Turkey - Demographic and Health Survey - 2009

Publication date: 2009

Turkey Demographic and Health Survey 2008 Hacettepe University Institute of Population Studies Ankara, Turkey With the contributions of General Directorate of Mother and Child Health / Family Planning, Ministry of Health, Ankara, Turkey and T.R. Prime Ministry State Planning Organization Ankara, Turkey Funded by The Scientific and Technological Research Council of Turkey (TÜBİTAK) “Support Programme for Research and Development Projects of Public Institutions” (KAMAG) October 2009 Hacettepe University Institute of Population Studies T.R. Ministry of Health General Directorate of Mother and Child Health and Family Planning T.R. Prime Ministry State Planning Organization The Scientific and Technological Research Council of Turkey Publication No: IPS-HU.09.01 ISBN 978-975-491-275-3 The contents of this document are the sole responsibility of Hacettepe University Institute of Population Studies and can under no circumstances be regarded as reflecting the position of the The Scientific and Technological Research Council of Turkey (TÜBİTAK). The Turkey Demographic and Health Survey, 2008 (TDHS-2008) has been conducted by the Hacettepe University Institute of Population Studies. The beneficiary institutions under this project are T.R. Ministry of Health and T.R. Prime Ministry Undersecretary of State Planning Organization. The financial support of the TDHS-2008 has been provided by the Scientific and Technological Research Council of Turkey (TÜBİTAK) within the scope of the Support Programme for Research and Development Projects of Public Institutions. TDHS-2008 is fully comparable with the models and standards developed by the worldwide Demographic and Health Surveys (MEASURE/DHS+) project. ICF Macro International Inc. provided technical assistance on tabulation, the review and formatting of the final report. Additional information about the TDHS-2008 may be obtained from Hacettepe University, Institute of Population Studies, 06100 Ankara, Turkey (telephone: +90 312-305-1115; fax: +90 312-311-8141; e- mail: hips@hacettepe.edu.tr; internet: www.hips.hacettepe.edu.tr). Information about the MEASURE/DHS+ project may be obtained from ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: reports@macroint.com; internet: www.measuredhs.com). Suggested citation: Hacettepe University Institute of Population Studies (2009) Turkey Demographic and Health Survey, 2008. Hacettepe University Institute of Population Studies, Ministry of Health General Directorate of Mother and Child Health and Family Planning, T.R. Prime Ministry Undersecretary of State Planning Organization and TÜBİTAK, Ankara, Turkey. Printed by Hacettepe University Hospitals Printing House Table of Contents i TABLE OF CONTENTS List of Tables and Figures . v Foreword . xi Summary of Findings . xv Map of Turkey . xxi CHAPTER 1 INTRODUCTION 1.1 Geography. 1 1.2 History . 1 1.3 Administrative Divisions and Political Organization. 3 1.4 Social and Cultural Features . 3 1.5 Economy . 4 1.6 Regional Divisions . 6 1.7 Population . 7 1.8 Population and Family Planning Policies and Programs . 9 1.9 Health Priorities and Programs . 10 1.10 Health Care System in Turkey . 10 1.11 Objectives and Organization of the Survey . 11 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Characteristics of the Household Population . 17 2.2 Fosterhood and Orphanhood . 21 2.3 Education of the Household Population . 23 2.4 Housing Characteristics . 32 2.5 Household Wealth . 38 2.6 Birth Registration . 40 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Background Characteristics . 43 3.2 Education and Literacy Level . 45 3.3 Employment and Occupation. 48 3.4 Social Security Coverage. 54 3.5 Health Insurance Coverage . 54 3.6 Smoking Status . 57 Table of Contentsii CHAPTER 4 FERTILITY 4.1 Current Fertility. 60 4.2 Fertility Differentials . 61 4.3 Fertility Trends . 63 4.4 Children Ever Born and Children Surviving . 67 4.5 Birth Intervals . 69 4.6 Age at First Birth . 71 4.7 Teenage Pregnancy and Motherhood . 73 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Family Planning Methods . 75 5.2 Ever Use of Contraceptive Methods . 78 5.3 Current Use of Contraceptive Methods . 79 5.4 Trends in Current Use of Family Planning . 82 5.5 Number of Children at First Use of Contraception . 84 5.6 Knowledge of the Fertile Period . 85 5.7 Timing of Female Sterilization . 85 5.8 Source for Family Planning Methods . 86 5.9 Informed Choice . 89 5.10 Discontinuation of Contraceptive Use . 89 5.11 Intention to Use Contraception among Non-Users . 91 5.12 Reasons for Non-Use of Contraception . 93 CHAPTER 6 ABORTIONS AND STILLBIRTHS 6.1 Life-time Experience with Pregnancy Terminations . 95 6.2 Current Levels and Trends in Abortion Rates . 96 6.3 Patterns of Contraceptive Use Prior to and After Induced Abortion . 100 6.4 Decision Maker of Induced Abortion . 101 6.5 Timing of Induced Abortion . 102 6.6 Abortion Provider. 103 6.7 Age-specific and Total Abortion Rates . 104 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY 7.1 Current Marital Status . 107 7.2 Age at First Marriage . 109 7.3 Postpartum Amenorrhea, Postpartum Abstinence, and Insusceptibility . 111 7.4 Menopause . 115 Table of Contents iii CHAPTER 8 FERTILITY PREFERENCES 8.1 Desire for More Children . 117 8.2 Need for Family Planning Services. 121 8.3 Ideal Number of Children . 123 8.4 Planning Status of Births . 126 8.5 Total Wanted Fertility . 127 CHAPTER 9 INFANT AND CHILD MORTALITY 9.1 Assessment of Data Quality. 130 9.2 Levels and Trends in Infant and Child Mortality . 132 9.3 Differentials in Infant and Child Mortality . 134 9.4 Perinatal Mortality . 136 9.5 High-risk Fertility Behaviour. 137 CHAPTER 10 REPRODUCTIVE HEALTH 10.1 Antenatal Care . 141 10.2 Number and Timing of Antenatal Care Visits . 144 10.3 Components of Antenatal Care . 145 10.4 Place of Delivery . 148 10.5 Assistance During Delivery . 150 10.6 Postnatal Care . 152 CHAPTER 11 CHILD HEALTH 11.1 Child’s Weight and Size at Birth . 157 11.2 Vaccination of Children . 159 11.3 Prevalence and Treatment of Diarrhea . 163 CHAPTER 12 CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS 12.1 Initiation of Breastfeeding . 169 12.2 Breastfeeding Status by the Age of Child . 171 12.3 Duration and Frequency of Breastfeeding . 173 12.4 Types of Complementary Food . 174 12.5 Iodization of Household Salt . 176 12.6 Nutritional Status of Children . 177 12.7 Nutritional Status of Mothers . 182 Table of Contentsiv CHAPTER 13 WOMEN’S STATUS 13.1 Interspousal Difference in Age and Education . 187 13.2 Factors Influencing Women’s Employment . 189 13.3 Child Care while Working . 192 13.4 Women’s Attitudes towards Being Subject to Physical Violence and Controlling Behaviors . 194 13.5 Attitudes towards Gender Roles . 198 13.6 Women’s Roles in Reproductive Decisions . 200 13.7 Women’s Status and Reproductive Health Outcomes . 201 REFERENCES . 203 APPENDIX A LIST OF PERSONNEL . 205 APPENDIX B SURVEY DESIGN . 207 B.1 Sample Design and Implementation . 207 B.2 Sample Frame . 208 B.3 Stratification. 208 B.4 Sample Allocation . 211 B.5 Sample Selection . 212 B.6 Questionnaire Development and Pre-test . 214 B.7 Data Collection Activities . 216 B.8 Data Processing and Analysis . 217 B.9 Calculation of Sample Weights . 217 B.10 Coverage of the Sample. 222 APPENDIX C SAMPLING ERRORS . 225 APPENDIX D DATA QUALITY TABLES . 249 APPENDIX E CHILD GROWTH STANDARDS, WHO-2006 . 255 APPENDIX F QUESTIONNAIRES . 257 APPENDIX G SUMMARY INDICATORS . 343 List of Tables and Figures | v LIST OF TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 16 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence. 18 Table 2.2.1 Age distribution of household population . 19 Table 2.2.2 Population by age from selected sources . 20 Table 2.3 Household composition . 21 Table 2.4 Children's living arrangements and orphanhood . 22 Table 2.5.1 Educational attainment of household population: Males . 24 Table 2.5.2 Educational attainment of household population: Females . 25 Table 2.6.1 School attendance ratios: Primary school . 28 Table 2.6.2 School attendance ratios: High school . 29 Table 2.7.1 Grade repetition rates . 30 Table 2.7.2 Grade dropout rates . 31 Table 2.8 Household drinking water. 33 Table 2.9 Household sanitation facilities . 34 Table 2.10 Household characteristics . 36 Table 2.11 Household durable goods . 37 Table 2.12 Wealth quintiles . 39 Table 2.13 Birth registration of children under age five . 41 Figure 2.1 Population Pyramid . 18 Figure 2.2 Age-specific Attendance Rates . 26 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Background characteristics of respondents . 44 Table 3.2 Educational attainment . 46 Table 3.3 Literacy . 47 Table 3.4 Employment status . 49 Table 3.5 Type of occupation . 51 Table 3.6 Employment in public or private sector . 52 Table 3.7 Type of employment . 53 Table 3.8 Social security coverage . 55 Table 3.9 Health insurance coverage . 56 Table 3.10 Use of cigarattes . 58 vi | List of Tables and Figures CHAPTER 4 FERTILITY Table 4.1 Current fertility . 60 Table 4.2 Fertility by background characteristics . 62 Table 4.3 Trends in fertility. 64 Table 4.4 Age-specific fertility rates . 66 Table 4.5 Fertility by marital duration . 67 Table 4.6 Children ever born and children surviving . 68 Table 4.7 Birth intervals . 70 Table 4.8 Age at first birth . 71 Table 4.9 Median age at first birth. 72 Table 4.10 Teenage pregnancy and motherhood . 73 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence . 61 Figure 4.2 Trends in Age-specific Fertility Rates, 1978-2008 . 65 Figure 4.3 Age-specific Fertility Rates during the Last 2 Decades . 66 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 76 Table 5.2 Knowledge of contraceptive methods by background characteristics . 77 Table 5.3 Ever use of contraception . 78 Table 5.4 Current use of contraception by age . 79 Table 5.5 Current use of contraception by background characteristics . 80 Table 5.6 Trends in current use of contraception . 82 Table 5.7 Trends in current use of contraception by residence and region . 84 Table 5.8 Number of children at first use of contraception . 84 Table 5.9 Timing of female sterilization . 86 Table 5.10 Source of supply for modern contraceptive methods . 87 Table 5.11 Trends in source of supply for selected modern methods . 87 Table 5.12 Informed choice . 88 Table 5.13 Contraceptive discontinuation rates . 90 Table 5.14 Reasons for discontinuation of contraception . 91 Table 5.15 Future use of contraception. 92 Table 5.16 Preferred method of contraception for future use . 92 Table 5.17 Reasons for not intending to use contraception in the future . 93 Figure 5.1 Current Use of Family Planning by Region and Method . 81 Figure 5.2 Current Use of Family Planning Methods, Turkey 1993, 1998, 2003 and 2008 . 83 Figure 5.3 Knowledge of Fertile Period . 85 List of Tables and Figures | vii CHAPTER 6 ABORTIONS AND STILLBIRTHS Table 6.1 Number of abortions and stillbirths . 96 Table 6.2 Induced abortions by background characteristics . 97 Table 6.3 Abortions and stillbirths per 100 pregnancies . 98 Table 6.4 Trends in induced abortions . 99 Table 6.5 Method used before abortion . 100 Table 6.6 Method used after abortion . 100 Table 6.7 Decision maker of abortion. 101 Table 6.8 Timing of last induced abortion . 103 Table 6.9 Abortion providers . 104 Table 6.10 Total abortion rates . 105 Table 6.11 Induced abortion by background characteristics . 106 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 7.1.1 Current marital status . 108 Table 7.1.2 Trends in proportion never married . 108 Table 7.2 Age at first marriage . 109 Table 7.3 Median age at first marriage . 110 Table 7.4 Postpartum amenorrhea, abstinence, and insusceptibility . 112 Table 7.5 Median duration of postpartum insusceptibility by background characteristics . 114 Table 7.6 Menopause . 115 Figure 7.1 Percentage of Births Whose Mothers are Amenorrheic, Abstaining, or Insusceptible . 113 CHAPTER 8 FERTILITY PREFERENCES Table 8.1 Fertility preferences by number of living children . 118 Table 8.2 Fertility preference by age . 119 Table 8.3 Desire to limit childbearing . 120 Table 8.4 Need and demand for family planning among currently married women. 122 Table 8.5 Ideal number of children. 124 Table 8.6 Mean ideal number of children . 125 Table 8.7 Fertility planning status . 126 Table 8.8 Wanted fertility rates . 128 Figure 8.1 Fertility Preferences of Currently Married Women Age 15-49 . 119 viii | List of Tables and Figures CHAPTER 9 INFANT AND CHILD MORTALITY Table 9.1 Infant and child mortality . 132 Table 9.2 Early childhood mortality rates by socioeconomic characteristics . 134 Table 9.3 Early childhood mortality rates by biodemographic characteristics . 135 Table 9.4 Perinatal mortality . 137 Table 9.5 High-risk fertility behavior . 138 Figure 9.1 Trends in Childhood Mortality Rates, Estimates for 5-Year Periods Preceding the TDHS-1993, TDHS-1998, TDHS-2003 and TDHD-2008 . 133 CHAPTER 10 REPRODUCTIVE HEALTH Table 10.1 Antenatal care . 143 Table 10.2 Number of antenatal care visits and timing of first visit . 145 Table 10.3 Components of antenatal care . 147 Table 10.4 Place of delivery . 149 Table 10.5 Assistance during delivery . 151 Table 10.6 Type of provider of first postnatal checkup for women . 153 Table 10.7 Timing of first postnatal checkup for women . 154 Table 10.8 Type of provider of first postnatal checkup for child . 155 Table 10.9 Timing of first postnatal checkup for child . 156 CHAPTER 11 CHILD HEALTH Table 11.1 Child’s weight and size at birth. 158 Table 11.2 Vaccinations by source of information. 160 Table 11.3 Vaccinations by background characteristics . 161 Table 11.4 Vaccinations by current age of child . 162 Table 11.5 Prevalence of diarrhea . 164 Table 11.6 Diarrhea treatment . 166 Table 11.7 Feeding practices during diarrhea . 167 CHAPTER 12 CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS Table 12.1 Initial breastfeeding . 170 Table 12.2 Breastfeeding status by age. 172 Table 12.3 Median duration and frequency of breastfeeding. 174 Table 12.4 Foods consumed by children in the day or night preceding the interview . 175 Table 12.5 Iodization of household salt . 176 Table 12.6 Nutritional status by children’s characteristics . 179 Table 12.7 Nutritional status by mother’s characteristics . 180 Table 12.8 Anthropometric indicators of maternal nutritional status . 183 Table 12.9 Nutritional status of women by background characteristics . 184 List of Tables and Figures | ix Figure 12.1 Nutritional Status of Children by Age . 181 CHAPTER 13 WOMEN’S STATUS AND DECISION MAKING ON DEMOGRAPHIC AND HEALTH OUTCOMES Table 13.1 Differences in age and education between spouses . 188 Table 13.2 Main reason for not working. 190 Table 13.3 Main reason for quitting job . 191 Table 13.4 Child care while working. 193 Table 13.5 Attitude towards physical violence . 195 Table 13.6 Frequency of some controlling behaviors. 196 Table 13.7 Controlling behaviors . 197 Table 13.8 Attitude towards gender roles . 199 Table 13.9 Decision making. 200 Table 13.10 Justification of physical violence and reproductive health outcomes . 201 APPENDIX B SURVEY DESIGN Table B.1 List of strata by region, NUTS 1 region, residence, type and province, Turkey 2008 . 209 Table B.2 Allocation of sample households . 211 Table B.3 Distribution of sample clusters . 212 Table B.4.1 Design weights and nonresponse factors . 219 Table B.4.2 Design weights and nonresponse factors: Half sample . 220 Table B.5 Final sample weights . 221 Table B.6.1 Sample implementation according to residence and region . 223 Table B.6.2 Sample implementation according to NUTS 1 regions . 224 APPENDIX C SAMPLING ERROS Table C.1 List of selected variables for sampling errors . 228 Table C.2 Sampling errors: National Sample . 229 Table C.3 Sampling errors: Urban Areas . 230 Table C.4 Sampling errors: Rural Areas. 231 Table C.5 Sampling errors: West . 232 Table C.6 Sampling errors: South . 233 Table C.7 Sampling errors: Central . 234 Table C.8 Sampling errors: North . 235 Table C.9 Sampling errors: East . 236 Table C.10 Sampling errors: İstanbul . 237 Table C.11 Sampling errors: West Marmara . 238 Table C.12 Sampling errors: Aegean . 239 Table C.13 Sampling errors: East Marmara . 240 Table C.14 Sampling errors: West Anatolia . 241 Table C.15 Sampling errors: Mediterranean . 242 x | List of Tables and Figures Table C.16 Sampling errors: Central Anatolia . 243 Table C.17 Sampling errors: West Black Sea . 244 Table C.18 Sampling errors: East Black Sea . 245 Table C.19 Sampling errors: Northeast Anatolia . 246 Table C.20 Sampling errors: Central East Anatolia . 247 Table C.21 Sampling errors: Southeast Anatolia . 248 APPENDIX D DATA QUALITY TABLES Table D.1 Age distribution of de facto household population . 249 Table D.2 Age distribution of eligible and interviewed women . 250 Table D.3 Completeness of reporting . 250 Table D.4 Births by calendar years . 251 Table D.5 Reporting of age at death in days . 252 Table D.6 Reporting of age at death in months . 253 APPENDIX E CHILD GROWTH STANDARDS, WHO-2006 Table E.1 Nutritional status of children, according to child growth standards, WHO-2006. 256 Foreword | xi FOREWORD Hacettepe University Institute of Population Studies was established in 1967 and is the principal institution for carrying out nationwide scientific studies on fertility, mortality, migration and maternal and child health issues in Turkey. Through a series of national household surveys conducted every five years, the Institute has collected reliable nationwide data on population characteristics and maternal and child health since 1968. These data have allowed the demographic structure in Turkey to be assessed regularly for four-decade period. The results of these studies served as the basis on which population and health policies have been formed, maternal and child health service plans prepared, and the coverage and impact of these plans evaluated. The Turkey Demographic and Health Survey, 2008 (TDHS-2008) is the ninth national demographic survey series carried out by the Institute of Population Studies since 1968, for every five years. It is an honor for the Institute to gain the general approval and confidence of all scholars and institutions of national and international level for yielding high quality information on a national level and providing comprehensive reports. The seven demographic surveys conducted in Turkey between 1968 and 1998 were financially supported by various international sources. The TDHS-2003 was realized by the combination of national budget and European Union sources. However, for the first time, the TDHS-2008 was financed entirely from the national budget of Republic of Turkey. The financial support of the TDHS-2008 has been provided by The Scientific and Technological Research Council of Turkey (TÜBİTAK) within the scope of the Support Programme for Research and Development Projects of Public Institutions (KAMAG). The survey is an indicator of the institutionalization and the importance of this survey, which is one of the best example of the collaboration of universities and public institutions in Turkey. In addition, these surveys have been included into the formal statistics program prepared by Turkey Statistical Institute. Preparatory activities of the TDHS-2008 began in March 2007. In this context, activities relating to sampling and questionnaire design were accomplished in this period. Following the completion of the preparatory activities, listing and fieldwork took place between June and December of 2008. The TDHS-2008 was conducted in 81 provinces and 634 clusters which were selected in such fashion as to represent the country, the urban-rural and regional levels. Interviews were completed with 7,405 ever-married women in reproductive ages in 10,525 households. In March 2009, the preliminary report that included some key indicators obtained from the TDHS-2008 was published and disseminated to public and academic organizations concerned with population and maternal and child health issues. The results of the TDHS-2008 present considerable changes in population and health indicators towards the positive direction. The findings point out significant improvements particularly in the use of modern contraception, receiving antenatal care and in child health. xii | Foreword The declines in total fertility rate, and especially infant mortality rate are also noteworthy. A careful assessment of the survey results that reflect the changes in population and health indicators will help to re-determine the planning of services, resources, personnel, target groups and priorities in the population and health sectors. The contributions of Hacettepe University administrators the general directors and experts of the public institutions and staff of the Institute of Population Studies were instrumental in the realization of various stages of the TDHS-2008. I would like to express my gratitude to them for their much appreciated efforts. First of all, I would like to thank The Scientific and Technological Research Council of Turkey who have supported the TDHS-2008 project as a Research and Development (R&D) project under the Support Programme for Research and Development Projects of Public Institutions. The Ministry of Health provided extensive support to the TDHS-2008 in every stage as in the previous Demographic and Health Surveys conducted by the Institute. I deeply appreciate first Prof. Dr. Recep Akdağ, the Minister of Health, and especially Dr. Mehmet Rifat Köse, General Director of the Mother and Child Health and Family Planning for their productive, supportive, analytical and enriching contributions. Moreover, I also would like to acknowledge the efforts of directors of the General Directorate of Primary Health Services, and personnel in the General Directorate as well as the provincial health directors and other health personnel in the provinces where the survey was carried out. I would like to thank to Mr. Kemal Madenoğlu, the undersecretary of the State Planning Organization, and his staff for their efforts in various stages of the project. I would like to thank Mr. Ömer Toprak, the President of the State Institute of Statistics, and Ms. Hasibe Dedeş, the director of the Survey, Analysis and Statistics Division, and other staff for their efforts and contributions in selecting the sample of the TDHS-2008 with scientific sensitivity. I am grateful to the high level officials of Ministry of Interior that provided necessary permissions for field survey as well as province governors and sub-governors and district governers who administratively supported the implementation of the field survey. I would like to express my special appreciation to Prof. Dr. Uğur Erdener, the Rector of the Hacettepe University and staff in the Scientific Research Unit of the University as they shared all the difficulties with us and gave valuable support in every stage of the TDHS-2008. My thanks are also to the Steering Committee Members of TDHS-2008 for their valuable contributions. I deeply appreciate all respondents who accepted to be involved in the survey and answered the questionnaires and all staff of the field teams, without them we would have been unable to conduct this survey. Foreword | xiii I would like to thank Dr. Ann A. Way, the vice president of the ICF Macro and her colleagues for their important inputs in data entry, data analysis and in finalization of english report. Finally, I extend my gratitude to the technical director of the TDHS-2008 Assoc. Prof. Dr. Ismet Koç, the field director Dr. Elif Kurtuluş Yiğit, and Assist. Prof. Dr. A. Sinan Türkyılmaz, Assoc. Prof. Dr. Banu Akadlı Ergöçmen, Mehmet Ali Eryurt and Dr. Yadigar Coşkun, who are responsible for sampling, questionnaire design, data entry and data analysis, as well as all research assistants. I would like to thank, Hülya Çulpan as an executive secretary of the Institute and other administrative staff for carrying out all administrative procedures of the project. Moreover, I present my appreciation and respect to all our family members for their endless support and patience during the laborious times in and out of work days. I wish the results of this study would provide positive contributions to the health of our country’s women and children. Prof. Dr. Sabahat