Zimbabwe DHS Final Report (2010-2011)

Publication date: 2012

Zimbabwe Demographic and Health Survey 2010-11 Zimbabwe National Statistics Agency Harare, Zimbabwe ICF International, Inc. Calverton, Maryland USA March 2012 ZIMBABWEANS AND AMERICANS IN PARTNERSHIP TO FIGHT HIV/AIDS The 2010-11 Zimbabwe Demographic and Health Survey (2010-11 ZDHS) was implemented by the Zimbabwe National Statistics Agency (ZIMSTAT). The funding for the ZDHS was provided by the United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), the United Nations Population Fund (UNFPA), the United Nations Development Program (UNDP), the United Nations Children’s Fund (UNICEF), the United Kingdom Department for International Development (DFID), the European Union (EU), and the Government of Zimbabwe. ICF International supported the project through the MEASURE DHS project, a USAID-funded project providing support, technical assistance, and funding for population and health surveys in countries worldwide. Additional information about the ZDHS may be obtained from the Zimbabwe National Statistics Agency, P.O. Box CY 342, Causeway, Harare, Zimbabwe (Telephone: (263-4) 793-971/2 and 797-756; Fax (263-4) 794-757; E-mail: census@mweb.co.zw). Information about the MEASURE DHS project may be obtained from ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572- 0999, E-mail: info@measuredhs.com, Internet: http://www.measuredhs.com. Cover photo ©2010 Rex Harris • www.flickr.com/photos/sheepdog_rex/ • Used with permission. Recommended citation: Zimbabwe National Statistics Agency (ZIMSTAT) and ICF International. 2012. Zimbabwe Demographic and Health Survey 2010-11. Calverton, Maryland: ZIMSTAT and ICF International Inc. Table of Contents • iii CONTENTS TABLES AND FIGURES . ix PREFACE . xv MILLENNIUM DEVELOPMENT GOAL INDICATORS . xvii MAP OF ZIMBABWE . xviii CHAPTER 1 INTRODUCTION 1.1 Geography and Economy . 1 1.2 Population . 2 1.3 Objectives of the Survey . 3 1.4 Survey Implementation . 4 1.4.1 Sample Design . 4 1.4.2 Questionnaires . 4 1.4.3 Anthropometry, Anaemia, and HIV Testing . 5 1.4.4 Training of Field Staff . 7 1.4.5 Fieldwork . 7 1.4.6 Data Processing . 7 1.5 Response Rates . 8 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2.1 Household Characteristics . 9 2.1.1 Drinking Water . 9 2.1.2 Sanitation Facilities and Waste Disposal . 11 2.1.3 Housing Characteristics . 12 2.1.4 Household Durable Goods . 13 2.2 Household Wealth . 14 2.3 Hand Washing . 15 2.4 Household Population by Age, Sex, and Residence . 16 2.5 Household Composition . 18 2.6 Birth Registration . 19 2.7 Children’s Living Arrangements, School Attendance, and Parental Survival . 20 2.8 Education of the Household Population . 22 2.8.1 Educational Attainment . 22 2.8.2 School Attendance Ratios . 23 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Characteristics of Survey Respondents . 27 3.2 Educational Attainment by Background Characteristics . 29 3.3 Literacy . 31 3.4 Exposure to Mass Media . 33 3.5 Employment Status . 35 3.6 Occupation . 38 3.7 Type of Employment . 40 3.8 Health Insurance Coverage . 41 3.9 Use of Tobacco . 43 iv • Table of Contents CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY 4.1 Marital Status . 47 4.2 Polygyny . 48 4.3 Age at First Marriage . 50 4.4 Age at First Sexual Intercourse . 51 4.5 Recent Sexual Activity . 53 CHAPTER 5 FERTILITY 5.1 Current Fertility . 57 5.2 Fertility by Background Characteristics . 58 5.3 Fertility Trends . 59 5.4 Children Ever Born and Living . 60 5.5 Birth Intervals . 61 5.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 62 5.7 Median Duration of Postpartum Insusceptibility by Background Characteristics . 63 5.8 Menopause . 65 5.9 Age at First Birth . 65 5.10 Median Age at First Birth by Background Characteristics . 66 5.11 Teenage Pregnancy and Motherhood . 67 CHAPTER 6 FERTILITY PREFERENCES 6.1 Fertility Preferences by Number of Living Children . 69 6.2 Desire to Limit Childbearing by Background Characteristics . 70 6.3 Ideal Number of Children . 72 6.4 Mean Ideal Number of Children by Background Characteristics . 73 6.5 Fertility Planning Status . 74 6.6 Wanted Fertility Rates . 75 CHAPTER 7 FAMILY PLANNING 7.1 Knowledge of Contraceptive Methods . 77 7.2 Current Use of Contraception . 79 7.3 Current Use of Contraception by Background Characteristics . 81 7.4 Source of Modern Contraceptive Methods . 84 7.5 Use of Social Marketing Brand Pills . 85 7.6 Use of Social Marketing Brand Condoms . 86 7.7 Informed Choice . 86 7.8 Rates of Discontinuing Contraceptive Methods . 87 7.9 Reasons for Discontinuing Contraceptive Methods . 88 7.10 Knowledge of the Fertile Period . 89 7.11 Need and Demand for Family Planning . 90 7.12 Future Use of Contraception . 93 7.13 Exposure to Family Planning Messages in the Media . 94 7.14 Contact of Nonusers with Family Planning Providers . 96 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Background and Assessment of Data Quality . 99 8.2 Infant and Child Mortality Levels and Trends . 101 8.3 Socioeconomic Differentials in Early Childhood Mortality . 102 8.4 Biodemographic Differentials in Early Childhood Mortality . 103 8.5 Perinatal Mortality . 104 8.6 High-Risk Fertility Behaviour . 105 Table of Contents • v CHAPTER 9 MATERNAL HEALTH CARE 9.1 Antenatal Care . 107 9.2 Number and Timing of Antenatal Visits . 109 9.3 Components of Antenatal Care . 109 9.4 Tetanus Toxoid . 111 9.5 Place of Delivery . 113 9.6 Assistance during Delivery . 114 9.7 Postnatal Care for the Mother . 116 9.8 Postnatal Care for the Newborn . 119 9.9 Problems in Accessing Health Care . 122 CHAPTER 10 CHILD HEALTH 10.1 Child’s Weight and Size at Birth . 125 10.2 Vaccination of Children . 127 10.3 Prevalence and Treatment of Acute Respiratory Infection . 130 10.4 Prevalence and Treatment of Fever . 131 10.5 Diarrhoeal Disease . 133 10.5.1 Prevalence of Diarrhoea . 133 10.5.2 Treatment of Diarrhoea . 134 10.5.3 Feeding Practices during Diarrhoea . 135 10.6 Knowledge of ORS Sachets . 137 10.7 Disposal of Children’s Stools . 137 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 139 11.1.1 Measurement of Nutritional Status among Young Children . 139 11.1.2 Data Collection . 140 11.1.3 Levels of Child Malnutrition. 141 11.1.4 Trends in Child Malnutrition . 143 11.2 Breastfeeding . 144 11.2.1 Initiation of Breastfeeding . 144 11.2.2 Breastfeeding Status by Age . 146 11.2.3 Median Duration of Breastfeeding . 148 11.3 Dietary Diversity among Young Children . 149 11.3.1 Foods and Liquids Consumed by Infants and Young Children . 150 11.3.2 Infant and Young Child Feeding (IYCF) Practices . 151 11.4 Anaemia Prevalence in Children . 154 11.5 Micronutrient Intake and Supplementation among Children . 156 11.6 Presence of Iodized Salt in Households . 158 11.7 Adults’ Nutritional Status . 159 11.7.1 Nutritional Status of Women . 159 11.7.2 Nutritional Status of Men . 161 vi • Table of Contents 11.8 Anaemia Prevalence in Adults . 162 11.8.1 Anaemia Prevalence among Women . 162 11.8.2 Anaemia Prevalence among Men . 163 11.9 Micronutrient Intake among Mothers . 164 CHAPTER 12 MALARIA 12.1 Ownership of Mosquito Nets . 167 12.2 Indoor Residual Spraying . 168 12.3 Use of Mosquito Nets by Persons in the Household . 169 12.3.1 Use of Mosquito Nets by Children Under Five Years . 170 12.3.2 Use of Mosquito Nets by Pregnant Women . 171 12.4 Use of Intermittent Preventive Treatment of Malaria in Pregnancy . 173 12.5 Prevalence, Diagnosis, and Prompt Treatment of Fever among Young Children . 174 12.6 Prevalence of Anaemia in Children . 176 CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 HIV/AIDS Knowledge, Transmission, and Prevention Methods . 180 13.2 Knowledge about Mother-to-Child Transmission . 185 13.3 Attitudes towards People Living with HIV/AIDS . 187 13.4 Attitudes towards Negotiating for Safer Sexual Relations with Husbands . 189 13.5 Attitudes towards Condom Education for Young People. 190 13.6 Multiple Sexual Partners . 192 13.7 Paid Sex . 196 13.8 Coverage of HIV Testing Services . 197 13.9 Male Circumcision. 201 13.10 Self-reporting of Sexually Transmitted Infections . 202 13.11 Injections . 204 13.12 HIV/AIDS-Related Knowledge and Behaviour among Young People . 206 13.12.1 Knowledge about HIV/AIDS and Source for Condoms . 206 13.12.2 First Sex . 207 13.12.3 Premarital Sex . 208 13.12.4 Multiple Sexual Partners . 210 13.12.5 Age-mixing in Sexual Relationships . 211 13.12.6 Coverage of HIV Testing Services . 212 CHAPTER 14 HIV PREVALENCE 14.1 Coverage Rates for HIV Testing . 216 14.2 HIV Prevalence . 218 14.2.1 HIV Prevalence by Age and Sex . 218 14.2.2 HIV Prevalence by Other Socioeconomic Characteristics . 219 14.2.3 HIV Prevalence by Other Sociodemographic and Health Characteristics . 221 14.2.4 HIV Prevalence by Sexual Risk Behaviour. 222 14.3 HIV Prevalence among Young People . 224 14.4 HIV Prevalence by Other Characteristics Related to HIV Risk . 226 14.5 Male Circumcision and HIV Prevalence . 227 14.6 HIV Prevalence among Couples . 228 Table of Contents • vii CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Women’s and Men’s Employment . 231 15.2 Women’s Control Over Their Own Earnings and Relative Magnitude of Women’s Earnings . 232 15.3 Women’s Ownership of Assets . 236 15.4 Women’s and Men’s Participation in Decision making . 238 15.5 Attitudes towards Wife Beating . 242 15.6 Women’s Empowerment Indicators . 246 15.7 Current Use of Contraception by Women’s Empowerment . 247 15.8 Ideal Family Size and Unmet Need by Women’s Empowerment . 247 15.9 Women’s Empowerment and Reproductive Health Care . 248 15.10 Differentials in Infant and Child Mortality by Women’s Empowerment . 249 CHAPTER 16 DOMESTIC VIOLENCE 16.1 Measurement of Violence . 252 16.1.1 The Use of Valid Measures of Violence . 252 16.1.2 Ethical Considerations . 253 16.1.3 Subsample for the Violence Module . 254 16.2 Women’s Experience of Physical Violence . 254 16.3 Force at Sexual Initiation . 255 16.4 Experience of Sexual Violence . 256 16.5 Experience of Different Forms of Violence . 258 16.6 Violence During Pregnancy . 259 16.7 Marital Control by Husband or Partner . 261 16.8 Forms of Spousal Violence . 263 16.9 Violence by Spousal Characteristics and Women’s Indicators . 266 16.10 Frequency of Spousal Violence . 267 16.11 Onset of Spousal Violence . 269 16.12 Types of Injuries to Women due to Spousal Violence . 269 16.13 Violence by Women against Their Husband . 270 16.14 Help-Seeking Among Women Who Have Experienced Violence . 272 16.15 Changes in Domestic Violence between 2005-06 and 2010-11 . 274 CHAPTER 17 ADULT AND MATERNAL MORTALITY 17.1 Data . 275 17.2 Direct Estimates of Adult Mortality . 276 17.2.1 Levels of Adult Mortality . 277 17.2.2 Trends in Adult Mortality . 277 17.3 Direct Estimates of Maternal Mortality . 278 REFERENCES . 281 APPENDIX A SAMPLE IMPLEMENTATION . 285 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 295 APPENDIX C DATA QUALITY TABLES . 313 APPENDIX D PERSONS INVOLVED IN THE 2010-11 ZIMBABWE DEMOGRAPHIC AND HEALTH SURVEY . 321 APPENDIX E QUESTIONNAIRES . 327 Tables and Figures • ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Population size and growth rate . 2 Table 1.2 Demographic indicators . 3 Table 1.3 Results of the household and individual interviews . 8 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION Table 2.1 Household drinking water . 10 Table 2.2 Household sanitation facilities . 11 Table 2.3 Household characteristics . 12 Table 2.4 Household possessions . 13 Table 2.5 Wealth quintiles . 15 Table 2.6 Hand washing . 16 Table 2.7 Household population by age, sex, and residence . 17 Table 2.8 Household composition . 18 Table 2.9 Birth registration of children under age five . 19 Table 2.10 Children's living arrangements and orphanhood . 20 Table 2.11 School attendance by survivorship of parents . 21 Table 2.12.1 Educational attainment of the female household population . 22 Table 2.12.2 Educational attainment of the male household population . 23 Table 2.13 School attendance ratios . 24 Figure 2.1 Population pyramid . 17 Figure 2.2 Age-specific attendance rates of the de facto population 5 to 24 years . 25 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 28 Table 3.2.1 Educational attainment: Women . 29 Table 3.2.2 Educational attainment: Men . 30 Table 3.3.1 Literacy: Women . 32 Table 3.3.2 Literacy: Men . 32 Table 3.4.1 Exposure to mass media: Women . 33 Table 3.4.2 Exposure to mass media: Men . 34 Table 3.5.1 Employment status: Women . 36 Table 3.5.2 Employment status: Men . 37 Table 3.6.1 Occupation: Women. 39 Table 3.6.2 Occupation: Men . 40 Table 3.7 Type of employment: Women . 41 Table 3.8.1 Health insurance coverage: Women . 42 Table 3.8.2 Health insurance coverage: Men . 43 Table 3.9.1 Use of tobacco: Women . 44 Table 3.9.2 Use of tobacco: Men . 45 Figure 3.1 Women’s employment status in the past 12 months . 35 CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY Table 4.1 Current marital status . 47 Table 4.2.1 Number of women's co-wives . 48 Table 4.2.2 Number of men's wives . 49 Table 4.3 Age at first marriage . 50 Table 4.4 Median age at first marriage by background characteristics . 51 Table 4.5 Age at first sexual intercourse . 52 x • Tables and Figures Table 4.6 Median age at first sexual intercourse by background characteristics . 53 Table 4.7.1 Recent sexual activity: Women . 54 Table 4.7.2 Recent sexual activity: Men . 55 CHAPTER 5 FERTILITY Table 5.1 Current fertility . 58 Table 5.2 Fertility by background characteristics . 58 Table 5.3.1 Trends in age-specific fertility rates . 59 Table 5.3.2 Trends in age-specific and total fertility rates . 60 Table 5.4 Children ever born and living . 61 Table 5.5 Birth intervals . 62 Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility . 63 Table 5.7 Median duration of amenorrhoea, postpartum abstinence, and postpartum insusceptibility . 64 Table 5.8 Menopause . 65 Table 5.9 Age at first birth . 66 Table 5.10 Median age at first birth . 66 Table 5.11 Teenage pregnancy and motherhood . 67 Figure 5.1 Trends in age-specific fertility rates . 60 CHAPTER 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . 70 Table 6.2.1 Desire to limit childbearing: Women . 71 Table 6.2.2 Desire to limit childbearing: Men . 71 Table 6.3 Ideal number of children by number of living children . 73 Table 6.4 Mean ideal number of children by background characteristics . 74 Table 6.5 Fertility planning status . 75 Table 6.6 Wanted fertility rates . 76 CHAPTER 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods . 78 Table 7.2 Current use of contraception by age . 80 Table 7.3.1 Current use of contraception by background characteristics . 82 Table 7.3.2 Trends in the current use of contraception . 83 Table 7.4 Source of modern contraceptive methods . 84 Table 7.5.1 Use of social marketing brand pills . 85 Table 7.5.2 Use of social marketing brand condoms . 86 Table 7.6 Informed choice . 87 Table 7.7 12-month contraceptive discontinuation rates . 88 Table 7.8 Reasons for discontinuation . 89 Table 7.9 Knowledge of fertile period . 90 Table 7.10.1 Need and demand for family planning among currently married women . 91 Table 7.10.2 Need and demand for family planning for all women and for women who are not currently married . 92 Table 7.11 Future use of contraception . 94 Table 7.12 Exposure to family planning messages . 95 Table 7.13 Contact of nonusers with family planning providers . 96 Figure 7.1 Trends in contraceptive use among currently married women . 83 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 101 Table 8.2 Mortality rates for the five years preceding the survey . 101 Table 8.3 Early childhood mortality rates by socioeconomic characteristics . 102 Table 8.4 Early childhood mortality rates by demographic characteristics . 103 Table 8.5 Perinatal mortality . 105 Tables and Figures • xi Table 8.6 High-risk fertility behaviour . 106 CHAPTER 9 MATERNAL HEALTH CARE Table 9.1 Antenatal care . 108 Table 9.2 Number of antenatal care visits and timing of first visit . 109 Table 9.3 Components of antenatal care . 111 Table 9.4 Tetanus toxoid injections . 112 Table 9.5 Place of delivery . 113 Table 9.6 Assistance during delivery . 115 Table 9.7 Timing of first postnatal checkup for the mother . 117 Table 9.8 Type of provider of first postnatal checkup for the mother. 118 Table 9.9 Timing of first postnatal checkup for the newborn . 120 Table 9.10 Type of provider of first postnatal checkup for the newborn . 121 Table 9.11 Problems in accessing health care . 122 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth. 126 Table 10.2 Vaccinations by source of information . 128 Table 10.3 Vaccinations by background characteristics . 128 Table 10.4 Trends in vaccination coverage . 129 Table 10.5 Prevalence and treatment of symptoms of ARI . 131 Table 10.6 Prevalence and treatment of fever . 132 Table 10.7 Prevalence of diarrhoea . 133 Table 10.8 Diarrhoea treatment . 135 Table 10.9 Feeding practices during diarrhoea . 136 Table 10.10 Knowledge of ORS sachets . 137 Table 10.11 Disposal of children's stools . 138 Figure 10.1 Trends in vaccination coverage among children 12-23 months . 130 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 142 Table 11.2 Initial breastfeeding . 145 Table 11.3 Breastfeeding status by age . 146 Table 11.4 Median duration of breastfeeding . 149 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 150 Table 11.6 Infant and young child feeding (IYCF) practices . 152 Table 11.7 Prevalence of anaemia in children . 155 Table 11.8 Micronutrient intake among children . 157 Table 11.9 Presence of iodized salt in household . 158 Table 11.10.1 Nutritional status of women . 159 Table 11.10.2 Nutritional status of men . 161 Table 11.11.1 Prevalence of anaemia in women . 162 Table 11.11.2 Prevalence of anaemia in men . 164 Table 11.12 Micronutrient intake among mothers . 165 Figure 11.1 Nutritional status of children by age . 143 Figure 11.2 Trends in nutritional status of children under age five . 144 Figure 11.3 Infant feeding practices by age . 147 Figure 11.4 IYCF indicators on breastfeeding status . 148 Figure 11.5 IYCF indicators on minimum acceptable diet . 153 Figure 11.6 Trends in anaemia status among children age 6-59 months . 156 Figure 11.7 Trends in nutritional status among women age 15-49 . 160 Figure 11.8 Trends in anaemia status among women age 15-49 . 163 xii • Tables and Figures CHAPTER 12 MALARIA Table 12.1 Household possession of mosquito nets . 168 Table 12.2 Indoor residual spraying against mosquitoes . 169 Table 12.3 Use of mosquito nets by persons in the household . 170 Table 12.4 Use of mosquito nets by children . 171 Table 12.5 Use of mosquito nets by pregnant women . 172 Table 12.6 Prophylactic use of antimalarial drugs and use of intermittent preventive treatment (IPTp) by women during pregnancy . 173 Table 12.7 Prevalence, diagnosis, and prompt treatment of children with fever . 175 Table 12.8 Type and timing of antimalarial drugs taken by children with fever . 176 Table 12.9 Haemoglobin < 8.0 g/dl in children . 177 CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS . 180 Table 13.2 Knowledge of HIV prevention methods. 181 Table 13.3.1 Comprehensive knowledge about HIV/AIDS: Women . 183 Table 13.3.2 Comprehensive knowledge about HIV/AIDS: Men . 184 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 186 Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 187 Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 188 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 190 Table 13.7 Adult support of education about condom use to prevent AIDS . 191 Table 13.8.1 Multiple sexual partners: Women . 192 Table 13.8.2 Multiple sexual partners: Men . 193 Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners . 195 Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse . 196 Table 13.11.1 Coverage of prior HIV testing: Women . 198 Table 13.11.2 Coverage of prior HIV testing: Men . 199 Table 13.12 Pregnant women counseled and tested for HIV . 201 Table 13.13 Male circumcision . 202 Table 13.14 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 203 Table 13.15 Prevalence of medical injections . 205 Table 13.16 Comprehensive knowledge about HIV/AIDS and of a source of condoms among young people . 206 Table 13.17 Age at first sexual intercourse among young people . 207 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among young people . 209 Table 13.19.1 Multiple sexual partners in the past 12 months among young people: Women . 210 Table 13.19.2 Multiple sexual partners in the past 12 months among young people: Men . 211 Table 13.20 Age-mixing in sexual relationships among women and men age 15-19 . 212 Table 13.21 Recent HIV tests among young people . 213 Figure 13.1 Women and men seeking advice or treatment for STIs . 204 Figure 13.2 Trends in age at first sexual intercourse . 208 CHAPTER 14 HIV PREVALENCE Table 14.1 Coverage of HIV testing by residence and province . 216 Table 14.2 Coverage of HIV testing by selected background characteristics . 217 Table 14.3 HIV prevalence by age . 218 Table 14.4 HIV prevalence by socioeconomic characteristics . 220 Table 14.5 HIV prevalence by demographic characteristics . 222 Table 14.6 HIV prevalence by sexual behaviour . 223 Table 14.7 HIV prevalence among young people by background characteristics . 225 Table 14.8 HIV prevalence among young people by sexual behaviour . 226 Table 14.9 HIV prevalence by other characteristics . 226 Table 14.10 Prior HIV testing by current HIV status . 227 Table 14.11 HIV prevalence by male circumcision . 228 Tables and Figures • xiii Table 14.12 HIV prevalence among couples . 229 Figure 14.1 HIV prevalence among all adults age 15-49, and by sex, Zimbabwe 2005-06 and 2010-11 . 219 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women and men . 232 Table 15.2.1 Control over women's cash earnings and relative magnitude of women's cash earnings: Women . 233 Table 15.2.2 Control over men's cash earnings . 235 Table 15.3 Women's control over their own earnings and over those of their husbands . 236 Table 15.4.1 Ownership of assets: Women . 237 Table 15.4.2 Ownership of assets: Men . 238 Table 15.5 Participation in decision making . 239 Table 15.6.1 Women's participation in decision making by background characteristics . 240 Table 15.6.2 Men's participation in decision making by background characteristics . 242 Table 15.7.1 Attitude toward wife beating: Women . 244 Table 15.7.2 Attitude toward wife beating: Men . 245 Table 15.8 Indicators of women's empowerment . 246 Table 15.9 Current use of contraception by women's empowerment . 247 Table 15.10 Women's empowerment and ideal number of children and unmet need for family planning . 248 Table 15.11 Reproductive health care by women's empowerment . 249 Table 15.12 Early childhood mortality rates by indicators of women's empowerment . 250 Figure 15.1 Number of decisions in which currently married women participate . 241 CHAPTER 16 DOMESTIC VIOLENCE Table 16.1 Experience of physical violence . 254 Table 16.2 Persons committing physical violence . 255 Table 16.3 Force at sexual initiation . 256 Table 16.4 Experience of sexual violence . 257 Table 16.5 Age at first experience of sexual violence . 258 Table 16.6 Persons committing sexual violence . 258 Table 16.7 Experience of different forms of violence . 259 Table 16.8 Violence during pregnancy . 260 Table 16.9 Degree of marital control exercised by husbands . 262 Table 16.10 Forms of spousal violence . 263 Table 16.11 Spousal violence by background characteristics . 265 Table 16.12 Spousal violence by husband's characteristics and empowerment indicators . 266 Table 16.13 Frequency of spousal violence . 268 Table 16.14 Onset of marital violence . 269 Table 16.15 Injuries to women due to spousal violence . 270 Table 16.16 Violence by women against their spouse . 271 Table 16.17 Help seeking to stop violence . 272 Table 16.18 Sources from where help was sought . 273 Table 16.19 Trends in domestic violence in the past 12 months . 274 Figure 16.1 Percentage of ever-married women who have experienced specific forms of violence committed by their most recent husband/partner, ever and during the past 12 months . 264 CHAPTER 17 ADULT AND MATERNAL MORTALITY Table 17.1 Data on siblings . 276 Table 17.2 Adult mortality rates . 277 Table 17.3 Maternal mortality . 278 xiv • Tables and Figures APPENDIX A SAMPLE IMPLEMENTATION . 285 Table A.1 Population . 285 Table A.2 Sample allocation of clusters and households . 286 Table A.3 Sample allocation of completed interviews with women and men . 287 Table A.4 Sample implementation: Women . 287 Table A.5 Sample implementation: Men . 288 Table A.6 Coverage of HIV testing by social and demographic characteristics: Women . 289 Table A.7 Coverage of HIV testing by social and demographic characteristics: Men . 290 Table A.8 Coverage of HIV testing by sexual behaviour characteristics: Women . 291 Table A.9 Coverage of HIV testing by sexual behaviour characteristics: Men . 292 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 298 Table B.2 Sampling errors for national sample . 299 Table B.3 Sampling errors for urban sample . 300 Table B.4 Sampling errors for rural sample . 301 Table B.5 Sampling errors for Manicaland sample . 302 Table B.6 Sampling errors for Mashonaland Central sample . 303 Table B.7 Sampling errors for Mashonaland East sample . 304 Table B.8 Sampling errors for Mashonaland West sample . 305 Table B.9 Sampling errors for Matabeleland North sample . 306 Table B.10 Sampling errors for Matabeleland South sample . 307 Table B.11 Sampling errors for Midlands sample . 308 Table B.12 Sampling errors for Masvingo sample . 309 Table B.13 Sampling errors for Harare sample . 310 Table B.14 Sampling errors for Bulawayo sample . 311 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 313 Table C.2.1 Age distribution of eligible and interviewed women . 314 Table C.2.2 Age distribution of eligible and interviewed men . 315 Table C.3 Completeness of reporting . 316 Table C.4 Births by calendar years . 317 Table C.5 Reporting of age at death in days . 318 Table C.6 Reporting of age at death in months . 319 Table C.7 Nutritional status of children based on NCHS/CDC/WHO international reference population . 320 APPENDIX D PERSONS INVOLVED IN THE 2010-11 ZIMBABWE DEMOGRAPHIC AND HEALTH SURVEY . 321 APPENDIX E QUESTIONNAIRES . 327 Preface • xv PREFACE he 2010-11 Zimbabwe Demographic and Health Survey (2010-11 ZDHS) presents the major findings of a survey of a large, nationally representative sample of nearly 11,000 households. This survey was conducted by the Zimbabwe National Statistics Agency (ZIMSTAT) from late September 2010 through March 2011. The 2010-11 ZDHS is a follow-up to the 1988, 1994, 1999, and 2005-06 ZDHS surveys and provides updated estimates of basic demographic and health indicators. In contrast with past ZDHS surveys, the 2010-11 ZDHS was carried out using electronic personal digital assistants (PDAs) rather than paper questionnaires for recording responses during interviews. A preliminary report was published in June 2011. The primary objective of the 2010-11 ZDHS is to provide current information for policymakers, planners, researchers, and programme managers. Topics include fertility levels; nuptiality; sexual activity; fertility preferences; knowledge and use of family planning methods; breastfeeding practices; nutritional status of mothers and young children; early childhood mortality and maternal mortality; maternal and child health; malaria prevention and treatment; awareness and behaviour regarding HIV and other sexually transmitted infections; and domestic violence. Additionally, the 2010-11 ZDHS provides population-based prevalence estimates for anaemia among men, women, and young children and for HIV among women age 15-49 and men age 15-54. ZIMSTAT extends its acknowledgement and gratitude to the various agencies and individuals in the government, donor community, and public sector for support that facilitated the successful implementation of the survey. Specific mention is due to the following: the Ministry of Health and Child Welfare (MOHCW), the National Microbiology Reference Laboratory (NMRL), the USAID/Zimbabwe Mission, the United Nations Population Fund (UNFPA), the United Nations Development Program (UNDP), the United Nations Children’s Fund (UNICEF), the Centers for Disease Control and Prevention (CDC), the United Kingdom Department for International Development (DFID), the European Union (EU), the National AIDS Council (NAC), Population Services International (PSI), University of Zimbabwe (UZ), the Joint United Nations Programmes on HIV and AIDS (UNAIDS), the Zimbabwe National Family Planning Council (ZNFPC), and the World Health Organization (WHO). ICF International provided technical assistance and funding to the 2010-11 ZDHS through the MEASURE DHS project, a USAID-funded programme supporting the implementation of population and health surveys in countries worldwide. Finally, we wish to thank all field personnel for commitment to high-quality work under difficult conditions and all ZDHS respondents for their patience and cooperation. Mutasa Dzinotizei Director General Zimbabwe National Statistics Agency T Millennium Development Goal Indicators • xvii Millennium Development Goal Indicators, Zimbabwe 2010-11 Sex Total Indicator Male Female 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under 5 years of age 11.1 8.4 9.7 2. Achieve universal primary education 2.1 Net attendance ratio in primary education1 87.4 88.8 88.1 2.3 Literacy rate of 15-24 year-olds2 95.2 96.2 95.7a 3. Promote gender equality and empower women 3.1 Ratio of girls to boys in primary, secondary, and tertiary education 3.1a Ratio of girls to boys in primary education3 na na 1.0 3.1b Ratio of girls to boys in secondary education3 na na 1.0 3.1c Ratio of girls to boys in tertiary education3 na na 0.7 4. Reduce child mortality 4.1 Under five mortality rate4 87 68 84 4.2 Infant mortality rate4 64 44 57 4.3 Proportion of 1 year old children immunised against measles 78.1 80.2 79.1 5. Improve maternal health 5.1 Maternal mortality ratio5 na na 960 5.2 Proportion of births attended by skilled health personnel6 na na 66.2 5.3 Contraceptive prevalence rate7 na 58.5 na 5.4 Adolescent birth rate8 na 114.6 na 5.5 Antenatal care coverage 5.5a At least one visit na 89.8 na 5.5b Four or more visits na 64.8 na 5.6 Unmet need for family planning na 12.8 na 6. Combat HIV/AIDS, malaria and other diseases 6.1 HIV prevalence among population age 15-24 3.6 7.3 5.5 6.2 Condom use at last high-risk sex9 73.7 48.0 60.9 6.3 Percentage of population age 15-24 years with comprehensive correct knowledge of HIV/AIDS10 47.0 51.9 49.5a 6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years 0.91 0.94 0.92 6.7 Percentage of children under 5 sleeping under insecticide-treated bednets 9.2 10.2 9.7 6.8 Percentage of children under 5 with fever who are appropriately treated with anti-malarial drugs11 2.1 2.5 2.3 Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved drinking water source12 95.1 68.7 76.7 7.9 Percentage of population with access to improved sanitation13 49.8 31.8 37.3 na = Not applicable a The total is calculated as the simple arithmetic mean of the percentages in the columns for males and females 1 Based on reported attendance, not enrollment, in primary education among primary school age children (6-10 year-olds). The rate also includes children of primary school age attending secondary education. This is a proxy for MDG indicator 2.1, Net enrollment ratio. 2 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence. 3 Based on reported net attendance not gross enrollment, among 6-12 year-olds for primary, 13-18 year-olds for secondary and 19-24 year-olds for tertiary education. 