Turkey - Demographic and Health Survey - 2014

Publication date: 2014

Turkey Demographic and Health Survey 2013 T u r k e y 2 0 1 3 ISBN: 978-975-491-389-7 D e m o g ra p h ic a n d H e a lth S u rv e y 2013 Turkey Demographic and Health Survey Hacettepe University Institute of Population Studies Ankara, Turkey with the contributions of T.R. Ministry of Development Ankara,Turkey and T.R. Ministry of Health Ankara, Turkey Funded by The Scientific and Technological Research Council of Turkey (TÜBİTAK) “Support Programme for Research and Development Projects of Public Institutions” (KAMAG) November 2014 Hacettepe University Institute of Population Studies T.R. Ministry of Development The Scientific and Technological Research Council of Turkey 2013 Turkey Demographic and Health Survey Hacettepe University Institute of Population Studies Ankara, Turkey with the contributions of T.R. Ministry of Development Ankara,Turkey and T.R. Ministry of Health Ankara, Turkey Funded by The Scientific and Technological Research Council of Turkey (TÜBİTAK) “Support Programme for Research and Development Projects of Public Institutions” (KAMAG) November 2014 Hacettepe University Institute of Population Studies T.R. Ministry of Development The Scientific and Technological Research Council of Turkey 2013 Turkey Demographic and Health Survey Hacettepe University Institute of Population Studies Ankara, Turkey with the contributions of T.R. Ministry of Development Ankara,Turkey and T.R. Ministry of Health Ankara, Turkey Funded by The Scientific and Technological Research Council of Turkey (TÜBİTAK) “Support Programme for Research and Development Projects of Public Institutions” (KAMAG) November 2014 Hacettepe University Institute of Population Studies T.R. Ministry of Development The Scientific and Technological Research Council of Turkey Publication No: IPS-HU.14.02 ISBN 978-975-491-389-7 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 2013 Turkey Demographic and Health Survey (TDHS-2013) has been conducted by the Hacettepe University Institute of Population Studies. The beneficiary institution under this project is T.R. Ministry of Development. The financial support of the TDHS-2013 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-2013 is fully comparable with the models and standards developed by the worldwide Demographic and Health Surveys (The DHS Program) project. ICF International Inc. provided technical assistance on data processing, tabulation, the review of the final report. Additional information about the TDHS-2013 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 DHS program project may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA (telephone: 301-407-6500; fax: 301-407-6501; e-mail: info@DHSprogram.com; internet: www.DHSprogram.com). Suggested citation: Hacettepe University Institute of Population Studies (2014), “2013 Turkey Demographic and Health Survey”. Hacettepe University Institute of Population Studies, T.R. Ministry of Development and TÜBİTAK, Ankara, Turkey. Printed by Elma Teknik Basm Matbaaclk Ltd. Şti. Çatal Sok. 11/A Maltepe/Ankara Tel: 0312 2299265 Table of Contents | i 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 . 2 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 . 11 1.11 Objectives and Organization of the Survey . 12 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 . 33 2.5 Household Wealth . 39 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 Publication No: IPS-HU.14.02 ISBN 978-975-491-389-7 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 2013 Turkey Demographic and Health Survey (TDHS-2013) has been conducted by the Hacettepe University Institute of Population Studies. The beneficiary institution under this project is T.R. Ministry of Development. The financial support of the TDHS-2013 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-2013 is fully comparable with the models and standards developed by the worldwide Demographic and Health Surveys (The DHS Program) project. ICF International Inc. provided technical assistance on data processing, tabulation, the review of the final report. Additional information about the TDHS-2013 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 DHS program project may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA (telephone: 301-407-6500; fax: 301-407-6501; e-mail: info@DHSprogram.com; internet: www.DHSprogram.com). Suggested citation: Hacettepe University Institute of Population Studies (2014), “2013 Turkey Demographic and Health Survey”. Hacettepe University Institute of Population Studies, T.R. Ministry of Development and TÜBİTAK, Ankara, Turkey. Printed by Elma Teknik Basm Matbaaclk Ltd. Şti. Çatal Sok. 11/A Maltepe/Ankara Tel: 0312 2299265 Table of Contents | i 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 . 2 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 . 11 1.11 Objectives and Organization of the Survey . 12 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 . 33 2.5 Household Wealth . 39 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 ii | Table of Contents ii 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 . 66 4.5 Birth Intervals . 68 4.6 Age at First Birth . 70 4.7 Teenage Pregnancy and Motherhood . 72 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 . 83 5.5 Number of Children at First Use of Contraception . 85 5.6 Knowledge of the Fertile Period . 86 5.7 Timing of Female Sterilization . 87 5.8 Source for Family Planning Methods . 88 5.9 Discontinuation of Contraceptive Use . 90 5.10 Intention to Use Contraception among Non-users . 92 5.11 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 Characteristics of Induced Abortions . 101 6.5 Age-specific and Total Abortion Rates . 103 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY 7.1 Current Marital Status . 105 7.2 Age at First Marriage . 107 7.3 Postpartum Amenorrhea, Postpartum Abstinence, and Insusceptibility . 109 7.4 Menopause . 113 Table of Contents | iii iii CHAPTER 8 FERTILITY PREFERENCES 8.1 Desire for More Children . 115 8.2 Need for Family Planning Services . 119 8.3 Ideal Number of Children . 122 8.4 Planning Status of Births . 125 8.5 Total Wanted Fertility . 126 CHAPTER 9 INFANT AND CHILD MORTALITY 9.1 Assessment of Data Quality . 129 9.2 Levels and Trends in Infant and Child Mortality . 132 9.3 Differentials in Infant and Child Mortality . 133 9.4 Perinatal Mortality . 136 9.5 High-risk Fertility Behavior . 138 CHAPTER 10 REPRODUCTIVE HEALTH 10.1 Antenatal Care . 141 10.2 Number and Timing of Antenatal Care Visits . 143 10.3 Components of Antenatal Care . 145 10.4 Place of Delivery . 147 10.5 Assistance During Delivery . 149 10.6 Postnatal Care . 151 CHAPTER 11 NUTRITIONAL STATUS AND CHILD HEALTH 11.1 Initiation of Breastfeeding . 157 11.2 Breastfeeding Status by the Age of the Child . 159 11.3 Duration and Frequency of Breastfeeding . 161 11.4 Types of Complementary Foods . 161 11.5 Nutritional Status of Children . 163 11.6 Nutritional Status of Women . 169 11.7 Child’s Weight and Size at Birth . 171 11.8 Vaccination of Children . 173 CHAPTER 12 WOMEN’S STATUS 12.1 Interspousal Differences in Age and Education . 177 12.2 Factors Influencing Women’s Employment . 179 12.3 Child Care While Working . 184 12.4 Women’s Attitude towards Being Subject to Physical Violence and Controlling Behaviors . 184 12.5 Attitude towards Gender Roles . 188 12.6 Women’s Roles in Reproductive Decisions . 190 Table of Contents | iii iii CHAPTER 8 FERTILITY PREFERENCES 8.1 Desire for More Children . 115 8.2 Need for Family Planning Services . 119 8.3 Ideal Number of Children . 122 8.4 Planning Status of Births . 125 8.5 Total Wanted Fertility . 126 CHAPTER 9 INFANT AND CHILD MORTALITY 9.1 Assessment of Data Quality . 129 9.2 Levels and Trends in Infant and Child Mortality . 132 9.3 Differentials in Infant and Child Mortality . 133 9.4 Perinatal Mortality . 136 9.5 High-risk Fertility Behavior . 138 CHAPTER 10 REPRODUCTIVE HEALTH 10.1 Antenatal Care . 141 10.2 Number and Timing of Antenatal Care Visits . 143 10.3 Components of Antenatal Care . 145 10.4 Place of Delivery . 147 10.5 Assistance During Delivery . 149 10.6 Postnatal Care . 151 CHAPTER 11 NUTRITIONAL STATUS AND CHILD HEALTH 11.1 Initiation of Breastfeeding . 157 11.2 Breastfeeding Status by the Age of the Child . 159 11.3 Duration and Frequency of Breastfeeding . 161 11.4 Types of Complementary Foods . 161 11.5 Nutritional Status of Children . 163 11.6 Nutritional Status of Women . 169 11.7 Child’s Weight and Size at Birth . 171 11.8 Vaccination of Children . 173 CHAPTER 12 WOMEN’S STATUS 12.1 Interspousal Differences in Age and Education . 177 12.2 Factors Influencing Women’s Employment . 179 12.3 Child Care While Working . 184 12.4 Women’s Attitude towards Being Subject to Physical Violence and Controlling Behaviors . 184 12.5 Attitude towards Gender Roles . 188 12.6 Women’s Roles in Reproductive Decisions . 190 iv | Table of Contents iv REFERENCES . 191 APPENDIX A LIST OF PERSONNEL . 193 APPENDIX B SURVEY DESIGN B.1 Sample Design and Implementation . 195 B.2 Sample Frame . 196 B.3 Stratification . 196 B.4 Sample Allocation . 199 B.5 Sample Selection . 200 B.6 Questionnaire Development and Pre-test . 202 B.7 Data Collection Activities . 203 B.8 Data Processing and Analysis . 204 B.9 Calculation of Sample Weights . 205 B.10 Coverage of the Sample . 209 APPENDIX C SAMPLING ERRORS . 215 APPENDIX D DATA QUALITY . 239 APPENDIX E ADDITIONAL TABLES . 247 APPENDIX F QUESTIONNAIRES . 259 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 the 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 the male household population . 24 Table 2.5.2 Educational attainment of the female household population . 25 Table 2.6.1 School attendance ratios: primary and secondary school . 28 Table 2.6.2 School attendance ratios: high school . 29 Table 2.7.1 Grade repetition rates . 31 Table 2.7.2 Grade dropout rates . 32 Table 2.8 Household drinking water . 34 Table 2.9 Household sanitation facilities . 35 Table 2.10 Housing characteristics . 37 Table 2.11 Household possessions . 38 Table 2.12 Wealth quintiles . 40 Table 2.13 Birth registration of children under age five . 41 Figure 2.1 Population Pyramid . 18 Figure 2.2 Age-specific attendance ratios . 27 BÖLÜM 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/private sector . 52 Table 3.7 Type of employment . 53 Table 3.8 Social security coverage . 56 Table 3.9 Health insurance coverage . 57 iv | Table of Contents iv REFERENCES . 191 APPENDIX A LIST OF PERSONNEL . 193 APPENDIX B SURVEY DESIGN B.1 Sample Design and Implementation . 195 B.2 Sample Frame . 196 B.3 Stratification . 196 B.4 Sample Allocation . 199 B.5 Sample Selection . 200 B.6 Questionnaire Development and Pre-test . 202 B.7 Data Collection Activities . 203 B.8 Data Processing and Analysis . 204 B.9 Calculation of Sample Weights . 205 B.10 Coverage of the Sample . 209 APPENDIX C SAMPLING ERRORS . 215 APPENDIX D DATA QUALITY . 239 APPENDIX E ADDITIONAL TABLES . 247 APPENDIX F QUESTIONNAIRES . 259 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 the 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 the male household population . 24 Table 2.5.2 Educational attainment of the female household population . 25 Table 2.6.1 School attendance ratios: primary and secondary school . 28 Table 2.6.2 School attendance ratios: high school . 29 Table 2.7.1 Grade repetition rates . 31 Table 2.7.2 Grade dropout rates . 32 Table 2.8 Household drinking water . 34 Table 2.9 Household sanitation facilities . 35 Table 2.10 Housing characteristics . 37 Table 2.11 Household possessions . 38 Table 2.12 Wealth quintiles . 40 Table 2.13 Birth registration of children under age five . 41 Figure 2.1 Population Pyramid . 18 Figure 2.2 Age-specific attendance ratios . 27 BÖLÜM 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/private sector . 52 Table 3.7 Type of employment . 53 Table 3.8 Social security coverage . 56 Table 3.9 Health insurance coverage . 57 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 . 63 Table 4.4 Trends in age-specific fertility rates . 65 Table 4.5 Children ever born and living . 67 Table 4.6 Birth intervals . 69 Table 4.7 Age at first birth . 70 Table 4.8 Median age at first birth . 71 Table 4.9 Teenage pregnancy and motherhood . 73 Figure 4.1 Age-specific fertility rates . 61 Figure 4.2 Trends in age-specific fertility rates . 64 Figure 4.3 Age-specific fertility rates during the last two 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 by age . 78 Table 5.4 Current use of contraception by age . 79 Table 5.5 Current use of contraception by background characteristics . 81 Table 5.6 Trends in current use of contraception . 83 Table 5.7 Trends in current use of contraception by residence and region . 85 Table 5.8 Number of children at first use of contraception . 86 Table 5.9 Timing of sterilization . 88 Table 5.10 Source of modern contraception methods . 89 Table 5.11 Trends in source of supply for selected modern methods . 89 Table 5.12 Twelve-month contraceptive discontinuation rates . 90 Table 5.13 Reasons for discontinuation . 91 Table 5.14 Future use of contraception . 92 Table 5.15 Preferred method of contraception for future use . 93 Table 5.16 Reason for not intending to use contraception in the future . 94 Figure 5.1 Current use of contraception . 82 Figure 5.2 Trends in the use of contraception . 84 Figure 5.3 Knowledge of the fertile period . 87 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 induced abortion . 100 Table 6.6 Method used after induced abortion . 100 Table 6.7 Age-specific and total induced abortion rates . 103 Table 6.8 Total abortion rate by background characteristics . 104 Figure 6.1 Decision maker for last induced abortion . 101 Figure 6.2 Timing of last induced abortion . 102 Figure 6.3 Provider of last induced abortion . 102 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 7.1.1 Current marital status . 106 Table 7.1.2 Trends in proportion never married . 106 Table 7.2 Age at first marriage . 107 Table 7.3 Median age at first marriage . 108 Table 7.4 Postpartum amenorrhea, abstinence and insusceptibility . 110 Table 7.5 Median duration of amenorrhea, postpartum abstinence and postpartum insusceptibility . 112 Table 7.6 Menopause . 113 Figure 7.1 Postpartum amenorrhea, abstinence and insusceptibility . 111 CHAPTER 8 FERTILITY PREFERENCES Table 8.1 Fertility preferences by number of living children . 116 Table 8.2 Fertility preference by age . 117 Table 8.3 Desire to limit childbearing . 118 Table 8.4 Need and demand for family planning among currently married women. 121 Table 8.5 Ideal number of children by number of living children . 123 Table 8.6 Mean ideal number of children . 124 Table 8.7 Fertility planning status . 125 Table 8.8 Wanted fertility rates . 127 Figure 8.1 Fertility preferences . 117 Figure 8.2 Trends in unmet need for family planning . 120 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 . 63 Table 4.4 Trends in age-specific fertility rates . 65 Table 4.5 Children ever born and living . 67 Table 4.6 Birth intervals . 69 Table 4.7 Age at first birth . 70 Table 4.8 Median age at first birth . 71 Table 4.9 Teenage pregnancy and motherhood . 73 Figure 4.1 Age-specific fertility rates . 61 Figure 4.2 Trends in age-specific fertility rates . 64 Figure 4.3 Age-specific fertility rates during the last two 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 by age . 78 Table 5.4 Current use of contraception by age . 79 Table 5.5 Current use of contraception by background characteristics . 81 Table 5.6 Trends in current use of contraception . 83 Table 5.7 Trends in current use of contraception by residence and region . 85 Table 5.8 Number of children at first use of contraception . 86 Table 5.9 Timing of sterilization . 88 Table 5.10 Source of modern contraception methods . 89 Table 5.11 Trends in source of supply for selected modern methods . 89 Table 5.12 Twelve-month contraceptive discontinuation rates . 90 Table 5.13 Reasons for discontinuation . 91 Table 5.14 Future use of contraception . 92 Table 5.15 Preferred method of contraception for future use . 93 Table 5.16 Reason for not intending to use contraception in the future . 94 Figure 5.1 Current use of contraception . 82 Figure 5.2 Trends in the use of contraception . 84 Figure 5.3 Knowledge of the fertile period . 87 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 induced abortion . 100 Table 6.6 Method used after induced abortion . 100 Table 6.7 Age-specific and total induced abortion rates . 103 Table 6.8 Total abortion rate by background characteristics . 104 Figure 6.1 Decision maker for last induced abortion . 101 Figure 6.2 Timing of last induced abortion . 102 Figure 6.3 Provider of last induced abortion . 102 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 7.1.1 Current marital status . 106 Table 7.1.2 Trends in proportion never married . 106 Table 7.2 Age at first marriage . 107 Table 7.3 Median age at first marriage . 108 Table 7.4 Postpartum amenorrhea, abstinence and insusceptibility . 110 Table 7.5 Median duration of amenorrhea, postpartum abstinence and postpartum insusceptibility . 