Uganda - Demographic and Health Survey - 1989

Publication date: 1989

Uganda Demographic and Health Survey 1988 ! 1989 Ministry of Health _ hw*~ Demographic and Health Surveys Institute for Resource Development/Macro Systems, Inc. © Uganda Demographic and Health Survey 1988/1989 Emmanuel M. Kaijuka Edward Z.A. Kaija Anne R. Cross Edilberto Loaiza Ministry of Health Entebbe, Uganda In collaboration with Ministry of Planning and Economic Development Department of Geography, Makerere University Institute of Statistics and Applied Economics, Makerere University and Institute for Resource Development/Macro Systems, Inc. Columbia, Maryland USA October 1989 This report presents the findings of the Uganda Demographic and Health Survey. implemented by the Ministry of Health in 1988/1989. The survey was a collaborative effort between the Minislry of Health, the Ministry of Planning and Economic Development, Makerere University and the Institute for Resource Development (IRD). The survey is part of the worldwide Demographic and Health Surveys (DHS) programme, which is designed to collect data on fertility, family planning, and matecnal and child health. Funding for the survey was provided by the U.S. Agency for International Development through IRD (Contract No. DPE-3023-C-00-.4083-O0) and the Govenunont of Uganda. Additional information can be obtained from the Ministry of Health, P.O. Box 8, Entebbe, Uganda, (Telephone 042-20201, Telex 61372 HEALTH UGA) or the Ministry of Planning. Statistics Division, P.O. Box 13. Entebbe, Uganda (Telephone Number 042-20741) (Telex 20147 Entebbe). Additional information about rite DHS progranmae can be obtained by writing to: DHS Progranune, IRD//vlacro Systems, Inc., 8850 Stanford Boulevard, Suite 4000. Columbia, MD 21045, USA (Telephone 301-290-2800, Telex 87775, Fax 301-290- 2999) CONTENTS Page CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii L IST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v L IST OF F IGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv MAP OF UGANDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii CHAPTER 1. BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1,1 1,2 1.3 1.4 1.5 1.6 1.7 Geography, History, and the Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Availability of Demographic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Population and Family Planning Policies and Programmes . . . . . . . . . . . . . . . . . 3 Health Priorities and Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Objectives of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Organisation of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Background Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . 6 CHAFFER 2. MARRIAGE AND EXPOSURE TO THE RISK OF PREGNANCY . . . . . . . . . 11 2.1 2.2 2.3 2.4 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Polygamy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Age at First Union . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Breastfeeding, Postpartum Amenorrhoea and Abstinence . . . . . . . . . . . . . . . . . . . . 14 CHAPTER 3. FERTILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.1 3.2 3.3 Current Fertility Levels and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 CHAPTER 4. CONTRACEPTIVE KNOWLEDGE AND USE . . . . . . . . . . . . . . . . . . . . . . . . 27 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Contraceptive Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Contraceptive Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Knowledge of the Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Source of Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Attitude Toward Pregnancy and Reasons for Nonuse . . . . . . . . . . . . . . . . . . . . . . 37 Intention to Use in the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Attitude Toward Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 iii CHAPTER 5. 5.1 5.2 5.3 5.4 Page FERTILITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Future Fertility Preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Need for Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Ideal Number of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Unplanned Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 CHAPTER 6. 6.1 6.2 6.3 6.4 MORTAL ITY AND HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Maternity Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Child Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Nutritional Status of Otildren . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 APPENDIX A SURVEY DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 APPENDIX B ESTIMATES OF SAMPLING ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 APPENDIX C UGANDA DEMOGRAPHIC AND HEALTH SURVEY STAFF . . . . . . . . . . . . . 99 APPENDIX D QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 iv Table 1.1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 2.6 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 LIST OF TABLES Page Basic socioeconomic indicators, Uganda, Various years . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Demographic indices, Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Percent distribution of women by background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Percent distribution of women by level of education according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Percent of women who own or have access to selected household amenities according to residence and region, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Percent distribution of women by current marital status, according to age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Percentage of currently married women in a polygynous union, by age, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . 13 Percentage of women by age at first marriage, proportion of women married at different ages and median age at first marriage, according to current age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Median age at first union among women aged 20-49 years, by current age and background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Percentage of births whose mothers are still breastfeeding, postpartum amenorrhoeic, abstaining, or insusceptible, by number of months since birth, Uganda, 1988/1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Mean number of months of breastfeeding, postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility, by background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Total fertility rates (TFRs) for calendar periods and for five years preceding the survey, and mean number of children ever born (CEB) to women 40-49 years of age, by background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . 19 Crude birth rates and total fertility rates from various censuses, Uganda . . . . . . . . . . . . 21 Percent of all women who are currently pregnant by age, Uganda, 1988/89 . . . . . . . . . . 21 Age-period fertility rate by age of woman at birth of child, Uganda, 1988/89 . . . . . . . . 22 Percent distribution of all women and currently married women by number of children ever bom (CEB), according to age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . 22 Page Table 3.6 Table 3.7 Table 3.8 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Mean number of children ever born to ever-married women, by age at first marriage and years since first marriage, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . 23 Percent distribution of women by age at first birth, according to current age, Uga0da, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Median age at first birth among women aged 2049 years, by current age and background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Percentage of all women and currently married women knowing any contraceptive method and knowing a source (for information or services), by specific method, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Percentage of currently married women knowing at least one modem method and knowing a source for a modem method, by background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Percent distribution of women who have herd of a contraceptive method by main problem perceived in using the method, according to specific method, Uganda, 1988/1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Percent distribution of women knowing a contraceptive method by supply source they said they would use, according to specific method, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Percentage of all women and currently married women who have ever used a contraceptive method, by specific method and age, Uganda, 1988/89 . . . . . . . . . . . . . 32 Percent distribution of all women and currently married women, by contraceptive method currently being used, according to age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Percent distribution of currently married women, by contraceptive method currently being used, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Percent distribution of ever-married women by number of living children at the time of first use of contraception, according to current age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Percent distribution of all women and women who have ever used periodic abstinence by knowledge of the fertile period during the ovulatory cycle, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Percent distribution of current users of modem methods by most recent source of supply or information, according to specific method, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 vi Page Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Percent distribution of nonpregnant women who are sexually active and who are not using any contraceptive method by attitude toward becoming pregnant in the next few weeks, according to number of living children, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Percent distribution of nonpmgnant women who are sexually active and who are not using any contraceptive method and who would be unhappy if they become pregnant, by main mason for nonuse, according to age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Percent distribution of currently married women who are not currently using any contraceptive method, by intention to use in the future, according to number of living children, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Percent distribution of currently married women who are not using a contraceptive method, but who intend to use in the future, by prefermd method according to whether they intend to use in the next 12 months or later, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . . . . . . 39 Percent distribution of all women by whether they feel it is acceptable to have family planning information presented on the radio, in the newspaper, or taught in school, by background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . 40 Percent distribution of currently married women who know a contraceptive method by the husband and wife's attitude toward the use of family planning, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Percent of currently married women knowing a contraceptive method who approve of family planning and who say their husband approves of family planning by background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . 42 Percent distribution of currently married women knowing a contraceptive method by number of times discussed family planning with husband, according to current age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Percent distribution of currently married women by desire for children, according to number of living children, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . 45 Percent distribution of currently married women by desire for children, according to age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Percentage of currently married women who want no more children (including those sterilized) by number of living children and background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Percentage of currently married women who are in need of family planning and the percentage who am in need and intend to use family planning in the future by background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . 49 vii Page Table 5.5 Table 5.6 Table 5.7 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 6.9 Percentage distribution of rural women by distance to the closest facility offering family planning services by type of facility, Uganda, 1988/89 . . . . . . . . . . . . . 50 Percent distribution of all women by ideal number of children and mean ideal number of children for all women and currently married women, according to number of living children, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . 52 Mean ideal number of children for all women by age and background characteristics, Uganda, 1988/89 . 52 Infant and childhood mortality by five-year calendar periods, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Infant and childhood mortality by background characteristics of the mother for the ten-year period preceding the survey, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . 56 Infant and childhood mortality by selected demographic characteristics for the ten-year period preceding the survey, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . 58 Percent distribution of births in the 5 last years by type of prenatal care for mother and percentage of births whose mother received a tetanus toxoid injection, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . 58 Percent distribution of births in the last 5 years by type of assistance during delivery, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . 59 Mean number of children ever bern, surviving, and dead, and proportion of children dead among those bern, by age of women, Uganda, 1988/89 . . . . . . . . . . . . . . 60 Among all children under 5 years of age, the percent with health card seen by interviewer, the percentage who are immunised as recorded on a health card or as reported by the mother and , among children with health card seen, the percentage for whom BCG, DPT, Polio and Measles immunisations are recorded on the health card, according to age, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Among all children aged 12-23 months, the percent with health card seen by interviewer, the percentage who are immunised as recorded on a health card or as reported by the mother and, among children with health card seen, the percentage for whom BCG, DPT, Polio and Measles immunisations are recorded on the health card, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Among children under 5 years of age, the percentage reported by the mother to have had diarrhoea in the past 24 hours and the past 2 weeks, according to the background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 viii Page Table 6.10 Among children under 5 years of age, who had diarrhoea in the past two weeks, the percentage consulting a medical facility, the percentage receiving different treatments as reported by the mother, and the percentage not consulting a medical facility and not receiving treatment, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table 6.11 Among mothers of children under 5 the percent who know about ORT, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . 67 Table 6.12 Among children under 5 years of age, the percentage who am reported by the mother as having had fever in the past four weeks, and among them the percentage consulting a medical facility, the percentage receiving various treatments and the percentage not consulting a medical facility and not receiving treatment, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Table 6.13 Among children under 5 years of age, the percentage who are reported by the mother as having suffered from severe cough with difficult or rapid breathing in the past four weeks, and among them, the percentage consulting medical facility, the percentage receiving various treatments and the percentage not consulting a medical facility and not receiving treatment, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . 69 Table 6.14 Percent distribution of children aged 0-60 months by standard deviation category from the mean of height-for-age, using the NCHS/CDC/WHO international reference population, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Table 6.15 Percent distribution of children aged 0-60 months by standard deviation category from the mean of weight-for-height, using the NCHS/CDC/WHO intemational reference population, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Table 6.16 Percent distribution of children aged 0-60 months, the percent in each height-for-age standard deviation category by each weight-for-height standard deviation category (Waterlow classification) using the NCHS/CDC/WHO intemational reference population, Uganda, 1988/89 . . . . . . . . . . . . 76 Table 6.17 Percent distribution of children aged 0-60 months by standard deviation category from the mean of weight-for-age, using the NCHS/CDC/WHO international reference population, according to background characteristics, Uganda, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 APPENDIX A Table A.1 Summary of results of household and individual interviews, UDHS, 1988/89 . . . . . . . . . . . 80 Table A.2 Summary of results of household and individual interviews and response rates by place of residence, UDHS 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 ix Page APPENDIX B Table B.1 Table B.2.1 Table B.2.2 Table B.2.3 Table B.2.4 Table B.2.5 Table B.2.6 Table B.2.7 Table B.2.8 Table B.2.9 Table B.2.10 Table B.2.11 Table B.2.12 List of selected variables with sampling errors, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . 85 Sampling errors for the entire population, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Sampling errors for the urban population, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Sam ~ling errors for the rural population, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Sam ~ling errors for women aged 15-24, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Sam ~ling errors for women aged 25-34, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Sam ~ling errors for women aged 35-49, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Sam ~ling errors for West Nile Region, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Sam ~ling errors for East Region, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Sam ~ling errors for Central Region, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Sam ~ling errors for West Region, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Sam ~ling errors for South West Region, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Sampling errors for Kampala, UDHS, 1988/89 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 N~re l .1 N~m2.1 N~re3 .1 ~re4 .1 N~re4 .2 ~re4 .3 ~re4 .4 N~re4 .5 N~re5 .1 H~re5 .2 ~re6 .1 F ib re6 .2 H~re6 .3 ~re6 .4 ~re6 .5 H~re6 .6 LIST OF FIGURES Page Background characteristics of UDHS respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Union status by current age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Total fertility rate 0-4 years before the survey, and children ever born to women 40-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Family planning knowledge and use, currently married women, 15-49 . . . . . . . . . . . . . 28 Current use of family planning by residence and region, currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Current use of family planning by education and number of living children, currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Source of family planning supply, current users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Attitudes toward family planning, currently married women knowing a method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Fertility preferences, currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Fertility preferences by number of living children, currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Trends in infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Differentials in infant mortality for the period 1978-88 . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Immunisation coverage, children under 5 years with health cards . . . . . . . . . . . . . . . . . 63 Age distribution of measured children and all children . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Nutritional status of children 3-36 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Cress-tabulation of weight-for-height and height-for-age . . . . . . . . . . . . . . . . . . . . . . . . 