Timor-Leste - Demographic and Health Survey - 2010

Publication date: 2009

Timor-Leste Demographic and Health Survey 2009-10 Tim or-Leste 2009-10 D em ographic and H ealth Survey � � � � � � � Timor-Leste Demographic and Health Survey 2009-10 National Statistics Directorate Ministry of Finance Democratic Republic of Timor-Leste Dili, Timor-Leste ICF Macro Calverton, Maryland, U.S.A. December 2010 This report summarizes the findings of the 2009-10 Timor-Leste Demographic and Health Survey (TLDHS) carried out by the National Statistics Directorate of the Ministry of Finance. ICF Macro provided financial and technical assistance for the survey through the USAID-funded MEASURE DHS program, which is designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. Financial support was provided by USAID, the Government of Australia (AusAID), the Government of Ireland (Irish AID), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations Development Fund (UNDP), and the World Health Organization (WHO). UNFPA supported the survey with administrative, logistical, and technical assistance. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID or donor organizations. Additional information about the 2009-2010 TLDHS may be obtained from the National Statistics Directorate, P.O. Box 10, Timor-Leste; Telephone: (977-1) 670-3339527; Internet: www.dne.mof.gov.tl. Additional information about the MEASURE DHS program may be obtained from MEASURE DHS, ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, U.S.A.; Telephone: 1-301-572-0200; Fax: 1-301-572-0999; Email: reports@measuredhs.com. Suggested citation: National Statistics Directorate (NSD) [Timor-Leste], Ministry of Finance [Timor-Leste], and ICF Macro. 2010. Timor-Leste Demographic and Health Survey 2009-10. Dili, Timor-Leste: NSD [Timor- Leste] and ICF Macro. Contents | iii CONTENTS TABLES AND FIGURES . ix FOREWORD . xvii ACKNOWLEDGMENTS . xix CONTRIBUTORS TO THE REPORT . xxi SUMMARY OF FINDINGS . xxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxxi MAP OF TIMOR-LESTE . xxxii CHAPTER 1 INTRODUCTION 1.1 History, Geography, and Economy . 1 1.1.1 History. 1 1.1.2 Geography . 2 1.1.3 Economy . 2 1.2 Population . 3 1.3 Population and Reproductive Health Policies and Programs . 3 1.4 Objectives of the Survey . 4 1.5 Organization of the Survey . 5 1.6 Sample Design . 5 1.6.1 Sampling Frame . 5 1.6.2 Sample Selection . 5 1.7 Questionnaires . 6 1.8 Hemoglobin Testing . 7 1.9 Pretest, Training, and Fieldwork . 7 1.9.1 Pretest . 7 1.9.2 Training . 7 1.9.3 Fieldwork . 8 1.10 Data Processing . 8 1.11 Response Rates . 8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age and Sex . 11 2.2 Household Composition . 12 2.2.1 Children’s Living Arrangements and Orphanhood . 13 2.2.2 School Attendance by Survivorship of Parents . 14 2.3 Educational Attainment of Household Members . 15 2.3.1 Grade Repetition and Dropout Rates . 20 2.4 Housing Characteristics . 22 2.5 Household Durable Goods . 26 2.6 Wealth Quintiles . 27 2.7 Birth Registration . 28 iv | Contents CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Characteristics of Survey Respondents . 31 3.2 Educational Attainment and Literacy . 32 3.3 Access to Mass Media . 36 3.4 Employment . 38 3.4.1 Employment Status . 38 3.4.2 Occupation . 41 3.4.3 Earnings, Employers, and Continuity of Employment . 43 3.5 Knowledge and Attitudes Concerning Tuberculosis . 44 3.6 Use of Tobacco . 46 CHAPTER 4 FERTILITY 4.1 Current Fertility . 49 4.2 Fertility Differentials . 50 4.3 Fertility Trends . 52 4.4 Children Ever Born and Surviving . 54 4.5 Birth Intervals . 55 4.6 Age at First Birth . 56 4.7 Adolescent Pregnancy and Motherhood . 57 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods . 60 5.2 Knowledge of Contraceptive Methods by Background Characteristics . 61 5.3 Ever Use of Contraception . 62 5.4 Current Use of Contraception . 64 5.5 Trend in Current Use of Contraception . 66 5.6 Current Use of Contraception by Background Characteristics . 66 5.7 Number of Children at First Use of Contraception . 68 5.8 Knowledge of Fertile Period . 69 5.9 Timing of Female Sterilization . 70 5.10 Source of Modern Contraception Methods . 70 5.11 Payment of Fees for Modern Contraceptive Methods . 71 5.12 Informed Choice . 71 5.13 Future Use of Contraception . 72 5.14 Reasons for Non-use of Contraception in the Future . 73 5.15 Preferred Method of Contraception for Future Use . 73 5.16 Exposure to Family Planning Messages . 74 5.17 Contact of Non-users with Family Planning Providers . 75 5.18 Husband’s Knowledge of Wife’s Use of Contraception . 76 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status . 79 6.2 Polygyny . 80 6.3 Age at First Marriage . 81 6.4 Age at First Sexual Intercourse . 83 6.5 Recent Sexual Activity . 85 6.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 88 6.7 Menopause . 89 Contents | v CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 91 7.2 Desire to Limit Childbearing by Background Characteristics . 92 7.3 Need for Family Planning Services . 94 7.4 Ideal Family Size . 95 7.5 Fertility Planning . 97 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Definition, Data Quality, and Methodology . 99 8.2 Assessment of Data Quality. 99 8.3 Levels and Trends in Infant and Child Mortality . 100 8.4 Socioeconomic Differentials in Mortality . 102 8.5 Demographic Characteristics and Child Mortality . 103 8.6 Perinatal Mortality . 105 8.7 High-Risk Fertility Behavior . 106 CHAPTER 9 ADULT AND MATERNAL MORTALITY 9.1 Data Quality Analysis . 109 9.2 Adult Mortality . 111 9.3 Maternal Mortality . 111 CHAPTER 10 MATERNAL HEALTH 10.1 Antenatal Care . 113 10.2 Number and Timing of Antenatal Visits . 115 10.3 Components of Antenatal Care . 115 10.4 Tetanus Toxoid Vaccination . 117 10.5 Knowledge of Danger Signs During Pregnancy . 118 10.6 Delivery Care . 119 10.6.1 Place of Delivery . 119 10.6.2 Assistance during Delivery . 121 10.7 Newborn Care . 122 10.7.1 Knowledge of Danger Signs for Newborns . 122 10.7.2 Care for Umbilical Cord . 123 10.7.3 Drying and Bathing of Newborns . 125 10.8 Timing of First Postnatal Checkup . 126 10.9 Type of Provider of First Postnatal Checkup . 127 10.10 Problems in Accessing Health Care . 128 CHAPTER 11 CHILD HEALTH 11.1 Child’s Size at Birth . 131 11.2 Vaccination Coverage . 132 11.3 Trends in Vaccination Coverage . 135 11.4 Acute Respiratory Infection . 136 11.5 Fever . 137 vi | Contents 11.6 Diarrheal Disease . 139 11.6.1 Incidence and Treatment of Diarrhea . 139 11.6.2 Feeding Practices . 141 11.7 Knowledge of ORS Packets . 143 11.8 Stool Disposal . 144 CHAPTER 12 NUTRITION OF CHILDREN AND WOMEN 12.1 Nutritional Status of Children . 147 12.1.1 Nutritional Status of Children . 147 12.1.2 Trends in Children’s Nutritional Status . 151 12.2 Initiation of Breastfeeding . 153 12.3 Breastfeeding Status by Age . 154 12.4 Duration and Frequency of Breastfeeding . 156 12.5 Types of Complementary Foods . 157 12.6 Infant and Young Child Feeding (IYCF) Practices . 158 12.7 Anemia in Children . 160 12.8 Micronutrient Intake among Children . 162 12.9 Nutritional Status of Women . 165 12.10 Foods Consumed by Mothers . 166 12.11 Micronutrient Intake among Mothers . 167 12.12 Prevalence of Anemia in Women . 170 CHAPTER 13 MALARIA 13.1 Mosquito Nets . 174 13.1.1 Ownership of Mosquito Nets . 174 13.1.2 Use of Mosquito Nets by Children . 175 13.1.3 Use of Mosquito Nets by Women . 176 13.1.4 Prevalence and Management of Childhood Malaria . 178 CHAPTER 14 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 14.1 Knowledge of HIV/AIDS and of Transmission and Prevention Methods . 182 14.1.1 Knowledge of AIDS. 182 14.1.2 Knowledge of HIV Prevention Methods . 183 14.1.3 Comprehensive Knowledge of HIV Transmission . 184 14.2 Attitudes toward People Living with HIV/AIDS . 187 14.3 Risky Behaviors . 189 14.3.1 Multiple Sexual Partners and Higher-risk Sexual Intercourse . 189 14.3.2 Paid Sex . 190 14.4 Knowledge of HIV Testing . 191 14.5 Male Circumcision . 193 14.6 Reports of Recent Sexually Transmitted Infections . 193 14.7 Prevalence of Medical Injections . 195 Contents | vii 14.8 HIV/AIDS-related Knowledge and Behavior among Youth . 197 14.8.1 Comprehensive Knowledge about HIV/AIDS and Source for Condoms 197 14.8.2 Age at First Sex and Condom Use at First Sexual Intercourse . 199 14.8.3 Recent Sexual Activity among Never-married Youth . 201 14.8.4 Drunkenness during Sex among Young Adults . 201 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Employment and Form of Earnings. 203 15.2 Control Over and Relative Magnitude of Women’s Earnings . 204 15.3 Control Over Men’s Cash Earnings . 206 15.4 Women’s Participation in Decisionmaking . 208 15.5 Attitudes toward Wife Beating . 213 15.6 Attitudes toward Refusing Sex with Husband . 216 15.7 Current Use of Contraception by Women’s Status . 222 15.8 Ideal Family Size and Unmet Need by Women’s Status . 222 15.9 Reproductive Health Care by Women’s Status . 224 CHAPTER 16 DOMESTIC VIOLENCE 16.1 Measurement of Violence . 226 16.1.1 The Use of Valid Measures of Violence . 226 16.1.2 Ethical Considerations . 227 16.1.3 Special Training for Implementing the Domestic Violence Module . 227 16.1.4 Characteristics of the Sub-sample of Respondents for the Domestic Violence Module . 228 16.2 Experience of Domestic Violence by Women . 228 16.3 Perpetrators of Physical Violence Against Women . 230 16.4 Women’s Experience of Force at Sexual Initiation . 231 16.5 Experience of Sexual Violence and Perpetrators of Sexual Violence . 231 16.6 Experience of Different Types of Violence . 233 16.7 Violence during Pregnancy . 233 16.8 Marital Control . 234 16.9 Types of Spousal Violence . 236 16.10 Violence by Spousal Characteristics and Empowerment Indicators . 240 16.11 Frequency of Spousal Violence . 241 16.12 Onset of Spousal Violence . 242 16.13 Types of Injuries to Women Resulting from Spousal Violence . 242 16.14 Physical Violence by Women against Their Spouse . 243 16.15 Help-seeking Behavior of Women who Experience Violence . 245 16.16 Family Support for Abused Women in Need . 245 16.17 Social Norms and Values . 247 REFERENCES . 249 APPENDIX A SAMPLE IMPLEMENTATION . 255 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 261 APPENDIX C DATA QUALITY . 281 APPENDIX D SURVEY PERSONNEL . 289 APPENDIX E QUESTIONNAIRES . 293 Tables and Figures | ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 12 Table 2.2 Household composition . 13 Table 2.3.1 Children’s living arrangements and orphanhood . 14 Table 2.3.2 School attendance by survivorship of parents . 15 Table 2.4.1 Educational attainment of the female household population . 16 Table 2.4.2 Educational attainment of the male household population . 18 Table 2.5 School attendance ratios . 19 Table 2.6 Grade repetition and dropout rates . 21 Table 2.7 Household drinking water . 23 Table 2.8 Household sanitation facilities . 24 Table 2.9 Household characteristics . 25 Table 2.10 Household durable goods . 27 Table 2.11 Wealth quintiles . 28 Table 2.12 Birth registration of children under age five . 29 Figure 2.1 Population Pyramid . 12 Figure 2.2 Percentage of Women and Men with No Education, by Age Group . 17 Figure 2.3 Age-specific Attendance Rates of the de facto Population 5 to 24 Years . 22 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 32 Table 3.2.1 Educational attainment: Women . 33 Table 3.2.2 Educational attainment: Men . 34 Table 3.3.1 Literacy: Women . 35 Table 3.3.2 Literacy: Men . 36 Table 3.4.1 Exposure to mass media: Women . 37 Table 3.4.2 Exposure to mass media: Men . 38 Table 3.5.1 Employment status: Women . 39 Table 3.5.2 Employment status: Men . 40 Table 3.6.1 Occupation: Women . 41 Table 3.6.2 Occupation: Men . 42 Table 3.7 Type of employment: Women . 43 Table 3.8.1 Knowledge and attitude concerning tuberculosis: Women . 44 Table 3.8.2 Knowledge and attitude concerning tuberculosis: Men . 46 Table 3.9.1 Use of tobacco: Women . 47 Table 3.9.2 Use of tobacco: Men . 48 x | Tables and Figures CHAPTER 4 FERTILITY Table 4.1 Current fertility . 49 Table 4.2 Fertility by background characteristics . 51 Table 4.3 Trends in age-specific fertility rates . 52 Table 4.4 Trends in fertility . 53 Table 4.5 Children ever born and living . 54 Table 4.6 Birth intervals . 55 Table 4.7 Age at first birth . 56 Table 4.8 Median age at first birth . 57 Table 4.9 Teenage pregnancy and motherhood . 58 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence . 50 Figure 4.2 Trends in Total Fertility Rates 1995-2010 . 53 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 60 Table 5.2 Knowledge of contraceptive methods by background characteristics . 61 Table 5.3.1 Ever use of contraception: Women . 63 Table 5.3.2 Ever use of contraception: Men . 64 Table 5.4 Current use of contraception by age . 65 Table 5.5 Current use of contraception by background characteristics . 67 Table 5.6 Number of children at first use of contraception . 69 Table 5.7 Knowledge of fertile period . 69 Table 5.8 Source of modern contraception methods . 70 Table 5.9 Informed choice . 72 Table 5.10 Future use of contraception . 73 Table 5.11 Reason for not intending to use contraception in the future . 73 Table 5.12 Preferred method of contraception for future use . 74 Table 5.13 Exposure to family planning messages . 75 Table 5.14 Contact of nonusers with family planning providers . 76 Table 5.15 Husband/partner’s knowledge of women’s use of contraception . 77 Figure 5.1 Trends in Use of Contraception among Currently Married Women, 1997-2010 . 66 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 79 Table 6.2 Number of co-wives and wives . 80 Table 6.3 Age at first marriage . 81 Table 6.4.1 Median age at first marriage: Women . 82 Table 6.4.2 Median age at first marriage: Men . 83 Table 6.5 Age at first sexual intercourse . 84 Table 6.6 Median age at first intercourse: Men . 85 Table 6.7.1 Recent sexual activity: Women . 86 Table 6.7.2 Recent sexual activity: Men . 87 Table 6.8 Postpartum amenorrhea, abstinence and insusceptibility . 88 Table 6.9 Median duration of amenorrhea, postpartum abstinence and postpartum insusceptibility . 89 Table 6.10 Menopause . 90 Tables and Figures | xi CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 92 Table 7.2.1 Desire to limit childbearing: Women . 93 Table 7.2.2 Desire to limit childbearing: Men . 93 Table 7.3 Need and demand for family planning among currently married women . 95 Table 7.4 Ideal number of children . 96 Table 7.5 Mean ideal number of children. 97 Table 7.6 Fertility planning status . 98 Table 7.7 Wanted fertility rates . 98 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 101 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 103 Table 8.3 Early childhood mortality rates by demographic characteristics . 104 Table 8.4 Perinatal mortality . 105 Table 8.5 High-risk fertility behavior . 106 Figure 8.1 Mortality Trends . 102 CHAPTER 9 ADULT AND MATERNAL MORTALITY Table 9.1 Completeness of information on siblings . 110 Table 9.2 Year of birth of respondents and siblings . 110 Table 9.3 Sibship size and sex ratio of siblings . 111 Table 9.4 Adult mortality rates . 111 Table 9.5 Direct estimates of maternal mortality . 112 CHAPTER 10 MATERNAL HEALTH Table 10.1 Antenatal care . 114 Table 10.2 Number of antenatal care visits and timing of first visit . 115 Table 10.3 Components of antenatal care . 116 Table 10.4 Tetanus toxoid injections . 117 Table 10.5 Knowledge of danger signs during pregnancy . 119 Table 10.6 Place of delivery . 120 Table 10.7 Assistance during delivery . 121 Table 10.8 Knowledge of danger signs for newborns . 123 Table 10.9 Instruments used to cut the umbilical cord . 124 Table 10.10 Application of material after the umbilical cord was cut . 125 Table 10.11 Drying and bathing of newborns . 126 Table 10.12 Timing of first postnatal checkup. 127 Table 10.13 Type of provider of first postnatal checkup . 128 Table 10.14 Problems in accessing health care . 129 CHAPTER 11 CHILD HEALTH Table 11.1 Child’s weight and size at birth . 132 Table 11.2 Vaccinations by source of information . 133 Table 11.3 Vaccinations by background characteristics . 134 xii | Tables and Figures Table 11.4 Vaccinations in first year of life. 135 Table 11.5 Prevalence and treatment of symptoms of ARI . 137 Table 11.6 Prevalence and treatment of fever . 138 Table 11.7 Prevalence of diarrhea . 139 Table 11.8 Diarrhea treatment . 141 Table 11.9 Feeding practices during diarrhea . 142 Table 11.10 Knowledge of ORS packets or pre-packaged liquids . 143 Table 11.11 Disposal of children’s stools . 144 Figure 11.1 Immunization Coverage of Children 12-23 Months. 133 Figure 11.2 Trends in Children 12-23 Months Fully Immunized . 136 CHAPTER 12 NUTRITION OF CHILDREN AND WOMEN Table 12.1 Nutritional status of children . 149 Table 12.2 Initial breastfeeding . 153 Table 12.3 Breastfeeding status by age . 155 Table 12.4 Median duration and frequency of breastfeeding . 157 Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview . 158 Table 12.6 Infant and young child feeding (IYCF) practices . 160 Table 12.7 Prevalence of anemia in children . 161 Table 12.8 Micronutrient intake and food supplementation among children . 163 Table 12.9 Signs of night blindness among children . 164 Table 12.10 Nutritional status of women . 166 Table 12.11 Foods consumed by mothers in the day or night preceding the interview . 167 Table 12.12 Micronutrient intake among mothers . 169 Table 12.13 Prevalence of anemia in women . 170 Figure 12.1 Nutritional Status of Children by Age . 150 Figure 12.2 Trends in Nutritional Status of Children, 2002-2010 . 152 Figure 12.3 Trends in Nutritional Status of Children, 2007-2010, WHO Child Growth Standards. 152 Figure 12.4 Infant Feeding Practices by Age . 156 Figure 12.5 Infant and Young Child Feeding (IYCF) Practices . 159 CHAPTER 13 MALARIA Table 13.1 Ownership of mosquito nets . 174 Table 13.2 Use of mosquito nets by children . 175 Table 13.3 Use of mosquito nets by women . 176 Table 13.4 Use of mosquito nets by pregnant women . 177 Table 13.5 Prevalence and prompt treatment of fever . 178 Table 13.6 Type and timing of antimalarial drugs . 179 CHAPTER 14 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 14.1 Knowledge of AIDS. 182 Table 14.2 Knowledge of HIV prevention methods . 184 Table 14.3.1 Comprehensive knowledge about AIDS: Women . 185 Table 14.3.2 Comprehensive knowledge about AIDS: Men . 186 Tables and Figures | xiii Table 14.4.1 Accepting attitudes toward those living with HIV/AIDS: Women . 187 Table 14.4.2 Accepting attitudes toward those living with HIV/AIDS: Men . 188 Table 14.5 Multiple sexual partners in the past 12 months: Men . 190 Table 14.6 Payment for sexual intercourse: Men . 191 Table 14.7 Knowledge of a place to get an HIV test . 192 Table 14.8 Male circumcision . 193 Table 14.9 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms . 194 Table 14.10 Prevalence of medical injections . 196 Table 14.11 Comprehensive knowledge about AIDS and of a source of condoms among youth . 198 Table 14.12 Age at first sexual intercourse among youth . 199 Table 14.13 Condom use at first sexual intercourse among youth . 200 Table 14.14 Premarital sexual intercourse during premarital sexual intercourse among youth . 201 Table 14.15 Drunkenness during sexual intercourse among youth . 202 Figure 14.1 Women and Men Seeking Advice or Treatment for STIs . 195 Figure 14.2 Source of Last Medical Injection . 197 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women. 204 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women . 205 Table 15.2.2 Control over men’s cash earnings . 207 Table 15.3 Women’s control over her own earnings and over those of her husband . 208 Table 15.4.1 Women’s participation in decision making . 209 Table 15.4.2 Women’s participation in decision making according to men . 209 Table 15.5.1 Women’s participation in decision making by background characteristics . 211 Table 15.5.2 Men’s attitude toward wives’ participation in decision making . 212 Table 15.6.1 Attitude toward wife beating: Women . 214 Table 15.6.2 Attitude toward wife beating: Men . 215 Table 15.7.1 Attitude toward refusing sexual intercourse with husband: Women . 217 Table 15.7.2 Attitude toward refusing sexual intercourse with husband: Men . 218 Table 15.7.3 Men’s attitude toward a husband’s rights when his wife refuses to have sexual intercourse . 219 Table 15.8 Indicators of women’s empowerment . 221 Table 15.9 Current use of contraception by women’s status . 222 Table 15.10 Women’s empowerment and ideal number of children and unmet need for family planning . 223 Table 15.11 Reproductive health care by women’s empowerment . 224 Figure 15.1 Number of Household Decisions in Which Women Participate . 210 CHAPTER 16 DOMESTIC VIOLENCE Table 16.1 Experience of physical violence . 229 Table 16.2 Persons committing physical violence . 230 Table 16.3 Force at sexual initiation . 231 xiv | Tables and Figures Table 16.4 Experience of sexual violence . 232 Table 16.5 Experience of different forms of violence . 233 Table 16.6 Violence during pregnancy . 234 Table 16.7 Degree of marital control exercised by husbands . 235 Table 16.8 Forms of spousal violence . 237 Table 16.9 Spousal violence by background characteristics. 238 Table 16.10 Spousal violence by husband’s characteristics and empowerment indicators . 241 Table 16.11 Frequency of spousal violence among those who report violence . 242 Table 16.12 Onset of marital violence . 243 Table 16.13 Injuries to women due to spousal violence . 245 Table 16.14 Violence by women against their spouse . 246 Table 16.15 Help seeking to stop violence . 248 Figure 16.1 Percentage of Ever-married Women Who Have Experienced Specific Forms of Physical and Sexual Violence Committed by Their Husband/Partner . 238 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Sample allocation of clusters and households according to district and by type of residence, Timor-Leste 2009-10 . 256 Table A.2 Sample allocation of expected number of completed women and men interviews according to district and by type of residence, Timor-Leste 2009-10 . 256 Table A.3 Sample implementation: Women . 258 Table A.4 Sample implementation: Men . 259 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Timor-Leste 2009-10 . 263 Table B.2 Sampling errors for National sample, Timor-Leste 2009-10 . 264 Table B.3 Sampling errors for Urban sample, Timor-Leste 2009-10 . 265 Table B.4 Sampling errors for Rural sample, Timor-Leste 2009-10 . 266 Table B.5 Sampling errors for Aileu sample, Timor-Leste 2009-10 . 267 Table B.6 Sampling errors for Ainaro sample, Timor-Leste 2009-10 . 268 Table B.7 Sampling errors for Baucau sample, Timor-Leste 2009-10 . 269 Table B.8 Sampling errors for Bobonaro sample, Timor-Leste 2009-10 . 270 Table B.9 Sampling errors for Covalima sample, Timor-Leste 2009-10 . 271 Table B.10 Sampling errors for Dili sample, Timor-Leste 2009-10 . 272 Table B.11 Sampling errors for Ermera sample, Timor-Leste 2009-10 . 273 Table B.12 Sampling errors for Lautem sample, Timor-Leste 2009-10. 274 Table B.13 Sampling errors for Liquiçá sample, Timor-Leste 2009-10 . 275 Table B.14 Sampling errors for Manatuto sample, Timor-Leste 2009-10 . 276 Table B.15 Sampling errors for Manufahi sample, Timor-Leste 2009-10 . 277 Table B.16 Sampling errors for Oecussi sample, Timor-Leste 2009-10 . 278 Table B.17 Sampling errors for Viqueque sample, Timor-Leste 2009-10 . 279 APPENDIX C DATA QUALITY Table C.1 Household age distribution . 281 Table C.2.1 Age distribution of eligible and interviewed women . 282 Table C.2.2 Age distribution of eligible and interviewed men . 282 Tables and Figures | xv Table C.3 Completeness of reporting . 283 Table C.4 Births by calendar years . 283 Table C.5 Reporting of age at death in days . 284 Table C.6 Reporting of age at death in months . 285 Table C.7 Nutritional status of children . 286 Table C.8 Completeness of information on siblings . 287 Table C.9 Indicators on data quality . 287 Table C.10 Sibship size and sex ratio of siblings . 287 Foreword | xvii FOREWORD The 2009-10 Timor-Leste Demographic and Health Survey (TLDHS) is the first national level population and health survey conducted as part of the global Demographic and Health Surveys (DHS) program supported by USAID, but the second Demographic and Health survey in the country. The first DHS was done in 2003 under the guidance of ACIL Australia Pty Ltd, University of Newcastle and the Australian National University. The TLDHS 2009-10 is implemented by the National Statistics Directorate of the General Directorate for Policy Analysis and Research of the Ministry of Finance, under the aegis of the Ministry of Health. The 2009-10 TLDHS supplements and complements the information collected through the censuses, updates the available information on population and health issues, and provides guidance in planning, implementing, monitoring and evaluating Timor-Leste’s health programs. Further, the results of the survey assist in monitoring the progress made towards meeting the Millennium Development Goals (MDGs) and other international initiatives. The 2009-10 TLDHS includes topics related to fertility levels and determinants; family planning; fertility preferences; infant, child, adult and maternal mortality; maternal and child health; nutrition; malaria; domestic violence; knowledge of HIV/AIDS and women’s empowerment. The 2009-10 TLDHS for the first time also includes anemia testing among women age 15-49 and children age 6-59 months. As well as providing national estimates, the survey also provides disaggregated data at the level of various domains such as administrative district, as well as for urban and rural areas. This being the third survey of its kind in the country (after the 2002 MICS and the 2003 DHS), there is considerable trend information on demographic and reproductive health indicators. This survey is the result of concerted effort on the part of various individuals and institutions, and it is with great pleasure that we would like to acknowledge the work put in to produce this very important and useful document. The participation and cooperation that was extended by the members of the Steering Committee in the different phases of the survey is greatly appreciated. On behalf of the Government of Timor-Leste, we the Ministers of Finance and of Health, would like to extend our appreciation for the technical support by ICF Macro International and financial support from our development partners namely; the United States Agency for International Development (USAID), the Government of Australia (AusAID), the Government of Ireland (Irish Aid), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations Development Fund (UNDP) and the World Health Organization (WHO). This report contains enormous valuable information that when used correctly and consistently will undoubtedly improve the lives of many of our people. It is now time for program managers and policy makers to use the information to enable us to achieve our health and social targets as set by the Government. Acknowledgments | xix ACKNOWLEDGMENTS The 2009-10 Timor-Leste Demographic and Health Survey (TLDHS) with the main objective to generate demographic, health and social indicators, was conducted between August 2009 and January 2010. It is the second DHS to be carried out in the country since independence. Preliminary results were launched in April 2010. This report is the main output from the DHS project and will be followed by other thematic analyses depending on the program needs of the country. The 2009-10 TLDHS is a classic example of a project involving many interested groups; the Ministry of Health as the main users, the National Statistics Directorate as the implementer and a consortium of development partners who have provided both technical and financial/administrative support to implement the survey. As a result of the huge demand for data from the TLDHS, its success was accomplished through the concerted efforts of many organizations, institutions, government ministries and individuals who assisted in a variety of ways to plan, prepare, collect, process, analyze and publish the results. The Government through the Director of National Statistics Directorate under the General Directorate of Policy Analysis and Research in Ministry of Finance wishes to thank them all for their inputs into this noble process. We express our deep sense of appreciation to the technical experts from ICF Macro, the National Statistics Directorate staff who worked on the project, UNFPA for mobilizing the resources to cover local costs and administrative support; and to members of the Steering Committee who provided critical inputs at all levels. Additionally, we would like to thank the various technical experts in the fields of population and health for their valuable input in the various phases of the survey. Their expertise was invaluable during the finalization of the questionnaires, training of field staff, reviewing the draft tables and finalizing the report. Our gratitude goes to the national staff who worked during data collection, data capture and cleaning. More importantly, all the Timorese who provided the data during interviews deserve special thanks for their patience and willingness to provide the requisite information. The Government extends sincere gratitude to the development partners for their financial contributions to this project, particularly the United States Agency for International Development (USAID), the Government of Australia (AusAID), the Government of Ireland (Irish Aid), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations Development Fund (UNDP), and the World Health Organization (WHO). We sincerely hope that the information in this report will be fully utilized in the national development planning process by all stakeholders for the welfare of the Timorese people. Antonío Freitas Director General, Analysis and Research Ministry of Finance Contributors to the Report | xxi CONTRIBUTORS TO THE REPORT Elias dos Santos Ferreira, National Statistics Directorate Americo Soares, National Statistics Directorate Lourenco Soares, National Statistics Directorate Juselina Corte-Real, National Statistics Directorate Cesar Melito dos Santos Martins, National Statistics Directorate Isabel Gomes, Maternal and Child Health, Ministry of Health Aurea Celina Martins, Family Planning Section, Ministry of Health Misliza Vital, Child Health, Ministry of Health Jose Lima, Immunization Section, Ministry of Health Fatima Isabel C. Guzmao, Maternal and Reproductive Health, Ministry of Health Dirce Maria Soares, Nutrition Section, Ministry of Health Feliciano, Nutrition Section, Ministry of Health Maria do Rosario de Fatima Mota, Malaria Program, Ministry of Health Elizabeth Dos Reis, HIV/AIDS Section, Ministry of Health Teresa d.j. Vaz Cabral, University of Timor-Leste Dominique Freire, Health Alliance International Beth Elson, Health Alliance International Kiyoe Narita, Health Alliance International Melanie M. Soares, Health Alliance International Ruhul Amin, TAIS/USAID Brett Sutton, TAIS/USAID Asecelina J.M., Family Planning Unit, TAIS/USAID Fredrick Otieno Okwayo, UNFPA Anusara Singhkamarwang, World Food Program Crystal Karakochuk, UNICEF Faraja Chiwile, UNICEF Christine Chan, SEPI Pav Govindasamy, ICF Macro Anjushree Pradhan, ICF Macro Consultant Joy Fishel, ICF Macro Lyndsey Wilson-Williams, ICF Macro Velma Lopez, ICF Macro Summary of Findings | xxiii SUMMARY OF FINDINGS The 2009-10 Timor-Leste Demographic and Health Survey (TLDHS) is the second national- level population and health survey conducted in Timor-Leste and the first conducted as part of the global Demographic and Health Surveys (DHS) program. The sample for the survey was selected independently in every stratum, through a two- stage selection process, to provide estimates for each of the 13 districts and for both urban and rural areas of the country. The 2009-10 TLDHS was designed to cover a nationally representative sample of residential households, taking into account nonresponse; to obtain completed inter- views of women age 15-49 in every selected household; and to obtain completed interviews of men age 15-49 in every third selected household. Each household selected for the TLDHS was eligible for interview with the Household Questionnaire, and a total of 11,463 households were interviewed. All eligible women age 15-49 in the selected households and all eligible men age 15-49 in every third household were inter- viewed with the Women’s and Men’s Question- naires, respectively. A total of 13,137 women age 15-49 and 4,076 men age 15-49 were interviewed. Data collection took place over a six-month period, from early August 2009 to early February 2010. The survey obtained detailed information on fertility, fertility preferences, marriage, sexual activity, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood mortality, maternal and child health, awareness and behavior regarding HIV and AIDS, and other sexually transmitted infections (STIs). In addition, the 2009-10 TLDHS collected informa- tion on domestic violence, malaria and use of mosquito nets, and anemia testing and anthropo- metric measurements for women and children. The survey was implemented by the National Statistics Directorate of the Directorate General for Analysis and Research of the Ministry of Finance, under the aegis of the Ministry of Health (MOH) of Timor-Leste. Technical support was provided by ICF Macro, and financial support was provided by USAID, the Government of Australia (AusAID), the Government of Ireland (Irish AID), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations Development Fund (UNDP), and the World Health Organization (WHO). UNFPA supported the survey with administrative, logistical, and technical assistance. A steering committee was formed to be responsible for coordination, oversight, advice, and decision- making on all major aspects of the survey. The steering committee was composed of representatives from various ministries and key stakeholders, including the MOH, National Statistics Directorate, USAID, and international nongovernmental organizations (INGOs). FERTILITY Fertility Levels and Trends. The total fertility rate for Timor-Leste for the three years preceding the survey is 5.7 births per woman and is the highest in South East Asia and in Asia (together with Afghanistan) (PRB, 2010) but below the levels of Africa. At this level, it is estimated that the population will increase from its current size of 1.2 million to 1.9 million by the year 2025 and to 3.2 million by the year 2050. Fertility Differentials. As expected, fertility is considerably higher in rural areas than in urban areas. Rural women have on average about one child more than urban women (6.0 compared with 4.9 births per woman). As the age-specific fertility rates (ASFRs) show, the pattern of high rural fertility is prevalent in all age groups. The rural-urban difference in fertility is most pro- nounced for women age 20-24 (236 births per 1,000 women in rural areas versus 187 births per 1,000 women in urban areas). There are considerable differentials in fertility among districts, with fertility ranging from a low of 4.4 births per woman in Covalima to a high of 7.2 births per woman in Ainaro. The level of fertility is inversely related to women’s educational attainment, decreasing rapidly from 6.1 births among women with no education to 2.9 births among women with more than secondary education. Fertility is also inversely associated with wealth quintile. Women in the lowest wealth quintile have an average of 7.3 births, xxiv | Summary of Findings about three children more than women in the highest quintile (4.2 births). Unplanned Fertility. Despite a marked increase in the level of contraceptive use over the past eight years, the 2009-10 TLDHS data indicate that unplanned pregnancies are not uncommon. Overall, 86 percent of births are wanted, 12 percent of births in the country are mistimed (wanted later), and 2 percent are unwanted. Data from the 2003 DHS show that there has been little change in the status of planning for children, with 86 percent of births in the five years preceding the survey planned and 11 percent mistimed. Unwanted births declined from 4 percent in 2003 to 2 percent in 2009-10. Fertility Preferences. There is considerable desire among currently married Timorese to control the timing and number of births. Thirty- five percent of currently married women would like to wait two or more years before the next birth, and 36 percent do not want to have another child, or are sterilized. About one in ten (9 percent) of currently married women would like to have a child soon (within two years). In addition, 17 percent are undecided about whether to have a child or not. The proportion of currently married women who want no more children more than doubled in the last seven years, from 17 percent as reported in the 2003 DHS to 36 percent in the 2009-10 TLDHS. Currently married women and men prefer about six children. Data from the 2003 DHS show that the ideal number of children preferred by currently married women has changed little over the last seven years. FAMILY PLANNING Knowledge of Contraception. Findings from the 2009-10 TLDHS show that 78 percent of currently married women and 66 percent of currently married men in Timor-Leste know of at least one modern method of family planning. The most widely known modern contraceptive methods among currently married women are injectables (70 percent) and the pill (58 percent). Currently, married men are most likely to know of the male condom (54 percent) and injectables (46 percent). Twenty-seven percent of currently married men mentioned knowledge of a tradi- tional method compared with 22 percent of currently married women. Over the past seven years there has been a considerable increase in the overall knowledge of contraceptive methods in the country. Use of Contraception. More than one in five currently married women (22 percent) is using a method of family planning, with 21 percent using a modern contraceptive method. This indicates that modern contraceptive methods are highly favored over either natural family planning methods or other traditional methods. One percent of women report currently using a traditional method. The rhythm method is slightly more popular than withdrawal. Injectables are by far the most popular modern method, and they are used by 16 percent of currently married women. Two percent of women use the pill, and about 1 percent of women each use the IUD or implants, or they are sterilized. Most women who are sterilized are over age 30. Injectables are popular among women age 20-44. Trends in Contraceptive Use. There has been a marked increase in the use of contra- ception by currently married women since 2002. Use of modern methods doubled in the five years between 2002 and 2007 and rose by nearly 50 percent in the three years between 2007 and the 2010. The increase in use of modern methods contributed to a three-fold increase in overall contraceptive use, from 7 percent to 21 percent, in a matter of 7 to 8 years. Differentials in Contraceptive Use. Women in urban areas (30 percent) are more likely to use a family planning method than rural women (20 percent), reflecting wider availability and easier access to methods in urban than in rural areas. Contraceptive use varies by district with much of the difference due to the use of injectables. Use of a modern method among currently married women is highest in Covalima (43 percent) and lowest in Baucau (8 percent). Current use varies markedly between women who have some education and those who have none, however, there is little variation among educated women by specific level of education. Wealth has a positive effect on women’s contraceptive use, with modern contraceptive use increasing markedly as household wealth increases, from 15 percent among currently married women in the lowest wealth quintile to 32 percent among those in the highest wealth quintile. Summary of Findings | xxv Source of Modern Methods. Forty-five percent of all users are served by community health centers, 20 percent by health posts, 17 percent by government and referral hospitals, 3 percent by integrated community health services (SISCa), and 2 percent by mobile clinics. In the private medical sector, most users are served by private hospitals/clinics (8 percent of all users). Most contraceptives sold in private hospitals/ clinics are provided through the Timor-Leste Contraceptive Retail Sales Company. Unmet Need for Family Planning. About one in three currently married women has an unmet need for family planning, with 21 percent having an unmet need for spacing and 10 percent having an unmet need for limiting. Twenty-two percent of women have a met need for family planning. If all currently married women who say they want to space or limit their children were to use a family planning method, the contraceptive prevalence rate would increase to 53 percent from the current 22 percent. Currently, only 42 percent of the family planning needs of currently married women are being met. MATERNAL HEALTH Antenatal Care. Antenatal care from a skilled birth attendant, that is, from a doctor, nurse, midwife, or assistant nurse, is very common in Timor-Leste, with 86 percent of women reporting receipt of such care. The majority of women received care from a nurse or midwife (80 percent). Four percent of women received care from a doctor, and less than 2 percent received care from an assistant nurse. One percent of women received care from a traditional birth attendant. Thirteen percent of women did not receive care from a health provider for their last birth in the five years preceding the survey. Antenatal care from a skilled provider is lowest in Ermera (71 percent) and highest in Dili (96 percent). There has been a significant improvement in the proportion of women receiving antenatal care from a skilled provider—an increase of 41 percent, from 61 percent in the 2003 DHS to 86 percent in the 2009-10 TLDHS. Neonatal tetanus is a leading cause of neonatal death in developing countries where a high proportion of deliveries occur at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) vaccinations are given to pregnant women to prevent neonatal tetanus. The survey results show that three-quarters of mothers with a live birth in the five years preceding the survey received two or more tetanus toxoid injections during their last preg- nancy, and four-fifths were protected for their last birth. Mothers in Manatuto are most likely to have received two or more tetanus toxoid injections (92 percent) and to have had their last birth protected against neonatal tetanus (95 percent) compared with mothers in all other districts; tetanus toxoid coverage is lowest among mothers in Ermera and Ainaro. With regard to antimalarial indicators, the results show that overall, 39 percent of all women and 45 percent of pregnant women slept under some sort of net the night before the interview. Thirty-seven percent of all women and 43 percent of pregnant women slept under an ever-treated net, and 34 percent and 41 percent, respectively, slept under an ITN. In households that own at least one ITN, a substantially larger proportion of women slept under an ITN the night before the survey (77 percent of all women and 84 percent of pregnant women). Delivery Care. Just over one in five births are delivered in a health facility, with the vast majority delivered in a public (21 percent) rather than in a private (1 percent) facility. The majority of births (78 percent) are delivered at home. Delivery in a health facility is most common among young mothers (25 percent), mothers of first-order births (31 percent), and mothers who have had at least four antenatal visits (31 percent). Half (53 percent) of the children in urban areas are born in a health facility, compared with only 12 percent in rural areas. Delivery in a health facility also varies by district, with facility delivery in Dili being much more likely than in any other district (63 percent). Less than 10 percent of births in Ermera, Oecussi, and Ainaro are delivered in a health facility. Thirty percent of births are delivered by a skilled provider (doctor, nurse, assistant nurse, or midwife), with a nurse or midwife being the most common skilled provider. Three percent of deliveries are performed by a doctor, and less than 1 percent are performed by an assistant nurse. Nearly one-fifth of deliveries are carried out by traditional birth attendants (18 percent). Women receive assistance from a relative or some other person for nearly one in two births (49 percent), while 3 percent of births take place without any type of assistance at all. xxvi | Summary of Findings Postnatal Care. The majority of women (68 percent) did not receive a postnatal check. Among those who received postnatal care, 16 percent received it in less than four hours after delivery, 5 percent received care within 4 to 23 hours, and 3 percent received care within the first two days. Seven percent received postnatal care 3 to 41 days following delivery. Maternal Mortality. Maternal mortality in Timor-Leste is high relative to many developed countries. Respondents reported 120 maternal deaths in the seven years preceding the survey. The maternal mortality rate, which is the annual number of maternal deaths per 1,000 women age 15-49, for the period zero to six years preceding the survey, is 0.96. Maternal deaths accounted for 42 percent of all deaths to women age 15-49; in other words, more than two in five Timorese women who died in the seven years preceding the survey died from pregnancy or pregnancy- related causes. The maternal mortality ratio, which measures the obstetric risk associated with each live birth for the seven years preceding the survey is 557 deaths per 100,000 live births (or alternatively, about 6 deaths per 1,000 live births). The 95 percent confidence interval places the true MMR for 2009-10 anywhere between 408 and 706. CHILD HEALTH Childhood Mortality. Under-5 mortality for the most recent period (0-4 years before the survey or, roughly, during the calendar years 2005-2009) is 64 deaths per 1,000 live births. This means that 1 in 16 children born in Timor- Leste dies before the fifth birthday. Seventy percent of deaths among children under age 5 occur during the first year of life: infant mortality is 45 deaths per 1,000 live births. During infancy, the risk of neonatal deaths and postneonatal deaths is 22 and 23 per 1,000 live births, respectively. Data from the TLDHS for the three five-year periods preceding the survey indicate a decline in childhood mortality. This is consistent with comparison of the TLDHS 2009-10 mortality data with the 2003 DHS survey results, which shows a substantial (23 percent) improvement in child survival. For example, under-5 mortality declined from 83 per 1,000 live births during the period 1999-2003 to 64 per 1,000 live births during the period 2005-2009. This decline is caused principally by a decrease in the infant mortality rate, from 60 deaths per 1,000 for the zero to four years preceding the 2003 DHS to 45 per 1,000 during the same period prior to the 2009-10 TLDHS. Childhood Vaccination Coverage. Fifty- three percent of Timorese children age 12-23 months are fully immunized, and 23 percent received no vaccinations. Forty-seven percent of children age 12-23 months are fully vaccinated by 12 months of age. The percentage of children fully vaccinated nearly tripled from 18 percent in 2003. Seventy-seven percent of children received the BCG vaccination, 75 percent received the first DPT dose, and 75 percent received the first polio dose. Coverage for all three vaccinations declines with subsequent doses; 66 percent of children received the recommended three doses of DPT, and 56 percent received three doses of polio. These figures reflect dropout rates (which represent the proportion of children who received the first dose of a vaccine but who did not get the third dose) of 12 percent for DPT and 25 percent for polio, respectively. This is a huge improve- ment from 2003 when the dropout rates for DPT and polio were 45 and 62 percent, respectively. Sixty-eight percent of children received the measles vaccine. Hepatitis B coverage varies slightly from DPT coverage, although they have been given together in a tetravalent vaccine since 2007. This difference is likely due to the inclusion of a small number of children who received the DPT vaccine before the tetravalent vaccine was introduced. Childhood Illness and Treatment. Among children under 5 years of age, 2 percent had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey. Seven in ten children with symptoms of ARI (71 percent) were taken to a health facility or provider, and 45 percent were prescribed antibiotics. One-fifth of children (19 percent) under 5 years of age were reported to have had fever in the past two weeks. Seventy-three percent of children with a fever were taken to a health facility or provider for treatment. Six percent of children under age 5 with fever in the two weeks preceding the survey were given antimalarial drugs, and 36 percent received antibiotics. Sixteen percent of all children under the age of 5 had diarrhea in the two weeks before the survey, and 1 percent had diarrhea with blood. Overall, 72 percent of children with diarrhea were taken to a health provider for treatment of diarrhea. Seventy-eight percent of children with Summary of Findings | xxvii diarrhea were treated either with oral rehydration salts (ORS) (71 percent) or recommended home fluids (RHF) (40 percent). Ten percent of children were given increased fluids. Overall, 79 percent of children under age 5 with diarrhea were treated with ORS, RHF, or increased fluids. Six percent of children with diarrhea were treated with antibiotics, home remedies were given to 18 percent of children with diarrhea, and 13 percent of children with diarrhea were given no treatment at all. Six percent of children with diarrhea received zinc only. NUTRITION Nutritional Status of Children. Fifty-eight percent of children under age 5 are stunted, and 33 percent are severely stunted. Nineteen percent of children under age 5 are wasted, and 7 percent are severely wasted. The weight-for-age indicator shows that 45 percent of children under age 5 are underweight, and 15 percent are severely underweight. In addition, 5 percent of Timorese children under age 5 are overweight. There has been a slight rise in the level of stunting, wasting, and underweight over the past 6 years. Stunting increased from 49 percent to 53 percent, wasting increased from 12 percent to 17 percent, and underweight increased from 46 percent to 52 percent. Breastfeeding Practices. Breastfeeding is nearly universal in Timor-Leste, with 97 percent of children born in the five years preceding the survey having been breastfed at some time. On average, four in five children are breastfed within the first hour of birth (82 percent), and 96 percent are breastfed within one day of birth. Thirteen percent of children are given a pre- lacteal feed, that is, something other than breast milk, during the first three days of life. The percentage of children who are breastfed early has increased in the past six years, the increase being more pronounced for children breastfed within one hour of birth. There has been a rise in the percentage of children breastfed within one hour of birth by about 74 percent, from 47 percent in the 2003 DHS to 82 percent in 2009- 10 TLDHS. Contrary to WHO’s recommendations, how- ever, only about half (52 percent) of children under age 6 months are exclusively breastfed in Timor-Leste. The 2009-10 TLDHS results also indicate that the proportion of children receiving complementary foods in a timely fashion is encouraging, with 78 percent of children age 6-8 months receiving complementary foods. The practice of bottle-feeding with a nipple is not widespread in Timor-Leste. Intake of Vitamin A. Ensuring that children age 6-59 months receive enough vitamin A may be the single most effective child survival intervention. Deficiencies in this micronutrient can cause blindness and can increase the severity of infections such as measles and diarrhoea. Nearly four-fifths (79 percent) of last-born children age 6-35 months consumed vitamin A- rich foods, and 52 percent of young children consumed foods rich in iron in the 24-hour period before the survey. One in two children (51 percent) age 6-59 months received a vitamin A supplement in the six months before the survey. This is an improvement over the last five years. Along with vitamin A deficiency, the preva- lence of worm infestation has been high in Timor-Leste. Thirty-five percent of children age 6-59 months received deworming tablets in the six months preceding the survey. Prevalence of anemia. Iron-deficiency anemia is a major threat to maternal health and child health. More than one in three (38 percent) Timorese children age 6-59 months old are anemic, with 25 percent mildly anemic, 13 percent moderately anemic, and less than 1 percent severely anemic. Children in Manatuto district have the highest prevalence of anemia (68 percent), and children in Ermera district have the lowest prevalence (15 percent). Nutritional Status of Women. Overall, 15 percent of women are shorter than 145 cm. Women in rural areas are much shorter on average than women in urban areas, with 17 percent falling below the 145 cm cutoff compared with only 9 percent of women in urban areas. Women living in Dili are least likely to be below 145 cm (7 percent), while women in Ermera are most likely (31 percent). Twenty-seven percent of women were found to be malnourished with BMI <18.5 indicating that malnutrition among women is a serious public health concern in Timor-Leste. About 5 percent of Timorese women are overweight or obese. Women’s nutritional status has improved over the years. The proportion of malnourished women (BMI <18.5) has decreased by 29 percent in the past decade, from 38 percent in the 2003 DHS to 27 percent in the 2009-10 TLDHS. xxviii | Summary of Findings However, the level of chronic energy deficiency among nonpregnant women is still high, with more than one-quarter of women having a BMI less than 18.5. The mean BMI has increased only slightly over the years from 19.5 in the 2003 DHS to 20.2 in the 2009-10 TLDHS. A mother’s nutritional status during preg- nancy is important both for the child’s intra- uterine development and for protection against maternal morbidity and mortality. Night blind- ness is an indicator of severe vitamin A deficiency, and pregnant women are especially prone to experience it. More than nine in ten mothers (94 percent) consumed vitamin A-rich foods, and more than one-half (53 percent) consumed iron-rich foods in the 24 hours preced- ing the survey. Fifty-five percent of women received vitamin A postpartum, an improvement from the 23 percent of women who received vitamin A postpartum reported in the 2003 TLDHS. Iron supplementation during pregnancy has been a key health initiative in Timor-Leste since 2003. The proportion of women who took iron supplements during pregnancy has risen from 43 percent in 2003 to 61 percent in 2009-10. However, 37 percent of women did not take any iron supplements during their most recent preg- nancy. Further, only 16 percent of women took the recommended dose of iron supplements for 90 days or more during their pregnancy. In addition, 13 percent of women received deworming medication during pregnancy, 31 percent received supplementary food while pregnant with their last birth, and 29 percent received supplementary food while breastfeeding their last-born child. Thirteen percent of mothers reported having difficulty seeing at night but, when this figure is adjusted to include only those mothers who had no difficulty seeing in the daytime, only 2 percent of mothers suffered from night blindness during their most recent pregnancy in the last five years. This is a decrease from the 13 percent of mothers reported with night blindness in the DHS 2003 survey. Iron deficiency anemia is one of the most common nutritional problems in Timor-Leste. Overall 21 percent of Timorese women age 15- 49 are anemic, with 18 percent mildly anemic, 4 percent moderately anemic, and less than 1 percent severely anemic. However, pregnant women are more likely to be anemic (28 percent) than women who are breastfeeding (25 percent) and women who are neither pregnant nor breast- feeding (19 percent). HIV AND AIDS Knowledge of HIV and AIDS. Forty-four percent of women and 61 percent of men have heard of HIV and AIDS. Women are most aware that the chances of getting the HIV virus can be reduced by limiting sex to one uninfected partner who has no other partners (36 percent). In addition, 26 percent mention that abstaining from sexual intercourse will prevent the transmission of HIV. Among men, the most commonly known prevention method is also limiting sex to one uninfected partner who has no other partners (49 percent). Knowledge of condoms and the role that they can play in preventing the transmission of HIV is much less common among women than among men (30 percent versus 45 percent). Fewer women and men (27 percent and 42 percent, respectively) are also aware that both using condoms and limiting sex to one uninfected partner can reduce the risk of getting the HIV virus. Many Timorese adults lack accurate knowledge about the ways in which the HIV virus can and cannot be transmitted, with women being much less knowledgeable than men. Only 33 percent of women and 46 percent of men know that a healthy-looking person can have the HIV virus. One in four women and two in five men know that HIV cannot be transmitted by mosquito bites, or that a person cannot become infected by sharing food with a person who has HIV or sharing clothes with a person who has HIV. About twice as many men as women (28 percent and 15 percent, respectively) say that a healthy looking person can have the virus and reject the two most common local misconcep- tions (that HIV can be transmitted by mosquito bites and by sharing food). Attitudes towards People Living with HIV and AIDS. Knowledge and beliefs affect how people treat those they know to be living with HIV or AIDS. In the 2009-10 TLDHS, a number of questions were posed to respondents to measure their attitudes towards people living with HIV or AIDS (PLWA). Twice as many women as men (55 percent and 26 percent, respectively) state that they would be willing to care for a family member with the AIDS virus in their home. Eighty-four percent of women and 87 percent of men say that they would not want to keep secret that a family member was infected with the AIDS virus, while 44 percent of women Summary of Findings | xxix and 28 percent of men say that a female teacher with AIDS should be allowed to continue teaching. A relatively lower proportion of women and men (34 percent and 22 percent, respectively) say they would buy fresh vege- tables from a shopkeeper with AIDS. The percentage expressing accepting attitudes on all four measures is low: 11 percent among women and 3 percent among men. HIV-Related Behavioral Indicators. Just over 1 percent of men age 15-49 reported having had two or more sexual partners during the 12 months prior to the survey, with men reporting a mean number of just under two partners in their lifetime. Among men with two or more partners in the 12 months preceding the survey, 19 percent used a condom at last sex. Five percent of men reported that they had engaged in paid sex in the year before the survey, and among those who paid for sex, only 26 percent reported using a condom the last time they paid for sex. DOMESTIC VIOLENCE The 2009-10 TLDHS included a series of questions that focus on specific aspects of domestic and interpersonal violence, including acts of physical, sexual, and emotional violence. Due to ethical considerations, only one woman was administered the domestic violence module in each selected household, and the violence module was not administered if privacy could not be obtained. Approximately one-third of women (38 percent) have experienced physical violence since age 15. One percent of women experienced physical violence often, while 28 percent experienced physical violence sometimes in the past 12 months. Urban women are more likely than rural women to have experienced physical violence since the age of 15 (49 percent compared with 35 percent). This is corroborated by the fact that more than half of the women in Dili district, which is primarily urban, reported experiencing physical violence since the age of 15 years. Women in Manufahi (76 percent) are most likely to report having ever experienced physical violence. Experience of physical violence in the past 12 months is highest among women in Manufahi (65 percent) and lowest in Ainaro (8 percent). Among ever-married women who have ever experienced physical violence, 74 percent reported that a current husband or partner committed the physical violence against them, while 6 percent reported that they experienced physical violence by a former husband/partner. Other perpetrators commonly reported by ever- married women were mother/stepmother (34 percent) and father/stepfather (26 percent), sisters and brothers (11 percent), and other relatives (6 percent). About 3 percent of women have experienced sexual violence, with the proportion of women who have experienced sexual violence ranging from less than 1 percent in Viqueque to 7 percent in Baucau, Lautem, and Aileu. For 16 percent of women who ever experienced sexual violence, the first experience of such violence occurred at age 15-19; 6 percent first experienced sexual violence at age 10-14; and less than 1 percent first experienced sexual violence before age 10. One in ten women who experienced sexual violence first experienced it at age 20-49. The main perpetrators of sexual violence against ever-married women are current husbands/ partners (71 percent) or former husbands/partners (9 percent). The findings from the survey also indicate that overall, 4 percent of women in Timor-Leste experienced physical violence during pregnancy. Violence by husbands against wives is not the only form of spousal violence; women may sometimes be the perpetrators of violence. Six percent of married women report that they have initiated physical violence against their current or most recent husbands, while 5 percent say that they have committed such violence in the 12 months preceding the survey. About one in five women (24 percent) who experience violence seek help. Women who experience both physical and sexual violence (50 percent) are most likely to seek help. Seven percent of women who experienced violence in Manufahi sought help, compared with one in two women in Covalima (51 percent). Millennium Development Goal Indicators | xxxi MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators Timor-Leste 2009-10 Indicator Sex Total Male Female 1.8 Prevalence of underweight children under five years of age 45.5 43.8 44.7 2.1 Net attendance ratio in primary school1 70.3 77.4 71.1 2.3 Literacy rate of 15-24 year-olds 86.1 84.1 na 3.1 Ratio of girls to boys in primary, secondary and tertiary education na na 93.3 4.1 Under five mortality rate2 85 76 64 4.2 Infant mortality rate2 59 53 45 4.3 Percentage of 1 year old children immunized against measles 69.0 66.5 67.8 5.1 Maternal mortality ratio3 na na 557 5.2 Percentage of births attended by skilled health personnel na na 29.9 5.3 Contraceptive prevalence rate4 na 22.3 na 5.4 Adolescent birth rate5 na 51 na 5.5 Antenatal care coverage At least one visit na 87.5 na Four or more visits na 55.1 na 5.6 Unmet need for family planning na 30.8 na 6.2 Condom use at last high-risk sex6 13.2 * na 6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS 19.7 12.2 na 6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years 0.82 0.68 0.75 6.7 Percentage of children under five sleeping under ITN 40.7 41.4 41.0 6.8 Percentage of children under five with fever treated with appropriate antimalarial drugs 6.4 5.1 5.7 Urban Rural Total 7.8 Percentage of population with sustainable access to an improved water source 88.2 56.6 64.0 7.9 Percentage of population with access to improved sanitation 65.9 35.8 43.0 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Net attendance ratio measured in the TLDHS approximates MDG indicator 2.1, Net enrollment ratio. 2 Expressed in terms of deaths per 1,000 live births 3 Expressed in terms of maternal deaths per 100,000 live births 4 Percentage of currently married women using any method of contraception 5 Equivalent to the age-specific fertility rate for women age 15-19, expressed in terms of births per 1,000 women age 15-19. 6 High-risk sex is defined as sexual intercourse with a non-marital, non-cohabiting partner. Expressed as a percentage of men and women age 15-24 who had high-risk sex in the past 12 months. xxxii | Map of Timor-Leste Introduction | 1 INTRODUCTION 1 1.1 HISTORY, GEOGRAPHY, AND ECONOMY 1.1.1 History Timor-Leste is a small country in Southeast Asia. It occupies primarily the eastern half of the island of Timor, with West Timor being part of the Republic of Indonesia. Timor-Leste includes the nearby islands of Ataúro and Jaco, and also Oecussi, an exclave in Indonesian West Timor. The first inhabitants are thought to be descended from Australoid and Melanesian people. Contact between the Portuguese and the island of Timor began in the early 16th century, with trade and eventual colonization occurring in the middle of the century. In 1859, the western portion of the island was ceded to the Dutch. During World War II, Japan occupied Timor-Leste from 1942 to 1945. Portugal resumed colonial authority after the Japanese defeat. The country declared independence from Portuguese rule on November 28, 1975, but was invaded and occupied by Indonesian forces just nine days later on December 7, 1975. It was incorporated into Indonesia in July 1976 as a province known as Timor-Timur. Between 1974 and 1999, there were an estimated 102,800 conflict-related deaths (approximately 18,600 killings and 84,200 “excess” deaths from hunger and illness), the majority of which occurred during the Indonesian occupation (UNESCO, 2009). On August 30, 1999, in a UN-sponsored referendum, an overwhelming majority of the Timorese people voted for independence from Indonesia. Immediately following the referendum, however, anti-independence Timorese militias organized with support from the Indonesian military and began a punitive “scorched-earth” campaign. The majority of the country’s infrastructure was destroyed, including homes, irrigation and water supply systems, schools, and nearly all of the country’s electrical grid. The militias killed approximately 1,400 Timorese and forcibly pushed 300,000 people into West Timor as refugees (CIA, 2010). On September 20, 1999, the International Force for East Timor (INTERFET) began deploying to the country and brought the violence to an end. Following a transitional period administered by the United Nations under the United Nations administration in East Timor (UNTAET), Timor-Leste was internationally recognized as an independent country on May 20, 2002. The country became officially known as the Democratic Republic of Timor-Leste. Kay Rala Xanana Gusmão became the first president, and Mari Alkatiri assumed the role of first prime minister. The relationship between the armed forces and the police remained fragile, and the authority of the state faced multiple challenges. In early 2006, following claims of discrimination within the military of Timor-Leste, nearly 600 military personnel deserted their barracks and were eventually relieved of duty. In April, riots broke out in Dili among rival groups within the military and police. Renewed fighting between the pro-government troops and disaffected Falentil troops broke out in May 2006 and resulted in further destruction of property. Forty people were reported as killed, and more than 20,000 residents fled their homes to internally displaced persons camps outside of the city (Head, 2006). In July 2006, after calls for his resignation, Prime Minister Alkatiri stepped down and was replaced by Jose Ramos-Horta. Following the most recent presidential elections held in April 2007, Jose Ramos-Horta became the president on May 20, 2007 and Kay Rala Xanana Gusmão was sworn in as the Prime Minister on August 8, 2007 (Wikipedia, 2010). 2 | Introduction 1.1.2 Geography Timor-Leste is variously known as Timor-Timur, timur meaning “east” in Malay; Timor- Leste, leste meaning “east” in Portuguese; and Timor Lorosa’e, Lorosa’e meaning “rising sun” in Tetum. The island of Timor is part of the Malay Archipelago and is the largest and easternmost of the Lesser Sunda Islands. To the north of the mountainous island are the Ombai Strait and Wetar Strait, to the south is the Timor Sea, which separates the island from Australia, and to the west lies the Indonesian province of East Nusa Tenggara. The highest point of Timor-Leste is Mount Tatamailau at 2,963 meters. The island of Timor is located at coordinates between 8°50′S and 125°55′E, and the country covers a total area of 14,919 square kilometers (National Statistics Directorate, 2006). The local climate is tropical and generally hot and humid, characterized by distinct rainy and dry seasons. Timor-Leste is divided into 13 administrative districts, 65 sub-districts, and 442 Sucos and 2,225 aldeias. The 13 districts are Ainaro, Alieu, Baucau, Bobonaro, Covalima, Dili, Ermera, Lautem, Liquiçá, Manatuto, Manufahi, Oecussi, and Viqueque. Thirty percent of the population lives in the urban areas, and the rest live in rural areas (NSD, 2010). Dili is the capital. It is the largest city and the main port. The second-largest city is the eastern town of Baucau. Dili has the only functioning international airport, though there is also an airstrip in Baucau that is used for domestic flights. Several languages are spoken in the country. Tetum is the most common language in Timor- Leste and is the first official national language. Portuguese, spoken by fewer people, is the other official language. English and Indonesian are working languages. 1.1.3 Economy Timor-Leste’s economy is one of the poorest in the world (CIA, 2010). During colonization and even before then, Timor-Leste was best known for its sandalwood. In late 1999, about 70 percent of the economic infrastructure of Timor-Leste was destroyed by Indonesian troops and anti- independence militias. Some 300,000 people fled westward. Over the next three years, a massive international program led by the United Nations and manned by civilian advisers, peacekeepers, and police officers led to substantial reconstruction in the country (CIA, 2010). Timor-Leste still suffers from the aftereffects of the conflict. The country faces great challenges in continuing to rebuild infrastructure and strengthen the civil administration. One promising long-term project has been the joint development with Australia of petroleum and natural gas resources in the southeastern waters off Timor. Following independence, Timor-Leste negotiated the Timor Sea Treaty with Australia. This treaty replaced a previous agreement, the Timor Gap treaty, brokered between Indonesia and Australia in 1989. The Timor Sea Treaty established the Joint Petroleum Development Area (JPDA), which is administered jointly by both countries. Under the terms of the treaty, Timor-Leste receives 90 percent of the revenue from petroleum production in the JPDA, and Australia receives the remaining 10 percent. Agriculture and fishery are the backbone of the Timorese economy, and coffee plantations have been of major significance. In 2007, a poor harvest led to deaths from starvation in several parts of the country, and 11 districts required food supplies through international aid. The 2007 Timor-Leste Survey of Living Standards reported that nearly 50 percent of the Timorese lived below the national poverty line, estimated at $0.88 per capita per day. Based on a recent survey-to-survey imputation calculation, the incidence of poverty in the country is predicted to have declined by 9 percentage points between 2007 and 2009 (MOF, 2010). Timor-Leste’s Human Development Index for 2010 is 0.502—positioning the country at 120 out of 169 countries and areas (UNDP, 2010). This is an increase of 17 percent from 0.428 in 2005. During the same period, Timor- Leste’s life expectancy at birth increased by over 2 years. Introduction | 3 The government of Timor-Leste has laid out the Fourth Constitutional Government Program for 2007-2012 as the country’s development strategy for the current five years. It defines the long- term development goals in terms of reducing poverty and promoting the equitable growth and life of the Timorese population. The Office of the Prime Minister is preparing the Strategic Development Plan to address the national priorities for the country over the period 2011-2030. 1.2 POPULATION The first census following independence was conducted in 2004, and the second census was completed in August 2010. According to the 2004 Census, the population of Timor-Leste is 923,198 and the annual growth rate is 5.3 percent (NSD, 2006). The population increased by 24 percent over the last 15 years, growing from 747,547 in 1990 to 923,198 in 2004 (NSD, 2006). The population is currently estimated at 1,066,582 with an annual growth rate of 2.4 percent between the 2004 Census and the 2010 Census (NSD, 2010). According to the 2004 Census, life expectancy was estimated at 59 years, and increased to 62 years according to the 2010 Census. 1.3 POPULATION AND REPRODUCTIVE HEALTH POLICIES AND PROGRAMS Shortly after the country gained independence, the Ministry of Health initiated the first National Health Policy Framework (NHPF) for 2002-12, which prioritizes the health needs of the Timorese people and emphasizes the importance of understanding the social determinants of health within the local cultural context. The NHFP seeks to “provide quality of health for the East Timorese by establishing and developing a cost-effective and needs-based health system which will specially address the health issues and problems of women, children, and other vulnerable groups, particularly the poor, in a participatory way” (MOH, 2002a). The NHPF serves as the basis for the formulation of the National Health Promotion Strategy (NHPS) and the National Reproductive Health Strategy (NRHS), which is an outcome of the 1994 International Conference on Population and Development (ICPD) held in Cairo (MOH, 2004a). The primary objectives of the NRHS are: • to substantially increase the level of knowledge in the general population on issues related to sexuality and reproductive health; • to promote family planning in order to stabilize the population growth rate and reduce the incidence of unintended, unwanted, and mistimed pregnancies; • to ensure that all women and men have access to basic reproductive health care services, health promotion, and information on issues related to reproduction; • to reduce the level of maternal mortality and morbidity; • to reduce the level of prenatal and neonatal mortality and morbidity; • to reduce the burden of STIs/HIV; • to meet changing reproductive health needs over the life cycle and to improve the health status of people of reproductive age. Family planning is one of the major components of the Timor-Leste planned development activities under the First Development Plan, 2002-2007. The Timor-Leste Family Planning and Maternal and Child Health project (FP/MCH) functions under the Ministry of Health. The Ministry of Health endorsed the National Family Planning Policy for Timor-Leste in March 2004. The primary objective of this policy is to address population growth and provide guidance on the development and implementation of family planning programs and activities in Timor-Leste (MOH, 2004b). The FP/MCH project began in 2002, and since then it has gradually involved all 13 districts of Timor-Leste. Family planning services have become an integral part of government health services. Currently, temporary modern family planning methods (male condoms, contraceptive pills, and injectables) are provided by peripheral health workers and volunteers on a regular basis through national, regional, zonal, and district hospitals; primary health care centers/health centers; and health 4 | Introduction posts and sub-health posts. Services such as implants and IUD insertions are available only at a limited number of hospitals, health centers, and selected health posts where trained personnel are available. Depending on the district, sterilization services are provided at some static sites in the 13 districts through scheduled “seasonal” or mobile outreach services. A number of local nongovernmental organizations (NGOs) and international nongovernmental organizations (INGOs) also are currently involved in the delivery of family planning services at the grass roots level. 1.4 OBJECTIVES OF THE SURVEY The principal objective of the 2009-10 Timor-Leste Demographic and Health Survey (TLDHS) was to provide current and reliable data on fertility and family planning behavior, child mortality, adult and maternal mortality, child nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. The specific objectives of the survey were to: • collect data at the national level that will allow the calculation of key demographic rates; • analyze the direct and indirect factors that determine the levels and trends in fertility; • measure the level of contraceptive knowledge among women and men, and measure the level of practice among women by method, according to urban or rural residence; • collect quality data on family health, including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under age 5, and maternity care indicators, including antenatal visits, assistance at delivery, and postnatal care; • collect data on infant and child mortality and on maternal and adult mortality; • obtain data on child feeding practices, including breastfeeding, and collect anthropometric measures to use in assessing the nutritional status of women and children; • collect information on knowledge of tuberculosis (TB), knowledge of the spread of TB, and attitudes towards people infected with TB among women and men; • collect data on use of treated and untreated mosquito nets, persons who sleep under the nets, use of drugs for malaria during pregnancy, and use of antimalarial drugs for treatment of fever among children under age 5; • collect data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS, and evaluate patterns of recent behavior regarding condom use; • collect information on the sexual practices of women and men; their number of sexual partners in the past 12 months, and over their lifetime; risky sexual behavior, including condom use at last sexual intercourse; and payment for sex; • conduct hemoglobin testing on women age 15-49 and children age 6-59 months in a sub- sample of households selected for the survey to provide information on the prevalence of anemia among women of reproductive age and young children; • collect information on domestic violence This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general, and on reproductive health in particular, at both the national and district levels. A long-term objective of the survey is to strengthen the technical capacity of government organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the 2009-10 TLDHS provides national and district-level estimates on population and health that are comparable to data collected in similar surveys in other developing countries. The first Demographic and Health Survey (DHS) in Timor-Leste was done in 2003. Unlike the 2003 DHS, however, the 2009-10 TLDHS was conducted under the worldwide MEASURE DHS program, funded by the United States Agency for International Development (USAID) and with technical assistance provided by ICF Macro. Data from the 2009-10 TLDHS allow for comparison of information gathered over a longer period of time and add to the vast and growing international database on demographic and health variables. Introduction | 5 1.5 ORGANIZATION OF THE SURVEY The TLDHS 2009-10 was implemented by the National Statistics Directorate of the Directorate General for Analysis and Research of the Ministry of Finance, under the aegis of the Ministry of Health (MOH) of Timor-Leste. Technical support was provided by ICF Macro, and financial support was provided by USAID, the Government of Australia (AusAID), the Government of Ireland (Irish AID), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations Development Fund (UNDP), and the World Health Organization (WHO). UNFPA supported the survey with administrative, logistical, and technical assistance. A steering committee was formed to be responsible for coordination, oversight, advice, and decision making on all major aspects of the survey. The steering committee was composed of representatives from various ministries and key stakeholders, including the MOH, National Statistics Directorate, USAID, and international NGOs. 1.6 SAMPLE DESIGN The primary focus of the 2009-10 TLDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately. In addition, the sample was designed to provide estimates of most key variables for the 13 districts. 1.6.1 Sampling Frame The TLDHS used the sampling frame provided by the list of census enumeration areas (EAs) with population and household information from the 2004 Population and Housing Census (PHC). Administratively, Timor-Leste is divided into 13 districts. Stratification is achieved by separating each of the 13 districts into urban and rural areas. In total, 26 sampling strata were created. Samples were selected independently in every stratum, through a two-stage selection process. Implicit stratification was achieved at each of the lower administrative levels by sorting the sampling frame before sample selection, both according to administrative units and also by using a probability proportional-to-size selection at the first stage of sampling. The implicit stratification also allowed for the proportional allocation of sample points at each of the lower administrative levels. 1.6.2 Sample Selection At the first stage of sampling, 455 enumeration areas (116 urban areas and 339 rural areas) were selected with probability proportional to the EA size, which is the number of households residing in the EA at the time of the census. A complete household listing operation in all of the selected EAs is the usual procedure to provide a sampling frame for the second-stage selection of households. However, a complete household listing was only carried out in select clusters in Dili, Ermera, and Viqueque, where more than 20 percent of the households had been destroyed. In all other clusters, a complete household listing was not possible because the country does not have written boundary maps for clusters. Instead, using the GPS coordinate locations for structures in each selected cluster as provided for by the 2004 PHC, households were randomly selected using their Geographic Information System (GIS) location identification in the central office. A map for each cluster was then generated, marking the households to be surveyed with their location identification. The maps also contained all the other households, roads, rivers, and major landmarks for easier location of selected households in the field. To provide statistically reliable estimates of key demographic and health variables and to cater for nonresponse, 27 households each were selected. 6 | Introduction The survey was designed to cover a nationally representative sample of 12,285 residential households, taking into account nonresponse; to obtain completed interviews of 11,800 women age 15-49 in every selected household; and to obtain completed interviews of 3,800 men age 15-49 in every third selected household. 1.7 QUESTIONNAIRES Three questionnaires were administered in the TLDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. These questionnaires were adapted from the standard MEASURE DHS core questionnaires to reflect the population and health issues relevant to Timor-Leste based on a series of meetings with various stakeholders from government ministries and agencies, NGOs, and international donors. The final draft of each questionnaire was discussed at a questionnaire design workshop organized by NSD on March 10, 2009, in Dili. These questionnaires were then translated and back translated from English into the two main local languages−Tetum and Bahasa—and pretested prior to the main fieldwork to ensure that the original meanings of the questions were not lost in translation. The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. For children under age 18, survival status of the parents was determined. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, and ownership of mosquito nets. Additionally, the Household Questionnaire was used to record height and weight measurements for women age 15-49 and children under age 5, and to list hemoglobin measurements for women age 15-49 and children age 6-59 months. The Woman’s Questionnaire was used to collect information from women age 15-49. These women were asked questions on the following topics: • Background characteristics (education, residential history, media exposure, etc.) • Birth history and childhood mortality • Knowledge and use of family planning methods • Fertility preferences • Antenatal, delivery, and postnatal care • Breastfeeding and infant feeding practices • Vaccinations and childhood illnesses • Marriage and sexual activity • Woman’s work and husband’s background characteristics • Awareness and behavior regarding AIDS and other sexually transmitted infections (STIs) • Maternal mortality • Domestic violence The Man’s Questionnaire was administered to all men age 15-49 living in every third household. The Man’s Questionnaire collected much of the same information found in the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health, nutrition, maternal mortality, or domestic violence. Introduction | 7 1.8 HEMOGLOBIN TESTING In one-third of the households selected for the 2009-10 TLDHS, women age 15-49 and children age 6-59 months were tested for anemia. Anemia testing was only carried out if consent was provided by the respondent and, in the case of a minor, by the parent or guardian. The protocol for hemoglobin testing was approved by the Ministry of Health in Timor-Leste. Hemoglobin testing is the primary method for diagnosis of anemia. In the 2009-10 TLDHS, testing was done using the HemoCue system. A consent statement was read to the eligible woman and to the parent or responsible adult of young children and women age 15-17. This statement explained the purpose of the test, informed prospective subjects and/or their caretakers that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Before the blood was taken, the finger was wiped with an alcohol prep swab and allowed to air-dry. Then the palm side of the end of one finger was punctured with a sterile, nonreusable, self- retractable lancet. A drop of blood was collected with a HemoCue microcuvette and placed in a HemoCue photometer where the results were displayed. For children age 6-11 months who were particularly undernourished and thin, a heel puncture was made to draw a drop of blood. The results were recorded in the Household Questionnaire, as well as on a brochure, given to each woman, parent, or responsible adult, which explained what the results meant. 1.9 PRETEST, TRAINING, AND FIELDWORK 1.9.1 Pretest For the pretest, 10 interviewers were recruited to interview in the two local languages. The training for the pretest and fieldwork took place from April 27 to May 23, 2009. Both rural and urban households were selected for the pretest in three districts (Bobonaro, Viqueque, and Dili). Based on the findings of the pretest, the Household, the Woman’s, and the Man’s Questionnaires were further refined in both of the local languages. 1.9.2 Training The National Statistics Directorate (NSD), in close coordination with the MOH, recruited and trained 101 persons for the fieldwork to serve as supervisors, field editors, male and female interviewers, quality control staff, and reserves. They participated in the main training held in Dili from July 13 – August 8, 2009. Staff from MOH, NSD, and ICF Macro led the four-week training course, which was conducted mainly in Tetum and included lectures, presentations, practical demonstrations, and practice interviewing in small groups as well as several days of field practice. The participants also received anthropometric training and training in hemoglobin testing. After the training on how to complete the Household, Woman’s, and Man’s Questionnaires was completed, all trainees were given written and oral tests to gauge their understanding of the TLDHS questionnaires and interviewing techniques. On the basis of their scores on the exam and overall performance in the classroom and during field practice, 88 trainees were selected to participate in the main fieldwork. From the group, 10 of the best trainees were selected as quality control staff, 13 of the best male trainees were selected as supervisors, and 13 of the best female interviewers were identified as field editors. The remaining 52 trainees were selected to be interviewers. All selected field staff were trained in anthropometric measurement taking. After completing the interviewers’ training, the field editors and supervisors were trained for an additional three days on how to supervise the fieldwork and edit questionnaires in the field, in order to ensure data quality. The participants also received training on hemoglobin testing. 8 | Introduction 1.9.3 Fieldwork Data collection began on August 10, 2009, by 13 teams consisting of three female interviewers, one male interviewer, a male supervisor, and a female field editor. Fieldwork was completed on February 7, 2010. Fieldwork supervision was coordinated at NSD; 6 quality control teams made up of one male and one female member each, monitored data quality. Additionally, close contact between NSD and the teams was maintained through field visits by senior staff, members of the steering committee, and ICF Macro staff. Regular communication was also maintained through cell phones. 1.10 DATA PROCESSING The processing of the TLDHS results began soon after the start of fieldwork. Completed questionnaires were returned periodically from the field to the NSD data processing center in Dili, where they were entered and edited by 13 data processing personnel who were specially trained for this task. The data processing personnel included a supervisor, a questionnaire administrator, 2 office editors, and 13 data entry operators. The concurrent processing of the data was an advantage because field check tables could be generated to monitor various data quality parameters while the teams were still in the field. As a result, specific feedback was given to the teams to improve performance. The data entry and editing phase of the survey was completed by the end of February 2010. 1.11 RESPONSE RATES Table 1.1 shows household and individual response rates for the 2009-10 TLDHS. A total of 12,128 households were selected for the sample, of which 11,671 were found to be occupied during data collection. Of these existing households, 11,463 were successfully interviewed, giving a household response rate of 98 percent. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Timor-Leste 2009-10 Result Residence Total Urban Rural Household interviews Households selected 3,012 9,116 12,128 Households occupied 2,851 8,820 11,671 Households interviewed 2,745 8,718 11,463 Household response rate1 96.3 98.8 98.2 Interviews with women age 15-49 Number of eligible women 3,625 10,171 13,796 Number of eligible women interviewed 3,233 9,904 13,137 Eligible women response rate2 89.2 97.4 95.2 Interviews with men age 15-49 Number of eligible men 1,183 3,238 4,421 Number of eligible men interviewed 1,015 3,061 4,076 Eligible men response rate2 85.8 94.5 92.2 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Introduction | 9 In these households, 13,796 women were identified as eligible for the individual interview. Interviews were completed with 13,137 women, yielding a response rate of 95 percent. Of the 4,421 eligible men identified in the selected sub-sample of households, 4,076 or 92 percent were successfully interviewed. Response rates were higher in rural than urban areas, with the rural-urban difference in response rates more marked among eligible men than among eligible women. The tabulations in the rest of the report discuss in detail the main demographic and health findings from interviews with these eligible women and men. Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter presents descriptive summaries of the social, economic, and demographic characteristics of households sampled for the survey. The basic characteristics of the sampled population (i.e., age, sex, education, and place of residence) coupled with the socioeconomic conditions of the households form the basis of the background information used to analyze most key demographic and health indices in this report. This information is crucial for the interpretation of key demographic and health indicators. From these indicators, meaningful policies and programs for interventions are drawn, and the representativeness of the survey is measured. One focus of this chapter is to describe the environment in which men, women, and children live. This description presents the general characteristics of the population, such as the age-sex structure, literacy and education, household arrangements (headship, size), and housing facilities (sources of water supply, sanitation facilities, dwelling characteristics, and household possessions). A distinction is made between urban and rural areas because many of these indicators differ depending on place of residence. In the 2009-10 TLDHS, a household is defined as a person or a group of persons, related or unrelated, who live together in the same house or compound, share the same housekeeping arrange- ments, and eat together as a unit. The Household Questionnaire was used to collect information on all usual residents and visitors who spent the night preceding the survey in the household. This mode of data collection allows the analysis of either the de jure (usual) residents of the household or the de facto household population (all individuals who spent the night preceding the interview in the household, including visitors). Wherever possible, the 2009-10 TLDHS data are compared with data from other surveys conducted in the country, such as the 1997 Indonesia DHS (CBS et al., 1998), the 2002 Multiple Indicator Cluster Survey (MICS) (UNICEF, 2003), the 2003 DHS (MOH et al., 2004), and the 2007 Timor-Leste Survey of Living Standards (TLSLS) (NSD, 2007). However, when comparing the 2009- 10 TLDHS with other surveys, caution should be exercised in interpreting the results because the sample size, design, study population, period of coverage, and methods of estimation of key indicators may differ and therefore not be exactly comparable. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Age and sex are important variables in analyzing demographic trends. Table 2.1 and Figure 2.1 present the distribution of the de facto household population in the 2009-10 TLDHS survey by five-year age groups, according to sex and urban-rural residence. The age structure is typical of a young population characterized by high fertility. This type of population structure imposes a heavy burden on the social and economic assets of a country. Although the results of the 2009-10 TLDHS indicate that 45 percent of the population is under age 15, this percentage represents a small improvement over the results of the 2003 survey in which 51 percent of the population was under age 15. About four percent of the population is in the older age groups (age 65 or older), and this percentage has not changed since 2003. 12 | Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Timor-Leste 2009-10 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 14.8 14.7 14.8 15.3 15.0 15.2 15.2 15.0 15.1 5-9 16.1 15.0 15.6 16.3 15.7 16.0 16.3 15.6 15.9 10-14 12.7 13.0 12.8 14.4 13.9 14.1 14.0 13.7 13.8 15-19 11.1 11.0 11.1 10.4 9.7 10.1 10.6 10.0 10.3 20-24 8.4 10.0 9.2 6.2 6.9 6.6 6.8 7.6 7.2 25-29 7.4 7.7 7.6 5.1 5.5 5.3 5.7 6.0 5.8 30-34 5.4 5.7 5.5 4.0 4.6 4.3 4.3 4.8 4.6 35-39 6.2 5.1 5.6 5.1 5.3 5.2 5.4 5.3 5.3 40-44 4.7 4.7 4.7 4.6 4.3 4.4 4.6 4.4 4.5 45-49 3.6 3.4 3.5 4.1 3.6 3.8 3.9 3.6 3.8 50-54 3.2 3.3 3.3 3.4 4.2 3.8 3.3 4.0 3.7 55-59 2.1 1.5 1.8 2.6 2.3 2.5 2.5 2.1 2.3 60-64 1.9 2.0 2.0 4.1 4.6 4.3 3.6 4.0 3.8 65-69 1.1 1.2 1.1 2.3 2.3 2.3 2.0 2.1 2.0 70-74 0.6 0.7 0.6 1.0 1.2 1.1 0.9 1.1 1.0 75-79 0.3 0.2 0.3 0.6 0.4 0.5 0.5 0.4 0.4 80+ 0.3 0.6 0.4 0.5 0.5 0.5 0.4 0.5 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 8,072 7,618 15,689 25,555 25,647 51,202 33,626 33,265 66,891 Figure 2.1 Population Pyramid 80 + 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 Age 0246810 0 2 4 6 8 10 Timor-Leste 2009-10 Percent Female Male 2.2 HOUSEHOLD COMPOSITION The size and composition of households and the sex of the head of household are important factors affecting the welfare of the household. Table 2.2 shows the information collected in the 2009- 10 TLDHS on the sex of the head of household and the mean household size. More than four in five (88 percent) households are headed by males, while one-eighth (12 percent) of households are headed by females. The percentage of female-headed households is higher in rural areas (13 percent) than in urban areas (11 percent). The mean household size in Timor-Leste is 5.8 persons, with households in urban areas only marginally larger (5.9 persons) than those in rural areas (5.8 persons). Three percent of all households are single-person households, and the proportion of single-person households does not differ much between urban and rural areas. A sizeable proportion of households (15 percent) have 9 or more usual members, with urban households slightly more likely to be large than rural households. Household Population and Housing Characteristics | 13 Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18, according to residence, Timor-Leste 2009-10 Characteristic Residence Total Urban Rural Household headship Male 88.8 87.4 87.7 Female 11.2 12.6 12.3 Total 100.0 100.0 100.0 Number of usual members 0 0.1 0.0 0.0 1 2.9 3.2 3.1 2 6.2 6.8 6.7 3 9.4 9.4 9.4 4 14.4 12.4 12.9 5 16.0 14.6 14.9 6 15.3 15.4 15.4 7 11.1 13.5 13.0 8 8.8 10.2 9.9 9+ 15.8 14.4 14.7 Total 100.0 100.0 100.0 Mean size of households 5.9 5.8 5.8 Percentage of households with orphans and foster children under 18 Foster children1 18.0 17.6 17.7 Double orphans 1.4 1.7 1.6 Single orphans2 7.6 10.1 9.5 Foster and/or orphan children 21.6 23.6 23.1 Number of households 2,695 8,768 11,463 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households where neither their mother nor their father is a de jure resident. 2 Single orphans includes children with one dead parent and an unknown survival status of the other parent. 2.2.1 Children’s Living Arrangements and Orphanhood The 2009-10 TLDHS also collected information on the presence of foster children and orphans in the households. Foster children are defined here as children under age 18 living in households with neither their mother nor their father present; orphans are children with one or both parents dead. Foster children and orphans are of concern because they may be at increased risk of neglect or exploitation when their mothers or fathers are not present to assist them. Table 2.2 also shows that 23 percent of the households have orphans or foster children under age 18. The proportion of households in Timor-Leste with orphans or foster children is high and reflects the political turmoil in the country over the past two decades. Rural households are slightly more likely to have orphans or foster children than urban households. Eighteen percent of households have foster children, 10 percent have at least one single orphan (either parent is dead), and 2 percent have at least one double orphan (both parents are dead). Detailed information on living arrangements and orphanhood for children under age 18 is presented in Table 2.3.1. Of the 34,411 children under age 18 reported in the 2009-10 TLDHS, about 82 percent live with both parents. About 7 percent live with their mother but not their father, with 4 percent living with their mother only even though their father is alive. About 2 percent live with their father but not their mother, with less than 1 percent living with their father even though their mother is alive. Nine percent of children under age 18 live with neither of their natural parents. Table 2.3.1 also provides data on the extent of orphanhood. Less than 1 percent of children under age 18 have lost both parents, while 7 percent have lost either their mother or father. 