Turkmenistan - Demographic and Health Survey - 2001

Publication date: 2001

Turkmenistan 2000Demographic andHealth SurveyDem ographic and H ealth Survey Turkm enistan 2000 World Summit for Children Indicators, Turkmenistan 2000 Childhood mortality Childhood undernutrition Clean water supply Sanitary excreta disposal Basic education Family planning Antenatal care Delivery care Low birth weight Iodized salt intake Vitamin A supplements Exclusive breastfeeding Continued breastfeeding Timely complementary feeding Vaccinations Diarrhea control Acute respiratory infection Home management of illness Children in especially difficult situations HIV/AIDS Infant mortality rate Under-five mortality rate Percent stunted (children under 5 years) Percent wasted (children under 5 years) Percent underweight (children under 5 years) Percent of households within 15 minutes of safe water supply1 Percent of households with flush toilets, pit toilet/latrine Net primary school attendance rate2 Contraceptive prevalence rate (any method, currently married women) Contraceptive prevalence rate (any method, all women) Percent of women who received antenatal care from a health professional3 Percent of births in the 5 years preceding the survey attended by a health professional Percent of births in the 5 years preceding the survey at low birth weight4 Percent of households that use iodized salt5 Percent of children age 6-59 months who received a vitamin A dose in the six months preceding the survey Percent of children under 6 months who are exclusively breastfed Percent of children age 12-15 months still breastfeeding Percent of children age 20-23 months still breastfeeding Percent of children age 6-9 months receiving breast milk and complementary foods Percent of children age 12-23 months with BCG vaccination Percent of children age 12-23 months with at least 3 doses of DPT vaccinations Percent of children age 12-23 months with at least 3 doses of polio vaccinations Percent of children age 12-23 months with measles vaccination Percent of children age 0-59 months with diarrhea in the 2 weeks preceding the survey who received oral rehydration salts (ORS) or recommended home fluids (RHF) Percent of children age 0-59 months with acute respiratory infection (ARI) in the 2 weeks preceding the survey who were taken to a health provider Percent of children age 0-59 months with diarrhea who were taken to a health provider Percent of children with at least one parent dead6 Percent of children who do not live with either biological parent6 Percent of women age 15-49 who correctly state 2 ways of avoiding HIV infection7 Percent of women age 15-49 who believe that AIDS can be transmitted from mother to child during pregnancy, delivery and breastfeeding, Percent of women age 15-49 who know of a place to get tested for the AIDS virus Percent of women age 15-49 who have been tested for the AIDS virus 74 per 1,000 94 per 1,000 22.3 5.7 12.0 62.1 99.2 84.9 61.8 39.2 98.1 97.2 6.0 75.3 15.3 15.9 75.1 26.1 70.6 99.1 97.9 97.1 92.9 46.7 50.9 38.5 4.5 1.1 40.6 52.6 12.4 4.2 1 Piped water or protected well water 2 Based on de facto children 3 For the last live birth in the five years preceding the survey 4 For children without a reported birth weight, the proportion with low birth weight is assumed to be the same as the proportion with low birth weight in each birth size category among children who have a reported birth weight. 5 15 parts per million or more 6 Based on de jure children 7 Having sex with only one partner who has no other partners and using a condom every time they have sex Turkmenistan Demographic and Health Survey 2000 Gurbansoltan Eje Clinical Research Center for Maternal and Child Health Ministry of Health and Medical Industry Ashgabad, Turkmenistan ORC Macro Calverton, Maryland, USA September 2001 Gurbansoltan Eje Clinical Research Center for Maternal and Child Health ORC Macro The report summarizes the findings of the 2000 Turkmenistan Demographic and Health Survey (2000 TDHS), which was conducted by the Gurbansoltan Eje Clinical Research Center for Maternal and Child Health of the Ministry of Health and Medical Industry of Turkmenistan. ORC Macro provided technical assistance. Funding was provided by the U.S. Agency for International Development (USAID) and logistical support was provided by UNFPA/Turkmenistan. The TDHS is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information on the Turkmenistan survey may be obtained from Gurbansoltan Eje Clinical Research Center for Maternal and Child Health Ministry of Health and Medical Industry 28 Khalmamedo Street Ashgabad, Turkmenistan Telephone: 993-12-43-5191 Fax: 73272-43-5315 E-mail: nkcozmr@online.tm Additional information about the DHS program may be obtained by contacting: MEASURE DHS+ ORC Macro 11785 Beltsville Drive Suite 300 Calverton, MD 20705 USA Tel: 301-572-0200 Fax: 301-572-0999 E-mail: reports@macroint.com Internet: http://www.measuredhs.com Recommended citation: Gurbansoltan Eje Clinical Research Center for Maternal and Child Health (GECRCMCH), Ministry of Health and Medical Industry [Turkmenistan], and ORC Macro. 2001. Turkmenistan Demographic and Health Survey 2000. Calverton, Maryland, USA: GECRCMCH and ORC Macro. Contents * iii CONTENTS Page Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Map of Turkmenistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx CHAPTER 1 INTRODUCTION, OBJECTIVES, AND SURVEY DESIGN . . . . . . . . . . . . . . . 1 B.S. Sopyev and C.M. Nazarov 1.1 Geography and Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.3 Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.4 Health Care System and Epidemiological Situation . . . . . . . . . . . . . . . . . . . . . . 3 1.5 Reproductive Health Policy and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.6 Demographic and Health Data Collection System in Turkmenistan . . . . . . . . . . 5 1.7 Objectives and Organization of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 CHAPTER 2 HOUSING CHARACTERISTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 B.S. Sopyev and K. Fair 2.1 Demographic Characteristics of Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.2 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.3 Educational Level of Household Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.3.1 Educational Attainment of Household Members . . . . . . . . . . . . . . . . . . 13 2.3.2 School Attendance Ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.4 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 CHAPTER 3 WOMEN’S CHARACTERISTICS AND STATUS . . . . . . . . . . . . . . . . . . . . . . 19 A.Y. Khaitova, B.A. Gairova, and S. Kishor 3.1 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.1.1 Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.1.2 Educational Level of Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3.1.3 Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.1.4 Employment Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.1.5 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.1.6 Employer and Forms of Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3.1.7 Decision making Regarding Use of Cash Earnings . . . . . . . . . . . . . . . . . 28 3.2 Direct measures of women’s empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.2.1 Household Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.2.2 Women’s Agreement with Reasons for Refusing Sexual Relations . . . . . 33 iv * Contents Page CHAPTER 4 FERTILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 C.M. Nazarov, A. Mukhamedova, and K. Weinstein 4.1 Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.2 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 4.3 Children Ever Born and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.4 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.5 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 4.6 Pregnancy and Motherhood among Women Age 15-19 . . . . . . . . . . . . . . . . . . 46 CHAPTER 5 CONTRACEPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 S.M. Turayeva, N.M. Bekmuradov, and K. Weinstein 5.1 Knowledge of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 5.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.4 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . 56 5.5 Knowledge of the Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.6 Source of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.7 Informed Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 5.8 Discontinuation within 12 Months of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 5.9 Intention to Use Contraception among Nonusers . . . . . . . . . . . . . . . . . . . . . . . 63 5.10 Reasons for Nonuse of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 5.11 Exposure to Family Planning Messages in the Media . . . . . . . . . . . . . . . . . . . . 64 5.12 Contact of Nonusers with a Service Provider . . . . . . . . . . . . . . . . . . . . . . . . . . 66 5.13 Spousal Communication on the Use of Contraception . . . . . . . . . . . . . . . . . . . 68 CHAPTER 6 INDUCED ABORTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 A.S. Ezimova, A.Y. Khaitova, and G.A. Akmuradova 6.1 Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 6.2 Lifetime Experience with Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 6.3 Rates of Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6.4 Trends in Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.5 Use of Contraception before Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 6.6 Service Providers and Medical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 6.7 Attitudes toward Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . . 81 C.M. Nazarov, G.K. Ezizova, and D. Sharman 7.1 Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 7.2 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 7.3 Exposure to Intercourse Before and After Marriage . . . . . . . . . . . . . . . . . . . . . 85 7.4 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Contents * v Page 7.5 Postpartum Amenorrhea, Abstinence, and Insusceptibility . . . . . . . . . . . . . . . . 87 7.6 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 CHAPTER 8 FERTILITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 S.M. Turayeva, E.A. Shellenov, and G.S. Murikova 8.1 Fertility Preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 8.2 Need for Contraceptive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 8.3 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 8.4 Unplanned and Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 CHAPTER 9 INFANT AND CHILD MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 V.R. Charyeva, E.Y. Samarkina, and J.M. Sullivan 9.1 Mortality Rates Based on MOHMI Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 9.2 Mortality Rates Based on TDHS Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 9.3 Comparison of Mortality Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 9.4 Socioeconomic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . 105 9.5 Demographic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . 106 9.6 Mortality Differentials by Women’s Status . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 9.7 Perinatal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 9.8 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 CHAPTER 10 MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 S.M. Turayeva, A.B. Dzhunelov, and N.S. Gandimova 10.1 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 10.2 Timing of Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 10.3 Content of Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 10.4 Place and Assistance during Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 10.5 Delivery Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 10.6 Postnatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 10.7 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 10.8 Acute Respiratory Infection and Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 10.9 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 CHAPTER 11 NUTRITION OF WOMEN AND CHILDREN . . . . . . . . . . . . . . . . . . . . . . 127 G.R. Dzhorayeva, G.Y. Khodzhayeva, and T.R. Tagirova 11.1 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 11.2 Breastfeeding by Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 11.3 Duration and Frequency of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 11.4 Complementary Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 11.5 Nutritional Status of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 11.6 Nutritional Status of Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 vi * Contents Page 11.7 Micronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 11.8 Use of Iodized Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 CHAPTER 12 ANEMIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 G.K. Kariyeva, A. Magtymova, and A. Sharman 12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 12.2 Prevalence of Anemia among Women Age 15-49 . . . . . . . . . . . . . . . . . . . . . . 142 12.3 Iron Supplementation during Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 12.4 Anemia Prevalence among Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 CHAPTER 13 SEXUALLY TRANSMITTED INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . 149 J.M. Sullivan, S.M. Turayeva, and A.Y. Khaimova 13.1 Awareness of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 13.2 Knowledge of HIV/ AIDS Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 13.3 Programmatically Important Risk-reducing Practices . . . . . . . . . . . . . . . . . . . 151 13.4 Knowledge of HIV/AIDS-related Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 13.5 Social Aspects of HIV/AIDS Prevention and Mitigation . . . . . . . . . . . . . . . . . . 154 13.6 Acceptability of HIV/AIDS Messages in the Media . . . . . . . . . . . . . . . . . . . . . 156 13.7 Knowledge of Symptoms of Sexually Transmitted Infections . . . . . . . . . . . . . 156 13.8 Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 13.9 Knowledge of Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 13.10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 APPENDIX A: SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 A. Aliaga APPENDIX B: ESTIMATES OF SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 APPENDIX C: DATA QUALITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 APPENDIX D: QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Tables and Figures * vii TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION, OBJECTIVES, AND SURVEY DESIGN Table 1.1 Results of the household and individual interviews . . . . . . . . . . . . . . . . . 8 CHAPTER 2 HOUSING CHARACTERISTICS Table 2.1 Household population by age, residence, and sex . . . . . . . . . . . . . . . . . 10 Table 2.2 Population by age according to selected sources . . . . . . . . . . . . . . . . . . 11 Table 2.3 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 2.4 Fosterhood and orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Table 2.5 Educational attainment of household population . . . . . . . . . . . . . . . . . 14 Table 2.6 School attendance ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table 2.7 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Table 2.8 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure 2.1 Population pyramid of Turkmenistan . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Figure 2.2 Age-specific attendance ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 CHAPTER 3 WOMEN’S CHARACTERISTICS AND STATUS Table 3.1 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . 20 Table 3.2 Religion, ethnicity, and residence by region . . . . . . . . . . . . . . . . . . . . . 21 Table 3.3 Educational attainment by background characteristics . . . . . . . . . . . . . 21 Table 3.4 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Table 3.5 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Table 3.6 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Table 3.7 Employment and form of earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Table 3.8 Decision of use of earnings and contribution of earnings to household expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 3.9 Control over earnings according to contributions to household expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 3.10 Household decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 3.11 Final say in household decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Table 3.12 Women’s agreement with reasons for refusing sexual relations . . . . . . . 35 Figure 3.1 Percent distribution of women age 15-49 by employment status . . . . . . 25 CHAPTER 4 FERTILITY Table 4.1 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table 4.2 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 39 Table 4.3 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 viii * Tables and Figures Page Table 4.4 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Table 4.5 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Table 4.6 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Table 4.7 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Table 4.8 Pregnancy and motherhood among women age 15-19 . . . . . . . . . . . . . 47 Figure 4.1 Age-specific fertility rates by ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . 38 Figure 4.2 Total fertility rate by background characteristics . . . . . . . . . . . . . . . . . 40 Figure 4.3 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Figure 4.4 Percent of nonfirst birth born within 24 hours of previous birth . . . . . . 44 CHAPTER 5 CONTRACEPTION Table 5.1 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Table 5.2 Knowledge of contraceptive methods by background characteristics . . . 52 Table 5.3 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Table 5.4 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Table 5.5 Current use of contraception by background characteristics . . . . . . . . . 55 Table 5.6 Current use of contraception by women’s status . . . . . . . . . . . . . . . . . . 57 Table 5.7 Number of children at the time of first use of contraception . . . . . . . . . 57 Table 5.8 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Table 5.9 Source of supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Table 5.10 Informed choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table 5.11 First-year contraceptive discontinuation rates . . . . . . . . . . . . . . . . . . . . 61 Table 5.12 Reasons for discontinuing contraceptive methods . . . . . . . . . . . . . . . . . 62 Table 5.13 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Table 5.14 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . 63 Table 5.15 Reason for not intending to use contraception . . . . . . . . . . . . . . . . . . . 63 Table 5.16 Exposure to family planning messages on radio and television . . . . . . . 64 Table 5.17 Exposure to family planning messages in print media . . . . . . . . . . . . . . 65 Table 5.18 Contact of nonusers with family planning providers . . . . . . . . . . . . . . . 66 Table 5.19 Discussion of family planning with husband . . . . . . . . . . . . . . . . . . . . . 67 Table 5.20 Attitudes of couples toward family planning . . . . . . . . . . . . . . . . . . . . . 68 Figure 5.1 Current Use of Contraception among Currently Married Women age 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Figure 5.2 Percentage of married women age 15-49 currently using contraception by background characteristics . . . . . . . . . . . . . . . . . . . . 56 CHAPTER 6 INDUCED ABORTION Table 6.1 Pregnancy outcome by background characteristics . . . . . . . . . . . . . . . . 69 Table 6.2 Pregnancy outcome by women’s status . . . . . . . . . . . . . . . . . . . . . . . . . 71 Table 6.3 Lifetime experience with induced abortion . . . . . . . . . . . . . . . . . . . . . . 72 Table 6.4 Induced abortion rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Table 6.5 Induced abortion by background characteristics . . . . . . . . . . . . . . . . . . 76 Table 6.6 Trends in age-specific induced abortion . . . . . . . . . . . . . . . . . . . . . . . . 77 Tables and Figures * ix Page Table 6.7 Use of contraception prior to pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 77 Table 6.8 Source of services and procedure used for induced abortion . . . . . . . . . 78 Table 6.9 Timing of induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Table 6.10 Women’s attitude toward induced abortion . . . . . . . . . . . . . . . . . . . . . 80 Figure 6.1 Age-specific rates of fertility (ASFR) and induced abortion (ASAR) . . . 74 Figure 6.2 Total induced abortion rate by background characteristics . . . . . . . . . . 75 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 7.1 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Table 7.2 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Table 7.3 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Table 7.4 Age at first sexual intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Table 7.5 Median age at first intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Table 7.6 Sexual relationships of nonmarried women . . . . . . . . . . . . . . . . . . . . . 87 Table 7.7 Recent sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Table 7.8 Postpartum amenorrhea, abstinence and insusceptibility . . . . . . . . . . . 89 Table 7.9 Median duration of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics . . . . . . . . . . . . . . . . 90 Table 7.10 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Figure 7.1 Marital Status of Women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Figure 7.2 Percentage of Women Married by Specific Exact Ages . . . . . . . . . . . . . 83 CHAPTER 8 FERTILITY PREFERENCES Table 8.1 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . 91 Table 8.2 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Table 8.3 Desire to limit childbearing by background characteristics . . . . . . . . . . 93 Table 8.4 Need for contraception among currently married women . . . . . . . . . . . 95 Table 8.5 Ideal number children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Table 8.6 Mean ideal number of children by background characteristics . . . . . . . 97 Table 8.7 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Table 8.8 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Figure 8.1 Fertility preferences for currently married women 15-49 . . . . . . . . . . . 92 CHAPTER 9 INFANT AND CHILD MORTALITY Table 9.1 Infant mortality rates government of Turkmenistan . . . . . . . . . . . . . . 102 Table 9.2 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Table 9.3 Infant and child mortality by background characteristics . . . . . . . . . . 106 Table 9.4 Infant and child mortality by demographic characteristics . . . . . . . . . 107 Table 9.5 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 x * Tables and Figures Page Table 9.6 Perinatal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Table 9.7 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Figure 9.1 Trends in mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 CHAPTER 10 MATERNAL AND CHILD HEALTH Table 10.1 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Table 10.2 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . 115 Table 10.3 Antenatal care content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Table 10.4 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Table 10.5 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Table 10.6 Delivery characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Table 10.7 Timing of postnatal care and care providers . . . . . . . . . . . . . . . . . . . . 121 Table 10.8 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . 122 Table 10.9 Prevalence of symptoms of acute respiratory infection and fever . . . . 123 Table 10.10 Knowledge of oral rehydration solution (ORS) packets . . . . . . . . . . . . 124 Table 10.11 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Table 10.12 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Table 10.13 Feeding practices during diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 CHAPTER 11 NUTRITION OF WOMEN AND CHILDREN Table 11.1 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Table 11.2 Breastfeeding status by child’s age . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Table 11.3 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . 131 Table 11.4 Foods consumed by children in preceding 24 hours . . . . . . . . . . . . . . 132 Table 11.5 Nutritional status of children by demographic characteristics . . . . . . . 134 Table 11.6 Nutritional status of children by background characteristics . . . . . . . . 135 Table 11.7 Anthropometric indicators of women’s nutritional status . . . . . . . . . . 137 Table 11.8 Nutritional status of women by background characteristics . . . . . . . . 138 Table 11.9 Micronutrient intake among children . . . . . . . . . . . . . . . . . . . . . . . . . 139 Table 11.10 Iodization of household salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 CHAPTER 12 ANEMIA Table 12.1 Anemia among women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Table 12.2 Anemia among women by nutritional status, reproductive history, and IUD use . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Table 12.3 Iron supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Table 12.4 Anemia among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Table 12.5 Anemia among children by demographic characteristics and nutritional status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Tables and Figures * xi Page CHAPTER 13 SEXUALLY TRANSMITTED INFECTIONS Table 13.1 Knowledge of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Table 13.2 Knowledge of ways to avoid AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Table 13.3 Knowledge of specific ways to avoid AIDS . . . . . . . . . . . . . . . . . . . . . 152 Table 13.4 Knowledge of AIDS related issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Table 13.5 Discussion of AIDS with partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Table 13.6 Social aspects of AIDS prevention and migration . . . . . . . . . . . . . . . . 155 Table 13.7 Discussion of AIDS in the media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Table 13.8 Knowledge of signs and symptoms of STIs . . . . . . . . . . . . . . . . . . . . . 157 Table 13.9 Number of sexual partners of married women . . . . . . . . . . . . . . . . . . 158 Table 13.10 Number of sexual partners of married men . . . . . . . . . . . . . . . . . . . . . 159 Table 13.11 Knowledge and source of male condom and access . . . . . . . . . . . . . . . 160 APPENDIX A: SAMPLE DESIGN Table A.1 Sample allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Table A.2 Sample implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 APPENDIX B: ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . . . . . . . . . . . . . . . . . . . . 172 Table B.2 Sampling errors for women - Total sample . . . . . . . . . . . . . . . . . . . . . 173 Table B.3 Sampling errors for women - Urban sample . . . . . . . . . . . . . . . . . . . . 174 Table B.4 Sampling errors for women - Rural sample . . . . . . . . . . . . . . . . . . . . . 175 Table B.5 Sampling errors for women - Ashgabad City sample . . . . . . . . . . . . . . 176 Table B.6 Sampling errors for women - South sample . . . . . . . . . . . . . . . . . . . . 177 Table B.7 Sampling errors for women - Balkan sample . . . . . . . . . . . . . . . . . . . . 178 Table B.8 Sampling errors for women - Dashoguz sample . . . . . . . . . . . . . . . . . 179 Table B.9 Sampling errors for women - Lebap sample . . . . . . . . . . . . . . . . . . . . 180 Table B.10 Sampling errors for women - Mary sample . . . . . . . . . . . . . . . . . . . . . 181 APPENDIX C: DATA QUALITY TABLES Table C.1 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Table C.2 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . 184 Table C.3 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Table C.4 Births by calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Table C.5 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Table C.6 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . 188 xii * Tables and Figures Foreword * xiii FOREWORD Protecting and strengthening the health of each citizen is a priority goal of the National program of the President of Turkmenistan, Saparmurat Turkmenbashi, “Strategy for Social- economic Transformation to the Year 2010.” The Ministry of Health and Medical Industry directs significant efforts to improve quality and accessibility of medical services in Turkmenistan. Special attention is paid to medical services for women and children as well as preventive care and medical services in rural areas. Preventive care is a fundamental principle of the national health policy. The 2000 Turkmenistan Demographic and Health Survey (TDHS) was the first national-level population and health survey in Turkmenistan. The purpose of the survey was to provide objective information on fertility, health, and nutrition of women and children. This information is important for understanding the factors that influence the reproductive health of women and the health and survival of infants and young children. It can be used in planning effective policies and programs regarding the health and nutrition of women and their children in Turkmenistan. The 2000 TDHS was implemented by the Gurbansoltan Eje Clinical Research Center for Maternal and Child Health. It was sponsored by the Ministry of Health and Medical Industry. Sampling design and listing operations for the survey were carried out by the staff of the National Institute of State Statistics and Information. The 2000 TDHS survey was funded by the U. S. Agency for International Development (USAID) through the UNFPA Turkmenistan country office. Technical assistance for the program was provided by the MEASURE DHS+ project of ORC Macro in Calverton, Maryland, USA. I would like to express my thanks to the USAID Regional Office for Central Asia, the USAID Mission in Turkmenistan and the UNFPA Country Office in Turkmenistan for their support of the survey. I am grateful to the staff of the MEASURE DHS+ program for their technical backstopping. Also, my sincere thanks go to the 2000 TDHS senior technical staff and to the members of all interviewing teams and the data processing team for their devotion and efforts in accomplishing the survey activities on time. Gurbanguly M. Berdymukhamedov Minister of Health and Medical Industry Turkmenistan Summary of Findings * xv SUMMARY OF FINDINGS The Turkmenistan Demographic and Health Survey (TDHS) is a nationally represen- tative survey of 7,919 women of reproductive age (15-49). Survey fieldwork was conducted from June to September 2000. The TDHS was sponsored by the Minis- try of Health and Medical Industry (MOHMI) of the Republic of Turkmenistan. The Gurbansoltan Eje Clinical Research Center for Maternal and Child Health implemented the survey with technical assistance from the De- mographic and Health Surveys Program. The National Institute of State Statistics and Infor- mation (Turkmenmelihasabat) conducted sampling activities for the survey. The U.S. Agency for International Development (USAID) provided funding for the survey. UNFPA/Turkmenistan assisted with survey coordination and logistic support. The TDHS was designed to provide policymakers and program managers at MOHMI with detailed information on the health status of women and children. Some of the health indicators provided by the TDHS—such as fertility and infant mortality rates—are available from other sources. However, other survey indicators are not available from other sources—for example anemia status and nutritional indices for women and children. Thus, when taken to- gether, the TDHS and existing data provide a more complete picture of health conditions in Turkmenistan than was previously available. RESPONDENT CHARACTERISTICS______________________________________ Marital status and ethnicity. Sixty-two percent of women age 15-49 are currently married, 6 percent are widowed, divorced or separated and 32 percent have never been married. The great majority of respondents practice Islam (93 percent) and most are of Turkmen ethnicity (78 percent). Education and media exposure. Women in Turkmenistan are well educated. Seventy-two percent have attended primary/secondary school, another 20 percent have attended secondary-special and 7 percent have a higher education. Access to the mass media is good; 94 percent of respondents reported watching television weekly. Employment and earnings. Women participate extensively in economic activities. Approximately half of respondents (49 percent) were working and almost all working women (99 percent) reported cash earnings. Most respondents (77 percent) said that they had full or partial control over how their earnings were spent. FERTILITY______________________________________ Fertility rates. For the three years preceding the survey (mid-1997 to mid-2000), the estimated crude birth rate was 24.6 births per 1,000 population. This is higher than the MOHMI rate of 20.3 (the average of the annual rates for calendar years 1997 to 1999). Another index of current fertility is the total fertility rate (TFR). The TFR indicates the number of children a woman would have if she passed through the childbearing ages at the current age-specific fertility rates. The survey estimate of the TFR was 2.9 children per woman. This is significantly higher than the TFR for the neighboring country of Kazakhstan (2.1 children per woman) for approximately the same period. The TFR is lower by about one child in urban areas (2.5 children per woman) than in rural areas (3.3 children per woman). By region, fertility is lowest in Ashgabad City (2.1 children per woman) and highest in Dashoguz (3.1 children per woman). Trends over time. Official estimates of the crude birth rate (CBR) for the 1990s indi- cate substantial fertility decline. For example, between 1993 and 1997 the CBR declined by xvi * Summary of Findings 37 percent (from 33.1 per 1,000 to 21.6 per 1,000). The survey confirmed this rapid de- cline, indicating a decline in fertility of 25 per- cent over approximately the same period. Age at first birth. Childbearing in the teenage years is associated with increased social and health problems for both the mother and her child. The TDHS found that only 2.6 percent of women age 15-19 have given birth. Moreover, almost all births to teenage women occurred at age 19. Thus, the median age at initiation of childbearing in Turkmenistan is 23 years, which is older than in Kazakhstan, Uzbekistan, or the Kyrgyz Republic. Birth intervals. Children born soon after a previous birth, especially those born within 24 months of the previous birth, have an increased risk of illness and death. In Turkmenistan, 36 percent of second and higher order births occurred after a birth interval of less than 24 months. The percentage of births following a birth interval of less than 24 months was greater among women in rural areas (40 percent) than among women in urban areas (30 percent). CONTRACEPTION_________________________________________ Knowledge. Knowledge of contracep- tive methods is widespread in Turkmenistan. Among currently married women, knowledge of at least one method is universal (99 per- cent). Married women have knowledge of, on average, six methods of contraception. Married women of all ages, all educational levels, all ethnic groups, and all regions of the country have a high level of knowledge of contraceptive methods. Ever use. Among currently married women, 89 percent have used contraception at some time. As expected, older women are more likely to have used contraception than younger women. Current use. Among currently married women, 62 percent are currently using contra- ception. Fifty-three percent are using a modern method and 9 percent are using a traditional method. The IUD is by far the most commonly used method: two out of three current users have an IUD (39 percent of currently married women). Among the 9 percent of traditional users, withdrawal is the most popular method (5 percent of currently married women). As expected, contraceptive prevalence rates increase with the respondent’s age and the number of living children that she has. However, there is little difference in levels of current use by background characteristics. For example, current use is virtually the same for married women in both urban (62 percent) and rural areas (61 percent). Discontinuation of use. An important issue in the provision of contraceptive services to current users is the rate of discontinuation of use and the reasons for discontinuation. Among women who began to use a method in the five years preceding the survey, 58 percent stopped using that method within 12 months. The rate of discontinuation was highest among users of the lactation amenorrhea method, the condom, and withdrawal (85, 56, and 44 percent). The most frequently reported reasons for discon- tinuation were switching to another method, health concerns, and desire to become preg- nant. Source of supply. Most users of mod- ern contraceptive methods obtain their method through the public sector (96 percent). Fifty- four percent obtain their method from hospitals or public health clinics, 15 percent from women’s consulting centers, and 27 percent from public pharmacies. Fertility preferences. Among currently married women, 60 percent reported that they want no more children (53 percent) or that they are infecund or have been sterilized (7 percent). Another 32 percent want another child, and 8 percent are undecided about having another child. Future use. Of the 38 percent of cur- rently married women who are not using contraception, almost half (47 percent) re- ported that they intend to use in the future. Most women (89 percent) who intend to use in the future indicated that the IUD is their pre- ferred method. Summary of Findings * xvii INDUCED ABORTION_________________________________________ In Turkmenistan, as in most of the former Soviet Union, induced abortion has long been used as a means of fertility control. In a manner analogous to the analysis of fertility, the total abortion rate (TAR) provides a useful measure of the incidence of induced abortion. The TAR is the number of induced abortions a woman would have in her lifetime if she passed through her childbearing ages at the current age-specific abortion rates. Abortion rates. For the three-year period preceding the survey (mid-1977 to mid- 2000), the total abortion rate for Turkmenistan was 0.9. The total abortion rate was higher in urban areas (1.0 abortions per woman) than in rural areas (0.7 abortions per woman). The highest levels of induced abortion were in Ashgabad City and the Lebap Region (1.1 and 1.2 abortions per woman, respectively). Attitudes toward abortion. Sixty per- cent of respondents indicated that they disap- prove of induced abortion. However, about one-quarter of respondents reported that if confronted with an unintentional pregnancy, they would have an abortion, and another one- quarter said they were undecided about whether they would have an abortion if they unintentionally became pregnant. MATERNAL AND CHILD HEALTH_________________________________________ Turkmenistan has a well-developed health system with an extensive infrastructure of facilities. This system includes general hospi- tals, delivery hospitals, women’s consulting centers, and doctor’s assistant/midwife posts. There is an extensive network of the latter facilities in rural areas. Antenatal care. Almost all respondents who gave birth in the last five years (98 per- cent) received antenatal care from either a doctor (81 percent) or a nurse/midwife (17 percent). In general, in Turkmenistan women seek antenatal care early and continue to receive care throughout their pregnancy. The median number of antenatal care visits is ten. Place of delivery. Most births in Turkmenistan (95 percent) occur in public facilities, primarily hospitals (89 percent). Almost all deliveries (97 percent) are under the supervision of a doctor (82 percent) or a nurse/ midwife (15 percent). Vaccination rates. Among children 12- 23 months of age (i.e., children who should be fully vaccinated), the survey found high levels of coverage for the vaccines recommended by the World Health Organization (WHO). Cover- age exceeds 97 percent for BCG (protection against tuberculosis), DPT/DT (protection against diphtheria, pertussis, and tetanus), polio, and measles. Overall, 90 percent of children have received all of these WHO-recom- mended vaccinations. Breastfeeding. Breastfeeding is nearly universal in Turkmenistan: 97 percent of children born in the three years preceding the survey were breastfed. Overall, 18 percent of children are breastfed within an hour of deliv- ery, and 76 percent are breastfed within 24 hours of delivery. The median duration of breastfeeding is 18 months. However, the median duration of exclusive breastfeeding, which WHO recommends for six months, is only 0.5 months. Among breastfed children, there is little complementary feeding in the period immedi- ately after birth. At 2-3 months of age, only 7 percent of children receive solid foods. This figure increases to 43 percent for children 4-5 months of age and exceeds 90 percent for children 8-9 months of age. Nutritional status of children. Two important nutritional indicators for children are the proportion stunted (short for their age) and the proportion wasted (underweight relative to their height). In a well-nourished population, it is expected that about 2.3 percent of children will be moderately or severely stunted or wasted. Among children under age five in Turkmenistan, 22 percent are stunted and 6 percent are wasted. There are regional differ- xviii * Summary of Findings ences, particularly for stunting. The percentage of children stunted in Dashoguz (27 percent) is twice as high as in Ashgabad City (13 percent). INFANT MORTALITY RATES_________________________________________ Official government estimates of infant mortality are based on data collected according to protocols established during the time of the former Soviet Union. Those protocols classify a pregnancy that ends at less than 28 weeks of gestation as a miscarriage unless the infant survives for at least seven days. In the TDHS, infant mortality data were collected based on the international definition of a live birth, i.e., a birth that shows any sign of life, irrespective of the gestational age at the time of delivery (United Nations, 1999). Be- cause of the difference between the govern- ment data collection system and that of the TDHS in the definition of a live birth, the TDHS estimate of the infant mortality rate (IMR) would be expected to exceed the official gov- ernment estimates. IMR estimates. The government esti- mate of the IMR for the five-year period 1996- 2000 is 32 per 1,000. The survey IMR estimate for that period is 74 per 1,000. The IMR esti- mate for Kazakhstan, for approximately the same period, is 62 per 1,000. IMR differentials. It is known that closely spaced births (i.e., births within 24 months of a previous birth) put infants at relatively high risk of dying. In Turkmenistan, 36 percent of second and higher order births occur within 24 months of a previous birth. Infant mortality for those births (94 per 1,000) is almost twice as high as for births occurring after an interval of 48 or more months (49 per 1,000). This suggests that a program promoting birth spacing could reduce infant mortality. The survey also found significant differ- ences in the IMR between urban areas (60 per 1,000) and rural areas (80 per 1,000). ANEMIA STATUS_________________________________________ The TDHS was the first study of anemia in Turkmenistan based on a nationally repre- sentative sample of women and children. The survey measured the hemoglobin level of capillary blood. Anemia among women. Nine percent of respondents in the TDHS had hemoglobin levels indicating moderate (8 percent) or severe anemia (1 percent). These figures are identical to recent findings for Kazakhstan. There were notable differences in the level of moderate to severe anemia by region. The level was twice as high in the Balkan and Dashoguz regions (12 percent) as in Ashgabad City (6 percent). Anemia among children. Seventeen percent of children under the age of five exhib- ited moderate (16 percent) or severe anemia (1 percent). Again, these figures are almost identical to recent findings for Kazakhstan (17 percent moderate and 1 percent severe anemia). ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)__________________________________________ Compared with other parts of the world, Turkmenistan has been relatively untouched by the AIDS epidemic. Currently, there is only one known case of AIDS and one other person known to be HIV positive in Turkmenistan. Almost no respondents reported that they knew an HIV-infected person or anyone who had died of AIDS. Knowledge. Awareness and knowledge of HIV/AIDS is limited. Seventy-three percent of respondents reported having heard of HIV/ AIDS, but only 50 percent believe that they could adopt behavior patterns that would reduce their risk of contracting the disease. Further evidence of limited knowledge of HIV/AIDS was the fact that only 31 percent of respondents recognized that condom use is a risk-reducing behavior. Summary of Findings * xix Attitudes toward infected individuals. The survey found unsympathetic attitudes toward HIV-infected individuals. Only a small proportion of respondents (24 percent) re- ported that an infected person should be al- lowed to keep that information private, and a large proportion (73 percent) reported that they believe an infected person should not be allowed to work alongside other people in a shop or office. These findings suggest that respondents have the mistaken idea that they can become HIV-infected through ordinary human contact. Use of the media for AIDS education. The survey indicates that much needs to be done to educate the population about HIV/AIDS. It is significant that more than 95 percent of respondents felt it would be acceptable to provide HIV/AIDS educational messages via radio, television, and the print media. Introduction, Objections, and Survey Design * 1 INTRODUCTION, OBJECTIVES, AND SURVEY DESIGN 1 B.S. Sopyev and C.M. Nazarov 1.1 GEOGRAPHY AND POPULATION Turkmenistan is situated in the center of central Asia to the north of the Kopetdag mountain range, bounded by the Caspian Sea to the west and the Amu Daria River to the east. The territory of Turkmenistan is 491,200 square kilometers; it stretches 1,100 kilometers from west to east and 650 kilometers from north to south. The country borders Kazakhstan to the north, Uzbekistan to the east and northeast, Iran to the south, and Afghanistan to the southeast. The Karakum Desert occupies a large part of the territory of Turkmenistan. The Kopetdag Mountains and Small and Big Balkan ranges stretch from Turkmenbashy City to the Serax Region. The official state language is Turkmen, which belongs to the Turkic language group. The main religion is Sunni Islam. According to the data of the National Institute of State Statistics and Information (Turkmenmelihasabat), as of January 1, 2001, the population of Turkmenistan was 5.2 million people. Forty-five percent of the population is urban. Currently, Turkmenistan is experiencing intensive socioeconomic changes with significant impact on population and health. The demographic changes in Turkmenistan are characterized by population growth in urban and rural areas primarily due to high natural increase. High population growth has resulted in a unique population age structure. The percentage of children and teenagers in the population is high (40.3 percent). The proportion of the population that is working is also large (53.6 percent). Women now represent 50 percent of the population. The main factors currently determining the demographic situation in Turkmenistan are the following: a high proportion of married women, a low level of divorce, and a high birth rate. Nevertheless, in recent years, it has become evident that the birth rate has decreased. Another demographic feature of Turkmenistan is that the majority of women give birth at a young age, which is more favorable for childbearing and birth. One of the most important components of population growth in addition to the birth rate is the mortality rate. According to government statistics, the mortality rate has declined. In urban and rural areas, male mortality prevails over female mortality. As a result, average life expectancy for men is 63.4 years, compared with 70.4 years for women. The level of population replacement is comparatively high in Turkmenistan: there are 3.5 births for each death. The birth rate in rural areas is 1.8 times higher than in urban areas. Life expectancy at birth is 66.8 years in Turkmenistan. Life expectancy is constantly increasing through decline in newborn and maternal mortality. The number of fertile women increased during the last 5 years to approximately 1,570,000. Migration and natural translocations influence population growth. In the process of international migration, the contribution of different republics of the former Soviet Union is not 2 * Introduction, Objections, and Survey Design equal: Russian Federation, 60.3 percent; Uzbekistan, 14.5 percent; Ukraine, 3.4 percent; Kazakhstan, 13.1 percent; Azerbaijan, 2 percent. Of the total migration, 66 percent is rural population migration. 1.2 HISTORY Turkmenistan has a unique history and in both a geographical and political sense, plays an important role in the development of central Asia. Turkmen from ancient times have inhabited the territory of modern Turkmenistan. They have broad multilateral relationships with Asian countries, especially neighboring states such as Iran and Afghanistan. The Russian-Turkmen trade relationship has existed since the 10th century. Until gaining its independence, Turkmenistan did not have full sovereignty in conducting internal and foreign policy as a part of Russia and as a part of the Soviet Union. Turkmenistan was founded as a result of the people’s will, as expressed in an independence referendum on October 27, 1991, that was adopted by the Parliament. The first elections for the President of Turkmenistan were held October 27,1990, after the new Turkmenistan Constitution had been adopted. On June 21, 1992, recurring elections for the President of Turkmenistan were held. Saparmurad Ataevich Niazov was unanimously elected as President of Turkmenistan. On December 12, 1995, Turkmenistan was granted the status of neutrality by the United Nations (UN) General Assembly. Turkmenistan is the only country that has been granted constant- neutrality status in the history of the UN. State neutrality status demonstrates the will of Turkmenistan to follow a hands-off policy and peaceful coexistence with neighboring countries and all nations of the world. Neutrality also has a positive influence on internal human rights protection and creates an environment for providing for the welfare of the population. 1.3 ECONOMY During its years of independence, Turkmenistan has developed its own state and economic model, which is based on historical, national, ethnic, and social traditions of the Turkmen nation. The model of governmental development for Turkmenistan has proved highly effective. The social security of the population and equal opportunities for the commonwealth are based on economic achievements and internal production growth. Turkmenistan has large mineral resources, such as oil, gas, sulfate, salt, and limestone. The country possesses 64 percent of all oil reserves in central Asia and is the fourth largest natural gas producer in the world. Besides mineral products, other components of the Turkmenistan economy are the growth and export of cotton, the production of chemicals, the construction of machinery, the production of construction materials, the textile industry, and carpet weaving. Imports include mainly industrial and technical goods. Besides Commonwealth of Independent States (CIS) countries, the main trade partners of Turkmenistan are Turkey, Iran, Japan, Germany, Italy, and Israel. In agriculture, the government considers it most important to have efficient composition of economic relations, liberalization, and governmental protection. In agrobusiness, priority is given Introduction, Objections, and Survey Design * 3 to food production and the integration of different levels of producers into the manufacturing of final products. Turkmenistan pays close attention to the expansion and modification of road and railway networks and the development of new air and sea routes. Such attention helps not only for the development of internal transportation networks but also for including them in the international communications system. Civil aviation and the sea fleet are constantly increasing their pool of aircraft and vessels. Overall, structural shifts in the economy have supported the development of the market structure of the country, ensuring that the country will move forward, maintain food security and advance the well-being of the population. For example, Turkmenistan, is the only country in the world where gas, water, electricity, and salt are free of charge for its citizens. Public transportation costs are subsidized, and flour is available at a privileged price for children, students, invalids, and retired people. The literacy level in Turkmenistan is 99 percent. The education system includes preschools, secondary schools, vocational schools, and high schools. Prior to independence, Turkmenistan was developing as a regional subsystem of one national economic complex of a large country. The structure of its economy was determined by interunion labor subdivision. The supply of national consumer goods and food for the population was provided through a centralized system. The government now implements an active policy aimed at ensuring economic stability. The main document for the policy is the program “Ten Years of Stability.” In 2000, the national program “The Strategy for Social Economic Reform till 2010” was adopted. High levels of gas, oil, and cotton production are foreseen in it. Food independence is also an area of focus in the program. The technological context is aimed at a high production of fuel, energy, mineral, and agricultural resources. All of this will ensure high rates of economic growth, which will promote human development. 1.4 HEALTH CARE SYSTEM AND EPIDEMIOLOGICAL SITUATION The highest value for every country is a healthy nation, and the main objective of state policy is the creation of conditions for the thorough development of each citizen. For improvement of health services delivery, the President of Turkmenistan approved the program “Health in 1995.” The objective of the national program was the improvement of health through reforming the health care system. The priority directions for the health care system were identified: mother and child health protection; tuberculosis (TB) control; sexually transmitted infections (STIs), AIDS, viral hepatitis, and cardiovascular disease prevention. For solving those problems, it was indicated as necessary to retrain medical staff, to modify treatment protocols, to improve the population information system, and to guarantee the drug supply and the medical equipment supply for primary health units. The reforms in health care are in the spheres of health management, financing, primary health care, hospital services, drug supply and use of people’s resources, infrastructure, medical science, and legislation. The governmental allocations to the health care system are aimed first of all at preventive medicine. 4 * Introduction, Objections, and Survey Design Beginning in 1996, family practice was implemented all over the country, and the state system of voluntary health insurance began to work. Currently, 92 percent of the population participates in the insurance system. Insurance payments go directly to the State Fund of Health Development and compose about 90 percent of it. The purchase of essential drugs, vaccines, and immune-prevention drugs are provided for by the fund. Essential drugs are sold for insurance receipts. The contract system of hiring staff is operating in all health institutions. Beginning in February 1996, the Ministry of Health and Medical Industry (MOHMI) of Turkmenistan started to implement state licensing of medical and pharmaceutical activities. With the aim to concentrate financial, human, and technical resources, all inefficient, small etrap (regional), velayat (district), and central health institutions were disbanded and replaced by large multifunctional medical facilities that were renamed hospitals. A total of 1,470 health- preventive institutions were disbanded and replaced by rural or urban houses of health, central hospitals, and maternal and child health (MCH) centers at the regional, town, and district levels. The network of district multiprofile hospitals has successfully developed, merging with diagnostic centers and consultative departments. Such merging helps to avoid profile duplications and to reorient the main part of the resources from inpatient care to primary health and preventive medicine. The number of hospitalizations significantly decreased by means of controlling the number of directions for hospitalization. That was achieved by improving the level of primary and medicosanitary services. The level of bed use increased through the decrease of average length of stay in the hospital (from 14.8 days in 1995 to 11.8 days in 1999). The use of international standards for calculation of bed rotation helped to decrease the average length of staying in bed for the patient to 9.1 days (during a 10-month period in 2000). Medical staff resources in health care are undergoing reform through revision of the quantity and quality of medical education. Beginning in 1995 in the area of health reform, 20,000 jobs (about 18.4 percent) were eliminated. This was done mainly by the elimination of vacant positions for doctors (2,000) and middle medical personal (12,500). Currently, the third step of the reform is underway, causing the elimination 10,000 more jobs. Reducing the number of staff in health institutions will improve the professional level and will help to distribute the staff rationally. For successful implementation of the above-named objectives, MOHMI and the World Health Organization (WHO) have designed and are implementing the pilot project, including a model for a village primary-health treatment-prevention unit, founded on the basis of former FAPs (feldsher- obstetrician points) and SVAs (village ambulances) using the staff of former units. Pilot project activities are oriented toward effective integrated medical service delivery, which will ensure delivery of a number of services: health improvement, reproductive health for families, prevention, diagnostics, and treatment. The pilot site experience will be applied to other primary health units around the country. For decreasing infant mortality rates, MOHMI has focused on the prevention of acute respiratory infection (ARI), acute intestinal infection (AII), and poliomyelitis. The United Nations Population Fund (UNFPA) and United Nations Children’s Fund (UNICEF) support the implementation of these projects. In 1999, MOHMI adopted recommendations on “Adaptation and Implementation of WHO/UNICEF Materials on Integrated Management of Child Infections in Turkmenistan.” An orientation meeting has been held to provide health workers information on WHO/UNICEF clinical approaches to integrated management of child infections. The pilot regions have been Introduction, Objections, and Survey Design * 5 chosen—Turkmenabat City and Gizilarbat Region. Data on child mortality and morbidity has been provided to WHO experts for program planning purposes. 1.5 REPRODUCTIVE HEALTH POLICY AND PROGRAMS The government is paying close attention to the issues of maternal and child health. After adopting the Cairo Program of Actions, MOHMI, together with UNFPA, approved the Strategic Plan on reproductive health through 2005. According to this plan, Turkmenistan will provide the reproductive health services to give women the opportunity to successfully complete pregnancy and labor and to give couples a good chance to have a healthy child. The government gives families and individuals the right to decide the number of their children, as well as optional birth spacing, and supplies families with information on these issues. The most important medical-social problems for women are reproductive health and decrease of mortality and morbidity. In 1998, after rationalization of primary health institutions, polyclinics were reorganized into houses of health, and women’s consultations were moved to the houses of health according to district principals. Each institution provides an exact list of reproductive health services at the level of primary contact with a patient. In Turkmenistan reproductive health services do not pursue the objective of decreasing the birth rate in the country or limiting the number of children. According to national interests, it is oriented toward avoiding pregnancy for women from high-risk groups, toward preventing maternal mortality, and toward ensuring optimal birth spacing. Of all methods of contraception, the IUD is the most commonly used (20 percent of women of fertile age) due to its security and convenience of use. Less popular are hormonal pills (1.3 percent) and injectables (0.6 percent). Surgical methods of sterilization are familiar but are not in demand. Overall, government statistics indicate that approximately 22 percent of women in the fertile age use modern contraceptives. In connection with the implementation of the Reproductive Health Program, the tendency of the abortion rate to decrease becomes obvious. Recently, miniabortions have begun to prevail in the total abortion rate. Currently, with the decrease of the total abortion rate, the number of miniabortions has also decreased. Because of the availability of medical abortions up to 12 weeks of pregnancy, criminal abortions are not frequent. Their part in the total abortion rate was only 0.4 percent to 0.06 percent for 1998-1999. The number of abortions for women under 15 was even less (0.1 percent in 1998 and 0.01 percent in 1999). 1.6 DEMOGRAPHIC AND HEALTH DATA COLLECTION SYSTEM IN TURKMENISTAN The demographic and health data collection system in Turkmenistan is based on the registration of events and a periodical census. Demographic data collection and analysis is the prerogative of the Turkmenmelihasabat (National Institute of State Statistics and Information). The data on birth, death, marriage, and divorce are registered at the local administrative level. These data are forwarded to the Turkmenmelihasabat through regional and district statistical offices. The Turkmenmelihasabat is responsible for conducting censuses and demographic analysis during the periods between censuses. The last census in Turkmenistan was conducted in 1995, and its results were published in 1996. The Turkmenmelihasabat is also responsible for the tabulation of health data for the country and the publication of demographic data and social and economic information. 6 * Introduction, Objections, and Survey Design 1.7 OBJECTIVES AND ORGANIZATION OF THE SURVEY The Turkmenistan Demographic and Health Survey (TDHS 2000) is the first national survey of maternal and child health in Turkmenistan. The survey was implemented by the Gurbansoltan Eje Clinical Research Center for Maternal and Child Health (MCH Institute) and was financed through the U.S. Agency for International Development (USAID). Technical support was provided by the MEASURE DHS+ project of ORC Macro and logistical support by UNFPA/Turkemenistan. The purpose of the survey was to develop a single integrated set of data for the government of Turkmenistan to use in planning effective policies and programs in the areas of health and nutrition. TDHS 2000 collected data on women’s reproductive history, knowledge and use of contraceptive methods, breastfeeding practices and nutrition, vaccination coverage, and episodes of diseases among children under the age of five. Information on the knowledge of and attitudes toward HIV/AIDS, other sexually transmitted infections, and tuberculosis were also collected. The survey also included the measurement of the hemoglobin level in the blood to assess the prevalence of anemia and measurements of height and weight to assess nutrition status. The TDHS 2000 also contributes to the growing international database on demographic and health-related variables. Sampling Design and Implementation Sampling and listing of households were designed and implemented by the Turkmenmelihasabat (National Institute of State Statistics and Information) with support from the MEASURE DHS+ project of Macro International Inc. The TDHS 2000 was designed to collect demographic and health data from a nationally representative sample of women in the reproductive ages (i.e., women 15-49). The design specification was based on the objectives of estimating sociodemographic and health indicators, including fertility and mortality rates, at the national level, for urban and rural areas and for the six regions of the country (Ashgabad City and Akhal, Balkan, Dashoguz, Lebap and Mary). The sample design was specified in terms of households. The design called for a two-stage stratified probability sample that was self-weighting within each of the six regions. In the first stage, standard segments were selected with probability proportional to size. Overall, 231 PSUs were selected: 118 in urban areas and 113 in rural areas. A complete household listing was conducted in the PSUs. In the second stage, households were selected with probability proportional to the inverse of the first stage probability of PSU selection. Among the 6,391 currently occupied households in the selected sample, the Household Schedule was completed in 6,302, for a response rate of 98.6 percent. Of the eligible 8,250 women age 15-49 in those households, 7,919 were interviewed for a response rate of 96.0 percent. The overall survey response rate was 94.7 percent. Additional details of sampling procedures are given in Appendix A and estimates of the sampling errors for selected statistics are given in Appendix B. Introduction, Objections, and Survey Design * 7 Questionnaires Two questionnaires were used for TDHS 2000: the Household Questionnaire and Women’s Questionnaire. These questionnaires were based on the model survey instruments developed for the MEASURE DHS+ project and were adapted to the data needs of Turkmenistan during consultations with specialists in the area of reproductive health and child health and nutrition. The questionnaires were developed at first in English and then translated into Russian and Turkmen. A pretest was conducted in April 2000. Based on the pretest, the questionnaires were revised and finalized. The Household Questionnaire was used to enumerate all usual members and visitors in a sample household and to collect information related to the socioeconomic status of the household. In the first part of the Household Questionnaire, information was collected on age, sex, education attainment, and relationship to the head of household for each person listed as a household member or visitor. A primary objective of the first part of the Household Questionnaire was to identify women who would be eligible for the individual interview. In the second part of the Household Questionnaire, information was collected on the characteristics of the dwelling unit, such as the source of water and the type of toilet facilities, and on the availability of a variety of consumer goods. The Women’s Questionnaire was used to collect information from eligible respondents (i.e., women age 15-49 who were usual household members or who were present in the household the night before interviewer’s visit) on the following major topics: · Background characteristics · Pregnancy history · Outcome of pregnancies, antenatal and postnatal care · Child health and nutrition practices · Child immunization and episodes of diarrhea and respiratory illness · Knowledge and use of contraception · Marriage and fertility preferences · Husband’s background and women’s work · Knowledge of HIV/AIDS and other sexually transmitted infections · Maternal and child anthropometry · Hemoglobin measurement of women and children. Training and Fieldwork The TDHS 2000 questionnaires were pretested in April 2000. Eight interviewers were trained during a one-week period at the MCH Institute of Turkmenistan. The pretest included one week of interviewing in an urban area (Ashgabad City). A total of 100 women were interviewed. Pretest interviewers were retained to serve as supervisors and field editors for the main survey. Fifty-five people, mostly physicians, were recruited as field supervisors, editors, health investigators, and interviewers for the main survey fieldwork. They were trained at the MCH Institute for three and a half weeks in June 2000. Training consisted of lectures and practice in the classroom, as well as role playing. The training of health investigators, who were responsible for anthropometric measurements (height and weight) and hemoglobin testing of women and children, was accomplished in two days in the classroom and three days in the field. 