112 Table 7.6 Menopause . 113 Figure 7.1 Postpartum amenorrhea, abstinence and insusceptibility . 111 CHAPTER 8 FERTILITY PREFERENCES Table 8.1 Fertility preferences by number of living children . 116 Table 8.2 Fertility preference by age . 117 Table 8.3 Desire to limit childbearing . 118 Table 8.4 Need and demand for family planning among currently married women. 121 Table 8.5 Ideal number of children by number of living children . 123 Table 8.6 Mean ideal number of children . 124 Table 8.7 Fertility planning status . 125 Table 8.8 Wanted fertility rates . 127 Figure 8.1 Fertility preferences . 117 Figure 8.2 Trends in unmet need for family planning . 120 viii | List of Tables and Figures CHAPTER 9 INFANT AND CHILD MORTALITY Table 9.1 Early childhood mortality rates . 132 Table 9.2 Early childhood mortality rates by socioeconomic characteristics . 134 Table 9.3 Early childhood mortality rates by demographic characteristics . 135 Table 9.4 Perinatal mortality . 137 Table 9.5 High-risk fertility behavior . 139 Figure 9.1 Trends in childhood mortality rates . 133 CHAPTER 10 REPRODUCTIVE HEALTH Table 10.1 Antenatal care . 142 Table 10.2 Number of antenatal care visits and timing of first visit . 144 Table 10.3 Components of antenatal care . 146 Table 10.4 Place of delivery . 148 Table 10.5 Assistance during delivery . 150 Table 10.6 Type of provider of first postnatal checkup for the mother . 152 Table 10.7 Timing of first postnatal checkup for the mother . 153 Table 10.8 Type of provider of first postnatal checkup for the newborn . 154 Table 10.9 Timing of first postnatal checkup for the newborn . 155 CHAPTER 11 NUTRITIONAL STATUS AND CHILD HEALTH Table 11.1 Initial breastfeeding . 158 Table 11.2 Breastfeeding status by age . 160 Table 11.3 Median duration of breastfeeding . 162 Table 11.4 Foods and liquids consumed by children in the day or night preceding the interview . 163 Table 11.5 Nutritional status of children by children’s characteristics . 167 Table 11.6 Nutritional status of children by mothers’ characteristics . 168 Table 11.7 Nutritional status of women . 170 Table 11.8 Child's size and weight at birth. 172 Table 11.9 Vaccinations by source of information . 174 Table 11.10 Vaccinations by background characteristics . 175 Table 11.11 Vaccinations by current age of child . 176 CHAPTER 12 WOMEN’S STATUS Table 12.1 Differences in age and education between spouses . 178 Table 12.2 Main reasons for not working . 181 Table 12.3 Main reasons for quitting job . 182 Table 12.4 Child care while working . 183 Table 12.5 Attitude towards wife beating . 185 Table 12.6 Frequency of controlling behaviors . 186 List of Tables and Figures | ix Table 12.7 Controlling behaviors . 187 Table 12.8 Attitude towards gender roles . 189 Table 12.9 Decision making . 190 APPENDIX B SURVEY DESIGN Table B.1 List of strata by region, NUTS 1 region, residence, type and province . 197 Table B.2 Allocation of sample households . 199 Table B.3 Distribution of sample clusters . 200 Table B.4 Distribution of women aged 15-49 . 209 Table B.5.1 Sample implementation according to residence and region . 211 Table B.5.2 Sample implementation according to residence and region and never-married women . 212 Table B.5.3 Sample implementation according to NUTS 1 region . 213 APPENDIX C SAMPLING ERRORS Table C.1 List of indicators for sampling errors . 218 Table C.2 Sampling errors: National Sample . 219 Table C.3 Sampling errors: Urban . 220 Table C.4 Sampling errors: Rural . 221 Table C.5 Sampling errors: West . 222 Table C.6 Sampling errors: South . 223 Table C.7 Sampling errors: Central . 224 Table C.8 Sampling errors: North . 225 Table C.9 Sampling errors: East . 226 Table C.10 Sampling errors: İstanbul . 227 Table C.11 Sampling errors: West Marmara . 228 Table C.12 Sampling errors: Aegean . 229 Table C.13 Sampling errors: East Marmara . 230 Table C.14 Sampling errors: West Anatolia . 231 Table C.15 Sampling errors: Mediterranean . 232 Table C.16 Sampling errors: Central Anatolia . 233 Table C.17 Sampling errors: West Black Sea . 234 Table C.18 Sampling errors: East Black Sea . 235 Table C.19 Sampling errors: North East Anatolia . 236 Table C.20 Sampling errors: Central East Anatolia . 237 Table C.21 Sampling errors: South East Anatolia . 238 viii | List of Tables and Figures CHAPTER 9 INFANT AND CHILD MORTALITY Table 9.1 Early childhood mortality rates . 132 Table 9.2 Early childhood mortality rates by socioeconomic characteristics . 134 Table 9.3 Early childhood mortality rates by demographic characteristics . 135 Table 9.4 Perinatal mortality . 137 Table 9.5 High-risk fertility behavior . 139 Figure 9.1 Trends in childhood mortality rates . 133 CHAPTER 10 REPRODUCTIVE HEALTH Table 10.1 Antenatal care . 142 Table 10.2 Number of antenatal care visits and timing of first visit . 144 Table 10.3 Components of antenatal care . 146 Table 10.4 Place of delivery . 148 Table 10.5 Assistance during delivery . 150 Table 10.6 Type of provider of first postnatal checkup for the mother . 152 Table 10.7 Timing of first postnatal checkup for the mother . 153 Table 10.8 Type of provider of first postnatal checkup for the newborn . 154 Table 10.9 Timing of first postnatal checkup for the newborn . 155 CHAPTER 11 NUTRITIONAL STATUS AND CHILD HEALTH Table 11.1 Initial breastfeeding . 158 Table 11.2 Breastfeeding status by age . 160 Table 11.3 Median duration of breastfeeding . 162 Table 11.4 Foods and liquids consumed by children in the day or night preceding the interview . 163 Table 11.5 Nutritional status of children by children’s characteristics . 167 Table 11.6 Nutritional status of children by mothers’ characteristics . 168 Table 11.7 Nutritional status of women . 170 Table 11.8 Child's size and weight at birth. 172 Table 11.9 Vaccinations by source of information . 174 Table 11.10 Vaccinations by background characteristics . 175 Table 11.11 Vaccinations by current age of child . 176 CHAPTER 12 WOMEN’S STATUS Table 12.1 Differences in age and education between spouses . 178 Table 12.2 Main reasons for not working . 181 Table 12.3 Main reasons for quitting job . 182 Table 12.4 Child care while working . 183 Table 12.5 Attitude towards wife beating . 185 Table 12.6 Frequency of controlling behaviors . 186 List of Tables and Figures | ix Table 12.7 Controlling behaviors . 187 Table 12.8 Attitude towards gender roles . 189 Table 12.9 Decision making . 190 APPENDIX B SURVEY DESIGN Table B.1 List of strata by region, NUTS 1 region, residence, type and province . 197 Table B.2 Allocation of sample households . 199 Table B.3 Distribution of sample clusters . 200 Table B.4 Distribution of women aged 15-49 . 209 Table B.5.1 Sample implementation according to residence and region . 211 Table B.5.2 Sample implementation according to residence and region and never-married women . 212 Table B.5.3 Sample implementation according to NUTS 1 region . 213 APPENDIX C SAMPLING ERRORS Table C.1 List of indicators for sampling errors . 218 Table C.2 Sampling errors: National Sample . 219 Table C.3 Sampling errors: Urban . 220 Table C.4 Sampling errors: Rural . 221 Table C.5 Sampling errors: West . 222 Table C.6 Sampling errors: South . 223 Table C.7 Sampling errors: Central . 224 Table C.8 Sampling errors: North . 225 Table C.9 Sampling errors: East . 226 Table C.10 Sampling errors: İstanbul . 227 Table C.11 Sampling errors: West Marmara . 228 Table C.12 Sampling errors: Aegean . 229 Table C.13 Sampling errors: East Marmara . 230 Table C.14 Sampling errors: West Anatolia . 231 Table C.15 Sampling errors: Mediterranean . 232 Table C.16 Sampling errors: Central Anatolia . 233 Table C.17 Sampling errors: West Black Sea . 234 Table C.18 Sampling errors: East Black Sea . 235 Table C.19 Sampling errors: North East Anatolia . 236 Table C.20 Sampling errors: Central East Anatolia . 237 Table C.21 Sampling errors: South East Anatolia . 238 x | List of Tables and Figures APPENDIX D DATA QUALITY Table D.1 Age distribution of de facto household population . 241 Table D.2 Age distribution of eligible and interviewed women . 242 Table D.3 Completeness of reporting . 242 Table D.4 Births by calendar years . 243 Table D.5 Reporting of age at death in days . 244 Table D.6 Reporting of age at death in months . 245 APPENDIX E ADDITIONAL TABLES Table E.1 Educational attainment: Ever Married Women . 249 Table E.2 Literacy: Ever Married Women . 250 Table E.3 Employment status: Ever Married Women . 251 Table E.4 Type of occupation: Ever Married Women . 252 Table E.5 Employment in public/private sector: Ever Married Women . 253 Table E.6 Type of employment: Ever Married Women . 254 Table E.7 Social security coverage: Ever Married Women . 255 Table E.8 Health insurance coverage: Ever Married Women . 256 Table E.9 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 257 Table E.10 Nutritional status of women . 258 Foreword | xi FOREWORD The importance of reliable and comparable information has increased significantly in today’s world. If the data that involve information with aforementioned qualities also include details that cannot be collected by other data sources along with society related basic indicators, then they become more valuable for not only portraying the situation of the period that they were collected in, but also for enabling multivariate studies that cover several factors. Nowadays, sample surveys are one of the most effective ways of collecting representative quantitative data. In Turkey and in the World, important experiences were obtained in the field of studying the population which is the common ground for all of the social studies with sample surveys. Concerning this subject, “Demographic and Health Surveys (DHS) are the most widespread surveys. They are being carried out in many countries with large numbers. Our country has a unique series in this field owing to quinquennial Demographic Surveys conducted by Hacettepe University Institute of Population Studies since 1968. This survey series has become a part of “Demographic and Health Surveys” with “1993 Turkey Demographic and Health Survey (TDHS-1993)”. “2013 Turkey Demographic and Health Survey (TDHS-2013)”, whose descriptive findings are shared in this report, is the tenth demographic survey and fifth TDHS carried out by the Institute. Hacettepe University Institute of Population Studies has increased its survey experience by carrying out qualitative and quantitative surveys at both national and regional level along with demographic survey series that started just one year after its establishment in 1967. Our Institute maintains its position as the only institution in Turkey that provides graduate education in the field of population. In addition to the department of “Demography” the institute established two new departments namely “Social Research Methodology” and “Policy and Strategy Studies”. With these newly established departments, the Institute aims to share its survey experience through education and to transform the produced data into meaningful policies. Following TDHS-2008, TDHS-2013 is the second survey, which was financed entirely from the national budget of Republic of Turkey. This financial support has been provided by the Scientific and Technological Research Council of Turkey (TÜBİTAK) within the scope of the Support Program for Research and Development Projects of Public Institutions (KAMAG) with the support of Ministry of Development as the beneficiary institution. Furthermore TDHS-2013 is also a part of the official statistics program prepared by the Turkish Statistical Institute. TDHS-2013 was initiated in September 2012 as a 36-month project. After the completion of sample design, sample selection, and questionnaire design, the listing activity x | List of Tables and Figures APPENDIX D DATA QUALITY Table D.1 Age distribution of de facto household population . 241 Table D.2 Age distribution of eligible and interviewed women . 242 Table D.3 Completeness of reporting . 242 Table D.4 Births by calendar years . 243 Table D.5 Reporting of age at death in days . 244 Table D.6 Reporting of age at death in months . 245 APPENDIX E ADDITIONAL TABLES Table E.1 Educational attainment: Ever Married Women . 249 Table E.2 Literacy: Ever Married Women . 250 Table E.3 Employment status: Ever Married Women . 251 Table E.4 Type of occupation: Ever Married Women . 252 Table E.5 Employment in public/private sector: Ever Married Women . 253 Table E.6 Type of employment: Ever Married Women . 254 Table E.7 Social security coverage: Ever Married Women . 255 Table E.8 Health insurance coverage: Ever Married Women . 256 Table E.9 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 257 Table E.10 Nutritional status of women . 258 Foreword | xi FOREWORD The importance of reliable and comparable information has increased significantly in today’s world. If the data that involve information with aforementioned qualities also include details that cannot be collected by other data sources along with society related basic indicators, then they become more valuable for not only portraying the situation of the period that they were collected in, but also for enabling multivariate studies that cover several factors. Nowadays, sample surveys are one of the most effective ways of collecting representative quantitative data. In Turkey and in the World, important experiences were obtained in the field of studying the population which is the common ground for all of the social studies with sample surveys. Concerning this subject, “Demographic and Health Surveys (DHS) are the most widespread surveys. They are being carried out in many countries with large numbers. Our country has a unique series in this field owing to quinquennial Demographic Surveys conducted by Hacettepe University Institute of Population Studies since 1968. This survey series has become a part of “Demographic and Health Surveys” with “1993 Turkey Demographic and Health Survey (TDHS-1993)”. “2013 Turkey Demographic and Health Survey (TDHS-2013)”, whose descriptive findings are shared in this report, is the tenth demographic survey and fifth TDHS carried out by the Institute. Hacettepe University Institute of Population Studies has increased its survey experience by carrying out qualitative and quantitative surveys at both national and regional level along with demographic survey series that started just one year after its establishment in 1967. Our Institute maintains its position as the only institution in Turkey that provides graduate education in the field of population. In addition to the department of “Demography” the institute established two new departments namely “Social Research Methodology” and “Policy and Strategy Studies”. With these newly established departments, the Institute aims to share its survey experience through education and to transform the produced data into meaningful policies. Following TDHS-2008, TDHS-2013 is the second survey, which was financed entirely from the national budget of Republic of Turkey. This financial support has been provided by the Scientific and Technological Research Council of Turkey (TÜBİTAK) within the scope of the Support Program for Research and Development Projects of Public Institutions (KAMAG) with the support of Ministry of Development as the beneficiary institution. Furthermore TDHS-2013 is also a part of the official statistics program prepared by the Turkish Statistical Institute. TDHS-2013 was initiated in September 2012 as a 36-month project. After the completion of sample design, sample selection, and questionnaire design, the listing activity xii | Foreword took place in July-September 2013; and data collection and data entry activities in September 2013-January 2014. In TDHS-2013, interviews were completed with 11,794 households and 9,746 women in 15-49 age group in 641 clusters. Primary findings were disseminated to main beneficiary institutions and international organizations through the preliminary report meeting in April 2014. This report descriptively reflects the situation and trends in the Demographic and Health indicators. The investigation and evaluation of the results by academics, decision- makers, service providers and users are of vital importance. It is considered that, along with academic studies, this study will have a key position in determining related policies and setting priorities. In realization of TDHS-2013, many institutions and individuals had significant efforts, contributions and support at various stages. T.R. Ministry of Development has played a significant role in the realization of this study by embracing the Project since the very beginning. I would like to thank the General Director and the officials of General Directorate of Social Sectors and Coordination, particularly Mr. Minister and Mr. Undersecretary. I would like to thank the Scientific and Technological Research Council of Turkey (TÜBİTAK) and Support Program for Research and Development Projects of Public Institutions (KAMAG) unit, which enabled the realization of TDHS-2013 with our own resources for their support. T.R. Ministry of Health, which is among the