Turkey - Demographic and Health Survey - 1994

Publication date: 1994

Turkey Demograpmc ana Health Survey 1993 Ministry of Health General Directorate of Mother and Child Health and Family Planning | Hacettepe University Institute of Population Studies @DHS Demographic and Health Surveys Macro IntemaUonal Inc. Turkish Demographic and Health Survey 1993 Ministry of Health, General Directorate of Mother and Child Health and Family Planning Ankara, Turkey Hacettepe University, Institute of Population Studies Ankara, Turkey Demographic and Health Surveys, Macro International Inc. Calverton, Maryland, USA October 1994 This report summarises the findings of the 1993 Turkish Demographic and Health Survey (TDHS) conducted by the Institute of Population Studies, Hacettepe University (HIPS), under a subcontract through an agreement between the General Directorate of Mother and Child Health and Family Planning, Ministry of Health and Macro International Inc. of Calverton, Maryland, USA. Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development (USAID). The TDHS is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect, analyse and disseminate demographic data on fertility, family planning, and maternal and child health. The survey is also the most recent in a series of demographic surveys carried out in Turkey by HIPS to provide information on fertility and child mortality levels; family planning awareness, approval and use; and basic indicators of maternal and child health. Additional information on the TDHS can be obtained from tile General Directorate of Mother and Child Health and Family Planning, Ministry of Health, Slhhiye, Ankara, Turkey (Telephone: 312-4314871 ; Fax: 312-4314872), or from Hacettepe University, Institute of Population Studies, 06100 Ankara, Turkey (Telephone: 312-3107906; Fax: 312-311814 I). Information on the worldwide DHS program may be obtained by writing: DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA (Telephone: 301-572-0200; Fax: 301-572-0999). Recommended citation: Ministry of Health [Turkey], Hacettepe University Institute of Population Studies, and Macro International Inc. 1994. Turkish Demographic and Health Survey 1993. Ankara, Turkey. CONTENTS Page TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi i F IGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x i i i SUMMARY OF F INDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv MAP OF TURKEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi i i CHAPTER 1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 by Attila Hancto~,lu 1. I Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 1.3 Administrative Divisions and Political Organisation . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.4 Social and Cultural Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.5 Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.6 Regional Breakdown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.7 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.8 Population and Family Planning Policies and Programs . . . . . . . . . . . . . . . . . . . . . . 6 1.9 Health Priorities and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 I . I0 Health Care System in Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.11 Objectives and Organisation of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 CHAPTER 2 2.1 2.2 2.3 CHARACTERIST ICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . 1 t by Turgay Onalan and Attila Hancto~lu Characteristics of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Background Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . 18 C I IAPTER 3 3.1 3.2 3.3 3.4 3.5 3.6 FERT IL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 by Aykut Toros Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Children Ever Born and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Teenage Pregnancy and Motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 iii CHAPTER 4 Page FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 by Ay$e Akin Dervi~o~,lu and Gul ErgOr 4.1 Knowledge of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 4.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.4 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . 40 4.5 Problems with Current Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 4.6 Use of Name-brand Pills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " . . . . . 41 4.7 Knowledge of the Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.8 Timing of Sterilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.9 Sources for Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 4.10 Contraceptive Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 4.11 Intent to Use Family Planning Among Nonusers . . . . . . . . . . . . . . . . . . . . . . . . . . 47 CHAPTER 5 5.1 5.2 5.3 5.4 5.5 ABORTIONS AND STILLBIRTHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 I bv Ay~e Akm Dervi~o~lu and G~il ErgOr Abortion and Stillbirth Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Abortions and Stillbirths by Selected Background Characteristics . . . . . . . . . . . . . 53 Contraceptive Use Before and After Induced Abortions . . . . . . . . . . . . . . . . . . . . . 54 Reasons for Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Timing of Induced Abortions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 CHAPTER 6 6.1 6.2 6.3 6.4 6.5 PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . . . . . . . . 59 by Banu Akadh Erg~J~men Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Marital Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Postpartum Amenorrhoea, Postpartum Abstinence, and Insusceptibility . . . . . . . . . 64 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 CHAPTER 7 7.1 7.2 7.3 7.4 FERTILITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 by Turgay Onalan Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Demand for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Ideal and Actual Number of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 iv CHAPTER 8 8.1 8.2 8.3 8.4 8.5 Page INFANT AND CHILD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 by Attila Hancto~,lu Definitions of Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Levels and Trends in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 High-risk Fertility Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 CHAPTER9 9.1 9.2 9.3 9.4 MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 by Mehmet Ali Biliker, Dilek Haznedaro~lu, and Nedret Emiro~,lu Antenatal Care and Delivery Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Immunisation of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 CHAPTER I0 INFANT FEEDING, MATERNAL AND CHILDHOOD NUTRIT ION . . . . . . 107 by Ergiil Tuncbilek 10.1 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 10.2 Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 10.3 Maternal Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " . . . . . . . . . . . . . . . 116 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 APPENDICES APPENDIX A PERSONNEL INVOLVED IN THE TURKISH DEMOGRAPHIC AND HEALTH SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 APPENDIX B SURVEY DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 by Mahir Ulusoy, Alfredo Aliaga, and Attila Hanclo~lu B.I B.2 B.3 B.4 B.5 B.6 B.7 B.8 B.9 Sample Design and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Sample Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Sample Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Sample Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Questionnaire Development and Pretest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Data Collection Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Data Processing and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Coverage of the Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Page APPENDIX C EST IMATES OF SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . 141 by Mahir Ulusoy and Alfredo Aliaga APPENDIX D DATA QUALITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 APPENDIX E CALCULAT ION OF CONTRACEPT IVE D ISCONTINUATION RATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 APPENDIX F SURVEY INSTRUMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 vi LIST OF TABLES Table 1.1 Table 2.1 Table 2.2 Table 2,3 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2,9 Table 2.10 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3,8 Table 3.9 Table 3.10 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Page Results of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . l0 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . 12 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Educational level of the household population . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Median age at first birth by background characteristics . . . . . . . . . . . . . . . . . . . . 3 l Teenage pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Children born to teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Knowledge of contraceptive methods and source for methods . . . . . . . . . . . . . . . 34 Knowledge of modern contraceptive methods and source for methods . . . . . . . . . 35 Ewr use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . 39 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . 41 Problems with current method of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Use of social marketing brand pills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 vii Table 4. I 0 Table 4. t 1 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 6. I Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 7.6 Table 7.7 Table 7.8 Page Timing of sterilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Source of supply for modem comraceptive methods . . . . . . . . . . . . . . . . . . . . . . 44 Contraceptive discontinuation rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Reasons for discontinuation of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Ft ture use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Reasons for not using contraception . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . 48 Preferred method o f contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . 49 Abortions and stillbirths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Total abortion rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 induced abortion and stillbirths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 induced abortions throughout life of a woman . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Method used before abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Method used after abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Method used after abortion and past use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Reasons for induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 T iming of induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Abortion providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Current marital ~tatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Marital exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Median age gt first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Postpartum amenorrhoea, abstinence and insusceptibility . . . . . . . . . . . . . . . . . . . 64 Median duration of postpartum abstinence and insusceptibility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Termination o f exposure to the risk o f pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 67 Fertility preference by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . 70 Fertility preference by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Desire to limit (stop) childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . 74 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Wanted fertility zales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 viii Table 8. I Table 8.2 Table 8.3 Table 8.4 "Fable 9.1 "Fable 9.2 Fable 9.3 Table 9.4 Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 9.9 Table 9. I 0 Table 9.1 I Table 9.12 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 10.6 'Fable 10.7 Table 10.8 Table B. I Table B.2 Table B.3 Table B.4 Table B.5 Table B.6 Table C. 1 Table C.2 Page Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . 81 Inthnt and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . 83 High-risk fertility behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Antenatal care (ANC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . 90 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Vaccinations in the first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . . 102 Prevalence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Treatment of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Feeding practices during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Breastfeeding and supplementation by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . 1 I 1 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . 113 Nutritional status by socioeconomic characteristics . . . . . . . . . . . . . . . . . . . . . . 115 Anthropometric indicators of maternal nutritional statns . . . . . . . . . . . . . . . . . . 117 Differentials in maternal anthropometric indicators . . . . . . . . . . . . . . . . . . . . . . 118 Number of households to be selected from regions by power allocation and probability proportional to size . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Distribution of clusters in regions and urban and rural areas . . . . . . . . . . . . . . . . 131 Weights for regions and compensating factors for nonresponse . . . . . . . . . . . . . 137 Response rates in five regions and settlement types . . . . . . . . . . . . . . . . . . . . . . 137 Final weights for households and individual women . . . . . . . . . . . . . . . . . . . . . 138 Results of the household and individual interviews by residence and region . . . . 139 List of selected variables for sampling errors, Turkey 1993 . . . . . . . . . . . . . . . . 146 Sampling errors - Entire sample, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . . 147 ix Table C.3 Table C.4 Table C.5 Table C.6 Table C.7 Table C.8 Table C.9 Table C. 10 Table C. 1 I Table C. 12 Table C. 13 Table D. I ]'able D.2 Table D.3 Table D.4 Table D.5 Table D.6 Page Sampling errors - Urban areas, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Sampling errors - Rural areas, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Sampling errors- Western Region, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . 150 Sampling errors - Southern Region, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . 15 I Sampling errors - Central Region, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . 152 Sampling errors - Northern Region, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . 153 Sampling errors - Eastern Region, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . 154 Sampling errors - Age 15-24, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Sampling errors - Age 25-34, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Sampling errors - Age 35-49, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Sampling errors for total fertility rates and infant mortality rates, Turkey 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . 162 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Births by calendar year since birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 X LIST OF FIGURES Figure 2.1 Figure 2.2 Figure 3.1 Figure 3.2 Figure4.1 Figure4.2 Figure4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7 Figure 6.1 Figure 6.2 Figure 6.3 Figure 7.1 Figure 8.1 Figure 8.2 Figure 8.3 Figure 9.1 Figure 9.2 Figure 9.3 Figure 9.4 Figure 9.5 Figure 9.6 Figure 9.7 Figure 9.8 Figure 10.1 Page Population p~cramid of Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 School enrollment by age and place of residence . . . . . . . . . . . . . . . . . . . . . . . . . 16 Age-specific fertility rates by urban-rural residence . . . . . . . . . . . . . . . . . . . . . . . 24 Age-specific fertility rates during the last 20 years . . . . . . . . . . . . . . . . . . . . . . . 27 Ever use of family planning, Turkey 1978-1993 . . . . . . . . . . . . . . . . . . . . . . . . . 37 Current use of family planning, Turkey 1988-1993 . . . . . . . . . . . . . . . . . . . . . . . 38 Current use of family planning by region and method . . . . . . . . . . . . . . . . . . . . . 40 Knowledge of fertile period among ever-married women and users of periodic abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Source of supply of modern contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . 45 Future use of contraception among nonusers currently married . . . . . . . . . . . . . . 48 Reasons for not using contraception among nonusers currently married . . . . . . . . 49 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Median age at first marriage among women age 25-49, by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Percentage of births whose mothers are amenorrhoeic, abstaining or insusceptible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Fertility preferences among currently married women 15-49 . . . . . . . . . . . . . . . . 70 Trends in infant mortality in Turkey, 1993 TDHS and 1988 TPHS . . . . . . . . . . . 80 Infant mortality by selected background characteristics . . . . . . . . . . . . . . . . . . . . 82 Infant mortality by selected demographic characteristics . . . . . . . . . . . . . . . . . . . 83 Source of antenatal care (ANC) by maternal age and birth order . . . . . . . . . . . . . 89 Antenatal care by region and residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Place of delivery by maternal age and birth order . . . . . . . . . . . . . . . . . . . . . . . . 93 Place of delivery by region and residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Vaccination coverage among children age 12-23 months . . . . . . . . . . . . . . . . . . . 97 Prevalence of acute respiratory infection by sex and birth order . . . . . . . . . . . . . 101 Prevalence of acute respiratory infection by residence and region . . . . . . . . . . . . 101 Percentage of children under five years with diarrhoea, by age, sex, birth order and residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Growth of children under five years, mean z-scores by age in months . . . . . . . . 114 xi PREFACE The Turkish Demographic and Health Survey (TDHS) is a nationwide sanaple survey of women of reproductive age designed to provide, among other things, information on fertility, family planning, child survival, and health of children. The survey was conducted by the Institute of Population Studies, Hacettepe University, Ankara, Turkey, under an agreement through a subcontract signed between the General Directorate of Mother and Child Health and Family Planning, Ministry of Health and Macro International Inc. of Calverton, Maryland, USA, as part of the worldwide Demographic and Health Surveys program, which is being administered by the latter organisation. Tile major objectives of the TDHS were to provide concerned circles in Turkey with data useful for making informed policy choices and for enhancing the design and implementation of programs aimed at promoting family planning and improving the health status of the population. As noted above, the survey collected data on major health phenomena, family planning, fertility, and infant and child mortality. In addition to providing information on recent demographic and health trends, tile TDHS was further intended to serve as a source of demographic data for comparison with earlier surveys conducted by tile Institute of Population Studies, particularly the 1988 Turkish Population and Health Survey, the 1983 Turkish Fertility and Health Survey, and the 1978 Turkish Fertility Survey. We owe a special debt of gratitude to everyone in the TDHS team, whose untiring eflbrts and devotion made possible the successfid implementation of tile survey. We wish to record our sincere gratitude to Dr. Attila Hanclo~lu, Project Technical Director, Dr. Turgay 0nalan, Field Director, and Dr. Banu Akadh Erg69men, Head of Data Processing, who, in addition to performing tile tasks implied by their functions, participated in all pllases of the project from its inception to its completion. We also wish to thank Dr. Mahir Ulusoy, who took care of the sampling and listing activities, Dr. Turgay Co~kun, who made valuable contributions during the training of the TDHS fieldwork teams on anthropometric measurements, and Dr. G01 Erg6r, who was involved with and contributed to the study in various stages. We also thank the Steering Committee members for their valuable contributions and advice, and the staff of the State Institute of Statistics for their assistance in the sampling activities. We owe an immense debt to tile Regional Coordinators, Research Assistants, Supervisors, Interviewers, Field Editors, and Measurers for their meticulous assistance and hard work; theirs was the most delicate and risky job. We are also grateful to all the respondents for their patience and generosity with their time. We would also like to thank all the Governors of the provinces our teams visited, as well as the government officials in these provinces for their support in providing our teams with accommodation and vehicles. Very special acknowledgment is due tile U.S. Agency for International Development (USAID) for prov:ding funding and technical assistance for the survey. We thank Dr. Pmar Senlet, USAID Population Advisor in Ankara, for her unfailing support to the project. We would also like to acknowledge the contribution of UNICEF Ankara to the survey, especially to the UNICEF Representative, Mr.Claudio Sepulveda. xiii We are most gratefid to Macro International Inc. for providing technical assistance. We wish to record our deepest gratitude to Dr. Edilberto Loaiza, country monitor, for his valuable contributions; Dr. Alfredo Aliaga, sampling expert, for his fruitful collaboration with the TDHS team in activities related to sampling and listing, and Jeanne Cushing, for her expertise in data processing. Dr. Ann Way, also from Macro International Inc., had a large part at the inception of the project; we thank her for her contributions. Finally, special thanks are extended to those at Macro International Inc. who reviewed and produced the TDHS report. Prof. Dr. Ergtil Tunc;bilek Survey Director Hacettepe University Institute of Population Studies Prof. Dr. Ay~e Akin Dervi~o~lu Project Director Ministry of Health General Directorate of MCH/FP xiv SUMMARY OF FINDINGS The 1993 Turkish Demographic and Healtb Survey (TDHS) is a nationally representative survey of ever-married women less than 50 years old. The survey was designed to provide information on fertility levels and trends, infant and child mortality, family planning, and maternal and child bealth. Tbe TDItS was conducted by the Hacettepe University Institute of Population Studies under a subcontract tbrougb an agreement between tbe General Directorate of Mother and Cbild Health and Family Planning, Ministry of tlealth and Macro International Inc. of Calverton, Maryland. Fieldwork was conducted from August to October 1993. Interviews were carried out in 8,619 households and witb 6,519 women. Fertilit~ in Turkey is continuing to decline. If Turkish women maintain current fertility