25-29 and for women with 1-2 children. It is highest among women in the Sughd region (35 percent) and lowest among women in the DRS region (13 percent). Women who are divorced, separated, or widowed are more likely to have experienced physical, sexual, or emotional violence from a husband (36 percent) than women who are currently married (24 percent). Patterns by education and wealth are not consistent. For example, women in the highest education category are the least likely to have experienced at least one form of spousal violence, closely followed by women in the lowest education category. Domestic Violence • 205 Table 14.9 Spousal violence by background characteristics Percentage of ever-married women age 15-49 who have ever experienced emotional, physical or sexual violence committed by their husband/partner, by background characteristics, Tajikistan 2012 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual violence Physical and sexual and emotional violence Physical or sexual violence Physical or sexual or emotional violence Number of ever- married women Age 15-19 12.5 7.9 1.7 0.8 0.8 8.7 15.7 132 20-24 11.8 17.3 4.0 3.8 2.3 17.4 22.2 800 25-29 13.8 23.5 4.2 3.5 1.7 24.2 29.8 848 30-39 10.5 20.9 3.6 3.2 2.0 21.3 24.7 1,178 40-49 9.8 18.0 5.9 4.1 2.6 19.8 22.7 1,135 Residence Urban 13.3 21.6 3.8 3.3 2.1 22.1 26.0 1,023 Rural 10.7 18.8 4.6 3.6 2.1 19.7 23.9 3,070 Region Dushanbe 11.4 14.7 2.4 2.3 2.2 14.8 16.9 366 GBAO 7.1 14.6 2.8 2.0 0.7 15.4 18.2 84 Sughd 23.6 23.0 8.3 6.2 4.3 25.1 34.6 1,272 DRS 4.0 11.5 1.2 1.0 0.5 11.6 12.6 916 Khatlon 5.4 23.0 3.5 3.2 1.2 23.3 25.2 1,455 Marital status Married or living together 10.5 18.6 4.1 3.3 1.8 19.5 23.6 3,812 Divorced/separated/widowed 22.4 31.1 8.2 7.6 6.9 31.8 35.8 281 Number of living children 0 9.0 11.7 3.0 2.4 0.6 12.3 16.2 460 1-2 15.9 22.0 5.2 4.6 3.2 22.6 28.6 1,542 3-4 9.5 19.9 3.8 2.9 1.7 20.8 23.7 1,354 5+ 6.5 18.4 4.6 3.3 1.5 19.7 22.2 737 Employment Employed for cash 12.7 19.4 4.3 3.4 2.3 20.3 25.0 1,049 Employed not for cash 8.2 21.5 4.7 4.1 1.8 22.2 24.1 344 Not employed 11.2 19.3 4.4 3.6 2.1 20.1 24.3 2,696 Education None/primary 5.1 18.9 2.7 2.7 1.7 18.9 19.5 229 General basic 12.8 20.5 3.8 3.1 1.6 21.2 26.6 1,252 General secondary 10.5 19.2 4.7 3.7 2.2 20.3 23.7 2,031 Professional primary/middle 16.5 22.9 8.0 7.7 4.9 23.2 29.0 313 Higher 9.8 13.1 2.1 0.8 0.7 14.4 18.3 268 Wealth quintile Lowest 5.8 16.4 4.5 2.7 0.9 18.2 20.8 765 Second 9.7 22.5 3.3 2.9 1.8 22.9 26.3 821 Middle 14.3 18.9 5.8 5.1 3.7 19.5 24.8 818 Fourth 12.7 20.0 4.6 4.1 2.6 20.5 24.5 840 Highest 13.5 19.6 3.7 2.9 1.5 20.4 25.4 849 Total 11.3 19.5 4.4 3.6 2.1 20.3 24.4 4,093 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Totals include four women for whom employment status is missing. 206 • Domestic Violence Table 14.10 presents information on ever-married women age 15-49 who have experienced emotional, physical, or sexual violence committed by their husband, according to spousal characteristics and empowerment indicators. Table 14.10 Spousal violence by husband's characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have ever experienced emotional, physical, or sexual violence committed by their husband/partner, by husband's characteristics and empowerment indicators, Tajikistan 2012 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual violence Physical and sexual and emotional violence Physical or sexual violence Physical or sexual or emotional violence Number of ever- married women Husband's/partner's education None/primary 10.3 10.2 1.4 1.4 1.4 10.2 13.1 99 General basic 16.8 18.5 5.3 4.3 3.4 19.6 25.2 527 General secondary 11.5 20.6 4.8 3.9 2.4 21.5 25.4 2,001 Professional primary/middle 9.4 23.2 5.5 4.1 1.5 24.6 28.9 558 Higher 9.1 16.6 2.5 2.3 1.3 16.8 20.5 897 Husband's/partner's alcohol consumption Does not drink alcohol 8.0 15.2 3.1 2.5 1.4 15.8 19.1 3,301 Drinks alcohol but is never drunk * * * * * * * 2 Is sometimes drunk 21.7 33.0 6.6 5.1 2.2 34.5 42.8 672 Is often drunk 48.2 66.2 28.0 26.6 23.8 67.7 73.4 110 Spousal education difference Husband has more education 9.9 19.7 3.3 2.8 1.5 20.2 24.1 2,002 Wife has more education 15.7 19.4 7.2 6.2 4.2 20.4 25.5 653 Both have equal education 11.4 19.6 4.7 3.5 2.0 20.8 24.7 1,406 Neither has any education * * * * * * * 17 Spousal age difference1 Wife older 9.6 22.7 3.9 2.4 0.0 24.2 28.5 155 Wife is same age 14.3 19.1 5.1 5.1 3.0 19.1 23.3 329 Wife 0-4 years younger 10.7 19.2 3.9 2.9 1.6 20.2 24.2 2,070 Wife 5-9 years younger 9.5 16.8 4.4 3.6 2.0 17.6 22.0 1,035 Wife 10 or more years younger 8.8 20.2 3.5 3.1 1.8 20.6 24.3 206 Number of marital control behaviors displayed by husband/partner2 0 5.5 12.2 2.2 2.1 1.0 12.3 14.2 1,033 1-2 6.8 17.9 3.3 2.4 0.8 18.8 21.6 2,269 3-4 31.0 31.0 9.6 8.0 6.4 32.6 44.5 623 5 33.9 43.1 12.8 11.6 11.0 44.3 50.2 169 Number of decisions in which women participate3 0 8.6 17.9 4.2 3.6 1.8 18.6 21.9 1,298 1-2 14.5 22.3 6.5 5.0 2.7 23.8 30.0 885 3 9.8 17.2 2.6 2.1 1.2 17.8 21.5 1,629 Number of reasons for which wife- beating is justified4 0 11.9 15.9 2.9 2.5 1.4 16.3 21.8 1,405 1-2 11.9 21.2 5.4 4.4 2.5 22.2 26.3 971 3-4 12.6 22.5 4.8 3.8 2.1 23.5 27.7 830 5 8.4 20.6 5.1 4.1 2.8 21.6 23.4 887 Woman's father beat her mother Yes 23.2 35.8 12.2 11.0 6.8 36.9 43.1 526 No 9.8 16.6 3.2 2.5 1.4 17.4 21.4 3,227 Don’t’ know/missing 7.6 22.0 2.9 2.5 1.7 22.4 24.3 341 Woman afraid of husband Most of the time afraid 16.2 29.4 6.5 5.9 3.6 30.0 34.5 1,778 Sometimes afraid 7.1 11.5 2.7 1.8 1.0 12.4 15.8 1,939 Never afraid 9.1 8.0 2.9 1.1 1.1 9.7 16.0 293 Total 11.3 19.5 4.4 3.6 2.1 20.3 24.4 4,093 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 11 women for whom husband’s education is missing, 7 women for whom husband’s alcohol consumption is missing, 15 women for whom spousal education difference is missing, 17 women for whom spousal age difference is missing, and 84 women for whom information on how often they are afraid of their husband is missing. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Includes only women who have been married only once. 2 According to the wife's report. See Table 14.7 for list of behaviors. 3 According to the wife's report. See Table 15.6 for list of decisions. 4 According to the wife's report. See Table 15.7 for list of reasons. Domestic Violence • 207 Results show that the percentage of ever-married women who have experienced physical, sexual, or emotional violence tends to increase as the level of education of the husband increases, from 13 percent of ever-married women whose husbands have no education or only primary education to 29 percent of those whose husbands have professional primary or middle education. Spousal violence is highest among women whose husbands get drunk very often (73 percent) and lowest among those whose husbands do not drink alcohol (19 percent). Spousal violence increases linearly with the number of controlling behaviors displayed by the husband. Among women whose husbands exhibit five types of controlling behaviors, half (50 percent) have experienced one or more forms of violence. In contrast, among women whose husbands display none of the five controlling behaviors, only 14 percent have experienced any form of spousal violence. Women’s experience of violence is not correlated with the number of household decisions in which they participate, being equally low among women who do not participate in any decisions and those who participate in all three decisions asked about. Similarly, although spousal violence is lowest among women who do not think wife beating is justified for any of the given reasons, it is almost as low among those who feel wife beating is justified for all five of the given reasons. Women whose fathers did not beat their mothers are much less likely to experience any type of violence by their husband than women whose fathers beat their mothers (21 percent versus 43 percent). Women who are afraid of their husbands most of the time are about twice as likely to have experienced some form of spousal violence (35 percent) as women who are only sometimes or never afraid of their husbands (16 percent each). 14.9 RECENT EXPERIENCE OF SPOUSAL VIOLENCE Table 14.11 shows the percentage of ever-married women who have experienced physical or sexual violence by any husband/partner in the past 12 months, by background characteristics. Overall, 15 percent of ever-married women experienced physical or sexual violence by a husband in the past 12 months. The percentage of women who have experienced spousal physical or sexual violence in the past 12 months is higher among women age 25-29, women living in the Sughd region, and women who have one or two children. Currently married women are less likely to have experienced physical or sexual violence by a husband in the past 12 months than those previously married. There is no clear correlation between a woman’s education level or wealth quintile and the experience of physical or sexual violence in the past 12 months. As expected, women who are afraid of their husbands most of the time are also much more likely to have experienced spousal violence in the previous 12 months than those who are only sometimes or never afraid of their husbands. 208 • Domestic Violence Table 14.11 Physical or sexual violence in the past 12 months by any husband/partner Percentage of ever-married women who have experienced physical or sexual violence by any husband/partner in the past 12 months, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who have experienced physical or sexual violence in the past 12 months from any husband/partner Number of ever- married women Age 15-19 8.4 132 20-24 14.4 800 25-29 19.0 848 30-39 15.7 1,178 40-49 13.3 1,135 Residence Urban 16.4 1,023 Rural 14.8 3,070 Region Dushanbe 10.5 366 GBAO 11.2 84 Sughd 20.3 1,272 DRS 11.3 916 Khatlon 14.6 1,455 Marital status Married or living together 14.9 3,812 Divorced/separated/widowed 20.0 281 Number of living children 0 9.6 460 1-2 18.1 1,542 3-4 15.9 1,354 5+ 11.5 737 Employment Employed for cash 13.7 1,049 Employed not for cash 12.9 344 Not employed 16.1 2,696 Education None/primary 13.1 229 General basic 16.7 1,252 General secondary 15.0 2,031 Professional primary/middle 18.1 313 Higher 8.7 268 Wealth quintile Lowest 12.2 765 Second 17.5 821 Middle 15.4 818 Fourth 16.1 840 Highest 14.7 849 Woman afraid of husband Most of the time afraid 22.6 1,778 Sometimes afraid 9.5 1,939 Never afraid 4.9 293 Total 15.2 4,093 Note: Any husband/partner includes all current, most recent and former husbands/partners. Total includes 4 women for whom employment status is missing and 84 women for whom information on how often they are afraid of their husband is missing. Domestic Violence • 209 14.10 ONSET OF SPOUSAL VIOLENCE To obtain information on the onset of marital violence, the 2012 TjDHS asked women how long after marriage the onset of spousal violence occurred, if ever. Table 14.12 shows the data for currently married women who have only been married once. Table 14.12 Experience of spousal violence by duration of marriage Among currently married women age 15-49 who have been married only once, the percentage who first experienced physical or sexual violence committed by their current husband/partner by specific exact years since marriage according to marital duration, Tajikistan 2012 Years since marriage Percentage whose first experience of spousal physical or sexual violence by exact marital duration: Percentage who have not experienced spousal sexual or physical violence Number of currently married women who have been married only once Before marriage 2 years 5 years 10 years <2 0.0 na na na 88.5 434 2-4 0.3 16.0 na na 80.0 632 5-9 0.1 13.3 20.9 na 78.1 704 10+ 0.3 10.5 15.8 18.8 79.8 1,844 Total 0.2 12.1 16.9 18.6 80.6 3,614 na = Not applicable The data show that about four in five currently married women (81 percent) have never experienced physical or sexual violence by their current husband, whereas less than 1 percent experienced violence before marriage, 12 percent experienced it in the first two years of marriage, 17 percent experienced it in the first five years, and 19 percent experienced it within the first ten years of marriage. These data clearly suggest that for a considerable percentage of women who experience spousal physical or sexual violence, the violence began relatively early in their marriage. 14.11 PHYSICAL CONSEQUENCES OF SPOUSAL VIOLENCE In the 2012 TjDHS, ever-married women were asked whether they had sustained some form of injury as a result of physical or sexual violence inflicted by their husband. Just over one-quarter of women (27 percent) who reported ever having experienced spousal physical or sexual violence suffered some sort of injury; 25 percent suffered cuts, bruises, or aches; 8 percent had eye injuries, sprains, dislocations, or burns; and 3 percent had deep wounds, broken bones, broken teeth, or other serious injuries (Table 14.13). The prevalence of all forms of injury is similar among women who had experienced violence in the past 12 months. Table 14.13 Injuries to women due to spousal violence Percentage of ever-married women age 15-49 who have experienced specific types of spousal violence by types of injuries resulting from the violence, according to the type of violence and whether they experienced the violence ever and in the 12 months preceding the survey, Tajikistan 2012 Type of violence Cuts, bruises, or aches Eye injuries, sprains, dislocations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of ever- married women who have ever experienced any physical or sexual violence Experienced physical violence1 Ever2 26.2 8.0 2.9 27.5 798 In the past 12 months 27.6 8.1 2.8 29.0 593 Experienced sexual violence Ever2 38.0 17.2 3.8 40.0 179 In the past 12 months 38.4 16.6 4.0 41.1 135 Experienced physical or sexual violence1 Ever2 25.2 7.8 2.8 26.6 832 In the past 12 months 26.4 7.8 2.7 27.9 621 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. 1 Excludes women who reported violence only in response to a direct question on violence during pregnancy 2 Includes in the past 12 months 210 • Domestic Violence 14.12 VIOLENCE BY WOMEN AGAINST THEIR SPOUSE In cases of domestic violence, either person (husband or wife) can be the perpetrator of violence. In the 2012 TjDHS, ever-married women were asked about instances when they were the instigator of spousal violence, specifically, whether they had ever hit, slapped, kicked, or done anything else to physically hurt their husband at a time when he was not already beating or physically hurting the respondent. Table 14.14 shows the percentage of ever-married women age 15-49 who reported initiating physical violence against their spouses ever and in the 12 months prior to the survey, by background characteristics. Table 14.14 Violence by women against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting her, ever and in the past 12 months, according to women's own experience of spousal violence and background characteristics, Tajikistan 2012 Background characteristic Percentage who have committed physical violence against their husband/partner Number of ever-married women Ever1 Past 12 months Women experienced spousal physical violence Ever1 7.2 5.9 798 In the past 12 months 8.4 7.0 593 Never 0.7 0.7 3,295 Age 15-19 0.4 0.4 132 20-24 1.3 0.8 800 25-29 2.1 2.1 848 30-39 2.1 1.7 1,178 40-49 2.5 2.1 1,135 Residence Urban 2.4 1.8 1,023 Rural 1.9 1.6 3,070 Region Dushanbe 2.3 1.5 366 GBAO 1.4 1.2 84 Sughd 3.3 2.6 1,272 DRS 0.8 0.8 916 Khatlon 1.6 1.5 1,455 Marital status Married or living together 1.8 1.5 3,812 Divorced/separated/widowed 4.5 3.5 281 Employment Employed for cash 2.8 2.4 1,049 Employed not for cash 2.9 2.6 344 Not employed 1.6 1.3 2,696 Number of living children 0 0.6 0.6 460 1-2 3.0 2.3 1,542 3-4 1.8 1.6 1,354 5+ 1.1 1.1 737 Education None/primary 2.3 2.3 229 General basic 1.3 1.2 1,252 General secondary 2.1 1.9 2,031 Professional primary/middle 3.8 2.1 313 Higher 2.0 1.1 268 Wealth quintile Lowest 1.1 1.1 765 Second 1.9 1.9 821 Middle 1.9 1.7 818 Fourth 2.5 1.7 840 Highest 2.4 1.9 849 Total 2.0 1.7 4,093 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes four women for whom employment status is missing. 1 Includes in the past 12 months Domestic Violence • 211 Overall, only 2 percent of ever-married women reported that they had ever initiated physical violence against their husbands, and 2 percent had done so in the past 12 months. Women who have been physically abused by their husband ever and in the past 12 months are more likely to have initiated spousal physical abuse than women who have never been abused (7 to 8 percent and 1 percent, respectively). Women who are divorced, sepa- rated, or widowed are slightly more likely to initiate spousal violence than women who are currently married. Women’s use of violence against their husbands does not vary much by other background charac- teristics. Table 14.15 presents information on ever-married women who have committed physical violence against their spouse, ever and in the past 12 months, according to spousal characteristics and empowerment indicators. Results show initiation of violence by women who have ever committed physical violence against their husband is highest among those whose husbands get drunk often (12 percent). Women’s violence against their spouse generally increases with the number of controlling behaviors displayed by the husband. As expected, women with a father who beat their mother are more likely to commit physical spousal violence than women with a father who did not (7 percent versus 1 percent). Women’s initiation of violence does not vary much by other characteristics. Similar patterns are observed in variations of women’s physical violence against their spouse in the past 12 months by background characteristics. Table 14.15 Women's violence against their husband by husband's characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting her, ever and in the past 12 months, according husband's characteristics and empowerment indicators, Tajikistan 2012 Background characteristic Percentage who have committed physical violence against their husband/partner Number of ever-married women Ever1 Past 12 months Husband's/partner's education None/primary 0.9 0.9 99 General basic 1.4 1.4 527 General secondary 2.2 1.7 2,001 Professional primary/middle 2.4 2.2 558 Higher 1.8 1.5 897 Husband's/partner's alcohol consumption Does not drink alcohol 1.1 0.9 3,301 Drinks alcohol but is never drunk * * 2 Is sometimes drunk 4.6 4.1 672 Is often drunk 11.5 10.1 110 Spousal education difference Husband has more education 1.5 1.4 2,002 Wife has more education 2.9 2.2 653 Both have equal education 2.2 1.8 1,406 Neither has any education * * 17 Spousal age difference2 Wife older 0.7 0.7 155 Wife is same age 3.6 3.6 329 Wife 0-4 years younger 1.8 1.5 2,070 Wife 5-9 years younger 1.3 0.7 1,035 Wife 10 or more years younger 3.1 3.1 206 Number of marital control behaviors displayed by husband/partner3 0 2.0 1.9 1,033 1-2 1.2 1.0 2,269 3-4 3.4 2.6 623 5 7.1 5.7 169 Number of decisions in which she participates4 0 1.5 1.1 1,298 1-2 2.2 1.8 885 3 1.8 1.8 1,629 Number of reasons for which wife- beating is justified5 0 1.9 1.5 1,405 1-2 2.2 2.1 971 3-4 2.3 2.0 830 5 1.6 1.1 887 Father beat mother Yes 7.2 5.7 526 No 1.3 1.1 3,227 Don’t know/missing 0.6 0.6 341 Woman afraid of husband/partner Most of the time afraid 2.4 2.1 1,778 Sometimes afraid 1.1 0.9 1,939 Never afraid 3.7 2.7 293 Total 2.0 1.7 4,093 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 11 women for whom husband’s education is missing, 7 women for whom husband’s alcohol consumption is missing, 15 women for whom spousal education difference is missing, 17 women for whom spousal age difference is missing, and 84 women for whom information on how often they are afraid of their husband is missing. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Includes in the past 12 months. 2 Includes only women who have been married only once. 3 According to the wife's report. See Table 14.7 for list of behaviors. 4 According to the wife's report. See Table 15.6 for list of decisions. 5 According to the wife's report. See Table 15.7 for list of decisions. 212 • Domestic Violence 14.13 HELP-SEEKING BEHAVIOR BY WOMEN WHO EXPERIENCE VIOLENCE This final section of this chapter describes help-seeking behavior by women age 15-49 who have ever experienced physical or sexual violence. Table 14.16 shows the percent distribution of women who have ever experienced physical or sexual violence committed by anyone, according to whether they ever sought help to stop the violence and, if not, whether or not they told anyone about the violence. Table 14.16 Help seeking to stop violence Percent distribution of women age 15-49 who have ever experienced physical or sexual violence by their help-seeking behavior, by type of violence and background characteristics, Tajikistan 2012 Background characteristic Sought help to stop violence Never sought help but told someone Never sought help, never told anyone Missing/ don't know Total Number of women who have ever experienced any physical or sexual violence Type of violence experienced Physical only 17.1 9.6 63.6 9.7 100.0 870 Sexual only (0.0) (12.9) (87.1) (0.0) 100.0 34 Physical and sexual 40.4 11.4 44.8 3.5 100.0 173 Age 15-19 25.2 9.5 59.0 6.2 100.0 83 20-24 21.3 6.0 57.6 15.0 100.0 176 25-29 15.8 13.3 67.1 3.8 100.0 242 30-39 20.8 8.1 62.2 8.9 100.0 303 40-49 21.5 12.1 58.3 8.2 100.0 273 Residence Urban 19.8 13.7 59.8 6.7 100.0 298 Rural 20.4 8.6 61.9 9.0 100.0 779 Region Dushanbe 22.8 20.7 46.5 10.0 100.0 78 GBAO 16.9 8.0 73.1 2.0 100.0 19 Sughd 31.3 8.4 56.6 3.7 100.0 397 DRS 12.9 4.1 62.0 21.1 100.0 163 Khatlon 12.4 12.0 67.7 7.9 100.0 421 Marital status Never married 22.1 13.4 54.8 9.6 100.0 99 Married or living together 18.9 9.5 63.6 8.0 100.0 874 Divorced/separated/widowed 30.2 11.4 48.0 10.4 100.0 104 Number of living children 0 21.3 10.3 60.0 8.4 100.0 172 1-2 23.8 10.0 57.5 8.7 100.0 411 3-4 20.6 8.3 66.1 5.0 100.0 324 5+ 10.0 13.2 62.7 14.0 100.0 170 Employment Employed, for cash 23.4 10.3 57.9 8.4 100.0 291 Employed, not for cash 29.8 4.8 57.2 8.1 100.0 96 Not employed 17.7 10.7 63.5 8.2 100.0 687 Education None/primary 11.4 16.5 60.8 11.3 100.0 54 General basic 15.7 8.3 65.0 10.9 100.0 354 General secondary 21.9 11.1 60.1 6.8 100.0 525 Professional primary/middle 34.0 7.8 51.4 6.9 100.0 96 Higher 18.0 8.3 67.3 6.5 100.0 49 Wealth quintile Lowest 16.7 10.5 62.0 10.7 100.0 185 Second 17.4 8.2 62.8 11.6 100.0 240 Middle 26.2 6.8 58.9 8.1 100.0 202 Fourth 23.8 10.1 61.3 4.8 100.0 221 Highest 17.6 14.3 61.3 6.8 100.0 229 Total 20.3 10.0 61.3 8.4 100.0 1,077 Note: Women can report more than one source from which they sought help. Total includes two women for whom employment status is missing. Figures in parentheses are based on 25-49 unweighted cases. Domestic Violence • 213 Overall, one in five women (20 percent) who have experienced any type of physical or sexual violence sought help to stop the violence. Ten percent never sought help but told someone about the violence, whereas the vast majority (61 percent) never sought help and never told anyone about the violence. Women who have experienced both physical and sexual violence (40 percent) are more than twice as likely to have sought help as women who experienced only physical violence. Similarly, women who are divorced, separated, or widowed are more likely to have sought help to stop the violence than women who are either currently married or never-married. Also more likely to seek help are women who are employed, but not for cash, and women who have professional primary or middle education. Table 14.17 shows the percentage of abused women who reported seeking help, by sources from which help was sought. The most common sources of help are the respondent’s own family (reported by 74 percent of women), the husband’s family (reported by 36 percent of women), neighbors (reported by 7 percent of women), and the police (reported by 4 percent of women). Differences by type of violence are not large. Table 14.17 Sources for help to stop the violence Percentage of women age 15-49 who have experienced physical or sexual violence and sought help by sources from which they sought help, according to the type of violence that women reported, Tajikistan 2012 Person Type of violence experienced Total Physical only Physical and sexual Own family 75.7 69.8 73.8 Husband/partner's family 30.7 45.7 35.5 Husband/partner 0.5 0.0 0.3 Friend 0.9 4.0 1.9 Neighbor 6.4 7.5 6.8 Doctor/medical personnel 1.0 6.6 2.8 Police 3.6 5.5 4.2 Lawyer 0.4 0.0 0.3 Social work organization 0.0 1.1 0.3 Other 1.2 1.3 1.2 Number of women who have experienced violence and sought help 148 70 218 Women’s Empowerment and Demographic and Health Outcomes • 215 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 he 1994 International Conference on Population and Development declared that “advancing gender equality and equity and the empowerment of women and the elimination of all kinds of violence against women, and ensuring women’s ability to control their own fertility are cornerstones of population and development related programs” (United Nations, 1994). Women’s empowerment has been defined to encompass women having a sense of self-worth, access to opportunities and resources, choices and the ability to exercise them, control over their own lives, and influence over the direction of social change. Empowerment and autonomy are essential for the achievement of sustainable development. The full participation and partnership of both women and men is required in productive and reproductive life, including the sharing of responsibilities for the care and nurture of children as well as for the maintenance of the household. According to the United Nations Development Program’s (UNDP’s) Human Development Report for 2013, Tajikistan ranks 57 out of 186 countries on the Gender Inequality Index, which is defined in the report as “a composite measure reflecting inequality in achievements between women and men in three dimensions: reproductive health, empowerment, and the labor market”(UNDP, 2013). The 2012 Global Gender Gap Index, developed by the World Economic Forum, ranks Tajikistan much lower—96 out of 135 countries in terms of gender equality (Hausmann et al., 2012). In this chapter, indicators of women’s empowerment including employed women’s control over their own earnings, women’s ownership of assets, women’s participation in household decisions, and women’s acceptance of wife beating are discussed. In addition, two summary indicators of women’s empowerment are defined: an index of the number of household decisions (0-3) in which the respondent participates and an index of the number of reasons (0-5) the respondent accepts as justifying wife beating. The ranking of women on these two indices is then related to selected demographic and health outcomes that include contraceptive use, ideal family size, unmet need for contraception, reproductive health care, and child mortality. T Key Findings • One-third of currently married employed women who earn cash report deciding themselves how their earnings will be used; 48 percent say that they decide jointly how to use their earnings with their husband. • Just over half of all women age 15-49 own a house, either alone or jointly, whereas only 29 percent own land. • Less than half (43 percent) of currently married women report that each of three household decisions is made alone or jointly with their husbands: making decisions about their own health care, making major household purchases, and visits to their family or relatives. • Six in ten women agree with one or more reasons justifying wife beating; more than half think it is justifiable for a man to beat his wife if she goes out without telling him. Four in ten women agree that husband is justified in beating his wife if she is neglecting the children (44 percent) or arguing with a husband (40 percent). 