Tezcan Director Institute of Population Studies Hacettepe University Summary of Findings | xv SUMMARY OF FINDINGS The Turkey Demographic and Health Survey, 2008 (TDHS-2008) is a nationally representative sample survey designed to provide information on levels and trends on fertility, infant and child mortality, family planning and maternal and child health. Survey results are presented at the national level, by urban and rural residence, for each of the five regions in the country, and for the 12 geographical regions (NUTS1) for some of the survey topics The entire funding for the TDHS-2008 was provided by the Government of Turkey through the Scientific and Technological Research Council of Turkey (TÜBİTAK) within the scope of the Support Programme for Research and Development Projects of Public Institutions (KAMAG). Hacettepe University Institute of Population Studies (HUIPS) carried out the TDHS-2008 in collaboration with the General Directorate of Mother and Child Health and Family Planning, Ministry of Health and the Undersecretary of State Planning Organization. TDHS-2008 is the most recent in the series of demographic surveys carried out in Turkey by HUIPS and it is the fourth survey conducted as part of the worldwide Demo- graphic and Health Surveys program. The survey was fielded between October 2008 and December 2008. Interviews were completed with 10,525 households and with 8,003 ever-married women at reproductive ages (15-49). Ever-married women at ages 15-49 who were present in the household on the night before the interview or who usu- ally live in that household were eligible for the survey. CHARACTERISTICS OF HOUSEHOLD POPULATION Turkey has a young population structure; 27 percent of the population is under age 15. The population age 65 and over accounts for 7 percent of the total population in Turkey. The mean household size in Turkey is 4 per- sons, varying from an average of 3.8 persons in the urban areas to 4.2 persons in rural ar- eas. The majority of the population in Turkey has attended school. Among the population with schooling, about one-third of both males and females have completed at least second level primary school. The proportion of population with at least high school edu- cation is 26 percent for males and 18 per- cent for females. However, the indicators for successive cohorts show a substantial in- crease over time in the educational attain- ment of both men and women. The results show that 94 percent of births in the past five years in Turkey were registered. The percentage of unregistered children decreased from 16 percent in TDHS-2003 to 6 percent in TDHS-2008. CHARACTERISTICS OF RESPONDENTS A third of women interviewed in the TDHS- 2008 were less than 30 years of age; ninety- five percent were married at the time of interview. Eighty-two percent of women in xvi | Summary of Findings Turkey graduated at least from secondary school, and the percentage of literate women is 89 percent. A significant proportion of women (21 percent) had completed at least high school. Survey results show considerable improvement in the educational levels of women in reproductive ages. While 38 percent of women had been in employment during the 12 month period preceding the survey. About half of employed women work in the service sector, 40 percent work in the agriculture, and remaining 8 percent work in the industry. Sixty-nine percent of employed women are not under the coverage of social security. However, 84 percent of women are under the coverage of health insurance. Among all ever-married women age 15-49, 22 percent reported that they smoke regu- larly or rarely. According to maternity status, 11 percent of pregnant women and 17 percent of breastfeeding women report that they smoke. The mean number of cigarettes is around 11 per day among women age 15-49. FERTILITY BEHAVIOR Levels and Trends The findings of the TDHS-2008 indicate that if a woman was to maintain the current fer- tility rates throughout her reproductive years, she would be expected to have 2.16 children on the average by the end of her reproductive years. Although, women in Turkey still experience their prime reproductive years during their twenties, the TDHS-2008 points out an important change in the age pattern of fertility that is observed for the first time in Turkey. The highest age- specific fertility rates were observed in the 20-24 age group in all surveys conducted before TDHS-2008, the 25-29 age group is the one for which highest age-specific fertility rate is attained in TDHS-2008. This shows that not only fertility levels are changing in Turkey, but also age patterns of fertility are, due to postponements in childbearing towards later ages. Socioeconomic and Demographic Differentials The urban-rural gap in fertility levels appears to be closing. However, some re- gional differences remain. Except for South and East Anatolia, fertility is below replace- ment level. Despite a pronounced decline in fertility in recent decades, period fertility in the East is still well above three children. Fertility decreases rapidly with increasing educational level. Women with no education have on average one more children than that of women who have high school and more education. Another important trend is the steady rise in the age at first birth among women in Turkey. Younger women are much less likely than older women to have given birth to their first child while they were in their teens. Age at Marriage In Turkey, marriage is very important from a demographic perspective, because, besides being prevalent throughout the country, almost all births occur within marriage. Therefore, age at first marriage is a significant demographic indicator since it represents the onset of a woman’s exposure to the risk of pregnancy. The TDHS-2008 results document an in- crease in the median age at first marriage across age cohorts, from 19.5 years for the 45-49 age group to 22.1 years for the 25-29 age group. The results also show pro- nounced differences in the age at first mar- riage by educational level of women. Among women age 25-49 there is a differ- ence of almost 5 years in the timing of entry into marriage between those with no Summary of Findings | xvii education and those who has at least high school education. FAMILY PLANNING USE Family Planning Knowledge Knowledge of family planning methods is almost universal among women in Turkey. Almost all women interviewed in the survey had heard of at least one modern method. The IUD and pill are the most widely known modern contraceptive methods among women followed by the male condom, fe- male sterilization and injectables. Levels and Trends Ninety-one percent of both ever-married and currently married women have used a family planning method at some time in their life. Overall, 73 percent of currently married women are using contraception, with 46 per- cent depending on modern methods and 27 percent using traditional methods. The IUD is the most widely used modern method (17 percent) followed by male condom (14 per- cent). Withdrawal continues to be the most widely used traditional method. Twenty six percent of currently married women report current use of withdrawal. Differentials in Use The use of contraceptive methods varies by age. Current use of any method is the high- est among currently married women (84 percent) in the 35-39 age group. The use of withdrawal peaks among women in the 40- 44 age group (32 percent) while the highest level of IUD use (23 percent) is found among women age 35-39. Current use of contraceptive methods also varies according to urban rural residence, region, level of education, and number of living children. Discontinuation of Use Discontinuation of contraceptive use can highlight program areas that require im- provement as well as groups of users who have particular concerns that need to be ad- dressed. The TDHS-2008 results indicate that 35 percent of contraceptive users in Turkey stop using a contraceptive method within 12 months of starting use. The IUD, which is not generally intended as a short- term method, has the lowest discontinuation rate (13 percent). Coitus-related methods are more easily discontinued. For example, 37 percent of condom users discontinue within one year of use. Regarding future use, almost half of currently married non-users intend to use family planning at some time in the future. Provision of Services The public sector is the major source of con- traceptive methods in Turkey. Sixty-one per- cent of current users obtain their contracep- tives from the public sector. In the public sector more than half of the users obtain modern contraceptive methods from health centers or MCH/FP centers. Pharmacies are the second most commonly used source, providing contraceptive methods to one- fourth of all users of modern methods. INDUCED ABORTION Overall, 22 percent of pregnancies during the five-year period before the survey termi- nated in other than a live birth. Induced and spontaneous abortions comprised the great- est share among non-live terminations, with relatively few women having had a stillbirth. There were 21 abortions per 100 pregnan- cies, of which 10 were induced. The total abortion rate (TAR) per woman is 0.29 for the five years preceding the TDHS-2008. The age-specific rates increase to a peak among women age 35-39, and decline among older women. Women living in the East region and in rural settlements are the least likely to have ever had an induced abortion. xviii | Summary of Findings Overall, a substantial proportion of abortions (67 percent) took place in the first month of pregnancy. Private sector providers are pre- ferred for having had an abortion (70 per- cent). The need for family planning counselling after an abortion is highlighted by the finding that, in the month following an induced abortion, 32 percent of women did not use any method and 22 percent used withdrawal. NEED FOR FAMILY PLANNING Fertility Preferences Sixty-seven percent of currently married women do not want to have more births in the future or are already sterilized for contraceptive purposes. An additional 14 percent of the women want to wait at least two years for another birth. Thus, four out of every five currently married women can be regarded as in need of using family planning services either to avoid or to postpone child- bearing. Among the currently married women, the mean ideal number of children is 2.5 for women indicating that most women want small families. Results from the survey suggest that, if all unwanted births were prevented, the total fertility rate at the national level would be 1.6 children per woman, or 0.6 children less than the ac- tual total fertility rate. Unmet Need for Family Planning The total demand for family planning is 79 percent, and 92 percent of this demand is satisfied. The demand for limiting purposes is three times as high as the demand for spacing purposes (55 and 18 percent, re- spectively). The total unmet need among currently married women is 6 percent, almost the same with the findings of TDHS- 2003. CHILD MORTALITY Levels and Trends For the five years preceding the TDHS- 2008, the infant mortality rate is estimated at 17 per thousand, the child mortality rate at 6 per thousand, and the under five mortality rate at 24 per thousand. For the same period, daths in neonatal period account for 76 percent of all infant deaths. All the indicators of infant and child mortality have declined rapidly in recent years. Socioeconomic and Demographic Differ- entials The TDHS-2008 findings point out to significant differences in infant and child mortality between regions and by urban- rural residence. They also show that the educational level of mother is an important correlate of infant and child mortality. In addition to the differentials observed between socio-economic groups, infant and child mortality rates also correlate strongly with the young age of the mother at birth, high-birth order and short birth intervals, with children in these categories facing an elevated risk of dying compared to children in other subgroups. In addition, low weight at birth affects children’s chances of survival. MATERNAL HEALTH Care during Pregnancy Ninety-two percent of mothers received an- tenatal care during the pregnancy preceding their most recent birth in the five years pre- ceding the survey, with 90 percent receiving care from a doctor. Overall, 87 percent of women made an antenatal care visit before the sixth month of pregnancy, and 74 percent of the woman made more than four visits. Younger, low parity women, women living in urban areas and in the regions other Summary of Findings | xix than the East, and women with at least first primary level education are more likely to have received antenatal care compared to other women. Delivery Care and Postnatal Care In Turkey, 90 percent of all births in the five years preceding the survey were delivered at a health facility. Public sector health facili- ties were used to a much greater extent for delivery (70 percent) than private facilities. The proportion of all births delivered with the assistance of a doctor or trained health personnel is 91 percent. Eighty-three percent of women reported that they had a postnatal checkup and the majority of postnatal care was provided by a doctor (82 percent). Among the ones receiving postnatal care, 63 percent received care within less than four hours. On the other hand, 16 percent did not receive any care after the delivery of their last live birth. In Turkey, younger, high parity women (four births or more), women living in rural areas and in the East region and the women with no education were more likely to receive no postnatal care. Postnatal checkups for the baby are important in reducing infant deaths. Approximately 90 percent of infants receive postnatal care from health personnel and most of these babies—67 percent of all last births—are seen for care within four hours following delivery in Turkey. The variations across subgroups in the likelihood of an infant receiving postnatal care from a health provider and in the timing when postnatal care is first received are similar to the patterns observed with respect to the mother’s receipt of postnatal care. CHILD HEALTH Childhood Vaccination Coverage Universal immunization of children against the six vaccine-preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles) is one of the most cost-effective programs in reducing infant and child morbidity and mortality. Among children age 15-26 months, 81 percent of them had received all of the recommended eight vaccines. The percentage of children who are fully vaccinated is lowest in the rural areas (71 percent) and in the Eastern region (64 percent). The vaccination coverage percentages are also related to mother’s education and the children’s sex, birth order and household welfare. Prevalence and Treatment of Diarrhea Dehydratation is a serious result of diarrhea that is one of the most important causes of childhood mortality. Overall, 23 percent of children had experienced diarrhea while only 1 percent of those children had bloody stools in the last two weeks preceding THDS-2008. Approximately half of children with diarrhea are taken to a health provider. Eighty-five percent of them received some kind of treatment from a health facility or a health provider for this illness. NUTRITION INDICATORS FOR CHILDREN AND WOMEN Breastfeeding and supplemental feeding Breastfeeding is almost universal in Turkey; 97 percent of all children are breastfed for some period of time. Complementary feeding is on the way of decreasing in Turkey among very young children in Turkey. In the first two months of life, 69 percent are exclusively breastfed. This percentage was only 44 percent in the TDHS-2003. The median dura- tion of breastfeeding for all children is 16 xx | Summary of Findings months. Among children who are breast- feeding and younger than six months, 25 per- cent received infant formula. Iodization of Salt Iodine deficiency contributes to higher rates of childhood morbidity and mortality. Ac- cording to tests conducted during the survey, the table salt in 85 percent of the households did include neither iodide nor iodate. Iodized salt is not used in one-third of rural house- holds. Approximately half of the households in Central and Southeast Anatolia use iodized salt. Nutritional Status of Children By age five, 10 percent of children are 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. Wasting is a less serious problem. Three percent of children are underweight for their age. Obesity is a problem among mothers. Ac- cording to BMI calculations, 58 percent of mothers are overweight, of which 24 percent are obese. Mean BMI increases rapidly with age, exceeding 25.0 for the majority of women age 25 and older. WOMEN’S STATUS Interspousal difference in age and education Currently married women are, on average, 4.2 years younger than their husband. Only five percent women are two or more years older than their husband. Regarding the education difference, women are most likely to be married to men who have more education than they have. The reasons for not working and child care Thirty-one percent of women reported child- care as the reason for not working; followed by being a housewife (22 percent) and no permission for working by family or husband (20 percent). Eight person of women reported that they did not need working. Of women who worked in the 12 months prior to the survey, 67 percent had no children under 6 years of age. Overall, in Turkey the main source of child care is either the mother or the relatives. The proportion of institutional care is very small with approximately 7 percent. Domestic Violence In TDHS-2008, women were asked whether a husband would be justified in perpetrating physical violence to his wife for different reasons. The percentage of women who accept one reason as a justification for physical violence was found to be 25 percent. REGIONS AND PROVINCES 01 WEST 02 SOUTH 03 CENTRAL 04 NORTH 05 EAST 09 Aydın 01 Adana 03 Afyon 60 Tokat 08 Artvin 02 Adıyaman 62 Tunceli 10 Balıkesir 07 Antalya 05 Amasya 64 Uşak 28 Giresun 04 Ağrı 63 Şanlıurfa 16 Bursa 15 Burdur 06 Ankara 66 Yozgat 29 Gümüşhane 12 Bingöl 65 Van 17 Çanakkale 31 Hatay 11 Bilecik 68 Aksaray 37 Kastamonu 13 Bitlis 69 Bayburt 20 Denizli 32 Isparta 14 Bolu 70 Karaman 52 Ordu 21 Diyarbakır 72 Batman 22 Edirne 33 İçel 18 Çankırı 71 Kırıkkale 53 Rize 23 Elazığ 73 Şırnak 34 İstanbul 46 K.Maraş 19 Çorum 81 Düzce 55 Samsun 24 Erzincan 75 Ardahan 35 İzmir 80 Osmaniye 26 Eskişehir 57 Sinop 25 Erzurum 76 Iğdır 39 Kırklareli 38 Kayseri 61 Trabzon 27 Gaziantep 79 Kilis 41 Kocaeli 40 Kırşehir 67 Zonguldak 30 Hakkari 45 Manisa 42 Konya 74 Bartın 36 Kars 48 Muğla 43 Kütahya 78 Karabük 44 Malatya 54 Sakarya 50 Nevşehir 47 Mardin 59 Tekirdağ 51 Niğde 49 Muş 77 Yalova 58 Sivas 56 Siirt Map of Turkey | xxi xxii | Map of Turkey REGIONS AND PROVINCES 01 İSTANBUL 04 EAST 06 MEDITERRANEAN 08 WEST 10 NORTHEAST 12 SOUTHEAST 34 İstanbul MARMARA 01 Adana BLACK SEA ANATOLIA ANATOLIA 02 WEST 11 Bilecik 07 Antalya 05 Amasya 04 Ağrı 02 Adıyaman MARMARA 14 Bolu 15 Burdur 18 Çankırı 24 Erzincan 21 Diyarbakır 10 Balıkesir 16 Bursa 31 Hatay 19 Çorum 25 Erzurum 27 Gaziantep 17 Çanakkale 26 Eskişehir 32 Isparta 37 Kastamonu 36 Kars 47 Mardin 22 Edirne 41 Kocaeli 33 İçel 55 Samsun 69 Bayburt 56 Siirt 39 Kırklareli 54 Sakarya 46 K.Maraş 57 Sinop 75 Ardahan 63 Şanlıurfa 59 Tekirdağ 77 Yalova 80 Osmaniye 60 Tokat 76 Iğdır 72 Batman 03 AEGEAN 81 Düzce 07 CENTRAL 67 Zonguldak 11 CENTRAL EAST 73 Şırnak 03 Afyon 05 WEST ANATOLIA 74 Bartın ANATOLIA 79 Kilis 09 Aydın ANATOLIA 38 Kayseri 78 Karabük 12 Bingöl 20 Denizli 06 Ankara 40 Kırşehir 09 EAST 13 Bitlis 35 İzmir 42 Konya 50 Nevşehir BLACK SEA 23 Elazığ 43 Kütahya 70 Karaman 51 Niğde 08 Artvin 30 Hakkari 45 Manisa 58 Sivas 28 Giresun 44 Malatya 48 Muğla 66 Yozgat 29 Gümüşhane 49 Muş 64 Uşak 68 Aksaray 52 Ordu 62 Tunceli 71 Kırıkkale 53 Rize 65 Van 61 Trabzon Introduction | 1 INTRODUCTION 1 Sabahat Tezcan 1.1 Geography Turkey occupies a surface area of 774,815 square kilometers. About three percent of the total area lies in Southeastern Europe (Thrace) and the remainder in Southwestern Asia (Anatolia or Asia Minor). Turkey has borders with Greece, Bulgaria in the Thrace and Syria, Iraq, Iran, Georgia, Armenia, and Nahcivan (Azerbaijan) in the south and east Anatolia that is also called Asia Minor. The shape of the country resembles a rectangle, stretching in the east- west direction for approximately 1,565 kilometers and in the north-south direction for nearly 650 kilometers. The three sides of Turkey are surrounded by seas: in the north, the Black Sea; in the northwest, the Sea of Marmara; in the west, the Aegean Sea; and in the south, the Mediterranean Sea. The total coastline of Turkey is around 8,333 kilometers. The Anatolian peninsula lies on an elevated steppe-like and semi-arid central plateau surrounded by mountains on all sides, except the west. The Taurus Mountains in the south and the Northern Anatolia Mountains in the north stretch parallel to the coastline, meeting in the eastern part of the country. The average altitude of the country is around 1,130 meters above sea level. However, there are vast differences in altitude among the regions, ranging from an average of 500 meters in the west to 2,000 meters in the east Anatolia. The climate is characterized by variations of temperature and rainfall, depending on topography of the country. The average rainfall is 500 millimeters; however, it ranges from 2,000 millimeters in Rize, a province on the Eastern Black Sea coast, to less than 300 millimeters in some parts of Central Anatolia. The typical climatic conditions of Turkey include dry, hot summers and cold, rainy, snowy winters especially in the central and eastern regions. In summer, temperatures do not display large variations across the country, whereas in winter, the temperature ranges from an average of –10°C in the east to +10°C in the south. 1.2 History Anatolia was dominated by the Seljuqs for almost two centuries (1055-1243) and afterwards she became the core of the Ottoman Empire, which ruled also in the Europe, Middle East and Africa for almost six centuries. At the end of The First World War, the Ottoman Empire collapsed and immediately an effort to create a new state from the ruins of an Empire began throughout the country. The Turkish resistance movements were transformed into a complete war of independence when Mustafa Kemal landed at Samsun on 19 May 1919. The Turkish forces achieved success under very difficult conditions. The Lausanne Treaty, signed on 24 July 1923, recognized the creation of a new Turkish State with 2 | Introduction virtually the same borders as those of the National Pact of 1920 and guaranteed her complete independence. The Republic was proclaimed on 29 October 1923 in order to give the state a democratic form in the contemporary sense. Subsequently, the country’s present borders were established following the annexing of Hatay, a province on the southern border, in 1939. The founding of the Republic signified radical shifts from the previous social order as a succession of social and economic reforms. The wearing of the turban and fez that were symbols of the former order were banned and the "hat" became the official headgear (25 November 1925); the international hour and calendar systems were adopted (26 November 1925); the dervish lodges and tombs and the titles of tariqahs (sects) were abolished (25 November 1925); a modern Turkish Civil Code was introduced (17 February 1926) to replace the old civil code and the Shariah Laws which were the foundation stones of Ottoman law; the Latin alphabet was adopted instead of Arabic script and unity of basic education was adopted (1 November 1928). The schools where mostly religion-related instruction was given were closed, and a program of compulsory education was set up which aimed at applying contemporary teaching methods. An amendment made to the Constitution in 1928 removed the clause which had stated that “the religion of the state is Islam”. A new clause was put in the Constitution in 1937 stating that Turkey is a secular state. The Surname Law was adopted on 21 June 1934 and also the same year women in Turkey enjoyed voting and election rights. Mustafa Kemal, the founder of the new Turkish State and Republic, was given the surname of "Atatürk" (Father of the Turks). In short, the direction of change, led by Atatürk, was one away from a religious, oriental Empire to a modern, contemporary and secular Republic. Turkey did not become involved to the Second World War at the beginning but when the war was about to end, Turkey sided with the USA, Britain and the Soviet Union and declared war against Germany and Japan. However, Turkey did not take part actively in the war. Turkey signed the United Nations Treaty dated 24 January 1945. Turkey, which was officially invited to the San Francisco Conference on 5 March 1945, was among the founding members of the United Nations. From the foundation of the Turkish Republic to 1946, the country was governed by one party system. In the mid and late 1940s, new political parties formed. The first multiparty election held in 1946 and the second was in 1950 when the Democrat Party won, putting the Republican People's Party into the opposition. With the introduction of multi-party period, Turkey achieved a more liberal and democratic environment. Although Turkish political history included three military interventions (1960, 1971, and 1980), Turkey has succeeded in preserving a parliamentary, multi-party democratic system until today, and this makes it unique among other countries where Islam has prominence. With the foundation of the Republic, Turkey turned her face to the ‘Western world’, as establishing close relations with European countries and the United States of America. Turkey is a member of the United Nations, the Council of Europe and the North Atlantic Treaty Organization (NATO) and an associate member of the European Union. Since 2000, Turkey has achieved a noteworthy achievement in introducing new social, economic and political reforms within the context of the harmonization process with EU that was initiated with the Introduction | 3 Helsinki Summit of 1999 (State Planning Organization 2003). Turkey also maintains close relations with the countries of the Middle East, stemming from deep-rooted cultural and historical links. 