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 quintile. The regional variations in fertility are marked, ranging from a high of 3.27 births in the East to a low of 1.73 births in the West. All regions in Turkey, except the East and the Central regions, exhibit TFRs below 2.10, known as replacement level of fertility. Consistent with this finding, among all NUTS 1 regions, the fertility rates are below the replacement level, with the exception of the West Anatolia, and the regions located in the eastern part of Turkey. The TFR is inversely related to the level of education. The TFR decreases rapidly with increasing educational level, from 2.65 births among women with no education to 1.53 births among women who had completed high school or higher. Fertility also decreases with increasing wealth, from 3.39 births among women in the lowest wealth quintile to 1.36 births among women in the highest wealth quintile. Table 4.2 also shows the mean number of children ever born (CEB) to women age 40-49. The comparison of the TFR with the mean CEB among women 40-49 suggests that fertility has fallen sharply in Turkey over the past two decades. Women age 40-49 had an average of 3.31 births during their lifetime, over one birth more than women bearing children will have at the current rates. The decline in fertility implied by a comparison of the current fertility with completed fertility has been greater in rural than in urban areas. The largest implied decline in fertility by region is observed in East region, where the TFR is more than 2 births lower than the mean number of children ever born to women 40-49. The differentials in completed fertility across educational groups are even more striking. The mean number of children ever born is 5 among women age 40-49 with no education, compared with just under 2 among the women who have completed high school or higher. With regard to the trend in fertility, the decline in fertility implied by a comparison of the TFR with the mean CEB is substantial for women in the lowest educational category (2.2 births). Considering wealth quintiles, the comparison suggests that during the past few decades, fertility has fallen by more than one child in all, with the greatest decline occurring among women in the lowest wealth quintile. The TDHS-2008 results show that slightly less than 4 percent of all women at reproductive age were pregnant at the time of the survey. The regional variation in the proportion of pregnant women follows a pattern similar to that of fertility. Surprisingly, the percentage of women who were pregnant is higher for women with high school or higher education than for women with a second level primary education, as it was in the TDHS-2003. This may be due in part to the fact that, on average, highly-educated women are younger than women in the other education categories and thus more likely to be in the family-building stage than other women. The proportion of women currently pregnant declines as the level of household welfare of women, as represented in the wealth quintiles, rises (Table 4.2). 4.3 Fertility Trends In addition to comparison of current and completed fertility, trends in fertility in Turkey can be assessed in two other ways. First, the TFR estimates from the TDHS-2008 can be compared with estimates obtained in earlier surveys. Second, fertility trends can be investigated by using the retrospective data from the birth histories collected in the same survey. This method of examining trends provides a basis for assessing the quality of data that were derived from successive surveys. 64 | Fertility 4.3.1 Comparison with Previous Surveys A comparison of fertility rates obtained from previous demographic surveys conducted during 1978-2003 with the fertility rates from the TDHS-2008 is shown in the Table 4.3 and Figure 4.2. The surveys vary in the time frames for which the TFR estimates are available. For example, the rates from the 1978, 1988 and 1993 surveys are based on births in a one-year period before the survey, while the rates for the TDHS-1998, TDHS-2003 and TDHS-2008 surveys are based on a three-year period before the interview date. Table 4.3 shows that both the level and pattern of fertility has changed during the 1978- 2008 period. The total fertility rate in Turkey, which was over 4 during the late 1970s, decreased to 3 births during the late 1980s and, in the 1990s, stabilized around 2.6 births. The stabilization in fertility observed in the 1990s, gave way to a declining trend in the current decade and the level of fertility dropped to 2.16 births. These findings indicate that total fertility rate in Turkey has declined by 17 percent during the ten-year period between the 1998 and 2008 TDHS surveys. This reduction is especially striking, given the comparatively low overall fertility level during the decade. When the long-term fertility trend is considered, i.e., the trend for the 1978-2008 period, it is observed that total fertility rate decreased from 4.33 to 2.16 in Turkey. In other words, it has almost halved within this 30-year period. Table 4.3 Trends in fertility Age specific fertility rates (per 1,000 women) and total fertility rate, the 1978 Turkey Fertility Survey (TFS), the 1988 Turkey Population and Health Survey (TPHS), and the 1993, 1998, 2003 and 2008 Turkey Demographic and Health Surveys (TDHS) Age at birth TFS- 1978 TPHS- 1988 TDHS- 1993 TDHS- 1998 TDHS- 2003 TDHS- 2008 15-19 93 45 56 60 46 35 20-24 259 193 179 163 136 126 25-29 218 183 151 150 134 133 30-34 154 102 94 93 78 91 35-39 101 55 38 42 38 36 40-44 38 19 12 13 12 10 45-49 2 7 0 1 2 1 TFR 15 49 4.33 3.02 2.65 2.61 2.23 2.16 Note: 1978, 1988 and 1993 rates refer to the year before the survey; 1998, 2003 and 2008 rates refer to the 3-year period before the survey. The trends in age-specific fertility rates for the period of 1978-2008 are presented in Figure 4.2. Between 1978 and 2008, there has been a pronounced decrease in the age-specific fertility rates in almost all age groups. Overall, the age pattern of fertility has not changed remarkably during this period; however, due to the especially marked decline in the fertility rate in 20-24 age group the fertility rate observed for the 25-29 age group is now higher than that of 20-24 cohort for the first time in Turkey. The shift in the peak childbearing rate from the 20-24 to 25-29 age group, Fertility | 65 reflects the increased desire to postpone births to later ages and is one of the most striking results of fertility transition in Turkey. In line with this finding, when the variation in the age pattern of fertility between 2003 and 2008 is considered, the overall reduction in the total fertility rate during this period is mainly due to the declines that occurred in the fertility rates of women in younger age groups. 4.3.2 Retrospective Data from TDHS-2008 Birth Histories One way of examining fertility trends over time is to compare age-specific fertility rates from the TDHS-2008 for successive five-year periods preceding the survey, as presented in Table 4.4 and Figure 4.3. The numerators of the rates are classified by five-year segments of time preceding the survey and the mother’s age at the time of birth. Because women age 50 years and over were not interviewed in the TDHS-2008, the rates for older age groups become progressively more truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 35-39 for the period 15-19 years prior to the survey, because women in that age group would have been 50 years or older at the time of the survey and were not interviewed. The age-specific fertility rates calculated over a 20-year time frame from the TDHS-2008 provide further evidence of a substantial decline in fertility at all ages. The results show that the fertility decline is proportionately greater for women in the prime childbearing ages of 20-29 than women in age 30 and above. Women in the prime childbearing ages experienced an 18 percent decline in fertility in the five years preceding the survey, as opposed to 12 percent 66 | Fertility among women in the age 30 and above. This pattern appears to be in line with that of other populations experiencing fertility decline. What is perhaps more unusual is that there has also been 30 percent decline in fertility among women age 15-19 suggesting that women are waiting later to begin childbearing in Turkey. Table 4.4 Age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age, Turkey 2008 Age at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 15-19 38 55 62 80 20-24 129 155 186 207 25-29 127 148 157 169 30-34 89 93 98 [108] 35-39 38 46 [50] 40-44 10 [17] 45-49 [1] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Table 4.5 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. The decline in fertility has occurred at all marital TDHS-2008 Fertility | 67 durations; however, the decline was greatest among women with longer marital durations. This pattern is not unexpected. Fertility within the first several years of marriage typically remains resistant to change, even when fertility is declining, because fertility decline usually begins among older women who want to stop childbearing, not among young couples postponing births who are likely to have not yet achieved their desired family size. 4.4 Children Ever Born and Children Surviving Data on the number of children ever born reflect the accumulation of life time births women have given and therefore have limited relevance to current fertility levels, particularly when the country has experienced a decline in fertility. Moreover, the data are subject to recall error, which is typically greater for older than younger women. Nevertheless, the information on children ever born (or parity) is useful in looking at a number of issues. The parity data show how average family size varies across age groups. The percentage of women in their forties who have never had children also provides an indicator of the level of primary infertility or the inability to bear children. Voluntary childlessness is rare in developing countries like Turkey, so that married women in their late forties with no live births are predominantly those involuntarily. A comparison of the differences in the mean number of children ever born and surviving reflects the cumulative effects of mortality levels during the period in which women have been bearing children. Table 4.6 shows the percent distribution of all women and currently married women by the number of children ever born and the mean number of children surviving. The distribution of children ever born by age shows that early childbearing is not common in Turkey: nearly 96 percent of women age 15-19 have never given birth. However, this proportion declines rapidly to 33 percent for women age 25-29, and to 7 percent or less among women age 35 and over. Only 2 percent of women age 45-49 have never given birth, indicating that childbearing among women in Turkey is nearly universal. Women who have reached the end of their reproductive period have 3.5 children which is 1.5 higher than the total fertility rate. This difference in between is due to the major decline in fertility that took place in the past decade. Table 4.5 Fertility by marital duration Fertility rates for ever-married women by duration since first marriage in years, for five-year periods preceding the survey, Turkey 2008 Marriage duration at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 0-4 260 291 307 316 5-9 143 149 181 193 10-14 80 91 100 133 15-19 40 53 69 [118] 20-24 15 23 [32] [69] 25-29 3 [13] [69] Note: Age-specific fertility rates are per 1,000 women. Estimates enclosed in brackets are truncated. 68 | Fertility Table 4.6 Children ever born and children surviving Percent distribution of all women and of currently married women by number of children ever born (CEB) and mean number of children ever born and living, according to five-year age groups, Turkey 2008 Age group Number of children ever born (CEB) Total percent Number of women Mean number of CEB Mean number of 0 1 2 3 4 5 6 7 8 9 10+ living children ALL WOMEN 15-19 96.1 3.5 0.4 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,871 0.04 0.04 20-24 65.4 21.1 10.7 2.1 0.6 0.0 0.0 0.1 0.0 0.0 0.0 100.0 1,834 0.52 0.51 25-29 33.2 25.6 25.1 9.7 3.7 1.7 0.6 0.3 0.1 0.0 0.0 100.0 1,751 1.35 1.30 30-34 16.6 17.3 33.5 17.1 7.6 3.9 1.8 1.1 0.4 0.3 0.4 100.0 1,546 2.15 2.05 35-39 7.4 10.0 35.6 22.5 12.2 5.4 2.8 2.0 0.9 0.5 0.7 100.0 1,396 2.75 2.60 40-44 4.5 7.9 34.1 22.9 12.2 8.0 3.0 2.6 2.1 1.4 1.3 100.0 1,223 3.13 2.87 45-49 2.4 6.8 27.3 26.1 15.3 7.7 4.6 3.3 2.3 1.8 2.4 100.0 1,116 3.51 3.16 Total 37.4 13.8 22.2 12.7 6.4 3.3 1.5 1.1 0.7 0.5 0.5 100.0 10,738 1.70 1.60 CURRENTLY MARRIED WOMEN 15-19 59.3 36.5 3.7 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 180 0.46 0.45 20-24 24.0 45.8 23.9 4.6 1.3 0.1 0.0 0.3 0.0 0.0 0.0 100.0 820 1.15 1.13 25-29 12.9 32.8 33.1 12.9 4.8 2.3 0.7 0.4 0.1 0.0 0.0 100.0 1,314 1.76 1.71 30-34 5.5 19.0 37.9 19.7 8.9 4.5 2.1 1.2 0.5 0.4 0.5 100.0 1,326 2.45 2.34 35-39 2.7 9.7 37.5 23.8 13.2 5.8 3.0 2.0 0.9 0.6 0.7 100.0 1,262 2.90 2.74 40-44 2.3 7.0 34.6 24.3 12.7 8.1 3.0 2.9 2.3 1.4 1.5 100.0 1,096 3.25 2.99 45-49 2.2 5.8 27.1 27.2 14.7 8.0 4.7 3.3 2.5 1.9 2.6 100.0 1,002 3.57 3.22 Total 9.0 19.7 32.3 18.7 9.2 4.7 2.2 1.6 1.0 0.7 0.8 100.0 6,999 2.49 2.33 Generally, fertility levels of currently married women are higher for all age groups, especially younger ones. Overall, currently married women age 15-49 have had an average of 3.6 children compared with 3.5 children among all women. Since only ever-married women were interviewed in the TDHS-2008, information on the reproductive histories of never-married women is not available. However, virtually all births in Turkey occur within marriage; thus, in calculating these fertility measures for all women, never-married women were assumed to have had no births. The marked differences between the results for currently married women and for all women at the younger ages are due to the comparatively large numbers of never-married women in those age groups who, as noted, are assumed to have had no births. Consistent with expectations, the mean number of children ever born and mean number of living children rise consistently with increasing age of women, thus presupposing minimal or no recall lapse, which reinforces confidence in the birth history reports. Comparison of the mean number of children ever born with the mean number of living children reveals the experience of child loss among women in Turkey. By the end of their reproductive years (age 45-49), women in Turkey have given birth, on average, to 3.5 children, with 3.2 surviving. This confirms that survival probability of children increases continuously in Turkey. Voluntary childlessness is uncommon in Turkey and currently married women with no children are likely to be those who are unable to bear children. The level of childlessness among married women at the end of their reproductive period can be used as an indicator of the level of primary sterility. The TDHS-2008 results indicate that, in Turkey, primary sterility among older currently married women is 2 percent. Fertility | 69 4.5 Birth Intervals Examination of birth intervals, defined as the length of time between two successive live births, is important in providing insights into birth spacing patterns, which in turn provides information on mother and child health.Short birth intervals increase the risks of maternal and child mortality. Studies have shown that children born less than 24 months after a previous sibling are under risk of poorer health. Short birth intervals also threaten maternal health. Table 4.7 shows the percent distribution of non-first births that occurred in the five years preceding the TDHS-2008 by the number of months since the previous birth. Findings point out long birth intervals in Turkey, and a median birth interval of 44 months. Lengthy breastfeeding and a long period of postpartum amenorrhea are likely to contribute to the relatively high percentage of long birth intervals births in Turkey. Approximately three-fifths of non-first births occur three or more years after the previous birth, while slightly more than one-fifth of births take place 24-35 months after the previous birth. One fifth of children are born after an interval that is considered “too short,” i.e., less than 24 months. A comparison with TDHS-2003 shows that there has been progress on this issue (27 percent). The median birth interval also increased by 22 percent between the surveys, rising from 36 months at the time of the TDHS-2003 to 44 months in the 2008 survey. Birth intervals do not vary much by sex of the preceding child. In general younger women have shorter birth intervals than older women. While 29 percent of women age 20-29 space their births less than 24 months apart, the corresponding statistic for women 30- 39 is 13 percent. Birth intervals also increase with the child’s birth order. The birth interval varies markedly by the survival status of the preceding birth. More than four times as many births occurred within an 18-month interval when the preceding child had died than when the child was still alive. The median birth interval is 45 months if the previous child is living, but falls to 25 months if the preceding child is dead. In general, variations in birth intervals by residence, region, education, and wealth are consistent with differences in fertility levels; i.e., birth intervals are shorter when the TFR is high and longer when TFR is low. Thus, births to urban mothers have a longer median interval than rural births (47.8 months and 34.2 months, respectively). Median birth intervals are shortest in the regions located in the eastern part of Turkey (31-33 months), and significantly longer in West Marmara and West Black Sea regions (56 months each). Births to mothers with with less than primary education have shorter intervals than births to mothers who have high school or higher education. For example, whereas 30 percent of births to mothers who did not attend school or did not complete the first primary level are born less than 24 months after their older sibling, the corresponding statistic for women with high school or higher education is 15 percent. It is worth noting that the percentage of birth intervals shorter than 24 months is low for first level primary school graduates. The median birth interval increases with the wealth quintile, from 30.3 months among non-first births in the lowest wealth quintile to 69.4 months in the highest quintile. 70 | Fertility Table 4.7 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Turkey 2008 Background characteristic Number of months since previous birth Number of non-first births Median number of months since previous birth7-17 18-23 24-35 36-47 48-59 60+ Total Age group 20-29 15.7 13.1 27.0 19.2 10.8 14.2 100.0 1,032 32.8 30-39 6.8 5.8 15.3 10.6 14.8 46.7 100.0 1,047 56.5 40+ 5.8 9.6 15.8 8.8 6.2 53.8 100.0 144 63.5 Birth order 2-3 10.2 9.1 18.6 15.0 13.2 33.8 100.0 1,545 45.7 4-6 12.2 9.0 24.1 12.3 11.4 31.0 100.0 533 40.5 7+ 13.6 15.3 31.9 15.7 7.1 16.3 100.0 152 31.9 Sex of prior birth Male 11.4 9.7 19.4 14.4 12.0 33.1 100.0 1,137 44.7 Female 10.4 9.3 22.4 14.5 12.7 30.8 100.0 1,094 42.9 Survival of prior birth Living 9.9 9.5 20.6 14.7 12.5 32.7 100.0 2,147 44.6 Dead 37.7 8.5 25.4 6.6 9.9 12.0 100.0 84 25.3 Residence Urban 9.3 7.5 19.0 14.4 13.1 36.7 100.0 1,535 47.8 Rural 14.5 13.9 24.9 14.4 10.8 21.4 100.0 696 34.2 Region West 9.1 4.2 19.7 13.7 14.1 39.2 100.0 695 51.8 South 9.8 8.7 21.6 14.4 14.4 31.1 100.0 303 45.2 Central 7.8 8.0 14.3 14.5 12.2 43.2 100.0 441 52.0 North 7.9 10.6 12.9 11.4 24.3 32.8 100.0 114 51.3 East 15.8 16.0 27.3 15.7 7.7 17.5 100.0 679 31.5 Region (NUTS 1) İstanbul 6.2 2.7 23.2 11.8 14.3 41.9 100.0 327 53.0 West Marmara 3.2 1.6 18.8 14.0 13.4 48.9 100.0 41 56.3 Aegean 12.0 5.3 20.6 13.3 13.4 35.4 100.0 272 47.1 East Marmara 9.4 5.4 9.5 18.3 16.5 40.8 100.0 144 54.6 West Anatolia 9.0 8.4 12.1 14.3 14.0 42.3 100.0 214 52.8 Mediterranean 9.8 8.7 21.6 14.4 14.4 31.1 100.0 303 45.2 Central Anatolia 8.3 12.3 15.9 18.7 8.7 36.2 100.0 105 44.0 West Black Sea 7.0 10.1 12.5 10.6 14.9 44.8 100.0 95 56.2 East Black Sea 8.0 9.4 12.7 9.2 28.0 32.7 100.0 52 51.6 Northeast Anatolia 15.7 13.4 28.3 14.8 8.0 19.9 100.0 93 32.3 Central East Anatolia 16.1 14.1 27.3 18.2 6.4 17.9 100.0 182 32.6 Southeast Anatolia 15.7 17.5 27.0 14.8 8.2 16.8 100.0 404 30.6 Education No educ./Prim. inc. 14.2 15.3 26.9 15.6 10.2 17.7 100.0 622 32.8 First level primary 9.5 7.5 20.4 14.6 13.4 34.6 100.0 1,173 46.2 Second level primary 10.2 10.1 17.8 13.8 12.3 35.9 100.0 138 46.8 High school and higher 10.1 5.0 11.2 11.6 12.7 49.4 100.0 299 59.3 Wealth quintile Lowest 16.0 16.5 29.0 14.9 8.6 15.0 100.0 658 30.3 Second 12.0 9.2 25.0 16.0 11.1 26.7 100.0 556 39.1 Middle 11.3 7.3 18.3 13.0 18.9 31.2 100.0 383 48.1 Fourth 3.8 5.6 13.1 17.8 12.4 47.2 100.0 339 57.4 Highest 5.2 1.9 6.9 8.5 14.6 63.0 100.0 296 69.4 Total 10.9 9.5 20.8 14.4 12.4 32.0 100.0 2,231 44.0 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Note: Total includes 8 non-first births to women 15-19, which are not shown separately. Fertility | 71 4.6. Age at First Birth The age at which childbearing commences is an important determinant of the overall level of fertility as well as the health and welfare of the mother and child. Women who marry early are typically exposed to the risk of pregnancy for a longer period, especially when there is little or no contraceptive use. Thus, early childbearing generally leads to a larger family size than later onset of childbearing. A rise in the median age at first birth is typically a sign of transition from high to low fertility. Early childbearing also tends to restrict educational and economic opportunities for women. Table 4.8 presents the percentages of all women by exact age at first birth for different age cohorts. Women under age 25 were not included in the calculation of median ages at first birth because more than half had not yet given birth. Overall, the TDHS-2008 found that, for women 25-49 years old, median age at first birth was 22.3 years. A comparison with the TDHS- 2003 results, where the median age was 21.8 years, indicates that the average age at which women have their first birth increased by a half year during the five-year period between the surveys. An examination of the variations in the median age at first birth across age cohorts shown in the last column of Table 4.8 indicates that the age at first birth has been continuously increasing over the past several decades in Turkey. Women in younger age groups are more likely to give their first births at later ages than women in older age groups. Women aged 25-29 (median age 23.9) give birth for the first time one year later on average than women aged 30-34 (23.0), and 3 years later than women aged 45-49 (21.0). Further evidence of a trend toward delayed onset of childbearing among younger women is found in the changes across age cohorts in the percentages giving birth for the first time at various ages: for example, while 19 percent of women age 45-49 had their first birth by exact age 18, only 7-8 percent of women in the age groups 20-24 and 25-29 had started childbearing by the same age. Table 4.8 Age at first birth Percentage of women who gave birth by specific exact ages, and median age at first birth, by current age, Turkey 2008 Current age Percentage who have never given birth Number of women Median age at first birth Percentage who gave birth by exact age 15 18 20 22 25 15-19 0.1 NA NA NA NA 96.1 1,871 a 20-24 0.7 6.9 17.2 NA NA 65.4 1,834 a 25-29 0.5 8.0 21.9 36.9 56.6 33.2 1,751 23.9 30-34 1.0 10.8 26.6 43.9 64.1 16.6 1,546 23.0 35-39 1.3 11.3 29.3 51.5 72.1 7.4 1,396 21.9 40-44 2.2 15.4 32.0 50.8 72.4 4.5 1,223 21.9 45-49 1.8 18.5 38.9 60.1 79.3 2.4 1,116 21.0 25-49 1.3 12.2 28.9 47.4 67.7 14.5 7,033 22.3 NA = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Table 4.9 presents differentials in the median age at first birth by background characteristics according to the mother’s age at the time of the survey. The median age at first 72 | Fertility birth is higher in urban areas than in rural areas, with a difference of almost one and a half years for all women age 25-49. The results indicate that the urban-rural difference in median age at first birth has increased over time, with a gap of more than two years among younger (25-29) than compared to less than a year among older women (45-49). Among region of residence, İstanbul has the highest median age at first birth (22.9 years) for women age 25-49, while the Central Anatolia Region has the lowest median age at first birth (21.0 years). This indicates that women in the Central Anatolia Region initiated childbearing approximately two years earlier on average than women in İstanbul. There is a positive relationship between educational attainment and median age at first birth. Women with at least second level primary education begin childbearing more than two years (22.7 years) later than women with no education (20.5 years). The data also show that women who belong to the wealthiest quintile had their first child 3 years later than women in the poorest quintile. Table 4.9 Median age at first birth Median age at first birth among women age 25-49 years, by current age, according to background characteristics, Turkey 2008 Current age Women age Background characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 24.4 23.3 22.0 22.2 21.2 22.7 Rural 22.2 21.6 21.0 21.2 20.4 21.3 Region West 24.6 23.7 22.2 22.4 21.3 22.8 South 22.9 22.9 22.5 22.5 22.1 22.7 Central 23.1 22.0 20.9 20.9 20.0 21.4 North 24.6 23.6 22.3 22.5 21.6 22.9 East 22.9 21.6 21.0 21.3 19.8 21.6 Region (NUTS 1) İstanbul a 23.9 21.8 22.8 21.0 22.9 West Marmara 24.2 23.0 22.9 22.4 20.6 22.5 Aegean 23.2 22.6 22.3 21.4 21.2 22.0 East Marmara a 24.5 21.4 21.9 21.9 23.1 West Anatolia 23.1 22.5 21.8 21.9 20.6 22.2 Mediterranean 22.9 22.9 22.5 22.5 22.1 22.7 Central Anatolia 22.4 21.0 20.7 20.5 20.0 21.0 West Black Sea 24.3 22.4 21.8 21.3 20.5 22.0 East Black Sea 24.0 24.0 22.5 22.4 22.0 22.8 Northeast Anatolia 22.3 22.5 21.0 20.2 21.2 21.5 Central East Anatolia 23.2 21.2 21.4 22.0 20.6 21.8 Southeast Anatolia 23.1 21.5 20.7 21.0 18.9 21.4 Education No educ./Primary incomplete 23.0 20.6 20.4 20.3 19.7 20.5 First level primary 23.0 21.7 21.6 21.5 20.7 21.7 Second level primary a 23.7 21.4 21.2 20.7 22.7 High school and higher a 26.2 25.0 24.6 23.8 a Wealth quintile Lowest 21.3 20.9 20.7 21.6 19.9 20.9 Second 21.8 21.6 21.1 21.7 20.7 21.4 Middle 23.8 22.0 21.8 21.1 20.7 22.0 Fourth 24.2 23.0 21.8 21.9 20.8 22.3 Highest a 24.8 23.3 23.0 22.3 24.0 Total 21.3 20.9 20.7 21.6 19.9 20.9 Note: The medians for cohorts 15-19 and 20-24 could not be determined because some women may still have a birth before reaching age 20 or 25, respectively. a=Median ages at first birth for women in some of the categories in the age groups 25-29 and 25-49 cannot be calculated because less than half of these women had a first birth before age 25. Fertility | 73 4.7 Teenage Pregnancy and Motherhood The issue of adolescent fertility is important for both health and social reasons. Adolescent childbearing has potentially negative demographic and social consequences. Children born to very young mothers face an increased risk of illness and death. Teenage mothers, especially those under age 18, are more likely to experience adverse pregnancy outcomes and maternity-related mortality than more mature women. In addition, early childbearing limits a teenager’s ability to pursue educational opportunities and can limit access to job opportunities. Table 4.10 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child and percentage who have begun childbearing, by background characteristics, Turkey 2008 Percentage who Background characteristic Have had a live birth Are pregnant with first child Percentage who have begun childbearing Number of women Current age 15 0.4 0.0 0.4 404 16 1.7 0.5 2.2 392 17 1.3 3.1 4.4 304 18 6.6 3.1 9.7 410 19 9.4 3.5 12.9 360 Residence Urban 3.1 1.9 5.0 1,386 Rural 6.5 2.1 8.6 476 Region West 3.8 1.8 5.5 711 South 3.2 1.3 4.5 265 Central 4.2 3.3 7.5 326 North 3.1 1.5 4.6 121 East 4.4 1.8 6.1 472 Region (NUTS 1) İstanbul 3.3 1.7 5.0 353 West Marmara 4.7 1.2 5.9 56 Aegean 4.8 4.5 9.3 140 East Marmara 2.5 1.3 3.9 224 West Anatolia 2.6 5.0 7.6 80 Mediterranean 3.2 1.3 4.5 265 Central Anatolia 6.4 1.6 7.9 136 West Black Sea 5.0 3.3 8.3 86 East Black Sea 2.7 0.4 3.1 84 Northeast Anatolia 3.9 1.3 5.2 93 Central East Anatolia 7.3 3.1 10.4 91 Southeast Anatolia 3.6 1.5 5.1 287 Education No education/Primary incomplete 5.5 1.6 7.2 424 First level primary 3.4 4.2 7.6 297 Second level primary 0.7 0.3 1.0 4,440 High school and higher 2.6 1.3 3.9 356 Wealth quintile Lowest 6.1 1.9 8.0 416 Second 6.8 4.3 11.1 338 Middle 3.3 1.4 4.8 448 Fourth 2.0 2.3 4.3 291 Highest 1.4 0.4 1.7 300 Total 3.9 2.0 5.9 1,871 74 | Fertility Table 4.10 shows the percentage of women age 15-19 who are mothers or are pregnant with their first child by background characteristics. Teenagers who have never married are assumed to have had no pregnancies and no births. The TDHS-2008 shows that 6 percent of adolescents have started childbearing: 4 percent have had a live birth, and 2 percent are currently pregnant with their first child. Since TDHS-2003, there has been an important decline in the proportion of adolescents who have begun childbearing, from 8 percent to the current level of 6 percent. The proportion of teenagers who have started having children increases rapidly with age. While less than 1 percent of women age 15 have started childbearing, 13 percent of women age 19 is either a mother or is pregnant with their first child. Rural teenagers are more likely than urban teenagers to have started childbearing (9 percent compared with 5 percent). Teenage childbearing varies significantly across region of residence, ranging from 3 percent in East Black Sea Region to 10 percent in Central East Anatolia. Surprisingly, as in the TDHS-2003 (13 percent), women in the Aegean Region have one of the highest levels of teenage childbearing in Turkey, with 9 percent. There is an inverse relationship between early childbearing and education. Teenagers with less education are more likely to start childbearing earlier than better-educated women; 7 percent of teenagers with no education had begun childbearing compared with 4 percent of those with high school and higher education. By wealth status, the proportion of teenagers who have begun childbearing increases from 2 percent among those living in households in the highest wealth quintile to 8-11 percent among those in the second and lowest wealth quintiles. Family Planning | 75 FAMILY PLANNING 5 Banu Akadlı Ergöçmen, Elif Yiğit and F. Hande Tunçkanat One of the major objectives of the TDHS-2008 is to assess the level of knowledge and use of contraceptive methods in Turkey among women of reproductive ages. This chapter focuses on the findings of the TDHS-2008 with respect to knowledge, attitudes and past and current use of different family planning methods. Also, the timing of sterilization is reviewed for those who rely on this method with the purpose of family planning. Special attention is focused on source of contraception, informed choice, nonuse, reasons for discontinuation and intention of future use. 5.1 Knowledge of Family Planning Methods Having adequate information about the family planning methods is crucial in the decision on whether to use a contraceptive method and which method to use. To have familiarity with the contraceptive methods is also an important step, at first toward gaining access to and then using the right contraceptive method. Information about knowledge of contraceptive methods was collected by asking the respondent to name all of the methods or ways they have ever known or heard of by which a couple could delay or avoid pregnancy. For methods which were not mentioned spontaneously, a description of the method was then read by the interviewer and the respondents were asked if they had heard of the method. In this report contraceptive methods are grouped into two types as modern and traditional. Modern methods include: female sterilization, male sterilization, the pill, intrauterine device (IUD), injectables, implants, male condom, female condom, diaphragm, and emergency contraception. Traditional methods include: rhythm method (periodic abstinence) and withdrawal. Any other method mentioned by the respondent was also recorded, including lactational amenorrhoea and folk methods named spontaneously by the respondent. However, it is noteworthy that information obtained through these questions does not reflect the quality of the knowledge. Therefore, information on “knowledge of a family planning method” is simply a sign of having heard of that method. The level of knowledge of contraceptive methods among ever-married women and currently married women by specific methods is presented at Table 5.1. Knowledge of at least one family planning method is almost universal among women; there is almost no difference in the proportions of currently married and ever-married women who have heard a family planning method. Almost all women also know at least one modern method. The most widely known modern methods among both ever-married and currently married women are the IUD (98 percent), the pill (98 percent), male condom (92 percent), female sterilization (92 percent) and injectables (84 and 85 percent respectively for ever and currently married women). Among modern methods, female condom and emergency pills which are new methods for Turkey appear as the least known methods (17 percent and 29 percent respectively). Among traditional 76 | Family Planning methods, knowledge of withdrawal is widespread with at least 92 percent of ever-married and currently married women. The mean numbers of methods recognized by ever-married and currently married women are similar; on average, each ever-married and currently married woman know 7.7 methods. Table 5.1 Knowledge of contraceptive methods Percentage of ever-married women and of currently married women age 15-49 who know any contraceptive method, by specific method, Turkey 2008 Method Ever-married women Currently married women Any method 99.7 99.8 Any modern method 99.5 99.6 Female sterilization 91.5 91.6 Male sterilization 43.0 42.8 Pill 97.8 98.0 IUD 97.9 98.0 Injectables 84.4 84.9 Implants 41.1 41.0 Male condom 92.1 92.3 Female condom 17.1 17.0 Diaphragm 34.7 34.8 Emergency contraception 29.1 29.2 Any traditional method 93.4 93.6 Periodic abstinence 42.9 42.7 Withdrawal 92.0 92.4 Folk method 6.7 6.7 Mean number of methods known 7.7 7.7 Number of women 7,405 6,999 In Table 5.2, the percentage of currently married women who know any method of contraception and any modern method are presented by background characteristics. In all age groups, residential areas, education levels and wealth categories knowledge of any method and any modern method is widespread with at least 98 percent of currently married women having heard of at least one method of contraception and one modern method. Family Planning | 77 Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women age 15-49 who have heard of at least one contraceptive method and who have heard of at least one modern method by background characteristics, Turkey 2008 Background characteristic Heard of any method Heard of any modern method Number of women Age 15-19 99.4 99.1 180 20-24 99.9 99.8 820 25-29 100.0 99.7 1,314 30-34 99.7 99.4 1,326 35-39 99.9 99.8 1,262 40-44 99.8 99.7 1,096 45-49 99.3 99.1 1,002 Residence Urban 99.9 99.8 5,284 Rural 99.5 99.0 1,716 Region West 99.9 99.8 3,049 South 99.5 99.1 849 Central 100.0 99.8 1,542 North 100.0 99.8 455 East 99.3 99.0 1,105 Region (NUTS 1) İstanbul 100.0 99.8 1,379 West Marmara 99.6 99.6 308 Aegean 100.0 99.8 1,010 East Marmara 99.8 99.8 722 West Anatolia 100.0 99.9 679 Mediterranean 99.5 99.1 849 Central Anatolia 99.8 99.4 356 West Black Sea 100.0 100.0 416 East Black Sea 100.0 99.5 180 Northeast Anatolia 100.0 99.7 188 Central East Anatolia 98.7 97.9 318 Southeast Anatolia 99.5 99.3 594 Education No education/Primary incomplete 99.1 98.4 1,274 First level primary 99.9 99.8 3,671 Second level primary 99.9 99.9 594 High school and higher 100.0 100.0 1,461 Wealth quintile Lowest 99.0 98.3 1,094 Second 99.7 99.2 1,366 Middle 100.0 99.9 1,475 Fourth 100.0 100.0 1,512 Highest 100.0 100.0 1,553 Total 99.8 99.6 6,999 78 | Family Planning 5.2 Ever Use of Contraceptive Methods Women interviewed in the TDHS-2008 who said that they had heard of a method of family planning were asked whether they had ever-used that method. Ever use of family planning methods is defined as the use of a contraceptive method at any time during a woman’s reproductive years. Table 5.3 shows the percentages of ever-married and currently married women who have ever used any contraceptive method by specific method and age. Overall, 91 percent of both ever-married and currently married women have used a family planning method at some time. Ever use of modern method (78 percent) and traditional method (64 percent) is slightly higher for currently married women compared to the ever use of these methods for ever-married women (77 percent and 63 percent). The methods most commonly ever used by ever-married women are withdrawal (61 percent), male condom (43 percent), IUD (41 percent) and the pill (34 percent). These are also the most widely used methods among currently married women; however, the percentages who have ever used of withdrawal (62 percent), male condom (44 percent), are slightly higher among currently married women compared to the levels among ever-married women. Table 5.3 Ever use of contraception Percentage of ever-married women and of currently married women age 15-49 who have ever used any contraceptive method by specific method, according to age, Turkey 2008 Modern method Traditional method Age Any method Any modern method Female sterili- zation Male steriliz- ation Pill IUD Inject- ables Im- plants Male condom Female condom Dia- phragm Emer- gency contra- ception Any tradi- tional method Perio- dic absti- nence With- drawal Other Number of women EVER MARRIED WOMEN 15-19 62.3 38.4 0.0 0.0 9.8 5.3 2.8 0.0 26.3 0.0 0.0 1.6 50.0 3.3 48.2 1.4 183 20-24 84.0 65.5 0.6 0.0 24.0 20.0 5.8 0.1 46.3 0.0 1.1 1.3 62.4 2.6 61.1 1.4 836 25-29 92.4 76.9 3.5 0.0 32.6 30.1 9.5 0.4 51.8 0.1 1.5 3.9 67.9 6.6 66.1 1.3 1,353 30-34 92.9 81.0 7.4 0.0 37.6 44.1 10.8 0.2 50.0 0.3 3.1 3.3 66.4 9.2 64.0 1.8 1,379 35-39 93.3 83.5 13.3 0.2 35.4 51.1 8.3 0.1 41.7 0.0 3.4 1.7 62.7 7.3 60.7 1.3 1,336 40-44 90.9 79.1 12.6 0.2 36.4 50.5 5.1 0.3 38.0 0.2 6.4 2.3 60.9 8.1 58.5 1.7 1,202 45-49 90.8 76.1 11.1 0.1 40.8 48.2 4.5 0.1 29.1 0.3 6.7 0.7 59.6 8.5 56.6 2.2 1,115 Total 90.5 76.9 8.2 0.1 34.4 40.8 7.5 0.2 42.7 0.2 3.6 2.3 63.2 7.2 61.1 1.6 7,405 CURRENTLY MARRIED WOMEN 15-19 62.4 38.5 0.0 0.0 9.4 5.4 2.9 0.0 26.7 0.0 0.0 1.6 50.0 3.4 48.0 1.5 180 20-24 84.3 65.6 0.6 0.0 23.6 20.0 5.8 0.1 46.3 0.0 1.2 1.3 62.6 2.7 61.3 1.5 820 25-29 92.4 77.0 3.6 0.0 32.5 30.2 9.3 0.4 51.9 0.1 1.4 3.8 67.7 6.5 66.0 1.3 1,314 30-34 93.5 81.7 7.6 0.0 37.5 44.3 10.8 0.2 50.5 0.4 3.0 3.0 67.2 9.6 64.7 1.8 1,326 35-39 94.2 84.2 13.5 0.2 35.4 51.3 7.6 0.1 42.6 0.1 3.4 1.4 64.0 7.4 62.2 1.3 1,262 40-44 93.1 81.1 13.1 0.2 37.1 51.1 5.5 0.3 39.5 0.0 6.4 2.1 62.7 8.8 60.4 1.6 1,096 45-49 92.1 77.7 11.5 0.2 41.1 48.5 5.0 0.1 30.6 0.3 7.0 0.8 61.0 8.5 58.5 1.9 1,002 Total 91.3 77.6 8.3 0.1 34.3 40.7 7.5 0.2 43.7 0.1 3.6 2.2 64.2 7.4 62.1 1.6 6,999 Note: Other includes folk methods and LAM. Family Planning | 79 Across age groups, ever use of any family planning method is the lowest among ever- married and currently married women in the 15-19 age group. After age 25, the percentages who have ever used family planning exceeds 90 percent in all cohorts. 5.3 Current Use of Contraceptive Methods As shown in Table 5.4, the contraceptive prevalence rate (percentage of currently married women age 15-49 who are currently using any method of family planning) at the time of the survey is 73 percent. Forty-six percent of currently married women use a modern contraceptive while 27 percent use a traditional method. Table 5.4 Current use of contraception by age Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to age, Turkey 2008 Modern method Traditional method Age Any method Any modern method Female sterili- zation Male steriliz- ation Pill IUD In- ject- ables Im- plants Male con- dom Female con- dom Dia- phragm Any tradi- tional method Perio- dic anst nence With- drawal Other Not currently using Total Number of women 15-19 40.2 17.6 0.0 0.0 4.0 3.8 0.8 0.0 9.1 0.0 0.0 22.6 0.0 21.1 1.4 59.8 100.0 180 20-24 63.4 37.4 0.6 0.0 5.8 11.7 1.2 0.0 18.1 0.0 0.0 26.0 0.0 25.6 0.4 36.6 100.0 820 25-29 73.6 47.2 3.6 0.0 7.3 15.9 1.7 0.2 18.4 0.0 0.1 26.3 0.5 25.6 0.3 26.4 100.0 1,314 30-34 78.6 51.5 7.6 0.0 8.4 18.8 1.1 0.0 15.4 0.1 0.1 27.1 0.6 26.5 0.1 21.4 100.0 1,326 35-39 83.8 57.2 13.5 0.2 5.1 23.0 0.5 0.0 14.6 0.0 0.2 26.6 0.7 25.6 0.4 16.2 100.0 1,262 40-44 78.7 46.0 13.1 0.2 2.4 18.8 0.4 0.0 11.1 0.0 0.1 32.6 0.8 31.8 0.0 21.3 100.0 1,096 45-49 58.9 35.1 11.5 0.2 2.1 12.4 0.2 0.0 8.4 0.0 0.3 23.8 0.8 22.8 0.2 41.1 100.0 1,002 Total 73.0 46.0 8.3 0.1 5.3 16.9 0.9 0.0 14.3 0.0 0.1 27.0 0.6 26.2 0.2 27.0 100.0 6,999 Note: Other includes folk methods and LAM. The findings indicate that around one in every four currently married women uses withdrawal. The most commonly used modern method among currently married women is IUD, which is used by 17 percent of women. The second most widely used modern method is male condom (14 percent). It is also noteworthy that female sterilization is used by 8 percent of currently married women, which is a larger proportion than that using the pill (5 percent). Use of any contraceptive method varies by age of women. Current use of any method is lowest among currently married women age 15-19 (40 percent), then rises to a peak of 84 percent in the 35-39 age group and subsequently declines to 59 percent among currently married women age 45-49. The most popular method among women at all ages is withdrawal; withdrawal use peaks at 32 percent among women age 40-44. The highest IUD use rate is found among women age 35-39 age group (23 percent). 80 | Family Planning Table 5.5 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Turkey 2008 Modern method Traditional method Background characteristic Any method Any modern method Fe- male steril. Male steril. Pill IUD In- Ject ables Im- plants Male con- dom Fe- male con- dom Dia- prhagm Any tradi- tional method Rhy thm With- drawal Other Not Cur- rently using Total Num- ber of women Number of living children 0 28.0 15.2 0.3 0.0 4.8 0.3 0.0 0.0 9.8 0.0 0.0 12.8 0.6 12.0 0.3 72.0 100.0 636 1-2 78.1 49.0 4.1 0.1 5.7 19.0 0.9 0.1 19.1 0.0 0.1 29.1 0.7 28.1 0.2 21.9 100.0 3,836 3-4 79.1 50.2 16.0 0.2 5.0 19.1 0.8 0.0 9.0 0.0 0.2 28.9 0.4 28.2 0.3 20.9 100.0 1,938 5+ 68.7 45.8 19.5 0.0 4.9 13.6 1.8 0.0 5.8 0.0 0.3 22.9 0.1 22.8 0.1 31.3 100.0 589 Residence Urban 74.3 47.8 8.3 0.1 5.6 17.5 0.8 0.0 15.4 0.0 0.1 26.5 0.7 25.6 0.2 25.7 100.0 5,284 Rural 68.9 40.4 8.5 0.0 4.6 15.0 1.1 0.0 11.0 0.0 0.3 28.6 0.2 28.0 0.3 31.1 100.0 1,716 Region West 76.3 48.2 8.4 0.1 5.8 17.4 0.8 0.0 15.5 0.0 0.1 28.1 0.5 27.1 0.4 23.7 100.0 3,049 South 70.4 45.8 10.0 0.0 4.1 18.3 0.5 0.0 12.9 0.0 0.0 24.6 0.6 24.1 0.0 29.6 100.0 849 Central 75.5 48.8 6.4 0.1 4.9 18.4 0.9 0.1 17.8 0.1 0.1 26.7 0.9 25.7 0.1 24.5 100.0 1,542 North 75.6 41.4 12.9 0.0 5.2 9.8 0.9 0.0 12.0 0.0 0.5 34.2 0.4 33.6 0.2 24.4 100.0 455 East 61.4 37.8 7.7 0.0 5.6 15.1 1.3 0.0 8.1 0.0 0.1 23.5 0.3 22.9 0.3 38.6 100.0 1,105 Region (NUTS 1) İstanbul 74.3 45.4 8.5 0.2 4.9 18.4 1.3 0.0 12.2 0.0 0.0 28.9 0.4 28.3 0.2 25.7 100.0 1,379 West Marmara 76.2 46.4 7.4 0.0 5.6 17.1 0.4 0.0 15.6 0.0 0.4 29.7 0.6 29.2 0.0 23.8 100.0 308 Aegean 80.0 53.1 7.0 0.2 6.0 17.8 0.6 0.0 21.6 0.0 0.0 26.9 0.7 25.5 0.6 20.0 100.0 1,010 East Marmara 76.8 45.9 8.8 0.0 6.4 14.0 0.4 0.0 15.9 0.0 0.3 30.9 1.0 29.7 0.2 23.2 100.0 722 West Anatolia 75.7 51.6 6.1 0.3 5.1 19.2 0.8 0.3 19.7 0.0 0.1 24.2 0.9 23.3 0.0 24.3 100.0 679 Mediterranean 70.4 45.8 10.0 0.0 4.1 18.3 0.5 0.0 12.9 0.0 0.0 24.6 0.6 24.1 0.0 29.6 100.0 849 Central Anatolia 72.2 47.8 8.4 0.0 6.1 20.7 0.6 0.0 11.8 0.0 0.2 24.4 0.9 23.2 0.2 27.8 100.0 356 West Black Sea 77.5 46.0 10.8 0.0 5.6 13.0 1.2 0.0 15.0 0.2 0.2 31.5 0.1 31.1 0.2 22.5 100.0 416 East Black Sea 68.2 35.4 13.0 0.0 3.4 8.0 1.3 0.0 8.9 0.0 0.7 32.7 0.8 31.9 0.0 31.8 100.0 180 Northeast A. 70.4 44.6 4.7 0.0 7.2 23.6 2.0 0.0 6.9 0.0 0.1 25.8 0.5 24.2 1.2 29.6 100.0 188 Central East A. 62.3 34.0 8.4 0.0 5.3 13.2 0.5 0.0 6.6 0.0 0.0 28.3 0.1 27.6 0.5 37.7 100.0 318 Southeast A. 57.8 37.9 8.1 0.0 5.4 13.5 1.4 0.0 9.3 0.0 0.1 19.9 0.3 19.6 0.1 42.2 100.0 594 Education No/Prim. inc 60.8 35.3 12.3 0.0 3.1 13.4 0.8 0.0 5.6 0.0 0.1 25.5 0.0 24.8 0.7 39.2 100.0 1,274 First level prim. 76.8 46.8 9.5 0.1 5.3 18.2 0.9 0.0 12.6 0.0 0.1 30.0 0.3 29.5 0.2 23.2 100.0 3,671 Sec.level prim. 66.5 40.7 3.0 0.0 5.2 15.0 0.9 0.3 16.1 0.0 0.3 25.8 0.7 25.0 0.1 33.5 100.0 594 High and higher 76.7 55.3 3.9 0.1 7.3 17.4 0.8 0.0 25.4 0.1 0.1 21.4 1.7 19.7 0.0 23.3 100.0 1,461 Wealth quintile Lowest 63.3 38.0 9.5 0.0 4.7 13.8 1.8 0.0 8.0 0.0 0.2 25.3 0.0 24.8 0.5 36.7 100.0 1,094 Second 70.5 40.9 8.9 0.0 5.6 17.4 0.6 0.0 8.3 0.0 0.1 29.6 0.3 28.9 0.5 29.5 100.0 1,366 Middle 75.3 47.0 8.8 0.0 4.3 19.0 1.0 0.0 13.8 0.0 0.0 28.3 0.3 27.9 0.0 24.7 100.0 1,475 Fourth 73.8 46.9 8.2 0.2 6.1 15.7 0.5 0.0 16.0 0.0 0.1 27.0 1.1 25.5 0.3 26.2 100.0 1,512 Highest 79.1 54.3 6.7 0.2 5.8 17.7 0.6 0.1 22.9 0.1 0.2 24.8 0.9 23.9 0.0 20.9 100.0 1,553 Total 73.0 46.0 8.3 0.1 5.3 16.9 0.9 0.0 14.3 0.0 0.1 27.0 0.6 26.2 0.2 27.0 100.0 6,999 Note: Other includes folk methods and LAM. Current use of contraceptive methods varies according to background characteristics of women (Table 5.5). Current use of family planning increases rapidly after women have a child. Twenty-eight percent of currently married women with no children use family planning and the level increases to 78 percent for women with 1 or 2 living children. The level of current use drops off to 69 percent among women with five or more living children. Family Planning | 81 As regards the place of residence and region, there are marked differences in the percentages of women using a contraceptive method at the time of survey. In urban areas the percentage of women using a method of family planning is higher (74 percent) than that among women residing in rural areas (69 percent). Much of the urban-rural gap in family planning use is due to the greater use of modern methods among urban women (48 percent) compared with rural women (40 percent). Among the five regions, the lowest current use of contraception is observed in the East. Current use is 76 percent in the West, Central and North regions. However, it is noteworthy that in the North current use of any modern method is lower than in any of the other regions except the East while current use of any traditional method is higher in the North (34 percent) than in the remaining regions. With regard to NUTS 1 regions, current use is lowest in the Southeast Anatolia (58 percent) and highest in the Aegean Region (80 percent). As to the method mix of five regions (Figure 5.1), the North region has the lowest IUD use (10 percent) and the highest female sterilization (13 percent) and withdrawal use (34 percent). When the NUTS 1 regions are considered (Table 5.5), the East Black Sea has the highest use of female sterilization (13 percent) and the lowest rates of use of the IUD and the pill (8 percent and 3 percent respectively). The highest proportion of currently married women using withdrawal (32 percent) among the NUTS 1 regions is also observed in the East Black Sea (Table 5.5). The level of current use of family planning is lowest among women who never attended school or did not complete primary school (61 percent) and rises, although not uniformly, with education to 77 percent among women with a high school or higher education. Somewhat surprisingly, the level of use among women with a second level primary education (67 percent) TDHS-2008 82 | Family Planning is lower than the use rate among women with first level primary education (77 percent). Because second level primary education was introduced relatively recently, it includes a comparatively high proportion of younger women, which helps to explain the somewhat lower use rate. Differences in use of family planning methods are also apparent by wealth quintile. Contraceptive use is lowest in the lowest wealth quintile (63 percent) and it gradually rises to 79 percent in the highest wealth quintile. Current use of any modern method ranges from 38 percent of currently married women in the lowest wealth quintile to 54 in the highest quintile. Second wealth quintile has the highest proportion (30 percent) for current use of any traditional method. 5.4 Trends in Current Use of Family Planning Table 5.6, presents the trends in the use of contraceptive methods in Turkey for the last 20 years. The contraceptive use in Turkey was stable at around 63 percent in the 10-year period from 1988 to 1998 and then increased substantially in the following decade, reaching 71 percent in 2003 and 73 percent in 2008 (Table 5.6). The modern contraceptive use rose over the last 20- year period, from 31 percent to 46 percent. In line with the increase in the use of modern methods, an overall decline has been observed in traditional methods although use of withdrawal remained almost at the same level. Table 5.6 Trends in current use of contraception Percent distribution of currently married women age 15-49 by contraceptive method currently used, TPHS-1988, TDHS-1993, TDHS-1998, TDHS-2003 and TDHS-2008 Contraceptive method TPHS-1988 TDHS-1993 TDHS-1998 TDHS-2003 TDHS-2008 Any method 63.4 62.6 63.9 71.0 73.0 Any modern method 31.0 34.5 37.7 42.5 46.0 Pill 6.2 4.9 4.4 4.7 5.3 IUD 14.0 18.8 19.8 20.2 16.9 Male condom 7.2 6.6 8.2 10.8 14.3 Female sterilization 1.7 2.9 4.2 5.7 8.3 Other modern methods 2.0 1.3 1.1 1.1 1.1 Any traditional method 32.3 28.1 26.1 28.5 27.0 Periodic abstinence 3.5 1.0 1.1 1.1 0.6 Withdrawal 25.7 26.2 24.4 26.4 26.2 Other traditional methods 3.1 0.9 0.6 1.0 0.2 Not currently using 36.6 37.4 36.1 29.0 27.0 Total 100.0 100.0 100.0 100.0 100.0 Family Planning | 83 Figure 5.2, shows the trend in family planning use for selected methods between 1993 and 2008. Overall, there has been significant change in the level of modern method use since 1993 from 35 percent to 46 percent in 2008. However, the pace of change in modern method use was not as rapid during the period between the TDHS-2003 and the TDHS-2008 as it was between TDHS-1998 and TDHS-2003. Much of the overall increase in use rates during the 15 years preceding the TDHS-2008 has been due to greater use of male condom and female sterilization. Use of the pill remained essentially stable over the period since 1993 while use of the IUD dropped off slightly, from 19 percent to 17 percent. The prevalence of withdrawal as a traditional method did not changed significantly, with around 1 in every 4 married couple using withdrawal throughout the period. Table 5.7 shows the trend in contraceptive use by residence and region during the last 15 years. The use of modern contraceptive methods increased in both urban and rural areas and in all regions over the period. The trend in the use of traditional methods was more erratic during the entire period; however, use of traditional methods declined in all residential categories between the 2003 and 2008. Overall, the increase in use of all contraceptive methods was greater over the 15-year period in rural areas (23 percent) and in the Central, North, and, especially, East regions (20 percent, 18 percent, and 45 percent, respectively) than that observed for Turkey as a whole (17 percent). TDHS-2008 84 | Family Planning Table 5.7 Trends in current use of contraception by residence and region Percentage of currently married women 15-49 currently using any method, a modern method and a traditional method by residence and region, TDHS-1993, TDHS-1998, TDHS-2003 and TDHS-2008 Residence Region Surveys Urban Rural West South Central North East Total TDHS-1993 Any method 66.2 56.1 71.5 62.8 62.7 64.2 42.3 62.6 Any modern 38.9 26.8 37.3 36.7 36.6 29.8 26.3 34.5 Any traditional 27.3 29.3 34.2 26.0 26.1 34.4 16.0 28.1 TDHS-1998 Any method 66.7 58.1 70.5 60.3 68.3 67.0 42.0 63.9 Any modern 40.8 31.4 40.5 35.1 42.8 35.2 26.7 37.7 Any traditional 25.2 31.4 29.2 24.6 24.7 31.5 15.2 25.5 TDHS-2003 Any method 73.6 64.5 74.2 70.8 74.2 71.9 57.9 71.0 Any modern 45.8 34.4 45.7 44.8 46.6 32.5 31.4 42.5 Any traditional 27.8 30.1 28.6 26.0 27.6 39.4 26.5 28.5 TDHS-2008 Any method 74.3 68.9 76.3 70.4 75.5 75.6 61.4 73.0 Any modern 47.8 40.4 48.2 45.8 48.8 41.4 37.8 46.0 Any traditional 26.5 28.6 28.1 24.6 26.7 34.2 23.5 27.0 5.5 Number of Children at First Use of Contraception Table 5.8 shows the distribution of ever-married women by current age group and number of living children at the time of first use of contraception. This information is useful in identifying the stage in the family-building process when women begin using family planning as well as their motivation for using family planning. Table 5.8 Number of children at first use of contraception Percent distribution of ever-married women age 15-49 by number of living children at the time of first use of contraception, according to current age, Turkey 2008 Number of living children at time of first use of contraception Current age Never used 0 1 2 3 4+ Missing Total Number of women 15-19 37.7 37.6 22.8 1.3 0.6 0.0 0.0 100.0 183 20-24 16.0 36.4 40.0 6.6 0.7 0.2 0.2 100.0 836 25-29 7.6 38.4 40.1 9.5 2.1 2.1 0.2 100.0 1,353 30-34 7.1 30.6 40.2 12.7 5.1 4.0 0.2 100.0 1,379 35-39 6.7 18.8 42.7 18.3 7.0 6.5 0.0 100.0 1,336 40-44 9.1 16.0 37.5 18.8 8.5 9.7 0.4 100.0 1,202 45-49 9.2 11.3 34.6 18.0 13.4 13.5 0.0 100.0 1,115 Total 9.5 25.5 38.9 13.9 6.1 5.9 0.2 100.0 7,405 The results indicate that overall women in Turkey are adopting family planning at lower parities; 26 percent of ever-married women begin using contraception before they gave birth, and an additional 39 percent began after having one child (Table 5.8). Early use of family planning is higher among younger women; 38 percent of ever-married women age 15-19 started contraceptive use before they began having children compared with 11 percent of ever-married Family Planning | 85 women age 45-49. The pattern implies that younger women are adopting family planning to delay or space births, while older women are adopting family planning to limit births. 5.6 Knowledge of the Fertile Period Successful use of natural family planning methods depends largely on an understanding of when during the menstrual cycle a woman is most likely to conceive. An elementary knowledge of reproductive physiology is thus the foundation for the successful practice of coitus-associated methods such s withdrawal, and especially, periodic abstinence. In the TDHS-2008, women were asked whether there are certain days a woman is more likely to become pregnant if she has sexual intercourse. Those who responded affirmatively to that question were asked whether this time is just before the period begins, during the period, right after the period ends or halfway between two periods. Overall, 26 percent of ever-married women reported the correct timing of the fertile period (Figure 5.3). Thirty percent do not know when the fertile period is. The small number of periodic abstinence users was considerably more knowledgeable than the average women. 5.7 Timing of Female Sterilization The results in Table 5.9 show that 61 percent of ever-married women who are sterilized had had the operation between ages 25 and 34, while 11 percent were sterilized before age 25 and 28 percent after age 35. The median reported age at female sterilization was 31.5 years. A comparison of this figure with the median ages at sterilization reported in three previous surveys TDHS-2008 86 | Family Planning (31.8 in the TDHS-1993, 31.7 in TDHS-1998, and 31.6 in TDHS-2003) shows that the median age at sterilization has not changed substantially over the past 15 years in Turkey. Table 5.9 Timing of female sterilization Percent distribution of sterilized ever-married women age 15-49 by age at the time of sterilization and median age at sterilization, according to the number of years since the operation, Turkey 2008 Age at time of sterilization Years since operation <25 25-29 30-34 35-39 40-44 45-49 Total Number of women Median age1 <2 11.5 17.8 34.7 25.8 9.7 0.6 100.0 107 32.3 2-3 8.5 14.4 40.9 24.0 11.0 1.3 100.0 117 33.0 4-5 4.1 25.6 41.1 20.9 8.4 0.0 100.0 80 32.2 6-7 4.0 29.7 22.1 36.5 7.7 0.0 100.0 90 32.7 8-9 (12.1) (13.8) (42.6) (29.4) (2.2) 0.0 100.0 39 31.9 10+ 19.5 39.2 34.1 7.2 0.0 0.0 100.0 175 a Total 11.2 25.8 35.2 21.3 6.2 0.4 100.0 607 31.5 a = not calculated due to censoring 1Median ages are calculated only for women sterilized at less than 40 years of age to avoid problems of censoring Note: Parentheses indicate that a figure is based on 25-49 unweighted cases 5.8 Source for Family Planning Methods Information on where women obtain their contraceptives is useful for family planning programme managers and implementers for logistic planning. In the TDHS-2008, women who reported using a modern contraceptive method at the time of the survey were asked where they had obtained the method the last time they acquired it. The results suggest that, in Turkey, public sector providers are the generally preferred source for modern contraceptives. Of the modern method users, 61 percent named a public sector provider as the source of their method, 35 percent mentioned a private sector source and the remaining 4 percent reported using other sources, such as markets/shops (Table 5.10). Among public sector providers, health centers/health houses, government hospitals, and maternity houses are most often cited as the source for modern methods (33 percent, 15 percent and 7 percent respectively). Among private sector providers, private hospitals and pharmacies are the main sources of supply (7 percent and 23 percent respectively). With regard to sources for specific methods, public sector providers are the principal source for female sterilization and the IUD; 8 in every 10 women who had had female sterilization report that the operation took place in a public institution. Similarly, 78 percent of IUD users obtain the method from a public institution, most often from health center/health house. Pills are obtained primarily from pharmacies (62 percent), followed by health centers/health houses (34 percent). Pharmacies (48 percent) also are the principal source for male condoms, followed again by health centers/ health houses (38 percent). Markets/shops are the providers of condom for 12 percent of users. The trend in the sources for modern methods during the five-year period between the TDHS 2003-and TDHS-2008 is presented in Table 5.11. As regards the pill, IUD and condom, the proportion of users relying on public sector sources increased during the period. During the period, the proportion of condom users served by market/shops also doubled. Family Planning | 87 Table 5.10 Source of supply for modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Turkey 2008 Pill IUD Male condom Female sterili- zation All other modern methods1 All modern methods Public sector 36.8 78.0 39.1 80.0 47.4 60.9 Government hospital 1.2 15.1 0.4 46.1 11.1 14.7 Maternity house 0.9 8.0 0.1 18.5 2.9 6.6 MCHFP Centre 1.1 7.2 0.6 0.0 1.1 3.0 Health Centre/ Health house 33.5 44.8 37.9 0.1 23.6 32.6 SSK Hospital/Dispensary 0.0 1.1 0.0 9.0 3.8 2.2 Training and Research hospital 0.0 0.0 0.0 1.4 3.7 0.3 Family Health Centre/Family Doctor 0.0 1.8 0.0 0.0 1.2 0.7 University Hospital 0.0 0.1 0.0 4.7 0.0 0.9 Other public sector 0.1 0.1 0.0 0.0 10.0 0.0 Private medical 62.6 21.9 48.0 18.9 51.3 34.8 Private hospital/Polyclinic 0.1 9.9 0.0 17.9 0.0 7.0 Private Doctor 0.7 10.7 0.0 1.0 3.1 4.2 Private Midwife/Nurse 0.0 0.1 0.0 0.0 0.8 0.0 Pharmacy 61.5 0.8 47.9 0.0 47.3 23.3 Other private sector 0.2 0.4 0.1 0.0 0.0 0.2 Other private 0.2 0.0 12.4 0.0 1.3 3.9 Market/Shop 0.0 0.0 12.3 0.0 0.0 3.8 Friends, relatives 0.2 0.0 0.1 0.0 1.3 0.1 Other 0.2 0.0 0.1 0.2 0.0 0.1 DK/Missing 0.2 0.1 0.3 0.9 0.0 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 374 1,182 1,002 607 78 3,243 1 Includes users of modern methods other than those of given in the table. Table 5.11 Trends in source of supply for selected modern methods Percent distribution of current users of the female sterilization the pill, the IUD and the male condom by the most recent source of supply of the method, Turkey 2008 Female Sterilization Pill IUD Male condom Source of supply for method TDHS 2003 TDHS 2008 TDHS 2003 TDHS 2008 TDHS 2003 TDHS 2008 TDHS 2003 TDHS 2008 Public sector 82.0 81.0 30.6 36.8 71.3 78.0 34.1 39.1 Private sector 16.3 18.9 67.5 62.6 27.6 21.9 59.3 48.0 Other 1.0 0.2 1.6 0.4 1.0 0.0 6.3 12.6 Unknown 0.6 0.9 0.2 0.2 0.0 0.1 0.1 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 88 | Family Planning Table 5.12 Informed choice Among current users of modern contraceptive methods who adopted the current method in the five years preceding the survey, percentage who were informed about the side effects of the method used, percentage who were informed what to do if side effects were experienced, and percentage who were informed of other methods that could be used for contraception by specific method, and background characteristics, Turkey 2008 Background characteristic Informed about side effects or problems of method used Informed what to do if experienced side effects Informed of other methods that could be used Modern method Female sterilization 45.4 38.4 33.4 Male sterilization 100.0 100.0 100.0 Pill 62.0 50.1 53.1 IUD 70.7 68.6 44.5 Injectables 74.7 53.1 62.0 Male condom 26.2 21.0 39.0 Female condom 0.0 0.0 100.0 Diaphragm 25.1 25.1 55.1 Residence Urban 51.2 45.4 44.4 Rural 46.2 40.1 37.1 Region West 53.1 47.8 46.8 South 56.2 49.4 48.5 Central 45.7 40.6 39.7 North 46.5 35.6 46.0 East 45.4 38.8 30.8 Region (NUTS 1) İstanbul 53.1 48.3 49.7 West Marmara 50.7 39.8 40.9 Aegean 51.2 50.3 46.6 East Marmara 52.6 40.4 43.1 West Anatolia 46.6 42.0 40.8 Mediterranean 56.2 49.4 48.5 Central Anatolia 45.3 42.5 35.0 West Black Sea 42.2 33.3 43.3 East Black Sea 58.0 50.5 43.5 Northeast Anatolia 58.6 45.1 41.1 Central East Anatolia 45.0 36.0 26.5 Southeast Anatolia 41.0 37.8 29.0 Education No education/Primary incomplete 46.5 40.4 25.7 First level primary 51.7 46.1 41.8 Second level primary 46.0 39.5 44.6 High school and higher 50.5 44.3 51.5 Wealth quintile Lowest 46.2 41.1 30.7 Second 49.4 44.2 37.6 Middle 51.4 47.3 42.1 Fourth 49.4 42.9 43.0 Highest 52.6 44.6 53.7 Total 50.2 44.3 42.9 Number 1,941 1,941 1,941 Family Planning | 89 5.9 Informed Choice Women who are well informed about the side effects and problems associated with methods and know of a range of method options are better placed to make an informed choice about the method they would like to use. To obtain information on these issues, current users of various modern contraceptive methods were asked whether they were informed of the possible side effects and what they should do if they experience any side effects, at the time they adopted their method; they were also asked whether they were informed about other methods. Table 5.12 presents information on three aspects of informed choice. Half of the current users of modern contraceptive methods who adopted the current method in the five years preceding the survey were informed about potential side effects of their method. Forty-four percent were told what to do if they experience any side effects, and 43 percent were given information about other family planning methods. Considering the results by methods, users of injectables and IUDs appear to be better informed than users of other methods about potential side effects of the method used (75 percent and 71 percent respectively). Women living in the urban areas, women with higher levels of education and women who are in the top two wealth quintiles are more likely to be informed about the side effects or problems of the method, what to do if they experience side effects and other contraceptive options than their counterparts. Women living in the East region generally appear to have less access to informed choice than women in other regions. 5.10 Discontinuation of Contraceptive Use Reproductive goals can only be realized when couples use contraceptive methods effectively and continuously. In countries like Turkey where ideal family size has declined and contraceptive prevalence has risen, contraceptive effectiveness becomes an increasingly important determinant of fertility. In addition, the discontinuation of methods is of primary concern since it guides policy makers and health professionals in their efforts to improve service delivery. Thus, information on discontinuation can highlight program areas that require development, as well as groups of users who have particular concerns that need to be addressed. Table 5.13 presents first-year contraceptive discontinuation rates by reason for discontinuation, according to the method discontinued. The discontinuation rate refers to the proportion of women who have started using a contraception method at some time in the 5 years prior to the survey, but then stopped using that method within 12 months of having started it. The rate is calculated using information from the reproductive event calendar included in the TDHS-2008. In the calendar, all segments of contraceptive use between January 2003 and the date of interview were recorded along with reasons for any discontinuation of use during the period. 90 | Family Planning Table 5.13 Contraceptive discontinuation rates Percentage of contraceptive users who discontinued use of a method within 12 months after beginning its use, by reason for discontinuation and specific method, Turkey 2008 Reasons for discontinuation Contraceptive method Method failure Desire to become pregnant Switched to another method Other reason All reasons Pill 4.4 9.5 26.2 10.1 50.2 IUD 1.7 0.9 7.9 2.9 13.4 Male condom 5.1 10.6 16.5 4.9 37.1 Withdrawal 11.4 9.8 11.9 4.4 37.5 All methods 7.0 7.8 15.3 5.2 35.3 The results indicate that 35 percent of contraceptive users in Turkey stop using a contraceptive method within 12 months of starting use. The rates vary by method. Discontinuation rates are highest for the pill (50 percent) followed by withdrawal (38 percent) and male condom (37 percent). The one-year discontinuation rate is lowest for IUD (13 percent). Since IUD is not generally intended as a short-term method, a low discontinuation rate is to be expected. Switching to another method is common among those who discontinued use (15 percent). Eight percent of users discontinued use of a method of contraception within 12 months of initiating use with the desire to become pregnant. Another 7 percent of users stopped using as a result of method failure, and the remaining 5 percent stopped due to other reasons. Switching to another method accounts for an especially large portion of the relatively high discontinuation of the pill (26 percent). Withdrawal use is associated with a comparatively high rate of method failure (11 percent). Table 5.14 presents the distribution of all discontinuations during the five years prior to the survey by main reason for discontinuation according to the method used. The desire to become pregnant accounted for one-fourth of all discontinuations. One-fifth of user discontinued because they became pregnant while using. Side effects and wanting a more effective method were also frequently mentioned as reasons for discontinuation of modern methods (14 percent and 10 percent respectively). Method failure was more common among users of periodic abstinence (39 percent) and withdrawal (35 percent) than among users of other methods. Seventeen percent of condom discontinuations also were due to method failure. Side effects were also a frequently mentioned reason for discontinuing use. More than half of the injectable discontinuations were due to side effects. Family Planning | 91 Table 5.14 Reasons for discontinuation of contraception Percent distribution of method discontinuations in the five years preceding the survey the by main reason for discontinuation, according to specific method, Turkey 2008 Reason Pill IUD Injection Condom Diaphragm Periodic absti- nence With- drawal Other All methods Became pregnant 8.7 5.7 5.9 16.7 (14.7) 39.3 34.7 (22.4) 20.7 Wanted to become pregnant 22.1 23.1 6.3 33.4 (2.5) 16.2 27.1 (8.3) 25.6 Husband disapproved 0.6 0.6 1.2 7.7 (4.4) 0.0 1.9 (0.0) 2.5 Side effects 27.9 37.1 50.9 2.7 (14.8) 0.0 0.3 (0.0) 13.7 Health concerns 16.3 8.4 16.7 1.1 (6.9) 0.8 0.9 (0.0) 5.4 Access/availability 0.8 0.0 1.2 2.5 (21.6) 0.0 0.1 (0.0) 0.9 Wanted a more effective method 3.7 0.9 2.8 11.8 (1.6) 20.9 15.8 (30.7) 10.0 Inconvenient to use 1.8 0.2 0.6 4.3 (0.6) 1.3 1.2 (0.0) 1.7 Infrequent sex/husband away 4.0 0.7 1.2 2.5 (0.0) 7.0 2.4 (2.0) 2.4 Cost too much 0.6 0.0 0.0 1.2 (3.6) 0.0 0.0 (0.0) 0.4 Fatalistic 0.1 0.0 0.0 0.0 (3.3) 0.0 0.2 (2.8) 0.1 Difficult to get pregnant/menopausal 1.5 2.6 2.2 2.0 (10.4) 2.3 3.0 (0.0) 2.5 Marital dissolution/separation 2.6 3.9 0.3 2.2 (4.4) 0.0 1.6 (3.2) 2.3 Other 4.8 12.9 6.3 6.7 (5.9) 3.2 3.7 (4.1) 6.2 Don't know 0.1 0.0 0.6 0.1 (0.0) 0.0 0.1 (0.0) 0.1 Missing 4.4 3.9 4.1 5.0 (5.3) 9.1 7.0 (26.5) 5.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 804 903 174 961 42 83 2,000 35 5,002 Note: Parentheses indicate that a figure is based on 25-49 unweighted cases 5.11 Intention to use Contraception among Non-Users A key indicator of the changing demand for family planning is the extent to which non- users of contraception plan to use family planning in the future. To obtain information on the intentions, the TDHS-2008 survey asked currently married women who were not using contraception at time of survey whether they planned to use a method of contraception within next 12 months or at some time in the future. Table 5.15 presents the results according to the number of living children. Overall, 47 percent of currently married non-users do not intend to use a method of contraception at any time in the future. Additionally, 3 percent say that they are unsure of their future intentions. On the other hand, almost half of currently married women who are not using a contraceptive method intend to use family planning at some time in the future; 32 percent state that they intend to use a method within next 12 months, and 16 percent intend to use later. The percentage of married women who do not intend to use a method of family planning increases as the number of living children increases, from 35 percent among women with one child up to 60 percent among women with four or more children. 92 | Family Planning Table 5.15 Future use of contraception Percent distribution of currently married women who are not using a contraceptive method by intention to use in the future, according to number of living children, Turkey 2008 Number of living children Intention 0 1 2 3 4+ Total In next 12 months 10.0 38.2 41.0 32.5 33.3 32.3 Use later 44.1 20.2 8.1 7.1 3.0 15.9 Unsure about timing 1.9 1.4 0.7 0.3 0.7 1.0 Unsure about use 5.2 4.1 1.8 2.2 2.4 3.1 Does not intend 37.9 35.2 47.1 57.3 60.0 46.7 Total 99.1 99.0 98.7 99.4 99.4 99.1 Number of women 314 466 451 299 358 1,889 The TDHS-2008 also obtained information from non-users who intended to use a method at some time in the future on the contraceptive method they would prefer to use. The IUD (31 percent) is by far the most popular method among these nonusers, followed by the pill (13 percent) and withdrawal (13 percent) (Table 5.16). Ten percent expressed a preference for the male condom and the same percentage mentioned female sterilization. Method preferences vary somewhat with age; nonusers age 30 and above are more likely to prefer long-term methods like the IUD and female sterilization while nonusers under age 30 were somewhat more likely to prefer the pill, injectable or male condom. Table 5.16 Preferred method of contraception for future use Percent distribution of currently married women age 15-49 who are not using a contraceptive method but who intend to use in the future by preferred method, Turkey 2008 Mother's age Method 15-29 30-49 Percent distribution Female sterilization 8.0 14.0 10.0 Male sterilization 0.1 0.9 0.4 Pill 14.5 10.9 13.3 IUD 30.2 33.9 31.4 Injectables 6.6 2.4 5.2 Implants 0.7 1.1 0.8 Condom 11.4 8.0 10.2 Diaphragm 0.7 0.0 0.5 Periodic abstinence 0.0 2.2 0.7 Withdrawal 12.8 12.0 12.5 Other 2.5 3.7 2.9 Unsure 12.5 10.9 12.0 Total 100.0 100.0 100.0 Number of women 619 312 932 Family Planning | 93 5.12 Reasons for Non-Use of Contraception Table 5.17 presents the reasons nonusers who do not intend to use in the future give for not planning to use. Nonusers who do not intend to use in the future are mainly over age 30 (89 percent), and their reasons for non-use are quite different from the reasons of younger nonusers. In particular, nonusers over age 30 are more likely than younger nonusers to cite a lack of exposure to pregnancy as the reason they do not plan to use family planning; for example, 42 percent mention they are menopausal or have had a hysterectomy and 28 percent report that they are infecund. However, the latter reason is also among the most commonly cited reasons for not intending to use a method among younger non-users (29 percent). Table 5.17 Reason for not intending to use contraception in the future Percent distribution of currently married women age 15-49 who are not using contraception and who do not intend to use in the future by main reason for not intending to use, Turkey 2008 Mother's age Reason <30 30+ Total Fertility-related reasons Not having sex 1.4 5.2 4.8 Infrequent sex 1.9 2.8 2.7 Menopausal, hyster. 