4 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the 5-year period preceding the survey. 5 Expressed in terms of maternal deaths per 100,000 live births in the 7-year period preceding the survey 6 Among births in the five years before the survey 7 Percentage of currently married women age 15-49 using any method of contraception 8 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19 9 Higher-risk sex refers to sexual intercourse with a non-marital, non-cohabitating partner. Expressed as a percentage of men and women age 15- 24 who had higher-risk sex in the past 12 months. 10 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about transmission or prevention of HIV. 11 Measured as the percentage of children age 0-59 months who were ill with a fever in the two weeks preceding the interview and received any anti-malarial drug 12 Percentage of de-jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, protected spring, rainwater collection, or bottled water 13 Percentage of de-jure population whose household has a flush toilet, ventilated improved pit latrine, or pit latrine with a slab, and does not share this facility with other households xviii • Map of Zimbabwe Introduction • 1 INTRODUCTION 1 1.1 GEOGRAPHY AND ECONOMY imbabwe lies just north of the Tropic of Capricorn between the Limpopo and Zambezi rivers. The country is landlocked, bordered by Mozambique on the east, South Africa on the south, Botswana on the west, and Zambia on the north and northwest. It is part of a great plateau, which constitutes the major feature of the geology of southern Africa. Almost the entire surface area of Zimbabwe is more than 300 metres above sea level, with nearly 80 percent of the land lying more than 900 metres above sea level and about 5 percent lying more than 1,500 metres above sea level. About 70 percent of the surface rock in Zimbabwe is granite, schist, or igneous, and it is rich in mineral wealth. Soil types range from clay or sandy loam in the high veldt to Kalahari sands in the hot and dry western part of the country. The climate of Zimbabwe is a blend of cool, dry, sunny winters and warm, wet summers. Average annual precipitation totals increase with increasing altitude; however, temperature drops with increasing altitude. The Eastern Highlands of the country are therefore associated with cool and wet conditions, while the Sabi, Limpopo, and Zambezi valleys are hot and dry. Mining and agriculture are the backbone of the country’s economy, even though the country is richly endowed with some of the world’s most impressive manmade and natural tourist attractions, such as the Great Zimbabwe Ruins and Victoria Falls. Zimbabwe has abundant natural resources, including 8.6 million hectares of potentially arable land and more than 5 million hectares of forests, national parks, and wildlife estates. There are adequate supplies of surface and ground water that could be harnessed for generation of electric power, irrigation of crops, and domestic and industrial use. Mineral resources are varied and extensive, including platinum, gold, asbestos, coal, nickel, iron, copper, lithium, and precious stones such as emeralds and diamonds. The economy is diversified but biased toward agriculture and mining, which are by far the country’s major foreign-currency earning sectors. In addition to mineral processing, major industries include food processing, construction, chemicals, textiles, wood and furniture, and production transport equipment. In recent years the mining industry has faced challenges such as frequent power outages, inefficient infrastructure, flight of skilled workers, and shortages of funds for working capital and recapitalisation. The manufacturing industry also has suffered constraints such as deindustrialisation, inadequate and erratic supply of key economic enablers (namely electricity, fuel, coal, and water), and the high cost of establishing business. The agriculture sector has well-developed commercial and communal farming systems. As a result of the country’s resettlement scheme, Zimbabwe now has some A1 and A2 farms that previously were largely commercial farms. The communal and resettlement sector’s contribution to the production of industrial raw materials and food products has increased substantially since 1980, despite its poor physical and socioeconomic infrastructure. The agricultural sector continues to face many challenges such as poor irrigation, unaffordable inputs, and low capitalisation levels. The main agricultural export product is tobacco, along with maize, cotton, sugar, and groundnuts. However, the economic challenges of recent years have affected export crops. Z 2 • Introduction In 2011, the inclusive government of Zimbabwe implemented a five-year strategic development plan, the Zimbabwe 2011-2015 Medium Term Plan (MTP) (MEPIP, 2011). It outlines the economic policies, projects, and programmes that will guide the nation and set priorities through 2015. The goals of the MTP are to maintain macroeconomic stability, restore the economy’s capacity to produce goods and services competitively, and empower people to fully participate in the economy so as to achieve the vision of the plan. The MTP empowers Zimbabweans both socially and economically in order to eradicate poverty and ensure sustainable development. 1.2 POPULATION According to the 2002 census, the population of Zimbabwe was 11.6 million. Estimates, rather than actual counts, of the total population are available from the beginning of the century through 1951, when the census began to include non-Africans. Table 1.1 presents population growth rates compiled from the population censuses. The average annual growth in the population reached a peak of 3.5 percent in 1951 and 1961 and then dropped to 3 percent between 1982 and 1992. The annual population growth rate between 1992 and 2002 was 1.1 percent. Table 1.1 Population size and growth rate Population size and annual rate of increase in the population, Zimbabwe 1901-2002 Year Population (’000) Annual growth rate (percent) 1901 713 - 1911 907 2.4 1921 1,147 2.4 1931 1,464 2.5 1941 2,006 3.2 1951 2,829 3.5 1961 3,969 3.5 1969 5,134 3.3 1982 7,608 3.0 1992 10,412 3.1 2002 11,632 1.1 Source: Central Statistical Office, 2002 Table 1.2 shows that the population of people of African descent was 99 percent in 2002. The population of European, Asian, and Coloured descendants made up the remaining 1 percent in 2002. The 2002 census estimated the crude birth rate and the crude death rate to be about 30 births per thousand population and 17 deaths per thousand population, respectively. Forty-one percent of the population of Zimbabwe was below age 15, 55 percent was between age 15 and 64, and a very small proportion (4 percent) was age 65 or above. Introduction • 3 Table 1.2 Demographic indicators Selected demographic indicators, Zimbabwe 1992 and 2002 Indicator 1992 Census 2002 Census Total population (thousands) 10,412 11,632 Distribution by ethnic group (percent) African 98.8 99.3 European 0.8 0.4 Coloured 0.3 0.2 Asian 0.1 0.1 Distribution by age group (percent) 0-14 45.1 40.6 15-64 51.3 55.0 65+ 3.3 4.0 Not stated 0.3 0.4 Crude birth rate (births per 1,000 population) 34.5 30.3 Crude death rate (deaths per 1,000 population) 9.5 17.2 Number of males per 100 females in the total population 95 94 Life expectancy at birth 61.0 45.0 Source: Central Statistical Office, 2002 1.3 OBJECTIVES OF THE SURVEY The 2010-2011 Zimbabwe Demographic and Health Survey (2010-11 ZDHS) is one of a series of surveys undertaken by the Zimbabwe National Statistics Agency (ZIMSTAT) as part of the Zimbabwe National Household Survey Capability Programme (ZNHSCP) and the worldwide MEASURE DHS programme. The Ministry of Health and Child Welfare (MOH&CW) and the Zimbabwe National Family Planning Council (ZNFPC) contributed significantly to the design and implementation of the 2010-11 ZDHS and to the analysis of the survey results. Financial support for the 2010-11 ZDHS was provided by the government of Zimbabwe, the United States Agency for International Development (USAID), the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the United Kingdom Department for International Development (DFID), the European Union (EU), the United Nations Population Fund (UNFPA), the United Nations Development Fund (UNDP), the United Nations Children’s Fund (UNICEF), and the Centers for Disease Control and Prevention (CDC). The Demographic and Health Research Division of ICF International provided technical assistance during all phases of the survey. The 2010-11 ZDHS is a follow-on to the 1988, 1994, 1999, and 2005-06 ZDHS surveys and provides updated estimates of basic demographic and health indicators covered in these earlier surveys. Data on malaria prevention and treatment, domestic violence, anaemia, and HIV/AIDS were also collected in the 2010-11 ZDHS. In contrast to the earlier surveys, the 2010-11 ZDHS was carried out using electronic personal digital assistants (PDAs) rather than paper questionnaires for recording responses during interviews. The primary objective of the 2010-11 ZDHS is to provide up-to-date information on fertility levels, nuptiality, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of mothers and young children, early childhood mortality and maternal mortality, maternal and child health, and knowledge and behaviour regarding HIV/AIDS and other sexually transmitted infections (STIs). 4 • Introduction 1.4 SURVEY IMPLEMENTATION 1.4.1 Sample Design The sample for the 2010-11 ZDHS was designed to provide population and health indicator estimates at the national and provincial levels. The sample design allows for specific indicators, such as contraceptive use, to be calculated for each of Zimbabwe’s 10 provinces (Manicaland, Mashonaland Central, Mashonaland East, Mashonaland West, Matabeleland North, Matabeleland South, Midlands, Masvingo, Harare, and Bulawayo). The sampling frame used for the 2010-11 ZDHS was the 2002 Population Census. Administratively, each province in Zimbabwe is divided into districts and each district into smaller administrative units called wards. During the 2002 Population Census, each of the wards was subdivided into enumeration areas (EAs). The 2010-11 ZDHS sample was selected using a stratified, two-stage cluster design, and EAs were the sampling units for the first stage. Overall, the sample included 406 EAs, 169 in urban areas and 237 in rural areas. Households were the units for the second stage of sampling. A complete listing of households was carried out in each of the 406 selected EAs in July and August 2010. Maps were drawn for each of the clusters, and all private households were listed. The listing excluded institutional living facilities (e.g., army barracks, hospitals, police camps, and boarding schools). A representative sample of 10,828 households was selected for the 2010-11 ZDHS. All women age 15-49 and all men age 15-54 who were either permanent residents of the selected households or visitors who stayed in the household the night before the survey were eligible to be interviewed. Anaemia testing was performed in each household among eligible women and men who consented to being tested. With the parent’s or guardian’s consent, children age 6-59 months were also tested for anaemia. Also, among eligible women and men who consented, blood samples were collected for laboratory testing of HIV in each household. In addition, one eligible woman in each household was randomly selected to be asked additional questions about domestic violence. 1.4.2 Questionnaires Three questionnaires were used for the 2010-11 ZDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. These questionnaires were adapted from model survey instruments developed for the MEASURE DHS project to reflect population and health issues relevant to Zimbabwe. Relevant issues were identified at a series of meetings with various stakeholders from government ministries and agencies, nongovernmental organizations (NGOs), and international donors. Also, more than 30 individuals representing 19 separate stakeholders attended a questionnaire design meeting on 8-9 February 2010. In addition to English, the questionnaires were translated into two major languages, Shona and Ndebele. The Household Questionnaire was used to list all of the usual members and visitors of selected households. Some basic information was collected on the characteristics of each person listed, including his or her age, sex, education, and relationship to the head of the household. For children under age 18, survival status of the parents was determined. The data on age and sex obtained in the Household Questionnaire were used to identify women and men who were eligible for an individual interview. Additionally, the Household Questionnaire collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, Introduction • 5 materials used for the floor of the house, ownership of various durable goods, and ownership and use of mosquito nets (to assess the coverage of malaria prevention programmes). The Woman’s Questionnaire was used to collect information from all women age 15-49. These women were asked questions on the following topics: • Background characteristics (age, education, media exposure, etc.) • Birth history and childhood mortality • Knowledge and use of family planning methods • Fertility preferences • Antenatal, delivery, and postnatal care • Breastfeeding and infant feeding practices • Vaccinations and childhood illnesses • Marriage and sexual activity • Women’s work and husbands’ background characteristics • Malaria prevention and treatment • Awareness and behaviour regarding AIDS and other sexually transmitted infections (STIs) • Adult mortality, including maternal mortality • Domestic violence The Man’s Questionnaire was administered to all men age 15-54 in each household in the 2010-11 ZDHS sample. The Man’s Questionnaire collected much of the same information found in the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health. In this survey, instead of using paper questionnaires, interviewers used personal digital assistants to record responses during interviews. The PDAs were equipped with Bluetooth technology to enable remote electronic transfer of files (e.g., transfer of assignment sheets from team supervisors to interviewers and transfer of completed questionnaires from interviewers to supervisors). The PDA data collection system was developed by the MEASURE DHS project using the mobile version of CSPro. CSPro is software developed jointly by the U.S. Census Bureau, the MEASURE DHS project, and Serpro S.A. 1.4.3 Anthropometry, Anaemia, and HIV Testing The 2010-11 ZDHS incorporated three “biomarkers”: anthropometry, anaemia testing, and HIV testing. In contrast to the data collection procedure for the household and individual interviews, data related to biomarkers were initially recorded on a paper form (the Biomarker Data Collection Form) and subsequently entered into the PDA. The protocol for anaemia testing and for blood specimen collection for HIV testing was reviewed and approved by the Medical Research Council of 6 • Introduction Zimbabwe (MRCZ), the Institutional Review Board of ICF Macro (now ICF International), and the CDC. Anthropometry. In all households, height and weight measurements were recorded for children age 0-59 months, women age 15-49, and men age 15-54. Anaemia testing. Blood specimens for anaemia testing were collected from all children age 6-59 months, women age 15-49, and men age 15-54 who voluntarily provided written consent to be tested. Blood samples were drawn from a drop of blood taken from a finger prick (or a heel prick in the case of children age 6-12 months with especially small or thin fingers) and collected in a microcuvette. Haemoglobin analysis was carried out on site using a battery-operated portable HemoCue analyzer. Results were provided verbally and in writing. Parents of children with a haemoglobin level under 7 g/dl were instructed to take the child to a health facility for follow-up care. Likewise, nonpregnant women, pregnant women, and men were referred for follow-up care if their haemoglobin levels were below 7 g/dl, 9 g/dl, and 9 g/dl, respectively. All households in which anthropometry and/or anaemia testing was conducted were given a brochure explaining the causes and prevention of anaemia. HIV testing. ZDHS biomarker technicians collected blood specimens for laboratory testing of HIV from all women age 15-49 and men age 15-54 who provided written consent to be tested. The protocol for blood specimen collection and analysis was based on the anonymous linked protocol developed for MEASURE DHS. This protocol allows for merging of HIV test results with the sociodemographic data collected in the individual questionnaires after removal of all information that could potentially identify an individual. Interviewers explained the procedure, the confidentiality of the data, and the fact that the test results would not be made available to the respondent. If a respondent consented to HIV testing, five blood spots from the finger prick were collected on a filter paper card to which a barcode label unique to the respondent was affixed. A duplicate label was attached to the Biomarker Data Collection Form. A third copy of the same barcode was affixed to the Blood Sample Transmittal Form to track the blood samples from the field to the laboratory. Respondents were asked whether they would consent to having the laboratory store their blood sample for future unspecified testing. If respondents did not consent to additional testing using their sample, it was indicated on the Biomarker Data Collection Form that they refused additional tests, and the words “no additional testing” were written on the filter paper card. Each household, whether individuals consented to HIV testing or not, was given an informational brochure on HIV/AIDS and a list of fixed sites providing voluntary counselling and testing services in surrounding districts within the province. Blood samples were dried overnight and packaged for storage the following morning. Samples were periodically collected in the field, along with the completed questionnaires, and transported to ZIMSTAT in Harare to be logged in and checked; they were then transported to the National Microbiology Reference Laboratory (NMRL) in Harare. Once it arrived at NMRL, each blood sample was logged into the CSPro HIV Test Tracking System database, given a laboratory number, and stored at -20˚C until tested. The HIV testing protocol stipulated that blood could be tested only after questionnaire data collection had been completed, data had been verified and cleaned, and all unique identifiers other than the anonymous barcode number had been removed from the data file. The algorithm called for testing all samples on Introduction • 7 the first assay test, an enzyme-linked immunosorbent assay (ELISA), the Ani Labsystems HIV EIA. A negative result was considered negative. All samples with positive results were subjected to a second ELISA, the Vironostika® HIV Uni-Form II Plus O (Biomerieux). Positive samples on the second test were considered positive. If the first and second tests were discordant, a third confirmatory test, the HIV 2.2 western blot (DiaSorin), was administered. The final result was considered positive if the western blot confirmed it to be positive and negative if the western blot confirmed it to be negative. If the western blot results were indeterminate, the sample was considered indeterminate. 1.4.4 Training of Field Staff ZIMSTAT staff and a variety of experts from government ministries, NGOs, and donor organizations participated in a three-day training of trainers session conducted from 30 June to 2 July 2010. Immediately following this training session, pretest training and fieldwork took place. For two weeks in July 2010, 16 participants were trained to administer both paper and electronic questionnaires, take anthropometric measurements, and collect blood samples for anaemia and HIV testing. A representative from the NMRL assisted in training participants on use of finger pricks for blood collection and on proper handling and storage of dried blood spots for HIV testing. The pretest fieldwork was conducted over four days and covered approximately 100 households. Debriefing sessions were held with the pretest field staff, and modifications to the questionnaires were made based on lessons drawn from the exercise. ZIMSTAT recruited and trained 125 people for the main fieldwork to serve as supervisors, deputy supervisors, interviewers, and reserve interviewers. Training of field staff for the main survey was conducted during a four-week period in late August and September 2010. The training course consisted of instruction regarding interviewing techniques and field procedures, a detailed review of questionnaire content, instruction on how to administer the paper and electronic questionnaire, instruction and practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews with real respondents in areas outside the 2010-11 ZDHS sample points. In addition, interviewers who were assigned as team biomarker technicians completed field practice in anthropometry, anaemia testing, and blood collection. Team supervisors and deputy supervisors were trained in data quality control procedures, fieldwork coordination, and use of special programs for the PDAs. Deputy supervisors were also trained in using Global Positioning System (GPS) receivers to obtain coordinates for sample clusters. 1.4.5 Fieldwork Fifteen interviewing teams carried out data collection for the 2010-11 ZDHS. Each team consisted of one team supervisor, one deputy supervisor, three female interviewers, three male interviewers, and one driver. Three of the interviewers on each team also served as biomarker technicians. Electronic data files were transferred from each interviewer’s PDA to the team supervisor’s PDA each day. Thirteen senior staff members from ZIMSTAT coordinated and supervised fieldwork activities. Electronic data files were transferred to ZIMSTAT staff PDAs during field visits. Participants in fieldwork monitoring also included a survey technical specialist, a consultant, and two data processing staff from the MEASURE DHS project as well as representatives from other organisations supporting the survey, including NMRL, UNFPA, USAID, and ZNFPC. Data collection took place over a six-month period, from 29 September 2010 through late March 2011. 8 • Introduction 1.4.6 Data Processing All electronic data files for the ZDHS were returned to the ZIMSTAT central office in Harare, where they were stored on a password-protected computer. The data processing operation included secondary editing, which involved resolution of computer-identified inconsistencies and coding of open-ended questions. Two members of the data processing staff processed the data. Data editing was accomplished using CSPro software. Office editing and data processing were initiated in October 2010 and completed in May 2011. 1.5 RESPONSE RATES Table 1.3 shows response rates for the 2010-11 ZDHS. A total of 10,828 households were selected for the sample, of which 10,166 were found to be occupied during the survey fieldwork. The shortfall was largely due to members of some households being away for an extended period of time and to structures that were found to be vacant at the time of the interview. Of the 10,166 existing households, 9,756 were successfully interviewed, yielding a household response rate of 96 percent. A total of 9,831 eligible women were identified in the interviewed households, and 9,171 of these women were interviewed, yielding a response rate of 93 percent. Of the 8,723 eligible men identified, 7,480 were successfully interviewed (86 percent response rate). The principal reason for nonresponse among both eligible men and women was the failure to find them at home despite repeated visits to the households. The lower response rate among men than among women was due to the more frequent and longer absences of men from the households. Nevertheless, the response rates for both women and men were higher in the 2010-11 ZDHS than in the 2005-06 ZDHS (in which response rates were 90 percent for women and 82 percent for men). Table 1.3 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Zimbabwe 2010-11 Residence Result Urban Rural Total Household interviews Households selected 3,718 7,110 10,828 Households occupied 3,558 6,608 10,166 Households interviewed 3,325 6,431 9,756 Household response rate1 93.5 97.3 96.0 Interviews with women age 15-49 Number of eligible women 3,808 6,023 9,831 Number of eligible women interviewed 3,437 5,734 9,171 Eligible women response rate2 90.3 95.2 93.3 Interviews with men age 15-54 Number of eligible men 3,253 5,470 8,723 Number of eligible men interviewed 2,539 4,941 7,480 Eligible men response rate2 78.1 90.3 85.8 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 9 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 his chapter presents information on demographic and socioeconomic characteristics of the household population such as age, sex, education, and place of residence. The environmental profile of households included in the 2010-11 ZDHS sample is also examined. Taken together, these descriptive data provide a context for the interpretation of demographic and health indices and can furnish an approximate indication of the representativeness of the survey. In the 2010-11 ZDHS, a household referred to a person or group of related and unrelated persons who lived together in the same dwelling unit(s), who acknowledged one adult male or female as the head of the household, who shared the same housekeeping arrangements, and who were considered a single unit. Information was collected from all usual residents of each selected household and visitors who had stayed in the selected household the night before the interview. Those persons who stayed in the selected household the night before the interview (whether usual residents or visitors) represent the de facto population; usual residents alone constitute the de jure population. To maintain comparability with other surveys, all tables in this report refer to the de facto population unless otherwise specified. 2.1 HOUSEHOLD CHARACTERISTICS The physical characteristics of households and the availability and accessibility of basic household facilities are important in assessing the general welfare and socioeconomic condition of the population. The 2010-11 ZDHS collected information on a range of housing characteristics. These data are presented for households and are further disaggregated by residence. 2.1.1 Drinking Water Table 2.1 shows information on drinking water. The source of drinking water is an indicator of water quality. Sources that are likely to be of suitable quality are listed under “improved source,” while sources not of suitable quality are listed under “non-improved source,” reflecting the categorizations of the WHO/UNICEF Joint Monitoring Programme (JMP) for Water and Sanitation (WHO/UNICEF JMP, 2012). T Key Findings • Seventy-nine percent of Zimbabwean households are using an improved source of drinking water. • Ownership of mobile phones has risen dramatically since the 2005-06 ZDHS. Whereas 14 percent of households owned a mobile phone in 2005-06, 62 percent of households reported owning a mobile phone in the 2010-11 ZDHS. • Five in ten children under age 5 have a birth certificate or have had their birth registered. • Approximately one-fifth of children under age 18 are orphaned (that is, one or both parents are not living). • Ninety-three percent of males and 91 percent of females age 6 and over have ever attended school. 10 • Housing Characteristics and Household Population Table 2.1 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Zimbabwe 2010-11 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source Piped water into dwelling/yard/plot 71.0 7.3 28.8 71.5 5.1 25.4 Public tap/standpipe 5.5 4.2 4.7 5.2 3.1 3.7 Tubewell/borehole 11.6 37.0 28.4 12.0 38.5 30.4 Protected dug well 6.5 20.8 16.0 6.2 21.0 16.5 Protected spring 0.0 1.1 0.7 0.1 1.0 0.7 Rainwater 0.0 0.0 0.0 0.0 0.0 0.0 Bottled water 0.2 0.0 0.1 0.2 0.0 0.1 Non-improved source Unprotected dug well 3.6 17.3 12.7 3.4 18.4 13.8 Unprotected spring 0.3 3.5 2.4 0.4 3.6 2.6 Tanker truck/cart with drum 0.7 0.1 0.3 0.4 0.1 0.2 Surface water 0.2 8.6 5.8 0.3 9.2 6.4 Other source 0.2 0.1 0.1 0.4 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 94.9 70.4 78.7 95.1 68.7 76.7 Time to obtain drinking water (round trip) Water on premises 80.1 23.2 42.4 79.9 21.6 39.4 Less than 30 minutes 14.2 47.3 36.1 14.3 47.1 37.1 30 minutes or longer 5.1 28.4 20.6 5.3 30.4 22.8 Don't know 0.6 1.0 0.9 0.4 0.9 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 16.0 4.9 8.6 16.2 4.7 8.2 Bleach/chlorine added 13.4 14.9 14.4 14.5 15.8 15.4 Strained through cloth 0.0 0.1 0.1 0.0 0.1 0.1 Ceramic, sand or other filter 0.5 0.2 0.3 0.6 0.3 0.4 Solar disinfection 0.2 0.0 0.1 0.1 0.0 0.0 Other 0.3 0.7 0.6 0.3 0.6 0.6 No treatment 72.6 80.9 78.1 71.6 80.3 77.6 Percentage using an appropriate treatment method2 27.1 18.7 21.5 28.1 19.3 22.0 Number 3,290 6,466 9,756 12,344 28,057 40,401 1 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. The majority of households in Zimbabwe (79 percent) have access to an improved source of water (95 percent in urban areas and 70 percent in rural areas). This proportion is virtually the same as that found in the 2005-06 ZDHS. With regard to specific sources, 29 percent of households have water piped into the dwelling, yard, or plot, while 28 percent of households use a tubewell/borehole, 16 percent use a protected dug well, and 5 percent use a public tap or standpipe. Seven in 10 urban households drink water that is piped into the dwelling, yard, or plot. In rural areas, tubewells/boreholes are the main source of drinking water (37 percent), followed by protected and unprotected dug wells (21 percent and 17 percent, respectively). In 80 percent of urban households, water is available within the dwelling or plot (on premises). In contrast, three-quarters of rural households obtain water from a source not on the premises, with 28 percent of these households reporting that it takes 30 minutes or longer (round trip) to access drinking water. Most households (78 percent) do not treat their drinking water. Nine percent of households boil their water, and 14 percent use bleach or chlorine. The latter proportion is higher than in 2005-06, Housing Characteristics and Household Population • 11 when 2 percent of households reported that they used bleach or chlorine to treat water used for drinking. Among urban households, 73 percent do not treat their water, compared with 81 percent in rural areas. Much of this difference is attributable to the higher proportion of urban than rural households that report boiling water prior to drinking it (16 percent and 5 percent, respectively). 2.1.2 Sanitation Facilities and Waste Disposal Table 2.2 presents information on the proportion of households that have access to hygienic sanitation facilities by type of toilet/latrine. A household’s sanitation facility is classified as unhygienic if it is shared with other households or if it is unimproved (i.e., it does not effectively separate human waste from human contact). The types of facilities considered improved are toilets that flush or pour flush into a piped sewer system, septic tank, or pit latrine; ventilated improved pit (VIP) latrines or Blair toilets; and pit latrines with a slab. Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Zimbabwe 2010-11 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 44.9 30.8 35.5 49.8 31.8 37.3 Flush/pour flush to piped sewer system 36.0 1.9 13.4 40.6 1.6 13.5 Flush/pour flush to septic tank 5.2 1.2 2.5 5.5 0.9 2.3 Flush/pour flush to pit latrine 1.4 0.5 0.8 1.5 0.4 0.7 Ventilated improved pit (VIP) latrine/Blair toilet 1.3 16.4 11.3 1.2 17.6 12.6 Pit latrine with slab 1.0 10.7 7.4 1.0 11.3 8.1 Shared facility1 48.5 18.9 28.9 44.0 15.5 24.2 Flush/pour flush to piped sewer system 38.5 0.6 13.4 35.9 0.4 11.3 Flush/pour flush to septic tank 3.7 0.3 1.5 3.0 0.2 1.0 Flush/pour flush to pit latrine 2.5 0.1 0.9 2.1 0.1 0.7 Ventilated improved pit (VIP) latrine/Blair toilet 1.8 11.5 8.2 1.5 9.1 6.8 Pit latrine with slab 2.1 6.4 4.9 1.6 5.7 4.4 Non-improved facility 6.6 50.3 35.6 6.2 52.7 38.5 Flush/pour flush not to sewer/septic tank/pit latrine 1.0 0.1 0.4 0.9 0.1 0.3 Pit latrine without slab/open pit 1.9 11.5 8.3 2.1 12.5 9.3 Bucket 1.7 0.0 0.6 1.5 0.0 0.5 No facility/bush/field 1.9 38.6 26.2 1.6 40.0 28.3 Other 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,290 6,466 9,756 12,344 28,057 40,401 1 Facilities that would be considered improved if they were not shared by two or more households Thirty-six percent of households in Zimbabwe have improved toilet facilities that are not shared with other households. Slightly less than half of these households have flush toilets, mainly toilets connected to a piped sewer system (13 percent). Nineteen percent of households use some type of a latrine that is not shared with other households. Most urban households with improved, not shared facilities have toilets that are piped to a sewer system or flushed to a septic tank or pit latrine (43 percent). In rural areas, the most common improved, non-shared toilets are VIP latrines and Blair toilets (16 percent), followed by pit latrines with a slab (11 percent). Slightly more than one-quarter of Zimbabwean households have improved facilities that are shared with other households. Urban households are more than twice as likely to share an improved facility as rural households (49 percent and 19 percent, respectively). Half of rural households have an unimproved facility, compared with 7 percent of urban households. The most common unimproved facilities in urban households are buckets, pit latrines without a slab/open pits, and no 12 • Housing Characteristics and Household Population facility/bush/field (2 percent each). Thirty-nine percent of households in rural areas have no toilet facility, a slightly lower proportion than that reported in the 2005-06 ZDHS (45 percent). 2.1.3 Housing Characteristics Table 2.3 presents information on a number of household dwelling characteristics along with the percentage of households using various types of fuel for cooking and the frequency of smoking inside the home. These characteristics reflect the household’s socio- economic situation. They also may influence environmental conditions that have a direct bearing on household members’ health and welfare. Thirty-seven percent of households in Zimbabwe have access to electricity that is connected via power lines. There is a significant difference in access to electricity between urban and rural areas. In urban areas 83 percent of households have electricity, compared with 13 percent in rural areas. The most commonly used flooring material is cement (67 percent), followed by dung (16 percent) and earth/sand (13 percent). In urban areas, 87 percent of households have cement floors, compared with 58 percent in rural areas. Earth/sand or dung floors are found in 41 percent of rural dwelling units. Data were collected on the number of sleeping rooms per household. Forty-two percent of households have one room used for sleeping, while 33 percent have two rooms and 25 percent have three or more rooms. The number of rooms used for sleeping does not vary much by place of residence. Information on type of fuel used for cooking and place for cooking was obtained to assess the extent to which household members may be exposed to the potentially harmful effects of smoke from cooking with solid fuels, that is, coal, plant materials, and animal waste (WHO, 2011). Slightly less than 7 of 10 households in Zimbabwe use some type of solid fuel. Almost all households using solid fuels cook with wood. In rural areas, 94 percent of households use wood for cooking, compared with 20 percent in urban areas. A majority of urban households use electricity for cooking (73 percent); in contrast, only 6 percent of rural households use electricity for this purpose. Table 2.3 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Zimbabwe 2010-11 Housing characteristic Residence Total Urban Rural Electricity Yes 83.2 13.3 36.9 No 16.8 86.7 63.1 Total 100.0 100.0 100.0 Flooring material Earth/sand 1.6 18.2 12.6 Dung 0.4 23.1 15.5 Wood planks 0.6 0.4 0.5 Parquet or polished wood 1.6 0.2 0.7 Vinyl or asphalt strips 0.4 0.1 0.2 Ceramic tiles 5.0 0.2 1.9 Cement 86.8 57.5 67.4 Carpet 3.2 0.2 1.2 Other 0.4 0.1 0.2 Total 100.0 100.0 100.0 Rooms used for sleeping One 48.7 38.3 41.8 Two 29.0 35.7 33.4 Three or more 22.2 26.0 24.8 Total 100.0 100.0 100.0 Place for cooking In the house 77.5 33.3 48.2 In a separate building 4.5 54.4 37.6 Outdoors 17.9 12.3 14.2 No food cooked in household 0.1 0.0 0.0 Total 100.0 100.0 100.0 Cooking fuel Electricity 73.2 5.6 28.4 LPG/natural gas/biogas 0.4 0.0 0.2 Kerosene/paraffin 5.2 0.2 1.9 Jelly 0.1 0.0 0.0 Coal/lignite 0.0 0.0 0.0 Charcoal 0.2 0.1 0.1 Wood 19.8 93.9 68.9 Straw/shrubs/grass 0.0 0.0 0.0 Agricultural crop waste 0.0 0.0 0.0 Other 0.9 0.0 0.3 No food cooked in household 0.1 0.0 0.0 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 20.0 94.1 69.1 Frequency of smoking in the home Daily 11.7 20.3 17.4 Weekly 2.1 3.8 3.2 Monthly 1.8 1.7 1.7 Less than monthly 1.7 1.9 1.8 Never 82.7 72.3 75.9 Total 100.0 100.0 100.0 Number 3,290 6,466 9,756 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood, straw/shrubs/grass, and agricultural crop waste Housing Characteristics and Household Population • 13 The potential for exposure to harmful effects of smoke from using solid fuels for cooking is increased if cooking occurs within the home itself rather than outdoors or in a separate building. Forty-eight percent of households in Zimbabwe cook in the house, 38 percent cook in a separate building, and 14 percent cook outdoors. Seventy-eight percent of urban households cook in the house, compared with 33 percent of rural households. On the other hand, two-thirds of rural households cook in a separate building or outdoors, versus just over a fifth of urban households. Information on frequency of smoking inside the home was obtained to assess the percentage of households in which there is exposure to secondhand smoke, which causes health risks in children and adults who do not smoke. Pregnant women who are exposed to secondhand smoke have a higher risk of delivering a low birth weight baby (Windham et al., 1999), and children exposed to secondhand smoke are at increased risk for respiratory and ear infections and poor lung development (U.S. Department of Health and Human Services, 2006). Seventeen percent of Zimbabwean households report that someone smokes at the home daily, 3 percent report that someone smokes at least once a week, 2 percent report that someone smokes monthly, and 2 percent report that someone smokes less frequently than once a month. In 76 percent of households, smoking never occurs in the home. Overall, smoking inside the home is less frequent in urban areas than in rural areas; smoking never occurs in 72 percent of rural households, compared with 83 percent of urban households. 2.1.4 Household Durable Goods Information on ownership of durable goods and other possessions is presented in Table 2.4 by residence. In general, ownership of household effects, means of transportation, and agricultural land and farm animals is a rough measure of a household’s socio- economic status. Table 2.4 shows that, with respect to household effects, 38 percent of households have a radio, 36 percent have a television, 62 percent have a mobile telephone, and 4 percent have a non-mobile phone. Urban households are more likely than rural households to own modern conveniences powered by electricity, such as a radio (49 percent and 32 percent, respectively) and a television (74 percent and 17 percent, respectively). Eighteen percent of Zimbabwean households own a solar panel, which may be a convenient means to power or charge electrical devices, especially in the absence of access to electricity that is available via power lines. Consistent with the observation that access to electricity that is connected is much lower in rural areas than urban areas (Table 2.3), ownership of solar panels is much higher in rural areas (25 percent) than urban areas (5 percent). Table 2.4 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, livestock/farm animals, and bank account by residence, Zimbabwe 2010-11 Possession Residence Total Urban Rural Household effects Battery/generator 11.0 13.2 12.4 Solar panel 5.1 24.7 18.1 Radio 48.9 32.3 37.9 Television 73.7 17.3 36.3 Mobile telephone 90.1 48.0 62.2 Non-mobile telephone 11.0 0.6 4.1 Refrigerator 45.9 4.3 18.3 Computer 10.2 0.8 4.0 Means of transport Bicycle 20.7 23.5 22.6 Animal drawn cart 9.6 23.9 19.0 Motorcycle/scooter 1.6 0.9 1.1 Car/truck 15.6 3.1 7.3 Boat with a motor 0.6 0.1 0.3 Wheelbarrow 26.5 33.5 31.1 Tractor 1.0 0.7 0.8 Ownership of agricultural land 30.9 79.6 63.2 Ownership of farm animals1 31.1 80.0 63.5 Ownership of bank account 40.4 12.2 21.7 Number 3,290 6,466 9,756 1 Cattle, horses, mules/donkeys, goats, sheep, pigs, rabbits, or chickens/poultry 14 • Housing Characteristics and Household Population The most common means of transportation owned by households in both urban and rural areas is a wheelbarrow (27 percent in urban areas and 34 percent in rural areas). Bicycles, owned by 21 percent of urban households and 24 percent of rural households, are also a common means of transport. Around 1 in 4 rural households and 1 in 10 urban households own an animal drawn cart. Urban households are much more likely to own a car or truck than rural households (16 percent and 3 percent, respectively). A small proportion of households in both urban and rural areas own a motorcycle or scooter (2 percent and 1 percent, respectively). Sixty-three percent of households own agricultural land, and 64 percent own farm animals. Among urban households, 31 percent own agricultural land, compared with 80 percent in rural areas. In Zimbabwe, 22 percent of households have a bank account. Households in urban areas are over three times more likely than households in rural areas to have a bank account (40 percent versus 12 percent). 2.2 HOUSEHOLD WEALTH Information on household assets was used to create an index that is used throughout this report to represent the wealth of the households interviewed in the 2010-11 ZDHS. The wealth index was developed and tested in a large number of countries in relation to inequalities in household income, use of health services, and health outcomes (Rutstein et al., 2000). It has been shown to be consistent with expenditure and income measures (Rutstein, 1999). The wealth index is constructed using household asset data, including ownership of consumer items ranging from a television to a bicycle or car, as well as dwelling characteristics such as source of drinking water, sanitation facilities, and type of flooring material. In its current form, which takes account of urban-rural differences in these items and characteristics, the wealth index is created in three steps.1 In the first step, a subset of indicators common to urban and rural areas is used to create wealth scores for households in both areas. For purposes of creating scores, categorical variables are transformed into separate dichotomous (0-1) indicators. These indicators and those that are continuous are then examined using a principal components analysis to produce a common factor score for each household. In the second step, separate factor scores are produced for households in urban and rural areas using area-specific indicators. The third step combines the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting area-specific scores through a regression on the common factor scores. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index is computed, national-level wealth quintiles (from lowest to highest) are formed by assigning the household score to each de jure household member, ranking each person in the population by that score, and then dividing the ranking into five equal categories, each comprising 20 percent of the population. Thus, throughout this report, wealth quintiles are expressed in terms of quintiles of individuals in the overall population rather than quintiles of individuals at risk for any one health or population indicator. For example, quintile rates for infant mortality refer to infant mortality rates per 1,000 live births among all people in the population quintile concerned, as distinct from quintiles of live births or newly born infants, who constitute the only members of the population at risk of mortality during infancy. 1 The approach to the construction of the wealth index in ZDHS surveys prior to the 2010-11 survey did not take into account urban-rural differences. Housing Characteristics and Household Population • 15 Table 2.5 presents wealth quintiles by urban-rural residence and province. Also included in the table is the Gini Coefficient, which indicates the level of concentration of wealth, 0 being an equal distribution and 1 a totally unequal distribution. Almost all of the urban population is represented in the fourth and highest quintiles (91 percent), while around 6 in 10 households in rural areas are in the lowest and second wealth quintiles. The wealth quintile distribution among provinces shows large variations. As expected, the two urban provinces, Bulawayo and Harare, have the largest proportions in the highest wealth quintile (69 percent and 53 percent, respectively). In contrast, Matabeleland North and Masvingo have the largest proportions in the lowest wealth quintile (61 percent and 33 percent, respectively). Table 2.5 Wealth quintiles Percent distribution of the de jure population by wealth quintiles and the Gini Coefficient, according to residence and province, Zimbabwe 2010-11 Residence/province Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 0.0 1.1 8.2 36.9 53.9 100.0 12,344 0.09 Rural 28.8 28.3 25.2 12.6 5.1 100.0 28,057 0.40 Province Manicaland 17.5 21.5 29.2 20.4 11.3 100.0 5,623 0.38 Mashonaland Central 25.9 28.8 21.6 13.2 10.5 100.0 3,936 0.41 Mashonaland East 10.2 29.7 34.1 15.5 10.6 100.0 4,158 0.31 Mashonaland West 18.2 24.4 22.1 22.8 12.5 100.0 4,650 0.35 Matabeleland North 61.0 13.5 8.6 8.5 8.3 100.0 2,181 0.59 Matabeleland South 26.8 23.2 26.7 17.3 6.1 100.0 2,293 0.39 Midlands 27.0 23.7 15.9 17.6 15.7 100.0 5,230 0.45 Masvingo 33.0 27.4 20.0 12.1 7.5 100.0 4,397 0.43 Harare 0.0 1.6 10.1 35.4 52.9 100.0 5,916 0.10 Bulawayo 0.0 0.3 2.1 28.3 69.4 100.0 2,016 0.08 Total 20.0 20.0 20.0 20.0 20.0 100.0 40,401 0.39 2.3 HAND WASHING Hand washing with soap and water is ideal. However, hand washing with a non-soap cleaning agent such as ash or sand is an improvement over not using any cleansing agent. To obtain hand-washing information, interviewers asked to see the place where members of the household most often washed their hands; information on the availability of water and/or cleansing agents was recorded only for households where the hand washing place was observed. Table 2.6 shows that interviewers observed the place most often used for hand washing in 56 percent of households. Interviewers were able to observe the hand washing place more often in urban areas (67 percent) than in rural areas (51 percent). The most common reason interviewers were not able to observe the place where members of the household washed their hands was that there was no specific place designated for hand washing (data not shown). 16 • Housing Characteristics and Household Population Table 2.6 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap and other cleansing agents, Zimbabwe 2010-11 Background characteristic Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed Total Number of households with place for hand washing observed Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Residence Urban 66.8 3,290 60.5 1.1 28.7 3.2 0.0 6.4 100.0 2,197 Rural 51.0 6,466 32.8 1.9 35.6 3.9 1.7 24.2 100.0 3,295 Province Manicaland 51.6 1,436 42.7 1.4 49.4 1.7 0.4 4.4 100.0 741 Mashonaland Central 24.0 890 45.9 0.7 31.7 3.5 0.0 18.2 100.0 214 Mashonaland East 38.6 1,042 43.4 4.6 23.6 7.6 4.7 16.1 100.0 402 Mashonaland West 38.2 1,077 53.9 3.7 31.6 2.1 0.8 8.0 100.0 412 Matabeleland North 65.4 495 26.3 1.2 24.7 4.5 2.2 41.2 100.0 324 Matabeleland South 70.1 511 21.8 0.0 24.2 8.3 0.6 45.1 100.0 358 Midlands 81.5 1,153 44.3 1.2 34.6 6.1 2.1 11.8 100.0 939 Masvingo 74.4 1,066 24.3 0.6 35.2 2.1 0.4 37.4 100.0 792 Harare 56.3 1,564 55.9 2.2 32.5 2.0 0.0 7.4 100.0 881 Bulawayo 82.1 522 78.2 0.2 20.5 0.6 0.2 0.3 100.0 428 Wealth quintile Lowest 51.0 1,835 22.3 2.4 33.4 3.4 2.6 35.9 100.0 935 Second 46.2 1,785 25.7 2.2 40.0 4.7 2.2 25.2 100.0 825 Middle 43.9 1,933 35.1 1.1 36.8 4.6 1.2 21.2 100.0 849 Fourth 61.3 2,144 45.8 1.7 36.4 3.6 0.3 12.2 100.0 1,315 Highest 76.2 2,059 69.4 0.9 23.6 2.6 0.1 3.4 100.0 1,568 Total 56.3 9,756 43.9 1.6 32.8 3.6 1.1 17.1 100.0 5,492 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only as well as those with soap and another cleansing agent Among households where the hand washing place was observed, the most common hand washing agent was soap and water (44 percent), followed by water only (33 percent), soap but no water (4 percent), water with another cleansing agent (2 percent), and, finally, another cleansing agent but no water (1 percent). In the case of 17 percent of the households, no water, soap, or any other cleansing agent was observed at the hand washing place; lack of water and a cleansing agent decreased with increasing wealth quintile. 2.4 HOUSEHOLD POPULATION BY AGE, SEX, AND RESIDENCE The 2010-11 ZDHS Household Questionnaire collected data on the demographic and social characteristics of all usual residents of the sampled household and on visitors who had spent the previous night in the household. Table 2.7 shows the distribution of the 2010-11 ZDHS household population by five-year age groups, according to sex and residence. A total of 40,343 individuals resided in the 9,756 households successfully interviewed; 21,249 were female (representing 53 percent of the population), and 19,094 were male (representing 47 percent of the population). The age-sex structure of the population is shown in the population pyramid in Figure 2.1. The broad base of the pyramid indicates that Zimbabwe’s population is young, a scenario typical of countries with high fertility rates. The proportion of children under age 15 was around 43 percent in 2010-11, while the proportion of individuals age 65 and older was about 5 percent. Housing Characteristics and Household Population • 17 Table 2.7 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Zimbabwe 2010-11 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 14.0 12.3 13.1 16.2 14.9 15.5 15.5 14.1 14.8 5-9 11.6 10.5 11.0 16.0 14.3 15.1 14.7 13.2 13.9 10-14 10.5 10.3 10.4 17.0 14.6 15.8 15.1 13.3 14.1 15-19 9.6 11.9 10.8 10.8 8.9 9.8 10.4 9.8 10.1 20-24 10.9 12.7 11.9 7.2 7.9 7.6 8.3 9.4 8.9 25-29 10.8 11.2 11.0 6.4 7.3 6.9 7.8 8.5 8.2 30-34 8.4 8.6 8.5 5.1 5.9 5.5 6.1 6.7 6.4 35-39 6.9 5.8 6.3 4.4 5.1 4.8 5.2 5.3 5.2 40-44 5.0 4.2 4.6 3.1 3.1 3.1 3.7 3.5 3.6 45-49 2.9 3.5 3.2 2.3 3.1 2.7 2.4 3.2 2.8 50-54 2.8 3.1 2.9 1.9 3.9 3.0 2.2 3.7 3.0 55-59 2.7 2.1 2.4 2.5 2.8 2.7 2.6 2.6 2.6 60-64 1.3 1.3 1.3 2.0 2.5 2.3 1.8 2.1 2.0 65-69 1.2 0.9 1.0 1.6 1.6 1.6 1.4 1.4 1.4 70-74 0.4 0.6 0.5 1.1 1.4 1.3 0.9 1.2 1.0 75-79 0.6 0.6 0.6 1.1 1.0 1.0 0.9 0.9 0.9 80+ 0.5 0.6 0.5 1.2 1.6 1.4 1.0 1.3 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,714 6,589 12,303 13,380 14,660 28,040 19,094 21,249 40,343 Figure 2.1 Population Pyramid ZDHS 2010-11 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Age 0246810 0 2 4 6 8 10 Percent FemaleMale 18 • Housing Characteristics and Household Population 2.5 HOUSEHOLD COMPOSITION Table 2.8 shows that a female heads 45 percent of the households in Zimbabwe. This is an increase from the proportion in 2005-06, when 38 percent of households were headed by females. Almost all of the growth in female-headed households has taken place in urban areas; the proportion of female-headed households increased in urban areas from 29 percent to 45 percent during the period between the two surveys while remaining essentially stable in rural areas (43 percent in 2005-06 and 44 percent in 2010-11). Table 2.8 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under age 18, according to residence, Zimbabwe 2010-11 Characteristic Residence Total Urban Rural Household headship Male 54.6 55.9 55.4 Female 45.4 44.1 44.6 Total 100.0 100.0 100.0 Number of usual members 0 0.3 0.2 0.3 1 13.1 10.9 11.6 2 15.2 11.4 12.7 3 20.3 17.1 18.2 4 20.5 17.9 18.8 5 13.3 15.5 14.7 6 8.7 10.7 10.0 7 4.1 7.3 6.2 8 2.1 3.7 3.1 9+ 2.5 5.2 4.3 Total 100.0 100.0 100.0 Mean size of households 3.8 4.3 4.1 Percentage of households with orphans and foster children under age 18 Foster children1 23.9 36.9 32.6 Double orphans 5.8 10.7 9.0 Single orphans2 14.4 22.0 19.5 Foster and/or orphan children 29.2 42.6 38.1 Number of households 3,290 6,466 9,756 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2 Includes children with one dead parent and an unknown survival status of the other parent The average household size has decreased slightly, from 4.5 people in 2005-06 to 4.1 people in 2010-11. Urban households are, on average, slightly smaller (3.8 people) than rural households (4.3 people). Information was also collected on the living arrangements and survival status of all children under age 18 residing in the ZDHS sample households. These data can be used to assess the extent to which households are faced with a need to care for orphaned or foster children. Orphans include children whose mother or father has died (single orphans) as well as children who have lost both parents (double orphans). In the case of foster children, both parents are alive but the children are living in a household where neither their natural mother nor natural father resides. Overall, 38 percent of households in Zimbabwe are caring for foster and/or orphaned children. Rural households are more Housing Characteristics and Household Population • 19 likely than urban households to be caring for foster and/or orphaned children (43 percent versus 29 percent). 2.6 BIRTH REGISTRATION The registration of births is the inscription of the facts of each birth into an official log kept at the registrar’s office. Information on the registration of births was collected in the household interview, where respondents were asked whether children under age 5 residing in the household had a birth certificate. If they responded that the child did not have a birth certificate, an additional question was posed to ascertain whether the child’s birth had ever been registered with the births and deaths registry. Table 2.9 shows the percentage of de jure children under age 5 whose births were officially registered and the percentage who had a birth certificate at the time of the survey. Table 2.9 Birth registration of children under age five Percentage of de jure children under age five whose births are registered with the civil authorities, according to background characteristics, Zimbabwe 2010-11 Background characteristic Children whose births are registered Number of children Percentage who had a birth certificate Percentage who did not have a birth certificate Percentage registered Age <2 17.7 21.4 39.1 2,524 2-4 40.2 15.8 56.0 3,388 Sex Male 30.4 17.9 48.3 2,938 Female 30.8 18.5 49.3 2,974 Residence Urban 48.1 17.1 65.2 1,600 Rural 24.1 18.6 42.7 4,312 Province Manicaland 28.1 15.4 43.5 884 Mashonaland Central 28.8 17.3 46.1 608 Mashonaland East 28.3 23.2 51.5 616 Mashonaland West 25.6 11.7 37.3 684 Matabeleland North 32.7 25.0 57.7 299 Matabeleland South 28.7 28.1 56.8 346 Midlands 26.2 22.5 48.8 773 Masvingo 21.9 13.6 35.5 693 Harare 47.1 13.6 60.7 759 Bulawayo 50.0 27.4 77.4 249 Wealth quintile Lowest 16.6 18.8 35.4 1,387 Second 21.2 19.9 41.1 1,282 Middle 27.9 19.5 47.4 1,180 Fourth 38.1 16.7 54.8 1,187 Highest 59.8 15.1 74.9 877 Total 30.6 18.2 48.8 5,912 20 • Housing Characteristics and Household Population The proportion of de jure children whose births were registered was 49 percent. Thirty-one percent had a birth certificate, and 18 percent did not. There is little variation by sex in the proportion of children registered, but there is evidence that children age 2-4 are more likely than those under age 2 to be registered (56 percent and 39 percent, respectively). Children in urban households are more likely to have their birth registered than children in rural households (65 percent and 43 percent, respectively). The proportion of registered births was highest in Bulawayo (77 percent). Children in Masvingo were least likely to have their births registered (36 percent). Households in the highest wealth quintile were most likely to register children’s births, and households in the lowest quintile were least likely (75 percent versus 35 percent). A comparison of the 2005-06 ZDHS with the 2010-11 ZDHS reveals that the percentage of children under age 5 whose births were registered has dropped sharply (74 percent versus 49 percent). 2.7 CHILDREN’S LIVING ARRANGEMENTS, SCHOOL ATTENDANCE, AND PARENTAL SURVIVAL As mentioned above, information was collected on the living arrangements and survival status of all children under age 18 residing in the ZDHS sample households to assess the potential burden on households of the need to provide for orphaned or foster children. These data were also used to assess the situation from the perspective of the children themselves. Table 2.10 presents the proportion of children under age 18 who are not living with one or both parents, either because the parent(s) died or for other reasons. Table 2.10 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Zimbabwe 2010-11 Background characteristic Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Per- centage not living with a biological parent Per- centage with one or both parents dead1 Number of children Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing information on father/ mother Age 0-4 54.1 27.7 2.3 1.0 0.2 10.2 0.5 1.3 0.7 2.0 100.0 12.6 5.1 5,912 <2 60.9 31.9 1.5 0.3 0.0 4.0 0.1 0.2 0.2 0.8 100.0 4.5 2.0 2,524 2-4 49.0 24.6 3.0 1.5 0.4 14.8 0.7 2.0 1.0 2.8 100.0 18.7 7.4 3,388 5-9 42.3 17.9 5.2 3.0 0.6 16.1 2.0 5.2 3.8 3.8 100.0 27.1 17.4 5,596 10-14 34.6 13.6 9.4 3.0 1.9 12.8 2.9 8.0 9.8 4.0 100.0 33.5 33.0 5,715 15-17 28.2 10.0 10.3 2.9 1.9 15.0 4.0 9.7 14.9 3.3 100.0 43.5 41.4 2,489 Sex Male 42.1 18.8 6.1 2.5 1.1 12.5 2.0 5.4 5.9 3.4 100.0 25.8 21.1 9,881 Female 41.5 18.4 6.3 2.2 0.9 14.0 2.1 5.4 6.1 3.1 100.0 27.6 21.4 9,832 Residence Urban 47.0 17.7 6.4 3.3 1.0 12.3 1.8 3.9 4.6 1.9 100.0 22.7 18.2 5,002 Rural 40.0 18.9 6.1 2.1 1.1 13.6 2.1 5.9 6.5 3.7 100.0 28.0 22.3 14,711 Province Manicaland 40.8 21.3 6.2 2.7 1.0 13.6 1.7 5.3 5.5 1.9 100.0 26.1 20.1 2,848 Mashonaland Central 50.7 16.2 6.3 1.7 0.6 10.8 2.2 4.4 5.2 1.8 100.0 22.7 19.2 1,985 Mashonaland East 39.0 18.1 6.2 2.0 0.7 15.2 2.9 5.1 6.8 4.0 100.0 30.0 22.5 2,117 Mashonaland West 47.2 17.0 6.0 1.9 0.9 11.2 2.1 4.9 6.4 2.5 100.0 24.6 20.6 2,338 Matabeleland North 37.1 19.7 8.2 1.9 1.4 13.3 2.2 6.0 5.2 5.1 100.0 26.7 23.8 1,126 Matabeleland South 25.2 21.8 7.1 1.6 0.5 17.7 2.2 7.0 7.3 9.5 100.0 34.2 25.2 1,217 Midlands 42.9 14.1 5.6 3.0 1.5 13.1 2.2 6.8 7.0 4.0 100.0 29.0 23.7 2,605 Masvingo 35.6 23.8 6.0 2.3 1.4 13.7 1.6 6.3 6.7 2.7 100.0 28.3 22.4 2,326 Harare 52.6 15.7 5.8 2.9 1.0 11.2 1.4 3.8 4.3 1.2 100.0 20.8 16.8 2,300 Bulawayo 31.3 22.8 6.3 4.1 1.3 16.1 2.5 5.2 5.5 4.9 100.0 29.2 21.8 850 Wealth quintile Lowest 44.3 18.4 7.2 1.9 1.2 10.2 1.5 5.0 6.2 4.2 100.0 22.8 21.8 4,457 Second 39.8 19.2 6.2 1.3 0.9 13.8 2.3 6.0 6.5 3.9 100.0 28.6 22.4 4,385 Middle 36.5 19.2 6.8 1.8 1.0 15.0 2.8 6.6 7.0 3.5 100.0 31.3 24.8 4,104 Fourth 43.3 18.8 5.7 2.9 0.9 13.7 1.8 5.2 5.4 2.4 100.0 26.1 19.4 3,635 Highest 46.4 17.1 4.7 4.7 1.2 14.0 1.9 4.1 4.3 1.7 100.0 24.3 16.6 3,132 Total <15 43.8 19.9 5.6 2.3 0.9 13.0 1.8 4.8 4.7 3.3 100.0 24.3 18.4 17,224 Total <18 41.8 18.6 6.2 2.4 1.0 13.2 2.0 5.4 6.0 3.3 100.0 26.7 21.3 19,713 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both parents dead, and one parent dead but missing information on survival status of the other parent Housing Characteristics and Household Population • 21 Around 6 in 10 Zimbabwean children under age 18 are not living with both parents. More than one-quarter of children are not living with either parent. Just over one-fifth of children under age 18 are orphaned, that is, one or both parents are dead. The percentage of orphaned children increases rapidly with age, from 5 percent of children under age 5 to 41 percent of children age 15-17. Rural children (22 percent) are more likely to be orphaned than urban children (18 percent). Harare (17 percent) had the lowest proportion of children orphaned, and Matabeleland South had the highest (25 percent). The percentage of children with one or both parents dead peaks at the middle wealth quintile (25 percent) and is lowest at the highest wealth quintile (17 percent). Table 2.11 presents data on school attendance rates and parental survivorship among de jure children age 10-14. The table contrasts the situation among children whose parents are both dead (double orphans) with that among children whose parents are both alive and the children are living with at least one parent. The school attendance ratio in the final column of the table allows an assessment of the extent to which orphaned children are disadvantaged in terms of access to education; ratios below 1.0 indicate that access to education is more limited for double orphans. Table 2.11 School attendance by survivorship of parents For de jure children age 10-14, the percentage attending school by parental survival and the ratio of the percentage attending, by parental survival, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage attending school by survivorship of parents Both parents deceased Number Both parents alive and living with at least one parent Number Ratio1 Sex Male 85.9 281 95.0 1,489 0.90 Female 89.6 281 95.2 1,441 0.94 Residence Urban 90.8 101 96.3 732 0.94 Rural 87.1 460 94.7 2,197 0.92 Province Manicaland 94.5 82 93.7 406 1.01 Mashonaland Central 94.1 (42) 94.6 310 1.00 Mashonaland East 91.6 67 94.4 326 0.97 Mashonaland West 71.9 74 96.4 392 0.75 Matabeleland North 76.4 26 93.9 176 0.81 Matabeleland South 84.9 39 94.5 128 0.90 Midlands 89.7 91 95.0 364 0.94 Masvingo 86.3 77 94.9 355 0.91 Harare 97.6 (47) 96.6 355 1.01 Bulawayo 86.3 (16) 98.2 116 0.88 Wealth quintile Lowest 82.1 137 91.3 675 0.90 Second 89.7 146 95.0 649 0.94 Middle 91.1 142 95.1 554 0.96 Fourth 81.9 85 97.2 540 0.84 Highest 97.9 51 98.1 511 1.00 Total 87.8 561 95.1 2,930 0.92 Notes: Table is based only on children who usually live in the household. Figures in parentheses are based on 25-49 unweighted cases. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with at least one parent The results in Table 2.11 show that double orphans are slightly less likely than children whose parents are both alive and who live with at least one parent to be currently in school (88 percent and 95 percent, respectively). An examination of school attendance ratios suggests that 22 • Housing Characteristics and Household Population double orphans in Mashonaland West (0.75) and Matabeleland North (0.81) are the most disadvantaged relative to children whose parents are both alive and who live with at least one parent. 