77 xi PREFACE The Uganda Demographic and Health Survey (UDHS) was conducted at a time when Uganda needed baseline information for planning and implementing national and regional programmes. The survey was conducted as part of the worldwide Demographic and Health Surveys (DHS) programme in which surveys are being carried out in countries in Africa, Asia, Latin America and the Near East. The UDHS used an ample survey designed to collect information on fertility, family planning, and mammal and child health. The survey was conducted by the Ministry of Health in close collaboration with the Ministry of Planning and Economic Development, the Institute of Statistics and Applied Economics and the Geography Depamnent, Makerere University. Fieldwork for the Uganda Demographic and Health Survey was carried out from September 1988 to February 1989 with financial and technical assistance from the U.S. Agency for Intemational Development and the Uganda Government. The Institute for Resource Development (IRD), a Macro Systems company, provided technical assistance under terms of an agreement with the Uganda Government (through the Ministry of Health). The objectives of the UDHS were to collect data on fertility, family planning knowledge, attitudes and use among women; and on maternal and child health coverage such as immunisation, breastfeeding, diarrhoeal diseases in children, nutrition, maternity care and child morbidity and treatment. Planning for the UDHS started in 1987 when a statistical committee was set up by the Ministry of Health. Members included experts from the Ministry of Health, the Ministry of Planning and Economic Development, UNICEF, Makerere University and the Family Planning Association of Uganda. The role of the committee was to adapt the DHS model questionnaire to the social, economic, and health situation in Uganda. The UDHS would not have been completed successfully without the relentless effort and dedication of several institutions and individuals, especially the employees of the Ministry of Health, the Ministry of Planning and Economic Development, Makerere University, and the Institute for Resource Development. In particular, I wish to extend my gratitude and appreciation to the following individuals and institutions who contributed to the success of the UDHS project: Administrative: Mr. A.M. Ogola, Permanent Secretary, Ministry of Health; Mr. Paul Cohn, Health/Population/AIDS Officer; Mr. David Puckett, Technical Adviser for Child Survival (TACS). Technical: Dr. Emmanuel M. Kaijuka, Ministry of Health/UDHS Project Director; Mr. Edward Kaija, Ministry of Planning and Economic Development/UDHS Project Coordinator, Dr. James Ntozi, Institute of Statistics and Applied Economics, Makerere University; Dr. John Kabera, Department of Geography, Makerere University; Professor Ben Kiregyera, Makerere University/Sampler, Ms. Anne R. Cross, Mr. Roger Pearson and Dr. Edilberto Loaiza, DHS coordinators, Dr. Chris Scott and Dr. Alfredo Aliaga, DHS samplers, IRD/Macro Systems, Inc. Field Staff: Dr. V. Mwaka, Department of Geography, Makerere University/Field Coordinator;, Mr. Ssekamatte, Makerere University/Field Supervisor, Ms. Rose Kabasinguzi, Mwanamugimu Nutrition Unit, Mulago Hospital/Field Supervisor; and the field editors and enumerators. Data Processing: Mr. David Cantor, Ms. Elizabeth Britton, Dr. Sidney Moore, and Mr. Robert D. Wolf, lRD/Macro Systems, Inc.; Miss Catherine Zigiti, Ministry of Health and their assistants. xiii Institutions: The Ministry of Local Government, the Minisu-y of Planning and Economic Development, and the Family Planning Association of Uganda provided administrative and field staff. UNICEF provided both technical and financial support to UDHS project. In conclusion, I wish to extend my sincere thanks to all those who in one way or another contributed to the success of the UDHS project. Z.K.R. KAHERU Minister of Health xiv SUMMARY The Uganda Demographic and Health Survey (UDHS) was conducted by the Ministry of Health in 24 districts between September 1988 and February 1989. The sample covered 4730 women aged 15- 49. Nine northern districts were not surveyed due to security reasons (see map). The purpose of the survey was to provide planners and policymakers with baseline information regarding fertility, family planning, and maternal and child health. The survey data were also needed by UNFPA and UNICEF- Kampala for planning and evaluation of current projects in Uganda. The UDHS data indicate that fertility is high in Uganda, with women having an average of seven births by the time they reach the end of their childbearing years. Overall, fertility in Uganda has remained the same, that is, just over seven children per woman during the last 15 years. Women in urban areas, especially Kampala, have fewer children than women in rural areas. A significant finding is that fertility is linked to education: women with higher education have an average of 5 births, compared with 7 births for women with primary education. Childbearing begins at an early age, with 60 percent of Ugandan women having their first birth before the age of 20. Less than 3 percent of women have their first birth at age 25 or older. A major factor contributing to high fertility is age at first marriage; 54 percent of women marry before they reach 18 years of age and only 2 percent remain unmarried throughout their entire life. However, with increasing levels of education among women, there is evidence of a trend toward later marriage. The median age at first union has risen from 17 for older women to 18 for those age 20-24. Urban women marry 2 years later on average than rural women, while women with middle and higher education marry 4 years later than women with no education. Polygyny is common in Uganda, with 33 percent of currently married women reporting that their husband has other wives. The practice declines with higher levels of education. Breastfeeding and postpartum abstinence provide some protection from pregnancy after the birth of a child. In Uganda, babies are breastfed for an average of 19 months and postpartum amenorrhoea lasts an average of 13 months. However, sexual abstinence after a birth is short, with an average duration of only 4 months. UDHS data show a decline in duration of breastfeeding and postpartum abstinence, especially among younger, urban, and educated women. The low level of contraceptive use in Uganda is one of the leading factors contributing to high fertility, as evidenced by the UDHS data. Although 84 percent of currently married Ugandan women know at least one contraceptive method and 77 percent know of a source for a contraceptive method, only 22 percent have ever used a method; and only 5 percent are currently using a method. Low rates of use are due partially to the desire of women to have many children. However, access to family planning services may also be a factor since most clinics are in urban areas, while 89 percent of women live in rural areas. Among currently married women using contraception, periodic abstinence is the most common method used (1.6 percent), followed by pill (1.1 percent) and female sterilisation (0.8 percen0. Contraceptive use is higher among women with more children and women who reside in urban areas, especially Kampala. There are strong differentials in family planning use by education level. The level of use among women with higher education is eighteen times the rate for women with no education. Forty-two percent of users of modern methods obtained their method from government hospitals, while 33 percent reported Family Planning Association of Uganda (FPAU) clinics as the source. Ten percent of users rely on private sources such as private doctors and clinics. XV The most common reasons for nonuse of contraception cited by women who are exposed to the risk of pregnancy, but do not want to get pregnant immediately are: fear of side effects, prohibition by religion, lack of knowledge, and disapproval by parmer. Despite the low level of contraceptive use in Uganda, the UDHS indicates that the potential need for family planning is great. Although 39 percent of the currently married women want another child soon (within 2 years), 33 percent want to space their pregnancies for at least two years and another 19 percent want no more children. This means that 52 percent of currently married women in the surveyed area are potentially in need of family planning services either to limit or to space their births. Furthermore, 35 percent of the women who had a birth in the 12 months prior to the survey indicated that their last birth was either unwanted or mistimed. UDHS data indicate that infant and childhood mortality remain high. For every thousand live births, 100 children die before reaching their first birthday and 180 children die before reaching age five. While these rates indicate high levels of mortality, there is some evidence that rates have declined in the five years before the survey. Forty-four percent of children under five with health cards have been fully immunised against the major vaccine-preventable diseases. This percentage is higher if children without health cards who have been immunised are included. UDHS data further indicated high levels of prevalence of certain illnesses. Of children under five, 24 percent had diarrhea in the two weeks before the survey. Forty-one percent of children under five were reported to have had a fever in the previous four weeks and 22 percent had an episode of severe cough with difficult or rapid breathing in the four weeks preceding the interview. Various types of treatment including antibiotics and antimalarials were used to treat the illnesses. The nutritional status of children in Uganda was assessed from UDHS data. Overall, 45 percent of the children age 0-60 months were found to be stunted, that is, two or more standard deviations below the mean reference population for height-for-age. These children are defined as chronically undernourished. xvi CHAPTER 1 BACKGROUND 1.1 Geography, History, and the Economy Geography The Republic of Uganda is located in East Africa and lies astride the equator (see map). It is a landlocked country bordering Kenya in the east, Tanzania and Rwanda in the south, Zaire in the west and Sudan in the north. The country has an area of 241,038 square kilometres, 18 percent of which is open water and swamps and 12 percent is forest reserves and game parks. Lake Victoria, the third largest lake in the world, makes up most of the open water area and is shared by Kenya and Tanzania. Uganda has a favourable climate because of its relatively high altitude. Temperatures range between 17°C and 26°C. The Central, West and South West regions receive heavy rainfall during the months of March through May and light rainfall between September and December. The levels of rainfall diminish towards the North as the border with the Sudan is approached. The soil composition varies accordingly, being generally fertile in the Central, West and South West regions and becoming less fertile as one moves from the East to the North. Due to these combinations of climatic conditions, Uganda has tropical rain forest vegetation in the south and savanna woodlands and semi-desert vegetation in the north. The regional agricultural potential is determined by these climatic conditions and the land's population carrying capacity is closely related to these agricultural potentials. History Uganda is composed of many tribal groupings of Bantu, Nilotics, Nilo-Hamites and those of Sudanese origin. Before independence, Uganda was basically divided into kingdoms or similar groupings consisting of mainly homogeneous tribal groups, which occupied various parts of the country, spoke various languages and had unique cultural identities. This diversity has given rise to a rich cultural and social heritage. One of the most widely spoken languages is Luganda, followed by Swahili and English. English is the official language of the country. Independence from British colonial rule was obtained in October 1962. After achieving sovereignty, Uganda became a member of the Commonwealth, the United Nations, the Organisation of African Unity, the African-Caribbean-Pacific States, and the Preferential Trade Area. At present Uganda is divided into 34 districts ~ which do not necessarily represent tribal groups, but were created for the ease of administration. Districts are further divided into 149 counties, 750 sub-counties and 3,721 parishes. In most cases parishes are divided into two sub-parisbes. The Economy Uganda has an agricultural economy with 90 percent of the population dependant on agriculture and agro-based industries. Agricultural produce contributes 98 percent of Uganda's exports and the country is basically self-sufficient in food. From 1960 to 1970, Uganda had an expanding economy with a Gross Domestic Product (GDP) growth rate of 5 percent per annum, compared to a population growth rate of 2.6 percent per annum. At the time of the survey there were 33 districts in Uganda. A 34th district consisting of islands in Lake Victoria was created recently. However, during the past 25 years, the country experienced a period of civil and military unrest with the resultant destruction of social infrastructure and disruption of the economy. This has had a tremendous negative impact on the economic, educational, and health situation of the general population. By 1985, per capita GDP had fallen 43 percent and per capita Gross National Product (GNP) was estimated at $220 (US). Since 1986, however, the National Resistance Movement Government has introduced and implemented a recovery programme which is steadily moving the country toward economic prosperity. Table 1.1 presents some basic socioeconomic indicators. Table i.I Basic socioeconomic indicators, Dganda, var ious years Indicator Year Value Populat ion (thousands) Total area (sq. km.) Land area (sq. km.) Women of chi ldbear ing age as percent of the total popul, Populat ion growth rate(year) Life e×pectancy - males - females Hospital beds Beds per 1O,00O populat ion Populat ion per physic ian 1988 15,947.8 1988 241,038 1988 197,100 1985 23 69-80 2.8 1969 45.6 1969 46.9 1981 20,136 1981 15 1981 23,009 Source: Ministry of P lanning and Economic DevelopMent, various Development Plans 1.2 Availability of Demographic Data The population of Uganda, estimated at more than 16 million, is increasing 2.8 percent per year. At this rate of growth, the population can be expected to double every 25 years. The high rate of growth is due primarily to the high levels of fertility prevailing in the country; each woman has an average of 7 children by the end of her childbearing years (Table 1.2). The first systematic census which generated useable demographic data was held in 1948. Prior to this date, there were administrative counts or estimates varying in methodology, coverage and content. After the 1948 census, other censuses were conducted in 1959, 1969 and 1980. Some data from the census of 1980 were not available for inclusion into this report. The next census will be conducted in 1990. Surveys have not been instrumental as a source of demographic data in Uganda. Although post- census or intercensal surveys were planned after each of the censuses, they were not implemented, due to logistical or financial problems. A few small-scale surveys were carried out by researchers at Makerere University, but none was representative of the whole country. Civil registration in Uganda is incomplete and of limited use as a source of demographic information. The Births and Deaths Registration Ordinance of 1904 provided for voluntary registration of the native population and people did not seriously respond to it. In 1973, registration was made compulsory. Efforts are being made to improve the system although coverage is still incomplete. 2 Table 1.2 Demographic indices, Uganda Census year I ndex 1948 1959 1969 1980 Populat ion 4,917,555 6,449,558 9,456,466 12,636,179 Intercensal growth rate 2.5 3.2 2.8 Sex ratio 100.0 100.8 101.8 98.2 Crude birth rate 42 44 50 50 Total fert i l i ty rate 5.9 5.9 7.1 7.4 Crude death rate 25 20 19 20 Infant mortal i ty rate 200 160 120 115 Percent urban 4.8 7.8 8.7 Density (Pop./Km.) 25.2 33.2 48.4 64.1 Source: Stat ist ics Department, Ministry of P lanning and Economic Development, Entebbe Information on emigration and immigration is collected at border posts, ports, and international airports where immigration cards are filled out. These cards collect social and demographic data on age, sex, date of birth, occupation, place of birth and residence, and reason for movement, in addition to place of origin and destination. There is evidence of sizeable illegal entrance and departure from the country. Internal migration is unrecorded and can only be estimated from censuses or surveys. There are official resettlement schemes which may have systematic records. As a result of the varying climatic conditions mentioned above, certain regions are more densely populated than others. The country is divided into four major administrative regions: East, West, North and Central, but for purposes of this report, the country is divided into six major regions: West Nile, East, Central, West, South West and Kampala. This division was due primarily to the different major languages into which the survey questionnaire was translated. Kampala region consisted of the capital city and its suburbs, and because of its high population compared to some regions, it was regarded as a region. 1.3 Population and Family Planning Policies and Programmes Family planning activities in Uganda started in 1957 with the establishment of the Family Planning Association of Uganda (FPAU), an affiliate of the International Planned Parenthood Federation (IPPF). Since the inception of the FPAU, family planning services have been largely limited to urban centres, despite the fact that 90 percent of the population resides in rural areas. With the acceptance and introduction of its primary health care strategy, the Govemment has integrated family planning into the overall matemal and child health program as a means of reducing matemal morbidity and mortality in Uganda. Currently, family planning services are provided through clinics administered by FPAU, government and non-government health units. Available data indicate that most accepters use oral contraceptives, female sterilisation, injectables and IUDs, while few couples use condoms. Natural family planning has gained some support in Uganda. A natural family planning programme organised by the Uganda Catholic Medical Secretariat covers most dioceses in Uganda and provides services through health units and home visits. 3 Since 1980, family planning has been increasingly viewed as an important component of maternal and child health. As a consequence, most government hospitals and health centres provide family planning services. In spite of this support and increasing family planning acceptance, national coverage has remained very low because of the heavy concentration of the services in the urban centres. Uganda does not have an explicit population policy, but in 1988, a population secretariat was established in the Ministry of Planning and Economic Development. The secretariat's overall responsibility is to coordinate population activities conducted in different ministries and to develop population guidelines for the country. 1.4 Health Priorities and Programmes Health services in Uganda are provided by the Ministry of Health, the Ministry of Local Government and non-government organisations (NGOs), particularly religious groups. The Ministry of Health is responsible for planning and developing health policies and for providing health care in all govemment hospitals. The Ministry of Local Government is in charge of health care delivery at the district level and below. NGOs provide services both to hospitals and to smaller medical units. In its continuing efforts to expand services to the majority of the population, the government is gradually shifting away from costly curative services to cost-effective, preventive services. The government is developing a health policy with the goal of health for all people by means of a nationwide network of preventive and curative health services in a self-sustaining cost recovery system. Particular emphasis is placed on maternal and child health services, environmental sanitation, provision of essential drugs, water supply, and health education. The goal of the system is to extend health coverage to all Ugandan citizens by the turn of the century through community participation. 1.5 Objectives of the Survey The primary objective of the UDHS was to provide data on fertility, family planning, childhood mortality and basic indicators of maternal and child health. Additional information was collected on educational level, literacy, sources of household water and housing conditions. The available demographic data were incomplete and hardly any recent information concerning family planning or other health and social indicators existed at the national level. A more specific objective was to provide baseline data for the South West region and the area in Central region known as the Luwero Triangle, where the Uganda government and UNICEF are currently supporting a primary health care project. In order to effectively plan strategies and to evaluate progress in meeting the project goals and objectives, there was a need to collect data on the health of the target population. Another important goal of UDHS was to enhance the skills of those participating in the project so that they could conduct high-quality surveys in the future. Finally, the contribution of Ugandan data to an expanding international data set was an objective of the UDHS. 1.6 Organisation of the Survey The Uganda Demographic and Health Survey (UDHS) was conducted between September, 1988 and February, 1989 by the Ministry of Health, with the assistance of the Statistics Department of the Ministry of Planning and Economic Development and both the Department of Geography and the Institute of Statistics and Applied Economics at Makerere University. Financial and technical support for the survey was provided by the Demographic and Health Surveys Programme at the Institute for Resource Development (IRD) in Columbia, Maryland, through its contract with the U.S. Agency for Intemational 4 Development (USAID). In addition, UNICEF provided some of the vehicles used for the listing operation and fieldwork. The UDHS used a stratified, weighted probability sample of women aged 15-49 selected from 206 clusters. Due to security problems at the time of sample selection, 9 districts, containing an estimated 20 percent of the country's population, were excluded from the sample frame. Primary sampling units in rural areas were sub-parishes, which, in the absence of a more reliable sampling frame, were selected with a probability proportional to the number of registered taxpayers in the sub-parish. Teams visited each selected sub-parish and listed all the households by name of the household head. Individual households were then selected for interview from this list. The South West region and the area in Central region known as Luwero Triangle were each oversamp~~ a sample- sLz_e sufficient to produce m"n-de-N~nile~V~-sguna~es of ce~ain v~ables for_ ~gse two alreas: i~esults fi'om oversampled areas are p~n~gra-~y3n- i i i i~ report. Because Ugandans often pay taxes in rural areas or in their place of work instead of their place of residence, it was not possible to use taxpayer rolls as a sampling frame in urban areas. Consequently, a complete list of all administrative urban areas known as Resistance Council Ones (RCls) was compiled, and a sampling frame was created by systematically selecting 200 of these units with equal probability. The households in these RCls were listed, and 50 RCls were selected with probability proportional to size. Finally, 20 households were then systematically selected in each of the 50 RCls for a total of 1,000 urban households. Three questionnaires were used for the UDHS: the bousehold questionnaire, the individual woman's questionnaire, and the service availability questionnaire. The household questionnaire listed all usual members of the household and their visitors, together with information on their age and sex and information on the fostering of children under 15. It was used to identify women who were eligible for the individual interview, namely, those aged 15-49 who slept in the household the night before the household interview, whether they normally lived there or were visiting. For those women who were either absent or could not be interviewed during the first visit, a minimum of three revisits were made before recording nonresponse. Women were interviewed with the individual questionnaire, which contained questions on fertility, family planning and maternal and child health. The service availability (SA) questionnaire collected information on family planning and health services and other socioeconomic characteristics of the selected areas and was completed for each rural cluster and for each urban area. The SA questionnaire was administered by a different team of interviewers from the one carrying out the individual women's interview. The same clusters chosen for the individual interviews were visited by the SA interviewer who was instructed to assemble 3 or 4 "knowledgeable" residents. These people were asked about the services available in the community and the distances to them. Based on this information, interviewers visited the facilities close to the cluster and collected information about equipment, staffing, services available, and general infrastructure. Results on service availability are not included in this report. The household and the individual questionnaires were translated into four languages: Luganda, Lugbara, Runyankole-Rukiga and Runyoro-Rutom. Luganda questionnaires were used in the East region, where there are a number of languages, but most people speak Luganda. A pretest of the translated questionnaires was conducted in October 1987 by interviewers who completed a three-week training course. A three-week training course for the main survey was held in September 1988. Fifty-six interviewers, six field editors and six supervisors took part in the survey. All interviewers were women, although some of the supervisors and field editors were men. Field staff were recruited from the Ministries of Health and Planning and from among people who answered advertisements in the national press and passed selection interviews. A major qualification of the interviewers was educational 5 achievement and a good command of at least one of the local languages covered by the four translations. All field staff had at least Senior Four secondary school education and several were university graduates. Senior survey staff came from the Ministries of Health and Planning, as well as Makerere University. The National Director of the UDHS was the Assistant Director of Medical Services in charge of Maternal and Child Health. IRD provided technical collaboration through periodic staff visits regarding sample selection, questionnaire design, anthropemetric measurement, training of interviewers, and data processing and analysis. Completed questionnaires were sent to the data processing room at Makerere University where data entry and machine editing proceeded concurrently with fieldwork. Four desktop computers and ISSA, the Integrated System for Survey Analysis, were used to process the UDHS data. Of the households sampled, 5,101 were successfully interviewed, a completion rate of 91.3 pement. A total of 4,857 eligible women were identified in these households, of which 4,730 were interviewed, a completion rate of 97.4 percent. Data entry and editing were completed a few days after fieldwork ended. 