main beneficiary institutions, has provided enormous support at all stages of TDHS-2013, especially in the field work as in previous Demographic and Health Surveys. I owe Mr Minister and the Director of Public Health Institution of Turkey and its officials a debt of gratitude. Furthermore, I would like to express my gratitude to authorities of Provincial Directorates of Health and Provincial Directorates of Public Health as well as all health personnel in the provinces who contributed to the realization of the survey. I would like to thank the President of the Turkish Statistical Institute and officials of Sampling and Analysis Techniques Department, who did not withhold any of their support and knowledge during sample design and selection, and computation of sampling weights. I would also like to thank Mr./Ms. Governors and deputy Governors, district governors, and other public institution officials in the provinces for providing necessary approvals and for their support. I would like to express my gratitude to the Rector of the Hacettepe University, Prof. Dr. Murat Tuncer for his support. I would also like to extend my thanks to the staff in the Scientific Research Projects Coordination Unit and The Directorate of Strategy Development of the University. Foreword | xiii I pay tribute to valuable contributions of the Steering Committee members of TDHS- 2013 and contributions of academics, employees of public and international institutions, who did not withhold their support and recommendations during the questionnaire design. I am grateful to all respondents in selected households of the survey sample who accepted to be involved in the survey and answered the questions, as well as the personnel in pre-testing, listing, data collection and data entry for their efforts. Without their participation, this survey could not have been carried out. I would like to thank all experts at the DHS Program/ICF International team for their contributions to data entry, data processing and analysis and to the finalization of the report in English, as well as to making the survey reach international standards. Last but not least, I express my gratitude to our Institute’s professors, academic staff, project assistants and administrative personnel, who actualized the survey by contributing to all stages of TDHS-2013 with their endeavors and knowledge. Assoc. Prof. Dr. Ahmet Sinan Türkylmaz Project Director xii | Foreword took place in July-September 2013; and data collection and data entry activities in September 2013-January 2014. In TDHS-2013, interviews were completed with 11,794 households and 9,746 women in 15-49 age group in 641 clusters. Primary findings were disseminated to main beneficiary institutions and international organizations through the preliminary report meeting in April 2014. This report descriptively reflects the situation and trends in the Demographic and Health indicators. The investigation and evaluation of the results by academics, decision- makers, service providers and users are of vital importance. It is considered that, along with academic studies, this study will have a key position in determining related policies and setting priorities. In realization of TDHS-2013, many institutions and individuals had significant efforts, contributions and support at various stages. T.R. Ministry of Development has played a significant role in the realization of this study by embracing the Project since the very beginning. I would like to thank the General Director and the officials of General Directorate of Social Sectors and Coordination, particularly Mr. Minister and Mr. Undersecretary. I would like to thank the Scientific and Technological Research Council of Turkey (TÜBİTAK) and Support Program for Research and Development Projects of Public Institutions (KAMAG) unit, which enabled the realization of TDHS-2013 with our own resources for their support. T.R. Ministry of Health, which is among the main beneficiary institutions, has provided enormous support at all stages of TDHS-2013, especially in the field work as in previous Demographic and Health Surveys. I owe Mr Minister and the Director of Public Health Institution of Turkey and its officials a debt of gratitude. Furthermore, I would like to express my gratitude to authorities of Provincial Directorates of Health and Provincial Directorates of Public Health as well as all health personnel in the provinces who contributed to the realization of the survey. I would like to thank the President of the Turkish Statistical Institute and officials of Sampling and Analysis Techniques Department, who did not withhold any of their support and knowledge during sample design and selection, and computation of sampling weights. I would also like to thank Mr./Ms. Governors and deputy Governors, district governors, and other public institution officials in the provinces for providing necessary approvals and for their support. I would like to express my gratitude to the Rector of the Hacettepe University, Prof. Dr. Murat Tuncer for his support. I would also like to extend my thanks to the staff in the Scientific Research Projects Coordination Unit and The Directorate of Strategy Development of the University. Foreword | xiii I pay tribute to valuable contributions of the Steering Committee members of TDHS- 2013 and contributions of academics, employees of public and international institutions, who did not withhold their support and recommendations during the questionnaire design. I am grateful to all respondents in selected households of the survey sample who accepted to be involved in the survey and answered the questions, as well as the personnel in pre-testing, listing, data collection and data entry for their efforts. Without their participation, this survey could not have been carried out. I would like to thank all experts at the DHS Program/ICF International team for their contributions to data entry, data processing and analysis and to the finalization of the report in English, as well as to making the survey reach international standards. Last but not least, I express my gratitude to our Institute’s professors, academic staff, project assistants and administrative personnel, who actualized the survey by contributing to all stages of TDHS-2013 with their endeavors and knowledge. Assoc. Prof. Dr. Ahmet Sinan Türkylmaz Project Director xiv | Foreword Summary of Findings | xv SUMMARY OF FINDINGS The 2013 Turkey Demographic and Health Survey (TDHS-2013) is a nationally repre- sentative sample survey designed to provide information on levels and trends on fertility, infant and child mortality, family planning and maternal and child health. Survey re- sults 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 funding for the TDHS-2013 was provided by the Government of Turkey through the Scientific and Technological Research Council of Turkey (TÜBİTAK) within the scope of the Support Program for Research and Development Projects of Public Institutions (KAMAG). Hacettepe University Institute of Population Studies (HUIPS) carried out the TDHS-2013 in collaboration with the Ministry of Development and the Ministry of Health. TDHS-2013 is the most recent in the series of demographic surveys carried out in Turkey by HUIPS and it is the fifth survey conducted as part of the worldwide Demo- graphic and Health Surveys program. The survey was fielded between September 2013 and January 2014. Interviews were completed with 11,794 households and with 9,746 women at reproductive ages (15-49). Women at ages 15-49, who usually live in that household or who were present in the household on the night before the interview, were eligible for the survey. All tables in this report are based on women who spent the night before the interview at the selected household. CHARACTERISTICS OF HOUSEHOLD POPULATION Turkey has a young population structure; 26 percent of the population is under age 15. The population age 65 and over accounts for 8 percent of the total population in Turkey. The mean household size in Turkey is below 4 persons, varying from an average of 3.6 persons in the urban areas to 3.9 persons in rural areas. The majority of the population in Turkey has attended school. Forty-nine percent of males, 36 percent of females have completed at least secondary school. The proportion of population with at least high school education is 29 percent for males and 21 percent for females. However, the indicators for successive cohorts show a substantial increase over time in the educational attainment of both men and women. The results show that 99 percent of births in the past five years in Turkey were registered. The percentage of unregistered children decreased from 6 percent in TDHS- 2008 to 1 percent in TDHS-2013. CHARACTERISTICS OF RESPONDENTS Almost half of women interviewed in the TDHS-2013 were less than 30 years of age; 68 percent were married at the time of interview. Fifty-three percent of women in Turkey graduated at least from secondary school, and the percentage of literate women is 93 percent. A significant proportion of women (31 percent) had completed at least xiv | Foreword Summary of Findings | xv SUMMARY OF FINDINGS The 2013 Turkey Demographic and Health Survey (TDHS-2013) is a nationally repre- sentative sample survey designed to provide information on levels and trends on fertility, infant and child mortality, family planning and maternal and child health. Survey re- sults 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 funding for the TDHS-2013 was provided by the Government of Turkey through the Scientific and Technological Research Council of Turkey (TÜBİTAK) within the scope of the Support Program for Research and Development Projects of Public Institutions (KAMAG). Hacettepe University Institute of Population Studies (HUIPS) carried out the TDHS-2013 in collaboration with the Ministry of Development and the Ministry of Health. TDHS-2013 is the most recent in the series of demographic surveys carried out in Turkey by HUIPS and it is the fifth survey conducted as part of the worldwide Demo- graphic and Health Surveys program. The survey was fielded between September 2013 and January 2014. Interviews were completed with 11,794 households and with 9,746 women at reproductive ages (15-49). Women at ages 15-49, who usually live in that household or who were present in the household on the night before the interview, were eligible for the survey. All tables in this report are based on women who spent the night before the interview at the selected household. CHARACTERISTICS OF HOUSEHOLD POPULATION Turkey has a young population structure; 26 percent of the population is under age 15. The population age 65 and over accounts for 8 percent of the total population in Turkey. The mean household size in Turkey is below 4 persons, varying from an average of 3.6 persons in the urban areas to 3.9 persons in rural areas. The majority of the population in Turkey has attended school. Forty-nine percent of males, 36 percent of females have completed at least secondary school. The proportion of population with at least high school education is 29 percent for males and 21 percent for females. However, the indicators for successive cohorts show a substantial increase over time in the educational attainment of both men and women. The results show that 99 percent of births in the past five years in Turkey were registered. The percentage of unregistered children decreased from 6 percent in TDHS- 2008 to 1 percent in TDHS-2013. CHARACTERISTICS OF RESPONDENTS Almost half of women interviewed in the TDHS-2013 were less than 30 years of age; 68 percent were married at the time of interview. Fifty-three percent of women in Turkey graduated at least from secondary school, and the percentage of literate women is 93 percent. A significant proportion of women (31 percent) had completed at least xvi | Summary of Findings high school. Survey results show considerable improvement in the educational levels of women in reproductive ages. Thirty five percent of women had been in employment during the 12 month period preceding the survey. About six in ten of employed women work in the service sector, 24 percent work in the agriculture, and remaining 14 percent work in the industry. Half of employed women are not under the coverage of social security. However, 89 percent of women are under the coverage of health insurance. FERTILITY BEHAVIOR Levels and Trends The findings of the TDHS-2013 indicate that if a woman was to maintain the current fer- tility rates throughout her reproductive years, she would be expected to have 2.26 children on the average by the end of her reproductive years. Women in Turkey ex- perience their prime reproductive years during their twenties, yet the age specific fertility peaks at the 25-29 age group; a phenomena observed since the TDHS-2008. There has not been a significant change in the level of fertility since 2008; yet this finding shows that age patterns of fertility are changing in Turkey, 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. Fertility is below replacement level in the West and Central regions. Despite a pronounced decline in fertility in recent decades, period fertility in the East is still well above three children. Fertility decreases with increasing educa- tional level. Women with no education have on average two more children than that of women who have high school and more edu- cation. Another important trend is the steady rise in the age at first birth among women in Turkey. Older women are much more likely than younger 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-2013 results document an in- crease in the median age at first marriage across age cohorts, from 20.2 years for the 45-49 age group to 22 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 6 years in the timing of entry into marriage between those with no education and those who has at least high school education. 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 pill and IUD are the most widely known modern contraceptive methods among women followed by the female sterilization, male condom and injectables. FAMILY PLANNING USE Summary of Findings | xvii Levels and Trends Ninety-two percent of currently married women have used a family planning method at some time in their life. Overall, 74 percent of currently married women are using contraception, with 47 percent depending on modern methods and 26 percent using traditional methods. The IUD is the most widely used modern method (17 percent) followed by male condom (16 percent). 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 15- 19 age group (28 percent) while the highest level of IUD use (21 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-2013 results indicate that 32 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 (11 percent). Coitus-related methods are more easily discontinued. For example, 33 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. Fifty-six 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 government hospitals. Pharmacies are the second most commonly used source, providing contraceptive methods to one- fourth of all users of modern methods. INDUCED ABORTION Overall, 20 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 19 abortions per 100 pregnan- cies, of which 5 were induced. The total abortion rate (TAR) per woman is 0.14 for the five years preceding the TDHS-2013. The age-specific rates increase to a peak among women age 35-39, and decline among older women. Levels of induced abortions among women living in the East are less than among women in other regions. Overall, a substantial proportion of abortions (63 percent) took place in the first month of pregnancy. Private sector providers are pre- ferred for having had an abortion (62 per- cent). The need for family planning counseling after an abortion is highlighted by the finding that, in the month following an induced abortion, 48 percent of women did not use any method and 14 percent used withdrawal. xvi | Summary of Findings high school. Survey results show considerable improvement in the educational levels of women in reproductive ages. Thirty five percent of women had been in employment during the 12 month period preceding the survey. About six in ten of employed women work in the service sector, 24 percent work in the agriculture, and remaining 14 percent work in the industry. Half of employed women are not under the coverage of social security. However, 89 percent of women are under the coverage of health insurance. FERTILITY BEHAVIOR Levels and Trends The findings of the TDHS-2013 indicate that if a woman was to maintain the current fer- tility rates throughout her reproductive years, she would be expected to have 2.26 children on the average by the end of her reproductive years. Women in Turkey ex- perience their prime reproductive years during their twenties, yet the age specific fertility peaks at the 25-29 age group; a phenomena observed since the TDHS-2008. There has not been a significant change in the level of fertility since 2008; yet this finding shows that age patterns of fertility are changing in Turkey, 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. Fertility is below replacement level in the West and Central regions. Despite a pronounced decline in fertility in recent decades, period fertility in the East is still well above three children. Fertility decreases with increasing educa- tional level. Women with no education have on average two more children than that of women who have high school and more edu- cation. Another important trend is the steady rise in the age at first birth among women in Turkey. Older women are much more likely than younger 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-2013 results document an in- crease in the median age at first marriage across age cohorts, from 20.2 years for the 45-49 age group to 22 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 6 years in the timing of entry into marriage between those with no education and those who has at least high school education. 