2.8 EDUCATION OF THE HOUSEHOLD POPULATION 2.8.1 Educational Attainment The educational level of household members is among the most important characteristics of the household because it is associated with many factors that have a significant impact on health- seeking behaviour, reproductive behaviour, use of contraception, and the health of children. Tables 2.12.1 and 2.12.2 show the distribution of female and male household members age 6 and above by the highest level of schooling ever attended (even if they did not complete that level) and the median number of years of education completed according to age, urban-rural residence, province, and wealth quintile. The majority of Zimbabweans have attained some education, and there is very little difference by sex in educational attainment. Overall, 94 percent of males age 6 and over have ever attended school, compared with 91 percent of females. Table 2.12.1 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Zimbabwe 2010-11 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 16.9 82.8 0.1 0.2 0.0 0.0 0.0 100.0 2,299 0.6 10-14 1.0 71.0 10.4 17.5 0.1 0.0 0.0 100.0 2,818 4.7 15-19 1.2 8.9 12.9 75.3 1.1 0.5 0.1 100.0 2,081 8.7 20-24 0.9 7.4 14.8 68.4 3.7 4.5 0.2 100.0 1,992 10.0 25-29 1.4 8.0 16.9 65.2 1.7 6.0 0.6 100.0 1,810 10.0 30-34 2.2 9.1 18.3 61.8 1.3 6.6 0.6 100.0 1,432 9.5 35-39 3.2 11.9 19.7 58.7 0.6 5.2 0.6 100.0 1,125 8.7 40-44 5.9 15.3 17.8 54.2 0.4 5.4 1.0 100.0 736 8.4 45-49 14.6 28.1 23.8 25.7 0.3 5.8 1.7 100.0 678 6.3 50-54 22.9 34.4 22.2 14.1 0.0 3.4 3.0 100.0 777 4.7 55-59 19.8 40.6 20.8 13.9 0.0 2.7 2.2 100.0 547 4.5 60-64 26.5 48.1 11.3 10.1 0.1 1.0 2.8 100.0 451 3.2 65+ 41.4 42.5 7.6 4.6 0.2 1.3 2.4 100.0 1,012 1.3 Residence Urban 3.3 22.9 9.3 55.2 2.2 6.0 1.1 100.0 5,656 8.9 Rural 11.0 39.6 15.1 32.1 0.3 1.3 0.5 100.0 12,102 5.9 Province Manicaland 8.4 37.2 13.9 36.0 0.6 3.5 0.4 100.0 2,409 6.3 Mashonaland Central 12.6 40.9 14.3 29.4 0.4 2.1 0.4 100.0 1,652 5.6 Mashonaland East 7.4 35.4 15.1 39.6 0.7 1.3 0.6 100.0 1,840 6.4 Mashonaland West 9.5 37.2 14.0 37.0 0.4 1.1 0.8 100.0 1,967 6.2 Matabeleland North 15.9 37.8 16.0 28.2 0.3 0.9 1.0 100.0 953 5.3 Matabeleland South 8.1 38.1 17.9 33.6 0.3 1.4 0.7 100.0 999 6.2 Midlands 9.5 35.6 12.1 39.6 0.6 2.2 0.3 100.0 2,292 6.3 Masvingo 10.9 38.8 14.6 32.5 0.4 2.5 0.4 100.0 2,005 6.0 Harare 3.2 21.4 8.3 57.0 2.5 6.3 1.3 100.0 2,683 9.2 Bulawayo 3.4 23.6 11.2 52.6 2.6 4.8 1.8 100.0 960 8.6 Wealth quintile Lowest 16.5 44.4 16.5 22.0 0.1 0.0 0.6 100.0 3,521 4.5 Second 10.2 41.1 15.9 32.0 0.1 0.1 0.5 100.0 3,477 5.8 Middle 9.7 37.3 14.0 37.3 0.4 0.8 0.6 100.0 3,474 6.2 Fourth 4.6 28.3 12.3 50.4 1.0 2.7 0.6 100.0 3,547 7.5 Highest 2.2 21.4 7.9 54.4 2.9 10.0 1.2 100.0 3,740 9.7 Total 8.6 34.3 13.3 39.4 0.9 2.8 0.7 100.0 17,759 6.5 Note: In Zimbabwe, primary level is referred to as grades 1-7. Secondary level is referred to as forms 1-6. With the primary and secondary levels combined, there is a total of 13 years of schooling. 1 Completed 7th grade at the primary level 2 Completed 6th grade at the secondary level Housing Characteristics and Household Population • 23 Table 2.12.2 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Zimbabwe 2010-11 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median years completed Age 6-9 19.0 80.8 0.1 0.1 0.0 0.0 0.0 100.0 2,256 0.5 10-14 1.2 76.7 8.8 13.1 0.0 0.0 0.2 100.0 2,879 4.5 15-19 1.0 13.3 13.0 70.6 1.2 0.4 0.5 100.0 1,995 8.4 20-24 0.7 7.7 10.8 65.8 7.6 6.5 0.8 100.0 1,587 10.2 25-29 1.2 6.3 11.5 66.0 5.8 8.3 1.0 100.0 1,481 10.3 30-34 1.3 6.2 12.3 65.7 3.7 9.8 1.1 100.0 1,161 10.3 35-39 1.0 5.9 14.8 65.7 2.7 8.9 0.9 100.0 986 10.2 40-44 1.7 5.3 9.8 67.4 2.0 12.0 1.9 100.0 701 10.3 45-49 2.7 16.1 17.2 49.4 2.8 9.7 2.0 100.0 467 9.5 50-54 6.2 21.3 31.2 31.1 0.9 7.1 2.3 100.0 416 6.7 55-59 8.1 32.7 23.4 26.7 0.7 4.6 3.9 100.0 494 6.3 60-64 14.6 33.0 21.1 19.7 0.4 4.1 7.1 100.0 346 5.8 65+ 20.9 43.3 14.2 12.0 0.4 4.9 4.2 100.0 810 3.8 Residence Urban 3.0 20.5 6.6 54.2 5.0 9.0 1.5 100.0 4,769 10.1 Rural 6.5 41.5 13.1 34.8 0.9 2.2 0.9 100.0 10,811 6.1 Province Manicaland 4.4 38.1 11.5 38.4 1.7 4.9 1.0 100.0 2,133 6.5 Mashonaland Central 5.8 39.7 12.1 38.3 1.2 2.2 0.7 100.0 1,542 6.3 Mashonaland East 4.8 36.6 12.2 41.5 1.0 3.4 0.5 100.0 1,610 6.6 Mashonaland West 6.5 37.5 11.1 39.2 1.3 2.4 2.0 100.0 1,912 6.4 Matabeleland North 11.2 42.4 17.5 25.1 1.0 1.7 1.1 100.0 823 5.4 Matabeleland South 5.2 43.6 17.5 29.4 1.2 1.9 1.3 100.0 857 6.0 Midlands 6.8 35.6 10.8 41.0 1.2 4.1 0.5 100.0 2,005 6.6 Masvingo 6.6 43.7 11.2 33.0 1.4 3.6 0.5 100.0 1,583 5.9 Harare 2.9 18.3 5.7 56.8 6.2 8.6 1.5 100.0 2,357 10.2 Bulawayo 2.7 23.0 8.8 50.2 4.2 8.2 2.8 100.0 758 9.0 Wealth quintile Lowest 10.0 50.4 13.7 24.9 0.1 0.1 0.9 100.0 2,813 4.7 Second 6.5 43.1 13.8 34.7 0.7 0.5 0.8 100.0 3,049 6.0 Middle 5.5 38.9 12.8 39.3 0.9 1.1 1.4 100.0 3,226 6.3 Fourth 3.6 25.6 10.2 52.9 2.3 4.2 1.2 100.0 3,170 8.5 Highest 2.3 20.1 5.6 49.6 6.4 14.6 1.3 100.0 3,322 10.2 Total 5.5 35.1 11.1 40.8 2.2 4.3 1.1 100.0 15,580 6.7 Note: In Zimbabwe, primary level is referred to as grades 1-7. Secondary level is referred to as forms 1-6. With the primary and secondary levels combined, there is a total of 13 years of schooling. 1 Completed 7th grade at the primary level 2 Completed 6th grade at the secondary level The median number of years of educational attainment is slightly higher for males (6.7 years) than for females (6.5 years). As expected, regardless of sex, educational attainment is higher among urban than rural residents. Among both males and females, the median number of years of schooling is lowest in Matabeleland North and highest in Harare and Bulawayo. Educational attainment rises with wealth quintile, peaking in the highest wealth quintile for both sexes. 2.8.2 School Attendance Ratios In Table 2.13, school attendance ratios are presented by level of schooling and sex, residence, province, and wealth quintile. The net attendance ratio (NAR) is an indicator of participation in schooling among children of official school age—age 6-12 for primary school and age 13-18 for secondary school—and the gross attendance ratio (GAR) indicates participation at each level of schooling among those of any age between 5 and 24. The GAR is nearly always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level.2 Finally, the Gender Parity Index (GPI), or the ratio of female to male attendance rates at the primary and secondary levels, indicates the magnitude of the gender gap 2 Students who are overage for a given level of schooling may have started school overage, may have repeated one or more grades, or may have dropped out of school and later returned. 24 • Housing Characteristics and Household Population in school attendance. A GPI less than one indicates that a smaller proportion of females than males attend school. Table 2.13 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Zimbabwe 2010-11 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 85.6 90.1 88.0 1.05 97.5 100.0 98.8 1.03 Rural 86.8 86.5 86.6 1.00 106.5 103.1 104.8 0.97 Province Manicaland 88.7 85.6 87.2 0.97 109.9 100.3 105.1 0.91 Mashonaland Central 88.8 88.7 88.7 1.00 109.0 106.1 107.6 0.97 Mashonaland East 86.1 86.4 86.2 1.00 104.0 98.9 101.5 0.95 Mashonaland West 84.7 85.3 85.0 1.01 102.3 105.2 103.7 1.03 Matabeleland North 82.6 86.9 84.8 1.05 108.5 105.2 106.8 0.97 Matabeleland South 89.6 89.2 89.4 1.00 103.3 106.8 104.9 1.03 Midlands 83.2 87.3 85.3 1.05 102.8 103.6 103.2 1.01 Masvingo 88.3 87.6 87.9 0.99 105.7 100.7 103.2 0.95 Harare 87.2 88.4 87.8 1.01 98.0 97.4 97.7 0.99 Bulawayo 85.4 92.9 89.3 1.09 97.2 104.9 101.3 1.08 Wealth quintile Lowest 83.6 83.0 83.3 0.99 105.1 98.5 101.7 0.94 Second 88.1 88.4 88.3 1.00 106.7 105.5 106.1 0.99 Middle 86.4 87.6 87.0 1.01 107.0 106.1 106.6 0.99 Fourth 85.8 89.1 87.5 1.04 103.4 101.9 102.6 0.99 Highest 89.6 90.4 90.0 1.01 98.0 100.0 99.0 1.02 Total 86.6 87.3 87.0 1.01 104.5 102.3 103.4 0.98 SECONDARY SCHOOL Residence Urban 61.7 56.4 58.7 0.91 70.9 62.9 66.4 0.89 Rural 42.7 44.4 43.5 1.04 49.5 49.2 49.3 0.99 Province Manicaland 48.8 49.1 48.9 1.01 56.9 52.4 54.8 0.92 Mashonaland Central 39.7 35.9 37.9 0.90 47.9 38.7 43.5 0.81 Mashonaland East 53.4 56.2 54.8 1.05 58.6 61.9 60.2 1.06 Mashonaland West 43.1 40.4 41.8 0.94 52.3 47.3 50.0 0.90 Matabeleland North 28.8 44.3 36.2 1.54 34.7 48.7 41.4 1.41 Matabeleland South 35.6 39.9 37.7 1.12 38.3 43.4 40.8 1.13 Midlands 44.7 51.4 48.0 1.15 54.5 56.3 55.4 1.03 Masvingo 49.7 46.6 48.2 0.94 58.7 54.0 56.3 0.92 Harare 60.0 52.3 55.7 0.87 65.1 58.8 61.6 0.90 Bulawayo 67.7 62.6 64.7 0.92 74.1 70.1 71.8 0.95 Wealth quintile Lowest 26.7 30.5 28.7 1.14 31.2 34.2 32.7 1.10 Second 42.6 45.2 43.8 1.06 47.7 49.3 48.5 1.03 Middle 46.9 48.6 47.6 1.04 55.3 54.5 54.9 0.98 Fourth 52.4 51.1 51.7 0.97 60.3 55.5 57.9 0.92 Highest 69.4 62.6 65.6 0.90 80.7 70.8 75.0 0.88 Total 47.3 48.2 47.8 1.02 54.7 53.6 54.1 0.98 1 The NAR for primary school is the percentage of the primary-school age (6-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (13-18 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary- school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. The results in Table 2.13 show that, 87 percent of children age 6 to 12 attend primary school and 48 percent of children age 13 to 18 attend secondary school. There is virtually no difference in the NARs for males and females at either the primary or secondary level. At the primary level, the NAR in urban areas is only slightly higher than in rural areas (88 percent and 87 percent, respectively), Housing Characteristics and Household Population • 25 while there is a much wider gap in the NAR between urban and rural areas at the secondary level (59 percent and 44 percent, respectively). By province, only small differences in NAR are observed at the primary school level. In contrast, at the secondary level, there is a high degree of variation in NAR. Bulawayo (65 percent) has the highest NAR and Matabeland North the lowest (36 percent). Attendance is higher among wealthy households than poorer households at both the primary and secondary levels, with greater differences observed at the secondary level. For example, 29 percent of children age 13 to 18 in the lowest wealth quintile attend secondary school, compared with 66 percent in the highest wealth quintile. At the primary school level, the GAR is 103 percent. This figure exceeds the primary school NAR (87 percent) by 16 percent, indicating that a number of children outside the official school age population are attending primary school. At the secondary level, the GAR (54 percent) is closer to the NAR (48 percent), indicating that fewer children outside of the official school age population are attending secondary school. The GPIs for the NAR and GAR are close to 1 at both the primary and secondary school levels. Reflecting the high level of primary school attendance among both boys and girls, variations in GPIs by background characteristics are generally minor and, in a number of subgroups, favour girls. At the secondary level, GAR GPI differences are generally somewhat larger than those observed at the primary level. For example, Table 2.13 shows that the gender gap is somewhat wider in the highest wealth quintile (0.88) than in the lowest wealth quintile (1.10), where, in fact, more girls than boys attend secondary school. Age-specific attendance rates (ASARs) for the population age 5 to 24 are presented in Figure 2.2 by age and sex. The ASAR indicates participation in schooling at any level, from primary to higher levels of education. The trends are the same for males and females. Approximately half of children attend school by age 6. In the 8-13 age group, 9 of 10 children attend school. At age 14, attendance rates begin to decline with increasing age, and the decline is faster for females than males after age 15. Figure 2.2 Age-specific Attendance Rates of the de facto Population 5 to 24 Years ZDHS 2010-11 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Male Female Characteristics of Respondents • 27 CHARACTERISTICS OF RESPONDENTS 3 his chapter presents information on demographic and socioeconomic characteristics of the survey respondents such as age, education, place of residence, marital status, employment, and wealth status. This information is useful for understanding the factors that affect use of reproductive health services, contraceptive use, and other health behaviours, as they provide a context for the interpretation of demographic and health indices. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Background characteristics of the 9,171 women age 15-49 and 7,480 men age 15-54 interviewed in the 2010-11 ZDHS are presented in Table 3.1. The distribution of respondents according to age shows a similar pattern for men and women. The proportion of respondents in each age group declines with increasing age for both sexes. Forty-one percent of women and 44 percent of men are in the 15-24 age group, and 33 percent of women and 31 percent of men are in the 25-34 age group. Fifty-nine percent of women and 50 percent of men are married, while 3 percent of women and 1 percent of men are in informal unions. Male respondents are much more likely than female respondents to have never married (45 percent versus 24 percent). Six percent of female respondents and 1 percent of male respondents are widowed. Men are less likely to be divorced or separated than women (3 percent versus 8 percent). The proportion of men in urban areas (37 percent) does not vary much from that of women (39 percent). The largest proportions of both male and female respondents live in Harare (18 percent and 19 percent, respectively) and Manicaland (14 percent and 13 percent, respectively). The smallest proportions live in Matabeleland North and Matabeleland South (5 percent each). T Key Findings • Literacy rates are high in Zimbabwe: 94 percent of women and 96 percent of men are literate. • Among women who were employed in the past 12 months, 36 percent worked in sales and services. Among men who were employed in the past 12 months, 29 percent worked in agriculture. • Twenty-one percent of men report that they smoke cigarettes, while less than 1 percent of women report using any form of tobacco. Both proportions are comparable to those reported in the 2005-06 ZDHS. 28 • Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 21.2 1,945 1,980 24.4 1,735 1,848 20-24 20.1 1,841 1,815 19.3 1,372 1,332 25-29 18.4 1,686 1,696 17.4 1,236 1,186 30-34 14.1 1,296 1,287 13.6 970 962 35-39 11.5 1,051 1,034 11.6 828 818 40-44 8.0 732 727 8.3 589 570 45-49 6.8 620 632 5.3 379 388 Religion Traditional 0.6 57 63 3.9 280 249 Roman Catholic 8.4 773 764 10.0 712 696 Protestant 16.8 1,539 1,511 13.9 991 935 Pentecostal 21.1 1,939 1,850 14.5 1,030 997 Apostolic Sect 38.0 3,488 3,396 27.7 1,968 1,955 Other Christian 8.4 768 953 7.7 550 556 Muslim 0.5 43 40 0.6 42 41 None 6.1 558 589 21.5 1,526 1,666 Other 0.1 6 5 0.1 10 9 Marital status Never married 24.0 2,197 2,332 45.3 3,221 3,322 Married 59.4 5,443 5,317 49.7 3,531 3,402 Living together 2.8 260 261 0.8 53 62 Divorced/separated 7.8 711 680 3.4 238 255 Widowed 6.1 560 581 0.9 66 63 Residence Urban 38.7 3,548 3,437 36.9 2,621 2,412 Rural 61.3 5,623 5,734 63.1 4,488 4,692 Province Manicaland 13.4 1,227 1,011 13.7 972 789 Mashonaland Central 9.5 871 904 10.4 738 789 Mashonaland East 9.0 824 847 9.4 667 714 Mashonaland West 11.2 1,026 970 12.3 872 836 Matabeleland North 4.8 443 767 4.9 349 557 Matabeleland South 5.1 467 835 4.9 352 650 Midlands 12.2 1,123 979 12.5 885 808 Masvingo 9.9 909 816 8.2 585 517 Harare 18.8 1,722 1,196 18.4 1,307 894 Bulawayo 6.1 558 846 5.4 382 550 Education No education 2.3 212 224 0.8 56 69 Primary 28.0 2,568 2,650 21.2 1,508 1,671 Secondary 65.1 5,966 5,904 70.7 5,027 4,893 More than secondary 4.6 424 393 7.3 519 471 Wealth quintile Lowest 16.9 1,546 1,707 15.1 1,074 1,223 Second 17.4 1,594 1,585 17.1 1,216 1,244 Middle 18.3 1,681 1,589 19.3 1,371 1,355 Fourth 22.6 2,073 2,060 23.4 1,664 1,606 Highest 24.8 2,278 2,230 25.1 1,786 1,676 Total 15-49 100.0 9,171 9,171 100.0 7,110 7,104 50-54 na na na na 370 376 Total 15-54 na na na na 7,480 7,480 Note: Education categories refer to the highest level of schooling attended, whether or not that level was completed. na = Not applicable Education is an important factor in influencing an individual’s attitude and outlook on various aspects of life. Generally, educational attainment in Zimbabwe is high; 78 percent of men and 70 percent of women have attended secondary school or higher. Twenty-one percent of men and 28 percent of women have attended only primary school. One percent of men and 2 percent of women have no education. Characteristics of Respondents • 29 The majority of the respondents (74 percent of men and 93 percent of women) are Christians. Men (22 percent) are more likely than women (6 percent) to report no religion. Men are also more likely to practice traditional religion than women (4 percent and 1 percent, respectively). 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Tables 3.2.1 and 3.2.2 present the percent distributions of female and male respondents by highest level of education attained, according to age, urban-rural residence, and province. Overall, the results show a high level of education in Zimbabwe among both female and male respondents. Men have a slight advantage in average educational attainment, having completed a median of 10 years of schooling compared with 9 years among women. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Zimbabwe 2010-11 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 0.3 8.4 13.6 72.6 2.4 2.7 100.0 9.2 3,786 15-19 0.1 9.2 12.7 76.0 1.3 0.7 100.0 8.8 1,945 20-24 0.5 7.6 14.7 69.0 3.5 4.7 100.0 10.0 1,841 25-29 1.4 9.0 16.1 66.1 1.4 6.0 100.0 10.0 1,686 30-34 1.6 9.5 19.5 61.9 0.7 6.7 100.0 9.3 1,296 35-39 2.4 12.2 20.8 58.0 0.7 5.9 100.0 8.7 1,051 40-44 5.9 16.7 16.5 55.2 0.4 5.4 100.0 8.4 732 45-49 14.3 32.5 22.7 24.8 0.3 5.3 100.0 6.1 620 Residence Urban 0.8 4.4 8.8 75.3 2.7 7.9 100.0 10.2 3,548 Rural 3.3 15.8 21.5 56.2 0.7 2.5 100.0 8.0 5,623 Province Manicaland 1.9 12.8 18.3 60.1 1.3 5.7 100.0 8.7 1,227 Mashonaland Central 5.3 23.4 17.5 49.7 0.6 3.4 100.0 7.1 871 Mashonaland East 2.0 6.9 18.8 68.4 1.5 2.4 100.0 9.0 824 Mashonaland West 2.7 16.3 18.7 59.7 0.6 2.0 100.0 8.3 1,026 Matabeleland North 4.5 16.0 27.4 50.2 0.4 1.5 100.0 7.2 443 Matabeleland South 1.6 10.0 25.7 59.4 0.9 2.4 100.0 8.3 467 Midlands 2.7 11.2 15.0 65.8 0.8 4.5 100.0 9.0 1,123 Masvingo 2.4 14.1 21.7 56.4 0.7 4.6 100.0 8.4 909 Harare 0.7 4.6 7.6 76.3 3.1 7.8 100.0 10.2 1,722 Bulawayo 1.1 2.0 10.7 75.6 3.5 7.0 100.0 10.2 558 Wealth quintile Lowest 5.7 25.5 27.5 41.1 0.2 0.1 100.0 6.6 1,546 Second 3.1 16.3 23.0 57.2 0.1 0.2 100.0 7.8 1,594 Middle 2.4 12.5 17.1 65.5 0.8 1.7 100.0 8.5 1,681 Fourth 1.3 6.2 13.4 73.3 1.6 4.3 100.0 10.0 2,073 Highest 0.4 2.4 7.2 73.1 3.6 13.2 100.0 10.3 2,278 Total 2.3 11.4 16.6 63.6 1.5 4.6 100.0 9.0 9,171 Note: In Zimbabwe, primary level is referred to as grades 1-7. Secondary level is referred to as forms 1-6. With the primary and secondary levels combined, there is a total of 13 years of schooling. 1 Completed 7th grade at the primary level 2 Completed 6th grade at the secondary level 30 • Characteristics of Respondents Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Zimbabwe 2010-11 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 0.6 10.0 11.5 70.9 4.1 3.0 100.0 9.3 3,107 15-19 0.7 12.2 11.9 74.0 1.1 0.2 100.0 8.6 1,735 20-24 0.6 7.1 10.9 66.9 8.0 6.5 100.0 10.2 1,372 25-29 0.7 6.5 12.2 65.2 5.0 10.5 100.0 10.2 1,236 30-34 0.6 6.2 13.3 65.9 2.7 11.3 100.0 10.2 970 35-39 0.7 7.1 16.4 64.5 1.8 9.4 100.0 10.1 828 40-44 1.4 5.3 10.9 68.7 1.5 12.2 100.0 10.3 589 45-49 2.2 18.6 16.3 51.3 2.1 9.5 100.0 8.9 379 Residence Urban 0.1 2.1 5.8 72.9 6.5 12.5 100.0 10.4 2,621 Rural 1.2 12.4 16.6 63.9 1.7 4.3 100.0 8.9 4,488 Province Manicaland 0.4 9.0 11.9 67.8 2.3 8.7 100.0 9.8 972 Mashonaland Central 1.3 15.9 14.8 62.1 2.0 3.8 100.0 8.7 738 Mashonaland East 0.3 6.5 12.8 72.3 1.8 6.3 100.0 10.0 667 Mashonaland West 0.4 9.0 16.3 68.0 2.5 3.8 100.0 9.3 872 Matabeleland North 5.8 16.8 26.8 44.3 2.3 4.0 100.0 7.1 349 Matabeleland South 0.2 12.1 28.0 52.8 2.7 4.2 100.0 7.9 352 Midlands 0.6 9.7 10.7 70.9 2.7 5.3 100.0 9.7 885 Masvingo 1.3 11.4 11.1 65.2 2.8 8.2 100.0 9.7 585 Harare 0.2 1.8 4.9 74.1 7.5 11.5 100.0 10.4 1,307 Bulawayo 0.0 1.6 8.0 70.3 5.2 15.0 100.0 10.3 382 Wealth quintile Lowest 2.6 22.9 22.4 51.6 0.3 0.2 100.0 7.0 1,074 Second 1.0 11.2 19.7 66.0 1.2 1.0 100.0 8.6 1,216 Middle 0.6 9.6 15.3 70.4 1.9 2.2 100.0 9.2 1,371 Fourth 0.5 4.3 8.8 76.8 3.0 6.6 100.0 10.2 1,664 Highest 0.0 1.4 3.4 66.2 8.6 20.4 100.0 10.6 1,786 Total 15-49 0.8 8.6 12.6 67.2 3.5 7.3 100.0 10.0 7,110 50-54 5.7 28.2 29.9 28.9 1.1 6.2 100.0 6.5 370 Total 15-54 1.0 9.6 13.5 65.3 3.4 7.2 100.0 9.9 7,480 Note: In Zimbabwe, primary level is referred to as grades 1-7. Secondary level is referred to as forms 1-6. With the primary and secondary levels combined, there is a total of 13 years of schooling. 1 Completed 7th grade at the primary level 2 Completed 6th grade at the secondary level Younger respondents are more likely to be educated and to have reached higher levels of education than older respondents. For example, the proportion of women with no education ranges from less than 1 percent among those age 15-19 to 14 percent among those age 45-49. Women age 15-19 also are more than twice as likely as women age 45-49 to have attended at least some secondary school (78 percent versus 30 percent). Similarly, 75 percent of men age 15-19 have attended at least some secondary school, compared with 63 percent of men age 45-49. The improvement in level of education among younger cohorts reflects the significant expansion of and improved accessibility to the educational system after independence in 1980. Rural respondents are less educated than their urban counterparts. For example, 59 percent of rural women have attended secondary school or higher, as compared with 86 percent of urban women. Similarly, 92 percent of urban men have attended secondary school or higher, compared with 70 percent of rural men. Characteristics of Respondents • 31 Harare and Bulawayo, which are urban centres, have the most educated populations; in these provinces, 1 percent or less of both male and female respondents have never attended school, and more than 9 in 10 men and 8 in 10 women have attended secondary school or higher. Mashonaland Central and Matabeleland North have the highest proportions of women with no education (5 percent each) and the lowest proportions of women with at least some secondary schooling (54 percent and 52 percent, respectively). Matabeleland North has by far the highest proportion of men with no education (6 percent versus 1 percent or less in the other provinces) and the lowest proportion with a secondary or higher education (51 percent versus 60 percent or more in the other provinces). Higher wealth status is associated with greater educational attainment. For example, the proportion of female respondents who have attended secondary school or higher varies from 41 percent in the lowest quintile to 90 percent in the highest quintile. Among male respondents, 95 percent in the highest wealth quintile have attended secondary school or higher, compared with 52 percent in the lowest quintile. 3.3 LITERACY Literacy is widely acknowledged as benefiting both individuals and society. It is also associated with a number of positive health outcomes. In the 2010-11 ZDHS, literacy status was determined by respondents’ ability to read all or part of a sentence. Respondents who had not attended school or had attended only primary school were asked to demonstrate their ability to read. Those with a secondary education or higher were assumed to be literate. Tables 3.3.1 and 3.3.2 show the percent distributions of women and men by level of schooling attended and level of literacy, along with the percentage of respondents who are literate, according to background characteristics. Literacy rates in Zimbabwe are very high; overall, 94 percent of women and 96 percent of men are literate. Given the high overall rate, variations in literacy across subgroups of the population are generally small. The rate is lower among women age 45-49 (79 percent) than among both women in younger age cohorts (90 percent or higher) and men in the same age cohort (94 percent). Women and men in urban areas have slightly higher literacy rates (98 percent and 99 percent, respectively) than their rural counterparts (91 percent and 94 percent, respectively). Bulawayo and Harare have the highest literacy rates for both women (99 percent and 98 percent, respectively) and men (99 percent each). Mashonaland Central has the lowest literacy rate for women (86 percent), while Matabeleland North has the lowest rate for men (84 percent). As with educational attainment, literacy is directly associated with wealth status. 32 • Characteristics of Respondents Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Zimbabwe 2010-11 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Age 15-24 77.6 13.6 5.0 3.6 0.2 0.0 100.0 96.2 3,786 15-19 78.0 12.8 5.5 3.4 0.3 0.0 100.0 96.3 1,945 20-24 77.2 14.5 4.4 3.7 0.1 0.1 100.0 96.1 1,841 25-29 73.5 16.3 5.2 4.9 0.0 0.1 100.0 95.0 1,686 30-34 69.4 18.5 6.6 5.3 0.2 0.0 100.0 94.5 1,296 35-39 64.6 21.2 7.7 6.3 0.1 0.2 100.0 93.5 1,051 40-44 60.9 20.8 8.3 9.6 0.2 0.3 100.0 90.0 732 45-49 30.5 33.0 15.6 20.4 0.1 0.5 100.0 79.0 620 Residence Urban 86.0 9.8 2.5 1.7 0.0 0.1 100.0 98.2 3,548 Rural 59.4 22.5 9.1 8.7 0.2 0.1 100.0 91.0 5,623 Province Manicaland 67.1 22.5 4.9 5.4 0.1 0.0 100.0 94.4 1,227 Mashonaland Central 53.7 25.8 6.3 14.0 0.0 0.1 100.0 85.8 871 Mashonaland East 72.3 14.6 8.1 5.0 0.0 0.0 100.0 95.0 824 Mashonaland West 62.3 21.2 7.9 8.6 0.0 0.0 100.0 91.4 1,026 Matabeleland North 52.1 25.5 10.2 9.8 2.1 0.2 100.0 87.9 443 Matabeleland South 62.7 20.3 9.9 6.7 0.3 0.0 100.0 92.9 467 Midlands 71.1 18.1 6.5 4.0 0.0 0.2 100.0 95.7 1,123 Masvingo 61.8 16.3 13.0 8.5 0.0 0.4 100.0 91.1 909 Harare 87.1 8.6 2.8 1.4 0.0 0.0 100.0 98.6 1,722 Bulawayo 86.1 11.2 1.1 1.5 0.0 0.1 100.0 98.4 558 Wealth quintile Lowest 41.3 30.2 13.1 14.6 0.6 0.2 100.0 84.5 1,546 Second 57.6 23.0 9.7 9.6 0.1 0.1 100.0 90.3 1,594 Middle 68.0 19.3 6.4 6.2 0.0 0.1 100.0 93.7 1,681 Fourth 79.2 14.0 4.2 2.5 0.1 0.1 100.0 97.4 2,073 Highest 90.0 7.1 2.2 0.7 0.0 0.1 100.0 99.3 2,278 Total 69.7 17.6 6.5 6.0 0.1 0.1 100.0 93.8 9,171 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Zimbabwe 2010-11 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Age 15-24 78.0 10.5 6.7 4.7 0.1 0.0 100.0 95.2 3,107 15-19 75.3 11.4 7.6 5.6 0.0 0.0 100.0 94.3 1,735 20-24 81.4 9.4 5.6 3.4 0.2 0.0 100.0 96.3 1,372 25-29 80.6 10.8 5.7 2.9 0.0 0.0 100.0 97.1 1,236 30-34 79.9 11.0 5.5 3.5 0.2 0.0 100.0 96.3 970 35-39 75.8 13.9 6.7 3.5 0.0 0.2 100.0 96.4 828 40-44 82.4 9.3 5.0 3.3 0.0 0.0 100.0 96.7 589 45-49 62.9 20.1 10.6 6.4 0.0 0.0 100.0 93.6 379 Residence Urban 92.0 5.0 2.0 0.9 0.0 0.0 100.0 99.1 2,621 Rural 69.8 15.2 9.0 5.8 0.1 0.0 100.0 94.0 4,488 Province Manicaland 78.7 11.6 5.6 4.0 0.0 0.0 100.0 96.0 972 Mashonaland Central 68.0 18.4 8.9 4.7 0.0 0.0 100.0 95.3 738 Mashonaland East 80.4 9.2 5.5 4.9 0.0 0.0 100.0 95.1 667 Mashonaland West 74.2 18.0 5.6 2.2 0.0 0.0 100.0 97.8 872 Matabeleland North 50.6 15.4 17.5 15.6 0.8 0.2 100.0 83.5 349 Matabeleland South 59.7 17.0 14.8 7.9 0.6 0.0 100.0 91.5 352 Midlands 79.0 11.0 6.0 4.0 0.0 0.0 100.0 96.0 885 Masvingo 76.3 11.1 7.5 4.9 0.0 0.2 100.0 94.9 585 Harare 93.2 3.4 2.6 0.8 0.0 0.0 100.0 99.2 1,307 Bulawayo 90.4 6.4 1.7 1.5 0.0 0.0 100.0 98.5 382 Wealth quintile Lowest 52.1 22.9 14.3 10.4 0.3 0.0 100.0 89.3 1,074 Second 68.1 17.9 8.6 5.2 0.0 0.1 100.0 94.7 1,216 Middle 74.5 14.2 7.9 3.4 0.0 0.0 100.0 96.5 1,371 Fourth 86.4 6.6 4.2 2.8 0.0 0.0 100.0 97.2 1,664 Highest 95.2 2.5 1.2 1.0 0.1 0.0 100.0 98.9 1,786 Total 15-49 78.0 11.4 6.4 4.0 0.1 0.0 100.0 95.9 7,110 50-54 36.2 39.0 17.9 6.9 0.0 0.0 100.0 93.1 370 Total 15-54 75.9 12.8 7.0 4.2 0.1 0.0 100.0 95.7 7,480 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Respondents • 33 3.4 EXPOSURE TO MASS MEDIA The 2010-11 ZDHS collected information on respondents’ exposure to common print and electronic media. Respondents were asked how often they read a newspaper, listened to the radio, or watched television. This information is important because it indicates the extent to which Zimbabweans are regularly exposed to mass media, often used to convey messages on family planning, HIV/AIDS awareness, and other health topics. Tables 3.4.1 and 3.4.2 show the percentages of female and male respondents who were exposed to different types of mass media by age, urban-rural residence, province, level of education, and wealth quintile. Sixteen percent of women and 31 percent of men read newspapers at least once a week, 36 percent of women and 42 percent of men watch television at least once a week, and 33 percent of women and 49 percent of men listen to the radio at least once a week. Overall, only 8 percent of women and 17 percent of men are exposed to all three media at least once per week. Almost half of women and one-third of men are not exposed to any of the three media on a regular basis. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Zimbabwe 2010-11 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 17.7 38.1 34.1 8.8 46.7 1,945 20-24 17.2 38.6 35.9 9.3 45.3 1,841 25-29 17.1 36.9 33.1 9.0 48.3 1,686 30-34 15.5 35.1 32.1 7.6 48.1 1,296 35-39 14.4 30.1 29.9 7.2 53.9 1,051 40-44 16.1 33.4 30.3 7.4 51.6 732 45-49 10.8 27.5 25.4 5.6 61.2 620 Residence Urban 30.2 67.8 44.9 16.9 21.1 3,548 Rural 7.4 15.2 24.9 2.8 66.8 5,623 Province Manicaland 15.9 29.9 38.5 7.1 47.6 1,227 Mashonaland Central 11.3 24.1 32.7 4.1 53.8 871 Mashonaland East 12.3 21.4 33.7 4.4 55.3 824 Mashonaland West 8.7 28.9 27.3 4.7 57.5 1,026 Matabeleland North 4.7 15.9 6.5 0.6 79.3 443 Matabeleland South 5.4 12.3 15.9 1.7 76.6 467 Midlands 10.8 29.0 23.2 5.3 59.2 1,123 Masvingo 8.3 16.6 21.1 3.5 68.2 909 Harare 32.6 65.8 47.2 18.4 20.9 1,722 Bulawayo 35.5 84.9 55.1 23.5 9.4 558 Education No education 0.6 11.4 13.4 0.0 79.8 212 Primary 3.6 17.5 23.6 1.5 68.0 2,568 Secondary 19.1 41.5 36.1 9.6 42.4 5,966 More than secondary 58.8 72.7 48.1 34.1 14.5 424 Wealth quintile Lowest 1.9 2.4 11.3 0.2 87.3 1,546 Second 4.5 6.8 20.9 1.2 74.4 1,594 Middle 8.7 13.1 28.8 2.2 62.3 1,681 Fourth 18.2 52.8 41.1 9.0 30.8 2,073 Highest 37.8 79.0 50.3 22.4 12.5 2,278 Total 16.2 35.5 32.6 8.3 49.1 9,171 34 • Characteristics of Respondents Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Zimbabwe 2010-11 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of men Age 15-19 20.0 38.1 43.2 11.0 40.7 1,735 20-24 32.0 45.2 51.4 17.0 30.2 1,372 25-29 36.4 45.6 50.4 18.2 29.0 1,236 30-34 35.7 42.3 52.5 20.0 30.8 970 35-39 35.9 42.1 49.7 19.5 33.5 828 40-44 39.0 43.4 52.7 21.1 29.4 589 45-49 31.0 38.9 49.1 19.4 37.8 379 Residence Urban 57.3 72.1 55.2 32.5 12.7 2,621 Rural 16.1 24.9 45.6 7.8 45.4 4,488 Province Manicaland 29.1 37.2 54.8 16.9 32.2 972 Mashonaland Central 18.6 28.3 50.9 8.8 38.9 738 Mashonaland East 23.9 28.1 50.0 9.7 37.3 667 Mashonaland West 25.4 43.8 59.8 16.7 29.3 872 Matabeleland North 21.0 27.3 32.0 13.3 56.5 349 Matabeleland South 14.1 19.4 28.3 7.0 62.4 352 Midlands 27.4 38.3 42.2 11.5 37.5 885 Masvingo 11.5 21.2 30.9 2.3 54.8 585 Harare 58.0 69.9 56.6 32.3 13.2 1,307 Bulawayo 61.3 85.7 59.6 39.9 6.2 382 Education No education 1.3 18.0 19.3 1.3 73.3 56 Primary 8.3 20.3 38.9 3.8 53.0 1,508 Secondary 34.2 46.1 52.4 18.9 29.4 5,027 More than secondary 73.9 71.8 51.1 37.2 10.2 519 Wealth quintile Lowest 5.1 10.1 32.4 2.0 63.9 1,074 Second 11.2 17.3 46.0 3.9 47.9 1,216 Middle 18.6 25.3 48.7 8.3 41.8 1,371 Fourth 39.9 56.5 55.2 22.2 21.7 1,664 Highest 62.5 78.5 56.2 36.3 9.4 1,786 Total 15-49 31.3 42.3 49.2 16.9 33.4 7,110 50-54 26.4 42.1 49.2 13.9 33.1 370 Total 15-54 31.1 42.3 49.2 16.7 33.3 7,480 The proportions of respondents who are not exposed to any media on at least a weekly basis are highest among women age 45-49 and among men age 15-19 (61 percent and 41 percent, respectively). Urban residents are more likely to be exposed to all forms of mass media than rural residents. Overall, 67 percent of rural women and 45 percent of rural men reported having no exposure to any form of mass media at least once a week, compared with 21 percent of urban women and 13 percent of urban men. Harare and Bulawayo residents are more likely to read newspapers, watch television, and listen to the radio than people living in other provinces. Women in Matabeleland North and men in Matabeleland South are most likely to report having no exposure to any of the three media (79 percent and 62 percent, respectively). Not surprisingly, media exposure is related to education among both women and men. For example, 80 percent of women with no education report that they are not exposed to any media on at least a weekly basis, compared with 15 percent of women with more than a secondary education. Similarly, 73 percent of men who never attended school have no exposure to any media at least once a week, as compared with 10 percent of men with more than a secondary education. Characteristics of Respondents • 35 Media exposure among women and men is also affected by wealth status. For example, 38 percent of women in the highest wealth quintile read a newspaper at least once a week, compared with 2 percent of women in the lowest wealth quintile. Among men, 63 percent in the highest wealth quintile and 5 percent in the lowest quintile read a newspaper at least once a week. Seventy-nine percent of both women and men in the highest wealth quintile watch television at least once a week, in contrast to 2 percent of women and 10 percent of men in the lowest wealth quintile. Differences between wealth quintiles are less pronounced with respect to listening to the radio at least once a week. Fifty percent of women and 56 percent of men in the highest wealth quintile listen to the radio at least once a week, compared with 11 percent of women and 32 percent of men in the lowest wealth quintile. 3.5 EMPLOYMENT STATUS The 2010-11 ZDHS asked respondents several questions about their current employment status and continuity of employment in the 12 months prior to the survey. Figure 3.1 and Table 3.5.1 present the proportion of women who were currently employed (i.e., who were working in the seven days preceding the survey), the proportion who were not currently employed but had been employed at some time during the 12 months before the survey, and the proportion who had not been employed at any time during the 12-month period. Table 3.5.2 presents employment status data for men. Overall, 37 percent of women reported that they were currently employed. An additional 6 percent of women were not currently employed but had worked in the 12 months preceding the survey. Approximately 7 in 10 men age 15-49 were either currently employed (61 percent) or had worked in the year prior to the survey (8 percent). Figure 3.1 Women’s Employment Status in the Past 12 Months ZDHS 2010-11 Insert long title here 57% Insert really long tit 6% Currently employed 37% Did not work in last 12 months 57% Not currently employed, but worked in last 12 months 6% 36 • Characteristics of Respondents Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Zimbabwe 2010-11 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 14.8 4.3 80.9 100.0 1,945 20-24 33.0 8.1 58.9 100.0 1,841 25-29 42.1 6.1 51.9 100.0 1,686 30-34 46.6 7.2 46.2 100.0 1,296 35-39 46.3 6.4 47.3 100.0 1,051 40-44 56.1 4.9 39.0 100.0 732 45-49 48.4 3.3 48.3 100.0 620 Marital status Never married 24.6 6.0 69.4 100.0 2,197 Married or living together 38.0 6.1 55.9 100.0 5,703 Divorced/separated/widowed 55.0 5.7 39.3 100.0 1,271 Number of living children 0 24.2 6.0 69.8 100.0 2,510 1-2 41.4 6.0 52.6 100.0 3,731 3-4 44.2 6.7 49.1 100.0 2,052 5+ 39.8 4.3 55.9 100.0 878 Residence Urban 44.4 6.3 49.3 100.0 3,548 Rural 32.6 5.8 61.6 100.0 5,623 Province Manicaland 48.2 4.5 47.3 100.0 1,227 Mashonaland Central 50.8 9.8 39.3 100.0 871 Mashonaland East 39.4 4.9 55.7 100.0 824 Mashonaland West 29.9 5.5 64.6 100.0 1,026 Matabeleland North 16.1 3.1 80.8 100.0 443 Matabeleland South 22.4 6.3 71.3 100.0 467 Midlands 30.4 6.5 63.1 100.0 1,123 Masvingo 22.0 4.4 73.6 100.0 909 Harare 47.5 6.7 45.8 100.0 1,722 Bulawayo 37.1 7.4 55.5 100.0 558 Education No education 35.2 3.2 61.6 100.0 212 Primary 35.0 5.9 59.1 100.0 2,568 Secondary 35.7 6.1 58.2 100.0 5,966 More than secondary 72.2 6.2 21.6 100.0 424 Wealth quintile Lowest 23.9 6.0 70.2 100.0 1,546 Second 29.5 6.0 64.5 100.0 1,594 Middle 36.7 5.8 57.6 100.0 1,681 Fourth 43.4 6.3 50.3 100.0 2,073 Highest 46.2 6.0 47.9 100.0 2,278 Total 37.2 6.0 56.8 100.0 9,171 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Respondents • 37 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Zimbabwe 2010-11 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 27.0 5.1 67.9 100.0 1,735 20-24 61.1 9.8 29.1 100.0 1,372 25-29 75.1 9.0 15.9 100.0 1,236 30-34 77.0 7.1 15.9 100.0 970 35-39 76.8 8.6 14.5 100.0 828 40-44 78.4 5.7 15.9 100.0 589 45-49 74.2 7.8 18.0 100.0 379 Marital status Never married 43.1 6.9 50.0 100.0 3,221 Married or living together 77.1 8.1 14.8 100.0 3,584 Divorced/separated/widowed 69.4 8.9 21.7 100.0 304 Number of living children 0 46.5 7.0 46.6 100.0 3,594 1-2 77.1 8.7 14.2 100.0 1,889 3-4 78.5 7.4 14.0 100.0 1,122 5+ 70.2 8.0 21.7 100.0 504 Residence Urban 67.5 6.6 26.0 100.0 2,621 Rural 57.8 8.2 34.1 100.0 4,488 Province Manicaland 58.1 8.2 33.7 100.0 972 Mashonaland Central 81.0 4.6 14.4 100.0 738 Mashonaland East 58.9 11.6 29.6 100.0 667 Mashonaland West 58.2 8.6 33.1 100.0 872 Matabeleland North 35.6 7.0 57.4 100.0 349 Matabeleland South 49.9 10.4 39.8 100.0 352 Midlands 62.5 9.2 28.3 100.0 885 Masvingo 50.6 4.6 44.8 100.0 585 Harare 72.0 5.5 22.4 100.0 1,307 Bulawayo 54.5 8.1 37.4 100.0 382 Education No education 46.0 3.7 50.4 100.0 56 Primary 60.3 8.4 31.2 100.0 1,508 Secondary 59.8 7.6 32.6 100.0 5,027 More than secondary 80.5 5.5 14.1 100.0 519 Wealth quintile Lowest 47.1 10.5 42.4 100.0 1,074 Second 55.0 8.8 36.2 100.0 1,216 Middle 62.1 7.1 30.8 100.0 1,371 Fourth 68.9 6.7 24.4 100.0 1,664 Highest 66.6 6.2 27.3 100.0 1,786 Total 15-49 61.3 7.6 31.1 100.0 7,110 50-54 68.7 8.7 22.6 100.0 370 Total 15-54 61.7 7.6 30.7 100.0 7,480 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Women and men in the 15-19 age group are less likely to be currently employed than their counterparts in older age groups, a finding that is partially due to the fact that many in this age cohort are students. Women who are divorced, separated, or widowed are more likely to be currently employed (55 percent) than other women. Men who are married or living with their partner are more likely to be currently employed (77 percent) than men who have never been married or who are divorced, separated, or widowed. 38 • Characteristics of Respondents Women and men with no children are less likely to be currently employed than those who have children. This finding may be linked to the fact that the former are typically younger than those with children. A higher percentage of urban women and men (44 percent and 68 percent, respectively) than their rural counterparts (33 percent and 58 percent, respectively) are currently employed. There are substantial provincial variations in women’s and men’s employment status. Women in Manicaland, Mashonaland Central, and Harare are much more likely to be currently employed than women in other provinces; around half of women in each of these provinces reported that they were employed in the seven days before the survey. Men in Mashonaland Central, Harare, and Midlands are much more likely than men in other provinces to be currently employed (81 percent, 72 percent, and 63 percent, respectively). Women and men with more than a secondary education were most likely to be currently employed (72 percent and 81 percent, respectively). Women with more than a secondary education were twice as likely as those with less education to be currently employed. Among men, unemployment decreased with increasing level of education. The proportion of women who were currently employed increased with increasing wealth quintile. Among men, a similar trend was observed. Twenty-four percent of women in the lowest wealth quintile were currently employed as compared to 46 percent in the highest wealth quintile. For men the employment rate ranges from 47 percent in the lowest wealth quintile to a peak of 69 percent in the fourth wealth quintile. 3.6 OCCUPATION Respondents who were currently employed or had worked in the 12 months preceding the survey were further asked to specify their occupation. Information on the current occupation of employed women and men is shown in Tables 3.6.1 and 3.6.2. Women are most likely to be employed in sales and services (36 percent), followed by agriculture (21 percent). Men age 15-49 are most commonly employed in agriculture (29 percent) and unskilled manual labour (23 percent). Urban women are most often employed in sales and services (45 percent). Among urban men, the most common occupations are skilled manual labour (26 percent) and unskilled manual labour (24 percent). In rural areas, the majority of women (35 percent) and men (45 percent) are employed in agriculture. Mashonaland West has the highest percentage of women in agricultural occupations (37 percent), while Mashonaland Central has the highest percentage of men working in agriculture (56 percent). Matabeleland North has the highest percentage of women in sales and services (52 percent), and Harare has the highest percentage of men employed in that sector (22 percent). Harare and Bulawayo have the highest percentages of men employed in skilled manual labour (26 percent and 30 percent, respectively). Masvingo has the highest percentage of women in professional, technical, and managerial occupations (17 percent), while Matabeleland North has the highest percentage of men in those occupations (16 percent). Characteristics of Respondents • 39 Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Zimbabwe 2010-11 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Other Don’t know/ missing Total Number of women Age 15-19 0.3 1.7 30.9 0.4 14.7 32.0 19.2 0.0 0.9 100.0 371 20-24 4.9 4.1 37.1 2.0 21.2 9.8 17.9 1.4 1.6 100.0 757 25-29 9.8 3.1 38.7 0.8 18.9 6.9 19.4 1.7 0.6 100.0 812 30-34 11.5 4.5 35.9 2.7 16.5 7.4 18.6 1.9 1.1 100.0 698 35-39 10.2 2.9 36.9 1.9 15.5 6.0 21.6 3.5 1.4 100.0 554 40-44 12.7 3.2 34.6 0.7 17.1 3.8 24.4 2.1 1.5 100.0 447 45-49 7.9 1.6 32.1 1.7 18.2 4.9 29.9 1.8 1.9 100.0 320 Marital status Never married 9.8 5.6 30.4 2.4 14.9 26.0 6.5 1.6 2.6 100.0 672 Married or living together 8.7 2.7 36.2 1.4 18.2 3.8 26.3 1.8 0.9 100.0 2,515 Divorced/separated/widowed 6.6 3.0 39.9 1.3 19.0 12.5 14.6 2.1 1.0 100.0 772 Number of living children 0 9.3 5.4 32.5 2.3 14.5 22.6 9.2 2.2 2.0 100.0 758 1-2 10.5 3.3 38.3 1.5 19.0 6.8 17.7 2.1 0.8 100.0 1,768 3-4 7.3 2.7 35.6 0.9 18.8 5.6 26.6 1.3 1.3 100.0 1,045 5+ 1.4 0.3 32.6 2.1 16.1 4.2 40.8 1.1 1.3 100.0 387 Residence Urban 9.3 5.1 45.1 2.2 18.1 11.3 3.2 3.6 2.1 100.0 1,801 Rural 7.8 1.7 28.3 1.0 17.5 7.6 35.2 0.4 0.5 100.0 2,158 Province Manicaland 9.7 0.8 30.5 2.0 18.5 7.7 29.9 0.7 0.2 100.0 646 Mashonaland Central 5.3 2.1 31.4 0.1 18.4 6.6 34.7 0.2 1.3 100.0 528 Mashonaland East 7.1 3.4 30.6 0.5 14.0 11.4 31.5 1.4 0.0 100.0 365 Mashonaland West 4.9 2.0 26.5 1.6 20.4 6.4 37.1 0.7 0.3 100.0 363 Matabeleland North 13.2 1.3 52.4 1.5 12.7 13.3 3.6 1.2 0.9 100.0 85 Matabeleland South 7.6 3.6 35.5 1.0 20.7 16.5 7.5 1.5 6.2 100.0 134 Midlands 9.9 4.3 33.2 1.2 16.5 8.8 25.3 0.5 0.3 100.0 415 Masvingo 17.2 2.2 39.6 1.3 15.4 7.5 16.6 0.0 0.3 100.0 240 Harare 8.0 5.3 44.6 2.1 18.7 10.6 2.8 5.7 2.2 100.0 934 Bulawayo 9.6 6.0 44.0 4.2 17.4 12.0 3.0 0.3 3.5 100.0 248 Education No education 0.0 0.0 16.4 0.0 23.6 10.3 48.8 0.0 0.8 100.0 82 Primary 0.3 0.1 29.4 1.3 17.3 14.0 36.3 1.0 0.3 100.0 1,050 Secondary 5.3 3.7 42.4 1.5 19.4 8.5 15.8 2.1 1.4 100.0 2,494 More than secondary 60.9 11.1 13.2 3.1 5.7 0.0 0.8 2.5 2.6 100.0 332 Wealth quintile Lowest 0.2 0.3 30.3 1.4 17.1 7.8 42.3 0.5 0.1 100.0 462 Second 2.5 0.4 27.4 0.4 17.2 8.4 43.2 0.0 0.4 100.0 566 Middle 7.4 1.2 35.9 1.0 16.6 6.8 29.4 1.0 0.8 100.0 713 Fourth 7.7 3.9 42.2 1.9 20.0 8.8 11.9 2.2 1.5 100.0 1,029 Highest 15.9 6.5 36.7 2.2 17.2 12.1 3.9 3.4 2.1 100.0 1,188 Total 8.5 3.3 35.9 1.5 17.8 9.3 20.7 1.8 1.2 100.0 3,959 Occupation also varies with level of education. Sixty-one percent of women and 55 percent of men with more than a secondary education are employed in the professional, technical, and managerial sector. Women and men with no education or only a primary education most commonly work in the agricultural sector. Employed women and men in the lowest wealth quintile are concentrated in agricultural occupations (42 percent and 52 percent, respectively). Sales and services is the most common occupation among women in the highest wealth quintile (37 percent). Men in the highest wealth quintile are most commonly employed in skilled manual labour (24 percent). 40 • Characteristics of Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Zimbabwe 2010-11 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Other Don’t know/ missing Total Number of men Age 15-19 1.5 0.0 8.5 9.0 19.3 6.1 53.9 0.9 0.8 100.0 557 20-24 5.2 1.9 12.6 17.0 26.8 3.4 29.0 2.5 1.5 100.0 973 25-29 8.0 4.9 14.1 20.8 24.3 2.2 22.2 2.7 0.9 100.0 1,040 30-34 9.3 3.2 12.0 22.1 21.9 4.2 23.2 2.8 1.2 100.0 816 35-39 10.9 4.9 8.6 21.9 21.8 3.2 25.7 1.4 1.6 100.0 707 40-44 14.2 5.5 8.7 22.2 20.0 2.4 23.8 2.0 1.2 100.0 496 45-49 12.1 3.6 5.0 25.8 16.4 2.8 31.4 2.8 0.2 100.0 311 Marital status Never married 7.2 2.6 11.5 13.7 23.6 3.8 34.3 2.2 1.2 100.0 1,609 Married or living together 9.0 4.0 10.6 22.8 21.2 3.4 25.6 2.3 1.1 100.0 3,053 Divorced/separated/widowed 5.5 1.5 10.2 17.0 31.9 1.9 28.3 1.4 2.1 100.0 238 Number of living children 0 7.8 2.9 11.3 14.3 23.7 4.1 32.9 1.9 1.0 100.0 1,920 1-2 8.5 3.8 13.3 22.1 22.6 3.5 22.1 2.8 1.3 100.0 1,621 3-4 9.7 4.4 8.1 23.6 21.5 2.4 27.1 1.6 1.4 100.0 965 5+ 5.3 2.0 6.1 24.7 18.6 2.5 37.5 2.7 0.6 100.0 394 Residence Urban 11.7 6.2 19.0 25.8 23.6 4.4 4.0 3.9 1.5 100.0 1,941 Rural 6.0 1.6 5.6 15.5 21.8 2.8 44.7 1.1 0.9 100.0 2,960 Province Manicaland 11.9 4.1 6.8 19.4 28.8 1.9 23.0 0.0 4.2 100.0 644 Mashonaland Central 3.8 1.9 5.4 12.6 15.3 2.5 55.8 1.6 1.1 100.0 632 Mashonaland East 6.9 2.3 5.9 14.3 24.9 2.7 40.4 2.3 0.5 100.0 470 Mashonaland West 4.1 2.6 8.3 17.0 25.0 2.9 37.4 2.6 0.3 100.0 583 Matabeleland North 15.8 0.7 13.7 24.8 19.7 6.1 15.8 2.5 0.8 100.0 149 Matabeleland South 6.3 2.7 6.6 15.1 36.7 1.9 26.0 3.4 1.4 100.0 212 Midlands 7.2 1.3 8.6 21.4 25.0 2.2 34.2 0.0 0.2 100.0 635 Masvingo 9.5 2.3 6.1 14.7 14.9 4.2 47.9 0.3 0.2 100.0 323 Harare 10.9 6.8 22.3 25.9 19.4 5.3 3.4 4.7 1.2 100.0 1,014 Bulawayo 9.2 5.1 19.2 30.4 20.5 6.8 3.1 5.9 0.0 100.0 239 Education No education (5.7) (0.0) (2.6) (13.2) (23.4) (0.0) (55.0) (0.0) (0.0) 100.0 28 Primary 0.6 0.4 5.5 15.4 25.3 7.5 43.8 1.2 0.3 100.0 1,037 Secondary 4.5 3.8 12.8 21.8 23.8 2.6 26.9 2.6 1.3 100.0 3,390 More than secondary 54.8 7.9 9.9 12.6 6.0 0.5 4.3 2.0 1.9 100.0 446 Wealth quintile Lowest 0.4 0.6 4.6 14.8 23.7 2.8 51.6 1.2 0.4 100.0 619 Second 2.0 0.8 5.0 15.1 22.4 2.3 51.0 0.8 0.6 100.0 776 Middle 2.7 0.7 8.3 17.7 24.4 3.6 38.7 1.5 2.4 100.0 949 Fourth 9.1 3.7 13.2 21.2 26.3 4.9 18.3 2.9 0.5 100.0 1,258 Highest 18.9 8.0 17.2 24.2 17.1 2.9 6.8 3.4 1.6 100.0 1,299 Total 15-49 8.2 3.4 10.9 19.5 22.5 3.4 28.6 2.2 1.1 100.0 4,901 50-54 9.0 3.8 6.5 21.1 17.0 4.0 32.4 3.8 2.4 100.0 287 Total 15-54 8.3 3.5 10.7 19.6 22.2 3.5 28.8 2.3 1.2 100.0 5,187 Note: Figures in parentheses are based on 25-49 unweighted cases. 3.7 TYPE OF EMPLOYMENT Table 3.7 shows the percent distribution of women employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural). Fifty percent of women engaged in agricultural work and 77 percent of women engaged in nonagricultural work are paid in cash only. Most of the remaining women in both occupational categories receive a combination of cash and in-kind payments; however, 13 percent of women working in agriculture and 3 percent of women in nonagricultural occupations are not paid for their work. Seventy-four percent of women engaged in agricultural work and 53 percent of women engaged in nonagricultural work are self-employed. Regardless of their occupation, most other women work for someone outside the family rather than a family member. Sixty percent of women engaged in agricultural work are seasonally employed, and 60 percent of women engaged in nonagricultural work are employed all year. Characteristics of Respondents • 41 Table 3.7 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Zimbabwe 2010-11 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 49.9 77.1 71.6 Cash and in-kind 35.2 19.5 22.7 In-kind only 2.4 0.9 1.2 Not paid 12.5 2.5 4.6 Total 100.0 100.0 100.0 Type of employer Employed by family member 1.7 3.4 3.1 Employed by nonfamily member 24.7 43.3 39.5 Self-employed 73.7 53.3 57.4 Total 100.0 100.0 100.0 Continuity of employment All year 32.3 60.2 54.4 Seasonal 59.7 22.8 30.3 Occasional 8.0 17.0 15.3 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 818 3,101 3,959 Note: Total includes women with information missing on type of employment. 3.8 HEALTH INSURANCE COVERAGE The 2010-11 ZDHS collected data on respondents’ health insurance coverage (Tables 3.8.1 and 3.8.2). The majority of women (93 percent) and men (91 percent) do not have health insurance. Among women with health insurance, most are covered by social security or other employer plans. Six percent of women have insurance through their employer, less than 1 percent are covered under a privately purchased commercial plan, and the remaining women are covered through some other mechanism. As expected, women who reside in urban areas and women in the highest wealth quintile are most likely to have health insurance. Education is strongly associated with health insurance coverage. Nearly half of women with more than a secondary education have health insurance, compared with 2 percent of women with no education, 1 percent with only a primary education, and 7 percent with only a secondary education. As was the case with women, men are most commonly covered by social security and other employer-based plans; 7 percent of men are covered through their employer, 2 percent are covered under a privately purchased commercial plan, and less than 1 percent are covered through some other mechanism. Again, higher education greatly increases the chance a man will have health insurance coverage. Forty-two percent of men with more than a secondary education have health insurance, compared with 3 percent of men with no education, 1 percent with only a primary education, and 8 percent with only a secondary education. 42 • Characteristics of Respondents Table 3.8.1 Health insurance coverage: Women Percentage of women age 15-49 with specific types of health insurance coverage, according to background characteristics, Zimbabwe 2010-11 Background characteristic Social security Other employer- based insurance Mutual Health Organization/ community- based insurance Privately purchased commercial insurance Other None Number of women Age 15-19 0.6 3.3 0.2 0.4 0.0 95.6 1,945 20-24 0.8 3.6 0.3 0.9 0.1 94.4 1,841 25-29 0.6 5.0 0.8 0.5 0.0 93.2 1,686 30-34 1.3 5.6 0.5 1.8 0.0 91.3 1,296 35-39 1.1 5.3 0.5 1.0 0.0 92.1 1,051 40-44 1.6 7.4 0.5 1.9 0.0 89.1 732 45-49 1.3 8.0 0.5 0.9 0.0 89.3 620 Residence Urban 1.3 9.8 0.9 1.8 0.0 86.5 3,548 Rural 0.7 1.7 0.2 0.4 0.0 97.0 5,623 Province Manicaland 0.7 3.1 0.1 0.6 0.2 95.4 1,227 Mashonaland Central 0.5 4.5 0.3 0.8 0.0 93.8 871 Mashonaland East 0.8 2.7 0.3 0.4 0.0 96.1 824 Mashonaland West 1.1 2.4 0.2 0.4 0.0 96.0 1,026 Matabeleland North 0.2 2.0 0.3 0.5 0.0 97.0 443 Matabeleland South 0.0 2.1 0.0 2.6 0.0 95.4 467 Midlands 0.6 5.9 0.2 0.9 0.0 92.6 1,123 Masvingo 2.0 2.1 0.3 1.2 0.0 94.4 909 Harare 1.0 10.1 1.1 1.4 0.0 86.5 1,722 Bulawayo 1.7 7.6 1.5 0.7 0.0 88.8 558 Education No education 0.5 1.0 0.0 0.0 0.0 98.4 212 Primary 0.3 0.8 0.0 0.1 0.0 98.8 2,568 Secondary 0.8 4.9 0.4 0.8 0.0 93.2 5,966 More than secondary 6.6 30.1 4.5 8.7 0.5 51.1 424 Wealth quintile Lowest 0.0 0.5 0.0 0.0 0.0 99.5 1,546 Second 0.4 0.4 0.0 0.0 0.0 99.1 1,594 Middle 0.4 1.3 0.0 0.2 0.0 98.2 1,681 Fourth 0.7 4.6 0.4 0.8 0.0 93.4 2,073 Highest 2.4 13.7 1.3 2.9 0.1 80.0 2,278 Total 0.9 4.8 0.4 0.9 0.0 93.0 9,171 Characteristics of Respondents • 43 Table 3.8.2 Health insurance coverage: Men Percentage of men age 15-49 with specific types of health insurance coverage, according to background characteristics, Zimbabwe 2010-11 Background characteristic Social security Other employer- based insurance Mutual Health Organization/ community- based insurance Privately purchased commercial insurance Other None Number of men Age 15-19 0.2 2.1 0.4 1.3 0.4 95.8 1,735 20-24 0.5 3.4 0.8 1.5 0.4 93.7 1,372 25-29 1.1 6.5 1.1 2.5 0.0 89.3 1,236 30-34 0.4 7.9 0.8 2.0 0.1 89.1 970 35-39 1.1 7.7 0.7 3.6 0.1 87.1 828 40-44 0.4 10.1 1.0 2.8 0.0 86.0 589 45-49 2.0 11.5 0.7 0.7 0.0 85.7 379 Residence Urban 1.3 10.1 1.5 4.0 0.4 83.3 2,621 Rural 0.3 3.2 0.3 0.8 0.1 95.5 4,488 Province Manicaland 1.5 5.7 0.4 2.0 0.0 91.4 972 Mashonaland Central 0.4 2.8 0.0 1.5 0.4 95.0 738 Mashonaland East 0.1 2.4 0.9 1.0 0.3 95.4 667 Mashonaland West 0.2 3.3 0.2 0.5 0.3 95.7 872 Matabeleland North 0.8 1.8 0.5 1.1 0.0 95.9 349 Matabeleland South 1.4 2.9 0.4 2.7 0.0 92.8 352 Midlands 0.1 9.2 0.8 2.2 0.0 88.0 885 Masvingo 0.3 6.3 0.6 1.1 0.1 91.6 585 Harare 0.9 9.1 1.7 3.3 0.6 84.7 1,307 Bulawayo 1.1 8.3 1.4 5.1 0.0 85.1 382 Education No education 0.0 2.8 0.0 0.0 0.0 97.2 56 Primary 0.1 1.3 0.0 0.0 0.0 98.6 1,508 Secondary 0.5 5.1 0.5 2.0 0.2 92.0 5,027 More than secondary 4.4 24.5 5.1 8.5 1.1 58.1 519 Wealth quintile Lowest 0.1 0.1 0.0 0.0 0.0 99.9 1,074 Second 0.0 1.1 0.2 0.2 0.1 98.4 1,216 Middle 0.1 2.1 0.0 0.4 0.0 97.4 1,371 Fourth 0.7 6.2 0.6 1.8 0.0 91.0 1,664 Highest 1.8 14.6 2.3 6.0 0.7 75.6 1,786 Total 15-49 0.7 5.7 0.7 2.0 0.2 91.0 7,110 50-54 2.0 10.3 0.5 3.4 0.0 84.0 370 Total 15-54 0.7 5.9 0.7 2.1 0.2 90.6 7,480 3.9 USE OF TOBACCO The 2010-11 ZDHS collected information on women’s and men’s tobacco use. Tobacco use has been shown to adversely affect both the health of users and those around them and is considered by the World Health Organization to be the primary cause of preventable deaths worldwide (WHO, 2011). Tables 3.9.1 and 3.9.2 present the percentages of women and men who smoke cigarettes or a pipe or use other tobacco products (e.g., snuff). Table 3.9.2 also includes information obtained from male cigarette smokers on number of cigarettes smoked in the 24 hours before the interview. Almost all women (more than 99 percent) and a large majority of men age 15-49 (78 percent) reported that they do not use tobacco. Given the small number of women who report using tobacco, it is not informative to examine the pattern of tobacco use among women by background characteristics. Among men, tobacco use is lowest among those under age 25. It is somewhat more common among men living in rural areas than among urban residents and more common among men in Mashonaland Central than among men living in other provinces. Tobacco use among men generally decreases with increasing education and wealth status. 44 • Characteristics of Respondents Most of the male respondents who use tobacco products smoke cigarettes. Overall, one in five men smoke cigarettes. Among cigarette users, 8 in 10 smoked at least three cigarettes within 24 hours of prior to the interview, and nearly one-third smoked 10 or more cigarettes during the same period. Table 3.9.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, according to background characteristics and maternity status, Zimbabwe 2010-11 Background characteristic Uses tobacco Does not use tobacco Number of women Cigarettes Pipe Snuff Other tobacco Age 15-19 0.1 0.0 0.1 0.0 99.8 1,945 20-24 0.0 0.0 0.1 0.0 99.9 1,841 25-29 0.3 0.0 0.4 0.0 99.3 1,686 30-34 0.1 0.0 0.3 0.0 99.6 1,296 35-39 0.1 0.0 0.4 0.0 99.5 1,051 40-44 0.3 0.0 0.7 0.1 99.0 732 45-49 0.5 0.2 2.0 0.0 97.7 620 Maternity status Pregnant 0.0 0.0 0.4 0.1 99.5 758 Breastfeeding (not pregnant) 0.1 0.0 0.2 0.0 99.7 1,902 Neither 0.2 0.0 0.4 0.0 99.4 6,511 Residence Urban 0.3 0.0 0.3 0.0 99.4 3,548 Rural 0.1 0.0 0.4 0.0 99.5 5,623 Province Manicaland 0.0 0.0 0.4 0.0 99.6 1,227 Mashonaland Central 0.1 0.0 0.3 0.0 99.6 871 Mashonaland East 0.0 0.0 0.5 0.0 99.5 824 Mashonaland West 0.0 0.0 0.7 0.0 99.3 1,026 Matabeleland North 0.7 0.3 1.1 0.0 98.4 443 Matabeleland South 0.4 0.0 0.8 0.3 98.6 467 Midlands 0.2 0.0 0.0 0.0 99.8 1,123 Masvingo 0.0 0.0 0.1 0.0 99.9 909 Harare 0.2 0.0 0.2 0.1 99.6 1,722 Bulawayo 0.5 0.0 0.2 0.0 99.3 558 Education No education 0.6 0.6 1.9 0.0 97.5 212 Primary 0.2 0.0 0.6 0.1 99.2 2,568 Secondary 0.2 0.0 0.2 0.0 99.6 5,966 More than secondary 0.0 0.0 0.2 0.0 99.8 424 Wealth quintile Lowest 0.2 0.1 0.6 0.0 99.3 1,546 Second 0.0 0.0 0.2 0.0 99.7 1,594 Middle 0.1 0.0 0.4 0.0 99.5 1,681 Fourth 0.2 0.0 0.3 0.0 99.5 2,073 Highest 0.2 0.0 0.3 0.0 99.5 2,278 Total 0.2 0.0 0.4 0.0 99.5 9,171 Characteristics of Respondents • 45 Table 3.9.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Zimbabwe 2010-11 Background characteristic Uses tobacco Does not use tobacco Number of men Percent distribution of men who smoke cigarettes by number of cigarettes in the past 24 hours Total Number of cigarette smokers Cigarettes Pipe Snuff Other tobacco 0 1-2 3-5 6-9 10+ Don't know Age 15-19 3.8 0.1 0.2 1.1 95.5 1,735 9.2 21.4 48.7 6.3 14.4 0.0 100.0 66 20-24 17.6 2.0 0.7 3.2 80.8 1,372 7.5 21.1 31.8 18.7 19.5 1.6 100.0 241 25-29 30.6 1.4 1.3 4.8 67.9 1,236 2.8 17.4 28.5 16.1 34.1 1.0 100.0 378 30-34 28.1 2.4 1.8 3.8 70.4 970 6.6 13.1 28.9 12.5 37.6 1.2 100.0 272 35-39 28.5 1.7 2.4 3.0 69.2 828 2.0 13.1 31.4 19.0 33.8 0.8 100.0 236 40-44 24.2 1.4 3.4 2.5 72.3 589 4.7 11.7 33.5 14.2 35.2 0.7 100.0 143 45-49 32.8 4.9 4.7 2.4 64.7 379 6.2 8.7 25.8 17.9 39.2 2.2 100.0 124 Residence Urban 17.2 0.4 0.8 2.4 81.6 2,621 5.7 13.6 28.1 15.0 37.0 0.5 100.0 452 Rural 22.4 2.2 1.8 3.2 75.6 4,488 4.6 16.2 32.0 16.2 29.7 1.4 100.0 1,007 Province Manicaland 23.2 2.2 1.6 2.9 74.9 972 4.6 19.7 33.2 14.7 27.1 0.8 100.0 225 Mashonaland Central 26.8 5.9 2.8 4.6 69.7 738 2.8 14.7 35.1 17.0 29.9 0.6 100.0 198 Mashonaland East 23.1 1.5 1.0 6.6 75.6 667 0.4 14.2 24.8 20.8 39.3 0.5 100.0 154 Mashonaland West 23.9 0.0 1.1 1.8 74.7 872 3.6 14.5 33.2 14.7 32.4 1.4 100.0 208 Matabeleland North 14.0 0.5 1.5 0.1 85.6 349 8.7 16.3 29.8 18.3 20.1 6.8 100.0 49 Matabeleland South 22.0 1.3 1.4 0.3 77.5 352 6.7 13.4 28.9 22.0 28.5 0.6 100.0 77 Midlands 18.3 0.5 1.7 4.4 79.0 885 6.4 15.6 32.0 12.0 33.4 0.6 100.0 162 Masvingo 17.5 3.0 2.5 0.8 81.2 585 10.5 12.0 30.0 11.8 32.7 3.1 100.0 103 Harare 16.8 0.5 0.7 2.8 82.2 1,307 6.3 15.5 27.1 15.1 36.0 0.0 100.0 219 Bulawayo 16.8 0.2 0.7 1.1 81.9 382 4.9 14.8 29.1 18.1 30.3 2.8 100.0 64 Education No education 21.5 2.5 4.0 1.3 75.2 56 * * * * * * 100.0 12 Primary 27.5 2.7 2.6 4.9 69.5 1,508 3.3 13.7 34.3 17.9 28.9 1.9 100.0 414 Secondary 19.3 1.3 1.1 2.6 79.4 5,027 4.4 16.3 29.1 15.6 34.0 0.7 100.0 971 More than secondary 12.1 0.5 1.3 0.8 86.9 519 19.0 15.1 33.4 8.9 23.7 0.0 100.0 63 Wealth quintile Lowest 26.2 2.8 2.2 4.4 71.1 1,074 5.8 15.1 34.1 14.3 29.0 1.7 100.0 281 Second 21.7 1.8 2.0 4.3 76.1 1,216 4.1 14.5 27.1 20.6 32.7 1.1 100.0 264 Middle 24.3 2.6 1.9 2.6 74.5 1,371 4.2 14.0 32.5 17.6 30.8 0.9 100.0 333 Fourth 19.5 0.8 0.9 2.3 79.2 1,664 6.0 16.7 28.7 14.8 32.2 1.6 100.0 324 Highest 14.4 0.6 0.9 1.9 84.4 1,786 4.4 16.9 31.2 11.7 35.5 0.4 100.0 258 Total 15-49 20.5 1.6 1.5 2.9 77.8 7,110 4.9 15.4 30.8 15.9 31.9 1.1 100.0 1,459 50-54 33.8 3.6 4.0 1.3 63.6 370 0.0 12.6 35.3 15.8 34.4 1.9 100.0 125 Total 15-54 21.2 1.7 1.6 2.8 77.1 7,480 4.5 15.2 31.1 15.9 32.1 1.2 100.0 1,584 Note: An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. Marriage and Sexual Activity • 47 MARRIAGE AND SEXUAL ACTIVITY 4 arriage is a primary indication of the exposure of women to the risk of pregnancy and therefore is important to the understanding of fertility. Populations in which women marry at a young age tend to have high fertility and initiate early childbearing. For this reason, there is an interest in age at marriage. More direct measures of the beginning of exposure to pregnancy are also included in this chapter: age at first intercourse and the frequency of intercourse. 4.1 MARITAL STATUS Table 4.1 presents the percent distribution of women and men by current marital status. The proportion of women who have never married (or lived with a man) declines sharply with age, from 74 percent of women age 15-19 to 2 percent of women age 45-49. Marriage is thus nearly universal in Zimbabwe. Although nearly all men eventually marry, men tend to marry later than women and thus a higher percentage of men than women age 15-49 are not currently married (45 percent versus 24 percent). Six in ten women and five in ten men age 15-49 are currently married or living together with a partner as though married (Married and Living together columns, Table 4.1). Eight percent of women and 3 percent of men age 15-49 are separated or divorced, the same levels seen in the 2005-06 ZDHS. Six percent of women and 1 percent of men age 15-49 are widowed. Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Zimbabwe 2010-11 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed WOMEN 15-19 74.1 21.7 1.5 1.0 1.7 0.0 100.0 23.2 1,945 20-24 25.0 63.1 2.7 3.5 4.9 0.8 100.0 65.7 1,841 25-29 9.5 74.8 4.0 4.2 5.4 2.1 100.0 78.8 1,686 30-34 5.4 75.2 2.8 4.7 5.7 6.1 100.0 78.1 1,296 35-39 2.9 73.4 4.2 5.1 4.1 10.4 100.0 77.6 1,051 40-44 3.6 63.5 3.2 5.2 3.4 21.2 100.0 66.7 732 45-49 1.6 62.6 1.4 4.8 2.9 26.6 100.0 64.0 620 Total 24.0 59.4 2.8 3.7 4.1 6.1 100.0 62.2 9,171 MEN 15-19 98.9 0.9 0.1 0.0 0.1 0.0 100.0 1.0 1,735 20-24 71.2 25.1 1.0 1.2 1.4 0.1 100.0 26.1 1,372 25-29 30.2 63.1 1.6 2.8 2.1 0.2 100.0 64.7 1,236 30-34 10.0 82.0 0.7 3.1 3.5 0.8 100.0 82.6 970 35-39 3.5 88.9 0.6 2.2 2.3 2.5 100.0 89.5 828 40-44 3.6 88.6 0.9 3.0 1.8 2.0 100.0 89.5 589 45-49 1.9 89.5 0.5 1.0 1.6 5.6 100.0 89.9 379 Total 15-49 45.3 49.7 0.8 1.7 1.6 0.9 100.0 50.4 7,110 50-54 1.9 88.1 0.7 1.9 2.7 4.6 100.0 88.8 370 Total 15-54 43.2 51.6 0.7 1.7 1.7 1.1 100.0 52.3 7,480 M Key Findings • Median age at first marriage among women is 19.7 years; median age at first marriage for men is 24.8 years. • The average woman and man in Zimbabwe initiate sexual activity before marriage. The median age at first sexual intercourse is 18.9 years for women and 20.6 years for men. • Eleven percent of currently married women are married to men who are in a polygynous union; 5 percent of currently married men are in a polygynous union. 