1.7 Background Characteristics of Survey Respondents Table 1.3 and Figure 1.1 show the background characteristics of all women interviewed in the survey. Encompassing 25 percent of UDHS respondents, 15-19 year olds are the largest age group. The percentages decrease gradually at each successive age group with 20-24 and 25-29 year olds constituting 21 and 18 percent, respectively. A young population distribution is to be expected in a country with nigh fertility such as Uganda. The data indicate that almost 12 percent of women between 15-49 years of age, live in urban areas. Comparison with census data shows that a slight increase in urbanisation may have taken place in the past 30 years (see Table 1.2); however, since the UDHS excluded the more rural nortbem part of the country, twelve percent is a slight overestimate. The distribution of women by region is divided: for East, Central and South West regions, each accounts for 25-30 percent of respondents, for West Nile, West, and Kampala, each accounts for 6 percent of respondents. Table 1.3 indicates that 44 percent of all women are Catholic, 42 percent are Protestant, 12 percent are Moslem, 1 percent are Seventh Day Adventists and less than 1 percent belong to other religions. Information on religion was collected because religious affiliation may affect attitude toward acceptance of certain family planning methods. All women interviewed in the UDHS were asked if they had ever attended school. Those who had were further asked the nighest level of school attended, according to the country's formal education system. Those women who had never attended school and those who had not completed primary education were requested to read a short sentence written in a local language. Respondents were grouped into five education categories: those with no education; those with 1-6 years of primary education (some primary); those who completed primary school (including those with Junior 1 level); those with some secondary school (middle--including those with Junior 2 or 3 or level 1-4 of secondary school) and those with more than a secondary 4 education (higher). The latter category also includes women who completed at least one year of vocational training after secondary 4 or who completed at least two years of vocational after secondary level 3. Almost 40 percent of respondents have never been to school and an additional 43 percent have only some primary education. Altogether, fewer than 20 percent have completed primary education, and only 3 percent have more than a secondary education. One reason for the low level of education among women has been the preference for educating boys rather than girls. For example, in 1982, there were twice as many boys as girls enrolled in Standard 7 in government schools. This situation is currently changing, due to vigorous govemment efforts, and soon females will be about equally represented at all levels of education. Table 1.3 Percent d istr ibut ion of women by back- ground characterist ics, Uganda, 1988/89 Weighted Unwtd. Background Weighted No. of No. of Character ist ic Percent Women Women Age 15-19 24.5 1157 1199 20-24 20.8 985 982 25-29 18.2 859 877 30-34 13.1 620 601 35-39 9.7 459 452 40-44 7.3 345 332 45-49 6.4 304 287 Residence Urban 11.5 542 964 Rural 88.5 4188 3766 Region West Nile 5.6 265 161 East 27.6 1305 865 Central 24.9 1177 1392 West 5.8 273 166 South West 29.9 1415 1619 Kampala 6.3 296 52T Luwero Triangle 10.4 491 873 Rel ig ion Cathol ic 44.3 2096 2062 Protestant 42.1 1991 2083 Musl im 11.6 547 489 Seventh Day Adventist 1.3 64 73 Other 0.7 32 23 Educat ion * NO education 37 .8 1788 1631 Some pr imary 43.3 2048 2030 Primary completed 8.7 410 447 ! Middle 7.8 367 443 ~ Higher 2.5 118 179 Total 100.0 4730 4730 * Throughout this report, women who completed Junior 1 were considered to have completed pri- mary. Those with Junior 2 or 3 were tabulated in Middle, along with those who completed sec- ondary educat ion up to level 4. Women with more than secondary 4 education were put in the Higher category, which includes women who went on to complete at least one year of vocat ional training after secondary 4 or who completed at least two years of such training after secondary 3. 7 100 80 60 40 20 0 Percent Figure 1.1 Background Characteristics of UDHS Respondents 88 18 43 38 ~-~ 7 6 12 15- 20- 25- ao - 35 - 40- 45- Ur - Ru- 19- 24- 29- 34- 39- 44- 49- ban ra l AGE GROUP RESIDENCE 9 8 Note: SP • Some Pr imary , CP • Complete P r imary , M • M idd le , H • Higher None SP CP M H EDUCATION Uganda DHS 1988/89 Table 1.4 shows that education is inversely related to age, that is, older women are less educated than younger women. For example, whereas 67 percent of women 45-49 have no education, only 21 percent of women aged 15-19 fall in this category. The proportion of respondents with no education is three times higher in rural areas (41 percent) than in urban areas (13 percent). Two major factors influence this urban-rural differential. First, access to schools is more difficult in rural than in urban areas. Secondly, rural children are more likely to drop out of school due to inability to pay school fees. Table 1.4 shows that West Nile region has the highest proportion of uneducated women, (65 percent), followed by South West region (46 percent) and East region (40 percent). Kampala has the smallest proportion of uneducated women (10 percent) and the highest proportion of women with middle (28 percent) and higher (17 percent) education. Until recently, vocational and university education was limited to Kampala, where most graduates with higher education remain. In addition to the question on educational attainment, respondents were shown sentences written in their language and asked to read them. The next-to-last column in Table 1.4 shows the percentage of women with no formal education who can read. About 9 percent of the women with no education can read; the percentage is higher among older women and among residents of Kampala and the South West region. Availability of various household amenities is an indicator of socioeconomic status, as well as having potential relevance for the health status of household members; the presence of a refrigerator may have an impact on nutrition and the presence of soap in the household may be regarded as a measure of personal hygiene, since it can be used for washing the body as well as washing utensils and clothes. Availability of a radio in a household is important since many educational messages, especially those regarding health education, are communicated by radio. Table 1.4 Percent distr ibut ion of women by level of education, according to background characterist ics, Uganda, 1988/89 Level of Educat ion Percent Weighted Background Literate Number Character- Some Pr imary with No of istic None Primary Complete Middle Higher Total Educat ion* Women Age 15-19 20.7 56.6 10.5 11.6 0.7 100.0 4.7 1157 20-24 30.0 44.1 12.0 9.9 4.0 I00.0 6.1 985 25-29 38.6 2.6 8.9 6.1 3.9 100.0 9.3 859 30-34 43.6 37.7 9.7 5.7 3.3 I00.0 9.7 620 35-39 52.5 32.6 4.8 7.1 3.0 100.0 12.5 459 40-44 59.3 34.1 2.9 2.9 0.6 I00.0 ll.l 345 45-49 67.4 29.9 0.6 1.8 0.3 100.0 7.6 304 Residence Urban 13.4 34.9 12.9 24.4 14.5 i00.0 14.7 542 Rural 41.0 44.4 8.i 5.6 0.9 lOO.O 8.4 4188 Region West Nile 65.2 27.3 3.1 2.5 1.9 i00.0 2.9 265 East 39.9 44.6 7.5 7.1 0.9 100.0 3.2 1305 Central 26.4 50.8 10.6 10.1 2.2 i00.0 7.1 1177 West 38.0 42.2 11.4 7.2 1.2 10g.0 7.9 273 South West 46.0 41.5 7.6 3.3 1.6 100.0 15.2 1415 Kampala 9.5 31.9 14.0 27.9 16.7 100.0 16.0 296 Total 37.8 43.3 8.7 7.8 2.5 I00.0 8.7 4730 * The proport ion of women with no educat ion who can read a sentence in their local language. Table 1.5 presents data on the percent of women who own or have access to various household possessions, according to residence and region. Only 7 percent of women have electricity in their homes, and consequently, very few have hot plates/cookers, refrigerators, or televisions. Thirty percent have a charcoal iron and 21 percent have a charcoal stove. More than one in three women has a bicycle in the household, and 85 percent have soap. Over one-quarter have access to a radio and more than one-third listen to a radio at least once a week. Not surprisingly, urban women am much more likely to have household amenities than rural women. One-half of urban women live in homes with electricity, and a majority of urban women have a radio, charcoal iron, and charcoal stove in their homes. Regionally, women in Kampala are far more likely to have access to these amenities than women in other regions, and women in West Nile are the least likely. For example, 76 percent of women in Kampala have a radio in their households, followed by Central and West regions (34 percent). Women in West Nile are the least likely to have radios (11 percent) and are therefore least likely to benefit from the messages sent by radio Uganda. 9 Table 1,5 Percent of women who own or have access to selected household amenit ies according to residence and region, Uganda, 1988/89 Residence Region West South KaJn- Household Amenity Urban Rural Ni le East Central West West pala Total E lectr ic i ty 51.1 1.7 0.0 4.2 6.5 0.0 2.3 62.6 7.4 Hot p late/cooker 25.0 0.6 0.0 1.2 2.4 O.0 0,7 36.4 3.4 Televis ion 14.6 0.2 0.0 1.0 0.2 0.0 0.1 23.9 1.9 Refr igerator 11.5 0.0 0.0 0.4 0.3 O.0 0.4 16.5 1.3 Charcoal iron 54.7 27.1 39.8 31.8 31.8 33.7 19.5 56.4 30.2 Charcoal stove 82.2 12.9 8.1 18,4 26.8 i0,2 7.9 91.1 20.9 Bicycle 24.2 36.1 37.9 44.2 39.9 42,2 22.7 20.7 34.7 Soap in house 94.5 83.2 64.6 79.9 88.9 86.7 86.5 93.4 84.5 Radio 66.2 23.4 10.6 23.7 33.8 33.7 20.3 76.1 28.3 Listen to radio weekly 72.1 30.8 19.3 29.4 45.3 43.4 25.4 79.7 35,5 Number of women 542 4188 265 1305 1177 273 1415 296 4739 10 CHAPTER 2 MARRIAGE AND EXPOSURE TO THE RISK OF PREGNANCY 2.1 Current Marital Status In Uganda, childbearing takes place mainly within socially prescribed and relatively stable marital unions. Therefore, the study of the pat~rns of marriage is essential to the understanding of fertility patterns in Uganda. Marriage, whether legal, customary or consensual, is the primary indication of the exposure of women to the risk of pregnancy. There are several types of marriage in Uganda, including legal marriage, customary marriage and other unions. Legal marriage includes both religious and registered marriage. Customary marriage varies according to region and tribal groupings. In some areas a marriage is recognised so long as the parents of the bride and bridegroom agree, while in other areas a marriage is recognised only after the payment of the dowry is completed. Living together without fulfilling the legal or customary procedures is not encouraged but is socially tolerated and is becoming very common, particularly in urban areas. In the long run, these unions become acceptable to society but have serious implications for legal and inheritance rights and customary obligations. In Table 2.1 the term "married" is intended to mean legal or formal marriage, while "living together" designates an informal union. In subsequent tables, the two categories are combined and referred to collectively as "currently married" or "currently in union". Those widowed, divorced, and not living together (separated) make up the remainder of the "ever-married" or "ever in union". In most cases, the distinction between not living together (or separated) and divorced is difficult to make. Divorce has connotations of legal or customary procedures while separation implies a temporary disunion pending divorce or reunion. Table 2.1 and Figure 2.1 show the percent distribution of women by marital status at the time of the survey, according to age. That 41 percent of women 15-19 have already entered some kind of marital union is indicative of a general tendency to marry early. The legal age at marriage for women in Uganda is 16 years. By the time women reach the age of 30, 95 percent have been married; by the age of 35, 99 percent have been involved in some kind of marital union. The percentage of women who are widowed is low in the younger age groups and high in the age groups 40-44 and 45-49. The same pattern applies for divorced women. This is due to the fact that older women have had a longer time in which to get divorced than younger, newly married women. Also, young divorced women remarry easily while older divorced women fred it difficult to remarry. Hence, the high percentages of divorced women are concentrated in age groups 40-44 and 45-49. Apart from age group 15-19, where widowhood, divorce and separation are small (because these women have just married), the percentage separated is almost uniform for all age groups. 2.2 Polygyny The custom of a man having more than one wife, polygyny, has long been acceptable in Uganda. Some religious denominations allow polygny, while others oppose it; however, the practice is rapidly declining as more women attain higher educational levels. Table 2.2 shows the percentage of currently married women in polygynous unions by age and selected background characteristics. Overall, 33 percent of currently married women report that their husband has other wives. The percentage increases with age of the woman, from 21 percent of women 15-19, to over 40 percent of women in their 40s. This may indicate that polygyny is decreasing among younger women. 11 Table 2.1 Percent distribution of women by current marital status, according to age, Uganda, 1988/89 Current Marital Status A~e Wtd. Never Living No. Mar- Mar- To- Widow- Di- Sepa- of tied tied gether ed vorced rated Total Women 15-19 59.2 26.9 9.6 0.4 1.7 2.2 100.0 1157 20-24 17.0 56.3 15.8 I.i 3.6 6.3 i00.0 985 25-29 4.8 65.5 16.6 1.9 4.8 6.4 100.0 859 30-34 2.5 64.9 16.7 3.6 5.4 6.9 100.0 620 35-39 1.0 64.9 14.1 6.0 7.4 6.5 100.0 459 40-44 1.0 63.6 9.5 i0.0 10.4 5.6 I00.0 345 45-49 0.9 64.4 8.8 10.7 9.1 6.1 I00.0 304 Total 19.5 53.8 13.5 3.1 4.8 5.3 i00.0 4730 100% 75% 50% 25% 0% 15-19 Figure 2.1 Union Status by Current Age 20-24 25-29 30-34 35-39 40-44 45-49 Current Age R Never In union ~] Living together [~ Married ~ Wldowed/dlv./oep. Uganda DHS 1988/89 Polygyny is slightly more common in rural areas, where 33 percent of the women report polygynous unions, compared with 31 percent in urban areas. The distributions for individual age groups are irregular, but generally indicate a similar pattern. The regional distribution shows that the South West is least polygynons, partie,O~rly at the younger ages. This is probably due to a high proportion of Christians, particularly Protestants, who 12 Table 2.2 Percentage of current ly marr ied women in a polygynous union, by age, according to background characterist ics, Uganda, 1988/69 Age Background Character ist ic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 16.2 33.1 54.3 28.6 41.7 40.0 20.0 31.0 Rural 22.3 30.4 36.8 39.4 39.7 43.2 40.0 33.3 Region West Ni le (14.3) 37.0 34.8 30.4 (35.3) (37.5) (50.0) 33.1 East 35.3 40.9 43.7 47.5 38.3 46.4 43.6 42.3 Central 19.0 32.3 32.5 32.9 36.4 35.6 43.6 31.8 West (21.4) 36.0 35.5 (56.3) (26.7) (58.3) (60.0) 39.0 South West 15.3 20.9 21.4 31.3 43.3 41.7 29.6 27.1 Kampala 18.2 32.4 33.7 27.8 48.4 (56.3) (25.0) 33.2 Luwero Triangle 21.5 37.8 36.7 33.3 29.6 29.3 51.3 33.8 Education No education 22.3 32.5 26.7 38.4 37.7 43.9 36.8 33.9 Some pr imary 20,7 29.4 33.9 35.3 40.5 43.2 41.2 32.2 Primary compl. 27.3 35.8 39.7 31.8 (61.1) (20.0} (0.0) 36.2 Middle (1487) 31.6 35.8 27.6 38.5 (50.0) (50.0) 31.7 Higher (0.0) 17.4 22.2 28.6 (33.3) (0.0) (0.0) 22.7 Total 21.2 30.9 31.4 35.6 39.7 42.9 38.1 32.9 Note: The numbers in parentheses are based on fewer than 20 unweighted cases. oppose polygyny. Protestants account for over 50 percent of the population in the South West. Central region and Kampaia also show relatively little polygyny, basically because these are areas where development is most pronounced. People are generally more educated and are engaged in paid employment such that sustaining polygyny would be difficult. Polygyny is high in'the East where the greatest concentration of Moslems is found. The distribution of polygyny does not correlate well with education level, although women with higher education are least likely to be in a polygynous union. It should be noted that the relationship between polygyny and fertility is not straightforward. There is a tendency for women in polygynous unions to compete with co-wives in number of children, so as to have the largest share of family property. In this respect, the desire to have as many sons as possible is likely, and polygyny may be one of the factors which sustains high fertility. On the other hand, polygyny encourages prolonged birth spacing, which would tend to lower fertility among women in polygynous unions. 2.3 Age at First Union Although a significant number of births take place outside a marital union, the majority occur in union. Age at first marriage is, therefore, an important indicator of exposure to the risk of conception and childbirth. Table 2.3 gives the percent distribution of women by age at first union (including never- married women) and median age at first union, according to current age. 13 Table 2.3 Percent d is t r ibut ion of women by age at first marriage, proport ion of women marr ied at d i f ferent ages and median age at first marriage, according to current age, Uganda, 1988/89 Percent Marr ied Age at First Marr iage by Age: Curt- Wtd. Med- ent Never No.of Jan Age Marr ied <15 15-17 18-19 20-21 22-24 25+ Total 18 20 25 Women Age* 15-19 59.2 11.6 25.4 3.8 0.0 0.0 0.0 I00.0 1157 20-24 17.0 17.8 34.7 20.3 7.4 2.7 0.0 100.0 52.5 72.8 82.9 985 17.8 25-29 4.8 17.2 38.9 18oi 10.5 7.5 3.0 100.0 56.1 74.2 92.2 859 17.5 30-34 2.5 19.9 42.1 17.1 8.0 5.9 4.5 100.O 62.0 79.1 93.0 620 17.0 35-39 1.0 27 .1 38.1 15.0 7.4 7.3 4.0 i00.0 65.2 80.2 94.9 459 16.8 40-44 1.0 27.4 39.5 16.1 6.7 9.5 3.8 180.0 66.9 83.0 95.2 345 16.6 45-49 0.9 26.7 38.5 15.6 9.2 4.0 5.0 1O0.0 65.2 80.8 99.0 304 16.7 Total 19.5 18.6 35.1 14.3 6.3 4.1 2.1 100.O 53.7 68.0 78.4 4730 - * Def ined as the exact age by which 50 percent of women have exper ienced marriage. - Some data for women age 15-19 and the median for all women have been omitted, since a substant ia l proport ion of these women have not yet married. The median age at marriage suggests that there has been recently a slight rise in the age at first union, since women aged 20-24 and 25-29 entered their first union later (age 18) than women aged 30 and above (age 17). Younger women tend to enter their first union at a later age than older cohorts, as can be seen by the higher percentage of women married by age 18, 20, and 25 among older women. The exception is age group 45-49, which shows a lower percentage of women marrying by age 18, 20 and 25; this may be a result of misreporting of age at marriage due to recall lapse. Further indication of the trend toward later marriage is found in the analysis of data for eight districts from the 1980 census, which indicates that the singulate mean age at marriage for females rose from 17.7 in 1969 to 19.6 in 1980. The median age at first union according to selected characteristics shows that urban women generally marry later than rural women and that in both urban and rural areas, the median age at first marriage is generally higher for younger women than for older women (Table 2.4). Women in Kampala, South West, and West Nile marry later than women in the other regions. The figures by age group for West Nile and Kampala vary greatly due to the small number of women involved. As in many countries, there is a strong inverse relationship between age at marriage and education; the median age at first marriage is six years later for those with higher education (23 years) than for those with no education (17 years) and women with intermediate levels of schooling are in between. The balance of evidence seems to suggest that there has been a slight increase in the age at first union, which in the long run, will probably contribute to a gradual decline in fertility. 2.4 Breastfeeding, Postpartum Amenorrhoea and Abstinence Data were collected in the UDHS on factors other than contraception that affect the length of pregnancy intervals. The factors were breastfeeding, amenorrhoea and sexual abstinence. The information was obtained for aU live births during the five years prior to the survey and was analysed for all births within the 36 months prior to the survey. There were 3176 weighted births occurring 0-35 months prior to the survey. 