rates during their reproductive years, they can expect to have all average of 2.7 children by tbe end of their reproductive years. The highest fcrtility rate is obse~'ed for the age group 20-24. Tbere are marked regional differences in fertility rates, ranging from 4.4 children per woman in the East to 2.0 children per woman in tbe West. Fertility also varies widely by urban-rural residence and by education level. A woman living in rural areas will have almost one child more than a woman living in an urban area. Women wbo bave no education have almost one child more tban women who have a primary-level education and 2.5 children more than women wilh secondary-level education. The first requirement of success ill family planning is the knowledge of family planning methods. Knowledge of any method is almost universal among Turkish women and almost all tbose who know a method also know the source of the metbod. Eighty percent of currently married women have used a method sometime in tbeir life. One third of currently married women report ever using tbe IUD. Overall, 63 percent of currcntly married women are currently using a metbod. The majority of these women are modern method users (35 percent), but a very substantial proportion use traditional methods (28 percent). rbe I UD is the most commonly used nloderu method (I 9 percent), lbllowed by the condom (7 percent) and the pill (5 percent). Regional differences are substantial. The level of current use is 42 percent in tile East, 72 percent in tile West and more than 60 percent in tile other three regions. "File common complaints about tile methods are side efl'ects and health concerns; tbese are especially prevalent for the pill and IUD. A basic knowledge of reproductive plDsiology is necessary, especially in tile use of coitus-related methods. However, only 22 percent of cver-married v, olnen kDow the correct time of ovulation. Information on the sources of methods is important for plamling the services. The majority of users (55 percent) obtain the methods from government services. Primary health care units are tile major public sector suppliers (35 percent) and pllarmacies are the major private sector suppliers (26 percent). Tile discontinuation rate of the IUD is the lowest among all inelhods. Intbrmation on tile intentions of current non-users was also collected tbr the cstimation of futnre dcmand. Of this group, 46 percent do not intend to use any method in the future ,,,dlereas 45 percent havc the intention to use. Of lbe latter women, the majority report that their method of choice v, ill be the IUD. Abortion rates have decreased slightl) since 1990. The decrease is observed tbr induced abortions rather than spontaneous abortions. For tile 3ear preceding tile survey, the abortion rate is 29 per 100 pregnancies, tile induced abortion rate is 18 per 100 pregnancies and the spontaneous abortion rate is 12 per 100 pregnancies. The abortion incidence is twice as high in tile Central, Southern and Northern regions and ahnosl three times as high in the Western region compared to tile Eastern region. "I'here have been 1.5 stillbirths per 100 pregnancies in the last five years preceding tile survey. Overall, 72 percent of women bad had no abortions, 15 percent had one abortion, 8 percent had two abortions and 5 percent had three or more abortions. There is a very important oppontmit) for family plamling cotmselling after an abortion, ttowever, the results show that this opporttmity is not ulilised well. In tile month after an induced abortion. XV 39 percent of women did not use any inethod and 27 percent used withdrawal. The main reason for obtaining an abortion was the desire not to have any more children (58 percent). Overall, 44 percent of abortions took place in the first month of pregnanc)~ 31 percent in the second month, 13 percent in tile third inonth and 12 percent in tile fourth or later months of pregnancy. Some 67 percent of abortions were perlbrmed by private physicians and 27 percent were perlbrmed in tile government hospitals: there are no significant differences between regions in terms of the .place ",,,llere induced abortions are performed. The age at first marriage is one of the important determinants of fertility. "FI)HS results suggest tbat there has been an increase over the past 20 years in tile age at first marriage in Turkey. "File median age at first marriage among ~omen age 25-29 is 20 )'ears compared to 18.3 )'ears among women age 45-49. There are differences in the age at inarriage across places of residence and regions. Even more pronounced differences are observed by educational level of women. Among '~,,omen age 25-40, there is a difference of ahnost 5 years in the timing of entry into marriage between those with little or no education and those x,,llo completed at least tile secondary level. More than two-thirds of currently married wolnen in Turkey say that they do not want ally more children. An additional 14 percent 'e, ant to ~,,ait at least two )'ears before having another child. When asked ho',~ inany children they would like to bare i f the)were to start their reproductive lives all over again and be able to choose exactly, WOlnen reported an average ideal talnil) size of 2.4 children. Results from tile surve) suggest that i f all unwanted births were eliminated, the total fertility rate at tile national level would bc 1.8 children per V~Olnan. nearly one child lower than the actual level of 2.7. Twenty percent ofthe births in the five ,,'ears preceding the survey were un',vanted birtbs and 12 percent of them were mistimed. The unmet need for family planning in Turke) indicates that there is potential for further increases in contraceptive use. Twelve percent of curreatl) married ~,omen are considered to be in need of family planning. These are V, Olnen who want no more children (8 percent) or who want to delay the next birth (4 percent) but are not using fimlil) planning. Data on infant and child mortalit) ffOln the f l ) l lS appear to be of reasonable quality according to a preliminary assesslnent of tile qualit) of birth bistor)data. [:or the five ),ears preceding tile TD[IS, tile infant mortalit) rate is estimated at 53 per thousand, tile child Inortality rate at 9 per thousand, and the under-five mortalit~ rate at 61 per thousand. For the same period, the results show that in Turkey, the neonatal mortalit) rate is higher than the postneonatal inortalit)' rate, and that all tile indicators of infant and child mortalit) have declined rapidl~ in recent )ears. The general agreelneat of the TDI-IS results with those from previous sur~,eys confirms the plausibility of the fDIIS findings. The TDItS fhldiags point to significant differences in inthnt and child mortality between regions and urban and rural areas, and show tbat tile educational level of the inother and the presence of medical inatemity care are important correlates of infant and child mortalit). In addition to the differentials observed bet~,een socioeconomic groups, infant and child mortality rates also appear to correlate strongly vJth demographic variables. Age of mother at birth and order of birth show the expected U-shaped relationship witb inlbnt and child mortality. Elevated risksof mortalit) are also apparent in the case of short birth intervals. Among the maternal health hldicators, antenatal care was received from trained health personnel by 62 percent of pregnant women. For more than half of the births, antenatal care started before the fifth month of pregnancy. Tetanus toxoid coverage for women is Io~. with 16 percent having one dose and 26 percent having two doses or more. Tile TDtlS shows that 60 percent of all deliveries took place at a health facilit). Deliveries at home are inore likely to occur without the assistance of trained health personnel. xvi One of the major child health indicators is immunisation coverage. Among children age 12-23 months, the coverage rates for BCG and the first two doses of DPT and polio were about 90 percent, with most of the children receiving those vaccines before age one. The results indicate that 65 percent of the children had received all vaccinations at some time before the survey. On a regional basis, coverage is significantly lower in the Eastern region (41 percent), followed by the Northern and Central regions (61 percent and 65 percent, respectively). Acute respiratory infections (ARI) and diarrhoea are the two most prevalent diseases of children under age five in Turkey. In the two weeks preceding the survey, the prevalence of ARI was 12 percent and the prevalence of diarrhoea was 25 percent for children under age five. Among children with diarrhoea 56 percent were given more fluids than usual. Breastfeeding in Turkey is widespread. Almost all Turkish children (95 percent) are breastfed for some period of time. The median duration of breastfeeding is 12 months, but supplementary foods and liquids are introduced at an early age. One-third of children are being given supplementary food as early as one month of age and by the age of 2-3 months, half of the children are already being given supplementary foods or liquids. By age five, almost one-filth of children arc stunted (short for their age), compared to an international reference population. Stunting is more prevalent in rural areas, in the East, among children of mothers with little or no education, among children who are of higher birth order, and among those born less than 24 months after a prior birth. Overall, wasting is not a problem. Two percent of children are wasted (thin for their height), and I I percent of children under five are underweight for their age. The survey results show that obesity is d problem among mothers. According to Body Mass Index (BMI) calculations, 51 percent of mothers are overweight, of which 19 percent are obese. xvii TURKEY M~-I_)I I I-HHANIcAIV ,bI-A /~'1 ~¢( ~'~4 REGIONS AND PROVINCES WEST SoLrrH CENTRAL 09 Aydm 01 Adana 03 Aft/on 10 Bahkasir 07 Antalya 05 Amasya 16 Bursa 15 Burdur 06 Ankara 17 (~anakkale 27 Gaziantep 11 Bilecik 20 Denizli 31 Hatay 14 Bolu 22 Edime 32 !sparta 18 (~ankm 34 !stanbul 33 I~;el 19 C.,orum 35 Izmir 48 Mu~la 26 EskL~,ehir 39 Ktrklareli 38 Kayseri 41 Kocaeli 40 K~r~ehir 45 Manisa 42 Konya 54 Sakarya 43 KOtahya 59 Tekirda~ 50 Nev~=hir 51 Nk]de 60 Tokat 64 U~k 66 Yozgat 68 Aksaray 70 Karaman 71 Kmkkale ,HCIVAN '.ARBAIJAN) NORTH EAST 08 Artvin 02 Ad=yaman 47 Mardin 28 Giresun 04 A0n 49 Mu~ 37 Kastamonu 12 Bing{~l 56 Siirt 52 Ordu 13 Bitlis 58 Sivas 53 R~Ye 21 Diyarbak=r 62 Tunceli 55 Samsun 23 ElazL~ 63 ~.Urfa 57 Sinop 24 Erzincan 65 Van 61 Trabzon 25 E~urum 69 Bayburt 67 Zonguldak 29 G=3m0~hane 72 Batman 74 Barbn 30 Hakkafi 73 ,~mak 36 Kars 75 Ardahan 44 Malatya 76 I~d=r 46 K. Mara~ CHAPTER 1 INTRODUCTION Attila Hanclo lu 1.1 Geograp Turkey has a surface area of 774,815 square kilometres and has land area in both Europe and Asia. About 3 percent of her total area lies in southeastern Europe (Thrace) and the remainder, in southwestern Asia (Anatolia, or Asia Minor). Turkey shares borders with Greece, Bulgaria, Syria, Iraq, Iran, Georgia, Armenia and Nahcivan (Azerbaijan). The shape of the country resembles a rectangle, stretching in the east- west direction for roughly 1,565 kilometres and in the noah-south direction for roughly 650 kilometres. Turkey is surrounded by seas in the north (the Black Sea), in the northwest (Marmara), in the west (the Aegean) and in the south (the Mediterranean), giving it a total coastline of approximately 8,333 kilometres. Anatolia consists of a semi-arid central plateau surrounded by mountains. The Northern Anatolia mountains in the north and the Taurus mountains in the south stretch parallel to the coastline, meeting in the eastern part of the country. The eastern region of the country is characterized by rugged mountainous areas. The average altitude of the country is approximately 1130 metres above sea level. However, there are vast differences in altitude among regions, ranging from an average of 500 metres in the west to 2,000 metres in the east. The climate is characterized by variations of temperature and rainfall, depending on topography. The average rainfall is 500 millimetres. In Rize, a province on the Black Sea coast, however, the average increases to 2,000 millimetres, while it is less than 300 millimetres in parts of Central Anatolia. Dry, hot summers and cold, rainy winters are the typical climatic conditions of Turkey. In summer, temperatures do not display large variations among different regions of the country, whereas in winter, temperatures range from an average of-10°C in the eastern areas to +10°C in the south. 1.2 History Anatolia was dominated by the Seljuqs for almost two centuries (1055-1243) and later became the core of the Ottoman Empire, one of the most powerful forces in the Middle East and Europe. Following the demise of the Empire, the Republic of Turkey was founded on its remnants, after the War of Independence led by Mustafa Kemal Atatfirk was won. The foundation of the modem Republic not only marked the end of the Ottoman era and drew the present borders of modem Turkey (with the exception of Hatay province, which was not annexed until 1939), but also signified a radical departure from the previous social formation. A modem constitution was introduced, the Sultanate and Caliphate were abolished, religious schools and courts were closed, Western headgear and dress were adopted, Islamic Law was abandoned and replaced with modified versions of the Swiss and Italian Civil and Penal Codes, and the Arabic alphabet was replaced with an alphabet based on Latin characters. In short, the direction of change, led by Atatiirk, was one from a religious, oriental Empire to a modern, Westernized, secular Republic. After both the death of Atattirk in 1938 and the Second World War, during which Turkey was initially neutral but eventually sided with the Allies, the country became less stable politically, but more democratic. The one-party system came to an end in 1950, when the first multiparty election was held; significantly, the Republican People's Party lost to the opposition, the Democrat Party. Turkey then entered a period of liberalization and democratization. Turkey has succeeded in preserving a parliamentary, multi- party system until today, with tbe exception of three military interventions in 1960, 1971, and 1980. Turkey is a member of the United Nations and the Council of Europe and is an associate member of the European Community. Close relations have been establisbed witb the Western world, manifested in its membership in NATO. Turkey maintains good relations with the countries of the Middle East, stemming from deep-rooted cultural and historical links. 1.3 Administrative Divisions and Political Organisation The Turkish administrative structure, since the founding of the Republic, has been shaped by three fundamental codes, namely, the Constitutions of 1924, 1961, and 1982. Tbese constitutions specify that Turkey is a Republic with a parliamentary system and that the will oftbe people is vested in tbe Turkisb Grand National Assembly (TGNA). All tbree constitutions adopt basic individual, social and political rights, and accept tbe principle of separation of powers. The legislative body of the Republic is the TGNA. The TGNA is composed of 450 deputies, who are elected in democratic elections for five-year periods. The President of the Republic is elected by the TGNA for a seven-year term. Tbe Council of Ministers, the executive branch of the Republic, is composed of the Prime Minister and tbe Cabinet Ministers. Tbe judiciary consists of tbe Constitutional Court, the Court of Appeals, the Military Court of Appeals, the Court of Jurisdictional Disputes, and the civil and military Courts. Turkey is administratively divided into 76 provinces. These are further subdivided into districts (ilq'e), subdivisions (bltcak), and villages. The head of the province is the governor, wbo is appointed by ' and responsible to the central government. The governor, as the chiefadm inistrative officer in tbe province, carries out the policies of the central government, supervises the overall administration of the province, coordinates the work of the various ministry representatives appointed by the central antlmrity in the capital Ankara, and maintains law and order within bis/her jurisdiction. At the municipality level, local governments, each administered by a mayor and a municipal council, are elected by the municipal electoral body for a term of four years. Every locality with a population of more tbau 2,000 is entitled to form a municipal administration. Municipalities are expected to provide basic services such as electricity, water, gas, the building and maintenance of roads, and sewage and garbage disposal facilities. Educational and health services are mainly provided by the central government, but municipalities also provide some health services. 1.4 Social and Cultural Features Turkey has a highly heterogeneous social and cultural structure. The "modern" and "traditiooal" exist simultaneously;there are sharp contrasts between population groups. Attitudes to life are reminiscent of those in the Western world especially for the inhabitants of metropolitan areas. People are more conservative and religious in the rural areas oftbe country. Traditional opposition to modernization persists in the less developed areas in the north and east. Family ties are strong and influence tbe formation of values, attitudes, aspirations, and goals. Altbough laws can be considered to be quite liberal on gender equality, patriarchal ideology still characterizes social life. 2 Citizens of Turkey are predominantly Muslim. About 98 percent of the population belong to the Sunni and Alevi sectsof the Muslim religion, the Sunnis forming the overwhelming majority. Ethnically, Turks predominate; Kurdish, Arabic, Greek, Circassian, Georgian, Armenian, and Jewish communities of varying sizes complete the ethnic mosaic of the rich and complex culture of the Turkish society. One of the most striking achievements since the founding of the Republic has been the increase in both literacy and education. In 1935, only 10 percent of females and 29 percent of males were literate in Turkey. According to the latest census figures, in 1990, these were 72 and 89 percent, respectively, for the population age 6 and over. Educational attainment has also increased dramatically. The rate for primary school attendance today is around 90 percent. Moderate achievements have also been made in increasing the proportions of males and females with higher than primary-level education. A five-year primary school education is compulsory in Turkey; however, this causes drop-outs after primary school. Considerable regional and urban-rural differences in literacy and educational attainment exist in the country in addition to differences between males and females (State Institute of Statistics, 1992; 1994). 1.5 Economy Turkish governments have adopted various economic strategies for the development of the country since the founding of the Republic. Liberal policies were implemented during the early years, when the economy was based almost exclusively on agriculture. These policies continued until 1929, and moderate improvements were gained in the mechanization of agriculture. This period was followed by a period of "Etatism," characterized by the strong hand of the state in economic affairs and trade protectionism. The first serious improvements in industry were achieved during this period. Turkey remained neutral during the Second World War, but the war still imposed heavy restraints on the economy, slowing down the industrialization process. After the war, a "mixed economy" regime followed, whereby private enterprise gained recognition side by side with the state economic enterprises. Also, more emphasis was placed on agricultural development. The military intervention in 1960 and tile consequent military govermnent brought about the preparation of a series of Five-Year Development Plans, the first of which became operative in 1963. Preparations for the Seventh Plan are currently under way. The Turkish economy can now he called a "free enterprise" economy; the intervention of the state in economic matters has gradually decreased since the early 1980s. The policies of the 1980s and 1990s have aimed to articulate the backward sections of the economy to the capitalist market, to provide incentives to the improvement of export-oriented industries, to ease the restrictions on imports and exports, and to facilitate the inflow of foreign capital. In general, Turkey is self-sufficient in terms of its agricultural production and does not import foodstuffs. Wheat, barley, sugar beets, potatoes, and rice are grown in the interior, and cotton, tobacco and citrus are grown for export around the coastal areas. Turkey is not rich in mineral resources. The country's main problem is the inadequacy of primary energy resources, and thus the cost of fuel oil is extremely high. Copper, chromium, borax, coal, and bauxite are among the mineral resources in the country. The main industries are steel, cement, textiles, and fertilizers. Machinery, chemicals and metals are imported mainly from the OECD countries. In recent years, there has been a significant increase in the amount of industrial goods exported to Europe and Arab countries. Turkey can be classified as a middle-income country in the 1990s. The rate of economic growth has been comparatively high in recent years and the economy has undergone a radical transformation, fi'om an agricultural base to an industrial one. 1.6 Regional Breakdown Due to the diverse geographical, climatic, cultural, social, and economic characteristics of different parts of the country, Turkey is perhaps best described by using a conventional regional breakdown of the country. Five regions (Western, Southern, Central, Northern, and Eastern) are distinguished, reflecting, to some extent, differences in socioeconomic development levels and demographic conditions among sections of the country. This regional breakdown is frequently used for sampling and analysis purposes in social surveys. The Western region is the most densely settled, the most industrialized and socioecohomically, the most advanced region of the country. It includes |stanbul (previously the capital of the Ottoman Empire), which is Turkey's largest city and the country's manufacturing and commercial centre. The region also includes |zmir, the country's third largest city. Coastal provinces form a relatively urbanized, fast-growing area. The Aegean coast is also a major agricultural area, where cotton is grown in the river valleys and fruit is cultivated on the hillsides. With dry summers and mild, rainy winters, agricultural yields from the fertile soils are good. The region contributes most of the gross domestic product of the country. Most of the industrial establishments are situated in the Western region. The Southern region includes highly fertile plains and some rapidly growing industrial centres. Adana, one of the new metropolises of Turkey, is located in this region. The semitropical coastal plains are cut off by steep mountains from the Anatolian highlands to the north. Hot, dry summers and mild, wet winters describe the climatic conditions of the region. Cultivation of cotton and citrus provide high incomes and export earnings; recent decades have witnessed an industrial boom and an inflow of migrants, especially from the Eastern region. The Central region is an arid grazing area and includes Ankara, the capital and second largest city. Industrial production in the region is low, except for some minor industries located around Ankara. The region specializes in the production of cereals. Given the dry, temperate climate, fruit tree cultivation and sheep and cattle raising are also common. The Northern region has a fertile coastal strip, but in most places it is only a few kilometres wide; the region is relatively isolated from the rest of the country by mountainous terrain. The region specializes in small-scale, labour-imensive crops like hazelnut and tea. The region receives large quantities of rainfall. Zonguldak, a western province, has extensive coal reserves and is a centre for mining and the steel industry. The Eastern region includes the least developed provinces of the country. The sparse vegetation, rugged mountainous terrain, short summers, and severe climate are suited to animal husbandry rather than settled farming. In addition to having limited potential for agriculture, the region is also poor in terms of industrial production. However, much of the arid and semi-arid earth in the south of the region will be transformed into fertile land upon the completion of a large irrigation and energy project, the Southeast Anatolia Project. The project is by far the most serious and optimistic development program planned for the region. In addition to economic benefits, the project is also expected to reverse the migration flow from the region to the rest of the country. 