1.1 41.9 37.2 Subfecund, infecund 28.8 27.8 27.9 Husband infecund 6.5 2.5 3.0 Opposition to use Husband opposed 3.4 0.6 0.9 Religious prohibit. 5.3 0.8 1.3 Fatalistic 6.7 2.9 3.4 Embarrassed 0.0 0.2 0.2 Lack of knowledge Knows no method 8.1 0.8 1.7 Knows no source 0.5 0.2 0.2 Method-related reasons Health concerns 5.6 3.0 3.3 Fear side effects 0.0 0.3 0.3 Lack of access 0.0 0.1 0.1 Cost too much 0.0 0.1 0.1 Inconvenient to use 0.4 0.0 0.1 Other 30.4 9.6 11.9 Don't know 0.0 0.8 0.7 Missing 0.0 0.4 0.4 Total 100.0 100.0 100.0 Number of women 101 781 882 Abortions and Stillbirths | 95 ABORTIONS AND STILLBIRTHS 6 Sabahat Tezcan, Banu Ergöçmen and F. Hande Tunçkanat This chapter presents results from the TDHS-2008 concerning induced abortions, spontaneous abortions (miscarriages), and stillbirths. Stillbirths and spontaneous abortions are important maternal health indicators. Induced abortions also are important from a maternal health perspective since the practice can have adverse effects on the health of women. Additionally, induced abortions have significance for family planning services because one of the important goals of family planning is to eliminate unwanted pregnancies. Women may resort to induced abortions when problems of availability and accessibility to contraceptive services exist or when there are psychosocial barriers that keep them from using contraceptive methods to avoid unwanted pregnancies. Women may also have induced abortion in order to avoid pregnancy that occurred as a result of contraceptive failure. Abortion was legalized in Turkey in 1983 with the enactment of the new population planning law, which provided for safe abortion on request during the first ten weeks of gestation for every woman who needed the service. Since the law was legislated, induced abortion has been available to women at government hospitals for a nominal fee and from the private sector. The TDHS-2008 questionnaire included questions to determine the total number of induced and spontaneous abortions and stillbirths a woman had during her entire reproductive period. In the calendar module, detailed information was collected on the duration of each pregnancy ending in an abortion and on the place where abortion occurred for each pregnancy terminated since January 2003. In addition, information was obtained from women who reported having any pregnancy that ended in miscarriage, abortion or still birth on the month and year in which the last such pregnancy terminated. For last pregnancies that ended in an induced abortion, information was also collected on the person who made the decision to have the abortion, the woman’s childbearing preference at the time, the place where pregnancy ended, and if the woman was informed about contraceptives when she had the abortion. 6.1 Life-time Experience with Pregnancy Terminations Table 6.1 presents the percent distribution of ever-married women by the total number of abortions (induced and spontaneous) and stillbirths that they reported ever having had during their reproductive lives. According to the table, only 4 percent of women have had a stillbirth. One-fifth of ever- married women in reproductive age reported ever having had a spontaneous abortion while slightly more than one-fifth of ever married women (22 percent) ever had an induced abortion. As the table shows, relatively few ever-married women had more than one spontaneous or 96 | Abortions and Stillbirths induced abortion (6 percent and 8 percent, respectively). Less than one percent said that they had more than one pregnancy end in a still birth. Table 6.1 Number of abortions and stillbirths Percent distribution of ever-married women by number of abortions (spontaneous and induced) and stillbirths, Turkey 2008. Number of terminations Abortions Spontaneous Induced Stillbirths None 79.6 77.9 96.0 1 14.6 14.2 3.5 2 4.1 5.0 0.4 3 1.1 1.9 0.1 4 0.3 0.7 0.0 5 or more 0.2 0.2 0.0 Missing 0.1 0.1 0.0 Total 100.0 100.0 100.0 Mean number 0.28 0.34 0.05 Number of women 7,405 7,405 7,405 6.2 Current Levels and Trends in Abortion Rates Table 6.2 presents the percentage of ever-married women age 15-49 who had ever had an induced abortion by background characteristics. The proportion ever having an induced abortion increases directly with age, from 3 percent of ever-married women in 15-19 age group to 39 percent among women age 45-49. This rise is particularly marked among women age 30 and older, with women age 45-49 more than twice as likely as women age 30-34 to report they have had an abortion. The proportion of ever-married women who have had an induced abortion also increases steadily with the number of living children, from 6 percent of women with no living children to a peak of 29 percent among women with five or more children. Women with three or more children are around twice as likely as women with 1-2 children to have had an abortion. According to Table 6.2, the proportion of women who have ever had an abortion is higher among urban than rural women (23 percent and 18 percent, respectively). With regard to region, women in the Eastern part of Turkey (14 percent) are the least likely to have ever had an induced abortion and women in the West (26 percent), Central and the North (22 percent) regions are the most likely to report an induced abortion. Considering the NUTS 1 regions, the percentage of women who have had induced abortion is the highest in Istanbul (31 percent) and lowest in Southeast Anatolia (12 percent). There is little variation in the percentage of women with an induced abortion by education. However, the percentage of women who have had induced abortion increases with the wealth quintile, from 15 percent in the lowest wealth quintile up to 29 percent in the highest wealth quintile. Abortions and Stillbirths | 97 Table 6.3 shows the rates of abortions (spontaneous and induced) and stillbirths per 100 pregnancies for the five-year period prior to the TDHS-2008. According to table, 22 of every 100 pregnancies among ever-married women terminated in other than a live birth during 2003- 2008 period. There were 21 total abortions per 100 pregnancies, of which 10 were induced. Only Table 6.2 Induced abortions by background characteristics Percentage of ever-married women age 15-49 ever having an induced abortion, by selected background characteristics, Turkey 2008. Characteristics Induced Abortions Number Age 15-19 2.9 183 20-24 3.6 836 25-29 11.7 1,353 30-34 18.8 1,379 35-39 25.9 1,336 40-44 32.7 1,202 45-49 39.2 1,115 Number of living children 0 5.9 698 1-2 12.7 1,552 3-4 24.9 2,511 5+ 29.4 1,367 Residence Urban 23.3 5,615 Rural 17.9 1,790 Region West 26.1 3,252 South 17.8 894 Central 21.8 1,631 North 22.0 477 East 14.1 1,151 Region (NUTS1) İstanbul 30.9 1,491 West Marmara 22.0 327 Aegean 24.7 1,065 East Marmara 19.5 759 West Anatolia 20.7 717 Mediterranean 17.8 894 Central Anatolia 19.2 371 West Black Sea 24.2 448 East Black Sea 20.3 186 Northeast Anatolia 17.6 191 Central East Anatolia 15.5 327 Southeast Anatolia 12.3 628 Education No education/Primary incomplete 21.0 1,358 First level primary 23.6 3,840 Second level primary 17.1 643 High school and higher 21.0 1,564 Wealth quintile Lowest 14.8 1,154 Second 19.1 1,429 Middle 21.6 1,559 Fourth 23.5 1,618 Highest 28.6 1,645 Total 22.0 7,405 98 | Abortions and Stillbirths about one out of every 100 pregnancies ended in a stillbirth. Table 6.3 Abortions and stillbirths per 100 pregnancies Number of abortions (spontaneous and induced) and stillbirths per 100 pregnancies during the five-year period prior to the survey Turkey 2008. Outcome Number per 100 pregnancies Abortions 20.5 Spontaneous 10.5 Induced 10.0 Stillbirths 1.1 Information on the trend in the levels of induced abortions during the period between the TDHS-1993 and TDHS-2008 are presented by background characteristics in Table 6.4. Overall, the results suggest that there was a substantial decline in level of induced abortions during the period covered by the surveys, from 18 abortions per 100 pregnancies at the time of the 1993 survey to 11 induced abortions per 100 pregnancies in the 2008 survey. Considering the trends within subgroups, ın urban areas, there were 10 induced abortions per 100 pregnancies at the time of the TDHS-2008, which was almost half the level of 21 induced abortions per 100 pregnancies reported for urban areas in the TDHS-1993. Although not as large, induced abortions also declined for urban areas over the period from 12 per 100 pregnancies in the TDHS-1993 to 8 in the TDHS-2008. All of the regions also had substantial decreases in the numbers of pregnancies ending in induced abortions. The West had the largest decline, from 25 per 100 pregnancies at the time of the TDHS-1993 to 14 in the TDHS-2008. Despite this decline, the West, which had the highest percentage of pregnancies ending in an induced abortion in the TDHS-1993, continued to have the highest proportion at the time of TDHS-2008. In the East, which had the lowest level of induced abortion among the regions throughout the period, the number of induced abortions per 100 pregnancies also dropped substantially, from 9 in 1993 to 5 in 2008. For the NUTS 1 regions, information on induced abortion is available only from the 2003 and 2008 TDHS surveys. A comparison of the results from the two surveys indicates that induced abortions levels decreased in 7 out of the 12 regions. Among the remaining regions, the largest increase occurred in the East Black Sea region. The results in Table 6.4 also indicate that induced abortion rates have decreased within all educational categories since the TDHS-1993, with the decline being greatest for women with a second level of primary education. Information on induced abortion levels is not available by wealth quintiles in the previous surveys; however, the TDHS-2008 results show that the percentage of pregnancies ending in induced abortions per 100 pregnancies in the highest wealth quintile is almost 4 times more than the number in the lowest wealth quintile (18 and 5 respectively). Abortions and Stillbirths | 99 Table 6.4 Trends in induced abortions Trends in the number of induced abortion per 100 pregnancies during the five year period prior to survey, TDHS-1993, TDHS-1998, TDHS-2003 and TDHS 2008. Background characteristic TDHS-1993 TDHS-1998 TDHS-2003 TDHS-2008 Age 15-19 3.8 5.8 3.4 3.2 20-24 8.3 7.7 5.6 4.1 25-29 20.4 12.6 9.5 9.7 30-34 27.9 23.3 19.1 12.8 35-39 36.2 33.4 25.5 25.5 40-44 47.1 42.5 33.7 29.9 45-49 47.6 66.2 27.6 - Residence Urban 21.3 16.1 13.2 10.8 Rural 12.4 11.6 7.2 7.8 Region West 24.9 18.0 14.7 14.1 South 16.3 13.7 10.2 9.9 Central 19.8 16.7 14.9 8.8 North 17.0 15.6 8.8 11.5 East 8.7 7.6 5.2 4.6 Region (NUTS 1) İstanbul NA NA 15.1 17.9 West Marmara NA NA 13.0 13.6 Aegean NA NA 20.4 13.6 East Marmara NA NA 7.4 7.0 West Anatolia NA NA 15.5 6.2 Mediterranean NA NA 10.2 9.9 Central Anatolia NA NA 10.0 6.7 West Black Sea NA NA 17.0 13.9 East Black Sea NA NA 6.3 11.5 Northeast Anatolia NA NA 10.8 5.5 Central East Anatolia NA NA 4.4 5.1 Southeast Anatolia NA NA 3.9 4.1 Education No educ/Prim. inc. 13.9 11.8 8.3 5.5 First level primary 19.4 15.1 11.5 11.1 Second level primary 22.6 17.3 12.8 7.1 High sch.and higher NA NA 14.8 13.1 Wealth quintile Lowest NA NA NA 5.3 Second NA NA NA 8.4 Middle NA NA NA 10.9 Fourth NA NA NA 8.8 Highest NA NA NA 18.4 Total 18.0 14.5 11.3 10.0 NA= Not applicable 100 | Abortions and Stillbirths 6.3 Patterns of Contraceptive Use Prior to and After Induced Abortion Data from the TDHS-2008 calendar can be utilized to examine the women’s use of contraception before and after an induced abortion. An examination of the patterns of contraceptive use before a woman has an abortion is important because pregnancies that end in abortions often result from the use of ineffective contraceptive methods or from the failure to use methods effectively as well as from not using contraception at all. According to the TDHS-2008 results, all of these factors are related to abortion in Turkey. As Table 6.5 shows, in around one-third of last abortions during the five-year period prior to the survey, the woman was not using any contraceptive method in the month before she became pregnant. Among abortions in which contraception was used immediately prior to the pregnancy, women were more likely to be using a traditional than a modern method. 39 percent of abortions occurred following a period of use of withdrawal, and 5 percent of abortions occurred after using periodic abstinence. Twenty-two percent of abortions occurred following a period in which a woman was using a modern method, with an abortion more likely to have occurred after use of the condom (11 percent) than the pill (5 percent) or IUD (5 percent). Table 6.6 presents the use of contraception in the month following an abortion. According to the table, about one in three women with an induced abortion were using contraception within a month after pregnancy for their last abortion. Forty-three percent used modern methods while 25 percent used traditional methods (especially withdrawal). In comparison with the mix of methods used before abortion, this represented a substantial increase in the use of modern methods. The condom (15 percent) was the most frequently adopted modern method followed closely by the pill (14 percent) and the IUD (12 percent). Table 6.5 Method used before abortion Method used within one month before pregnancy for the last abortion reported in the five years preceding the survey, Turkey 2008. Method Percentage using method before abortion Pill 4.8 IUD 5.0 Injections 0.4 Diaphragm/foam/jelly 0.6 Male condom 10.8 Periodic abstinence 5.3 Withdrawal 39.0 Other 0.4 Not using 33.7 Total 100.0 Number 417 Table 6.6 Method used after abortion Method used within one month after pregnancy for the last abortion reported in the five years preceding the survey, Turkey 2008. Method Percentage using method after abortion Pill 14.0 IUD 11.6 Injections 1.6 Male condom 14.9 Female Sterilization 0.5 Periodic abstinence 3.4 Withdrawal 21.7 Not using 32.3 Unknown 0.1 Total 100.0 Number 417 Abortions and Stillbirths | 101 6.4 Decision Maker of Induced Abortion Table 6.7 presents the percent distribution of women who have ever had induced abortion by the person who decided on the last abortion during the five-year period prior to the survey according to selected background characteristics. Overall, the table reveals that, in almost half of women’s last induced abortions, the decision to end the pregnancy was made jointly woman herself and her husband (48 percent). Almost one-quarter of the women made the decision to have their last abortion by themselves. Doctors were cited by women as the decision maker for 22 percent of the abortions while only 4 percent of abortions were decided by partner. Table 6,7 Decision maker of abortion Percent distribution of women who ever had an induced abortion by the person who decided on ending the pregnancy at the time of the last abortion during the five-year period before the survey, according to background characteristics, Turkey 2008, Person decided to end pregnancy Background characteristic Woman and husband Women herself Doctor Husband Other Missing Total Number Age 15-24 (26.1) (31.1) (30.7) (10.4) (0.0) (1.6) 100.0 33 25-29 49.2 15.7 26.3 5.5 0.4 2.9 100.0 113 30-34 43.3 27.4 23.3 4.6 0.6 0.8 100.0 137 35-39 56.5 25.4 12.2 3.3 0.6 2.0 100.0 102 40 and over 55.6 26.4 15.9 1.0 0.0 1.0 100.0 98 Residence Urban 47.7 26.0 20.4 4.0 0.3 1.6 100.0 382 Rural 49.2 15.8 27.3 4.9 0.8 1.9 100.0 100 Region West 46.9 27.0 20.4 3.7 0.0 2.1 100.0 243 South 52.0 15.0 30.1 1.4 0.0 1.4 100.0 58 Central 52.4 22.2 18.3 5.5 1.5 0.0 100.0 98 North (45.8) (20.5) (26.1) (6.2) (0.0) (1.5) 100.0 30 East 42.2 24.6 23.3 5.9 0.8 3.1 100.0 54 Education No education/ Prim incomplete 44.4 24.9 22.5 5.7 1.2 1.3 100.0 55 First level primary 51.2 22.5 19.2 4.0 0.5 2.7 100.0 273 Second level primary (35.9) (36.1) (20.3) (7.6) (0.0) (0.0) 100.0 29 High sc. and higher 45.5 23.7 27.7 3.1 0.0 0.0 100.0 124 Wealth quintile Lowest 49.9 24.3 14.5 7.6 2.2 1.4 100.0 58 Second 46.3 28.6 20.3 1.5 0.7 2.8 100.0 97 Middle 53.5 23.4 15.5 3.9 0.0 3.7 100.0 108 Fourth 40.6 18.5 28.0 12.3 0.0 0.6 100.0 72 Highest 48.0 23.7 27.4 0.9 0.0 0.0 100.0 147 Total 48.0 23.9 21.8 4.2 0.4 1.7 100.0 482 Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. 102 | Abortions and Stillbirths With respect to the differences by background characteristics in the person(s) cited responsible for the decision to have last abortion, Table 6.7 shows that women under age 35 were somewhat more likely than older women to cite a doctor as having made the decision and older women were slightly more likely than younger women to say the decision was made jointly with their husband. Urban women (26 percent) are more likely than rural women (16 percent) to have made the decision on their own and rural women were somewhat more likely than urban women (20 percent) to cite a doctor as the decision-maker (27 percent). Among the five geographic regions in Turkey, West has the highest proportion of induced abortions (27 percent) that were decided by woman herself while South has the lowest (15 percent). The percentages of abortions that were decided jointly by woman and her partner are highest in South and Central (52 percent) and lowest in East (42 percent). South is the region with the highest proportion of abortions in which a doctor was cited as the decision-maker (30 percent). The person making the decision about the last abortion is not clearly related to either the woman’s educational level or the wealth quintile. 6.5 Timing of Induced Abortion Although abortions are legal for up to the 10th week of pregnancy (2.5 months), it is safer for women’s health to have an abortion as early as possible. Table 6.8 shows the percent distribution of ever-married women with an induced abortion in the five-years prior to survey by the months pregnant at the time of the last abortion according to selected background characteristics. Overall, 67 percent of the abortions occurred in the first month of pregnancy and 22 percent in the second month of pregnancy. As women reported, only 11 percent of induced abortions were performed in the third month of pregnancy or later, i.e., potentially outside of the recommended time limit. Women age 30 and older are more likely to have had abortion in the first month of pregnancy than younger women. Among the other subgroups, urban women, women in the West, women with a high school or higher education, and women in the highest wealth quintile are most likely to report the last abortion occurred during the first month of pregnancy. The proportion having the last abortion in the third month of pregnancy or later was highest among women in the lowest wealth quintile and women in the East (23 percent and 22 percent, respectively). Abortions and Stillbirths | 103 Table 6.8 Timing of last induced abortion Percent distribution of women who had an induced abortion in the 5 years preceding the survey by the number of months the woman was pregnant at time of last abortion, according to background characteristics, Turkey 2008. Months of pregnancy Background characteristic 1 2 3+ Total Number Age 15-24 56.4 33.1 10.5 100.0 64 25-29 56.1 24.9 19.0 100.0 122 30-34 69.3 21.8 8.9 100.0 101 35-39 88.4 8.4 3.1 100.0 94 40-44 (78.4) (15.2) (6.3) 100.0 36 Residence Urban 71.7 19.0 9.3 100.0 328 Rural 51.6 31.7 16.7 100.0 89 Region West 70.4 21.7 7.8 100.0 213 South 65.2 24.8 10.0 100.0 52 Central 67.0 20.0 13.0 100.0 81 North (60.4) (27.8) (11.8) 100.0 27 East (60.6) (17.8) (21.6) 100.0 45 Education No educ./Primary incomplete (60.3) (25.3) (14.4) 100.0 47 First level primary 65.9 22.1 12.0 100.0 230 Second level primary (53.6) (40.1) (6.3) 100.0 27 High sc. and higher 76.9 15.0 8.1 100.0 112 Wealth quintile Lowest 50.7 26.7 22.6 100.0 50 Second 64.7 28.6 6.7 100.0 81 Middle 69.2 25.8 5.0 100.0 94 Fourth 66.3 21.6 12.1 100.0 61 Highest 74.7 12.8 12.5 100.0 130 Total 67.4 21.7 10.8 100.0 417 Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. 6.6 Abortion Provider Table 6.9 presents information on the abortion provider. The great majority of women who had had an induced abortion in the five-year period preceding the survey reported the abortion took place at a private doctor’s office or at a private hospital or clinic (70 percent). About 26 percent of women reported that they had obtained the abortion at a public sector services. The share of women that sought abortion services from university hospitals is only 1 percent. An examination of the percent distribution of women with recent induced abortions by source of abortion according to age does not reveal any specific pattern. However, rural women were somewhat less likely than urban women to have had the abortion performed at private doctor’s office rather than hospitals or clinics. The North region has the highest proportion of women with an induced abortion that took place in state hospital, maternity house or other public sector services. 104 | Abortions and Stillbirths Table 6.9 reveals that women with higher educational attainment are less likely to obtain an abortion at public sector services and more likely to have their abortion provided by a private hospital or clinic. In the highest wealth quintile, almost 82 percent of women with an abortion had obtained the abortion from private sector services while this percentage decline to 52 percent among women in the lowest wealth quintile. Similarly, women in the lowest wealth quintile were more likely than other women to have had the abortion performed at a public health facilities. Table 6.9 Abortion providers Percent distribution of women who had an induced abortion in the five years preceding the survey by the service provider for the last abortion, according to background characteristics. Turkey 2008. Abortion provider Background characteristic State/ Sample hospital Maternity house Other public Private University hospital Other Missing Total Number of abortion Age 15-19 27.2 9.2 2.7 56.6 1.1 0.8 2.5 100.0 57 20-24 21.4 2.1 1.7 70.4 0.0 4.4 0.0 100.0 66 25-29 14.2 10.6 1.2 70.0 1.1 0.7 2.3 100.0 96 30-34 23.7 3.1 1.0 69.6 2.6 0.0 0.0 100.0 83 35-39 7.5 4.3 3.0 82.6 0.0 0.0 2.7 100.0 88 40-44 18.4 9.0 1.8 63.8 2.3 2.6 2.1 100.0 77 Residence Urban 13.1 7.5 1.0 74.6 1.2 1.0 1.6 100.0 382 Rural 34.8 2.4 4.7 53.4 0.8 2.0 1.9 100.0 100 Region West 13.9 4.4 1.6 76.0 0.0 2.0 2.1 100.0 243 South 15.4 5.8 1.4 70.2 4.7 1.1 1.4 100.0 58 Central 21.8 8.1 2.7 65.9 1.5 0.0 0.0 100.0 98 North (26.7) (9.6) (1.5) (59.2) (1.5) (0.0) (1.5) 100.0 30 East 23.4 11.3 1.7 58.0 1.7 0.8 3.1 100.0 54 Education No education/ Primary incom. 28.0 10.8 5.2 54.8 0.0 0.0 1.3 100.0 55 First level primary 17.9 4.8 1.9 70.6 0.9 1.1 2.7 100.0 273 Second level primary (20.7) (3.8) (0.0) (75.5) (0.0) (0.0) (0.0) 100.0 29 High sch. and higher 11.3 8.5 0.4 74.9 2.4 2.5 0.0 100.0 124 Wealth quintile Lowest 36.5 5.3 4.1 51.9 0.8 0.0 1.4 100.0 58 Second 21.7 4.7 1.8 67.6 1.3 0.0 2.8 100.0 97 Middle 11.2 10.5 1.3 70.1 0.6 2.7 3.7 100.0 108 Fourth 19.0 7.1 3.1 64.7 2.1 3.4 0.6 100.0 72 Highest 11.3 4.7 0.6 81.9 1.1 0.4 0.0 100.0 147 Total 17.6 6.4 1.8 70.2 1.1 1.2 1.7 100.0 482 Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. 6.7 Age-specific and Total Abortion Rates Abortion rates for the five-year period preceding the survey are shown in Table 6.10 by place of residence. The age-specific rates represent the probability that a woman of a particular age will have an abortion during a one-year period and are shown per 1,000 women. A useful summary index of the age-specific abortion rates is the total abortion rate (TAR). This rate is Abortions and Stillbirths | 105 analogous to the total fertility rate (TFR). The TAR is the lifetime average number of abortions a woman would have if she experienced the current age-specific abortion rates. The TAR per women is 0.3 for the five years preceding the TDHS-2008. The age- specific rates increase to a peak among women in the 35-39 age group and then decline among older women. The rates of abortion are the same or higher in urban than rural areas at all ages, except the 15-19 cohort where the age specific abortion rate in rural is 4 times more than in urban. Total abortion rates are shown by some additional background characteristics in Table 6.11. Among five geographical regions, the West has the highest total abortion rate while East has the lowest (0.34 and 0.21 respectively). Considering the NUTS I regions, the total abortion rate is highest in Istanbul (0.42) and lowest in West Anatolia (0.18). There is a distinct difference in between the TAR for women with no education or primary incomplete (0.19) and those with a high school or higher educational level (0.35). With regard to wealth quintile, no regular pattern is observed; the highest quintile has the highest rate (0.34) while lowest wealth quintile has the lowest rates (0.22). Table 6.10 Total abortion rates Age-specific and cumulative abortion rates for the five year period preceding the survey by residence, Turkey 2008 Current age Urban Rural Total 15-19 1 4 1 20-24 7 5 6 25-29 16 13 15 30-34 14 14 14 35-39 17 11 16 40-44 6 6 6 45-49 0 0 0 TAR 15-49 0.30 0.27 0.29 TAR 15-44 0.30 0.27 0.29 TAR = Total abortion rate expressed per woman 106 | Abortions and Stillbirths Table 6.11 Induced abortion by background characteristics Total induced abortion rate for the five years preceding the survey by background characteristics, Turkey 2008 Background characteristic TAR (15-49) Residence Urban 0.30 Rural 0.27 Region West 0.34 South 0.30 Central 0.25 North 0.29 East 0.21 Region (NUTS 1) İstanbul 0.42 West Marmara 0.26 Aegean 0.35 East Marmara 0.19 West Anatolia 0.18 Mediterranean 0.30 Central Anatolia 0.21 West Black Sea 0.35 East Black Sea 0.28 Northeast Anatolia 0.21 Central East Anatolia 0.24 Southeast Anatolia 0.20 Education No education/Primary incomplete 0.19 First level primary 0.31 Second level primary 0.20 High school and higher 0.35 Wealth quintile Lowest 0.22 Second 0.32 Middle 0.31 Fourth 0.23 Highest 0.34 Total 0.29 TAR = Total abortion rate expressed per 15-49 woman. Other Proximate Determinants of Fertility | 107 OTHER PROXIMATE DETERMINANTS OF FERTILITY 7 Banu Akadlı Ergöçmen, Mehmet Ali Eryurt and Tuğba Adalı Fertility levels in most populations can be explained by some key proximate determinants that affect a woman’s risk of becoming pregnant. These determinants are nuptiality (including consensual unions), postpartum insusceptibility (including postpartum amenorrhea and sexual abstinence), the onset of menopause, contraceptive use and abortion. This chapter addresses the principal factors other than contraception and abortion that affect fertility. Marriage is a principal indicator of women’s exposure to the risk of pregnancy in societies where sexual activity usually takes place within marriage. Populations in which age at marriage is low tend to experience early childbearing and high fertility. Therefore, an increase in the average age at which women marry can help to explain the downward trends in fertility levels. The durations of postpartum amenorrhea and sexual abstinence influence the length of time that a woman is insusceptible to pregnancy, which in turn influence birth spacing. The onset of menopause marks the end of a woman’s reproductive life cycle. Taken together, these factors determine the length and pace of a woman’s reproductive life and therefore are important in understanding fertility levels and differentials. 7.1 Current Marital Status In the TDHS-2008, only ever-married women were interviewed through the individual questionnaire. As part of the interview, they were asked the basic questions on marital status and age at marriage that are included in the standard DHS questionnaire. Unlike the standard DHS questionnaire, however, the TDHS-2008 did not ask about the age at which women initiated sexual activity. In addition, a special country-specific nuptiality module included in the individual questionnaire obtained information on family formation, religious marriages, and consanguinity. Although never-married women were not interviewed in the survey, information about them was collected in the household questionnaire. The distribution of all women age 15-49 by their marital status at the time of the survey is presented in Table 7.1.1. This is a descriptive table of basic importance in defining the population base for many of the subsequent tables in this and other chapters. In the table, the term married refers both to “currently married” and “living together”. Table 7.1.1 shows that the majority of women at childbearing age are currently married (65 percent), one-third (31 percent) are never married, and the remaining 4 percent are either divorced, separated or widowed. The proportion of never-married women declines rapidly with age, from 90 percent among teenagers to 23 percent among women in their late twenties. Four percent of women in their late thirties have never married, and only 0.1 percent of women age 45-49, who are approaching the end of the reproductive years, have never married. These data confirm the universality of marriage in Turkey. 108 | Other Proximate Determinants of Fertility Table 7.1.1 Current marital status Percent distribution of women age 15-49 by current marital status, according to age, Turkey 2008 Current age Never married Marital status Number of womenMarried Widowed Divorced Separated Total 15-19 90.2 9.6 0.0 0.1 0.1 100.0 1,871 20-24 54.4 44.7 0.0 0.6 0.2 100.0 1,834 25-29 22.7 75.0 0.3 1.3 0.7 100.0 1,751 30-34 10.8 85.8 0.4 2.6 0.4 100.0 1,546 35-39 4.3 90.4 1.8 2.6 0.9 100.0 1,396 40-44 1.7 89.6 3.9 4.0 0.7 100.0 1,223 45-49 0.1 89.8 6.4 2.1 1.6 100.0 1,116 Total 31.0 65.2 1.5 1.7 0.6 100.0 10,738 Table 7.1.1 also shows that, as age increases, the proportion of women widowed, divorced or separated also increases. The proportion widowed rises from less than 1 percent of women under age 30 to 6 percent among women at ages 45-49. Divorce and separation are socially discouraged, and therefore are uncommon in Turkey (2 percent and 1 percent respectively). The percentage of women who are divorced is markedly higher among women age 30-44 (4 percent or less) than in other age groups. Table 7.1.2 Trends in proportion never married Percent distribution of women who have never married, by age group, as reported in various surveys, Turkey 1978-2008 Current age TFS 1978 TFHS 1983 TPHS 1988 TDHS 1993 TDHS 1998 TDHS 2003 TDHS 2008 15-19 77.8 70.0 85.4 86.5 84.5 88.1 90.2 20-24 26.2 34.2 39.3 41.5 39.3 50.2 54.4 25-29 7.5 8.5 12.2 15.6 12.9 20.0 22.7 30-34 2.6 3.4 4.5 4.3 6.5 8.2 10.8 35-39 0.9 2.6 2.9 1.8 2.4 4.1 4.3 40-44 1.6 1.0 2.8 2.2 1.8 3.0 1.7 45-49 0.7 0.8 1.8 0.9 1.7 1.5 0.1 The proportion of the female population that remains single directly influences fertility levels because childbearing outside marriage is uncommon in Turkey. Table 7.1.2 shows the trend in the proportion of never-married women by age group from previous surveys conducted in Turkey. During the last three decades, this proportion increased in almost all age groups, with the increases being especially marked in the 20-34 age groups. Other Proximate Determinants of Fertility | 109 7.2 Age at First Marriage In Turkey, marriage marks the onset of the socially acceptable time for childbearing. The age at first marriage has a major impact on childbearing because women who marry early will have, on average, a longer period of exposure to pregnancy, which in turn often leads to a higher number of lifetime births. In Turkey, the minimum legal age at marriage with parental consent is 17 years for both males and females. Information from the TDHS-2008 on women’s age at first marriage is shown in Table 7.2. The survey found that, among women age 25-49, 43 percent marry by age 20, one-fourth marry by age 18 and 5 percent enter marriage before their 15th birthday. Table 7.2 also shows that the median age at first marriage is 20.8 years, indicating that half of women in that age group married before that age. There has been a steady increase in the age at first marriage over the last two decades in Turkey. This is evident from changes in the median age at first marriage across cohorts in Table 7.2; the median increases from 19.5 years for women in their late forties to 22.1 for women in their late twenties. A comparison of the TDHS-2008 results for women age 25-49 with the findings of previous surveys also confirms the increasing tendency to delay marriage; the age at first marriage has increased by almost 2 years during the 15-year period between the TDHS-1993 and the TDHS-2008. Table 7.2 Age at first marriage Percentage of women who were first married by specific exact ages and median age at first marriage, according to current age, Turkey 2008 Current age Percentage first married by exact age: Percen- tage never married Number of women Median age at first marriage 15 18 20 22 25 15-19 0.9 NA NA NA NA 90.2 1,871 a 20-24 2.5 14.0 29.2 NA NA 54.4 1,834 a 25-29 2.3 17.1 33.7 49.5 67.4 22.7 1,751 22.1 30-34 4.6 21.9 39.3 55.8 74.8 10.8 1,546 21.3 35-39 4.4 23.8 45.7 63.8 80.0 4.3 1,396 20.4 40-44 6.7 28.1 48.1 64.7 81.2 1.7 1,223 20.2 45-49 7.5 35.3 55.3 71.3 85.6 0.1 1,116 19.5 20-49 4.4 22.2 40.3 NA NA 18.6 8,867 NA 25-49 4.8 24.3 43.2 59.8 76.8 9.2 7,033 20.8 NA = Not applicable a Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Although the median is a convenient summary measure, not all changes in age at marriage are necessarily reflected in the median. Cohort trends in age at marriage can be more thoroughly examined by comparing the percentages who first marry at specific ages for successive 5-year age groups. These percentages also confirm that substantial changes have occurred in the age at which women marry in Turkey over the past several decades. The percentages of women married at each specific age are all lower for the younger cohorts than for the older cohorts. For example, among the oldest cohort, 55 percent married by age 20, whereas only 34 percent of women in their late 110 | Other Proximate Determinants of Fertility twenties married by age 20. There has been a marked decline in the proportion of women getting married at very young ages; for example, the proportion of women married by age 15 has dropped from 8 percent among women in the oldest cohort to 2 percent among women age 25-29. Table 7.3 Median age at first marriage Median age at first marriage among women age 25-49 by current age, according to background characteristics, Turkey 2008 Current age Women age 25-49Background characteristics 25-29 30-34 35-39 40-44 45-49 Residence Urban 22.6 21.6 20.6 20.6 19.8 21.1 Rural 20.4 20.1 19.7 19.3 18.6 19.6 Region West 22.8 22.0 20.7 21.0 19.9 21.3 South 21.6 21.3 21.3 20.8 20.3 21.1 Central 21.6 20.7 19.6 19.4 18.7 20.0 North 22.6 22.0 20.9 20.5 20.0 21.3 East 21.4 19.9 19.1 18.7 17.7 19.6 Region (NUTS 1) İstanbul 23.2 22.2 20.4 21.4 19.8 21.4 West Marmara 21.6 21.3 21.9 21.0 19.2 20.9 Aegean 21.2 21.0 20.5 20.0 20.0 20.6 East Marmara 23.4 22.4 20.5 20.5 19.8 21.5 West Anatolia 21.9 21.3 20.4 21.1 19.5 21.0 Mediterranean 21.6 21.3 21.3 20.8 20.3 21.1 Central Anatolia 20.6 19.9 19.0 18.6 19.2 19.4 West Black Sea 22.5 20.9 20.3 19.4 19.1 20.5 East Black Sea 22.5 21.9 21.5 20.8 19.4 21.3 Northeast Anatolia 20.3 21.2 19.6 18.5 18.8 19.8 Central East Anatolia 21.3 19.6 19.1 19.0 18.0 19.6 Southest Anatolia 21.7 19.9 18.9 18.6 17.4 19.5 Education No educ./Prim.inc. 21.1 18.9 18.4 18.5 17.8 18.7 First level primary 21.5 20.1 20.2 19.9 19.3 20.2 Second level primary 24.3 21.7 19.9 19.7 19.4 21.4 High school and higher a 24.1 23.6 23.5 22.9 24.1 Wealth quintile Lowest 19.7 19.3 18.7 19.2 18.6 19.2 Second 20.4 20.3 19.5 19.7 18.8 19.8 Middle 22.3 20.3 20.5 20.0 18.9 20.5 Fourth 22.3 21.6 20.3 20.2 19.3 20.8 Highest a 22.8 21.8 21.7 21.3 22.5 Total 22.1 21.3 20.4 20.2 19.5 20.8 a Omitted because less than 50 percent of the women married for the first time before reaching the beginning of the age group Table 7.3 compares the current level and cohort trends in the median age at marriage for different subgroups of the population. Urban women tend to marry 1.5 years later than their rural counterparts (21.1 years and 19.6 years respectively). This pattern is observed for all age groups. Looking at the regional variations, the median age at first marriage for women age 25-49 is lowest in the East and Central (19.6 years and 20.0 years, respectively) and above 21 in the other regions. Other Proximate Determinants of Fertility | 111 Comparisons of the NUTS 1 regions indicate that East Marmara has the highest median age (21.5 years) at marriage and Central Anatolia has the lowest (19.4 years). The upward trend in the age at marriage is observed within all regions, with the median age at first marriage for younger women generally higher than those for older women. For example, the median age at first marriage in the 25-29 age group in Southeast Anatolia is 21.7 years, more than four years later than the age at marriage reported for women age 45-49 (17.4 years). Likewise, in İstanbul and East Marmara, half of the women in the 25-29 age group married after age 23, which is more than three years later than women in their late forties. The level of education has a positive association with the median age at first marriage, with the differences between women who have completed at least high school and other women being especially pronounced. The median age at first marriage for women with a high school or higher education is 24.1 years, nearly three years higher than the median age for women with a second level primary education and more than five years higher than the median age for women with less than primary education (Table 7.3). The median age at first marriage also increases with household wealth. Women in the highest wealth quintile marry more than three years later than those from the lowest wealth quintile (22.5 years and 19.2 years respectively). 7.3 Postpartum Amenorrhea, Postpartum Abstinence, and Insusceptibility The period of postpartum amenorrhea is the interval between childbirth and the return of menstruation. This period is largely determined by the duration and intensity of breastfeeding. Postpartum abstinence refers to the voluntary sexual inactivity after childbirth. Delaying the resumption of sexual relations after a birth prolongs the period of postpartum protection. Postpartum amenorrhea and sexual abstinence after birth jointly determine the length of the period women are insusceptible to pregnancy following birth; women are insusceptible if they are either abstaining from sex after childbirth or are amenorrhoeic. In TDHS-2008, women who gave birth in the five years preceding the survey were asked about the duration of amenorrhea and sexual abstinence after each birth that occurred during the period. Table 7.4 presents the percentage of births whose mothers were postpartum amenorrheic, abstaining, and postpartum insusceptible by the number of months since birth for the three years preceding the survey. The estimates of the median and mean durations shown in the table are calculated from these current status proportions. In calculating these averages, the data were grouped by two-month intervals to minimize fluctuations. The results in Table 7.4 show that a great majority of women (87 percent) are amenorrheic during the first two months following the birth, but this value decreases to 64 percent after the second month. Only one-fourth of women are amenorrheic after the sixth month. 112 | Other Proximate Determinants of Fertility In Turkey, the period of sexual abstinence after birth traditionally lasts 40 days. The estimates of postpartum abstinence in Table 7.4 are compatible with this tradition. Seventy-eight percent of all mothers abstained from sexual relations during first two months following the birth. However, starting from the second month after the birth, the contribution of abstinence to the period of insusceptibility is greatly reduced. At 2-3 months following a birth, the percentage of abstaining mothers decreases to 15 percent and by 6-7 months, to less than 1 percent (Figure 7.1). Table 7.4 Postpartum amenorrhea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Turkey 2008 Number of months since birth Percentage of births for which the mother is Number of birthsAmenorrheic Abstaining Insusceptible < 2 87.2 77.5 97.9 88 2-3 64.2 14.7 67.6 133 4-5 33.6 1.9 34.7 133 6-7 26.0 0.6 26.6 106 8-9 20.2 0.8 20.2 92 10-11 12.3 0.0 12.3 136 12-13 5.4 0.3 5.7 123 14-15 5.1 0.7 5.1 112 16-17 3.7 0.9 4.2 133 18-19 2.3 0.3 2.6 133 20-21 0.6 0.7 1.2 96 22-23 0.0 0.0 0.0 110 24-25 1.6 0.0 1.6 114 26-27 0.0 0.7 0.7 124 28-29 0.0 0.4 0.4 116 30-31 0.0 0.0 0.0 109 32-33 0.0 0.0 0.0 115 34-35 0.0 2.0 2.0 95 Total 14.1 4.8 15.2 2,068 Median 3.6 1.7 3.9 NA Mean 5.6 2.4 5.9 NA NA = Not applicable Other Proximate Determinants of Fertility | 113 Overall, the median duration of postpartum amenorrhea is 3.6 months, abstinence is 1.7 months, and insusceptibility is 3.9 months. Thus, the TDHS-2008 results, which are similar to the findings of previous surveys, indicate that the period of postpartum amenorrhea is comparatively longer than the period of postpartum abstinence and therefore is the primary determinant of the length of postpartum insusceptibility to pregnancy in Turkey. In the absence of contraception, variations in postpartum amenorrhea and abstinence are the most important determinants of the interval between births and, ultimately, of completed fertility. Table 7.5 shows the median duration of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics of mothers. In general, the average duration of postpartum abstinence in Turkey does not vary much by background characteristics, except for minor differences across regions and by the mother’s level of education. For example, postpartum abstinence seems to be practiced for a slightly longer period in the West Marmara, East Black Sea and Central East Anatolia than in other regions. West Black Sea has the shortest median duration of postpartum abstinence (1.1 months). Given the generally similar durations of postpartum abstinence, variations across in the period of insusceptibility mainly reflect differences in the durations of amenorrhea. Older women who are above age 30 have a longer median duration of amenorrhea (4.1 months) than younger women who are under age 30 (3.3 months). Urban women have a shorter median duration of amenorrhea than their rural counterparts (3.2 and 4.9 months, respectively). There are considerable regional variations in the period of amenorrhea. The shortest durations for postpartum amenorrhea are observed in some coastal regions, namely East Marmara, Mediterranean, and East Black Sea regions (2.4 months) and the highest durations are observed in TDHS-2008 114 | Other Proximate Determinants of Fertility Central Anatolia and West Marmara regions (5.1 and 5.0 months, respectively). Postpartum amenorrhea is inversely related with mother’s education. The median duration of amenorrhea is 3.9 months among women who do not have education, while it is 2.6 months for women with at least high school education. There is an inverted U-shaped relationship between the duration of amenorrhea and wealth status. Table 7.5 Median duration of postpartum insusceptibility by background characteristics Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey , by background characteristics, Turkey 2008 Background characteristic Amenorrheic Abstaining Insusceptible Number of births Mother’s age <30 3.3 1.6 3.6 1,342 30+ 4.1 1.8 4.4 726 Residence Urban 3.2 1.7 3.5 1,472 Rural 4.9 1.7 5.1 596 Region West 3.1 1.6 3.6 708 South 2.4 1.7 2.7 245 Central 4.8 1.7 5.0 456 North 2.4 2.0 2.5 125 East 3.6 1.8 3.8 535 Region (NUTS 1) İstanbul 3.6 1.6 3.8 318 West Marmara 5.0 2.0 5.0 55 Aegean 3.8 1.6 4.1 264 East Marmara 2.4 1.5 3.5 183 West Anatolia 3.6 1.8 3.8 208 Mediterranean 2.4 1.7 2.7 245 Central Anatolia 5.1 1.8 5.9 108 West Black Sea 4.2 1.1 4.8 104 East Black Sea 2.4 2.1 3.0 49 Northeast Anatolia 3.2 1.6 3.5 74 Central East Anatolia 4.7 2.1 4.7 149 Southeast Anatolia 3.4 1.6 3.7 312 Education No educ./Prim.inc. 3.9 1.9 4.4 442 First level primary 3.6 1.4 3.7 965 Second level primary 4.3 1.8 4.4 222 High school and higher 2.6 1.9 3.5 439 Wealth quintile Lowest 3.3 1.8 3.5 493 Second 5.3 1.9 5.6 467 Middle 4.5 1.4 4.5 451 Fourth 2.7 1.4 3.0 340 Highest 2.9 1.9 3.2 317 Total 3.6 1.7 3.9 2,068 Note: Medians are based on current status Other Proximate Determinants of Fertility | 115 Durations of postpartum insusceptibility by sub-population groups exhibit a pattern similar to those for amenorrhea. In general, women over age 30, rural women, women living in the Central region, uneducated women and women living in the second and third quintile households are insusceptible for relatively longer periods. 7.4 Menopause Exposure to the risk of becoming pregnant declines with age. After age 30, women’s susceptibility to pregnancy decreases as the proportion of infecund women increases. Onset of menopause is a main determinant of infecundity. Table 7.6 presents the percentage women age 30 and over who are menopausal. Menopausal women are defined as women who are neither pregnant nor postpartum amenorrheic, but who have not had a menstrual period in the six months preceding the survey. Women who report that they have had a hysterectomy are also defined as menopausal. Overall, 10 percent of women age 30-49 are estimated to be menopausal. The percentage of menopausal women increases with age, from less than 1 percent for women in their early thirties to 42 percent for women age 48-49. Table 7.6 Menopause Percentage of women age 30-49 who are menopausal, by age, Turkey 2008 Age Percentage menopausal Number of women Age 30-34 0.6 1,379 35-39 1.9 1,336 40-41 4.0 445 42-43 9.3 487 44-45 15.5 527 46-47 30.5 402 48-49 42.0 457 Total 9.8 5,033 Fertility Preferences | 117 FERTILITY PREFERENCES 8 Mehmet Ali Eryurt, A. Sinan Türkyılmaz and Pelin Çağatay Information on future reproductive preferences is of considerable importance for refining and modifying current family planning policies. Insight into the fertility preferences allows an assessment of the potential unmet need for contraception. Similar to the previous demographic surveys, the TDHS-2008 asked women a series of questions to ascertain their fertility preferences. Respondents were first asked about whether if they wanted additional children and, if so how long would they prefer to wait before the next child. They were also asked, if they could start afresh, how many children in all they would want. Bearing in mind that the underlying rationale of most family planning programs is to give couples the freedom and ability to bear the number of children they want and to achieve the spacing of births they prefer, the importance of this chapter is obvious. The analysis and interpretation of data on fertility preferences have been criticized on the grounds that answers are misleading, because they do not take into account the effect of social pressures or the attitudes of other family members, particularly the husband, who may exert a major influence on reproductive decisions. Although the evidence from surveys in which both husbands and wives are interviewed suggests that there is no radical difference in between the views of the two sexes, the preferences of TDHS-2008 respondents expressed at the time of the survey are obviously subject to change in response social-familial pressures and other pressures. 8.1 Desire for More Children Fertility desires of currently married women were determined by asking whether or not they wanted to have another child and, if so, how soon. The inclusion of women who are currently pregnant complicated the measurement of views on future childbearing. For these women, the question on desire for more children was rephrased to refer to desire for another child after the one that they were expecting. To take into account the way in which the preference variable was defined for pregnant women, when the results are classified by number of living children, the current pregnancy is counted as equivalent to a living child. A current pregnancy may also have influenced the responses to question of how soon a woman wanted the next child; i.e., in some cases, the answers of pregnant women with respect to preferred waiting time before the next birth may have included the remaining gestation period of the current pregnancy, and thus, may not be strictly comparable with the answers of non-pregnant women. Also, it should be noted that women who have been sterilized for contraceptive purposes were not asked about their desire for another child. However, for purposes of the fertility preference analysis, these women are classified as wanting no more children. 118 | Fertility Preferences Table 8.1 and Figure 8.1 show the percent distribution of currently married women by desire for more children according to the number of living children (including any current pregnancy). The table allows the potential need for contraceptive services for spacing as well as for limiting births. The results indicate that the majority of currently married women in Turkey desire to control their future fertility. Sixty-seven percent of currently married want to limit child-bearing: 59 percent want no more children, and an additional 8 percent have been sterilized. Additionally, although 26 percent of currently married women want to have a child at some time in the future, 14 percent of them want to wait for another child at least two years. Thus, about four out of every five currently married are potentially in need of contraception, for the purpose of either limiting their family size or spacing births. The proportion of currently married women who are undecided about having another child is only 3 percent. As expected, the desire for more children declines noticeably as the number of living children increases. Sixty-five percent of currently married women with one child want to have a child in the future, whereas only 3 percent of women with four or more children want to have another. A strong desire to stop childbearing is evident among women who have had two living children and remains at high levels at higher order parities. Table 8.1 Fertility preferences by number of living children Percent distribution of currently married women age 15-49 by desire for children, according to number of living children, Turkey 2008 Number of living children1 Desire for children 0 1 2 3 4+ Total 15-49 Have another soon2 71.6 19.9 4.9 1.9 1.5 11.5 Have another later3 17.3 43.3 8.9 3.8 1.7 14.3 Have another, undecided when 1.2 1.4 0.3 0.5 0.2 0.6 Undecided 1.3 4.4 4.0 1.2 1.1 2.8 Want no more 4.3 27.8 72.3 71.3 75.6 58.7 Sterilized4 0.4 0.4 6.1 16.5 16.2 8.3 Declared infecund 3.9 2.7 3.3 4.6 3.7 3.5 Missing 0.0 0.0 0.1 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 493 1,443 2,469 1,349 1,246 6,999 1 Includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization Fertility Preferences | 119 Table 8.2 shows the percent distribution of currently married women by the desire for more children according to current age. As expected, the proportion of women who want more children decreases with age. Eighty-nine percent of women age 15-19 want more children, compared with 10 percent of women age 35-39 years. The proportion of women who want to delay the next birth for two or more years also decreases rapidly with age as women shift from wanting another birth to desiring to limit childbearing. Thus, the desire to space births is mainly concentrated among women under age 25. Table 8.2 Fertility preference by age Percent distribution of currently married women age 15-49 by desire for more children, according to age, Turkey 2008 Desire for More children Current age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total 15-49 Have another soon1 32.4 23.8 16.0 13.2 8.5 4.0 1.8 11.5 Have another later2 55.5 45.2 28.2 10.6 1.2 0.4 0.0 14.3 Have another, undecided when 0.6 1.9 0.7 0.7 0.4 0.1 0.1 0.6 Undecided 3.8 3.7 5.3 3.9 2.7 0.5 0.1 2.8 Want no more 7.7 24.5 45.7 63.3 71.6 76.0 71.8 58.7 Sterilized 0.0 0.6 3.6 7.6 13.5 13.1 11.5 8.3 Declared infecund 0.0 0.2 0.5 0.7 1.8 5.7 14.5 3.5 Missing 0.0 0.0 0.0 0.0 0.2 0.2 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 180 820 1,314 1,326 1,262 1,096 1,002 6,999 1 Wants next birth within 2 years. 2 Wants to delay next birth for 2 or more years TDHS-2008 120 | Fertility Preferences Table 8.3 shows the percentage of respondents who want no more children by number of living children and selected background variables. The table provides information about subgroup variations in the potential demand for fertility control. Table 8.3 Desire to limit childbearing Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Turkey 2008 Number of living children1 Background characteristic 0 1 2 3 4+ Total Residence Urban 4.2 30.7 78.6 87.7 92.8 66.5 Rural 6.8 18.4 77.5 88.0 90.0 68.8 Region West 5.9 34.9 82.7 89.1 92.0 66.9 South 4.9 15.2 78.0 87.1 89.7 67.3 Central 4.6 24.3 76.7 92.9 95.8 67.9 North 1.2 32.3 83.7 90.6 89.9 69.8 East 1.7 13.0 55.6 74.3 90.8 64.8 Region (NUTS 1) İstanbul 5.3 34.4 77.2 87.3 89.7 64.3 West Marmara 6.8 36.1 93.0 87.0 94.2 69.3 Aegean 2.9 35.7 84.5 92.0 94.1 69.9 East Marmara 8.1 30.9 85.4 90.8 94.2 68.3 West Anatolia 7.7 23.8 74.2 90.5 98.2 65.2 Mediterranean 4.9 15.2 78.0 87.1 89.7 67.3 Central Anatolia 3.6 21.7 74.3 96.7 94.9 71.5 West Black Sea 0.0 33.3 81.3 95.5 97.0 71.8 East Black Sea 2.3 21.7 77.7 83.0 83.2 64.1 Northeast Anatolia 0.0 17.0 76.7 81.0 88.4 69.2 Central East Anatolia 2.2 13.9 57.9 85.2 91.3 65.0 Southeast Anatolia 2.0 9.7 46.9 64.9 91.2 63.1 Education No education/Primary inc. 2.4 15.6 64.7 77.4 90.4 73.1 First level primary 3.5 29.7 78.5 90.1 93.2 72.8 Second level primary 5.7 19.6 71.6 91.1 91.3 47.5 High school and higher 5.9 32.5 85.7 91.0 97.0 55.3 Wealth quintile Lowest 7.5 15.3 69.1 80.4 90.8 69.7 Second 0.6 19.9 71.2 89.8 89.3 67.7 Middle 6.5 30.2 76.7 88.8 91.4 65.9 Fourth 5.0 22.9 79.0 90.5 97.0 64.6 Highest 4.3 39.9 86.6 86.6 98.3 68.1 Total 4.7 28.2 78.4 87.8 91.8 67.0 Note: Women who have been sterilized are considered to want no more children. 1The number of living children includes the current pregnancy. As expected, the desire to limit the childbearing increases rapidly in all subgroups with the number of living children. Overall, roughly similar proportions of women want to terminate childbearing in urban and rural areas (67 and 69 percent, respectively).Women living in the North (70 percent) are the most likely to desire stop childbearing while those living in the East are the least likely (65 percent). In the NUTS 1 regions, the percentage of currently married women who want no more children ranges from 63 percent in the Southeast Anatolia to 72 percent in West Black Sea and Central Anatolia. Fertility Preferences | 121 Education is known to be negatively associated with the desire to stop childbearing, largely because better-educated women tend to be younger and still in the early stages of the family-building process. The TDHS-2008 results conform to this pattern, with the proportion of women who desire to stop childbearing decreasing as the level of education increases. Thus, 73 percent of currently married women with less than a primary education want to stop childbearing, compared with 48 percent of those who have completed secondary education. A similar pattern was observed in the TDHS-2003. Overall, the desire to limit childbearing is not consistently related to wealth status. However, significant differences in the proportions of currently married women who do not want another child are observed among women with one or two children. For example, at parity 2, 69 percent of women in the lowest wealth quintile want to limit childbearing, compared with 87 percent of those who are in the highest wealth quintile. 8.2 Need for Family Planning Services One of the major concerns of family planning programs is to define the size of the potential demand for contraception and to identify women who are in need of contraceptive services. Currently married fecund women who either want to postpone the next birth (need for spacing) or who want no more children (need for limiting), but who are not using a contraceptive method, are considered to have unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted, respectively. Similarly, amenorrheic women are classified as having unmet need if their last birth was mistimed or unwanted. Nonusers who are unsure as to whether or when they want another child are included in the unmet need for spacing purposes since they need to use a contraceptive until they decide they definitely want a child within a short time or do not want another at all. Women who are currently using family planning methods are said to have a met need for family planning. The sum of unmet need and met need constitute the total demand for family planning. Table 8.4 presents the percentage of currently married women with unmet need, met need and the total demand for family planning, according to whether the need is for spacing births or limiting family size by selected background characteristics. The total demand for family planning among currently married women age 15-49 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 (59 and 20 percent, respectively). Overall, 6 percent of currently married women in Turkey have an unmet need for family planning, 4 percent for limiting and 2 percent for spacing births. Although the percentage with an unmet need for family planning remained virtually unchanged between 2003 and 2008 (6.0 percent in TDHS-2003 and 6.2 percent in TDHS-2008), it remains considerably below the level observed in the TDHS-1993 (12 percent). 122 | Fertility Preferences Table 8.4 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage for the demand for contraception that is satisfied, by background characteristics, Turkey 2008 Unmet need for family planning1 Met need for family planning2 Total demand for family planning3 Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Percentage of demand satisfied Number of women Age 15-19 11.9 2.8 14.7 38.1 2.2 40.2 50.5 5.0 55.5 73.5 180 20-24 6.0 2.9 8.9 45.8 17.6 63.4 52.0 20.5 72.5 87.8 820 25-29 3.8 3.6 7.4 34.5 39.1 73.6 38.4 42.6 81.0 90.9 1,314 30-34 1.6 5.0 6.6 18.7 59.9 78.6 20.3 65.2 85.5 92.3 1,326 35-39 0.6 3.3 3.9 6.9 76.9 83.8 7.5 80.3 87.8 95.5 1,262 40-44 0.0 4.7 4.8 2.4 76.2 78.7 2.5 81.0 83.4 94.3 1,096 45-49 0.1 5.0 5.1 0.2 58.7 58.9 0.4 63.7 64.0 92.0 1,002 Residence Urban 2.0 3.4 5.4 19.1 55.2 74.3 21.2 58.7 79.9 93.2 5,284 Rural 2.6 6.2 8.8 14.6 54.3 68.9 17.4 60.5 77.9 88.7 1,716 Region West 1.7 2.6 4.3 18.8 57.5 76.3 20.5 60.2 80.7 94.7 3,049 South 1.7 4.2 5.9 16.0 54.3 70.4 17.8 58.6 76.5 92.3 849 Central 2.0 3.3 5.2 19.4 56.1 75.5 21.5 59.4 80.9 93.6 1,542 North 1.2 3.8 4.9 16.4 59.1 75.6 17.9 62.9 80.8 93.9 455 East 4.4 9.4 13.9 16.1 45.3 61.4 20.6 54.9 75.5 81.6 1,105 Region (NUTS 1) İstanbul 1.5 2.8 4.3 20.8 53.5 74.3 22.3 56.5 78.9 94.5 1,379 West Marmara 0.6 2.4 3.0 17.4 58.7 76.2 18.1 61.1 79.1 96.2 308 Aegean 1.5 2.6 4.0 18.0 62.0 80.0 19.5 64.5 84.0 95.2 1,010 East Marmara 2.1 1.6 3.7 16.8 60.0 76.8 18.9 61.6 80.5 95.4 722 West Anatolia 2.8 3.2 6.0 20.5 55.2 75.7 23.4 58.4 81.8 92.7 679 Mediterranean 1.7 4.2 5.9 16.0 54.3 70.4 17.8 58.6 76.5 92.3 849 Central Anatolia 2.3 5.6 7.8 17.4 54.8 72.2 19.9 60.4 80.2 90.2 356 West Black Sea 1.0 3.6 4.5 18.2 59.3 77.5 19.6 62.9 82.5 94.5 416 East Black Sea 1.7 3.8 5.5 14.9 53.2 68.2 16.9 57.0 73.9 92.5 180 Northeast Anatolia 3.3 6.9 10.3 16.2 54.2 70.4 19.5 61.2 80.7 87.3 188 Central East Anatolia 4.1 9.6 13.7 17.3 44.9 62.3 21.4 54.7 76.1 82.0 318 Southeast Anatolia 5.0 10.2 15.2 15.5 42.3 57.8 20.7 52.6 73.3 79.3 594 Education No educ./Primary inc. 3.3 8.0 11.3 8.5 52.3 60.8 11.8 60.4 72.2 84.3 1,274 First level primary 1.4 4.0 5.4 15.0 61.8 76.8 16.5 66.0 82.5 93.4 3,671 Second level primary 3.0 1.8 4.8 30.3 36.2 66.5 33.4 38.1 71.5 93.3 594 High school and higher 2.7 1.7 4.4 28.9 47.7 76.7 31.7 49.4 81.1 94.6 1,461 Wealth quintile Lowest 3.8 8.8 12.5 13.0 50.3 63.3 17.1 59.1 76.2 83.5 1,094 Second 3.1 4.9 8.0 16.0 54.6 70.5 19.1 59.5 78.6 89.8 1,366 Middle 1.7 2.9 4.6 18.6 56.7 75.3 20.3 59.9 80.2 94.3 1,475 Fourth 1.9 2.3 4.2 19.9 53.9 73.8 21.8 56.2 78.1 94.6 1,512 Highest 0.9 2.9 3.7 21.0 58.1 79.1 21.9 61.0 82.9 95.5 1,553 Total 2.1 4.1 6.2 18.0 55.0 73.0 20.2 59.1 79.4 92.1 6,999 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed; amenorrheic women who are not using family planning and whose last birth was mistimed, or whose last birth was unwanted but now say they want more children; and fecund women who are neither pregnant nor amenorrheic, who are not using any method of family planning, and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted; amenorrheic women who are not using family planning, whose last child was unwanted and who do not want any more children; and fecund women who are neither pregnant nor amenorrheic, who are not using any method of family planning, and who want no more children. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 3 Total demand for family planning includes pregnant or amenorrheic women who became pregnant while using a method (method failure). As expected, unmet need for spacing purposes is higher among younger women, while unmet need for limiting childbirth is higher among older women. Women living in rural settlements tend to have greater unmet need than in urban settlements (9 percent and 5 percent, respectively). Among the regions, the West has the lowest unmet need (4 percent) and the East has the highest (14 percent). Similarly, unmet need varies substantially across the NUTS 1 regions from 3 percent in West Marmara to 15 percent in Southeast Anatolia. Since Fertility Preferences | 123 educated women are more likely to use a contraceptive method than uneducated women, it is not unexpected that unmet need decreases and the percentage of demand satisfied increases with increasing educational level. The differentials by wealth quintile show a similar pattern, with the wealthiest women having the lowest unmet need. 8.3 Ideal Number of Children Thus far in this chapter, interest has focused on the respondent’s wishes for the future, implicitly taking into account the number of sons and daughters she already has. The TDHS- 2008 attempted to obtain a measure of fertility preferences that is less dependent on the woman’s current family size by asking about respondent’s ideal number of children. In ascertaining the total ideal number of children, the respondent was required to perform the more difficult task of considering abstractly and independently of her actual family size the number of children she would choose if she could start the family building process over again. To obtain this measure, respondents who had no children were asked, “If you could choose exactly the number of children to have in your whole life, how many would that be?” For respondents who had children, the question was, “If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?” There is usually a close association between actual and ideal number of children. The reason is twofold. First, woman who want a large family tend to have more children than other woman has. Second, women may adjust their ideal family size so that as the actual number of children increases, their ideal family size also increases. It is also possible that women with large families, being on average older than those with small families, may prefer larger ideal family size because of attitudes they acquired 20 or 30 years ago. Despite the likelihood that some rationalization occurs in the determination of ideal number of children, respondents often state ideals that are lower than their actual number of surviving children. Table 8.5 shows the distribution of ever-married women by their ideal number of children and mean ideal number of children according to actual number of living children. Except for women with no children, there is a positive relationship between the actual and ideal number of children. Half of the respondents (51 percent) stated two children as the ideal number while only 18 percent of women consider four or more children as ideal. Among both ever-married and currently married women the mean ideal family size is 2.5 children. Women with four or more children have a mean ideal family size of 3.2 children, compared with 2.2 children for women with no children or only one child. Interestingly, the mean ideal family size among currently married women has remained about the same for the last 15 years (2.4 in TDHS-1993 and 2.5 in TDHS-1998, TDHS-2003 and TDHS-2008). 124 | Fertility Preferences Table 8.5 Ideal number of children Percent distribution of women 15-49 by ideal number of children, and mean ideal number of children for ever-married women and for currently married women, according to number of living children, Turkey 2008 Number of living children1 Ideal number of children 0 1 2 3 4+ Total 0 2.3 2.4 2.8 1.8 2.3 2.4 1 12.3 10.4 5.7 8.5 3.0 7.2 2 61.9 60.5 61.3 31.0 33.7 50.6 3 14.6 18.1 17.2 34.0 17.8 20.5 4 6.4 5.9 10.7 18.6 29.8 14.3 5 0.9 1.2 1.2 1.9 4.3 1.9 6+ 0.6 0.3 0.6 1.7 5.0 1.5 Non-numeric responses 0.9 1.1 0.5 2.4 4.1 1.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 555 1,550 2,587 1,404 1,308 7,405 Mean ideal number children for:2 Ever-married women 2.2 2.2 2.3 2.8 3.2 2.5 Number 550 1,533 2,574 1,370 1,255 7,282 Currently married 2.2 2.2 2.4 2.8 3.2 2.5 Number 488 1,426 2,456 1,317 1,194 6,881 1The number of living children includes current pregnancy for women. 2The means exclude women who gave non-numeric responses. Table 8.6 shows the mean ideal number of children for ever-married women by age and selected background characteristics. The mean ideal number of children does not vary significantly by age. There is also little difference by residence, with the ideal family size only slightly higher in rural areas than urban areas. However, greater differences are observed across region. The mean ideal number of children is lowest in West and Central regions and highest in the East (2.3 children and 3.1 children, respectively). Similarly, education and wealth status also show notable inverse relationships with the mean ideal number of children. The difference between women with less than a primary education and those who have high school or higher education is almost one child. Women in the three wealthiest quintiles have a lower mean ideal family size than women in the lowest two quintiles. Fertility Preferences | 125 Table 8.6 Mean ideal number of children Mean ideal number of children for ever-married women age 15-49 by background characteristics, Turkey 2008 Age Background characteristic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Number of women1 Residence Urban 2.3 2.4 2.3 2.4 2.6 2.6 2.6 2.5 5,541 Rural 2.6 2.5 2.6 2.7 2.6 2.8 2.9 2.7 1,741 Region West 2.3 2.2 2.3 2.3 2.4 2.4 2.4 2.3 3,237 South 2.4 2.7 2.6 2.7 2.9 3.0 3.0 2.8 873 Central 2.0 2.2 2.1 2.4 2.4 2.6 2.5 2.3 1,594 North 2.3 2.3 2.2 2.3 2.4 2.5 2.6 2.4 470 East 3.0 2.8 2.8 3.1 3.3 3.4 3.7 3.1 1,108 Region (NUTS 1) İstanbul 2.2 2.1 2.3 2.4 2.5 2.4 2.5 2.4 1,488 West Marmara 1.8 2.1 2.2 2.0 2.0 2.2 2.1 2.1 322 Aegean 2.2 2.3 2.4 2.3 2.3 2.5 2.5 2.4 1,058 East Marmara 2.3 2.2 2.2 2.3 2.3 2.4 2.3 2.3 756 West Anatolia 2.1 2.1 2.1 2.4 2.4 2.6 2.5 2.3 686 Mediterranean 2.4 2.7 2.6 2.7 2.9 3.0 3.0 2.8 873 Central Anatolia 2.1 2.2 2.3 2.4 2.3 2.5 3.0 2.4 368 West Black Sea 2.1 2.0 2.1 2.2 2.3 2.4 2.5 2.3 448 East Black Sea 2.5 2.7 2.4 2.8 2.6 2.7 2.9 2.7 179 Northeast Anatolia 2.1 2.3 2.5 2.6 2.6 3.3 3.1 2.6 187 Central East Anatolia 2.7 2.9 2.7 3.1 3.2 3.0 4.0 3.1 313 Southeast Anatolia 3.5 3.0 3.0 3.3 3.6 3.6 3.7 3.3 603 Education No education/Primary incomplete 3.2 2.8 3.0 3.1 3.2 3.2 3.2 3.1 1,307 First level primary 2.5 2.5 2.4 2.5 2.5 2.5 2.6 2.5 3,778 Second level primary 2.1 2.2 2.3 2.3 2.0 2.5 2.7 2.2 640 High school and higher 2.0 2.1 2.1 2.3 2.3 2.4 2.1 2.2 1,557 Wealth quintile Lowest 2.6 2.9 2.9 2.9 2.9 3.1 3.3 3.0 1,114 Second 2.5 2.5 2.4 2.7 2.8 2.7 2.8 2.6 1,394 Middle 2.2 2.3 2.4 2.3 2.5 2.5 2.5 2.4 1,540 Fourth 2.2 2.2 2.2 2.4 2.3 2.6 2.5 2.4 1,602 Highest 2.2 2.1 2.1 2.3 2.5 2.5 2.5 2.4 1,633 Total 2.4 2.4 2.4 2.5 2.6 2.6 2.7 2.5 7,282 1Number of women who gave a numeric response 126 | Fertility Preferences 8.4 Planning Status of Births The issue of unplanned and unwanted fertility was further investigated in the TDHS- 2008 by asking women for each child born in the preceding five years and for any current pregnancy, if the pregnancy was desired at the time (“planned”), not desired at the time but wanted at a later time, or unwanted at any time. The women’s responses form a potentially powerful indicator of the degree to which couples successfully control childbearing. In addition, the data can be used to gauge the effect of the prevention of unwanted births on period fertility. The questions on planning of births were extremely demanding. The respondent was required to recall accurately her wishes at one or more points in time during the last five years and to report them clearly and honestly. The danger of rationalization was clearly present; an unwanted conception may well have become a cherished child. Despite the potential problems of comprehension, recall, and truthfulness, results from many surveys have proved that answers to questions about the planning status of births are surprisingly plausible, indicating that respondents are willing to report unwanted and mistimed conceptions. Nevertheless, some postpartum rationalization undoubtedly occurs; therefore, this approach likely underestimates unwanted fertility. Table 8.7 shows the percent distribution of births in the five years preceding the survey and current pregnancies by whether the birth (pregnancy) was wanted by the mother then, wanted later, or not wanted at all, according to birth order and age of mother at birth. Overall, 71 percent of births in the five-year period preceding the survey were planned, 11 percent were mistimed, and 18 percent were unwanted. The percentage of planned births was somewhat lower at the time of the TDHS-2003 (66 percent). Table 8.7 Fertility planning status Percent distribution of births to women 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother's age at birth, Turkey 2008 Planning status of birth Birth order and mother's age at birth Wanted then Wanted later Wanted no more Missing Total Number of births Birth order 1 90.1 8.5 1.2 0.2 100.0 1,357 2 74.4 15.9 9.1 0.5 100.0 1,148 3 59.7 12.7 27.5 0.2 100.0 621 4+ 42.7 4.2 52.1 1.0 100.0 761 Mother's age at birth <20 79.1 13.0 6.9 1.1 100.0 384 20-24 75.3 12.5 11.7 0.5 100.0 1,250 25-29 72.2 12.1 15.6 0.1 100.0 1,172 30-34 64.3 6.4 29.0 0.3 100.0 733 35-39 61.9 4.5 31.9 1.8 100.0 270 40 and over 53.8 0.8 45.4 0.0 100.0 77 Total 71.3 10.5 17.7 0.5 100.0 3,886 Fertility Preferences | 127 Table 8.7 shows that, in general, the proportion of unwanted births increases sharply with increasing birth order, ranging from 1 percent of first births to half of fourth and higher births. On the other hand, the proportion of mistimed births has an inverted U-shaped relationship with birth order. A similar pattern is observed for the mother’s age at birth: the older the mother at the time of birth, the larger the percentage of children that are unwanted. Only 12 percent of births to women age 20-24 are unwanted, compared with 45 percent of births to women age 40 and over. The percentage of mistimed births is highest among women under age 30 and drops off sharply among women age 30 and older. 