8 * Introduction, Objections, and Survey Design Table 1.1 Results of the household and individual interviews Number of households, number of interviews and response rates, Turkmenistan 2000 _________________________________________________________ Residence _________________ Result Urban Rural Total ________________________________________________________ Household interviews Households sampled Households found Households interviewed Household response rate Individual interviews Number of eligible women Number of eligible women interviewed Eligible woman response rate 3,688 3,162 6,850 3,347 3,044 6,391 3,277 3,026 6,303 97.9 99.4 98.6 3,836 4,414 8,250 3,693 4,226 7,919 96.3 95.7 96.0 At the end of the training, the field staff was divided into six survey teams. Each team consisted of eight people, including one supervisor, one editor, five interviewers, and one health investigator. Besides this, six field coordinators were recruited from the staff of the MCH Institute and were responsible for communication and coordination of activities between the center and field teams. The personnel for the survey teams were partly recruited from the staff of the MCH Institute and partly from different regions of the country. All six teams started data collection on June 28, 2000, in Ashgabad. Beginning in mid-July, all six teams started data collection in the field. Data collection was completed on September 15, 2000. Data Processing Questionnaires were returned to the MCH Institute for final editing and data processing. The office editing staff checked that questionnaires for all selected households and eligible respondents were returned from the field. Additionally, final editing included coding for a set of categories such as occupation and type of iron pills. Data were then entered and edited on computers using the Integrated System for Survey Analysis (ISSA) package, with data software translated into Russian. Office editing and data entry activities began on August 15 and were completed on October 14, 2000. Survey Response Rates Table 1.1 summarizes the results of the fieldwork for the TDHS 2000. Overall, the household response rate was 98.6 percent and the individual women response rate was 96.0 percent. As is usually the case in household surveys, response rates were somewhat higher in rural than in urban areas. Household Population and Housing Characteristics * 9 2HOUSEHOLD POPULATION ANDHOUSING CHARACTERISTICS B.S. Sopyev and K. Fair This chapter provides a descriptive summary of the demographic and socioeconomic characteristics of the household population and the individual respondents in the 2000 Turkmenistan Demographic and Health Survey (TDHS). This information is useful for interpreting the survey findings and serves as an approximate indicator of the representativeness of the survey and of the quality of the data. This chapter is divided into three parts. The first part deals with the characteristics of the household population in terms of age-sex composition, household size and distribution, and educational background. The second part describes the housing environment in which the respondents and their children live. The background characteristics of women age 15 to 49 years are discussed in the last part of the chapter. 2.1 DEMOGRAPHIC CHARACTERISTICS OF HOUSEHOLDS The Household Questionnaire was used in the TDHS 2000 to collect data on the demographic and social characteristics of all the usual residents of the sampled household and visitors who had spent the previous night in the household. A household, as defined in the survey, refers to a person or group of people usually living and eating together and jointly running the household’s economy (de jure population). A visitor is someone who is not a usual resident of the household but slept in the household the night before the interview. The distribution of the TDHS 2000 household population is presented in Table 2.1 and Figure 2.1, by five-year age groups according to urban-rural residence and sex. The total de facto population in the selected households was 30,830 people. In general, the survey results show that females outnumber males in Turkmenistan (52 and 48 percent, respectively). The male/female ratio varies by age. It is as high as 108 males per 100 females among those below age 15 and as low as 75 males per 100 females among those, age 65 and older. The ratio is almost similar in urban and rural areas (94 and 95 males per 100 women, respectively) More than one-third (36 percent) of the population consists of children 14 years of age and under, with the proportion of children in rural areas greater than in urban areas (38 and 34 percent, respectively). Starting with age group 10-14, there is a gradual decrease in the proportion of the population in each successive age group. The relatively small size of the male and female populations in age group 55-59 is a reflection of the low birth rates during World War II (i.e., 55 to 60 years prior to the TDHS 2000). Women 15-49 years of age, who are the main TDHS respondents, constitute about one-half of the de facto household population: 51 percent. The results further indicate that 59 percent of the population of Turkmenistan is in the 15-64 age group, and the population age 65 years and older accounts for 5 percent of the total population. A distinct feature of the age distribution of the population is that the proportion of the dependent population—those younger than 15 or older than 65—is higher in rural areas (43 percent) than in urban areas (39 percent). This difference may be attributed to rural-urban migration of the economically active population—those age 15 to 65—especially youth, in search of jobs. 10 * Household Population and Housing Characteristics Table 2.1 Household population by age, residence, and sex Percent distribution of the de facto household population by five-year age group, according to sex and urban- rural residence, Turkmenistan 2000 ______________________________________________________________________________________________ Urban Rural Total ______________________ _____________________ _______________________ Age Male Female Total Male Female Total Male Female Total ______________________________________________________________________________________________ 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+ Missing/don’t know Total Number 9.8 9.5 9.6 13.1 11.6 12.3 11.7 10.6 11.1 12.5 11.4 11.9 13.2 12.3 12.7 12.9 11.9 12.4 13.0 11.3 12.2 13.3 13.2 13.2 13.2 12.4 12.8 9.8 9.3 9.5 10.6 11.2 10.9 10.2 10.4 10.3 8.6 8.8 8.7 9.1 10.8 10.0 8.9 9.9 9.4 8.4 7.9 8.2 9.1 7.9 8.5 8.8 7.9 8.3 7.7 7.5 7.6 6.8 6.1 6.4 7.1 6.7 6.9 6.8 6.7 6.7 5.2 5.8 5.5 5.9 6.2 6.0 5.7 5.9 5.8 4.9 5.0 5.0 5.3 5.4 5.3 4.9 5.2 5.0 3.8 3.6 3.7 4.3 4.3 4.3 4.0 4.5 4.2 2.6 3.3 3.0 3.2 3.8 3.5 2.0 2.2 2.1 1.8 1.9 1.8 1.9 2.0 1.9 2.8 3.4 3.1 2.4 2.5 2.5 2.6 2.9 2.8 1.7 2.1 1.9 1.8 1.8 1.8 1.8 2.0 1.9 1.5 2.1 1.8 1.3 1.6 1.5 1.4 1.8 1.6 0.7 1.3 1.0 0.5 0.7 0.6 0.6 1.0 0.8 0.3 1.0 0.7 0.4 0.7 0.6 0.4 0.8 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 6,497 6,947 13,443 8,449 8,938 17,387 14,946 15,885 30,830 Male Female Household Population and Housing Characteristics * 11 The percent distribution of the population by broad age groups according to the 1995 Turkmenistan Census and the TDHS 2000 is presented in Table 2.2. There appears to be a progressive decline since the 1995 Census in the proportion of the population under 15, as well as a concomitant increase in the median age. The growth of the 15-64 age group results in a declining dependency ratio, calculated as the ratio of people in the dependent age groups to people in the economically active age group. This slight aging of the population is the result of a continuous decline in fertility levels since 1990. Correspondence of the percent distribution of the population in broad age groups between the TDHS 2000 and the 1995 Turkmenistan Census confirms the overall quality of the TDHS sample. 2.2 HOUSEHOLD COMPOSITION Information on the size and composition of sample households by urban-rural residence is presented on Table 2.3. The head of household (as recognized by other members) and the relationship of each household member to the head was determined in each household. In general, heads of households are male (74 percent). In urban areas the proportion of households headed by men (65 percent) is less than the proportion in rural areas (81 percent). About 42 percent of households consist of between one and four members, with the average size of a household in Turkmenistan being 5.1 members. There are significant differences in the household size between urban and rural areas, with the average urban household consisting of 4.4 members compared to 5.7 in rural households. Only 3 percent of households include a child under 15 neither of whose parents were household members. Table 2.4 presents information on children under age 15 by survival status of the parents according to selected socio- biological factors. Eighty-eight percent of children under age 15 live with both parents. As children get older, fewer of them live with both par- ents; 94 percent of children in the age group 0-live with both parents, compared to 84 per- cent in the age group 10-14 years. Rural children are more likely than urban children to live with both parents. Eight percent of Table 2.2 Population by age, according to select sources Percent distribution of the population by age group, according to selected sources, Turkmenistan 2000 ___________________________________ 1995 2000 Age group Census TDHS ___________________________________ <15 40.5 36.3 15-64 56.0 58.8 65+ 3.4 4.9 Missing/DK 0.1 0.0 Total 100.0 100.0 Median age 19.6 21.8 Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, and presence of foster children in household, according to urban-rural residence, Turkmenistan 2000 _________________________________________________ Residence Characteristic Urban Rural Total_________________________________________________ Sex of household head Male 65.6 81.4 73.5 Female 34.4 18.6 26.5 Total 100.0 100.0 100.0 Number of usual members 1 9.5 3.9 6.7 2 12.3 4.4 8.4 3 13.8 7.6 10.7 4 19.2 13.8 16.5 5 17.5 18.8 18.1 6 11.5 18.1 14.8 7 7.6 13.6 10.6 8 3.5 7.7 5.6 9+ 4.8 12.1 8.4 Total 100.0 100.0 100.0 Mean size 4.4 5.7 5.1 Percentage with foster children 3.6 3.2 3.4 _________________________________________________ Note: Table is based on de jure household members, i.e., usual residents 12 * Household Population and Housing Characteristics Table 2.4 Fosterhood and orphanhood Percent distribution of de jure children under age 15 by survival status of parents and child’s living arrangements, according to background characteristics, Turkmenistan 2000 ______________________________________________________________________________________________________ Living Living with mother with father Not living with but not father but not mother either parent Living ____________ ____________ _______________________ Missing with Father Mother info. on Number Background both Father Father Mother Mother Both only only Both father/ of characteristic parents alive dead alive dead alive alive alive dead mother Total children _____________________________________________________________________________________________________ Age 0-2 3-5 6-9 10-14 Sex Male Female Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Total 93.9 4.5 0.7 0.1 0.0 0.4 0.0 0.0 0.0 0.4 100.0 2,058 91.0 4.5 1.6 0.3 0.5 1.1 0.2 0.1 0.0 0.8 100.0 2,175 87.1 5.1 3.4 0.6 0.9 0.9 0.1 0.2 0.2 1.5 100.0 3,164 83.6 4.9 5.5 0.7 1.6 0.8 0.1 0.2 0.2 2.4 100.0 3,999 88.2 4.4 3.3 0.5 0.8 0.8 0.0 0.1 0.1 1.7 100.0 5,736 87.5 5.2 3.3 0.4 1.1 0.8 0.2 0.2 0.1 1.2 100.0 5,660 81.7 9.1 4.4 0.7 0.8 1.2 0.0 0.2 0.1 1.7 100.0 4,656 92.1 1.8 2.5 0.3 1.0 0.6 0.1 0.1 0.2 1.3 100.0 6,740 77.5 13.0 4.6 0.5 0.3 1.4 0.0 0.3 0.1 2.2 100.0 1,104 90.7 2.5 3.4 0.4 0.8 0.6 0.3 0.1 0.1 1.2 100.0 1,732 86.8 4.9 4.6 0.4 0.8 1.4 0.0 0.0 0.1 0.9 100.0 975 91.2 3.1 2.0 0.5 0.8 0.8 0.1 0.1 0.1 1.3 100.0 2,334 86.8 4.5 3.7 0.7 0.9 0.8 0.2 0.1 0.2 2.3 100.0 2,736 89.0 4.7 2.8 0.2 1.5 0.5 0.0 0.2 0.2 0.9 100.0 2,514 87.9 4.8 3.3 0.5 0.9 0.8 0.1 0.1 0.1 1.5 100.0 11,396 ______________________________________________________________________________________________________ Note: Orphans are children with both parents dead children under 15 are living with only their mother; of these, 3 percent have lost their fathers and 5 percent have fathers who are still alive. Regarding orphanhood, about 3 percent of children under age 15 have fathers who have died, and less than 1 percent have mothers who have died, while an insignificant proportion (0.1 percent) have lost both parents. 2.3 EDUCATIONAL LEVEL OF HOUSEHOLD MEMBERS The high correlation between level of education and positive health and other social indicators makes education an important variable in any study of households. Higher education, especially for women, is usually associated with greater knowledge and use of sound health practices and family planning methods. 1 Youth who are overage for a given level of schooling may have started school overage, or may have repeated one or more grades in school, or may have dropped out of school and later returned. Household Population and Housing Characteristics * 13 Turkmenistan’s primary and secondary educational system has three levels: primary (classes 1 through 4, age 7 to 10 years), principal (classes 5 through 9, age 11 to 15 years), secondary (classes 10 and 11, age 16 to 17 years). Most schools in Turkmenistan offer all three levels of primary/secondary education. The primary and principal education levels are compulsory. Students who leave school after the principal level may continue in secondary-special (vocational) education. Students who finish all three levels of primary/secondary school can continue on in higher education at universities or in academic training classes. 2.3.1 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Table 2.5 presents information on the highest level of education attained by the population according to sex, age, residence, and region. The data shows the high educational level of Turkmenistan’s population with about 97 percent of men and 95 percent of women having had at least some education. Educational attainment is slightly higher among men than women, although the differences are minor. Most of household members age 6 and older have attended school, and 10 percent of men and nearly 6 percent of women have some higher education. There are noticeable attainment differences by residence, with urban residents being more likely than rural residents to have attended secondary special or higher education. Educational attainment is also significantly higher in Ashgabad City than elsewhere. Patterns in educational attainment among female respondents (women age 15-49) are similar to those among the entire female household population. Nearly all women have attended school, with younger women being more likely than older women to have attended school and attained higher levels of schooling. The greatest differences in attainment are between urban and rural areas, and between Ashgabad City and other regions. 2.3.2 SCHO OL ATTENDANCE RATIOS Table 2.6 presents net and gross attendance ratios by school level, sex, and residence. The net attendance ratio (NAR) indicates participation in schooling among those of official school age, which is age 7-10 for primary and 11-17 for secondary. The gross attendance ratio (GAR) indicates participation in schooling among youth of any age, from age 7-24, and is expressed as a percentage of the school-age population for that level of schooling. The GAR is always higher than the NAR for the same level, because the GAR includes participation by youth who may be older, or younger, than the official age range for that level.1 A NAR of 100 percent would indicate that all of the children in the official age range for the level are attending that level. The GAR can exceed 100 percent, if there is significant overage or underage participation at that level of schooling. The difference between these ratios indicates the incidence of overage and underage participation. School participation among those household members of school age is generally high, though participation is lower at the secondary level. The primary NAR is slightly higher among male than female children (86 versus 84 percent) and at the secondary level, is virtually the same among male and female youth (both about 79 percent). The NAR at both the primary and secondary levels is comparable in urban and rural areas. 14 * Household Population and Housing Characteristics Table 2.5 Educational attainment of household population Percent distribution of the de facto male and female household population age six and over by highest level of education attended, according to background characteristics, Turkmenistan 2000 _______________________________________________________________________________________________________________ Level of education _________ _____________________________________________________ Median Background No Primary/ Secondary- Don’t’ know/ number of characteristic education secondary special Higher missing Total Number years _____________________________________________________________________________________________________________ MALES ______________________________________________________________________________________________________________ Age 6-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Missing/DK Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Total 21.9 78.1 0.0 0.0 0.0 100.0 1,154 0.9 1.1 98.8 0.0 0.1 0.0 100.0 1,969 4.7 0.5 93.2 3.4 3.0 0.0 100.0 1,527 8.5 0.7 73.7 17.1 8.5 0.0 100.0 1,326 9.6 0.2 61.9 26.4 11.5 0.0 100.0 1,312 9.8 1.1 53.7 30.9 14.2 0.0 100.0 1,068 9.9 0.6 52.0 31.1 16.1 0.2 100.0 881 10.0 1.0 52.5 26.7 19.8 0.0 100.0 789 9.9 0.8 44.3 29.0 25.6 0.2 100.0 636 11.2 0.1 45.8 24.2 29.6 0.2 100.0 479 11.3 1.5 47.5 25.7 25.2 0.0 100.0 279 11.0 3.1 58.7 19.8 17.7 0.7 100.0 388 9.5 8.8 68.2 9.9 12.9 0.3 100.0 622 6.7 68.7 31.3 0.0 0.0 0.0 100.0 3 0.0 2.9 63.9 19.5 13.7 0.1 100.0 5,540 9.3 3.5 76.2 12.6 7.6 0.0 100.0 6,893 9.1 2.1 56.1 18.6 22.9 0.3 100.0 1,505 9.6 2.2 75.6 14.5 7.7 0.0 100.0 1,848 9.1 3.4 69.9 18.4 8.3 0.0 100.0 1,206 9.2 3.5 78.5 10.6 7.4 0.0 100.0 2,436 9.2 3.5 66.2 20.9 9.4 0.1 100.0 2,797 9.2 3.9 73.6 12.8 9.7 0.0 100.0 2,641 9.1 3.2 70.7 15.7 10.3 0.1 100.0 12,434 9.2 ______________________________________________________________________________________________________________ FEMALES ______________________________________________________________________________________________________________ Age 6-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Missing/DK Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Total 24.3 75.7 0.0 0.0 0.0 100.0 1,115 0.8 1.4 98.6 0.0 0.0 0.0 100.0 1,965 4.8 0.7 93.6 4.5 1.1 0.1 100.0 1,647 8.5 0.6 78.2 16.3 4.8 0.1 100.0 1,577 9.5 1.6 62.5 27.9 8.0 0.0 100.0 1,257 9.8 1.3 55.4 31.3 12.1 0.0 100.0 1,064 9.9 2.1 63.5 26.3 7.9 0.2 100.0 979 9.7 2.0 69.3 18.6 9.9 0.2 100.0 852 9.7 3.2 64.4 21.9 10.5 0.0 100.0 683 9.6 2.5 63.2 17.7 16.1 0.5 100.0 603 9.6 4.1 78.1 9.3 7.6 0.9 100.0 318 7.4 5.2 74.1 12.6 7.9 0.1 100.0 460 6.9 17.6 68.8 8.2 5.3 0.1 100.0 891 6.2 100.0 0.0 0.0 0.0 0.0 100.0 2 0.0 3.9 66.0 20.7 9.3 0.2 100.0 5,964 9.2 5.3 83.6 8.2 2.8 0.0 100.0 7,450 8.7 3.4 57.1 21.8 17.2 0.5 100.0 1,709 9.5 5.0 85.8 7.5 1.6 0.0 100.0 1,969 8.7 5.0 77.0 14.8 3.0 0.1 100.0 1,236 8.9 4.8 81.1 10.5 3.6 0.0 100.0 2,540 9.0 4.2 68.5 20.2 7.1 0.0 100.0 3,106 9.1 5.5 82.7 8.7 3.0 0.1 100.0 2,853 8.9 4.7 75.8 13.8 5.7 0.1 100.0 13,414 9.0 Household Population and Housing Characteristics * 15 Table 2.6 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population, by level of schooling, sex and residence, Turkmenistan 2000 ________________________________________________________________________ Net attendance ratio1 Gross attendance ratio2 ______________________ ______________________ Residence Male Female Total Male Female Total ________________________________________________________________________ PRIMARY SCHOOL________________________________________________________________________ Urban Rural Total 86.4 84.0 85.3 102.1 98.4 100.3 84.9 84.3 84.6 100.8 100.6 100.7 85.6 84.2 84.9 101.3 99.7 100.5 ________________________________________________________________________ SECONDARY SCHOOL________________________________________________________________________ Urban 78.8 80.1 79.4 86.8 87.1 87.0 Rural 78.2 78.3 78.3 83.6 81.6 82.5 Total 78.5 79.0 78.7 85.0 83.8 84.4 ________________________________________________________________________ 1 The NAR for primary school is the percentage of the primary-school age (7-10 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (11-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100%. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100%. There is significant overage participation at the primary school level, as indicated by the gap between the net and gross attendance ratios: About 15 percent of the students are either older than age 10 or younger than age 7, with most being overage rather than underage. At the secondary level, a far smaller proportion of students are overage (5 percent). Figure 2.2 presents the age-specific attendance rates (ASAR) for the population age 7-24, by sex. The ASAR indicates participation in schooling at any level, from primary through higher education. The closer the ASAR is to 100 percent, the higher is the proportion of people of the given age that is attending school. Most of youth of primary to secondary school age (7-17) attend school, and there are no significant differences by gender. The relatively lower age-specific attendance rate (ASAR) among children age 7 (32 percent) reflects the fact that many of these 7- year-olds were likely only age 6 during the school year covered by the survey, and hence were not eligible to attend school at that point in time. From age 17-24, a successively smaller proportion of individuals attend school. 