1.7 Population Turkey's population was 13.6 million in 1927 according to the census, which was performed four years after the establishment of the Republic. Beginning with the 1935 census, subsequent population censuses were undertaken at 5-year intervals. The last one, in 1990, put Turkey's population at 56.5 million, which showed that the country's population had quadrupled since the founding of the Republic. 4 Turkey is among the 20 most populous countries of the world and is the most populous country of the Middle East (State Institute of Statistics, 1993; United Nations, 1985). Intercensal estimates of population growth have been around 20-25 per thousand since the 1970s. The latest estimate of the population growth rate was 21.7 per thousand for the 1985-1990 period. Population growth rates have fluctuated since the first census. The fluctuations have been particularly striking in the last two decades, owing their origins to varying rates of decline in the fertility and mortality rates, as well as to changes/reversals in migration trends; Turkish workers' emigration to Western Europe in the 1960s has been largely replaced by population movements to other countries, and a new trend of an inflow of population from neighbouring countries has been observed in the last decade. An increase in the number of expatriate workers returning from work in Europe is also a phenomenon of the same period (State Planning Organisation, 1993). Turkey has a young population as a result of the high fertility and growth rates in the recent past. A third of the population is under 15 years of age, while the proportion of elderly is quite low. However, the absolute number of elderly is expected to increase considerably in the near future. Marriage, predominantly civil, is widely practiced in Turkey. Religious marriages also account for a significant proportion of the marriages; however, the main custom is to undergo a civil as well as a religious ceremony to get married. The average age at marriage is relatively low, about 18 years for females. The universality of marriage in Turkey is observed in the proportions never married; at the end of the reproductive ages, in age group 45-49, only 1.6 percent of females were never married, whereas the corresponding figure for males in the same age group was 2.6 percent, according to the 1990 Population Census. Marriages in Turkey are also known to be very stable; divorce rates are very low (Hanclo~lu and Akadh Erg6~men, 1992). Recent decades have witnessed dramatic declines in fertility rates. In the early 1970s, the total fertility rate was around 5 children per woman, whereas the latest estimates in the late 1980s had put the total fertility rate at about 3 children per woman. The crude birth rate is estimated to have been around 25 per thousand in the late 1980s. There is a considerable shortage of information on mortality in Turkey, particularly adult mortality. However, due to the relatively easy estimation of the indicator through fertility surveys, infant mortality rates can be traced back for a relatively long period of time. The infant mortality rate in the late 1950s was around 200 per thousand. It declined to about 130 per thousand during the mid 1970s and to an estimated 67 per thousand during the 1985-1990 period. Crude death rates have also declined from around 30 per thousand in the 1940s to 8 per thousand in the late 1980s. The latest estimates put life expectancy in Turkey at 62.7 years for males and 67.3 for females (Shorter, 1994). The population of Turkey has undergone an intensive process of urbanization, especially from the 1950s onwards. According to the 1970census, only 32.3percent ofthepopulationwaslivinginlocalities with more than 20,000 population. The corresponding figure in the 1990 census was 51.4 percent. The rate of urbanization has been approximately 50 per thousand during the 1970-1990 period. This process has inevitably caused problems in the provision of urban services and the emergence of large areas of squatter housing in unplanned cities. According to the projections prepared by the State Planning Organisation for the Seventh Five-Year Development Plan, the population of Turkey is expected to reach 69.5 million in the year 2000 and 82 million in 2010 (Shorter, 1994). 1.8 Population and Family Planning Policies and Programs The government of the Turkish Republic implemented a somewhat pronatalist population policy until the mid-1960s, after which an antinatalist policy was adopted. This shift in policy is manifested in the Population Planning Law of 1965 (State Planning Organisation, 1993). Due to the heavy human losses during the First World War and the War of Independence, the defense needs of the country and the shortage of manpower, as well as the high infant and child mortality rates, a need to increase fertility and population growth was perceived during the early years of the Republic. A number of laws having direct or indirect implications on fertility and population growth were passed. These laws included monetary awards to women with more than 5 children, prohibitions on the import and sale of contraceptives, and prohibitions on abortions on social grounds. The traditional attitudes of Turkish governments to population growth began to change in the 1950s, mainly due to medical problems, especially with the realization of the existence of high maternal mortality caused by illegal abortions. High urban population growth and employment problems were also factors contributing to the new antinatalist environment in government circles. The State Planning Organisation and the Ministry of Health pioneered the policy change; previous policies were liberalized by allowing limited importation of contraceptives. As mentioned, The Population Planning Law was enacted in 1965. The law mandated the Ministry of Health with the responsibility for implementing the new family planning policy. The State Planning Organisation, on the other hand, incorporated the notion of population planning in the First Five-Year Development Plan. In 1983, the Population Planning Law was revised and a more liberal and comprehensive law was passed; the name remained the same. The new law legalized abortions up to the tenth week of pregnancy and voluntary surgical contraception. It also specified the training of auxiliary health personnel in inserting IUDs and included other measures to improve family planning services and mother and child health. 1.9 Health Priorities and Programs Mother and child health and family planning services have been given a priority status in the antinatalist policies of the government in recent decades due to the large proportion of women of reproductive ages'and children in the Turkish population, the high infant, child and maternal mortality rates, the high demand for family planning services, and the limited prenatal and postnatal care. A number of programs are being implemented, with special emphasis on provinces which have been designated as priority development areas, as well as programs focusing on squatter housing districts in metropolitan cities, rural areas and special risk groups. Specific programs in immunisation, childhood diarrhoeal diseases, acute respiratory infections, promotion of breastfeeding and growth monitoring, nutrition, antenatal and delivery care, safe motherhood, Information, Education, and Communication programs for mother and child health and family planning activities are currently being implemented. 1.10 Health Care System in Turkey The Ministry of Health is officially responsible for designing and implementing nation-wide health policies and delivering health-care services. Besides the Ministry of Health, other sectors and non- Governmental Organisations contribute to carrying out some health services. 6 At the central level, the Ministry of Health is responsible for the implementation of curative and preventive health-care services throughout the country within the principles of primary health care. The responsibility for delivering the services and implementing specific Primary Health Care programs is shared by various General Directorates (Primary Health Care, Mother and Child Health and Family Planning, Health Training) and by various Departments (Departments of Tuberculosis Control, Malaria Control, Cancer Control). At the provincial level, the health care system is under the responsibility of Health Directorates, under the supervision of the Governor. The provincial Health Director is responsible for delivering all primary health-care services as well as curative services. The present network of Health Centres and Health Houses was formed on the basis of "Legislation for the Socialization of Health Services" so that services and facilities are extended down to the village level. A substantial proportion of villages have health centres or health houses. These are located so as to provide easy access to the other villages. The most basic element of the health service is tile Health House, which serves a population of 2500-3000 and is staffed by a midwife. The Health Centre serves a population of 5,000-10,000 and is staffed by a team consisting of a physician, a nurse, a health officer, midwives, an environmental health technician and a driver. Health Centres mainly offer integrated, polyvalent, primary health-care services. Mother and Child Health and Family Planning Centres and Tuberculosis Dispensaries also offer preventive health services. This network of health systems works as a health team and is mainly responsible for delivering primary health services, maternal and child health, family planning, and public education services. These health facilities are also the main sources of the health information system. 1.11 Objectives and Organisation of the Survey Objectives The Turkish Demographic and Health Survey (TDHS) is a national sample survey of ever-married women of reproductive ages, designed to collect data on fertility, marriage patterns, family planning, early age mortality, socioeconomic characteristics, breastfeeding, immunisation of children, treatment of children during episodes of illness, and nutritional status of women and children. The TDHS, as part of the international DHS project, is also the latest survey in a series of national-level population and health surveys in Turkey, which have been conducted by the Institute of Population Studies, Haeettepe University (HIPS). More specifically, the objectives of the TDHS are to: Collect data at the national level that will allow the calculation of demographic rates, particularly fertility and childhood mortality rates; Analyse the direct and indirect factors that determine levels and trends in fertility and childhood mortality; Measure the level of contraceptive knowledge and practice by method, region, and urban- rural residence; Collect data on mother and child health, including immunisations, prevalence and treatment of diarrhoea, acute respiratory infections among children under five, antenatal care, assistance at delivery, and breastfeeding; Measure the nutritional status of children under five and of their mothers using anthropometric measurements. 7 The TDHS information is intended to assist policy makers and administrators in evaluating existing programs and in designing new strategies for improving family planning and health services in Turkey. Organisation The TDHS was carried out by HIPS, through a subcontract under an agreement signed by the General Directorate of Mother and Child Health and Family Planning, Ministry of Health, and Macro International Inc., of Calverton, Maryland, USA. Technical and financial support for the survey was provided by Macro International Inc. through its Demographic and Health Surveys (DHS) program, a project sponsored by the United States Agency for International Development (USAID) to carry out population and health surveys in developing countries. The Hacettepe Institute of Population Studies began preparations to carry out a Turkish demographic survey in 1993 as far back as December 1991. With the aim of continuing the series of quinquennial demographic surveys carried out since 1968, a preliminary questionnaire was designed, based on the model questionnaires used in the World Fertility Surveys, the Contraceptive Prevalence Surveys and the Family and Fertility Surveys, and on questionnaires used in previous demographic surveys in Turkey. Several international organisations, including the United Nations, were contacted in an effort to secure funding for the survey. In December 1992, Macro International Inc. expressed an interest in providing funding for the implementation of a DHS survey in Turkey, and contacted the General Directorate of Mother and Child Health and Family Planning, Ministry of Health, and the Hacettepe Institute of Population Studies for this purpose. An agreement was signed between the General Directorate and Macro International Inc., and the General Directorate subcontracted the implementation of the survey activities to HIPS. A steering committee consisting of representatives from the General Directorate, HIPS, the Hacettepe University Department of Public Health, the State Planning Organisation, and the State Institute of Statistics was set up to provide advice on the implementation of the survey. The persons involved in the TDHS are listed in Appendix A. Questionnaires Two questionnaires were used in the main fieldwork for the TDHS: the Household Questionnaire and the Individual Questionnaire for ever-married women of reproductive age. The questionnaires were based on the model survey instruments developed in the DHS program and on the questionnaires that had been employed in previous Turkish population and health surveys. The questionnaires were adapted to obtain data needed for program planning in Turkey during consultations with population and health agencies. Both questionnaires were developed in English and translated into Turkish; the English versions are reproduced in Appendix F. The Household Questionnaire was used to enumerate all usual members of and visitors to the selected households and to collect information relating to the socioeconomic position of the households. In the first part oftbe Household Questionnaire, basic information was collected on the age, sex, educational attainment, marital status and relationship to the head of household for each person listed as a household member or visitor. The objective of the first part of the Household Questionnaire was to obtain the information needed to identify women who were eligible for the individual interview as well as to provide basic demographic data for Turkish households. In the second part of the Household Questionnaire, questions were included on the dwelling unit, such as the number of rooms, the flooring material, the source of water, and the type of toilet facilities, and on the household's ownership of a variety of consumer goods. 8 The Individual Questionnaire for women covered the following major topics: Background characteristics Reproduction Marriage Knowledge and use of family planning Other issues relating to contraception Maternal care and breastfeeding Immunisation and health Fertility preferences Husband's background, women's work and residence Values, attitudes and beliefs Matemal and child anthropometry. The woman's questionnaire included a monthly calendar, which was used to record fertility, contraception, postpartum amenorrhoea and abstinence, breastfeeding, marriage, and migration histories for periods of more than five years, beginning in January 1988, up to the survey month. In addition, the fieldwork teams measured the heights and weights of children under age five and of their mothers, as well as mothers' ann circumference. Sample The sample for the TDHS was designed to provide estimates of population and health indicators, including fertility and mortality rates for the nation as a whole, fOr urban and rural areas, and for the five major regions of the country. A weighted, multistage, stratified cluster sampling approach was used in the selection of the TDHS sample. Sample selection was undertaken in three stages. The sampling units at the first stage were settlements that differed in population size. The frame for the selection of the primary sampling units (PSUs) was prepared using the results of the 1990 Population Census. The urban frame included provinces and district centres and settlements with populations of more than 10,000; the rural frame included subdistricts and villages with populations of less than 10,000. Adjustments were made to consider the growth in some areas right up to survey time. In addition to the rural-urban and regional stratifications, settlements were classified in seven groups according to population size. The second stage of selection involved the list of quarters (administrative divisions of varying size) for each urban settlement, provided by the State Institute of Statistics (SIS). Every selected quarter was subdivided according tothe number of divisions(approximately 100 households)assigned to it. In rural areas, a selected village was taken as a single quarter, and wherever necessary, it was divided into subdivisions of approximately 100 households. In cases where the number of households in a selected village was less than 100 households, the nearest village was selected to complete the 100 households during the listing activity, which is described below. After the selection of the secondary sampling units (SSUs), a household listing was obtained for each by the TDHS listing teams. The listing activity was carried out in May and June. From the household lists, a systematic random sample of households was chosen for the TDHS. All ever-married women age 12-49 who were present in the household on the night before the interview were eligible for the survey. A more technical and detailed description of the TDHS sample design, selection and implementation is presented in Appendix B. Fieldwork and Data Processing Data collection for the TDHS was carried out by 17 teams; each team consisted of four to five interviewers, a field editor, a measurer and the team supervisor. Six of the teams used notebook-type computers lbr data entry and editing in the field. In these teams, the field editor used a data entry program written in ISSA (Integrated System for Survey Analysis). In the other teams, editing was done manually. The field staff, including the editors working with notebooks, were trained during a four-week period in July 1993. The main fieldwork began in August 1993 and was completed in late October. All callbacks and re-interviews were completed by the end of October. Questionnaires were returned to the Hacettepe Institute of Population Studies in Ankara for data processing. The office editing teams checked that the questionnaires for all selected households and eligible respondents were returned from the field. The comparatively few questions that had not been precoded (e.g., occupation) were coded at this time. The data were then entered and edited using microcomputers and the ISSA package. The office editing and data processing activities were initiated almost immediately atter the beginning of fieldwork and were completed in November 1993. The results of the household and individ- ual questionnaires are summarized in Table I.I. Information is provided on the overall coverage of the sample, including household and individual response rates. In all, 10,63 t households were se- lected tbr the TDHS. At the time of tile survey, 8,900 households were considered as occnpied and, thus, available for interview. The main rea- sons field teams were unable to interview some households were that some dwelling units that were listed were found to be vacant at the time of the interview or the household was away for an extended period. Of the 8,900 occupied house- holds, 97 percent (8,619 households) were suc- cessfully interviewed. Table I I Resulls of the houschold and individual interviews Nnmber of households, number of" interviews, and response rates, Turkey 1993 Urban Rural Total I Iousebolds selected 7065 3566 I (163 I IIouseholds tbund 5752 3148 8900 I Iouseholds interviewed 5491 3128 8619 Household response rate 95.5 99.4 96.8 Eligible women 4344 2518 6862 Eligible women interviewed 4125 2394 6519 Eligible women response rate 95.(I 95.1 95.0 Overall response rate 90.6 94.5 92.