48 • Marriage and Sexual Activity 4.2 POLYGYNY Polygyny (the practice of having more than one wife) has implications for the frequency of exposure to sexual activity and therefore fertility. The extent of polygyny in Zimbabwe was measured by asking all women currently married or living with a man the question: “Does your husband/partner have other wives, does he live with other women as if married, or does he maintain a small house?” If the answer is yes, the woman is asked: “Including yourself, in total, how many wives or live-in partners does he have?” Currently married men or men living with a woman are asked: “Do you have other wives, or do you live with other women as if married?” If the answer is yes, the man is asked: “Altogether, how many wives or live-in partners do you have?” Table 4.2.1 shows the distribution of currently married women by the number of co-wives, according to selected background characteristics. The majority of married women report their husband or partner has no other wives (84 percent). Eleven percent of women report their husbands have more than one wife, while 5 percent report that they don’t know if their husbands have other wives. These figures are the same as reported in the 2005-06 ZDHS. Table 4.2.1 Number of women's co-wives Percent distribution of currently married women age 15-49 by number of co-wives, according to background characteristics, Zimbabwe 2010-11 Background characteristic Number of co-wives Total Number of women 0 1 2+ Don’t know Age 15-19 90.5 4.7 1.4 3.4 100.0 452 20-24 88.9 5.8 0.9 4.4 100.0 1,210 25-29 84.0 8.6 2.2 5.2 100.0 1,329 30-34 84.5 7.9 2.3 5.4 100.0 1,012 35-39 80.6 11.5 3.6 4.2 100.0 815 40-44 78.3 12.7 5.4 3.6 100.0 488 45-49 76.4 14.7 4.3 4.6 100.0 397 Residence Urban 85.4 6.0 1.1 7.5 100.0 1,937 Rural 83.5 10.2 3.2 3.1 100.0 3,766 Province Manicaland 77.7 12.4 4.1 5.8 100.0 798 Mashonaland Central 80.7 13.6 2.4 3.3 100.0 626 Mashonaland East 88.5 8.9 2.5 0.2 100.0 541 Mashonaland West 86.0 8.6 2.9 2.5 100.0 718 Matabeleland North 75.4 8.4 4.4 11.8 100.0 257 Matabeleland South 80.7 8.2 1.1 10.1 100.0 230 Midlands 88.8 8.1 2.5 0.6 100.0 695 Masvingo 87.5 8.3 2.8 1.4 100.0 626 Harare 85.1 5.1 0.9 8.9 100.0 972 Bulawayo 85.9 3.1 1.1 9.9 100.0 239 Education No education 71.4 12.7 12.1 3.8 100.0 154 Primary 80.9 11.4 3.8 3.9 100.0 1,827 Secondary 86.3 7.4 1.5 4.9 100.0 3,485 More than secondary 86.8 6.2 1.1 5.8 100.0 237 Wealth quintile Lowest 81.2 11.3 4.6 2.9 100.0 1,109 Second 83.6 11.4 2.8 2.3 100.0 1,085 Middle 85.5 8.8 2.7 3.0 100.0 1,077 Fourth 85.1 6.6 1.1 7.2 100.0 1,291 Highest 85.3 6.3 1.4 7.0 100.0 1,141 Total 84.2 8.8 2.5 4.6 100.0 5,703 The proportion of women with co-wives increases with age. The proportions of women who report having no co-wives are lowest in Manicaland, Mashonaland Central, Matabeleland North, and Matabeleland South. Marriage and Sexual Activity • 49 There is an inverse relationship between education and polygyny. Women with no education are least likely to report having no co-wives (71 percent) compared with women who are educated. The difference is especially pronounced when compared with women who have more than secondary education (87 percent). Patterns of polygyny across other background characteristics are less clear because the level of “don’t know” responses also varies across background characteristics. For example, although the percentage of women who report having one or more co-wives decreases with increasing wealth quintile (from 16 to 8 percent), the percentage of women who say they don’t know whether or not their husband has other wives increases with increasing wealth quintile (from 3 to 7 percent). In general though, the pattern does seem to indicate a decreasing level of polygyny with increasing wealth quintile. Though only 5 percent of men age 15-49 report themselves as having more than one wife, as many as 10 percent of men age 50-54 report having more than one wife (Table 4.2.2). Provinces in which 6 percent or more of men age 15-49 report having more than one wife are Matabeleland North, Mashonaland East, Mashonaland Central, and Masvingo. The percentage of men age 15-49 who report being in a polygynous union declines somewhat with increasing education and wealth quintile. Table 4.2.2 Number of men's wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Zimbabwe 2010-11 Background characteristic Number of wives Total Number of men 1 2+ Age 15-19 * * 100.0 17 20-24 94.9 5.1 100.0 358 25-29 96.7 3.3 100.0 800 30-34 94.5 5.5 100.0 802 35-39 95.0 5.0 100.0 740 40-44 95.7 4.3 100.0 528 45-49 95.9 4.1 100.0 341 Residence Urban 97.2 2.8 100.0 1,301 Rural 94.5 5.5 100.0 2,283 Province Manicaland 95.3 4.7 100.0 496 Mashonaland Central 94.0 6.0 100.0 421 Mashonaland East 93.6 6.4 100.0 334 Mashonaland West 95.8 4.2 100.0 468 Matabeleland North 93.2 6.8 100.0 160 Matabeleland South 99.2 0.8 100.0 124 Midlands 95.2 4.8 100.0 450 Masvingo 94.5 5.5 100.0 320 Harare 97.2 2.8 100.0 653 Bulawayo 97.9 2.1 100.0 159 Education No education (94.0) (6.0) 100.0 31 Primary 95.0 5.0 100.0 788 Secondary 95.4 4.6 100.0 2,461 More than secondary 97.6 2.4 100.0 304 Wealth quintile Lowest 93.2 6.8 100.0 637 Second 93.3 6.7 100.0 615 Middle 96.6 3.4 100.0 646 Fourth 96.9 3.1 100.0 857 Highest 96.4 3.6 100.0 829 Total 15-49 95.5 4.5 100.0 3,584 50-54 89.7 10.3 100.0 329 Total 15-54 95.0 5.0 100.0 3,913 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 50 • Marriage and Sexual Activity 4.3 AGE AT FIRST MARRIAGE For most societies, marriage marks the point in a woman’s life when childbearing first becomes socially acceptable. Women who marry early will, on average, have longer exposure to pregnancy and a greater number of lifetime births. Information on age at first marriage was obtained by asking all ever-married respondents the month and year they started living together with their first spouse. Table 4.3 presents the percentages of both women and men who first married by specific exact ages and the median age at first marriage, according to current age. The median age at marriage among women has risen by about one year, from 18.7 years among women age 45-49 to 19.9 years among women age 25-39. The proportion of women married by age 15 declined from 8 percent among those age 40-49 years to 3 percent among women age 15-19 years. Overall, three in ten women age 20-49 married by the time they were 18, and half married by age 20. Table 4.3 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Zimbabwe 2010-11 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 2.8 na na na na 74.1 1,945 a 20-24 3.9 30.5 55.2 na na 25.0 1,841 19.6 25-29 4.9 29.7 50.8 68.8 83.7 9.5 1,686 19.9 30-34 5.1 27.6 50.8 66.1 81.4 5.4 1,296 19.9 35-39 7.3 29.9 50.8 68.8 81.8 2.9 1,051 19.9 40-44 8.1 32.5 54.5 67.2 79.4 3.6 732 19.6 45-49 7.5 40.0 63.8 78.3 90.0 1.6 620 18.7 20-49 5.6 30.7 53.4 na na 10.5 7,226 19.7 25-49 6.1 30.8 52.8 69.0 82.9 5.5 5,385 19.7 MEN 15-19 0.1 na na na na 98.9 1,735 a 20-24 0.3 2.2 9.0 na na 71.2 1,372 a 25-29 0.2 3.7 11.9 28.7 52.7 30.2 1,236 24.6 30-34 0.5 2.8 9.9 24.3 53.2 10.0 970 24.7 35-39 1.0 4.3 9.9 25.5 53.0 3.5 828 24.6 40-44 1.2 4.4 12.6 22.9 45.8 3.6 589 25.4 45-49 0.6 4.7 11.4 23.1 48.2 1.9 379 25.2 20-49 0.5 3.4 10.6 na na 28.0 5,375 a 25-49 0.6 3.8 11.1 25.6 51.5 13.2 4,002 24.8 20-54 0.6 3.5 10.7 na na 26.3 5,745 a 25-54 0.6 3.9 11.3 25.8 51.9 12.2 4,373 24.8 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women or men began living with their spouse or partner for the first time before reaching the beginning of the age group Men tend to enter into marriage at a later age than women. The median age at first marriage among men age 25-49 is 24.8, five years older than women. Only 1 in 10 men age 20-49 marries by age 20, compared with 5 in 10 women in the same age group. Marriage and Sexual Activity • 51 Table 4.4 presents the median age at first marriage among women and men, by background characteristics. Among women age 25-49, median age at marriage is more than one year older among urban women (20.9) than among rural women (19.2). The lowest median age at marriage is observed in Mashonaland Central (18.1 years), while the highest is seen in Bulawayo (21.7 years). Table 4.4 Median age at first marriage by background characteristics Median age at first marriage among women age 20-49 and age 25-49, and median age at first marriage among men age 25-54, according to background characteristics, Zimbabwe 2010-11 Background characteristic Women age Men age 20-49 25-49 25-54 Residence Urban a 20.9 a Rural 19.1 19.2 24.0 Province Manicaland 19.4 19.4 24.7 Mashonaland Central 18.1 18.1 23.0 Mashonaland East 19.2 19.4 a Mashonaland West 18.7 18.8 23.7 Matabeleland North a 20.2 a Matabeleland South a 21.0 a Midlands 19.5 19.6 24.1 Masvingo 19.6 20.1 a Harare a 20.9 a Bulawayo a 21.7 a Education No education 17.8 17.7 24.1 Primary 18.0 18.0 23.5 Secondary a 20.4 24.8 More than secondary a 23.4 a Wealth quintile Lowest 18.5 18.7 23.7 Second 18.8 19.0 23.9 Middle 19.3 19.4 24.7 Fourth 19.9 20.0 24.6 Highest a 21.3 a Total 19.7 19.7 24.8 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50 percent of the respondents began living with their spouses/partners for the first time before reaching the beginning of the age group There is a marked relationship among women’s level of education and median age at marriage. The median age at first marriage among women age 25-49 with no formal education is 17.7 years, and it rises steadily to 23.4 years among those with more than a secondary education. There is a positive correlation between wealth and age at marriage. The median age at marriage among women age 25-49 in the lowest quintile is two and a half years younger than women in the highest wealth quintile (18.7 and 21.3 years of age, respectively). Median age at first marriage among men age 25-54 is 24.8 years, which is five years older than the median age among women age 25-49. Differences in the median age at first marriage among men by background characteristics are not as large as those observed among women. 4.4 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage can be used as a proxy for the beginning of exposure to the risk of pregnancy. However, because some women are sexually active before marriage, the age at which women initiate sexual intercourse more precisely marks the beginning of their exposure to reproductive risks. 52 • Marriage and Sexual Activity The percentages of women and men who had sexual intercourse by specific exact ages are presented in Table 4.5. The median age at first intercourse among women age 25-49 is 18.9 years. Six percent of women age 25-49 have had sexual intercourse by age 15 and 38 percent by age 18. By age 20, about six in ten Zimbabwean women have had sexual intercourse. Table 4.5 Age at first sexual intercourse Percentage of women and men age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had intercourse, and median age at first sexual intercourse, according to current age, Zimbabwe 2010-11 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had sexual intercourse Number Median age at first sexual intercourse 15 18 20 22 25 WOMEN 15-19 3.9 na na na na 66.0 1,945 a 20-24 3.7 38.0 64.2 na na 15.0 1,841 18.9 25-29 5.0 34.6 57.9 74.3 86.1 3.6 1,686 19.3 30-34 3.9 35.8 60.1 75.3 87.0 2.3 1,296 19.1 35-39 6.1 39.3 59.4 75.1 84.3 0.8 1,051 18.9 40-44 7.2 41.2 63.1 75.7 84.5 0.3 732 18.7 45-49 6.8 48.6 73.2 84.4 90.2 0.3 620 18.1 20-49 5.0 38.2 62.0 na na 5.2 7,226 18.9 25-49 5.5 38.3 61.2 76.1 86.2 1.9 5,385 18.9 15-24 3.8 na na na na 41.2 3,786 a MEN 15-19 3.6 na na na na 75.3 1,735 a 20-24 4.2 22.9 48.3 na na 26.9 1,372 a 25-29 2.9 21.5 43.6 62.2 82.7 6.7 1,236 20.6 30-34 2.5 20.4 43.0 61.4 78.0 2.2 970 20.6 35-39 2.0 20.3 42.0 62.3 78.9 0.8 828 20.7 40-44 1.4 18.5 38.6 59.0 74.3 1.1 589 20.9 45-49 2.8 20.1 43.6 64.7 76.7 0.3 379 20.5 20-49 2.9 21.1 43.9 na na 9.1 5,375 a 25-49 2.4 20.4 42.4 61.8 79.0 2.9 4,002 20.6 15-24 3.9 na na na na 53.9 3,107 a 20-54 2.7 20.8 43.6 na na 8.5 5,745 a 25-54 2.3 20.1 42.2 61.7 78.7 2.7 4,373 20.6 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Zimbabwean men exhibit a slightly older median age at first intercourse compared with women. Among men age 25-49, the median age at first intercourse is 20.6 years. Two percent of men age 25-49 have had sexual intercourse by age 15 and 20 percent by age 18. By age 20, about four in ten men have initiated sexual intercourse (42 percent). Table 4.6 presents the median age at first sexual intercourse among women and men, by background characteristics. The most notable pattern is the increasing median age at marriage among women with increasing education. The median age rises steadily, from 17 among women with no education to 22 among women with more than secondary education, an increase of five years of age. Other differentials by background characteristics differ by only a year or two. Marriage and Sexual Activity • 53 Table 4.6 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 20-49 and age 25-49, and median age at first sexual intercourse among men age 25-54, according to background characteristics, Zimbabwe 2010-11 Background characteristic Women age Men age 20-49 25-49 25-54 Residence Urban a 20.0 20.8 Rural 18.3 18.4 20.6 Province Manicaland 18.9 18.9 21.4 Mashonaland Central 17.9 18.0 20.2 Mashonaland East 18.4 18.3 20.5 Mashonaland West 18.5 18.5 20.3 Matabeleland North 18.0 18.0 20.0 Matabeleland South 17.9 17.9 19.1 Midlands 18.9 18.9 20.6 Masvingo 19.0 19.2 21.1 Harare a 20.5 21.2 Bulawayo 19.8 19.7 20.8 Education No education 16.9 16.9 20.8 Primary 17.4 17.4 20.2 Secondary 19.5 19.7 20.8 More than secondary a 22.3 21.5 Wealth quintile Lowest 17.8 17.9 20.3 Second 18.1 18.3 20.6 Middle 18.5 18.5 20.8 Fourth 19.4 19.5 20.8 Highest a 20.3 20.7 Total 18.9 18.9 20.6 a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group 4.5 RECENT SEXUAL ACTIVITY In the absence of effective contraception, the probability of becoming pregnant is highly dependent upon the frequency of intercourse. Information on sexual activity, therefore, can be used to refine measures of exposure to pregnancy. Men and women who have had sex were asked how long ago they most recently had sexual intercourse. Tables 4.7.1 and 4.7.2 show the distribution of women and men by recent sexual activity, by background characteristics. Although about eight in ten women age 15-49 have ever had sexual intercourse (Table 4.7.1), only about five in ten women age 15-49 are currently sexually active – that is, they have had sexual intercourse in the four weeks preceding the survey. Seventeen percent of women had been sexually active within the 12-month period prior to the survey, although not in the month prior to the interview. Thirteen percent of women have had sexual intercourse, but not for one or more years. Eighteen percent of women age 15-49 have never had sexual intercourse. A higher percentage of women between the ages of 25 and 39 is currently sexually active than women of other ages. Women in union are much more likely to report recent sexual activity than women who are divorced, separated, widowed, or never married; three-quarters of currently married women report being recently sexually active. 54 • Marriage and Sexual Activity Table 4.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Zimbabwe 2010-11 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years2 Missing Age 15-19 18.5 11.2 3.6 0.8 66.0 100.0 1,945 20-24 53.5 22.2 8.0 1.2 15.0 100.0 1,841 25-29 64.7 21.5 9.3 0.9 3.6 100.0 1,686 30-34 64.5 17.6 14.7 0.8 2.3 100.0 1,296 35-39 62.1 17.0 18.8 1.4 0.8 100.0 1,051 40-44 54.9 14.2 28.7 1.9 0.3 100.0 732 45-49 47.8 14.5 35.0 2.4 0.3 100.0 620 Marital status Never married 4.7 11.6 6.9 1.3 75.5 100.0 2,197 Married or living together 76.5 16.9 5.6 1.0 0.1 100.0 5,703 Divorced/separated/widowed 12.3 29.4 56.4 2.0 0.0 100.0 1,271 Marital duration3 0-4 years 74.4 20.1 4.1 1.2 0.2 100.0 1,580 5-9 years 79.5 16.1 4.2 0.2 0.0 100.0 1,126 10-14 years 78.3 14.5 6.5 0.6 0.0 100.0 876 15-19 years 77.6 14.3 7.3 0.8 0.0 100.0 597 20-24 years 74.5 15.0 8.7 1.8 0.0 100.0 368 25+ years 71.3 17.0 9.5 2.2 0.0 100.0 383 Married more than once 77.0 16.8 5.2 1.0 0.0 100.0 771 Residence Urban 46.7 15.4 13.8 1.4 22.8 100.0 3,548 Rural 52.8 18.6 12.5 1.1 15.2 100.0 5,623 Province Manicaland 49.8 19.6 12.2 0.6 17.8 100.0 1,227 Mashonaland Central 61.5 15.4 8.9 0.7 13.5 100.0 871 Mashonaland East 53.5 16.8 14.1 0.0 15.6 100.0 824 Mashonaland West 59.3 13.3 10.8 1.3 15.2 100.0 1,026 Matabeleland North 44.1 23.5 14.0 4.9 13.5 100.0 443 Matabeleland South 40.6 25.4 15.6 0.6 17.7 100.0 467 Midlands 51.4 14.7 12.8 1.2 19.9 100.0 1,123 Masvingo 48.8 20.9 13.5 1.1 15.8 100.0 909 Harare 47.3 13.3 15.4 1.4 22.6 100.0 1,722 Bulawayo 37.1 23.9 12.2 1.3 25.4 100.0 558 Education No education 51.6 16.6 25.4 3.9 2.5 100.0 212 Primary 56.3 20.1 14.2 1.3 8.2 100.0 2,568 Secondary 47.9 16.3 11.8 1.0 23.0 100.0 5,966 More than secondary 49.4 16.4 15.5 1.2 17.5 100.0 424 Wealth quintile Lowest 55.6 19.4 12.3 1.4 11.3 100.0 1,546 Second 51.8 20.4 11.9 1.3 14.5 100.0 1,594 Middle 51.5 17.5 14.7 0.8 15.6 100.0 1,681 Fourth 51.8 16.1 13.5 1.1 17.5 100.0 2,073 Highest 43.8 14.9 12.4 1.2 27.7 100.0 2,278 Total 50.4 17.3 13.0 1.2 18.1 100.0 9,171 1 Excludes women who had sexual intercourse within the past 4 weeks 2 Excludes women who had sexual intercourse within the past 4 weeks or within 1 year 3 Excludes women who are not currently married Marriage and Sexual Activity • 55 Table 4.7.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Zimbabwe 2010-11 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the past 4 weeks Within 1 year1 One or more years2 Missing Age 15-19 6.0 10.9 6.9 0.8 75.3 100.0 1,735 20-24 33.6 27.6 11.5 0.4 26.9 100.0 1,372 25-29 66.1 19.1 6.7 1.4 6.7 100.0 1,236 30-34 78.5 13.9 3.9 1.5 2.2 100.0 970 35-39 83.2 11.3 3.6 1.1 0.8 100.0 828 40-44 81.9 12.2 3.6 1.2 1.1 100.0 589 45-49 78.0 13.0 6.9 1.8 0.3 100.0 379 Marital status Never married 10.6 21.1 11.7 0.9 55.6 100.0 3,221 Married or living together 88.7 9.5 0.7 1.0 0.1 100.0 3,584 Divorced/separated/widowed 29.2 44.2 23.9 2.7 0.0 100.0 304 Marital duration3 0-4 years 87.2 11.6 0.3 0.5 0.3 100.0 903 5-9 years 90.7 7.6 0.4 1.3 0.0 100.0 654 10-14 years 90.3 8.1 0.5 1.1 0.0 100.0 535 15-19 years 87.6 9.3 1.1 2.1 0.0 100.0 332 20-24 years 88.7 9.9 0.9 0.4 0.0 100.0 161 25+ years 84.6 10.1 3.7 1.7 0.0 100.0 57 Married more than once 88.6 9.5 1.0 1.0 0.0 100.0 941 Residence Urban 50.0 17.0 7.4 1.7 24.0 100.0 2,621 Rural 51.3 15.8 6.3 0.7 26.0 100.0 4,488 Province Manicaland 51.5 14.8 6.4 0.6 26.8 100.0 972 Mashonaland Central 55.3 15.6 6.7 0.3 22.0 100.0 738 Mashonaland East 48.9 17.8 5.8 0.7 26.9 100.0 667 Mashonaland West 53.6 13.6 5.5 0.9 26.4 100.0 872 Matabeleland North 50.1 17.6 5.1 1.9 25.4 100.0 349 Matabeleland South 44.1 24.7 7.3 1.2 22.7 100.0 352 Midlands 51.1 15.7 6.7 1.0 25.6 100.0 885 Masvingo 53.5 11.5 6.2 1.3 27.5 100.0 585 Harare 51.2 15.5 8.5 0.7 24.1 100.0 1,307 Bulawayo 37.6 27.0 6.9 4.8 23.7 100.0 382 Education No education 49.3 18.2 3.9 0.4 28.3 100.0 56 Primary 52.4 16.9 6.9 0.8 23.0 100.0 1,508 Secondary 49.3 15.8 6.5 1.1 27.3 100.0 5,027 More than secondary 61.0 18.3 7.7 2.1 11.0 100.0 519 Wealth quintile Lowest 60.1 13.4 5.6 0.7 20.2 100.0 1,074 Second 50.7 15.1 5.6 0.5 28.1 100.0 1,216 Middle 47.8 17.1 6.9 0.6 27.6 100.0 1,371 Fourth 50.7 16.1 7.4 1.7 24.1 100.0 1,664 Highest 47.6 18.1 7.3 1.5 25.5 100.0 1,786 Total 15-49 50.8 16.2 6.7 1.1 25.2 100.0 7,110 50-54 78.8 11.7 6.7 2.5 0.2 100.0 370 Total 15-54 52.2 16.0 6.7 1.1 24.0 100.0 7,480 1 Excludes men who had sexual intercourse within the past 4 weeks 2 Excludes men who had sexual intercourse within the past 4 weeks or within 1 year 3 Excludes men who are not currently married Five in ten men age 15-49 report having had sexual intercourse within the four weeks preceding the interview. Sixteen percent of men had been sexually active within the 12-month period prior to the survey, but not in the month prior to the interview, and 7 percent had not been sexually active for one or more years. Twenty-five percent of men age 15-49 have never had sexual intercourse. Two-thirds of men age 25-29 are currently sexually active, similar to levels observed among women. However, among younger ages (15-24) a higher percentage of women are sexually active, as compared with men; among older ages (30-49) a higher percentage of men are sexually active, as compared with women. Never married, and divorced, separated, or widowed men are also more likely than women to report being sexually active. Fertility • 57 FERTILITY 5 n the 2010-2011 ZDHS, data were collected on current and completed fertility. The birth histories of women interviewed in the survey contribute to a description of level and differentials in current fertility. Attention is next focused on trends in fertility, including examination of age-specific fertility rates in periods going back 15 to 20 years. Measures of several proximate determinants of fertility that influence exposure to the risk of pregnancy are also presented: duration of postpartum amenorrhoea, postpartum abstinence, and menopause. The chapter concludes with a presentation of information on age of women at their first birth and patterns of teenage childbearing. The fertility indicators presented in this chapter are based on reports of reproductive histories provided by women age 15-49. As in the previous ZDHS surveys, each woman was asked to provide information on the total number of sons and daughters to whom she had given birth and who were living with her, the number living elsewhere, and the number who had died, in order to obtain the total number of live births. In the birth history, women reported the details of each live birth separately, including such information as name, month, year of birth, sex, and survival status. For children who had died, information on age at death was collected. 5.1 CURRENT FERTILITY Measures of current fertility presented in this chapter include age-specific fertility rates (ASFRs), the total fertility rate (TFR), the general fertility rate (GFR), and the crude birth rate (CBR). These rates are presented for the three-year period preceding the survey, a period covering a portion of the calendar years 2007 through 2011. The three-year period was chosen to calculate rates (rather than a longer or a shorter period) as a balance among providing the most current information, reducing sampling error, and avoiding problems of the displacement of births. Age-specific fertility rates are useful in understanding the age pattern of fertility. Numerators of ASFRs are calculated by identifying live births that occurred in the period 1 to 36 months preceding the survey (determined from the date of interview and date of birth of the child); they are then classified by the age of the mother (in five-year groups) at the time of the child’s birth. The denominators of these rates are the number of woman-years lived by the survey respondents in each of the five-year age groups during the specified period. I Key Findings • The total fertility rate for Zimbabwe is 4.1 children per woman. This represents a small increase since the 2005-06 ZDHS (3.8 children per woman). • Fertility among urban women is markedly lower (3.1 children per woman) than among rural women (4.8 children per woman). • Among women who had a live birth in the three years preceding the survey, the median duration of insusceptibility to pregnancy is 12.7 months. • Twelve percent of women age 30-49 are menopausal. • The median age at first birth among women age 25-49 is 20.2. 58 • Fertility The TFR is a common measure of current fertility and is defined as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the current age-specific fertility rates. The GFR represents the number of live births per 1,000 women of reproductive age. The CBR is the number of live births per 1,000 population. The latter two measures are based on birth history data for the three-year period before the survey and the age-sex distribution of the household population. Table 5.1 shows the age-specific and aggregate fertility measures calculated from the 2010-11 ZDHS. The total fertility rate for Zimbabwe is 4.1 children per woman. Peak childbearing occurs during ages 20-24 and 25-29, then drops sharply after age 39. Fertility among urban women is markedly lower (3.1 children per woman) than among rural women (4.8 children per woman). This pattern of lower fertility in urban areas is evident in every age group. 5.2 FERTILITY BY BACKGROUND CHARACTERISTICS Table 5.2 show differentials in fertility by urban-rural residence, province, level of education, and wealth quintile. The TFR ranges from about three births per woman in the urban provinces of Harare (3.1) and Bulawayo (2.8) to a high of 4.8 births per woman in Manicaland. Educational attainment is closely linked to a woman’s fertility: the TFRs for women with no formal education and women with a primary education are 4.5 and 4.9 children per woman, respectively, while that for women with at least some secondary education is 3.9 children or fewer per woman. Table 5.2 also allows for a general assessment of differential trends in fertility over time among population subgroups. The mean number of children ever born to women age 40-49 years is a measure of past fertility. The mean number of children ever born to older women who are nearing the end of their reproductive period is an indicator of average completed fertility of women who began childbearing during the three decades preceding the survey. If fertility remained constant over time and the reported data on both children ever born and births during the three years preceding the survey are reasonably accurate, the TFR and the mean number of children ever born for women 40-49 Table 5.1 Current fertility Age-specific and total fertility rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Zimbabwe 2010-11 Age group Residence Total Urban Rural 15-19 71 144 115 20-24 167 245 212 25-29 160 217 194 30-34 120 167 149 35-39 79 117 104 40-44 14 46 35 45-49 5 15 12 TFR(15-49) 3.1 4.8 4.1 GFR 115 172 150 CBR 34 34 34 Notes: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women age 15-44 CBR: Crude birth rate, expressed per 1,000 population Table 5.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Zimbabwe 2010-11 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 3.1 7.3 3.5 Rural 4.8 8.9 5.0 Province Manicaland 4.8 8.8 4.9 Mashonaland Central 4.5 9.1 5.0 Mashonaland East 4.5 7.3 4.2 Mashonaland West 4.5 8.5 5.0 Matabeleland North 4.1 7.7 5.2 Matabeleland South 4.2 6.6 4.6 Midlands 4.2 7.6 4.8 Masvingo 4.7 11.1 4.6 Harare 3.1 8.4 3.5 Bulawayo 2.8 4.8 3.2 Education No education 4.5 6.1 5.4 Primary 4.9 9.5 5.2 Secondary 3.9 8.1 3.7 More than secondary 2.5 4.3 2.8 Wealth quintile Lowest 5.3 9.9 5.4 Second 5.1 10.2 5.0 Middle 4.4 9.8 4.9 Fourth 3.8 7.7 3.9 Highest 2.6 5.2 3.5 Total 4.1 8.3 4.5 Note: Total fertility rates are for the period 1-36 months preceding the interview. Fertility • 59 years would be similar. When fertility levels have been falling, the TFR will be substantially lower than the mean number of children ever born among women age 40-49. Overall, a comparison of past (completed) and current (TFR) fertility indicators suggests a decline from 4.5 to 4.1 children per woman. There have been substantial and varied declines in both urban and rural areas, and across province and education categories. The largest declines have occurred among women in urban areas, in Matabeleland North, women with no education, and women in the highest wealth quintile. At the time of the survey, 8 percent of interviewed women reported that they were pregnant. This percentage is an underestimate of the true percentage pregnant because many women at early durations of pregnancy will not yet know for sure that they are pregnant, and some women may not want to declare that they are pregnant. 5.3 FERTILITY TRENDS The data in Table 5.3.1 provide evidence of fluctuations in fertility in Zimbabwe over the past 20 years. The table uses information from the retrospective birth histories obtained from ZDHS respondents to examine trends in age-specific fertility rates for successive five-year periods before the survey. To calculate these rates, births were classified according to the period of time in which the birth occurred and the mother’s age at the time of birth. Because women age 50 and above were not interviewed in the survey, the rates are successively truncated for periods more distant from the survey date. For example, rates cannot be calculated for women age 35-39 for the period 15 to 19 years before the survey because these women would have been over the age of 50 at the time of the survey and were not interviewed. Fertility has fallen among women over age 20 over the past two decades but has increased slightly for those in the 15 to 19 age group. Among women above age 20, substantial declines in age- specific fertility rates were observed from 15 to 19 years before the survey to 0 to 4 years before the survey. Fertility decline is steepest among women age 30-34. It is noteworthy, however, that age- specific fertility rates are higher in the 0 to 4 years before the survey than in the 5 to 9 years before the survey for women who gave birth at ages 15-19, 20-24, and 30-34. Table 5.3.2 and Figure 5.1 show trends in current fertility rates based on successive ZDHS surveys. Overall, fertility declined by 1.4 births between the 1988 and 2010-11 surveys. However, the decline has not been entirely steady; fertility declined between 1988 and 2005-06, from 5.4 children per woman to 3.8 children per woman, but increased in 2010-11 to 4.1 children per woman. Table 5.3.1 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Zimbabwe 2010-11 Mother's age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 112 103 110 108 20-24 201 199 212 216 25-29 179 184 207 197 30-34 144 136 174 [195] 35-39 95 98 [123] 40-44 31 [57] 45-49 [13] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 60 • Fertility Table 5.3.2 Trends in age-specific and total fertility rates Age-specific and total fertility rates (TFR) for the three-year period preceding several surveys, Zimbabwe 1985-2011 Mother’s age at birth 1988 ZDHS1 (1985-1988) 1994 ZDHS (1991-1994) 1999 ZDHS (1996-1999) 2005-06 ZDHS (2002-03 - 2005-06) 2010-11 ZDHS (2007-08-2010-11) 15-19 102 99 112 99 115 20-24 251 210 199 205 212 25-29 250 194 180 172 194 30-34 212 172 135 144 149 35-39 158 117 108 86 104 40-44 80 52 46 42 35 45-49 32 14 15 13 12 TFR 15-49 5.4 4.3 4.0 3.8 4.1 Note: Age-specific fertility rates are per 1,000 women. 1 Fertility rates presented here differ slightly from those published in the 1988 ZDHS report (CSO and IRD, 1989), which were based on the five-year period preceding the survey. Figure 5.1 Trends in Age-specific Fertility Rates ZDHS 2010-11 # # # # # # # ' ' ' ' ' ' ' $ $ $ $ $ $ $ & & & & & & & 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 250 300 Bi rt hs p e r 1 ,0 00 w om en 1988 ZDHS 1994 ZDHS 1999 ZDHS 2005-06 ZDHS 2010-11 ZDHS & $ ' # 5.4 CHILDREN EVER BORN AND LIVING The distribution of women by the number of children ever born is presented in Table 5.4 for all women and for currently married women. The table also shows the mean number of children ever born to women in each five-year age group. These distributions reflect the accumulation of births among ZDHS respondents over the past 30 years and, therefore, their relevance to the current situation is limited. However, the information on children ever born is useful for observing how average family size varies across age groups and for observing the level of primary infertility. On average, women in their early twenties have given birth to about one child, women in their early thirties have had close to three children, and women currently at the end of their childbearing years have had almost five children. Of the 4.9 children ever born to women age 45-49, 4.5 survived to the time of the survey. Fertility • 61 Table 5.