14 | Household Population and Housing Characteristics The percentage of children not living with a biological parent increases with age from 4 percent of children age 0-4 years to 19 percent of children age 15-17 years. The highest proportion of children not living with a parent is in Bobonaro and Covalima (12 percent each), and the lowest is in Lautem and Oecussi (7 percent each). By wealth status, the proportion of children under age 18 not living with a natural parent rises from 8 percent among those in the lowest two wealth quintiles to 12 percent among those in the highest wealth quintile. Table 2.3.1 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Timor-Leste 2009-10 Background characteristic Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Missing information on father/ mother Total Percentage not living with a biological parent Percentage with one or both parents dead1 Number of children Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Age 0-4 88.6 5.5 1.5 0.5 0.3 3.0 0.3 0.2 0.2 0.0 100.0 3.7 2.5 10,075 <2 89.7 6.7 1.3 0.2 0.1 1.6 0.2 0.1 0.1 0.0 100.0 2.0 1.8 3,876 2-4 87.9 4.7 1.6 0.6 0.4 3.9 0.3 0.3 0.2 0.0 100.0 4.7 2.9 6,198 5-9 84.5 3.3 2.5 0.8 1.3 5.9 0.6 0.7 0.5 0.0 100.0 7.6 5.6 10,672 10-14 77.0 2.3 4.7 1.1 2.4 8.9 1.1 1.4 1.0 0.0 100.0 12.4 10.6 9,284 15-17 68.4 2.5 6.3 1.2 2.5 13.0 1.6 2.4 2.0 0.1 100.0 19.1 14.9 4,381 Sex Male 81.7 3.7 3.3 0.8 1.5 6.6 0.8 0.9 0.7 0.0 100.0 9.0 7.2 17,607 Female 81.5 3.4 3.2 0.9 1.4 6.9 0.8 1.0 0.7 0.0 100.0 9.5 7.2 16,804 Residence Urban 81.8 3.2 2.9 1.3 0.9 7.5 0.7 1.0 0.7 0.1 100.0 9.8 6.2 7,890 Rural 81.6 3.7 3.4 0.7 1.6 6.6 0.8 0.9 0.7 0.0 100.0 9.0 7.5 26,521 District Aileu 85.8 1.6 3.3 0.1 1.8 5.4 0.3 1.1 0.6 0.0 100.0 7.5 7.2 1,424 Ainaro 77.2 5.7 3.9 1.3 2.7 6.4 1.2 0.7 0.8 0.0 100.0 9.1 9.4 2,041 Baucau 83.0 2.6 2.7 0.1 1.6 7.2 0.7 1.2 0.7 0.1 100.0 9.9 7.0 3,921 Bobonaro 77.1 3.8 4.4 1.3 1.7 9.0 0.7 1.2 0.8 0.0 100.0 11.7 8.8 3,175 Covalima 77.9 4.8 4.4 0.4 0.8 7.9 1.1 1.2 1.4 0.0 100.0 11.7 8.9 1,981 Dili 85.3 2.0 2.3 1.4 0.8 6.4 0.5 0.8 0.5 0.1 100.0 8.2 4.9 5,279 Ermera 77.4 7.2 3.3 1.5 1.3 6.6 0.9 0.9 0.8 0.0 100.0 9.2 7.3 4,429 Lautem 82.9 3.7 4.4 0.5 1.6 4.9 0.6 0.9 0.5 0.0 100.0 6.9 8.0 2,546 Liquiçá 81.2 3.8 3.0 0.8 1.9 6.9 0.6 1.0 0.7 0.0 100.0 9.3 7.2 2,042 Manatuto 85.0 1.7 2.9 0.5 0.8 7.3 0.4 0.7 0.6 0.0 100.0 9.0 5.5 1,553 Manufahi 80.1 4.5 2.1 1.5 1.2 8.5 1.0 0.5 0.6 0.0 100.0 10.6 5.4 1,305 Oecussi 86.4 1.7 3.2 0.1 1.4 4.4 1.2 0.9 0.6 0.0 100.0 7.1 7.3 2,260 Viqueque 82.3 2.3 3.5 0.1 1.9 7.3 0.6 0.9 1.0 0.0 100.0 9.9 8.0 2,455 Wealth quintile Lowest 82.7 3.3 4.5 0.4 1.5 5.3 0.9 0.5 0.9 0.0 100.0 7.6 8.3 7,204 Second 81.6 3.6 4.0 0.8 2.6 5.3 0.5 1.1 0.7 0.0 100.0 7.5 8.8 6,857 Middle 83.1 4.2 2.8 0.6 1.2 5.5 0.8 1.0 0.8 0.0 100.0 8.1 6.6 6,788 Fourth 79.5 3.7 3.1 1.2 1.2 8.6 1.1 1.0 0.7 0.0 100.0 11.4 7.0 6,772 Highest 81.1 3.2 1.9 1.1 0.8 9.3 0.5 1.2 0.6 0.1 100.0 11.6 5.1 6,790 Total <15 83.6 3.7 2.8 0.8 1.3 5.9 0.6 0.7 0.5 0.0 100.0 7.8 6.1 30,031 Total <18 81.6 3.6 3.3 0.8 1.5 6.8 0.8 1.0 0.7 0.0 100.0 9.2 7.2 34,411 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both dead, and one parent dead but missing information on survival status of the other parent. 2.2.2 School Attendance by Survivorship of Parents Children who are orphaned may be at a greater risk of dropping out of school because of lack of financial and psychological support. The TLDHS included information to monitor such situations and collected information on school attendance of children age 10-14 by parental survival, which is presented in Table 2.3.2. The data confirm that children age 10-14 whose parents are both dead are less likely to be attending school (66 percent) than children whose parents are both living, with the child residing with at least one parent (87 percent). The overall ratio of school attendance of the former group to the latter group is 0.75. Further breakdown by background characteristics was not possible due to the low number of orphans. Household Population and Housing Characteristics | 15 Table 2.3.2 School attendance by survivorship of parents For de jure children 10-14 years of age, the percentage attending school by parental survival, according to background characteristics, Timor-Leste 2009-10 Background characteristic Percentage attending school by survivorship of parents Ratio1 Both parents deceased Number Both parents alive and living with at least one parent Number Sex Male 71.4 50 87.5 3,790 0.82 Female (58.8) 40 86.9 3,685 (0.68) Residence Urban (77.8) 20 89.4 1,627 (0.87) Rural 62.3 70 86.6 5,847 0.72 Total 65.8 91 87.2 7,474 0.75 Note: Table is based only on children who usually live in the household. Figures in parentheses are based on 25-49 unweighted cases. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent 2.3 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Timor-Leste is beginning to rebuild itself and move forward as an independent nation following years of unrest and instability created by Indonesian rule, UN governance, and internal conflict. Education is important to this effort because it helps individuals make informed decisions that have a positive impact on their health and well-being. The educational system was completely disrupted from 1999 until 2000, with more than 90 percent of the schools damaged and no longer functional (UNESCO, 2009; Fleischhacker and Uhlin, 2004). Indonesian teachers left the country, and the textbooks and the school curricula were no longer relevant under a new government. Schools were vandalized and destroyed yet again after the 2006 crisis. Renewed efforts have since been under way to reconstruct the educational system in the country. The country has gone through three different systems of education. The Portuguese introduced a western curriculum during the colonial period (1511-1975). Portuguese was the medium of instruction in schools; however, the vast majority of Timorese had limited access to education. Only a few elite Timorese men, primarily those who supported the Portuguese and who carried out administrative functions of the country, were educated (Fleischhacker and Uhlin, 2004). The basic compulsory education comprised nine years in the Portuguese system, with the first cycle (1o Ciclo) lasting four years (age 6 -9), the second cycle (2 o Ciclo) lasting two years (age 10-12), and the third cycle (3 o Ciclo) lasting three years (age 13-15). The first cycle is equivalent to primary education (escolas básicas), while the second and third cycles combined are equivalent to secondary (secundárias) education (AngloINFO, 2010). During the Indonesian occupation, education was made accessible to the public. Indonesian teachers devoted themselves to promoting education in the country, with Bahasa Indonesia as the medium of instruction in schools. The Indonesian education system included six years of primary education, three years of lower secondary education (SMP), and three years of upper secondary education (SMA). In addition, higher education through a university was divided into Sarjana (S1) comprising four years, Pasca Sarjana (S2) comprising 2 years, and PhD (S3) comprising two years. There were also two years of pre-primary education, or kindergarten, known as Taman Kanak-Kanak. The current system of education, which began in October 2008, consists of 6 years of basic or primary education (from age 6-11 for grades 1 through 6; 3 years of pre-secondary education (from age 12-14 for grades 7 through 9); and an additional three years of secondary education (from age 15- 17 for grades 10 through 12). Secondary education is organized through two modalities (1) general secondary education, preparing students for university education, and (2) technical professional secondary education, preparing students for entry into the labor market (UNESCO, 2009). 16 | Household Population and Housing Characteristics The Early Childhood Care and Education (ECCE) is not compulsory in Timor-Leste and is not considered a part of the formal educational system, although the National Education Policy 2007- 2012 recognizes the importance of preschool education (UNESCO, 2009). The impact of these three different systems of formal education in the country is reflected in the educational attainment of women and men interviewed in the 2009-10 TLDHS. Early studies have reported that primary school enrolment among children changed little between 1999 and 2007, growing from 65 percent to 74 percent (UNESCO, 2009). In 2007 only 47 percent of children had completed primary school. The government set as a target the completion of primary school by all children by 2015 (NSD, 2007). Table 2.4.1 shows the percent distribution of the de facto female household population age 6 and older by highest level of education attended or completed and according to background characteristics. Thirty-seven percent of women have never been to school, about 30 percent have some primary education, 5 percent completed only primary school, 26 percent have some secondary education or have completed secondary school, and about 2 percent have more than secondary school education. Table 2.4.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age 6 and over by highest level of schooling attended or completed and median grade completed, according to background characteristics, Timor-Leste 2009-10 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 31.7 67.9 0.1 0.2 0.0 0.0 0.1 100.0 4,243 0.2 10-14 9.4 67.8 1.7 21.2 0.0 0.0 0.0 100.0 4,560 3.4 15-19 12.1 15.1 4.1 64.6 3.4 0.6 0.0 100.0 3,329 7.0 20-24 16.0 12.5 7.5 33.1 24.4 6.5 0.0 100.0 2,538 8.6 25-29 25.1 13.5 10.8 20.6 24.9 5.0 0.0 100.0 2,000 6.3 30-34 31.2 13.2 13.9 17.6 18.9 5.1 0.0 100.0 1,601 5.4 35-39 37.4 15.8 12.3 17.1 14.9 2.5 0.0 100.0 1,751 4.4 40-44 55.5 15.2 7.5 8.9 10.8 2.0 0.0 100.0 1,451 0.0 45-49 68.5 15.9 5.2 4.8 3.4 2.1 0.2 100.0 1,186 0.0 50-54 86.8 8.3 1.5 1.7 1.1 0.5 0.1 100.0 1,334 0.0 55-59 89.4 6.5 1.0 1.6 0.7 0.3 0.5 100.0 701 0.0 60-64 96.4 2.2 0.8 0.1 0.3 0.0 0.2 100.0 1,325 0.0 65+ 97.6 1.7 0.1 0.2 0.2 0.0 0.2 100.0 1,325 0.0 Residence Urban 21.9 28.4 4.1 24.1 15.6 5.8 0.2 100.0 6,259 4.9 Rural 42.0 30.3 4.8 17.4 5.0 0.5 0.0 100.0 21,095 1.0 District Aileu 36.1 32.8 4.6 21.2 4.7 0.4 0.0 100.0 1,140 1.8 Ainaro 47.9 26.9 2.5 16.9 4.9 0.9 0.0 100.0 1,554 0.1 Baucau 38.1 30.4 3.6 20.4 6.7 0.7 0.1 100.0 3,195 1.7 Bobonaro 44.7 29.5 4.9 15.8 4.5 0.7 0.1 100.0 2,687 0.7 Covalima 32.8 31.0 5.5 23.4 6.4 0.8 0.1 100.0 1,701 2.3 Dili 16.1 27.9 4.1 25.0 18.7 7.8 0.3 100.0 4,239 5.9 Ermera 51.9 28.2 3.4 13.3 3.1 0.1 0.0 100.0 3,331 0.0 Lautem 30.3 33.5 6.4 22.2 7.1 0.5 0.0 100.0 1,803 2.7 Liquiçá 42.3 31.2 4.0 16.3 5.7 0.5 0.0 100.0 1,665 1.0 Manatuto 34.2 30.6 5.4 19.9 8.9 1.0 0.0 100.0 1,299 2.3 Manufahi 39.4 29.3 4.0 20.4 6.0 0.7 0.2 100.0 1,100 1.6 Oecussi 45.4 30.6 9.8 11.2 2.6 0.5 0.0 100.0 1,698 0.2 Viqueque 40.2 31.0 4.6 18.0 5.3 0.9 0.0 100.0 1,943 1.4 Wealth quintile Lowest 52.3 31.1 4.4 10.8 1.3 0.1 0.0 100.0 5,397 0.0 Second 46.5 31.6 4.3 14.8 2.7 0.1 0.0 100.0 5,488 0.3 Middle 41.9 29.2 5.1 18.6 4.8 0.4 0.0 100.0 5,564 1.1 Fourth 31.3 29.9 5.2 23.7 8.4 1.5 0.1 100.0 5,500 2.9 Highest 14.8 27.6 4.1 26.7 19.9 6.7 0.2 100.0 5,405 6.2 Total 37.4 29.9 4.6 18.9 7.4 1.7 0.1 100.0 27,354 1.8 Note: Total includes 10 cases with information missing on age. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Household Population and Housing Characteristics | 17 The data show that the proportion of women with no education has declined by age, suggesting some improvement in education over the years. During the Portuguese era, the proportion of women who were educated was low. As seen in Figure 2.2, there has been a steady increase in the percentage of the population who has ever attended school in each sequential age cohort. Rapid increases in school attendance among women start in the cohort of women who were age 50-54 at the time of the survey. At the time of the Indonesian invasion in 1975, these women were age 16-20. Figure 2.2 Percentage of Women and Men with No Education, by Age Group 32 9 12 16 25 31 37 56 69 87 89 96 98 35 10 11 14 21 22 22 30 39 56 66 84 89 6-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Age group 0 20 40 60 80 100 Percent Women Men Timor-Leste 2009-10 Increases in secondary education have also been substantial: 10 percent of women age 45-49 have attended any secondary school or higher compared with 69 percent of women age 15-19. It is also important to note that 32 percent of girls age 6-9 have no education; however, many of the girls in this age group may not yet have attained the official age required to start school by the start of the ongoing school year. Education varies by place of residence. The proportion of women with no education is almost twice as high in rural (42 percent) as in urban areas (22 percent). Conversely, three times as many urban women as rural women have completed secondary school (16 percent compared with 5 percent). Women’s educational attainment varies by district. More than half of the female population in Ermera has no education compared with 16 percent in Dili. As expected, women in households belonging to the highest wealth quintile are least likely to be uneducated (15 percent) compared with those in the lowest quintile (52 percent). Table 2.4.2 shows that 30 percent of men have never been to school, 39 percent have had some primary education or have completed primary education, 29 percent have had some secondary or have completed secondary education, and 3 percent have more than secondary education. Men exhibit a trend similar to that for women with regard to the level of educational attainment over the years (Figure 2.2). Differences in educational attainment among men by background characteristics are similar to those discussed for women. 18 | Household Population and Housing Characteristics Table 2.4.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age 6 and older by highest level of schooling attended or completed and median grade completed, according to background characteristics, Timor-Leste 2009-10 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 34.5 65.2 0.1 0.1 0.0 0.0 0.0 100.0 4,532 0.1 10-14 9.5 71.2 1.6 17.7 0.0 0.0 0.0 100.0 4,695 3.1 15-19 10.8 19.6 3.6 62.1 3.1 0.7 0.2 100.0 3,559 6.7 20-24 14.0 12.4 6.2 34.8 25.3 7.3 0.1 100.0 2,276 11.7 25-29 20.5 16.3 7.7 15.1 30.3 10.1 0.0 100.0 1,908 8.1 30-34 21.8 15.0 11.3 12.3 28.5 11.0 0.1 100.0 1,459 7.1 35-39 22.2 16.5 11.7 17.6 23.6 8.0 0.3 100.0 1,807 5.9 40-44 30.4 18.9 8.2 12.9 25.1 4.4 0.1 100.0 1,546 5.1 45-49 39.4 23.9 7.3 10.1 16.2 3.1 0.0 100.0 1,327 2.4 50-54 56.4 26.1 5.0 4.5 6.8 1.3 0.1 100.0 1,117 0.0 55-59 65.9 21.3 5.3 3.4 2.4 1.7 0.0 100.0 843 0.0 60-64 83.6 11.5 2.7 0.8 1.0 0.4 0.1 100.0 1,196 0.0 65+ 89.1 8.8 0.8 0.7 0.4 0.0 0.2 100.0 1,311 0.0 Residence Urban 16.5 31.8 4.2 21.7 17.3 8.3 0.3 100.0 6,629 5.2 Rural 33.8 35.0 4.6 17.3 8.0 1.3 0.0 100.0 20,947 2.0 District Aileu 32.2 35.8 6.2 17.0 7.2 1.5 0.0 100.0 1,182 2.1 Ainaro 38.8 33.2 3.4 17.1 6.5 1.0 0.0 100.0 1,580 1.5 Baucau 29.3 36.8 3.4 18.7 10.3 1.4 0.1 100.0 3,135 2.4 Bobonaro 36.2 34.2 5.1 15.0 8.2 1.3 0.0 100.0 2,572 1.8 Covalima 23.7 36.2 5.9 20.7 11.7 1.8 0.1 100.0 1,731 3.2 Dili 13.0 30.4 4.1 21.8 20.0 10.4 0.3 100.0 4,622 6.0 Ermera 42.9 31.6 4.2 16.2 4.7 0.4 0.0 100.0 3,299 0.9 Lautem 21.5 37.8 4.3 22.4 12.2 1.9 0.0 100.0 1,828 3.4 Liquiçá 31.1 37.6 4.2 17.8 6.9 2.3 0.0 100.0 1,724 2.3 Manatuto 28.6 35.2 4.9 17.9 11.1 2.1 0.1 100.0 1,222 2.9 Manufahi 31.1 30.3 6.2 21.8 8.7 1.6 0.2 100.0 1,153 3.0 Oecussi 42.5 34.5 5.8 11.1 4.3 1.9 0.0 100.0 1,618 0.6 Viqueque 30.2 37.2 3.3 18.2 8.9 2.3 0.0 100.0 1,910 2.3 Wealth quintile Lowest 44.5 34.6 4.4 12.8 3.3 0.5 0.0 100.0 5,391 0.4 Second 37.9 35.3 4.4 16.0 5.8 0.5 0.1 100.0 5,462 1.4 Middle 33.8 34.8 5.3 17.2 7.8 1.1 0.1 100.0 5,448 2.0 Fourth 23.3 34.8 4.7 22.3 12.5 2.4 0.0 100.0 5,479 3.7 Highest 10.1 31.9 3.6 23.0 21.1 10.1 0.2 100.0 5,797 6.4 Total 29.6 34.2 4.5 18.3 10.2 3.0 0.1 100.0 27,576 2.7 Note: Total includes 2 cases with information missing on age. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Males are more likely to be educated than females at all levels of education, with the exception of completion of primary education where there is little difference. The median number of years of schooling completed is about one year higher for males (2.7 years) than females (1.8 years). There has been improvement in the proportion of the population with no education since the 2003 DHS survey. The proportion of females with no education decreased from 47 percent in 2003 to 37 percent in 2009-10. Similarly, the proportion of males with no education decreased from 37 to 30 percent. The male-female gap in educational attainment has narrowed slightly over the years. The 2009-10 TLDHS collected information on school attendance for the population age 5-24 that allows the calculation of net attendance ratios (NARs) and gross attendance ratios (GARs) (see Table 2.5). The NAR for primary school is the percentage of the primary-school-age (age 6-11) population that is attending primary school. The NAR for secondary school is the measure of the secondary-school-age (age 12-17) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. The GAR however, measures participation at each level of schooling among persons age 5-24. The GAR is almost always higher than the NAR for the same level because the GAR includes participation by those who may be older (because they may have started school late, repeated one or more grades, or dropped out and returned) or may be younger than the official age range for that level. Household Population and Housing Characteristics | 19 Table 2.5 presents data on the NAR and GAR for the de facto household population by level of schooling and sex, according to place of residence, region, and wealth quintile. Seventy-one percent of children age 6-11, who should be attending primary school, are currently doing so. The net enrolment rate for primary school was reported to be 77 percent in the 2007 TLSLS. Table 2.5 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Timor-Leste 2009-10 Background characteristic Net attendance ratio Gross attendance ratio Male Female Total Gender Parity Index Male Female Total Gender Parity Index PRIMARY SCHOOL Residence Urban 77.1 79.8 78.3 1.04 100.9 101.5 101.2 1.01 Rural 68.3 69.9 69.1 1.02 100.6 99.3 99.9 0.99 District Aileu 72.0 76.0 73.9 1.06 113.8 119.6 116.6 1.05 Ainaro 64.3 67.2 65.7 1.04 103.9 94.5 99.3 0.91 Baucau 72.8 73.4 73.1 1.01 103.3 101.6 102.5 0.98 Bobonaro 71.2 74.0 72.6 1.04 102.9 98.7 100.8 0.96 Covalima 82.6 83.5 83.0 1.01 113.7 108.7 111.3 0.96 Dili 75.0 76.8 75.8 1.02 91.5 93.9 92.6 1.03 Ermera 56.4 57.2 56.8 1.01 89.2 88.4 88.8 0.99 Lautem 80.0 80.9 80.4 1.01 108.1 115.0 111.2 1.06 Liquiçá 62.7 65.1 63.8 1.04 105.5 101.2 103.5 0.96 Manatuto 77.5 79.9 78.7 1.03 103.8 104.1 104.0 1.00 Manufahi 75.6 76.1 75.8 1.01 108.4 102.4 105.4 0.95 Oecussi 58.5 63.6 60.9 1.09 87.0 93.5 90.1 1.07 Viqueque 71.4 74.6 72.9 1.04 105.5 102.1 103.9 0.97 Wealth quintile Lowest 56.9 62.2 59.4 1.09 90.2 94.4 92.2 1.05 Second 68.2 67.7 67.9 0.99 103.9 100.6 102.3 0.97 Middle 69.7 72.1 70.9 1.03 105.1 102.5 103.9 0.98 Fourth 75.9 77.6 76.7 1.02 105.3 102.9 104.1 0.98 Highest 82.0 82.1 82.0 1.00 100.2 98.7 99.5 0.98 Total 70.3 72.1 71.1 1.03 100.6 99.8 100.2 0.99 SECONDARY SCHOOL Residence Urban 57.7 61.2 59.4 1.06 89.6 94.5 92.0 1.05 Rural 38.6 43.6 41.0 1.13 62.0 62.6 62.3 1.01 District Aileu 32.3 46.4 39.8 1.44 61.6 69.5 65.8 1.13 Ainaro 38.9 48.0 43.2 1.23 57.2 64.1 60.5 1.12 Baucau 44.4 50.6 47.4 1.14 69.0 68.2 68.6 0.99 Bobonaro 36.1 42.3 39.2 1.17 60.8 65.5 63.2 1.08 Covalima 48.6 62.0 55.0 1.28 78.7 91.8 85.0 1.17 Dili 59.3 64.3 61.7 1.08 90.2 97.3 93.7 1.08 Ermera 33.4 29.7 31.6 0.89 59.6 47.5 53.7 0.80 Lautem 53.6 49.5 51.6 0.92 78.3 72.3 75.5 0.92 Liquiçá 35.4 37.1 36.2 1.05 59.1 57.8 58.5 0.98 Manatuto 48.7 57.4 53.4 1.18 73.5 71.8 72.5 0.98 Manufahi 48.1 53.6 50.7 1.12 74.5 77.7 76.0 1.04 Oecussi 25.0 26.5 25.8 1.06 38.9 44.1 41.6 1.13 Viqueque 41.4 48.1 44.6 1.16 65.6 69.2 67.3 1.05 Wealth quintile Lowest 27.8 28.5 28.1 1.03 45.2 41.3 43.3 0.91 Second 32.4 35.9 34.1 1.11 56.3 54.1 55.3 0.96 Middle 38.4 46.1 42.3 1.20 63.5 66.9 65.2 1.05 Fourth 52.2 57.0 54.6 1.09 83.6 83.9 83.8 1.00 Highest 63.5 70.3 66.7 1.11 92.6 102.7 97.4 1.11 Total 43.0 47.5 45.2 1.10 68.4 69.7 69.1 1.02 1 The NAR for primary school is the percentage of the primary-school age (6-11 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (12-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. 20 | Household Population and Housing Characteristics The GAR at the primary school level is 100 percent. The distribution shows that both the NAR and GAR are much lower at the secondary school level: 45 percent of students age 12-17 who should be attending secondary school are in school (NAR). The GAR for secondary school is 69 percent. A UNESCO report in 2008 estimated that the GER (gross enrollment ratio) in secondary school in 2005 was 53 percent (UNESCO, 2009). The results show that the NARs for females and males are similar in primary school. In secondary school, the NAR for females (48 percent) is only slightly higher than for males (43 percent), suggesting that there is not much of a gender gap in school attendance in Timor-Leste. The GAR at primary level is slightly higher for males than females, however, indicating relatively higher over-age or under-age attendance among males compared with attendance among females. School attendance ratios at both the primary and secondary levels are lower in rural than in urban areas. For instance, the NAR at the primary school level in rural areas is 69 percent compared with 78 percent in urban areas. Similarly, the GAR at the secondary school level is 62 percent in rural areas, compared with 92 percent in urban areas. Regional differences are obvious for the NAR and GAR at the primary school levels, with attendance ratios being notably lower in Ermera and Oecussi compared with all other districts. The GAR at the secondary school level is especially low for Oecussi (42 percent). There is a strong relationship between household economic status and school attendance that can be seen at both the primary and secondary levels and among males and females. For example, the NAR for primary school increases from 59 percent among students from poorer households (lowest wealth quintile) to 82 percent among pupils from richer households (highest wealth quintile). The Gender Parity Index (GPI) represents the ratio of the NAR (or GAR) for females to the NAR (or GAR) for males. It is presented in Table 2.5 at both the primary and secondary levels and offers a summary measure of gender differences in school attendance rates. A GPI of less than 1 indicates that a smaller proportion of females than males attends school. In Timor-Leste, the GPI for the GAR is almost 1 (0.99) for primary school attendance and slightly higher than 1 (1.02) for secondary school attendance, indicating the virtual non-existence of a gender gap in education in the country. 2.3.1 Grade Repetition and Dropout Rates According to UNESCO, 16 percent of children in Timor-Leste repeat grades, 25 percent drop out, and only 46 percent reach Grade 6 (UNESCO, 2009). At the pre-secondary level the completion rate is 49 percent, and among all children age 12 to 14 years in the country, only 28 percent of them complete the pre-secondary level, indicating a considerable number of dropouts. The 2009-10 TLDHS also assessed grade repetition and dropout rates. Table 2.6 presents these rates for the de facto household population age 5-24 who attended primary school in the previous school year. Repetition and drop-out rates describe the flow of pupils through the educational system. Repetition rates indicate the percentage of pupils who attended a particular class during the previous school year who are repeating that grade in the current school year; that is, they attended the same grade during the 2009-10 academic year as they had attended during the 2008-09 year1. Dropout rates show the percentage of pupils who attended class during the 2008-09 academic year but who did not attend school the following year. Repetition and dropout rates approach zero when pupils nearly always progress to the next grade at the end of the school year. They often vary across grades, indicating points in the school system where pupils are not regularly promoted to the next grade or they decide to drop out of school. 1 The TLDHS covered the academic years 2007-08 as previous and 2008-09 as current for households interviewed in academic year 2008-09. Similarly, for households interviewed in 2009-10 the current academic year was considered as 2009-10 and the previous as 2008-09. The tabulation takes this into account. Household Population and Housing Characteristics | 21 Table 2.6 Grade repetition and dropout rates Repetition and dropout rates, for the de facto household population age 5-24 who attended primary school in the previous school year, by school grade, according to background characteristics, Timor-Leste 2009-10 Background characteristic School grade 1 2 3 4 5 6 REPETITION RATE1 Sex Male 2.0 0.6 0.4 0.7 0.5 0.2 Female 1.4 0.7 0.3 0.3 0.6 0.1 Residence Urban 2.4 0.6 0.1 0.8 1.6 0.3 Rural 1.6 0.7 0.4 0.4 0.2 0.1 District Aileu 0.8 0.8 0.6 0.0 0.0 0.9 Ainaro 1.0 0.0 0.0 0.8 0.0 0.0 Baucau 0.5 0.0 1.4 0.0 0.0 0.0 Bobonaro 1.7 1.1 0.7 0.9 0.0 0.0 Covalima 2.3 0.5 0.0 0.0 0.4 0.0 Dili 1.7 0.5 0.0 0.7 2.1 0.0 Ermera 2.9 1.1 0.7 0.0 1.3 0.0 Lautem 2.5 1.9 0.3 1.6 0.0 0.0 Liquiçá 2.6 0.3 0.0 2.3 0.5 1.9 Manatuto 0.0 0.6 0.0 0.0 0.0 0.0 Manufahi 0.5 0.0 0.0 0.0 0.0 0.0 Oecussi 2.1 0.7 0.0 0.0 0.0 0.0 Viqueque 1.6 0.5 0.0 0.0 0.0 0.0 Wealth quintile Lowest 1.2 0.2 0.8 0.3 0.5 0.3 Second 1.4 0.7 0.0 0.3 0.0 0.0 Middle 2.4 0.5 0.7 1.0 0.4 0.0 Fourth 2.2 1.4 0.0 0.4 0.0 0.2 Highest 1.5 0.5 0.3 0.6 1.6 0.2 Total 1.7 0.6 0.4 0.5 0.5 0.1 DROPOUT RATE2 Sex Male 1.1 1.0 2.2 2.4 2.6 4.1 Female 1.4 2.0 2.2 2.2 2.2 4.4 Residence Urban 3.5 1.1 3.3 6.2 3.4 10.1 Rural 0.6 1.6 1.9 1.2 2.2 2.4 District Aileu 0.4 0.0 0.0 0.0 0.6 0.9 Ainaro 0.0 0.4 0.0 0.0 1.4 0.7 Baucau 0.0 0.5 0.0 0.0 0.0 1.1 Bobonaro 0.0 0.0 0.3 0.0 0.0 0.0 Covalima 2.5 1.6 3.8 3.5 3.3 8.8 Dili 7.2 8.9 12.2 13.7 14.6 15.9 Ermera 0.0 0.0 0.0 0.0 0.0 0.0 Lautem 0.0 0.0 0.0 0.0 0.0 2.8 Liquiçá 0.0 0.0 0.9 0.0 0.0 0.0 Manatuto 0.8 0.8 0.6 0.0 0.0 0.8 Manufahi 1.1 0.0 0.7 0.7 0.0 2.6 Oecussi 0.0 0.0 0.0 0.0 0.7 2.2 Viqueque 0.0 0.5 0.0 0.8 0.7 0.5 Wealth quintile Lowest 0.5 0.2 0.9 1.3 0.7 2.5 Second 0.1 0.6 0.2 0.4 1.2 1.4 Middle 0.6 0.8 0.6 0.0 0.4 1.2 Fourth 1.5 1.4 2.5 1.6 3.0 5.3 Highest 3.6 4.9 6.5 8.2 6.6 8.7 Total 1.2 1.5 2.2 2.3 2.4 4.3 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who no longer attend school. For both sexes the repetition rate is higher in grade 1 than in grades 2 through 6. In grade 1 the repetition rate is 2 percent for males, compared with 1 percent for females, but in grade 2 the repetition rate for females is slightly higher than that for males. There are small variations by urban- rural residence in almost all grades, except in grade 5 where urban residents have a higher repetition 22 | Household Population and Housing Characteristics rate (2 percent) than their rural counterparts (0.2 percent). Larger differentials are observed by districts, especially in grade 1. While as high as 3 percent of pupils in the Ermera, Lautem, and Liquiçá districts, respectively, repeat grade 1, there is no grade repetition in grade 1 in Manatuto. In grade 6 only, pupils in Liquiçá (2 percent) and Aileu (1 percent) repeat the grade. In general, dropout rates are higher than repetition rates for all grades. Dropout rates across grades are similar (1 to 2 percent), except for grade 6 (4 percent). Males and females have similar dropout rates for almost all grades. It is interesting to note that the dropout rates are higher at all levels in urban areas than in rural areas, except for grade 2. There are wide regional variations in dropout rates. Dropout rates are markedly higher in Dili than in all other districts, and this may be attributed to the displacement of the population, particularly in Dili, due to the political strife and subsequent instability in years 2006-2008. Figure 2.3 shows the age-specific attendance rates (ASAR) for the de facto household population, age 5-24, by sex. The ASAR shows participation in schooling at any level, from primary through higher education. The closer the ASAR is to 100, the higher the participation of a given age population at that level. A little more than 66 percent of children who are age 7 attend school. School attendance rises markedly up to age 12, remains high up to age 13, and then gradually declines. There are no marked differences in the proportion of males and females attending school up to age 18, after which there are substantially higher proportions of males than females attending school. Figure 2.3 Age-specific Attendance Rates of the de facto Population 5 to 24 Years 13 42 67 80 83 88 87 89 86 82 81 73 73 60 48 38 27 16 15 7 11 35 69 76 85 85 89 89 86 84 79 75 71 62 58 44 41 32 16 13 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age (years) 0 20 40 60 80 100 Percent Female Male Timor-Leste 2009-10 2.4 HOUSING CHARACTERISTICS There is a strong correlation between the socioeconomic condition of households and the vulnerability of their members, especially children, to common diseases. The amenities and assets available to households are important in determining the general socioeconomic status of the population. The 2009-10 TLDHS included questions on household access to electricity, sources of drinking water, types of sanitation facilities, flooring materials, and ownership of durable goods. The availability of and accessibility to improved drinking water may, to a large extent, minimize the prevalence of waterborne diseases among household members, especially young children. The source of drinking water is important because potentially fatal diarrheal diseases, such as typhoid, cholera, and dysentery, are common in Timor-Leste. Table 2.7 shows the percent Household Population and Housing Characteristics | 23 distribution of households by main source of drinking water, time taken to collect drinking water, person in the household who usually collects drinking water, and treatment of water, according to residence. Table 2.7 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and the de jure population by treatment of drinking water, according to residence, Timor-Leste 2009-10 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source Piped water into dwelling/yard/plot 38.1 11.7 17.9 38.8 12.2 18.5 Public tap/standpipe 25.1 27.1 26.6 24.5 28.1 27.3 Tube well or borehole 10.3 3.2 4.9 10.6 3.1 4.9 Protected dug well 3.1 4.9 4.5 3.1 4.6 4.3 Protected spring 4.1 8.4 7.4 4.2 8.4 7.4 Rainwater 0.0 0.2 0.1 0.0 0.1 0.1 Non-improved source Unprotected dug well 4.6 7.0 6.5 4.9 6.7 6.3 Unprotected spring 5.8 32.6 26.3 5.7 32.1 25.8 Tanker truck/cart with small tank 0.2 0.5 0.5 0.3 0.5 0.5 Surface water 0.7 3.3 2.7 0.7 3.2 2.6 Bottled water, improved source for cooking/washing1 7.7 0.1 1.9 6.9 0.1 1.7 Bottled water, non-improved source for cooking/washing1 0.1 0.0 0.0 0.1 0.0 0.0 Other 0.2 1.0 0.8 0.2 0.9 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 88.4 55.6 63.3 88.2 56.6 64.0 Time to obtain drinking water (round trip) Water on premises 78.3 38.1 47.5 78.8 38.6 48.1 Less than 30 minutes 13.7 26.3 23.3 13.0 26.1 23.0 30 minutes or longer 7.4 34.4 28.1 7.4 34.2 27.9 Don’t know/missing 0.7 1.2 1.1 0.8 1.1 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 13.4 42.3 35.5 13.1 41.8 35.0 Adult male 15+ 3.7 7.4 6.5 3.0 6.5 5.7 Female child under age 15 3.2 8.5 7.2 3.7 9.4 8.0 Male child under age 15 0.8 2.5 2.1 1.1 2.6 2.2 Other 0.5 1.3 1.1 0.3 1.1 0.9 Water on premises 78.3 38.1 47.5 78.8 38.6 48.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 74.9 84.0 81.9 75.8 85.3 83.0 Bleach/chlorine 4.4 1.9 2.5 5.2 2.0 2.8 Strained through cloth 58.0 62.0 61.0 58.6 62.6 61.6 Ceramic, sand, or other filter 0.1 0.2 0.2 0.1 0.2 0.2 Solar disinfection 0.0 0.1 0.0 0.0 0.0 0.0 Other 9.8 6.4 7.2 8.1 6.1 6.6 No treatment 22.2 15.1 16.8 21.6 13.9 15.7 Percentage using an appropriate treatment method3 77.4 84.5 82.8 78.1 85.8 84.0 Number 2,695 8,768 11,463 15,852 51,134 66,985 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source, according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. Overall, 63 percent of households obtain their drinking water from an improved source. Eighteen percent of households have access to piped water in their dwelling, yard, or plot, while 27 percent access drinking water from a public tap. Nine percent of households get their drinking water from a tube well or borehole or a protected dug well, and 7 percent have access to protected spring 24 | Household Population and Housing Characteristics water. Thirty-six percent of households use non-improved sources of drinking water. There is a big difference between urban and rural households in access to improved sources of drinking water (88 and 56 percent, respectively). The major source of drinking water for rural households is unprotected springs (33 percent). Twenty-seven percent of rural households use a public tap or standpipe as their main source of drinking water. Access to piped drinking water has increased since 2003 when 38 percent of the households had access to it compared with 45 percent in 2009-10. Nearly one in two households has access to drinking water on the premises, just under one in four takes less than 30 minutes, and three in ten take 30 minutes or longer to get to and return from their nearest source of drinking water. Not surprisingly most urban households have water on their premises or take less than 30 minutes to access their water source. Table 2.7 also provides information on the person who usually collects drinking water. Adult females age 15 and older are most likely to collect drinking water for the household if it is not on the premises (36 percent), followed by female children and adult men (7 percent each). Seventeen percent of households do not treat their water prior to drinking. The most common treatment methods are boiling (82 percent) and straining through cloth (61 percent). In the 2009-10 TLDHS, it was possible for households to report more than one method of treatment. An improved toilet facility is considered the most efficient and hygienic method of human waste disposal. Table 2.8 shows the percent distribution of households by type of toilet facility, according to residence. Overall, 41 percent of households use improved, not shared, toilet facilities. There are marked differences by urban-rural residence. Sixty-five percent of urban households and 34 percent of rural households use improved toilet facilities that are not shared with other households. However, 37 percent of households have no toilet facilities, a situation that is more common in rural areas (45 percent) than in urban areas (14 percent). Table 2.8 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Timor- Leste 2009-10 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 65.3 33.9 41.3 65.9 35.8 43.0 Flush/pour flush to piped sewer system 14.7 6.9 8.7 15.6 7.3 9.3 Flush/pour flush to septic tank 33.6 4.5 11.4 31.5 4.9 11.2 Flush/pour flush to pit latrine 9.4 8.8 9.0 10.4 8.8 9.2 Ventilated improved pit (VIP) latrine 4.1 2.8 3.1 4.7 3.0 3.4 Pit latrine with slab 3.3 10.1 8.5 3.5 11.0 9.2 Composting toilet 0.2 0.8 0.6 0.2 0.8 0.7 Non-improved facility 34.7 66.1 58.6 34.2 64.2 57.1 Any facility shared with other households 16.7 6.2 8.6 17.0 6.2 8.7 Flush/pour flush not to sewer/ septic tank/pit latrine 0.6 0.5 0.5 0.6 0.5 0.5 Pit latrine without slab/open pit 1.1 2.4 2.1 1.0 2.6 2.3 Bucket 0.6 0.4 0.4 0.6 0.4 0.5 Hanging toilet/hanging latrine 0.2 0.1 0.1 0.2 0.1 0.1 No facility/bush/field 13.5 44.7 37.4 12.7 43.0 35.8 Other 2.0 11.8 9.5 2.1 11.4 9.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,695 8,768 11,463 15,852 51,134 66,985 Household Population and Housing Characteristics | 25 Table 2.9 presents the distribution of households by household characteristics, according to residence. Overall, 38 percent of households in Timor-Leste have electricity; four-fifths (83 percent) of households in urban areas have electricity, compared with about one in four (24 percent) households in rural areas. The 2009-10 TLDHS findings show that the proportion of households with electricity has increased over the past five years, growing from 26 percent in 2003. Table 2.9 Household characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Timor-Leste 2009-10 Housing characteristic Households Population Urban Rural Total Urban Rural Total Electricity Yes 83.4 24.0 38.0 84.4 24.8 38.9 No 16.6 76.0 62.0 15.6 75.2 61.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 27.1 70.4 60.2 26.1 69.2 59.0 Dung 0.5 0.7 0.7 0.5 0.7 0.7 Wood/planks 1.4 1.6 1.5 1.5 1.4 1.4 Palm/bamboo 1.5 2.1 1.9 1.4 1.8 1.7 Parquet or polished wood 0.2 0.1 0.2 0.2 0.1 0.1 Vinyl or asphalt strips 0.0 0.0 0.0 0.0 0.0 0.0 Ceramic tiles 14.8 1.2 4.4 13.6 1.3 4.2 Cement 53.9 23.7 30.8 56.1 25.3 32.6 Carpet 0.2 0.1 0.1 0.3 0.1 0.1 Other 0.3 0.1 0.1 0.3 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 11.9 16.2 15.2 8.6 12.6 11.7 Two 31.7 35.3 34.5 28.8 32.8 31.8 Three or more 56.2 47.9 49.8 62.4 54.1 56.1 Missing 0.3 0.6 0.5 0.2 0.5 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 13.5 10.4 11.1 12.8 8.8 9.7 In a separate building 78.9 85.8 84.2 80.0 87.7 85.9 Outdoors 7.4 3.8 4.6 6.9 3.5 4.3 Other 0.0 0.0 0.0 0.0 0.0 0.0 Missing 0.1 0.0 0.0 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 8.2 0.3 2.2 7.1 0.3 1.9 LPG/natural gas/biogas 1.7 0.1 0.5 1.2 0.0 0.3 Kerosene 8.9 0.5 2.5 8.0 0.4 2.2 Coal/lignite 0.0 0.0 0.0 0.0 0.0 0.0 Charcoal 0.3 0.3 0.3 0.4 0.3 0.3 Wood 80.7 98.8 94.5 83.0 98.9 95.2 Straw/shrubs/grass 0.2 0.1 0.1 0.3 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 81.2 99.1 94.9 83.7 99.3 95.6 Number of households 2,695 8,768 11,463 15,852 51,134 66,985 Type of fire/stove among households using solid fuel1 Closed stove with chimney 1.0 0.2 0.3 0.9 0.1 0.3 Open fire/stove with chimney 0.6 0.4 0.4 0.7 0.4 0.4 Open fire/stove with hood 14.9 14.1 14.2 16.0 15.4 15.6 Open fire/stove without chimney or hood 83.0 83.4 83.3 82.0 82.2 82.2 Other 0.5 1.9 1.6 0.5 1.8 1.5 Missing 0.0 0.1 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population using solid fuel 2,189 8,691 10,880 13,268 50,773 64,041 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 26 | Household Population and Housing Characteristics The type of flooring material used in dwellings is a proxy indicator of the socioeconomic status of a household as well as a potential source of exposure to disease-causing agents. Most households in Timor-Leste have rudimentary or natural flooring made of earth, sand, or mud mixed with dung. Finished floors made of tiles, cement, polished wood, and carpet are seen in just over one in three households (36 percent). However, over the past five years there has been a small increase in the percentage of households with finished floors, (28 percent in 2003 compared with 36 percent in 2009-10). Rural households are much more likely to have earth and sand floors (70 percent) than urban households (27 percent). The second most common flooring material in rural areas is cement (24 percent). About 15 percent of urban households have ceramic floors, and less than 2 percent have palm/bamboo floors. The number of rooms used for sleeping indicates the extent of crowding in households. Overcrowding increases the risk of contracting infectious diseases like acute respiratory infections and skin diseases, which particularly affect children. In the 2009-10 TLDHS, about half of the households had three or more rooms for sleeping; 35 percent had two rooms, and 15 percent had one room. Households in rural areas are less likely than those in urban areas to have three or more rooms for sleeping (48 and 56 percent, respectively). The presence and extent of indoor pollution is dependent on whether food is cooked inside the house, the type of fuel used for cooking, and whether households have a chimney or hood to ventilate cooking fumes. One in ten households (11 percent) cooks inside the house, 84 percent cook in a separate building, and 5 percent cook outdoors. This pattern was observed in both urban and rural areas. The majority of households in Timor-Leste use solid fuels (primarily wood) for cooking (95 percent). Although nearly all households in rural areas use wood for cooking (99 percent), 81 percent of urban households use wood. Urban households are also much more likely to use kerosene (9 percent) and electricity (8 percent) for cooking. The data also indicate that among households that use solid fuel for cooking, more than four in five do not use a chimney or hood (83 percent), and there is no marked difference between urban and rural areas. A closed fire or stove with a chimney is used by less than 1 percent of households in Timor-Leste. 2.5 HOUSEHOLD DURABLE GOODS Information was collected in the 2009-10 TLDHS on the availability of household durable goods, such as household effects, means of transportation, and ownership of agricultural land and farm animals. Table 2.10 shows that 40 percent of households own a mobile telephone, 35 percent own a radio, 23 percent own a television, and 9 percent own a refrigerator. Urban households are much more likely than rural households to own these goods. For example, 49 percent of urban households own a radio, compared with 30 percent of rural households. Mobile telephones are available in 74 percent of households in urban areas and 30 percent of rural households, while 60 percent of urban households have a television and only 11 percent of households in rural areas have a television. The most common means of transportation in the country is a motorcycle or scooter, owned by 13 percent of households, and another 11 percent of households own a bicycle, 9 percent own an animal-drawn cart, and 4 percent own a car or truck. Less than 1 percent of households own a boat with a motor. In general, urban households are much more likely to own a means of transport than rural households. Household Population and Housing Characteristics | 27 Table 2.10 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, Timor-Leste 2009-10 Possession Households Population Urban Rural Total Urban Rural Total Household effects Radio 49.0 30.1 34.5 49.6 32.1 36.2 Television 60.4 10.9 22.5 62.1 12.1 23.9 Mobile telephone 73.5 29.8 40.1 75.6 33.3 43.3 Non-mobile telephone 1.5 0.3 0.6 1.8 0.4 0.7 Refrigerator 30.6 2.2 8.9 29.7 2.5 8.9 Means of transport Bicycle 24.1 6.9 11.0 26.2 7.7 12.0 Animal drawn cart 15.2 7.6 9.4 16.9 8.4 10.4 Motorcycle/scooter 32.4 7.5 13.4 33.5 8.5 14.4 Car/truck 12.3 1.4 3.9 11.8 1.5 4.0 Boat with a motor 0.6 0.7 0.7 0.8 0.7 0.7 Ownership of agricultural land 42.7 91.6 80.1 45.4 92.0 81.0 Ownership of farm animals1 70.6 93.4 88.1 74.3 94.1 89.4 Number 2,695 8,768 11,463 15,852 51,134 66,985 1 Cattle, cows, bulls, horses, donkeys, goats, sheep, or chickens Four in five households (80 percent) own agricultural land, and 88 percent have farm animals. Table 2.10 shows that rural households are more than two times as likely to own agricultural land as urban households (92 and 43 percent, respectively). Similarly, 93 percent of rural households own farm animals, compared with only 71 percent of urban households. 2.6 WEALTH QUINTILES The wealth quintile provides information on the economic status of households in a surveyed country. Wealth quintiles provide a consistent measure of combined indicators of household income and expenditures. The wealth quintile, as constructed, uses information on household ownership of various consumer items, ranging from household assets like a television, means of transport like a bicycle, and ownership of land and farm animals, to dwelling characteristics, such as source of drinking water, sanitation facilities, and type of building materials used in the construction of houses. Each asset is assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores are standardized in relation to a normal distribution with a mean of zero and standard deviation of one. Each household is then assigned a score for each asset, and the scores are summed for each household; individuals are ranked according to the total score of the household in which they reside. The sample is then divided into quintiles from one (lowest) to five (highest). A single asset index is developed for the whole sample; separate indices are not prepared for the urban and rural populations. The 2009-10 TLDHS provides an opportunity to examine the distribution of the population in Timor-Leste by household economic status. Table 2.11 shows the percent distribution of the de jure population by wealth quintiles, according to residence and districts. Fifty-eight percent of the urban population is in the highest wealth quintile, compared with only 9 percent of the rural population. The rural population is more likely to be in the lowest three lowest quintiles. Dili is by far the wealthiest district in the country, with 71 percent of its population in the highest quintile. Nearly one in two households in Oecussi is in the poorest wealth quintile, and more than three in five households in Ainaro, Oecussi, and Viqueque are in the lowest two quintiles. 28 | Household Population and Housing Characteristics Table 2.11 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, according to residence and region, Timor-Leste 2009-10 Residence/ region Wealth quintile Total Number of population Lowest Second Middle Fourth Highest Residence Urban 4.5 6.1 9.3 22.2 57.8 100.0 15,852 Rural 24.6 24.2 23.3 19.2 8.7 100.0 51,134 District Aileu 20.6 27.9 25.1 18.2 8.2 100.0 2,785 Ainaro 30.9 32.2 19.7 12.1 5.2 100.0 3,830 Baucau 26.9 28.9 19.3 13.4 11.5 100.0 7,590 Bobonaro 15.2 19.7 26.1 27.8 11.1 100.0 6,323 Covalima 17.2 17.7 23.1 25.1 16.8 100.0 3,993 Dili 0.4 2.1 6.5 20.1 71.0 100.0 10,905 Ermera 9.8 30.2 31.9 21.5 6.6 100.0 8,132 Lautem 28.0 16.7 20.4 24.5 10.4 100.0 4,547 Liquiçá 15.7 18.8 25.3 25.1 15.2 100.0 4,082 Manatuto 22.2 10.9 22.5 27.7 16.8 100.0 3,088 Manufahi 28.3 25.1 18.1 16.6 12.0 100.0 2,699 Oecussi 46.6 17.1 14.4 14.2 7.6 100.0 4,281 Viqueque 35.3 25.5 17.4 13.0 8.7 100.0 4,730 Total 19.9 19.9 20.0 19.9 20.3 100.0 66,985 2.7 BIRTH REGISTRATION Birth registration by definition means ensuring that the birth of a child is officially registered with the state (UNICEF, 2007). The Convention on the Rights of the Child (UN General Assembly, 1989) states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Parents are required to give their children a name and to register the child because the child has a right to know who his or her parents are and to have a nationality through registration in accordance with national laws and international standards. Studies have shown that in Timor-Leste, parents preferred to register the name and identity of their children through baptism (UNICEF, 2007). Although there was an attempt to register vital events, such as births, deaths, and marriages, prior to 1999, the ensuing violence and destruction left little record of such registration. Since Timor-Leste has gained independence, UNICEF and Plan International have been instrumental in promoting birth registration in Timor-Leste. In 2000, the United Nations Transitional Administration in East Timor (UNTAET) set up the first civil registration administration in Timor- Leste. This was followed by the establishment of the Central Civil Registry within the Ministry of Internal Affairs, whereby births, marriages, and deaths were registered. The responsibility of vital registration was then shifted to the Ministry of Justice under the Division of Civil Registry and Notary in 2002. Since 2003 UNICEF has supported the efforts of the Ministry of Justice to run mobile registration campaigns in the districts (UNICEF, 2005). Further, Plan International has collaborated with UNICEF in two districts to promote universal birth registration and by 2007 had facilitated birth registration of about 90,000 children in Timor-Leste (Plan, 2009; Cody, 2009). The 2009-10 TLDHS collected information on the percentage of children under age 5 whose births were officially registered with the civil authority. Excluded were registrations with the church during baptism. Table 2.12 shows the percentage of children under age 5 whose births were officially registered and the percentage with a birth certificate at the time of the survey, by background characteristics. Not all children reported as registered had a birth certificate at the time of the survey, so some certificates may have been lost or never issued. The births of 55 percent of children under age 5 have been registered: 41 percent have a birth certificate, and 15 percent do not have a birth certificate. Data from the 2003 DHS showed that 53 Household Population and Housing Characteristics | 29 percent of children under age 5 were reported to have been registered (hospital record, village record, proof of birth, and birth certificate), but only 9 percent had a birth certificate. The significant increase in the number of children with a birth certificate is probably due to the mobile registration campaigns launched by the Ministry of Justice in the districts. Nearly two-thirds of children age 2-4 years have been registered (65 percent), compared with two-fifths of children below age 2 (40 percent). About 14-16 percent of all these children do not have a birth certificate. There is no substantial variation in birth registration by sex of child. Rural children are more likely to be registered (57 percent) than urban children (50 percent). Most children in Manufahi are registered (91 percent), in contrast with children living in Viqueque, Covalima, Dili, and Liquiçá, where 40 percent or fewer are registered. The percentage of children registered ranges from a low of 50 percent among those in the lowest wealth quintile to a high of 59 percent among those in the middle wealth quintile. Table 2.12 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of children whose births are registered Number of children Had a birth certificate Did not have a birth certificate Total registered Age <2 26.7 13.5 40.1 3,876 2-4 49.1 15.5 64.6 6,198 Sex Male 40.5 14.4 54.8 5,112 Female 40.5 15.0 55.5 4,962 Residence Urban 37.7 12.0 49.7 2,341 Rural 41.3 15.5 56.8 7,734 District Aileu 50.7 18.4 69.1 370 Ainaro 33.0 26.9 59.9 596 Baucau 46.5 20.4 66.9 1,057 Bobonaro 55.9 4.1 60.0 954 Covalima 30.9 5.8 36.7 471 Dili 31.4 8.9 40.3 1,615 Ermera 63.4 3.4 66.8 1,279 Lautem 37.1 9.3 46.3 801 Liquiçá 27.9 12.4 40.3 583 Manatuto 45.8 22.1 67.8 460 Manufahi 43.7 47.6 91.3 384 Oecussi 26.9 33.3 60.2 789 Viqueque 21.6 12.6 34.3 715 Wealth quintile Lowest 30.9 19.1 50.0 2,164 Second 40.3 14.0 54.3 2,006 Middle 44.4 14.4 58.9 2,048 Fourth 43.9 13.1 56.9 1,961 Highest 43.8 12.4 56.1 1,895 Total 40.5 14.7 55.2 10,075 Characteristics of Respondents | 31 CHARACTERISTICS OF RESPONDENTS 3 This chapter describes the demographic and socioeconomic profile of respondents interviewed in the 2009-10 TLDHS. This information is useful in the interpretation of findings and in understanding the results presented later in the report. The survey collected basic information on respondents’ age, level of education, marital status, religion, ethnicity, and wealth status. In addition, information was collected on respondents’ exposure to mass media and literacy status, employment status, occupation, and type of earnings. Additional information collected includes knowledge and attitudes concerning tuberculosis and use of tobacco. For the first time, the 2009-10 TLDHS gathered information from all women and men irrespective of their marital status, in contrast with the 2003 DHS, which sampled only ever-married women and men. The discussion in this report therefore refers to both unmarried and married women and men. In addition, tables in this report show detailed information for men age 15-49, so that characteristics associated with women in the same age group may be compared. Throughout this report, numbers in the tables reflect weighted numbers. In most cases, percentages based on 25 to 49 unweighted cases are shown in parentheses. Percentages based on fewer than 25 unweighted cases are suppressed and replaced with an asterisk to caution readers when interpreting data that a percentage based on fewer than 50 cases may not be statistically reliable1. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS A description of the background characteristics of the 13,137 women age 15-49 and 4,076 men age 15-49 interviewed in the 2009-10 TLDHS is shown in Table 3.1. More than half of the respondents (56 percent of women and 55 percent of men) are under age 30. In general, the proportion of women and men in each age group declines as age increases (with the exception of women and men in the age group 35-39), reflecting the comparatively young age structure of the population in Timor-Leste. Three-fifths of women (60 percent) and just over half of men (53 percent) are currently married or living together. Thirty-six percent of women in the sample have never married compared with 46 percent of men. On the other hand, women are more likely to be divorced, separated, or widowed than men (4 percent compared with 1 percent). The place of residence is a background characteristic that determines access to services and exposure to information pertaining to reproductive health and other aspects of life. The majority of respondents reside in rural areas: nearly one in five respondents lives in Dili, and about one in ten lives in Baucau and Ermera. Respondents are least likely to reside in Manufahi. Women are disadvantaged in terms of educational attainment. This is observed at all levels of education. The male-female difference is especially obvious among those with no education and those with secondary or higher levels of education. Nearly three in ten women have no education compared with one in five men. Similarly, 48 percent of women have secondary or higher levels of education compared with 55 percent of men. The vast majority of respondents are Roman Catholic (98 percent), while 1 to 2 percent of women and men are Protestant. 1 For mortality rates, parentheses are used if based on 250 to 499 children exposed to the risk of mortality in any of the component rates, and suppressed if based on fewer than 250 children exposed to the risk of mortality in any of the component rates. 32 | Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Weighted percent Weighted Unweighted Weighted percent Weighted Unweighted Age 15-19 23.9 3,144 3,243 24.4 994 1,009 20-24 17.8 2,343 2,323 15.8 643 643 25-29 14.4 1,897 1,877 14.4 586 575 30-34 11.7 1,534 1,478 10.8 439 437 35-39 12.8 1,684 1,722 13.6 553 544 40-44 10.6 1,388 1,358 11.3 462 460 45-49 8.7 1,146 1,136 9.8 400 408 Marital status Never married 35.6 4,675 4,706 45.8 1,865 1,869 Married 57.8 7,588 7,548 48.8 1,988 1,993 Living together 2.4 318 329 4.2 170 159 Divorced/separated 1.8 231 219 0.4 18 18 Widowed 2.5 325 335 0.8 35 37 Residence Urban 26.2 3,439 3,233 27.0 1,102 1,015 Rural 73.8 9,698 9,904 73.0 2,974 3,061 District Aileu 4.2 554 1,036 4.4 181 298 Ainaro 4.7 619 841 5.3 217 296 Baucau 10.7 1,408 1,007 10.2 415 297 Bobonaro 9.6 1,262 1,062 8.7 357 319 Covalima 5.9 781 989 5.8 236 297 Dili 18.8 2,466 1,227 19.5 797 403 Ermera 11.7 1,542 1,082 12.1 491 355 Lautem 6.6 864 1,023 7.6 308 366 Liquiçá 6.1 801 1,069 6.2 252 315 Manatuto 4.6 603 1,135 4.7 190 366 Manufahi 3.6 470 791 3.4 137 228 Oecussi 6.7 884 1,000 5.8 235 271 Viqueque 6.7 882 875 6.4 260 265 Education No education 29.3 3,854 3,922 19.4 791 798 Primary 22.9 3,005 3,112 25.7 1,046 1,070 Secondary 44.4 5,829 5,804 49.3 2,009 2,025 More than secondary 3.4 449 299 5.7 230 183 Religion Roman Catholic 97.7 12,840 12,833 98.2 4,003 4,006 Muslim 0.2 22 20 0.3 14 5 Protestant 1.9 253 264 1.3 53 56 Hindu 0.2 21 18 0.1 4 6 Other 0.0 1 2 0.1 3 3 Total 15-49 100.0 13,137 13,137 100.0 4,076 4,076 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. 3.2 EDUCATIONAL ATTAINMENT AND LITERACY Tables 3.2.1 and 3.2.2 show the distribution of respondents by educational attainment, according to background characteristics. Twenty-nine percent of women age 15-49 have never been to school, 14 percent have some primary education, 9 percent have completed primary education, 29 percent have some secondary education, and 19 percent have completed secondary or a higher level of education. Older women and those who reside in rural areas are most likely to have no education. The urban-rural difference in the level of education is pronounced among those who have completed secondary or higher levels of schooling. For example, women in urban areas are more than three times as likely as those in rural areas to have completed secondary education or a higher level of education (39 percent and 12 percent, respectively). Characteristics of Respondents | 33 Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Timor-Leste 2009-10 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 13.4 13.3 6.9 47.8 15.5 3.0 100.0 7.7 5,487 15-19 11.8 13.4 6.5 61.6 6.4 0.3 100.0 7.4 3,144 20-24 15.6 13.2 7.6 29.3 27.8 6.5 100.0 8.6 2,343 25-29 24.7 13.3 11.5 19.9 25.4 5.3 100.0 6.3 1,897 30-34 30.5 13.4 13.4 17.9 19.3 5.4 100.0 5.5 1,534 35-39 37.9 15.2 12.3 16.9 15.0 2.7 100.0 4.4 1,684 40-44 54.8 15.1 7.2 9.9 10.6 2.4 100.0 a 1,388 45-49 68.3 16.2 4.7 5.0 3.9 1.9 100.0 a 1,146 Residence Urban 14.5 10.1 5.8 30.6 28.8 10.2 100.0 11.2 3,439 Rural 34.6 15.4 10.0 27.9 11.2 1.0 100.0 5.0 9,698 District Aileu 31.4 15.3 9.6 32.6 10.3 0.8 100.0 5.3 554 Ainaro 39.9 10.7 5.9 28.5 13.4 1.7 100.0 4.8 619 Baucau 27.1 15.6 7.0 31.5 17.4 1.5 100.0 6.0 1,408 Bobonaro 39.6 14.6 10.1 24.3 10.1 1.3 100.0 4.1 1,262 Covalima 21.7 15.1 10.5 36.4 14.6 1.7 100.0 6.6 781 Dili 10.5 9.8 5.2 29.5 31.7 13.3 100.0 12.5 2,466 Ermera 49.3 12.9 8.2 21.6 7.6 0.2 100.0 1.2 1,542 Lautem 20.2 13.6 12.8 38.2 14.2 1.0 100.0 6.5 864 Liquiçá 33.5 19.1 7.9 27.1 11.6 0.8 100.0 4.5 801 Manatuto 24.5 15.9 8.9 30.5 18.9 1.4 100.0 6.0 603 Manufahi 27.2 14.4 8.1 34.3 14.5 1.5 100.0 6.0 470 Oecussi 41.0 17.6 18.4 16.6 5.5 0.9 100.0 3.4 884 Viqueque 32.1 15.4 9.5 29.7 11.8 1.6 100.0 5.2 882 Wealth quintile Lowest 49.0 19.1 10.3 18.0 3.4 0.1 100.0 0.9 2,314 Second 40.8 17.8 9.8 24.6 6.8 0.2 100.0 3.3 2,468 Middle 33.2 14.5 10.4 30.4 10.8 0.7 100.0 5.2 2,590 Fourth 22.7 13.1 9.2 34.4 17.5 3.0 100.0 7.0 2,687 Highest 8.0 7.4 5.4 33.0 35.1 11.1 100.0 13.1 3,077 Total 29.3 14.0 8.9 28.6 15.8 3.4 100.0 5.7 13,137 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level a = Omitted because less than 50 percent of women had any education before reaching the beginning of the age group. Educational attainment is directly related to the economic status of respondents. An analysis of education by wealth quintile indicates that women in the highest wealth quintile are most likely to complete secondary or a higher level of education. For example, nearly one in two women in the highest wealth quintile has completed secondary or higher education, compared with less than 4 percent of women in the lowest wealth quintile. A similar pattern in educational attainment is found among men (Table 3.2.2). However, men are more educated than women in all categories. One in five men has never had formal schooling, one in five has some primary education, one in thirteen has completed primary school, three in ten have some secondary education, and more than one in four men has completed secondary or higher education. Women have completed a median of 6 years of schooling compared with 7 years for men. 34 | Characteristics of Respondents Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Timor-Leste 2009-10 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 11.7 13.9 6.6 48.7 16.9 2.1 100.0 7.6 1,636 15-19 10.8 15.7 7.1 59.7 6.3 0.5 100.0 7.3 994 20-24 13.2 11.2 5.9 31.8 33.3 4.6 100.0 12.2 643 25-29 20.4 19.9 6.9 12.4 31.3 9.2 100.0 7.7 586 30-34 19.1 18.6 9.1 16.3 28.5 8.4 100.0 7.6 439 35-39 20.0 17.2 12.7 17.9 20.8 11.5 100.0 6.1 553 40-44 29.2 18.2 8.9 13.2 24.7 5.9 100.0 5.3 462 45-49 37.5 27.0 8.3 10.2 13.3 3.8 100.0 2.3 400 Residence Urban 9.3 11.4 5.9 27.6 31.0 14.9 100.0 13.1 1,102 Rural 23.2 19.7 9.0 28.2 17.7 2.2 100.0 5.7 2,974 District Aileu 17.9 17.7 11.1 31.2 19.7 2.4 100.0 6.6 181 Ainaro 29.7 16.7 7.0 31.0 14.0 1.6 100.0 5.4 217 Baucau 15.7 22.7 7.4 27.3 24.6 2.3 100.0 7.1 415 Bobonaro 28.9 16.8 8.5 25.2 18.2 2.4 100.0 5.5 357 Covalima 12.5 14.7 12.7 32.4 23.0 4.7 100.0 7.9 236 Dili 7.1 10.7 6.0 24.5 34.3 17.4 100.0 13.9 797 Ermera 37.1 20.9 6.9 23.4 11.0 0.7 100.0 3.7 491 Lautem 11.0 9.2 9.0 42.0 24.3 4.6 100.0 8.3 308 Liquiçá 17.5 24.4 6.6 30.5 18.1 2.9 100.0 6.0 252 Manatuto 17.8 20.1 8.2 28.0 23.1 2.8 100.0 6.6 190 Manufahi 20.0 14.3 7.9 37.7 16.6 3.6 100.0 6.9 137 Oecussi 29.1 27.3 13.7 18.2 7.9 3.7 100.0 4.0 235 Viqueque 19.0 21.7 8.4 28.7 18.1 4.1 100.0 6.0 260 Wealth quintile Lowest 32.3 22.0 10.7 26.2 8.2 0.5 100.0 4.2 728 Second 26.6 21.8 10.6 26.4 14.2 0.4 100.0 5.1 781 Middle 23.3 20.3 9.5 29.6 15.2 2.0 100.0 5.6 786 Fourth 15.0 17.5 5.8 30.2 27.4 4.1 100.0 8.1 849 Highest 4.0 8.0 5.2 27.4 36.9 18.5 100.0 14.1 932 Total 15-49 19.4 17.5 8.2 28.0 21.3 5.7 100.0 7.1 4,076 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Literacy is widely acknowledged as benefiting the individual and the society and is associated with a number of positive outcomes for health, nutrition, and the overall well-being of both men and women. In the 2009-10 TLDHS, literacy was determined by the respondents’ ability to read all or part of a sentence. During data collection, interviewers carried a set of cards on which simple sentences were printed in five of the major languages. These cards were used to test a respondent’s reading ability. Only those who had never been to school and those who had not completed the primary level were asked to read the cards in the language they were most likely able to read. Those who had attended secondary school or received higher education were assumed to be literate. Table 3.3.1 indicates that more than two-thirds of women in Timor-Leste (68 percent) are literate. The literacy status varies by place of residence. Four-fifths of women residing in urban areas are literate compared with three-fifths of their rural counterparts. The level of literacy by age shows a consistent decrease with increasing age. This suggests that the younger generations have had more opportunity to learn to read than the older generations. Eighty-six percent of women age 15-19 are literate compared with 29 percent of women age 45-49. Characteristics of Respondents | 35 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Timor-Leste 2009-10 Background characteristic Pre- secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-19 68.3 11.2 6.6 13.9 0.0 0.0 0.0 100.0 86.1 3,144 20-24 63.6 9.5 8.3 18.5 0.0 0.1 0.0 100.0 81.4 2,343 25-29 50.6 10.9 10.3 27.9 0.1 0.2 0.0 100.0 71.8 1,897 30-34 42.7 14.3 10.1 32.8 0.0 0.1 0.0 100.0 67.1 1,534 35-39 34.6 12.0 12.5 40.9 0.1 0.0 0.0 100.0 59.0 1,684 40-44 22.9 9.6 10.3 56.8 0.1 0.2 0.0 100.0 42.8 1,388 45-49 10.8 8.9 9.5 70.3 0.0 0.3 0.1 100.0 29.3 1,146 Residence Urban 69.6 8.0 6.1 16.1 0.0 0.1 0.0 100.0 83.8 3,439 Rural 40.0 12.0 10.4 37.4 0.1 0.1 0.0 100.0 62.4 9,698 District Aileu 43.6 11.6 9.8 35.0 0.0 0.0 0.0 100.0 65.0 554 Ainaro 43.5 5.1 9.2 42.2 0.0 0.0 0.1 100.0 57.8 619 Baucau 50.4 12.1 6.9 30.7 0.0 0.0 0.0 100.0 69.3 1,408 Bobonaro 35.6 10.8 11.6 41.4 0.1 0.4 0.0 100.0 58.0 1,262 Covalima 52.7 10.6 10.9 25.6 0.0 0.1 0.1 100.0 74.2 781 Dili 74.5 7.9 6.7 10.7 0.0 0.1 0.0 100.0 89.2 2,466 Ermera 29.5 5.5 12.2 52.5 0.2 0.1 0.0 100.0 47.2 1,542 Lautem 53.4 14.4 10.3 21.8 0.0 0.1 0.0 100.0 78.1 864 Liquiçá 39.5 11.0 12.3 37.1 0.0 0.0 0.1 100.0 62.8 801 Manatuto 50.8 14.5 8.4 26.3 0.0 0.0 0.0 100.0 73.7 603 Manufahi 50.3 11.6 8.4 29.6 0.0 0.1 0.0 100.0 70.3 470 Oecussi 23.0 20.6 8.0 48.3 0.0 0.1 0.0 100.0 51.6 884 Viqueque 43.1 15.3 8.2 33.1 0.1 0.1 0.0 100.0 66.6 882 Wealth quintile Lowest 21.6 14.9 10.0 53.2 0.1 0.2 0.0 100.0 46.5 2,314 Second 31.6 11.2 12.2 44.9 0.1 0.0 0.0 100.0 55.1 2,468 Middle 41.9 11.8 10.4 35.6 0.1 0.1 0.0 100.0 64.2 2,590 Fourth 55.0 10.5 9.3 25.2 0.0 0.1 0.0 100.0 74.7 2,687 Highest 79.1 7.4 5.2 8.1 0.0 0.1 0.1 100.0 91.8 3,077 Total 47.8 10.9 9.2 31.9 0.0 0.1 0.0 100.0 68.0 13,137 1 Refers to women who attended pre-secondary school or higher and women who can read a whole sentence or part of a sentence Not surprisingly, literacy is highest in Dili, the most urban district in the country, with nine in ten women being literate. Less than one in two women in Ermera is literate, however. There is also a significant difference in literacy levels by women’s wealth status, with literacy rising from a low of 47 percent among women in the lowest wealth quintile to a high of 92 percent among women in the highest wealth quintile. This reaffirms the positive association between economic status and literacy. Men are more likely to be literate than women (Table 3.3.2). Four-fifths of Timorese men age 15-49 are literate. The gap in urban-rural literacy among men is smaller than the gap among women, suggesting that men in rural areas are better able to access learning than women. The level of literacy ranges from a low of 56 percent of men in Oecussi to a high of 92 percent of men in Dili. Nearly all men (95 percent) in the highest wealth quintile are literate. 36 | Characteristics of Respondents Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Timor-Leste 2009-10 Background characteristic Pre- secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Age 15-19 66.4 13.4 6.9 13.2 0.2 0.0 100.0 86.6 994 20-24 69.7 8.8 6.8 14.6 0.0 0.0 100.0 85.4 643 25-29 52.8 12.8 12.9 21.3 0.0 0.1 100.0 78.6 586 30-34 53.2 16.6 10.7 19.5 0.0 0.0 100.0 80.5 439 35-39 50.2 17.3 9.1 23.4 0.0 0.0 100.0 76.6 553 40-44 43.7 14.2 11.7 30.1 0.0 0.3 100.0 69.6 462 45-49 27.2 20.0 12.2 40.6 0.0 0.0 100.0 59.4 400 Residence Urban 73.4 9.6 5.5 11.2 0.2 0.1 100.0 88.6 1,102 Rural 48.1 15.9 11.0 25.0 0.0 0.1 100.0 75.0 2,974 District Aileu 53.3 9.0 13.1 24.6 0.0 0.0 100.0 75.4 181 Ainaro 46.6 14.7 8.4 29.6 0.0 0.7 100.0 69.7 217 Baucau 54.2 20.8 8.1 17.0 0.0 0.0 100.0 83.0 415 Bobonaro 45.8 19.5 14.4 20.2 0.0 0.0 100.0 79.8 357 Covalima 60.0 4.6 17.1 18.3 0.0 0.0 100.0 81.7 236 Dili 76.2 9.5 5.8 8.2 0.2 0.0 100.0 91.6 797 Ermera 35.0 6.8 18.0 40.1 0.0 0.0 100.0 59.9 491 Lautem 70.8 14.2 3.5 11.5 0.0 0.0 100.0 88.5 308 Liquiçá 51.5 19.5 4.9 24.1 0.0 0.0 100.0 75.9 252 Manatuto 53.9 25.8 1.4 18.9 0.0 0.0 100.0 81.1 190 Manufahi 57.8 8.9 8.5 24.7 0.0 0.0 100.0 75.3 137 Oecussi 29.9 22.7 3.3 43.8 0.0 0.2 100.0 55.9 235 Viqueque 50.9 18.2 15.1 15.8 0.0 0.0 100.0 84.2 260 Wealth quintile Lowest 35.0 18.2 11.0 35.8 0.0 0.0 100.0 64.2 728 Second 41.1 16.7 13.0 29.1 0.0 0.2 100.0 70.7 781 Middle 46.9 16.5 12.7 23.9 0.0 0.0 100.0 76.1 786 Fourth 61.6 13.5 7.5 17.3 0.0 0.1 100.0 82.6 849 Highest 82.8 7.7 4.6 4.7 0.2 0.0 100.0 95.1 932 Total 15-49 54.9 14.2 9.5 21.3 0.0 0.1 100.0 78.6 4,076 1 Refers to men who attended pre-secondary school or higher and men who can read a whole sentence or part of a sentence 3.3 ACCESS TO MASS MEDIA Access to information through the media is essential to increasing people’s knowledge and awareness of what is taking place around them, which may eventually affect their perceptions and behavior. In the 2009-10 TLDHS, exposure to media was assessed by asking respondents if they listened to a radio, watched television, or read newspapers or magazines at least once a week. This information is useful for program managers and planners engaged in determining which media may be most effective for disseminating health information to targeted audiences. The detailed results are presented in Tables 3.4.1 and 3.4.2 by background characteristics. Media exposure in Timor-Leste is relatively low, with just over one in ten women and men exposed to all three specified types of mass media. Just over one-third of women are exposed to the radio, and a similar proportion is exposed to television at least once a week. Exposure to the radio and television is slightly higher among men, with two-fifths of men exposed to the radio and the television. Just over one-fifth of women and men read a newspaper at least once a week. Media exposure declines with age among women, but the relationship is less clear among men. Young women under 24 years of age are more likely to be exposed to the mass media than older women, presumably in part because of their higher level of education. There is also a wide gap in exposure to mass media by place of residence. For example, the proportion of newspaper readers is Characteristics of Respondents | 37 Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Timor-Leste 2009-10 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number of women Age 15-19 32.7 40.5 40.0 15.5 38.5 3,144 20-24 27.0 40.2 41.9 15.2 41.8 2,343 25-29 21.8 38.6 39.3 12.7 44.9 1,897 30-34 18.3 38.5 34.5 11.7 49.5 1,534 35-39 15.3 30.6 30.6 7.8 55.2 1,684 40-44 11.9 31.0 29.5 7.1 56.4 1,388 45-49 7.3 24.3 23.1 5.1 65.8 1,146 Residence Urban 36.7 76.4 59.5 27.5 15.4 3,439 Rural 16.5 22.0 27.4 6.3 59.2 9,698 District Aileu 20.5 15.3 31.3 5.1 57.8 554 Ainaro 11.9 10.7 18.3 3.4 74.3 619 Baucau 16.4 23.7 31.2 8.0 57.4 1,408 Bobonaro 17.1 29.6 32.7 8.6 51.1 1,262 Covalima 23.5 36.1 43.3 8.6 38.3 781 Dili 42.2 87.9 67.8 33.3 6.6 2,466 Ermera 17.3 10.5 19.1 2.7 67.5 1,542 Lautem 12.0 29.0 21.9 4.2 60.8 864 Liquiçá 22.9 29.4 42.0 11.5 45.1 801 Manatuto 26.7 36.3 32.4 16.7 52.3 603 Manufahi 24.9 30.0 50.1 10.2 37.6 470 Oecussi 7.8 29.2 18.4 4.9 63.7 884 Viqueque 11.6 21.6 15.8 3.6 67.1 882 Education No education 0.4 13.2 16.0 0.1 76.5 3,854 Primary 12.5 27.1 28.1 3.8 55.6 3,005 Secondary 37.2 52.0 49.8 20.3 28.0 5,829 More than secondary 67.1 91.0 74.7 55.6 4.3 449 Wealth quintile Lowest 7.1 8.3 10.3 1.4 81.6 2,314 Second 12.3 10.6 17.3 2.2 71.1 2,468 Middle 16.2 16.5 29.9 4.2 57.9 2,590 Fourth 22.3 42.1 43.4 10.1 35.6 2,687 Highest 44.7 89.4 68.2 35.3 5.6 3,077 Total 21.8 36.3 35.8 11.8 47.7 13,137 significantly higher among urban women (37 percent) than among their rural counterparts (17 percent). About one in three women and men in Dili are exposed to all three media sources at least once a week. Media exposure among women is lowest in Ermera where less than 3 percent of women are exposed to all three media sources at least once a week. Men in Liquiçá, Ermera, and Bobonaro are least likely to be exposed to all three sources of media at least once a week. Not surprisingly, media exposure is highly related to the educational level as well as the economic status of the respondent. Exposure to mass media is highest among women with secondary or a higher level of education and among those who are in the highest wealth quintile. The lower level of exposure to media among poor respondents may be because they are less likely to own a radio or television and, therefore, are less likely to be consistently exposed to these media sources. A similar relationship is observed between media exposure among men and their education and wealth. 38 | Characteristics of Respondents Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Timor-Leste 2009-10 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number of men Age 15-19 18.0 45.7 42.0 9.2 38.7 994 20-24 22.3 48.8 52.3 15.0 32.6 643 25-29 24.5 43.6 47.8 13.4 35.7 586 30-34 24.4 40.4 43.2 12.5 39.9 439 35-39 22.9 39.6 40.5 14.9 44.5 553 40-44 21.7 34.4 41.9 12.9 46.5 462 45-49 12.1 27.3 34.9 4.9 51.1 400 Residence Urban 36.8 74.0 59.4 25.9 13.9 1,102 Rural 14.9 29.3 37.8 6.6 50.1 2,974 District Aileu 21.8 27.7 46.5 10.2 42.6 181 Ainaro 13.6 16.3 32.5 4.7 58.5 217 Baucau 29.0 35.3 40.5 9.0 36.2 415 Bobonaro 10.1 32.7 43.9 3.9 42.8 357 Covalima 12.0 35.7 43.3 7.0 43.6 236 Dili 43.0 80.4 62.3 31.0 9.7 797 Ermera 12.0 10.7 22.0 3.6 70.5 491 Lautem 10.5 36.8 26.2 4.6 53.0 308 Liquiçá 7.2 38.0 39.8 4.1 47.6 252 Manatuto 11.1 53.5 83.2 8.8 14.2 190 Manufahi 18.3 46.5 60.3 8.9 29.1 137 Oecussi 23.7 43.8 46.4 15.2 40.4 235 Viqueque 15.5 32.2 24.2 12.5 63.5 260 Education No education 0.2 15.8 21.1 0.0 71.1 791 Primary 10.6 28.9 35.5 4.2 51.9 1,046 Secondary 28.9 53.4 54.0 16.4 26.1 2,009 More than secondary 67.3 80.9 67.5 47.2 6.5 230 Wealth quintile Lowest 9.3 19.4 21.2 3.1 67.3 728 Second 12.1 18.4 30.1 2.9 59.0 781 Middle 12.3 23.8 39.8 4.9 49.2 786 Fourth 21.9 45.3 50.9 9.7 31.0 849 Highest 43.2 89.0 69.3 34.0 4.6 932 Total 15-49 20.8 41.4 43.7 11.9 40.3 4,076 3.4 EMPLOYMENT 3.4.1 Employment Status The 2009-10 TLDHS asked respondents a number of questions regarding their employment status, including whether they were working in the seven days preceding the survey and, if not, whether they had worked in the 12 months before the survey. The results for women and men are presented in Tables 3.5.1 and 3.5.2. At the time of the survey, about two-fifths of women were currently employed, and less than one percent was not employed but had worked sometime during the past 12 months. The proportion of women currently employed increases with age. Current employment is lowest among women age 15-19 (23 percent) and highest among those age 45-49 (58 percent). Women who are divorced, separated, or widowed are more likely to be currently employed than other women. Women who have three or more children are more likely to be currently employed than those with two or fewer children. Less than one-third of women in urban areas were currently working compared with two-fifths of women in rural areas. The higher rural rate of employment reflects the importance of farm work and perhaps a shortage of income, but the distinction between paid and Characteristics of Respondents | 39 Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Timor-Leste 2009-10 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 22.7 0.3 77.0 100.0 3,144 20-24 31.1 0.5 68.4 100.0 2,343 25-29 38.2 0.7 61.1 100.0 1,897 30-34 44.3 0.5 55.0 100.0 1,534 35-39 48.6 0.4 50.9 100.0 1,684 40-44 56.7 0.9 42.2 100.0 1,388 45-49 58.1 0.5 41.2 100.0 1,146 Marital status Never married 28.7 0.4 70.9 100.0 4,675 Married or living together 43.1 0.6 56.2 100.0 7,906 Divorced/separated/widowed 65.2 1.0 33.8 100.0 556 Number of living children 0 30.3 0.4 69.2 100.0 5,178 1-2 38.8 0.4 60.7 100.0 2,350 3-4 45.8 0.6 53.3 100.0 2,554 5+ 47.9 0.7 51.4 100.0 3,055 Residence Urban 30.2 0.8 68.8 100.0 3,439 Rural 42.0 0.4 57.5 100.0 9,698 District Aileu 66.0 0.6 33.4 100.0 554 Ainaro 29.7 0.0 70.3 100.0 619 Baucau 26.1 0.2 73.7 100.0 1,408 Bobonaro 44.1 0.1 55.8 100.0 1,262 Covalima 41.6 0.2 58.2 100.0 781 Dili 28.8 1.2 69.8 100.0 2,466 Ermera 43.3 0.1 56.6 100.0 1,542 Lautem 17.5 0.5 82.0 100.0 864 Liquiçá 37.4 0.2 62.4 100.0 801 Manatuto 36.4 0.2 63.4 100.0 603 Manufahi 47.7 0.1 52.0 100.0 470 Oecussi 84.9 2.0 13.1 100.0 884 Viqueque 33.3 0.4 66.0 100.0 882 Education No education 51.6 0.6 47.8 100.0 3,854 Primary 43.6 0.5 55.9 100.0 3,005 Secondary 27.9 0.4 71.6 100.0 5,829 More than secondary 42.7 1.2 56.0 100.0 449 Wealth quintile Lowest 49.1 0.5 50.3 100.0 2,314 Second 42.0 0.5 57.4 100.0 2,468 Middle 41.1 0.5 58.4 100.0 2,590 Fourth 33.7 0.7 65.7 100.0 2,687 Highest 31.6 0.6 67.6 100.0 3,077 Total 38.9 0.5 60.5 100.0 13,137 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. unpaid work may not be especially meaningful in a society with high rates of subsistence living. Current employment rises from 18 percent among women in Lautem to 85 percent among women in Oecussi. Current employment is highest among women with no education and lowest among women with secondary education. Current employment varies inversely with wealth quintile, rising from 32 percent among women in the wealthiest households to 49 percent among women in the poorest households. 40 | Characteristics of Respondents Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Timor-Leste 2009-10 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 65.7 2.8 31.6 100.0 994 20-24 78.8 2.9 18.3 100.0 643 25-29 88.6 3.1 8.3 100.0 586 30-34 95.2 1.4 3.4 100.0 439 35-39 95.6 1.2 3.2 100.0 553 40-44 94.9 2.3 2.8 100.0 462 45-49 95.7 1.2 3.1 100.0 400 Marital status Never married 71.4 3.1 25.5 100.0 1,865 Married or living together 95.7 1.6 2.7 100.0 2,158 Divorced/separated/widowed 90.3 0.0 9.7 100.0 53 Number of living children 0 73.0 3.0 24.0 100.0 2,009 1-2 95.8 1.5 2.7 100.0 638 3-4 96.1 1.6 2.4 100.0 720 5+ 95.3 1.7 3.0 100.0 709 Residence Urban 65.4 4.4 30.2 100.0 1,102 Rural 91.6 1.5 6.9 100.0 2,974 District Aileu 84.5 0.4 15.1 100.0 181 Ainaro 86.7 1.5 11.8 100.0 217 Baucau 94.7 0.9 4.4 100.0 415 Bobonaro 85.6 5.2 9.2 100.0 357 Covalima 90.3 0.8 8.9 100.0 236 Dili 60.3 4.3 35.3 100.0 797 Ermera 99.4 0.1 0.5 100.0 491 Lautem 89.2 1.9 8.9 100.0 308 Liquiçá 91.3 5.5 3.2 100.0 252 Manatuto 95.1 2.4 2.5 100.0 190 Manufahi 74.9 1.2 23.9 100.0 137 Oecussi 95.8 0.4 3.8 100.0 235 Viqueque 81.0 1.2 17.9 100.0 260 Education No education 95.1 1.3 3.7 100.0 791 Primary 90.2 2.1 7.7 100.0 1,046 Secondary 77.9 2.9 19.2 100.0 2,009 More than secondary 80.9 0.9 18.3 100.0 230 Wealth quintile Lowest 91.8 0.9 7.3 100.0 728 Second 92.8 1.1 6.1 100.0 781 Middle 90.0 1.9 8.1 100.0 786 Fourth 82.6 2.9 14.5 100.0 849 Highest 69.1 4.1 26.8 100.0 932 Total 15-49 84.5 2.3 13.2 100.0 4,076 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. The proportion currently employed is much higher among men than women (Table 3.5.2). The majority of men age 15-49 (85 percent) were employed at the time of survey. The percentage of currently employed men rises with age, from 66 percent among men age 15-19 to 96 percent among men age 45-49. Never-married men, men with no children, urban men, those living in Dili, those with a secondary education, and those in the highest wealth quintile are least likely to be currently employed. Characteristics of Respondents | 41 3.4.2 Occupation Respondents who were currently employed or who had worked in the 12 months preceding the survey were asked further about their occupation. The results are presented in Tables 3.6.1 and 3.6.2, which show data on employed women and men, respectively, by occupation and according to background characteristics. Agriculture is the dominant sector of the economy of Timor-Leste, and most employed persons work in the agricultural sector. Specifically, 61 percent of employed women and 67 percent of employed men are engaged in agricultural jobs. Tables 3.6.1 and 3.6.2 further show that 22 percent of women and 14 percent of men are employed in sales and service. The survey indicates that 6 percent of employed women are manual workers (skilled and unskilled), while 7 percent are engaged in the professional, technical, and managerial fields. The type of occupation varies greatly by gender. Women are less likely than men to be highly educated or to have attended vocational or technical schools. Therefore, their employment in the professional, technical, and managerial sector is somewhat low compared with that of men (7 percent compared with 11 percent). Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Timor-Leste 2009-10 Background characteristic Professional/ technical/ managerial Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of women Age 15-19 1.5 14.6 0.3 5.5 6.3 71.3 0.5 100.0 725 20-24 5.8 22.8 0.0 7.2 4.4 58.9 1.0 100.0 740 25-29 8.5 26.7 0.2 6.7 4.9 52.0 1.0 100.0 737 30-34 8.5 25.9 0.5 6.7 4.2 52.8 1.5 100.0 687 35-39 7.1 22.4 0.4 5.3 3.5 60.5 0.8 100.0 826 40-44 8.3 21.1 0.2 5.5 2.4 62.1 0.4 100.0 800 45-49 5.6 19.3 0.2 4.9 1.6 68.4 0.1 100.0 671 Marital status Never married 5.7 18.2 0.0 6.4 4.1 64.4 1.3 100.0 1,360 Married or living together 6.8 23.4 0.3 5.9 4.2 58.7 0.6 100.0 3,458 Divorced/separated/ widowed 6.5 21.0 0.5 4.2 0.3 67.4 0.0 100.0 368 Number of living children 0 6.0 18.4 0.0 6.6 4.4 63.4 1.2 100.0 1,592 1-2 7.5 26.6 0.4 6.9 3.4 55.0 0.2 100.0 922 3-4 8.4 26.0 0.3 6.1 4.3 53.9 1.0 100.0 1,187 5+ 4.9 19.3 0.3 4.5 3.4 67.1 0.4 100.0 1,484 Residence Urban 15.2 44.8 0.2 10.2 7.5 19.2 2.9 100.0 1,067 Rural 4.3 15.9 0.3 4.9 2.9 71.6 0.2 100.0 4,119 District Aileu 3.2 7.5 0.0 2.4 6.9 79.8 0.1 100.0 369 Ainaro 9.4 10.2 0.0 3.2 2.6 74.6 0.0 100.0 184 Baucau 7.8 26.1 0.4 6.7 3.0 54.6 1.3 100.0 370 Bobonaro 3.4 18.0 0.2 14.3 0.3 63.6 0.1 100.0 558 Covalima 7.6 24.3 0.0 4.0 0.0 64.1 0.0 100.0 326 Dili 17.6 48.6 0.5 12.3 5.4 11.7 4.0 100.0 740 Ermera 3.8 3.8 0.5 2.1 0.6 89.3 0.0 100.0 670 Lautem 12.7 24.8 0.0 5.7 0.3 55.5 1.0 100.0 155 Liquiçá 4.6 19.7 0.3 4.0 0.8 70.3 0.3 100.0 301 Manatuto 5.2 24.4 0.0 10.2 3.0 56.9 0.2 100.0 221 Manufahi 4.8 22.9 0.0 3.6 0.6 68.1 0.0 100.0 225 Oecussi 1.4 24.7 0.0 1.4 12.9 59.5 0.0 100.0 769 Viqueque 4.4 10.3 0.7 2.8 1.6 79.8 0.4 100.0 298 Education No education 0.6 14.7 0.3 4.6 2.2 77.3 0.3 100.0 2,012 Primary 1.2 19.8 0.1 4.8 4.6 68.6 0.9 100.0 1,326 Secondary 13.4 30.3 0.3 8.0 5.5 41.7 0.9 100.0 1,651 More than secondary 45.6 36.9 0.0 10.3 3.2 1.3 2.7 100.0 197 Wealth quintile Lowest 1.3 12.3 0.2 3.5 3.7 78.8 0.2 100.0 1,149 Second 1.9 13.5 0.0 3.5 2.2 78.6 0.4 100.0 1,049 Middle 3.1 13.9 0.5 4.9 3.4 73.9 0.2 100.0 1,077 Fourth 6.8 26.0 0.3 6.9 4.8 54.7 0.6 100.0 922 Highest 20.9 46.6 0.2 11.6 5.5 12.7 2.5 100.0 990 Total 6.5 21.8 0.2 5.9 3.9 60.8 0.8 100.0 5,186 42 | Characteristics of Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Timor-Leste 2009-10 Background characteristic Professional/ technical/ managerial Sales and services Skilled manual Unskilled manual Domestic service Agriculture Missing Total Number of men Age 15-19 3.6 5.4 1.1 2.8 1.0 85.7 0.4 100.0 680 20-24 8.3 10.6 1.8 4.6 1.1 72.6 1.1 100.0 525 25-29 12.4 18.8 1.6 5.9 0.2 58.4 2.7 100.0 537 30-34 13.0 22.2 3.3 4.9 0.1 56.1 0.4 100.0 424 35-39 14.2 19.5 1.8 4.9 0.1 58.8 0.7 100.0 535 40-44 15.6 14.5 0.9 6.4 0.0 61.5 1.1 100.0 449 45-49 11.8 13.7 1.3 0.1 0.0 71.8 1.4 100.0 387 Marital status Never married 8.2 8.5 1.3 4.2 0.9 76.2 0.7 100.0 1,390 Married or living together 12.6 18.5 1.9 4.3 0.1 61.3 1.4 100.0 2,101 Divorced/separated/ widowed 4.9 5.1 2.1 5.0 0.0 82.9 0.0 100.0 47 Number of living children 0 8.8 9.4 1.3 4.2 0.8 74.6 1.0 100.0 1,527 1-2 10.3 20.4 2.6 4.7 0.4 59.1 2.5 100.0 621 3-4 13.1 22.1 1.2 5.4 0.0 57.4 0.7 100.0 703 5+ 13.3 12.3 2.0 2.8 0.0 69.2 0.4 100.0 688 Residence Urban 19.5 36.0 1.6 10.1 0.6 29.2 2.9 100.0 769 Rural 8.4 8.4 1.7 2.6 0.4 78.0 0.6 100.0 2,769 District Aileu 10.9 3.6 0.0 0.8 0.0 84.3 0.4 100.0 154 Ainaro 4.5 6.7 0.0 0.8 2.7 85.3 0.0 100.0 192 Baucau 5.4 13.4 2.9 3.7 0.0 72.2 2.4 100.0 396 Bobonaro 6.4 10.5 0.8 1.8 0.0 80.1 0.4 100.0 324 Covalima 15.1 11.9 3.0 3.3 0.0 66.6 0.0 100.0 215 Dili 24.3 45.9 2.4 11.9 0.4 10.9 4.2 100.0 515 Ermera 3.4 3.4 0.3 0.7 0.0 92.1 0.0 100.0 489 Lautem 7.2 8.2 1.5 3.9 1.5 77.7 0.0 100.0 280 Liquiçá 12.3 12.3 4.3 6.6 0.0 63.6 0.9 100.0 244 Manatuto 8.0 21.9 4.1 5.1 1.3 58.8 0.9 100.0 185 Manufahi 19.9 8.4 0.0 3.1 0.0 68.6 0.0 100.0 105 Oecussi 8.4 6.2 0.2 0.9 0.4 83.8 0.0 100.0 226 Viqueque 16.3 4.5 0.5 6.3 0.0 71.9 0.5 100.0 214 Education No education 4.2 6.4 1.7 0.9 0.0 86.7 0.1 100.0 762 Primary 8.1 9.8 2.5 2.8 0.2 76.2 0.3 100.0 965 Secondary 12.1 18.8 1.3 6.0 0.7 59.6 1.5 100.0 1,623 More than secondary 40.0 32.7 0.0 10.3 0.7 11.3 5.0 100.0 188 Wealth quintile Lowest 4.2 2.3 1.0 2.0 0.3 90.1 0.2 100.0 675 Second 5.2 5.2 1.2 2.0 0.3 85.4 0.8 100.0 733 Middle 8.0 6.4 2.4 2.0 0.4 80.2 0.6 100.0 722 Fourth 14.7 17.9 1.1 5.7 0.4 58.9 1.2 100.0 726 Highest 22.1 41.1 2.5 9.9 0.6 21.1 2.7 100.0 682 Total 15-49 10.8 14.4 1.6 4.3 0.4 67.4 1.1 100.0 3,538 The relationship between occupation and age is mixed. One notable finding is the relatively higher percentages of women age 25-34 employed in sales and services and engaged in professional, technical, and managerial occupations. Residence has a significant effect on the type of occupation. As expected, a high proportion of respondents in rural areas—seven in ten employed women, and eight in ten employed men—are engaged in agricultural work. Urban women are most likely to be engaged in sales and services compared with other occupations. Women and men in Dili are much more likely to be engaged in sales and services and in professional, technical, and managerial occupations, and are least likely to be engaged in agriculture. On the other hand, women and men in Ermera are most likely to be engaged in agriculture and least likely to be engaged in sales and services. Characteristics of Respondents | 43 3.4.3 Earnings, Employers, and Continuity of Employment Table 3.7 shows the percent distribution of women by type of earnings and employment characteristics. These tables also present data on whether respondents are involved in agricultural or nonagricultural occupations because all of the employment variables shown in the tables are strongly influenced by the sector of employment. Table 3.7 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), Timor-Leste 2009-10 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 2.3 45.6 19.3 Cash and in-kind 0.3 2.1 1.0 In-kind only 1.1 0.5 0.9 Not paid 96.2 51.7 78.8 Missing 0.0 0.1 0.0 Total 100.0 100.0 100.0 Type of employer Employed by family member 19.3 11.1 16.1 Employed by nonfamily member 1.3 37.8 15.6 Self-employed 79.5 51.2 68.4 Total 100.0 100.0 100.0 Continuity of employment All year 26.9 68.0 42.9 Seasonal 57.0 22.7 43.7 Occasional 16.1 9.2 13.5 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 3,154 1,992 5,186 Note: Total includes 40 women with missing information on type of employment who are not shown separately. Four-fifths of working women are not paid for their work. This is because the vast majority of women (96 percent) engaged in agricultural work are unpaid workers, most likely employed by family members at the peak of the agricultural season. On the other hand, almost one in two women employed in nonagricultural work will receive cash earnings. More than two-thirds of women are self-employed, with self-employment much higher in the agricultural (80 percent) than in the nonagricultural sector (51 percent). Women are as likely to be employed by a family member as by a nonfamily member (16 percent each). One in five women working in the agricultural sector is working for a family member compared with only 11 percent of women working in the nonagricultural sector. In addition, the proportion of women employed by someone outside the family is higher among those working in the nonagricultural sector than among those working in the agricultural sector (38 percent versus 1 percent). About two in five women work all year. A similar proportion works seasonally, while one in seven works occasionally. Continuity of employment also varies by sector. The majority of women employed in the agricultural sector are seasonal workers (57 percent), compared with only one in four among those working in the nonagricultural sector. On the other hand, 68 percent of women working in the nonagricultural sector work all year compared with 27 percent of women engaged in agricultural work. 44 | Characteristics of Respondents 3.5 KNOWLEDGE AND ATTITUDES CONCERNING TUBERCULOSIS Tuberculosis (TB) is a leading cause of death in the world and a major public health problem in the developing world. TB is caused by the bacteria Mycobacterium tuberculosis, whose transmission is mainly airborne through droplets that are coughed or sneezed by infected persons. The infection is primarily concentrated in the lungs, but in some cases it can be transmitted to other areas of the body. Tuberculosis is a major public health problem in Timor-Leste. The very young and very old and persons with a suppressed immune system (brought on from HIV infection or other causes) are especially prone to contracting TB when exposed to it. The 2009- 10 TLDHS collected information from women and men of reproductive age on the level of awareness of TB. Specifically, respondents were asked whether they had ever heard of the illness, how it spreads from one person to another, whether it can be cured, and whether they would want to keep the information secret if a member of their family got TB. This information is useful in policy formulation and implementation of programs designed to combat and limit the spread of the disease. Table 3.8.1 Knowledge and attitude concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentages who know that TB is spread through the air by coughing, 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, Timor-Leste 2009-10 Background characteristic Among all women: Among women who have heard of TB: Percentage who have heard of TB Number of women Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of women Age 15-19 78.0 3,144 66.7 88.1 9.6 2,451 20-24 80.2 2,343 67.0 90.2 11.2 1,879 25-29 79.0 1,897 66.3 88.4 10.4 1,499 30-34 80.3 1,534 68.1 87.2 11.7 1,232 35-39 76.7 1,684 65.1 87.6 9.6 1,293 40-44 75.2 1,388 64.7 85.3 10.8 1,044 45-49 75.2 1,146 66.7 85.7 7.9 862 Residence Urban 88.0 3,439 59.5 85.7 17.5 3,027 Rural 74.6 9,698 69.4 88.8 7.2 7,233 District Aileu 73.8 554 64.4 87.2 0.9 409 Ainaro 70.5 619 65.4 80.8 14.7 436 Baucau 85.9 1,408 76.7 95.4 0.8 1,210 Bobonaro 68.4 1,262 63.8 87.4 24.8 864 Covalima 76.7 781 41.6 94.3 5.4 599 Dili 91.6 2,466 56.9 84.0 24.9 2,259 Ermera 62.0 1,542 98.7 99.3 3.1 955 Lautem 83.0 864 44.3 89.6 2.9 717 Liquiçá 59.6 801 70.4 87.8 6.1 478 Manatuto 80.9 603 81.1 93.0 5.8 488 Manufahi 89.7 470 88.9 96.6 0.9 422 Oecussi 90.0 884 62.4 60.2 2.9 796 Viqueque 71.1 882 62.5 93.0 5.1 627 Education No education 63.4 3,854 67.1 84.1 8.6 2,444 Primary 73.8 3,005 66.2 85.6 8.0 2,217 Secondary 88.6 5,829 65.8 90.6 11.2 5,167 More than secondary 96.4 449 72.0 88.2 20.1 433 Wealth quintile Lowest 67.7 2,314 60.1 80.5 5.4 1,568 Second 69.8 2,468 71.7 89.7 6.1 1,724 Middle 75.9 2,590 70.0 90.4 7.5 1,967 Fourth 80.7 2,687 69.3 90.9 8.9 2,167 Highest 92.1 3,077 62.1 86.9 18.3 2,834 Total 78.1 13,137 66.5 87.9 10.2 10,260 Characteristics of Respondents | 45 Tables 3.8.1 and 3.8.2 show the percentage of women and men who have heard of TB, and among those who have heard of it, their knowledge and attitudes concerning TB, according to background characteristics. TB awareness is very high in Timor-Leste, with 78 percent of women and 83 percent of men aware of it. Differences in awareness of TB by age are not prominent. Rural women and men are less likely to be aware of TB than their urban counterparts. Awareness of TB is lowest among women in Liquiçá and men in Ermera, and highest among women in Dili and men in Manatuto. Not surprisingly, awareness of TB rises with education and wealth quintile. Sixty-seven percent of women and 64 percent of men age 15-49 reported that TB is spread through the air when coughing or sneezing. Knowledge of the spread of TB through the air is higher in rural than urban areas among women, but among men, it is higher in urban than in rural areas. Surprisingly, almost all women who are aware of TB in Ermera are also aware of how it is spread and that it can be cured. Knowledge of how it is spread is lowest in Covalima, although nearly all women in Covalima who are aware of TB believe it can be cured. All men in Manatuto who are aware of TB are also aware of how it is spread and that it can be cured. There is little difference in the knowledge of how TB is spread by education among women, but among men knowledge increases markedly with education. There is no clear pattern between knowledge of how TB is spread and wealth quintile. Most respondents are aware that TB is curable. Eighty-eight percent of women, and 93 percent of men believe that TB can be cured. Women’s belief that TB can be cured varies minimally by education, wealth quintile, and place of residence. A relatively small percentage of women and men mention that they would want to keep a family member’s TB a secret. However, women are five times more likely than men to want to keep secret that a family member has TB (10 percent compared with 2 percent). Differences by age are not large, although the oldest cohort of women is least likely to want to keep this secret. More than twice as many women in urban as in rural areas want to keep a family member’s TB a secret. Among women, wanting to keep secret a family member’s TB is much higher in Dili and Bobonaro, and highest among the most educated and wealthiest women. Differences by background characteristics are not as marked among men. 46 | Characteristics of Respondents Table 3.8.2 Knowledge and attitude concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentages who know that TB is spread through the air by coughing, 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, Timor-Leste 2009-10 Background characteristic Among all men: Among men who have heard of TB: Percentage who have heard of TB Number of men Percentage who report that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of men Age 15-19 77.9 994 59.5 91.3 2.2 774 20-24 87.1 643 64.3 93.7 3.3 560 25-29 87.4 586 67.5 92.8 2.6 512 30-34 86.8 439 66.8 94.6 1.3 381 35-39 86.0 553 64.5 95.1 1.9 476 40-44 81.6 462 63.5 94.1 0.6 377 45-49 75.1 400 61.3 92.0 1.8 300 Residence Urban 94.3 1,102 76.6 95.9 2.9 1,039 Rural 78.7 2,974 57.9 92.0 1.7 2,340 District Aileu 71.3 181 77.8 79.9 0.9 129 Ainaro 90.9 217 41.6 83.9 0.3 197 Baucau 94.1 415 28.2 96.3 0.8 390 Bobonaro 85.4 357 11.3 81.1 9.3 304 Covalima 91.5 236 88.9 93.5 0.0 216 Dili 97.2 797 82.5 96.3 3.4 774 Ermera 39.5 491 47.2 95.2 1.0 194 Lautem 92.5 308 61.3 92.0 0.9 285 Liquiçá 63.3 252 78.1 91.6 0.5 159 Manatuto 99.7 190 100.0 100.0 0.0 189 Manufahi 63.9 137 98.7 99.4 0.0 88 Oecussi 95.7 235 66.5 98.0 1.1 225 Viqueque 87.5 260 77.5 96.9 1.0 228 Education No education 58.1 791 52.0 84.8 4.0 460 Primary 76.7 1,046 54.8 92.1 2.2 802 Secondary 94.0 2,009 67.4 95.1 1.5 1,888 More than secondary 99.7 230 87.1 98.5 2.2 230 Wealth quintile Lowest 77.0 728 59.7 92.0 1.4 561 Second 73.7 781 51.2 90.3 2.4 575 Middle 77.8 786 58.8 91.4 1.8 612 Fourth 85.8 849 63.2 95.1 2.0 729 Highest 96.9 932 77.6 95.5 2.6 903 Total 15-49 82.9 4,076 63.6 93.2 2.1 3,379 3.6 USE OF TOBACCO Smoking has negative effects on health and is associated with increased risk of lung and heart diseases. Women and men interviewed in the 2009-10 TLDHS were asked about their smoking habits. Table 3.9.1 and 3.9.2 show the percentages of women and men who smoke cigarettes or tobacco and the percent distributions of female and male cigarette smokers by number of cigarettes smoked in the preceding 24 hours, according to background characteristics. Use of tobacco is much more common among Timorese men than women. Sixty-six percent of men smoke cigarettes, while 25 percent consume other forms of tobacco, compared with just 3 percent of women who smoke cigarettes and 3 percent who consume other forms of tobacco. Use of tobacco is most common among older men, those living in rural areas, men with little or no education, and men in the lower wealth quintiles, with much of this difference due to the use of other tobacco. Use of tobacco varies little by background characteristics among women; however, it must be noted that 4 percent each of pregnant women and women currently breastfeeding use tobacco. Characteristics of Respondents | 47 Table 3.9.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics and maternity status, Timor-Leste 2009-10 Background characteristic Uses tobacco Does not use tobacco Number of women Number of cigarettes in the last 24 hours Total Number of cigarette smokers Cigarettes Pipe Other tobacco 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 0.4 0.0 0.2 99.6 3,144 * * * * * 100.0 11 20-24 1.8 0.1 0.7 98.1 2,343 (60.0) (20.9) (4.3) (6.4) (8.5) 100.0 42 25-29 2.2 0.0 1.7 97.2 1,897 (38.2) (38.6) (2.7) (13.3) (7.2) 100.0 42 30-34 2.7 0.2 2.6 95.7 1,534 48.3 32.0 8.0 11.7 0.0 100.0 42 35-39 4.9 0.1 4.8 92.3 1,684 52.6 21.7 14.4 11.3 0.0 100.0 82 40-44 6.4 0.1 7.3 89.0 1,388 53.7 26.2 13.2 4.2 2.7 100.0 89 45-49 6.5 0.4 10.2 86.4 1,146 44.4 31.2 11.0 13.4 0.0 100.0 75 Residence Urban 3.5 0.1 2.4 95.1 3,439 56.9 18.8 10.3 10.7 3.3 100.0 121 Rural 2.7 0.1 3.2 95.4 9,698 47.5 31.0 10.6 8.9 1.9 100.0 262 District Aileu 7.0 0.1 5.6 91.9 554 52.4 23.2 8.8 14.3 1.4 100.0 39 Ainaro 0.5 0.0 0.9 98.9 619 * * * * * 100.0 3 Baucau 1.3 0.0 1.5 97.6 1,408 * * * * * 100.0 18 Bobonaro 0.9 0.1 1.5 97.6 1,262 * * * * * 100.0 12 Covalima 1.2 0.0 4.1 95.0 781 * * * * * 100.0 9 Dili 3.4 0.1 1.8 95.7 2,466 64.3 16.2 7.3 7.3 4.9 100.0 83 Ermera 2.1 0.2 1.8 97.5 1,542 * * * * * 100.0 33 Lautem 4.2 0.4 3.1 93.2 864 (38.0) (46.6) (2.8) (7.0) (5.6) 100.0 37 Liquiçá 8.4 0.1 7.8 88.7 801 72.5 24.1 2.3 0.0 1.1 100.0 68 Manatuto 3.1 0.0 1.9 95.6 603 (58.8) (38.2) (0.0) (2.9) (0.0) 100.0 19 Manufahi 8.0 0.0 6.2 90.5 470 20.8 28.1 35.2 15.9 0.0 100.0 38 Oecussi 1.9 0.2 4.9 93.9 884 * * * * * 100.0 17 Viqueque 1.0 0.0 4.4 95.1 882 * * * * * 100.0 9 Education No education 4.9 0.2 6.8 90.9 3,854 45.2 30.8 10.1 13.1 0.9 100.0 188 Primary 3.4 0.1 2.9 94.9 3,005 56.8 26.6 10.0 2.9 3.7 100.0 103 Secondary 1.5 0.0 0.7 98.2 5,829 53.4 19.2 13.1 10.1 4.2 100.0 85 More than secondary 1.6 0.0 0.4 98.4 449 * * * * * 100.0 7 Maternity status Pregnant 2.8 0.0 2.1 96.3 899 (49.3) (23.0) (8.6) (11.2) (7.9) 100.0 26 Breastfeeding (not pregnant) 2.5 0.1 2.9 95.8 2,953 39.2 37.2 7.6 10.9 5.1 100.0 75 Neither 3.0 0.1 3.1 95.0 9,285 53.6 24.9 11.5 8.9 1.1 100.0 283 Wealth quintile Lowest 2.7 0.1 5.3 93.2 2,314 42.6 33.0 15.4 6.5 2.6 100.0 63 Second 3.6 0.1 3.8 94.7 2,468 43.8 32.2 9.2 12.7 2.0 100.0 89 Middle 2.9 0.2 3.0 95.6 2,590 54.1 26.1 9.6 8.8 1.3 100.0 76 Fourth 2.5 0.1 2.1 96.2 2,687 58.5 26.7 7.6 7.2 0.0 100.0 67 Highest 2.9 0.1 1.4 96.4 3,077 53.6 19.3 11.4 10.6 5.2 100.0 88 Total 2.9 0.1 3.0 95.3 13,137 50.5 27.2 10.5 9.5 2.3 100.0 383 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Among male cigarette smokers, two-fifths smoked 10 or more cigarettes, one-fourth smoked 3 to 5 cigarettes, one-fifth smoked 6 to 9 cigarettes, and one-eighth smoked 1 to 2 cigarettes in the 24 hours prior to the survey. Among women who smoked, half smoked just 1 to 2 cigarettes, one-fourth smoked 3 to 5 cigarettes, and one in ten smoked either 6 to 9 or 10 or more cigarettes in the past 24 hours. 48 | Characteristics of Respondents Table 3.9.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Timor-Leste 2009-10 Background characteristic Uses tobacco Does not use tobacco Number of men Number of cigarettes in the last 24 hours Total Number of cigarette smokers Cigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 34.9 0.2 9.4 63.7 994 0.3 21.6 39.6 17.4 21.2 0.0 100.0 347 20-24 73.1 0.0 20.2 25.1 643 0.0 11.4 32.1 20.5 36.0 0.0 100.0 470 25-29 84.2 0.0 25.3 13.2 586 0.5 10.0 23.3 21.7 44.5 0.0 100.0 494 30-34 79.4 0.0 30.0 15.8 439 1.4 9.6 23.2 19.3 46.5 0.0 100.0 349 35-39 72.4 0.4 32.2 23.0 553 1.0 9.0 23.5 22.7 43.7 0.1 100.0 400 40-44 72.0 0.4 38.8 20.7 462 1.0 12.6 22.8 22.5 41.1 0.0 100.0 332 45-49 71.7 0.3 43.9 20.1 400 0.7 15.1 21.7 18.8 43.7 0.0 100.0 287 Residence Urban 62.5 0.0 9.9 36.0 1,102 0.1 9.8 23.7 20.2 46.2 0.0 100.0 689 Rural 66.9 0.2 31.2 28.5 2,974 0.9 13.3 27.8 20.7 37.3 0.0 100.0 1,990 District Aileu 70.5 0.0 26.4 27.2 181 0.0 13.3 24.6 29.1 33.1 0.0 100.0 127 Ainaro 65.8 0.0 38.2 28.1 217 0.0 20.6 27.4 25.4 26.6 0.0 100.0 143 Baucau 69.7 0.4 8.9 28.7 415 0.0 4.6 34.3 29.1 32.1 0.0 100.0 289 Bobonaro 49.6 0.0 20.8 34.5 357 0.0 11.4 29.9 26.9 31.8 0.0 100.0 177 Covalima 72.5 0.0 21.3 25.6 236 0.0 17.1 51.3 16.8 14.8 0.0 100.0 171 Dili 62.5 0.0 5.7 37.3 797 0.0 6.4 22.4 20.8 50.4 0.0 100.0 498 Ermera 76.5 0.4 51.2 23.2 491 0.0 11.0 34.3 25.7 29.1 0.0 100.0 376 Lautem 48.5 0.3 7.5 51.3 308 0.0 6.3 15.1 21.1 57.5 0.0 100.0 149 Liquiçá 65.4 0.0 32.6 27.4 252 0.5 33.6 25.9 10.5 29.6 0.0 100.0 165 Manatuto 72.1 0.0 20.9 25.1 190 0.0 1.5 1.9 5.1 91.0 0.4 100.0 137 Manufahi 61.9 0.0 44.5 21.5 137 0.0 23.6 32.7 15.6 28.0 0.0 100.0 85 Oecussi 79.0 0.4 66.3 16.9 235 9.1 30.8 26.6 13.3 20.2 0.0 100.0 186 Viqueque 67.5 0.4 33.1 29.4 260 0.0 3.5 11.7 13.2 71.7 0.0 100.0 176 Education No education 70.9 0.5 51.5 18.6 791 1.3 15.2 25.2 23.0 35.3 0.0 100.0 560 Primary 72.5 0.1 34.6 23.3 1,046 1.0 12.0 27.9 20.7 38.3 0.1 100.0 758 Secondary 60.8 0.1 12.5 38.0 2,009 0.2 11.8 27.3 19.7 41.1 0.0 100.0 1,221 More than secondary 60.6 0.0 7.1 39.4 230 0.0 8.1 22.2 18.4 51.2 0.0 100.0 140 Wealth quintile Lowest 65.4 0.7 42.0 26.5 728 2.2 18.3 26.4 17.3 35.7 0.0 100.0 476 Second 67.5 0.0 38.8 26.9 781 0.7 15.3 27.6 22.3 34.1 0.0 100.0 527 Middle 67.5 0.0 28.3 28.2 786 0.2 12.7 30.3 24.4 32.4 0.0 100.0 531 Fourth 67.3 0.2 18.7 30.8 849 0.4 10.3 27.6 19.2 42.5 0.0 100.0 571 Highest 61.5 0.0 5.0 38.5 932 0.0 6.6 22.1 19.5 51.6 0.1 100.0 574 Total 15-49 65.7 0.2 25.4 30.5 4,076 0.7 12.4 26.7 20.6 39.6 0.0 100.0 2,679 Fertility | 49 FERTILITY 4 One of the major objectives of the 2009-10 TLDHS was to examine levels, trends and differentials in fertility in Timor-Leste. Fertility is one of the three principal components of population dynamics that determines the size and structure of the population of a country. Analysis in this chapter is based on birth histories collected from women age 15-49 who were interviewed during the survey. These women were asked the number of children living at home, children living elsewhere, and children who had died, in order to obtain the total number of live births that the women had in their lifetime. For each live birth, information was collected on the name, sex, age, and survival status of the child. For children who had died, age at death was recorded. Information from the birth history was then used to assess current and completed fertility and factors related to fertility, such as age at first birth, birth intervals, and adolescent childbearing. In addition to information on live births, the survey included questions pertaining to pregnancies in the past five years that did not result in a live birth, including the month and year the pregnancy ended and the duration of the pregnancy. This chapter analyzes the information collected in the 2009-10 TLDHS on current fertility and differentials by the background characteristics of the women. Trends in fertility and cumulative fertility in Timor-Leste are reported. The chapter also examines the length of birth intervals, age at first birth, and frequency of teenage pregnancy and motherhood. As is standard practice, the analysis of fertility presented here is based only on live births. 4.1 CURRENT FERTILITY The level of current fertility is one of the most important demographic indicators for determining the status of women in a society. Health and family planning policy makers are aware of its direct relevance to population policy and programs. Measures of current fertility are presented in Table 4.1 for the three-year period preceding the survey, corresponding roughly to the calendar years 2007-2009. A three-year period was chosen because it reflects the most current information, while also allowing the rates to be calculated on a sufficient number of cases so as not to compromise the statistical precision of the estimate. Several measures of fertility are shown in this table. Age-specific fertility rates (ASFRs)1, expressed as the number of births per thousand women in a specified age group, are calculated by dividing the number of live births to women in a specific age group by the number of woman-years lived in that age group. The total fertility rate (TFR) is the sum of the ASFRs and 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. 