8.5 Total Wanted Fertility Another approach to measuring the extent of unwanted fertility is to compare the total wanted fertility rate (TWFR) with the total fertility rate (TFR). The total wanted fertility rate represents the level of fertility that theoretically would result if all unwanted births were avoided. The wanted fertility rate is calculated in a similar manner as the total fertility rates presented in Chapter 4, except that births classified as unwanted are omitted from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. The total wanted fertility rate provides another indicator of fertility aspirations and may be interpreted as the number of wanted births that a woman would bear by age 50, if she experienced the wanted fertility rates observed for the past three years. A birth is considered wanted if the number of living children at the time of conception was less than the ideal number of children reported at the time of the survey. There is a difference between ideal family size and the wanted fertility rate in that the wanted fertility rate takes observed fertility as its starting point and can never be larger than the actual TFR; ideal family size can be and often is larger than the number of children ever born. This characteristic of the wanted fertility rate has an advantage and a disadvantage. It may be the more realistic measure, because it takes into account the fact that fecundity impairment prevents some women from having wanted births and from achieving their desired family size. But it has the disadvantage of interpretive complexity and, like any period measure, is vulnerable to temporary influences on the level of recent fertility. Table 8.8 show that, the total wanted fertility rate for Turkey is 1.6 children, which is 27 percent less than the actual total fertility rate of 2.2 children. In other words, if all unwanted births were prevented, the TFR would be 0.6 children less than the observed level. Table 8.8 also shows that wanted fertility is lower than the replacement level in all subgroups. The lowest wanted fertility rates are observed among women living in the richer households, women having high school and higher education, and women living in the West region. The gap between actual and wanted fertility rates is highest among poorest women, women living in the East region, women who have no education, and rural women. On the other hand, the gap is smallest for the richest women and women who have completed secondary or higher education. 128 | Fertility Preferences Table 8.8 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Turkey 2008 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 1.6 2.00 Rural 1.8 2.68 Region West 1.4 1.73 South 1.7 2.09 Central 1.7 2.20 North 1.6 2.08 East 2.0 3.27 Education No education/Primary incomplete 1.5 2.65 First level primary 1.7 2.25 Second level primary 1.0 1.30 High school and higher 1.4 1.53 Wealth quintile Lowest 2.0 3.39 Second 1.8 2.51 Middle 1.8 2.19 Fourth 1.3 1.67 Highest 1.2 1.36 Total 1.6 2.16 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Chapter 4. Infant and Child Mortality | 129 INFANT AND CHILD MORTALITY 9 İsmet Koç, İlknur Yüksel and Mehmet Ali Eryurt This chapter describes levels, trends, and differentials in early childhood mortality and the prevalence of high risk fertility behaviour of women in Turkey. The information is disaggregated by socioeconomic and demographic characteristics since studies have shown the existence of differentials in mortality by these characteristics and the disaggregation helps to identify subgroups that are at high risk. Information on infant and child mortality rates contributes to a better understanding of Turkey’s socioeconomic situation and sheds light on the quality of life of the population. Childhood mortality in general and infant mortality in particular are often used as broad indicators of social development or as specific indicators of health status. Childhood mortality analyses are thus useful in identifying promising directions for health programmes and advancing child survival efforts. Measures of childhood mortality are also useful for population projections. One of the targets of the Millennium Development Goals (MDGs) is a two-third reduction in infant and child mortality by 2015, to be achieved through upgrading the proportion of births attended by skilled health personnel, increasing immunization against the eight vaccine preventable diseases, and upgrading the status of women through education and enhancing their participation in the labour force. Results from the TDHS-2008 are timely in evaluating the impact of some of the major national policies on the achievement of this fundamental MDG goal. The mortality rates presented in this chapter are computed from information gathered from the birth history section of the individual questionnaire. Ever-married women in the age group 15-49 were asked whether they had ever given birth, and if they had, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of their children in chronological order starting with the first child. Women were asked whether a birth was single or multiple; the sex of the child; the date of birth (month and year); survival status; age of the child on the date of the interview if alive; and if not alive, the age at death of each live birth. Age at death was recorded in days for children dying in the first month of life, in months for children dying before their second birthday, and in years for children dying at later ages. In this chapter, the following direct estimates of infant and child mortality1 derived from the birth history data are used: 1A detailed description of the method for calculating the probabilities presented here is given in Rutstein (1984). The mortality estimates are not rates but are true probabilities calculated according to the conventional life-table approach. Deaths and exposure in any period are first tabulated for the age intervals 0, 1-2, 3-5, 6-11, 12-23, 24-35, 36-47, and 48-59 months. Then age-interval-specific probabilities of survival are calculated. Finally, probabilities of mortality for larger age segments are produced by multiplying the relevant age-interval survival probabilities together and subtracting the product from one: 130 | Infant and Child Mortality Neonatal mortality, the probability of dying in the first month of life · Post-neonatal mortality, the probability of dying after the first month of life but before the first birthday · Infant mortality (1q0), the probability of dying in the first year of life · Child mortality (4q1), the probability of dying between the first and fifth birthday · Under-five mortality (5q0), the probability of dying before the fifth birthday. The rates of childhood mortality are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one. In addition to questions on live births, women were asked additional questions about pregnancies that ended in miscarriage, abortion, or stillbirth. This information was collected for the five years preceding the survey to minimize recall errors. Information on stillbirths and deaths that occurred within seven days of birth is used to estimate perinatal mortality, which is the number of stillbirths and early neonatal deaths per 1,000 stillbirths and live births. 9.1 Assessment of Data Quality The accuracy of mortality estimates depends both on the sampling variability associated with the estimates and on nonsampling errors. Sampling variability and sampling errors are discussed in detail in Appendix C. Nonsampling errors depend on the extent to which the date of birth and age at death are accurately reported and recorded and the completeness with which child deaths are reported. Omission of births and deaths affects mortality estimates, displacement of birth and death dates impacts mortality trends, and misreporting of age at death may distort the age pattern of mortality. Typically, the most serious source of nonsampling errors in a survey that collects retrospective information on births and deaths is the underreporting of births and deaths of children who were dead at the time of the survey. It may be that mothers are reluctant to talk about their dead children because of the sorrow associated with their death, or they may live in a culture that discourages discussion of the dead. Underreporting of births and deaths is generally more severe the further back in time an event occurred. Several tables are presented in Appendix D which may be used to examine the occurrence of such problems in the TDHS-2008. An unusual pattern in the distribution of births by calendar years is an indication of omission of children or age displacement. Table D.3 presents that the percentage of live births in the 15 years preceding the survey for which information on year of birth was missing. Around two percent of births had information on the year but not the month of birth. Both month and year of birth were missing for less than 1 percent of all live births in the 15-year period before the TDHS-2008. Approximately 1 percent of deaths recorded in the birth histories lacked an age at death. Table D.4 also shows that the overall percentage of births for which a month and year of birth was reported is relatively complete, with incomplete information being only slightly higher for children who have died than those who are alive (81 percent versus 97 percent). There is somewhat greater deterioration in the completeness of birth date information the further back one goes from the survey date, but the percentage is above 95 percent for births occurring since 1994 and 100 percent for births occurring in 2003 or later, i.e., in the period covered by the calendar. Infant and Child Mortality | 131 Age displacement is common in surveys that include both demographic and health information for children under a specified age. This shifting usually results from interviewers transferring births out of the five-year period for which data are collected on maternal and child health indicators (January 2003 to date of interview for the TDHS-2008) in an attempt to reduce the length of interview. Table D.4 shows there is some age displacement across this boundary. The distribution of births shows a deficit in 2003 and an excess in 2002, as denoted by the calendar year ratios; the deficit is much larger for dead than living children. The deficit among births in 2003 can be attributed to the transference of births by interviewers out of the period for which health data were collected. The transference of children and especially deceased children out of the five-year period preceding the survey, is likely to underestimate the true level of childhood mortality for that period. There is also evidence of a possible omission of children who died, as evidenced by the lower numbers of dead children in 2003- 2005 compared with 2000-2002. However, as the cutoff dates for the most recent 5-year period include only two months from 2003 (November and December), the underestimation originated from the transference of deceased children out of the five-year period preceding the survey is at a negligible level. Only 2 under five deaths and 73 births taken place during November-December 2003 were included into the numerator and denominator of the mortality rates estimated for the five-year period preceding the survey. One further check that was performed to assess the reliability of birth history data was to calculate sex ratios at birth for all live births. These ratios are expected to fluctuate around 105 male births per 100 female births. Table D.4 shows that the overall sex ratio for all births in the birth history is 106, which is in line with expectations. The sex ratio of live births during the period of 2004-2008 is also in line with expectations, at 104. For earlier periods, fluctuations are observed in sex ratios at birth, without any systematic over or under reporting of males or females. Underreporting of deaths is usually assumed to be higher for deaths that occur very early in infancy. Omission of deaths or misclassification of deaths as stillbirths may also be more common among women who have had several children or in cases where death took place a long time ago. In order to assess the impact of omission on measures of child mortality, two indicators are used: the percentage of deaths that occurred under seven days among all deaths that occurred under one month and the percentage of neonatal among all infant deaths. It is hypothesized that omission will be more prevalent among those who died immediately after birth than those who lived longer and that it will be more serious for events that took place in the distant past rather than those in the more recent past. Selective underreporting of early neonatal deaths would result in an abnormally low ratio of deaths within the first seven days of life to all neonatal deaths. Table D.5 shows data on age at death for early infant deaths. Early infant deaths do not seem to have not been underreported in the TDHS-2008 survey as suggested by the high ratio of deaths in the first seven days of life to all neonatal deaths (88 percent for the most recent period). Table D.6 shows that the proportion of infant deaths occuring during the first month of life (79 percent) are also entirely plausible and in line with declining mortality rates in Turkey. Heaping of the age at death on certain digits is another problem that is inherent in most retrospective surveys. Misreporting of age at death biases age pattern estimates of mortality if 132 | Infant and Child Mortality the net result is the transference of deaths between age segments for which the rates are calculated; for example, child mortality may be overestimated relative to infant mortality if children who died in the first year of life are reported as having died at age one or older. In an effort to minimize misreporting of age at death, TDHS-2008 interviewers were instructed to record deaths under one month in days and under two years in months. In addition, they were trained to probe deaths reported at exactly 1 year or 12 months to ensure that they had actually occurred at 12 months. The distribution of deaths under 2 years during the 20 years prior to the survey by month of death shows that there is definite heaping at 12, and 18 months of age with corresponding deficits in adjacent months (Table D.6). However, heaping is less pronounced for deaths in the five years preceding the survey, for which the most recent mortality rates are calculated. Finally, in addition to recall errors for the more distant retrospective periods, there are structural reasons for limiting mortality estimation to recent periods, preferably to the 0-4, 5-9, and 10-14 years before the survey. In particular, except for the most recent period, rates are slightly biased estimates because they are based on the child mortality experience of women age 15-44 and 15-39, respectively, instead of women age 15-49. Therefore, estimating mortality for the periods further than 10-14 years before the survey is not advisable. 9.2 Levels and Trends in Infant and Child Mortality Mortality rates for children under five years of age are presented in Table 9.1 for the three five-year periods preceding the survey. Data from the TDHS-2008 show that under-five mortality during the five years preceding the survey (which roughly corresponds to the date December 2003-November 2008) is 24 per 1,000 live births. This means that slightly more than 2 in 100 children born in Turkey die before reaching the fifth birthday. The infant mortality rate is 17 deaths per 1,000 live births, and the child mortality rate is 6 per 1,000. The risk of dying in the first month of life (13 per 1,000) is nearly three times greater than in the subsequent 11 months (4 per 1,000). Deaths in the neonatal period account for 76 percent of all infant deaths. Table 9.1 Infant and child mortality Neonatal, post neonatal, infant, child and under-five mortality rates by five-year periods preceding the TDHS-2008, TDHS-2003 and TDHS-1998 Years preceding survey Approximate reference date Neonatal Mortality (NN) Post neonatal Mortality (PNN) Infant Mortality (1q0) Child Mortality (4q1) Under-five Mortality (5q0) TDHS-2008 0-4 2003-2008 13 4 17 6 24 5-9 1998-2003 17 16 33 9 41 10-14 1993-1998 21 23 50 10 59 TDHS-2003 0-4 1998-2003 17 12 29 9 37 5-9 1993-1998 24 22 47 10 56 TDHS-1998 0-4 1993-1998 26 17 43 10 52 The figures in Table 9.1 show a relatively fast pace of decline in infant and child mortality rates in Turkey. A decrease about 48 percent is observed in infant mortality rate for Infant and Child Mortality | 133 the five-year between 1998-2003 and 2003-2008. In the same period, there was a 33 percent decrease in child mortality and 41 percent decrease in overall under-five mortality. The decline in child mortality rate during the last five years is especially noteworthy, considering the stability in child mortality rate at a level of 9-10 per thousand during the period 5-14 years the TDHS-2008. Table 9.1 also presents comparable mortality estimates from the TDHS-1998, TDHS- 2003 and TDHS-2008. The early age mortality rates obtained from TDHS-2008 are consistent with the findings of previous surveys calculated for the same reference periods. The consistency between the surveys is impressive. The difference between early age mortality rates calculated from the TDHS-2008 data set for reference periods of TDHS-2003 and TDHS- 1998 and findings obtained from those two previous surveys is less than 5 per thousand. This difference is negligible and constitutes virtually full agreement between independent estimates in the last three surveys. Once again, this finding highlights the excellent quality of the birth history data for the three surveys from which the early childhood mortality rates are calculated. Both approaches to examining mortality trends, i.e., comparisons of the rates from the TDHS- 2008 across successive to the 5-year periods preceding survey as well as comparison of TDHS-2008 rates to those of TDHS-2003 and TDHS-1998, indicate that the decrease in infant and child mortality rates in Turkey has accelerated in recent years, especially in the last five years (Table 9.1 and Figure 9.1). 134 | Infant and Child Mortality 9.3 Differentials in Infant and Child Mortality Table 9.2 shows differentials in childhood mortality for four socioeconomic variables: residence, region, mother’s education, and wealth quintile. A ten-year period is used to calculate the mortality estimates by these background characteristics, so as to obtain enough cases in each category. Although, the use of the ten-year reference period improves the reliability of the mortality estimates, these findings must be interpreted with caution given the comparatively large sampling errors associated with the ten-year rates. Table 9.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality for the ten-year period preceding the survey by socioeconomic characteristics, Turkey 2008 Socioeconomic characteristic Neonatal mortality (NN) Post neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 13 9 22 7 29 Rural 20 14 33 10 43 Region West 9 7 16 10 26 South 17 13 30 6 35 Central 12 9 22 1 23 North 16 8 24 3 27 East 24 15 39 11 50 Selected regions of residence (NUTS 1) Istanbul 2 6 9 14 23 Southeast Anatolia 20 13 33 12 45 Education No education/Prim. incomplete 23 18 41 12 53 First level primary 14 10 24 5 29 Second level primary and higher 9 4 13 8 21 Wealth quintile Lowest 22 19 41 11 52 Second 19 11 30 9 38 Middle 10 6 16 4 21 Fourth 11 7 18 4 23 Highest 7 4 12 9 20 Total 15 11 26 8 33 1 Computed as the difference between infant and neonatal mortality rates The infant mortality rate for the ten-year period preceding the survey is found to be 26 per 1,000 live births. The infant mortality rates calculated from TDHS-1998 and TDHS-2003 for the same period were 48 and 36 per 1,000 live births. The infant mortality rate in the rural areas is about 33 percent higher than in urban areas. Most of this difference appears to be attributable to differences in the post-neonatal mortality. Variations in mortality levels are also evident by region. Neonatal mortality exceeds post-neonatal mortality in all regions. The East has the highest mortality rates at all ages; which was true in previous demographic and health surveys. The mother’s level of education is inversely related to her child’s risk of dying. This pattern is expected because education exposes mothers to information about better nutrition, use of contraception to limit and space births, health care during pregnancy, and childhood Infant and Child Mortality | 135 illnesses, vaccinations, and treatments, all of which contribute to lower mortality risks for children. The TDHS-2008 results indicate that the largest decrease in mortality by mother’s education was in the postneonatal period; the rate is almost 78 percent lower for children whose mothers have at least some secondary education, compared with children whose mothers have no or an incomplete primary education. A child’s risk of dying is also associated with the economic status of the household. All childhood mortality rates, except for child mortality, are lowest for those in the highest wealth quintile. The risk of dying by age five in the top quintile is about one-third of that in the bottom quintile. The relationship between childhood mortality and household wealth is especially notable for neonatal and post neonatal mortality rates. Besides socio-economic characteristics, a number of demographic characteristics of the child and the mother have been found to affect mortality risks, including the sex of the child, mother’s age at birth, birth order, length of previous birth interval, and the size of the child at birth. The relationship between these demographic characteristics and childhood mortality is shown in Table 9.3. Again, for all variables except birth size, mortality estimates are calculated for a ten-year period before the survey to reduce the sampling variability. Table 9.3 Early childhood mortality rates by biodemographic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality for the ten-year period preceding the survey by biodemographic characteristics, Turkey 2008 Biodemographic characteristic Neonatal mortality (NN) Post neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Sex of child Male 15 13 28 8 36 Female 15 8 23 7 30 Mother’s age at birth < 20 22 12 33 12 45 20-29 12 11 23 6 29 30-39 19 8 27 11 37 40-49 28 6 34 0 34 Birth order 1 13 7 21 5 26 2-3 12 10 22 7 28 4-6 23 17 40 12 52 7+ 30 17 47 17 63 Previous birth interval2 < 2 years 27 24 51 12 62 2 years 15 12 27 7 33 3 year 11 6 17 2 19 4 years or more 11 7 18 9 27 Size at birth3 Small or very small 18 6 24 NA NA Average or larger 9 2 11 NA NA NA= not applicable 1 Computed as the difference between the infant and child mortality rates 2 Excludes first-order births 3 Refers for the five-year period before the survey 136 | Infant and Child Mortality Male children in general experience higher mortality than female children. The sex difference is especially pronounced for postneonatal mortality. The relationship between mother’s age at delivery and infant mortality generally exhibits a U-shaped curve. Infant mortality rate is substantially higher among children born to mothers less than 20 and those age 40 and over. The TDHS-2008 results show that there is a clear positive association between birth order and the probability of dying -the risk of dying increases with higher order births. Mortality among children is negatively associated with the length of the previous birth interval. For example, infant mortality decreases sharply from 51 per 1,000 live births for children born less than two years after a previous birth to 18 per 1,000 live births for children born four years or more after a previous birth. Children’s weight at birth is also closely associated with their chances of survival, particularly during the first year of life. Children reported as “small or very small” at birth were at two times the risk of dying compared with children whose size at birth was reported as “average or larger.” 9.4 Perinatal Mortality Perinatal deaths are composed of pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths within the first seven days of life (early neonatal deaths). The causes of stillbirths and early neonatal deaths overlap, and examining just one or the other can understate the true level of mortality around delivery. For these reasons, it is suggested that both events be combined and examined together. The perinatal death rate is calculated by dividing the total number of perinatal deaths by the total number of pregnancies reaching seven months of gestation. The distinction between a stillbirth and an early neonatal death is a delicate one, often depending on the observed presence or absence of some signs of life after delivery. In the TDHS-2008, information on stillbirths was obtained for the five years preceding the survey, using the calendar at the end of the Women’s Questionnaire. Table 9.4 presents the number of stillbirths and early neonatal deaths and the perinatal mortality rate for the five-year period preceding the TDHS-2008, by selected demographic and socioeconomic characteristics. Out of the 3,490 reported pregnancies of at least seven months’ gestation during the five years preceding the survey, 27 ended in stillbirths and 40 ended in early neonatal deaths, yielding an overall perinatal mortality rate of 19 per 1,000 stillbirths and live births. Comparable data from the TDHS-2003 suggest that perinatal mortality has declined from 24 per 1,000 to its current level. Perinatal mortality is highest among women who were 40-49 years or under age 20 at the time of the birth. The interval between the previous and current pregnancies is strongly associated with perinatal mortality. Pregnancies that occured less than 15 months after a previous pregnancy are approximately two times more likely to have ended in perinatal death as pregnancies that followed an interval of 15-26 and 27-38 months. Perinatal mortality is slightly higher in urban areas than in rural areas. The West has the highest perinatal mortality rate among all regions. Highly educated mothers are less likely to experience perinatal losses than uneducated mothers. Infant and Child Mortality | 137 Table 9.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Turkey, 2008 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother’s age at birth <20 3 8 34 347 20-29 12 17 13 2,177 30-39 9 15 26 897 40-49 4 0 (51) 70 Previous pregnancy interval in months First pregnancy 6 11 16 1,090 <15 0 9 28 315 15-26 3 6 15 561 27-38 3 2 14 403 39+ 15 12 24 1,121 Residence Urban 20 30 20 2,496 Rural 7 10 17 995 Region West 18 12 25 1,191 South 3 5 18 444 Central 1 10 14 742 North 0 0 (2) 197 East 6 13 21 917 Selected NUTS 1 Regions Istanbul 9 3 21 557 Southeast Anatolia 3 7 18 536 Education No education/Prim. incomplete 7 8 20 788 First level primary 16 26 25 1,707 Second level primary and higher 4 6 9 995 Wealth quintile Lowest 6 10 19 858 Second 7 13 24 824 Middle 5 6 16 714 Fourth 2 7 14 581 Highest 7 4 22 513 Total 27 40 19 3,490 1 Stillbirths are foetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration. Note: Figures in parentheses are based on less than 250 unweighted pregnancies. 9.5 High-risk Fertility Behavior Many studies have found a strong relationship between children’s chances of dying and certain fertility behaviors. In general, the probability of dying in early childhood is much greater if children are born to mothers who are “too young” or “too old”, if they are born after a short birth interval, or if they are born to mothers with high parity. For this analysis, mothers are classified as “too young” if they are less than 18 years of age and “too old” if they are over 34 years of age at the time of delivery. A short birth interval is defined as a birth occurring within 138 | Infant and Child Mortality 24 months of a previous birth, and a high birth order is defined as occurring after three or more previous births (birth order four or higher). After cross-classification of births by combinations of all three characteristics, a birth may have from zero to three high-risk characteristics. All risk categories are potentially avoidable except for one: first births to mothers age 18-34. Table 9.5 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Turkey 2008 Births in the 5 years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married womena Not in any high risk category 33.2 1.0 31.1b Unavoidable risk category First order births between ages 18 and 34 years 31.8 1.4 7.4 Single high-risk category Mothers's age <18 2.7 1.5 0.2 Mothers's age >34 3.8 0.2 20.9 Birth interval <24 months 8.2 3.1 7.3 Birth order >3 11.2 1.5 6.1 Subtotal 26.0 1.8 34.5 Multiple high-risk category Age <18 & birth interval <24 monthsc 0.1 0.0 0.1 Age >34 & birth interval <24 months 0.3 0.0 0.4 Age >34 & birth order >3 4.1 3.3 22.8 Age >34 & birth interval <24 months & birth order >3 0.7 8.3 0.9 Birth interval <24 months & birth order >3 3.9 3.5 2.7 Subtotal 9.0 3.6 27.0 In any avoidable high-risk category 35.0 2.3 61.4 Total 100.0 NA 100.0 Number of births/women 3,463 NA 6,999 a Women were assigned to risk categories according to the status they would have at the birth of a child, if the child were conceived at the time of the survey: age less than 17 years and 3 months, age older than 34 years and 2 months, latest birth less than 15 months ago, and latest birth of order 3 or higher. b Includes sterilised women. c Includes the combined categories Age <18 and birth order >3. NA=Not Applicable. Table 9.5 shows the percent distribution of births in the five-year period preceding the survey and the distribution of all currently married women across various risk categories. It also shows the relative risk of children dying across the different risk categories. The purpose of this table is to identify areas in which changes in reproductive behavior would be likely to reduce infant and child mortality. Mortality risk is represented by the proportion of children born during the five years preceding the survey who had died by the time of the survey. The “risk ratio” is the ratio of the proportion of dead children in a given high-risk category to the proportion of dead children not in any high-risk category. Infant and Child Mortality | 139 One in three children born in the five years preceding the survey were not in any of the high-risk categories. More than one-third of births (35 percent) fell in any avoidable high-risk categories. The remainder (32 percent) fell into the category of unavoidable risk, that is, first order births to women age 18-34. Thus, 61 percent of births in Turkey were in some elevated risk category. The most common single categories are the birth order three or higher (11 percent) and the birth interval less than 24 months (8 percent). In general, risk ratios are higher for children in a multiple high risk category than in a single high-risk category. The most vulnerable births are births to women age 34 or older with a birth interval less than 24 months and birth order of three or higher; and births at an interval less than 24 months and of birth order 3 and higher. These children are more than 8 and about 4 times as likely to die as children who were not in any high-risk category. One percent and 3 percent of births, respectively, fall into these two categories. The last column of Table 9.5 shows the distribution of currently married women who have the potential for having a high-risk birth by category. This column is purely hypothetical and does not take into consideration the protection provided by family planning, postpartum insusceptibility, and prolonged abstinence. However, it provides an insight into the magnitude of high risk births. Sixty-one percent of women who were married at the time of the TDHS- 2008 were found to be at risk of conceiving a child with an increased risk of dying. Approximately one in four births (23 percent) is to women who are too old and having more than 3 children. A substantially higher proportion of women (35 percent) have the potential of having a birth in a single high-risk category and 27 percent of women are in a multiple high- risk category. Reproductive Health | 141 REPRODUCTIVE HEALTH 10 Banu Akadlı Ergöçmen, Sabahat Tezcan and Pelin Çağatay This chapter provides information from the TDHS-2008 on the use of maternal and child health services. Specifically, it presents the findings on antenatal care, delivery and postnatal care. This information can be used to identify the subgroups that are at risk because they are not using reproductive health services and help policymakers in the planning and implementing of appropriate strategies to improve those services. The results in this section are based on data obtained from mothers on all live births that occurred in the five years preceding the survey. It should be mentioned that questions about postnatal care were included for the first time in this survey and were asked only for the last birth occurred in the five years preceding the survey. Aspects of antenatal care (ANC) that are examined include the type of provider, number of visits made, components of the antenatal care, and the stage of pregnancy at the time of the first visit. With regard to delivery services, information is presented on the person assisting and the type and place of delivery. Postnatal care services are assessed according to the timing of first checkup and type of service provider. 10.1 Antenatal Care Table 10.1 shows the percent distribution of women who had a live birth in the five years preceding the survey by the provider of antenatal care during pregnancy for the last birth, according to the selected background characteristics. In collecting the information about the ANC provider, interviewers were instructed to record all providers a woman had consulted for care if more than one source of ANC was mentioned for the same pregnancy. However, for this tabulation, only the provider with the highest qualifications is considered if there were more than one provider. It is important to take into account in reviewing these results that the quality of antenatal services is not reflected in these figures. As it is seen from Table 10.1, 92 percent of women received antenatal care from a medical provider (doctor and nurse/midwife) at least once for the last birth in the five years preceding the survey. Almost all women (90 percent) sought ANC from the doctor. When compared to the results of the previous demographic survey conducted in 2003, there are substantial improvements in ANC coverage. The proportion of last births with ANC increased from 81 percent to 92 percent within the five-year period between the surveys. This represents around a 50 percent decrease in the proportion of women who did not have any antenatal care. 142 | Reproductive Health Although ANC coverage levels are generally high, the results in Table 10.1 document some differences in the proportions of women receiving ANC from a health provider by background characteristics. Considering the mother’s age at birth, younger women (92-93 percent) had somewhat higher antenatal care rates than women age 35 and older (86 percent). More noticeable differences are observed when birth order is considered. Almost all mothers sought for ANC from a doctor (96 percent) and nurse/midwife (2 percent) for their first births. However, the proportion of women who received ANC from a trained provider decreased substantially as the birth order increased, to a level of 72 percent among mothers of children of birth order sixth or higher. Variations are evident by residence and region as well. The percentage of rural women who did not receive ANC is two times higher than the national average, and almost three times the level among urban women. Although there have been significant improvements in ANC coverage between 2003 and 2008, the gap between the East and other regions is still comparatively wide; ANC coverage exceeded 90 percent in all regions except the East (79 percent). Considering the NUTS 1 regions, ANC coverage was lowest in Northeast Anatolia, Central East Anatolia and Southeast Anatolia (73 percent, 76 percent and 82 percent respectively). There was a close relationship between education and the use of antenatal care services. As women’s educational level increased, the proportion of last live births having ANC also increases. Almost all births to women with at least high school education received antenatal care from health personnel compared 8 out of 10 births to women with no or incomplete primary education. Similarly, wealth was closely associated with receiving antenatal care. Women in households in the lowest wealth quintile (76 percent) were much less likely to receive ANC than women in households in middle and higher quintiles (above 98 percent). Reproductive Health | 143 Table 10.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the last birth and the percentage receiving antenatal care for the last birth from a health provider, according to background characteristics, Turkey 2008 Background characteristic Doctor Nurse/ midwife Traditional birth attendant No one Missing Total Percentage receiving antenatal care from a health provider Number of women Age at birth <20 88.2 3.8 0.0 8.0 0.0 100.0 92.0 221 20-34 90.2 2.4 0.0 7.1 0.2 100.0 92.7 2,273 35-49 84.6 1.7 0.0 13.4 0.3 100.0 86.3 274 Birth order 1 95.9 2.2 0.0 1.6 0.2 100.0 98.2 896 2-3 90.8 1.9 0.0 7.1 0.1 100.0 92.7 1,340 4-5 79.7 3.6 0.0 16.7 0.0 100.0 83.3 362 6+ 66.0 6.3 0.0 26.9 0.8 100.0 72.3 171 Residence Urban 93.0 1.7 0.0 5.0 0.2 100.0 94.7 2,049 Rural 79.4 4.7 0.0 15.7 0.1 100.0 84.2 719 Region West 94.7 2.1 0.0 3.1 0.0 100.0 96.9 1,004 South 93.6 1.0 0.0 5.1 0.3 100.0 94.6 354 Central 90.8 3.6 0.1 5.2 0.2 100.0 94.4 627 North 91.4 4.3 0.0 4.2 0.0 100.0 95.8 165 East 76.8 2.3 0.0 20.5 0.5 100.0 79.1 619 Region (NUTS 1) İstanbul 95.1 0.6 0.0 4.3 0.0 100.0 95.7 472 West Marmara 95.3 3.1 0.0 1.7 0.0 100.0 98.3 79 Aegean 92.8 4.1 0.0 3.1 0.0 100.0 96.9 346 East Marmara 95.3 2.2 0.0 1.9 0.6 100.0 97.6 252 West Anatolia 89.2 4.4 0.0 6.3 0.0 100.0 93.7 287 Mediterranean 93.6 1.0 0.0 5.1 0.3 100.0 94.6 354 Central Anatolia 89.0 4.3 0.4 6.2 0.0 100.0 93.3 145 West Black Sea 95.4 3.3 0.0 1.3 0.0 100.0 98.7 148 East Black Sea 88.8 3.4 0.0 7.8 0.0 100.0 92.2 65 Northeast Anatolia 70.2 2.7 0.0 26.1 1.0 100.0 72.9 92 Central East Anatolia 74.3 1.8 0.0 23.7 0.3 100.0 76.0 176 Southeast Anatolia 79.8 2.4 0.0 17.4 0.4 100.0 82.2 352 Education No educ./Prim. incomp. 74.4 3.8 0.0 21.5 0.3 100.0 78.3 541 First level primary 90.5 2.8 0.0 6.5 0.2 100.0 93.2 1,365 Second level primary 95.4 1.7 0.0 2.9 0.0 100.0 97.1 272 High school and higher 98.4 0.9 0.0 0.5 0.2 100.0 99.3 591 Wealth quintile Lowest 71.6 4.4 0.0 23.5 0.4 100.0 76.1 572 Second 87.3 3.3 0.1 9.2 0.1 100.0 90.6 635 Middle 96.7 1.9 0.0 1.3 0.2 100.0 98.5 597 Fourth 95.8 2.2 0.0 2.0 0.0 100.0 98.0 497 Highest 98.6 0.0 0.0 1.1 0.3 100.0 98.6 466 Total 89.5 2.5 0.0 7.8 0.2 100.0 92.0 2,768 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. 144 | Reproductive Health 10.2 Number and Timing of Antenatal Care Visits Antenatal care is most beneficial and effective in avoiding adverse pregnancy outcomes when it is sought early during pregnancy. The first antenatal visit should take place before the third month of pregnancy. The advantage of early detection of pregnancy is that a woman’s normal baseline health status can be assessed, making early diagnosis of any negative condition easier. The total number of antenatal visits is also important in assessing the adequacy of ANC since regular visits allow proper monitoring of the mother and child throughout pregnancy. According to the recommended schedule, antenatal care visits should be done monthly until the 7th month (28 weeks' gestation), then every two weeks until 36 weeks gestation, and then every week until 40 weeks or delivery. This represents a minimum of 10 visits throughout the pregnancy. Information on the number and timing of antenatal visits made to health providers for the last birth in the five years preceding the survey is presented in Table 10.2 by place of residence. In Turkey, around three-quarters of women had four or more antenatal visits. Noticeable improvements with regard to the number of ANC visits occurred among rural mothers during the period between the 2003 and 2008 TDHS surveys; the percentage of rural women who reported making at least four ANC visits in 2008 was more than 1.5 times the figure in 2003. Nevertheless, significant differences in the proportion of women having four or more visits still exist between urban and rural areas (80 percent and 55 percent, respectively). With regard to the timing of the first ANC visit, overall, women made an ANC visit before the sixth month for 87 percent of last births in the five years preceding the survey. Considering the differences by residence, 91 percent of women in urban areas sought care before the sixth month of pregnancy compared to 76 percent in rural areas. This represents a marked increase over the levels reported at the time of the 2003 TDHS (71 percent at the national level and 80 percent and 52 percent in urban and rural areas, respectively). Thus, when compared to the TDHS-2003, the TDHS-2008 findings show that not only more women are receiving antenatal care; they appear also to be more aware of the importance of early ANC visits than before. Considering only the births for which care was received, the median duration of pregnancy at first visit is 2.2 months in Turkey. On average, women living in rural areas seek antenatal care later in their pregnancy (2.8 months) than urban women (2.0 months). Reproductive Health | 145 Table 10.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the last live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to place of residence, Turkey 2008 Place of Residence Number and timing of ANC visits Urban Rural Total Number of ANC visits None 5.0 15.7 7.8 1 3.1 7.7 4.3 2-3 11.1 21.4 13.8 4+ 80.4 54.8 73.7 Don't know/missing 0.4 0.3 0.4 Total 100.0 100.0 100.0 Months of pregnancy at time of first ANC visit No antenatal care 5.0 15.7 7.8 <4 78.9 60.8 74.2 4-5 11.7 15.1 12.5 6-7 3.4 5.7 4.0 8+ 0.8 2.5 1.2 Don't know/missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Number of women 2,049 719 2,768 Median months of pregnancy at first visit (for those with ANC) 2.0 2.8 2.2 Number of women with ANC 1,942 605 2,547 10.3 Components of Antenatal Care Pregnancy complications are an important cause of maternal and early neonatal child mortality and morbidity. Thus, the effectiveness of ANC in ensuring safe motherhood depends in part on the tests and measurements done during the checkups to detect potential complications. To obtain information on the nature of the ANC women are receiving, the TDHS- 2008 included a series of questions about the care mothers received during ANC visits for the last birth during the five years prior to the survey. Women who had at least one ANC visit were asked if they were weighed, blood pressure measured, urine and blood samples taken, an ultrasound performed, and an external examination conducted during any of their ANC visits. In 146 | Reproductive Health addition, regardless of whether or not women received ANC, women were asked if they received iron tablets at any time during pregnancy. Table 10.3 shows that, among women receiving antenatal care, 92 percent had their blood pressure measured, which is one of the most important components of antenatal care for mothers. Urine and blood samples were taken for 82 and 86 percent of women, respectively. Ninety-six percent of women had ultrasound was performed during at least one of their visits to a medical provider. Eighty-three percent had their weight measured. Women were much less likely to have an external examination (74 percent) during ANC than the other tests or procedures shown in Table 10.3. Including both women who had ANC and those that did not get any care, 80 percent reported receiving iron tablets. Overall, the levels of use reported in TDHS- 2008 for all services mentioned above are notably higher than the levels reported in TDHS-2003. Differences by age in the proportions of women reporting having had the various components of care are not large, with women age 20-34 somewhat more likely to receive all components of ANC, except for urine sample and external physical examination, than older and younger women. There is an inverse relationship between the proportions reporting have the various antenatal care procedures and the child’s birth order. The likelihood of receiving all components of ANC (except for external physical examination) is the highest for first births. Considering the residential differentials, urban women were more likely than rural women to have had all of the ANC components. Although regional differences are smaller than in 2003, variations are still observed. Women in the East were least likely to have had the various routine ANC screening procedures. Especially notable is the low level of iron supplementation among women in the East compared to women in the other regions (61 percent compared to 83 percent or more). As regards NUTS 1 regions, except for ultrasound, the proportions having the various ANC procedures were lowest in Southeast Anatolia. Central East and Northeast Anatolia had the lowest percentages of women reporting they received iron tablets (53 percent and 57 percent, respectively). As expected, the likelihood of having the various components of ANC is positively associated with both education and wealth. The education and wealth differentials were smallest for ultrasound and largest for weight measurement and iron supplementation. Reproductive Health | 147 Table 10.3 Components of antenatal care Percentage of women with a live birth in the five years preceding the survey who received antenatal care for the last birth, by content of antenatal care, and percentage of women with a live birth in the five years preceding the survey who received iron tablets for the last birth, according to background characteristics, Turkey 2008 Among women who received antenatal care, percentage who had: Background characteristic Weight measured Blood pressure measured Urine sample taken Blood sample taken Ultra- sound External exam Number of women receiving ANC Received iron tablets Number of women Age at birth <20 79.2 91.2 84.3 85.1 96.4 73.3 204 72.5 221 20-34 83.6 92.4 82.3 86.2 96.5 74.3 2,107 81.7 2,273 35-49 78.9 91.3 78.9 83.2 93.0 74.8 237 70.9 274 Birth order 1 88.1 94.9 86.9 91.1 98.5 74.4 879 88.8 896 2-3 85.2 92.4 83.5 87.2 97.1 75.9 1,243 80.5 1,340 4-5 69.5 88.3 71.4 73.1 91.0 69.9 302 69.7 362 6+ 53.8 81.6 61.2 64.7 82.7 68.3 123 50.7 171 Residence Urban 86.0 93.3 84.1 88.2 97.3 74.3 1,942 83.5 2,049 Rural 72.7 88.9 76.1 78.2 92.6 74.4 605 69.7 719 Region West 91.8 96.4 87.5 91.0 97.9 78.5 972 85.6 1,004 South 84.8 93.1 80.3 85.4 95.6 73.0 335 82.6 354 Central 89.9 94.2 86.4 88.4 98.4 75.2 592 87.1 627 North 87.4 97.1 88.7 91.8 96.3 68.0 158 82.6 165 East 53.5 79.5 65.8 70.8 90.3 67.8 490 61.3 619 Region (NUTS 1) İstanbul 90.2 94.7 86.3 90.2 99.4 77.4 452 82.7 472 West Marmara 95.5 99.1 87.3 93.8 97.4 89.2 78 88.3 79 Aegean 87.5 94.5 84.9 86.8 96.4 79.2 336 87.1 346 East Marmara 94.7 97.0 88.6 93.3 97.9 73.4 245 89.5 252 West Anatolia 91.4 96.8 89.1 91.2 98.5 71.7 269 86.8 287 Mediterranean 84.8 93.1 80.3 85.4 95.6 73.0 335 82.6 354 Central Anatolia 93.2 94.9 83.9 86.1 98.3 78.7 136 84.9 145 West Black Sea 90.0 94.9 91.9 91.8 96.4 73.6 147 87.0 148 East Black Sea 84.4 98.8 88.6 92.3 96.9 70.6 60 79.5 65 Northeast Anatolia 72.7 89.5 80.2 81.6 89.9 81.8 67 56.8 92 Central East Anatolia 54.3 83.2 71.0 75.0 88.2 68.9 134 53.2 176 Southeast Anatolia 48.8 75.4 60.0 66.4 91.4 64.0 289 66.6 352 Education No educ./Prim. incomp. 57.7 82.3 67.7 70.3 88.1 71.3 423 57.3 541 First level primary 84.1 92.9 81.6 84.7 96.6 74.0 1,273 81.7 1,365 Second level primary 86.5 93.1 84.3 90.4 99.3 72.1 264 88.2 272 High school and higher 96.6 97.7 92.8 97.3 99.6 78.1 587 92.8 591 Wealth quintile Lowest 62.6 82.0 71.1 72.0 87.2 68.7 435 61.8 572 Second 74.4 88.2 73.7 79.7 96.4 78.4 576 74.8 635 Middle 87.9 95.5 82.1 87.0 96.9 70.4 589 87.7 597 Fourth 91.2 95.7 91.3 93.7 99.3 75.9 487 88.4 497 Highest 97.1 99.1 93.7 96.8 100.0 77.7 460 90.1 466 Total 82.8 92.2 82.2 85.8 96.2 74.3 2,547 79.9 2,768 148 | Reproductive Health 10.4 Place of delivery The TDHS-2008 collected information on the place of delivery for all children born in the five years preceding the survey. Table 10.4 presents these results by background characteristics. Overall, the TDHS-2008 found that 90 percent of all births were delivered at a health facility compared to 78 percent in the TDHS-2003. Women were more than three times as likely to deliver in a public sector facility as in a private facility (70 percent and 20 percent, respectively). Considering subgroup differences, women under age 35 (around 90 percent) were somewhat more likely to deliver at a health facility than older women (84 percent). The percentage of women delivering at a health facility declined as the birth order increase, from 96 percent among first births to 61 percent for sixth and higher order births. Furthermore, there was a positive relationship between the number of antenatal care visits and the likelihood of delivering in a health facility delivery. Almost all births to women having at least four or more antenatal checkups occurred at a health facility (97 percent). On the other hand, deliveries were much more likely to occur at home if the mother had no antenatal visits (34 percent). Deliveries at health facilities are more common in urban areas (94 percent) than in rural areas, where one fifth of deliveries occur at home. The proportion of health facility deliveries is above the national average in all regions except the East, where 72 percent occur at a health facility. The highest percentage of deliveries taking place in a health facility is observed for the Central region (98 percent), followed by the West and the North region (96 percent). Considering the NUTS 1 regions, in West Marmara, all deliveries occur at a health facility. On the other hand, Central East Anatolia, Southeast Anatolia and Northeast Anatolia have the lowest percentages of health facility deliveries (65 percent, 75 percent and 76 percent respectively). Both the level of education and wealth status are positively associated with the likelihood of delivering in a health facility. The proportions of births occurring at a health facility rise from 71 percent among women in the lowest education and wealth quintile levels to nearly 100 percent among women in the highest education and wealth categories. Regarding the type of facility, the majority of births to women in İstanbul are delivered in private institutions (58 percent). The proportion choosing a private sector facility increases with educational attainment and wealth level. Forty percent of women with at least high school education and 49 percent in the highest wealth quintile chose to deliver their baby in a private health facility. On the other hand, women in the lowest education and wealth quintile are the least likely among all of the subgroups in Table 10.4 to deliver in a private facility (9 percent and 4 percent, respectively). Reproductive Health | 149 Table 10.4 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Turkey 2008 Health facility Background characteristic Public sector Private sector Home Other Missing Total Percentage delivered in a health facility Number of births Age at birth <20 75.0 13.7 10.4 0.0 1.0 100.0 88.6 344 20-34 69.1 21.4 9.2 0.2 0.2 100.0 90.4 2,811 35-49 68.3 16.2 13.5 0.0 2.1 100.0 84.4 308 Birth order 1 71.7 24.2 3.9 0.0 0.2 100.0 95.9 1,214 2-3 71.8 20.4 7.3 0.2 0.4 100.0 92.2 1,563 4-5 65.3 14.3 18.8 0.6 1.0 100.0 79.6 448 6+ 52.1 8.7 38.1 0.2 0.9 100.0 60.9 237 Residence Urban 68.9 25.1 5.4 0.1 0.5 100.0 94.0 2,475 Rural 71.3 7.7 20.4 0.3 0.3 100.0 79.0 988 Region West 59.9 36.1 3.3 0.2 0.5 100.0 96.0 1,174 South 74.0 18.2 7.2 0.2 0.4 100.0 92.2 441 Central 86.3 12.0 1.2 0.0 0.5 100.0 98.3 741 North 89.3 6.3 3.9 0.0 0.5 100.0 95.6 197 East 62.1 10.2 27.2 0.2 0.3 100.0 72.2 911 Region (NUTS 1) İstanbul 36.9 58.3 4.3 0.0 0.5 100.0 95.2 548 West Marmara 89.5 10.5 0.0 0.0 0.0 100.0 100.0 88 Aegean 82.4 13.4 3.3 0.4 0.6 100.0 95.8 427 East Marmara 80.7 17.6 0.6 0.5 0.5 100.0 98.4 275 West Anatolia 86.0 12.3 1.2 0.0 0.6 100.0 98.3 345 Mediterranean 74.0 18.2 7.2 0.2 0.4 100.0 92.2 441 Central Anatolia 77.7 19.6 2.8 0.0 0.0 100.0 97.2 177 West Black Sea 90.9 5.3 3.2 0.0 0.6 100.0 96.3 172 East Black Sea 92.1 5.1 2.8 0.0 0.0 100.0 97.2 79 Northeast Anatolia 72.8 2.7 23.4 0.0 1.1 100.0 75.5 128 Central East Anatolia 59.2 6.1 33.6 0.6 0.4 100.0 65.3 250 Southeast Anatolia 60.8 13.9 25.2 0.1 0.1 100.0 74.7 533 Education No educ./Prim. incomp. 62.2 9.0 28.3 0.3 0.2 100.0 71.2 781 First level primary 74.9 18.0 6.2 0.2 0.7 100.0 92.9 1,691 Second level primary 80.9 16.6 2.4 0.0 0.0 100.0 97.6 322 High school and higher 59.3 40.3 0.3 0.0 0.2 100.0 99.6 669 Antenatal care visits1 None 60.0 5.1 33.8 1.1 0.0 100.0 65.1 216 1-3 76.2 9.7 13.8 0.3 0.0 100.0 85.9 501 4+ 70.7 26.6 2.6 0.0 0.1 100.0 97.2 2,041 Wealth quintile Lowest 66.2 4.3 28.5 0.6 0.4 100.0 70.5 852 Second 78.5 13.4 7.7 0.0 0.5 100.0 91.8 818 Middle 76.8 19.7 2.9 0.1 0.6 100.0 96.4 709 Fourth 70.1 28.7 0.9 0.0 0.3 100.0 98.8 579 Highest 50.3 48.5 0.9 0.0 0.3 100.0 98.9 506 Total 69.6 20.1 9.7 0.2 0.4 100.0 89.7 3,463 1Includes only the last birth in the five years preceding the survey. Note: An asterisk indicates a figure is based on fewer than 25 unweighted cases. 150 | Reproductive Health 10.5 Assistance during delivery Assistance by medically trained birth attendants during delivery is considered to be essential in the reduction of maternal and neonatal mortality. The type of assistance a woman receives during the birth of her child depends to a great extent on the place of delivery. Births that are delivered outside the health facility are much less likely to be assisted by a doctor or other trained health personnel. Overall, as Table 10.5 shows, medically trained providers assisted at the delivery of 91 percent of all births, compared to 83 percent at the time of the TDHS-2003. More than six in ten births are delivered by doctors, a little more than one-quarter by nurse/midwives and 8 percent by traditional birth attendants or relatives/friends. The likelihood that trained health personnel assisted at delivery varies according to background characteristics in Table 10.4. Births to older women are slightly less likely than births among women under age 35 to be assisted by medical personnel. The proportion of births assisted at delivery by a medical provider declines sharply with birth order, from 97 percent among first births to 65 percent among the small number of sixth and higher order births. Furthermore, urban women are more likely than rural women to have medical assistance at delivery (96 and 80 percent, respectively). Medical assistance at delivery is least likely for births in the East region, births to women with no education or incomplete primary and births in the lowest wealth quintile. On the other hand, almost all births to women in the highest wealth quintile and to women with high school or more education are delivered with medical assistance. Among the NUTS 1 regions, the proportions of medically assisted deliveries are much lower than the national average in Central East Anatolia, Northeast Anatolia and Southeast Anatolia. There are also differences in the percentage of deliveries assisted by specific types of providers. For instance, in the East—especially in Southeast region—the proportion of births assisted by a doctor (33 percent and 29 percent, respectively) is lower than that assisted by a nurse/midwife (42 percent and 49 percent respectively). Not surprisingly, the place of delivery is closely associated with the type of assistance at delivery. Almost none of the deliveries taking place outside a facility are assisted by a doctor and only 16 percent are assisted by a nurse midwife. The proportions of births delivered with the assistance of a traditional birth attendant or a relative of friend is highest among births of order 6 or higher (34 percent), births in rural areas (19 percent), in the East (24 percent) and Central East Anatolia (33 percent), and births in the lowest wealth quintile (25 percent) and education category (25 percent). In Turkey, caesarean deliveries are very common; 37 percent of all deliveries are delivered by caesarean section. The caesarean delivery rate is substantially higher than that reported at the time of the TDHS-2003 (21 percent). The likelihood of delivering by caesarean section increases with the age of the mother and decreases with child’s birth order. Forty-five percent of first births are caesarean deliveries. Caesarean deliveries are more common among women living in urban areas (42 percent) than rural areas (24 percent). Forty percent or more of births are caesarean deliveries in all regions except the East, where only 16 percent of births are delivered by caesarean section. The C-section rate increases directly with education and wealth; 60 percent or more of births in the highest education and wealth categories are delivered by caesarean section, more than three times the rate among births in the lowest education and wealth levels. Reproductive Health | 151 Table 10.5 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of birth assisted by a skilled provider and percentage delivered by caesarean-section, according to background characteristics, Turkey 2008 Person providing assistance during delivery Background characteristic Doctor Nurse/ midwife Traditional birth attendant Relative/ other No one Don't know/ missing Total Percentage delivered by a health provider1 Percentage delivered by C-section Number of births Age at birth <20 60.1 30.4 5.3 2.7 0.4 1.2 100.0 90.4 26.6 344 20-34 64.4 27.4 3.4 4.3 0.4 0.2 100.0 91.8 37.0 2,811 35-49 65.6 22.0 4.0 6.9 0.3 1.2 100.0 87.6 45.4 308 Birth order 1 73.2 23.7 1.9 0.8 0.1 0.2 100.0 96.9 44.6 1,214 2-3 66.3 26.9 3.2 3.0 0.4 0.3 100.0 93.2 37.7 1,563 4-5 47.0 36.2 5.4 9.7 0.7 1.0 100.0 83.2 21.9 448 6+ 34.7 30.0 12.4 21.1 0.9 0.9 100.0 64.7 18.3 237 Place of delivery Health facility 71.2 28.6 0.1 0.0 0.0 0.0 100.0 99.8 40.8 3,107 Elsewhere 0.8 15.9 35.9 43.8 3.3 0.3 100.0 16.7 0.1 341 Residence Urban 71.2 24.5 1.9 1.7 0.3 0.4 100.0 95.7 41.7 2,475 Rural 46.1 34.0 8.0 10.9 0.5 0.4 100.0 80.2 24.3 988 Region West 82.5 15.5 0.9 0.8 0.1 0.2 100.0 98.0 46.0 1,174 South 60.4 33.7 2.8 1.8 0.8 0.6 100.0 94.0 39.8 441 Central 76.0 22.5 0.7 0.2 0.1 0.5 100.0 98.5 43.3 741 North 64.0 32.0 1.0 2.5 0.0 0.5 100.0 96.0 44.8 197 East 32.5 41.9 10.5 13.9 0.7 0.4 100.0 74.4 16.1 911 Region (NUTS 1) İstanbul 90.2 7.7 0.5 1.6 0.0 0.0 100.0 97.9 49.1 548 West Marmara 80.2 18.3 1.5 0.0 0.0 0.0 100.0 98.5 54.4 88 Aegean 79.5 18.7 1.3 0.0 0.0 0.6 100.0 98.2 45.1 427 East Marmara 67.7 30.7 0.3 0.3 0.5 0.5 100.0 98.4 41.0 275 West Anatolia 82.2 16.2 0.8 0.0 0.2 0.6 100.0 98.4 42.3 345 Mediterranean 60.4 33.7 2.8 1.8 0.8 0.6 100.0 94.0 39.8 441 Central Anatolia 65.8 31.8 1.6 0.8 0.0 0.0 100.0 97.6 36.2 177 West Black Sea 67.2 29.3 1.2 1.7 0.0 0.6 100.0 96.5 44.3 172 East Black Sea 64.5 33.1 0.0 2.4 0.0 0.0 100.0 97.6 50.6 79 Northeast Anatolia 41.9 33.5 6.9 14.7 1.7 1.3 100.0 75.5 21.9 128 Central East Anatolia 35.6 30.4 16.0 16.6 0.7 0.7 100.0 66.0 16.8 250 Southeast Anatolia 28.7 49.4 8.9 12.4 0.5 0.1 100.0 78.1 14.4 533 Education No educ./Prim. incomp. 40.8 33.1 10.2 14.7 1.0 0.3 100.0 73.9 18.9 781 First level primary 65.2 29.7 2.4 2.0 0.2 0.6 100.0 94.8 35.5 1,691 Second level primary 70.1 27.5 1.6 0.7 0.0 0.2 100.0 97.6 38.8 322 High school and higher 85.7 13.9 0.2 0.0 0.1 0.2 100.0 99.6 59.5 669 Wealth quintile Lowest 34.8 38.6 10.8 14.4 0.9 0.5 100.0 73.4 18.1 852 Second 60.2 33.5 3.1 2.3 0.4 0.5 100.0 93.7 30.1 818 Middle 71.9 25.8 0.9 1.2 0.1 0.1 100.0 97.7 39.7 709 Fourth 79.7 19.4 0.3 0.1 0.0 0.5 100.0 99.1 48.5 579 Highest 90.9 8.6 0.2 0.0 0.0 0.3 100.0 99.5 60.9 506 Total 64.1 27.2 3.6 4.3 0.4 0.4 100.0 91.3 36.7 3,463 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. 1Health provider includes doctor, nurse and midwife. Note: An asterisk indicates a figure is based on fewer than 25 unweighted cases. 152 | Reproductive Health 10.6 Postnatal Care Care after delivery is very important for both mother and her child, especially for births occurring at home. In order to assess the extent of postnatal care utilization, women whose last live birth occurred in the five years preceding the survey were asked in the TDHS-2008, whether they and/or that child had received a postnatal checkup from a health provider and, if yes, within how many days of delivery the checkup was received. These questions were asked both of women who delivered in a health facility or at home. Table 10.6 and Table 10.7 present the type of the provider and the timing of the first postnatal checkup for the mother, respectively. Eighty-two percent of women reported that they had a postnatal checkup, almost all by a doctor. The proportion of women receiving postnatal care for the last birth does not vary markedly with age, but is substantially higher among women with three or fewer births than higher parity mothers. The likelihood of receiving postnatal care is also higher for women in urban areas than in rural areas. In all regions except the East (64 percent), the proportion of women having postnatal care is above the national average. The Aegean and West Marmara regions have the highest proportions having a postnatal checkup (94 percent and 91 percent, respectively) and Northeast Anatolia and Central East Anatolia the lowest (60 percent and 56 percent, respectively). Furthermore, there is a strong relationship between receiving postnatal care and educational level. Ninety-four percent of women with at least high school education have postnatal care compared to 63 percent for women with less than primary education. Likewise, as the wealth level of women increases, the likelihood of receiving postnatal care increases; 94 percent of women in the highest wealth quintile receive care after delivery compared to 64 percent of women in the lowest quintile (Table 10.6). With respect to the timing of the first postnatal care visit, the results in Table 10.7 indicate that 63 percent of women have the first checkup within four hours after delivery. Considering regional differences, the likelihood of receiving postnatal care shortly after delivery is lowest in the East (49 percent) and varies from 35 percent in the Central East Anatolia to 75 percent in Istanbul. It increases markedly with education and the wealth quintile (Table 10.7). 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. As Tables 10.8 and 10.9 show, 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. Reproductive Health | 153 Table 10.6 Type of provider of first postnatal checkup for women Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution by type of provider of the mother's first postnatal health check for the last live birth, according to background characteristics, Turkey 2008 Type of health provider of mother's first postnatal checkup Background characteristic Doctor/ nurse/ midwife Other Don't know/ missing No check-up Total Number of women Age at birth <20 78.1 1.0 0.9 20.0 100.0 221 20-34 82.1 0.3 2.5 15.1 100.0 2,273 35-49 81.0 0.6 3.0 15.3 100.0 274 Birth order 1 86.5 0.4 2.4 10.7 100.0 896 2-3 84.6 0.5 2.5 12.4 100.0 1,340 4-5 69.0 0.0 2.9 28.1 100.0 362 6+ 60.5 0.6 0.7 38.2 100.0 171 Residence Urban 84.6 0.4 2.7 12.2 100.0 2,049 Rural 73.3 0.4 1.6 24.8 100.0 719 Region West 88.6 0.1 1.9 9.4 100.0 1,004 South 80.1 0.9 2.5 16.5 100.0 354 Central 88.4 0.8 2.8 8.0 100.0 627 North 84.3 0.0 1.8 13.9 100.0 165 East 63.9 0.3 3.1 32.6 100.0 619 Region (NUTS 1) İstanbul 87.1 0.0 1.2 11.7 100.0 472 West Marmara 91.4 0.0 1.7 7.0 100.0 79 Aegean 94.2 0.5 0.7 4.5 100.0 346 East Marmara 83.1 0.6 5.6 10.8 100.0 252 West Anatolia 87.9 1.1 2.8 8.2 100.0 287 Mediterranean 80.1 0.9 2.5 16.5 100.0 354 Central Anatolia 86.4 0.0 1.9 11.7 100.0 145 West Black Sea 88.7 0.0 3.0 8.3 100.0 148 East Black Sea 82.0 0.0 0.5 17.4 100.0 65 Northeast Anatolia 59.6 0.0 4.4 36.0 100.0 92 Central East Anatolia 56.0 1.1 1.3 41.6 100.0 176 Southeast Anatolia 69.0 0.0 3.7 27.3 100.0 352 Education No educ./Prim. inc. 62.8 0.3 1.8 35.2 100.0 541 First level primary 84.2 0.6 1.9 13.2 100.0 1,365 Second level primary 86.6 0.7 3.3 9.3 100.0 272 High school and higher 90.8 0.0 3.8 5.4 100.0 591 Wealth quintile Lowest 63.5 0.4 1.7 34.3 100.0 572 Second 81.5 0.4 2.0 16.2 100.0 635 Middle 85.9 0.9 1.7 11.5 100.0 597 Fourth 86.6 0.4 4.5 8.6 100.0 497 Highest 93.6 0.0 2.6 3.8 100.0 466 Total 81.7 0.4 2.4 15.5 100.0 2,768 154 | Reproductive Health Table 10.7 Timing of first postnatal checkup for women Among women age 15-49 giving birth in the five years preceding the survey, the percent distribution of the mother's first postnatal check-up for the last live birth by time after delivery, according to background characteristics, Turkey 2008 Timing after deliver of mother's first postnatal checkup Background characteristic Less than 4 hours 4-23 hours 2 days 3-41 days Don't know/ missing No check- up Total Number of women Mother's age at birth <20 53.9 14.8 5.3 2.3 3.7 20.0 100.0 221 20-34 64.4 11.8 4.7 2.9 1.1 15.1 100.0 2,273 35-49 62.7 13.6 2.7 2.3 3.4 15.3 100.0 274 Birth order 1 66.7 13.3 5.2 3.0 1.2 10.7 100.0 896 2-3 66.0 12.5 4.6 2.7 1.7 12.4 100.0 1,340 4-5 52.3 11.1 3.7 2.7 2.1 28.1 100.0 362 6+ 48.7 6.7 2.7 2.7 1.1 38.2 100.0 171 Residence Urban 66.9 12.1 4.9 2.8 1.1 12.2 100.0 2,049 Rural 53.3 12.5 3.6 3.0 2.9 24.8 100.0 719 Region West 69.7 12.2 4.9 2.8 1.0 9.4 100.0 1,004 South 61.7 11.4 5.8 2.5 2.1 16.5 100.0 354 Central 67.3 15.3 4.2 2.8 2.4 8.0 100.0 627 North 66.9 10.4 7.9 0.2 0.7 13.9 100.0 165 East 49.1 10.2 2.8 3.8 1.5 32.6 100.0 619 Region (NUTS 1) İstanbul 74.7 6.2 3.7 3.7 0.0 11.7 100.0 472 West Marmara 70.2 13.4 6.4 3.1 0.0 7.0 100.0 79 Aegean 67.5 16.0 6.7 1.6 3.7 4.5 100.0 346 East Marmara 61.2 21.0 3.2 1.7 2.2 10.8 100.0 252 West Anatolia 66.1 16.0 3.7 4.2 1.9 8.2 100.0 287 Mediterranean 61.7 11.4 5.8 2.5 2.1 16.5 100.0 354 Central Anatolia 67.7 13.0 5.8 1.5 0.4 11.7 100.0 145 West Black Sea 69.9 11.1 8.8 0.9 0.9 8.3 100.0 148 East Black Sea 67.5 9.3 4.2 0.5 1.1 17.4 100.0 65 Northeast Anatolia 47.4 8.0 2.4 4.4 1.8 36.0 100.0 92 Central East Anatolia 35.0 10.2 4.9 5.3 3.0 41.6 100.0 176 Southeast Anatolia 56.6 10.8 1.9 2.8 0.6 27.3 100.0 352 Education No educ./Prim. inc. 48.2 8.7 3.0 3.1 1.8 35.2 100.0 541 First level primary 65.0 12.1 4.9 2.7 2.0 13.2 100.0 1,365 Second level primary 62.5 19.6 4.6 2.7 1.4 9.3 100.0 272 High school and higher 73.8 12.3 5.2 2.8 0.5 5.4 100.0 591 Wealth quintile Lowest 46.8 9.5 4.2 2.8 2.4 34.3 100.0 572 Second 65.0 11.8 3.7 1.6 1.8 16.2 100.0 635 Middle 62.4 15.1 6.4 2.8 1.8 11.5 100.0 597 Fourth 71.5 11.4 3.7 3.4 1.5 8.6 100.0 497 Highest 74.1 13.4 4.8 3.8 0.1 3.8 100.0 466 Total 63.4 12.2 4.6 2.8 1.6 15.5 100.0 2,768 Reproductive Health | 155 Table 10.8 Type of provider of first postnatal checkup for child Among last births in the five years preceding the survey, the percent distribution by type of provider of the child's first postnatal health check for the last live birth, according to background characteristics, Turkey 2008 Type of health provider of child's first postnatal checkup Background characteristic Doctor/ nurse/ midwife Other Don't know/ missing No check-up Total Number of children Mother's age at birth <20 87.7 0.4 0.0 11.9 100.0 221 20-34 88.4 0.8 0.1 10.6 100.0 2,273 35-49 85.1 0.8 0.0 14.1 100.0 274 Birth order 1 93.9 0.5 0.0 5.6 100.0 896 2-3 89.0 1.2 0.1 9.6 100.0 1,340 4-5 79.4 0.1 0.2 20.3 100.0 362 6+ 67.3 0.6 0.0 32.1 100.0 171 Residence Urban 91.1 0.9 0.1 7.9 100.0 2,049 Rural 79.2 0.7 0.0 20.2 100.0 719 Region West 95.4 0.6 0.0 4.0 100.0 1,004 South 88.2 0.4 0.2 11.2 100.0 354 Central 92.7 1.1 0.3 5.9 100.0 627 North 95.1 0.3 0.0 4.6 100.0 165 East 69.3 1.2 0.0 29.5 100.0 619 Region (NUTS 1) İstanbul 96.3 0.6 0.0 3.1 100.0 472 West Marmara 92.8 0.8 0.0 6.4 100.0 79 Aegean 95.6 0.7 0.0 3.8 100.0 346 East Marmara 94.2 1.0 0.0 4.8 100.0 252 West Anatolia 90.5 1.3 0.7 7.5 100.0 287 Mediterranean 88.2 0.4 0.2 11.2 100.0 354 Central Anatolia 95.1 0.4 0.0 4.5 100.0 145 West Black Sea 95.2 0.3 0.0 4.5 100.0 148 East Black Sea 92.2 0.0 0.0 7.8 100.0 65 Northeast Anatolia 65.5 0.0 0.3 34.2 100.0 92 Central East Anatolia 69.1 1.3 0.0 29.6 100.0 176 Southeast Anatolia 70.4 1.5 0.0 28.1 100.0 352 Education No education/Primary inc. 71.3 0.8 0.0 27.9 100.0 541 First level primary 88.6 1.1 0.2 10.1 100.0 1,365 Second level primary 95.8 0.2 0.0 4.0 100.0 272 High school and higher 98.3 0.3 0.0 1.3 100.0 591 Wealth quintile Lowest 70.8 0.5 0.2 28.6 100.0 572 Second 87.0 0.9 0.0 12.0 100.0 635 Middle 92.1 0.9 0.3 6.7 100.0 597 Fourth 95.7 0.5 0.0 3.7 100.0 497 Highest 97.1 1.2 0.0 1.7 100.0 466 Total 88.0 0.8 0.1 11.1 100.0 2,768 156 | Reproductive Health Table 10.9 Timing of first postnatal checkup for child Among last births in the five years preceding the survey, the percent distribution of the child's first postnatal check-up for the last live birth by time after delivery, according to background characteristics, Turkey 2008 Timing after delivery of child's first postnatal checkup Background characteristic Less than 4 hours 4-23 hours 2 days 3-41 days Don't know/ missing No check-up Total Number of children Mother's age at birth <20 68.1 7.0 6.3 5.3 1.3 11.9 100.0 221 20-34 67.2 7.6 5.0 7.8 1.7 10.6 100.0 2,273 35-49 60.3 7.8 6.2 8.0 3.5 14.1 100.0 274 Birth order 1 73.2 7.3 5.7 6.4 1.9 5.6 100.0 896 2-3 68.0 8.3 5.5 6.8 1.8 9.6 100.0 1,340 4-5 56.4 6.8 3.9 11.1 1.6 20.3 100.0 362 6+ 43.4 5.3 3.4 12.6 3.2 32.1 100.0 171 Residence Urban 70.0 7.8 5.3 7.2 1.8 7.9 100.0 2,049 Rural 57.0 7.1 4.9 8.7 2.1 20.2 100.0 719 Region West 78.6 7.3 4.3 5.0 0.8 4.0 100.0 1,004 South 63.7 7.2 6.2 9.5 2.1 11.2 100.0 354 Central 68.9 9.7 6.5 6.1 2.9 5.9 100.0 627 North 71.4 9.3 8.6 5.3 0.9 4.6 100.0 165 East 45.3 5.6 4.0 12.9 2.8 29.5 100.0 619 Region (NUTS 1) İstanbul 85.2 3.7 0.6 6.8 0.6 3.1 100.0 472 West Marmara 76.8 5.9 5.0 5.9 0.0 6.4 100.0 79 Aegean 76.5 10.0 6.7 2.0 1.1 3.8 100.0 346 East Marmara 71.4 12.3 6.2 2.6 2.7 4.8 100.0 252 West Anatolia 65.7 10.2 5.7 8.0 3.0 7.5 100.0 287 Mediterranean 63.7 7.2 6.2 9.5 2.1 11.2 100.0 354 Central Anatolia 63.6 9.0 11.5 9.9 1.5 4.5 100.0 145 West Black Sea 68.0 11.0 9.9 4.1 2.5 4.5 100.0 148 East Black Sea 74.5 4.7 7.6 5.3 0.0 7.8 100.0 65 Northeast Anatolia 43.9 5.3 5.3 9.7 1.6 34.2 100.0 92 Central East Anatolia 40.3 7.2 5.9 12.6 4.3 29.6 100.0 176 Southeast Anatolia 48.1 4.9 2.7 13.8 2.3 28.1 100.0 352 Education No education/Primary inc. 48.8 6.0 3.9 10.9 2.4 27.9 100.0 541 First level primary 67.2 7.7 5.6 7.8 1.6 10.1 100.0 1,365 Second level primary 68.9 10.4 7.5 6.1 3.0 4.0 100.0 272 High school and higher 80.4 7.5 4.5 4.7 1.5 1.3 100.0 591 Wealth quintile Lowest 48.5 5.2 4.9 11.2 1.7 28.6 100.0 572 Second 66.0 7.0 5.8 6.8 2.4 12.0 100.0 635 Middle 65.5 11.2 6.1 8.4 2.0 6.7 100.0 597 Fourth 76.4 6.5 5.7 5.4 2.4 3.7 100.0 497 Highest 80.8 7.9 3.2 5.7 0.8 1.7 100.0 466 Total 66.6 7.6 5.2 7.6 1.9 11.1 100.0 2,768 Child Health | 157 CHILD HEALTH 11 Sabahat Tezcan, Elif Kurtuluş Yiğit and F. Hande Tunçkanat This chapter looks at several factors that are important in improving the survival chances for young children in Turkey. The chapter first presents findings from the TDHS-2008 concerning birth weight and size. It then considers information on the vaccination status and on diarrhea treatment practices. 