14 Table 2.4 Median age at first union among women aged 20-49 years, by current age and background characterist ics, Uganda, 1988/89 Current Age Current Age 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 19.5 19.4 18.4 19.2 17.4 16.7 18.6 Rural 17.8 17.4 16.9 16.6 16.8 16.8 17.2 Region West Ni le 16.9 17.0 17.5 (17.5) (19.0) (18.5) 17.4 East 16.9 16.8 16.3 16.2 15.8 15.9 16.5 Central 17.7 17.6 16.6 16.4 16.3 16.9 17.1 West 18.4 17.7 17.5 (14.8) (16.0) (17.3) 17.5 South West 18.9 17.9 17.6 17.6 18.0 17.2 18.0 Kampala 19.6 20.0 18.4 20.0 17.3 (17.0) 19.3 Luwero Triangle 17.7 17.5 16.6 16.4 16.1 16.7 17.1 Educat ion No education 16.9 17.1 16.7 16.5 16.4 16.7 16.7 Some pr imary 17.7 17.4 16.7 16.7 16.7 16.6 17.2 Primary comp. 18.6 18.6 17.9 19.1 (18.0) (20.5) 18.5 Middle 20.6 19.8 20.2 19.5 (20.0) (18.5) 20.1 Higher 23.2 (22.7) (22.6) (25.2) (25.5) 23.5 Total 18.1 17.7 17.1 17.1 16.7 16.8 17.5 Note: The numbers in parentheses are based on fewer than 20 unweighted cases. Table 2.5 gives the proportion of births whose mother are still breastfeeding, amenorrhoeic, or abstaining, by months since the birth. The results show that breastfeeding is a common practice among Ugandan women. Eighty-two percent of births are breastfed 10 months after delivery and 42 percent are still breastfed at 20 months. After that, breasffeeding diminishes rapidly and at 24 months only 13 percent of the births are still being breastfed. Overall, the median duration of breastfeeding is 19 months. Postpartum amenorrhoea is the period following a birth before the retum of the menstrual cycle. In most societies, this period lasts about three months, during which time the woman is usually infecund. However, the length of amenorrhoea depends to a large extent on the woman's physiological condition. Factors such as nutrition, mental stress, and the length of breastfeeding influence the return of the menstrual cycle. In Table 2.5, the importance of breasffeeding can be seen by the fact that duration of amenorrhoea follows a pattern similar to duration of breasffeeding, with half of the women still amenorrboeic 12 months after birth. Postpartum sexual abstinence is widely practiced in Uganda, as in much of sub-Saharan Africa. Postpartum sexual abstinence is usually accompanied by breasffe~ding, which is considered essential to the health and normal development of the child. However, the period of postpartum abstinence is shorter than the period of breasffeeding--less than 40 percent of women were still abstaining only 2-3 months 15 after birth. Column four in Table 2.5 shows the proportion of women protected from pregnancy due to either amenorrhoea or abstinence. Over half of the women are still insusceptible to pregnancy 12 months after birth, primarily due to amenorrhoea. Table 2.5 Percentage of births whose mothers are stil l breastfeeding, postpartum amenorrhoeic, abstaining, or insusceptible, by number of months since birth, Uganda, 1988/89 Months Breast- Amenor- Abstain- Insus- No. of Since Birth feeding rhoeic ing ceptible* Births Less than 2 90.9 91.9 68.9 95.1 163 2-3 91.5 82.5 37.8 86.6 172 4-5 89.9 71.1 18.1 75.3 182 6-7 87.6 68.7 18.0 72.1 197 8-9 88.1 68.0 9.5 69.2 186 I0-ii 81.7 51.5 6.5 53.7 206 12-13 84.7 52.1 9.4 56.3 190 14-15 71.2 40.7 7.7 43.5 226 16-17 65.7 30.0 6.0 33.8 179 18-19 52.4 22.1 3.4 24.3 139 20-21 42.2 17.1 6.1 19.8 153 22-23 22.9 6.2 3.2 8.5 181 24-25 13.1 6.9 1.1 7.6 203 26-27 4.7 1.7 1.9 3.6 159 28-29 4.5 2.8 0.4 2.8 160 30-31 4°6 3.8 1.6 4.4 173 32-33 4.7 2.1 0.9 3.0 156 34-35 2.7 0.0 2.7 2.7 151 Total 52.0 35.7 11.2 38.1 3176 Median 19.0 12.9 1.8 13.5 Note: Includes births 0-35 months before survey. * E i ther amenorrhoeic or absta in ing at the time of the survey Table 2.6 presents the mean number of months of breastfeeding, amenorrhoea, abstinence and insusceptibility by background characteristics of the mother. These estimates were calcula~d using the "prevalencefmcidence" method borrowed from epidemiology: the total number of women breastfeeding (or umenorrhoeic, abstaining or insusceptible) is divided by the average number of births per month in the 36 months before the survey. The average duration of breastfeeding is 19 months, which is longer than in several other sub- Saharan countries: Liberia (17 months) and Senegal (18 months). Ugandan women under age 30 breastfeed their children for slightly shorter durations than women aged 30 and over. Differentials by region show that West Nile women breastfeed for longer durations on average (26 months), while women in Kampala have the shortest average duration of breastfeeding (15 months). Table 2.6 also indicates that women with higher education breastfeed their children for shorter durations on average (14 months), probably due to their greater participation in the labour force which necessitates staying away from their children for long periods of time. 16 Table 2.6 Mean ntunber of months of breastfeeding, postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibi l i ty, by background characterist ics, Uganda, 1988/89 Background Breast- Amenor- Abstain- Insus- No. of Character ist ic feeding rhoeic ing ceptible* Births Age <30 18.3 11.7 3.9 12.7 2155 30+ 19.2 14.7 4.7 15.8 1063 Residence Urban 15.3 9.4 5.9 11.5 316 Rural 19.0 13.1 4.0 14.0 2900 Region West Ni le 25.7 20.0 10.7 22.0 177 East 18.6 13.0 4.6 13.7 879 Central 16.7 ii.i 3.6 12.1 812 West 17.9 11.9 2.6 12.5 209 South West 19.8 13.3 2.9 14.3 964 Kampala 14.9 8.8 6.4 11.4 174 Luwero Triangle 16.4 10.9 3.6 11.8 340 Education No educat ion 19.8 14.8 4.5 15.7 1308 Some primary 18.2 11.8 3.5 12.8 1338 Primary completed 17.8 II.i 3.5 11.9 296 Middle 16.4 10.6 7.5 13.0 195 Higher 14.0 5.4 2.6 5.9 77 Total 18.6 12.7 4.1 13.7 3216 Note: Includes births 1-36 months before survey. Estimates are based on current status method (see text). * ' Either amenorrhoeic or absta in ing at the time of the survey These findings imply a trend towards a shorter duration of breastfeeding. This can have adverse effects on the health of children since breast milk provides protection against certain illnesses. Shorter durations of brcastfeeding also result in shorter periods of amenorrhoea, which may lead to higher fertility, if not compensated for with greater contraception. Most women know that breasffeeding tends to suppress the return of menstruation following a birth, thereby lengthening the period of amenorrhoea. Women in Uganda are now increasingly aware of the benefits of breastfeeding, which will hopefully result in a trend towards prolonged breastfeeding. Table 2.6 indicates that the mean duration of postpartum amenorrhoea is 13 months. Postpartum amenorrhoea is longer for rural women (13 months) than for urban women (9 months). The mean duration of postpartum sexual abstinence is 4 months and is higher in urban areas (6 percent) than rural areas (4 months). It is also substantially longer for women in West Nile than for women in other regions. 17 CHAPTER 3 FERTILITY 3.1 Current Fertility Levels and Trends In the past, fertility indices in Uganda have been almost entirely derived from population censuses using indirect methods. This is because there have not been any nationwide demographic surveys. Furthermore, Uganda did not participate in the World Fertility Survey. The first systematic census was conducted in 1948 with others in 1959, 1969, and 1980; reasonable fertility estimates are available only for these census years. The Uganda Demographic and Health Survey (UDHS) is the first national survey with the capacity to generate rural/urban, national, and regional indices. Current Fertility The total fertility rate (TFR) is defined as the number of births a woman would have if she survived through the reproductive period of 15-49 years and if she were subjected to the age-specific fertility rates which women are currently experiencing. The TFR is a measure of current fertility. Table 3.1 and Figure 3.1 show 'I'PRS for the periods 1985-88, 1982-84 and for the five-year period prior to the survey (approximately 1984-88). Also shown is the average number of children ever born to women 40-49, who have generally completed their childbearing. The Table 3.1 Total fert i l i ty rates (TFRs) for calendar year per iods and for f ive years preceding the survey, and mean number of chi ldren ever born (CEB) to women 40-49 years of age, by background characterist ics, Uganda, 1988/89 Total Fert i l i ty Rates* Mean Number of 0-4 Chi ldren Years Ever Born Background 1985- 1982- Before to Women Character ist ic 1988'* 1984 Survey Age 40-49 Residence Urban 5.7 6.1 5.7 6.9 Rural 7.6 7.6 7.5 7.5 Region West Ni le 7.4 7.2 7.2 7.4 East 7.6 7.0 7.4 7.1 Central 7.2 8.0 7.2 7.3 West 8.2 7.2 8.0 7.9 South West 7.8 7,5 7.6 8.0 Kampala 5.9 6.2 5.9 7.8 Luwero Tr iangle 7.3 7.3 7.3 7.9 Educat ion No educat ion 8.0 7.7 7.7 7.6 Some pr imary 7.2 7.3 7.2 7.4 Pr imary completed 7.1 8.4 7.3 7.3 Middle 6.6 7.0 6.7 7.9 Sigher 5.2 7.2 5.1 5.0 Total 7.4 7.4 7.3 7.5 * Based on women aged 15-49 ** Includes exposure in 1988 and 1989 up to the t ime of interview data indicate high levels of fertility in Uganda (an average of 7.4 births per woman) with no indication of a recent decline. Fertility in urban areas is lower than in rural areas. This is true for all the periods under observation, as well as for older women aged 40-49 years. Urban women tend to be more educated, more likely to be engaged in wage employment, and more likely to have access to family planning services. 19 Figure 3.1 Total Fertility Rate 0-4 Years Before the Survey, and Children Ever Born to Women 40-49 Years RESIDENCE Urban Rural EDUCATION None Primary Complete Primary Middle Higher REGION West Nile East Central West South West Kampala 0 2 4 6 8 10 NO. of Children TFR i CEB Uganda DHS 1988/89 When the TH, ts are examined on a regional basis, it is seen that Kampala has the lowest fertility. It should be kept in mind that Kampala is the capital city of Uganda and has the typical characteristics of urban areas. The South West and the West regions on the average stand out with fertility higher than the rest of the country. Fertility in the South West, particularly Ankole (i.e., Mbarara and Bushenyi Districts) has always been high and was the highest in the country according to the 1969 census. In the remaining regions, the TFRs are lower. Fertility generally declines with increasing education and women with higher education have much lower fertility than the rest of the women. Fertility Trends Trends in fertility can be observed by comparing the total fertility rate for the period 1985- 88 with the rl~t,t for the period 1982-84, and the mean number of children ever born to women aged 40-49. It should be noted that the fertility of women aged 40-49 refers to a specific cohort of women and to a reproductive experience that spans the past 25 to 30 years. Overall, the TH, t for the various periods has remained about the same, that is, just above 7 children per woman. In urban areas, there seems to be a sure decline in fertility from 6.9 for women aged 40-49 to the current level of 5.7; while in rural areas, the TFR shows no change. In the regions, the differences between various periods are so small that one can conclude that the rPK has remained stable, with only a slight indication of decline. Kampala, however, shows a sharp decline from 7.8 (completed fertility of women aged 40-49 years) to 5.9, the "I'I~R for the period 1985-88. The trend by education shows that fertility has declined during the eighties among women with primary education and more, although the data on completed fertility among women 40-49 show a decline only for women with middle education. The data should be viewed with caution since the number of women is small in some categories. 20 In the past, a sharp increase in fertility was observed between census years 1959 and 1969, as indicated in Table 3.2, and it appears that the TFR rose slightly from 1969 to the present. Another indicator of current fert'flity is the percentage of women who are pregnant, which is shown in Table 3.3 by age of woman. Overall, 13 percent of women reported themselves pregnant at the time of the survey, which may be a low estimate, since many women at early stages of pregnancy may not know that they are pregnant. Eleven percent of teenagers and 20 percent of women aged 20-24 were pregnant, showing the extreme youthfulness of childbearing in Uganda. Such early childbearing has serious implications for both maternal and child health. Table 3.2 Crude bir th rates and total fert i l i ty rates from various censuses, Uganda Year of Est imate Rate 1948 1959 1969 1985-88" Crude bir th rate 42 44 50 Total fert i l i ty rate 5.9 5.9 7.1 7.4 * UDHS, based on women 15-49 Table 3.4 presents age-specific fertility rates for different five-year periods preceding the survey. Since women 50 years of age and over were not included in the survey, fertility rates cannot be calculated for the older age groups back into time. The data indicate that fertility is highest among women aged 20-24, and only slightly lower for women aged 25-29. For the last three five-year periods, the figures show a steady decrease in fertility for every age group. Although data from birth histories are often subject to error in reporting both the number and timing of births, which can lead to misrepresentation of trends in fertility, the data in Table 3.4 appear to indicate that fertility in Uganda is declining, which supports the figures presented above for changes observed in urban areas. 3.2 Children Ever Born Table 3.3 Percent of all women who are current ly pregnant by age, Uganda, 1988/89 Percent No. of Age Pregnant Women 15-19 10.8 1157 20-24 19.5 985 25-29 16.8 859 30-34 14.6 620 35-39 9.7 459 40-44 4.6 345 45-49 0.5 304 Total 13.0 4730 Information on children ever born describes the childbirth history of a cohort of women from the time they started childbearing up to the present. This lifetime or cumulated fertility is important for understanding current fertility in areas where statistics on current fertility are unreliable. The percent distribution of all women and currently married women by the number of children ever bom is presented in Table 3.5. At younger ages, the numbers are different for all women and for currently married women; however, for the older age groups, the distributions are almost the same, indicating that since most women marry by age 25, the categories of "all women" and "currently married women" are almost identical after the age 25. Fourteen percent of all women have 8 or more children, that is, above the observed '|~rt of around 7 children. The percentage of all women who had 8 or more children in 1969 was 15 (Republic of Uganda, 1976), showing that there has been hardly any change since 1969. These percentages are sizeable and indicate either a widespread preference for large families or considerable nonuse of contraception, or both. 21 Table 3.4 Age-per iod fert i l i ty rate by age of woman at b i r th of child, Uganda, 1988/89 Number of Years Preceding Survey Age at B ir th 0-4 5-9 10-14 15-19 20-24 25-29 30-34 15-19 187 213 222 232 236 226 (185) 20-24 325 331 338 333 352 (308) 25-29 319 326 335 322 (337) 30-34 273 288 294 (300) 35-39 224 2]3 (243) 40-44 96 (138) 45-49 (36) Cumulat ive 15-29 4.2 4.4 4.5 4.4 Note: F igures in parentheses are part ia l ly t runcated rates. Table 3.5 Percent distribution of all women and currently married women by number of children ever born (CEB), according to age, Uganda, 1988/89 Number of Children Ever Born Age 0 1 2 3 4 5 6 7 8 9 I0+ Wtd. Mean NO. of NO. Total Women Born All Women 15-19 69.7 22.3 7.0 1.0 0.0 0.0 0.8 0.0 0.0 0.0 0.0 100.0 1157 0.4 20-24 16.7 24.6 28.3 20.3 7.4 2.3 0.4 O.0 0.0 0.0 0.0 1O0.0 985 1.9 25-29 6.2 7.4 12.9 19.0 21.4 17.4 9.5 4.7 1.4 0.i 0.0 I00.0 859 3.6 30-34 4.6 6.2 8.3 8.1 9.7 13.5 16.4 19.8 9.1 2.2 2.2 I00.0 620 5.0 35-39 2.1 4.5 2.0 5.0 4.7 9.0 10.9 18.1 17.4 11.7 14.7 I00.0 459 6.8 40-44 5.8 4.8 1.6 3.4 3.8 10.2 6.7 6.2 14.8 15.9 26.9 I00.0 345 7.2 45-49 5.3 4.1 1.8 3.2 3.5 8.0 5.4 8.5 11.7 14.7 33.8 I00.0 304 7.8 Total 23.2 13.8 11.5 9.9 7.7 7.5 5.8 6.2 5.0 3.5 5.8 I00.0 4730 3.5 Currently Married Women 15-19 38.7 42.0 16.5 2.7 0.I 0.0 0.0 O.O 0.0 0.0 0.0 I00.0 422 0.8 20-24 7.6 24.1 31.3 24.5 9.3 2.7 0.4 0.0 0.0 0.0 0.0 I00.0 710 2.1 25-29 3.7 6.1 12.5 19.2 23.3 18.7 10.5 4.3 1.5 0.i 0.0 100.O 705 3.8 30-34 3.3 5.6 7.8 7.3 10.0 13.4 16.5 20.9 10.1 2.7 2.6 180.0 506 5.3 35-39 1.7 3.8 1.8 4.6 4.7 7.7 10.8 16.7 17.4 14.3 16.5 I00.0 363 7.0 40-44 8.I 3.1 0.7 3.4 3.6 1O.0 6.1 7.0 14.8 14.9 31.4 I00.0 252 7.6 45-49 4.2 2.9 1.5 3.8 2.6 7.3 5.9 7.5 10.2 16.0 38.0 I00.0 223 8.1 Total 9.1 14.1 13.5 12.3 9.9 9.1 7.2 7.3 5.8 4.4 7.4 i00.0 3180 4.2 22 Women who have almost completed their childbearing (40-44 and 45-49), have had well over 7 births on average (7.2 and 7.8, respectively). For currently married women, the mean number of children ever born is 7.6 and 8.1, for women aged 40-44 and 45-49 respectively. It is interesting to note that 60 percent of all women aged 45-49 gave birth to 8 or more children and 34 percent gave birth to ten or more children. It is clear that the cohorts which have recently completed childbearing had extremely high fertility. Since contraceptive use in Uganda is low and marriage is almost universal, infecundity is probably the major reason that some older women have no children. It can be seen that 5-6 percent of all women aged 40-44 and 45-49 are childless. The figure is sightly lower (4-5 percent) for married women. Furthermore, 3-5 percent of older women have had only one birth. This is not fikely to be a result of contraceptive use, but rather sub-fecundity (sterility). Cumulative fertility as measured by children ever bom to ever-married women, according to the duration of marriage and age at first marriage is presented in Table 3.6. In the absence of deliberate fertility control, the number of children a woman bears will depend largely on the age at which she marries (assuming that she does not experience premarital childbearing) and the duration of her marriage, and women married earlier will give birth to more children than women married later. This relationship is expected because women who marry earlier are younger and exposed to the risk of conception for a longer period of time than women married later. Tab le 3.6 Mean number of ch i ld ren ever born to ever -marr ied women, by age at f i rs t marr iage and years s ince f i r s t marr iage , Uganda, 1988/89 Age at F i zs t Mar r iage Years S ince F i r s t Mar r iage <Ib 15-17 18-19 20-21 22-24 25+ Tota l 0 4 l .O 1.0 1.2 1.4 1.6 2.1 1.2 5-9 2.5 2.9 3.0 3.1 2.8 (5.5) 2 .9 10-14 4.4 4.9 4.5 4.4 5.5 5.1 4.7 15-19 5.6 5.9 6.0 6.5 (6.0) (5.2) 5 .9 20-24 7.4 "J .2 7 .9 8.2 6.3 (7.1) 7.4 25-29 7 .6 7.2 7 .6 8.0 (4.8) 7.4 30+ 8.2 7.8 (8.3) 8.0 Tota l 5.0 4.2 3 .9 3 .9 3.5 3.9 4 .3 Note : Numbers in parentheses are based on fewer than 20 unweighted casss . - Not ava i lab le due to age t runcat ion . Overall, women married at an early age produce more children than women married later, however, this pattern is primarily due to the fact that women who married earlier were more likely to be older when the survey occurred, and thus had more children. When the figures are examined for individual duration groups, the relationship is inconsistent. For example, for marriages lasting 0-4 years, the average number of children rises with age at marriage. It appears that women married in their teens space births, while women married at age 20 or over produce children more frequently. For other marriage duration groups, the pattern fluctuates, sometimes rising with age at marriage and sometimes falling. 23 3.3 Age at First Birth The age at which women start childbearing is an important demographic indicator. Although there are births which occur outside marital unions in Uganda, it is still true that the majority of births occur among married couples. So an increase in the age at marriage will in most cases imply an increase in the age at first birth, especially in the absence of premarital childbearing and wide use of contraceptives. Table 3.7 shows the percent distribution of women by age at first birth according to current age. Table 3.7 Percent d ist r ibut ion of women by age at first birth, according to current age, Uganda, 1988/89 Age at First Birth Weighted Median Number Age at Current No of First Age Births <15 15-17 18-19 20-21 22-24 25+ Total Women Birth* 15-19 69.7 3.5 22.2 4.7 0.0 O.0 0.0 i00.0 1157 20-24 16.7 5.5 36.2 25.8 12.6 3.2 0.0 180.0 985 18.6 25-29 6.2 9.0 36.8 22.0 13.4 9.6 2.9 100.0 859 18.3 30-34 4.6 10.0 40.1 21.4 12.9 7.8 4.8 100,0 620 18.0 35-39 2.1 10.3 39.2 23.1 10.9 7.3 7.2 1O0.0 459 18.0 40-44 5.8 14.8 31.8 22.1 13.2 6.5 5.7 100.0 345 18.3 45-49 5.3 10.7 31.8 21.9 15.5 6.4 8.3 100.0 304 18.6 Total 23.2 7.7 33.1 18.6 9.8 4.9 2.7 I00.0 4730 * Def ined as the exact age by which 50 percent of women have had a birth. The median age at first birth for the various age groups is almost uniform. For example, the median age at first birth of women aged 45-49 is 18.6, which is identical to the median age for women aged 20-24. Table 3.7 shows that 8 percent of women had a birth before 15 years of age. This percentage is notable and is due to the early age at which women become sexually active and contributes to the medico-social problems related to teenage pregnancy. The percentage of women who gave birth before age 15 is lower for younger women, that is, it rises from about 6 percent for the women aged 20-24 to over 15 percent for women aged 40-44. On the other hand, only 3 percent of all women deliver their first birth at age 25 and older. This means that having a child before the age of 25 is almost universal among Ugandan women. Table 3.8 presents the median age at first birth for women aged 20-49 by background characteristics of women. Urban women and women in West Nile, South West, and Kampala regions have a somewhat higher median age at first birth than rural women and women in other regions. Age at first birth definitely increases with education, from 18 for women with no education or some primary education to 24 among women with higher education. 24 The conclusion drawn from the results of the UDHS is that there has bccn a small increase in overall fertility during the last twenty years, with a possible slight decline duc to the effects of modcmisation (education) observed in the urban areas (mainly Kampala). Table 3.8 M~dian age at f irst b i r th among women aged 20-49 years, by current age and background characterist ics, Uganda, 1988/89 Current Age Background Character ist ic 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 19.8 18.5 18.5 18.8 18.2 18.2 19.0 Rural 18.6 18.5 18.2 18.0 18.3 18.8 18.4 Region West Ni le 18.8 18.0 17.9 (18.8) (21.0) (19.7) 18.9 East 18.0 17.8 17.5 17.2 18.3 18.0 17.8 Central 18.2 18.2 17.8 17.8 17.8 18.6 18.0 West 18.6 18.9 17.6 (15.9) (16.5) (20.0) 18.0 South West 19.6 19.1 19.0 19.1 19.3 19.4 19,3 Kampala 19.7 18.2 18.6 18.7 18.0 (17.3) 18.8 Luwero Tr iangle 18.2 18.2 18.1 17.6 17.6 18.5 18,0 Education No educat ion 18.3 18.5 17.8 18.2 18.3 18,8 18.3 Some pr imary 18.4 18.0 18.1 17.7 17.9 17.9 18,1 Pr imary completed 19.2 18.8 17.8 19.2 (19.0) (22.5) 18,9 Middle 20.6 19.1 19.1 19.1 (19.0) (20.5) 19,7 Higher 23.7 21.5 (22.2) (25.7) (25.5) 23,6 Total 18.8 18.5 18.2 18.3 18.3 18.8 18,5 Note: Median age is the exact age by which 50 percent of women have had a birth. Note: Nun~bers in parentheses are based on fewer than 20 unweighted cases. 25 CHAPTER 4 CONTRACEPTIVE KNOWLEDGE AND USE 4.1 Contracept ive Knowledge Collection of data about knowledge and use of contraceptive methods was a major objective of the UDHS. Furthermore, data about the places where contraceptive methods could be obtained and the type of family planning services offered to clients provided useful information regarding family planning coverage. To determine knowledge of contraception, respondents were first asked to list ways or methods that a couple could use to delay or avoid a pregnancy. If a respondent did not spontaneously mention a particular method, the method was then described by the interviewer and the respondent was asked if she recognised the method. If the answer was positive, the respondent was asked whether she had ever used the method, the place where she would go to obtain the method if she wanted to use it and the main problem, if any, with using the method. Descriptions of seven modem methods (the pill, IUD, injection, condom, female sterilisation, male sterilisation, and vaginal methods--diaphragm, foam and jelly) and two traditional methods (periodic abstinence (rhythm) and withdrawal) were included in the questionnaire. Traditional methods mentioned by the respondent, such as herbs and tying strings around the waist were recorded as a tenth category "any other method". Table 4.1 and Figure 4.1 indicate that 82 percent of all women interviewed know of at least one contraceptive method (84 percent of married women), while only 75 percent of all women know where to get a method of contraception (77 percent of the married women). More than 3 out of 4 women know of at least one modem method (77 percent of all women and 78 percent of married women). The most well-known modem method is the pill which is known by 66 percent of all women and 68 percent of married women. This is not surprising, since it is the most widely available contraceptive and probably the easiest to use. Female sterilisation is the next most well-known method (59 percent of all women and 63 percent of married women). It is surprising that sources for female sterilisation are more widely known than sources for the pill. Sixty percent of married women know where they can be sterilised, whereas 54 percent know where to get the pill. Male sterilisation is the least known method with only 9 percent of married women reporting awareness of this method. Vaginal methods (diaphragm/foam/jelly) are also largely unknown, with 12 percent of married women knowing one of these methods. Most women who know of these methods also know a source for obtaining them. Among the traditional methods, 43 percent of all women and 45 percent of married women know of periodic abstinence. The percentages for withdrawal are about half of periodic abstinence. Surprisingly, 31 percent and 33 percent of all women and married women, respectively, report knowledge of traditional methods other than periodic abstinence and withdrawal. Table 4.2 shows the percentage of currently married women who know at least one modem method and a place to obtain it by age, type of residence (rural or urban), region, and education. Age differentials in knowledge are not great, although knowledge tends to increase until age 30, after which it levels off, and drops slightly for the oldest women. This is probably due to the fact that women marry in their teens and early 20s. As more women get married, demand for/and knowledge of contraceptive methods rises to meet their needs. Also, the more women attend MCH clinics with young children or during pregnancy, the more likely it is they will be told about these methods. 