1 Numerators of the 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 (in 5-year groups) of the mother at the time of birth (determined by the mother’s date of birth). The denominators of the rates are the number of woman-years lived in each of the specified 5-year groups during the 1 to 36 months preceding the survey. Table 4.1 Current fertility Age-specific and total rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Timor-Leste 2009-10 Age group Residence Total Urban Rural 15-19 35 57 51 20-24 187 236 221 25-29 251 287 276 30-34 235 261 254 35-39 171 205 197 40-44 64 96 89 45-49 33 51 47 TFR (15-49) 4.9 6.0 5.7 GFR 153 183 175 CBR 33.1 33.2 33.2 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population 50 | Fertility The general fertility rate (GFR) is the number of live births occurring during a specified period per 1,000 women age 15-44. The crude birth rate (CBR) is the number of births per 1,000 population during a specified period. Table 4.1 shows the current fertility for Timor-Leste at the national level and by urban-rural residence. The total fertility rate for Timor-Leste for the three years preceding the survey is 5.7 births per woman and is the highest in South East Asia and Asia (together with Afghanistan) (PRB, 2010) but below the levels of Africa. At this level, it is estimated that the population will increase from its current size of 1.2 million to 1.9 million by the year 2025 and 3.2 million by the year 2050 (PRB, 2010). As expected, fertility is considerably higher in rural areas than in urban areas. Rural women have on average about one child more than urban women (6.0 compared with 4.9 births per woman). As the ASFRs show, the pattern of high rural fertility is prevalent in all age groups (Figure 4.1). The urban-rural difference in fertility is most pronounced for women age 20-24 (187 births per 1,000 women in urban areas versus 236 births per 1,000 women in rural areas). Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence Timor-Leste 2009-10 & & & & & & & $ $ $ $ $ $ $ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group 0 50 100 150 200 250 300 Births per 1,000 women Urban Rural Total$ & The overall age pattern of fertility as reflected in the ASFRs indicates that childbearing begins early. Fertility is low among adolescents and increases to a peak of 276 births per 1,000 among women age 25-29 and declines thereafter. 4.2 FERTILITY DIFFERENTIALS Table 4.2 presents the differentials in the total fertility rates, the percentage of women who are currently pregnant and the mean number of children ever born (CEB) to women age 40-49, by urban-rural residence, district, education, and wealth quintile. There are considerable differentials in fertility among districts, with fertility ranging from a low of 4.4 births per woman in Covalima to a high of 7.2 births per woman in Ainaro. The level of fertility is inversely related to women’s educational attainment, decreasing rapidly from 6.1 births among women with no education to 2.9 births among women with more than secondary education. Fertility is also inversely associated with wealth quintile. Women in the lowest wealth quintile have an average of 7.3 births, about three children more than women in the highest quintile (4.2 births). Fertility | 51 Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Timor- Leste 2009-10 Background characteristic Total fertility rate Percentage women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 4.9 7.1 5.5 Rural 6.0 6.7 5.9 District Aileu 5.6 5.4 6.3 Ainaro 7.2 8.4 6.7 Baucau 5.5 6.1 5.0 Bobonaro 6.0 5.4 6.0 Covalima 4.4 5.8 5.5 Dili 4.6 6.9 5.4 Ermera 6.6 6.8 6.9 Lautem 6.7 8.6 6.5 Liquiçá 5.5 7.0 6.5 Manatuto 5.5 6.6 5.8 Manufahi 5.9 8.8 5.5 Oecussi 6.6 7.0 5.4 Viqueque 5.6 7.7 5.3 Education No education 6.1 6.7 6.0 Primary 6.5 7.7 6.2 Secondary 5.2 6.4 5.2 More than secondary 2.9 8.3 3.1 Wealth quintile Lowest 7.3 6.9 5.9 Second 6.0 7.8 6.0 Middle 6.1 7.0 5.9 Fourth 5.3 6.4 6.0 Highest 4.2 6.3 5.3 Total 5.7 6.8 5.8 Note: Total fertility rates are for the period 1-36 months prior to interview. Table 4.2 also presents a crude assessment of trends in the various subgroups by comparing current fertility with a measure of completed fertility: the mean number of children ever born to women age 40-49. The mean number of children ever born to older women who are nearing the end of their reproductive period is an indicator of average completed fertility of women who began childbearing three decades before the survey. If fertility remained constant over time, and the reported data on both children ever born and births during the three years preceding the survey are reasonably accurate, the TFR and the mean number of children ever born for women 40-49 are expected to be similar. When fertility levels have been falling, the TFR will be substantially lower than the mean number of children ever born among women age 40-49. The comparison between the two measures suggests that overall fertility has remained constant in the past few decades, because the TFR in the three years preceding the survey and the mean number of children ever born to women 40-49 are similar (5.7 and 5.8, respectively). However, it is interesting to note that there are marked differences between the two measures by background characteristics. While there has been little difference in rural fertility, urban fertility has fallen by 0.6 births over the last few decades. This decline is not reflected in the overall fertility because the urban population is much smaller than the rural population, and overall fertility is therefore more likely to reflect fertility in rural areas. There has been a notable decline in fertility in the last few decades in Aileu, Covalima, Dili, and Liquiçá and smaller declines in Ermera and Manatuto. On the other hand, fertility has increased markedly in Ainaro, Baucau, and Oecussi, with smaller increases in Lautem, Manufahi, and Viqueque. No changes were seen in Bobonaro. Increases in fertility were also observed among women with little to no education and women in the lowest wealth quintile. 52 | Fertility The percentage of women who reported being pregnant at the time of the survey is also presented in Table 4.2. This percentage may be underreported since women may not be aware of a pregnancy, especially at the very early stages, while some women who are early in their pregnancy may not want to reveal that they are pregnant. Seven percent of women were pregnant at the time of the survey. Urban women were more likely to be pregnant than rural women. Current pregnancy is highest in Manufahi and Lautem. The proportion of women currently pregnant varies by women’s education, but the pattern is unclear and is highest among women with more than secondary education. The percentage currently pregnant ranges from 6 percent among women in the highest wealth quintile to a high of 8 percent among women in the second wealth quintile. 4.3 FERTILITY TRENDS Trends in fertility over time can also be examined by comparing age-specific fertility rates from the TLDHS 2009-10 for successive five-year periods preceding the survey, as presented in Table 4.3. Because women age 50 and older were not interviewed in the survey, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 35-39 for the period 15 to 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. Table 4.3 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, Timor-Leste 2009-10 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 54 75 80 85 20-24 224 271 251 226 25-29 284 313 295 273 30-34 257 294 270 [274] 35-39 200 230 [238] 40-44 97 [165] 45-49 [48] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. Table 4.3 shows that the ASFRs in the 0 to 4 years before the survey for women age 20-34 (the peak childbearing years) are very similar to what they were in the 15 to 19 years before the survey and mirror somewhat the pattern seen in Table 4.2. The results also show that fertility over the past two decades has dropped uniformly only among women age 15-19 and 35-39. Among women age 20-24, fertility increased substantially from the period 15 to 19 years before the survey to the period 5 to 9 years before the survey, with the ASFR in the most recent five years similar to what it was two decades ago. A similar trend is seen among women age 25-29, with fertility in the most recent five-year period slightly higher than what it was two decades ago. An increase in fertility is also observed among women age 30-34 in the 5 to 9 years before the survey from the ASFR observed 10 to 14 years ago. The marked increase in fertility, particularly in the 5-9 years before the survey, which corresponds to the years 1999-2000 to 2003-04, can be attributed to the virtual collapse of the overall health system, and particularly the family planning program, following the struggle for independence from Indonesia and the ensuing chaos. Table 4.4 and Figure 4.2 compare fertility trends seen in the 2009-10 data with estimates obtained in earlier surveys conducted in the country. The TFR estimated from the 2003 DHS is 7.8 children per woman. It is unclear if this estimate is based on a denominator that adjusts for the fact that the survey only interviewed ever-married women. If it did not, then it is likely that the estimate of 7.8 may be higher than what it would have been, and the 2-child decline in fertility between the two surveys may in fact be less. Nevertheless, it is important to point out that the trend in ASFRs Fertility | 53 calculated in the 2003 DHS follows closely the trend in the ASFRs found in the TLDHS and corroborates the findings of the spike in TFR in the period immediately following the withdrawal of Indonesia. The 2002 MICS survey provides an indirect measure of TFR at 7.4 children per woman in the 12 months preceding the survey. This is high compared with the 1997 IDHS, in which the TFR was estimated at 4.4 children per woman among all women. Table 4.4 Trends in fertility Age-specific fertility rates (per 1,000 women) and total fertility rates (TFR), Timor- Leste 2009-10 Age group 2009-10 TLDHS (2007-2009) 2003 DHSa (2001-2003) 2002 MICSb (2001-2002) 1997 IDHSc (1995-1997) 15-19 51 78 80 u 20-24 221 322 319 u 25-29 276 362 355 u 30-34 254 329 290 u 35-39 197 260 245 u 40.44 89 138 118 u 45-49 47 66 68 u TFR 5.7 7.8 7.4 4.4 u = unavailable a MOH et al., 2004 p. 70 b UNICEF, 2003 p. 72. Based on indirect estimates for the 12 months preceding the survey. c CBS, NFPCB, MOH, and Macro International, 1998 p. 39. ASFRs for Timor- Leste are not published in this report. Figure 4.2 Trends in Total Fertility Rates 1995-2010 4.4 7.4 7.8 5.7 1995-1997 (1997 IDHS) 2001-2002 (2002 MICS) 2001-2003 (2003 DHS) 2007-2009 (2009-10 TLDHS) Survey 0 2 4 6 8 10 Children per woman Timor-Leste 2009-10 Many factors may have contributed to the decline in fertility in the most recent five-year period. The relative political stability following the 1999 and 2006 crises and the return of people from remote rural areas to semi-urban or urban areas may have exposed them to social and economic influences encouraging smaller families. Furthermore, exposure to family planning messages through the mass media, and wider and easier access to modern family planning methods not previously available in Timor-Leste may also have had an impact. 54 | Fertility 4.4 CHILDREN EVER BORN AND SURVIVING Data on the number of children ever born reflect the accumulation of births over the past 30 years and therefore have limited relevance to current fertility levels, particularly when the country has experienced a decline in fertility. Moreover, the data are subject to recall error, which is typically greater for older than for younger women. Nevertheless, the information on children ever born (or parity) increases our understanding of a number of issues. The parity data show how average family size varies across age groups. The percentage of women in their forties who have never had children also provides an indicator of the level of primary infertility or the inability of women to bear children. Comparison of the differences in the mean number of children ever born and surviving reflects the cumulative effects of mortality levels during the period in which women have been bearing children. Table 4.5 shows the percent distribution of all women and currently married women by number of children ever born, mean number of children ever born, and mean number of children living. More than nine in ten women age 15-19 (94 percent) have never given birth. However, this proportion declines to one in five (21 percent) among women age 25-29 and to less than 10 percent among women age 30 and above, indicating that childbearing among Timorese women is very high. On average, Timorese women nearing the end of their reproductive years have attained a parity of about 6 children. Table 4.5 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Timor-Leste 2009-10 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 94.3 4.4 1.0 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 3,144 0.07 0.07 20-24 56.2 18.7 14.9 7.7 1.9 0.6 0.0 0.0 0.0 0.0 0.0 100.0 2,343 0.82 0.77 25-29 21.2 12.6 20.2 19.1 15.9 7.3 2.9 0.6 0.1 0.1 0.0 100.0 1,897 2.34 2.16 30-34 9.5 6.2 8.4 15.6 18.6 17.5 13.7 5.9 3.0 1.2 0.3 100.0 1,534 3.94 3.56 35-39 7.7 2.8 5.6 9.1 15.0 14.3 15.8 12.5 9.0 5.4 2.8 100.0 1,684 5.04 4.50 40-44 5.6 3.5 4.8 6.9 10.6 11.5 15.6 13.0 11.1 7.2 10.1 100.0 1,388 5.80 5.06 45-49 7.8 2.7 4.6 7.1 8.7 11.5 13.7 13.2 11.2 7.8 11.8 100.0 1,146 5.86 5.07 Total 39.0 7.9 8.4 8.5 8.6 7.3 6.9 4.9 3.7 2.3 2.5 100.0 13,137 2.73 2.44 CURRENTLY MARRIED WOMEN 15-19 32.1 51.6 12.7 3.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 243 0.88 0.83 20-24 10.3 37.4 30.8 16.2 4.0 1.2 0.0 0.0 0.0 0.0 0.0 100.0 1,100 1.70 1.60 25-29 5.4 13.7 24.4 23.3 19.6 9.0 3.6 0.8 0.2 0.1 0.0 100.0 1,516 2.85 2.64 30-34 3.0 5.6 8.2 16.7 20.4 19.3 15.0 6.6 3.4 1.3 0.4 100.0 1,362 4.29 3.88 35-39 2.9 1.8 5.1 9.6 15.9 15.2 17.5 13.4 9.9 5.7 3.0 100.0 1,514 5.41 4.84 40-44 1.8 2.8 4.5 7.0 10.1 11.7 16.8 13.8 12.3 8.1 11.1 100.0 1,211 6.19 5.42 45-49 4.6 2.1 3.8 6.4 9.2 11.4 14.5 13.7 12.7 8.5 13.3 100.0 960 6.25 5.40 Total 5.4 11.4 12.9 13.4 13.6 11.3 11.0 7.6 5.9 3.6 3.9 100.0 7,906 4.29 3.84 The same pattern is replicated for currently married women, except that the mean number of children ever born is higher for currently married women (4.3 children) than for all women (2.7 children). The difference between all women and currently married women in the mean number of children ever born is due to a substantial proportion of young and unmarried women in the former category who exhibit lower fertility. As expected, the mean number of children ever born and mean number of children surviving rise with the increasing age of women. Comparison of the mean number of children ever born with the mean number of living children reveals the experience of child loss among Timorese women. By the end of their reproductive years (age 45-49), women in Timor-Leste have given birth, on average, to 5.9 children, with 5.1 surviving. Voluntary childlessness is uncommon in Timor-Leste, and currently married women with no children are likely to be those who are sterile or unable to bear children. The level of childlessness among married women at the end of their reproductive period can be used as an indicator of the level Fertility | 55 of primary sterility. In Timor-Leste, primary sterility among older currently married women (45-49) is around 5 percent. 4.5 BIRTH INTERVALS A 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 an increased risk of death for the mother and baby, particularly when the birth interval is less than 24 months. Table 4.6 shows the percent distribution of non-first births in the five years preceding the survey by number of months since the preceding birth, according to background characteristics. The median birth interval in Timor-Leste is 29 months. The median number of months since a preceding birth increases markedly with age, from a low of 25.5 months among mothers age 15-19 to a high of 33.9 months among mothers age 40-49. There is no notable difference in the length of the median birth interval by birth order or sex of the preceding birth. Table 4.6 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Timor-Leste 2009-10 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 (17.0) (26.8) (46.0) (7.2) (1.1) (1.9) 100.0 48 25.5 20-29 12.1 25.5 42.6 13.1 4.5 2.3 100.0 2,829 26.3 30-39 7.7 17.9 38.6 18.3 8.3 9.2 100.0 3,847 30.4 40-49 5.7 16.4 33.0 20.6 9.6 14.7 100.0 1,414 33.9 Birth order 2-3 9.7 23.6 39.5 14.5 5.6 7.1 100.0 2,954 27.8 4-6 8.7 18.2 37.6 18.0 8.2 9.3 100.0 3,389 30.1 7+ 8.0 19.0 41.0 18.4 7.8 5.8 100.0 1,796 29.3 Sex of preceding birth Male 8.9 19.4 39.4 16.9 7.0 8.4 100.0 4,134 29.3 Female 9.0 21.4 38.6 16.7 7.4 7.0 100.0 4,005 28.6 Survival of preceding birth Living 7.9 20.1 39.6 17.3 7.4 7.7 100.0 7,529 29.3 Dead 21.5 23.3 32.4 11.0 4.4 7.5 100.0 609 25.1 Residence Urban 11.4 20.6 32.8 17.8 7.4 10.0 100.0 1,912 29.2 Rural 8.2 20.3 40.9 16.5 7.1 7.0 100.0 6,226 28.9 District Aileu 7.0 22.9 40.3 17.4 6.9 5.6 100.0 296 28.9 Ainaro 10.4 25.2 41.7 13.2 4.6 5.0 100.0 495 27.2 Baucau 6.4 22.3 39.5 16.7 7.2 7.8 100.0 810 28.7 Bobonaro 9.1 20.4 39.0 14.2 8.6 8.8 100.0 755 29.4 Covalima 6.4 14.1 34.1 22.8 10.7 12.0 100.0 361 34.2 Dili 12.9 21.3 29.9 17.9 7.6 10.4 100.0 1,334 28.8 Ermera 10.3 19.8 42.2 15.0 6.3 6.3 100.0 1,060 27.8 Lautem 5.8 18.1 49.8 15.6 5.8 4.8 100.0 644 28.8 Liquiçá 10.3 18.8 41.6 16.3 6.8 6.2 100.0 472 29.4 Manatuto 8.6 21.0 44.3 13.3 6.0 6.8 100.0 351 28.3 Manufahi 9.2 20.7 44.2 15.4 5.3 5.1 100.0 310 27.6 Oecussi 5.4 16.5 36.1 21.4 9.7 11.0 100.0 679 32.5 Viqueque 8.2 22.2 37.1 19.9 6.9 5.7 100.0 572 28.7 Education No education 7.6 20.0 39.5 17.0 7.3 8.6 100.0 2,938 29.5 Primary 8.9 19.2 41.2 17.0 6.6 7.2 100.0 2,368 28.8 Secondary 10.5 21.8 36.8 16.4 7.5 6.9 100.0 2,687 28.4 More than secondary 5.8 18.6 35.6 19.1 6.8 14.2 100.0 145 31.9 Wealth quintile Lowest 7.6 20.3 39.5 18.8 6.7 7.1 100.0 1,812 29.6 Second 7.7 21.8 41.3 16.1 6.5 6.6 100.0 1,634 28.6 Middle 9.2 19.1 42.1 15.6 6.7 7.3 100.0 1,613 28.6 Fourth 10.0 20.5 40.5 14.3 7.4 7.4 100.0 1,538 28.1 Highest 10.5 20.0 31.3 19.0 8.7 10.4 100.0 1,542 30.7 Total 8.9 20.3 39.0 16.8 7.2 7.7 100.0 8,139 29.0 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. Figures in parentheses are based on 25-49 unweighted cases. 56 | Fertility Studies have shown that the death of a preceding child leads to a shorter birth interval than when the preceding child survived. The median birth interval is four months shorter among births for which the previous sibling is dead than among births in which the previous sibling is alive (25.1 months and 29.3 months, respectively). This difference in the birth intervals may be due to the desire of parents to replace a dead child as well as the loss of the fertility-delaying effects of breastfeeding. There are no marked differences in the median birth intervals by urban-rural residence, education of mother or wealth status of households. However, the median birth interval is noticeably higher in Covalima and Oecussi than in the other districts. 4.6 AGE AT FIRST BIRTH The onset of childbearing at an early age has a major effect on the health of both mother and child. It also lengthens the reproductive period, thereby increasing the level of fertility. Table 4.7 shows the median age at first birth and the percentage of women who gave birth by exact ages, by five-year age cohorts. Table 4.7 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Timor-Leste 2009-10 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 0.4 na na na na 94.3 3,144 a 20-24 0.7 8.8 24.4 na na 56.2 2,343 a 25-29 1.5 12.9 30.2 49.4 69.5 21.2 1,897 22.1 30-34 2.4 14.6 31.1 51.0 74.8 9.5 1,534 21.9 35-39 2.4 13.3 28.6 47.0 69.1 7.7 1,684 22.4 40-44 2.5 16.0 30.6 46.1 67.6 5.6 1,388 22.5 45-49 2.0 10.9 23.3 38.2 58.5 7.8 1,146 23.6 25-49 2.1 13.6 29.1 46.9 68.5 11.0 7,650 22.4 na = Not applicable a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Childbearing begins early in Timor-Leste. The median age at first birth is 22.1 years for the youngest cohort (age 25-29) of women for whom a median age can be computed, and the median age varies between 21.9 among women age 30-34 and 23.6 years among women 45-49. Fourteen percent of Timorese women have given birth before reaching age 18, while nearly half have had a birth by age 22. More than two-thirds of Timorese women have become mothers by age 25. Table 4.8 shows the median age at first birth by background characteristics. The median age at first birth is slightly higher in urban areas than in rural areas. The urban-rural difference is widest among women age 45-49. The median age at first birth is lowest among women in Covalima (21.3 years) and highest among women in Baucau (24.0 years). It is higher among women with secondary education than among women with no education. Fertility | 57 Table 4.8 Median age at first birth Median age at first birth among women age 25-49 years, according to background characteristics, Timor-Leste 2009-10 Background characteristic Current age Women age 25-49 25-29 30-34 35-39 40-44 45-49 Residence Urban 22.4 22.8 23.5 22.3 22.7 22.7 Rural 22.0 21.5 22.1 22.6 24.0 22.3 District Aileu 21.8 20.9 21.8 23.0 22.7 22.0 Ainaro 21.7 21.0 23.2 22.7 24.7 22.4 Baucau 23.4 21.8 23.7 24.5 27.6 24.0 Bobonaro 22.9 21.1 22.2 22.2 23.6 22.4 Covalima 20.5 20.5 21.3 21.9 23.5 21.3 Dili 22.6 23.1 24.1 22.4 22.7 23.0 Ermera 22.5 21.7 21.4 21.6 23.5 21.9 Lautem 21.7 21.9 21.7 21.7 22.9 21.9 Liquiçá 23.2 20.9 21.6 21.6 22.9 21.9 Manatuto 22.0 22.8 23.3 22.5 22.9 22.7 Manufahi 21.9 21.5 21.9 22.8 24.1 22.1 Oecussi 20.5 20.8 22.0 22.5 21.3 21.5 Viqueque 21.0 21.9 22.9 24.0 25.2 22.7 Education No education 21.7 21.1 21.9 22.3 23.5 22.2 Primary 20.7 20.9 21.5 21.5 22.9 21.3 Secondary 22.6 22.5 23.5 23.8 26.4 23.0 More than secondary a 26.2 27.4 29.9 23.2 a Wealth quintile Lowest 21.1 21.1 22.4 23.5 26.1 22.5 Second 22.2 21.3 22.1 22.5 24.1 22.2 Middle 22.5 21.6 21.8 22.2 23.2 22.2 Fourth 22.2 22.1 21.7 21.9 22.5 22.1 Highest 22.4 22.8 23.8 22.4 23.0 22.9 Total 22.1 21.9 22.4 22.5 23.6 22.4 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 4.7 ADOLESCENT PREGNANCY AND MOTHERHOOD Early teenage pregnancy can cause severe health problems for both the mother and child. Moreover, an early start to childbearing greatly reduces the educational and employment opportunities of women and is associated with higher levels of fertility. Table 4.9 shows the percentage of women age 15-19 who have had a live birth, the percentage who are pregnant with their first child and the combined percentage of those who have begun childbearing, by background characteristics. Seven percent of women age 15-19 have already had a birth or are pregnant with their first child. The percentage of women who have begun childbearing increases rapidly with age, from 1 percent among women age 15 to 20 percent among women age 19. Rural women are more than twice as likely as urban women to have begun childbearing early. Adolescent childbearing is lowest in Dili (2 percent) and highest in Oecussi (16 percent). Teenage pregnancy is also markedly higher among women with little or no education (13 to 16 percent) than among mothers with secondary or higher levels of education. The percentage of teenagers who have begun childbearing is also relatively higher among those in the lowest three wealth quintiles compared with those in the highest two wealth quintiles. 58 | Fertility Table 4.9 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child and percentage who have begun childbearing, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 0.2 0.8 1.0 718 16 1.4 0.8 2.3 636 17 2.3 1.4 3.7 626 18 8.6 2.9 11.5 607 19 18.0 2.3 20.3 557 Residence Urban 2.9 0.8 3.7 771 Rural 6.6 1.8 8.4 2,373 District Aileu 3.9 0.7 4.6 161 Ainaro 5.3 2.8 8.1 154 Baucau 4.5 1.9 6.4 341 Bobonaro 9.9 1.0 10.9 329 Covalima 8.3 1.2 9.5 222 Dili 1.6 0.4 2.0 506 Ermera 4.6 0.8 5.3 398 Lautem 5.4 2.0 7.4 211 Liquiçá 4.4 1.6 6.0 190 Manatuto 7.5 1.7 9.2 161 Manufahi 6.1 2.4 8.4 96 Oecussi 13.3 2.5 15.8 179 Viqueque 4.8 5.2 10.0 197 Education No education 11.1 2.1 13.2 370 Primary 12.4 3.1 15.5 626 Secondary 2.8 1.1 3.8 2,138 More than secondary * * * 11 Wealth quintile Lowest 7.1 2.0 9.1 551 Second 7.3 2.0 9.3 589 Middle 7.3 1.8 9.1 645 Fourth 4.8 1.7 6.5 664 Highest 2.5 0.5 3.0 695 Total 5.7 1.6 7.2 3,144 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Family Planning | 59 FAMILY PLANNING 5 In 2002, the Council of Ministers for Timor-Leste developed and approved the first family planning policy for the country (MOH, 2004a). Despite the presence of this policy, reproductive choice remains a relatively new concept for families in Timor-Leste. Findings from the 2009-10 TLDHS suggest that the total fertility ratio (TFR) of 5.7 children per women in Timor-Leste is the highest in South East Asia and also in Asia, where the rank is shared with Afghanistan (PRB, 2010). This high total fertility rate has immediate and serious implications for childbearing women and the health care system. The ability to provide quality reproductive health services will be severely compromised because existing resources are scarce, and high fertility will only increase these demands on the system. According to the International Conference on Population and Development (ICPD) Program of Action, family planning programs must enable couples and individuals to decide freely and responsibly the number and spacing of their children; to provide individuals and couples with the information and means to make these decisions; to ensure informed choices; and to make available a full range of safe and effective family planning methods (MOH, 2004a). Family planning continues to be a priority of the National Reproductive Health Strategy 2004–2015. The objectives of the National Family Planning Program are (1) to reduce the population growth rate gradually by promoting the concept of a small family norm to the population in general and to the rural population in particular; (2) to increase the availability of and the demand for family planning services; (3) to provide quality services; and (4) to reduce unmet need for services (MOH, 2004b). The National Family Planning Program also aims to expand and sustain adequate family planning services at the community level utilizing all health facilities. To achieve this, family planning services are being offered at integrated community health service (SISCa) posts. These are mobile outreach services that provide integrated care, including health promotion, on a monthly basis, in almost every suco in the country. Health facilities have been encouraged to play a more effective role in the national family planning program. The Ministry of Health (MOH) plans to train health care providers in not only the technical and managerial aspects of contraception but also in appropriate interpersonal communication and counseling skills. Contraceptive services will be provided as part of primary health care. Advice on natural methods (standard days method and lactational amenorrhea method) as well as the provision of condoms, pills, and injectables will be provided at the health post level; implants and IUDs will be available at level two community health centers with beds (CHC-2); and sterilization will be available at referral hospitals and higher level health centers that have appropriate equipment and trained staff. Specific strategies will be developed to cover areas of unmet demand for family planning, particularly for older mothers still of childbearing age. This chapter evaluates the level of knowledge of various contraceptive methods and discusses past and current prevalence of use. For users of periodic abstinence (rhythm method), knowledge of the ovulatory cycle is examined, and for those relying on sterilization, the timing of the method of adoption is reviewed. Special attention is focused on the source of contraception, informed choice, non-use, and intention to use contraceptive methods in the future. The chapter also contains information on exposure to family planning messages through the media, contact with family planning providers, and a husband’s knowledge of his wife’s use of contraception. These topics are of practical use to policy and program administrators to formulate effective family planning strategies. Although the chapter focus is on women, results from the survey of men are also presented because men play an important role in the realization of reproductive goals. Wherever possible, comparisons are made with findings from previous surveys in order to evaluate progress in family planning in Timor-Leste over time. 60 | Family Planning 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Knowledge of contraceptive methods is an important precursor to use. The ability to spontaneously name or recognize a family planning method when described is a simple test of a respondent’s familiarity with a method but is not necessarily an indication of the comprehensiveness of their knowledge. Information on knowledge of contraception was collected by first asking a respondent to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method spontaneously, the interviewer described the method and asked whether the respondent recognized it. The survey collected information on eleven modern family planning methods—female and male sterilization, the pill, the IUD, injectables, implants, female and male condoms, lactational amenorrhea method (LAM), emergency contraception, the standard days method, and two traditional methods—rhythm method and withdrawal. Folk methods, such as use of plants and herbs, could be mentioned spontaneously by respondents. In Table 5.1, information about knowledge of specific contraceptive methods is presented for all women and men as well as for currently married women and men and for sexually active unmarried men. Findings from the 2009-10 TLDHS show that 78 percent of currently married women and 66 percent of currently married men in Timor-Leste know of at least one modern method of family planning. The most widely known modern contraceptive methods among currently married women are injectables (70 percent) and the pill (58 percent). Currently married men are most likely to know of the male condom (54 percent) and injectables (46 percent). Twenty-seven percent of currently married men mentioned knowledge of a traditional method compared with 22 percent of currently married women. Sexually active unmarried men are most knowledgeable about the male condom (90 percent) followed by injectables (55 percent). The pattern of knowledge for all women and men is similar to that described for currently married women and men. The mean number of methods known is slightly higher among married women (3.3) than among married men (3.0). Table 5.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who know any contraceptive method, by specific method, Timor-Leste 2009-10 Method Women Men All women Currently married women All men Currently married men Sexually active unmarried men1 Any method 71.4 78.1 66.4 66.6 92.8 Any modern method 71.1 77.7 66.1 66.4 92.1 Female sterilization 20.0 23.9 21.2 26.8 31.7 Male sterilization 4.0 4.8 8.7 11.3 13.6 Pill 50.1 57.6 33.1 40.3 47.7 IUD 28.1 35.9 15.7 20.6 21.3 Injectables 61.2 70.3 36.0 45.5 55.3 Implants 31.5 40.0 19.3 25.3 35.4 Male condom 27.7 26.2 58.0 53.7 90.4 Female condom 10.4 10.1 10.4 11.1 15.3 Lactational amenorrhea (LAM) 7.0 9.5 4.8 7.1 0.4 Emergency contraception 3.2 4.0 3.7 5.2 2.2 Standard days method 13.2 16.8 9.8 14.6 6.8 Any traditional method 16.9 21.7 23.1 27.4 54.9 Rhythm 13.2 17.0 8.3 12.5 6.1 Withdrawal 7.7 10.2 19.4 21.7 54.6 Folk method 2.7 3.8 3.3 5.1 0.0 Mean number of methods known by respondents 15-49 2.8 3.3 2.5 3.0 3.8 Number of respondents 13,137 7,906 4,076 2,158 215 Note: There are too few sexually active unmarried women to analyze their knowledge separately. 1 Had last sexual intercourse within 30 days preceding the survey Family Planning | 61 According to the 2003 DHS, knowledge of contraception for ever-married women and men was 38 percent and 30 percent, respectively. These percentages are not exactly comparable to the 2009-10 TLDHS; they also include knowledge among women and men who are widowed and divorced, and as such may be slightly inflated. Nevertheless, it is important to note that over the past seven years there has been a considerable increase in the overall knowledge of contraceptive methods in the country. This increase in knowledge may be attributed to the successful dissemination of family planning messages through the mass media and, to a lesser degree, through service providers in family planning and reproductive health. 5.2 KNOWLEDGE OF CONTRACEPTIVE METHODS BY BACKGROUND CHARACTERISTICS The study of differentials in knowledge of contraceptive methods by background characteristics is important because it helps to identify subgroups of the population to target for family planning services. Table 5.2 presents, by background characteristics, the percentages of currently married women and men who have heard of any method and any modern method of family planning. Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women and currently married men age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method by background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Heard of any method Heard of any modern method1 Number of women Heard of any method Heard of any modern method1 Number of men Age 15-19 70.4 70.4 243 * * 4 20-24 77.3 77.2 1,100 66.4 66.4 125 25-29 82.3 82.1 1,516 69.0 69.0 359 30-34 83.3 82.8 1,362 73.8 73.0 368 35-39 78.3 78.2 1,514 70.1 70.1 492 40-44 77.1 76.5 1,211 61.2 61.1 433 45-49 68.2 67.2 960 58.9 58.7 378 Residence Urban 88.7 88.3 2,025 84.0 83.6 567 Rural 74.5 74.1 5,881 60.4 60.2 1,592 District Aileu 68.8 68.7 299 59.6 59.6 92 Ainaro 57.8 57.4 382 51.4 50.7 101 Baucau 56.2 55.8 852 31.2 31.0 237 Bobonaro 78.8 78.3 739 87.6 87.6 170 Covalima 95.5 95.5 458 92.8 92.8 123 Dili 92.9 92.6 1,459 87.5 87.0 416 Ermera 72.1 71.3 881 17.5 17.5 233 Lautem 88.0 87.6 541 87.1 87.1 163 Liquiçá 76.2 75.6 460 75.0 75.0 124 Manatuto 74.8 74.6 353 100.0 100.0 96 Manufahi 78.6 77.8 319 38.9 37.4 77 Oecussi 95.1 94.9 603 91.2 91.2 165 Viqueque 61.8 61.8 559 47.2 47.2 159 Education No education 66.0 65.5 2,909 40.5 40.3 523 Primary 80.3 79.8 2,027 62.4 62.4 650 Secondary 87.9 87.6 2,739 81.4 81.0 853 More than secondary 96.5 96.5 231 94.3 94.3 132 Wealth quintile Lowest 65.5 65.0 1,467 57.2 56.9 413 Second 67.9 67.1 1,487 48.5 48.5 408 Middle 76.7 76.6 1,559 62.3 62.3 411 Fourth 84.3 83.9 1,571 72.1 71.5 447 Highest 92.5 92.4 1,821 88.4 88.3 479 Total 15-49 78.1 77.7 7,906 66.6 66.4 2,158 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, diaphragm, foam or jelly, lactational amenorrhea method (LAM), standard days method, and emergency contraception 62 | Family Planning Knowledge of a modern method rises from 70 percent among currently married women age 15-19 to a peak at 83 percent among those age 30-34 and then declines to 67 percent among the oldest cohort of women. Currently married women in urban areas (88 percent) are more likely to have heard about a modern method of family planning than rural women (74 percent), perhaps reflecting the wider availability and easier access to methods in urban than in rural areas as well as better penetration of mass media and higher literacy in urban areas. Knowledge of a modern method varies widely by district and ranges from a low of 56 percent of currently married women in Baucau to a high of 96 percent in Covalima. Knowledge rises with level of education, from 66 percent among women with no education to 97 percent among women with more than secondary education. Similarly, there is a direct relationship between knowledge and wealth quintile, with knowledge rising from 65 percent of currently married women in the poorest households to 92 percent of women in the richest households. Currently married men exhibit a similar pattern in knowledge by background characteristics, with the exception of knowledge by district, where men in Ermera are least likely to know of a modern method (18 percent) in contrast with men in Manatuto who have universal knowledge of contraceptives. 5.3 EVER USE OF CONTRACEPTION Data on ever use of contraception has special significance because it reveals the cumulative success of programs promoting the use of family planning among couples. Ever use refers to use of a method at any time, with no distinction between past and present use. In the 2009-10 TLDHS, respondents who had heard of a method of family planning were asked if they had ever used a method. Table 5.3.1 shows the percentage of all women and currently married women who have ever used family planning by specific method and age. Thirty-two percent of currently married women have ever used a method of contraception, and 30 percent have ever used a modern method. Among currently married women, nearly one in four has ever used injectables, making it the most commonly used modern method. Four percent of currently married women have used the pill, and 2 percent each have used the IUD or implants. About 3 percent of currently married women report having used traditional methods. Ever use of contraception varies with women’s age. The pattern of ever use is curvilinear, with use being lowest among women in the youngest age group (15-19), increasing with age, and reaching a plateau among women in their thirties before declining thereafter. The level of ever-use of any modern method among currently married women rises to a high of 35 percent among those age 30-39 and then declines to 24 percent among women age 45-49. Ever-use among all women follows a similar pattern. The 2009-10 TLDHS collected information on ever use of contraception for men but with respect to five male methods only: male sterilization, condoms, standard days method, rhythm method, and withdrawal. As evident in Table 5.3.2, fewer than one in ten currently married men age 15-49 (9 percent) has ever used a method, with most having used a modern method (6 percent). Ever- use is highest among sexually active unmarried men, with nearly one in two men having ever used a method. Among currently married men, the condom is the most commonly used method (3 percent), and they are much more likely to report ever-use of condoms than women. Two percent of currently married men reported having used the standard days method. There is no clear pattern between ever- use and age among men. Ever-use of a modern method declines from 7 percent among currently married men age 20-24 to a plateau around 6 percent among those age 25-44, and then decreases to 3 percent among the oldest cohort. Five percent of currently married men report having used a traditional method, with withdrawal twice as likely to have been used as the rhythm method. Fa m ily P la nn in g | 6 3 T ab le 5 .3 .1 E ve r u se o f c on tra ce pt io n: W om en P er ce nt ag e of a ll w om en a nd o f c ur re nt ly m ar rie d w om en a ge 1 5- 49 w ho h av e ev er u se d an y co nt ra ce pt iv e m et ho d by m et ho d, a cc or di ng to a ge , T im or -L es te 2 00 9- 10 A ge 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 um be r of w om en Fe m al e st er ili - za tio n M al e st er ili - za tio n Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M Em er - ge nc y co nt ra - ce pt io n St an da rd da ys m et ho d Rh yt hm W ith - dr aw al Fo lk m et ho d AL L W O M EN 15 -1 9 0. 8 0. 8 0. 0 0. 0 0. 1 0. 0 0. 5 0. 0 0. 1 0. 0 0. 0 0. 1 0. 0 0. 1 0. 0 0. 1 0. 0 3, 14 4 20 -2 4 9. 8 9. 1 0. 0 0. 0 1. 3 0. 1 7. 5 0. 4 0. 0 0. 0 0. 2 0. 0 0. 2 0. 8 0. 4 0. 3 0. 1 2, 34 3 25 -2 9 26 .7 25 .9 0. 1 0. 0 3. 1 1. 0 22 .2 0. 9 0. 7 0. 0 0. 2 0. 0 0. 5 1. 4 0. 6 0. 5 0. 4 1, 89 7 30 -3 4 33 .2 31 .5 0. 8 0. 1 3. 9 2. 5 24 .8 1. 3 1. 2 0. 0 0. 5 0. 0 0. 6 2. 6 1. 3 1. 0 0. 4 1, 53 4 35 -3 9 33 .8 32 .4 1. 0 0. 0 4. 3 1. 9 26 .4 1. 5 0. 2 0. 0 0. 4 0. 0 0. 8 2. 3 1. 5 0. 5 0. 5 1, 68 4 40 -4 4 32 .8 30 .5 0. 8 0. 1 4. 8 2. 3 23 .0 2. 1 0. 4 0. 0 0. 5 0. 0 1. 1 3. 7 1. 9 1. 0 1. 3 1, 38 8 45 -4 9 23 .3 22 .0 2. 0 0. 0 2. 5 1. 0 16 .1 2. 1 0. 0 0. 0 0. 4 0. 0 0. 5 2. 0 0. 9 0. 5 0. 8 1, 14 6 To ta l 19 .5 18 .5 0. 5 0. 0 2. 4 1. 0 14 .8 0. 9 0. 3 0. 0 0. 2 0. 0 0. 4 1. 5 0. 8 0. 5 0. 4 13 ,1 37 C U RR EN TL Y M A RR IE D W O M EN 15 -1 9 8. 9 7. 9 0. 0 0. 0 1. 4 0. 0 6. 3 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 1. 0 0. 0 1. 0 0. 0 24 3 20 -2 4 20 .5 19 .0 0. 0 0. 0 2. 9 0. 3 15 .7 0. 8 0. 1 0. 0 0. 3 0. 0 0. 4 1. 7 0. 8 0. 7 0. 2 1, 10 0 25 -2 9 32 .8 31 .8 0. 1 0. 0 3. 7 1. 2 27 .2 1. 1 0. 8 0. 0 0. 3 0. 0 0. 7 1. 8 0. 7 0. 6 0. 4 1, 51 6 30 -3 4 37 .1 35 .3 0. 9 0. 1 4. 4 2. 9 27 .7 1. 5 1. 3 0. 0 0. 5 0. 0 0. 7 3. 0 1. 5 1. 2 0. 5 1, 36 2 35 -3 9 36 .9 35 .4 1. 1 0. 0 4. 8 2. 0 28 .7 1. 6 0. 2 0. 0 0. 4 0. 0 0. 9 2. 6 1. 7 0. 6 0. 6 1, 51 4 40 -4 4 35 .8 33 .6 0. 9 0. 1 5. 3 2. 5 25 .1 2. 3 0. 5 0. 0 0. 6 0. 0 1. 3 3. 7 1. 8 1. 0 1. 5 1, 21 1 45 -4 9 25 .6 24 .3 2. 2 0. 0 2. 8 1. 2 17 .8 2. 3 0. 0 0. 0 0. 5 0. 0 0. 6 2. 2 0. 9 0. 6 1. 0 96 0 To ta l 31 .5 29 .9 0. 8 0. 0 4. 0 1. 7 23 .9 1. 5 0. 5 0. 0 0. 4 0. 0 0. 7 2. 5 1. 2 0. 8 0. 7 7, 90 6 L A M = L ac ta tio na l a m en or rh ea m et ho d | 63Family Planning 64 | Family Planning Table 5.3.2 Ever use of contraception: Men Percentage of all men, currently married men, and sexually active unmarried men age 15-49 who have ever used any contraceptive method by method, according to age, Timor-Leste 2009-10 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Number of men Male sterili- zation Male condom Standard days method Rhythm With- drawal ALL MEN 15-19 4.4 1.7 0.1 1.5 0.2 3.1 0.1 3.1 994 20-24 13.9 8.7 0.2 8.1 0.5 6.9 0.3 6.6 643 25-29 13.9 10.1 0.6 9.4 0.4 6.0 0.7 5.4 586 30-34 10.5 8.0 0.9 5.5 1.6 4.6 1.6 3.5 439 35-39 9.3 6.0 0.4 3.8 2.1 5.2 1.4 4.3 553 40-44 10.1 5.9 0.2 3.5 2.9 5.8 2.2 3.9 462 45-49 5.8 2.8 0.1 1.5 1.2 3.7 1.4 2.9 400 Total 15-49 9.4 5.8 0.3 4.6 1.1 4.9 0.9 4.3 4,076 CURRENTLY MARRIED MEN 15-19 * * * * * * * * 4 20-24 8.8 7.0 0.0 5.5 1.5 5.3 1.5 3.7 125 25-29 10.0 6.2 1.0 5.0 0.4 5.4 0.7 4.7 359 30-34 8.3 5.6 1.1 2.7 1.9 4.9 1.9 3.5 368 35-39 9.8 6.3 0.5 3.8 2.3 5.6 1.6 4.6 492 40-44 9.8 5.5 0.3 2.9 3.1 6.1 2.4 4.0 433 45-49 6.2 3.0 0.1 1.5 1.3 3.9 1.5 3.1 378 Total 15-49 8.9 5.5 0.5 3.3 1.9 5.2 1.6 4.0 2,158 SEXUALLY ACTIVE UNMARRIED MEN1 15-19 57.2 7.8 0.0 7.8 0.0 50.5 0.0 50.5 45 20-24 48.8 22.5 0.0 21.7 0.7 28.6 0.0 28.6 81 25-29 48.8 38.3 0.0 38.3 1.6 17.4 1.0 16.4 58 30-49 35.5 30.4 0.0 30.4 0.0 6.7 0.0 6.7 31 Total 15-49 48.6 24.8 0.0 24.5 0.7 27.0 0.3 26.8 215 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Men who had sexual intercourse within 30 days preceding the survey 5.4 CURRENT USE OF CONTRACEPTION Current use of contraception is defined as the proportion of women who reported the use of a family planning method at the time of the interview. The level of current use—usually calculated among currently married women—is the most widely used and valuable measure of the success of a family planning program. Table 5.4 shows the percent distribution by age of all women and currently married women who are using specific family planning methods. Similar information on current use was not collected for men. Table 5.4 shows that more than one in five currently married women (22 percent) is using a method of family planning, with 21 percent using a modern contraceptive method. This indicates that modern contraceptive methods are highly favored over either natural family planning methods or other traditional methods. Contraceptive use varies by age. Use is lower among younger women (because they are in the early stage of family building) and among older women (some of whom are no longer fecund) than among those at intermediate ages. For example, current use of a modern contraceptive method is 7 percent among currently married women age 15-19, rises to 26-27 percent among women age 30-39, and then drops sharply to 12 percent at age 45-49. The low use among older women may be due to a combination of decreased fertility and lower awareness of contraception in this age cohort. Injectables are by far the most popular modern method, and they are used by 16 percent of currently married women. Two percent of women use the pill, and about 1 percent of women each use the IUD or implants, or they are sterilized. Most women who are sterilized are over age 30. Injectables are popular among women age 20-44. One percent of women report currently using a traditional method. The rhythm method is slightly more popular than withdrawal. Fa m ily P la nn in g | 6 5 T ab le 5 .4 C ur re nt u se o f c on tra ce pt io n by a ge P er ce nt d ist rib ut io n of a ll w om en a nd o f c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to a ge , T im or -L es te 2 00 9- 10 A ge 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 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 Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om LA M St an da rd da ys m et ho d Rh yt hm W ith - dr aw al Fo lk m et ho d AL L W O M EN 1 5- 19 0. 6 0. 6 0. 0 0. 1 0. 0 0. 5 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 1 0. 0 99 .4 10 0. 0 3, 14 4 2 0- 24 7. 5 7. 0 0. 0 0. 6 0. 1 5. 8 0. 3 0. 0 0. 0 0. 2 0. 5 0. 2 0. 3 0. 0 92 .5 10 0. 0 2, 34 3 2 5- 29 19 .2 18 .7 0. 1 1. 4 0. 8 15 .3 0. 7 0. 3 0. 0 0. 2 0. 5 0. 2 0. 2 0. 1 80 .8 10 0. 0 1, 89 7 3 0- 34 24 .8 23 .8 0. 8 1. 5 2. 4 17 .0 0. 8 0. 7 0. 0 0. 5 1. 0 0. 5 0. 3 0. 1 75 .2 10 0. 0 1, 53 4 3 5- 39 24 .5 23 .5 1. 0 2. 0 1. 5 17 .6 0. 8 0. 0 0. 1 0. 6 1. 0 0. 5 0. 4 0. 1 75 .5 10 0. 0 1, 68 4 4 0- 44 21 .5 19 .3 0. 8 2. 3 1. 3 13 .1 1. 2 0. 1 0. 0 0. 5 2. 2 1. 2 0. 3 0. 8 78 .5 10 0. 0 1, 38 8 4 5- 49 11 .3 10 .4 2. 0 0. 4 0. 7 6. 5 0. 5 0. 0 0. 1 0. 2 0. 9 0. 2 0. 1 0. 5 88 .7 10 0. 0 1, 14 6 T ot al 13 .6 12 .8 0. 5 1. 0 0. 8 9. 6 0. 5 0. 1 0. 0 0. 3 0. 7 0. 3 0. 2 0. 2 86 .4 10 0. 0 13 ,1 37 C U RR EN TL Y M A RR IE D W O M EN 1 5- 19 7. 9 6. 8 0. 0 0. 9 0. 0 5. 9 0. 0 0. 0 0. 0 0. 0 1. 0 0. 0 1. 0 0. 0 92 .1 10 0. 0 24 3 2 0- 24 15 .7 14 .6 0. 0 1. 4 0. 2 12 .1 0. 6 0. 0 0. 0 0. 3 1. 1 0. 4 0. 7 0. 0 84 .3 10 0. 0 1, 10 0 2 5- 29 23 .8 23 .1 0. 1 1. 7 1. 0 18 .9 0. 8 0. 4 0. 0 0. 2 0. 7 0. 3 0. 3 0. 1 76 .2 10 0. 0 1, 51 6 3 0- 34 27 .8 26 .7 0. 9 1. 7 2. 7 19 .1 0. 9 0. 8 0. 0 0. 6 1. 1 0. 6 0. 4 0. 2 72 .2 10 0. 0 1, 36 2 3 5- 39 27 .0 25 .9 1. 1 2. 2 1. 7 19 .3 0. 8 0. 0 0. 1 0. 6 1. 1 0. 6 0. 4 0. 1 73 .0 10 0. 0 1, 51 4 4 0- 44 24 .6 22 .1 0. 9 2. 7 1. 5 14 .9 1. 4 0. 2 0. 0 0. 6 2. 5 1. 3 0. 3 0. 9 75 .4 10 0. 0 1, 21 1 4 5- 49 13 .2 12 .2 2. 2 0. 4 0. 8 7. 8 0. 6 0. 0 0. 1 0. 2 1. 0 0. 2 0. 2 0. 6 86 .8 10 0. 0 96 0 T ot al 22 .3 21 .1 0. 8 1. 7 1. 3 15 .7 0. 8 0. 2 0. 0 0. 4 1. 2 0. 6 0. 4 0. 3 77 .7 10 0. 0 7, 90 6 N ot e: If m or e th an o ne m et ho d is us ed , o nl y th e m os t e ffe ct iv e m et ho d is co ns id er ed in th is ta bu la tio n. LA M = L ac ta tio na l a m en or rh ea m et ho d | 65Family Planning 66 | Family Planning 5.5 TREND IN CURRENT USE OF CONTRACEPTION There has been a marked increase in the use of contraception by currently married women since 2002. Use of modern methods doubled in the five years between 2002 and 2007 and rose by nearly 50 percent in the three years between the 2007 TLSLS and the 2009-10 TLDHS. The increase in use of modern methods contributed to a three-fold increase in overall contraceptive use, from 7 percent to 21 percent, in a matter of 7 to 8 years. It is interesting to note that use of a modern method was 25 percent in 1997 (CBS et al., 1998) but fell sharply to 7 percent following the struggle for national independence when there was a total disruption of services previously provided through the Indonesian National Family Planning Program (BKKBN), which had extensive service networks extending down to volunteers at the village level. Figure 5.1 Trends in Use of Contraception among Currently Married Women, 1997-2010 25 7 7 14 21 27 7 10 20 22 1997 IDHS 2002 MICS 2003 DHS 2007 TLSLS 2009-10 TLDHS 0 5 10 15 20 25 30 Percent Modern method Any method Timor-Leste 2009-10 Note: Lactational amenorrhea method (LAM) is included as a traditional method in the 2002 MICS and the 2003 DHS, but as a modern method in the 2009-10 TLDHS. 5.6 CURRENT USE OF CONTRACEPTION BY BACKGROUND CHARACTERISTICS The study of differentials in current use of contraception is important because it helps to identify subgroups of the population to target for family planning services. Table 5.5 presents the percent distribution of currently married women by their current use of family planning methods, according to background characteristics. This table allows comparison of levels of current contraceptive use among major population groups. It also permits an examination of differences in the method mix among current users within the various subgroups. Substantial differences in the use of contraceptive methods among subgroups of currently married women can be seen in Table 5.5. Women in urban areas are more likely to use a family planning method than rural women, reflecting wider availability and easier access to methods in urban than in rural areas. The contraceptive prevalence rate for modern methods is 28 percent in urban areas, compared with 19 percent in rural areas. Fa m ily P la nn in g | 6 7 T ab le 5 .5 C ur re nt u se o f c on tra ce pt io n by b ac kg ro un d ch ar ac te ris tic s P er ce nt d ist rib ut io n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T im or -L es te 2 00 9- 10 B ac kg ro un d ch ar ac te ris tic An y m et ho d An y m od er n m et ho d 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 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 Pi ll IU D In je ct - ab le s Im pl an ts M al e co nd om LA M St an da rd da ys m et ho d Rh yt hm W ith - dr aw al Fo lk m et ho d R es id en ce U rb an 30 .4 28 .2 1. 7 3. 7 2. 6 17 .7 0. 6 1. 0 0. 1 0. 8 2. 2 1. 6 0. 6 0. 0 69 .6 10 0. 0 2, 02 5 Ru ra l 19 .6 18 .7 0. 5 1. 0 0. 9 15 .0 0. 9 0. 0 0. 0 0. 3 0. 9 0. 2 0. 3 0. 4 80 .4 10 0. 0 5, 88 1 D is tr ic t Ai le u 20 .7 19 .5 0. 2 1. 6 0. 7 16 .3 0. 5 0. 0 0. 2 0. 0 1. 2 1. 2 0. 0 0. 0 79 .3 10 0. 0 29 9 Ai na ro 14 .1 13 .7 0. 2 0. 9 0. 8 10 .7 0. 8 0. 0 0. 0 0. 4 0. 4 0. 0 0. 0 0. 4 85 .9 10 0. 0 38 2 Ba uc au 8. 0 7. 6 1. 0 1. 2 0. 7 3. 5 0. 6 0. 0 0. 0 0. 6 0. 4 0. 2 0. 0 0. 2 92 .0 10 0. 0 85 2 Bo bo na ro 20 .4 20 .4 0. 8 1. 0 0. 8 16 .1 1. 5 0. 0 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 79 .6 10 0. 0 73 9 C ov al im a 43 .8 43 .2 0. 9 1. 4 0. 6 38 .6 1. 3 0. 0 0. 0 0. 4 0. 6 0. 6 0. 0 0. 0 56 .2 10 0. 0 45 8 D ili 33 .2 30 .5 2. 1 4. 5 2. 7 18 .2 0. 6 1. 3 0. 2 0. 9 2. 6 2. 0 0. 6 0. 0 66 .8 10 0. 0 1, 45 9 Er m er a 18 .8 15 .3 0. 0 0. 4 0. 6 13 .9 0. 4 0. 0 0. 0 0. 0 3. 5 0. 0 1. 8 1. 8 81 .2 10 0. 0 88 1 La ut em 17 .7 17 .5 0. 3 1. 6 1. 9 13 .4 0. 2 0. 0 0. 0 0. 1 0. 2 0. 2 0. 0 0. 0 82 .3 10 0. 0 54 1 Li qu iç á 24 .5 23 .8 1. 1 2. 8 1. 6 16 .9 1. 0 0. 0 0. 0 0. 5 0. 7 0. 0 0. 0 0. 7 75 .5 10 0. 0 46 0 M an at ut o 20 .7 20 .0 0. 8 1. 8 2. 2 15 .2 0. 2 0. 0 0. 0 0. 0 0. 7 0. 4 0. 2 0. 2 79 .3 10 0. 0 35 3 M an uf ah i 25 .3 24 .2 0. 2 1. 1 1. 6 19 .1 1. 7 0. 0 0. 0 0. 6 1. 0 0. 0 1. 0 0. 0 74 .7 10 0. 0 31 9 O ec us si 24 .1 23 .4 0. 2 0. 1 0. 6 19 .4 2. 5 0. 1 0. 0 0. 5 0. 7 0. 3 0. 3 0. 2 75 .9 10 0. 0 60 3 Vi qu eq ue 13 .1 12 .7 0. 0 0. 4 1. 0 10 .3 0. 4 0. 0 0. 0 0. 7 0. 4 0. 4 0. 0 0. 0 86 .9 10 0. 0 55 9 E du ca tio n N o ed uc at io n 15 .9 14 .7 0. 6 0. 5 0. 8 11 .8 0. 9 0. 0 0. 1 0. 1 1. 1 0. 1 0. 4 0. 7 84 .1 10 0. 0 2, 90 9 Pr im ar y 25 .8 25 .1 0. 7 1. 0 1. 2 20 .8 1. 2 0. 0 0. 0 0. 2 0. 7 0. 3 0. 3 0. 1 74 .2 10 0. 0 2, 02 7 Se co nd ar y 25 .7 24 .2 0. 9 3. 5 1. 8 16 .3 0. 6 0. 3 0. 0 0. 8 1. 5 1. 2 0. 3 0. 0 74 .3 10 0. 0 2, 73 9 M or e th an se co nd ar y 32 .8 29 .5 2. 3 1. 8 3. 8 13 .8 0. 3 4. 6 0. 9 1. 9 3. 3 1. 6 1. 7 0. 0 67 .2 10 0. 0 23 1 W ea lth q ui nt ile Lo w es t 15 .0 14 .5 0. 3 0. 4 0. 7 12 .3 0. 7 0. 0 0. 0 0. 0 0. 5 0. 0 0. 0 0. 4 85 .0 10 0. 0 1, 46 7 Se co nd 16 .4 15 .5 0. 1 0. 7 0. 6 13 .2 0. 7 0. 0 0. 1 0. 2 0. 9 0. 1 0. 2 0. 6 83 .6 10 0. 0 1, 48 7 M id dl e 18 .0 16 .9 0. 4 0. 7 0. 4 14 .4 1. 0 0. 0 0. 0 0. 1 1. 1 0. 1 0. 6 0. 3 82 .0 10 0. 0 1, 55 9 Fo ur th 25 .3 24 .4 1. 0 1. 3 1. 5 19 .5 0. 6 0. 0 0. 0 0. 5 0. 9 0. 4 0. 4 0. 2 74 .7 10 0. 0 1, 57 1 H ig he st 34 .2 31 .7 1. 8 4. 9 3. 1 18 .3 1. 2 1. 1 0. 1 1. 3 2. 4 1. 8 0. 6 0. 0 65 .8 10 0. 0 1, 82 1 N um be r of li vi ng ch ild re n 0 0. 7 0. 2 0. 0 0. 0 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 0. 5 0. 0 0. 5 0. 0 99 .3 10 0. 0 46 9 1- 2 16 .7 16 .0 0. 3 1. 4 0. 6 12 .4 0. 6 0. 5 0. 0 0. 3 0. 7 0. 3 0. 4 0. 0 83 .3 10 0. 0 2, 10 3 3- 4 26 .7 25 .6 0. 8 2. 5 1. 6 18 .6 1. 1 0. 4 0. 1 0. 6 1. 1 0. 6 0. 4 0. 1 73 .3 10 0. 0 2, 42 1 5+ 26 .2 24 .4 1. 3 1. 5 1. 8 18 .2 1. 0 0. 0 0. 1 0. 5 1. 8 0. 8 0. 4 0. 7 73 .8 10 0. 0 2, 91 3 To ta l 22 .3 21 .1 0. 8 1. 7 1. 3 15 .7 0. 8 0. 2 0. 0 0. 4 1. 2 0. 6 0. 4 0. 3 77 .7 10 0. 0 7, 90 6 N ot e: If m or e th an o ne m et ho d is us ed , o nl y th e m os t e ffe ct iv e m et ho d is co ns id er ed in th is ta bu la tio n. L A M = L ac ta tio na l a m en or rh ea m et ho d | 67Family Planning 68 | Family Planning Contraceptive use varies by district with much of the difference due to the use of injectables. Use of a modern method among currently married women is highest in Covalima (43 percent) and lowest in Baucau (8 percent). The most popular method in Covalima is injectables where 39 percent of currently married women use them. Three in ten currently married women in Dili, the most urbanized district in the country, use a modern method of family planning, with 18 percent currently using injectables, 5 percent using the pill, 3 percent using IUDs, and 2 percent using sterilization. About 1 percent use implants, the male condom, and the standard days method. The scale-up in the provision of implants in Timor-Leste has been relatively recent, but at the current rate, they may soon overtake the IUD as the method of choice (Marie Stopes International, 2010). Sterilization services have in recent years been very limited, with most sterilizations provided by visiting surgical providers during a short window of time. Data for 2010 show that there is a full-time provider of both male and female sterilization services currently as well as a plan for training others in these surgical techniques, so use of sterilization could be expected to increase significantly over the coming years (Marie Stopes International, 2010). Although current use varies markedly between women who have some education and those who have none, there is little variation among educated women by specific level of education. Women with more than secondary education (30 percent) are twice as likely to use a modern method of contraception as women with no education (15 percent). Women with more than secondary education are more likely than other women to use male condoms (5 percent) and IUDs (4 percent), and they are more likely to be sterilized and to use the standard days method (2 percent each). On the other hand, injectables are most common among women with primary education (21 percent). Wealth has a positive effect on women’s contraceptive use, with modern contraceptive use increasing markedly as household wealth increases, from 15 percent among currently married women in the lowest wealth quintile to 32 percent among those in the highest wealth quintile. There is a direct association between the use of modern family planning methods and the number of children that women have, except among women with five or more children. Not surprisingly, use is lowest among women with no children (less than 1 percent), rises to 16 percent among women with 1 to 2 children, is 26 percent among women with three to four children, and then decreases slightly to 24 percent among women with five or more children. As expected, female sterilization is popular among high-parity women (5+ children). Current use of traditional methods is more common in urban than in rural areas and is highest in Ermera district, among women with more than secondary education, among women in the highest wealth quintile, and among women with five or more children. Effective use of a traditional method requires knowledge of a woman’s fertile period, and educated women, who are also more likely to be urban and belong to wealthier households, are most likely to effectively understand and use a traditional method; hence there is this uncommon pattern of use by educated, urban, wealthy women. Ermera appears to be an exception to this demographic pattern, but a detailed examination reveals that Ermera has a different pattern of use of traditional methods when compared with the pattern in Dili. Folk methods and withdrawal are the predominant methods in Ermera (at 2 percent each), with less than 0.1 percent using the rhythm method. Dili, on the other hand, has 2 percent of currently married women using the rhythm method. Similarly, the use of folk methods shifts to use of the rhythm method as education increases. 5.7 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION To examine the timing of initial family planning use during the family building process, the 2009-10 TLDHS asked all women about the number of living children they had at first use. Table 5.6 shows this information by age group and allows analysis of cohort changes in parity at first use of contraception. Family Planning | 69 Use increases with parity but with little difference among women with 1, 2, or 3 children (about 3 percent each). Nine percent of all women first used a method of family planning when they had four or more children. Younger women report first use of contraception at lower parities than older women, suggesting a shift toward the early use of contraception and the desire to delay childbearing among younger Timorese women. For example, 9 percent of women age 25-29 first used contraception when they had 2 children compared with 2 percent of women age 45-49. Table 5.6 Number of children at first use of contraception Percent distribution of women age 15-49 by number of living children at the time of first use of contraception, according to current age, Timor-Leste 2009-10 Current age Never used Number of living children at time of first use of contraception Total Number of women 0 1 2 3 4+ Missing 15-19 99.2 0.2 0.4 0.1 0.1 0.0 0.0 100.0 3,144 20-24 90.2 0.1 4.1 3.5 1.6 0.4 0.0 100.0 2,343 25-29 73.3 0.1 4.5 8.7 6.8 6.5 0.1 100.0 1,897 30-34 66.8 0.3 5.6 4.3 6.1 16.6 0.3 100.0 1,534 35-39 66.2 0.2 3.5 2.4 5.8 21.8 0.1 100.0 1,684 40-44 67.2 0.4 3.7 3.1 5.2 20.4 0.0 100.0 1,388 45-49 76.7 0.2 1.8 2.0 2.7 16.5 0.0 100.0 1,146 Total 80.5 0.2 3.1 3.2 3.5 9.4 0.1 100.0 13,137 5.8 KNOWLEDGE OF FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for the successful practice of the rhythm method. As shown in Tables 5.1, 5.3.1 and 5.4, respectively, 13 percent of all women and 17 percent of currently married women have heard of the rhythm method, but only 1 percent of currently married women have ever used the rhythm method, and less than half a percent are currently using the method. Table 5.7 shows respondents’ knowledge about the time during the menstrual cycle when a woman is most likely to get pregnant. Overall, only one in ten women correctly reported the most fertile time as being halfway between two menstrual periods. Nearly one in two women (46 percent) incorrectly reported that a woman’s most fertile period is right after menstruation has ended; one in five women each mentioned that there was no specific time when a woman is most fertile or that she did not know when a woman is most fertile. The small number of users of the rhythm method makes it difficult for any meaningful analysis of knowledge among rhythm users. The limited knowledge of when a woman is most fertile indicates that there is much scope for educating women and men on female physiology. Current teaching on reproductive physiology and anatomy is limited in Timor-Leste, although this is undergoing curriculum development and review. The very high levels of misconception regarding the occurrence of the woman’s most fertile period also represent a real challenge to those not using a modern method of contraception and not wishing to become pregnant. This also has implications for Timor-Leste’s high teenage pregnancy rates. Table 5.7 Knowledge of fertile period Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Timor-Leste 2009-10 Perceived fertile period Users of rhythm method Nonusers of rhythm method All women Just before her menstrual period begins (25.2) 4.7 4.8 During her menstrual period (0.0) 3.3 3.3 Right after her menstrual period has ended (38.5) 46.2 46.2 Halfway between two menstrual periods (19.7) 9.5 9.6 Other (0.0) 0.0 0.0 No specific time (15.3) 17.5 17.5 Don’t know (1.2) 18.7 18.6 Total 100.0 100.0 100.0 Number of women 44 13,093 13,137 Note: Figures in parentheses are based on 25-49 unweighted cases. 70 | Family Planning 5.9 TIMING OF FEMALE STERILIZATION In countries where female sterilization is prevalent, there is interest in trends in the adoption of the method and age at the time of sterilization. There were only 54 women in the 2009-10 TLDHS sample who were sterilized at the time of the survey. Due to these small numbers, a separate table is not shown in this report. The median age at sterilization was 34.1 years, with the majority sterilized before age 40 (79 percent), and 20 percent were sterilized between 40 and 44 years. 5.10 SOURCE OF MODERN CONTRACEPTION METHODS Table 5.8 on source of contraception is intended simply to document the main sources of contraception for users of different modern methods of contraception. Information on where women obtain the contraceptive method that they use is important for program managers and implementers in designing family planning policies and programs. All current users of modern contraceptive methods were asked the most recent source of their methods. The government sector remains the major source of contraceptive methods in Timor-Leste, providing methods to almost nine in ten current users. Eighty-eight percent of users get their methods from the government sector, 9 percent from the private medical sector, and 2 percent from other sources. The share of the government sector has increased slightly over the past five years. Data from the 2003 DHS show that the government sector supplied methods to 80 percent of users. Forty-five percent of all users are served by community health centers, 20 percent by health posts, 17 percent by government and referral hospitals, 3 percent by integrated community health services (SISCa), and 2 percent by mobile clinics. In the private medical sector, most users are served by private hospitals/clinics (8 percent of all users). Most contraceptives sold in private hospitals/ clinics are provided through the Timor-Leste Contraceptive Retail Sales Company. Table 5.8 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, Timor-Leste 2009-10 Source Female sterilization Pill IUD Injectables Implants Total1 Public sector 91.7 77.2 96.9 89.3 97.9 88.4 National hospital 55.4 2.3 28.4 1.4 0.0 5.5 Referral hospital 29.1 15.4 15.6 10.2 16.2 11.8 Community health center 4.1 42.9 39.5 48.3 59.3 45.4 Health post 0.0 13.3 10.7 23.6 13.1 20.3 SISCa post 0.0 1.8 0.0 4.1 2.0 3.4 Mobile clinic 0.0 1.5 2.0 1.7 7.3 1.8 Other public 3.1 0.0 0.6 0.0 0.0 0.2 Private medical sector 2.1 13.9 2.4 9.7 2.1 9.3 Private hospital/clinic 0.0 9.5 2.4 8.2 2.1 7.5 Pharmacy 0.0 2.4 0.0 0.5 0.0 0.9 Private doctor’s office 0.0 1.5 0.0 0.2 0.0 0.3 Mobile clinic 0.0 0.0 0.0 0.1 0.0 0.0 Field worker 0.0 0.0 0.0 0.1 0.0 0.1 Other private medical 2.1 0.6 0.0 0.5 0.0 0.5 Other source 0.0 8.9 0.0 0.8 0.0 1.8 Shop 0.0 0.6 0.0 0.0 0.0 0.4 Friend/relative 0.0 5.3 0.0 0.2 0.0 0.6 Marie Stopes (NGO) 0.0 1.5 0.0 0.3 0.0 0.4 Other NGO 0.0 1.5 0.0 0.3 0.0 0.4 Other 6.2 0.0 0.0 0.2 0.0 0.4 Missing 0.0 0.0 0.7 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 65 135 105 1,255 68 1,647 1 Total includes other modern methods but excludes lactational amenorrhea method (LAM) and standard days method. Family Planning | 71 Female and male sterilizations are performed mostly in government hospitals (55 and 29 percent, respectively). Forty-eight percent of women using injectables obtain their supply from community health centers, and 24 percent obtain them from health posts. Pills are primarily obtained from community health centers (43 percent) and referral hospitals (15 percent). Fifty-nine percent of implants are provided through community health centers. IUDs are mostly inserted at community health centers (40 percent) and national hospitals (28 percent). These findings point to the continued reliance on government facilities as a major source of contraceptives. There is clearly scope for greater utilization of SISCa posts for provision of some family planning methods since there are a greater number of SISCa posts than all fixed facilities combined. Although SISCa offers services on a monthly basis, many family planning methods do not necessarily require more frequent visits. Injectables are the most preferred method, which can certainly be offered during a monthly service. 5.11 PAYMENT OF FEES FOR MODERN CONTRACEPTIVE METHODS The majority of users (98 percent) in Timor-Leste do not pay for contraception (data not shown). In most cases the only cost borne by public sector users is a registration fee, whereas the small number of private sector users who pay must bear the cost of the consultancy and payment for the method as well as the registration fee. 5.12 INFORMED CHOICE Informed choice is an important tool for monitoring the quality of family planning services. All providers of sterilization must inform potential users that the operation is a permanent, irreversible procedure; potential users also must be informed of alternate methods that could be used. Users of temporary methods also should be informed about choices they have and other methods available. Family planning providers also should inform all method users of potential side effects and what to do if they experience a problem. This information assists users in coping with side effects and decreases unnecessary discontinuation of temporary methods. Table 5.9 presents information on informed choice by type and source of method. The data show that 61 percent of current users were informed about possible side effects or problems associated with use, 55 percent of users were informed about what to do if they experienced side effects, and 53 percent were told of other methods that could be used. The private sector is more likely than the public sector to inform users about side effects or problems associated with using a method. In contrast, the public sector is more likely than the private sector to inform clients of what to do if they experience side effects and to tell them about other methods that can be used. Information on whether women who had been sterilized were told if the method was permanent is not shown by the method source due to the very small number of cases. 72 | Family Planning Table 5.9 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, the percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods that they could use, by method and source, Timor-Leste 2009-10 Method/source Among women who started last episode of modern contraceptive method within five years preceding the survey: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if 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 Female sterilization (78.0) (78.0) (48.8) 42 Pill 67.2 66.7 64.1 113 IUD 76.5 66.4 64.8 97 Injectables 59.2 52.5 50.7 1,123 Implants 53.2 53.8 60.7 64 Initial source of method1 PUBLIC 59.2 55.6 53.7 1,287 National hospital 81.0 62.7 54.0 69 Referral hospital 46.7 42.2 35.9 181 Community health center 61.7 59.4 55.8 663 Health post 57.7 53.1 58.1 301 SISCa post (58.5) (61.9) (68.7) 46 Other public * * * 1 Mobile clinic * * * 27 PRIVATE MEDICAL 79.1 45.3 39.6 118 Private hospital/clinic 84.0 45.1 33.2 95 Pharmacy * * * 7 Private doctor’s office * * * 6 Mobile clinic * * * 3 Field worker * * * 1 Other private medical * * * 7 OTHER PRIVATE * * * 31 Shop * * * 1 Friend/relative * * * 7 Marie Stopes (NGO) * * * 5 Other NGO * * * 18 OTHER * * * 3 Total 61.3 55.3 53.1 1,440 Note: Table includes users of only the methods listed individually. Figures in parentheses are based on 25-49 unweighted cases. As asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Source at start of current episode of use 5.13 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which non-users of contraception plan to use family planning in the future. Currently married women who were not using contraception at the time of the survey were asked about their intention to use family planning in the future. The results appear in Table 5.10. Among currently married women who are not using contraception, 20 percent report that they intend to use a family planning method in the future, 54 percent say that they do not intend to use a method in the future, and 27 percent are unsure of their future intention. Depending on the number of living children, there are differences in the percentage of women who intend to use family planning. The proportion of women intending to use family planning peaks at 26 percent among non-users with one child, declines to 22 percent among women with three children, and further declines sharply to 17 percent among women who have four or more children. This is despite the fact that women with four or more children have a strong demand to delay their next child or have no more children (see Table 7.1). Family Planning | 73 Table 5.10 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, Timor-Leste 2009-10 Intention Number of living children1 Total 0 1 2 3 4+ Intends to use 10.4 26.0 23.2 21.8 17.0 19.5 Unsure 17.8 31.1 31.6 28.6 24.3 26.6 Does not intend to use 71.7 43.0 45.3 49.6 58.7 53.8 Missing 0.2 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 300 831 918 932 3,160 6,141 1 Includes current pregnancy 5.14 REASONS FOR NON-USE OF CONTRACEPTION IN THE FUTURE An understanding of the reasons women give for not using family planning methods is critical to designing programs that could improve the quality of services and widen the method mix. Table 5.11 shows the percent distribution of currently married women who are not using a contraceptive method and who do not intend to use one in the future by the main reasons for not intending to use. Fifty-five percent of women do not intend to use contraception in the future because of opposition to its use, with the majority stating that they them- selves are opposed to its use (46 percent). Nine per- cent mention that their husband/partner is opposed to the use of contraception. Twenty-one percent of women cited method-related reasons for non-use, the most common of these being fear of side effects (10 percent) and health concerns (8 percent). Sixteen percent of women cited fertility-related reasons for non-use in the future, with 7 percent of these women reporting themselves as subfecund or infecund. Six percent of women mention that they don’t know of a method or a source for a method. 5.15 PREFERRED METHOD OF CONTRACEPTION FOR FUTURE USE Future demand for specific methods of family planning can be assessed by asking nonusers who intend to use in the future which methods they prefer to use. Table 5.12 provides some indication of currently married women’s preferences for the method they might use in the future. However, the information should be interpreted with caution because two conditions are implied here: intention to use and method preferred if intention is followed. Most currently married women would prefer to use injectables (71 percent) and pills (11 percent) in the future. About 4 percent of women each mentioned the IUD or implants as a preferred method for future use. These percentages should also be interpreted in the context of overall limited awareness of methods other than injectables. It is highly likely that increasing awareness of other methods and their advantages and disadvantages will lead to a greater variety of methods being preferred by women according to individual need. Table 5.11 Reason for not intending to use contraception in the future Percent distribution of currently married women age 15- 49 who are not using contraception and who do not intend to use in the future by main reason for not intending to use, Timor-Leste 2009-10 Reason Percent distribution Fertility-related reasons Infrequent sex/no sex 1.5 Menopausal/had hysterectomy 4.3 Subfecund/infecund 6.7 Wants as many children as possible 3.2 Opposition to use Respondent opposed 46.0 Husband/partner opposed 8.5 Others opposed 0.2 Religious prohibition 0.3 Lack of knowledge Knows no method 5.4 Knows no source 0.3 Method-related reasons Health concerns 8.3 Fear of side effects 10.1 Lack of access/too far 0.5 Inconvenient to use 0.1 Interfere with body’s normal process 2.0 Other 1.4 Don’t know 1.4 Total 100.0 Number of women 3,306 74 | Family Planning Table 5.12 Preferred method of contraception for future use Percent distribution of currently married women age 15-49 who are not using a contraceptive method but who intend to use in the future by preferred method, Timor-Leste 2009-10 Method Percent distribution Female sterilization 0.5 Pill 11.1 IUD 4.1 Injectables 71.1 Implants 3.7 Condom 0.4 Periodic abstinence 1.0 Withdrawal 0.1 Other 1.8 Unsure 3.7 Missing 2.5 Total 100.0 Number of women 1,199 5.16 EXPOSURE TO FAMILY PLANNING MESSAGES The electronic media such as radio and television are important for communicating messages about family planning. Information on the level of exposure to such media is important for program managers and planners to effectively target population subgroups for information, education, and communication (IEC) campaigns. In Timor-Leste, the most common media source is the radio. Television is mostly found in urban areas, while the print media are accessed mostly by the educated. To assess the extent to which media serve as a source of family planning messages, respondents were asked if they had heard or seen a message about family planning on the radio, on television, in the print media (newspaper, magazine, poster, or billboard), or at a street drama in the months preceding the survey. The results are shown in Table 5.13. One in five women (21 percent) and one in three men (32 percent) age 15-49 have heard a family planning message recently on the radio, and 21 percent of women and 23 percent of men have heard family planning messages on television. Ten percent of women and 15 percent of men have read about family planning in a newspaper or magazine. Sixty-eight percent of women and 59 percent of men have not been exposed to family planning messages in the past few months through any of the specified media sources. With the exception of the youngest age group, exposure is generally higher among younger respondents (20-29 years) than among older respondents (45-49 years). Not surprisingly, women and men residing in urban areas are much more likely to have been exposed to family planning messages in any media than their rural counterparts. This is especially true for messages on television and in the print media. By district, exposure to family planning messages among women is highest in Dili and lowest in Oecussi (with 27 percent and 94 percent exposed to no media messages, respectively). Exposure among men is highest in Manatuto and lowest in Ermera (with 14 percent and 80 percent exposed to no media messages, respectively), Not surprisingly, exposure to media messages on family planning increases with education and wealth quintile. Family Planning | 75 Table 5.13 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on the radio or television or in a newspaper in the past few months, according to background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Radio Television News- paper/ magazine None of these three media sources Number Radio Television News- paper/ magazine None of these three media sources Number Age 15-19 19.3 18.2 11.2 68.6 3,144 23.3 16.7 11.7 66.8 994 20-24 23.7 23.2 11.9 63.0 2,343 38.6 25.2 13.6 54.0 643 25-29 23.2 24.2 11.6 62.3 1,897 36.8 27.8 17.9 53.0 586 30-34 22.6 23.6 8.7 65.0 1,534 35.5 23.2 15.9 56.7 439 35-39 18.2 18.4 8.3 71.0 1,684 36.2 29.5 17.1 52.2 553 40-44 20.4 20.5 5.8 70.6 1,388 31.0 25.6 15.2 58.9 462 45-49 14.1 15.5 5.5 77.6 1,146 27.6 19.2 11.8 65.2 400 Residence Urban 33.7 49.9 13.9 39.2 3,439 35.6 37.3 23.2 48.0 1,102 Rural 15.9 10.3 8.1 77.6 9,698 30.7 18.2 11.3 62.6 2,974 District Aileu 34.8 12.5 10.4 57.6 554 29.7 18.6 15.5 65.9 181 Ainaro 16.0 5.1 4.6 81.4 619 23.1 9.5 15.2 72.3 217 Baucau 16.6 14.0 11.1 75.2 1,408 29.8 12.9 4.8 65.3 415 Bobonaro 26.4 16.7 8.3 66.3 1,262 36.6 20.4 7.2 55.4 357 Covalima 13.6 7.1 8.3 79.3 781 53.8 34.6 39.4 36.9 236 Dili 38.5 62.2 13.8 27.4 2,466 36.3 39.4 23.9 47.3 797 Ermera 4.9 2.1 5.0 91.0 1,542 18.0 5.4 3.8 79.5 491 Lautem 15.6 11.6 10.5 74.8 864 25.4 23.4 27.6 58.9 308 Liquiçá 26.3 18.8 14.9 63.2 801 38.4 25.2 6.7 55.2 252 Manatuto 21.8 20.1 19.9 67.5 603 76.2 48.8 7.5 13.5 190 Manufahi 27.3 18.3 6.0 67.0 470 22.8 17.3 7.1 75.0 137 Oecussi 3.7 3.4 2.8 93.6 884 26.3 18.0 17.6 63.3 235 Viqueque 8.1 10.3 6.2 85.4 882 11.3 20.8 5.9 74.6 260 Education No education 9.5 6.3 1.3 86.7 3,854 11.5 6.5 0.5 86.0 791 Primary 15.7 13.2 5.1 76.4 3,005 24.1 15.6 6.6 69.2 1,046 Secondary 28.1 30.6 15.8 53.8 5,829 40.7 30.3 19.6 47.0 2,009 More than secondary 50.4 63.9 31.6 22.9 449 62.3 55.2 54.1 19.4 230 Wealth quintile Lowest 6.5 3.3 2.0 91.6 2,314 18.1 9.3 8.3 75.6 728 Second 9.7 3.6 3.8 86.6 2,468 24.1 11.0 7.0 71.0 781 Middle 16.5 6.9 7.2 77.2 2,590 32.2 14.0 9.9 63.8 786 Fourth 25.3 20.2 11.9 63.1 2,687 36.8 28.5 15.7 52.7 849 Highest 39.2 59.3 20.0 29.9 3,077 44.9 47.7 28.4 36.4 932 Total 15-49 20.6 20.6 9.6 67.5 13,137 32.0 23.3 14.5 58.7 4,076 5.17 CONTACT OF NON-USERS WITH FAMILY PLANNING PROVIDERS When family planning providers visit women in the field or when women visit health facilities, family planning fieldworkers and health providers are expected to discuss family planning issues, to discuss contraceptive options available, and to motivate non-users to adopt a method of family planning. To get insight into the level of contact between non-users and health workers, women were asked if a fieldworker had visited them and discussed family planning during the 12 months preceding the survey. In addition, women were asked if they had visited a health facility for any reason in the 12 months preceding the survey and whether anyone at the facility had discussed family planning with them during the visit. Table 5.14 shows that 15 percent of nonusers were visited by fieldworkers who discussed family planning during the 12 months preceding the survey. At the same time, 13 percent of nonusers visited a health facility in the past 12 months and discussed family planning during their visit, whereas 31 percent visited a health facility but did not discuss family planning, indicating a missed opportunity to inform and educate women about family planning. Four in five women did not discuss family planning in the past 12 months, either with a fieldworker or at a health facility. One of the reasons for the low exposure from fieldworkers could be the lack of emphasis on family planning during home visits. Equally, there may be lack of emphasis on family planning during other 76 | Family Planning consultations at a health facility. Given the relatively high coverage of ANC services in Timor-Leste, this represents at least one under-utilized opportunity for education and promotion in family planning. This low level of contact of nonusers with family planning providers varies little by urban-rural residence, education, and wealth. Exposure is lowest among very young women (15-19 years) and among women residing in Ermera, Baucau, and Ainaro. Table 5.14 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the last 12 months were visited by a 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 neither discussed family planning with a fieldworker nor at a health facility, by background characteristics, Timor-Leste 2009-10 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 neither discussed family planning with fieldworker nor at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 10.2 4.4 27.0 87.9 3,124 20-24 15.0 11.9 30.3 79.4 2,167 25-29 17.4 17.4 36.6 73.2 1,532 30-34 19.4 17.9 36.9 70.8 1,154 35-39 18.6 19.4 33.0 73.0 1,272 40-44 18.8 17.3 31.2 73.2 1,089 45-49 16.2 12.4 30.6 78.3 1,016 Residence Urban 15.8 8.3 30.3 79.8 2,815 Rural 15.2 14.0 31.7 78.2 8,540 District Aileu 32.4 18.1 39.8 64.4 491 Ainaro 5.1 7.5 29.0 91.1 565 Baucau 2.7 5.2 36.0 93.0 1,340 Bobonaro 39.5 25.1 32.2 55.0 1,111 Covalima 14.4 11.4 50.8 79.3 573 Dili 20.8 6.3 26.6 76.0 1,976 Ermera 3.3 5.0 47.6 93.2 1,376 Lautem 11.2 14.1 16.1 80.4 768 Liquiçá 17.7 12.8 29.2 76.9 689 Manatuto 18.9 16.3 20.9 77.8 530 Manufahi 12.6 16.5 27.7 79.8 390 Oecussi 16.0 34.1 30.7 61.5 739 Viqueque 8.0 11.6 14.4 83.5 808 Education No education 15.3 14.1 31.6 78.0 3,390 Primary 17.0 15.2 32.9 75.3 2,471 Secondary 14.4 10.5 30.5 80.7 5,123 More than secondary 18.5 10.7 30.8 77.4 371 Wealth quintile Lowest 12.8 15.6 26.8 78.8 2,092 Second 12.0 10.8 33.1 82.6 2,220 Middle 15.7 13.9 35.2 77.6 2,308 Fourth 19.4 14.0 31.7 74.9 2,283 Highest 16.4 9.1 29.6 79.2 2,453 Total 15.3 12.6 31.3 78.6 11,355 5.18 HUSBAND’S KNOWLEDGE OF WIFE’S USE OF CONTRACEPTION Concealment of contraceptive use is an indication of absence of communication or disagreement on use of family planning. To shed light on the extent of communication regarding use of contraception among married couples, currently married women who were using contraception at the time of the survey were asked whether their husband knew of their use. Almost all users (97 percent) reported that their husbands know about their use of contraception (Table 5.15), an indication, perhaps, that Timorese husbands in general are supportive of contraceptive use among their wives. Family Planning | 77 Table 5.15 Husband/partner’s knowledge of women’s use of contraception Among currently married women age 15-49 who are using a method, percent distribution by whether they report that their husbands/partners know about their use, according to background characteristics, Timor-Leste 2009-10 Background characteristic Knows1 Does not know Unsure whether knows/ missing Total Number of women Age 15-19 * * * 100.0 19 20-24 95.5 2.9 1.6 100.0 173 25-29 97.7 0.8 1.5 100.0 361 30-34 95.7 3.2 1.2 100.0 379 35-39 95.8 2.1 2.1 100.0 408 40-44 97.5 2.5 0.0 100.0 298 45-49 96.4 2.8 0.7 100.0 127 Residence Urban 95.0 2.4 2.6 100.0 615 Rural 97.3 2.2 0.5 100.0 1,150 District Aileu 97.4 2.6 0.0 100.0 62 Ainaro 94.6 4.4 1.1 100.0 54 Baucau 95.3 2.3 2.3 100.0 69 Bobonaro 93.7 5.4 0.9 100.0 151 Covalima 99.3 0.3 0.5 100.0 201 Dili 94.2 2.8 3.0 100.0 484 Ermera 100.0 0.0 0.0 100.0 165 Lautem 97.3 2.7 0.0 100.0 96 Liquiçá 96.2 2.5 1.3 100.0 113 Manatuto 95.9 2.6 1.5 100.0 73 Manufahi 99.3 0.7 0.0 100.0 81 Oecussi 96.9 2.7 0.4 100.0 145 Viqueque 100.0 0.0 0.0 100.0 73 Education No education 96.9 2.6 0.5 100.0 462 Primary 96.4 2.9 0.7 100.0 524 Secondary 97.2 1.4 1.4 100.0 704 More than secondary (88.6) (2.7) (8.8) 100.0 76 Wealth quintile Lowest 97.3 2.7 0.0 100.0 220 Second 97.1 2.4 0.6 100.0 244 Middle 97.2 2.6 0.2 100.0 281 Fourth 95.4 2.4 2.2 100.0 398 Highest 96.4 1.8 1.8 100.0 623 Total 96.5 2.2 1.2 100.0 1,765 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes women who report use of male sterilization, male condoms, or withdrawal Other Proximate Determinants of Fertility | 79 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 This chapter addresses the principal factors other than contraception that affect a woman’s risk of becoming pregnant. The principal factors are nuptiality (including age at first marriage and age at first sexual intercourse), postpartum amenorrhea and sexual abstinence, and menopause. In societies where sexual activity usually takes place within marriage, marriage signals the onset of a woman’s exposure to the risk of childbearing. Postpartum amenorrhea and sexual abstinence affect the duration of a woman’s insusceptibility to pregnancy, which in turn affects birth spacing. The onset of menopause marks the end of a woman’s reproductive life. These variables taken together determine the length and pace of a woman’s reproductive life and are, therefore, important for understanding fertility. 6.1 CURRENT MARITAL STATUS Table 6.1 shows the marital status by age and sex. Three-fifths of women (60 percent) and just over one in two men (53 percent) age 15-49 are currently in a union. Thirty-six percent of women age 15-49 have never been married, whereas the proportion of men age 15-49 who have never been married is considerably higher (46 percent). The proportion that have never married decreases sharply with age for both women and men: among women, from 92 percent in the age group 15-19 to 3 percent in the age group 45-49; and among men, from nearly 100 percent in the age group 15-19 to less than 2 percent in the age group 45-49. Table 6.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Timor-Leste 2009-10 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed WOMEN 15-19 91.8 6.0 1.7 0.1 0.3 0.0 100.0 7.7 3,144 20-24 51.0 42.2 4.7 0.9 0.9 0.3 100.0 47.0 2,343 25-29 16.6 75.8 4.1 0.6 1.6 1.3 100.0 79.9 1,897 30-34 6.7 86.5 2.3 1.0 1.7 1.9 100.0 88.8 1,534 35-39 5.1 88.6 1.3 0.8 1.2 3.0 100.0 89.9 1,684 40-44 4.0 86.2 1.0 0.9 1.8 6.2 100.0 87.2 1,388 45-49 3.2 83.3 0.5 0.8 1.2 11.0 100.0 83.8 1,146 Total 15-49 35.6 57.8 2.4 0.6 1.1 2.5 100.0 60.2 13,137 MEN 15-19 99.6 0.3 0.1 0.0 0.0 0.0 100.0 0.4 994 20-24 80.1 14.6 4.8 0.0 0.6 0.0 100.0 19.4 643 25-29 37.8 54.1 7.2 0.3 0.1 0.5 100.0 61.3 586 30-34 15.2 77.1 6.6 0.1 0.3 0.7 100.0 83.7 439 35-39 8.8 84.7 4.3 0.1 0.6 1.5 100.0 88.9 553 40-44 3.5 89.7 4.2 0.2 0.3 2.1 100.0 93.8 462 45-49 1.8 88.6 6.1 0.0 0.9 2.6 100.0 94.6 400 Total 15-49 45.8 48.8 4.2 0.1 0.3 0.8 100.0 53.0 4,076 About 3 percent of women age 15-49 are widowed compared with less than one percent of men in the same age group. The proportion of women who are widowed increases with age, and at age 45-49 more than one in ten women is widowed. At age 45-49, only about 3 percent of men are widowed. About 2 percent of women and less than half a percent of men age 15-49 are divorced or separated1. 1 Data from 2003 DHS on marital status was derived from the household-level questionnaire administered to ever-married women only, so no comparison on marital status can be made. 80 | Other Proximate Determinants of Fertility 6.2 POLYGYNY Polygyny (the practice of having more than one wife) has implications for the frequency of exposure to sexual activity and, therefore, fertility. The extent of polygyny is ascertained from responses of currently married women to questions on whether their husband or partner has other wives and, if so, how many. Similarly, currently married men were asked for the number of wives they have. Table 6.2 presents, by background characteristics, the proportion of currently married women age 15-49 who are in a polygynous union. Data from the 2009-10 TLDHS show that about 2 percent of currently married women are in a polygynous union; that is, they have co-wives. The data further indicate that women in the youngest age group (15-19) and older women (40-49) are more likely to be in polygynous unions than women age 20-39. For example, about 3 percent of women age 45-49 are in a polygynous union compared with 1 percent of women age 20-24. Table 6.2 Number of co-wives and wives Percentage of currently married women age 15-49 with co-wives and percentage of currently married men age 15-49 with two or more wives, according to background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Percentage with co-wives Number of women Percentage with 2+ wives Number of men Age 15-19 2.4 243 * 4 20-24 1.2 1,100 0.0 125 25-29 1.5 1,516 0.0 359 30-34 2.1 1,362 0.6 368 35-39 1.9 1,514 1.3 492 40-44 2.6 1,211 0.9 433 45-49 2.9 960 2.0 378 Residence Urban 1.4 2,025 0.8 567 Rural 2.2 5,881 1.0 1,592 District Aileu 0.5 299 0.0 92 Ainaro 1.1 382 0.0 101 Baucau 1.6 852 1.3 237 Bobonaro 2.0 739 0.8 170 Covalima 3.9 458 0.0 123 Dili 0.7 1,459 0.9 416 Ermera 3.2 881 1.3 233 Lautem 6.6 541 2.8 163 Liquiçá 1.5 460 0.0 124 Manatuto 0.5 353 0.0 96 Manufahi 1.5 319 0.0 77 Oecussi 0.7 603 0.0 165 Viqueque 2.7 559 2.8 159 Education No education 2.9 2,909 2.1 523 Primary 1.7 2,027 0.8 650 Secondary 1.4 2,739 0.4 853 More than secondary 0.0 231 0.8 132 Wealth quintile Lowest 2.7 1,467 0.8 413 Second 1.8 1,487 0.0 408 Middle 2.6 1,559 2.1 411 Fourth 2.0 1,571 1.9 447 Highest 1.1 1,821 0.0 479 Total 2.0 7,906 0.9 2,158 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Other Proximate Determinants of Fertility | 81 Data by place of residence show only small differences. Polygyny ranges from a low of less than 1 percent among women living in Manatuto and Aileu to a high of 7 percent among women who live in Lautem. There is an inverse relationship between education and polygyny, with the proportion of women in a polygynous union decreasing from 3 percent among women with no education to zero among women with more than secondary education. Differences in the prevalence of polygyny among women in different wealth quintiles are not large. Table 6.2 also shows the percentage of currently married men 15-49 with two or more wives, according to background characteristics. The data indicate that less than 1 percent of men report having two or more wives, with polygyny higher among older men, among men living in Viqueque and Lautem, and among men with no education. 6.3 AGE AT FIRST MARRIAGE Marriage marks the point in a woman’s life when childbearing becomes socially acceptable. Age at first marriage has a major effect on childbearing because women who marry early have, on average, a longer period of exposure to the risk of becoming pregnant and a greater number of lifetime births. Information on age at first marriage was obtained by asking respondents the month and year, or age, at which they started living with their first husband or wife. Table 6.3 shows the percentage of women and men who have married by specific ages, according to current age. Marriage occurs relatively early in Timor-Leste: among women age 25-49, 24 percent are married by age 18, 42 percent are married by age 20, 59 percent are married by age 22, and 77 percent are married by age 25. The median age at (first) marriage among women age 25-49 is Table 6.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Timor-Leste 2009-10 Current age Percentage first married by exact age: Percentage never married Number Median age at first marriage 15 18 20 22 25 WOMEN 15-19 1.4 na na na na 91.8 3,144 a 20-24 3.0 18.9 35.3 na na 51.0 2,343 a 25-29 3.6 24.2 44.2 60.7 78.1 16.6 1,897 20.6 30-34 6.3 25.8 46.6 64.4 81.3 6.7 1,534 20.4 35-39 5.0 23.7 41.4 59.3 77.1 5.1 1,684 20.9 40-44 7.2 26.8 42.4 57.8 76.2 4.0 1,388 21.0 45-49 4.8 20.1 34.6 50.3 69.3 3.2 1,146 22.0 20-49 4.8 23.0 40.6 na na 17.9 9,993 a 25-49 5.3 24.3 42.3 59.0 76.8 7.8 7,650 20.9 MEN 15-19 0.0 na na na na 99.6 994 a 20-24 0.0 3.2 9.7 na na 80.1 643 a 25-29 0.0 3.8 12.8 25.5 50.1 37.8 586 25.0 30-34 0.0 5.3 13.5 27.5 50.7 15.2 439 24.9 35-39 0.0 6.2 14.4 25.7 50.7 8.8 553 24.9 40-44 0.0 4.0 12.3 23.9 46.2 3.5 462 25.4 45-49 0.0 4.3 12.8 23.1 43.1 1.8 400 26.2 20-49 0.0 4.4 12.5 na na 28.4 3,082 a 25-49 0.0 4.7 13.2 25.2 48.5 14.8 2,440 a 30-49 0.0 5.0 13.3 25.1 47.9 7.5 1,854 25.3 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner na = Not applicable due to censoring a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group 82 | Other Proximate Determinants of Fertility 20.9 years. Although the proportion of women married by age 15 has declined from 7 percent among women age 40-44 to 1 percent among women age 15-19, there is a noticeable decrease in the median age at marriage over the last few decades from 22.0 years among women age 45-49 to 20.6 years among women age 25-29. This trend is in contrast to what is usually seen in countries undergoing social change and increased access to schooling, which typically bring about a delay in the age at marriage. This trend is also confirmed when comparing similarly collected information from the 2003 DHS where the median age at first marriage among women age 25-49 was found to be 21.4 years. The system of dowry accepted in some communities in Timor-Leste, in which a man pays dowry to the prospective bride’s family, could exert some pressure for early marriage among women, because a man who marries a woman who is already pregnant is not obliged to give a dowry to her family prior to marriage. Men on the other hand marry much later than women. Table 6.3 shows that among men age 30-49, 5 percent were married by age 18, 13 percent by age 20, 25 percent by age 22, and 48 percent by age 25. The median age at marriage among men age 30-49 is 25.3 years. Table 6.4.1 shows the median age at first marriage among women age 25-49 by five-year age groups, according to background characteristics. Urban women marry only slightly later than rural women. The median age at marriage by district shows some notable variation. Women in Covalima marry two years earlier than women in Baucau. Table 6.4.1 Median age at first marriage: Women Median age at first marriage among women by five-year age groups and age 25-49, according to background characteristics, Timor-Leste 2009-10 Background characteristic Current age Women age 25-49 25-29 30-34 35-39 40-44 45-49 Residence Urban 20.7 21.2 21.9 20.5 21.0 21.1 Rural 20.6 20.1 20.7 21.2 22.2 20.8 District Aileu 20.6 19.8 20.6 21.0 20.8 20.6 Ainaro 20.0 20.1 21.6 21.0 22.9 20.8 Baucau 22.3 20.1 21.6 22.6 26.1 22.2 Bobonaro 21.1 19.7 20.7 21.5 22.0 21.0 Covalima 18.9 19.1 19.5 20.1 20.9 19.7 Dili 20.9 21.5 22.5 20.6 21.5 21.4 Ermera 21.1 20.7 20.1 20.4 22.0 20.8 Lautem 20.5 20.0 20.9 20.4 20.3 20.4 Liquiçá 21.7 20.1 20.2 20.6 21.1 20.7 Manatuto 20.6 21.4 21.8 21.2 22.2 21.3 Manufahi 20.3 20.2 20.9 21.6 22.7 20.7 Oecussi 18.8 19.4 20.3 20.7 19.6 19.8 Viqueque 19.9 20.6 20.7 22.3 22.9 21.0 Education No education 20.3 19.8 20.4 20.8 21.8 20.7 Primary 19.3 19.3 20.0 20.0 21.0 19.7 Secondary 21.0 21.0 21.8 22.3 25.0 21.5 More than secondary 24.9 24.9 (25.7) * * a Wealth quintile Lowest 19.8 19.9 20.8 22.0 23.8 20.9 Second 20.6 19.8 20.7 21.1 22.3 20.8 Middle 21.0 20.0 20.4 20.8 21.6 20.7 Fourth 20.6 20.4 20.4 20.3 20.8 20.5 Highest 20.8 21.3 22.0 20.9 21.8 21.3 Total 20.6 20.4 20.9 21.0 22.0 20.9 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. a = Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Other Proximate Determinants of Fertility | 83 There is no clear relationship between age at marriage and education. Women with primary education marry one year earlier (19.7) than women with no education (20.7) and two years earlier than women with secondary education (21.5). Similarly, the median age by wealth quintiles declines from 20.9 among women in the lowest wealth quintile to 20.5 among women in the fourth wealth quintile, then rises to 21.3 among women in the highest wealth quintile. Table 6.4.2 shows the median age at first marriage for men age 30-49 by five-year age groups, according to background characteristics. Median age among men varies substantially by place of residence. Urban men marry one and a half years later than rural men. Similarly, men in Dili marry nearly four years later than men in Oecussi. Table 6.4.2 Median age at first marriage: Men Median age at first marriage among men by five-year age groups and age 30-49, according to background characteristics, Timor-Leste 2009-10 Background characteristic Current age Men age 30-49 25-29 30-34 35-39 40-44 45-49 Residence Urban a 24.8 26.5 28.3 27.5 26.4 Rural 25.0 24.9 24.3 25.0 26.1 25.0 District Aileu (a) * (24.7) (25.2) (29.7) 25.7 Ainaro a (24.2) (25.0) (24.6) * 25.4 Baucau (24.0) (25.5) (23.9) (25.2) (29.2) 25.6 Bobonaro (a) (24.7) (25.4) (24.8) (26.4) 25.4 Covalima (a) (26.4) (23.8) (23.9) (26.2) 25.0 Dili 24.5 (24.6) 26.9 (29.4) (29.0) 26.9 Ermera (24.9) (25.6) (23.2) (24.7) (24.7) 24.8 Lautem (24.2) (24.5) 22.9 (25.1) (25.1) 24.1 Liquiçá a * (27.8) (25.9) (26.1) 26.3 Manatuto a (23.7) (25.6) (26.3) (28.1) 25.6 Manufahi (24.0) (26.7) (24.7) (25.6) * 25.2 Oecussi (23.7) (22.6) (23.2) (24.2) (23.9) 23.3 Viqueque (24.0) (24.5) 24.2 (24.8) (26.2) 24.7 Education No education a 25.7 25.0 24.3 25.4 25.0 Primary 23.3 23.4 24.3 24.6 24.8 24.3 Secondary a 24.8 24.6 26.2 29.4 25.6 More than secondary (a) (26.9) (27.5) * * 28.0 Wealth quintile Lowest 24.2 23.8 23.8 24.7 26.8 24.7 Second 24.8 25.7 25.3 25.4 27.6 25.9 Middle a 26.0 23.7 25.7 24.7 24.8 Fourth a 24.0 24.8 24.7 25.0 24.6 Highest a 24.8 26.8 28.1 28.0 26.7 Total 25.0 24.9 24.9 25.4 26.2 25.3 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. a = Omitted because less than 50 percent of the men married for the first time before reaching the beginning of the age group Education also influences age at marriage among men substantially, ranging from a low of 24.3 among men with primary education to a high of 28.0 years among men with more than secondary education. Similarly, men from the highest wealth quintile marry about one year later than men in the second wealth quintile and two years later than those from the other quintiles. 6.4 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is often used as a proxy for first exposure to intercourse and risk of pregnancy. But the two events may not occur at the same time because some people may engage in sexual activity before marriage. In the 2009-10 TLDHS, all women and men, irrespective of their marital status, were asked how old they were when they first had sexual intercourse. Table 6.5 shows by specific ages the proportions of women and men who had first sexual intercourse. 84 | Other Proximate Determinants of Fertility Table 6.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first intercourse, according to current age, Timor-Leste 2009-10 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse 15 18 20 22 25 WOMEN 15-19 1.1 na na na na 91.4 3,144 a 20-24 2.7 16.8 33.1 na na 50.6 2,343 a 25-29 2.9 22.4 43.8 59.6 76.3 16.6 1,897 20.7 30-34 5.5 25.2 44.7 62.7 79.2 6.2 1,534 20.5 35-39 4.2 22.4 39.6 57.7 74.8 4.8 1,684 20.9 40-44 5.6 25.2 41.5 57.2 73.9 3.9 1,388 21.0 45-49 3.8 20.6 35.4 51.1 69.2 2.8 1,146 21.8 20-49 4.0 21.7 39.4 na na 17.6 9,993 a 25-49 4.3 23.2 41.4 58.1 75.1 7.5 7,650 20.9 MEN 15-19 0.8 na na na na 89.9 994 a 20-24 0.1 9.2 32.6 na na 44.0 643 a 25-29 0.4 6.8 25.6 48.6 71.5 14.8 586 22.2 30-34 0.1 9.0 23.5 46.7 66.2 5.9 439 22.6 35-39 0.2 9.7 21.5 39.2 64.8 3.9 553 23.2 40-44 0.6 5.6 20.7 40.2 61.6 2.3 462 23.5 45-49 0.5 8.0 19.7 38.9 56.8 1.1 400 23.9 20-49 0.3 8.1 24.5 na na 14.0 3,082 a 25-49 0.4 7.8 22.4 42.9 64.8 6.1 2,440 23.0 30-49 0.3 8.1 21.4 41.2 62.6 3.4 1,854 23.3 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group The median age at first sexual intercourse among women age 25-49 is 20.9 years and is identical to the median age at first marriage, suggesting that Timorese women generally begin sexual intercourse at the time of their first marriage. Table 6.5 also shows that the median age at first sexual intercourse has decreased over the last two decades, from 21.8 years for women age 45-49 to 20.7 years for women age 25-29. The median age at first sexual intercourse among men age 25-49 (23.0 years) is two years later than among women in the same age group, primarily because men tend to marry later than women and, presumably, even among men, sexual intercourse tends to be initiated upon marriage. Nevertheless, the median age at first sexual intercourse among men age 30-49 is 23.3 years which is earlier than the median age at first marriage, indicating that some Timorese men do initiate sexual intercourse prior to marriage. Furthermore, the data show that about 28 percent of men age 20-49 are not married (Table 6.3), but only 14 percent in the same age group report never having had sexual intercourse (Table 6.5). The variation in the median age at first sexual intercourse among women by background characteristics is nearly identical to the median age at first marriage and is, therefore, not shown or discussed separately here. Table 6.6 shows the median age at first sexual intercourse for men, according to background characteristics. Differences by background characteristics are contrary to those discussed for median age at first marriage (Table 6.4.2). For example, the median age at first sexual intercourse is higher among rural than urban men in contrast with the median age at first marriage, which is higher among urban than rural men. Differences in the median age at first sexual intercourse by district are substantial. Men age 25-49 in Covalima initiate sex about five years earlier than men in Viqueque, Manufahi, Manatuto, and Ainaro; four years earlier than men in Liquiçá and Aileu; three years earlier Other Proximate Determinants of Fertility | 85 than men in Ermera; and two years earlier than men in Dili, with much smaller differences among men in Oecussi and Lautem. This is probably related to the well-known presence of commercial sex workers in Covalima. Men with primary education initiate sexual intercourse one year earlier than men at all the other education levels. Men in the second wealth quintile initiate sexual intercourse one year later than men in the lowest, fourth, and highest wealth quintiles. Table 6.6 Median age at first intercourse: Men Median age at first sexual intercourse among men by five-year age groups, age 25-49, and age 30-49, according to background characteristics, Timor-Leste 2009-10 Background characteristic Age Men age 25-49 Men age 30-49 25-29 30-34 35-39 40-44 45-49 Residence Urban 20.9 21.4 23.0 23.0 21.8 22.0 22.5 Rural 23.0 23.1 23.3 23.7 24.5 23.4 23.7 District Aileu (22.4) * (23.3) (23.6) (27.9) 23.8 25.1 Ainaro 24.0 (23.6) (24.8) (23.9) * 24.4 24.7 Baucau (a) (26.6) (24.6) (27.2) (30.0) a 26.5 Bobonaro (a) (24.7) (25.4) (24.4) (26.8) a 25.4 Covalima (18.8) (19.7) (20.0) (20.0) (20.2) 19.7 20.0 Dili 20.9 (21.3) 23.2 (23.7) (22.3) 22.2 22.9 Ermera (23.1) (24.3) (22.7) (21.6) (23.9) 23.0 22.9 Lautem (20.4) (20.3) 20.5 (20.7) (20.4) 20.5 20.5 Liquiçá 22.9 * (23.4) (24.2) (25.5) 23.9 24.8 Manatuto 22.8 (24.0) (25.3) (25.7) (28.1) 24.4 25.3 Manufahi (23.7) (27.2) (24.9) (25.5) * 24.9 25.2 Oecussi (19.5) (20.1) (19.7) (19.7) (20.6) 20.0 20.1 Viqueque (24.3) (24.7) 24.5 (25.4) (25.2) 24.8 24.9 Education No education 23.2 23.5 23.3 22.6 24.0 23.3 23.3 Primary 21.1 22.5 23.2 21.3 23.0 22.2 22.7 Secondary 22.6 22.3 22.8 24.7 25.2 23.3 23.7 More than secondary (21.6) (23.2) (23.9) * * 23.2 23.8 Wealth quintile Lowest 21.9 21.5 22.2 23.4 24.3 22.7 22.8 Second 22.5 22.8 24.4 23.3 25.8 23.8 24.3 Middle 23.0 24.5 22.7 24.8 22.8 23.2 23.3 Fourth 22.5 23.3 23.3 22.5 22.3 22.8 22.9 Highest 21.4 21.2 23.3 23.6 24.0 22.6 23.1 Total 22.2 22.6 23.2 23.5 23.9 23.0 23.3 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. a = Omitted because less than 50 percent of the men had intercourse for the first time before reaching the beginning of the age group 6.5 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the frequency of intercourse. Therefore, information on sexual activity can be used to refine measures of exposure to the risk of pregnancy. All women and men were asked how long ago their last sexual activity occurred, and Tables 6.7.1 and 6.7.2 show the percent distribution of women and men by recent sexual activity. About half of women age 15-49 were sexually active in the four weeks before the survey, 12 percent had been sexually active in the year before the survey but not in the month prior to the interview, and 7 percent had not been sexually active for one or more years. Thirty-five percent of women had never had sexual intercourse. 