216 • Women’s Empowerment and Demographic and Health Outcomes 15.1 EMPLOYMENT AND FORM OF EARNINGS Employment, particularly employment for cash, and control over how earnings are used are important indicators of empowerment for women. Women interviewed in the 2012 TjDHS were asked whether they were employed at the time of the survey and, if not, whether they were employed at any time during the 12 months preceding the survey. Table 15.1 shows the percentage of currently married women age 15-49 who were employed at any time in the 12 months preceding the survey, and the percent distribution of employed women by the type of earnings they received (cash, in-kind, both, or neither). Table 15.1 Employment and cash earnings of currently married women Percentage of currently married women age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women employed in the past 12 months by type of earnings, according to age, Tajikistan 2012 Age Among currently married women: Percent distribution of currently married women employed in the past 12 months, by type of earnings Total Number of women Percentage employed Number of respondents Cash only Cash and in-kind In-kind only Not paid Missing/ don't know 15-19 13.5 266 (25.1) (32.4) (10.7) (31.7) (0.0) 100.0 36 20-24 20.7 1,320 41.6 23.3 8.9 26.0 0.2 100.0 273 25-29 29.9 1,332 42.9 20.3 9.3 26.8 0.5 100.0 399 30-34 30.4 1,014 54.2 20.6 9.4 15.5 0.3 100.0 308 35-39 39.1 923 57.5 18.4 7.4 16.2 0.4 100.0 361 40-44 44.5 879 63.3 16.9 7.6 11.8 0.3 100.0 391 45-49 38.6 770 50.2 26.1 7.5 16.1 0.0 100.0 297 Total 31.8 6,504 51.6 20.8 8.4 18.9 0.3 100.0 2,066 Note: Figures in parentheses are based on 25-49 unweighted cases. Almost one-third of currently married women age 15-49 reported being employed in the past 12 months. By age, employment increases from 14 percent among married women age 15-19 to 45 percent among women age 40-44, before declining to 39 percent in the oldest age group (45-49 years). Although employment is assumed to go hand in hand with payment for work, not all women receive earnings for the work they do. Even among women who receive earnings, not all are paid in cash. Fifty-two percent of employed married women are paid in cash only, 21 percent receive both cash and in- kind earnings, 8 percent are paid in kind, and 19 percent do not receive any form of payment for their work. Women under age 30 are more likely to be unpaid than their older counterparts. 15.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS Besides receiving an income, women need to have control over their earnings to be empowered. In the survey, to assess control over earnings, currently married women with cash earnings in the past 12 months were asked who the main decision maker is with regard to the use of their earnings. It is expected that women who control their own cash earnings will have a greater say in the use of other household resources. Table 15.2.1 shows the percent distribution of currently married women who received cash earnings in the past 12 months, according to the person who mainly decides on the use of their earnings. One-third of currently married women who earn cash report that they themselves mainly decide how their cash earnings are used; another 48 percent report that they decide jointly with their husbands, 10 percent report that their husbands alone decide how their earnings are used, and 7 percent report that someone else mainly decides. Women age 25-29 are slightly less likely than older and younger women to mainly decide by themselves how their earnings are used (28 percent). Women with no children and those with five or more children are less likely to make their own decisions regarding the use of their earnings than women with one to four children. More than one in four childless married women says that someone other than she herself or her husband usually decides how her earnings are used. Rural women are less likely than urban women to mainly make decisions themselves about spending their earnings. Women’s Empowerment and Demographic and Health Outcomes • 217 Table 15.2.1 Control over women's cash earnings and relative magnitude of women's cash earnings Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey, by person who decides how wife's cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Tajikistan 2012 Background characteristic Person who decides how the wife's cash earnings are used: Total Wife's cash earnings compared with husband's cash earnings: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing More Less About the same Husband has no earnings Don't know/ Missing Age 15-19 * * * * * 100.0 * * * * * 100.0 21 20-24 33.8 37.2 6.5 19.0 3.5 100.0 3.0 74.5 9.7 4.2 8.7 100.0 177 25-29 27.5 40.8 14.4 16.6 0.7 100.0 3.1 83.1 9.9 1.2 2.7 100.0 252 30-34 34.1 49.5 8.0 7.2 1.2 100.0 4.7 79.3 11.5 1.9 2.6 100.0 231 35-39 31.5 57.7 8.6 0.9 1.2 100.0 9.1 73.7 11.6 3.1 2.6 100.0 274 40-44 33.4 52.6 11.7 0.0 2.3 100.0 12.5 69.6 11.1 3.0 3.9 100.0 314 45-49 37.0 48.6 10.4 0.0 4.0 100.0 12.5 66.8 13.0 3.1 4.6 100.0 227 Number of living children 0 23.7 37.7 9.9 26.2 2.5 100.0 4.4 66.7 17.4 5.4 6.2 100.0 124 1-2 35.8 43.6 11.1 8.2 1.4 100.0 7.7 77.9 8.8 2.0 3.6 100.0 485 3-4 35.7 49.4 9.7 4.1 1.2 100.0 8.3 76.0 11.2 1.8 2.6 100.0 587 5+ 25.6 57.4 11.0 1.5 4.4 100.0 8.2 69.4 12.1 4.2 6.2 100.0 299 Residence Urban 37.3 48.8 9.9 1.4 2.7 100.0 12.5 66.6 14.6 2.1 4.3 100.0 417 Rural 30.9 47.9 10.6 8.8 1.7 100.0 6.0 77.6 9.8 2.9 3.8 100.0 1,078 Region Dushanbe 36.0 46.6 10.7 0.3 6.4 100.0 10.2 61.9 16.4 2.4 9.2 100.0 145 GBAO 44.6 44.6 8.8 1.0 1.0 100.0 24.3 57.2 12.9 4.6 1.0 100.0 40 Sughd 36.3 48.6 12.0 2.6 0.6 100.0 4.6 83.0 10.1 0.9 1.4 100.0 523 DRS 40.7 47.3 4.2 4.7 3.1 100.0 13.8 58.8 17.9 3.0 6.5 100.0 133 Khatlon 26.7 48.5 10.5 12.2 2.1 100.0 7.5 74.9 9.3 3.9 4.4 100.0 655 Education None/primary 27.3 27.2 13.0 30.4 2.1 100.0 6.5 72.3 8.9 2.4 9.8 100.0 75 General basic 28.9 47.3 11.6 9.9 2.3 100.0 4.0 72.5 14.5 2.7 6.3 100.0 267 General secondary 32.7 48.3 11.1 5.0 2.9 100.0 7.1 75.7 9.9 3.5 3.8 100.0 662 Professional primary/ middle 37.4 46.1 9.7 6.7 0.0 100.0 9.3 78.3 9.6 1.7 1.1 100.0 235 Higher 33.9 56.4 7.2 1.2 1.3 100.0 12.5 70.9 12.7 1.2 2.6 100.0 257 Wealth quintile Lowest 28.7 52.6 12.8 3.8 2.2 100.0 8.2 67.9 13.1 5.4 5.4 100.0 286 Second 26.0 44.3 12.1 15.3 2.3 100.0 6.4 78.1 9.2 3.2 3.1 100.0 323 Middle 29.9 48.7 8.3 11.2 1.8 100.0 4.3 78.4 9.5 1.7 6.1 100.0 215 Fourth 37.3 45.2 12.7 3.5 1.2 100.0 6.0 81.4 7.9 1.6 3.0 100.0 273 Highest 39.3 49.8 6.9 1.7 2.4 100.0 11.7 69.6 14.3 1.3 3.1 100.0 399 Total 32.7 48.1 10.4 6.7 2.0 100.0 7.8 74.5 11.1 2.6 3.9 100.0 1,496 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. There is variation among the regions in who makes decisions on how women’s earnings are used. The proportion of married employed women who mainly decide by themselves about the use of their earnings ranges from a high of 45 percent in the GBAO region to a low of 27 percent in the Khatlon region. Decisions by someone other than the wife or her husband about how the wife’s earnings are used also varies by region, ranging from less than one percent in Dushanbe region to 12 percent of women in the Khatlon region. The relationship between women’s education and their decision-making power regarding their earnings does not show strong patterns except that married women with no education or only primary education are much more likely to have someone other than themselves or their husbands make decisions about how to use their earnings. Women’s ability to decide themselves on how to spend their earnings generally increases with their wealth quintile. Thirty-nine percent of women in the highest wealth quintile mainly decide by themselves about the use of their earnings compared with 29 percent of women in the lowest wealth quintile. Table 15.2.1 also shows information about how married women say their cash earnings compare with those of their husbands. Three-quarters of married women who earn cash say that they earn less than their husbands. Eleven percent say that they earn about the same as their husbands, while 8 percent say they earn more than their husbands, and 3 percent say their husbands have no earnings. Older women are 218 • Women’s Empowerment and Demographic and Health Outcomes more likely than younger women to earn about the same or more than their husbands. Similarly, urban women are more likely than rural women to earn about the same or more than their husbands. In the GBAO region, almost one-quarter of married women who earn cash earn more than their husbands. On the other hand, married women in the Sughd region are the least likely to earn more than their husbands (5 percent) and most likely to earn less than their husbands (83 percent). Married women in the highest education and wealth categories are more likely to earn more than their husbands than women in other education and wealth categories; however, there is no clear relationship between wife’s and husband’s comparative cash earnings and either education or wealth quintile of the woman. 15.3 WOMEN’S CONTROL OVER THEIR HUSBAND’S EARNINGS Table 15.2.2 shows data about control over the husband’s cash earnings from the wife’s perspective, by background characteristics. Among currently married women age 15-49 who say their husbands receive cash earnings, almost half (48 percent) say they decide jointly with their husbands how their husbands’ earnings will be used, while 29 percent say their husbands mainly make decisions themselves. Sixteen percent of women say someone else makes decisions about their husbands’ earnings. Only a small proportion of women (7 percent) say that they mainly make decisions on how their husbands’ earnings are used. Table 15.2.2 Control over men's cash earnings Percent distribution of currently married women age 15-49 whose husbands receive cash earnings, by person who decides how husband's cash earnings are used, according to background characteristics, Tajikistan 2012 Background characteristic Person who decides how husband’s cash earnings are used: Number of women Mainly wife Husband and wife jointly Mainly husband Other Missing Total Age 15-19 2.4 28.5 25.8 43.0 0.3 100.0 248 20-24 2.9 37.0 26.2 33.5 0.5 100.0 1,284 25-29 4.0 39.6 32.6 23.6 0.2 100.0 1,312 30-34 7.4 47.9 32.5 12.3 0.0 100.0 997 35-39 11.0 58.2 28.1 2.6 0.1 100.0 907 40-44 12.0 59.3 27.8 0.5 0.4 100.0 862 45-49 9.4 61.8 28.4 0.0 0.4 100.0 744 Number of living children 0 2.3 36.4 25.9 34.5 0.8 100.0 708 1-2 5.8 42.3 29.9 21.9 0.2 100.0 2,283 3-4 8.8 51.9 29.4 9.9 0.0 100.0 2,236 5+ 8.7 58.4 29.5 2.7 0.6 100.0 1,128 Residence Urban 8.1 48.1 36.0 7.6 0.2 100.0 1,537 Rural 6.6 47.8 27.1 18.2 0.3 100.0 4,818 Region Dushanbe 8.8 43.9 45.1 2.2 0.0 100.0 543 GBAO 21.6 54.7 19.5 4.2 0.0 100.0 123 Sughd 6.9 42.9 35.1 15.0 0.1 100.0 1,983 DRS 4.5 50.6 24.5 20.1 0.3 100.0 1,529 Khatlon 7.5 51.1 23.8 17.2 0.5 100.0 2,177 Education None/primary 3.8 38.1 27.8 30.1 0.3 100.0 344 General basic 5.8 41.2 30.2 22.4 0.3 100.0 1,965 General secondary 7.3 50.9 29.3 12.2 0.3 100.0 3,187 Professional primary/middle 9.4 48.0 31.9 10.5 0.2 100.0 467 Higher 9.8 65.2 21.2 3.8 0.0 100.0 392 Wealth quintile Lowest 7.7 50.2 29.8 11.8 0.6 100.0 1,168 Second 6.1 45.5 27.4 20.6 0.4 100.0 1,263 Middle 6.9 46.3 26.2 20.5 0.1 100.0 1,284 Fourth 6.3 48.0 27.9 17.6 0.2 100.0 1,343 Highest 7.9 49.5 34.8 7.7 0.0 100.0 1,297 Total 7.0 47.9 29.2 15.7 0.3 100.0 6,355 Women’s Empowerment and Demographic and Health Outcomes • 219 There are some interesting patterns in control of husband’s earnings by women’s background characteristics. For example, among married women age 15-19, 43 percent say that someone else mainly makes decisions about how to spend their husbands’ earnings. This finding may reflect the fact that younger married couples are more likely to live with their parents, who may therefore exert some influence over decisions about spending income. Other groups with relatively large proportions reporting that someone else mainly decides on how to use the husband’s earnings include women with no children, rural women, women in the DRS region, and women with less education. Table 15.3 shows, for currently married women who earned cash in the past 12 months, the person who mainly decides how their cash earnings are used, and for all currently married women whose husbands earned cash in the past 12 months, the person who mainly decides how their husband’s cash earnings are used, according to the relative magnitude of the earnings of the women and their husbands. As expected, women whose earnings exceed their husband’s are more likely to have control over their own earnings. On the other hand, women who receive the same amount of pay as their husbands are much more likely to say that decisions on the use of their earnings are mainly made jointly with their husbands. Table 15.3 Women's control over their earnings and over those of their husbands Percent distribution of currently married women age 15-49 with cash earnings in the last 12 months by person who decides how the wife's cash earnings are used and percent distribution of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband's cash earnings are used, according to the relation between wife's and husband's cash earnings, Tajikistan 2012 Women's earnings relative to husband's earnings Person who decides how the wife's cash earnings are used: Total Number of women Person who decides how husband's cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing Mainly wife Wife and husband jointly Mainly husband Other Missing More than husband 47.8 45.1 5.7 1.4 0.0 100.0 116 23.1 58.4 16.7 1.8 0.0 100.0 116 Less than husband 33.5 47.5 11.5 7.4 0.1 100.0 1,115 8.4 57.0 22.7 11.8 0.0 100.0 1,115 Same as husband 15.5 72.3 8.0 4.1 0.0 100.0 166 3.0 80.7 11.9 4.4 0.0 100.0 166 Husband has no cash earnings or did not work (55.7) (30.0) (8.1) (3.9) (2.3) 100.0 39 na na na na na na 0 Woman worked but has no cash earnings na na na na na na 0 8.7 52.7 28.3 10.0 0.3 100.0 555 Woman did not work na na na na na na 0 6.1 43.4 31.9 18.3 0.3 100.0 4,344 Total1 32.7 48.1 10.4 6.7 2.0 100.0 1,496 7.0 47.9 29.2 15.7 0.3 100.0 6,355 na = Not applicable. Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes 59 cases where a woman does not know whether she earned more or less than her husband. With regard to the husband’s cash earnings, decisions on using the earnings are most likely to be made jointly, regardless of the relative income of the wife or whether the wife receives any cash earnings. Nevertheless, women who earn more than their husbands are more likely to be the main decisionmaker as to how to use their husbands’ earnings than women who earn the same or less than their husbands or who have no cash earnings. Women who earn about the same amount as their husbands are the most likely to say they make joint decisions about how to use the husbands’ earnings. 15.4 OWNERSHIP OF ASSETS Asset ownership, particularly of land and housing, has many beneficial effects for households, including protection against financial ruin. For women, asset ownership is a source of financial empowerment and can provide protection in the case of marital dissolution or abandonment. The limited information available suggests that women are much less likely than men to own productive assets. Information on women’s asset ownership can provide important insights into women’s status and demographic and health outcomes. Accordingly, the TjDHS asked women about their ownership, alone or jointly, of two of the most important assets: land1 and housing. 1 According to the Land Code of the Republic of Tajikistan, land is exclusively owned by the State (GOT, 2008). However, upon appropriate State registration, use of a land plot can be given for perpetual use to natural persons and Continued… 220 • Women’s Empowerment and Demographic and Health Outcomes The 2012 TjDHS asked women if they owned land or a house, alone or jointly. If respondents are the sole owners of the asset (they do not share ownership with anyone), then they own the asset “Alone.” If respondents own the asset with someone else, then they are classified as owning the asset “Jointly only.” If they own more than one asset, and some assets are owned alone and some jointly with someone else, then they are classified in the “Both alone and jointly” category. Finally, respondents who do not own the specific asset, either alone or jointly, are in the “Does not own” category. As shown in Table 15.4, almost half of all women interviewed said they did not own a house, while 71 percent said they did not own land. Almost one-third of women said they owned a house jointly, while 4 percent owned a house alone and 17 percent owned a house alone and jointly. As might be expected, the proportions of women who do not own a house at all or do not own land at all are highest among younger women and decline with age. Urban and rural women are about equally likely to own a house either alone or jointly, whereas urban women are far less likely than rural women to own land. The percentage of women who do not own a house is highest in the Khatlon region (60 percent), while the percentage who do not own land is highest in Dushanbe (97 percent). Women’s education shows a slight tendency to be positively related to ownership of a house but is not related to ownership of land. With regard to wealth, the proportion of women who do not own a house varies little by wealth quintile. However, the proportion of women who do not own land increases steadily as wealth quintile increases, perhaps because wealthier women are more concentrated in urban areas. Table 15.4 Ownership of assets Percent distribution of women age 15-49 by ownership of housing and land, according to background characteristics, Tajikistan 2012 Background characteristic Percentage who own a house: Total Percentage who own land: Total NumberAlone Jointly Alone and jointly Percent- age who do not own a house Missing Alone Jointly Alone and jointly Percent- age who do not own land Missing Age 15-19 0.2 15.2 9.8 74.7 0.1 100.0 0.1 3.2 5.8 90.9 0.1 100.0 2,013 20-24 0.4 21.6 16.8 61.1 0.1 100.0 0.2 7.7 12.5 79.3 0.3 100.0 1,950 25-29 1.6 29.8 17.8 50.5 0.3 100.0 0.2 12.9 13.6 73.2 0.1 100.0 1,609 30-34 5.5 35.8 19.4 39.0 0.2 100.0 2.2 15.9 14.7 66.6 0.6 100.0 1,188 35-39 6.4 46.9 21.6 24.8 0.2 100.0 2.9 25.3 16.1 55.3 0.3 100.0 1,030 40-44 8.9 52.1 20.2 18.7 0.1 100.0 4.0 29.7 15.9 49.9 0.5 100.0 991 45-49 12.9 49.2 21.5 16.1 0.3 100.0 7.3 28.5 17.7 46.4 0.1 100.0 875 Residence Urban 6.7 33.9 12.7 46.6 0.2 100.0 1.5 8.0 6.6 83.5 0.5 100.0 2,413 Rural 2.9 31.0 18.6 47.4 0.2 100.0 1.8 16.9 14.8 66.3 0.2 100.0 7,243 Region Dushanbe 6.2 37.6 8.2 47.8 0.2 100.0 0.4 1.6 0.7 96.7 0.7 100.0 881 GBAO 11.5 38.4 7.9 41.7 0.5 100.0 11.1 33.0 7.4 48.2 0.3 100.0 220 Sughd 4.4 41.5 15.4 38.4 0.2 100.0 1.7 15.3 12.5 70.3 0.2 100.0 2,872 DRS 2.1 25.5 33.7 38.5 0.2 100.0 1.6 9.1 23.3 65.6 0.3 100.0 2,240 Khatlon 3.4 25.7 10.6 60.2 0.1 100.0 1.6 19.8 9.6 68.8 0.2 100.0 3,444 Education None/primary 2.1 23.5 18.6 55.9 0.0 100.0 0.4 14.3 14.3 71.0 0.0 100.0 567 General basic 1.9 26.5 16.7 54.8 0.2 100.0 0.8 11.2 12.0 75.7 0.3 100.0 3,349 General secondary 4.9 35.3 18.2 41.5 0.2 100.0 2.4 18.1 13.9 65.3 0.3 100.0 4,474 Professional primary/ middle 4.6 37.9 14.7 42.6 0.2 100.0 2.2 13.4 11.9 72.5 0.0 100.0 645 Higher 7.8 35.3 13.4 43.5 0.0 100.0 2.8 10.4 8.4 78.4 0.1 100.0 620 Wealth quintile Lowest 2.9 36.8 15.9 44.2 0.2 100.0 2.0 29.9 12.7 55.2 0.2 100.0 1,878 Second 3.5 28.5 16.8 51.1 0.1 100.0 2.6 18.5 12.2 66.7 0.1 100.0 1,913 Middle 2.5 24.9 22.5 50.0 0.1 100.0 1.4 10.0 17.8 70.6 0.2 100.0 1,904 Fourth 3.7 32.1 18.3 45.6 0.3 100.0 1.5 9.6 14.3 74.4 0.2 100.0 1,971 Highest 6.5 36.1 12.3 45.0 0.1 100.0 1.3 6.1 7.1 85.1 0.5 100.0 1,989 Total 3.8 31.7 17.1 47.2 0.2 100.0 1.8 14.6 12.8 70.6 0.3 100.0 9,656 ________________________________________ legal entities of the Republic of Tajikistan. Land suitable for agricultural needs can be allocated to natural persons and legal entities for agricultural production. Women’s Empowerment and Demographic and Health Outcomes • 221 15.5 WOMEN’S EMPOWERMENT The 2012 TjDHS survey collected information from women on other measures of women’s autonomy and status. In particular, questions were asked about women’s participation in household decisions and their attitudes regarding gender roles. Such information provides insight into women’s control over household resources and environment, factors that are relevant to understanding women’s demographic and health behavior. The ability of women to make decisions that affect the personal circumstances of their own lives is an essential aspect of empowerment and serves as an important contributor to their overall welfare. To assess currently married women’s decisionmaking autonomy, the 2012 TjDHS collected information on women’s participation in three types of decisions: their own health care, major household purchases, and visits to the woman’s family or relatives. Table 15.5 shows the percent distribution of currently married women age 15-49, according to the person who usually makes decisions concerning these matters. Table 15.5 Participation in decision making Percent distribution of currently married women age 15-49 by person who usually makes decisions about various issues, Tajikistan 2012 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 14.5 39.7 30.5 6.2 8.9 0.2 100.0 6,504 Major household purchases 7.9 46.8 25.1 8.2 11.7 0.2 100.0 6,504 Visits to her family or relatives 9.4 46.5 25.1 7.6 11.1 0.3 100.0 6,504 Between 40 and 47 percent of women make each of the three types of decisions jointly with their husbands. Husbands have more input into decisions than women, since 25 to 31 percent mainly make each of the three decisions, compared with only 8 to 15 percent of women. Women have more say in decisions related to their own health care than in the other two types of decisions; 15 percent say that they mainly make decisions about their health care by themselves. Still, 31 percent of the women report that their husbands mainly make decisions for them about their health care. Table 15.6 shows how currently married women’s participation (alone or jointly) in decision making varies by background characteristics. The table presents the results for the three specific types of decisions asked about, namely women’s own health care, making major household purchases, and visits to the woman’s family or relatives. In addition, the table includes two summary indicators: the proportion of women involved in making all three decisions and the proportion not involved in making any of the three decisions. Just over half of currently married women participate in each individual decision, either alone or jointly with their husbands. Forty-three percent of currently married women participate in all three decisions, and 34 percent do not participate in any of the decisions. Women’s participation in all three decisions varies by background characteristics. Participation in decision making increases steadily with age, with married women age 15-19 being the least likely to participate in all three decisions. As expected, employed women who have cash earnings are more likely to participate in all three decisions (53 percent) than women who are not employed (41 percent) or women who are employed but not for cash (32 percent). The proportion of married women who participate in all three household decisions increases steadily as the number of children increases, from 27 percent of childless women to 54 percent of those with five or more children. Urban women participate more in all three decisions than their rural counterparts (47 percent versus 42 percent, respectively). 222 • Women’s Empowerment and Demographic and Health Outcomes Table 15.6 Women's participation in decision making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Tajikistan 2012 Background characteristic Specific decisions All three decisions None of the three decisions Number of women Woman's own health care Making major household purchases Visits to her family or relatives Age 15-19 30.4 25.7 27.9 18.0 61.1 266 20-24 40.7 37.6 39.5 29.2 50.5 1,320 25-29 45.8 40.9 43.7 32.1 45.1 1,332 30-34 54.7 58.2 57.9 44.3 31.7 1,014 35-39 66.0 70.7 69.0 56.1 20.9 923 40-44 66.9 73.7 74.3 58.1 17.9 879 45-49 71.2 73.0 75.1 60.3 16.1 770 Employment (last 12 months) Not employed 51.4 51.7 53.3 41.4 37.9 4,432 Employed for cash 65.8 66.2 65.8 52.7 22.0 1,496 Employed not for cash 46.1 48.9 49.9 31.5 37.1 564 Number of living children 0 40.0 35.5 39.0 27.1 51.1 746 1-2 50.3 47.2 49.1 38.0 40.3 2,333 3-4 59.1 62.8 62.1 48.3 27.6 2,268 5+ 61.9 66.8 68.2 53.6 23.9 1,157 Residence Urban 58.5 58.5 61.8 47.3 28.6 1,571 Rural 52.9 53.6 54.0 41.8 36.0 4,933 Region Dushanbe 51.9 52.7 60.3 40.7 29.9 559 GBAO 69.3 73.6 73.9 58.3 16.5 129 Sughd 53.0 54.5 56.8 39.0 31.8 2,022 DRS 63.4 59.7 58.5 53.8 33.2 1,546 Khatlon 48.8 51.0 51.1 39.2 39.2 2,249 Education None/primary 39.8 38.3 44.3 31.0 49.1 356 General basic 48.0 46.9 46.9 37.4 43.0 2,016 General secondary 56.2 58.3 59.5 45.4 30.9 3,260 Professional primary/middle 65.1 60.7 62.8 48.2 24.6 475 Higher 70.2 73.1 73.9 58.1 14.6 397 Wealth quintile Lowest 49.4 53.8 54.5 41.4 38.0 1,210 Second 47.8 48.6 48.9 37.9 41.6 1,287 Middle 55.4 54.4 54.2 43.1 34.4 1,307 Fourth 57.6 55.8 58.2 43.5 30.6 1,379 Highest 60.4 60.9 63.1 49.3 27.1 1,320 Total 54.2 54.8 55.9 43.1 34.2 6,504 Note: Totals include 12 women missing information as to employment status. Among administrative regions, women’s participation in decisionmaking is lowest in the Sughd and Khatlon regions (39 percent each) and highest in the GBAO region (58 percent). The Khatlon region has the highest percentage of married women who do not participate in any of the three types of decisions (39 percent). Women’s participation in decisionmaking increases steadily as education level increases. Only 31 percent of married women with no education or only primary education participate in all three types of decisions, compared with 58 percent of women with higher education. The relationship between women’s participation in decisionmaking and wealth is not so strong, although it is positively correlates with increasing wealth quintile. Women’s Empowerment and Demographic and Health Outcomes • 223 Women may have a say in some, but not all decisions. The number of decisions that a woman makes by herself or jointly with her husband is positively related to women’s empowerment and reflects the degree of control women are able to exercise in areas that affect their lives and environments. Figure 15.1 shows the percent distribution of currently married women according to the number of decisions in which they participate. Two in five currently married women participate in all three household decisions; one in three currently married women participates in none. Figure 15.1 Number of decisions in which currently married women participate, Tajikistan 2012 TjDHS 2012 The 2005 MICS survey included similar questions to the 2012 TjDHS about decisionmaking. Results indicate that there has been an increase in the proportion of married women who participate in making decisions about large household purchases, from 42 percent in 2005 to 55 percent in 2012. In contrast, the proportion of married women who participate in making decisions about their own health care has hardly changed (52 percent in 2005 and 54 percent in 2012). Similarly, the proportion of women participating in decisions about visits to their relatives remains flat at 55 percent in 2005 and 56 percent in 2012 (SCS, 2007). 15.6 ATTITUDES TOWARD WIFE BEATING The problems that women face are many and diverse. One of the most serious is violence, and Tajikistan is no exception in this regard. One of the most common forms of violence against women worldwide is abuse by the husband or partner (Heise et al., 1999). The 2012 TjDHS obtained information on women’s attitudes toward wife beating. Women were asked their opinion on whether a husband is justified in hitting or beating his wife under a series of circumstances: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual intercourse with him. A woman’s attitude toward wife beating is considered a proxy for her perception of women’s status. A lower score on the “number of reasons wife beating is justified” indicates a woman’s greater sense of entitlement, self-esteem, and status and reflects positively on her sense of empowerment. Agreement with wife beating as justified indicates that a woman generally accepts the right of a man to control her behavior even by means of violence. Such a perception could act as a barrier to accessing health care for her children and herself, affect her attitude toward contraceptive use, and have an impact on her general well-being. 