(I In the interviewed households, 6,862 women were identified as eligible for the individual interview, i.e., they were ever-married women younger than 50 years of age who were present in the household on the night before the interview. Interviews were successfully completed with 6,519 of these women (95 percent). Among the small number of eligible women not interviewed in the survey, the principal reason for nonresponse was the failure to find the woman at home after repeated visitsto the household. The overall response rate for the women's sample was 92 percent. A more complete description of the fieldwork, coverage of the sample, and data processing is presented in Appendix B. 10 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Turgay Unalan Attila Hanclo~lu Information on the background characteristics of tile households included in tile survey and tile individual respondents is essential for'the interpretation of survey findings and provides a rough measure of the representativeness of the sample of women and households. The information in this chapter is presented in three sections: characteristics of the household population (age-sex structure and education), housing characteristics (including water supply, sanitation, flooring material and ownership of consumer goods), and background characteristics of survey respondents (age, marital status, residence, and education levels)• 2.1 Characteristics of the Household Population The Turkish Demographic and Health Survey (TDHS) household questionnaire included two questions that would distinguish between the de jure population (persons who are usual residents in the selected household) and the de facto population (persons who spent the night before the interview in the selected household). Unless otherwise indicated, all tabulations in this report are based on the de filcto survey poptllation in the selected households. A household was defined as a person or a group of persons living together and sharing a commou source of food• Age Tile age distribution of the household population in the TDHS is shown in Table 2.1 and Figure 2. I by five-year age groups, ~ according to sex. The population pyramid (Figure 2.1 ) reflects the effects of past demographic trends on the population and gives an indication of future trends. The narrowing oftbe base of the pyramid is indicative of a recent decline in fertility, whereas the narrow top points to high mortality in the past; the greater concentration of the population in the 10-19 age group implies that large cohorts will be entering reproductive ages in the next decade• Table 2.2 presents the population age structure found in the TDHS and in other data sources ill the country. The age groups used allow the computation of the age dependency ratio at different points ill time. The age dependency ratio is the ratio of non-productive persons (persons age 0 to 14 and those age 65 and over) to persons age 15 to 64. It is an indicator of the dependency responsibility of adults in their productive years. The percentage of the population under 15 years of age appears to have declined between 1989 and 1993. As a result, the percentages in the 15-64 and 65 and over categories show an increase. This pattcrn is typical of populations that are experiencing a fertility decline. The dependency ratio also decreased, from 66 in 1989 to 63 in 1993. The decline in the dependency ratio indicates a lessening of the economic burden on persons in the productive age groups, i.e., those who support people in the non- productive age groups• tSingle-year age distributions are presented in Appendix D, which includes tables on the quality of the TDHS data. 11 Table 2.1 Household population by age, residence and sex Percent distribution of the de facto household population by five-year age groups, according to urban-rural residence and sex, Turkey 1993 Urban Rural Total Age group Male Female Total Male Female Total Male Female Total 0-4 9.1 8.7 8.9 10.3 8.6 9.4 9.6 8.6 9.1 5-9 11.3 10.0 10.6 12.0 11.5 11.9 11.6 10.6 11.1 10-14 12.5 11.8 12.1 14.5 I3.0 13.7 13.2 12.2 12.7 15-19 11.3 11.8 11.5 11.1 12.5 11.9 11.2 12.1 11.6 20-24 8.5 10.0 9.3 7.2 9.0 8.I 8.0 9.6 8.8 25-29 8.8 8.4 8.6 6.0 6.3 6.2 7.7 7.5 7.6 30-34 7.3 8.0 7.7 5.4 5.9 5.7 6.6 7.1 6.9 35-39 7.2 6.4 6.8 5.3 5.2 5.3 6.5 5.9 6.2 40-44 5.8 5.6 5.7 3.9 4.3 4.1 5.1 5.1 5.1 45-49 4.0 3.7 3.8 4.0 3.7 3.8 4.0 3.7 3.8 50-54 3.7 4.5 4.1 3.9 4,7 4.3 3.8 4,6 4.2 55-59 3.2 3.2 3.2 4,4 4.4 4.4 3.7 3.7 3.7 60-64 3.0 2.9 3.0 4.3 4.2 4.2 3.5 3.5 3.5 65-69 2.1 2.2 2.1 3.6 3.5 3.5 2.6 2.7 2.7 70-74 1.1 1.2 1.2 1.8 1.3 1.5 1.3 1.3 1.3 75-79 0.5 0.6 0.5 1.0 0.7 0.8 0.7 0.7 0.7 80 + 0.6 1.0 0.9 1.3 1.2 1.2 0.9 1.1 1.0 Total 100.0 100.0 I00.0 I00.0 100.0 100.0 100.0 100.0 I00.0 Number 11473 11655 23128 7237 7919 15156 18710 19574 38284 Figure 2.1 Population Pyramid of Turkey 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 o-4 ~5 le 10 5 0 5 10 Percent 15 TDHS 1993 12 Table 2.2 Population by age from selected sources Percent distribution of the population by age group, selected sources, Turkey 1989-1993 TDS CP TDHS Age group 1989 1990 1993 Less than 15 35.4 35.0 33.0 15-64 60.4 60.7 61.4 65+ 4.2 4.3 5.6 Total 100.0 100.0 100.0 Median age 22.0 22.2 23.1 Age dependency ratio 65.7 64.7 62.7 Sources: 1989 Turkish Demographic Survey. SIS, 1991. 1990 Census of Population. SIS, 1993. Househo ld Compos i t ion Table 2.3 presents the percent distribu- tion of households by sex of head of the house- hold, household size, and relationship of house- hold members to the head of the household, ac- cording to urban-rural residence, as calculated from the TDHS. The household composition usually affects the allocation of resources (fi- nancial, emotional, etc.) available to household members. In cases where women are heads of household, it is usually found that financial re- sources are limited. Similarly, the size of the household affects the well-being of its members. Where the size of the household is large, crowd- ing can lead to health problems. Of all households covered in the TDHS, I0 percent are headed by women. The propor- tion is slightly higher in urban than in rural areas. There are, on average, 4.5 persons in a household. Rural households are 0.8 persons larger than urban households. Considering adult household members age 15 and over only, the majority of households consist of two related adults of the opposite sex or three or more re- lated adults. Five percent of households consist of only one adult. Educat ion Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, and relationship structure, according to urban- rural residence, Turkey 1993 Residence Chamcteristic Urban Rural Total Household headship Male 89.3 91.4 90.0 Female 10.7 8.6 I 0.0 Number of usual members 0 1.4 2.4 1.8 I 4.3 4.6 4.4 2 13.6 14.7 14.0 3 18.0 10.9 15.5 4 24.5 15.5 21.3 5 17.3 14.5 16.3 6 9.6 I1.1 10.1 7 5.5 8.6 6.6 8 2.6 6.7 4.0 9+ 3.2 I 1.0 6.0 Mean size 4.2 5.0 4.5 Relationship structure One adult 5.0 5.2 5.0 Two related adults: Of opposite sex 44.4 32.6 40.2 Of same sex 1.7 1.0 1.5 Three or more related adults 46.6 58.6 50.9 Other 2.3 2.6 2.4 Total 100.0 100.0 100.0 Number of households 5563 3056 8619 Note: Table is based on de .jure members, i.e., usual residents. The education level of household members is perhaps their most important characteristic. Many phenomena, such as reproductive behavior, use of contraception, health of children, and proper hygienic habits, are issues that are affected by the education of household members. Table 2.4 shows the education 13 "Fable 2.4 Educational level of the household nopulation Percent distribution of the de facto household population age six and over by highest level of education attended, according to selected background characteristics, Turkey 1993 Level of education Missing/ Median Background No Primary Primary Secondary Secondary Don't number characteristic education incomplete graduate incomplete graduate+ know Total Number of years MALE POPULATION Age 6-9 29.2 690 0.6 0.1 0.0 I.I I000 1801 0.0 10-14 2,1 34.9 26.3 30.1 6,5 01 1000 2480 5.4 15-19 1.7 2.2 34.8 11.9 492 0.2 1000 2100 7.9 20-24 2.5 1.5 39.7 9.5 46.7 0,1 100.0 1498 7.0 25-29 3.1 1.2 46.5 7.8 41.2 0.2 1000 1444 6,0 30-34 3.6 1.7 48.9 5.7 39.8 0.3 100.0 1231 5.9 35-39 6.7 2.5 53.6 5.1 31.8 0.3 100.0 1212 5.7 40-44 7.5 3.2 56.6 5.2 27.3 0.2 1000 953 5.7 45-49 13.7 5.7 53.1 3.4 239 02 I00.0 743 5.6 50-54 22.6 7.5 47.5 2.7 19.3 04 100.0 703 5.4 55-59 30.0 9.8 46.1 0.5 134 0.2 I00.0 687 5.2 60-64 38,8 10.5 37.9 1.5 107 06 1000 659 4.9 65+ 51.0 10.1 28.4 1.0 84 I I 100.0 1039 0.0 Missing/Don't know * * * * * * 100.0 7 * Residence Urban 9.7 14.1 32.9 10,3 327 0,3 1000 10201 5 8 Rural 18.2 18.4 42.4 7.1 13,4 0,5 1000 6356 5.3 Region West 86 13.7 38.9 9.4 29.1 0.3 I00.0 5620 5.7 South 10.7 15.8 40.8 9.6 22.6 05 1000 2591 5.5 Central 119 15.5 35,9 9.3 271 03 I00.0 3628 5.6 North 133 166 361 9.4 24.0 0.6 1000 1360 55 East 230 19.2 300 79 19.5 0,4 [00.0 3358 5.3 Total 130 158 365 9,1 253 03 I000 16557 5.6 FEMALE POPULATION Age 6-9 326 65.4 06 0.1 0,3 1.0 I00.0 1719 0.0 10-14 5.8 311 355 21,4 61 OI I00.0 2398 5.3 15-19 74 22 53.7 4.3 324 00 1000 2364 5 7 2(I-24 14.2 3.4 517 3,3 27,4 (10 I000 1872 5.6 25-29 18.1 47 513 2.4 234 01 1000 1474 5.5 30-34 22,5 5 6 51 2 23 184 00 I000 1396 5.4 35-39 31.9 72 450 18 14,1 O0 1000 1158 5.2 40~14 403 9.4 37.1 1.9 112 0 1 100.0 992 50 45-49 433) I 1.8 31.5 1.4 I 1.4 00 I000 728 0.0 50-54 54.4 10.7 25.6 1.3 74 06 I00,0 897 00 55-59 63.7 10.8 21.2 03 33 0,7 1000 730 0.0 60-64 70.8 1 I.I 13.6 0.4 3.5 06 1000 676 00 65+ 768 77 t0.6 0.3 4.1 0.5 100.0 II 19 0.0 Missing/Don'l know * * * I000 5 * Residence Urban 23.7 145 341 61 214 0.2 I000 10449 5.3 Rural 371 172 38.5 2.5 44 03 1000 7079 0.0 Region West 201 139 39.8 6.0 199 03 1000 5776 54 South 26.8 15.9 37.5 5.0 14.6 02 1000 2697 52 Central 259 17 5 37.1 4.4 14.8 0.3 I00.0 4048 52 North 333 14.8 367 3.q II I 02 1000 1614 51 East 48.1 16.3 25.9 28 66 03 I000 3393 O0 Ioml 29.1 15.6 35.9 4.7 14.5 0.2 100.0 17528 51 * Less Ihan 25 eases 14 level of household members by age group, residence, and region tbr each sex. Primary education is compulsory in Turkey; it usually starts at age 7 and lasts five years. Secondary education is for 3 years. Recent national policy, however, encourages parents to send their children to primary school at age 6. At present, therefore, a child can start school at either of two different ages. Approximately 71 percent of men and 55 percent of women have completed at least primary school, and 25 percent of men and 15 percent of women have completed secondary school or higher. Table 2.4 also shows the median number of years of schooling attained by males and females in each five-year age group. Overall, males have a median duration of schooling of 5.6 years, 0.5 years longer than females. The gap in the median uunlber of years of schooling between males and females is more than I year for the population above age 15, but is negligible among those age 10-14 years. Presented also in Table 2.4 is the level of education by urbau-rural residence and region. The proportion of persons with no education is much higher in rural areas than in urban areas, and this difference is observed for both males and females. Three-fourths of males and two-thirds of females in the urban areas are graduates of at least primary school. The proportion of secondary school graduates differs markedly between urban and rural areas, for males and, in a more pronounced way, for females. The proportion of secondary school graduates is five times higher for females in urban areas than in rural areas. Overall, regional differences in education are considerable. The overall level of education is highest in the Western region and lowest in the Eastern region. School Enrollment Table 2.5 presents information on school eurollment by age, sex, and residence. These rates are simple ratios of the number of enrolled persons in a specific age group to the total number in that age group. Figure 2.2 depicts the levels of school enrollment by age and place of residence. According to the TDHS, 73 percent of children age 6-10 were enrolled in school at the survey date. The percentage enrollment drops to 62 percent in the age group I 1-15 years. For people age 15 and under, the percentage enro;'.ed in school is higher for males titan females. Enrollment after age 15 drops significantly; whereas 2 in 3 children age 6-15 are in school, by age 16-20 the ratio drops to only I in 4 children, and by age 21-24, only 1 in 10 children are attending school. There are differences in school enrollment between urban attd rural residents at all ages for both sexes; the rural attd/or female population has consistently lower school enrollment titan the urban and/or male population. As age increases, the gap between males and females widens. Table 2.5 School enrollment Percentage of the de facto household population age 6-24 years enrolled in school, by age group, sex, and urban-rural residence. Turkey 1993 Age group Male Female Total Urban Rural Total Urban Rural Total Urban Rural Total 6-10 75.5 72.1 74.1 72.5 68.7 70.8 74.1 70.4 72.5 11-15 78.1 62.6 71.7 64.7 35.1 5t.9 71.6 48.7 61.9 6-15 76.8 67.2 72.9 68.5 51.4 61.1 72.8 59.2 67.1 16-20 38.9 24.6 33.6 26.9 4.8 17.6 32.6 13.2 24.8 21-24 16.8 6.5 13.2 9.1 2.6 6.8 12.6 4.4 9.7 15 Figure 2.2 School Enrollment by Age and Place of Residence Percent 8O SO 40 20 0 6-15 16-20 21-24 Age TDHS 1993 2.2 Housing Characteristics In order to assess the socioeconomic conditions in which respondents live, household heads or respondents of the household questionnaire were asked to give specific infonnation about their household environment. The type of water, sanitation facilities, quality of the floor, and crowding are important determinants of the health status of household members, particularly of children. Table 2.6 presents the major housing characteristics by place of residence. Overall, 63 percent of the households get their drinking water from pipes. Sources used by households to obtain drinking water differ considerably by area of residence. Water that is piped into the residence is used by 75 percent of the households in urban areas versus 42 percent in rural areas. In rural areas, water from springs is the second main source of drinking water (27 percent) and another 16 percent obtain water from a public tap. The second source of drinking water in urban areas is bottled water. Modern sanitation facilities are not widely available in rural areas. Pit toilets are used instead (85 percent) and only 3 percent of households have no toilet facility. In urban areas, most of the population use flush toilets (86 percent). The flooring material of dwelling units is usually cement (34 percent), wood planks (25 percent), or marley (14 percent). Cement is the most common flooring material in both rural areas (38 percent) and urban areas (32 percent). The flooring material of I in 5 households in rural areas is earth. Information on the number of rooms households use for sleeping was collected as a measure of crowding. The mean number of persons per sleeping room is 2.5 for the country as a wllole; this number varies from 2.3 in urban areas to 2.8 in rural areas. The sleeping room is shared by one or two persons in about 75 percent of urban households but this figure drops to 62 percent of rural households. 16 Table 2.6 Itousing characteristics Percent distribution of households by housing characteristics, according to urban-rural residence, Turkey 1993 Residence ttousing characteristic Urban Rural Total Source of drinking water Piped into residence 74,5 42.0 62.9 Public tap 3.8 16.3 8.2 Well in residence 0.6 3.8 1.7 Public well 0.1 4.0 1.5 Spring 5.7 27.4 13.4 River, stream 0.0 1.0 0.4 Pond, lake 0.0 0.2 0.0 Dam 0.0 0.2 0. I Rainwater 0.0 0.3 0.2 Tanker truck 1.5 0.2 I, I Bottled water 12.7 0.6 8.4 Other 0.3 0.2 0.2 Stationary tank/pool 0.7 3.7 1.8 Missing/Don't know 0.1 0.1 0.1 Total 100.0 I00.0 100.0 Sanitation facility Flush toilet 85.7 I 1.6 59.4 Closed pit 12.3 60.5 29.4 Open pit 1.5 24.5 9.7 No facility 0.4 3.3 1.4 Missing 0. I 0. I 0. I Total 100.0 100.0 100.0 Flooring Earth 2.2 20.1 8.6 Wood planks 18.9 37.2 25.4 Parquet, polished wood 7.7 0.4 5.1 Cement 31.7 37.6 33.9 Carpet 2.2 0.6 1.6 Marley 20.3 2. I 13.8 Mosaic 13.5 1.2 9. I Square flagstone 2. I 0.5 1.6 Other 1.3 0.2 0.8 Missing/Don't know 0.1 0.1 0. I Total 100.0 100.0 100.0 Persons per sleeping room I-2 74.9 61.8 70.2 3-4 21.0 27.5 23.3 5-6 3. I 6.7 4.4 7 + 0.9 3.9 2.0 Missing/Don't know 0. I 0. I 0. I Total 100.0 100.0 100.0 Mean persons per room 2.3 2.8 2.5 Number of households 5563 3056 8619 17 Household Durable Goods The availability of durable consumer goods is a good indicator of household socioeco- nomic level. Moreover, particular goods have specific benefits. Having access to a radio or a television exposes household members to innovative ideas, a refrigerator prolongs the wholesomeness of foods, and a means of transport allows greater access to many services away from the local area. Table 2.7 presents the availability of selected consumer goods by residence. Most of the population in Turkey enjoy the convenience of electrical appliances. Around 9 in 10 Turkish households own a television set and a refrigerator, while ahnost 8 in 10 own a ra- dio cassette player and more than half own a tele- phone, an oven, a vacuum cleaner, and a washing machine. Urban households are more likely to have the convenience of all of these items than rural households. 2.3 Background Characteristics of Survey Respondents Iable 2.7 llousehold durable goods Percentage of households possessing spccilic durable consumer goods, by urban-rural rcsidcncc, lurkcy 1993 Residence Durable goods IMpart Rural Iotal Refl'igerator 94.7 74 1 874 Oven 75.4 378 62 I Washing machine 70,5 21.6 53.2 Dishwasher II1-I 0.5 6,9 Vacuum cleaner 66,7 185 496 Television 92.8 75.5 86,7 Video recorder 156 3.6 I 1.4 Radio cassette player 792 72.2 767 Music scl 22.1/ 5.3 16.0 l elephonc 68.4 37.9 57.6 Car 23.8 127 19.9 Computer 3.2 112 2. I More lhan 30 books 311 6.3 22.3 Total number of households 5563 31156 8619 General Characteristics A description of the basic characteristics of the ever-married women interviewed in the TDIIS is essential as background for interpreting findings presented later in the report. Table 2.8 provides the percent distributiou of women by age, marital status, level of education, urban-rural residence, and region. Women were asked two questions in the individual interview to assess their age: "In what month and year were you born?" and "How old are you?" Interviewers were trained to use probing techniques for situatious in which respondents knew neither their age nor date of birth; as a last resort, interviewers were iustructed to record their best estimate of the respondent's age. Five percent of women are under 20 years of age, 35 percent are age 20 to 29, 36 percent are age 30 to 39, and the rest (24 percent) are 40 or over. Of the ever-married women in the sample, 96 percent are currently married, while the rest are either widowed, divorced, or separated, indicating the rarity of marital dissolution in Turkey. One in three women interviewed in the survey has either never attended school or has some primary education but did not finish primary school, 51 percent have either completed primary school or have some secondary education, and 15 percent are at least secondary school graduates. This distribution of the respondents according to educational groups reveals a specific character of educational attaim'ncnt in "rurkey: once individuals attend school, they are likely to complete it, rather than drop out before completion. The proportions of women in the "Primary incomplete" and "Secondary incomplete" categories are low, making their use as separate categories for demographic analysis impossible. Therefore, contrary to the conventions used in most other surveys conducted in the Demographic and I lealth Surveys program, the education categories in the following sections have been arranged based on graduation from, rather than ',Ttet~&mc;. ;n the various education levels~ The first two categories are combined to form the category 18 "women who have less education than primary school graduation"; the third and fourth groups are combined to form "women who have either completed primary school or attended secondary school without completing it," and the fifth group is kept the same, i.e., "women who have at least completed secondary scbool." About two-thirds of women live in ur- ban areas and the rest live in rural areas. Ac- cording to the data, 36 percent of respondents live in the Western region, 23 percent live in the Central region, 16 percent live in tbe Eastern region, 15 percent live in the Southern region, and the remaining 9 percent live in the Northern region. Different ia ls in Educat ion "Fable 2.9 sbows thc distribution of the surveyed women by education, according to se- lected characteristics, as a first eftbrt to clarify lbe relationsbip between the explanatory or background variables used in later tabulations. O f particular importance are possible diffcrences in the educational composition of womcn from different age groups, regions, and urban-rural backgrounds. Education is inversely related to age. tbat is, older women are generally less educated than younger women. For cxample, 45 percent of women age 45-49 have had no formal education, whereas only 16 percent of women age 15-19 bave never been to school. Women in urban areas are more likely to have bigher education than their rural cotmterparts. The urban-rural difference is most pronounced at the secondary or higber level; only 3 percent of women in rural areas have secondary or nlore education, whereas the percentage in urban areas is 22. Provided also in Table 2.9 is intbrmation on women's level of Table 2.8 Background charactcristics of respondents Percent dislribution of ever-married women by selected background characteristics. I'urkcy 1993 Number of wonlen Background Weighted Un- characteristic percent Weighted ~ eightcd Age 15-19 50 332 330 20-24 16.1) 1040 1 I)3 I 25-29 18.6 1211 1230 30-34 19.7 1283 1280 35-39 16.5 11)73 1085 40-44 13.8 9111 888 45-49 10.4 679 675 Marital status Married 96.1 6271 6273 Widowed 2.3 148 149 I)iw~rced 1 2 76 73 Scparaled ()A 24 24 Education No education 27. I 1765 1769 Primal. incomplele 6.6 431 433 Primary graduate 48.8 3182 3192 Sccondar). incomplete 24 157 155 Secondary graduate + 15 1 984 970 Residence tlrban 64.1 4181 4125 Rural 35.9 2338 2394 Region Wcst 35,7 2325 1875 Soulh 15.3 998 1295 Central 23.3 15211 1471 North 9.4 612 101)4 East 16.3 1064 874 All ~omen I00.0 6519 6519 education by rcgion. The Eastern region has the highest proportion of uneducated women (56 percem). The proportion of women who have attended at least primary school is higher in the West than in othe: rcgions. 19 Table 2.9 Level of education Percent distribution of women by the highest level of education auended, according to selected background characteristics, Turkey 1993 Level of education Background No Pr imary Primary Secondary Secondary Number characteristic education incomplete graduate incomplete graduate+ Total of women Age 15-19 16.1 3.1 67.6 4.5 8.7 100.0 332 20-24 17.l 3.9 57.3 3.3 18.4 100.0 1040 25-29 19.1 4.4 54.6 2.5 19A 100.0 1211 30-34 21.9 6.0 52.4 2.3 17.4 100.0 1283 35-39 33.2 6.8 45.0 2.1 12.9 100,0 1073 40-44 40.2 10.3 37.1 1.6 10.8 100.0 901 45-49 44.6 12.2 31.2 1.8 10.2 100.0 679 Residence Urban 21.2 5.5 48.4 3.3 21,6 I00.0 4181 Rural 37.6 8.6 49.5 0.9 3.4 I00.0 2338 Region West 15.8 5.4 55.2 3.4 20.2 100.0 2325 South 27.6 6.8 48.6 2.3 14.7 100.0 998 Central 22.4 8.4 53.0 2.2 14.0 100.0 1520 North 30.7 6.0 48.8 2.3 12.2 100.0 612 East 55.8 6.9 29.2 0.7 7.4 100,0 1064 Total 27.1 6.6 48.8 2.4 15.1 100.0 6519 Access to Media Women were asked if they usually read a newspaper, listen to a radio or watch television at least once a week. This information is important to program planners seeking to reach women with family planning and health messages through the media. Less than half of women read a newspaper at least once a week. Overall, 89 percent of women watch television weekly and 75 percent listen to the radio weekly (see Table 2.10). Although exposure to mass media varies little across age groups, women under age 40 are slightly more exposed to mass media than older women. Media access is stronger among the urban and educated population. A much higher proportion of educated and urban women read newspapers. Similarly, the proportion of educated women who watch television and listen to the radio is higher than less educated women. 