86 | Other Proximate Determinants of Fertility Table 6.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Timor-Leste 2009-10 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the last 4 weeks Within 1 year1 One or more years Missing Age 15-19 5.1 2.7 0.7 0.1 91.4 100.0 3,144 20-24 32.7 12.0 4.5 0.2 50.6 100.0 2,343 25-29 58.4 17.6 7.1 0.3 16.6 100.0 1,897 30-34 69.3 16.0 8.0 0.5 6.2 100.0 1,534 35-39 70.0 17.4 7.7 0.0 4.8 100.0 1,684 40-44 70.2 14.5 11.3 0.2 3.9 100.0 1,388 45-49 64.5 15.5 17.0 0.3 2.8 100.0 1,146 Marital status Never married 0.1 0.2 0.4 0.1 99.1 100.0 4,675 Married or living together 75.5 19.5 4.8 0.3 0.0 100.0 7,906 Divorced/separated/ widowed 3.4 11.4 84.9 0.2 0.0 100.0 556 Marital duration2 0-4 years 67.3 26.5 5.8 0.4 0.0 100.0 1,426 5-9 years 74.2 20.5 5.1 0.1 0.0 100.0 1,605 10-14 years 78.2 17.2 4.1 0.5 0.0 100.0 1,550 15-19 years 80.4 15.6 3.9 0.1 0.0 100.0 1,391 20-24 years 77.0 18.1 4.8 0.1 0.0 100.0 1,043 25+ years 76.4 18.6 4.6 0.4 0.0 100.0 768 Married more than once 77.9 14.6 7.5 0.0 0.0 100.0 123 Residence Urban 47.2 9.6 6.0 0.5 36.6 100.0 3,439 Rural 45.0 13.2 6.8 0.1 34.8 100.0 9,698 District Aileu 45.3 7.7 5.2 0.3 41.5 100.0 554 Ainaro 52.8 8.1 4.2 0.3 34.5 100.0 619 Baucau 53.9 5.4 4.1 0.0 36.6 100.0 1,408 Bobonaro 44.7 13.6 5.2 0.0 36.5 100.0 1,262 Covalima 48.6 10.0 6.8 0.0 34.6 100.0 781 Dili 50.3 7.8 5.0 0.6 36.4 100.0 2,466 Ermera 22.6 27.9 11.3 0.0 38.2 100.0 1,542 Lautem 52.3 9.8 5.9 0.7 31.3 100.0 864 Liquiçá 43.3 11.0 7.7 0.1 37.9 100.0 801 Manatuto 37.6 15.6 8.5 0.1 38.3 100.0 603 Manufahi 54.9 9.9 5.3 0.3 29.6 100.0 470 Oecussi 55.3 11.3 6.5 0.1 26.8 100.0 884 Viqueque 39.8 18.1 10.5 0.2 31.4 100.0 882 Education No education 54.9 17.0 10.5 0.1 17.5 100.0 3,854 Primary 52.5 12.4 8.0 0.4 26.7 100.0 3,005 Secondary 36.3 9.2 3.4 0.2 50.9 100.0 5,829 More than secondary 41.3 10.6 5.2 0.0 43.0 100.0 449 Wealth quintile Lowest 48.4 12.5 8.2 0.1 30.8 100.0 2,314 Second 42.6 14.8 7.7 0.2 34.6 100.0 2,468 Middle 44.4 13.3 6.3 0.2 35.9 100.0 2,590 Fourth 43.8 12.8 5.7 0.1 37.7 100.0 2,687 Highest 48.5 8.9 5.5 0.5 36.6 100.0 3,077 Total 45.6 12.3 6.6 0.2 35.3 100.0 13,137 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married The proportion of women who were sexually active during the four weeks before the survey increases with age, from 5 percent at age 15-19 to about 70 percent by age 30-44, and decreases to 65 percent at age 45-49. Women who are currently in a union are much more likely to be sexually active in the four weeks preceding the survey than women who were formerly married or who have never been married. Women married for fewer than five years are less likely to be sexually active in the recent past than women married for longer durations. There is little difference in recent sexual activity among women who have been married more than once and women who have been married just once. Other Proximate Determinants of Fertility | 87 Similarly, there is little difference in recent sexual activity among rural and urban women. Recent sexual activity is lowest among women in Ermera (23 percent), with about half as many women sexually active in the last four weeks as women in most other districts. Women who have no education are much more likely than women who have secondary and higher education to be sexually active. By wealth quintile, the percentage of women sexually active is U-shaped, i.e., higher among the women in the lowest and highest wealth quintile. Table 6.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Timor-Leste 2009-10 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the last 4 weeks Within 1 year1 One or more years Missing Age 15-19 4.8 2.7 2.7 0.0 89.9 100.0 994 20-24 25.0 17.1 13.9 0.0 44.0 100.0 643 25-29 59.3 17.7 7.8 0.3 14.8 100.0 586 30-34 69.2 18.8 6.1 0.0 5.9 100.0 439 35-39 76.1 15.0 5.0 0.0 3.9 100.0 553 40-44 78.7 13.0 5.1 0.9 2.3 100.0 462 45-49 78.2 12.0 8.2 0.5 1.1 100.0 400 Marital status Never married 11.1 9.4 8.5 0.0 71.0 100.0 1,865 Married or living together 80.7 15.4 3.6 0.4 0.0 100.0 2,158 Divorced/separated/ widowed 15.2 14.0 70.7 0.0 0.0 100.0 53 Marital duration2 0-4 years 74.2 21.6 4.1 0.0 0.0 100.0 429 5-9 years 80.7 15.9 2.5 0.8 0.0 100.0 470 10-14 years 82.7 14.1 2.8 0.4 0.0 100.0 485 15-19 years 83.9 12.3 3.8 0.0 0.0 100.0 406 20-24 years 83.3 13.6 3.1 0.0 0.0 100.0 220 25+ years 77.9 11.2 9.3 1.6 0.0 100.0 124 Married more than once (91.7) (6.0) (2.3) (0.0) (0.0) 100.0 25 Residence Urban 47.4 15.4 6.8 0.7 29.7 100.0 1,102 Rural 48.2 11.6 6.7 0.0 33.5 100.0 2,974 District Aileu 42.8 12.1 15.1 0.0 30.1 100.0 181 Ainaro 43.5 6.6 8.5 0.0 41.4 100.0 217 Baucau 57.7 0.8 1.5 0.0 40.0 100.0 415 Bobonaro 39.0 8.1 1.4 0.0 51.4 100.0 357 Covalima 61.1 12.3 7.5 0.0 19.1 100.0 236 Dili 51.9 16.4 4.7 1.0 26.1 100.0 797 Ermera 27.5 23.2 12.1 0.0 37.2 100.0 491 Lautem 51.0 6.7 5.3 0.0 36.9 100.0 308 Liquiçá 50.0 7.6 15.2 0.0 27.1 100.0 252 Manatuto 69.7 19.3 1.1 0.0 9.9 100.0 190 Manufahi 46.7 7.0 5.9 0.0 40.3 100.0 137 Oecussi 55.2 20.3 4.3 0.0 20.2 100.0 235 Viqueque 40.1 14.7 9.9 0.0 35.4 100.0 260 Education No education 54.7 15.0 6.6 0.0 23.7 100.0 791 Primary 54.0 12.6 5.8 0.4 27.2 100.0 1,046 Secondary 40.2 11.4 6.8 0.1 41.4 100.0 2,009 More than secondary 65.6 14.7 9.8 0.9 9.0 100.0 230 Wealth quintile Lowest 50.7 9.8 5.7 0.0 33.8 100.0 728 Second 44.8 12.7 6.4 0.0 36.0 100.0 781 Middle 47.0 11.7 7.1 0.0 34.2 100.0 786 Fourth 45.3 13.3 9.2 0.7 31.5 100.0 849 Highest 51.8 14.8 5.1 0.2 28.1 100.0 932 Total 15-49 48.0 12.6 6.7 0.2 32.5 100.0 4,076 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes men who had sexual intercourse within the last 4 weeks 2 Excludes men who are not currently married 88 | Other Proximate Determinants of Fertility There is little difference in the proportion of men and women age 15-49 who have been sexually active in the past four weeks (48 percent compared with 46 percent). Thirteen percent of men had sexual intercourse in the year before the survey but not in the month prior to the survey, while 7 percent had not been sexually active for one year or more. One in three men said that they have never had sex. As with women, sexual activity among men increases with age and peaks between age 40-44. Men currently in a union are much more likely to be sexually active than those not currently in a union. There is little variation in current sexual activity by marital duration or urban-rural residence. Regional variation for men shows similar patterns as for women. Recent sexual activity is lowest among men living in Ermera (28 percent) and highest among men living in Manatuto (70 percent). In contrast to the pattern found for women, the proportion of men sexually active in the past four weeks is highest among those with more than secondary education. As with women, the relationship between recent sexual activity and wealth quintile is U-shaped. 6.6 POSTPARTUM AMENORRHEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhea is the interval between the birth of a child and the resumption of menstruation, during which the risk of pregnancy is reduced. Postpartum protection from conception depends upon the intensity and duration of breastfeeding. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. A woman is considered insusceptible if she is not ex- posed to the risk of pregnancy, either be- cause she is amenorrheic or because she is abstaining from sexual intercourse following a birth. In the TLDHS, infor- mation was obtained about the duration of amenorrhea and the duration of sexual abstinence following childbirth for births in the three years preceding the survey. Table 6.8 shows the percentage of births in the three years preceding the survey for which mothers were postpar- tum amenorrheic, abstaining, and insus- ceptible, by number of months since birth. The results show that Timorese women are amenorrheic for a median of 8.2 months, abstain for a median of 3.2 months, and are insusceptible to pregnancy for a median of 9.1 months. In general, the proportion of women who are amenorrheic or abstaining decreases with increasing months after delivery. The proportion who are amenorrheic drops from 97 percent in the first two months after birth to 25 percent at 12 to 13 months and 7 percent at 24 to 25 months after birth. The majority of Timorese women (93 percent) are still abstaining from sex in the first two months following birth. A comparison of data from the 2003 DHS indicates that the median duration of postpartum amenorrhea has increased from 7.3 months to 8.2 months, which may be partly explained by the increase in exclusive breastfeeding, which contributes to anovulation and amenorrhea. Table 6.8 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, Timor- Leste 2009-10 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 <2 96.7 92.7 97.7 270 2-3 84.5 56.6 89.2 333 4-5 73.5 31.7 76.7 394 6-7 56.9 24.0 63.0 310 8-9 48.9 18.4 54.9 339 10-11 38.7 11.1 42.7 313 12-13 24.9 7.7 27.4 322 14-15 17.8 8.4 23.2 361 16-17 13.5 6.4 17.1 308 18-19 12.5 4.9 16.0 311 20-21 7.0 4.6 11.2 293 22-23 5.2 4.1 7.5 239 24-25 6.5 2.7 7.5 337 26-27 5.6 4.1 8.5 407 28-29 5.1 4.2 7.4 388 30-31 4.0 2.4 6.1 338 32-33 1.9 2.7 4.4 308 34-35 2.7 2.1 4.8 265 Total 28.2 15.6 31.5 5,836 Median 8.2 3.2 9.1 na Mean 10.4 6.1 11.6 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 Other Proximate Determinants of Fertility | 89 Table 6.9 shows the median duration of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics. The duration of postpartum insusceptibility is one month longer among women age 30-49 than among women age 15-29, is substantially longer among rural than urban women, and longer among women residing in Covalima than in the other districts. The duration of postpartum insusceptibility is also longer among women with no education than among those with some primary or secondary education, and twice as long among women from the lowest and second wealth quintiles as among women from the highest wealth quintile. Table 6.9 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, Timor-Leste 2009-10 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother’s age 15-29 7.7 3.2 8.6 30-49 8.8 3.2 9.9 Residence Urban 5.0 2.3 5.7 Rural 9.1 3.6 9.8 District Aileu 7.7 (2.3) 8.0 Ainaro 9.3 (2.3) 9.4 Baucau 8.8 (2.4) 9.5 Bobonaro 7.0 2.6 7.8 Covalima 8.3 3.8 12.1 Dili 4.2 2.1 4.6 Ermera 11.2 7.0 11.7 Lautem 6.5 (2.2) 7.0 Liquiçá 10.8 2.9 11.6 Manatuto 8.3 5.4 9.5 Manufahi 10.0 3.4 10.2 Oecussi 10.5 4.4 10.7 Viqueque 9.0 (5.8) 9.6 Education No education 10.0 3.5 10.7 Primary 8.4 3.3 9.5 Secondary 7.2 3.1 8.3 More than secondary * * * Wealth quintile Lowest 9.6 3.4 10.3 Second 9.9 3.5 10.2 Middle 8.1 3.3 9.0 Fourth 8.8 3.2 9.9 Highest 4.6 2.4 5.5 Total 8.2 3.2 9.1 Note: Medians are based on the status at the time of the survey (current status). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth 6.7 MENOPAUSE The risk of becoming pregnant declines with age. The term infecundity denotes a process rather than a well-defined event, and although the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a group of women. Table 6.10 presents data on menopause, an indicator of decreasing exposure to the risk of pregnancy (infecundity) for women age 30 and over. In the context of the available survey data, women are considered menopausal if they are neither pregnant nor postpartum amenorrheic and have not had a menstrual period for at least six months preceding the survey. The proportion of women who are menopausal increases with age from 90 | Other Proximate Determinants of Fertility 2 percent among women age 30-34 to 37 percent among women age 48-49. Overall, 8 percent of women age 30-49 are menopausal, indicating a relatively low level of infecundity among Timorese women. The proportion of currently married women age 30-49, who are menopausal as reported in the 2003 DHS is 17 percent, more than double the proportion reported in the 2009-10 TLDHS. Table 6.10 Menopause Percentage of women age 30-49 who are menopausal, by age, Timor-Leste 2009-10 Age Percentage menopausal1 Number of women 30-34 1.9 1,534 35-39 2.5 1,684 40-41 8.0 641 42-43 9.7 518 44-45 11.4 487 46-47 18.4 448 48-49 36.5 439 Total 8.2 5,753 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 Fertility Preferences | 91 FERTILITY PREFERENCES 7 Information on fertility preferences can be useful in understanding future fertility patterns and demand for contraception. The data are also used to construct measures of unmet need for contraception and assessments of unwanted or mistimed births. Fertility preferences also help to evaluate the overall attitudes of women toward childbearing and the general course of fertility. In the 2009-10 TLDHS, currently married women and men were asked about their fertility preferences, including their desire to have another child, the length of time they would like to wait before having another child, and what they consider to be their ideal number of children. These data make it possible to quantify fertility preferences and, in combination with the data on contraceptive use, permit estimation of the unmet need for family planning, for both spacing and limiting births. However, the interpretation of data on fertility preferences is controversial because respondents’ reported preferences are, in most cases, hypothetical, and do not take into consideration the influence of social pressure. Thus, preferences are subject to change and rationalization. Nevertheless, information on future reproductive intentions is of fundamental importance in the development of population policies and in refining and modifying existing family planning programs. 7.1 DESIRE FOR MORE CHILDREN In the 2009-10 TLDHS, currently married women and men were asked whether they want to have another child, and if so, how soon. The same question was phrased differently in the case of pregnant women or men whose wife or wives were pregnant at the time of the interview to ensure that they were asked not about the current pregnancy but rather about the desire for subsequent children. Table 7.1 shows future reproductive intentions of currently married women and men by the number of living children. Nine percent of women want to have another child soon (within two years), and 35 percent want another child two or more years later. This compares with 11 percent in the 2003 DHS. Another 35 percent want no more children, and about 1 percent have been sterilized. The total of women who either want to delay their next child or have no more children is therefore 70 percent, which contrasts greatly with the 22 percent who are currently taking contraceptives. This indicates an enormous opportunity to reach these women with contraceptive methods that match their needs and desires. The desire to stop childbearing—including those already sterilized—increases with the number of living children—from 2 percent among women with no children to 67 percent among women with six or more children. The proportion of currently married women who want no more children more than doubled in the last seven years, from 17 percent as reported in the 2003 DHS to 36 percent in the 2009-10 TLDHS. Presumably women who want no more children would benefit from increased awareness of long-term contraceptive methods and sterilization options. The great majority of these women are either taking no contraceptives or are still choosing injectables, which require administration every three months or more frequently. Asking these women to regularly access services appears to impose an unnecessary burden on them when longer-term and more permanent methods are available. Men’s reproductive intentions differ somewhat from those of women in the same age group. Men are more likely than women (15 percent compared with 9 percent) to want another child soon. On the other hand, there is only a small difference in their desire to want another child later (39 percent compared with 35 percent). Women are much more likely to want to limit childbearing than men, however. More than one in three women want no more children or are sterilized (36 percent) compared with about one in four men (23 percent), and this difference is consistent at all parities. 92 | Fertility Preferences Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Timor-Leste 2009-10 Desire for children Number of living children Total 15-49 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 27.7 15.7 10.9 11.5 6.9 4.7 2.0 8.6 Have another later3 4.3 60.0 54.8 47.1 35.9 26.6 12.7 35.1 Have another, undecided when 2.1 2.2 1.7 1.1 0.6 1.1 0.7 1.2 Undecided 21.9 14.7 17.7 17.4 15.8 17.3 16.8 16.9 Want no more 2.2 5.4 13.2 21.0 38.9 48.4 65.4 34.8 Sterilized4 0.0 0.2 0.3 0.7 0.9 0.9 1.4 0.8 Declared infecund 41.7 1.8 1.4 1.3 0.9 1.1 0.9 2.8 Missing 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 303 942 1,159 1,277 1,227 977 2,022 7,906 MEN5 Have another soon2 44.9 19.6 16.9 14.9 14.5 8.3 8.1 14.7 Have another later3 6.5 53.6 50.1 47.3 39.9 33.8 22.6 38.7 Have another, undecided when 2.8 2.8 3.9 2.5 1.0 0.4 1.4 2.0 Undecided 17.4 15.8 16.5 17.3 21.9 24.0 25.6 20.3 Want no more 0.7 7.3 11.5 16.5 20.6 31.9 40.7 21.8 Sterilized4 0.0 0.9 1.1 1.0 1.2 0.4 1.7 1.1 Declared infecund 27.7 0.0 0.0 0.5 0.9 1.1 0.0 1.5 Missing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 87 270 343 381 346 253 479 2,158 1 The number of living children includes current pregnancy for women. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 5 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). 7.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS Tables 7.2.1 and 7.2.2 show the desire to limit childbearing among currently married women and men by background characteristics. Urban women are more likely to want to limit childbearing than rural women. Differences by district in the desire to limit childbearing range from a low of 20 percent in Ainaro to a high of 48 percent in Oecussi. Overall, the desire to limit childbearing is higher among women with no education than among those with any level of education. This is true even taking into account the difference in fertility among women with different levels of education. For example, among women with one child, 16 percent of women with no education want no more children compared with 4 percent or less of women with some education. Among women with four or more children, the difference in desire to limit childbearing by education is small. Women living in the wealthiest households are more likely to want to limit childbearing than women in other households. A similar pattern is seen among men in the desire to limit childbearing by urban-rural residence, education, and wealth quintile, although the differences are smaller. The pattern by district differs somewhat, with men in Lautem and Ainaro least likely to want to limit the number of children and men in Covalima and Manatuto most likely. Given that men in Covalima and Manatuto had the greatest exposure to family planning messages, there appears to be an association between exposure to family planning messages and men’s desire to limit the number of children. Fertility Preferences | 93 Table 7.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Timor-Leste 2009-10 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 3.3 5.2 19.0 23.0 56.2 61.6 78.8 40.6 Rural 1.9 5.8 11.5 21.0 33.8 45.7 63.6 33.8 District Aileu * 9.2 10.1 22.9 25.9 43.6 65.9 36.0 Ainaro * 2.0 6.7 1.6 22.4 23.6 39.6 19.7 Baucau (4.3) 4.0 24.3 21.8 45.9 59.5 74.2 43.4 Bobonaro * 5.3 10.4 18.9 28.0 34.6 54.6 26.9 Covalima * 8.3 18.2 26.4 46.7 55.4 80.9 38.4 Dili (4.1) 5.6 20.9 25.8 65.8 67.2 80.2 42.7 Ermera (0.0) 8.1 4.1 17.7 22.5 41.9 57.6 31.4 Lautem * 3.3 0.0 3.8 27.3 34.5 68.5 29.9 Liquiçá (0.0) 6.1 6.9 24.7 19.7 31.6 60.8 30.2 Manatuto (3.5) 8.6 9.2 28.1 45.8 69.5 91.1 45.4 Manufahi * 7.6 9.2 20.9 29.6 60.6 56.0 29.4 Oecussi * 4.5 23.7 30.9 54.0 64.6 84.4 47.7 Viqueque (3.9) 1.9 7.6 20.6 15.6 37.7 54.6 25.6 Education No education 3.9 15.9 19.1 30.9 38.8 50.7 68.0 44.9 Primary 0.0 3.9 11.5 16.9 39.0 46.9 67.9 36.7 Secondary 1.9 2.2 10.8 17.0 40.4 47.5 61.6 25.6 More than secondary * (3.1) (17.9) (37.7) * * * 27.3 Wealth quintile Lowest 1.9 7.2 9.2 18.3 30.2 41.0 63.3 34.5 Second 1.7 3.7 12.2 18.1 35.5 46.9 60.3 33.1 Middle 3.7 7.7 9.1 22.8 31.1 43.1 64.8 32.9 Fourth 0.0 3.3 14.8 19.3 36.6 49.5 68.7 34.0 Highest 2.9 6.6 20.5 26.5 57.5 66.6 79.3 42.1 Total 2.2 5.6 13.5 21.6 39.8 49.2 66.8 35.6 Note: Women who have been sterilized are considered to want no more children. Figures in parentheses are based on 25- 49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. 1 The number of living children includes the current pregnancy. Table 7.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Timor-Leste 2009-10 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban * 4.3 23.2 18.9 29.3 36.9 53.6 25.9 Rural 0.8 10.1 8.1 16.8 19.1 31.2 39.7 21.8 District Aileu * * (14.0) * * (43.1) (57.0) 30.5 Ainaro * * * * (10.7) * * 8.6 Baucau * * (8.1) (10.9) (21.4) * (37.9) 20.5 Bobonaro * * * (19.0) * * (42.6) 23.4 Covalima * * * (44.0) * * (64.4) 44.8 Dili * (3.1) (25.2) (19.1) (33.6) * (64.2) 28.1 Ermera * * * * * * (16.4) 10.0 Lautem * * * * (15.9) (6.4) (14.1) 7.3 Liquiçá * (11.1) (6.7) (7.1) * * 51.8 23.1 Manatuto * * (6.8) (42.3) * (72.2) 83.8 44.4 Manufahi * * * * * * * 15.3 Oecussi * * * (22.1) (11.5) (33.8) (79.6) 29.3 Viqueque * * * * (18.0) * (38.1) 18.2 Education No education * 9.9 17.3 21.2 22.7 22.9 37.4 23.7 Primary * 12.7 6.8 21.6 16.2 32.2 46.0 25.1 Secondary (0.0) 4.0 13.2 13.6 25.2 35.8 42.2 21.0 More than secondary * * * (15.5) * * * 20.4 Wealth quintile Lowest * (3.6) 6.2 15.6 11.0 23.1 43.9 21.0 Second * 10.7 4.8 10.3 21.8 12.6 31.8 16.6 Middle * 9.1 12.3 14.0 24.4 34.9 31.2 20.5 Fourth * 9.1 9.3 27.6 15.8 43.1 46.1 25.2 Highest * (7.1) 23.6 18.3 36.8 (47.6) 67.5 29.5 Total 15-49 0.7 8.2 12.6 17.5 21.8 32.3 42.4 22.8 Note: Men who have been sterilized or who state in response to the question about desire for children that their wife has been sterilized are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. 1 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). 94 | Fertility Preferences 7.3 NEED FOR FAMILY PLANNING SERVICES Data in this section provide information on the extent of need and the potential demand for family planning services in Timor-Leste. Currently married fecund women who want to postpone their next birth for two or more years or who want to stop childbearing altogether but are not using a contraceptive method are considered to have an unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted. Similarly, amenorrheic women who are not using family planning and whose last birth was mistimed are considered to have an unmet need for spacing. Those whose last child was unwanted have an unmet need for limiting. Women who are currently using a family planning method are said to have a met need for family planning. The total demand for family planning services comprises those who fall in the met need and unmet need categories. Table 7.3 shows the need for family planning among currently married women by background characteristics. About one in three currently married women has an unmet need for family planning, with 21 percent having an unmet need for spacing and 10 percent having an unmet need for limiting. Twenty-two percent of women have a met need for family planning. If all currently married women who say they want to space or limit their children were to use a family planning method, the contraceptive prevalence rate would increase to 53 percent from the current 22 percent. Currently, only 42 percent of the family planning needs of currently married women are being met. There has been a seven-fold increase in unmet need for family planning over the past seven years, with unmet need rising from 4 percent in 2003 to 31 percent in 2009-10. Correspondingly, there has been an increase in met need over the same period, from 9 percent in 2003 to 22 percent in 2009- 10, resulting in a four-fold increase in total demand for family planning (13 percent to 53 percent). However, the percentage of demand satisfied declined by 44 percent over the same period, from 75 percent to 42 percent. This indicates that despite the very significant scaling up of family planning services, growth in demand for services has been even stronger. An acceleration of the scaling up of contraceptive service provision is called for. However, it should be noted that the calculation of unmet need differed slightly between the 2003 and 2009-10 surveys, and, therefore, the numbers are not strictly comparable. With the exception of women in the youngest and oldest age groups, overall unmet need varies little with age. However, the need for spacing does decrease with age, from 34 percent among women age 20-24 to 5 percent among women age 45-49. On the other hand, the unmet need for limiting increases with age, from 1 percent among women age 20-24 to 19 percent among women age 40-44, and then falls to 16 percent among women in the oldest age group. Overall, unmet need varies little by urban-rural residence; however, while the unmet need for spacing is greater among rural than urban women (22 percent compared with 18 percent), the unmet need for limiting is lower among rural than urban women (10 percent compared with 12 percent). The proportion of urban women’s total demand that is satisfied is higher than that of rural women (51 percent compared with 38 percent). Women in Covalima are least likely to have an unmet need for family planning (17 percent), and women in Ainaro are most likely (43 percent). With the exception of women with more than secondary education, who are least likely to have an unmet need for family planning (25 percent), there is little difference in unmet need among the other educational groups. In general, there is an inverse relationship between unmet need and wealth, with unmet need declining from 35 percent among women in the poorest households to 28 percent among women in the richest households. Fertility Preferences | 95 Table 7.3 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, Timor- Leste 2009-10 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 26.6 0.2 26.9 7.6 0.2 7.9 34.2 0.5 34.7 22.6 243 20-24 33.5 1.1 34.6 14.3 1.5 15.7 47.7 2.6 50.3 31.2 1,100 25-29 27.5 4.4 32.0 20.7 3.1 23.8 48.2 7.5 55.8 42.7 1,516 30-34 22.0 9.0 31.0 16.6 11.3 27.8 38.6 20.3 58.9 47.3 1,362 35-39 18.9 14.6 33.5 12.2 14.7 27.0 31.2 29.3 60.4 44.6 1,514 40-44 11.5 19.2 30.7 5.6 19.0 24.6 17.1 38.1 55.3 44.5 1,211 45-49 4.9 16.1 21.0 1.3 12.0 13.2 6.1 28.1 34.2 38.7 960 Residence Urban 17.6 11.6 29.2 16.5 13.9 30.4 34.1 25.4 59.5 51.0 2,025 Rural 21.5 9.8 31.3 11.0 8.6 19.6 32.5 18.3 50.9 38.4 5,881 District Aileu 21.6 8.5 30.1 11.0 9.7 20.7 32.6 18.2 50.8 40.8 299 Ainaro 37.5 5.9 43.4 8.9 5.2 14.1 46.4 11.1 57.4 24.5 382 Baucau 19.1 15.7 34.8 3.6 4.5 8.0 22.7 20.1 42.8 18.8 852 Bobonaro 32.7 9.0 41.6 13.3 7.1 20.4 46.0 16.1 62.1 32.9 739 Covalima 11.4 5.9 17.3 24.9 18.9 43.8 36.2 24.9 61.1 71.7 458 Dili 16.0 13.0 29.0 17.9 15.2 33.2 34.0 28.2 62.2 53.3 1,459 Ermera 16.1 6.7 22.9 12.4 6.4 18.8 28.5 13.1 41.6 45.1 881 Lautem 19.5 8.8 28.3 8.0 9.6 17.7 27.6 18.4 46.0 38.5 541 Liquiçá 21.4 7.6 29.0 14.0 10.5 24.5 35.4 18.1 53.5 45.8 460 Manatuto 13.8 13.4 27.1 11.1 9.7 20.7 24.8 23.0 47.9 43.3 353 Manufahi 15.9 6.6 22.4 16.3 9.0 25.3 32.1 15.6 47.7 53.0 319 Oecussi 23.9 16.0 39.8 9.9 14.2 24.1 33.8 30.1 63.9 37.7 603 Viqueque 24.2 7.0 31.2 7.5 5.6 13.1 31.6 12.6 44.2 29.6 559 Education No education 18.6 12.3 31.0 7.1 8.8 15.9 25.7 21.1 46.8 33.9 2,909 Primary 20.0 10.4 30.4 13.0 12.8 25.8 33.0 23.2 56.2 46.0 2,027 Secondary 23.0 8.3 31.3 16.8 8.9 25.7 39.8 17.2 57.0 45.1 2,739 More than secondary 19.9 5.5 25.4 21.6 11.2 32.8 41.5 16.7 58.2 56.3 231 Wealth quintile Lowest 23.0 12.0 35.0 8.3 6.7 15.0 31.3 18.8 50.0 30.0 1,467 Second 21.0 9.2 30.1 8.8 7.6 16.4 29.7 16.8 46.5 35.2 1,487 Middle 23.8 9.8 33.5 10.5 7.5 18.0 34.3 17.3 51.5 34.9 1,559 Fourth 20.4 7.6 28.0 14.5 10.9 25.3 34.8 18.5 53.3 47.5 1,571 Highest 15.6 12.3 27.9 18.5 15.7 34.2 34.1 28.0 62.1 55.1 1,821 Total 20.5 10.2 30.8 12.4 9.9 22.3 32.9 20.2 53.1 42.1 7,906 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrheic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrheic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and who say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using some method of family planning and who say they want no more children. Note that the specific methods used are not taken into account here. 7.4 IDEAL FAMILY SIZE In the TLDHS, ideal family size was measured in two ways. Respondents who did not have any children were asked the number of children they would like to have if they could choose the exact number to have, and respondents who had living children were asked how many children they would like to have if they could go back to the time when they did not have any children and choose exactly the number of children to have. Even though these questions are based on hypothetical situations, they provide two measures. First, for men and women who have not yet started a family, the data provide 96 | Fertility Preferences an idea of future fertility. Second, for older, high-parity women, the excess of past fertility over the ideal family size provides a measure of unwanted fertility. Responses to these questions for both women and men are presented in Table 7.4. Almost all women and men were able to provide a numeric response to these questions, with only 4 percent of women and 3 percent of men providing a non-numeric response. In contrast, the 2003 DHS reported that 20 percent of women gave a non-numeric response. Table 7.4 Ideal number of children Percent distribution of women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to number of living children, Timor-Leste 2009- 10 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN1 0 3.7 0.3 0.1 0.1 0.1 0.4 0.6 1.6 1 0.2 1.9 0.0 0.0 0.0 0.3 0.1 0.3 2 19.5 10.3 9.4 3.4 3.1 1.6 0.8 10.1 3 8.0 7.3 5.5 9.5 2.2 1.6 1.4 5.7 4 36.7 41.8 38.6 29.3 29.4 9.5 6.9 28.9 5 8.7 10.8 13.2 14.2 13.7 21.2 5.2 10.8 6+ 18.3 24.3 30.6 41.5 49.0 61.4 80.4 38.7 Non-numeric responses 4.9 3.3 2.6 2.0 2.5 4.1 4.6 3.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,008 1,090 1,262 1,346 1,290 1,028 2,113 13,137 Mean ideal number children for:2 All 3.9 4.4 4.7 5.1 5.4 6.2 7.2 5.0 Number 4,760 1,055 1,229 1,319 1,258 985 2,015 12,622 Currently married 4.6 4.5 4.8 5.1 5.4 6.2 7.2 5.7 Number 288 919 1,132 1,251 1,197 940 1,926 7,654 MEN3 0 6.2 0.9 0.0 0.0 0.0 0.0 0.0 3.0 1 0.2 0.2 0.0 0.5 0.0 0.0 0.0 0.1 2 12.5 7.0 7.1 1.1 0.7 0.8 0.5 7.4 3 9.8 7.6 2.8 5.5 0.2 1.3 0.1 6.1 4 34.5 41.4 42.6 24.2 21.1 11.8 7.3 28.9 5 13.5 9.1 15.2 24.8 15.2 20.7 4.5 13.9 6+ 19.6 31.6 30.8 42.6 60.8 62.4 84.6 37.6 Non-numeric responses 3.9 2.2 1.5 1.2 2.0 3.0 3.0 3.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,961 282 348 394 349 255 486 4,076 Mean ideal number children for:2 All 4.1 4.7 4.8 5.4 5.9 6.1 7.4 5.0 Number 1,885 276 343 389 342 247 472 3,954 Currently married 4.1 4.8 4.9 5.4 5.9 6.1 7.4 5.8 Number 87 264 338 378 339 246 464 2,115 1 The number of living children includes current pregnancy for women. 2 Means are calculated by excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). There is little difference between women and men in the overall mean ideal number of children they prefer. All women and men express a desire for five children. Currently married women and men prefer about six children, however. Data from the 2003 DHS show that the ideal number of children preferred by currently married women has changed little over the last seven years. Two in five women and men prefer an ideal family size of six children or more, while three in ten prefer 4 children. One-tenth of women express a preference for either two children or five children, with fewer men favoring two children over five children. There has been little change in the mean ideal number of children preferred over the last seven years. Fertility Preferences | 97 Table 7.4 shows that the mean ideal family size increases with the number of living children among both women and men, rising from 4 children among respondents with no children to just over 7 children among respondents with six or more children, indicating the positive association between actual and ideal number of children. This positive association between actual and ideal number of children could be due to two factors. First, to the extent that women are able to implement their fertility desires, women who want larger families will tend to achieve larger 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. Table 7.5 shows the mean ideal number of children for all women age 15-49 by background characteristics. The mean ideal number of children increases with age, ranging from a low of 3.9 children among women age 15-19 to a high of 6.1 children among women age 45-49. In the 2003 DHS the corresponding figures were 4.8 children for women age 15-19 and 5.8 for women age 45-49. This preference for fewer children in the youngest cohort may foretell an emerging shift in ideal family size preferences. The mean ideal number of children is higher in rural than in urban areas. The mean ideal number of children is lowest among women in Dili (4.3) and highest among women Ainaro (6.5). The mean ideal number of children varies inversely with education, with a nearly two-child difference between women with no education (5.8) and women with more than secondary education (3.9). The mean ideal number of children varies inversely with wealth, from 5.4 among women in the lowest quintile to 4.3 among women in the highest wealth quintile. 7.5 FERTILITY PLANNING Information collected from the TLDHS can also be used to estimate the level of unwanted fertility. Moreover, 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, wanted later (mistimed), or not wanted at all (unwanted) 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 may in fact result in an underestimate of the true extent of unwanted births. Table 7.6 shows the percent distribution of births (including current pregnancy) in the five years preceding the survey by planning status of the birth, and according to birth order and age of mother at birth. According to the data, 86 percent of births in the five years preceding the survey were wanted then, 12 percent were mistimed, and 2 percent were unwanted. In general, the proportion of unwanted births increases with birth order. Four percent of births of order four and higher and one percent of births of order three are unwanted. Mistimed births are most common at parity level two. Data from the 2003 DHS show that there has been little change in the planning status of children, with 86 percent of births in the five years preceding the survey planned and 11 percent mistimed. Unwanted births declined from 4 percent in 2003 to 2 percent in 2009-10. Table 7.5 Mean ideal number of children Mean ideal number of children for all women age 15-49 by background characteristics, Timor-Leste 2009-10 Background characteristic Mean Number of women1 Age 15-19 3.9 2,988 20-24 4.4 2,271 25-29 5.0 1,846 30-34 5.5 1,486 35-39 5.9 1,616 40-44 6.0 1,334 45-49 6.1 1,080 Residence Urban 4.4 3,204 Rural 5.2 9,417 District Aileu 5.3 543 Ainaro 6.5 552 Baucau 4.8 1,391 Bobonaro 5.2 1,247 Covalima 4.6 739 Dili 4.3 2,322 Ermera 5.8 1,534 Lautem 5.6 806 Liquiçá 4.8 755 Manatuto 4.5 586 Manufahi 4.9 450 Oecussi 4.5 855 Viqueque 5.4 843 Education No education 5.8 3,726 Primary 5.2 2,891 Secondary 4.4 5,575 More than secondary 3.9 429 Wealth quintile Lowest 5.4 2,232 Second 5.3 2,397 Middle 5.2 2,504 Fourth 5.0 2,578 Highest 4.3 2,910 Total 5.0 12,622 1 Number of women who gave a numeric response 98 | Fertility Preferences The percentage of unwanted births also increases with the mother’s age at birth, rising from a low of less than 1 percent among mothers below 30 years of age at birth to a high of 12 percent among mothers age 45-49 at birth. Mistimed births are generally more common among younger mothers (<34 years) than among older mothers (35-49 years). Table 7.6 Fertility planning status Percent distribution of births to women 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Timor-Leste 2009-10 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 92.7 6.8 0.3 0.1 100.0 1,836 2 83.1 16.4 0.3 0.2 100.0 1,695 3 84.9 14.3 0.8 0.1 100.0 1,594 4+ 85.0 11.2 3.7 0.1 100.0 5,602 Mother’s age at birth <20 88.2 11.1 0.4 0.3 100.0 810 20-24 85.7 13.7 0.4 0.2 100.0 2,621 25-29 86.7 12.6 0.7 0.1 100.0 2,533 30-34 85.5 11.5 2.8 0.2 100.0 2,266 35-39 86.5 9.3 4.2 0.0 100.0 1,692 40-44 82.5 9.7 7.7 0.0 100.0 655 45-49 82.8 5.7 11.5 0.0 100.0 149 Total 86.0 11.7 2.2 0.1 100.0 10,727 The extent of unwanted births can also be estimated using information on ideal family size to calculate what the total fertility rate would be if all unwanted births were avoided. 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. Table 7.7 shows total wanted fertility rates and actual fertility rates, by background characteristics. Total wanted fertility rates are calculated in the same way as the total fertility rate but exclude unwanted births from the numerator. In this case, unwanted births are those that exceed the number mentioned as ideal by the respondent. This rate represents the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been avoided. Table 7.7 shows that women on average have about half a child more than the wanted number of 5.1 children. The observed total fertility rate is 17 percent higher than the wanted total fertility rate in urban areas, and is 11 percent higher in rural areas. There is a one- child difference between wanted and actual fertility in the district of Oecussi, and there is a slightly less than one-child difference in Liquiçá and Manufahi, with smaller differences in the other districts. The gap between wanted and observed fertility is widest among women with primary education and among women in the lowest wealth quintile. Table 7.7 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Timor-Leste 2009-10 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 4.2 4.9 Rural 5.4 6.0 District Aileu 5.0 5.6 Ainaro 6.9 7.2 Baucau 5.3 5.5 Bobonaro 5.6 6.0 Covalima 4.1 4.4 Dili 3.8 4.6 Ermera 5.9 6.6 Lautem 5.9 6.7 Liquiçá 4.6 5.5 Manatuto 5.3 5.5 Manufahi 5.0 5.9 Oecussi 5.6 6.6 Viqueque 5.4 5.6 Education No education 5.6 6.1 Primary 5.8 6.5 Secondary 4.7 5.2 More than secondary 2.7 2.9 Wealth quintile Lowest 6.6 7.3 Second 5.4 6.0 Middle 5.7 6.1 Fourth 4.8 5.3 Highest 3.6 4.2 Total 5.1 5.7 Note: Rates are calculated based on births to women age 15-49 in the period 1 to 36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. Infant and Child Mortality | 99 INFANT AND CHILD MORTALITY 8 Infant and child mortality rates are the basic indicators of a country’s socioeconomic development and quality of life as well as the specific measures of its health status. Measures of childhood mortality have value in population projections and show the progress of health programs and policies. Variations in mortality by demographic characteristics, such as sex and age, and by socioeconomic characteristics, such as urban-rural residence, district, mother’s education, and household wealth, serve to highlight those factors that most influence child survival. Analysis of mortality measures helps identify promising directions for health and nutrition programs and improves the overall odds of children surviving to adulthood. This chapter presents estimates of levels, trends, and differentials in neonatal, postneonatal, infant, child, and under-5 mortality in Timor-Leste. The data for mortality estimates were collected through the birth history section of the Woman’s Questionnaire. Women of reproductive age (15-49) were asked a series of questions on the number of biological sons and daughters living with them, the number living elsewhere, and the number who have died. In addition, for each live birth, women were asked to provide information on sex, date of birth, whether the birth was single or multiple, and survival status of the child. Current age was collected for living children, and age at death was collected for children who died. 8.1 DEFINITION, DATA QUALITY, AND METHODOLOGY Childhood mortality estimates in DHS surveys measure the risk of dying from birth through age 5. The rates of childhood mortality presented in this chapter are defined as follows: Neonatal mortality (NN): the probability of dying between birth and the first month of life Postneonatal mortality (PNN): the difference between infant and neonatal mortality Infant mortality (1q0): the probability of dying between birth and exact age 1 Child mortality (4q1): the probability of dying between exact age 1 and exact age 5 Under-5 mortality (5q0): the probability of dying between birth and exact age 5. All rates are expressed per 1,000 live births, except child mortality, which is expressed per 1,000 children surviving to age 12 months. Information on stillbirths and deaths that occurred within seven days of birth is used to estimate perinatal mortality, which is the number of stillbirths and early neonatal deaths per 1,000 stillbirths and live births. 8.2 ASSESSMENT OF DATA QUALITY The accuracy of mortality estimates depends on the sampling variability of the estimates and on nonsampling errors. Sampling variability and sampling errors are discussed in detail in Appendix C. Nonsampling errors depend on the extent to which the date of birth and age at death are accurately reported and recorded and the completeness with which child deaths are reported. Omission of births and deaths affects mortality estimates, displacement of birth and death dates influences mortality trends, and misreporting of age at death may distort the age pattern of mortality. Typically, the most serious source of nonsampling errors in a survey that collects retrospective information on births and deaths is the underreporting of births and deaths of children who were dead at the time of the survey. It may be that mothers are reluctant to talk about their dead children because of the sorrow associated 100 | Infant and Child Mortality with their death, or they may live in a culture that discourages discussion of the dead. The possible occurrence of these data problems in the 2009-10 TLDHS is discussed with reference to the data quality tables in Appendix C. Underreporting of births and deaths is generally more common the further back in time an event has occurred. An unusual pattern in the distribution of births by calendar years is an indication of omission of children or age displacement. In the TLDHS, the cutoff date for asking health questions was January 2004. Table C.4 shows that the overall percentage of births for which a month and year of birth was reported is almost 100 percent for both children who have died and children who are alive. Table C.4 shows some age displacement across this boundary for both living and dead children. The distribution of living children and the total number of children shows a deficit in 2004 and an excess in 2003, as denoted by the calendar year ratios. The deficit in 2004 can be attributed to the transference of births by interviewers out of the period for which health data were collected. Transference is proportionately higher for dead children than for living children, and this displacement may affect mortality rates. The transference of children, especially deceased children, out of the five-year period preceding the survey is likely to result in an underestimate of the true level of childhood mortality for that period. Underreporting of deaths is usually assumed to be more common for deaths that occur very early in infancy. Omission of deaths or misclassification of deaths as stillbirths may also be more common among women who have had several children or in cases where death took place a long time ago. To assess the impact of omission on measures of child mortality, two indicators are used: (1) the percentage of deaths that occurred within seven days of birth to the number that occurred within one month of birth and (2) the percentage of neonatal to infant deaths. It is hypothesized that omission will be more prevalent for those who died immediately after birth than for those who lived longer, and that it will be more common for events that took place in the distant past compared with those that took place in the more recent past. Table C.5 shows data on age at death for early infant deaths. Selective underreporting of early neonatal deaths would result in an abnormally low ratio of deaths within the first seven days of life to all neonatal deaths. Early infant deaths have not been greatly underreported in the TLDHS survey, as suggested by the high ratio of deaths in the first seven days of life to all neonatal deaths (76 percent in the five years preceding the survey). Heaping of the age at death on certain digits is another problem that is inherent in most retrospective surveys. Misreporting of age at death biases age pattern estimates of mortality if the net result is the transference of deaths between age segments for which the rates are calculated. For example, child mortality may be overestimated relative to infant mortality if children who died in the first year of life are reported as having died at age 1 or older. In an effort to minimize misreporting of age at death, interviewers were instructed to record deaths at under 1 month in days and deaths at under 2 years in months. In addition, they were trained to probe deaths reported at exactly 1 year or 12 months to ensure that they had actually occurred at 12 months. The distribution of deaths under 2 years during the 20 years prior to the survey by month of death shows that there is some heaping at 6, 9, and 12 months of age, with corresponding deficits in adjacent months (Table C.6). However, heaping is less pronounced for deaths in the five years preceding the survey, for which the most recent mortality rates are calculated. 8.3 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Neonatal, postneonatal, infant, child, and under-5 mortality rates are shown in Table 8.1 for cohorts of children born in three consecutive five-year periods before the survey. Under-5 mortality for the most recent period (0-4 years before the survey or, roughly, during the calendar years 2005- 2009) is 64 deaths per 1,000 live births. This means that 1 in 16 children born in Timor-Leste dies before the fifth birthday. Seventy percent of deaths among children under age 5 occur during the first year of life: infant mortality is 45 deaths per 1,000 live births. During infancy, the risk of neonatal deaths and postneonatal deaths is 22 and 23 per 1,000 live births, respectvely. The proportion of child deaths that occurs in the neonatal period (34 percent) in Timor-Leste is lower than the global estimation of 38 percent (Lawn et al., 2005). Infant and Child Mortality | 101 Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Timor-Leste 2009-10 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 22 23 45 20 64 5-9 30 37 68 32 98 10-14 36 47 83 36 115 1 Computed as the difference between the infant and neonatal mortality rates Mortality trends can be examined in two ways: by comparing mortality rates for three five- year periods preceding a single survey and by comparing mortality estimates obtained from various surveys. However, comparisons between surveys should be interpreted with caution because quality of data, time references, and sample coverage vary. In particular, sampling errors associated with mortality estimates are large and should be taken into account when examining trends between surveys. Data from the TLDHS for the three five-year periods preceding the survey indicate a decline in childhood mortality. For example, infant mortality estimates show a decline from 83 in the 10 to 14 years preceding the survey to 68 in the five- to nine-year period preceding the survey and to 45 during the most recent five-year period. A similar trend is seen for the other under-5 mortality indicators. Comparison of the TLDHS 2009-10 mortality data with the 2003 DHS survey results shows a substantial (23 percent) improvement in child survival (Figure 8.1). For example, under-5 mortality declined from 83 per 1,000 live births during the period 1999-2003 to 64 per 1,000 live births during the period 2005-2009. This is caused principally by a decrease in the infant mortality rate, from 60 per 1,000 for the zero to four years preceding the 2003 DHS to 45 per 1,000 during the same period prior to the 2009-10 TLDHS. The decline in neonatal, infant and under-5 mortality in the five years preceding the TLDHS 2009-10 indicates that Timor-Leste is on track to reduce infant and under-5 mortality to reach the target for Millennium Development Goal (MDG) 4, that is, to reduce under-5 mortality by two-thirds by 2015. It is notable that the proportion of neonatal deaths to under-5 deaths (34 percent) is relatively lower in Timor-Leste than in the other neighboring countries of Indonesia, Philippines, Bangladesh, India, and Nepal as measured in the latest DHS surveys in these countries. Neonatal mortality is generally higher than postneonatal mortality, but the pattern observed in the 2009-10 TLDHS is unusual. The common indicators of data quality, including the proportion of neonatal deaths that occur in the first seven days, the ratio of neonatal deaths to perinatal deaths, and the heaping of deaths around one month do not show obvious problems with data quality; however, it is possible that some neonatal deaths have been omitted. 102 | Infant and Child Mortality Figure 8.1 Mortality Trends 21 39 60 23 83 22 23 45 20 64 Neonatal Postneonatal Infant Child Under-five 0 20 40 60 80 100 Deaths per 1,000 2003 DHS 2009-10 TLDHS Timor-Leste 2009-10 Note: Data for the neonatal mortality and postneonatal mortality rates for the 2003 DHS are unadjusted. 8.4 SOCIOECONOMIC DIFFERENTIALS IN MORTALITY Child survival closely relates to socioeconomic and demographic characteristics such as residence, region, mother’s education, and household wealth status (quintile). These differentials are presented in Table 8.2. To minimize sampling errors associated with mortality estimates and to ensure a sufficient number of cases for statistical reliability, the mortality rates shown in Table 8.2 are calculated for a ten-year period. Mortality in rural areas is consistently higher than in urban areas. In the 10-year period before the survey, infant mortality in rural areas was 61 deaths per 1,000 live births, compared with 42 deaths per 1,000 live births in urban areas. The under-5 mortality rate during the same period was 87 deaths per 1,000 live births in rural areas and 61 deaths per 1,000 live births in urban areas. This variation between rural and urban settings may be because of poor access to health care, a weak communication system (road and transport, telecommunication), and frequent uses of harmful indigenous practices in the rural areas (MOH, 2002b; Zwi et al., 2009; HAI, 2005). The TLDHS 2009-10 data show wide variations in mortality by district. Under-5 mortality is lowest in Baucau (42 deaths per 1,000 live births) and highest in Ermera (102 deaths per 1,000 live births), with Liquiçá (101 per 1,000) following closely behind. Neonatal mortality is highest in Manufahi (44 per 1,000) and contributes to 51 percent of under-5 mortality in the district. Infant mortality varies from 30 deaths per 1,000 live births in Baucau to 77 per 1,000 in Ainaro. Infant and Child Mortality | 103 Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by background characteristic, Timor-Leste 2009-10 Background characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 21 21 42 20 61 Rural 28 33 61 28 87 District Aileu 27 29 56 21 76 Ainaro 31 46 77 22 97 Baucau 11 18 30 12 42 Bobonaro 27 23 50 36 85 Covalima 37 38 76 21 95 Dili 21 18 39 22 60 Ermera 23 47 70 34 102 Lautem 36 33 69 31 98 Liquiçá 31 37 68 35 101 Manatuto 31 19 50 20 69 Manufahi 44 19 62 25 86 Oecussi 25 41 66 27 92 Viqueque 24 31 54 24 77 Mother’s education No education 27 34 61 31 90 Primary 27 32 59 27 84 Secondary 26 25 51 19 69 More than secondary (9) (12) (21) * * Wealth quintile Lowest 24 37 62 27 87 Second 30 38 68 28 94 Middle 29 30 59 32 89 Fourth 25 30 56 27 81 Highest 22 16 38 15 52 Note: Numbers in parentheses are based on 250-499 unweighted exposed persons; an asterisk indicates that a rate is based on fewer than 250 unweighted exposed persons and has been suppressed. 1 Computed as the difference between the infant and neonatal mortality rates As expected, a mother’s education is inversely related to a child’s risk of dying. Under-5 mortality among children of mothers with no education (90 deaths per 1,000 live births) is substantially higher than under-5 mortality among children of women with secondary level education (69 deaths per 1,000 live births). The direct association between level of education and under-5 mortality is also seen for infant mortality. Children of women with no education (61 deaths per 1,000 live births) are much more likely to die in the first year than children of women with secondary education (51 deaths per 1,000 live births).The relationship between household wealth and under-5 mortality is not always consistent, although children born to mothers in the highest wealth quintile clearly are at much lower risk of dying than children born to mothers in the other quintiles. 8.5 DEMOGRAPHIC CHARACTERISTICS AND CHILD MORTALITY Studies have shown that a number of demographic factors are strongly associated with the survival chances of young children. These factors include sex of child, age of mother at birth, birth order, length of preceding birth interval, and size of child at birth. Table 8.3 shows the relationship between childhood mortality and these demographic variables. Again, for all variables except birth size, mortality estimates are calculated for the 10-year period preceding the survey to reduce sampling variability. Mortality rates by birth size are for the five-year period preceding the survey because information on birth size was collected only for children born in the past five years. Childhood mortality is higher for males than females (Table 8.3) for all mortality rates. Under-5 mortality rates for male and female children are 85 and 76 deaths per 1,000 live births, respectively. The excess mortality among male children is mostly due to their higher biological risk during the first month of life. 104 | Infant and Child Mortality Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 10-year period preceding the survey, by demographic characteristics, Timor-Leste 2009-10 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 28 31 59 27 85 Female 24 29 53 24 76 Mother’s age at birth <20 35 39 74 31 103 20-29 26 32 58 26 83 30-39 25 27 53 24 75 40-49 22 19 41 25 65 Birth order 1 34 29 63 22 83 2-3 26 28 53 24 76 4-6 22 31 53 25 77 7+ 27 35 62 34 94 Previous birth interval2 <2 years 35 44 79 38 114 2 years 21 26 48 24 71 3 years 19 22 41 18 58 4+ years 13 17 31 16 46 Birth size3 Small/very small 34 26 61 na na Average or larger 18 21 40 na na na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey Results from the TLDHS 2009-10 confirm the expected relationship between mothers who give birth at a very young age and childhood mortality. For example, under-5 mortality is 103 deaths per 1,000 livebirths to mothers age less than 20 years at birth compared with 83 and 75 deaths per 1,000 livebirths to mothers age 20-29 and 30-39, respectively. However, a similar pattern is not visible for older mothers age 40-49 who, similar to very young mothers, are also in a high-risk group. Under-five mortality to mothers age 40-49 is 65 deaths per 1,000 livebirths. This anomalous distribution may be due to large sampling errors associated with the much smaller number of births to women in this age group. In general, first births and births of order 7 and higher also suffer significantly higher rates of mortality than births of orders 2-3 and 4-6. For example, 1 in 16 first births did not survive to the first year, compared with 1 in 19 second- and third-order births. In contrast, child mortality and postneonatal mortality tend to increase linearly with birth order. The increase in the child mortality rate with birth order may reflect a more intense competition faced by higher birth order children for the caregiver’s time, for utilization of health care, and for nutritious food once children are weaned. Short birth intervals are associated with an increased risk of dying. Different studies have revealed an association between short birth intervals (less than 2 years) and increased mortality, even after controlling for other demographic and socioeconomic variables. In Table 8.3, all childhood mortality rates show a sharp decrease as the length of the birth interval increases. Neonatal, infant, child, and under-5 mortality rates are more than two and a half times higher for children born after an interval of less than 2 years, compared with children who are born after an interval of 4 years or longer. A child’s size at birth has often been found to be an important indicator of the chances of survival during infancy. The majority of births in Timor-Leste take place at home, and these babies are seldom weighed at birth. The mother’s assessment of the size of the baby at birth is therefore used as a proxy for birth weight. The TLDHS results indicate that among babies assessed by their mother to be small or very small, infant mortality is one and a half times the level observed for babies assessed as average or larger at birth. Infant and Child Mortality | 105 8.6 PERINATAL MORTALITY The perinatal mortality rate serves as a good indicator of the state of health of a population generally, and this holds true at delivery in particular. It reflects the level of utilisation of health services and the ability of women to cope with the demands of childbirth to deliver a healthy baby. Women in the TLDHS 2009-10 were asked to report on any pregnancy loss that occurred in the five years preceding the survey. For each pregnancy that did not end in a live birth, the duration of pregnancy was recorded. In this report, perinatal deaths include pregnancy losses of at least seven months’ gestation (stillbirths) and deaths among live births that occurred within the first seven days of life (early neonatal deaths). The perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the sum of all stillbirths and live births. Information on stillbirths and infant deaths that occurred within the first week of life is highly sus- ceptible to omission and misreporting. However, retrospective surveys such as the TLDHS 2009-10 generally provide more representative and accurate perinatal death rates than the vital registration system and hospital-based studies. Table 8.4 shows that out of the 9,850 reported pregnancies of at least seven months’ gestation, 22 were stillbirths and 158 were early neonatal deaths, yielding an overall perinatal mortality rate of 18 per 1,000 pregnancies of seven or more months’ duration. Perinatal mortality is highest among mothers less than age 20 (24 per 1,000 pregnancies) and lowest among mothers age 20-29 (16 per 1,000 pregnan- cies). First pregnancies and pregnancies that occur after an interval of less than 15 months are much more likely than pregnan- cies that occur after longer intervals to end in a perinatal loss. Perinatal mortality is also higher among women in rural areas than in urban areas (20 and 14 per 1,000 pregnancies, respectively). Mothers with more than secondary education are less likely to experience pregnancy losses than less educated mothers. There is no clear relationship between perinatal mortality and household wealth status. Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Timor-Leste 2009-10 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnan- cies of 7+ months duration Mother’s age at birth <20 2 16 24 748 20-29 10 64 16 4,686 30-39 5 68 20 3,688 40-49 5 11 22 728 Previous pregnancy interval in months4 First pregnancy 4 35 24 1,639 <15 2 17 36 509 15-26 9 56 19 3,331 27-38 3 28 13 2,449 39+ 4 23 14 1,922 Residence Urban 6 28 14 2,358 Rural 16 130 20 7,491 District Aileu 0 5 13 359 Ainaro 1 14 25 580 Baucau 0 6 7 970 Bobonaro 1 17 20 936 Covalima 5 6 23 458 Dili 0 20 12 1,652 Ermera 5 22 22 1,258 Lautem 5 12 22 763 Liquiçá 3 9 20 585 Manatuto 0 8 19 433 Manufahi 1 16 41 393 Oecussi 2 11 16 785 Viqueque 0 12 17 678 Mother’s education No education 7 48 17 3,305 Primary 8 44 19 2,774 Secondary 6 65 20 3,552 More than secondary 0 1 6 218 Wealth quintile Lowest 4 25 14 2,094 Second 2 48 25 1,962 Middle 7 37 22 1,998 Fourth 6 22 14 1,909 Highest 3 27 16 1,887 Total 22 158 18 9,850 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration, expressed per 1000. 4 Categories correspond to birth intervals of <24 mos., 24-35 mos., 36-47 mos., and 48+ mos. 106 | Infant and Child Mortality 8.7 HIGH-RISK FERTILITY BEHAVIOR The survival of infants and children depends in part on the demographic and biological characteristics of their mothers. These characteristics are of particular importance because many health problems are easily avoidable at a relatively low cost. Infants and children have an elevated risk of dying if their mothers are too young (under 18 years of age) or too old (over 35 years old), if they are born after too short a birth interval (less than 24 months), and if they are of high birth order (mother has three or more children). Although first births are commonly associated with higher mortality risk, they are not included in the high-risk category because the risks associated with first births are unavoidable. Table 8.5 shows the percent distribution of children born in the five years preceding the survey and the percent distribution of currently married women, by risk factors. The table also shows the risk ratio (of dying) for children, by comparing the proportion of dead children in each risk category with the proportion of dead children not in any high-risk category. Table 8.5 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Timor- Leste 2009-10 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 18.7 1.00 12.2a Unavoidable risk category First order births between ages 18 and 34 years 15.1 1.33 3.6 Single high-risk category Mother’s age <18 1.9 1.52 0.3 Mother’s age >34 1.5 1.73 4.7 Birth interval <24 months 9.6 1.36 9.1 Birth order >3 21.8 1.26 13.8 Subtotal 34.9 1.32 27.9 Multiple high-risk category Age <18 & birth interval <24 months2 0.2 * 0.2 Age >34 & birth interval <24 months 0.3 * 0.3 Age >34 & birth order >3 16.7 1.30 35.5 Age >34 & birth interval <24 months & birth order >3 4.9 2.75 8.8 Birth interval <24 months & birth order >3 9.3 1.90 11.5 Subtotal 31.3 1.70 56.3 In any avoidable high-risk category 66.2 1.50 84.2 Total 100.0 na 100.0 Number of births/women 9,828 na 7,906 Notes: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women Two-thirds (66 percent) of births in Timor-Leste have elevated mortality risks that are avoidable, and about one in five (19 percent) are not in any high-risk category. Among those who are at risk, 35 percent of births are in a single high-risk category, while 31 percent of births are in multiple high-risk categories. In general, risk ratios are higher for children in multiple high-risk categories than for those in a single high-risk category. Infant and Child Mortality | 107 The most vulnerable births are those to women who are age 35 or older, with a birth interval less than 24 months, and birth order of three or higher. These children are about three times more likely to die than children not in any high-risk category. However, only five percent of births are in this category. Twenty-two percent of births occur to mothers who have three or more births, and another 17 percent of births occur to mothers who are 35 years or older and have had three or more children. These children whose mothers are 35 years or older and have had three or more children however, are only slightly more likely to die than children in the no high-risk category. The final column of Table 8.5 shows the distribution of currently married women who have the potential for having a high-risk birth, by category of risk. Thirty-six percent of women are over age 35 and have three or more children. The potential for having a birth in a multiple high-risk category is much higher (56 percent) than the potential for having a birth in a single high-risk category (28 percent). Eighty-four percent of women are in any high-risk category. Adult and Maternal Mortality | 109 ADULT AND MATERNAL MORTALITY 9 The Safe Motherhood Initiative, launched in 1987, drew increased worldwide attention to reproductive health, as did the need for reliable countrywide estimates of maternal deaths. In response to this increased interest, DHS surveys began collecting maternal mortality data through a series of questions designed to obtain a direct measure of maternal mortality. More recently, in an effort to improve global health, the United Nations Development Program initiated the Millennium Development Goals (MDG), with Goal 5 focused on the reduction of maternal mortality by three- quarters between 1990 and 2015. The government of Timor-Leste hopes that its strong commitment to a reproductive health strategy, a national family planning policy, training for health providers on safe, clean deliveries and emergency obstetric care, and the equipping of established health facilities will result in a reduction in the maternal mortality ratio (MMR) to 252 deaths per 100,000 by the year 2015 from a baseline estimate of 660 in 2000 (UNDP and the Government of Timor-Leste, 2009). Estimates of maternal mortality in Timor-Leste have ranged from a low of 380 deaths per 100,000 live births to a high of 880 deaths per 100,000 live births (HAI, 2010). Data from WHO, UNICEF, UNFPA, and the World Bank for 2005 indicate that the MMR is 380 deaths per 100,000 live births (WHO et al., 2004). In 2008, WHO, UNICEF, UNFPA, and the World Bank estimated, from reports by national authorities, an adjusted maternal mortality ratio of 370 per 100,000 women and a lifetime risk of 1 in 44 deaths to women from maternal causes (WHO et al., 2010). These various model-based estimates of MMR are extrapolated from indirect estimates of other published health-related information. Estimating maternal mortality requires a comprehensive and accurate reporting of maternal deaths. Data from the 2009-10 TLDHS provides for the first time a direct estimate of maternal mortality from a population-based survey. The data presented in this chapter will play a vital role in filling the need for a reliable national estimate of maternal mortality. Nevertheless, it is important for users of this information to understand the inherent problems associated with measuring maternal mortality in general if they are to avoid misinterpretation of the survey results. This holds particularly true when comparing results obtained from other indirect and model-based estimates. Direct estimates of maternal mortality use data on the age of surviving sisters of survey respondents, the age at death of sisters who have died, and the number of years that have passed since the deaths of sisters. 9.1 DATA QUALITY ANALYSIS To obtain the sibling history, each respondent was first asked to give the total number of her mother’s live births. The respondent was then asked to provide a list of all of the children born to her mother, starting with the first-born and the first-born’s survival status at the time of the interview. For living siblings, the current age was collected. For deceased siblings, the age at death and years since death were collected. Interviewers were carefully instructed to obtain precise information wherever possible, and when respondents were unable to provide exact age at death or years since death, particularly in the case of events that occurred decades ago, approximate but quantitative answers were accepted. For sisters who died at age 12 and above, three additional questions were asked: whether the sister was pregnant at the time of death, whether she died during childbirth, and whether she died within two months of the end of a pregnancy or childbirth. Listing all siblings in chronological order of their birth is believed to result in better reporting of events than would be the case if the interviewer obtained only information on sisters. Moreover, the information collected also allows direct estimates of adult male and female mortality. 110 | Adult and Maternal Mortality The estimation of adult and maternal mortality requires reasonably accurate reporting of the number of brothers and sisters a respondent has ever had, the number who have died, and for maternal mortality, the number of sisters who have died of maternity-related causes. One measure of the quality of the data collected is the completeness of information on siblings. Table 9.1 shows data from the 2009-10 TLDHS on the number of siblings reported by the respondents and the completeness of the data reported on current age, age at death, and years since death. Of the 63,481 siblings reported in the sibling history, survival status was not reported for 16 siblings (<0.01 percent). Among surviving siblings, current age (used for estimating exposure to death) was missing for 90 siblings (0.2 percent). For 99 percent of deceased siblings, both age at death and years since death were reported (with missing age at death, or years since death, or both, missing for <1 percent of dead siblings). Therefore the overall level of completeness of information on siblings appears to be good. Table 9.1 Completeness of information on siblings Number of sisters and brothers reported by interviewed women and completeness of age data for living siblings and age at death (AD) and years since death (YSD) data for dead siblings, Timor-Leste 2009-10 Sisters Brothers Total Number Percent Number Percent Number Percent All siblings 30,861 100.0 32,621 100.0 63,481 100.0 Living 26,061 84.4 27,258 83.6 53,318 84.0 Dead 4,790 15.5 5,357 16.4 10,147 16.0 Status Unknown 10 0.0 7 0.0 16 0.0 Living siblings 26,061 100.0 27,258 100.0 53,318 100.0 Age reported 26,013 99.8 27,215 99.8 53,228 99.8 Age missing 48 0.2 42 0.2 90 0.2 Dead siblings 4,790 100.0 5,357 100.0 10,147 100.0 AD and YSD reported 4,766 99.5 5,319 99.3 10,085 99.4 Missing only AD 4 0.1 9 0.2 13 0.1 Missing only YSD 2 0.0 4 0.1 7 0.1 Missing both 18 0.4 24 0.5 42 0.4 The distribution of respondents’ year of birth in relation to their siblings is another crude measure of the quality of maternal mortality data. If there is no bias in reporting, the year of birth of siblings should be roughly equivalent to the year of birth of respondents overall. The median year of birth of respondents is the same as that of their siblings, indicating that there is no serious underreporting of siblings (Table 9.2). Yet another crude measure of data quality is the mean number of siblings, or the mean sibship size (Table 9.3). Sibship size is expected to decline as fertility declines over time. The absence of a monotonic decline in sibship size, even though fertility has declined in Timor-Leste, is an indication that there may be some omission in the reporting of older siblings. However, since adult mortality rates are reported here for the seven years preceding the survey, this omission is unlikely to affect the calculation of mortality rates. Moreover, if the omission occurred mostly among sisters who did not survive to adulthood (which is most likely the case), such errors may not bias the estimation of maternal mortality. The possible omission of sisters is also suggested by the sex ratios that are larger than the internationally accepted sex ratio of 103-105, indicating that the sisters are underreported or the brothers are overreported. Nevertheless, it should be borne in mind that any information that relies on recall of events will suffer from some degree of misreporting, especially if it pertains to deceased persons and to events that occurred a long time before the survey. Table 9.2 Year of birth of respondents and siblings Percent distribution of respondents and siblings by year of birth, Timor-Leste 2009-10 Year of birth Respondents Siblings Before 1950 0.0 0.7 1950-54 0.0 1.3 1955-59 0.1 3.1 1960-64 8.7 5.4 1965-69 10.6 7.7 1970-74 12.9 9.8 1975-79 11.6 10.5 1980-84 14.6 13.6 1985 or later 41.5 48.0 Total 100.0 100.0 Lower range 1959 1923 Upper range 1995 2009 Median 1971 1971 Number of cases 13,137 63,458 Adult and Maternal Mortality | 111 Table 9.3 Sibship size and sex ratio of siblings Mean sibship size and sex ratio of births, Timor-Leste 2009-10 Year of birth of respondents Mean sibship size Sex ratio at birth of siblings 1955-59 5.3 80.0 1960-64 5.1 106.6 1965-69 5.2 101.2 1970-74 5.3 104.3 1975-79 5.5 105.4 1980-84 5.8 101.0 1985-89 6.2 107.9 1990-95 6.5 108.9 Total 5.8 105.7 9.2 ADULT MORTALITY It is advisable to begin by discussing overall adult mortality. If the overall mortality estimates display a general, stable, and plausible pattern, they lend credence to the maternal mortality estimates derived thereafter because maternal mortality is a subset of adult mortality. Direct estimates of male and female adult mortality are obtained from information collected in the sibling history. Age- specific death rates are computed by dividing the number of deaths in each age group by the total person-months of exposure in that age group during a specified reference period. In total, female respondents in the 2009-10 TLDHS reported 63,481 siblings, of whom 30,861 were sisters and 32,621 were brothers (Table 9.1). Direct estimates of age-specific mortality rates for females and males are shown in Table 9.4 for the period zero to six years before the survey. This seven-year period is taken as a compromise between the desire to minimize recall bias and the desire to minimize sampling errors associated with small numbers. The number of sibling deaths is fairly small, and because of the large sampling variability at each five-year age group, it is preferable to aggregate the data over the age range of 15-49 years. There are more female than male deaths in the seven years preceding the survey (288 compared with 237 per 1,000 population). The female mortality rate is 2.4 deaths per 1,000 population and is 16 percent higher than the male mortality rate of 2.0 deaths per 1,000 population. In the absence of comparable estimates of adult mortality, it may be useful to refer to indirect estimates of adult mortality from the World Health Organization (WHO). For the year 2006, which is roughly equivalent to the midpoint for the reference period of adult mortality rates in the 2009-10 TLDHS, the WHO estimates adult mortality for the age group of 15-60 years at 237 per 1,000 for men and 161 per 1,000 for women (WHO, 2008). 9.3 MATERNAL MORTALITY Maternal deaths are a subset of all female deaths and are associated with pregnancy and childbearing. Two survey methods are generally used to estimate maternal mortality in developing countries: the indirect sisterhood method (Graham et al., 1989) and a direct variant of the sisterhood method (Rutenberg and Sullivan, 1991). Information on maternal mortality for the period of zero to Table 9.4 Adult mortality rates Direct estimates of female and male mortality for the period 0 to 6 years prior to the survey, Timor-Leste 2009-10 Age Deaths Exposure years Mortality rates1 FEMALE 15-19 38 26,996 1.42 20-24 52 26,051 1.99 25-29 51 20,387 2.49 30-34 68 17,247 3.97 35-39 28 14,917 1.85 40-44 33 10,412 3.16 45-49 18 5,917 3.06 15-49 288 121,927 2.35a MALE 15-19 47 28,503 1.65 20-24 23 27,180 0.85 25-29 46 21,459 2.12 30-34 30 17,734 1.67 35-39 32 15,002 2.11 40-44 36 10,539 3.39 45-49 24 6,188 3.95 15-49 237 126,605 2.02a 1 Expressed per 1,000 population a Age-adjusted rate 112 | Adult and Maternal Mortality six years before the survey is shown in Table 9.5. Age-specific mortality rates are calculated by dividing the number of maternal deaths by years of exposure. To remove the effect of truncation bias (the upper boundary for eligibility in the TLDHS survey is 49 years), the overall rate for women age 15-49 is standardized by the age distribution of the survey respondents. Maternal deaths are defined as any death that occurred during pregnancy, childbirth, or within two months of the birth or termination of a pregnancy. Table 9.5 Direct estimates of maternal mortality Direct estimates of maternal mortality for the period 0-6 years prior to the survey, Timor-Leste 2009-10 Age Maternal deaths Exposure years Mortality rates1 Proportion of maternal deaths to female deaths 15-19 8 26,996 0.286 20.2 20-24 22 26,051 0.862 43.3 25-29 24 20,387 1.198 48.2 30-34 32 17,247 1.842 46.4 35-39 12 14,917 0.836 45.2 40-44 15 10,412 1.439 45.5 45-49 6 5,917 1.026 33.5 Total 120 121,927 0.960a 41.7 General fertility rate (GFR) 0.172a Maternal mortality ratio (MMR)2 557 1 Expressed per 1,000 woman-years of exposure 2 Expressed per 100,000 live births; calculated as the maternal mortality rate divided by the general fertility rate a Age-adjusted rate na = Not available Maternal mortality in Timor-Leste is high relative to many developed countries. However, for each age group, maternal deaths are a relatively rare occurrence. As such, the age-specific pattern should be interpreted with caution. Respondents reported 120 maternal deaths in the seven years preceding the survey. The maternal mortality rate, which is the annual number of maternal deaths per 1,000 women age 15-49, for the period zero to six years preceding the survey, is 0.96. Maternal deaths accounted for 42 percent of all deaths to women age 15-49; in other words, more than two in five Timorese women who died in the seven years preceding the survey died from pregnancy or pregnancy-related causes. The MMR, which is obtained by dividing the age-standardized maternal mortality rate by the age-standardized general fertility rate, is often considered a more useful measure of maternal mortality because it measures the obstetric risk associated with each live birth. Table 9.5 shows that the MMR for Timor-Leste for the seven years preceding the survey is 557 deaths per 100,000 live births (or alternatively, about 6 deaths per 1,000 live births). The 95 percent confidence interval places the true MMR for 2009-10 anywhere between 408 and 706. As pointed out at the beginning of the chapter, the MMR estimate from the 2009-10 TLDHS is the first direct measure of maternal mortality because it is based on survey data and is therefore not comparable to other model-based estimates of MMR that have been used in Timor-Leste in earlier years. Nevertheless, it is important to point out that the MMR for Timor-Leste remains one of the highest in the world, and government programs must address this problem. Necessary interventions include increasing women’s access to reproductive health care, (through more and better health facilities that offer family planning and maternity care), increasing skilled birth attendance, and educating women about birth spacing. These issues are discussed in detail in the following chapters of this report. Maternal Health | 113 MATERNAL HEALTH 10 Making Pregnancy Safer, a program launched by WHO, is a significant component of the Safe Motherhood Initiative of 1987. The program’s framework is designed to ensure that all pregnancies are wanted, that women can progress safely through pregnancy and childbirth, and that infants are born alive and healthy (WHO, 2010). The government of Timor-Leste recognizes the importance of the availability of good basic and comprehensive essential services for all women during pregnancy and childbirth. The intent of the government is to reduce levels of maternal and neonatal mortality and morbidity in the country. The National Reproductive Health Strategy (NRHS) for Timor-Leste incorporates four basic strategic approaches to make pregnancy safer (MOH, 2004a): • To substantially increase the level of knowledge in the general population on issues related to pregnancy and childbirth • To improve the quality and the coverage of prenatal, delivery, postnatal, and perinatal health care • To improve emergency obstetric care through recognition, early detection, and management or referral of complications of pregnancy and delivery • To integrate effective detection and management of STI cases, including HIV, in maternal and perinatal care Traditional beliefs and practices around childbearing and child rearing are very strong in Timor-Leste. A high number of maternal deaths have been documented (see Chapter 9). The absence of a basic health service infrastructure, which was destroyed during the Indonesian withdrawal in 1999, has compromised health services for women and children. Since then, Timor-Leste has set health as its national priority, yet gaps persist in the availability of strong and sustained community- wide health promotion strategies (WHO Timor-Leste, 2004). Efforts from agencies such as the Health Alliance International (HAI), United Nations Children’s Fund (UNICEF), and United Nations Population Fund (UNFPA) have addressed the issues of maternal and newborn care in support of the Ministry of Health (HAI, 2008). This chapter presents findings on several aspects of maternal health in Timor-Leste: antenatal, delivery, postnatal, and newborn care practices as well as problems in accessing health care for women. 10.1 ANTENATAL CARE The quality of antenatal care (ANC) can be measured by the qualifications of the provider and the number and frequency of ANC visits. Antenatal care quality can also be monitored through the content of services received and the kinds of information given to mothers during their visits. Information about ANC was obtained from women who gave birth in the five years preceding the survey. Table 10.1 shows the percent distribution of mothers in the five years preceding the survey by source of care received during pregnancy, according to selected background characteristics. Women were asked to report on whom they saw for care for their last birth, and if they saw more than one provider, only the provider with the highest qualification is included in the table. Antenatal care from a skilled birth attendant, that is, from a doctor, nurse, midwife, or assistant nurse, is very common in Timor-Leste, with 86 percent of women reporting receipt of such care. The majority of women receive care from a nurse or midwife (80 percent). Four percent of women receive care from a doctor, and less than 2 percent receive care from an assistant nurse. One 114 | Maternal Health 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 antenatal care from a skilled provider for the most recent birth, according to background characteristics, Timor-Leste 2009-10 Background characteristic Doctor Nurse/ midwife Assistant nurse Community health worker Traditional birth attendant Other No one Total Percentage receiving antenatal care from a skilled provider1 Number of women Mother’s age at birth <20 3.6 81.2 1.6 0.8 1.1 0.0 11.8 100.0 86.3 358 20-34 4.2 82.6 1.5 0.4 0.7 0.2 10.4 100.0 88.2 3,966 35-49 4.0 74.9 1.8 0.3 1.4 0.2 17.5 100.0 80.6 1,691 Birth order 1 5.6 81.0 2.0 0.6 0.8 0.1 9.9 100.0 88.6 849 2-3 4.2 83.7 1.5 0.2 0.7 0.2 9.6 100.0 89.4 1,748 4-5 3.8 82.4 1.2 0.2 1.0 0.1 11.2 100.0 87.4 1,516 6+ 3.5 75.3 1.7 0.5 1.3 0.4 17.3 100.0 80.6 1,902 Residence Urban 8.7 83.7 0.7 0.5 0.8 0.6 4.9 100.0 93.2 1,484 Rural 2.6 79.2 1.9 0.3 1.0 0.1 15.0 100.0 83.6 4,531 District Aileu 6.3 86.2 0.2 0.5 0.7 0.6 5.5 100.0 92.8 220 Ainaro 3.1 71.3 0.0 0.2 0.0 0.9 24.5 100.0 74.4 318 Baucau 2.0 84.9 0.5 0.5 0.5 0.0 11.5 100.0 87.4 598 Bobonaro 2.5 84.6 0.7 0.7 0.3 0.0 11.2 100.0 87.8 587 Covalima 4.3 87.5 0.6 0.3 0.8 0.0 6.5 100.0 92.3 322 Dili 9.2 86.2 0.7 0.6 0.6 0.6 2.2 100.0 96.1 1,043 Ermera 2.4 66.9 1.3 0.2 0.4 0.1 28.7 100.0 70.5 719 Lautem 3.0 81.8 0.8 0.2 0.6 0.0 13.6 100.0 85.6 444 Liquiçá 3.2 86.8 6.5 0.0 0.0 0.0 3.6 100.0 96.4 358 Manatuto 1.4 92.1 0.4 0.2 1.1 0.0 4.7 100.0 93.9 264 Manufahi 3.3 71.0 1.4 0.3 0.2 0.3 23.5 100.0 75.7 238 Oecussi 5.4 77.6 0.9 0.0 6.3 0.0 9.8 100.0 83.9 492 Viqueque 1.5 68.4 8.0 0.7 0.4 0.3 20.8 100.0 77.8 412 Mother’s education No education 2.2 72.0 2.2 0.2 1.6 0.2 21.6 100.0 76.3 1,980 Primary 3.4 81.3 1.7 0.8 1.1 0.2 11.5 100.0 86.4 1,656 Secondary 5.7 86.5 1.1 0.3 0.3 0.2 5.9 100.0 93.3 2,226 More than secondary 12.9 87.1 0.0 0.0 0.0 0.0 0.0 100.0 100.0 154 Wealth quintile Lowest 2.2 69.3 2.7 0.2 2.4 0.3 22.9 100.0 74.2 1,226 Second 1.7 75.7 1.6 0.2 1.0 0.1 19.7 100.0 79.0 1,171 Middle 3.0 83.1 1.4 0.6 0.3 0.0 11.5 100.0 87.5 1,203 Fourth 5.6 85.2 1.7 0.2 0.8 0.1 6.4 100.0 92.6 1,170 Highest 7.7 88.4 0.5 0.6 0.2 0.5 2.1 100.0 96.6 1,244 Total 4.1 80.3 1.6 0.4 1.0 0.2 12.5 100.0 86.0 6,015 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 1 Skilled provider includes doctor, nurse, midwife, and assistant nurse percent of women receive care from a traditional birth attendant. Thirteen percent of women did not receive care from a health provider for their last birth in the five years preceding the survey. These findings reveal that there has been a significant improvement in the proportion of women receiving ANC from a skilled provider—an increase of 41 percent, from 61 percent in the 2003 DHS to 86 percent in the 2009-10 TLDHS. These findings are also consistent with the results of the 2008 Knowledge, Practices, and Coverage (KPC) survey conducted by HAI in selected districts. The KPC survey found that 84 percent of women surveyed reported receiving ANC from health professionals (HAI, 2008). Mothers age 35 years and older are less likely than younger mothers to receive ANC from a skilled provider. Care from a skilled provider is also less likely for mothers of babies of order 6 and higher. There is a marked difference by urban-rural residence in the percentages of mothers who receive ANC from a skilled provider, with 93 percent getting care in urban settings and 84 percent receiving care in rural settings. Antenatal care from a skilled provider is lowest in Ermera (71 percent) and highest in Dili (96 percent) and Liquiçá (97 percent). There is a direct relationship between ANC received from a skilled provider and both education and wealth quintiles. Care from a skilled provider increases with education, rising from 76 percent of mothers with no education to 100 percent of mothers with more than secondary education. Similarly, by wealth quintile, receipt of antenatal care from a skilled provider rises from 74 percent Maternal Health | 115 among women in the lowest wealth quintile to 97 percent among women in the highest wealth quintile. 10.2 NUMBER AND TIMING OF ANTENATAL VISITS Antenatal care is more beneficial in preventing adverse pregnancy outcomes when sought early in the pregnancy and continued through delivery. It is possible during visits to detect health problems associated with a pregnancy. In the event of any complications, more frequent visits are advised, and admission to a health facility may be necessary. Table 10.2 shows that more than one in two pregnant women (55 percent) made four or more visits for care during their entire pregnancy. Urban women are more likely than rural women to have made four or more visits (63 percent and 53 percent, respectively). 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 5 years preceding the survey, by number of ANC visits for the most recent live birth, by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Timor-Leste 2009-10 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 4.9 15.0 12.5 1 2.2 3.5 3.2 2-3 29.1 28.6 28.7 4+ 62.8 52.5 55.1 Don’t know/missing 1.0 0.4 0.6 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 4.9 15.0 12.5 <4 52.9 42.9 45.3 4-5 33.3 30.4 31.1 6-7 7.3 10.3 9.6 8+ 0.7 1.1 1.0 Don’t know/missing 0.9 0.4 0.5 Total 100.0 100.0 100.0 Number of women 1,484 4,531 6,015 Median months pregnant at first visit (for those with ANC) 3.8 4.0 3.9 Number of women with ANC 1,411 3,853 5,264 About one in two women (45 percent) made their first ANC visit before the fourth month of pregnancy. The median duration of pregnancy at the first visit is 3.9 months (3.8 months in urban areas and 4 months in rural areas). 10.3 COMPONENTS OF ANTENATAL CARE The content of ANC is important in assessing the quality of care received. 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 the appropriate actions to take are essential components of good care. Table 10.3 presents information on the percentage of women who took iron tablets or syrup and intestinal parasite drugs during their last pregnancy in the five years preceding the survey. The table also shows the percentage of women who were informed about the signs of pregnancy complications and, among women receiving care, the percentage who received specific, routine ANC services, according to background characteristics. 116 | Maternal Health Table 10.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentages who took iron tablets (or syrup) and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific ANC services, according to background characteristics, Timor-Leste 2009-10 Background characteristic Among women with a live birth in the last five years, the percentage who during the pregnancy of their last birth: Among women who received antenatal care for their most recent birth in the last five years, the percentage with selected services: Took iron tablets or syrup Took intestinal parasite drugs Number of women with a live birth in the last five years Informed of signs of pregnancy compli- cations Weighed Blood pressure measured Urine sample taken Blood sample taken Number of women with ANC for their most recent birth Mother’s age at birth <20 62.2 15.9 358 50.5 94.8 91.9 14.9 12.3 316 20-34 65.5 12.7 3,966 55.8 97.3 93.9 18.3 13.6 3,552 35-49 57.5 14.1 1,691 56.7 96.3 92.4 17.6 15.1 1,396 Birth order 1 65.1 12.6 849 51.7 95.7 91.7 20.7 15.4 764 2-3 66.5 13.2 1,748 53.6 97.8 94.5 19.4 13.7 1,581 4-5 64.7 12.0 1,516 57.2 97.3 94.6 15.9 12.7 1,346 6+ 57.7 14.7 1,902 58.5 96.2 92.1 16.8 14.5 1,573 Residence Urban 76.2 6.7 1,484 46.0 97.5 95.0 26.2 16.7 1,411 Rural 58.7 15.4 4,531 59.3 96.7 92.8 14.9 12.9 3,853 District Aileu 85.1 8.9 220 77.6 99.0 99.0 11.6 7.7 208 Ainaro 67.7 2.1 318 24.9 97.8 92.9 19.3 9.7 240 Baucau 5.9 9.6 598 17.5 100.0 96.0 23.2 12.9 529 Bobonaro 52.7 29.0 587 38.0 92.3 81.2 19.2 33.4 521 Covalima 63.9 12.0 322 77.8 97.7 97.6 29.0 17.9 301 Dili 84.7 3.6 1,043 40.7 98.8 96.8 24.5 12.5 1,020 Ermera 47.8 23.9 719 85.7 98.0 96.5 3.3 7.1 512 Lautem 87.7 14.1 444 68.8 98.7 97.3 18.1 8.3 384 Liquiçá 69.0 20.9 358 72.7 95.0 89.1 10.8 11.3 345 Manatuto 87.6 35.0 264 77.4 97.9 94.4 7.9 5.1 252 Manufahi 46.5 6.4 238 47.1 91.6 81.5 18.8 20.1 182 Oecussi 74.2 8.0 492 81.5 91.5 91.3 17.1 17.9 444 Viqueque 65.2 3.0 412 53.6 98.2 94.9 17.9 10.3 326 Mother’s education No education 53.5 14.3 1,980 56.7 94.7 91.2 13.0 13.1 1,552 Primary 64.9 14.7 1,656 58.9 96.8 91.6 14.9 12.6 1,465 Secondary 68.7 11.7 2,226 53.5 98.3 95.9 22.4 15.0 2,093 More than secondary 83.6 6.9 154 45.6 100.0 98.5 36.0 19.8 154 Wealth quintile Lowest 55.1 8.7 1,226 55.7 94.1 90.3 12.9 11.0 945 Second 53.4 14.4 1,171 55.3 95.7 92.4 15.7 13.4 941 Middle 62.0 18.6 1,203 60.8 97.6 93.8 15.0 13.1 1,065 Fourth 66.2 16.9 1,170 58.8 97.5 93.1 17.2 16.2 1,095 Highest 78.0 8.2 1,244 48.9 98.9 96.6 26.8 15.2 1,218 Total 63.1 13.3 6,015 55.7 96.9 93.4 17.9 13.9 5,264 Among women with a live birth in the past five years, 63 percent took iron tablets or syrup while pregnant with the last birth. There are substantial variations by background characteristics. Two-thirds of women age 20-34 took iron tablets or syrup compared with lower percentages among women in the other age groups. The consumption of iron tablets or syrup is much higher among urban than rural women (76 and 59 percent, respectively), and among women who reside in Lautem, Manatuto, Aileu, and Dili (more than 80 percent each). On the other hand, only 6 percent of women in Baucau took iron tablets or syrup for their last birth in the five years preceding the survey. Not surprisingly, the consumption of iron tablets or syrup increases with the mother’s educational level and household wealth. Maternal Health | 117 A much lower percentage of Timorese mothers took intestinal parasite drugs (13 percent) while pregnant with their last birth in the five years before the survey. Consumption of drugs for control of intestinal parasites is most common among very young mothers (< 20 years), mothers with children of birth order 6 and higher, rural women, those residing in Manatuto, mothers with no education, and mothers living in households in the middle wealth quintile. More than half (56 percent) of moth- ers who received ANC reported that they were informed of pregnancy complications during their visit. Surprisingly, urban mothers, those with more than secondary education, and those in the highest wealth quintile are less likely than other mothers to be informed about pregnancy complications. Across districts, mothers living in Baucau are least likely to be informed about signs of pregnancy complications, in contrast with mothers living in Ermera, who are most likely to be informed of the danger signs as- sociated with a pregnancy. The vast majority of mothers who re- ceived ANC were weighed (97 percent) and had their blood pressure taken (93 percent). A much smaller percentage of women who went for care had a urine or blood sample taken (18 and 14 percent, respectively). Older mothers age 35-49, mothers having their first birth, urban residents, those living in Covalima, highly educated mothers, and those in the highest wealth quintile were more likely than their counterparts to have had their urine sample taken. A similar pattern was seen for blood pressure measurement. 10.4 TETANUS TOXOID VACCINATION Tetanus toxoid injections are given during pregnancy for the prevention of neo- natal tetanus, a major cause of death among infants. For full protection, a pregnant woman should receive at least two doses during each pregnancy. If a woman has been vaccinated during a previous pregnancy or during maternal and neonatal tetanus vacci- nation campaigns, however, she may only require one dose for the current pregnancy. Five doses provide lifetime protection. Table 10.4 shows the percentage of women who had a live birth in the five years preceding the survey and whose last birth was protected against neonatal tetanus, according to background characteristics. Three-quarters of mothers with a live birth in the five years preceding the survey received two or more tetanus toxoid injections during their last pregnancy, and four-fifths were protected for their last birth. Table 10.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Timor- Leste 2009-10 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 78.8 80.0 358 20-34 78.2 81.9 3,966 35-49 69.6 74.7 1,691 Birth order 1 80.9 82.2 849 2-3 79.4 83.4 1,748 4-5 75.2 80.5 1,516 6+ 70.7 74.8 1,902 Residence Urban 76.9 84.3 1,484 Rural 75.4 78.3 4,531 District Aileu 88.3 90.8 220 Ainaro 63.0 66.7 318 Baucau 81.9 82.4 598 Bobonaro 75.6 78.1 587 Covalima 87.0 89.4 322 Dili 76.5 86.8 1,043 Ermera 62.7 65.5 719 Lautem 75.2 80.5 444 Liquiçá 81.0 84.3 358 Manatuto 91.6 94.8 264 Manufahi 68.6 71.2 238 Oecussi 73.8 75.8 492 Viqueque 75.4 77.4 412 Mother’s education No education 67.6 70.0 1,980 Primary 77.5 81.2 1,656 Secondary 81.1 86.3 2,226 More than secondary 87.7 94.8 154 Wealth quintile Lowest 67.9 70.2 1,226 Second 69.9 72.8 1,171 Middle 77.4 81.0 1,203 Fourth 80.0 84.5 1,170 Highest 83.6 90.1 1,244 Total 75.8 79.8 6,015 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within ten years of the last live birth), or five or more injections prior to the last birth. 118 | Maternal Health Mothers less than 20 years of age and mothers of first-order births are more likely (79 percent and 81 percent, respectively) to have received two or more tetanus injections during their last pregnancy than older mothers age 35-49 (70 percent) and mothers of higher order births (71 percent and above). Mothers in Manatuto are most likely to have received two or more tetanus toxoid injections (92 percent) and to have had their last birth protected against neonatal tetanus (95 percent) compared with mothers in all other districts; tetanus toxoid coverage is lowest among mothers in Ermera and Ainaro. Education and wealth have a positive effect on whether women receive tetanus toxoid injections. For example, 88 percent of mothers with more than secondary education received at least two injections during their last pregnancy, compared with 68 percent of mothers with no education. Similarly, 84 percent of mothers in the highest wealth quintile received at least two doses of tetanus toxoid injection, compared with 68 percent of mothers in the lowest quintile. 10.5 KNOWLEDGE OF DANGER SIGNS DURING PREGNANCY The 2009-10 TLDHS also included women’s knowledge of danger signs associated with pregnancy. It is important for mothers and their families to recognize danger signs during pregnancy so that they can seek timely medical care. Women who responded that they had been told about danger signs associated with pregnancy during one of their ANC visits were asked to describe the symptoms they associated with the need to seek immediate care. Table 10.5 shows the percentage of women with a birth in the five years preceding the survey who could name various symptoms that indicate the need to seek immediate care. Fifty-six percent of women mentioned severe abdominal pain as a danger sign, 47 percent mentioned severe headache, 36 percent mentioned vaginal bleeding, 26 percent mentioned blurred vision and swelling of the hands and face, and 11 percent mentioned convulsions. Severe abdominal pain is most commonly reported as a danger sign by mothers more than age 20, mothers with births of order 2 and higher, Baucau residents, and those mothers with secondary education. Note that a higher percentage of rural mothers are able to cite the various danger signs than urban mothers, with the pattern by other background characteristics being less consistent. Maternal Health | 119 Table 10.5 Knowledge of danger signs during pregnancy Percentage with a live birth in the five years preceding the survey who can name various symptoms during pregnancy that indicate the need to seek immediate care, according to background characteristics, Timor-Leste 2009-10 Background characteristic Vaginal bleeding Severe abdominal pain Severe headache Convulsions Blurred vision and swelling of hands and face Other/ don’t know Number of women Mother’s age at birth <20 36.8 47.5 47.9 9.8 25.6 13.2 358 20-34 37.0 56.9 45.4 11.1 25.9 12.4 3,966 35-49 34.5 56.9 48.7 9.8 27.8 11.8 1,691 Birth order 1 36.0 53.3 43.0 8.9 26.7 13.0 849 2-3 35.2 56.2 45.8 10.1 25.4 12.9 1,748 4-5 36.1 57.6 48.2 11.2 27.2 11.0 1,516 6+ 37.6 56.7 47.3 11.4 26.6 12.4 1,902 Residence Urban 32.8 55.8 35.7 6.4 21.0 12.2 1,484 Rural 37.5 56.5 50.0 12.0 28.2 12.3 4,531 District Aileu 48.5 71.6 45.5 13.6 17.5 8.2 220 Ainaro 32.2 47.4 40.4 15.1 40.3 4.3 318 Baucau 25.5 80.9 35.5 3.8 43.3 2.0 598 Bobonaro 34.2 26.1 41.5 2.7 30.8 14.9 587 Covalima 27.3 52.9 37.2 13.8 9.8 13.8 322 Dili 32.6 55.9 35.9 3.6 19.8 11.1 1,043 Ermera 53.8 53.6 70.8 16.2 19.1 2.0 719 Lautem 29.6 60.9 21.5 26.3 15.7 21.0 444 Liquiçá 31.6 57.0 32.9 12.1 29.5 16.5 358 Manatuto 37.5 69.1 71.2 8.9 29.1 23.2 264 Manufahi 58.6 61.9 37.8 10.9 17.9 10.1 238 Oecussi 30.1 52.3 85.8 6.1 57.4 14.3 492 Viqueque 43.1 58.6 47.7 20.6 7.6 30.4 412 Education No education 34.1 54.2 50.6 11.6 28.5 13.1 1,980 Primary 36.9 54.4 48.8 10.8 27.7 12.6 1,656 Secondary 37.3 59.8 41.7 9.9 24.1 11.3 2,226 More than secondary 44.9 53.9 38.9 7.5 19.2 11.8 154 Wealth quintile Lowest 31.7 55.6 48.9 10.9 28.7 18.0 1,226 Second 36.7 56.8 48.2 12.2 29.4 10.6 1,171 Middle 39.8 54.3 48.8 13.5 26.6 10.7 1,203 Fourth 38.2 56.9 46.9 11.6 25.0 10.8 1,170 Highest 35.4 57.9 40.0 5.3 22.6 11.0 1,244 Total 36.3 56.3 46.5 10.6 26.4 12.3 6,015 10.6 DELIVERY CARE Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that may cause the death or serious illness of the mother, the baby, or both. Hence, an important component in the effort to reduce the health risks to mothers and children is to increase the proportion of babies delivered in a safe, clean environment and under the supervision of health professionals. 10.6.1 Place of Delivery Table 10.6 presents the percent distribution of live births in the five years preceding the survey, by place of delivery and by percentage delivered in a health facility, according to background characteristics. Just over one in five births are delivered in a health facility, with the vast majority delivered in a public (21 percent) rather than in a private (1 percent) facility. The majority of births (78 percent) are delivered at home. Delivery in a health facility is more common among younger mothers (25 percent), mothers of first-order births (31 percent), and mothers who have had at least four antenatal visits (31 percent). More than half (53 percent) of the children in urban areas are born 120 | Maternal Health Table 10.6 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, Timor-Leste 2009-10 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 23.4 1.1 75.2 0.3 100.0 24.5 745 20-34 22.8 0.7 76.3 0.1 100.0 23.5 6,789 35-49 16.8 0.3 82.8 0.0 100.0 17.0 2,294 Birth order 1 29.8 1.0 69.1 0.2 100.0 30.8 1,679 2-3 26.0 1.0 72.8 0.1 100.0 27.0 2,964 4-5 19.5 0.5 79.7 0.1 100.0 20.1 2,415 6+ 13.1 0.2 86.5 0.0 100.0 13.3 2,770 Residence Urban 50.5 2.3 46.7 0.3 100.0 52.8 2,353 Rural 12.3 0.1 87.5 0.1 100.0 12.4 7,475 District Aileu 11.7 0.0 87.8 0.3 100.0 11.7 359 Ainaro 7.2 0.0 92.7 0.1 100.0 7.2 579 Baucau 21.1 0.0 78.8 0.0 100.0 21.1 970 Bobonaro 16.1 0.0 83.7 0.1 100.0 16.1 934 Covalima 28.0 0.2 71.4 0.4 100.0 28.2 453 Dili 60.1 3.2 36.2 0.4 100.0 63.3 1,652 Ermera 3.0 0.2 96.8 0.0 100.0 3.2 1,252 Lautem 20.5 0.1 79.3 0.0 100.0 20.7 758 Liquiçá 12.5 0.6 86.9 0.0 100.0 13.1 582 Manatuto 25.4 0.0 74.6 0.0 100.0 25.4 433 Manufahi 11.0 0.2 88.9 0.0 100.0 11.1 393 Oecussi 4.4 0.3 95.4 0.0 100.0 4.6 783 Viqueque 13.9 0.1 85.7 0.0 100.0 14.1 678 Mother’s education No education 7.1 0.1 92.8 0.0 100.0 7.2 3,298 Primary 15.1 0.5 84.2 0.2 100.0 15.5 2,765 Secondary 36.5 1.3 62.0 0.1 100.0 37.8 3,546 More than secondary 73.7 1.7 24.7 0.0 100.0 75.3 218 Antenatal care visits1 None 1.6 0.0 98.3 0.0 100.0 1.6 751 1-3 23.2 0.9 75.9 0.0 100.0 24.1 1,919 4+ 30.7 0.6 68.7 0.0 100.0 31.3 3,312 Wealth quintile Lowest 5.2 0.0 94.7 0.0 100.0 5.2 2,090 Second 7.0 0.1 92.9 0.0 100.0 7.1 1,960 Middle 12.8 0.2 86.9 0.1 100.0 13.0 1,992 Fourth 27.1 0.8 71.7 0.3 100.0 27.9 1,903 Highest 57.8 2.2 39.6 0.1 100.0 60.1 1,884 Total 21.4 0.7 77.8 0.1 100.0 22.1 9,828 Note: Total includes 33 cases with information missing on number of ANC visits. 