27 Table 4.1 Percentage of all women and current ly marr ied women knowing any contracept ive method and knowing a source (For Information or Services), by speci f ic method, Uganda, 1986189 Knows Method Knows Source Method AW CMW AW CM~ Any method 81.9 84.0 74.5 76.7 Any modern method 76.5 77.9 70.7 72.3 Pi l l 66.4 67.7 53.6 54.4 IUD 20.2 21.1 15.9 16.3 Inject ion 39.7 40.8 34.9 35.5 Diaphragm/Foam/Je l ly 11.3 11.6 8.8 8.7 Condom 32.5 31.1 21.9 20.9 Female ster i l i zat ion 59.1 62.6 56.4 59.7 Male ster i l i zat ion 8.2 8.6 7.5 8.2 Any tradit ional method 58.6 62.4 39.1 41.2 Per iodic abst inence 42.6 45.0 39.1 41.2 Withdrawal 20.5 22.0 OthGr 31.I 33.4 AW = All women (4730); CMW = Current ly marr ied women (3180) Figure 4.1 Family Planning Knowledge and Use Currently Married Women 15-49 Percent 100 80 60 40 20 0 / Know Method Ever Used Currently Using J ~==~ Modern method - - Any method i Uganda DHS 1988/89 28 Table 4.2 Percentage of current ly marr ied women knowing at least one modern method and knowing a source for a modern method s by background characterist ics, Uganda, 1988/89 Background Knows Wtd. Character- Modern Knows No. of istic Method Source Women Age 15-19 74.4 69.5 422 20-24 78.2 72.9 710 25-29 83.2 77.7 705 30-34 76.9 69.8 506 35-39 79.3 74.2 363 40-44 76.1 70.3 252 45-49 69.1 61.8 223 Residence Urban 94.2 90.3 290 Rural 76.3 70.4 2890 Region West Ni le 17.8 11.9 194 East 84.8 75.4 979 Central / 78.7 74.1 777 West 61.0 56.8 194 South West 83.3 79.9 886 Kampala 96.3 93.3 151 Luwero Tr iangle 89.7 84.9 313 Educat ion No education 67.1 58.7 1409 Some pr imary 83.2 79.2 1294 Primary comp. 94.1 91.5 241 Middle 95.3 93.1 172 Higher 99.1 99.1 64 Total 77.9 72.2 3180 As expected, the percentage of married women who know at least one modem method is higher among urban women (94 percent) than rural women (76 percent). Almost all women who know a modem method also know of a place to obtain it (90 percent for urban women and 70 percent for rural women). Given that most family planning clinics are in urban areas, the difference in knowledge between urban and rural women is not surprising. Women in West Nile seem to have the least knowledge about modem methods and their sources, with only 18 percent knowing a modem method and 12 percent knowing a source. There are two possible explanations for this. Foremost, the sample in West Nile was small and more prone to erratic results. Secondly, there are concentralions of Catholics and Moslems in West Nile who generally do not use contraceptives. In contrast, the figures for Kampala, South West and East regions are high. 29 The education of women is an important determinant of knowledge of family planning methods. Table 4.2 shows that the percentage of women knowing a method and its source increases as educational level increases. Thus, 99 percent of women with higher education know at least one family planning method and its source, compared with 67 percent and 59 percent of women with no education. In an effort to identify obstacles to the wider use of family planning methods, the UDHS interviewers asked respondents who rcported knowing about a method, what they thought was the main problem, if any, with using the method. As shown in Table 4.3, between 50 and 70 percent of women answered either "don't know", or "no problem". A substantial proportion of women cited bealth-rclated problems as the main reason associated with using modem methods. The proportion of women giving this reason was 45 percent for the pill, 33 percent for the IUD, and 32 percent for injection. The only other commonly cited reason was "method permanent" which was given by 27 percent of women who know female sterilisation, 36 percent of women who know male sterilisation, and oddly, by 9 percent of women who know injection. Lack of effectiveness was cited as a problem for periodic abstinence and withdrawal more frequently than it was for modem methods. For withdrawal, women also gave inconvenience of the method and disapproval of the husband or parmer as problems with using the method. Table 4.3 Percent d is t r ibut ion of women who have ever heard of a contraceptive method by main problem perceived ~n using the method, according to specific method, Uganda, 1988/89 Contraceptive Method Main Diaphragm/ Female Male Periodic Problem InJec- Foam Con- 5terl i i- Sterl l l- Absti- With- Perceived Pill IUD tlon Jelly d i lm sat[on sation ne[ice drawal Not effect ive 1.7 3.1 0.6 4.8 4.8 0.3 0.i 15.7 12.5 Husband disapproved 0.I 0.4 0.I I.I 2.6 0.3 2.8 6.2 11.9 Health concerns 45.0 33.3 31.8 21.0 22.4 22.9 10.4 0.0 2.0 Access/avai labi l i t y 0,0 0.0 0.i 0.0 0.0 0.0 0.0 0.0 0.0 Costs too much 0.0 0.I 0.4 0.i 0.2 l.l l.l 0.0 0.0 Inconvenient to use 0.8 2.1 1.0 6.5 5.6 0.0 0.0 4.4 18.7 Method permanent 3.0 ].4 8.6 0.7 0.3 26.6 35.8 0.2 0.2 Other 0.6 0.0 0.4 0.0 0.4 0.7 0.8 1.3 0.5 None 7.0 7.1 8.7 10.q 11.6 11.8 7.5 38.9 23.6 Don't know 41.8 51.4 48,2 55.7 52.2 36.3 41.5 33.3 30.6 Total I00.0 i00.0 i00,0 i00,0 i00.0 i00.0 i00.0 i00.0 i00.0 Number 3141 956 1878 535 1536 2796 390 2015 968 Knowledge of a source for modem family planning methods is a precondition for their use. However, the level of use may be quite low if methods arc not easily accessible. Table 4.4 shows the type of supply source that women say they would use to obtain specific methods if they wanted to use them. For all methods except periodic abstinence, govemment hospitals are by far the most frequently named potential source. For the pill, 1UD, injection, and diaphragm, foam and jelly, the next most frequently mentioned source is the Family Planning Association of Uganda (FPAU) clinic, followed by the "don't know" rcsponses. For the condom, 15 percent cited FPAU, while twice as many did not know wherc to obtain condoms. When asked wherc they could obtain advice about periodic abstinence, most women cited the church (54 percent); eleven percent rcsponded "nowherc." 30 Table 4.4 Percent distribution of women knowing a contraceptive method by supply source they said they would use, according to specific method, Uganda, 1988/89 Contraceptive Method Supply Source Diaphra~/ Female Male Periodic that Would InJec- Foam Con- Steri l i - Ster i l l - Abst l - be Used Pil l IUD tlon Jel ly dom sation satlon hence Government hospital 47.1 48.4 09.5 37.4 33.9 90.1 81.i 7.8 Govt. health center 1.4 i.i 1.4 1.9 1.0 0.7 1.2 0.7 FPAU* cl inic 21.8 24.8 22.6 29.3 15.1 1.7 5.8 6.0 Mobi le cl inic 0.2 0.i 0.2 0.4 0.3 0.0 0.I 0.2 Field worker 0.2 0.0 0.2 0.4 0.0 0.0 0.0 1.3 Private doctor 1.2 1.2 0.0 0.8 0.7 0.2 0.5 i.I Private hosp. ,c l in ic 2.5 2.7 2.7 0.8 1.7 2.8 2.3 0.5 Pharmacy/shop 5.1 0.0 0.0 5.8 12.0 0.0 0.0 1.8 Church 0.6 0.0 0.0 0.5 0.4 0.0 0.4 04.1 Friends, relat ives 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 Other 0.4 0.0 0.0 0.3 0.9 0.0 0.1 6.9 Nowhere 0.0 0.3 0.5 0.0 0.5 0.0 0.0 11.2 Don't know 19.2 20.5 11.9 22.3 32.5 4.2 8.1 8.1 Miss ing 0.I 0.9 0.2 0.0 0.2 0.3 0.4 0.1 Total 100.0 i00.0 I00.0 i00.0 i00.0 100 .0 I00.0 i00.0 Number 3141 956 1878 535 1536 2796 390 2015 * Family Planning Association of Uganda 4.2 Contracept ive Use For each family planning method that a respondent said she had heard of, she was also asked if she had ever used it. As shown in Table 4.5 and Figure 4.1, 21 percent of all women and 22 percent of currently married women have used a method at some point in their lives. Thirteen percent of all women report having used periodic abstinence, 6 percent have used the pill, 4 percent have used withdrawal, and 1 percent have used injection. Fewer than one percent of women have used any of the other methods, including condoms; this is of particular concern, given the emphasis placed on use of condoms to prevent AIDS. Women in their late 20s and 30s are somewhat more likely to have used a method of family planning than either younger or older women, although the differences are not great, especially among currently married women. On the whole, current use of contraception is still very low. Only 6 percent of all women and 5 percent of currently married women reported using a contraceptive method at the time of the interview, and only half of these were using a modem method. Periodic abstinence is the most popular method, followed by the pill and female sterilisation. The IUD, injection and condom account for a very small percentage of users. The percentage of currently married women using any method increases with age except in the oldest age group, 45-49, where it declines slightly. The percentage rises from 2 hi the 15-19 age group to 8 in the 40-44 and 45-49 age groups. Interestingly, family planning use is slightly higher among all women than among currently married women, which implies that single women use methods to avoid pregnancies outside marriage. With regard to differentials in current use by background characteristics, Table 4.7 and Figure 4.2 show that contraceptive use is five times higher among urban married women (18 percent) than rural 31 Table 4.5 Percentage of all women and currently married women who havl ever used a contraceptive method, by specific method and age, Uganda, 1988/89 Contraceptive Method Perl- Weighted Any Disph. Female Any odic With- Number A~y Modern InJec- Foam Con- Sterl- Trad'l Abstl- draw- of Age Method Method Pill IUD tlon Jelly dom llsat. Method nence al Other Women All Women 15-19 13.3 3.6 3.0 0.0 0.I 0.0 0.6 0.0 10.9 9.1 1.7 1.4 1157 20-24 22.9 7.5 6.4 0.2 0.6 0.i 1.2 0.0 17.9 14.9 5.4 2.2 985 25-29 25.7 9.6 8.2 0.7 1.0 0.4 1.3 0.3 20.7 16.3 6.1 2.5 859 30-34 23.9 8.9 6.7 0.8 2.1 0.5 0.8 0.7 18.5 14.8 4.7 3.5 620 35-39 25.0 i0.i 6.5 1.0 4.2 0.4 0.4 1.3 19.0 14.9 4.6 2.9 459 40-44 20.9 10.5 4.9 0.6 3.4 0.4 0.6 3.9 15.0 11.2 2.8 4.7 345 45-49 18.1 4.5 1.9 0.5 I.i 0.2 0.0 2.5 15.6 10.2 4.8 4.2 304 Total 20.9 7.4 5.5 0.5 1.3 0.2 0.8 0.7 16.5 13.1 4.2 2.6 4730 Currently )1 .~" ~ q 15-19 19.8 4.5 3.8 0.0 0.1 0.0 0.8 0.0 16.5 12.0 3.6 2.8 422 20-24 18.6 5.0 4.5 0.i 0.4 0.1 0.6 0.0 15.3 11.9 5.5 2.3 710 25-29 24.3 8.0 6.6 0.7 0.7 0.3 1.0 0.2 20.2 16.4 6.0 1.9 705 30-34 22.1 8.9 4.7 0.9 2.0 0.3 0.8 0.5 18.0 14.2 4.1 3.7 508 35-39 24.1 9.9 5.8 1.1 3.6 0.0 0.0 1.7 18.4 15.3 4.4 2.3 363 40-44 21.5 11.0 5.5 0.2 2.8 0.3 0.9 3.8 15.5 11.3 3.2 5.8 252 45-49 18.9 5.1 2.6 0.7 1.2 0.3 0.0 2.5 15.7 I0.0 5.0 5.1 223 Total 21.5 7.0 5.0 0.5 1.3 0.2 0.7 0.8 17.4 13.5 4.8 3.0 3180 Figure 4.2 Current Use of Family Planning by Residence and Region Currently Married Women 15-49 Percent 4O 30 20 10 0 Urban Rural west Nile RESIDENCE East 25 South Central West Kampala West REGION Uganda DHS 1988/89 32 married women (4 percent). Urban users arc also much more likely to be using a modem method than rural users. This urban emphasis is reflected in the rates by region, where Kampala leads with 25 percent of married women using contraception. Use is also higher than average in West region (7 percent) and is lowest in West Nile, where less than one percent of married women are using a method. Table 4.7 and Figure 4.3 also show very large differentials in contraceptive use according to level of education. Thirty-four percent of women with higher education currently use a contraceptive method compared with 2 percent of women with no education. Thus, even without other motivating factors such as a vigorous family planning education campaign or an increase in standards of development, contraceptive use might be expected to increase in the future simply as a result of trends toward urbanisation and increasing educational attainment of women. Family planning use also increases with the number of living children a woman has. The percentage of currently married women using any method ranges from 1 percent among women with no children to 7 percent among women with 4 or more children. This is an indication of decreasing desire for more children as women realist that it is not necessary to have additional children when those already bom can survive. Table 4.6 Percent distribution of all women and currently married women, by contraceptive method currently being used, according to age, Uganda, 1988/89 Contraceptive Method Female Peri- Not Weighted Any Steri- Any odic With- Cur- Number Any Modern InJec- Con- lisa- Trad'l Abst i - draw- rently of Age Method Method Pil l IUD tion dom tion Method nence al Other Using Total Women All Women 15-19 2.6 1.2 1.2 0.0 0.0 0.0 0.0 1.3 1.2 20-24 5.4 1.8 1.6 0.i 0.2 0.0 0.0 3.6 3.1 25-29 5.7 2.6 1.8 0.4 0.I 0.1 0.3 3.1 2.2 30-34 6.7 3.1 1.3 0.I 1.0 0.0 0.7 3.7 2.5 35-39 7.9 5.6 1.9 0.5 1.8 0.0 1.3 2.3 2.2 40-44 0.6 5.4 0.7 0.2 0.6 0.0 3.9 3.1 1.6 45-49 7.1 2.5 0.0 0.0 0.0 0.0 2.5 4.5 2.7 Total 5.5 2.7 1.4 0.2 0.4 0,0 0.7 2.9 2.2 Currently W .~ . -., 15-19 1.7 1.2 1.2 0.0 0.0 0.0 0.0 0.5 0.5 20-24 2.8 1.1 0.9 0.1 0.1 0.0 0.0 1.7 1.4 25-29 4.3 1.9 1.1 0,4 0.i 0.i 0.2 2.4 1.8 30-34 5.9 2.6 1.1 0.i 1.0 0.0 0.5 3.3 2.0 35-39 8.1 6.0 1.8 0.6 1.8 0.0 1.7 2.2 2.0 40-44 8.2 5.2 1.0 0.2 0.2 0.0 3.8 2.9 0.9 45-49 7.9 2.5 0.0 0.0 0.0 0.0 2.5 5.5 3.0 0.0 0.I 97.4 100.0 1157 0.4 0.i 94.6 100.0 985 0.6 0.2 94.3 100.0 859 0.3 0.8 93.3 100.0 620 0.0 0.2 92.1 100.0 459 0,0 1,5 91,4 100,0 3~5 I.i 0.7 92.9 I00.0 304 0.3 0.4 94.5 I00.0 4730 ~,~,~ ~ L~ 1 ~ 0.0 0.0 98.5 100.0 422 0.3 0.0 97.2 I00.0 710 0.6 0.I 95.7 100.0 705 0.3 0.9 94.1 100.0 506 0.0 0.2 91.9 i00.0 363 0.0 2.1 91.8 I00.0 252 1.5 1.0 92.1 i00.0 223 Total 4.9 2.5 i.i 0.2 0.4 0.0 0.8 2.4 1.6 0.3 0.4 95.1 100.0 3180 33 Table 4.7 Percent distr ibut ion of currently married women by contraceptive method currently being used, according to background characteristics, Uganda, 1988/89 Contraceptive Method Current ly Being Used T Female Peri- Not O Weighted Background Any Any In Steri- Any odic With- Cur- T Number Character- Me- Modern Jec- Con- lisa- Trad. Abst l - draw- rently A of ist lc thod Method Pi l l IUD tion dom tlon meth. nence al Oth. using L Women Residence Urban 18.0 12.2 7.0 1.7 1.7 0.2 1.6 5.8 4.5 0.8 0.6 82.0 100.0 290 Rural 3.6 1.5 0.5 0.I 0.3 0.0 0.7 2.0 1.3 0.3 0.4 96.4 100.0 2890 Region West Nile 0.8 0.0 0.0 0.0 0.0 0.0 0.0 0.8 0.8 0.0 0.0 99.2 100.0 194 East 3.5 2.0 0.2 0.3 0.6 0.0 0.9 1.5 1.2 0.2 0.2 96.5 I00.0 979 Central 4.7 2.4 I.I 0.0 0.3 0.0 1.0 2.3 1.2 0.3 0.8 95.3 100.0 777 West 6.8 3.4 1.7 0.0 0.0 0.0 1.7 3.4 1.7 0.8 0.8 93.2 100.0 194 South West 3.6 0.9 0.5 0.0 0.2 0.0 0.2 2.7 1.8 0.5 0.4 96.4 100.0 886 Kampa la 24.6 17.9 I0.I 2.2 2.6 0.4 2.6 6.7 5.6 0.7 0.4 75.4 100.0 151 Luwero Tri. 5.0 2.2 0.7 0.0 0.0 0.0 1.4 2.9 2.3 0.2 0.4 95.0 100.0 313 Educat ion No educa. 1.9 0.9 0.2 0.0 0.3 0.0 0.4 l.O 0.6 0.2 0.2 98.1 i00.0 1409 Some prim. 4.8 2.3 0.8 0.2 0.4 0.0 0.9 2.5 1.7 0.2 0.6 95.2 i00.0 1294 Prim. comp. 9.1 4.0 1.4 0.2 I.I 0.0 1.3 5.1 3.i 1.4 0.7 90.9 i00.0 241 Middle 12.7 7.2 3.9 1.0 0.3 0.0 2.0 5.5 4.4 0.8 0.3 87.3 100.0 172 Higher 34.1 22.7 15.8 2.6 0.9 0.9 2.6 11.4 7.9 2.6 0.9 65.9 100.0 64 No. of l iving chi ldren None 0.9 0.4 0,4 0.0 0,0 0.O 0.0 0.4 0.4 0.0 0.0 99.1 I00.0 380 1 2.7 1.2 0.7 0.i 0.I 0.0 0.3 1.5 4.I 0.4 0.0 97.3 I00.0 538 2 3.9 2.7 1.9 O.0 0.0 0.I 0.7 I.I 0.8 0.0 0.3 96.1 i00.0 487 3 4.4 2.0 I.i 0.9 0.O 0.0 0.6 2.4 1.9 0.5 0.0 95.6 I00.0 444 4+ 7.4 3.7 l.O 0.4 1.0 0.0 1.9 3.7 2.3 0.5 0.9 92.6 1O0.0 1331 Total 4.9 2.5 i.I 0.2 0.4 O.0 0.8 2.4 1.6 0.3 0.4 95.1 I00.0 3180 4 The number of children at the time family planning is first used is an indicator of the acceptance of family planning for spacing purposes (Table 4.8). The data indicate a strong shift in the timing of first contraceptive use. Only 3 percent of ever-married women 45-49 first used contraception when they had no children, compared to 14 percent of women 15-19. 4.3 Knowledge of the Fertile Period Table 4.9 shows the percent distribution of all women and of women who have ever used periodic abstinence by knowledge of the fertile period during the ovulatory cycle. The data indicate that knowledge of the reproductive cycle is very limited, with one-third of all women answering "don't know", and only 10 percent giving the "correct" response ("in the middle of her cycle"). Women who have used periodic abstinence are more likely to know when they are most fertile, and only 13 percent said they did 34 not know. It should be noted that the response categories for this question arc only one attempt at dividing the ovulatory cycle into distinct periods. It is possible that women who gave an answer of, say, "one week aider her period" were coded in the category "just atter her period has ended", instead of in the category "in the middle of the cycle". Thus, women may actually have a more accurate understanding of their fertility cycles than is reflected in the data. Table 4.8 Percent d istr ibut ion of ever-marr led women by number of l iv ing chi ldren at time of first use of contraception, according to current age, Uganda, 1988/89 Number of L iving Chi ldren at Time First Used Wtd. Never No. of Age Used None 1 2 3 4+ Total Women 15-19 80.7 14.0 4.0 1.2 0.0 0.0 I00.0 472 20-24 78.8 8.7 7.6 3.2 1.0 0.4 i00.0 818 25-29 74.7 6.4 5.6 6.2 3.0 3.8 100.0 817 30-34 76.5 3.6 3.5 4.1 3.6 8.6 100.0 605 35-39 75.1 3.0 2.5 1.9 3.5 14.0 100.0 454 40-44 79.0 i.i 2.4 1.3 2.5 13.6 I00.0 342 45-49 81.9 2.9 0.3 1.7 1.3 11.9 100.0 302 Total 77.6 6.3 4.4 3.3 2.2 6.1 I00.0 3809 Figure 4.3 Current Use of Family Planning by Education and Number of Living Children Percent Currently Married Women 15-49 40 34 30 2O 13 10 5 0 None SP CP MiddleHigher EDUCATION Note: SP • Some Pr imary , CP • Complete P r imary 7 0 1 2 3 4* NO. OF CHILDREN Uganda DHS 1988/89 35 4.4 Source for Methods In the UDHS, women using modem methods of contraception were asked where they obtained their method the last time they received their supply. Table 4.10 and Figure 4.4 show that overall, 42 percent of users of modem methods rely on government hospitals and 33 percent rely on the Family Planning Association of Uganda (FPAU). Thirteen percent of users obtain their method from a private doctor, clinic or pharmacy. Sources vary by the type of method used. For supply methods (pill, condom, injection), the FPAU pmvides 44 percent of users with supplies, while government hospitals provide 24 percent of users with supplies. Interestingly, FPAU is a more significant supplier to Table 4.9 Percent d istr ibut ion of al l women and women who have ever used per iod ic abst inence by knowledge of the fert i le per iod dur ing the ovulatory cycle, Uganda, 1988/89 Ever Users of Knowledge of the All Per iodic Fert i le Per iod Women ~bst inenoe During her menstrual per iod 0.5 0.2 Right after her per iod has ended 47.0 58.8 In the middle of the cycle 10.1 21.3 Just h~fore her per iod begins 2.6 3.2 At any time 6.2 2.9 Other 0.7 0.4 Don't know 32.9 13.2 Total I00.0 i00.0 Number 4730 621 actual users than is reflected in responses regarding potential sources (Table 4.4). For clinic methods (IUD and male and female sterilisation), the FPAU services only 12 percent of users, while government hospitals provide for 78 percent. Ninety percent of female sterilisations are done in government hospitals and the remaining 10 percent in either private hospitals or clinics. Table 4.10 Percent distribution of current users of modern methods by most recent source of supply or information, according to specific method, Uganda, 1988/89 Total Total Female Source of supply Clinic sterlli- Total Supply Methods Plll Methods satlon Users Government hospital 24.4 25.0 78.3 90.3 41.9 Government health center 7.2 4.4 0.0 0.0 4.7 FPAG* clinic 44.1 42.2 12.3 0.0 33.2 Mobile clinic 0.7 0.9 0.0 0.0 0.8 Field worker 2.6 0.9 0.0 0.0 1.6 Prlvate doctor 5.9 7.8 0.0 0.0 3.9 Private hospital, clinic 4,7 5.2 9.4 9.7 6.3 Pharmacy 4.2 5.6 0.0 0.0 3.1 Church 3.9 5.2 0.0 0.0 2.4 Friends, relatives 1.0 1.3 0.0 0.0 0.8 Other 0.7 0.9 0.0 0.0 0.8 Missing 0.7 0.9 0.0 0°0 0.8 Total 100.0 100.0 100.0 100.0 I00,0 Nu~er of users 95 65 41 34 126 Note: Totals include 1 condom user, 19 injection users (both are supply methods), and 7 IUD users (clinic method}. * Family Planning Association of Uganda 36 Figure 4.4 Source of Family Planning Supply Current Users of Modern Methods Government )ther 8% Pharmacy 3% Private Sources* 10% FPAU 33% • Inc ludee pr ivate doctors and hoapltale Uganda DHS 1988/89 4.5 Attitude Toward Pregnancy and Reasons for Nonuse Nonpregnant women who are sexually active and not using contra- ception are exposed to the risk of pregnancy. These women were asked about their attitude toward becoming pregnant in the next few weeks. Table 4.11 shows that 44 percent of women reported that they would be happy if they became pregnant in the following few weeks, 51 percent said that they would be unhappy if they became pregnant, and 5 percent said it would not matter. The pro- portion who would be unhappy increased with the number of living children a woman already had, from 28 percent among women with no children, to 67 percent among those with 4 or more children. Table 4.11 Percent distribution of nonpregnant women who are sexually active and who are not using any contraceptive method by attitude toward becoming pregnant in the next few weeks, according to number of llvlng children, Uganda, 1988/69 Attitude Toward Becoming Pregnant in Next Few Weeks Wtd. Number of Would Number Living Not of Children Nappy Unhappy Matter Total Women None 68.1 27.9 4.0 100.0 556 1 57.4 37.6 5.0 100.0 507 2 46.9 49.3 3.8 100.0 447 3 41.7 54.5 3.6 100.0 376 4+ 27.4 67.2 5.4 i00.0 1180 Total 44.3 51.0 4.7 I00.0 3066 Women who would be unhappy if they became pregnant, were asked the main reason for not using any method. Table 4.12 shows that 33 percent report lack of knowledge of contraception as the main reason for nonuse, while 20 percent report that religion prohibits them from using contraception. Other reasons for nonnse include opposition to family planning either by the respondent, her husband, or others (9 percent), lack of accessibility (9 percent), inconvenience of the method (8 percent), and being postpartum, amenorrhoeic or breasffeeding (6 percent). It is important to note that many of the reasons 37 given by nonusers of contraceptive methods can be addressed by a combination of improved accessibility to family planning services and a health education campaign. Table 4.12 Percent d istr ibut ion of nonpregnant women who are sexual ly ~ct ive and who are not using any contracept ive method, who would be unhappy if they became pregnant ,by main reason for nonuse, according to age, Uganda, 1988/89 Main Reason for Nonuse Age <30 30+ Total Lack of knowledge 37.9 27.5 33.4 Opposed to F.P. 6.3 3.1 4.9 Husband disapproves 4.0 3.6 3.8 Others d isapprove 0.6 0.4 0,5 Infrequent sex 2.8 4.4 3.5 Postpartum/breastfeeding 6.2 4.7 5,6 Menopausal/subfecund 2.5 2.0 2.3 Health concerns 1.0 1.3 1.2 Access/avai labi l l ty 8.5 9.2 8.8 Costs too much 0.8 2.6 1.6 Fata l is t ic 0.4 1.2 0.8 Rel ig ion 23.7 14.4 19.6 Inconvenient to use 0.0 18.3 8.1 Other 4.6 6,0 5.2 Don't know 0.6 1.2 0.8 Total i00.0 i00.0 I00.0 Number of women 870 693 1563 4.6 Intention to Use in the Future The intention to use contraception in the future provides an indication of the potential demand for family planning and acts as an indicator of potential use among current nonusers. In the UDHS, women who were not using a contraceptive method at the time of the interview were asked if they intended to use a method to avoid pregnancy at any time in the future. Table 4.13 shows the percent distribution of currently married women who are not currently using any contraceptive method by their intention to use a method in future, according to living children. Over 70 percent of these women do not intend to use contraception in the future, 21 percent intend to use, and 8 percent are unsure. The intention not to use contraception falls somewhat as the number of children increases, and the intention to use in the next 12 months increases with the number of living children. Those women who said they intended to use a method of family planning at some time in the future were asked which method they preferred. The pill (Table 4.14) is the most frequently cited method (33 percent), followed by injection (22 percent) and periodic abstinence (11 percent). There are only minor differences in method preference according to whether the respondent intends to use in the next 12 months or later. 