20 Table 2.10 Access to mass media Percentage of women who usually read a newspaper at least once a week, watch television at least once a week, or listen to the radio at least once a week, by selected background characteristics, Turkey 1993 Read Watch Listen to Number Background newspaper television radio of characteristic weekly weekly weekly women Age 15-19 46.1 84.0 79.1 332 20-24 49.3 90.1 8 I. I 1040 25-29 48.3 90.7 75.5 121 I 30-34 50.4 90.0 73.7 1283 35-39 43.4 89.1 75.5 1073 40-44 38.6 86.8 71.8 90 I 45-49 32.7 87.6 68.6 679 Residence Urban 56.7 93.1 78.8 4181 Rural 24.1 81.6 68.2 2338 Region West 57.8 93.5 77.2 2325 South 45.8 89.0 77.6 998 Central 42.8 89.7 76.1 1520 North 44.3 89.8 75.7 612 East 20.0 77.6 65.8 1064 Education No education 4.9 76.5 57.3 1765 Primary incomplete 23.2 88.0 70.4 431 PrimaD' graduate 54.3 92.7 79.9 3182 Secondary incomplete 79.5 97.7 88.9 157 Secondary graduate + 90.8 98.6 90.8 984 Total 45.0 89.0 75.0 6519 21 CHAPTER 3 FERTILITY Aykut Toros The fertility measures presented in this chapter are based on the retrospective reproductive histories of women age 15-49 interviewed in the TDItS. Each woman was asked the number of sons and daughters living with her, the number living elsewhere, and the number who had died. She was then asked fnr a history of all her births, including the month and year of each, the nalne and sex and, if deceased, the age at death. If alive, the current age and whether he/she was living with the mother were also asked. Based on this ilfformation, measures of cmupleted fertility (number of children ever born) and current fertility (age-specific rates) are examined. These measures are also analyzed in connection with various background characteristics. Cumulative fertility and children ever born are also looked at in this chapter. The tables display the data on children ever born by the woman's current age and by her age at marriage. The chapter concludes with an analysis of information on the age of the woman at the time of her first birth. The data are important because they indicate the beginning of the woman's reproductive life. 3.1 Data Quality I:,stimatiol++ oF Ibl'lility is based on the is+timber of births x+ithin a gi'+cn period of tilnc, usuall) a calendar year or Oll¢ ftdl yeaF preceding the s1.1rvcy, Data l'roln man) courdries are vuln.,,ral+Je to various sources of errors (i.e., inemory errt;rs, omissions by survival stattlS of children, etc. ). Among these sc>urccs, inc,,;rrcct rel)ortiI++g of the dates of recent births and omissions of births arc most hnportant in estimating current I'ertilh,,, levels. [Jnfortuilatcly. Tttrkish data are no exception to this. Various demographic data sources in "l'urkc+'+ have produced distributions that dircctl) or indirectly point out errors in the data sets. For htstanc+2, the 1985 Population Census counted 986,730 children at age one but 1,014,61 ] children at age zero. Similarly, the 1990 Population Census counted 1,00?.7t)'o children at age one and I,I 16,403 children at age zero. A similar relationship ~,+as observed in the 1978 lurkish l:ertility Sur, cy (681 and 728 children, respectively). l'l++ese results all impl'., at face "+aluc. htcrcashlg trends in fertility, but in ~icxs of the well-documented decline in fc+lilit3 in Turkey in the last halfcemur.~, this can not be real. Persistence "ol'a meanirtgl'ul magnitude" of such inconsistencies it++ man+', data sources indicates a regularity or a character, rather than an tmexpected finding. The Preliminary Report o1" the 1093 ID I IS that was pul+,lished earlier this .~¢ar used thrce-.~ear averages thaI ,.~. el'c sul~ject to the aboVc-lnentioned "pseudo dippings" of fcllil ity trends during 111¢ last I]',c ",.ears. l)uc Io the eXisIeltc{2 Of stlch findings |'rollt most stll'V¢)%, a number of prelil++++inar) el+seeks ~¢r¢ perlbrlned to assess xq++cther tile fcrliliI) data fronl tllc '1'I)I IS lL'lalillg to the one full :.ear preceding the survey were plausible, these included checks of the sex ratios of hirths declared, to scc if there v.'as sex- selective omission of births, and tabulalhms of the background characteristics of children born m the last 8 years to see whether births had been selectivel)omitted b3 such characteristics as sur', i,.al status, place of residence, educati,,m of moll++er, etc. In both cases, tIe+ere appeared lobc no signilicant s¢lccli', it} in the birtl++s declared. Additionally, t,.so types of analyses '.',er e undertaken ISar Ihc saint purpc~s¢. First, the ,+'~ell- ktloV+ Is+ l~;ongaarts model ~.~. as used to pr£icct a([jI.isled l~rtiliu, estimates oI" pre'. ious sur'. cys to the +xcar 1903 (for adjusted fcrlilit,, estimates of previous sur,,¢.,.s, scc IlIP%, IOWg, pp. 158-173). Sccont.l. current i~rcgnancics reported in the FI)I I% ~er¢ used to calculalc a "v.ould-bc" Iotal I~rtilh3 ratc Ior calendar )ear 1993. 'lhe total Ibrlilil~. rates eslimalcd for 190 ~ from bolh t3 pc,, t~l anal~. ,,c~. rangcd from 2.6 to 2.g.v. hich 23 are very close to the total fertility rate estimate of 2.7 3resented in this chapter. Further analysis should be carried out to gain msight into the nature of such patterns in fertility data from the TDHS, as well as in other fertility surveys in Turkey, and to assess the possible impact of these patterns on indicators other than fertility. 3.2 Current Fertility The current level of fertility is the most important topic in this chapter because of its direct relevance to popu- lation policies and programmes. Age-specific fertility rates (ASFR) for the year before the survey are presented in Table 3. I and Figure 3. I for the country as a whole and for urban and rural areas. The total fertility rate (TFR) for women 15-44 years of age in addition to that for 15-49 is shown for comparative purposes. Numerators for the age-specific fertility rates in Ta- ble 3.1 are calculated by isolating live births that occurred in the 1-12 months preceding the survey (determined from the date of birth of the child) and classifying them by age of 'Fable 3.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the year preceding the survey, by urban-rural residence, Turkey 1993 Residence Age group Urban Rural Total 15-|9 55 47 56 20-24 163 204 179 25-29 139 176 151 30-34 77 126 94 35-39 33 49 38 40-44 8 18 12 45-49 0 0 0 TFR 15-49 2.4 3.1 2.7 TFR 15-44 2.4 3.1 2.7 GFR 87 102 95 CBR 21.7 24.0 22.9 Note: Rates are for the period 1-12 months preceding the survey. Rates for age group 45-49 may be slightly biased due 1o truncation. TFR: Total Fertility rate expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per I,O00 women CBR: Crude birth rate, expressed per 1,000 population Figure 3.1 Age-Specific Fertility Rates by Urban-Rural Residence Births per 1,000 women 250 190 100 0o~ 9 [ i i I1~ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age TDHS 1993 24 the mother (in five-year age groups) of the mother at the time of birth (determined from the date of birth of the mother). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-12 months preceding the survey. The crude birth rate (also shown in Table 3.1) is calculated by summing the product of the age- specific rates multiplied by the proportion of women in the specific age group out of the total de facto population, male and female. Age-specific fertility rates are estimated for the twelve months preceding the survey. There is a typical skewed distribution towards the younger ages. The highest fertility rate is observed for the age group 20-24. After age 24, the curve declines in an upward concave form, implying modem levels of fertility control in the upper ages. Total fertility rate (number of children a woman would bear if she lived through these rates throughout her reproductive life span) is slightly over three children (3. I) for women living in rural areas, and decreases to around two child,'en (2.4) in urban areas. The national average is 2.7 children per woman. When compared with evidence from previous surveys (see HIPS, 1980, 1987, 1989) the urban/rural gap appears to be closing. The crude birth rate has fallen to the lower twenties. As expected, birth rates are higher in rural areas (24.0 per thousand) than in urban areas (21.7 per thousand). The national average (22.9 per thousand) implies a rather low population growth rate even if the crude death rate is very low. The current total fertility for major groups in the population is summarised in Table 3.2. The table also provides a basis for inferring trends in fertility by com- paring current synthetic measures with the average num- ber of children ever born to women currently 40-49 years of age. Although comparison of completed fertility among women age 40 or more with the total fertility rate can provide an indication of fertility change, such an approach is vulnerable to an understatement of parity for older women. The findings on contraceptive use (Chapter 4) and nuptiality (Chapter 6) are also of crucial importance in reaching a balanced judgment about fertility trends. The levels of fertility show variations across background characteristics of the population. This is clearly seen among the region and education categories. Variations are true for past fertility experience (mean "Fable 3.2 Fertility by background characteristics Total fertility rate for the year preceding the survey and mean number of children ever born to women age 40-49, by selected background characteristics, Turkey 1993 Mean number of children Total ever born Background fertility to women characteristic rate ~ age 40-49 Residence Urban 2.4 4.0 Rural 3.1 5.6 Region West 2.0 3.5 South 2.4 4.8 Central 2.4 4.7 North 3.2 4.7 East 4.4 7,3 Education No educ./Pri, incomp. 4.2 5.9 Pri. comp./Sec, incomp. 2,4 3.7 Sec. comp./+ 1,7 2.2 Total 2.7 4.6 IRate for women age 15-49 years number of children for women age 40-49) as well as current fertility levels (total fertility rates). Regional variations of fertility involve three regional groupings. The Eastern region is notable as a high fertility region, with a total fertility rate exceeding four children (4.4). Northern, Central and Southern regions constitute another group, with rates between two and three children (3.2, 2.4 and 2.4, respectively). The lowest rate (2.0) is found in the Western region and is comparable to that of many Western European countries. 25 Gronping regions according to current levels of fertility is also cogent for differences in the past " li:rtility experiences. Although the inean nulnber of children born to women age 40-49 is inucb higher (aboul twice) than the corresponding TFRs ill eacll of the regions, notable variations are observed as with currenl ['crtilil 3. The table suggests an overall decline in fertility, kceping regional diffcrences almost the same, during the last three decades. Past experience as well as current levels of fertility show strong variations by literacy and by levels of education. Both the total fertility rate and the number ofcbildrcn ever born declined nlore than fifty per- cent alnong women with at least a secondary level of education conlpared to women wilh no education. Fertility trends can be analyzed in two ways. One is to compare TDI IS data with previous surveys. Fertility trends can also be examined based on TI)I IS data alone, l laving the colnplete birth history nlakes inorc direct evidence on Irends available, thereby permitting nlorc accurate conclusions. I Iowever, use of birlh histories for analysis of trends places a great burden on the quality of data, which should always be interpreted ~vith caution. Table 3.3 shows the age-specific ferlilit> rates lbr five-year periods preceding tile survey. Tile age-specific schedule of rates in Table 3.3 is progressively truncated as time betbre tile survey increases. The bottom diagonal of estimates (enclosed in brackets) is also truncated. Total fi:rtility rates can be calculated fronl tile age-specific rates in Table 3.3. but only by sunlnling across ages nnaffected by truncation. lahlc 33 Age-specific Icrtilils rates Agc-spccili¢ 6:llilit3 rates Ibr Iixc-),.:ar periods preceding the stlr~c3, b~ nlolller's age, [tlrkex ]093 Nl l lnbcr of x cars preceding the surx¢) Molhcl's age (1-4 5-9 I O- 1.1 15 - 19 15-19 5"Z g14 121 129 20-24 174 231 269 3hi 25-29 116 Ig.I 235 255 30-34 s4 123 156 ll871 35-39 .13 71 II/J2l 4 n-.l. l 13 12t, I 45-49 121 Nolo: Ag¢-spccilic Ik:rtilil) rill¢~, ilr¢ per J.ni)n ~OIIlC11. Iisli- IllillC ~, enclosed ill brackets life IrtlllCalcd The decline of fcrtili b' over tinlc, which is implied by the earlier tables, is seen much more clearly in Figure 3.2. Considering thai fertility over age 40 is alalosl negligible, cunlnlalion of ASFRs up 1o age 40 and conlparisons using this figure shov, tllat I;.:rlili b declined b~, ahnost filly percent daring tile last decade (4.4 hi 1980 ',s 2.5 in 19901. It is interesting to iloie thai this sur',e~ produced higher Ik:rlilit> levels for the early 1980s than tile 1983 survex (a TI:I~, for age 40 o1+4.4 ',s 3.9). In fact. all of Ille quinquennial national surveys conducted in I urkcy ', icldcd higher rates I'~r the preceding 5- I 0 ~ears than the pre', ious surx c.vs" estimates of 0-4 years ( i.e. same relt:rence period~, I'ronl consecuti,, ¢ sur~ e> s ). 26 Figure 3.2 Age-Specific Fertility Rates during the Last 20 Years Births per 1,000 women 350 250 20O 150 1001 50 01 . . . . . 15-10 20-24 25-20 30-34 3S-39 40-44 45-49 Mother's Age Dates ere approximate and refer to Sept. 03, the mid-point of field work. TDHS 1993 Table 3.4 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. These rates are similar to those presented in Table 3.3 and lhe same admonitions apply in their interpretation. Fertility early in marriage often remains resistant to change, even when fertility is declining, because fertility decline usually begins at the older ages (wben women start to limit tile number of births) and not by young couples postponing births. Therefore, a complete examination of duration-specific trends requires interpretation in the light of other evidence. Fertility rates are declining ill general, bnt as shown earlier, tile decline is greater among women who are in their later years of childbearing. Table 3.4 iudicates that a decline of fertility by one-fifth, front 372 to 306, among women in the early years of childbearing is not negligible. I lowever, substantial declines by al- most one half, from 302 to 167, are observed lbr the peak fertility ages and very dramatic changes (more than sixty percent) occur in the age groups that have followed during the last two decades. Although this pattern is quite cornmon among populations with increasing fertility control, the speed of change is worth noting. The table also indicates that the decline of fertility was more rapid during the late 1980s than during the early 1980s. Table 3.4 Fertility by marital duration Fertility rates for ever-married women by duration since first marriage in years, for five-year periods preceding the survey. Turkey 1993 Marriage Number ol")'ears preceding the survey duration at birth 0-4 5-9 10-14 15-19 0-4 306 350 359 372 5-9 167 221 268 302 10-14 91 140 197 226 15-19 55 94 139 1199] 20-24 28 55 I I 161 25-29 9 {27 l Note: Fertility rates are per 1,000 women. I'stimates enclosed in brackets are truncated. 27 3.3 Children Ever Born and Living The distribution of women by number of children ever born is presented in Table 3.5 for all women and for currently married women. In the TDHS questionnaire, the total number ofchildren~ver bona was ascertained by a sequence of questions designed to maximize recall. Life-time fertility reflects the accumulation of births over the past 30 years and therefore its relevance to the current situation is limited. The results in Table 3.5 for younger wometi who are currently married differ from those for the sample as a whole because of the large number of unmarried women with minimal fertility. Differences at older ages, though minimal, generally reflect the impact of marital dissolution. The parity distribution for older currently married women provides an additional measure of primary infertility. Mean number of children ever born compared with mean number of children surviving can lead to a quick evaluation of the survival status of the children. Almost one in five of children bona by women age 45-49 had not survived at the time of the survey (4.9 vs 4.0). The proportion of children surviving among younger women is much higher. This may not only be because of shorter exposure to risk by the children of the younger cohorts, but also because of the improved mortality conditions in general. Of all children born (mean of 2.0), 87 percent (mean of 1.8) had survived at the time of the survey. Just as marriage is universal in Turkey (see Chapter 6), the proportion of women preferring to remain childless is very low. The proportion of women with no children declines in tandem with the proportion remaining single, and almost all women who are married by the age of 45-49 have children. Just over two percent of the currently married women who are about to complete their reproductive period remain childless, probably due to sterility rather than preference. Table 3.5 Children cvcr born and l iv ing Percent distribution (11" all ~malcn and of currently married women by number of children ever born (CI':B) and mean number ever born and l iving, according to l ive-year age groups. Turkey 1993 Number of children ever born (('EB) Number Mean no Mean no. Age of of of living group 0 I 2 3 4 5 6 7 8 9 10+ Total women CEB children AI.I, WOMEN Age 15-19 93.8 5.2 09 0 1 00 00 00 00 0.0 00 0(I I000 2460 0 1 0 1 20-24 525 26.6 145 43 12 0.4 05 00 00 0.0 00 100.0 1777 0.8 07 15-29 22.1 166 324 16.5 7.3 30 12 04 0.3 I) 1 01 1000 1436 1.9 17 30-34 77 78 30.4 241 129 81 41 25 12 0.7 05 1000 1340 3.0 2.7 35-39 50 45 21.3 23.5 146 104 82 48 2.8 27 22 100.0 1093 38 3.4 40-44 4.8 44 18.4 159 157 106 96 67 48 34 5.7 100.0 921 44 3.8 45-49 29 41 123 16.4 158 142 10.3 76 43 36 85 100.0 685 49 4.0 Iotal 389 1(19 169 119 73 48 34 2.1 13 10 15 100.0 9712 2.0 18 CURRENTI.Y MARRIED WOMEN Age 15,19 544 386 64 {).6 00 00 0.0 00 00 00 00 1000 329 0.5 0.5 20-24 187 454 249 75 21 (16 08 00 00 0.0 00 1000 1026 1.3 1.3 25-29 74 195 387 197 87 37 1.5 0.4 03 01 0.0 1000 1190 2.3 21 30-34 32 78 314 258 138 87 43 27 I I 07 0.5 100.0 1254 31 28 35-39 2 t) 4 I 214 245 151 103 87 49 2.9 29 23 1000 1026 39 35 40-44 2{) 40 192 162 162 101 100 71 5 I 35 60 1000 833 46 3.9 4~-49 21 3 b II 4 165 157 153 112 79 4.2 34 87 1000 613 5.0 4.1 Lolal 90 163 252 179 109 71 52 31 18 14 21 1000 6271 3.0 2.7 28 3.4 Birth Intervals There has been a fair amount of research to indicate that short birth intervals are deleterious to the health of babies. This is particularly true for babies born at intervals of less than 24 months. Table 3.6 shows the percent distribution of births in the five years preceding the survey by the number of months since the previous birth. The median birth interval is closeto three years (33.6 months). This is only ten months longer than the minimum considered safe. Thirty percent of the births were born with intervals of less than 24 months. This percentage shows striking variations by background variables. Among women with at least a secondary -level education, the percentage of risky birth intervals is less than one half of those with no education (16 percent and 32 percent, respectively). The smallest proportion of risky birth intervals is observed in the Table 3.6 Birth intervals [Percent distribution of births in the five years preceding the survey by number of months since previous birth, accordill to demographic and socioeconomic characteristics, Turkey 1993 Number of months since previous bird1 Characteristic 7-17 18-23 24-35 36-47 48+ Median number o1" monllls Number since of previous Iotal births birth Age of mother 15-19 (47.8) (27.3) (20.3) (4.6) (0.01 100.0 26 (19.21 20-24 24.9 26.4 28,0 13.5 7.2 100.0 456 23.7 25-29 14.3 13.2 26.8 20. I 25.6 100.0 844 33.6 30-34 I 1.3 11,6 21.6 14.6 40.9 100.0 694 39.0 35-39 1O.I 9,1 21.1 15.8 43.9 100.0 324 42.2 40-44 10,6 12.4 14.9 21.1 41.0 100.0 129 44.4 45-49 (0.0) (8.4) (24.8) (ll.0) (55.8) 100.0 25 (48.7) Birth order 2-3 15.4 15.1 22.8 15.6 31A 100.0 1501 33.8 4-6 I 1.6 13.3 26.4 17.9 30.8 100.0 665 35.2 7 + 19.3 15.4 25.6 18.6 2 I.I 100.0 332 28.7 Sex of prior birth Male 12,9 14.6 23.7 17.1 31.7 100.0 1216 35.1 Female 16,7 14.7 24.6 16,2 27.8 100.0 1282 32.0 Survival of prior birth Living 13,0 14,2 24.2 17.3 31.3 100,0 2286 35.2 Dead 34,5 20.2 23.8 9.2 12,3 100.0 212 23.0 Residence Urban 13.7 13.4 22.7 16.1 34.1 100.0 1410 36.1 Rural 16.4 16.3 26.1 17,2 24.0 100.0 1088 31.1 Region West 12.2 12.5 18.0 14.5 42.8 100.0 557 41.4 South 15.0 14.2 24.6 14.6 31.6 100.0 407 33.6 Central 17.7 13. I 21.7 16. I 31 4 100.0 545 34.4 North 13.0 15.0 22.5 17.4 32.1 100.0 235 35.7 East 15.4 17.6 30.6 19.4 17.0 100.0 754 29.2 Education No educ./Pri, incomp. 16. I 15.9 28.2 17.6 22.2 100.0 I 146 30.5 Pri. comp./Scc, incomp. 15.2 14.6 21.0 15.9 33.3 100.0 1132 35.6 Sec. compJ+ 74 8.6 18.9 15.2 49.9 100.0 220 47.9 Total 14.9 14.7 24. I t 6.6 29.7 100.0 2498 33.6 Note: First-order births are excluded. "l'he interval Ibr mult ip le births is Ih~ number of months shlcc the preceding pregnancy that ended in a l ive birth. ( ) Figures in parentheses are based on 25-49 cases. 29 Western region and the highest proportion in the Eastern region (25 percent and 33 percent, respectively). Sex of child appcars to be inlluential in a woman's decision of whether or not to have another child immediately. Short intervals lollowing a female birth-are more frequent than for male births (31 percent and 28 percent, respectively). Among all the factors presented in the table, survival status of the preceding child appears to be the most iiH]uential in determining the proportion of short birth intervals (27 percent for surviving children and 55 percent lbr deceased children). 3.5 Age at First Birth The age at which childbearing begins has important demographic consequences as well as important consequences for the mother and child. In many countries, postponement of first births, reflecting an increase in the age at marriage, has contributed greatly to overall fertility decline. The proportion of women who become mothers before the age of 20 is also a measure of the magnitude of adolescent fertility, which is a major health and social concern in many countries. Table 3.7 presents the distribution of Turkish women by age at first birth, according to their current age. [ab le 3.7 Age at lirst birlh Percent distrihutitm of women 15-49 b} age at tlrst birth, according to current age. lu rkex 1993 l~'tlr rent ZlgC Median W~lncn Age at first birth Number age at with no of Iirst births < 15 15-17 I 8-19 20-21 22-24 25+ I'otal women birth 15-19 93.8 0.1 3.4 23 NA NA NA 1000 2460 a 20-24 52.6 17 93 139 164 6.1 NA 100.0 1777 a 25-29 22.1 2.3 144 17.9 16,9 187 7,7 1000 1436 21.8 30-34 77 1.9 166 244 194 16,8 13.2 100,0 1340 20.7 35-39 5.0 23 Ig t l 24.5 19.6 16.4 13.6 100.0 1093 20.4 40-44 4.8 27 193 20.3 200 21.5 11.4 100.0 921 20.7 45-49 29 31 193 20.5 207 19.9 13,6 IO0.O 685 20.6 NA - Not applicable al.ess than 5a percent of the women in the age group x to x+4 have had a birth by age v Age of childbearing is increasing gradually. The median has risen from 20.6 years among women age 45-49 years to 21.8 years among women age 25-29 years, despite these women not yet having reached their upper years of childbearing. The table indicates dramatic changes in adolescent fertility. Some 25 percent of women age 20-24 during the survey had become mothers before age 20; this percentage is substantially lower than the percentage for the previous cohort (35 percent). For earlier cohorts, the proportion of women becoming mothers in lheir teens was more than a third, and even close to half, of the wonlen . "File median age at first birth lbr different cohorts is summarised in Table 3.8 and the entry age into motherhood for different subgroups of the population can be compared (the medians for cohorts 15-19 and 20-24 could not be determined because half the women had not yet had a birth). 