11.1 Child’s Weight and Size at Birth For all births in the five years preceding the survey, the birth weight was recorded in the TDHS-2008 questionnaire from either a written record if available or the mother’s recall. In addition, the mother’s perception of the baby’s size at birth was obtained. Table 11.1 presents the percent distribution of live births in the five years preceding the survey by the reported birth weight and the mother’s perception of the baby’s size at birth according to mother’s background characteristics. Children whose birth weight is less than 2.5 kilograms or children reported to be “very small” or “smaller than average” at birth have been shown to have a higher than average risk of dying during early childhood. Overall, Table 11.1 shows that data on the child’s weight at birth were available for more than eight in ten births during the five-year period prior to the TDHS-2008. Birth weight information was less likely to be available for births of order six and higher, rural births, births in the East, births in Central East and Southeast Anatolia and births to mothers in the lowest education and wealth categories than for other births. Among births with a reported weight, 11 percent had a low birth weight (less than 2.5 kg.). In addition, 11 and 14 percent of all babies were reported to be “very small” and “smaller than average” respectively by mothers. Although the differentials are not large, both the proportions of low-birth-weight babies and of babies reported as “very small” or “smaller than average” were higher among births to mothers age 35 and older compared with births to mothers under age 35. Low birth weight and small size were also somewhat more common among births of order four and higher than lower parity births. Among the five geographical regions of Turkey, the West had the lowest proportion of live births with low birth weight (9 percent) while the East had the highest proportion (17 percent). The proportion of babies considered as “very small” at birth by mothers in East (18 percent) is more than double in the West, Central and North regions (8 percent in all three regions). The percentage of children weighing less than 2.5 kilograms at birth varies from 7 percent in the Aegean to 18 percent in Northeast Anatolia. The Aegean region also had the lowest percentage of births mothers considered to be “very small” while Southeast Anatolia had the highest percentage (6 percent and 20 percent, respectively). Women with secondary or 158 | Child Health higher education were less likely to have babies with a low birth weight and also less likely to report their children’s size at birth as “very small” than less educated mothers. The likelihood of having a low birth weight or “very small” baby also declined with the wealth quintile. Table 11.1 Child's weight and size at birth Percent distribution of live births in the five years preceding the survey with a reported birth weight by birth weight; percentage of births with a reported birth weight; and percent distribution of all live births in the five years preceding the survey by mother's estimate of baby's size at birth and, according to background characteristics, Turkey 2008 Percent distribution of births with a registered reported birth weight1 Percent distribution of all live births by size of child at birth as reported by mother Background characteristic Less than 2.5 kg 2.5 kg or more Total Number of births Percentage of all births with a reported birth weight Very small Smaller than average Average or bigger Don't know/ missing Total Number of births Mother's age at birth <20 12.7 87.3 100.0 282 82.1 16.8 10.4 71.8 1.0 100.0 344 20-34 10.5 89.5 100.0 2,382 84.8 10.6 13.8 75.3 0.4 100.0 2,811 35-49 14.3 85.7 100.0 243 78.8 11.9 15.7 70.9 1.5 100.0 308 Birth order 1 9.8 90.2 100.0 1,113 91.7 11.7 12.7 75.0 0.6 100.0 1,214 2-3 10.2 89.8 100.0 1,378 88.2 9.3 13.9 76.6 0.2 100.0 1,563 4-5 17.3 82.7 100.0 310 69.2 14.2 16.2 68.5 1.1 100.0 448 6+ 17.2 82.8 100.0 106 44.7 16.5 12.1 70.2 1.3 100.0 237 Residence Urban 10.8 89.2 100.0 2,241 90.5 10.3 13.3 75.9 0.6 100.0 2,475 Rural 12.0 88.0 100.0 666 67.4 13.9 14.5 71.2 0.5 100.0 988 Region West 9.1 90.9 100.0 1,132 96.5 8.1 12.3 79.2 0.5 100.0 1,174 South 11.6 88.4 100.0 384 87.2 13.1 12.2 74.4 0.4 100.0 441 Central 10.4 89.6 100.0 728 98.2 8.3 14.4 76.6 0.7 100.0 741 North 10.3 89.7 100.0 186 94.5 7.5 13.3 78.7 0.5 100.0 197 East 16.7 83.3 100.0 477 52.4 17.8 15.5 66.1 0.6 100.0 911 Region (NUTS 1) İstanbul 10.9 89.1 100.0 536 97.9 10.8 13.4 75.3 0.5 100.0 548 West Marmara 7.6 92.4 100.0 87 99.2 7.3 12.8 79.9 0.0 100.0 88 Aegean 7.0 93.0 100.0 400 93.6 5.8 11.0 82.7 0.6 100.0 427 East Marmara 8.3 91.7 100.0 269 98.0 6.5 12.0 81.0 0.5 100.0 275 West Anatolia 11.2 88.8 100.0 341 98.8 8.8 13.5 76.5 1.2 100.0 345 Mediterranean 11.6 88.4 100.0 384 87.2 13.1 12.2 74.4 0.4 100.0 441 Central Anatolia 11.9 88.1 100.0 173 97.7 8.4 19.5 72.1 0.0 100.0 177 West Black Sea 7.7 92.3 100.0 164 95.3 7.1 11.2 81.1 0.6 100.0 172 East Black Sea 14.5 85.5 100.0 75 94.8 7.2 15.3 77.5 0.0 100.0 79 Northeast Anatolia 18.0 82.0 100.0 82 64.0 15.4 18.0 65.4 1.1 100.0 128 Central East Anatolia 16.5 83.5 100.0 120 48.2 15.5 16.1 67.1 1.2 100.0 250 Southeast Anatolia 16.3 83.7 100.0 275 51.6 19.5 14.5 65.7 0.3 100.0 533 Education No/Primary incomplete 18.3 81.7 100.0 420 53.8 17.3 15.1 67.1 0.5 100.0 781 First level primary 10.9 89.1 100.0 1,516 89.7 11.0 13.9 74.5 0.7 100.0 1,691 Second level primary 6.6 93.4 100.0 308 95.7 7.2 11.5 81.1 0.2 100.0 322 High school and higher 8.9 91.1 100.0 663 99.1 7.0 12.4 80.2 0.5 100.0 669 Wealth quintile Lowest 16.5 83.5 100.0 479 56.2 15.3 16.3 67.7 0.7 100.0 852 Second 12.2 87.8 100.0 689 84.3 13.0 14.4 72.1 0.5 100.0 818 Middle 9.6 90.4 100.0 676 95.4 10.5 11.6 77.7 0.1 100.0 709 Fourth 8.1 91.9 100.0 563 97.2 8.1 11.2 79.8 0.8 100.0 579 Highest 9.4 90.6 100.0 501 99.0 6.5 13.4 79.4 0.7 100.0 506 Total 11.0 89.0 100.0 2,908 84.0 11.3 13.6 74.5 0.6 100.0 3,463 1Based on either written record or the mother’s recall. Child Health | 159 11.2 Vaccination of Children Universal immunization of children against six common 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. To be fully immunized, a child should receive the following vaccinations: one dose of BCG, three doses of DPT and polio, and one dose of measles vaccine. BCG, which is given in the second month of life or at first clinical contact, protects against tuberculosis. DPT protects against diphtheria, pertussis, and tetanus. DPT and polio (OPV) each require three vaccinations at approximately six, ten and 14 weeks of age. However, since this regime is not always carefully followed, the goal is to for a child to have all three doses by 12 months of age. Previously, it was also recommended that children receive a measles vaccination at 9 months of age. The vaccination schedule was changed in July 2006 to include a measles, mumps, and rubella (MMR) vaccination given around 12-14 months of age. In addition to receiving protection against all six vaccine- preventable illnesses, it is also recommended that children be given three doses of Hepatitis B vaccine in the context of the Ministry’s of Health “extended immunisation program” that has been in place since August 1998. In the TDHS-2008, information was collected on immunization status (BCG, DPT, polio, measles, and hepatitis B) of all children born in or after January 2005. To obtain data for each eligible child, mothers were asked whether they had a vaccination card for the child, and if so, to show the card to the interviewer. The dates of the vaccinations were copied from the card to the questionnaire. Mothers were also asked whether the child has been given any vaccination not recorded on the card. If a vaccination card was not available for the child, the mother was asked a number of questions in order to determine the vaccination status of the child for each specific vaccine. In case of DPT, polio and hepatitis, the mother was asked to report the number of doses of the vaccine that the child had received. 11.2.1 Vaccination Coverage of Children Age 15-26 Months Table 11.2 presents information on vaccination coverage according to the source of information used to determine coverage, i.e., the child’s vaccination card or the mother’s report. Data are presented for children age 15-26 months. This differs from the age range of 12-23 months that was used in presenting vaccination coverage data in the TDHS-2003 and earlier reports. The change in the age range reflects the fact that, with the introduction of the MMR vaccine into the immunization schedule, the age by which children should have received all of the recommended vaccines has shifted upward from 12 to 15 months. With regard to the source of information on the child’s vaccination status, Table 11.2 shows information was recorded from a vaccination card for 73 percent of children while mothers provided the information for the remaining 27 percent. For children for whom a written record was seen, the proportion fully vaccinated against tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles during the first 15 months of life was 64 percent while this proportion was 17 percent for those whose information based on the mother’s report. 160 | Child Health Table 11.2 Vaccinations by source of information Percentage of children age 15-26 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's statement), and percentage vaccinated by 15 months of age, Turkey 2008 Source of information BCG Measles DPT Polio Hepatitis B All1 None All + Hepatitis Number of children1 2 3 1 2 3 1 2 3 Vaccinated at any time before survey Vaccination card 71.3 65.9 72.3 71.6 70.8 71.9 70.8 69.7 72.1 71.9 70.0 63.8 0.0 62.8 516 Mother's statement 24.6 23.3 24.9 20.1 18.5 24.8 21.5 19.1 24.3 18.8 15.9 16.8 1.6 14.0 195 Either source 95.9 89.3 97.2 91.8 89.3 96.8 92.3 88.8 96.5 90.7 85.9 80.5 1.6 76.8 711 Vaccinated by 15 months of age 2 95.7 85.9 96.5 90.9 85.3 96.1 91.8 85.3 96.4 90.7 83.9 74.6 1.7 70.9 711 1 Children who are fully vaccinated (i.e., those who have received BCG, measles, and three doses of DPT and polio). 2For children whose information was based on the mother's report, the proportion of vaccinations given during the first 15 months of life was assumed to be the same as for children with a written record of vaccination. Taking into account both the card information and the mother’s report, Table 11.2 shows that 81 percent of the children received the full schedule of vaccinations against these six diseases. Most children who were immunized against these six diseases were also fully immunized against hepatitis B; overall, 77 percent of children received all of the basic immunizations plus 3 doses of the hepatitis B vaccines. Only 2 percent of all children between ages 15-26 months had not received any vaccination at all. 11.2.2 Coverage Rates by Background Characteristics Table 11.3 presents information on differentials in the various vaccination indicators by background characteristics. The proportion of children for whom a vaccination card was seen varies considerably across the subgroups in the table. For example, the proportion of children with a card was 63 percent in the South compared with 80 percent in the West. The results in Table 11.3 show that female children were slightly more likely than male children to have been vaccinated against all seven vaccine-preventable diseases (79 percent and 75 percent respectively). The proportion of children fully immunized declined from 81 percent among first order births to 55 percent among sixth and higher order births. As expected, there are differences in coverage by place of residence. The percentage of children receiving the first dose of the polio vaccine was similar for children living in urban and rural areas (97 and 95 percent respectively). However, the percentages receiving the second and third polio doses were 89 and 81 for rural children compared with 94 and 92 for urban children. The coverage rates for the third DPT and hepatitis doses and for the BCG and measles vaccines were also higher for urban children than for rural children. Overall, 80 percent of urban children were fully vaccinated against all seven diseases compared to 67 percent for rural children. Child Health | 161 Table 11.3 Vaccinations by background characteristics Percentage of children age 15-26 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Turkey 2008 Background characteristic BCG DPT Polio Measles Hepatitis All1 None Percent- age with a vaccine- ation card seen All +Hep Number of children1 2 3 1 2 3 1 2 3 Sex Male 96.0 97.6 92.5 89.4 97.3 93.5 89.1 88.1 97.0 91.2 85.9 78.7 1.1 74.9 75.0 370 Female 95.8 96.7 91.0 89.3 96.2 91.0 88.5 90.5 95.9 90.2 86.0 82.6 2.2 70.2 78.7 340 Birth order 1 97.9 98.3 94.2 92.3 97.4 93.1 90.9 88.8 97.6 94.5 91.5 82.4 1.1 75.3 80.8 278 2-3 96.1 97.9 91.9 89.5 97.5 93.3 89.6 93.4 97.1 90.6 85.0 85.1 1.2 74.9 79.7 321 4-5 92.2 92.8 82.7 81.9 93.8 84.3 78.5 82.8 92.7 79.0 73.7 65.2 3.4 58.3 60.6 66 6+ 88.2 91.7 88.9 80.9 92.4 91.9 86.1 72.6 91.0 85.8 76.6 59.6 4.9 61.0 55.0 46 Residence Urban 96.5 97.8 93.9 92.1 97.3 93.6 91.7 90.3 97.0 93.1 88.9 84.2 1.6 75.8 80.3 515 Rural 94.3 95.5 86.2 82.2 95.4 89.0 81.4 86.5 94.9 84.5 78.2 71.0 1.6 64.4 67.4 196 Region West 97.3 98.4 95.2 93.7 97.3 94.3 91.7 90.4 97.5 92.6 87.9 84.6 1.6 79.7 78.5 256 South 96.1 98.9 89.9 88.1 97.8 89.5 87.7 93.9 96.9 91.0 85.5 81.8 1.1 62.6 77.9 95 Central 96.4 98.3 95.6 94.3 98.2 96.4 94.5 94.8 99.2 96.8 94.5 90.0 1.2 70.9 89.6 149 North 100.0 100.0 91.2 88.1 100.0 95.6 85.8 97.8 99.2 88.1 85.8 83.6 0.0 74.6 82.7 43 East 92.2 92.5 84.3 79.2 93.3 86.5 80.8 77.7 91.5 83.0 75.6 64.3 2.8 68.5 60.5 167 Region (NUTS 1) İstanbul 95.7 97.8 95.7 95.7 95.7 93.5 93.5 84.8 97.8 93.5 89.1 80.4 2.2 76.1 73.9 134 Southeast A. 94.8 95.8 90.0 84.5 95.3 90.0 85.5 76.5 93.7 88.5 79.9 66.7 2.1 71.7 62.4 97 Education No//Prim. inc. 92.8 92.3 85.7 81.5 91.7 85.1 81.0 77.2 92.2 85.4 77.6 64.9 3.2 69.5 62.3 117 First level p. 94.9 97.4 91.6 89.8 96.6 92.9 89.6 89.9 97.1 89.4 84.1 81.6 1.8 72.5 76.0 358 Sec. level p. 98.0 99.2 92.1 89.4 99.2 92.4 87.4 95.8 98.0 93.2 89.4 84.4 0.8 75.5 82.3 72 High and h. 99.5 99.5 96.3 94.0 99.7 96.2 93.3 93.5 97.5 96.4 94.5 87.8 0.2 73.7 86.3 163 Wealth quintile Lowest 90.4 91.8 82.8 78.1 92.1 85.8 78.0 79.6 91.0 81.4 75.7 62.2 3.8 61.1 60.0 148 Second 96.7 97.1 88.4 85.9 95.3 87.9 85.1 92.6 96.2 85.7 80.6 81.6 2.1 71.3 77.3 163 Middle 97.7 99.4 95.7 94.3 98.8 95.4 93.9 89.5 98.8 93.8 91.2 86.2 0.6 81.0 82.0 166 Fourth 99.5 98.9 97.1 94.9 99.2 97.7 94.2 94.7 99.5 98.7 91.6 89.5 0.5 68.6 83.7 111 Highest 95.9 99.3 96.9 95.6 99.3 96.9 94.9 91.1 97.6 97.4 93.0 85.3 0.7 80.5 82.9 124 Total 95.9 97.2 91.8 89.3 96.8 92.3 88.8 89.3 96.5 90.7 85.9 80.5 1.6 72.6 76.8 711 1Children who are fully vaccinated (i.e., those who have received BCG, measles, and three doses of DPT and polio). Considering regional differences, the percentage children who were fully immunized was lowest in the East (61 percent) and highest in the Central region (90 percent). The data in Table 11.3 also show that drop-out rates for DPT and polio were higher in the North compared to other regions. With regard to the two NUTS 1 regions for which are sufficient cases to look at coverage rates, the proportion fully vaccinated against the seven diseases was substantially higher in İstanbul (74 percent) than in Southeast Anatolia (62 percent). 162 | Child Health Mother’s educational status was directly related to the likelihood that a child was vaccinated. The percentage of children who were fully vaccinated varied from 62 percent among children whose mothers with no or incomplete primary education to 86 percent among children whose mothers had at least a high school education. Coverage rates also rose rapidly with wealth; 60 percent of children in the lowest wealth quintile were fully immunized against the seven diseases compared to more than 80 percent of children in the third or higher quintiles. 11.2.3 Trends in Vaccination Coverage Table 11.4 shows the percentage of children age 12-35 months who received specific vaccines before 15 months of age according to the child’s current age. The table can be used to look at trends over time in the proportion of children who have received all of the recommended vaccinations. In considering the trends, it is important to remember that, for children whose information was based on the mother’s recall, the proportion of vaccinations given before age 15 months is assumed to be the same as that for children for whom a vaccination record was available. Table 11.4 Vaccinations by current age of child Percentage of children age 12-35 months at the time of the survey who received specific vaccines by 15 months of age, and percentage with a vaccination card, by current age of child, Turkey 2008 Vaccine Child’s age in months Total12-23 24-35 BCG 95.9 94.3 95.1 DPT 1 96.6 92.8 94.6 DPT 2 91.2 82.2 86.4 DPT 3 85.9 75.5 80.4 Polio 1 95.8 94.4 95.1 Polio 2 92.3 82.6 87.2 Polio 3 86.3 75.6 80.7 Measles 85.8 82.5 84.3 Hepatitis1 96.5 94.0 95.2 Hepatitis 2 90.8 85.0 87.6 Hepatitis3 84.7 72.1 77.9 All vaccinations1 74.9 66.5 70.5 All vaccinations plus hepatitis 71.3 61.7 66.2 No vaccinations 1.8 3.4 2.6 Percentage with vaccination card seen2 75.8 57.5 65.6 Number of children 534 672 1,206 1 Children who have received BCG, measles, and three doses each of DPT and polio vaccines 2 Information was obtained either from a vaccination card or from the mother if there was no written record. For children whose information was based on the mother's report, the proportion of vaccinations given before age 15 months is assumed to be the same as that for children with a written vaccination record. The proportion of children for whom vaccination cards were seen declines with increasing age of child, from 76 percent among children age 12-23 months to 58 percent among children age 24-35 months. This suggests that either there has been an increase in vaccination Child Health | 163 levels in the recent past or the mothers misplaced vaccination cards for a greater proportion of older children. Similarly, the proportion of children who received all vaccines before age 15 months is higher for children age 12-23 months (75 percent) than for children in the 24-35 age groups (67 percent). 11.3 Prevalence and Treatment of Diarrhea Dehydration caused by diarrhea is one of the most important causes of childhood mortality. In Turkey, the National Control of Diarrheal Diseases Programme was established in 1986 with the objective of reducing child deaths by preventing dehydration. Oral Rehydration Therapy (ORT) has been actively promoted since the inception of this programme. In the TDHS-2008, mothers who had children under age five were asked if their children experienced diarrhea during the last two weeks before the survey. Mothers were also asked what treatment they had given to children who had diarrhea. As the prevalence of diarrhea varies seasonally, the results represent the prevalence of diarrhea during the period of the TDHS-2008 fieldwork (October-December 2008) and not the average throughout the year in Turkey. Table 11.5 shows the percentage of children under five years of age with diarrhea during the last two weeks preceding the survey by selected background characteristics. Overall, 23 percent of children suffered from diarrhea during the period, and 1 percent had diarrhea with bloody stools. As expected, the small number of children living in households with non-improved, shared toilet facilities had a higher rate of diarrheal illness than children living in households with improved, not shared facilities (23 percent and 47 percent, respectively). Looking at the variation by other background characteristics, children age 6-23 months were more likely than younger and older children to have had diarrhea. There was little variation in diarrhea prevalence by sex and place of residence. Children living in the East (36 percent), children living in Central East Anatolia (43 percent), children whose mothers have no education (36 percent), and children in the lowest wealth quintile (31 percent) had higher rates of diarrheal illness than other children. 164 | Child Health Table 11.5 Prevalence of diarrhea Percentage of children under age five who had diarrhea in the last two weeks preceding the survey, by background characteristics, Turkey 2008 Diarrhea in the two weeks preceding the survey Number of childrenBackground characteristic All diarrhea Diarrhea with blood in stools Toilet facility Improved, not shared 22.5 1.1 1,987 Non-improved or shared 46.7 3.3 68 Age in months <6 18.5 0.8 361 6-11 33.6 2.4 336 12-23 25.6 1.0 704 24-35 18.4 0.9 672 Sex Male 22.3 1.6 1,041 Female 24.4 0.8 1,032 Residence Urban 22.8 0.9 1,477 Rural 24.7 1.9 596 Region West 20.4 0.6 715 South 20.3 0.4 245 Central 16.2 0.4 459 North 18.8 0.0 125 East 35.9 3.3 529 Region (NUTS 1) İstanbul 22.7 0.9 324 West Marmara 18.0 0.0 55 Aegean 16.4 0.6 269 East Marmara 17.9 0.0 182 West Anatolia 17.0 0.0 210 Mediterranean 20.3 0.4 245 Central Anatolia 20.2 1.6 106 West Black Sea 14.6 0.0 104 East Black Sea (23.6) (0.0) 49 Northeast Anatolia 29.4 2.9 74 Central East Anatolia 42.7 5.1 147 Southeast Anatolia 34.2 2.6 309 Education No education/Primary incomplete 36.2 3.0 440 First level primary 20.0 0.9 966 Second level primary 23.1 1.0 221 High school and higher 18.0 0.2 446 Wealth quintile Lowest 31.3 2.2 493 Second 24.4 1.7 464 Middle 20.7 0.3 449 Fourth 21.4 1.0 344 Highest 15.4 0.3 324 Total 23.3 1.2 2,073 Note: Parentheses indicate a figure is based on 25-49 unweighted cases. Child Health | 165 Findings related to the treatment of diarrhea are presented in Table 11.6. A simple and effective response to the dehydration with diarrhea is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy (ORT). ORT includes the use of a solution prepared by mixing water with the commercially prepared packet of oral rehydration salts (ORS) or a recommended home fluid (RHF), typically prepared with sugar, salt and water. The majority of children under five years of age with diarrheal episodes received some kind of treatment. Sixty-three percent of mothers reported that they increased the fluids given the child during the diarrheal episodes or used some form of oral rehydration therapy. Almost half of the children with diarrhea were taken to health provider (47 percent). Use of ORT and increased fluids was more common among children age 12 months and older than among younger children. Girls were less likely to be taken to a health provider during a diarrheal episode and to receive ORT or increased fluids than boys. The type of diarrhea made a difference in the likelihood of a consultation with a health provider; among the small number of children with bloody diarrhea, 70 percent were taken to a health provider compared to 46 percent among children with diarrhea who did not have bloody stools. On the other hand, the percentages receiving ORT or increased fluids were almost identical among children with bloody and non-bloody diarrhea. Urban mothers were more likely then rural mothers to use some form of oral rehydration therapy (ORT), but rural mothers were as likely to seek care from a health provider as urban mothers. Among the regions, the West had the highest percentage seeking health care (54 percent) and using ORT or increased fluids (75 percent). Treatment practices did not vary consistently with either the mother’s education or the wealth quintile. The TDHS-2008 also investigated the extent to which mothers made changes in the amount of fluids and food that a child received during a diarrheal episode. To obtain this information, mothers who had a child under age five with diarrhea during the two week period preceding the survey were asked whether they had changed the amount that child was given to drink and eat during the diarrheal episode. Table 11.7 shows that 27 percent of children with diarrhea were offered the same amount of fluids as usual, 49 percent were offered more fluids than usual, and 16 percent were given less fluid than usual. Among children with diarrhea only 6 percent received more food than before the illness. More than half of children with diarrheal episode were offered less food than they usually had. Optimally, children ill with diarrhea should be offered around the same amount of food as when they are not sick and increased fluids. Table 11.7 shows that feeding practices were optimal for only 17 percent of children who had a diarrheal episode in the two week period prior to the survey. Overall the table shows that 22 percent of the children who experienced diarrhea were fed and given fluids appropriately during their illness or received some form of ORT. Children whose mothers had a high school or higher education, children in the two highest wealth quintiles, children from the West, and children from Istanbul were more likely than other children to have been fed and given fluids appropriately or to have received ORT. 166 | Child Health Table 11.6 Diarrhea treatment Among children under age five who had diarrhea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given no treatments, by background characteristics, Turkey 2008 Oral rehydration therapy (ORT) Background characteristic Percentage of children with diarrhea taken to a health provider ORS packets or pre- packaged liquid Recommended home fluids (RHF) Either ORS or RHF Increased fluids ORT or increased fluids No treatment Number of children Age in months <6 47.7 9.2 7.5 14.7 24.1 32.9 24.6 67 6-11 49.4 21.0 11.0 28.1 40.6 59.7 14.3 113 12-23 48.8 24.7 17.3 32.8 54.5 70.1 16.0 181 24-35 42.0 19.6 10.0 22.6 61.8 71.7 9.9 124 Sex Male 52.8 19.6 11.1 25.5 54.2 65.8 11.6 232 Female 41.7 21.1 14.0 27.6 44.0 60.3 18.6 252 Type of diarrhea Non bloody 45.9 20.0 11.9 26.1 49.2 62.9 15.5 454 Bloody (70.1) (20.7) (15.8) (29.8) (51.9) (62.6) (12.6) 25 Residence Urban 47.3 21.4 12.0 26.9 49.8 65.2 12.8 336 Rural 46.4 18.1 14.0 26.0 47.0 57.9 20.8 147 Region West 53.7 24.6 20.1 30.3 53.7 75.4 8.1 146 South 43.5 17.6 8.0 24.3 37.2 49.4 28.5 50 Central 29.1 7.2 4.1 10.1 59.0 62.6 17.0 75 North 46.3 26.3 8.9 35.2 45.0 53.7 15.9 24 East 49.9 22.3 11.9 29.8 44.8 58.3 16.4 190 Region (NUTS 1) İstanbul 44.5 31.7 19.8 35.7 56.4 84.2 4.0 73 Southeast Anatolia 50.5 19.9 5.7 22.7 43.1 53.6 15.9 106 Education No education /Primary incomplete 49.3 26.2 16.7 33.1 42.0 61.1 16.2 159 First level primary 47.8 15.7 10.0 22.6 45.5 59.0 14.6 193 Second level primary 54.6 21.2 14.1 29.1 47.9 63.4 11.8 51 High school and higher 35.6 19.5 9.7 21.7 71.7 75.8 17.0 80 Wealth quintile Lowest 46.3 21.2 15.1 28.5 42.5 56.2 20.2 154 Second 52.6 26.1 17.8 33.9 44.2 61.2 15.7 113 Middle 50.8 21.3 10.4 28.5 45.4 69.4 8.1 93 Fourth 39.0 14.5 7.8 16.0 67.6 74.0 7.8 74 Highest 41.3 11.9 4.2 16.1 58.5 59.7 23.2 50 Total 47.0 20.4 12.6 26.6 48.9 63.0 15.2 484 Note: Parentheses indicate a figure is based on 25-49 unweighted cases. Child Health | 167 Table 11.7 Feeding practices during diarrhea Percent distribution of children under age five who had diarrhea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, the percentage of children given increased fluids and continued feeding during the diarrhea episode, and the percentage of children who continued feeding and were given ORT and/or increased fluids during the episode of diarrhea, by background characteristics, Turkey 2008 Background characteristic Amount of liquids offered Amount of food offered Percentage given increased fluids and continued feeding Percentage given ORT or increased fluids and continued Number of children with diarrheaMore Same as usual Much less Don't know/ missing Total More Same as usual Much less Don't know/ missing Total Age in months <6 24.1 34.3 9.1 32.5 100.0 11.7 40.0 15.7 32.6 100.0 18.5 22.6 67 6-11 40.6 39.7 15.2 4.5 100.0 5.5 41.2 50.2 3.1 100.0 18.9 23.5 113 12-23 54.5 23.1 20.3 2.0 100.0 6.5 29.7 63.1 0.7 100.0 12.5 19.1 181 24-35 61.8 18.0 15.6 4.5 100.0 4.3 31.5 59.4 4.9 100.0 21.1 23.5 124 Sex Male 54.2 22.0 15.7 8.0 100.0 8.1 31.2 53.4 7.3 100.0 19.1 23.5 232 Female 44.0 32.0 17.0 6.9 100.0 4.9 37.1 51.8 6.2 100.0 15.1 20.1 252 Type of diarrhea Non bloody 49.2 27.5 15.9 7.5 100.0 6.1 34.5 52.8 6.7 100.0 16.7 21.8 454 Bloody (51.9) (24.0) (15.4) (8.6) (100.0) (11.4) (34.1) (45.8) (8.6) (100.0) (24.1) (24.1) 25 Residence Urban 49.8 26.6 16.8 6.8 100.0 5.5 34.0 53.5 7.0 100.0 17.2 21.7 336 Rural 47.0 28.6 15.4 9.0 100.0 8.6 34.9 50.5 6.0 100.0 16.6 21.9 147 Region West 53.7 25.1 16.6 4.5 100.0 5.3 35.2 56.4 3.2 100.0 21.5 25.5 146 South 37.2 40.6 11.7 10.5 100.0 2.9 43.5 46.4 7.1 100.0 12.5 15.9 50 Central 59.0 27.4 8.3 5.2 100.0 3.9 36.7 54.3 5.1 100.0 16.4 20.0 75 North 45.0 34.7 12.7 7.6 100.0 9.3 35.7 49.3 5.7 100.0 15.9 21.2 24 East 44.8 24.4 21.0 9.8 100.0 8.9 30.0 51.0 10.1 100.0 15.1 21.1 190 Region (NUTS1) İstanbul 56.4 23.8 15.8 4.0 100.0 4.0 39.6 52.5 4.0 100.0 23.8 31.7 73 Southeast Anat. 43.1 20.3 22.4 14.2 100.0 9.3 30.0 46.1 14.6 100.0 14.6 19.7 106 Education No/Primary inc. 42.0 28.7 19.4 9.9 100.0 9.3 29.5 52.2 9.0 100.0 16.5 22.3 159 First level prim. 45.5 26.9 20.9 6.6 100.0 4.2 31.6 58.0 6.3 100.0 11.0 14.1 193 Second level p. 47.9 28.4 13.5 10.2 100.0 8.2 36.4 48.0 7.5 100.0 15.2 24.5 51 High and higher 71.7 24.2 1.2 3.0 100.0 4.9 49.0 43.2 3.0 100.0 33.9 37.3 80 Wealth quintile Lowest 42.5 27.2 19.2 11.1 100.0 10.0 28.9 52.4 8.8 100.0 15.5 19.5 154 Second 44.2 25.0 21.8 8.9 100.0 5.3 37.2 49.1 8.4 100.0 12.2 22.1 113 Middle 45.4 27.7 22.6 4.3 100.0 4.6 16.3 74.1 5.0 100.0 8.1 11.6 93 Fourth 67.6 23.7 4.4 4.3 100.0 1.9 47.0 46.8 4.3 100.0 29.1 31.0 74 Highest 58.5 36.6 1.4 3.5 100.0 7.9 58.9 29.7 3.5 100.0 31.5 32.7 50 Total 48.9 27.2 16.4 7.5 100.0 6.4 34.3 52.6 6.7 100.0 17.0 21.7 484 Note: Parentheses indicate a figure is based on 25-49 unweighted cases. Children’s and Women’s Nutritional Status | 169 CHILDREN’S AND WOMEN’S NUTRITIONAL STATUS 12 Elif Kurtuluş Yiğit, Sabahat Tezcan and F.Hande Tunçkanat The TDHS-2008 obtained information on several aspects of infant feeding practices including the duration and intensity of breastfeeding, the types of the complimentary foods given, and whether or not a bottle with a nipple was used. To further assess the nutritional status of all children under age five and women age 15-49, anthropometric (height and weight) measurements were also obtained. With respect to the child, they relate directly to the nutritional status, which in turn influences the risk of morbidity and mortality of young children. The magnitude of the effects is influenced by both the duration and intensity of breastfeeding, and by the age at which the child receives supplemental foods and liquids. Anthropometric measures obtained for women also allow an assessment of their nutrition status. Maternal nutrition status has important implications for the health of the mother and her child. A woman who is in poor nutritional health has a greater risk of having an adverse pregnancy outcome and is more likely to give birth to underweight babies. 12.1 Initiation of Breastfeeding Breastfeeding of infants is among the most important factors contributing to the maintenance of healthy growth. Breast milk contains all the nutrients needed by children in the first 4-6 months of life. Moreover, breast milk is clean and always available at just the right temperature, and it promotes a close mother-child relationship. In addition, it provides some immunity to disease through the mother's antibodies, helps in reducing the prevalence of nutritional deficiencies, and avoids food-borne infections. Table 12.1 shows the percentage of children born in the five years preceding the survey according to breastfeeding status and the timing of the initial breastfeeding by selected background characteristics. Breastfeeding is almost universal in Turkey; 97 percent of all children are breastfed for some period of time, with minimal differences by background characteristics. Early initiation of breastfeeding is of benefit to both mother and infant. Suckling stimulates production of oxytocin, a hormone that causes the mother's uterus to contract thus returning it back to normal size and function. The first breast milk, colostrum, protects the newborn infant from infections because of its high concentration of antibodies. Information from the TDHS-2008 indicates that initiation to breastfeeding is rather late (Table 12.1). Only 39 percent of ever-breastfed children started breastfeeding within one hour after birth, and 27 percent were not put to the breast within 24 hours of their birth. These proportions are below from those reported in the TDHS-2003 suggesting that there continues to be a shift away from early initiation of breastfeeding, which is the optimal pattern. 170 | Children’s and Women’s Nutritional Status Table 12.1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed, and among children ever breastfed, percentage who started breastfeeding within one hour and within one day of birth and percentage who received a prelacteal feed, by background characteristics, Turkey 2008 Background characteristic Percentage ever breastfed Number of children Percentage who started breastfeeding within 1 hour after birth Percentage who started breastfeeding within 1st day of birth1 Percentage who received a prelacteal feed2 Number of children ever breastfed Assistance at delivery Health professional 3 96.6 3,161 40.6 75.8 23.5 3,054 Traditional birth attendant 97.0 126 19.4 49.4 25.7 122 Other 98.3 150 26.2 48.2 16.2 148 Place of delivery Health facility 96.5 3,107 40.6 76.0 23.7 3,000 At home 97.7 336 26.1 51.6 19.2 328 Sex Male 97.2 1,770 36.9 73.5 22.2 1,720 Female 96.1 1,693 41.1 73.2 24.2 1,627 Residence Urban 96.7 2,475 41.0 76.2 23.5 2,393 Rural 96.7 988 33.9 66.1 22.3 955 Region West 96.7 1,174 47.9 80.0 23.4 1,135 South 95.4 441 40.7 75.2 20.9 420 Central 97.2 741 31.8 76.0 27.0 720 North 97.3 197 41.0 77.0 20.2 191 East 96.7 911 32.1 61.0 21.5 881 Region (NUTS 1) İstanbul 96.3 548 53.8 81.2 22.1 528 West Marmara 98.5 88 46.8 80.9 23.4 87 Aegean 96.8 427 41.7 75.5 25.8 414 East Marmara 98.3 275 40.9 82.7 28.8 270 West Anatolia 96.7 345 27.7 75.6 26.0 334 Mediterranean 95.4 441 40.7 75.2 20.9 420 Central Anatolia 96.3 177 35.2 74.9 25.0 170 West Black Sea 97.0 172 33.5 77.1 20.9 167 East Black Sea 97.5 79 45.5 76.2 16.5 77 Northeast Anatolia 96.9 128 42.4 66.0 11.6 124 Central East Anatolia 96.5 250 26.7 57.3 26.1 241 Southeast Anatolia 96.8 533 32.2 61.5 21.7 516 Education No education/Primary inc 96.9 781 31.8 62.6 22.5 756 First level primary 96.5 1,691 40.2 75.4 21.9 1,631 Second level primary 97.8 322 39.9 77.7 19.5 315 High school and higher 96.5 669 43.9 78.7 29.0 646 Wealth quintile Lowest 95.9 852 32.6 60.2 19.7 817 Second 96.3 818 38.5 73.2 21.3 787 Middle 97.5 709 35.8 76.7 23.2 691 Fourth 97.7 579 45.1 80.0 23.9 566 Highest 96.3 506 47.8 83.2 30.9 487 Total 96.7 3,463 39.0 73.4 23.2 3,348 Note: Table is based on all births whether the children are living or dead at the time of interview. 1 Includes children who started breastfeeding within one hour of birth. 2 Children given something other than breast milk during the first three days of life before the mother started breastfeeding regularly. 3 Doctor, nurse/midwife, or auxiliary midwife. Children’s and Women’s Nutritional Status | 171 Since TDHS-2003, decreases in the proportions of children for whom breastfeeding was initiated early occurred in all regions, especially in the West, Central and North. Despite these changes, marked variations in the timing of initiation of breastfeeding still remain across subgroups. Initiation of breastfeeding within one hour of birth is much more common for babies born in health facilities or with the assistance of a health professional than among babies born at home or with the assistance of a traditional birth attendant or other nonprofessional. Breastfeeding is more likely to be initiated within one hour of birth for urban than rural children (41 percent and 34 percent, respectively). The percentage of children who started breastfeeding within one hour after birth is highest in the West region (48 percent) and lowest in the Central and East regions (32 percent). When NUTS 1 levels are considered, İstanbul has the highest proportion of children for whom breastfeeding was initiated within an hour of birth and Central East Anatolia has the lowest (54 percent and 27 percent, respectively). The percentage of children of whom breastfeeding was initiated within an hour of birth varies from 32 percent for births to mothers with no education to 44 percent for births to mothers with at least high school education. Breastfeeding is initiated early most often for children in the highest wealth quintile (48 percent) and least often for children in the lowest quintile (33 percent). The proportion of children who started breastfeeding within first day of birth also varies across subgroups. For example, the East, where mothers are usually less educated and are more likely to give birth without the assistance of a medically trained person, has the lowest proportion; 61 percent of all children in this region were put to the breast during the first day. Regarding the education patterns, 63 percent of children of mothers with no education started breastfeeding within first day of their birth compared with 79 percent of births to the most highly educated mothers. Prelacteal feeding is the practice of giving other liquids to an infant during the period immediately after birth before mother’s milk is flowing easily. Table 12.1 shows this practice is not as common today in Turkey as in the past. Overall, 23 percent of children received a prelacteal feed. This percentage is highest for children living in East Marmara (29 percent) and children in the highest wealth quintile (31 percent). 12.2 Breastfeeding Status by the Age of the Child UNICEF and WHO recommend that children be exclusively breastfed (i.e., without receiving other liquids or solid foods or plain water) during the first 6 months of life and that solid or mushy supplements be given beginning with the seventh month of life. While complementary feeding is acceptable after the first 6 months, breastfeeding is recommended to be continued through the second year of life. Use of bottles with nipples is not recommended at any age. The percent distribution of living children by breastfeeding status at the time of the survey is shown in Table 12.2. The child’s breastfeeding status is based on information collected from mothers on feeding practices in the last 24 hours before the interview. "Exclusively breastfed" refers to children who receive breast milk only. "Children who are fully breastfed" includes those who are exclusively breastfed and those who receive only plain water in addition to breast milk. Table 12.2 also shows the percentage who drank anything from a bottle with a nipple in the day or night before the interview. The table allows for an assessment of the timing of the introduction of liquid and solid supplements. This is important since early introduction of supplementary food 172 | Children’s and Women’s Nutritional Status increases the risk of gastrointestinal infections, which is one of the leading causes of infant mortality in Turkey. Table 12.2 Breastfeeding status by age Percent distribution of the youngest children under three years living with the mother by breastfeeding status and percentage of children using a bottle with a nipple, according to age in months, Turkey 2003 Age in months Not breastfeeding Exclusively breastfed Breastfeeding and consuming: Total Percentage using a bottle with a nipple Number of children Plain water only Water- based liquids/ juice Other milk Comple- mentary foods <2 1.5 68.9 7.3 0.0 22.2 0.0 100.0 21.8 85 2-3 2.3 42.0 28.3 1.7 23.3 2.3 100.0 36.1 133 4-5 7.5 23.6 15.7 5.2 29.3 18.8 100.0 57.0 143 6-7 16.2 1.6 4.7 1.2 10.9 65.5 100.0 59.8 105 8-9 23.6 1.6 2.8 0.0 2.1 69.9 100.0 49.7 91 10-11 31.1 0.0 0.5 0.6 4.5 63.3 100.0 58.9 140 12-15 33.3 0.0 0.5 0.2 1.1 64.9 100.0 51.9 233 16-19 58.5 0.0 0.0 0.0 0.4 41.1 100.0 56.0 267 20-23 78.4 0.0 1.1 0.0 0.3 20.3 100.0 52.9 204 24-27 90.6 0.2 0.0 0.0 0.0 9.1 100.0 53.2 239 28-31 92.0 0.0 0.0 0.0 0.0 8.0 100.0 43.7 223 32-35 96.6 0.0 0.0 0.0 0.0 3.4 100.0 40.1 210 <6 4.1 41.6 18.4 2.6 25.3 8.0 100.0 41.0 361 6-9 19.6 1.6 3.8 0.6 6.8 67.5 100.0 55.1 196 Note: Breastfeeding status refers to a last “24-hour” period (yesterday and last night). Children classified as breastfeeding and consuming plain water only consume no supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, water-based liquids/juice, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and water-based liquids and who do not receive complementary foods are classified in the water-based liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. The TDHS-2008 results in Table 12.2 indicate that, in the first two months of life, 69 percent of babies are being exclusively breastfed, a figure which is significantly higher than that found in the TDHS-2003 (44 percent). The table also shows that the proportion of babies under two months of age that are predominantly breastfed, i.e., receiving only water, water-based liquids or juices in addition to breast milk is 7 percent compared to 47 percent in the TDHS-2003. Twenty percent of babies less than 2 months of age are receiving milk other than breast milk. By age 2-3 months, the proportion of children exclusively breastfed drops to 42 percent. The table shows that, after the sixth month, feeding with other milk and complementary foods is more common than breastfeeding. By 12-15 months, 33 percent of children are not being breastfed, which is lower than the THDS-2003 figure (45 percent). Bottle-feeding is discouraged among very young children, because it contributes to an increased risk of gastrointestinal infections. Table 12.2 shows that, among children less than six months of age the percentage of using a bottle with a nipple is 41 percent, and it increases to a peak of 60 percent among children age 6-7 months. Children’s and Women’s Nutritional Status | 173 12.3 Duration and Frequency of Breastfeeding Table 12.3 shows the median durations of any, exclusive and predominant breastfeeding by background characteristics. The median duration of breastfeeding among all children is 16 months, which is one and a half months longer than the median reported in TDHS-2003. Differences in breastfeeding durations are also evident among subgroups. Male children (16.9 months) are breastfed 2 months longer than the female children (14.9 months). Women living in the East are breastfeeding their children for an average of almost 18 months, which is 2-3 months longer than in any other region. Median durations for exclusive breastfeeding are very short, around two months or less for all subgroups. There are also only comparatively minor variations in the median duration of predominant breastfeeding across subgroups. Male children, children living in rural areas, children from the Central region, and those whose mothers have a first level primary education or are in the second and middle wealth quintiles are likely to have a somewhat longer period of predominant breastfeeding than other children. The frequency of breastfeeding is also examined in Table 12.3. It is important for an infant to breastfeed frequently as it improves milk production. In addition, frequent feeds help to prolong the period of postpartum amenorrhea during which the mother is insusceptible to pregnancy. Ninety-five percent of children under 6 months of age were breastfed 6 times or more in the 24-hour period preceding the survey. The percentage of children breastfed 6 times or more is lowest in the Central region (92 percent) and highest among male children (97 percent). On the average, children were breastfed 6 times in day time and 5 times at evening and night. 174 | Children’s and Women’s Nutritional Status Table 12.3 Median duration and frequency of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, percentage of breastfeeding children under six months living with the mother who were breastfed six or more times in the 24 hours preceding the survey, and mean number of feeds (day/night), by background characteristics, Turkey 2008 Median duration (months) of breastfeeding1 Breastfeeding children under six months2 Background characteristic Any breastfeeding Exclusive breastfeeding Predominant breastfeeding3 Number of children Percentage breastfed 6+ times in last 24 hours Mean number of day feeds Mean number of night feeds Number of children Sex Male 16.9 2.0 4.0 1,058 97.4 7.2 5.8 152 Female 14.9 1.6 3.1 1,044 92.9 6.5 5.0 177 Residence Urban 15.9 2.0 3.5 1,495 95.8 6.9 5.3 235 Rural 15.1 1.3 4.0 606 93.1 6.7 5.6 94 Region West 15.2 1.6 3.4 719 95.9 7.2 5.6 114 South 14.7 1.2 2.1 249 95.8 (6.0) (4.3) 35 Central 14.7 2.0 4.2 463 92.2 6.0 4.9 81 North 15.2 1.9 2.6 127 94.4 * * 17 East 17.7 2.0 3.8 543 96.3 7.2 6.0 83 Region (NUTS1) İstanbul 15.5 2.1 3.3 327 100.0 7.3 4.2 55 Southeast Anatolia 17.6 2.2 4.2 317 94.0 7.0 6.0 51 Education No/ Primary inc. 17.0 1.3 3.7 450 94.7 7.1 5.9 72 First level primary 14.7 2.3 4.1 978 95.4 7.0 5.2 150 Second level prim. 16.1 1.9 3.4 223 (93.4) (6.8) (5.0) 40 High school and higher 16.6 0.7 1.8 451 95.4 6.1 5.3 68 Wealth quintile Lowest 16.1 1.9 3.7 502 95.3 7.5 6.5 72 Second 14.0 2.1 4.3 472 97.0 7.5 5.2 79 Middle 15.8 1.6 4.2 456 97.6 6.2 5.0 73 Fourth 16.5 2.0 3.0 346 89.8 6.9 4.9 63 Highest 16.5 0.6 1.2 327 (94.1) (5.4) (5.1) 41 Total 15.7 1.8 3.6 2,101 95.0 6.8 5.4 329 Mean for all children 16.0 3.2 4.5 - - - - - Note: Median and mean durations are based on current status. 1It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2Excludes children who do not have a valid answer on the number of times breastfed 3Either exclusively breastfed or received breast milk and plain water, water-based liquids, and/or juice only (excludes other milk) Note: An asterisk indicates a figure is based on fewer than 25 unweighted cases. Parentheses indicate a figure is based on 25-49 unweighted cases. 12.4 Types of Complementary Foods Table 12.4 shows the percentage of breastfed and non-breastfed children receiving different types of supplements. Because children may have received more than one type of supplement, the percentages do not add to 100. Among breastfeeding children under 6 months of age, 25 percent received infant formula. The percentage that were given infant formula peaks at 46 percent for infants age 6-7 months and then decreases to 22 percent among babies age 8-9 months who are increasingly being given other fluids. Although the numbers of observations are small for the first year of life for non-breastfed children, the results for this group also suggest Children’s and Women’s Nutritional Status | 175 that infant formula is commonly given in the first months of life, with other types of milk being given more often as baby grows older. Table 12.4 Foods consumed by children in the day or night preceding the interview Percentage of youngest children under three years of age living with the mother who consumed specific foods in the day or night preceding the interview, by breastfeeding status and age, Turkey 2008 Age in months Infant formula Other milk/ cheese/ yoghurt Other liquids1 Food made from grains Fruits/ vegetables Meat/ fish/ shellfish/ poultry/ eggs Number of children BREASTFEEDING CHILDREN <2 21.3 4.1 18.3 0.0 0.0 0.0 84 2-3 18.4 11.8 49.2 0.5 1.6 0.3 130 4-5 34.7 33.1 67.3 8.3 19.1 3.3 129 6-7 46.0 76.2 96.9 63.7 52.4 30.5 88 8-9 21.8 79.6 95.5 76.5 71.3 48.1 69 10-11 29.4 81.1 100.0 75.0 68.4 56.8 94 12-15 17.0 84.3 100.0 91.5 79.0 70.9 154 16-19 12.7 81.0 100.0 90.9 82.8 66.1 106 20-23 (2.2) (76.2) (100.0) (93.7) (81.5) (74.4) 39 24-35 (3.5) (79.0) (98.8) (98.8) (65.8) (62.0) 40 <6 25.2 17.9 48.5 3.3 7.8 1.4 343 6-9 35.3 77.7 96.3 69.4 60.8 38.3 157 NONBREASTFEEDING CHILDREN <2 * * * * * * 5 2-3 * * * * * * 4 4-5 * * * * * * 14 6-7 * * * * * * 18 8-9 (66.5) (90.6 ) (90.6) (69.4) (48.3) (50.2) 24 10-11 (54.7) (90.8) (98.6) (85.9) (73.9 ) (58.7) 46 12-15 41.2 88.8 92.6 88.9 74.2 67.0 84 16-19 28.1 90.1 98.8 93.7 75.6 76.1 163 20-23 10.1 89.8 95.9 92.5 82.3 70.6 169 24-35 5.0 90.5 98.0 96.0 85.7 81.1 642 <6 * * * * * * 23 6-9 (70.2) (83.8) (92.0) (68.7) (60.8) (42.1) 42 Note: Breastfeeding status and food consumed refer to a “24-hour” period (yesterday and last night). An asterisk indicates a figure is based on fewer than 25 unweighted cases. Parentheses indicate a figure is based on 25-49 unweighted cases. 1 Does not include plain water In summary, although breastfeeding is widespread in Turkey, exclusive breastfeeding is not widely practiced as recommended. In the first sixth months, only one child out of four is exclusively breastfed. Early introduction of infant formula and other liquids is common, and bottle-feeding is a comparatively popular feeding practice. Efforts to increase the proportions of breastfeeding have been successful in the recent years but must continue in the future. 176 | Children’s and Women’s Nutritional Status 12.5 Iodization of Household Salt Iodine deficiency is one of the main causes of children’s mental retardation and psycho- motor growth. In addition, iodine deficiency has been shown to increase the probability of stillbirth and miscarriage during pregnancy. It also results in low level of school success and insufficiency in working performance because of its negative effects on mental growth. International efforts to address the problems associated with iodine deficiency have focused on fortifying salt with iodine. About half of the sampled households in the TDHS-2008 were asked questions about the use of salt for cooking. A small sample of the salt was taken and first tested to find out whether salt was iodated. In the situations that there was no iodate in the salt, it was examined for iodide. Changes in color after the salt was dropped into the test solution were recorded. It is important to note that the order of tests was different in the TDHS-2003. The test results are presented in Table 12.5. Table 12.5 Iodization of household salt Percent distribution of households with salt tested for iodine content by level of iodine in salt (parts per million), percentage of households tested, and percentage of households with no salt, according to background characteristics, Turkey 2008 Result of salt test Result of salt test Background characteristic Salt was not tested Salt was tested Missing Total- percent Total Not iodized Iodized (potassium iodure test) < 15 ppm (potassium iodide) >= 15 ppm Total - percent Total Residence Urban 2.5 95.6 1.9 100.0 3,938 10.1 6.8 7.1 76.0 100.0 3,764 Rural 3.2 95.1 1.6 100.0 1,321 28.5 12.0 12.0 47.6 100.0 1,257 Region West 2.8 95.6 1.6 100.0 2,420 6.5 4.3 5.2 84.0 100.0 2,313 South 3.4 94.8 1.8 100.0 632 21.4 11.1 7.5 60.0 100.0 599 Central 2.5 95.6 1.9 100.0 1,149 14.9 10.4 8.8 66.0 100.0 1,098 North 2.6 95.4 2.0 100.0 360 10.5 10.1 14.5 64.8 100.0 343 East 2.0 95.6 2.4 100.0 700 38.6 13.8 15.9 31.7 100.0 669 Region (NUTS 1) İstanbul 3.0 94.5 2.5 100.0 1,065 2.6 3.5 1.9 92.0 100.0 1,006 West Marmara 3.3 95.2 1.6 100.0 274 13.6 1.2 6.6 78.6 100.0 261 Aegean 2.8 96.8 0.4 100.0 817 12.0 5.7 8.0 74.3 100.0 791 East Marmara 2.1 96.9 1.0 100.0 520 7.3 7.6 8.6 76.5 100.0 504 West Anatolia 2.4 96.9 0.7 100.0 520 7.5 10.9 6.2 75.5 100.0 504 Mediterranean 3.4 94.8 1.8 100.0 632 21.4 11.1 7.5 60.0 100.0 599 Central Anatolia 3.1 92.0 4.9 100.0 261 25.3 11.8 8.2 54.8 100.0 240 West Black Sea 1.4 95.7 2.9 100.0 333 15.3 9.9 15.5 59.3 100.0 319 East Black Sea 4.3 94.0 1.8 100.0 147 11.8 9.5 17.9 60.8 100.0 138 Northeast A. 0.4 97.6 2.0 100.0 123 19.8 20.9 22.1 37.3 100.0 120 Central East A. 2.6 96.3 1.0 100.0 190 42.1 16.8 14.2 26.9 100.0 183 Southeast A. 2.3 94.4 3.3 100.0 378 42.1 10.3 14.4 33.1 100.0 357 Total 2.7 95.5 1.8 100.0 5,260 14.7 8.1 8.3 68.9 100.0 5,022 Children’s and Women’s Nutritional Status | 177 In the TDHS-2008, the salt test was completed successfully in 96 percent of the households eligible for the test. In 15 percent of the households where test was done, the salt was not iodized, i.e., it did not include iodide or iodate. In 8 percent of the households, the household was observed to have salt with potassium iodide while in 69 percent of the households the salt contained an adequate level of potassium iodate (>=15 ppm). There are differences by residence and region in terms of the availability of iodized salt. Nine in 10 households in urban areas were using iodized salt compared with 7 in 10 households in rural areas. Use of iodized salt was most common in the West. More than half of the households in Central East and Southeast Anatolia did not use iodized salt or used salt that did not have an adequate level of potassium iodate. 12.6 Nutritional Status of Children One of the major contributions of the TDHS to the study of child health status is the anthropometric data collected for all children under five years of age. Both weight and height (length) measurements were obtained for each child. Employing this information, standard indices are used to describe the nutritional status of the children: height-for-age, weight-for-height, and weight-for-age. In any large population, there is obviously a natural variation in height and weight. This variation approximates a normal distribution. For purposes of analyzing anthropometric data, it is standard practice, thus, to use a reference population. The reference population serves as a point of comparison, facilitating the examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. For the TDHS-2008 the nutritional status of children in the survey population is compared against an international reference population defined by the U.S. National Center for Health Statistics (NCHS) and accepted by the U.S. Centers for Disease Control (CDC) and the World Health Organization (WHO). The use of the international reference population is based on the finding that well- nourished young children of all population groups (for which data exist) follow very similar growth patterns before puberty. In addition to this, tables based on WHO Child Growth Standards, 2006 are presented in Appendix E. As recommended by the World Health Organization (WHO) the evaluation of nutritional status involves three basic indices. The height-for-age index provides an indicator of linear growth retardation among children. Children who are more than two standard deviations below the median of the reference population in terms of height-for-age may be considered stunted (short for their age), or chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the median of the reference population are considered severely stunted. Stunting reflects the outcome of a failure to receive adequate balanced nutrition over a long period of time and is also affected by recurrent and chronic illness. Thus, height-for-age represents a measure of the long-term effects of malnutrition in a population and does not vary appreciably according to the season of data collection. Stunted children are not immediately obvious in a population; a stunted three-year-old child could look like a well-fed two-year-old. 178 | Children’s and Women’s Nutritional Status The weight-for-height index measures body mass in relation to body length. Children who are more than two standard deviations below the median of the reference population in terms of their weight-for-height may be considered too thin (“wasted”) or acutely malnourished. Severe wasting represents the failure to receive adequate balanced nutrition in a short period before the survey and may be the result of recent illness episodes, especially diarrhea, or of seasonal variations in food supply. The weight-for-age index takes into account both acute and chronic malnutrition and often is used to monitor nutritional status on a longitudinal basis. It is a useful tool in clinical settings for continuous assessment of nutritional progress and growth. Children whose weight- for-age is below minus two standard deviations from the median of the reference population are classified as "underweight". In the TDHS-2008, all children under five years of age whose mother was interviewed are included in the anthropometric data collection. However, not all eligible children are included in the results presented here; height or weight measurements are missing for 26 percent of eligible children (see Table D.3 in Appendix D). In addition, since two of the indices (height-for-age and weight-for-age) are influenced by the accuracy of the reporting of the child's age, one percent of children were excluded from the calculation because the month and year of birth was not known. Hence, height and weight data are shown for 73 percent of the eligible children. Table 12.6 shows how the percentage of children under five years of age classified as malnourished according to the height-for-age, weight-for-height, and weight-for-age indices varies with the child's age and selected other characteristics. For purposes of comparison, in the reference population, only 2.3 percent of children fall below minus two (-2 SD) for each of the three indices. Table 12.6 shows that one in 10 children under age five is stunted (i.e., short for their age), with around one-third of these children classified as severely stunted. On the other hand comparatively few children are wasted; less than one percent of children under age five have a weight-for-height z-score below -2SDs. Looking at the weight-for-age index, 3 percent of children under age 5 are underweight. Figure 12.1 and Table 12.6 shows the percentages of children under five years of age classified as malnourished according to three anthropometric indices of nutritional status of children by child’s age in months. Plotted values in the figure are smoothed by a five-month moving average. The youngest children show little evidence of malnutrition. However, the proportion classified as stunted exhibits a steady increase starting in the first year of life. Among children 24- 59 months of age, around 12 percent are classified as stunted. Severe stunting peaks in the 24-35 month age range. Among children age 48-59 months, around 3 percent are still considered severely stunted. These patterns reflect inadequate, unbalanced feeding practices and/or the presence of recurrent and chronic infections. Children’s and Women’s Nutritional Status | 179 The proportion of underweight increases to around 4 percent in the 24-35 month age range and then declines to below two percent at age 48 months. Finally, as the figure shows, the percentages of children who are wasted are at very low levels across all ages. Table 12.6 Nutritional Status by children’s characteristics Among children under five years, the percentage classified as undernourished according to the three indices of anthropometric status: height-for-age , weight-for-age and weight-for-height by background characteristics, Turkey 2008 Height-for age Weight-for height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Mean Z- score Percentage below -2 SD1 Mean Z- score Percentage below -3 SD Percentage below -2 SD1 Mean Z- score Number of children Age in months <6 0.4 3.6 0.5 1.2 0.5 0.4 0.5 0.9 175 6-9 0.4 2.4 0.1 1.7 0.2 0.0 2.8 0.2 149 10-11 1.3 8.3 0.1 3.2 0.2 0.4 3.1 0.0 108 12-23 2.9 12.0 0.6 1.5 0.6 0.2 3.7 0.1 528 24-35 5.1 12.4 0.5 0.3 0.4 0.4 3.8 0.0 506 36-47 3.7 9.8 0.5 0.7 0.3 0.2 2.7 0.2 476 48-59 3.3 12.0 0.6 0.1 0.5 0.3 1.9 0.0 532 Sex Male 2.5 9.9 0.4 1.5 0.4 0.3 2.3 0.0 1,299 Female 4.0 10.8 0.4 0.2 0.4 0.2 3.4 0.0 1,175 Birth order 1 1.5 6.7 0.2 1.0 0.4 0.2 1.2 0.2 862 2-3 2.7 10.3 0.4 0.5 0.4 0.2 2.3 0.0 1,154 4-5 6.4 14.4 0.7 1.6 0.4 0.5 7.0 0.2 295 6+ 9.7 22.5 1.1 1.0 0.5 1.1 7.6 0.3 162 Birth interval in months First birth 1.6 6.6 0.2 1.1 0.4 0.2 1.2 0.2 874 <24 9.3 22.2 0.9 1.2 0.4 0.5 5.8 0.3 319 24-47 4.4 13.8 0.7 0.8 0.4 0.3 4.0 0.1 562 48+ 1.5 6.9 0.3 0.5 0.4 0.3 2.6 0.1 719 Size at birth Very small 8.2 19.3 0.9 1.0 0.1 1.3 6.7 0.5 284 Small 5.2 16.0 0.8 0.9 0.3 0.3 6.7 0.3 321 Average or larger 2.1 8.0 0.3 0.8 0.5 0.1 1.6 0.2 1,863 Total 3.2 10.3 0.4 0.9 0.4 0.3 2.8 0.0 2,474 Note: Figures are for children born in the period 0-59 months preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international reference population. Children are classified as malnourished if their z-scores are below minus two or minus three standard deviations (-2 SD or -3 SD) from the median of the reference population. Tables based on WHO Child Growth Standards, 2006 are presented in Appendix E 1Includes children who are below -3 SD 180 | Children’s and Women’s Nutritional Status 12.7 Nutritional Status by mother’s characteristics Among children under five years, the percentage classified as undernourished according to the three indices of anthropometric status: height-for-age , weight-for-age and weight-for-height by mother’s background characteristics, Turkey 2008 Height-for age Weight-for height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Mean Z- score Percentage below -2 SD1 Mean Z- score Percentage below -3 SD Percentage below -2 SD1 Mean Z- score Number of children Residence Urban 2.1 7.6 0.3 0.8 0.5 0.2 2.1 0.1 1,781 Rural 5.9 17.4 0.8 0.9 0.4 0.5 4.8 0.2 692 Region West 1.4 7.6 0.2 0.9 0.5 0.0 1.0 0.2 848 South 2.7 7.6 0.4 0.0 0.5 0.3 3.0 0.1 339 Central 0.9 4.5 0.2 0.5 0.5 0.0 2.1 0.2 533 North 1.4 7.0 0.3 1.5 0.5 0.4 2.8 0.2 124 East 8.3 21.0 0.9 1.5 0.3 0.8 5.8 0.4 631 Region (NUTS 1) İstanbul 0.7 7.5 0.2 1.5 0.6 0.0 1.5 0.3 396 West Marmara 1.0 4.6 0.2 1.0 0.4 0.0 1.0 0.2 66 Aegean 2.7 6.4 0.3 0.0 0.2 0.0 1.2 0.0 289 East Marmara 0.6 7.2 0.1 1.0 0.4 0.0 2.3 0.2 218 West Anatolia 0.6 3.3 0.2 0.2 0.5 0.0 1.5 0.2 246 Mediterranean 2.7 7.6 0.4 0.0 0.5 0.3 3.0 0.1 339 Central Anatolia 1.4 9.4 0.4 0.5 0.6 0.0 1.2 0.2 123 West Black Sea 0.8 4.1 0.3 1.6 0.6 0.4 1.2 0.3 119 East Black Sea (1.5) (11.0) (0.3) (0.0) (0.5) (0.0) (4.2) (0.2) 48 Northeast Anatolia 10.6 22.2 1.1 1.3 0.5 1.1 7.2 0.3 90 Central East Anatolia 7.4 18.0 0.9 1.1 0.1 1.7 7.9 0.5 159 Southeast Anatolia 8.1 22.1 0.9 1.7 0.3 0.4 4.6 0.3 382 Education No educ./Prim.incomp. 9.9 22.6 1.0 1.4 0.3 0.8 7.2 0.3 541 First level primary 1.9 8.0 0.4 0.5 0.4 0.2 2.1 0.0 1,236 Second level primary 0.6 6.4 0.2 0.4 0.5 0.0 1.0 0.2 228 High school and 0.2 4.2 0.0 1.5 0.5 0.0 0.6 0.4 469 Wealth quintile Lowest 8.9 22.0 1.0 1.0 0.3 0.7 6.9 0.4 612 Second 1.8 10.8 0.5 0.7 0.5 0.3 1.9 0.0 575 Middle 2.1 7.9 0.3 0.6 0.4 0.2 1.8 0.2 525 Fourth 0.8 2.5 0.0 1.1 0.4 0.0 1.4 0.3 407 Highest 0.0 2.1 0.1 1.1 0.6 0.0 0.6 0.5 355 Total 3.2 10.3 0.4 0.9 0.4 0.3 2.8 0.0 2,474 Note: Figures are for children born in the period 0-59 months preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international reference population. Children are classified as malnourished if their z-scores are below minus two or minus three standard deviations (-2 SD or -3 SD) from the median of the reference population. Tables based on WHO Child Growth Standards, 2006 are presented in Appendix E. 1Includes children who are below -3 SD Note: Parentheses indicate a figure is based on 25-49 unweighted cases. Children’s and Women’s Nutritional Status | 181 The fact that the under-nutrition increases with increasing birth order is important. For example, about 23 percent of children of birth order six or above are stunted (H/A below -2 SD). Birth interval also is related to the prevalence of stunting. Children who are born with an interval of less than two years are much more prone to be stunted. Of these children, 22 (-2 SD) percent are stunted and 9 (-3SD) percent are severely stunted. Table 12.7 also shows the percentage of children under five years of age classified as malnourished according to the three anthropometric indices by selected socio-economic characteristics. There are particularly striking differences in the percentage classified as stunted according to the mother's level of education. The percentage of children whose mothers have a high school education or higher who are below the -2 SD cut-off point (4 percent) is significantly lower than the percentage of children whose mothers have no education or not completed primary school (23 percent). There are also notable residential and regional differences. Stunting is more common in rural (17 percent) than in urban residences (8 percent). The highest level of stunting is seen in the East region (21 percent) and the lowest levels are in the Central and North regions (5 and 7 percent, respectively). In North East and Southeast Anatolia, 22 percent of children under five are stunted. Similar patterns are observed for the weight-for- height and weight-for-age indices. There has been an improvement in the nutritional status of children in Turkey during the five-year period between the surveys. For example a comparison of the TDHS-2008 findings with the results of the TDHS-2003 indicates that, the proportion stunted in the TDHS-2008 survey is 2 percentage points lower than the level observed in TDHS-2003 (12 percent). Further TDHS-2008 182 | Children’s and Women’s Nutritional Status improvements in the nutritional status of Turkish children are dependent upon reducing the numbers of children exposed to the key risk factors, especially short birth intervals and high parity. An intersectoral and interdiscipliner approach is necessary to discourage mothers from introducing supplementary food too early, to train mothers on the timely introduction of appropriate supplementation, and to assist couples to keep the number of children within their desired limits and ensure optimal birth spacing through effective family planning. 12.7 Nutritional Status of Mothers In order to assess women’s nutritional status, women who had given birth in the five-year period before the interview were weighed and their heights measured using the same equipment used to obtain children’s measurements (i.e., an electronic scale and wooden height board). For all women with a birth in the five-year period before the survey, Table 12.8 presents the distributions as well as the means and standard deviations for three anthropometric indicators for eligible women: height, weight, and the body mass index. The weight and BMI distributions exclude pregnant women and women with a birth within the 2 months prior to the measurement. The table shows that anthropometric measures are available for most of the eligible women, with height or weight measurements missing for 7 percent of respondents. Balanced nutrition during childhood and the adolescent period has a positive impact on linear growth, whereas poor nutrition and experience of a severe illness, particularly in early childhood, can affect growth negatively. In turn, maternal height is useful in predicting the risk of delivery complications since short stature is frequently associated with a small pelvis size. The height below which women are considered to be at risk of such complications is in the range of 140-150 centimeters, with 145 centimeters being the widely accepted cutoff for identifying maternal malnutrition. According to the TDHS-2008 results (Table 12.8), the mean height for mothers was 157 centimeters, almost the same reported in the TDHS-2003. Two percent of mothers were shorter than 145 centimeters and 10 percent were below 150 centimeters. The mean maternal weight was 66 kilograms. Nearly one-third (32 percent) of mothers weighed more than 70 kilograms. The body mass index (BMI) assesses the relation between height and weight and is calculated by dividing the weight in kilograms by the squared height in meters. A body mass index of less than 18.5 is used to identify cases of chronic malnutrition, according to the WHO definition, BMI higher than 25.0 is often used to identify overweight women with problems of overweight and BMI over than 30.0 with obesity. In the TDHS-2008, the mean BMI of non- pregnant mothers was 26.7. The mothers’ BMI fell below 18.5 in less than 2 percent of cases. Fifty-eight percent of the mothers had a BMI above 25.0, including 24 percent who had a BMI of at least 30. Children’s and Women’s Nutritional Status | 183 Table 12.8 Anthropometric indicators of maternal nutritional status Percent distribution and mean and standard deviation for women who had a birth in the five years preceding the survey, by selected anthropometric indicators (height, weight, and body mass index (BMI)), Turkey 2008 Total Distribution Including Missing Respondent height's in cm Mean 156.9 - Standard deviation 5.7 - 130.0-134.9 0.0 0.0 135.0-139.9 0.3 0.2 140.0-144.9 1.5 1.4 145.0-149.9 8.3 7.8 150.0-154.9 26.5 24.7 155.0-159.9 34.0 31.6 160.0-164.9 21.2 19.7 165.0-169.9 6.9 6.4 170.0-174.9 1.1 1.0 175.0-179.9 0.0 0.0 >= 180.0 0.0 0.0 Missing - 7.0 Number of women 2,574 2,768 Respondent's weight in Kg Mean 65.5 - Standard deviation 13.1 - 35.0-39.9 0.2 0.2 40.0-49.9 9.2 8.6 50.0-59.9 27.2 25.4 60.0-69.9 31.8 29.6 >= 70.0 31.6 29.4 Missing - 6.9 Number of women 2,323 2,495 Respondent's BMI in Kg/m2 Mean 26.7 - Standard deviation 5.2 - 12.0-15.9 (Severe) 0.0 0.0 16.0-16.9 (Moderate) 0.4 0.3 17.0-18.4 (Mild) 1.3 1.2 18.5-20.4 (Normal) 8.5 7.8 20.5-22.9 (Normal) 17.1 15.8 23.0-24.9 (Normal) 14.4 13.4 25.0-26.9 (Overwt.) 16.7 15.5 27.0-28.9 (Overwt.) 12.5 11.6 29.0-29.9 (Overwt.) 5.2 4.8 >= 30.0 (Obese) 23.9 22.2 Missing - 7.2 Number of women 2,315 2,495 Note: The weight and BMI measures exclude pregnant women and those who are less than 3 months postpartum. 184 | Children’s and Women’s Nutritional Status Table 12.9 Nutritional status of women by background characteristics Among ever-married women age 15-49 who had a birth in the five years preceding the survey, mean height, percentage under 145 cm, mean body mass index (BMI), and percentage with specific BMI levels, by background characteristics, Turkey 2008 Height BMI (kg/m2) Background characteristic Mean height in cm Percent- age below 145 cm Number of women Mean BMI 18.5- 24.9 (normal) <18. 5 (thin) 17.0- 18.4 (mildly thin) 16.0-16.9 (moderat- ely thin) <16.0 (sever- ely thin) >=25.0 (over- weight or obese) 25.0- 29.9 (over- weight) >=30. 0 (obese) Number of women Age 15-19 157.9 0.8 71 24.3 62.0 1.1 1.1 0.0 0.0 36.9 28.3 8.6 58 20-24 157.2 1.4 567 24.8 53.7 2.3 1.7 0.6 0.0 44.0 30.7 13.3 494 25-29 157.2 0.8 854 26.1 44.7 2.1 1.6 0.5 0.0 53.2 32.1 21.1 763 30-34 157.0 2.0 633 27.3 32.0 1.2 1.0 0.2 0.0 66.8 42.2 24.6 578 35-39 156.0 3.1 321 29.1 24.5 0.4 0.4 0.0 0.0 75.1 32.7 42.4 300 40-44 153.9 7.8 104 29.8 21.4 0.9 0.9 0.0 0.0 77.7 33.2 44.5 99 45-49 (154.7) (2.8) (23) (30.4) (10.7) (1.1) (1.1) (0.0) (0.0) (88.3) (47.2) (41.1) 23 Residence Urban 157.1 1.3 1,888 26.8 39.0 1.3 1.1 0.2 0.0 59.7 35.2 24.5 1,713 Rural 156.3 3.2 686 26.4 42.5 2.6 1.6 0.9 0.0 54.9 32.5 22.4 601 Region West 157.0 2.2 932 26.5 41.1 1.5 1.3 0.2 0.0 57.4 33.3 24.1 850 South 157.2 1.1 341 27.2 34.6 1.3 1.3 0.0 0.0 64.1 39.1 25.0 316 Central 157.0 1.7 579 26.6 39.9 1.9 1.0 0.9 0.0 58.1 35.8 22.4 529 North 156.1 1.3 150 26.2 44.9 3.0 2.0 1.0 0.0 52.1 29.7 22.4 142 East 156.5 1.8 571 26.7 39.8 1.4 1.1 0.2 0.1 58.8 33.7 25.2 478 Region (NUTS1) İstanbul 156.4 2.8 437 26.6 41.3 0.7 0.7 0.0 0.0 57.9 32.4 25.5 391 West Marmara 157.6 0.9 73 26.3 42.5 5.2 5.2 0.0 0.0 52.3 25.7 26.6 68 Aegean 157.3 1.9 326 27.0 38.0 1.6 0.8 0.8 0.0 60.5 37.5 23.0 296 East Marmara 156.7 2.3 234 25.9 43.9 1.8 1.1 0.6 0.0 54.3 34.0 20.4 214 West Anatolia 157.8 0.3 259 26.7 36.3 2.4 1.4 1.0 0.0 61.3 38.7 22.6 239 Mediterranean 157.2 1.1 341 27.2 34.6 1.3 1.3 0.0 0.0 64.1 39.1 25.0 316 Central Anatolia 157.4 1.6 135 26.2 48.7 1.0 1.0 0.0 0.0 50.3 27.6 22.8 127 West Black Sea 156.1 2.9 141 26.6 41.7 3.2 2.9 0.3 0.0 55.1 32.1 22.9 131 East Black Sea 155.9 1.9 57 26.4 44.6 1.7 0.0 1.7 0.0 53.7 30.3 23.4 55 Northeast Anatolia 157.3 1.4 86 25.8 49.5 4.2 3.2 0.6 0.3 46.3 23.3 23.0 74 Central East Anatolia 156.7 2.1 160 26.6 39.5 0.9 0.9 0.0 0.0 59.6 38.3 21.3 138 Southeast Anatolia 156.2 1.8 325 26.9 37.3 0.8 0.6 0.2 0.0 61.9 34.1 27.8 266 Education No/Primary inc. 155.7 3.2 501 27.2 37.6 1.0 0.9 0.1 0.0 61.4 32.7 28.7 421 First level prim. 156.2 2.0 1,282 27.4 34.6 1.2 0.9 0.4 0.0 64.2 36.0 28.2 1,159 Sec. level prim. 157.8 1.5 251 25.1 55.2 1.0 0.6 0.3 0.1 43.9 28.6 15.2 228 High and high. 158.9 0.2 540 25.4 47.2 3.3 2.7 0.6 0.0 49.4 35.2 14.2 507 Wealth quintile Lowest 156.1 3.3 546 26.8 42.6 1.2 1.1 0.1 0.0 56.2 32.2 24.1 463 Second 156.2 2.2 600 26.7 35.9 2.5 1.6 0.8 0.0 61.7 38.3 23.4 527 Middle 156.1 2.6 552 27.0 38.9 0.7 0.1 0.6 0.0 60.4 32.1 28.2 510 Fourth 158.1 0.1 459 26.1 43.3 2.4 2.3 0.1 0.1 54.2 31.9 22.3 419 Highest 158.3 0.2 417 26.7 40.0 1.3 1.3 0.0 0.0 58.7 38.0 20.7 396 Total 156.9 1.8 2,574 26.7 39.9 1.6 1.3 0.4 0.0 58.4 34.5 23.9 2,315 1 Excludes pregnant women and women with a birth in the preceding 2 months Note: Parentheses indicate a figure is based on 25-49 unweighted cases. Table 12.9 shows the nutritional status of mothers by selected background characteristics. Younger women appear to be taller than women age 35 and over. More educated women are taller compared to less educated women. Mothers who have had no education or did not Children’s and Women’s Nutritional Status | 185 complete primary education are, on the average, 3.4 centimeters shorter than those with high school education or more. BMI increases rapidly with age, exceeding 25.0 for the majority of women age 25 and older. Residential variations in the BMI are comparatively small; the mean BMI is highest in the South (27.2) and lowest in the North (26.2). In İstanbul, the percentage of women with a BMI of 25 and higher is 58, which is almost the same as the percentage for all women in Turkey. Body mass index also appears to be related with the educational levels. Mothers with no education had an average BMI of 27 while mothers with high school education or more had an average BMI of 25. Women’s Status | 187 WOMEN’S STATUS 13 İlknur Yüksel, Banu Akadlı Ergöçmen and Pelin Çağatay This chapter highlights information on a range of factors that influence women’s status. First of all, basic data collected on the husband’s age and education during the interviews with TDHS-2008 respondents provide insights into interspousal differences and these indicators can be important in determining familial roles. Information on child care arrangements among women who work and the reasons women have for not working provide insights into the factors that influence women’s employment opportunities. Finally, data on attitudes towards physical violence, controlling behaviors of husbands, and household decision-making roles further contribute to an understanding of the factors determining women’s status. 