16 * Household Population and Housing Characteristics 2.4 HOUSING CHARACTERISTICS Table 2.7 provides information on selected housing characteristics by residence. This information is helpful in assessing the general socioeconomic conditions of the population. To assess the conditions in which respondents live, they were asked questions about certain characteristics of their households, including electricity, source of drinking water, type of sanitation facilities, time to water sources, handwashing facilities, type of fuel for cooking, quality of the floor, and ownership of a garden or dacha and animals. As seen from Table 2.7, virtually all sampled households are supplied with electricity. The source of drinking water usually determines its quality. Fifty-five percent of households in Turkmenistan have piped water. Most other households use well water. Eighty-one percent of urban households use piped water, most of which (50 percent) have the pipes inside. In rural areas, 29 percent of households have piped water, while more than one-third of the population uses water from wells, and 20 percent uses water from open sources. Tanker trucks provide water to 6 percent of rural households. Most or urban and rural households are within 15 minutes of a source of water. One indicator of sanitary conditions is the type of toilet in a household. In Turkmenistan, a majority of households (71 percent) have traditional pit toilets (latrines) and 28 percent have flush toilets. In urban areas, 55 percent of households have a flush toilet, compared with 1 percent in rural areas. Ninety-eight percent of rural households have traditional pit toilets. Handwashing facilities are available in most households: 78 percent or more of households have water, soap or another cleaning agent, and a basin available for handwashing. Household Population and Housing Characteristics * 17 Table 2.7 Housing characteristics Percent distribution of households by housing characteristics, according to residence, Turkmenistan 2000 _______________________________________________________ Residence ________________ Background characteristic Urban Rural Total _______________________________________________________ Electricity Yes No Missing Total Source of drinking water Piped into residence Piped into yard/plot Public tap Open well in residence Open well in yard/plot Open public well Open water Tanker truck Bottled water Other Missing Total Time to water source <15 minutes (%) Sanitation facilities Own flush toilet Traditional pit toilet No facility/bush Other Missing Total Handwashing facilities Water/tap in household Soap/cleansing agent in household Basin in household Type of cooking fuel Electricity LPG, natural gas Biogas Charcoal Firewood, straw Missing Total Flooring material Earth/sand Wood planks Parquet/polished wood Linoleum PVC tiles Cement Other Missing Total Household owns A dacha or access to garden Animals Total 99.7 99.6 99.6 0.2 0.2 0.2 0.2 0.2 0.2 100.0 100.0 100.0 49.9 1.1 25.7 31.1 27.9 29.5 8.1 5.6 6.9 0.3 3.2 1.7 6.1 24.4 15.2 1.6 10.4 6.0 0.6 20.0 10.2 1.9 6.3 4.0 0.0 0.0 0.0 0.1 1.0 0.5 0.2 0.2 0.2 100.0 100.0 100.0 96.3 88.6 92.5 54.5 0.9 27.9 44.9 98.0 71.3 0.3 0.9 0.6 0.1 0.0 0.0 0.2 0.2 0.2 100.0 100.0 100.0 90.1 66.0 78.2 91.8 75.8 83.9 89.7 73.5 81.6 0.6 0.4 0.5 97.9 94.1 96.0 1.3 4.9 3.1 0.0 0.0 0.0 0.0 0.5 0.3 0.2 0.1 0.2 100.0 100.0 100.0 0.8 4.1 2.4 70.7 90.9 80.7 0.9 0.0 0.5 24.6 0.8 12.8 2.7 4.1 3.4 0.1 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.1 100.0 100.0 100.0 23.1 79.4 51.1 32.4 86.6 59.3 3.174 3,129 6,303 Virtually all households in Turkmenistan use biogas or natural gas for cooking. Regarding the type of flooring material, a large percentage (81 percent) of households have wood planks, which are slightly more common in rural house- holds (91 percent) than urban house- holds (71 percent). Twenty-five percent of urban households have linoleum floors. In the TDHS 2000, households were asked if any member owned a da- cha or had access to a garden from which he or she obtained fruits and vegetables during the growing season. The data indicate that 23 percent of urban house- holds and 79 percent of rural households in Turkmenistan have access to a dacha or garden. Households were also asked about ownership of animals. Eighty-seven percent of rural households own animals, compared with only 32 percent in urban areas. Household Durable Goods Table 2.8 indicates the percentage of households owning specific durable goods by residence. Ownership of a radio or a television is a measure of access to mass media; refrigerator ownership indi- cates the capacity for hygienic food stor- age; and ownership of a bicycle, motorcy- cle, or private car shows the means of transportation available to the household. The availability of durable consumer goods is a rough measure of household socioeconomic status. The results show that 46 percent of households have a radio, 93 percent have a television, 86 percent have a re- frigerator, 42 percent have a telephone, 13 percent have a bicycle, 18 percent have a private motorcycle, and 29 per- cent have a car. About 3 percent of households have none of these durable goods. 18 * Household Population and Housing Characteristics Table 2.8 Household durable goods Percentage of households possessing various durable consumer goods, by residence, Turkmenistan 2000 _________________________________________________ Residence Durable consumer goods Urban Rural Total _________________________________________________ Radio Television Telephone Refrigerator Bicycle Motorcycle Car/truck None of the above Number of households 47.1 43.9 45.5 94.3 92.1 93.2 66.0 17.3 41.9 90.5 81.5 86.1 9.9 16.3 13.1 9.7 26.1 17.8 27.2 30.8 29.0 2.1 2.9 2.5 3,174 3,129 6,303 Urban-rural differentials can be seen in the ownership of specific durable goods. In general, these goods are more available in urban households than in rural households except for the car and motorcycle ownership. For example, more than half of urban households have a telephone (66 percent), while the proportion in rural areas is only 17 percent. Ninety-one percent of households in urban areas have a refrigerator, compared with 82 percent in rural areas. A higher proportion of both urban and rural households own a television (94 and 92 percent, respectively). Rural households are almost three times more likely to own a motorcycle than urban households due to the greater need for transportation in rural areas. Women’s Characteristics, and Status * 19 WOMEN’S CHARACTERISTICS AND STATUS 3 A.Y. Khaitova, B.A. Gairova, and S. Kishor The purpose of this chapter is to present a profile of the demographic and socioeconomic characteristics of women age 15-49 who were identified by the TDHS 2000 Household Questionnaire as eligible respondents for the Women’s Questionnaire. In addition, data are presented on women’s status in Turkmenistan. This information is useful for understanding the context of reproduction and health and provides indicators of the status of women and of women’s empowerment. Three aspects of women’s situation are presented: education, employment, and direct measures of empowerment. While education and employment can contribute to women’s empowerment, direct measures of women’s empowerment allow an evaluation of women’s perception of their own rights and their degree of control over their own lives. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1.1 BACKGROUND CHARACTERISTICS Table 3.1 presents the percent distribution of women by age, current marital status, residence, region, highest educational level, and ethnicity. Women were asked two questions to determine their ages: “In what month and year were you born?” and “How old were you at your last birthday?” Interviewers were trained in probing techniques for situations in which respondents did not know their age or date of birth. Results show that the percentage of women in five-year age groups declines steadily with increasing age. About 39 percent of women are in the age group 15-24 and 29 percent of women are in the age group 25-34. Married women comprise large proportions of the total women interviewed (62 percent), while never-married women constitute 32 percent. Two percent of women are widowed and 4 percent of women are divorced. Forty-seven percent of respondents reside in urban areas and 53 percent live in rural areas. The percent distribution of the interviewed women by region of residence is as follows: 13 percent live in Ashgabad City, 15 percent in Akhal Region, 9 percent in Balkan Region, 21 percent in Dashoguz Region, 20 percent in Lebap Region, and 23 percent in Mary Region. Almost all TDHS 2000 respondents had attended at least primary/secondary school, 20 percent had a secondary-special education, and 7 percent had a higher education. Ethnically, the respondents in the TDHS 2000 are distributed as follows: ethnic Turkmens, 78 percent; ethnic Uzbeks, 11 percent; ethnic Russians, 5 percent; ethnic Kazakhs, 1 percent and other ethnic groups 5 percent. Table 3.2 shows the distribution of women by ethnicity, religion, and residence according to region. The data indicates that Turkmens are dominant ethnic group in all survey regions. Dashoguz and Lebap regions have relatively high concentration of women of Uzbek ethnicity. Russian women make up 27 percent of the respondents in Ashgabad City and present in less than 5 percent in other survey regions. 20 * Women’s Characteristics, and Status Table 3.1 Background characteristics of respondents Percent distribution of women by background characteristics, Turkmenistan 2000__________________________________________________ Number of women __________________ Background Weighted Un- characteristic percent Weighted weighted____________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married/living together Widowed Divorced/separated Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education No education Primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Russian Kazakh Other Total 19.9 1,574 1,589 19.5 1,541 1,580 15.9 1,256 1,260 13.4 1,060 1,059 12.3 974 958 10.7 845 817 8.4 669 656 32.4 2,563 2,655 61.8 4,892 4,829 2.2 174 168 3.7 289 267 46.6 3,691 3,693 53.4 4,228 4,226 13.1 1,038 585 14.5 1,145 1,081 9.0 709 1,000 20.6 1,628 2,833 20.3 1,607 1,263 22.6 1,791 1,157 1.0 76 76 72.3 5,725 5,843 19.6 1,556 1,515 7.1 563 485 78.2 6,191 5,906 10.8 857 1,269 5.3 420 299 1.0 80 133 4.7 371 312 100.0 7,919 7,919 ___________________________________________________ Note: Education categories refer to the highest level of education attended, whether or not that level was competed. The dominant religion in Turkmenistan is Muslim: more than 90 percent of the respondents in all survey regions except Ashgabad City reported that they are Mus- lims. In the capital city of Ashgabad, which has high concentration of women of Russian ethnicity, 27 percent of women said they are Christians. The majority of women in Turkmenistan reside in rural areas. An exception is Balkan region, where 80 per- cent of women reside in urban areas. 3.1.2 EDUCATIONAL LEVEL OF RESPONDENTS Table 3.3 shows the percent distribu- tion of women by the highest level of educa- tion attended according to background characteristics. Approximately 72 percent of respondents have attended primary/second- ary school, 20 percent have attended secondary-special school, and 7 percent have had higher education. There are significant differences in education between urban and rural areas and between regions. The proportion of respondents with higher education in urban areas is more than three times higher than in rural areas. This proportion is also higher in Ashgabad City compared to other regions. The proportion of respondents with secondary-special education in urban areas is more than two times higher than in rural areas This proportion is higher in Ashgabad City, Balkan and Lebap regions compared to other survey regions. The level of education of Turkmen and Uzbek women is about similar. More than 70 percent of Turkmen and Uzbek women have primary/secondary education. Sixteen percent of Turkmen and 22 percent of Uzbek women have secondary-special education. Seven percent of Turkmen and 5 percent of Uzbek women have higher education. Among women of other ethnic groups 41 percent have attended secondary-special school, and 12 percent have had higher education. Women’s Characteristics, and Status * 21 Table 3.2 Residence, ethnicity, and religion by region Percent distribution of women by residence, ethnicity, and religion, according to region, Turkmenistan 2000 ______________________________________________________________________________________ Region ______________________________________________________ Background Ashgabad characteristic City Akhal Balkan Dashoguz Lebap Mary Total ______________________________________________________________________________________ Residence Urban Rural Ethnicity Turkmen Uzbek Russian Kazakh Other Religion Muslim Christian Other Not religious Don't know Total Number 100.0 32.0 79.6 32.8 44.3 26.5 46.6 0.0 68.0 20.4 67.2 55.7 73.5 53.4 67.4 94.1 88.7 59.0 80.1 85.8 78.2 0.5 0.2 0.3 36.5 14.9 0.8 10.8 23.8 2.3 4.0 0.6 2.5 3.9 5.3 0.0 0.4 2.4 2.6 0.2 0.7 1.0 8.3 3.1 4.6 1.3 2.4 8.8 4.7 71.6 97.1 94.8 99.1 96.8 93.5 93.1 27.3 2.8 5.1 0.7 2.9 5.2 6.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.0 0.0 0.1 0.2 1.1 0.4 0.2 0.1 0.1 0.0 0.1 0.1 0.1 100.0 100.0 100.0 100.0 100.0 100.0 100.0 1,038 1,145 709 1,628 1,607 1,791 7,919 Table 3.3 Educational attainment by background characteristics Percent distribution of women by highest level of schooling attained, and median number of years of schooling, according to background characteristics, Turkmenistan 2000 __________________________________________________________________________________ Highest level of education attended _________________________________ None/ Median Background Primary/ Secondary- Number of years of characteristic secondary special Higher Total women schooling ___________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Ethnicity Turkmen Uzbek Other Total 94.0 4.5 1.4 100.0 1,574 8.5 79.3 15.8 4.9 100.0 1,541 9.5 64.2 28.1 7.8 100.0 1,256 9.8 56.8 31.0 12.2 100.0 1,060 9.9 65.4 26.0 8.6 100.0 974 9.7 71.2 19.2 9.6 100.0 845 9.7 67.6 21.5 10.9 100.0 669 9.6 60.5 28.0 11.4 100.0 3,691 9.7 84.3 12.3 3.3 100.0 4,228 9.4 51.7 27.5 20.8 100.0 1,038 9.9 86.4 11.4 2.2 100.0 1,145 9.3 73.6 22.1 4.3 100.0 709 9.5 79.7 15.5 4.8 100.0 1,628 9.5 59.1 31.9 9.0 100.0 1,607 9.8 84.0 12.2 3.8 100.0 1,791 9.4 76.9 16.4 6.7 100.0 6,191 9.5 73.6 21.6 4.8 100.0 857 9.6 46.9 40.9 12.2 100.0 871 10.8 73.2 19.6 7.1 100.0 7,919 9.5 22 * Women’s Characteristics, and Status Table 3.4 Access to mass media Percentage of women who usually read a newspaper once a week, watch television once a week, or listen to the radio daily, by background characteristics, Turkmenistan 2000 ___________________________________________________________________________ Mass media ____________________________________ No Reads a Watches Listens to All Number Background mass newspaper television the radio three of characteristic media weekly weekly daily media women ___________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education Primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Other Total 4.1 29.8 95.3 28.8 13.1 1,574 4.7 31.1 93.9 30.7 15.0 1,541 4.6 34.2 93.9 31.4 15.6 1,256 4.4 33.7 93.7 36.1 17.1 1,060 5.6 30.5 92.7 34.8 16.7 974 6.9 32.8 92.1 36.3 16.9 845 5.0 26.6 92.2 38.4 13.6 669 3.3 38.6 95.4 35.5 19.2 3,691 6.2 25.1 92.2 30.7 11.8 4,228 1.5 40.6 97.5 44.8 24.0 1,038 8.9 11.2 89.7 33.6 6.5 1,145 8.0 41.0 88.8 38.5 19.2 709 4.0 28.6 94.9 31.6 18.0 1,628 4.1 37.8 94.8 29.1 15.5 1,607 4.6 32.0 93.7 28.0 11.6 1,791 6.1 23.1 92.4 29.8 10.6 5,800 1.9 46.7 96.5 38.3 23.1 1,556 0.6 75.2 98.7 50.7 42.2 563 5.2 30.2 93.4 33.7 15.0 6,191 3.5 28.5 95.5 24.2 12.8 857 4.3 42.6 93.8 35.9 19.5 871 4.9 31.4 93.7 32.9 15.3 7,919 3.1.3 ACCESS TO MASS MEDIA During the TDHS 2000 interviews, women were asked about their exposure to the mass media which is an indicator of their access to information about health and family planning. Table 3.4 shows that 94 percent of women watch TV weekly, 33 percent listen to the radio weekly, while 31 percent read a newspaper at least once a week. There is little difference by age in access to the mass media. Women in Ashgabad City, Balkan and Dashoguz regions have more access to all three types of mass media (24, 19 and 18 percent, respectively) than women in Akhal, Lebap and Mary regions (7, 16 and 12 percent, respectively). There is an association between a respondent’s exposure to mass media and her education level; the higher the education level, more likely they are to avail themselves of all three media. Women’s Characteristics, and Status * 23 3.1.4 EMPLOYMENT STATUS The TDHS 2000 asked a series of questions to determine women’s employment status over the 12 months preceding the survey. For women who were employed, information was also obtained on the nature of employment including occupation and type of earnings, if any. Like education, employment can also be a source of empowerment for women, especially if it puts them in control of income. The measurement of women’s employment is difficult, however. The difficulty arises largely because some of the work that women do, especially work on family farms, family businesses or in the informal sector is often not perceived by women themselves as employment, and hence not reported as such. To avoid underestimating women’s employment, the TDHS 2000 asked women several questions to ascertain their employment status. First women were asked “Aside from your own housework, are you currently working?” Women who answered “No” to this question were then asked “As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business, or work on the family farm or in the family business. Are you currently doing any of these things or any other work?” Women who answered “No” to this question were asked “Have you done any work in the last 12 months?” Women are currently employed if they answered “Yes” to either of the first two questions. Women who answered “Yes” to the third question are not currently employed but have worked in the past 12 months. All employed women were asked their occupation, whether they were paid in cash, in kind, or not paid at all, and where and for whom they worked. Table 3.5 and Figure 3.1 show that, in Turkmenistan, half of all women age 15-49 were either currently employed or had worked during the 12 months preceding the survey. Almost all women who had worked at all during the 12 months preceding the survey, were also working at the time of the survey. Only 2 percent of women who had worked at any time during the past 12 months (1 percent of all women) were not currently working. Women’s current work participation first increases with age from 27 percent for women age 15-19 to 57 percent for women age 30-34 and then plateaus at 61-62 percent for women in the older age groups (age 35-49). Urban women are slightly more likely than rural women to be employed, although the differential by residence, especially in the proportion currently employed, is small. By region, the proportion of women employed at any time in the past 12 months is highest in the Lebap Region (55 percent) and lowest in the Dashoguz, Akhal, and Mary regions (46-47 percent). The likelihood of employment varies sharply with education. Only 42 percent of women who have no more than secondary education worked at any time in the 12 months preceding the survey compared with 70 percent of women with secondary-special education and 80 percent of women with higher education. Uzbek women (47 percent), followed by Turkmen women (50 percent) are less likely than women of other ethnicities (60 percent) to have been employed at any time in the 12 months preceding the survey. In Turkmenistan, almost all women who work earn cash for the work they do (Table 3.5). Overall, only 1 percent of women who are employed are not earning cash, and this proportion is never greater than 2 percent for any subgroup of employed women. 24 * Women’s Characteristics, and Status Table 3.5 Employment Percent distribution of women by employment status in the 12 months preceding the survey and, among those currently working, whether or not they earned cash, according to background characteristics, Turkmenistan 2000 ______________________________________________________________________________________________________________________ Employed in the 12 months preceding Not the survey employed Currently working ________________ in the 12 ________________ Not months Did not Background Currently currently preceding Earned earn characteristic employed employed the survey Missing Total Number cash cash Total Number ______________________________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married/living together Widowed Divorced, separated Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education None/primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Other Total 27.1 1.0 71.6 0.3 100.0 1,574 97.9 2.1 100.0 426 46.4 1.2 52.2 0.2 100.0 1,541 99.0 1.0 100.0 715 51.1 1.2 47.5 0.1 100.0 1,256 99.2 0.8 100.0 643 57.1 0.6 42.3 0.0 100.0 1,060 99.4 0.6 100.0 605 61.1 0.6 38.1 0.2 100.0 974 98.6 1.4 100.0 595 61.2 0.5 38.3 0.0 100.0 845 98.1 1.9 100.0 517 61.5 1.3 37.2 0.0 100.0 669 99.6 0.4 100.0 411 41.1 1.2 57.4 0.3 100.0 2,563 98.3 1.7 100.0 1,055 52.3 0.9 46.8 0.1 100.0 4,892 99.1 0.9 100.0 2,557 68.8 0.4 30.8 0.0 100.0 174 97.3 2.7 100.0 120 62.4 0.6 37.0 0.0 100.0 289 100.0 0.0 100.0 181 41.3 1.2 57.2 0.3 100.0 2,942 98.5 1.5 100.0 1,214 50.7 0.9 48.4 0.0 100.0 2,334 99.5 0.5 100.0 1,183 57.0 0.7 42.2 0.1 100.0 1,710 98.7 1.3 100.0 975 57.9 0.6 41.4 0.1 100.0 934 98.5 1.5 100.0 541 51.2 1.5 47.2 0.1 100.0 3,691 98.8 1.2 100.0 1,891 47.8 0.5 51.5 0.2 100.0 4,228 98.9 1.1 100.0 2,021 51.4 2.1 46.3 0.2 100.0 1,038 99.4 0.6 100.0 534 46.9 0.1 52.7 0.3 100.0 1,145 98.6 1.4 100.0 537 51.7 4.4 43.7 0.1 100.0 709 98.8 1.2 100.0 367 46.3 0.2 53.3 0.1 100.0 1,628 98.4 1.6 100.0 754 54.7 0.4 44.7 0.2 100.0 1,607 98.3 1.7 100.0 879 47.0 0.6 52.5 0.0 100.0 1,791 99.6 0.4 100.0 841 41.4 1.0 57.5 0.1 100.0 5,800 98.4 1.6 100.0 2,399 68.7 0.9 30.3 0.2 100.0 1,556 99.5 0.5 100.0 1,068 79.0 0.6 20.4 0.0 100.0 563 99.4 0.6 100.0 445 48.5 1.0 50.4 0.1 100.0 6,191 98.7 1.3 100.0 3,000 46.2 0.5 53.2 0.1 100.0 857 98.4 1.6 100.0 396 59.3 0.9 39.6 0.2 100.0 871 100.0 0.0 100.0 516 49.4 0.9 49.5 0.1 100.0 7,919 98.9 1.1 100.0 3,912 Women’s Characteristics, and Status * 25 3.1.5 OCCUPATION Table 3.6 shows the occupational profiles of currently employed women by background characteristics. Over one-third (39 percent) of all employed women are in professional, technical, or managerial occupations, 28 percent are in agricultural occupations, 14 percent are in skilled manual occupations, and 9 percent are in the unskilled manual occupations. Sales and service occupations account for only 5 percent of women’s employment. The largest variation in the proportion of women in the professional, technical, or managerial occupations is by level of education. Only 19 percent of women who have completed at most secondary school are in professional, technical, or managerial occupations compared with 66 percent of women who have secondary-special education and 86 percent of women who have higher education. Notably, these occupations also account for about half of all employed women who are divorced or separated, have 1-2 children, live in urban areas, live in Ashgabad City, belong to ethnic groups other than Turkmen and Uzbek, or are age 25-34. Working women who have no children, and those in the Dashoguz area are about equally likely to be in agricultural occupations as in professional, technical, or managerial occupations. By contrast, working women who are age 15-19, are never married, have five or more children, live in rural areas or in the Akhal or Mary regions, or have only secondary education or less, are much more likely to be in agricultural occupations than in any other kind of occupations. Sales and service occupations are relatively more important in the occupational profiles of urban women and women who are not Turkmen, whereas unskilled manual occupations are relatively more important in the occupational profiles of the oldest women, widowed or other formerly married women, women with three or more children, and women with secondary education or less, than for any other women. Women’s participation in skilled manual occupations declines sharply with age and number of living children. One-fourth or more of employed women age 15-19, never-married women, and women living in the Akhal and Balkan regions are employed in skilled manual occupations. 