34 10 13 43 0 1 2 3 Number of decisions Percentage 224 • Women’s Empowerment and Demographic and Health Outcomes Table 15.7 shows the percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics. Three in five women agree that a husband is justified in beating his wife for at least one of the reasons listed. The most widely accepted reason for wife beating among women in Tajikistan is going out without telling her husband (51 percent), followed by neglecting the children (44 percent), and arguing with him (40 percent). Just over one-quarter of women agree that refusing to have sexual intercourse (27 percent) and burning the food (28 percent) are acceptable reasons for a man to beat his wife. Table 15.7 Attitude toward wife beating Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Tajikistan 2012 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 21.5 31.2 38.3 33.6 17.0 46.5 2,013 20-24 29.6 42.6 53.2 45.0 28.7 61.6 1,950 25-29 32.1 44.2 56.9 49.9 31.5 64.2 1,609 30-34 31.6 43.6 56.5 48.8 30.6 66.4 1,188 35-39 30.3 39.7 50.8 46.3 29.9 62.8 1,030 40-44 28.5 41.8 51.1 47.0 30.6 63.2 991 45-49 27.4 39.6 51.2 45.5 28.2 59.4 875 Employment (last 12 months) Not employed 27.9 41.0 51.1 44.6 27.9 59.1 6,523 Employed for cash 27.5 37.0 47.6 41.9 24.4 58.3 2,295 Employed not for cash 33.4 39.8 53.1 48.5 29.7 66.6 823 Number of living children 0 23.0 32.1 40.5 34.5 18.6 48.0 3,483 1-2 29.4 43.1 54.5 48.1 31.1 63.5 2,588 3-4 30.0 43.4 55.2 48.4 30.0 67.0 2,385 5+ 38.2 49.2 61.0 56.4 38.6 69.6 1,200 Marital status Never married 20.7 28.2 35.9 31.1 14.3 43.3 2,648 Married or living together 31.9 45.3 57.4 50.3 33.0 67.2 6,504 Divorced/separated/widowed 22.5 32.5 37.2 36.0 21.6 46.9 504 Residence Urban 21.0 32.0 42.5 35.8 20.0 50.8 2,413 Rural 30.8 42.6 53.1 47.1 29.7 62.5 7,243 Region Dushanbe 11.8 24.2 38.9 30.0 14.2 46.3 881 GBAO 22.2 23.1 33.8 35.3 16.4 45.0 220 Sughd 24.6 37.3 43.6 32.2 24.6 57.5 2,872 DRS 26.3 47.0 58.2 54.9 34.6 62.2 2,240 Khatlon 37.3 42.7 55.1 51.7 28.7 63.9 3,444 Education None/primary 40.4 51.0 62.4 54.6 32.0 68.0 567 General basic 30.9 42.3 52.5 47.1 29.9 60.7 3,349 General secondary 28.1 40.0 52.0 44.6 27.5 61.7 4,474 Professional primary/middle 22.2 34.5 40.0 37.1 21.9 52.1 645 Higher 11.7 22.5 28.1 24.7 12.7 37.9 620 Wealth quintile Lowest 38.1 45.1 55.0 51.6 35.1 65.9 1,878 Second 36.4 45.6 56.5 51.8 31.0 65.4 1,913 Middle 27.8 39.7 52.4 45.8 27.5 60.8 1,904 Fourth 22.9 38.9 48.2 39.0 24.2 57.9 1,971 Highest 17.2 31.1 40.7 34.0 19.0 48.4 1,989 Total 28.3 40.0 50.5 44.3 27.3 59.6 9,656 Note: Totals include 14 women missing information as to employment status. Women’s Empowerment and Demographic and Health Outcomes • 225 Agreement with at least one reason for wife beating is somewhat lower among women 15-19 and those who are childless, but otherwise varies little with age or number of children. Women who are either not employed or employed and get paid in cash are slightly less likely to agree with at least one reason for wife beating than women who are employed but not for cash. Agreement with at least one reason for wife beating is lowest among women who have never married, followed by women who are divorced, separated, or widowed; it is highest among currently married women. Urban women are less likely than rural women to agree with wife beating, as are women in the GBAO and Dushanbe regions. The percentage of women who agree with at least one of the specified reasons for wife beating decreases as education and wealth quintile increase. Although acceptance of wife beating is prevalent in Tajikistan, there is evidence that it is declining. Data from the 2005 MICS survey indicate that the proportion of women who agree that wife beating is justified is lower in 2012 for each of the five specified reasons: if she burns the food (declined from 44 percent in 2005 to 28 percent in 2012); if she argues with him (from 68 percent in 2005 to 40 percent in 2012); if she goes out without telling him (from 62 percent in 2005 to 51 percent in 2012); if she neglects the children (from 61 percent in 2005 to 44 percent in 2012), and if she refuses to have sex with him (from 48 percent in 2005 to 27 percent in 2012) (SCS, 2007). 15.7 INDICATORS OF WOMEN’S EMPOWERMENT Women’s empowerment has important implications for demographic and health outcomes, including women’s use of family planning and maternal health care services. To examine how selected demographic and health outcomes vary by women’s empowerment, information on women’s participation in household decisionmaking and their attitudes toward wife beating are summarized in two separate indices. The first index is the number of decisions (0 to 3) in which women participate, either alone or jointly with their husbands (see Table 15.6 for the list of decisions). This index reflects the degree of control that women are able to exercise through making decisions in areas that affect their own lives and environments and is positively related to women’s empowerment (i.e., a higher number of decisions indicates greater empowerment). The second index is the number of reasons (0 to 5) for which women think a husband is justified in beating his wife (see Table 15.7 for the list of reasons). This index is negatively related to women’s empowerment (i.e., a lower score is interpreted as reflecting a greater sense of entitlement, higher self- esteem, and a higher status of women). In general, it is expected that women who participate in making household decisions are also more likely to have gender-egalitarian beliefs and to reject wife beating. Accordingly, Table 15.8 provides an overview of how these two basic empowerment indices—number of decisions in which women participate and number of reasons for which wife beating is justified—relate to one another. Women’s rejection of all the reasons for wife beating varies only somewhat by the number of decisions they participate in. Specifically, 27-30 percent of women who participate in 0-2 decisions reject all the reasons for wife beating, compared with 39 percent of women who participate in all three decisions. However, the proportion of women who participate in all three decisions varies more uniformly with the number of reasons for which wife beating is justified. The percentage of women who participate in all three decisions is highest (51 percent) for women who do not agree with any reason for wife beating and falls steadily to 38 percent of women who agree with all five reasons for wife beating. 226 • Women’s Empowerment and Demographic and Health Outcomes Table 15.8 Indicators of women's empowerment Percentage of currently married women age 15-49 who participate in all decision making and the percentage who disagree with all of the reasons justifying wife-beating, by value on each of the indicators of women's empowerment, Tajikistan 2012 Empowerment indicator Percentage who participate in all decision making Percentage who disagree with all the reasons justifying wife-beating Number of women Number of decisions in which women participate1 0 na 29.5 2,225 1-2 na 27.1 1,476 3 na 38.5 2,803 Number of reasons for which wife- beating is justified2 0 50.5 na 2,135 1-2 40.7 na 1,616 3-4 39.3 na 1,346 5 38.3 na 1,408 na = Not applicable 1 See Table 15.6 for the list of decisions. 2 See Table 15.7 for the list of reasons. 15.8 CURRENT USE OF CONTRACEPTION BY WOMEN’S EMPOWERMENT A woman’s desire and ability to control her fertility and the contraceptive method she chooses are likely to be affected by her status in the household, her self-image, and her own sense of empowerment. A woman who feels that she is unable to control other aspects of her life may be less likely to feel that she can make and carry out decisions about her fertility. She may also feel the need to choose methods that can be hidden from others or that do not depend on her husband’s cooperation. Table 15.9 shows the distribution of currently married women age 15-49 by current contraceptive method, according to the two women’s empowerment indices. Table 15.9 Current use of contraception by women's empowerment Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women's status, Tajikistan 2012 Empowerment indicator Any method Any modern method Modern methods Any traditional method Not currently using Total Number of women Female sterilization Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 22.3 20.1 0.3 18.2 1.7 2.2 77.7 100.0 2,225 1-2 28.7 26.8 0.7 23.2 2.9 1.9 71.3 100.0 1,476 3 32.0 29.8 0.8 26.7 2.4 2.1 68.0 100.0 2,803 Number of reasons for which wife-beating is justified3 0 31.5 29.2 0.6 25.6 3.0 2.2 68.5 100.0 2,135 1-2 31.0 28.7 0.5 25.9 2.3 2.3 69.0 100.0 1,616 3-4 24.5 22.3 0.4 19.6 2.3 2.3 75.5 100.0 1,346 5 22.3 20.9 0.9 19.0 1.0 1.4 77.7 100.0 1,408 Total 27.9 25.8 0.6 23.0 2.2 2.1 72.1 100.0 6,504 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly, and lactational amenorrhea method. 2 See Table 15.6 for the list of decisions. 3 See Table 15.7 for the list of reasons. Women’s Empowerment and Demographic and Health Outcomes • 227 As might be expected, contraceptive use is positively associated with women’s participation in household decisionmaking and negatively associated with women’s agreement with wife beating. In particular, use of any method and any modern method increases steadily with the number of decisions in which women participate. For example, only 20 percent of married women who do not participate in making any household decisions are using a modern method of contraception, compared with 30 percent of those who participate in all three decisions. Similarly, use of any method and any modern method decrease as the number of reasons for which wife-beating is justified increase. The proportion of married women using a modern method of contraception decreases from 29 percent of women who do not believe wife-beating is justified for any of the reasons to 21 percent of those who believe wife-beating is justified for all five reasons. 15.9 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S EMPOWERMENT The ability of women to make decisions effectively has important implications for their fertility preferences and for meeting their goals for family size. In particular, it is expected that more empowered women will want smaller families and be better able to negotiate decisions regarding fertility and family planning. Hence, ideal family size and unmet need for family planning—which reflects women’s unsatisfied need for contraception—should both be lower among more empowered women. Table 15.10 shows how women’s ideal family size and their unmet need for family planning vary by the two indicators of women’s empowerment. The mean ideal family size does not show much association with either of the two indicators. It is almost uniform across the number of decisions in which women participate, and is lower only among women who do not believe wife beating is justified for any of the five reasons. Table 15.10 Ideal number of children and unmet need for family planning, by women's empowerment Mean ideal number of children for women 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women's empowerment, Tajikistan 2012 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of currently married women For spacing For limiting Total Number of decisions in which women participate3 0 3.8 2,195 15.3 9.4 24.7 2,225 1-2 3.8 1,445 11.4 11.9 23.3 1,476 3 3.9 2,760 9.3 11.9 21.2 2,803 Number of reasons for which wife-beating is justified4 0 3.4 3,726 11.6 10.7 22.3 2,135 1-2 3.7 2,112 11.8 9.3 21.1 1,616 3-4 3.7 1,778 13.0 11.5 24.4 1,346 5 3.7 1,721 11.3 13.0 24.3 1,408 Total 3.6 9,336 11.8 11.0 22.9 6,504 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.9 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 15.6 for the list of decisions. 4 See Table 15.7 for the list of reasons. There is an association between participation in decision making and unmet need for family planning. Women who participate in no household decisions have the highest unmet need for family planning (25 percent), compared with those who participate in one to two decisions (23 percent) or in all three decisions (21 percent). There is no apparent association between acceptance of wife beating and unmet need. 228 • Women’s Empowerment and Demographic and Health Outcomes 15.10 REPRODUCTIVE HEALTH CARE BY WOMEN’S EMPOWERMENT Table 15.11 examines whether empowered women are more likely to access antenatal, delivery, and postnatal care services from medically trained health personnel. In societies where health care is widespread, women’s empowerment may not affect their access to reproductive health services. In other societies, however, increased empowerment of women is likely to increase their ability to seek out and use health services from qualified health providers to better meet their own reproductive health goals, including the goal of safe motherhood. The table includes only women who had a birth in the five years preceding the survey and examines their access to antenatal care, delivery care, and postnatal care from trained health personnel for their most recent birth. Table 15.11 Reproductive health care by women's empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance and postnatal care from health personnel for the most recent birth, by indicators of women's empowerment, Tajikistan 2012 Empowerment indicator Percentage receiving antenatal care from a skilled provider1 Percentage receiving delivery care from a skilled provider1 Percentage of women with a postnatal checkup in the first two days after birth2 Number of women with a child born in the last five years Number of decisions in which women participate3 0 76.4 96.6 78.6 1,433 1-2 84.4 95.3 83.4 774 3 79.1 97.8 80.6 1,288 Number of reasons for which wife- beating is justified4 0 80.8 97.2 82.5 1,120 1-2 83.8 98.1 89.7 868 3-4 77.7 96.2 77.2 774 5 72.1 95.5 71.4 839 Total 78.8 96.8 80.5 3,601 1 “Skilled provider” includes doctor, nurse, midwife, or feldsher. 2 Includes women who received a postnatal checkup from a doctor, nurse, midwife, feldsher, or traditional birth attendant (TBA) in the first two days after the birth. Includes women who gave birth in a health facility and those who did not give birth in a health facility. 3 Restricted to currently married women. See Table 15.6 for the list of decisions. 4 See Table 15.7 for the list of reasons. Decisionmaking is not related to women’s access to reproductive health care for their most recent birth. For example, the proportion of married women receiving antenatal care from health personnel increases from 76 percent of those who participate in no household decisions to 84 percent of those who participate in one to two decisions, but then falls to 79 percent of women who participate in all three decisions. There are similar zigzag relationships for delivery care and postnatal care. However, attitudes towards wife beating do seem to be associated with women’s access to reproductive health care for their most recent birth. The proportion of women receiving antenatal care from a skilled provider generally decreases with the number of reasons for which women feel wife beating is justified, from 81 to 84 percent of women who believe wife beating is justified for zero to two reasons to 72 percent of those who believe it is justified for all five reasons. There is a similar negative relationship between attitudes towards wife beating and postnatal care. The proportion of women receiving delivery care from a skilled provider is almost uniformly high across the number of reasons for justifying wife beating. Women’s Empowerment and Demographic and Health Outcomes • 229 15.11 INFANT AND CHILD MORTALITY AND WOMEN’S EMPOWERMENT The ability of women to access information, make decisions, and act effectively in their own interests or in the interests of those who depend on them are essential aspects of empowerment. It follows that if women, who are the primary caretakers of children, are empowered, the health and survival of their children would be enhanced. In fact, mother’s empowerment fits into the Mosley-Chen framework on child survival as an intervening individual-level variable that affects child survival through proximate determinants (Mosley and Chen, 1984). Table 15.12 shows that infant, child, and under-5 mortality rates are highest among women who do not participate in any household decisions, although they do not decline uniformly as women’s participation in decision making increases. Similarly, infant mortality and under-5 mortality rates are lowest among women who do not agree with any reason for wife beating and generally tend to rise with women’s agreement with wife beating. For example, among women who do not agree with any reason for wife beating, under-5 mortality is 40 per 1,000 live births, compared with 61 for women who agree with three to four reasons for wife beating. Table 15.12 Early childhood mortality rates by women's status Infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by indicators of women's empowerment, Tajikistan 2012 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Number of decisions in which women participate1 0 44 11 54 1-2 32 9 40 3 36 10 46 Number of reasons for which wife- beating is justified2 0 31 9 40 1-2 38 8 46 3-4 50 11 61 5 37 14 51 1 Restricted to currently married women. See Table 15.6 for the list of decisions. 2 See Table 15.7 for the list of reasons. References • 231 REFERENCES Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], and World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt]. 2011. Afghanistan Mortality Survey 2010. Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO. AIDS Foundation East West (AFEW), 2013. Accessed online 24 March 2013. http://www.afew.org/about- afew/where-we-work/tajikistan/. Analytical and Information Center, Ministry of Health of the Republic of Uzbekistan; State Department of Statistics, Ministry of Macroeconomics and Statistics [Uzbekistan]; and ORC Macro. 2004. Uzbekistan Health Examination Survey 2002. Calverton, Maryland, USA: Analytical and Information Center, State Department of Statistics, and ORC Macro. Black, R. E., L. H. Allen, Z. A. Bhutta, L. E. Caulfied, M. de Onis, M. Ezzati, C. Mathers, and J. Rivera, for the Maternal and Child Undernutrition Study Group. 2008. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet 371:243. doi:10.1016/S0140-6736(07)61690-0. Bradley, Sarah E. K., Trevor N. Croft, Joy D. Fishel, and Charles F. Westoff. 2012. Revising Unmet Need for Family Planning. DHS Analytical Studies No. 25. Calverton, Maryland, USA: ICF International. Central Asia Newswire. 2010. Accessed online on 24 March 2013. http://www.universalnewswires.com/centralasia/viewstory.aspx?id=2246 Cesar, G. V., L. Adair , C. Fall, P. C. Hallal, R. Martorell, L. Richter, H. Singh Sachdev. 2008. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 317(9609): 340-357. Curtis, Glenn E. 1997. Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan: country studies. Federal Research Division, Library of Congress, edited by Glenn E. Curtis. Washington, D.C., U.S. G.P.O. [1997] http://lcweb2.loc.gov/frd/cs/tjtoc.html. Ensink, Jeroen. 2008. Health impact of handwashing with soap. WELL factsheet. Available at http://www.lboro.ac.uk/well/resources/fact-sheets/fact-sheets-htm/Handwashing.htm. Government of the Republic of Tajikistan (GOT). 2008. “The Land Code of the Republic of Tajikistan” As amended by Law No. 498 of December 12,1997; Law No. 746 of May 14, 1999; Law No. 15 of May 12, 2001; Law No. 23 of February 28, 2004; Law No. 199 of July 28, 2006; Law No. 357 of January 5, 2008, Law No. 405 of June 2008. Government of the Republic of Tajikistan (GOT). 2010. The resolution of the Majlisi Namoyadagoni Majlisi Oli (Lower Chamber of Parliament) of the Republic of Tajikistan, Decree No. 1557 of 24 February 2010 about “On Approving Poverty Reduction Strategy of the Republic of Tajikistan for the P eriod of 2010-2012.” Government of the Republic of Tajikistan (GOT) and Ministry of Health (MOH). 2012. UNGASS Country Progress Report on HIV/AIDS Response, Reporting Period of January 2010-December 2011. Dushanbe, Tajikistan: GOT. 232 • References Hausmann, Ricardo, Laura D. Tyson, and Saadia Zahidi. 2012. The Global Gender Gap Report. Geneva. Switzerland: World Economic Forum. Heise, L., J. Pitanguy, and A. Germain. 1994. Violence against Women: The Hdden Health burden. Washington, D.C.: The World Bank. Heise, L. M. Ellsberg, and M. Gottemoeller. 1999. “Ending Violence against Women.” Population Reports, Series L, No. 11. Baltimore, Maryland, USA.: Johns Hopkins University School of Public Health, Population Information Program. International Council for Control of Iodine Deficiency Disorders (ICCIDD), United Nations Children’s Fund (UNICEF), and World Health Organization (WHO). 2001. Assessment of Iodine Deficiency Disorders and Monitoring their Elimination: A Guide for Programme Managers. Geneva, Switzerland: ICCIDD, UNICEF, and WHO. International Monetary Fund (IMF). 2012. Republic of Tajikistan: Poverty Reduction Strategy Paper— Progress Report (Poverty Reduction Strategy of the Republic of Tajikistan for 2010-2012—Annual Progress Report for 2010). IMF Country Report No. 12/33. International Monetary Fund, Washington, D.C. Jejeeboy, S.J. 1998. “Associations between Wife-beating and Fetal and Infant Death: Impressions from a Survey in Eural India.” Studies in Family Planning 29(3): 300-308. Khodjamurodov, G. and B. Rechel. 2010. “Tajikistan: Health System Review.” Health Systems in Transition, 2010, 12(2):1-154 Kish, L. 1965. Survey Sampling. New York: John Wiley and Sons Inc. Krug, E.G., L. Dahlberg, J. Mercy, A. Zwi, and R. Lozano, eds. 2002. World Report on Violence and Health. Geneva, Switzerland: World Health Organization. Luby SP, Agboatwalla M, Feikin DR, et al. 2005. “Effect of Handwashing on Child Health: A Randomised Controlled Trial.” Lancet 2005; 366: 225-233. Ministry of Health of the Republic of Tajikistan (MOH). 2001. The MOH Decree № 136 dated April 10, 2001, “About a partial change and addition to the MOH decree № 484 dated December 7, 1993. About improvement of the system for prevention of controllable infections.” Dushanbe, Tajikistan: MOH. Ministry of Health of the Republic of Tajikistan (MOH). 2008. The MOH Decree № 21 dated January 18, 2008, “About introduction of changes and additions to the MOH decree №136 dated April 10, 2001. About improvement of measures for prevention of vaccine preventable infections,” Dushanbe, Tajikistan: MOH. Ministry of Health of the Republic of Tajikistan (MOH). 2009. The MOH Decree № 184 dated March 28, 2009, “On introduction of changes and additions to the MOH decree №136 dated April 10, 2001. About Improvement of Measures for Prevention of Vaccine perfeveventable infections.” Dushanbe, Tajikistan: MOH. Ministry of Health of the Republic of Tajikistan (MOH), and United Nations Children’s Fund (UNICEF). 2010. Micronutrient Status Survey in Tajikistan 2009. UNICEF, Dushanbe, September 2010. available at untj.org/files/library/Micronutrient_Status_Survey_in_Tajikistan-2009.pdf ] Mosley, W. Henry and Lincoln C. Chen. 1984. “An Analytical Framework for the Study of Child Survival in Developing Countries,” Population and Development Review, Supplement to Vol. 10: 25-45. References • 233 National Institute of Population Studies (NIPS) [Pakistan], and Macro International Inc. 2008. Pakistan Demographic and Health Survey 2006-07. Islamabad, Pakistan: National Institute of Population Studies and Macro International Inc. National Scientific and Applied Center for Preventive Medicine (NCPM) [Moldova] and ORC Macro. 2006. Moldova Demographic and Health Survey 2005. Calverton, Maryland: NCPM and ORC Macro. National Statistical Service (NSS) [Armenia], Ministry of Health (MOH), and ICF International. 2012. Armenia Demographic and Health Survey 2010. Calverton, Maryland: National Statistical Service, Ministry of Health, and ICF International. Naeye R., L. Burt, D. Wright, W. Blanc and D. Tatter. 1971. “Neonatal Mortality, the Male Disadvantage.” Pediatrics 1971; 48:6 902-906 Pan American Health Organization (PAHO), and World Health Organization (WHO). 2003. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, D.C., and Geneva, Switzerland: WHO. Rutstein, S. O., and K. Johnston. 2004. The DHS Wealth Index. DHS Comparative Report No. 6. Calverton, Maryland: ORC Macro. Rutstein, S. O., and G. Rojas. 2006. Guide to DHS Statistics. Calverton, Maryland: ORC Macro. Rutstein, S. 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers. Calverton, Maryland: Macro International. Shemyakina Olga. 2011. The Labor Market, Education and Armed Conflict in Tajikistan. The World Bank Poverty Reduction and Economic Management Network, Gender and Development Unit, July 2011, Policy Research Working Paper 5738. Statistical Agency under the President of the Republic of Tajikistan (SA). 2010. Results of Survey on Infant, Child and Maternal Mortality in the Republic of Tajikistan in 2010. Dushanbe, Tajikistan: SA. Statistical Agency under the President of the Republic of Tajikistan (SA). 2012a. Demographic Yearbook of the Republic of Tajikistan 2011. Dushanbe, Tajikistan: SA. Statistical Agency under the President of the Republic of Tajikistan (SA). 2012b. Labor Market in the Republic of Tajikistan. Dushanbe, Tajikistan: SA. Statistical Agency under President of the Republic of Tajikistan (SA). 2012c. Tajikistan in Figures. Dushanbe, Tajikistan: SA Statistical Agency under the President of the Republic of Tajikistan (SA). 2013a. Health Care in the Republic of Tajikistan 2012. Dushanbe, Tajikistan: SA. Statistical Agency under the President of the Republic of Tajikistan (SA). 2013b. Statistical Yearbook of the Republic of Tajikistan 2012, Dushanbe, Tajikistan State Committee on Statistics (SCS) of the Republic of Tajikistan. 2007. Tajikistan Multiple Indicator Cluster Survey 2005. Final Report. Dushanbe, Tajikistan: SCS. State Statistical Committee (SSC) [Azerbaijan] and Macro International Inc. 2008. Azerbaijan Demographic and Health Survey 2006. Calverton, Maryland, USA: State Statistical Committee and Macro International Inc. 234 • References Strauss, M. A. 1990. Measuring Intra-family Conflict and Violence: “The Conflict Tactics Scale.” In Physical Violence in American Families: Risk Factors and Adaptation to Violence in 8,145 Families. New Brunswick, New Jersey: Transaction Publications. The Joint United Nations Programme on HIV/AIDS (UNAIDS). 2013. Accessed online on 24 March 2013. http://www.unaids.org/en/regionscountries/countries/tajikistan/. Ukrainian Center for Social Reforms (UCSR), State Statistical Committee (SSC) [Ukraine], Ministry of Health (MOH) [Ukraine], and Macro International Inc. 2008. Ukraine Demographic and Health Survey 2007. Calverton, Maryland, USA: UCSR and Macro International. United Nations Children’s Fund (UNICEF). 2000. Unpublished. Multiple Indicator Cluster Survey Tajikistan 2000, draft report. Available at http://www.childinfo.org/files/tajikistan.pdf. United Nations Children’s Fund (UNICEF). 2008. The State of Children and Women in Tajikistan. Comparative Analysis of MICS 2000 and MICS 2005 Results. Tajikistan: UNICEF, United Nations Children’s Fund (UNICEF). 2012. Birth Registration is Critical to Future Interventions. Available at http://www.childinfo.org/birth_registration.html. United Nations Children’s Fund (UNICEF) and World Health Organization (WHO). 2012. Progress on Drinking Water and Sanitation: 2012 Update. New York, New York, USA: UNICEF and WHO. United Nations Development Program (UNDP). 1994. Report of the International Conference on Population and Development. A/CONF.171/13. Electronic version made available by the United Nations Population Information Network (POPIN) Gopher. Population Division, Department for Economic and Social Information and Policy Analysis: UNDP. United Nations Development Program (UNDP). 2013. Human Development Report 2013. New York: UNDP. United Nations General Assembly. 1991. Advancement of Women: Convention on the Elimination of all Forms of Discrimination against Women, Report of the Secretary-General. New York: United Nations. United Nations General Assembly. 2001. United Nations General Assembly Declaration of Commitment on HIV/AIDS A/RES/S-26/2, 2 August 2001. New York, New York: :United Nations. US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: a Report of the Surgeon General. Atlanta, GA: USDHSS. Windham, G. C., A. Eaton, and B. Hopkins. 1999. “Evidence for an Association between Environmental Tobacco Smoke Exposure and Birth Weight: A Meta-analysis and New Data.” Paediatric Perinatal Epidemiology 13:35-37. World Bank. 2005. Tajikistan: Health Sector Note. Washington, DC: The World Bank. Available at https://openknowledge.worldbank.org/handle/10986/8467 License: CC BY 3.0 Unreported. World Bank Group. 2013. Tajikistan Partnership Program Snapshot. World Health Organization (WHO). 2001. Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence against Women. Geneva, Switzerland: Department of Gender and Women’s Health, World Health Organization. References • 235 World Health Organization (WHO). 2005. Guiding Principles for Feeding Nonbreastfed Children 6 to 24 Months of Age. Geneva, Switzerland: WHO. World Health Organization (WHO). 2006a. Fuel for Life, Household Energy and Health. Geneva, Switzerland. World Health Organization (WHO) Multicentre Growth Reference Study Group. 2006b. WHO child growth standards: Length/height-for-age, weight-for-length, weight-for-height and body mass index-for- age: Methods and Development. Geneva, Switzerland: WHO. World Health Organization (WHO). 2007. Standards for Maternal and Neonatal care. Geneva: WHO. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/effective_antenatal_care.pdf World Health Organization (WHO). 