13.1 Interspousal Differences in Age and Education Large differences in age and education levels between spouses may be associated with differences in relative power. Table 13.1 presents data from the TDHS-2008 on differences in age and education levels between spouses. With regard to interspousal age differences, only five percent of women are two or more years older than their husband. One in every four women is about the same age, i.e., no more than one year older or younger than their spouse. Forty-three percent of currently married women are married to men who are at least five years older than they are and, in the case of 9 percent of the women, the husband is 10 or more years older. Currently married women are, on average, 4.2 years younger than their husband Considering the variation in interspousal ages across subgroups, the mean difference is greatest among young women, particularly among those under age 20 (6.6 years). This group represents a comparatively small proportion of all married women since the overall age at marriage has been rising in Turkey however, it is important to be aware of the age gap in planning programs to further discourage early marriage. Considering regional differences, Northeast Anatolia is well above the national average with a mean age difference between spouses of 5.3 years. Since men typically are better educated than women (see Chapter 2), it is not surprising that the results in Table 13.1 show that husbands have attained, on average, higher educational levels than their wives. Forty-six percent of women are married to men who have more education than they have, and only 13 percent of women are more highly educated than their spouse. Overall, the mean difference in educational attainment between women and their spouses is 1.6 years. 188 | Women’s Status Table 13.1 Differences in age and education between spouses Percent distribution of currently married women by interspousal age and education differences and mean difference in age and education by background characteristics, Turkey 2008 Background characteristic Interspousal age difference Mean difference in age (husband- wife) Number Interspousal education differential Mean difference in education (husband- wife) Number Wife older by 2+ years About the same age Husband older 2- 4 years Husband older 5- 9 years Husband older 10+ years Husband better educated Wife better educated Both have equal education Neither educated Age 15-19 0.0 7.6 16.9 59.6 16.0 6.6 180 46.0 31.9 20.0 2.2 0.8 178 20-24 1.2 11.7 31.3 44.2 11.7 5.3 820 50.4 16.2 32.5 0.8 1.6 815 25-29 3.0 23.6 29.9 35.7 7.9 4.3 1,314 43.4 15.7 39.6 1.3 1.4 1,309 30-34 5.3 23.7 28.2 33.9 8.8 4.1 1,326 43.3 12.5 42.2 2.0 1.4 1,323 35-39 5.5 22.0 29.9 33.5 9.2 4.1 1,262 46.2 9.7 42.2 1.9 1.8 1,258 40-44 7.5 24.1 30.6 28.7 9.1 3.7 1,093 47.8 10.7 38.8 2.7 1.9 1,095 45-49 7.7 24.0 32.9 28.2 7.3 3.6 1,002 49.0 10.2 37.2 3.6 1.9 1,001 Employment Not employed 4.6 21.0 28.6 36.0 9.9 4.4 4,423 49.5 12.4 35.7 2.4 1.9 4,413 Employed 5.7 22.8 32.2 31.7 7.6 3.9 2,572 40.7 13.8 44.1 1.4 1.3 2,567 Number of living children 0 7.5 25.7 26.5 32.5 7.9 3.8 636 40.8 23.3 34.8 1.0 1.0 635 1-2 4.7 20.9 31.5 34.4 8.4 4.2 3,836 43.1 15.2 41.2 0.5 1.3 3,825 3-4 4.7 20.7 29.4 35.7 9.6 4.4 1,936 49.6 7.3 40.9 2.2 2.1 1,935 5+ 4.9 24.9 25.5 32.2 12.4 4.4 588 62.1 5.5 20.0 12.4 3.0 585 Residence Urban 4.7 21.1 30.1 35.0 9.1 4.3 5,283 45.9 14.3 38.1 1.7 1.6 5,268 Rural 5.9 23.4 29.4 32.6 8.7 4.0 1,712 47.4 8.7 40.7 3.2 1.9 1,711 Region West 4.4 20.9 30.9 35.6 8.1 4.2 3,047 41.6 15.2 42.3 0.8 1.3 3,043 South 5.0 19.2 28.6 36.7 10.6 4.7 849 43.4 12.4 41.7 2.5 1.5 847 Central 5.5 23.5 31.4 32.4 7.2 3.8 1,542 44.5 12.1 43.0 0.5 1.4 1,540 North 5.8 26.7 29.4 29.6 8.6 3.7 455 47.8 13.2 38.3 0.6 1.9 453 East 5.7 20.9 26.3 33.9 13.1 4.7 1,103 63.2 8.1 20.9 7.8 3.0 1,097 Region (NUTS1) İstanbul 4.5 22.6 30.7 34.0 8.2 4.0 1,379 39.5 16.2 43.5 0.8 1.2 1,379 West Marmara 4.3 21.4 34.4 32.6 7.4 3.9 308 38.4 14.1 47.0 0.6 1.1 308 Aegean 3.2 18.0 30.1 40.2 8.4 4.6 1,008 42.0 11.9 44.8 1.2 1.3 1,006 East Marmara 5.9 22.7 33.8 30.6 7.0 3.7 722 47.5 14.2 38.3 0.0 1.6 719 West Anatolia 6.5 24.8 31.1 30.7 7.0 3.6 679 41.6 16.3 41.6 0.4 1.1 679 Mediterranean 5.0 19.2 28.6 36.7 10.6 4.7 849 43.4 12.4 41.7 2.5 1.5 847 Central Anatolia 4.3 22.3 28.2 37.3 7.9 4.2 356 49.9 8.9 40.2 1.0 2.0 356 West Black Sea 5.8 26.6 29.0 30.3 8.3 3.7 416 45.8 13.4 40.1 0.7 1.5 412 East Black Sea 5.5 22.5 29.3 33.0 9.7 4.2 180 52.1 12.3 35.0 0.5 2.3 179 Northeast A. 3.5 16.0 26.1 39.1 15.3 5.3 188 60.1 10.7 23.0 6.3 2.6 187 Central East A. 6.5 19.8 23.8 34.3 15.6 4.9 317 64.5 7.1 18.8 9.6 3.3 315 Southeast A. 6.0 23.0 27.6 32.2 11.2 4.3 594 63.8 7.7 21.1 7.4 3.0 591 Education No /prim.inc. 6.7 23.9 26.3 31.3 11.8 4.3 1,270 84.8 2.5 1.4 11.2 4.4 1,265 First level primary 4.9 21.2 30.2 34.7 9.1 4.2 3,671 41.9 4.0 54.0 0.0 1.8 3,664 Sec. and higher 4.2 21.1 31.7 35.8 7.3 4.1 2,054 30.2 35.2 34.5 0.0 (0.4) 2,051 Wealth quintile Lowest 7.4 22.4 27.6 31.7 10.9 4.1 1,092 48.3 8.0 37.0 6.7 2.0 1,090 Second 5.1 23.7 29.4 32.4 9.4 4.1 1,366 45.1 8.5 42.7 3.7 1.8 1,361 Middle 4.3 21.8 31.4 33.9 8.5 4.2 1,473 47.9 12.1 39.0 1.0 1.8 1,470 Fourth 5.0 20.2 29.7 36.2 8.9 4.3 1,512 45.5 13.9 40.3 0.3 1.7 1,507 Highest 3.7 20.5 30.9 36.8 8.1 4.3 1,553 45.1 20.1 34.8 0.0 1.1 1,551 Total 5.0 21.6 29.9 34.4 9.0 4.2 6,996 46.3 12.9 38.8 2.0 1.6 6,980 As regards the variation in interspousal education differences, the gap tends to rise with age and especially parity; 62 percent of women with at least five children are less educated than their spouse compared to 41 percent among women with no children. Regional variations in interspousal education differences are also observed. For instance, women living Women’s Status | 189 in South East and Central East Anatolia are most likely to be less educated than their spouses (64 and 65 percent, respectively) while women in West Marmara and Istanbul are most likely to have equal or more education than their husband (61 and 60 percent, respectively). Not surprisingly, the interspousal gap in education is greatest among women with the least education. Eighty-five percent of women who have never attended school or have not completed the primary level are married to men who better educated than themselves. On the other hand, 70 percent of women with at least second level primary education have attained the same or more years of schooling than their husbands. As the wealth level increases, women are also more likely to have attained the same or more education than their husbands. 13.2 Factors Influencing Women’s Employment In TDHS-2008, data were collected on a number of aspects of women’s work history. The information obtained about the level of women’s employment and about their occupations is presented in detail in Chapter 3. This chapter focuses on the data obtained in the TDHS-2008 that help to better understand the factors that shape women’s employment opportunities, which in turn can be an important influence on her status. 13.2.1 Reasons for Not Working and Quitting the Job Table 13.2 presents the percent distribution of women who were not employed in the 12 months prior to the survey by the main reason that they did not work during the period. Thirty-one percent of women reported child care as the reason for not working, followed by their role as a housewife (22 percent). A fifth of women indicated that the husband or family would not allow them to work. Eight percent of women reported that they did not need work. As expected, the proportion of women who report their main reason for not working as child care is higher among women age 20-34 years than their younger and older counterparts. Regarding regions, child care was most often cited as the reason for not working in the West (35 percent) and least often in the East region (24 percent). The proportion of women citing their role as a housewife as the reason was highest in rural areas and in the East and it decreased with increased education and wealth. The highest proportions of women saying that they were not allowed to work were observed for women age 15-19 and women with no children (32 percent and 29 percent, respectively). In TDHS-2008, additional information was obtained about the work situation from all women for at least six months after age 12. Table 13.3 shows the percent distribution of women who had worked at some time after age 12 and were not working at the time of the survey by the main reason that they had for quitting their last job. The findings indicate that 27 percent of women quit their jobs when they married. As expected, the proportion citing marriage as the main reason they quit a job is higher for younger women and women who are in the lowest education level and wealth quintile than for other women. The results show that the proportion of women who quit their jobs because of pregnancy or to provide child care (11 percent) is the same as the proportion who quit for work-related reasons such as low salary, working without social security, or a shutdown of workplace (11 percent). Ten percent of women who quit their job reported that they left their job because they no longer wanted to work. 190 | Women’s Status Table 13.2. Main reason for not working Percent distribution of ever-married women who were not employed during the 12 months preceding the survey by the main reason for not working, according to background characteristics, Turkey 2008 Main reason for not working Background characteristic Just about to start working Student House- wife Retired Income recipient Family worker Disabled/ Sick Caring for elderly Caring for children Get married Just graduated Does not allow to work Just migrated/ left Does not need to work No job Does not want to work Other Missing Number of women Age 15-19 0.0 0.2 18.0 0.0 0.0 0.0 2.4 0.0 27.0 1.2 0.0 32.3 0.0 11.2 4.2 2.7 0.8 0.0 165 20-24 1.0 0.7 13.4 0.0 0.0 0.2 0.3 0.6 43.3 0.7 0.3 25.4 0.8 6.7 3.4 1.5 1.0 0.6 694 25-29 0.5 0.2 14.8 0.1 0.0 0.0 2.1 0.3 48.6 0.1 0.0 20.5 0.0 6.7 3.4 1.1 1.5 0.1 965 30-34 0.4 0.0 18.5 0.2 0.2 0.2 3.8 0.2 42.9 0.0 0.0 17.2 0.4 7.4 6.3 0.5 1.9 0.0 906 35-39 0.1 0.0 26.5 0.2 0.0 0.1 7.6 1.0 28.1 0.3 0.0 18.6 0.1 7.9 6.6 0.4 1.9 0.6 860 40-44 0.3 0.0 30.6 2.8 0.0 0.2 11.4 1.9 14.3 0.0 0.0 18.4 0.1 8.6 7.6 0.9 2.4 0.4 776 45-49 0.1 0.0 32.6 7.8 0.0 0.3 15.6 1.0 6.0 0.0 0.0 15.6 0.1 9.7 7.6 0.8 2.7 0.1 755 Employment Not employed 0.2 0.1 23.0 1.6 0.0 0.1 6.3 0.7 31.2 0.1 0.1 20.2 0.2 8.1 5.3 0.9 1.6 0.3 4,622 Employed 2.0 0.0 16.1 2.0 0.0 0.8 8.2 1.5 31.3 1.0 0.0 14.4 0.5 6.5 9.9 0.8 4.6 0.2 499 Marital status Married or living together 0.3 0.1 22.8 1.4 0.0 0.1 5.7 0.6 32.1 0.2 0.0 20.1 0.2 8.0 5.4 0.9 1.8 0.3 4,878 Formerly married 1.5 0.0 14.2 5.9 0.0 0.5 22.0 5.0 14.2 1.2 0.0 10.5 1.0 7.1 13.2 0.7 2.7 0.2 242 Number of LC 0 2.3 1.4 18.4 1.6 0.0 0.2 5.3 0.9 7.8 1.3 0.5 28.9 0.4 13.5 11.3 2.4 2.7 1.0 480 1-2 0.3 0.0 17.2 2.3 0.0 0.1 4.5 0.7 38.5 0.2 0.0 19.4 0.3 8.1 5.5 0.7 1.9 0.2 2,737 3-4 0.0 0.0 29.3 1.0 0.1 0.1 8.6 0.5 26.8 0.0 0.0 19.0 0.2 6.6 5.0 1.1 1.4 0.3 1,454 5+ 0.0 0.0 35.3 0.0 0.0 0.3 12.6 1.6 26.1 0.0 0.0 12.9 0.0 5.4 3.3 0.1 2.2 0.1 449 Residence Urban 0.5 0.2 21.1 1.9 0.0 0.0 6.1 0.7 31.4 0.2 0.1 20.7 0.3 8.3 5.4 1.0 1.9 0.2 4,203 Rural 0.1 0.0 27.9 0.4 0.0 0.8 8.2 0.9 30.5 0.3 0.0 14.7 0.1 6.2 7.2 0.6 1.6 0.5 917 Region West 0.5 0.2 16.5 2.1 0.0 0.1 7.4 0.7 35.4 0.3 0.0 19.3 0.2 8.0 6.3 1.0 1.7 0.3 2,187 South 0.1 0.0 28.5 1.2 0.0 0.0 8.4 0.9 29.0 0.1 0.0 17.9 0.3 5.5 5.5 0.7 1.7 0.3 633 Central 0.5 0.2 22.6 2.4 0.2 0.4 5.0 1.0 30.1 0.0 0.2 19.1 0.4 10.7 4.3 0.9 1.7 0.2 1,156 North 0.7 0.0 15.7 0.8 0.0 0.7 6.3 0.9 32.8 0.6 0.2 16.1 0.2 8.7 13.0 0.8 2.5 0.0 223 East 0.0 0.0 33.4 0.1 0.0 0.1 4.9 0.4 23.9 0.2 0.0 22.9 0.1 5.6 4.6 1.0 2.3 0.3 921 Region (NUTS 1) İstanbul 0.5 0.3 22.0 2.1 0.0 0.0 6.8 0.8 33.7 0.5 0.0 18.5 0.3 7.5 5.2 0.5 1.0 0.3 1,120 West Marmara 0.3 0.0 18.7 2.5 0.0 0.0 9.5 1.3 32.3 0.0 0.0 18.3 0.0 3.0 11.3 0.0 2.7 0.0 211 Aegean 0.0 0.0 8.3 2.3 0.0 0.0 8.2 0.9 40.5 0.0 0.0 19.8 0.3 8.0 7.1 1.1 2.9 0.6 602 East Marmara 1.1 0.4 11.2 1.1 0.0 0.3 6.7 1.1 34.0 0.0 0.0 23.6 0.4 11.0 5.4 2.0 1.9 0.0 448 West Anatolia 0.8 0.3 26.7 4.1 0.4 0.1 3.8 0.5 30.1 0.0 0.4 15.4 0.4 11.6 2.6 1.0 1.5 0.1 559 Mediterranean 0.1 0.0 28.5 1.2 0.0 0.0 8.4 0.9 29.0 0.1 0.0 17.9 0.3 5.5 5.5 0.7 1.7 0.3 633 Central Anatolia 0.2 0.0 19.5 0.9 0.0 1.1 4.2 0.5 29.8 0.0 0.0 22.5 0.3 13.1 6.1 0.6 0.9 0.2 295 West Black Sea 0.3 0.0 20.7 0.8 0.0 0.0 7.4 1.6 27.5 0.6 0.0 17.6 0.2 7.7 10.8 1.5 2.9 0.3 263 East Black Sea 2.4 0.0 12.5 0.5 0.0 2.4 9.2 0.0 36.6 0.0 0.5 15.4 0.0 10.1 7.9 0.5 2.1 0.0 70 Northeast Anatolia 0.0 0.2 22.4 0.2 0.0 0.0 3.9 0.3 27.5 0.2 0.0 23.4 0.4 8.9 8.9 0.5 2.8 0.5 141 Central East Anatolia 0.0 0.0 48.6 0.0 0.0 0.2 3.4 0.6 13.0 0.2 0.0 23.2 0.0 2.7 5.0 0.9 2.1 0.2 283 Southeast Anatolia 0.1 0.0 28.0 0.2 0.0 0.0 5.7 0.3 29.2 0.3 0.0 22.6 0.1 6.3 3.3 1.2 2.3 0.4 496 Education No 0.0 0.0 33.0 0.1 0.0 0.3 10.2 0.7 22.2 0.1 0.0 21.5 0.0 4.2 4.3 0.5 2.3 0.5 1,010 First level primary 0.1 0.0 23.0 0.8 0.0 0.2 7.2 0.8 31.7 0.3 0.0 20.4 0.4 7.1 5.4 0.9 1.6 0.1 2,659 Sec.level prim. and higher 1.2 0.5 13.8 4.4 0.1 0.0 2.5 0.7 36.7 0.1 0.2 16.7 0.1 12.1 7.3 1.1 2.1 0.4 1,451 Wealth quintile Lowest 0.0 0.0 29.4 0.3 0.0 0.6 11.0 1.0 33.4 0.2 0.0 14.4 0.1 2.2 5.2 0.3 1.6 0.3 696 Second 0.1 0.0 25.8 0.3 0.0 0.2 7.0 0.7 31.9 0.1 0.0 21.6 0.6 4.2 5.5 0.8 1.0 0.3 985 Middle 0.2 0.0 21.6 0.9 0.0 0.1 8.1 0.9 33.1 0.2 0.0 20.0 0.4 5.5 5.3 1.2 2.4 0.2 1,155 Fourth 0.3 0.2 20.0 1.5 0.0 0.0 5.3 1.0 30.1 0.5 0.2 23.9 0.0 8.4 5.8 0.9 1.7 0.3 1,216 Highest 1.3 0.4 18.1 4.9 0.2 0.1 2.7 0.3 28.5 0.0 0.0 15.8 0.1 17.2 6.6 1.0 2.5 0.2 1,068 Total 0.4 0.1 22.4 1.7 0.0 0.2 6.5 0.8 31.2 0.2 0.0 19.6 0.2 7.9 5.7 0.9 1.9 0.3 5,120 Note: Row total is 100 Women’s Status | 191 Table 13.3. Main reason for quitting job Percent distribution of women who worked for at least 6 months after age 12 and were not working at the time of the survey according to the main reason for quitting the last job by background characteristics Turkey 2008 Main reason for quitting job Background characteristic Pregnant/ child care House- work Sick/ disabled Appoint- ment of partner Just moved/ migrated Opposition of partner/ elderly Not need to work Did not want to work Worked unpaid Dis- missed Sick/ elderly care in family Work related problems Marriage Retire- ment To find a better job Sea- sonal/ Tempo- rary Other Missing Number of women Age 15-19 1.7 0.0 1.0 0.0 3.9 3.1 0.6 9.2 0.0 1.6 2.5 5.2 56.6 0.0 2.8 1.5 10.2 0.0 69 20-24 10.1 0.1 1.1 0.0 4.2 7.8 0.8 11.2 0.9 0.6 3.1 8.2 36.9 0.0 8.6 2.0 4.4 0.0 417 25-29 10.3 1.1 2.5 0.3 2.6 3.4 2.1 11.7 0.0 4.5 2.0 13.2 28.0 0.0 12.1 1.3 4.7 0.3 876 30-34 15.0 1.1 2.3 0.7 4.5 2.4 0.7 11.1 0.4 2.6 2.2 12.1 26.3 0.1 12.1 1.8 4.5 0.2 806 35-39 11.0 0.2 5.8 1.4 7.1 2.5 0.6 12.6 0.4 3.9 2.0 11.0 25.8 0.0 8.4 3.1 3.8 0.4 653 40-44 9.7 1.3 7.2 0.5 8.7 2.2 1.5 7.3 0.0 3.7 3.0 11.4 22.2 2.9 11.9 1.7 4.6 0.3 695 45-49 8.1 1.4 8.8 0.9 8.7 2.8 1.5 7.3 0.2 3.8 3.3 7.9 21.2 8.4 7.4 2.0 6.2 0.3 667 Employment Not employed 11.3 1.0 5.2 0.3 5.7 3.5 1.6 11.8 0.3 2.7 2.9 8.5 29.8 2.4 6.0 1.5 5.3 0.4 2,577 Employed 9.7 0.8 3.6 1.2 6.2 2.6 0.8 7.8 0.1 4.4 1.9 14.6 21.5 1.0 17.1 2.6 4.1 0.1 1,607 Marital status Married or living together 11.1 1.0 4.3 0.6 5.8 3.2 1.3 10.5 0.3 3.2 2.6 10.3 27.5 1.6 9.8 1.9 4.7 0.2 3,856 Formerly married 6.4 0.0 7.6 0.9 6.0 2.7 1.3 7.2 0.0 4.6 1.7 17.6 15.9 4.0 15.8 1.9 6.1 0.5 328 Number of living children 0 0.9 0.5 2.5 0.4 4.7 3.2 0.9 12.9 0.0 3.9 2.3 14.0 26.2 1.5 18.9 1.5 5.8 0.1 494 1-2 12.0 0.5 3.0 0.7 4.3 3.1 1.3 10.7 0.3 3.6 2.5 11.9 26.2 1.9 10.9 2.2 4.7 0.2 2,633 3-4 12.5 2.1 8.2 0.5 9.0 3.6 0.9 8.9 0.3 2.9 2.7 7.9 27.1 1.8 5.1 1.5 4.3 0.6 880 5+ 9.7 1.7 15.2 0.0 16.0 2.7 3.6 2.8 0.0 0.3 2.3 2.1 31.4 1.6 2.0 1.9 6.1 0.5 177 Residence Urban 10.7 1.0 4.1 0.7 5.9 3.3 1.2 10.9 0.2 3.6 2.5 11.7 24.7 2.1 10.5 1.7 4.9 0.3 3,542 Rural 10.7 0.6 7.2 0.0 5.4 2.4 1.8 6.2 0.4 1.7 2.5 6.3 37.5 0.4 8.9 3.2 4.4 0.3 641 Region West 12.4 1.0 4.1 0.7 6.0 3.6 0.8 10.9 0.3 4.1 2.3 12.7 22.7 1.8 10.5 1.6 4.4 0.2 2,435 South 9.8 0.5 6.3 0.5 4.8 3.6 1.0 10.0 0.6 1.2 3.2 7.4 35.5 1.3 8.2 2.9 3.3 0.0 454 Central 8.2 0.9 3.7 0.7 6.3 1.8 2.0 11.7 0.0 3.9 1.8 10.0 24.3 3.1 12.1 2.3 7.2 0.2 672 North 7.5 0.2 4.8 0.3 8.0 1.6 0.7 5.3 0.4 1.9 2.8 7.4 41.7 1.1 11.5 0.5 4.0 0.4 329 East 7.6 1.4 7.5 0.6 3.2 4.3 4.3 7.2 0.0 1.1 4.5 7.4 33.7 0.5 5.3 4.3 6.2 1.0 294 Region (NUTS 1) İstanbul 14.9 0.2 3.4 0.5 5.1 3.8 0.5 9.3 0.2 3.6 2.4 13.4 23.9 1.7 10.5 1.4 5.2 0.0 1,231 West Marmara 10.0 0.3 6.5 0.0 5.8 2.4 1.3 9.0 0.0 6.7 3.1 11.2 24.5 2.1 7.4 5.1 4.4 0.3 225 Aegean 10.9 2.2 5.0 1.2 7.5 3.5 1.4 13.1 0.6 3.5 2.5 10.3 18.6 2.3 11.5 1.1 4.1 0.6 598 East Marmara 9.3 1.6 3.9 0.6 6.7 2.9 0.8 14.0 0.0 3.7 1.4 13.1 24.5 1.3 10.4 1.9 3.6 0.3 577 West Anatolia 5.8 0.8 3.2 0.8 3.9 0.8 2.6 10.1 0.0 6.6 0.9 9.8 22.7 5.3 16.0 1.5 8.8 0.2 307 Mediterranean 9.8 0.5 6.3 0.5 4.8 3.6 1.0 10.0 0.6 1.2 3.2 7.4 35.5 1.3 8.2 2.9 3.3 0.0 454 Central Anatolia 6.8 1.4 4.1 1.2 8.6 5.8 3.3 10.7 0.0 2.7 3.3 10.7 22.6 2.5 8.2 2.7 4.9 0.6 103 West Black Sea 8.0 0.3 4.7 0.6 10.0 1.0 0.3 6.2 0.2 1.3 3.3 9.3 39.2 0.8 9.6 0.6 4.2 0.3 275 East Black Sea 7.7 0.6 5.5 0.0 5.1 2.8 1.2 6.0 0.6 2.2 2.2 5.0 40.9 1.2 13.0 1.4 4.4 0.3 122 Northeast Anatolia 4.7 0.0 12.4 0.0 6.1 4.1 4.0 4.0 0.0 1.3 2.7 11.3 36.5 0.7 2.0 1.4 8.8 0.0 36 Central East Anatolia 5.6 0.8 5.2 2.4 4.1 7.6 2.3 7.8 0.0 0.6 3.1 9.5 31.8 0.8 9.4 1.4 7.6 0.0 77 Southeast Anatolia 9.2 1.9 7.0 0.0 2.3 3.0 5.3 7.7 0.0 1.3 5.6 5.9 34.6 0.3 4.3 5.0 5.2 1.6 177 Education No edu./Prim.incomplete 10.3 2.6 10.6 0.1 7.8 3.6 2.1 4.2 0.0 1.9 2.4 4.1 36.5 0.4 5.1 2.8 4.6 0.9 430 First level p. 10.2 1.1 5.5 0.5 8.0 4.0 1.0 9.6 0.5 2.3 3.2 9.0 30.8 1.0 7.1 2.4 3.4 0.3 1,982 Sec.level prim. and higher 11.3 0.3 2.1 0.9 3.0 2.2 1.4 12.3 0.0 4.9 1.7 14.6 19.5 3.0 14.9 1.2 6.4 0.1 1,772 Wealth quintile Lowest 10.7 0.6 11.5 0.0 7.6 3.1 1.3 3.8 0.3 0.5 3.6 4.4 37.2 0.0 8.0 3.6 3.8 0.0 354 Second 7.5 1.9 4.3 0.2 6.8 3.8 1.1 9.4 0.5 2.3 3.5 8.4 36.9 0.3 6.5 2.4 4.1 0.3 610 Middle 11.4 0.5 6.7 0.1 5.8 3.2 1.1 12.5 0.5 3.5 2.6 7.0 31.1 1.7 5.9 2.3 3.4 0.5 810 Fourth 9.6 1.1 4.6 0.6 6.9 3.8 1.7 9.3 0.1 3.3 1.7 16.0 23.5 1.2 10.1 1.4 4.6 0.4 1,120 Highest 12.8 0.6 1.4 1.4 4.0 2.3 1.0 11.8 0.1 4.6 2.3 11.8 18.7 3.7 15.4 1.5 6.5 0.0 1,290 Total 10.7 0.9 4.6 0.6 5.8 3.2 1.3 10.2 0.3 3.3 2.5 10.9 26.6 1.8 10.2 1.9 4.8 0.3 4,184 Note: Row total is 100 192 | Women’s Status 13.3 Child Care while Working Of women who worked in the 12 months prior to the survey, 67 percent had no children under 6 years of age. For the 33 percent of women who have one or more children under age 6, child care is an important issue in participating in the labor force. Table 13.4 focuses on the primary child care provider for children under six years of age that these women rely on when they are working. The persons women rely on to provide this care both reflect the presence of intra-family solidarity in childrearing and underline the patriarchal structure of Turkish society. Relatives provide child care for the majority of the children. In one-fourth of the cases, it is the husband’s mother who takes care of the children under 6 years of age while their mother is at work, 11 percent are cared for by the woman’s own mother, and 7 percent by other adult relatives including the husband. A similar percentage is cared for by another child within the household; in almost all of these cases, the caregiver is a girl. In 30 percent of the cases, the mother takes care of children indicating that she is either taking the child with her to work or she is working at home. The proportions of children in kindergarten or cared for by a baby sitter are very small (7 percent and 5 percent, respectively). The proportion of working women saying that they themselves care for their child while working is higher among women with no or incomplete primary education, women in the East, women in Northeast Anatolia, women working in the agriculture and service sectors, and women in the middle or lower wealth quintiles than among women in other subgroups. Urban women, women with a high school or higher education, women from Istanbul and East Marmara, and women in the highest wealth quintiles are most likely to rely on babysitters or to say the child is enrolled in kindergarten. Women’s Status | 193 13.4 Child care while working Percent distribution of working women who have a child under age 6 according to the person who cares for the youngest child under age 6 while mother is at work by background characteristics, Turkey 2008 Person looks after youngest child when respondent at work Background characteristic No children under 6 years One or more children Herself Husband Female children Respondent's mother Mother in law Male children Other relatives Baby- sitter Kinder- garden Not worked since last birth Other Missing Total Number of women Residence Urban 68.8 31.2 29.4 3.6 3.8 16.1 16.8 0.4 3.3 8.3 10.1 2.6 3.9 1.9 100.0 1,405 Rural 65.1 34.9 31.8 1.0 10.2 3.8 36.7 0.7 6.5 0.7 1.8 0.7 4.2 1.8 100.0 870 Education No . 67.2 32.8 44.0 1.4 14.8 0.5 26.7 1.2 5.8 0.0 0.0 0.0 4.1 1.6 100.0 348 First level p. 70.7 29.3 35.5 2.9 8.3 4.4 30.7 0.7 5.9 1.8 1.6 1.0 5.0 2.2 100.0 1,172 Sec. level p. 73.4 26.6 35.0 2.7 4.4 15.5 23.0 0.0 2.6 0.0 7.5 4.2 3.8 1.3 100.0 137 Higher 60.0 40.0 16.3 2.4 0.1 24.4 16.5 0.0 2.6 13.2 16.7 3.6 2.7 1.5 100.0 619 Region West 73.7 26.3 23.5 2.9 5.0 16.1 21.3 0.5 4.0 6.6 10.2 1.4 5.4 3.1 100.0 1,060 South 66.2 33.8 36.5 1.2 6.5 9.1 24.8 0.0 6.9 5.5 6.2 0.0 2.1 1.2 100.0 258 Central 64.4 35.6 24.0 1.7 4.9 12.2 33.0 1.2 2.3 3.7 5.8 5.3 5.1 0.9 100.0 475 North 64.7 35.3 35.9 5.4 3.3 5.8 26.2 0.4 10.4 6.4 4.5 0.4 0.9 0.5 100.0 253 East 48.9 51.1 47.2 1.4 14.0 2.9 21.0 0.0 3.4 3.1 1.6 0.6 3.0 1.8 100.0 229 Region (NUTS 1) İstanbul 74.5 25.5 18.6 6.2 3.1 21.7 12.4 0.0 6.2 9.3 9.3 0.0 6.2 6.9 100.0 368 West Marmara 81.4 18.6 25.5 0.0 0.0 12.3 38.7 0.0 8.1 0.0 9.2 3.1 3.1 0.0 100.0 116 Aegean 70.4 29.6 20.5 1.7 5.8 18.0 37.5 0.0 1.7 3.4 5.6 2.8 1.5 1.5 100.0 462 East Marmara 68.3 31.7 28.1 0.0 5.1 8.4 20.1 1.4 3.7 6.6 13.5 1.6 11.5 0.0 100.0 309 West Anatolia 67.0 33.0 41.6 0.0 0.0 5.3 16.7 1.2 1.4 7.4 8.6 11.5 5.3 1.2 100.0 159 Mediterranean 66.2 33.8 36.5 1.2 6.5 9.1 24.8 0.0 6.9 5.5 6.2 0.0 2.1 1.2 100.0 258 Central A. 66.0 34.0 12.2 7.4 8.9 13.8 33.2 5.7 3.2 0.0 4.9 2.5 4.9 3.2 100.0 76 West Black A. 64.2 35.8 27.3 4.2 9.3 9.5 30.7 0.0 8.1 4.7 4.9 0.0 0.7 0.7 100.0 185 East Black Sea 62.9 37.1 38.8 6.9 2.5 4.7 23.5 0.8 9.1 8.0 3.9 0.8 0.8 0.0 100.0 116 Northeast A. 52.2 47.8 53.8 1.0 4.0 4.2 19.0 0.0 1.0 0.0 2.1 1.0 5.0 8.9 100.0 50 Central East A 48.9 51.1 43.7 0.0 15.5 0.0 18.4 0.0 9.8 7.8 2.0 0.0 2.9 0.0 100.0 44 Southeast A. 46.3 53.7 46.1 2.0 16.9 3.4 22.6 0.0 2.1 2.7 1.3 0.6 2.4 0.0 100.0 132 Economic sector Agriculture 66.3 33.7 31.8 0.9 10.8 2.8 38.3 0.8 6.2 0.0 1.0 0.7 4.1 2.6 100.0 976 Industry 75.2 24.8 17.9 0.0 3.6 29.0 30.3 0.0 2.2 0.0 9.2 3.9 3.7 0.0 100.0 156 Service 67.3 32.7 30.4 4.2 2.8 16.4 12.7 0.3 3.5 10.3 11.4 2.7 4.0 1.4 100.0 1,143 Wealth quintile Lowest 57.7 42.3 39.7 1.0 15.4 1.3 33.8 0.4 3.4 0.0 0.4 0.0 3.2 1.4 100.0 456 Second 66.1 33.9 35.3 1.9 5.7 6.2 33.0 1.8 8.1 0.0 1.7 1.5 2.8 2.1 100.0 443 Middle 71.3 28.7 38.2 0.6 6.7 10.2 21.0 0.3 4.4 3.4 2.4 1.9 9.4 1.4 100.0 402 Fourth 75.4 24.6 27.1 3.3 1.0 17.8 18.5 0.0 6.1 5.8 10.9 0.6 2.9 5.9 100.0 400 Highest 67.8 32.2 13.5 5.4 0.2 22.1 14.9 0.0 2.5 15.7 17.6 4.7 3.1 0.1 100.0 574 Total 67.4 32.6 30.4 2.5 6.4 11.0 24.9 0.5 4.6 5.2 6.7 1.9 4.0 1.8 100.0 2,275 194 | Women’s Status 13.4 Women’s Attitudes towards Being Subject to Physical Violence and Controlling Behaviors Domestic violence is one form of violation of human rights of women. Tolerance as well as the experience of domestic violence form significant barriers to the empowerment of women and women’s autonomy in all spheres of social life and have adverse consequences for women’s health, health-seeking behavior, and the health of their children. In TDHS-2008, women were asked whether a husband would be justified in beating his wife in each of the following situations: “if she burns the food”, “if she argues with him”, “if she neglects the children”, “if she refuses to have sex with him”, “if she does not cook food”, “if she neglects the housework” and “if she wastes money”. Table 13.5 presents differences by background characteristics in the percentages of ever-married women who agreed that wife beating would be justified in each of these circumstances. Overall, 25 percent women accepted at least one of the situations as a justification for physical violence. This represent a decrease from the TDHS-2003 when 39 percent agreed that physical violence was justified in at least one of the situations. With regard to the specific situations, women most often agree that physical violence is justified if woman wastes money or neglects the children (15 percent each) and are least likely to say that violence is justified if a wife burns the food. There are notable differences in the proportions agreeing that physical violence may be justified by background characteristics. For example, while 36 percent of women in rural areas think that physical violence would be justified in at least one of the circumstances specified, the proportion drops to 21 percent for urban women. For both urban and rural women, “wastes money” is the most often agreed reason for violence. Forty percent of women in the East agree that physical violence is justified in at least one of the circumstance compared with 18 percent in the West. Regarding the NUTS 1 regions, the highest proportion agreeing that physical violence may sometimes be justified is observed in Central East Anatolia (45 percent) and the lowest proportion in West Marmara region (12 percent). The percentage agreeing that physical violence is justified in at least one of the circumstances decreases with over 40 percent in the lowest education and wealth categories to less than 10 percent in highest categories. Women’s Status | 195 Table 13.5 Attitude toward physical violence Percentage of ever-women age 15-49 who agree that a husband is justified physical violence for specific reasons by background characteristics, Turkey 2008 Husband is justified physical violence if she: Background characteristic Burns the food Argues with him Neglects the children Refuses to have sexual intercourse with him Does not cook food Neglects the housework Wastes money Percentage who agree with at least one specified reason Number of women Age 15-19 5.3 17.4 15.9 6.4 4.1 11.5 16.7 29.6 183 20-24 1.2 11.3 11.6 4.2 3.5 8.9 13.1 23.5 836 25-29 1.8 9.5 13.5 3.6 3.3 8.7 12.4 20.7 1,353 30-34 1.8 8.6 13.1 4.2 3.6 8.2 13.5 21.7 1,379 35-39 2.2 10.7 14.4 5.3 4.4 10.1 15.1 25.0 1,336 40-44 3.4 12.0 16.9 7.7 6.6 13.9 19.5 28.3 1,202 45-49 4.1 14.0 17.0 7.2 8.5 13.0 18.6 29.0 1,115 Employment (last 12 months) Not employed 2.5 10.6 14.5 5.4 4.7 10.8 15.6 24.4 4,629 Employed 2.4 11.7 14.6 5.3 5.3 9.9 15.0 25.1 2,776 Marital status Married or living together 2.5 11.0 14.6 5.4 4.8 10.5 15.4 24.7 6,999 Divorced/separated/widowed 1.4 10.8 14.2 4.7 6.8 8.9 14.1 23.7 406 Number of living children 0 1.9 7.6 12.4 3.2 2.1 7.9 11.3 18.9 698 1-2 1.1 7.5 10.4 3.2 2.3 6.8 10.6 18.1 4,062 3-4 2.7 14.6 18.4 6.7 7.0 13.5 21.1 32.8 2,023 5+ 11.3 26.3 30.9 17.9 18.0 27.2 32.7 47.7 621 Residence Urban 1.5 8.8 12.1 4.2 3.4 8.3 12.9 20.9 5,615 Rural 5.5 18.1 22.1 9.1 9.8 17.1 23.0 36.4 1,790 Region West 1.1 7.3 11.1 3.8 2.9 6.9 10.9 18.3 3,252 South 2.5 11.8 16.3 5.8 7.0 12.7 16.7 25.5 894 Central 1.7 10.5 10.3 3.9 2.9 7.7 16.4 24.5 1,631 North 1.8 14.1 19.1 6.1 6.0 12.3 19.8 31.1 477 East 7.7 20.4 26.9 11.4 11.4 21.8 23.7 39.5 1,151 Region (NUTS 1) İstanbul 1.0 7.8 11.3 4.4 3.2 7.2 11.9 18.4 1,491 West Marmara 1.1 4.8 7.0 2.1 1.6 5.6 7.8 11.7 327 Aegean 1.0 8.9 10.1 3.2 3.4 6.7 11.3 20.4 1,065 East Marmara 1.8 6.5 11.2 2.7 2.0 6.1 10.7 19.2 759 West Anatolia 0.7 7.7 8.5 2.7 1.4 5.6 12.9 19.3 717 Mediterranean 2.5 11.8 16.3 5.8 7.0 12.7 16.7 25.5 894 Central Anatolia 2.7 13.7 14.5 4.9 3.9 9.2 19.6 31.2 371 West Black Sea 2.8 15.4 20.8 9.0 7.5 15.6 25.6 37.0 448 East Black Sea 1.5 14.3 16.2 5.9 4.8 12.2 17.0 27.1 186 Northeast Anatolia 8.5 20.2 25.6 11.0 11.7 23.3 24.1 36.8 191 Central East Anatolia 9.4 20.7 32.4 12.9 15.8 25.2 27.3 45.3 327 Southeast Anatolia 6.6 20.3 24.5 10.8 9.1 19.5 21.7 37.4 628 Education No education/Prim. Incomp. 8.6 25.1 29.8 13.9 14.9 24.3 30.3 46.9 1,358 First level primary 1.6 10.8 14.8 4.9 3.9 10.4 16.5 26.6 3,840 Second level primary 0.7 6.8 6.9 1.7 1.1 4.0 7.4 13.8 643 High school and higher 0.0 1.3 3.7 0.6 0.3 1.2 2.8 5.3 1,564 Wealth quintile Lowest 8.0 23.6 28.2 13.4 14.3 23.6 27.6 42.9 1,154 Second 4.2 16.0 19.7 7.4 7.1 14.7 22.0 34.6 1,429 Middle 1.4 11.5 15.2 4.6 3.1 10.3 16.7 27.8 1,559 Fourth 0.4 6.0 10.9 2.8 2.1 6.5 10.3 17.9 1,618 Highest 0.2 2.4 3.5 1.3 0.9 1.6 4.7 7.1 1,645 Total 2.5 11.0 14.5 5.4 4.9 10.4 15.4 24.7 7,405 196 | Women’s Status In TDHS-2008, women were also asked about selected controlling behaviors that they had experienced in their relations with their (last) husbands. The behaviors about which they were asked included: “preventing the woman from seeing female friends”, “limiting her contact with her family”, “insisting on knowing where she is”, “distrusting her with money” and “accusing her being unfaithful”. They were asked to categorize the frequency with which they experienced each behavior (i.e., “often”, “sometimes” and “never”). Table 13.6 shows that the controlling behavior women most often experienced involved the husband insisting on knowing where the woman is and preventing the woman from seeing female friends (37 percent and 11 percent, respectively). Table 13.7 presents variations across subgroups in the percentages of women reporting that their husband had often or sometimes exhibited the five controlling behaviors. Almost one in four women reported that they are faced with at least one controlling behavior by their husbands. The percentage of women reporting that they experienced the various controlling behaviors generally decreases with the women’s age. The percentages experiencing the behaviors are uniformly higher for the divorced/separated women than their married counterparts. Regarding the regional differentials, the percentages experiencing the specific controlling behaviors were highest in the East, except for “accusing her of being unfaithful”. Table 13.6. Frequency of some controlling behaviors Percentage of ever-married women age 15-49 as regards some controlling behaviors, Turkey 2008 Often Sometimes Never Not appl./Not suitable Missing Number of women Preventing her from seeing female friends 3.8 6.7 89.2 0.1 0.1 7,405 Limiting her contact with her family 3.0 3.8 93.0 0.2 0.1 7,405 Insisting on knowing where she is 24.9 12.5 62.3 0.3 0.1 7,405 Distrusting her with money 2.6 3.5 93.5 0.3 0.1 7,405 Accusing her of being unfaithful 1.3 2.5 95.8 0.1 0.4 7,405 Women’s Status | 197 Table 13.7. Controlling behaviors Percentage of ever-married women age 15-49 who experienced some controlling behaviors from their husband by background characteristics, Turkey 2008 Background characteristic Prevent from seeing female friends Limit to contact with her family Insist on knowing Distrust with money Accuse of being unfaithful Number of women Age 15-19 18.2 5.9 44.1 5.6 4.0 183 20-24 16.3 9.3 53.1 6.7 5.1 836 25-29 11.6 7.1 38.7 5.2 4.9 1,353 30-34 9.1 6.9 36.4 6.2 2.5 1,379 35-39 10.9 6.4 33.1 6.7 3.4 1,336 40-44 8.7 7.2 32.7 6.2 3.4 1,202 45-49 7.2 4.6 34.2 5.6 3.6 1,115 Employment (last 12 months) Not employed 10.9 6.9 38.2 6.4 3.9 4,629 Employed 10.0 6.7 36.0 5.5 3.5 2,776 Marital status Married or living together 9.5 5.6 36.5 5.4 3.2 6,999 Divorced/separated/widowed 29.2 27.1 51.9 17.1 13.8 406 Number of living children 0 12.8 7.5 45.9 7.0 3.7 698 1-2 10.0 5.6 34.8 5.7 4.2 4,062 3-4 10.3 8.0 38.2 6.5 2.9 2,023 5+ 12.7 9.8 41.5 6.3 3.5 621 Residence Urban 11.2 7.0 37.7 6.3 4.2 5,615 Rural 8.7 6.0 36.4 5.4 2.3 1,790 Region West 10.7 6.0 34.6 6.0 4.1 3,252 South 7.1 5.9 37.0 4.7 2.4 894 Central 10.6 6.8 37.9 6.4 3.8 1,631 North 9.9 5.5 37.5 5.4 3.6 477 East 13.1 10.2 44.7 7.1 3.9 1,151 Region (NUTS 1) İstanbul 13.2 7.1 35.7 6.6 5.1 1,491 West Marmara 6.5 3.6 29.9 6.0 4.4 327 Aegean 7.3 5.3 33.4 3.9 2.6 1,065 East Marmara 10.6 5.1 33.0 6.1 3.2 759 West Anatolia 11.1 6.9 37.4 7.4 4.4 717 Mediterranean 7.1 5.9 37.0 4.7 2.4 894 Central Anatolia 12.5 6.4 43.3 8.3 4.3 371 West Black Sea 9.6 8.0 42.2 5.7 2.9 448 East Black Sea 12.3 5.2 36.5 5.9 4.0 186 Northeast Anatolia 14.1 8.9 47.1 6.2 3.5 191 Central East Anatolia 13.2 11.0 40.5 7.0 3.4 327 Southeast Anatolia 12.9 10.3 46.2 7.4 4.2 628 Education No education/Prim.incomp. 13.8 9.6 40.8 8.4 4.6 1,358 First level primary 10.6 6.8 36.7 5.7 3.6 3,840 Second level primary 12.3 7.3 40.0 7.0 4.0 643 High school and higher 7.1 4.0 34.9 4.4 3.2 1,564 Wealth quintile Lowest 12.0 9.3 42.2 7.4 3.7 49.2 Second 12.2 7.6 41.0 6.4 4.3 47.9 Middle 10.9 5.8 37.5 6.4 3.7 42.4 Fourth 10.3 6.4 35.3 5.7 3.6 41.8 Highest 8.1 5.6 32.7 4.7 3.3 37.0 Total 10.6 6.8 37.4 6.1 3.7 7,405 198 | Women’s Status 13.5 Attitudes towards Gender Roles In order to better understand attitudes towards gender roles, women were asked in the TDHS-2008 whether they agreed or disagreed with a series of nine statements about women’s roles in the household, society and political life and about the education of male and female children. The statements for which they were asked if they agreed included: “the important decisions in the family should be made only by men of the family”, “a woman shouldn’t argue with her partner even if she disagrees with him”, “it is better to educate a son than a daughter”, “men are wiser” and “women should be virgin when they get married”. The statements with which they were asked if they disagreed included: “men should also do the housework like cooking, washing, ironing, and cleaning”, “a married woman should work outside the home if she wants to”, “a woman may go anywhere she wants without her partner’s permission” and “women should be more involved in politics”. Table 13.8 presents the percentages of women who agreed or disagreed with the various statements by background characteristics of women. Higher levels of agreement with the first set of five statements and higher levels of disagreement with the second set of four statements are assumed to reflect a greater tendency to defer to men and to traditional roles for women. Overall, looking at the first set of statements, women were most likely to agree with the statements “women should be virgin when they get married” (80 percent) and “a woman shouldn’t argue with her partner even if she disagrees with him” (41 percent) and least likely to agree with the statement that “it is better to educate a son than a daughter” (12 percent). Considering the second set of statements, women were most likely to disagree with that a woman may go anywhere she wants without her partner’s permission” (69 percent) and least likely to disagree that “a married woman should work outside the home if she wants to” (8 percent). Although the variations are not uniform, the proportions agreeing with the first five statements or disagreeing with the second four statements, i.e., showing the greatest deference to male roles and traditional values, tended to be highest among women with five or more children, rural women, women in the East region, women with no or incomplete primary education, and women in the lowest wealth quintile. Women’s Status | 199 Table 13.8. Attitude towards gender roles Percentage of ever-married women age 15-49 who agree and disagree with the specific statements about gender roles by background characteristics, Turkey 2008 Agree Disagree Background characteristic Important family decisions should be made only by men Women should not argue with husband even if she disagrees Better to educate son rather than daughter Men are wiser Women should be virgin when they get married Men should also do housework Married women should work outside if she wants to Women may go anywhere without husbands permission Women should be more involved in politics Number of women Age 15-19 20.4 47.1 19.3 16.3 82.2 51.0 20.8 80.6 30.0 183 20-24 17.5 47.1 10.6 13.6 79.0 36.5 10.9 73.2 30.1 836 25-29 13.0 36.9 8.1 9.7 77.0 31.1 7.8 70.2 22.9 1,353 30-34 13.6 35.2 9.0 13.1 75.5 29.7 5.5 65.5 18.9 1,379 35-39 16.7 43.4 12.7 14.6 83.1 30.7 7.2 70.1 17.6 1,336 40-44 20.1 40.8 14.9 18.6 82.8 33.9 8.5 69.2 19.3 1,202 45-49 23.0 44.9 18.2 23.6 84.7 33.5 8.1 68.3 14.9 1,115 Employment (last 12 months) Not employed 17.1 41.9 13.1 15.2 81.7 35.2 9.0 69.7 21.1 4,629 Employed 17.2 39.5 11.0 15.5 77.9 28.5 6.6 69.1 19.3 2,776 Marital status Married or living together 17.1 41.0 12.2 15.1 80.8 33.0 8.2 69.5 20.4 6,999 Formerly married 17.8 42.1 12.9 20.3 71.1 28.1 5.6 69.1 19.7 406 Number of living children 0 12.1 39.8 9.9 12.2 70.3 29.4 9.5 68.6 22.5 698 1-2 12.1 35.6 9.2 11.2 76.0 28.5 5.7 66.1 20.7 4,062 3-4 23.3 47.4 15.4 18.8 89.1 36.8 9.3 73.9 19.0 2,023 5+ 36.1 57.4 25.2 34.8 90.3 50.2 18.3 77.5 20.7 621 Residence Urban 13.5 38.8 11.1 12.9 78.6 29.8 6.8 67.1 20.0 5,615 Rural 28.5 47.9 16.0 23.2 85.4 41.8 12.3 76.8 21.7 1,790 Region West 12.2 36.7 11.9 12.3 76.4 28.9 5.4 66.0 20.1 3,252 South 20.1 48.9 13.7 17.1 84.0 32.7 8.1 71.9 22.3 894 Central 16.0 37.3 10.6 14.4 81.2 33.8 7.6 72.5 21.0 1,631 North 20.1 46.9 10.8 15.6 83.4 28.7 8.1 72.4 17.8 477 East 29.2 50.0 15.2 23.8 85.7 43.6 16.3 71.7 19.9 1,151 Region (NUTS 1) İstanbul 12.2 35.3 12.5 11.3 72.9 27.2 5.9 63.2 22.4 1,491 West Marmara 15.0 36.8 11.3 12.5 79.1 28.9 3.7 61.6 12.7 327 Aegean 12.8 36.8 12.3 13.9 77.9 31.2 6.0 69.5 19.0 1,065 East Marmara 9.1 39.3 7.4 13.1 82.0 30.7 5.4 72.3 20.3 759 West Anatolia 11.9 34.2 8.9 10.5 77.3 29.3 6.3 68.0 19.4 717 Mediterranean 20.1 48.9 13.7 17.1 84.0 32.7 8.1 71.9 22.3 894 Central Anatolia 21.7 39.9 15.9 17.8 86.0 37.3 9.8 76.5 22.9 371 West Black Sea 27.2 50.5 12.9 17.9 85.3 37.9 8.3 76.9 20.9 448 East Black Sea 17.0 39.3 11.5 17.5 84.3 25.4 8.0 69.3 16.9 186 Northeast Anatolia 30.0 49.2 16.3 23.1 85.8 47.4 16.0 71.7 14.2 191 Central East Anatolia 28.4 54.3 11.9 25.1 86.3 43.8 15.7 73.0 19.2 327 Southeast Anatolia 29.3 47.8 16.5 23.3 85.2 41.9 16.8 70.8 22.2 628 Education No educ./Prim. Inc. 36.9 54.5 24.8 32.7 87.2 46.1 17.0 76.9 21.3 1,358 First level primary 18.2 44.1 12.9 15.7 85.9 35.2 7.9 71.7 21.6 3,840 Sec. level primary/higher 3.2 27.3 3.4 4.1 66.2 20.0 3.0 60.9 17.8 2,207 Wealth quintiles Lowest 37.8 52.6 20.9 30.1 86.0 47.8 14.8 78.4 20.2 1,154 Second 24.3 48.3 17.3 20.3 85.9 41.0 12.2 77.7 22.0 1,429 Middle 16.7 47.0 11.8 14.8 86.0 33.9 8.7 73.9 23.2 1,559 Fourth 10.1 38.4 9.7 11.4 79.8 27.8 4.9 65.8 21.1 1,618 Highest 3.9 23.6 4.9 5.1 66.3 18.5 2.3 55.4 15.8 1,645 Total 17.2 41.0 12.3 15.3 80.3 32.7 8.1 69.4 20.4 7,405 200 | Women’s Status 13.6 Women’s Roles in Reproductive Decisions The decisions taken by women themselves about important social and demographic events such as marriage, divorce, contraceptive use and induced abortion are related to women’s status. Table 13.9 shows the person that TDHS respondents reported were responsible for these decisions in their own lives. All TDHS respondents were asked the marriage to their spouse was arranged. Forty-two percent of women reported that they and their husbands decided by themselves to marry. If marriages arranged by families but with the consent of women are included, the proportion of women who have a say who they married rises to 87 percent. Table 13.9 shows that the decision about divorce was most often taken by women (57 percent) or jointly with their former spouse (26 percent). When contraception and induced abortion are considered, the decisions are most often jointly taken by couples (62 percent and 48 percent respectively). Table 13.9 Decision making Percent distribution of ever-married women age 15- 49 according to the person they perceived as responsible for decision relating to marriage, divorce, contraceptive use and induced abortion, Turkey 2008 Percentage Decision about marriage Families- with consent 44.4 Families- without consent 6.8 Ourselves 42.3 Eloped 5.5 Abducted 0.6 Other 0.3 Total percent 100.0 Number of women Decision about divorce Herself 56.0 Husband 12.0 Both 26.4 Other 0.9 Missing 4.6 Total percent 100.0 Number of women Decision about contraceptive use Respondent 25.5 Husband 12.5 Joint 61.9 Missing 0.2 Total percent 100.0 Number of women Decision about induced abortion Doctor 21.8 Herself 23.9 Husband 4.2 Herself and husband/partner 48.0 Other 0.4 Missing 1.7 Total 100.0 Women’s Status | 201 13.7 Women’s Status and Reproductive Health Outcomes Table 13.10 considers how key reproductive health indicators vary with one of the measures of women’s status for which data was collected in the TDHS-2008, according to attitudes towards physical violence. As described earlier in the chapter, TDHS respondents were asked about seven circumstances which might justify a husband’s use of physical violence. Women are categorized into four groups in Table 13.10 according to the number of reasons with which the women agreed and the proportions who utilized maternal health care services and who were using family planning were calculated for each of the groups. The results in the table show that the likelihood of utilizing maternal health services or contraception tends to decline as the number of circumstances with which women agreed physical violence was justified increases. For example, the percentage using any family planning method declined from 74 percent among women who did not agree that physical violence was justified in any of the circumstances to 57 percent among women who believed that violence was justified in five or more of the circumstances. Table 13.10 Justification of physical violence and health outcomes Percentage of ever-married women age 15-49 who justify physical violence by reproductive health care (for women with last birth in 5 years) and contraception indicators, Turkey 2008 Number of reasons for physical violence is justified 0 1-2 3-4 5+ Total Reproductive health care Received antenatal care from health personnel 94.2 89.0 83.0 75.4 92.0 Received delivery assistance from health personnel 95.8 90.8 90.4 74.0 93.9 Received postnatal care from health personnel within the first two days since delivery 79.8 74.9 75.0 49.5 77.5 Current use of contraception Any method 74.4 73.5 63.8 56.8 73.0 Any modern method 47.8 45.2 35.5 30.6 46.0 Female sterilization 8.0 8.4 11.1 10.2 8.3 Temporary modern female methods 23.7 24.6 18.8 16.3 23.2 Male condom 16.1 11.8 5.6 4.1 14.3 Any traditional method 26.6 28.3 28.3 26.2 27.0 Not currently using 25.5 26.3 36.1 43.1 27.0 References | 203 REFERENCES Gwatkin, D.R., S. Rutstein, K. Johnson, R.P. Pande, and A. Wagstaff. (2000). Socio-economic differencesin health, nutrition and poverty. HNP/Poverty Thematic Group of The World Bank. Washington, D.C.: The World Bank. Hacettepe University Institute of Population Studies (1980), Turkish Fertility Survey, 1978, HUIPS, Ankara. Hacettepe University Institute of Population Studies (1987), 1983 Turkish Population and Health Survey, HUIPS, Ankara. Hacettepe University Institute of Population Studies (1987), 1988 Turkish Population and Health Survey, HUIPS, Ankara. Hacettepe University Institute of Population Studies and Macro International Inc. (1999). Turkey Demographic and Health Survey 1998, HUIPS, Ankara. Koç, İ. (2004). Türkiye’de çocukların nüfusa kayıt olmamasını etkileyen değişkenler ve nüfusa kayıt olmaya geçiş süreci [Factors affecting birth registration of children and transtion to birth registration in Turkey]. Nüfusbilim Dergisi, Vol. 24: 35-44. Ministry of Foreign Affairs. (2004). Turkish Economy, Website: http://www.mfa.gov.tr/ grupd/default.htm, September 7, 2004. Ministry of Health, Hacettepe University Institute of Population Studies, and Macro International Inc. (1994). Turkey Demographic and Health Survey 1993, HUIPS, Ankara. Ministry of Health, Hacettepe University Institute of Population Studies, and Macro International Inc. (2004). Turkey Demographic and Health Survey 2003, HUIPS, Ankara. Population Reference Bureau. (2008). 2008 World Population Data Sheet. Web Site: http://www.prb.org/Publications/Datasheets/2008/2008wpds.aspx, June 4, 2009 Rutstein, S.O. (1984). Infant and child mortality: Levels, trends, and demographic differentials. Revised edition. WFS Comparative Studies No. 43. Voorburg. Netherland. Rutstein, S. (1999). Wealth versus expenditure: Comparison between the DHS Wealth Index and household expenditures in four departments of Guatemala. Unpublished. References | 204 Rutstein S., K. Johnson, and D. Gwatkin. (2000). Poverty, health inequality, and its health and demographic effects. Paper presented at the 2000 Annual Meeting of the Population Association of America, Los Angeles, California. State Planning Organization (SPO). (2003). Türkiye’nin Avrupa Birliğine Katılım Sürecine İlişkin 2003 Yılı İlerleme Raporu [2003 Regular Report on Turkey’s Progress Towards Accession]. SPO, General Directorate of the Relations with the European Union, Ankara. State Planning Organization (SPO). (2007). Ninth Development Plan 2007-2013. SPO, Ankara Turkey Statistical Institute (TURKSTAT). (2003). 2000 Census of Population: Social and Economic Characteristics of Population. Ankara: SIS. Turkey Statistical Institute (TURKSTAT). (2006). Population and Development Indicators. Web site: http://nkg.tuik.gov.tr/, June 6, 2009. Turkey Statistical Institute (TURKSTAT). (2008). Population and Development Indicators. Web site: http://nkg.tuik.gov.tr/, June 6, 2009. UNICEF (2005) Child Protection: Birth Registration, http://www.unicef.org/protection/index_birthregistration.html World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation. (2004). Meeting on the MDG drinking water and sanitation target: A mid-term assessment of progress. New York: World Health Organization and United Nations Children’s Fund. World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) Joint Monitoring Programme for Water Supply and Sanitation. (2005). Water for life: making it happen. Geneva: World Health Organization and United Nations Children’s Fund. Appendix A | 205 LİST OF PERSONNEL APPENDIX A Project Director Prof. Dr. Sabahat Tezcan Project Technical Coordinator Assoc. Prof. Dr. İsmet Koç Field Coordinator Dr. Elif Kurtuluş Yiğit Sampling and Listing Coordinator Assist. Prof. Dr. A. Sinan Türkyılmaz Listing Field Coordinator Mehmet Ali Eryurt Data Entry and Data Analysis Coordinator Dr. Yadigar Coşkun Field Coordinators Mehmet Ali Eryurt Dr. İlknur Yüksel Pelin Çağatay Tuğba Adalı Hande Tunçkanat Mustafa İşlek Ceren Gökçen Aslı Sevin Questionnaire Design Assoc. Prof. Dr. İsmet Koç Dr. Elif Kurtuluş Yiğit Mehmet Ali Eryurt Steering Committee Hacettepe University Institute of Population Studies Prof. Dr. Sabahat Tezcan Assoc. Prof. Dr. Banu A. Ergöçmen Assoc. Prof. Dr. İsmet Koç Assist. Prof. Dr. A. Sinan Türkyılmaz Ministry of Health Dr. M. Rifat Köse Dr. İbrahim Açıkalın Dr. Tanju Altunsu Dr. Sema Özbaş Dr. Rukiye Gül State Planning Organization Kemal Madenoğlu Tuncer Kocaman Turkish Statistical Institute Enver Taştı Hasibe Dedeş Meryem Demirci MEASURE DHS (Data Analysis and Report Review) Dr. Ann Way Albert Themme Sarah E. Bradley 206 | Appendix A A. MİTHAT ŞİMŞEK A. SELCAN ÖZDEMİRCİ A.TUĞRUL PEHLİVANOĞLU ABDULLAH TEKİK ADİL ÇETİNKAYA AHMET BARDAK AHMET ÇİÇEK AHMET GAZİ ZEYREK ALİ CENGİZ ALİ ÇEVİKASLAN ALİ HİLMİ EVREN ALİ RIZA MERAL ALİ SUNAOĞLU ALKEME ZAİM ANIL BÖLÜKOĞLU ARDA BALKAN ARİFE GÜLEÇ ASLAN KÖKNEL ASLI BİLGE KALAY AYCAN ERASLAN AYSUN ÇELİK AYSUN KAYA AYŞE KABAN AYŞE KAPLAN BAHADIR GÜNEŞ BAHAR GÜLER BELGİN AKGÜL BERNA ŞAFAK ZÜLFİKAR BETÜL DÖNGEL BETÜL KANSU BİHTER ÖRÜCÜ BURCU ARIKAN BURCU ÖRENCİK BÜLENT KAYA CAFER KAYA CANAN DOĞAN CANAN ÖZGÜNAY CANSU AYKAÇ CENGİZ ARIKAN CENGİZ YILMAZ CEVAT TOSUN ÇAĞLA TÜRK DAMLA EROĞLU DEMET SAYINTA DERYA ABDALOĞLU DERYA GÜNGÖRMEZ DİDEM KARAKELLE DİDEM TAŞKIN DİĞDEM SANDALCI DİLEK BALCI DİLEK GÜLEÇ DİLEK YILDIZ DÖNDÜ KOÇAK DUYGU ÇORAPÇI DUYGU ÇOTUROĞLU DUYGU TATAR EBRU İPEK EBRU KÖZ EDA ZERAN ELÇİN ÇAVLAN ELİF CEYLAN EMEL GÜNDOĞDU EMEL YAMAN EMİNE ALİŞAN EMİNE APAYDIN EMRE YAŞA ENDER GÖKOĞLAN ERDEM ASLAN ERDEM KOYUNCU EREN ÇAĞATAY ERGÜNAL DEMİRBAĞ ERTAN AKKURT ERTUĞRUL GAZİ KIYICI ESEN TÜRKYILMAZ ESİN DUYGUN ESRA BULUT ESRA DURSUN EZEL UYSAL EZGİ HAMURCU FATİH BURAK ÖZTÜRK FATMA SAYAN FATMA ULUSOY FERHAT DEMİR FERİDE YILDIZ FİLİZ YILDIZ FULYA AYDIN FUNDA AKKOYUN GÖKHAN AKARKEN GÖKHAN DENİZ GÖKMEN ÇABUK GÖZDE ÜNLÜ GÜL ÖZDEMİR GÜL VARLI GÜLCAN ALTAŞ GÜLDEN ALTINTOP GÜLNUR ARSLAN GÜRKAN KUŞ GÜRSEL ÖZDEMİR H. NADİR ÇAKIR H. RAMAZAN GÜLER HACER TAŞÇENE HAKAN YÜZÜAK HALİDE GÖK HALİL CAN EMRE HEDİYE GENÇ HİLAL OLGUN IRMAK ÇENGEL İ. CEMRE KARABULUT İBRAHİM LAÇIN İHSAN OKAN EREN İNCI BULUT İSHAK TÜRKAN İSMAİL YÜKSEL KAMURAN ATAY KENAN YILDIZ KIYMET ACAR KÜRŞAT ÖZÇELİK LEVENT BİLER LEYLA ADIYAMAN M. EMRE AYTAÇ M.ÜMİT DOĞRU MAKBULE GÜRBÜZ MEHMET ALİ KILIÇ MERT S. RENKMEN METİN KARAMAN METİN ÖZTÜRK MİHRİCAN ARSLAN MUKADDES KAYA MURAT GÜLTEKİN MURAT HELİK MUSA TURAL MUZAFFER KURAL NAZLI K. SEVİNÇ NAZMİ GÜRSEL NEBAHAT BAYRAM NEHİR GÜNDOĞDU NEŞE ÇİFTÇİ NEŞE İSTANBULLUOĞLU NEŞE TOPÇU NEVİM HINISLI NEVRA AKINCILAR NİL CANIMOĞLU NİMET BASUTER NURCAN AĞBABA NURCAN ÖZŞAHIN NURİ ARAS NURSEL ÇİÇEK NURTEN ERTÜRK OĞUZ GÜNDÜZ OĞUZHAN KOYUNCU OSMAN BEYAZTAŞ OSMAN KILIK OYA CABADAĞ ÖZGE AKTAŞ ÖZGÜR YÜCE ÖZLEM KAPLAN ÖZLEM TUNA ÖZNUR TURAN PINAR GÜLLÜ PINAR KORKUT PINAR ÖZDEMIR PINAR UYSAL R. SEDA POLATSOY RAZAN ORPAK RECEP YILMAZ RIDVAN ÇİFTÇİ SELDA SEZGİN SELAHATTİN ULUĞ SELVİ GÜZEL SEMAHİ AYDIN SEMRA GÜLEÇ SEMRA YENİHAYAT SERKAN ATALAY SERKAN ÇALIŞKAN SERTAÇ ASLAN SERVER BOLAT SEVER ÖZKAN SEZEN YILDIZ SONER ÖZKÖK SÜLEYMAN POLAT ŞEFİKA ÜNERİ ŞULE DEMİR ŞÜKRAN EROL TUBA BAL TUNCAY DİL TUNCER BOZDEMİR UĞUR BİRKANDAN ÜLKÜ ATİK ÜMİT AÇIKGÖZ VOLKAN CANBULAT YELİZ ÖZDEMIR YELİZ PALA YEŞİM ERGÜN YILMAZ BAYAR YILMAZ SAYAN ZAHİDE COŞKUN ZELAL DEMIRER ZEYNEP AKKAYA ZEYNEP ÇUKADAR ZEYNEP YILDIZ ZÖHRE BENLİ ZUHAL AKDOĞAN FIELD, DATA ENTRY AND LISTING STAFF Appendix B | 207 SURVEY DESIGN APPENDIX B A. Sinan Türkyılmaz, İsmet Koç and Elif Yiğit The major features of sample design and implementation for the Turkish Demographic and Health Survey, 2008 (TDHS-2008) are described in this section. Sample design features that are discussed include: target sample size, choice of domains, sampling stages, stratification, degree of clustering, and the relationship of design decisions to the nature of the sample frame1. Aspects of the sample implementation include the cartographic and listing work that was needed to update, improve, or generate the ultimate sample lists of households or individuals, as well as the procedures for the final household selection. This section also presents information on fieldwork, including descriptions of the recruitment and training of interviewers, the composition of interviewing teams, quality control procedures, and various practical problems encountered. Response rates2 for urban and rural areas and regions are presented. An account is also given of the data processing and analysis, including a description of the calculation of the final weighting factors (design and non-response weights). B.1 Sample Design and Implementation A weighted, multistage, stratified cluster sampling approach was used in the selection of the TDHS-2008 sample. The sample was designed in this fashion because of the need to provide estimates for a variety of characteristics for various domains. These domains, which are frequently employed in the tabulation of major indicators from the survey, are: · Turkey as a whole; · Urban and rural areas (each as a separate domain); · Each of the conventional major five regions of the country, namely the West, South, Central, North, and East regions · The 12 NUTS 13 regions, for selected indicators which are based on sufficient number of observations · The seven metropolitan cities which are larger than one million population (İstanbul, Ankara, İzmir, Bursa, Adana, Konya, Gaziantep) The major objective of the TDHS-2008 sample design was to ensure that the survey would provide estimates with acceptable precision for these domains for most of the important demographic characteristics, such as fertility, infant and child mortality, and contraceptive 1 For an additional description of these aspects of sample designs for DHS surveys, see the DHS Sampling Manual, Basic Documentation Series, No. 8, pp. 59-66, 1996. 2 For a more complete discussion of the calculation of response rates, see the DHS Sampling Manual, Basic Documentation Series, No. 8, pp. 55-57, 1996. 3 Information is provided on NUTS regions in the sections that follow. 208 | Appendix B prevalence, as well as for the health indicators. The different populations targeted by the TDHS- 2008 survey included the total population for the Household Questionnaire and all ever married women younger than age 50 for the Individual Questionnaire. The aim was to survey these populations by selecting a representative sample of households. An adult member in every household was interviewed in order to collect information on household members. In addition, some information was collected for households in a sub-sample of one-half of all households. All ever-married women age 15-49 in the household who were identified as eligible in the household schedule were interviewed. B.2 Sample Frame Different criteria have been used to describe "urban" and "rural" settlements in Turkey. In the demographic surveys of the 1970s, a population size of 2,000 was used to differentiate between urban and rural settlements. In the 1980s, the cut-off point was increased to 10,000 and, in some surveys in the 1990s, to 20,000. A number of surveys used information on the administrative status of settlements in combination with population size to differentiate settlement types. The urban frame of the TDHS-2008 consisted of a list of provincial centers, district centers, and other settlements with populations larger than 10,000, regardless of administrative status. The rural frame consisted of all district centers, sub-districts and villages not included in the urban frame. The urban-rural definitions of the TDHS-2008 are identical with those in the TDHS-1998 and TDHS-2003. Initial information on all settlements in Turkey was obtained from the 2007 Address-Based Population Registration System (ABPRS-2007). The results of ABPRS-2007 provided a computerized list of all settlements (provincial and district centers, sub-districts and villages) and their populations. The Address Based Population Registration System (ABPRS) is a newly developed system which registers each person who has a citizen ID number (or a special number for resident aliens) at a specific address. For this system, the National Address Data Base which is a new address data base was also developed by municipalities in collaboration with Turkey Statistical Institute (TURKSTAT). B.3 Stratification Currently Turkey is divided administratively into 81 provinces. For purposes of selection in prior surveys in Turkey, these provinces have been grouped into five regions. This regional breakdown has been shown to be as a powerful variable for understanding the demographic, social, cultural, and economic differences between different parts of the country. The five regions- West, South, Central, North, and East -include varying numbers of provinces. A list of the provinces in each of the regions is provided in Table B.1. In addition to the conventional five geographic regions, a new system of regional breakdown was adopted in late 2002. In accordance with the accession process of Turkey to the European Union, the State Planning Office and the Turkish Statistical Institute constructed three Appendix B | 209 levels of NUTS regions, which have since become official (Law No. 2002/4720). The NUTS stands for “The Nomenclature of Territorial Units for Statistics”. The NUTS is a statistical classification that is used by member countries of European Union (EU). For purposes of the system, Turkey`s 81 provinces were designated as regions of NUTS 3 level; these were further aggregated into 26 regions to form the NUTS 2 regions. NUTS 1 regions were formed by aggregating NUTS 2 regions into 12 regions. Table B.1 List of strata by region, NUTS 1 region, residence, type and province, Turkey 2008 Stratum Region NUTS 1 Region Type Province 1 West İstanbul Urban/Metropol İstanbul 2 West İstanbul Rural İstanbul 3 West West Marmara Urban Edirne, Kırklareli, Tekirdağ, Balıkesir, Çanakkale 4 West West Marmara Rural Edirne, Kırklareli, Tekirdağ, Balıkesir, Çanakkale 5 West Aegean Urban/Metropol İzmir 6 West Aegean Urban İzmir, Aydın, Denizli, Muğla, Manisa 7 West Aegean Rural İzmir, Aydın, Denizli, Muğla, Manisa 8 Central Aegean Urban Afyon, Kütahya, Uşak 9 Central Aegean Rural Afyon, Kütahya, Uşak 10 West East Marmara Urban/Metropol Bursa 11 West East Marmara Urban Bursa, Kocaeli, Sakarya, Yalova 12 West East Marmara Rural Bursa, Kocaeli, Sakarya, Yalova 13 Central East Marmara Urban Bilecik, Eskişehir, Bolu, Düzce 14 Central East Marmara Rural Bilecik, Eskişehir, Bolu, Düzce 15 Central West Anatolia Urban/Metropol Ankara 16 Central West Anatolia Urban/Metropol Konya 17 Central West Anatolia Urban Ankara, Konya, Karaman 18 Central West Anatolia Rural Ankara, Konya, Karaman 19 South Mediterranean Urban/Metropol Adana 20 South Mediterranean Urban Antalya, Burdur, Isparta, Adana, İçel, Hatay, K. Maraş, Osmaniye 21 South Mediterranean Rural Antalya, Burdur, Isparta, Adana, İçel, Hatay, K. Maraş, Osmaniye 22 Central Central Anatolia Urban Kırşehir, Nevşehir, Niğde, Aksaray, Kırıkkale, Kayseri, Sivas, Yozgat 23 Central Central Anatolia Rural Kırşehir, Nevşehir, Niğde, Aksaray, Kırıkkale, Kayseri, Sivas, Yozgat 24 North West Black Sea Urban Zonguldak, Bartın, Karabük, Kastamonu, Sinop, Samsun 25 North West Black Sea Rural Zonguldak, Bartın, Karabük, Kastamonu, Sinop, Samsun 26 Central West Black Sea Urban Çankırı, Amasya, Çorum, Tokat 27 Central West Black Sea Rural Çankırı, Amasya, Çorum, Tokat 28 North East Black Sea Urban Artvin, Giresun, Gümüşhane, Ordu, Rize, Trabzon 29 North East Black Sea Rural Artvin, Giresun, Gümüşhane, Ordu, Rize, Trabzon 30 East Northeast Anatolia Urban Erzincan, Erzurum, Bayburt, Ağrı, Kars, Ardahan, Iğdır 31 East Northeast Anatolia Rural Erzincan, Erzurum, Bayburt, Ağrı, Kars, Ardahan, Iğdır 32 East Central East Anatolia Urban Bingöl, Elazığ, Malatya, Tunceli, Bitlis, Hakkari, Muş, Van 33 East Central East Anatolia Rural Bingöl, Elazığ, Malatya, Tunceli, Bitlis, Hakkari, Muş, Van 34 East Southeast Anatolia Urban/Metropol Gaziantep 35 East Southeast Anatolia Urban Adıyaman, Gaziantep, Kilis, Diyarbakır, Şanlıurfa, Mardin, Siirt, Batman, Şırnak 36 East Southeast Anatolia Rural Adıyaman, Gaziantep, Kilis, Diyarbakır, Şanlıurfa, Mardin, Siirt, Batman, Şırnak 210 | Appendix B One of the priorities of the TDHS-2008 was to produce a sample design that was methodologically and conceptually consistent with the designs of previous demographic surveys carried out by the Hacettepe Institute of Population Studies. In surveys prior to the TDHS-1993, the five-region breakdown of the country was used for stratification. In TDHS-1993, a more detailed stratification taking into account sub-regions was employed to obtain a better dispersion of the sample. The criteria for subdividing the five major regions into sub-regions were the infant mortality rates of each province, estimated from the 1990 Population Census using indirect techniques.4 Using the infant mortality estimates as well as geographic proximity, the provinces in each region were grouped into 14 sub-regions at the time of the TDHS-1993. The sub-regional division developed during the TDHS-1993 was used in TDHS-1998. However, the new NUTS regions necessitated further steps for sample design, namely that the sample design of the TDHS would allow using the conventional five regions as well as the NUTS 1 regions as sample domains. The conventional five regions cannot be obtained by aggregating the 12 NUTS 1 regions. To ensure both regional breakdowns were served by the sample design, 20 mutually exclusive strata had to be created, which, when appropriately aggregated, would produce the five conventional regions or the NUTS 1 regions. It became clear during this exercise, however, that if slight modifications were made to the boundaries of the 5 regions a smaller number of strata would be sufficient for reflecting both breakdowns in the sample design. More specifically, changing the regions to which only 6 provinces out of 81 were included would make it possible to construct 15 strata and serve the same purpose. This exercise was undertaken; also, a series of statistical tests were carried out to make sure that the modification to the regional boundaries would not make any difference in terms of regional indicators. This stratification approach was used during the sample design of TDHS-2003 and repeated for the sample design of TDHS-2008. Two of the NUTS 1 regions, İstanbul and the Southeastern Anatolia, were given special attention in the sample design process and a comparatively larger share of the total sample was allocated to these regions to ensure that statistically sound estimates for a larger number of indicators would be obtained than would be the case for the remaining 10 NUTS 1 regions. Policymakers, researchers and other stakeholders had voiced interest in information on demographic and health indicators for İstanbul and the Southeastern Anatolian regions in the past. Finally as it was in the sample design of TDHS-2003, the seven metropolitan cities with one million plus populations were also considered as separate stratum. Thus, in total, 36 separate strata were created for the sample design of the TDHS-2008. This included the 15 “divisions” by urban and rural stratum, and the seven metropolitan cities as mutually exclusive strata. 4 See Hancioğlu, A. 1991. Indirect estimation of mortality from information on the survival status of a close relative: Turkey 1970-1985, Unpublished Doctoral Dissertation, Hacettepe Institute of Population Studies, Ankara. Appendix B | 211 B.4 Sample Allocation The target sample size of the TDHS-2008 was set at 13,510 households which was 35 percent larger than that of the TDHS-1998 and 400 households larger than TDHS-2003. The increased sample size was mainly related with the designation of new strata, the special attention given to İstanbul, North and Southeast Anatolia region, and adjustments to ensure optimum allocation among the NUTS 1 regions. It also reflected a concern to allocate at least 900 households for each NUTS 1 region (Table B.2). Table B.2 Allocation of sample households Number of targeted households by region for the last four TDHS surveys in Turkey Regional categories TDHS 1993 TDHS 1998 TDHS 2003 TDHS 2008 Region West 2,700 2,800 4,330 3,860 South 1,700 1,800 1,840 1,900 Central 2,100 2,100 2,450 2,690 North 1,500 1,500 1,580 1,910 East 2,000 1,800 2,960 3,150 NUTS 1 Regions İstanbul - - 2,080 1,210 West Marmara - - 740 940 Aegean - - 1,000 1,050 East Marmara - - 1,040 1,030 West Anatolia - - 890 1900 Mediterranean - - 1,840 1,110 Central Anatolia - - 740 920 West Black Sea - - 1,030 1,230 East Black Sea - - 840 970 Northeast Anatolia - - 740 900 Central East Anatolia - - 740 900 Southeast Anatolia - - 1,480 1,350 Total 10,000 10,000 13,160 13,510 Note: The number of households for TDHS-1993 and TDHS-1998 are not shown since NUTS 1 regions have been used only since 2002. To have an adequate representation of clusters within each of the five major regions, it was decided to select 25 households per standard urban segment (under the assumption of each cluster consisting of 100 households) and 15 households per standard rural segment. On this basis, the total number of selected standard segments by regions is shown in Table B.3. 212 | Appendix B Table B.3 Distribution of sample clusters Number of clusters by region, NUTS 1 Regions and urban-rural residence, Turkey 2003 Urban segments Rural segments Number of segments (Population > 10,000) (Population < 10,000) Regional categories (Cluster size= 25 HHs) (Cluster size= 15 HHs) Region West 128 44 172 South 52 40 92 Central 80 46 126 North 56 34 90 East 84 70 154 NUTS 1 Regions İstanbul 46 4 50 West Marmara 28 16 44 Aegean 30 20 50 East Marmara 34 12 46 West Anatolia 36 14 50 Mediterranean 52 40 92 Central Anatolia 26 18 44 West Black Sea 36 22 58 East Black Sea 28 18 46 Northeast Anatolia 24 20 44 Central East Anatolia 24 20 44 Southeast Anatolia 36 30 66 Total 400 234 634 B.5 Sample Selection Selection Procedures For the first-stage sample selection, settlements were grouped within each of the 36 strata, and a systematic random sample of settlements with probability proportional to size (PPS) based on the 2007 Address Based Population Registration System was selected from the settlement lists. The output from this first stage of the selection was a list of all of the settlements included in the TDHS-2008 sample along with the number of clusters to be drawn from each settlement. In Turkey, settlements are not divided into small area units with well-defined boundaries (e.g., census enumeration areas) that can be used for conducting surveys. For settlements in which 502 clusters were to be selected, however, household lists were available from the National Address Data Base that was prepared in 2007 by municipalities in collaboration with the TURKSTAT. For those settlements, the household lists were subdivided into segments of approximately 100. The list of these segments constituted the frame for the selection of the 502 clusters. For each of the selected clusters, TURKSTAT provided a list of the dwellings units with their full addresses (quarter, area, avenue/street, building and door number). Appendix B | 213 TURKSTAT was not able to provide household lists from the National Address Data Base for settlements without municipalities from which 132 clusters were to be drawn for the TDHS- 2008. For these settlements, the list of households had to be prepared in the field. In the case of small settlements (less than 250 households), the entire settlement was listed. In the case of the small number of settlements in which there were more than 250 households, an estimate of the total number of households in the settlement was obtained through a quick count, and 250 households were listed. Listing and Mapping Activities Although the TURKSTAT had dwelling lists for many clusters, they did not have the maps correspond to the clusters. For this reason, the selected clusters had to be formed with streets that were not always adjacent to each other. Moreover, the lists provided by the TURKSTAT did not reflect changes that may have occurred during the period between when they were formed and the survey date. Two types of changes were possible: those that could be updated during listing, such as the construction of a new building on the street, a change in the use of a building (e.g., a flat can be used as an office instead of a dwelling), or changes in the names of streets, and those that were more problematic, e.g., the appearance of new quarters in urban centers. In an effort to develop strategies for dealing with these as well as other possible problems that might arise, a pilot listing activity was undertaken in the capital, Ankara, before the actual listing activity began. The final listing forms, sketch map formats, and listing and mapping manuals were developed based on this pilot activity. Forty-four university students/graduates trained during a five-day training program. Seventeen listing teams were then formed each including one mapper and one lister. Each team was provided with maps describing the location of the settlements they were expected to visit, as well as other materials needed for the listing. The listing operation started in mid-June 2008 and it was carried under the supervision of the research assistants and regional coordinators from the Hacettepe Institute of Population Studies. The cluster (standard segment) size was around 100 households for the clusters in urban areas. Some of the selected villages did not include 100 households. In these cases, the village that was nearest to the selected village was included in the sample, and the names of these villages were provided to the listing teams; the lists of 100 households were completed from the two neighboring villages. The listing operation was completed on the last week of July 2008. Overall, the quality of the listing work produced by the listers was good although it varied somewhat largely in response to problems the listing teams experienced in working in some geographic areas. Only one cluster was not listed due to problems of accessibility. Spatial data were also collected for the cluster level by using GPS tools. For this purpose each listing team were given a hand computer with a GPS feature which was used to collect altitude, latitude and longitude information for the beginning and ending points of each cluster. 