1.3 Administrative Divisions and Political Organization Since the foundation of the Republic, the Turkish administrative structure has been shaped by three Constitutions (1924, 1961, and 1982). These three constitutions proclaimed Turkey to be a Republic with a parliamentary system and specified that the will of the people is vested in the Turkish Grand National Assembly (TGNA). All three constitutions adopted basic individual, social and political rights, and accepted the principle of separation of powers, namely legislative, administrative and judicial. The legislative body of the Republic is the TGNA. The TGNA is composed of 550 deputies, who are elected for four-year terms. The President of the Republic is elected by the TGNA for a five-year term. The Prime Minister and other Cabinet Ministers compose the Council of Ministers, the executive branch of the Republic. The judiciary consists of the Court of Appeals, the Court of Jurisdictional Disputes, the Military Court of Appeals, the Constitutional Court, and the civil and military Courts. Turkey is administratively divided into 81 provinces. These are further subdivided into districts (ilçe), subdivisions (bucak), and villages (köy). The head of the province is the governor, who is appointed by the council of ministers and approved by the president of the republic and responsible to the central government. The governor, as the chief administrative officer in the province, carries out the policies of the central government, supervises the overall administration of the province, coordinates the activities of the various ministry representatives appointed by the central authority in the capital Ankara, and maintains law and order within his/her jurisdiction. A mayor and a municipal council, elected by the municipal electoral body for a term of five years, administer local government at the municipality level. Every locality with a population of more than 2,000 is entitled to form a municipal administration. Municipalities are expected to provide basic services such as; electricity, water, gas, building and maintenance of roads, and sewage and garbage disposal facilities within the boundaries of the municipality. Educational and health services are mainly provided by the central government, but municipalities of metropols also provide limited health services for those who are at lower economic and social strata. 1.4 Social and Cultural Features Turkey varies in social and cultural structure, with ‘modern’ and ‘traditional’ life styles co-existing simultaneously within the society. For the inhabitants of metropolitan areas daily life is similar to the Western countries. On the other hand, people living in outskirts of urban areas and rural settlements are relatively conservative and traditional. Family ties are still strong and influential in the formation of values, attitudes, aspirations, and goals. 4 | Introduction Although laws are considered to be quite liberal on gender equality, patriarchal ideology characterizes the social life in many ways. The citizens of Turkey are predominantly Muslim. About 98 percent of the population belongs to Muslim religion. The rich and complex culture of the Turkish society pertains to its ethnic structure. 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. In 2006, the female and male literacy rates for population age 15 and over were 80 and 96 percent, respectively (TURKSTAT 2006). Educational attainment has also increased dramatically. The net primary education enrolment ratio is 97 percent; 98 percent for males and 96 for females. Five years compulsory education has been enhanced to eight years in 1997. Moderate advances have also been made in increasing the proportions of males and females with higher than primary-level education. Besides the net secondary education enrolment ratio is 59 percent; 61 percent for males and 56 percent for females (TURKSTAT 2008). 1.5 Economy After the foundation of the Turkish Republic, various economic development strategies were adopted. In the early years of the Republic, the Turkish economy was very weak since a bankrupt country was inherited from the Ottoman Empire. The economy was almost exclusively based on the agriculture, and it was totally undeveloped and poor. The creation and development of industry was clearly the first step that had to be taken to achieve a healthy and balanced economy. Throughout the 1920s liberal policies were implemented; the government promoted the development of industry through private enterprise, encouraged and assisted by favorable legislation and the introduction of credit facilities. These liberal policies continued until 1929, and moderate improvements were realized in the mechanization of agriculture. In the following decade, the state, under the so-called étatiste system, assumed the role of entrepreneur, owning and developing large sectors of agriculture, industry, mining, commerce and public works. The origins of modern industrialization in Turkey can be traced to the era of the 1930s. Although the beginnings of the industrialization drive were evident in the immediate aftermath of the formation of the republic in 1923, the real breakthrough occurred in the context of the 1930s. Although Turkey did not actually participate in the Second World War, the country was faced with heavy restraints on the economy, which slowed down the industrialization process. A "mixed economy" regime followed the war, with the transition to democracy in 1950 signifying a shift towards a more liberal economic order; private enterprise gained recognition side by side with the state economic enterprises. Also, more emphasis was placed on trade liberalization, agricultural and infrastructural development, and the encouragement of privatization and foreign capital. A series of Five-Year Development Plans were prepared beginning in the 1960s. The first of these plans became operative in 1963. A basic objective was to replace the era of Introduction | 5 unplanned and uncontrolled expansion during the 1950s. Before 1980, Turkey followed an economic policy based on the substitution of imports, and instead of importing it was aimed to manufacture those goods in the country to meet domestic demand. Newly established industrial branches were protected for long periods of time by customs tariffs and other taxes. In the 1980s, governments followed a strategy of renewing economic growth based on an export-oriented strategy. In this way, substantial economic reforms were prepared and applied beginning in January 1980. Privatization implementations were started in the country in 1984. Following the stagnation of the late 1970s, growth recovered in response to a combination of an increased flow of exports and inputs of foreign capital. The liberal economic strategy followed in the 1980s was not unique to that period. The differences between the liberal and étatiste phases are not only the nature of the trade regime and the attitude toward foreign direct investment, but also the mode of state intervention in the economy. Industrialization during the 1990s has been shaped by three dynamics. First, the state’s direct influence on the distribution of the resources was lessened. Second, competition gained importance, with increased emphasis on industrial performance and reconstruction of the industry. Third, general globalization and integration into the European Union gained speed. During the 1990s, privatization also gained importance as a solution to economic capital problems. An autonomous committee was founded in order to regulate privatization. Some of the state enterprises have been privatized within the frame of this program, and further privatization is to continue. Turkey is nearly self-sufficient country in terms of its agricultural production. Wheat, barley, sugar beets, potatoes, leguminous plants and rice are grown, principally for domestic consumption, and cotton, tobacco, citrus, grapes, fig, hazelnuts, and pistachios are also grown for export, But recently, some agricultural products are rather imported. Turkey is not rich in mineral resources. One of the country's main problems is the inadequacy of primary energy resources. Copper, chromium, borax, coal, and bauxite are among the mineral resources in the country. The main industries are textiles, steel, cement, fertilizers, automotive and electrical household goods. Machinery, chemicals and some metals are imported mainly from the OECD countries. Turkey is classified as a middle-income country. Since 2001, key structural reforms have been adopted within the context of the harmonization process with EU. Despite some recent progress, reducing inflation pressure, increasing export revenues, reducing unemployment problem and addressing insufficient capital for new investments remain key issues (State Planning Organization 2003; Ministry of Foreign Affairs 2004). In early 2008’s, the global financial crises emerged in the world economy and hit almost all economies in the world. Inevitably, Turkey has also been affected from this crisis. The most important effect is the cut in public investments especially in social sector provisioning. In addition to that private sector has serious financial problems. Thus the unemployment has been increasing since late 2007. 6 | Introduction 1.6 Regional Divisions The diverse geographical, climatic, cultural, social, and economic characteristics of different parts of the country are the basis for the conventional regional breakdown within Turkey. Five regions (West, South, Central, North, and East) are distinguished, reflecting, to some extent, differences in socioeconomic development levels and demographic conditions within the country. This regional breakdown is frequently used for sampling and analysis purposes in social surveys. Additionally from 2002 onwards, within the framework of the EU harmonization process, a new statistical region definition has been adopted which compromised NUTS I (12 regions), NUTS II (26 regions) and NUTS III (81 provinces). The West region is the most densely settled, the most industrialized, and the most socio-economically advanced region of the country. The region includes both İstanbul, (until 1923 the capital of the Ottoman Empire), which is Turkey's largest city, and the country's manufacturing, commercial and cultural centre, and İzmir, the country's third largest city. The coastal provinces within the West region form a relatively urbanized, fast-growing area. The Aegean coast is also a major agricultural area, where cotton, and fruits mostly grapes and fig are cultivated on the fertile plains. With dry summers and mild, rainy winters, agricultural yields from the fertile soils are good. Most of the industrial establishments are situated in the West region and the region contributes most of the gross domestic product of the country. The South includes highly fertile plains and some rapidly growing industrial centers. Adana, Mersin, and Antalya are the new metropolises located in this region. Steep mountains cut off the semitropical coastal plains from the Anatolian highlands to the north. Hot, dry summers and mild, wet winters describe the climatic conditions of the region. Cultivation of cotton, sugar beets and citrus provide high incomes and export earnings. Tourism centers in the region is another important source of revenue. The South region has witnessed an industrial boom and an inflow of migrants, especially from the East and Southeastern provinces in the recent decades. The Central region is a dry grazing area and includes Ankara, the capital and second populous city. Industrial production in the region is rising modestly, as minor city centers rapidly develop, and Kayseri is the best example of this . Industrial production in the region specializes in cereal and related processed foods, furniture and marble. Given the dry, temperate climate, fruit tree cultivation and sheep and cattle rising are also common. The North region has a fertile coastal strip, but in most places it is only a few kilometers wide; the coastal region is relatively isolated from the inner parts of the region and the rest of the country by mountainous terrain. The region specializes in growing small-scale, labor-intensive crops like hazelnuts, tobacco and tea. The region receives large quantities of rainfall throughout the year. Zonguldak, a western province, has extensive coal mine reserves and is a centre for coal mining and the steel industry. The region has a great deal of tourism potential that has been improving recently. The East region is considered as the least developed part of the country. Rugged mountainous terrain, short summers, and the severe climate are suited to animal husbandry Introduction | 7 rather than settled farming. However, with the “Southeast Anatolia Project”, the economy in the Southeast has improved in the recent years. Atatürk Dam was built (1983–1992) and Urfa irrigation channels were constructed and water was provided to arid and semi-arid lands, leading to agricultural development in the Southeast Anatolia. In addition to economic benefits, the project is also expected to reverse the migration flow from the region to the rest of the country. Although the capacity of agriculture has increased, the region is still poor in terms of industrial production. A substantial number of villages and adjacent arable lands have been abandoned because of terrorist movements in last 20 years especially in East and Southeast Anatolia. In addition to this, large-scale development projects in the frame of Southeast Anatolia Project, natural disasters, or improved settlement policies have also led to significant migration both within and outside of the region in the last two decades. In response to these trends, the government initiated “Return to Villages and Rehabilitation Project” (RVRP) directed at this population. The main purposes of the RVRP, which covers the 14 provinces in the East and Southeast Anatolia, are to settle those who want to return to their villages on or around the lands of their former villages or on other suitable places, establish the necessary social and economic infrastructure, provide sustainable living conditions in these settlements, re- establish and vitalize the interrupted rural life, form a more balanced settlement design in the rural areas, and achieve a more rational distribution of public investments and services (State Planning Organization 2003). 1.7 Population In 1927, Turkey's population was 13.6 million according to the first national census, which was conducted four years after the establishment of the Republic. Beginning with the 1935 census, subsequent population censuses were undertaken regularly at 5-year intervals until 1990. After 1990, population censuses were carried out in years ending with 0. The latest, fourteenth, Population Census which was carried out on 22nd October 2000, put the population of Turkey at 67.4 million (TURKSTAT 2003). Turkey is among the 20 most populous countries of the world, and it is the second most populous country of the Middle East after Iran and the second populous country of the Europe after Germany. According to projections, her population currently is around 71.5 million (TURKSTAT 2008). The population of Turkey continuously increased in 1927–2008 period. The annual population growth rate reached its highest value (29 per thousand) in the 1955–1960 period. The latest intercensal estimate of the population growth rate was 18 per thousand for the 1990–2000 period. According to the projections of the Turkish Statistic Institute (TURKSTAT), the population of Turkey is expected to reach 76 million in the year 2010 and 84 million in 2025. The total population is expected to be stabilized around mid 21st century between 88-90 million (Population Reference Bureau 2008). Turkey has a young population structure as a result of the high fertility and growth rates of the recent past. One-third of the population is under 15 years of age, whilst the proportion 65+ comprises only 6 percent according to 2000 national census results. However, today’s prevailing demographic forces of the population are altering the age structure in new 8 | Introduction ways. First of all, recent decades have witnessed dramatic declines especially in fertility rates. In the early 1970s, the total fertility rate was around 5 children per woman, whereas the estimates in the late 1990s indicate it has nearly halved to 2.6 children and it is estimated as 2,2 in 2006 (TURKSTAT 2006) The crude birth rate was estimated at 18 per thousand in second half of 2000’s. Also in 2000’s, fertility has shown a reduction above expected. As a result, the median age of the population, which averaged around 20 years between 1940 and 1960 in Turkey, has increased continuously since 1970, reaching 25 years for male and 26 years for female population in 2008. There have been significant changes in the growth rates by age groups. The growth rates for young age groups have decreased whereas the population of older age groups has increased faster than the average for Turkey. The share of elderly population has increased to 7 percent in 2008 implying nearly 5 million population over 65 (TURKSTAT 2008). It is expected that increase in the population size of 15–64 and 65+ will continue also in the next years (15-16 percent of total population will be 65+ in 2050) while population size of youth will nearly stabilize (TURKSTAT 2003). There is lack of accurate, complete and continuous information on mortality in Turkey, particularly child mortality. The information is available mainly for deaths in town and city centers and these data are also incomplete. According to reported causes of deaths, the main causes of death in order of importance are cardio–vascular diseases (46 percent), all malignancies (15 percent) and all accidents (4 percent). In contrast to adult mortality, data on the level of child mortality have been available for a relatively long period from a series of fertility surveys. The infant mortality rate in the late 1950s was around 200 per thousand live births. It declined to about 130 during the mid-1970s and to an estimated 17 in 2006. Likewise, crude death rates have also declined from around 30 per thousand in the 1940s to 6 per thousand in second half of 2000’s. The latest estimates put life expectancy in Turkey at 71 years for males and 75 for females (TURKSTAT 2006). Marriage, predominantly civil, is widely practiced in Turkey. Religious marriages also account for a significant proportion of the marriages; however, the widespread custom is to have a civil as well as a religious ceremony. The universality of marriage in Turkey is observed in the low proportions never married. According to demographic surveys, in the age group 45-49 which marks the end of the reproductive ages, only two percent of females had never married, whereas the corresponding figure for males in the same age group was three percent. Although in recent decade divorces are slightly increasing. Marriages in Turkey are also known to be still very stable due to the close family ties. The population of Turkey has undergone an intensive process of urbanization, especially from the 1950s onwards. The share of the population living in cities, which was 25 percent in 1950, climbed to 70 percent in 2007. The rate of urbanization has been approximately 33 per thousand during the 1990-2000 period. The rapid urbanization has inevitably caused environmental and administrative problems in the provision of services and the emergence of large areas of squatter housing in unplanned settlements around metropolitan cities. Social problems related to the adaptation to city life and culture also are evident, for example violence and delinquencies in metropolitan areas are increasing in recent years. Introduction | 9 Turkey has had a long history of external migration. Throughout the 1960s and 1970s, the migrant flow was mainly directed to Western European countries, principally Germany. During the 1980s, however, it became more oriented towards the oil-producing countries of the Middle East. In the past two decades, the political turmoil in that region and changes in policies and practices governing the labor force in the European Union have continued to influence emigration patterns. At the same time, due to political conditions in neighboring countries, Turkey has found herself subjected to waves of asylum seekers from the Balkans, Middle East countries, and also from distant Asian and African countries (International Organization for Migration 1996). After the collapse of USSR, the migratory movement to CIS (Commonwealth of Independent States) countries and middle-east countries turned out to be the new route for Turkish investors and workers. 1.8 Population and Family Planning Policies and Programs In Turkey, policies related to population have been formulated since the establishment of the Republic in 1923. During the early years of the Republic, there was a perceived need to increase fertility, since the country had suffered from 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 high infant and child mortality rates, led Turkey to continue to follow a pronatalist population policy until the late 1950s. A number of laws directly or indirectly encouraging population growth were passed during the period. These laws included monetary awards to women with more than 5 children, tax reduction incentives, prohibitions on the advertisement, import and sale of contraceptives (except for health reasons), and prohibition of abortions on social grounds. The high population growth rates prevailing in the 1950s which led to increased numbers of illegal abortions and, as a consequence, to high maternal mortality, brought the population debate into the political agenda. High urban population growth and employment problems were also factors contributing to the new antinatalist environment in government circles. The State Planning Organization and the Ministry of Health pioneered the policy change, and the first Population Planning Law was enacted in 1965. The law mandated the Ministry of Health to have responsibility for implementing the new family planning policy. The policy allowed the importation of modern contraceptives methods, provided services at state health institutions free of charge and supported health education for couples. In addition, the State Planning Organization incorporated the notion of population planning in the First Five-Year Development Plan. In 1983, a more liberal and comprehensive Population Planning Law was passed. The new law legalized induced abortions (up to the tenth week of pregnancy) on social and economical grounds and voluntary surgical contraception. It also permitted the trained auxiliary health personnel to insert IUDs and included other measures to improve family planning services and mother and child health. The latest Seven Year Development Plan of the State Planning Organization states that population policy seeks to reach a population structure which is in harmony with the balanced and sustainable development targets of the society. Thus, the strengthening of qualitative aspects of population including increased education and improved health levels and a reduction in unbalanced development and 10 | Introduction inequalities among regions are primary objectives of population policy (State Planning Organization 2007). 