26 * Women’s Characteristics, and Status Table 3.6 Occupation Percent distribution of currently employed women by occupation (agricultural or nonagricultural occupation) and type of nonagricultural occupation, according to background characteristics, Turkmenistan 2000 ________________________________________________________________________________________________________________________________________________________________ Nonagricultural occupation ______________________________________________ Professional/ Background Technical/ Sales, Skilled Unskilled characteristic Agriculture Managerial services manual manual Missing Total Number _____________________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married/living together Widowed Divorced/separated Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education Primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Other Total 39.7 15.0 4.0 30.8 6.9 3.5 100.0 426 26.5 35.0 4.5 19.4 7.9 6.6 100.0 715 20.9 49.7 3.7 14.0 5.8 5.9 100.0 643 21.2 47.2 5.9 10.3 10.1 5.3 100.0 605 30.1 43.5 3.7 8.8 8.9 5.0 100.0 595 31.2 39.2 6.2 9.8 9.8 3.8 100.0 517 29.6 37.4 4.6 6.9 15.2 6.4 100.0 411 31.7 27.9 3.9 24.9 6.5 5.0 100.0 1,055 28.2 42.7 4.7 10.0 9.3 5.2 100.0 2,557 18.0 44.6 8.9 8.1 16.1 4.3 100.0 120 3.9 52.8 6.0 15.2 13.1 9.1 100.0 181 29.6 30.4 4.3 23.7 6.7 5.2 100.0 1,214 14.7 53.6 4.2 11.2 7.8 8.5 100.0 1,183 28.8 41.1 6.2 9.4 11.7 2.8 100.0 975 49.9 24.1 3.4 8.1 11.6 2.9 100.0 541 0.8 54.8 7.7 17.0 10.8 8.8 100.0 1,891 52.8 24.6 1.8 11.5 7.2 2.0 100.0 2,021 0.3 55.2 6.8 12.9 9.1 15.7 100.0 534 36.3 20.4 2.2 27.6 9.9 3.7 100.0 537 2.2 40.1 5.4 37.4 10.3 4.6 100.0 367 40.8 39.0 4.0 6.1 7.3 2.7 100.0 754 23.9 45.5 6.9 9.7 10.2 3.8 100.0 879 43.0 34.4 2.7 8.2 7.9 3.9 100.0 841 42.7 18.7 4.3 18.4 12.2 3.8 100.0 2,399 5.4 65.8 5.9 9.8 5.5 7.6 100.0 1,068 0.4 86.4 3.3 1.9 0.0 7.9 100.0 445 32.1 35.8 3.5 15.6 9.1 3.8 100.0 3,000 23.1 45.1 8.3 11.3 8.2 4.0 100.0 396 5.8 54.5 8.3 8.2 8.4 14.8 100.0 516 27.7 39.2 4.6 14.2 9.0 5.3 100.0 3,912 3.1.6 EMPLOYER AND FORMS OF EARNINGS Table 3.7 shows the percent distribution of employed women by type of employer and type of earnings according to background characteristics. In Turkmenistan, 3 percent of women who are currently working are self employed, 17 percent are employed by a family member, and the vast majority, 81 percent, are employed by someone else. Almost all women who work, irrespective of the type of employer, work for cash. Although the majority of working women in all subgroups of the population are working for someone else, the type of employer does vary substantially by the background characteristics of women. The youngest women (age 15-19), followed by women age 20-24, are much more likely than women in older age groups to be working for a family member Women’s Characteristics, and Status * 27 Table 3.7 Employer and form of earnings Percent distribution of currently employed women by employer and type of earnings, (cash, in kind, no payment), according to background characteristics, Turkmenistan 2000 __________________________________________________________________________________________________________ Employed by a Self-employed nonrelative Employed by a relative _____________ ______________ ______________________ Does Does Does not not not Background Earns earn Earns earn Earns earn characteristic cash cash cash cash cash cash Missing Total Number __________________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education Primary/secondary Secondary-special Higher Occupation Agricultural Nonagricultural Ethnicity Turkmen Uzbek Other Total 3.1 0.7 58.5 0.1 36.3 0.9 0.3 100.0 426 3.4 0.4 77.2 0.2 18.4 0.4 0.0 100.0 715 2.1 0.6 85.6 0.1 11.5 0.2 0.0 100.0 643 2.2 0.2 84.6 0.3 12.3 0.0 0.3 100.0 605 1.6 0.0 83.6 0.4 13.4 1.0 0.0 100.0 595 1.3 0.0 82.9 1.6 13.9 0.4 0.0 100.0 517 0.9 0.0 85.7 0.4 12.6 0.0 0.4 100.0 411 3.1 0.3 84.8 0.2 11.0 0.6 0.0 100.0 1,891 1.3 0.2 76.1 0.7 21.3 0.2 0.2 100.0 2,021 4.9 0.3 87.4 0.0 7.1 0.3 0.0 100.0 534 0.4 0.8 53.8 0.0 44.4 0.6 0.0 100.0 537 4.4 0.0 64.9 0.0 29.5 1.1 0.2 100.0 367 1.5 0.1 91.4 1.4 5.6 0.1 0.0 100.0 754 2.2 0.3 87.6 0.6 8.6 0.7 0.1 100.0 879 1.1 0.2 81.9 0.2 16.3 0.0 0.4 100.0 841 2.3 0.4 72.0 0.6 24.0 0.5 0.2 100.0 2,399 2.1 0.0 92.6 0.2 4.9 0.3 0.0 100.0 1,068 1.7 0.4 95.3 0.2 2.3 0.0 0.0 100.0 445 0.5 0.1 71.1 1.1 26.8 0.3 0.1 100.0 1,084 2.8 0.3 83.8 0.2 12.3 0.4 0.1 100.0 2,828 2.2 0.3 77.8 0.5 18.6 0.5 0.1 100.0 3,000 2.1 0.5 85.1 0.4 11.1 0.4 0.3 100.0 396 1.9 0.0 91.1 0.0 7.0 0.0 0.0 100.0 516 2.2 0.3 80.3 0.4 16.3 0.4 0.1 100.0 3,912 __________________________________________________________________________________________________________ Note: Earns cash includes both women who receive only cash and those who receive both cash and in-kind payment. Does not earn cash includes both women who receive only in-kind payment and those who receive no payment. or to be self employed. Only 59 percent of working women age 15-19 work for someone else, compared with 83 percent or more of women age 25 or older. Rural working women (22 percent) are about twice as likely as urban working women (12 percent), to be working for a family member. Twenty-five percent of working women who have at most completed secondary education work for a family member, compared with 5 percent or less of working women with secondary-special or higher education. One in five Turkmen working women work for a family member compared with about one in ten or less of women from other ethnic groups. Women working in agricultural occupations are also more than twice as likely as those working in nonagricultural occupations to be employed by a family member. Working for a family member is most common, however, in the Akhal and Balkan regions. In these regions, 45 percent and 31 percent, respectively, of working women work for a family member, higher than in any other subgroup of the population. Although very few women are self employed, the proportion self employed is much higher among working women in Ashgabad City and in the Balkan Region (4-5 percent) than among women in most of the other subgroups of the population. 28 * Women’s Characteristics, and Status 3.1.7 DECISIONMAKING REGARDING USE OF CASH EARNINGS Employed women who earn cash for their work were asked who the main decisionmaker is with regard to the use of their earnings. This information allows the assessment of women’s control over their own earnings. Table 3.8 shows how working women’s control over their own earnings varies by background characteristics. While 24 percent of women alone decide how their earnings are to be used, the majority, 54 percent, take these decisions jointly with their partner or someone else. More than one out of five women (22 percent) have no part in the decision on how their earnings are used. The likelihood that women do not participate at all in the decision about how their earnings are to be used declines sharply with age, from 51 percent for women age 15-19 to 5 percent for women age 45-49. Among currently married women the proportion not participating in this decision is only 14 percent, but few also make this decision alone (19 percent). Almost all (91 percent) of widowed, divorced, or separated women tend to take this decision alone, however. In addition, working women who belong to ethnicities other than Turkmen or Uzbek (48 percent) or who live in Ashgabad City (45 percent) are also more likely than most other women to take the decision about the use of their earnings by themselves. About one-third of women who live in urban areas, have secondary-special education, live in the Balkan Region, or have 1-2 children, take these decisions alone. Notably, about one-third or more of women who are never married, have no children, live in rural areas, or live in the Mary Region do not participate at all in decisions about how their earnings are to be used. In order to assess the relative importance of women’s earnings in meeting household expenditures, TDHS 2000 asked employed women who earned cash “On average, how much of your household’s expenditure do your earnings pay for: almost none, less than half, about half, more than half, or all?” This information not only allows an evaluation of the relative importance of women’s earnings in the household economy, but has implications for the empowerment of women. It is expected that employment and earnings are more likely to empower women if they perceive their earnings as important for meeting the needs of their households. The variation by background characteristics in the extent to which women’s earnings pay for their households’ expenditures (for women who are employed and earn cash), is also shown in Table 3.8. From Table 3.8, it is clear that when women work for cash, their earnings are critical to meeting household expenditures in a substantial proportion of cases. Specifically, in the case of 35 percent of women who earn cash, the woman’s earnings alone pay for at least half of her household’s expenditures. This suggests that the households of almost one in five women age 15-49 are dependent on the earnings of women alone to meet the majority of their expenditures. For women who earn cash, the likelihood that their earnings pay for at least half of their household’s expenditures rises with age, from 16 percent for women age 15-19 to over 40 percent for women age 30-49. At least half of the household’s expenditures are met by the woman’s earnings in the case of 40 percent or more of working women with 1-4 children. Notably too, households’ of at least half of the women who are divorced, separated, or widowed, who live in the Balkan Region, who have higher education, or who belong to ethnicities other than Turkmen or Uzbek depend on women’s earnings to meet at least half of their expenditures. The earnings of women play a much more important role in meeting household expenditures in urban than rural areas. Table 3.9 shows whether working women’s control over their own earnings varies by the extent to which their earnings help to meet household expenditures. With the exception of women whose earnings pay for almost none of their households’ expenditures, among all other women who work for cash, the proportion who alone take the decision about how their earnings are to be used increases with the extent to which their earnings pay for household expenditures. For example, Women’s Characteristics, and Status * 29 among currently married women 15 percent of women whose earnings pay for less than half of household expenditures, 21 percent of women whose earnings pay for half or more of household expenditures, and 53 percent of women whose earnings pay for all household expenditures alone take the decision on how their earnings should be used. Surprisingly, however, among currently married women, the proportion who do not participate at all in the decision on the use of their earnings first declines from 17 percent to 9 percent as contributions to household expenditures increase from less than half to half or more than half, but then rises again to 14 percent for women whose earnings are used to meet all of the household’s expenditures. Among women, whose earnings meet almost none of their households’ expenditures, the use of earnings is about equally likely to be decided alone by women themselves as by a husband or someone else if the woman is currently married; but if she is not currently married, she alone is most likely to decide how her earnings are to be used. Table 3.8 Decision of use of earnings and contribution of earnings to household expenditures Percent distribution of women receiving cash earnings by person who decides how earnings are used and by proportion of household expenditures met by earnings, according to background characteristics, Turkmenistan 2000 _________________________________________________________________________________________________________________________________ Person who decides how earnings Proportion of household expenditures met are used by earnings _______________________________ _______________________________________ Less Half Background Self Someone Almost than or characteristic only Jointly else Missing Total none half more All Missing Total Number _________________________________________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married or in union Divorced, separated, widowed Number of living children 0 1-2 3-4 5+ Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education Primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Other Total 12.8 35.7 51.1 0.4 100.0 3.9 80.0 15.4 0.4 0.3 100.0 418 17.2 39.7 42.9 0.2 100.0 4.3 72.6 20.1 2.8 0.2 100.0 708 24.0 49.8 26.0 0.2 100.0 2.6 65.2 28.5 3.7 0.0 100.0 637 25.2 62.7 12.1 0.0 100.0 1.4 54.5 39.3 4.8 0.0 100.0 602 27.6 65.0 7.4 0.0 100.0 1.1 56.9 33.5 8.5 0.0 100.0 587 24.2 66.1 9.7 0.0 100.0 0.7 54.4 39.6 5.3 0.0 100.0 507 38.8 56.6 4.6 0.0 100.0 0.6 56.4 33.9 9.1 0.0 100.0 410 17.4 34.1 48.1 0.4 100.0 4.5 76.2 18.0 1.0 0.3 100.0 1,037 18.6 67.2 14.2 0.0 100.0 1.3 60.8 34.3 3.6 0.0 100.0 2,533 91.3 5.4 3.3 0.0 100.0 1.6 34.0 35.3 29.0 0.0 100.0 297 19.6 35.3 44.7 0.4 100.0 4.4 74.7 18.9 1.7 0.2 100.0 1,196 30.8 52.1 17.1 0.0 100.0 1.5 55.0 35.1 8.4 0.0 100.0 1,177 23.4 68.6 8.0 0.0 100.0 0.7 58.7 35.2 5.4 0.0 100.0 962 19.1 70.7 10.2 0.0 100.0 1.3 61.1 34.4 3.1 0.0 100.0 533 35.5 50.8 13.6 0.1 100.0 1.9 54.6 35.7 7.9 0.0 100.0 1,869 13.1 56.1 30.7 0.1 100.0 2.5 70.6 24.7 2.0 0.1 100.0 1,998 44.9 44.6 10.4 0.0 100.0 1.0 56.0 33.3 9.7 0.0 100.0 530 13.4 61.2 25.3 0.0 100.0 0.8 85.5 12.3 1.4 0.0 100.0 530 32.1 52.9 15.0 0.0 100.0 2.7 43.2 51.3 2.8 0.0 100.0 362 20.0 61.0 18.8 0.2 100.0 1.5 70.0 25.2 3.2 0.2 100.0 743 24.3 57.2 18.6 0.0 100.0 3.9 57.6 34.4 4.2 0.0 100.0 864 16.7 44.5 38.5 0.3 100.0 2.4 60.6 29.8 7.0 0.2 100.0 838 18.9 52.0 29.0 0.1 100.0 2.5 69.2 24.9 3.4 0.1 100.0 2,362 32.7 54.1 13.2 0.0 100.0 1.9 54.6 36.1 7.4 0.0 100.0 1,063 29.7 60.5 9.3 0.5 100.0 1.3 49.0 42.9 6.7 0.1 100.0 442 19.4 54.5 26.0 0.1 100.0 2.4 66.0 28.3 3.3 0.1 100.0 2,961 26.5 59.0 14.2 0.3 100.0 1.9 59.9 29.7 8.3 0.2 100.0 389 47.5 44.2 8.3 0.0 100.0 1.3 47.2 40.3 11.2 0.0 100.0 516 23.9 53.6 22.4 0.1 100.0 2.2 62.9 30.0 4.9 0.1 100.0 3,867 30 * Women’s Characteristics, and Status 3.2 DIRECT MEASURES OF WOMEN’S EMPOWERMENT In addition to information on women’s education, employment status, and earnings control, TDHS 2000 also obtained information on some additional direct measures of women’s status and empowerment. Specifically, questions were asked on women’s participation in household decisionmaking and on their opinions about when a wife should be able to refuse sex to her husband. These data provide insight into women’s control over their lives and their environment and their attitudes toward traditional gender roles, which are all important aspects of women’s empowerment relevant for understanding demographic and health behaviors. These questions are used to define two different indicators of women’s empowerment: women’s participation in decisionmaking and their degree of acceptance of a wife’s right to refuse her husband sex. The first measure requires little justification since the ability to take decisions about ones own life is essential to the concept of empowerment. Beliefs about whether and when a woman can refuse sex to her husband reflect issues of gender equity with regard to sexual rights and bodily integrity. Besides yielding an important measure of empowerment, the information about women’s attitudes toward sexual rights will be useful for improving and monitoring reproductive health programs that depend on women’s willingness and ability to control their own sexual lives. 3.2.1 HOUSEHOLD DECISIONMAKING In order to assess women’s decisionmaking roles, women were asked who in their families usually has the final say in five different decisions, namely, decisions about the respondent’s own health care, making large household purchases, making household purchases for daily needs, visits to family, friends, or relatives, and what food should be cooked each day. Table 3.10 shows the percent distribution of women according to who in the household usually has the final say on each one of the different types of decisions. Most currently married women, three out of four, usually take decisions alone on what food to cook each day. Only a minority of women, however, alone have the final say on each of the other decisions. Even in decisions about their own health care, only 41 percent of women alone have the final say, and in decisions about daily household purchases, only 33 percent alone have the final say. One in ten women or less alone have the final say about visits to family or relatives or about large household purchases. In addition, for 17 percent of currently married women, husbands or someone else takes decisions about the woman’s health care without her involvement in the final say. Similarly, more than one-fifth of currently married women are not involved at all (either alone or jointly with someone else in the final say) in each of the decisions about large household purchases, daily household purchases, and visits to family and relatives. Notably, women who are currently not married are even more likely than married women to not have the final say at all in each of the different decisions. For example, about half of unmarried or formerly married women do not participate in decisions about their own health care and in decisions about what food to cook; the proportion not involved at all rises to two-thirds for decisions about daily household purchases and large household purchases. Table 3.11 shows how participation in decisionmaking varies for all women by background characteristics. Women are said to participate in a decision if they alone or jointly with a husband or someone else have the final say. The proportion of women who participate in all five decisions increases more or less steadily with age, from 18 percent for women age 15-19 to 78 percent for women age 45-49. At least 3 out of 4 women in all the age groups 30-34 and above participate in Women’s Characteristics, and Status * 31 Ta bl e 3. 10 H ou se ho ld d ec isi on m ak in g Pe rc en t d ist rib ut io n of w om en b y pe rs on w ho m ak es s pe ci fic h ou se ho ld d ec isi on s an d m ar ita l s ta tu s, ac co rd in g to ty pe o f d ec isi on , T ur km en ist an 2 00 0 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ M ar rie d/ liv in g to ge th er N ot m ar rie d/ no t l iv in g to ge th er __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Jo in tly Jo in tly Jo in tly w ith So m eo ne Jo in tly w ith So m eo ne Se lf w ith so m eo ne H us ba nd el se Se lf w ith so m eo ne H us ba nd el se H ou se ho ld d ec isi on on ly hu sb an d el se on ly on ly M iss in g To ta l N um be r on ly hu sb an d el se on ly on ly M iss in g To ta l N um be r __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ O w n he al th c ar e 40 .3 40 .4 2. 6 9. 3 7. 3 0. 1 10 0. 0 4, 89 2 32 .3 0. 3 20 .4 0. 1 46 .8 0. 0 10 0. 0 3, 02 7 La rg e ho us eh ol d pu rc ha se s 7. 2 61 .1 4. 0 13 .6 14 .1 0. 0 10 0. 0 4, 89 2 13 .4 0. 5 18 .2 0. 2 67 .7 0. 0 10 0. 0 3, 02 7 D ai ly h ou se ho ld p ur ch as es 32 .3 39 .1 3. 6 10 .9 14 .0 0. 1 10 0. 0 4, 89 2 17 .4 0. 5 16 .3 0. 1 65 .6 0. 1 10 0. 0 3, 02 7 V isi ts to fa m ily , f rie nd s, o r r el at iv es 9. 8 64 .2 3. 8 10 .4 11 .8 0. 0 10 0. 0 4, 89 2 17 .3 0. 7 24 .1 0. 1 57 .8 0. 1 10 0. 0 3, 02 7 W ha t f oo d to c oo k ea ch d ay 76 .3 9. 8 5. 4 0. 9 7. 6 0. 0 10 0. 0 4, 89 2 28 .9 0. 2 22 .8 0. 0 48 .1 0. 0 10 0. 0 3, 02 7 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ N ot e: N ot m ar rie d/ no t l iv in g to ge th er in cl ud es n ev er m ar rie d, d iv or ce d, w id ow ed a nd s ep ar at ed w om en . Ta bl e 3. 9 C on tro l o ve r e ar ni ng s ac co rd in g to c on tri bu tio n to h ou se ho ld e xp en di tu re s Pe rc en t d ist rib ut io n of w om en r ec ei vi ng c as h ea rn in gs b y pe rs on w ho d ec id es h ow e ar ni ng s ar e us ed a nd m ar ita l s ta tu s, a cc or di ng to h ow m uc h of h ou se ho ld ex pe nd itu re s ar e m et b y ea rn in gs , T ur km en ist an 2 00 0 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ M ar rie d/ liv in g to ge th er N ot m ar rie d/ no t l iv in g to ge th er __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Jo in tly Jo in tly C on tri bu tio n Jo in tly w ith So m eo ne w ith So m eo ne to h ou se ho ld Se lf w ith so m eo ne H us ba nd el se Se lf so m eo ne el se ex pe nd itu re s on ly hu sb an d el se on ly on ly To ta l N um be r on ly el se on ly M iss in g To ta l N um be r __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Pr op or tio n of h ou se ho ld e xp en di tu re s m et b y ea rn in gs Al m os t n on e (2 6. 5) (4 2. 7) (4 .9 ) (1 7. 2) (8 .6 ) 10 0. 0 32 52 .1 6. 0 41 .8 0. 0 10 0. 0 52 Le ss th an h al f 15 .1 65 .8 2. 6 7. 6 9. 0 10 0. 0 1, 54 0 21 .4 32 .7 45 .5 0. 4 10 0. 0 89 1 H al f o f m or e 21 .0 69 .0 0. 6 7. 7 1. 7 10 0. 0 87 0 48 .6 24 .8 26 .6 0. 0 10 0. 0 29 1 Al l 53 .0 28 .4 3. 6 14 .9 0. 0 10 0. 0 91 95 .8 2. 5 1. 6 0. 0 10 0. 0 96 To ta l1 18 .6 65 .2 2. 0 8. 0 6. 1 10 0. 0 2, 53 3 33 .9 27 .7 38 .1 0. 3 10 0. 0 1, 33 4 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ N ot e: N ot m ar rie d/ no t l iv in g to ge th er in cl ud es n ev er m ar rie d, d iv or ce d, w id ow ed a nd s ep ar at ed w om en . P ar en th es es in di ca te th at a fi gu re is b as ed o n 25 -4 9 un w ei gh te d ca se s. 1 To ta l i nc lu de s 3 ca se s fo r w hi ch p ro po rti on o f h ou se ho ld e xp en di tu re s m et b y ea rn in gs w as m iss in g. 32 * Women’s Characteristics, and Status 3.11 Final say in household decisions Percentage of women who say that they alone or jointly have the final say in specific household decisions, according to background characteristics, Turkmenistan 2000 _____________________________________________________________________________________________________________________ Alone or jointly have say in _____________________________________________________ Visits to Has final Has final Own Making Making family, What food say in all say in no Background health large daily relatives, to cook specified specified Number of characteristic care purchases purchases friends daily decisions decisions women _____________________________________________________________________________________________________________________ Age 15-19 41.1 19.9 22.6 31.0 43.2 17.7 43.3 1,574 20-24 60.9 35.4 38.8 45.4 61.4 28.9 25.2 1,541 25-29 76.6 58.6 60.1 65.0 82.2 48.1 9.7 1,256 30-34 84.8 77.2 77.5 80.2 93.5 63.4 2.9 1,060 35-39 88.8 82.4 83.7 85.6 96.0 72.7 2.4 974 40-44 89.9 83.9 89.8 91.3 97.6 73.5 0.6 845 45-49 90.9 87.7 90.0 92.1 95.5 78.4 1.9 669 Marital status Never married 46.3 22.9 25.2 34.1 45.2 19.9 39.3 2,563 Married/living together 83.3 72.3 75.0 77.8 91.6 61.0 4.8 4,892 Widowed 95.9 92.3 93.3 92.2 94.9 86.8 1.2 174 Divorced, separated 87.1 78.2 78.9 82.0 84.4 72.6 6.7 289 Number of living children 0 50.0 26.2 28.7 37.1 49.1 22.5 36.2 2,942 1-2 80.8 68.9 70.5 73.5 88.1 58.2 6.7 2,334 3-4 87.4 79.2 82.6 84.2 96.2 67.6 2.0 1,710 5+ 88.9 83.3 86.0 89.1 96.7 72.6 1.0 934 Residence Urban 78.4 63.9 66.5 71.9 80.9 55.1 11.0 3,691 Rural 65.9 50.9 53.3 57.3 72.4 43.1 20.3 4,228 Region Ashgabad City 81.3 64.9 68.1 74.1 81.8 55.8 9.0 1,038 Akhal 81.4 66.3 67.3 77.6 79.0 61.4 12.4 1,145 Balkan 83.8 67.8 64.1 79.2 80.6 57.0 8.3 709 Dashoguz 78.3 60.9 61.7 64.4 78.4 57.3 13.2 1,628 Lebap 67.9 49.6 53.7 55.1 73.3 40.9 18.2 1,607 Mary 52.6 45.1 50.7 51.5 70.8 32.2 25.8 1,791 Education Primary/secondary 67.3 52.0 54.3 59.7 73.0 44.4 19.2 5,800 Secondary-special 82.4 69.6 71.6 74.2 84.7 59.0 7.9 1,556 Higher 87.6 72.7 78.5 81.8 88.3 63.8 4.4 563 Ethnicity Turkmen 69.1 54.5 57.1 62.0 74.6 46.4 17.9 6,191 Uzbek 79.2 61.0 63.5 64.4 81.9 53.5 9.4 857 Other 82.9 70.3 72.4 78.9 83.6 60.2 8.8 871 Current em ployment Not employed 65.7 48.9 51.4 55.7 70.9 41.6 21.3 3,995 For cash 78.1 65.4 67.8 72.8 82.1 56.0 10.4 3,867 Not for cash (69.5) (55.8) (61.2) (64.5) (71.1) (48.7) (16.6) 43 Total1 71.7 57.0 59.4 64.1 76.4 48.7 16.0 7,919 _____________________________________________________________________________________________________________________ Note: Parentheses indicate that a figure is based on 25-49 unweighted cases. 