214 | Appendix B These machines were also used for navigation during the TDHS-2008 fieldwork and helped teams to find the location of clusters as well as individual addresses. Free satellite photos and maps from “Google earth” and “Google map” were also used frequently by listing teams. They also were used to prepare maps for interviewing teams for use during the field activity. B.6 Questionnaire Development and Pre-test Questionnaires Two main types of questionnaires were used to collect the TDHS-2008 data: the Household Questionnaire and the Individual Questionnaire for ever-married women of reproductive ages. The contents of these questionnaires were based on the DHS Model "A" Questionnaire, which was designed for the DHS program for use in countries with high contraceptive prevalence. Additions, deletions and modifications were made to the DHS model questionnaire in order to collect information particularly relevant to Turkey. Attention also was paid to ensuring the comparability of the TDHS-2008 findings with previous demographic surveys carried out by the Hacettepe Institute of Population Studies. In the process of designing the TDHS-2008 questionnaires, national and international population and health agencies were consulted for their comments. All TDHS-2008 questionnaires were developed in Turkish and translated into English. English versions of the Household and Individual questionnaires are reproduced in Appendix E. The Household Questionnaire was used to enumerate all usual members of and visitors to the selected households and to collect information relating to the socioeconomic position of the households. The Household Questionnaire included four sections. In the first section of the Household Questionnaire, basic information was collected on the age, sex, educational attainment, recent migration and residential mobility, employment, marital status, and relationship to the head of household of each person listed as a household member or visitor. The key objective of the first section of the Household Questionnaire was to obtain the information needed to identify women who were eligible for the individual interview as well as to provide basic demographic data for Turkish households. The second section of the Household Questionnaire included questions on never married women age 15-49, with the objective of collecting information on basic background characteristics of this group of women. The third section was used to collect information on the welfare of the elderly people. The final section of the Household Questionnaire was used to collect information on housing characteristics, such as the number of rooms, the flooring material, the heating system, the source of water, and the type of toilet facilities, and on the household's ownership of a variety of consumer goods. This section also incorporated a module that was used to collect information, from one-half of households, on salt iodization. In households where salt was present, test kits were used to test whether the salt used in the household was fortified with potassium iodine or potassium iodate, i.e. whether salt was iodized. Appendix B | 215 The Individual Questionnaire for ever-married women age 15-49 obtained information on the following subjects: § Background characteristics § Migration history § Marriage history and information on marriage § Pregnancy, birth history and fertility preferences § Assisted reproductive techniques § Knowledge and use of contraceptive methods § Antenatal and postnatal care § Breastfeeding, nutrition and diarrhea § Immunization § Women’s work history and status § Maternal and child anthropometry. The Individual Questionnaire also included a monthly calendar, which was used to record fertility, contraception, and marriage for a period of approximately 6 years (depending on the month of interview) beginning in January 2003 up to the survey month. In addition, fieldwork teams measured the heights and weights of children under age five and ever-married women at ages 15-49. Pre-test In addition to initial pre-tests conducted during the period of questionnaire preparation, four-day pre-test was conducted in April 2008 to ensure that the questions in the TDHS-2008 questionnaires were in a logical sequence, that the wording of the questions was comprehensible, appropriate and meaningful, and that the pre-coded answers were adequate. For this pretest, 20 interviewers were trained at the Hacettepe Institute of Population Studies for a period of ten days. The training period included both classroom training and interviews in the field. The interviewers were all university students and graduates. In addition to the interviewers, research assistants, who would later become supervisors and regional coordinators, also received training. Fieldwork for the pre-test was carried out in one district in central Ankara, one district in squatter housing areas of Ankara, and one village in Ankara province. A total of 212 households and 198 ever-married women interviews were completed during the pre-test. Frequency distributions and cross tabulations were obtained shortly after the completion of the interviews. Based on the evaluation of these results and on the feedback obtained from the interviewers, as well as from the Ministry of Health, several minor changes were made to the TDHS-2008 questionnaires. 216 | Appendix B B.7 Data Collection Activities Staff Recruitment and Training Candidates for the positions of interviewers, field editors, supervisors and measurers were solicited in announcements sent to all universities in Ankara. All candidates for the field staff positions were interviewed in four groups by the staff of the Institute of Population Studies using interview guidelines prepared for this purpose. Individuals who met a number of the requirements and had the necessary qualifications were accepted into the training program. All candidates accepted into the training program for the field staff positions were university students or university graduates. Previous survey experience was not among the qualifications for the candidates for the position of interviewers in order to ensure that the trainees had no biases that might result from their previous experience. Among 555 candidates, 240 applicants were selected during the interviews, and accepted for the training program. Training of the candidates for the fieldwork positions was conducted in September 2008 for three weeks at the Hacettepe Institute of Population Studies. The training program included general lectures related to the demographic situation in Turkey, family planning and mother and child health; questionnaire training; role playing and mock interviews; field practice in areas not covered in the survey; and quizzes to test the progress and capabilities of the candidates. A variety of materials were used during the training sessions, including manuals for supervisors and editors, and for interviewers. All trainees received the same classroom training during the first two weeks of the training period; at the end of the third week, supervisors, field editors, and measurers were selected from among the candidates, and a number of unsuccessful candidates were eliminated at this stage. Separate classroom training sessions were organized for supervisors, field editors, and measurers. After the completion of classroom training, a four-day pilot study was conducted in the urban and rural areas of Ankara to complement the training program. Based on the performance of candidates during the training and pilot study, 152 individuals were selected for the main fieldwork and the data entry activities. Fieldwork Fieldwork for the TDHS-2008, including initial interviews, call-backs and re-interviews began in the first week of October 2008, and was completed at the first week of December 2008. The fieldwork of TDHS-2008 was carried out by 19 teams, each consisting of a supervisor, a field editor, a measurer, and 5 female interviewers. Fieldwork teams visited all 81 provinces in Turkey. All fieldwork activities were completed in one stage. Senior academic staff of the Institute was responsible for visiting the fieldwork teams in turn, checking the quality of data collected, and reporting periodically to the field director in Ankara. Appendix B | 217 A total of 634 clusters were selected for the TDHS-2008 sample. Of these, interviews were successfully completed in 633 clusters. Due to problems of access, one cluster had not been listed and, consequently, was not visited by the fieldwork teams. B.8 Data Processing and Analysis TDHS-2008 questionnaires were returned to the Hacettepe Institute of Population Studies by the fieldwork teams for data processing as soon as interviews were completed in a province. The office editing staff checked that the questionnaires for all selected households and eligible respondents were returned from the field. A total of 25 data entry staff worked in data entry activities of the TDHS-2008. The data entry of the TDHS-2008 began in the beginning of November 2008, and was completed at the second week of the January 2009. The data were entered and edited on microcomputers using the Census and Survey Processing System (CSPro) software. CSPro is designed to fulfill the census and survey data processing needs of data-producing organizations worldwide. CSPro is developed by MEASURE partners, the U.S. Bureau of the Census, ICF Macro's MEASURE DHS+ project, and SerPro S.A. CSPro allows range, skip, and consistency errors to be detected and corrected at the data entry stage. The machine entry and editing activities were initiated within two weeks after the beginning of the fieldwork, and were completed a week after the completion of the fieldwork. During data entry process, full verification was reached by entering each questionnaire to the computers twice by different data editors. B.9 Calculation of Sample Weights As mentioned earlier, the TDHS-2008 sample is not a self-weighted one. In particular, a disproportionate number of sample units were chosen from some of the strata, since there would have been inadequate numbers of observations for these areas if the target number of households had been proportionally allocated across regions. The following describes the procedure for calculating the weights to be used in the analysis of the TDHS-2008 results. Since the final selection was not implemented proportionally in strata, and since there was some variation in urban and rural non-response rates, separate weights are calculated for each of the 36 strata. The major component of the weight is the reciprocal of the sampling fraction employed in calculating the number of units in that particular stratum: Wh = 1 / fh 218 | Appendix B The term f (h), the sampling fraction at the hth stratum, is the product of the probabilities of selection at every stage in a stratum: f h = P1h * P2h * P3h where Pih is the probability of the sample unit in the i-th sample stage for the h-th strata. A second component taken into account in the calculation of the weights is the level of nonresponse for the household and the individual interviews. The adjustment for household nonresponse is equal to the inverse value of: Rhh = Completed households/Eligible households. Eligible households include households where interviews were completed, households where there were no competent respondents, households where interviews were postponed and eventually not completed, refusals, and those dwellings that were not found by the fieldwork teams. Similarly, the adjustment for non-response in the women’s survey is equal to the inverse value of: Rww = Completed women questionnaires/Eligible women. Approximately half of the households were selected for interview with special modules included in the household questionnaire. The rule for the selection of a household for a half-sample was very simple. If the cluster was even-numbered, then the households whose number was even were selected for the half-sample and vice versa in odd numbered. A separate set of sampling weights was calculated for the half-sample by following procedures similar to those described above. For the half samples, the adjustment for nonresponse is defined as: Rhs = Completed questionnaires for half-sample/Eligible households for half-sample The weights for the regions and the factors compensating for nonresponse are shown in Table B.4.1 for women and Table B.4.2 for half sample. The weights for the TDHS-2008 also include an adjustment for the missing cluster. The unadjusted weights for the households were calculated by multiplying the above factors for each stratum; they were then standardized by multiplying these weights by the ratio of the number of completed interviewed households to the total unadjusted weighted number of households. A similar standardization procedure was followed in obtaining the weights for the individual women’s and half sample data. The final weights for households and individual women are shown in Table B.5. Appendix B | 219 Table B.4.1. Design weights and nonresponse factors Design weights and nonresponse factors by strata for the entire TDHS-2008 sample, Turkey 2008 Strata Region NUTS 1 Region Residence Inverse of sampling fraction Household level Women level 1 West İstanbul Urban/Metropol 3425414/1150 1078/789 594/506 2 West İstanbul Rural 55728/60 47/41 28/26 3 West West Marmara Urban 583440/700 615/519 346/314 4 West West Marmara Rural 392548/240 211/198 112/109 5 West Aegean Urban/Metropol 811628/400 367/318 215/201 6 West Aegean Urban 831914/250 217/194 147/140 7 West Aegean Rural 713302/240 212/205 117/109 8 Central Aegean Urban 242227/100 95/79 54/51 9 Central Aegean Rural 203272/60 56/55 52/48 10 West East Marmara Urban/Metropol 429416/400 366/307 243/221 11 West East Marmara Urban 673644/300 268/246 190/178 12 West East Marmara Rural 238686/120 115/112 85/76 13 Central East Marmara Urban 291593/150 127/114 91/85 14 Central East Marmara Rural 154023/60 50/48 37/34 15 Central West Anatolia Urban/Metropol 1123155/500 455/352 251/222 16 Central West Anatolia Urban/Metropol 244714/300 271/246 197/179 17 Central West Anatolia Urban 238708/100 78/62 44/43 18 Central West Anatolia Rural 240887/210 166/156 114/113 19 South Mediterranean Urban/Metropol 364155/400 348/327 247/232 20 South Mediterranean Urban 1244297/900 778/663 500/477 21 South Mediterranean Rural 712548/600 513/484 331/304 22 Central Central Anatolia Urban 593588/650 557/500 393/382 23 Central Central Anatolia Rural 346764/270 237/227 156/152 24 North West Black Sea Urban 403285/700 624/532 378/348 25 North West Black Sea Rural 340479/240 213/196 144/135 26 Central West Black Sea Urban 236382/200 186/162 115/107 27 Central West Black Sea Rural 192401/90 75/74 47/44 28 North East Black Sea Urban 308048/700 553/466 340/303 29 North East Black Sea Rural 336903/270 187/161 88/82 30 East Northeast Anatolia Urban 217599/600 555/526 439/413 31 East Northeast Anatolia Rural 216966/300 259/256 199/189 32 East Central East Anatolia Urban 390823/600 552/512 455/426 33 East Central East Anatolia Rural 273865/300 259/246 236/213 34 East Southeast Anatolia Urban/Metropol 261066/400 366/340 292/275 35 East Southeast Anatolia Urban 646905/500 453/418 360/326 36 East Southeast Anatolia Rural 362757/450 402/394 366/342 220 | Appendix B Table B.4.2 Design weights and nonresponse factors: Half sample Design weights and nonresponse factors by strata for the half samples, Turkey 2008 Strata Region NUTS 1 Region Residence Inverse of sampling fraction Household level 1 West İstanbul Urban/Metropol 2 * 3425414/1150 537/400 2 West İstanbul Rural 2 * 55728/60 25/22 3 West West Marmara Urban 2 * 583440/700 304/254 4 West West Marmara Rural 2 * 392548/240 107/100 5 West Aegean Urban/Metropol 2 * 811628/400 189/166 6 West Aegean Urban 2 * 831914/250 105/96 7 West Aegean Rural 2 * 713302/240 108/104 8 Central Aegean Urban 2 * 242227/100 48/36 9 Central Aegean Rural 2 * 203272/60 28/28 10 West East Marmara Urban/Metropol 2 * 429416/400 187/160 11 West East Marmara Urban 2 * 673644/300 136/125 12 West East Marmara Rural 2 * 238686/120 59/56 13 Central East Marmara Urban 2 * 291593/150 65/57 14 Central East Marmara Rural 2 * 154023/60 24/22 15 Central West Anatolia Urban/Metropol 2 * 1123155/500 230/173 16 Central West Anatolia Urban/Metropol 2 * 244714/300 136/126 17 Central West Anatolia Urban 2 * 238708/100 40/32 18 Central West Anatolia Rural 2 * 240887/210 82/78 19 South Mediterranean Urban/Metropol 2 * 364155/400 176/163 20 South Mediterranean Urban 2 * 1244297/900 381/322 21 South Mediterranean Rural 2 * 712548/600 252/238 22 Central Central Anatolia Urban 2 * 593588/650 281/249 23 Central Central Anatolia Rural 2 * 346764/270 117/113 24 North West Black Sea Urban 2 * 403285/700 310/256 25 North West Black Sea Rural 2 * 340479/240 109/102 26 Central West Black Sea Urban 2 * 236382/200 93/80 27 Central West Black Sea Rural 2 * 192401/90 37/36 28 North East Black Sea Urban 2 * 308048/700 269/231 29 North East Black Sea Rural 2 * 336903/270 86/74 30 East Northeast Anatolia Urban 2 * 217599/600 271/260 31 East Northeast Anatolia Rural 2 * 216966/300 126/124 32 East Central East Anatolia Urban 2 * 390823/600 279/262 33 East Central East Anatolia Rural 2 * 273865/300 128/121 34 East Southeast Anatolia Urban/Metropol 2 * 261066/400 186/172 35 East Southeast Anatolia Urban 2 * 646905/500 225/209 36 East Southeast Anatolia Rural 2 * 362757/450 201/196 Appendix B | 221 Table B.5. Final sample weights Final weights by strata, Turkey 2008 Strata Region NUTS 1 Region Residence Household weight in entire sample Women weight in entire sample Household weight in half sample 1 West İstanbul Urban/Metropol 2,62369 2,91133 2,57124 2 West İstanbul Rural 0,68643 0,69875 0,67866 3 West West Marmara Urban 0,63674 0,66321 0,64143 4 West West Marmara Rural 1,12371 1,09141 1,12533 5 West Aegean Urban/Metropol 1,50971 1,52643 1,48547 6 West Aegean Urban 2,39968 2,38169 2,34029 7 West Aegean Rural 1,98153 2,01049 1,98457 8 Central Aegean Urban 1,87791 1,87950 2,07671 9 Central Aegean Rural 2,22387 2,27727 2,17842 10 West East Marmara Urban/Metropol 0,82512 0,85758 0,80678 11 West East Marmara Urban 1,57712 1,59126 1,57091 12 West East Marmara Rural 1,31668 1,39197 1,34748 13 Central East Marmara Urban 1,39618 1,41289 1,42541 14 Central East Marmara Rural 1,72393 1,77331 1,80068 15 Central West Anatolia Urban/Metropol 1,87195 2,00059 1,92028 16 Central West Anatolia Urban/Metropol 0,57933 0,60268 0,56614 17 Central West Anatolia Urban 1,93609 1,87263 1,91863 18 Central West Anatolia Rural 0,78693 0,75042 0,77540 19 South Mediterranean Urban/Metropol 0,62462 0,62859 0,63207 20 South Mediterranean Urban 1,04593 1,03633 1,05188 21 South Mediterranean Rural 0,81151 0,83520 0,80854 22 Central Central Anatolia Urban 0,65586 0,63780 0,66266 23 Central Central Anatolia Rural 0,86447 0,83864 0,85505 24 North West Black Sea Urban 0,43566 0,44730 0,44859 25 North West Black Sea Rural 0,99394 1,00215 0,97481 26 Central West Black Sea Urban 0,87486 0,88878 0,88347 27 Central West Black Sea Rural 1,39685 1,41039 1,41279 28 North East Black Sea Urban 0,33668 0,35710 0,32952 29 North East Black Sea Rural 0,93436 0,94782 0,93244 30 East Northeast Anatolia Urban 0,24670 0,24787 0,24306 31 East Northeast Anatolia Rural 0,47172 0,46948 0,47253 32 East Central East Anatolia Urban 0,45275 0,45709 0,44601 33 East Central East Anatolia Rural 0,61964 0,64895 0,62095 34 East Southeast Anatolia Urban/Metropol 0,45295 0,45461 0,45383 35 East Southeast Anatolia Urban 0,90396 0,94357 0,89561 36 East Southeast Anatolia Rural 0,54855 0,55490 0,54990 222 | Appendix B B.10 Coverage of the Sample The results of sample implementation for the household and the individual interviews for the country as a whole, for urban and rural areas, and for the five regions of Turkey are shown in Tables B.6.1 and for NUTS 1 regions in Table B.6.2 The results indicate that, of the 13,521 households selected, the TDHS fieldwork teams successfully completed interviews with 10,525 (78 percent). The main reasons that eligible households were not interviewed were that some of the listed dwelling units were found to be vacant at the time of the interview or the household was away for an extended period. A total of 11,911 households were located and visited, of which 10,525 households were successfully interviewed. Overall, the household response rate was calculated as 88 percent. The household response rate was higher in rural areas than in urban areas, and highest in the East region (95 percent). Among NUTS 1 regions, the household response rate was the lowest in İstanbul (74 percent) and highest in Northeast Anatolia (96 percent). In the interviewed households, 8,003 eligible women were identified, of whom 93 percent were interviewed. Among the number of eligible women not interviewed in the survey, the principal reason for non-response was the failure to find the woman at home after repeated visits to the household. The eligible woman response rate was similar in urban and rural areas, and it varied across the five regions from 91 to 94 percent. The response rate for eligible women in İstanbul (86 percent) was the lowest among the NUTS 1 regions. The response rates of 12 NUTS 1 ranged between 86 and 97 percent. The highest response rate was in Central Anatolia (97 percent). The overall response rate for women in the TDHS-2008 was calculated as 82 percent. It ranged from 76 percent in the Central region to 88 percent in the East region. In terms of NUTS 1 regions, the overall response rates ranged from 63 percent in İstanbul to 91 percent in Northeast Anatolia. Appendix B | 223 Table B.6.1 Sample implementation according to residence and region Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall response rates, according to urban-rural residence and region, Turkey 2008 Residence Region Result Urban Rural West South Central North East Total Selected households Completed (C) 76.6 81.4 75.5 77.5 77.1 70.9 85.7 77.8 None of household members or no eligible member at home during visit (HP) 5.7 2.4 7.4 2.8 5.0 5.9 2.2 4.8 Postponed (P) 0.3 0.0 0.6 0.0 0.2 0.2 0.0 0.2 Refused (R) 5.4 1.1 6.0 5.3 4.2 4.0 1.7 4.3 Dwelling not found (DNF) 0.8 0.5 0.5 0.2 0.7 1.3 1.0 0.7 Household absent (HA) 5.1 7.1 3.5 7.4 6.4 9.8 4.0 5.6 Dwelling vacant/address not a dwelling (DV) 5.6 6.6 5.8 5.6 5.8 7.5 5.2 5.9 Dwelling destroy (DD) 0.0 0.2 0.0 0.2 0.1 0.0 0.1 0.1 Partly Completed (PC) 0.2 0.2 0.2 0.3 0.2 0.3 0.0 0.2 Other (O) 0.3 0.4 0.4 0.6 0.3 0.1 0.2 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 10,017 3,504 3,858 1,902 2,691 1,910 3,160 13,521 Household response rate (HRR1) 86.1 95.0 83.7 89.9 88.2 85.9 94.6 88.4 Eligible women Completed (EWC) 92.2 93.6 90.5 94.0 94.1 91.4 93.1 92.5 Not at home (EWNH) 5.0 4.7 5.7 4.3 3.6 6.5 4.7 4.9 Postponed (EWP) 0.2 0.0 0.4 0.0 0.3 0.0 0.1 0.2 Refused (EWR) 1.6 0.4 2.3 0.5 1.4 1.3 0.8 1.3 Partly completed (EWPC) 0.5 0.5 0.6 0.7 0.1 0.3 0.6 0.5 Incapacitated (EWI) 0.2 0.3 0.3 0.3 0.1 0.2 0.1 0.2 Other (EWO) 0.3 0.5 0.2 0.3 0.3 0.3 0.6 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 5,891 2,112 2,073 1,078 1,551 950 2,351 8,003 Eligible women response rate (EWRR2) 92.2 93.6 90.5 94.0 94.1 91.4 93.1 92.5 Overall response rate (ORR3) 79.4 88.9 75.8 84.5 83.0 78.5 88.1 81.8 Note: The household response rate is calculated for completed households as a proportion of completed, no competent respondent, postponed, refused, dwelling not found and partly completed. The eligible woman response rate is calculated for completed interviews as a proportion of completed, not at home, postponed, refused, partially completed and "other." The overall response rate is the product of the household and woman response rates. 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: C ____________________________ C + HP + P + R + DNF + PC 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: EWC _______________________________________________ EWC + EWNH + EWP + EWR + EWPC +EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR 224 | Appendix B Table B.6.2 Sample implementation according to NUTS 1 regions Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall response rates, according to NUTS 1 regions, Turkey 2008 Region of residence ( NUTS 1) Result İstanbul West Marmara Aegean East Marmara West Anatolia Mediter- ranean Central Anatolia West Black Sea East Black Sea North- east A. Central East A. South- east A. Total Selected households Completed (C) 68.7 75.3 81.0 80.3 73.5 77.5 79.1 78.3 64.6 86.8 83.5 86.2 77.8 None of household members or no eligible member at home during visit (HP) 12.3 5.8 5.4 3.4 7.7 2.8 3.4 5.8 4.9 1.6 1.6 3.0 4.8 Postponed (P) 1.9 0.0 0.1 0.1 0.1 0.0 0.0 0.4 0.2 0.0 0.0 0.0 0.2 Refused (R) 9.4 5.1 3.1 4.9 5.3 5.3 3.5 3.1 4.8 1.6 1.7 1.9 4.3 Dwelling not found (DNF) 0.5 0.5 0.1 1.0 0.6 0.2 0.3 1.4 1.4 0.4 2.5 0.4 0.7 Household absent (HA) 0.8 6.7 3.4 3.7 5.4 7.4 8.7 5.7 14.0 4.8 2.8 4.3 5.6 Dwelling vacant/address not a dwelling (DV) 4.8 6.4 6.4 6.3 6.6 5.6 4.9 5.1 9.6 4.6 7.4 4.2 5.9 Dwelling destroy (DD) 0.0 0.1 0.0 0.0 0.2 0.2 0.0 0.0 0.0 0.1 0.2 0.1 0.1 Partly Completed (PC) 0.3 0.0 0.4 0.3 0.2 0.3 0.1 0.2 0.2 0.0 0.1 0.0 0.2 Other (O) 1.3 0.0 0.1 0.1 0.5 0.6 0.1 0.0 0.1 0.2 0.3 0.0 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 1,206 953 1,049 1,029 1,110 1,902 922 1,229 970 901 896 1,347 13,521 Household response rate (HRR) 73.8 86.8 89.9 89.3 84.1 89.9 91.6 87.8 84.7 96.1 93.5 94.3 88.4 Eligible women Completed (EWC) 85.7 92.4 93.8 92.0 91.9 94.0 97.3 92.7 90.0 94.4 92.4 92.7 92.5 Not at home (EWNH) 7.9 4.4 4.3 5.6 4.8 4.3 2.0 4.8 7.7 3.9 4.3 5.6 4.9 Postponed (EWP) 1.0 0.4 0.0 0.0 0.0 0.0 0.0 0.6 0.0 0.2 0.0 0.1 0.2 Refused (EWR) 3.5 2.6 1.4 1.2 2.5 0.5 0.4 1.5 0.9 0.2 1.3 0.9 1.3 Partly completed (EWPC) 1.3 0.0 0.3 0.5 0.0 0.7 0.2 0.3 0.5 0.6 0.7 0.5 0.5 Incapacitated (EWI) 0.0 0.2 0.2 0.8 0.2 0.3 0.0 0.1 0.2 0.0 0.0 0.2 0.2 Other (EWO) 0.6 0.0 0.0 0.0 0.7 0.3 0.2 0.0 0.7 0.8 1.3 0.1 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 622 458 585 646 606 1,078 549 684 428 638 682 1,026 8,003 Eligible women response rate (EWRR) 85.7 92.4 93.8 92.0 91.9 94.0 97.3 92.7 90.0 94.4 92.4 92.7 92.5 Overall response rate (ORR) 63.2 80.2 84.4 82.1 77.3 84.5 89.1 81.4 76.2 90.6 86.4 87.4 81.8 Appendix C | 225 SAMPLING ERRORS APPENDIX C A. Sinan Türkyılmaz and Tuğba Adalı The estimates from a sample survey are affected by two types of errors: (1) nonsampling errors, and (2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the TDHS-2008 to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the TDHS-2008 is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the TDHS-2008 sample is the result of a three-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the TDHS-2008 is the ISSA Sampling Error Module (SAMPERR). This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance in which: 226 | Appendix C in which where h represents the stratum which varies from 1 to H, mh is the total number of enumeration areas selected in the hth stratum, yhi is the sum of the weighted values of variable y in ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the TDHS, there were 633 non-empty clusters. Hence, 633 replications were created. The variance of a rate r is calculated as follows: in which where r is the estimate computed from the full sample of 633 clusters, r(i) is the estimate computed from the reduced sample of 632 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, SAMPERR computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. SAMPERR also computes the relative error and confidence limits for the estimates. Sampling errors for the TDHS-2008 are calculated for a number of variables considered to be of primary interest. Results for women are presented in this appendix for the country as a whole, for urban and rural areas, for each of the five regions, and for the twelve NUTS1 regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table C.1. Tables C.2-C.21 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative úû ù êë é ÷ø öçè æ åå -z m z 1-m m x f-1=var(r) h 2 h2 hi m =1ih h H =1h 2 h xr.-y=zand ,xr.-y=z hhhhihihi )rr( )1-k(k 1=var(r) i 2 k 1=i -å r)1-k(-rk=r (i)i Appendix C | 227 standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In general, the relative standard errors for most estimates for the country as a whole are small, except for estimates of very small proportions. There are some differentials in the relative standard errors for the estimates for sub-populations. For example, for the contraceptive prevalence rate (CPR), i.e. the proportion of currently married women aged 15-49 who were using any method of contraception at the time of the interview, the relative standard error for the country as a whole, for urban areas, and for rural areas are 0.9 percent, 1.1 percent, and 1.8 percent, respectively. To obtain the 95 percent confidence limits for the CPR, one adds and subtracts twice the standard error to the sample estimate, i.e. 0.730 ± 2x0.007. The results indicate that there is a high probability (95 percent) that the true value of the CPR for the country as a whole lies between 71.6 percent and 74.4 percent. 228 | Appendix C Table C.1 List of selected variables for sampling errors, Turkey 2008 Variable Estimate Base population Urban residence Proportion Ever married women 15-49 No education Proportion Ever married women 15-49 With secondary education or higher Proportion Ever married women 15-49 Currently married (in union) Proportion Ever married women 15-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women 40-49 Mean All women 15-49 Knowing any contraceptive method Proportion Currently married women 15-49 Knowing any modern contraceptive method Proportion Currently married women 15-49 Ever used any contraceptive method Proportion Currently married women 15-49 Currently using any contraceptive method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using IUD Proportion Currently married women 15-49 Currently using condom Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using female sterilization Proportion Currently married women 15-49 Currently using periodic abstinence Proportion Currently married women 15-49 Currently using withdrawal Proportion Currently married women 15-49 Obtained method from public sector source Proportion Currently married women 15-49 Want no more children Proportion Currently married women 15-49 Want to delay birth at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean Ever married women 15-49 Mothers received medical care at delivery Proportion Births in last 5 years Child having health card, seen Proportion Children 15-26 months Child received BCG vaccination Proportion Children 15-26 months Child received DPT vaccination (3 doses) Proportion Children 15-26 months Child received polio vaccination (3 doses) Proportion Children 15-26 months Child received measles vaccination Proportion Children 15-26 months Child fully immunized Proportion Children 15-26 months Height-for-age (-2SD) Proportion Children 0-59 months Weight-for-height (-2SD) Proportion Children 0-59 months Weight-for-age (-2SD) Proportion Children 0-59 months BMI < 18.5 Proportion Women15-49 who gave birth in 5 years Total fertility rate (last 3 years) Rate Women-years of exposure to child-bearing Neonatal mortality (last 5 years) Rate Number of births exposed to death Post-neonatal mortality (last 5 years) Rate Number of births exposed to death Infant mortality (last 5 years) Rate Number of births exposed to death Child mortality (last 5 years) Rate Number of births exposed to death Under-five mortality (last 5 years) Rate Number of births exposed to death Appendix C | 229 Table C.2 Sampling errors: National Sample, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.758 0.006 7405 7405 1.306 0.009 0.745 0.771 No education 0.183 0.008 7405 7405 1.796 0.044 0.167 0.200 With secondary education or higher 0.298 0.011 7405 7405 2.103 0.038 0.276 0.320 Currently married (in union) 0.945 0.004 7405 7405 1.463 0.004 0.937 0.953 Currently pregnant 0.039 0.002 11184 10738 1.182 0.061 0.035 0.044 Children ever born 1.704 0.042 11184 10738 0.938 0.025 1.620 1.789 Children surviving 1.596 0.040 11184 10738 0.944 0.025 1.517 1.675 Children ever born to women 40-49 3.313 0.059 2231 2339 1.320 0.018 3.195 3.432 Knowing any contraceptive method 0.998 0.000 7042 6999 0.880 0.000 0.997 0.999 Knowing any modern contraceptive method 0.996 0.001 7042 6999 1.024 0.001 0.994 0.997 Ever used any contraceptive method 0.913 0.004 7042 6999 1.196 0.004 0.905 0.921 Currently using any contraceptive method 0.730 0.007 7042 6999 1.291 0.009 0.716 0.744 Currently using a modern method 0.460 0.007 7042 6999 1.258 0.016 0.445 0.475 Currently using pill 0.053 0.003 7042 6999 1.273 0.064 0.047 0.060 Currently using IUD 0.169 0.006 7042 6999 1.293 0.034 0.157 0.180 Currently using condom 0.143 0.006 7042 6999 1.459 0.043 0.131 0.155 Currently using injectables 0.009 0.001 7042 6999 1.228 0.157 0.006 0.011 Currently using female sterilization 0.083 0.004 7042 6999 1.239 0.049 0.075 0.091 Currently using periodic abstinence 0.006 0.001 7042 6999 1.303 0.205 0.003 0.008 Currently using withdrawal 0.262 0.007 7042 6999 1.407 0.028 0.247 0.277 Obtained method from public sector source 0.600 0.012 3162 3243 1.321 0.019 0.577 0.623 Want no more children 0.588 0.007 7039 6993 1.234 0.012 0.573 0.602 Want to delay birth at least 2 years 0.143 0.006 7039 6993 1.367 0.040 0.132 0.155 Ideal number of children 2.520 0.021 7261 7282 1.499 0.008 2.478 2.562 Mothers received medical care at delivery 0.913 0.008 3857 3463 1.306 0.009 0.897 0.929 Child having health card, seen 0.726 0.021 774 711 1.233 0.029 0.684 0.768 Child received BCG vaccination 0.959 0.006 774 711 0.788 0.006 0.948 0.971 Child received DPT vaccination (3 doses) 0.893 0.012 774 711 0.988 0.013 0.870 0.917 Child received polio vaccination (3 doses) 0.888 0.013 774 711 1.076 0.015 0.863 0.914 Child received measles vaccination 0.893 0.015 774 711 1.321 0.017 0.862 0.923 Child fully immunized 0.805 0.018 774 711 1.192 0.022 0.769 0.841 Height-for-age (-2SD) 0.103 0.007 2733 2474 1.119 0.072 0.089 0.118 Weight-for-height (-2SD) 0.009 0.002 2733 2474 1.159 0.249 0.004 0.013 Weight-for-age (-2SD) 0.028 0.004 2733 2474 1.063 0.128 0.021 0.036 BMI < 18.5 0.016 0.003 2465 2315 1.117 0.180 0.010 0.022 Total fertility rate (last 3 years) 2.156 0.059 na 30944 1.369 0.027 2.038 2.273 Neonatal mortality (last 5 years) 13.237 2.289 3912 3511 1.107 0.173 8.658 17.816 Post-neonatal mortality (last 5 years) 4.164 1.021 3914 3512 0.933 0.245 2.121 6.206 Infant mortality (last 5 years) 17.400 2.527 3914 3512 1.080 0.145 12.347 22.454 Child mortality (last 5 years) 6.351 1.550 3923 3523 1.265 0.244 3.252 9.450 Under-five mortality (last 5 years) 23.641 2.864 3925 3524 1.103 0.121 17.914 29.368 Neonatal mortality (last 10 years) 15.041 1.519 8117 7289 1.010 0.101 12.003 18.080 Post-neonatal mortality (last 10 years) 10.431 1.320 8122 7295 1.115 0.127 7.790 13.071 Infant mortality (last 10 years) 25.472 2.158 8122 7295 1.103 0.085 21.156 29.788 Child mortality (last 10 years) 7.679 1.273 8129 7299 1.208 0.166 5.132 10.225 Under-five mortality (last 10 years) 32.955 2.511 8134 7305 1.135 0.076 27.934 37.976 NA = Not applicable 230 | Appendix C Table C.3 Sampling errors: Urban Areas, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 1.000 0.000 5429 5615 na 0.000 1.000 1.000 No education 0.152 0.010 5429 5615 2.027 0.065 0.133 0.172 With secondary education or higher 0.348 0.015 5429 5615 2.267 0.042 0.318 0.377 Currently married (in union) 0.941 0.005 5429 5615 1.532 0.005 0.931 0.951 Currently pregnant 0.037 0.003 8457 8203 1.047 0.082 0.031 0.043 Children ever born 1.590 0.067 8457 8203 0.727 0.042 1.457 1.723 Children surviving 1.502 0.063 8457 8203 0.727 0.042 1.376 1.627 Children ever born to women 40-49 3.100 0.070 1628 1757 1.467 0.022 2.960 3.239 Knowing any contraceptive method 0.999 0.000 5141 5284 0.931 0.000 0.998 1.000 Knowing any modern contraceptive method 0.998 0.001 5141 5284 1.125 0.001 0.996 0.999 Ever used any contraceptive method 0.926 0.004 5141 5284 1.201 0.005 0.917 0.935 Currently using any contraceptive method 0.743 0.008 5141 5284 1.331 0.011 0.727 0.759 Currently using a modern method 0.478 0.009 5141 5284 1.226 0.018 0.461 0.495 Currently using pill 0.056 0.004 5141 5284 1.304 0.075 0.048 0.064 Currently using IUD 0.175 0.007 5141 5284 1.262 0.038 0.162 0.189 Currently using condom 0.154 0.007 5141 5284 1.476 0.048 0.139 0.169 Currently using injectables 0.008 0.002 5141 5284 1.287 0.202 0.005 0.011 Currently using female sterilization 0.083 0.005 5141 5284 1.246 0.058 0.073 0.092 Currently using periodic abstinence 0.007 0.001 5141 5284 1.289 0.216 0.004 0.010 Currently using withdrawal 0.256 0.008 5141 5284 1.372 0.033 0.239 0.273 Obtained method from public sector source 0.580 0.013 2445 2550 1.277 0.022 0.554 0.605 Want no more children 0.583 0.008 5138 5277 1.210 0.014 0.566 0.600 Want to delay birth at least 2 years 0.146 0.007 5138 5277 1.442 0.049 0.132 0.161 Ideal number of children 2.466 0.025 5355 5541 1.593 0.010 2.416 2.515 Mothers received medical care at delivery 0.957 0.006 2589 2475 1.275 0.006 0.945 0.969 Child having health card, seen 0.758 0.026 524 515 1.339 0.035 0.705 0.810 Child received BCG vaccination 0.965 0.006 524 515 0.733 0.006 0.953 0.977 Child received DPT vaccination (3 doses) 0.921 0.013 524 515 1.078 0.014 0.894 0.947 Child received polio vaccination (3 doses) 0.917 0.016 524 515 1.258 0.017 0.886 0.948 Child received measles vaccination 0.903 0.020 524 515 1.532 0.023 0.862 0.944 Child fully immunized 0.842 0.023 524 515 1.384 0.027 0.796 0.887 Height-for-age (-2SD) 0.076 0.007 1846 1781 1.109 0.097 0.061 0.091 Weight-for-height (-2SD) 0.008 0.003 1846 1781 1.286 0.338 0.003 0.014 Weight-for-age (-2SD) 0.021 0.004 1846 1781 1.145 0.188 0.013 0.029 BMI < 18.5 0.013 0.003 1742 1713 1.141 0.244 0.007 0.019 Total fertility rate (last 3 years) 2.005 0.065 na 23502 1.343 0.033 1.875 2.135 Neonatal mortality (last 10 years) 13.146 1.748 5432 5185 1.029 0.133 9.650 16.642 Post-neonatal mortality (last 10 years) 9.072 1.590 5433 5188 1.204 0.175 5.892 12.251 Infant mortality (last 10 years) 22.218 2.556 5433 5188 1.148 0.115 17.105 27.330 Child mortality (last 10 years) 6.646 1.531 5438 5190 1.321 0.230 3.585 9.707 Under-five mortality (last 10 years) 28.716 2.862 5439 5193 1.150 0.100 22.993 34.439 NA = Not applicable Appendix C | 231 Table C.4 Sampling errors: Rural Areas, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.000 0.000 1976 1790 na na 0.000 0.000 No education 0.281 0.013 1976 1790 1.310 0.047 0.254 0.307 With secondary education or higher 0.142 0.013 1976 1790 1.647 0.091 0.116 0.168 Currently married (in union) 0.959 0.005 1976 1790 1.051 0.005 0.949 0.968 Currently pregnant 0.047 0.004 2871 2533 0.983 0.085 0.039 0.055 Children ever born 2.076 0.077 2871 2533 0.989 0.037 1.923 2.230 Children surviving 1.900 0.069 2871 2533 0.991 0.037 1.761 2.039 Children ever born to women 40-49 3.932 0.111 607 586 1.080 0.028 3.709 4.154 Knowing any contraceptive method 0.995 0.001 1901 1716 0.852 0.001 0.993 0.998 Knowing any modern contraceptive method 0.990 0.002 1901 1716 0.972 0.002 0.985 0.994 Ever used any contraceptive method 0.872 0.009 1901 1716 1.190 0.010 0.854 0.890 Currently using any contraceptive method 0.689 0.012 1901 1716 1.146 0.018 0.665 0.714 Currently using a modern method 0.404 0.016 1901 1716 1.382 0.039 0.373 0.435 Currently using pill 0.046 0.005 1901 1716 1.094 0.115 0.035 0.056 Currently using IUD 0.150 0.011 1901 1716 1.400 0.077 0.127 0.172 Currently using condom 0.110 0.010 1901 1716 1.419 0.093 0.089 0.130 Currently using injectables 0.011 0.003 1901 1716 1.091 0.236 0.006 0.016 Currently using female sterilization 0.085 0.008 1901 1716 1.209 0.091 0.069 0.100 Currently using periodic abstinence 0.002 0.001 1901 1716 1.290 0.640 0.000 0.005 Currently using withdrawal 0.280 0.016 1901 1716 1.525 0.056 0.249 0.312 Obtained method from public sector source 0.675 0.027 717 692 1.549 0.040 0.621 0.729 Want no more children 0.603 0.015 1901 1716 1.309 0.024 0.574 0.632 Want to delay birth at least 2 years 0.134 0.008 1901 1716 1.008 0.059 0.118 0.150 Ideal number of children 2.692 0.040 1906 1741 1.288 0.015 2.611 2.772 Mothers received medical care at delivery 0.802 0.021 1268 988 1.341 0.026 0.760 0.844 Child having health card, seen 0.644 0.031 250 196 0.938 0.048 0.582 0.706 Child received BCG vaccination 0.943 0.014 250 196 0.876 0.015 0.915 0.970 Child received DPT vaccination (3 doses) 0.822 0.025 250 196 0.904 0.030 0.773 0.871 Child received polio vaccination (3 doses) 0.814 0.023 250 196 0.840 0.028 0.768 0.859 Child received measles vaccination 0.865 0.017 250 196 0.714 0.019 0.832 0.899 Child fully immunized 0.710 0.026 250 196 0.818 0.037 0.658 0.762 Height-for-age (-2SD) 0.174 0.018 887 692 1.156 0.101 0.139 0.209 Weight-for-height (-2SD) 0.009 0.003 887 692 0.740 0.273 0.004 0.015 Weight-for-age (-2SD) 0.048 0.008 887 692 0.954 0.161 0.032 0.063 BMI < 18.5 0.026 0.007 723 601 1.094 0.262 0.012 0.039 Total fertility rate (last 3 years) 2.676 0.130 na 7258 1.438 0.049 2.416 2.935 Neonatal mortality (last 10 years) 19.698 2.958 2685 2104 0.973 0.150 13.783 25.614 Post-neonatal mortality (last 10 years) 13.773 2.399 2689 2107 0.978 0.174 8.975 18.570 Infant mortality (last 10 years) 33.471 3.970 2689 2107 1.022 0.119 25.531 41.411 Child mortality (last 10 years) 10.213 2.307 2691 2109 1.034 0.226 5.599 14.827 Under-five mortality (last 10 years) 43.342 5.019 2695 2112 1.124 0.116 33.303 53.381 NA = Not applicable 232 | Appendix C Table C.5 Sampling errors: West, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.859 0.008 1876 3252 1.018 0.010 0.843 0.876 No education 0.119 0.015 1876 3252 1.969 0.124 0.090 0.149 With secondary education or higher 0.338 0.023 1876 3252 2.101 0.068 0.292 0.384 Currently married (in union) 0.938 0.007 1876 3252 1.333 0.008 0.923 0.952 Currently pregnant 0.036 0.004 2645 4628 1.150 0.124 0.027 0.044 Children ever born 1.497 0.072 2645 4628 0.946 0.048 1.353 1.640 Children surviving 1.411 0.067 2645 4628 0.939 0.047 1.278 1.544 Children ever born to women 40-49 2.805 0.092 653 1124 1.368 0.033 2.621 2.989 Knowing any contraceptive method 0.999 0.001 1763 3049 0.898 0.001 0.998 1.000 Knowing any modern contraceptive method 0.998 0.001 1763 3049 1.101 0.001 0.995 1.000 Ever used any contraceptive method 0.940 0.006 1763 3049 1.095 0.007 0.927 0.952 Currently using any contraceptive method 0.763 0.012 1763 3049 1.196 0.016 0.739 0.787 Currently using a modern method 0.482 0.012 1763 3049 0.999 0.025 0.458 0.506 Currently using pill 0.058 0.006 1763 3049 1.163 0.111 0.045 0.071 Currently using IUD 0.174 0.011 1763 3049 1.198 0.062 0.153 0.196 Currently using condom 0.155 0.011 1763 3049 1.272 0.071 0.134 0.177 Currently using injectables 0.008 0.003 1763 3049 1.194 0.320 0.003 0.013 Currently using female sterilization 0.084 0.008 1763 3049 1.155 0.091 0.068 0.099 Currently using periodic abstinence 0.005 0.002 1763 3049 1.052 0.338 0.002 0.009 Currently using withdrawal 0.271 0.013 1763 3049 1.229 0.048 0.245 0.298 Obtained method from public sector source 0.536 0.021 859 1483 1.209 0.038 0.494 0.577 Want no more children 0.587 0.012 1761 3044 1.055 0.021 0.562 0.611 Want to delay birth at least 2 years 0.138 0.011 1761 3044 1.307 0.078 0.117 0.160 Ideal number of children 2.342 0.039 1865 3237 1.570 0.017 2.264 2.420 Mothers received medical care at delivery 0.980 0.007 651 1174 1.337 0.007 0.965 0.994 Child having health card, seen 0.797 0.041 139 256 1.200 0.052 0.714 0.880 Child received BCG vaccination 0.973 0.005 139 256 0.367 0.005 0.963 0.983 Child received DPT vaccination (3 doses) 0.937 0.022 139 256 1.081 0.023 0.894 0.980 Child received polio vaccination (3 doses) 0.917 0.029 139 256 1.263 0.031 0.860 0.974 Child received measles vaccination 0.904 0.037 139 256 1.536 0.041 0.830 0.979 Child fully immunized 0.846 0.041 139 256 1.374 0.048 0.764 0.928 Height-for-age (-2SD) 0.076 0.012 481 848 0.985 0.161 0.052 0.100 Weight-for-height (-2SD) 0.009 0.005 481 848 1.223 0.592 0.000 0.019 Weight-for-age (-2SD) 0.010 0.005 481 848 1.142 0.501 0.000 0.021 BMI < 18.5 0.015 0.006 484 850 1.057 0.389 0.003 0.026 Total fertility rate (last 3 years) 1.734 0.099 na 13276 1.188 0.057 1.536 1.932 Neonatal mortality (last 10 years) 9.040 2.739 1419 2565 1.003 0.303 3.561 14.519 Post-neonatal mortality (last 10 years) 7.225 2.551 1420 2568 1.195 0.353 2.123 12.326 Infant mortality (last 10 years) 16.265 4.351 1420 2568 1.156 0.268 7.562 24.968 Child mortality (last 10 years) 9.817 2.915 1422 2570 1.133 0.297 3.986 15.648 Under-five mortality (last 10 years) 25.923 5.133 1423 2573 1.121 0.198 15.656 36.189 NA = Not applicable Appendix C | 233 Table C.6 Sampling errors: South, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.716 0.018 1013 894 1.300 0.026 0.679 0.753 No education 0.197 0.019 1013 894 1.516 0.096 0.159 0.235 With secondary education or higher 0.248 0.018 1013 894 1.352 0.074 0.211 0.285 Currently married (in union) 0.950 0.007 1013 894 1.000 0.007 0.936 0.963 Currently pregnant 0.037 0.006 1534 1338 1.096 0.152 0.026 0.049 Children ever born 1.689 0.106 1534 1338 0.946 0.063 1.476 1.902 Children surviving 1.590 0.099 1534 1338 0.941 0.062 1.392 1.788 Children ever born to women 40-49 3.259 0.121 331 293 1.148 0.037 3.017 3.500 Knowing any contraceptive method 0.995 0.002 962 849 0.989 0.002 0.990 0.999 Knowing any modern contraceptive method 0.991 0.003 962 849 1.087 0.003 0.984 0.997 Ever used any contraceptive method 0.881 0.013 962 849 1.246 0.015 0.855 0.907 Currently using any contraceptive method 0.704 0.018 962 849 1.229 0.026 0.668 0.740 Currently using a modern method 0.458 0.021 962 849 1.309 0.046 0.416 0.500 Currently using pill 0.041 0.007 962 849 1.096 0.172 0.027 0.055 Currently using IUD 0.183 0.015 962 849 1.216 0.083 0.152 0.213 Currently using condom 0.129 0.013 962 849 1.218 0.102 0.103 0.156 Currently using injectables 0.005 0.002 962 849 0.784 0.361 0.001 0.008 Currently using female sterilization 0.100 0.010 962 849 0.985 0.095 0.081 0.119 Currently using periodic abstinence 0.006 0.003 962 849 1.297 0.556 0.000 0.012 Currently using withdrawal 0.241 0.016 962 849 1.159 0.066 0.209 0.273 Obtained method from public sector source 0.719 0.024 441 392 1.128 0.034 0.670 0.767 Want no more children 0.573 0.016 962 849 0.990 0.028 0.541 0.604 Want to delay birth at least 2 years 0.121 0.011 962 849 1.059 0.092 0.099 0.144 Ideal number of children 2.799 0.049 989 873 1.241 0.017 2.701 2.897 Mothers received medical care at delivery 0.940 0.009 497 441 0.820 0.010 0.922 0.959 Child having health card, seen 0.626 0.048 108 95 1.013 0.076 0.531 0.721 Child received BCG vaccination 0.961 0.020 108 95 1.043 0.020 0.922 1.000 Child received DPT vaccination (3 doses) 0.881 0.028 108 95 0.905 0.032 0.825 0.938 Child received polio vaccination (3 doses) 0.877 0.029 108 95 0.915 0.033 0.819 0.935 Child received measles vaccination 0.939 0.022 108 95 0.950 0.023 0.895 0.983 Child fully immunized 0.818 0.034 108 95 0.915 0.042 0.750 0.886 Height-for-age (-2SD) 0.076 0.015 382 339 1.111 0.198 0.046 0.106 Weight-for-height (-2SD) 0.000 0.000 382 339 na na 0.000 0.000 Weight-for-age (-2SD) 0.030 0.010 382 339 1.053 0.329 0.010 0.049 BMI < 18.5 0.013 0.006 357 316 1.019 0.466 0.001 0.025 Total fertility rate (last 3 years) 2.092 0.115 na 3773 1.160 0.055 1.862 2.322 Neonatal mortality (last 10 years) 17.274 4.003 1018 902 0.938 0.232 9.267 25.280 Post-neonatal mortality (last 10 years) 12.699 3.906 1018 902 1.041 0.308 4.887 20.511 Infant mortality (last 10 years) 29.973 5.519 1018 902 0.960 0.184 18.935 41.011 Child mortality (last 10 years) 5.642 2.269 1018 902 0.995 0.402 1.103 10.181 Under-five mortality (last 10 years) 35.446 5.665 1018 902 0.888 0.160 24.116 46.776 NA = Not applicable 234 | Appendix C Table C.7 Sampling errors: Central, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.728 0.015 1460 1631 1.311 0.021 0.697 0.758 No education 0.072 0.009 1460 1631 1.331 0.125 0.054 0.090 With secondary education or higher 0.360 0.019 1460 1631 1.500 0.052 0.323 0.398 Currently married (in union) 0.945 0.008 1460 1631 1.288 0.008 0.930 0.961 Currently pregnant 0.033 0.005 2034 2222 1.175 0.141 0.023 0.042 Children ever born 1.703 0.057 2034 2222 0.974 0.034 1.589 1.818 Children surviving 1.591 0.054 2034 2222 0.994 0.034 1.484 1.698 Children ever born to women 40-49 3.219 0.110 425 477 1.427 0.034 2.999 3.439 Knowing any contraceptive method 1.000 0.000 1386 1542 0.757 0.000 0.999 1.000 Knowing any modern contraceptive method 0.998 0.001 1386 1542 0.784 0.001 0.996 1.000 Ever used any contraceptive method 0.942 0.006 1386 1542 0.903 0.006 0.930 0.953 Currently using any contraceptive method 0.755 0.012 1386 1542 1.019 0.016 0.732 0.779 Currently using a modern method 0.488 0.018 1386 1542 1.340 0.037 0.452 0.524 Currently using pill 0.049 0.006 1386 1542 1.057 0.125 0.037 0.061 Currently using IUD 0.184 0.010 1386 1542 0.994 0.056 0.163 0.205 Currently using condom 0.178 0.014 1386 1542 1.406 0.081 0.149 0.207 Currently using injectables 0.009 0.003 1386 1542 1.117 0.313 0.003 0.015 Currently using female sterilization 0.064 0.007 1386 1542 1.083 0.111 0.050 0.078 Currently using periodic abstinence 0.009 0.003 1386 1542 1.309 0.370 0.002 0.016 Currently using withdrawal 0.257 0.016 1386 1542 1.347 0.061 0.226 0.289 Obtained method from public sector source 0.596 0.024 679 757 1.267 0.040 0.549 0.644 Want no more children 0.616 0.016 1385 1540 1.229 0.026 0.584 0.649 Want to delay birth at least 2 years 0.149 0.010 1385 1540 1.056 0.068 0.129 0.169 Ideal number of children 2.339 0.031 1437 1594 1.200 0.013 2.276 2.401 Mothers received medical care at delivery 0.985 0.005 666 741 1.037 0.005 0.975 0.995 Child having health card, seen 0.709 0.050 142 149 1.266 0.071 0.609 0.810 Child received BCG vaccination 0.964 0.015 142 149 0.933 0.016 0.934 0.994 Child received DPT vaccination (3 doses) 0.943 0.017 142 149 0.836 0.018 0.909 0.976 Child received polio vaccination (3 doses) 0.945 0.013 142 149 0.635 0.013 0.920 0.970 Child received measles vaccination 0.948 0.015 142 149 0.802 0.016 0.918 0.979 Child fully immunized 0.900 0.023 142 149 0.866 0.025 0.855 0.945 Height-for-age (-2SD) 0.045 0.010 472 533 1.033 0.223 0.025 0.065 Weight-for-height (-2SD) 0.005 0.003 472 533 0.976 0.631 0.000 0.011 Weight-for-age (-2SD) 0.021 0.008 472 533 1.269 0.395 0.004 0.038 BMI < 18.5 0.019 0.007 470 529 1.046 0.343 0.006 0.033 Total fertility rate (last 3 years) 2.198 0.122 na 6513 1.286 0.055 1.955 2.442 Neonatal mortality (last 10 years) 12.491 3.259 1358 1483 1.042 0.261 5.974 19.008 Post-neonatal mortality (last 10 years) 9.312 2.819 1360 1484 1.115 0.303 3.674 14.949 Infant mortality (last 10 years) 21.803 4.026 1360 1484 1.021 0.185 13.751 29.855 Child mortality (last 10 years) 1.414 1.077 1358 1483 1.025 0.762 0.000 3.567 Under-five mortality (last 10 years) 23.186 4.090 1360 1484 1.007 0.176 15.005 31.366 NA = Not applicable Appendix C | 235 Table C.8 Sampling errors: North, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.553 0.024 868 477 1.402 0.043 0.506 0.601 No education 0.156 0.023 868 477 1.866 0.148 0.110 0.201 With secondary education or higher 0.305 0.023 868 477 1.463 0.075 0.259 0.351 Currently married (in union) 0.954 0.007 868 477 1.042 0.008 0.939 0.968 Currently pregnant 0.025 0.005 1209 684 1.116 0.200 0.015 0.035 Children ever born 1.648 0.151 1209 684 1.367 0.092 1.346 1.951 Children surviving 1.560 0.141 1209 684 1.358 0.091 1.277 1.842 Children ever born to women 40-49 3.112 0.129 293 162 1.257 0.041 2.853 3.370 Knowing any contraceptive method 1.000 0.000 827 455 na 0.000 1.000 1.000 Knowing any modern contraceptive method 0.998 0.002 827 455 1.295 0.002 0.994 1.000 Ever used any contraceptive method 0.928 0.009 827 455 1.054 0.010 0.909 0.947 Currently using any contraceptive method 0.756 0.016 827 455 1.077 0.021 0.724 0.788 Currently using a modern method 0.414 0.026 827 455 1.512 0.063 0.362 0.466 Currently using pill 0.052 0.008 827 455 1.085 0.161 0.035 0.069 Currently using IUD 0.098 0.014 827 455 1.331 0.140 0.071 0.126 Currently using condom 0.120 0.013 827 455 1.187 0.112 0.093 0.147 Currently using injectables 0.009 0.004 827 455 1.171 0.418 0.002 0.017 Currently using female sterilization 0.129 0.014 827 455 1.213 0.110 0.101 0.158 Currently using periodic abstinence 0.004 0.002 827 455 0.833 0.450 0.000 0.008 Currently using withdrawal 0.336 0.024 827 455 1.442 0.071 0.288 0.383 Obtained method from public sector source 0.600 0.031 361 191 1.187 0.051 0.539 0.661 Want no more children 0.568 0.022 827 455 1.260 0.038 0.525 0.612 Want to delay birth at least 2 years 0.124 0.013 827 455 1.098 0.101 0.099 0.149 Ideal number of children 2.386 0.045 858 470 1.474 0.019 2.296 2.475 Mothers received medical care at delivery 0.960 0.009 352 197 0.696 0.010 0.941 0.979 Child having health card, seen 0.746 0.062 68 43 1.180 0.083 0.622 0.869 Child received BCG vaccination 1.000 0.000 68 43 na 0.000 1.000 1.000 Child received DPT vaccination (3 doses) 0.881 0.053 68 43 1.249 0.060 0.776 0.986 Child received polio vaccination (3 doses) 0.858 0.048 68 43 1.077 0.056 0.762 0.953 Child received measles vaccination 0.978 0.021 68 43 1.277 0.022 0.936 1.000 Child fully immunized 0.836 0.049 68 43 1.057 0.059 0.738 0.934 Height-for-age (-2SD) 0.070 0.023 224 124 1.382 0.332 0.024 0.117 Weight-for-height (-2SD) 0.015 0.010 224 124 1.182 0.628 0.000 0.035 Weight-for-age (-2SD) 0.028 0.013 224 124 1.160 0.456 0.002 0.054 BMI < 18.5 0.030 0.013 251 142 1.186 0.418 0.005 0.055 Total fertility rate (last 3 years) 2.082 0.117 na 1945 0.988 0.056 1.848 2.316 Neonatal mortality (last 10 years) 16.084 5.796 771 432 1.311 0.360 4.492 27.676 Post-neonatal mortality (last 10 years) 7.925 3.477 772 432 1.113 0.439 0.970 14.880 Infant mortality (last 10 years) 24.009 6.417 772 432 1.204 0.267 11.175 36.842 Child mortality (last 10 years) 3.461 2.562 772 433 1.216 0.740 0.000 8.586 Under-five mortality (last 10 years) 27.387 7.917 773 433 1.288 0.289 11.553 43.222 NA = Not applicable 236 | Appendix C Table C.9 Sampling errors: East, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.634 0.013 2188 1151 1.235 0.020 0.609 0.660 No education 0.524 0.021 2188 1151 1.989 0.041 0.481 0.566 With secondary education or higher 0.133 0.013 2188 1151 1.777 0.097 0.107 0.159 Currently married (in union) 0.960 0.005 2188 1151 1.196 0.005 0.950 0.970 Currently pregnant 0.063 0.005 3683 1892 1.019 0.080 0.053 0.073 Children ever born 2.222 0.116 3683 1892 0.970 0.052 1.989 2.454 Children surviving 2.048 0.107 3683 1892 0.975 0.052 1.834 2.263 Children ever born to women 40-49 5.578 0.173 539 288 1.331 0.031 5.232 5.924 Knowing any contraceptive method 0.993 0.002 2104 1105 0.950 0.002 0.990 0.997 Knowing any modern contraceptive method 0.990 0.002 2104 1105 0.897 0.002 0.986 0.994 Ever used any contraceptive method 0.818 0.013 2104 1105 1.540 0.016 0.792 0.844 Currently using any contraceptive method 0.614 0.015 2104 1105 1.439 0.025 0.583 0.644 Currently using a modern method 0.378 0.013 2104 1105 1.274 0.036 0.351 0.405 Currently using pill 0.056 0.006 2104 1105 1.103 0.099 0.045 0.067 Currently using IUD 0.151 0.008 2104 1105 1.084 0.056 0.134 0.168 Currently using condom 0.081 0.007 2104 1105 1.192 0.088 0.067 0.095 Currently using injectables 0.013 0.002 2104 1105 0.929 0.180 0.008 0.017 Currently using female sterilization 0.077 0.006 2104 1105 1.012 0.076 0.065 0.089 Currently using periodic abstinence 0.003 0.001 2104 1105 1.071 0.452 0.000 0.005 Currently using withdrawal 0.229 0.013 2104 1105 1.406 0.056 0.203 0.255 Obtained method from public sector source 0.723 0.020 822 420 1.279 0.028 0.683 0.763 Want no more children 0.571 0.015 2104 1105 1.355 0.026 0.542 0.601 Want to delay birth at least 2 years 0.174 0.011 2104 1105 1.389 0.066 0.151 0.197 Ideal number of children 3.137 0.053 2112 1108 1.521 0.017 3.031 3.242 Mothers received medical care at delivery 0.744 0.022 1691 911 1.674 0.030 0.700 0.789 Child having health card, seen 0.685 0.029 317 167 1.116 0.043 0.626 0.743 Child received BCG vaccination 0.922 0.015 317 167 0.993 0.016 0.893 0.952 Child received DPT vaccination (3 doses) 0.792 0.025 317 167 1.095 0.032 0.741 0.843 Child received polio vaccination (3 doses) 0.808 0.023 317 167 1.017 0.028 0.763 0.854 Child received measles vaccination 0.777 0.024 317 167 1.000 0.030 0.730 0.824 Child fully immunized 0.643 0.027 317 167 0.998 0.042 0.589 0.698 Height-for-age (-2SD) 0.210 0.018 1174 631 1.382 0.086 0.174 0.247 Weight-for-height (-2SD) 0.015 0.004 1174 631 1.035 0.240 0.008 0.022 Weight-for-age (-2SD) 0.058 0.008 1174 631 1.125 0.133 0.043 0.073 BMI < 18.5 0.014 0.003 903 478 0.902 0.255 0.007 0.020 Total fertility rate (last 3 years) 3.274 0.142 na 5222 1.405 0.043 2.990 3.557 Neonatal mortality (last 10 years) 23.791 2.690 3551 1908 1.015 0.113 18.411 29.172 Post-neonatal mortality (last 10 years) 15.094 2.331 3552 1908 1.107 0.154 10.431 19.756 Infant mortality (last 10 years) 38.885 3.751 3552 1908 1.105 0.096 31.383 46.387 Child mortality (last 10 years) 11.434 2.240 3559 1912 1.169 0.196 6.954 15.914 Under-five mortality (last 10 years) 49.874 4.670 3560 1912 1.224 0.094 40.535 59.214 NA = Not applicable Appendix C | 237 Table C.10 Sampling errors: İstanbul, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.988 0.003 532 1491 0.703 0.003 0.981 0.995 No education 0.122 0.023 532 1491 1.607 0.187 0.077 0.168 With secondary education or higher 0.352 0.041 532 1491 1.996 0.117 0.270 0.435 Currently married (in union) 0.925 0.015 532 1491 1.326 0.016 0.895 0.955 Currently pregnant 0.035 0.007 756 2131 0.944 0.200 0.021 0.049 Children ever born 1.564 0.129 756 2131 0.773 0.083 1.305 1.823 Children surviving 1.471 0.118 756 2131 0.755 0.080 1.234 1.707 Children ever born to women 40-49 3.010 0.147 183 515 1.058 0.049 2.716 3.304 Knowing any contraceptive method 1.000 0.000 492 1379 na 0.000 1.000 1.000 Knowing any modern contraceptive method 0.998 0.002 492 1379 1.002 0.002 0.994 1.000 Ever used any contraceptive method 0.931 0.009 492 1379 0.785 0.010 0.914 0.949 Currently using any contraceptive method 0.743 0.020 492 1379 1.005 0.027 0.704 0.783 Currently using a modern method 0.454 0.017 492 1379 0.774 0.038 0.419 0.489 Currently using pill 0.049 0.012 492 1379 1.265 0.251 0.024 0.074 Currently using IUD 0.184 0.018 492 1379 1.042 0.099 0.147 0.220 Currently using condom 0.122 0.018 492 1379 1.250 0.151 0.085 0.159 Currently using injectables 0.013 0.005 492 1379 0.966 0.385 0.003 0.022 Currently using female sterilization 0.085 0.014 492 1379 1.131 0.168 0.056 0.113 Currently using periodic abstinence 0.004 0.003 492 1379 0.996 0.690 0.000 0.010 Currently using withdrawal 0.283 0.022 492 1379 1.058 0.076 0.240 0.326 Obtained method from public sector source 0.507 0.031 224 632 0.930 0.061 0.445 0.570 Want no more children 0.559 0.018 491 1376 0.790 0.032 0.524 0.595 Want to delay birth at least 2 years 0.158 0.017 491 1376 1.035 0.108 0.124 0.192 Ideal number of children 2.379 0.067 531 1488 1.431 0.028 2.245 2.513 Mothers received medical care at delivery 0.979 0.012 192 548 1.204 0.013 0.954 1.000 Height-for-age (-2SD) 0.075 0.019 139 396 0.875 0.254 0.037 0.114 Weight-for-height (-2SD) 0.015 0.011 139 396 1.067 0.737 0.000 0.036 Weight-for-age (-2SD) 0.015 0.010 139 396 1.000 0.685 0.000 0.035 BMI < 18.5 0.007 0.007 138 391 1.018 0.996 0.000 0.022 Total fertility rate (last 3 years) 1.780 0.159 na 6006 0.998 0.089 1.462 2.099 Neonatal mortality (last 10 years) 2.441 2.460 422 1200 1.028 1.008 0.000 7.361 Post-neonatal mortality (last 10 years) 6.083 3.508 423 1203 0.986 0.577 0.000 13.099 Infant mortality (last 10 years) 8.524 4.185 423 1203 0.980 0.491 0.154 16.893 Child mortality (last 10 years) 14.203 5.315 423 1203 0.921 0.374 3.573 24.833 Under-five mortality (last 10 years) 22.606 7.348 424 1206 0.988 0.325 7.911 37.301 NA = Not applicable 238 | Appendix C Table C.11 Sampling errors: West Marmara, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.636 0.028 423 327 1.208 0.044 0.580 0.693 No education 0.092 0.021 423 327 1.505 0.230 0.050 0.134 With secondary education or higher 0.292 0.027 423 327 1.219 0.092 0.238 0.346 Currently married (in union) 0.942 0.009 423 327 0.820 0.010 0.923 0.961 Currently pregnant 0.024 0.008 575 445 1.207 0.320 0.009 0.039 Children ever born 1.372 0.079 575 445 1.013 0.058 1.214 1.530 Children surviving 1.286 0.073 575 445 1.016 0.057 1.140 1.432 Children ever born to women 40-49 2.459 0.149 157 124 1.328 0.061 2.160 2.757 Knowing any contraceptive method 0.996 0.004 397 308 1.189 0.004 0.989 1.000 Knowing any modern contraceptive method 0.996 0.004 397 308 1.189 0.004 0.989 1.000 Ever used any contraceptive method 0.934 0.011 397 308 0.867 0.012 0.912 0.955 Currently using any contraceptive method 0.762 0.023 397 308 1.064 0.030 0.716 0.807 Currently using a modern method 0.464 0.024 397 308 0.972 0.052 0.415 0.513 Currently using pill 0.056 0.011 397 308 0.995 0.206 0.033 0.079 Currently using IUD 0.171 0.026 397 308 1.387 0.154 0.118 0.223 Currently using condom 0.156 0.017 397 308 0.908 0.106 0.123 0.190 Currently using injectables 0.004 0.004 397 308 1.180 0.995 0.000 0.011 Currently using female sterilization 0.074 0.015 397 308 1.139 0.202 0.044 0.104 Currently using periodic abstinence 0.006 0.004 397 308 1.128 0.749 0.000 0.014 Currently using withdrawal 0.292 0.025 397 308 1.091 0.085 0.242 0.342 Obtained method from public sector source 0.536 0.050 187 144 1.368 0.093 0.436 0.636 Want no more children 0.619 0.028 397 308 1.147 0.045 0.563 0.675 Want to delay birth at least 2 years 0.117 0.021 397 308 1.287 0.178 0.076 0.159 Ideal number of children 2.098 0.043 417 322 1.244 0.020 2.013 2.183 Mothers received medical care at delivery 0.985 0.010 119 88 0.878 0.010 0.965 1.000 Height-for-age (-2SD) 0.046 0.025 89 66 1.095 0.529 0.000 0.096 Weight-for-height (-2SD) 0.010 0.010 89 66 0.910 0.969 0.000 0.029 Weight-for-age (-2SD) 0.010 0.010 89 66 0.910 0.969 0.000 0.029 BMI < 18.5 0.052 0.027 92 68 1.148 0.525 0.000 0.106 Total fertility rate (last 3 years) 1.382 0.131 na 1338 1.063 0.095 1.120 1.644 NA = Not applicable Appendix C | 239 Table C.12 Sampling errors: Aegean, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.691 0.024 549 1065 1.205 0.034 0.644 0.739 No education 0.107 0.030 549 1065 2.258 0.278 0.048 0.167 With secondary education or higher 0.317 0.035 549 1065 1.783 0.112 0.246 0.388 Currently married (in union) 0.948 0.008 549 1065 0.880 0.009 0.932 0.965 Currently pregnant 0.034 0.008 730 1436 1.256 0.236 0.018 0.050 Children ever born 1.571 0.059 730 1436 0.782 0.038 1.452 1.690 Children surviving 1.483 0.058 730 1436 0.825 0.039 1.366 1.600 Children ever born to women 40-49 2.749 0.190 165 319 1.495 0.069 2.368 3.129 Knowing any contraceptive method 1.000 0.000 519 1010 na 0.000 1.000 1.000 Knowing any modern contraceptive method 0.998 0.002 519 1010 1.014 0.002 0.994 1.000 Ever used any contraceptive method 0.955 0.012 519 1010 1.347 0.013 0.930 0.980 Currently using any contraceptive method 0.800 0.022 519 1010 1.233 0.027 0.757 0.843 Currently using a modern method 0.531 0.027 519 1010 1.219 0.050 0.478 0.585 Currently using pill 0.060 0.009 519 1010 0.829 0.145 0.042 0.077 Currently using IUD 0.178 0.020 519 1010 1.199 0.113 0.138 0.219 Currently using condom 0.216 0.019 519 1010 1.042 0.087 0.178 0.254 Currently using injectables 0.006 0.003 519 1010 1.006 0.577 0.000 0.013 Currently using female sterilization 0.070 0.010 519 1010 0.851 0.137 0.051 0.089 Currently using periodic abstinence 0.007 0.003 519 1010 0.924 0.488 0.000 0.014 Currently using withdrawal 0.255 0.025 519 1010 1.296 0.097 0.206 0.305 Obtained method from public sector source 0.577 0.041 277 542 1.364 0.070 0.496 0.658 Want no more children 0.630 0.023 518 1008 1.094 0.037 0.583 0.676 Want to delay birth at least 2 years 0.122 0.020 518 1008 1.414 0.167 0.081 0.162 Ideal number of children 2.362 0.065 546 1058 1.279 0.027 2.233 2.492 Mothers received medical care at delivery 0.982 0.011 215 427 1.189 0.011 0.961 1.000 Height-for-age (-2SD) 0.064 0.022 148 289 0.987 0.338 0.021 0.108 Weight-for-height (-2SD) 0.000 0.000 148 289 na na 0.000 0.000 Weight-for-age (-2SD) 0.012 0.008 148 289 0.931 0.700 0.000 0.028 BMI < 18.5 0.016 0.012 152 296 1.210 0.775 0.000 0.040 Total fertility rate (last 3 years) 1.912 0.199 na 4261 1.300 0.104 1.514 2.310 NA = Not applicable 240 | Appendix C Table C.13 Sampling errors: East Marmara, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.781 0.014 594 759 0.801 0.017 0.754 0.808 No education 0.096 0.013 594 759 1.105 0.139 0.070 0.123 With secondary education or higher 0.323 0.027 594 759 1.411 0.084 0.268 0.377 Currently married (in union) 0.951 0.007 594 759 0.808 0.008 0.937 0.965 Currently pregnant 0.042 0.009 877 1126 1.187 0.214 0.024 0.061 Children ever born 1.397 0.156 877 1126 1.068 0.112 1.084 1.710 Children surviving 1.309 0.147 877 1126 1.077 0.112 1.016 1.603 Children ever born to women 40-49 2.726 0.153 203 263 1.379 0.056 2.420 3.031 Knowing any contraceptive method 0.998 0.002 565 722 1.125 0.002 0.993 1.000 Knowing any modern contraceptive method 0.998 0.002 565 722 1.125 0.002 0.993 1.000 Ever used any contraceptive method 0.953 0.011 565 722 1.236 0.012 0.931 0.975 Currently using any contraceptive method 0.768 0.016 565 722 0.878 0.020 0.737 0.800 Currently using a modern method 0.459 0.021 565 722 0.988 0.045 0.418 0.501 Currently using pill 0.064 0.008 565 722 0.793 0.128 0.048 0.080 Currently using IUD 0.140 0.012 565 722 0.789 0.082 0.117 0.163 Currently using condom 0.159 0.015 565 722 0.992 0.096 0.129 0.190 Currently using injectables 0.004 0.003 565 722 1.065 0.718 0.000 0.009 Currently using female sterilization 0.088 0.012 565 722 1.004 0.136 0.064 0.112 Currently using periodic abstinence 0.010 0.005 565 722 1.234 0.530 0.000 0.020 Currently using withdrawal 0.297 0.022 565 722 1.168 0.076 0.252 0.342 Obtained method from public sector source 0.555 0.037 267 333 1.212 0.067 0.481 0.629 Want no more children 0.594 0.030 565 722 1.474 0.051 0.533 0.655 Want to delay birth at least 2 years 0.138 0.021 565 722 1.430 0.150 0.097 0.180 Ideal number of children 2.304 0.052 592 756 1.375 0.023 2.200 2.409 Mothers received medical care at delivery 0.984 0.009 216 275 1.071 0.009 0.965 1.000 Height-for-age (-2SD) 0.072 0.020 173 218 0.957 0.282 0.031 0.113 Weight-for-height (-2SD) 0.010 0.008 173 218 0.977 0.730 0.000 0.026 Weight-for-age (-2SD) 0.023 0.015 173 218 1.296 0.643 0.000 0.054 BMI < 18.5 0.018 0.011 169 214 1.024 0.586 0.000 0.039 Total fertility rate (last 3 years) 1.799 0.131 na 3168 0.975 0.073 1.537 2.060 NA = Not applicable Appendix C | 241 Table C.14 Sampling errors: West Anatolia, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.882 0.014 557 717 1.030 0.016 0.854 0.910 No education 0.037 0.008 557 717 1.042 0.225 0.020 0.054 With secondary education or higher 0.462 0.035 557 717 1.675 0.077 0.391 0.532 Currently married (in union) 0.947 0.015 557 717 1.529 0.015 0.917 0.976 Currently pregnant 0.036 0.007 742 932 1.086 0.204 0.021 0.051 Children ever born 1.665 0.056 742 932 0.765 0.034 1.553 1.776 Children surviving 1.591 0.054 742 932 0.786 0.034 1.483 1.699 Children ever born to women 40-49 2.844 0.164 158 213 1.539 0.057 2.517 3.171 Knowing any contraceptive method 1.000 0.000 531 679 na 0.000 1.000 1.000 Knowing any modern contraceptive method 0.999 0.001 531 679 0.682 0.001 0.997 1.000 Ever used any contraceptive method 0.942 0.009 531 679 0.909 0.010 0.924 0.961 Currently using any contraceptive method 0.757 0.019 531 679 1.033 0.025 0.719 0.796 Currently using a modern method 0.516 0.030 531 679 1.360 0.057 0.457 0.575 Currently using pill 0.051 0.011 531 679 1.129 0.212 0.029 0.073 Currently using IUD 0.192 0.015 531 679 0.905 0.081 0.161 0.223 Currently using condom 0.197 0.025 531 679 1.448 0.127 0.147 0.247 Currently using injectables 0.008 0.004 531 679 1.143 0.549 0.000 0.017 Currently using female sterilization 0.061 0.011 531 679 1.062 0.181 0.039 0.083 Currently using periodic abstinence 0.009 0.005 531 679 1.303 0.606 0.000 0.019 Currently using withdrawal 0.233 0.024 531 679 1.311 0.103 0.185 0.281 Obtained method from public sector source 0.551 0.027 274 352 0.901 0.049 0.497 0.606 Want no more children 0.593 0.021 530 677 0.972 0.035 0.551 0.634 Want to delay birth at least 2 years 0.157 0.013 530 677 0.828 0.083 0.131 0.183 Ideal number of children 2.340 0.059 540 686 1.352 0.025 2.222 2.458 Mothers received medical care at delivery 0.984 0.009 271 345 1.131 0.009 0.967 1.000 Height-for-age (-2SD) 0.033 0.015 187 246 1.083 0.457 0.003 0.064 Weight-for-height (-2SD) 0.002 0.002 187 246 0.692 1.009 0.000 0.007 Weight-for-age (-2SD) 0.015 0.010 187 246 1.123 0.662 0.000 0.034 BMI < 18.5 0.024 0.010 179 239 0.899 0.420 0.004 0.044 Total fertility rate (last 3 years) 2.402 0.208 na 2789 1.272 0.087 1.986 2.817 NA = Not applicable 242 | Appendix C Table C.15 Sampling errors: Mediterranean, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.716 0.018 1013 894 1.300 0.026 0.679 0.753 No education 0.197 0.019 1013 894 1.516 0.096 0.159 0.235 With secondary education or higher 0.248 0.018 1013 894 1.352 0.074 0.211 0.285 Currently married (in union) 0.950 0.007 1013 894 1.000 0.007 0.936 0.963 Currently pregnant 0.037 0.006 1534 1338 1.096 0.152 0.026 0.049 Children ever born 1.689 0.106 1534 1338 0.946 0.063 1.476 1.902 Children surviving 1.590 0.099 1534 1338 0.941 0.062 1.392 1.788 Children ever born to women 40-49 3.259 0.121 331 293 1.148 0.037 3.017 3.500 Knowing any contraceptive method 0.995 0.002 962 849 0.989 0.002 0.990 0.999 Knowing any modern contraceptive method 0.991 0.003 962 849 1.087 0.003 0.984 0.997 Ever used any contraceptive method 0.881 0.013 962 849 1.246 0.015 0.855 0.907 Currently using any contraceptive method 0.704 0.018 962 849 1.229 0.026 0.668 0.740 Currently using a modern method 0.458 0.021 962 849 1.309 0.046 0.416 0.500 Currently using pill 0.041 0.007 962 849 1.096 0.172 0.027 0.055 Currently using IUD 0.183 0.015 962 849 1.216 0.083 0.152 0.213 Currently using condom 0.129 0.013 962 849 1.218 0.102 0.103 0.156 Currently using injectables 0.005 0.002 962 849 0.784 0.361 0.001 0.008 Currently using female sterilization 0.100 0.010 962 849 0.985 0.095 0.081 0.119 Currently using periodic abstinence 0.006 0.003 962 849 1.297 0.556 0.000 0.012 Currently using withdrawal 0.241 0.016 962 849 1.159 0.066 0.209 0.273 Obtained method from public sector source 0.719 0.024 441 392 1.128 0.034 0.670 0.767 Want no more children 0.573 0.016 962 849 0.990 0.028 0.541 0.604 Want to delay birth at least 2 years 0.121 0.011 962 849 1.059 0.092 0.099 0.144 Ideal number of children 2.799 0.049 989 873 1.241 0.017 2.701 2.897 Mothers received medical care at delivery 0.940 0.009 497 441 0.820 0.010 0.922 0.959 Height-for-age (-2SD) 0.076 0.015 382 339 1.111 0.198 0.046 0.106 Weight-for-height (-2SD) 0.000 0.000 382 339 na na 0.000 0.000 Weight-for-age (-2SD) 0.030 0.010 382 339 1.053 0.329 0.010 0.049 BMI < 18.5 0.013 0.006 357 316 1.019 0.466 0.001 0.025 Total fertility rate (last 3 years) 2.092 0.115 na 3773 1.160 0.055 1.862 2.322 NA = Not applicable Appendix C | 243 Table C.16 Sampling errors: Central Anatolia, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.657 0.028 534 371 1.349 0.042 0.601 0.712 No education 0.151 0.024 534 371 1.551 0.159 0.103 0.199 With secondary education or higher 0.301 0.029 534 371 1.439 0.095 0.244 0.358 Currently married (in union) 0.959 0.006 534 371 0.713 0.006 0.947 0.972 Currently pregnant 0.030 0.006 797 561 1.069 0.213 0.017 0.042 Children ever born 1.753 0.135 797 561 1.123 0.077 1.483 2.023 Children surviving 1.610 0.127 797 561 1.170 0.079 1.356 1.864 Children ever born to women 40-49 3.919 0.179 158 111 1.267 0.046 3.561 4.277 Knowing any contraceptive method 0.998 0.002 512 356 0.957 0.002 0.995 1.000 Knowing any modern contraceptive method 0.994 0.003 512 356 0.996 0.003 0.987 1.000 Ever used any contraceptive method 0.919 0.012 512 356 1.015 0.013 0.895 0.944 Currently using any contraceptive method 0.722 0.025 512 356 1.282 0.035 0.671 0.773 Currently using a modern method 0.478 0.020 512 356 0.897 0.041 0.439 0.518 Currently using pill 0.061 0.011 512 356 1.039 0.180 0.039 0.083 Currently using IUD 0.207 0.021 512 356 1.152 0.100 0.166 0.249 Currently using condom 0.118 0.016 512 356 1.109 0.134 0.086 0.149 Currently using injectables 0.006 0.003 512 356 0.984 0.563 0.000 0.013 Currently using female sterilization 0.084 0.010 512 356 0.855 0.125 0.063 0.105 Currently using periodic abstinence 0.009 0.005 512 356 1.098 0.511 0.000 0.018 Currently using withdrawal 0.232 0.016 512 356 0.866 0.070 0.200 0.265 Obtained method from public sector source 0.642 0.050 246 170 1.624 0.077 0.543 0.742 Want no more children 0.632 0.021 512 356 0.983 0.033 0.590 0.674 Want to delay birth at least 2 years 0.138 0.008 512 356 0.528 0.058 0.122 0.155 Ideal number of children 2.425 0.046 529 368 0.926 0.019 2.334 2.516 Mothers received medical care at delivery 0.976 0.011 252 177 0.999 0.011 0.954 0.998 Height-for-age (-2SD) 0.094 0.019 176 123 0.885 0.202 0.056 0.132 Weight-for-height (-2SD) 0.005 0.005 176 123 0.944 0.984 0.000 0.015 Weight-for-age (-2SD) 0.012 0.008 176 123 1.044 0.709 0.000 0.029 BMI < 18.5 0.010 0.001 183 127 0.125 0.092 0.008 0.012 Total fertility rate (last 3 years) 2.094 0.172 na 1585 1.172 0.082 1.749 2.438 NA = Not applicable 244 | Appendix C Table C.17 Sampling errors: West Black Sea, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.560 0.019 634 448 0.948 0.033 0.522 0.597 No education 0.134 0.024 634 448 1.742 0.176 0.087 0.181 With secondary education or higher 0.270 0.027 634 448 1.520 0.099 0.217 0.324 Currently married (in union) 0.928 0.010 634 448 0.961 0.011 0.909 0.948 Currently pregnant 0.028 0.005 825 602 0.892 0.179 0.018 0.038 Children ever born 1.809 0.107 825 602 1.125 0.059 