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 pill and IUD are the most widely known modern contraceptive methods among women followed by the female sterilization, male condom and injectables. FAMILY PLANNING USE Summary of Findings | xvii Levels and Trends Ninety-two percent of currently married women have used a family planning method at some time in their life. Overall, 74 percent of currently married women are using contraception, with 47 percent depending on modern methods and 26 percent using traditional methods. The IUD is the most widely used modern method (17 percent) followed by male condom (16 percent). 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 15- 19 age group (28 percent) while the highest level of IUD use (21 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-2013 results indicate that 32 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 (11 percent). Coitus-related methods are more easily discontinued. For example, 33 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. Fifty-six 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 government hospitals. Pharmacies are the second most commonly used source, providing contraceptive methods to one- fourth of all users of modern methods. INDUCED ABORTION Overall, 20 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 19 abortions per 100 pregnan- cies, of which 5 were induced. The total abortion rate (TAR) per woman is 0.14 for the five years preceding the TDHS-2013. The age-specific rates increase to a peak among women age 35-39, and decline among older women. Levels of induced abortions among women living in the East are less than among women in other regions. Overall, a substantial proportion of abortions (63 percent) took place in the first month of pregnancy. Private sector providers are pre- ferred for having had an abortion (62 per- cent). The need for family planning counseling after an abortion is highlighted by the finding that, in the month following an induced abortion, 48 percent of women did not use any method and 14 percent used withdrawal. xviii | Summary of Findings NEED FOR FAMILY PLANNING Fertility Preferences Fifty-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 18 percent of the women want to wait at least two years for another birth. Among the currently married women, the mean ideal number of children is 2.9 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 1.9 children per woman, or 0.4 children less than the actual total fertility rate. Unmet Need for Family Planning The total demand for family planning is 79 percent, and 93 percent of this demand is satisfied. The total demand for limiting pur- poses is two times as high as the demand for spacing purposes (54 and 26 percent, re- spectively). The total unmet need among currently married women is 2 percentage points lower in TDHS 2013 than the total unmet need in TDHS-2008, which was 8 percent. CHILD MORTALITY Levels and Trends For the five years preceding the TDHS- 2013, the infant mortality rate is estimated at 13 per thousand, the child mortality rate at 2 per thousand, and the under five mortality rate at 15 per thousand. For the same period, the neonatal mortality rate is 7 per thousand. All the indicators of infant and child mortality have declined in recent years. Socioeconomic and Demographic Differentials The TDHS-2013 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 age of the mother (young or older than 35) 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-seven percent of mothers received antenatal care during the pregnancy preceding their most recent birth in the five years preceding the survey, with 95 percent receiving care from a doctor. Overall, 95 percent of women made an antenatal care visit before the sixth month of pregnancy, and 89 percent of the woman made more than four visits. Low parity women, women living in urban areas and in the regions other 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, 97 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 (60 percent) than private facilities. The proportion of all births delivered with the assistance of a doctor or trained health personnel is 97 percent. Summary of Findings | xix Ninety-four percent of women reported that they had a postnatal checkup and the majority of postnatal care was provided by a doctor (70 percent). Among the women giving birth in the five years preceding the survey, 74 percent received care within less than four hours based on their last live birth. On the other hand, 6 percent did not receive any care after the delivery of their last live birth. In Turkey, 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 95 percent of infants receive postnatal care from health personnel and most of these babies—61 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 preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, meningitis, measles, mumps, rubella, hepatitis B and pneumonia) is one of the most cost-effective programs in reducing infant and child morbidity and mortality. Among children age 15-26 months, 74 percent of them had received all of the recommended five vaccines. The percentage of children who are fully vaccinated is lowest in the rural areas (65 percent) and in the Eastern region (68 percent). The vaccination coverage percentages are also related to mother’s education and the children’s sex, birth order and household welfare. NUTRITION INDICATORS FOR CHILDREN AND WOMEN Breastfeeding and Supplemental Feeding Breastfeeding is almost universal in Turkey; 96 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 the first two months of life, 58 percent of children under three years old are exclusively breastfed. This percentage was 69 percent in the TDHS- 2008. The median duration of breastfeeding for all children is 17 months. Among children who are breastfed and younger than six months, 28 percent received infant formula. 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. Two percent of children are underweight for their age. Obesity is a problem among women. Ac- cording to BMI calculations, 55 percent of women are overweight, and 27 percent are obese. Mean BMI increases rapidly with age, from 22.5 in 15-19 age group to 30.7 for the age group of 40-49. xviii | Summary of Findings NEED FOR FAMILY PLANNING Fertility Preferences Fifty-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 18 percent of the women want to wait at least two years for another birth. Among the currently married women, the mean ideal number of children is 2.9 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 1.9 children per woman, or 0.4 children less than the actual total fertility rate. Unmet Need for Family Planning The total demand for family planning is 79 percent, and 93 percent of this demand is satisfied. The total demand for limiting pur- poses is two times as high as the demand for spacing purposes (54 and 26 percent, re- spectively). The total unmet need among currently married women is 2 percentage points lower in TDHS 2013 than the total unmet need in TDHS-2008, which was 8 percent. CHILD MORTALITY Levels and Trends For the five years preceding the TDHS- 2013, the infant mortality rate is estimated at 13 per thousand, the child mortality rate at 2 per thousand, and the under five mortality rate at 15 per thousand. For the same period, the neonatal mortality rate is 7 per thousand. All the indicators of infant and child mortality have declined in recent years. Socioeconomic and Demographic Differentials The TDHS-2013 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 age of the mother (young or older than 35) 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-seven percent of mothers received antenatal care during the pregnancy preceding their most recent birth in the five years preceding the survey, with 95 percent receiving care from a doctor. Overall, 95 percent of women made an antenatal care visit before the sixth month of pregnancy, and 89 percent of the woman made more than four visits. Low parity women, women living in urban areas and in the regions other 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, 97 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 (60 percent) than private facilities. The proportion of all births delivered with the assistance of a doctor or trained health personnel is 97 percent. Summary of Findings | xix Ninety-four percent of women reported that they had a postnatal checkup and the majority of postnatal care was provided by a doctor (70 percent). Among the women giving birth in the five years preceding the survey, 74 percent received care within less than four hours based on their last live birth. On the other hand, 6 percent did not receive any care after the delivery of their last live birth. In Turkey, 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 95 percent of infants receive postnatal care from health personnel and most of these babies—61 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 preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, meningitis, measles, mumps, rubella, hepatitis B and pneumonia) is one of the most cost-effective programs in reducing infant and child morbidity and mortality. Among children age 15-26 months, 74 percent of them had received all of the recommended five vaccines. The percentage of children who are fully vaccinated is lowest in the rural areas (65 percent) and in the Eastern region (68 percent). The vaccination coverage percentages are also related to mother’s education and the children’s sex, birth order and household welfare. NUTRITION INDICATORS FOR CHILDREN AND WOMEN Breastfeeding and Supplemental Feeding Breastfeeding is almost universal in Turkey; 96 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 the first two months of life, 58 percent of children under three years old are exclusively breastfed. This percentage was 69 percent in the TDHS- 2008. The median duration of breastfeeding for all children is 17 months. Among children who are breastfed and younger than six months, 28 percent received infant formula. 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. Two percent of children are underweight for their age. Obesity is a problem among women. Ac- cording to BMI calculations, 55 percent of women are overweight, and 27 percent are obese. Mean BMI increases rapidly with age, from 22.5 in 15-19 age group to 30.7 for the age group of 40-49. xx | Summary of Findings WOMEN’S STATUS Interspousal Difference in Age and Education Currently married women are, on average, 4.3 years younger than their husband. Only four 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 Twenty-two percent of women reported being a housewife as the reason for not working; followed by child-care (19 percent) and being a student (17 percent). Eight percent of women reported that they did not need working. Of women who worked in the 12 months prior to the survey, 70 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 approximately 15 percent. Domestic Violence In TDHS-2013, 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 13 percent. M ap o f T ur ke y | xx i R EG IO N S AN D PR O VI N CE S 01 W ES T 02 S O UT H 03 C EN TR AL 04 N O RT H 05 E AS T 09 A yd n 01 A da na 03 A fy on 60 T ok at 08 A rtv in 02 A d ya m an 62 Tu n ce li 10 B al k es ir 07 A n ta lya 05 A m as ya 64 U şa k 28 G ire su n 04 A ğr  63 Ş an lu rfa 16 B u rs a 15 B u rd ur 06 A n ka ra 66 Y oz ga t 29 G üm üş ha ne 12 B in gö l 65 V an 17 Ç an ak ka le 31 Ha ta y 11 B ile cik 68 A ks ar ay 37 K as ta m on u 13 B itli s 69 B ay bu rt 20 D en izl i 32 Is pa rta 14 B ol u 70 K ar am an 52 O rd u 21 D iya rb ak r 72 Ba tm a n 22 E di rn e 33 İç el 18 Ç an kr  71 K r kk al e 53 R ize 23 E la z ğ 73 Ş rn ak 34 İs ta nb ul 46 K . M ar a ş 19 Ç oru m 81 D üz ce 55 S am su n 24 E rz in ca n 75 A rd ah an 35 İz m ir 80 O sm a n iye 26 E sk işe hi r 57 S in op 25 E rz u ru m 76 Iğ d r 39 K rk la re li 38 K ay se ri 61 T ra bz on 27 G az ia nt ep 79 K ilis 41 K oc ae li 40 K rş e hi r 67 Z on gu ld ak 30 H ak ka ri 45 M an is a 42 K o n ya 74 B ar tn 36 K ar s 48 M u ğl a 43 K üt ah ya 78 K ar ab ük 44 M al a ty a 54 S ak ar ya 50 N ev şe hi r 47 M ar di n 59 T ek ird ağ 51 N iğ de 49 M u ş 77 Ya lo va 58 S iva s 56 S iir t xx | Summary of Findings WOMEN’S STATUS Interspousal Difference in Age and Education Currently married women are, on average, 4.3 years younger than their husband. Only four 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 Twenty-two percent of women reported being a housewife as the reason for not working; followed by child-care (19 percent) and being a student (17 percent). Eight percent of women reported that they did not need working. Of women who worked in the 12 months prior to the survey, 70 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 approximately 15 percent. Domestic Violence In TDHS-2013, 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 13 percent. M ap o f T ur ke y | xx i R EG IO N S AN D PR O VI N CE S 01 W ES T 02 S O UT H 03 C EN TR AL 04 N O RT H 05 E AS T 09 A yd n 01 A da na 03 A fy on 60 T ok at 08 A rtv in 02 A d ya m an 62 Tu n ce li 10 B al k es ir 07 A n ta lya 05 A m as ya 64 U şa k 28 G ire su n 04 A ğr  63 Ş an lu rfa 16 B u rs a 15 B u rd ur 06 A n ka ra 66 Y oz ga t 29 G üm üş ha ne 12 B in gö l 65 V an 17 Ç an ak ka le 31 Ha ta y 11 B ile cik 68 A ks ar ay 37 K as ta m on u 13 B itli s 69 B ay bu rt 20 D en izl i 32 Is pa rta 14 B ol u 70 K ar am an 52 O rd u 21 D iya rb ak r 72 Ba tm a n 22 E di rn e 33 İç el 18 Ç an kr  71 K r kk al e 53 R ize 23 E la z ğ 73 Ş rn ak 34 İs ta nb ul 46 K . M ar a ş 19 Ç oru m 81 D üz ce 55 S am su n 24 E rz in ca n 75 A rd ah an 35 İz m ir 80 O sm a n iye 26 E sk işe hi r 57 S in op 25 E rz u ru m 76 Iğ d r 39 K rk la re li 38 K ay se ri 61 T ra bz on 27 G az ia nt ep 79 K ilis 41 K oc ae li 40 K rş e hi r 67 Z on gu ld ak 30 H ak ka ri 45 M an is a 42 K o n ya 74 B ar tn 36 K ar s 48 M u ğl a 43 K üt ah ya 78 K ar ab ük 44 M al a ty a 54 S ak ar ya 50 N ev şe hi r 47 M ar di n 59 T ek ird ağ 51 N iğ de 49 M u ş 77 Ya lo va 58 S iva s 56 S iir t xx ii | M ap o f T ur ke y R EG IO N S AN D PR O VI N CE S 01 İS TA NB UL 04 E AS T 06 M ED IT ER RA NE AN 08 W ES T 10 N O RT HE AS T 12 S O UT HE AS T 34 İs ta nb ul M AR M AR A 01 A da na BL AC K SE A AN AT O LI A AN AT O LI A 02 W ES T 11 B ile cik 07 A n ta lya 05 A m as ya 04 A ğr  02 A d ya m an M AR M AR A 14 B ol u 15 B u rd ur 18 Ç an kr  24 E rz in ca n 21 D iya rb ak r 10 B al k es ir 16 B u rs a 31 Ha ta y 19 Ç oru m 25 E rz u ru m 27 G az ia nt ep 17 Ç an ak ka le 26 E sk işe hi r 32 Is pa rta 37 K as ta m on u 36 K ar s 47 M ar di n 22 E di rn e 41 K oc ae li 33 İç el 55 S am su n 69 B ay bu rt 56 S iir t 39 K rk la re li 54 S ak ar ya 46 K . M ar a ş 57 S in op 75 A rd ah an 63 Ş an lu rfa 59 T ek ird ağ 77 Y al ov a 80 O sm a n iye 60 T ok at 76 Iğ d r 72 Ba tm a n 03 A EG EA N 81 D üz ce 07 CE NT RA L 67 Z on gu ld ak 11 C EN TR AL EA ST 73 Ş rn ak 03 A fy on 05 W ES T AN AT O LI A 74 B ar tn AN AT O LI A 79 K ilis 09 A yd n AN AT O LI A 38 K ay se ri 78 K ar ab ük 12 B in gö l 20 D en izl i 06 A n ka ra 40 K rş eh ir 09 E AS T 13 B itli s 35 İz m ir 42 K on ya 50 N ev şe hi r BL AC K SE A 23 E la z ğ 43 K üt ah ya 70 K ar am an 51 N iğ de 08 A rtv in 30 H ak ka ri 45 M an is a 58 S iva s 28 G ire su n 44 M al at ya 48 M u ğl a 66 Y oz ga t 29 G üm üş ha ne 49 M u ş 64 U şa k 68 A ks ar ay 52 O rd u 62 Tu n ce li 71 K r kk al e 53 R ize 65 V an 61 T ra bz on xx ii | M ap o f T ur ke y R EG IO N S AN D PR O VI N CE S 01 İS TA NB UL 04 E AS T 06 M ED IT ER RA NE AN 08 W ES T 10 N O RT HE AS T 12 S O UT HE AS T 34 İs ta nb ul M AR M AR A 01 A da na BL AC K SE A AN AT O LI A AN AT O LI A 02 W ES T 11 B ile cik 07 A n ta lya 05 A m as ya 04 A ğr  02 A d ya m an M AR M AR A 14 B ol u 15 B u rd ur 18 Ç an kr  24 E rz in ca n 21 D iya rb ak r 10 B al k es ir 16 B u rs a 31 Ha ta y 19 Ç oru m 25 E rz u ru m 27 G az ia nt ep 17 Ç an ak ka le 26 E sk işe hi r 32 Is pa rta 37 K as ta m on u 36 K ar s 47 M ar di n 22 E di rn e 41 K oc ae li 33 İç el 55 S am su n 69 B ay bu rt 56 S iir t 39 K rk la re li 54 S ak ar ya 46 K . M ar a ş 57 S in op 75 A rd ah an 63 Ş an lu rfa 59 T ek ird ağ 77 Y al ov a 80 O sm a n iye 60 T ok at 76 Iğ d r 72 Ba tm a n 03 A EG EA N 81 D üz ce 07 CE NT RA L 67 Z on gu ld ak 11 C EN TR AL EA ST 73 Ş rn ak 03 A fy on 05 W ES T AN AT O LI A 74 B ar tn AN AT O LI A 79 K ilis 09 A yd n AN AT O LI A 38 K ay se ri 78 K ar ab ük 12 B in gö l 20 D en izl i 06 A n ka ra 40 K rş eh ir 09 E AS T 13 B itli s 35 İz m ir 42 K on ya 50 N ev şe hi r BL AC K SE A 23 E la z ğ 43 K üt ah ya 70 K ar am an 51 N iğ de 08 A rtv in 30 H ak ka ri 45 M an is a 58 S iva s 28 G ire su n 44 M al a ty a 48 M u ğl a 66 Y oz ga t 29 G üm üş ha ne 49 M u ş 64 U şa k 68 A ks ar ay 52 O rd u 62 Tu n ce li 71 K r kk al e 53 R ize 65 V an 61 T ra bz on Introduction | 1 INTRODUCTION 1 Ahmet Sinan Türkylmaz 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 and Bulgaria in the Thrace and with Syria, Iraq, Iran, Georgia, Armenia, and Nahcivan (Azerbaijan) in South and East Anatolia, 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. 