1 Includes only the most recent birth in the five years preceding the survey in a health facility, compared with only 12 percent in rural areas. Delivery in a health facility also varies by district, with facility delivery in Dili being much more likely than in any other district (63 percent). Less than 10 percent of births in Ermera, Oecussi, and Ainaro are delivered in a health facility. There is a strong association between health facility delivery, mother’s education, and wealth quintile. The proportion of deliveries in a health facility is 7 percent among births to mothers with no education; this compares with 75 percent among births to mothers with more than secondary education. A similar pattern is seen in terms of wealth quintiles: delivery at a health facility is significantly less likely among births to mothers in the lowest two wealth quintiles (5 percent and 7 percent, respectively), compared with 60 percent of births in the highest wealth quintile. Maternal Health | 121 10.6.2 Assistance during Delivery Obstetric care from a trained provider during delivery is critical for the reduction of maternal and neonatal mortality. Home deliveries are usually less likely to be assisted by a health professional, whereas health facility deliveries are more likely to be assisted by a trained health professional. Table 10.7 shows the distribution of live births in the five years preceding the survey by the person assisting during delivery. Thirty percent of births are delivered by a skilled provider (doctor, nurse, assistant nurse, or midwife), with a nurse or midwife being the most common skilled provider. Three percent of deliveries are performed by a doctor, and less than 1 percent are performed by an assistant nurse. Nearly one-fifth of deliveries are carried out by traditional birth attendants (18 percent). Women receive assistance from a relative or some other person for nearly one in two births (49 percent), while 3 percent of births take place without any type of assistance at all. Table 10.7 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled birth attendant, and percentage delivered by caesarean-section, according to background characteristics, Timor-Leste 2009-10 Background characteristic Person providing assistance during delivery Percentage delivered by a skilled birth attendant1 Percentage delivered by C- section Number of births Doctor Nurse/ midwife Assistant nurse Traditional birth attendant Relative/ other No one Don’t know/ missing Total Mother’s age at birth <20 1.1 31.4 0.5 20.1 44.7 1.8 0.3 100.0 33.0 0.9 745 20-34 3.1 27.8 0.6 17.7 48.2 2.6 0.0 100.0 31.5 1.9 6,789 35-49 2.9 20.8 0.6 17.8 52.5 5.5 0.0 100.0 24.3 1.6 2,294 Birth order 1 4.1 34.5 0.6 17.4 41.9 1.3 0.2 100.0 39.2 3.6 1,679 2-3 3.3 30.9 0.5 17.9 45.3 2.0 0.0 100.0 34.8 1.6 2,964 4-5 2.1 24.9 0.7 18.7 50.4 3.2 0.1 100.0 27.7 1.2 2,415 6+ 2.3 18.2 0.5 17.6 55.8 5.6 0.0 100.0 21.0 1.1 2,770 Place of delivery Health facility 12.3 85.9 1.0 0.3 0.4 0.0 0.0 100.0 99.3 7.8 2,171 Elsewhere 0.2 9.6 0.5 23.0 62.7 4.1 0.0 100.0 10.3 0.0 7,646 Residence Urban 7.6 50.9 0.6 16.5 22.8 1.5 0.1 100.0 59.1 4.0 2,353 Rural 1.4 18.8 0.6 18.4 57.1 3.7 0.0 100.0 20.7 1.0 7,475 District Aileu 3.4 19.6 0.7 10.1 61.5 4.3 0.3 100.0 23.8 0.9 359 Ainaro 0.6 9.9 0.0 2.0 85.9 1.6 0.0 100.0 10.5 0.3 579 Baucau 1.6 25.3 0.7 5.6 65.6 1.3 0.0 100.0 27.5 0.7 970 Bobonaro 0.9 24.4 0.2 3.9 61.1 9.3 0.1 100.0 25.6 1.8 934 Covalima 3.1 37.5 0.0 11.9 45.8 1.6 0.0 100.0 40.6 1.9 453 Dili 9.3 59.1 0.5 17.9 12.7 0.4 0.1 100.0 68.9 4.8 1,652 Ermera 1.1 10.9 0.1 23.5 62.2 2.2 0.0 100.0 12.1 0.1 1,252 Lautem 1.9 23.5 0.6 26.3 44.9 2.8 0.0 100.0 25.9 2.0 758 Liquiçá 2.1 19.8 1.5 4.7 64.7 7.2 0.0 100.0 23.4 1.4 582 Manatuto 1.6 35.3 0.0 23.7 31.5 7.8 0.0 100.0 36.9 1.6 433 Manufahi 2.0 16.0 0.9 36.5 37.8 6.8 0.0 100.0 19.0 1.3 393 Oecussi 1.6 8.0 0.2 62.6 26.3 1.4 0.0 100.0 9.8 0.6 783 Viqueque 1.4 21.2 2.7 2.7 70.3 1.8 0.0 100.0 25.2 1.7 678 Mother’s education No education 0.9 12.3 0.3 20.5 60.8 5.2 0.0 100.0 13.5 0.5 3,298 Primary 1.8 20.3 0.7 20.7 53.2 3.2 0.2 100.0 22.7 1.3 2,765 Secondary 5.0 41.5 0.8 14.1 37.1 1.6 0.0 100.0 47.2 2.6 3,546 More than secondary 13.7 73.7 0.0 5.7 6.8 0.0 0.0 100.0 87.5 11.1 218 Wealth quintile Lowest 0.6 9.4 0.6 24.0 60.5 4.8 0.0 100.0 10.6 0.6 2,090 Second 1.1 12.4 0.6 18.8 63.4 3.6 0.0 100.0 14.2 0.5 1,960 Middle 1.8 19.0 0.8 16.7 57.9 3.8 0.0 100.0 21.5 0.8 1,992 Fourth 3.6 33.4 0.4 15.9 43.7 2.7 0.2 100.0 37.5 2.3 1,903 Highest 7.7 60.9 0.5 13.6 16.6 0.8 0.0 100.0 69.0 4.7 1,884 Total 2.9 26.4 0.6 17.9 48.9 3.2 0.0 100.0 29.9 1.7 9,828 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Total includes 11 births with information missing on place of delivery. 1 Skilled birth attendant includes doctor, nurse, midwife, and assistant nurse. 122 | Maternal Health Skilled providers are most likely to attend births to young mothers less than age 20 and first- order births (33 percent and 39 percent, respectively). Not surprisingly, an overwhelming majority of births delivered in a health facility are attended by a skilled provider as opposed to births delivered elsewhere. Three-fifths of urban births (59 percent) are assisted by skilled providers, compared with 21 percent of births in rural areas. Births in Dili are most likely to be attended by skilled providers (69 percent). Less than 10 percent of births in Oecussi are attended by skilled providers. Highly educated mothers are most likely to have their births delivered by skilled attendants (88 percent) as are mothers in the wealthiest households (69 percent). Less than 2 percent of births are delivered by caesarean section. Not surprisingly all C-section deliveries take place in health facilities, primarily in urban areas, to highly educated mothers who are also from wealthy households. Of the districts, C-section deliveries are most common in Dili (5 percent). 10.7 NEWBORN CARE Women who did not deliver their last-born child in a health facility were asked about the practice of taking care of newborns, including cord cutting practices, application of materials on the umbilical cord after cutting, and drying and bathing of newborn children. Women were also asked about their knowledge of danger signs for a newborn that would prompt mothers to seek immediate attention. 10.7.1 Knowledge of Danger Signs for Newborns Skilled care for mothers and their newborns is critical in the first month following delivery. Timorese mothers were asked to name symptoms indicating the need to seek immediate health care for an infant within one month of delivery. Table 10.8 shows the percentage of women with a live birth in the five years preceding the survey who can name various symptoms in a newborn that indicate the need to seek immediate care. About three-quarters of mothers mentioned fever as a symptom needing immediate care. Lesser percentages mentioned poor suckling (35 percent), fast breathing (23 percent), pustules on the skin (12 percent), infection or discharge around the umbilical cord (11 percent), and severe chest indrawing (9 percent) as danger signs needing immediate medical attention. As noted with knowledge of pregnancy danger signs, rural mothers are more likely than urban mothers to mention each of these danger signs. Maternal Health | 123 Table 10.8 Knowledge of danger signs for newborns Percentage with a live birth in the five years preceding the survey who can name various symptoms in an infant within one month after birth that indicate the need to seek immediate care, according to background characteristics, Timor-Leste 2009-10 Background characteristic Poor suckling Fast breathing Severe chest indrawing Fever Pustules on the skin Infection/ discharge around the umbilical cord Hypo- thermia Difficult to wake/ lethargic Other Don’t know Number of women Mother’s age at birth <20 37.3 21.9 7.5 71.0 9.1 9.0 3.0 4.3 16.5 7.1 358 20-34 35.3 22.7 8.9 72.3 12.7 11.2 3.6 4.8 15.7 5.3 3,966 35-49 35.0 23.1 9.1 74.4 10.7 11.9 2.3 3.6 15.8 5.2 1,691 Birth order 1 35.0 21.5 7.0 69.9 10.5 11.3 3.2 5.1 16.2 6.4 849 2-3 35.0 22.9 9.1 71.7 12.6 11.2 3.5 4.6 15.5 4.8 1,747 4-5 34.7 22.6 9.1 74.8 13.7 10.9 3.0 4.8 17.6 5.6 1,516 6+ 36.4 23.3 9.3 73.5 10.4 11.7 3.1 3.6 14.3 5.3 1,902 Residence Urban 31.5 20.1 4.5 72.2 11.6 9.6 1.6 4.1 15.2 4.0 1,484 Rural 36.6 23.6 10.3 73.0 12.0 11.8 3.7 4.5 15.9 5.9 4,531 District Aileu 44.3 25.0 17.3 72.2 11.1 14.6 6.0 8.7 14.5 2.9 220 Ainaro 34.9 28.7 18.8 57.1 8.6 4.0 13.0 11.0 12.2 1.6 318 Baucau 49.1 25.0 12.3 69.1 4.7 32.6 2.0 1.6 1.7 0.5 598 Bobonaro 37.3 10.4 1.3 55.3 2.8 16.0 1.4 0.7 6.4 11.7 587 Covalima 32.7 21.2 11.0 66.3 5.3 1.1 4.0 9.2 12.2 1.4 322 Dili 31.7 17.6 2.9 76.5 14.0 9.9 1.5 2.7 13.9 3.2 1,043 Ermera 38.6 7.6 7.6 91.1 12.3 1.6 0.7 4.6 17.9 0.6 719 Lautem 16.6 28.1 3.9 90.8 2.2 3.4 2.2 0.7 8.0 4.3 444 Liquiçá 19.3 12.9 13.0 70.1 15.8 5.9 2.6 3.2 25.3 3.9 358 Manatuto 63.0 21.2 10.2 78.4 25.6 24.0 5.4 12.3 26.0 4.4 264 Manufahi 36.3 43.8 13.6 43.4 12.9 20.8 3.4 5.6 9.0 6.1 238 Oecussi 31.0 55.6 9.4 92.5 33.8 12.0 1.0 4.3 57.4 0.6 492 Viqueque 34.5 24.6 15.3 52.4 9.1 4.4 8.8 6.1 4.1 33.4 412 Education No education 35.3 20.4 9.7 71.7 12.4 10.8 3.1 4.5 16.1 6.5 1,980 Primary 33.2 25.2 8.4 74.7 12.6 10.2 3.4 4.2 17.5 5.4 1,656 Secondary 36.6 22.7 8.8 72.2 11.1 12.8 3.0 4.4 13.6 4.6 2,226 More than secondary 41.3 27.7 3.8 75.2 9.5 8.0 3.8 6.9 22.3 1.7 154 Wealth quintile Lowest 34.6 28.9 9.9 71.9 12.7 9.8 3.4 4.2 19.0 9.2 1,226 Second 35.9 24.0 10.7 71.8 12.3 12.3 3.5 3.7 13.9 5.3 1,171 Middle 35.8 21.2 9.9 74.3 9.5 10.8 3.4 5.2 14.6 5.0 1,203 Fourth 35.5 20.3 8.2 71.8 12.1 11.4 3.0 5.1 15.9 4.2 1,170 Highest 34.9 19.4 5.6 74.2 12.8 12.1 2.6 3.9 15.2 3.1 1,244 Total 35.3 22.8 8.9 72.8 11.9 11.3 3.2 4.4 15.7 5.4 6,015 10.7.2 Care for Umbilical Cord The primary care of newborns includes the proper practice of cutting the umbilical cord. Traditionally, the cord is usually cut with a razor blade, knife, scissors, or even a piece of bamboo, none of which is generally sterile. In some cultures, the cord is not cut until the placenta is delivered, and it is cut only after cord pulsation stops upon the delivery of the placenta. Table 10.9 shows that a new or boiled blade was used in only one in five of the most recent noninstitutional births. The most common instrument used in noninstitutional births was a pair of scissors (56 percent), with a knife or bamboo used in 12 percent and 10 percent of births, respectively. A used blade cut the umbilical cord in a very small percentage of births (2 percent). Scissors were used in a high number (82 percent) of recent noninstitutional births in Liquiçá. 124 | Maternal Health Table 10.9 Instruments used to cut the umbilical cord Percent distribution of most recent noninstitutional live births in the five years preceding the survey, by type of instrument used to cut the umbilical cord, according to background characteristics, Timor-Leste 2009-10 Background characteristic Instrument used to cut the umbilical cord Total Number of births New/ boiled blade Used blade Knife Scissors Bamboo Other Don’t know Mother’s age at birth <20 17.1 3.1 12.7 60.6 6.1 0.3 0.0 100.0 267 20-34 20.2 2.3 11.1 57.1 8.7 0.1 0.4 100.0 2,874 35-49 20.1 2.5 13.6 51.7 11.8 0.1 0.2 100.0 1,362 Birth order 1 19.7 2.6 9.0 60.0 8.2 0.3 0.3 100.0 547 2-3 17.8 1.8 12.3 58.7 8.5 0.2 0.6 100.0 1,208 4-5 18.9 2.5 13.0 55.8 9.7 0.0 0.1 100.0 1,150 6+ 22.7 2.8 11.9 51.8 10.5 0.1 0.2 100.0 1,597 Residence Urban 26.6 1.3 8.5 58.7 4.0 0.0 1.0 100.0 648 Rural 18.9 2.6 12.6 55.2 10.4 0.1 0.2 100.0 3,854 District Aileu 39.0 7.0 7.5 36.9 9.6 0.0 0.0 100.0 188 Ainaro 38.4 0.8 5.9 54.2 0.5 0.0 0.2 100.0 290 Baucau 11.4 1.8 44.6 32.4 9.4 0.0 0.4 100.0 443 Bobonaro 16.5 2.9 1.7 77.5 0.9 0.0 0.6 100.0 482 Covalima 10.0 0.8 10.0 76.3 2.0 0.8 0.0 100.0 224 Dili 36.2 1.2 4.6 53.4 3.5 0.0 1.2 100.0 348 Ermera 44.6 1.5 1.4 50.0 2.5 0.0 0.0 100.0 692 Lautem 0.7 1.6 13.1 70.8 13.6 0.0 0.2 100.0 345 Liquiçá 8.3 2.5 0.5 82.2 5.0 0.0 1.4 100.0 302 Manatuto 5.5 3.1 13.6 54.9 23.0 0.0 0.0 100.0 185 Manufahi 7.4 2.8 4.8 72.0 12.8 0.3 0.0 100.0 205 Oecussi 16.3 6.1 26.5 31.6 19.2 0.2 0.0 100.0 463 Viqueque 0.6 0.6 14.6 51.5 32.1 0.6 0.0 100.0 337 Education No education 23.0 2.7 12.2 48.8 12.9 0.2 0.2 100.0 1,795 Primary 17.8 2.7 14.1 56.7 8.5 0.1 0.2 100.0 1,353 Secondary 18.3 1.7 9.8 63.4 6.2 0.0 0.6 100.0 1,323 More than secondary (15.9) (0.0) (1.5) (82.6) (0.0) (0.0) (0.0) 100.0 30 Wealth quintile Lowest 13.2 3.4 18.4 47.3 17.1 0.2 0.3 100.0 1,141 Second 21.8 3.0 13.6 52.0 9.3 0.0 0.4 100.0 1,061 Middle 23.6 1.9 8.8 57.9 7.6 0.2 0.1 100.0 1,022 Fourth 21.5 1.7 8.7 62.4 5.4 0.1 0.1 100.0 819 Highest 22.2 1.1 5.0 68.0 2.3 0.0 1.3 100.0 459 Total 20.0 2.4 12.0 55.7 9.5 0.1 0.3 100.0 4,502 Note: Figures in parentheses are based on 25-49 unweighted cases. Table 10.10 shows that the majority of mothers with noninstitutional births did not apply anything to the umbilical cord after it was cut (53 percent). Nineteen percent of births had ointment or powder applied, 10 percent had oil applied, 7 percent had ash applied, 6 percent were treated with traditional medicine, and 5 percent had betadine applied to the cord. Differences by background characteristics varied depending on the types of material applied. Maternal Health | 125 Table 10.10 Application of material after the umbilical cord was cut Percentage of most recent noninstitutional live births in the five years preceding the survey, by material applied to the cord immediately after cutting and tying it, according to background characteristics, Timor-Leste 2009-10 Background characteristic Material applied to the cord Number of births Oil Ash Ointment/ powder Traditional medicine Betadine Other/ don’t know Nothing applied to cord Mother’s age at birth <20 10.5 5.4 23.7 5.3 3.4 3.7 53.5 267 20-34 9.1 7.2 19.3 5.9 5.7 4.8 52.6 2,874 35-49 10.2 7.0 18.0 5.0 5.0 4.8 54.6 1,362 Birth order 1 9.9 7.3 21.5 6.1 3.6 6.4 50.3 547 2-3 9.7 7.3 19.7 5.7 6.1 4.5 51.4 1,208 4-5 9.5 8.0 18.9 5.9 6.0 5.0 52.8 1,150 6+ 9.3 6.0 18.1 5.1 5.0 4.3 56.1 1,597 Residence Urban 6.5 8.8 26.9 3.5 6.8 4.9 47.9 648 Rural 10.0 6.7 17.9 5.9 5.1 4.7 54.2 3,854 District Aileu 9.7 19.7 13.3 4.5 8.7 2.0 51.3 188 Ainaro 6.5 3.5 35.3 3.2 2.1 2.3 48.1 290 Baucau 8.4 18.6 23.8 1.3 4.7 2.3 46.5 443 Bobonaro 46.3 3.6 10.4 8.1 3.1 2.3 35.5 482 Covalima 19.6 0.9 16.9 2.5 15.4 6.8 47.1 224 Dili 4.1 14.5 30.1 1.7 3.5 5.0 47.4 348 Ermera 0.3 0.2 19.3 7.9 2.6 0.0 75.9 692 Lautem 4.9 4.9 23.5 4.1 4.1 1.0 59.6 345 Liquiçá 12.3 2.2 8.3 2.3 13.3 4.9 59.0 302 Manatuto 3.2 5.3 25.2 10.0 8.6 19.3 32.2 185 Manufahi 2.7 12.7 34.9 2.7 6.0 11.1 33.4 205 Oecussi 0.4 8.4 12.6 7.9 3.4 4.2 64.4 463 Viqueque 1.2 5.1 6.3 12.1 5.9 15.8 53.9 337 Education No education 10.0 8.7 15.6 6.1 2.6 4.1 56.5 1,795 Primary 9.0 5.7 21.0 6.5 5.7 4.9 53.4 1,353 Secondary 9.1 6.3 21.7 3.9 8.4 5.5 49.2 1,323 More than secondary (21.8) (0.0) (33.3) (6.6) (18.7) (0.0) (32.9) 30 Wealth quintile Lowest 6.7 8.8 15.3 6.5 2.6 5.1 58.2 1,141 Second 10.1 8.4 17.2 6.7 3.6 4.0 55.0 1,061 Middle 12.1 5.4 19.4 5.3 5.6 4.7 52.9 1,022 Fourth 9.5 5.3 23.2 5.0 6.9 5.2 50.4 819 Highest 9.7 6.3 25.6 2.3 13.2 4.9 43.3 459 Total 9.5 7.0 19.2 5.6 5.4 4.8 53.3 4,502 Note: Figures in parentheses are based on 25-49 unweighted cases. 10.7.3 Drying and Bathing of Newborns Health professionals recommend not bathing a newborn for at least 24 hours after birth to prevent hypothermia. However, although two-thirds of last-born noninstitutional babies are dried and placed on the mother’s chest before the placenta is delivered, the majority of newborns born in a non- facility are also bathed one to five hours after delivery (Table 10.11). In fact, 27 percent of the noninstitutional newborns are bathed within the first hour of birth. 126 | Maternal Health Table 10.11 Drying and bathing of newborns Percentage of most recent noninstitutional live births in the five years preceding the survey who were dried before the delivery of the placenta, and percent distribution of most recent noninstitutional live births in the five years preceding the survey by timing of first bath, according to background characteristics, Timor-Leste 2009-10 Background characteristic Baby dried before placenta delivered Timing of first bath Number of births Within the first hour 1-5 hours 6-23 hours 24 hours later Don’t know Total Mother’s age at birth <20 69.5 24.1 71.5 1.6 2.9 0.0 100.0 267 20-34 65.1 28.4 63.5 2.3 5.1 0.8 100.0 2,874 35-49 63.7 23.8 68.7 1.8 5.2 0.5 100.0 1,362 Birth order 1 65.6 24.2 68.5 3.2 3.3 0.8 100.0 547 2-3 65.6 27.8 63.7 2.1 5.7 0.7 100.0 1,208 4-5 64.5 28.4 64.2 1.9 4.8 0.7 100.0 1,150 6+ 64.6 25.7 66.8 1.8 5.2 0.5 100.0 1,597 Residence Urban 69.7 25.5 56.2 4.3 12.8 1.3 100.0 648 Rural 64.2 27.0 67.1 1.7 3.7 0.5 100.0 3,854 District Aileu 79.0 4.3 82.4 5.6 6.8 0.8 100.0 188 Ainaro 93.9 48.3 46.3 3.5 1.1 0.9 100.0 290 Baucau 46.3 10.1 86.8 0.0 2.0 1.1 100.0 443 Bobonaro 95.7 17.0 81.2 0.9 1.0 0.0 100.0 482 Covalima 73.9 21.4 63.6 5.9 9.1 0.0 100.0 224 Dili 79.0 25.9 49.0 5.0 18.5 1.6 100.0 348 Ermera 53.8 26.0 73.5 0.0 0.4 0.0 100.0 692 Lautem 50.8 42.1 43.7 2.2 11.5 0.5 100.0 345 Liquiçá 57.0 36.1 49.9 1.5 12.1 0.5 100.0 302 Manatuto 61.1 36.3 58.0 1.8 3.4 0.6 100.0 185 Manufahi 23.5 11.2 75.5 5.2 6.0 2.0 100.0 205 Oecussi 61.0 31.2 66.4 0.5 0.7 1.2 100.0 463 Viqueque 69.7 36.7 57.6 2.9 2.6 0.3 100.0 337 Education No education 64.9 26.6 68.2 1.4 3.1 0.6 100.0 1,795 Primary 64.5 25.7 67.1 1.7 5.0 0.5 100.0 1,353 Secondary 65.2 28.3 60.6 3.1 7.3 0.8 100.0 1,323 More than secondary (79.5) (14.3) (55.8) (13.3) (16.6) (0.0) 100.0 30 Wealth quintile Lowest 61.2 28.8 65.9 1.5 3.1 0.6 100.0 1,141 Second 62.6 26.0 68.5 1.8 3.1 0.6 100.0 1,061 Middle 67.6 24.9 69.1 1.7 3.9 0.3 100.0 1,022 Fourth 66.7 27.5 62.8 2.4 6.4 0.9 100.0 819 Highest 70.7 26.3 54.7 4.2 13.8 1.0 100.0 459 Total 65.0 26.8 65.5 2.1 5.0 0.6 100.0 4,502 Note: Figures in parentheses are based on 25-49 unweighted cases. 10.8 TIMING OF FIRST POSTNATAL CHECKUP 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. A postnatal care visit is also an ideal time to educate a new mother on how to care for herself and her newborn. Safe motherhood programs emphasize the importance of postnatal care, recommending that all women receive at least two postnatal checkups and iron supplementation for 45 days following a delivery. Table 10.12 shows the percentage of mothers who received postnatal care for their last live birth in the five years preceding the survey. The majority of women (68 percent) did not receive a postnatal check. Among those who received postnatal care, 16 percent received it in less than four hours after delivery, 5 percent received care within 4 to 23 hours, and 3 percent received care within the first two days. Seven percent received postnatal care 3 to 41 days following delivery. Differences by background characteristics are pronounced. Younger mothers (less than 35 years), mothers of first Maternal Health | 127 Table 10.12 Timing of first postnatal checkup Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution of the mother’s first postnatal check-up for the last live birth by time after delivery, according to background characteristics, Timor- Leste 2009-10 Background characteristic Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Number of women Less than 4 hours 4-23 hours 2 days 3-41 days Don’t know/ missing Mother’s age at birth <20 16.1 4.2 5.1 5.4 0.6 68.6 100.0 358 20-34 17.5 5.8 3.5 7.7 0.2 65.4 100.0 3,966 35-49 14.0 3.6 2.6 6.2 0.3 73.3 100.0 1,691 Birth order 1 21.1 5.9 4.0 7.9 0.2 60.8 100.0 849 2-3 19.9 6.4 3.9 7.7 0.4 61.6 100.0 1,748 4-5 15.5 5.3 2.9 7.0 0.1 69.2 100.0 1,516 6+ 11.8 3.3 3.0 6.3 0.2 75.4 100.0 1,902 Residence Urban 33.5 11.6 5.7 6.2 0.5 42.4 100.0 1,484 Rural 10.8 2.9 2.6 7.4 0.1 76.1 100.0 4,531 District Aileu 14.4 3.1 3.6 4.2 0.8 73.9 100.0 220 Ainaro 7.7 1.2 1.8 8.2 0.2 80.9 100.0 318 Baucau 12.3 9.8 3.1 2.5 0.3 72.0 100.0 598 Bobonaro 8.3 0.8 0.8 15.9 0.4 73.8 100.0 587 Covalima 29.6 4.6 2.1 9.2 0.0 54.4 100.0 322 Dili 40.1 14.5 5.0 5.2 0.6 34.6 100.0 1,043 Ermera 2.5 0.5 0.9 12.3 0.0 83.8 100.0 719 Lautem 13.3 4.0 6.3 3.2 0.0 73.3 100.0 444 Liquiçá 15.6 2.3 3.7 10.3 0.2 67.9 100.0 358 Manatuto 20.0 5.5 8.4 9.4 0.0 56.8 100.0 264 Manufahi 11.7 3.4 2.2 3.2 0.0 79.4 100.0 238 Oecussi 7.0 1.2 3.7 2.6 0.0 85.5 100.0 492 Viqueque 11.7 1.6 2.9 3.8 0.3 79.7 100.0 412 Education No education 6.5 1.5 1.4 7.5 0.1 83.0 100.0 1,980 Primary 13.0 4.2 2.3 6.1 0.2 74.2 100.0 1,656 Secondary 25.7 7.9 5.6 7.5 0.4 53.0 100.0 2,226 More than secondary 46.1 19.8 7.9 8.4 0.0 17.8 100.0 154 Wealth quintile Lowest 6.6 1.2 1.1 4.6 0.0 86.4 100.0 1,226 Second 6.6 1.5 2.2 5.9 0.0 83.8 100.0 1,171 Middle 10.7 2.7 3.1 9.1 0.1 74.3 100.0 1,203 Fourth 19.7 5.6 4.4 8.8 0.4 61.0 100.0 1,170 Highest 37.9 14.1 5.8 7.1 0.6 34.5 100.0 1,244 Total 16.4 5.1 3.4 7.1 0.2 67.8 100.0 6,015 1 Includes women who received a checkup after 41 days births, urban residents, women in Dili, highly educated women, and wealthy women were more likely than their counterparts to receive care in less than four hours following delivery. Older mothers, those having births of order six and higher, rural mothers, uneducated mothers, and those in the poorest households are most likely not to receive postnatal care at all. Mothers residing in Oecussi, Ermera, and Ainaro are least likely to receive postnatal care. 10.9 TYPE OF PROVIDER OF FIRST POSTNATAL CHECKUP Table 10.13 presents information on the provider of postnatal care, according to the mothers’ background characteristics. In Timor-Leste, 31 percent of mothers obtain postnatal care from a health professional, and women do not get postnatal care from traditional birth attendants. More than two in three (68 percent) do not receive any postnatal care within 41 days, which almost marks the end of the postnatal period. 128 | Maternal Health Table 10.13 Type of provider of first postnatal checkup Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution by type of provider of the mother’s first postnatal health check for the last live birth, according to background characteristics, Timor-Leste 2009-10 Background characteristic Type of health provider of mother’s first postnatal checkup No postnatal checkup1 Total Number of women Doctor/ nurse/ midwife Auxiliary nurse/ midwife Community health worker Traditional birth attendant Other Don’t know/ missing Mother’s age at birth <20 30.9 0.2 0.2 0.1 0.0 0.0 68.6 100.0 358 20-34 33.8 0.6 0.1 0.0 0.0 0.1 65.4 100.0 3,966 35-49 26.0 0.7 0.0 0.0 0.0 0.0 73.3 100.0 1,691 Birth order 1 38.4 0.8 0.1 0.0 0.0 0.0 60.8 100.0 849 2-3 37.6 0.5 0.1 0.0 0.0 0.0 61.6 100.0 1,748 4-5 29.7 0.8 0.2 0.0 0.0 0.0 69.2 100.0 1,516 6+ 23.9 0.5 0.0 0.0 0.0 0.1 75.4 100.0 1,902 Residence Urban 56.9 0.4 0.1 0.0 0.0 0.1 42.4 100.0 1,484 Rural 23.1 0.7 0.1 0.0 0.0 0.0 76.1 100.0 4,531 District Aileu 25.4 0.3 0.2 0.2 0.0 0.0 73.9 100.0 220 Ainaro 18.8 0.0 0.0 0.0 0.2 0.0 80.9 100.0 318 Baucau 28.0 0.0 0.0 0.0 0.0 0.0 72.0 100.0 598 Bobonaro 25.2 0.7 0.3 0.0 0.0 0.0 73.8 100.0 587 Covalima 44.4 1.1 0.0 0.0 0.0 0.0 54.4 100.0 322 Dili 64.9 0.2 0.1 0.0 0.0 0.2 34.6 100.0 1,043 Ermera 16.2 0.0 0.0 0.0 0.0 0.0 83.8 100.0 719 Lautem 25.5 1.2 0.1 0.0 0.0 0.0 73.3 100.0 444 Liquiçá 28.6 3.3 0.2 0.0 0.0 0.0 67.9 100.0 358 Manatuto 43.0 0.0 0.2 0.0 0.0 0.0 56.8 100.0 264 Manufahi 20.3 0.2 0.0 0.0 0.0 0.0 79.4 100.0 238 Oecussi 13.4 0.9 0.2 0.0 0.0 0.0 85.5 100.0 492 Viqueque 19.1 1.0 0.0 0.0 0.2 0.0 79.7 100.0 412 Education No education 16.3 0.6 0.1 0.0 0.0 0.0 83.0 100.0 1,980 Primary 24.9 0.7 0.1 0.0 0.0 0.0 74.2 100.0 1,656 Secondary 46.2 0.6 0.2 0.0 0.0 0.1 53.0 100.0 2,226 More than secondary 82.2 0.0 0.0 0.0 0.0 0.0 17.8 100.0 154 Wealth quintile Lowest 12.5 1.0 0.0 0.0 0.0 0.0 86.4 100.0 1,226 Second 15.9 0.2 0.1 0.0 0.0 0.0 83.8 100.0 1,171 Middle 25.1 0.6 0.0 0.0 0.1 0.0 74.3 100.0 1,203 Fourth 37.8 0.9 0.3 0.0 0.0 0.0 61.0 100.0 1,170 Highest 64.8 0.4 0.1 0.0 0.1 0.2 34.5 100.0 1,244 Total 31.4 0.6 0.1 0.0 0.0 0.0 67.8 100.0 6,015 1 Includes women who received a checkup after 41 days Differentials in type of postnatal care provider are similar to those for postnatal care coverage in general. The likelihood of women receiving postnatal care from health professionals decreases with increasing parity. Women in the highest wealth quintile are more than five times as likely to receive postnatal care from a health professional as those in the lowest wealth quintile. Similarly, mothers with more than secondary education are five times as likely to receive postnatal care from a health professional as those with no education. Women in urban areas are more likely to receive postnatal care from a health professional than those in rural areas (57 percent and 24 percent, respectively). Finally, women in Oecussi (14 percent) have least access to a postnatal checkup from a health professional because of the low level of facility-based delivery care in this district. 10.10 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. Maternal Health | 129 Where health services are present, there are many factors—social, cultural, and economic— that cause women not to use the services, particularly when the health concern is related to sexual or reproductive matters. Information on such factors is particularly important in understanding and addressing the barriers women face in seeking care during pregnancy and at the time of delivery. In the 2009-10 TLDHS, women were asked whether each of the following factors would be a big problem or not a big problem in seeking health care for themselves: getting permission to go for treatment, getting money for treatment, distance to a health facility, having to take transportation, not wanting to go alone to the health facility, concern that there may not be a female provider, concern that there may be no health provider, and concern that there may be no drugs available. The results are shown in Table 10.14. 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, Timor-Leste 2009-10 Background characteristic Problems in accessing health care Number of women Getting permission to go for treatment Getting money for treatment Distance to health facility Having to take transport Not wanting to go alone Concern no female provider available Concern no provider available Concern no drugs available At least one problem accessing health care Age 15-19 24.9 37.8 53.2 59.6 48.4 64.9 81.9 86.5 96.0 3,144 20-34 22.7 33.6 52.5 58.0 42.6 61.7 81.4 85.8 95.7 5,774 35-49 22.3 36.6 54.4 61.0 40.1 63.7 84.1 87.9 96.2 4,219 Number of living children 0 24.3 36.4 51.6 57.9 45.6 63.3 80.9 85.7 95.6 5,178 1-2 21.4 32.5 52.6 57.4 42.1 61.5 83.1 87.4 96.0 2,350 3-4 22.4 34.7 53.3 58.7 41.2 60.3 83.2 86.9 95.8 2,554 5+ 22.9 37.4 56.7 63.9 41.7 66.2 83.7 87.5 96.6 3,055 Marital status Never married 24.6 36.9 51.5 57.9 45.9 63.1 80.5 85.6 95.6 4,675 Married or living together 22.3 34.7 54.3 60.3 41.7 63.1 83.4 87.3 96.1 7,906 Divorced/separated/ widowed 21.9 37.5 53.7 58.2 41.8 63.2 83.1 86.1 95.8 556 Employed last 12 months Not employed 26.8 38.8 55.6 60.0 42.3 63.0 84.0 87.8 96.1 7,951 Employed for cash 16.7 20.7 38.1 42.3 33.2 41.6 81.7 85.3 93.7 1,054 Employed not for cash 17.5 33.3 52.6 62.5 47.5 68.6 79.5 84.9 96.1 4,130 Residence Urban 21.5 28.1 32.3 35.3 32.5 41.3 78.6 83.7 94.2 3,439 Rural 23.7 38.3 60.7 67.9 47.0 70.8 83.7 87.7 96.6 9,698 District Aileu 46.1 64.2 71.2 74.8 69.9 74.3 90.1 92.6 95.4 554 Ainaro 28.4 56.3 59.3 48.9 46.8 71.4 86.6 89.2 91.8 619 Baucau 46.8 54.5 62.5 87.0 13.9 70.4 97.2 97.5 98.9 1,408 Bobonaro 2.3 12.3 40.8 42.6 48.7 60.1 64.5 91.4 96.1 1,262 Covalima 40.5 61.1 77.4 62.3 50.6 43.6 83.6 83.8 95.4 781 Dili 19.7 23.9 26.1 30.6 34.1 32.8 75.8 82.4 94.7 2,466 Ermera 5.5 10.3 42.8 77.9 53.2 91.9 68.3 66.3 99.8 1,542 Lautem 47.8 57.8 74.3 75.7 69.7 84.5 99.2 99.2 99.6 864 Liquiçá 26.8 43.3 53.6 50.6 35.9 64.3 68.7 70.5 83.9 801 Manatuto 19.1 42.3 58.4 44.6 34.7 68.2 84.1 83.5 90.6 603 Manufahi 4.4 16.4 41.3 54.9 53.4 28.9 89.5 92.4 96.1 470 Oecussi 11.7 33.8 70.0 61.4 15.2 74.7 94.5 97.4 98.3 884 Viqueque 18.0 39.6 79.2 84.5 73.2 75.3 97.5 97.6 100.0 882 Education No education 20.8 38.1 60.0 68.3 45.4 71.8 82.3 86.2 97.0 3,854 Primary 23.7 39.0 59.1 63.8 43.9 66.0 83.4 88.1 95.9 3,005 Secondary 24.1 32.8 47.9 53.8 42.4 57.5 82.3 86.2 95.4 5,829 More than secondary 26.6 27.7 27.5 24.6 29.3 41.4 77.7 86.1 93.9 449 Wealth quintile Lowest 24.6 48.8 72.1 75.8 48.1 72.9 90.6 93.2 97.8 2,314 Second 24.6 39.1 62.7 73.2 49.9 74.1 83.7 86.8 96.9 2,468 Middle 22.0 36.6 57.9 66.5 46.8 69.7 80.5 84.8 96.2 2,590 Fourth 22.7 32.2 50.7 55.5 41.2 62.9 80.2 85.6 95.4 2,687 Highest 22.1 25.1 29.9 33.3 32.7 41.5 78.7 84.0 93.9 3,077 Total 23.1 35.6 53.3 59.4 43.2 63.1 82.4 86.6 95.9 13,137 Note: Total includes 2 women with information missing on employment status. 130 | Maternal Health More than ninety-six percent of Timorese women reported that they have at least one problem when they access health care for themselves. The two major concerns were no availability of drugs (87 percent) and no availability of a health care provider (82 percent). Concern about not having a female provider is also sizeable (63 percent). Women had about equal concern regarding the distance to the health facility and having to take transport (more than one in two women). Getting permission to go for treatment was the least of women’s worries (23 percent). Two in five considered not wanting to go alone to be a problem. In general, women with more than secondary education and women in the highest wealth quintile were least likely to report having a serious problem in accessing health facilities. Child Health | 131 CHILD HEALTH 11 This chapter presents the findings on child health from the 2009-10 TLDHS. Its focus is on vaccination status and treatment practices that are commonly used for children experiencing three major childhood illnesses: acute respiratory infection (ARI), fever, and diarrhea. Information on children’s birth weight and size, treatment practices, and contact with health facilities when children are sick paves the way for strategic planning and implementation of programs to reduce neonatal and infant mortality. Combined with data on childhood mortality, this information can be used to identify subgroups of women and children at increased risk because of non-use of maternal and child health (MCH) services and to assist with planning effective improvements for these services. Information was obtained for all live births that occurred in the five years preceding the survey. Wherever possible, data from the 2009-10 TLDHS are compared with data from the earlier DHS survey in Timor-Leste, conducted in 2003. However, caution should be used in interpreting the trend data due to differences in the definitions and methodology used in these surveys. 11.1 CHILD’S SIZE 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 illnesses and the child’s chances of survival. Children whose birth weight is less than 2.5 kilograms, or children reported to be “very small” or “smaller than average” are considered to have a higher-than-average risk of early childhood death. Birth weight was recorded in the questionnaire, if available from written records or mother’s recall, for all births in the five years preceding the survey. Because birth weight may not be known for many babies, and particularly for babies delivered at home and who are not weighed at birth, the mother’s estimate of the baby’s size at birth was also obtained. Even though it is subjective, it can be a useful proxy for the weight of the child. Table 11.1 presents information on children’s weight and size at birth. Birth weight was reported for only 26 percent of births in the five years preceding the survey. It is unlikely that these births are representative of all births because births in urban areas and births to mothers in higher wealth quintiles are over-represented, and the pattern of birth weights by background characteristics is likely to be biased. Nevertheless it is important to note that 10 percent of babies weighed at birth were less than 2.5 kilograms. Low birth-weight babies are twice as likely to be born to mothers less than age 20 at birth, and they are more likely to be first-order births, births born to mothers who smoked cigarettes/tobacco, and births to uneducated mothers. One in four children in Ainaro, one in five children in Aileu, and one in six children in Ermera and Manufahi who were weighed at birth are of low weight. Differences by urban-rural residence and wealth quintile are minimal. Most children were reported by their mothers as average or larger at birth (82 percent), while 10 percent of children were reported as smaller than average, and 5 percent were reported as very small at birth. The characteristics of mothers with very small children at birth are similar to the characteristics of children whose weight at birth was less than 2.5 kilograms, consistent with the notion that a mother’s description of the size of the baby at birth is a good proxy in the absence of a recorded weight. Children born to very young mothers (<20 years), first-order births, children born to mothers who smoke, and children of mothers with no education, are more often reported to be very small at birth than children of other mothers. In addition, rural children are twice as likely as urban children to be reported as very small. Nearly one in five children born in Manufahi and one in six children born in Oecussi are reported as very small at birth. Children born in the poorest households are also more likely to be reported as very small at birth. 132 | Child Health Table 11.1 Child’s weight and size at birth Percent distribution of live births in the five years preceding the survey with a reported birth weight by birth weight; percent distribution of all live births in the five years preceding the survey by mother’s estimate of baby’s size at birth and percentage of all births with a reported birth weight, according to background characteristics, Timor- Leste 2009-10 Background characteristic Percent distribution of births with a reported birth weight1 Total Number of births Percentage of all births with a reported birth weight Percent distribution of all live births by size of child at birth Total Number of births Less than 2.5 kg 2.5 kg or more Very small Smaller than average Average or larger Don’t know/ missing Mother’s age at birth <20 18.0 82.0 100.0 209 28.1 6.3 12.0 80.1 1.7 100.0 745 20-34 9.6 90.4 100.0 1,874 27.6 4.9 10.5 82.3 2.3 100.0 6,789 35-49 8.5 91.5 100.0 503 21.9 5.5 9.7 82.6 2.2 100.0 2,294 Birth order 1 12.3 87.7 100.0 592 35.3 6.1 11.5 80.8 1.6 100.0 1,679 2-3 9.0 91.0 100.0 911 30.7 5.0 10.7 82.2 2.1 100.0 2,964 4-5 9.0 91.0 100.0 592 24.5 5.2 10.5 82.2 2.2 100.0 2,415 6+ 10.8 89.2 100.0 491 17.7 4.8 9.4 83.2 2.6 100.0 2,770 Mother’s smoking status Smokes cigarettes/ tobacco 13.6 86.4 100.0 87 18.3 6.9 17.3 74.3 1.4 100.0 478 Does not smoke 9.9 90.1 100.0 2,498 26.7 5.1 10.1 82.6 2.2 100.0 9,350 Residence Urban 10.1 89.9 100.0 1,310 55.7 2.9 12.3 81.9 2.9 100.0 2,353 Rural 10.1 89.9 100.0 1,275 17.1 5.9 9.8 82.3 2.0 100.0 7,475 District Aileu 20.0 80.0 100.0 74 20.7 2.1 5.5 90.9 1.5 100.0 359 Ainaro 24.0 76.0 100.0 44 7.7 1.4 3.2 94.8 0.7 100.0 579 Baucau 12.0 88.0 100.0 218 22.4 1.0 8.2 90.8 0.0 100.0 970 Bobonaro 7.7 92.3 100.0 287 30.7 13.1 13.1 73.2 0.6 100.0 934 Covalima 8.6 91.4 100.0 168 37.1 1.4 2.4 95.8 0.4 100.0 453 Dili 9.1 90.9 100.0 1,063 64.3 2.0 12.5 81.9 3.6 100.0 1,652 Ermera 17.8 82.2 100.0 47 3.7 1.2 1.5 97.3 0.0 100.0 1,252 Lautem 3.7 96.3 100.0 196 25.8 8.0 25.5 49.2 17.4 100.0 758 Liquiçá 16.0 84.0 100.0 109 18.7 4.4 18.8 76.5 0.4 100.0 582 Manatuto 12.9 87.1 100.0 121 27.8 0.9 1.5 97.4 0.1 100.0 433 Manufahi 17.9 82.1 100.0 58 14.7 18.5 17.7 63.3 0.5 100.0 393 Oecussi 8.5 91.5 100.0 55 7.1 17.7 17.8 64.5 0.0 100.0 783 Viqueque 8.2 91.8 100.0 146 21.5 0.5 4.5 94.4 0.6 100.0 678 Mother’s education No education 13.7 86.3 100.0 349 10.6 6.4 9.6 82.1 1.9 100.0 3,298 Primary 11.1 88.9 100.0 560 20.3 6.0 11.6 79.8 2.6 100.0 2,765 Secondary 8.8 91.2 100.0 1,506 42.5 3.6 10.0 84.2 2.2 100.0 3,546 More than secondary 10.6 89.4 100.0 171 78.4 1.4 13.7 84.0 0.9 100.0 218 Wealth quintile Lowest 10.6 89.4 100.0 172 8.2 8.3 11.0 77.5 3.1 100.0 2,090 Second 16.5 83.5 100.0 218 11.1 5.5 9.4 83.1 2.0 100.0 1,960 Middle 11.7 88.3 100.0 365 18.3 4.8 9.3 84.4 1.6 100.0 1,992 Fourth 10.5 89.5 100.0 635 33.4 4.3 10.9 83.0 1.7 100.0 1,903 Highest 8.1 91.9 100.0 1,195 63.4 2.5 11.5 83.5 2.5 100.0 1,884 Total 10.1 89.9 100.0 2,586 26.3 5.2 10.4 82.2 2.2 100.0 9,828 1 Based on either a written record or the mother’s recall 11.2 VACCINATION COVERAGE The 2009-10 TLDHS collected information on immunization coverage for all children born in the five years before the survey. The government of Timor-Leste has adopted the World Health Organization (WHO) and UNICEF guidelines for vaccinating children. According to these guidelines, to be considered fully vaccinated, a child should receive the following vaccinations: one dose each of BCG and measles, three doses of polio vaccine (after polio 0, given at birth), and three doses of DPT. Currently, the tetravalent vaccine DPT-HepB introduced in 2007 has replaced the previous DPT vaccine, so in effect, children fully vaccinated in more recent years are also protected against Hepatitis B. BCG, which protects against tuberculosis, is recommended at birth or at first clinical contact. DPT-HepB protects against diphtheria, pertussis (whooping cough), tetanus, and Hepatitis B. A dose of polio vaccine is recommended at birth (Polio 0) or within 2 weeks/14 days of birth. The DPT-HepB and polio vaccine schedule recommends three vaccinations at approximately 6, 10, and 14 weeks of age. The measles vaccine is recommended at age 9 months. It is recommended that children receive the complete schedule of vaccinations before age 12 months. Child Health | 133 In the TLDHS, information on vaccination coverage was obtained in two ways—from health cards (LISIO) and from mother’s verbal reports. All mothers were asked to show the interviewer the health cards on which the child’s immunizations are recorded. If the card was available, the interviewer copied the dates of each vaccination received. If a vaccination was not recorded on the card, the mother was asked to recall whether that particular vaccination had been given. If the mother was not able to present a card for a child, she was asked to recall whether the child had received BCG, polio, DPT-HepB, and measles vaccinations. If she recalled that the child had received the polio or DPT-HepB vaccines, she was asked about the number of doses that the child received. The data presented here are for children age 12-23 months, the youngest cohort of children who have reached the age by which they should be fully vaccinated, and are restricted to children who were alive at the time of the survey. Table 11.2 shows the percentage of children age 12-23 months who received specific vaccines at any time before the survey by source of information. Fifty-three percent of Timorese children age 12-23 months are fully immunized, and 23 percent received no vaccinations (Figure 11.1). Forty-seven percent of children age 12-23 months are fully vaccinated by 12 months of age. Table 11.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother’s report), and percentage vaccinated by 12 months of age, Timor-Leste 2009-10 Source of information BCG DPT Polio1 Hepatitis B Measles All basic vaccina- tions2 No vaccina- tions Number of children 1 2 3 0 1 2 3 1 2 3 Vaccinated at any time before survey Vaccination card 49.4 49.0 47.8 47.0 47.7 49.1 47.9 47.0 49.0 47.6 46.8 44.6 44.4 0.0 870 Mother’s report 27.3 26.1 23.5 19.4 17.6 25.7 21.4 9.1 25.7 22.6 18.9 23.2 8.2 22.6 882 Either source 76.7 75.1 71.3 66.4 65.3 74.9 69.3 56.2 74.6 70.3 65.7 67.8 52.6 22.7 1,752 Vaccinated by 12 months of age3 76.6 74.2 69.9 64.2 65.2 74.0 68.1 54.4 73.7 69.0 62.9 60.0 47.2 23.1 1,752 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother’s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. Figure 11.1 Immunization Coverage of Children 12-23 Months 62 51 48 40 18 18 77 66 56 68 53 23 BCG DPT3 Polio3 Measles All vaccinations No vaccinations 0 20 40 60 80 100 Percent of children 12-23 months DHS 2003 TLDHS 2009-10 Timor-Leste 2009-10 134 | Child Health Looking at coverage for specific vaccines, 77 percent of children received the BCG vaccination, 75 percent received the first DPT dose, and 75 percent received the first polio dose. Coverage for all three vaccinations declines with subsequent doses; 66 percent of children received the recommended three doses of DPT, and 56 percent received three doses of polio. These figures reflect dropout rates (which represent the proportion of children who received the first dose of a vaccine but who did not get the third dose) of 12 percent for DPT and 25 percent for polio, respectively. This is a huge improvement from 2003 when the dropout rates for DPT and polio were 45 and 62 percent, respectively. It is interesting to note that dropout rates for polio are higher than for DPT despite the fact that these vaccines should be given together. This may be related to polio vaccination being deliberately withheld when a child has diarrhea or to parental concern for a child receiving it during an episode of diarrhea and refusing it. Sixty-eight percent of children received the measles vaccine (Figure 11.1). Hepatitis B coverage varies slightly from DPT coverage, although they have been given together in a tetravalent vaccine since 2007. This difference is likely due to the inclusion of a small number of children who received the DPT vaccine before the tetravalent vaccine was introduced. Table 11.3 shows the percentages of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report) and the percentages with a vaccination card. Table 11.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report), and percentage with a vaccination card, by background characteristics, Timor-Leste 2009-10 Background characteristic BCG DPT Polio1 Hepatitis B Measles All basic vaccina- tions2 No vaccina- tions Percentage with a vaccina- tion card seen Number of children 1 2 3 0 1 2 3 1 2 3 Sex Male 77.8 76.3 72.4 68.6 66.6 76.3 70.8 58.4 75.5 71.5 68.2 69.0 54.3 21.6 51.8 894 Female 75.7 73.8 70.1 64.1 64.1 73.3 67.8 53.8 73.7 69.0 63.2 66.5 50.8 23.8 47.4 859 Birth order 1 80.7 78.8 75.4 71.4 67.5 78.3 75.5 60.9 78.4 74.6 70.8 70.6 57.9 19.3 54.9 323 2-3 77.7 75.3 71.3 67.4 66.1 75.5 70.0 54.1 75.0 70.5 66.1 70.3 51.1 21.4 45.7 505 4-5 77.7 76.6 72.9 67.0 67.6 76.0 70.2 55.6 76.2 71.9 66.8 68.6 51.1 21.4 50.0 418 6+ 72.5 71.3 67.3 61.8 61.3 71.0 64.0 55.6 70.6 66.0 61.3 62.9 51.9 27.1 49.9 507 Residence Urban 85.3 81.1 77.3 70.9 74.3 80.7 73.3 49.2 80.2 75.7 69.5 74.3 47.7 14.5 43.7 424 Rural 74.0 73.2 69.3 65.0 62.5 73.0 68.1 58.4 72.8 68.5 64.5 65.7 54.1 25.3 51.5 1,328 District Aileu 88.0 87.2 87.2 86.4 77.7 88.0 88.0 83.2 87.2 87.2 85.6 83.3 79.2 12.0 73.6 66 Ainaro 59.3 56.7 54.6 52.0 57.9 57.2 54.1 51.7 56.0 53.9 52.0 50.4 46.1 40.7 32.3 113 Baucau 58.2 58.2 53.0 51.8 49.4 59.1 52.7 50.7 58.2 53.0 51.8 52.0 47.1 40.9 48.0 180 Bobonaro 82.4 82.4 82.4 81.5 74.7 82.4 82.4 56.1 82.8 81.9 81.5 79.8 55.2 17.6 49.7 157 Covalima 91.2 88.5 84.5 81.2 57.0 87.2 85.9 71.4 88.5 80.6 77.3 79.7 61.9 8.8 41.2 69 Dili 86.6 81.7 77.6 70.7 76.3 81.0 72.9 44.1 80.3 75.5 68.6 73.3 43.4 13.4 40.5 281 Ermera 64.6 62.0 56.3 51.5 52.0 63.6 52.9 50.3 62.3 55.8 51.0 54.2 44.6 35.4 45.2 200 Lautem 86.8 87.5 86.0 80.9 80.1 86.4 84.6 75.4 86.8 83.5 79.4 80.1 74.6 12.1 73.8 140 Liquiçá 85.6 80.6 70.6 59.4 66.9 80.6 67.1 50.2 79.9 70.0 59.4 66.3 43.7 14.4 52.2 106 Manatuto 71.8 71.8 71.2 69.3 66.8 71.2 69.3 59.9 71.8 71.2 69.3 64.9 53.6 28.2 48.9 87 Manufahi 69.2 69.1 60.2 53.2 58.9 69.7 60.5 46.4 69.8 59.4 53.3 68.4 42.8 28.6 39.1 80 Oecussi 85.9 86.8 83.4 74.1 65.4 86.8 80.7 63.8 86.8 83.4 74.1 74.8 60.0 10.3 64.2 143 Viqueque 74.4 73.1 69.9 64.4 63.3 69.0 67.5 60.2 70.7 69.1 64.5 66.8 57.1 25.6 48.8 130 Mother’s education No education 67.9 66.8 61.4 56.6 56.0 66.8 58.5 50.4 66.7 60.8 56.3 58.6 46.6 31.0 45.1 571 Primary 77.3 76.1 72.2 66.2 63.2 74.4 70.1 57.4 75.7 70.9 65.2 67.1 54.0 22.3 50.1 478 Secondary 82.5 80.4 77.9 73.8 73.3 80.6 77.0 61.3 79.7 76.7 72.9 74.8 57.7 17.2 54.3 661 More than secondary (100.0) (90.5) (90.5) (86.8) (90.5) (100.0) (86.8) (39.0) (90.5) (90.5) (86.8) (90.5) (39.0) (0.0) (34.2) 43 Wealth quintile Lowest 64.5 64.4 60.9 54.8 52.5 64.1 59.6 49.1 63.5 59.8 54.2 53.7 43.2 33.9 43.1 381 Second 70.9 68.6 66.2 62.5 60.6 69.0 64.1 56.8 68.5 65.7 62.3 63.7 53.5 28.9 50.6 359 Middle 78.8 77.9 71.9 68.3 64.1 77.8 71.3 58.5 78.2 71.4 68.0 71.0 55.8 20.7 52.3 349 Fourth 84.8 83.3 79.0 75.8 71.1 81.3 77.1 69.0 82.9 78.6 74.0 78.0 65.5 15.0 57.4 346 Highest 87.0 83.3 80.3 72.5 81.3 84.2 76.3 47.2 82.0 77.9 72.0 74.7 45.2 12.5 45.1 317 Total 76.7 75.1 71.3 66.4 65.3 74.9 69.3 56.2 74.6 70.3 65.7 67.8 52.6 22.7 49.6 1,752 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) Child Health | 135 Boys (54 percent) are somewhat more likely to be fully vaccinated than girls (51 percent). Surprisingly, children in rural areas (54 percent) are more likely to be fully vaccinated than children in urban areas (48 percent). Vaccination coverage varies significantly by district, with Manufahi and Dili having the lowest coverage of fully immunized children at 43 percent each. Aileu and Lautem have the highest coverage of fully immunized children at 79 and 75 percent, respectively. Many of the districts with lower coverage of fully vaccinated children have the highest dropout rates, especially for polio. Dili has a very high dropout rate between polio 1 and polio 3 at 46 percent, compared with less than 5 percent for Aileu. The single biggest reason that full vaccination coverage in rural areas is higher than in urban areas is the very low polio 3 coverage in urban areas (49 percent). In fact all other vaccines have higher coverage in urban than rural areas. Even though oral polio vaccine has minimum side effects and can be given to persons with diarrhea, it can lead to gastrointestinal upset like diarrhea and vomiting, prompting physicians (who operate predominantly in urban areas) to withhold the vaccine from children with diarrhea. Additionally, mothers may not return for follow-up visits upon the physician’s advice to bring their children back once the diarrhea has ceased. The considerably lower coverage in urban areas and particularly in Dili could also be attributed to the 2006 civil unrest in the country, which disrupted all basic health services, severely damaged infrastructure, and displaced thousands of residents from their homes. Vaccination coverage is highest for first-born children (58 percent), with little difference in coverage for children of birth order two and above (about 51 percent). Children whose mothers attend only primary or secondary school are more likely to be fully vaccinated than children whose mothers have no education. The proportion of children fully vaccinated generally increases with wealth quintile, from 43 percent in the lowest wealth quintile to 66 percent in the fourth quintile, and decreases for children in the highest wealth quintile (45 percent). 11.3 TRENDS IN VACCINATION COVERAGE Table 11.4 shows by age cohorts the percentage of children age 12-59 months (at the time of the survey) who received specific vaccines by 12 months of age and the percentage with a vaccination card. Thirty-six percent of children received all their vaccinations by 12 months of age. Children in the oldest cohort (48-59 months) were less likely to have received all their vaccinations (28 percent) than children age 12-23 months (47 percent). This pattern is seen with each vaccine but is most marked when all the vaccines are considered together. Vaccination cards were shown to interviewers for 50 percent of children age 12-23 months, compared with 16 percent of children age 48-59 months. The difference may partly be a result of the cards for older children being lost or misplaced over the longer period of time and may partly be due to a better card uptake in more recent years. Table 11.4 Vaccinations in first year of life Percentage of children age 12-59 months at the time of the survey who received specific vaccines by 12 months of age, and percentage with a vaccination card, by current age of child, Timor-Leste 2009-10 Age in months BCG DPT Polio1 Hep B Measles All basic vaccina- tions2 No vaccina- tions Percent- age with a vaccina- tion card seen Number of children 1 2 3 0 1 2 3 1 2 3 12-23 76.6 74.2 69.9 64.2 65.2 74.0 68.1 54.4 73.7 69.0 62.9 60.0 47.2 23.1 49.6 1,752 24-35 73.0 70.5 66.6 60.2 58.1 70.3 63.0 45.8 69.6 65.8 58.9 56.5 38.2 26.9 34.7 1,959 36-47 70.7 67.0 64.0 54.7 53.6 67.2 60.2 38.7 66.4 63.4 53.5 51.1 31.4 30.0 26.3 1,947 48-59 64.3 61.7 56.8 49.9 46.7 60.9 52.9 31.8 61.2 56.0 49.2 52.8 27.9 36.3 16.2 1,745 Total 71.6 69.0 64.9 57.6 56.2 68.7 61.5 42.9 68.3 64.1 56.4 55.6 36.3 28.3 31.7 7,403 Note: Information was obtained from the vaccination card or if there was no written record, from the mother. For children whose information was based on the mother’s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccinations. 1 Polio 0 is the polio vaccination given at birth. 2 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 136 | Child Health The difference in vaccination coverage by 12-month cohorts from the 2009-10 TLDHS supports a trend towards increased vaccination coverage in 2009-10 compared with previous surveys. An analysis of long-term trends in coverage is shown in Figure 11.2. The percentage of children 12- 23 months who are fully vaccinated dropped substantially between the 1997 IDHS and the 2002 MICS, primarily because of the total disruption of all health services following the struggle for independence from Indonesian rule. Coverage has since risen to a high of 53 percent in the most recent DHS. Compared with coverage in the 2003 DHS, coverage against all vaccine antigens increased significantly in the 2009-10 TLDHS. The percentage of children fully vaccinated nearly tripled, increasing from 18 percent in 2003 to 53 percent in 2009-10. However, it is important to note that while the 2003 DHS considered full immunization to include four polio doses, including polio 0 given at birth, the 2009-10 survey does not require children to have received polio 0 in order to have received all basic vaccinations. Recalculating the 2009-10 TLDHS data to include polio 0 in the estimate of children fully immunized confirms that coverage has increased two and a half times, from 18 percent in 2003 to 46 percent in 2009-10. The percentage who received no vaccination is reported at 18 percent in 2003, which is less than the current 2009-10 TLDHS estimate of 23 percent. Although the percentage of children fully immunized increased between the 2003 DHS and the 2007 TLSLS, the relatively lower coverage in the latter survey conducted two years before the 2009-10 TLDHS could be attributed to the disruption of health services following the 2006 civil unrest. Figure 11.2 Trends in Children 12-23 Months Fully Immunized 56 5 18 27 46 17 59 18 0 23 IDHS 1997 MICS 2002 DHS 2003* TLSLS 2007* TLDHS 2009-10* 0 10 20 30 40 50 60 70 Percent of children 12-23 months Fully immunized No vaccinations Timor-Leste 2009-10 * Includes 4 doses of polio u = unavailable u 11.4 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is one of the leading causes of death among young children in Timor-Leste. In the case of pneumonia, early diagnosis and treatment with antibiotics can prevent a large proportion of deaths due to acute respiratory infection (ARI). The prevalence of ARI in the 2009-10 TLDHS was estimated by asking mothers whether their children under age 5 had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey. These symptoms, though compatible with pneumonia, are subjective (i.e., mother’s perception of illness) and were not validated by a medical examination. Table 11.5 shows the percentage of children under 5 years who had a cough accompanied by short, rapid breathing (symptoms of ARI). Child Health | 137 The data indicate that two percent of children had symptoms of ARI in the two weeks preceding the survey. Differentials in the prevalence of ARI by background characteristics are minimal; however, it is worth noting that the prevalence of ARI symptoms is slightly higher among children age 12-23 months, among children living in urban areas, among children living in Lautem, and among children of mothers who have more than secondary education. Seven in ten children with symptoms of ARI (71 percent) were taken to a health facility or provider, and 45 percent were prescribed antibiotics (data not shown). 11.5 FEVER Fever is a symptom of malaria and other acute infections in children. Malaria and other illnesses that cause fever contribute to high levels of malnutrition and mortality. Although fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Because malaria is one of the major causes of death in infancy and childhood in many developing countries, the so- called presumptive treatment of fever with anti- malarial medication is advocated in many countries where malaria is endemic. The survey was fielded over six months, from August 2009 to February 2010. Malaria transmission is at its peak at the end of the wet season, which occurs from November to May (Cooper et al., 2010). Malaria in Timor-Leste is discussed in greater detail in Chapter 13. Table 11.6 shows the percentage of children under age 5 with fever during the two weeks preceding the survey and the percentage receiving various treatments, by selected background characteristics. One-fifth of children (19 percent) under 5 years of age were reported to have had fever in the past two weeks. Fever is most common among children age 6-11 months (28 percent) and then decreases with age. The prevalence of fever is higher among children who live in urban areas (24 percent) compared with those who live in rural areas (18 percent). District differentials show that the proportion of children with fever is highest in Liquiçá (34 percent) and lowest in Ainaro (5 percent). Fever prevalence increases slightly as wealth quintile increases but shows no clear relationship by education of the mother. Table 11.5 Prevalence and treatment of symptoms of ARI Percentage of children under age 5 who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey, according to background characteristics, Timor-Leste 2009-10 Background characteristic Children under age 5 Percentage with symptoms of ARI1 Number of children Age in months <6 1.9 983 6-11 2.3 942 12-23 2.8 1,752 24-35 2.1 1,959 36-47 2.0 1,947 48-59 1.3 1,745 Sex Male 2.0 4,742 Female 2.2 4,586 Mother’s smoking status Smokes cigarettes/tobacco 2.4 453 Does not smoke 2.0 8,875 Cooking fuel Electricity or gas 2.1 196 Kerosene 0.2 216 Coal/lignite * 1 Charcoal (0.0) 31 Wood/straw2 2.1 8,885 Residence Urban 2.8 2,269 Rural 1.8 7,059 District Aileu 2.6 340 Ainaro 1.1 536 Baucau 0.0 941 Bobonaro 3.6 884 Covalima 3.0 426 Dili 2.3 1,597 Ermera 1.2 1,172 Lautem 5.6 719 Liquiçá 3.0 550 Manatuto 0.9 416 Manufahi 0.8 369 Oecussi 2.5 734 Viqueque 0.3 644 Mother’s education No education 1.7 3,122 Primary 2.0 2,611 Secondary 2.3 3,381 More than secondary 3.9 214 Wealth quintile Lowest 1.5 1,973 Second 2.0 1,834 Middle 2.3 1,875 Fourth 2.3 1,819 Highest 2.3 1,827 Total 2.1 9,328 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Symptoms of ARI (cough accompanied by short, rapid breathing which was chest-related) is considered a proxy for pneumonia. 2 Includes grass, shrubs, crop residues 138 | Child Health Seventy-three percent of children with a fever were taken to a health facility or provider for treatment. Six percent of children under age 5 with fever in the two weeks preceding the survey were given antimalarial drugs, and 36 percent received antibiotics. According to the Integrated Management of Childhood Illness (IMCI) and the national malaria treatment guidelines, all children with fever should be tested for malaria parasites using either a microscope or rapid diagnostic test (RDT) for final diagnosis or classification. Thus, not all children with fever are treated with antimalarial drugs. Treatment of malaria is also dependent on the availability of appropriate antimalarial drugs, RDTs, and microscopy tests in health facilities or at SISCa. However, in the absence of the primary use of RDTs, the use of microscopy testing is promoted in health facilities, and patients with fever are immediately prescribed paracetamol or antibiotics even before the malaria test results are returned (see detailed discussion in Chapter 13). Differentials in the percentage of children for whom advice or treatment is sought by background characteristics such as mother’s education and wealth status are minimal. Table 11.6 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage of children for whom treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who took antibiotic drugs, by background characteristics, Timor-Leste 2009-10 Background characteristic Among children under age 5: 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 14.7 983 63.4 3.9 33.7 145 6-11 27.8 942 74.2 4.0 35.6 262 12-23 23.4 1,752 72.1 6.9 40.6 410 24-35 21.3 1,959 75.3 6.4 38.0 417 36-47 17.6 1,947 71.3 5.8 32.5 342 48-59 12.3 1,745 76.0 5.3 33.3 214 Sex Male 18.7 4,742 73.4 6.4 35.5 887 Female 19.7 4,586 72.2 5.1 37.1 903 Residence Urban 24.1 2,269 77.5 5.2 35.1 546 Rural 17.6 7,059 70.7 5.9 36.8 1,243 District Aileu 14.9 340 80.8 24.2 49.9 51 Ainaro 4.9 536 (38.8) (5.9) (30.8) 26 Baucau 14.9 941 80.5 1.1 62.8 140 Bobonaro 26.4 884 78.7 1.4 34.5 234 Covalima 20.0 426 79.8 8.5 19.9 85 Dili 24.6 1,597 79.3 5.1 30.6 392 Ermera 12.7 1,172 69.4 15.2 20.3 149 Lautem 29.6 719 66.9 1.7 31.7 213 Liquiçá 33.8 550 66.7 7.7 37.8 186 Manatuto 19.3 416 81.3 1.4 59.2 80 Manufahi 11.3 369 55.7 5.8 35.7 42 Oecussi 20.6 734 56.1 1.9 35.0 151 Viqueque 6.3 644 (80.2) (21.9) (66.7) 41 Mother’s education No education 17.7 3,122 68.3 7.7 32.5 552 Primary 20.6 2,611 70.3 3.7 32.2 539 Secondary 19.2 3,381 77.6 5.2 42.9 648 More than secondary 23.7 214 (86.6) (10.9) (35.7) 51 Wealth quintile Lowest 16.1 1,973 58.6 5.1 33.8 317 Second 16.9 1,834 68.9 4.7 33.4 310 Middle 18.6 1,875 77.1 5.6 41.0 348 Fourth 22.6 1,819 73.2 6.9 32.0 410 Highest 22.1 1,827 82.7 5.9 40.8 404 Total 19.2 9,328 72.8 5.7 36.3 1,790 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner Child Health | 139 11.6 DIARRHEAL DISEASE Dehydration caused by severe diarrhea is a major cause of morbidity and mortality among young children in Timor- Leste, although the condition can be easily treated with oral rehydration therapy (ORT) and zinc. Exposure to diarrhea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. In the 2009-10 TLDHS, mothers were asked whether any of their children under 5 years of age had diarrhea during the two weeks preceding the survey. If a child had diarrhea, the mother was asked about feeding practices during the diarrheal episode and about what actions were taken to treat the diarrhea. However, the validity of this indicator is affected by the mother’s perception of diarrhea as an illness and her capacity to recall the events. Moreover, because the prevalence of diarrhea varies seasonally, the results of the 2009-10 TLDHS—which pertain to the fieldwork period from August to February—should be interpreted with caution. 11.6.1 Incidence and Treatment of Diarrhea Table 11.7 shows the percentage of children under age 5 with diarrhea in the two weeks preceding the survey, by selected background characteristics. Overall, 16 percent of all children under the age of 5 had diarrhea in the two weeks before the survey, and 1 percent had diarrhea with blood. Not surprisingly, very young children are least likely to have had diarrhea, presumably because most of them are exclusively breastfed and hence less exposed to contaminated food. Diarrhea is relatively more common among young children age 6– 11 months (22 percent) and age 12–23 months (25 percent), with prevalence declining at older ages. Age 12-23 months is when children start walking and are at increased risk of contamination from the environment. The introduction of other liquids and foods at the time of weaning can also facilitate the spread of disease-causing microbes. Prevalence of diarrhea among children is highest in Liquiçá (25 percent) and lowest in Ainaro (4 percent). Additionally, prevalence of diarrhea is highest among female children; children who live in urban areas, children whose mothers have more than secondary education, and children with mothers in the higher wealth quintiles. This anomaly in the prevalence of diarrhea may be due to the fact that urban, educated, and wealthy mothers are more likely than other mothers to recognize diarrhea as a serious childhood illness and report it. In the same vein, it is not surprising that diarrhea prevalence is Table 11.7 Prevalence of diarrhea Percentage of children under age 5 who had diarrhea in the two weeks preceding the survey, by background characteristics, Timor- Leste 2009-10 Background characteristics Diarrhea in the two weeks preceding the survey All diarrhea Diarrhea with blood Number of children Age in months <6 7.9 0.4 983 6-11 22.2 1.5 942 12-23 25.1 2.3 1,752 24-35 17.2 1.4 1,959 36-47 12.5 0.7 1,947 48-59 8.5 0.4 1,745 Sex Male 14.6 1.2 4,742 Female 16.6 1.1 4,586 Source of drinking water1 Improved 16.5 1.2 6,079 Not improved 13.8 1.1 3,249 Toilet facility2 Improved, not shared 17.2 1.2 3,728 Non-improved or shared 14.5 1.1 5,600 Residence Urban 18.9 1.1 2,269 Rural 14.5 1.1 7,059 District Aileu 12.7 1.4 340 Ainaro 3.9 0.4 536 Baucau 15.1 0.4 941 Bobonaro 20.1 0.8 884 Covalima 18.1 2.4 426 Dili 19.7 1.1 1,597 Ermera 12.8 0.4 1,172 Lautem 21.7 2.0 719 Liquiçá 25.3 1.1 550 Manatuto 11.9 1.2 416 Manufahi 8.4 0.5 369 Oecussi 16.7 2.9 734 Viqueque 4.6 1.1 644 Mother’s education No education 13.7 1.0 3,122 Primary 15.9 1.5 2,611 Secondary 16.8 1.1 3,381 More than secondary 18.8 0.9 214 Wealth quintile Lowest 13.1 1.1 1,973 Second 13.6 1.2 1,834 Middle 15.4 0.5 1,875 Fourth 18.8 1.8 1,819 Highest 17.2 1.0 1,827 Total 15.6 1.1 9,328 1 See Table 2.7 for definition of categories. 2 See Table 2.8 for definition of categories. 140 | Child Health higher among children who live in households with improved drinking water and in households that do not share toilet facilities. Mothers of children with diarrhea in the two weeks preceding the survey were asked what was done to manage or treat the illness. Table 11.8 shows the percentage of children with diarrhea who were taken to a health facility or provider for treatment, the percentage who received ORT, and the percentage who were given other treatments, by background characteristics. Overall, 72 percent of children with diarrhea were taken to a health provider for treatment of diarrhea. Children age 48-59 months are more likely than children in other age groups to be taken to a health facility or provider for treatment (79 percent). Differences in treatment-seeking behavior by gender of the child, urban-rural residence, and mother’s education are small. Children in the highest wealth quintile are more likely than other children to be taken to a health facility or provider for treatment when they have diarrhea. During diarrhea, oral rehydration therapy (ORT), which involves giving children a solution prepared by mixing water with a commercially prepared packet of oral rehydration salts (ORS) or recommended home fluids (RHF)—usually a home-made sugar-salt-water solution—is a simple and effective remedy for dehydration. In the 2009-10 TLDHS, 78 percent of children with diarrhea were treated either with ORS (71 percent) or RHF (40 percent). Ten percent of children were given increased fluids. Overall, 79 percent of children under age 5 with diarrhea were treated with ORT or increased fluids. Use of ORS varies by age from 50 percent among children less than age 6 months to 72 percent among children age 48-59 months. ORS use is higher among female than male children and among children without bloody diarrhea. There is little difference in the use of ORS by mother’s education, but ORS use varies by districts, ranging from 59 percent in Manufahi to 92 percent in Baucau. There is no clear pattern in regard to ORS use and wealth quintiles. Antibiotics are generally not recommended for treating nonbloody diarrhea in young children. In the 2009-10 TLDHS, 6 percent of children with diarrhea were treated with antibiotics, with no notable difference between bloody and nonbloody diarrhea (7 percent and 6 percent, respectively). Giving antibiotics to treat diarrhea is most likely in children age 6-11 months and in children in urban areas. Home remedies were given to 18 percent of children with diarrhea, and 13 percent of children with diarrhea were given no treatment at all. Zinc is offered along with ORT to children with diarrhea as per IMCI protocol. Zinc is not a substitute for ORT but when taken in addition to ORT, it reduces the severity and duration of diarrhea. Table 11.8 shows that 6 percent of children with diarrhea received zinc only. Children living in urban areas and in Dili are most likely to have received zinc. Children whose mothers completed secondary or higher education and those in the highest wealth quintile were also more likely to receive zinc than children of mothers with no education and children in the lowest wealth quintile. Child Health | 141 Table 11.8 Diarrhea treatment Among children under age 5 who had diarrhea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of children with diarrhea for whom advice or treatment was sought from a health facility or provider1 Oral rehydration therapy (ORT) Other treatments No treat- ment Number of children ORS packets Recom- mended home fluids (RHF) Either ORS or RHF Increased fluids ORT or increased fluids Anti- biotic drugs Anti- motility drugs Zinc supple- ments Intra- venous solution Home remedy/ other Age in months <6 58.7 49.9 26.9 60.6 7.0 62.4 4.6 0.0 4.9 0.0 18.8 29.7 77 6-11 73.3 74.1 36.1 80.8 8.0 80.8 7.3 0.0 7.1 0.0 17.8 12.8 209 12-23 73.9 74.6 37.1 79.6 11.2 80.3 6.6 0.0 5.0 0.2 21.0 11.3 439 24-35 70.7 71.5 43.7 78.3 10.5 79.0 5.6 0.0 5.6 0.3 15.2 12.6 336 36-47 70.4 67.2 46.9 76.7 9.6 78.2 6.0 0.2 7.2 0.0 16.2 11.1 244 48-59 79.3 71.8 42.3 82.1 12.1 82.8 4.8 0.0 5.0 0.0 17.2 10.2 148 Sex Male 72.7 67.8 40.3 75.4 9.1 76.2 6.4 0.0 6.6 0.1 18.3 13.3 692 Female 71.8 73.8 40.0 80.8 11.1 81.6 5.8 0.1 5.2 0.1 17.5 12.1 762 Type of diarrhea Non bloody 72.2 71.1 40.1 78.4 9.9 79.2 6.0 0.0 5.6 0.2 17.3 12.8 1,349 Bloody 72.1 69.0 40.6 76.8 13.0 77.3 6.7 0.0 8.3 0.0 24.8 11.3 106 Residence Urban 69.3 65.0 40.1 73.0 4.7 73.7 9.7 0.1 13.6 0.0 14.6 13.2 429 Rural 73.5 73.5 40.1 80.4 12.4 81.3 4.6 0.0 2.6 0.2 19.3 12.4 1,025 District Aileu 81.1 79.9 72.5 86.0 2.4 86.0 11.0 0.0 3.7 0.0 25.0 6.2 43 Ainaro (56.4) (58.4) (57.4) (70.3) (2.7) (70.3) (13.0) (0.0) (0.0) (0.0) (16.7) (19.5) 21 Baucau 85.0 92.1 19.8 95.5 0.0 95.5 0.0 0.0 0.0 0.0 3.4 4.5 142 Bobonaro 83.6 78.3 31.3 85.3 45.8 86.8 2.2 0.3 0.0 0.0 27.0 7.5 178 Covalima 63.7 68.9 49.9 75.9 17.8 78.3 7.2 0.0 0.0 0.0 14.2 14.5 77 Dili 67.3 62.4 39.2 71.0 2.6 71.6 12.1 0.0 18.3 0.0 13.8 12.6 315 Ermera 77.5 72.2 66.2 79.2 0.0 79.2 14.1 0.0 0.0 0.0 23.5 15.9 150 Lautem 61.0 61.5 12.5 65.5 14.5 67.1 2.6 0.0 7.9 0.7 25.3 23.3 156 Liquiçá 68.9 63.6 31.7 69.6 4.9 70.1 1.0 0.0 6.0 0.0 28.4 17.9 139 Manatuto 81.9 84.6 53.3 90.7 7.7 90.7 5.5 0.0 8.8 0.0 13.2 5.5 50 Manufahi 49.4 59.0 50.0 74.2 0.0 74.2 0.0 0.0 1.9 0.0 19.6 10.2 31 Oecussi 68.8 73.0 68.1 85.6 7.0 86.1 2.4 0.0 0.0 0.0 5.4 12.6 123 Viqueque (86.0) (76.7) (19.9) (86.9) (3.8) (90.7) (3.4) (0.0) (0.0) (3.4) (16.9) (0.0) 30 Mother’s education No education 68.3 71.8 41.1 79.6 9.1 80.0 5.8 0.0 3.4 0.0 16.7 12.8 429 Primary 71.9 71.0 40.3 77.7 13.3 79.0 7.8 0.0 3.4 0.2 21.3 11.7 415 Secondary 74.7 69.3 40.2 77.1 8.6 77.8 5.1 0.1 8.1 0.2 16.1 13.8 569 More than secondary (83.0) (85.3) (26.7) (85.3) (10.7) (87.5) (5.0) (0.0) (25.0) (0.0) (20.8) (3.9) 40 Wealth quintile Lowest 66.0 69.6 38.5 80.7 6.2 81.1 2.6 0.0 2.2 0.0 13.0 12.7 259 Second 70.3 69.0 31.2 76.0 13.5 77.0 4.9 0.0 2.0 0.4 21.7 13.7 250 Middle 77.6 79.5 44.8 84.3 13.3 84.3 9.5 0.0 3.3 0.4 21.6 8.2 289 Fourth 68.2 66.5 43.7 74.9 13.1 77.0 3.9 0.0 5.4 0.0 19.5 16.0 343 Highest 78.4 70.6 40.4 76.0 4.6 76.3 9.2 0.2 14.7 0.0 13.8 12.1 314 Total 72.2 71.0 40.1 78.2 10.2 79.0 6.1 0.0 5.8 0.1 17.9 12.7 1,454 Note: ORT includes solution prepared from oral rehydration salt (ORS), pre-packaged ORS packet, and recommended home fluids (RHF). Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner 11.6.2 Feeding Practices Mothers or caregivers are encouraged to continue normal feeding of children with diarrhea and to increase the amount of fluids being given, in addition to continuing to breastfeed as much as possible if the children are breastfed. These practices help to reduce dehydration and minimize the adverse consequences of diarrhea on the child’s nutritional status. Mothers interviewed in the 2009-10 TLDHS were asked whether they gave the child less, the same amount, or more fluids and food than usual when their child had diarrhea. Table 11.9 shows, by feeding practices, the percent distribution of children under age 5 who had diarrhea in the two weeks preceding the survey. 14 2 | C hi ld H ea lth T ab le 1 1. 9 F ee di ng p ra ct ic es d ur in g di ar rh ea P er ce nt d ist rib ut io n of c hi ld re n un de r ag e 5 w ho h ad d ia rr he a in th e tw o w ee ks p re ce di ng th e su rv ey 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 RT a nd /o r i nc re as ed fl ui ds d ur in g th e ep iso de o f d ia rr he a, b y ba ck gr ou nd c ha ra ct er ist ic s, T im or -L es te 2 00 9- 10 B ac kg ro un d ch ar ac te ris tic Am ou nt o f l iq ui ds o ffe re d To ta l Am ou nt o f f oo d of fe re d To ta l Pe rc en ta ge g iv en in cr ea se d flu id s an d co nt in ue d fe ed in g1 ,2 Pe rc en ta ge w ho co nt in ue d fe ed in g an d w er e gi ve n O RT a nd /o r in cr ea se d flu id s3 N um be r o f ch ild re n w ith di ar rh ea M or e Sa m e as us ua l So m e- w ha t l es s M uc h le ss N on e D on ’t kn ow / m iss in g M or e Sa m e as us ua l So m 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 iss in g A ge in m on th s < 6 7. 0 43 .0 40 .1 6. 3 3. 6 0. 0 10 0. 0 2. 1 31 .7 28 .4 10 .5 12 .2 11 .8 3. 3 10 0. 0 2. 5 41 .5 77 6- 11 8. 0 44 .4 37 .2 9. 3 0. 6 0. 5 10 0. 0 2. 6 32 .1 37 .7 19 .3 6. 7 1. 1 0. 5 10 0. 0 4. 3 58 .4 20 9 12 -2 3 11 .2 41 .4 34 .6 12 .8 0. 0 0. 0 10 0. 0 3. 2 28 .5 46 .9 18 .3 2. 4 0. 7 0. 0 10 0. 0 7. 9 63 .7 43 9 24 -3 5 10 .5 43 .1 33 .1 13 .0 0. 3 0. 0 10 0. 0 3. 2 35 .5 42 .9 17 .5 0. 8 0. 0 0. 0 10 0. 0 7. 6 63 .4 33 6 36 -4 7 9. 6 43 .7 35 .1 11 .7 0. 0 0. 0 10 0. 0 4. 2 36 .8 42 .9 14 .4 1. 7 0. 0 0. 0 10 0. 0 7. 1 64 .8 24 4 48 -5 9 12 .1 39 .2 40 .2 8. 0 0. 5 0. 0 10 0. 0 9. 4 26 .4 50 .8 12 .8 0. 5 0. 0 0. 0 10 0. 0 12 .1 71 .0 14 8 S ex M al e 9. 1 43 .6 34 .8 11 .9 0. 4 0. 1 10 0. 0 4. 1 33 .3 41 .8 17 .2 2. 9 0. 5 0. 2 10 0. 0 6. 9 60 .1 69 2 Fe m al e 11 .1 41 .4 36 .3 10 .8 0. 4 0. 0 10 0. 0 3. 6 30 .8 44 .9 16 .2 2. 8 1. 4 0. 3 10 0. 0 7. 7 64 .9 76 2 T yp e of d ia rr he a N on b lo od y 9. 9 42 .7 36 .0 10 .9 0. 4 0. 1 10 0. 0 3. 6 32 .5 44 .1 15 .7 3. 0 0. 9 0. 3 10 0. 0 7. 2 63 .4 1, 34 9 Bl oo dy 13 .0 39 .9 30 .2 16 .3 0. 5 0. 0 10 0. 0 7. 1 26 .3 34 .5 28 .4 1. 3 2. 5 0. 0 10 0. 0 9. 3 53 .7 10 6 R es id en ce U rb an 4. 7 46 .0 35 .8 13 .1 0. 4 0. 0 10 0. 0 0. 7 42 .8 37 .9 17 .3 0. 1 0. 7 0. 5 10 0. 0 3. 8 58 .8 42 9 Ru ra l 12 .4 41 .0 35 .5 10 .6 0. 4 0. 1 10 0. 0 5. 2 27 .5 45 .7 16 .4 4. 0 1. 1 0. 1 10 0. 0 8. 8 64 .3 1, 02 5 D is tr ic t Ai le u 2. 4 29 .5 25 .0 43 .0 0. 0 0. 0 10 0. 0 1. 2 28 .3 36 .8 32 .4 0. 0 1. 2 0. 0 10 0. 0 2. 4 56 .5 43 Ai na ro (2 .7 ) (4 8. 1) (2 3. 2) (2 3. 2) (2 .7 ) (0 .0 ) 10 0. 0 (0 .0 ) (2 5. 9) (4 1. 6) (2 9. 7) (0 .0 ) (2 .7 ) (0 .0 ) 10 0. 0 (2 .7 ) (4 1. 6) 21 Ba uc au 0. 0 17 .9 74 .2 7. 9 0. 0 0. 0 10 0. 0 2. 3 14 .2 75 .7 7. 9 0. 0 0. 0 0. 0 10 0. 0 0. 0 87 .6 14 2 Bo bo na ro 45 .8 21 .7 14 .9 17 .7 0. 0 0. 0 10 0. 0 10 .3 15 .1 33 .8 24 .4 15 .4 1. 1 0. 0 10 0. 0 27 .5 52 .4 17 8 C ov al im a 17 .8 41 .6 37 .0 1. 8 1. 8 0. 0 10 0. 0 3. 5 26 .1 50 .1 15 .6 3. 5 1. 2 0. 0 10 0. 0 10 .6 58 .7 77 D ili 2. 6 48 .9 35 .7 12 .9 0. 0 0. 0 10 0. 0 0. 6 46 .1 36 .5 15 .4 0. 0 0. 6 0. 6 10 0. 0 2. 6 58 .1 31 5 Er m er a 0. 0 24 .6 64 .4 11 .1 0. 0 0. 0 10 0. 0 0. 0 20 .0 66 .5 8. 4 3. 1 2. 1 0. 0 10 0. 0 0. 0 69 .1 15 0 La ut em 14 .5 72 .3 8. 2 4. 3 0. 7 0. 0 10 0. 0 14 .1 32 .8 16 .2 35 .6 0. 0 1. 3 0. 0 10 0. 0 14 .1 44 .4 15 6 Li qu iç á 4. 9 54 .7 27 .8 10 .9 1. 6 0. 0 10 0. 0 2. 2 51 .0 29 .9 12 .6 2. 7 1. 6 0. 0 10 0. 0 3. 8 57 .5 13 9 M an at ut o 7. 7 33 .5 47 .8 11 .0 0. 0 0. 0 10 0. 0 5. 5 31 .3 48 .9 9. 9 3. 3 0. 0 1. 1 10 0. 0 7. 7 79 .7 50 M an uf ah i 0. 0 27 .9 60 .0 12 .1 0. 0 0. 0 10 0. 0 1. 9 24 .2 59 .7 14 .3 0. 0 0. 0 0. 0 10 0. 0 0. 0 64 .0 31 O ec us si 7. 0 62 .7 25 .6 3. 4 0. 5 0. 8 10 0. 0 0. 8 36 .4 55 .1 5. 6 0. 5 0. 8 0. 8 10 0. 0 6. 1 80 .5 12 3 Vi qu eq ue (3 .8 ) (5 5. 9) (2 3. 8) (1 6. 5) (0 .0 ) (0 .0 ) 10 0. 0 (0 .0 ) (5 2. 9) (2 7. 2) (1 6. 5) (3 .4 ) (0 .0 ) (0 .0 ) 10 0. 0 (3 .8 ) (7 0. 8) 30 M ot he r’ s ed uc at io n N o ed uc at io n 9. 1 42 .6 34 .9 12 .8 0. 4 0. 2 10 0. 0 2. 6 30 .0 42 .9 18 .5 4. 1 1. 6 0. 2 10 0. 0 5. 4 60 .9 42 9 Pr im ar y 13 .3 37 .4 37 .7 11 .0 0. 5 0. 0 10 0. 0 4. 4 30 .8 43 .9 15 .7 4. 3 1. 0 0. 0 10 0. 0 10 .2 63 .3 41 5 Se co nd ar y 8. 6 46 .2 35 .0 9. 8 0. 4 0. 0 10 0. 0 4. 7 33 .5 44 .4 15 .6 1. 2 0. 6 0. 1 10 0. 0 6. 4 63 .6 56 9 M or e th an s ec on da ry (1 0. 7) (3 9. 7) (2 9. 6) (2 0. 0) (0 .0 ) (0 .0 ) 10 0. 0 (0 .0 ) (4 4. 7) (2 8. 6) (2 1. 7) (0 .0 ) (0 .0 ) (5 .0 ) 10 0. 0 (1 0. 7) (6 0. 8) 40 W ea lth q ui nt ile Lo w es t 6. 2 53 .0 32 .6 7. 8 0. 0 0. 4 10 0. 0 3. 4 34 .6 41 .0 18 .3 0. 9 1. 5 0. 4 10 0. 0 5. 7 65 .8 25 9 Se co nd 13 .5 40 .2 34 .4 11 .0 0. 8 0. 0 10 0. 0 5. 8 25 .9 47 .0 14 .7 5. 2 1. 5 0. 0 10 0. 0 10 .1 60 .1 25 0 M id dl e 13 .3 39 .6 37 .3 9. 5 0. 3 0. 0 10 0. 0 4. 9 30 .5 43 .3 15 .2 5. 5 0. 5 0. 0 10 0. 0 7. 7 66 .9 28 9 Fo ur th 13 .1 34 .6 35 .9 15 .6 0. 7 0. 0 10 0. 0 3. 3 27 .2 47 .3 18 .6 2. 7 0. 9 0. 0 10 0. 0 9. 4 59 .1 34 3 H ig he st 4. 6 46 .8 37 .0 11 .4 0. 2 0. 0 10 0. 0 2. 4 41 .4 38 .3 16 .1 0. 4 0. 6 0. 8 10 0. 0 3. 8 62 .0 31 4 To ta l 10 .2 42 .5 35 .6 11 .3 0. 4 0. 1 10 0. 0 3. 9 32 .0 43 .4 16 .7 2. 9 1. 0 0. 2 10 0. 0 7. 3 62 .7 1, 45 4 N ot e: F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 1 E qu iv al en t t o th e U N IC EF /W H O in di ca to r “ H om e m an ag em en t o f d ia rr he a. ” M IC S In di ca to r 3 4 2 C on tin ue 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 3 E qu iv al en t t o U N IC EF M IC S In di ca to r 3 5. 142 | Child Health Child Health | 143 Ten percent of children with diarrhea were given more to drink than usual, 43 percent were given the same as usual, and 36 percent were given somewhat less to drink than usual. It is particularly unfortunate that 12 percent of children with diarrhea were given much less or nothing to drink. Food intake is curtailed even more than fluid intake during episodes of diarrhea. Only 4 percent of children with diarrhea were given more to eat than usual, 32 percent were given the same amount of food as usual, and 63 percent were given less food to eat than usual or none at all. These patterns reflect a gap in practical knowledge among some mothers regarding the nutritional requirements of children during diarrheal episodes. A study on health-care-seeking behavior found diverse and varied local beliefs and practices related to childhood diarrhea (Zwi et al., 2009). For example, certain communities expressed a belief that diarrhea was caused by breastfeeding, contamination, food consumption patterns, and the season. The initial response to diarrhea was usually homemade rehydration, boiled leaves, or both. The 2009-10 TLDHS findings and other studies indicate a need for further health education efforts to reduce the number of children that become dehydrated or malnourished because of improper feeding practices during diarrhea. Overall, 7 percent of children with diarrhea were given increased fluids and continued feeding, and 63 percent received continued feeding and were given ORT, increased fluids, or both. Children age 48-59 months were more likely than other children to receive continued feeding, ORT, and/or increased fluids during the last episode of diarrhea. Differen- tials in these indicators by other background charac- teristics are very minimal. 11.7 KNOWLEDGE OF ORS PACKETS As mentioned earlier, a simple and effective response to dehydration caused by diarrhea is a prompt increase in the child’s fluid intake through some form of ORT, 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 Timor-Leste, mothers were asked whether they knew about ORS packets. Table 11.10 shows the percentage of mothers with a birth in the five years preceding the survey who knew about ORS packets for treatment of diarr- hea. Knowledge of ORS is widespread in Timor- Leste, with 89 percent of mothers having heard of it. Mothers age 15-19 are slightly less likely to know about ORS than older mothers. Knowledge of ORS is high among urban mothers and increases with level of education and wealth of mothers. Mothers in Ermera district are less likely than mothers in other districts to have heard of ORS. Table 11.10 Knowledge of ORS packets Percentage of mothers age 15-49 who gave birth in the five years preceding the survey who know about ORS packets for treatment of diarrhea by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of women who know about ORS packets Number of women Age 15-19 85.4 178 20-24 89.9 1,012 25-34 88.4 2,615 35-49 89.1 2,210 Residence Urban 91.2 1,484 Rural 88.1 4,531 District Aileu 93.8 220 Ainaro 95.8 318 Baucau 89.2 598 Bobonaro 94.5 587 Covalima 93.1 322 Dili 91.3 1,043 Ermera 74.0 719 Lautem 91.3 444 Liquiçá 80.6 358 Manatuto 90.2 264 Manufahi 93.3 238 Oecussi 97.3 492 Viqueque 79.5 412 Education No education 83.7 1,980 Primary 88.8 1,656 Secondary 93.2 2,226 More than secondary 93.4 154 Wealth quintile Lowest 85.2 1,226 Second 85.6 1,171 Middle 88.6 1,203 Fourth 90.5 1,170 Highest 94.2 1,244 Total 88.8 6,015 ORS = Oral rehydration salts 144 | Child Health 11.8 STOOL DISPOSAL Contact with human feces directly, or indirectly by animal contact with the feces, can lead to diarrheal diseases. Hence, the safe disposal of children’s stools is important in preventing the spread of disease. Table 11.11 shows the percent distribution of mothers who have their youngest child under age 5 living with them, by the way in which the child’s stools are disposed of, according to background characteristics and type of toilet facilities in the household. Twenty-eight percent of mothers of children under age 5 dispose of their youngest child’s stools safely (that is, children use a toilet or latrine, the stools are rinsed in the toilet or latrine, or the stools are buried). Thirteen percent of mothers put or rinse their children’s stools into a drain or ditch, 4 percent throw them into the garbage, and 45 percent of mothers leave them in the open. Table 11.11 Disposal of children’s stools Percent distribution of youngest children under age five 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, Timor-Leste 2009-10 Background characteristic Manner of disposal of children’s stools Total Percentage of children whose stools are disposed of safely 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 2.9 12.1 5.0 28.4 4.5 27.4 19.4 0.2 100.0 20.0 973 6-11 4.2 12.3 6.9 20.9 5.3 35.6 14.9 0.0 100.0 23.3 927 12-23 5.4 11.8 9.0 9.7 2.7 53.0 8.1 0.2 100.0 26.3 1,616 24-35 10.5 12.7 7.7 6.6 3.7 51.2 7.6 0.0 100.0 30.9 1,176 36-47 13.6 14.7 6.0 6.9 3.3 50.2 5.4 0.0 100.0 34.3 735 48-59 19.2 19.0 4.7 6.7 1.9 43.6 4.9 0.0 100.0 42.9 454 Toilet facility Improved, not shared1 12.8 20.2 5.4 11.7 4.0 36.7 9.1 0.2 100.0 38.4 2,419 Non-improved or shared 4.5 8.0 8.2 14.5 3.4 50.1 11.3 0.0 100.0 20.7 3,461 Residence Urban 13.0 23.9 9.5 7.6 5.4 28.0 12.3 0.3 100.0 46.4 1,447 Rural 6.3 9.5 6.2 15.2 3.0 50.0 9.7 0.0 100.0 22.0 4,432 District Aileu 2.5 11.2 3.4 8.0 5.5 48.6 20.8 0.0 100.0 17.2 214 Ainaro 0.4 6.0 1.6 18.9 1.0 68.4 3.8 0.0 100.0 7.9 310 Baucau 5.1 10.4 5.9 1.6 9.3 44.0 23.7 0.0 100.0 21.4 595 Bobonaro 23.1 7.2 8.8 17.3 1.1 35.3 7.3 0.0 100.0 39.1 569 Covalima 3.2 9.5 2.6 18.9 3.2 59.4 2.9 0.3 100.0 15.3 311 Dili 13.8 24.2 9.9 5.6 6.3 24.1 15.7 0.4 100.0 47.8 1,017 Ermera 4.6 22.0 0.3 27.9 1.2 43.8 0.2 0.0 100.0 26.9 708 Lautem 2.3 18.0 0.5 4.0 2.3 60.1 12.8 0.0 100.0 20.7 438 Liquiçá 7.7 7.6 0.9 10.6 2.8 70.3 0.0 0.0 100.0 16.2 347 Manatuto 21.1 6.0 0.8 23.1 1.1 47.7 0.2 0.0 100.0 27.9 259 Manufahi 1.4 6.0 0.6 23.1 4.9 62.7 1.4 0.0 100.0 8.0 229 Oecussi 1.2 2.5 40.8 6.8 3.6 18.5 26.6 0.0 100.0 44.5 479 Viqueque 3.6 10.9 0.3 22.1 0.5 59.3 3.4 0.0 100.0 14.8 402 Education No education 5.4 8.2 7.4 15.5 2.0 51.2 10.3 0.0 100.0 21.0 1,938 Primary 6.7 10.1 8.1 13.0 4.3 46.8 11.0 0.0 100.0 24.9 1,617 Secondary 10.5 19.4 5.9 12.3 4.3 38.1 9.3 0.1 100.0 35.8 2,176 More than secondary 15.2 15.7 7.7 5.3 7.0 28.5 19.4 1.4 100.0 38.6 148 Wealth quintile Lowest 2.0 1.9 9.9 15.6 2.1 55.6 12.8 0.1 100.0 13.8 1,199 Second 3.5 6.9 6.1 14.2 3.0 55.2 11.1 0.0 100.0 16.5 1,149 Middle 6.2 9.5 6.3 14.6 3.6 51.2 8.7 0.0 100.0 22.0 1,170 Fourth 11.7 20.4 4.6 13.7 3.2 36.2 9.7 0.4 100.0 36.8 1,148 Highest 16.1 26.2 8.1 8.8 6.0 25.2 9.5 0.0 100.0 50.5 1,213 Total 7.9 13.0 7.0 13.4 3.6 44.6 10.4 0.1 100.0 28.0 5,879 1 Non-shared facilities that are of the types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; pit latrine with a slab; and a composting toilet. Child Health | 145 There are marked differences in the way children’s stools are disposed of, according to background characteristics. For example, older children are more likely than younger children to have their stools disposed of safely. As expected, children in urban areas and children living in households with an improved toilet facility are more likely to have safe disposal of their stools than children in rural areas and in households without such facilities. By region, the proportion of children whose stools are disposed of safely ranges from 8 percent in Ainaro and Manufahi to 48 percent in Dili. Surprisingly, although a high percentage of children’s stools are not disposed of safely in Ainaro, it had the lowest prevalence of diarrhea among children under age 5 in the two weeks preceding the survey (4 percent). Safe disposal of children’s stools increases with mother’s level of education and household wealth quintile. Nutrition of Children and Women | 147 NUTRITION OF CHILDREN AND WOMEN 12 This chapter reviews the nutritional status of children and women in Timor-Leste. The specific topics discussed are (1) infant and young child feeding practices, including breastfeeding and feeding with solid/semi-solid foods; (2) quantity and quality of foods, including their diversity and frequency; (3) micronutrient intake and food supplementation among children and women; (4) night blindness among children, and (5) anemia among women and children. The section also covers anthropometric assessment of the nutritional status of children under 5 years of age and the nutritional status of women 15-49 years of age. The poor nutritional status of children and women has been a serious problem in Timor-Leste for many years. The most common forms of malnutrition in the country are protein energy malnutrition (PEM) and micronutrient deficiencies. The National Nutrition Strategy, developed in 2004, provides comprehensive documentation of the country’s goals (MOH, 2004c). In addition, the country has drafted a breastfeeding policy, a National Salt Law, and Infant and Young Child Feeding (IYCF) strategies . Several programs with an explicit nutrition component have been launched in the country under the initiative of the Directorate of Community Health and through the Nutrition Department of the Ministry of Health. The major partners in initiating programs to address the problem of malnutrition are the World Health Organization, UNICEF, the World Food Program (WFP), USAID, CARE International, Oxfam, World Vision, Concern, Alola Foundation, Medico do Mundo (MDM), TAIS (Timor-Leste Asistensia Integradu Saude), and other international and national nongovernmental organizations. The findings in the following section are highlighted with respect to these initiatives. 12.1 NUTRITIONAL STATUS OF CHILDREN Anthropometric data on height and weight collected in the 2009-10 TLDHS permit the analysis and evaluation of the nutritional status of young children in Timor-Leste. This analysis allows identification of subgroups in the population that are at increased risk of faltered growth, disease, impaired mental and physical development, and death. The nutritional status of young children and women of reproductive age reflects household, community, and national development. Children and women in developing countries are most vulnerable to malnutrition because of inadequate dietary intake, infectious diseases, inadequate access to appropriate health care, and inequitable distribution of food within the household. 12.1.1 Nutritional Status of Children The 2009-10 TLDHS included information on the nutritional status of children less than age 5 for three indices: weight-for-age, height-for-age, and weight-for-height. Weight measurements were taken using a lightweight electronic SECA scale with a digital screen, designed and manufactured under the guidance of UNICEF, and height measurements were carried out using a measuring board from Shorr Productions. Children younger than 24 months were measured lying down (recumbent length) on the board, while standing height was measured for older children. The scale allowed for the weighing of very young children through an automatic mother-child adjustment that eliminated the mother’s weight while she was standing on the scale with her baby. The nutritional status of children in the survey population is compared with the WHO Child Growth Standards, which are based on an international sample (from Brazil, Ghana, India, Norway, Oman, and the United States) of ethnically, culturally, and genetically diverse healthy children living under optimum conditions conducive to achieving a child’s full genetic growth potential (WHO, 2006). The WHO Child Growth Standards are used here instead of the former NCHS/CDC/WHO 148 | Nutrition of Children and Women international reference population because of the prescriptive, rather than descriptive, nature of the WHO Child Growth Standards versus the NCHS/CDC/WHO international reference population. The WHO Child Growth Standards identify the breastfed child as the normative model for growth and development, and they document how children should grow under optimum conditions and infant feeding and child health practices. The 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. The internationally based standard population serves as a point of comparison, facilitating the examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. For the purposes of comparison with previous surveys, indices are expressed in standard deviation units (SD) from the median of the NCHS/CDC/WHO international reference population, which was in use prior to the new WHO Child Growth Standards. Each of the three nutritional status indicators is expressed in standard deviation units (z-scores) from the median of the reference population. In any large population, there is variation in height and weight; this variation approximates a normal distribution. The three indices—height-for- age, weight-for-height, and weight-for-age—provide different information about growth and body composition, which can be used to assess nutritional status. The height-for-age index indicates linear growth retardation and cumulative growth deficits. Children whose height-for-age z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age (stunted) and chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the median of the reference population are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is worsened by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and does not vary according to recent dietary intake. The weight-for-height index measures body mass in relation to body length and describes current nutritional status. Children whose z-scores are below minus two standard deviations (-2 SD) from the median of the reference population are considered to be thin for their height (wasted) and acutely malnourished. Wasting represents failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake during a recent episode of illness, causing loss of weight and the onset of malnutrition. Children whose weight-for- height is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely wasted. Children whose weight-for-height is above two standard deviations (+2 SD) from the median reference population are considered to be overweight. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. Height and weight data were collected from the sampled household population in Timor- Leste. A total of 9,989 children under age 5 were identified in the households. Information on height or weight was missing for 3 percent of children who were not present and for 8 percent who refused to be measured. The final analysis of nutritional status is based on the remaining 8,1711 children (88 percent). The results are shown in Table 12.1. 1 These are unweighted numbers. Nutrition of Children and Women | 149 Table 12.1 Nutritional status of children Percentage of children under 5 years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight- for-age, by background characteristics, Timor-Leste 2009-10 Background characteristic Height-for-age Weight-for-height Weight-for-age Number of children Percentage below -3 SD Percentage below -2 SD1 Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Percentage below -3 SD Percentage below -2 SD1 Percentage above +2 SD Mean Z-score (SD) Age in months <6 15.3 26.0 -0.6 8.8 19.8 16.6 -0.1 4.8 14.9 3.7 -0.7 563 6-8 17.5 34.6 -1.3 7.2 18.6 9.4 -0.5 7.9 25.1 0.0 -1.3 351 9-11 19.0 37.8 -1.6 6.7 16.2 7.8 -0.6 11.1 28.7 1.0 -1.4 392 12-17 33.5 60.4 -2.0 7.8 21.8 4.2 -0.8 14.5 40.7 0.9 -1.6 828 18-23 45.1 69.0 -2.5 6.1 15.2 4.7 -0.8 17.5 46.9 1.5 -1.8 692 24-35 39.6 63.8 -2.4 7.3 17.5 2.8 -0.8 16.3 49.3 0.5 -1.9 1,752 36-47 36.9 66.5 -2.5 5.9 17.1 3.9 -0.8 17.7 48.7 0.1 -2.0 1,864 48-59 28.6 57.8 -2.3 7.3 21.5 2.3 -1.0 17.7 53.9 0.0 -2.1 1,729 Sex Male 34.5 60.3 -2.2 7.8 20.3 4.5 -0.8 16.3 45.5 0.7 -1.8 4,106 Female 31.2 56.0 -2.1 6.2 17.0 4.9 -0.7 14.5 43.8 0.6 -1.8 4,065 Birth interval in months2 First birth3 31.9 56.0 -2.1 7.8 20.8 3.8 -0.9 15.4 44.9 0.5 -1.8 1,304 <24 34.6 60.9 -2.3 7.4 18.4 4.9 -0.7 15.9 44.5 0.5 -1.8 1,790 24-47 33.3 58.5 -2.2 6.3 17.3 4.6 -0.8 15.0 45.3 0.7 -1.8 3,539 48+ 26.9 53.0 -1.9 7.4 21.2 5.8 -0.8 15.5 40.9 0.9 -1.7 953 Size at birth2 Very small 36.6 64.7 -2.3 10.1 21.0 3.6 -1.0 20.7 54.1 0.4 -2.1 406 Small 32.8 58.7 -2.1 5.7 18.3 5.1 -0.8 16.6 46.3 0.5 -1.8 800 Average or larger 32.6 57.7 -2.2 7.0 18.7 4.8 -0.8 15.0 43.8 0.7 -1.8 6,212 Mother’s interview status Interviewed 32.5 57.9 -2.2 7.0 18.6 4.7 -0.8 15.4 44.5 0.7 -1.8 7,587 Not interviewed but in household 32.3 55.9 -2.2 6.7 18.1 6.9 -0.6 12.2 40.5 1.1 -1.7 218 Not interviewed, and not in the household4 40.6 63.4 -2.4 8.2 19.2 4.5 -0.8 18.4 51.3 0.0 -2.0 367 Mother’s nutritional status5 Thin (BMI<18.5) 38.1 64.5 -2.4 7.1 22.3 3.4 -1.0 21.7 54.3 0.4 -2.1 1,852 Normal (BMI 18.5-24.9) 31.6 56.3 -2.1 7.2 17.9 5.0 -0.7 13.6 42.0 0.8 -1.7 5,265 Overweight/obese (BMI ≥25) 21.3 50.2 -2.0 4.0 11.2 6.5 -0.5 9.8 31.9 0.7 -1.5 448 Residence Urban 21.5 49.2 -1.9 4.5 14.9 4.3 -0.7 9.7 34.9 0.9 -1.5 1,794 Rural 36.1 60.6 -2.2 7.7 19.7 4.8 -0.8 17.0 47.4 0.6 -1.9 6,377 District Aileu 16.7 31.4 -0.6 29.8 49.4 1.4 -1.9 12.0 41.2 1.7 -1.6 271 Ainaro 43.8 69.1 -2.7 6.7 18.2 10.2 -0.4 17.0 47.7 1.2 -1.8 482 Baucau 39.6 58.1 -2.4 5.5 21.6 11.2 -0.4 17.5 43.0 1.0 -1.7 687 Bobonaro 45.0 72.6 -2.7 6.8 15.3 9.7 -0.5 18.8 52.5 0.5 -2.0 792 Covalima 36.8 64.7 -2.4 4.4 13.8 3.6 -0.7 13.2 47.4 0.3 -1.8 373 Dili 16.1 43.9 -1.7 4.1 14.5 4.5 -0.6 7.9 30.1 1.0 -1.4 1,289 Ermera 48.9 68.5 -2.6 6.8 20.7 2.7 -0.9 23.6 58.0 0.3 -2.2 1,077 Lautem 18.7 51.0 -1.9 2.9 9.6 1.8 -0.7 6.7 32.1 0.0 -1.5 714 Liquiçá 34.7 56.9 -2.2 5.1 15.1 4.4 -0.7 14.6 41.4 1.0 -1.7 456 Manatuto 21.2 46.7 -1.5 10.8 19.7 2.6 -0.9 8.7 34.4 0.1 -1.5 429 Manufahi 37.1 64.7 -2.3 5.6 14.9 3.2 -0.7 13.5 43.7 0.6 -1.8 296 Oecussi 40.6 69.1 -2.5 9.0 26.9 1.0 -1.3 28.5 62.8 0.1 -2.3 708 Viqueque 25.0 51.5 -1.8 9.3 19.4 3.0 -1.0 12.7 44.8 1.3 -1.7 597 Mother’s education6 No education 38.6 62.6 -2.3 8.0 20.9 5.0 -0.8 18.8 48.8 0.8 -1.9 2,734 Primary 33.9 59.7 -2.2 6.8 18.7 4.4 -0.8 15.9 46.5 0.6 -1.8 2,175 Secondary 26.3 52.7 -2.0 6.1 16.7 4.7 -0.7 11.8 38.9 0.7 -1.6 2,736 More than secondary 15.9 41.6 -1.7 4.7 10.5 5.2 -0.6 6.5 32.0 0.0 -1.4 160 Wealth quintile Lowest 37.3 63.0 -2.3 8.8 20.8 4.8 -0.8 18.9 49.4 0.5 -1.9 1,762 Second 40.8 63.5 -2.4 6.7 18.7 6.7 -0.7 17.3 48.0 0.9 -1.9 1,629 Middle 36.1 60.5 -2.3 7.6 19.6 4.0 -0.8 17.3 48.1 0.6 -1.9 1,663 Fourth 28.6 55.4 -2.0 6.5 17.6 3.3 -0.8 13.1 41.4 0.3 -1.7 1,599 Highest 20.2 47.1 -1.8 5.1 16.2 4.8 -0.7 9.6 35.3 1.1 -1.5 1,518 Total 32.9 58.1 -2.2 7.0 18.6 4.7 -0.8 15.4 44.7 0.7 -1.8 8,171 Note: Table is based on children who slept in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 164 children with information missing on size at birth and 119 children with information missing on mother’s nutritional status. 1 Includes children who are below -3 standard deviations (SD) from the WHO Child Growth standards population median 2 Excludes children whose mothers were not interviewed 3 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval 4 Includes children whose mothers are deceased 5 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. 6 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 150 | Nutrition of Children and Women Figure 12.1 Nutritional Status of Children by Age Timor-Leste 2009-10 # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 Age in months 0 10 20 30 40 50 60 70 80 Percent Stunted Wasted Underweight & $ # Fifty-eight percent of children under age 5 are stunted, and 33 percent are severely stunted. Nineteen percent of children under age 5 are wasted, and 7 percent are severely wasted. The weight- for-age indicator shows that 45 percent of children under age 5 are underweight and 15 percent are severely underweight. Table 12.1 highlights another problem among young children in Timor-Leste: 5 percent are overweight [Z-scores are above two standard deviations (+2 SD)]. Table 12.1 and Figure 12.1 indicate that stunting is apparent even among children less than 6 months of age (26 percent). Stunting increases with the age of the child; this is evidenced by the increase in stunting from 35 percent among children age 6-8 months to 69 percent among children age 18-23 months and gradually decreases to 58 percent by age 48-59 months. More male children (60 percent) than female children (56 percent) are stunted. Size at birth is an important indicator of the nutritional status of children: stunting is higher among children who were reported to have been very small at birth (65 percent) than among children who were average or larger in size at birth (58 percent). More rural children (61 percent) than urban children (49 percent) are stunted. District variation in nutritional status of children is substantial. Stunting among children is highest in Bobonaro district (73 percent) and lowest in Aileu district (31 percent). The percentage of children stunted decreases as mother’s BMI and education level increase. Stunting is more prevalent in children with thin (BMI <18.5) mothers compared with those with overweight/obese (BMI ≥25) mothers (65 percent vs. 50 percent). Wasting is high among children less than 6 months of age (20 percent). The highest percentage of wasting is seen among children age 12-17 months and age 48-59 months (22 percent each). Wasting decreases with size at birth; wasting is higher among children who were reported to be very small at birth (21 percent) than among children who were average or larger in size at birth (19 percent). The proportion of children who are wasted is higher in rural areas (20 percent) than in urban areas (15 percent). Wasting is higher in children whose mother has a low body mass index (BMI) (22 percent) compared with children whose mother has a high BMI (11 percent). Wasting is especially pronounced in Aileu (49 percent) compared with Lautem, the district with the lowest prevalence of wasting (10 percent). A report submitted by an Emergency Needs Assessment Mission conducted by the World Food Program and the Food and Agriculture Organization in August 2003 indicated that the nutritional status in districts with a bad harvest had deteriorated, and Aileu was identified as one of these districts (WFP and FAO, 2003). Wasting is higher among children from the lowest wealth quintile (21 percent) as compared with children from the highest wealth quintile (16 percent). Nutrition of Children and Women | 151 It is further observed that the highest proportion of overweight children (+2 SD) is in the age group less than age 6 months, with 17 percent of children in that age group being overweight. There is hardly any difference between urban and rural areas in the proportions of children overweight. Looking at district patterns, the prevalence of overweight children ranges from 1 percent in Oecussi and Aileu to 11 percent in Baucau. Although variations by mother’s level of education and wealth quintile are not large, the highest proportions of overweight children are seen among the most educated mothers and mothers who live in households in the second quintile. Table 12.1 and Figure 12.1 show that the percentage of children who are underweight increases sharply, from 15 percent among children under age 6 months to 25 percent among children age 6-8 months, to 29 percent among children age 9-11 months, and to above 40 percent among children age 12 months and older. This may be due to inappropriate and/or inadequate feeding practices because the increasing levels of children who are underweight for their age coincides with the age at which normal complementary feeding starts. Children who are reported to be very small in size at birth are more likely to be underweight (54 percent) compared with those children who are reported to be average or larger in size at birth (44 percent). Children living in rural areas are more likely to be underweight (47 percent) compared with those children living in urban areas (35 percent). Children of mothers with low BMI, those with no education, and those belonging to households in the lowest wealth quintile are most likely to be underweight. 12.1.2 Trends in Children’s Nutritional Status The results of the 2009-10 TLDHS show children’s nutritional status compared with the status from earlier surveys conducted in Timor-Leste. However, several factors make direct comparisons difficult. Because the data in the previous surveys were analyzed based on the NCHS/CDC/WHO international reference population, it was necessary to re-calculate the current data accordingly to make it comparable. Therefore, comparison of data on nutritional status of children should be made with caution. The data from the 2009-10 TLDHS and Figure 12.2, indicate that there has been a slight rise in the level of stunting, wasting, and underweight over the past 6 years. Stunting increased from 49 percent to 53 percent, wasting increased from 12 percent to 17 percent, and underweight increased from 46 percent to 52 percent2. The results indicate that achieving the Millennium Development Goal of a 50 percent reduction in the prevalence of underweight children under 5 years of age by the year 2015 continues to be a challenge. It can be further noted that, with use of the new WHO Child Growth Standards, the nutritional status of children can be compared using data from the 2007 Living Standard Survey and the current 2009-10 TLDHS. Figure 12.3 shows that malnutrition has remained high in general, and the proportion of children who have chronic malnutrition has increased from 54 percent to 58 percent. However, the proportion of children who are wasted has decreased from 25 percent to 19 percent, while the proportion of children who are severely wasted has remained the same over the time period. Similarly, the percentage of underweight children has declined, with an 8 percent decline occurring in the past two years. However, the percentage of severely underweight children has remained the same. These findings indicate that the effort to reduce malnutrition among children is showing some positive results but still has a long way to go. 2 Comparison should be carried with caution as there are overlaps in the confidence interval of these estimates. 