2008. Indicators for Assessing Infant and Young Child Feeding Practices: Conclusions of a Consensus Meeting Held 6-8 November 2007 in Washington D.C., USA. Geneva, Switzerland: WHO. World Health Organization (WHO). 2011. NCD Country Profiles: (Tajikistan). 2011. Available at http://www.who.int/nmh/countries/tjk_en.pdf. World Health Organization (WHO). 2012a. Global Tuberculosis Report. 2012. Geneva, Switzerland, World Health Organization (WHO/HTM/TB/2012.6). World Health Organization (WHO). 2012b. Tobacco, Fact Sheet N°339, Geneva, Switzerland: World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs339/en/index.html. World Health Organization, Regional Office for Europe (WHO/EURO). 2012. Tajikistan Tuberculosis Country Work Summary. Copenhagen, Denmark, World Health Organization. World Health Organization, Regional Office for Europe (WHO/EURO). 2013. European Health for All Database (HFA-DB). Available on January 2013 at http://data.euro.who.int/hfadb/ and http://data.euro.who.int/hfadb/tables/tableC.php?w=1280&h=102F World Health Organization (WHO) and UNICEF. 1998. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: WHO and UNICEF. Zaleskis R, Tsogt G, Dadu A et al. 2009. World Health Organization/United Nations Development Programme Review of Tuberculosis Control in the Republic of Tajikistan. Copenhagen, Denmark: World Health Organization, Regional Office for Europe (WHO/EURO). Zimmerman, C. 1994. Plates in a Basket will Rattle: Domestic Violence in Cambodia. Phnom Penh: The Asia Foundation, USAID. Appendix A • 237 SAMPLE DESIGN APPENDIX A A.1 INTRODUCTION he 2012 Tajikistan Demographic and Health Survey (2012 TjDHS) is the first of its kind implemented in Tajikistan. A nationally representative sample of 6,675 households was selected. All women age 15-49 who were usual residents of the selected households or who slept in the households the night before the survey were eligible for the survey. The main objectives of the 2012 TjDHS were to provide up-to-date information on fertility and fertility preferences, awareness and use of family planning methods, maternal and child health and childhood mortality levels, and knowledge and attitudes toward HIV/AIDS and other sexually transmitted infections (STIs). The survey was designed to produce representative results for the country as a whole, for urban and rural areas separately, and for each of the five administrative regions. A.2 SAMPLE FRAME The sampling frame used for the 2012 TjDHS is the 2010 Tajikistan Population and Housing Census (TjPHC) conducted by the Statistical Agency under the President of the Republic of Tajikistan. The sampling frame for the urban areas is a list of enumeration areas (EAs) covering all urban areas of the country. An EA is a geographical area, usually a city block, consisting of an adequate number of households; each EA serves as a counting unit for the population census. Each EA has a sketch map delineating its boundaries, with identification information and a measure of size, which is the number of residential households enumerated in the 2010 TjPHC. However, such materials do not exist for the rural areas. The Statistical Agency collected a list of natural villages through its regional offices in 2010, with estimated population in each village. The list of EAs in the urban areas and the list of natural villages in the rural areas constituted the sampling frame for the 2012 TjDHS, with the primary sampling units (PSUs) being EAs in urban areas and natural villages in rural areas. Table A.1 below shows the distribution of households in the sampling frame by region and by type of residence. In Tajikistan, the region size varies from 3 percent for the region of Gorno-Badakhshan Autonomous Oblast (GBAO) to 33 percent for the region of Sughd; 33 percent of the households reside in urban areas. Table A.1 Households Distribution of households by region and by residence, Tajikistan 2012 Region Number of households in frame* Percentage of households that are urban Percent distribution of households across regions Urban Rural Total GBAO1 5,111 25,851 30,962 16.5 2.7 Dushanbe 138,588 na 138,588 100.0 12.2 DRS2 40,731 196,014 236,745 17.2 20.9 Sughd 110,001 259,882 369,883 29.7 32.7 Khatlon 75,344 281,242 356,586 21.1 31.5 Tajikistan 369,775 762,989 1,132,764 32.6 100.0 na = Not applicable *Source: The 2012 Tajikistan DHS sampling frame. 1 The Gorno-Badakhshan Autonomous Oblast region. 2 Districts of Republican Subordination. T 238 • Appendix A A.3 SAMPLING PROCEDURES AND SAMPLE ALLOCATION The sample for the 2012 TjDHS was a stratified sample selected in two stages. In the first stage, 356 primary sampling units (PSU) were selected with a stratified probability proportional to size selection from the sampling frame. The PSU size was the number of households residing in the PSU recorded at the 2010 census. Stratification was achieved by separating every region into urban and rural areas. Therefore, the five regions were stratified into nine sampling strata, consisting of five urban strata and four rural strata (the region of Dushanbe has only urban areas). Samples were selected independently in every stratum, with a predetermined number of PSUs to be selected as shown in Table A.2. Implicit stratification with proportional allocation should have been achieved at each of the lower administrative unit levels by sorting the sampling frame within a sampling stratum according to administrative unit before the sample selection, and by using a probability proportional to size selection procedure. After the selection of PSUs and before the main survey, a household listing operation was carried out in all of the selected PSUs. The resulting lists of households served as the sampling frame for the selection of households in the second stage. In the second stage of selection, 15 households per cluster were selected in every urban cluster, except in the region of Dushanbe, by an equal probability systematic sampling. In the region of Dushanbe and in all the rural clusters, 20 households per cluster were selected by equal probability systematic sampling. A spreadsheet indicating the selected household numbers for each cluster was prepared for facilitating the household selection in the central office. The survey interviewers were asked to interview only the pre-selected households. No replacements and no changes of the pre-selected households were allowed in the implementing stages in order to prevent bias. Table A.2 below shows the sample allocation of PSUs and households by region and by type of residence. Among the 356 clusters selected, 164 are in urban areas and 192 are in rural areas. Among the 6,675 selected households, 2,835 are from urban areas and 3,840 are from rural areas. Table A.2 Sample allocation of clusters and households Sample allocation of clusters and households by region, according to residence, Tajikistan 2012 Region Sample allocation of clusters Sample allocation of households Urban Rural Total Urban Rural Total GBAO 9 33 42 135 660 795 Dushanbe 75 0 75 1,500 0 1,500 DRS 17 62 79 255 1240 1,495 Sughd 29 51 80 435 1020 1,455 Khatlon 34 46 80 510 920 1,430 Tajikistan 164 192 356 2,835 3,840 6,675 A.4 SAMPLE PROBABILITIES AND SAMPLING WEIGHTS Due to the non-proportional allocation of the sample to the different regions and the differences in response rates, analysis of the 2012 TjDHS data requires the data to be weighted to ensure the actual representation of the survey results at the national level as well as at the regional level. Since the 2012 TjDHS sample is a two-stage stratified cluster sample, sampling weights were calculated based on sampling probabilities for each sampling stage and for each cluster. We use the following notations: P1hi: first stage’s sampling probability of the ith cluster in stratum h P2hi: second-stage’s sampling probability within the ith cluster (households) Phi: overall sampling probability of any household of the ith cluster in stratum h Appendix A • 239 Let nh be the number of clusters selected in stratum h, Mhi the number of households according to the sampling frame in the ith cluster, and  hiM the total number of households in the stratum h. The probability of selecting the ith cluster in stratum h is calculated as follows: M M nP hi hih hi =1 Let hiL be the number of households listed in the household listing operation in cluster i in stratum h, let him be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster is calculated as follows: hi hi hi L mP =2 The overall selection probability of each household in cluster i of stratum h is therefore the product of the selection probabilities: hihihi PPP 21 ×= Therefore, the design weight for each household in cluster i of stratum h is the inverse of its overall selection probability: hihi PW /1= A spreadsheet containing all sampling parameters and selection probabilities was prepared to facilitate the calculation of the design weights. Design weights were adjusted for household non-response as well as for individual non-response to get the sampling weights for households and women surveyed, respectively. The differences in the household sampling weights and the individual sampling weights are introduced by individual nonresponse. Finally, the household and individual sampling weights were normalized to give the total number of un-weighted cases equal to the total number of weighted cases at the national level, for both households and individuals. The normalized weights are relative weights, which are valid for estimating means, proportions, and ratios but not valid for estimating population totals and for pooled data. A.5 SURVEY RESULTS Table A.3 shows the survey implementation results by giving the number of households selected and interviewed, women eligible and interviewed, and the various response rates. According to the definition of each category, the completion rates for the household survey and the woman’s survey are based on the following formula. The household completion rate is calculated by: 100 * C _______________________________ C + HP + R + DNF The eligible women completion rate (EWC) is equivalent to the percentage of interviews completed over total eligible women calculated by: 100 * EWC _____________________________________________________ EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 240 • Appendix A Table A.3 Sample implementation: Women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall women response rates, according to urban-rural residence and region (unweighted), Tajikistan 2012 Result Residence Region Total Urban Rural Dushanbe GBAO Sughd DRS Khatlon Selected households Completed (C) 94.4 97.9 94.8 95.8 98.6 96.1 96.3 96.4 Household present but no competent respondent at home (HP) 1.3 0.5 1.5 1.9 0.1 0.7 0.4 0.9 Refused (R) 0.7 0.0 0.9 0.0 0.0 0.2 0.2 0.3 Dwelling not found (DNF) 0.0 0.1 0.0 0.0 0.0 0.2 0.0 0.0 Household absent (HA) 3.0 1.3 2.3 1.6 1.2 2.1 2.5 2.0 Dwelling vacant/address not a dwelling (DV) 0.6 0.2 0.3 0.5 0.0 0.5 0.5 0.4 Dwelling destroyed (DD) 0.0 0.1 0.0 0.0 0.0 0.1 0.1 0.0 Other (O) 0.1 0.0 0.1 0.1 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 2,835 3,839 1,500 795 1,450 1,499 1,430 6,674 Household response rate (HRR)1 97.9 99.4 97.5 98.1 99.9 98.8 99.4 98.8 Eligible women Completed (EWC) 99.0 98.4 99.0 95.6 99.7 97.9 99.4 98.6 Not at home (EWNH) 0.7 1.0 0.9 3.1 0.1 1.3 0.1 0.9 Postponed (EWP) 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Refused (EWR) 0.1 0.1 0.0 0.3 0.0 0.2 0.0 0.1 Partly completed (EWPC) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Incapacitated (EWI) 0.2 0.5 0.2 0.8 0.2 0.5 0.4 0.4 Other (EWO) 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 3,443 6,351 1,751 1,118 2,090 2,384 2,451 9,794 Eligible women response rate (EWRR)2 99.0 98.4 99.0 95.6 99.7 97.9 99.4 98.6 Overall women response rate (OWRR)3 96.9 97.8 96.5 93.8 99.6 96.8 98.7 97.4 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C _______________________________ C + HP + R + DNF 2 The eligible women response rate (EWRR) is equivalent to the percentage of interviews completed (EWC). 3 The overall women response rate (OWRR) is calculated as: OWRR = HRR * EWRR/100 Appendix B • 241 ESTIMATES OF SAMPLING ERRORS APPENDIX B he estimates from a sample survey are affected by two types of errors: (1) non-sampling errors and (2) sampling errors. Non-sampling errors are the results from mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2012 Tajikistan Demographic and Health Survey (TjDHS 2012) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the TjDHS 2012 is only one of many samples that could have been selected from the same population, using the same design and identical size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability among all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the TjDHS 2012 sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulas. The computer software used to calculate sampling errors for the TjDHS 2012 was a SAS program. This program uses the Taylor linearization method for variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ( )  = =         − − −== H h h h m i hi h h h m zz m mf x rvarrSE h 1 2 1 2 2 2 1 11)()( in which hihihi rxyz −= , and hhh rxyz −= T 242 • Appendix B where h represents the stratum, which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and fh is the sampling fraction of PSU in the hth stratum, which is small and ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulas. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the TjDHS 2012, there were 356 non-empty clusters. Hence, 356 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − − =  in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 356 clusters, r(i) is the estimate computed from the reduced sample of 355 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, the program computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design, such as multistage and cluster selection. The program also computes the relative standard error and the confidence limits for the estimates. Sampling errors for the TjDHS 2012 are calculated for selected variables considered to be of primary interest for the survey. The results are presented in this appendix for the country as a whole, for urban and rural areas separately, and for each of the five regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 through B.9 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering a simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to childbearing. The confidence interval (e.g., as calculated for children ever born to women age 40-49) can be interpreted as follows: the overall average from the national sample is 4.543, and its standard error is 0.073. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 4.543±2×0.073. There is a high probability (95 percent) that the true average number of children ever born to all women age 40-49 is between 4.398 and 4.688. For the total sample, the value of the design effect (DEFT), averaged over all variables for the women’s survey, is 1.51, which means that, due to multi-stage and clustering of the sample, the average standard error is increased by a factor of 1.51 over that in an equivalent simple random sample. Appendix B • 243 Table B.1 List of selected variables for sampling errors, Tajikistan DHS 2012 Variable Estimate Base population WOMEN Urban residence Proportion All women age 15-49 No education/primary Proportion All women age 15-49 Secondary education or higher Proportion All women age 15-49 Never married (never in union) Proportion All women age 15-49 Currently married (in union) Proportion All women age 15-49 Married before age 20 Proportion All women age 25-49 Had sexual intercourse before age 18 Proportion All women age 25-49 Currently pregnant Proportion All women age 15-49 Children ever born Mean All women age 15-49 Children surviving Mean All women age 15-49 Children ever born to women age 40-49 Mean All women age 40-49 Know any contraceptive method Proportion Currently married women 15-49 Know a modern method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently using a traditional method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using IUD Proportion Currently married women 15-49 Currently using condoms Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using female sterilization Proportion Currently married women 15-49 Currently using rhythm Proportion Currently married women 15-49 Currently using withdrawal Proportion Currently married women 15-49 Used public sector source Proportion Currently married women 15-49 Want no more children Proportion Currently married women 15-49 Want to delay next birth at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean All women age 15-49 Mothers received antenatal care for last birth Proportion Women with a live birth in the last 5 years Births with skilled attendant at delivery Proportion Births occurring 1-59 months before survey Had diarrhea in the past 2 weeks Proportion Children under age 5 Treated with ORS Proportion Children under age 5 with diarrhea in past 2 weeks Sought medical treatment for diarrhea Proportion Children under age 5 with diarrhea in past 2 weeks Vaccination card seen Proportion Children age 18-29 months Received BCG vaccination Proportion Children age 18-29 months Received DPT vaccination (3 doses) Proportion Children age 18-29 months Received polio vaccination (3 doses) Proportion Children age 18-29 months Received measles vaccination Proportion Children age 18-29 months Received all vaccinations Proportion Children age 18-29 months Height-for-age (-2SD) Proportion Children under age 5 who are measured Weight-for-height (-2SD) Proportion Children under age 5 who are measured Weight-for-age (-2SD) Proportion Children under age 5 who are measured Body Mass Index (BMI) <18.5 Proportion All women age 15-49 who are measured Had an HIV test and received results in past 12 months Proportion All women age 15-49 Accepting attitudes towards people with HIV Proportion All women age 15-49 who have heard of HIV/AIDS Has heard of HIV/AIDS Proportion All women age 15-49 Know about condoms Proportion All women age 15-49 Know about limiting partners Proportion All women age 15-49 Experienced physical violence since age 15 by anyone Proportion All women age 15-49 Ever experienced any sexual violence Proportion All women age 15-49 Experienced physical or sexual violence by any husband/partner Proportion All ever married women age 15-49 Experienced physical or sexual violence in the last 12 months by any husband/partner Proportion All ever married women age 15-49 Total abortion rate (3 years) Rate Women-years of exposure to childbearing Total fertility rate (3 years) Rate Women-years of exposure to childbearing Neonatal mortality rate1 Rate Children exposed to the risk of mortality Post-neonatal mortality rate1 Rate Children exposed to the risk of mortality Infant mortality rate1 Rate Children exposed to the risk of mortality Child mortality rate1 Rate Children exposed to the risk of mortality Under -five mortality rate1 Rate Children exposed to the risk of mortality 1 The mortality rates are calculated for 5 years and 10 years before the survey for the national sample and regional samples, respectively. 244 • Appendix B Table B.2 Sampling errors: National sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.250 0.007 9,656 9,656 1.572 0.028 0.236 0.264 No education/primary 0.059 0.006 9,656 9,656 2.651 0.108 0.046 0.071 Secondary or higher education 0.941 0.006 9,656 9,656 2.651 0.007 0.929 0.954 Never married (never in union) 0.274 0.006 9,656 9,656 1.273 0.021 0.263 0.286 Currently married (in union) 0.674 0.006 9,656 9,656 1.228 0.009 0.662 0.685 Married before age 20 0.471 0.011 5,755 5,693 1.599 0.022 0.450 0.492 Had sexual intercourse before age 18 0.147 0.007 5,755 5,693 1.503 0.048 0.133 0.161 Currently pregnant 0.076 0.003 9,656 9,656 1.127 0.040 0.070 0.082 Children ever born 2.122 0.028 9,656 9,656 1.274 0.013 2.066 2.179 Children surviving 1.973 0.024 9,656 9,656 1.202 0.012 1.925 2.022 Children ever born to women age 40-49 4.543 0.073 1,932 1,866 1.493 0.016 4.398 4.688 Know any contraceptive method 0.951 0.005 6,388 6,504 1.795 0.005 0.942 0.961 Know a modern method 0.950 0.005 6,388 6,504 1.795 0.005 0.941 0.960 Currently using any method 0.279 0.008 6,388 6,504 1.439 0.029 0.263 0.295 Currently using a modern method 0.258 0.008 6,388 6,504 1.470 0.031 0.242 0.275 Currently using a traditional method 0.021 0.002 6,388 6,504 1.366 0.117 0.016 0.026 Currently using pill 0.023 0.002 6,388 6,504 1.234 0.101 0.018 0.028 Currently using IUD 0.185 0.007 6,388 6,504 1.404 0.037 0.172 0.199 Currently using condoms 0.022 0.002 6,388 6,504 1.114 0.092 0.018 0.027 Currently using injectables 0.020 0.003 6,388 6,504 1.572 0.138 0.014 0.025 Currently using female sterilization 0.006 0.001 6,388 6,504 1.150 0.187 0.004 0.008 Currently using rhythm 0.001 0.000 6,388 6,504 1.036 0.375 0.000 0.002 Currently using withdrawal 0.019 0.002 6,388 6,504 1.348 0.120 0.015 0.024 Used public sector source 0.884 0.009 1,725 1,686 1.205 0.011 0.865 0.902 Want no more children 0.440 0.009 6,388 6,504 1.449 0.020 0.422 0.458 Want to delay birth at least 2 years 0.189 0.006 6,388 6,504 1.132 0.029 0.178 0.200 Ideal number of children 3.573 0.024 9,368 9,336 1.565 0.007 3.525 3.620 Mothers received antenatal care for last birth 0.788 0.013 3,482 3,601 1.944 0.017 0.761 0.815 Births with skilled attendant at delivery 0.874 0.012 5,013 5,233 2.202 0.014 0.849 0.898 Had diarrhea in the past 2 weeks 0.151 0.007 4,838 5,031 1.340 0.049 0.136 0.165 Treated with ORS 0.603 0.026 723 757 1.311 0.042 0.552 0.654 Sought medical treatment for diarrhea 0.537 0.027 723 757 1.333 0.049 0.484 0.590 Vaccination card seen 0.910 0.010 1,092 1,148 1.174 0.011 0.890 0.930 Received BCG vaccination 0.983 0.004 1,092 1,148 1.166 0.005 0.974 0.992 Received DPT vaccination (3 doses) 0.931 0.011 1,092 1,148 1.484 0.012 0.908 0.953 Received polio vaccination (3 doses) 0.923 0.009 1,092 1,148 1.174 0.010 0.904 0.941 Received measles vaccination 0.952 0.010 1,092 1,148 1.647 0.011 0.932 0.973 Received all vaccinations 0.887 0.014 1,092 1,148 1.472 0.016 0.860 0.915 Height-for-age (-2SD) 0.262 0.009 4,664 5,080 1.378 0.035 0.243 0.280 Weight-for-height (-2SD) 0.099 0.006 4,664 5,080 1.306 0.058 0.088 0.111 Weight-for-age (-2SD) 0.121 0.007 4,664 5,080 1.360 0.056 0.108 0.135 Body Mass Index (BMI) <18.5 0.106 0.005 8,832 8,800 1.423 0.044 0.097 0.116 Had an HIV test and received results in past 12 months 0.050 0.003 9,656 9,656 1.392 0.062 0.044 0.056 Accepting attitudes towards people with HIV 0.058 0.006 6,068 5,943 1.939 0.100 0.046 0.070 Has heard about HIV/AIDS 0.616 0.013 9,656 9,656 2.706 0.022 0.589 0.642 Know about condoms 0.364 0.013 9,656 9,656 2.685 0.036 0.338 0.390 Know about limiting partners 0.430 0.013 9,656 9,656 2.630 0.031 0.404 0.457 Experienced physical violence since age 15 by anyone 0.188 0.008 5,547 5,547 1.612 0.045 0.171 0.205 Ever experienced any sexual violence 0.037 0.004 5,547 5,547 1.409 0.096 0.030 0.045 Experienced physical or sexual violence by any husband/partner 0.212 0.010 4,405 4,093 1.591 0.046 0.192 0.231 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.152 0.008 4,405 4,093 1.519 0.054 0.136 0.169 Total abortion rate (3 years) 0.472 0.035 27,205 27,208 1.186 0.075 0.402 0.543 Total fertility rate (3 years) 3.756 0.086 27,205 27,208 1.299 0.023 3.585 3.928 Neonatal mortality rate (0-4 years) 19.455 2.479 5,070 5,286 1.198 0.127 14.498 24.413 Post-neonatal mortality rate (0-4 years) 15.042 2.085 5,068 5,288 1.161 0.139 10.871 19.212 Infant mortality rate (0-4 years) 34.497 3.147 5,073 5,289 1.161 0.091 28.202 40.792 Child mortality rate (0-4 years) 9.194 1.882 4,743 4,924 1.329 0.205 5.431 12.957 Under-five mortality rate (0-4 years) 43.374 3.703 5,085 5,301 1.180 0.085 35.968 50.780 Appendix B • 245 Table B.3 Sampling errors: Urban sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 1.000 0.000 3,408 2,413 na 0.000 1.000 1.000 No education/primary 0.034 0.004 3,408 2,413 1.344 0.123 0.025 0.042 Secondary or higher education 0.966 0.004 3,408 2,413 1.344 0.004 0.958 0.975 Never married (never in union) 0.270 0.009 3,408 2,413 1.229 0.035 0.251 0.288 Currently married (in union) 0.651 0.010 3,408 2,413 1.226 0.015 0.631 0.671 Married before age 20 0.432 0.013 2,105 1,488 1.186 0.030 0.406 0.457 Had sexual intercourse before age 18 0.137 0.010 2,105 1,488 1.289 0.071 0.118 0.156 Currently pregnant 0.063 0.005 3,408 2,413 1.298 0.086 0.052 0.074 Children ever born 1.980 0.035 3,408 2,413 1.060 0.018 1.910 2.050 Children surviving 1.862 0.031 3,408 2,413 1.041 0.017 1.799 1.925 Children ever born to women age 40-49 3.797 0.082 771 543 1.241 0.022 3.634 3.961 Knows any contraceptive method 0.964 0.005 2,178 1,571 1.182 0.005 0.954 0.973 Know a modern method 0.963 0.005 2,178 1,571 1.155 0.005 0.954 0.972 Currently using any method 0.315 0.013 2,178 1,571 1.324 0.042 0.289 0.342 Currently using a modern method 0.290 0.013 2,178 1,571 1.350 0.045 0.264 0.316 Currently using a traditional method 0.025 0.004 2,178 1,571 1.205 0.160 0.017 0.033 Currently using pill 0.033 0.005 2,178 1,571 1.245 0.143 0.024 0.043 Currently using IUD 0.205 0.011 2,178 1,571 1.262 0.053 0.183 0.227 Currently using condoms 0.032 0.004 2,178 1,571 1.077 0.127 0.024 0.040 Currently using injectables 0.011 0.003 2,178 1,571 1.246 0.255 0.005 0.016 Currently using female sterilization 0.006 0.002 2,178 1,571 1.081 0.288 0.003 0.010 Currently using rhythm 0.002 0.001 2,178 1,571 1.057 0.470 0.000 0.004 Currently using withdrawal 0.021 0.004 2,178 1,571 1.219 0.177 0.014 0.029 Used public sector source 0.838 0.017 647 463 1.151 0.020 0.805 0.871 Want no more children 0.427 0.014 2,178 1,571 1.351 0.034 0.398 0.456 Want to delay birth at least 2 years 0.180 0.011 2,178 1,571 1.281 0.059 0.159 0.201 Ideal number of children 3.403 0.035 3,302 2,339 1.490 0.010 3.333 3.473 Mothers received antenatal care for last birth 0.827 0.016 1,112 802 1.428 0.020 0.794 0.859 Births with skilled attendant at delivery 0.934 0.011 1,543 1,119 1.563 0.012 0.911 0.957 Had diarrhea in the past 2 weeks 0.179 0.013 1,502 1,086 1.197 0.072 0.154 0.205 Treated with ORS 0.578 0.036 278 194 1.101 0.063 0.505 0.650 Sought medical treatment for diarrhea 0.502 0.036 278 194 1.073 0.072 0.430 0.575 Vaccination card seen 0.889 0.020 328 230 1.153 0.023 0.849 0.930 Received BCG vaccination 0.985 0.009 328 230 1.336 0.009 0.967 1.003 Received DPT vaccination (3 doses) 0.918 0.017 328 230 1.078 0.018 0.885 0.952 Received polio vaccination (3 doses) 0.912 0.017 328 230 1.085 0.019 0.877 0.946 Received measles vaccination 0.937 0.017 328 230 1.257 0.018 0.903 0.971 Received all vaccinations 0.877 0.019 328 230 1.057 0.022 0.838 0.916 Height-for-age (-2SD) 0.214 0.015 1,421 1,092 1.316 0.070 0.184 0.245 Weight-for-height (-2SD) 0.099 0.010 1,421 1,092 1.226 0.099 0.080 0.119 Weight-for-age (-2SD) 0.107 0.011 1,421 1,092 1.255 0.098 0.086 0.128 Body Mass Index (BMI) <18.5 0.102 0.007 3,160 2,233 1.350 0.071 0.087 0.116 Had an HIV test and received results in past 12 months 0.078 0.006 3,408 2,413 1.241 0.073 0.067 0.089 Accepting attitudes towards people with HIV 0.060 0.009 2,402 1,740 1.841 0.149 0.042 0.078 Has heard about HIV/AIDS 0.721 0.017 3,408 2,413 2.153 0.023 0.688 0.754 Know about condoms 0.421 0.017 3,408 2,413 1.963 0.039 0.388 0.454 Know about limiting partners 0.497 0.019 3,408 2,413 2.217 0.038 0.459 0.535 Experienced physical violence since age 15 by anyone 0.208 0.014 2,171 1,399 1.578 0.066 0.180 0.235 Ever experienced any sexual violence 0.034 0.006 2,171 1,399 1.468 0.169 0.022 0.045 Experienced physical or sexual violence by any husband/partner 0.229 0.015 1,723 1,023 1.494 0.066 0.199 0.260 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.164 0.012 1,723 1,023 1.371 0.075 0.140 0.189 Total abortion rate (3 years) 0.579 0.056 9,620 6,813 1.057 0.097 0.466 0.691 Total fertility rate (3 years) 3.274 0.113 9,620 6,813 1.244 0.034 3.048 3.500 Neonatal mortality rate (0-9 years) 17.621 2.821 2,945 2,105 1.041 0.160 11.979 23.264 Post-neonatal mortality rate (0-9 years) 17.239 2.615 2,944 2,105 0.952 0.152 12.009 22.469 Infant mortality rate (0-9 years) 34.860 3.941 2,948 2,108 0.951 0.113 26.978 42.743 Child mortality rate (0-9 years) 7.786 1.858 2,906 2,061 1.102 0.239 4.070 11.502 Under-five mortality rate (0-9 years) 42.375 4.496 2,950 2,111 0.986 0.106 33.384 51.367 na = Not applicable 246 • Appendix B Table B.4 Sampling errors: Rural sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.000 0.000 6,248 7,243 na na 0.000 0.000 No education/primary 0.067 0.008 6,248 7,243 2.635 0.124 0.050 0.084 Secondary or higher education 0.933 0.008 6,248 7,243 2.635 0.009 0.916 0.950 Never married (never in union) 0.276 0.007 6,248 7,243 1.246 0.026 0.262 0.290 