38 Table 4.13 Percent d istr ibut ion of current ly marr ied women who are not currQntly us ing any contracept ive method, by intent ion to use in the future, according to number of l iv ing children, Uganda, 1988/89 Number of L iving Chi ldren Intention to Use in the Future None 1 2 3 4+ Total Intend to use in next 12 months 2.0 5.3 ii.0 10.9 17.0 11.9 Intend to use later 5.2 9.1 7.0 8.5 5.8 6.9 Intend to use, not sure when 0.2 0.7 2.5 2.2 4.0 2.6 Unsure about whether wil l use 7.9 Ii.0 6.8 9.6 6.4 7.6 Do not intend to use 83.9 73.9 72.8 68.8 68.8 70.8 Total 100.0 i00.0 i00.0 100.0 i00.0 100.0 Number of women 275 496 513 425 1316 3025 Note: Women who were pregnant at the time of the survey are included. Table 4.14 Percent d istr ibut ion of current ly marr ied women who are not using a contracept ive method but who intend to use in the future, by preferred method, according to whether they intend to use in the next 12 months or later, Uganda# 1988/89 Intends to Use: In Next After Preferred 12 12 Method Months Months Total Pil l 34.7 30.5 33.1 IUD 3.5 2.3 3.1 Inject ion 23.0 19.9 21.9 D iaphra~/Foam/ Je l l y 0.6 1.2 0.8 Condom 0.2 1.6 0.7 Female ster i l izat ion 7.7 9.3 8.3 Male ster i l izat ion 0.0 0.3 0.1 Per iodic abst inence 11.3 11.7 11.4 Withdrawal 1.5 0.7 1.2 Other 8.3 6.6 7.7 Don't know 0.9 15.8 11.4 Total 100.0 I00.0 i00.0 Number of women 361 208 568 39 4.7 Attitude Toward Family Planning Attitude toward family planning is an important indicator of future use of contraception. Information about attitudes toward family planning was obtained by asking respondents four questions: whether they accepted the idea of family planning information being (1) provided on the radio or in the newspaper, or (2) taught in school, (3) whether they themselves approved or disapproved of couples using a method to avoid pregnancy, and, if married, (4) whether they thought their husband approved or disapproved of couples using family planning. Table 4.15 shows that 68 percent of all women find it acceptable to provide family planning information on the radio or in the newspaper and 66 percent find it acceptable to teach family planning in school. It is clear that acceptability of family planning information on the radio or in school is higher for urban women than rural and increases as the educational level increases. Among regions, women in Kampala and East region accept the idea of family planning most frequently, and women in West Nile accept it least. As noted earlier, the West Nile sample may be predominantly Moslem. Table 4.15 Percent d istr ibut ion of al l women by whether they feel it is acceptable to have family planning information presented on the radio, in the newspaper, or taught in school, by background characteristics, Uganda, 1988/89 Radio or Newspaper Taught in School Not Not No. Background Accept- Accept- Don't Accept- Accept- Don't of Character ist ic able able Know able able Know Women Residence Urban 80.2 17.3 2.5 73.0 24.7 2.3 542 Rural 66.4 28.4 5.2 65.4 30.0 4.6 4188 Region West N i le 32.9 50.9 16.1 30.4 55.3 14.3 265 East 78.7 16.7 4.7 78.1 16.7 5.1 1305 Central 62.6 34.1 3.3 58.5 38.0 3.5 1177 West 60.8 34.3 4.8 57.8 37.3 4.8 273 South West 67.5 27.6 4.9 69.1 28.2 2.7 1415 Kampala 82.5 15.2 2.3 71.9 26.0 2.1 296 Luwero Tr iangle 72.2 25.3 215 68.5 29.2 2.3 491 Educat ion No educat ion 58.4 34.8 6,8 59.0 34.7 6.3 1788 Some pr imary 70.0 25.2 4.9 68.2 27.7 4.0 2048 Primary complete 80.3 18.6 1.1 75.5 23.1 1.4 410 Middle 81.1 17.4 1.6 76.0 23.7 0.3 367 Sigher 93.7 4.7 1.6 81.1 17.5 1.4 118 Total 68.0 27.1 4.9 66.3 29.4 4.3 4730 40 Table 4.16 and Figure 4.5 show the percent distribution of currently married women who know a contraceptive method by the husband's and wife's attitude toward the use of family planning. Seventy- one percent of currently married women knowing about family planning approve of family planning use by couples. Only 26 percent of married women think that their husband approves of family planning use by couples. One-third of women do not know their husband's attitude. Table 4.16 Percent distribution of currently married women who know a contraceptive method by the husband's and Wife's attitude toward the use of family planning, Uganda, 1988/89 Wife's Husband's Attitude Toward Family Planning Attitude Toward Family Disap- Don't Planning proves Approves Know Total Number Disapproves 15.7 1.4 11.7 28.8 770 Approves 24.2 24.7 21.6 70.5 1881 Hissing 0.2 0.3 0.2 0.7 19 Total 40.1 26.4 33.4 100.0 2670 Number 1070 705 895 2670 2670 Figure 4.5 Attitudes Toward Family Planning Currently Married Women Knowing a Method Percent ~oo j 71 8O 60 40 20 I / 0 wife Approves Husband Approves Both Approve Couple Hal Dlscuued Uganda DHS 1988/89 41 As shown in Table 4.17, there are few differences in either wife's or husband's approval of family planning use by age of the wife. Approval is higher for both wives and husbands in urban areas and in Kampala, and lower in rural areas and West Nile. Also, the more educated the respondent, the more likely she is to approve of family planning use and the more likely she is to report that her husband approves. Table 4.17 Percentage of currently married women knowing a contraceptive method who approve of family planning and who say their husband approves of family planning by background characterist ics, Uganda, 1988/89 Background Woman Husband Character ist ic Approves Approves Total Age 15-19 64.7 22.2 346 20-24 72.4 27.1 602 25-29 73.8 26.2 616 38-34 68.3 29.8 420 35-39 66.9 27.9 310 48-44 76.3 25.4 208 45-49 67.6 23.5 168 Residence Urban 81.6 46.4 278 Rural 69.2 24.1 2392 Region West Ni le 47.0 10.6 108 East 74.0 20.5 848 Central 63.6 25.8 682 West 69.7 34.2 125 South West 73.5 29.7 761 Kampala 63.6 51.4 146 Luwero Triangle 67.2 20.5 297 Educat ion No educat ion 64.0 17.7 1065 Some primary 78.5 26.8 1141 Primary completed 82.5 38.4 233 Middle 86.1 43.2 168 Sigher 91.3 76.7 63 Total 70.5 26.4 2670 Currently married women were asked how often they talked to their husbands about family planning in the past year. The results in Table 4.18 indicate that 60 percent had never discussed family planning with their husband in the year preceding the UDHS, 27 percent had discussed the subject once or twice, and 14 percent had done so more often. The youngest and the oldest women am least likely to have discussed family planning with their husband. 42 Table 4.18 Percent distr ibut ion of current ly marr ied women knowing a contracept ive method by number of t imes d iscussed family p lanning with husband, according to current age, Uganda, 1988/89 Age Number of T imes Discussed Family P lanning Wtd. Number Once or More of Never Twice Often Total Women 15-19 67.8 23.1 9.1 i00.0 346 20-24 61.3 27.4 11.3 i00.0 602 25-29 57.2 29.2 13.6 100.0 616 30-34 56.3 26.0 17.6 i00.0 420 35-39 52.6 30.1 17.3 i00.0 310 40-44 55.4 24.9 19.7 1O0.0 208 45-49 72.6 17.1 10.3 I00.0 168 Total 59.6 26.5 13.8 100.0 2670 43 CHAPTER 5 FERTILITY PREFERENCES 5.1 Future Fertility Preferences This chapter analyses the fertility preferences of women aged 15-49. The results are important for family planning programmes which use the information to evaluate the need for family planning services. The goal of family planning programmes is to allow women to have the number of children they want, when they want them. The UDHS questionnaire includes a number of questions tu ascertain fertility preferences. Each currently married woman was asked if she wanted to have another child and if so, how long she wanted to wait before having her next child. AU women, regardless of marital status, were asked how many children they would like to have, if they could go back to the time when they didn't have any children. This latter variable is referred to in this report as the "ideal" number of children. Additionally, women who had a birth in the five years before the survey were asked if the birth was either unwanted or mistimed. As shown in Table 5.1 and Figure 5.1, 39 percent of women want to have another child within the next two years, 33 percent want to wait at least two years before having another child, 19 percent do not want any more children, and the remaining 9 percent are either undecided (as to when they want or whether they want another birth) or say that they cannot have any more children. Table 5.1 Percent distr ibut ion of current ly marr ied women by desire for children, according to number of l iv ing children, Uganda, 1988/89 Number of L iving Chi ldren Desire for More Chi ldren 0 1 2 3 4 5 6+ Total Want another: Soon (within two years) 74.3 51.8 47.8 36.9 30.8 30.4 17.8 38.6 Later (after 2+ years) 3.6 40.7 43.9 40.5 46.3 35.4 16.0 33.4 Undecided when 5.7 2.0 2.4 2.0 1.5 2.8 0.2 2.0 Want no more 0.0 1.8 3.8 8.5 17.9 24.6 55.1 19.4 Undecided if want more 3.4 1.2 1.1 3.0 3.1 3.9 5.8 3.2 Say can't have more 13.1 2.7 0.9 i.I 0.4 2.8 5.2 3.4 Total i00.0 I00.0 100.0 i00.0 100.0 I00.0 i00,0 100.0 N~ber 279 510 532 444 367 305 743 3180 The wsults show a high inverse correlation between the number of living children a woman has and her desire for more children (Figure 5.2). Almost three-quarters of the childless women want to have a baby within the next two years. This high demand falls to one-half for women with one child. As family size increases, the demand for another child decreases; however, it is notable that 18 percent of the women with six or more children stiU want to have another child within the next two years. 45 Figure 5.1 Fertility Preferences Currently Married Women 15-49 Want to Space (2* yrs.) 33% Want No More 19% Want Another Soon 39% ndecided 5% Intecund 3% Uganda DHS 1988/89 100% 80% 60% 40% 20% 0% 0 Figure 5.2 Fertility Preferences by Number of Living Children Currently Married Women 15-49 2 3 4 Number of Living Children 5 6+ Want No More Undecided I,, Want to Space m Want Soon | I Infecund Uganda DHS 1988/89 46 One would expect a different pattem in the case of the women who want another child, but after two years or more. As expected, only 4 percent of the childless women want to wait to have a baby. The demand rises to a peak at 3 children, where nearly half of the women want to have another child after two or more years. Thereafter, it declines steadily until only 16 percent of women with 6 or more living children want to have another child after two or more years. As expected, the proportion of women who want to stop childbearing rises with the number of children, from zero percent among childless women to 55 percent of women with 6 or more children (Figure 5.2). Several conclusions can be made here. First, there is still a very high demand for children in this society; even among women with 6 or more children, one-third still want to have more children. Secondly, there is a high demand for spacing of children, even among women with only one or two children. It also should be noted that there are few women who either want to have another child but are not sure when, or are undecided whether they want another child or not. Table 5.2 shows the percent distribution of currently married women by desire for children, according to age. The demand for more children declines with age, because the younger women are more likely to have fewer children, while the older women are more likely to have a greater number. The demand for another child within the next two years is highest among the 15-19 age-group, where nearly 50 percent of the women want a child within two years. The demand then declines, to a low of 20 percent for the 45-49 age group. Table 5.2 Percent distr ibut ion of current ly marr ied women by desire for children, according to age, Uganda, 1988/89 Age Desire for More Chi ldren 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Want another: Soon (within two years) 47.7 43.4 41.1 36.8 34.7 27.7 20.5 38.6 Later (after 2+ years) 43.8 48.3 41.9 30.6 17.1 9.3 0.4 33.4 Undecided when 3.1 2.3 1.3 2.4 2.9 0.7 0.0 2.0 Want no more 0.9 3.3 ii.4 22.0 37.8 50.7 59.8 19.4 Undecided if want more 3.3 1.6 3.0 4.5 4.0 4.4 1.5 3.1 Say can't have more 1.1 1.0 1.3 3.7 3.5 7.3 17.9 3.5 Total I00.0 i00.0 100.0 i00.0 I00.0 i00.0 i00.0 I00.0 Number 422 710 705 506 363 252 223 3180 The women who want to wait two or more years to have another child present a different pattern. Except for the first age group the proportion of women wanting a child after two years or more declines with age. Almost half of the women 20-24 want to walt two or more years for their next child, compared to less than 1 percent of women 45-49. The proportion of women wanting no more children is lowest for the youngest age group (1 percent), but increases to 22 percent for women in their early thirties. One-half of the women aged 40-44 want no more children and 60 percent of those 45-49 years old want no more. Similarly, the proportion of women who say that they cannot have more children increases with age to 18 percent for women 45-49. 47 The demand for children can be further analysed according to background characteristics of women. Table 5.3 presents the percentage of women who want no more children by the number of living children they have, according to background variables. Overall, there appears to be little difference in reproductive intentions between urban and rural women; 21 per cent of urban women do not want to have another child, compared with 19 percent of rural women. However, once they have 3 or more ch i ldren, urban women are somewhat more likely to want no more children. The regional distribution of currently married women who want no more children reveals some interesting patterns. Overall, the percentage of women who want no more children is about 20, with Kampala being slightly higher. West Nile region is lower, with only 11 percent wanting no more children. This may be due to the religious composition in West Nile; over 90 percent of the women interviewed in West Nile are either Catholic or Moslem. Tabla 5.3 Percentage of currsnt ly marr ied women who want no more chi ldren (including those steri l ized) by number of l iving chi ldren and background characterist ics, Uganda, 1968/89 Number of L iv ing Chi ldren Background Character ist ic 1 2 3 4+ Total Residence Urban 1.0 2.8 13.9 50.0 20.9 Rural 1.5 3.4 6.4 37.4 18.9 Region West N i le (0.0) 5.8 (Ii.i) 16.2 i i .0 East 4.3 4.6 9.4 43.9 21.4 Central 0.7 3.4 7.4 34.9 16.6 West (O.0) 13.0 (23.5) 33.9 22.0 South West O.0 0.0 2.7 40.0 19.9 Kampala 2.0 5.5 14.6 53.1 23.1 Luwero Tr iangle 1.2 4.8 2.6 32.4 16.0 Educat ion No educat ion 2.5 3.8 7.7 37.2 21.1 Some pr imary 0.8 2.8 6.4 39.1 17.2 Pr imary completed 0.0 0.0 I0.5 34.7 15.4 Middle 3.7 8.2 2.9 50.6 22.3 Higher (O.0) 0.0 (25.0) 68.6 25.8 Total 1.4 3.3 7.7 39.1 19.3 () = fewer than 20 unweighted cases. There is greater variation when the number of living children is considered, especially among women with two or more living children. Among women with two living children, up to 13 percent in the West region do not want to have more children, compared with 5 percent or less in other regions. For women with three living children, nearly 15 percent in Kampala do not want more children, while in the South West the proportion is only 3 percent. One should note that in the 1969 census, the highest fertility in Uganda was reported in the South West (Ankole). At four or more living children there is a sharp increase in the proportion of women not wanting another child, with the exception of West Nile. More than 50 percent of the women in Kampala and more than 40 percent of those in the East do not want another child, while less than 20 percent of women in West Nile want no more children. There is need to point out that in addition to religious affiliation and other socioeconomic variables, the sample sizes in West Nile, West, and Kampala regions were small and subject to sampling errors. Education is another variable which seems to influence the desire for more children, although overall, the differences are not important. Variation can be seen when family size is taken into account. At one and two living children, the pattern is erratic. This may be due to the small number of women with more than primary education. When family size reaches 4 or more, 66 percent of the women with higher education and 51 percent of those with middle level education want no more children. For the rest, the percentage is considerably lower. It is clear, therefore, that the desire to stop childbearing is positively associated with education only at higher levels of education. 48 5.2 Need for Fami ly P lanning Women who are not using contraception and either want no more children or want to space their next child are considered to be in need of family planning. According to this, more than 50 percent of all women in Uganda are in need of family planning. Given the high demand for children among women, there is a much greater need for family planning services for spacing than for stopping purposes. Table 5.4 shows that 37 percent of currently married women want to wait two or more years before their next birth and are not.using contraception, and 17 percent want no more children and are not using contraception. Table 5.4 Percentage of current ly marr ied women who are in need of family p lanning and the percentage who are in need and who intend to use family p lanning in the future by background characterist ics, Uganda, 1988/89 Not Using Contracept ion Not Us ing Contracept ion but Intends to Use Wtd. Want Want to Want Want to Number Background No Post- No Post- of Character ist ic More pone* Total More pone* Total Women Residence Urban 14.9 32.6 47.5 8.3 15.3 23.6 290 Rural 17.1 37.3 54.3 5.4 7.9 13.3 2890 Region West Ni le 10.2 53.4 63.6 0.8 4.2 5.1 194 East 19.4 35.1 54.6 6.2 8.6 14.9 979 Central 14.8 34.1 48.8 4.5 6.6 11.1 777 West 16.9 44,1 61.0 8.5 10.2 18,6 194 South West 17.6 37.0 54.7 5.9 9.5 15.3 886 Kampala 15.3 30.2 45.5 9.7 17.2 26.9 151 Luwero Triangle 13.1 34.7 47.8 4.3 8.1 12.4 313 Educat ion NO educat ion 19.9 34,8 54.7 3.7 5.1 8.8 1409 Some pr imary 14.7 36.9 51.8 6.5 9.1 15.7 1294 Pr imary completed 12.3 46.0 58.3 9.0 17.3 26.4 241 Middle 15.8 43.0 58.8 9.0 17.1 26.1 172 Higher 14.5 27.9 42.4 10.6 18.0 28.5 64 Total 16.9 36.8 53.7 5.7 8.6 14.3 3180 * Want next birth after two or more years 49 The need for family planning is slightly greater in rural areas than in urban. By region of residence, the need is greatest in West Nile, where 64 percent of the women arc in need of family planning. By contrast, need is least in Kampala, where 45 percent are in need. When educational levels are compared, the greatest need for family planning is found in the middle education group. Among these women nearly 60 percent are in need of family planning, whether for spacing or limiting. The lowest level of need is among women with higher education (42 percent). Of those in need of family planning, only a small proportion say they intend to use family planning in the future. Thus, only 14 percent (27 percent of those in need) of currently married women are in need of and intend to use family planning. Although rural women have a greater need for family planning, the intention to use family planning is greatest among urban women (24 vs. 13 percent). The pattern by region is also reversed since Kampala has the largest proportion of women intending to use family planning (27 percent), while West Nile has the smallest (5 percent). 5.3 Ideal Number of Children In order to obtain greater insight into fertility preferences among Ugandan women, all the UDHS respondents were asked: "(If you could go back to the time when you didn't have any children, and) if you could choose the number of children to have in your whole life, how many would that be?" Women with children were asked the entire question, while those with no children were asked the question excluding the part in parentheses. Table 5.5 presents the distribution of women by ideal number of children, according to the number of living children. It is interesting to note that on the whole, less than one-tenth of women gave non-numeric responses (e.g., "As many as God gives me", "It is not up to me to decide"). This suggests that Ugandan women have a good idea of the number of children they consider ideal. Table 5.5 Percent d ist r ibut ion of al l women by ideal number of chi ldren and mean ideal number of chi ldren for all women and current ly marr ied women, according to number of l iving children, Uganda, 1988/69 Number of L iving Chi ldren* Ideal Number of Chi ldren 0 1 2 3 4 5 6+ Total 0 0.5 0.I 0.i 0.0 0.0 0.0 0.I 0.2 1 0.6 0.6 0.0 0.0 0.0 0.2 0.I 0.3 2 2.5 1.6 2.8 0.3 0.5 0.8 1.2 1.6 3 4.7 3.4 1.3 2.1 0.4 0.2 2.1 2.5 4 22.6 21.7 20.6 17.7 14.3 8.5 12.4 17.8 5 11.2 11.3 14.4 9.8 7.2 13.8 3.3 9.8 6+ 50.5 53.9 54.7 63.1 66.7 65.0 71.7 59.8 Non-n~er ic response 7.4 7.3 6.1 7.0 10.9 10.0 9.1 8.1 Total i00,0 I00,0 i00,0 I00.0 i00.0 i00.0 i00.0 i00.0 Number of women II01 728 658 531 437 368 908 4730 Mean (all women) 5.9 6.0 6.1 6.6 6.8 6.9 7.5 6.5 Mean (currently married) 6.3 6.2 6.2 6.7 6.9 7.0 7.7 6.8 * Includes current pregnancy. 50 It is clear that very few women think that three children or less is an ideal family size. Furthermore, the number of living children a woman has seems to have little effect. The percentage choosing 4 as the ideal number of children is considerably higher, being 20 percent for women with fewer than four children. This percentage decreases as the current family size increases. Surprisingly, the proportion choosing an ideal of 5 children is considerably lower than the proportion choosing either 4 or 6 or more children. This may be due to avoidance of the figure 5, perhaps as a result of myths about the number. Most women consider a large family to be the ideal; sixty percent of women report 6 or more children as the ideal number. This ranges from 50 percent of the women who have not yet started childbearing to 70 percent of women with 6 or more living children. The results presentedl in this table further show that claims that women may rationalise the families they already have when asked questions about ideal family size are not entirely true. The fact is, a high proportion of women say that they want more children than they already have. The mean ideal number of children is 6.5 for all women and 6.8 among currently married women. Despite fluctuations, the mean ideal number of children tends to increase with number of living children, which may reflect the fact that women who want more children actually end up having them, or that there is some rationalisation as mentioned above. On the other hand, it may be that younger, lower parity women are actually lowering their ideal family goals. Ideal number of children varies considerably according to background variables. Table 5.6 shows the mean ideal number of children for all women by age group and background characteristics. The mean increases with age in a pattern similar to that found in Table 5.5 for number of living children, from 5.9 for women 15-19 to 7.5 for women 45-49. The mean ideal number of children expressed by urban women (5.5) is about one child less than that expressed by rural women (6.6). Among the younger age groups, i.e. below 40, urban women clearly state a lower ideal number than their rural counterparts. At older ages the difference becomes less pronounced, until for age group 45-49, urban women express an ideal that is almost one child higher than the rural women. This may be due in part to the small numbers of women at older ages. Kampala has the lowest ideal number of children (5.3), with little variation among the other regions. Data by education category reflects the expected pattern. Women with higher education express the lowest ideal number of children (4.7). This increases as education declines, until the highest ideal of over 7 children, expressed by women with no education. Although background variables clearly influence ideal family size, even the lower ideal numbers of children reported by some groups are still quite high by international standards. 