30 Table 3.8 Median age at llrst birth by background characteristics Median age at first birth among women 25-49, by current age and selected background characteristics, Turkey 1993 Current age Women Background age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 22.1 21.0 20.6 20.9 20.8 21.1 Rural 21.3 19.9 20.0 20.3 211. I 20.3 Region West 22.6 21.3. 21.0 20.9 21.2 21.4 South 22.7 21.3 20.6 20.8 20.8 21.3 Central 20.9 20.3 20.0 20.3 20.2 20.3 North 22. I 20.3 20.4 20.9 19.9 20.7 least 20.5 19.7 19.5 20.3 20.2 19.9 Education No educ./Pri, incomp. 19.7 19.4 19.6 20.2 20.2 19.8 I'ri. comp./Sec, ineomp. 21.5 20.5 20.3 20.5 20.5 20.6 Sec. comp./+ 25.1 24.0 24.6 23.9 24,4 24.5 Total 21.8 20.7 20.4 20.7 20.6 20.8 Note: The medians for cohorts 15-19 and 20-24 could not be determined because some women may still have a birth before reaching age 20 or 25, respectively. The median age at first birth is almost 21 years (20.8) among all women 25-49. It varies considerably according to background variables. Women living in urban areas tend to have their first birth one year later than women living in rural areas. Women living in the Eastern region become mothers about 1.5 years younger than women living in the Western region. Levels of edncation show the biggest difference among the background variables considered in this table. Women with no education become mothers at the age of 19.8 years, and women with at least a secondary level of education wait an additional four years (24.5) to become mothers. 3.6 Teenage Pregnancy and Motherhood Table 3.9 shows the percentage of women age 15-19 who are mothers or pregnant with their first child. About one in twelve (8 percent) of women age 17 have become mothers or are pregnant with their first child. The proportion increases steeply to one in seven (15 percent) among women age 18 and close to one in four (23 percent) among women age 19. Higher proportions of teenagers living in urban areas have begun childbearing than teenagers living in rural areas (10 percent vs 7 percent). Although fertility is highest in the Eastern region, the highest percentage of teenagers who have begun childbearing is found in the Northern region (I 1.4 percent). Levels of education again appear to be the most influential variable on teenage fertility, not only because of the years of schooling, which have postponed births, but also because of changed attitudes. 31 Table 3.9 Teenage pregnancy and motherhood Percentage of teenagers 15-19 who are mothers or pregnant with their firs child, by selected background characteristics, Turkey 1993 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of characteristie Mothers child bearing teenagers Age 15 0.2 0.8 1.0 765 16 1.9 1.5 3.4 287 17 3.8 4.3 8.1 489 18 9.6 4.9 14.5 460 19 17.8 5.2 23.1 459 Residence Urban 6.7 3.3 I 0. I 1360 Rural 4.2 2.3 6.5 1419 Region West 5.2 3.2 8.3 669 South 6.8 2.8 9.5 364 Central 6.8 3.4 10.3 541 North 7.8 3.7 11.4 165 East 7.2 3.7 10.9 592 Education No educ./Pri, incomp. 14.2 5.5 19.7 217 Pri. comp./Sec, incomp. 7.1 3.6 10.7 1570 Sec. comp./+ 1.6 1.4 3.0 610 Total "* 6.2 3.2 9.3 2460 Note: The sum of the absolute values does not add up to the total value it the last three categories due to the ever-married factors used. Although most teens who have begun childbearing have given birth only once, a small proportion have given birth twice. Table 3.10 shows the distribution of women age 15-19 by number of children ever born, excluding those who are currently pregnant. One percent of women age 18 and 4 percent of women age 19 have given birth to two children. By giving birth early and presumably with short intervals, these women and their children are at a higher risk of dying. The issue of high-risk childbearing is discussed in Chapter 8. Table 3.10 Children born to teenagers Percent distribution of teenagers 15-19 by number of children ever born (CEB), Turkey 1993 Number of Mean children ever born number Number of of Age 0 I 2+ Total CEB teenagers 15 99.8 0.2 0.0 100.0 0.00 765 16 98.1 1.9 0.0 100.0 0.02 287 17 96.2 3.8 0.0 100.0 0.04 489 18 90.4 8.6 1.0 100.0 0.11 460 19 82.2 13.8 4.0 100.0 0.22 459 Total 93.8 5.2 1.0 100.0 0.07 2460 32 CHAPTER4 FAMILY PLANNING Ay~e Akin Dervi~o~lu Giil ErgSr Population policy in Turkey has gone through two major phases. Starting from the early years of the Republic, pronatalist policies were in effect until 1965, when antinatalist policies were accepted. A milestone in family planning practices in the country was the 1983 law that allows abortions on request, legalizes voluntary surgical contraception for males and females, permits midwifes to insert IUDs, and authorises general practitioners to terminate pregnancies by the menstrual regulation method after certification. Family planning services are provided for the most part by the Ministry of Health, primarily through Maternal and Child Health (MCH) and Primary Health Care Centers. Government hospitals also offer family planning services and are the sites for all male and female sterilisations and pregnancy terminations. Other public sector institutions also provide family planning services, including Social Security. Except for vasectomies and pregnancy terminations, all family planning services at public health institutions are provided free of charge. Physicians in private practice are another important group of providers. Some contraceptive methods like the pill, condom and spermicides are available at pharmacies. Various issues relating to fertility regulation in Turkey are addressed in this chapter beginning with an appraisal of the knowledge of different contraceptive methods and the sources of supply and a consideration of current and past practice. Knowledge of the ovulatory cycle by users of periodic abstinence is examined as is the timing of method adoption for those relying on sterilisation~ Special attention is focused on nonuse, reasons for discontinuation, and intention to use in the future. These topics are of practical use to policymakers and program managers in several ways. The early sections concern the main preconditions to adoption of contraception, such as knowledge of methods and supply of sources. Levels of use of contraceptives provide the most obvious and widely accepted criterion of success of the program, especially when results from earlier surveys are available so that progress can be charted. The examination of use in relation to need pinpoints segments of the population for whom intensified efforts at service provision are most needed. 4.1 Knowledge of Contraception Determining the level of knowledge of contraceptive methods and of services wa s a major objective of the TDHS, since knowledge of specific methods and of the places where they can be obtained is a precondition for use. Information about knowledge of contraceptive methods was collected by asking the 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 if she recognized it. Eight modern methods - - the pill, IUD, injection, barrier methods (diaphragm, foam, foaming tablets and jelly), condoms, female sterilisation, male sterilisation, and Norplant - - were described, as well as two traditional methods - - periodic abstinence (rhythm method) and withdrawal. Any other methods mentioned by the respondent, such as herbs, vaginal douche or breastfeeding, were also recorded. For each method recognized, the respondent was asked if she knew where a person could obtain the method. If she reported knowing about the rhythm method or withdrawal, she was asked if she knew where a person 33 could obtain advice on how to use the method. Although questions on Norplant and injection were asked, these methods were not available at the time of the survey but were expected to be introduced in the country in the near future. The data on women's knowledge reported in Table 4.1 is based on the combination of probed and spontaneous answers. Knowledge of any method is almost universal among women. The pill and the IUD are the most widely known modern methods, followed by the condom. Knowledge of female sterilisation and male sterilisatiou, which were introduced into family planning programs later than other methods, is tess than knowledge of the pill, IUD or condom; however, knowledge of these methods has increased from the levels observed in the 1988 TPHS, from 65 percent to 76 percent in the case of femate sterilisation and from 28 percent to 35 percent in the case of male sterilisation. Withdrawal is the most widely recognized traditional method. Almost everyone who knows a method also knows the source of a method; 95 percent of women are aware of at least one place to obtain family planning infonnation or services. Lack o1" inlbrmation about where to obtain a method is clearly not a barrier to contraceptive use in Turkey. Table 4.1 Know, ledge of contraceptive methods and source lot methods I'crcenlagc of all ~.t.olncn and currently married ' .~ ,omen who know specific contraceptive rnethods and who know a source (lbr inlbrmalion or services), by specilic methods. Furkcy 1993 Know nlethod Know a source I Currently Currently Contraceptive All married All married nlethod women '~'~ O tTle I1 ~omen women Any method 99.0 99.1 94.7 94.8 Modern method 98.6 98.6 94.5 94.6 Pill 95.7 95.7 88.6 88.7 IUD 96.9 97. I 90.4 90.6 Injection 38.8 38.8 32.6 32.5 Vaginal methods 574 57.5 51.7 51.8 Condom 805 80.8 73.1 73 A Female steri[isation 75,5 75.6 67.1 67.2 Male sterilisation 35.1 35.1 316 31.7 Norplant 6.7 6.7 3 1 3.(1 Any traditional method 890 89.1 36.0 36.0 Periodic abstinence 34.9 34.8 21.3 21.0 Withdrawal 87.1 87.4 31.2 31.2 Vaginal douche 31 3.1 0.0 0.0 Oth~tr traditional methods 60 59 0.0 0.0 Number of women 6519 6271 6519 6271 II:or modern methods, source refizrs to a place to obtain the melhod or procedure. [:or traditional methods, source rclk'rs to a place or person to obtain advice on practicing these methods. 34 Knowledge of any modern method of contraception is chosen as a summary indicator in preference to knowledge of any method because of its greater relevance for program promotion, which is usually confined to modern methods. Knowledge of a source for information or services for modern methods is also presented as are the mean number of methods known. Questions on method and source knowledge were asked of all ever-married women; however, the results are presented for currently married women because they are the immediate potential users. There are no significant differences in the percentages knowing any modern method according to age, residence, region or level of education; however, both knowledge of a source and the mean number of methods known vary according to these background characteristics. For example, knowledge of a source is 87 percent among women with no education compared to 100 percent among women with a higher than primary education. Knowledge of a source for modem methods is 86 percent among illiterate respondents, compared to 98 percent among those who are literate (data not shown). Table 4.2 presents differences in contraceptive knowledge by background characteristics. The mean number of methods known is 6.2 methods. For modern methods, the mean is 4.9 methods and the mean for traditional methods is 1.3. The mean number of methods known is highest in the 25-29 and 30-34 age groups and increases as the level of education increases. Urban residents know somewhat more methods Table 4.2 Knowledge of contraception Mean number of all methods, modem methods and traditional methods known, by selected background characteristics, Turkey 1993 Mean number of: Modem Traditional Number Background Methods methods methods of characteristic known known I known 2 women Age 15-19 5.2 4.2 1.0 329 20-24 6.0 4.7 1.3 1026 25-29 6.5 5.1 1.4 1190 30-34 6.6 5.2 1.4 1254 35-39 6.3 5.0 1.3 1026 40-44 6. I 4.8 1.3 833 45-49 5.7 4.4 1.3 613 Residence Urban 6.7 5.2 t.5 4005 Rural 5.3 4.3 I.I 2266 Region West 6.6 5.0 1.5 2207 South 6.3 5.0 1.3 964 Central 6.3 5.0 1.3 1472 North 5.9 4.7 1.3 589 East 5.3 4,4 0.9 1039 Education No educ./Pri, incomp. 5.2 4.2 1.0 2102 Pri. comp./Sec, incomp. 6.3 4.9 1.4 3227 Sec. comp./+ 8.() 6.0 1.9 942 Total 6.2 4.9 I 3 6271 Ilncludes pill, IUD, injection, vaginal methods (foaming tablets/diaphragm/ lbam/ielly), condom, female sterilisation, male sterilisation and Norplant. 2Includes withdrawal, vaginal douche, and periodic abstinence. 35 than rural residents, and the mean number of methods varies by region from 5.3 methods in the East to 6.6 methods in the West. 4.2 Ever Use of Contraception All women interviewed in the TDHS who said that they had heard of a method of family planning were asked if they had ever used it. If all the answers were negative, the respondents were further asked whether they had "ever used anything or tried in any way to delay or avoid getting pregnant." As seen in Table 4.3, 80 percent of currently married women have used a family planning method at some time in their lives. Among currently married women, ever use of any method is lowest for the 15- 19 age group (37 percent), it peaks at 88 percent in the 30-34 age group and then it gradually decreases to 78 percent in the 45-49 age group. 'Fable 4.3 Ever use of contraception Among currently married women, the percentage who have ever used a contraceptive method, by specific method, according to age, Turkey 1993 Age Modern methods Traditional methods Any Vaginal Female Male Any Periodic Number Any modern Injec- meth- Con- sterili- sterili- trad. absti- With- Vaginal of method method Pill IUD tion ods dora sation sation method nence drawal douche Other women 15-19 37.4 16.6 4.6 7,8 0.9 1.4 7.7 0.0 0,0 29.0 1.5 28.5 0.5 0.3 329 20-24 70.0 47.2 18.2 23.8 0.7 4.7 20.7 0.3 0.0 51.2 5.2 49.3 O.g 0,3 1026 25-29 84.7 65,7 32.8 36.8 1.6 7.8 26.9 1.7 0.2 62.4 7.2 59.7 0.7 1.2 1190 30-34 88.4 72.1 41.1 46.7 1,8 11.9 29.2 3.2 0.0 62.5 8.9 58.9 2.0 1.0 1254 35-39 87.8 71.7 43.2 42.1 3.1 13.8 25.3 4.6 0.5 62.6 7.1 59,1 2.0 1.7 1026 40"14 82.6 66.2 42.0 34.9 3.1 14.4 22.4 4.8 0.1 58.2 7.7 52.9 3.0 2.6 833 45-19 78.0 59.3 38.5 25,4 3.5 12.0 191 5.0 0.0 54.6 8.6 48.6 3.5 5.2 613 Total 80.1 61.8 34.1 34.6 2.1 10.1 23.7 2.9 0.1 57.5 7.1 54.1 1.8 1.6 6271 The age pattern varies somewhat according to the type of method. Ever use of modern methods is highest among women in their thirties, with almost three in four women in these age groups reporting that they have used a modern method at some time. The level of ever use of traditional methods reaches to more than 60 percent amdng women age 25-29 and stays at this level among women 30-39, before dropping off among women age 40 and older. Ever use of traditional methods is lower than ever use of modern methods in every age group, with the exception of women age 15-24. Considering specific methods, around one-third of currently married women report ever using the IUD or the pill while 24 percent have tried the condom. Only one in ten women or fewer have ever used any of the other modern methods. Withdrawal, the most frequently used traditional method, has been used by 54 percent of currently married women. Comparison of the levels of ever use found in the TDHS with the levels reported in earlier surveys shows that the level of ever use among ever-married women increased steadily between 1978 and 1988 (Figure 4.1). However, with the exception of the IUD, there was little or no change in the level of ever use of most methods between 1988 and 1993, and there wei'e small declines in the ever-use rates for the pill and rhythm. 36 Percent 70 60 50 40 30 20 10 0 Modern methods Figure 4.1 Ever Use of Family Planning, Turkey 1978-1993 !i!i!~ Pill IUD Condom Female Withdrawal Rhythm sterllls. TDHS 1993 4.3 Current Use of Contraception The level of current use is the most widely used and valuable measure of the success of a family planning program. Further, it can be used to estimate the reduction in fertility attributable to contraception. Table 4.4 presents data on the proportion of currently married women who are using contraception by age. Overall, 63 percent of currently married women are using a contraceptive method. The majority of these women are modem method users (35 percent), but a substantial proportion use traditional methods (28 percent), particularly withdrawal. Withdrawal is, in fact, the most widely used method (26 percent) as it was in the previous surveys in Turkey. The tUD is the most commonly used modern method (19 percent). The condom (7 percent) and the pill (5 percent) are the second and third most popular modem methods, respectively. Current use of the 1UD has increased markedly and that of female sterilisation has increased slightly, but condom and pill use have decreased compared to the 1988 TPHS (Figure 4.2). Considering age patterns, modem method use is most prevalent in the 30-34 age group, while traditional method use peaks in the 35-39 age group. Modem methods are practiced more frequently than traditional methods in every age group except the 15-19 and 40-49 age groups. ]'able 4.4 Current use o f contraception Percent distribution of currently married women by contraceptive method currently used, according to age, Turkey 1993 Any modern Any meth- Age method od Pill Modem methods Traditional methods IUD Any Pro- Not Vaginal Female Male trial. Periodic longed using Number Injec- meth- Con- sterili- sterili- meth- absti- With- absti- Vaginal any of lion ods dora sation sation od hence drawal hence douche Other method Total women 15-19 24.1 9.3 0.6 6.2 0.0 0.0 2,5 0.0 0.0 14.8 0.0 14.2 0,0 0.2 0.4 75.9 I00.0 329 20-24 51.1 28.2 5.1 16.4 00 0.9 5.5 0.3 0.0 229 0.5 22.4 00 0.0 0.0 48.9 100.0 1026 25-29 68.0 41.7 9.0 23.3 0.1 0.6 7.0 1.7 0.0 263 0.5 25.4 0.2 0.2 00 32.0 100.0 1190 30-34 76.5 46.0 6.2 26.3 0.0 1.7 8.5 3.3 0.0 30.5 18 27.8 02 0.5 02 23.5 100.0 1254 35-39 76.8 41.0 3.9 22.1 0.3 1.7 8.2 4.6 0.2 35.8 0.7 34.2 01 0.5 0.3 23.2 1000 1026 40-14 61.0 29.2 2.1 13.4 0.1 1.8 7.0 4.8 0.0 31.8 1.6 28.4 0.0 1.3 0.5 39.0 100.0 833 45-49 41.7 175 19 6.9 0.0 1.0 2.7 5.0 0.0 24.2 0.8 20.6 0.0 2.1 0.7 58.3 100.0 613 Total 62.6 34.5 4.9 18.8 0.1 1.2 6.6 2.9 0.0 28.1 1.0 26.2 0.1 0.6 0.2 37.4 100.0 6271 Figure 4.2 Current Use of Family Planning Turkey 1988-1993 Modern methods ::l 34.5 Pill IUD :! Condom | Female atariliaation Traditional methods Rhythm :f Wlthdrmwsl 0 ~ . 6 . 2 .T ~2.9 29.1 32.3 9 10 15 20 25 30 35 40 Percent TDHS 1993 The levels of current contraceptive use among main groups of the population can be compared in Table 4.5. Overall, use of any method is higher in urban than in rural areas. Much of the urban-rural difference in use is owed to the substantially higher level of use of modem methods among urban women (39 percent) compared to rural women (27 percent). In turn, almost all of the difference in modern method use is due to greater use of the IUD among urban women (22 percent) than rural women 04 percent). 38 Table 4.5 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to selected background characteristics. Turkey 1993 Modem methods rradiUonal methods Any Female All Periodic Not N .nber Background Any modern Vaginal Con- slcri- wddi- absU- Wilh- currently of characteristic method method Pill IUD methods dom [isation tlonal hence drawal Other using Total women Residence Urban 66.2 38.9 5.0 21,5 1.3 7.8 3.3 27.3 1.4 24.9 0A 33.8 100.0 4005 Rural 561 26.8 4,8 14.1 I.I 4.6 2.2 29.3 0,1 28.5 07 439 1(10.0 2265 Region West 71.5 37.3 62 18.8 1.2 8.4 2,7 34.2 1.3 31.5 0.4 28.5 100.0 2207 South 62.8 36.7 4.2 20.9 2.2 6,1 33 26,0 1.0 24.7 0.3 37.2 100.0 964 Central 62.7 36.6 4.3 21.9 1.2 6.1 3.1 26.1 I.I 23.7 1,3 37.3 100.0 1472 North 64.2 29.8 52 11.5 1,7 7.1 4.3 34.4 0.4 33.6 0.4 358 100,0 589 East 42.3 26.3 36 16.5 0.7 3.7 1.8 16.0 0.3 15.6 0.1 577 100.0 1039 Education No educ./Pri, incomp. 50.4 25.6 37 13,4 1,3 3.6 3.6 24.8 0.2 23.6 1.0 49.6 100.0 2102 Pri comp./Sec, incomp. 67.5 35.9 5.6 20.4 1,2 63 2.4 31,5 0.6 30,1 0.8 32.5 100.0 3227 See. comp./+ 73.0 49.7 5.3 25.3 1.7 .4.5 2.9 23.3 4.0 187 0,6 27.0 100.0 942 Living children None 8.6 2.9 1.4 0.2 0.0 1.3 00 5.7 1.0 46 0.1 914 100.0 596 I 58.0 31.4 4.8 17,5 0.8 7.6 0,7 26.5 1.0 25.3 0.2 42.0 100.0 1069 2 78,3 45.6 6.4 26,1 1.6 8.9 2,6 32.6 1,4 30.4 0.8 21.7 100.0 1778 3 733 39.8 59 20.6 1.5 78 4,0 33.6 I,I 31.1 1.3 267 100.0 1203 4+ 60.2 32.1 4.1 17,0 1.4 4.7 4,9 28.1 03 26,4 1.4 39.8 100.0 1625 Total 62.6 34.5 4.9 18.8 1.3 6,6 2.0 28.1 1.0 26.2 09 37.4 100.0 6271 Regional differences in use are substantial. The level of current use is only 42 percent in the East, whereas it exceeds 70 percent in the West and 60 percent in the other three regions. Modem method use is bigher than traditional use in all regions except the North, and it decreases from a high of 37 percent in the West to 26 percent in the East. Traditional method use is high in both the Western and Northern regions (34 percent). In fact, much of lhe difference in overall prevalence between the Western region and the Southern and Central regions is due to the higher level of traditional method use in the West. Regional differences in the current use of specific methods are presented in Figure 4.3. The main differences between regions are in pill and IUD use, which are lowest in the East and the North, respectively. Female sterilisation and withdrawal are highest in the North. Current use increases directly with education (Table 4.5). Among women who have no education, the percentages currently using modem and traditional methods are almost identical. In contrast, women with a primary or higher education are more likely to use modem than traditional methods. Women with secondary or more education are the group most likely to be using modem contraceptive methods, especially the IUD and the condom. Half of all women in this education group are users of a modern method, and a quarter are using IUDs. Use of contraception increases rapidly with number of living children, peaking at 78 percent among women with two children, after which it declines slightly among women with three or more children. There appears to be little effort to delay first birth; less than nine percent of the currently married women with no children are using a method. 