1 Total includes 13 cases for which information employment status was missing. Women’s Characteristics, and Status * 33 each decision. Among younger women, however, participation varies greatly by type of decision. By marital status, never-married women are least likely to participate in each decision and widowed women are the most likely to do so. Notably, more than one-third of never-married women do not participate in all of these decisions. Participation in all decisions, as well as in each of the different decisions increases with the number of children. Twenty-three percent of women with no children participate in all decisions compared with 73 percent of women with five or more children. Urban women are more likely than rural women to participate in decisionmaking, and participation in each decision increases with education. By region, participation in all decisions varies from 61 percent for women in the Akhal Region and 56-57 percent for women in the Dashoguz, Balkan, and Ashgabad City regions, to 32 percent for women in the Mary Region. One in four women in the Mary Region and one in five in the Lebap Region do not participate in any of these decisions at all. Turkmen women are somewhat less likely to participate in each of the decisions than Uzbek women, as well as women of other ethnicities. As expected women who work, especially women who work for cash, are more likely than women who do not work, to participate in all decisions. Women may have a say in some and not in other decisions. To assess each woman’s overall degree of engagement in household decisionmaking, the total number of decisions she participates in (i.e., she alone has the final say or does so jointly with her husband or someone else) are added together. The total number of decisions a woman participates in yields a very simple measure of her empowerment in terms of decisionmaking control. Figure 3.3 shows the percent distribution of women in Turkmenistan according to this measure. Overall, about half (49 percent) of the women participate in all five of the decisions, and 16 percent do not participate in any of the decisions. The remainder of the women are distributed about equally among those who participate in only one, only two, only three, and only four decisions. 3.2.2 WOMEN’S AGREEMENT WITH REASONS FOR REFUSING SEXUAL RELATIONS The extent of control women have over when and with whom they have sex has important implications for demographic and health outcomes. To measure women’s agreement with a woman’s right to refuse her husband sex, TDHS 2000 asked respondents whether a wife is justified in refusing to have sex with her husband under four circumstances: she is tired or not in the mood, she has recently given birth, she knows her husband has sex with other women, and she knows her husband has a sexually transmitted disease. These four circumstances for which women’s opinions are sought were chosen because they are effective in combining issues regarding women’s rights and women’s health. Table 3.12 shows the percentage of women who say that women are justified in refusing sex to their husbands for specific reasons by background characteristics. The table also shows how this indicator of women’s empowerment varies with the women’s participation in decisionmaking. It is worth noting that, unlike in the case of the previous indicator of empower- ment, this indicator is positively related to empowerment: the more the reasons women agree with, the higher is their empowerment in terms of their belief in women’s sexual rights. Overall, 52 percent of women in Turkmenistan agree that women can refuse sex to their husbands for all of the four reasons they were asked about. Women are least likely to say that a wife is justified in refusing her husband sex if she is tired or not in the mood (61 percent) and most likely to agree that a wife is justified in refusing sex (75 percent) if she has recently given birth. Notably, however, 20 percent of women say that a wife is not justified in refusing her husband sex for any of the four reasons. Rural women are more likely than urban women to not agree with any of the reasons, and by region, women in the Akhal Region, followed by those in the Mary and Dashoguz regions are more likely than women in other regions to not agree with any of the reasons for refusing sex. However the women who appear least empowered in terms of this indicator are the 34 * Women’s Characteristics, and Status Table 3.12 Women’s agreement with reasons for refusing sexual relations Percentage of women who agree with specific reasons for justifying a wife refusing to have sexual relations with her husband, according to background characteristics, Turkmenistan 2000 ______________________________________________________________________________________________________ Reason justifying wife refusing sexual relations with husband _________________________________________ Knows husband has sexual Agrees Agrees Tired, not Gave relations Knows with all with no Number Background in the birth with other husband specified specified of characteristic mood recently women has AIDS1 reasons reason women _______________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married or in union Divorced, separated, widowed No. of living children 0 1-2 3-4 5+ Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education None/primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Other Current employment Not employed For cash Not for cash Number of decisions in which women has final say2 0 1-2 3-4 5 Total3 32.8 41.3 37.4 38.5 26.0 51.9 1,574 54.9 66.8 59.1 64.5 46.7 26.7 1,541 68.8 86.7 77.1 83.3 60.5 8.8 1,256 72.4 88.0 77.9 85.8 63.8 6.3 1,060 71.7 89.3 78.5 84.0 63.3 7.3 974 73.3 88.4 76.4 84.0 62.5 7.8 845 72.6 90.5 78.0 83.6 63.0 6.2 669 35.2 43.9 39.9 42.5 28.8 49.2 2,563 72.9 89.6 78.6 85.1 63.3 5.9 4,892 71.5 88.8 77.3 84.1 63.7 7.3 463 39.7 49.2 44.2 47.3 32.6 44.0 2,942 75.1 91.1 80.9 87.5 67.0 5.0 2,334 71.9 89.8 78.4 85.7 62.5 5.7 1,710 69.5 87.4 74.5 79.4 58.0 8.2 934 68.0 80.7 73.0 78.4 60.3 14.6 3,691 54.2 69.6 59.9 65.0 45.1 24.7 4,228 72.0 84.4 77.4 81.5 65.5 12.7 1,038 49.6 61.7 53.9 50.9 43.7 36.0 1,145 67.5 83.1 75.7 74.8 58.9 12.4 709 61.6 67.9 59.6 70.1 53.5 22.5 1,628 72.9 85.9 75.8 80.2 61.3 9.4 1,607 46.3 70.7 60.2 69.9 37.8 24.3 1,791 54.1 69.4 60.4 64.8 45.2 24.9 5,800 76.8 89.6 80.6 88.4 69.4 6.6 1,556 82.2 90.1 83.5 90.8 76.5 6.8 563 57.8 73.3 64.2 69.0 49.4 21.5 6,191 68.1 76.4 68.5 75.5 58.8 16.3 857 72.8 83.9 76.2 83.0 65.1 13.0 871 55.1 69.9 61.5 65.5 46.9 24.6 3,995 66.1 79.9 70.6 77.2 57.6 15.3 3,867 71.1 83.2 74.1 76.0 63.4 13.7 43 34.7 43.4 40.7 42.0 28.9 49.1 1,264 55.7 71.5 62.9 67.1 45.9 21.9 1,535 63.2 84.3 69.9 77.9 52.4 11.3 1,265 70.2 83.3 74.2 80.3 62.2 12.6 3,855 60.6 74.8 66.0 71.2 52.2 20.0 7,919 ______________________________________________________________________________________________________ Note: Parentheses indicate that a figure is based on 25-49 unweighted cases 1 Acquired Immuno Deficiency Syndrome 2 Either by herself or jointly with others 3 Total includes 13 cases for which information on employment status was missing Women’s Characteristics, and Status * 35 youngest women (age 15-19), never-married women, women with no children, and women who do not participate in any household decisions. Almost half of all of these women say that women are not justified in refusing their husbands sex for any of the four reasons asked about. Employed women are more likely to agree with each of the four reasons for refusing sex, than unemployed women. Also the likelihood that women will agree with all of the four reasons increases sharply with women’s participation in decision making: only 29 percent of women who do not participate in any decision say that women can refuse sex to their husbands for all of the four reasons compared with 62 percent of women who participate in all five decisions. Women in Turkmenistan, in general, score high on this measure of empowerment. Nonetheless, the fact that 48 percent of all women, as well as 23 percent of the most educated women and 38 percent of women with the highest level of decision making participation, say that there is at least one reason out of these four for which women are not justified in refusing sex to their husbands does suggest that a significant proportion of women do not feel that a wife has the right to unconditionally decide whether and when she wishes to have sex with her husband. This has implications not only for women’s empowerment, but also for those health initiatives that rest implicitly on the assumption that women can control sexual encounters or feel justified in doing so. 36 * Women’s Characteristics, and Status 1 Numerators for age-specific fertility rates are calculated by summing the number of live births that occurred in the 1 to 36 months preceding the survey (determined from the date of interview and birth date of the child) and classifying them by age (in five-year groups) of the mother at the time of birth (determined from the birth date of the mother). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1 to 36 months preceding the survey. Fertility * 37 FERTILITY 4 C.M. Nazarov, A. Mukhamedova, and K. Weinstein For the TDHS 2000 data to accurately describe the fertility status of the population of Turkmenistan, it was necessary for women to state their complete pregnancy history. To promote reporting of all pregnancies that women have had, the TDHS asked women to make separate accountings of live births, abortions (both induced and miniabortions), miscarriages, and stillbirths. The accounting of live births was achieved by asking separately about the number of sons and daughters living with the respondent, the number living elsewhere, and the number who had died. The accounting of all pregnancies was double-checked by interviewers probing for intervening pregnancies in all pregnancy intervals. Each woman’s pregnancy history was obtained in reverse chronological order, from the most recent pregnancy to the respondent’s first pregnancy. The outcome of each pregnancy was recorded (live birth, induced abortion, miniabortion, miscarriage, or stillbirth), as was the date the pregnancy ended. For each pregnancy that resulted in a live birth, information was collected on the sex of the child, survival status, and age (for living children) or age at death (for deceased children). For each pregnancy that did not result in a live birth, duration of the pregnancy was collected and recorded in the calendar portion of the questionnaire. This chapter presents the findings pertaining to live births. Findings pertaining to pregnancy loss are presented in chapter 6 of this report. 4.1 CURRENT FERTILITY Age-specific fertility rates (ASFRs) and the total fertility rate (TFR) presented in Table 4.1 and Figure 4.1 were calculated directly from the information obtained in the pregnancy history. The reported rates refer to the three-year period preceding the survey. Age-specific fertility rates were calculated by dividing the number of births to women in a five-year age interval by the number of woman-years lived in that age interval.1 The total fertility rate is a construct of the age- specific rates computed by summing the age-specific rates and multiplying by five. The TFR is expressed per woman and is calculated to provide a snapshot view of current fertility levels. The TFR is interpreted as the number of children a woman would have in her lifetime if she experienced the currently observed age-specific fertility rates during her childbearing years. If fertility were to remain constant at current levels, Turkmen women would give birth to an average of 2.9 children. Fertility among urban women is lower than it is among rural women during most of the childbearing years, resulting in a TFR among urban women that is 0.8 children lower than among rural women. If fertility were to remain constant at current levels, urban women would have 2.5 children, while rural women would have 3.3 children. Urban women experience their peak childbearing years during their early twenties (age 20-24) while rural women go on to experience their highest rates of childbearing in their late twenties (25-29). 38 * Fertility Table 4.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by residence and ethnicity, Turkmenistan 2000 _____________________________________________________________________ Residence Ethnicity ________________ _________________________ Age group Urban Rural Turkmen Uzbek Other Total _____________________________________________________________________ 15-19 36 26 26 61 21 30 20-24 165 199 179 255 143 184 25-29 144 244 213 147 105 195 30-34 87 124 118 65 44 105 35-39 50 47 51 42 33 48 40-44 11 17 15 9 9 14 45-49 0 3 2 (0) (0) 1 TFR 15-49 2.46 3.30 3.02 2.90 1.78 2.89 TFR 15-44 2.46 3.28 3.01 2.90 1.78 2.88 GFR 87 116 107 114 59 103 CBR 20.5 28.2 - - - 24.6 ____________________________________________________________________ Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. Rates in parentheses indicate that they are based on fewer than 250 woman-years of exposure. TFR: Total fertility rate, expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population 2 The Ministry of Health and Medical Industry reports the following crude birth rates: 28.1 in 1995, 24.0 in 1996, 21.6 in 1997, 20.8 in 1998, and 18.5 in 1999. Fertility * 39 Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage currently pregnant and mean number of children ever born to women age 40-49, by background characteristics, Turkmenistan 2000 _________________________________________________________ Mean number of children Total Percentage ever born Background fertility currently to women characteristic rate1 pregnant1 age 40-49 _________________________________________________________ Residence Urban 2.46 3.65 4.05 Rural 3.30 5.07 5.71 Region Ashgabad City 2.10 3.46 3.25 Akhal 2.91 4.68 5.27 Balkan 2.68 3.41 4.82 Dashoguz 3.14 4.98 5.77 Lebap 2.97 5.40 4.78 Mary 3.09 3.79 4.92 Education Primary/secondary 3.03 4.58 5.40 Secondary-special 2.59 3.76 3.57 Higher 2.59 4.42 3.52 Ethnicity Turkmen 3.02 4.52 5.25 Uzbek 2.90 5.25 5.31 Other 1.78 2.80 2.87 Total 2.89 4.41 4.84 ________________________________________________________ 1Women age 15-49 years Women of Turkmen and Uzbek ethnicity exhibit similar overall levels of fertility: Turkmen women exhibit a TFR of 3.0 and Uzbek women exhibit a TFR of 2.9. Women of other ethnicities exhibit a significantly lower level of fertility than either Turkmen or Uzbek women, exhibiting a TFR of only 1.8 children. Table 4.1 also presents two other summary measures of fertility: the general fertility rate (GFR) and the crude birth rate (CBR). These measures are calculated from the birth history data for the three-year period preceding the survey and the age and sex distribution of the household population. The GFR represents the annual number of births in the population per 1,000 women age 15-44. The crude birth rate is the annual number of births in the population per 1,000 population. The CBR of 24.6 as calculated from the TDHS data is higher than that reported by the Ministry of Health and Medical Industry for 1999 of 18.5.2 Table 4.2 and Figure 4.2 present TFRs for the three years preceding the survey by background characteristics. The greatest regional variation in fertility is seen between Ashgabad City and the rest of Turkmenistan. With a TFR of 2.1, women in Ashgabad City exhibit a TFR that is one child fewer than women elsewhere in Turkmenistan, who exhibit TFRs between 2.9 and 3.1, with the exception of the Balkan Region, which exhibits a slightly lower TFR of 2.7. 40 * Fertility Women in Turkmenistan exhibit a childbearing pattern, observed in many societies, of lower fertility among women with higher education. The TFR declines from 3 children per woman among women with primary or secondary education to 2.6 children among women with either secondary- special or higher education. Table 4.2 also shows the percentage of women who report themselves to be currently pregnant. Because women at early stages of pregnancy may not yet know they are pregnant, this proportion may be underestimated. Percentages are generally low, commensurate with fertility that is relatively low overall. Table 4.2 also shows the mean number of children ever born (CEB) to women age 40-49. Trends in fertility can be inferred by comparing the TFR (a measure of current fertility) with the mean number of CEB (a measure of completed fertility). If there had been no change in fertility for three or more decades before the survey, the TFR and CEB would be nearly the same. That the TFR (2.9 children per woman) is as much as two children lower than the CEB (4.8) indicates that fertility has declined in Turkmenistan over the past three decades. The TFR is lower than the CEB among both urban and rural women and in every region, educational level, and ethnic group. 3 Truncation progressively limits how far into the past fertility rates can be calculated. For example, rates cannot be calculated for women age 40-44 for the period 10-14 years before the survey because these women would have been over age 50 years at the time of the survey and therefore not interviewed. Partial rates (based on partial exposure time) can be calculated for women age 40-44 for the period 5-9 years before the survey because some of these women were age 45-49 at the time of the survey and therefore included for interview. Partial rates that are subject to truncation are shown in brackets in Table 4.3. Fertility * 41 Table 4.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother’s age at the time of birth, Turkmenistan 2000 _________________________________________________ Number of years preceding the survey _________________________________ Mother’s age 0-4 5-9 10-14 15-19 _________________________________________________ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 29 30 21 24 192 224 243 256 204 267 307 310 113 179 208 [214] 50 78 [128] - 16 [30] - - [2] - - - _________________________________________________ Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 4.2 FERTILITY TRENDS To examine fertility trends more directly, it is possible to look at the ASFRs over time. Age-specific fertility rates can be calculated for the preceding 20 years from the TDHS data.3 Table 4.3 presents age- specific fertility rates for five-year periods preceding the survey using data on live births from respondents’ pregnancy histories. With the exception of 15- to 19- year-olds, there is evidence of a decline in fertility for all cohorts for which rates can be calculated. The decline in fertility from 5 to 9 to 0 to 4 years prior to the survey increases from a 14 percent decline among 20- to 24-year-olds to a 36 percent decline among 35- to 39-year-olds. The TDHS data indicate that fertility among 25- to 29-year-olds has fallen by one-quarter over the past 20 years. Figure 4.3 provides a graphical representation of these declines. 42 * Fertility 4.3 CHILDREN EVER BORN AND LIVING Table 4.4 presents the distribution of all women and currently married women by number of children ever born. The main difference between the data for currently married women and the total sample occurs among women under the age of 25, the majority of whom are unmarried, with no children. The table also shows the mean number of children ever born by five-year age group of the mother. The mean number of children ever born among all women is only two children; among currently married women, it is three children. Again, the difference is largely due to the fact that the youngest women have not yet had their children. The mean number of children ever born rises steadily with age, reaching five children among women age 45-49. A cursory view of the survival status of children can be made by comparing the mean number of children ever born to the mean number surviving, which is also shown in Table 4.4. Overall, 10 percent of live births had not survived to the time of the survey. The proportion of children who have not survived to the time of the survey slowly increases from 8 percent among women currently age 20-24 to 13 percent among women age 45-49. 4.4 Children ever born and living Percent distribution of all women and currently married women by number of children ever born, and mean number of children ever born and mean number of ever born living children, according to five-year age group, Turkmenistan 2000 _______________________________________________________________________________________________________________________________ Mean Number of children ever born (CEB) Number Mean number __________________________________________________________________________ of number of living Age group 0 1 2 3 4 5 6 7 8 9 10+ Total women of CEB children _______________________________________________________________________________________________________________________________ ALL WOMEN _______________________________________________________________________________________________________________________________ 15-19 97.4 2.5 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,574 0.03 0.03 20-24 61.4 21.6 13.3 3.2 0.3 0.1 0.0 0.0 0.0 0.0 0.0 100.0 1,541 0.60 0.55 25-29 21.4 20.6 36.2 16.1 4.4 1.1 0.2 0.0 0.0 0.0 0.0 100.0 1,256 1.66 1.52 30-34 6.7 9.8 26.4 30.2 17.8 5.4 2.8 0.7 0.1 0.1 0.0 100.0 1,060 2.75 2.51 35-39 5.1 5.3 14.3 22.5 22.8 18.3 7.7 2.7 0.5 0.5 0.3 100.0 974 3.61 3.21 40-44 2.6 3.6 9.3 13.8 18.2 18.1 16.5 8.7 4.9 2.4 1.8 100.0 845 4.68 4.14 45-59 1.4 6.8 8.7 11.8 11.1 18.3 14.4 12.8 6.8 4.0 4.0 100.0 669 5.05 4.38 Total 36.6 10.90 15.4 12.5 8.8 6.7 4.3 2.5 1.2 0.7 0.6 100.0 7,919 2.12 1.90 _______________________________________________________________________________________________________________________________ CURRENTLY MARRIED WOMEN _______________________________________________________________________________________________________________________________ 15-19 55.5 42.7 1.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 83 0.46 0.42 20-24 18.3 44.5 29.1 7.3 0.6 0.3 0.0 0.0 0.0 0.0 0.0 100.0 682 1.28 1.19 25-29 7.2 23.2 43.1 19.6 5.3 1.3 0.2 0.1 0.0 0.0 0.0 100.0 1,015 1.98 1.82 30-34 1.8 8.4 27.3 32.5 19.9 6.0 3.1 0.8 0.1 0.1 0.0 100.0 934 2.97 2.70 35-39 2.6 4.8 12.8 23.3 24.2 19.3 8.6 2.9 0.6 0.5 0.3 100.0 857 3.79 3.38 40-44 1.6 2.9 8.5 12.4 19.0 19.2 17.9 9.4 4.8 2.3 2.0 100.0 765 4.84 4.28 45-49 0.7 5.4 7.3 11.3 11.1 18.0 16.2 13.7 7.2 4.7 4.3 100.0 556 5.27 4.59 Total 6.1 15.3 22.6 18.6 13.5 9.9 6.8 3.7 1.7 1.0 0.9 100.0 4,892 3.18 2.85 Fertility * 43 Table 4.