1.9 Health Priorities and Programs Mother and child health and family planning services have been given a priority status in the policies of the government in recent decades. These services gained importance due to the large proportion of women of reproductive ages and children in the Turkish population, high infant, child and maternal mortality rates, the demand for family planning services, and the limited prenatal and postnatal care. A number of child survival programs to improve services have been implemented since 1985, with special emphasis on provinces which have been designated as priority development areas as well as on squatter housing districts in metropolitan cities, rural areas, and special risk groups. The initiatives include programs (GOBIFF) in growth monitoring, healthy and balanced nutrition, early diagnosis and prompt treatment of childhood diarrheal diseases, acute respiratory infections, promotion of breastfeeding, immunization, reproductive health, family planning, and antenatal and delivery care, safe motherhood and female education. IEC (Information, Education, and Communication) programs to promote the mother and child health and family planning activities are also being widely implemented. Additionally, The General Health Insurance Law was enacted by the Grand National Assembly of Turkey in 2006 and application was started in October 2007. With this law, all people under 18 included into General Health Insurance, regardless of their parents have social security status. 1.10 Health Care System in Turkey The Ministry of Health is officially responsible for designing and implementing health policies and delivering health-care services nationwide. Besides the Ministry of Health, other public sector institutions and non-governmental and private organizations contribute to providing mostly curative health services. 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, Maternal and Child Health and Family Planning, Therapeutic Services, Health Education) and by various Departments (Departments of Tuberculosis Control, Cancer Control). At the provincial level, the health-care system is 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 existing network of Health Centers and Health Houses was formed on the basis of "Legislation for the Socialization of Health Services" so that services and facilities were extended down to the village level. A substantial proportion of villages have health centers or health houses, and sites were located so as to provide easy access to other villages. Introduction | 11 The simplest element of the socialized health services is the Health House, which serves a population of 2,500-3,000 and is staffed by a midwife. The Health Center serves a population of 5,000-10,000 and is staffed by a team consisting of a physician(s), a nurse(s), a health officer, midwives, an environmental health technician, medical secretary and a driver. Health Centers mainly offer integrated, polyvalent primary health-care services. Mother and Child Health and Family Planning Centers and Tuberculosis Dispensaries also offer primary preventive health services. This network of health facilities is responsible for delivering primary health care services, maternal and child health, family planning, and public health education services. These health facilities are also the main sources of the health information system. In 2003, Health Transformation Programme was launched in Turkey, and the major goal of this programme is to organize, finance and deliver the health care services in an effective and efficient way in conformity with equity. Moreover, in December of 2004 the Turkish family medicine legislation has been passed from National Assembly. Accordingly each family medicine practitioner is expected to serve approximately 3000-4000 individuals and is responsible to give preventive and curative health services to all registered persons. Until July 2009 family medicine has been started in 33 provinces and covers 17 million population. 1.11 Objectives and Organization of the Survey 1.11.1 Objectives The 2008 Turkey Demographic and Health Survey (TDHS–2008) is the ninth in a series of national-level population and health surveys that have been conducted by the Hacettepe University Institute of Population Studies (HUIPS), in the last four decades. The primary objective of the TDHS-2008 is to provide data on socioeconomic characteristics of households and ever married women between ages 15-49 year, fertility, childhood mortality, marriage patterns, family planning, maternal and child health, nutritional status of women and children, and reproductive health. The survey obtained detailed information on these issues from a sample of ever-married women in the reproductive ages (15-49). The TDHS-2008 was designed to produce information in the field of demography and health that to a large extent cannot be obtained from other sources. 12 | Introduction Specifically, the objectives of the TDHS-2008 included: · Collecting data at the national level that allows the calculation of some demographic and health indicators, particularly fertility and childhood mortality rates; · Obtaining information on direct and indirect factors that determine levels and trends in fertility and childhood mortality; · Measuring the level of contraceptive knowledge and practice by method and some background characteristics i.e. region, and urban- rural residence; · Collecting data relative to mother and child health, including immunizations, diarrhea , antenatal care and postnatal care, assistance at delivery, and breastfeeding; · Measuring the nutritional status of children under five and their mothers; and · Collecting data at the national level on elderly welfare and usage of iodide salt. The TDHS-2008 information is intended to contribute data to assist policy makers and administrators to evaluate existing programs and to design new strategies for improving demographic, social and health policies in Turkey. Another important purpose of the TDHS- 2008 is to sustain the flow of information for the interested organizations in Turkey and abroad on the Turkish population structure in the absence of reliable and sufficient vital registration system. Additionally, demographic health surveys in Turkey starting with TDHS-2008 were accepted as a part of the Official Statistic Programme. 1.11.2 Administration and Funding of the Survey The Turkey Demographic and Health Survey, 2008 (TDHS-2008) has been conducted by the Hacettepe University Institute of Population Studies in collaboration with the Ministry of Health General Directorate of Mother and Child Health and Family Planning Undersecretary of State Planning Organization. The TDHS-2008 has been financed by The Scientific and Technological Research Council of Turkey (TÜBİTAK) under the Support Programme for Research Projects of Public Institutions, as a 42 months project. The TDHS-2008, unlike the previous surveys of this series was for the first time funded entirely from the national budget. A steering committee consisting of the academic staff of HUIPS and representatives of the General Directorate of Mother and Child Health and Family Planning of the Ministry of Health, the State Planning Organization and the Turkish Statistical Instıtute participated in all phases of the project. The staff of the Institute and other persons involved in the various activities of the TDHS–2008 is listed in Appendix A. Introduction | 13 1.11.3 Questionnaires Two types of questionnaires were used in the TDHS-2008: the Household Questionnaire and the Individual Questionnaire for ever-married women of reproductive ages. The contents of the questionnaires were based on the International MEASURE/DHS+ survey project model questionnaires and on the questionnaires that had been employed in previous Turkish population and health surveys. In developing the questionnaire, close attention was paid to obtaining the data needed for program planning in Turkey as specified during consultations with general directorate of MCH/FP and representatives of other related public institutions. Additionally input was obtained from other institutions studying on demographic and health issues. Ensuring the comparability of the TDHS–2008 findings with previous demographic surveys, particularly with TDHS–1993, TDHS–1998 and TDHS-2003 was an important goal during questionnaire development. A pretest of questionnaire was conducted in April 2008 and based on the pretest results, some minor modifications were made to the questionnaires. The Household Questionnaire was used to enumerate all members of and visitors1 to the selected households and to collect information relating to the socio-economic level of the households. In the first part of the household questionnaire, basic information was collected on the age, sex, educational attainment, marital status and relationship to the head of household of each person listed as a household member or visitor. The objective of the first part of the Household Questionnaire was to identify women who were eligible for the Individual Questionnaire. Some additional information on never-married women in 15–49 ages listed in the household schedule was provided at the second part. The third part of the household questionnaire was devoted to collecting data on welfare of the elderly, if any, in the households. In this part, there are questions on the income, health insurance and physical capabilities (i.e. ability to carry on daily activities for all persons age 60 and over living in the household and/or were present in the household on the night before the interview. In the fourth part, questions were included on the dwelling unit and on the ownership of a variety of consumer goods. Also in this part; questions were included about the storage of the salt used for cooking at home. Salt- related questions were asked in the half of the sampled clusters, and salt iodization tests were applied in the interviewed households in these clusters. The Women’s Questionnaire was designed for women listed in the household schedule, aged 15-49 and have been married at least once. This questionnaire covers the major topics listed below: · Background characteristics · Migration history · Marriage history and information on marriage · Pregnancy, birth history and fertility preferences · Assisted reproductive techniques 1 Persons who were not usual household members but who were present in that household on the night before the interview were identified as “visitors” and included in the household roster in order to obtain de facto survey population. 14 | Introduction · Knowledge and use of contraceptive methods · Antenatal and postnatal care · Breastfeeding,nutrition, diarrhea and immunization of children under age five · Women’s work history and status · Husband’s background characteristics · Anthropometric measurements of women and their children under five The calendar module in the Individual Questionnaire was used to record on a monthly basis fertility, contraceptive use and marriage events for six and a half years beginning from January 2003 up to the survey month. English versions of the two questionnaires can be seen in Appendix E. 1.11.4 Sample The sample design and sample size of the TDHS-2008 makes it possible to perform analyses for Turkey as a whole, for urban and rural areas and for the five demographic regions of the country (West, South, Central, North and East). The TDHS-2008 sample is of sufficient size to allow for analysis on some of the survey topics at the level of the 12 geographical regions (NUTS 1) which were adopted at the second half of the year 2002 within the context of Turkey’s move to join the European Union. Among these 12 regions, İstanbul and the Southeastern Anatolian Project regions (GAP in Turkish initials). In the selection of the TDHS-2008 sample, a weighted, multi-stage, stratified cluster sampling approach was used. Sample selection for the TDHS-2008 was undertaken in three stages. In the first stage, settlements were selected for the sample. The frame for the settlement selection was prepared using information on the population sizes of settlements obtained from the 2007 Address Based Population Registration System. Settlements with population of 10,000 and more were defined as “urban”, while settlements with populations less than 10,000 were considered as “rural” for purposes of the TDHS-2008 sample design. The selection of the settlements in each stratum was done with probability proportional to their population size. The second stage of the sample selection involved the selection of a pre- determined number of small areal units, i.e., clusters, out of the settlements selected in the first stage. The total number of clusters in TDHS-2008 was set at 634. For 502 clusters, household lists, each including approximately 100 households, were provided by TURKSTAT, using the National Address Database (UAVT in Turkish initials) prepared for municipalities. For the remaining 132 clusters, TURKSTAT was unable to provide data. Therefore, for these clusters, household lists were prepared during a separate household listing operation conducted by HIPS before the main survey. The cluster lists provided by TURKSTAT were also updated during the listing activities. In the third stage, a fixed number of households were selected from each cluster by systematic random sampling method using the updated household lists. Twenty-five households were selected from the clusters selected from urban settlements and 15 households from the Introduction | 15 clusters drawn from rural settlements. The total number of households selected in TDHS-2008 is 13,251. All ever-married women at ages 15-49 who usually live in the selected households and/or were present in the household the night before the interview were regarded as eligible for Ever-Married Women Questionnaire. A more technical and detailed description of the TDHS-2008 sample design, selection and implementation is presented in Appendix B. 1.11.5 Fieldwork and Data Processing The TDHS-2008 data collection was carried out by 19 teams. Each team consisted of 8 people; 5 female interviewers, one male measurer, one field editor and a team supervisor. The Institute’s research assistants and project assistants also worked in the field as team supervisors. An instructor of the Institute served as the field director. Other academic staff of the Institute visited teams as regional coordinators during the survey and coordinated communications between the teams and field director. All were responsible to the director of the Institute who was in overall charge of the project. A three-week training was given to the field staff in September 2008. The fieldwork began in the first week of October 2008 and was completed in the first week of December 2008. The questionnaires completed in the field were returned to the Institute of Populations Studies for data entry. Once the questionnaires arrived at the Institute, data entry and editing were done using CSPro package. During the data entry process, full verification between the field data and the data entered was achieved by have each questionnaire keyed by two different data editors and comparing the results and resolving any differences. The office editing and processing activities in the Institute began in the first week of November 2008 and were completed in the second week of January 2009. The results of the household and individual questionnaires are summarized in Table 1.1. Information is provided on the overall coverage of the sample, including household and individual response rates. In all, 13,521 households were selected for the TDHS-2008. At the time of listing phase of the survey, 11,911 households were considered occupied and, thus, available for interview. Of the 11,911 occupied households, 88 percent (10,525 households) were successfully interviewed. The main reasons the field teams were unable to interview some households were because some dwelling units that had been listed were found to be vacant at the time of the interview or the household was away for an extended period. 16 | Introduction Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates by residence, Turkey 2008 Result Urban Rural Total Household interviews Households selected 10,017 3,504 13,521 Households occupied 8,909 3,002 11,911 Households interviewed 7,672 2,853 10,525 Household response rate 86.1 95.0 88.4 Individual interviews Eligible women 5,891 2,112 8,003 Eligible women interviewed 5,429 1,976 7,405 Eligible women response rate 92.2 93.6 92.5 In the interviewed 10,525 households, 8,003 women were identified as eligible for the individual interview, i.e. they were ever-married, in reproductive ages (15-49) and present in the household on the night before the interview. Interviews were successfully completed with 7,405 of these women (92.5 percent). Among the eligible women not interviewed in the survey, the principal reason for non-response was the failure to find the women at home after repeated visits to the household. A more complete description of the fieldwork, coverage of the sample, and data processing is presented in Appendix B. Household Population and Housing Characteristics | 17 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 Mehmet Ali Eryurt, A. Sinan Türkyılmaz and İsmet Koç This chapter provides a summary of demographic and socioeconomic profile of the TDHS-2008 sample and a descriptive assessment of the environment in which women and children live. It presents information on the general characteristics of the household population such as age-sex composition, literacy and education, household arrangements (headship, household size) and housing facilities (sources of water supply, sanitation facilities and dwelling characteristics), and household possessions. A distinction is made between urban and rural settings where many of these indicators usually differ. Besides providing the background for better understanding of many social and demographic phenomena discussed in the following chapters, this general description is useful for assessing the level of economic and social development of the population of Turkey. In addition, it may provide useful input for the assessment of the representativeness of the survey sample. 2.1 Characteristics of the Household Population In the TDHS-2008, a household was defined as a person or group of persons living together and sharing a common source of food. The TDHS-2008 collected information about all persons who usually live in selected household (the de jure population) and persons who spent the night before the interview in the households (the de facto population). Because the differences between these populations are very small, the sampling probabilities were based on de facto population information, and to maintain comparability with past surveys and censuses all tables in this report are based on de facto populations, unless otherwise stated. 2.1.1 Age and Sex Composition Age and sex are important demographic variables in the study of a variety of demographic processes such as fertility, nuptiality and mortality. Table 2.1 gives the percent distribution of the TDHS-2008 population by five-year age groups, according to urban-rural residence and sex. The population age structure is a reflection of the past history of demographic events in the population, especially fertility and mortality. It is also a useful device to test the quality of the data collected in regard to age reporting. The population spending the night before the survey (de facto population) in the selected TDHS-2008 households included 40,054 persons, of which 49 percent were males and 51 percent were females. The proportion of females is slightly higher in rural areas than in urba areas (52 and 51 percent respectively). Seventy-three percent of the population reside in urban areas. 18 | Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Turkey 2008 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 8.7 8.0 8.3 9.6 8.8 9.2 8.9 8.2 8.6 5-9 9.8 8.4 9.1 10.8 9.9 10.3 10.1 8.8 9.4 10-14 9.5 8.8 9.1 10.3 9.6 9.9 9.7 9.0 9.4 15-19 9.1 9.6 9.3 8.9 8.1 8.5 9.0 9.2 9.1 20-24 7.9 9.3 8.6 6.5 7.6 7.0 7.5 8.8 8.2 25-29 9.4 9.4 9.4 6.4 7.1 6.8 8.6 8.8 8.7 30-34 8.1 8.6 8.3 6.2 6.3 6.2 7.6 7.9 7.8 35-39 7.5 7.5 7.5 6.2 6.0 6.1 7.2 7.1 7.1 40-44 6.7 6.6 6.7 6.0 5.6 5.8 6.5 6.4 6.4 45-49 6.2 5.9 6.0 5.8 5.4 5.6 6.1 5.8 5.9 50-54 5.4 5.7 5.6 5.3 6.0 5.7 5.4 5.8 5.6 55-59 4.1 3.7 3.9 5.1 4.9 5.0 4.4 4.0 4.2 60-64 2.6 2.5 2.5 3.1 3.9 3.5 2.7 2.9 2.8 65-69 1.8 2.0 1.9 3.0 3.5 3.3 2.1 2.4 2.3 70-74 1.3 1.6 1.4 2.8 2.8 2.8 1.7 1.9 1.8 75-79 1.1 1.2 1.2 2.4 2.1 2.3 1.5 1.5 1.5 80 + 0.8 1.2 1.0 1.3 2.2 1.8 0.9 1.4 1.2 Don't know/missing 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 14,402 14,874 29,276 5,202 5,576 10,778 19,604 20,450 40,054 TDHS-2008 Household Population and Housing Characteristics | 19 The population pyramid based on the total de facto household population in the interviewed households of the TDHS-2008 (Figure 2.1) provides valuable information about the current age and sex composition of Turkey’s population as well as changes in the age and sex composition over time. The population pyramid shows the effects of the transition from a high fertility and high mortality regime to a declining fertility and mortality regime within Turkey. The recent rapid fertility decline is reflected in the constricted base of the pyramid, with the population age 0-4 years smaller than the 5-14 age groups which are numerically the largest cohorts. At age 20-24, the sex ratio and the relative size of the male age group are low compared with the adjacent age cohorts This may be explained by the fact that a greater proportion of males are in the military service in this age group than in the other cohorts and, accordingly, were not present on the night before the interview in the selected household and, thus, not accounted as “de facto” household members. According to the survey results, 27 percent of the population in Turkey is below age 15 (Table 2.2.1). The proportion of elderly (aged 65 and over) accounts for 7 percent of the total population, the highest level in the history of Turkey. This trend is the result of the convergence of three demographic changes experienced recently in Turkey: rapidly declining fertility which has reduced the numbers in the youngest age groups, increasing life expectancy at all ages, and the growth in size of the cohorts reaching age 65 years of age, due to high fertility in earlier decades. Looking at urban-rural differences, the proportion under age 15 is greater in the rural population than in the urban population (30 and 27 percent, respectively). Similarly, the rural population has a greater proportion elderly than the urban population (10 percent and 6 percent, respectively). Another important urban-rural difference is that the proportion in the working ages, namely those aged 15-64 years, is significantly higher in the urban population than the rural population. This finding may reflect the effects of rural-to-urban migration of the economically active population. Table 2.2.1 Age distribution of household population Percent distribution of household population by age group and residence, Turkey 2008 Age Group Urban Rural Total 0-14 26.6 29.5 27.4 15-64 67.9 60.4 65.8 65+ 5.5 10.1 6.8 Total 100.0 100.0 100.0 Number 29,276 10,778 40,054 20 | Household Population and Housing Characteristics Table 2.2.2 compares the distribution of the household population by broad age groups for the last four demographic surveys, the last two censuses carried out in 1990 and 2000 and population information derived from address based population registration system for the year 2008. The table reveals that the share of population under age 15 decreased from 35 percent to 27 percent and the share of elderly population increased from 4 percent to 7 percent between 1990 and 2008. The dependency ratio, defined as the ratio of the non-productive population (persons under age 15 and age 65 and over) to the population age 15-64, is calculated based on these figures. The dependency ratio, which was around 65 percent at the time of the 1990 Population Census, had declined to 52 percent at the time of the TDHS-2008. The decline reflects a significant decrease in the burden placed on persons in the productive ages to support older and younger household members. In line with this finding the median age of household population increased 4.3 years from 22.2 years in 1990 to 26.5 years in 2008. Both changes in dependency ratio and in the median age of population are consistent with the gradual aging of the population that occurs as fertility declines. Table 2.2.2 Population by age from selected sources Percent distribution of the population by age group, selected sources, Turkey 1990-2008 Age group PC 1990 TDHS 1993 TDHS 1998 PC 2000 TDHS 2003 ABPRS 2008 TDHS 2008 Less than 15 35.0 33.0 31.5 29.8 29.1 26.3 27.4 15-64 60.7 61.4 62.6 64.5 64.0 66.9 65.8 65 and + 4.3 5.5 5.9 5.7 6.9 6.8 6.