Currently married (in union) 0.681 0.007 6,248 7,243 1.202 0.010 0.667 0.695 Married before age 20 0.485 0.014 3,650 4,205 1.643 0.028 0.458 0.512 Had sexual intercourse before age 18 0.150 0.009 3,650 4,205 1.501 0.059 0.132 0.168 Currently pregnant 0.080 0.004 6,248 7,243 1.057 0.045 0.073 0.088 Children ever born 2.170 0.036 6,248 7,243 1.260 0.017 2.098 2.242 Children surviving 2.011 0.031 6,248 7,243 1.184 0.015 1.949 2.072 Children ever born to women age 40-49 4.850 0.095 1,161 1,323 1.481 0.020 4.660 5.039 Know any contraceptive method 0.948 0.006 4,210 4,933 1.795 0.007 0.935 0.960 Know a modern method 0.946 0.006 4,210 4,933 1.798 0.007 0.934 0.959 Currently using any method 0.268 0.010 4,210 4,933 1.428 0.036 0.248 0.287 Currently using a modern method 0.248 0.010 4,210 4,933 1.462 0.039 0.229 0.268 Currently using a traditional method 0.019 0.003 4,210 4,933 1.384 0.152 0.014 0.025 Currently using pill 0.020 0.003 4,210 4,933 1.237 0.135 0.014 0.025 Currently using IUD 0.179 0.008 4,210 4,933 1.401 0.046 0.163 0.196 Currently using condoms 0.019 0.002 4,210 4,933 1.126 0.123 0.015 0.024 Currently using injectables 0.023 0.004 4,210 4,933 1.527 0.155 0.016 0.030 Currently using female sterilization 0.006 0.001 4,210 4,933 1.142 0.232 0.003 0.008 Currently using rhythm 0.001 0.000 4,210 4,933 1.071 0.570 0.000 0.002 Currently using withdrawal 0.019 0.003 4,210 4,933 1.348 0.151 0.013 0.024 Used public sector source 0.901 0.011 1,078 1,223 1.218 0.012 0.879 0.923 Want no more children 0.445 0.011 4,210 4,933 1.430 0.025 0.423 0.466 Want to delay birth at least 2 years 0.192 0.007 4,210 4,933 1.072 0.034 0.179 0.205 Ideal number of children 3.629 0.029 6,066 6,997 1.526 0.008 3.571 3.687 Mothers received antenatal care for last birth 0.777 0.016 2,370 2,799 1.933 0.021 0.744 0.810 Births with skilled attendant at delivery 0.857 0.015 3,470 4,114 2.131 0.018 0.826 0.888 Had diarrhea in the past 2 weeks 0.143 0.009 3,336 3,945 1.333 0.061 0.125 0.160 Treated with ORS 0.612 0.032 445 563 1.319 0.052 0.548 0.675 Sought medical treatment for diarrhea 0.549 0.033 445 563 1.354 0.061 0.482 0.616 Vaccination card seen 0.915 0.011 764 918 1.140 0.012 0.892 0.938 Received BCG vaccination 0.982 0.005 764 918 1.090 0.005 0.972 0.992 Received DPT vaccination (3 doses) 0.934 0.013 764 918 1.502 0.014 0.907 0.961 Received polio vaccination (3 doses) 0.926 0.011 764 918 1.149 0.012 0.904 0.947 Received measles vaccination 0.956 0.012 764 918 1.678 0.013 0.931 0.981 Received all vaccinations 0.890 0.017 764 918 1.481 0.019 0.857 0.923 Height-for-age (-2SD) 0.274 0.011 3,243 3,988 1.312 0.040 0.253 0.296 Weight-for-height (-2SD) 0.099 0.007 3,243 3,988 1.251 0.069 0.086 0.113 Weight-for-age (-2SD) 0.125 0.008 3,243 3,988 1.296 0.065 0.109 0.142 Body Mass Index (BMI) <18.5 0.108 0.006 5,672 6,567 1.397 0.053 0.096 0.119 Had an HIV test and received results in past 12 months 0.040 0.004 6,248 7,243 1.450 0.089 0.033 0.048 Accepting attitudes towards people with HIV 0.057 0.007 3,666 4,204 1.919 0.129 0.043 0.072 Has heard about HIV/AIDS 0.580 0.017 6,248 7,243 2.723 0.029 0.546 0.614 Know about condoms 0.345 0.017 6,248 7,243 2.769 0.048 0.312 0.378 Know about limiting partners 0.408 0.017 6,248 7,243 2.655 0.041 0.375 0.441 Experienced physical violence since age 15 by anyone 0.181 0.010 3,376 4,148 1.558 0.057 0.161 0.202 Ever experienced any sexual violence 0.039 0.004 3,376 4,148 1.325 0.114 0.030 0.048 Experienced physical or sexual violence by any husband/partner 0.206 0.012 2,682 3,070 1.546 0.059 0.182 0.230 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.148 0.010 2,682 3,070 1.485 0.069 0.128 0.169 Total abortion rate (3 years) 0.438 0.044 17,585 20,396 1.201 0.099 0.351 0.525 Total fertility rate (3 years) 3.920 0.107 17,585 20,396 1.272 0.027 3.707 4.134 Neonatal mortality rate (0-9 years) 20.325 2.252 6,234 7,462 1.109 0.111 15.822 24.829 Post-neonatal mortality rate (0-9 years) 19.083 2.323 6,226 7,459 1.261 0.122 14.438 23.729 Infant mortality rate (0-9 years) 39.408 3.140 6,242 7,473 1.125 0.080 33.129 45.688 Child mortality rate (0-9 years) 11.018 1.868 5,920 7,109 1.334 0.170 7.283 14.754 Under-five mortality rate (0-9 years) 49.992 4.029 6,257 7,490 1.243 0.081 41.935 58.050 na = Not applicable Appendix B • 247 Table B.5 Sampling errors: Dushanbe sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 1.000 0.000 1,733 881 na 0.000 1.000 1.000 No education/primary 0.047 0.008 1,733 881 1.595 0.173 0.030 0.063 Secondary or higher education 0.953 0.008 1,733 881 1.595 0.008 0.937 0.970 Never married (never in union) 0.281 0.012 1,733 881 1.078 0.041 0.258 0.304 Currently married (in union) 0.635 0.014 1,733 881 1.204 0.022 0.607 0.663 Married before age 20 0.444 0.017 1,085 554 1.105 0.038 0.411 0.477 Had sexual intercourse before age 18 0.165 0.013 1,085 554 1.162 0.079 0.139 0.192 Currently pregnant 0.055 0.005 1,733 881 0.983 0.098 0.044 0.066 Children ever born 1.977 0.046 1,733 881 1.000 0.023 1.885 2.070 Children surviving 1.879 0.043 1,733 881 0.983 0.023 1.794 1.965 Children ever born to women age 40-49 3.628 0.110 388 196 1.147 0.030 3.409 3.848 Know any contraceptive method 0.933 0.010 1,098 559 1.298 0.011 0.913 0.952 Know a modern method 0.930 0.009 1,098 559 1.228 0.010 0.911 0.949 Currently using any method 0.317 0.016 1,098 559 1.161 0.051 0.285 0.350 Currently using a modern method 0.287 0.016 1,098 559 1.174 0.056 0.255 0.320 Currently using a traditional method 0.030 0.006 1,098 559 1.130 0.194 0.018 0.041 Currently using pill 0.027 0.005 1,098 559 1.052 0.191 0.017 0.037 Currently using IUD 0.196 0.014 1,098 559 1.199 0.073 0.167 0.225 Currently using condoms 0.052 0.007 1,098 559 1.106 0.142 0.037 0.067 Currently using injectables 0.001 0.001 1,098 559 0.980 1.008 0.000 0.003 Currently using female sterilization 0.005 0.002 1,098 559 0.852 0.352 0.002 0.009 Currently using rhythm 0.005 0.003 1,098 559 1.229 0.529 0.000 0.010 Currently using withdrawal 0.020 0.005 1,098 559 1.062 0.223 0.011 0.029 Used public sector source 0.796 0.026 323 163 1.170 0.033 0.743 0.848 Want no more children 0.396 0.022 1,098 559 1.463 0.055 0.353 0.439 Want to delay birth at least 2 years 0.132 0.015 1,098 559 1.468 0.114 0.102 0.162 Ideal number of children 3.444 0.040 1,674 851 1.285 0.012 3.365 3.523 Mothers received antenatal care for last birth 0.808 0.026 570 295 1.565 0.032 0.757 0.859 Births with skilled attendant at delivery 0.956 0.010 795 414 1.196 0.010 0.937 0.975 Had diarrhea in the past 2 weeks 0.174 0.019 780 404 1.278 0.107 0.137 0.211 Treated with ORS 0.569 0.043 140 70 0.972 0.076 0.482 0.655 Sought medical treatment for diarrhea 0.465 0.044 140 70 0.974 0.094 0.377 0.553 Vaccination card seen 0.836 0.027 183 90 0.975 0.032 0.782 0.891 Received BCG vaccination 0.976 0.018 183 90 1.613 0.019 0.940 1.013 Received DPT vaccination (3 doses) 0.869 0.028 183 90 1.094 0.032 0.813 0.924 Received polio vaccination (3 doses) 0.867 0.029 183 90 1.141 0.034 0.808 0.925 Received measles vaccination 0.933 0.022 183 90 1.173 0.024 0.889 0.977 Received all vaccinations 0.830 0.031 183 90 1.110 0.038 0.767 0.893 Height-for-age (-2SD) 0.189 0.018 722 392 1.163 0.098 0.152 0.226 Weight-for-height (-2SD) 0.103 0.014 722 392 1.239 0.137 0.075 0.131 Weight-for-age (-2SD) 0.093 0.011 722 392 1.081 0.123 0.070 0.116 Body Mass Index (BMI) <18.5 0.096 0.007 1,612 820 1.017 0.078 0.081 0.111 Had an HIV test and received results in past 12 months 0.080 0.008 1,733 881 1.193 0.098 0.064 0.095 Accepting attitudes towards people with HIV 0.041 0.006 1,140 567 1.096 0.158 0.028 0.053 Has heard about HIV/AIDS 0.644 0.029 1,733 881 2.550 0.046 0.585 0.703 Know about condoms 0.373 0.023 1,733 881 2.020 0.063 0.326 0.420 Know about limiting partners 0.431 0.027 1,733 881 2.267 0.063 0.377 0.485 Experienced physical violence since age 15 by anyone 0.149 0.016 1,124 513 1.483 0.106 0.118 0.181 Ever experienced any sexual violence 0.021 0.005 1,124 513 1.154 0.237 0.011 0.030 Experienced physical or sexual violence by any husband/partner 0.161 0.017 885 366 1.336 0.103 0.128 0.194 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.105 0.014 885 366 1.327 0.130 0.078 0.133 Total abortion rate (3 years) 0.667 0.081 4,896 2,486 0.957 0.121 0.506 0.828 Total fertility rate (3 years) 3.384 0.158 4,896 2,486 1.273 0.047 3.069 3.699 Neonatal mortality rate (0-9 years) 11.029 3.002 1,550 795 1.132 0.272 5.024 17.033 Post-neonatal mortality rate (0-9 years) 10.804 3.856 1,546 792 1.184 0.357 3.092 18.516 Infant mortality rate (0-9 years) 21.833 4.515 1,550 795 1.074 0.207 12.802 30.863 Child mortality rate (0-9 years) 6.878 2.421 1,549 790 1.127 0.352 2.036 11.719 Under-five mortality rate (0-9 years) 28.560 5.184 1,550 795 1.061 0.182 18.193 38.927 na = Not applicable 248 • Appendix B Table B.6 Sampling errors: GBAO sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.143 0.011 1,069 220 0.988 0.074 0.122 0.165 No education/primary 0.006 0.002 1,069 220 1.009 0.385 0.001 0.011 Secondary or higher education 0.994 0.002 1,069 220 1.009 0.002 0.989 0.999 Never married (never in union) 0.368 0.015 1,069 220 1.012 0.041 0.338 0.398 Currently married (in union) 0.586 0.016 1,069 220 1.044 0.027 0.554 0.617 Married before age 20 0.272 0.019 677 139 1.121 0.071 0.233 0.310 Had sexual intercourse before age 18 0.076 0.012 677 139 1.165 0.156 0.052 0.100 Currently pregnant 0.060 0.007 1,069 220 0.964 0.116 0.046 0.075 Children ever born 1.789 0.071 1,069 220 1.123 0.039 1.648 1.930 Children surviving 1.660 0.063 1,069 220 1.105 0.038 1.534 1.786 Children ever born to women age 40-49 3.960 0.199 250 51 1.482 0.050 3.561 4.359 Know any contraceptive method 0.979 0.008 626 129 1.378 0.008 0.963 0.995 Know a modern method 0.979 0.008 626 129 1.378 0.008 0.963 0.995 Currently using any method 0.350 0.031 626 129 1.635 0.089 0.288 0.413 Currently using a modern method 0.349 0.031 626 129 1.650 0.090 0.286 0.412 Currently using a traditional method 0.002 0.002 626 129 0.974 1.000 0.000 0.005 Currently using pill 0.025 0.006 626 129 0.913 0.230 0.013 0.036 Currently using IUD 0.238 0.025 626 129 1.481 0.106 0.188 0.289 Currently using condoms 0.030 0.008 626 129 1.228 0.279 0.013 0.047 Currently using injectables 0.056 0.010 626 129 1.104 0.181 0.036 0.076 Currently using female sterilization 0.000 0.000 626 129 na na 0.000 0.000 Currently using rhythm 0.000 0.000 626 129 na na 0.000 0.000 Currently using withdrawal 0.002 0.002 626 129 0.974 1.000 0.000 0.005 Used public sector source 0.868 0.028 220 45 1.217 0.032 0.813 0.924 Want no more children 0.465 0.024 626 129 1.225 0.053 0.416 0.514 Want to delay birth at least 2 years 0.226 0.021 626 129 1.259 0.093 0.184 0.268 Ideal number of children 3.240 0.069 1,063 218 1.470 0.021 3.102 3.378 Mothers received antenatal care for last birth 0.851 0.020 328 67 1.029 0.024 0.811 0.892 Births with skilled attendant at delivery 0.925 0.016 445 91 1.011 0.018 0.892 0.957 Had diarrhea in the past 2 weeks 0.164 0.023 432 88 1.242 0.142 0.118 0.211 Treated with ORS 0.781 0.065 71 15 1.264 0.083 0.651 0.911 Sought medical treatment for diarrhea 0.408 0.066 71 15 1.095 0.161 0.276 0.539 Vaccination card seen 0.893 0.031 84 17 0.927 0.035 0.831 0.956 Received BCG vaccination 0.988 0.012 84 17 0.994 0.012 0.964 1.012 Received DPT vaccination (3 doses) 0.868 0.037 84 17 0.992 0.042 0.795 0.942 Received polio vaccination (3 doses) 0.929 0.026 84 17 0.931 0.028 0.877 0.982 Received measles vaccination 0.964 0.020 84 17 0.997 0.021 0.924 1.005 Received all vaccinations 0.831 0.045 84 17 1.096 0.054 0.741 0.921 Height-for-age (-2SD) 0.243 0.024 447 93 1.180 0.100 0.194 0.291 Weight-for-height (-2SD) 0.081 0.016 447 93 1.224 0.200 0.048 0.113 Weight-for-age (-2SD) 0.130 0.023 447 93 1.409 0.177 0.084 0.176 Body Mass Index (BMI) <18.5 0.133 0.012 986 202 1.120 0.091 0.109 0.157 Had an HIV test and received results in past 12 months 0.073 0.012 1,069 220 1.443 0.157 0.050 0.097 Accepting attitudes towards people with HIV 0.103 0.013 822 169 1.231 0.127 0.077 0.129 Has heard about HIV/AIDS 0.771 0.037 1,069 220 2.906 0.049 0.696 0.846 Know about condoms 0.473 0.031 1,069 220 2.028 0.066 0.411 0.535 Know about limiting partners 0.677 0.040 1,069 220 2.798 0.059 0.597 0.758 Experienced physical violence since age 15 by anyone 0.144 0.018 621 126 1.304 0.128 0.107 0.181 Ever experienced any sexual violence 0.020 0.005 621 126 0.795 0.221 0.011 0.029 Experienced physical or sexual violence by any husband/partner 0.157 0.022 445 84 1.260 0.139 0.114 0.201 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.112 0.020 445 84 1.357 0.182 0.071 0.152 Total abortion rate (3 years) 0.420 0.091 3,005 617 1.160 0.216 0.239 0.602 Total fertility rate (3 years) 3.295 0.203 3,005 617 1.170 0.062 2.889 3.702 Neonatal mortality rate (0-9 years) 12.884 4.678 770 158 0.959 0.363 3.528 22.240 Post-neonatal mortality rate (0-9 years) 15.657 3.746 763 156 0.831 0.239 8.165 23.148 Infant mortality rate (0-9 years) 28.541 5.365 770 158 0.791 0.188 17.810 39.272 Child mortality rate (0-9 years) 8.130 3.855 721 147 1.158 0.474 0.420 15.839 Under-five mortality rate (0-9 years) 36.438 6.515 772 158 0.858 0.179 23.408 49.468 na = Not applicable Appendix B • 249 Table B.7 Sampling errors: Sughd sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.211 0.013 2,084 2,872 1.438 0.061 0.185 0.237 No education/primary 0.015 0.003 2,084 2,872 1.272 0.227 0.008 0.022 Secondary or higher education 0.985 0.003 2,084 2,872 1.272 0.003 0.978 0.992 Never married (never in union) 0.253 0.012 2,084 2,872 1.240 0.047 0.230 0.277 Currently married (in union) 0.704 0.012 2,084 2,872 1.194 0.017 0.680 0.728 Married before age 20 0.483 0.023 1,268 1,746 1.616 0.047 0.438 0.529 Had sexual intercourse before age 18 0.116 0.012 1,268 1,746 1.298 0.101 0.093 0.140 Currently pregnant 0.068 0.006 2,084 2,872 1.041 0.084 0.057 0.080 Children ever born 1.923 0.047 2,084 2,872 1.181 0.024 1.829 2.017 Children surviving 1.806 0.039 2,084 2,872 1.079 0.022 1.728 1.885 Children ever born to women age 40-49 3.732 0.130 409 560 1.497 0.035 3.471 3.992 Know any contraceptive method 0.975 0.006 1,468 2,022 1.448 0.006 0.963 0.986 Know a modern method 0.973 0.006 1,468 2,022 1.497 0.006 0.961 0.986 Currently using any method 0.353 0.019 1,468 2,022 1.540 0.054 0.315 0.392 Currently using a modern method 0.307 0.019 1,468 2,022 1.607 0.063 0.268 0.346 Currently using a traditional method 0.046 0.007 1,468 2,022 1.267 0.151 0.032 0.060 Currently using pill 0.020 0.004 1,468 2,022 1.061 0.194 0.012 0.028 Currently using IUD 0.229 0.017 1,468 2,022 1.509 0.072 0.196 0.262 Currently using condoms 0.026 0.004 1,468 2,022 1.009 0.161 0.018 0.035 Currently using injectables 0.022 0.005 1,468 2,022 1.423 0.248 0.011 0.033 Currently using female sterilization 0.007 0.002 1,468 2,022 1.064 0.328 0.002 0.012 Currently using rhythm 0.002 0.001 1,468 2,022 0.964 0.504 0.000 0.005 Currently using withdrawal 0.044 0.007 1,468 2,022 1.229 0.150 0.030 0.057 Used public sector source 0.887 0.018 454 620 1.197 0.020 0.852 0.923 Want no more children 0.456 0.020 1,468 2,022 1.563 0.045 0.415 0.497 Want to delay birth at least 2 years 0.166 0.010 1,468 2,022 1.024 0.060 0.147 0.186 Ideal number of children 3.210 0.047 2,042 2,812 1.654 0.015 3.116 3.305 Mothers received antenatal care for last birth 0.941 0.019 724 1,000 2.192 0.020 0.902 0.979 Births with skilled attendant at delivery 0.952 0.020 1,005 1,383 2.456 0.021 0.912 0.993 Had diarrhea in the past 2 weeks 0.075 0.010 975 1,343 1.158 0.139 0.054 0.096 Treated with ORS 0.614 0.072 72 101 1.145 0.117 0.470 0.757 Sought medical treatment for diarrhea 0.660 0.069 72 101 1.111 0.104 0.523 0.797 Vaccination card seen 0.981 0.009 209 288 0.994 0.010 0.962 1.000 Received BCG vaccination 1.000 0.000 209 288 na 0.000 1.000 1.000 Received DPT vaccination (3 doses) 0.953 0.024 209 288 1.655 0.025 0.905 1.002 Received polio vaccination (3 doses) 0.958 0.019 209 288 1.360 0.020 0.920 0.996 Received measles vaccination 0.969 0.018 209 288 1.493 0.018 0.933 1.005 Received all vaccinations 0.933 0.030 209 288 1.719 0.032 0.874 0.993 Height-for-age (-2SD) 0.272 0.019 934 1,365 1.229 0.070 0.234 0.310 Weight-for-height (-2SD) 0.084 0.010 934 1,365 1.087 0.123 0.063 0.105 Weight-for-age (-2SD) 0.104 0.012 934 1,365 1.098 0.116 0.080 0.128 Body Mass Index (BMI) <18.5 0.100 0.009 1,926 2,651 1.240 0.085 0.083 0.117 Had an HIV test and received results in past 12 months 0.073 0.007 2,084 2,872 1.264 0.099 0.059 0.088 Accepting attitudes towards people with HIV 0.013 0.003 1,618 2,227 1.032 0.219 0.008 0.019 Has heard about HIV/AIDS 0.776 0.020 2,084 2,872 2.133 0.025 0.737 0.815 Know about condoms 0.449 0.026 2,084 2,872 2.378 0.058 0.397 0.501 Know about limiting partners 0.515 0.025 2,084 2,872 2.258 0.048 0.466 0.565 Experienced physical violence since age 15 by anyone 0.222 0.018 1,249 1,663 1.492 0.079 0.187 0.258 Ever experienced any sexual violence 0.074 0.009 1,249 1,663 1.236 0.123 0.056 0.093 Experienced physical or sexual violence by any husband/partner 0.258 0.020 1,043 1,272 1.451 0.076 0.218 0.297 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.203 0.017 1,043 1,272 1.359 0.083 0.169 0.237 Total abortion rate (3 years) 0.413 0.064 5,855 8,069 1.158 0.154 0.285 0.540 Total fertility rate (3 years) 3.313 0.128 5,855 8,069 1.035 0.039 3.056 3.570 Neonatal mortality rate (0-9 years) 17.640 3.329 1,898 2,610 1.023 0.189 10.983 24.298 Post-neonatal mortality rate (0-9 years) 13.032 3.458 1,898 2,608 1.240 0.265 6.117 19.948 Infant mortality rate (0-9 years) 30.673 4.857 1,899 2,611 1.130 0.158 20.959 40.387 Child mortality rate (0-9 years) 9.138 2.616 1,813 2,490 1.078 0.286 3.907 14.369 Under-five mortality rate (0-9 years) 39.530 6.676 1,904 2,618 1.306 0.169 26.178 52.883 na = Not applicable 250 • Appendix B Table B.8 Sampling errors: DRS sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.129 0.012 2,334 2,240 1.664 0.090 0.106 0.152 No education/primary 0.071 0.010 2,334 2,240 1.927 0.144 0.051 0.092 Secondary or higher education 0.929 0.010 2,334 2,240 1.927 0.011 0.908 0.949 Never married (never in union) 0.253 0.010 2,334 2,240 1.106 0.039 0.233 0.272 Currently married (in union) 0.690 0.011 2,334 2,240 1.098 0.015 0.669 0.711 Married before age 20 0.481 0.017 1,326 1,276 1.252 0.036 0.446 0.515 Had sexual intercourse before age 18 0.177 0.015 1,326 1,276 1.408 0.083 0.148 0.207 Currently pregnant 0.080 0.006 2,334 2,240 1.030 0.072 0.068 0.091 Children ever born 2.189 0.047 2,334 2,240 1.033 0.022 2.095 2.284 Children surviving 2.053 0.042 2,334 2,240 1.010 0.021 1.968 2.138 Children ever born to women age 40-49 4.752 0.123 408 392 1.225 0.026 4.506 4.998 Know any contraceptive method 0.913 0.012 1,611 1,546 1.690 0.013 0.890 0.937 Know a modern method 0.913 0.012 1,611 1,546 1.690 0.013 0.890 0.937 Currently using any method 0.223 0.012 1,611 1,546 1.179 0.055 0.199 0.248 Currently using a modern method 0.220 0.012 1,611 1,546 1.169 0.055 0.196 0.244 Currently using a traditional method 0.004 0.002 1,611 1,546 1.043 0.430 0.001 0.007 Currently using pill 0.022 0.004 1,611 1,546 1.196 0.199 0.013 0.031 Currently using IUD 0.166 0.011 1,611 1,546 1.227 0.069 0.143 0.189 Currently using condoms 0.017 0.004 1,611 1,546 1.181 0.225 0.009 0.024 Currently using injectables 0.008 0.002 1,611 1,546 1.058 0.297 0.003 0.012 Currently using female sterilization 0.007 0.002 1,611 1,546 1.076 0.315 0.003 0.012 Currently using rhythm 0.000 0.000 1,611 1,546 na na 0.000 0.000 Currently using withdrawal 0.004 0.002 1,611 1,546 1.043 0.430 0.001 0.007 Used public sector source 0.912 0.016 351 340 1.055 0.017 0.881 0.944 Want no more children 0.410 0.016 1,611 1,546 1.310 0.039 0.378 0.442 Want to delay birth at least 2 years 0.242 0.012 1,611 1,546 1.137 0.050 0.218 0.266 Ideal number of children 3.679 0.038 2,238 2,141 1.240 0.010 3.603 3.754 Mothers received antenatal care for last birth 0.787 0.031 921 887 2.278 0.039 0.725 0.848 Births with skilled attendant at delivery 0.804 0.028 1,366 1,316 2.114 0.035 0.748 0.860 Had diarrhea in the past 2 weeks 0.093 0.011 1,320 1,271 1.287 0.116 0.072 0.115 Treated with ORS 0.684 0.043 123 119 0.954 0.063 0.598 0.769 Sought medical treatment for diarrhea 0.558 0.057 123 119 1.178 0.102 0.444 0.671 Vaccination card seen 0.838 0.024 302 292 1.143 0.029 0.789 0.886 Received BCG vaccination 0.970 0.011 302 292 1.105 0.011 0.948 0.991 Received DPT vaccination (3 doses) 0.918 0.020 302 292 1.251 0.022 0.878 0.957 Received polio vaccination (3 doses) 0.860 0.023 302 292 1.173 0.027 0.814 0.907 Received measles vaccination 0.953 0.016 302 292 1.347 0.017 0.920 0.986 Received all vaccinations 0.827 0.026 302 292 1.187 0.031 0.775 0.879 Height-for-age (-2SD) 0.263 0.016 1,286 1,296 1.178 0.061 0.231 0.295 Weight-for-height (-2SD) 0.098 0.010 1,286 1,296 1.114 0.101 0.078 0.118 Weight-for-age (-2SD) 0.127 0.010 1,286 1,296 0.992 0.079 0.107 0.147 Body Mass Index (BMI) <18.5 0.100 0.007 2,115 2,035 1.000 0.065 0.087 0.113 Had an HIV test and received results in past 12 months 0.034 0.005 2,334 2,240 1.387 0.153 0.024 0.045 Accepting attitudes towards people with HIV 0.026 0.006 1,092 1,033 1.266 0.233 0.014 0.039 Has heard about HIV/AIDS 0.461 0.023 2,334 2,240 2.216 0.050 0.415 0.507 Know about condoms 0.277 0.018 2,334 2,240 1.958 0.066 0.240 0.313 Know about limiting partners 0.330 0.020 2,334 2,240 2.043 0.060 0.290 0.370 Experienced physical violence since age 15 by anyone 0.130 0.014 1,261 1,242 1.487 0.108 0.102 0.159 Ever experienced any sexual violence 0.009 0.003 1,261 1,242 1.059 0.321 0.003 0.014 Experienced physical or sexual violence by any husband/partner 0.119 0.014 1,008 916 1.341 0.115 0.092 0.147 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.113 0.013 1,008 916 1.323 0.117 0.087 0.140 Total abortion rate (3 years) 0.453 0.068 6,596 6,336 1.110 0.150 0.317 0.588 Total fertility rate (3 years) 3.881 0.145 6,596 6,336 1.317 0.037 3.591 4.172 Neonatal mortality rate (0-9 years) 19.629 2.976 2,453 2,371 0.906 0.152 13.676 25.582 Post-neonatal mortality rate (0-9 years) 18.287 3.169 2,454 2,373 1.026 0.173 11.949 24.625 Infant mortality rate (0-9 years) 37.916 4.165 2,458 2,376 0.901 0.110 29.587 46.245 Child mortality rate (0-9 years) 8.285 2.188 2,328 2,253 1.132 0.264 3.909 12.661 Under-five mortality rate (0-9 years) 45.887 4.803 2,463 2,381 0.917 0.105 36.281 55.493 na = Not applicable Appendix B • 251 Table B.9 Sampling errors: Khatlon sample, Tajikistan 2012 VARIABLE R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.176 0.009 2,436 3,444 1.208 0.053 0.157 0.194 No education/primary 0.094 0.016 2,436 3,444 2.711 0.171 0.061 0.126 Secondary or higher education 0.906 0.016 2,436 3,444 2.711 0.018 0.874 0.939 Never married (never in union) 0.298 0.011 2,436 3,444 1.139 0.035 0.277 0.319 Currently married (in union) 0.653 0.010 2,436 3,444 1.079 0.016 0.632 0.674 Married before age 20 0.475 0.019 1,399 1,978 1.454 0.041 0.437 0.514 Had sexual intercourse before age 18 0.153 0.014 1,399 1,978 1.436 0.090 0.126 0.181 Currently pregnant 0.086 0.006 2,436 3,444 1.019 0.067 0.075 0.098 Children ever born 2.304 0.060 2,436 3,444 1.201 0.026 2.183 2.424 Children surviving 2.105 0.051 2,436 3,444 1.133 0.024 2.002 2.208 Children ever born to women age 40-49 5.416 0.135 477 667 1.352 0.025 5.145 5.686 Know any contraceptive method 0.960 0.009 1,585 2,249 1.926 0.010 0.941 0.979 Know a modern method 0.959 0.010 1,585 2,249 1.906 0.010 0.940 0.978 Currently using any method 0.238 0.012 1,585 2,249 1.161 0.052 0.213 0.263 Currently using a modern method 0.229 0.012 1,585 2,249 1.177 0.054 0.204 0.254 Currently using a traditional method 0.009 0.002 1,585 2,249 0.996 0.266 0.004 0.013 Currently using pill 0.025 0.005 1,585 2,249 1.188 0.185 0.016 0.035 Currently using IUD 0.154 0.010 1,585 2,249 1.063 0.063 0.135 0.173 Currently using condoms 0.015 0.003 1,585 2,249 1.062 0.216 0.009 0.022 Currently using injectables 0.029 0.006 1,585 2,249 1.411 0.206 0.017 0.041 Currently using female sterilization 0.004 0.002 1,585 2,249 1.052 0.397 0.001 0.008 Currently using rhythm 0.000 0.000 1,585 2,249 na na 0.000 0.000 Currently using withdrawal 0.009 0.002 1,585 2,249 0.996 0.266 0.004 0.013 Used public sector source 0.890 0.017 377 518 1.038 0.019 0.857 0.924 Want no more children 0.457 0.014 1,585 2,249 1.088 0.030 0.429 0.484 Want to delay birth at least 2 years 0.186 0.010 1,585 2,249 0.983 0.052 0.166 0.205 Ideal number of children 3.866 0.042 2,351 3,314 1.288 0.011 3.783 3.949 Mothers received antenatal care for last birth 0.668 0.025 939 1,351 1.661 0.038 0.618 0.719 Births with skilled attendant at delivery 0.846 0.022 1,402 2,029 1.903 0.026 0.803 0.889 Had diarrhea in the past 2 weeks 0.235 0.015 1,331 1,924 1.179 0.062 0.206 0.265 Treated with ORS 0.579 0.037 317 453 1.234 0.065 0.504 0.653 Sought medical treatment for diarrhea 0.520 0.037 317 453 1.215 0.072 0.445 0.595 Vaccination card seen 0.926 0.017 314 459 1.194 0.019 0.892 0.961 Received BCG vaccination 0.982 0.008 314 459 1.065 0.008 0.966 0.997 Received DPT vaccination (3 doses) 0.940 0.019 314 459 1.443 0.020 0.902 0.978 Received polio vaccination (3 doses) 0.951 0.012 314 459 1.046 0.013 0.927 0.976 Received measles vaccination 0.945 0.021 314 459 1.624 0.022 0.903 0.986 Received all vaccinations 0.910 0.023 314 459 1.483 0.026 0.864 0.957 Height-for-age (-2SD) 0.269 0.017 1,275 1,934 1.270 0.061 0.236 0.302 Weight-for-height (-2SD) 0.111 0.011 1,275 1,934 1.220 0.099 0.089 0.133 Weight-for-age (-2SD) 0.135 0.014 1,275 1,934 1.342 0.103 0.107 0.163 Body Mass Index (BMI) <18.5 0.116 0.010 2,193 3,091 1.465 0.086 0.096 0.137 Had an HIV test and received results in past 12 months 0.031 0.004 2,436 3,444 1.245 0.140 0.023 0.040 Accepting attitudes towards people with HIV 0.127 0.014 1,396 1,947 1.598 0.112 0.099 0.156 Has heard about HIV/AIDS 0.565 0.030 2,436 3,444 2.954 0.053 0.506 0.625 Know about condoms 0.341 0.027 2,436 3,444 2.808 0.079 0.287 0.395 Know about limiting partners 0.408 0.028 2,436 3,444 2.767 0.068 0.353 0.463 Experienced physical violence since age 15 by anyone 0.208 0.015 1,292 2,004 1.369 0.074 0.177 0.239 Ever experienced any sexual violence 0.030 0.006 1,292 2,004 1.213 0.192 0.018 0.041 Experienced physical or sexual violence by any husband/partner 0.246 0.019 1,024 1,455 1.409 0.077 0.208 0.283 Experienced physical or sexual violence in the last 12 months by any husband/partner 0.146 0.015 1,024 1,455 1.365 0.103 0.116 0.177 Total abortion rate (3 years) 0.492 0.068 6,853 9,700 1.053 0.138 0.356 0.628 Total fertility rate (3 years) 4.200 0.173 6,853 9,700 1.227 0.041 3.854 4.545 Neonatal mortality rate (0-9 years) 23.495 3.757 2,508 3,634 1.064 0.160 15.981 31.008 Post-neonatal mortality rate (0-9 years) 24.844 3.719 2,509 3,634 1.166 0.150 17.405 32.283 Infant mortality rate (0-9 years) 48.339 5.051 2,513 3,641 1.041 0.104 38.238 58.440 Child mortality rate (0-9 years) 13.261 3.167 2,415 3,490 1.322 0.239 6.926 19.596 Under-five mortality rate (0-9 years) 60.959 6.324 2,518 3,648 1.151 0.104 48.311 73.606 na = Not applicable Appendix C • 253 DATA QUALITY TABLES APPENDIX c Table C.1 Household age distribution Single-year age distribution of the de facto household population by sex (weighted), Tajikistan 2012 Age Female Male Number Percent Number Percent 0 575 2.9 596 3.4 1 586 2.9 555 3.1 2 590 2.9 620 3.5 3 483 2.4 525 3.0 4 461 2.3 474 2.7 5 367 1.8 413 2.3 6 523 2.6 533 3.0 7 417 2.1 481 2.7 8 448 2.2 448 2.5 9 443 2.2 425 2.4 10 442 2.2 396 2.2 11 384 1.9 436 2.5 12 462 2.3 516 2.9 13 410 2.0 458 2.6 14 493 2.5 452 2.6 15 374 1.9 410 2.3 16 475 2.4 465 2.6 17 445 2.2 462 2.6 18 443 2.2 340 1.9 19 417 2.1 280 1.6 20 445 2.2 308 1.7 21 443 2.2 303 1.7 22 409 2.0 297 1.7 23 387 1.9 258 1.5 24 387 1.9 251 1.4 25 407 2.0 271 1.5 26 366 1.8 250 1.4 27 313 1.6 244 1.4 28 323 1.6 263 1.5 29 300 1.5 212 1.2 30 284 1.4 212 1.2 31 280 1.4 205 1.2 32 256 1.3 193 1.1 33 229 1.1 194 1.1 34 219 1.1 135 0.8 35 204 1.0 184 1.0 36 249 1.2 175 1.0 37 224 1.1 149 0.8 38 206 1.0 150 0.8 39 206 1.0 157 0.9 40 218 1.1 170 1.0 41 211 1.1 150 0.8 42 211 1.0 166 0.9 43 197 1.0 143 0.8 44 228 1.1 148 0.8 45 206 1.0 144 0.8 46 181 0.9 149 0.8 47 219 1.1 162 0.9 48 169 0.8 173 1.0 49 149 0.7 144 0.8 50 224 1.1 165 0.9 51 191 0.9 163 0.9 52 220 1.1 171 1.0 53 161 0.8 151 0.9 54 158 0.8 138 0.8 55 167 0.8 141 0.8 56 124 0.6 99 0.6 57 120 0.6 102 0.6 58 120 0.6 98 0.6 59 94 0.5 91 0.5 60 118 0.6 96 0.5 61 65 0.3 58 0.3 62 90 0.4 76 0.4 63 95 0.5 89 0.5 64 75 0.4 50 0.3 65 71 0.4 70 0.4 66 43 0.2 41 0.2 67 42 0.2 34 0.2 68 39 0.2 34 0.2 69 28 0.1 35 0.2 70+ 492 2.4 532 3.0 Total 20,099 100.0 17,679 100.0 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. 