39 Figure 4.3 Current Use of Family Planning by Region and Method Percent 190 75 50 25 9 West South Central North REGION J East TDHS 1993 4.4 Number of Children at First Use of Contraception In many cultures, family planning is used only when couples have already had as many children as they want. As the concept of planning families gains acceptance, however, couples may begin to use contraception for spacing births as well as for limiting family size. Moreover, young women may be particularly motivated to use family planning to delay the timing of the first child. To explore the possible motivation for use of contraceptives, a question was asked on the number of children the respondent had when contraception was first used. These results shown in Table 4.6 allows us examine cohort change (as indicated by differences between age groups) in the early adoption of contraception, One third of women start using contraception aider they have one child. There are clear distinctions between cohorts in the parity at which a method was first accepted, with women who are younger than 35 being much more likely to have adopted at lower parities than older women. 4.5 Problems with Current Method All current contraceptive users in the TDHS were asked whether they had experienced problems with the method they were using and, if so, what the problems were. Identifying problems with the use of specific methods has practical implications for future educational and promotional campaigns. In the last five years there has been more emphasis on counselling, in order to improve the qiaality of family planning services. Information, education and communication (IE&C) programs affect the continuation of methods. In general, most of the current users were pleased with their choice of method (Table 4.7). Most of the problems reported for modem methods are for the pill and, to a lesser degree, for the IUD. Most of the women who are using traditional methods did not report any problems. 40 Table 4.6 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at the time of first use of contraception, according to current age, Turkey 1993 Number of living children at time Never of first use of contraception Number used of Current age contraception 0 1 2 3 4+ Total women 15-19 62.4 18.2 17.9 1.5 0.0 0.0 100.0 332 20-24 30.7 17.4 42.0 8.5 1.2 0.2 100.0 1040 25-29 15.8 14.8 42.0 17.9 6.1 3.4 I00.0 1211 30-34 11.9 10.4 39.2 19.5 9.7 9.3 I00.0 1283 35-39 13.2 8.3 30.4 17.7 12.5 17.9 I00.0 1073 40-44 18.4 6.4 23.6 19.5 11.2 20.9 I00.0 901 45-49 22.8 5.1 17.3 19.6 12.7 22.5 I00.0 679 Total 20.4 11.3 33.2 16.3 8.1 10.7 100.0 6519 In Table 4.7, of the specific problems reported, 13 percent of the women using pills complained about side effects and 8 percent had health concerns related to the method. Among IUD users, side effects and health concerns were problems for an identical percentage of users (6 percent). The percentages reporting concerns about side effects and health concerns may reflect inappropriate counselling as well as the prejudice mostly to the pills that is reflected to the women by the medical personnel (i.e., the "medical barrier"). Table 4.7 Problems with current method of contraception Percent distribution of contraceptive users by the main problem with current method, according to specific methods, Turkey 1993 Female Periodic Main Vaginal Con- sterili- absti- With- problem Pill IUD methods dom sation nence drawal No problem 78.4 87.4 94.4 94.4 92.9 93.8 96. I Husband disapproves 0.4 0.2 1.6 3.0 0.0 0.0 1.4 Side effects 13.2 6.3 2.4 0.4 2.9 0.0 0.2 Health concerns 7.6 6.1 0.0 0.0 3.5 0.0 0.6 Other t 0.4 0.0 1.6 2.2 0.7 6.2 1.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 308 1178 76 415 186 60 1642 qncludes access/availability, inconvenient to use, and can get pregnant. 4.6 Use of Name-brand Pills In order to measure the extent to which the social marketing program has reached the general pub- lic, all TDHS respondents who reported that they were currently using the pill were asked to show the packet of the pills they were using, or, i f they could not, to tell the interviewer which brand they were using. Table 4.8 presents the percentage of pill users who are using a social marketing brand. Of all the current pill users 73 percent were able to show the pills they were using to the interviewer. The most commonly 41 used pill brand was Lo-femenal (17 percent), which is distributed tree of charge by the Ministry of Health; it is followed by Desolet (16 percent), which is sold at pharmacies. Among the group who reported themselves as current users of the pill and could not show the packet, 42 percent could not remember the brand that they were using. Minipill (progesterone only) use is only I percent among the pill users ("other" category). 4.7 Knowledge of the Ferti le Period A basic knowledge of reproductive physiology is useful for successful practice of coitus-related methods such as withdrawal, the condom, or barrier methods, but it is especially important for users of periodic abstinence or the rhythm method. The successful pract:,,~e of periodic abstinence depends on an understanding of when during the ovulatory cycle a woman is most likely to conceive. Table 4.9 presents the percent distribution of all respondents and those who have ever used periodic abstinence and withdrawal by reported knowledge of the fertile period in the ovulatory cycle. Table 4.8 Use of social marketing brand pills Percent distribution of pill users who are using a social marketing brand, Turkey 1993 Brand Pills currently Pills not used shown shown Total Desolet 17.2 14.5 16.4 Eugynon 6.8 3.6 5.9 Femulen 0.9 - 1).7 Lo-fcmenal 22.6 1.3 16.8 I,o-ovral 2.7 3.6 3.11 I,yndiol 13. I 7.2 I 1.5 Microgynon 9.9 1.2 7.6 Minulet - 1.2 0 .3 Myraloo (1.5 1.2 0.7 Ovral 13.6 6.0 I 1.5 Ovulen 2.3 4.8 3.0 Triquilar 3.6 4.8 3.9 Trinordiol 3.6 - 2.6 Other 2.7 6.0 3.6 Don't know - 42.2 I 1.5 Missing 0.5 2.4 1.0 Total 100.0 100.0 I00.0 Number 221 83 304 Women in Turkey do not have sufficient knowledge on the timing of ovulation. Only 22 percent of ever-married women know the correct time of ovulation, 47 percent have no idea as to the time, and 31 percent have incorrect knowledge (Figure 4.4). Women who have ever used the rhythm method have better knowledge than all ever-married women; 80 percent know the correct time of ovulation, 8 percent report that they do not know about the time of ovulation and 12 percent have incorrect knowledge. Ever users of withdrawal have similar knowledge about time of ovulation as all women. Table 4.9 Knowledge of fertile period Percent distribution of ever-married women, women who have ever used periodic abstinence, and women who have ever used withdrawal, by knowledge of the fertile period during the ovulatory cycle, Turkey 1993 Ever users Ever users Perceived All of periodic of with- fertile period women abstinence drawal During her period 0.7 0.7 0.9 At~er period cnded 7.7 6.4 8.7 Middle o1" her cycle 22.3 79.7 24.6 Before period begins 1.0 1.7 1.0 Other 0.4 0.4 0.5 No particular time 20.5 3.0 19.4 Don't know 47.3 8. I 44.8 Missing 0. I 0.0 0.1 Total 100.0 100.0 100.0 Number 6519 465 3480 42 Figure 4.4 Knowledge of Fertile Period among Ever-Married Women and Users of Periodic Abstinence No I)articul"~ time 21% Other 10% Middle of "~e cycle 22% Don't know 47% Ever-Married Women Middle of the cycle 80% Periodic Abst inence TDHS 1993 4.8 Timing of Sterilisation In countries where contraceptive steritisation is practiced, there is interest in knowing the trend in the adoption of the method and in determining whether the age at the time of the operation is declining. Table 4.10 presents the percent distribution of sterilised women by age at the time of sterilisation, according to the number of years since the operation. The median age at the time of the operation is presented only for women less than 40 years of age to minimize problems of censoring. "Fable 4.10 Timing of sterilisation Percent distribution of sterilised women by age at the time of sterilisation, according to the number of years since the opcration, Turkey 1993 Age at time ol"sterilisation Number Ycars sincc of Median operation <25 25-29 30-34 35-39 40-44 45-49 Total women age I <2 (1.3) (26.6) (46.2) 117.61 (5.8) (2.5) 100.0 45 (32.3) 2-3 (9.2) (24.9) 131.31 (27.9) (6.7) (0.0) 100.0 36 (32.2) 4-5 (23.7) (3.6) (29.3) (28.8) (14.61 (0.0) 100.0 30 133.1) 6-7 * * * * * * 100.0 21 * 8-9 * * * * * * 100.0 22 * Ill+ (18.7) (37.1) (34.11 (10.1) (0.0) (0.0) 100.0 33 Total 11.4 24.9 36.0 20.8 6.3 0.6 100.0 187 318 iMedian age was calculated only for women less than 40 years of age to avoid problems of censoring. * Less than 25 cases ( ) Figures in parentheses are based on 25-49 cases 43 The results in Table 4.10 suggest that the age at which sterilisation is adopted has been decreasing slightly in Turkey. The median age at the time of sterilisation for women who have been sterilised 4-7 years before the survey was 33 years, almost one year higher than the median age (32 years) among users who adopted the method more recently. However, conclusions about the timing of sterilisation adoption must be viewed with some caution because of the comparatively small number of users in each time period. 4.9 Sources for Family Planning Methods At present, the IUD, pills, condoms and other modem methods are available free of charge in the government sector through the primary health care units and hospitals. Pharmacies and private physicians also supply methods, but charge for their services. All current users of modem methods of family planning were asked to report the most recent source of supply for their methods. Because women often do not know the exact category of the source they use (e.g., government hospital, private health center, etc.), interviewers were instructed to write the name of the source. Supervisors and field editors were to verify that the name and the type of source were consistent. This practice was designed to improve the reporting of data on sources of family planning. The results are presented in Table 4.11. The majority of users (55 percent) obtained their methods from government services (Figure 4.5). Primary health care units (health centers) are the major public sector suppliers of family planning methods (35 percent). Among private sector sources, pharmacies (25 percent) are the major suppliers of methods, followed by private doctors (15 percent) and private hospitals or clinics (3 percent). Looking at sources for specific methods (Table 4.11), pharmacies are the main source of pills, condoms and vaginal methods (69 percent, 65 percent and 91 percent, respectively). For the IUD, the principal source is government health centres/houses/MCH-FP centers (49 percent) and hospitals (22 percent); however, private doctors (24 percent) are also important providers of the IUD. The majority of female sterilisation operations take place in government hospitals (83 percent). Provision of modem methods by nongovernmental organizations (NGOs) in Turkey is still at insignificant levels, not exceeding one percent for any of the modem methods. Table 4.11 Sourceofsupply for modern contraceptive methods Percent distribution of current users of modem contraceptive methods by most recent source of supply, according to specific methods. Turkey 1993 Female All Vaginal Con- sterili- modern Source of supply Pill IUD methods dora sation methods Public 24.2 70.9 3.7 28.7 83.4 54.8 Government hospital 3.0 22.3 1.6 2.6 82.8 20.3 Government health centre 21.2 48.6 2.1 26.1 0.6 34.5 Medical private 75.3 28.1 96.3 66.2 15.5 43.3 Private hospital/Clinic 0.0 3.8 0.0 0.3 8.9 2.9 Pharmacy 69.4 0.3 91.2 65.2 0.0 25.6 Private doctor 5.9 24.0 5.1 0.7 6.6 14.8 Other 0.5 1.0 0.0 5.1 I.I 1.9 Total 100.0 100,0 100.0 100.0 100.0 100.0 Number 308 1178 76 415 186 2170 44 Figure 4.5 Source of Supply of Modern Contraceptive Methods ~arnment hospital 20~ Private hoa Pharmacy 25~ Other pHvate 2~ vale doctor lS~ TDHS 1993 4.10 Cont racept ive Discontinuation Cumulative one-year contraceptive discontinuation rates d.ueto method failure, desire for pregnancy, or other reasons are presented in Table 4.12, according to specific method. The discontinuation rates shown are true,multiple decrement life-table rates (sometimes referred to as "net rates") where the various reasons for discontinuation are treated as competing risks and are additive across reasons for discontinuing. The rates are calculated from information collected in the calendar portion of the questionnaire (see Appendix E). The rates refer to all episodes of contraceptive use occurring during the period of t ime covered by the calendar, not just those episodes that began during this period. Specifically, the rates presented in Table Table 4.12 Contraceptive discontinuation rates First-year contraceptive discontinuation rates due to method failure, desire for pregnancy, side effects, or other reasons, according to specific method All Method Desire for Side other All Method failure pregnancy effects reasons reasons Pill 6.3 5.8 22.5 20.8 55.3 IUD 1.0 0.8 6.0 2.3 10.1 Diaphragm/Foam/Jelly 16.1 4.9 2.3 36.7 60.0 Condom 8.6 5.9 0.6 33.7 48.8 Periodic abstinence 24.6 15.3 0.8 20.2 60.9 Withdrawal 14.9 6.4 0.2 17.3 38.8 Total 9.7 5.0 4.9 17. I 36.7 45 4.12 refer to the 60-month period 3-63 months prior to the survey; the month of the interview and the prior 2 months are ignored in order to avoid the bias that may be introduced by unrecognized pregnancies. Proper counselling and type of services affect the continuation of methods. Crowded family planning centres lower the quality of services, limiting one-to-one contact with the clients. Regular follow- ups or visits are required to maintain the continuation of the method. The highest discontinuation rates are for barrier methods (diaphragm, foam or jelly) and periodic abstinence (60 percent and 61 percent, respectively). The discontinuation rate for the pill (55 percent) is also quite high. The lowest discontinuation rate (10 percent) is fgr the IUD. The discontinuation rate for withdrawal, the most widely used traditional method, is relatively low (39 percent) in comparison to that for some modern methods. Side effects for the pill and IUD (23 percent and 6 percent, respectively) account for a large part of their high discontinuation rates. The highest failure rate is observed for periodic abstinence (25 percent). This may be due to the fact that periodic abstinence is used mostly by the delayers, who are not highly motivated. The failure rate for withdrawal for the first year is relatively low compared to the rates for other countries, e.g., 18 percent as reported by Hatcher et al. (1990). The high level of the failure rate for the pill (6 percent), compared to the typical first-year failure rate of 3 percent, may be due to its misuse. Table 4.13 shows the percent distribution of the discontinuation of contraceptive methods in the last five years by main reason for discontinuation, according to specific method. Major reasons for discontinuation of the pill and IUDs were side effects and health concerns (41 percent and 47 percent, respectively); discontinuation due to side effects was higher among pill users than IUD users. The main reason for discontinuation of withdrawal was becoming pregnant (42 percent) with 17 percent accounting to the desire to change to a more effective method. Similarly, 14 percent of the discontinuation of condom use resulted from changing to a more effective method, while husband disapproval accounted for 23 percent of the discontinuations. Table 4.13 Reasons Ibr discontinuation of contraception Percent distribution of contraceptive method discontinuatkm in the live 2,'cars prcccding the survey by main reason lbr discontinuation, according to spccilic methods. Turkey 1993 Modern Traditional methods methods Vaginal Periodic Reason tbr meth- Con- absti- With- All discontinuation Pill IUD ods dora nence drawal methods Became pregnant 12.2 6.9 24.0 17.9 39.6 41.7 25.9 To become pregnant 13.3 16. I 10.2 18.9 25.9 18.0 16.7 I lusband disapproved 1.0 0. I 5.7 23.3 1).5 3.8 5. I Side clli:cts 26.8 16.3 1).6 02 0.0 0.1 8.0 I Icalth concerns 14.2 31).2 4.8 1.1 2.3 0.5 8.8 Access/Availability 2,6 0.0 5.8 4.8 0.0 0.0 1.3 More effective method 3.4 0.7 1 1.6 13.6 9.9 17.3 I 0.8 Inconvenient to use 1).8 0.0 9.9 5.5 2.9 1.2 1.9 Infrequent sex 6.7 1.8 5.4 1.5 0.0 33 3.4 Cost 08 0.1 1.4 0.1 0.0 0.0 0.2 Fatalistic 0.4 0.0 (}.0 0.3 0.0 0. I 0.2 Menopause 2.3 2.5 7.8 1.3 2.5 3.0 2.9 Marital dissolution 0.0 I. 1 0.5 1).7 1.0 1).7 0.6 Other I 1.3 19. I 9.2 6.9 5.7 2.7 8.2 Missing 4.2 5.1 3. I 39 9.7 7,6 6.0 Total 100.0 100.0 100.0 100.0 I00.0 IO0.O I00.0 Number 811 848 171 583 121 1942 4547 46 4.11 Intent to Use Family Planning Among Nonusers Intent to use contraception in the future provides a forecast of potential demand for services and is a convenient indicator of the disposition towards contraception among current nonusers. Women who were not using a contraceptive method at the time of the survey were asked if they thought they would do something to keep from getting pregnant at any time in the future. In addition, those who reported that they were intending to use were asked whether they planned to begin use within the next 12 months. The distinction between intended use in the next 12 months and later use should provide a more trustworthy indication of demand in the near future. Since intention to use family planning is closely related to the number of children a woman has and past experience with contraception, the data on future use in Table 4.14 are broken down by these two factors. The reasons for not using contraception given by women who do not intend to use a method are presented in Table 4.15. Nonusers who said that they did intend to use family planning in the future were asked which method they preferred to use. These results are presented in Table 4.16. Among currently married nonusers, 46 percent do not intend to use any method in the fitture while 31 percent intend to begin use in 12 months, 14 percent intend to use later and 8 percent are unsure of their intent or the timing (Table 4.14 and Figure 4.6). The proportion intending to use varies with number of living children, peaking at 64 percent among women with one child. The timing of the intention to use also varies with the number of living children; nonusers with two or more children are much more likely than those with no children to say that they plan to begin use within the next 12 months. Table 4.14 Futuru use of contraception Percent distribution of currently married women who are not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living children, Turkey 1993 Past experience with contraception and future intentions Number of living children I 0 I 2 3 4+ Total Never used before Intend use/12 months 2.9 29.3 Intend use later 26.3 12.6 Unsure as to timing 0.8 2.1 Unsure as to intent 10.3 5.4 Docs not intend use 44.9 19.0 Missing 0.5 0.8 Previously used Intend use/12 months 2.1 12.3 Intend use later 8.9 9.3 Unsure as to liming 0.0 0.4 Unsure as to intent 0.7 1.0 Does not intend to use 2.6 7.3 Missing 0.0 0.5 Total 100.0 100.0 Nonusers currently married Intend use/12 months 5.0 41.5 Inlcnd use later 35.2 22.0 lJnsurc as to timing 0.8 2.5 Unsure as to intent I 1.0 6.4 Does not intend to use 47.5 26.4 Missing 0.5 1.2 Total 100.0 100.0 Number 361 492 11.2 9. I I 1.3 13.4 4.1 1.0 2.7 8.4 0.7 0.0 0.6 0.9 2.9 2.5 3.7 4.7 17.4 15.5 28.8 25.0 0.0 0.0 0.4 0.4 32.7 25.3 14.9 17.4 3.9 4.1 2.3 5.4 1.2 1.4 0.3 0.6 1.6 2.5 1.0 1.3 22.8 36.0 33.0 21.4 1.5 2.6 1.0 I.I 100.0 100.0 100.0 100.0 43,9 34.4 26.0 30.8 7.9 5.1 5.1 13.9 1,9 1.4 0.9 1,5 4,5 5.0 4.7 6,0 40.3 51,5 61.9 46.4 1.5 2.6 1.4 t.4 I(10.0 I00.0 I00.0 I00.0 459 346 689 2347 tlncludes current pregnancy 47 Figure 4.6 Future Use of Contraception among Nonusers Currently Married i n tends to use later 14~ Unsu~ 9~ In tends to use In 12 months 31~ Does not intend to use 47~ TDHS 1993 Nonusers are almost evenly divided be- tween past users and never users. An examination of intention to use among these two groups indi- cates that past users are only slightly more likely than never users to express an intention to use in the future; past users are more likely than never users to say that they will begin use within the next 12 months. Table 4.15 and Figure 4.7 show the rea- sons for nonuse among nonusers who do not in- tend to adopt any method in the future. Nonusers who do not intend to use in the future are mainly over the age of 30 (81 percent), and their reasons for nonuse are quite different from the reasons given by younger nonusers. The majority of these older nonusers are not exposed to pregnancy; 35 percent had a hysterectomy or are menopausal and 35 percent reported that it was difficult for them to get pregnant. The main reason for nonuse among women under age 30 was a desire for children (51 percent), and the second most frequently mentioned reason was infertility (19 percent). Table 4.15 Reasons for not using contraception Percent distribution of women who are not using a contraceptive method and who do not intend to use in the future by main reason for not using, according to age, Turkey 1993 Reason for Age not using contraception 15-29 30-49 Total Wants children 50.7 7.9 15.9 Lack of knowledge 3.5 0.9 1.3 Partner opposed 5.8 1.4 2.3 Costs too much 0.0 0.2 0.1 Side effects 2.6 1.2 1.4 Health concerns 2.7 1.7 1.9 Hard to get methods 0.1 0.6 0.5 Religion 2.5 1.8 2.0 Opposed to family planning 0.1 0.3 0.2 Fatalistic 4.4 3.7 3.9 Infrequent sex 3.0 6.8 6.1 Difficult to be pregnant 18.5 35.4 32.2 Menopausal/Had hysterectomy 0.8 34.9 28.5 Inconvenient 0.0 0.4 0.3 Other 5.4 2.8 3.4 Total 100.0 100.0 100.0 Number 204 886 1090 48 Figure 4.7 Reasons for Not Using Contraception among Nonusers Currently Married Difficult to gmt pregnant 32% Rallglon, fatalistic 6% Wants children 19% Other 15% Menopausal MUSOand opposes 2~ 28q TDHS 1993 In the groups who intend to use in the next 12 months or later, the majority report that their method of choice will be the IUD. Women who are not sure of the timing of future use also are more likely to pre- fer the IUD (29 percent) than other methods, but significant proportions also prefer the pill (18 percent), and 11 percent want to be sterilised (Table 4.16). Table 4.16 Preferred method of contraception for future use Percent distribution of currently married women who are not using a contraceptive method but who intend to use in the future by preferred method, according to whether they intend to use in the next 12 months or later, Turkey 1993 Intend to use In next After Preferred method 12 12 Unsure of contraception months months when Total Pill 13.1 14.2 (17.7) 13.5 IUD 54.0 46.7 (29.2) 50.6 Injection 3.2 2.2 (2.9) 2.8 Diaphragm/Foam/Jelly 1.1 1.8 (0.0) 1.3 Condom 2.9 3.1 (4.8) 3.0 Norplant 1.5 1.2 (2.9) 1.4 Female sterilisation 5.2 6.6 (11.4) 5.7 Male sterilisation 0.3 0.2 (0.0) 0.3 Periodic abstinence 0.5 0.0 (0.0) 0.3 Withdrawal 6.9 6.9 (2.9) 6.7 Abstinence 0.0 0.3 (0.0) 0.1 Other 1.2 3.0 (0.0) 1.7 Don't know/Missing 10.1 13.8 (28.2) 12.6 Total 100.0 100.0 100.0 100.0 Number 722 325 35 1082 ( ) Figures in parentheses are based on 25-49 cases. 