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Median age 22.2 23.1 24.3 24.8 24.7 26.3 26.5 Dependency ratio 64.7 62.7 59.7 55.1 56.3 49.5 51.9 Sources: 1990 and 2000 Population Census (PC), TDHS-1993, TDHS-1998, TDHS-2003, TDHS-2008 and Adress Based Population Registration System (ABPRS) 2.1.2 Household Composition Table 2.3 presents the distribution of households in the TDHS-2008 sample by sex of the head of the household and by the number of household members. These characteristics are important because they are often associated with socioeconomic differences between households. Unlike previous tables in this chapter, it should be noted that Table 2.3 is based on de jure members, i.e., usual residents. The household composition usually affects the allocation of financial and other resources available to household members. In cases where women are heads of households, it is usually found that financial resources are more limited compared with male-headed households. Similarly, the size of the household affects the overall well being of its members. Household size is also associated with crowding in the dwelling, which can lead to unfavorable health conditions. As expected, given the cultural patterns in Turkey, male- headed households are predominant in the TDHS-2008 sample; 87 percent of households are headed by a male and the remaining 13 percent of households are headed by female. The Household Population and Housing Characteristics | 21 proportion of female-headed households is about the same level in rural (13 percent) and urban areas (12 percent). There are on average 3.9 persons per household. Slightly less than half of the households have three or fewer members, one quarter have four members, and 29 percent has five or more members. There are marked differences in size between urban and rural households. In urban areas, 27 percent of households have five or more members compared with 37 percent in rural areas. The mean household size is 3.8 persons in the urban areas and 4.2 persons in the rural areas. Table 2.3 Household composition Percent distribution of households by sex of head of household and by household size and mean size of household according to residence, Turkey 2008 Characteristic Urban Rural Total Sex of head of household Male 87.0 87.6 87.2 Female 13.0 12.4 12.8 Total 100.0 100.0 100.0 Number of usual members 0 0.2 0.6 0.3 1 6.0 7.6 6.4 2 16.8 20.8 17.8 3 23.1 15.6 21.2 4 27.3 18.7 25.1 5 13.4 12.8 13.2 6 6.6 8.5 7.1 7 3.1 6.0 3.8 8 1.4 2.8 1.8 9+ 2.1 6.6 3.2 Total 100.0 100.0 100.0 Number of households 7,866 2,659 10,525 Mean size of households 3.8 4.2 3.9 Note: The table is based on de jure members, i.e., usual residents. 2.2 Fosterhood and Orphanhood Foster children are children under 18 years of age who are not living with either of their biological parents. Orphaned children are children under 18 years of age who have lost one or both of their biological parents. To measure the prevalence of child fostering and orphanhood, four questions were asked in the Household Questionnaire on the survival and residence of the parents of children under 18 years of age. Table 2.4. presents detailed information relevant to children’s living arrangements and orphanhood for children under 18 years of age. 22 | Household Population and Housing Characteristics Table 2.4 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Turkey 2008 Living with mother but not with father Living with father but not with mother Not living with either parent Background characteristic Li vi ng w ith bo th p ar en ts Fa th er a liv e Fa th er d ea d M ot he r a liv e M ot he r d ea d Bo th a liv e On ly fa th er al iv e On ly m ot he r al iv e Bo th d ea d M is si ng To ta l Pe rc en ta ge no t l iv in g wi th a b io lo - gi ca l p ar en t Pe rc en ta ge wi th o ne o r bo th p ar en ts de ad Nu m be r o f ch ild re n Age <2 98.0 1.3 0.1 0.1 0.0 0.3 0.0 0.0 0.0 0.2 100.0 0.3 0.1 1,401 2-4 96.8 1.7 0.4 0.5 0.0 0.5 0.0 0.0 0.0 0.0 100.0 0.5 0.5 2,001 5-9 94.4 2.6 0.8 0.8 0.2 0.9 0.0 0.1 0.0 0.1 100.0 1.1 1.2 3,768 10-14 91.3 3.1 2.1 0.9 0.9 1.4 0.0 0.1 0.0 0.1 100.0 1.5 3.1 3,798 15-17 86.2 2.2 3.7 0.6 1.0 5.4 0.1 0.5 0.1 0.2 100.0 6.1 5.4 2,352 Sex Male 93.0 2.5 1.6 0.8 0.5 1.4 0.1 0.1 0.0 0.1 100.0 1.5 2.3 6,806 Female 92.7 2.3 1.4 0.6 0.5 2.1 0.0 0.2 0.0 0.1 100.0 2.4 2.2 6,515 Residence Urban 92.6 2.7 1.5 0.8 0.4 1.7 0.1 0.1 0.0 0.1 100.0 1.9 2.1 9,461 Rural 93.3 1.6 1.6 0.5 0.9 1.8 0.0 0.1 0.0 0.1 100.0 2.0 2.7 3,860 Region West 92.7 2.6 1.4 0.7 0.2 2.1 0.0 0.1 0.0 0.2 100.0 2.2 1.7 4,744 South 93.7 2.0 2.0 0.5 0.4 1.1 0.0 0.1 0.0 0.1 100.0 1.3 2.6 1,696 Central 91.6 3.6 0.9 1.2 0.4 2.2 0.0 0.1 0.0 0.0 100.0 2.3 1.4 2,640 North 93.4 2.6 0.8 0.6 0.8 1.4 0.1 0.2 0.0 0.0 100.0 1.8 1.9 764 East 93.4 1.3 2.2 0.3 0.9 1.2 0.1 0.3 0.1 0.1 100.0 1.7 3.6 3,477 Region (NUTS 1) İstanbul 93.0 2.5 1.5 0.9 0.1 1.4 0.0 0.1 0.0 0.5 100.0 1.5 1.8 2,268 West Marmara 90.0 4.4 2.0 0.2 0.3 3.1 0.0 0.0 0.0 0.0 100.0 3.1 2.3 396 Aegean 92.0 2.3 1.3 1.0 0.6 2.6 0.0 0.0 0.1 0.0 100.0 2.7 2.0 1,606 East Marmara 93.2 2.5 0.5 1.0 0.0 2.9 0.0 0.0 0.0 0.0 100.0 2.9 0.5 1,058 West Anatolia 92.3 5.2 0.2 0.7 0.3 1.4 0.0 0.0 0.0 0.0 100.0 1.4 0.5 1,140 Mediterranean 93.7 2.0 2.0 0.5 0.4 1.1 0.0 0.1 0.0 0.1 100.0 1.3 2.6 1,696 Central Anatolia 91.2 3.1 1.4 1.1 0.4 2.3 0.1 0.4 0.0 0.0 100.0 2.7 2.3 664 West Black Sea 93.0 1.8 1.8 0.9 0.5 2.0 0.0 0.0 0.0 0.0 100.0 2.0 2.3 706 East Black Sea 91.5 3.0 0.8 0.4 1.4 1.8 0.2 0.6 0.1 0.1 100.0 2.7 3.2 318 Northeast Anatolia 94.9 1.2 1.3 0.4 0.4 1.3 0.1 0.1 0.3 0.0 100.0 1.8 2.1 533 Central East Anatolia 92.7 1.6 2.4 0.0 1.2 1.1 0.0 0.8 0.0 0.2 100.0 1.9 4.4 959 Southeast Anatolia 93.3 1.3 2.3 0.4 1.0 1.3 0.2 0.1 0.0 0.1 100.0 1.5 3.6 1,977 Wealth quintile Lowest 91.9 1.8 2.4 0.8 0.7 1.8 0.0 0.2 0.1 0.4 100.0 2.0 3.3 3,341 Second 93.2 1.9 1.5 0.7 0.6 1.9 0.0 0.2 0.0 0.0 100.0 2.1 2.3 2,969 Middle 92.4 2.4 1.1 0.6 0.6 2.4 0.1 0.3 0.0 0.0 100.0 2.8 2.1 2,533 Fourth 93.1 2.7 1.4 1.0 0.2 1.5 0.1 0.1 0.1 0.0 100.0 1.7 1.8 2,286 Highest 93.9 3.8 0.9 0.1 0.4 0.8 0.0 0.0 0.0 0.2 100.0 0.8 1.3 2,191 Total <15 94.2 2.5 1.1 0.7 0.4 0.9 0.0 0.1 0.0 0.1 100.0 1.0 1.6 10,969 Total <18 92.8 2.4 1.5 0.7 0.5 1.7 0.0 0.1 0.0 0.1 100.0 1.9 2.3 13,321 Household Population and Housing Characteristics | 23 In Turkey, the majority of children under age 18 (93 percent) live with both parents. Differences in children’s living arrangement by background characteristics are quite small, except for age. As expected, the proportion of children living with both parents decreases with increasing age. Five percent of children live with only one parent, 4 percent with their mothers and 1 percent with their fathers. Three percent of children live with only one parent because the other parent is dead. Foster children – children not living with either parent – account for only 2 percent of children under 18, and orphaned children–children who have lost one or both parents–account for 2 percent. 2.3 Education of the Household Population Educational attainment is an important characteristic of household members. Many phenomena such as reproductive behavior, use of contraception and the health of children are affected by the education of household members. Primary education in Turkey starts at age 6 and continues for 8 years. The eight years of primary education (5 years for primary level; 3 years for secondary level) are considered as basic education and have been compulsory since 1997. High school, which includes additional four years of schooling, is not compulsory in Turkey. Results from household interviews can be used to look at both educational attainment among household members and school attendance among children and young adults. 2.3.1 Educational Attainment of Household Members Tables 2.5.1 and 2.5.2 show the distribution of the de facto male and female household population age six and over by the highest level of education attended, according to background characteristics. The results reveal that gender differentials in educational attainment still continue. Overall, females are less educated than males. Thirty-three percent of females in TDHS-2008 households have no education or have not completed at least the first primary level, compared to 20 percent of males. One-fourth of males and about one-fifth of females have high school and higher education. The median number of years of schooling for men is 5.1 years, which is 0.6 year higher than the median for women (4.5 years). An examination of the changes in educational attainment by successive age groups indicates that there has been a marked improvement in the educational attainment of both men and women. For example, the median number of years of schooling among males age 20-24 years (10.4 years) is double that among the 40-44 age group (5.0 years). Although not quite as large, a similar differential is noticeable among females. Although the differentials in educational attainment between males and females still persists, the gap has also narrowed among younger cohorts. As expected, urban residents are both more likely to have attended school and to have remained in school for a longer period than rural residents. However, gender differences in educational attainment are more visible in urban than in rural areas. The median number of years of schooling is 6.6 years among urban men, almost two years higher than the median among urban women (4.7 years). The difference is much smaller in rural areas, where the median years of schooling are 4.6 and 4.1, respectively for men and women. 24 | Household Population and Housing Characteristics Table 2.5.1 Educational attainment of household population: Males Percent distribution of the de facto male household populations age six and over by highest level of schooling attended or completed and number of years of schooling, according to background characteristics, Turkey 2008 Background characteristic No education/ Primary incomplete First level primary1 Second level primary2 High school and higher3 Missing Total Number Median number of years Age 6-9 99.3 0.1 0.0 0.0 0.6 100. 1,615 0.7 10-14 31.1 54.7 14.0 0.1 0.1 100. 1,899 5.0 15-19 3.5 7.6 68.4 20.4 0.1 100. 1,773 8.7 20-24 3.9 16.4 20.3 59.2 0.2 100. 1,471 10.4 25-29 4.0 32.0 15.7 47.8 0.5 100. 1,691 8.8 30-34 2.5 41.4 12.3 43.7 0.1 100. 1,481 7.7 35-39 4.4 51.1 13.2 30.8 0.5 100. 1,407 5.0 40-44 5.4 51.6 14.4 28.3 0.3 100. 1,279 5.0 45-49 5.8 54.5 10.0 29.1 0.6 100. 1,189 4.9 50-54 7.6 52.6 10.3 28.8 0.7 100. 1,061 4.9 55-59 13.5 58.3 7.5 20.2 0.5 100. 853 4.7 60-64 21.4 51.2 9.6 17.5 0.3 100. 529 4.6 65+ 43.8 39.6 4.8 10.7 1.1 100. 1,226 4.1 Residence Urban 17.6 33.5 17.8 30.6 0.4 100. 12,892 6.6 Rural 26.1 45.5 15.3 12.7 0.5 100. 4,598 4.6 Region West 15.8 37.7 16.9 29.3 0.3 100. 7,452 5.8 South 20.9 39.9 17.5 21.2 0.4 100. 2,109 4.9 Central 16.7 35.1 17.5 30.3 0.4 100. 3,669 6.3 North 20.0 38.4 15.9 25.2 0.5 100. 1,145 4.9 East 32.4 33.1 17.5 16.1 0.9 100. 3,116 4.7 Region (NUTS 1) İstanbul 16.0 35.9 16.4 31.5 0.3 100. 3,530 6.4 West Marmara 15.5 43.6 16.2 24.5 0.2 100. 768 4.9 Aegean 16.7 40.5 16.6 26.0 0.2 100. 2,392 5.0 East Marmara 14.3 35.4 19.0 30.9 0.5 100. 1,637 7.0 West Anatolia 14.0 32.0 16.9 36.8 0.3 100. 1,590 7.4 Mediterranean 20.9 39.9 17.5 21.2 0.4 100. 2,109 4.9 Central Anatolia 19.4 39.0 16.7 24.7 0.3 100. 852 5.0 West Black Sea 21.4 38.0 18.0 22.0 0.7 100. 1,036 4.9 East Black Sea 20.7 35.2 15.6 27.9 0.5 100. 474 5.0 Northeast Anatolia 30.5 31.4 16.6 20.8 0.6 100. 523 4.8 Central East 32.3 32.5 17.0 17.6 0.6 100. 850 4.7 Southeast Anatolia 32.9 33.7 18.1 14.1 1.2 100. 1,729 4.6 Wealth quintile Lowest 35.0 45.1 13.8 5.5 0.7 100. 3,275 4.4 Second 24.6 45.3 17.4 12.2 0.5 100. 3,405 4.7 Middle 16.9 40.7 20.0 21.7 0.7 100. 3,502 5.0 Fourth 13.1 34.8 18.5 33.3 0.3 100. 3,617 7.2 Highest 11.3 19.3 15.7 53.6 0.1 100. 3,692 10.2 Total 19.8 36.7 17.1 25.9 0.5 100. 17,491 5.1 1Completed 5 years at the first level primary 2Completed 3 years at the second level primary 3Completed at least 3 years at the high school Household Population and Housing Characteristics | 25 Table 2.5.2 Educational attainment of household population:Females Percent distribution of the de facto female household populations age six and over by highest level of schooling attended or completed and median number of years of schooling, according to background characteristics, Turkey 2008 Background characteristic No education/ Primary incomplete First level primary1 Second level primary2 High school and higher3 Missing Total Number Median number of years Age 6-9 99.5 0.1 0.0 0.0 0.4 100.0 1,504 0.8 10-14 29.0 55.3 15.1 0.4 0.2 100.0 1,847 5.1 15-19 8.7 10.5 59.7 21.1 0.0 100.0 1,877 8.3 20-24 13.7 28.7 15.2 42.4 0.0 100.0 1,806 7.6 25-29 12.7 43.9 8.0 35.3 0.2 100.0 1,800 4.9 30-34 11.8 49.1 6.5 32.4 0.2 100.0 1,626 4.8 35-39 19.8 55.7 5.8 18.5 0.2 100.0 1,448 4.6 40-44 23.3 51.9 5.4 18.8 0.5 100.0 1,304 4.5 45-49 28.0 50.7 4.7 16.3 0.3 100.0 1,178 4.4 50-54 38.3 43.3 5.7 12.2 0.6 100.0 1,178 4.3 55-59 52.8 33.7 4.2 9.2 0.1 100.0 821 2.7 60-64 62.5 27.0 1.9 8.6 0.0 100.0 587 0.0 65+ 76.4 16.9 2.4 3.4 0.9 100.0 1,480 0.0 Residence Urban 28.1 35.2 13.7 22.7 0.3 100.0 13,476 4.7 Rural 47.6 37.4 8.8 5.9 0.3 100.0 4,992 4.1 Region West 25.3 38.7 12.9 22.7 0.4 100.0 7,643 4.7 South 35.6 35.7 13.8 14.6 0.2 100.0 2,286 4.5 Central 26.8 39.0 12.6 21.3 0.3 100.0 3,968 4.7 North 38.1 34.6 11.4 15.6 0.2 100.0 1,272 4.4 East 56.6 25.7 10.0 7.5 0.3 100.0 3,299 2.6 Region (NUTS 1) İstanbul 23.6 35.0 14.9 25.7 0.7 100.0 3,520 4.9 West Marmara 25.2 47.2 11.8 15.6 0.2 100.0 801 4.6 Aegean 28.6 41.1 10.5 19.7 0.1 100.0 2,592 4.6 East Marmara 25.6 42.3 11.0 21.0 0.1 100.0 1,669 4.7 West Anatolia 19.6 37.2 13.7 29.3 0.3 100.0 1,729 4.9 Mediterranean 35.6 35.7 13.8 14.6 0.2 100.0 2,286 4.5 Central Anatolia 35.0 37.8 13.4 13.8 0.1 100.0 914 4.5 West Black Sea 35.7 36.6 11.9 15.3 0.4 100.0 1,164 4.4 East Black Sea 42.7 30.3 12.4 14.5 0.1 100.0 515 4.3 Northeast Anatolia 51.8 25.7 11.5 10.8 0.2 100.0 541 3.5 Central East 58.6 23.2 10.3 7.7 0.2 100.0 921 2.1 Southeast Anatolia 57.0 26.7 9.4 6.4 0.4 100.0 1,814 2.6 Wealth quintile Lowest 59.7 30.4 8.0 1.6 0.3 100.0 3,544 2.0 Second 44.6 38.7 11.5 4.8 0.4 100.0 3,660 4.2 Middle 30.4 43.6 13.7 11.9 0.3 100.0 3,691 4.5 Fourth 21.2 39.6 15.3 23.7 0.2 100.0 3,796 4.8 Highest 13.0 26.4 12.9 47.2 0.4 100.0 3,776 9.1 Total 33.4 35.8 12.3 18.2 0.3 100.0 18,468 4.5 1Completed 5 years at the first level primary 2Completed 3 years at the second level primary 3Completed at least 3 years at the high school 26 | Household Population and Housing Characteristics The East is the most disadvantaged region with respect to educational attainment. Gender differences in the likelihood of attending school are greatest in the East and Central, and smallest in the South and North. In the East, the difference between median numbers of years for males and females is 2.1 years, while in the South the gap is 0.4 years. Among NUTS-1 regions Southeast Anatolia and Central East Anatolia stand out as having the lowest educational attainment. Educational attainment is strongly associated with wealth status of the household. In the lowest wealth quintile, for example, 35 percent of men and 60 percent of women have no education or have not completed first level primary, and just 6 percent of men and 2 percent of women have high school and higher education. In the highest wealth quintile, around half of both women and men have a high school or higher education and only 11 percent of men and 13 percent of women have not attended school or have completed less than the first primary level. The median number of years of schooling in the highest wealth quintile is more than twice that of lowest quintile for males and more than four times that in the lowest quintile for females. 2.3.2 School Attendance Ratios The TDHS-2008 collected information on current school attendance for the population age 6-24 years. The age-specific attendance rates for the population in this age range by sex are shown in Figure 2.2. TDHS-2008 Household Population and Housing Characteristics | 27 The comparatively low age-specific attendance rate for children age 6 reflects that some of these children turned six after the start of the school year and thus were not eligible to attend school in that year. Overall, the majority of children of both sexes age 15 and under were attending school. However, school attendance rates are generally higher among boys than among girls. The gender gap in school attendance increases somewhat with age, particularly among the post-first level primary ages (i.e., 13 and over). Data on net attendance ratios (NAR) and gross attendance ratios (GAR) by residence, region and wealth quintiles according to sex and school level are shown in Table 2.6.1 and Table 2.6.2. The NAR for primary school is the percentage of the primary school-age (6-13 years) population that is attending primary school. The NAR for high school is the percentage of the high school age (14-16 years) population that is attending high school. By definition, the NAR cannot exceed 100 percent. The GAR for primary school is the total number of primary school students of any age, expressed as the percentage of the official primary school age population (6-13 years). The GAR for high school is the total number of high school students up to age 24, expressed as the percentage of the official high school age population (14-16 years). If there are significant numbers of over-age and under-age students at a given level of schooling, the GAR can exceed 100 percent.The GAR is generally higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level. Children are considered to be attending school currently if they were in school at any point during the current school year. Tables 2.6.1 and Table 2.6.2 show that, among children 6 to 13 years, 93 percent attended primary school, and 61 percent of children age 14 to 16 years attended high school. For primary education, males and females were almost equally likely to be in school because primary school is compulsory; nine in ten males and females were enrolled in school. For high school, males were more likely to be in school (65 percent for males and 57 percent for females). At the primary school level, the NAR and the GAR do not differ much by urban- rural residence, with attendance in the urban areas is only slightly higher than rural areas. At the high school level, the urban NAR is 68 percent compared to 41 in rural areas and the urban GAR is 102 compared to 57 in the rural areas. The disparity in educational attainment between the East and other regions is significant both at the primary and particularly at the high school level. NUTS 1 regional disparities are also especially pronounced than at the high school level: the NAR, for example, ranges from a low of 41 percent in Northeast Anatolia, to a high of 73 percent in West Anatolia. Although attendance is higher among wealthy households at both primary and high school levels, wealth has a greater impact on attendance at the high school level. The high school NAR is only 28 percent in the lowest wealth quintile compared with 88 percent in the highest wealth quintile. The Gender Parity Index (GPI), which represents the ratio of the NAR (GAR) for females to the NAR (GAR) for males is also presented at both the primary and high school levels in Tables 2.6.1 and 2.6.2. The GPI indicates the magnitude of the gender gap in attendance. If there is no gender difference, the GPI will be equal to one, whereas the wider the disparity in favor of males, the closer the GPI will be to 0. If the gender gap favors females, the GPI will exceed one. The GPI for primary and high school are 0.98 and 0.83, respectively. These values were 0.92 and 0.78 in TDHS-2003. Thus, although a gender gap 28 | Household Population and Housing Characteristics still persists, the situation has improved during between the TDHS-2003 and TDHS-2008. Urban-rural differentials in the GPI are small at the primary school level; however, there are marked differences at the high school level. As expected, there are significant regional differentials; girls residing in the eastern part of Turkey are particularly disadvantaged. Looking at wealth status of the households, the gender gap for high school is the widest (0.58) in the lowest wealth quintile and lowest in the fourth and highest wealth quintiles (0.92). Table 2.6.1 School attendance ratios: Primary School Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Turkey 2008 Net attendance ratio Gross attendance ratio Background characteristic Male Female Total Gender Parity Index Male Female Total Gender Parity Index Residence Urban 94.2 92.8 93.5 0.98 98.2 96.6 97.5 0.98 Rural 91.8 89.8 90.8 0.98 97.7 93.3 95.4 0.95 Region West 95.2 93.8 94.5 0.98 98.3 96.7 97.5 0.98 South 93.4 93.3 93.4 1.00 99.7 97.1 98.5 0.97 Central 96.0 94.6 95.3 0.99 98.8 97.9 98.3 0.99 North 96.5 97.2 96.9 1.01 98.3 100.6 99.5 1.02 East 88.9 85.2 87.1 0.96 96.4 90.4 93.5 0.94 Region (NUTS 1) İstanbul 94.6 91.0 93.0 0.96 96.8 93.8 95.5 0.97 West Marmara 94.7 98.0 96.4 1.03 101.2 99.3 100.3 0.98 Aegean 95.9 94.8 95.3 0.99 97.9 97.4 97.7 0.99 East Marmara 97.1 97.0 97.0 1.00 100.4 102.6 101.5 1.02 West Anatolia 94.9 95.5 95.2 1.01 99.0 97.5 98.2 0.98 Mediterranean 93.4 93.3 93.4 1.00 99.7 97.1 98.5 0.97 Central Anatolia 96.5 95.6 96.1 0.99 99.3 98.6 99.0 0.99 West Black Sea 96.4 94.0 95.2 0.98 99.1 97.9 98.5 0.99 East Black Sea 97.0 95.8 96.4 0.99 97.9 100.4 99.2 1.03 Northeast Anatolia 89.0 85.2 87.1 0.96 97.5 90.1 93.9 0.92 Central East Anatolia 87.4 82.6 85.1 0.95 93.3 87.1 90.3 0.93 Southeast Anatolia 89.6 86.4 88.1 0.96 97.5 92.1 95.0 0.94 Wealth quintile Lowest 89.0 84.2 86.6 0.94 97.0 88.8 92.9 0.91 Second 92.8 92.9 92.8 1.00 97.7 96.6 97.2 0.98 Middle 94.7 95.2 95.0 1.02 98.4 98.4 98.4 1.00 Fourth 96.8 94.3 95.7 0.97 98.5 98.3 98.4 1.00 Highest 96.3 96.7 96.5 1.01 99.2 99.3 99.2 1.00 Total 93.5 91.9 92.7 0.98 98.1 95.6 96.9 0.98 Household Population and Housing Characteristics | 29 Table 2.6.2 School attendance ratios: High School Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), according to background characteristics, Turkey 2008 Net attendance ratio Gross attendance ratio Background characteristic Male Female Total Gender Parity Index Male Female Total Gender Parity Index Residence Urban 70.9 65.7 68.1 0.93 108.3 95.4 101.6 0.88 Rural 49.9 32.2 41.1 0.65 72.1 40.9 56.5 0.57 Region West 71.5 67.2 69.3 0.94 107.4 96.5 101.8 0.90 South 58.4 61.7 60.2 1.06 87.3 81.7 84.2 0.94 Central 74.5 57.6 65.9 0.77 113.4 84.2 98.5 0.74 North 74.5 69.9 71.9 0.94 106.5 92.2 98.6 0.87 East 51.4 35.4 43.5 0.69 79.6 53.9 67.0 0.68 Region (NUTS 1) İstanbul 74.5 64.6 69.0 0.87 117.5 94.8 104.8 0.81 West Marmara 76.4 64.3 70.9 0.84 101.5 90.8 96.6 0.89 Aegean 68.9 65.0 67.0 0.94 108.8 93.7 101.5 0.86 East Marmara 72.9 64.9 69.5 0.89 97.4 87.0 92.9 0.89 West Anatolia 74.0 71.2 72.6 0.96 107.7 106.0 106.8 0.98 Mediterranean 58.4 61.7 60.2 1.06 87.3 81.7 84.2 0.94 Central Anatolia 68.8 56.4 61.4 0.82 105.1 79.5 89.8 0.76 West Black Sea 70.7 63.7 66.9 0.90 108.6 87.0 96.7 0.80 East Black Sea 78.2 61.5 68.0 0.79 125.7 83.6 99.9 0.66 Northeast Anatolia 43.6 38.4 41.2 0.88 62.5 68.7 65.4 1.10 Central East Anatolia 51.4 35.9 43.2 0.70 87.5 51.7 68.4 0.59 Southeast Anatolia 53.5 34.3 44.4 0.64 81.2 51.0 66.8 0.63 Wealth quintile Lowest 33.0 22.1 27.5 0.67 54.8 31.8 43.2 058 Second 58.6 43.6 51.2 0.75 87.9 68.1 78.1 0.77 Middle 71.5 60.9 65.8 0.85 104.6 87.3 95.2 0.83 Fourth 88.5 80.4 84.0 0.90 130.1 112.7 120.5 0.86 Highest 86.3 88.7 87.5 1.03 131.7 121.1 126.5 0.92 Total 65.2 57.1 61.0 0.88 98.5 81.5 89.7 0.83 2.3.3 Repetition and Dropout Rates Repetition and dropout rates describe the flow of students through the school system. The repetition rate is the percentage of students in a given grade of the previous school year who are repeating that grade in the current school year. The dropout rate is the percentage of students who were enrolled in school in the previous school year but were not attending school during the current school year. By asking about the grade children attended during the previous school year, it is possible to calculate dropout rates and repetition rates. Repetition and dropout rates approach zero where students almost always progress to the next grade at the end of the school year. Repetition and dropout rates often vary across grades, indicating points in the school system where students are not regularly promoted to the next grade or decide to drop out of school. 