254 • Appendix C Table C.2 Age distribution of eligible and interviewed women De facto household population of women age 10-54 and interviewed women age 15-49; and percent distribution and percentage of eligible women who were interviewed (weighted), by five-year age groups, Tajikistan 2012 Age group Household population of women age 10-54 Interviewed women age 15-49 Percentage of eligible women interviewed Number Percentage 10-14 2,190 na na na 15-19 2,154 2,132 21.0 99.0 20-24 2,073 2,053 20.2 99.1 25-29 1,709 1,687 16.6 98.7 30-34 1,269 1,258 12.4 99.2 35-39 1,088 1,077 10.6 99.0 40-44 1,064 1,058 10.4 99.4 45-49 924 909 8.9 98.3 50-54 954 na na na 15-49 10,281 10,174 100.0 99.0 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both the household population of women and interviewed women are household weights. Age is based on the household questionnaire. na = Not applicable Table C.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Tajikistan 2012 Subject Reference group Percentage with information missing Number of cases Birth date Births in the 15 years preceding the survey Month only 0.21 13,495 Month and year 0.01 13,495 Age at death Deceased children born in the 15 years preceding the survey 0.05 692 Age/date at first union1 Ever-married women age 15-49 0.02 7,008 Respondent's education All women age 15-49 0.00 9,656 Diarrhea in past 2 weeks Living children age 0-59 months 0.34 5,031 Anthropometry Living children age 0-59 months from the Household Questionnaire Height 1.04 5,422 Weight 0.97 5,422 Height or weight 1.16 5,422 1 Both year and age missing. Table C.4 Births by calendar years Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living (L), dead (D), and total (T) children (weighted), Tajikistan 2012 Calendar year Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 Living Dead Total Living Dead Total Living Dead Total Living Dead Total 2012 631 14 645 99.9 100.0 99.9 102.6 127.6 103.1 na na na 2011 1,105 41 1,145 100.0 100.0 100.0 96.8 175.1 98.8 na na na 2010 1,123 41 1,164 99.8 100.0 99.8 111.4 88.1 110.5 106.5 96.0 106.1 2009 1,004 45 1,049 100.0 100.0 100.0 99.8 130.2 101.0 100.5 104.9 100.6 2008 876 45 920 100.0 100.0 100.0 107.7 75.6 105.9 96.0 100.6 96.2 2007 820 44 863 99.9 100.0 99.9 117.3 164.5 119.3 92.6 114.1 93.5 2006 894 32 926 100.0 99.3 100.0 90.3 55.1 88.9 110.7 73.5 108.8 2005 796 43 839 99.7 100.0 99.7 120.3 183.1 122.9 94.2 119.8 95.2 2004 796 40 836 100.0 97.2 99.9 103.7 125.5 104.7 99.2 87.5 98.6 2003 809 49 858 99.8 100.0 99.8 96.1 170.7 99.2 104.8 98.6 104.4 2012-2008 4,739 185 4,924 99.9 100.0 99.9 103.5 111.3 103.8 na na na 2007-2003 4,115 208 4,322 99.9 99.4 99.9 104.6 135.6 105.9 na na na 2002-1998 3,664 286 3,950 99.8 95.5 99.5 102.3 114.0 103.1 na na na 1997-1993 3,353 352 3,705 99.9 97.5 99.7 103.0 129.3 105.3 na na na < 1992 3,184 409 3,593 99.9 99.3 99.8 111.1 140.6 114.1 na na na All 19,055 1,440 20,494 99.9 98.2 99.8 104.7 127.5 106.1 na na na na = Not applicable 1 Both year and month of birth given. 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively. 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x. Appendix C • 255 Table C.5 Reporting of age at death in days Distribution of reported deaths under age 1 month by age at death in days and percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Tajikistan 2012 Age at death (days) Number of years preceding the survey Total 0-19 0-4 5-9 10-14 15-19 <1 7 7 7 9 29 1 34 35 28 22 119 2 11 8 11 2 32 3 14 10 17 9 50 4 4 3 7 3 17 5 7 5 3 2 16 6 4 2 2 0 8 7 2 5 6 3 15 8 3 2 1 1 6 9 0 1 1 1 4 10 5 2 1 2 10 11 0 1 1 2 5 12 1 0 1 0 2 13 0 0 2 0 2 14 1 2 0 2 5 15 2 3 2 0 7 17 0 0 2 1 2 18 3 0 0 1 4 20 3 3 3 3 12 21 0 0 0 0 0 22 1 0 0 1 2 24 0 0 1 4 5 25 0 0 0 2 2 27 3 0 0 0 3 28 0 0 0 2 2 30 0 0 0 0 0 Total 0-30 103 87 96 73 359 Percentage early neonatal1 77.7 79.6 77.0 65.5 75.5 1 ≤6 days / ≤30 days. Table C.6 Reporting of age at death in months Distribution of reported deaths under age 2 by age at death in months and percentage of infant deaths reported to occur at age under 1 month, for five-year periods of birth preceding the survey (weighted), Tajikistan 2012 Age at death (months) Number of years preceding the survey Total 0-19 0-4 5-9 10-14 15-19 <1a 103 87 96 73 359 1 15 11 8 12 46 2 4 11 15 16 47 3 10 21 13 16 60 4 5 9 13 11 38 5 9 4 5 14 32 6 6 6 11 15 39 7 3 3 10 21 37 8 8 7 14 12 41 9 2 9 13 22 44 10 8 3 4 9 24 11 5 2 4 2 13 12 8 11 20 45 83 13 1 2 5 4 11 14 2 1 3 1 6 15 0 0 0 3 3 16 1 2 0 5 7 17 0 0 0 7 7 18 2 0 3 6 11 19 0 0 0 1 1 20 0 1 2 0 3 23 0 0 0 1 1 24+ 0 2 1 0 2 Missing 0 0 0 0 0 Total 0-11 176 175 207 223 781 Percentage neonatal1 58.4 49.9 46.3 32.5 45.9 a Includes deaths under 1 month reported in days. 1 Under 1 month/under 1 year. 25 6 • A pp en di x C Ta bl e C .7 N ut rit io na l s ta tu s of c hi ld re n ba se d on th e N C H S /C D C /W H O In te rn at io na l R ef er en ce P op ul at io n P er ce nt ag e of c hi ld re n un de r a ge 5 c la ss ifi ed a s m al no ur is he d ac co rd in g to th re e an th ro po m et ric in di ce s of n ut rit io na l s ta tu s: h ei gh t-f or -a ge , w ei gh t-f or -h ei gh t, an d w ei gh t-f or -a ge , b y ba ck gr ou nd c ha ra ct er is tic s, b as ed o n th e N C H S /C D C /W H O In te rn at io na l R ef er en ce P op ul at io n, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic H ei gh t-f or -a ge W ei gh t-f or -h ei gh t W ei gh t-f or -a ge N um be r of c hi ld re n P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 1 M ea n Z- sc or e (S D ) P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 1 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 1 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) A ge in m on th s <6 1. 9 7. 9 0. 1 1. 7 8. 9 5. 2 -0 .3 0. 7 4. 6 5. 5 -0 .1 42 4 6- 8 5. 6 16 .3 -0 .4 4. 7 12 .9 6. 8 -0 .3 4. 4 11 .9 3. 3 -0 .6 30 0 9- 11 5. 7 18 .1 -0 .7 3. 4 15 .6 5. 6 -0 .6 3. 2 20 .3 1. 9 -1 .1 28 8 12 -1 7 7. 3 18 .9 -1 .0 3. 2 16 .3 2. 7 -0 .8 6. 3 23 .3 0. 8 -1 .3 52 3 18 -2 3 10 .2 31 .0 -1 .4 1. 4 10 .5 3. 5 -0 .5 4. 2 21 .0 0. 9 -1 .2 54 1 24 -3 5 8. 4 22 .7 -1 .1 1. 9 6. 9 2. 9 -0 .4 4. 9 18 .7 1. 2 -1 .1 1, 16 1 36 -4 7 8. 3 21 .3 -1 .1 1. 0 3. 9 3. 9 -0 .2 1. 8 12 .7 1. 1 -0 .9 96 0 48 -5 9 7. 5 21 .1 -1 .2 2. 0 6. 2 3. 4 -0 .3 2. 8 11 .9 0. 3 -1 .0 88 2 Se x M al e 7. 1 20 .4 -1 .0 2. 4 8. 5 3. 6 -0 .4 3. 1 14 .8 1. 4 -0 .9 2, 58 9 Fe m al e 7. 8 21 .2 -1 .0 1. 8 8. 7 3. 9 -0 .4 4. 0 16 .5 1. 6 -1 .0 2, 48 9 B irt h in te rv al in m on th s2 Fi rs t b irt h3 7. 1 20 .6 -1 .0 2. 8 9. 1 4. 1 -0 .4 4. 0 16 .2 1. 2 -1 .0 1, 65 4 <2 4 9. 5 23 .2 -1 .1 1. 8 8. 1 3. 2 -0 .3 4. 1 17 .3 1. 0 -1 .0 1, 08 4 24 -4 7 7. 3 20 .1 -1 .0 1. 8 9. 3 3. 6 -0 .4 3. 3 16 .0 1. 9 -0 .9 1, 39 7 48 + 5. 2 19 .1 -0 .9 1. 8 7. 3 3. 9 -0 .4 2. 0 11 .6 2. 0 -0 .9 82 0 Si ze a t b irt h2 V er y sm al l 13 .5 29 .7 -1 .3 5. 9 15 .8 3. 1 -0 .7 10 .3 36 .3 1. 5 -1 .4 12 6 S m al l 12 .2 28 .3 -1 .3 2. 9 8. 7 2. 4 -0 .6 5. 3 24 .0 1. 3 -1 .3 51 6 A ve ra ge o r l ar ge r 6. 8 19 .4 -0 .9 1. 9 8. 4 4. 1 -0 .3 2. 9 13 .7 1. 6 -0 .9 3, 89 8 M is si ng 5. 2 21 .8 -1 .1 2. 5 8. 4 2. 1 -0 .5 4. 2 17 .2 1. 1 -1 .1 41 5 M ot he r's in te rv ie w s ta tu s In te rv ie w ed 7. 4 20 .8 -1 .0 2. 1 8. 6 3. 7 -0 .4 3. 5 15 .6 1. 5 -0 .9 4, 95 5 N ot in te rv ie w ed b ut in h ou se ho ld 0. 7 12 .7 -1 .1 0. 0 4. 4 7. 3 -0 .3 3. 0 6. 0 2. 7 -0 .9 61 N ot in te rv ie w ed a nd n ot in th e ho us eh ol d4 19 .7 29 .9 -1 .3 0. 0 11 .0 2. 5 -0 .7 7. 4 22 .6 0. 0 -1 .3 62 M ot he r's n ut rit io na l s ta tu s5 Th in (B M I< 18 .5 ) 6. 5 19 .3 -1 .0 2. 4 14 .0 2. 7 -0 .8 3. 5 23 .7 1. 5 -1 .2 42 0 N or m al (B M I 1 8. 5- 24 .9 ) 7. 7 21 .4 -1 .0 2. 3 8. 3 3. 5 -0 .4 3. 7 15 .8 1. 5 -1 .0 3, 14 8 O ve rw ei gh t/o be se (B M I > = 25 ) 6. 8 20 .0 -0 .9 1. 5 7. 7 4. 5 -0 .3 3. 1 12 .6 1. 5 -0 .8 1, 40 5 R es id en ce U rb an 6. 1 18 .2 -0 .7 2. 6 9. 4 4. 3 -0 .4 2. 9 14 .5 1. 9 -0 .8 1, 09 9 R ur al 7. 8 21 .5 -1 .1 1. 9 8. 4 3. 6 -0 .4 3. 7 15 .9 1. 4 -1 .0 3, 97 9 R eg io n D us ha nb e 7. 0 15 .6 -0 .6 2. 3 8. 8 4. 1 -0 .4 2. 9 11 .9 1. 9 -0 .7 39 7 G B A O 6. 9 18 .8 -0 .9 0. 9 5. 3 1. 4 -0 .6 2. 2 13 .9 1. 1 -1 .0 93 S ug hd 8. 8 23 .4 -1 .0 2. 1 8. 2 7. 7 -0 .1 3. 9 13 .2 2. 4 -0 .8 1, 36 5 D R S 6. 5 20 .7 -1 .0 2. 2 8. 5 2. 6 -0 .5 3. 3 17 .1 1. 3 -1 .0 1, 29 3 K ha tlo n 7. 2 20 .2 -1 .0 2. 0 9. 1 1. 8 -0 .5 3. 6 17 .1 0. 9 -1 .1 1, 92 9 C on tin ue d… 256 • Appendix C A pp en di x C • 2 57 Ta bl e C .7 — C on tin ue d P er ce nt ag e of c hi ld re n un de r f iv e ye ar s cl as si fie d as m al no ur is he d ac co rd in g to th re e an th ro po m et ric in di ce s of n ut rit io na l s ta tu s: h ei gh t-f or -a ge , w ei gh t-f or -h ei gh t, an d w ei gh t-f or -a ge , b y ba ck gr ou nd c ha ra ct er is tic s, b as ed o n th e N C H S /C D C /W H O In te rn at io na l R ef er en ce P op ul at io n, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic H ei gh t-f or -a ge 1 W ei gh t-f or -h ei gh t W ei gh t-f or -a ge N um be r of c hi ld re n P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 M ea n Z- sc or e (S D ) P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) M ot he r's e du ca tio n6 N on e/ pr im ar y 9. 4 20 .5 -1 .1 2. 5 10 .7 2. 2 -0 .7 6. 0 23 .4 0. 4 -1 .2 41 2 G en er al b as ic 7. 3 21 .7 -1 .0 2. 1 8. 8 2. 8 -0 .4 3. 9 16 .3 0. 8 -1 .0 1, 97 6 G en er al s ec on da ry 7. 3 20 .9 -1 .0 2. 0 8. 2 4. 7 -0 .3 2. 8 14 .3 2. 4 -0 .9 2, 08 5 P ro fe ss io na l p rim ar y/ m id dl e 4. 7 16 .5 -0 .8 2. 0 6. 6 4. 0 -0 .4 3. 3 13 .8 0. 9 -0 .8 29 7 H ig he r 6. 6 16 .2 -0 .6 2. 6 8. 2 6. 4 -0 .2 2. 4 8. 5 2. 6 -0 .6 24 7 W ea lth q ui nt ile Lo w es t 10 .5 25 .1 -1 .2 2. 3 8. 6 2. 0 -0 .5 4. 6 19 .7 0. 8 -1 .1 99 5 S ec on d 7. 6 24 .1 -1 .1 2. 1 7. 9 2. 4 -0 .5 4. 3 17 .7 1. 3 -1 .1 1, 08 7 M id dl e 5. 4 17 .2 -0 .9 1. 7 8. 5 4. 6 -0 .3 2. 4 12 .9 1. 4 -0 .9 1, 05 7 Fo ur th 7. 0 19 .8 -0 .9 1. 8 9. 5 5. 6 -0 .3 3. 5 15 .0 2. 3 -0 .9 1, 02 6 H ig he st 6. 9 17 .5 -0 .7 2. 6 8. 4 4. 3 -0 .3 2. 8 12 .4 1. 8 -0 .8 91 4 To ta l 7. 4 20 .8 -1 .0 2. 1 8. 6 3. 8 -0 .4 3. 5 15 .6 1. 5 -0 .9 5, 07 9 N ot e: T ab le is b as ed o n ch ild re n w ho s le pt in th e ho us eh ol d th e ni gh t b ef or e th e in te rv ie w . E ac h of th e in di ce s is e xp re ss ed in s ta nd ar d de vi at io n un its (S D s) fr om th e m ed ia n of th e N C H S/ C D C /W H O In te rn at io na l R ef er en ce P op ul at io n. T ab le is b as ed o n ch ild re n w ith v al id d at es o f b irt h (m on th a nd y ea r) a nd v al id m ea su re m en t o f b ot h he ig ht a nd w ei gh t. 1 I nc lu de s ch ild re n w ho a re b el ow – 3 st an da rd d ev ia tio ns (S D s) fr om th e In te rn at io na l R ef er en ce P op ul at io n m ed ia n. 2 E xc lu de s ch ild re n w ho se m ot he rs w er e no t i nt er vi ew ed . 3 F irs t-b or n tw in s (tr ip le ts , e tc .) ar e co un te d as fi rs t b irt hs b ec au se th ey d o no t h av e a pr ev io us b irt h in te rv al . 4 I nc lu de s ch ild re n w ho se m ot he rs a re d ec ea se d. 5 E xc lu de s ch ild re n w ho se m ot he rs w er e no t w ei gh ed a nd m ea su re d. M ot he r’s n ut rit io na l s ta tu s in te rm s of B M I ( Bo dy M as s In de x) is p re se nt ed in T ab le 1 2. 9. 6 F or w om en w ho a re n ot in te rv ie w ed , i nf or m at io n is ta ke n fro m th e H ou se ho ld Q ue st io nn ai re . E xc lu de s ch ild re n w ho se m ot he rs a re n ot li st ed in th e H ou se ho ld Q ue st io nn ai re . Appendix C • 257 Appendix D • 259 PERSONS INVOLVED IN THE 2012 TAJIKISTAN DEMOGRAPHIC AND HEALTH SURVEY APPENDIX D National Director Bakhtya Muhammadieva, Director, Statistical Agency under the President of the Republic of Tajikistan (RT) National Directors for Medical Affairs Saida Jobirova, First Deputy Minister of Health Sherali Rakhmatulloev, Head of Department of Organization of Health Services for Mothers, Children and Family Planning Statistical Agency under the President of the RT Abduvali Kulov, Tajikistan DHS Technical Director Elena Budnikova, Tajikistan DHS Deputy Technical Director Tatyana Gukasova, Tajikistan DHS Secretary-Assistant of Director Elena Kislitsyna, Survey Specialist (retired) Ikhtier Kholmatov, Coordinator of Data Entry Parviz Yakubov, Deputy Coordinator of Data Entry Lubov Zhdanova, Office Editor Salohiddin Faisiev, Administrative Support Ministry of Health Gulbahor Ashurova, Head of Section of Protection of Maternal Health and Family Planning Sanavbar Rakhmatulloeva, Main Specialist, Department of Organization of Health Services for Mothers, Children and Family Planning Alijon Soliev, Head of M&E Department, Republican AIDS Center Gulnara Ahmedjanova, Republican Center of Reproductive Health Barno Yangibaeva, Chief of Integrated Management of Childhood Illness Department, the Republican Scientific Clinical Center of Pediatrics and Pediatric Surgery Sanoat Norkulova, National Trainer, Integrated Management of Childhood Illness (IMCI) Program, Tajik State Medical University Faculty Member Urunbish Uzakova, Main Untenured Specialist of the MOH on Obstetrics and Gynecology Ibodullo Sheraliev, Deputy Director, Republican Center of Medical Statistics and Informatics ICF International Gulnara Semenov, Technical Director, Regional Coordinator Alfredo Aliaga, Senior Sampling Specialist Ruilin Ren, Senior Sampling Specialist Shawna Kelly, Data Processing Specialist Anne Cross, Survey Specialist Ann Way, Survey Specialist Saida Ismayilova, Consultant Audrey Shenett, Production Specialist Nancy Johnson, Editor Christopher Gramer, Cover Design Erica Nybro, Dissemination Specialist 260 • Appendix D Field Staff Dushanbe 1 Voris Murodov, Supervisor Jurabek Muhammadiev, Editor Gulrukhsor Rahmonova, Interviewer Zuhro Sattorova, Interviewer Dilbar Rasulova, Interviewer Zumrad Tosheva, Interviewer Dushanbe 2 Olga Stodolya, Supervisor Shahlo Alimova, Editor Zarragul Murodova, Interviewer Lalita Zabirova, Interviewer Zarina Yusupova, Interviewer Ozoda Zokirova, Interviewer Firuza Ganieva, Interviewer Dushanbe 3 Saymurod Zayniddinov, Supervisor Hilola Begova, Editor Khursheda Kasimova, Interviewer Dilafruz Rajabova, Interviewer Niso Kholova, Interviewer Manzura Islomova, Interviewer Zulfiya Mazorieva, Interviewer Zebo Jumaeva, Interviewer Sughd 4 Salimboy Sharifov, Supervisor Shoira Karimova, Editor Fakhriniso Muhidinova, Interviewer Dilafruz Gafurova, Interviewer Nigora Nematova, Interviewer Shahlo Boboeva, Interviewer Sughd 5 Bihikoyat Mamadjonova, Supervisor Farhod Karimov, Editor Gulandom Malikova, Interviewer Gulafzo Alieva, Interviewer Tahmina Shokirova, Interviewer Lutfiya Dadojonova, Interviewer Sughd 6 Kumri Shamsieva, Supervisor Farhod Habibov, Editor Shahnoza Bobokalonova, Interviewer Nargis Dadojonova, Interviewer Barno Hakimova, Interviewer Marhabo Saidova, Interviewer Khatlon 7 Shuhrat Shokirov, Supervisor Sulhiya Alifbekova, Editor Khursand Otajonova, Interviewer Nurinoso Yahyoeva, Interviewer Zulaykho Zikriyoeva, Interviewer Jamila Nozimova, Interviewer Khatlon 8 Jumakhon Ashurov, Supervisor Nematullo Hojiev, Editor Firuza Chalishova, Interviewer Bozorgul Rahimova, Interviewer Muhayo Kosimova, Interviewer Tahmina Kholova, Interviewer Khatlon 9 Bobojon Alikhonov, Supervisor Mahmadsaid Karimov, Editor Surayo Teshaeva, Interviewer Farishta Habibulloeva, Interviewer Sanavbar Safarbekova, Interviewer Saodat Valieva, Interviewer DRS 10 Zikriyo Homidov, Supervisor Dilbar Nizomova, Editor Ruzigul Bobobekova, Interviewer Zulaykho Kuganova, Interviewer Zarina Gulomjonova, Interviewer Zamira Zohidova, Interviewer Zarina Mansurova, Interviewer DRS 11 Gulizor Gadoeva, Supervisor Davron Shoibroimov, Editor Nargis Sharipova, Interviewer Kibriyo Bekova, Interviewer Mehrubon Boboeva, Interviewer Sharofat Ganieva, Interviewer DRS 12 Ilhom Nabiev, Supervisor Nigina Davlyatova, Editor Gulshoda Shovalieva, Interviewer Kholida Saidova, Interviewer Nilufar Huseynova, Interviewer Sabzina Minakova, Interviewer Mamlakat Akbarova, Interviewer Appendix D • 261 GBAO 13 Shahlo Giyosova, Supervisor Satrimo Zamirova, Editor Mahingul Murodalieva, Interviewer Sayligul Garibmamadova, Interviewer Rukiya Tashbekova, Interviewer Zebuniso Kishkorova, Interviewer GBAO 14 Gulrukhsor Rakamova, Supervisor Zuhro Shukrihudoeva, Editor Ozodamoh Nazirova, Interviewer Davlat Rajushchova, Interviewer Tojigul Ochibangieva, Interviewer Amonbegim Bandalieva, Interviewer Regional Coordinators for DHS Field Work/ Heads of Regional Offices of the SA Kiemiddin Norov, Dushanbe Matluba Yusupova, Sughd Yusuf Safarov, Khatlon Saidkabar Kurbanov, DRS Firdaus Asmatbekov, GBAO Data Entry Staff Shohida Sherova Mahmadyusuf Siddikov Sveta Shley Abdugaffor Sharipov Meroj Hojiev Safargul Hasanova Husein Orzuev Mahmadhuja Mahmadiev Malika Azimova Guli Norbekova P. Jalilova Luda Zakharova Bakhtovar Soliev Tahmina Gafurova Samira Umarova Muhayo Sotieva Firuza Aminova Mavluda Mirzoeva Tojiniso Manonova Aleksandr Kharchenko Robiya Safarova Gulchehra Munavarova Lola Jalilova Diyor Boronov Shahnoza Akhmedova Safiya Sanovbarova Kholniso Shoimardonova Havasmoh Saidova Ganjina Kholova Farhod Ziyoviddinov 262 • Appendix D Listers and Mappers Listers Qayum Buriev Murod Nizomiddinov Oymahmad Ashurov S. Rahmonov S. Abdualimov G. Saidasanov Kh. Mamadayozov G. Dustaliev O. Hamroev Q. Hakimov A. Shohibrohimov K. Rajabov S. Sadiev S. Karimov A. Yunusov F. Kholov F. Ibrogimov Kh. Saidov A. Khujaev F. Mahmudov Mappers Sh. Eshonov H. Nasriddinov J. Usmonov A. Yoftakov J. Jaborov R. Rabiev G. Raqamova Sh. Shamirov A. Qurbonov Sh. Shokirov Yusuf Boymahmadov Q. Odinaev Yusuf Qosimov I. Sangov S. Yatimov Kh. Salomov Kh. Malikov S. Sharifov M. Ashurov A. Gaziev Regional Coordinators for Listing Shodmon Shokirov Nuralisho Sulemunshoev Abdumajid Saydulloev Appendix E • 263 QUESTIONNAIRES APPENDIX E 2012 TAJIKISTAN DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE TAJIKISTAN № THE STATISTICAL AGENCY UNDER PRESIDENT OF THE REPUBLIC OF TAJIKISTAN THE MINISTRY OF HEALTH IDENTIFICATION PLACE NAME NAME OF HOUSEHOLD HEAD CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. NUMBER RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: 1 COMPLETED TOTAL PERSONS 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT IN HOUSEHOLD AT HOME AT TIME OF VISIT 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 4 POSTPONED TOTAL ELIGIBLE 5 REFUSED WOMEN 6 DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER (SPECIFY) LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE LANGUAGE OF LANGUAGE OF NATIVE LANGUAGE TRANSLATOR USED QUESTIONNAIRE: INTERVIEW: OF RESPONDENT (YES = 1, NO = 2) CODES: TAJIK-1; RUSSIAN-2 ; UZBEK-3; OTHER-6 (SPECIFY_________) SUPERVISOR FIELD EDITOR NAME NAME EDITOR OFFICE KEYED BY 1 2 3 HH-1 THIS PAGE IS INTENTIONALLY BLANK HH-2 INTRODUCTION AND CONSENT GIVE CARD WITH CONTACT INFORMATION SIGNATURE OF INTERVIEWER: DATE: . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . 2 ENDRESPONDENT AGREES TO BE INTERVIEWED Do you have any questions? May I begin the interview now? Hello. My name is _______________________________________. I am working with the Statistical Agency. Together with the Ministry of Health we are conducting a survey about health all over Tajikistan. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact the person listed on this card. HH-3 IF AGE 15 IF AGE OR OLDER 0-4 YEARS LINE USUAL RESIDENTS AND AGE NO. VISITORS 1 9 11 CIRCLE CIRCLE LINE LINE NUMBER NUMBER OF ALL OF ALL IF 95 WOMEN CHILDREN IF NO, PROBE: OR MORE, 1 = MARRIED AGE AGE 0-5 SEE CODES RECORD OR LIVING 15-49 BELOW. '95'. TOGETHER AFTER LISTING THE 2 = DIVORCED/ NAMES AND RECORDING SEPARATED THE RELATIONSHIP 3 = WIDOWED AND SEX FOR EACH 4 = NEVER- 1 = HAS PERSON, ASK MARRIED CERTIFICATE QUESTIONS 2A-2C AND 2=REGISTERED TO BE SURE THAT THE NEVER 3 = NEITHER LISTING IS COMPLETE. LIVED 8 = DON'T TOGETHER KNOW THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-19 FOR EACH PERSON. M F Y N Y N IN YEARS 01 1 2 1 2 1 2 01 01 02 1 2 1 2 1 2 02 02 RESIDENCE MARITAL STATUS Does (NAME) usually live here? ELIGIBILITY HOUSEHOLD SCHEDULE RELATIONSHIP TO HEAD OF HOUSEHOLD How old is (NAME)? What is (NAME)'s current marital status? 8 SEX Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household? 2 3 4 75 6 Is (NAME) male or female? Did (NAME) stay here last night? BIRTH 11A Does (NAME) have a birth certificate? Has (NAME)'s birth ever been registered with the civil th it ? 03 1 2 1 2 1 2 03 03 04 1 2 1 2 1 2 04 04 05 1 2 1 2 1 2 05 05 06 1 2 1 2 1 2 06 06 07 1 2 1 2 1 2 07 07 08 1 2 1 2 1 2 08 08 09 1 2 1 2 1 2 09 09 10 1 2 1 2 1 2 10 10 CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD 01 = HEAD 08 = BROTHER OR SISTER 02 = WIFE OR HUSBAND 09 = OTHER RELATIVE 03 = SON OR DAUGHTER 10 = ADOPTED/FOSTER/ 04 = SON-IN-LAW OR STEPCHILD DAUGHTER-IN-LAW 11 = NOT RELATED 05 = GRANDCHILD 98 = DON'T KNOW 06 = PARENT 07 = PARENT-IN-LAW HH-4 IF AGE 0-17 YEARS IF AGE 3 YEARS OR OLDER LINE SURVIVORSHIP AND RESIDENCE OF EVER ATTENDED CURRENT/RECENT NO. BIOLOGICAL PARENTS SCHOOL OR PRE-SCHOOL SCHOOL OR PRE-SCHOOL ATTENDANCE What is the total number of years of schooling (NAME) has had? SEE CODES BELOW. SEE CODES BELOW. IF YES: IF YES: RECORD RECORD SEE CODES MOTHER'S FATHER'S BELOW. LINE LINE NUMBER. NUMBER. IF NO, IF NO, RECORD RECORD '00'. '00'. Y N DK Y N DK Y N LEVEL GRADE Y N Y N LEVEL GRADE 01 1 2 8 1 2 8 1 2 1 2 1 2 GO TO 14 GO TO 16 NEXT LINE NEXT LINE 02 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE IF AGE 3-24 YEARS During 2011- 2012 school year, what level and grade [is/was] (NAME) attending? 18 1914 15 Has (NAME) ever attended school or pre- school? What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level? Did (NAME) attend school or pre- school at any time during the (2011- 2012) school year? Does (NAME)'s natural mother usually live in this household or was she a guest last night? What is her name? 12 13 Does (NAME)'s natural father usually live in this household or was he a guest last night? Is (NAME)'s natural mother alive? 16 Is (NAME)'s natural father alive? What is his name? Did (NAME) receive a diploma (attestat) for completing secondary education? 17A16A 17 CHECK 17: IF GRADES10- 11 AT LEVEL 1, OR LEVEL "2" OR "3" PROFESSIO NAL- PRIMARY OR MIDDLE LEVEL RECORDED, ASK: 03 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 04 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 05 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 06 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 07 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 08 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 09 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 10 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE CODES FOR Qs. 17 AND 19: EDUCATION LEVEL GRADE 0 = PRE-SCHOOL (1-4 ) 1 = GENERAL EDUCATION SCHOOL (1-11 )00 = LESS THAN 1 YEAR COMPLETED 2 = PROFESSIONAL PRIMARY (1-3) (USE '00' FOR Q. 17 ONLY. 3= PROF. MIDDLE (1-4) THIS CODE IS NOT ALLOWED 4 = HIGHER (1-5+) FOR Q. 19) 5 = POSTGRADUATE 98 = DON'T KNOW 8 = DON'T KNOW HH-5 IF AGE 15 IF AGE OR OLDER 0-4 YEARS LINE USUAL RESIDENTS AND AGE NO. VISITORS 1 9 11 CIRCLE CIRCLE LINE LINE NUMBER NUMBER OF ALL OF ALL IF 95 WOMEN CHILDREN IF NO, PROBE: OR MORE, 1 = MARRIED AGE AGE 0-5 SEE CODES RECORD OR LIVING 15-49 BELOW. '95'. TOGETHER AFTER LISTING THE 2 = DIVORCED/ NAMES AND RECORDING SEPARATED THE RELATIONSHIP 3 = WIDOWED AND SEX FOR EACH 4 = NEVER- 1 = HAS PERSON, ASK MARRIED CERTIFICATE QUESTIONS 2A-2C AND 2=REGISTERED TO BE SURE THAT THE NEVER 3 = NEITHER LISTING IS COMPLETE. LIVED 8 = DON'T TOGETHER KNOW THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-19 FOR EACH PERSON. RESIDENCE MARITAL STATUS Does (NAME) usually live here? ELIGIBILITYRELATIONSHIP TO HEAD OF HOUSEHOLD How old is (NAME)? What is (NAME)'s current marital status? 8 SEX Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household? 2 3 4 75 6 Is (NAME) male or female? Did (NAME) stay here last night? BIRTH 11A Does (NAME) have a birth certificate? Has (NAME)'s birth ever been registered with the civil th it ? M F Y N Y N 11 1 2 1 2 1 2 11 11 12 1 2 1 2 1 2 12 12 13 1 2 1 2 1 2 13 13 IN YEARS 14 1 2 1 2 1 2 14 14 15 1 2 1 2 1 2 15 15 16 1 2 1 2 1 2 16 16 17 1 2 1 2 1 2 17 17 18 1 2 1 2 1 2 18 18 19 1 2 1 2 1 2 19 19 20 1 2 1 2 1 2 20 20 TICK HERE IF CONTINUATION SHEET USED CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD 01 = HEAD 08 = BROTHER OR SISTER 02 = WIFE OR HUSBAND 09 = OTHER RELATIVE YES NO 03 = SON OR DAUGHTER 10 = ADOPTED/FOSTER/ 04 = SON-IN-LAW OR STEPCHILD DAUGHTER-IN-LAW 11 = NOT RELATED YES NO 05 = GRANDCHILD 98 = DON'T KNOW 06 = PARENT 07 = PARENT-IN-LAW YES NO ADD TO TABLE ADD TO TABLE ADD TO TABLE 2A) Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed? 2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here? 2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed? HH-6 IF AGE 0-17 YEARS IF AGE 3 YEARS OR OLDER LINE SURVIVORSHIP AND RESIDENCE OF EVER ATTENDED CURRENT/RECENT NO. BIOLOGICAL PARENTS SCHOOL OR PRE-SCHOOL SCHOOL OR PRE-SCHOOL ATTENDANCE What is the total number of years of schooling (NAME) has had? SEE CODES BELOW. SEE CODES BELOW. IF YES: IF YES: RECORD RECORD SEE CODES MOTHER'S FATHER'S BELOW. LINE LINE NUMBER. NUMBER. IF NO, IF NO, RECORD RECORD '00'. '00'. IF AGE 3-24 YEARS During 2011- 2012 school year, what level and grade [is/was] (NAME) attending? 18 1914 15 Has (NAME) ever attended school or pre- school? What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level? Did (NAME) attend school or pre- school at any time during the (2011- 2012) school year? Does (NAME)'s natural mother usually live in this household or was she a guest last night? What is her name? 12 13 Does (NAME)'s natural father usually live in this household or was he a guest last night? Is (NAME)'s natural mother alive? 16 Is (NAME)'s natural father alive? What is his name? Did (NAME) receive a diploma (attestat) for completing secondary education? 17A16A 17 CHECK 17: IF GRADES10- 11 AT LEVEL 1, OR LEVEL "2" OR "3" PROFESSIO NAL- PRIMARY OR MIDDLE LEVEL RECORDED, ASK: Y N DK Y N DK Y N LEVEL GRADE Y N LEVEL GRADE 11 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 12 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 13 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 14 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 15 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 16 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 17 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 18 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 19 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE 20 1 2 8 1 2 8 1 2 Y N 1 2 GO TO 14 GO TO 16 NEXT LINE 1 2 NEXT LINE CODES FOR Qs. 17 AND 19: EDUCATION LEVEL GRADE 0 = PRE-SCHOOL (1-4 ) 1 = GENERAL EDUCATION SCHOOL (1-11 ) 00 = LESS THAN 1 YEAR COMPLETED 2 = PROFESSIONAL PRIMARY (1-3) (USE '00' FOR Q. 17 ONLY. 3 = PROF. MIDDLE (1-4) THIS CODE IS NOT ALLOWED 4 = HIGHER (1-5+) FOR Q. 19) 5 = POSTGRADUATE 98 = DON'T KNOW 8 = DON'T KNOW HH-7 NO. QUESTIONS AND FILTERS SKIP 101 DAILY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 WEEKLY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 MONTHLY . . . . . . . . . . . . . . . . . . . . . . . . . . 3 LESS THAN MONTHLY . . . . . . . . . . . . . . . . 4 NEVER . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 102 PIPED WATER PIPED INTO DWELLING . . . . . . . . . . . . 11 PIPED TO YARD/PLOT . . . . . . . . . . . . . . 12 105 PUBLIC TAP/STANDPIPE . . . . . . . . . . . . 13 TUBE WELL OR BOREHOLE . . . . . . . . . . . . 21 DUG WELL PROTECTED WELL . . . . . . . . . . . . . . . . 31 UNPROTECTED WELL . . . . . . . . . . . . . . 32 WATER FROM SPRING PROTECTED SPRING . . . . . . . . . . . . . . 41 UNPROTECTED SPRING . . . . . . . . . . . . 42 RAINWATER . . . . . . . . . . . . . . . . . . . . . . . . 51 105 TANKER TRUCK . . . . . . . . . . . . . . . . . . . . 61 CART WITH SMALL TANK . . . . . . . . . . . . 71 SURFACE WATER (RIVER/DAM/ LAKE/POND/STREAM/CANAL/ IRRIGATION CHANNEL) . . . . . . . . . . . . 81 BOTTLED WATER . . . . . . . . . . . . . . . . . . . . 91 OTHER 96 (SPECIFY) 103 IN OWN DWELLING . . . . . . . . . . . . . . . . . . 1 IN OWN YARD/PLOT . . . . . . . . . . . . . . . . 2 105 ELSEWHERE . . . . . . . . . . . . . . . . . . . . . . 3 How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never? What is the main source of drinking water for members of your household? Where is that water source located? HOUSEHOLD CHARACTERISTICS CODING CATEGORIES 104 MINUTES . . . . . . . . . . . . . . . . DON'T KNOW . . . . . . . . . . . . . . . . . . . . 998 105 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . 8 107 106 BOIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A ADD BLEACH/CHLORINE . . . . . . . . . . . . B STRAIN THROUGH A CLOTH . . . . . . . . . C USE WATER FILTER (CERAMIC/ SAND/COMPOSITE/ETC.) . . . . . . . . . . . . D RECORD ALL MENTIONED. SOLAR DISINFECTION . . . . . . . . . . . . . . . . E LET IT STAND AND SETTLE . . . . . . . . . . . . F OTHER X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . Z How long does it take to go there, get water, and come back? Do you do anything to the water to make it safer to drink? What do you usually do to make the water safer to drink? Anything else? HH-8 NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 107 FLUSH OR POUR FLUSH TOILET FLUSH TO PIPED SEWER SYSTEM . . . . . . . . . . . . . . . . . . . . . . 