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Turkmenistan 2000 _________________________________________________________________________________________________ Number of months since previous birth Median Number ______________________________________ number of of Characteristic 7-17 18-23 24-35 36-47 48+ Total months births _________________________________________________________________________________________________ Age of mother 15-19 * * * * * 100.0 * 2 20-29 27.1 23.0 33.0 9.5 7.4 100.0 24.0 1,161 30-39 10.5 14.8 33.5 13.9 27.3 100.0 31.7 1,093 40+ 2.6 6.2 19.5 17.0 54.8 100.0 55.0 146 Birth order 2-3 21.3 20.7 32.3 10.9 14.9 100.0 26.1 1,666 4-6 11.6 12.4 33.0 13.8 29.3 100.0 32.3 626 7+ 5.5 15.4 30.2 18.5 30.4 100.0 34.9 109 Sex of prior birth Male 17.3 19.1 30.1 12.5 21.0 100.0 28.3 1,168 Female 18.8 17.5 34.5 11.4 17.8 100.0 27.3 1,233 Survival of prior birth Yes 15.2 18.8 33.1 12.7 20.3 100.0 28.3 2,113 No 38.7 14.7 27.6 6.8 12.2 100.0 22.9 288 Residence Urban 14.7 15.2 29.5 12.9 27.6 100.0 29.9 920 Rural 20.1 20.2 34.2 11.4 14.2 100.0 26.4 1,481 Region Ashgabad City 14.4 11.9 34.9 9.2 29.6 100.0 30.0 220 Akhal 15.7 19.0 31.8 12.4 21.0 100.0 27.9 340 Balkan 12.3 12.2 28.1 16.6 30.7 100.0 34.8 177 Dashoguz 17.3 21.5 35.7 11.1 14.3 100.0 26.6 564 Lebap 18.2 18.9 30.2 14.2 18.5 100.0 27.3 480 Mary 22.7 18.4 31.7 10.5 16.7 100.0 26.9 620 Education Primary/secondary 18.4 18.9 34.1 11.6 17.0 100.0 27.4 1,679 Secondary-special 17.9 18.2 27.6 12.7 23.6 100.0 28.2 538 Higher 14.9 13.0 30.9 13.7 27.5 100.0 30.6 184 Ethnicity Turkman 18.8 18.8 32.6 11.9 17.8 100.0 27.3 1,994 Uzbek 14.9 18.1 34.5 14.0 18.6 100.0 28.2 276 Other 13.9 10.5 24.2 8.2 43.2 100.0 36.5 132 Total 18.0 18.3 32.4 12.0 19.3 100.0 27.7 2,401 _________________________________________________________________________________________________ Note: First births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 4.4 BIRTH INTERVALS The length of birth intervals is an important component of childbearing. Research has shown that children born too close to a previous birth have an increased risk of dying, especially when the interval between births is less than 24 months. Table 4.5 presents the percent distribution of second- and higher-order births in the five years prior to the survey by the number of months since the previous birth. The median birth interval length is 27.7 months, just over 2 years. Overall, 36 percent of births occur within 24 months of the previous birth (see Figure 4.4). 44 * Fertility Two-thirds of closely spaced births occur to women who are in their twenties. Half the births these women had were born within 24 months of the previous birth. Because these are young women, the lowest birth orders (two or three births) also show the greatest likelihood of being born soon after the previous birth. Births that occur after a prior death are more likely than births following a living child to be born within 24 months: half versus one-third, respectively. Table 4.5 shows that the distribution of births by birth interval length varies by other background characteristics as well. Forty percent of births born to rural women were born within 24 months of the previous birth, whereas 30 percent of births to urban women were born so soon thereafter. Births to women in the regions of Mary, Dashoguz, Lebap, and Akhal are all more likely to be born within 24 months of the previous birth (35 to 41 percent are born within this interval) than are births to women in Ashgabad City or the Balkan Region, where one-quarter of births are born within this interval. A differential of the same magnitude is observed by education and ethnicity. Thirty-seven percent of births to women with primary, secondary, or secondary-special education are born within 24 months of the previous birth, whereas 28 percent of births to women with higher education are born within this interval. Thirty-eight percent of births to Turkmen women and 33 percent of births to Uzbek women are born within 24 months of the previous birth, whereas 24 percent of births born to women of other ethnicities are born within this interval. Fertility * 45 Table 4.6 Age at first birth Percent distribution of women 15-49 by age at first birth, according to current age, Turkmenistan 2000 ___________________________________________________________________________________________________ Women Median with Age at first birth Number age at no _________________________________________ of first Current age births <15 15-17 18-19 20-21 22-24 25+ Total women birth ___________________________________________________________________________________________________ 15-19 97.4 0.0 1.0 1.6 na na na 100.0 1,574 a 20-24 61.4 0.1 1.8 12.6 14.8 9.4 0.0 100.0 1,541 a 25-29 21.4 0.1 1.7 11.0 22.4 30.6 12.9 100.0 1,256 23.3 30-34 6.7 0.1 0.8 9.1 21.8 38.1 23.5 100.0 1,060 23.4 35-39 5.1 0.0 1.5 8.6 24.7 34.9 25.3 100.0 974 23.3 40-44 2.6 0.0 1.2 17.7 30.0 30.6 18.0 100.0 845 22.1 45-49 1.4 0.2 3.9 21.5 28.8 28.7 15.6 100.0 669 21.7 _________________________________________________________________________________________________ na = Not applicable a Median not included because less than 50 percent of the women in the age group x to x+4 had a birth by age x 4.5 AGE AT FIRST BIRTH The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. Early initiation into childbearing is generally associated with large family size and rapid population growth when family planning is not widely practiced. Table 4.6 presents the percent distribution of women by age at first birth according to current age. Initiation into childbearing is heavily concentrated within the ages of 20-24. Women now in their twenties and thirties are less likely than women now in their forties to have begun childbearing in their teens. So while initiation into childbearing is concentrated within the early twenties, there has been a slight shift, resulting in a median age of initiation among women in their late twenties and thirties that is 1 year later than the median age among women in their early forties and 1.5 years later than women in their late forties. This slight increase among women age 25-39, compared with women in their forties, can also be seen in Table 4.7, which presents the median age at first birth for cohorts age 25 and above across background characteristics. The only other differential of note is by ethnicity. Turkmen women initiate childbearing, on average, at a later age than do Uzbek women or women of other ethnicities. Turkmen women age 25-29 have a median age at first birth (23.7) that is two years later than Uzbek women (21.6) or women of other ethnicities (21.4). 46 * Fertility Table 4.7 Median age at first birth Median age at first birth among women age 25-49 years, by current age and background characteristics, Turkmenistan 2000 __________________________________________________________________________________________ Current age _________________________________________________ Background Ages characteristic 25-29 30-34 35-39 40-44 45-49 25-49 __________________________________________________________________________________________ Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education Primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Other Total 22.8 23.1 23.2 22.1 21.9 22.7 23.6 23.7 23.3 22.1 21.6 23.0 23.2 22.8 23.7 22.3 22.5 23.0 23.6 23.2 23.2 22.2 21.5 22.9 23.7 24.3 24.0 23.0 21.6 23.5 23.9 24.3 23.5 21.9 21.8 23.2 22.3 22.7 22.6 22.5 21.1 22.3 23.4 23.5 22.8 21.7 21.7 22.8 23.1 23.3 23.0 21.7 21.4 22.5 23.0 23.2 23.4 22.7 21.7 23.0 a 24.4 24.8 25.1 24.5 24.8 23.7 23.7 23.5 22.3 21.7 23.2 21.6 22.4 21.9 21.5 21.4 21.7 21.4 21.7 22.4 21.6 21.7 21.8 23.3 23.4 23.3 22.1 21.7 22.9 __________________________________________________________________________________________ Note: The medians for cohorts 15-19 and 20-24 could not be determined because half the women have not had a birth before reaching age 15 and age 20, respectively. a Omitted because less than 50 percent of the women in the age group x to x+4 have had a birth by age x. 4.6 PREGNANCY AND MOTHERHOOD AMONG WOMEN AGE 15-19 Fertility among women age 15-19 warrants special attention because young mothers at this age as, well as their children, are at high risk of encountering social and health problems. There has been much research done on this topic, but the causality of the problems has proven difficult to identify. Children born to young mothers are associated with higher levels of illness and mortality during childhood than are children born to older mothers. Table 4.8 presents the percentage of women age 15-19 who are mothers or pregnant with their first child. The TDHS reports that early childbearing is minimal in Turkmenistan, almost nonexistent before the age of 19. Twelve percent of women age 19 have begun childbearing in Turkmenistan. Fertility * 47 Table 4.8 Pregnancy and motherhood among women age 15-19 Percentage of women 15-19 who are mothers or pregnant with their first child, by background characteristics, Turkmenistan 2000 _______________________________________________________________________ Percentage who are: Percentage _____________________ who have Number Pregnant with begun child of Background characteristic Mothers 1st child bearing women _______________________________________________________________________ Age 15 16 17 18 19 Residence Urban Rural Education Primary/secondary Secondary-special Higher Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Ethnicity Turkmen Uzbek Other Total 0.0 0.0 0.0 296 0.0 0.2 0.2 319 1.4 1.9 3.3 320 3.1 2.4 5.5 307 8.3 3.3 11.7 333 2.8 1.0 3.8 659 2.5 2.1 4.6 915 2.8 1.5 4.3 1,480 0.0 4.1 4.1 71 * * * 23 0.0 0.0 0.0 157 3.4 2.1 5.5 241 4.1 2.9 7.0 128 2.4 1.3 3.7 336 2.8 2.2 5.0 349 2.8 1.3 4.1 364 2.5 1.4 3.9 1,263 4.3 2.0 6.3 178 1.8 3.6 5.4 132 2.6 1.6 4.3 1,574 _______________________________________________________________________ Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Women were asked about both the male condom and the female condom. Use of the word condom in this text will refer to the male condom; the female condom will be referred to explicit ly as the female condom. 2 Emergency contraception refers to pills that a woman can take the day after having sexual intercourse to avoid becom ing pregnant. The lactational amenorrhea method refers to a specifically taught method of pregnancy avoidance to delay the return of the menstrual period by feeding an infant only but breast milk for up to six months after birth. Contraception * 49 CONTRACEPTION 5 S.M. Turayeva, N.M. Bekmuradov, and K. Weinstein A primary function of reproductive health programs is to advocate conscious entry into parenthood for both men and women, i.e., to grant families the right to define their desired number of children and provide the means to achieve that goal. This involves the control of reproductive behavior, including conception, preservation of the fetus, and childbearing, as well as prevention of conception and interruption of pregnancy. Contraception not only helps couples avoid undesired pregnancies but also allows them to control the timing of their childbearing. By controlling the time they enter into parenthood, the time they stop childbearing, and the intervals between births, couples can achieve their ultimate desired family size. Appropriate spacing of pregnancies and births has positive effects on the overall health of both mother and child and is also a contributing factor in the reduction of maternal and infant mortality and secondary sterility. The efficacy of contraception depends on people’s knowledge of methods and on the availability of methods to meet the varying needs of a wide spectrum of potential users. Availability of methods, in turn, depends on the quality and quantity of service providers and on available financial and technical resources. The topics addressed in this chapter include knowledge of contraceptive methods, sources of supply, use of methods in the past and present, reasons for nonuse, desire to use in the future, and attitudes and exposure to messages about contraception. These data can serve as an information base for the Ministry of Health and Medical Industry to better define the need for contraceptives and better define the allocation of resources. 5.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Determining levels of knowledge and use of contraceptive methods was one of the major objectives of the TDHS survey. Data on contraceptive knowledge were collected by asking the respondent to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent did not mention a particular method spontaneously, the interviewer would describe the unmentioned method and ask whether the respondent had heard of such a method. Thus, knowledge of a contraceptive method is defined simply as having heard of a method. Contraceptive methods include both modern and traditional methods. Modern methods include the pill, the IUD, injectables, female and male sterilization, implants, barrier methods (diaphragm, foam, jelly, and both male and female condoms1), emergency contraception, and the lactational amenorrhea method (LAM).2 Traditional methods include periodic abstinence (rhythm method) and withdrawal. 50 * Contraception Table 5.1 Knowledge of contraceptive methods Percentage of all women, of currently married women, of sexually active unmarried women, of sexually inactive unmarried women, and of women with no sexual experience who know any specific contraceptive method, Turkmenistan 2000 ____________________________________________________________________________________________ Unmarried women _________________ Women Currently Not with no Contraceptive All married Sexually sexually sexual method women women active active experience ______________________________________________________________________________________________ Any method Any modern method Pill IUD Injection Diaphragm/cervical cap Foam/jelly Female condom Male condom Female sterilization Male sterilization Implants Emergency contraception Lactational amenorrhea (LAM) Any traditional method Periodic abstinence Withdrawal Other Mean number of methods known Number of women 93.5 99.3 * 98.7 81.5 93.5 99.3 * 98.7 81.5 67.1 79.2 * 78.8 41.8 92.3 98.5 * 97.9 79.4 62.9 75.0 * 69.2 38.6 7.7 9.3 * 16.9 2.9 13.4 16.3 * 24.8 5.9 6.3 7.5 * 10.4 3.4 59.6 68.4 * 69.7 41.1 34.2 42.3 * 44.1 17.0 8.9 10.9 * 16.1 3.7 3.2 4.0 * 3.3 1.6 7.7 9.6 * 12.9 3.1 64.6 87.5 * 80.6 17.9 44.6 61.2 * 57.1 10.6 28.9 38.6 * 40.8 8.2 33.2 46.7 * 40.8 6.2 4.8 6.8 * 8.8 0.3 4.9 6.0 * 6.1 2.7 7,919 4,892 6 460 2,561 ___________________________________________________________________________________________ Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Unmarried sexually active: Unmarried women who have had sexual intercourse in the 30 days preceding the survey. Unmarried not sexually active: Unmarried women who have had sexual intercourse but have not had sexual intercourse in the 30 days preceding the survey. Women with no sexual experience: Women who have never had sexual intercourse. LAM: Knowledge of lactational amenorrhea method includes women who know that to use the method, a woman must be exclusively or fully breastfeeding, be less than six months postpartum, be postpartum, be postpartum amenorrheic and who know to use another contraceptive method when any of the previous criteria do not hold. Information on knowledge of contraception is presented in Table 5.1. Every married woman has heard of the IUD (99 percent). Five modern methods are known to more than two-thirds of married women: the IUD (99 percent), LAM (88 percent), the pill (79 percent), injectables (75 percent), and the condom (68 percent). Female sterilization is known to 42 percent of married women. The remaining modern methods are known only to a minority of married women. Knowledge of a traditional method of contraception is substantial, but not universal; 39 percent of married women have heard of periodic abstinence, and 47 percent have heard of withdrawal. The mean number of methods known, also shown in Table 5.1, is a rough indicator of the breadth of knowledge of family planning methods. Married women know an average of six methods. Contraception * 51 Unmarried women are classified into three categories: unmarried women who have had sexual intercourse at some time in the past but are not currently sexually active, unmarried women who are currently sexually active, and finally, those who have never had sexual intercourse. Unmarried women who have had sexual intercourse at some time but are not currently sexually active have essentially the same levels of knowledge as currently married women. This is not surprising since most of these women are formerly married, either currently widowed or divorced. Unmarried women are considered to be not sexually active if they have not had intercourse in the 30 days preceding the survey. There were only six unmarried women who have had sexual intercourse who are currently sexually active, too few to show in the table. One method stands out as being known to women who have never had sexual intercourse; more than three-quarters of such women have heard of the IUD. All other methods are known to fewer than half the women who have never had sexual intercourse. Women who have never had sexual intercourse have heard of an average of 2.7 methods. For purposes of communicating information about methods of contraception, women of reproductive age who have not yet engaged in sexual intercourse are an audience as important as sexually active women because they are certain to engage in sexual activity in the near future. Table 5.2 presents the percentage of currently married women who know of at least one method of contraception (modern or traditional) and the percentage who know of at least one modern method, by background characteristics. Essentially every married woman knows of at least one modern method of contraception. The only category of women for whom knowledge is less than universal is women age 15-19, among whom nine out of ten know of a method. 5.2 EVER USE OF CONTRACEPTION All respondents who had heard of a method of contraception were asked whether they (or a partner with them) had ever used the method; each method was inquired about separately. An additional probe was made for women who reported no contraceptive use. The results are presented in Table 5.3 for all women and for currently married women by five-year age groups. Overall, 89 percent of currently married women have used a method of contraception at some time in their life, 87 percent have used a modern method. Most of women who have ever used a method have used either the IUD (61 percent of married women) or LAM (63 percent of married women). Other modern methods have been used by comparatively few married women. Condoms are the next most commonly used modern method with 10 percent of currently married women having used a condom at some time. Other modern methods have been used at some time by fewer than 10 percent of married women. Although more women have used modern methods more often than traditional methods, one-quarter of married women have in fact used a traditional method at some time. Sixteen percent of currently married women have used withdrawal, and 8 percent have used periodic abstinence. Only 59 percent of all women age 15-49 have used a method of contraception at some time. Levels of ever use among all women are lower than among currently married women because most of women who are not married have not yet had sexual intercourse and have not yet had cause to use a method. Thirty-two percent of respondents have never had sexual intercourse. Knowledge of contraception among these women is important since most of women who have not yet had sexual intercourse will do so at some time in the future, but statistics on use do not yet apply to these women. 52 * Contraception Table 5.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women who know at least one contraceptive method and who know at least one modern method, by background characteristics, Turkmenistan 2000 _________________________________________________________ Knows Knows any Number Background any modern of characteristic method method1 women __________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Ashgabad City Akhal Balkan Dashoguz Lebap Mary Education Primary/secondary Secondary-special Higher Ethnicity Turkmen Uzbek Other Total 91.2 91.2 83 99.0 99.0 682 99.9 99.8 1,015 99.8 99.8 934 99.2 99.2 857 99.4 99.4 765 99.2 99.2 556 99.1 99.1 2,307 99.6 99.5 2,585 98.9 98.9 639 99.6 99.6 699 98.1 98.1 424 99.2 99.2 950 99.3 99.2 1,030 100.0 100.0 1,150 99.1 99.1 3,347 99.9 99.9 1,149 99.7 99.7 396 99.4 99.4 3,776 98.7 98.7 554 99.6 99.6 563 99.3 99.3 4,892 _________________________________________________________ 1 Female sterilization, pill, IUD, injectables, implants, male condom, female condom, diaphragm, foam or jelly, lactational amenorrhea method (LAM), and emergency contraception. 5.3 CURRENT USE OF CONTRACEPTION Table 5.4 presents levels of current use of contraception for all women and for currently married women by five-year age groups. Figure 5.1 shows the distribution of currently married women by method currently used. More than half of currently married women (53 percent) are currently using a modern method of contraception, while only 9 percent are using a traditional method. As discussed in the section on ever use, most of women who are not married have not yet had sexual intercourse, so the discussion of use will focus on married women. Contraception * 53 Table 5.4 Current use of contraception Percent distribution of all women and currently married women, by contraceptive method currently used, according to age, Turkmenistan 2000 _________________________________________________________________________________________________________________________________________ Modern method Traditional method ____________________________________________________________ ____________________________ Lac- tational Any Female amenor- Any tra- Periodic Not Number Any modern Inject- Foam/ Male sterili- rhea ditional absti- With- using a of Age method method Pill IUD ables jelly condom zation (LAM) method nence drawal Other method Total women _________________________________________________________________________________________________________________________________________ ALL WOMEN _________________________________________________________________________________________________________________________________________ 15-19 1.5 1.2 0.0 0.4 0.0 0.0 0.1 0.0 0.7 0.3 0.0 0.2 0.1 98.5 100.0 1,574 20-24 24.1 21.6 0.3 12.1 0.2 0.0 0.4 0.1 8.4 2.5 0.3 1.4 0.7 75.9 100.0 1,541 25-29 50.2 45.0 1.5 29.1 0.6 0.0 2.2 0.6 10.9 5.2 0.8 3.8 0.7 49.8 100.0 1,256 30-34 63.2 54.8 1.2 42.2 1.0 0.2 2.8 1.1 6.3 8.4 1.7 5.4 1.3 36.8 100.0 1,060 35-39 66.9 57.2 1.1 46.5 1.0 0.0 1.4 3.1 4.1 9.6 3.0 5.2 1.4 33.1 100.0 974 40-44 63.4 52.5 1.5 42.9 1.6 0.0 2.2 3.6 0.7 10.9 3.4 6.7 0.8 36.6 100.0 845 45-49 33.1 26.6 0.0 22.3 0.6 0.0 0.4 3.2 0.1 6.5 1.9 3.6 1.0 66.9 100.0 669 Total 39.2 33.8 0.8 24.9 0

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