30 | Household Population and Housing Characteristics Table 2.7.1 Grade repetition rates Repetition rates for the de facto household population age 6-24 who attended primary school in the previous school year by school grade, according to background characteristics, Turkey 2008 School grade Background characteristic 1 2 3 4 5 6 7 8 Sex Male 2.2 1.2 1.3 1.2 0.9 0.1 0.3 0.1 Female 1.5 0.7 0.2 0.7 0.0 0.0 0.7 0.0 Residence Urban 1.8 1.0 0.9 1.0 0.5 0.1 0.6 0.0 Rural 2.2 1.0 0.5 0.8 0.4 0.0 0.2 0.0 Region West 2.7 0.6 0.9 1.1 0.9 0.0 1.0 0.0 South 0.0 0.6 0.0 0.0 0.0 0.0 0.0 0.0 Central 1.5 0.3 0.4 0.0 0.0 0.0 0.0 0.0 North 3.1 0.0 0.0 0.0 2.4 0.0 0.0 0.0 East 1.4 2.5 1.6 2.2 0.0 0.1 0.6 0.2 Region (NUTS 1) İstanbul 4.1 0.0 1.8 2.5 0.0 0.0 2.2 0.0 West Marmara 2.1 5.8 0.0 0.0 0.0 0.0 0.0 0.0 Aegean 0.0 0.0 0.0 0.0 2.9 0.0 0.0 0.0 East Marmara 1.7 2.1 0.0 0.0 0.0 0.0 0.0 0.0 West Anatolia 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 Mediterranean 0.0 0.6 0.0 0.0 0.0 0.0 0.0 0.0 Central Anatolia 3.9 0.0 1.4 0.0 0.0 0.0 0.0 0.0 West Black Sea 3.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 East Black Sea 4.6 0.0 0.0 0.0 4.8 0.0 0.0 0.0 Northeast Anatolia 0.7 1.5 0.0 1.0 0.0 0.9 2.0 1.0 Central East Anatolia 1.8 3.8 1.9 3.8 0.0 0.0 0.0 0.0 Southeast Anatolia 1.3 1.2 1.8 1.7 0.0 0.0 0.5 0.0 Wealth quintile Lowest 4.8 0.8 0.5 0.9 1.8 0.0 0.3 0.0 Second 0.4 2.2 2.0 0.8 0.0 0.2 0.3 0.2 Middle 1.2 1.1 0.0 0.4 0.0 0.0 1.7 0.0 Fourth 0.5 0.0 0.5 2.9 0.0 0.0 0.0 0.0 Highest 1.8 0.5 0.6 0.0 0.0 0.0 0.0 0.0 Total 1.9 1.0 0.8 1.0 0.5 0.0 0.5 0.0 Note: The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. Although an automatic promotion policy does not operate officially in Turkey, very few primary school students repeat grades. Table 2.7.1 indicates that apart from first grade, when 2 percent repeated, the rates for grades 2 to 8 are all less than 1 percent. Household Population and Housing Characteristics | 31 Table 2.7.2 Grade dropout rates Dropout rates for the de facto household population age 6-24 who attended primary school in the previous school year by school grade, according to background characteristics, Turkey 2008 School grade Background characteristic 1 2 3 4 5 6 7 8 Sex Male 0.2 0.0 0.9 0.2 1.1 1.7 1.2 17.3 Female 0.1 0.7 1.1 1.1 1.9 1.5 1.5 26.9 Residence Urban 0.1 0.5 1.1 0.2 0.6 1.6 1.0 17.3 Rural 0.3 0.0 0.6 1.5 3.6 1.5 2.1 35.1 Region West 0.0 1.0 1.8 0.0 0.0 2.0 0.3 19.8 South 0.0 0.0 0.6 0.0 1.7 1.3 2.3 21.4 Central 0.0 0.0 0.5 0.0 0.0 0.0 0.0 22.5 North 0.0 0.0 0.0 0.0 0.0 0.0 4.8 10.9 East 0.6 0.0 0.7 2.2 4.9 2.6 2.8 27.4 Region (NUTS 1) İstanbul 0.0 2.5 3.6 0.0 0.0 4.1 0.0 20.3 West Marmara 0.0 0.0 0.0 0.0 0.0 0.0 0.0 11.5 Aegean 0.0 0.0 0.0 0.0 0.0 0.0 0.0 26.6 East Marmara 0.0 0.0 0.0 0.0 0.0 0.0 1.4 14.6 West Anatolia 0.0 0.0 0.0 0.0 0.0 0.0 0.0 15.0 Mediterranean 0.0 0.0 0.6 0.0 1.7 1.3 2.3 21.4 Central Anatolia 0.0 0.0 1.9 0.0 0.0 0.0 0.0 26.1 West Black Sea 0.0 0.0 0.0 0.0 0.0 0.0 0.0 24.0 East Black Sea 0.0 0.0 0.0 0.0 0.0 0.0 10.6 6.0 Northeast Anatolia 0.7 0.0 0.0 3.9 0.9 0.9 2.0 26.9 Central East Anatolia 1.8 0.0 1.1 2.1 9.3 3.7 1.7 31.2 Southeast Anatolia 0.0 0.0 0.7 1.9 3.9 2.6 3.4 25.9 Wealth quintile Lowest 0.4 1.3 1.0 2.3 4.4 5.9 3.4 43.4 Second 0.0 0.0 2.7 0.3 1.4 1.2 1.9 30.0 Middle 0.3 0.0 0.7 0.0 0.3 0.0 0.0 20.4 Fourth 0.0 0.0 0.0 0.0 0.0 0.0 1.0 10.8 Highest 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.9 Total 0.2 0.3 1.0 0.6 1.5 1.6 1.3 21.7 Note: The dropout rate is the percentage of students in a given grade in the previous year who are not attending school in the current school year. As Table 2.7.2 indicates, in general, dropout rates increase only modestly with grade level through grade 7. However, the rate increases to 22 percent for grade 8. The high dropout rate at grade 8 reflects the fact that many of the students who complete the 8-year compulsory primary school are unable for various reasons to move to the next educational level (i.e., high school). In general, dropout rates are higher in rural than urban areas. For example, the rates of rural children at grade 8 is double that of urban children (35 percent and 17 percent 32 | Household Population and Housing Characteristics respectively). Regional differentials in the dropout rate are also noteworthy. At grade 8, East Black Sea has the lowest dropout rate (6 percent) and Central East Anatolia has the highest rate (31 percent). Dropout rates are negatively associated with wealth; students in the lowest wealth quintile have the highest dropout rates. 2.4 Housing Characteristics The physical characteristics and availability and accessibility of basic household facilities are important in assessing the general welfare and socioeconomic condition of the population. The TDHS-2008 gathered information on housing characteristics such as sources of drinking water and time to the nearest water source, type of toilet facilities, main material of the floor, and the number of sleeping rooms in the house. These characteristics are highly correlated with health and are also indicative of socioeconomic status. Tables 2.8-2.10 present this information by urban–rural residence. 2.4.1 Drinking Water Increasing the proportion of people with sustainable access to improved drinking water is one of the Millennium Development Goals that Turkey, along with other nations worldwide has adopted (United Nations General Assembly, 2001). The source of drinking water is an indicator of whether it is suitable for drinking. Sources that are likely to be of suitable quality are classified under “Improved source”, and sources that may not be of suitable quality are grouped under “Non-improved source” (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004). In TDHS-2008, piped water in house/garden or public piped water outside house/garden, public well or well in house/garden, piped surface water in house/garden and bottled water were categorized as “improved sources”. Although it was not determined in the TDHS-2008 if a well was ‘protected’, households obtaining water from wells were accepted as having an improved source. “Non- improved source” included spring/public fountain, river/stream/pond/lake/dam, rainwater, tanker truck and other water sources. Households with no access to drinking water within their own premises were also asked about the time required to obtain water. Lack of ready access to a water source may limit the amount of safe drinking water. Moreover the water may be contaminated during transport or storage. Table 2.8 provides information on the source of drinking water and the time to obtain drinking water by urban-rural residence. Overall, 92 percent of households in Turkey have access to an improved source of drinking water. Urban households are more likely than rural households to have an improved water source (94 percent and 88 percent, respectively). Approximately 35 percent of the households use piped water within their dwelling, 39 percent use bottled water and 16 percent use piped surface water. The source for drinking water differs considerably by residence. The most common source of drinking water in urban settlements is bottled water (49 percent). Forty-one percent get drinking water from pipes in their residence. Among rural households the most common source of drinking water is the piped surface water (53 percent). Nineteen percent of rural households have piped water and 7 percent obtains drinking water from a well in residence. Household Population and Housing Characteristics | 33 More than nine in ten households (92 percent) report having water on their premises. Overall, drinking water is available on the premises in 93 percent of households in urban areas and 88 percent in rural areas. Ninety-four percent of households have access to water within 15 minutes. Four percent of the households spent 30 minutes or longer to obtain drinking water. As expected, there is better access to water in urban areas than in rural areas. Table 2.8 Household drinking water Percent distribution of households by source, time to collect, according to residence, Turkey 2008 Source of drinking water Urban Rural Total Improved, not shared 93.7 88.4 92.3 Piped into residence 40.8 18.7 35.2 Public tap 0.1 0.2 0.1 Well in residence 0.4 7.1 2.1 Public well 0.3 1.4 0.6 Piped surface water in house/garden 3.0 53.4 15.7 Bottled water 49.1 7.6 38.6 Non-improved 6.2 11.6 7.8 Spring/public fountain 4.8 7.4 5.5 River/stream/pond/lake/dam 0.2 0.4 0.3 Tanker truck 0.1 0.2 0.2 Other 1.1 3.5 1.7 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Time to obtain drinking water (round trip)1 Water on premises 93.3 87.8 91.9 Less than 30 minutes 2.3 5.4 3.1 30 minutes or longer 3.7 2.7 3.5 Don't know/missing 0.7 4.1 1.5 Total 100.0 100.0 100.0 Time to obtain drinking water (round trip) Less than 15 minutes 94.8 91.4 93.9 Number 7,866 2,659 10,525 1 Includes households that have drinking water on the premises. 34 | Household Population and Housing Characteristics 2.4.2 Sanitation Facilities Ensuring adequate sanitation facilities is another Millennium Development Goal. The lack of availability of hygienic sanitary facilities poses a serious health problem. Table 2.9 shows the proportion of households and of the de jure population having access to hygienic sanitation facilities. Hygienic status is determined on the basis of type of facility used and whether or not it is a shared facility. A household’s toilet/latrine facility is classified as hygienic if it is used only by household members (i.e., not shared) and the type of facility effectively separates human waste from human contact (WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2004). The types of facilites that are most likely to meet this criteria are flush or pour flush into a piped sewer system and pit latrine with a slab. Table 2.9 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Turkey 2008 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Toilet inside or outside No facility/bush/public toilet 0.1 0.8 0.3 0.1 1.3 0.4 Inside 94.5 61.3 86.1 93.5 57.4 83.6 Outside 5.0 35.1 12.6 6.0 38.3 14.8 Inside and outside 0.4 2.8 1.0 0.4 3.0 1.1 Type of toilet facility Flush toilet 94.8 40.8 81.1 94.5 35.6 78.4 Open pit 0.5 15.3 4.2 0.7 18.4 5.5 Closed pit 4.5 41.8 13.9 4.6 43.1 15.2 Other 0.1 1.1 0.4 0.1 1.4 0.4 Missing 0.1 0.2 0.1 0.0 0.3 0.1 Share toilet with other households No 99.1 94.7 98.0 99.1 93.9 97.7 Yes 0.9 5.3 2.0 0.9 6.1 2.3 Improved, not shared facility Flush/pour flush to piped sewer system 94.1 39.8 80.4 93.8 34.7 77.6 Pit latrine with slab/closed pit 4.4 39.3 13.2 4.5 40.6 14.4 Non-improved facility Any facility shared with other households 0.5 3.5 1.2 0.5 3.7 1.4 Pit latrine without slab/open pit 0.5 14.5 4.0 0.7 17.3 5.2 No facility/bush/field 0.1 0.8 0.3 0.1 1.3 0.4 Other 0.1 1.1 0.4 0.1 1.4 0.4 Missing 0.3 0.9 0.5 0.4 1.1 0.6 Number 7,866 2,659 10,525 29,828 11,241 41,069 Household Population and Housing Characteristics | 35 The majority of households in Turkey have a toilet facility inside of the dwelling (86 percent), and only one percent share their toilet facility with other households. More than nine in ten households have improved toilet facilities that are not shared with other households, of which 80 percent flush to a piped sewer system and 13 percent use pit latrine with slab. Improved sanitation facilities are much more common in urban areas (99 percent) than in rural areas (79 percent). Most urban household have flush toilets (95 percent) while, in rural areas, pit latrines (42 percent closed pit and 15 percent open pit) are more common than flush toilets (41 percent). The percentage of population having modern toilet facilities are somewhat lower compared with households, particularly in rural areas where households are larger. 2.4.3 Other Household Characteristics The physical characteristics of the household reflect the household’s economic status and have an important environmental impact on maternal and child health. Information on household characteristics such as type of flooring material, type of heating, number of rooms used for sleeping, existence of separate kitchen and bathroom are shown in Table 2.10. With regard to flooring, the most commonly used flooring material is cement (22 percent) followed by parquet (polished wood), wood planks, marley and laminate with 19, 14, 11 and 10 percent respectively. There are substantial differences in the flooring materials in urban and rural dwellings. Among rural households, 40 percent have a cement floor, compared with about 16 percent of urban households. More than one third of the urban households live in dwellings with parquet or laminate floors. Eleven percent of households in rural areas have earth floors, compared to less than 1 percent in urban areas. The great majority of households in Turkey have a separate kitchen and separate bathroom (95 percent). This characteristic is more common in urban areas than in rural areas (98 percent and 84 percent, respectively). Information on heating systems was also collected in TDHS-2008. Substantial differences in the types of systems used for heating are observed among urban and rural households. Urban households are more likely than rural households to use central and flat heating, while rural households are more likely than urban households to use stoves. Eighty-three percent of rural households burn wood or coal in the stove and 10 percent burn dried cow dung. Thirty-five percent of urban households use natural gas to heat their houses, and 54 percent use wood/coal. Finally, data on the number of sleeping rooms per household was collected in the TDHS-2008 to help assess the extent of crowding. Table 2.10 shows that 80 percent of households have one or 2 rooms for sleeping and 20 percent have three or four rooms for sleeping. On average, there are 2.0 persons per sleeping room in Turkey. Rural households have more people per sleeping room than urban households (2.3 and 1.9 persons per sleeping room, respectively). 36 | Household Population and Housing Characteristics Table 2.10 Household characteristics Percent distribution of households by housing characteristics, according to residence, Turkey 2008 Housing characteristic Urban Rural Total Main material of floor Earth, sand 0.7 11.0 3.3 Wood planks 10.8 22.5 13.7 Parquet, polished wd 23.5 5.3 18.9 Karo 9.2 4.7 8.1 Cement 15.8 40.0 21.9 Carpet 5.2 4.6 5.0 Marley 13.3 4.5 11.1 Mozaic 2.5 1.0 2.1 Laminate 12.6 2.5 10.0 Other 6.5 4.0 5.9 Heating Central heating-natural gas 5.6 0.6 4.4 Central heating-diesel oil/gas oil 0.1 0.0 0.1 Central heating-wood/coal 7.1 0.9 5.5 Central heating-other 0.3 0.0 0.2 Flat heating-natural gas 25.8 0.5 19.4 Flat heating-diesel oil/gas oil 0.4 0.3 0.3 Flat heating-other 0.7 0.8 0.7 Stove-natural gas 3.7 0.0 2.8 Stove-diesel oil/gas oil 0.1 0.0 0.1 Stove-wood/coal 46.8 83.3 56.0 Stove-dried cow dung 0.7 10.1 3.1 Stove-other 0.5 0.3 0.4 Electric heater 4.0 1.2 3.3 Other 4.3 1.6 3.6 Missing 0.1 0.2 0.1 Household has separate room used as kitchen No 2.0 15.7 5.5 Yes 98.0 84.3 94.5 Separate bathroom No 1.9 15.9 5.4 Yes 98.1 84.1 94.5 Number of sleeping room 1-2 78.4 83.5 79.7 3-4 21.3 15.8 19.9 5-6 0.2 0.6 0.3 7+ 0.0 0.1 0.0 Missing 0.1 0.0 0.0 Total 100.0 100.0 100.0 Mean number of persons per sleeping room 1.9 2.3 2.0 Number of households 7,866 2,659 10,525 Household Population and Housing Characteristics | 37 2.4.4 Household Durable Goods Ownership of household effects and other possessions is a useful indicator of household’s social and economic well- being. Moreover, particular goods have specific benefits. For example, 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 2.11 presents the availability of selected household possessions by residence. A great majority of households in Turkey own most basic appliances. Television sets, refrigerators, washing machine and mobile telephone are present in more than nine in ten households. More than eight in ten households have an iron and vacuum cleaner, and 77 percent have an oven. Fifty-six percent of households have satellite television, and 27 percent have an internet connection in their dwellings. With regard to the other household effects shown in Table 2.11, ownership rates vary from less than one percent of households for garbage dispensers and dryers to 50 percent for mixers. Urban households are more likely to own almost all of these items than rural households; the only exception is satellite TV. Relatively few households have a means of transportation in rural areas. The most common means of transportation owned by households is a car (34 percent in urban areas and 26 percent in rural areas). Table 2.11 Household durable goods Percentage of households possessing various household effects and means of transportation by residence, Turkey 2008 Possesion Urban Rural Total Household effects Refrigerator 98.5 95.2 97.6 Oven 83.0 59.3 77.0 Washing Machine 95.4 81.0 91.8 Iron 92.6 73.2 87.7 Vacuum Cleaner 91.3 66.7 85.1 Television 96.3 94.8 95.9 Non-mobile telephone 65.6 58.4 63.8 Mobile telephone 94.8 83.0 91.8 None of the above 0.1 0.8 0.3 Microwave oven 14.9 5.1 12.4 Mixer 58.4 26.2 50.3 Dish washer 43.5 10.8 35.2 Garbage dispenser 0.7 0.3 0.6 Dryer 0.8 0.3 0.7 LCD/Plasma TV 7.7 2.1 6.2 Pay TV 15.4 2.7 12.2 Satellite TV 54.2 61.2 56.0 Video camera 13.2 3.8 10.8 DVD/VCD player 44.7 22.3 39.1 Camera 38.8 17.2 33.4 Laptop 14.0 3.4 11.4 Computer 35.0 10.4 28.8 Internet 32.8 9.0 26.8 Indoor sports equipment 6.4 0.9 5.0 Air conditioner 14.0 4.6 11.7 Means of transport Car 34.3 26.2 32.3 Taxi/minibus 4.0 5.5 4.4 Tractor 1.8 22.2 7.0 Motorcycle 4.4 11.2 6.1 Number of households 7,866 2,659 10,525 38 | Household Population and Housing Characteristics 2.5 Household Wealth In addition to standard background characteristics, most of the results throughout this report are shown by wealth quintiles, an indicator of the economic status of households. Although TDHS-2008 did not collect data on consumption or income, the survey collected a detailed information on dwelling and household characteristics and access to a variety of consumer goods and services, and assets which are used as a measure of socio-economic status. The wealth index is a recently developed measure that has been tested in a number of countries in relation to inequities in household income, use of health services, and health outcomes (Rutstein et al., 2000). The resulting wealth index is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The wealth index was constructed using household asset data including ownership of a number of possesions ranging from a television to a car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities, and type of flooring material. A single asset index was developed on the basis of data from the survey sample and used in all the tabulations presented in the report. Each asset was assigned a weight (factor score) generated through principal component analysis, and the resulting asset scores were standardized in relation to a standard normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household. Individuals were ranked according to the total score of the household in which they reside. To create wealth quintiles the de jure population was classified into five wealth categories, each with the same number of persons, according to an index representing the wealth of the household in which the person resided. At the national level, approximately 20 percent of the population is in each wealth quintile. Table 2.12 shows the distribution of the de jure population by the five wealth quintiles according to urban-rural residence, region and NUTS 1 region. These distributions indicate the degree to which wealth is evenly (or unevenly) distributed by geographic areas. More than half of the households (53 percent) in rural areas are in the lowest quintile in contrast to 8 percent in urban areas. On the other hand more than half of the urban households (52 percent) are in the fourth and highest wealth quintiles as opposed to 9 percent of rural households. As expected, there are huge variations among regions in terms of the wealth quintile distribution. The East region has the largest proportion in the lowest wealth quintile (46 percent) and West region has the largest proportion in the highest quintile (29 percent). In line with this finding, all the NUTS1 regions located in the eastern part of Turkey, namely Northeast Anatolia, Central East Anatolia and Southeast Anatolia regions have the largest proportions in the lowest quintile (52, 49 and 43 percent, respectively) and İstanbul, East Marmara and West Anatolia regions have the smallest proportions in the lowest quintile (2, 5 and 7 percent, respectively). Household Population and Housing Characteristics | 39 Table 2.12 Wealth quintiles Percent distribution of the jure population by wealth quintiles coeeficient according to residence and region, Turkey 2008 Wealth quintile Residence/region Lowest Second Middle Fourth Highest Total Number of population Residence Urban 7.7 17.9 22.5 25.2 26.6 100.0 29,828 Rural 52.6 25.5 13.3 6.2 2.4 100.0 11,241 Region West 8.8 15.0 20.7 26.2 29.3 100.0 16,828 South 28.7 27.3 19.8 15.1 9.2 100.0 5,056 Central 13.9 19.3 22.2 21.9 22.7 100.0 8,636 North 21.3 25.7 24.2 17.9 11.0 100.0 2,771 East 45.8 26.5 14.7 8.6 4.4 100.0 7,777 Region (NUTS 1) İstanbul 1.5 11.6 19.7 28.8 38.4 100.0 7,791 West Marmara 19.6 20.9 23.0 26.5 10.0 100.0 1,713 Aegean 18.0 19.3 19.2 21.2 22.3 100.0 5,619 East Marmara 4.6 16.3 26.9 26.3 25.9 100.0 3,752 West Anatolia 7.3 13.6 19.4 23.9 35.8 100.0 3,734 Mediterranean 28.4 27.3 20.0 15.2 9.1 100.0 5,056 Central Anatolia 23.5 20.4 21.7 19.7 14.8 100.0 2,017 West Black Sea 20.8 27.2 24.6 16.6 10.8 100.0 2,510 East Black Sea 27.1 21.3 22.8 18.0 10.7 100.0 1,137 Northeast Anatolia 51.7 15.8 13.1 12.2 7.2 100.0 1,275 Central East Anatolia 48.6 25.0 15.1 8.0 3.3 100.0 2,186 Southeast Anatolia 42.9 30.2 15.1 7.7 4.1 100.0 4,278 Total 20.0 20.0 20.0 20.0 20.0 100.0 41,069 40 | Household Population and Housing Characteristics 2.6 Birth Registration The registration of births is the inscription of the facts of each birth into an official log kept at the registrar’s office. Birth registration is basic to ensuring a child’s legal status and, thus, basic rights and services (UNICEF, 2006; United Nations General Assembly, 2002). In the TDHS-2008, mothers of children were asked if their child’s birth had been registered. A child’s birth born in 1998 or later was considered to have been registered if the mother reported that the birth was registered. Mothers were not asked whether or not the child actually had a birth certificate since some certificates may have been lost or were never issued. Table 2.13 shows the percentage of children under five years of age whose births were officially registered. The results show that 94 percent of births in the past five years in Turkey were registered. The percentage of unregistered children decreased from 16 percent in the TDHS- 2003 (Koç, 2004) to 6 percent in TDHS-2008. Table 2.13 shows that here is little variation in birth registration rates by the child`s sex. Urban children are somewhat more likely to be registered than rural children. However, the percentage of unregistered children has decreased both in urban and rural areas since the TDHS-2003 (13 and 21 percent respectively). In four of the five regions, the percentage of children whose birth was not registered is 5 percent or less, while in the East, 11 percent of children were not registered. The NUTS1 regions located in the Eastern part of the country have a relatively higher percentage of unregistered children. There is a positive relationship between birth registration and the educational level of the mother and welfare of the household; the highest registration rates are found for children in households in the higher wealth quintiles and children of educated mothers. Household Population and Housing Characteristics | 41 Table 2.13 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, according to background characteristics, Turkey 2008 Birth registration Background characteristic Yes No Number of children Age of child <1 87.9 12.1 706 1 94.6 5.4 714 2-4 95.5 4.5 2,043 Sex of child Male 94.8 5.2 1,770 Female 92.6 7.4 1,693 Residence Urban 94.6 5.4 2,475 Rural 91.6 8.4 988 Region West 94.7 5.3 1,174 South 96.2 3.8 441 Central 96.0 4.0 741 North 96.6 3.4 197 East 88.9 11.1 911 Region (NUTS 1) İstanbul 94.7 5.3 548 West Marmara 98.5 1.5 88 Aegean 93.4 6.6 427 East Marmara 98.0 2.0 275 West Anatolia 95.1 4.9 345 Mediterranean 96.2 3.8 441 Central Anatolia 96.2 3.8 177 West Black Sea 94.8 5.2 172 East Black Sea 97.2 2.8 79 Northeast Anatolia 87.7 12.3 128 Central East Anatolia 87.4 12.6 250 Southeast Anatolia 89.9 10.1 533 Education No education/Primary incomplete 86.4 13.6 781 First level primary 95.1 4.9 1,691 Second level primary 95.6 4.4 322 High school and higher 97.9 2.1 669 Wealth quintile Lowest 88.8 11.2 852 Second 92.4 7.6 818 Middle 96.3 3.7 709 Fourth 95.6 4.4 579 Highest 98.5 1.5 506 Total 93.7 6.3 3,463 Characteristics of Survey Respondents | 43 CHARACTERISTICS OF SURVEY RESPONDENTS 3 Elif Yiğit, İlknur Yüksel and A. Sinan Türkyılmaz The purpose of this chapter is to provide a description of the situation of ever-married women in Turkey by considering how the ever-married women interviewed in the TDHS-2008 are distributed according to age, marital status, region, urban-rural residence, education, and wealth quintiles. This information is useful for understanding the context of reproduction and health status of women. In addition, the information about women’s employment and details about the occupation status of employed women are also provided. 