5.4 Unplanned Fertility To get a more direct assessment of the need for family planning, it is useful to find out the extent to which births are either mistimed or unwanted. Respondents in the UDHS who had a biRh in the five years preceding the survey were asked: "At the time you became pregnant with (NAME), did you want to have that child then, did you want to wait until later, or did you want no more children at all?" The results from this question are presented in Table 5.7 for births that occurred in the 12 months before the survey. The majority of women (65 percent) wanted the birth when it occurred. However, a substantial number of women (30 percent) would have preferred to wait longer before having that birth, and 5 percent reported that they had not wanted the birth at all. It is significant that in a pro-natalist country such as Uganda 5 pereent of women reported that a birth was unwanted. Birth order seems to have little effect on the proportions of births unwanted or mistimed. 51 Table 5.6 Mean ideal number of chi ldren for al l women by age and background characteristics, Uganda, 1968/89 Age Background Character is t ic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 5.2 5.1 5.2 5.6 5.7 7.2 8.2 5.5 Rural 6.1 6.2 6.7 7.0 7.3 7.5 7.5 6.7 Region West Ni le 6.4 5.7 6.0 7.0 7.9 (7.7) (9.1) 6.7 East 5.6 6.1 6.4 6.6 6.8 6.6 6.6 6.3 Central 5.8 5.9 6.3 6.7 7.3 7.4 7.5 6.4 West 5.3 5.4 6.8 (7.9) (7.7) (7.3) (6.3) 6.4 South West 6.3 6.4 6.9 7.1 7.2 8.2 8.0 6.9 Kampala 5.3 4.9 4.9 5.3 5.8 6.7 (8.4) 5.3 Luwero Tr iangle 5.8 6.0 6.3 6.9 7.7 7.4 7.4 6.5 Educat ion No e~ucat ion 6.7 6.7 7.1 7.6 7.6 7.7 7.7 7.3 Some pr imary 6.0 6.0 6.4 6.6 7.1 7.2 7.5 6.4 Pr imary completed 5.4 5.7 5.7 5.9 5.8 (7.9) (6.0) 5.7 Middle 5.0 5.0 5.4 5.4 5.7 (6.7) (7.4) 5.2 Higher (4.8) 4.4 4.1 4.8 (5.4) (5.4) (4.0) 4.5 Total 5.9 5.9 6.3 6.8 7.1 7.5 7.6 6.4 () = fewer than 20 unweighted cases. Table 5.7 Percentage of women who had a b i r th in the last 12 months by fert i l i ty p lanning status and b i r th order, Uganda, 1988/89 Birth Order P lanning Status of Birth 1-2 3+ Total Wanted then 67.7 64.2 65.3 Wanted later 31.7 29.4 30.1 Wanted no more chi ldren 0.6 6.3 4.6 Total 100.0 100.0 100.0 Number 370 801 1170 52 CHAPTER 6 MORTALITY AND HEALTH 6.1 Mortality One of the major objectives of the Uganda Demographic and Health Survey was to collect data on mortality and health of children. Information on these topics is relevant both to the assessment of the morbidity and mortality levels in the population and of the health policies and programmes in Uganda. Information on mortality and the health status of children serves the needs of health ministries by locating sectors of the population which are at high risk and by assessing the coverage of the existing services. In this section mortality rates are presented for three age intervals: Infant mortality--the probability of dying between birth and exact age one; Childhood mortality--the probability of dying between age one and age five; Under five mortality--the probability of dying between birth and exact age five. Mortality rates are calculated on a period basis (i.e., based on deaths occurring during a certain time period), rather than on a birth cohort basis (i.e., based on deaths occurring to those born during a certain period) for two reasons. First, period-specific rates are more appropriate for programme evaluation and second, the data necessary for the calculation of cohort-based childhood mortality rates are only partially available for the five-year period immediately preceding the survey. The data for estimation of mortality rates were collected by asking the respondents about their childbearing experience, namely the number of sons and daughters who live in the household, who live elsewhere, and who have died. Additional questions on sex, date of birth, status of survival, and current age or age at death of each of a respondent's live bi~hs were asked. The data obtained from these questions are used to calculate infant and childhood mortality rates. Readers interested in this section should note that estimates of infant and childhood mortality based on survey data have limitations, First, most mortality estimates using survey data are based on relatively small numbers of cases, especially when mortality levels are low, leading to unreliable estimates. To reduce this problem, mortality measures based on the UDHS are calculated for five or ten year periods. The second limitation is that birth histories are collected through retrospective reports. This method of data collection is subject to underreporting of events and misreporting of birth and death dates. The extent of these errors affects the overall results. However, such data problems are usually less serious for time periods close to the survey date. Third, estimates of mortality trends using birth histories as reported by women in the reproductive ages at a given point in time are affected by truncation bias because women past age 49 are not interviewed. Estimates of mortality in the past are based only on those births reported by women interviewed at the time of the survey and therefore exclude births in the past that occurred to women who are 50 or older when the survey was done. As the length of the time period covered extends further into the past, the resulting truncation bias of information becomes progressively severe. To minimize the effect of this bias, analysis of trends in infant and birth mortality from the UDHS is limited to a period not exceeding 15 years prior to the survey. 53 Several analyses were conducted in order to investigate some of these potential problems. For example, the data on age at death were tested for digit preference at 12 months of age. In the absence of digit preference, the distribution of deaths by age should be more or less uniform. The distribution of deaths by age in months is as follow: Age in Months Number of Deaths 8 82 9 89 10 20 11 19 12 300 13 12 14 22 15 19 16 10 17 8 18 54 Clearly, there is a great concentration of responses at 12 months of age, and a deficiency of events in the immediately preceding and succeeding months. Since infant mortality covers only deaths under 12 months, a correction of this problem would involve an increase in infant mortality, and a decrease in child mortality. Mortality Levels and Trends 1973-1988 Table 6.1 and Figure 6.1 show infant and childhood mortality rates for the five-year period preceding the survey (1983-1988) and for two earlier five-year time periods (1973-1977 and 1978-1982). The infant mortality rate for the period 1983-1988 is 101 per 1,000 live births and the childhood mortality rate is 88 per 1,000. This means that of 1000 live bi~hs in Uganda, 101 do not live to their first birthday and an additional 88 do not live to age five. The overall probability of dying between birth and exact age five is 180 per 1,000. Table 6.1 Infant and chi ldhoood morta l i ty by f ive-year calendar periods, Uganda, 1988/89 Infant Chi ldhood Under 5 Mortal i ty Morta l i ty Morta l i ty Rate Rate Rate Per iod (lq0) (4ql) (Sq0) 1983-1988" 101.2 88.1 180.4 1978-1982 113.9 97.0 199.9 1973-1977 91.9 96.5 179.6 * Includes calendar year 1988 up to the month preceding date of interview. 54 Figure 6.1 Trends in Infant and Child Mortality Rate per 1,000 250 200 150 114 100 50' o Infant Mortal ity I- 97 97 200 118 Under 5 Mortality r -~ 1983-88 Child Mortality 1973-77 ~ 1973-82 The rates for the 1973-1977 period are lower than for the periods 1978-1982 and 1983-1988. This is an indication of increasing mortality, particularly for infants. One likely reason for this increase is the deterioration and destruction of the health infrastructure during the civil unrest in Uganda from 1973 to 1982. However during the period 1983-1988, health services, especially those aimed at prevention of diseases among children (e.g., immunisation programmes) improved markedly. By the end of the 1983- 1988 period, infant mortality had declined by 11 percent, childhood mortality by 9 percent and the overall probability of dying between birth and exact age five by 10 percent. Table 6.2 and Figure 6.2 show mortality differentials by urban-rural residence, region, and mother's level of education for the ten-year period (1978-88) preceding the survey. The infant mortality rate for the urban population is only slightly lower (103 per 1,000) than for the rural population (107 per 1,000); however, childhood mortality in urban areas is much lower than in rural areas. Region-specific rates are lowest in South West region (172) and highest in West Nile (211). Differentials associated with the level of mother's education indicate lower levels of both infant and childhood mortality for children whose mothers have completed primary education and above, than those children whose mothers have either no education or have not completed primary education. Children born to women with the highest level of education have half the risk of dying under 5 than children born to women with no education. Mortality differentials by sex, mother's age at birth, birth order, and length of the previous birth interval are shown in Table 6.3. As expected, mortality rates arc somewhat higher in males than females during infancy and childhood. Infant mortality rates are also higher among children of mothers less than 20 and over 40 years of age, which is the pattern found in many other countries. Infant and childhood mortality estimates by birth order are highest among the first born and 2-3 subsequent children. 55 Table 6.2 Infant and childhoood mortality by back- ground characteristics of the mother for the ten-year period preceding the survey, Uganda, 1988/89 Infant Childhood Under 5 Mortality Mortality Mortality Rate Rate Rate Background (lq0) (4ql) (Sq0) Characteristic 1976-88' 1978-88" 1978-88" Residence Urban 103.1 67.6 163.7 Rural 106.6 94.0 190.6 Region West Nile 121.7 101.4 210.8 East 118.0 199.4 206.5 Central 98.9 97.5 186.8 West 120.6 66.0 178.7 South West 95.5 84.9 172.3 Kampala 107.6 74.3 173.9 Luwero Triangle 98,3 105.6 193.5 Education No educat ion 116.6 92.6 198.4 Some pr imary 103.6 102.6 195.5 P~imary completed 85.2 74.8 153.6 Middle 88.1 55.5 138.6 Higher 73.0 26.0 97.1 Total 106.3 91.6 188.2 * Includes calendar year 1988 up to the month preceding date of interview. The length of the preceding birth interval depicts the most significant differentials. The infant mortality rates are 142 per 1,000 births born after intervals of less than two years, 84 for births after intervals of 2 to 3 years and 68 for births after intervals of 4 years or more. This means that children born less than two years after an older sibling have more than twice the risk of dying in infancy as those bom 4 or more years after a prior birth. These differentials suggest that an increase in birth spacing practices would substantially reduce infant and childhood morality levels in Uganda. Additional evidence of the high level of childhood mortality in Uganda is shown in Table 6.4 which gives the mean number of children ever born, surviving, and dead, and proportion dead among children ever born by age of mother. Almost 20 percent of all children bom to women 15-49 have died. As expected, the proportion dead rises with age of woman, which reflects the fact that children of older women were themselves born longer ago and have been exposed longer to the risk of mortality. 56 Figure 6.2 Differentials in Infant Mortality For the Period 1978-88 Rate per 1,000 200 150 100 50 0 Urban Rural RESIDENCE None SP CP M H EDUCATION 2 2 -3 4+ yrs . yrs . yrs . BIRTH INTERVAL Note: SP • Some Pr imary , CP • Complete P r imary , M • M idd le , H - Higher 6.2 Maternity Care In Uganda maternity care is provided by several categories of trained health workers and non- trained service providers. The health care that a mother receives during pregnancy and at the time of delivery is important to the survival and well-being of the child as well as the mother. The quality and adequacy of maternity services contribute to a great extent to the levels of infant and maternal mortality of any country. In the UDHS, information on the type of maternity care which women receive in Uganda was obtained by asking respondents whether they had seen anyone for a prenatal checkup for all births in the five years preceding the interview. They were also asked if anyone assisted them with the delivery of that child. If they had received a prenatal checkup or assistance at delivery, they were asked who provided the care. For cases in which matemity care was received from more than one provider, the most qualified provider was recorded by the interviewer. It should be noted that a small proportion of traditional birth attendants in Uganda are trained. For all births in the five years before the survey, mothers were also asked if they had received an injection to protect the baby from getting tetanus. Neonatal tetanus has been one of the major causes of neonatal deaths in Uganda and the level of tetanus toxoid vaccinations during pregnancy is one of the measures of the success of routine immunisation programmes in the prevention of neonatal tetanus. The respondent's ability to distinguish the tetanus toxoid vaccination from other injections she may have received during pregnancy may affect the quality of the results. Table 6.5 indicates that for 76 percent of births in the last five years, the mother received prenatal care from trained nurses and for 56 percent, the mother received at least one tetanus toxoid injection. For a small proportion of births (11 percent), the mothers received prenatal care from a doctor. It is important to note the high percentage of mothers who did not obtain prenatal care at all (12 percent). 57 Table 6.3 Infant and chi ldhoood morta l i ty by selected demographic characterist ics, for the ten-year per iod preceding the survey, Uganda, 1988/89 Infant Chi ldhood Under 5 Mortal i ty Morta l i ty Morta l i ty Rate Rate Rate Demographic (lq0) (4ql) (5q0) Character is t ic 1978-88' 1978-88, 1978-88. Sex of chi ld Male I i i .0 97.3 197.5 Female 101.7 86.0 178.9 Age of mother at b i r th Less than 20 119.8 117.4 223.1 20-29 104.3 91.6 186.3 30-39 94.2 66.2 154.2 40-49 129.7 63.8 185.2 Birth order F irst 117.8 106.1 211.5 2-3 104.1 105.1 198.3 4-6 104.7 86.0 181.7 7+ 101.2 65.0 159.6 Previous birth interval <2 years 142.2 104.9 232.2 2-3 years 84.1 82.0 159.3 4 years or more 68.2 68.8 132.4 * Includes calendar year 1988 up to the month preceding date of interview. Table 6.4 Mean number of chi ldren ever born, surviving, and dead, and proport ion of chi ldren dead among those born, by age of woman, Uganda, 1988/89 Mean Number of Children: Age Wtd. Propor- Number Ever Sur- t ion of Born r iv ing Dead Dead Women 15-19 0.39 0.34 0.06 0.14 1157 20-24 1.86 1.53 0.33 0.18 985 25-29 3.65 3.00 0.64 0.18 859 30-34 5.04 4.10 0.95 0.19 620 35-39 6.79 5.55 1.24 0.18 459 40-44 7.24 5.76 1.47 0.20 345 45-49 7.77 5.97 1.80 0.23 304 Total 3.49 2.83 0.67 0.19 4730 58 Table 6.5 Percent distr ibut ion of births in the last 5 years by type of prenatal care for the mother and percentage of b i r ths whose mother received a tetanus toxoid injection, according to background characterist ics, Uganda, 1988/89 Type of Prenatal Care Percent Receiv ing Trained Trad' l Tetanus Number Background Nurse/ Birth Toxoid of Character ist ic Doctor Midwife Attend. Other None Miss ing Total In ject ion Births Age <30 11.3 76.4 0.6 0.6 ii.0 0.I I00.0 57.3 3184 30+ 10.7 74.3 0.8 0.2 13.3 0.6 100.0 '52.5 1820 Residence Urban 29.1 66.2 0.I 0.0 3.7 0.9 I00.0 74.9 487 Rural 9.I 76.6 0.7 0.5 12.7 0.3 100.0 53.5 4517 Region West Ni le 12.0 54.5 2.4 0.0 30,5 0.6 I00.0 57.5 274 East 7.0 88.0 0.6 0.0 4.1 0.3 100.0 68.9 1378 Central 20.0 70.6 0.2 0.4 8.6 0.I 100.0 47.9 1267 West 3.1 59.8 2.6 5.7 28.4 0.5 100.0 52.1 319 South West 4.7 78.3 0.4 0.0 16.4 0.2 I00.0 45.9 1499 Kampala 34.2 61.2 0.0 0.0 3.2 1.5 i00.0 79.7 267 Luwero Triangle 16.4 72.0 0.I 0.I 11.4 0.0 I00.0 50.9 524 Education No education 6.8 74.3 1.0 0.5 17.1 0.3 100.0 49.7 2071 Some pr imary 10.3 78.2 0.5 0.3 10.3 0.3 i00.0 56.0 2058 Pr imary completed 17.0 78.8 0.4 0.0 3.7 0.I i00.0 64.9 448 Middle 23.3 71.0 0.0 2.1 3.0 0.5 i00.0 72.0 310 Higher 44.4 53.7 0.0 0.0 1.0 1.0 100.0 73.3 117 Total Ii.I 75.6 0.6 0.5 11.9 0.3 100.0 55.6 5004 There are almost no differentials by age of the mother in type of prenatal care obtained or the proportion receiving tetanus injections; however, births to urban women are three times more likely to benefit from prenatal care from a doctor (29 percent) than births to rural women (9 percent). This is at least partly due to the high concentration of health units in urban areas, coupled with the preference of most service providers to work in urban areas, thus leaving rural areas, underserved. About 30 percent of births to women in West Nile and West regions do not benefit from any prenatal care at all, while for 90 percent or more of births to women in East and Central regions and Kampala, the mothers obtain prenatal care from either a doctor or trained nurse or midwife. It is clear that the higher the educational attainment of the mother, the greater the likelihood that she will seek prenatal care and obtain a tetanus injection. Comparison between the proportion of biiths benefitting from prenatal care from trained staff and the proportion receiving assistance at delivery shows a large disparity between the two services (Table 6.6). While mothers receive prenatal care from trained nurses for 76 percent of their births, only 36 59 percent of births are assisted at delivery by the same service providers. The disparity is even larger with doctors; Table 6.5 shows that for 11 percent of births, women see doctors for prenatal care, compared with only 3 percent of births assisted at delivery by a doctor. Furthermore, the proportion of women without any type of assistance at delivery (17 percent), is much greater than for women receiving no assistance (12 percent). Table 6.6 Percent d istr ibut ion of b ir ths in the last 5 years by type of assistance during delivery, according to background chalacterist ics, Uganda, 1986/89 Type of Assistance at Delivery Trained Trad' 1 Number Background Doc- Nurse/ Birth Rela- Miss- of Characteristic tot Midwife Attend. tire Othe~ None ing Total Births Age <30 3.1 38.4 5.9 38.6 1.7 11.9 0.2 100.0 3184 30+ 2.3 30.4 7.1 30.6 1.8 27.1 0.7 100.0 1820 Residence Urban 12.2 67.7 2.4 10.9 1.2 4.7 0.9 100.0 487 Rural 1.8 32.0 6.8 38.4 1.8 18.8 0.3 I00.0 4517 Region West Ni le . 1.2 17.4 22.8 37.7 0.0 20.4 0.6 i00.0 274 East 1.9 45.7 4.6 33.9 2.1 11.4 0.4 100.0 1378 Central 3.9 47.8 7.2 32.1 1.3 7.5 0.2 100.0 1267 West 1.0 20.I i0.3 46.4 4.1 17.5 0.5 i00.0 319 South West 1.0 16.4 4.3 43.0 1.7 33.4 0.3 100.0 1499 Kampala 17.5 68.8 1.3 6.5 1.3 3.2 1.5 100.0 267 Luwero Tr iangle 4.5 38.7 6.7 37.8 1.9 10.3 0.0 100.0 524 Educat ion No educat ion I.I 22.1 7.8 40.0 2.2 26.3 0.4 I00.0 2071 Some primary 2.9 38.2 5.9 37.8 1.6 13.3 0.4 I00.0 2058 Primary completed 3.5 04.6 5.5 27.6 1.4 7.4 0.i 100.0 448 Middle 8.1 66.4 1.8 17.5 1.2 4.4 0.6 I00.0 310 Higher 16.4 70.1 4.2 2.4 0.0 5.9 1.0 100.0 117 Total 2.8 35.5 6.3 35.7 1.8 17,4 0.4 100.0 5004 Table 6.6 shows that 6 percent of births in the five years before the survey received assistance at delivery from a traditional birth attendant and 36 percent from a relative. Although the UDHS interviewers were trained to distinguish the different types of providers that assisted the respondent at delivery, it may have been difficult to distinguish a traditional birth attendant from a relative, especially since some traditional birth attendants may in fact, be related to the mother. If this is true, the proportion of births assisted by traditional birth attendants may be higher than the 6 percent reported in the UDHS. It may also be possible that the relatively high proportion (17 percent) of births reportedly assisted by no one, may include some births assisted by birth attendants. 60 Younger women, urban women, women in Kampala, and better educated women are more likely to obtain assistance at delivery from a doctor, trained nurse or midwife than are other women. The proportion of births to women with no education who are not assisted at delivery by any service provider (26 percent) is about 4 times higher than it is for births to women who completed primary education or more. The inability of a pregnant woman to easily obtain prenatal care and assistance at delivery may be one of the major contributing factors keeping infant and maternal mortality high in Uganda. 6.3 Child Health Indicators Questions on immunisation coverage, the prevalence and treatment of diarrhoea, fever, and respiratory illness among children under the age of five were asked of respondents in the UDHS. The purpose of these questions was to provide information on the frequency and mode of treatment of three illnesses that contribute to the high infant and childhood mortality in Uganda. Data were only collected for children under five whose mothers were interviewed in the UDHS. Immunisation of Children Women who had children under age five were asked if their children had health cards. If the health card was available, the interviewer then copied from the card the dates on which the child had received immunisations against the following diseases: tuberculosis (BOG); diphtheria, whooping cough (pertussis) and tetanus (DPT); polio and measles. If the child had no card or the interviewer was not able to examine the card, the mother was then asked if the child had ever received a vaccination. No attempt was made to obtain information on specific vaccinations for these children because of the possible unreliability of the mother's recall and lack of knowledge about the immuhisation programme in general. Table 6.7 indicates that health cards were seen for 44 percent of all children under five and mothers reported an additional 26 percent of children had at least one immunlsation but could not produce a card? We can therefore assume that about 70 percent of children under five in Uganda have received some immunisation. Uganda launched the Expanded Programme of Immunisation in October 1983 and since then the programme has made steady progress. The following immunisation schedule has been used nationally: Ag¢ Immunisations Birth BCG and Polio 6 Weeks DPT, Polio 10 Weeks DPT, Polio 14 Weeks DPT, Polio 9 Months Measles Readers of this report should note that polio vaccination was not given at billh in Uganda until 1988 when the Uganda Technical Committee on Immunisation adopted the recommendation by the World Health Organisation. Therefore in the UDHS children who had received 3 polio vaccinations were regarded as having been completely immunised against polio. tResults not shown here also indicate that for the 44 percent of children under five with health cards seen, about 87 percent had a BCG scar. Among children whose mothers reported at least one immunisation (26 percent) 68 percent had a BCG scar. Overall, 56 percent of the children under the age five have a BCG scar. 61 Table 6.7 ~ong all children under 5 years of age, the percentage with health cards seen by interviewer, the percentage who are i~un ised as recorded on a health card or as reported by the mother and, among children with health cards, the percentage for for whom BCG, DPT, polio and measles im~unisations are recorded on the health card, according he age, Uganda, 1988/89 Among All Children ~nong All Children Under 5 with Health Cards seen, Under 5, Percent with: the Percent Who Have Received: Num- With Some Mother All bet Health Inunun- Reports ImJnun- of Age in Card isation Child DPT DPT DPT Polio Polio Polio Meas- isa- Chil- Months Seen on card Immun. BCG 1 2 3 1 2 3 lee tions* dren <6 23.0 23.0 7.1 100.0 69.5 24.2 11.4 77.0 28.1 12.8 0.6 0.0 433 6-11 48.0 48.0 15.6 98.4 90.1 66.0 45.9 89.7 66.6 48.9 21.9 15.1 540 12-17 48.9 48.9 20.5 99.3 94.8 72.9 53.6 95.4 74.2 54.1 63.8 42.6 541 18-23 49.9 49.7 24.0 96.3 95.7 81.3 61.5 95.3 82.1 61.6 81.5 54.8 405 24-59 44.9 44.8 34.0 97.2 97.7 78.7 59.8 97.9 78.2 59.2 85.0 82.8 2411 Total 44.0 44.0 26.4 97.7 94.6 73.6 54.7 95.0 73.9 54.5 68.7 43.7 4330 * 8CG, at least 3 doses of DPT and polio, and measles Table 6.7 and Figure 6.3 show that among children under five for whom health cards were available, 98 percent have received a BCG vaccination, 55 percent have received three doses of DPT vaccine, 55 percent have received three doses of polio vaccine, and 69 percent have received vaccine against measles. Overall, 44 percent of the children under five with health cards have been fully immunised against vaccine-preventable diseases. There is a substantial drop-off between the proportion of children who receive the first dose of either DPT or polio and the proportion who go on to get the second and third doses. Except for the first 2 age groups, when some children cannot be expected to have received all immunisations, the differences by age group are not large. Table 6.8 presents similar information by background characteristics, but is restricted to children 12-23 months of age, since these children represent the best way to evaluate the coverage of the immunisation programme. The data show that there is little difference in immunisation coverage between boys and girls, but that a greater proportion of children are immunised in urban areas than rural areas. Although the same proportion of rural children as urban children receive the first few immunisations, far fewer continue on to obtain the later doses. West region has the highest proportion of children with health cards seen. Of those with health cards seen, two and a half times as many children in Kampala are fully immunised as in West Nile (77 percent vs. 29 percent). The higher the mother's education, the more likely she has a health card for her child and the more likely her child has received immunisations. Estimates of coverage for all children, including those whose health cards were not seen can be derived by multiplying the proportion of children with particular immunisations recorded on health cards by the proportion of children whose health cards were seen. For example, multiplying the 47.7 percent of children 12-23 months who are fully immunised according to their health cards by the 49.3 percent who produced health cards for the interviewers, gives an estimate of 23.5 percent of all children 12-23 months who were fully immunised. This produces a minimum estimate of coverage, since the method assumes that all children without cards have not received any immunisation. 