152 | Nutrition of Children and Women Figure 12.2 Trends in Nutritional Status of Children, 2002-2010, NCHS/CDC/WHO Standards 47 12 53 49 12 46 53 17 52 Height-for-age Weight-for-height Weight-for-age 0 10 20 30 40 50 60 Percent below -2 SD MICS 2002 DHS 2003 TLDHS 2009-10 Timor-Leste 2009-10 Note: Data for the 2009-10 TLDHS are recalculated using the NCHS/CDC/WHO reference population to be comparable to the estimates from the earlier surveys. Figure 12.3 Trends in Nutritional Status of Children, 2007-2010, WHO Child Growth Standards 24 8 15 54 25 49 33 7 15 58 19 45 Height- for- age Weight- for- height Weight- for- age Height- for- age Weight- for- height Weight- for- age 0 10 20 30 40 50 60 70 Percent TLSLS 2007 TLDHS 2009-10 Timor-Leste 2009-10 Severe1 Any Malnutrition2 1 Percentage below -3 SD 2 Percentage below -2 SD Nutrition of Children and Women | 153 12.2 INITIATION OF BREASTFEEDING Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the uterus to contract and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child. Table 12.2 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and for the last children born in the five years preceding the survey ever breastfed, the percentage who started breastfeeding within one hour and within one day of birth and the percentage who received a prelacteal feed, by background characteristics, Timor-Leste 2009-10 Background characteristic Breastfeeding among children born in last five years Among last-born children ever breastfed: Percentage ever breastfed Number of children born in last five years Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 96.6 5,021 81.3 96.2 12.8 3,048 Female 96.6 4,807 82.1 96.5 12.6 2,835 Residence Urban 95.8 2,353 83.5 95.5 17.0 1,435 Rural 96.8 7,475 81.1 96.6 11.3 4,448 District Aileu 97.6 359 81.1 99.8 6.9 218 Ainaro 96.8 579 82.7 97.1 6.9 310 Baucau 99.3 970 78.0 99.2 12.8 597 Bobonaro 85.6 934 84.3 97.8 19.9 548 Covalima 98.2 453 87.2 92.3 13.3 317 Dili 95.7 1,652 87.5 96.4 17.0 1,007 Ermera 99.1 1,252 87.3 98.7 5.8 715 Lautem 98.7 758 67.1 95.7 9.2 441 Liquiçá 96.4 582 69.0 88.2 29.9 350 Manatuto 97.9 433 90.1 99.1 9.2 259 Manufahi 97.2 393 72.0 93.1 13.8 231 Oecussi 98.1 783 84.7 94.1 10.4 487 Viqueque 98.4 678 77.6 97.2 4.6 404 Mother’s education No education 96.9 3,298 80.0 96.7 11.2 1,948 Primary 96.5 2,765 80.7 95.9 12.3 1,625 Secondary 96.2 3,546 83.4 96.3 13.7 2,160 More than secondary 98.6 218 89.0 97.3 21.0 151 Assistance at delivery Health professional3 95.7 2,941 84.4 96.6 15.2 1,945 Traditional birth attendant 97.7 1,762 79.5 95.2 9.9 1,007 Other 96.9 4,808 81.2 96.7 11.5 2,744 No one 92.7 313 71.8 94.5 19.0 188 Place of delivery Health facility 95.9 2,171 84.8 96.4 16.0 1,468 At home 96.8 7,641 80.6 96.3 11.6 4,413 Other * 5 * * * 2 Wealth quintile Lowest 98.3 2,090 79.2 96.1 8.5 1,211 Second 96.6 1,960 80.4 97.0 11.1 1,155 Middle 95.9 1,992 80.7 95.3 11.6 1,175 Fourth 95.9 1,903 82.1 96.1 15.2 1,138 Highest 96.2 1,884 85.9 97.3 17.0 1,204 Total 96.6 9,828 81.7 96.3 12.7 5,883 Note: Table is based on births in the last five years whether the children are living or dead at the time of interview. Total for number of children born in the five years before the survey includes four children with information missing on assistance at delivery and 11 children with information missing on place of delivery. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse/midwife, or assistant nurse 154 | Nutrition of Children and Women Table 12.2 shows the percentages of children born in the five years preceding the survey who were ever breastfed, who started breastfeeding within one hour and within one day of birth, and among last-born children ever breastfed in the five years before the survey, the percentage who received a prelacteal feed. Breastfeeding is nearly universal in Timor-Leste, with 97 percent of children born in the five years preceding the survey having been breastfed at some time. The percentage of children ever breastfed does not vary much by background characteristics. On average four in five children are breastfed within the first hour of birth (82 percent) and 96 percent are breastfed within one day of birth. Thirteen percent of children are given a prelacteal feed, that is, something other than breast milk, during the first three days of life. The percentage of children who are breastfed early has increased in the past six years, the increase being more pronounced for children breastfed within one hour of birth. There has been a rise in the percentage of children breastfed within one hour of birth by about 74 percent, from 47 percent in the 2003 DHS to 82 percent in 2009-10 TLDHS. There is no difference in the timing of initial breastfeeding by sex of the child or by rural or urban areas. Children from Manatuto are most likely to be breastfed immediately after birth (90 percent), and nearly all children in this region (99 percent) are breastfed within one day of birth. Children in Liquiçá are least likely to be breastfed, with 69 percent breastfed within one hour and 88 percent fed within one day of birth. As expected, the proportion of children given a prelacteal feed is also high in Liquiçá at 30 percent. Women who have completed more than secondary school or a higher level of education are more likely to breastfeed within one hour of birth (89 percent) compared with women who have no education (80 percent). Women who have received more than secondary school education are more likely to give a prelacteal feed (21 percent) compared with women with no education (11 percent). Moreover, other characteristics of the infant and mother, such as type of assistance at delivery and place of delivery, have important influences on early breastfeeding practices. There is a difference in initiation of breastfeeding within one hour between children delivered by a health professional (84 percent) and children delivered with no assistance (72 percent). Eighty-five percent of children delivered in a health facility have initiated breastfeeding within one hour of birth. Initiation of breastfeeding within an hour of birth for children delivered at home has improved by 71 percent over the past years, rising from 48 percent in the 2003 DHS to 82 percent in the 2009-10 TLDHS. Differences in early breastfeeding by wealth are small, although larger proportions of children in the highest wealth quintile are likely to be breastfed within an hour of birth. 12.3 BREASTFEEDING STATUS BY AGE UNICEF and WHO recommend that children be exclusively breastfed during the first six months of life and that children be given solid or semisolid complementary food in addition to continued breastfeeding after six months. The nutrition program under the National Nutrition Strategy 2004 promotes exclusive breastfeeding through the age of 6 months and thereafter promotes introducing complementary foods along with continued breast milk until the child is at least two years of age (MOH, 2004c). Exclusive breastfeeding is recommended in the first 6 months of life because breast milk is uncontaminated and contains all the nutrients necessary for children. Information on breastfeeding was obtained in the 2009-10 TLDHS by asking mothers about the current breastfeeding status of all children under age 3 and, for the youngest child born in the three years before the survey and living with the mother, food (liquids or solids) given to the child the day before the survey. Table 12.3 shows the percent distribution of youngest children under age 3 years by breastfeeding status and the percentage of children under age 3 using a bottle with a nipple. Contrary to WHO’s recommendations, only about half (52 percent) of children under age 6 months are exclusively breastfed in Timor-Leste. There are high proportions of children 0-5 months receiving food other than breast milk with complementary food (26 percent), plain water only (7 percent), and other milk (14 percent). Nutrition of Children and Women | 155 Table 12.3 Breastfeeding status by age Percent distribution of youngest children under age 3 who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under age 3 using a bottle with a nipple, according to age in months, Timor-Leste 2009-10 Age in months Percent distribution of youngest children under three living with their mother by breastfeeding status Total Percentage currently breast- feeding Number of youngest children under 3 years Percentage using a bottle with a nipple1 Number of all children under 3 years Not breast- feeding Exclusively breastfed Breastfeeding and consuming: Plain water only Other milk Comple- mentary foods 0-1 1.8 71.1 6.2 14.8 6.2 100.0 98.2 264 3.1 269 2-3 2.6 54.6 6.9 16.6 19.4 100.0 97.4 321 8.4 324 4-5 1.7 35.4 7.2 11.9 43.8 100.0 98.3 387 9.4 389 6-8 4.5 9.3 1.1 6.9 78.2 100.0 95.5 464 15.3 472 9-11 7.9 2.8 0.9 1.4 86.9 100.0 92.1 463 13.4 470 12-17 32.4 0.5 0.0 0.4 66.7 100.0 67.6 910 19.2 946 18-23 59.0 0.1 0.1 0.0 40.8 100.0 41.0 706 16.9 806 24-35 85.0 0.0 0.0 0.0 15.0 100.0 15.0 1,176 12.9 1,959 0-3 2.2 62.0 6.6 15.8 13.4 100.0 97.8 586 6.0 593 0-5 2.0 51.5 6.8 14.3 25.5 100.0 98.0 973 7.3 983 6-9 5.1 7.8 1.1 5.9 80.1 100.0 94.9 626 14.1 636 12-15 29.4 0.4 0.0 0.1 70.2 100.0 70.6 622 19.9 650 12-23 44.0 0.3 0.1 0.2 55.4 100.0 56.0 1,616 18.1 1,752 20-23 66.6 0.0 0.2 0.0 33.2 100.0 33.4 429 16.8 506 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, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Based on all children under three years It can be noted that the data reported here cannot be directly compared with data from the previous surveys as the methodology and data collection were different from the current survey. However, it can still be highlighted here: the 2003 DHS indicated 31 percent of children less that 6 months are being exclusively breastfed, a lower percentage than that indicated by the 2002 MICS survey (44 percent). The current finding does indicate a rise in the proportion of children fewer than 6 months of age who are exclusively breastfed (52 percent). Table 12.3 and Figure 12.4 also show that seven in ten children (71 percent) under 2 months of age are exclusively breastfed, 6 percent consumed breast milk and plain water, and 15 percent consumed other milk in addition to breast milk. The proportion of children exclusively breastfed declines at age 6-8 months by 74 percent from the preceding cohort as complementary foods are introduced. 156 | Nutrition of Children and Women Figure 12.4 Infant Feeding Practices by Age <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 0 10 20 30 40 50 60 70 80 90 100 Percent Exclusively breastfed Plain water only Other milk Comple- mentary foods Not breast- feeding Timor-Leste 2009-10 The 2009-10 TLDHS results also indicate that the proportion of children receiving complementary foods in a timely fashion is encouraging, with 78 percent of children age 6-8 months receiving complementary foods. This is an important Infant and Young Child Feeding (IYCF) indicator. Bottle-feeding is usually associated with increased risk of illness, and especially diarrheal diseases, because of the difficulty in sterilizing the nipples properly. Bottle-feeding also shortens the period of postpartum amenorrhea and increases the risk of pregnancy. The practice of bottle-feeding with a nipple is not widespread in Timor-Leste. However, the percentage of children who are bottle- fed rises from 3 percent among children under age 2 months to 19 percent among children age 12-17 months and generally drops to 13 percent among children 24-35 months. It is noteworthy that 7 percent of children less than 6 months old are bottle-fed, and a considerable proportion of children 12- 23 months are being bottle-fed (18 percent). 12.4 DURATION AND FREQUENCY OF BREASTFEEDING Table 12.4 shows the median duration and frequency of breastfeeding by selected background characteristics. The estimates of median and mean durations of breastfeeding are based on current status data, that is, the proportion of last-born children in the 3 years preceding the survey who were being breastfed at the time of the survey. Both duration and frequency of breastfeeding can affect the length of postpartum amenorrhea. The median duration of any type of breastfeeding in Timor-Leste is 17.5 months, while the mean duration is about 18.2 months. The median duration of exclusive breastfeeding is 2.5 months, while the mean duration is 4 months. The median duration of exclusive breastfeeding is longest in Aileu (5.5 months) and shortest in Dili (1.6 months). The data also show that the median duration of breastfeeding among children is longer in the lowest two wealth quintiles (3.1 months or longer) compared with children in the highest wealth quintile (1.4 months). Nutrition of Children and Women | 157 Table 12.4 also shows that the overwhelming majority of children under age 6 months were breastfed six or more times in the 24 hours preceding the survey (98 percent). In line with expectations, breastfeeding is slightly more frequent in the daytime than at night (mean number of daytime feeds is 7 compared with 6 at night). The mean number of daytime feeds is highest among children residing in Bobonaro district (8.5) and lowest among children in Dili (6.1). Table 12.4 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the 3 years preceding the survey, percentage of breastfeeding children under 6 months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Timor-Leste 2009-10 Background characteristic Median duration (months) of breastfeeding among children born in the last 3 years1 Frequency of breastfeeding among children under 6 months2 Any breastfeeding Exclusive breastfeeding Predominant breastfeeding3 Percentage breastfed 6+ times in last 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 17.3 2.3 3.0 97.6 6.9 6.0 502 Female 17.8 2.8 3.4 98.2 7.2 6.1 453 Residence Urban 16.9 2.0 2.1 96.3 6.3 5.5 221 Rural 17.7 2.7 3.6 98.3 7.2 6.2 734 District Aileu 19.6 5.5 6.3 96.3 6.2 5.2 44 Ainaro 19.2 4.5 4.8 97.2 6.2 5.0 49 Baucau 15.2 2.7 2.9 96.5 6.6 5.7 91 Bobonaro 16.5 * 3.8 98.7 8.5 6.4 103 Covalima 17.8 1.9 2.0 100.0 7.7 6.6 46 Dili 15.3 1.6 1.7 97.6 6.1 5.4 165 Ermera 18.5 2.6 4.3 100.0 7.8 8.0 141 Lautem 17.5 2.1 3.0 95.1 6.7 5.6 63 Liquiçá 18.5 4.2 4.8 98.7 7.8 6.7 60 Manatuto 17.1 * * 98.7 7.0 6.9 42 Manufahi 20.0 4.3 4.7 96.5 7.8 4.8 36 Oecussi 20.0 3.2 3.4 97.1 6.2 5.2 75 Viqueque 14.3 (2.9) (3.1) 97.5 6.5 4.8 40 Mother’s education No education 18.7 2.7 3.7 99.0 7.4 6.4 330 Primary 17.6 2.7 3.3 96.7 6.7 5.8 244 Secondary 16.7 2.2 2.8 98.2 7.0 5.9 358 More than secondary * * * 88.8 4.8 5.2 24 Wealth quintile Lowest 17.3 3.1 3.6 97.7 7.1 5.9 211 Second 18.5 3.3 3.9 99.2 7.4 6.6 203 Middle 17.3 2.2 3.6 97.2 7.2 5.9 198 Fourth 18.6 2.5 3.2 97.3 6.9 5.8 167 Highest 14.0 1.4 1.6 97.8 6.3 5.9 176 Total 17.5 2.5 3.2 97.9 7.0 6.0 955 Mean for all children 18.2 4.0 4.4 na na na na Note: Median and mean durations are based on current status. Includes children living and deceased at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding 2 Excludes children without a valid answer on the number of times breastfed 3 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only 12.5 TYPES OF COMPLEMENTARY FOODS WHO recommends the introduction of solid food to infants around the age of 6 months because by that age breast milk by itself is no longer sufficient to maintain a child’s optimal growth. Table 12.5 shows information on the types of food given to the youngest child under 3 years of age living with the mother on the day or night preceding the survey, according to their breastfeeding status. The percentage of children receiving solid or semisolid food increases gradually by age. It is encouraging to note that at 6-8 months of age, about four in five breastfed children are consuming solid or semisolid food (82 percent). 158 | Nutrition of Children and Women Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under 3 years of age 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, Timor-Leste 2009-10 Age in months Liquids Solid or semi-solid foods Any solid or semi- solid food Food made with oil, fat and butter Sugary foods Number of children Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry, and eggs Cheese, yogurt, other milk product BREASTFEEDING CHILDREN 0-1 14.4 11.4 1.0 0.6 5.3 2.9 1.0 1.6 0.0 2.6 0.6 6.3 1.7 2.1 260 2-3 22.0 13.7 1.5 7.3 15.1 2.3 1.9 1.3 0.6 2.8 0.2 19.6 0.5 0.4 313 4-5 24.0 17.0 2.3 14.3 41.6 9.4 0.8 2.1 1.0 11.3 0.6 44.5 4.8 5.6 381 6-8 23.1 18.6 5.7 12.3 80.7 25.6 8.5 8.2 2.2 29.3 2.1 81.9 10.8 9.9 443 9-11 19.4 13.2 21.9 5.8 93.2 45.7 12.4 17.8 4.5 43.9 1.9 94.3 25.0 26.5 426 12-17 18.9 17.1 41.0 5.6 97.5 71.8 28.2 30.7 15.1 52.4 3.1 98.5 41.6 37.0 615 18-23 19.6 15.7 51.7 4.4 99.4 72.7 32.5 31.6 12.1 51.2 0.8 99.4 37.1 39.9 290 24-35 16.9 11.1 68.1 5.6 99.1 82.1 27.3 48.0 18.1 56.9 3.9 100.0 46.9 54.3 177 6-23 20.2 16.3 29.3 7.1 92.6 54.1 20.2 22.1 8.8 44.4 2.2 93.5 29.2 28.2 1,773 Total 20.1 15.3 22.6 7.4 70.1 39.8 14.4 17.0 6.7 32.6 1.7 71.7 21.5 21.5 2,903 NONBREASTFEEDING CHILDREN 12-17 23.0 24.1 46.1 6.6 99.0 79.5 29.9 35.7 14.0 58.8 5.5 99.8 44.9 45.1 295 18-23 13.8 13.5 58.0 6.1 99.1 86.7 33.1 40.5 9.9 56.8 7.0 99.3 44.8 47.0 416 24-35 11.0 13.8 65.8 4.0 99.0 83.9 38.7 42.4 15.9 61.1 3.7 99.8 48.4 47.7 999 6-23 19.6 20.1 51.3 7.9 98.8 82.4 31.0 38.5 11.1 57.1 6.0 99.3 44.3 45.5 769 Total 15.5 17.2 58.9 5.7 98.2 82.4 35.0 40.3 13.6 58.8 4.7 98.9 46.1 46.2 1,788 Note: Breastfeeding status and food consumed refer to a 24-hour” period (yesterday and last night). Nonbreastfeeding children under the age of 12 months are included in the total but are not shown separately. 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 pumpkin, squash, carrots, sweet potatoes, dark green leafy vegetables, mangoes, and papayas However, the introduction of other liquids such as water, juice, and formula takes place earlier than the recommended age of 6 months. Even among the youngest group of breastfeeding children (<2 months), 14 percent drink infant formula in addition to breast milk, and 11 percent drink other milk in addition to breast milk. Forty-five percent of breastfed children age 4-5 months have started consuming solid or semisolid food. The early introduction of water and foods increases the risk of infections, and thus contributes to malnutrition. Consumption of liquids other than milk increases gradually with age, and by age 12-17 months, 41 percent of breastfed children receive liquid supplements other than milk. Consumption of milk other than breast milk peaks at 6-8 months (19 percent) and declines thereafter. Supplementing with infant formula starts at 14 percent among breastfed children age 0-1 months and increases to 24 percent among breastfed children age 4-5 months. In all age groups, children are more likely to consume foods made from grains than other types of solid or semisolid foods. Twenty-six percent of breastfed children 6-8 months consumed vitamin A-rich fruits and vegetables in the day and night preceding the survey. Meat, fish, poultry, and eggs have bodybuilding substances essential to good health, and they are important for balanced physical and mental development. These foods are introduced later into the diet of children in Timor- Leste, and few children consume them. For instance, at age 6-8 months, only 29 percent of breastfed children consume meat, fish, shellfish, poultry, or eggs. As expected, more nonbreastfeeding children at age 6-23 months consume solid or semi-solid foods than breastfeeding children. 12.6 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Infant and young child feeding (IYCF) practices include timely initiation of feeding solid/semi-solid foods from age 6 months, feeding small amounts, and increasing the amount of foods and frequency of feeding as the child gets older, while maintaining frequent breastfeeding. For the average, healthy breastfed child, solid/semi-solid foods should be provided two to three times per day at 6-8 months and three to four times per day between ages 9 and 24 months, with an additional snack being offered 1 to 2 times per day, as desired. The minimum infant and young child feeding (IYCF) Nutrition of Children and Women | 159 practices for children age 6-23 months are defined as continued breastfeeding, feeding at least the minimum number of times per day (according to age), and feeding from the minimum number of food groups per day. However, not all infants and young children are breastfed. Therefore, for nonbreastfed children, the criteria reflected under “feeding practices” are receiving replacement feeding (that is, commercially produced infant formula, tinned, powdered, or fresh animal milk, cheese, yogurt, and other milk products), being fed at least the minimum number of times, and eating from the minimum number of food groups for nonbreastfed infants and young children. As an integral part of the national nutrition strategy, various approaches have been developed by the Nutrition Department of the Ministry of Health, including the creation of awareness of growth monitoring and the timely introduction of complementary food and feeding practices. The National Strategy for Infant and Young Child Feeding was developed in 2003 and includes training of health workers on IYCF counseling and conducting a workshop on IYCF for all the nutrition and health education staff in all thirteen districts (MOH, 2004c). Moreover, the Nutrition Department of the MOH is working closely with Alola Foundation and UNICEF to organize mother’s support groups to enhance knowledge of timely initiation of proper feeding practices. In 2010, doctors and midwives were trained on IYCF practices and counseling in order to provide appropriate services and support to communities. Figure 12.5 and Table 12.6 highlight infant and young child feeding practices among children age 6-23 months living with the mother. About 30 percent of children age 6-23 months are fed according to all three IYCF practices; that is, they are given milk or milk products and foods from recommended food groups and are fed at least the recommended minimum number of times. Seventy- eight percent are given breast milk or milk products, 54 percent are given the recommended number of foods (food from three or more groups for breastfed children), and 55 percent are fed at least as often as recommended. These feeding practices are better among children age 12-17 months. For example, 25 percent of children age 6-8 months are fed according to IYCF recommendations, compared with 37 percent of children age 12-17 months. The findings indicate that there is no significant difference in feeding practices by sex of the child, residence, or mother’s education. However, children who are born to mothers in the higher wealth quintiles are more likely than other children to be fed according to recommendations. Figure 12.5 Infant and Young Child Feeding (IYCF) Practices 41 5 30 59 95 70 Breastfed Nonbreastfed All 6-23 months Breastfeeding status 0 20 40 60 80 100 Percent Fed with all 3 IYCF practices Not fed with all 3 IYCF practices Timor-Leste 2009-10 160 | Nutrition of Children and Women 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 upon number of food groups and times they are fed during the day or night preceding the survey by breastfeeding status and background characteristics, Timor-Leste 2009-10 Background characteristic Among breastfed children 6-23 months, percentage fed: Among non-breastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: 3+ food groups1 Minimu m times or more2 Both 3+ food groups and minimu m times or more Number of breastfed children 6-23 months Milk or milk products3 4+ food groups 4+ times or more With 3 IYCF practices4 Number of non- breastfed children 6-23 months Breast- milk or milk products3 3+ or 4+ food groups5 Minimum times or more6 With all 3 IYCF practices Number of all children 6-23 months Age in months 6-8 28.0 75.2 26.5 443 * * * * 21 98.6 28.9 72.2 25.3 464 9-11 47.1 64.7 32.9 426 (39.3) (56.4) (20.1) (0.0) 37 95.2 47.8 61.1 30.3 463 12-17 69.9 70.5 51.4 615 29.7 52.8 22.0 7.3 295 77.2 64.4 54.8 37.1 910 18-23 69.1 75.7 54.0 290 20.3 55.1 17.6 4.1 416 53.0 60.9 41.4 24.6 706 Sex Male 52.8 71.2 41.3 912 29.8 51.3 19.7 7.0 398 78.7 52.4 55.5 30.8 1,310 Female 54.8 71.1 41.0 862 22.1 57.1 18.4 2.9 371 76.6 55.5 55.2 29.6 1,232 Residence Urban 65.1 65.7 43.4 367 48.4 75.0 15.6 7.8 226 80.3 68.9 46.6 29.8 593 Rural 50.9 72.5 40.6 1,407 16.8 45.4 20.6 3.9 542 76.8 49.3 58.1 30.4 1,949 District Aileu 49.2 44.1 32.6 68 (26.0) (45.3) (6.6) (3.4) 16 85.6 48.4 36.8 26.9 85 Ainaro 16.1 49.7 9.1 111 18.0 17.0 4.6 0.0 42 77.5 16.4 37.3 6.6 153 Baucau 58.6 77.2 43.0 191 13.5 47.5 12.4 1.8 90 72.3 55.0 56.5 29.8 282 Bobonaro 56.5 91.4 54.7 156 27.4 48.3 26.2 5.7 72 77.1 53.9 70.9 39.3 228 Covalima 40.9 70.9 29.6 76 (21.6) (23.6) (9.9) (0.0) 33 76.5 35.7 52.6 20.7 109 Dili 75.5 66.9 49.2 232 52.8 82.9 14.0 9.5 163 80.5 78.6 45.1 32.8 395 Ermera 49.7 67.4 48.3 236 (23.1) (38.4) (64.7) (11.3) 62 84.1 47.4 66.8 40.6 298 Lautem 42.7 68.1 22.0 157 23.0 34.6 10.2 0.8 66 77.2 40.3 50.9 15.7 223 Liquiçá 73.5 78.4 61.7 108 23.7 85.4 27.7 7.3 41 79.2 76.7 64.6 46.9 149 Manatuto 60.9 86.2 56.1 79 14.5 74.3 17.1 2.6 41 70.5 65.5 62.4 37.6 120 Manufahi 75.6 50.0 41.8 81 (30.7) (65.8) (5.6) (3.0) 22 85.1 73.5 40.5 33.5 103 Oecussi 43.8 71.7 32.8 164 8.0 45.6 21.8 3.4 47 79.5 44.2 60.6 26.3 211 Viqueque 45.1 87.5 40.6 114 10.9 44.6 15.4 4.3 74 65.0 44.9 59.1 26.3 187 Mother’s education No education 48.1 72.9 39.3 583 16.3 47.9 22.1 2.9 210 77.9 48.0 59.5 29.7 792 Primary 52.8 71.9 40.6 527 16.7 44.9 20.3 4.6 202 76.9 50.6 57.6 30.6 729 Secondary 59.9 68.4 43.1 634 35.4 61.9 16.3 5.0 321 78.3 60.6 50.9 30.3 956 More than secondary * * * 29 * * * * 36 (73.8) (64.3) (47.7) (31.7) 65 Wealth quintile Lowest 43.6 73.2 32.6 401 9.1 34.4 15.9 1.5 155 74.7 41.0 57.2 24.0 556 Second 46.8 70.9 37.6 370 11.2 41.3 21.9 1.8 150 74.4 45.2 56.8 27.3 520 Middle 54.6 70.1 43.4 376 17.9 48.0 15.1 3.2 136 78.2 52.8 55.5 32.7 512 Fourth 59.8 70.7 45.5 372 38.1 59.9 22.5 4.4 138 83.3 59.8 57.7 34.4 510 Highest 70.2 70.2 50.1 254 48.7 80.3 19.9 12.2 191 78.0 74.6 48.6 33.8 444 Total 53.8 71.1 41.2 1,773 26.1 54.1 19.1 5.0 769 77.6 53.9 55.4 30.2 2,542 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Food groups: a. infant formula, milk other than breastmilk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge, 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; h. foods made with oil, fat, butter. 2 At least twice a day for breastfed infants 6-8 months and at least three times a day for breastfed children 9-23 months 3 Includes commercial infant formula, fresh, tinned and powdered animal milk, and cheese, yogurt and other milk products 4 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 and are fed at least the minimum number of times per day with at least the minimum number of food groups. 5 3+ food groups for breastfed children and 4+ food groups for non-breastfed children 6 Fed solid or semi-solid food at least twice a day for infants 6-8 months, 3+ times for other breastfed children, and 4+ times for non-breastfed children 12.7 ANEMIA IN CHILDREN Anemia is a condition characterized by a reduction in the red blood cell volume and a decrease in the concentration of hemoglobin in the blood. Hemoglobin is necessary for transporting oxygen to tissues and organs in the body. About half of the global burden of anemia is due to iron deficiency. Iron deficiency, in turn, is largely due to an inadequate dietary intake of bioavailable iron, increased iron requirements during rapid growth periods (such as pregnancy and infancy), and increased blood loss due to hookworm infestation. Nutritional anemia includes the anemia burden due to deficiency in iron plus deficiencies in folate, vitamins B and B12, and certain trace elements involved with red blood cell production. Anemia in children is associated with impaired mental and Nutrition of Children and Women | 161 physical development and with increased morbidity and mortality. Anemia can be a particularly serious problem for pregnant women, leading to premature delivery and low birth weight3. The 2009-10 TLDHS included anemia testing of children age 6-59 months and women age 15-49 in every third household selected for the 2009-10 TLDHS sample. Anemia levels were determined by measuring the level of hemoglobin in the blood, with a decreased concentration characterizing anemia. For hemoglobin measurements, a drop of capillary blood was taken with a finger prick (using sterile, disposable instruments). Hemoglobin concentration was measured using the HemoCue photometer system. Table 12.7 Prevalence of anemia in children Percentage of children age 6-59 months classified as having anemia, by background characteristics, Timor-Leste 2009-10 Background characteristic Anemia status by hemoglobin level Number of children Mild (10.0-10.9 g/dl) Moderate (7.0-9.9 g/dl) Severe (<7.0 g/dl) Any anemia (<11.0 g/dl) Age in months 6-8 34.5 24.3 0.8 59.6 106 9-11 36.5 29.6 0.8 66.9 129 12-17 27.1 23.6 0.8 51.5 296 18-23 27.4 18.6 0.4 46.3 258 24-35 30.2 11.6 0.2 42.0 589 36-47 18.1 8.2 0.4 26.8 615 48-59 19.7 5.7 0.1 25.5 574 Sex Male 24.1 13.6 0.2 38.0 1,286 Female 25.5 12.4 0.6 38.4 1,281 Mother’s interview status Interviewed 24.5 13.5 0.4 38.4 2,362 Not interviewed but in household 28.5 8.5 1.1 38.1 73 Not interviewed, and not in the household1 27.7 7.0 0.0 34.7 132 Residence Urban 20.9 12.1 0.1 33.1 511 Rural 25.8 13.2 0.5 39.4 2,056 District Aileu 20.9 16.6 2.1 39.6 103 Ainaro 19.8 10.7 0.5 31.0 161 Baucau 38.6 12.5 0.0 51.1 253 Bobonaro 30.7 13.4 0.0 44.1 255 Covalima 19.8 15.6 0.8 36.2 108 Dili 17.6 7.7 0.0 25.3 365 Ermera 11.0 4.3 0.0 15.4 324 Lautem 29.6 16.2 0.4 46.3 247 Liquiçá 25.9 14.0 0.5 40.5 142 Manatuto 31.4 36.0 0.4 67.9 130 Manufahi 30.8 6.9 0.0 37.7 77 Oecussi 31.7 12.4 0.5 44.5 217 Viqueque 23.0 19.2 1.5 43.7 185 Mother’s education2 No education 24.7 11.0 0.4 36.1 881 Primary 26.6 14.9 0.5 42.0 672 Secondary 22.8 14.7 0.4 37.9 844 More than secondary 28.4 8.4 0.0 36.8 37 Wealth quintile Lowest 24.0 16.7 0.5 41.2 570 Second 26.1 9.7 0.2 36.0 544 Middle 27.5 12.2 0.5 40.2 498 Fourth 23.5 14.9 0.4 38.8 494 Highest 22.8 11.1 0.3 34.1 461 Total 24.8 13.0 0.4 38.2 2,566 Note: Table is based on children who slept in the household the night before the interview. Prevalence of anemia, based on hemoglobin levels, is adjusted for altitude using CDC formulas (CDC, 1998). Hemoglobin in grams per deciliter (g/dl). Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 3 WHO considers anemia prevalence over 40 percent in a population to be a major public health problem, from 20-40 percent is considered a medium-level public health problem, and from 5-19.9 percent is a mild public health problem (WHO, 2001a). 162 | Nutrition of Children and Women Table 12.7 shows the percentage of children age 6-59 months classified as having anemia, by background characteristics. Nearly two in five (38 percent) Timorese children age 6-59 months old are anemic, with 25 percent mildly anemic, 13 percent moderately anemic, and less than 1 percent severely anemic. It is noteworthy that children 36 months and older are less likely to be anemic than younger children. Rural children (39 percent) are slightly more likely to have anemia than urban children (33 percent). Children in Manatuto district have the highest prevalence of anemia (68 percent), and children in Ermera district have the lowest prevalence (15 percent). There is no consistent pattern between prevalence of anemia and mother’s education or sex of the child. Children in the highest wealth quintile are less likely to have anemia (34 percent) compared with children in the lowest wealth quintile (41 percent). The levels of childhood anemia as reported in DHS 2003 show 32 percent of children are anemic, indicating minimal improvement over the years. 12.8 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency has serious consequences for childhood morbidity and mortality. Children can receive micronutrients from foods, fortified foods, and direct supplementation. Vitamin A is an essential micronutrient for the immune system. Severe vitamin A deficiency (VAD) can cause eye damage. VAD can also increase the severity of infections, such as measles and diarrheal diseases in children, and can slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store enough vitamin A for four to six months. The 2009-10 TLDHS collected information on the consumption of vitamin A-rich foods and supplements. Table 12.8 shows the intake of several key micronutrients among children. Nearly four- fifths (79 percent) of last-born children age 6-35 months consumed vitamin A-rich foods in the 24- hour period before the survey. Consumption of vitamin A-rich foods increases from 38 percent among children age 6-8 months to 93 percent among children age 24-35 months. There is no difference by sex in the consumption of vitamin A-rich foods. Breastfeeding children are much less likely to consume foods rich in vitamin A than nonbreastfeeding children. Urban children (87 percent) are more likely than rural children (77 percent) to consume vitamin A-rich foods. Children born to mothers with more than a secondary level of education are more likely to have received foods rich in vitamin A than children born to mothers with a primary education. Children of older mothers are somewhat more likely than their counterparts to receive vitamin A-rich foods. Children living in the wealthiest households are much more likely to consume vitamin A-rich foods than children living in other households. Fifty-two percent of young children consumed foods rich in iron during the 24 hours before the survey. Noticeable differences by background characteristics are also seen in the consumption of iron-rich foods by young children. Consumption of iron-rich foods peaks at 60 percent among children age 24-35 months and is slightly higher among nonbreastfeeding children, urban children, and children of mothers age 20 and older. Children living in the wealthiest households (76 percent) are much more likely to consume foods rich in iron than children living in households in the lowest two wealth quintiles (less than 40 percent). An important strategy for preventing vitamin A deficiency in Timor-Leste has been the distribution of vitamin A capsules through the Timor-Leste national immunization campaign, which has been in place since 2000. In addition to the campaigns, vitamin A supplements are also readily available and distributed at health facilities and integrated community health service (SISCa) posts. The campaigns cover all the districts in the country. During the distribution periods, children age 6-11 months receive 100,000 international units (IU), and children 12-59 months receive 200,000 IU of vitamin A. Children under 6 months are not covered because most children in this age group are breastfed and receive vitamin A through breast milk. Information on vitamin A and supplements is based on the mother’s recall. Nutrition of Children and Women | 163 Table 12.8 Micronutrient intake and food supplementation among children Among youngest children age 6-35 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey, and among all children age 6-59 months, the percentages who were given vitamin A supplements in the 6 months preceding the survey, who were given iron supplements in the last seven days, who were given deworming medication in the 6 months preceding the survey, and who have ever received supplementary food, by background characteristics, Timor-Leste 2009-10 Background characteristic Among youngest children age 6-35 months living with the mother: Among all children age 6-59 months: Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supplements in last 6 months Percentage given iron supplements in last 7 days Percentage given deworming medication in last 6 months3 Percentage ever given supplementary food Number of children Age in months 6-8 37.7 30.1 464 36.5 20.3 12.4 33.9 472 9-11 62.5 44.4 463 51.6 17.8 17.9 38.3 470 12-17 84.5 54.5 910 52.7 24.8 28.7 39.6 946 18-23 88.3 54.5 706 55.2 21.5 36.2 37.7 806 24-35 92.6 60.4 1,176 51.7 21.7 39.0 35.4 1,959 36-47 na na na 52.4 18.8 41.4 33.6 1,947 48-59 na na na 48.2 16.2 38.9 30.4 1,745 Sex Male 78.5 50.7 1,889 50.6 20.0 35.7 34.0 4,224 Female 79.8 53.6 1,829 50.8 19.8 35.1 35.4 4,121 Breastfeeding status Breastfeeding 68.6 45.5 1,950 51.2 22.0 22.8 40.7 2,025 Not breastfeeding 91.0 59.4 1,760 50.7 19.2 39.7 33.1 6,239 Residence Urban 86.8 69.5 906 50.5 26.9 40.3 15.4 2,037 Rural 76.7 46.5 2,812 50.8 17.7 33.8 40.9 6,308 District Aileu 81.3 42.4 124 70.4 20.7 46.8 36.6 296 Ainaro 53.7 20.1 216 19.8 9.2 7.3 26.2 485 Baucau 82.7 60.7 375 45.4 2.2 28.2 24.2 850 Bobonaro 81.4 53.9 354 55.7 37.2 43.4 61.8 779 Covalima 67.7 38.4 172 72.3 8.1 48.0 48.0 379 Dili 91.2 78.9 614 48.2 31.4 43.4 7.6 1,424 Ermera 70.7 31.6 443 37.7 16.0 22.8 38.1 1,031 Lautem 79.8 54.4 306 58.5 8.0 45.3 20.8 653 Liquiçá 87.7 54.4 210 61.6 35.0 38.0 54.0 488 Manatuto 81.1 63.6 167 76.9 41.4 64.4 49.6 371 Manufahi 91.7 73.3 150 40.0 12.9 37.7 55.0 332 Oecussi 69.5 37.9 314 65.6 9.4 35.5 76.4 657 Viqueque 80.7 42.5 273 38.0 20.3 15.1 3.8 599 Mother’s education No education 76.6 40.6 1,173 42.9 15.7 29.2 37.2 2,788 Primary 76.9 49.7 1,049 53.4 18.7 35.3 39.1 2,361 Secondary 82.6 61.9 1,405 55.6 23.1 40.3 30.2 3,009 More than secondary 85.7 76.7 92 54.1 47.3 51.4 15.5 188 Mother’s age at birth 15-19 58.0 35.8 104 50.3 15.9 31.0 46.2 147 20-29 78.7 53.1 1,645 51.2 20.8 36.2 34.4 3,504 30-39 80.4 53.4 1,462 50.7 19.6 35.3 34.1 3,444 40-49 81.4 48.5 508 49.2 18.6 33.9 35.8 1,250 Wealth quintile Lowest 74.0 39.8 788 43.8 10.7 27.5 38.3 1,759 Second 73.5 38.5 723 44.4 13.5 29.4 36.6 1,629 Middle 78.1 49.1 750 50.7 21.3 35.1 41.8 1,671 Fourth 82.4 57.7 730 56.6 25.0 39.0 36.7 1,646 Highest 88.4 76.3 727 58.5 29.7 46.6 19.7 1,641 Total 79.2 52.1 3,718 50.7 19.9 35.4 34.7 8,345 Note: Information on vitamin A and iron supplements and deworming medication is based on the mother’s recall and immunization card (where available). Total for youngest children age 6-35 months living with the mother includes 8 children with information missing on breastfeeding status. Total for all children 6-59 months includes 79 children with information missing on breastfeeding status. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, squash, carrots, sweet potatoes, dark green leafy vegetables, mango, and papaya 2 Includes meat (including organ meat) 3 Deworming for intestinal parasites is commonly done for helminthes. One in two children (51 percent) age 6-59 months received a vitamin A supplement in the six months before the survey (Table 12.8). This is an improvement over the last five years; the 2003 DHS reported that 34 percent of children age 6-59 months had received vitamin A supplementation during 164 | Nutrition of Children and Women the most recent distribution preceding the survey. Differences in the consumption of vitamin A supplements by sex, residence, breastfeeding status, and mother’s age at birth are small. Differences in vitamin A supplementation by wealth quintiles is marked, with children in the highest wealth quintile much more likely to receive vitamin A supplements than children in the lowest wealth quintile (59 percent versus 44 percent). Children residing in Ainaro are least likely (20 percent) to receive vitamin A supplements compared with children in Manatuto (77 percent). Along with vitamin A deficiency, the prevalence of worm infestation has been high in Timor-Leste (MOH, 2004c). The Ministry of Health therefore integrated the deworming of children age 2-5 into the national biannual vitamin A supplementation program. By 2003, the entire country was covered. Deworming medication is given to children from age 6-59 months. Information on deworming of children was collected in the 2009-10 TLDHS survey. Table 12.8 indicates that 35 percent of children age 6-59 months received deworming tablets in the six months preceding the survey. Children over 24 months are more likely to receive deworming tablets. Children in urban areas are more likely to receive deworming tablets than rural children. District-level varia- tion among children who receive deworming tablets is high, ranging from 7 percent in Ainaro to 64 percent in Manatuto. Mother’s education has a positive influence on children receiving deworming tablets. Age in the 2009-10 TLDHS does not refer to the age of the child during the vitamin A or deworming distribution but rather refers to age on the day of the interview (current status). The inclusion of these “ineligible” children in the denominator may account for some underestimation in the coverage of vitamin A and deworming in these specific age groups at the time of the survey. The 2009-10 TLDHS also assessed reported cases of night blindness among children age 12-59 months. As it would be difficult for mothers to report correctly whether her child had night blindness, two proxy questions were administered: a question on whether the child showed any restriction of movement during the evenings compared with the daytime; and whether the child showed any signs of tripping or bumping into things in the evenings. These types of proxy reports have been used in other population-based surveys in which the parent/guardian was asked if the child has difficulty seeing in the evenings and, to be more specific, was prompted to probe for whether the child bumps into objects or trips over objects in the evenings (Wedner et al., 2004). Table 12.9 Signs of night blindness among children Among children 12-59 months, the percentage who in the past 6 months have exhibited less movement in the evenings and who have tipped over or bumped into things in the evening, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage who in the past 6 months have: Number of children Exhibited less movement in the evenings Tripped over or bumped into things in the evenings Age in months 12-17 6.9 10.3 946 18-23 8.4 14.9 806 24-35 6.7 14.3 1,959 36-47 6.8 12.0 1,947 48-59 5.1 10.7 1,745 Sex Male 6.5 12.0 3,736 Female 6.6 12.9 3,667 Breastfeeding status Breastfeeding 7.0 11.4 1,144 Not breastfeeding 6.5 12.5 6,181 Residence Urban 5.3 13.2 1,828 Rural 7.0 12.1 5,575 District Aileu 6.0 11.4 268 Ainaro 23.3 38.4 435 Baucau 5.7 10.0 736 Bobonaro 4.8 13.1 690 Covalima 1.4 1.1 335 Dili 4.7 15.1 1,277 Ermera 0.4 0.3 915 Lautem 4.1 9.8 559 Liquiçá 36.5 41.7 438 Manatuto 2.6 1.9 330 Manufahi 7.3 28.8 302 Oecussi 0.5 4.2 584 Viqueque 1.9 0.4 533 Mother’s education No education 7.4 12.3 2,520 Primary 6.4 12.6 2,059 Secondary 6.1 12.5 2,661 More than secondary 2.5 10.8 163 Mother’s age at birth 15-19 4.2 15.4 98 20-29 6.7 12.6 3,054 30-39 6.8 12.7 3,099 40-49 5.6 10.9 1,152 Wealth quintile Lowest 7.0 12.0 1,553 Second 7.0 13.0 1,441 Middle 6.0 11.8 1,473 Fourth 7.0 11.6 1,445 Highest 5.8 13.7 1,491 Total 6.6 12.4 7,403 Note: Total includes 77 children with information missing on breastfeeding status. Nutrition of Children and Women | 165 Table 12.9 indicates that about 7 percent of the children showed restricted movements in the evenings and 12 percent were reported to trip or bump into objects. Children age 18-23 months are most likely to show these signs. Children in Ainaro and Liquiçá most often showed these symptoms. It can be noted here that the proportion of children receiving vitamin A supplementation in the 6 months before the survey was lowest in Ainaro (20 percent in Table 12.8). 12.9 NUTRITIONAL STATUS OF WOMEN A woman’s nutritional status has important implications for her health as well as for the health of her children. Malnutrition in women results in reduced productivity, an increased susceptibility to infections, delayed recovery from illness, and heightened risk of adverse pregnancy outcomes. A woman with poor nutritional status, as indicated by a low body mass index (BMI), short stature, anemia, or other micronutrient deficiency, has a greater risk of obstructed labor, having a baby with a low birth weight, producing lower quality breast milk, dying from postpartum hemorrhage, and experiencing illness for herself and her baby. The 2009-10 TLDHS collected information on the height and weight of women in the reproductive age group. In this report, two indicators of nutritional status are presented—height and BMI. The height of a woman is associated with past socioeconomic status and nutrition during childhood and adolescence. A woman’s height is used to predict the risk of difficulty in delivery because small stature is often associated with small pelvic size and the potential for obstructed labor. The risk of giving birth to a low birthweight baby is influenced by the mother’s nutritional status. The cut-off point for the height at which mothers can be considered at risk varies between populations but normally falls between 140 and 150 centimeters. As in other DHS surveys, a cut-off point of 145 cm is used for the 2009-10 TLDHS. The index used to measure thinness or obesity is known as the BMI, defined as weight in kilograms divided by height squared in meters (kg/m2). A cut-off point of 18.5 is used to define thinness or acute undernutrition, and a BMI of 25 or above usually indicates overweight or obesity. According to WHO, a prevalence of more than 20 percent of women with a BMI less than 18.5 indicates a serious public health problem (WHO, 1995). Table 12.10 presents the values of the two indicators of nutritional status and the proportion of women falling into high-risk categories, according to background characteristics. Women for whom there was no information on height and/or weight and for whom a BMI could not be estimated (pregnant women and women with a birth in the preceding two months) are excluded from this analysis. The data analysis on BMI is based on 11,698 women, while the height analysis is based on 12,845 women age 15-49 years. Overall, 15 percent of women are shorter than 145 cm. Women in rural areas are much shorter on average than women in urban areas, with 17 percent falling below the 145 cm cutoff compared with only 9 percent of women in urban areas. Women living in Dili are least likely to be below 145 cm (7 percent), while women in Ermera are most likely (31 percent). Women with a secondary and higher level of education are less likely to be short than women who have no education. Women in the highest wealth quintile are less likely to be below 145 cm than women in the lowest wealth quintile (8 percent and 17 percent, respectively). Table 12.10 shows that there are large differentials across background characteristics in the percentage of women assessed as malnourished or “thin” (BMI less than 18.5) and overweight (BMI 25 or higher). Twenty-seven percent of women were found to be malnourished with BMI <18.5 indicating that malnutrition among women is a serious public health concern in Timor-Leste. About 5 percent of Timorese women are overweight or obese. Women age 15-19 are more likely to be thin or undernourished than women in other age cohorts (33 percent). Women are more likely to have a BMI less than 18.5 in rural areas (28 percent) than in urban areas (24 percent). However, the 166 | Nutrition of Children and Women Table 12.10 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Timor-Leste 2009-10 Background characteristic Height Body Mass Index1 Percentage below 145 cm Number of women Mean Body Mass Index (BMI) Normal Thin Overweight/obese Number of women 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17 (Mod- erately and severely thin) ≥25.0 (Total over- weight or obese) 25.0-29.9 (Over- weight) ≥30.0 (Obese) Age 15-19 22.0 3,045 19.5 65.1 33.4 22.3 11.1 1.5 1.2 0.4 2,952 20-29 12.8 4,139 20.1 68.6 27.9 18.8 9.1 3.5 2.9 0.6 3,539 30-39 12.6 3,175 20.7 69.1 22.8 15.6 7.2 8.0 6.8 1.2 2,804 40-49 12.3 2,487 20.6 67.7 23.9 15.9 7.9 8.5 7.5 1.0 2,403 Residence Urban 8.8 3,276 20.8 66.5 24.4 16.4 8.0 9.1 7.5 1.6 2,973 Rural 16.9 9,570 20.0 68.0 28.2 19.0 9.2 3.7 3.3 0.5 8,725 District Aileu 15.6 539 20.3 76.6 20.8 15.9 4.8 2.6 2.3 0.3 501 Ainaro 23.0 605 20.5 74.1 21.0 14.7 6.3 5.0 4.3 0.7 544 Baucau 16.7 1,388 20.5 79.7 16.9 11.8 5.0 3.4 3.2 0.3 1,282 Bobonaro 11.8 1,249 19.5 57.1 39.4 24.0 15.4 3.4 3.1 0.4 1,149 Covalima 13.9 772 20.4 58.7 31.4 21.1 10.4 9.9 9.0 0.9 719 Dili 7.1 2,350 21.1 68.5 21.6 15.6 6.0 9.9 8.0 1.8 2,134 Ermera 31.3 1,518 19.6 66.8 31.3 21.3 10.1 1.9 1.6 0.2 1,384 Lautem 8.8 839 20.3 67.5 27.8 18.6 9.2 4.7 3.5 1.2 746 Liquiçá 16.5 788 19.8 64.1 32.8 23.1 9.7 3.1 2.6 0.5 715 Manatuto 7.8 596 20.3 75.0 21.1 13.6 7.5 3.9 3.3 0.6 544 Manufahi 14.1 462 20.0 65.1 29.8 18.9 10.9 5.1 4.3 0.7 409 Oecussi 10.3 878 19.5 60.9 36.3 22.3 14.0 2.8 2.4 0.5 794 Viqueque 17.3 861 20.2 66.9 27.2 18.9 8.3 5.8 5.1 0.7 777 Education No education 17.3 3,791 20.0 68.0 28.0 18.7 9.3 3.9 3.5 0.5 3,446 Primary 15.2 2,956 20.3 66.3 27.3 18.2 9.1 6.4 5.5 0.9 2,666 Secondary 13.5 5,677 20.2 67.7 27.4 18.5 8.9 4.9 4.0 0.9 5,204 More than secondary 8.2 422 21.1 72.4 18.3 14.0 4.3 9.3 9.3 0.0 382 Wealth quintile Lowest 17.2 2,277 19.7 67.9 29.9 19.4 10.6 2.2 1.8 0.4 2,053 Second 19.7 2,440 19.9 68.5 28.8 19.0 9.8 2.8 2.3 0.5 2,203 Middle 17.1 2,550 19.9 67.8 28.9 20.0 8.9 3.3 3.0 0.4 2,312 Fourth 13.8 2,628 20.2 65.7 28.4 18.8 9.6 6.0 5.1 0.8 2,411 Highest 7.9 2,950 21.1 68.4 21.6 15.2 6.4 10.0 8.4 1.6 2,720 Total 14.8 12,845 20.2 67.6 27.2 18.3 8.9 5.1 4.3 0.8 11,698 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 percentage of overweight or obese women is higher in urban areas (9 percent) than in rural areas (4 percent). Bobonaro district (39 percent) has the highest percentage of undernourished women compared with Baucau district, which has the lowest percentage (17 percent). The percentage of women who are thin declines as level of education and household wealth increases. However, the proportion of overweight or obese women increases with increasing educational level and is highest among those in the highest wealth quintile. Women’s nutritional status has improved over the years. The proportion of malnourished women (BMI <18.5) has decreased by 29 percent in the past decade, from 38 percent in the 2003 DHS to 27 percent in the 2009-10 TLDHS. However, the level of chronic energy deficiency among nonpregnant women is still high, with more than one-quarter of women having a BMI less than 18.5. The mean BMI has increased only slightly over the years from 19.5 in the 2003 DHS to 20.2 in the 2009-10 TLDHS. 12.10 FOODS CONSUMED BY MOTHERS The quality and quantity of food that mothers eat influences their health and their children’s health, especially breastfeeding children. The 2009-10 TLDHS included questions on the types of foods that mothers of children under age 3 ate during the day and night preceding the interview. Table 12.11 shows that most mothers of young children eat foods made from grains (92 percent), nearly one in two (50 percent) eats foods made from roots or tubers, one in five (20 percent) eats foods Nutrition of Children and Women | 167 Table 12.11 Foods consumed by mothers in the day or night preceding the interview Among mothers age 15-49 with a child under age 3 living with them, the percentage who consumed specific types of foods in the day or night preceding the interview, by background characteristics, Timor-Leste 2009-10 Background characteristic Liquids Solid or semi-solid foods Foods made with oil/ fat/butter Sugary foods Number of mothers Milk Tea/ coffee Other liquids Foods made from grains Foods made from roots/ tubers Foods made from legumes Meat/ fish/ shellfish/ poultry/ eggs Cheese/ yogurt Vitamin A-rich fruits/ vege- tables1 Other fruits/ vege- tables Other solid or semi- solid food Age 15-19 5.1 77.2 11.3 95.7 41.3 18.3 42.0 2.9 81.9 39.3 52.1 37.6 19.8 164 20-29 4.9 81.0 16.9 92.0 49.6 19.9 55.5 6.6 88.9 36.9 49.8 51.5 23.9 2,131 30-39 5.4 84.0 15.3 93.3 50.0 21.1 53.2 7.4 88.3 35.2 50.3 49.6 23.3 1,811 40-49 4.8 84.4 15.5 89.4 51.8 19.4 44.8 3.9 84.0 35.0 52.1 51.1 20.6 585 Residence Urban 9.4 84.7 24.9 92.4 48.3 31.0 73.7 15.4 94.0 41.6 47.5 56.3 33.1 1,134 Rural 3.7 81.7 13.1 92.3 50.2 16.8 46.1 3.6 85.9 34.3 51.3 48.3 19.9 3,557 District Aileu 5.4 92.7 23.0 81.6 54.6 21.5 37.7 9.3 93.1 31.2 31.6 45.5 13.2 168 Ainaro 4.4 90.9 6.3 84.8 57.9 23.1 26.3 4.8 96.5 34.4 65.2 46.0 7.7 266 Baucau 5.5 79.7 7.4 95.1 68.2 6.7 59.8 1.5 89.0 27.7 37.6 55.0 7.5 466 Bobonaro 3.2 64.7 24.7 92.4 35.4 23.7 49.8 4.8 86.5 31.7 60.6 18.3 23.4 458 Covalima 2.2 79.4 4.0 96.6 20.0 6.7 42.2 0.9 74.2 9.6 35.7 29.1 9.4 218 Dili 8.9 86.3 30.5 91.5 45.5 33.5 83.3 21.4 96.0 40.4 49.3 65.3 44.6 785 Ermera 1.6 88.2 16.0 92.1 60.6 13.2 35.1 3.0 78.6 28.5 29.7 66.0 32.6 585 Lautem 6.9 78.2 10.6 90.4 34.0 15.6 51.2 2.0 80.7 29.2 60.4 27.8 5.9 370 Liquiçá 4.1 85.8 17.9 96.6 76.3 41.9 56.0 7.9 96.6 46.3 80.3 80.7 51.5 271 Manatuto 7.1 89.4 10.1 92.2 64.9 25.1 67.2 8.0 95.1 69.5 83.7 67.1 50.3 211 Manufahi 14.8 89.9 11.5 97.5 83.6 10.2 80.0 2.0 98.5 44.9 39.1 0.6 6.4 186 Oecussi 2.6 84.7 9.1 93.6 14.5 22.5 38.3 0.9 72.8 31.3 84.7 64.5 7.8 391 Viqueque 2.1 71.3 11.3 93.1 54.0 8.2 33.1 1.3 92.6 58.0 7.7 44.0 9.0 318 Education No education 2.9 83.6 14.0 90.4 53.3 18.9 42.0 4.1 85.4 32.9 52.1 48.3 19.7 1,505 Primary 3.7 82.2 13.7 93.0 44.6 21.0 48.6 4.5 86.7 35.0 51.4 48.1 20.2 1,298 Secondary 7.3 82.5 18.1 93.3 49.6 21.0 62.6 8.2 90.2 39.5 48.5 53.0 27.0 1,769 More than secondary 16.8 69.8 32.5 93.2 62.6 17.8 89.1 30.5 96.7 37.6 43.8 57.7 40.1 118 Wealth quintile Lowest 1.9 81.7 11.8 90.8 49.0 16.2 37.5 1.9 82.0 31.5 56.1 43.8 13.3 1,001 Second 2.4 80.9 11.3 91.3 50.7 14.8 38.4 2.8 85.8 33.7 46.2 47.3 17.6 928 Middle 4.0 84.3 12.5 93.0 52.8 20.8 49.3 3.3 88.2 35.0 49.5 47.4 20.7 950 Fourth 6.7 81.6 16.2 92.4 46.5 21.7 60.3 8.0 89.9 37.8 52.4 49.7 27.0 900 Highest 11.1 83.7 28.5 94.2 49.6 28.1 80.5 16.7 93.9 43.0 47.3 63.8 38.1 912 Total 5.1 82.4 15.9 92.3 49.7 20.2 52.8 6.4 87.8 36.1 50.4 50.2 23.1 4,691 Note: Foods consumed in the last “24-hour” period (yesterday and last night). 1 Includes pumpkin, squash, carrots, sweet potatoes, green leafy vegetables, mangoes, and papayas made from legumes, and 88 percent of mothers eat vitamin A-rich fruits and vegetables. More than one in two (53 percent) mothers eat meat, fish, shellfish, poultry, and eggs, and 36 percent eat other fruits and vegetables. Smaller proportions of mothers consume cheese/yogurt or milk (6 percent and 5 percent, respectively), and 50 percent eat foods made with oil, fat, or butter. Eighty-two percent of mothers drink tea or coffee, and 23 percent eat sugary foods. 12.11 MICRONUTRIENT INTAKE AMONG MOTHERS Micronutrient deficiencies are a result of inadequate intake of micronutrient-rich foods and the inadequate utilization of available micronutrients in the diet as a result of infections, parasitic infestations, and other factors. Measures of micronutrient fortification, micronutrient supplementation with iron and vitamin A, consumption of vitamin A-rich and iron-rich foods, and micronutrient status in terms of anemia and night blindness are discussed in this section. A mother’s nutritional status during pregnancy is important both for the child’s intrauterine development and for protection against maternal morbidity and mortality. Night blindness is an indicator of severe vitamin A deficiency, and pregnant women are especially prone to experience it. This section discusses women’s micronutrient intake, both in terms of food and supplementation. 168 | Nutrition of Children and Women Table 12.12 shows data on micronutrient intake among mothers of young children by background characteristics. More than nine in ten mothers (94 percent) consumed vitamin A-rich foods, and more than one-half (53 percent) consumed iron-rich foods in the 24 hours preceding the survey. Consumption of vitamin A-rich foods is higher among mothers residing in urban areas, more educated mothers, and those in the highest wealth quintile. Similarly, urban residence, education, and wealth are positively associated with consumption of iron-rich foods. Mothers living in urban areas are much more likely to consume iron-rich foods (74 percent) than mothers living in rural areas (46 per cent). Women living in Manufahi and Dili are most likely to receive vitamin A-rich foods (99 percent each) compared with women living in Oecussi, who are least likely (84 percent). In addition, women in Dili are most likely to receive iron-rich foods (83 percent), and women in Ainaro are the least likely (26 percent). Supplementation with vitamin A capsules (200,000 IU) for postpartum mothers through health care facilities and community volunteers is a strategy to reduce night blindness caused by vitamin A deficiency. Table 12.12 shows that 55 percent of women received vitamin A postpartum, an improvement from the 23 percent of women who received vitamin A postpartum reported in the 2003 DHS. Women 20-39 years of age are more likely to receive vitamin A postpartum. There is a marked urban-rural difference, with 61 percent of urban women receiving vitamin A, compared with 53 percent of women residing in the rural areas. Women with a higher level of education and those in the highest wealth quintile are also more likely to receive vitamin A postpartum. Vitamin A supplementation is highest in Covalima district (71 percent) and is lowest in Viqueque (37 percent). Thirteen percent of mothers reported having difficulty seeing at night but, when this figure is adjusted to include only those mothers who had no difficulty seeing in the daytime, only 2 percent of mothers suffered from night blindness during their most recent pregnancy in the last five years. This is a decrease from the 13 percent of mothers reported with night blindness in the DHS 2003 survey. Night blindness during pregnancy is more prevalent among mothers in urban areas, mothers with higher education, and mothers in the poorest households. The prevalence of night blindness during pregnancy among districts in Timor-Leste is variable, with the highest prevalence in Lautem (7 percent) and lowest prevalence in Bobanaro (0.1 percent). Besides improving food intake, supplementation is an important strategy for addressing the problem of micronutrient deficiency. Iron supplementation during pregnancy has been a key health initiative in Timor-Leste since 2003. According to the nutrition strategy, all pregnant women are supplied with iron-folic acid tablets free of charge. The iron-folic acid tablets are provided to all pregnant women from the beginning of the second trimester of pregnancy. Health staff are trained and equipped to provide iron tablets to pregnant and postnatal women at the facility and community levels (MOH, 2004c). Presumably as a result of these existing program interventions, the proportion of women who took iron supplements during pregnancy has risen from 43 percent in 2003 to 61 percent in 2009-10. However, 37 percent of women did not take any iron supplements during their most recent pregnancy. Further, only 16 percent of women took the recommended dose of iron supplements for 90 days or more during their pregnancy. Table 12.12 also shows that 13 percent of women received deworming medication during pregnancy, 31 percent received supplementary food while pregnant with their last birth, and 29 percent received supplementary food while breastfeeding their last-born child. Variations by background characteristics are similar to those discussed earlier. N ut rit io n of C hi ld re n an d W om en | 1 69 T ab le 1 2. 12 M ic ro nu tri en t i nt ak e am on g m ot he rs A m on g w om en a ge 1 5- 49 w ith a c hi ld u nd er a ge 3 li vi ng w ith h er , t he p er ce nt ag es w ho c on su m ed v ita m in A -r ic h an d iro n- ric h fo od s in th e 24 h ou rs p re ce di ng th e su rv ey ; am on g w om en a ge 1 5- 49 w ith a c hi ld b or n in th e la st 5 y ea rs , t he pe rc en ta ge w ho r ec ei ve d a vi ta m in A d os e in t he f irs t tw o m on th s af te r th e bi rth o f th e la st c hi ld ; an d am on g m ot he rs a ge 1 5- 49 w ho d ur in g th e pr eg na nc y of t he la st c hi ld b or n in t he f iv e ye ar s pr io r to t he s ur ve y, t he p er ce nt a g e w ho su ffe re d fro m n ig ht b lin dn es s, th e pe rc en ta ge w ho to ok ir on ta bl et s or s yr up fo r s pe ci fic n um be rs o f d ay s, th e pe rc en ta ge w ho to ok d ew or m in g m ed ic at io n, a nd th e pe rc en ta ge o f w om en w ho re ce iv ed s up pl em en ta l f oo d du rin g pr eg na nc y or w hi le b re as tfe ed in g, b y ba ck gr ou nd c ha ra ct er ist ic s, T im or -L es te 2 00 9- 10 B ac kg ro un d ch ar ac te ris tic Am on g w om en w ith a c hi ld u nd er th re e ye ar s liv in g w ith h er Am on g w om en w ith a c hi ld b or n in th e la st fi ve y ea rs Pe rc en ta ge co ns um ed Vi ta m in A ric h fo od s1 Pe rc en ta ge co ns um ed iro n- ric h fo od s2 N um be r o f w om en Pe rc en ta ge w ho re ce iv ed vi ta m in A do se p os t- pa rtu m 3 Pe rc en ta ge w ho su ffe re d ni gh t b lin dn es s du rin g pr eg na nc y of la st bi rth N um be r o f d ay s w om en to ok ir on ta bl et s or s yr up du rin g pr eg na nc y of la st b irt h Pe rc en ta ge o f w om en w ho to ok de w or m in g m ed ic at io n du rin g pr eg na nc y of la st b irt h5 Pe rc en ta ge o f w om en w ho re ce iv ed su pp le m en ta ry fo od d ur in g pr eg na nc y of la st bi rth Pe rc en ta ge o f w om en w ho re ce iv ed su pp le m en ta ry fo od w hi le b re as t- fe ed in g af te r l as t bi rth N um be r o f w om en Re po rte d Ad ju st ed 4 N on e < 60 60 -8 9 90 + D on ’t kn ow / m iss in g A ge 15 -1 9 90 .4 42 .0 16 4 51 .7 15 .3 2. 3 39 .9 43 .2 4. 2 10 .8 1. 8 16 .6 34 .1 29 .9 17 8 20 -2 9 94 .5 55 .5 2, 13 1 56 .0 11 .8 1. 6 34 .2 41 .8 5. 2 17 .0 1. 7 12 .4 32 .4 29 .8 2, 43 8 30 -3 9 93 .8 53 .2 1, 81 1 55 .5 14 .5 2. 2 36 .1 39 .4 5. 0 17 .5 2. 0 14 .0 30 .2 28 .3 2, 40 1 40 -4 9 91 .9 44 .8 58 5 50 .4 13 .4 2. 4 44 .5 35 .2 5. 9 12 .0 2. 3 13 .1 29 .4 28 .8 99 8 R es id en ce U rb an 96 .5 73 .7 1, 13 4 60 .6 12 .2 2. 5 23 .6 50 .6 8. 0 15 .5 2. 3 6. 7 12 .2 11 .6 1, 48 4 Ru ra l 92 .9 46 .1 3, 55 7 52 .8 13 .6 1. 8 41 .2 36 .3 4. 3 16 .4 1. 8 15 .4 37 .2 34 .7 4, 53 1 D is tr ic t Ai le u 94 .6 37 .7 16 8 66 .0 20 .8 1. 2 14 .9 60 .6 8. 0 14 .4 2. 2 8. 9 19 .8 21 .9 22 0 Ai na ro 97 .7 26 .3 26 6 52 .7 8. 2 0. 9 32 .0 58 .2 1. 5 7. 4 0. 9 2. 1 44 .1 37 .5 31 8 Ba uc au 94 .6 59 .8 46 6 64 .8 8. 6 1. 4 94 .1 3. 3 2. 1 0. 5 0. 0 9. 6 40 .0 24 .3 59 8 Bo bo na ro 95 .2 49 .8 45 8 56 .6 7. 7 0. 1 47 .3 48 .3 1. 6 1. 4 1. 4 29 .0 44 .9 46 .1 58 7 C ov al im a 84 .7 42 .2 21 8 70 .5 7. 4 0. 7 36 .1 62 .2 0. 0 0. 6 1. 1 12 .0 37 .8 39 .6 32 2 D ili 98 .5 83 .3 78 5 61 .9 10 .0 2. 2 15 .1 52 .3 10 .5 19 .6 2. 5 3. 6 6. 3 4. 6 1, 04 3 Er m er a 90 .1 35 .1 58 5 40 .4 8. 2 0. 3 52 .2 4. 9 3. 5 39 .4 0. 1 23 .9 39 .9 38 .6 71 9 La ut em 91 .5 51 .2 37 0 41 .4 28 .0 6. 7 12 .3 55 .0 10 .4 20 .9 1. 4 14 .1 11 .5 11 .7 44 4 Li qu iç á 98 .3 56 .0 27 1 65 .4 34 .7 3. 2 30 .4 48 .7 2. 6 11 .9 6. 4 20 .9 52 .0 36 .0 35 8 M an at ut o 96 .9 67 .2 21 1 59 .3 7. 7 1. 8 12 .4 26 .3 5. 4 53 .4 2. 6 35 .0 28 .2 29 .5 26 4 M an uf ah i 99 .1 80 .0 18 6 52 .5 13 .0 3. 5 53 .5 45 .5 0. 5 0. 2 0. 2 6. 4 42 .9 49 .0 23 8 O ec us si 83 .5 38 .3 39 1 49 .7 22 .9 2. 7 25 .7 59 .8 5. 1 3. 5 5. 9 8. 0 58 .4 66 .5 49 2 Vi qu eq ue 94 .6 33 .1 31 8 36 .7 7. 4 2. 3 34 .8 24 .4 9. 6 30 .1 1. 0 3. 0 1. 3 1. 9 41 2 E du ca tio n N o ed uc at io n 92 .6 42 .0 1, 50 5 45 .8 14 .1 1. 7 46 .4 33 .7 3. 9 13 .8 2. 2 14 .3 34 .1 32 .2 1, 98 0 Pr im ar y 92 .4 48 .6 1, 29 8 54 .6 14 .9 2. 0 35 .0 41 .7 5. 9 15 .6 1. 9 14 .7 33 .5 31 .3 1, 65 6 Se co nd ar y 95 .3 62 .6 1, 76 9 61 .9 11 .6 2. 1 31 .2 42 .7 5. 9 18 .3 1. 8 11 .7 28 .0 26 .1 2, 22 6 M or e th an s ec on da ry 10 0. 0 89 .1 11 8 67 .1 9. 9 3. 7 16 .4 55 .1 5. 2 23 .3 0. 0 6. 9 8. 5 6. 3 15 4 W ea lth q ui nt ile Lo w es t 89 .9 37 .5 1, 00 1 41 .8 14 .9 2. 5 44 .8 38 .4 5. 3 8. 9 2. 6 8. 7 34 .5 32 .8 1, 22 6 Se co nd 91 .7 38 .4 92 8 49 .9 13 .7 2. 1 46 .4 33 .4 3. 7 14 .5 1. 9 14 .4 35 .8 31 .8 1, 17 1 M id dl e 94 .7 49 .3 95 0 53 .6 12 .8 1. 7 38 .0 37 .7 4. 2 19 .4 0. 7 18 .6 37 .1 35 .5 1, 20 3 Fo ur th 96 .2 60 .3 90 0 61 .8 15 .6 1. 9 33 .8 40 .1 4. 2 19 .4 2. 6 16 .9 32 .7 29 .6 1, 17 0 H ig he st 96 .9 80 .5 91 2 66 .4 9. 6 1. 8 21 .8 49 .0 8. 5 18 .8 1. 8 8. 2 15 .9 15 .9 1, 24 4 To ta l 93 .8 52 .8 4, 69 1 54 .7 13 .3 2. 0 36 .9 39 .8 5. 2 16 .2 1. 9 13 .3 31 .0 29 .0 6, 01 5 1 In cl ud es m ea t ( an d or ga n m ea t), fi sh , p ou ltr y, e gg s, p um pk in , s qu as h, c ar ro ts , s w ee t p ot at oe s, m an go , a nd p ap ay a, 2 I nc lu de s m ea t ( an d or ga n m ea t), fi sh , p ou ltr y, e gg s 3 I n th e fir st tw o m on th s af te r d el iv er y 4 W om en w ho re po rte d ni gh t b lin dn es s bu t d id n ot re po rt di ffi cu lty w ith v isi on d ur in g th e da y 5 D ew or m in g fo r i nt es tin al p ar as ite s is co m m on ly d on e fo r h el m in th es a nd fo r s ch ist os om ia sis | 169Nutrition of Children and Women 170 | Nutrition of Children and Women 12.12 PREVALENCE OF ANEMIA IN WOMEN The most common cause of anemia in developing countries is inadequate intake of iron, folate, vitamin B12, or other nutrients. Anemia can also result from sickle cell disease, malaria, and intestinal worm infestation. Anemia may be the underlying cause of maternal mortality, spontaneous abortion, premature birth, and low birth weight. Iron and folic acid supplementation and deworming among pregnant women are important measures for reducing anemia prevalence among vulnerable groups of women. Anemia is characterized by a low level of hemoglobin in the blood. The 2009-10 TLDHS measured hemoglobin levels to identify anemia in women. Table 12.13 Prevalence of anemia in women Percentage of women age 15-49 with anemia, by background characteristics, Timor-Leste 2009-10 Background characteristic Anemia status by hemoglobin level Number of women Mild anemia Moderate anemia Severe anemia Any anemia Not pregnant 10.0-11.9 g/dl 7.0-9.9 g/dl <7.0 g/dl <12.0 g/dl Pregnant 10.0-10.9 g/dl 7.0-9.9 g/dl <7.0 g/dl <11.0 g/dl Age 15-19 19.0 2.4 0.1 21.5 975 20-29 15.8 4.2 0.2 20.2 1,297 30-39 14.1 4.1 0.7 18.9 1,022 40-49 22.8 3.3 0.2 26.3 765 Number of children ever born 0 16.5 2.3 0.2 19.0 1,550 1 20.8 6.7 0.0 27.5 331 2-3 17.8 3.7 0.5 21.9 673 4-5 15.3 4.3 0.5 20.1 635 6+ 19.3 4.0 0.2 23.5 870 Maternity status Pregnant 17.7 9.8 0.3 27.8 307 Breastfeeding 20.0 4.7 0.4 25.1 935 Neither 16.6 2.5 0.2 19.4 2,817 Using IUD Yes 19.7 7.1 0.0 26.8 28 No 17.4 3.6 0.3 21.3 4,031 Smoking status Smokes cigarettes/tobacco 18.2 7.6 0.9 26.8 194 Does not smoke 17.4 3.4 0.3 21.0 3,865 Residence Urban 14.7 4.4 0.1 19.1 1,004 Rural 18.4 3.3 0.3 22.0 3,055 District Aileu 24.1 3.5 0.0 27.5 183 Ainaro 9.1 1.0 0.0 10.1 207 Baucau 16.3 1.0 0.0 17.3 424 Bobonaro 18.8 6.8 0.0 25.6 376 Covalima 19.1 5.7 0.6 25.4 241 Dili 12.5 4.2 0.0 16.7 706 Ermera 19.4 1.7 0.3 21.4 494 Lautem 21.9 3.0 0.5 25.5 289 Liquiçá 15.8 4.6 0.3 20.7 247 Manatuto 29.2 3.5 0.0 32.6 196 Manufahi 9.5 2.5 0.8 12.8 137 Oecussi 16.6 5.2 0.7 22.5 288 Viqueque 20.4 3.7 1.2 25.2 271 Education No education 19.8 3.9 0.5 24.1 1,210 Primary 15.5 4.2 0.2 19.9 953 Secondary 17.3 3.1 0.2 20.6 1,768 More than secondary 12.5 3.1 0.0 15.6 128 Wealth quintile Lowest 18.3 3.5 0.5 22.3 755 Second 18.4 3.3 0.3 22.0 776 Middle 18.4 2.9 0.2 21.5 801 Fourth 17.4 3.2 0.3 21.0 831 Highest 15.1 4.8 0.1 20.0 896 Total 17.5 3.6 0.3 21.3 4,059 Note: Prevalence is adjusted for altitude and for smoking status if known using CDC formulas (CDC, 1998). Nutrition of Children and Women | 171 Iron deficiency anemia is one of the most common nutritional problems in Timor-Leste. Table 12.13 indicates that three in ten pregnant women (28 percent) are anemic. To address the problem of anemia in women, iron-folic acid supplementation was introduced as part of the Ministry of Health programming, covering all 13 districts. The program involved distributing iron-folic acid supplements to pregnant women through health facilities and SISCa. Table 12.13 shows that overall 21 percent of Timorese women age 15-49 are anemic, with 18 percent mildly anemic, 4 percent moderately anemic, and less than 1 percent severely anemic4. However, pregnant women are more likely to be anemic than women who are neither pregnant nor breastfeeding (28 percent and 19 percent, respectively). Anemia is higher among rural than urban women (22 percent versus 19 percent). Anemia ranges from 10 percent in Ainaro to 33 percent in Manatuto. There is a higher prevalence of anemia in women with no education and in those in the lowest wealth quintile. Women using IUDs are more likely to be anemic (27 percent) than women who do not use IUDs. 4 The level of anemia in women reported in the 2003 DHS cannot be compared with the 2009-10 TLDHS data as no adjustment for smoking was made in the 2003 DHS. Malaria | 173 MALARIA 13 Malaria remains a leading public health problem in Timor-Leste. Most of the estimated one million population in the country is at high risk of malaria, with about 80 percent of the cases reported from just 4 of the 13 districts—Dili, Viqueque, Covalima and Lautem (WHO SEAR, 2010). The number of confirmed cases has risen from 15,212 in 2000 to 45,973 in 2008. Slide positivity increased from 44 percent to 50 percent between 2002 and 2008, and the percentage attributed to Plasmodium falciparum increased from 53 percent to 73 percent over the same period (WHO SEAR, 2010). This increase may be due to an actual increase in malaria or to the strengthening of diagnostic facilities and improved monitoring and evaluation. The Ministry of Health (MOH) estimates between 100,000 and 200,000 cases of suspected malaria are reported each year in public health facilities, representing 12 percent of outpatient attendance. Of this figure, about 40,000 are children under age 5. Malaria also accounts for about four percent of hospital admissions (MOH, 2003). The existing climatic conditions in Timor-Leste are conducive to the spread of mosquitoes and the perennial transmission of malaria. The number of reported cases peak during the post-wet season of November to May (Cooper, et al., 2010). Still, a relatively large number of cases are recorded throughout the rest of the year. However, because there is relative variation in the topography of the country, the intensity of transmission varies with altitude, and endemicity is reduced in the higher altitudes (WHO SEAR, 2010). Timor-Leste’s efforts to control malaria date back to the pre-independence era when various strategies were employed at different times. In 1999, the country adopted the Roll Back Malaria initiative and has since been implementing a combination of curative and preventive interventions. The National Malaria Control Strategy focuses on early case management and delivery of effective antimalarial therapies, universal access to long-lasting insecticidal nets (LLINs), selective use of indoor residual spraying (IRS), and promotion of behavioral change and communication (BCC). Since 2003, the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) has substantially funded malaria control programs in Timor-Leste (Martins et al., 2009). The NMS supports the recommendation of WHO’s Roll Back Malaria (RBM) strategy, and in aiming to achieve the Millennium Development Goals (MDGs), has modified its LLIN distribution program accordingly, to ensure that there is one LLIN for every two persons considered to be at risk of malaria (95 percent of the population), thereby providing universal access to LLIN coverage. This is a shift from the earlier strategy of approximately two nets per household targeted for distribution to households with children under age 5 and pregnant women, the two most vulnerable groups, and therefore of primary focus (MOH, 2003). LLINs are distributed to pregnant women through antenatal clinics in public health facilities. It is reported that approximately 60 percent of the population is covered under the country’s bed net program (WHO SEAR, 2010). Case management of malaria is done at hospitals, community health centers (CHCs), and health posts (HPs) and also during visits to mobile clinics. Since 2007, the antimalaria drug policy has shifted its focus and adopted artemether-lumefantrine, an artemisinin-based combination therapy (ACT), as the drug of choice for the treatment of uncomplicated P. falciparum malaria across the country. This is because of the emergence of chloroquine and sulfadoxine-pyramethamine-resistant strains of the parasite. Health care providers in both the public and private sectors were trained in the new protocol for the treatment of malaria, which stipulated that the provision of ACT must be based on the results of a laboratory examination (microscopy), or a Rapid Diagnostic Test (RDT), where microscopy was not available. Chloroquine continues to be the drug of choice for the treatment of P. vivax, the second, but less common, malaria parasite in Timor-Leste. 174 | Malaria 13.1 MOSQUITO NETS 13.1.1 Ownership of Mosquito Nets A simple and relatively inexpensive way to control malaria is through the use of bed nets, which effectively breaks the host-vector link by creating a physical barrier between humans and the female Anopheles mosquito, which feeds primarily at night. Treating bed nets with an insecticide that leaves a residual effect has the added advantage of repelling and/or killing the mosquitoes. This leads to a reduction in the vector population and, eventually, to the termination of their ability to transmit malaria. The Timor-Leste health service therefore promotes the ownership and use of insecticide- treated mosquito nets, particularly factory-treated LLINs, as one of the primary interventions for reducing malaria transmission and morbidity in the country. The two types of LLINs promoted by the MOH are Olyset and Permanet, which require re-treatment after about four years or 20 washes, in contrast with the standard insecticide-treated nets (ITNs) that need to be re-treated every six months, or after three washes. Table 13.1 shows the percentage of households with at least one and more than one mosquito net (treated or untreated), ever-treated net, and ITN, by background characteristics. The data show that 45 percent of households in Timor-Leste own at least one mosquito net, whether treated or untreated, 44 percent own at least one ever-treated net, and 41 percent of households own at least one ITN. More than one in three households own more than one of any type of net. Urban households are more likely to own at least one ITN than rural households. Households belonging to the fourth and fifth wealth quintiles are more likely to have at least one ITN compared with those in the lower wealth quintiles. Households in Covalima (62 percent) are most likely to have at least one ITN compared with all other districts. Ownership of ITNs is particularly low in Ainaro, Baucau, Ermera, and Manufahi, probably due to their higher altitude and reduced risk of mosquito exposure. Table 13.1 Ownership of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), ever treated mosquito net, and insecticide-treated net (ITN), and the average number of nets per household, by background characteristics, Timor-Leste 2009-10 Background characteristic Any type of mosquito net Ever-treated mosquito net1 Insecticide-treated mosquito net (ITNs)2 Number of households Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ever treated nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Residence Urban 60.6 43.5 1.3 55.8 37.9 1.1 51.0 34.0 1.0 2,695 Rural 40.8 26.7 0.8 39.9 26.0 0.8 37.7 24.1 0.7 8,768 District Aileu 52.5 37.4 1.1 51.9 36.7 1.1 51.8 36.6 1.0 445 Ainaro 20.8 10.3 0.3 16.1 8.1 0.3 15.5 7.9 0.3 674 Baucau 24.9 16.6 0.5 24.8 16.6 0.5 22.5 15.0 0.4 1,338 Bobonaro 48.8 33.9 1.0 45.3 29.9 0.9 41.6 26.6 0.8 1,097 Covalima 66.5 52.4 1.4 65.5 51.2 1.4 62.4 47.7 1.3 684 Dili 61.2 43.9 1.3 55.8 37.6 1.1 51.4 34.1 1.0 1,911 Ermera 26.8 14.9 0.5 26.7 14.9 0.5 26.7 14.9 0.5 1,253 Lautem 54.3 32.8 1.0 54.3 32.8 1.0 53.4 31.8 1.0 751 Liquiçá 41.2 23.3 0.8 40.2 22.6 0.7 38.0 20.9 0.7 640 Manatutu 61.9 48.5 1.4 61.8 48.4 1.4 54.7 40.7 1.2 490 Manufahi 27.9 18.3 0.5 27.3 17.5 0.5 23.3 15.0 0.4 495 Oecussi 58.6 34.4 1.1 57.0 33.1 1.0 54.3 30.5 0.9 817 Viqueque 47.9 33.4 1.0 47.9 33.4 1.0 43.3 29.9 0.9 869 Wealth quintile Lowest 25.1 12.4 0.4 24.6 12.2 0.4 23.6 11.6 0.4 2,432 Second 33.7 19.2 0.6 32.8 18.6 0.6 31.2 17.3 0.5 2,354 Middle 44.6 28.8 0.8 43.5 27.6 0.8 41.2 26.1 0.8 2,254 Fourth 60.9 43.4 1.3 58.9 41.2 1.2 55.5 38.1 1.1 2,187 Highest 65.7 52.0 1.5 60.9 46.7 1.4 55.2 41.0 1.2 2,235 Total 45.4 30.6 0.9 43.6 28.8 0.9 40.9 26.4 0.8 11,463 1 An ever-treated net is (1) a factory net that does not require any further treatment or (2) any pretreated net. 2 An insecticide treated net (ITN) is (1) a factory treated net that does not require any further treatment or (2) a pretreated net obtained within the past 12 months. Malaria | 175 13.1.2 Use of Mosquito Nets by Children Age is an important factor in determining levels of acquired immunity against malaria. For the first six months of life, antibodies acquired from the mother during pregnancy protect children from malaria. Upon weaning, this immunity is gradually lost, and children start developing their own immunity over a period of time. Unlike immunity for some other infectious diseases, immunity against malaria is not permanent, and protection from infection requires the regular use of protective interventions. ITNs confer some protection if used regularly. In the 2009-10 TLDHS, respondents to the Household Questionnaire were asked about the use of mosquito nets by all members of the household the night before the interview. Table 13.2 presents information on the use of mosquito nets by children under age 5 in all households, and in households with an ITN, by background characteristics. The results show that 45 percent of children under age 5 in all households slept under a treated or untreated mosquito net the night before the survey, and 41 percent slept under an ITN. In households that own at least one ITN, more than four in five children (83 percent) slept under an ITN. Table 13.2 Use of mosquito nets by children Among children under five years of age in all households, the percentages of children under five years of age who slept the night before the survey under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN), and among children under five years of age in households with at least one ITN, the percentage who slept the night before the survey under an ITN, by background characteristics, Timor-Leste 2009-10 Background characteristic Children under age 5 in all households Children under age 5 in households with an ITN2 Percentage who slept under any net last night Percentage who slept under an ever- treated net last night1 Percentage who slept under an ITN last night2 Number of children Percentage who slept under an ITN last night2 Number of children Age (in years) <1 47.3 45.6 43.5 2,037 86.8 1,021 1 47.3 45.4 43.5 1,871 85.4 952 2 44.3 42.5 39.4 2,135 82.0 1,028 3 43.8 42.4 41.0 2,140 82.4 1,065 4 42.0 40.0 37.9 1,913 78.5 925 Sex Male 44.4 42.7 40.7 5,112 82.4 2,526 Female 45.4 43.6 41.4 4,985 83.7 2,465 Residence Urban 60.0 54.9 50.6 2,329 83.6 1,410 Rural 40.4 39.6 38.2 7,768 82.8 3,581 District Aileu 56.3 56.0 56.0 367 86.7 237 Ainaro 22.6 18.2 18.1 596 81.9 132 Baucau 29.9 29.9 28.8 1,055 90.9 334 Bobonaro 48.1 44.8 42.9 972 87.1 478 Covalima 65.3 63.8 61.4 474 89.0 327 Dili 62.4 56.5 52.3 1,606 84.0 999 Ermera 28.3 28.2 28.2 1,287 81.7 444 Lautem 49.0 49.0 47.5 792 75.0 501 Liquiçá 43.5 43.2 40.8 584 86.2 276 Manatutu 59.6 59.5 56.0 462 89.5 289 Manufahi 28.3 28.0 24.6 389 86.9 110 Oecussi 49.1 47.5 44.9 791 74.3 479 Viqueque 44.3 44.3 40.5 721 76.1 384 Wealth quintile Lowest 25.0 24.7 23.6 2,170 72.6 706 Second 34.3 33.4 32.6 2,020 84.0 784 Middle 44.0 43.1 41.8 2,049 85.2 1,005 Fourth 59.3 57.4 54.7 1,965 84.6 1,272 Highest 65.2 59.9 54.9 1,892 85.0 1,224 Total 44.9 43.1 41.0 10,096 83.0 4,991 1 An ever-treated net is (1) a factory net that does not require any further treatment or (2) any pretreated net. 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment or (2) a pretreated net obtained within the past 12 months. 176 | Malaria Among children under age 5, those less than 1 year of age are most likely to have slept under any net (47 percent), an ever-treated net (46 percent), or an ITN (44 percent) the night before the survey. Children in rural areas are less likely than those in urban areas to have slept under any net, an ever-treated net, or an ITN. The proportion of children who slept under any type of mosquito net is highest in Covalima (65 percent) and lowest in Ainaro (23 percent). The proportion of children who slept under a mosquito net generally increases with increasing wealth quintile; thus while 25 percent of children in the lowest wealth quintile slept under a net the night before the survey, about two and a half times more children in the highest wealth quintile (65 percent) slept under a net. Similar variations were observed among households with an ITN. 13.1.3 Use of Mosquito Nets by Women Pregnant women are one of the groups most vulnerable to malaria. The disease adversely affects birth outcomes and can lead to spontaneous abortions, pre-term labor, low birthweight babies, and stillbirths. This has prompted many advocacy campaigns to educate not only pregnant women, but also the general public on the importance of preventing malaria during pregnancy. In Timor-Leste, the key malaria preventive method employed during pregnancy is the use of ITNs. As with children under age 5, pregnant women in Timor-Leste have been targeted for bed net distribution over the past five years, and those who slept under an ITN the night before the survey are considered regular users of an ITN. Table 13.3 Use of mosquito nets by women Among all women age 15-49 in all households, the percentages who slept the night before the survey under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN), and among all women age 15-49 in households with at least one ITN, the percentage who slept the night before the survey under an ITN, by background characteristics, Timor-Leste 2009-10 Background characteristic Women age 15-49 in all households Women age 15-49 in households with ITN2 Percentage who: Number of women Slept under any net last night Slept under an ever-treated net last night1 Slept under an ITN last night2 Percentage who slept under an ITN last night2 Number of women Residence Urban 51.1 45.7 41.4 3,628 78.3 1,917 Rural 34.5 33.7 31.7 10,228 77.0 4,214 District Aileu 45.2 44.8 44.8 584 79.1 331 Ainaro 19.4 14.8 14.5 653 78.0 121 Baucau 21.8 21.8 20.7 1,485 75.7 406 Bobonaro 44.5 40.4 37.0 1,331 82.9 595 Covalima 58.2 56.7 53.2 824 82.9 529 Dili 51.0 45.3 41.5 2,601 79.5 1,357 Ermera 21.4 21.3 21.3 1,626 71.9 482 Lautem 39.9 39.9 38.1 912 69.6 499 Liquiçá 33.6 32.9 30.4 844 75.0 342 Manatutu 55.7 55.4 48.2 636 85.6 358 Manufahi 25.3 24.8 21.9 496 77.4 141 Oecussi 45.9 43.8 41.0 932 71.1 537 Viqueque 39.4 39.4 34.6 930 74.6 432 Education No education 27.9 26.7 25.3 4,106 75.1 1,383 Primary 41.3 40.2 37.8 3,163 80.3 1,489 Secondary 44.1 41.5 38.1 6,130 76.9 3,042 More than secondary 49.4 43.0 37.7 455 79.0 217 Wealth quintile Lowest 20.5 20.1 19.0 2,438 71.5 649 Second 27.7 26.9 25.8 2,589 75.8 881 Middle 35.1 34.1 32.6 2,754 76.5 1,172 Fourth 49.5 47.7 44.5 2,864 79.2 1,611 Highest 55.6 50.2 44.9 3,210 79.2 1,818 Total 38.9 36.8 34.2 13,856 77.4 6,131 Note: Total for women in all households includes 2 women with information missing on education. 1 An ever-treated net is (1) a factory net that does not require any further treatment or (2) any pretreated net. 2 An insecticide treated net (ITN) is (1) a factory treated net that does not require any further treatment or (2) a pretreated net obtained within the past 12 months. Malaria | 177 Tables 13.3 and 13.4 show the percentages of all women and pregnant women, respectively, in all households who slept under a mosquito net (treated or untreated) the night before the survey, and the proportions of women and pregnant women in households that own at least one ITN who slept under an ITN the night before the survey, by background characteristics. The results show some differences between all women and pregnant women in the use of nets. Overall, 39 percent of all women and 45 percent of pregnant women slept under any net the night before the interview; 37 percent and 43 percent, respectively, slept under an ever-treated net, and 34 percent and 41 percent, respectively, slept under an ITN. As with children under age 5, in households that own at least one ITN, a substantially larger proportion of women slept under an ITN the night before the survey (77 percent of all women and 84 percent of pregnant women). Table 13.4 Use of mosquito nets by pregnant women Among pregnant women age 15-49 in all households, the percentages who slept the night before the survey under a mosquito net (treated or untreated), under an ever-treated mosquito net, and under an insecticide-treated net (ITN), and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept the night before the survey under an ITN, by background characteristics, Timor-Leste 2009-10 Background characteristic Pregnant women age 15-49 in all households Pregnant women age 15-49 in households with ITN2 Percentage who: Number of women Slept under any net last night Slept under an ever- treated net last night1 Slept under ITN last night2 Percentage who slept under an ITN last night2 Number of women Residence Urban 59.2 52.5 49.6 233 81.8 141 Rural 40.3 39.7 37.7 676 85.7 298 District Aileu 56.7 56.7 56.7 30 (88.9) 19 Ainaro 20.7 16.2 15.2 55 * 10 Baucau 33.0 33.0 31.1 89 * 28 Bobonaro 59.2 54.9 49.0 73 (94.7) 38 Covalima 60.4 59.2 58.1 46 (88.3) 30 Dili 60.7 52.6 50.3 156 80.1 98 Ermera 23.5 23.5 23.5 107 (84.0) 30 Lautem 48.5 48.5 45.7 76 75.8 46 Liquiçá 40.8 40.8 38.5 57 (94.4) 23 Manatutu 64.6 64.6 60.5 42 94.7 27 Manufahi 25.7 25.7 20.0 42 * 11 Oecussi 43.2 42.4 40.8 64 (66.2) 40 Viqueque 49.5 49.5 48.1 73 (88.4) 40 Education No education 28.6 27.4 25.7 266 74.0 92 Primary 48.5 46.6 45.9 238 88.5 124 Secondary 53.5 50.4 46.8 370 85.4 203 More than secondary (58.2) (58.2) (56.4) 35 * 20 Wealth quintile Lowest 27.5 27.0 27.0 164 77.2 58 Second 31.8 31.0 30.4 197 84.9 71 Middle 45.1 44.1 40.3 191 85.7 90 Fourth 62.2 61.3 58.6 175 90.7 113 Highest 58.9 51.5 47.6 182 80.4 108 Total 45.1 43.0 40.7 909 84.4 439 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. 1 An ever-treated net is (1) a factory net that does not require any further treatment or (2) any pretreated net. 2 An insecticide treated net (ITN) is (1) a factory treated net that does not require any further treatment or (2) a pretreated net obtained within the past 12 months. Among all women, those living in urban areas (51 percent) are more likely to have slept under a mosquito net the night before the survey than rural women (35 percent); the same pattern is seen for pregnant women, although the proportions are higher (59 and 40 percent, respectively). As with children, use of any mosquito net by all women is highest in Covalima (58 percent) and lowest in Ainaro (19 percent), and a similar pattern is observed regarding the use of an ITN. Among pregnant women, use is highest in Manatuto. Education is positively related to sleeping under a mosquito net, with only 28 percent of women with no education sleeping under a net the night before the survey, compared with 49 percent of women with more than secondary education. A similar pattern is seen among pregnant women. Similarly, women in the higher wealth quintiles are most likely to have slept under an ever-treated net or an ITN. 178 | Malaria 13.1.4 Prevalence and Management of Childhood Malaria A common manifestation of malaria is fever, and the presence of fever is used as an entry point to assess and classify a sick child’s condition. In the 2009-10 TLDHS, mothers were asked whether their children under age 5 had a fever in the two weeks preceding the survey. Although fever can occur year-round, malaria is more prevalent during the end of the rainy season. The fieldwork for the TLDHS spanned the six months from mid-August 2009 to early February 2010 and did not fully encompass the peak season for malaria transmission of November to May. Such temporal factors should be taken into account when interpreting the occurrence of fever as an indicator of malaria prevalence. If a fever was reported, the mother was asked whether treatment was sought at a health facility and whether the child was given any medication and, if so, how soon the medication was taken after the onset of fever. Table 13.5 shows the percentage of children under age 5 with fever in the two weeks preceding the survey, and among children with fever, the percentage who received antimalarial drugs and the percentage who took antimalarial drugs the same day or the next, by background characteristics. One in five children under age 5 (19 percent) had a fever in the two weeks preceding the survey. Of these, 6 percent received an antimalarial drug. Only 2 percent of children received anti- malarial drugs the same day or the next day after the onset of fever. Table 13.5 Prevalence and prompt treatment of fever Percentage of children under age 5 with fever in the two weeks preceding the survey, and among children with fever, the percentage who took antimalarial drugs and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, Timor-Leste 2009-10 Background characteristic Among children under age 5: Among children under age 5 with fever: Percentage with fever in the two weeks preceding the survey Number of children Percentage who took antimalarial drugs Percentage who took antimalarial drugs same or next day Number of children Age (in months) <12 21.1 1,925 4.0 1.1 407 12-23 23.4 1,752 6.9 2.4 410 24-35 21.3 1,959 6.4 3.3 417 36-47 17.6 1,947 5.8 3.5 342 48-59 12.3 1,745 5.3 1.0 214 Residence Urban 24.1 2,269 5.2 1.9 546 Rural 17.6 7,059 5.9 2.6 1,243 District Aileu 14.9 340 24.2 9.5 51 Ainaro 4.9 536 (5.9) (5.9) 26 Baucau 14.9 941 1.1 0.0 140 Bobonaro 26.4 884 1.4 1.4 234 Covalima 20.0 426 8.5 5.3 85 Dili 24.6 1,597 5.1 1.5 392 Ermera 12.7 1,172 15.2 6.5 149 Lautem 29.6 719 1.7 0.0 213 Liquiçá 33.8 550 7.7 4.5 186 Manatutu 19.3 416 1.4 0.7 80 Manufahi 11.3 369 5.8 0.0 42 Oecussi 20.6 734 1.9 0.6 151 Viqueque 6.3 644 (21.9) (6.1) 41 Mother’s education No education 17.7 3,122 7.7 3.5 552 Primary 20.6 2,611 3.7 1.6 539 Secondary 19.2 3,381 5.2 1.7 648 More than secondary 23.7 214 (10.9) (6.9) 51 Wealth quintile Lowest 16.1 1,973 5.1 1.7 317 Second 16.9 1,834 4.7 1.3 310 Middle 18.6 1,875 5.6 2.8 348 Fourth 22.6 1,819 6.9 2.1 410 Highest 22.1 1,827 5.9 3.6 404 Total 19.2 9,328 5.7 2.4 1,790 Note: Figures in parentheses are based on 25-49 unweighted cases. Malaria | 179 The highest prevalence of fever is reported among children age 12-23 months (23 percent). Fever is least common among children age 48-59 months (12 percent).The proportion of children with fever differs by urban-rural residence, with 24 percent of urban children having fever in the two weeks before the survey as opposed to 18 percent in the rural areas. Liquiçá reported the highest proportions of children with fever (34 percent), while Ainaro had the lowest proportion (5 percent). Children older than 12 months are most likely to be given antimalarial drugs for the treatment of fever and to receive the drugs the same or the next day. There is hardly any urban-rural variation in getting antimalarial drugs. Children of mothers with no education are more likely to receive anti- malarial drugs (8 percent) than children of mothers with primary and secondary education. Table 13.6 presents information on the type and timing of antimalarial drugs given to children under age 5 who had fever in the two weeks preceding the survey, by background characteristics. Fansidar is the most common antimalarial drug given to children with fever (3 percent), followed by chloroquine (2 percent), and quinine (1 percent). The very low percentage of children with fever treated with antimalarial drugs can be attributed to the revised protocol put in place since 2007 that advocates treatment for malaria upon confirmation by microscopy testing or Rapid Diagnostic Tests (RDTs). As discussed in Chapter 11, the majority of children with fever are prescribed paracetemol or antibiotics in the absence of the availability of RDTs or while waiting for the laboratory results Table 13.6 Type and timing of antimalarial drugs Among children under age 5 with fever in the two weeks preceding the survey, percentage who took specific antimalarial drugs and percentage who took each type of drug the same or next day after developing the fever, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of children who took drug: Percentage of children who took drug the same or next day: Number of children with fever SP/ Fansidar Chloro- quine Quinine ACT Other anti- malarial SP/ Fansidar Chloro- quine Quinine ACT Other anti- malarial Age (in months) <12 2.3 1.4 0.9 0.6 0.8 0.9 0.4 0.2 0.0 0.4 407 12-23 3.7 1.5 1.1 0.1 0.5 2.2 0.0 0.2 0.0 0.0 410 24-35 3.1 1.2 2.2 0.2 0.7 1.1 0.9 0.5 0.2 0.7 417 36-47 2.0 2.7 1.1 0.2 0.2 1.7 1.2 0.9 0.0 0.2 342 48-59 2.2 1.8 1.3 0.7 0.0 0.2 0.8 0.0 0.0 0.0 214 Residence Urban 2.8 1.5 0.2 0.1 0.7 1.3 0.4 0.0 0.0 0.4 546 Rural 2.7 1.7 1.8 0.5 0.4 1.3 0.7 0.6 0.1 0.2 1,243 District Aileu 21.0 0.0 2.1 2.1 1.0 9.5 0.0 0.0 0.0 0.0 51 Ainaro (0.0) (3.0) (0.0) (0.0) (3.0) (0.0) (3.0) (0.0) (0.0) (3.0) 26 Baucau 1.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 140 Bobonaro 0.8 0.8 0.0 0.0 0.0 0.8 0.8 0.0 0.0 0.0 234 Covalima 0.0 8.5 0.0 0.0 0.0 0.0 5.3 0.0 0.0 0.0 85 Dili 2.6 1.5 0.0 0.0 1.0 1.0 0.0 0.0 0.0 0.5 392 Ermera 11.4 1.0 8.4 1.0 1.0 6.5 1.0 1.0 0.0 1.0 149 Lautem 0.3 1.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 213 Liquiçá 1.6 0.4 4.9 0.8 0.0 1.2 0.4 2.9 0.0 0.0 186 Manatutu 0.0 0.7 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.7 80 Manufahi 3.0 0.0 2.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 42 Oecussi 1.3 0.6 0.0 0.0 0.0 0.6 0.0 0.0 0.0 0.0 151 Viqueque (2.5) (17.0) (0.0) (5.0) (2.5) (0.0) (3.6) (0.0) (2.5) (0.0) 41 Mother’s education No education 3.8 0.8 3.3 0.6 0.8 2.2 0.5 1.0 0.0 0.3 552 Primary 1.8 1.1 0.3 0.4 0.3 0.7 0.6 0.0 0.0 0.2 539 Secondary 2.5 2.7 0.6 0.2 0.0 1.2 0.5 0.2 0.2 0.0 648 More than secondary (4.0) (2.9) (0.0) (0.0) (4.0) (0.0) (2.9) (0.0) (0.0) (4.0) 51 Wealth quintile Lowest 1.3 2.2 1.4 0.3 0.5 0.3 0.2 1.0 0.0 0.2 317 Second 1.9 0.7 1.7 0.3 0.0 0.2 0.7 0.0 0.3 0.0 310 Middle 3.5 1.3 1.0 0.8 0.4 2.3 0.4 0.0 0.0 0.2 348 Fourth 3.0 1.8 1.8 0.4 0.9 1.1 0.4 0.6 0.0 0.4 410 Highest 3.6 2.2 0.8 0.0 0.5 2.3 1.2 0.4 0.0 0.5 404 Total 2.7 1.7 1.3 0.3 0.5 1.3 0.6 0.4 0.1 0.3 1,790 Note: Figures in parentheses are based on 25-49 unweighted cases. 180 | Malaria to arrive. The revised protocol for the treatment of malaria can also explain the large difference between results obtained in the 2003 DHS on treatment of fever among children under age 5 with antimalarials and the 2009-10 TLDHS. Because of the need to treat malaria quickly, it can be useful for parents to have antimalarial drugs at home. The 2009-10 TLDHS findings show that antimalarial drugs were at home when the child became ill in about 46 percent of cases (data not shown). HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 181 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 14 Acquired Immune Deficiency Syndrome (AIDS) was first recognized internationally in 1981. According to the Joint United Nations Program on AIDS (UNAIDS), the number of people living with the human immunodeficiency virus (HIV) continued to grow, and it is estimated that in 2008 33.4 million people worldwide were living with HIV, with a threefold increase in prevalence since 1990 (UNAIDS and WHO, 2009). Timor-Leste was free of HIV during most of the time when the developed countries were compiling measures to fight the epidemic. However, as contact with the outside world increases, cases of HIV have been on the rise, although no information to date is available on the prevalence for the country as a whole. According to the Ministry of Health the first reported case of HIV in Timor-Leste was in 2003. Between then and December 2009, there have been 151 cases of HIV reported in the country (DRTL, 2010). Forty-eight percent of HIV-positive cases in the past 12 months were reported among men and 52 percent among women (DRTL, 2010). In addition, 8 percent of HIV-positive cases were among children under age 5. Epidemiological studies have identified sexual intercourse, intravenous injections, blood transfusions, and fetal transmission from infected mothers as the main routes of transmission of HIV. Integrated bio-behavioral surveys (IBBS) conducted on a regular basis since 2009 among the most at- risk populations, such as female sex workers (FSWs), injecting drug users (IDUs), men having sex with men (MSM), the Policia Nacional de Timor-Leste (PNTL), Falintil-Forças de Defesa de Timor- Leste (F-FDTL) and clients of FSWs, in selected geographical areas of Timor-Leste, indicate a low- level epidemic concentrated in high-risk groups (DRTL, 2010). To address the challenges posed by HIV, the government of Timor-Leste has identified clear strategic directions under its National HIV/AIDS/STI Strategic Plan for 2006-2010 (MOH, 2006). The National HIV/AIDS/STI Strategic Plan outlines the following principles: • A strategy based on respect for human rights • A strategy that is participatory and multi-sectoral • A strategy that is built on partnership and that draws upon the strengths of government, nongovernment, private-sector, and faith-based organizations and that includes the involvement of HIV-positive people • A strategy that is evidence-driven but encourages creativity • A strategy that is consistent with the principles underlying the development of Timor- Leste • A strategy that is multifaceted, drawing on the underlying tenets of health promotion The health service delivery is outlined in the Basic Package of Services Policy, which is particularly relevant to HIV/AIDS and STI strategies as it provides a context for planning capacity development actions to address service delivery needs and to identify linkages in service delivery across different policy areas (MOH, 2004d). Currently, the National HIV/AIDS Program is in the process of revising the strategic plan for the 2011-2016 five-year period. The activities of the National HIV/AIDS Program include screening blood samples; producing strategic information; implementing a comprehensive monitoring and evaluation system, which includes a surveillance plan; generating information, education, and communication (IEC) materials; promoting condoms; offering voluntary counseling and testing (VCT) for screening and treatment of sexually transmitted infections (STIs); providing antiretroviral 182 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior (ARV) treatment; providing care and support for people living with HIV and AIDS (PLHA); and training health workers in the clinical management of AIDS patients (MOH, 2006; DRTL, 2010). The 2009-10 TLDHS included a series of questions on knowledge of HIV/AIDS and attitudes toward people with AIDS. All women and men age 15-49 were first asked if they had ever heard of AIDS. Those who had heard of AIDS were questioned further about their knowledge of HIV transmission and prevention. Respondents were also asked about their perception of the precautions a person can take to avoid getting infected with HIV. Additional questions dealt with common local misconceptions regarding the mode of transmission of HIV. This chapter presents current levels of HIV/AIDS knowledge, attitudes, and related behaviors in the general adult population. A specific focus is HIV/AIDS knowledge and patterns of sexual activity among youth, who are the main target of many HIV prevention efforts. 14.1 KNOWLEDGE OF HIV/AIDS AND OF TRANSMISSION AND PREVENTION METHODS 14.1.1 Knowledge of AIDS Respondents in the 2009-10 TLDHS were asked whether they have heard of AIDS. Table 14.1 shows the percentages of women and men age 15-49 who have heard of AIDS. Forty-four Table 14.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Timor- Leste 2009-10 Background characteristic Women Men Has heard of AIDS Number of women Has heard of AIDS Number of men Age 15-24 53.4 5,487 62.6 1,636 15-19 51.8 3,144 56.8 994 20-24 55.5 2,343 71.6 643 25-29 47.4 1,897 70.6 586 30-39 38.2 3,219 61.6 992 40-49 27.2 2,534 49.4 861 Marital status Never married 56.3 4,675 64.2 1,865 Ever had sex (59.3) 40 83.9 540 Never had sex 56.3 4,635 56.2 1,325 Married/living together 37.3 7,906 58.1 2,158 Divorced/separated/ widowed 29.2 556 41.8 53 Residence Urban 70.1 3,439 85.1 1,102 Rural 34.4 9,698 51.7 2,974 District Aileu 36.2 554 53.2 181 Ainaro 28.8 619 46.4 217 Baucau 54.3 1,408 64.3 415 Bobonaro 39.5 1,262 61.8 357 Covalima 48.5 781 77.3 236 Dili 79.7 2,466 92.9 797 Ermera 13.8 1,542 20.8 491 Lautem 36.3 864 58.0 308 Liquiçá 33.9 801 52.9 252 Manatuto 52.1 603 98.9 190 Manufahi 36.3 470 46.0 137 Oecussi 27.6 884 51.0 235 Viqueque 26.8 882 31.7 260 Education No education 12.8 3,854 22.1 791 Primary 26.8 3,005 43.8 1,046 Secondary 68.8 5,829 80.2 2,009 More than secondary 97.1 449 100.0 230 Wealth quintile Lowest 20.1 2,314 35.3 728 Second 26.2 2,468 44.3 781 Middle 34.6 2,590 54.7 786 Fourth 48.9 2,687 68.7 849 Highest 78.8 3,077 92.1 932 Total 15-49 43.8 13,137 60.7 4,076 Note: Figures in parentheses are based on 25-49 unweighted cases HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 183 percent of women and 61 percent of men have heard of AIDS. Knowledge is inversely related to age, rising from 27 percent among women age 40-49 to 53 percent among those age 15-24. This pattern is true for men with the exception of those age15-24. Knowledge rises from 49 percent among men age 40-49 to 71 percent among men age 25-29 and then falls to 63 percent among the youngest cohort. Knowledge is higher among never-married than ever-married respondents. Knowledge is twice as high among urban compared with rural women, with the urban-rural difference among men being somewhat less substantial. Women in Dili and men in Manatuto are most likely to have heard of AIDS, and women and men in Ermera are least likely. Knowledge of AIDS increases with level of education and household wealth for both women and men. 14.1.2 Knowledge of HIV Prevention Methods The promotion of sexual and reproductive health is necessary for the prevention of HIV infection. This includes educating the public to adopt specific prevention behaviors, including: • Abstinence from sexual activity that can transmit infection • Being faithful to one partner who is also faithful and uninfected • Consistent condom use Table 14.2 presents levels of knowledge about the various HIV prevention methods by background characteristics. Of the prevention methods discussed in the survey, women are most aware that their risk of getting HIV can be reduced by limiting sex to one uninfected partner who has no other partners (36 percent). In addition, 26 percent of women mention that abstaining from sexual intercourse will prevent the transmission of HIV. Among men, the most commonly cited prevention method also is limiting sex to one uninfected partner who has no other partners (49 percent). Knowledge of condoms and the role that they can play in preventing the transmission of AIDS is much more common among men than among women (45 percent versus 30 percent). Fewer men and women (42 percent and 27 percent, respectively) are also aware that both using condoms and limiting sex to one uninfected partner can reduce the risk of getting the AIDS virus. Young women age 15-24 are relatively more knowledgeable of the various modes of prevention than older women. For instance, 32 percent of women age 15-24 said that using condoms and limiting sex to one uninfected partner can reduce the risk of HIV infection, compared with only 17 percent of women age 40-49. The relationship between age and knowledge of transmission of HIV among men is less clear. Knowledge of HIV prevention methods among both women and men is highest among never-married respondents and lowest among those divorced, separated, or widowed. Knowledge of HIV prevention methods is consistently higher in urban than in rural areas among women and men. Education has a positive impact on a respondent’s knowledge of AIDS. For example, 62 percent of women with more than secondary education know that using condoms and limiting sexual intercourse to one uninfected partner can reduce a person’s chances of getting HIV, compared with 8 percent of women with no education. A similar pattern is seen for men, although the gap in knowledge by education is not as large as that observed for women. Similarly, women and men living in households in the higher wealth quintiles are more likely than those in the lower wealth quintiles to be aware of ways to prevent HIV transmission. 