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Zimbabwe 2010-11 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 81.4 16.6 1.9 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,945 0.21 0.20 20-24 28.8 38.6 26.2 5.6 0.7 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,841 1.11 1.03 25-29 10.3 23.3 37.0 19.3 7.3 2.2 0.6 0.1 0.0 0.0 0.0 100.0 1,686 2.00 1.86 30-34 5.6 11.5 26.5 28.8 15.8 7.4 3.4 0.8 0.3 0.0 0.0 100.0 1,296 2.79 2.58 35-39 2.9 7.2 16.2 22.6 23.9 14.5 7.0 3.3 1.6 0.4 0.3 100.0 1,051 3.60 3.31 40-44 3.0 5.9 12.6 20.0 21.0 14.3 10.9 6.1 3.2 1.3 1.6 100.0 732 4.09 3.74 45-49 2.2 5.3 7.7 13.3 15.9 16.8 13.6 12.3 6.2 3.6 3.1 100.0 620 4.91 4.46 Total 26.4 18.8 19.6 13.9 9.2 5.4 3.2 1.8 0.9 0.4 0.4 100.0 9,171 2.10 1.93 CURRENTLY MARRIED WOMEN 15-19 40.5 52.0 7.0 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 452 0.67 0.64 20-24 10.7 46.7 34.0 7.7 0.9 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,210 1.41 1.32 25-29 4.4 21.5 40.3 22.0 8.2 2.6 0.8 0.1 0.0 0.0 0.0 100.0 1,329 2.20 2.05 30-34 1.4 8.5 27.1 31.0 18.2 8.5 4.1 1.0 0.4 0.0 0.0 100.0 1,012 3.05 2.84 35-39 1.5 4.0 14.9 22.7 25.4 16.3 8.5 4.0 1.8 0.5 0.4 100.0 815 3.87 3.57 40-44 2.1 3.8 9.7 17.6 22.5 17.6 11.2 7.7 3.8 1.7 2.3 100.0 488 4.46 4.08 45-49 1.8 4.1 5.8 12.3 15.4 16.9 14.3 12.5 7.7 4.7 4.5 100.0 397 5.25 4.78 Total 7.3 21.7 25.3 17.9 12.0 7.1 4.1 2.3 1.2 0.6 0.6 100.0 5,703 2.71 2.50 Results at younger ages for currently married women differ from those for all women because of the large number of unmarried women with minimal fertility. Differences at older ages generally reflect the impact of marital dissolution (either divorce or widowhood). Less than 2 percent of currently married women age 45-49 have never had a child. If the desire for children is universal in Zimbabwe, this percentage represents a rough measure of primary infertility or the inability to bear children. 5.5 BIRTH INTERVALS Information on the length of birth intervals provides insight into birth spacing patterns, which affect fertility as well as infant and child mortality. Research has shown that children born too soon after a previous birth are at increased risk of poor health, particularly when the interval is less than 24 months. Table 5.5 shows the distribution of births in the five years before the survey by the interval since the preceding birth, according to various background and demographic characteristics. The median birth interval in Zimbabwe is 47.1 months. About 9 percent of all children are born after too short an interval (less than 24 months). The median interval is shorter among births to women under age 30 than among births to older mothers. The median birth interval is much lower for births in which a preceding sibling did not survive. This is largely due to replacement fertility, whereby a mother will get pregnant again soon after the death of a child. When the sibling from the preceding birth dies, the median birth interval is more than 20 months shorter than when the sibling from the preceding birth is living (27.5 months and 48.5 months, respectively). The median birth interval in urban areas (52.1 months) is somewhat higher than in rural areas (45.5 months). Of all the provinces, the longest birth interval is observed in Harare (56.6 months) and the shortest in Manicaland (40.7 months). Women with no education and women with more than secondary education have the longest birth interval (59.5 months each). 62 • Fertility Table 5.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Zimbabwe 2010-11 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 (16.5) (18.5) (55.8) (9.2) (0.0) (0.0) 100.0 41 (27.8) 20-29 4.6 6.6 26.4 26.3 18.0 18.2 100.0 1,933 40.7 30-39 2.3 2.8 14.4 18.3 16.6 45.5 100.0 1,552 56.5 40-49 2.4 6.2 12.7 12.2 8.2 58.3 100.0 256 65.3 Sex of preceding birth Male 4.7 4.9 21.0 21.6 16.1 31.7 100.0 1,909 46.7 Female 2.6 5.4 20.7 22.1 17.0 32.2 100.0 1,873 47.6 Survival of preceding birth Living 1.7 4.4 20.4 22.5 17.4 33.6 100.0 3,455 48.5 Dead 24.2 12.7 25.3 15.6 7.5 14.8 100.0 327 27.5 Birth order 2-3 3.4 5.1 20.7 22.2 17.5 31.1 100.0 2,475 47.0 4-6 3.7 4.8 20.8 21.2 15.4 34.1 100.0 1,121 47.8 7+ 6.5 7.4 22.7 21.6 11.5 30.3 100.0 187 44.2 Residence Urban 2.9 5.1 16.4 19.0 15.3 41.4 100.0 1,017 52.1 Rural 3.9 5.2 22.5 22.9 17.0 28.5 100.0 2,765 45.5 Province Manicaland 5.6 5.8 28.1 21.9 15.0 23.5 100.0 582 40.7 Mashonaland Central 2.5 3.0 17.9 27.2 19.5 29.9 100.0 453 47.8 Mashonaland East 2.4 3.0 22.5 16.8 18.4 36.9 100.0 356 51.4 Mashonaland West 6.2 6.8 15.0 22.4 15.0 34.6 100.0 510 47.8 Matabeleland North 3.5 4.4 22.7 21.5 16.7 31.2 100.0 190 47.2 Matabeleland South 2.2 8.2 24.4 21.5 16.1 27.6 100.0 177 42.7 Midlands 2.0 4.6 25.3 25.7 14.5 27.8 100.0 461 44.0 Masvingo 4.9 5.3 20.9 20.6 20.4 27.8 100.0 417 46.8 Harare 2.2 5.8 13.8 18.2 14.3 45.8 100.0 505 56.6 Bulawayo 2.0 5.2 20.4 20.3 18.1 33.9 100.0 132 49.1 Education No education 1.9 2.1 17.2 21.2 9.1 48.5 100.0 88 59.5 Primary 3.9 4.9 23.4 22.5 15.4 29.9 100.0 1,395 45.3 Secondary 3.5 5.5 19.7 21.8 17.8 31.8 100.0 2,197 47.7 More than secondary 5.4 4.5 12.4 16.0 12.6 49.2 100.0 102 59.5 Wealth quintile Lowest 4.1 5.3 24.7 26.6 16.9 22.3 100.0 944 42.1 Second 4.5 5.2 21.8 21.8 14.8 31.8 100.0 852 45.9 Middle 2.6 5.2 22.9 23.5 17.3 28.5 100.0 719 45.9 Fourth 2.8 5.2 18.5 16.9 18.0 38.7 100.0 748 51.1 Highest 4.1 4.6 12.7 18.2 15.7 44.6 100.0 519 54.8 Total 3.7 5.1 20.8 21.9 16.6 31.9 100.0 3,782 47.1 Notes: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Figures in parentheses are based on 25-49 unweighted cases. 5.6 POSTPARTUM AMENORRHOEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhoea refers to the interval between childbirth and the return of menstruation. During this period, the risk of pregnancy is greatly reduced. The duration of this protection from conception until after childbirth depends on the duration and intensity of breastfeeding and the length of time before the resumption of sexual intercourse. Women who gave birth during the three years prior to the survey were asked about their breastfeeding practices, the duration of amenorrhoea, and sexual abstinence. Women are considered insusceptible if they are not exposed to the risk of pregnancy, either because they are amenorrhoeic or are still abstaining from sex after birth. The results are shown in Table 5.6. Fertility • 63 Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrhoeic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Zimbabwe 2010-11 Months since birth Percentage of births for which the mother is: Number of births Amenorrhoeic Abstaining Insusceptible1 < 2 85.5 91.3 98.2 175 2-3 61.4 39.8 71.9 243 4-5 67.5 19.9 71.9 285 6-7 60.2 18.2 66.9 244 8-9 62.9 12.7 66.0 209 10-11 53.7 12.7 56.8 237 12-13 45.3 10.7 49.9 227 14-15 41.2 7.5 44.1 208 16-17 31.2 6.0 34.9 187 18-19 20.2 8.2 26.6 159 20-21 10.2 7.5 17.1 160 22-23 9.9 8.3 17.6 162 24-25 3.9 4.2 8.1 174 26-27 2.6 8.0 9.1 190 28-29 2.5 5.4 7.2 172 30-31 0.0 4.7 4.7 178 32-33 2.3 7.6 9.6 186 34-35 2.0 5.6 6.8 179 Total 34.4 15.9 40.2 3,573 Median 11.6 2.3 12.7 na Mean 11.6 5.9 13.6 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth The period of postpartum amenorrhoea is considerably longer than the period of postpartum abstinence and is therefore the principal determinant of the length of postpartum insusceptibility in Zimbabwe. The median duration of amenorrhoea is 11.6 months, women abstain for a median of 2.3 months, and they are insusceptible to pregnancy for a median of 12.7 months. Almost all women are virtually insusceptible to pregnancy during the first two months after a birth, and both amenorrhoea and abstinence are important factors in their insusceptibility. However, starting from the second month after birth, the contribution of abstinence to the period of insusceptibility is greatly reduced as more women resume sexual relations. At 12 to 13 months after birth, less than half (45 percent) are still amenorrhoeic, while only about one in nine (11 percent) are still abstaining. The proportion of amenorrhoeic women continues to drop sharply, to 20 percent at age 18-19 months postpartum and to 4 percent at 24-25 months postpartum. 5.7 MEDIAN DURATION OF POSTPARTUM INSUSCEPTIBILITY BY BACKGROUND CHARACTERISTICS In the absence of contraception, variations in postpartum amenorrhoea and abstinence are the most important determinants of the interval between births and ultimately the completion of fertility. Table 5.7 shows the median durations of postpartum amenorrhoea, abstinence, and insusceptibility by selected background characteristics. Although the median number of months of postpartum amenorrhoea for women age 30-49 is three months longer than that for women age 15-29 (13.6 months compared with 10.6 months, respectively), postpartum abstinence does not vary by age (2.3 months for both age groups). Postpartum insusceptibility is about three months longer for older women compared with younger women (14.3 and 11.6 months, respectively). Women in rural areas have a longer period of amenorrhoea than in urban areas (12.2 versus 9.3 months), but have a similar period of sexual abstinence to women in urban areas. By province, Bulawayo and Matabeleland South have the shortest duration of postpartum amenorrhoea (4.9 and 7.1 months, respectively), while 64 • Fertility Mashonaland Central and Mashonaland East have the longest periods (15.8 and 14.7 months, respectively). Overall, women in Bulawayo have the shortest insusceptibility (7.2 months), while those in Mashonaland East have the longest (16.5 months). Table 5.7 Median duration of amenorrhoea, postpartum abstinence, and postpartum insusceptibility Median number of months of postpartum amenorrhoea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Postpartum amenorrhoea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 10.6 2.3 11.6 30-49 13.6 2.3 14.3 Residence Urban 9.3 2.2 11.4 Rural 12.2 2.3 13.1 Province Manicaland 10.7 2.6 11.5 Mashonaland Central 15.8 (2.0) 16.1 Mashonaland East 14.7 (2.3) 16.5 Mashonaland West 12.6 (2.1) 13.3 Matabeleland North 13.1 (3.3) 14.3 Matabeleland South 7.1 (3.4) 8.9 Midlands 9.6 2.7 11.2 Masvingo 9.8 2.2 11.0 Harare 11.1 (2.1) 12.2 Bulawayo 4.9 (3.5) 7.2 Education No education * * * Primary 11.2 2.3 12.2 Secondary 11.9 2.2 12.9 More than secondary * * * Wealth quintile Lowest 13.4 2.5 13.8 Second 13.3 2.6 14.1 Middle 11.8 2.3 12.8 Fourth 10.3 2.1 11.7 Highest 6.9 2.2 8.3 Total 11.6 2.3 12.7 Note: Medians are based on the status at the time of the survey (current status). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes births for which mothers are either still amenorrhoeic or still abstaining (or both) following birth Postpartum insusceptibility generally decreases with increasing wealth quintile; the median duration of postpartum insusceptibility is 13.8 months for women in the lowest wealth quintile compared with 8.3 months for women in the highest wealth quintile. This difference is due primarily to differences in postpartum amenorrhoea: women in the lowest quintile resume menstruation more than 6 months later than women in the highest quintile (13.4 months compared with 6.9 months). In contrast, only small differences are reported in median duration of postpartum abstinence. Fertility • 65 5.8 MENOPAUSE Fecundity refers to the ability to have children. The risk of pregnancy declines with age as increasing proportions of women become infecund. Although the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a population. Table 5.8 presents data on menopause, an indicator of decreasing exposure to the risk of pregnancy for women age 30 years and over. Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Zimbabwe 2010-11 Age Percentage menopausal1 Number of women 30-34 3.7 1,296 35-39 7.0 1,051 40-41 11.0 333 42-43 13.9 258 44-45 19.7 257 46-47 31.8 263 48-49 42.6 242 Total 11.6 3,699 1 Percentage of all women who are not pregnant and not postpartum amenorrhoeic whose last menstrual period occurred six or more months preceding the survey The percentage of women who have reached menopause refers to the population of women who are neither pregnant nor postpartum amenorrhoeic and have not had a menstrual period in the six months preceding the survey, or women who report being menopausal. Table 5.8 shows that overall, 12 percent of women age 30-49 are menopausal. The proportion of menopausal women increases with age, from 4 percent among women age 30-34 to 43 percent among women age 48-49. 5.9 AGE AT FIRST BIRTH The age at which childbearing begins has an impact on the health and welfare of a mother and her children. In many countries, the postponement of first births has contributed to an overall fertility decline. Table 5.9 shows the distribution of women by age at first birth, according to their current age. The median age at first birth in Zimbabwe is around 20 for most age groups. Although this broad measure has not changed since the 2005-06 ZDHS, more detailed analysis of trends in age at first birth does reveal a decline in early childbearing. For example, whereas about 24 percent of women age 35-39 had a birth at age 18, only 21 percent of women currently age 20-24 had their first birth at age 18. This slow but steady trend reflects positively on efforts to keep girls and women in school through more advanced levels to improve their social and economic status. 66 • Fertility Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by specific exact ages, percentage who have never given birth, and median age at first birth, according to current age, Zimbabwe 2010-11 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 0.9 na na na na 81.4 1,945 a 20-24 1.2 20.5 48.0 na na 28.8 1,841 a 25-29 1.8 20.8 44.2 65.6 83.2 10.3 1,686 20.5 30-34 1.7 20.1 46.6 66.1 84.0 5.6 1,296 20.3 35-39 4.4 23.5 47.9 67.6 85.1 2.9 1,051 20.2 40-44 3.4 25.0 49.7 68.1 82.9 3.0 732 20.0 45-49 3.1 26.4 58.6 76.2 88.5 2.2 620 19.5 20-49 2.3 21.9 47.9 na na 11.7 7,226 a 25-49 2.6 22.4 47.9 67.7 84.3 5.8 5,385 20.2 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group 5.10 MEDIAN AGE AT FIRST BIRTH BY BACKGROUND CHARACTERISTICS Table 5.10 summarises the median age at first birth for different age cohorts across residential, educational, and wealth status subgroups. For women age 25-49 years, the median age at first birth is higher in urban areas than in rural areas (21.1 compared with 19.7 years). For this same cohort, age at first birth increases markedly with increasing level of education. For example, women with primary education have their first birth five years earlier than women with more than secondary education (18.8 compared with 24.3). Table 5.10 Median age at first birth Median age at first birth among women age 20-49 (25-49) years, according to background characteristics, Zimbabwe 2010-11 Background characteristic Women age Women age 20-49 25-49 Residence Urban a 21.1 Rural 19.7 19.7 Province Manicaland a 20.2 Mashonaland Central 19.2 19.3 Mashonaland East 20.0 20.2 Mashonaland West 19.5 19.6 Matabeleland North 19.6 19.8 Matabeleland South 19.7 19.6 Midlands 19.9 20.1 Masvingo a 20.6 Harare a 21.3 Bulawayo a 21.0 Education No education 18.6 18.6 Primary 18.8 18.8 Secondary a 20.8 More than secondary a 24.3 Wealth quintile Lowest 19.3 19.4 Second 19.5 19.7 Middle 19.8 19.8 Fourth a 20.4 Highest a 21.6 Total a 20.2 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group Fertility • 67 5.11 TEENAGE PREGNANCY AND MOTHERHOOD The issue of adolescent fertility is important on both health and social grounds. Children born to very young mothers are at increased risk of sickness and death. Teenage mothers are more likely to experience adverse pregnancy outcomes and are also more constrained in their ability to pursue educational opportunities than young women who delay childbearing. Table 5.11 shows the percent distribution of women age 15-19 years who have given birth or were pregnant with their first child at the time of the survey, according to selected background characteristics. Overall, 24 percent of women age 15-19 have begun childbearing. The proportion of teenagers who have had a live birth rises rapidly with age, from 3 percent at age 15 to 41 percent at age 19. Rural teenagers, those with less education, and those in the lowest wealth quintile tend to start childbearing earlier than other teenagers. Table 5.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 2.6 1.3 3.9 381 16 6.5 3.4 9.9 420 17 14.1 6.0 20.1 360 18 28.9 7.4 36.4 395 19 41.1 6.7 47.8 389 Residence Urban 12.3 4.1 16.4 745 Rural 22.6 5.4 28.0 1,200 Province Manicaland 22.9 4.0 27.0 263 Mashonaland Central 22.3 8.0 30.3 178 Mashonaland East 19.1 5.9 25.1 160 Mashonaland West 21.5 2.1 23.6 194 Matabeleland North 24.0 7.2 31.1 100 Matabeleland South 19.1 4.0 23.1 127 Midlands 17.7 5.3 23.0 257 Masvingo 17.6 5.7 23.3 188 Harare 14.7 5.6 20.3 338 Bulawayo 9.6 1.4 11.0 141 Education No education * * * 2 Primary 34.2 7.7 41.9 426 Secondary 14.4 4.2 18.6 1,503 More than secondary * * * 14 Wealth quintile Lowest 30.9 5.5 36.4 300 Second 20.1 7.4 27.5 348 Middle 23.0 6.1 29.1 371 Fourth 19.1 4.0 23.1 416 Highest 6.7 2.8 9.6 510 Total 18.6 4.9 23.5 1,945 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Fertility Preferences • 69 FERTILITY PREFERENCES 6 nformation on fertility preferences is of considerable importance to family planning programme planners because it allows an assessment of the need for contraception, whether for spacing or limiting births, and of the extent of unwanted and mistimed pregnancies. Data on fertility preferences can also be useful as an indicator of the direction that future fertility patterns may take. The 2010-11 ZDHS respondents were asked about whether they wanted more children and, if so, how long they would prefer to wait before the next child. They were also asked, if they could start afresh, how many children they would want. 6.1 FERTILITY PREFERENCES BY NUMBER OF LIVING CHILDREN Table 6.1 presents fertility preferences among currently married women and men by number of living children. In classifying people according to their fertility preferences, the desired timing of the next birth is taken into account. Slightly more than half (53 percent) of married women in Zimbabwe would like to have another child. Among the women who do want another child, about one-third want a child within the coming two years, while most (two-thirds) would prefer to wait two or more years before having their next birth. Four in ten married women want no more children. Thus, the majority of women (73 percent) want either to delay their next birth (for two or more years into the future) or end childbearing altogether. As expected, the desire for more children declines noticeably as the number of living children increases. Eight in ten married women with no children want to have a child soon (within two years), while fewer than 1 in 10 women with four or more children want to have another soon. Among women with three or more children, the desire to limit childbearing predominates, with the proportion reporting they do not want another child increasing from 50 percent among women with three children to 85 percent among women with six or more children. The proportion of currently married men who want no more children also increases with the increasing number of children, but is lower than the proportion of women who want no more children at every parity. I Key Findings • Slightly more than half of currently married women (53 percent) and men (63 percent) would like to have another child. • Four in ten currently married women and almost three in ten currently married men want no more children. • The mean ideal number of children for all women is 3.8 and for all men is 4.3. • Overall, 68 percent of all births were wanted at the time of conception, 25 percent were reported as mistimed (wanted later), and 7 percent were unwanted. • The total wanted fertility rate is 3.4 children, compared with the actual fertility rate of 4.1 children. 70 • Fertility Preferences Table 6.1 Fertility preferences by number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Zimbabwe 2010-11 Desire for children Number of living children Total 15-49 Total 15-54 0 1 2 3 4 5 6+ WOMEN1 Have another soon2 82.0 23.5 15.9 12.1 9.4 4.2 3.8 17.9 na Have another later3 4.5 60.1 42.2 27.7 15.1 7.7 3.9 33.4 na Have another, undecided when 1.2 2.0 2.0 1.0 0.8 1.1 0.1 1.4 na Undecided 1.1 4.5 7.0 7.2 6.0 5.3 2.6 5.6 na Want no more 3.2 9.4 31.7 49.5 65.2 78.1 85.2 39.3 na Sterilised4 0.0 0.3 0.3 1.9 2.4 2.6 2.2 1.1 na Declared infecund 8.1 0.2 0.8 0.6 1.1 1.0 2.2 1.1 na Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 na Number of women 288 1,309 1,548 1,093 714 376 375 5,703 na MEN5 Have another6 81.4 88.8 67.1 55.1 39.0 39.7 38.0 62.6 58.9 Undecided 4.1 3.1 7.2 9.0 9.0 7.3 5.9 6.6 6.3 Want no more 9.1 5.8 23.0 32.6 49.2 50.8 54.8 28.0 32.1 Sterilised4 0.2 0.0 0.1 0.0 0.3 0.4 0.0 0.1 0.1 Declared infecund 5.2 2.3 2.6 3.3 2.5 1.9 1.3 2.7 2.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 218 780 910 687 453 255 281 3,584 3,913 na = Not applicable 1 The number of living children includes the current pregnancy. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 5 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). 6 Includes men who want a/another child soon, later, or are undecided as to the timing of a/another child 6.2 DESIRE TO LIMIT CHILDBEARING BY BACKGROUND CHARACTERISTICS Tables 6.2.1 and 6.2.2 present the percentages of currently married women and men who want no more children, by number of living children and selected background characteristics. Overall, four in ten married women want no more children; this is true among both urban and rural women. However, a larger proportion of urban women want no more children at each parity, with the exception of those with no children. For example, 68 percent of urban women with three children say they do not want another child, compared with 44 percent of rural women with three children. The results suggest that urban women are more likely to want to limit their family size at lower parities than rural women. Five in ten married women in Matabeleland South and Bulawayo want no more children. Provinces in which the lowest percentages of married women report wanting no more children are Harare, Mashonaland Central, Masvingo, and Manicaland (36 to 38 percent). The percentage of women wanting no more children generally increases with increasing education once women have two or more children. About half of women with secondary education want no more children by the time they have three children, while half of women with more than secondary education want no more children once they have two children. The percentage of women wanting no more children also increases with increasing wealth quintile among women with two or more children. Fertility Preferences • 71 Table 6.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Zimbabwe 2010-11 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 1.4 12.1 37.1 67.5 80.6 84.7 (100.0) 40.8 Rural 4.3 8.1 28.4 43.6 63.2 79.7 86.1 40.3 Province Manicaland (5.5) 4.6 29.1 45.3 61.6 (79.3) 82.0 37.6 Mashonaland Central (0.0) 9.1 22.6 33.9 66.4 (80.8) (82.0) 36.8 Mashonaland East (5.7) 8.0 37.6 56.2 75.1 (79.3) (90.1) 44.6 Mashonaland West (9.7) 8.8 32.5 49.3 70.1 (86.3) (85.6) 42.8 Matabeleland North * 10.3 32.1 49.1 71.3 (63.8) (92.8) 43.6 Matabeleland South * 22.2 36.5 69.8 70.4 (88.1) (86.0) 52.2 Midlands (3.7) 11.2 32.1 49.7 70.4 (77.0) 89.5 41.7 Masvingo (0.0) 10.4 32.0 44.0 46.9 (84.0) (89.1) 37.1 Harare (1.7) 10.1 30.3 61.8 79.7 * * 36.3 Bulawayo * 11.3 52.1 80.0 (84.8) * * 50.4 Education No education * * * * (71.9) (67.4) (86.8) 60.5 Primary 2.5 13.1 26.2 43.1 61.9 80.6 89.6 46.5 Secondary 2.5 8.3 32.5 53.1 72.4 82.8 82.8 35.8 More than secondary * 13.5 52.3 (89.8) * * * 49.4 Wealth quintile Lowest (2.3) 6.8 22.0 36.6 56.8 67.4 85.9 38.6 Second 1.5 11.8 27.1 40.4 60.4 81.7 85.0 39.5 Middle (5.0) 7.3 32.3 47.7 67.7 77.9 87.0 39.9 Fourth 0.0 11.1 27.2 59.8 79.4 98.4 (92.0) 39.0 Highest 6.9 10.7 47.0 70.1 78.4 (92.7) (100.0) 45.4 Total 3.2 9.7 32.1 51.4 67.6 80.7 87.4 40.5 Notes: Women who have been sterilised are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 The number of living children includes the current pregnancy. Table 6.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Zimbabwe 2010-11 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 12.5 7.8 28.8 39.5 56.7 57.8 (57.8) 29.9 Rural 7.7 4.2 18.6 28.9 46.4 48.6 54.2 27.1 Province Manicaland * 5.0 17.9 26.2 55.2 * (45.1) 26.9 Mashonaland Central * 3.4 16.5 24.3 35.6 (41.2) (50.8) 22.4 Mashonaland East * 3.0 22.6 31.4 (48.8) (55.7) (52.7) 27.6 Mashonaland West * 6.2 20.5 35.2 45.3 (55.6) * 28.9 Matabeleland North (12.9) 10.6 (38.9) (35.6) (36.7) * (41.1) 29.1 Matabeleland South * (22.2) 39.2 (40.3) (52.4) * (69.7) 44.1 Midlands * 1.2 23.2 30.1 (45.9) (58.6) (68.4) 28.9 Masvingo (15.9) 3.9 13.6 (35.8) (62.0) * (35.8) 25.1 Harare * 6.2 27.9 36.7 (50.3) (52.0) * 27.2 Bulawayo * 13.7 36.0 (49.7) (85.2) * * 40.3 Education No education * * * * * * * (28.3) Primary 2.8 3.7 17.3 25.2 35.0 46.8 58.7 26.1 Secondary 11.3 6.3 22.0 32.7 52.6 52.6 52.9 27.6 More than secondary * 6.1 39.4 51.3 (67.0) * * 38.0 Wealth quintile Lowest (5.9) 1.3 15.2 22.5 40.3 31.8 46.8 23.0 Second (6.8) 5.0 14.8 27.6 35.7 (45.0) 53.0 24.8 Middle (16.5) 6.2 18.7 26.4 51.3 (53.0) 59.9 27.1 Fourth 4.8 5.0 27.1 42.2 52.8 70.6 (67.2) 30.3 Highest (14.3) 9.0 31.2 38.9 64.7 (63.5) (57.2) 33.1 Total 15-49 9.4 5.8 23.1 32.6 49.5 51.2 54.8 28.1 50-54 * * * (72.9) 85.9 73.7 76.2 77.0 Total 15-54 11.2 6.0 24.5 34.6 53.9 55.5 61.8 32.2 Notes: Men who have been sterilised or who state in response to the question about desire for children that their wife has been sterilised are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). 72 • Fertility Preferences Table 6.2.2 shows that urban men want no more children in somewhat higher proportions than rural men at each parity. By province, Matabeleland South has the highest proportion of men who want no more children (44 percent), while Mashonaland Central has the lowest percentage (22 percent). For men, as for women, the desire to limit childbearing is positively associated with wealth quintile. About one-third of men in the highest wealth quintile want to limit childbearing after having two children (31 percent) compared with one in seven men (15 percent) in the lowest two quintiles. 6.3 IDEAL NUMBER OF CHILDREN Women and men, regardless of marital status, were asked what number of children they would choose to have if they could start afresh. Respondents who had no children were asked, “If you could choose exactly the number of children to have in your whole life, how many would that be?” For respondents who had children, the question was rephrased as follows: “If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?” Responses to these questions are summarised in Table 6.3 for both women and men age 15-49. The data in the top portion of each panel in Table 6.3 indicate that the vast majority of women and men were able to give a numeric answer to this hypothetical question. Only 1 percent gave a non- numeric answer such as “it is up to God,” “any number,” or “I do not know.” The mean ideal number of children among women is 3.8 and among men is 4.3. In general, men want slightly larger families than women, and the mean ideal number is slightly higher among the currently married population. Overall, 56 percent of women and 60 percent of men want four or more children. When interpreting the findings in Table 6.3, remember that the actual and stated ideal number of children tend to be related. There are several reasons for this. First, to the extent that women are able to implement their fertility desires, women who want large families will achieve large families. Second, because women with large families are, on average, older women, they may prefer a greater number of children because of the attitudes towards childbearing to which they were exposed during the early stages of their reproductive lives. Finally, some women may have difficulty admitting that they would prefer fewer children than they currently have if they could begin childbearing again. Such women are likely to report their actual number as their preferred number. Indeed, women who have fewer children do report a smaller ideal number of children than women with more children. The mean ideal number of children among all women with one child is 3.3, compared with 6.2 among all women with six or more children. The relationship between the actual and ideal number of children is also presented for men in Table 6.3. Men who have fewer children report a smaller ideal number of children than men with more children. For example, the average ideal number of children is 3.6 among all men with one child, compared with 7.8 among men with six or more children. Fertility Preferences • 73 Table 6.3 Ideal number of children by number of living children Percent distribution of women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to the number of living children, Zimbabwe 2010-11 Ideal number of children Number of living children Total 0 1 2 3 4 5 6+ WOMEN1 0 3.1 1.3 1.3 2.0 1.1 0.7 0.7 1.8 1 3.6 4.0 1.7 1.1 0.6 0.3 0.7 2.3 2 34.1 23.4 20.3 11.6 6.1 6.6 2.2 20.2 3 23.8 27.4 18.1 14.8 8.1 5.5 2.2 18.6 4 23.6 28.6 39.9 38.0 33.8 21.3 22.2 30.9 5 6.7 8.7 11.0 19.5 17.2 24.2 13.1 12.0 6+ 4.2 5.9 7.2 12.2 32.3 39.5 55.8 13.3 Non-numeric responses 0.8 0.8 0.4 0.8 0.9 1.7 3.1 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,305 1,836 1,925 1,337 848 468 453 9,171 Mean ideal number of children for:2 All women 3.0 3.3 3.6 4.1 4.8 5.2 6.2 3.8 Number of women 2,285 1,821 1,917 1,326 840 460 439 9,089 Currently married women 3.6 3.4 3.6 4.1 4.8 5.2 6.1 4.1 Number of currently married women 287 1,301 1,544 1,085 707 370 361 5,656 MEN3 0 1.1 0.1 0.2 0.1 0.7 0.8 0.1 0.7 1 2.3 1.7 1.8 1.0 0.1 0.0 1.6 1.8 2 17.3 14.6 14.3 3.1 3.2 2.3 1.5 13.0 3 26.8 34.9 21.0 17.2 7.6 4.9 3.4 23.0 4 25.2 28.7 33.8 33.0 33.8 13.7 11.6 27.2 5 14.2 12.9 19.3 27.7 22.1 27.1 11.6 17.0 6+ 11.7 6.5 8.8 17.2 32.2 49.0 68.4 16.2 Non-numeric responses 1.3 0.6 0.8 0.7 0.3 2.2 1.9 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 3,458 928 986 720 473 260 284 7,110 Mean ideal number of children for men 15-49:2 All men 3.8 3.6 4.0 4.6 5.2 6.2 7.8 4.3 Number of men 3,412 923 978 715 472 255 278 7,033 Currently married men 4.1 3.6 3.9 4.6 5.2 6.2 7.8 4.6 Number of currently married men 217 777 902 682 451 249 276 3,555 Mean ideal number of children for men 15-54:2 All men 3.8 3.6 4.0 4.6 5.2 6.1 8.2 4.4 Number of men 3,427 932 1,007 758 539 319 413 7,395 Currently married men 4.2 3.6 3.9 4.6 5.2 6.1 8.2 4.8 Number of currently married men 225 782 922 719 513 311 405 3,876 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent's wife is pregnant (or if any wife is pregnant for men with more than one current wife). 6.4 MEAN IDEAL NUMBER OF CHILDREN BY BACKGROUND CHARACTERISTICS Table 6.4 shows the mean ideal number of children among all women age 15-49, by background characteristics. The mean ideal number of children increases steadily with age, from 3.1 among women age 15-19 to 5.4 among women age 45-49. Women in rural areas have higher family size norms than those in urban areas (4.1 and 3.3 children, respectively). This is further reflected in the fact that women in Harare and Bulawayo have the smallest ideal family size norms (3.3 and 3.1 children, respectively). The ideal number of children among women in the remaining provinces ranges from 3.5 to 4.3 children. 