62 100 Figure 6.3 Immunisation Coverage Children Under 5 Years With Health Cards Percent 80 60 40 20 0 BCQ DPT DPT Polio Polio Measles All* 1 3 1 3 • Includes BCQ, measles, and at least 3 doses DPT and polio, Uganda DHS 1988/89 A more precise estimate of the coverage for children 12-23 months can be obtained by assuming that from those children whose mothers reported immunisation, some did get the specific vaccine. The results shown below are obtained by adding to the proportion vaccinated according to the health card the proportion vaccinated according to the information from the mother. This second value is obtained by using the following proportions of those observed in the health card seen: BCG = 1.0 (meaning that all the children with mothers information got BCG), DPT1 and PV1 = .95 (meaning that 95 percent of the children with mothers information got the vaccine) DPT2 and PV2 = .90, DFI'3 and PV3 = .80, MEASLES= .90, and .75 as fully immunised. These values are the median values observed among seven countries for which DHS has implemented surveys (to be presented in a forthcoming analysis). When this method of estimation is applied to UDHS data, the result is an estimate of 31 percent of children 12-23 months fully immunised. The method was also applied to UDHS data from Mbarara District in South West region for comparison with a UNICEF survey conducted in Mbarara in 1988 (Republic of Uganda, 1989b). The results are: Immunisation Received BCG DPT1 DPT2 DPT3 PV1 PV2 PV3 MSLS All Some None UDHS 60 61 48 33 60 48 31 50 31 33 36 UNICEF 52" 49 38 26 49 39 25 29 17 41 42 Source: Baseline Survey for the South-West Integrated Project Mbaram. Ministry of Health, UNICEF. March-April 1988, Tables 10-14. Based on the results, the UDHS estimates for Mbarara District, signal a higher immunisation coverage than that obtained in the UNICEF study. However this could be attributed to the assumption made earlier, which will eventually inflate the coverage value. 63 Table 6.8 Among all children aged 12-23 months, the percentage with health cards seen by interviewer, the percentage who are immunlsed as recorded on a health card or as repor6ed by the mother and, among children with health cards, the percentage for wh~ BCG, DPT, polio and measles immunisatlons are recorded on the health card, according to background characteristics, Uganda, 1988/89 Among Children 12-23 Among Children 12-23 Months with Health Cards Seen, Months I Percent with: the Percent Who Have Received: Num- With Some Mother All bet Background Health Immuni- Reports Immu- of Character- Card satlon Some DPT DPT DPT Polio Polio Polio Meas- nlsa- Chll- istic Seen on Card Immun. 8CG 1 2 3 1 2 3 les tlone* dren Sex of child Male 51.2 51.0 21.9 98.4 93.6 79.0 59.0 93.9 79.0 59.0 73.3 50.0 459 Female 47.5 47.5 22.2 97.6 96.8 74.1 55.0 96.8 76.2 55.7 69.5 45.1 487 Residence Urban 56.5 56.5 31.2 97.7 96.6 89.7 85.1 98.6 89.7 85.1 85.9 75.9 87 Rural 48.6 48.5 21.1 98.0 95.0 75.0 53.7 95.2 76.2 54.1 70.0 44.5 880 Region West Nile 58.6 58.6 20.7 I00.0 I00.0 41.2 29.4 i00.0 41.2 29.4 82.4 29.4 48 East 42.7 42.7 27.6 96.6 89.7 63.3 41.2 91.2 67.7 44.2 58.4 31.9 262 Central 41.6 41.6 22.6 98.4 95.8 86.6 68.0 95.8 86.6 66.4 67.1 49.4 250 West 70.6 70.6 20.6 100.0 91.7 70.8 50.0 91.7 70.8 50.0 62.5 45.8 56 South Nest 58.2 55.9 13.9 97.9 98.3 85.0 62.6 97.7 85.0 62.6 82.3 56.9 283 Kampala 51.8 51.8 40.0 97.7 97.7 88.6 88.6 97.7 88.6 88.6 81.8 77.3 48 Luwero Trl. 48.4 48°4 19.0 96.6 97.8 86.6 69.7 97.8 86.5 69.7 80.9 59.6 10q Education No education 44.7 44.5 18.0 97.7 93.9 68oi 42.9 93.9 69.1 42.8 66.5 35.7 375 Some primary 50.4 50.4 24.6 97.6 95.9 79.6 60.2 96.7 80.4 61.1 71.6 49.6 416 Primary comp. 56.0 56.0 18.9 98.8 91.7 74.7 61.1 90.0 78.2 61.1 74.0 50.5 83 Middle 57.6 57.6 33.9 I00.0 I00.0 i00.0 94.8 i00.0 I00.0 94.8 83.3 83.3 46 Higher 83.6 63.6 28.2 I00o0 100.0 90.3 87.0 i00.0 90.3 87.0 93.4 80.4 27 Total 49°3 49.2 22.0 98°0 95.2 76.5 57.0 95.4 77.6 57.4 71.5 47.7 946 * BCG, at least 3 doses of DPT and polio, and measles In the UDHS, information was collected on recent episodes of diarrhoea and the treatment provided for children under the age of five. Respondents were asked whether each child had experienced an episode of diarrhoea in the last 24 hours or in the last two weeks. Additional questions were asked about the occurrence of fever and respiratory illness in the four weeks preceding the interview and the treatment given to the children suffering from such illnesses. The data collected cannot be used to measure the incidence of such diseases but they provide an estimate of children under 5 years whose mothers report that they had illness during the specified number of weeks preceding the survey. Caution should be taken in interpreting the results of these questions, as the responses are clearly dependent upon what the mother understands as diarrhoea, fever, or respiratory illness and her ability to recall when the episode of the illness in question occurred. The number of cases of diarrhoea, fever, and respiratory illness also vary seasonally. 64 Diarrhoea Table 6.9 shows that 14 percent of children under 5 years of age were reported by the mother to have had diarrhoea in the 24 hours before the interview and 24 percent had diarrhoea in the two weeks before the interview. Diarrhoea prevalence is highest among children 6-17 months of age, with over 40 percent reported to have had an episode in the previous two weeks. This is the age when children begin to eat other foods besides breastmilk and may be exposed to more contaminating agents. Prevalence of diarrhoea is somewhat higher among rural children than urban children and among children in East region. Differences by sex of child and by education of mother are small, except for the highest level of education. Table 6.10 indicates the percentage of children with diarrhoea in the two weeks before the survey who consulted a medical facility and the type of treatment received. Overall, 15 percent were taken to a medical facility, 15 percent received some form of oral rehydration therapy (ORT), 30 percent received some other treatment and 63 percent received no treatment. Children under 6 months of age are less likely than older children be taken to a medical facility or to receive treatment for their episode of diarrhoea. Children who live in urban areas, Kampala, or whose mothers have higher education are more likely to receive some treatment and more likely to receive ORT than other children. This is probably due to the increased access to health facilities in urban areas compared with limited access to similar facilities in rural areas. Oral rehydration therapy is an effective and inexpensive way to treat the dehydration caused by diarrhoea. In the UDHS, all mothers of children under the age of five were asked if they knew of a product called Dalozi for treating diarrhoea--specially prepared packets of oral rehydration salts (ORS). Table 6.11 shows that just under half of the mothers had heard of the packets. Knowledge about ORS increases dramatically with the level of education of women. It is also substantially higher among urban women and women in Kampala. Table 6.9 Among children under 5 years of age, the percentage reported by the mother to have had diarrhoea in the past 24 hours and the past two weeks, according to background characteristics, Uganda, 1988/89 Percent of Children Under 5 with Diarrhoea in: Number of Chil- Background Past Past dren Character- 24 Two Under istic Hours Weeks 5 Age of child Under 6 months 20.5 27.5 433 6-11 months 27.4 43.3 540 12-17 months 22.6 42.2 541 18-23 months 17.6 34.6 405 24-59 months 7.5 13.7 2411 Sex Male 15.2 25.4 2122 Female 13.2 23.2 2208 Residence Urban 11.2 20.1 425 Rural 14.5 24.8 3904 Region West Nile 15.1 24.0 240 East 21.3 33.6 1178 Central 10.3 19.0 1083 West 14.0 24.4 269 South West 11.4 20.9 1331 Kampala 11.1 21.5 228 Luwero Triangle 9.4 20.3 447 Education No education 13.9 23.4 1785 Some primary 15.1 26.5 1769 Primary comp. 14.3 24.0 402 Middle 13.8 20.4 268 Higher 3.2 13.7 106 Total 14.2 24.3 4330 65 Table 6.10 Among chi ldren under 5 years of age, who had diarrhoea in the past two weeks, the percentage consult ing a medical facil ity, the per- centage receiv ing di f ferent treatments as reported by the mother, and the percentage not consult ing a medical faci l i ty and not receiv ing treatment, according to background characterist ics, Uganda, 1988/89 Percent of Chi ldren with Diarrhoea Treated with: I Not Con- Percent sult ing Chil- Consult - Faci l i ty dren Background ing a Home Other No and No with Character- Medical ORS Solu- Treat- Treat- Treat- Diar- istic Faci l i ty Packets tion ment ment ment* rhoea Age Under 6 months 7.2 10.9 0.0 12.6 80.5 12.8 119 6-11 months 16.6 17.9 1.8 24.3 65.0 11.4 234 12-17 months 19.7 14.7 1.7 33.7 57.6 ]0.6 229 18-23 months 14.4 11.4 0.8 35.3 57.4 12.9 140 24-59 months 13.0 12.1 1.5 32.0 61.0 11.9 332 Sex Male 13.8 13.2 1.6 28.6 63.3 11.2 540 Female 15.8 14.3 1.0 29.2 62.4 12.4 513 Residence Urban 20.4 20.4 2.6 34.9 57.2 7.9 86 Rural 14.3 13.1 1.2 28.4 63.4 12.1 967 Region West Ni le 5.7 14.3 0.0 11.4 74.3 25.7 58 East 14.9 12.9 0.4 30.4 61.7 5.9 396 Central 16.7 12.2 4.3 32.1 62.7 11.9 206 West 20.0 12.5 2.5 25.0 67.5 15.0 66 South West 12.3 14.4 0.3 27.5 62.6 16.7 279 Kampala 23.0 24.1 2.3 36.8 55.2 9.2 49 Luwero Tr iangle 17.4 18.0 6.8 36.6 54.0 13.0 91 Educat ion No educat ion 12.8 13.6 1.2 25.5 65.0 14.0 418 Some pr imary 16.6 12.6 0.5 31.7 68.8 9.8 469 Pr imary completed 17.1 21.4 4.6 30.8 60.4 9.7 97 Middle 7.1 7.7 4.1 20.9 73.5 11.2 55 Higher 19.5 27.3 0.0 54.2 45.8 22.7 14 Total 14.8 13.7 1.3 28.9 62.9 11.7 1053 * Percents may add to more than 100, since chi ldren may receive more than treatment. :Some chi ldren did not consult a medical faci l i ty but received treatment from other sources. 66 Fever The questions in the UDHS on fever were designed to obtain a rough estimate of the extent to which children experienced a bout of malaria during the 4 weeks preceding the interview and what type of treatment was given for the fever. It should be noted that malaria is endemic in Uganda and therefore most fevers in children are attributed to malaria infection. Overall, 41 percent of the children under five were reported to have had a fever in the previous 4 weeks, of whom 45 percent were taken to a medical facility, 57 percent were treated with antimalarial drugs, and 70 percent were given other medicines (Table 6.12). While 4 percent were given antibiotics for treatment of fever, 14 percent were given no treatment at all. Fever prevalence is highest among children 6-17 months of age and among children in East region. As expected, medical consultation is higher for urban children and children in Kampala. Cough/Difficult Breathing Upper respiratory tract infection is one of the three main causes of morbidity and mortality among children under five in Uganda. To obtain information on the prevalence of respiratory illness, respondents were asked whether for each child under age five there was an episode of severe cough with difficult or rapid breathing in the four weeks preceding the interview. Twenty-two percent of the children were reported to have had a cough in the past 4 weeks, of whom 48 percent consulted a medical provider, while 23 percent received antibiotics for treatment and another 23 percent got no treatment (Table 6.13). Fifteen percent of children who had severe cough with difficult or rapid breathing did not receive anything at all to treat the illness. This may be due to the inaccessibility of the respondents to a health unit, lack of money to pay for medical consultation, or lack of severity of the illness. Table 6.11 Among mothers of children under 5 the percent who know about ORT, according to background characteristics, Uganda, 1988/89 Background Characteristic Percent Residence Urban 81.3 Rural 43.9 Region West Nile 26.0 East 44.4 Central 62.0 West 52.5 South West 34.4 Kampala 93.1 Education None 32.4 Some primary 51.8 Primary completed 73.7 Middle 85.3 Higher 87.1 Total 50.6 6.4 Nutritional Status of Children Nutritional status assessment is based on the concept that in a well-nourished population, there will be a statistically predictable distribution of children of a given age with respect to height and weight. In terms of a particular index (say, height-for-age), the distribution will approximate the normal curve, that is, about 68 percent of children will have a height within 1 standard deviation from the mean for that age. About 14 percent will be relatively tail for their age, that is, between +1 and +2 standard deviations from the mean and another 14 percent will be relatively short for their age, that is, between -1 and -2 standard deviations from the mean. Finally, about 2 percent will be very tall for their age, that is, more than +2 standard deviations from the mean and another 2 percent will be very short for their age, that is, more than -2 standard deviations from the mean. Comparison of the distribution of height and weight in a given population with that of a standard reference population facilitates analyses across countries and over time. For comparative purposes, the nutritional status tables in this report use the reference population defined by the U.S. National Center for Health Statistics (NCHS) and accepted by the U.S. Centers for Disease Control (CDC) and the World Health Organisation (WHO). 67 Table 6.12 ~,mong chi ldren under 5 years of ages the percentage who are reported by the mother as having had fever in the past four weeks, and, among the~ the percentage consult ing a medical facility, the percentage receiving various treatments, and the percentage not consult ing a medical faci l i ty and not receiving treatment, according to background characterist ics, Uganda, 1988/89 Background Character ist ic Among Chi ldren with Fever, Percent Not Con- Number Percent Treated by:* sult ing of with Medical Chil- Fever Consult Anti- Anti- Other No Faci l i ty dren in Past Medical mal- bio- Medi- Treat- and No Under 4 Weeks Faci l i ty arial tics cine ment Treatment* 5 Age Under 6 months 35.3 40.3 44.7 3.6 57.3 20.4 15.3 433 6-11 months 52.8 54.5 60.2 4.4 71.3 12.4 6.6 540 12-17 months 51.2 48.3 56.3 1.6 71.2 13.1 9.0 541 18-23 months 46.6 44.0 58.8 7.6 69.8 10.6 6.3 405 24-59 months 36.9 41.0 58.2 4.1 70.8 13.4 8.8 2411 SeM Boy 41.4 46.7 56.9 5.4 69.1 14.D 8.5 2122 Girl 41.4 42.4 57.4 2.9 70.2 13.0 9.0 2208 Residence Urban 31.6 62.8 55.6 8.8 75.3 9.2 2.9 425 Rural 42.5 43.0 57.3 3.7 69.2 13.8 9.3 3904 Region West Nile 43.8 50.0 34.4 4.7 81.3 15.6 14.1 240 East 67.0 46.1 65.4 3.5 64.8 14.6 i0.I 1178 Central 38.2 41.5 41.7 4.6 82.2 7.8 4.8 1083 West 34.8 38.6 70.2 1.8 80.7 5.3 5.3 269 South West 23.9 39.2 61.3 4.7 58.3 20.8 11.4 1331 Kampala 91.9 66.7 53.5 8.5 69.8 9.3 2.3 228 Luwero Triangle 42.9 46.2 62.5 3.2 78.0 8.2 5.6 447 Education No education 39.4 42.8 53.3 3.1 64.8 18.1 13.0 1785 Some pr imary 44.3 44.1 58.0 3.9 69.9 12.4 8.0 1769 Primary completed 46.7 50.9 64.6 6.3 80.3 5.6 1.6 402 Middle 34.7 47.1 61.9 6.0 78.7 7.1 0.6 268 Higher 23.0 48.7 65.4 16.0 88.4 2.3 0.0 106 Total 41.4 44.5 57.1 4.1 69.7 13.5 8.8 4330 :Percents may add to more than I00, since chi ldren may receive more than one treatment. *Some chi ldren did not consult a medical faci l i ty but received treatment from other sources. 68 Table 6.13 Among chi ldren under 5 years of age, the percentage who are reported by the mother as having suffered from severe cough with dif f icult or rapid breathing in the past four weeks, and, ~unong them the percentage con- sult ing a medical facility, the peroentage receiving various treatments, and the percentage not consult ing a medical faci l i ty and not receiving treatment, according to background characteristics, Uganda, 1988/89 Among Chi ldren with Cough, Percent Percent Treated by|* Not Con- No. Of with sult ing Chi l - P~ackground Cough Consult Anti- Other No Medi .Fa- dren Character- in Past Medical b lo- Cough Medi- Treat- ei l i ty & Under istlc 4 Weeks Faci l ity tics Syrup cine ment No Treat.' 5 Age Under 6 months 22.4 29.8 14.7 21.0 61.7 31.1 24.6 433 6-11 months 30.2 53.6 24.2 30.7 59.8 21.2 11.6 548 12-17 months 24.7 51.6 20.0 26.0 57.7 24.6 14.5 541 18-23 months 26.0 48.4 21.7 22.6 49.6 30.7 15.1 405 24-59 months 19.6 49.2 25.6 28.3 58.8 19.5 13.5 2411 Sex Male 22.5 49.4 23.2 29.7 54.1 23.2 14.9 2122 Female 22.3 47.1 23.0 24.5 62.0 22.5 14.3 2208 Residence Urban 20.1 56.6 21.7 52.0 51.3 14.5 5°3 425 Rural 22.7 47.4 23.2 24.6 58.8 23.7 15.5 3904 Region West Nile 25.3 56.8 21.6 16.2 51.4 27.0 27.0 240 East 21.9 67.7 38.9 29.9 54.6 24.8 13.6 i178 Central 19.4 50.1 15.4 37.9 67.9 12.6 8.7 1083 West 15.2 52.0 12.0 32.0 72.0 16.0 12.0 269 South West 26.7 29.6 18.5 15.4 56.1 29.0 18.6 1331 Kampala 20.2 59.8 17.1 59.8 45.1 12.2 2.4 228 Luwero Triangle 17.6 50.7 27.9 28.6 72.9 5.7 4.3 447 Education No education 21,3 44.2 24.5 21.3 57.1 28.2 19.4 1788 Some pr imary 25.2 47.4 21.4 24.9 60.8 20.7 12.9 1769 Primary completed 21.3 58.4 20.9 41.8 56.0 19.0 7.7 402 Middle 18.2 68.2 30.6 86.8 51,5 10.1 7.5 268 Higher 15.8 56.5 29.8 59.8 36.5 13.5 3.4 106 Total 22.4 48.2 23.1 27.0 58.1 22.9 14.6 4330 * Percents may add to more than I00 r since chi ldren may receive more than one treatment. 'Some chi ldren did not consult a medical faci l i ty but received treatment from other sources. In the UDHS, all children under the age of five born to women interviewed were eligible for measurement of weight and height. Of the 3621 eligible children, 3150, or 87 percent were weighed and measured. The most common reason for not being measured was that the child was not in the house at the time of the interview. 69 The accuracy of anthropometric data depends heavily on the ability of the measurer to perform the measurements correctly. In order to minimise errors, team supervisors and field editors were trained to weigh and measure children following procedures described in the United Nations manual "How to Weigh and Measure Children". Each participant was provided with a copy of this manual to which he/she could refer. Equipment consisted of standardised 25-kg. hanging scales and portable, wooden measuring boards. Trainees Were taught to measure to DHS standards: these are to weigh children to within 100 grams of true weight and to measure supine length within 0.5 centimeters of true length. A test of weighing accuracy was carded out and each team was given two members who passed the test. During the survey, spot checks on measurement techniques were made by an experienced anthropometrist and a second standardisation test was conducted to check on accuracy. Inaccurate reporting of age of children can adversely affect the validity of the anthropometric data. While age in years is sufficient for most demographic analyses, age in months is required for anthropometric assessment. This is because a child can be misclassified as severely undemourished or ovemourisbed if his/her reported age is in error by just a few months. In the UDHS, efforts were made to obtain accurate information on birth dates of children by probing carefully and utilising the information on the health card whenever possible. The data presented in the subsequent tables are based on children with exact dates of birth from which exact ages were calculated. Figure 6.4 shows the distribution of all children, and of children measured, by age in months. The presence of minimal heaping indicates that UDHS anthropometric data are not influenced by misreported ages. Percent 3 Figure 6.4 Age Distribution of Measured Children and All Children 2 1 0 0 8 12 18 24 30 36 Age in Months Measured children - -~ All children i i Uganda DHS 1988/89 Four standard indices of physical growth that describe the nutritional status of children 0 through 60 months are presented in this report: Height-for-age Weight-for-height Height-for-age by weight-for-height Weight-for-age. 70 Each index provides different information on the nutritional status of children. Height-for-age is a measure of linear growth. A child who is 2 or more standard deviations (SD) below the mean of the reference population in terms of height for age is considered short for his/her age which could reflect the cumulative effect of chronic malnutrition. Such a child is referred to as "stunted". Weight-for-height describes current nutritional status. A child who is 2 or more standard deviations below the mean of the reference population in terms of weight-for-height is considered thin for his/her age which could reflect a recent episode of illness resulting in acute malnutrition. Such a child is referred to as "wasted". Height-for-age by weight for height is a cross tabulation of the above two indices (also known as a Waterlow table) and can indicate children who are both chronically and acutely undernourished. Children who are 2 or more standard deviations below the mean of the reference population on both indices are considered severely undernourished. Weight-for-age is a composite index of weight for height and height for age and does not provide additional information beyond that already provided by the three indices described above. However weight-for-age is commonly used in clinical settings to monitor the growth of children on a longitudinal basis and is included in this report to provide a useful reference for clinical weight programmes. The terms "stunted" and "wasted" are purely descriptive. Stunting is a measure of chronic undernutrition that indicates growth retardation. It is typically associated with poor economic conditions. Sev

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