11 FLUSH TO SEPTIC TANK . . . . . . . . . . . . 12 FLUSH TO PIT LATRINE . . . . . . . . . . . . 13 FLUSH TO SOMEWHERE ELSE . . . . . . . 14 FLUSH, DON'T KNOW WHERE . . . . . . . 15 PIT LATRINE VENTILATED IMPROVED PIT LATRINE . . . . . . . . . . . . . . . . . . . . 21 PIT LATRINE WITH SLAB . . . . . . . . . . . . 22 PIT LATRINE WITHOUT SLAB/ OPEN PIT . . . . . . . . . . . . . . . . . . . . . . 23 COMPOSTING TOILET . . . . . . . . . . . . . . . . 31 BUCKET TOILET . . . . . . . . . . . . . . . . . . . . 41 HANGING TOILET/HANGING LATRINE . . . . . . . . . . . . . . . . . . . . . . . . . . 51 NO FACILITY/BUSH/FIELD . . . . . . . . . . . . 61 110 OTHER 96 (SPECIFY) 108 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 110 109 NO. OF HOUSEHOLDS IF LESS THAN 10 . . . . . . . . . 10 OR MORE HOUSEHOLDS . . . . . . . 95 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 110 YES NO ELECTRICITY . . . . . . . . . . . . . . 1 2 RADIO . . . . . . . . . . . . . . . . . . . . 1 2 Electricity? A radio? Do you share this toilet facility with other households? How many households use this toilet facility? What kind of toilet facility do members of your household usually use? Does your household have: 0 A black and white television? B&W TELEVISI . . . . . . . . . . . . . . 1 2 COLOR TELEVISION . . . . . 1 2 A washing machine? WASHING MACHINE . . . . . 1 2 A vacuum cleaner? VACUUM CLEANER . . . . . 1 2 A computer? COMPUTER . . . . . . . . . . . . . . 1 2 MOBILE TELEPHONE . . . . . 1 2 NON-MOBILE TELEPHONE . . . 1 2 REFRIGERATOR . . . . . . . . . 1 2 A digital camera? CAMERA . . . . . . . . . . . . . . 1 2 A video camera/camcorder? VIDEOCAMERA . . . . . . . . . 1 2 A table/hon-tohta? TABLE . . . . . . . . . 1 2 A chair? CHAIR . . . . . . . . . 1 2 A sofa/divan? SOFA . . . . . . . . . 1 2 A bed? BED . . . . . . . . . 1 2 A buffet/curio cabinet/wall unit? BUFFET . . . . . . . . . . . . . . 1 2 An air conditioner? AIRCONDITIONER . . . . . . . . . 1 2 A DVD player? DVD . . . . . . . . . 1 2 A Satellite antenna/dish? DISH . . . . . . . . . 1 2 A freezer? FREEZER . . . . . . . . . 1 2 An electric fan? FAN . . . . . . . . . . . . . . . . . . . 1 2 A sewing machine? SEWING MACHINE . . . . . . . . . 1 2 A wood/coal/gas stove (in-door heater "burzhuika")? BURZHUIKA . . . . . . . . . . . . . . 1 2 A mini-generator ("dvizhok")? DVIZHOK 1 2 A fuel or wood stock WOOD/FUEL . . . . . . . . . . . . . . 1 2 A carpet (handmade or machine made)? CARPET . . . . . . . . . . . . . . . . . . . . 1 2 A connection to the Internet (world wide web)? INTERNET CONNECTION. . . . . . . 1 2 A non-mobile telephone? A refrigerator? A color television? A mobile telephone? HH-9 NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 111 ELECTRICITY . . . . . . . . . . . . . . . . . . . . . . . . 01 LPG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02 NATURAL GAS . . . . . . . . . . . . . . . . . . . . . . 03 BIOGAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 KEROSENE . . . . . . . . . . . . . . . . . . . . . . . . 05 COAL, LIGNITE . . . . . . . . . . . . . . . . . . . . . . 06 CHARCOAL . . . . . . . . . . . . . . . . . . . . . . . . 07 WOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08 STRAW/SHRUBS/GRASS . . . . . . . . . . . . . . 09 AGRICULTURAL CROP . . . . . . . . . . . . . . . . 10 ANIMAL DUNG . . . . . . . . . . . . . . . . . . . . . . 11 NO FOOD COOKED IN HOUSEHOLD . . . . . . . . . . . . . . . . . . . . 95 114 OTHER 96 (SPECIFY) 112 IN THE HOUSE . . . . . . . . . . . . . . . . . . . . . . 1 IN A SEPARATE BUILDING . . . . . . . . . . . . 2 OUTDOORS . . . . . . . . . . . . . . . . . . . . . . . . 3 OTHER 6 (SPECIFY) 113 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 114 MAIN MATERIAL OF THE FLOOR. NATURAL FLOOR EARTH/SAND . . . . . . . . . . . . . . . . . . . . 11 RECORD OBSERVATION. RUDIMENTARY FLOOR WOOD PLANKS . . . . . . . . . . . . . . . . . . 21 FINISHED FLOOR PARQUET OR POLISHED WOOD 31 114 Do you have a separate room which is used as a kitchen? What type of fuel does your household mainly use for cooking? Is the cooking usually done in the house, in a separate building, or outdoors? WOOD . . . . . . . . . . . . . . . . . . . . . . . . 31 VINYL OR LINOLEUM . . . . . . . 32 CERAMIC TILES . . . . . . . . . . . . . . . . . . 33 CEMENT . . . . . . . . . . . . . . . . . . . . . . . . 34 CARPET . . . . . . . . . . . . . . . . . . . . . . . . . . 35 OTHER 96 (SPECIFY) 115 MAIN MATERIAL OF THE ROOF. NATURAL ROOFING NO ROOF . . . . . . . . . . . . . . . . . . . . . . . . 11 RECORD OBSERVATION. THATCH . . . . . . . . . . . . . . . . 12 SOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 RUDIMENTARY ROOFING WOOD PLANKS . . . . . . . . . . . . . . . . . . . . 23 CARDBOARD . . . . . . . . . . . . . . . . . . . . 24 FINISHED ROOFING METAL . . . . . . . . . . . . . . . . . . . . . . . . . . 31 WOOD . . . . . . . . . . . . . . . . . . . . . . . . . . 32 CALAMINE/CEMENT FIBER . . . . . . . . . 33 CERAMIC TILES . . . . . . . . . . . . . . . . . . . . 34 CEMENT/CEMENT BLOCKS 35 ROOFING SHINGLES/SHIFER . . . . . . . . . 36 TAULE (TARRED ROOFING PAPER) . . . . 37 OTHER 96 (SPECIFY) HH-10 NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 116 MAIN MATERIAL OF THE EXTERIOR WALLS. NATURAL WALLS NO WALLS . . . . . . . . . . . . . . . . . . . . . . . . 11 RECORD OBSERVATION. CANE/TRUNKS . . . . . . . . . . . . . . 12 DIRT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 RUDIMENTARY WALLS STONE WITH MUD . . . . . . . . . . . . . . . . 22 UNCOVERED ADOBE . . . . . . . . . . . . . . 23 PLYWOOD . . . . . . . . . . . . . . . . . . . . . . 24 CARDBOARD . . . . . . . . . . . . . . . . . . . . 25 REUSED WOOD . . . . . . . . . . . . . . . . . . 26 FINISHED WALLS CEMENT . . . . . . . . . . . . . . . . . . . . . . . . 31 STONE WITH LIME/CEMENT . . . . . . . . . 32 BRICKS . . . . . . . . . . . . . . . . . . . . . . . . . . 33 CEMENT BLOCKS . . . . . . . . . . . . . . . . . . 34 COVERED ADOBE . . . . . . . . . . . . . . . . 35 WOOD PLANKS/SHINGLES . . . . . . . . . 36 OTHER 96 (SPECIFY) 117 ROOMS . . . . . . . . . . . . . . . . . . . . . . 118 YES NO WATCH . . . . . . . . . . . . . . . . . . 1 2 BICYCLE . . . . . . . . . . . . . . . . . . 1 2 MOTORCYCLE/SCOOTER . . . 1 2 ANIMAL-DRAWN CART . . . . . 1 2 CAR/TRUCK . . . . . . . . . . . . . . 1 2 119 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 121 An animal-drawn cart? A car or truck? A bicycle? A motorcycle or motor scooter? How many rooms in this household are used for sleeping? Does any member of this household own: Does any member of this household own any agricultural land? A watch? 120 ARE (SOTKA) . . . . . . . 1 . HECTARES . . . . . . . . . 2 . IF 99.5 OR MORE ARES, RECORD IN HECTARES. 100 ARES= 1 HECTAR 95 OR MORE HECTARES . . . . . . . . . . . . 9950 IF 95 OR MORE HECTARES, CIRCLE '9950'. DON'T KNOW . . . . . . . . . . . . . . . . . . . . 9998 121 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 123 Does this household own any livestock, herds, other farm animals, beehives or poultry? How many hectares of agricultural land do members of this household own? HH-11 NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 122 IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. IF UNKNOWN, ENTER '98'. CATTLE . . . . . . . . . . . . . . . . . . . . . . COWS/BULLS . . . . . . . . . . . . . . . . HORSES/DONKEYS/MULES . . . . . GOATS . . . . . . . . . . . . . . . . . . . . . . SHEEP . . . . . . . . . . . . . . . . . . . . . . PIGS . . . . . . . . . . . . . . . . . . . . . . RABBITS . . . . . . . . . . . . . . . . . . . . . . POULTRY . . . . . . . . . . . . . . . . . . BEEHIVE . . . . . . . . . . . . . . . . . . . . 123 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 137 OBSERVED . . . . . . . . . . . . . . . . . . . . . . . . 1 NOT OBSERVED, NOT IN DWELLING/YARD/PLOT . . . . . . . 2 NOT OBSERVED, NO PERMISSION TO SEE . . . . . . . . . . . 3 NOT OBSERVED, OTHER REASON . . . . . 4 (SKIP TO 140) Does any member of this household have a bank account? Horses, donkeys, or mules? Please show me where members of your household most often wash their hands. Goats? Poultry? Beehive (number of units)? How many of the following animals does this household own? Cattle? Milk cows or bulls? Sheep? Rabbits? Pigs? (SKIP TO 140) 138 OBSERVATION ONLY: WATER IS AVAILABLE . . . . . . . . . . . . . . 1 WATER IS NOT AVAILABLE . . . . . . . . . . . . 2 OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. 139 OBSERVATION ONLY: SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) . . . A OBSERVE PRESENCE OF SOAP, DETERGENT, OR ASH, MUD, SAND . . . . . . . . . . . . . . . . . . . . B OTHER CLEANSING AGENT. NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C 140 ASK RESPONDENT FOR A TEASPOONFUL OF 0 PPM (NO IODINE) . . . . . . . . . . . . . . . . . . . 1 COOKING SALT. BELOW 15 PPM . . . . . . . . . . . . . . . . . . . 2 15 PPM AND ABOVE . . . . . . . . . . . . . . . . . . . 3 TEST SALT FOR IODINE. NO SALT IN HH . . . . . . . . . . . . . . . . . . . 4 SALT NOT TESTED 6 (SPECIFY REASON) HH-12 320 INSTRUCTIONS TABLE FOR SELECTION OF ONE WOMAN FOR THE DOMESTIC VIOLENCE INTERVIEW • LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. • THIS IS THE ROW NUMBER YOU SHOULD CIRCLE IN THE TABLE BELOW. • RECORD HERE____ ____ THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE: • THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE IN THE TABLE BELOW. • FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. • THIS IS THE ORDER (RANK) NUMBER OF THE ELIGIBLE WOMAN WHO WILL BE ASKED THE HOUSEHOLD RELATIONS QUESTIONS. • RECORD THE LINE NUMBER OF THE SELECTED WOMAN IN THE BOX BELOW IN Q321 FOR EXAMPLE: • IF THE HOUSEHOLD QUESTIONNAIRE NUMBER IS ‘3716’, • GO TO ROW 6 AND CIRCLE THE ROW NUMBER ('6'). • IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, RECORD IN THE BOX "03" AND GO TO COLUMN 3 AND CIRCLE THE COLUMN NUMBER ('3'). • DRAW LINES FROM ROW 6 AND COLUMN 3 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT (‘2'). • THIS IS THE ORDER/RANK NUMBER OF THE SELECTED WOMEN IN THE HOUSEHOLD SCHEDULE AND IT MEANS YOU HAVE TO SELECT THE SECOND ELIGIBLE WOMAN. • SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE WOMEN ARE ‘02', ‘03', AND ‘07’; THEN THE ELIGIBLE WOMAN FOR THE HOUSEHOLD RELATIONS QUESTIONS IS THE SECOND ELIGIBLE WOMAN, I.E., THE WOMAN WITH HOUSEHOLD LINE NUMBER ‘03'. • RECORD THE LINE NUMBER OF THE SELECTED WOMAN IN THE BOX BELOW IN Q321 LAST DIGIT OF THE QUESTIONNAIRE NUMBER TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD 1 2 3 4 5 6 7 8+ 0 1 2 2 4 3 6 5 4 321 401 RECORD HERE LINE NUMBER OF THE WOMAN SELECTED FOR THE DV MODULE 1 1 1 3 1 4 1 6 5 2 1 2 1 2 5 2 7 6 3 1 1 2 3 1 3 1 7 4 1 2 3 4 2 4 2 8 5 1 1 1 1 3 5 3 1 6 1 2 2 2 4 6 4 2 7 1 1 3 3 5 1 5 3 8 1 2 1 4 1 2 6 4 3 7 59 1 1 2 1 2 HH-13 WEIGHTAND HEIGHT MEASUREMENTS FOR CHILDREN AGE 0-5 401 CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 402. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). CHILD 1 CHILD 2 CHILD 3 402 LINE NUMBER FROM COLUMN 11 LINE LINE LINE NUMBER . . . . . NUMBER . . . . . NUMBER . . . . . NAME FROM COLUMN 2 NAME NAME NAME 403 IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH DAY . . . . . . . . . . DAY . . . . . . . . . . DAY . . . . . . . . . . FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT MONTH . . . . . MONTH . . . . . MONTH . . . . . INTERVIEWED, ASK: YEAR YEAR YEAR 404 CHECK 403: YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 CHILD BORN IN JANUARY NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 2007 OR LATER? (GO TO 403 FOR NEXT (GO TO 403 FOR NEXT (GO TO 403 FOR NEXT CHILD OR, IF NO CHILD OR, IF NO CHILD OR, IF NO MORE CHILDREN, MORE CHILDREN, MORE CHILDREN, GO TO 414) GO TO 414) GO TO 414) 405 WEIGHT IN KILOGRAMS KG. . KG. . KG. . NOT PRESENT . . . 9994 NOT PRESENT . . . 9994 NOT PRESENT . . . 9994 REFUSED . . . . . . . 9995 REFUSED . . . . . . . 9995 REFUSED . . . . . . . 9995 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 406 HEIGHT IN CENTIMETERS CM. . CM. . CM. . NOT PRESENT . . . 9994 NOT PRESENT . . . 9994 NOT PRESENT . . . 9994 REFUSED . . . . . . . 9995 REFUSED . . . . . . . 9995 REFUSED . . . . . . . 9995 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 407 MEASURED LYING DOWN OR LYING DOWN . . . . . . . 1 LYING DOWN . . . . . . . 1 LYING DOWN . . . . . . . 1 STANDING UP? STANDING UP 2 STANDING UP 2 STANDING UP 2 What is (NAME)'s birth date? STANDING UP? STANDING UP . . . . . . . 2 STANDING UP . . . . . . . 2 STANDING UP . . . . . . . 2 NOT MEASURED . . . . . 3 NOT MEASURED . . . . . 3 NOT MEASURED . . . . . 3 413 GO BACK TO 403 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 414. HH-14 CHILD 4 CHILD 5 CHILD 6 402 LINE NUMBER FROM COLUMN 11 LINE LINE LINE NUMBER . . . . . NUMBER . . . . . NUMBER . . . . . NAME FROM COLUMN 2 NAME NAME NAME 403 IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH DAY . . . . . . . . . . DAY . . . . . . . . . . DAY . . . . . . . . . . FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT MONTH . . . . . MONTH . . . . . MONTH . . . . . INTERVIEWED, ASK: YEAR YEAR YEAR 404 CHECK 403: YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 CHILD BORN IN JANUARY NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 2007 OR LATER? (GO TO 403 FOR NEXT (GO TO 403 FOR NEXT (GO TO 403 IN FIRST CHILD OR, IF NO CHILD OR, IF NO COLUMN OF NEW MORE CHILDREN, MORE CHILDREN, QUESTIONNAIRE; OR, GO TO 414) GO TO 414) IF NO MORE CHILDREN, GO TO 414) 405 WEIGHT IN KILOGRAMS KG. . KG. . KG. . NOT PRESENT. . . . . 9994 NOT PRESENT. . . . . 9994 NOT PRESENT. . . . . 9994 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 406 HEIGHT IN CENTIMETERS CM. . CM. . CM. . NOT PRESENT . . . 9994 NOT PRESENT . . . 9994 NOT PRESENT . . . 9994 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 OTHER . . . . . . . . . . 9996 407 MEASURED LYING DOWN OR LYING DOWN . . . . . . . . 1 LYING DOWN . . . . . . . . 1 LYING DOWN . . . . . . . . 1 STANDING UP? STANDING UP . . . . . . . . 2 STANDING UP . . . . . . . . 2 STANDING UP . . . . . . . . 2 NOT MEASURED 3 NOT MEASURED 3 NOT MEASURED 3 What is (NAME)'s birth date? NOT MEASURED . . . . . 3 NOT MEASURED . . . . . 3 NOT MEASURED . . . . . 3 413 GO BACK TO 403 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE CHILDREN, GO TO 414. HH-15 WEIGHT AND HEIGHT MEASUREMENTS FOR WOMEN AGE 15-49 414 CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 415. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). WOMAN 1 WOMAN 2 WOMAN 3 415 LINE NUMBER LINE LINE LINE FROM COLUMN 9 NUMBER . . . . . . . . . . . . NUMBER . . . . . . . . . . . . NUMBER . . . . . . . . . . . . NAME FROM COLUMN 2 NAME NAME NAME 416 WEIGHT IN KILOGRAMS KG. . KG. . KG. . NOT PRESENT . . . . . . . . . . 99994 NOT PRESENT . . . . . . . . . . 99994 NOT PRESENT . . . . . . . . . . 99994 REFUSED . . . . . . . . . . . . . . 99995 REFUSED . . . . . . . . . . . . . . 99995 REFUSED . . . . . . . . . . . . . . 99995 OTHER . . . . . . . . . . . . . . . . 99996 OTHER . . . . . . . . . . . . . . . . 99996 OTHER . . . . . . . . . . . . . . . . 99996 417 HEIGHT IN CENTIMETERS CM. . CM. . CM. . NOT PRESENT . . . . . . . . . . . . 9994 NOT PRESENT . . . . . . . . . . . . 9994 NOT PRESENT . . . . . . . . . . . . 9994 REFUSED . . . . . . . . . . . . . . . . 9995 REFUSED . . . . . . . . . . . . . . . . 9995 REFUSED . . . . . . . . . . . . . . . . 9995 OTHER . . . . . . . . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . . . . . . . . 9996 442 GO BACK TO 416 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END INTERVEIW HH-16 WEIGHT AND HEIGHT MEASUREMENTS FOR WOMEN AGE 15-49 414 CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 415. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). WOMAN 4 WOMAN 5 WOMAN 6 415 LINE NUMBER LINE LINE LINE FROM COLUMN 9 NUMBER . . . . . . . . . . . . NUMBER . . . . . . . . . . . . NUMBER . . . . . . . . . . . . NAME FROM COLUMN 2 NAME NAME NAME 416 WEIGHT IN KILOGRAMS KG. . KG. . KG. . NOT PRESENT . . . . . . . . . . 99994 NOT PRESENT . . . . . . . . . . 99994 NOT PRESENT . . . . . . . . . . 99994 REFUSED . . . . . . . . . . . . . . 99995 REFUSED . . . . . . . . . . . . . . 99995 REFUSED . . . . . . . . . . . . . . 99995 OTHER . . . . . . . . . . . . . . . . 99996 OTHER . . . . . . . . . . . . . . . . 99996 OTHER . . . . . . . . . . . . . . . . 99996 417 HEIGHT IN CENTIMETERS CM. . CM. . CM. . NOT PRESENT . . . . . . . . . . . . 9994 NOT PRESENT . . . . . . . . . . . . 9994 NOT PRESENT . . . . . . . . . . . . 9994 REFUSED . . . . . . . . . . . . . . . . 9995 REFUSED . . . . . . . . . . . . . . . . 9995 REFUSED . . . . . . . . . . . . . . . . 9995 OTHER . . . . . . . . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . . . . . . . . 9996 442 GO BACK TO 416 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END INTERVEIW HH-17 2012 TAJIKISTAN DEMOGRAPHIC AND HEALTH SURVEY WOMAN'S QUESTIONNAIRE TAJIKISTAN THE STATISTICAL AGENCY UNDER PRESIDENT OF THE REPUBLIC OF TAJIKISTAN THE MINISTRY OF HEALTH IDENTIFICATION PLACE NAME NAME OF HOUSEHOLD HEAD CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME AND LINE NUMBER OF WOMAN CHECK QUESTION 321 IN THE HOUSEHOLD QUESTIONNAIRE. IS THIS WOMAN SELECTED FOR QUESTIONS IN "SECTION 11-DV" ? . . . . . . . . . . . . (YES = 1, NO=2) INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. NUMBER RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: 1 COMPLETED 4 REFUSED 2 NOT AT HOME 5 PARTLY COMPLETED 7 OTHER 3 POSTPONED 6 INCAPACITATED (SPECIFY) LANGUAGE OF LANGUAGE OF NATIVE LANGUAGE TRANSLATOR USED QUESTIONNAIRE: INTERVIEW: OF RESPONDENT (YES = 1, NO = 2) CODES: TAJIK-1; RUSSIAN-2 ; UZBEK-3; OTHER-6 (SPECIFY_________) SUPERVISOR FIELD EDITOR NAME NAME EDITOR OFFICE KEYED BY 1 2 3 W-1 SECTION 1. RESPONDENT'S BACKGROUND INTRODUCTION AND CONSENT INFORMED CONSENT SIGNATURE OF INTERVIEWER: DATE: RESPONDENT AGREES TO BE INTERVIEWED . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . 2 END NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 RECORD THE TIME. HOUR . . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . . . 102 MONTH . . . . . . . . . . . . . . . . . . . DON'T KNOW MONTH . . . . . . . . . . . . 98 YEAR . . . . . . . . . . . . DON'T KNOW YEAR . . . . . . . . . . . . 9998 103 AGE IN COMPLETED YEARS COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT. 104 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 110 104A What is the total number of years of schooling you have had? YEARS OF SCHOOLING . . . . . 105 GENERAL SCHOOL . . . . . . . . . . . . . 1 PROFESSIONAL PRIMARY. . . . . . . . . . . . 2 PROFESSIONAL MIDDLE . . . . . . 3 HIGHER . . . . . . . . . . . . . . . . . . . . . . . . 4 POSTGRADUATE . . . . . . . . . . . . . . . 5 106 GRADE/FORM/YEAR . . . . . . . . IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'. 106A CHECK 105 AND 106: OTHER 110 GRADES 10-11 CODES AT LEVEL 1, OR CODES "2" OR "3" PROFESSIONAL-PRIMARY OR PROF. MIDDLE LEVEL CIRCLED,ASK: Did you receive an attestat for completing YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 secondary education? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 110 AT LEAST ONCE A WEEK . . . . . . . . . . 1 LESS THAN ONCE A WEEK . . . . . . . . 2 NOT AT ALL . . . . . . . . . . . . . . . . . . . . . 3 111 AT LEAST ONCE A WEEK . . . . . . . . . . 1 LESS THAN ONCE A WEEK . . . . . . . . 2 NOT AT ALL . . . . . . . . . . . . . . . . . . . . . 3 112 AT LEAST ONCE A WEEK . . . . . . . . . . 1 LESS THAN ONCE A WEEK . . . . . . . . 2 NOT AT ALL . . . . . . . . . . . . . . . . . . . . . 3 115 NUMBER OF TIMES . . . . . . . . NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 201 116 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 In the last 12 months, have you been away from home for more than one month at a time? In the last 12 months, how many times have you been away from home for one or more nights? Do you watch television at least once a week, less than once a week or not at all? What is the highest level of school you attended: general education school, professional primary(uchiliche), professional middle (tekhnikum, college) higher or postgraduate? What is the highest (grade/form/year) you completed at that level? Do you read a newspaper or magazine at least once a week, less than once a week or not at all? Do you listen to the radio at least once a week, less than once a week or not at all? In what month and year were you born? How old were you at your last birthday? Have you ever attended school? Hello. My name is _______________________________________. I am working with the Statistical Agency. Together with the Minsirty of Health we are conducting a survey about health all over Tajikistan. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. Do you have any questions? May I begin the interview now? In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household. W-2 SECTION 2. REPRODUCTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 201 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 206 202 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 204 203 SONS AT HOME . . . . . . . . . . . . DAUGHTERS AT HOME . . . . . IF NONE, RECORD '00'. 204 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 206 205 SONS ELSEWHERE . . . . . . . DAUGHTERS ELSEWHERE IF NONE, RECORD '00'. 206 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 IF NO, PROBE: NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 208 207 BOYS DEAD . . . . . . . . . . . . . . GIRLS DEAD . . . . . . . . . . . . . . IF NONE, RECORD '00'. 207A Were there any other children who were born alive, but who YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 died within a few minutes, hours, or days? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 208 207B CORRECT 207 AND THEN CONTINUE WITH QUESTION 208. 208 SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'. TOTAL BIRTHS . . . . . . . . . . . . 209 CHECK 208: PROBE AND YES NO CORRECT 201-208 AS NECESSARY. 209A Women sometimes have pregnancies which do not result in a live born child. That is, a pregnancy can be ended early by an abortion, a miscarriage, or a stillbirth. I will now ask you about each of them separately. In total, how many abortions have you had? IF NONE, RECORD '00' 209B How many miscarriages? IF NONE, RECORD '00' 209C How many stillbirths? IF NONE, RECORD '00' 209D SUM ANSWERS TO 208, 209A, 209B, 209C, AND ENTER TOTAL. IF NO PREGNANCIES, RECORD '00'. TOTAL . . . . . . . . . . . . . . . . . . . . 210 CHECK 209D: ONE OR MORE NO PREGNANCIES PREGNANCIES 226 Do you have any sons or daughters to whom you have given birth who are alive but do not live with you? How many sons are alive but do not live with you? Now I would like to ask about all the births you have had during your life. Have you ever given birth? Do you have any sons or daughters to whom you have given birth who are now living with you? How many sons live with you? And how many daughters live with you? TOTAL ABORTIONS TOTAL MISCARRIAGES TOTAL STILLBIRTHS Just to make sure that I have this right: you have had in TOTAL _____ pregnancies outcomes during your life. Is that correct? And how many daughters are alive but do not live with you? Have you ever given birth to a boy or girl who was born alive but later died? Any baby who cried or showed signs of life but did not survive? How many boys have died? And how many girls have died? Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct? W-3 21 1 P R E G N A N C Y H IS TO R Y. N ow I w an t t o ta lk a bo ut e ac h of y ou r p re gn an ci es , i nc lu di ng th os e w hi ch e nd ed in a li ve b irt h, a s till bi rth , a m is ca rri ag e, a nd a n in du ce d ab or tio n. S ta rti ng w ith y ou r f irs t p re gn an cy , p le as e te ll m e th e fo llo w in g in fo rm at io n: R E C O R D A LL P R E G A N C IE S . R E C O R D T W IN S A N D T R IP LE TS O N S E P A R A TE L IN E S . I F TH E R E M O R E T H A N 1 5 P R E G A N C IE S U S E A N A D D IT IO N A L Q U E S TI O N N A IR E 22 2A IF A LI V E : IF A LI V E : IF A LI V E : IF D IE D : IF D IE D : D id y ou r ( fir st /n ex t/e tc ) W as th is In w ha t m on th a nd W er e th er e C H E C K 2 12 : W ha t n am e w as Is (N A M E ) Is (N A M E ) H ow o ld Is (N A M E ) R EC O R D H ow o ld w as (N A M E ) pr eg na nc y a si ng le o r ye ar (w as th is c hi ld an y ot he r gi ve n to th is a bo y or st ill al iv e? w as liv in g w ith H O U SE H O LD w he n he /s he d ie d? en d in a li ve b irt h, a m ul tip le bo rn / di d th is pr eg na nc ie s R E C O R D S A M E ch ild ? gi rl? (N A M E ) yo u? LI N E N 0. a st illb irt h , bi rth ? pr eg na nc y en d? ) be tw ee n R E S P O N S E on h is /h er O F C H IL D . IF '1 Y R ', P R O B E : IF N O , P R O B E : a m is ca rr ia ge , th is a nd W R IT E 'B A B Y 1' la st H ow m an y m on th s ol d or a n ab or tio n? th e pr eg na nc y B A B Y 2' , E TC . bi rth da y? w as (N A M E )? w e w er e ju st IF N O N A M E R E C O R D D A YS IF ta lk in g ab ou t? W A S G IV E N R EC O R D LE S S T H A N 1 TO A C H IL D AG E IN R EC O R D '0 0' M O N TH ; M O N TH S IF 1 = H A S C E R TI FI C A TE IF Y E S , A D D C O M PL ET E IF C H IL D N O T LE S S T H A N T W O 2 = R E G IS TE R E D IT T O T A B LE YE AR S LI ST ED IN YE A R S ; O R Y E A R S . 3 = N E IT H E R H O U SE H O LD 8 = D O N 'T K N O W 01 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH S TI LL B IR TH . . 2 YE A R S S TI LL B IR TH . . . . . . 2 M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 02 YE S . . . 1 LI V E B IR TH . . .1 N A M E : B O Y 1 YE S . . 1 A G E IN YE S . 1 LI N E N O .: D A Y S . . 1 D oe s (N A M E ) h av e a de at h ce rti fic at e? H as (N A M E )'s d ea th ev er b ee n re gi st er ed in Z A G S ? 21 2 21 3 21 4 21 5 21 5A 21 6 21 7 21 8 21 9 22 0 22 1 22 2 22 2 G O TO 2 14 0 S O S G S O S LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 03 YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 04 YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 05 YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 22 2 G O TO 2 14 22 2 G O TO 2 14 22 2 G O TO 2 14 22 2 G O TO 2 14 IF A LI V E : IF A LI V E : IF A LI V E : IF D IE D : IF D IE D : D id y ou r n ex t W as th is In w ha t m on th a nd W er e th er e C H E C K 2 12 : W ha t n am e w as Is (N A M E ) Is (N A M E ) H ow o ld Is (N A M E ) R EC O R D H ow o ld w as (N A M E ) pr eg na nc y a si ng le o r ye ar (w as th is c hi ld an y ot he r gi ve n to th is a bo y or st ill al iv e? w as liv in g w ith H O U SE H O LD w he n he /s he d ie d? en d in a li ve b irt h, a m ul tip le bo rn / di d th is pr eg na nc ie s R E C O R D S A M E ch ild ? gi rl? (N A M E ) yo u? LI N E N 0. a st illb irt h , bi rth ? pr eg na nc y en d? ) be tw ee n R E S P O N S E on h is /h er O F C H IL D . IF '1 Y R ', P R O B E : IF N O , P R O B E : a m is ca rr ia ge , th is a nd W R IT E 'B A B Y 1' la st H ow m an y m on th s ol d or a n ab or tio n? th e pr eg na nc y B A B Y 2' , E TC . bi rth da y? w as (N A M E )? w e w er e ju st IF N O N A M E R E C O R D D A YS IF ta lk in g ab ou t? W A S G IV E N R EC O R D LE S S T H A N 1 TO A C H IL D AG E IN R EC O R D '0 0' M O N TH ; M O N TH S IF 1 = H A S C E R TI FI C A TE IF Y E S , A D D C O M PL ET E IF C H IL D N O T LE S S T H A N T W O 2 = R E G IS TE R E D IT T O T A B LE YE AR S LI ST ED IN YE A R S ; O R Y E A R S . 3 = N E IT H E R H O U SE H O LD 8 = D O N 'T K N O W 06 YE S . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 07 YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y D oe s (N A M E ) ha ve a d ea th ce rti fic at e? 21 8 21 9 22 0 22 1 H as (N A M E )'s d ea th ev er b ee n re gi st er ed in Z A G S ? 22 2 G O TO 2 14 22 2 G O TO 2 14 22 2A 21 2 21 3 21 4 21 5 22 2 21 5A 21 6 21 7 08 YE S . . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 09 YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 10 YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 22 2 G O TO 2 14 G O TO 2 14 22 2 G O TO 2 14 22 2 IF A LI V E : IF A LI V E : IF A LI V E : IF D IE D : IF D IE D : D id y ou r n ex t W as th is In w ha t m on th a nd W er e th er e C H E C K 2 12 : W ha t n am e w as Is (N A M E ) Is (N A M E ) H ow o ld Is (N A M E ) R EC O R D H ow o ld w as (N A M E ) pr eg na nc y a si ng le o r ye ar (w as th is c hi ld an y ot he r gi ve n to th is a bo y or st ill al iv e? w as liv in g w ith H O U SE H O LD w he n he /s he d ie d? en d in a li ve b irt h, a m ul tip le bo rn / di d th is pr eg na nc ie s R E C O R D S A M E ch ild ? gi rl? (N A M E ) yo u? LI N E N 0. a st illb irt h , bi rth ? pr eg na nc y en d? ) be tw ee n R E S P O N S E on h is /h er O F C H IL D . IF '1 Y R ', P R O B E : IF N O , P R O B E : a m is ca rr ia ge , th is a nd W R IT E 'B A B Y 1' la st H ow m an y m on th s ol d or a n ab or tio n? th e pr eg na nc y B A B Y 2' , E TC . bi rth da y? w as (N A M E )? w e w er e ju st IF N O N A M E R E C O R D D A YS IF ta lk in g ab ou t? W A S G IV E N R EC O R D LE S S T H A N 1 TO A C H IL D AG E IN R EC O R D '0 0' M O N TH ; M O N TH S IF 1 = H A S C E R TI FI C A IF Y E S , A D D C O M PL ET E IF C H IL D N O T LE S S T H A N T W O 2 = R E G IS TE R E D IT T O T A B LE YE AR S LI ST ED IN YE A R S ; O R Y E A R S . 