184 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 14.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, by having one sex partner who is not infected and has no other partners, and by abstaining from sexual intercourse, by background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Percentage who say that HIV can be prevented by Number of women Percentage who say that HIV can be prevented by Number of men Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Abstaining from sexual intercourse Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Abstaining from sexual intercourse Age 15-24 36.0 42.7 32.2 31.1 5,487 45.7 50.8 42.9 34.3 1,636 15-19 35.4 40.8 31.5 30.3 3,144 38.2 43.9 34.9 29.0 994 20-24 36.9 45.4 33.2 32.1 2,343 57.4 61.5 55.1 42.5 643 25-29 31.0 38.6 27.7 28.5 1,897 55.0 56.2 49.9 36.7 586 30-39 26.8 31.3 24.2 22.8 3,219 46.5 50.2 44.3 33.3 992 40-49 18.2 23.1 17.0 14.9 2,534 37.2 40.5 34.4 25.7 861 Marital status Never married 38.1 44.6 34.0 32.5 4,675 47.4 51.9 44.4 35.2 1,865 Ever had sex (51.4) (56.1) (48.2) (37.8) 40 76.0 76.7 72.1 48.2 540 Never had sex 38.0 44.5 33.9 32.4 4,635 35.8 41.8 33.1 29.9 1,325 Married/living together 25.2 31.1 22.9 22.2 7,906 44.1 47.4 41.2 30.7 2,158 Divorced/separated/ widowed 21.4 23.0 18.7 14.7 556 30.0 29.0 21.7 16.3 53 Residence Urban 44.4 55.3 39.6 41.9 3,439 67.0 73.7 62.4 55.4 1,102 Rural 24.4 28.6 22.1 19.8 9,698 37.4 40.2 35.0 24.1 2,974 District Aileu 31.1 34.3 30.0 27.1 554 39.6 44.9 38.0 5.0 181 Ainaro 14.8 17.2 11.4 16.6 619 18.6 23.6 12.4 3.1 217 Baucau 35.7 50.2 35.3 10.4 1,408 14.7 22.4 10.7 6.0 415 Bobonaro 24.6 26.0 18.1 23.0 1,262 44.4 47.6 40.5 46.9 357 Covalima 36.6 40.4 33.6 18.6 781 71.7 72.2 67.8 70.0 236 Dili 46.9 62.6 42.0 46.5 2,466 73.0 81.4 67.6 59.5 797 Ermera 13.5 13.7 13.5 13.5 1,542 20.6 20.0 20.0 20.2 491 Lautem 26.5 30.3 23.2 24.8 864 51.6 55.9 51.0 42.0 308 Liquiçá 25.6 28.7 22.4 25.5 801 44.1 47.6 42.1 30.2 252 Manatuto 39.5 41.5 32.9 42.6 603 97.6 98.9 97.6 1.1 190 Manufahi 27.2 31.9 25.6 28.9 470 45.0 44.6 44.2 42.0 137 Oecussi 23.6 24.7 22.1 24.1 884 42.8 45.4 42.1 42.0 235 Viqueque 17.3 18.0 15.8 16.6 882 19.6 17.9 15.5 6.8 260 Education No education 8.9 10.1 8.0 6.2 3,854 15.8 15.9 13.1 7.8 791 Primary 18.7 21.5 17.0 14.7 3,005 30.4 34.0 28.4 21.1 1,046 Secondary 46.0 56.0 41.2 41.2 5,829 59.6 65.2 56.0 44.0 2,009 More than secondary 67.4 83.1 61.8 61.5 449 92.2 93.1 88.1 70.1 230 Wealth quintile Lowest 14.7 15.7 13.3 11.1 2,314 27.0 27.9 24.5 17.2 728 Second 18.9 21.7 17.5 13.9 2,468 31.2 33.6 28.0 21.3 781 Middle 24.0 27.9 21.4 20.0 2,590 39.8 43.1 38.0 25.7 786 Fourth 34.7 40.3 31.0 29.4 2,687 51.5 57.0 49.1 38.9 849 Highest 49.7 63.9 44.7 47.2 3,077 71.1 77.1 66.2 54.2 932 Total 15-49 29.6 35.6 26.7 25.6 13,137 45.4 49.2 42.4 32.6 4,076 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 14.1.3 Comprehensive Knowledge of HIV Transmission The 2009-10 TLDHS also included questions to assess the prevalence of common misconceptions about AIDS and HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have the virus that causes AIDS, whether a person can get AIDS from mosquito bites, by sharing food with a person who has AIDS, or by sharing clothes with a person who has AIDS. The data presented in Tables 14.3.1 and 14.3.2 indicate that many Timorese adults lack accurate knowledge about the ways in which HIV can and cannot be transmitted, with women being much less knowledgeable than men. Only 33 percent of women and 46 percent of men know that a healthy-looking person can have HIV. One in four women and two in five men know that HIV cannot be transmitted by mosquito bites, or that a person cannot become infected by sharing food with a HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 185 person who has AIDS or by sharing clothes with a person who has HIV. About twice as many men as women (28 percent and 15 percent, respectively) say that a healthy looking person can have AIDS and reject the two most common local misconceptions (that HIV can be transmitted by mosquito bites and by sharing food with a person who has AIDS). Table 14.3.1 Comprehensive knowledge about AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of women A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites A person cannot become infected by sharing food with a person who has AIDS AIDS cannot be transmitted by sharing clothes with a person who has AIDS Age 15-24 39.4 31.3 30.0 30.2 17.9 12.2 5,487 15-19 38.5 29.7 29.1 29.3 16.9 11.2 3,144 20-24 40.5 33.4 31.3 31.3 19.3 13.5 2,343 25-29 36.5 25.0 24.9 25.5 14.3 11.5 1,897 30-39 30.6 21.0 22.6 21.5 13.8 10.8 3,219 40-49 20.7 13.8 14.6 14.1 8.1 6.2 2,534 Marital status Never married 42.1 33.0 31.7 31.8 18.9 13.0 4,675 Ever had sex (41.9) (27.1) (40.5) (25.7) (9.0) (5.0) 40 Never had sex 42.1 33.0 31.6 31.8 18.9 13.1 4,635 Married/living together 28.9 20.3 20.9 20.5 12.4 9.5 7,906 Divorced/separated/ widowed 20.2 12.1 15.1 15.1 7.5 6.0 556 Residence Urban 52.0 35.4 36.8 34.7 18.0 14.0 3,439 Rural 26.5 20.6 20.1 20.5 13.2 9.4 9,698 District Aileu 23.9 21.4 22.5 23.9 10.2 8.4 554 Ainaro 20.4 11.4 10.9 11.1 5.2 3.2 619 Baucau 51.0 45.8 42.4 43.6 35.7 23.5 1,408 Bobonaro 26.4 20.6 21.9 21.2 10.4 5.3 1,262 Covalima 31.3 25.0 26.1 24.6 13.2 11.1 781 Dili 59.9 36.3 39.7 35.0 17.3 13.8 2,466 Ermera 12.7 7.3 6.2 6.3 5.2 5.2 1,542 Lautem 24.0 23.0 23.7 26.1 13.2 11.1 864 Liquiçá 24.9 16.9 18.3 19.8 11.3 8.1 801 Manatuto 39.7 30.2 25.0 27.0 15.2 8.9 603 Manufahi 26.9 26.5 28.6 31.2 19.7 16.5 470 Oecussi 19.1 9.6 6.7 8.8 2.8 2.7 884 Viqueque 21.9 21.6 20.4 20.5 17.7 11.5 882 Education No education 9.2 6.9 7.4 6.9 4.4 3.5 3,854 Primary 19.7 13.1 13.8 13.6 7.8 5.9 3,005 Secondary 52.4 39.3 38.4 38.3 22.5 15.9 5,829 More than secondary 81.2 58.7 63.4 61.8 41.8 33.9 449 Wealth quintile Lowest 15.0 11.4 11.6 11.4 7.7 5.6 2,314 Second 19.9 16.5 16.0 17.1 11.1 8.7 2,468 Middle 25.3 20.3 19.7 19.8 12.0 8.3 2,590 Fourth 37.2 27.6 27.2 27.2 16.3 11.8 2,687 Highest 60.7 41.4 42.8 40.8 22.9 16.7 3,077 Total 15-49 33.2 24.5 24.5 24.3 14.5 10.6 13,137 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Two most common local misconceptions: AIDS can be transmitted by mosquito bites and by sharing food with a person with HIV 2 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 186 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 14.3.2 Comprehensive knowledge about AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of respondents who say that: Percentage who say that a healthy looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of men A healthy- looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites A person cannot become infected by sharing food with a person who has AIDS AIDS cannot be transmitted by sharing clothes with a person who has AIDS Age 15-24 45.3 43.0 41.8 44.1 28.4 19.7 1,636 15-19 38.1 38.0 37.8 40.8 23.7 14.7 994 20-24 56.3 50.7 47.8 49.3 35.6 27.4 643 25-29 57.2 48.2 51.5 52.2 33.9 23.7 586 30-39 47.7 43.7 43.6 44.8 30.3 21.7 992 40-49 36.3 33.3 34.4 34.9 22.7 16.4 861 Marital status Never married 46.7 44.0 43.4 45.6 29.1 20.8 1,865 Ever had sex 63.2 56.7 54.9 57.2 36.3 33.1 540 Never had sex 40.0 38.8 38.7 40.9 26.2 15.8 1,325 Married/living together 45.3 40.3 41.2 42.0 28.0 19.6 2,158 Divorced/separated/ widowed 23.8 33.4 28.0 29.3 19.4 10.5 53 Residence Urban 65.1 58.4 64.7 65.3 41.5 34.2 1,102 Rural 38.5 35.8 33.7 35.4 23.6 14.8 2,974 District Aileu 43.9 20.4 23.6 23.3 16.9 14.9 181 Ainaro 36.6 35.8 32.1 33.2 30.8 5.7 217 Baucau 60.4 56.3 53.5 54.5 50.3 6.1 415 Bobonaro 41.5 44.8 44.7 45.1 31.1 26.4 357 Covalima 11.5 44.8 49.1 55.4 6.2 5.8 236 Dili 73.3 65.3 73.3 74.4 47.2 40.4 797 Ermera 18.5 12.6 3.4 6.4 2.4 1.9 491 Lautem 36.6 32.2 41.5 43.8 19.4 18.9 308 Liquiçá 42.2 34.5 31.6 34.8 23.5 22.0 252 Manatuto 98.3 90.0 57.2 72.0 56.1 55.5 190 Manufahi 44.2 42.8 44.2 43.8 42.4 42.4 137 Oecussi 41.9 14.0 27.1 15.4 10.7 5.4 235 Viqueque 14.5 24.0 24.2 23.4 11.7 9.0 260 Education No education 14.9 11.9 10.4 10.4 4.8 2.6 791 Primary 30.4 26.5 25.9 27.6 14.9 9.6 1,046 Secondary 61.4 57.3 58.2 60.0 41.0 28.3 2,009 More than secondary 83.2 80.0 82.9 85.5 61.6 55.3 230 Wealth quintile Lowest 22.2 22.6 22.8 22.4 13.2 8.6 728 Second 32.6 29.1 27.8 29.9 18.4 9.9 781 Middle 40.0 36.3 34.8 37.2 24.3 16.3 786 Fourth 51.9 46.9 47.3 49.3 30.5 20.9 849 Highest 74.1 67.8 70.4 71.3 50.3 39.7 932 Total 15-49 45.7 41.9 42.0 43.5 28.4 20.0 4,076 1 Two most common local misconceptions: AIDS can be transmitted by mosquito bites and by sharing food with a person with HIV 2 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. Tables 14.3.1 and 14.3.2 also provide an assessment of the level of comprehensive knowledge of HIV prevention and transmission. Comprehensive knowledge is defined as knowing that both consistent condom use and limiting sexual partners to one uninfected person are HIV prevention methods; being aware that a healthy-looking person can have HIV; and rejecting the two most common local misconceptions—that HIV can be transmitted by mosquito bites or by sharing food with someone who has AIDS. According to the 2009-10 TLDHS results, 11 percent of women and 20 percent of men age 15-49 in Timor-Leste have comprehensive knowledge about AIDS. Tables 14.3.1 and 14.3.2 document considerable variation in comprehensive knowledge by respondents’ background characteristics. Comprehensive knowledge about AIDS decreases with age among both women and men. Comprehensive knowledge is higher among never-married women and men than among ever-married women and men. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 187 Comprehensive knowledge about AIDS is also higher among urban than rural residents, presumably because of better access to information through the mass media in urban than in rural areas. Comprehensive knowledge is positively related to education and wealth, increasing from 4 percent and 3 percent among women and men with no education, to 34 percent and 55 percent among women and men with more than secondary education. A similar pattern is observed with regard to comprehensive knowledge and wealth for both women and men. 14.2 ATTITUDES TOWARD PEOPLE LIVING WITH HIV/AIDS Knowledge and beliefs about HIV infection affect how people treat those they know to be living with HIV or AIDS. In the 2009-10 TLDHS, a number of questions were posed to respondents to measure their attitudes towards people living with HIV or AIDS (PLHA), including questions about their willingness to buy vegetables from an infected shopkeeper, to let others know the HIV status of family members, and to take care of relatives who have HIV in their own household. They were also asked whether an HIV-positive female teacher who is not sick should be allowed to continue teaching. Tables 14.4.1 and 14.4.2 show the percentages who express positive attitudes towards people living with HIV among women and men who have heard about the virus, by background characteristics. Table 14.4.1 Accepting attitudes toward those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with AIDS, by background characteristics, Timor-Leste 2009-10 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 the AIDS virus in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 54.7 35.1 45.9 82.5 10.8 2,929 15-19 53.2 34.5 44.9 81.0 9.8 1,629 20-24 56.5 35.8 47.2 84.3 12.0 1,299 25-29 56.4 35.0 45.3 84.7 10.3 900 30-39 56.0 33.1 42.7 85.7 12.2 1,229 40-49 53.0 31.7 38.3 87.6 11.4 690 Marital status Never married 54.3 35.2 45.1 82.5 10.6 2,634 Ever had sex * * * * * 24 Never had sex 54.4 35.4 45.3 82.5 10.7 2,610 Married/living together 55.4 33.0 43.6 85.8 11.4 2,952 Divorced/separated/ widowed 59.2 40.6 41.5 79.7 12.4 162 Residence Urban 60.1 36.4 45.3 83.9 13.7 2,410 Rural 51.4 32.6 43.4 84.3 9.2 3,338 District Aileu 56.7 38.9 56.0 94.7 16.6 201 Ainaro 68.8 21.6 45.8 76.1 4.0 178 Baucau 25.1 27.2 17.0 94.1 0.2 765 Bobonaro 45.1 48.7 42.7 68.6 9.0 499 Covalima 80.5 41.9 53.7 91.7 15.1 379 Dili 59.9 36.4 41.9 82.7 13.6 1,965 Ermera 48.4 17.0 14.6 89.5 0.5 212 Lautem 53.8 19.4 65.3 67.3 8.5 313 Liquiçá 59.1 40.0 55.6 79.1 15.3 272 Manatuto 61.9 18.9 69.6 89.1 6.9 314 Manufahi 28.7 39.6 49.8 84.5 7.2 171 Oecussi 71.0 36.6 44.2 89.6 19.6 244 Viqueque 75.7 44.4 76.5 92.1 31.1 236 Education No education 42.5 29.0 33.5 84.6 9.8 493 Primary 54.2 32.1 39.3 83.0 10.7 806 Secondary 55.8 34.6 46.2 83.7 10.7 4,013 More than secondary 63.7 40.5 47.1 89.3 16.6 436 Wealth quintile Lowest 51.0 27.2 41.3 86.0 8.4 465 Second 42.1 26.5 38.7 86.8 7.7 648 Middle 55.5 36.8 44.6 80.9 9.8 897 Fourth 55.2 35.3 46.2 83.2 11.4 1,314 Highest 58.9 36.1 45.1 84.7 12.8 2,425 Total 15-49 55.0 34.2 44.2 84.1 11.1 5,748 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 188 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 14.4.2 Accepting attitudes toward those living with HIV/AIDS: Men Among men age 15-49 who have heard of HIV/AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of men who: Percentage expressing acceptance attitudes on all four indicators Number of men who have heard of AIDS Are willing to care for a family member sick with AIDS in the respondent’s home Would buy fresh vegetables from shopkeeper who has the AIDS virus Say that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Age 15-24 25.4 22.6 28.6 85.9 2.7 1,024 15-19 24.9 21.5 26.8 83.8 2.2 564 20-24 26.1 24.0 30.7 88.5 3.2 460 25-29 27.7 27.0 31.1 87.2 4.1 414 30-39 25.2 18.3 26.9 88.3 3.8 611 40-49 29.0 20.0 24.3 89.1 3.7 425 Marital status Never married 25.4 22.3 29.0 86.9 2.8 1,198 Ever had sex 33.8 19.0 35.2 92.4 5.3 453 Never had sex 20.3 24.3 25.2 83.5 1.3 745 Married/living together 27.3 21.2 26.4 87.6 3.9 1,254 Divorced/separated/ widowed * * * * * 22 Residence Urban 20.1 14.8 25.3 83.3 2.4 938 Rural 30.2 26.2 29.4 89.7 3.9 1,536 District Aileu 60.0 49.0 44.7 84.5 30.1 96 Ainaro 15.5 54.5 58.2 98.6 4.8 101 Baucau 2.6 17.4 3.8 97.4 0.0 267 Bobonaro 23.5 37.8 18.3 69.3 1.4 220 Covalima 0.3 5.4 3.9 99.5 0.0 183 Dili 14.6 11.5 22.0 83.6 2.1 740 Ermera 3.5 60.7 6.4 92.9 0.0 102 Lautem 12.9 17.4 36.7 95.6 1.5 179 Liquiçá 37.5 33.1 42.9 92.5 2.3 133 Manatuto 96.3 4.0 60.1 99.7 3.7 187 Manufahi 86.5 49.4 73.9 11.7 0.0 63 Oecussi 77.3 29.1 36.5 94.6 15.0 120 Viqueque 8.5 3.9 41.5 84.4 0.0 83 Education No education 36.9 15.6 25.2 78.7 1.5 175 Primary 33.5 19.1 24.6 87.7 2.5 458 Secondary 23.6 23.3 27.8 87.9 3.5 1,611 More than secondary 23.2 21.8 36.4 88.7 5.4 230 Wealth quintile Lowest 35.1 17.6 26.2 89.8 2.6 257 Second 26.2 30.6 29.7 86.8 4.6 346 Middle 29.4 25.5 29.2 91.6 3.3 430 Fourth 28.0 25.2 28.5 84.9 2.6 583 Highest 21.2 15.4 26.4 86.2 3.6 858 Total 15-49 26.4 21.8 27.8 87.3 3.4 2,474 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Among those who have heard of AIDS, twice as many women as men (55 percent and 26 percent, respectively) state that they would be willing to care for a family member with AIDS in their home. Eighty-four percent of women and 87 percent of men say that they would not want to keep secret that a family member was infected with HIV, while 44 percent of women and 28 percent of men say that an HIV-positive female teacher should be allowed to continue teaching. A relatively lower proportion of women and men (34 percent and 22 percent, respectively) say they would buy fresh vegetables from a shopkeeper with AIDS. The percentage expressing accepting attitudes on all four measures is low: 11 percent among women and 3 percent among men. Stigma and attitudes associated with HIV and AIDS differ by respondents’ background characteristics. There are small differentials in the percentage expressing accepting attitudes toward those living with HIV/AIDS by age and marital status with one notable exception. Never-married men who have ever had sex are relatively more likely to express accepting attitudes towards people living with HIV or AIDS. Accepting attitudes are higher among women in urban areas than women in rural areas, but this trend is reversed among men. Exhibiting accepting attitudes towards people living with HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 189 HIV or AIDS on all four indicators ranges among women from a low of less than one percent in Baucau to a high of 31 percent in Viqueque, and among men from a low of 0 percent in Baucau, Covalima, Ermera, Manufahi, and Viqueque to a high of 30 percent among men in Aileu. Furthermore, women and men with more than secondary education and women living in the wealthiest households are also most likely to accept people living with HIV or AIDS. The relationship between wealth and acceptance among men is less clear. 14.3 RISKY BEHAVIORS The 2009-10 TLDHS included questions on respondents’ sexual partners during the 12 months preceding the survey. For male respondents, an additional question was asked about whether they paid for sex during the 12 months preceding the interview. Information on the use of condoms at the last sexual encounter with each partner in the last 12 months was collected from both women and men. Finally, sexually active women and men were asked about the total number of partners they had had during their lifetime. These questions are, of course, sensitive, and in interpreting the results in this section it is important to remember that respondents’ answers may be subject to some reporting bias. The discussion below focuses primarily on men because less than 1 percent of women reported having multiple sexual partners, and a separate analysis is not statistically meaningful. 14.3.1 Multiple Sexual Partners and Higher-risk Sexual Intercourse Table 14.5 presents information collected from men who had ever had intercourse about the number of sexual partners they had had during the 12-month period before the survey and the mean number of sexual partners that a man has had during his lifetime. Just over 1 percent of men age 15-49 reported having had two or more sexual partners during the 12 months prior to the survey, with men reporting a mean number of just under two partners in their lifetimes. Among men with two or more partners in the 12 months preceding the survey, 19 percent used a condom at last sex (data not presented). The differentials presented in Table 14.5 show that the percentage of men with two or more partners in the 12 months before the survey is higher among men age 25-29 than among younger and older men; higher among divorced, separated, or widowed men than among currently married or never married men; higher among urban than rural men; higher among highly educated men than among those with little or no education; and higher among men in the fourth and highest wealth quintiles. Due to the low number of men in the survey reporting multiple partners in the past 12 months, it is not possible to examine differentials in use of a condom at last sex among men with multiple partners. 190 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 14.5 Multiple sexual partners in the past 12 months: Men Percentage of men age 15-49 who had sexual intercourse with more than one sexual partner in the past 12 months; and the mean number of sexual partners during his lifetime for men who ever had sexual intercourse, by background characteristics, Timor-Leste 2009- 10 Background characteristic Among all men Among men who ever had sexual intercourse Percentage who had 2+ partners in the past 12 months Number of men Mean number of sexual partners in lifetime Number of men Age 15-24 0.9 1,636 1.8 442 15-19 0.3 994 1.8 98 20-24 1.9 643 1.8 344 25-29 2.5 586 2.0 453 30-39 1.4 992 1.8 866 40-49 1.6 861 1.8 752 Marital status Never married 1.8 1,865 2.4 515 Married/living together 1.0 2,158 1.7 1,950 Divorced/separated/ widowed 4.9 53 1.6 47 Residence Urban 2.2 1,102 2.4 712 Rural 1.1 2,974 1.6 1,801 District Aileu 6.2 181 1.4 125 Ainaro 0.3 217 1.3 108 Baucau 0.4 415 1.0 244 Bobonaro 0.4 357 1.0 173 Covalima 0.0 236 3.3 187 Dili 3.0 797 2.6 542 Ermera 0.4 491 1.6 158 Lautem 2.5 308 1.7 191 Liquiçá 0.0 252 1.6 179 Manatuto 0.4 190 1.3 170 Manufahi 0.4 137 1.2 81 Oecussi 1.1 235 2.5 187 Viqueque 1.9 260 1.1 168 Education No education 0.5 791 1.6 518 Primary 1.1 1,046 1.8 686 Secondary 1.6 2,009 1.9 1,111 More than secondary 3.8 230 2.6 197 Wealth quintile Lowest 1.4 728 1.7 452 Second 0.8 781 1.6 440 Middle 0.8 786 1.5 458 Fourth 1.5 849 1.9 532 Highest 2.4 932 2.4 631 Total 15-49 1.4 4,076 1.8 2,513 14.3.2 Paid Sex Paid sex is considered a high-risk sexual behavior. Male respondents in the 2009-10 TLDHS were asked whether they had paid money in exchange for sex in the past 12 months. Five percent of men reported that they had engaged in paid sex in the year before the survey (Table 14.6). Paid sex occurs most often among men age 20-24, divorced/separated/widowed men, urban men, men residing in Covalima, Manatuto and Dili, highly educated men, and men living in the wealthiest households. Among those who paid for sex, only 26 percent reported using a condom during their most recent encounter (data not shown). Only small numbers of men reported paying for sex, so an analysis of condom use among men who paid for sex by background characteristics is not statistically meaningful and is not shown in the report. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 191 Table 14.6 Payment for sexual intercourse: Men Percentage of men age 15-49 reporting payment for sexual intercourse in the past 12 months, by background characteristics, Timor-Leste 2009-10 Background characteristic Payment for sexual intercourse in the past 12 months Percentage who paid for sexual intercourse Number of men Age 15-24 6.1 1,636 15-19 3.0 994 20-24 10.7 643 25-29 8.5 586 30-39 5.2 992 40-49 2.0 861 Marital status Never married 9.3 1,865 Married/living together 1.8 2,158 Divorced/separated/ widowed 10.8 53 Residence Urban 10.3 1,102 Rural 3.5 2,974 District Aileu 1.0 181 Ainaro 1.6 217 Baucau 0.0 415 Bobonaro 0.0 357 Covalima 20.0 236 Dili 12.2 797 Ermera 3.4 491 Lautem 0.7 308 Liquiçá 4.9 252 Manatuto 15.0 190 Manufahi 0.0 137 Oecussi 1.7 235 Viqueque 1.4 260 Education No education 3.0 791 Primary 4.5 1,046 Secondary 5.8 2,009 More than secondary 13.5 230 Wealth quintile Lowest 2.6 728 Second 2.6 781 Middle 5.2 786 Fourth 4.7 849 Highest 10.4 932 Total 15-49 5.3 4,076 14.4 KNOWLEDGE OF HIV TESTING Knowledge of one’s HIV status helps HIV-negative individuals make specific decisions to reduce their risk and to increase safe sex practices so that they can remain disease-free. For those who are HIV infected, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. Testing of pregnant women is especially important to prevent mother-to-child transmission of HIV. Where migration is common, knowing one’s HIV status is especially important for curbing the spread of the infection and empowering women to seek preventive and curative measures to protect themselves and their children. The diagnosis of HIV infection benefits both the individual and the public in general. Advances in medical science have meant that having HIV need not necessarily be fatal, and with appropriate treatment, people with HIV can lead relatively normal lives. The capacity to ensure that all people diagnosed with HIV in Timor–Leste receive such treatment is now being established. Maximizing the diagnosis of HIV infection means that patterns of infection can be better monitored and interventions better targeted. The government of Timor-Leste is prioritizing the provision of 192 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior comprehensive voluntary counseling and testing (VCT) services at all levels of the health system. Because fear of discrimination and stigma is a major barrier to VCT access, confidentiality is of utmost importance (MOH, 2006). In the 2009-10 TLDHS, both male and female respondents were asked whether they know of a place where people can go to get tested for HIV. Table 14.7 shows that, among the adult population age 15-49, men (35 percent) are twice as likely as women (17 percent) to know where to go to be tested for HIV. Knowledge of a place to get an HIV test differs by respondents’ background characteristics. For instance, women and men in the oldest cohort are less likely to know of a place where they can get tested for HIV than their younger counterparts. Knowledge of HIV testing facilities is highest among urban women and men, among women who reside in Dili and men who reside in Manatuto (nearly all of whom are aware of a place to go to get tested), among men and women who have more than secondary education, and among respondents in the highest wealth quintile. Table 14.7 Knowledge of a place to get an HIV test Percentage of women and men age 15-49 who know where to get an HIV test, according to background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Percentage who know where to get an HIV test Number of women Percentage who know where to get an HIV test Number of men Age 15-24 19.9 5,487 33.2 1,636 15-19 18.0 3,144 27.3 994 20-24 22.3 2,343 42.4 643 25-29 19.7 1,897 43.0 586 30-39 16.4 3,219 36.0 992 40-49 10.1 2,534 30.2 861 Marital status Never married 21.4 4,675 34.5 1,865 Ever had sex (23.2) 40 52.3 540 Never had sex 21.4 4,635 27.3 1,325 Married/living together 14.9 7,906 35.2 2,158 Divorced/separated/ widowed 12.1 556 17.1 53 Residence Urban 29.5 3,439 38.3 1,102 Rural 12.7 9,698 33.3 2,974 District Aileu 22.9 554 18.4 181 Ainaro 13.2 619 29.6 217 Baucau 17.2 1,408 58.6 415 Bobonaro 10.5 1,262 28.8 357 Covalima 14.9 781 38.3 236 Dili 33.0 2,466 34.9 797 Ermera 6.3 1,542 18.0 491 Lautem 15.9 864 17.6 308 Liquiçá 9.3 801 37.5 252 Manatuto 21.9 603 98.0 190 Manufahi 19.4 470 22.4 137 Oecussi 7.7 884 48.7 235 Viqueque 15.2 882 12.6 260 Education No education 2.8 3,854 9.4 791 Primary 7.7 3,005 21.6 1,046 Secondary 28.5 5,829 47.0 2,009 More than secondary 56.1 449 72.3 230 Wealth quintile Lowest 6.5 2,314 21.5 728 Second 7.9 2,468 25.9 781 Middle 12.3 2,590 32.3 786 Fourth 19.7 2,687 41.5 849 Highest 34.2 3,077 48.0 932 Total 15-49 17.1 13,137 34.7 4,076 Note: Figures in parentheses are based on 25-49 unweighted cases. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 193 14.5 MALE CIRCUMCISION Male circumcision has been shown to be asso- ciated with lower transmission of STIs, including HIV (WHO and UNAIDS, 2007). To know the practice of male circumcision in Timor-Leste, men age 15-49 interviewed in the 2009-10 TLDHS were asked if they were circumcised. As seen in Table 14.8 male circumcision is not widespread in Timor-Leste, and only 6 percent of men have been circumcised. The practice is slightly more common among men age 25 and older, among men with little or no education, and among men in the lowest wealth quintile. The vast majority of circumcised men live in Oecussi. 14.6 REPORTS OF RECENT SEXUALLY TRANSMITTED INFECTIONS 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. The 2009-10 TLDHS asked respondents who had ever had sex whether they had had an STI in the past 12 months. They were also asked whether, in the past year, they had experienced a genital sore or ulcer, and whether they had any genital discharge. These symptoms are useful in identifying STIs in men. They are less easily interpreted in women because women are likely to experience more non-STI conditions of the reproductive tract that produce a genital discharge. In general, STIs are acquired through unprotected sexual intercourse and through the introduction of infected blood and blood products. STIs may also be transmitted from mother to fetus and from mother to neonate/infant during pregnancy and during the postpartum and breastfeeding periods (MOH, 2007). Table 14.9 shows that self-reported prevalence of STIs and STI symptoms is relatively low, with prevalence among women higher than among men. About 1 percent of women and men reported STI prevalence in the 12 months prior to the survey. It is likely that these figures, which are quite low, underestimate the actual prevalence of STIs among the sexually active population in Timor-Leste. Many STI symptoms are not easily recognized, and often STIs do not have any visible symptoms. Eight percent of women and 2 percent of men age 15-49 report having had a bad-smelling or abnormal genital discharge, 4 percent of women and 3 percent of men report a genital sore or ulcer, and twice as many women as men (8 percent and 4 percent, respectively) report having had an STI, genital discharge, or sore or ulcer in the past 12 months. Table 14.8 Male circumcision Percentage of men age 15-49 who report having been circumcised, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage circumcised Number of men Age 15-24 4.2 1,636 15-19 4.4 994 20-24 3.8 643 25-29 7.4 586 30-39 8.5 992 40-49 7.5 861 Residence Urban 6.6 1,102 Rural 6.3 2,974 District Aileu 2.5 181 Ainaro 1.3 217 Baucau 0.8 415 Bobonaro 2.6 357 Covalima 0.8 236 Dili 4.4 797 Ermera 0.6 491 Lautem 0.2 308 Liquiçá 0.8 252 Manatuto 0.7 190 Manufahi 0.0 137 Oecussi 83.0 235 Viqueque 0.9 260 Education No education 8.0 791 Primary 9.0 1,046 Secondary 4.5 2,009 More than secondary 5.2 230 Wealth quintile Lowest 13.0 728 Second 5.7 781 Middle 4.6 786 Fourth 4.7 849 Highest 4.8 932 Total 15-49 6.4 4,076 194 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 14.9 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Percentage of women who reported having in the past 12 months: Number of women who ever had sexual intercourse Percentage of men who reported having in the past 12 months: Number of men who ever had sexual intercourse STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/ genital discharge/ sore or ulcer STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/ genital discharge/ sore or ulcer Age 15-24 1.5 8.5 3.6 9.1 1,428 0.9 2.9 5.2 7.0 461 15-19 1.0 9.2 5.1 9.9 272 0.0 0.0 4.2 4.2 101 20-24 1.7 8.4 3.2 8.9 1,157 1.2 3.7 5.5 7.8 360 25-29 1.4 7.6 4.0 8.3 1,582 0.7 2.4 3.8 4.6 499 30-39 1.1 7.8 3.8 8.6 3,042 0.5 1.7 1.9 2.4 945 40-49 1.3 6.5 3.7 7.6 2,449 0.9 2.5 2.3 3.9 846 Marital status Never married (2.7) (12.9) (3.3) (12.9) 40 1.2 3.5 7.4 9.3 540 Married/living together 1.3 7.4 3.8 8.2 7,905 0.6 1.8 1.7 2.7 2,158 Divorced/separated/ widowed 1.4 8.2 4.1 9.3 556 0.0 7.0 5.9 7.0 53 Male circumcision Circumcised na na na na na 0.0 4.6 4.2 4.6 214 Not circumcised na na na na na 0.7 2.0 2.8 4.0 2,515 Residence Urban 2.9 6.4 2.9 8.2 2,180 1.4 4.2 5.4 7.5 774 Rural 0.7 7.9 4.1 8.3 6,322 0.4 1.5 2.0 2.7 1,977 District Aileu 2.1 8.1 4.2 8.9 324 0.0 0.0 0.0 0.0 127 Ainaro 0.7 2.8 1.2 3.7 406 0.5 2.7 1.2 3.3 127 Baucau 0.4 5.1 5.1 5.2 893 1.9 1.9 1.9 2.6 249 Bobonaro 0.0 2.6 0.7 2.7 801 0.0 0.0 0.0 0.0 173 Covalima 0.5 12.0 1.1 12.8 511 0.0 2.0 2.7 3.0 191 Dili 3.6 5.2 2.5 7.4 1,568 1.7 4.1 6.2 8.2 589 Ermera 0.3 2.2 0.7 2.2 952 0.0 1.0 0.5 1.0 308 Lautem 0.5 11.3 3.1 12.6 594 0.8 0.8 0.3 1.1 194 Liquiçá 0.6 6.4 1.6 7.0 498 1.3 9.2 7.9 12.1 183 Manatuto 1.0 11.3 2.8 11.9 372 0.0 1.9 8.6 9.8 171 Manufahi 6.0 41.5 33.2 41.9 331 0.7 0.7 0.7 0.7 82 Oecussi 0.6 13.0 7.2 13.6 647 0.0 0.5 0.0 0.5 188 Viqueque 0.1 1.4 1.2 1.9 605 0.0 0.0 0.4 0.4 168 Education No education 0.8 7.0 3.7 7.6 3,180 0.0 1.5 2.2 2.6 603 Primary 0.9 8.1 4.3 9.0 2,203 0.6 2.0 1.7 2.7 762 Secondary 2.1 8.0 3.7 9.0 2,863 1.0 3.0 4.1 5.5 1,176 More than secondary 1.3 3.3 1.3 4.4 256 1.9 0.9 3.1 4.9 210 Wealth quintile Lowest 0.5 9.0 4.9 9.5 1,601 0.0 1.3 1.1 2.0 482 Second 0.7 7.9 4.6 8.4 1,614 0.3 1.9 1.4 2.0 500 Middle 1.1 7.7 3.5 8.1 1,661 0.5 2.1 3.1 3.8 518 Fourth 0.9 7.5 3.0 7.8 1,675 0.8 1.8 2.9 3.6 581 Highest 2.9 5.9 3.0 7.9 1,950 1.6 3.9 5.4 7.7 670 Total 15-49 1.3 7.5 3.8 8.3 8,501 0.7 2.3 2.9 4.0 2,751 Note: Total includes 22 males with information missing on circumcision. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable Self-reported prevalence of STI or symptoms of STI among women vary minimally by age and marital status. But prevalence is distinctly higher among women residing in urban areas and in Manufahi. Prevalence is lowest among women with little to no education and among women in the lowest two wealth quintiles. Among men, prevalence is highest among the 20-24 age cohort, among never married men, circumcised men, those living in urban areas, those living in Baucau, those with more than secondary education, and those in the highest wealth quintile. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 195 In the 2009-10 TLDHS, women and men who reported an STI or STI symptoms in the past 12 months were asked about the advice or treatment they sought for it. Figure 14.1 shows that 44 percent of women and 29 percent of men sought no advice or treatment, while about 53 percent of women and 63 percent of men sought advice or treatment from clinics, hospitals, private doctors, or other health professionals. Figure 14.1 Women and Men Seeking Advice or Treatment for STIs 53 0 6 44 63 7 8 29 Clinic/hospital/ private doctor/ other health prof Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment 0 10 20 30 40 50 60 70 Percent Women Men Timor-Leste 2009-10 professional 14.7 PREVALENCE OF MEDICAL INJECTIONS Use of nonsterile injections in a health care setting can contribute to the transmission of bloodborne pathogens. To measure the potential risk of transmission of HIV associated with medical injections, respondents in the 2009-10 TLDHS were asked if they had received an injection in the past 12 months, and if so, whether their last injection was given with a syringe from a new, unopened package. It should be noted that medical injections can be self-administered (e.g., insulin for diabetes). These injections were not included in the calculation. Table 14.10 shows that 22 percent of women and 6 percent of men age 15-49 received a medical injection in the past 12 months. The average number of injections was less than 1 among women and men. The potential risk of transmission of HIV associated with such injections is very low because the vast majority of respondents—98 percent of women and men who received medical injections—reported that the syringe and needle were taken from a new, unopened package. These figures are encouraging for the Timorese population and for the Ministry of Health, because contaminated needles can be one means by which HIV is transmitted. 196 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 14.10 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the last 12 months, the average number of medical injections per person in the last 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Timor-Leste 2009-10 Background characteristic Women Men Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of men For last injection, syringe and needle taken from a new, unopened package Number of respondents receiving medical injections in the last 12 months Age 15-24 22.5 0.5 5,487 98.5 1,233 5.1 0.1 1,636 100.0 83 15-19 22.6 0.5 3,144 98.7 712 4.0 0.1 994 (100.0) 40 20-24 22.3 0.5 2,343 98.2 522 6.7 0.2 643 100.0 43 25-29 20.9 0.8 1,897 99.1 396 6.8 0.2 586 (100.0) 40 30-39 22.7 1.0 3,219 97.5 729 7.5 0.2 992 95.3 74 40-49 19.7 1.0 2,534 97.6 499 6.6 0.2 861 96.6 57 Residence Urban 18.4 0.4 3,439 98.6 633 9.5 0.3 1,102 98.1 104 Rural 22.9 0.9 9,698 98.1 2,225 5.0 0.1 2,974 97.7 150 District Aileu 53.6 1.0 554 98.9 297 8.2 0.1 181 * 15 Ainaro 14.8 0.3 619 99.4 92 1.5 0.0 217 * 3 Baucau 16.9 0.3 1,408 93.8 239 0.8 0.0 415 * 3 Bobonaro 5.5 2.9 1,262 96.1 69 0.0 0.0 357 * 0 Covalima 18.7 0.5 781 98.8 146 11.4 0.3 236 (100.0) 27 Dili 12.8 0.3 2,466 97.8 315 11.2 0.3 797 (96.2) 89 Ermera 3.0 0.1 1,542 (95.3) 45 1.2 0.0 491 * 6 Lautem 15.6 0.3 864 98.1 135 4.9 0.4 308 * 15 Liquiçá 60.3 1.6 801 99.1 483 4.6 0.1 252 * 12 Manatuto 35.0 1.0 603 98.8 211 30.9 0.9 190 99.1 59 Manufahi 30.1 0.7 470 100.0 142 3.7 0.0 137 * 5 Oecussi 68.0 1.7 884 98.5 601 8.6 0.2 235 * 20 Viqueque 9.3 0.2 882 97.5 82 0.0 0.0 260 * 0 Education No education 20.2 0.8 3,854 97.4 780 3.1 0.1 791 (93.8) 25 Primary 24.1 1.0 3,005 98.4 725 5.4 0.1 1,046 100.0 56 Secondary 22.0 0.6 5,829 98.4 1,284 7.2 0.2 2,009 98.7 145 More than secondary 15.3 0.4 449 100.0 69 11.9 0.3 230 * 27 Wealth quintile Lowest 27.4 0.7 2,314 98.3 635 3.6 0.1 728 (96.4) 26 Second 21.8 1.1 2,468 98.9 538 3.6 0.1 781 (100.0) 28 Middle 20.6 0.7 2,590 98.0 534 4.9 0.1 786 100.0 39 Fourth 21.7 0.9 2,687 97.6 584 6.2 0.2 849 98.9 53 Highest 18.4 0.6 3,077 98.0 567 11.6 0.4 932 96.4 108 Total 15-49 21.8 0.8 13,137 98.2 2,858 6.2 0.2 4,076 97.9 254 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist or other health worker. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. There are small variations by age in the likelihood of receiving an injection in the past 12 months among women, but among men it is highest among those age 30-39 (8 percent) and lowest among those age 15-19 (4 percent). The likelihood of receiving an injection in the past 12 months is higher among rural than urban women, but the reverse is true for men. It is highest among women with primary education and among women in the lowest wealth quintile, but highest among men with more than secondary education and men in the highest wealth quintile. Use of injections is highest among women residing in Oecussi and men in Manatuto. Respondents who had received an injection in the past 12 months were asked where they obtained their last injection. About two in three women (64 percent) and four in five men (83 percent) age 15-49 received their last medical injection from a public sector facility; 5 percent of women and 9 percent of men received their last injection from a private medical facility (Figure 14.2). Within the public sector, women are most likely to obtain their last medical injection at community health centers, while men are most likely to receive theirs from government hospitals. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 197 Figure 14.2 Source of Last Medical Injection 64 17 26 19 3 5 4 1 11 14 7 83 38 30 16 0 9 7 1 7 0 1 To tal pu bli c m ed ica l Go ve rnm en t h os pit al Co mm un ity he alt h c en ter He alt h p os t Ot he r p ub lic To tal pr iva te me dic al Pr iva te ho sp ita l/c lin ic/ do cto r Ot he r p riv ate m ed ica l Ho me Sc ho ol Ot he r 0 20 40 60 80 100 Percent Women Men Timor-Leste 2009-10 14.8 HIV/AIDS-RELATED KNOWLEDGE AND BEHAVIOR AMONG YOUTH Knowledge of HIV/AIDS issues and related sexual behavior among youth age 15-24 is of particular interest because the period between sexual initiation and marriage is for many young people a time of sexual experimentation that may involve high-risk behaviors. This section considers a number of issues that relate to both transmission and prevention of HIV/AIDS among youth, including the extent to which youth have comprehensive knowledge of HIV/AIDS transmission and prevention modes and knowledge of a source where they can obtain condoms. Issues such as abstinence, age at sexual debut, and condom use are also covered in this section. HIV programming for young people is complex. Social norms place value on sexual abstinence in Timor-Leste. To reinforce these norms, HIV programs targeted at youth must include a strong emphasis on the development of life skills. Youths, especially young women, need skills in assertiveness and negotiation if they are to take actions based on informed decision-making. It is important to educate young people regarding condom use to prevent the risk of HIV and other STI transmission (MOH, 2006). 14.8.1 Comprehensive Knowledge about HIV/AIDS and Source for Condoms Knowledge of how HIV is transmitted is crucial for enabling young people to avoid HIV infection. Table 14.11 shows that only 12 percent of women and 20 percent of men age 15-24 have comprehensive knowledge about HIV/AIDS. The level of comprehensive knowledge about HIV/ AIDS does not vary greatly by marital status within the male population. Among young women, comprehensive knowledge is higher among those who have never been married than among those ever-married. Comprehensive knowledge increases with age, as both men and women age 20-24 have a higher level of comprehensive knowledge of HIV compared to those age 15-19. Not surprisingly, comprehensive knowledge is higher among urban women (14 percent) than rural women (12 percent) and is twice as high among urban men as among rural men (34 percent and 15 percent, respectively). One in four young women in Baucau has comprehensive knowledge compared with less than 3 percent of young women in Ainaro. Comprehensive knowledge is relatively higher among young men in Manatuto (62 percent). Comprehensive knowledge generally rises with education and wealth quintile among both women and men. 198 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Because of the important role that condoms play in preventing the transmission of HIV, respondents were asked whether they know of a source of condoms. Only responses about “formal” sources were counted, that is, sources other than friends, family members, and home. Table 14.11 Comprehensive knowledge about AIDS and of a source of condoms among youth Percentage of young women and young men age 15-24 with comprehensive knowledge about AIDS and percentage with knowledge of a source of condoms, by background characteristics, Timor-Leste 2009-10 Background characteristic Women age 15-24 Men age 15-24 Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of women Percentage with comprehensive knowledge of AIDS1 Percentage who know a condom source2 Number of men Age 15-19 11.2 10.6 3,144 14.7 26.0 994 15-17 9.8 9.1 1,980 13.1 20.9 626 18-19 13.7 13.2 1,164 17.3 34.8 367 20-24 13.5 15.4 2,343 27.4 41.8 643 20-22 14.2 14.5 1,476 28.3 41.6 411 23-24 12.4 16.9 867 25.8 42.0 232 Marital status Never married 13.4 13.1 4,081 19.7 32.1 1,504 Ever had sex (8.8) (16.6) 23 33.6 68.8 329 Never had sex 13.4 13.1 4,058 15.8 21.9 1,175 Ever married 8.7 11.3 1,406 19.4 33.2 132 Residence Urban 14.0 18.2 1,456 33.5 37.3 431 Rural 11.6 10.7 4,031 14.7 30.4 1,205 District Aileu 10.1 9.6 270 13.8 22.4 76 Ainaro 2.5 9.0 250 3.1 33.1 92 Baucau 24.8 6.9 584 2.1 4.8 151 Bobonaro 6.6 10.6 567 24.1 31.3 161 Covalima 13.8 26.5 341 4.9 73.5 96 Dili 12.6 15.5 1,018 40.0 34.3 296 Ermera 9.3 1.6 673 2.6 22.1 244 Lautem 13.5 28.4 343 19.0 29.4 134 Liquiçá 10.5 10.5 351 24.9 29.0 103 Manatuto 12.0 25.3 267 61.8 98.0 80 Manufahi 20.9 20.6 195 46.4 16.2 53 Oecussi 4.2 10.9 300 5.8 38.3 63 Viqueque 14.5 3.7 328 9.3 17.6 86 Education No education 3.6 2.7 736 2.7 11.0 192 Primary 4.4 4.5 1,112 6.8 17.0 336 Secondary 15.6 16.3 3,475 25.6 39.6 1,073 More than secondary 31.0 36.2 164 (55.6) (67.8) 34 Wealth quintile Lowest 8.9 8.1 879 11.4 24.2 289 Second 10.8 6.9 1,031 11.1 25.8 317 Middle 9.7 10.0 1,134 17.8 30.0 327 Fourth 14.5 16.4 1,204 20.8 40.9 351 Highest 15.8 19.5 1,239 34.6 38.0 352 Total 12.2 12.7 5,487 19.7 32.2 1,636 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. The components of comprehensive knowledge are presented in Tables 14.2, 14.3.1, and 14.3.2. 2 For this table, the following responses are not considered sources for condoms: friends, family members, and home. As shown in Table 14.11, young men are more than twice as likely as young women to know where to obtain a condom (32 percent compared with 13 percent). Knowledge of a condom source among youth rises with age, is higher in urban than in rural areas, and varies positively with education and wealth. Young women in Lautem and young men in Manatuto are more likely than their counterparts to know of a source of condoms. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 199 14.8.2 Age at First Sex and Condom Use at First Sexual Intercourse Information from the 2009-10 TLDHS can be used to examine several important issues relating to the initiation of sexual activity among youth, including age at first sex and condom use at first sexual intercourse. Table 14.12 shows the proportions of women and men in the 15-24 age cohort who had sex before age 15 and before age 18. Two percent of young women and less than one percent of young men had sex by age 15, while 15 percent of young women and 10 percent of young men had sex by age 18. The female-male difference in the age at first sexual debut is primarily due to the earlier age at marriage of women. Table 14.12 Age at first sexual intercourse among youth Percentage of young women and of young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and of young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Timor-Leste 2009-10 Background characteristic Women age 15-24 Women age 18-24 Men age 15-24 Men 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 Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 1.1 3,144 na na 0.8 994 na na 15-17 0.9 1,980 na na 1.0 626 na na 18-19 1.5 1,164 12.4 1,164 0.6 367 12.4 367 20-24 2.7 2,343 16.8 2,343 0.1 643 9.2 643 20-22 1.9 1,476 15.9 1,476 0.1 411 10.5 411 23-24 4.2 867 18.4 867 0.0 232 6.9 232 Marital status Never married 0.0 4,081 0.4 2,161 0.6 1,504 9.5 878 Ever married 6.9 1,406 39.4 1,347 0.0 132 16.3 132 Knows condom source1 Yes 1.5 694 11.3 515 1.0 527 19.6 396 No 1.8 4,793 16.0 2,992 0.3 1,109 4.4 614 Residence Urban 1.9 1,456 11.7 1,015 0.7 431 11.0 286 Rural 1.7 4,031 16.9 2,492 0.5 1,205 10.1 724 District Aileu 1.6 270 13.9 158 0.8 76 7.1 54 Ainaro 1.0 250 17.0 157 0.0 92 4.2 46 Baucau 1.1 584 15.2 356 0.0 151 1.8 90 Bobonaro 3.2 567 16.9 368 0.0 161 1.4 95 Covalima 2.4 341 16.0 198 4.9 96 42.8 58 Dili 2.3 1,018 10.8 737 0.0 296 8.8 210 Ermera 0.3 673 13.8 415 0.2 244 4.9 156 Lautem 2.0 343 21.5 200 0.0 134 11.2 65 Liquiçá 1.2 351 13.7 231 2.2 103 21.3 65 Manatuto 1.2 267 15.2 166 0.7 80 24.8 48 Manufahi 1.5 195 14.4 135 0.0 53 3.5 33 Oecussi 3.1 300 26.6 192 0.0 63 (22.6) 37 Viqueque 2.2 328 17.7 195 0.0 86 5.0 53 Education No education 3.2 736 21.1 519 0.0 192 7.9 122 Primary 4.1 1,112 30.9 697 0.5 336 10.9 181 Secondary 0.9 3,475 10.0 2,130 0.6 1,073 10.7 674 More than secondary 0.0 164 0.6 162 0.0 34 (9.2) 33 Wealth quintile Lowest 2.6 879 21.8 520 0.9 289 9.2 161 Second 1.7 1,031 16.1 649 0.3 317 8.7 190 Middle 1.6 1,134 18.6 716 0.4 327 9.3 205 Fourth 2.3 1,204 13.4 807 0.3 351 12.5 236 Highest 1.0 1,239 9.8 815 0.9 352 11.5 218 Total 1.8 5,487 15.3 3,507 0.5 1,636 10.4 1,010 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 200 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Looking at the age patterns for young women, the proportion of women reporting that they had sex before age 15 and 18 are lower among those under age 20 than among those above age 20. Lower percentages of women age 18-19 had initiated sex before age 18 than women age 20-24. This likely reflects the effect of rising age at marriage, because a negligible proportion of never-married young women report that they had sex by age 15 or by age 18. There are obvious differences in age at first sexual intercourse among youth by district, education, and wealth quintile. For example, 4 percent of young women with primary education had first sexual intercourse before the age of 15, and about 31 percent had initiated sexual intercourse before the age of 18. On the other hand, less than 1 percent of young men with primary and secondary education had sexual intercourse before the age of 15, and 11 percent before age 18. Table 14.13 Condom use at first sexual intercourse among youth Among young women and young men age 15-24 who have ever had sexual intercourse, percentage who used a condom the first time they had sexual intercourse, by background characteristics, Timor-Leste 2009-10 Background characteristic Women age 15-24 Men age 15-24 Percentage who used a condom at first sexual intercourse Number of women who have ever had sexual intercourse Percentage who used a condom at first sexual intercourse Number of men who have ever had sexual intercourse Age 15-19 3.1 272 6.8 101 15-17 4.9 63 5.1 38 18-19 2.6 209 7.8 62 20-24 1.7 1,157 10.4 360 20-22 1.4 613 9.4 204 23-24 2.0 544 11.6 156 Marital status Never married (4.9) 23 11.2 329 Ever married 1.9 1,406 5.4 132 Knows condom source1 Yes 3.2 162 14.8 270 No 1.8 1,266 2.2 191 Residence Urban 1.6 342 12.2 128 Rural 2.1 1,087 8.5 333 District Aileu 2.7 60 (17.8) 25 Ainaro 1.1 71 * 15 Baucau 3.7 142 * 22 Bobonaro 3.3 167 * 13 Covalima 0.0 86 8.3 51 Dili 1.7 232 14.3 98 Ermera 1.0 151 (15.1) 67 Lautem 1.7 91 (2.3) 23 Liquiçá 0.8 92 3.4 45 Manatuto 2.3 71 4.8 62 Manufahi 4.8 72 * 9 Oecussi 0.0 97 * 20 Viqueque 2.1 96 * 12 Education No education 1.8 264 3.4 44 Primary 3.2 419 2.8 87 Secondary 1.4 717 10.2 303 More than secondary 0.0 29 * 27 Wealth quintile Lowest 2.8 243 7.0 64 Second 2.5 295 5.1 75 Middle 1.1 324 11.1 94 Fourth 1.7 319 12.6 114 Highest 2.1 247 9.6 114 Total 2.0 1,428 9.6 461 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicated that a figure is based on fewer than 25 cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. HIV/AIDS-Related Knowledge, Attitudes, and Behavior | 201 To assess the extent of condom use at first sexual exposure, respondents age 15-24 who had ever had sex were asked whether they had used condoms the first time they had sex. Table 14.13 shows that only 2 percent of young women and 10 percent of young men had used condoms during their first sexual encounter. Never-married male youth were much more likely than ever-married male youth to have used a condom. Among male youth, higher educational attainment, greater wealth, and urban residence are related to the higher use of condoms during the first sexual intercourse. Differences among young women by background characteristics are small. 14.8.3 Recent Sexual Activity among Never-married Youth The period between age at first sex and age at first marriage is often a time of sexual experimentation, which can increase the risk of contracting HIV. Table 14.14 presents data on the percentage of never-mar- ried young men age 15-24 who had not yet engaged in sex and the percentage who had had sex in the 12 months preceding the sur- vey. Data for young women is not shown separately because almost all never-married women report not having had sex. The table shows that about 78 per- cent of never-married young men have never had sexual intercourse. As a consequence, among male youth, the proportions reporting sexual activity within the 12-month period before the survey are relatively low (about 15 percent). About 12 percent of never-married young men reporting recent sexual activity in the past 12 months said that they used a condom the last time they had sex (data not shown). Prema- rital sexual intercourse among young men is higher at older ages, in urban areas, in Manatuto, among highly educated youth, and among those in the wealthiest quintiles. 14.8.4 Drunkenness during Sex among Young Adults Engaging in sexual intercourse while under the influence of alcohol can impair judgment, compromise power relations, and increase risky sexual behavior. Respondents who had sex in the 12 months preceding the survey were asked (for each partner) if they or their partner drank alcohol the last time they had sexual intercourse with that partner, and whether they or their partner was drunk. As shown in Table 14.15, very few young people (less than 1 percent of women and men) reported being drunk during their last sexual intercourse and less than 1 percent each of young women and men said that either they or their partners were drunk. There is little variation by background characteristics of respondents. Table 14.14 Premarital sexual intercourse during premarital sexual intercourse among youth Among never-married men age 15-24, the percentage who have never had sexual intercourse and the percentage who had sexual intercourse in the past 12 months, by background characteristics, Timor-Leste 2009- 10 Background characteristic Percentage who have never had sexual intercourse Men Percentage who had sexual intercourse in the past 12 months Number of never- married men Age 15-19 90.2 7.1 990 15-17 93.9 4.2 626 18-19 83.8 12.1 364 20-24 54.9 29.5 515 20-22 58.8 27.0 352 23-24 46.6 34.8 162 Knows condom source1 Yes 53.2 35.6 484 No 90.0 4.9 1,021 Residence Urban 75.3 17.4 402 Rural 79.2 13.8 1,102 District Aileu 71.1 10.0 71 Ainaro 89.3 4.9 87 Baucau 97.6 1.2 132 Bobonaro 100.0 0.0 148 Covalima 49.7 40.0 91 Dili 72.9 20.6 272 Ermera 78.2 10.9 228 Lautem 85.7 9.2 130 Liquiçá 61.9 16.6 95 Manatuto 25.4 73.9 74 Manufahi 95.4 0.0 46 Oecussi 76.0 17.2 57 Viqueque 97.8 0.0 76 Education No education 86.4 11.2 171 Primary 84.3 10.8 296 Secondary 76.8 15.2 1,004 More than secondary (22.9) (53.5) 34 Wealth quintile Lowest 83.9 10.9 268 Second 84.6 9.6 286 Middle 78.8 15.1 296 Fourth 73.2 15.0 323 Highest 72.1 21.8 331 Total 78.1 14.8 1,504 1 For this table, the following responses are not considered a source for condoms: friends, family members and home. 202 | HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 14.15 Drunkenness during sexual intercourse among youth Among all young women and young men age 15-24, the percentage who had sexual intercourse in the past 12 months while being drunk and the percentage who had sexual intercourse in the past 12 months when drunk or with a partner who was drunk, by background characteristics, Timor-Leste 2009-10 Background characteristic Women age 15-24 Men age 15-24 Percentage who had sexual intercourse in the past 12 months when drunk Percentage who had sexual intercourse in the past 12 months when drunk or with a partner who was drunk Number of women Percentage who had sexual intercourse in the past 12 months when drunk Percentage who had sexual intercourse in the past 12 months when drunk or with a partner who was drunk Number of men Age 15-19 0.0 0.5 3,144 0.2 0.2 994 15-17 0.0 0.3 1,980 0.3 0.3 626 18-19 0.1 0.7 1,164 0.2 0.2 367 20-24 0.1 1.1 2,343 1.5 1.8 643 20-22 0.0 0.9 1,476 1.7 1.7 411 23-24 0.2 1.4 867 1.1 1.9 232 Marital status Never married 0.0 0.0 4,081 0.7 0.7 1,504 Ever married 0.2 2.8 1,406 0.6 2.1 132 Knows condom source1 Yes 0.0 0.8 694 1.6 1.6 527 No 0.1 0.7 4,793 0.3 0.5 1,109 Residence Urban 0.0 0.4 1,456 1.5 2.0 431 Rural 0.1 0.8 4,031 0.4 0.4 1,205 District Aileu 0.0 0.0 270 0.0 0.0 76 Ainaro 0.3 0.5 250 0.6 0.6 92 Baucau 0.3 0.6 584 0.0 0.0 151 Bobonaro 0.0 0.0 567 0.0 0.0 161 Covalima 0.0 0.3 341 0.0 0.0 96 Dili 0.0 0.2 1,018 1.3 2.0 296 Ermera 0.0 0.0 673 0.8 0.8 244 Lautem 0.0 0.3 343 0.0 0.0 134 Liquiçá 0.0 0.7 351 2.6 2.6 103 Manatuto 0.0 0.2 267 3.0 3.0 80 Manufahi 0.0 5.3 195 0.0 0.0 53 Oecussi 0.2 5.4 300 0.0 0.0 63 Viqueque 0.0 0.3 328 0.0 0.0 86 Education No education 0.1 1.3 736 0.8 0.8 192 Primary 0.2 1.4 1,112 0.4 0.4 336 Secondary 0.0 0.4 3,475 0.6 0.8 1,073 More than secondary 0.0 0.0 164 (5.7) (5.7) 34 Wealth quintile Lowest 0.1 1.8 879 0.2 0.2 289 Second 0.1 0.7 1,031 0.2 0.2 317 Middle 0.0 0.4 1,134 0.6 0.6 327 Fourth 0.1 0.6 1,204 0.2 0.2 351 Highest 0.0 0.3 1,239 2.1 2.7 352 Total 15-24 0.1 0.7 5,487 0.7 0.8 1,636 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Women’s Empowerment and Demographic and Health Outcomes | 203 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 This chapter highlights information on additional indicators of women’s empowerment, other than education and employment, and relates those indices to demographic and health outcomes. Timorese society assigns strict gender roles for men and women that lead to discriminatory practices against women. In daily life, cultural norms in Timor-Leste assign the dominant role to men (patriarchal system) in planning or making decisions where tradition and customary law favors men over women. As a consequence, women lag behind men in educational attainment, literacy, and exposure to mass media, which are critical to women’s empowerment and can exert considerable influence on their development and their ability to strengthen their position within the household and in society in general. In addition, the existing patriarchal system, which is prevalent in Southeast Asia, undermines women vis-à-vis men and subsumes their contribution to society even when they are educated or come from wealthy households (Kandiyoti, 1988). As women’s involvement in the nondomestic sphere lessens, they become more dependent on men economically, which exacerbates their inability to participate in the decisionmaking process in the household. On the other hand, women in economically poor households are driven outside the domestic sphere in search of employment to fulfill their economic needs, which could in turn give them some degree of independence and role in the decisionmaking process (Kandiyoti, 1988). As discussed in Chapter 3, data from the 2009-10 TLDHS show that men have higher educational attainment at all levels than women, that greater proportions of men than women are literate, and that men are more likely to be currently employed than women. In addition, the data show that women who belong to households in the highest wealth quintile are less likely to be employed. In this chapter, we examine other factors that empower women, such as women’s control over their own cash earnings and that of their husband’s, their participation in decisionmaking, their acceptance of wife beating, and their attitude toward the right of women to refuse sexual intercourse with their husband. These data are used in the estimation of empowerment indicators and the extent to which women’s empowerment influences health outcomes (such as their reproductive health care practices, contraceptive use, and unmet need). 15.1 EMPLOYMENT AND FORM OF EARNINGS Table 15.1 shows the percentage of currently married women and men age 15-49 who were employed in the 12 months before the survey and the percent distribution of the employed respondents by type of earnings they received (cash, in-kind, both, or neither). Forty-four percent of currently married women reported being employed in the past 12 months. The percentage of currently married women who were employed increases with age up to 56 percent for women age 45-49. Although employment is assumed to go hand in hand with payment for work, not all women receive earnings for the work they do, and even among women who do receive earnings, not all are paid in cash. Only about one in five employed women (19 percent) receives payment in cash, and less than 1 percent receive both cash and payment in-kind. One percent receive payment in-kind only. Four in five employed women do not receive any form of payment for their work. As discussed in Chapter 3, these women are mostly involved in agricultural work and are predominantly working for a family member or are self-employed. 204 | Women’s Empowerment and Demographic and Health Outcomes Table 15.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Timor-Leste 2009-10 Among currently married respondents: Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Age Percentage employed Number of respondents Cash only Cash and in-kind In-kind only Not paid Missing Total Number of respondents WOMEN 15-19 30.1 243 5.6 1.3 2.1 90.9 0.0 100.0 73 20-24 31.1 1,100 16.9 1.3 0.4 81.5 0.0 100.0 342 25-29 36.5 1,516 21.4 1.2 1.6 75.4 0.4 100.0 553 30-34 42.4 1,362 22.9 0.5 0.8 75.8 0.0 100.0 578 35-39 47.4 1,514 19.7 0.7 1.2 78.4 0.0 100.0 718 40-44 54.4 1,211 16.7 0.7 1.2 81.5 0.0 100.0 659 45-49 55.7 960 14.8 0.8 0.7 83.7 0.0 100.0 535 Total 15-49 43.7 7,906 18.6 0.8 1.1 79.5 0.1 100.0 3,458 MEN 15-19 * 4 * * * * * * 4 20-24 98.5 125 24.5 0.4 0.8 74.3 0.0 100.0 123 25-29 97.8 359 38.9 0.2 0.8 60.2 0.0 100.0 351 30-34 97.5 368 38.6 0.5 0.8 60.1 0.0 100.0 358 35-39 96.7 492 34.7 0.8 1.1 63.3 0.2 100.0 476 40-44 97.7 433 33.4 0.5 1.2 64.8 0.0 100.0 424 45-49 96.8 378 24.9 0.9 0.5 73.6 0.0 100.0 366 Total 15-49 97.3 2,158 33.4 0.6 0.9 65.0 0.0 100.0 2,101 Note: Total includes 4 men age 15-19 not shown separately. Table 15.1 also shows that nearly all men age 15-49 were involved in some type of work in the 12 months preceding the survey. Men are more likely to receive cash for their work than women. About one in three men (33 percent) receive cash only for their work, less than 1 percent receive cash and payment in-kind, less than 1 percent are paid in-kind only, and 65 percent do not receive any payment for their work. This is again because a large proportion of men are involved in agricultural work and self-employed. Payment in-kind is not common in Timor-Leste. 15.2 CONTROL OVER AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS In addition to having access to income, women need to be able to have control over their earnings in order to be empowered. As a means to assess this, currently married women who earned cash for their work in the 12 months preceding the survey were asked who the main decisionmaker is with regard to the use of their earnings. Women’s perception on the magnitude of their earnings relative to those of their husband is also explored as another measure of their empowerment. Those data are presented in Table 15.2.1. More than one-third (36 percent) of currently married women who receive cash earnings report that they alone decide how their earnings are used, while more than half (58 percent) say that they decide jointly with their husband. Only 6 percent of women report that their husband alone decides how their earnings will be used. The proportion of currently married women who say that they decide by themselves how their earnings are used tripled from 12 percent in 2003 to the current level of 36 percent. On the other hand, the percentage of currently married women who say that they jointly decide with their husband decreased from 79 percent in the 2003 DHS to 58 percent in 2009-10, and those reporting that only husbands decide also decreased (8 percent and 6 percent, respectively). Women’s Empowerment and Demographic and Health Outcomes | 205 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women 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, Timor-Leste 2009-10 Person who decides how wife’s cash earnings are used: Wife’s cash earnings compared with husband's cash earnings: Background characteristic Mainly wife Wife and husband jointly Mainly husband Total More Less About the same Husband/ partner has no earnings Don’t know/ Missing Total Number of women Age 20-24 24.8 62.7 12.5 100.0 41.6 28.1 15.5 10.1 4.7 100.0 62 25-29 40.5 55.0 4.4 100.0 26.7 36.5 21.0 14.5 1.3 100.0 125 30-34 33.3 62.0 4.7 100.0 24.6 34.4 31.7 8.7 0.6 100.0 135 35-39 38.9 56.6 4.4 100.0 18.9 41.2 26.2 12.9 0.8 100.0 147 40-44 35.7 58.2 6.1 100.0 22.4 35.1 33.7 8.8 0.0 100.0 115 45-49 39.2 56.3 4.5 100.0 33.2 26.5 27.4 7.6 5.2 100.0 83 Number of living children 0 35.8 58.1 6.1 100.0 26.4 34.5 24.4 13.0 1.8 100.0 55 1-2 33.3 58.6 8.0 100.0 32.7 29.5 23.3 12.1 2.4 100.0 186 3-4 42.8 54.4 2.9 100.0 24.0 38.7 28.4 8.2 0.7 100.0 232 5+ 31.8 62.1 6.0 100.0 21.8 36.2 28.1 12.0 1.9 100.0 199 Residence Urban 41.6 54.3 4.1 100.0 26.8 37.7 26.9 7.7 0.9 100.0 344 Rural 30.9 62.2 6.9 100.0 25.0 32.3 26.2 14.1 2.3 100.0 328 Education No education 41.8 44.7 13.5 100.0 18.1 27.6 34.5 15.5 4.3 100.0 92 Primary 36.7 58.8 4.4 100.0 28.9 40.3 20.6 8.0 2.3 100.0 83 Secondary 36.2 59.5 4.3 100.0 26.7 37.2 25.2 9.6 1.3 100.0 376 More than secondary 32.5 63.7 3.8 100.0 27.4 30.6 28.9 13.1 0.0 100.0 121 Wealth quintile Lowest (40.4) (56.3) (3.4) 100.0 (11.2) (29.1) (34.8) (18.7) 6.2 100.0 47 Second (37.5) (52.5) (10.0) 100.0 (33.8) (34.3) (15.0) (11.9) 5.0 100.0 52 Middle 31.3 60.3 8.5 100.0 25.1 40.0 18.1 14.5 2.3 100.0 66 Fourth 26.5 65.7 7.7 100.0 25.9 36.1 19.8 17.1 1.0 100.0 117 Highest 39.5 56.5 4.0 100.0 26.8 34.7 30.6 7.2 0.7 100.0 391 Total 36.4 58.2 5.5 100.0 25.9 35.1 26.6 10.8 1.6 100.0 672 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 5 women age 15-19 not shown separately. Younger Timorese women are less likely to be involved in how their cash earnings are spent, and this may be attributed to their young age at marriage (20-24). It is also interesting to note that older women (age 45-49) are more likely to decide how their cash earnings are spent relative to younger women, although women in the age group 25-29 seem to be more empowered perhaps due to the fact that they are more highly educated and employed in the lucrative sales and services sector (see Chapter 3). Women with five or more children are less likely to decide on their own how their earnings will be used than women with three to four children and those with no children. On the other hand, 62 percent of currently married women with five or more children make joint decisions with their husbands. Urban women are much more independent in making decisions than rural women (42 percent and 31 percent, respectively). Alternatively, rural women are more likely than urban women to report that they make this decision jointly with their husband (62 percent versus 54 percent). However, as education increases, women are less likely to make sole decisions and more likely to make joint decisions about how their cash earnings are spent. This finding reaffirms that education by itself does not guarantee empowerment for women who live in a patriarchal society (Acharya, 2010). It will be interesting to see if this pattern surfaces in the discussion of the relationship between education and domestic violence in the next chapter. 206 | Women’s Empowerment and Demographic and Health Outcomes Women’s perception of how much they earn vis-à-vis their husband could also impact how empowered they feel. Thirty-five percent of women believe that they earn less than their husband, 27 percent believe that they earn as much as their husband, and 26 percent believe that they earn more. Women age 20-24, women with any education, women with fewer children, women in the highest wealth quintile, and urban women are more likely than their counterparts to report that they believe that they earn more than their husbands. 15.3 CONTROL OVER MEN’S CASH EARNINGS Currently married men age 15-49 who receive cash earnings and currently married women age 15-49 whose husbands receive cash earnings were asked who decides how the husband’s cash earnings are spent. Table 15.2.2 shows that 22 percent of men and 26 percent of women say that the wife mainly decides how the husband’s earnings are used. Three in four men (75 percent) and more than two in three women (68 percent) say that the husband and wife decide jointly how the husband’s cash earnings are used. Younger couples are less likely to share control over the husband’s earnings as reported by men. Rural men and women are more likely to say that decisions about how the husband’s cash earnings are spent are made jointly by the husband and wife. In general, men who have higher education and those in the middle wealth quintile are more likely to make decisions jointly about the use of the husband’s cash earnings, while more men in the highest wealth quintile said that their wife solely makes the decision (26 percent). This holds true for women also, as 37 percent of women in the highest wealth quintile said that they are responsible for deciding on the use of their husbands’ income, compared with 21 percent in the lowest wealth quintile. Women’s Empowerment and Demographic and Health Outcomes | 207 Table 15.2.2 Control over men's cash earnings Percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women age 15-49 whose husbands receive cash earnings, by person who decides how men's cash earnings are used, according to background characteristics, Timor-Leste 2009-10 Men Women Person who decides how husband’s cash earnings are used: Person who decides how husband’s cash earnings are used: Background characteristic Mainly wife Husband and wife jointly Mainly husband Total Number Mainly wife Husband and wife jointly Mainly husband Other Missing Total Number Age 15-19 na na na na 0 21.8 73.6 4.6 0.0 0.0 100.0 212 20-24 27.1 63.9 8.9 100.0 31 24.6 69.5 5.4 0.1 0.4 100.0 987 25-29 31.4 67.1 1.4 100.0 137 29.4 65.3 5.2 0.0 0.1 100.0 1,358 30-34 13.5 82.3 4.2 100.0 140 27.3 67.1 5.4 0.0 0.2 100.0 1,220 35-39 22.0 75.6 2.3 100.0 169 24.5 69.7 5.9 0.0 0.0 100.0 1,329 40-44 19.1 77.5 3.3 100.0 144 24.8 69.0 6.0 0.0 0.2 100.0 1,065 45-49 21.9 76.8 1.3 100.0 95 24.9 67.6 7.1 0.1 0.4 100.0 822 Number of living children 0 (21.7) (68.5) (9.8) 100.0 48 25.0 69.7 5.1 0.0 0.2 100.0 406 1-2 25.7 72.3 2.0 100.0 220 25.5 69.2 5.0 0.1 0.3 100.0 1,897 3-4 19.7 78.5 1.8 100.0 265 25.9 68.2 5.6 0.0 0.2 100.0 2,147 5+ 20.1 76.3 3.7 100.0 182 26.4 66.9 6.5 0.0 0.1 100.0 2,541 Residence Urban 27.2 70.3 2.6 100.0 372 40.2 53.3 5.9 0.1 0.6 100.0 1,933 Rural 15.9 80.9 3.2 100.0 343 20.5 73.8 5.7 0.0 0.0 100.0 5,059 Education No education (29.3) (70.7) (0.0) 100.0 61 21.4 72.0 6.5 0.0 0.1 100.0 2,511 Primary 23.2 70.4 6.4 100.0 151 24.0 70.1 5.8 0.1 0.0 100.0 1,756 Secondary 21.1 76.5 2.5 100.0 395 30.8 63.7 4.9 0.0 0.4 100.0 2,512 More than secondary 18.3 80.7 1.0 100.0 108 38.1 57.4 4.5 0.0 0.0 100.0 213 Wealth quintile Lowest (11.1) (88.9) (0.0) 100.0 29 21.3 72.4 6.2 0.0 0.1 100.0 1,209 Second 20.3 69.0 10.7 100.0 49 20.5 72.1 7.2 0.1 0.1 100.0 1,273 Middle 8.9 86.9 4.2 100.0 82 22.2 71.3 6.5 0.0 0.0 100.0 1,350 Fourth 22.3 76.2 1.5 100.0 194 25.0 70.1 4.6 0.0 0.3 100.0 1,409 Highest 25.5 72.0 2.5 100.0 361 36.8 58.1 4.7 0.0 0.3 100.0 1,750 Total 15-49 21.8 75.3 2.9 100.0 715 26.0 68.1 5.7 0.0 0.2 100.0 6,992 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 208 | Women’s Empowerment and Demographic and Health Outcomes Table 15.3 shows the percent distribution of currently married women age 15-49 who received cash earnings in the past 12 months by the person who decides how their cash earnings are used, and the percent distribution of currently married women age 15-49 whose husbands received cash earnings in the past 12 months by the person who decides how the husband’s cash earnings are used, according to the relative magnitude of the earnings of the women and her husband. Table 15.3 Women’s control over her own earnings and over those of her husband Percent distributions of currently married women age 15-49 with cash earnings in the past 12 months by person who decides how the woman's cash earnings are used and of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband's cash earnings are used, according to the relation between woman's and husband's cash earnings, Timor-Leste 2009-10 Person who decides how the wife's cash earnings are used: Person who decides how husband's cash earnings are used: Women’s earnings relative to husband’s earnings Mainly wife Wife and husband jointly Mainly husband Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing Total Number of women More than husband/partner 43.0 52.4 4.6 100.0 174 31.4 63.2 5.0 0.3 0.0 100.0 174 Less than husband/partner 32.9 60.4 6.7 100.0 236 31.7 65.6 2.8 0.0 0.0 100.0 234 Same as husband partner 29.9 63.9 6.1 100.0 179 19.3 72.7 8.0 0.0 0.0 100.0 177 Husband/ partner has no cash earnings/did not work 43.4 54.9 1.7 100.0 73 na na na na na na 0 Woman has no cash earnings na na na na 0 18.6 76.0 5.3 0.0 0.1 100.0 2,390 Woman did not work in past 12 months na na na na 0 30.0 63.6 6.1 0.0 0.3 100.0 4,007 Total1 36.4 58.2 5.5 100.0 672 26.0 68.1 5.7 0.0 0.2 100.0 6,992 Note: Totals include 11 women with information missing on earnings relative to husband. na = Not applicable 1 Excludes cases where a woman or her husband/partner has no earnings and includes cases where a woman does not know whether she earned more or less than her husband/partner Women who believe that they earn more than their husband are more likely to also say that they solely decide how their cash earnings are used (43 percent) than women who believe that their cash earnings are the same as their husband’s (30 percent) or that their cash earnings are less than their husband’s (33 percent). On the other hand, women who believe that they earn about the same amount as their husband are more likely to also say that they make joint decisions with their husband about how their cash earnings and those of their husband are used (64 percent and 73 percent, respectively). In Timorese culture married women are responsible for managing solely or jointly all cash earnings of their husband, irrespective of their own cash earning status. This is clearly indicated by the finding that 95 percent of women with no cash earnings participate alone or jointly with their husband in deciding how to use their husband’s cash earnings. 15.4 WOMEN’S PARTICIPATION IN DECISIONMAKING Women’s participation in the decisionmaking process is an important indicator of their empowerment. In order to assess women’s decisionmaking autonomy, the 2009-10 TLDHS sought information on women’s participation in four types of household decisions: her own health care, making large household purchases, making household purchases for daily needs, and visits to family or relatives. Table 15.4.1 shows the percent distribution of currently married women according to the person in the household who usually makes decisions concerning these matters. Women are considered to participate in decisionmaking if they make decisions alone or jointly with their husband. Women’s Empowerment and Demographic and Health Outcomes | 209 Table 15.4.1 Women’s participation in decisionmaking Percent distribution of currently married women by person who usually makes decisions about four kinds of issues, Timor-Leste 2009-10 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 22.8 63.8 13.2 0.0 0.0 0.1 100.0 7,906 Major household purchases 20.9 64.9 13.9 0.0 0.1 0.1 100.0 7,906 Purchases of daily household needs 62.9 32.0 4.8 0.0 0.2 0.1 100.0 7,906 Visits to her family or relatives 12.8 78.3 8.7 0.0 0.0 0.1 100.0 7,906 The strength of women’s role in decisionmaking varies with the type of decision. Timorese women are usually involved in all four specific decisions, although the extent of their involvement depends on the issue being decided. Sixty-three percent of currently married women reported that they alone made the final decision about daily household purchases, a significant increase from the 2003 DHS where only 44 percent said this. Regarding decisionmaking in other issues like one’s own health care, making major household purchases, and visiting family or relatives, women are more likely to decide jointly with their husbands. In the 2009-10 TLDHS, men were asked who (wife, husband, or both) should have the greater say in five specific decisions—making major household purchases, making daily household purchases, deciding when to visit the wife’s family or relatives, deciding what to do with the money the wife earns, and deciding how many children to have. Table 15.4.2 shows the percent distribution of currently married men age 15-49 by the person they think should have the greater say in making decisions about five types of issues. Table 15.4.2 Women’s participation in decisionmaking according to men Percent distribution of currently married men 15-49 by person who they think should have a greater say in making decisions about five kinds of issues, Timor-Leste 2009-10 Decision Wife Wife and husband equally Husband Don't know/ depends Total Number of men Major household purchases 4.3 88.4 6.8 0.5 100.0 2,158 Purchases of daily household needs 55.4 42.0 1.8 0.7 100.0 2,158 Visits to wife's family or relatives 9.9 84.3 4.2 1.5 100.0 2,158 What to do with the money wife earns 14.7 76.5 2.6 6.2 100.0 2,158 How many children to have 2.2 94.4 2.3 1.2 100.0 2,158 Table 15.4.2 shows that for most decisions, the majority of currently married men age 15-49 think that the husband and wife should have equal say in making decisions. This is especially true for decisions about the number of children to have (94 percent), decisions on major household purchases (88 percent), and visits to the wife’s family or relatives (84 percent). More than half (55 percent) of married men say that the wife should have the greater say in making decisions about small household purchases, while 42 percent think that the husband and wife should have equal say. On the other hand, 7 percent of married men say that the husband should have a greater say in making decisions about major household purchases, although most generally agree that it should not be the wife alone making such decision, with only 4 percent mentioning that the wife should have a greater say. Table 15.5.1 shows the percentage of married women who participate in the four decisions specified for female respondents, according to background characteristics. As noted above, a woman is considered to participate in a decision if she says she usually makes the decision alone or jointly with her husband. 210 | Women’s Empowerment and Demographic and Health Outcomes Eighty-seven percent of currently married women age 15-49 say that they make decisions about their own health care either by themselves or jointly with their husbands, and 86 percent say that they participate in decisions about major household purchases. Most currently married women say that they participate in decisions about daily household needs (95 percent) and in decisions about visits to their own family or relatives (91 percent). Overall, 74 percent of currently married women participate in all four decisions, and 1 percent do not participate in any of the four decisions. There is little difference in participation in decisionmaking among women by age and by the number of children they have. It is interesting to note that women who are employed for cash, those in urban areas, those with higher education, and those belonging to wealthier households are less likely to participate in all four decisions. It will be interesting to see if these women are also vulnerable to domestic violence, which is discussed in greater detail in the next chapter. The number of decisions in which a woman participates by herself or jointly with her husband is positively related to women’s empowerment and reflects the degree of decisionmaking control that women are able to exercise in areas that affect their lives and environments. Figure 15.1 shows the distribution of currently married women according to the number of decisions in which they participate. Figure 15.1 Number of Household Decisions in Which Women Participate 1 2 8 15 74 0 1 2 3 4 Number of decisions 0 20 40 60 80 Percent Timor-Leste 2009-10 Men were also asked about their attitude toward their wives’ participation in the decisionmaking process. Table 15.5.2 shows the percentage of currently married men age 15- 49 who think that the wife should have a greater or equal say with her husband on five specific kinds of decisions. More than three-quarters (78 percent) of currently married men age 15-49 believe that a wife should independently or jointly with her husband have a say in all five specified decisions. More than 90 percent of men agree on women’s participation in each of the decisions specified. This is an indication that Timorese men think that women’s participation in household decisionmaking is essential, although the previous table indicated that in reality this was not the case. Women’s Empowerment and Demographic and Health Outcomes | 211 Table 15.5.1 Women’s participation in decisionmaking 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, Timor-Leste 2009-10 Background characteristic Specific decisions Percentage who participate in all four decisions Percentage who participate in none of the four decisions Number of women Own health care Making major household purchases Making purchases for daily household needs Visits to her family or relatives Age 15-19 91.0 84.6 96.1 92.2 73.9 0.2 243 20-24 86.1 87.2 96.2 92.3 74.1 0.8 1,100 25-29 85.6 86.3 94.4 90.0 73.9 1.4 1,516 30-34 88.6 86.8 95.0 92.1 75.7 1.2 1,362 35-39 86.9 85.7 95.5 91.7 73.9 1.0 1,514 40-44 85.8 85.1 94.3 91.0 73.2 1.0 1,211 45-49 85.3 84.0 93.4 89.3 72.2 2.1 960 Employment (past 12 months) Not employed 85.8 84.2 94.9 90.1 70.9 1.1 4,439 Employed for cash 79.3 83.6 90.3 90.5 66.0 0.5 672 Employed not for cash 90.0 89.4 96.3 93.3 81.0 1.2 2,784 Number of living children 0 86.1 86.4 94.4 92.2 73.0 1.1 469 1-2 87.2 86.2 94.7 91.8 74.7 1.3 2,103 3-4 85.3 87.1 95.1 90.3 73.8 1.1 2,421 5+ 87.3 84.5 94.8 91.2 73.6 1.3 2,913 Residence Urban 84.2 86.2 90.2 86.5 68.1 1.3 2,025 Rural 87.4 85.7 96.5 92.7 75.9 1.2 5,881 District Aileu 78.6 82.2 84.3 81.9 70.8 9.7 299 Ainaro 93.2 96.5 96.9 88.2 81.5 1.2 382 Baucau 68.6 74.5 97.3 91.3 58.3 1.7 852 Bobonaro 100.0 99.6 99.7 99.9 99.3 0.0 739 Covalima 57.0 77.6 98.8 95.5 49.7 0.4 458 Dili 82.9 87.7 87.1 83.2 67.7 1.5 1,459 Ermera 92.2 90.8 94.9 89.0 82.1 0.7 881 Lautem 87.7 55.7 97.2 95.8 47.1 0.2 541 Liquiçá 90.1 94.6 97.5 95.4 84.9 0.8 460 Manatuto 95.2 97.9 98.8 98.8 93.7 0.7 353 Manufahi 94.3 65.7 91.4 91.1 61.5 0.6 319 Oecussi 97.1 94.2 100.0 96.6 89.5 0.0 603 Viqueque 96.2 90.9 95.4 88.0 78.9 1.3 559 Education No education 87.3 87.3 95.4 91.2 76.9 1.4 2,909 Primary 88.1 85.0 95.5 91.7 74.0 1.3 2,027 Secondary 85.2 85.1 94.5 91.1 71.5 1.0 2,739 More than secondary 82.3 84.9 87.0 86.5 64.3 0.9 231 Wealth quintile Lowest 88.2 85.3 96.7 92.6 76.6 1.3 1,467 Second 87.3 84.9 95.0 92.2 74.8 1.4 1,487 Middle 86.7 85.5 96.1 92.0 75.5 1.4 1,559 Fourth 87.5 85.9 96.5 92.4 74.1 1.1 1,571 Highest 83.9 87.4 90.8 87.3 69.6 0.9 1,821 Total 86.6 85.9 94.9 91.1 73.9 1.2 7,906 Note: Total includes 11 women with information missing on employment status. 212 | Women’s Empowerment and Demographic and Health Outcomes Table 15.5.2 Men's attitude toward wives' participation in decisionmaking Percentage of currently married men age 15-49 who think that a wife should have the greater say alone or equal say with her husband on five specific kinds of decisions, by background characteristics, Timor-Leste 2009-10 Background characteristic Specific decision All five decisions None of the five decisions Number of men Making major household purchases Making purchases for daily household needs Visits to her family or relatives What to do with the money the wife earns How many children to have Age 20-24 91.7 97.4 94.1 90.7 99.1 78.6 0.5 125 25-29 92.0 97.9 94.9 91.5 97.0 76.7 0.0 359 30-34 93.5 97.9 95.2 93.6 97.5 81.7 0.0 368 35-39 92.9 98.0 94.5 89.7 96.2 76.3 0.1 492 40-44 92.1 97.4 94.4 92.7 96.4 79.9 0.1 433 45-49 93.2 96.2 92.1 89.2 94.8 76.0 0.9 378 Employment (past 12 months) Not employed 86.2 98.7 93.2 80.1 99.0 67.6 0.0 57 Employed for cash 92.4 98.0 96.1 90.1 98.3 77.9 0.1 715 Employed not for cash 93.1 97.1 93.3 92.2 95.5 78.6 0.3 1,385 Number of living children 0 94.5 97.6 95.6 91.9 98.8 81.1 0.0 135 1-2 91.7 97.6 95.0 92.1 96.3 76.7 0.1 620 3-4 92.9 97.9 94.0 90.6 96.1 77.0 0.2 704 5+ 93.0 96.9 93.6 90.9 96.7 79.8 0.4 700 Residence Urban 90.9 97.0 96.4 84.2 97.5 72.5 0.3 567 Rural 93.3 97.6 93.5 93.7 96.2 80.1 0.2 1,592 District Aileu 69.0 94.2 59.4 93.9 96.1 45.2 1.3 92 Ainaro 97.3 97.9 99.2 97.9 95.8 93.1 0.0 101 Baucau 98.7 99.3 94.0 91.1 85.9 75.0 0.0 237 Bobonaro 99.2 94.6 91.2 89.1 96.1 75.1 0.0 170 Covalima 99.6 99.2 100.0 97.0 97.7 94.3 0.0 123 Dili 91.0 96.8 96.0 77.0 98.6 65.6 0.5 416 Ermera 100.0 100.0 100.0 100.0 100.0 100.0 0.0 233 Lautem 96.5 92.7 97.1 91.2 98.8 82.6 0.0 163 Liquiçá 96.9 97.8 92.6 85.5 95.1 77.8 0.0 124 Manatuto 100.0 97.2 99.4 100.0 100.0 96.7 0.0 96 Manufahi 12.7 98.5 97.8 97.8 90.3 9.9 1.5 77 Oecussi 95.4 98.3 87.8 95.4 98.8 81.4 0.6 165 Viqueque 100.0 99.4 97.4 99.4 99.4 96.7 0.0 159 Education No education 93.0 96.1 91.9 91.0 95.2 74.5 0.5 523 Primary 93.8 96.9 93.5 91.1 96.8 79.6 0.3 650 Secondary 92.1 98.4 96.0 91.0 96.8 78.9 0.1 853 More than secondary 89.6 99.2 95.6 94.3 98.8 79.1 0.0 132 Wealth quintile Lowest 92.8 97.9 91.5 94.6 96.6 79.6 0.2 413 Second 91.8 97.5 93.8 92.2 95.5 76.9 0.1 408 Middle 92.6 96.4 93.3 93.7 96.3 80.0 0.1 411 Fourth 94.6 97.6 95.4 89.6 96.8 78.8 0.3 447 Highest 91.5 97.8 96.7 86.9 97.3 75.4 0.4 479 Total 15-49 92.7 97.5 94.2 91.2 96.5 78.1 0.2 2,158 Note: Total includes 4 men age 15-19 not shown separately and 1 man with information missing on employment status. Women’s Empowerment and Demographic and Health Outcomes | 213 15.5 ATTITUDES TOWARD WIFE BEATING Another measure of women’s empowerment derives from the idea that gender equity is essential to empowerment. Women who believe that wife beating is justified seemingly have a lower status than women who think otherwise because they are more accepting of norms that give men the right to use force against women, which is a violation of women’s basic human rights. Violence against women has serious consequences for their mental and physical well-being, including their reproductive and sexual health (Heise et al., 1999). The attitude of women and men toward wife beating may be considered a proxy indicator for their attitude toward domestic violence. Women and men were asked whether a husband is justified in hitting or beating his wife in each of the following five situations: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual intercourse with him. The fewer situations, or reasons, that a woman agrees with indicates a greater sense of entitlement, self-esteem, and status, and reflects positively on her sense of empowerment. A woman who believes that a husband is justified in hitting or beating his wife, for any of the five specified reasons, may consider herself to be of low status both absolutely and relative to men. Such a perception could act as a barrier to accessing health care for herself and for her children, affect her attitude toward contraceptive use, and impact her general well-being. Table 15.6.1 shows that 86 percent of women believe that a husband is justified in beating his wife for at least one of the specified reasons. The most widely accepted reason for wife beating among women is neglecting the children (76 percent). About 64 percent of women believe that a husband is justified in beating his wife if she argues with him, and 72 percent believe that it is acceptable if she goes out without telling him. A smaller percentage of women believe that the husband is justified in hitting or beating his wife if she burns the food (43 percent) or denies him sexual intercourse (30 percent). Differentials by women’s background characteristics are small, except among women in Viqueque, who are least likely to sanction wife beating. Only 59 percent of women in Viqueque believe that a husband is justified in beating his wife for at least one specified reason. Among the Timorese, it is the man and/or his family who pays dowry at marriage to his wife’s family (Belis, Barlaque). However, once the payment is completed, the wife is often considered the property of the husband, thus losing her independence and status as an individual. In Viqueque, the payment of dowry is less prevalent and as such women in Viqueque may tend to exhibit greater self-esteem. Men age 15-49 are almost as likely as women to report that they find physical violence against women justifiable (Table 15.6.2). Overall, four in five Timorese men agree with at least one of the reasons for why a man is justified in beating his wife. Men are most likely to justify beating a wife if she neglects the children (71 percent). Like women, men are least likely to say that burning food (38 percent) or refusing to have sex (27 percent) are grounds for wife beating. About 44 percent of men feel that arguing with one’s husband is a justifiable reason for wife beating. 214 | Women’s Empowerment and Demographic and Health Outcomes Table 15.6.1 Attitude toward wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Timor-Leste 2009-10 Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Number of women Age 15-19 43.5 57.9 69.8 73.2 25.2 81.1 3,144 20-24 44.9 65.5 73.4 77.1 28.7 87.3 2,343 25-29 43.4 67.7 73.2 77.4 30.4 89.2 1,897 30-34 41.5 65.5 72.4 77.3 28.4 87.7 1,534 35-39 43.0 65.7 72.7 78.5 33.7 87.5 1,684 40-44 42.3 66.4 73.1 76.3 33.1 87.7 1,388 45-49 42.9 63.6 72.3 78.1 32.1 86.9 1,146 Employment (past 12 months) Not employed 44.2 60.0 70.0 74.2 26.3 85.0 7,943 Employed for cash 38.9 60.7 69.5 68.5 26.8 84.6 1,054 Employed not for cash 42.6 72.4 77.0 82.6 36.3 88.9 4,130 Marital status Never married 44.2 59.6 70.0 73.4 24.8 82.1 4,675 Married or living together 42.9 66.3 73.4 78.2 32.0 88.7 7,906 Divorced/separated/widowed 40.2 66.9 72.5 76.4 32.9 84.8 556 Number of living children 0 44.2 59.9 70.3 73.4 25.1 82.4 5,178 1-2 43.1 66.9 74.1 78.2 30.9 89.2 2,350 3-4 42.4 65.9 72.6 77.7 32.4 88.6 2,554 5+ 42.4 66.9 73.5 79.0 33.3 88.2 3,055 Residence Urban 48.0 63.1 69.5 72.3 21.5 89.3 3,439 Rural 41.6 64.3 73.1 77.9 32.3 85.1 9,698 District Aileu 50.6 65.8 78.2 77.4 42.5 86.5 554 Ainaro 36.8 27.6 58.7 59.5 13.9 64.5 619 Baucau 40.1 31.1 68.5 72.9 18.6 83.2 1,408 Bobonaro 19.3 60.2 76.2 85.7 10.2 88.7 1,262 Covalima 58.6 72.0 72.0 77.8 34.4 87.6 781 Dili 53.1 60.9 67.2 67.2 17.3 89.8 2,466 Ermera 51.4 90.9 91.3 92.1 51.1 96.2 1,542 Lautem 19.7 77.4 60.1 80.2 13.1 92.0 864 Liquiçá 70.4 80.9 83.0 82.9 67.8 88.7 801 Manatuto 48.9 78.9 72.9 70.0 44.0 83.0 603 Manufahi 22.4 66.7 62.5 83.2 12.7 91.0 470 Oecussi 60.9 74.3 88.0 90.3 68.5 92.3 884 Viqueque 14.9 49.7 49.5 54.4 10.4 59.1 882 Education No education 42.4 65.3 74.0 79.1 35.1 86.4 3,854 Primary 43.3 65.6 72.6 78.7 33.5 86.3 3,005 Secondary 43.8 62.5 71.1 74.0 24.5 85.9 5,829 More than secondary 43.3 59.4 67.4 70.1 19.2 88.1 449 Wealth quintile Lowest 38.9 59.1 68.0 74.2 31.8 81.1 2,314 Second 40.7 61.6 74.1 78.6 31.4 84.5 2,468 Middle 42.4 69.5 76.7 80.7 32.8 87.9 2,590 Fourth 44.1 67.1 72.7 78.3 30.6 87.7 2,687 Highest 48.5 62.1 69.5 71.0 22.4 88.5 3,077 Total 43.2 63.9 72.2 76.4 29.5 86.2 13,137 Note: Total includes 11 women with information missing on employment status. Women’s Empowerment and Demographic and Health Outcomes | 215 Table 15.6.2 Attitude toward wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Timor-Leste 2009-10 Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Number of men Age 15-19 36.6 39.5 58.5 61.9 23.9 72.3 994 20-24 37.9 42.9 63.1 70.1 27.6 79.7 643 25-29 38.1 44.2 65.4 72.7 23.2 83.3 586 30-34 39.0 46.9 68.2 77.6 28.0 85.1 439 35-39 36.1 47.5 68.6 78.6 28.5 87.2 553 40-44 37.6 49.4 67.7 73.2 28.9 84.8 462 45-49 38.8 43.8 69.8 72.7 28.5 81.2 400 Employment (past 12 months) Not employed 39.3 42.6 64.3 73.8 14.0 80.5 538 Employed for cash 29.3 37.6 61.0 70.8 17.8 78.3 973 Employed not for cash 40.3 46.9 66.3 70.6 32.4 81.7 2,564 Marital status Never married 36.6 41.4 60.8 65.8 24.1 76.0 1,865 Married or living together 38.2 46.3 68.1 75.5 28.5 84.7 2,158 Divorced/separated/widowed 45.0 53.9 68.2 78.1 25.6 87.9 53 Number of living children 0 36.9 42.1 61.2 66.2 24.6 76.7 2,009 1-2 37.9 44.8 67.7 75.8 26.3 84.4 638 3-4 34.5 44.4 67.7 75.9 26.4 85.0 720 5+ 41.9 49.1 69.4 75.5 32.0 84.6 709 Residence Urban 39.5 48.1 69.4 78.8 16.4 86.1 1,102 Rural 36.8 42.7 63.1 68.2 30.2 78.8 2,974 District Aileu 8.1 26.5 43.5 28.9 6.8 47.8 181 Ainaro 68.1 58.8 48.1 77.7 6.8 87.8 217 Baucau 11.0 18.3 58.3 63.6 71.4 93.9 415 Bobonaro 65.9 29.7 95.8 93.8 6.8 99.6 357 Covalima 27.1 64.0 69.3 74.3 33.3 94.7 236 Dili 34.6 45.9 70.7 82.4 8.8 86.0 797 Ermera 53.4 58.8 69.9 67.7 52.5 76.6 491 Lautem 76.1 75.5 90.7 88.5 45.7 94.6 308 Liquiçá 18.9 36.1 45.3 45.7 8.1 53.7 252 Manatuto 0.8 1.1 0.8 1.4 0.8 1.7 190 Manufahi 88.6 85.8 86.6 89.5 18.8 91.4 137 Oecussi 31.8 65.6 79.1 81.8 51.4 91.3 235 Viqueque 1.7 14.5 39.7 79.3 6.2 82.5 260 Education No education 37.1 46.5 64.8 72.2 28.7 81.4 791 Primary 35.0 41.3 63.4 68.3 29.0 78.7 1,046 Secondary 39.3 43.9 65.2 71.3 25.7 80.8 2,009 More than secondary 35.2 51.0 67.0 77.2 14.3 87.3 230 Wealth quintile Lowest 35.4 45.8 63.8 70.5 28.5 81.3 728 Second 41.1 45.9 63.9 68.6 30.0 80.2 781 Middle 37.4 41.9 62.3 67.3 29.3 79.4 786 Fourth 38.0 43.6 66.7 72.9 28.6 79.5 849 Highest 35.8 43.8 66.7 75.0 17.7 83.0 932 Total 15-49 37.5 44.1 64.8 71.1 26.5 80.7 4,076 Note: Total includes one man missing information on employment status 216 | Women’s Empowerment and Demographic and Health Outcomes 15.6 ATTITUDES TOWARD REFUSING SEX WITH HUSBAND Women’s sexual empowerment has important implications for demographic and health outcomes such as their exposure to HIV and other sexually transmitted infections. It is also an indicator of women’s empowerment in general, as it measures women’s level of acceptance of societal norms that socialize them to believe that women do not have the right to refuse sexual intercourse with their husband for any reason. The number of reasons that a wife finds acceptable for refusing sexual intercourse with her husband reflects perceptions of sexual roles and women’s rights over their bodies, and relates positively to women’s sense of self-esteem. To measure beliefs about women’s sexual empowerment, the 2009-10 TLDHS included questions on whether the respondent thinks that a wife is justified in refusing to have sexual intercourse with her husband under three circumstances: she knows her husband has a sexually transmitted disease, she knows her husband has sexual intercourse with other women, or she is tired or not in the mood. These three circumstances were chosen because they are effective in combining the issues of women’s rights and consequences for women’s health. Tables 15.7.1 and 15.7.2 show the responses of women and men, respectively. Table 15.7.1 shows that about two in three women agree with each of the specified circumstances under which a wife is justified in refusing to have sexual intercourse with her husband, and 51 percent agree with all three of the reasons. Women are most likely to agree that a woman can refuse to have sexual intercourse with her husband if she knows her husband has a sexually transmitted infection or if she is tired or not in the mood (67 percent each). Sixty-five percent think that a woman is justified in refusing sexual intercourse if she knows that her husband has intercourse with other women. Twenty percent of women agree with none of the specified reasons, meaning that they think that a woman should not refuse sexual intercourse with her husband under any circumstances. Women living in urban areas, those with higher education, and those in the highest wealth quintile are least likely to think all of the reasons for refusing sex are acceptable. Interestingly, these women are also less empowered with regard to other indicators, reinforcing the finding that within a patriarchal society educated, wealthy, and urban women are not automatically accorded equality. Table 15.7.2 shows the percentage of men who think that a wife is justified in refusing to have sexual intercourse with her husband under the same three specified circumstances: she knows her husband has a sexually transmitted disease, she knows her husband has sexual intercourse with other women, or she is tired or not in the mood. The results indicate that the proportion of men who think that a woman is justified in refusing sexual intercourse with her husband for all three specified reasons is almost the same as the proportion of women (53 and 51 percent, respectively). Seventy-two percent of men, compared with 67 percent of women, think that a wife is justified in refusing sexual intercourse with her husband if she knows he has a sexually transmitted infection; 71 percent of men, compared with 65 percent of women, think that a wife is justified in refusing sexual intercourse if she knows that her husband has intercourse with other women; and 75 percent of men, compared with 67 percent of women, think that a woman is justified in refusing sexual intercourse with her husband if she is tired or not in the mood. Men age 15-19, those who have primary education, those who are not employed, those who have never married, and those who have no children are least likely to accept all of the reasons for refusing sex. Notable differences are seen by education, with highly educated men more likely to agree with all of the specified reasons for women to refuse sexual intercourse. Conversely, these men are also least likely to agree with none of the specified reasons, indicating that urban, educated, and wealthy men are more accepting of women’s entitlement to control their sexuality. There are also substantial variations by district, with men in Viqueque less likely to accept all reasons for refusing sex (9 percent), while nearly all men in Manatuto agreed with all the specified reasons for refusing sex (99 percent). In the case of women, it was highest in Ermera (90 percent). Women’s Empowerment and Demographic and Health Outcomes | 217 Table 15.7.1 Attitude toward refusing sexual intercourse with husband: Women Percentage of all women age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Timor-Leste 2009-10 Wife is justified in refusing intercourse with her husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of women Age 15-19 54.5 50.9 48.6 37.9 35.5 3,144 20-24 64.9 62.8 65.3 47.9 20.5 2,343 25-29 71.2 70.2 74.4 53.1 11.7 1,897 30-34 73.9 71.1 75.9 57.4 12.8 1,534 35-39 76.7 72.5 76.0 59.5 11.3 1,684 40-44 73.3 71.7 72.9 56.5 13.4 1,388 45-49 72.1 70.2 71.6 57.1 15.4 1,146 Employment (past 12 months) Not employed 65.6 62.4 64.8 48.2 21.0 7,943 Employed for cash 60.7 62.4 68.6 44.4 17.9 1,054 Employed not for cash 72.7 70.1 69.5 56.8 17.2 4,130 Marital status Never married 55.1 51.4 49.7 38.0 34.3 4,675 Married or living together 74.3 72.5 76.2 57.5 11.1 7,906 Divorced/separated/widowed 72.4 68.3 71.7 56.9 15.4 556 Number of living children 0 56.8 53.7 52.2 39.9 32.1 5,178 1-2 72.0 70.1 75.6 54.2 11.1 2,350 3-4 73.6 71.4 74.8 55.6 11.4 2,554 5+ 76.7 74.2 77.2 61.6 11.5 3,055 Residence Urban 48.7 46.2 56.6 26.6 25.8 3,439 Rural 74.0 71.4 70.1 59.0 17.3 9,698 District Aileu 68.7 59.8 74.6 53.6 21.4 554 Ainaro 61.0 59.5 51.5 42.8 30.2 619 Baucau 89.5 89.4 88.8 86.7 8.9 1,408 Bobonaro 63.3 59.7 37.8 25.9 25.7 1,262 Covalima 75.9 60.3 68.4 40.0 8.1 781 Dili 38.6 34.2 51.6 14.2 29.7 2,466 Ermera 90.6 91.7 91.3 89.8 7.3 1,542 Lautem 80.8 66.0 71.1 54.0 11.4 864 Liquiçá 76.8 72.8 73.9 56.3 11.9 801 Manatuto 79.1 78.7 73.7 68.2 15.0 603 Manufahi 23.4 64.1 59.2 20.0 25.5 470 Oecussi 82.6 80.9 79.9 77.4 14.8 884 Viqueque 52.7 48.7 49.5 42.8 41.6 882 Education No education 74.3 71.8 70.6 59.1 16.6 3,854 Primary 69.4 67.1 69.7 54.2 18.5 3,005 Secondary 63.2 60.4 62.7 44.6 21.5 5,829 More than secondary 48.9 46.9 61.9 30.3 26.0 449 Wealth quintile Lowest 70.4 68.0 67.0 56.9 21.5 2,314 Second 73.5 71.1 69.5 58.7 18.1 2,468 Middle 74.0 71.2 70.1 58.0 17.0 2,590 Fourth 70.1 67.3 67.6 51.5 17.0 2,687 Highest 52.4 49.9 60.1 32.1 23.5 3,077 Total 67.4 64.8 66.6 50.5 19.5 13,137 Note: Total includes 11 women with information missing on employment status. 218 | Women’s Empowerment and Demographic and Health Outcomes Table 15.7.2 Attitude toward refusing sexual intercourse with husband: Men Percentage of all men age 15-49 who believe that a wife is justified in refusing to have sexual intercourse with her husband in specific circumstances, by background characteristics, Timor-Leste 2009-10 Wife is justified in refusing intercourse with her husband if she: Background characteristic Knows husband has a sexually transmitted disease Knows husband has intercourse with other women Is tired or not in the mood Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Number of men Age 15-19 58.3 55.7 58.3 39.6 28.0 994 20-24 72.4 68.7 75.0 53.7 13.6 643 25-29 75.4 76.4 82.4 55.8 6.3 586 30-34 80.4 78.6 82.7 59.6 4.8 439 35-39 74.6 78.5 83.9 56.9 4.7 553 40-44 78.9 80.1 83.7 62.0 5.4 462 45-49 79.3 76.3 78.3 57.7 6.7 400 Employment (past 12 months) Not employed 66.7 56.0 69.6 45.1 19.3 538 Employed for cash 76.0 77.2 83.0 55.7 5.6 973 Employed not for cash 71.5 71.9 73.6 53.5 13.4 2,564 Marital status Never married 64.0 60.2 65.5 44.1 21.3 1,865 Married or living together 78.7 80.2 84.0 60.6 4.6 2,158 Divorced/separated/widowed 75.9 80.0 72.2 54.6 9.1 53 Number of living children 0 64.8 61.7 66.5 45.1 20.2 2,009 1-2 81.3 81.0 85.2 62.4 3.9 638 3-4 76.6 81.7 84.4 59.3 3.6 720 5+ 79.1 77.8 82.4 60.1 6.2 709 Residence Urban 75.0 65.1 78.5 51.0 9.8 1,102 Rural 70.9 73.3 74.2 53.7 13.2 2,974 District Aileu 54.9 50.2 47.8 37.3 34.9 181 Ainaro 74.1 68.3 78.8 62.9 17.2 217 Baucau 65.3 85.9 79.9 51.3 6.4 415 Bobonaro 68.6 67.3 44.0 11.6 1.7 357 Covalima 86.7 90.1 89.6 78.2 1.8 236 Dili 70.3 60.4 78.6 45.4 11.2 797 Ermera 71.2 71.5 71.9 67.3 25.3 491 Lautem 91.4 73.4 92.8 68.4 2.5 308 Liquiçá 73.9 39.3 61.9 30.2 21.2 252 Manatuto 99.2 99.2 99.4 98.9 0.6 190 Manufahi 95.2 95.3 88.0 87.2 3.4 137 Oecussi 92.5 94.3 95.9 87.2 1.6 235 Viqueque 14.8 57.7 60.3 9.0 30.8 260 Education No education 66.9 70.0 72.3 49.1 13.6 791 Primary 70.0 68.2 69.2 48.2 15.4 1,046 Secondary 74.3 72.3 78.9 55.9 10.9 2,009 More than secondary 78.2 77.5 83.3 62.4 5.8 230 Wealth quintile Lowest 68.0 72.1 74.4 52.5 13.8 728 Second 67.9 70.1 70.3 50.4 16.2 781 Middle 73.9 73.2 75.4 54.3 11.0 786 Fourth 73.0 73.2 75.8 53.6 11.4 849 Highest 76.0 67.3 79.9 53.7 9.7 932 Total 15-49 72.0 71.1 75.4 53.0 12.3 4,076 Note: Total includes one man missing information on employment status. Twenty percent of women and 12 percent of men agree with none of the reasons. The two most accepted reasons for refusing to have sex, among women and men, are if the wife knows her husband has a sexually transmitted disease and if a wife is tired or not in the mood. Though not significant, for both women and men, the least acceptable reason for a wife to refuse sex is when she knows that her husband has intercourse with other women. Women’s Empowerment and Demographic and Health Outcomes | 219 Women’s empowerment is closely associated with the support she receives from her husband and family members. The 2009-10 TLDHS explored men’s attitude toward a husband’s rights when his wife refuses to have sexual intercourse. Men were asked whether, when a wife refuses to have sexual intercourse with him, a husband has the right to get angry and reprimand her, refuse her financial support, use force to have sex, or have sex with another woman. Table 15.7.3 indicates that the majority of men (55 percent) agree with none of the reasons to justify negative behavior on the part of a man if his wife refuses to have sexual intercourse with him. On the other hand, 6 percent of men agree with all of the specified rights for men to exhibit the specified negative behavior, with men in Ermera reporting this most often (28 percent), followed by men in Oecussi (17 percent). Table 15.7.3 Men’s attitude toward a husband’s rights when his wife refuses to have sexual intercourse Percentage of men age 15-49 who consider that a husband has the right to certain behaviors when a woman refuses to have sex with him when he wants her to, by background characteristics, Timor-Leste 2009-10 When a woman refuses to have sex with her husband, he has the right to: Percentage who agree with all of the specified reasons Percentage who agree with none of the specified reasons Background characteristic Get angry and reprimand her Refuse her financial support Use force to have sex Have sex with another woman Number of men Age 15-19 31.4 16.0 13.4 15.2 2.7 57.2 994 20-24 29.8 20.3 15.5 19.0 6.1 59.8 643 25-29 31.0 22.3 15.7 23.3 6.9 54.6 586 30-34 34.0 21.7 17.6 24.8 8.4 54.5 439 35-39 35.2 22.6 16.7 25.4 8.2 54.1 553 40-44 35.7 26.1 18.7 28.2 8.9 50.5 462 45-49 35.9 24.7 17.6 24.9 7.2 48.0 400 Employment (past 12 months) Not employed 18.9 8.9 5.2 10.1 1.2 72.8 538 Employed for cash 26.6 15.5 11.6 17.4 4.0 63.4 973 Employed not for cash 38.1 25.7 19.9 26.0 8.3 47.9 2,564 Marital status Never married 29.6 17.0 13.4 15.7 3.4 59.5 1,865 Married or living together 35.6 24.5 17.8 26.8 8.6 50.8 2,158 Divorced/separated/widowed 33.2 25.5 31.6 32.3 17.2 57.8 53 Number of living children 0 29.6 17.3 13.6 16.7 3.7 59.1 2,009 1-2 35.5 24.7 18.1 26.4 10.1 52.6 638 3-4 35.3 22.5 17.0 26.5 7.3 52.2 720 5+ 37.0 27.3 19.8 27.6 9.5 47.5 709 Residence Urban 23.6 12.8 6.2 11.2 2.3 67.6 1,102 Rural 36.2 24.1 19.6 25.7 7.8 50.1 2,974 District Aileu 13.0 3.3 1.1 2.7 0.7 85.9 181 Ainaro 8.7 7.4 0.4 7.3 0.0 82.6 217 Baucau 65.7 36.5 56.9 67.5 12.2 9.8 415 Bobonaro 16.6 14.8 34.7 24.2 0.7 35.0 357 Covalima 81.6 66.5 6.6 5.8 2.7 6.8 236 Dili 11.6 4.8 1.2 5.9 0.2 81.0 797 Ermera 41.7 35.1 33.5 44.2 27.7 48.5 491 Lautem 76.4 27.4 7.7 7.0 4.0 22.1 308 Liquiçá 3.8 2.4 2.1 2.3 0.0 92.1 252 Manatuto 1.1 0.3 0.3 0.6 0.3 98.6 190 Manufahi 33.7 5.8 6.2 6.2 5.4 64.6 137 Oecussi 65.5 64.4 23.5 72.9 16.7 17.7 235 Viqueque 10.0 5.6 2.0 6.2 0.0 84.3 260 Education No education 29.7 24.6 21.6 27.5 9.5 52.8 791 Primary 32.9 23.0 17.6 25.8 6.3 51.8 1,046 Secondary 35.0 19.7 14.2 19.1 5.6 55.5 2,009 More than secondary 24.6 12.4 5.2 8.2 2.1 69.6 230 Wealth quintile Lowest 38.6 24.3 14.1 25.4 5.0 48.7 728 Second 32.7 23.3 19.5 24.1 8.8 52.7 781 Middle 35.3 21.4 21.6 25.5 8.1 50.6 786 Fourth 37.2 24.3 16.5 22.5 7.7 52.0 849 Highest 22.3 13.5 9.3 13.2 2.5 67.6 932 Total 15-49 32.8 21.1 16.0 21.8 6.3 54.9 4,076 Note: Total includes one man missing information on employment status. 