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 consists of 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 region. 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 it became the core of the Ottoman Empire, which ruled also in Europe, the Middle East, and Africa for almost six centuries. At the end of the First World War, the Ottoman Empire collapsed, and an effort immediately began throughout the country to create a new state from the ruins of the Empire with the war of independence lead by Mustafa Kemal Atatürk. The Lausanne Treaty, signed on 24 July 1923, recognized the creation of a new Turkish State. The Republic was proclaimed on 29 October 1923; and the country’s present borders were established following the annexing of Hatay, a province on the southern border, in 1939. 2 | Introduction The founding of the Republic signified radical shifts from the previous social order as a succession of social and economic reforms occurred. The Sultanate and Caliphate were abolished. 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 accepted (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. In short, the direction of change, led by Atatürk, was one away from a religious, oriental Empire to a modern and secular Republic. Turkey did not become actively involved in the Second World War; but just when the war was about to end, Turkey sided with the USA, Britain and the Soviet Union and declared war against Germany and Japan. Afterwards, Turkey signed the United Nations Treaty dated 24 January 1945. Being officially invited to the San Francisco Conference on 5 March 1945, Turkey become one the founding members of the United Nations. From the foundation of the Republic to 1946, the country was governed by a 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 the 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 the EU that was initiated with the Helsinki Summit of 1999. 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 TGNA is the legislative body of the Republic is. It is composed of 550 deputies, who are elected for four-year terms. The President of the Republic was elected by the TGNA for a seven-year term only one time before the constitutional amendment in 2007. According Introduction | 3 to this amendment, the President of Republic can be elected by the public for no more than two five-year terms. 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, govern local administration at the municipality level. According to Law No. 5393 adopted on July 3, 2005, every locality with a population of more than 5,000 population and province and district centers are entitled to form a municipality. Recent metropolitan administrative reform took place with the Law No. 6360 dated November 12, 2012 and came into effect on December 6, 2012. With the law, the number of metropolitan municipalities expanded to 30, and the special provincial administrations in the provinces holding metropolitan municipality status were abolished. In addition, towns and villages within the boundaries of metropolitan areas have been eliminated and villages have been transformed to neighborhoods. Due to the regulation, 47 percent of villages and 54 percent of municipalities have been eliminated from the local government system, and a considerable amount of rural area has been transformed into urban area. This law brought a new structure in the local administration system. With another law, Law No 6447 dated March 14, 2013, the establishment of metropolitan municipalities and twenty-seven districts in fourteen provinces was accepted. These laws changed the definition and boundaries of greater municipalities. This change also has an effect on administrative definition of urban/rural, which classifies settlements according to their administrative status. 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 metropolitan areas 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 the outskirts of urban areas and in rural settlements are relatively conservative and traditional. Family ties are still strong and influential in the formation of values, attitudes, aspirations, and goals. 2 | Introduction The founding of the Republic signified radical shifts from the previous social order as a succession of social and economic reforms occurred. The Sultanate and Caliphate were abolished. 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 accepted (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. In short, the direction of change, led by Atatürk, was one away from a religious, oriental Empire to a modern and secular Republic. Turkey did not become actively involved in the Second World War; but just when the war was about to end, Turkey sided with the USA, Britain and the Soviet Union and declared war against Germany and Japan. Afterwards, Turkey signed the United Nations Treaty dated 24 January 1945. Being officially invited to the San Francisco Conference on 5 March 1945, Turkey become one the founding members of the United Nations. From the foundation of the Republic to 1946, the country was governed by a 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 the 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 the EU that was initiated with the Helsinki Summit of 1999. 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 TGNA is the legislative body of the Republic is. It is composed of 550 deputies, who are elected for four-year terms. The President of the Republic was elected by the TGNA for a seven-year term only one time before the constitutional amendment in 2007. According Introduction | 3 to this amendment, the President of Republic can be elected by the public for no more than two five-year terms. 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, govern local administration at the municipality level. According to Law No. 5393 adopted on July 3, 2005, every locality with a population of more than 5,000 population and province and district centers are entitled to form a municipality. Recent metropolitan administrative reform took place with the Law No. 6360 dated November 12, 2012 and came into effect on December 6, 2012. With the law, the number of metropolitan municipalities expanded to 30, and the special provincial administrations in the provinces holding metropolitan municipality status were abolished. In addition, towns and villages within the boundaries of metropolitan areas have been eliminated and villages have been transformed to neighborhoods. Due to the regulation, 47 percent of villages and 54 percent of municipalities have been eliminated from the local government system, and a considerable amount of rural area has been transformed into urban area. This law brought a new structure in the local administration system. With another law, Law No 6447 dated March 14, 2013, the establishment of metropolitan municipalities and twenty-seven districts in fourteen provinces was accepted. These laws changed the definition and boundaries of greater municipalities. This change also has an effect on administrative definition of urban/rural, which classifies settlements according to their administrative status. 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 metropolitan areas 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 the outskirts of urban areas and in 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 (TURKSTAT, 2006). According to the Address Based Population Registration System (ABPRS) in 2013, the female and male literacy rates for the population age 6 and over were 91 and 96 percent, respectively (2014). Educational attainment has also increased dramatically. The net primary education enrolment ratio for 2013-2014 educational year is around 99 percent (TURKSTAT, 2014). Five years compulsory education was enhanced to eight years in 1997, and to twelve years in 2012. Despite these developments, there are important differences in literacy and educational attainment between women and men, and among people by region and type of place of residence. 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 agriculture, and it was underdeveloped 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. During the Second World War, the country was faced with heavy restraints on the economy, which slowed down the industrialization process - despite not being involved in the war. 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 the 1980s, 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; while cotton, tobacco, citrus, grapes, fig, hazelnuts, and pistachios are also grown for export. However, recently, some agricultural products have been 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 Organization for Economic Cooperation and Development (OECD) countries. According to the World Bank, Turkey is an upper-middle income country. Since 2001, key structural reforms have been adopted within the context of the harmonization process with the EU. In her history, Turkey has been affected by global economic crises. The 2008 financial crisis had an effect on the Turkish economy in terms of national income and unemployment. Recent economic indicators show that the growth rate was 2.2 percent in 2012, compared to 12.4 percent in first quarter of 2011. Since the second quarter of 2011, the growth rate has been declining. The same trend has been observed in private investments and consumption expenditures. The decline in the growth rate was reflected in increases in the unemployment rate and the current account deficit. Since the first quarter of 2013, recovery signals were apparent. Turkey’s economic agenda for the last ten years aimed to reduce 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 (TURKSTAT, 2006). According to the Address Based Population Registration System (ABPRS) in 2013, the female and male literacy rates for the population age 6 and over were 91 and 96 percent, respectively (2014). Educational attainment has also increased dramatically. The net primary education enrolment ratio for 2013-2014 educational year is around 99 percent (TURKSTAT, 2014). Five years compulsory education was enhanced to eight years in 1997, and to twelve years in 2012. Despite these developments, there are important differences in literacy and educational attainment between women and men, and among people by region and type of place of residence. 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 agriculture, and it was underdeveloped 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. During the Second World War, the country was faced with heavy restraints on the economy, which slowed down the industrialization process - despite not being involved in the war. 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 the 1980s, 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; while cotton, tobacco, citrus, grapes, fig, hazelnuts, and pistachios are also grown for export. However, recently, some agricultural products have been 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 Organization for Economic Cooperation and Development (OECD) countries. According to the World Bank, Turkey is an upper-middle income country. Since 2001, key structural reforms have been adopted within the context of the harmonization process with the EU. In her history, Turkey has been affected by global economic crises. The 2008 financial crisis had an effect on the Turkish economy in terms of national income and unemployment. Recent economic indicators show that the growth rate was 2.2 percent in 2012, compared to 12.4 percent in first quarter of 2011. Since the second quarter of 2011, the growth rate has been declining. The same trend has been observed in private investments and consumption expenditures. The decline in the growth rate was reflected in increases in the unemployment rate and the current account deficit. Since the first quarter of 2013, recovery signals were apparent. Turkey’s economic agenda for the last ten years aimed to reduce 6 | Introduction inflation pressure, increase export revenues, reduce unemployment and address insufficient capital for new investments. The 2013 priorities for growth for Turkey by the OECD have been determined as improving educational achievement at all levels, reducing the cost of employment of the low-skilled, and reforming employment protection legislation. Finally, income inequality and poverty are socio-economic issues to be dealt with; and are observed at higher levels compared to those of OECD and EU countries. 1.6 Regional Divisions The diverse geographic, 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 Nomenclature of Units for Territorial Statistics (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 center, 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 this 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 are 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 Introduction | 7 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 center 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 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. 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 (SIS, 2003). Since the establishment of the ABPRS in 2007, TURKSTAT publishes the population of Turkey for the last day of each single year. This system includes every person who has a Citizen or resident ID number and counts everyone where he/she resides; it also includes institutional populations. According to ABPRS, Turkey’s population is about 76.7 million at the end of year 2013 (TURKSTAT, 2014). The population of Turkey continuously increased during the 1927-2013 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 TURKSTAT, the population of Turkey will reach 84 million in year 2023, which is the centennial of the foundation of the Republic. It is also estimated that it will reach 93.5 million by the year 2050. 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, while the proportion age 65 and over comprises only 6 percent, according to the 2000 national census results. However, today’s prevailing demographic forces of the population are altering the age structure in new 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 had nearly halved to 2.6 children and it is estimated at 2.26 with this survey. As a result, the median age of the population in Turkey, which averaged around 20 years between 1940 and 1960, has increased continuously since 6 | Introduction inflation pressure, increase export revenues, reduce unemployment and address insufficient capital for new investments. The 2013 priorities for growth for Turkey by the OECD have been determined as improving educational achievement at all levels, reducing the cost of employment of the low-skilled, and reforming employment protection legislation. Finally, income inequality and poverty are socio-economic issues to be dealt with; and are observed at higher levels compared to those of OECD and EU countries. 1.6 Regional Divisions The diverse geographic, 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 Nomenclature of Units for Territorial Statistics (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 center, 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 this 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 are 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 Introduction | 7 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 center 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 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. 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 (SIS, 2003). Since the establishment of the ABPRS in 2007, TURKSTAT publishes the population of Turkey for the last day of each single year. This system includes every person who has a Citizen or resident ID number and counts everyone where he/she resides; it also includes institutional populations. According to ABPRS, Turkey’s population is about 76.7 million at the end of year 2013 (TURKSTAT, 2014). The population of Turkey continuously increased during the 1927-2013 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 TURKSTAT, the population of Turkey will reach 84 million in year 2023, which is the centennial of the foundation of the Republic. It is also estimated that it will reach 93.5 million by the year 2050. 