1.596 2.022 Children surviving 1.684 0.100 825 602 1.159 0.059 1.483 1.884 Children ever born to women 40-49 3.204 0.146 218 157 1.221 0.046 2.912 3.496 Knowing any contraceptive method 1.000 0.000 593 416 na 0.000 1.000 1.000 Knowing any modern contraceptive method 1.000 0.000 593 416 na 0.000 1.000 1.000 Ever used any contraceptive method 0.931 0.010 593 416 0.946 0.011 0.912 0.951 Currently using any contraceptive method 0.775 0.020 593 416 1.149 0.025 0.735 0.814 Currently using a modern method 0.460 0.027 593 416 1.300 0.058 0.407 0.513 Currently using pill 0.056 0.010 593 416 1.010 0.171 0.037 0.075 Currently using IUD 0.130 0.015 593 416 1.082 0.115 0.100 0.160 Currently using condom 0.150 0.013 593 416 0.899 0.088 0.124 0.176 Currently using injectables 0.012 0.006 593 416 1.224 0.452 0.001 0.023 Currently using female sterilization 0.108 0.017 593 416 1.323 0.157 0.074 0.141 Currently using periodic abstinence 0.001 0.001 593 416 0.801 1.004 0.000 0.003 Currently using withdrawal 0.311 0.028 593 416 1.479 0.090 0.255 0.368 Obtained method from public sector source 0.619 0.035 282 194 1.193 0.056 0.550 0.688 Want no more children 0.611 0.025 593 416 1.259 0.041 0.560 0.661 Want to delay birth at least 2 years 0.129 0.014 593 416 0.997 0.107 0.101 0.156 Ideal number of children 2.251 0.036 633 448 1.092 0.016 2.179 2.322 Mothers received medical care at delivery 0.965 0.003 245 172 0.155 0.003 0.960 0.970 Height-for-age (-2SD) 0.041 0.019 165 119 1.239 0.457 0.004 0.078 Weight-for-height (-2SD) 0.016 0.010 165 119 1.046 0.630 0.000 0.036 Weight-for-age (-2SD) 0.012 0.009 165 119 1.113 0.774 0.000 0.031 BMI < 18.5 0.032 0.014 183 131 1.047 0.421 0.005 0.060 Total fertility rate (last 3 years) 1.905 0.126 na 1778 1.262 0.066 1.654 2.156 NA = Not applicable Appendix C | 245 Table C.18 Sampling errors: East Black Sea, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.582 0.051 385 186 2.024 0.088 0.480 0.684 No education 0.201 0.046 385 186 2.252 0.229 0.109 0.293 With secondary education or higher 0.349 0.042 385 186 1.739 0.121 0.265 0.434 Currently married (in union) 0.967 0.010 385 186 1.073 0.010 0.947 0.986 Currently pregnant 0.018 0.007 589 305 1.226 0.358 0.005 0.031 Children ever born 1.473 0.278 589 305 1.471 0.189 0.916 2.030 Children surviving 1.406 0.263 589 305 1.460 0.187 0.880 1.932 Children ever born to women 40-49 3.200 0.182 131 64 1.333 0.057 2.835 3.565 Knowing any contraceptive method 1.000 0.000 371 180 na 0.000 1.000 1.000 Knowing any modern contraceptive method 0.995 0.005 371 180 1.354 0.005 0.985 1.000 Ever used any contraceptive method 0.911 0.017 371 180 1.127 0.018 0.878 0.944 Currently using any contraceptive method 0.682 0.024 371 180 0.985 0.035 0.634 0.729 Currently using a modern method 0.354 0.026 371 180 1.027 0.072 0.303 0.405 Currently using pill 0.034 0.011 371 180 1.136 0.313 0.013 0.056 Currently using IUD 0.080 0.017 371 180 1.223 0.216 0.046 0.114 Currently using condom 0.089 0.021 371 180 1.394 0.231 0.048 0.131 Currently using injectables 0.013 0.007 371 180 1.136 0.510 0.000 0.027 Currently using female sterilization 0.130 0.018 371 180 1.033 0.139 0.094 0.166 Currently using periodic abstinence 0.008 0.004 371 180 0.861 0.500 0.000 0.016 Currently using withdrawal 0.319 0.023 371 180 0.944 0.072 0.274 0.365 Obtained method from public sector source 0.653 0.046 143 64 1.141 0.070 0.562 0.744 Want no more children 0.510 0.040 371 180 1.531 0.078 0.431 0.590 Want to delay birth at least 2 years 0.120 0.020 371 180 1.201 0.169 0.079 0.160 Ideal number of children 2.667 0.073 376 179 1.499 0.028 2.520 2.814 Mothers received medical care at delivery 0.976 0.023 159 79 1.936 0.024 0.930 1.000 Height-for-age (-2SD) 0.110 0.047 100 48 1.480 0.428 0.016 0.204 Weight-for-height (-2SD) 0.000 0.000 100 48 na na 0.000 0.000 Weight-for-age (-2SD) 0.042 0.022 100 48 1.089 0.520 0.000 0.087 BMI < 18.5 0.017 0.016 109 55 1.323 0.937 0.000 0.050 Total fertility rate (last 3 years) 2.103 0.200 na 806 0.971 0.095 1.704 2.502 NA = Not applicable 246 | Appendix C Table C.19 Sampling errors: Northeast Anatolia, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.536 0.021 602 191 1.016 0.039 0.494 0.577 No education 0.414 0.038 602 191 1.882 0.091 0.338 0.489 With secondary education or higher 0.205 0.031 602 191 1.864 0.150 0.143 0.266 Currently married (in union) 0.982 0.006 602 191 1.028 0.006 0.971 0.993 Currently pregnant 0.045 0.008 1022 329 0.990 0.174 0.030 0.061 Children ever born 1.994 0.242 1022 329 1.048 0.121 1.511 2.478 Children surviving 1.815 0.219 1022 329 1.050 0.121 1.377 2.253 Children ever born to women 40-49 5.266 0.327 142 45 1.288 0.062 4.612 5.920 Knowing any contraceptive method 1.000 0.000 591 188 na 0.000 1.000 1.000 Knowing any modern contraceptive method 0.997 0.002 591 188 1.214 0.003 0.993 1.000 Ever used any contraceptive method 0.856 0.018 591 188 1.241 0.021 0.820 0.892 Currently using any contraceptive method 0.704 0.026 591 188 1.361 0.036 0.653 0.755 Currently using a modern method 0.446 0.030 591 188 1.458 0.067 0.386 0.505 Currently using pill 0.072 0.014 591 188 1.302 0.193 0.044 0.100 Currently using IUD 0.236 0.021 591 188 1.178 0.087 0.195 0.278 Currently using condom 0.069 0.011 591 188 1.016 0.154 0.048 0.090 Currently using injectables 0.020 0.006 591 188 1.101 0.315 0.008 0.033 Currently using female sterilization 0.047 0.007 591 188 0.790 0.146 0.033 0.061 Currently using periodic abstinence 0.005 0.003 591 188 1.093 0.618 0.000 0.012 Currently using withdrawal 0.242 0.030 591 188 1.676 0.122 0.183 0.301 Obtained method from public sector source 0.697 0.047 274 84 1.679 0.067 0.604 0.791 Want no more children 0.645 0.022 591 188 1.101 0.034 0.601 0.688 Want to delay birth at least 2 years 0.130 0.012 591 188 0.877 0.093 0.106 0.155 Ideal number of children 2.647 0.072 590 187 1.259 0.027 2.504 2.791 Mothers received medical care at delivery 0.755 0.044 400 128 1.649 0.058 0.668 0.842 Height-for-age (-2SD) 0.222 0.039 288 90 1.485 0.175 0.144 0.300 Weight-for-height (-2SD) 0.013 0.008 288 90 1.138 0.584 0.000 0.029 Weight-for-age (-2SD) 0.072 0.016 288 90 1.038 0.216 0.041 0.103 BMI < 18.5 0.042 0.011 233 74 0.836 0.261 0.020 0.064 Total fertility rate (last 3 years) 2.590 0.176 na 872 1.067 0.068 2.237 2.943 NA = Not applicable Appendix C | 247 Table C.20 Sampling errors: Central East Anatolia, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.595 0.028 630 327 1.427 0.047 0.539 0.651 No education 0.582 0.029 630 327 1.483 0.050 0.523 0.640 With secondary education or higher 0.118 0.013 630 327 1.041 0.113 0.091 0.145 Currently married (in union) 0.973 0.004 630 327 0.671 0.004 0.964 0.982 Currently pregnant 0.062 0.008 952 497 1.065 0.130 0.046 0.078 Children ever born 2.400 0.125 952 497 0.957 0.052 2.149 2.651 Children surviving 2.164 0.112 952 497 0.964 0.052 1.941 2.388 Children ever born to women 40-49 5.690 0.360 161 83 1.262 0.063 4.970 6.411 Knowing any contraceptive method 0.987 0.004 611 318 0.829 0.004 0.979 0.994 Knowing any modern contraceptive method 0.979 0.004 611 318 0.761 0.004 0.970 0.988 Ever used any contraceptive method 0.815 0.016 611 318 1.025 0.020 0.783 0.847 Currently using any contraceptive method 0.623 0.022 611 318 1.113 0.035 0.579 0.666 Currently using a modern method 0.340 0.027 611 318 1.382 0.078 0.287 0.393 Currently using pill 0.053 0.012 611 318 1.325 0.228 0.029 0.077 Currently using IUD 0.132 0.016 611 318 1.182 0.122 0.100 0.165 Currently using condom 0.066 0.011 611 318 1.131 0.172 0.043 0.089 Currently using injectables 0.005 0.003 611 318 0.987 0.569 0.000 0.010 Currently using female sterilization 0.084 0.013 611 318 1.139 0.153 0.058 0.109 Currently using periodic abstinence 0.001 0.001 611 318 0.922 0.984 0.000 0.004 Currently using withdrawal 0.276 0.024 611 318 1.315 0.086 0.229 0.324 Obtained method from public sector source 0.738 0.036 215 109 1.203 0.049 0.666 0.810 Want no more children 0.566 0.025 611 318 1.254 0.044 0.516 0.616 Want to delay birth at least 2 years 0.184 0.018 611 318 1.166 0.099 0.148 0.221 Ideal number of children 3.059 0.063 605 313 0.992 0.021 2.932 3.186 Mothers received medical care at delivery 0.660 0.046 468 250 1.711 0.070 0.568 0.753 Height-for-age (-2SD) 0.180 0.035 300 159 1.492 0.193 0.110 0.249 Weight-for-height (-2SD) 0.011 0.006 300 159 1.059 0.573 0.000 0.024 Weight-for-age (-2SD) 0.079 0.023 300 159 1.401 0.287 0.034 0.125 BMI < 18.5 0.009 0.006 262 138 1.061 0.668 0.000 0.022 Total fertility rate (last 3 years) 3.334 0.214 na 1464 1.128 0.064 2.905 3.762 NA = Not applicable 248 | Appendix C Table C.21 Sampling errors: Southeast Anatolia, Turkey 2008 Variable Value R Standard error SE Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE Urban residence 0.689 0.017 952 628 1.139 0.025 0.654 0.723 No education 0.529 0.034 952 628 2.073 0.063 0.462 0.596 With secondary education or higher 0.119 0.020 952 628 1.934 0.170 0.079 0.160 Currently married (in union) 0.946 0.009 952 628 1.181 0.009 0.929 0.963 Currently pregnant 0.069 0.008 1705 1062 0.939 0.114 0.053 0.085 Children ever born 2.211 0.180 1705 1062 0.908 0.082 1.850 2.572 Children surviving 2.068 0.169 1705 1062 0.911 0.082 1.730 2.406 Children ever born to women 40-49 5.672 0.228 234 157 1.329 0.040 5.216 6.127 Knowing any contraceptive method 0.995 0.002 898 594 0.988 0.002 0.990 1.000 Knowing any modern contraceptive method 0.993 0.003 898 594 0.960 0.003 0.988 0.998 Ever used any contraceptive method 0.806 0.022 898 594 1.632 0.027 0.762 0.849 Currently using any contraceptive method 0.578 0.024 898 594 1.456 0.042 0.530 0.626 Currently using a modern method 0.379 0.018 898 594 1.133 0.048 0.342 0.415 Currently using pill 0.054 0.007 898 594 0.904 0.127 0.040 0.067 Currently using IUD 0.135 0.011 898 594 0.978 0.083 0.113 0.158 Currently using condom 0.093 0.011 898 594 1.158 0.121 0.071 0.116 Currently using injectables 0.014 0.003 898 594 0.846 0.235 0.008 0.021 Currently using female sterilization 0.081 0.008 898 594 0.901 0.101 0.065 0.098 Currently using periodic abstinence 0.003 0.002 898 594 1.102 0.732 0.000 0.006 Currently using withdrawal 0.196 0.017 898 594 1.297 0.088 0.161 0.230 Obtained method from public sector source 0.723 0.028 332 226 1.139 0.039 0.667 0.779 Want no more children 0.550 0.023 898 594 1.361 0.041 0.505 0.595 Want to delay birth at least 2 years 0.184 0.019 898 594 1.435 0.101 0.147 0.221 Ideal number of children 3.333 0.086 913 603 1.593 0.026 3.162 3.505 Mothers received medical care at delivery 0.781 0.028 823 533 1.514 0.036 0.724 0.838 Height-for-age (-2SD) 0.221 0.025 586 382 1.261 0.113 0.171 0.270 Weight-for-height (-2SD) 0.017 0.005 586 382 0.947 0.296 0.007 0.028 Weight-for-age (-2SD) 0.046 0.007 586 382 0.851 0.162 0.031 0.061 BMI < 18.5 0.008 0.004 408 266 1.028 0.581 0.000 0.017 Total fertility rate (last 3 years) 3.471 0.227 na 2873 1.427 0.065 3.017 3.925 Neonatal mortality (last 10 years) 19.634 3.410 1671 1088 0.999 0.174 12.814 26.454 Post-neonatal mortality (last 10 years) 13.199 3.459 1672 1088 1.107 0.262 6.281 20.117 Infant mortality (last 10 years) 32.832 5.160 1672 1088 1.122 0.157 22.513 43.151 Child mortality (last 10 years) 12.343 3.092 1675 1090 1.068 0.251 6.158 18.528 Under-five mortality (last 10 years) 44.771 6.528 1676 1090 1.236 0.146 31.715 57.827 NA = Not applicable Appendix D | 249 DATA QUALITY TABLES APPENDIX D Table D.1 Age distribution of de facto household population Single-year age distribution of the de facto household population by sex (weighted), Turkey 2008 Males Females Males Females Age Number Percent Number Percent Age Number Percent Number Percent 0 335 1.7 377 1.8 37 260 1.3 262 1.3 1 375 1.9 329 1.6 38 312 1.6 310 1.5 2 336 1.7 336 1.6 39 253 1.3 296 1.4 3 347 1.8 308 1.5 40 276 1.4 292 1.4 4 355 1.8 334 1.6 41 173 0.9 167 0.8 5 366 1.9 299 1.5 42 279 1.4 292 1.4 6 411 2.1 330 1.6 43 293 1.5 253 1.2 7 415 2.1 402 2.0 44 257 1.3 300 1.5 8 417 2.1 414 2.0 45 265 1.4 281 1.4 9 372 1.9 358 1.8 46 214 1.1 236 1.2 10 396 2.0 356 1.7 47 222 1.1 185 0.9 11 401 2.0 348 1.7 48 274 1.4 289 1.4 12 381 1.9 379 1.9 49 214 1.1 187 0.9 13 365 1.9 407 2.0 50 263 1.3 288 1.4 14 357 1.8 358 1.8 51 166 0.8 209 1.0 15 339 1.7 388 1.9 52 233 1.2 228 1.1 16 385 2.0 408 2.0 53 212 1.1 266 1.3 17 392 2.0 362 1.8 54 186 0.9 187 0.9 18 359 1.8 373 1.8 55 232 1.2 259 1.3 19 298 1.5 345 1.7 56 164 0.8 163 0.8 20 271 1.4 366 1.8 57 158 0.8 134 0.7 21 241 1.2 337 1.6 58 166 0.8 169 0.8 22 315 1.6 378 1.8 59 133 0.7 96 0.5 23 315 1.6 379 1.9 60 146 0.7 179 0.9 24 330 1.7 346 1.7 61 100 0.5 77 0.4 25 352 1.8 399 2.0 62 89 0.5 129 0.6 26 329 1.7 339 1.7 63 100 0.5 114 0.6 27 354 1.8 387 1.9 64 94 0.5 89 0.4 28 326 1.7 373 1.8 65 141 0.7 159 0.8 29 330 1.7 302 1.5 66 69 0.4 88 0.4 30 337 1.7 359 1.8 67 71 0.4 81 0.4 31 284 1.4 308 1.5 68 77 0.4 92 0.5 32 319 1.6 310 1.5 69 63 0.3 72 0.4 33 285 1.5 321 1.6 70+ 805 4.1 987 4.8 34 256 1.3 327 1.6 DK/missing 17 0.1 12 0.1 35 318 1.6 312 1.5 36 264 1.3 267 1.3 Total 19,604 100.0 20,450 100.0 DK = Don’t know Note: The de facto population includes all residents and nonresidents who slept in the household the night before the interview. 250 | Appendix D Table D.2 Age distribution of eligible and interviewed women De facto household population of women age 10-54, interviewed women age 15-49, and percentage of eligible women who were interviewed (weighted), by five-year age groups, Turkey 2008 Age group Household population of women age 10-54 Ever-married women age 10-54 Interviewed women age 15-49 Percentage of eligible women interviewedNumber Percent 10-14 1,847 0 NA NA NA 15-19 1,877 189 176 2.5 93.6 20-24 1,806 836 817 11.4 97.7 25-29 1,800 1,390 1,313 18.3 94.5 30-34 1,626 1,438 1,336 18.6 92.9 35-39 1,448 1,381 1,291 18.0 93.5 40-44 1,304 1,254 1,162 16.2 92.7 45-49 1,178 1,152 1,078 15.0 93.5 50-54 1,178 1,155 NA NA NA 15-49 11,038 7,640 7,172 100.0 93.9 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household schedule. NA = Not applicable Table D.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Turkey 2008 Subject Reference group Percentage with missing information Number of cases Month Only Births in the 15 years preceding the survey 1.89 10,874 Month and Year Births in the 15 years preceding the survey 0.12 10,874 Age at Death Births in the 15 years preceding the survey 1.04 438 Age/date at first union Ever married women age 15-49 0.04 7,405 Respondent's education All women age 15-49 0.00 7,405 Diarrhea in last 2 weeks Living children 0-36 months 0.27 3,398 Height - children Living children 0-59 months 25.56 3,398 Weight - children Living children 0-59 months 20.31 3,398 Height or weight - children Living children 0-59 months 25.94 3,398 Height - women Women age 15-49 who had a live birth in the last five years 6.89 2,768 Weight - women Women age 15-49 who had a live birth in the last five years 6.87 2,768 Height or weight - women Women age 15-49 who had a live birth in the last five years 7.06 2,768 Appendix D | 251 Table D.4 Births by calendar years Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living (L), dead (D), and total (T) children (weighted), Turkey 2008 Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 Calendar year L D T L D T L D T L D T 2008 600 8 608 100.0 100.0 100.0 92.1 135.3 92.6 - - - 2007 719 9 728 100.0 100.0 100.0 109.6 123.7 109.8 - - - 2006 695 10 705 100.0 100.0 100.0 97.2 193.1 98.2 103.0 80.1 102.5 2005 630 17 647 100.0 100.0 100.0 118.0 41.6 115.0 92.2 112.7 92.6 2004 672 20 692 100.0 100.0 100.0 102.1 142.5 103.1 104.8 116.9 105.1 2003 653 17 669 100.0 100.0 100.0 117.4 109.8 117.2 94.2 59.1 92.8 2002 714 37 751 97.8 83.4 97.1 135.5 172.4 137.1 96.6 146.2 98.2 2001 826 34 860 97.9 81.4 97.3 102.7 116.2 103.2 113.1 96.9 112.3 2000 747 33 780 98.7 84.8 98.1 107.3 176.9 109.6 96.2 96.6 96.2 1999 727 34 761 97.0 88.1 96.6 100.6 90.1 100.1 103.3 94.8 102.8 2004-2008 3,317 63 3,380 100.0 100.0 100.0 103.5 106.1 103.6 NA NA NA 1999-2003 3,666 155 3,821 98.2 86.1 97.8 111.5 130.5 112.2 NA NA NA 1994-1998 3,392 216 3,607 97.2 83.3 96.4 105.0 125.2 106.1 NA NA NA 1989-1993 3,034 240 3,274 95.2 72.7 93.5 102.3 82.3 100.7 NA NA NA < 1989 3,726 493 4,219 92.7 79.4 91.1 104.9 129.8 107.5 NA NA NA All 17,134 1,167 18,301 96.6 80.8 95.6 105.6 116.2 106.2 NA NA NA NA = Not applicable 1 Both year and month of birth given 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x 252 | Appendix D Table D.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Turkey 2008 Number of years preceding the survey Age at death (days) 0-4 5-9 10-14 15-19 Total 0-19 <1 14 18 32 14 77 1 15 8 16 24 62 2 5 7 7 8 27 3 5 7 8 10 30 4 1 3 4 3 12 5 1 1 4 5 11 6 0 5 0 2 7 7 1 2 6 6 15 8 1 1 1 0 2 9 1 0 2 1 4 10 1 0 2 1 4 12 0 2 0 0 3 13 0 0 0 0 0 15 1 3 2 7 12 17 0 0 1 1 3 19 0 0 1 0 1 20 1 2 5 9 17 21 0 0 3 0 3 22 0 0 0 0 0 23 0 0 0 2 2 25 0 0 0 0 0 26 0 0 1 0 1 27 0 0 0 0 0 28 0 0 0 0 0 29 0 0 0 1 1 30 0 1 3 2 7 Total 0-30 46 62 99 95 302 Percent early neonatal1 88 80 73 68 75 1 ((0-6 days)/(0-30 days)) * 100 Appendix D | 253 Table D.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months and the percentage of infant deaths reported to occur at age under one month, for five-year periods of birth preceding the survey, Turkey 2008 Number of years preceding the survey Age at death (months) 0-4 5-9 10-14 15-19 Total 0-19 <1a 46 62 99 95 302 1 2 5 13 11 32 2 1 3 11 4 19 3 2 7 8 15 31 4 2 7 9 6 24 5 1 3 9 12 25 6 2 8 7 9 25 7 1 6 4 7 18 8 0 2 9 7 19 9 0 7 2 4 13 10 0 2 1 3 5 11 0 2 5 4 11 12 1 7 6 14 27 13 0 2 1 0 3 14 0 1 0 1 2 15 2 1 4 1 9 16 1 1 0 1 3 18 1 5 4 6 17 20 1 0 0 0 1 1 Year 0 0 0 1 1 Total 0-11 58 114 176 176 524 Percent neonatal1 79 54 56 54 58 a Includes deaths under one month reported in days. 1 Under one month/under one year Appendix E | 255 THE CHILD GROWTH STANDARDS (WHO-2006) APPENDIX E 256 | Appendix E Table E.1 Nutritional status of children, according to Child Growth Standards, WHO-2006 Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Turkey 2008 Height-for-age Weight-for-height Weight-for-age Background characterisitic Percentage below -3 SD Percentage below -2 SD Mean Z- score (SD) Percentage below -3 SD Percentage below -2 SD Mean Z- score (SD) Percentage below -3 SD Percentage below -2 SD Mean Z- score (SD) Number of children Age in months <6 1.1 4.9 0.5 0.6 3.2 0.3 0.5 0.5 0.5 177.0 6-11 1.0 7.6 0.7 0.5 3.2 0.7 0.2 2.0 0.7 260.0 12-23 2.7 10.7 (0.4) 0.2 0.6 0.9 0.2 1.8 0.4 531.0 24-35 6.0 17.9 (0.2) 0.0 0.3 1.5 0.4 2.1 0.8 504.0 36-47 4.6 12.0 0.4 0.2 0.3 1.7 0.3 1.7 1.1 476.0 48-59 3.5 13.8 (0.2) 0.0 0.2 1.2 0.3 1.6 0.5 532.0 Region West 1.5 9.8 0.8 0.1 0.2 1.8 0.0 0.4 1.4 854.0 South 2.7 9.1 (0.5) 0.0 0.0 0.7 0.3 1.8 0.2 336.0 Central 1.1 6.5 0.0 0.3 1.2 1.0 0.0 1.1 0.6 538.0 North 2.1 7.8 (0.3) 0.4 1.5 0.7 0.4 2.0 0.3 123.0 East 9.3 23.3 (0.7) 0.2 1.7 0.8 1.0 3.8 0.1 630.0 Residence Urban 2.4 9.5 0.3 0.2 0.7 1.3 0.2 1.3 0.9 1,788.0 Rural 6.7 19.6 (0.6) 0.2 1.3 0.8 0.5 2.7 0.2 692.0 Region (NUTS 1) Istanbul 0.7 10.6 0.4 0.0 0.0 1.6 0.0 0.7 1.2 399.0 West Marmara 1.0 4.6 0.7 0.0 0.0 1.7 0.0 0.0 1.3 67.0 Aegean 2.7 8.6 0.9 0.0 0.0 1.8 0.0 0.0 1.5 292.0 East Marmara 1.4 10.0 0.6 1.0 2.7 1.2 0.0 2.3 1.0 220.0 West Anatolia 0.6 4.5 0.2 0.0 0.2 1.2 0.0 0.3 0.9 247.0 Mediterranean 2.7 9.1 (0.5) 0.0 0.0 0.7 0.3 1.8 0.2 336.0 Central Anatolia 2.6 10.4 0.0 0.0 1.2 1.3 0.0 0.7 0.8 123.0 West Black Sea 0.0 4.9 (0.3) 0.4 1.6 0.8 0.4 0.4 0.4 118.0 East Black Sea 5.5 13.9 (0.4) 0.0 0.0 0.7 0.0 4.2 0.3 48.0 Northeast Anatolia 11.6 25.8 (0.6) 0.0 1.3 1.2 1.3 5.5 0.3 91.0 Central East Anatolia 8.0 22.0 (0.7) 0.3 2.5 0.6 2.0 5.6 (0.1) 159.0 Southeast Anatolia 9.2 23.2 (0.7) 0.3 1.5 0.9 0.4 2.7 0.1 381.0 Education No/Primary inc. 10.9 25.7 (0.2) 0.4 1.7 1.5 0.9 5.3 0.7 544.0 First level primary 1.9 9.9 (0.3) 0.2 0.8 0.8 0.2 0.9 0.4 1,239.0 Second level primary 1.4 8.7 (0.2) 0.0 0.4 0.7 0.0 0.5 0.3 226.0 High sc. and higher 0.7 5.2 1.1 0.0 0.2 2.0 0.0 0.4 1.7 472.0 Wealth index Poorest 9.9 25.1 (0.8) 0.3 1.1 0.9 0.7 4.2 0.1 612.0 Poorer 2.0 12.4 (0.6) 0.2 0.9 0.7 0.3 1.3 0.1 577.0 Middle 2.5 9.9 0.2 0.3 1.1 1.2 0.2 1.0 0.8 528.0 Richer 1.0 3.8 1.3 0.0 0.3 2.1 0.0 0.6 1.8 407.0 Richest 0.0 3.7 0.6 0.0 0.5 1.4 0.0 0.5 1.2 356.0 Total 3.6 12.3 0.0 0.2 0.8 1.2 0.3 1.7 0.7 2,481.0 Appendix F | 257 QUESTIONNAIRES APPENDIX F HACETTEPE UNIVERSITY INSTITUTE OF POPULATION STUDIES 2008 TURKEY DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE IDENTIFICATION CLUSTER NO. HOUSEHOLD NO . 5 REGIONS. 12 REGIONS . PLACE OF RESIDENCE-URBAN(1)-RURAL(2) . PROVINCE __________________________________________ DISTRICT________________________________________ SUB-DISTRICT_______________________________________ VILLAGE ___________________________________ QUARTER_______________________________________________ STREET ___________________________________ NO_________ INTERVIEWER VISITS 1 2 3 FINAL VISIT DATE (DAY-MONTH) ____ ____ ____ ____ ____ ____ NAME-SURNAME OF INTERWIEVER ________________ ________________ _________________ RESULT (*) ____ ____ ____ NEXT VISIT DATE TIME ____ ____ ____ ____ ____ ____ ____ ____ TOTAL NUMBER OF VISITS (*) RESULT CODES NUMBER OF PERSONS 01 COMPLETED 02 NONE OF THE HOUSEHOLD MEMBERS OR NO ELIGIBLE MEMBER PRESENT AT HOME DURING VISITS 03 NONE OF THE HOUSEHOLD MEMBERS PRESENT AT HOME DURING THE SURVEY PERIOD 04 POSTPONED 05 REFUSED 06 DWELLING VACANT/ADDRESS NOT A DWELLING 07 DWELLING DESTROYED 08 DWELLING NOT FOUND 09 PARTLY COMPLETED 96 OTHER _______________________________ (SPECIFY) TOTAL NO. OF PERSONS IN HOUSEHOLD LIST. TOTAL USUAL RESIDENTS OF HOUSEHOLD. TOTAL EVER MARRIED 15-49 WOMEN. SUPERVISOR FIELD EDITOR KEYER - 1 KEYER - 2 ______________________________ ______________________________ ______________________________ ______________________________ DAY-MONTH DAY-MONTH DAY-MONTH DAY-MONTH CONSENT PAGE Hello, my name is _______________________________________. I am coming from Ankara, Hacettepe University Institute of Population Studies. We are conducting a survey with Ministry of Health on population and health. I want to talk to you and ask you some questions about these subjects. You are selected to this survey randomly. All your answers are confidential. Participation in the survey is completely voluntary but attending to this survey and sharing your experiences with us is going to be helpful for the other women in Turkey, and contribute to the planning and development of the services for mother and child health. First of all, I am going to ask questions about your household. Interview will take about 15 minutes to complete. Do you agree to interview? RESPONDENT AGREES TO BE INTERVIEWED .1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED.2 ASK THE PERSON WHO IS GOING TO ANSWER THE HOUSEHOLD QUESTIONNAIRE WHETHER HE/SHE HAS QUESTIONS ABOUT THE SURVEY. MAKE THE NECESSARY EXPLANATIONS AND START THE INTERVIEW. THANK TO THE PERSON WHOM YOU TALKED TO FOR SPENDING HIS/HER TIME AND FINISH THE INTERVIEW. Signature of the interviewer:. Date: _ _ / _ _ / _ _ _ _ HOUR MINUTE SECTION 1 – HOUSEHOLD LIST Now I would like to get some information about people in this household, such as age and education. HH LINE NO HOUSEHOLD LIST CONTINUE BY ASKING A-B-C-D-E. RELATION- SHIP TO HEAD OF HH HOUSEHOLD MEMBERSHIP SEX AGE A. Would you please tell me the names of the persons living in this household beginning with the household head? B. Is there anyone who usually lives in this house but is absent at present? C. Additionally, are there persons who do not live here but who have stayed here last night? D. Are there any other persons such as small children or infants? E. Are there any others who are not members of your family but live here, such as lodgers, friends, or servants? What is the relationship of . to the household head? USE CODE LIST. Does . usually live here? YES .1 NO.2 Did . sleep here last night? YES .1 NO.2 Is . male or female? MALE . 1 FEMALE . 2 How old is .? (what age has ……. completed?) OBTAIN AGE IN COMPLETED YEARS. IF OLDER THAN 95, WRITE “95”. (1) (2) (3) (4) (5) (6) (7) 01 1 2 1 2 1 2 02 1 2 1 2 1 2 03 1 2 1 2 1 2 04 1 2 1 2 1 2 05 1 2 1 2 1 2 06 1 2 1 2 1 2 07 1 2 1 2 1 2 08 1 2 1 2 1 2 09 1 2 1 2 1 2 10 1 2 1 2 1 2 TICK HERE IF AN ADDITIONAL QUESTIONNAIRE IS USED AND PROCEED WITH THE REST OF THE INTERVIEW ON THE ADDITIONAL QUESTIONNAIRE. (3) CODES FOR RELATIONSHIP TO HOUSEHOLD HEAD 01 HEAD 02 WIFE/HUSBAND 03 SON/DAUGHTER 04 SON/DAUGHTER- IN -LAW 05 GRANDCHILD 06 PARENT 07 PARENT -IN -LAW 08 SIBLING 09 SIBLING’S PARTNER 10 SIBLING’S CHILD 11 FATHER’S SIBLING 12 MOTHER’S SIBLING 13 STEP CHILD 14 COUSIN 15 GRAND PARENT 16 GRAND PARENT –IN- LAW 17 SIBLING –IN- LAW 18 SIBLING –IN- LAW’S PARTNER 19 SIBLING -IN-LAW’S CHILD 20 FATHER –IN-LAW’S SIBLING 21 MOTHER-IN-LAW’S SIBLING 22 SECOND WIFE 23 HUSBAND’S SECOND WIFE 24 STEP MOTHER/FATHER 25 ADOPTED CHILD 88 NOT RELATED 96 OTHER RELATIVE 0 1 HH LINE NO PLACE OF BIRTH PLACE OFRESIDENCE FOR VISITORS MATERNAL SURVIVAL PATERNAL SURVIVAL In which province was . born? Was it then a province centre, district centre, sub- district or village, or was it abroad? RECORD THE PRESENT PROVINCE OF PLACE OF BIRTH. PROVINCE TRAFFIC CODES. RECORD “90” FOR ABROAD. CHECK QUESTION 4. IF USUALLY LIVES IN THIS HOUSEHOLD, SKIP TO 10. IF NOT, ASK. Where does . live currently? Is this a province centre, district centre, sub- district or village, or is it abroad? Is.’s natural mother alive? ALIVE. 1 DEAD . 2 DK. . 8 RECORD LINE NO. IF LISTED IN THE HOUSE. RECORD “96” IF LIVING ELSEWHERE. Is.’s natural father alive? ALIVE . 1 DEAD . 2 DK. 8 RECORD LINE NO. IF LISTED IN THE HOUSE. RECORD “96” IF LIVING ELSEWHERE. (1) (8A) (8B) PROVINCE P.O.R. (9A) (9B) PROVINCE P.O.R. (10) (11) (12) (13) 01 1 2 8 12 1 2 8 14 02 1 2 8 12 1 2 8 14 03 1 2 8 12 1 2 8 14 04 1 2 8 12 1 2 8 14 05 1 2 8 12 1 2 8 14 06 1 2 8 12 1 2 8 14 07 1 2 8 12 1 2 8 14 08 1 2 8 12 1 2 8 14 09 1 2 8 12 1 2 8 14 10 1 2 8 12 1 2 8 14 (8B–9B) CODES FOR TYPE OF PLACE OF RESIDENCE 1 PROVINCE CENTER 2 DISTRICT CENTER 3 SUB-DISTRICT/VILLAGE 4 ABROAD HH LINE NO LITERACY AND EDUCATION STATUS AGES 6 AND OVER SCHOOL ATTENDANCE AGE 6-24 Is . literate? YES .1 NO .2 DK .8 Has . ever attended school? YES . 1 NO . 2 DK . 8 What is the highest level of school . attended? What is the highest grade …. completed at that level? USE CODE LIST. LEVEL GRADE Did . graduate from this school? (Did …… receive a diploma?) YES . 1 NO . 2 DK . 8 Is . attending school this educational year? YES . 1 NO . 2 DK . 8 Which level of school and grade is . attending? USE CODE LIST. LEVEL GRADE (1) (14) (15) (16A) (16B) (17) (18) (19A) (19B) 01 1 2 8 1 2 8 22 1 2 8 1 2 8 20 02 1 2 8 1 2 8 22 1 2 8 1 2 8 20 03 1 2 8 1 2 8 22 1 2 8 1 2 8 20 04 1 2 8 1 2 8 22 1 2 8 1 2 8 20 05 1 2 8 1 2 8 22 1 2 8 1 2 8 20 06 1 2 8 1 2 8 22 1 2 8 1 2 8 20 07 1 2 8 1 2 8 22 1 2 8 1 2 8 20 08 1 2 8 1 2 8 22 1 2 8 1 2 8 20 09 1 2 8 1 2 8 22 1 2 8 1 2 8 20 10 1 2 8 1 2 8 22 1 2 8 1 2 8 20 (16A-19A-21A) LEVEL CODES (16B-19B-21B) GRADE CODES 1 PRIMARY SCHOOL 2 SECONDARY SCHOOL 3 PRIMARY EDUCATION 4 HIGH SCHOOL 5 UNIVERSITY 6 MASTER’S DEGREE 7 Ph.D. 8 DK 00 LESS THAN ONE YEAR/PREPARATORY LEVEL 66 MASTER’S/Ph.D. 98 DK HH LINE NO SCHOOL ATTENDANCE AGE 6-24 MARITAL STATUS AGE 12 AND OVER Did . attend school last year? (2007-2008) YES . 1 NO . 2 DK . 8 Which level of school and grade did. attend? USE CODE LIST. LEVEL GRADE Has . ever married? YES .1 NO .2 What is.’s marital status? CURRENTLY MARRIED. 1 WIDOWED . 2 DIVORCED . 3 SEPARATED . 4 DK . 8 . RECORD HH LINE NO OF HUSBAND AND SKIP TO 25. IF HUSBAND IS NOT IN THE HOUSEHOLD LIST, RECORD “96”. (1) (20) (21A) (21B) (22) (23) (24) 01 1 2 8 22 1 2 26 1 2 3 4 8 25 02 1 2 8 22 1 2 26 1 2 3 4 8 25 03 1 2 8 22 1 2 26 1 2 3 4 8 25 04 1 2 8 22 1 2 26 1 2 3 4 8 25 05 1 2 8 22 1 2 26 1 2 3 4 8 25 06 1 2 8 22 1 2 26 1 2 3 4 8 25 07 1 2 8 22 1 2 26 1 2 3 4 8 25 08 1 2 8 22 1 2 26 1 2 3 4 8 25 09 1 2 8 22 1 2 26 1 2 3 4 8 25 10 1 2 8 22 1 2 26 1 2 3 4 8 25 HH LINE NO ELIGIBILITY FOR INDIVIDUAL INTERVIEW WOMEN AGED 15-49 ELIGIBILITY FOR NEVER MARRIED WOMEN MODULE WOMEN AGED 15-49 ELIGIBILITY TO THE WELFARE OF THE ELDERLY MODULE AGES 60 AND OVER CIRCLE LINE NUMBER IF EVER MARRIED WOMAN AGE 15-49 AND SKIP TO NEXT PERSON. IF NOT, SKIP TO 27. CIRCLE LINE NUMBER IF NEVER MARRIED WOMAN AGE 15-49 AND SKIP TO NEXT PERSON. IF NOT, SKIP TO 27. CIRCLE LINE NUMBER IF PERSON AGE 60 AND OVER AND SKIP TO NEXT PERSON. (1) (25) (26) (27) 01 01 01 01 02 02 02 02 03 03 03 03 04 04 04 04 05 05 05 05 06 06 06 06 07 07 07 07 08 08 08 08 09 09 09 09 10 10 10 10 AFTER DETERMINING THE ELIGIBLE PERSONS, GO BACK TO THE COVER PAGE AND COMPLETE THE NUMBER OF PERSONS SECTION. SECTION 2. NEVER MARRIED WOMAN INFORMATION FORM 50 CHECK 26 IN THE HOUSEHOLD LIST: AT LEAST ONE PERSON NOBODY WAS 70 WAS RECORDED RECORDED 51 TOTAL NUMBER OF NEVER MARRIED WOMEN. RECORD THE NAMES AND THE LINE NUMBERS OF NEVER MARRIED WOMEN FROM THE HOUSEHOLD LIST. ASK THE QUESTIONS SEPARATELY FOR EACH RECORDED WOMAN. IF THERE ARE MORE THAN ONE NEVER MARRIED WOMAN, BEGIN WITH THE WOMAN AT THE TOP OF LIST. IF THERE ARE MORE THAN TWO NEVER MARREID WOMEN, USE AN ADDITIONAL QUESTIONNAIRE. FROM 2 NAME ____________________________ NAME ____________________________ FROM 1 LINE NO …………………… LINE NO …………………… 53 For most of the time until . was 12 years old, in which province did she live? RECORD THE NAME AND CODE OF THE PROVINCE. PROVINCE NAME PROVINCE CODE ________________________ PROVINCE NAME PROVINCE CODE ________________________ 53A Was this place then a province centre, a district centre, a sub- district or a village ? Or was it abroad? PROVINCE CENTER .1 PROVINCE CENTER .1 DISTRICT CENTER .2 DISTRICT CENTER .2 SUBDSITRICT/VILLAGE .3 SUBDSITRICT/VILLAGE .3 ABROAD .4 ABROAD .4 DON’T KNOW .8 DON’T KNOW .8 54 How long has she been living continuously in ……. ((NAME OF CURRENT PLACE OF INTERVIEW OR USUAL RESIDENCE)? YEAR . YEAR . SINCE SHE WAS BORN.95 57 SINCE SHE WAS BORN.95 57 DON’T KNOW.98 DON’T KNOW.98 55 Where did she live before she moved here (there)? RECORD THE NAME AND CODE OF THE PROVINCE. PROVINCE NAME PROVINCE CODE ________________________ PROVINCE NAME PROVINCE CODE ________________________ 56 Was this place then a province centre, a district centre, a sub- district or a village ? Or was it abroad? PROVINCE CENTER .1 PROVINCE CENTER .1 DISTRICT CENTER .2 DISTRICT CENTER .2 SUBDSITRICT/VILLAGE .3 SUBDSITRICT/VILLAGE .3 ABROAD .4 ABROAD .4 DON’T KNOW .8 DON’T KNOW .8 FROM 2 NAME ____________________________ NAME ____________________________ FROM 1 LINE NO ……….……… LINE NO ……………………. 57 What is .’s mother tongue? RECORD ONE LANGUAGE ONLY. TURKISH .1 TURKISH .1 KURDISH .2 KURDISH .2 ARABIC .3 ARABIC .3 OTHER ________________________ (SPECIFY) 7 OTHER ________________________ (SPECIFY) 7 DON’T KNOW .8 59 DON’T KNOW .8 59 57A Which languages besides her mother tongue can . speak? RECORD ALL LANGUAGES MENTIONED. TURKISH .A TURKISH .A KURDISH .B KURDISH .B ARABIC .C ARABIC .C OTHER ________________________ (SPECIFY) U OTHER ________________________ (SPECIFY) U NO OTHER LANGUAGE. Y NO OTHER LANGUAGE. Y DON’T KNOW.X DON’T KNOW.X 59 Is . currently engaged or promised, or does show have a boyfriend whom she plans to marry? YES .1 YES .1 NO.2 NO.2 60 Did . work in a regular or an irregular job whether paid or unpaid in the past week? YES .1 63 YES .1 63 NO.2 NO. 2 DON’T KNOW.8 DON’T KNOW.8 61 As you know some women sell small things, sell goods at the market place, work on the family farm or business paid or unpaid, look after children, work as housemaids etc. Did ……. do any of these or any other work of similar nature in the last week? YES.1 63 YES.1 63 NO. 2 NO. 2 DON’T KNOW.8 DON’T KNOW.8 62 Does . have a job she normally works at? YES .1 YES .1 NO. 2 NO. 2 DON’T KNOW.8 67 DON’T KNOW.8 67 FROM 2 NAME ______________________________ NAME __________________________________ FROM 1 LINE NO…………………… LINE NO ……………………. 63 What is .’s occupation? What kind of job does she have? RECORD THE JOB IN DETAIL AND CIRCLE THE APPROPRIATE SECTOR IN THE NEXT COLUMN __________________________________ (1st WOMAN) __________________________________ (2nd WOMAN) AGRICULTURE.1 AGRICULTURE.1 INDUSTRY. SERVICES. DON’T KNOW. 2 3 8 INDUSTRY. SERVICES. DON’T KNOW. 2 3 8 64 Does . work for public or private PUBLIC.1 PUBLIC.1 sector? PRIVATE.2 PRIVATE.2 DON’T KNOW.8 DON’T KNOW.8 65 What is .’s status/position in her job? EMPLOYER.01 EMPLOYER. 01 WAGED, WORKER (REGULAR).02 WAGED, WORKER (REGULAR). 02 SALARIED, GOVERNMENT OFFICAL.03 SALARIED, GOVERNMENT OFFICAL. 03 DAILY WAGED (SEASONAL/TEMPORAL).04 DAILY WAGED (SEASONAL/TEMPORAL). 04 SELF EMPLOYED (REGULAR).05 SELF EMPLOYED (REGULAR). 05 SELF EMPLOYED (IRREGULAR). 06 SELF EMPLOYED (IRREGULAR). 06 UNPAID FAMILY WORKER.07 UNPAID FAMILY WORKER. 07 OTHER________________________________96 OTHER________________________________96 (SPECIFY) (SPECIFY) DON’T KNOW.98 DON’T KNOW.98 66 Does ………. pay social security when doing this job? (IF YES) According to which schedule? NO. SSK . EMEKLİ SANDIĞI . BAĞ-KUR . PRIVATE. YEŞİL KART . OTHER _________________________ (SPECIFY) DON’T KNOW. 0 1 2 3 4 5 7 8 NO. SSK . EMEKLİ SANDIĞI . BAĞ-KUR . PRIVATE. YEŞİL KART . OTHER _________________________ (SPECIFY) DON’T KNOW. 0 1 2 3 4 5 7 8 67 Is ………. covered by any health insurance? (IF YES) According to which schedule? NO. SSK . EMEKLİ SANDIĞI . BAĞ-KUR . PRIVATE HEALTH INSURANCE. YEŞİL KART . OTHER _________________________ (SPECIFY) DON’T KNOW. 0 1 2 3 4 5 7 8 NO. SSK . EMEKLİ SANDIĞI . BAĞ-KUR . PRIVATE HEALTH INSURANCE. YEŞİL KART . OTHER _________________________ (SPECIFY) DON’T KNOW. 0 1 2 3 4 5 7 8 68 IF THERE IS ANOTHER NEVER MARRIED WOMAN IN THE HOUSEHOLD, RETURN TO 53. SKIP TO NEXT SECTION OTHERWISE. IF THERE IS ANOTHER NEVER MARRIED WOMAN IN THE HOUSEHOLD, RETURN TO 53 IN THE 1ST COLUMN IN THE ADDITIONAL QUESTIONNAIRE. SKIP TO NEXT SECTION OTHERWISE. SECTION 3. WELFARE OF ELDERLY 70 CHECK 27; IN HOUSEHOLD LIST: THERE IS AT LEAST ONE PERSON AGE 60 NOBODY IS 123 AND OVER RECORDED RECORDED 71 TOTAL NUMBER OF ELDERLY PERSONS IN THE HOUSEHOLD LIST. ENTER THE NAME AND LINE NUMBER OF EACH PERSON 60 AND OVER LISTED IN THE HOUSEHOLD SCHEDULE. ASK QUESTIONS ABOUT EACH OF THE LISTED PERSONS SEPARATELY. BEGIN WITH THE FIRST ELDERLY ON THE HOUSEHOLD LIST. IF THERE ARE MORE THAN 2 ELDERLY, USE ADDITIONAL QUESTIONNAIRE. FROM 2 NAME ____________________________ NAME ____________________________ FROM 1 LINE NO . LINE NO . 72 Does ……… have any living own children? (IF YES) How many? NO LIVING CHILD.00 74 NO LIVING CHILD.00 74 NO. OF OWN CHILDREN . NO. OF OWN CHILDREN . 73 Where do……….’s own children live of his/her own? FOR ALL CHILDREN, CIRCLE MORE THAN ONE IF NECESSARY. SAME HOUSE.A SAME HOUSE.A SAME BUILDING/STREET OR QUARTER.B SAME BUILDING/STREET OR QUARTER.B SAME CITY/VILLAGE.C SAME CITY/VILLAGE.C CLOSE CITY/VILLAGE…….D CLOSE CITY/VILLAGE…….D DISTANT CITY/VILLAGE. E DISTANT CITY/VILLAGE.E OTHER COUNTRY. F OTHER COUNTRY. F DK. X DK.X 74 Does ……… have any living step children? IF YES: How many? NO LIVING STEP CHILD.00 76 NO LIVING STEP CHILD.00 76 NO. OF STEP CHILDREN . NO. OF STEP CHILDREN . 75 Where do……….’s step children live? FOR ALL CHILDREN, CIRCLE MORE THAN ONE IF NECESSARY. SAME HOUSE.A SAME HOUSE.A SAME BUILDING/STREET OR QUARTER. B SAME BUILDING/STREET OR QUARTER. B SAME CITY/VILLAGE.C SAME CITY/VILLAGE.C CLOSE CITY/VILLAGE…….D CLOSE CITY/VILLAGE…….D DISTANT CITY/VILLAGE. E DISTANT CITY/VILLAGE.E OTHER COUNTRY. F OTHER COUNTRY. F DK. X DK.X FROM 2 NAME ____________________________ NAME ____________________________ FROM 1 LINE NO ….………………… LINE NO ….………………… 76 Who takes the main responsibility for ……….’s needs, health and welfare? HIMSELF/HERSELF.01 HIMSELF/HERSELF.01 HUSBAND/WIFE.02 HUSBAND/WIFE.02 OWN DAUGHTER.03 OWN DAUGHTER.03 OWN SON.04 OWN SON.04 STEP DAUGHTER.05 STEP DAUGHTER.05 STEP SON.06 STEP SON.06 CHILDREN IN LAW.07 CHILDREN IN LAW.07 SIBLING.08 SIBLING.08 GRANDCHILD.09 GRANDCHILD.09 SIBLING’S CHILD.10 SIBLING’S CHILD.10 OTHER CLOSE RELATIVE.11 OTHER CLOSE RELATIVE.11 DISTANT RELATIVE.12 DISTANT RELATIVE.12 NEIGHBOUR.13 NEIGHBOUR.13 PAID CARETAKER.14 PAID CARETAKER.14 OTHER _________________________96 OTHER _________________________96 (SPECIFY) (SPECIFY) 77 Does . have any income? YES . 1 YES . 1 NO .2 79 NO . 2 79 78 What are the source(s) of this income? RECORD ALL MENTIONED. PENSION (SELF)………………….A PENSION (SELF)………………….A PENSION (INDIRECT)……. B PENSION (INDIRECT)…….B OLD AGE PENSION.C OLD AGE PENSION.C RENT/INTEREST…………….D RENT/INTEREST…………….D FROM RELATIVE IN TURKEY.E FROM RELATIVE HERE.E FROM RELATIVE ABROAD.F FROM RELATIVE ABROAD.F SALARY/WAGE……….G SALARY/WAGE……….G OTHER __________________________U OTHER __________________________U (SPECIFY) (SPECIFY) 79 Is he/she covered by any health insurance? (IF YES) According to which schedule? NO . SSK . EMEKLİ SANDIĞI . BAĞ-KUR . PRIVATE HEALTH INSURANCE. YEŞİL CARD . OTHER _________________________ (SPECIFY) DK . 0 1 2 3 4 5 7 8 NO . SSK . EMEKLİ SANDIĞI . BAĞ-KUR . PRIVATE HEALTH INSURANCE. YEŞİL CARD . OTHER _________________________ (SPECIFY) DK . 0 1 2 3 4 5 7 8 80 Does …. have a continuous health problem or disability that handicaps her/his daily life activities? YES. 1 YES.1 NO. .2 82 NO. .2 82 SINCE BIRTH .000 MONTH. 1 YEAR . 2 DON’T KNOW .998 SINCE BIRTH . 000 MONTH. 1 YEAR . 2 DON’T KNOW . 998 81 For how long has this health problem handicapped .’s daily activities? FROM 2 NAME ____________________________ NAME ____________________________ FROM 1 LINE NO ….………………… LINE NO ….………………… 82 Is………. continuously confined to bed? YES .1 85 YES .1 85 NO .2 NO .2 83 Is ………. confined to chair/armchair all day long? YES .1 YES .1 NO .2 NO .2 84 Is ……….’s daily life limited to house/flat or garden? YES .1 YES .1 NO . 2 NO. .2 85 Does ………. do the things I will list now easily, with difficulty or only with the assistance of another person? Getting into/out of bed? Dressing-undressing? Eating? Going to and using the toilet? Taking a bath? Shopping? Cooking? Daily housework? Outside errands (paying bills, going to a bank/hospital, etc.)? Travelling outside the city? EASY 1 1 1 1 1 1 1 1 1 1 WITH DIFF. 2 2 2 2 2 2 2 2 2 2 WITH ASSISTANCE 3 3 3 3 3 3 3 3 3 3 IMPOSSIB LE 4 4 4 4 4 4 4 4 4 4 EASY 1 1 1 1 1 1 1 1 1 1 WITH DIFF. 2 2 2 2 2 2 2 2 2 2 WITH ASSISTANCE 3 3 3 3 3 3 3 3 3 3 IMPOSSIB LE 4 4 4 4 4 4 4 4 4 4 86 IF THERE IS ANOTHER ELDERLY IN THE HOUSE RETURN TO QUESTION 72; OTHERWISE, SKIP TO NEXT SECTION IF THERE IS ANOTHER ELDERLY RETURN TO QUESTION 72 IN FIRST COLUMN IN ADDITIONAL QUESTIONNAIRE; OTHERWISE, SKIP TO NEXT SECTION SECTION 4. HOUSING CHARACTERISTICS 123 Now I will ask some questions about the dwelling that you usually live in. Does the house you live in belong to a household member, is it rented from someone else, is it a lodging, or do you just live here without having to pay anything? OWNED BY A HOUSEHOLD MEMBER.1 1 RENTED . 2 LODGING . 3 NO RENT PAID. 4 OTHER ___________________________________________ 7 (SPECIFY) 125 Does anyone from this household own a house other than this one elsewhere? YES . 1 NO . 2 129 What is the source of drinking water for members of your household? PIPED WATER PIPED WATER IN HOUSE/GARDEN. 11 ¾¾► 133 PUB. PIPED WATER OUTSIDE HOUSE/GARDEN . 12 WELL WATER WELL IN HOUSE/GARDEN . 21 ¾¾► 133 PUBLIC WELL . 22 SURFACE WATER PIPED SURFACE WATER IN HOUSE/GARDEN . 31 ¾¾► 133 SPRING/PUBLIC FOUNTAIN . 32 RIVER/STREAM/POND/LAKE/DAM . 33 RAINWATER . 41 ¾¾► 133 TANKER TRUCK . 51 BOTTLED WATER/DEMI JOHN/PET WATER. 61 ¾¾► 133 OTHER _________________________________________ 96 (SPECIFY) 130 How long does it take you go there, get water, and come back? MINUTE . ON PREMISES . 996 133 What is the source of daily use water for hand washing, dishwashing, and laundry in this house? PIPED WATER PIPED WATER IN HOUSE/GARDEN. 11 PUB. PIPED WATER OUTSIDE HOUSE/GARDEN . 12 WELL WATER WELL IN HOUSE/GARDEN . 21 PUBLIC WELL . 22 SURFACE WATER PIPED SURFACE WATER IN HOUSE/GARDEN . 31 SPRING/PUBLIC FOUNTAIN . 32 RIVER/STREAM/POND/LAKE/DAM . 33 RAIN WATER . 41 TANKER TRUCK . 51 BOTTLED WATER/DEMI JOHN/PET WATER. 61 WATER STATION . 71 OTHER _________________________________________ 96 (SPECIFY) 137 Is the toilet inside the house or outside? NO FACILITY/BUSH/FIELD/PUBLIC TOILET . 0 ¾¾► 141 INSIDE . 1 OUTSIDE . 2 INSIDE AND OUTSIDE . 3 OTHER __________________________________________ 7 (SPECIFY) 138 Is your toilet connected to the sewerage system? IF MORE THAN ONE TOILET IS USED, RECORD ACCORDING TO THE ONE INSIDE OR CLOSEST TO THE HOUSE. (IF NO) Is your toilet connected to open pit or closed pit? CONNECTED TO SEWERAGE . 1 OPEN PIT . 2 CLOSED PIT . 3 OTHER __________________________________________ 7 (SPECIFY) 139 Do only the members of your household use the toilet or is it shared with other household(s)? ONLY HOUSEHOLD MEMBERS . 1 WITH OTHER HOSEHOLD(S) . 2 141 How is your house heated in the winter? CENTRAL HEATING NATURAL GAS. 11 DIESEL OIL/GASOIL . 12 WOOD/COAL . 13 OTHER . 14 FLAT HEATING/COMBI BOILER NATURAL GAS. 21 DIESEL OIL/GASOIL . 22 OTHER . 23 STOVE NATURAL GAS. 31 DIESEL OIL/GASOIL . 32 WOOD/COAL . 33 DRIED COW DUNG . 34 OTHER . 35 ELECTRIC HEATER.40 OTHER _________________________________________ 96 (SPECIFY) 142A How many rooms are there in your house? Would you please include bedrooms, living rooms, sitting rooms and studying rooms? NO OF ROOMS . 142B From all you listed, how many rooms in your house are generally used for sleeping? ROOMS USED FOR SLEEPING . 142C Is there a separate kitchen? NO . 0 YES . 1 142D Is there a separate bathroom? NO . 0 YES . 1 143 What is the main material of the floor? NATURAL FLOOR EARTH . 11 RUDIMENTARY WOOD BLANKS . 21 FINISHED FLOOR PARQUET/POLISHED WOOD/LAMINA. 31 KARO . 32 CEMENT . 34 CARPET/WALL-TO-WALL CARPETS . 35 MARLEY . 36 MOZAIC . 37 LAMINATED . 38 OTHER _________________________________________ 96 (SPECIFY) 144 In order to get information about your household wealth, I want to learn whether you have some of the household assets. Do you have the following in the household? NO YES Refrigerator REFRIGATOR . 0 1 Gas or Electric oven GAS/ELECTRIC OVEN . 0 1 Microwave oven MICROWAVE OVEN. 0 1 Food processor/Mixer/Blender FOOD PROCESSOR/MIXER/BLENDER . 0 1 Dishwasher DISHWASHER . 0 1 Garbage dispenser GARBAGE DISPENSER . 0 1 Washing machine WASHING MACHINE . 0 1 Drying machine DRYING MACHINE . 0 1 Iron IRON . 0 1 Vacuum Cleaner VACUUM CLEANER. 0 1 LCD/Plasma TV LCD - PLASMA TELEVISION . 0 1 Television TELEVISION . 0 1 Paid TV services PAID TV SERVICES . 0 1 Satellite TV SATELLITE TV. . 0 1 Video camera VİDEO CAMERA . 0 1 DVD/VCD Player DVD/VCD PLAYER . 0 1 Camera CAMERA . 0 1 Cell phone (IF YES) How many members have cell phones? CELL PHONE . 0 Telephone TELEPHONE . 0 1 Laptop computer LAPTOP COMPUTER . 0 1 Desktop computer DESKTOP COMPUTER . 0 1 Internet connection İNTERNET CONNECTION . 0 1 Indoors sporting equipment (Treadmill, stationary bicycle, etc.) INDOORS SPORTS EQUIPMENT . 0 1 Air conditioner AIR CONDITIONER . 0 1 Private car (IF YES) How many? PRIVATE CAR . 0 Taxi/Minibus/Bus/other commercial vehicles TAXI/MINIBUS/BUS . 0 1 Tractor TRACTOR . 0 1 Motorcycle MOTOCYCLE . 0 1 146 Has there been any difficulty in covering the following expenditures in the last 12 months in your household? NOT YES NO APPLICABLE Food expenditures? FOOD . 1 2 3 Health expenditures? HEALTH . 1 2 3 Education expenditures? EDUCATON. 1 2 3 Rent? RENT. 1 2 3 Bills (Electricity, water, etc.)? BILLS . 1 2 3 Mortgage payments? MORTGAGE . 1 2 3 160 CHECK COVER PAGE: CLUSTER NO EVEN , HH NO ODD OR CLUSTER NO ODD, HH NO EVEN CLUSTER NO EVEN CLUSTER NO ODD 161 AND HH NO EVEN AND HH NO ODD 160A Now I want to test whether the salt that you use in your house is iodized or not. Can you please bring me a sample of the salt you use in your house? IF BOTH PRESERVING POT AND PACKAGE ARE AVALIABLE, APPLY POTASSIUM IODADE TEST BY TAKING A SAMPLE FROM PRESERVING POT AND RECORD THE RESULT. POTASSIUM IODADE TEST NOT IODIZED - 0 PPM (NO COLOUR). 11 LESS THAN 15 PPM (LIGHT COLOUR).12 15 PPM OR MORE (DARK COLOUR).13 NOT TESTED ___________________________________ 00 161 (SPECIFY) 160B APPLY POTASIUM IODURE TEST AND RECORD THE RESULT. POTASSIUM IODURE TEST NOT IODIZED - 0 PPM (NO COLOUR). 21 IODIZED (HAS COLOUR) . 22 NOT TESTED ___________________________________ 00 (SPECIFY) 161 LINE NO. OF THE RESPONDENT IN THE HOUSEHOLD SCHEDULE HOUSEHOLD LINE NO . 162 LANGUAGE USED FOR CONDUCTING THE HOUSEHOLD QUESTIONNAIRE TURKISH . 1 ¾►164S KURDISH . 2 ARABIC . 3 OTHER __________________________________________ 7 (SPECIFY) 163 WAS AN INTERPRETER USED? YES. 1 NO . 2 164S RECORD THE TIME HOUR-MINUTE. AGE – YEAR OF BIRTH TABLE AGE YEAR OF BIRTH AGE YEAR OF BIRTH HAS NOT CELEBRATED BIRTHDAY IN 2008 CELEBRATED BIRTHDAY IN 2008 HAS NOT CELEBRATED BIRTHDAY IN 2008 CELEBRATED BIRTHDAY IN 2008 DOES NOT KNOW DOES NOT KNOW 0 2007 -- 50 1957 1958 1 2006 2007 51 1956 1957 2 2005 2006 52 1955 1956 3 2004 2005 53 1954 1955 4 2003 2004 54 1953 1954 5 2002 2003 55 1952 1953 6 2001 2002 56 1951 1952 7 2000 2001 57 1950 1951 8 1999 2000 58 1949 1950 9 1998 1999 59 1948 1949 10 1997 1998 60 1947 1948 11 1996 1997 61 1946 1947 12 1995 1996 62 1945 1946 13 1994 1995 63 1944 1945 14 1993 1994 64 1943 1944 15 1992 1993 65 1942 1943 16 1991 1992 66 1941 1942 17 1990 1991 67 1940 1941 18 1989 1990 68 1939 1940 19 1988 1989 69 1938 1939 20 1987 1988 70 1937 1938 21 1986 1987 71 1936 1937 22 1985 1986 72 1935 1936 23 1984 1985 73 1934 1935 24 1983 1984 74 1933 1934 25 1982 1983 75 1932 1933 26 1981 1982 76 1931 1932 27 1980 1981 77 1930 1931 28 1979 1980 78 1929 1930 29 1978 1979 79 1928 1929 30 1977 1978 80 1927 1928 31 1976 1977 81 1926 1927 32 1975 1976 82 1925 1926 33 1974 1975 83 1924 1925 34 1973 1974 84 1923 1924 35 1972 1973 85 1922 1923 36 1971 1972 86 1921 1922 37 1970 1971 87 1920 1921 38 1969 1970 88 1919 1920 39 1968 1969 89 1918 1919 40 1967 1968 90 1917 1918 41 1966 1967 91 1916 1917 42 1965 1966 92 1915 1916 43 1964 1965 93 1914 1915 44 1963 1964 94 1913 1914 45 1962 1963 46 1961 1962 47 1960 1961 48 1959 1960 49 1958 1959 PROVINCE TRAFFIC CODES 01 ADANA 21 DİYARBAKIR 41 KOCAELİ 61 TRABZON 02 ADIYAMAN 22 EDİRNE 42 KONYA 62 TUNCELİ 03 AFYON 23 ELAZIĞ 43 KÜTAHYA 63 ŞANLIURFA 04 AĞRI 24 ERZİNCAN 44 MALATYA 64 UŞAK 05 AMASYA 25 ERZURUM 45 MANİSA 65 VAN 06 ANKARA 26 ESKİŞEHİR 46 K.MARAŞ 66 YOZGAT 07 ANTALYA 27 GAZİANTEP 47 MARDİN 67 ZONGULDAK 08 ARTVİN 28 GİRESUN 48 MUĞLA 68 AKSARAY 09 AYDIN 29 GÜMÜŞHANE 49 MUŞ 69 BAYBURT 10 BALIKESİR 30 HAKKARİ 50 NEVŞEHİR 70 KARAMAN 11 BİLECİK 31 HATAY 51 NİĞDE 71 KIRIKKALE 12 BİNGÖL 32 ISPARTA 52 ORDU 72 BATMAN 13 BİTLİS 33 İÇEL 53 RİZE 73 ŞIRNAK 14 BOLU 34 İSTANBUL 54 SAKARYA 74 BARTIN 15 BURDUR 35 İZMİR 55 SAMSUN 75 ARDAHAN 16 BURSA 36 KARS 56 SİİRT 76 IĞDIR 17 ÇANAKKALE 37 KASTAMONU 57 SİNOP 77 YALOVA 18 ÇANKIRI 38 KAYSERİ 58 SİVAS 78 KARABÜK 19 ÇORUM 39 KIRKLARELİ 59 TEKİRDAĞ 79 KİLİS 20 DENİZLİ 40 KIRŞEHİR 60 TOKAT 80 OSMANİYE 81 DÜZCE 90 ABROAD CONVERSION OF YEARS OF BIRTH FROM RUMI CALENDAR TO GREGORIAN CALENDAR YEARS RUMI YEARS + 584 = GREGORIAN YEAR HACETTEPE UNIVERSITY INSTITUTE OF POPULATION STUDIES 2008 TURKEY DEMOGRAPHIC AND HEALTH SURVEY EVER MARRIED WOMEN’S QUESTIONNAIRE IDENTIFICATION CLUSTER NO. HOUSEHOLD NO . 5 REGIONS. 12 REGIONS . PLACE OF RESIDENCE-URBAN(1)-RURAL(2) . PROVINCE __________________________________________ DISTRICT___________________________________________ SUB-DISTRICT___________________________________________ VILLAGE _______________________________________ QUARTER __________________________________________________ STREET ________________________________________ NO________ NAME-SURNAME OF WOMAN_______________________________ LINE NUMBER OF WOMAN. IF CURRENTLY MARRIED NAME SURNAME OF HUSBAND_____________________________ LINE NUMBER OF HUSBAND . INTERVIEWER VISITS 1 2 3 FINAL VISIT DATE (DAY-MONTH) ____ ____ ____ ____ ____ ____ INTERVIEWER'S NAME-SURNAME _________________ _________________ ________________ RESULT (*) ____ ____ ____ NEXT VISIT DAY-MONTH HOUR ____ ____ ____ ____ ____ ____ ____ ____ TOTAL NO OF VISITS (*) RESULT CODES 01 COMPLETED 02 WOMAN IS NOT AT HOME DURING VISITS 03 WOMAN IS NOT AT HOME DURING SURVEY DATE 04 POSTPONED 05 REFUSED 09 PARTLY COMPLETED 96 OTHER ______________________________ (SPECIFY) SUPERVISOR FIELD EDITOR KEYER - 1 KEYER - 2 ______________________________ ______________________________ ______________________________ ______________________________ DAY-MONTH DAY-MONTH DAY-MONTH DAY-MONTH CONSENT PAGE Hello, my name is _______________________________________. I am coming from Ankara, Hacettepe University Institute of Population Studies. We are conducting a survey with Ministry of Health on population and health. I want to talk to you and ask you some questions about these subjects. You are selected to this survey randomly. All your answers are confidential. Participation in the survey is completely voluntary but attending to this survey and sharing your experiences with us is going to be helpful for the other women in Turkey, and contribute to the planning and development of the services for mother and child health. Now I am going to ask questions about health and daily life. Interview will take about 40 minutes to complete. Do you agree to interview? RESPONDENT AGREES TO BE INTERVIEWED .1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED.2 ASK THE SELECTED PERSON TO INTERVIEW WHETHER HE/SHE HAS QUESTIONS ABOUT THE SURVEY. MAKE THE NECESSARY EXPLANATIONS AND START THE INTERVIEW. THANK THE SELECTED PERSON TO INTERVIEW FOR SPENDING HIS/HER TIME AND FINISH THE INTERVIEW. Signature of the interviewer:. Date: _ _ / _ _ / _ _ _ _ 1 9 SECTION 1A. RESPONDENT’S BACKGROUND 101S RECORD THE TIME HOUR-MINUTE. 105 First I would like to ask some questions about your age and educational status. In what year and month were you born? MONTH . DOESN’T KNOW MONTH. 98 YEAR . DOESN’T KNOW YEAR . 9998 106 How old are you exactly? What age have you completed? CHECK ANSWERS TO 105 AND 106 USING AGE-YEAR OF BIRTH TABLE. IF INCONSISTENT PROBE AND CORRECT. AGE MUST BE DETERMINED! AGE IN COMPLETED YEARS . 107 Have you ever attended school? YES . 1 NO . 2 114 108 What is the highest level you attended? PRIMARY SCHOOL . 11 GENERAL SECONDARY SCHOOL . 12 VOCATIONAL SECONDARY SCHOOL . 13 PRIMARY EDUCATİON . 14 GENERAL HIGH SCHOOL . 15 VOCATIONAL HIGH SCHOOL . 16 UNIVERSITY . 17 MASTER’S DEGREE. 18 Ph.D. . 19 109A What is the highest level you have completed at that level? RECORD “00” IF THE RESPONDENT COMPLETED PREPARATORY CLASS OR SHE DID NOT COMPLETE ANY GRADE, AND “66” FOR MASTER’S/Ph. D. GRADE . 109B Did you graduate (receive diploma) from this school? YES . 1 NO . 2 113 CHECK 108 AND 109A: ATTENDED SCHOOL FOR 5 OR LESS YEARS ATTENDED SCHOOL FOR 6 OR MORE YEARS 115B 114 Can you read a letter or newspaper easily, with difficulty, or not at all? NOT AT ALL . 0 WITH DIFFICULTY . 1 EASILY . 2 115B Aside from formal education; YES NO Have you ever attended a literacy course? LITERACY. 1 2 Have you ever attended Koran course? KORAN. 1 2 Have you ever attended any foreign language course? FOREIGN LANGUAGE. 1 2 Have you ever attended computer course? COMPUTER. 1 2 Have you ever attended any occupation/skill training course? OTHER. 1 2 115C Have you ever smoked cigarettes regularly? YES . 1 NO . 2 115G 115D How old were you when you started to smoke regularly? AGE STARTED TO SMOKE . 115E Do you currently smoke? YES . 1 NO . 2 115E What is the average number of cigarettes you smoke/smoked? DAY.1 WEEK.2 MONTH.3 115G Does anybody smoke in the kitchen, lounge or rooms in YES . 1 your house? NO . 2 116A What is your mother tongue? TURKISH . 1 KURDISH . 2 ARABIC . 3 OTHER ___________________________________________ 7 (SPECIFY) 116B In addition to your mother tongue, which language(s) can you speak? (IF YES) Which language(s)? RECORD ALL MENTIONED. TURKISH . A KURDIS . B ARABIC . C OTHER ___________________________________________ U (SPECIFY) NO OTHER LANGUAGE. Y 116C What is (was) your mother's mother tongue? What is (was) your father's mother tongue? USE THE CODES IN 116A. MOTHER . FATHER . 117A Is (was) your mother literate? YES . 1 NO . 2 117B Did your mother ever attend to school? DID NOT ATTEND SCHOOL . 0 (IF YES) Which school did she complete? ATTENDED PRIMARY SCHOOL, DID NOT FINISH . 1 PRIMARY SCHOOL GRADUATE . 2 SECONDARY SCHOOL GRADUATE. 3 HIGH SCHOOL GRADUATE. 4 COLLEGE UNIVERSITY GRADUATE / GRADUATE EDUCATION . 5 DON’T KNOW . 8 117C How many children born to your mother are alive today, including yourself? How many of them are male, how many of them are female? NUMBER OF MALE CHILDREN ALIVE . NUMBER OF FEMALE CHILDREN ALIVE. TOTAL NUMBER OF LIVING CHILDREN. 117D Did she have any other male or female children, who died YES . 1 later? NO . 2 118A (IF NO) He/she could die just after the birth or when he/she was a young baby. 117E How many children born to your mother have died? How many of them were female and how many male? NUMBER OF DECEASED MALE CHILDREN . NUMBER OF DECEASED FEMALE CHILDREN. SEX UNKNOWN. 118A Is (was) your father literate? YES . 1 NO . 2 118B Did your father ever attend school? DID NOT ATTEND SCHOOL . 0 (IF YES) Which school did he complete? ATTENDED PRIMARY SCHOOL, DID NOT FINISH . 1 PRIMARY SCHOOL GRADUATE . 2 SECONDARY SCHOOL GRADUATE. 3 HIGH SCHOOL GRADUATE. 4 COLLEGE UNIVERSITY GRADUATE / GRADUATE EDUCATION . 5 DON’T KNOW . 8 118C Are (were) your parents related? YES . 1 NO . 2 119A 118D In what way is (was) your father related to your mother? SON OF FATHER’S BROTHER. 1 SON OF FATHER’S SISTER . 2 SON OF MOTHER’S SISTER . 3 SON OF MOTHER’S BROTHER . 4 OTHER PATERNAL BLOOD RELATIVE . 5 OTHER MATERNAL BLOOD RELATIVE . 6 OTHER ___________________________________________ 7 (SPECIFY) DON’T KNOW . 8 SECTION 1B. MIGRATION HISTORY 119A Now I would like to talk to you about your place of birth and migrations. In which province were you born? RECORD THE NAME AND CODE OF THE PROVINCE. NAME OF PROVINCE PROVINCE CODE ________________________________________ 119B Was this place then a province centre, a district centre, a sub- district or a village ? Or was it abroad? PROVINCE CENTRE. 1 DISTRICT CENTRE . 2 SUBDISTRICT OR VILLAGE . 3 ABROAD . 4 119C For most of the time until you were 12 years old, where did you live? RECORD THE NAME AND CODE OF THE PROVINCE. NAME OF PROVINCE PROVINCE CODE ________________________________________ 119D Was this place then a province centre, a district centre, a sub- district or a village ? Or was it abroad? PROVINCE CENTRE. 1 DISTRICT CENTRE . 2 SUBDISTRICT OR VILLAGE . 3 ABROAD . 4 119E After you have completed age 12, have you ever changed YES . 1 your place of residence at least for 6 months? NO . 2 160 119F Now I wish to talk about all the different places of residences you have lived in for at least 6 months after you have completed age 12. Can you tell me the places you have lived in since then, starting from the one you were living at the age of 12? RECORD THE PLACE OF RESIDENCE AT AGE 12 ON THE FIRST LINE IN THE LIST, AND RECORD ALL MIGRATION MOVES IN ORDER. ASK THE QUESTIONS FOR EACH MOVEMENT SEPERATELY AND WRITE THE TOTAL NUMBER OF LINES TO THE BOX BELOW. ASK ONLY 119G AND 119H FOR CURRENT PLACE OF RESIDENCE. WARNING: USE ADDITIONAL QUESTIONNAIRE IF THERE ARE MORE THAN 6 MIGRATIONS. TOTAL NO. OF LINES CONTINUE THE INTERVIEW IN THE ADDITIONAL QUESTIONNAIRE. 119G In which province were you living? Next? RECORD THE NAME AND PROVINCE CODE OF THE PLACE OF RESIDENCE (PROVINCE, DISTRICT, SUB-DISTICT, VILLAGE). 119H When you were living there was this place a province centre, a district centre, a sub-district or village? Or was it abroad? 119I For how long did you live in .? RECORD IN MONTHS IF LESS THAN 2 YEARS. 119J At which month and year did you migrate from . to . ? 119K What was the main reason of migration from .? 01 PROVINCE CODE __________________ (PLACE OF RESIDENCE) PROVINCE CENTRE . 1 DISTRICT CENTRE . 2 SUBDISTRICT/VILLAGE . 3 ABROAD. 4 MONTH.1 MONTH. YEAR.2 YEAR. _________________(SPECIFY IF OTHER) 02 PROVINCE CODE __________________ (PLACE OF RESIDENCE) PROVINCE CENTRE . 1 DISTRICT CENTRE . 2 SUBDISTRICT/VILLAGE . 3 ABROAD. 4 MONTH.1 MONTH. YEAR.2 YEAR. _________________(SPECIFY IF OTHER) 03 PROVINCE CODE __________________ (PLACE OF RESIDENCE) PROVINCE CENTRE . 1 DISTRICT CENTRE . 2 SUBDISTRICT/VILLAGE . 3 ABROAD. 4 MONTH.1 MONTH. YEAR.2 YEAR. _________________(SPECIFY IF OTHER) 04 PROVINCE CODE __________________ (PLACE OF RESIDENCE) PROVINCE CENTRE . 1 DISTRICT CENTRE . 2 SUBDISTRICT/VILLAGE . 3 ABROAD. 4 MONTH.1 MONTH. YEAR.2 YEAR. _________________(SPECIFY IF OTHER) 05 PROVINCE CODE __________________ (PLACE OF RESIDENCE) PROVINCE CENTRE . 1 DISTRICT CENTRE . 2 SUBDISTRICT/VILLAGE . 3 ABROAD. 4 MONTH.1 MONTH. YEAR.2 YEAR. _________________(SPECIFY IF OTHER) 06 PROVINCE CODE __________________ (PLACE OF RESIDENCE) PROVINCE CENTRE . 1 DISTRICT CENTRE . 2 SUBDISTRICT/VILLAGE . 3 ABROAD. 4 MONTH.1 MONTH. YEAR.2 YEAR. _________________(SPECIFY IF OTHER) (119K) REASONS OF MIGRATION PERSONAL REASONS HUSBAND RELATED REASONS FAMILY RELATED REASONS 11 MARRIAGE 21 MOVING TO WHERE HUSBAND LIVES 31 MOVING TO WHERE PARENTS LIVE 41 HEALTH RELATED 12 EDUCATION 22 HUSBAND’S JOB CHANGE 32 PARENT’S JOB CHANGE REASONS 13 LOOKING FOR A JOB 23 APPOINMENT OF HUSBAND 33 APPOINTMENT OF PARENTS 51 SECURITY REASONS 14 CHANGE OF JOB 24 HUSBAND’S LOOKING FOR 34 PARENTS’ LOOKING FOR A JOB 15 APPOINTMENT A JOB 35 GOING NEAR CHILDREN 96 OTHER 16 RETURNING HOMELAND 25 HUSBAND DEAD /DIVORCED 36 PARENT DEAD/DIVORCE 17 OTHER 26 OTHER 37 OTHER ADD. QUES. SECTION 1C. MARRIAGE HISTORY 160 Now I want to ask some questions about your marriage(s). Are you currently married? YES, CURRENTLY MARRIED.1 ACCEPT THOSE LIVING TOGETHER AS BEING MARRIED. NO, CURRENTLY NOT MARRIED.2 160A Did you marry only once or more than once in your lifetime? (IF MORE THAN ONCE) How many times? NO. OF MARRIAGES. IF MARRIED ONLY ONCE, USE COLUMN 1. IF MARRIED MORE THAN ONCE, USE COLUMN 1 FOR FIRST HUSBAND, USE THE OTHER COLUMNS FOR RESPECTIVE HUSBANDS. 161 What was your (first, second) husband’s name? RECORD THE NAMES OF HUSBAND(S) BY STARTING WITH THE FIRST HUSBAND. 162 In which month and year did you start living with . ? 163 How old was your husband when you started to live together? 164 Did you have a civil marriage ceremony with .? Did you have a religious ceremony with .? 165 Which marriage ceremony took place earlier? 166 How much time elapsed between two ceremonies? RECORD “00” DAYS IF BOTH TOOK PLACE ON THE SAME DAY. RECORD IN DAYS IF LESS THAN ONE MONTH, RECORD IN MONTHS IF LESS THAN TWO YEARS, RECORD IN YEARS. OTHERWISE. 01 MONTH. YEAR. CIVIL AND RELI. CIVIL ONLY. RELI. ONLY. 167 NO CEREMONY. .1 .2 .3 .4 CIVIL. RELIGIOUS. .1 .2 DAY.1 MONTH.2 YEAR.3 (NAME) 02 MONTH. YEAR. CIVIL AND RELI. CIVIL ONLY. RELI. ONLY. 167 NO CEREMONY. .1 .2 .3 .4 CIVIL. RELIGIOUS. .1 .2 DAY.1 MONTH.2 YEAR.3 (NAME) 03 MONTH. YEAR. CIVIL AND RELI. CIVIL ONLY. RELI. ONLY. 167 NO CEREMONY. .1 .2 .3 .4 CIVIL. RELIGIOUS. .1 .2 DAY.1 MONTH.2 YEAR.3 (NAME) 04 MONTH. YEAR. CIVIL AND RELI. CIVIL ONLY. RELI. ONLY. 167 NO CEREMONY. .1 .2 .3 .4 CIVIL. RELIGIOUS. .1 .2 DAY.1 MONTH.2 YEAR.3 (NAME) 167 How was your marriage with . arranged? Did you decide together or was it arranged by your families? 168 Did you family take your consent when your marriage with . was arranged? 169 Did . or his family pays bridesmoney? (IF YES) Was it given in cash or in kind? 170 When you first started to live with . was there anyone else living with you in your household at that time? 171 Are (were) you related to .? (IF YES) What is (was) his relationship to you? 172 IS THIS MARRIAGE STILL GOING ON? BY FAMILIES. BY OURSELVES. ELOPED. ABDUCTED. 169 OTHER____________ .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. IN CASH/GOLD. IN KIND. BOTH. OTHER__________ (SPECIFY) .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. SON.OF.FATHER’S BRO. SON.OF.FATHER’S SIS. SON.OF.MOTHER’S SIS. SON.OF.MOTHER’S BRO. OTHER PAR. BL. REL. OTHER MAT. BL. REL. OTHER ___________________ (SPECIFY) .0 .1 .2 .3 .4 .5 .6 _7 YES. 177 NO. .1 .2 BY FAMILIES. BY OURSELVES. ELOPED. ABDUCTED. 169 OTHER____________ .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. IN CASH/GOLD. IN KIND. BOTH. OTHER__________ (SPECIFY) .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. SON.OF.FATHER’S BRO. SON.OF.FATHER’S SIS. SON.OF.MOTHER’S SIS. SON.OF.MOTHER’S BRO. OTHER PAR. BL. REL. OTHER MAT. BL. REL. OTHER ___________________ (SPECIFY) .0 .1 .2 .3 .4 .5 .6 _7 YES. 177 NO. .1 .2 BY FAMILIES. BY OURSELVES. ELOPED. ABDUCTED. 169 OTHER____________ .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. IN CASH/GOLD. IN KIND. BOTH. OTHER__________ (SPECIFY) .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. SON.OF.FATHER’S BRO. SON.OF.FATHER’S SIS. SON.OF.MOTHER’S SIS. SON.OF.MOTHER’S BRO. OTHER PAR. BL. REL. OTHER MAT. BL. REL. OTHER ___________________ (SPECIFY) .0 .1 .2 .3 .4 .5 .6 _7 YES. 177 NO. .1 .2 BY FAMILIES. BY OURSELVES. ELOPED. ABDUCTED. 169 OTHER____________ .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. IN CASH/GOLD. IN KIND. BOTH. OTHER__________ (SPECIFY) .1 .2 .3 .4 __7 YES. NO. .1 .2 NO. SON.OF.FATHER’S BRO. SON.OF.FATHER’S SIS. SON.OF.MOTHER’S SIS. SON.OF.MOTHER’S BRO. OTHER PAR. BL. REL. OTHER MAT. BL. REL. OTHER ___________________ (SPECIFY) .0 .1 .2 .3 .4 .5 .6 _7 YES. 177 NO. .1 .2 173 CHECK 161: RECORD THE NAMES OF HUSBAND(S) BY STARTING WITH THE FIRST HUSBAND. 174 In which month and year did your marriage with . end? 175 How did your marriage with . end? Did you get divorced, did . die or did you start to live separated? 176 Was it your decision to get divorced/live separated or was it your husband’s, or did you decide on it together? 177 DOES THE WOMAN HAVE ANOTHER MARRIAGE? 01 MONTH. YEAR. WIDOWED. 177 DIVORCED. STARTED LIVING SEPARATED. .1 .2 .3 HERSELF. HER HUSBAND. TOGETHER. OTHER ___________ (SPECIFY) .1 .2 .3 _7 YES. GO TO 162 NO. 178 .1 .2 (NAME) 02 MONTH. YEAR. WIDOWED. 177 DIVORCED. STARTED LIVING SEPARATED. .1 .2 .3 HERSELF. HER HUSBAND. TOGETHER. OTHER ___________ (SPECIFY) .1 .2 .3 _7 YES. GO TO 162 NO. 178 .1 .2 (NAME) 03 MONTH. YEAR. WIDOWED. 177 DIVORCED. STARTED LIVING SEPARATED. .1 .2 .3 HERSELF. HER HUSBAND. TOGETHER. OTHER ___________ (SPECIFY) .1 .2 .3 _7 YES. GO TO 162 NO. 178 .1 .2 (NAME) 04 MONTH. YEAR. WIDOWED. 177 DIVORCED. STARTED LIVING SEPARATED. .1 .2 .3 HERSELF. HER HUSBAND. TOGETHER. OTHER ___________ (SPECIFY) .1 .2 .3 _7 YES. GO TO 162 NO. 178 .1 .2 (NAME) 178 C ENTER “X” IN THE MONTH OF INTERVIEW IN THE 1ST COLUMN OF CALENDAR. IF CURRENTLY MARRIED THEN, DETERMINE MONTHS MARRIED OR IN UNION SINCE JANUARY 2003. ENTER “X FOR EACH MONTH MARRIED OR IN UNION, AND ENTER “O” FOR EACH MONTH NOT MARRIED/NOT IN UNION. NOTE: AFTER YOU HAVE COMPLETED THESE, ALL THE BOXES IN THE 1ST COLUMN FROM JANUARY 2003 TO INTERVIEW MONTH SHOULD BE FULL. 179 For your (first ) marriage with . which of these following ceremonies did you have ? YES NO Asking family consent? FAMILY CONSENT. 1 2 Promise ceremony to marriage? PROMISE CEREMONY . 1 2 Engagement ceremony? ENGAGEMENT . 1 2 Dower exhibition ceremony? DOWER EXHIBITION . 1 2 Henna night? HENNA NIGHT . 1 2 Marriage ceremony? MARRIAGE CEREMONY . 1 2 Wedding? WEDDING . 1 2 SECTION 2. PREGNANCY AND FERTILITY 200S RECORD THE TIME. HOUR – MINUTE. 201 Now I would like to ask about all the births you have had during your life. YES. 1 Have you ever given a live birth? NO. 2 206 202 Do you have any sons or daughters to whom you have given birth who are YES .1 living with you? NO .2 204 203 How many sons live with you? How many daughters live with you? IF NONE, RECORD “00”. SONS. DAUGHTERS. 204 Do you have any sons or daughters to whom you have given birth who are alive YES .1 but do not live with you? NO .2 206 205 How many sons are alive but do not live with you? How many daughters are alive but do not live with you? IF NONE, RECORD “00”. SONS ELSEWHERE . DAUGHTERS ELSEWHERE . 206 Have you ever given birth to a boy or a girl who was born alive but died later? YES .1 NO . 2 208 IF NO, PROBE BEFORE RECORDING: Any baby who cried or showed signs of life but only survived a few hours or days? 207 In all, how many boys have died? In all, how many girls have died? IF NONE, RECORD “00”. BOYS DECEASED. GIRLS DECEASED. 208 SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL TOTAL. IF NONE, RECORD “00”. 209 CHECK 208: Just to make sure that I have this right: You have had in TOTAL ______ live births during your life. Is this true? YES NO PROBE AND CORRECT 201-208. 210 CHECK 208. HAS AT LEAST HAS NO LIVE 227 ONE LIVE BIRTH BIRTHS 211 211 Now I would like to talk to you about all of your births. It is very important to learn about all of your births, whether still alive or not. Please let's start with the first one you had RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES MAKE SURE TO RECORD DECEASED CHILDREN FROM MULTIPLE BIRTHS BEFORE THOSE SURVIVING. 212 What name was given to your (first/next) baby? WRITE “BABY” IF THE BABY DIED BEFORE A NAME GIVEN. 213 RECORD SINGLE OR MULTIPLE BIRTH STATUS 214 Is …. a boy or a girl? 215 In what month and year. born? PROBE: In what season was s/he born? NOTE: FOR ALL CHILDREN, THE YEAR OF BIRTH; FOR CHILDREN BORN AFTER 2003, THE MONTH OF THE YEAR OF BIRTH MUST BE DETERMINED. 216 Is …… still alive? 217 How old was . at his/her last birthday? RECORD AGE IN COMPLETED YEARS. MAKE CALCULATIONS FOR CONSISTENCY. 01 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 02 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 03 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 04 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 05 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 06 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) BORN IN 1998 OR AFTER 218 Is. 218A 219 IF DEAD: 220 Is . 220A How much. 221 Were there living with you? RECORD THE LINE NUMBER OF CHILD IN THE HH LIST. IF S/HE WASN'T RECORDED IN HH LIST, RECORD "00". How old was . when he/she died? IF “1” YEAR., PROBE: How many months old was .? RECORD DAYS IF LESS THAN 1 MONTH, MONTHS IF LESS THAN 2 YEARS OR YEARS OTHERWISE. recorded in the population registry? time elapsed between .’s birth and registration? RECORD IN MONTHS IF LESS THAN 1 YEAR,”00” IF LESS THAN 1 MONTH any other live births between previous birth and .’s birth? IF YES.GO BACK AND CORRECT. YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 212 What name was given to your (first/next) baby? WRITE “BABY” IF THE BABY DIED BEFORE A NAME GIVEN. 213 RECORD SINGLE OR MULTIPLE BIRTH STATUS 214 Is …. a boy or a girl? 215 In what month and year. born? PROBE: In what season was s/he born? NOTE: FOR ALL CHILDREN, THE YEAR OF BIRTH; FOR CHILDREN BORN AFTER 2003, THE MONTH OF THE YEAR OF BIRTH MUST BE DETERMINED. 216 Is …… still alive? 217 How old was . at his/her last birthday? RECORD AGE IN COMPLETED YEARS. MAKE CALCULATIONS FOR CONSISTENCY. 07 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. . .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 08 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. . .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 09 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. . .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 10 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. . .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 11 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. . .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) 12 SINGLE. MULTIPLE. .1 .2 MALE. FEMALE. . .1 .2 MONTH. YEAR. YES. NO. 219 .1 .2 AGE (IN YEARS) (NAME) TICK HERE IF NUMBER OF LIVE BIRTHS IS MORE THAN 12 AND CONTINUE IN ANOTHER QUESTIONNAIRE FORM . BORN IN 1998 OR AFTER 218 Is. 218A 219 IF DEAD: 220 Is . 220A How much. 221 Were there living with you? RECORD THE LINE NUMBER OF CHILD IN THE HH LIST. IF S/HE WASN'T RECORDED IN HH LIST, RECORD "00". How old was . when he/she died? IF “1” YEAR., PROBE: How many months old was .? RECORD DAYS IF LESS THAN 1 MONTH, MONTHS IF LESS THAN TWO YEARS OR YEARS OTHERWISE. recorded in the population registry? time elapsed between .’s birth and registration? RECORD IN MONTHS IF LESS THAN 1 YEAR,”00” IF LESS THAN 1 MONTH any other live births between previous birth and .’s birth? GO BACK AND CORRECT IF YES. YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 YES . NO . .1 .2 GO TO 220 DAY . MONTH. YEAR . 1 2 3 YES. NO. 221 .1 .2 MONTH. YEAR . .1 .2 YES. NO. .1 .2 GO BACK AND CORRECT IF YES. 223A Have you had any live births since the birth of (NAME OF LAST BIRTH)? YES . 1 NO .2 224 223B GO BACK AND MAKE THE NECESSARY CORRECTIONS. 224 COMPARE THE NUMBER IN 208 WITH NUMBER OF BIRTHS IN BIRTH HISTORY ABOVE: NUMBERS ARE NUMBERS ARE SAME DIFFERENT (PROBE, RECONCILE AND MAKE NECESSARY CORRECTIONS) CHECK AND TICK: YEAR OF BIRTH IS RECORDED FOR EACH BIRTH (215). MONTH OF BIRTH IS RECORDED FOR EACH BIRTH AFTER 2003 (215). (IF ANY) CURRENT AGE IS RECORDED FOR EACH LIVING CHILD: (217). (IF ANY) FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED (219). FOR AGE AT DEATH 12 MONTHS OR 1 YR.: PROBED TO DETERMINE EXACT AGE IN MONTHS…. FOR THOSE BORN IN AND AFTER 1998: POPULATION REGISTRY QUESTIONS ARE ASKED (220-220A). 225 CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 2003 IF NONE, RECORD “0”. 226 C FOR EACH BIRTH SINCE JANUARY 2003 ENTER “D” IN THE MONTH OF BIRTH IN THE 2NDCOLUMN OF THECALENDAR. LEARN THE MONTHS IN PREGNANCIES FOR EACH BIRTHS AND RECORD “H” IN EACH OF THEPRECEDING MONTHS.(NUMBER OF “H” MUST BE LESS THAN PREGNANCY MONTHS) WRITE NAME OFCHILD TO THE LEFT OF THE “D” CODE. 227 Are you currently pregnant? YES .1 NO . 2 UNSURE .8 230A 228 How many months pregnant are you? MONTHS. C RECORD NUMBER OF COMPLETED MONTHS. ENTER “H”s IN COLUMN 2 OF THE CALENDAR BEGINNING WITH THE MONTH OF INTERVIEW AND FOR TOTAL NUMBER OF COMPLETED MONTHS. 229 At the time you became pregnant, did you want to become pregnant then, did you THEN.1 want to wait until later, or did you not want to have any more children at all? LATER.2 DID NOT WANT MORE CHILDREN.3 229A At the time you became pregnant, did your husband want you to get pregnant THEN.1 then, did he want to wait until later, or did he not want to have any more children LATER.2 at all? DID NOT WANT MORE CHILDREN.3 230A Have you ever had a pregnancy that ended in a miscarriage? YES . 1 NO .2 230C 230B In all, how many miscarriages have you had? NUMBER OF MISCARRIAGES. 230C Have you ever had a pregnancy that ended in an induced abortion? YES . 1 NO . 2 230E 230D In all, how many induced abortions have you had? NO. OF INDUCED ABORTION . 230E Have you ever had a pregnancy that ended in a stillbirth? YES . 1 NO . 2 230G 230F In all, how many still births have you had? NUMBER OF STILL BIRTHS . 230G CALCULATE THE TOTAL NUMBER OF COMPLETED PREGNANCIES. TOTAL NUMBER OF COMPLETED PREGNANCIES. TOTAL NUMBER OF PREGNANCIES ENDING IN MISCARRIAGES, INDUCED ABORTIONS OR STILL BIRTHS: SUM THE ANSWERS TO 230B, 230D AND 230F __________________ TOTAL NUMBER OF PREGNANCIES ENDING IN LIVE BIRTHS: SUM THE NUMBER OF SINGLE BIRTHS IN THE BIRTH HISTORY + __________________ ADD TO THAT SUM THE NUMBER OF MULTIPLE BIRTHS + __________________ TOTAL NUMBER OF COMPLETED PREGNANCIES: = __________________ 230H CHECK 230G: Just to make sure that I have this right. You have had in total _______ completed pregnancies. Is that correct? YES NO PROBE AND CORRECT 201-230G IF NECESSARY. 230I CHECK 230B, 230D AND 230F: HAD AT LEAST ONE INDUCED ABORTION, MISCARRIAGE OR STILLBIRTH HAD NO INDUCED ABORTIONS MISCARRIAGES OR STILLBIRTHS 234 231A Now I would like to ask about your recent induced abortions, miscarriages MONTH . YEAR. or stillbirths. When did the last such pregnancy end? 231B Was this an induced abortion, a miscarriage or a stillbirth? INDUCED ABORTION.1 MISCARRIAGE…………….2 STILLBIRTH.3 232 CHECK 231A: LAST INDUCED ABORTION/MISCARRIAGE/ LAST INDUCED ABORTION/MISCARRIAGE/ STILLBIRTH ENDED AFTER JANUARY 2003 STILLBIRTH ENDED BEFORE JANUARY 2003 234 233 How many months pregnant were you when the last pregnancy ended? MONTHS . C RECORD ALL INDUCED ABORTIONS, MISCARRIAGES AND STILLBIRTHS SINCE JANUARY 2003 IN COLUMN 2. PROBE TO DETERMINE HOW THE PREGNANCY ENDED (INDUCED ABORTION, MISCARRIAGE, STILL BIRTH). - How did this pregnancy end? (Was it an induced abortion, miscarriage, or stillbirth etc.) RECORD THE APPROPRIATE CODE AT THE MONTH AND YEAR WHERE THE PREGNANCY ENDED IN COLUMN 2. THEN ASK FOR DATES OF ANY OTHER PREGNANCIES BACK TO JANUARY 2003. REPEAT THE PROCEDURES AS DESCRIBED ABOVE FOR THESE PREGNANCIES. LEARN THE DURATION OF EACH PREGNANCY AND RECORD “H”FOR THE MONTHS BEFORE THE RESULTING CODE, AS MUCH TO FILL THIS DURATION. - What was the total duration of this pregnancy? How many months pregnant were you? 233A CHECK 231A, 231B AND CALENDAR: HAD AT LEAST ONE INDUCED ABORTION AFTER 2003 HAD NO INDUCED ABORTION AFTER 2003 234 233B Who decided to end your pregnancy with an induced abortion? DOCTOR. 