3.1 Background Characteristics Table 3.1 presents a description of the socio-demographic characteristics of the women interviewed in the TDHS-2008 including age, marital status, urban-rural residence, region of residence, education and wealth quintiles. 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 probe in situations in which respondents knew neither their age nor date of birth. As a last resort, interviewers were instructed to record their best estimate of the respondent's age. The data on age indicate that 32 percent of the ever-married women interviewed were less than 30 years of age, 37 percent were age 30-39, and 31 percent were in the 40-49 age groups. The comparatively small proportions in the 15-19 and 20-24 age groups are a result of the fact that a significant proportion of Turkish women are not yet married by these ages and, thus, were not eligible for interview. The drop in the proportions at the upper end of the age categories, on the other hand, is an outcome of high fertility in the past, which resulted in successively larger cohorts of women entering the reproductive age groups during the recent decades. At the time of the interviews, 95 percent of women were married, while the rest were either divorced/separated (3 percent) or widowed (2 percent). Although there appears to have been a small increase in the percentage of divorced or separated, these figures are consistent with the results of the previous surveys and indicate the rarity of marital dissolution in Turkey. Seventy-six percent of the TDHS-2008 respondents lived in urban areas. Respondents were most likely to live in the West (44 percent) and least likely to live in the North (6 percent). Regarding the NUTS 1 regions, 20 percent of women lived in İstanbul, followed by 14 percent in the Aegean, 12 percent in the Mediterranean, and 10 percent East Marmara regions, which are the most developed regions of the country. 44 | Characteristics of Survey Respondents Table 3.1 Background characteristics of respondents Percent distribution of ever-married women age 15-49 by selected background characteristics, Turkey 2008 Background characteristic Weighted percentage Weighted number Unweighted number Age 15-19 2.5 183 208 20-24 11.3 836 898 25-29 18.3 1,353 1,382 30-34 18.6 1,379 1,372 35-39 18.0 1,336 1,337 40-44 16.2 1,202 1,170 45-49 15.1 1,115 1,038 Marital status Married 94.5 6,999 7,042 Divorced/separated 3.3 248 217 Widowed 2.1 158 146 Residence Urban 75.8 5,615 5,429 Rural 24.2 1,790 1,976 Region West 43.9 3,252 1,876 South 12.1 894 1,013 Central 22.0 1,631 1,460 North 6.4 477 868 East 15.5 1,151 2,188 Region (NUTS 1) İstanbul 20.1 1,491 532 West Marmara 4.4 327 423 Aegean 14.4 1,065 549 East Marmara 10.2 759 594 West Anatolia 9.7 717 557 Mediterranean 12.1 894 1,013 Central Anatolia 5.0 371 534 West Black Sea 6.1 448 634 East Black Sea 2.5 186 385 Northeast Anatolia 2.6 191 602 Central East Anatolia 4.4 327 630 Southeast Anatolia 8.5 628 952 Education No education/Primary incomplete 18.3 1,358 1,748 First level primary 51.9 3,840 3,645 Second level primary 8.7 643 633 High school and higher 21.1 1,564 1,379 Wealth quintile Lowest 15.6 1,154 1,529 Second 19.3 1,429 1,542 Middle 21.1 1,559 1,586 Fourth 21.9 1,618 1,485 Highest 22.2 1,645 1,263 Total 15-49 100.0 7,405 7,405 Note: Education categories refer to the highest level of education completed. Characteristics of Survey Respondents | 45 Eighteen percent of the TDHS-2008 respondents did not have any education or had not completed first level of primary school. On the other hand, one out of five women (21 percent) had graduated from at least high school. Comparing these figures with the results of previous surveys, one finds that women in reproductive age groups today are far more educated in the past. 3.2 Education and Literacy Level Table 3.2 shows how women are distributed by educational attainment according to age, residence, region, and wealth quintiles. Due to the spread of education in recent decades in Turkey, younger women are more educated than older women. Twenty-seven percent of women age 45-49 had no education or did not complete the first primary level compared with only 12 percent in the 25-29 age groups. Twenty-nine percent of women age 25-29 completed at least high school compared to 16 percent of women age 45-59. Finally, it should be noted that the educational attainment of the youngest cohort clearly shows the effect of the increase in compulsory education from 5 years to 8 years in 1997; 48 percent of women 15-19 completed the second level primary. Women who live in the urban areas are much more likely to have higher education than their rural counterparts. Twenty-eight percent of rural women have no educational level completed, compared to only 15 percent of urban women. The percentage of urban women who completed at least high school is 26 while it is only 7 for rural women. The least educated women are in the East, where the median years of schooling is 3.2 years, compared with the national average of 4.6 years. Regarding the NUTS1 regions, women live in Central East Anatolia and Southeast Anatolia regions have the highest percentages having less than primary education (58 and 53 percent respectively). On the other hand, in the seven out of the 12 NUTS 1 regions, the median years of schooling exceeds the national rate (4.6 years). Educational attainment rises with the wealth quintile. In the lowest wealth quintile, 48 percent of women have no education or have not completed the primary level compared with 2 percent for the highest quintile. The median number of years of schooling is 10.3 years for women in the highest wealth quintile, while it is 4.1 years for the lowest quintile. Table 3.3 shows the literacy level of women by age, residence, region, and wealth quintile. The level of literacy is based on the women’s self-reported ability to read a newspaper or a letter easily, with difficulty or not at all. Since women who have at least 5 years of schooling were assumed to be literate, this question was asked only of the 18 percent of women who had not attended school or did not complete first level primary school. Overall, 89 percent of TDHS-2008 respondents are classified as literate; this includes the 82 percent who had completed at least a first level primary education and the 7 percent with less education who reported they were able to read. 46 | Characteristics of Survey Respondents Table 3.2. Educational attainment Percent distribution of ever-married women age 15-49 by highest level of schooling attended or completed, and median number of years of schooling,, according to background characteristics, Turkey 2008 Highest level of schooling attended or completed Background characteristic No education/ Primary incomplete First level primary1 Second level primary2 High school and higher3 Total Median number of years of schooling Number of women Age 15-24 17.3 40.2 24.5 18.0 100.0 4.9 1,019 15-19 20.9 18.5 48.2 12.4 100.0 7.3 183 20-24 16.5 45.0 19.3 19.2 100.0 4.8 836 25-29 12.1 50.9 8.6 28.5 100.0 4.8 1,353 30-34 12.6 52.5 6.4 28.5 100.0 4.7 1,379 35-39 19.6 57.7 5.8 16.9 100.0 4.5 1,336 40-44 23.1 55.0 5.0 16.9 100.0 4.5 1,202 45-49 27.3 52.5 4.6 15.6 100.0 4.4 1,115 Residence Urban 15.2 50.0 9.2 25.6 100.0 4.7 5,615 Rural 28.1 57.7 7.1 7.1 100.0 4.4 1,790 Region West 11.9 54.3 8.3 25.6 100.0 4.7 3,252 South 19.7 55.5 8.4 16.4 100.0 4.6 894 Central 7.2 56.8 12.1 23.9 100.0 4.8 1,631 North 15.6 54.0 8.8 21.7 100.0 4.7 477 East 52.4 34.3 5.2 8.0 100.0 3.2 1,151 Region (NUTS 1) Istanbul 12.2 52.5 7.7 27.5 100.0 4.8 1,491 West Marmara 9.2 61.6 8.3 21.0 100.0 4.7 327 Aegean 10.7 57.6 8.9 22.8 100.0 4.7 1,065 East Marmara 9.6 58.1 8.5 23.7 100.0 4.7 759 West Anatolia 3.7 50.1 13.3 32.8 100.0 4.9 717 Mediterranean 19.7 55.5 8.4 16.4 100.0 4.6 894 Central Anatolia 15.1 54.8 12.9 17.2 100.0 4.7 371 West Black Sea 13.4 59.5 9.2 17.9 100.0 4.6 448 East Black Sea 20.1 45.0 11.5 23.4 100.0 4.7 186 Northeast Anatolia 41.4 38.2 7.6 12.8 100.0 4.3 191 Central East Anatolia 58.2 30.0 5.1 6.7 100.0 0.9 327 Southeast Anatolia 52.9 35.2 4.6 7.3 100.0 3.0 628 Wealth quintile Lowest 47.7 46.5 4.2 1.6 100.0 4.1 1,154 Second 27.9 61.0 7.5 3.5 100.0 4.4 1,429 Middle 15.3 64.3 10.7 9.7 100.0 4.6 1,559 Fourth 8.5 57.2 10.2 24.1 100.0 4.8 1,618 Highest 2.0 30.6 9.4 58.0 100.0 10.3 1,645 Total 18.3 51.9 8.7 21.1 100.0 4.6 7,405 1Completed 5 years at the first level primary 2Completed 3 years at the second level primary 3Completed at least 3 years at the high school As expected, the percentage literate decreases with age, from 94 percent in the 15-19 age group to 83 percent among women age 45-49 years. Urban women are more likely than rural women to be literate (92 percent and 80 percent, respectively). The percentage literate is highest in the Central (96 percent) and lowest in the East (63 percent). Among the NUTS1 regions, Central East Anatolia, and South East Anatolia have the lowest literacy rates and West Anatolia, the highest (59, 62 and 98 percent, respectively). The literacy level increases with the wealth Characteristics of Survey Respondents | 47 quintile; 99 percent of women in the highest wealth quintile are literate compared to 65 percent in the lowest quintile. Table 3.3 Literacy Percent distribution of ever-married women age 15-49 by level of schooling attended and level of literacy and percentage literate, according to background characteristics, Turkey 2008 Ability to read of women with no schooling or completed less than first level primary education Background characteristic Secondary school or higher Not at all With difficulty Easily Total Percentage literate1 Number Age 15-19 79.1 5.6 4.8 10.4 100.0 94.4 183 20-24 83.5 7.1 3.6 5.8 100.0 92.9 836 25-29 87.9 6.9 2.7 2.5 100.0 93.1 1,353 30-34 87.4 8.1 2.2 2.3 100.0 91.9 1,379 35-39 80.4 12.6 3.9 3.1 100.0 87.4 1,336 40-44 76.9 14.5 4.9 3.7 100.0 85.5 1,202 45-49 72.7 17.4 6.5 3.5 100.0 82.6 1,115 Residence Urban 84.8 8.1 3.7 3.4 100.0 91.9 5,615 Rural 71.9 19.7 4.5 3.8 100.0 80.3 1,790 Region West 88.1 5.7 3.1 3.1 100.0 94.3 3,252 South 80.3 10.3 4.9 4.4 100.0 89.7 894 Central 92.8 3.9 1.8 1.5 100.0 96.1 1,631 North 84.4 8.5 3.9 3.2 100.0 91.5 477 East 47.6 37.2 8.2 7.0 100.0 62.8 1,151 Region (NUTS 1) İstanbul 87.8 5.7 3.0 3.6 100.0 94.3 1,491 West Marmara 90.8 5.4 1.7 2.1 100.0 94.6 327 Aegean 89.3 5.7 2.7 2.4 100.0 94.3 1,065 East Marmara 90.4 4.0 3.2 2.5 100.0 96.0 759 West Anatolia 96.3 1.6 1.2 0.9 100.0 98.4 717 Mediterranean 80.3 10.3 4.9 4.4 100.0 89.7 894 Central Anatolia 84.9 8.9 3.3 2.9 100.0 91.1 371 West Black Sea 86.6 7.7 3.2 2.5 100.0 92.3 448 East Black Sea 79.9 10.5 6.2 3.5 100.0 89.5 186 Northeast Anatolia 58.6 28.6 5.6 7.2 100.0 71.4 191 Central East Anatolia 41.8 41.4 9.6 7.1 100.0 58.6 327 Southeast Anatolia 47.1 37.7 8.3 6.9 100.0 62.3 628 Wealth quintile Lowest 52.3 34.6 7.1 5.9 100.0 65.4 1,154 Second 72.1 17.4 6.0 4.5 100.0 82.6 1,429 Middle 84.7 5.7 4.9 4.7 100.0 94.3 1,559 Fourth 91.5 3.9 2.3 2.3 100.0 96.1 1,618 Highest 98.0 0.7 0.4 1.0 100.0 99.3 1,645 Total 81.7 10.9 3.9 3.5 100.0 89.1 7,405 1 Refers to women who have at least secondary school education and women with no schooling or completed less than first level primary education but who can read with difficulty or easily. 48 | Characteristics of Survey Respondents 3.3 Employment and Occupation 3.3.1 Employment status Table 3.4 presents the employment status of the ever-married women interviewed in the TDHS-2008 by age, marital status, number of children, region, residence, educational level, and wealth quintiles. Employment, like education, can be a source of empowerment for women. In TDHS-2008, information was obtained about current employment, which refers to working in the last seven days, and employment at any time during the 12 months before the survey. The measurement of employment is difficult due to different perceptions of work. For example, women who work as an unpaid family worker or in the informal sector may not label themselves as working. In TDHS-2008, a number of the questions were asked about employment to ensure that informal or potentially ill-defined activities were captured. Table 3.4 indicates that 31 percent of women were currently working at the time of the survey, and 4 percent were not currently employed but had worked at some point during the 12 months prior to the survey. Younger women were less likely to be employed than their older counterparts. A strong association exists between employment and marital status; women who were not currently married were more likely to be employed than currently married women, possibly because women who were not married assume the role of breadwinner in the absence of a husband. As expected, childbearing has an impact on employment; women with no children were more likely to be employed than women who have children. The proportion of currently working women was higher in the rural than urban areas (49 and 25 percent respectively). More than half of the women in the North were currently working compared with 20 percent of women in the East. Regarding the NUTS 1 regions, 62 percent of women in East Black Sea Region were currently working, followed by Aegean and West Black Sea regions with 43 percent and 41 percent, respectively. Women with high school education and women in the lowest and highest wealth quintiles were more likely to be economically active than other women. Characteristics of Survey Respondents | 49 Table 3.4. Employment status Percent distribution of ever-married women age 15-49 by employment status, according to background characteristics, Turkey 2008 Employment status Background characteristic Currently employed Not currently employed Not employed last 12 months DK/Missing Total Number of women Age 15-19 9.8 7.9 80.5 1.8 100.0 183 20-24 17.0 5.0 76.0 2.0 100.0 836 25-29 28.7 4.6 63.6 3.1 100.0 1,353 30-34 34.1 3.2 59.7 2.9 100.0 1,379 35-39 35.6 3.4 57.6 3.4 100.0 1,336 40-44 35.2 2.2 58.3 4.3 100.0 1,202 45-49 32.1 3.1 59.9 4.9 100.0 1,115 Marital status Married or living together 30.2 3.4 63.0 3.5 100.0 6,999 Divorced/separated/widowed 39.9 8.4 48.7 2.9 100.0 406 Number of living children 0 31.2 9.3 57.6 1.9 100.0 698 1-2 32.5 3.4 61.2 2.9 100.0 4,062 3-4 27.9 3.0 64.8 4.4 100.0 2,023 5+ 27.7 1.2 65.4 5.7 100.0 621 Residence Urban 25.0 4.0 67.3 3.7 100.0 5,615 Rural 48.6 2.5 46.3 2.6 100.0 1,790 Region West 32.6 5.0 59.5 2.9 100.0 3,252 South 28.9 3.1 60.5 7.5 100.0 894 Central 29.1 2.8 65.9 2.2 100.0 1,631 North 53.0 2.9 41.7 2.4 100.0 477 East 19.9 1.7 74.4 3.9 100.0 1,151 Region (NUTS 1) İstanbul 24.7 5.4 65.2 4.7 100.0 1,491 West Marmara 35.4 4.7 56.6 3.3 100.0 327 Aegean 43.4 3.7 51.8 1.0 100.0 1,065 East Marmara 40.7 5.0 53.5 0.7 100.0 759 West Anatolia 22.1 3.3 70.8 3.8 100.0 717 Mediterranean 28.9 3.1 60.5 7.5 100.0 894 Central Anatolia 20.6 1.7 76.5 1.3 100.0 371 West Black Sea 41.3 2.5 53.7 2.6 100.0 448 East Black Sea 62.2 3.3 33.3 1.2 100.0 186 Northeast Anatolia 26.1 1.4 67.6 4.8 100.0 191 Central East Anatolia 13.5 0.7 81.7 4.0 100.0 327 Southeast Anatolia 21.0 2.4 73.1 3.6 100.0 628 Education No education/Primary incomplete 25.6 2.1 67.5 4.7 100.0 1,358 First level primary 30.5 3.3 62.4 3.8 100.0 3,840 Second level primary 21.3 5.4 69.6 3.7 100.0 643 High school and higher 39.6 5.1 54.1 1.3 100.0 1,564 Wealth quintile Lowest 39.6 2.7 54.1 3.7 100.0 1,154 Second 31.0 3.0 62.0 3.9 100.0 1,429 Middle 25.8 3.7 66.2 4.3 100.0 1,559 Fourth 24.7 3.9 68.3 3.0 100.0 1,618 Highest 34.9 4.5 58.3 2.4 100.0 1,645 Total 30.7 3.6 62.2 3.4 100.0 7,405 50 | Characteristics of Survey Respondents 3.3.2 Type of Occupation In the TDHS-2008, ever-married women who were currently working or worked in the last 12 months before the survey were asked about the type of occupation in which they were employed. Table 3.5 indicates that the 51 percent of women worked in the service sector, while 40 percent worked in agriculture and 8 percent in industry. Women age 15-19 and 45-49 were more likely to work in agriculture and less likely to have service jobs than other women. Married women are more likely to work in the agriculture, while formerly women are more likely to be employed in the service sector. The percentage working in the agricultural sector increased and the percentage working in the service sector declined with the number of living children increases. This may reflect the fact that higher parity women were from the rural areas where agricultural work is more common, while lower parity women were concentrated in urban areas, where women mainly worked in the service sector. Regarding the regions, the percentage of women working in agriculture was highest in the North followed closely by the East region. On the other hand, the highest levels of employment in the service sector were among women in the West and Central regions. In NUTS1 Regions, the highest proportion of women working in agriculture was observed in the East Black Sea, while the highest proportion of women working in the service sector were in West Anatolia and İstanbul. As expected, the percentage employed in agricultural occupations fell and the percentage employed in service occupations rose directly with both the education level and wealth quintile. 3.3.3 Employment by Economic Sector Table 3.6 presents information on the sector of the economy -public or private- in which women were employed. Nine in ten employed women worked in the private sector while one in ten works in the public sector. Public sector employment was highest for women in the West Anatolia region (25 percent), women with high school of higher education (39 percent), and women in the highest wealth quintile (36 percent). 