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, while the proportion age 65 and over comprises only 6 percent, according to the 2000 national census results. However, today’s prevailing demographic forces of the population are altering the age structure in new 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 had nearly halved to 2.6 children and it is estimated at 2.26 with this survey. As a result, the median age of the population in Turkey, which averaged around 20 years between 1940 and 1960, has increased continuously since 8 | Introduction 1970, reaching 30.4 years in 2013, while the median age for the world population is 29.4 (TURKSTAT, 2014). 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 proportion of the elderly population is about 8 percent. According to projections, the elderly will comprise 10 percent of the population in 2023; and this will include Turkey in the group of countries with an “old” population according to the United Nations definitions (TURKSTAT, 2014). The infant mortality rate in the late 1950s was around 200 per thousand live births. It declined to about 130 per thousand during the mid-1970s, and to an estimated 80 per thousand in mid-1980s. It has been estimated at 53, 43, 29 and 17 per thousand according last four Turkey Demographic and Health Surveys (TDHS) between 1993 and 2008. The latest estimate shows that this figure is just above 10 per thousand currently and puts the life expectancy at birth in Turkey as 75 years for men and 79 years for women (TURKSTAT, 2014). 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. In the recent decade, there has been a slight increase in divorces. 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 76 percent in 2010. 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. Turkey has had a long history of international 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 this 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. After the collapse of the Soviet Union, the migratory movement to CIS (Commonwealth of Independent States) countries and Middle Eastern countries turned out to be the new route for Turkish investors and workers. Turkey has been a country of emigration as well as of immigration and transit migration. Two migratory systems have remarkable influence in Turkey: the major reception zone of Europe and the emerging source regions of emigrants of Asia, Africa and the Middle East (İçduygu and Kirişçi, 2009). Although different periods can be constructed, the main periods of analysis can be set as 1960 and onwards as a period of Introduction | 9 emigration, and 1980 and onwards as a period of immigration and transit. Especially, for the case of emigration, it should be noted that migration is a continuing process, and for the case of Turkey emigration started with labor-related reasons and continued as network migration. Another era started in terms of inflows to Turkey, after the beginning of the Arab Spring on 18th of December 2010. This has resulted in both regular and irregular migration waves to Turkey from the Middle East, making Turkey a country of destination. Another influential phenomenon is irregular migration, which is mostly associated with economic and/or social poverty, social conflicts and political turmoil in neighboring countries. Although migrants from the Syrian Arab Republic (Syria) to Turkey are considered to belong to a specific migrant category given the status of regular migrants under “temporary protection” according to the Article 91 of the Law No. 6458 on Foreigners and International Protection, inflows have affected irregular migration as well. Perhaps, among all countries affected by the Arab Spring, flows from Syria have been affecting Turkey the most, as, tragically, Syria entered a period of civil war in June 2012. The Prime Ministry Disaster and Emergency Management Presidency (AFAD) report on Syrian Refugees in 2013 states that, “There is no accurate information on the total number of Syrian refugees living in Turkey.” According to AFAD, there are a total of 200,386 Syrian refugees in the camps as of August 23, 2013 operated by AFAD. According to the AFAD guesstimates, it is believed that there are a total of 350,000 Syrian refugees outside the camps in various cities. According to the reports of the United Nations, at the end of 2013, the number of Syrian citizens in Turkey will exceed 1 million (AFAD, 2013). By October 22, 2013, news on the media suggested there were over 600,000 Syrian refugees in Turkey. As of September 22, 2014, the number was reported to reach almost 1.6 million according to the press. The dramatic migration movement from Syria and Iraq is expected to continue as the war continues. 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 anti-natalist 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. 8 | Introduction 1970, reaching 30.4 years in 2013, while the median age for the world population is 29.4 (TURKSTAT, 2014). 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 proportion of the elderly population is about 8 percent. According to projections, the elderly will comprise 10 percent of the population in 2023; and this will include Turkey in the group of countries with an “old” population according to the United Nations definitions (TURKSTAT, 2014). The infant mortality rate in the late 1950s was around 200 per thousand live births. It declined to about 130 per thousand during the mid-1970s, and to an estimated 80 per thousand in mid-1980s. It has been estimated at 53, 43, 29 and 17 per thousand according last four Turkey Demographic and Health Surveys (TDHS) between 1993 and 2008. The latest estimate shows that this figure is just above 10 per thousand currently and puts the life expectancy at birth in Turkey as 75 years for men and 79 years for women (TURKSTAT, 2014). 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. In the recent decade, there has been a slight increase in divorces. 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 76 percent in 2010. 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. Turkey has had a long history of international 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 this 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. After the collapse of the Soviet Union, the migratory movement to CIS (Commonwealth of Independent States) countries and Middle Eastern countries turned out to be the new route for Turkish investors and workers. Turkey has been a country of emigration as well as of immigration and transit migration. Two migratory systems have remarkable influence in Turkey: the major reception zone of Europe and the emerging source regions of emigrants of Asia, Africa and the Middle East (İçduygu and Kirişçi, 2009). Although different periods can be constructed, the main periods of analysis can be set as 1960 and onwards as a period of Introduction | 9 emigration, and 1980 and onwards as a period of immigration and transit. Especially, for the case of emigration, it should be noted that migration is a continuing process, and for the case of Turkey emigration started with labor-related reasons and continued as network migration. Another era started in terms of inflows to Turkey, after the beginning of the Arab Spring on 18th of December 2010. This has resulted in both regular and irregular migration waves to Turkey from the Middle East, making Turkey a country of destination. Another influential phenomenon is irregular migration, which is mostly associated with economic and/or social poverty, social conflicts and political turmoil in neighboring countries. Although migrants from the Syrian Arab Republic (Syria) to Turkey are considered to belong to a specific migrant category given the status of regular migrants under “temporary protection” according to the Article 91 of the Law No. 6458 on Foreigners and International Protection, inflows have affected irregular migration as well. Perhaps, among all countries affected by the Arab Spring, flows from Syria have been affecting Turkey the most, as, tragically, Syria entered a period of civil war in June 2012. The Prime Ministry Disaster and Emergency Management Presidency (AFAD) report on Syrian Refugees in 2013 states that, “There is no accurate information on the total number of Syrian refugees living in Turkey.” According to AFAD, there are a total of 200,386 Syrian refugees in the camps as of August 23, 2013 operated by AFAD. According to the AFAD guesstimates, it is believed that there are a total of 350,000 Syrian refugees outside the camps in various cities. According to the reports of the United Nations, at the end of 2013, the number of Syrian citizens in Turkey will exceed 1 million (AFAD, 2013). By October 22, 2013, news on the media suggested there were over 600,000 Syrian refugees in Turkey. As of September 22, 2014, the number was reported to reach almost 1.6 million according to the press. The dramatic migration movement from Syria and Iraq is expected to continue as the war continues. 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 anti-natalist 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. 10 | Introduction 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 economic 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 Ninth Five-Year Development Plan of the Ministry of Development, which is valid for 2007-2013, 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, improved health levels, and a reduction in unbalanced development and inequalities among regions are primary objectives of population policy (Ministry of Development, 2006). The Tenth Five-Year Development Plan for 2014-2018 puts some significant purposes and targets as determining policies for increasing the total fertility rate gradually, especially by attending to the needs of women in working life. It was proposed to develop birth-related permits and rights, to encourage nurseries, and to provide flexible working opportunities in the plan. However, no substantial change has been made in legislation yet. 1.9 Health Priorities and Programs Maternal 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 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, antenatal and delivery care, safe motherhood, and female education. Information, Education, and Communication (IEC) 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 implementation started in October 2007. With this law, all people under 18 were included into the General Health Insurance system, regardless of their parents’ social security status. Introduction | 11 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 providing 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 Institutes and General Directorates such as the Turkey Public Health Institution, the Turkey Public Hospitals Institution, the Drugs and Medical Devices Institution, the General Directorate of Health Services, the General Directorate of Emergency Health Services, and the General Directorate of Health Development. 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. In 2003, Turkey launched a comprehensive health system reform (the Health Transformation Program), expanding health service delivery capacity and quality; reforming the health system financing, including the creation of a single social security risk pool and reforming the service provider payment mechanisms; and strengthening key public health programs, particularly those related to Maternal, Newborn, and Child Health (MNCH) and communicable diseases. The major goal of the Health Transformation Program (HTP) was to organize, finance and deliver health care services in an effective and efficient way in conformity with equity. Before the implementation of the Health Transformation Program, Turkey’s health system had a rather fragmented structure with limited coordination between Bağ-Kur (Self-Employed People’s Retirement Fund), Emekli Sandğ (Government Employee’s Retirement Fund), and SSK (Social Insurances Agency). The three social security institutions were working in silos with their own hospital network. Health care funding was provided by public, private, and philanthropic organizations, and financed by the government through the Ministry of Finance, social security institutions (SSK, Bağ-Kur and Emekli Sandğ), and out of pocket payments. All these institutions were using different reimbursement mechanisms. There was also a social assistance program, Green Card, for poor families. The key aspects of the HTP were: a) Increasing access to quality health care, including necessary health care infrastructure b) Health system financing and insurance reforms c) Strengthening public health Moreover, in December of 2004 the Turkish family medicine legislation was passed by the National Assembly. Accordingly, each family medicine practitioner serves approximately 3,000-4,000 individuals and is responsible for providing preventive and 10 | Introduction 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 economic 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 Ninth Five-Year Development Plan of the Ministry of Development, which is valid for 2007-2013, 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, improved health levels, and a reduction in unbalanced development and inequalities among regions are primary objectives of population policy (Ministry of Development, 2006). The Tenth Five-Year Development Plan for 2014-2018 puts some significant purposes and targets as determining policies for increasing the total fertility rate gradually, especially by attending to the needs of women in working life. It was proposed to develop birth-related permits and rights, to encourage nurseries, and to provide flexible working opportunities in the plan. However, no substantial change has been made in legislation yet. 1.9 Health Priorities and Programs Maternal 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 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, antenatal and delivery care, safe motherhood, and female education. Information, Education, and Communication (IEC) 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 implementation started in October 2007. With this law, all people under 18 were included into the General Health Insurance system, regardless of their parents’ social security status. Introduction | 11 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 providing 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 Institutes and General Directorates such as the Turkey Public Health Institution, the Turkey Public Hospitals Institution, the Drugs and Medical Devices Institution, the General Directorate of Health Services, the General Directorate of Emergency Health Services, and the General Directorate of Health Development. 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. In 2003, Turkey launched a comprehensive health system reform (the Health Transformation Program), expanding health service delivery capacity and quality; reforming the health system financing, including the creation of a single social security risk pool and reforming the service provider payment mechanisms; and strengthening key public health programs, particularly those related to Maternal, Newborn, and Child Health (MNCH) and communicable diseases. The major goal of the Health Transformation Program (HTP) was to organize, finance and deliver health care services in an effective and efficient way in conformity with equity. Before the implementation of the Health Transformation Program, Turkey’s health system had a rather fragmented structure with limited coordination between Bağ-Kur (Self-Employed People’s Retirement Fund), Emekli Sandğ (Government Employee’s Retirement Fund), and SSK (Social Insurances Agency). The three social security institutions were working in silos with their own hospital network. Health care funding was provided by public, private, and philanthropic organizations, and financed by the government through the Ministry of Finance, social security institutions (SSK, Bağ-Kur and Emekli Sandğ), and out of pocket payments. All these institutions were using different reimbursement mechanisms. There was also a social assistance program, Green Card, for poor families. The key aspects of the HTP were: a) Increasing access to quality health care, including necessary health care infrastructure b) Health system financing and insurance reforms c) Strengthening public health Moreover, in December of 2004 the Turkish family medicine legislation was passed by the National Assembly. Accordingly, each family medicine practitioner serves approximately 3,000-4,000 individuals and is responsible for providing preventive and 12 | Introduction curative health services to all registered persons. The Family Medicine Practitioner System follows up persons and preventive health services given to these persons. Since 2010, this system has been implemented all over Turkey. The system has replaced the previous primary health-care system of Health Houses and Health Centres. During the last decade, Turkey substantially increased the per-capita public expenditures in health, making a major investment in expanding health care infrastructure. A significant portion of this investment has been channeled for increasing access to primary and preventative health care with the family medicine practitioner system and implementing several measures in maternal, new born, and child health (MNCH). In the last decade, Turkey also witnessed a significant increase in the number of hospitals, the number of total beds, beds per 10,000 inhabitants, and the number of health care professionals. As a result of HTP, a substantial increase in overall primary care and inpatient care utilization/access, particularly in MNCH has been achieved. 