3 = N E IT H E R H O U SE H O LD 8 = D O N 'T K N O W YE S . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 22 2A D oe s (N A M E ) ha ve a d ea th ce rti fic at e? 21 2 21 3 21 4 21 5 21 5A 21 6 21 7 21 8 21 9 22 0 22 1 22 2 11 22 2 G O TO 2 14 12 22 2 G O TO 2 14 H as (N A M E )'s de at h ev er b e- en re gi st er ed in ZA G S ? YE S . . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y YE S . . . . . 1 LI V E B IR TH . . . . . 1 N A M E : B O Y 1 YE S . . . . 1 A G E IN YE S . . 1 LI N E N O .: D A Y S . . . 1 LI V E B IR TH . . . . . . 1 S IN G 1 M O N TH A D D S TI LL B IR TH . . . . 2 YE A R S S TI LL B IR TH . . . . . . 2 P R E G N M IS C A R R IA G E . . 3 G IR L 2 N O . . . . 2 N O . . . 2 M O N TH S 2 M IS C A R R IA G E . . . 3 M U LT 2 YE A R N O . . . . . . 2 A B O R TI O N . . . . . 4 A B O R TI O N . . . . . . 4 N E XT Y E A R S . . 3 N E XT P R E G N A N C Y P R E G N A N C Y N E XT P R E G N A N C Y 15 22 2 G O TO 2 14 13 22 2 G O TO 2 14 14 22 2 G O TO 2 14 222B YES . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . 2 IF YES, RECORD PREGNANCIES IN TABLE ABOVE. 222C RECORD AND COMPARE NUMBER OF EVENTS RECORDED IN PREGNANCY HISTORY WITH EARLIER RESPONSES TOTAL NUMBER OF PREGANCIES TOTAL NUMBER OF PREGANCIES SAME AS NUMBER IN 209D DIFFERENT (PROBE AND RECONCILE) TOTAL NUMBER OF LIVE BIRTH TOTAL NUMBER OF LIVE BIRTH SAME AS NUMBER IN 208 DIFFERENT (PROBE AND RECONCILE) TOTAL NUMBER OF ABORTIONS TOTAL NUMBER OF ABORTIONS SAME AS NUMBER IN 209A DIFFERENT (PROBE AND RECONCILE) 223 COMPARE 209D WITH TOTAL NUMBER OF PREGNANCIES IN PREGNANCY HISTORY AND MARK: NUMBERS ARE NUMBERS DIFFERENT (PROBE AND RECONCILE) ARE SAME CHECK: FOR EACH PREGNANCY: YEAR WHEN PREGNANCY ENDED IS RECORDED (Q.214) FOR EACH LIVE BIRTH SINCE JANUARY 2007, MONTH AND YEAR OF BIRTH IS RECORDED (Q.214) FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED (Qs. 218, 219) FOR EACH CHILD THAT DIED: AGE AT DEATH IS RECORDED (Qs. 218, 222). FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS (Q. 222). 224 CHECK 212 AND 214: ENTER THE NUMBER OF BIRTHS IN 2007 OR LATER NUMBER OF BIRTHS . . . . . . . . . . . . . . . . ( IN 212 CIRCLED CODE "1") NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Have you had any ended pregnancies since the last birth of (NAME OF THE LAST CHILD)/stillbirth/miscarriage/abortion ? W-7 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP CHECK 212 AND 214 225 FOR EACH BIRTH SINCE JANUARY 2007, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.) FOR EACH PREGNANCY TERMINATION SINCE JANUARY 2007 (ABORTION, MISCARRIAGE OR STILLBIRTH), ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED, AND 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF THE PREGNANCY. AS ABOVE, THE NUMBER OF P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED. 226 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 UNSURE . . . . . . . . . . . . . . . . . . . . . . . . 8 238 227 MONTHS . . . . . . . . . . . . . . . . . . RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS. 228 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 238 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 229 LATER . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO MORE . . . . . . . . . . . . . . . . . . . . . . 2 238 DAYS AGO . . . . . . . . . . . . 1 WEEKS AGO . . . . . . . . . 2 MONTHS AGO . . . . . . . . . 3 (DATE, IF GIVEN) YEARS AGO . . . . . . . . . 4 IN MENOPAUSE/ HAS HAD HYSTERECTOMY . . . 994 BEFORE LAST BIRTH/PREGNANCY 995 NEVER MENSTRUATED . . . . . . . . . 996 239 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 301 240 JUST BEFORE HER PERIOD BEGINS . . . . . . . . . . . . . . . . . . . . . . 1 DURING HER PERIOD . . . . . . . . . . . . 2 RIGHT AFTER HER PERIOD HAS ENDED . . . . . . . . . . . . 3 HALFWAY BETWEEN TWO PERIODS . . . . . . . . . . . . . . . . 4 OTHER 6 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 When did your last menstrual period start? From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant? Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods? _________________________ C Are you pregnant now? How many months pregnant are you? C When you got pregnant, did you want to get pregnant at that time? Did you want to have a baby later on or did you not want any (more) children? W-8 SECTION 3. CONTRACEPTION 301 01 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 02 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 03 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 04 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 05 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 06 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 07 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 08 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 09 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 10 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 11 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 12 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 13 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ________________________________ (SPECIFY) ________________________________ (SPECIFY) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 302 CHECK 226: NOT PREGNANT PREGNANT OR UNSURE 311 303 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 311 IUD. PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse. Implants. PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years. Pill. PROBE: Women can take a pill every day to avoid becoming pregnant. Condom. PROBE: Men can put a rubber sheath on their penis before sexual intercourse. Female Condom. PROBE: Women can place a sheath in their vagina before sexual intercourse. Lactational Amenorrhea Method (LAM). (2) Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. Have you ever heard of (METHOD)? Female Sterilization. PROBE: Women can have an operation to avoid having any more children. Emergency Contraception. PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy. (3) Are you currently doing something or using any method to delay or avoid getting pregnant? Male Sterilization. PROBE: Men can have an operation to avoid having any more children. Rhythm (or the Calendar) Method. PROBE: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant. Withdrawal. PROBE: Men can be careful and pull out before climax. Injectables. PROBE: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months. Have you heard of any other ways or methods that women or men can use to avoid pregnancy? W-9 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 304 FEMALE STERILIZATION . . . . . . . . . A MALE STERILIZATION . . . . . . . . . . . . B 307 CIRCLE ALL MENTIONED. IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . C INJECTABLES . . . . . . . . . . . . . . . . . . D IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP IMPLANTS . . . . . . . . . . . . . . . . . . . . . . E INSTRUCTION FOR HIGHEST METHOD IN LIST. PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . F CONDOM . . . . . . . . . . . . . . . . . . . . . . G FEMALE CONDOM . . . . . . . . . . . . . . H DIAPHRAGM . . . . . . . . . . . . . . . . . . . . I FOAM/JELLY . . . . . . . . . . . . . . . . . . . . J LACTATIONAL AMEN. METHOD . . . . . K RHYTHM/CALENDAR METHOD . . . . . L WITHDRAWAL . . . . . . . . . . . . . . . . . . M OTHER MODERN METHOD . . . . . . . X OTHER TRADITIONAL METHOD . . . Y 307 PUBLIC SECTOR GOVT. HOSPITAL . . . . . . . . . . . . . . 11 MATERNITY HOME . . . . . . . . . . . . . . 12 PROBE TO IDENTIFY THE TYPE OF SOURCE. HEALTH CENTER (URBAN/RURAL) 13 REPRODUCTIVE HEALTH CENTER. . 14 HEALTH HOUSE . . . . . . . . . 15 POLYCLINICS . . . . . . . . . . . . . . . . 16 INTEGRATED MANAGEMENT OF CHILD- HOOD ILLNESS CENTER(IMC . . . . 17 IMMUNIPROPHYLAXIS CENTER . . . .18 AIDS CENTER . . . . . . . . . . . . . . . . 19 HEALTHY LIFESTYLE CENTER . . . .20 FAMILY MEDICINE CENTER. . . . . . . 21 DISPENSARY . . . . . . . . . . . . . . . . . 22 IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE OTHER PUBLIC SECTOR, WRITE THE NAME OF THE PLACE. SECTOR 23 (SPECIFY) (NAME OF PLACE) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . 31 PRIVATE DOCTOR'S OFFICE . . . . . 32 PHARMACY . . . . . . . . . . . . . . . . . 33 OTHER PRIVATE MEDICAL SECTOR 36 (SPECIFY) OTHER 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 308A In what facility did the sterilization take place? Which method are you using? W-10 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 308 308A MONTH . . . . . . . . . . . . . . . . . . YEAR . . . . . . . . . . . . 309 CHECK 308/308A, 212 AND 214 : ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YES NO YEAR OF START OF USE OF CONTRACEPTION IN 308/308A GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION). 310 CHECK 308/308A: YEAR IS 2007 OR LATER YEAR IS 2006 OR EARLIER ENTER CODE FOR METHOD USED IN MONTH ENTER CODE FOR METHOD USED IN MONTH OF OF INTERVIEW IN THE CALENDAR INTERVIEW IN THE CALENDAR AND AND IN EACH MONTH BACK TO THE DATE EACH MONTH BACK TO JANUARY 2007. STARTED USING. THEN SKIP TO 311 USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2007. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS. IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH. ILLUSTRATIVE QUESTIONS: * * * IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO THE LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1. ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT. ILLUSTRATIVE QUESTIONS: * * Since what month and year have you been using (CURRENT METHOD) without stopping? PROBE: For how long have you been using (CURRENT METHOD) now without stopping? IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: How many months did it take you to get pregnant after you stopped using (METHOD)? AND ENTER ‘0’ IN EACH SUCH MONTH IN COLUMN 1. I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years. C 322 C When was the last time you used a method? Which method was that? When did you start using that method? How long after the birth of (NAME)? How long did you use the method then? Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason? C In what month and year was the sterilization performed? W-11 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 312 CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH NO METHOD USED ANY METHOD USED 314 313 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 324 314 CHECK 304: NO CODE CIRCLED . . . . . . . . . . . . . . 00 324 FEMALE STERILIZATION . . . . . . . . . 01 317A CIRCLE METHOD CODE: MALE STERILIZATION . . . . . . . . . . . . 02 326 IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 IF MORE THAN ONE METHOD CODE CIRCLED IN 304, INJECTABLES . . . . . . . . . . . . . . . . . . . . 04 CIRCLE CODE FOR HIGHEST METHOD IN LIST. IMPLANTS . . . . . . . . . . . . . . . . . . . . . . 05 PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 CONDOM . . . . . . . . . . . . . . . . . . . . . . 07 FEMALE CONDOM . . . . . . . . . . . . . . . . 08 DIAPHRAGM . . . . . . . . . . . . . . . . . . . . 09 FOAM/JELLY . . . . . . . . . . . . . . . . . . . . 10 LACTATIONAL AMEN. METHOD . . . . . 11 RHYTHM/CALENDAR METHOD . . . . . 12 315A WITHDRAWAL . . . . . . . . . . . . . . . . . . 13 OTHER MODERN METHOD . . . . . . . 95 326 OTHER TRADITIONAL METHOD . . . . . 96 315 PUBLIC SECTOR GOVT. HOSPITAL . . . . . . . . . . . . . . 11 MATERNITY HOME . . . . . . . . . . . . . . 12 HEALTH CENTER (URBAN/RURAL) 13 REPRODUCTIVE HEALTH CENTER. . 14 HEALTH HOUSE . . . . . . . . . 15 POLYCLINICS . . . . . . . . . . . . . . . . 16 INTEGRATED MANAGEMENT OF CHILD- HOOD ILLNESS CENTER(IMC . . . . 17 IMMUNIPROPHYLAXIS CENTER . . . .18 AIDS CENTER . . . . . . . . . . . . . . . . 19 315A HEALTHY LIFESTYLE CENTER . . . .20 FAMILY MEDICINE CENTER. . . . . . . 21 DISPENSARY . . . . . . . . . . . . . . . . . 22 OTHER PUBLIC SECTOR 23 (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . 31 PROBE TO IDENTIFY THE TYPE OF SOURCE. PRIVATE DOCTOR'S OFFICE . . . . . 32 PHARMACY . . . . . . . . . . . . . . . . . 33 IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, OTHER PRIVATE MEDICAL WRITE THE NAME OF THE PLACE. SECTOR 36 (SPECIFY) OTHER SOURCE SHOP/MARKET . . . . . . . . . . . . . . 41 FRIEND/RELATIVE . . . . . . . . . . . . . . 43 (NAME OF PLACE) OTHER _______________________ 96 (SPECIFY) Have you ever used anything or tried in any way to delay or avoid getting pregnant? Where did you learn how to use the rhythm/lactational amenorrhea method? You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time? (5) W-12 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 316 CHECK 304: IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 INJECTABLES . . . . . . . . . . . . . . . . . . . . 04 CIRCLE METHOD CODE: IMPLANTS . . . . . . . . . . . . . . . . . . . . . . 05 PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CONDOM . . . . . . . . . . . . . . . . . . . . . . 07 323 CIRCLE CODE FOR HIGHEST METHOD IN LIST. FEMALE CONDOM . . . . . . . . . . . . . . . . 08 DIAPHRAGM . . . . . . . . . . . . . . . . . . . . 09 320 FOAM/JELLY . . . . . . . . . . . . . . . . . . . . 10 LACTATIONAL AMEN. METHOD . . . . . 11 326 RHYTHM/CALENDAR METHOD . . . . . 12 326 317 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 319 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 317A 318 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 320 319 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 320 CHECK 317: CODE '1' CODE '1' CIRCLED NOT CIRCLED YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 322 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 321 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 322 CHECK 304: FEMALE STERILIZATION . . . . . . . . . 01 MALE STERILIZATION . . . . . . . . . . . . 02 326 CIRCLE METHOD CODE: IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 INJECTABLES . . . . . . . . . . . . . . . . . . . . 04 IF MORE THAN ONE METHOD CODE CIRCLED IN 304, IMPLANTS . . . . . . . . . . . . . . . . . . . . . . 05 CIRCLE CODE FOR HIGHEST METHOD IN LIST. PILL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 CONDOM . . . . . . . . . . . . . . . . . . . . . . 07 FEMALE CONDOM . . . . . . . . . . . . . . . . 08 DIAPHRAGM . . . . . . . . . . . . . . . . . . . . 09 FOAM/JELLY . . . . . . . . . . . . . . . . . . . . 10 LACTATIONAL AMEN. METHOD . . . . . 11 RHYTHM/CALENDAR METHOD . . . . . 12 WITHDRAWAL . . . . . . . . . . . . . . . . . . 13 326 OTHER MODERN METHOD . . . . . . . 95 OTHER TRADITIONAL METHOD . . . 96 At that time, were you told about other methods of family planning that you could use? Were you told what to do if you experienced side effects or problems? When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use? When you got sterilized, were you told about side effects or problems you might have with the method? Were you ever told by a health or family planning worker about side effects or problems you might have with the method? At that time, were you told about side effects or problems you might have with the method? Were you ever told by a health or family planning worker about other methods of family planning that you could use? W-13 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 323 PUBLIC SECTOR GOVT. HOSPITAL . . . . . . . . . . . . . . 11 PROBE TO IDENTIFY THE TYPE OF SOURCE. MATERNITY HOME . . . . . . . . . . . . . . 12 HEALTH CENTER (URBAN/RURAL) 13 IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE REPRODUCTIVE HEALTH CENTER. . 14 SECTOR, WRITE THE NAME OF THE PLACE. HEALTH HOUSE . . . . . . . . . 15 POLYCLINICS . . . . . . . . . . . . . . . . 16 INTEGRATED MANAGEMENT OF CHILD- HOOD ILLNESS CENTER(IMC . . . . 17 IMMUNIPROPHYLAXIS CENTER . . . .18 AIDS CENTER . . . . . . . . . . . . . . . . 19 (NAME OF PLACE) HEALTHY LIFESTYLE CENTER . . . .20 FAMILY MEDICINE CENTER. . . . . . . 21 DISPENSARY . . . . . . . . . . . . . . . . . 22 OTHER PUBLIC SECTOR 23 326 (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . 31 PRIVATE DOCTOR'S OFFICE . . . . . 32 PHARMACY . . . . . . . . . . . . . . . . . 33 OTHER PRIVATE MEDICAL SECTOR 36 (SPECIFY) OTHER SOURCE SHOP/MARKET . . . . . . . . . . . . . . 41 FRIEND/RELATIVE . . . . . . . . . . . . . . 43 OTHER _______________________ 96 (SPECIFY) 324 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 326 325 PUBLIC SECTOR GOVT. HOSPITAL A MATERNITY HOME . . . . . . . . . . . . . . B HEALTH CENTER (URBAN/RURAL) C PROBE TO IDENTIFY EACH TYPE OF SOURCE. REPRODUCTIVE HEALTH CENTER. . D HEALTH HOUSE . . . . . . . . . E IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE POLYCLINICS . . . . . . . . . . . . . . . . F SECTOR, WRITE THE NAME OF THE PLACE. INTEGRATED MANAGEMENT OF CHILD- HOOD ILLNESS CENTER(IMC . . . . G IMMUNIPROPHYLAXIS CENTER . . . . H AIDS CENTER . . . . . . . . . . . . . . . . I HEALTHY LIFESTYLE CENTER . . . . J FAMILY MEDICINE CENTER. . . . . . . K DISPENSARY . . . . . . . . . . . . . . . . . L (NAME OF PLACE(S)) OTHER PUBLIC SECTOR M (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . N PRIVATE DOCTOR'S OFFICE . . . . . O PHARMACY . . . . . . . . . . . . . . . . . P OTHER PRIVATE MEDICAL SECTOR Q (SPECIFY) OTHER SOURCE SHOP/MARKET . . . . . . . . . . . . . . R FRIEND/RELATIVE . . . . . . . . . . . . . . S OTHER _________________________ X (SPECIFY) Where is that? Any other place? Do you know of a place where you can obtain a method of family planning? Where did you obtain (CURRENT METHOD) the last time? W-14 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 326 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 327 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 401 328 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Did any staff member at the health facility speak to you about family planning methods? In the last 12 months, were you visited by a healthworker who talked to you about family planning? In the last 12 months, have you visited a health facility for care for yourself (or your children)? W-15 SECTION 4. PREGNANCY AND POSTNATAL CARE 401 CHECK 224: ONE OR MORE NO 556 BIRTHS BIRTHS IN 2007) IN 2007 OR LATER OR LATER 402 CHECK 214: ENTER IN THE TABLE THE PREGNANCY HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2007 OR LATER. ASK THE QUESTIONS ABOUT ALL OF LIVE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). 403 PREGNANCY HISTORY NUMBER LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH FROM 212 IN PREGNANCY PREGNANCY PREGNANCY PREGNANCY HISTORY TABLE HISTORY HISTORY HISTORY NUMBER NUMBER NUMBER 404 FROM 216 AND 218 NAME ________________ NAME ________________ NAME _________________ LIVING DEAD LIVING DEAD LIVING DEAD 405 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 (SKIP TO 408) (SKIP TO 430) (SKIP TO 430) NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 406 LATER . . . . . . . . . . . . 1 LATER . . . . . . . . . . . . 1 LATER . . . . . . . . . 1 NO MORE . . . . . . . 2 NO MORE . . . . . . . 2 NO MORE . . . . . . . 2 (SKIP TO 408) (SKIP TO 430) (SKIP TO 430) 407 MONTHS MONTHS MONTHS YEARS YEARS YEARS DON'T KNOW . . . 998 DON'T KNOW . . . 998 DON'T KNOW . . . 998 408 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 (SKIP TO 421) 409 HEALTH PERSONNEL FAMILY DOCTOR. A OTHER DOCTOR . . B NURSE/MIDWIFE . . C FELDSHER . . . . . D PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL OTHER PERSON MENTIONED. TRADITIONAL BIRTH ATTENDANT . . E COMMUNITY/ VILLAGE HEALTH WORKER . . . F OTHER X (SPECIFY) . .1 Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately.) When you got pregnant with (NAME), did you want to get pregnant at that time? Did you want to have a baby later on, or did you not want any (more) children? How much longer did you want to wait? Did you see anyone for antenatal care for this pregnancy? Whom did you see? Anyone else? . . 2 . .1 . . 2 . .1 . . 2 W-16 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 410 HOME YOUR HOME . . . A OTHER HOME . . . B PUBLIC SECTOR PROBE TO IDENTIFY EACH TYPE GOVT. HOSPITAL C OF SOURCE. MATERNITY HOME D HEALTH CENTER E IF UNABLE TO DETERMINE REPRODUCTIVE IF PUBLIC OR PRIVATE HEALTH CNTR . . F SECTOR, WRITE THE NAME POLYCLINIC. . . . . . G OF THE PLACE. OTHER PUBLIC SECTOR H (SPECIFY) (NAME OF PLACE(S)) PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . J OTHER PRIVATE MED. SECTOR K (SPECIFY) OTHER X (SPECIFY) 411 MONTHS . . . DON'T KNOW . . . . . 98 412 NUMBER OF TIMES DON'T KNOW . . . . . 98 413 YES NO BP . . . . . . . 1 2 URINE . . . . . 1 2 BLOOD . . . 1 2 414 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 414A YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 414B YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 (SKIP TO 421) As part of your antenatal care during this pregnancy, were any of the following done at least once: Did you give a urine sample? Did you give a blood sample? During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy? Was your blood pressure Have you been admitted to a health facility during this pregnancy, including day-bed occupancy? Where did you receive antenatal care for this pregnancy? Anywhere else? How many months pregnant were you when you first received antenatal care for this pregnancy? How many times did you receive antenatal care during this pregnancy? Did your husband/partner, a family member or a friend come with you to any antenatal care visits? W-17 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 414C TIMES DON'T KNOW . . . . 414D BLOOD PRESSURE . . A BLURRED VISION . . . . . B SEIZURES . . . . . . . . . . C BLEEDING . . . . . . . . . . D MISCARRIAGE THREAT E PRETERM LABOR THREAT . . . . . . . . . . F LABOR OVERDUE . . . . G FETAL/PLACENTAL PROBLEMS . . . . . . . H DIABETES . . . . . . . . . . I ANEMIA . . . . . . . . . . J STD . . . . . . . . . . . . . . . K OTHER INFECTION . . L TEST/DIAGNOSTICS. . M ACCIDENT/INJURY . . N OTHER X (SPECIFY) DON'T KNOW . . . . . . . Y 421 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 (SKIP TO 430) DON'T KNOW . . . . . 8 422 DAYS DON'T KNOW . . . 998 IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS. 430 VERY LARGE . . . . . 1 VERY LARGE . . . . . 1 VERY LARGE . . . . . 1 LARGER THAN LARGER THAN LARGER THAN AVERAGE . . . . . 2 AVERAGE . . . . . 2 AVERAGE . . . . . 2 AVERAGE . . . . . . . 3 AVERAGE . . . . . . . 3 AVERAGE . . . . . . . 3 SMALLER THAN SMALLER THAN SMALLER THAN AVERAGE . . . . . 4 AVERAGE . . . . . 4 AVERAGE . . . . . 4 VERY SMALL . . . . . 5 VERY SMALL . . . . . 5 VERY SMALL . . . . . 5 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 431 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 433) (SKIP TO 433) (SKIP TO 433) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 432 KG FROM CARD KG FROM CARD KG FROM CARD RECORD WEIGHT IN . . . KILOGRAMS FROM HEALTH CARD, IF AVAILABLE. KG FROM RECALL KG FROM RECALL KG FROM RECALL . . . DON'T KNOW 99998 DON'T KNOW 99998 DON'T KNOW 99998 998 Anythig else? RECORD ALL MENTIONED During the whole pregnancy, for how many days did you take the tablets or syrup? During this pregnancy, were you given or did you buy any iron tablets or iron syrup? 2 In total, how many times have you been hospitalised during this pregnancy, including day-bed occupancy? Please, list the reasons for all hospitalizations. 1 2 2 11 When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small? Was (NAME) weighed at birth? How much did (NAME) weigh? W-18 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 433 HEALTH PERSONNEL HEALTH PERSONNEL HEALTH PERSONNEL FAMILY DOCTOR. A FAMILY DOCTOR . A FAMILY DOCTOR. A OTHER DOCTOR . . B OTHER DOCTOR . . B OTHER DOCTOR . . B NURSE/MIDWIFE . . C NURSE/MIDWIFE . . C NURSE/MIDWIFE . . C FELDSHER . . . . . D FELDSHER . . . . . D FELDSHER . . . . . D PROBE FOR THE TYPE(S) OF OTHER PERSON OTHER PERSON OTHER PERSON PERSON(S) AND RECORD ALL TRADITIONAL BIRTH TRADITIONAL BIRTH TRADITIONAL BIRTH MENTIONED. ATTENDANT . . E ATTENDANT . . E ATTENDANT . . E RELATIVE/FRIEND . F RELATIVE/FRIEND . F RELATIVE/FRIEND . F IF RESPONDENT SAYS NO ONE OTHER OTHER OTHER ASSISTED, PROBE TO X X X DETERMINE WHETHER ANY (SPECIFY) (SPECIFY) (SPECIFY) ADULTS WERE PRESENT AT NO ONE ASSISTED Y NO ONE ASSISTED Y NO ONE ASSISTED Y THE DELIVERY. 434 HOME HOME HOME YOUR HOME . . . 11 YOUR HOME . . . 11 YOUR HOME . . . 11 (SKIP TO 438) (SKIP TO 448) (SKIP TO 448) OTHER HOME . . . 12 OTHER HOME . . . 12 OTHER HOME . . . 12 PROBE TO IDENTIFY THE TYPE PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR OF SOURCE. GOVT. HOSPITAL 21 GOVT. HOSPITAL 21 GOVT. HOSPITAL 21 MATERNITY HOME 22 MATERNITY HOME 22 MATERNITY HOME 22 HEALTH CENTER 23 HEALTH CENTER 23 HEALTH CENTER 23 HEALTH HOUSE 24 HEALTH HOUSE 24 HEALTH HOUSE 24 IF UNABLE TO DETERMINE OTHER PUBLIC OTHER PUBLIC OTHER PUBLIC IF PUBLIC OR PRIVATE SECTOR SECTOR SECTOR SECTOR, WRITE THE 26 26 26 NAME OF THE PLACE. (SPECIFY) (SPECIFY) (SPECIFY) PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR (NAME OF PLACE) PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ CLINIC . . . . . . . 31 CLINIC . . . . . . . 31 CLINIC . . . . . . . 31 OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE MED. SECTOR MED. SECTOR MED. SECTOR 36 36 36 (SPECIFY) (SPECIFY) (SPECIFY) OTHER 96 OTHER 96 OTHER 96 (SPECIFY) (SPECIFY) (SPECIFY) (SKIP TO 438) (SKIP TO 448) (SKIP TO 448) 434A HOURS 1 DAYS 2 IF LESS THAN ONE DAY, RECORD HOURS. WEEKS 3 IF LESS THAN ONE WEEK, RECORD DAYS. DON'T KNOW . . . 998 435 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 436 YES . . . . . . . . . . . . . . 1 (SKIP TO 439) NO . . . . . . . . . . . . . . 2 437 YES . . . . . . . . . . . . . . 1 (SKIP TO 439) NO . . . . . . . . . . . . . . 2 (SKIP TO 442) Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out? How long after (NAME) was delivered did you stay there? Who assisted with the delivery of (NAME)? Did anyone check on your health after you left the facility? I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility? Anyone else? Where did you give birth to (NAME)? W-19 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 438 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 (SKIP TO 442) 439 HEALTH PERSONNEL FAMILY DOCTOR. 11 OTHER DOCTOR . . 12 PROBE FOR MOST QUALIFIED NURSE/MIDWIFE . . 13 PERSON. FELDSHER . . . . . 14 OTHER PERSON TRADITIONAL BIRTH ATTENDANT 21 COMMUNITY/ VILLAGE HEALTH WORKER . . . 22 OTHER 96 (SPECIFY) 440 HOURS 1 DAYS 2 IF LESS THAN ONE DAY, RECORD HOURS. WEEKS 3 IF LESS THAN ONE WEEK, RECORD DAYS. DON'T KNOW . . . 998 442 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 (SKIP TO 446) DON'T KNOW . . . . . 8 443 HRS AFTER BIRTH . . 1 DAYS AFTER BIRTH . . 2 IF LESS THAN ONE DAY, WKS AFTER RECORD HOURS. BIRTH . . 3 IF LESS THAN ONE WEEK, RECORD DAYS. DON'T KNOW . . . 998 444 HEALTH PERSONNEL FAMILY DOCTOR. 11 OTHER DOCTOR . . 12 PROBE FOR MOST QUALIFIED NURSE/MIDWIFE . . 13 PERSON. FELDSHER . . . . . 14 OTHER PERSON TRADITIONAL BIRTH ATTENDANT 21 COMMUNITY/ VILLAGE HEALTH WORKER . . . 22 OTHER 96 (SPECIFY) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health? How many hours, days or weeks after the birth of (NAME) did the first check take place? Who checked on (NAME)'s health at that time? I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)? Who checked on your health at that time? How long after delivery did the first check take place? W-20 LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME ________________ NAME _________________ 445 HOME YOUR HOME . . . 11 OTHER HOME . . . 12 PROBE TO IDENTIFY THE TYPE PUBLIC SECTOR OF SOURCE AND CIRCLE THE GOVT. HOSPITAL 21 APPROPRIATE CODE. MATERNITY HOME 22 HEALTH CENTER. 23 IF UNABLE TO DETERMINE HEALTH HOUSE . . 24 IF PUBLIC OR PRIVATE INTEGR. MANAGEMENT SECTOR, WRITE THE CHILDHOOD ILLNESS NAME OF THE PLACE. CENTER . . . . . . 25 POLYCLINICS 26 OTHER PUBLIC 27 (NAME OF PLACE) (SPECIFY) PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . 31 OTHER PRIVATE MED. 36 (SPECIFY) OTHER 96 (SPECIFY) 446 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 447 YES . . . . . . . . . . . . . . 1 (SKIP TO 449) NO . . . . . . . . . . . . . . 2 (SKIP TO 450) 448 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 452) (SKIP TO 452) 449 MONTHS . . . MONTHS . . . MONTHS . . . DON'T KNOW . . . . . 98 DON'T KNOW . . . . . 98 DON'T KNOW . . . . . 98 450 CHECK 226: NOT PREGNANT PREG- OR IS RESPONDENT PREGNANT? NANT UNSURE (SKIP TO 452) 451 YES . . . . . . . . . . . . . . 1 NO . . . . .