49 CHAPTER5 ABORTIONS AND STILLBIRTHS Ayse Akin Dervi~o~lu Gill ErgOr In this chapter, the fertility outcomes that have not been discussed in previous chapters--induced abortions, spontaneous abortions, and stillbirths--will be addressed. Greater emphasis will be placed on induced abortions due to the importance of its effects on health and fertility. Although stillbirths and spontaneous abortions are important indicators of prenatal care and maternal health, induced abortions have significance for family planning services. Abortions have been used as a method of birth control over the years, despite the fact that they were hazardous and/or illegal. Induced abortion is a worldwide problem in women's health. Illegal abortion is a major cause of death among women of reproductive age in developing countries. The aim of family planning is to eliminate unwanted pregnancies. However, lack of access to contraception or non-use of contraception due to psychosocial factors or the failure of a contraceptive method may result in an unwanted pregnancy and 'may lead women to resort to induced abortion. Legalizing abortion provides safe conditions to terminate unwanted pregnancies. In May 1983, the new population planning law was accepted, by which Turkey chose to provide safe, equally available abortion for every women who needs the service. The new law introduced the following innovations: Legalized induced abortion on request during the first ten weeks of gestation Provided for pregnancy termination by a trained General Practitioner under the supervision of an ob/gyn specialist Legalized surgical contraception on request for both sexes Authorized trained nurse-midwives to provide effective contraceptive methods like IUD insertion Further emphasized the importance of intersectoral collaboration and cooperation for successful Family Planning activities. It was a comprehensive law in that it aimed to increase contraceptive use. After 1983, induced abortions have been performed at government hospitals for a nominal fee. The private sector also provides abortion services for a fee. In the 1993 TDHS, women were asked if they had had any abortions, miscarriages or stillbirths and if so, how many. If these events took place since 1988 the dates were also marked on the calendar section of the questionnaire. Information was also collected on the duration of the pregnancy in months before the abortion, the provider of the abortion, and the reason for the last abortion. 51 5.1 Abortion and Stillbirth Prevalence Abortion rates are calculated in three different ways, by dividing the number of abortions by the number of women in a specified time period and multiplying by 100 (per 100 women), by dividing the number of abortions by the number of pregnancies in the same time period and multiplying by 100 (per 100 pregnancies), and by dividing the number of abortions by the number of live births in the same time period and multiplying by 100 (per 100 live births). The total abortion rates show a slight decrease since 1990 as can be seen in the values for the induced abortions rather than the spontaneous abortions (Table 5.1). The decrease is from 21 per 100 pregnancies in 1990 to 18 in 1992. The low rates for 1988 and 1989 may be due to recall bias, i.e., they belong to a date further in the past. The spontaneous abortion rates were between 5 to 11 per 100 pregnancies during the same time period. The stillbirth incidence, between 1.1 and 1.9, did not show a trend in the five years before the survey. At the time of the survey, respondents reported that 13 of 100 pregnancies ended in induced abortions, 8 pregnancies ended in spontaneous abortions and 2 pregnancies ended in stillbirths. Table 5.1 Abortions and stillbirths Induced and spontaneous abortions and stillbirths per 100 pregnancies, 1988-1992, Turkey 1993 1992 1991 1990 1989 1988 Total I Induced abortion 17.9 18.0 20.6 15.7 12.9 13.4 Spontaneous abortion 10.8 8.9 9.1 6.0 4.7 8.3 Stillbirth 1.1 1.9 1.2 1.8 1.6 1.6 IThis category reflects the induced and spontaneous abortions and stillbirths per 100 pregnancies that women have had at the time of the survey. Table 5.2 shows the abortion rates calcu- lated up to the time of the survey. There have been 17 induced abortions per 100 live births and 52 induced abortions per 100 women, compared to 10 spontaneous abortions per 100 live births and 31 spontaneous abortions per 100 women. Table 5.2 also shows the abortion rates for the three years preceding the survey, There were 29 total abortions for 100 pregnancies, of which 18 were induced and 11 were spontaneous. Out of 100 women, 9 women had induced abor- tions and 5 women had spontaneous abortions in the same time period. In terms of live births there have been 25 induced abortions and 15 spontane- ous abortions per 100 live births. Abortion rates for the year preceding the survey are given at the end of Table 5.2. Table 5.2 Total abortion rates Total, induced, and spontaneous abortions per 100 women, 100 pregnancies, and 100 live births, Turkey 1993 Number of abortions per 100: Live Women Pregnancies births Total Total abortions 83.8 21.4 27.6 Induced abortions 52.4 13.4 17.2 Spontaneous abortions 31.4 8.0 10.3 Three years preceding Total abortions 13.8 28.5 40.3 Induced abortions 8.7 17.9 25.4 Spontaneous abortions 5.1 10.5 14.9 One year preceding Total abortions 5.4 29.4 42.4 Induced abortions 3.3 17.9 25.8 Spontaneous abortions 2.1 11.5 16~6 52 5.2 Abortions and Stillbirths by Selected Background Characteristics The induced abortion rates according to region differ considerably from East to West. As seen in Table 5.3 the abortion rates per 100 pregnancies are almost twice as high in the Central, Southern and Northern regions, and almost three times as high in the West as the abortion rate for the East. A similar gap is seen between the rural and urban areas, where induced abortions are nearly twice as high as in the rural areas. Induced abortions per 100 pregnancies increase steadily by age, reaching the highest level in the 45-49 age group with 48 abortions. This pattern differs from the 1988 TDHS, where the highest abortion rate was seen in the 35-39 age group. The effect of education is similar to that of 1988, with the abortion rate increasing with the level of education, from 14 in the least educated group to 23 in the secondary or higher educated group. Table 5.3 Induced abortion and stillbirths Induced abortions and stillbirths per 100 women, per 100 pregnancies according to background characteristics in the five years preceding the survey, Turkey 1993 Background characteristics Induced Stillbirths abortions per per 100 100 100 100 women pregnancies women pregnancies Region West 16.3 24.9 1.0 1.5 South 13.1 16.3 1.2 1.4 Central 15.4 19.8 1.1 1.4 North 13.7 17.0 1.1 1.4 East 9.5 8.7 1.9 1.7 Residence Urban 16.5 21.3 1.1 1.4 Rural 10.2 13.4 1.3 1.6 Age of woman 15-19 2.3 3.5 0.2 0.3 20-24 8.7 6.7 1.7 1.3 25-29 17.4 13.9 1.8 1.4 30-34 21.1 23.8 0.9 1.0 35-39 20,0 34.7 1.8 3.1 40-44 11.3 37.8 0.6 1.9 45-49 5.0 48.4 0.3 3.0 Education No ¢duc./Pri. ineomp. 11.2 13.9 1.5 1.9 Pri. eomp./Sec, incomp. 15.4 19.4 1.1 1.4 See. comp./+ 17.2 22.6 0.9 1.2 Total 14.3 17.9 1.2 1.5 There have been 1.5 stillbirths per 100 pregnancies and 1.2 stillbirths per 100 women in the last five years preceding the survey. There are slightly more stillbirths in the East than in the West. The rural and urban differences are not very pronounced. Stillbirths definitely increase after age 35 to 2 or 3 stillbirths per 100 pregnancies. There are more stillbirths in the group that has never attended school or did not complete primary school than in the higher educated groups. 53 As seen in Table 5.4, overall 72 percent of women have not had an abortion throughout their lives (by the time of the survey), whereas 15 percent had one abortion, 8 percent had two abortions and 6 percent had three or more abortions. As the number of living children increases, the percent of women who had an abortion increases as well as the number of abortions a woman has had. Looking at the abortions according to the desired number of children, the highest percentage of abortions is seen among the women who desire only one child, followed by the women who desire two children. "Fable 5,4 Induced abortions throughout life of a woman Percent distribution of ever-married women by number of induced abortions, according to number of living children and desired number of children. Turkey 1993 Number of induced abortions None I 2 3+ Total Number Living children None 96.7 2.7 0.2 (1.4 100.0 623 1 87.2 9.4 2.1 1.3 100.0 I 117 2 68.0 17.9 9.0 5.1 100.0 1838 3+ 63.6 17.8 10.4 8.2 100.0 2941 Desired children None 77.2 12.1 6.8 3.9 100.0 59 I 70.6 17.0 8.3 4. t 100.0 426 2 71.6 15.2 7.9 5.3 100.0 391 I 3+ 73.0 14.1 6.8 6.1 100.0 2006 Other 72.8 12.1 10.1 5.0 100.0 117 Total 72.0 14.9 7.6 5.5 100.0 6519 5.3 Contraceptive Use Before and After Induced Abort ions Abortions result from either a failure to use contraceptives or a failure to u~e them effectively. The distribution of women according to the contraceptive method they used in the month preceding the abortion is shown in Table 5.5. In the past five years, 34 percent of women who had an abortion were not using any method whereas 45 percent were using withdrawal one month before the last abortion. The high percentage of withdrawal users among the women who chose to have an abortion implies motivation to control their fertility, but unfortunately the method they have chosen is ineffective. Among the women who terminated their pregnancy with an induced abortion, 6 percent were using condoms, 5 percent the IUD, and 4 percent the pill. "Fable 5.5 Method used before abortion Method used within one month before pregnancy for the last abortion and belbre pregnancy for all abortions reported in the five years preceding the survey, Turkey 1993 Last All Method abortion abortions Pill 4.2 4.6 IUD 4.7 4.3 Diaphragm/Foam/Jelly 2,7 2.8 Condom 5.5 5.6 Periodic abstinence 2.6 2.5 Withdrawal 45.1 44.7 Other 1.4 1.2 No method 33.8 34.3 Total 100.0 100.0 Number 799 929 54 Table 5.6 shows the aftermath of abortion in terms of method use. The time during an abortion certainly is an opportunity to offer counseling for effective contraceptive use. However, this seems to be a missed opportunity for health care providers, since 39 percent of women who had an abortion do not use any method one month after an abortion and 27 percent use withdrawal. Effective methods practiced with in one month after an abortion include the IUD (11 percent), the pill (9 percent), and the condom (9 percent). It is interesting to look at the women who used withdrawal and the nonusers, since they account for most of the women who had an abortion. Table 5.7 shows that more than half of the women who were nonusers who had an abortion are still not using any method in the first month after the abortion, only 11 percent started using the pill, 11 percent started using IUD, 8 percent started using the condom, and 12 percent started to use withdrawal. Table 5.6 Method used after abortion Method used within one month after last abortion and after all abortions reported in the five years preceding the survey, Turkey 1993 Last All Method abortion abortions Pill 9.1 9.2 IUD 1 I. I 9.9 Diaphragm/Foam/Jelly 1.6 2.1 Condom 9.3 8.8 Female sterilisation 0.5 0.5 Periodic abstinence 1.3 1.5 Withdrawal 26.8 27.6 Other 1.5 1.7 No method 38.8 38.7 Total 100.0 100.0 Number 799 929 Among the withdrawal users who had an abortion 43 percent continued to use withdrawal and 32 percent were not using any method. Only 10 percent started to use the IUD, 5 percent the pill and 7 percent the condom after the abortion. "Fable 5.7 Method used after abortion and past use Method used within I month before last abortion and method used within one month after last abortion in the five years preceding the survey, Turkey 1993 Method used one month after the abortion Peri- Method used Female odic in the month Dia- Con- sterili- absti- With- No before abortion Pill IUD phragm dom sation nence drawal Other method Total Number Pill (30.3) (21.3) (0.0) (12.0) (0.0) (0.0) (7.5) (0.0) (28.9) 100.0 33 IUD (18.6) (17.6) (0.0) (11.6) (0.0) (0.0) (22.6) (0.0) (29.6) 100.0 38 Diaphragm/Foam/Jelly * * * * * * * * * 100.0 22 Condom (7.1) (5.1) (0.0) (39.5) (0.0) (2.2) (14.1) (0.0) (32.0) 100.0 44 Periodic abstinence * * * * * * * * * 100.0 2 I Withdrawal 4.9 10.4 O.S 7.3 0.3 0.0 43.4 1.4 31.5 100.0 360 No method I1.1 10.7 0.9 7.7 1.2 0.0 12.2 2.4 53.8 100.0 270 Total 9.1 I1.1 1.6 9.3 0.5 1.3 26.8 1.5 38.8 I00.0 788 a aEleven women who were using "other" methods in the month before the abortion are not included in this table. ( ) Figures in parentheses are based on 25-49 eases. * Less than 25 cases 5.4 Reasons for Induced Abortion Reasons for having an abortion for the last abortion a woman had are shown in Table 5.8. The most reported reason was not wanting any more children (58 percent). Socioeconomic reasons followed with 17 percent, physician's recommendation with 12 percent and recently ended a previous pregnancy accounted for 8 percent. 55 Table 5.8 Reasons for induced abortion Reason for last induced abortion among women who have at least one induced abortion, Turkey 1993 Reasons for induced abortion Previous Doctor Did not pregnancy Background recom- Socio- want just characteristics mended economic another ended Other t Total Number Region West 10.0 19.2 56.9 8.2 5.7 100.0 742 South 15.9 12.7 54.7 12.1 4.6 100.0 248 Central 10.6 15.6 60.6 7.4 5.8 100.0 393 North 12.2 18.1 61.0 5.5 4.2 100.0 145 East 22.4 13.1 55.1 4.5 4.9 100.0 171 Residence Urban 12.2 18.6 55.1 8.7 5.4 100.0 1269 Rural 13.4 I1.1 64.6 5.8 5.1 100.0 430 Age of woman 15-19 * * * * * 100.0 6 20-24 12.9 25.3 36.0 14.2 11.6 100.0 86 25-29 13.3 19.9 43.3 15.9 7.6 100.0 239 30-34 12.7 16.7 58.0 9.2 3.4 100.0 390 35-39 9.7 16.8 64.7 4.6 4.2 100.0 403 40-44 14.2 12.8 60.1 6.6 6.3 100.0 342 45-49 12.5 15.9 64.4 3.4 3.8 100.0 233 Education No educ./Pri, incomp. 16.7 12.7 61.8 4.5 4.3 100.0 515 Pri. comp./Sec, incomp. 11.0 18.0 55.5 8.9 6.6 100.0 876 See. comp./+ 9.5 19.7 55.8 I I.I 3.9 100.0 308 Total 12.4 16.7 57.5 8.0 5.4 100.0 1699 qncludes missing values, which are 4.3.percent of the total * Less than 25 cases There were some regional differences in the reasons for abortions. In the East, physician's recommendation was 22 percent, the highest of all the other regions, which is probably due to the high number of pregnancies a woman has. In the South the short time interval seemed to be a more important factor to end a pregnancy than in the other regions. In the urban areas socioeconomic factors and birth spacing were the more important reasons, while in rural areas not wanting any more children was reported more. As the age of the woman increased, the main reason for having the last induced abortion was "not wanting any more children." Socioeconomic reasons were reported more frequently by the younger age groups. Until age 30 between 12-16 percent of pregnancies were terminated because of a recent pregnancy. Socioeconomic reasons and child spacing are perceived more as a reason to have an abortion among the higher educated women. Among the uneducated, 17 percent report physician's recommendation as a reason for their abortion and 62 percent report that they did not want a0y more children. 56 5.5 Timing of Induced Abortions Although abortions are legal for up to 10 weeks of pregnancy (2.5 months), it is safer for a woman to have an abortion as early as possible. Table 5.9 shows the distribution of women with recent induced abortions by number of months of pregnancy at the time of the abortion, according to region and place of residence. Overall, 44 percent of abortions took place in the first month, 31 percent in the second month, 13 percent in the third month and 12 percent in the fourth or later months of pregnancy, which shows that at least 12 percent of the induced abortions were performed beyond the legal limits. This is especially noticeable in the East, where one fourth of abortions were done after the legal limits. These statistics may reflect a delay in access to health services. Urban-rural differences are also more apparent for the abortions after the third month of pregnancy. Notice that 11 percent of induced abortions were carried out after the third month in the urban areas, where access to health care should be easier, compared with 16 percent in the rural areas. Table 5.9 Timing of induced abortion Percent distribution of women with recent induced abortions by number of months of pregnancy, according to place of residence, Turkey 1993 Number of months pregnant Background characteristic 1 2 3 4+ Missing Total Number Region West 51.5 29.5 10.5 8.5 0.0 I00.0 508 South 38.8 33.6 14.6 12,6 0.4 100.0 191 Central 46.8 31.0 11.4 10.8 0,0 100.0 327 North 40.6 38.2 10.8 10.4 0.0 100.0 129 East 25.8 29.2 19.5 25.5 0.0 100.0 208 Residence Urban 47.2 29.9 12.0 10.8 0.1 100.0 946 Rural 35.5 34.1 14.4 16.0 0.0 100.0 417 Total 43.6 31.2 12.7 12.4 0.1 100.0 1363 This issue might be better explained when the abortion provider is taken into consideration. Table 5.10 shows that 67 percent of abortions were performed by private physicians and 27 percent by physicians in government hospitals. Although it differs by region, the private physician's share is not lower than 64 percent in any region. The percentage for physicians at government hospitals is the highest in the Western region, followed by the Central and Eastern regions. There are no marked urban and rural differences in terms of the place where the abortion service is provided. Three percent of unsafe induced abortions are performed either by the woman herself or by a nurse-midwife. Table 5.10 Abortion providers Percent distribution of women who used induced abortion to terminate their pregnan- cies during the last five years, by provider, according to place of residence, Turkey 1993 Self/ Physician Background Nurse- (gov't. Physician characteristic midwife hospital) (private) Missing Total Number Region West 1.0 32.7 64.3 2,0 100.0 379 South 7. I 17.6 73.5 1.8 100.0 13 I Central 2.7 30.2 64.9 2.2 100.0 234 North 4.3 14.6 78.1 2,9 100.0 84 East 5.0 24.7 67.0 3.3 100.0 I 01 Residence Urban 2. I 28.6 67.4 1.9 100.0 69 I Rural 5.2 24.2 67.2 3.4 100.0 238 Total 2.9 27.4 67.4 2.3 100.0 929 58 CHAPTER 6 PROXIMATE DETERMINANTS OF FERTILITY Banu Akadh Erg6fmen The principal factors other than contraception that affect a woman's risk of becoming pregnant, namely, nuptiality, postpartum amenorrhoea, abstinence from sexual relations, and secondary infertility, are addressed in this chapter. The nuptiality data collection procedure in the TDHS differs in various ways from the standard DHS questionnaire. In the TDHS, the nuptiality questions are after the fertility section and questions on recent sexual activity are not included because of the difficulty in addressing these questions to women. Instead there are some additional questions about family formation, religious marriages, and consanguinity. Although it is by no means always true, marriage is an indicator of exposure of women to the risk of pregnancy; therefore it is important for the understanding of fertility. Populations in which age at marriage is low also tend to experience early childbearing and high fertility. Trends in the age at which women marry can help to explain the trends in fertility levels. Measures of other proximate determinants of fertility are the durations of postpartum amenorrhoea and postpartum abstinence, and the level of secondary infertility. In the TDHS, only women 15-49 who had ever been married were interviewed with the Individual Questionnaire. However, some tables presented in this chapter are based on all women, i.e., on both ever- married and never-married women. In constructing these tables, the number of ever-married women interviewed in the survey is multiplied by an inflation factor that is equal to the ratio of all women to ever- married women interviewed as reported in the Household Questionnaire. With this procedure the denominators are expanded to represent all women. The inflation factors are calculated by single years of age and, where the results are presented by background characteristics, single-year inflation factors are calculated separately for each category of the characteristic. 6.1 Current Marital Status Current marital status at the time of the survey is shown in Table 6.1 and Figure 6.1. Overall, 65 percent are currently married, ~ 2 percent are widowed, 1 percent are divorced and 33 percent have never been married. In Turkey, marriage is almost universal. By the end of the reproductive years, only 1 percent of women have never married. The universality of marriage is also evident from the fact that among women age 30 and over, 96 percent or more are, or have been, married. The percentage of never married women declines rapidly with age, decreasing almost by half, from 87 percent among teenagers to 42 percent among women in their early twenties. As expected, tbe proportion of widows increases with age, from less than 1 percent of women under age 30 to 7 percent among women age 45-49. The percentage of divorced women is very low and women who are not living with their husbands are even less common than the divorced group. ~The term married refers both to "currently married" and "currently in union." 59 Table 6.1 Current marital status Percent distribution of women by current marital status, according to age, Turkey 1993 Marital status Number Never Not living of Age married Married Widowed Divorced together Total women 15-19 86.5 13.4 0.0 0.1 0.0 100.0 2460 20-24 41.5 57.7 0.1 0.4 0.3 100.0 1777 25-29 15.6 82.9 0.6 0.6 0.3 100.0 1436 30-34 4.3 93.5 1.0 1.0 0.2 100.0 1340 35-39 1.8 93.9 2.6 1.4 0.3 100.0 1093 40-44 2.2 90.5 5.2 1.9 0.2 100.0 921 45-49 0.9 89.6 7.0 1.7 0.8 100.0 685 Total 32.9 64.6 1.5 0.8 0.2 100.0 9712 Figure 6.1 Current Marital Status Percent 100 80 60 40 20 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age TDHS 1993 6.2 Marital Exposure Table 6.2 presents marital exposure to the risk of pregnancy. The table is based on the information collected in the calendar. Therefore it shows the percentage of months in the five years before the survey spent in a marital union and incorporates the effects of age at first marriage, marital dissolution, and remarriage. The table shows variations in exposure by age and background characteristics of women. 60 Table 6.2 Marital exposure Percentage of time spent in marital union in the five years preceding the survey by age and selected background characteristics, Turkey 1993 Age at time of survey Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 5.3 41.1 76.3 93.0 93.0 90.6 89.1 60.4 Rural 3.3 39.2 75.5 92.4 95.8 94.8 93.8 50.7 Region West 4.2 39.1 74.1 92.1 92.3 90.2 89.5 61.6 South 4.8 36.5 66.4 88.9 93.0 92.5 87.4 56.1 Central 5.0 43.1 80.9 95.3 93.5 92.3 93.8 60.8 North 6.6 37.6 81.1 90.2 96.0 91.8 92.3 63.3 East 5.9 44.4 81.5 95.0 96.8 95.3 92.1 53.0 Education No educ./Pri, incomp. 13.4 57.6 85.4 94.0 95.4 92.2 94.0 81.4 Pri. comp./Sec, ineomp. 5.3 43.9 78.8 93.8 94.9 93.1 87.6 54.8 Sec. comp./+ I.I 23.1 61.5 87.8 86.2 87.1 83.1 40.7 Total 4.8 40.4 76.0 92.7 93.9 91.8 90.9 58.3 Overall, women in Turkey were in marital unions for 58 percent of the time during the five years preceding the survey. The percentage of months spent married varies by age. Younger women spent less t ime in marriage than older women, because a large proportion were not yet married. The percentage of months spent married increases to 94 percent among women age 35-39 and then declines. This pattern reflects marital dissolution among women age 40 and above, mostly through widowhood, since divorce is less common. There are significant differences in marital exposure between regions. These differences are more marked in the younger age groups, indicating differences in the pace of entry into marriage. For example

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