1.11 Objectives and Organization of the Survey 1.11.1 Objectives The 2013 Turkey Demographic and Health Survey (TDHS–2013) is the tenth 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-2013 is to provide data on socioeconomic characteristics of households and women between ages 15-49, 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 women of reproductive age (15-49). The TDHS-2013 was designed to produce information in the field of demography and health that to a large extent cannot be obtained from other sources. Specifically, the objectives of the TDHS-2013 included: x Collecting data at the national level that allows the calculation of some demographic and health indicators, particularly fertility rates and childhood mortality rates, x Obtaining information on direct and indirect factors that determine levels and trends in fertility and childhood mortality, x Measuring the level of contraceptive knowledge and practice by contraceptive method and some background characteristics, i.e., region and urban-rural residence, x Collecting data relative to maternal and child health, including immunizations, antenatal care, and postnatal care, assistance at delivery, and breastfeeding, x Measuring the nutritional status of children under five and women in the reproductive ages , Introduction | 13 x Collecting data on reproductive-age women about marriage, employment status, and social status. The TDHS-2013 information is intended to provide 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- 2013 is to sustain the flow of information for the interested organizations in Turkey and abroad on the Turkish population structure in the absence of a reliable and sufficient vital registration system. Additionally, like the TDHS-2008, TDHS-2013 is accepted as a part of the Official Statistic Program. 1.11.2 Administration and Funding of the Survey The Turkey Demographic and Health Survey, 2013 (TDHS-2013) has been conducted by the Hacettepe University Institute of Population Studies in collaboration with the Ministry of Development and the Ministry of Health, Public Health Institution . The TDHS-2013 has been financed by the Scientific and Technological Research Council of Turkey (TÜBİTAK) under the Support Program for Research Projects of Public Institutions, as a 36-month project. The TDHS-2013 is the second demographic and health survey funded entirely from the national budget. A steering committee consisting of the academic staff of HUIPS and representatives of the Ministry of Health, the Ministry of Development, and the Turkish Statistical Institute participated in all phases of the project. The staff of the Institute and other persons involved in the various activities of the TDHS-2013 is listed in Appendix A. 1.11.3 Questionnaires Two types of questionnaires were used in the TDHS-2013: the Household Questionnaire and the Individual Questionnaire for all women of reproductive ages, 15 to 49. The contents of the questionnaires were based on the international DHS Program 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 the general directorate of MCH/FP and representatives of other related public institutions. Additionally, input was obtained from other institutions studying demographic and health issues. Ensuring that the findings of the TDHS-2013 would be comparable with previous demographic surveys, particularly with the TDHS-1993, TDHS-1998, TDHS-2003, and TDHS- 2008, was an important goal during questionnaire development. A pretest of the questionnaire was conducted in June 2013, and some minor modifications were made to the questionnaires based on the pretest results. 12 | Introduction curative health services to all registered persons. The Family Medicine Practitioner System follows up persons and preventive health services given to these persons. Since 2010, this system has been implemented all over Turkey. The system has replaced the previous primary health-care system of Health Houses and Health Centres. During the last decade, Turkey substantially increased the per-capita public expenditures in health, making a major investment in expanding health care infrastructure. A significant portion of this investment has been channeled for increasing access to primary and preventative health care with the family medicine practitioner system and implementing several measures in maternal, new born, and child health (MNCH). In the last decade, Turkey also witnessed a significant increase in the number of hospitals, the number of total beds, beds per 10,000 inhabitants, and the number of health care professionals. As a result of HTP, a substantial increase in overall primary care and inpatient care utilization/access, particularly in MNCH has been achieved. 1.11 Objectives and Organization of the Survey 1.11.1 Objectives The 2013 Turkey Demographic and Health Survey (TDHS–2013) is the tenth 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-2013 is to provide data on socioeconomic characteristics of households and women between ages 15-49, 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 women of reproductive age (15-49). The TDHS-2013 was designed to produce information in the field of demography and health that to a large extent cannot be obtained from other sources. Specifically, the objectives of the TDHS-2013 included: x Collecting data at the national level that allows the calculation of some demographic and health indicators, particularly fertility rates and childhood mortality rates, x Obtaining information on direct and indirect factors that determine levels and trends in fertility and childhood mortality, x Measuring the level of contraceptive knowledge and practice by contraceptive method and some background characteristics, i.e., region and urban-rural residence, x Collecting data relative to maternal and child health, including immunizations, antenatal care, and postnatal care, assistance at delivery, and breastfeeding, x Measuring the nutritional status of children under five and women in the reproductive ages , Introduction | 13 x Collecting data on reproductive-age women about marriage, employment status, and social status. The TDHS-2013 information is intended to provide 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- 2013 is to sustain the flow of information for the interested organizations in Turkey and abroad on the Turkish population structure in the absence of a reliable and sufficient vital registration system. Additionally, like the TDHS-2008, TDHS-2013 is accepted as a part of the Official Statistic Program. 1.11.2 Administration and Funding of the Survey The Turkey Demographic and Health Survey, 2013 (TDHS-2013) has been conducted by the Hacettepe University Institute of Population Studies in collaboration with the Ministry of Development and the Ministry of Health, Public Health Institution . The TDHS-2013 has been financed by the Scientific and Technological Research Council of Turkey (TÜBİTAK) under the Support Program for Research Projects of Public Institutions, as a 36-month project. The TDHS-2013 is the second demographic and health survey funded entirely from the national budget. A steering committee consisting of the academic staff of HUIPS and representatives of the Ministry of Health, the Ministry of Development, and the Turkish Statistical Institute participated in all phases of the project. The staff of the Institute and other persons involved in the various activities of the TDHS-2013 is listed in Appendix A. 1.11.3 Questionnaires Two types of questionnaires were used in the TDHS-2013: the Household Questionnaire and the Individual Questionnaire for all women of reproductive ages, 15 to 49. The contents of the questionnaires were based on the international DHS Program 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 the general directorate of MCH/FP and representatives of other related public institutions. Additionally, input was obtained from other institutions studying demographic and health issues. Ensuring that the findings of the TDHS-2013 would be comparable with previous demographic surveys, particularly with the TDHS-1993, TDHS-1998, TDHS-2003, and TDHS- 2008, was an important goal during questionnaire development. A pretest of the questionnaire was conducted in June 2013, and some minor modifications were made to the questionnaires based on the pretest results. 14 | Introduction 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. In the second part of the questionnaire, questions were included on the dwelling unit and on the ownership of a variety of consumer goods. The Women’s Questionnaire was designed for women listed in the household schedule age 15-49. This questionnaire covers the major topics listed below: x Background characteristics x Migration history x Marriage history and information on marriage x Pregnancy, birth history, and fertility preferences x Assisted reproductive techniques x Knowledge and use of contraceptive methods x Antenatal and postnatal care x Breastfeeding, nutrition, and immunization of children under age five x Women’s work history and status x Husband’s background characteristics x Anthropometric measurements of women and their children under five The calendar module in the Women's Questionnaire was used to record on a monthly basis fertility and contraceptive use for five years from January 2008 through the month of the survey. English versions of the two questionnaires can be seen in Appendix F. 1.11.4 Sample The sample design and sample size for the TDHS-2013 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-2013 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. 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 were included in the household roster in order to obtain the de facto survey population. Introduction | 15 In the selection of the TDHS-2013 sample, a weighted, multi-stage, stratified cluster sampling approach was used. Sample selection for the TDHS-2013 was undertaken in two stages. The first stage of selection included the selection of blocks as primary sampling units from each strata and this task was requested from the TURKSTAT. The frame for the block selection was prepared using information on the population sizes of settlements obtained from the 2012 Address Based Population Registration System. Settlements with a population of 10,000 and more were defined as “urban”, while settlements with populations less than 10,000 were considered “rural” for purposes of the TDHS-2013 sample design. Systematic selection was used for selecting the blocks; thus settlements were given selection probabilities proportional to their sizes. Therefore more blocks were sampled from larger settlements. The second stage of sample selection involved the systematic selection of a fixed number of households from each block, after block lists were obtained from TURKSTAT and were updated through a field operation; namely the listing and mapping fieldwork. Twenty- five households were selected as a cluster from urban blocks, and 18 were selected as a cluster from rural blocks. The total number of households selected in TDHS-2013 is 14,490. The total number of clusters in the TDHS-2013 was set at 642. Block level household lists, each including approximately 100 households, were provided by TURKSTAT, using the National Address Database prepared for municipalities. The block lists provided by TURKSTAT were updated during the listing and mapping activities. All 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 the Women’s Questionnaire and were interviewed. All analysis in this report is based on de facto women. A more technical and detailed description of the TDHS-2013 sample design, selection and implementation is presented in Appendix B. 1.11.5 Fieldwork and Data Processing The TDHS-2013 data collection was carried out by teams. Each team consisted of 8-9 people; 4-5 female interviewers, 1 male measurer, 1-2 field editors and a team supervisor. 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 an instructor of Institute who was in charge of the overall project. A three-week training was given to the field staff in September 2013. The fieldwork began on 15 September 2013, and completed in January 2014. The questionnaires completed in the field were returned to the Institute of Population Studies for data entry. Once the questionnaires arrived at the Institute, data entry and editing were done using the CSPro package. During the data entry process, full verification between the field data and the data entered was achieved by having each questionnaire keyed by two different data editors, 14 | Introduction 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. In the second part of the questionnaire, questions were included on the dwelling unit and on the ownership of a variety of consumer goods. The Women’s Questionnaire was designed for women listed in the household schedule age 15-49. This questionnaire covers the major topics listed below: x Background characteristics x Migration history x Marriage history and information on marriage x Pregnancy, birth history, and fertility preferences x Assisted reproductive techniques x Knowledge and use of contraceptive methods x Antenatal and postnatal care x Breastfeeding, nutrition, and immunization of children under age five x Women’s work history and status x Husband’s background characteristics x Anthropometric measurements of women and their children under five The calendar module in the Women's Questionnaire was used to record on a monthly basis fertility and contraceptive use for five years from January 2008 through the month of the survey. English versions of the two questionnaires can be seen in Appendix F. 1.11.4 Sample The sample design and sample size for the TDHS-2013 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-2013 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. 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 were included in the household roster in order to obtain the de facto survey population. Introduction | 15 In the selection of the TDHS-2013 sample, a weighted, multi-stage, stratified cluster sampling approach was used. Sample selection for the TDHS-2013 was undertaken in two stages. The first stage of selection included the selection of blocks as primary sampling units from each strata and this task was requested from the TURKSTAT. The frame for the block selection was prepared using information on the population sizes of settlements obtained from the 2012 Address Based Population Registration System. Settlements with a population of 10,000 and more were defined as “urban”, while settlements with populations less than 10,000 were considered “rural” for purposes of the TDHS-2013 sample design. Systematic selection was used for selecting the blocks; thus settlements were given selection probabilities proportional to their sizes. Therefore more blocks were sampled from larger settlements. The second stage of sample selection involved the systematic selection of a fixed number of households from each block, after block lists were obtained from TURKSTAT and were updated through a field operation; namely the listing and mapping fieldwork. Twenty- five households were selected as a cluster from urban blocks, and 18 were selected as a cluster from rural blocks. The total number of households selected in TDHS-2013 is 14,490. The total number of clusters in the TDHS-2013 was set at 642. Block level household lists, each including approximately 100 households, were provided by TURKSTAT, using the National Address Database prepared for municipalities. The block lists provided by TURKSTAT were updated during the listing and mapping activities. All 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 the Women’s Questionnaire and were interviewed. All analysis in this report is based on de facto women. A more technical and detailed description of the TDHS-2013 sample design, selection and implementation is presented in Appendix B. 1.11.5 Fieldwork and Data Processing The TDHS-2013 data collection was carried out by teams. Each team consisted of 8-9 people; 4-5 female interviewers, 1 male measurer, 1-2 field editors and a team supervisor. 