220 | Women’s Empowerment and Demographic and Health Outcomes Of all the specified reasons, men are most likely to agree that a husband has the right to get angry and reprimand his wife if she refuses to have sex with him (33 percent) and least likely to agree with having forced sex with his wife (16 percent). As men’s level of education increases, they are less likely to agree that a husband has the right to exhibit any of the specified behaviors. For example, 10 percent of men with no education condone negative behaviors, compared with 2 percent of men with more than secondary education. A similar relationship is seen with respect to wealth quintile, with the exception of men in the lowest wealth quintile. As household wealth rises from the second quintile to the highest quintile, the percentage of men who support all the specified reasons decreases from 9 percent to 3 percent, respectively. Men therefore exhibit the expected pattern; that is, urban, educated, and wealthy men are more tolerant of women’s sexual rights. Table 15.8 provides a brief overview on how the three basic empowerment indicators— number of decisions in which women participate, number of reasons for which wife beating is justified, and number of reasons for refusing to have sexual intercourse with husband—relate to each other. The first index shows the number of decisions in which women participate alone or jointly with their husband. This index ranges in value from 0 to 4 and is positively related to women’s empowerment. It reflects the degree of decisionmaking control that women are able to exercise in areas that affect their lives and environments. The second index is the number of reasons for which the respondent thinks that a husband is justified in beating his wife. This index ranges in value from 0 to 5. A lower score on this indicator is interpreted as reflecting a greater sense of entitlement and self-esteem, and higher status for women. The final index is the number of circumstances in which the respondent feels that a woman is justified in refusing sexual intercourse with her husband or partner. This index ranges in value from 0 to 3 and is positively related to women’s sense of self-esteem and empowerment. It reflects perceptions of sexual roles and women’s rights over their bodies. Women’s Empowerment and Demographic and Health Outcomes | 221 Table 15.8 Indicators of women’s empowerment Percentage of women age 15-49 who participate in all decisionmaking, percentage who disagree with all reasons for justifying wife beating, and percentage who agree with all reasons for refusing sexual intercourse with husband, by value on each of the indicators of women's empowerment, Timor-Leste 2009-10 Currently married women Percentage who disagree with all the reasons justifying wife beating Percentage who agree with all the reasons for refusing sexual intercourse with husband Empowerment indicator Percentage who participate in all decision- making1 Number of women Number of women Number of decisions in which women participate1 0 na 95 18.3 65.0 95 1-2 na 765 8.2 53.6 765 3-4 na 7,047 11.6 57.8 7,047 Number of reasons for which wife beating is justified2 0 76.6 895 na 39.4 1,815 1-2 70.2 1,867 na 41.1 2,984 3-4 74.0 3,414 na 47.8 5,552 5 76.5 1,730 na 73.5 2,785 Number of reasons given for refusing to have sexual intercourse with husband3 0 72.2 876 30.6 na 2,566 1-2 74.9 2,484 8.0 na 3,930 3 73.7 4,546 10.8 na 6,640 na = Not applicable 1 Restricted to currently married women. See Table 15.5.1 for the list of decisions. 2 See Table 15.6.1 for the list of reasons 3 See Table 15.7.1 for the list of reasons Table 15.8 shows these three indicators of women’s empowerment and how they relate to each other. It shows the percentage of married women age 15-49 who participate in all decisionmaking, the percentage of women who disagree with all the specified reasons for justifying wife beating, and the percentage of women who agree with all the specified reasons for a wife refusing to have sexual intercourse with her husband, by the value on each of the indicators. In general, the expectation is that women who participate in making household decisions are more likely to have gender-egalitarian beliefs. The findings on women’s empowerment indicate that among women who participate in all the decisions, 58 percent justified their right to refuse sexual intercourse with their husband for all reasons, compared with women who participated in 1-2 decisions (54 percent) and in no decisions (65 percent). Similarly, women who participated in all decisions are more likely to disagree with all the reasons for justifying wife beating (12 percent) than women who participate in fewer decisions (8 percent). However, it is also important to point out that women who participate in no decisions are most likely to disagree with all the reasons for justifying wife beating (18 percent). This anomalous pattern is difficult to explain. Similarly, women who do not support wife beating for any reason at all are most likely to participate in all the decisionmaking in the household (77 percent), but this percentage is similar to women who justify all five reasons for wife beating. The direction of the relationship between participation in decisionmaking and reasons to justify wife beating is not clear. Similarly, there is no strong relationship between participation decisionmaking and the number of reasons for refusing sexual intercourse with a husband. This may be attributed to the fact that Timorese women in general exhibit a culture of tolerance and acceptance of male domination, since the majority of women mentioned that it is acceptable for a man to beat his wife for at least one reason (86 percent as seen in Table 15.6.1). It is also noteworthy to point out that women who disagree with all the reasons justifying wife beating are also most likely to not accept any reason for a woman to refuse sexual intercourse with her husband (31 percent), and this percentage decreases to 8 percent for women who accept at least one to two reasons and 11 percent for women who accept all three reasons. 222 | Women’s Empowerment and Demographic and Health Outcomes 15.7 CURRENT USE OF CONTRACEPTION BY WOMEN’S STATUS A woman’s desire and ability to control her fertility and her choice of contraceptive method are in part affected by her status in the household and her own sense of empowerment. A woman who feels that she is unable to control 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 are less obvious or which do not depend on her husband’s cooperation. Table 15.9 shows the distribution of currently married women by contraceptive method used, according to the three empowerment indicators. The data indicate that there is a positive relationship between use of contraception and participation in household decisionmaking. For example, current use of modern contraceptive methods rises from 13 percent among women who participate in none of the household decisions to 21 percent among women who participate in one or more household decisions. Also noteworthy is the finding that women who believe that wife beating is justified for all of the five specified reasons are most likely to use a method of contraception. There is no clear trend in using a method of contraception and the belief in a woman’s right to refuse sexual intercourse with her husband. Perhaps this could also be attributed to the fact that women less often justify a wife refusing sex with her husband for any reason due to cultural norms. Table 15.9 Current use of contraception by women's status Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women's status, Timor-Leste 2009-10 Modern methods Empowerment indicator Any method Any modern method Female sterilization Temporary modern female methods1 Male condom Any traditional method Not currently using Total Number of women Number of decisions in which women participate2 0 16.2 12.5 0.0 12.5 0.0 3.8 83.8 100.0 95 1-2 23.8 21.4 0.7 20.7 0.0 2.4 76.2 100.0 765 3-4 22.2 21.2 0.8 20.1 0.3 1.1 77.8 100.0 7,047 Number of reasons for which wife beating is justified3 0 19.1 18.2 0.8 17.4 0.0 0.9 80.9 100.0 895 1-2 23.0 21.7 1.2 20.2 0.2 1.3 77.0 100.0 1,867 3-4 22.3 21.3 0.7 20.3 0.3 0.9 77.7 100.0 3,414 5 23.5 21.6 0.6 20.8 0.2 1.9 76.5 100.0 1,730 Number of reasons given for refusing to have sexual intercourse with husband4 0 22.5 21.8 0.6 20.5 0.7 0.8 77.5 100.0 876 1-2 27.8 26.3 1.1 24.8 0.3 1.5 72.2 100.0 2,484 3 19.3 18.2 0.6 17.4 0.1 1.2 80.7 100.0 4,546 Total 22.3 21.1 0.8 20.1 0.2 1.2 77.7 100.0 7,906 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, lactational amenorrhea method and standard days method 2 See Table 15.5.1 for the list of decisions. 3 See Table 15.6.1 for the list of reasons 4 See Table 15.7.1 for the list of reasons 15.8 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S STATUS The ability of women to make decisions effectively has important implications for their fertility preferences and the practice of family planning. An increase in women’s status and empowerment is recognized as important for efforts to reduce fertility through at least two main Women’s Empowerment and Demographic and Health Outcomes | 223 pathways: its negative association with desired family size and its positive association with women’s ability to meet their own family-size goals through the effective use of contraception. Table 15.10 shows how women’s ideal family size and their unmet need for family planning vary by women’s status indicators. The data indicate that there is a positive association between ideal family size and two of the three empowerment indicators. The relationship between ideal family size and decisionmaking is as expected: women who participate in no decisions have higher ideal family size (6.2) than women who participate in any decisions (5.7 or lower). There is little association between ideal family size and attitudes towards wife beating. On the contrary, ideal family size is highest among women who believe that a woman can refuse sexual intercourse with her husband for all specified reasons (5.2 children) and lowest among women who believe that sexual intercourse cannot be refused for any of the three reasons (4.5 children). Table 15.10 Women’s empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women age 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women's empowerment, Timor-Leste 2009-10 Mean ideal number of children1 Percentage of currently married women with an unmet need for family planning2 Number of currently married women Empowerment indicator Number of women For spacing For limiting Total Number of decisions in which women participate3 0 6.2 90 12.5 7.5 20.0 95 1-2 5.6 718 14.0 12.1 26.1 765 3-4 5.7 6,846 21.3 10.1 31.4 7,047 Number of reasons for which wife beating is justified4 0 4.9 1,702 23.2 8.3 31.5 895 1-2 5.0 2,881 22.0 9.2 31.3 1,867 3-4 5.0 5,357 19.9 10.3 30.3 3,414 5 5.0 2,682 18.7 12.1 30.8 1,730 Number of reasons given for refusing to have sexual intercourse with husband5 0 4.5 2,374 19.7 11.6 31.2 876 1-2 4.9 3,767 20.1 9.9 30.0 2,484 3 5.2 6,481 20.9 10.2 31.1 4,546 Total 5.0 12,622 20.5 10.2 30.8 7,906 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.3.1 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 15.5.1 for the list of decisions. 4 See Table 15.6.1 for the list of reasons. 5 See Table 15.7.1 for the list of reasons. Although there is no clear linear relationship between unmet need and women’s empowerment, the data show that unmet need is highest among women who participate in three to four household decisions. Again, educated women and those belonging to the highest wealth quintile are less often participating in all specified households decisions, which translates to their having a lower unmet need for family planning. There is no clear relationship between unmet need and women’s belief that refusing sexual intercourse and wife beating is acceptable for any reason. 224 | Women’s Empowerment and Demographic and Health Outcomes 15.9 REPRODUCTIVE HEALTH CARE BY WOMEN’S STATUS Table 15.11 shows women’s use of antenatal, delivery, and postnatal care services by the three indicators of women’s empowerment. 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 limited health services to better meet their own reproductive health goals, including the goal of safe motherhood. 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, Timor-Leste 2009-10 Empowerment indicator Received antenatal care from health personnel Received delivery assistance from health personnel Received postnatal care from health personnel within the first two days since delivery1 Number of women with a child born in the past five years Number of decisions in which women participate2 0 85.3 36.4 20.7 66 1-2 84.5 43.9 34.9 528 3-4 86.6 32.4 23.6 5,208 Number of reasons for which wife beating is justified3 0 80.6 33.2 22.4 658 1-2 87.3 37.0 26.2 1,413 3-4 87.7 34.3 25.8 2,585 5 84.1 27.7 21.8 1,360 Number of reasons given for refusing to have sexual intercourse with husband4 0 85.9 45.0 29.3 642 1-2 89.9 42.9 32.6 1,850 3 84.0 26.2 19.6 3,523 Total 86.0 33.3 24.6 6,015 Note: “Health personnel” includes doctor, nurse, midwife, or assistant nurse. 1 Includes deliveries in a health facility and not in a health facility 2 Restricted to currently married women. See Table 15.5.1 for the list of decisions. 3 See Table 15.6.1 for the list of reasons. 4 See Table 15.7.1 for the list of reasons. The data indicate that there is a correlation between women’s status, as measured by the number of reasons for justifying wife beating, and utilization of health services. Women who believe that wife beating is justified for all five reasons are less likely to receive antenatal care, delivery assistance, or postnatal care from health personnel than women who believe that wife beating is justified for one to two reasons. The relationship between utilization of health services and the other two women’s empowerment indicators is less clear. As antenatal care is widely accessible to most women, differences by empowerment index are not clearly reflected. Domestic Violence | 225 DOMESTIC VIOLENCE 16 In the words of former United Nations Secretary General, Kofi Annan, “violence against women is perhaps the most shameful human rights violation. And it is perhaps the most pervasive. It knows no boundaries of geography, culture, or wealth. As long as it continues, we cannot claim to be making real progress towards equality, development, and peace” (UNIFEM, 2003). The World Health Organization (WHO) defines domestic violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation” (Krug et al., 2002). Domestic violence is defined here as any act of violence resulting in physical, sexual, or psychological harm or suffering to women, girls, and also men, including threats of such acts, coercion, or arbitrary deprivation of liberty. Domestic violence is the most common form of gender-based violence in Timor-Leste. Studies have indicated that Timor-Leste has a long history of culturally accepted forms of domestic violence. People prefer not to talk about domestic violence, as it is considered a private matter. Therefore, reporting on domestic violence is considered a societal taboo. It is expressed that “Gender-based violence is widespread in Timor-Leste, yet perpetrators are rarely punished. Family disputes and domestic violence is often considered a ‘normal,’ yet very private occurrence within the family” (Concern.net, 2008). It is not a common practice to seek justice through traditional justice systems; the perpetrators of gender-based violence cannot simply be punished or removed from the community. Often the family of the perpetrator gives animals (water buffalos, goats, or pigs) to the victim’s family. This gift opens an avenue of reconciliation that concludes with a ceremony, usually a feast, indicating that there are no more hard feelings and no need for social disturbances. After the conclusion of such a ceremony, the perpetrator is once again allowed to move around freely. A baseline study conducted in 2007 in the two districts of Covalima and Bobonaro indicated that the patriarchal belief of women’s role in society, religion, and preconceived notions of sexuality make discussions of sexual and gender-based violence nearly impossible (UNMIT, 2009). After a concerted lobbying effort led by the Office of the Secretariat of State for the Promotion of Equality, the United Nations Population Fund (UNFPA), the United Nations Development Fund for Women (UNIFEM), UNMIT and local and international NGOs, the National Parliament in Timor-Leste passed a Law Against Domestic Violence on May 3, 2010, which came into force one month later. These efforts represented the culmination of seven years’ work, which involved harmonization with relevant provisions of the Timorese Criminal Code. The Law Against Domestic Violence clearly states that crimes of domestic violence are public crimes and also provides for medical, legal, and psycho-social support for survivors. However, consideration of the law did not occur until 2009 after the penal code was approved which included domestic violence as a punishable crime for the first time under Timorese or Indonesian rule (UNIFEM, 2010). The law was finally promulgated by the President on June 21, 2010. The 2009-10 TLDHS included a series of questions that focus on specific aspects of domestic and interpersonal violence. The module addresses women’s experience of interpersonal violence, including acts of physical, sexual, and emotional violence. Information was collected on both domestic violence (also known as spousal violence or intimate partner violence) and violence by other family members or unrelated individuals. Specifically, this chapter presents the findings on women who ever experienced interpersonal violence—physical violence since the age of 15, lifetime experience of sexual violence—and women who experienced partner violence ever and in the past 12 months. In addition, detailed information is presented on partner violence, including the physical consequences of violence and when partner violence began. 226 | Domestic Violence 16.1 MEASUREMENT OF VIOLENCE Collecting valid, reliable, and ethical data on intimate partner violence poses particular challenges because (1) what constitutes violence or abuse varies across cultures and individuals; (2) a culture of silence usually surrounds domestic violence and can affect reporting; and (3) the topic is a sensitive one. Ensuring the safety of respondents and interviewers when asking about domestic violence in a familial setting and protecting women who disclose violence raises specific ethical concerns. The responses to these challenges by the 2009-10 TLDHS are described below. 16.1.1 The Use of Valid Measures of Violence The 2009-10 TLDHS measures violence committed by spouses and other household members. Accordingly, information was obtained from ever-married women on violence by spouses and by others, and from never-married women on violence by anyone, including boyfriends/ girlfriends. International research on violence shows that intimate partner violence is one of the most common forms of violence against women. Thus, spousal/partner violence was measured in more detail than violence by other perpetrators by using a modified Conflict Tactics Scale (CTS) (Strauss, 1990). Specifically, spousal violence was measured using the following set of questions for women: (Does/did) your (last) husband/partner ever do any of the following things to you? 1. Push you, shake you, or throw something at you? 2. Slap you? 3. Twist your arm or pull your hair? 4. Punch you with his fist or with something that could hurt you? 5. Kick you, drag you, or beat you up? 6. Try to choke you or burn you on purpose? 7. Threaten or attack you with a knife, gun, or any other weapon? 8. Physically force you to have sexual intercourse with him even when you did not want to? 9. Force you to perform any sexual acts you did not want to? When the answer to the question was “yes,” women (with the exception of widows) were asked about the frequency of the act in the 12 months preceding the survey. A “yes” answer to one or more of items 1-7 above constitutes evidence of physical violence, while a “yes” answer to items 8 or 9 constitutes evidence of sexual violence. Emotional violence among ever-married women was measured in a similar way, using the following set of questions: (Does/did) your (last) husband ever: 1. Say or do something to humiliate you in front of others? 2. Threaten to hurt or harm you or someone close to you? 3. Insult you or make you feel bad about yourself? This approach of asking about specific acts to measure different forms of violence has the advantage of not being affected by different understandings of what constitutes a summary term such as violence. By including a wide range of acts, this approach has the additional advantage of giving the respondent multiple opportunities to disclose any experience of violence. In addition to these questions asked only of ever-married women, all women were asked about physical violence from persons other than their current or most recent spouse/partner with the question: From the time you were 15 years old, has anyone [other than your (current/last) husband/ Domestic Violence | 227 partner] hit, slapped, kicked, or done anything else to hurt you physically? Respondents who answered this question in the affirmative were asked who had done this to them and the frequency of such violence during the 12 months preceding the survey. All women were also asked: At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts? Respondents who said “yes” were then asked questions about the age at which this first happened and the person who committed the act. 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. 16.1.2 Ethical Considerations Three specific protections were built into the questionnaire, in accordance with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO, 2001b): • Only one eligible person in each household was administered the questions on violence. Individual interviews using TLDHS Women’s Questionnaires were carried out in every household selected for the DHS survey (that is, 11,463 households in the sample). The domestic violence module was administered to women in one-third of households selected for the TLDHS individual interview. The DHS protocol specifies that the domestic violence module can only be administered to one randomly selected person per household. Therefore, in households with more than one eligible woman, the respondent for the module was randomly selected through a specially designed simple selection procedure (based on the ‘Kish Grid’), which was built into the Household Questionnaire. Interviewing only one person in each household using the domestic violence module provides assurance to the selected respondent that other respondents in the household will not talk about the types of questions the selected respondent was asked. • Informed consent for the survey was obtained from the respondent at the beginning of the individual interview. In addition, at the beginning of the domestic violence section respondents were read an additional statement informing them that the subsequent questions could be sensitive and reassuring them of the confidentiality of their responses. • The domestic violence module was implemented only if privacy could be obtained. If privacy could not be obtained, the interviewer was instructed to skip the module, thank the respondent, and end the interview. If a translator was needed to conduct the interview, respondents were not asked questions from the domestic violence module to maintain privacy. 16.1.3 Special Training for Implementing the Domestic Violence Module Complete privacy is also essential for ensuring the security of the respondent and the interviewer. Asking about or reporting violence, especially in households where the perpetrator may be present at the time of interview, carries the risk of further violence. Accordingly, interviewers were provided specific training for implementing the domestic violence module in order to enable the field staff to collect violence data in a secure, confidential, and ethical manner. Although most women interviewed do not necessarily ask for help, some abused women may ask the interviewer for assistance. To prepare for this possibility, interviewers were provided with a nationwide list of available network services at the district level for women facing violence. These included contact information on central and regional offices of Psychosocial Recovery and 228 | Domestic Violence Development East Timor (PRADET), Polisia National Timor-Leste (PNTL), Forum Komunikasi Untuk Perempuan Timor Lorosa’e (FOKUPERS), and Institute Maun Alin iha Kristo (ISMAIK). PRADET supports victims of violence through its Fatin Hakmatek (Safe Place) program. Fatin Hakmatek provides services through a treatment facility and coordinates with other agencies to extend services in the country (Trembath and Grenfell, 2007). The Vulnerable Person’s Unit under the PNTL provides services to victims of violence, including gender-based violence, and has extensive coverage with an office in each district. The main focus of FOKUPERS is on providing counseling, assistance, and safe house or shelter facilities to individuals who fall victim to domestic and sexual violence in Maliana, Suai, Ermera, and Liquiçá districts (Trembath and Grenfell, 2007). These organizations form the gender-based violence referral network that provides coordinated services in Timor-Leste. The interviewers were trained to provide respondents with information on where they can seek help from officers at the district level. These officers are responsible for handling social welfare matters in the district, including the welfare of children and families. However, the interviewers were instructed to be very careful when providing such information, as in some cases men in the household may turn more violent towards women when they see such documents. 16.1.4 Characteristics of the Sub-sample of Respondents for the Domestic Violence Module Given that only one person was administered the domestic violence module in each selected household and that the violence module was not administered if privacy could not be obtained, 65 of the 3,022 women eligible for the violence module had to be excluded because of lack of privacy, and six women refused to be interviewed with the domestic violence module. It is noteworthy that the age, marital status, and residential, regional, educational, and wealth index distributions of the sub-sample of respondents selected for the violence module are virtually identical to the entire TLDHS sample of respondents and therefore representative of the reporting domains selected for the TLDHS (data not shown). 16.2 EXPERIENCE OF DOMESTIC VIOLENCE BY WOMEN This section of the chapter discusses women’s experience of violence by any individual. The data on domestic violence for women are weighted differently from the rest of the data collected in the Women’s Questionnaires. This was done to adjust for the fact that only one person per household was interviewed with the domestic violence module and to cater for nonresponse. The section begins by examining the experience of physical violence since age 15 and physical violence during pregnancy, and continues with findings on women’s lifetime experience of sexual violence. Background characteristics associated with increased risk of violence are also discussed. This report mainly presents information on domestic violence against women. Table 16.1 shows the percentage of women who have ever experienced physical violence since age 15, and in the past 12 months, by background characteristics. Approximately one-third of women (38 percent) have experienced physical violence since the age 15. Twenty-nine percent of women experienced physical violence often or sometimes in the past 12 months. One percent of women experienced physical violence often, while 28 percent experienced physical violence sometimes in the past 12 months. Domestic Violence | 229 Table 16.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced physical violence during the 12 months preceding the survey, by background characteristics, Timor-Leste 2009-10 Percentage who have ever experienced physical violence since age 151 Percentage who have experienced physical violence in the past 12 months Background characteristic Often Sometimes Often or sometimes Number of women Current age 15-19 30.3 0.1 24.6 24.7 700 20-24 34.8 1.3 25.7 27.0 513 25-29 48.1 0.7 37.9 38.6 403 30-39 43.6 2.2 31.2 33.4 765 40-49 36.5 1.2 23.3 24.4 570 Employed past 12 months Not employed 39.6 0.9 30.1 30.9 1,795 Employed for cash 42.9 4.5 24.6 29.1 219 Employed not for cash 34.3 0.9 25.0 25.9 937 Marital status Never married 28.7 0.1 21.4 21.4 992 Married or living together 42.3 1.3 32.4 33.7 1,843 Divorced/separated/widowed 52.9 7.9 16.5 24.4 116 Number of living children 0 29.4 0.1 22.2 22.3 1,106 1-2 44.3 2.1 34.5 36.6 527 3-4 44.3 1.2 32.0 33.2 594 5+ 41.9 2.0 29.0 31.0 724 Residence Urban 48.7 0.6 33.7 34.3 700 Rural 34.9 1.3 26.3 27.6 2,251 District Aileu 39.8 1.3 19.9 21.2 128 Ainaro 10.5 0.3 7.3 7.6 160 Baucau 44.3 3.5 31.0 34.5 334 Bobonaro 14.4 0.0 14.1 14.1 281 Covalima 57.4 0.4 57.0 57.4 177 Dili 52.7 1.0 31.8 32.8 474 Ermera 24.2 0.7 16.7 17.4 357 Lautem 53.1 1.1 41.2 42.3 192 Liquiçá 34.5 0.0 25.7 25.7 179 Manatuto 16.5 0.0 10.6 10.6 135 Manufahi 75.6 1.6 63.3 65.0 114 Oecussi 56.3 1.5 42.3 43.9 201 Viqueque 21.1 2.3 18.2 20.4 219 Education No education 37.4 1.4 27.6 29.0 896 Primary 41.1 1.8 30.6 32.4 695 Secondary 36.6 0.7 27.1 27.8 1,268 More than secondary 45.6 0.0 26.6 26.6 91 Wealth quintile Lowest 35.2 1.1 27.4 28.4 567 Second 36.8 2.3 27.0 29.3 572 Middle 36.2 1.2 27.1 28.3 597 Fourth 36.9 0.7 29.7 30.4 594 Highest 45.2 0.5 29.1 29.6 620 Total 38.1 1.1 28.1 29.2 2,951 Note: Includes women who are married by age 15. 1 Includes in the past 12 months The proportion of women who have ever experienced physical violence is highest among women age 25-29. These women are also more likely to report having experienced physical violence sometimes or often in the past 12 months (39 percent). Women who are employed for cash are more likely to report having experienced physical violence since age 15 than women who are unemployed or employed but not for cash. This may be an indication that working women who have an independent source of cash income may pose a challenge to the established norm of being dependent 230 | Domestic Violence on their male partners for their livelihood, and therefore this role reversal may subject them to greater violence. Formerly married women (divorced, separated, or widowed) are more likely to have ever experienced physical violence since age 15 than currently married and never-married women (53 percent, compared with 42 and 29 percent, respectively). Formerly married women are also more likely to have experienced physical violence often in the past 12 months (8 percent) than currently married women (1 percent), perhaps indicating the vulnerable position of women who have lost their spouse and become dependent on others for their basic needs. Women with no living children are the least likely to have experienced physical violence in the past 12 months. There is no clear pattern of rates of physical violence experienced by women with children. Urban women are more likely to have ever experienced physical violence since the age of 15 compared with rural women (49 percent compared with 35 percent). This is corroborated by the fact that more than half of the women in Dili district, which is primarily urban, reported experiencing physical violence since the age of 15 years. Women in Manufahi (76 percent) are most likely to report having ever experienced physical violence. Experience of physical violence in the past 12 months is highest among women in Manufahi (65 percent) and lowest in Ainaro (8 percent). The proportion of women who have ever experienced physical violence is highest among women with more than secondary education (46 percent) and those belonging to households in the highest wealth quintile (45 percent). This supports the assumption that highly educated women are usually from wealthier households, primarily located in urban areas and more likely to have access to cash earnings. These women may be victims of spousal violence because they have broken the cultural norms in a patriarchal society. On the other hand, it is also possible that educated, wealthier, and urban women are more likely to report any violence because they recognize that any form of violence is unacceptable, in contrast to their counterparts, who may be more accepting of violence against women as part and parcel of life and hence less likely to report their experience. 16.3 PERPETRATORS OF PHYSICAL VIOLENCE AGAINST WOMEN Table 16.2 identifies the perpetrators of physical violence, by women’s current marital status. The percentages do not sum to 100 because respondents could have experienced violence at the hands of several people. Among ever-married women who have ever experienced physical violence, 74 percent reported that a current husband or partner committed the physical violence against them, while 6 percent reported that they experienced physical violence by a former husband/partner. Other perpetrators commonly reported by ever-married women were mother/stepmother (34 percent) and father/stepfather (26 percent), sisters and brothers (11 percent), and other relatives (6 percent). Table 16.2 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 marital status, Timor-Leste 2009-10 Marital status Person Ever married Never married Total Current husband/partner 73.8 na 55.2 Former husband/partner 6.3 na 4.7 Current boyfriend 0.0 0.4 0.1 Former boyfriend 0.5 0.0 0.4 Father/ stepfather 25.7 59.1 34.2 Mother/ stepmother 34.2 64.5 41.9 Sister/brother 11.3 26.7 15.2 Daughter/ son 0.4 1.6 0.7 Other relative 5.9 8.2 6.5 Mother-in-law 0.2 na 0.2 Father-in-law 0.4 na 0.3 Teacher 1.4 12.8 4.3 Employer/ someone at work 0.0 1.2 0.3 Other 1.1 1.0 1.1 Number of women 842 284 1,126 na= Not applicable Domestic Violence | 231 Among women who have never been married, parents are the most common perpetrators of physical violence. Sixty-five percent reported mother/step-mother and 59 percent father/step-father as their perpetrators. Among never-married women, 27 percent also reported physical violence committed by siblings while 13 percent reported teachers as the perpetrators. 16.4 WOMEN’S EXPERIENCE OF FORCE AT SEXUAL INITIATION The 2009-10 TLDHS investigated women’s experience of sexual violence, including a question on whether the respondent’s first sexual intercourse was forced against her will. Because the idea of force can be interpreted in various ways, the question was worded as follows: The first time you had sexual intercourse, would you say that you had it because you wanted to or because you were forced to do it against your will? Table 16.3 shows that only 1 percent of women said their first sexual experience was forced against their will. This proportion is relatively higher among those who first had sex before age 15 (4 percent). In addition to the question on whether first sexual intercourse was forced, the 2009-10 TLDHS included two sets of questions on sexual violence. Sexual violence limits women’s ability to practice safe sex and to protect themselves from sexually transmitted infections and unwanted pregnancies (Krug et al., 2002). The first set of questions asked about sexual violence committed by their current spouse, if they were currently married, and the most recent spouse, if they were currently divorced, separated, or widowed. The second set of questions asked all respondents, irrespective of marital status, whether they had ever, as a child or as an adult, experienced sexual violence. Sexual violence here includes being forced to have sexual intercourse or perform any other sexual acts against one’s will. Tables 16.3 through 16.5 present the results on the experience of any sexual violence. The findings on sexual violence among women by a spouse or intimate partner are explored later in the chapter. 16.5 EXPERIENCE OF SEXUAL VIOLENCE AND PERPETRATORS OF SEXUAL VIOLENCE As shown in Table 16.4, about 3 percent of women have experienced sexual violence. Women age 30-39 are slightly more likely than other women to have experienced sexual violence. Women who are employed for cash are twice as likely to face sexual violence compared with women who do not work and those who work but not for cash income. Women who work in a cash economy may be more likely to encounter violence in their workplace compared with women employed in a non-cash economy who usually work for a family member and at home or closer to home. A higher proportion of women who are divorced/separated/widowed (9 percent) have experienced sexual violence compared with never-married women. Table 16.3 Force at sexual initiation Percentage of women age 15-49 who have ever had sexual intercourse who say that their first experience of sexual intercourse was forced against their will, by age at first sexual intercourse and whether the first sexual intercourse was at the time of first marriage or before, Timor-Leste 2009-10 Percentage whose first sexual intercourse was forced against their will Number of women who have ever had sex Age at first sexual intercourse <15 3.7 103 15-19 0.9 865 20-24 1.1 682 25-29 0.3 198 30-49 1.9 64 Missing 1.4 54 First sexual intercourse was: At the time of first marriage/ first cohabitation 1.1 1,717 Before first marriage/ first cohabitation1 1.0 194 Missing 1.4 54 Total 1.1 1,966 1 Includes never-married women 232 | Domestic Violence Table 16.4 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence, by background characteristics, Timor-Leste 2009- 10 Background characteristic Percentage who have ever experienced sexual violence1 Number of women Current age 15-19 2.0 700 20-24 2.4 513 25-29 3.9 403 30-39 5.1 765 40-49 3.3 570 Employed past 12 months Not employed 3.3 1,795 Employed for cash 6.1 219 Employed not for cash 2.9 937 Marital status Never married 1.3 992 Married or living together 4.1 1,843 Divorced/separated/widowed 9.3 116 Residence Urban 3.5 700 Rural 3.3 2,251 District Aileu 6.6 128 Ainaro 2.6 160 Baucau 7.0 334 Bobonaro 1.4 281 Covalima 2.6 177 Dili 2.3 474 Ermera 3.4 357 Lautem 6.8 192 Liquiçá 4.5 179 Manatuto 2.3 135 Manufahi 1.4 114 Oecussi 2.9 201 Viqueque 0.4 219 Education No education 3.9 896 Primary 3.9 695 Secondary 2.9 1,268 More than secondary 0.0 91 Wealth quintile Lowest 3.4 567 Second 4.8 572 Middle 3.2 597 Fourth 3.0 594 Highest 2.5 620 Total 3.4 2,951 1 Includes those whose sexual initiation was forced against their will Urban-rural differences in experience of sexual violence are minimal. By district, the proportion of women who have experienced sexual violence ranges from less than 1 percent in Viqueque to 7 percent in Baucau, Lautem, and Aileu. Women with no education (4 percent) are slightly more likely to experience sexual violence than women with secondary or higher levels of education. Sexual violence is also slightly lower among women in the highest wealth quintile than those in the other wealth quintiles. The 2009-10 TLDHS also collected information on age at first sexual violence and perpetrators of sexual violence. For 16 percent of women who ever experienced sexual violence, the first experience of such violence occurred at age 15-19; 6 percent first experienced sexual violence at age 10-14; and less than 1 percent first experienced sexual violence before age 10. One in ten women Domestic Violence | 233 who experienced sexual violence first experienced it at age 20-49 (data not shown). It is important to note that in the 2009-10 TLDHS questionnaire, if a respondent experienced sexual violence committed only by their current spouse/partner (or the most recent spouse if they are currently divorced/separated), and their sexual initiation was not forced against their will, information was not collected on age at first experience of sexual violence. The main perpetrators of sexual violence against ever-married women are current husbands/partners (71 percent) or former husbands/partners (9 percent). Seven percent of all women who have experienced sexual violence experienced it at the hands of current or former boyfriends, while 6 percent of women each experienced sexual violence committed by a relative other than their husband, boyfriend, father, or step-father; 4 percent experienced sexual violence committed by strangers (data not shown). 16.6 EXPERIENCE OF DIFFERENT TYPES OF VIOLENCE Table 16.5 shows the percentage of respondents who have experienced different forms of physical and sexual violence, by age. Overall, 36 percent of women age 15-49 have experienced only physical violence, while 1 percent have experienced only sexual violence. About 2 percent of women have experienced both physical and sexual violence, and nearly two in five women (39 percent) have experienced either physical or sexual violence. The likelihood of having experienced either physical or sexual violence increases with age, from 31 percent among women age 15-19 to 49 percent among women age 25-29 before declining to 38 percent among women in their 40s. Table 16.5 Experience of different forms of violence Percentage of women age 15-49 who have experienced different forms of violence, by current age, Timor-Leste 2009-10 Age Physical violence only Sexual violence only1 Physical and sexual violence1 Physical or sexual violence1 Number of women 15-19 28.5 0.2 1.8 30.5 700 15-17 28.2 0.2 0.1 28.5 446 18-19 29.1 0.1 4.7 33.9 254 20-24 33.9 1.5 0.9 36.3 513 25-29 44.9 0.8 3.1 48.8 403 30-39 40.0 1.4 3.6 45.1 765 40-49 34.5 1.3 2.0 37.8 570 Total 35.8 1.0 2.3 39.2 2,951 1 Includes forced sexual initiation 16.7 VIOLENCE DURING PREGNANCY Women who have ever been pregnant were asked about the experience of physical violence during pregnancy. The findings presented in Table 16.6 indicate that overall, 4 percent of women in Timor-Leste experienced physical violence during pregnancy. By background characteristics, the results show that violence during pregnancy is higher among women age 30-39, unemployed women, formerly married women, women with five or more children, rural women, women living in Liquiçá, women with no education, and women in the lowest wealth quintile, than among their counterparts in the other categories. 234 | Domestic Violence Table 16.6 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, Timor-Leste 2009-10 Background characteristic Percentage who have ever experienced physical violence during pregnancy Number of women who have ever been pregnant Current age 15-19 3.2 63 20-24 2.6 257 25-29 2.4 329 30-39 4.9 717 40-49 3.5 539 Employed past 12 months Not employed 4.3 1,064 Employed for cash 1.5 167 Employed not for cash 3.2 675 Marital status Never married * 1 Married or living together 3.4 1,792 Divorced/separated/widowed 8.8 113 Number of living children 0 1.1 61 1-2 3.9 527 3-4 3.1 594 5+ 4.3 724 Residence Urban 2.7 460 Rural 4.0 1,445 District Aileu 3.6 72 Ainaro 0.6 99 Baucau 4.7 224 Bobonaro 0.0 170 Covalima 0.9 107 Dili 3.3 326 Ermera 2.8 216 Lautem 11.1 136 Liquiçá 12.3 113 Manatuto 0.5 74 Manufahi 5.1 80 Oecussi 4.1 138 Viqueque 0.0 150 Education No education 4.8 733 Primary 3.6 483 Secondary 2.7 636 More than secondary (1.8) 54 Wealth quintile Lowest 5.1 376 Second 3.6 380 Middle 4.3 368 Fourth 3.7 378 Highest 1.9 404 Total 3.7 1,905 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 16.8 MARITAL CONTROL The International Rescue Committee reported in two studies conducted in 2003 that more than half of Timorese women felt unsafe in their relationship with their husband (IRC, 2003a) and 25 percent had experienced violence from an intimate partner (IRC, 2003b). Domestic Violence | 235 Domestic violence is not limited to physical and sexual violence. Verbal abuse, restrictions on freedom of movement, and withholding funds can also constitute violent behavior. This section of the chapter examines women’s experiences of marital control. Table 16.7 shows the percentage of ever-married women whose husbands have exhibited various types of behaviors aimed at controlling their wife/partner. Table 16.7 Degree of marital control exercised by husbands Percentage of ever-married women age 15-49 whose husband/partner ever demonstrates specific types of controlling behaviors, according to background characteristics, Timor-Leste 2009-10 Percentage of women whose husband: Background characteristic Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Does not trust her with any money Displays 3 or more of the specific behaviors Displays none of the specific behaviors Number of women Current age 15-19 21.3 19.7 16.4 8.4 49.0 6.3 16.0 46.8 67 20-24 36.1 17.3 10.7 3.3 36.7 8.5 16.1 49.2 271 25-29 36.4 15.5 9.8 6.3 32.3 9.4 14.5 47.0 341 30-39 27.9 13.4 7.4 3.3 27.5 7.6 11.1 56.6 729 40-49 29.9 15.8 8.0 3.4 29.3 6.2 14.7 55.3 551 Employed past 12 months Not employed 33.1 14.0 9.3 4.5 30.8 8.1 13.7 51.6 1,094 Employed for cash 42.3 20.2 10.7 3.4 38.7 17.0 15.6 38.9 170 Employed not for cash 24.5 15.9 7.5 3.5 29.1 4.5 12.9 59.2 695 Number of living children 0 35.3 23.0 14.9 8.8 35.9 8.8 22.6 50.9 115 1-2 33.9 16.6 9.1 3.7 33.1 8.6 14.0 49.0 527 3-4 32.0 13.7 9.6 3.9 29.2 7.7 13.0 53.8 594 5+ 27.0 14.2 6.8 3.6 29.8 6.6 12.3 56.1 724 Marital status and duration Currently married woman 30.7 14.3 8.6 3.8 30.6 7.1 13.0 53.6 1,843 Married only once 30.8 14.3 8.6 3.9 30.9 7.1 13.1 53.3 1,817 0-4 years 34.4 16.3 10.5 4.8 36.3 6.8 15.3 48.2 332 5-9 years 34.9 16.1 9.7 4.3 32.4 10.8 14.5 49.8 352 10+ years 28.5 13.2 7.8 3.5 28.8 6.0 12.0 55.8 1,133 Married more than once (19.1) (11.6) (8.2) (0.0) (13.5) (5.6) (10.8) (73.6) 26 Divorced/separated/widowed 34.2 29.4 10.5 7.0 34.6 16.4 22.1 47.7 116 Residence Urban 51.9 27.6 14.7 6.6 42.8 14.7 24.9 31.3 468 Rural 24.2 11.3 6.9 3.2 27.1 5.4 10.0 60.1 1,491 District Aileu 23.2 10.5 11.0 7.0 18.0 7.0 9.0 68.2 74 Ainaro 17.4 7.9 10.7 3.7 29.5 3.1 9.6 62.3 100 Baucau 48.1 9.0 5.5 3.3 30.4 7.8 8.1 43.5 230 Bobonaro 10.6 8.0 5.6 1.2 6.2 3.5 5.9 82.9 172 Covalima 11.1 19.2 4.0 0.6 28.0 0.0 8.0 66.6 115 Dili 66.8 34.0 17.0 6.1 45.2 18.5 30.3 19.8 336 Ermera 37.8 22.4 9.4 4.5 56.2 4.4 22.4 39.4 225 Lautem 28.6 12.3 12.7 10.2 27.8 11.0 16.2 53.6 136 Liquiçá 8.1 3.7 5.4 2.9 8.9 7.7 5.8 77.6 115 Manatuto 13.1 6.6 4.6 2.4 17.5 5.0 7.5 77.9 79 Manufahi 17.5 5.9 4.6 1.6 48.5 2.5 6.5 45.7 84 Oecussi 16.4 11.0 4.8 3.8 8.8 6.1 5.1 74.0 140 Viqueque 15.0 9.6 6.2 2.1 36.6 4.0 8.1 58.2 153 Education No education 24.0 13.0 7.3 2.9 28.1 5.1 11.1 59.6 753 Primary 29.2 16.6 9.7 6.0 31.3 8.1 16.0 54.6 495 Secondary 37.5 15.7 9.5 3.7 33.2 8.9 13.7 46.5 656 More than secondary (60.7) (27.3) (11.7) (5.1) (37.1) (22.7) (23.8) (32.7) 54 Wealth quintile Lowest 17.8 8.9 6.0 2.7 21.4 3.1 7.1 67.5 392 Second 27.6 11.7 8.7 4.5 30.8 8.3 11.8 57.0 389 Middle 26.1 15.2 9.0 3.8 29.5 4.5 12.7 56.1 379 Fourth 30.9 15.9 7.1 3.5 31.3 7.7 14.4 52.5 385 Highest 50.5 23.7 12.6 5.5 40.7 14.0 21.4 34.1 415 Total 30.9 15.2 8.8 4.0 30.9 7.6 13.6 53.2 1,959 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in parentheses are based on 25-49 unweighted cases. 236 | Domestic Violence To determine the degree of marital control husbands exercise over their wives, ever-married women were asked whether their current or last husband exhibited each of the following controlling behaviors: a) becomes jealous or gets angry if she talks to other men; b) accuses her of being unfaithful; c) does not permit meetings with female friends; d) tries to limit contact with her family; e) insists on knowing where she is at all times; and f) does not trust her with any money. The accumulation of such behaviors is more significant than the results for any single behavior and so, the proportion of women whose husbands exhibited at least three of the specified behaviors is highlighted. The findings show that nearly one in three (31 percent) ever-married women reported that their husbands insist on knowing where they are at all times; a similar proportion (31 percent) said that their husbands get jealous or angry if they talk to other men; and 15 percent said that their husbands frequently accuse them of being unfaithful. Nearly one in 10 women reported that their husbands do not allow them to meet with their female friends, and 8 percent said that their husbands do not trust them with money. Relatively uncommon is a husband’s attempt to limit his wife’s contact with her family (reported by only 4 percent of ever-married women). Fourteen percent of women said that their husbands exhibit three or more of the above-mentioned controlling behaviors, and 53 percent said that their husbands exhibit none of the controlling behaviors. There is hardly any difference in the proportion of ever-married women who report that their husbands exhibit three or more of the specified behaviors by age. There is an inverse relationship between the number of living children a woman has and the degree of control her husband exercises over them. For example, 23 percent of women with no living children reported that their husbands exhibit three or more of the specified controlling behaviors, compared with 12 percent of women with five or more children. Women who were formerly married (22 percent) are more likely than currently married women (13 percent) to say that their former husbands exhibited three or more of the controlling behaviors. The extent to which husbands exhibit three or more controlling behaviors is higher among urban women (25 percent) than the rural women (10 percent). This finding corroborates the fact that women in urban areas more often face domestic violence as discussed earlier in this chapter. Men in Dili (30 percent), Ermera (22 percent), and Lautem (16 percent) are more likely to exercise controlling behavior over their wives. Differences by education are not significant. Women in the highest wealth quintile report higher proportions of controlling behaviors exhibited by their husbands. 16.9 TYPES OF SPOUSAL VIOLENCE This section of the chapter is devoted to violence perpetrated by intimate partners who are married to the respondent or who live with the respondent as if married. Since spousal or intimate partner violence is the most common form of violence among women age 15-49, the 2009-10 TLDHS collected detailed information on the different types of violence experienced—physical, sexual, and emotional. Currently married women were asked about violence perpetrated by their current husband, and formerly married women were asked about violence perpetrated by their most recent husband. Respondents were asked about seven specific acts of physical violence, two acts of sexual violence, and three acts of emotional violence. The acts are listed in Table 16.8. The table shows that 34 percent of ever-married women have ever experienced physical violence at the hands of their husband or partner, and 31 percent have experienced physical violence in the past 12 months. Three percent have ever experienced sexual violence, and 2 percent experienced sexual violence in the past 12 months. The findings also show that 8 percent of women have ever experienced emotional violence and have experienced emotional violence in the past 12 months. Overall, 36 percent of ever-married women have experienced some kind of violence (physical, sexual, or emotional) by a husband or partner. Domestic Violence | 237 Table 16.8 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, Timor-Leste 2009-10 In the past 12 months1 Form of violence Ever Often Sometimes Often or sometimes Physical violence Any 33.5 1.7 29.0 30.7 Pushed her, shook her, or threw something at her 14.7 0.9 13.1 14.0 Slapped her 30.4 1.1 26.6 27.7 Twisted her arm or pulled her hair 7.9 0.8 6.7 7.4 Punched her with his fist or with something that could hurt her 5.3 0.0 4.8 4.9 Kicked her, dragged her, or beat her up 7.9 0.4 6.8 7.2 Tried to choke her or burn her on purpose 1.2 0.1 1.0 1.1 Threatened her or attacked her with a knife, gun, or any other weapon 0.9 0.0 0.6 0.6 Sexual violence Any 2.9 0.1 1.9 2.0 Physically forced her to have sexual intercourse with him even when she did not want to 2.0 0.1 1.6 1.7 Forced her to perform any sexual acts she did not want to 1.2 0.0 0.9 0.9 Sexual initiation was with current or most recent husband and was forced2 0.8 na na na Emotional violence Any 8.3 1.5 6.2 7.7 Said or did something to humiliate her in front of others 5.8 1.0 4.3 5.3 Threatened to hurt or harm her or someone close to her 3.2 0.5 2.5 3.0 Insulted her or made her feel bad about herself 3.9 1.0 2.5 3.5 Any form of physical and/or sexual violence 34.6 1.7 29.8 31.5 Any form of physical and sexual violence 1.8 0.1 1.0 1.2 Any form of emotional, physical, and/or sexual violence 36.1 2.2 31.1 33.3 Any form of emotional, physical, and sexual violence 1.0 0.1 0.6 0.7 Number of ever married women 1,959 1,890 1,890 1,890 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 widows 2 Excludes women who have been married more than once since their sexual initiation could not have been with the current/ most recent partner na= Not applicable Among the various physical acts of violence experienced by women in the past 12 months, slapping was the most commonly reported act, experienced by 28 percent of women. Fourteen percent of women were pushed, shaken, or had something thrown at them by their husband or partner, 7 percent had their arms twisted or hair pulled by their husband or partner, and 7 percent were kicked, dragged, or beaten up. Two percent of women were forced to have sex by their husband/partner when they did not want to (Figure 16.1). 238 | Domestic Violence Figure 16.1 Percentage of Ever-married Women Who Have Experienced Specific Forms of Physical and Sexual Violence Committed by Their Husband/Partner 15 30 8 5 8 1 1 2 1 34 14 28 7 5 7 1 1 2 1 32 0 10 20 30 40 Percent Ever Past 12 months Pushed her, shook her, or threw something at her Slapped her Twisted her arm or pulled her hair Punched her with his fist or with something that could hurt her Kicked her, dragged her, or beat her up Tried to choke her or burn her on purpose Threatened her or attacked her with a knife, gun, or any other weapon Physically forced her to have sexual intercourse with him even when she did not want to Forced her to perform any sexual acts she did not want to At least one of these acts Timor-Leste 2009-10 Table 16.9 shows the experience of spousal violence among ever-married women by background characteristics. Women age 25-29 are generally more likely to have experienced emotional, physical, or sexual violence than those in the older or younger age groups. For instance, more than two in five women age 25-29 experienced all three forms of violence, compared with less than one in three women in the other cohorts. The findings show that women who are unemployed are most likely to experience emotional, physical, or sexual violence (39 percent). Table 16.9 Spousal violence by background characteristics Percentage of ever-married women age 15-49 by whether they have ever experienced emotional, physical or sexual violence committed by their husband/partner, according to background characteristics, Timor-Leste 2009-10 Emotional violence Physical violence Sexual violence Physical or sexual violence Emotional, physical or sexual violence Number of women Current age 15-19 12.1 22.7 9.2 29.8 30.9 67 20-24 6.2 30.9 3.0 32.8 33.8 271 25-29 8.2 40.3 2.1 40.9 42.7 341 30-39 8.9 35.3 3.4 35.9 37.1 729 40-49 8.1 29.5 1.8 30.2 32.3 551 Employed last 12 months Not employed 9.7 36.2 2.7 36.9 38.6 1,094 Employed for cash 13.0 31.9 6.5 35.7 36.3 170 Employed not for cash 4.9 29.7 2.3 30.7 32.1 695 Number of living children 0 5.7 24.8 1.8 26.6 26.6 115 1-2 9.8 33.5 3.2 35.3 37.7 527 3-4 6.7 35.4 2.4 36.1 37.3 594 5+ 9.0 33.4 3.2 34.0 35.5 724 Continued… Domestic Violence | 239 Table 16.9—Continued Emotional violence Physical violence Sexual violence Physical or sexual violence Emotional, physical or sexual violence Number of women Marital status and duration Currently married woman 7.2 33.3 2.6 34.1 35.3 1,843 .Married only once 7.2 33.4 2.6 34.1 35.4 1,817 .0-4 years 5.6 29.1 2.1 30.1 31.6 332 .5-9 years 6.3 36.5 1.6 36.7 37.6 352 .10+ years 8.0 33.7 3.1 34.5 35.8 1,133 .Married more than once (7.0) (30.3) (0.0) (30.3) (30.3) 26 Divorced/separated/widowed 25.5 36.1 7.7 42.5 48.4 116 Residence Urban 13.8 43.9 3.4 45.5 48.5 468 Rural 6.6 30.2 2.7 31.1 32.2 1,491 District Aileu 7.7 22.5 5.4 26.5 28.0 74 Ainaro 3.1 11.0 0.5 11.5 13.0 100 Baucau 15.4 28.5 7.4 30.5 32.7 230 Bobonaro 3.0 22.1 1.8 23.3 24.2 172 Covalima 3.5 44.7 0.0 44.7 44.7 115 Dili 13.9 43.7 2.5 45.5 48.0 336 Ermera 2.5 16.1 1.2 16.1 17.0 225 Lautem 27.4 55.5 6.5 56.0 61.2 136 Liquiçá 4.0 24.0 4.1 25.3 26.2 115 Manatuto 2.2 10.6 2.1 11.1 12.0 79 Manufahi 4.7 77.0 1.3 77.6 77.6 84 Oecussi 4.6 53.8 2.4 54.8 55.3 140 Viqueque 2.1 25.7 0.5 25.7 26.2 153 Education No education 9.2 31.3 2.9 32.4 34.4 753 Primary 7.5 37.5 3.0 38.2 38.7 495 Secondary 8.1 32.4 3.0 33.8 35.5 656 More than secondary (5.1) (40.7) (0.0) (40.7) (43.5) 54 Wealth quintile Lowest 7.3 33.5 3.4 34.8 35.8 392 Second 8.5 34.5 3.6 35.4 36.5 389 Middle 6.5 28.9 2.9 29.4 30.1 379 Fourth 8.7 33.2 1.6 34.1 37.3 385 Highest 10.5 37.1 2.8 38.7 40.3 415 Respondent’s father beat her mother Yes 11.6 56.4 4.9 57.8 59.2 632 No 5.9 20.9 1.7 21.9 23.9 999 DK 9.2 28.0 2.5 28.6 28.9 324 Total 8.3 33.5 2.9 34.6 36.1 1,959 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 4 women with information missing on whether their fathers beat their mothers. Figures in parentheses are based on 25-49 unweighted cases. As expected, marital status shows a strong association with experience of violence. Women who are divorced, separated, or widowed are more likely to have experienced violence than other women. This finding suggests that the experience of violence may have contributed to the likelihood of the termination of a relationship. Currently married women who have been married for five years or more are more likely to experience emotional, physical, or sexual violence than women who have been married for less than five years. 240 | Domestic Violence By residence, urban women are more likely to experience violence than rural women. Women in Manufahi (78 percent), Lautem (61 percent), Oecussi (55 percent), and Dili (48 percent) are more likely to have ever experienced emotional, physical, or sexual violence than their counterparts in other districts. There is no distinct pattern between women experiencing violence committed by their husband by education. Women in the highest wealth quintile are slightly more likely to experience the three types of violence. Women with a history of family violence—whose father beat their mother — are more than twice as likely to experience all three types of violence from a husband or partner than women whose fathers or mothers were not abusive. This indicates that violence is accepted as a normal part of life. 16.10 VIOLENCE BY SPOUSAL CHARACTERISTICS AND EMPOWERMENT INDICATORS The perpetrators of spousal violence are usually husbands or partners, and it is therefore important to understand their characteristics. It is also useful to examine whether spousal violence varies with indicators of women’s status. Table 16.10 shows the percentage of ever-married women who have ever experienced different forms of spousal violence by their current or most recent husband, by spousal characteristics and women’s empowerment indicators. Husbands who have primary education are more likely to exhibit violent behavior against their wives/partners while those with no education and those with higher education are less likely to be violent. The husband’s alcohol consumption is strongly related to the wife’s reporting of violence. For example, the proportion of ever-married women who report having experienced emotional, physical, or sexual violence from their husbands varies from 26 percent among those whose husbands do not drink at all to 60 percent among those whose husbands get drunk very often. Women who are of the same age as their husband are more likely to experience emotional, physical, or sexual violence. Women in marriages in which neither spouse is educated are less likely to report experiencing violence from their husbands than those where both have equal levels of education (31 percent and 40 percent, respectively). Results show that there is a strong relationship between women’s empowerment status and their experience of spousal violence. Women whose husbands display five to six controlling behaviors are more likely to report experiencing emotional, physical, or sexual violence by their husbands than women whose husbands display no controlling behaviors (58 and 29 percent, respectively). Women who participate in three or four household decisions are less likely to experience spousal violence than women who participate in fewer decisions. Women with one or two reasons justifying the refusal to have sexual intercourse with their husbands are more likely to experience all three types of violence from their husbands than those with no reasons. Views about wife beating also appear to be related to actual experience of physical abuse. Women who believe that wife beating is justified for any of the five specified circumstances are more likely to report having experienced emotional, physical, or sexual violence from their husbands than women who do not think wife beating is justified for any reason (36 and 19 percent, respectively). To some extent, this pattern could be due to women’s rationalization of the abuse they have experienced. Domestic Violence | 241 Table 16.10 Spousal violence by husband’s characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have ever suffered emotional, physical, or sexual violence committed by their husband/partner, according to his characteristics, marital characteristics, and empowerment indicators, Timor-Leste 2009-10 Emotional violence Physical violence Sexual violence Physical or sexual violence Emotional, physical, or sexual violence Number of women Husband’s/partner’s education No education 7.4 27.9 1.5 28.6 30.0 590 Primary 10.0 39.1 3.8 40.4 42.1 573 Secondary 8.3 33.9 3.3 35.0 36.6 701 More than secondary 4.4 31.0 2.2 32.6 33.5 94 Husband’s/partner’s alcohol consumption Does not drink 4.7 24.5 2.7 25.6 26.1 926 Drinks/never gets drunk 2.9 26.0 2.9 26.0 27.1 68 Gets drunk sometimes 10.5 42.2 2.6 43.4 45.1 889 Gets drunk very often 31.6 47.3 8.1 47.3 59.8 76 Spousal age difference1 Wife older 10.4 33.3 2.6 33.5 34.9 200 Wife is same age 5.7 38.1 0.6 38.1 41.1 124 Wife’s 1-4 years younger 7.7 34.8 2.0 35.6 37.2 634 Wife’s 5-9 years younger 6.0 28.8 3.0 30.0 30.8 544 Wife’s 10+ years younger 7.2 36.4 3.7 36.9 37.5 336 Spousal education difference Husband better educated 8.5 35.6 4.2 37.0 38.8 737 Wife better educated 8.3 33.1 2.2 33.8 35.2 649 Both equally educated 7.3 39.2 1.2 39.2 40.0 121 Neither educated 7.3 28.5 1.4 29.4 30.7 439 Number of marital control behaviors displayed by husband/partner 0 3.6 27.4 1.1 27.7 28.7 1,042 1-2 9.0 39.4 3.7 41.2 42.2 651 3-4 23.3 40.9 7.0 43.6 48.4 216 5-6 32.3 51.6 12.0 51.6 58.2 50 Number of decisions in which women participate1 0 (20.4) (36.3) (4.5) (40.8) (43.8) 25 1-2 15.5 37.8 6.9 38.0 40.2 175 3-4 6.1 32.8 2.1 33.5 34.7 1,643 Number of reasons given for refusing to have sexual intercourse with husband 0 2.5 29.1 1.7 29.4 30.5 210 1-2 10.2 46.0 2.6 46.6 48.5 592 3 8.4 27.9 3.3 29.3 30.8 1,157 Number of reasons for which wife beating is justified 0 3.5 15.5 1.0 16.5 18.6 203 1-2 8.4 37.7 3.8 39.6 40.7 530 3-4 8.7 34.5 2.9 35.4 37.5 779 5 9.6 34.9 2.6 35.3 36.1 447 Total 8.3 33.5 2.9 34.6 36.1 1,959 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 2 women with information missing on husband’s education, 5 women with information missing on spousal age difference, and 15 women with information missing on spousal education difference. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes only currently married women 16.11 FREQUENCY OF SPOUSAL VIOLENCE The percent distribution of ever-married women (excluding widows) who reported physical or sexual violence by their current or most recent spouse in the 12 months preceding the survey by frequency with which violence was experienced, according to selected background characteristics, is not shown separately because the numbers associated with most cells are too small for meaningful statistical analysis by each background characteristic. Ninety-one percent of women who ever experienced emotional violence by their current or most recent husband have experienced such 242 | Domestic Violence violence in the 12 months preceding the survey, and 17 percent of them experienced emotional violence often (data not shown). Similarly, 91 percent of women who have ever experienced physical or sexual violence by their current or most recent husband have experienced such violence in the 12 months preceding the survey, and 5 percent have experienced such violence often. 16.12 ONSET OF SPOUSAL VIOLENCE To examine the timing of the onset of marital violence, the 2009-10 TLDHS asked ever-married women who had experienced physical or sexual spousal violence when the first episode of violence took place. Violence starts early in marriage in Timor-Leste, with 15 percent of ever-married women reporting the onset of violence within two years of marriage. For about 5 percent of the women who had experienced violence, the violence was initiated three to five years after marriage (data not shown). 16.13 TYPES OF INJURIES TO WOMEN RESULTING FROM SPOUSAL VIOLENCE In the 2009-10 TLDHS, women who ever experienced spousal physical violence—or sexual violence—were asked about the physical consequences of the violence. Specifically, they were asked if, as a consequence of what their spouse did to them, they ever had: a) cuts, bruises or aches; b) eye injuries, sprains, dislocations, or burns; and c) deep wounds, broken bones, broken teeth, or any other serious injury. Table 16.11 shows the percentage of ever-married women who reported any spousal physical violence or sexual violence, by type of injuries sustained. About one in five women who have ever experienced physical violence or sexual violence by their current or most recent husband/partner received at least one of the injuries asked about. Cuts, bruises, and aches are the most common injuries sustained by women for any type of violence. One percent of women reported receiving deep wounds, broken bones, broken teeth, or other serious injuries. A similar pattern is seen for women who experienced spousal violence in the past 12 months. Table 16.11 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 what their husband/partner did to them, according to the type of violence and whether they have experienced the violence ever and in the 12 months preceding the survey, Timor-Leste 2009-10 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 Experienced physical violence1 Ever2 18.7 4.4 1.0 19.8 656 In the past 12 months3 17.8 4.3 0.9 18.9 579 Experienced sexual violence4 Ever2 (53.6) (18.2) (0.0) (56.2) 46 In the past 12 months3 (59.8) (21.5) (0.0) (62.9) 39 Experienced physical or sexual violence4 Ever2 19.3 5.0 1.0 20.4 673 In the past 12 months3 18.8 5.1 0.9 19.8 596 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes women who experienced physical violence only during pregnancy 2 Includes in the past 12 months 3 Excludes widows 4 Excludes women whose sexual initiation was forced but who have not experienced any other form of physical or sexual violence Domestic Violence | 243 16.14 Physical Violence by Women against Their Spouse Violence by husbands against wives is not the only form of spousal violence; women may sometimes be the perpetrators of violence. In most cultures, however, the level of spousal violence initiated by wives is only a fraction of the level of spousal violence initiated by husbands. To measure spousal violence by women, the 2009-10 TLDHS also asked women about violence they themselves initiated against their spouse or other intimate partner. Specifically, women were asked: Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you? Respondents who said yes to this question were asked about the frequency of such violence in the 12 months preceding the survey. Table 16.12 shows the percentage of ever-married women (excluding widows) who have ever initiated violence against their current or most recent husbands and the percentage of all ever-married women who say that they have initiated spousal violence in the 12 months preceding the survey. Results shown indicate that overall, 6 percent of ever-married women report that they have ever initiated physical violence against their current or most recent husbands, while 5 percent say that they have committed such violence in the 12 months preceding the survey. Differentials by background characteristics for women who initiate physical violence against their current or most recent husbands are generally small. Women who reported experiencing physical violence at the hands of their husbands in the past 12 months (13 percent), women whose husbands get drunk sometimes (8 percent), and women in urban areas (8 percent) are more likely to initiate physical violence against their husbands than other women. Table 16.12 Violence by women against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their husband/partner when he was not already beating or physically hurting them ever and in the past 12 months, according to women’s own experience of spousal violence and their own and husband’s/partner’s characteristics, Timor-Leste 2009-10 Percentage who have committed physical violence against their current or most recent husband/partner Characteristic Ever Number of women In the past 12 months1 Number of women1 Woman’s experience of spousal physical violence Ever 13.1 656 10.6 636 In the past 12 months 13.4 579 11.5 579 Not past 12 months/widow/missing 11.2 77 0.6 56 Never 1.7 1,303 1.5 1,254 Current age 15-19 10.4 67 7.6 67 20-24 7.1 271 7.2 267 25-29 7.4 341 5.8 335 30-39 4.9 729 3.9 706 40-49 4.0 551 2.9 514 Employed past 12 months Not employed 6.2 1,094 4.9 1,076 Employed for cash 8.1 170 7.9 160 Employed not for cash 4.0 695 3.1 654 Number of living children 0 2.2 115 1.7 111 1-2 7.2 527 6.4 509 3-4 5.4 594 4.3 574 5+ 5.0 724 3.8 696 Residence Urban 8.2 468 5.9 455 Rural 4.7 1,491 4.1 1,434 Continued… 244 | Domestic Violence Table 16.12—Continued Percentage who have committed physical violence against their current or most recent husband/partner Characteristic Ever Number of women In the past 12 months1 Number of women1 District Aileu 2.0 74 1.0 72 Ainaro 2.1 100 2.2 99 Baucau 3.8 230 3.9 225 Bobonaro 2.1 172 1.9 164 Covalima 4.0 115 4.2 110 Dili 7.8 336 5.5 326 Ermera 5.8 225 5.0 220 Lautem 15.0 136 12.2 131 Liquiçá 10.0 115 9.6 108 Manatuto 2.1 79 1.7 77 Manufahi 12.0 84 11.2 81 Oecussi 3.1 140 0.8 134 Viqueque 0.5 153 0.0 142 Wealth quintile Lowest 3.7 392 3.8 373 Second 5.3 389 5.0 372 Middle 5.2 379 2.7 367 Fourth 7.6 385 6.3 378 Highest 5.9 415 4.8 400 Marital status and duration Currently married woman 5.3 1,843 4.5 1,843 Married only once 5.2 1,817 4.4 1,817 0-4 years 6.6 332 6.0 332 5-9 years 5.9 352 4.8 352 10+ years 4.6 1,133 3.8 1,133 Married more than once (11.1) 26 (11.1) 26 Divorced/separated/widowed 9.0 116 7.6 47 Education No education 4.3 753 4.0 716 Primary 7.5 495 5.8 481 Secondary 5.3 656 4.0 644 More than secondary (8.9) 54 (7.3) 49 Husband’s/partner’s education No education 4.1 590 3.6 546 Elementary 5.6 573 3.8 561 High school 6.3 701 5.8 690 College 8.1 94 5.1 92 Husband’s/partner’s alcohol consumption Does not drink 3.5 926 3.0 888 Drinks/never gets drunk 1.1 68 0.0 67 Gets drunk sometimes 7.9 889 6.4 861 Gets drunk very often 7.1 76 6.2 75 Spousal age difference2 Wife older 4.0 200 3.6 200 Wife is same age 6.0 124 6.0 124 Wife’s 1-4 years younger 5.6 634 4.9 634 Wife’s 5-9 years younger 3.7 544 2.5 544 Wife’s 10+ years younger 8.2 336 6.8 336 Spousal education difference Husband better educated 5.7 737 5.0 725 Wife better educated 6.0 649 4.5 629 Both equally educated 6.7 121 3.6 117 Neither educated 3.3 439 3.1 405 Total 5.5 1,959 4.5 1,890 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. Total includes 2 women with information missing on husband’s education, 5 women with information missing on spousal age difference, and 15 women with information missing on spousal education difference. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes widows 2 Currently married women Domestic Violence | 245 16.15 HELP-SEEKING BEHAVIOR OF WOMEN WHO EXPERIENCE VIOLENCE All respondents who have ever experienced physical or sexual violence by any person were asked a series of questions about whether and from whom they sought help to try to end the violence. This information is presented in Table 16.13. About one in five women (24 percent) who experience violence seek help. Women who experience both physical and sexual violence1 (50 percent) are most likely to seek help. The percentage of respondents who seek help varies from 19 percent among women age 15-19 to 27 percent among women age 25-29. Unemployed women are less likely to seek help than those who are employed for cash (24 and 36 percent, respectively). Women with no living children are slightly less likely to seek help than other women. Formerly married women (53 percent) who experienced physical violence are more likely to seek help than other respondents. District-level differences are large and could be due to differences in the degree of adherence to ingrained cultural norms. For example, 7 percent of women who experienced violence in Manufahi sought help, compared with one in two women in Covalima (51 percent). Women with no education and those in the lowest and second wealth quintiles were less likely to seek help than other women. Urban women were more likely to seek help to end violence. Women most often sought help from their own family members (82 percent) and from in-laws (27 percent). About 14 percent of women sought help from friends/neighbors. It is interesting to note that only 4 percent of women sought help from the police, while 1 percent of women sought help from social service organizations (data not shown separately). 16.16 FAMILY SUPPORT FOR ABUSED WOMEN IN NEED Women having a strong fallback position could be in a better position than those with no fallback position when faced with domestic 1 Physical violence here excludes violence during pregnancy, and sexual violence excludes those whose first sex was forced. Table 16.13 Help seeking to stop violence Among women age 15-49 who have ever experienced physical or sexual violence, percentage who fought back physically, fought back verbally or sought help from any source to end the violence according to type of violence and background characteristics, Timor-Leste 2009-10 Have sought help from any source Number of women Type of violence Physical only 21.8 1,057 Sexual only (27.4) 31 Both physical and sexual 50.3 69 Current age 15-19 19.2 214 20-24 25.1 186 25-29 27.1 197 30-39 24.3 345 40-49 22.7 215 Employed past 12 months Not employed 23.7 727 Employed for cash 35.6 96 Employed not for cash 20.1 333 Number of living children 0 17.1 330 1-2 26.8 240 3-4 25.3 273 5+ 26.7 312 Marital status and duration Never married 16.8 287 Currently married woman 23.8 805 Married only once 23.8 792 0-4 years 27.9 129 5-9 years 24.5 164 10+ years 22.5 499 Married more than once 21.0 13 Divorced/separated/widowed 52.7 64 Residence Urban 31.4 348 Rural 20.3 808 District Aileu 11.1 57 Ainaro (19.1) 20 Baucau 20.5 154 Bobonaro (31.4) 44 Covalima 50.9 102 Dili 34.4 251 Ermera (14.2) 88 Lautem 21.7 103 Liquiçá 17.6 65 Manatuto (22.8) 23 Manufahi 6.8 87 Oecussi 17.9 116 Viqueque (3.6) 46 Education No education 19.9 348 Primary 24.2 294 Secondary 25.2 472 More than secondary (33.8) 42 Wealth quintile Lowest 19.9 208 Second 16.7 218 Middle 23.7 222 Fourth 22.8 226 Highest 32.4 282 Total 23.7 1,156 Note: Excludes women whose sexual initiation was forced but who have not experienced any other form of physical or sexual violence. Figures in parentheses are based on 25-49 unweighted cases. 246 | Domestic Violence violence. Support from family members, the maternal home, and social service organizations established to support women in vulnerable positions all play an important role. The 2009-10 TLDHS asked women if they needed help or had a problem if they have any family members who could provide shelter for a few nights and provide financial support if needed. Table 16.14 indicates that 27 percent of women mentioned that they have family members who can provide shelter for them for a few nights if they needed it. However, it is worth noting that the majority of women do not have any family support outside the house, which makes them more vulnerable to their situation. Younger women (age 15-24), women employed for cash, never-married women, rural residents, and women residing in Ainaro are less likely to receive shelter from their families for a few days than their counterparts. One in five women have family members who can support the women financially if they needed it, again hinting at the fact that a majority of these women do not have such support. Women in Lautem and Ainaro are more vulnerable regarding these types of support systems. Table 16.14 Family support Percentage of women age 15-49 whose family can provide them shelter and financial support if they need it, by background characteristics, Timor-Leste 2009-10 Background characteristic Percentage of women whose family can give them shelter for a few nights if they need it Percentage of women whose family can give them financial support if they need it Number of women Current age 15-19 23.2 20.6 700 20-24 24.0 16.7 513 25-29 30.5 20.6 403 30-39 26.9 18.9 765 40-49 30.9 23.7 570 Employed last 12 months Not employed 27.6 20.9 1,795 Employed for cash 23.0 16.2 219 Employed not for cash 26.0 19.3 937 Marital status Never married 23.0 19.1 992 Married or living together 28.5 20.0 1,843 Divorced/separated/widowed 30.9 28.9 116 Residence Urban 30.0 19.9 700 Rural 25.7 20.1 2,251 District Aileu 38.9 14.2 128 Ainaro 4.8 5.1 160 Baucau 53.2 46.7 334 Bobonaro 30.5 25.5 281 Covalima 43.1 41.2 177 Dili 30.9 18.0 474 Ermera 24.2 23.4 357 Lautem 14.2 2.5 192 Liquiçá 13.6 13.3 179 Manatuto 19.9 10.5 135 Manufahi 9.7 8.6 114 Oecussi 20.5 12.0 201 Viqueque 13.2 8.9 219 Education No education 27.9 21.4 896 Primary 26.6 19.2 695 Secondary 25.7 19.6 1,268 More than secondary 31.8 20.7 91 Wealth quintile Lowest 23.7 17.4 567 Second 28.1 22.3 572 Middle 25.0 18.9 597 Fourth 27.2 21.1 594 Highest 29.6 20.6 620 Total 26.8 20.1 2,951 Domestic Violence | 247 16.17 SOCIAL NORMS AND VALUES The fact that domestic violence is often perceived as a private matter that should not be discussed in public provides a rationale for further exploration of the extent of social norms and values that exists in a society. Studies have shown that the cultural acceptance of gender roles and behavior has led to the reinforcement of violence against women. The 2009-10 TLDHS explored women’s attitudes regarding two specific behaviors used as a proxy for justifying patriarchal behavior that puts men in a higher social position than women. The first question asked if women believed that ‘men cannot control their sexual behavior.’ If women agree that men have no control over their sexual behavior, then they may believe that men’s unwanted sexual advances towards women are somehow justified and cannot be construed as violence. The second question asked women if they thought that ‘marital rape is allowable,’ meaning whether women believe that within marriage they cannot refuse sexual advances from their husband and therefore marital rape does not constitute sexual violence. It is interesting that nearly half of the women (47 percent) believed that men cannot control their sexual behavior (Table 16.15). Women in the older age cohort are more likely to believe this, with more than half of the women above age 25 years agreeing with the statement. The data shows that women who work for cash, those residing in urban areas, those with higher education and those belonging to wealthier households are least likely to support this belief. Still, the belief is strongly ingrained in the culture. Eighty-three percent of women in Ermera hold this belief compared with 18 percent of women in Bobonaro. About 29 percent of women in the 2009-10 TLDHS believed that marital rape is allowable, giving the husband authority over a woman’s sexuality. Women in the older cohort are more likely to believe this statement. Similarly, women who work but not for cash, who are currently married, who reside in rural areas, and who are not educated are more likely to believe that marital rape is allowable. Women in Manatuto (55 percent) and Ermera (46 percent) are more likely to believe that marital rape is allowable, while those living in Covalima (12 percent) are least likely to believe this. These findings demonstrate a need to raise awareness among women and men about individual rights in relation to sexuality and how they can work to reduce sexual violence. The responsibility for sexual assault lies with the perpetrators, who choose to engage in inappropriate behavior. Decreases over time in the proportion of women who believe that ‘men sometimes cannot control their sexual behavior’ or ‘marital rape is allowable’ may indicate an improvement in the level of awareness and empowerment. The data shown here can be a useful guide for program managers to initiate awareness-raising activities and human rights education interventions. 248 | Domestic Violence Table 16.15 Attitudes towards male sexuality and marital rape Percentage of women age 15-49 who believe that a man cannot control his sexual behavior and percentage who think that marital rape is allowable, by background characteristics, Timor-Leste 2009-10 Percentage of women who believe that a man cannot control his sexual behavior Percentage of women who believe that marital rape is allowable Number of women Current age 15-19 33.0 20.8 700 20-24 46.6 29.8 513 25-29 52.3 27.4 403 30-39 54.4 36.4 765 40-49 50.3 28.3 570 Employed last 12 months Not employed 45.7 26.4 1,795 Employed for cash 39.8 22.0 219 Employed not for cash 50.8 34.7 937 Marital status Never married 33.5 20.9 992 Married or living together 54.8 33.3 1,843 Divorced/separated/widowed 35.0 22.6 116 Residence Urban 41.7 20.7 700 Rural 48.5 31.2 2,251 District Aileu 38.8 15.6 128 Ainaro 24.5 15.7 160 Baucau 59.1 44.6 334 Bobonaro 17.9 35.2 281 Covalima 42.1 11.9 177 Dili 44.1 14.1 474 Ermera 83.1 46.4 357 Lautem 28.7 24.5 192 Liquiçá 52.9 35.9 179 Manatuto 63.7 55.0 135 Manufahi 25.7 34.6 114 Oecussi 45.9 17.5 201 Viqueque 50.1 18.7 219 Education No education 52.0 33.7 896 Primary 46.8 29.9 695 Secondary 43.2 25.8 1,268 More than secondary 48.2 11.4 91 Wealth quintile Lowest 40.7 29.9 567 Second 50.9 30.0 572 Middle 51.1 30.3 597 Fourth 45.5 32.0 594 Highest 46.0 21.8 620 Total 46.9 28.7 2,951 References | 249 REFERENCES Acharya, M. 2010. 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Sydney, Australia: UNSW School of Public Health and Community Medicine. Appendix A | 255 SAMPLE DESIGN Appendix A A.1 OBJECTIVES OF THE SURVEY The 2009 Timor-Leste Demographic and Health Survey (TLDHS 2009-10) was the second of its kind following the survey conducted in 2003. TLDHS 2009-10 selected a nationally representative sample consisting of 12,285 residential households. In sampled households, all women between the ages of 15 and 49 who were members of the households or who stayed in the households the night before the survey were eligible for the individual interview. The survey was designed to yield about 11,800 completed interviews of women age 15-49. The sample was designed to produce representative results for most of the indicators for the country as a whole, for the urban and rural areas, and for each of the thirteen districts. Apart from the female survey, a male survey was conducted in one-third of the households selected for the female survey. All men age 15-49 who were usual members of the household or who stayed in the household the night before the survey were eligible for the male individual interview. This sampling plan was expected to yield about 3,800 completed interviews of men age 15-49. In this sub-sample, all women who were eligible for the individual interview and all their young children aged 6-59 months were asked consent for an anemia testing. A.2 SAMPLING FRAME The sampling frame used for the TLDHS 2009 was the 2004 Timor-Leste Population and Housing Census (TLPHC) (NSD, 2006), provided by the National Statistics Directorate (NSD). The sampling frame is a complete list of 1,163 Enumeration Areas (EAs) created for the 2004 census. Among the 1,163 EAs, 240 are urban residence and 923 are rural residence. In Timor-Leste, 26.0% of the household population lives in urban areas, and they occupy 23.1% of the residential households. A.3 SAMPLING PROCEDURE AND SAMPLE ALLOCATION The sample for TLDHS 2009 was a stratified sample selected in two stages from the TLPHC 2004. Stratification was achieved by separating each of the 13 districts into urban and rural areas. In total, 26 sampling strata were created. Samples were selected independently in every stratum, through a two-stage selection process. Implicit stratification was achieved at each of the lower administrative levels by sorting the sampling frame before sample selection, according to administrative units and by using a probability proportional to size selection at the first stage of sampling. In the first stage, 455 EAs were selected with probability proportional to the EA size. The EA size was the number of households residing in the EA at the time of the census. Standard DHS procedures call for a new listing of households in the selected EAs before conducting the household selection. However, because of time and other constraints, the households were selected from the TLPHC 2004 census results without conducting a new household listing operation. In the second stage of selection, a fixed number of 27 households were randomly selected in every cluster by an equal probability systematic sampling procedure. This number was increased from the original design of 24 households per EA to account for the outdated census household listing. The household selection was carried out in the office. The GPS coordinates collected for each household 256 | Appendix A during the population census were used to relocate the selected households in the field during data collection. Table A.1 shows the sample allocation of clusters/EAs and households according to district and by type of residence. The final allocation was an equal size allocation of 34 EAs for each of the twelve districts except Dili district; a larger sample size of 47 EAs was allocated to Dili district. Dili district received a higher number of EAs in order to get adequate representation of the urban population of the country. In total, there were 116 urban clusters and 339 rural clusters selected in the TLDHS 2009-10 sample. Table A.2 below shows the sample allocation of expected number completed women and men interviews by district and by type of residence. Table A.1 Sample allocation of clusters and households according to district and by type of residence, Timor-Leste 2009-10 Allocation of EA Allocation of households District Urban Rural Total Urban Rural Total Aileu 2 32 34 54 864 918 Ainaro 8 26 34 216 702 918 Baucau 5 29 34 135 783 918 Bobonaro 8 26 34 216 702 918 Covalima 8 26 34 216 702 918 Dili 40 7 47 1,080 189 1 269 Ermera 6 28 34 162 756 918 Liquica 5 29 34 135 783 918 Lautem 11 23 34 297 621 918 Manufahi 8 26 34 216 702 918 Manatuto 2 32 34 54 864 918 Oecussi 9 25 34 243 675 918 Viqueque 4 30 34 108 810 918 Timor-Leste 116 339 455 3,132 9,153 12,285 Note: The sample allocation has taken into account the reform of the urban EAs in Covalima and Manatuto districts. Table A.2 Sample allocation of expected number of completed women and men interviews according to district and by type of residence, Timor-Leste 2009-10 Women 15-49 Men 15-49 (subsample) District Urban Rural Total Urban Rural Total Aileu 52 834 886 17 272 289 Ainaro 209 678 887 68 222 290 Baucau 131 756 887 43 247 290 Bobonaro 209 678 887 68 222 290 Covalima 209 678 887 68 222 290 Dili 1,042 182 1,224 341 60 401 Ermera 157 729 886 51 238 289 Liquica 131 756 887 43 247 290 Lautem 286 599 885 94 196 290 Manufahi 209 678 887 68 222 290 Manatuto 52 834 886 17 272 289 Oecussi 235 652 887 76 212 288 Viqueque 104 782 886 34 255 289 Timor-Leste 3,026 8,836 11,862 988 2,887 3,875 The above sample allocation on expected number of interviews was calculated based on the facts obtained from the TLDHS 2003 and the TLPHC 2004: there were 1.07 women and men aged 15-49 per household. The numbers in Table A.2 assume a female response rate of 97 percent, a male response rate of 95 percent; and a household response rate of 93 percent in both urban and rural areas. Appendix A | 257 A.4 SAMPLING PROBABILITY AND SAMPLING WEIGHTS Because of the non-proportional allocation of the sample to the different districts and to their urban-rural areas, sampling weights will be required for any analysis using TLDHS 2009-10 data to ensure the actual representativeness of the sample at the national level as well as district level. Since the TLDHS 2009 sample is a two-stage stratified cluster sample, sampling weights were calculated based on sampling probabilities separately for each sampling stage and for each cluster. We use the following notations: P1hi: first-stage sampling probability of the ith cluster in stratum h P2hi: second -stage sampling probability within the ith cluster (households) Let ah 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 the TLDHS sample is calculated as follows: M M a hi hih ∑ Let hib be the proportion of households in the selected segment compared to the total number of households in the EA i in stratum h if the EA is segmented, otherwise 1=hib . Then the probability of selecting cluster i in the sample is: hi hi hih 1hi b M M a = P ×∑ Let hig be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster is calculated as follows: hihi hi hi bM gP =2 The overall selection probability of each household in cluster i of stratum h is therefore the production of the selection probabilities: hihihi PPP 21 ×= The design weight for each household in cluster i of stratum h is the inverse of its selection probability: hihi PW /1= A spreadsheet containing all sampling parameters and selection probabilities was constructed to facilitate the calculation of sampling weights. Household sampling weights and the individual sampling weights were obtained by adjusting the above calculated design weight to compensate for household non-response and individual non-response, respectively. These weights were further normalized at the national level to achieve the number of un-weighted cases equal to the number of weighted cases for both households and individuals at the national level. The normalized weights are valid for estimating means, proportions, rates and ratios, but not valid for estimation of totals. No special weights were calculated for data collected on children because there was not a child’s questionnaire. For child indicators tabulated at the household level, household weights should be used; for child indicators tabulated at the individual level, the child’s mother’s/guardian’s weight should be used. Sampling errors for selected indicators are calculated and presented in Appendix B. A. 5 SU RV EY R ES U LT S T ab le A .3 S am pl e im pl em en ta tio n: W om en P er ce nt d ist rib ut io n of h ou se ho ld s an d el ig ib le w om en b y re su lts o f t he h ou se ho ld a nd in di vi du al in te rv ie w s, a nd h ou se ho ld , e lig ib le w om en a nd o ve ra ll re sp on se r at es , a cc or di ng t o ur ba n- ru ra l r es id en ce a nd d ist ric ts , T im or -L es te 20 09 -1 0 Re sid en ce D ist ric t R es ul t U rb an Ru ra l Ai le u Ai na ro Ba uc au Bo bo na ro C ov a Li m a D ili Er m er a La ut em Li qu ic a M an at ut o M an uf ah i O ec us si Vi qu eq ue To ta l S el ec te d ho us eh ol ds C om pl et ed (C ) 91 .1 95 .6 92 .4 96 .2 97 .7 97 .7 94 .0 90 .4 95 .6 92 .8 94 .2 96 .4 90 .3 98 .0 93 .9 94 .5 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt a t h om e (H P) 1. 2 0. 4 1. 3 0. 0 0. 4 0. 0 1. 2 1. 2 0. 7 0. 3 0. 5 0. 0 1. 4 0. 1 0. 3 0. 6 Po st po ne d (P ) 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 2 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 Re fu se d (R ) 1. 1 0. 4 1. 3 0. 3 0. 0 1. 0 0. 4 1. 6 0. 1 1. 1 0. 3 0. 2 0. 2 0. 4 0. 1 0. 6 D w el lin g no t f ou nd (D N F) 1. 2 0. 3 0. 3 0. 1 0. 0 0. 0 0. 7 2. 3 0. 0 1. 5 0. 2 0. 4 0. 3 0. 2 0. 2 0. 5 H ou se ho ld a bs en t ( H A) 1. 7 0. 8 0. 4 0. 3 0. 1 0. 4 0. 9 2. 1 1. 2 2. 0 1. 1 1. 2 2. 4 0. 3 0. 4 1. 0 D w el lin g va ca nt /a dd re ss n ot a d w el lin g (D V) 2. 2 1. 2 2. 1 2. 0 1. 7 0. 8 2. 0 1. 1 0. 7 0. 4 1. 9 1. 2 2. 2 0. 4 2. 6 1. 5 D w el lin g de st ro ye d (D D ) 1. 5 1. 3 2. 1 1. 1 0. 0 0. 1 0. 9 1. 3 1. 5 1. 6 1. 7 0. 5 3. 2 0. 4 2. 5 1. 3 T ot al 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed h ou se ho ld s 3, 01 2 9, 11 6 91 0 91 8 91 8 91 8 91 8 1, 14 9 91 2 91 6 91 8 91 8 91 8 91 8 89 7 12 ,1 28 H ou se ho ld re sp on se ra te (H RR )1 96 .3 98 .8 96 .9 99 .5 99 .6 99 .0 97 .6 94 .7 99 .0 96 .7 98 .9 99 .3 97 .9 99 .2 99 .3 98 .2 E lig ib le w om en C om pl et ed (E W C ) 89 .2 97 .4 94 .1 97 .9 98 .9 98 .2 93 .8 86 .2 95 .9 96 .6 92 .8 98 .7 95 .3 96 .8 96 .4 95 .2 N ot a t h om e (E W N H ) 4. 4 1. 1 2. 4 0. 1 0. 5 0. 5 3. 2 5. 1 1. 1 1. 3 3. 6 0. 3 1. 6 1. 4 2. 8 1. 9 Po st po ne d (E W P) 0. 2 0. 0 0. 0 0. 2 0. 0 0. 0 0. 1 0. 1 0. 0 0. 3 0. 0 0. 1 0. 0 0. 0 0. 0 0. 1 Re fu se d (E W R) 5. 2 0. 8 2. 7 1. 0 0. 3 1. 0 1. 4 7. 1 2. 4 0. 8 2. 6 0. 3 1. 9 1. 2 0. 7 2. 0 Pa rtl y co m pl et ed (E W PC ) 0. 6 0. 1 0. 3 0. 2 0. 0 0. 3 0. 0 1. 0 0. 0 0. 6 0. 1 0. 1 0. 4 0. 2 0. 2 0. 3 In ca pa ci ta te d (E W I) 0. 4 0. 6 0. 5 0. 5 0. 3 0. 0 1. 4 0. 3 0. 6 0. 5 1. 0 0. 4 0. 7 0. 5 0. 0 0. 5 O th er (E W O ) 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 0 0. 0 T ot al 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f w om en 3, 62 5 10 ,1 71 1, 10 1 85 9 1, 01 8 1, 08 1 1, 05 4 1, 42 3 1, 12 8 1, 05 9 1, 15 2 1, 15 0 83 0 1, 03 3 90 8 13 ,7 96 E lig ib le w om en re sp on se ra te (E W RR )2 89 .2 97 .4 94 .1 97 .9 98 .9 98 .2 93 .8 86 .2 95 .9 96 .6 92 .8 98 .7 95 .3 96 .8 96 .4 95 .2 O ve ra ll re sp on se ra te (O RR )3 85 .9 96 .2 91 .2 97 .5 98 .5 97 .3 91 .6 81 .7 94 .9 93 .4 91 .7 98 .0 93 .3 96 .1 95 .7 93 .5 1 U sin g th e nu m be r o f h ou se ho ld s fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H RR ) i s ca lc ul at ed a s: 10 0 * C — — — — — — — — — — — C + H P + P + R + D N F 2 U sin g th e nu m be r o f e lig ib le w om en fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e el ig ib le w om an re sp on se ra te (E W RR ) i s ca lc ul at ed a s: 10 0 * EW C — — — — — — — — — — — — — — — — — — — — — — — — — EW C + E W N H + E W P + E W R + E W PC + E W I + E W O 3 T he o ve ra ll re sp on se ra te (O RR ) i s ca lc ul at ed a s: O RR = H RR * E W RR /1 00 258 | Appendix A T ab le A .4 S am pl e im pl em en ta tio n: M en P er ce nt d ist rib ut io n of h ou se ho ld s an d el ig ib le m en b y re su lts o f t he h ou se ho ld a nd in di vi du al in te rv ie w s, a nd h ou se ho ld , e lig ib le m en a nd o ve ra ll re sp on se ra te s, a cc or di ng to u rb an -r ur al re sid en ce a nd d ist ric t, Ti m or -L es te 2 00 9- 10 Re sid en ce D ist ric t R es ul t U rb an Ru ra l Ai le u Ai na ro Ba uc au Bo bo na ro C ov a Li m a D ili Er m er a La ut em Li qu ic a M an at ut o M an uf ah i O ec us si Vi qu eq ue To ta l S el ec te d ho us eh ol ds C om pl et ed (C ) 91 .4 95 .7 91 .8 97 .7 97 .4 99 .3 93 .5 90 .1 93 .8 93 .8 95 .4 96 .1 90 .5 97 .7 94 .3 94 .6 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt a t h om e (H P) 1. 3 0. 5 1. 0 0. 0 0. 7 0. 0 1. 3 1. 8 1. 0 0. 0 1. 0 0. 0 1. 3 0. 0 0. 3 0. 7 Po st po ne d (P ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 3 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 Re fu se d (R ) 0. 9 0. 5 2. 6 0. 3 0. 0 0. 0 0. 7 1. 8 0. 3 1. 3 0. 3 0. 3 0. 0 0. 0 0. 0 0. 6 D w el lin g no t f ou nd (D N F) 1. 3 0. 3 0. 7 0. 3 0. 0 0. 0 0. 3 1. 8 0. 0 1. 6 0. 0 0. 7 0. 3 0. 3 0. 3 0. 5 H ou se ho ld a bs en t ( H A) 1. 7 0. 7 0. 7 0. 3 0. 0 0. 0 0. 3 2. 6 0. 7 2. 0 0. 7 1. 3 2. 9 0. 3 0. 0 0. 9 D w el lin g va ca nt /a dd re ss n ot a d w el lin g (D V) 1. 7 1. 2 1. 3 0. 7 2. 0 0. 7 3. 3 1. 0 0. 7 0. 3 1. 6 1. 6 1. 3 1. 0 2. 0 1. 3 D w el lin g de st ro ye d (D D ) 1. 7 1. 1 2. 0 0. 7 0. 0 0. 0 0. 7 0. 8 3. 3 1. 0 1. 0 0. 0 3. 6 0. 7 3. 0 1. 3 T ot al 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed h ou se ho ld s 1, 00 4 3, 04 0 30 4 30 6 30 6 30 6 30 6 38 3 30 4 30 6 30 6 30 6 30 6 30 6 29 9 4, 04 4 H ou se ho ld re sp on se ra te (H RR )1 96 .3 98 .7 95 .5 99 .3 99 .3 10 0. 0 97 .6 94 .3 98 .3 97 .0 98 .6 99 .0 98 .2 99 .7 99 .3 98 .1 E lig ib le m en C om pl et ed (E M C ) 85 .8 94 .5 81 .4 96 .1 96 .4 98 .5 90 .0 85 .4 97 .3 93 .6 84 .2 98 .1 90 .8 96 .1 95 .7 92 .2 N ot a t h om e (E M N H ) 6. 1 2. 9 6. 0 1. 9 1. 0 0. 6 8. 5 6. 6 0. 3 3. 3 7. 8 1. 1 5. 6 3. 2 1. 4 3. 8 Po st po ne d (E M P) 0. 2 0. 0 0. 3 0. 0 0. 0 0. 0 0. 0 0. 4 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 Re fu se d (E M R) 6. 4 1. 3 8. 7 1. 3 1. 9 0. 6 0. 6 6. 6 1. 1 0. 8 6. 7 0. 3 1. 2 0. 0 1. 4 2. 6 Pa rtl y co m pl et ed (E M PC ) 0. 8 0. 3 0. 3 0. 0 0. 3 0. 3 0. 3 0. 4 0. 3 1. 5 0. 3 0. 5 1. 2 0. 0 0. 4 0. 5 In ca pa ci ta te d (E M I) 0. 8 0. 9 3. 3 0. 6 0. 3 0. 0 0. 6 0. 6 1. 1 0. 8 1. 1 0. 0 1. 2 0. 7 1. 1 0. 9 T ot al 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f m en 1, 18 3 3, 23 8 36 6 30 8 30 8 32 4 33 0 47 2 36 5 39 1 37 4 37 3 25 1 28 2 27 7 4, 42 1 E lig ib le m en re sp on se ra te (E M RR )2 85 .8 94 .5 81 .4 96 .1 96 .4 98 .5 90 .0 85 .4 97 .3 93 .6 84 .2 98 .1 90 .8 96 .1 95 .7 92 .2 O ve ra ll re sp on se ra te (O RR )3 82 .6 93 .3 77 .8 95 .5 95 .8 98 .5 87 .8 80 .5 95 .6 90 .8 83 .1 97 .1 89 .2 95 .8 95 .0 90 .4 1 U sin g th e nu m be r o f h ou se ho ld s fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H RR ) i s ca lc ul at ed a s: 10 0 * C — — — — — — — — — — — C + H P + P + R + D N F 2 U sin g th e nu m be r o f e lig ib le m en fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e el ig ib le m an re sp on se ra te (E M RR ) i s ca lc ul at ed a s: 10 0 * EM C — — — — — — — — — — — — — — — — — — — — — — — — EM C + E M N H + E M P + E M R + E M PC + E M I + E M O 3 Th e ov er al l r es po ns e ra te (O RR ) i s ca lc ul at ed a s: O RR = H RR * E M RR /1 00 | 259Appendix A Appendix B | 261 ESTIMATES OF SAMPLING ERRORS Appendix B The estimates from a sample survey are affected by two types of errors: non-sampling errors and sampling errors. Non-sampling errors are the results of 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 Timor-Leste Demographic and Health Survey 2009-10 (TLDHS 2009-10) to minimize this type of error, non- sampling 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 TLDHS 2009-10 is only one of many samples that could have been selected from the same population, using the same design and expected 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 between 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 woul