01 HERSELF.02 HUSBAND.03 HERSELF AND HUSBAND TOGETHER.04 OTHER ____________________________ 96 (SPECIFY) 233C Did you desire this (last) pregnancy which ended in an induced abortion, did you NOT AT ALL………. 0 desire to get pregnant later, or did you not desire it at all? DESIRED…. 1 DESIRED IT LATER……….2 233D Where did the operation of last induced abortion take place? PUBLIC SECTOR GOVT./SAMPLE HOSPITAL. MATERNITY HOUSE. MCHFP CENTER. SSK HOSPITAL/DISPANSERY . TRAINING AND RESEARCH HOSP. FAMILY HEALTH CENTER/ FAMILY DOCTOR. OTHER __________________________ (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL . PRIVATE POLYCLINIC. PRIVATE DOCTOR . OTHER __________________________ (SPECIFY) UNIVERSITY HOSPITAL . VOLUNTARY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC . OTHER__________________________ (SPECIFY) 11 12 13 16 17 18 19 21 22 23 29 31 41 96 233E Did you receive any counseling about contraception usage after induced abortion YES.1 at the health facility where the (last) induced abortion was performed? NO.2 234 Did you ever make use of assisted reproductive techniques such as conventional YES.1 invitro fertilization, intrauterine insemination or intracytoplasmic sperm injection NO. 2 235 to get pregnant? 234A Did you ever get pregnant with the assistance of these techniques? YES.1 NO. 2 235 234B When did the last pregnancy that took place with the assistance of these MONTH. YEAR. techniques end? STILL PREGNANT.0000 234C CHECK 234B: PREGNANCY BY ASSISTED REPRODUCTIVE TECHNIQUES ENDED AFTER 2003 OR IS STILL GOING ON NO PREGNACY BY ASSISTED REPRODUCTIVE TECHNIQUES AFTER 2003 235 234D C ASK WHETHER IF ASSISTED REPRODUCTIVE TECHNIQUES WERE USED FOR ALL COMPLETED OR CURRENTPREGNANCIES SINCE JANUARY 2003. IF PREGNANCY IS COMPLETED, RECORD THE APPROPRIATE CODE INTHE MONTH IN WHICH THE PREGNANCY IS COMPLETED. RECORD THE MONTH OF INTERVIEW IF STILLPREGNANT IN THE 3RD COLUMN OF THE CALENDAR. ASK FOR ALL PREGNANCIES: - Did you make use of any assisted reproductive techniques for this pregnancy? - Which medical technique was used? 235 When did your last menstrual period start? DAYS AGO. WEEKS AGO…. MONTHS AGO. YEARS AGO. CURRENTLY PREGNANT. IN MENAPAUSE. HYSTEROCTOMY . BEFORE LAST BIRTH. . NEVER MENSTRUATED . .1 .2 .3 .4 . . . . . 5 .991 .992 .993 .994 .995 237 236 How old were you when you had your first menstrual period? AGE. 237 Think about the time between the beginning of a menstruation period and the YES. 1 beginning of the next menstruation period. NO. 2 Are there certain days when a woman is more likely to become pregnant if she has DON’T KNOW.8 239S sexual relations? 238 Is this time just before her period begins, during her period, right after her period has ended, or half way between two periods? JUST BEFORE HER PERIOD BEGINS . DURING HER PERIOD . RIGHT AFTER HER PERIOD HAS ENDED . HALF WAY BETWEEN TWO PERIODS . OTHER ____________________________ (SPECIFY) DON’T KNOW . 1 2 3 4 7 8 239S RECORD THE TIME. HOUR – MINUTE. SECTION 3. CONTRACEPTION 301 Now I would like to talk about contraception. There are various methods that a married couple can use to avoid pregnancy. CIRCLE CODE ‘1’ IN Q. 301A FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 302, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY AND ASK WHETHER SHE HAS HEARD THE METHOD. IN Q 302, CIRCLE CODE ‘2’ IF METHOD IS RECOGNIZED AND CODE ‘3’ IF NOT RECOGNIZED. THEN FOR EACH METHOD WITH CODE ‘1’ OR ‘2’ CIRCLED IN 301A OR 302, ASK 303. AFTER ASKING ABOUT ALL METHODS PROCEED TO 304. 301A Which ways or methods of contraception have you heard? SPON- TANEOUS 302 Have you ever heard this method? PROBED 303 Have you ever used this method? YES YES NO 01 TUBAL LIGATION Women can have an operation of tubal ligation to avoid having 1 2 3 Have you ever had such an operation to avoid having any more children? any more children. YES . NO . 1 2 02 MALE STERILIZATION 1 2 3 Has (had) your (former) husband ever had such an operation?Men can have an operation called vasectomy so that their wives would not get pregnant. YES . NO . 1 2 03 PILL Women can avoid a pregnancy by taking a pill every day. 1 2 3 YES . NO . 1 2 04 IUD Women can have the so called spiral or IUD placed in them by a doctor or a nurse. 1 2 3 YES . NO . 1 2 05 INJECTABLES Women can have an injection by a doctor or a nurse, which stops them from becoming pregnant for certain period of time. 1 2 3 YES . NO . 1 2 06 IMPLANT Women can have small rods placed in their arm and this can prevent pregnancy for several years. 1 2 3 YES . NO . 1 2 07 CONDOM Men can put a rubber sheath on their penis during sexual intercourse. 1 2 3 YES . NO . 1 2 08 FEMALE CONDOM Women can place a sheath in their vagina before sexual intercourse. 1 2 3 YES . NO . 1 2 09 DIAPHRAGM, FOAM, JELLY Women can place a sponge, suppository, diaphragm, jelly or cream inside themselves before intercourse. 1 2 3 YES . NO . 1 2 12 RHYTHM Some couples can avoid having sexual intercourse on certain days of the month when the woman is more likely to become pregnant. 1 2 3 YES . NO . 1 2 13 WITHDRAWAL Some men pull out during sexual intercourse before climax. 1 2 3 YES . NO . 1 2 14 EMERGENCY CONTRACEPTION Women can take pills up to three days after sexual intercourse to avoid becoming pregnant. 1 2 3 YES . NO . 1 2 15 Have you heard of any other method that women or men can use to avoid pregnancy? 1 3 ____________________________ (SPECIFY) YES . NO . 1 2 ____________________________ (SPECIFY) YES . NO . 1 2 304 CHECK 303: AT LEAST ONE NOT A SINGLE “YES” “YES” (EVER USED) 308 (NEVER USED) 305 Have you ever used anything or tried in any way to EVET . 1 307 delay or avoid getting pregnant? HAYIR . 2 306 C IN COLUMN 2 RECORD “N” IN MONTHS IN WHICH WOMAN IS NOT IN A UNION, RECORD “0” IN ALLMONTHS REMAINING. 331 307 Which method have you used or what have you done? CORRECT 303 AND 304, IF NECESSARY CORRECT 302. 308 Now I would like to ask you about the first time that you did TUBAL LIGATION.01 something or used a method to avoid getting pregnant. MALE STERILIZATION.02 PILL.03 What was the first method you ever used? IUD. 04 INJECTABLES.05 IMPLANT……………. 06 CONDOM. 07 FEMALE CONDOM.08 DIAPHRAGM/FOAM/JELLY.09 LACTATIONAL AMEN. METHOD.11 RHYTHM.12 WITHDRAWAL.13 EMERGENCY CONTRACEPTION.14 OTHER _________________________________ 96 (SPECIFY) 308A How old were you when you first used this method? AGE. 309A Did you have any children at that time? (IF YES) How many living children did you have at that time? IF NONE, RECORD “00. NUMBER OF CHILDREN. 310 CHECK 303: NOT HAD HAD TUBAL TUBAL 314A LIGATION LIGATION 311 CHECK 227: NOT PREGNANT PREGNANT 315A OR UNSURE 312 CHECK 160: CURRENTLY NOT MARRIED MARRIED 315 313 Are you currently doing something or using any method YES . 1 to delay or avoid getting pregnant? NO . 2 315A 314 Which method are you using? TUBAL LIGATION.A MALE STERILIZATION.B CIRCLE ALL MENTIONED. PILL.C IUD. D INJECTABLES.E IMPLANT……………. F 314A CIRCLE “A”FOR TUBAL LIGATION. CONDOM. G FEMALE CONDOM.H DIAPHRAGM/FOAM/JELLY.I LACTATIONAL AMEN. METHOD.K RHYTHM.L WITHDRAWAL.M OTHER _________________________________ U (SPECIFY) 314B CHECK 314 AND 314A: HAD TUBAL NOT HAD 315 LIGATION TUBAL LIGATION 314E In which month and year was this operation performed? MONTH. YEAR . 314F Before your sterilization operation, were you told that you would not able to have any (more) children because of this operation? YES.1 NO .2 315 C ENTER METHOD CODE FROM 314 IN CURRENT MONTH IN COLUMN 2 OF CALENDAR. THEN DETERMINEWHEN SHE STARTED USING THIS METHOD. ENTER METHOD CODE IN EACH MONTH OF USE.ILLUSTRATIVE QUESTIONS: When did you start using this method continuously? How long have you been using this method continuously? CHECK COLUMN 1 OF CALENDAR: IN COLUMN 2 OF CALENDAR ENTER “N” FOR MONTHS WOMAN NOT MARRIED. CHECK COLUMN 2 OF CALANDER: THERE ARE ALL BOXES ARE EMPTY BOXES FILLED 316 315A START WITH THE MOST RECENT USE. USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE BACK TO JANUARY 2003. USE NAMES OF CHILDREN, DATES OF BIRTH, AND STARTING AND ENDING DATES OF PREGNANCIES AS REFERENCE POINTS. IN COLUMN 2, ENTER CODE IN EACH MONTH OF METHOD USE OR”0” FOR NONUSE. ILLUSTRATIVE QUESTIONS FOR COLUMN 2: · When was the last time you used a method? Which method was that? · When did you start using that method? How long after the birth of (NAME)? · How long did you use the method then? IN COLUMN 3, ENTER CODES FOR DISCONTINUATION NEXT TO LAST MONTH OF USE. TO DO THIS, DETERMINE THE LAST MONTH OF METHOD USE FROM COLUMN 2. IN COLUMN 3, ENTER THE CODE FOR DISCONTINUATION. ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT. ILLUSTRATIVE QUESTIONS FOR COLUMN 3: · Why did you stop using the (METHOD)? · Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason? IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: “How many months did it take you to get pregnant after you stopped using (METHOD)?”AND ENTER “0” IN EACH SUCH MONTH IN COLUMN 2. 316 CHECK 314 AND 314A: NOT ASKED . 00 331 TUBAL LIGATION.01 CIRCLE THE CODE OF CURRENTLY USED METHOD. MALE STERLIZATION . 02 PILL .03 IF MORE THAN ONE METHOD WAS CIRCLED IN 314, IUD . 04 CIRCLE CODE FOR HIGHEST METHOD IN LIST. INJECTABLES. 05 IMPLANT . 06 CONDOM . 07 FEMALE CONDOM .08 DIAPHRAM/FOAM/JELLY . 09 LACTATIONAL AMEN. METHOD .11 RHYTM . 12 WITHDRAWAL .13 322 OTHER METHOD .96 319 Before you started to use the current method you are using, were you YES . 1 told about side effects or problems you might have by an health NO . 2 personnel (doctor/nurse/midwife)? 320 Were you told by any health personnel (doctor/nurse/midwife) about YES . 1 what to do if you experienced side effects or problems of the NO . 2 method you are currently using? 321 Before you started to use the current method, were you ever told by a YES . 1 health personnel (doctor/nurse/midwife) about other methods of NO . 2 contraception you could use? 322 Who decided to use the current method you are using? HERSELF .1 You, your husband, or together? PARTNER .2 TOGETHER .3 323 CHECK 316: NOT ASKED . 00 331 TUBAL LIGATION.01 CIRCLE THE CODE FOR CURENTLY USED METHOD. MALE STERLIZATION . 02 324A PILL .03 IUD . 04 INJECTABLES. 05 IMPLANT . 06 CONDOM . 07 FEMALE CONDOM .08 DIAPHRAM/FOAM/JELLY . 09 LACTATIONAL AMEN. METHOD .11 RHYTM . 12 WITHDRAWAL .13 326 OTHER METHOD . 96 324 Where did you obtain . you are currently using? PUBLIC SECTOR GOVERNMENT/SAMPLE HOSPITAL.11 MATERNITY HOUSE .12 MCHFP CENTRE. 13 HEALTH CENTRE.14 HEALTH HOUSE.15 SSK HOSPITAL/DISPENSARY. 16 TRAINING AND RESEARCH HOSPITAL.17 FAMILY HEALTH CENTRE/FAMILY DOCTOR.18 OTHER __________________________________ 19 (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL .21 PRIVATE POLYCLINIC .22 PRIVATE DOCTOR .23 PRIVATE MIDWIFE/NURSE .24 PHARMACY/MEDICAL STORE.25 324A Where did tubal ligation (or vasectomy) take place? OTHER __________________________________ 29 (SPECIFY) UNIVERSITY HOSPITAL . 31 VOLUNTARY ORGANIZATION/ ASSOCIATION/FOUNDATION.41 MARKET/SHOP . 52 RELATIVE/FRIEND/NEIGHBOUR.53 TRAD. MIDWIFE/MIDWIFE GRAN.54 OTHER __________________________________ 96 (SPECIFY) 325 Do you know another place where you could have obtained EVET .1 (METHOD)? HAYIR .2 325A At the time of tubal ligation operation, did you know another place where you could have the operation? 326 Would you like to use a different method of contraception YES . 1 than the one you are currently using? NO . 2 332A 326A Which method would you prefer to use? TUBAL LIGATION .01 MALE STERILIZATION .02 PILL .03 IUD .04 INJECTABLES .05 IMPLANT.06 CONDOM . 07 FEMALE CONDOM .08 DIAPHRAGM/FOAM/JELLY .09 LACTATIONAL AMEN. METHOD .11 RHYTHM .12 WITHDRAWAL .13 EMERGENCY PILL .14 OTHER __________________________________ 96 (SPECIFY) 326B What is the reason that you do not use (METHOD DOCTOR DOES NOT ADVISE.01 MENTIONED IN 326A) currently? EXPENSIVE.02 NOT AVAILABLE/ACCESS PROBLEMS.03 HARD TO FIND HERE. 04 DON'T KNOW HOW TO OBTAIN. 05 DON'T KNOW HOW TO USE IT.06 HUSBAND OBJECTS ………………….…………. 07 RELIGIOUS REASONS ………………….……. 08 HEALTH CONCERNS………………….……………09 SIDE EFFECTS ………………………………………10 OTHER __________________________________ 96 (SPECIFY) 326C SKIP TO 332A. 331 CHECK 227: NOT PREGNANT CURRENTLY 332B OR UNSURE PREGNANT 331A CHECK 160: CURRENTLY CURRENTLY 332B MARRIED NOT MARRIED 331B What is the main reason you are not using a method of contraception FERTILITY-RELATED REASONS to avoid pregnancy? NOT HAVING SEX .11 INFREQUENT SEX .12 MENOPAUSAL/HYSTERECTOMY .13 SUBFECUND/INFECUND . 14 HUSBAND IS INFECUND .15 POSTPARTUM/BREASTFEEDING .16 WANTS (MORE) CHILDREN .17 LACK OF KNOWLEDGE KNOWS NO METHOD .21 KNOWS NO SOURCE .22 METHOD-RELATED REASONS HEALTH CONCERNS .31 SIDE EFFECTS .32 LACK OF ACCESS/TOO FAR .33 COST TOO MUCH .34 INCONVENIENT TO USE .35 HUSBAND OPPOSED .41 RELIGIOUS REASONS .51 FATALISTIC.61 EMBARRASSED .71 OTHER __________________________________ 96 (SPECIFY) 331C GO TO 332B. 332A CHECK 316. TUBAL LIGATION .01 MALE STERILIZATION .02 CIRCLE THE CODE OF METHOD CURRENTLY USED. PILL .03 IUD .04 INJECTABLES .05 356 IMPLANT.06 CONDOM . 07 FEMALE CONDOM .08 DIAPHRAGM/FOAM/JELLY .09 LACTATIONAL AMEN. METHOD .11 RHYTHM .12 WITHDRAWAL .13 ANOTHER METHOD .96 332B Do you know of a place where you can obtain a method of YES. 1 contraception? NO. 2 351 332C Where is that? Any other place? PUBLIC SECTOR GOVERNMENT/SAMPLE HOSPITAL .A CIRCLE ALL MENTOINED. MATERNITY HOUSE .B MCHFP CENTRE. C HEALTH CENTRE .D HEALTH HOUSE .E SSK HOSPITAL/DISPENSARY .F TRAINING AND RESEARCH HOSPITAL.G FAMILY HEALTH CENTRE/FAMILY DOCTOR.H OTHER __________________________________ I (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL .J PRIVATE POLYCLINIC .K PRIVATE DOCTOR .L PRIVATE MIDWIFE/NURSE .M PHARMACY/MEDICAL STORE .N OTHER __________________________________ O (SPECIFY) UNIVERSITY HOSPITAL . P VOLUNTARY ORG./ASSOC./FOUND.R MARKET/SHOP. S RELATIVE/FRIEND/NEIGHBOUR .T TRAD. MIDWIFE/MIDWIFE GRAN .U OTHER __________________________________ V (SPECIFY) 351 CHECK 160: CURRENTLY NOT CURRENTLY MARRIED MARRIED 353 351A CHECK 316: CURRENTLY NOT CURRENTLY USING ANY METHOD USING A METHOD 356 352 Are you planning to use any contraceptive method to postpone or YES . 1 354 avoid pregnancy in the following 12 months? NO. 2 DON’T KNOW .8 353 Are you planning to use any contraceptive method to postpone or YES . 1 avoid pregnancy anytime in the future? NO. 2 DON’T KNOW .8 355 354 Which method do you prefer? TUBAL LIGATION .01 MALE STERILIZATION .02 PILL .03 IUD . 04 INJECTABLES .…………….05 IMPLANT/.06 CONDOM . 07 FEMALE CONDOM .08 DIAPHRAGM/FOAM/JELLY .09 LACTATIONAL AMEN. METHOD .11 RHYTHM .12 WITHDRAWAL .13 NOT SURE. 88 OTHER __________________________________ 96 (SPECIFY) 354A GO TO 356. 355 What is the main reason you don’t want to use a method of FERTILITY-RELATED REASONS contraception to avoid pregnancy ? NOT HAVING SEX .11 INFREQUENT SEX .12 MENOPAUSAL/HYSTERECTOMY .13 SUBFECUND/INFECUND . 14 HUSBAND IS INFECUND .15 LACK OF KNOWLEDGE KNOWS NO METHOD .21 KNOWS NO SOURCE .22 METHOD-RELATED REASONS HEALTH CONCERNS .31 SIDE EFFECTS .32 LACK OF ACCESS/TOO FAR .33 COST TOO MUCH .34 INCONVENIENT TO USE .35 HUSBAND OPPOSED .41 RELIGIOUS REASONS .51 FATALISTIC .61 EMBARRASSED .71 OTHER __________________________________ 96 (SPECIFY) DON’T KNOW .98 356 CHECK 160: CURRENTLY CURRENTLY MARRIED NOT MARRIED 359 356A CHECK 314 AND 314A: WOMAN NOT HAD WOMAN HAD TUBAL LIGATION TUBAL LIGATION OR 359 OR HUSBAND HUSBAND STERILIZED NOT STERILIZED 357 CHECK 227: NOT PREGNANT OR UNSURE CURRENTLY PREGNANT Now I have some questions Now I have some questions HAVE (A/ANOTHER) CHILD.1 about the future. about the future. NO MORE/NONE .2 Would you like to have(a/another) After the child you are expecting SAYS SHE CAN'T GET child or would you prefer not to would you like to have another child PREGNANT .3 359 have any (more) children? or would you prefer not to UNDECIDED/DON’T KNOW.8 have any more children? 357A CHECK 227: NOT PREGNANT OR UNSURE CURRENTLY PREGNANT NUMBER . How many more children would How many more children would you like to have in the future? you like to have in the future OTHER ANSWERS _____________________ 96 not counting the one you (SPECIFY) are currently pregnant with? 358 CHECK 227: MONTH.1 YEAR.2 NOT PREGNANT OR UNSURE CURRENTLY PREGNANT How long would you like to After the child you are SOON/NOW. 993 wait from now before the expecting now, how long SAYS SHE CAN'T GET birth of (a/another) child? would you like to wait before PREGNANT.994 the birth of another child? OTHER _____________________________ 996 (SPECIFY) DON’T KNOW .998 359 CHECK 216: HAS LIVING CHILDREN NO LIVING CHILDREN NONE.00 361A NUMBER . If you could go back to the time you If you could choose exactly did not have any children and could the number of children to have in OTHER ________________________________96 361A choose exactly the number of your whole life, how many (SPECIFY) children to have in your whole life, would that be? how many would that be? 360 How many of these children would you like to be boys, how many would BOYS you like to be girls and for how many would it not matter? NUMBER . OTHER ________________________________96 (SPECIFY) GIRLS NUMBER . OTHER ________________________________96 (SPECIFY) EITHER NUMBER . OTHER ________________________________96 (SPECIFY) 361A Did you experience any of the following health problems in the last 12 months? 361B Did you seek any treatment from any health personnel or health institution? YES NO Genital discharge? YES.…….1 1 2 NO….2 Genital itching? YES…….1 1 2 NO….2 Genital sore/ulcer? YES…….1 1 2 NO…….2 Painful urination (Dysuria)? YES…….1 1 2 NO…….2 Bleeding during intercourse ? YES…….1 1 2 NO…….2 Menstrual disorder? YES….….1 1 2 NO.……2 362 CHECK 316A AND 316B: SOUGHT NOT SOUGHT TRETMENT AT TREATMENT OR 400 LEAST ONCE NOT EXPERIENCED A PROBLEM 363 Did any health personnel inform you about your health YES. 1 problem(s)? NO. 2 SECTION 4. MOTHER AND CHILD HEALTH 400 CHECK 225. ONE OR MORE LIVE BIRTHS SINCE JANUARY 2003. NO LIVE BIRTHS SINCE JANUARY 2003. 709 401S RECORD THE TIME. HOUR – MINUTE. 402 ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 2003 IN THE TABLE, BEGINNING WITH THE LAST BIRTH. ASK THE QUESTIONS FOR ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS USE ADDITIONAL QUESTIONNAIRES- DO NOT USE THE LAST BIRTH COLUMN IN THE ADDITIONAL QUESTIONNAIRE. USE “NEXT TO LAST BIRTH” COLUMN AFTER CHANGING IT AS “SECOND TO LAST BIRTH”). I would like to ask you some more questions about the health of all your children born in the past five years. We will talk about one child at a time. 403 LINE NUMBER FROM Q212. LAST BIRTH LINE NUMBER…………….……. NEXT TO LAST BIRTH LINE NUMBER…………….……. 404 FROM 212 FROM 216 NAME___________________________ NAME___________________________ ALIVE DEAD ALIVE DEAD 405 At the time you became pregnant with . did you want to become pregnant then, did you want to wait until later, or did you want no (more) children at all ? NOT AT ALL. 407A THEN . LATER . 0 1 2 NOT AT ALL. 407A THEN. LATER . 0 1 2 406 How much longer would you like to have waited? MONTHS……………….1 YEARS………………….2 DON’T KNOW ………………….…998 MONTHS……………….1 YEARS………………….2 DON’T KNOW ………………….…998 407A When you were pregnant with .did you see anyone for antenatal care for this pregnancy? (IF YES) Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL MENTIONED. HEALTH PROFESSIONAL DOCTOR . NURSE/MIDWIFE . OTHER PERSON TRAD. MIDWIFE/GRAN . OTHER __________________________ (SPECIFY) NO ONE.……. 409G A B D U Y HEALTH PROFESSIONAL DOCTOR . NURSE/MIDWIFE. OTHER PERSON TRAD. MIDWIFE/GRAN. OTHER __________________________ (SPECIFY) NO ONE. 410 A B D U Y LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 407B Where did you go for antenatal care? Anywhere else? RECORD ALL MENTIONED. PUBLIC SECTOR GOVT./SAMPLE HOSPITAL . MATERNITY HOUSE . MCHFP CENTER . HEALTH CENTER. HEALTH HOUSE . SSK HOSPITAL/DISPANSERY. TRAINING AND RESEARCH HOSP. FAMILY AND HEALTH CENTER/ FAMILY DOCTOR . OTHER _______________________ (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL. PRIVATE POLYCLINIC . PRIVATE DOCTOR. PRIVATE NURSE/MIDWIFE (HEALTH CABIN). OTHER_______________________ (SPECIFY) UNIVERSITY HOSPITAL. VOLUNTARY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC . OTHER__________________________ (SPECIFY) A B C D E F G H I J K L M N O P U PUBLIC SECTOR GOVT./SAMPLE HOSPITAL . MATERNITY HOUSE . MCHFP CENTER . HEALTH CENTER. HEALTH HOUSE . SSK HOSPITAL/DISPANSERY . TRAINING AND RESEARCH HOSP. FAMILY AND HEALTH CENTER/ FAMILY DOCTOR . OTHER _______________________ (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL . PRIVATE POLYCLINIC . PRIVATE DOCTOR . PRIVATE NURSE/MIDWIFE (HEALTH CABIN) . OTHER_______________________ (SPECIFY) UNIVERSITY HOSPITAL. VOLUNTARY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC . OTHER__________________________ (SPECIFY) A B C D E F G H I J K L M N O P U 408 How many months pregnant were you with . when you first received antenatal care? MONTH . MONTH . 408A During your pregnancy with . when you went for the first time for antenatal care did you go because there was a problem or was it an ordinary check-up? THERE WAS A PROBLEM…….… ORDINARY CONTROL.…. OTHER __________________________ (SPECIFY) 1 2 7 THERE WAS A PROBLEM…….… ORDINARY CONTROL.…. OTHER __________________________ (SPECIFY) 1 2 7 409A How many times did you receive antenatal care during your pregnancy with .? NO. OF TIMES . NO. OF TIMES . 409B How many months pregnant were you with . when you received antenatal care for the last time? MONTH . MONTH . 409C In any of your antenatal checks: Were you weighed? Were you checked for your blood pressure? Had a blood test? Had a urine test? Had ultrasonographic check? Had abdomen control by hand? WEIGHED. BLOOD PRESSURE. BLOOD TEST. URINE TEST. ULTRASOUND. ABDOMINAL EXAMINATION. YES .1 .1 .1 .1 .1 .1 NO 2 2 2 2 2 2 LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 409F Have you been informed on the following topics in any of your antenatal checks? Nutrition during pregnancy? Situations that require emergency visits to health facilities? (Bleeding, high blood pressure, edema, fever, etc.)? Type of delivery (Caesarean section/vaginal)? Breastfeeding? Contraception use after birth? NUTRITION. EMERGENCIES. DELIVERY TYPE. BREASTFEEDING. CONTRACEPTION USE. YES .1 .1 .1 .1 .1 NO 2 2 2 2 2 409G Have you taken iron tablets during your pregnancy to ……? YES . NO . DON’T KNOW . 1 2 8 409H CHECK 407A: HAD ANTENATAL CARE? YES NO 410 409I What was the reason for you not receiving antenatal care during your pregnancy to ……? RECORD ALL MENTIONED. THERE WAS NO PROBLEM . ACESSIBILITY PROBLEMS . DISTRUST OF HEALTH FACILITY/PERSONNEL . PROBLEMS IN USING HEALTH INSTITUTION . TRADITIONS/CUSTOMS . ECONOMIC LIMITATIONS . POOR SERVICES . DOES NOT KNOW WHERE. FEAR . SHAME . HUSBAND DID NOT ALLOW . MOTHER IN LAW DID NOT ALLOW . OTHER FAMILY MEMBERS DID NOT ALLOW. OTHER __________________________ (SPECIFY) A B C D E F G H I J K L M U LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 410 Where did you give birth to .? HOME WOMAN’S HOME.…………. OTHER HOME……….………. PUBLIC SECTOR GOVT./SAMPLE HOSPITAL. MATERNITY HOUSE…………. MCHFP CENTER.……………. HEALTH CENTER……….…. HEALTH HOUSE…………….…. SSK HOSPITAL/DISPANSERY. TRAINING AND RESEARCH HOSP. FAMILY HEALTH CENTER/ FAMILY DOCTOR . OTHER ________________________ (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL…………. PRIVATE POLYCLINIC……. PRIVATE DOCTOR…. PRIVATE NURSE/MIDWIFE (HEALTH CABIN). OTHER ________________________ (SPECIFY) UNIVERSITY HOSPITAL. VOLUNATRY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC. OTHER ____________________________ (SPECIFY) 01 02 11 12 13 14 15 16 17 18 19 21 22 23 24 29 31 41 96 HOME WOMAN’S HOME.…………. OTHER HOME……….………. PUBLIC SECTOR GOVT./SAMPLE HOSPITAL. MATERNITY HOUSE…………. MCHFP CENTER.……………. HEALTH CENTER……….…. HEALTH HOUSE…………….…. SSK HOSPITAL/DISPANSERY . TRAINING AND RESEARCH HOSP . FAMILY HEALTH CENTER/ FAMILY DOCTOR . OTHER ________________________ (SPECIFY) PRIVATE SECTOR PRIVATE HOSPITAL…………. PRIVATE POLYCLINIC……. PRIVATE DOCTOR…. PRIVATE NURSE/MIDWIFE (HEALTH CABIN) . OTHER ________________________ (SPECIFY) UNIVERSITY HOSPITAL. VOLUNATRY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC. OTHER ____________________________ (SPECIFY) 01 02 11 12 13 14 15 16 17 18 19 21 22 23 24 29 31 41 96 413 Who assisted with the delivery of .? Anyone else? RECORD ALL MENTIONED. HEALTH PROFESSIONAL DOCTOR………………………. NURSE/MIDWIFE……………. OTHER PERSON TRADITIONAL MIDWIFE…. RELATIVE/FRIENDS…………. OTHER__________________________ (SPECIFY) NO ONE . A B D E U Y HEALTH PROFESSIONAL DOCTOR………………………. NURSE/MIDWIFE……………. OTHER PERSON TRADITIONAL MIDWIFE…. RELATIVE/FRIENDS…………. OTHER__________________________ (SPECIFY) NO ONE . A B D E U Y 414 How did .’s birth occur? Was it vaginal birth or caesarean section? NORMAL (VAGINAL) BIRTH . CAESAREAN . 1 2 NORMAL (VAGINAL) BIRTH . CAESAREAN . 1 2 LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 414B CHECK 410: DID THE BIRTH TAKE PLACE AT A HEALTH FACILITY? YES NO 443 YES NO 444 437 How long did you stay at the health facility after .’s birth? RECORD “00” IF LESS THAN ONE DAY. RECORD AS DAY IF LESS THAN ONE WEEK. DAY . 1 WEEK . 2 DON’T KNOW . 998 DAY . 1 WEEK . 2 DON’T KNOW. 998 439 Were you examined by a health professional before you returned home after birth? YES . NO . 442 1 2 YES . NO . 442 1 2 440 How much time elapsed between birth and your first examination? RECORD AS HOUR IF LESS THAN 1 DAY AND AS DAY IF LESS THAN 1 WEEK. HOUR . 1 DAY . 2 WEEK . 3 DON’T KNOW .998 441 Who examined you? Who else? DOCTOR . MIDWIFE/NURSE . OTHER __________________________ (SPECIFY) A B U 441A GO TO 448A. GO TO 453. 442 Were you examined by a health professional within two months following your departure from .? (THE PLACE MENTIONED AT 410) YES . 445 NO . 449 1 2 YES . 453 NO . 453 1 2 443 What was the main reason for not having done .’s birth in a health institution? NO REASON…………………. ACESSIBILITY PROBLEMS……. DISTRUST OF HEALTH FACILITY/PERSONNEL.…. HAPPENED SUDDENLY……….…. PROBLEMS IN USING HEALTH INSTUTION.…. EXPENSIVE……………………………. TRADITIONS/CUSTOMS………. NO PROBLEM.……………. FEAR. SHAME. OTHER __________________________ (SPECIFY) DON’T KNOW . 00 01 02 03 04 05 06 07 08 09 96 98 LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 444 In the two months after . was born, did any health care provider check your health? YES . NO . 449 1 2 YES . NO . 1 2 445 How long after delivery did the first check take place? RECORD IN HOURS IF LESS THAN 1 DAY, RECORD IN WEEKS IF LESS THAN 1 MONTH. HOUR . 1 DAY . 2 WEEK . 3 DON’T KNOW . 998 446 Who checked on your health at that time? Who else? DOCTOR . MIDWIFE/NURSE . OTHER __________________________ (SPECIFY) A B U 447 Where did this first check take place? HOUSE OWN HOUSE . OTHER HOUSE . PUBLIC SECTOR GOVT./SAMPLE HOSPITAL. MATERNITY HOUSE…………. MCHFP CENTER.……………. HEALTH CENTER……….…. HEALTH HOUSE…………….…. SSK HOSPITAL/DISPANSERY . TRAINING AND RESEARCH HOSP . FAMILY HEALTH CENTER/ FAMILY DOCTOR . OTHER _________________________ (BELİRTİN) PRIVATE SECTOR PRIVATE HOSPITAL…………. PRIVATE POLYCLINIC……. PRIVATE DOCTOR…. PRIVATE NURSE/MIDWIFE (HEALTH CABIN) . OTHER ________________________ (SPECIFY) UNIVERSITY HOSPITAL . VOLUNATRY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC. OTHER ____________________________ (SPECIFY) 01 02 11 12 13 14 15 16 17 18 19 21 22 23 24 29 31 41 96 448A In the two months after . was born, how many times did health care providers check your health? NUMBER OF TIMES . LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 448B In the health checks within two months after . was born, have you been informed on any the following topics? Mother’s nutrititon? Baby’s nutrition? Breastfeeding? Baby’s immunization? Breast care? Postpartum contraception use? Situations that require emergency visits to health facilities? Use of iron tablets? MOTHER’S NUTRITITON. BABY’S NUTRITION. BREASTFEEDING. IMMUNIZATION. BREAST CARE. CONTRACEPTION. EMERGENCIES. IRON TABLETS. YES .1 .1 .1 .1 .1 .1.1 .1 .1 NO 2 2 2 2 2 2 2 2 448C In any of the health checks within two months after . was born: Were you checked for your blood pressure? Had a blood test? Had a urine test? Checked for body temperature? Checked for bleeding? BLOOD PRESSURE. BLOOD TEST. URINE TEST. BODY TEMPERATURE. BLEEDING. YES .1 .1 .1 .1 .1 NO 2 2 2 2 2 449 Now I would like to ask you about the health checks (NAME OF CHILD) . attended within the two months after he/she was born. In the two months after . was born, did any health care provider check her/his health? YES . NO . 453 1 2 450 How long after delivery did the first check of . take place? RECORD IN HOURS IF LESS THAN ONE DAY, RECORD IN WEEKS IF LESS THAN ONE MONTH. HOUR . 1 DAY . 2 WEEK . 3 DON’T KNOW……………….….…998 451 Who checked on .’s health at that time? Who else? DOCTOR . MIDWIFE/NURSE . OTHER __________________________ (SPECIFY) A B U LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 452 Where did this first check of . take place? HOUSE OWN HOUSE . OTHER HOUSE . PUBLIC SECTOR GOVT./SAMPLE HOSPITAL. MATERNITY HOUSE…………. MCHFP CENTER.……………. HEALTH CENTER……….…. HEALTH HOUSE…………….…. SSK HOSPITAL/DISPANSERY . TRAINING AND RESEARCH HOSP . FAMILY HEALTH CENTER/ FAMILY DOCTOR . OTHR __________________________ (BELİRTİN) PRIVATE SECTOR PRIVATE HOSPITAL…………. PRIVATE POLYCLINIC……. PRIVATE DOCTOR…. PRIVATE NURSE/MIDWIFE (HEALTH CABIN) . OTHER ________________________ (SPECIFY) UNIVERSITY HOSPITAL . VOLUNATRY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC. OTHER ____________________________ (SPECIFY) 01 02 11 12 13 14 15 16 17 18 19 21 22 23 24 29 31 41 96 453 When . was born, was he/she very large, larger than average, average, smaller than average or very small? VERY LARGE……………………. LARGER THAN AVERAGE.……. AVERAGE.………………………. SMALLER THAN AVERAGE.…. VERY SMALL.………………………. DON’T KNOW………………………. 1 2 3 4 5 8 VERY LARGE……………………. LARGER THAN AVERAGE.……. AVERAGE.………………………. SMALLER THAN AVERAGE.…. VERY SMALL.……………………. DON’T KNOW………………………. 1 2 3 4 5 8 454 Was ……weighed at birth? YES . NO . 455A 1 2 YES . NO . 455A 1 2 455 How much did …… weigh? RECORD WEIGHT FROM HEALTH CARD, IF AVAILABE. GRAMS FROM CARD.1 FROM RECALL.2 DON’T KNOW………………….99998 GRAMS FROM CARD.1 FROM RECALL.2 DON’T KNOW………………….99998 455A Has …… been through a test for phenylketonuria? YES . NO . DON’T KNOW . 1 2 3 YES . NO . DON’T KNOW . 1 2 3 LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 455B Before, during or after the birth of . , did you ever pay money for the health services you have taken for yourself or for your child? While taking antenatal care? During delivery? While taking the postnatal checks? ANC. DELIVERY. PNC. YES .1 .1 .1 NO 2 2 2 456 Has your period returned since the birth of ……? YES . 458 NO . 459 1 2 457 Did your period return between the birth of …… and your next pregnancy? YES……………………………. NO……………………………. 461 1 2 458 For how many months after birth of …… did you not have your period? MONTH . DON’T KNOW . 98 MONTH. DON’T KNOW .98 459 CHECK 227: RESPONDENT CURRENTLY PREGNANT? NOT PREGNANT PREGNANT OR UNSURE 461 460 Have you resumed sexual relations since the birth of ……? YES . NO . 462 1 2 461 For how many months after the birth of …… did you not have sexual relations? RECORD AS “DAY” IF LESS THAN 2 MONTHS. DAY.1 MONTH.2 DON’T KNOW . 98 DAY.1 MONTH.2 DON’T KNOW .98 462 Did you ever breastfeed ….? YES . NO . 470B 1 2 YES . NO . 470B 1 2 463 How long after birth did you first put …… to the breast? RECORD “00” IF LESS THAN 1 HOUR. RECORD AS HOUR IF LESS THAN 24 HOURS, AS DAY IF MORE. HOUR . 1 DAY . 2 463A In the first three days after delivery, was . given anything to drink other than breast milk? YES . NO . 464 1 2 LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 463B What was given to ……? Anything else? RECORD ALL MENTIONED. MILK (OTHER THAN BREAST MILK). WATER . SUGAR WATER . SALT-SUGAR-WATER SOLUTION . FRUIT JUICE. BABY FORMULA . TEA . JUICE OF COOKED MEAL . HONEY . OTHER ____________________________ (SPECIFY) A B C D E F G H I U 464 CHECK 404: CHILD ALIVE? ALIVE DEAD 466 ALIVE DEAD 466 465 Are you still breastfeeding ……? YES . 468 NO . 1 2 YES . 470C NO . 1 2 466 For how many months did you breastfeed ……? MONTH . DON’T KNOW . 98 MONTH. DON’T KNOW .98 467 GO TO 470A. GO TO 470A. 468 How many times did you breastfeed …… last night between sunset and sunrise? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER. NUMBER OF NIGHTTIME FEEDINGS . 469 How many times did you breastfeed …… yesterday during the daylight hours? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER. NUMBER OF DAYTIME FEEDINGS . 469A GO TO 471. GO TO 471. LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 470A CHECK 466: BRESTFED FOR LESS THAN 6 MONTHS BRESTFED FOR 6 MONTHS OR LONGER 470C BRESTFED FOR LESS THAN 6 MONTHS BRESTFED FOR 6 MONTHS OR LONGER 470C 470B Why did you not breastfeed/stop breastfeeding ……? MOTHER SICK/WEAK . CHILD SICK/WEAK . CHILD DEAD . BREAST PROBLEM . INSUFFICIENT MILK . MOTHER WORKING . BABY DID NOT WANT IT . GOT PREGNANT . OTHER ___________________________ (SPECIFY) 11 12 13 14 15 16 17 18 96 MOTHER SICK/WEAK . CHILD SICK/WEAK . CHILD DEAD . BREAST PROBLEM . INSUFFICIENT MILK . MOTHER WORKING . BABY DID NOT WANT IT. GOT PREGNANT . OTHER ___________________________ (SPECIFY) 11 12 13 14 15 16 17 18 96 470C CHECK 404: CHILD ALIVE? ALIVE DEAD 488 ALIVE DEAD 488 471 Did …… drink anything from a bottle with a nipple yesterday or last night? YES . NO . DON’T KNOW . 1 2 8 YES . NO . DON’T KNOW . 1 2 8 471A Which supplementary nutrition other than breastmilk did you feed …… first? NONE. 476A MILK (OTHER THAN BREASTMILK). WATER. SUGAR WATER. SALT-SUGAR-WATER SOLUTION . FRUIT JUICE. BABY FORMULA. YOGHURT. TEA. JUICE OF COOKED MEAL. HONEY. OTHER ____________________________ (SPECIFY). 00 01 02 03 04 05 06 07 08 09 10 96 471B How many months old was . when you first fed him/her with supplementary food ? MONTHS . LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 472 At any time in last 24 hours was …… given any of the following? Eggs? Cheese? Yoghurt? Red meat? Chicken? Fish? Fresh vegetables/fruits? Water? Baby formula? Bottled/Boxed milk / Milk sold outside? Cereals or grains? Soup/juice of cooked meal? Bread? EGGS . CHEESE . YOGHURT . RED MEAT . CHICKEN . FISH . VEGETABLES/FRUITS. WATER . BABY FORMULA . MILK. CEREALS/GRAINS . SOUP/JUICE OF MEAL. BREAD . Y 1 1 1 1 1 1 1 1 1 1 1 1 1 N 2 2 2 2 2 2 2 2 2 2 2 2 2 DK 8 8 8 8 8 8 8 8 8 8 8 8 8 EGGS . CHEESE . YOGHURT . RED MEAT . CHICKEN . FISH . VEGETABLES/FRUITS . WATER . BABY FORMULA. MILK . CEREALS/GRAINS. SOUP/JUICE OF MEAL. BREAD . Y 1 1 1 1 1 1 1 1 1 1 1 1 1 N 2 2 2 2 2 2 2 2 2 2 2 2 2 DK 8 8 8 8 8 8 8 8 8 8 8 8 8 476A Has . had dierrahea in the last 15 days? YES . NO . 487 DON’T KNOW . 1 2 8 YES . NO . 487 DON’T KNOW . 1 2 8 477 Was there any blood in the stools? YES . NO . DON’T KNOW . 1 2 8 YES . NO . DON’T KNOW . 1 2 8 478 On the worst day of diarrhea, how many bowel movements did …… have? NUMBER OF BOWEL MOVEMENTS . DON’T KNOW . 98 NUMBER OF BOWEL MOVEMENTS . DON’T KNOW . 98 478A CHECK 471A: SUPPLEMENTARY NUTRITION GIVEN? GIVEN NOT GIVEN 488 GIVEN NOT GIVEN 488 479 Was . given the same amount to drink as before the diarrhea, or more or less when he/she had diarrhea? SAME. MORE . LESS . DON’T KNOW . 1 2 3 8 SAME . MORE . LESS . DON’T KNOW . 1 2 3 8 480 Was . given the same amount to eat as before the diarrhea, or more or less when he/she had diarrhea? SAME. MORE . LESS . DON’T KNOW . 1 2 3 8 SAME . MORE . LESS . DON’T KNOW . 1 2 3 8 LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 481 When . had diarrhea was he/she given any of the following to eat or drink? A fluid made from a special packet called ORS? Home made sugar-salt-water solution? Milk or baby formula? Soup? Ayran (Yoghurt based drink)? Tea? Rice-pudding/mashed potatoes? Other liquids? ORS PKT. HOME MADE ORS. MILK/BABY FORMULA. SOUP . AYRAN . TEA . RICE PUDDING/POTATOES. OTHER LIQUIDS. Y 1 1 1 1 1 1 1 1 N 2 2 2 2 2 2 2 2 D 8 8 8 8 8 8 8 8 ORS PKT . HOME MADE ORS . MILK/BABY FORMULA . SOUP . AYRAN . TEA . RICE PUDDING/POTATOES . OTHER LIQUIDS . Y 1 1 1 1 1 1 1 1 N 2 2 2 2 2 2 2 2 D 8 8 8 8 8 8 8 8 482 Was anything else given to treat diarrhea? YES . NO. DON’T KNOW. 1 2 8 YES . NO . DON’T KNOW . 1 2 8 484 Did you seek advice or treatment for the diarrhea? YES . NO. 486 DON’T KNOW. 1 2 8 YES . NO . 486 DON’T KNOW . 1 2 8 485 Where/from whom did you seek advice or treatment? Anywhere else? RECORD ALL MENTIONED. PUBLIC SECTOR PUBLIC SECTOR GOVT./SAMPLE HOSPITAL.A GOVT./SAMPLE HOSPITAL.A MATERNITY HOUSE .B MATERNITY HOUSE .B MCHFP CENTRE .C MCHFP CENTRE .C HEALTH CENTRE .D HEALTH CENTRE .D HEALTH HOUSE .E HEALTH HOUSE .E SSK HOSPITAL/DISPANSERY .F SSK HOSPITAL/DISPANSERY .F TRAINING AND RESEARCH HOSP.G TRAINING AND RESEARCH HOSP.G FAMILY HEALTH CENTER/ FAMILY DOCTOR .H FAMILY HEALTH CENTER/ FAMILY DOCTOR . H OTHER __________________________________I OTHER __________________________________I (SPECIFY) (SPECIFY) PRIVATE SECTOR PRIVATE SECTOR PRIVATE HOSPITAL .J PRIVATE HOSPITAL .J PRIVATE POLYCLINIC.K PRIVATE POLYCLINIC.K PRIVATE DOCTOR.L PRIVATE DOCTOR.L PRIVATE NURSE/MIDWIFE (HEALTH CABIN) .M PRIVATE NURSE/MIDWIFE (HEALTH CABIN) .M PHARMACY/MEDICAL STORE .N PHARMACY/MEDICAL STORE .N OTHER _______________________________O OTHER __________________________________O (SPECIFY) (SPECIFY) UNIVERSITY HOSPITAL .P UNIVERSITY HOSPITAL .P VOLUNATRY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC .R VOLUNATRY ORGANIZATION/ FOUNDATION HOSPITAL/CLINIC .R MARKET/SHOP.S MARKET/SHOP.S RELATIVE/FRIENDS/NEIGHBOURS.T RELATIVE/FRIENDS/NEIGHBOURS.T TRAD. MIDWIFE/GRAN.V TRAD. MIDWIFE/GRAN.V OTHER __________________________________U OTHER __________________________________U (SPECIFY) (SPECIFY) LAST BIRTH NAME___________________________ NEXT TO LAST BIRTH NAME___________________________ 486 CHECK 465: STILL BREASTFEEDING? YES NO 487 486A Did you make any changes in the breastfeeding frequency of . when he/she had diarrhea? YES . NO. 487 1 2 486B Did you breastfeed . less or more, did you stop brestfeeding? MORE. LESS . STOPPED BREASTFEEDING. 1 2 3 487 Is . currently attending daycare or kindergarten? NOT ATTENDING . DAYCARE CENTRE . KINDERGARTEN . 0 1 2 NOT ATTENDING . DAYCARE CENTRE . KINDERGARTEN . 0 1 2 487A GO TO 489A. GO TO 489A. 488 Where did ……die? HOUSE OWN HOUSE . OTHER HOUSE. PUBLIC SECTOR GOVT./SAMPLE HOSPITAL. MATERNITY HOUSE…………. MCHFP CENTER.……………. HEALTH CENTER……….…. HEALTH HOUSE………….…. SSK HOSPITAL/DISPANSERY. TRAINING AND RESEARCH HOSP. FAMILY HEALTH CENTER/ FAMILY DOCTOR. OTHER _________________________ (BELİRTİN) PRIVATE SECTOR PRIVATE HOSPITAL…………. PRIVATE POLYCLINIC……. PRIVATE DOCTOR…. PRIVATE NURSE/MIDWIFE (HEALTH CABIN). OTHER ________________________ (SPECIFY) UNIVERSITY HOSPITAL . OTHER ____________________________ (SPECIFY) 01 02 11 12 13 14 15 16 17 18 19 21 22 23 24 29 31 96 HOUSE OWN HOUSE . OTHER HOUSE. PUBLIC SECTOR GOVT./SAMPLE HOSPITAL. MATERNITY HOUSE…………. MCHFP CENTER.……………. HEALTH CENTER……….…. HEALTH HOUSE…………….…. SSK HOSPITAL/DISPANSERY. TRAINING AND RESEARCH HOSP. FAMILY HEALTH CENTER/ FAMILY DOCTOR. OTHER ________________________ (BELİRTİN) PRIVATE SECTOR PRIVATE HOSPITAL………. PRIVATE POLYCLINIC……. PRIVATE DOCTOR…. PRIVATE NURSE/MIDWIFE (HEALTH CABIN). OTHER ________________________ (SPECIFY) UNIVERSITY HOSPITAL . OTHER ___________________________ (SPECIFY) 01 02 11 12 13 14 15 16 17 18 19 21 22 23 24 29 31 96 489A GO BACK TO 405 IN NEXT COLUMN IFTHERE IS ANOTHER BIRTH. IF NO MORE BIRTHS, GO TO 490S. GO TO 405 IN AN EXTRA QUESTIONNAIRE IF THERE IS ANOTHER BIRTH. IF NOT, GO TO 490S. 490S RECORD THE TIME. HOUR – MINUTE. SECTION 5. IMMUNIZATION 500 CHECK 225: ONE OR MORE LIVE BIRTHS SINCE JANUARY 2005 NO LIVE BIRTHS SINCE JANUARY 2005 709 501 ENTER LINE NUMBER, NAME SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 2005 IN THE TABLE. ASK QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS USE ADDITIONAL QUESTIONNAIRES – DO NOT USE THE LAST BIRTH COLUMN IN THE ADDITIONAL QUESTIONNAIRE, USE ”NEXT TO LAST BIRTH” CLOUMN’ AND WRITE ”SECOND ONE BEFORE THE LAST BIRTH”) 501A LINE NUMBER FROM 212. LAST BIRTH LINE NO…………….……. NEXT TO LAST BIRTH LINE NO…………….……. 502 CHECK 212: CHECK 216: NAME___________________________ NAME___________________________ ALIVE DEAD ALIVE DEAD IF NO MORE BIRTHS, GO TO 510S IF THERE IS MORE BIRTHS GO TO 502 IN NEXT COLUMN . IF NO MORE BIRTHS, GO TO 510S IF THERE IS MORE BIRTHS GO TO 502 IN ADDITIONAL. QUESTIONNAIRE. 503 Do you have a card where ……’s vaccination are written down? (IF YES) May I see it please? YES, SEEN . YES, NOT SEEN . 506 NO CARD . 1 2 3 YES, SEEN . YES, NOT SEEN . 506 NO CARD . 1 2 3 504 (1) COPY VACCINATION DATES FOR EACH VACCINE FROM THE CARD. PAY ATTENTION TO APPOINTMENT DAYS AND THE CONSISTENCY OF VACCINATION DATES. (2) WRITE ‘44’ IN THE DAY CLOUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN BUT NO DATE IS RECORDED. DAY MO YEAR DAY MO YEAR BCG BCG BCG POLIO 1 P1. P1. POLIO 2 P2. P2. POLIO 3 P3. P3. DPT 1 D1. D1. DPT 2 D2. D2. DPT 3 D3. D3. MEASLES MEA MEA HEPATITUS B 1 H1. H1. HEPATITUS B 2 H2. H2. HEPATITUS B 3 H3. H3. LAST BIRTH LINE NO…………….……. NEXT TO LAST BIRTH LINE NO…………….……. 505 Has …… received any vaccination that are not recorded on this card? RECORD ‘YES’ IF ONLY RESPONDENT MENTIONS BCG, POLIO 1 – 3, DPT 1 – 3, MEASLES AND/OR HEPATITUES B 1 - 3 . YES.….……………………….……. NO………………………………. 509 DON’T KNOW……………….…. 1 2 8 YES .….……………………….……. NO .………………………………. 509 DON’T KNOW .…………….…. 1 2 8 505A PROBE VACCINATIONS AT 504, RECORD ‘66’ TO DAY SECTION OF THAT VACCINATION. SKIP TO 509 PROBE VACCINATIONS AT 504, RECORD ‘66’ TO DAY SECTION OF THAT VACCINATION. SKIP TO 509 506 Did…… ever receive any vaccinations to prevent him/her from getting infectious diseases? YES .………………………………. NO .………………………………. 509 DON’T KNOW .…………….…. 1 2 8 YES .………………………………. NO .………………………………. 509 DON’T KNOW .…………….…. 1 2 8 508A Please tell me if …… received any of the following vaccinations? BCG: A vaccination against tuberculosis, that is an injection in the left arm or shoulder that caused a scar? YES .………………………………. NO .………………………………. DON’T KNOW …………….…. 1 2 8 YES .………………………………. NO .………………………………. DON’T KNOW …………….…. 1 2 8 508B Polio vaccination: That is dropped in the mouth? YES .………………………………. NO .………………………………. 508D DON’T KNOW…………….…. 1 2 8 YES .………………………………. NO .………………………………. 508D DON’T KNOW…………….…. 1 2 8 508C How many times? NUMBER OF TIMES……….……. NUMBER OF TIMES……….……. 508D DPT vaccination: This vaccination includes diphtheria, whooping-cough and tetanus.and it is usually given at the same time as polio drops. YES .………………………………. NO .………………………………. 508F DON’T KNOW…………….…. 1 2 8 YES .………………………………. NO .………………………………. 508F DON’T KNOW…………….…. 1 2 8 508E How many times? NUMBER OF TIMES……….……. NUMBER OF TIMES……….……. 508F Measles vaccination? YES .………………………………. NO .………………………………. DON’T KNOW …………….…. 1 2 8 YES .………………………………. NO .………………………………. DON’T KNOW …………….…. 1 2 8 508G Hepatitus B vaccination? YES .………………………………. NO .………………………………. 509 DON’T KNOW…………….…. 1 2 8 YES .………………………………. NO .………………………………. 509 DON’T KNOW…………….…. 1 2 8 508H How many times? NUMBER OF TIMES……….……. NUMBER OF TIMES……….……. 509 RETURN TO 502 IN THE NEXT COLUMN IFTHERE IS ANOTHER BIRTH. SKIP TO 709 IF NOT. RETURN TO 502 IN THE ADDITIONAL QUESTIONNAIRE IF THERE IS ANOTHER BIRTH. SKIP TO 709 IF NOT. SECTION 7A. WOMEN’S WORK 709 Now I would like to ask you questions about working. Have you worked in a job whether paid or unpaid since you were 12 for at least 6 months? As you know some women sell small things, sell goods at the market place, work on the family farm or business, look after children, work as housemaids etc. Please include these kinds of jobs as well. YES .1 NO . 2 718A 709A Can you list me the jobs you have worked in whether paid or unpaid, for at least 6 months, since you were 12, starting from the first one? RECORD ALL JOBS LASTED SIX MONTHS OR LONGER THE WOMEN HAS WORKED AT FROM AGE 12 TO SURVEY DATE TO THE LIST WITH DETAILS, STARTING FROM THE FIRST ONE. ADD THE CURRENT JOB IN THE LIST REGARDLESS OF ITS DURATION. ASK THE QUESTIONS FOR EACH JOB SEPERATELY. CAUTION: IF THE RESPONDENT HAS WORKED AT MORE THAN 10 JOBS, USE AN ADDITIONAL QUESTIONNAIRE. CONTINUE THE INTERVIEW FROM THIS NEW QUESTIONNAIRE. 710 What was your job? RECORD THE JOB IN DETAIL. 711 In which year and month did you start working in this job? 712 In which sector were you working? 713 Was your job in public or private sector? 714 What was your position at work? USE THE CODE LIST. 715 Did you have any social security when doing your job? (IF YES) According to which schedule? USE THE CODE LIST. 01 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 02 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 03 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 04 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 05 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) (714) STATUS AT JOB (715) SOCIAL SECURITY 01 EMPLOYER 05 FOR HER OWN (REGULAR) 00 NONE 02 WAGED, WORKER (REGULAR) 06 FOR HER OWN (IRREGULAR) 01 SSK 03 SALARIED, GOVERNMENT 07 UNPAID FAMILY WORKER 02 EMEKLİ SANDIĞI OFFICER (REGULAR) 96 OTHER 03 BAĞ-KUR 04 DAILY WAGED (SEASONAL, 04 PRIVATE INSURANCE TEMPORARY) 96 OTHER 98 DON’T KNOW 709 Size şimdi çalışma durumunuza ilişkin sorular sormak istiyorum. 12 yaşınızdan bugüne kadar para karşılığında veya para almadan en az 6 ay süre ile herhangi bir işte çalıştınız mı? EVET .1 HAYIR .2 718 Bana 12 yaşından bu yana gelir getirsin veya getirmesin, en az 6 ay süre ile çalıştığınız tüm işleri 12 yaşında iken çalıştığınız işten başlayarak sırasıyla söyler misiniz? LİSTEDE BİRİNCİ SIRAYA KİŞİNİN 12 YAŞINI BİTİRDİĞİNDE ÇALIŞTIĞI İŞİ YAZIN VE ÇALIŞTIĞINIZ TÜM İŞLERİ SIRASIYLA KAYDEDİN. SORULARI HER İŞ İÇİN AYRI AYRI SORUN. DİKKAT: 6’DAN FAZLA İŞTE ÇALIŞMIŞ İSE, EK SORUKAĞIDI KULLANIN. GÖRÜŞMEYE YENİ AÇTIĞINIZ EK SORUKAĞIDINDAN DEVAM EDİN. 716 Are you currently working at this job? 716A How long have you worked at this job? RECORD IN MONTHS IF LESS THAN 2 YEARS. 716B In which month and year did you quit this job? 717 What was the reason of your resignment? USE THE CODE LIST. YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER) (717) REASON FOR RESIGNMENT 01 GOT PREGNANT/CHILD CARE 02 HOUSEWORK 03 SICK/DISABLED/HANDICAPPED 04 APPOINTMENT OF HUSBAND 05 JUST MOVED/MIGRATED 06 OPPOSITION OF HUSBAND/ELDERLY 07 DID NOT NEED TO WORK 08 DID NOT WANT TO WORK 09 WORKED UNPAID 10 DISMISSED 11 SICK/ELDERLY CARE IN FAMILY 12 WORKPLACE CLOSED 13 MARRIAGE 14 RETIREMENT 15 TO FIND/FOUND A BETTER JOB 16 SEASONAL/TEMPORARY 96 OTHER YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 BÖLÜM 7A. KADININ ÇALIŞMASI 709 Size şimdi çalışma durumunuza ilişkin sorular sormak istiyorum. 12 yaşınızdan bugüne kadar gelir getirsin veya getirmesin, en az 6 ay süre ile herhangi bir işte çalıştınız mı? Bildiğiniz gibi bazı kadınlar ufak-tefek şeyler satarlar, pazar yerinde satış yaparlar, para karşılığında ya da para almadan ailenin işyerinde ya da tarlasında çalışırlar, evde dikiş nakış yaparlar, çocuk bakıcılığı, ev temizliği gibi işler yaparlar. Bazı işler çalışma koşulları itibariyle yılın 6 aydan az süresini kapsayabilir. Lütfen bu tür işleri de dahil ederek cevap verin. EVET .1 HAYIR .2 718A 709A Bana 12 yaşından bu yana gelir getirsin veya getirmesin, en az 6 ay süre ile çalıştığınız tüm işleri ilk olarak çalıştığınız işten başlayarak sırasıyla söyler misiniz? LİSTEYE KADININ 12 YAŞINDAN İTİBAREN ARAŞTIRMA TARİHİNE KADAR ÇALIŞTIĞI TÜM İŞLERİ İLK YAPILAN İŞTEN BAŞLAYARAK AYRINTILI OLARAK YAZIN. KADININ HALEN ÇALIŞTIĞI İŞİ SÜRESİNE BAKMAKSIZIN LİSTEYE EKLEYİN. SONRA SORULARI HER İŞ İÇİN AYRI AYRI SORUN. DİKKAT: 5’TEN FAZLA İŞTE ÇALIŞMIŞ İSE, EK SORUKAĞIDI KULLANIN. GÖRÜŞMEYE EK SORUKAĞIDINDAN DEVAM EDİN. 710 What was your job? RECORD THE JOB IN DETAIL. 711 In which year and month did you start working in this job? 712 In which sector were you working? 713 Was your job in public or private sector? 714 What was your position at work? USE THE CODE LIST. 715 Did you have any social security when doing your job? (IF YES) According to which schedule? USE THE CODE LIST. 06 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 07 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 08 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 09 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) 10 MONTH. YEAR. AGRICULTURE.1 INDUSTRY.2 SERVICE.3 PUBLIC.1 PRIVATE.2 (JOB) (714) STATUS AT JOB (715) SOCIAL SECURITY 01 EMPLOYER 05 FOR HER OWN (REGULAR) 00 NONE 02 WAGED, WORKER (REGULAR) 06 FOR HER OWN (IRREGULAR) 01 SSK 03 SALARIED, GOVERNMENT 07 UNPAID FAMILY WORKER 02 EMEKLİ SANDIĞI OFFICER (REGULAR) 96 OTHER 03 BAĞ-KUR 04 DAILY WAGED (SEASONAL, 04 PRIVATE INSURANCE TEMPORARY) 96 OTHER 98 DON’T KNOW 709 Size şimdi çalışma durumunuza ilişkin sorular sormak istiyorum. 12 yaşınızdan bugüne kadar para karşılığında veya para almadan en az 6 ay süre ile herhangi bir işte çalıştınız mı? EVET .1 HAYIR .2 718 Bana 12 yaşından bu yana gelir getirsin veya getirmesin, en az 6 ay süre ile çalıştığınız tüm işleri 12 yaşında iken çalıştığınız işten başlayarak sırasıyla söyler misiniz? LİSTEDE BİRİNCİ SIRAYA KİŞİNİN 12 YAŞINI BİTİRDİĞİNDE ÇALIŞTIĞI İŞİ YAZIN VE ÇALIŞTIĞINIZ TÜM İŞLERİ SIRASIYLA KAYDEDİN. SORULARI HER İŞ İÇİN AYRI AYRI SORUN. DİKKAT: 6’DAN FAZLA İŞTE ÇALIŞMIŞ İSE, EK SORUKAĞIDI KULLANIN. GÖRÜŞMEYE YENİ AÇTIĞINIZ EK SORUKAĞIDINDAN DEVAM EDİN. 716 Are you currently working at this job? 716A How long have you worked at this job? RECORD IN MONTHS IF LESS THAN 2 YEARS. 716B In which month and year did you quit this job? 717 What was the reason of your resignment? USE THE CODE LIST. YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER) (717) REASON FOR RESIGNMENT 01 GOT PREGNANT/CHILD CARE 02 HOUSEWORK 03 SICK/DISABLED/HANDICAPPED 04 APPOINTMENT OF HUSBAND 05 JUST MOVED/MIGRATED 06 OPPOSITION OF HUSBAND/ELDERLY 07 DID NOT NEED TO WORK 08 DID NOT WANT TO WORK 09 WORKED UNPAID 10 DISMISSED 11 SICK/ELDERLY CARE IN FAMILY 12 WORKPLACE CLOSED 13 MARRIAGE 14 RETIREMENT 15 TO FIND/FOUND A BETTER JOB 16 SEASONAL/TEMPORARY 96 OTHER YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 YES. 718 NO. .1 .2 MONTH.1 MONTH. YEAR. ____________________ (SPECIFY IF OTHER)YEAR.2 718 CHECK 716: NOT CURRENTLY CURRENTLY 730A WORKING WORKING 718A Aside from your own housework, did you work in a job whether paid or unpaid in last one week? YES.1 720 NO.2 719 As you know some women sell small things, sell goods at the market place, work on the family farm or business, look after children, work as housemaids etc. Did you do any of these or any other work of similar nature in the last week? YES.1 720 NO.2 719A GO TO 727. 720 GO BACK AND CORRECT THE QUESTIONS BETWEEN 709-717 (ALSO 718-719 IF NECESSARY). 727 You told that you did not work last week. Do you have a job that you usually work? JUST ABOUT TO START WORKING.01 STUDENT.02 HOUSEWIFE.03 RETIRED.04 INCOME RECIPIENT.05 FAMILY WORKER.06 DISABLED/SICK.07 CARING FOR ELDERLY.08 CARING FOR CHILDREN.09 ABOUT TO GET MARRIED.10 TOO YOUNG.12 JUST GRADUATED. 13 HUSBAND/FAMILY DOES NOT ALLOW.14 JUST MIGRATED/LEFT.15 DOES NOT NEED TO WORK.16 OTHER __________________________________________ 96 (SPECIFY) 728 Are you currently looking for a job? YES.1 NO. 2 730 729 For how long have you been looking for a job? RECORD IN MONTHS IF LESS THAN 2 YEARS. MONTH .1 YEAR.2 730 Would you start to work within two weeks if you had a YES.1 chance to? NO. 2 730A Are you covered by any health insurance? (IF YES) According to which schedule? NO . 0 SSK .1 EMEKLİ SANDIĞI .2 BAĞ-KUR .3 PRIVATE HEALTH INSURANCE.4 YEŞİL KART .5 OTHER __________________________________________ 7 (SPECIFY) 730A CHECK 716: NOT CURRENTLY CURRENTLY 735 WORKING WORKING 731 CHECK 217 AND 218: HAS A CHILD LIVING WITH HER DOES NOT HAVE A CHILD WHOSE AGE IS LIVING WITH HER 5 OR LESS WHOSE AGE IS 5 735 OR LESS 732 Who usually takes care of …… (NAME OF THE YOUNGEST CHILD AT HOME) while you are working? WOMAN .01 HUSBAND .02 FEMALE CHILD .03 WOMAN’S MOTHER.05 HUSBAND’S MOTHER .06 MALE CHILD .07 OTHER RELATIVES .08 BABYSITTER………….09 KINDERGARDEN……………….10 HAS NOT WORKED SINCE LAST BIRTH.95 OTHER __________________________________________ 96 (SPECIFY) SECTION 7B. HUSBAND’S BACKGROUND 735 CHECK 160: CURRENTLY NOT MARRIED CURRENTLY 737 MARRIED 736 How old is your (last) husband? COMPLETED AGE . 737 Did your (last) husband ever attend school? YES .1 NO . 2 DON’T KNOW.8 740A 738 What was the highest level of school your (last) husband PRIMARY SCHOOL .11 attended? GENERAL SECONDARY SCHOOL .12 VOCATIONAL SECONDARY SCHOOL .13 PRIMARY EDUCATION .14 GENERAL HIGH SCHOOL .15 VOCATIONAL HIGH SCHOOL .16 UNIVERSITY .17 MASTER’S DEGREE.18 Ph. D. .19 DON’T KNOW .98 740A 739 What is the highest grade your (last) husband completed at that level? RECORD “00” IF HE COMPLETED PREPARATORY CLASS OR HE DID NOT COMPLETE ANY GRADE, AND “66” FOR MASTER’S/Ph. D. GRADE . DON’T KNOW.96 739A Did he graduate (receive diploma) from this school? YES . 1 NO .2 DON’T KNOW.8 740A CHECK 160: CURRENTLY NOT MARRIED CURRENTLY 740N MARRIED 740B Did your husband work in a regular or an irregular job whether paid or unpaid in the past week? YES .1 740E NO. . 2 740C Does your husband have a job he normally works at? YES .1 NO. .2 740J 740E What is (was) your husband’s occupation? What kind of job does (did) he have? ________________________________________________ (RECORD THE JOB IN DETAIL AND CIRCLE THE APPROPRIATE SECTOR IN THE NEXT COLUMN) AGRICULTURE.1 INDUSTRY.2 SERVICES.3 740F Does (did) your husband work for public or private PUBLIC.1 sector? PRIVATE.2 740G What is your husband’s status/position in his job? EMPLOYER.01 WAGED, WORKER (REGULAR).02 SALARIED, GOVERNMENT OFFICAL.03 DAILY WAGED (SEASONAL/TEMPORAL).04 FOR HIS OWN (REGULAR).05 FOR HIS OWN (IRREGULAR).06 UNPAID FAMILY WORKER.07 OTHER __________________________________________ 96 (SPECIFY) 740H Does (did) your husband pay social security when doing this job? (IF YES) According to which schedule? NO. . 0 SSK . 1 EMEKLİ SANDIĞI . 2 BAĞ-KUR . 3 PRIVATE.4 OTHER __________________________________________ 7 (SPECIFY) 740I GO TO 740N. 740J What is the reason for your husband’s not working? JUST ABOUT TO START WORKING.01 STUDENT.02 RETIRED.04 INCOME RECIPIENT.05 FAMILY WORKER.06 DISABLED/SICK.07 CARING FOR ELDERLY.08 CARING FOR CHILDREN.09 ABOUT TO SERVE/SERVING IN THE MILITARY. 11 LOOKING FOR A JOB/UNEMPLOYED.12 JUST GRADUATED. 14 JUST MIGRATED/LEFT.16 DOES NOT NEED TO WORK.17 OTHER __________________________________________ 96 (SPECIFY) DON’T KNOW.98 740K Is your husband looking for a job? YES. 1 NO. 2 DON’T KNOW.8 740M 740L For how long has your husband been looking for a job? RECORD IN MONTHS IF LESS THAN 2 YEARS. MONTH.1 YEAR.2 740M Would he start to work within two weeks if he had a chance to? YES .1 NO.2 DON’T KNOW.8 740N Is (was) your (last) husband covered by any health insurance? (IF YES) According to which schedule? NO. .0 SSK .1 EMEKLİ SANDIĞI .2 BAĞ-KUR .3 PRIVATE HEALTH INSURANCE.4 YEŞİL KART.5 OTHER __________________________________________ 7 (SPECIFY) 741A What is (was) your (last) husband’s mother tongue? RECORD ONE LANGUAGE ONLY. TURKISH . 1 KURDISH . 2 ARABIC . 3 OTHER ___________________________________________ 7 (SPECIFY) DON’T KNOW . 8 741B Can (could) your (last) husband speak any languages besides his mother tongue? (IF YES) Which language(s)? RECORD ALL MENTIONED. TURKISH . A KURDISH . B ARABIC . C OTHER ___________________________________________ U (SPECIFY) NO OTHER LANGUAGES . Y 741C What is (was) your (last) husband’s mother’s mother tongue? What is (was) your (last) husband’s father’s mother tongue? USE THE CODES IN 741A. MOTHER . FATHER . 741D Which language do (did) you usually use when talking with your (last) husband? TURKISH . 1 KURDISH . 2 ARABIC . 3 OTHER ___________________________________________ 7 (SPECIFY) 742A For most of the time until your (last) husband was 12 years old, where did he live? RECORD THE NAME AND CODE OF THE PROVINCE. NAME OF PROVINCE PROVINCE CODE ________________________________________ 742B Was this place then a province centre, a district centre, a PROVINCE CENTRE. 1 sub-district or a village ? Or was it abroad? DISTRICT CENTRE . 2 SUBDISTRICT OR VILLAGE . 3 ABROAD . 4 742C Are (were) your husband’s parents related? YES.1 NO.2 DON’T KNOW.8 761 742D In what way is (was) your husband’s father related to his SON OF FATHER’S BROTHER. 1 mother? SON OF FATHER’S SISTER . 2 SON OF MOTHER’S SISTER . 3 SON OF MOTHER’S BROTHER . 4 OTHER PARENTAL BLOOD RELATIVE . 5 OTHER MATERNALBLOOD RELATIVE . 6 OTHER ___________________________________________ 7 (SPECIFY) DON’T KNOW . 8 SECTION 7C. WOMEN’S STATUS Now I would like to get your opinion on some aspects of family life. Can you tell me whether you agree or disagree with each statement? The important decisions in the family should be made only by men of the family. Men should also do the housework like cooking, washing, ironing, and cleaning. A woman shouldn’t argue with her husband even if she disagrees with him. A married woman should work outside the home if she wants to. It is better to educate a son than a daughter. A woman may go anywhere she wants without her husband’s permission. Men are wiser. Women should be more involved in politics. Women should be virgins when they get married. 761 AGREE 1 1 1 1 1 1 1 1 1 DISAGREE 2 2 2 2 2 2 2 2 2 DON’T KNOW/ NO IDEA 8 8 8 8 8 8 8 8 8 762 Now I would like to ask you some questions about your daily life. IF YES, PROBE WHETHER REGULAR OR IRREGULAR NOT NO REGULAR IRREGULAR APPLICABLE Do you exercise? 0 1 2 3 Do you go to places other than your hometown for a holiday? 0 1 2 3 Do you go outside for meal with your family? 0 1 2 3 Do you organize meetings with your friends and/or neighbors? 0 1 2 3 Dou you use the internet? 0 1 2 3 Do you perform the namaz? 0 1 2 3 Do you fast? 0 1 2 3 Do you watch women’s programs on TV? 0 1 2 3 Do you wear head scarf when you go outside? 0 1 2 3 763 Now I will list some situations. Can you tell me whether you agree or disagree with a husband’s performance of physical violence to his wife under these situations? If she does not cook? If she burns the food? If she neglects the housework? If she neglects the children? If she answers him back? If she wastes money? If she refuses to have sexual intercourse? AGREES 1 1 1 1 1 1 1 DISAGREES 2 2 2 2 2 2 2 NO IDEA 8 8 8 8 8 8 8 764 Now I will ask you some questions about housework. Who does the types of housework in your house that I will list now primarily? H ER O W N H U SB A N D FE M A LE C H IL D R EN M A LE C H IL D R EN PA ID SE R V A N T/ M A ID O TH ER W O M EN O TH ER M EN N O O N E N O T A PP LI C A B LE Cooking? 11 12 13 14 15 16 17 18 00 Setting and cleaning the dining table? 11 12 13 14 15 16 17 18 00 Cleaning work such as wiping and sweeping? 11 12 13 14 15 16 17 18 00 Washing the dishes/placing the dishes in the dishwasher? 11 12 13 14 15 16 17 18 00 Doing the laundry? 11 12 13 14 15 16 17 18 00 Ironing? 11 12 13 14 15 16 17 18 00 Kitchen shopping? 11 12 13 14 15 16 17 18 00 Preparing the household budget and accounting? 11 12 13 14 15 16 17 18 00 Running errands in public offices, paying the bills? 11 12 13 14 15 16 17 18 00 Doing reparations or amendments? 11 12 13 14 15 16 17 18 00 Spending time with child(ren) at home (playing games, reading books, watching TV, etc.)? 11 12 13 14 15 16 17 18 00 Spending time with child(ren) outside the house (going to the park, movies, etc.)? 11 12 13 14 15 16 17 18 00 Helping child(ren) with homework? 11 12 13 14 15 16 17 18 00 765 Now I will read you some statements regarding situations some women experience. Can you please tell me how often you experience such situations in your relationship with your (last) husband? Often, sometimes or never? Does (did) your husband: Prevent you from seeing your female friends? Limit your contact with your family? Insist on knowing where you are at all times? Distrust you with money? Accuse you of being unfaithful? OFTEN 1 1 1 1 1 SOMETIMES 2 2 2 2 2 NEVER 3 3 3 3 3 NOT APPLICABLE 0 0 0 0 0 766S RECORD THE TIME. HOUR – MINUTE. 781 PRESENCE OF OTHERS DURING THE INTERVIEW. NO ONE .A CHILDREN UNDER 10 .B CIRCLE ALL APPROPRIATE ALTERNATIVES. MOTHER IN LAW .C HER MOTHER .D OTHER MEN . E OTHER WOMEN .F 782 WAS THE INTERVIEW INTERRUPTED? NO .000 IF YES, FOR HOW MANY MINUTES APPROXIMATELY? MINUTES .1 783 IN YOUR OPINION, WHAT IS THE RELIABILITY POOR . 1 OF THE RESPONSES? FAIR .2 GOOD .3 VERY GOOD .4 784 WHAT LANGUAGE WAS USED DURING THE INTERVIEW? TURKISH.1 800 KÜRDISH.2 ARABIC.3 OTHER _______________________________ 7 (SPECIFY) 785 WAS AN INTERPRETER USED DURING THE INTERVIEW? YES .1 NO . 2 SECTION 8. HEIGHT AND WEIGHT 800 RECORD THE NAME OF THE WOMAN AND IF ANY, THE NAME(S) OF THE CHILDREN THAT WAS BORN AFTER JANUARY 2003 AND STILL ALIVE IN 801, BY BEGINNING FROM THE YOUNGEST CHILD. RECORD THE LINE NO. OF CHILDREN IN 802. IF THERE ARE MORE THAN 2 LIVING CHILDREN THAT WERE BORN AFTER JANUARY 2003, USE AN ADDITIONAL QUESTIONNAIRE. MEAUSURE THE WEIGHT AND HEIGHT OF WOMAN AND HER LIVING CHILDREN THAT WERE BORN AFTER JANUARY 2003 AND RECORD IN THE APPROPRIATE FIELD. WOMAN YOUNGEST CHILD ALIVE NEXT – TO - YOUNGEST CHILD ALIVE 801 NAME CHECK 212 FOR CHILDREN. (NAME) ________________________ (NAME) ________________________ (NAME) ________________________ 802 LINE NO. IN 212. LINE NO . LINE NO . 803 HEIGHT (cm) . . . 804 WAS THE HEIGHT OF THE CHILD MEASURED LYING DOWN OR STANDING UP? LYING DOWN.1 LYING DOWN. 1 STANDING UP.2 STANDING UP.2 805 WEIGHT (Kilograms) . . . 806 DATE OF MEASUREMENT DAY . MONTH . DAY . MONTH . DAY . MONTH . 807 RESULT MEASURED.1 MEASURED.1 MEASURED.1 NOT AT HOME.3 NOT AT HOME.3 NOT AT HOME.3 REFUSED.4 REFUSED.4 REFUSED.4 OTHER ____________ 7 OTHER ____________ 7 OTHER ____________ 7 (SPECIFY) (SPECIFY) (SPECIFY) 808 NAME OF MEASURER _____________________________ 21 3 INTERVIEWER’S OBSERVATIONS To be filled after completing interview COMMENTS ABOUT WOMEN COMMENTS ON SPECIFIC QUESTIONS OTHER OBSERVATIONS SUPERVISOR’S OBSERVATIONS NAME OF THE SUPERVISOR: DATE: EDITOR’S OBSERVATIONS NAME OF THE EDITOR: DATE: CALENDAR 1 2 3 COLUMN 1: MARRIAGE 2 0 0 8 12 DEC 01 01 DEC 12 2 0 0 8 X MARRIED 11 NOV 02 02 NOV 11 O NOT MARRIED 10 OCT 03 03 OCT 10 09 SEP 04 04 SEP 09 COLUMN 2: BIRTHS AND PREGNANCIES 08 AUG 05 05 AĞU 08 D BIRTH 07 JULY 06 06 JULY 07 H PREGNANCY 06 JUNE 07 07 JUNE 06 K INDUCED ABORTION 05 MAY 08 08 MAY 05 F SPONTANEOUS ABORTION 04 APR 09 09 APR 04 J STILLBIRTH 03 MAR 10 10 MAR 03 02 FEB 11 11 FEB 02 01 JAN 12 12 JAN 01 COLUMN 2: CONTRACEPTIVE USE 0 NO METHOD 2 0 0 7 12 DEC 13 13 DEC 12 2 0 0 7 1 TUBAL LIGATION 11 NOV 14 14 NOV 11 2 MALE STERILIZATION 10 OCT 15 15 OCT 10 3 PILL 09 SEP 16 16 SEP 09 4 IUD 08 AUG 17 17 AĞU 10 5 INJECTABLES 07 JULY 18 18 JULY 07 6 IMPLANT 06 JUNE 19 19 JUNE 06 7 CONDOM 05 MAY 20 20 MAY 05 8 FEMALE CONDOM 04 APR 21 21 APR 04 9 DIAPHRAM/FOAM/JELLY 03 MAR 22 22 MAR 03 A EMERGENCY CONTRACEPTION 02 FEB 23 23 FEB 02 T RHYTIM 01 JAN 24 24 JAN 01 G WITHDRAWAL U OTHER _____________________________ 2 0 0 6 12 DEC 25 25 DEC 12 2 0 0 6 (SPECIFY) 11 NOV 26 26 NOV 11 N MONTHS OF WEDLOCK 10 OCT 27 27 OCT 10 09 SEP 28 28 SEP 09 COLUMN 3: DISCONTINUATION OF CONTRACEPTIVE USE 08 AĞU 29 29 AĞU 08 0 INFREQUENT SEX/PARTNER AWAY 07 JULY 30 30 JULY 07 1 BECAME PREGNANT WHILE USING 06 JUNE 31 31 JUNE 06 2 WANTED TO BECOME PREGNANT 05 MAY 32 32 MAY 05 3 HUSBAND DISAPPROVED 04 APR 33 33 APR 04 4 WANTED MORE EFFECTIVE METHOD 03 MAR 34 34 MAR 03 5 HEALTH CONCERNS 02 FEB 35 35 FEB 02 6 SIDE EFFECTS 01 JAN 36 36 JAN 01 7 LACK OF ACESS/TOO FAR 8 EXPENSIVE 2 0 0 5 12 DEC 37 37 DEC 12 2 0 0 5 9 INCONVINENT TO USE 11 NOV 38 38 NOV 11 Y FATALISTIC 10 OCT 39 39 OCT 10 M DIFFICULT TO GET PREGNANT/MENOPAUSE 09 SEP 40 40 SEP 09 B MARITAL DISSOLUTION/SEPERATION/WIDOWHOOD 08 AUG 41 41 AĞU 10 U OTHER_____________________________ 07 JULY 42 42 JULY 07 (SPECIFY) 06 JUNE 43 43 JUNE 06 X DON'T KNOW 05 MAY 44 44 MAY 05 04 APR 45 45 APR 04 03 MAR 46 46 MAR 03 COLUMN 3: ASSISTED REPRODUCTIVE TECHNIQUES 02 ŞUB 47 47 ŞUB 02 K NOT USED 01 JAN 48 48 JAN 01 A INTRAUTERINE INSEMINATION (INJECTION) T CONVENTIONAL INVITRO FERTILIZATION 2 0 0 4 12 DEC 49 49 DEC 12 2 0 0 4 E INTRACYROPLASMIC SPERM INJECTION 11 NOV 50 50 NOV 11 W DOESN'T KNOW TECHNIQUE 10 OCT 51 51 OCT 10 09 SEP 52 52 SEP 09 08 AUG 53 53 AĞU 10 07 JULY 54 54 JULY 07 06 JUNE 55 55 JUNE 06 05 MAY 56 56 MAY 05 04 APR 57 57 APR 04 03 MAR 58 58 MAR 03 02 FEB 59 59 FEB 02 01 JAN 60 60 JAN 01 2 0 0 3 12 DEC 61 61 DEC 12 2 0 0 3 11 NOV 62 62 NOV 11 10 OCT 63 63 OCT 10 09 SEP 64 64 SEP 09 08 AUG 65 65 AĞU 10 07 JULY 66 66 JULY 07 06 JUNE 67 67 JUNE 06 05 MAY 68 68 MAY 05 04 APR 69 69 APR 04 03 MAR 70 70 MAR 03 02 FEB 71 71 FEB 02 01 JAN 72 72 JAN 01 1 AGE – YEAR OF BIRTH TABLE AGE YEAR OF BIRTH AGE YEAR OF BIRTH HAS NOT CELEBRATED BIRTHDAY IN 2008 CELEBRATED BIRTHDAY IN 2008 HAS NOT CELEBRATED BIRTHDAY IN 2008 CELEBRATED BIRTHDAY IN 2008 DOES NOT KNOW DOES NOT KNOW 0 2007 -- 50 1957 1958 1 2006 2007 51 1956 1957 2 2005 2006 52 1955 1956 3 2004 2005 53 1954 1955 4 2003 2004 54 1953 1954 5 2002 2003 55 1952 1953 6 2001 2002 56 1951 1952 7 2000 2001 57 1950 1951 8 1999 2000 58 1949 1950 9 1998 1999 59 1948 1949 10 1997 1998 60 1947 1948 11 1996 1997 61 1946 1947 12 1995 1996 62 1945 1946 13 1994 1995 63 1944 1945 14 1993 1994 64 1943 1944 15 1992 1993 65 1942 1943 16 1991 1992 66 1941 1942 17 1990 1991 67 1940 1941 18 1989 1990 68 1939 1940 19 1988 1989 69 1938 1939 20 1987 1988 70 1937 1938 21 1986 1987 71 1936 1937 22 1985 1986 72 1935 1936 23 1984 1985 73 1934 1935 24 1983 1984 74 1933 1934 25 1982 1983 75 1932 1933 26 1981 1982 76 1931 1932 27 1980 1981 77 1930 1931 28 1979 1980 78 1929 1930 29 1978 1979 79 1928 1929 30 1977 1978 80 1927 1928 31 1976 1977 81 1926 1927 32 1975 1976 82 1925 1926 33 1974 1975 83 1924 1925 34 1973 1974 84 1923 1924 35 1972 1973 85 1922 1923 36 1971 1972 86 1921 1922 37 1970 1971 87 1920 1921 38 1969 1970 88 1919 1920 39 1968 1969 89 1918 1919 40 1967 1968 90 1917 1918 41 1966 1967 91 1916 1917 42 1965 1966 92 1915 1916 43 1964 1965 93 1914 1915 44 1963 1964 94 1913 1914 45 1962 1963 46 1961 1962 47 1960 1961 48 1959 1960 49 1958 1959 2 PROVINCE TRAFFIC CODES 01 ADANA 21 DİYARBAKIR 41 KOCAELİ 61 TRABZON 02 ADIYAMAN 22 EDİRNE 42 KONYA 62 TUNCELİ 03 AFYON 23 ELAZIĞ 43 KÜTAHYA 63 ŞANLIURFA 04 AĞRI 24 ERZİNCAN 44 MALATYA 64 UŞAK 05 AMASYA 25 ERZURUM 45 MANİSA 65 VAN 06 ANKARA 26 ESKİŞEHİR 46 K.MARAŞ 66 YOZGAT 07 ANTALYA 27 GAZİANTEP 47 MARDİN 67 ZONGULDAK 08 ARTVİN 28 GİRESUN 48 MUĞLA 68 AKSARAY 09 AYDIN 29 GÜMÜŞHANE 49 MUŞ 69 BAYBURT 10 BALIKESİR 30 HAKKARİ 50 NEVŞEHİR 70 KARAMAN 11 BİLECİK 31 HATAY 51 NİĞDE 71 KIRIKKALE 12 BİNGÖL 32 ISPARTA 52 ORDU 72 BATMAN 13 BİTLİS 33 İÇEL 53 RİZE 73 ŞIRNAK 14 BOLU 34 İSTANBUL 54 SAKARYA 74 BARTIN 15 BURDUR 35 İZMİR 55 SAMSUN 75 ARDAHAN 16 BURSA 36 KARS 56 SİİRT 76 IĞDIR 17 ÇANAKKALE 37 KASTAMONU 57 SİNOP 77 YALOVA 18 ÇANKIRI 38 KAYSERİ 58 SİVAS 78 KARABÜK 19 ÇORUM 39 KIRKLARELİ 59 TEKİRDAĞ 79 KİLİS 20 DENİZLİ 40 KIRŞEHİR 60 TOKAT 80 OSMANİYE 81 DÜZCE 90 ABROAD CONVERSION OF YEARS OF BIRTH FROM RUMI CALENDAR TO GREGORIAN CALENDAR YEARS RUMI YEARS + 584 = GREGORIAN YEAR 258 | Appendix F Appendix G | 343 SUMMARY INDICATORS APPENDIX G Turkey Demographic and Health Surveys, 1993, 1998, 2003 and 2008 Indicator 1993 1998 2003 2008 Fertility Total fertility rate (TFR) 15-49 2.73 2.61 2.22 2.15 Contraceptive prevalence rate Any method Any modern method Pill IUD Injection Condom Female sterilization Male sterilization Implants Any traditional method 62.6 34.5 4.9 18.8 0.1 6.6 2.9 0.0 - 28.1 63.9 37.7 4.4 19.8 0.5 8.2 4.2 0.0 - 25.5 71.0 42.5 4.7 20.2 0.4 10.8 5.7 0.1 - 28.5 73.0 46.0 5.3 16.9 0.9 14.3 8.3 0.1 0.0 27.0 Contraceptive use among married adolescent Percentage of currently married adolescent girls using a modern contraceptive method Age 15-19 9.3 15.7 16.9 17.6 Unmet need for family planning Percentage of currently married women under age 50 with unmet need for family planning 12.0 10.1 6.0 6.2 Antenatal coverage Percentage of last live births in the five years preceding the survey for which women received at least one ANC from a medically trained provider 62.3 67.9 80.9 92.0 Skilled asistance at delivery Percentage of births in the five years preceding the survey attended by medically trained provider 75.9 80.6 82.9 91.3 Postnatal care Percent distribution of the mother's first postnatal check-up for the last live birth by time after delivery <4 hours 4-23 h 2 days 3-41 days Total - - - - - - - - - - - - - - - 63.4 12.2 4.6 2.8 83.0 344 | Appendix G Indicator 1993 1998 2003 2008 Childhood mortality rates Neonatal mortality Post-neonatal mortality Infant mortality Child mortality Under-five mortality 29 23 53 9 61 26 17 43 10 52 17 12 29 9 37 13 4 17 6 24 Vaccination coverage Percentage of children age 15-26 months who received specific vaccines at any time before the survey BCG DPT3 Polio3 Measles All vaccines 89.1 77.1 77.2 77.9 64.7 88.5 58.7 64.4 78.5 45.7 87.7 64.4 69.1 79.4 54.2 95.9 89.3 88.8 89.3 80.5 Birth registration Percentage of children under five whose births are registered with the civil authorities 74.2 77.7 84.3 93.7 Treatment for diarrhea Percentage of children under age five with diarrhea treated with ORT (ORS or homemade solution) Increased fluid intake 16.3 57.0 29.0 57.0 - - 33.0 48.9 Treatment for ARI Percentage of children under age five with symptoms of ARI seeking care from a trained provider 37.3 - 41.0 - Nutritional status of children Percentage of children under age five considered malnourished according to three anthropometric indices of nutritional status Height-for-age (stunting) Moderate or severe Severe Weight for-height (wasting) Moderate or severe Severe Weight-for-age (underweight) Moderate or severe Severe 18.9 5.9 3.0 0.4 9.5 1.8 16.0 6.1 1.9 0.4 8.3 1.4 12.2 3.6 0.7 0.3 3.9 0.6 10.3 3.2 0.9 0.3 2.8 0.3 Knowledge of HIV/AIDS Percentage of women/men who have heard of HIV/AIDS Ever-married women Currently married men - - 83.4 92.9 88.1 - - - Sanitary excreta disposal Percentage of households with flush toilets, pit toilets/latrines 59.4 67.4 75.9 81.1 Appendix G | 345 Indicator 1993 1998 2003 2008 Education Percentage of females 15-19 with completed primary education Percentage of males 15-19 with completed primary education Percentage of females 20-24 with completed secondary education Percentage of males 20-24 with completed secondary education 90.4 96.1 27.4 46.7 89.4 96.0 27.7 42.4 85.1 95.0 44.2 63.3 91.3 96.5 57.6 79.5 Breastfeeding Percentage of children born in the five years preceding the survey who who started breastfeeding within one hour and within one day of birth Within 1 hour after birth Within 1 day of birth Percentage of children under 6 months who are exclusively breastfed (based on 24 hour recall) Percentage of children 6-9 months receiving breast milk and complementary food (based on 24 hour recall) 19.9 75.9 10.4 60.5 51.8 84.8 10.7 61.3 53.9 83.6 20.8 37.7 39.0 73.4 41.6 67.5 Maternal nutrition Percentage of women age 15-49 body mass İndex (BMI) and and percentage with specific BMI levels 12.0-15.9 (Thin-Severe) 16.0-16.9 (Thin-Moderate) 17.0-18.4 (Thin-Mild) 18.5-20.4 (Normal) 20.5-22.9 (Normal) 23.0-24.9 (Normal) 25.0-26.9 (Overweight) 27.0-28.9 (Overweight) 29.0-29.9 (Overweight) >= 30.0 (Obese) 2.3 (thin) 9.0 21.1 16.9 14.7 12.4 4.9 18.7 0.1 0.2 2.3 8.7 19.5 17.0 16.6 11.6 5.2 18.8 - 0.0 1.8 7.6 17.8 15.8 16.3 12.7 5.3 22.7 0.0 0.4 1.3 8.5 17.1 14.4 16.7 12.5 5.2 23.9 Front Matter Title Page Information and Citation Page Table of Contents List of Tables and Figures Foreword Summary of Findings Map of Turkey Chapter 01 - Introduction Chapter 02 - Household Population and Housing Characteristics Chapter 03 - Characteristics of Survey Respondents Chapter 04 - Fertility Chapter 05 - Family Planning Chapter 06 - Abortions and Stillbirths Chapter 07 - Other Proximate Determinants of Fertility Chapter 08 - Fertility Preferences Chapter 09 - Infant and Child Mortality Chapter 10 - Reproductive Health Chapter 11 - Child Health Chapter 12 - Children's and Women's Nutritional Status Chapter 13 - Women's Status References Appendix A - List of Personnel Appendix B - Survey Design Appendix C - Sampling Errors Appendix D - Data Quality Tables Appendix E - Child Growth Standards, WHO-2006 Appendix F - Questionnaires Household Questionnaire Ever Married Women's Questionnaire Appendix G - Summary Indicators

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