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 an instructor of Institute who was in charge of the overall project. A three-week training was given to the field staff in September 2013. The fieldwork began on 15 September 2013, and completed in January 2014. The questionnaires completed in the field were returned to the Institute of Population Studies for data entry. Once the questionnaires arrived at the Institute, data entry and editing were done using the CSPro package. During the data entry process, full verification between the field data and the data entered was achieved by having each questionnaire keyed by two different data editors, 16 | Introduction comparing the results and resolving any differences. The office editing and processing activities in the Institute began in September 2013 and were completed in the third week of January 2014. 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, 14,490 households were selected for the TDHS-2013. At the time of the listing phase of the survey, 12,640 households were considered occupied and, thus, eligible for interview. Of the eligible households, 93 percent (11,794) 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. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates by residence, Turkey 2013 Result Urban Rural Total Household interviews Households selected 10,484 4,006 14,490 Households occupied 9,239 3,401 12,640 Households interviewed 8,482 3,312 11,794 Household response rate 91.8 97.4 93.3 Individual interviews Eligible women 8,019 2,821 10,840 Eligible women interviewed 7,162 2,584 9,746 Eligible women response rate 89.3 91.6 89.9 In the interviewed 11,794 households, 10,840 women were identified as eligible for the individual interview, aged 15-49 and were present in the household on the night before the interview. Interviews were successfully completed with 9,746 of these women (90 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, Ayşe Abbasoğlu Özgören and İsmet Koç This chapter provides a summary of the demographic and socioeconomic profile of the sampled households in the TDHS-2013. The household questionnaire (Appendix F) collected information regarding general characteristics of the household population such as age-sex composition, literacy and education, household arrangements (headship, household size), housing facilities (sources of water supply, sanitation facilities and dwelling characteristics), and household possessions. Besides providing a background for better understanding the social, demographic and health indices discussed throughout this report, this chapter will provide an assessment of the level of economic and social development of the population of Turkey. In addition, it may assist in the assessing the representativeness of the survey sample. 2.1 Characteristics of the Household Population The TDHS-2013 collected information from all the usual residents who live in the selected household (the de jure population) and persons who stayed in the selected household the night before the interview (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 for the study of a variety of demographic processes such as fertility, nuptiality and mortality. Table 2.1 gives the percent distribution of the TDHS-2013 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. The de facto population (persons who stayed in the selected household the night before the interview) in the selected TDHS-2013 households included 41,476 persons, of which 20,587 were male and 20,889 were female. Results indicate a sex ratio of 99 males per 100 females. By residence, the sex ratio is higher in urban areas (100 male per 100 female) than in rural areas (94 males per 100 females). 16 | Introduction comparing the results and resolving any differences. The office editing and processing activities in the Institute began in September 2013 and were completed in the third week of January 2014. 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, 14,490 households were selected for the TDHS-2013. At the time of the listing phase of the survey, 12,640 households were considered occupied and, thus, eligible for interview. Of the eligible households, 93 percent (11,794) 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. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates by residence, Turkey 2013 Result Urban Rural Total Household interviews Households selected 10,484 4,006 14,490 Households occupied 9,239 3,401 12,640 Households interviewed 8,482 3,312 11,794 Household response rate 91.8 97.4 93.3 Individual interviews Eligible women 8,019 2,821 10,840 Eligible women interviewed 7,162 2,584 9,746 Eligible women response rate 89.3 91.6 89.9 In the interviewed 11,794 households, 10,840 women were identified as eligible for the individual interview, aged 15-49 and were present in the household on the night before the interview. Interviews were successfully completed with 9,746 of these women (90 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, Ayşe Abbasoğlu Özgören and İsmet Koç This chapter provides a summary of the demographic and socioeconomic profile of the sampled households in the TDHS-2013. The household questionnaire (Appendix F) collected information regarding general characteristics of the household population such as age-sex composition, literacy and education, household arrangements (headship, household size), housing facilities (sources of water supply, sanitation facilities and dwelling characteristics), and household possessions. Besides providing a background for better understanding the social, demographic and health indices discussed throughout this report, this chapter will provide an assessment of the level of economic and social development of the population of Turkey. In addition, it may assist in the assessing the representativeness of the survey sample. 2.1 Characteristics of the Household Population The TDHS-2013 collected information from all the usual residents who live in the selected household (the de jure population) and persons who stayed in the selected household the night before the interview (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 for the study of a variety of demographic processes such as fertility, nuptiality and mortality. Table 2.1 gives the percent distribution of the TDHS-2013 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. The de facto population (persons who stayed in the selected household the night before the interview) in the selected TDHS-2013 households included 41,476 persons, of which 20,587 were male and 20,889 were female. Results indicate a sex ratio of 99 males per 100 females. By residence, the sex ratio is higher in urban areas (100 male per 100 female) than in rural areas (94 males per 100 females). 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 2013 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 9.0 8.1 8.5 9.4 7.7 8.5 9.0 8.0 8.5 5-9 8.8 8.2 8.5 9.5 8.6 9.1 9.0 8.3 8.6 10-14 8.8 9.0 8.9 9.9 9.4 9.6 9.1 9.1 9.1 15-19 8.5 8.0 8.2 7.8 7.4 7.6 8.4 7.8 8.1 20-24 8.1 7.3 7.7 5.1 6.2 5.7 7.4 7.0 7.2 25-29 8.1 8.5 8.3 5.1 5.7 5.4 7.5 7.9 7.7 30-34 8.7 8.9 8.8 6.1 6.1 6.1 8.1 8.3 8.2 35-39 7.6 8.3 7.9 5.7 5.8 5.7 7.2 7.7 7.5 40-44 6.7 6.6 6.6 6.0 5.9 6.0 6.6 6.4 6.5 45-49 6.1 5.2 5.6 6.0 6.1 6.0 6.1 5.4 5.7 50-54 5.5 6.8 6.1 6.4 6.7 6.5 5.7 6.7 6.2 55-59 4.5 4.8 4.7 5.7 5.8 5.7 4.8 5.0 4.9 60-64 3.6 3.3 3.5 5.3 4.9 5.1 4.0 3.7 3.8 65-69 2.3 2.4 2.3 3.4 4.3 3.9 2.5 2.8 2.7 70-74 1.6 1.8 1.7 3.4 3.6 3.5 2.0 2.2 2.1 75-79 0.9 1.2 1.0 2.4 2.6 2.5 1.2 1.5 1.4 80 + 1.2 1.8 1.5 2.6 3.2 2.9 1.5 2.1 1.8 Don't know/missing 0.0 0.0 0.0 0.2 0.1 0.1 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 16,186 16,204 32,391 4,401 4,684 9,085 20,587 20,889 41,476 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Percentage of total population Age Figure 2.1 Population Pyramid The population pyramid for de facto household population, Turkey 2013 Male Female Household Population and Housing Characteristics | 19 The population pyramid in figure 2.1 shows the sex and age distribution of the population. It is indicative of a constricted population pyramid transitioning from a high fertility and high mortality regime to a declining fertility and mortality regime. The number of children less than 15 years old account for 26 percent of the total population whereas less than one tenth (8 percent) of the total population are 65 or older. The shift to more conservative birth rates (fertility decline) is evidenced by lower proportion of children age 0-4 than children age 5-14 age. Declining mortality rates have resulted in a higher proportion of elderly, the highest recorded 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 of children (under age 15) and elderly is slightly greater in rural areas than in urban areas (27 and 26 percent for children and 13 and 7 percent for elderly). Another important urban-rural difference is among the working age population (age 15-64), who represent 68 percent of the urban population and 60 percent of the rural population. The significantly higher urban working age population may reflect the effects of rural-to-urban migration of the economically active population. Table 2.2.1 Age distribution of the household population Percent distribution of the de facto household population by major age groups and residence, Turkey 2013 Age group Urban Rural Total 0-14 25.9 27.2 26.2 15-64 67.5 59.9 65.8 65+ 6.6 12.8 7.9 Don't know/missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number 32,391 9,085 41,476 Table 2.2.2 compares the distribution of the household population by age groups for the last five demographic surveys, the last two censuses carried out in 1990 and 2000 and population information derived from address based population registration system for 2013. The table reveals that between 1990 and 2013, the share of population under age 15 has decreased from 35 percent to 26 percent,whereas the share of the elderly population has increased from 4 percent to 8 percent. 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. Estimates show that the dependency ratio was around 65 percent at the time of the 1990 Population Census and has declined to nearly 52 percent in the TDHS-2013. The decline reflects a significant decrease in the burden placed on persons in the productive ages (ages 15-64) to support older and younger household members. In line 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 2013 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 9.0 8.1 8.5 9.4 7.7 8.5 9.0 8.0 8.5 5-9 8.8 8.2 8.5 9.5 8.6 9.1 9.0 8.3 8.6 10-14 8.8 9.0 8.9 9.9 9.4 9.6 9.1 9.1 9.1 15-19 8.5 8.0 8.2 7.8 7.4 7.6 8.4 7.8 8.1 20-24 8.1 7.3 7.7 5.1 6.2 5.7 7.4 7.0 7.2 25-29 8.1 8.5 8.3 5.1 5.7 5.4 7.5 7.9 7.7 30-34 8.7 8.9 8.8 6.1 6.1 6.1 8.1 8.3 8.2 35-39 7.6 8.3 7.9 5.7 5.8 5.7 7.2 7.7 7.5 40-44 6.7 6.6 6.6 6.0 5.9 6.0 6.6 6.4 6.5 45-49 6.1 5.2 5.6 6.0 6.1 6.0 6.1 5.4 5.7 50-54 5.5 6.8 6.1 6.4 6.7 6.5 5.7 6.7 6.2 55-59 4.5 4.8 4.7 5.7 5.8 5.7 4.8 5.0 4.9 60-64 3.6 3.3 3.5 5.3 4.9 5.1 4.0 3.7 3.8 65-69 2.3 2.4 2.3 3.4 4.3 3.9 2.5 2.8 2.7 70-74 1.6 1.8 1.7 3.4 3.6 3.5 2.0 2.2 2.1 75-79 0.9 1.2 1.0 2.4 2.6 2.5 1.2 1.5 1.4 80 + 1.2 1.8 1.5 2.6 3.2 2.9 1.5 2.1 1.8 Don't know/missing 0.0 0.0 0.0 0.2 0.1 0.1 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 16,186 16,204 32,391 4,401 4,684 9,085 20,587 20,889 41,476 6 4 2 0 2 4 6 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Percentage of total population Age Figure 2.1 Population Pyramid The population pyramid for de facto household population, Turkey 2013 Male Female Household Population and Housing Characteristics | 19 The population pyramid in figure 2.1 shows the sex and age distribution of the population. It is indicative of a constricted population pyramid transitioning from a high fertility and high mortality regime to a declining fertility and mortality regime. The number of children less than 15 years old account for 26 percent of the total population whereas less than one tenth (8 percent) of the total population are 65 or older. The shift to more conservative birth rates (fertility decline) is evidenced by lower proportion of children age 0-4 than children age 5-14 age. Declining mortality rates have resulted in a higher proportion of elderly, the highest recorded 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 of children (under age 15) and elderly is slightly greater in rural areas than in urban areas (27 and 26 percent for children and 13 and 7 percent for elderly). Another important urban-rural difference is among the working age population (age 15-64), who represent 68 percent of the urban population and 60 percent of the rural population. The significantly higher urban working age population may reflect the effects of rural-to-urban migration of the economically active population. Table 2.2.1 Age distribution of the household population Percent distribution of the de facto household population by major age groups and residence, Turkey 2013 Age group Urban Rural Total 0-14 25.9 27.2 26.2 15-64 67.5 59.9 65.8 65+ 6.6 12.8 7.9 Don't know/missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number 32,391 9,085 41,476 Table 2.2.2 compares the distribution of the household population by age groups for the last five demographic surveys, the last two censuses carried out in 1990 and 2000 and population information derived from address based population registration system for 2013. The table reveals that between 1990 and 2013, the share of population under age 15 has decreased from 35 percent to 26 percent,whereas the share of the elderly population has increased from 4 percent to 8 percent. 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. Estimates show that the dependency ratio was around 65 percent at the time of the 1990 Population Census and has declined to nearly 52 percent in the TDHS-2013. The decline reflects a significant decrease in the burden placed on persons in the productive ages (ages 15-64) to support older and younger household members. In line 20 | Household Population and Housing Characteristics with this finding,the median age increased 7.3 years from 22.2 years in 1990 to 29.5 years in 2013. Changes in the median age are consistent with the gradual aging of the population that occurs as fertility declines and life expectancy increases. Table 2.2.2 Population by age from selected sources Percent distribution of the population by age group, selected sources, Turkey 1990-2013 PC TDHS TDHS PC TDHS TDHS ABPRS TDHS Age group 1990 1993 1998 2000 2003 2008 2013 2013 0-14 35.0 33.0 31.5 29.8 29.1 27.4 24.6 26.2 15-64 60.7 61.4 62.6 64.5 64.0 65.8 67.7 65.8 65+ 4.3 5.6 5.9 5.7 6.9 6.8 7.7 7.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Median age 22.2 23.1 24.3 24.8 24.8 24.7 30.4 29.5 Dependency ratios 64.7 62.7 59.7 55.1 55.1 56.3 47.6 51.9 Sources: 1990 and 2000 Population Census (PC), TDHS-1993, TDHS-1998, TDHS-2003, TDHS-2008, TDHS- 2013 and Address Based Population Registration System (ABPRS) 2.1.2 Household Composition Table 2.3 presents the distribution of households in the TDHS-2013 sample by sex of the head of household, by the number of household members, and by households with orphans and foster children. These characteristics are important because they are associated with socioeconomic differences between households. Unlike previous tables, 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 female headed households, financial resources are usually more limited relative to 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 cultural patterns in Turkey, male- headed households are predominant in the TDHS-2013 sample: 85 percent of households are headed by a male and 15 percent of households are female headed. On average, there are 3.6 persons per household: slightly more than half of the households have three or fewer members (52 percent), 24 percent have four members, and a quarter (25 percent) have five or more members. There are some differences in urban and rural household composition. The proportion of female-headed households is same in rural and urban areas (15 percent), however, in urban areas, 23 percent of households have five or more members compared with 32 percent in rural areas. The mean household size is 3.6 persons in the urban areas and 3.9 persons in the rural areas. Household Population and Housing Characteristics | 21 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 2.3 shows that only 1 percent of households include foster children, namely children under age 18 living in households with neither their mother nor their father present. Household with foster and/or orphan children, on the other hand, corresponds to 2.3 of all households. Table 2.4 presents the percent distribution of children under age 18 by living arrangements and survival status of parents. Table 2.3 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18 years of age, according to residence, Turkey 2013 Residence Characteristic Urban Rural Total Household headship Male 85.0 85.3 85.1 Female 15.0 14.7 14.9 Total 100.0 100.0 100.0 Number of usual members 1 8.1 10.0 8.5 2 21.1 26.5 22.3 3 22.4 15.8 21.0 4 25.8 15.6 23.7 5 12.7 11.3 12.4 6 4.9 8.0 5.5 7 2.3 4.7 2.8 8 1.2 2.7 1.5 9+ 1.5 5.4 2.3 Total 100.0 100.0 100.0 Mean size of households 3.6 3.9 3.6 Percentage of households with orphans and foster children under 18 years of ag

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