3.3.4 Type of Employment Table 3.7 shows the differences type of employment of working women according to the basic characteristics. Around one-third of working women were employed as unpaid family workers while 17 percent were self-employed. Thirty-nine percent were waged workers, either regular or daily, and 10 percent were salaried government employees. Only two percent of women were employers. Regular waged or salaried employment was most common among women with high school and higher education and women in the highest wealth quintile, while working unpaid for a family member was most common among rural women, women in East Black Sea and Norteast Anatolia regions. Characteristics of Survey Respondents | 51 Table 3.5 Type of occupation Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by type of occupation according to background characteristics, Turkey 2008 Sector Background characteristic Agriculture Industry Service Total Number of women Age 15-19 (62.8) (8.9) (28.3) 100.0 32 20-24 45.5 11.4 43.1 100.0 184 25-29 33.1 9.0 57.9 100.0 451 30-34 33.0 10.5 56.5 100.0 515 35-39 37.4 7.7 54.9 100.0 521 40-44 42.9 6.7 50.4 100.0 449 45-49 54.7 6.3 39.0 100.0 392 Marital status Married or living together 41.8 8.3 49.9 100.0 2,348 Divorced/separated/widowed 22.7 9.0 68.3 100.0 196 Number of living children 0 24.4 14.1 61.5 100.0 282 1-2 33.2 8.2 58.5 100.0 1,457 3-4 52.9 7.3 39.8 100.0 624 5+ 79.0 4.5 16.5 100.0 180 Residence Urban 15.3 11.3 73.4 100.0 1,629 Rural 84.8 3.2 12.0 100.0 915 Region West 24.6 14.1 61.3 100.0 1,221 South 54.2 3.0 42.8 100.0 286 Central 46.3 3.7 50.0 100.0 521 North 65.4 1.6 33.0 100.0 267 East 62.1 3.5 34.4 100.0 249 Region (NUTS 1) İstanbul 3.5 16.7 79.8 100.0 449 West Marmara 45.1 18.9 36.0 100.0 131 Aegean 47.5 9.5 43.0 100.0 502 East Marmara 37.7 11.3 51.0 100.0 347 West Anatolia 17.9 0.4 81.7 100.0 182 Mediterranean 54.2 3.0 42.8 100.0 286 Central Anatolia 50.5 1.8 47.7 100.0 83 West Black Sea 55.0 2.5 42.5 100.0 196 East Black Sea 75.9 1.8 22.4 100.0 122 Northeast Anatolia 59.3 0.0 40.7 100.0 53 Central East Anatolia 56.2 7.8 36.0 100.0 47 Southeast Anatolia 64.1 3.5 32.4 100.0 147 Education No education/Primary incomplete 70.5 4.5 24.9 100.0 377 First level primary 53.7 8.8 37.5 100.0 1,297 Second level primary 25.4 20.4 54.3 100.0 172 High school and higher 2.7 6.8 90.5 100.0 698 Wealth quintile Lowest 86.8 2.1 11.1 100.0 487 Second 68.5 6.9 24.6 100.0 487 Middle 38.0 13.6 48.3 100.0 460 Fourth 17.2 14.9 67.9 100.0 464 Highest 2.3 5.8 91.9 100.0 647 Total 40.3 8.4 51.3 100.0 2,544 52 | Characteristics of Survey Respondents Table 3.6 Employment in public or private sector Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by employment in public and private sector according to background characteristics, Turkey 2008 Public/Private sector Background characteristic Public Private Total Number of women Age 15-19 (0.0) (100.0) 100.0 32 20-24 5.2 94.8 100.0 184 25-29 13.3 86.7 100.0 451 30-34 15.8 84.2 100.0 515 35-39 11.6 88.4 100.0 521 40-44 10.9 89.1 100.0 449 45-49 7.3 92.7 100.0 392 Marital status Married or living together 11.9 88.1 100.0 2,348 Divorced/separated/widowed 5.2 94.8 100.0 196 Number of living children 0 14.8 85.2 100.0 282 1-2 15.5 84.5 100.0 1,457 3-4 3.1 96.9 100.0 624 5+ 1.2 98.8 100.0 180 Residence Urban 16.5 83.5 100.0 1,629 Rural 2.2 97.8 100.0 915 Region West 11.3 88.7 100.0 1,221 South 6.6 93.4 100.0 286 Central 14.6 85.4 100.0 521 North 10.5 89.5 100.0 267 East 11.2 88.8 100.0 249 Region (NUTS 1) İstanbul 13.8 86.2 100.0 449 West Marmara 5.4 94.6 100.0 131 Aegean 10.4 89.6 100.0 502 East Marmara 10.1 89.9 100.0 347 West Anatolia 24.7 75.3 100.0 182 Mediterranean 6.6 93.4 100.0 286 Central Anatolia 9.0 91.0 100.0 83 West Black Sea 9.8 90.2 100.0 196 East Black Sea 11.8 88.2 100.0 122 Northeast Anatolia 14.0 86.0 100.0 53 Central East Anatolia 15.0 85.0 100.0 47 Southeast Anatolia 9.3 90.7 100.0 147 Education No education/Primary incomplete 0.5 99.5 100.0 377 First level primary 0.9 99.1 100.0 1,297 Second level primary 0.6 99.4 100.0 172 High school and higher 39.4 60.6 100.0 698 Wealth quintile Lowest 0.3 99.7 100.0 487 Second 0.6 99.4 100.0 487 Middle 2.0 98.0 100.0 460 Fourth 8.8 91.2 100.0 464 Highest 36.2 63.8 100.0 647 Total 11.4 88.6 100.0 2,544 Characteristics of Survey Respondents | 53 Table 3.7 Type of employment Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by type of employment, according to background characteristics, Turkey 2008 Type of employment Background characteristic Employer Waged, worker (regular) Salaried, government official Daily waged (seasonal/ temporal) For her own (regular) For her own (irregular) Unpaid family worker Other Missing Total Number of women Age 15-19 (0.0) (31.4) (0.0) (19.5) (0.0) (0.0) (49.0) (0.0) (0.0) 100.0 32 20-24 0.2 35.5 2.6 10.2 3.7 8.0 39.8 0.0 0.0 100.0 184 25-29 0.7 36.1 10.6 9.6 3.1 12.4 27.1 0.5 0.0 100.0 451 30-34 3.3 28.8 13.6 9.0 4.7 11.8 28.7 0.0 0.1 100.0 515 35-39 1.6 23.0 9.9 15.0 5.6 15.6 28.9 0.3 0.0 100.0 521 40-44 1.7 22.6 9.1 14.8 9.1 11.3 30.9 0.4 0.0 100.0 449 45-49 1.1 20.8 6.9 9.9 6.4 9.5 45.1 0.1 0.0 100.0 392 Marital status Married or living together 1.6 25.6 9.9 12.0 5.3 11.4 33.9 0.3 0.0 100.0 2,348 Divorced/separated/widowed 1.3 45.0 5.2 7.9 8.6 16.7 15.4 0.0 0.0 100.0 196 Number of living children 0 1.9 51.5 12.1 6.0 1.7 6.1 20.8 0.0 0.0 100.0 282 1-2 2.0 29.0 13.4 9.7 6.5 11.8 27.4 0.3 0.0 100.0 1,457 3-4 1.0 16.5 2.1 15.3 5.5 16.1 43.3 0.1 0.1 100.0 624 5+ 0.3 10.6 0.0 24.1 3.8 6.5 54.3 0.5 0.0 100.0 180 Residence Urban 2.5 38.6 13.9 8.3 6.9 16.2 13.3 0.3 0.0 100.0 1,629 Rural 0.1 6.6 1.8 17.8 3.1 4.0 66.5 0.1 0.0 100.0 915 Region West 1.9 37.9 9.2 9.9 7.4 12.9 20.3 0.3 0.0 100.0 1,221 South 2.0 21.6 5.6 25.3 5.2 9.9 29.9 0.5 0.0 100.0 286 Central 1.5 21.9 12.8 7.3 3.1 11.7 41.7 0.0 0.0 100.0 521 North 0.6 11.0 8.5 6.4 4.7 10.2 58.3 0.3 0.0 100.0 267 East 0.8 8.5 10.0 19.8 2.4 10.7 47.6 0.0 0.2 100.0 249 Region (NUTS 1) İstanbul 3.2 51.9 11.2 5.2 7.3 14.6 6.6 0.0 0.0 100.0 449 West Marmara 2.8 33.6 4.4 20.1 6.4 6.7 25.5 0.5 0.0 100.0 131 Aegean 0.8 24.3 8.4 12.7 6.7 6.6 40.5 0.0 0.0 100.0 502 East Marmara 0.9 26.5 9.0 7.8 6.5 17.3 31.2 0.9 0.0 100.0 347 West Anatolia 2.1 34.6 21.1 5.3 2.9 16.7 17.4 0.0 0.0 100.0 182 Mediterranean 2.0 21.6 5.6 25.3 5.2 9.9 29.9 0.5 0.0 100.0 286 Central Anatolia 0.8 17.2 9.7 10.1 1.5 18.4 42.2 0.0 0.0 100.0 83 West Black Sea 1.6 14.8 6.9 4.0 4.9 14.5 53.0 0.2 0.0 100.0 196 East Black Sea 0.3 7.9 10.1 9.1 4.9 3.5 64.0 0.3 0.0 100.0 122 Northeast Anatolia 0.5 5.6 13.5 4.1 3.2 13.0 60.1 0.0 0.0 100.0 53 Central East Anatolia 2.0 14.6 13.0 19.2 1.0 10.2 40.0 0.0 0.0 100.0 47 Southeast Anatolia 0.6 7.8 8.0 25.3 2.6 10.3 45.1 0.0 0.3 100.0 147 Education No education/Primary incomplete 0.1 10.6 0.0 26.8 6.2 11.0 45.0 0.2 0.0 100.0 377 First level primary 1.2 19.9 0.2 13.6 5.1 14.3 45.4 0.2 0.0 100.0 1,297 Second level primary 1.1 41.8 0.0 8.7 11.3 12.8 23.6 0.6 0.0 100.0 172 High school and higher 3.4 45.7 34.3 0.7 4.5 7.4 3.8 0.2 0.0 100.0 698 Wealth quintile Lowest 0.0 5.2 0.2 26.0 2.5 7.5 58.5 0.2 0.0 100.0 487 Second 0.2 12.6 0.0 17.8 5.0 11.7 52.6 0.1 0.0 100.0 487 Middle 0.5 28.4 1.5 11.1 5.2 16.8 36.2 0.1 0.1 100.0 460 Fourth 1.8 40.8 6.5 6.1 6.9 18.4 19.4 0.0 0.0 100.0 464 Highest 4.5 43.8 31.6 0.9 7.4 6.9 4.3 0.6 0.0 100.0 647 Total 1.6 27.1 9.5 11.7 5.5 11.8 32.4 0.2 0.0 100.0 2,544 54 | Characteristics of Survey Respondents 3.4. Social Security Coverage In the TDHS-2008, ever-married women who worked at any time in the 12 months prior to the survey were asked whether they had any social security when they were employed. Information on the type of social security coverage that the woman had was also obtained. Before the establishment of Social Security Institution in 2006, there were three different institutions which provided social security services for workers. These institutions- the Social Insurance Institution (SSK), the Retirement Fund (Emekli Sandığı) and the Social Insurance Institution for the Craftsmen and Artisans and Other Self Employers (Bağ-Kur) -had different retirement regimes. These three institutions under a single roof are still continuing. Therefore, during the TDHS-2008, working women were asked to classify themselves according to their institutions under which they were previously covered. As seen in Table 3.8, 69 percent of women did not have social security while they were working. The SSK had the highest coverage at 20 percent, followed by the Emekli Sandığı with 9 percent. The variation in social security coverage by basic characteristics is very similar to the patterns observed with respect to women’s working and occupation status. Working women who lived in urban areas, in the more developed regions, and women in the higher education group and highest wealth quintiles are more likely to have social security than their counterparts. Considering regional differentials, women were least likely to have social security in the East (84 percent), especially in South East Anatolia (87 percent). 3.5. Health Insurance Coverage All ever-married women age 15-49 interviewed in the TDHS-2008 were asked whether or not they were covered by any health insurance. Health insurance is provided by the three social security institutions and private insurance companies. “Yeşil Kart” is a national program which insures costs of treatments for people who are not covered by any social security system. According to Table 3.9, 16 percent of ever-married women are not covered by any health insurance in Turkey. This figure is 31 percent among women age 15-19 and exceeds 20 percent among rural women, women who have no education or have not completed first level primary school, and women in the two lowest wealth quintiles. In the NUTS1 regions, the proportion of who are not covered by health insurance is under 20 percent, except for Southeast and Northeast Anatolia. Among the different health insurance systems, 48 percent of women are covered by SSK, followed by Yeşil Kart (14 percent). It should be noted that Yeşil Kart use has the widest coverage in the East (40 percent) and for women in the lowest education and wealth quintile categories. Characteristics of Survey Respondents | 55 Table 3.8 Social security coverage Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by social security, according to background characteristics, Turkey 2008 Social security Background characteristic No SSK Emekli Sandığı Bağ-Kur Private Other Missing Total Number of women Age 15-19 (87.0) (13.0) (0.0) (0.0) (0.0) (0.0) (0.0) 100.0 32 20-24 72.1 25.2 2.2 0.0 0.0 0.2 0.2 100.0 184 25-29 58.9 31.8 8.1 1.1 0.1 0.0 0.0 100.0 451 30-34 56.3 25.7 13.2 4.3 0.2 0.2 0.1 100.0 515 35-39 72.6 15.2 9.9 2.2 0.0 0.0 0.0 100.0 521 40-44 74.7 13.1 9.4 2.7 0.0 0.1 0.0 100.0 449 45-49 80.8 10.3 6.9 1.9 0.1 0.0 0.0 100.0 392 Marital status Married or living together 69.1 19.0 9.4 2.3 0.1 0.1 0.0 100.0 2,348 Divorced/separated/widowed 64.0 29.8 4.7 1.5 0.0 0.0 0.0 100.0 196 Number of living children 0 47.1 41.8 9.1 1.9 0.1 0.0 0.0 100.0 282 1-2 61.4 22.8 13.1 2.5 0.1 0.1 0.0 100.0 1,457 3-4 87.5 7.5 2.0 2.7 0.1 0.1 0.1 100.0 624 5+ 95.8 4.2 0.0 0.0 0.0 0.0 0.0 100.0 180 Residence Urban 54.7 29.0 13.1 2.9 0.1 0.1 0.1 100.0 1,629 Rural 93.5 3.6 1.7 1.2 0.0 0.0 0.0 100.0 915 Region West 59.8 29.0 8.8 2.4 0.0 0.0 0.0 100.0 1,221 South 77.8 14.2 5.9 2.1 0.0 0.0 0.0 100.0 286 Central 70.0 14.4 12.1 3.2 0.2 0.2 0.0 100.0 521 North 83.0 7.3 7.9 1.4 0.4 0.0 0.0 100.0 267 East 83.7 6.3 8.4 0.9 0.0 0.4 0.4 100.0 249 Region (NUTS 1) İstanbul 46.2 40.7 10.5 2.6 0.0 0.0 0.0 100.0 449 West Marmara 65.3 28.0 3.4 3.4 0.0 0.0 0.0 100.0 131 Aegean 73.0 16.2 8.4 2.4 0.0 0.0 0.0 100.0 502 East Marmara 69.0 20.4 8.7 2.0 0.0 0.0 0.0 100.0 347 West Anatolia 52.5 24.3 19.9 3.2 0.0 0.0 0.0 100.0 182 Mediterranean 77.8 14.2 5.9 2.1 0.0 0.0 0.0 100.0 286 Central Anatolia 81.8 8.5 9.0 0.8 0.0 0.0 0.0 100.0 83 West Black Sea 79.7 9.9 6.3 3.3 0.5 0.5 0.0 100.0 196 East Black Sea 82.7 5.6 9.2 1.7 0.9 0.0 0.0 100.0 122 Northeast Anatolia 81.4 6.1 10.3 2.3 0.0 0.0 0.0 100.0 53 Central East Anatolia 75.2 11.8 10.1 1.0 0.0 1.0 1.0 100.0 47 Southeast Anatolia 86.9 4.7 7.4 0.4 0.0 0.3 0.3 100.0 147 Education No education/Primary inc. 94.9 3.9 0.0 1.0 0.0 0.1 0.1 100.0 377 First level primary 86.0 11.5 0.2 2.1 0.0 0.1 0.0 100.0 1,297 Second level primary 64.9 31.2 0.0 3.5 0.4 0.0 0.0 100.0 172 High school and higher 23.3 41.1 32.4 2.9 0.2 0.1 0.0 100.0 698 Wealth quintile Lowest 97.3 1.9 0.2 0.5 0.0 0.0 0.1 100.0 487 Second 92.0 7.3 0.0 0.5 0.0 0.3 0.0 100.0 487 Middle 79.3 17.9 1.2 1.4 0.0 0.1 0.1 100.0 460 Fourth 62.4 28.4 5.8 3.1 0.2 0.0 0.0 100.0 464 Highest 26.5 38.0 30.3 5.0 0.2 0.0 0.0 100.0 647 Total 68.7 19.8 9.0 2.3 0.1 0.1 0.0 100.0 2,544 56 | Characteristics of Survey Respondents Table 3.9 Health insurance coverage Percent distribution of ever married women age 15-49 by type of health insurance, according to background characteristics, Turkey 2008 Type of health insurance Background characteristic No SSK Emekli Sandığı Bağ-Kur Private Yesil Kart Other Missing Total Number of women Age 15-19 30.8 38.1 0.9 1.4 0.0 28.4 0.4 0.0 100.0 183 20-24 20.3 51.5 3.0 5.8 0.0 18.9 0.4 0.0 100.0 836 25-29 16.2 51.3 6.4 9.3 0.8 15.5 0.5 0.1 100.0 1,353 30-34 14.3 44.8 11.6 14.1 0.7 14.0 0.4 0.0 100.0 1,379 35-39 17.1 45.6 10.8 12.6 0.4 12.7 0.3 0.5 100.0 1,336 40-44 14.9 45.2 12.8 13.6 0.8 12.2 0.3 0.3 100.0 1,202 45-49 12.7 49.6 14.6 14.5 0.7 7.4 0.3 0.3 100.0 1,115 Residence Urban 14.1 53.3 11.4 10.1 0.7 10.0 0.3 0.2 100.0 5,615 Rural 22.5 29.3 5.3 16.8 0.1 25.3 0.5 0.1 100.0 1,790 Region West 16.2 57.5 8.4 10.7 0.8 5.8 0.3 0.3 100.0 3,252 South 17.6 41.4 7.6 14.4 0.2 18.1 0.6 0.0 100.0 894 Central 14.3 46.9 13.9 15.6 0.6 8.2 0.4 0.1 100.0 1,631 North 10.0 47.1 15.0 12.2 0.3 14.7 0.5 0.1 100.0 477 East 19.9 24.9 8.2 6.5 0.1 39.9 0.4 0.1 100.0 1,151 Region (NUTS 1) İstanbul 16.6 61.3 6.5 8.6 1.6 4.9 0.0 0.6 100.0 1,491 West Marmara 16.6 56.3 6.8 12.1 0.2 8.0 0.0 0.0 100.0 327 Aegean 16.7 50.1 11.8 13.9 0.2 7.1 0.1 0.2 100.0 1,065 East Marmara 13.0 58.3 10.0 14.3 0.1 3.2 1.0 0.0 100.0 759 West Anatolia 13.7 48.7 17.3 12.0 1.1 6.5 0.6 0.1 100.0 717 Mediterranean 17.6 41.4 7.6 14.4 0.2 18.1 0.6 0.0 100.0 894 Central Anatolia 15.5 40.0 11.0 16.7 0.2 15.8 0.5 0.2 100.0 371 West Black Sea 12.3 46.6 12.9 14.0 0.6 12.9 0.5 0.1 100.0 448 East Black Sea 9.1 43.8 15.2 15.5 0.4 16.0 0.0 0.0 100.0 186 Northeast Anatolia 20.7 21.6 11.1 9.3 0.1 36.4 0.5 0.3 100.0 191 Central East Anatolia 15.6 23.8 9.4 4.0 0.1 46.1 0.7 0.3 100.0 327 Southeast Anatolia 22.0 26.6 6.7 6.7 0.2 37.7 0.2 0.0 100.0 628 Education No education/Primary inc. 21.1 31.7 3.7 8.3 0.0 34.6 0.1 0.4 100.0 1,358 First level primary 17.8 49.2 6.2 14.5 0.2 11.4 0.4 0.2 100.0 3,840 Second level primary 17.3 55.4 6.2 8.6 0.3 11.8 0.4 0.0 100.0 643 High school and higher 7.1 53.8 25.8 8.9 2.1 1.8 0.4 0.0 100.0 1,564 Wealth quintile Lowest 26.7 18.9 0.5 7.1 0.0 46.5 0.4 0.1 100.0 1,154 Second 21.7 39.3 3.1 12.8 0.0 22.5 0.3 0.2 100.0 1,429 Middle 17.4 54.8 7.8 11.4 0.1 7.5 0.6 0.3 100.0 1,559 Fourth 12.1 61.5 11.2 12.4 0.2 1.9 0.4 0.3 100.0 1,618 Highest 6.5 54.0 23.1 13.6 2.3 0.3 0.2 0.0 100.0 1,645 Total 16.1 47.5 9.9 11.7 0.6 13.7 0.4 0.2 100.0 7,405 Characteristics of Survey Respondents | 57 3.6 Smoking Status Smoking affects women’s health and may adversely affect their children’s health, especially in terms of vulnerability to respiratory illness. In addition, cigarette use during pregnancy increases the risk of having a small or low birth weight baby. Table 3.10 indicates the percentage of cigarette use among ever-married women according to the basic socio-economic background characteristics and maternity status. To obtain this information, women were first asked about current and past cigarette use. In addition, women who currently smoke cigarettes were asked about the age when they began to smoke and the number of cigarettes they smoked each day. The TDHS-2008 results show that 30 percent of ever-married women have ever smoked and 22 percent of women are currently smoking. This proportion for cigarette use among ever- married women has increased since the TDHS-2003 (28 percent). Women in urban areas and in Istanbul are more likely than women in other areas to use cigarette. As the level of education increases, cigarette use also increases; the percentage of women who have at least a high school education are more than twice as likely to have ever used or be currently using cigarette as women in the lowest educational category (44 and 21 percent, respectively). Similarly, women who are in the highest wealth quintile smoke more than women in lower quintiles. Considering maternity status, one in ten pregnant women currently smoke and 17 percent of women who are breastfeeding are currently using cigarette. The mean age at which ever-married women began smoking cigarettes was 19.3 years. The mean number of cigarettes women reported using during the 24 hours before the survey was 10.5 cigarettes. 58 | Characteristics of Survey Respondents Table 3.10 Use of cigarettes Percentage of ever-married women age 15-49 who ever smoked cigarettes, and the percentage currently smoking, and among ever smokers the mean age they began smoking and the mean number of cigarettes smoked, according to socio-economic background characteristics and maternity status, Turkey 2008 Background characteristic Ever smoked Currently smoking Mean age for beginning smoking Mean number of cigarettes per day Number of smokers Number of woman Age 15-19 (15.0) (8.8) (15.0) (10.8) 27 183 20-24 26.0 19.0 16.3 8.8 217 836 25-29 34.1 26.2 17.7 9.1 461 1,353 30-34 33.8 25.1 18.7 10.1 466 1,379 35-39 27.5 21.4 20.2 11.0 367 1,336 40-44 31.3 25.2 21.5 12.0 376 1,202 45-49 25.2 17.6 21.5 12.1 281 1,115 Residence Urban 33.9 26.0 19.4 10.6 1,903 5,615 Rural 16.4 11.4 18.6 9.7 293 1,790 Region West 35.7 27.7 19.4 10.7 1,159 3,252 South 22.7 18.0 19.6 10.4 203 894 Central 26.3 18.8 19.1 10.7 429 1,631 North 25.5 18.5 19.2 8.6 121 477 East 24.6 17.8 18.8 10.3 283 1,151 Region (NUTS 1) İstanbul 39.0 29.5 19.3 10.6 582 1,491 West Marmara 30.4 24.4 18.9 11.1 100 327 Aegean 28.0 22.4 19.5 11.0 299 1,065 East Marmara 36.3 27.8 19.6 10.5 276 759 West Anatolia 31.4 22.2 19.2 11.1 225 717 Mediterranean 22.7 18.0 19.6 10.4 203 894 Central Anatolia 21.9 15.6 19.3 10.1 81 371 West Black Sea 24.0 17.8 19.1 8.4 108 448 East Black Sea (21.4) (15.5) (19.8) (8.9) 40 186 Northeast Anatolia 25.4 18.5 18.6 10.6 49 191 Central East Anatolia 28.5 20.5 17.8 11.0 93 327 Southeast Anatolia 22.4 16.3 19.6 9.7 141 628 Education No education/Primary incomplete 21.0 14.5 19.1 10.6 286 1,358 First level primary 26.1 19.3 19.3 10.3 1,002 3,840 Second level primary 34.0 27.4 18.2 10.7 218 643 High school and higher 44.1 35.1 19.7 10.7 690 1,564 Maternity status Pregnant 26.2 11.4 17.4 10.0 111 423 Breastfeeding (not pregnant) 26.0 16.5 18.0 8.0 242 932 Neither 30.5 24.1 19.6 10.9 1,843 6,050 Wealth quintile Lowest 18.0 13.0 18.7 9.8 210 1,166 Second 22.0 15.2 18.4 9.7 307 1,397 Middle 26.0 19.0 18.6 10.9 405 1,558 Fourth 34.4 27.7 20.1 10.4 559 1,625 Highest 43.1 33.2 19.6 11.0 715 1,659 Total 29.7 22.4 19.3 10.5 2,196 7,405 Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. Fertility | 59 FERTILITY 4 İsmet Koç, Pelin Çağatay and Tuğba Adalı This chapter presents the TDHS-2008 results on fertility levels, trends, patterns and differentials. The analysis is based on the birth histories collected from ever-married women age 15-49 interviewed during the survey. To obtain this information, women were first asked a series of questions to determine the total number of live births they had in their lifetime. For each live birth, information was then collected on the age, sex, and survival status of the child. For deceased children, age at death was recorded. Information from the birth history is used to assess current and completed fertility and to look at other factors related to fertility, including age at first birth, birth intervals, and teenage childbearing. The level of current fertility is one of the most important topics in this report because of its direct relevance to population policies and programs. Measures of current fertility presented in this chapter include age-specific fertility rates, the total fertility rate, the general fertility rate, and the crude birth rate. The various measures of current fertility are calculated for the three-year period preceding the survey, which roughly corresponds to the calendar period 2006-2008. A three-year period was chosen because it reflects the current situation, while also allowing the rates to be calculated on a sufficient number of cases so as not to compromise the statistical precision of estimates. The following measures of current fertility are derived from birth history data and presented in this chapter: Age-specific fertility rates1 (ASFR) are expressed as the number of births per thousand women in the age group and represent a valuable measure for assessing the current age pattern of childbearing. They are defined in terms of the number of live births during a specified period to women in the particular age group divided by the number of woman-years lived in that age group during the specified period. Total fertility rate (TFR) is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed rates of age-specific fertility. The TFR is obtained by summing the age-specific fertility rates and multiplying by five. General fertility rate (GFR) is the number of live births occurring during a specified period per 1,000 women age 15-44. Crude birth rate (CBR) is the number of births per 1,000 population during a specified period. 1Numerators of age-specific fertility rates are calculated by summing the live births that occurred in the 1-36 months preceding the survey (determined from the date of interview and date of birth of the child), and classifying them by the age of the mother (in five-year age groups) at the time of the child’s birth. The denominators of these rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. Because only women who had ever married were interviewed in the TDHS-2008, the number of women in the denominator of the rates was inflated by factors calculated from information in the household questionnaire on the proportions ever married to produce a count of all women. In this procedure, never married women are presumed not to have given birth. 60 | Fertility 4.1 Current Fertility Table 4.1 presents information on the current fertility levels for Turkey as a whole and for urban and rural areas. The total fertility rate for Turkey is 2.16 births per woman. This rate, which is just above the fertility replacement level (2.10), indicates that the fertility transition in Turkey is ongoing gradually but continuously. As expected, fertility is considerably higher in rural areas than urban areas. The TFR in rural areas is 2.68, which is 34 percent higher than the TFR in urban areas (2.00). When compared with results from previous demographic surveys, the urban- rural gap in fertility levels appears to be closing in Turkey. Considering the age pattern of fertility, the tendency for women to have children early in the childbearing period is still evident in Turkey (Table 4.1 and Figure 4.1). Approximately 70 percent of births take place before age 30. Births to women below age 20 and over age 35, to which morbidity and mortality risks related to pregnancy and birth are the highest, constitute about one-fifth of all births. The TDHS-2008 also documents an important shift in the age pattern of fertility, which is observed for the first time. While the highest age-specific fertility rates were observed in the 20-24 age groups in previous surveys, the 25-29 age group is the cohort with the highest age-specific fertility rate in the TDHS-2008. This picture shows that not only is the overall fertility level declining in Turkey, but also that the age patterns of fertility are changing, as childbearing is increasingly postponed to later ages. At every age rural women bear more children than urban women. The rural age-specific fertility rates rise sharply from age 15-19 to the peak at age 20-24, and then gradually decline. On the other hand, the urban age-specific fertility rates exhibit a more gradual increase to a peak Table 4.1 Current fertility Age-specific and cumulative fertility rates, general fertility rate, and crude birth rate for the three years preceding the survey, by urban-rural residence, Turkey 2008 Age group Urban Rural Total 15-19 32 47 35 20-24 116 159 126 25-29 128 150 133 30-34 86 107 91 35-39 32 51 36 40-44 7 18 10 45-49 0 4 1 TFR 15-49 2.00 2.68 2.16 GFR 15-44 71 92 76 CBR 18.4 19.4 18.6 Note: Rates are for the period 1-36 months preceding the survey. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate expressed per 1,000 population Fertility | 61 in the 25-29 age groups, an indication both of delayed marriage and some deliberate attempt to postpone or terminate births by urban women. Table 4.1 also presents two other summary measures of fertility: the crude birth rate and the general fertility rate. The crude birth rate in Turkey is 18.6 births per 1,000 population. The GFR is 76 per 1,000 women age 15-44. As with TFR, the GFR and CBR also vary by urban- rural residence. Thus, with a GFR of 92, the average annual number of births to rural women is nearly 30 percent higher than that for urban women (71 births per 1,000 women). The CBR in rural areas (19.4 per 1,000) is somewhat higher than the CBR in urban areas (18.4 per 1,000). 4.2 Fertility Differentials Table 4.2 shows several indicators of fertility, including the total fertility rate, the mean number of children ever born to women age 40-49, and the percentage of women age 15-49 who are currently pregnant, by key background characteristics. The mean number of children ever born to women age 40-49 is an indicator of cumulative fertility; it reflects the fertility performance of older women who are nearing the end of their reproductive period. If fertility remains stable over time, the two fertility measures, total fertility rate (TFR) and children ever born (CEB), tend to be very similar. On the other hand, if fertility levels have been falling, the TFR will be substantially lower than the mean CEB among women age 40-49. The percentage of women age 15-49 who are pregnant provides a useful additional measure of current fertility, TDHS-2008 62 | Fertility although it is recognized that it may not capture all early stage pregnancies since some women may be unaware of their pregnancy, or reluctant to disclose a pregnancy in its early stages. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Turkey 2008 Background characteristic Total fertility rate Percentage currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 2.00 3.7 3.10 Rural 2.68 4.7 3.93 Region West 1.73 3.6 2.80 South 2.09 3.7 3.26 Central 2.20 3.3 3.22 North 2.08 2.5 3.11 East 3.27 6.3 5.58 Region (NUTS 1) İstanbul 1.78 3.5 3.01 West Marmara 1.38 2.4 2.46 Aegean 1.91 3.4 2.75 East Marmara 1.80 4.2 2.73 West Anatolia 2.40 3.6 2.84 Mediterranean 2.09 3.7 3.26 Central Anatolia 2.09 3.0 3.92 West Black Sea 1.90 2.8 3.20 East Black Sea 2.10 1.8 3.20 Northeast Anatolia 2.59 4.5 5.27 Central East Anatolia 3.33 6.2 5.69 Southeast Anatolia 3.47 6.9 5.67 Education No education/Primary incomplete 2.65 4.5 4.96 First level primary 2.25 4.0 3.05 Second level primary 1.30 0.9 2.57 High school and higher 1.53 3.1 1.94 Wealth quintile Lowest 3.39 5.9 4.97 Second 2.51 5.0 3.83 Middle 2.19 3.7 3.24 Fourth 1.67 3.3 2.92 Highest 1.36 2.7 2.38 Total 2.16 3.9 3.31 Fertility | 63 Table 4.2 indicates that there are substantial variations in TFR by residence, region, education and wealth

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