74 • Fertility Preferences Table 6.4 Mean ideal number of children by background characteristics Mean ideal number of children for all women age 15-49 by background characteristics, Zimbabwe 2010-11 Background characteristic Mean Number of women1 Age 15-19 3.1 1,925 20-24 3.4 1,833 25-29 3.6 1,678 30-34 3.9 1,280 35-39 4.4 1,043 40-44 4.8 721 45-49 5.4 609 Residence Urban 3.3 3,528 Rural 4.1 5,561 Province Manicaland 4.3 1,217 Mashonaland Central 4.3 855 Mashonaland East 3.9 821 Mashonaland West 3.8 1,016 Matabeleland North 3.7 423 Matabeleland South 3.5 465 Midlands 3.7 1,121 Masvingo 4.1 907 Harare 3.3 1,715 Bulawayo 3.1 550 Education No education 5.6 205 Primary 4.5 2,531 Secondary 3.5 5,930 More than secondary 3.2 423 Wealth quintile Lowest 4.4 1,513 Second 4.2 1,581 Middle 4.0 1,669 Fourth 3.4 2,057 Highest 3.3 2,267 Total 3.8 9,089 1 Number of women who gave a numeric response The mean ideal number of children declines steadily with increasing education, by more than two children, and also declines with increasing wealth quintile, by about one child. 6.5 FERTILITY PLANNING STATUS The issue of unplanned and unwanted fertility was investigated in the 2010-11 ZDHS by asking women who had births during the five years before the survey whether the births were wanted at the time (planned), wanted at a later time (mistimed), or not wanted at all (unwanted). The responses to those questions provide a measure of the degree to which Zimbabwean couples have been successful in controlling childbearing. In addition, the information can be used to estimate the effect on fertility if unwanted pregnancies had been prevented. The questions on the planning status of recent births required the female respondent to recall accurately her wishes at one or more points in the past five years and report them honestly. These questions are subject to recall and accuracy bias in remembering how she felt about a particular pregnancy. She also may not be willing to admit that she had not wanted a child at its conception. Conversely, if the child has become an economic or health burden, she may now claim that it was unwanted. Despite these potential problems of comprehension, recall, and truthfulness, results from previous surveys have yielded plausible responses, with the most probable effect of biases in the answers being net underestimation of the level of unwanted fertility. Fertility Preferences • 75 Table 6.5 shows the distribution of births in the five years before the survey by whether a birth was wanted then, wanted later, or not wanted. Overall, 68 percent of all births were wanted at the time of conception, 25 percent were reported as mistimed (wanted later), and 7 percent were unwanted. The proportion of unwanted births is greater for births that are fourth order or more (18 percent) than for first births (1 percent). Similarly, a much larger proportion of births to older women are unwanted than are those to younger women. Whereas about 2 percent of births to women age 20-24 are unwanted, 34 percent of births to women age 40-44 are unwanted. Table 6.5 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother's age at birth, Zimbabwe 2010-11 Birth order and mother's age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Birth order 1 73.0 26.0 0.9 100.0 1,995 2 70.3 26.6 3.1 100.0 1,706 3 66.8 25.0 8.3 100.0 1,149 4+ 59.1 22.3 18.4 100.0 1,503 Mother's age at birth <20 66.3 32.6 1.1 100.0 1,199 20-24 69.8 27.7 2.4 100.0 2,003 25-29 71.5 23.4 5.0 100.0 1,543 30-34 68.7 18.9 12.1 100.0 976 35-39 56.1 18.3 25.7 100.0 486 40-44 55.3 10.8 34.0 100.0 121 45-49 * * * 100.0 25 Total 67.9 25.1 7.0 100.0 6,353 Note: Total includes women with missing information on planning status of birth. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 6.6 WANTED FERTILITY RATES Responses to the question on the ideal number of children are used to calculate a total “wanted” fertility rate. This measure is calculated in the same manner as the conventional total fertility rate, except that unwanted births are excluded from the numerator. A birth is considered wanted if the number of living children at the time of conception is less than the ideal number of children currently reported by the respondent. Wanted fertility rates express the level of fertility that theoretically would result if all unwanted births were prevented. Comparison of the actual fertility rate with the wanted rate indicates the potential demographic impact of eliminating unwanted births. Table 6.6 shows that the wanted fertility rate is 3.4 children, compared with the actual fertility rate of 4.1 children (rates calculated over the three years prior to the survey). In other words, Zimbabwean women are currently having an average of 0.7 children more than they actually want. The table also shows that regardless of place of residence, level of education, and wealth quintile, the wanted fertility rate is lower than the actual total fertility rate. Women in Matabeleland North and Matabeleland South have the largest gap between their actual and wanted fertility, which is slightly more than one child. Women in these provinces would have an average of three rather than four children if unwanted births were prevented. Women with higher levels of education as well as those in the highest wealth quintile seem to be the most successful in achieving their fertility goals; that is, the gap between wanted and actual fertility narrows as education and wealth quintile increase. 76 • Fertility Preferences Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 2.7 3.1 Rural 4.0 4.8 Province Manicaland 4.2 4.8 Mashonaland Central 4.1 4.5 Mashonaland East 3.8 4.5 Mashonaland West 3.6 4.5 Matabeleland North 2.9 4.1 Matabeleland South 3.1 4.2 Midlands 3.4 4.2 Masvingo 4.0 4.7 Harare 2.7 3.1 Bulawayo 2.2 2.8 Education No education 3.7 4.5 Primary 4.0 4.9 Secondary 3.4 3.9 More than secondary 2.0 2.5 Wealth quintile Lowest 4.3 5.3 Second 4.3 5.1 Middle 3.8 4.4 Fourth 3.3 3.8 Highest 2.3 2.6 Total 3.4 4.1 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 5.2. Family Planning • 77 FAMILY PLANNING 7 amily planning refers to a conscious effort by a couple to limit or space the number of children they want to have through the use of contraceptive methods. This chapter presents results from the 2010-11 ZDHS on a number of aspects of contraception: knowledge of specific contraceptive methods, attitudes and behaviour towards contraceptive use, current use, and source of current contraceptive methods. This chapter focuses on women who are sexually active because these women have the greatest risk of exposure to pregnancy and need for regulating their fertility. The results of interviews with men are presented alongside those with women because men play an equally important role in the realisation of reproductive health and family planning decision behaviour. 7.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Information on the knowledge of contraceptive methods was collected by asking respondents if they had heard of various methods that a couple can use to delay or avoid a pregnancy. Specifically, the interviewer named a method, described it, and asked whether the respondent had heard of it. In all, the interviewer asked about twelve different contraceptive methods. Provision was also made in the questionnaire to record any other methods the respondent had heard of but was not asked about by the interviewer. Contraceptive methods are classified into two broad categories, namely modern methods and traditional methods. Modern methods include female sterilisation, male sterilisation, the pill, the intrauterine device (IUD), injectables, implants, the male condom, the female condom, lactational amenorrhoea method (LAM), and emergency contraception. Traditional methods include rhythm (periodic abstinence), withdrawal, and various folk methods such as strings and herbs. Table 7.1 shows that knowledge of contraceptive methods is almost universal in Zimbabwe, with 98 percent of all women and 99 percent of all men knowing at least one method of contraception. F Key Findings • Knowledge of contraception is nearly universal in Zimbabwe; 98 percent of women and 99 percent of men report knowing about a contraceptive method. • Fifty-nine percent of currently married women use a contraceptive method, and 57 percent report using a modern method. This represents a small decline relative to the 2005-06 ZDHS in which corresponding values were 60 percent and 58 percent, respectively. • The most popular contraceptive method is the pill, currently in use by 41 percent of currently married women. • Government-sponsored facilities remain the chief providers of contraceptive methods in Zimbabwe; 73 percent of users of modern contraceptive methods obtain them from the public sector. • The unmet need for family planning, currently 13 percent among married women, has remained unchanged since 2005-06. If all married women with an unmet need for family planning were to use a contraceptive method, the prevalence rate in Zimbabwe would increase from 59 to 74 percent. • Reducing discontinuation of a contraceptive is important to addressing unmet need. Discontinuations occur most often because of method failure (12 percent) or method- related side effects or health concerns (17 percent). 78 • Family Planning Modern methods are more widely known than traditional methods; 98 percent of all women know of a modern method while 60 percent know of a traditional method. Similarly, 99 percent of all men know of a modern method while 72 percent know of a traditional method. Table 7.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who have heard of any contraceptive method, by specific method, Zimbabwe 2010-11 Method Women Men All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 97.8 99.1 99.8 98.9 99.9 99.2 Any modern method 97.8 99.1 99.8 98.9 99.9 99.2 Female sterilisation 43.6 45.9 46.9 50.8 58.0 49.5 Male sterilisation 26.7 28.4 32.0 41.2 45.4 40.4 Pill 94.7 98.1 98.5 91.6 97.5 94.0 IUD 61.0 66.9 73.5 44.1 55.6 39.3 Injectables 90.2 95.9 96.2 81.0 94.2 80.7 Implants 67.0 73.7 83.4 36.1 46.9 37.5 Male condom 93.9 95.8 98.7 97.9 99.3 98.9 Female condom 83.9 86.9 95.0 87.3 93.1 90.8 Lactational amenorrhoea (LAM) 12.0 13.9 13.9 10.0 13.4 8.3 Emergency contraception 19.6 20.1 30.9 29.3 33.3 39.3 Any traditional method 60.1 68.2 72.6 71.7 81.8 75.4 Rhythm 28.7 30.4 37.8 48.5 57.9 49.5 Withdrawal 55.2 64.1 67.6 65.5 75.5 69.7 Other 2.5 2.9 4.4 2.4 2.8 2.6 Mean number of methods known by respondents 15-49 6.8 7.2 7.8 6.9 7.7 7.0 Number of respondents 9,171 5,703 266 7,110 3,584 437 Mean number of methods known by respondents 15-54 na na na 6.9 7.7 7.0 Number of respondents na na na 7,480 3,913 442 na = Not applicable 1 Had last sexual intercourse within 30 days preceding the survey Women in Zimbabwe have heard of an average of seven contraceptive methods, a figure identical to that reported in the 2005-06 ZDHS. The pill, injectables, and male condoms are the contraceptive methods most widely known by women in Zimbabwe. Among all women age 15-49, 95 percent have heard of the pill, 94 percent have heard of the male condom, and 90 percent have heard of injectables. These figures also are identical to those reported in the 2005-06 ZDHS. However, knowledge of the female condom and implants has increased markedly since 2005-06: 69 percent of all women knew of the female condom in 2005-06 compared with 84 percent in 2010-11; 44 percent of all women knew of implants in 2005-06 compared with 67 percent in 2010-11. The most well-known methods of contraception among all men age 15-49 are the male condom (98 percent) and the pill (92 percent). Knowledge of other modern methods of contraception is high among men, particularly among men who are currently married. For example, 94 and 93 percent of currently married men have heard of injectables and the female condom, respectively. The lactational amenorrhoea method (LAM) is the least-known modern contraceptive method among currently married men (13 percent) and currently married women (14 percent). Knowledge of at least one contraceptive method among currently married women and men does not significantly vary across subgroups (data not shown). For all age groups of currently married women and men, the percentage who know at least one modern family planning method is or is nearly 100 percent (data not shown). Family Planning • 79 7.2 CURRENT USE OF CONTRACEPTION This section presents information on the prevalence of contraceptive use among women in Zimbabwe at the time of the survey. These results provide insight into one of the principal determinants of fertility, which also serves to assess the success of family planning programmes. Contraceptive use among all women, currently married women, and sexually active unmarried women is presented in Table 7.2. The contraceptive prevalence rate (CPR), or the percentage of currently married women who are using a contraceptive method in Zimbabwe, is 59 percent, while the CPR for modern contraceptive methods in the country is 57 percent. Among currently married women, the contraceptive method most commonly used is the pill (41 percent). The other modern methods that are used by currently married women are injectables (8 percent), male condoms (3 percent), implants (3 percent), female sterilisation (1 percent), female condom (less than 1 percent), IUD (less than 1 percent), and LAM (less than 1 percent). The use of modern contraceptive methods among currently married women increases with age, from 35 percent of women age 15-19 to 63 percent of women age 30-34, after which it falls to 41 percent of women age 45-49. An increase in the use of the pill is also evident in the younger age groups, from 30 percent of married women age 15-19 to 49 percent in the age group 20-24. The pattern of distribution of current use of modern contraceptives is similar to that observed in 2005-06, except that, in the 2010-11 ZDHS, contraceptive use rates among currently married women are slightly lower. A comparison between use rates in 2005-06 and 2010-11 shows increases in current use of any modern contraceptive method among currently married women age 40-49 but decreases in all other age groups. The only modern methods for which use increased were implants and male condoms, both of which increased from 1 percent in 2005-06 to 3 percent in the 2010-11 ZDHS. The overall level of use of modern family planning methods is higher for sexually active unmarried women (62 percent) than for currently married women (57 percent). The most striking differences are that, while 30 percent of sexually active unmarried women use male condoms, only 3 percent of currently married women use them, and 18 percent of sexually active unmarried women use the pill versus 41 percent of currently married women. Similar differences in modern contraceptive use between currently married women and sexually active unmarried women were observed in the 2005-06 ZDHS. 80 • F am ily P la nn in g Ta bl e 7. 2 C ur re nt u se o f c on tra ce pt io n by a ge P er ce nt d is tri bu tio n of a ll w om en , c ur re nt ly m ar rie d w om en , a nd s ex ua lly a ct iv e un m ar rie d w om en a ge 1 5- 49 , b y co nt ra ce pt iv e m et ho d cu rr en tly u se d, a cc or di ng to a ge , Z im ba bw e 20 10 -1 1 A ge A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tra di tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en Fe m al e st er ilis at io n P ill IU D In je ct ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M R hy th m W ith dr aw al O th er A LL W O M E N 15 -1 9 10 .3 10 .1 0. 0 7. 4 0. 0 1. 2 0. 2 1. 0 0. 0 0. 2 0. 2 0. 0 0. 2 0. 0 89 .7 10 0. 0 1, 94 5 20 -2 4 45 .0 44 .2 0. 0 33 .5 0. 0 6. 1 1. 5 2. 7 0. 1 0. 2 0. 7 0. 0 0. 7 0. 0 55 .0 10 0. 0 1, 84 1 25 -2 9 55 .9 54 .8 0. 1 39 .3 0. 0 7. 7 3. 6 3. 5 0. 4 0. 1 1. 1 0. 1 0. 8 0. 2 44 .1 10 0. 0 1, 68 6 30 -3 4 55 .6 54 .9 0. 3 36 .0 0. 4 9. 0 4. 0 4. 8 0. 2 0. 1 0. 7 0. 1 0. 5 0. 1 44 .4 10 0. 0 1, 29 6 35 -3 9 52 .8 52 .0 1. 1 33 .3 0. 4 8. 2 2. 4 5. 8 0. 6 0. 1 0. 8 0. 0 0. 7 0. 1 47 .2 10 0. 0 1, 05 1 40 -4 4 46 .3 45 .2 3. 6 23 .9 0. 0 8. 7 3. 3 4. 9 0. 8 0. 0 1. 2 0. 2 0. 6 0. 4 53 .7 10 0. 0 73 2 45 -4 9 33 .0 31 .1 6. 0 14 .7 0. 4 4. 0 1. 2 4. 5 0. 3 0. 0 1. 9 0. 1 1. 6 0. 2 67 .0 10 0. 0 62 0 To ta l 41 .3 40 .5 0. 9 27 .3 0. 2 6. 1 2. 2 3. 5 0. 3 0. 1 0. 8 0. 1 0. 6 0. 1 58 .7 10 0. 0 9, 17 1 C U R R EN TL Y M AR R IE D W O M EN 15 -1 9 36 .2 35 .4 0. 0 29 .9 0. 0 3. 5 0. 3 0. 9 0. 0 0. 8 0. 8 0. 0 0. 8 0. 0 63 .8 10 0. 0 45 2 20 -2 4 60 .2 59 .0 0. 0 48 .6 0. 1 7. 4 1. 3 1. 2 0. 1 0. 3 1. 1 0. 0 1. 1 0. 0 39 .8 10 0. 0 1, 21 0 25 -2 9 63 .4 62 .0 0. 1 46 .8 0. 0 8. 8 3. 8 2. 2 0. 2 0. 1 1. 4 0. 1 1. 0 0. 3 36 .6 10 0. 0 1, 32 9 30 -3 4 63 .9 63 .0 0. 4 43 .1 0. 6 10 .1 4. 6 3. 9 0. 2 0. 1 0. 9 0. 1 0. 7 0. 1 36 .1 10 0. 0 1, 01 2 35 -3 9 60 .3 59 .3 1. 1 40 .8 0. 3 8. 9 2. 2 5. 5 0. 5 0. 1 1. 0 0. 0 0. 9 0. 1 39 .7 10 0. 0 81 5 40 -4 4 59 .5 57 .9 3. 9 32 .4 0. 0 11 .4 3. 8 5. 3 1. 1 0. 0 1. 5 0. 2 0. 9 0. 4 40 .5 10 0. 0 48 8 45 -4 9 44 .2 41 .2 7. 9 21 .3 0. 1 5. 4 1. 6 4. 4 0. 5 0. 0 3. 0 0. 2 2. 4 0. 4 55 .8 10 0. 0 39 7 To ta l 58 .5 57 .3 1. 1 41 .3 0. 2 8. 3 2. 7 3. 1 0. 3 0. 2 1. 3 0. 1 1. 0 0. 2 41 .5 10 0. 0 5, 70 3 S EX U A LL Y A C TI VE U N M A R R IE D W O M E N 1 15 -1 9 (3 5. 1) (3 5. 1) (0 .0 ) (2 .0 ) (0 .0 ) (1 .9 ) (0 .0 ) (3 1. 2) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (6 4. 9) 10 0. 0 29 20 -2 4 57 .7 57 .7 0. 0 13 .6 0. 0 10 .2 4. 4 29 .4 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 42 .3 10 0. 0 61 25 + 67 .4 67 .1 0. 6 22 .0 0. 0 10 .3 2. 5 30 .6 1. 2 0. 0 0. 3 0. 0 0. 3 0. 0 32 .6 10 0. 0 17 7 To ta l 61 .7 61 .5 0. 4 18 .0 0. 0 9. 4 2. 7 30 .4 0. 8 0. 0 0. 2 0. 0 0. 2 0. 0 38 .3 10 0. 0 26 6 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. U se rs o f d ia ph ra gm a re in cl ud ed in a ny m od er n an d in a ny m et ho d, b ut a re to o fe w in n um be r to b e sh ow n se pa ra te ly . F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. LA M = L ac ta tio na l a m en or rh oe a m et ho d 1 W om en w ho h av e ha d se xu al in te rc ou rs e w ith in 3 0 da ys p re ce di ng th e su rv ey 80 • Family Planning Family Planning • 81 7. 3 CURRENT USE OF CONTRACEPTION BY BACKGROUND CHARACTERISTICS Table 7.3.1 presents information on current use of contraceptives among currently married women age 15-49 by background characteristics. Current use of contraception varies by number of living children, residence, province, education, and wealth quintile. Few married women without children use any contraceptive method (6 percent), but well over half with one or more children use contraception. Contraceptive use rises with an increase in the number of living children up to three or four and declines thereafter. Women in rural areas are less likely to use contraceptive methods than their counterparts in urban areas (57 percent compared with 62 percent). This trend is observed across all modern methods of contraception except injectables. Use of contraceptive methods is highest in the provinces of Mashonaland Central (64 percent) and Mashonaland East (63 percent). Matabeleland South has the lowest contraceptive prevalence rate among currently married women (46 percent). Contraceptive use is positively associated with women’s level of education. Although 43 percent of currently married women with no education use contraceptives, 67 percent of those with more than secondary education use contraceptives. Similarly, women in the two lowest wealth quintile (54 percent) are less likely to use contraceptives compared with women in the highest wealth quintile (65 percent). 82 • F am ily P la nn in g Ta bl e 7. 3. 1 C ur re nt u se o f c on tra ce pt io n by b ac kg ro un d ch ar ac te ris tic s P er ce nt d is tri bu tio n of c ur re nt ly m ar rie d w om en a ge 1 5- 49 b y co nt ra ce pt iv e m et ho d cu rre nt ly u se d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, Z im ba bw e 20 10 -1 1 B ac kg ro un d ch ar ac te ris tic A ny m et ho d A ny m od er n m et ho d M od er n m et ho d A ny tra di tio na l m et ho d Tr ad iti on al m et ho d N ot cu rr en tly us in g To ta l N um be r of w om en Fe m al e st er ili sa tio n P ill IU D In je ct ab le s Im pl an ts M al e co nd om Fe m al e co nd om LA M R hy th m W ith dr aw al O th er N um be r o f l iv in g ch ild re n 0 5. 6 5. 3 0. 0 2. 4 0. 0 0. 2 0. 2 2. 1 0. 4 0. 0 0. 4 0. 0 0. 4 0. 0 94 .4 10 0. 0 46 8 1- 2 62 .6 61 .8 0. 3 47 .9 0. 2 7. 9 2. 5 2. 6 0. 2 0. 2 0. 8 0. 1 0. 7 0. 0 37 .4 10 0. 0 2, 84 0 3- 4 67 .7 65 .8 2. 2 45 .0 0. 3 10 .3 3. 6 3. 9 0. 3 0. 2 1. 9 0. 0 1. 6 0. 3 32 .3 10 0. 0 1, 68 6 5+ 55 .3 53 .1 2. 6 31 .8 0. 1 10 .9 3. 2 3. 7 0. 6 0. 1 2. 2 0. 3 1. 4 0. 6 44 .7 10 0. 0 70 8 R es id en ce U rb an 61 .5 60 .4 1. 5 42 .9 0. 3 6. 8 4. 0 4. 2 0. 4 0. 2 1. 1 0. 2 0. 9 0. 1 38 .5 10 0. 0 1, 93 7 R ur al 57 .0 55 .7 0. 9 40 .5 0. 1 9. 1 2. 1 2. 5 0. 2 0. 2 1. 3 0. 1 1. 1 0. 2 43 .0 10 0. 0 3, 76 6 Pr ov in ce M an ic al an d 56 .2 54 .5 1. 3 35 .8 0. 1 10 .8 1. 4 3. 9 0. 5 0. 6 1. 6 0. 1 1. 3 0. 2 43 .8 10 0. 0 79 8 M as ho na la nd C en tra l 63 .8 61 .6 1. 3 49 .9 0. 1 5. 9 1. 1 2. 9 0. 4 0. 0 2. 2 0. 0 1. 8 0. 4 36 .2 10 0. 0 62 6 M as ho na la nd E as t 62 .5 60 .8 1. 0 43 .4 0. 3 9. 4 3. 1 2. 9 0. 5 0. 3 1. 7 0. 0 1. 7 0. 0 37 .5 10 0. 0 54 1 M as ho na la nd W es t 62 .1 61 .2 0. 3 46 .0 0. 1 9. 0 2. 2 3. 3 0. 3 0. 0 0. 9 0. 3 0. 7 0. 0 37 .9 10 0. 0 71 8 M at ab el el an d N or th 50 .8 49 .3 0. 7 27 .6 0. 8 12 .2 6. 5 1. 6 0. 0 0. 0 1. 4 0. 0 1. 0 0. 5 49 .2 10 0. 0 25 7 M at ab el el an d S ou th 46 .2 45 .2 1. 2 19 .8 0. 2 15 .7 3. 9 4. 3 0. 0 0. 0 1. 0 0. 0 0. 3 0. 7 53 .8 10 0. 0 23 0 M id la nd s 58 .5 57 .7 0. 8 41 .7 0. 0 10 .2 2. 9 1. 9 0. 0 0. 2 0. 9 0. 0 0. 6 0. 3 41 .5 10 0. 0 69 5 M as vi ng o 54 .2 54 .0 1. 2 41 .4 0. 0 7. 6 1. 8 1. 7 0. 2 0. 0 0. 2 0. 0 0. 2 0. 0 45 .8 10 0. 0 62 6 H ar ar e 59 .4 58 .2 1. 1 45 .8 0. 3 3. 5 3. 5 3. 2 0. 4 0. 4 1. 2 0. 2 1. 0 0. 0 40 .6 10 0. 0 97 2 B ul aw ay o 61 .0 59 .2 4. 6 33 .9 0. 0 6. 5 6. 0 7. 8 0. 4 0. 0 1. 8 0. 3 1. 6 0. 0 39 .0 10 0. 0 23 9 Ed uc at io n N o ed uc at io n 43 .0 42 .0 1. 3 31 .9 0. 0 5. 3 0. 8 1. 8 0. 9 0. 0 1. 0 0. 0 1. 0 0. 0 57 .0 10 0. 0 15 4 P rim ar y 54 .5 52 .9 1. 5 38 .1 0. 2 7. 7 1. 7 3. 1 0. 4 0. 2 1. 6 0. 1 1. 3 0. 3 45 .5 10 0. 0 1, 82 7 S ec on da ry 60 .7 59 .6 0. 8 43 .3 0. 2 8. 8 2. 9 3. 0 0. 3 0. 2 1. 1 0. 1 0. 9 0. 1 39 .3 10 0. 0 3, 48 5 M or e th an s ec on da ry 67 .4 66 .6 3. 2 42 .0 0. 0 7. 1 9. 6 4. 6 0. 0 0. 0 0. 8 0. 6 0. 2 0. 0 32 .6 10 0. 0 23 7 W ea lth q ui nt ile Lo w es t 54 .3 52 .4 0. 6 38 .5 0. 0 8. 4 1. 7 2. 4 0. 5 0. 1 1. 9 0. 0 1. 6 0. 4 45 .7 10 0. 0 1, 10 9 S ec on d 54 .3 53 .1 0. 9 39 .5 0. 0 7. 7 2. 2 2. 5 0. 1 0. 3 1. 2 0. 1 0. 9 0. 1 45 .7 10 0. 0 1, 08 5 M id dl e 57 .6 56 .4 0. 9 42 .3 0. 1 8. 9 1. 8 1. 9 0. 1 0. 4 1. 1 0. 0 1. 0 0. 1 42 .4 10 0. 0 1, 07 7 Fo ur th 61 .2 60 .0 0. 6 42 .2 0. 3 9. 4 2. 7 4. 4 0. 4 0. 2 1. 2 0. 1 1. 0 0. 1 38 .8 10 0. 0 1, 29 1 H ig he st 64 .6 63 .6 2. 8 43 .8 0. 4 7. 0 5. 2 4. 0 0. 5 0. 0 1. 0 0. 2 0. 6 0. 2 35 .4 10 0. 0 1, 14 1 To ta l 58 .5 57 .3 1. 1 41 .3 0. 2 8. 3 2. 7 3. 1 0. 3 0. 2 1. 3 0. 1 1. 0 0. 2 41 .5 10 0. 0 5, 70 3 N ot e: If m or e th an o ne m et ho d is u se d, o nl y th e m os t e ffe ct iv e m et ho d is c on si de re d in th is ta bu la tio n. U se rs o f a di ap hr ag m a re in cl ud ed in a ny m od er n an d an y m et ho d ca te go rie s bu t a re to o fe w in n um be r to b e sh ow n se pa ra te ly . LA M = L ac ta tio na l a m en or rh oe a m et ho d 82 • Family Planning Family Planning • 83 Table 7.3.2 and Figure 7.1 indicate that current use of contraceptive methods among currently married women rose steadily from 1984 to 2005-06 and then declined slightly in 2010-11. Overall, the contraceptive prevalence rate increased from 38 percent in 1984 to 59 percent in 2010-11. The use of modern contraceptive methods among currently married women has more than doubled, increasing from 27 percent in 1984 to 57 percent in 2010-11. Most notably, use of the pill increased from 23 percent in 1984 to 41 percent in 2010-11. The use of traditional methods of contraception declined from 12 percent in 1984 to 1 percent in 2010-11. Table 7.3.2 Trends in the current use of contraception Percent distribution of currently married women age 15-49 by contraceptive method currently used, Zimbabwe 1984-2011 Method 1984 ZRHS 1988 ZDHS 1994 ZDHS 1999 ZDHS 2005-06 ZDHS 2010-11 ZDHS Any method 38.4 43.1 48.1 53.5 60.2 58.5 Any modern method 26.6 36.1 42.2 50.4 58.4 57.3 Female sterilisation 1.6 2.3 2.3 2.6 2.0 1.1 Male sterilisation 0.1 0.2 0.2 0.1 0.1 0.0 Pill 22.6 31.0 33.1 35.5 43.0 41.3 IUD 0.7 1.1 1.0 0.9 0.3 0.2 Injectables 0.8 0.3 3.2 8.1 9.9 8.3 Implants na na 0.2 0.5 1.2 2.7 Male condom 0.7 1.2 2.3 1.8 1.4 3.1 LAM na na na 0.9 0.5 0.2 Other modern method 0.1 0.0 0.0 0.0 0.0 0.3 Any traditional method1 11.8 7.0 6.0 3.2 1.8 1.3 Rhythm/periodic abstinence 0.6 0.3 0.1 0.2 0.2 0.1 Withdrawal 6.5 5.1 4.2 2.6 1.2 1.0 Folk method/other 4.7 1.5 1.7 0.4 0.4 0.2 Not currently using 61.6 56.9 51.9 46.5 39.8 41.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,123 2,643 3,788 3,609 5143 5703 na = Not applicable 1Includes “other” traditional methods such as folk methods. The estimate for 1994 is different from the 4.3 percent published in the 1994 ZDHS report, because “folk method” was not included in the “Any traditional method” category in this report. Figure 7.1 Trends in Contraceptive Use among Currently Married Women ZDHS 2010-11 38 27 2 23 1 1 12 43 36 2 31 0 1 7 48 42 2 33 3 2 6 54 50 3 36 8 2 3 60 58 2 43 10 1 2 59 57 1 41 8 3 1 Any method Any modern method Female sterilisation Pill Injectables Male condom Any traditional method 0 10 20 30 40 50 60 70 Percentage of currently married women 1984 ZRHS 1988 ZDHS 1994 ZDHS 1999 ZDHS 2005-06 ZDHS 2010-11 ZDHS 84 • Family Planning 7.4 SOURCE OF MODERN CONTRACEPTIVE METHODS The information on where women obtain their contraceptive methods is useful for family planning programme managers and implementers of logistic planning. In the 2010-11 ZDHS, all women who reported that they were currently using any modern contraceptive method at the time of the survey were asked where they obtained the method the last time they acquired it. Since women may not know exactly in which category the source falls (e.g., government or private, health centre, or clinic), the interviewers were instructed to note the full name of the source or facility. Furthermore, supervisors were trained to verify that the name and type of source to maintain the consistency and improve the accuracy of the source. Table 7.4 shows that the majority of contraceptive users obtained them from the public sector (73 percent). Fourteen percent obtained contraceptives from the private medical sector, 4 percent from a mission facility, 4 percent from a retail outlet, and 2 percent from another private source. Table 7.4 Source of modern contraceptive methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Zimbabwe 2010-11 Source Female sterilisation Pill Injectables Implants1 Male condom Total2 Public sector 66.4 73.8 88.4 73.5 45.9 73.4 Government hospital/clinic 66.4 20.6 24.5 25.8 20.9 22.5 Rural/municipal clinic 0.0 22.9 28.0 15.8 13.2 21.9 Rural health centre 0.0 23.7 29.6 15.9 7.9 22.3 ZNFPC clinic 0.0 2.4 4.0 9.3 2.5 3.0 MOH mobile clinic 0.0 2.6 2.0 2.7 0.8 2.3 ZNFPC CBD/depot holder 0.0 1.4 0.0 3.1 0.1 1.1 Other public source 0.0 0.3 0.3 0.9 0.5 0.4 Mission facility 9.8 3.8 4.2 3.7 4.8 4.1 Private medical sector 23.8 15.5 6.7 12.0 14.8 14.1 Private hospital/clinic 21.4 1.8 4.4 6.5 1.8 3.0 Private doctor 2.4 0.6 1.4 5.2 0.0 1.0 Pharmacy 0.0 12.4 0.8 0.2 12.3 9.6 CBD 0.0 0.7 0.0 0.0 0.5 0.5 Other private 0.0 0.1 0.0 0.2 0.2 0.1 Retail outlet 0.0 2.7 0.0 0.0 26.5 4.1 General dealer 0.0 1.3 0.0 0.0 7.4 1.5 Supermarket 0.0 0.5 0.0 0.0 15.8 1.7 Tuck shop 0.0 0.5 0.0 0.0 3.1 0.6 Service station 0.0 0.0 0.0 0.0 0.2 0.0 Other retail 0.0 0.4 0.0 0.0 0.0 0.3 Other private source 0.0 2.7 0.2 0.0 3.7 2.2 Church 0.0 0.0 0.2 0.0 0.4 0.1 Friend/relative 0.0 2.7 0.0 0.0 3.2 2.1 Other 0.0 1.4 0.5 0.8 4.4 1.4 Missing 0.0 0.0 0.0 10.0 0.0 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 81 2,505 559 202 317 3,704 CBD = Community-based distribution 1 For users of implants, the source is where the respondent obtained the method when she started the current episode of use. Source of method is missing for implant users if they began using the method more than 5 years before the survey. 2 Total includes users of IUD, female condom, diaphragm, and other modern methods who are too few in number to be shown separately but excludes users of lactational amenorrhoea method (LAM). The public sector supplies the majority of injectables (88 percent), female sterilisation (66 percent), and implants and oral contraceptives (74 percent each). The main source of supply for male condoms is also the public sector (46 percent), although the retail outlets (27 percent) and private medical sector (15 percent) are also important sources. Family Planning • 85 Within the public sector, government hospitals/clinics are reported as the main source of female sterilisation (66 percent). Also within the public sector, government hospitals/clinics, rural/municipal clinics, and rural health centres were the most important sources for the pill, injectables, implants, and the male condom. 7.5 USE OF SOCIAL MARKETING BRAND PILLS Women who were currently using oral contraceptives were asked for the brand name of the pills they last used. This information is useful in monitoring the success of social marketing programmes that promote a specific brand. Table 7.5.1 presents information on the percentages of pill users using social marketing brands, by background characteristics. The public sector distributes Ovrette and Lo-Femenal, while Duofem, Micronor, Marvellon, and Excluton are marketed by the private sector. Table 7.5.1 Use of social marketing brand pills Among pill users age 15-49, the percent distribution of pill brands, by background characteristics, Zimbabwe 2010-11 Background characteristic Pill brands Total Number of women using the pill Ovrette secure Lo-Femenal control Duofem Other Don't know Age 15-19 69.3 30.1 0.0 0.6 0.0 100.0 144 20-24 51.9 46.8 0.3 0.1 0.9 100.0 617 25-29 40.0 56.2 2.5 0.8 0.6 100.0 662 30-34 32.7 66.0 0.9 0.2 0.1 100.0 467 35-39 28.7 70.6 0.3 0.1 0.3 100.0 350 40-44 16.8 81.3 0.7 1.1 0.0 100.0 175 45-49 21.1 77.4 1.5 0.0 0.0 100.0 91 Residence Urban 32.7 63.4 2.8 0.4 0.7 100.0 885 Rural 43.0 56.2 0.1 0.4 0.3 100.0 1,620 Province Manicaland 40.3 58.6 1.1 0.0 0.0 100.0 305 Mashonaland Central 41.8 58.1 0.0 0.1 0.0 100.0 332 Mashonaland East 42.2 56.6 0.0 1.2 0.0 100.0 249 Mashonaland West 40.7 57.6 0.0 0.4 1.3 100.0 340 Matabeleland North 32.1 64.4 1.0 0.0 2.5 100.0 83 Matabeleland South 27.0 71.8 1.2 0.0 0.0 100.0 66 Midlands 43.3 56.2 0.0 0.5 0.0 100.0 299 Masvingo 44.8 54.4 0.5 0.3 0.0 100.0 269 Harare 32.6 62.6 4.0 0.0 0.8 100.0 464 Bulawayo 36.3 58.1 1.9 3.0 0.7 100.0 99 Education No education 27.5 72.5 0.0 0.0 0.0 100.0 53 Primary 40.1 59.0 0.4 0.2 0.3 100.0 747 Secondary 40.2 57.5 1.3 0.5 0.5 100.0 1,603 More than secondary 27.6 69.5 2.9 0.0 0.0 100.0 102 Wealth quintile Lowest 46.6 53.1 0.0 0.2 0.1 100.0 449 Second 43.3 56.0 0.0 0.2 0.5 100.0 452 Middle 43.4 54.9 0.7 0.7 0.3 100.0 495 Fourth 34.7 63.1 1.2 0.2 0.7 100.0 588 Highest 31.1 64.8 3.0 0.7 0.4 100.0 521 Total 39.4 58.7 1.1 0.4 0.4 100.0 2,505 Note: Number of users of Micronor, Micronovum, Marvellon, and Trinodial are too few to be shown separately and are included in the column for Other brands. The majority of women using oral contraceptives used pills distributed by the public sector (98 percent). Among these women, 59 percent used Lo-Femenal and the remaining 39 percent used Ovrette. One percent of pill users used the private sector brand Duofem. 86 • Family Planning 7.6 USE OF SOCIAL MARKETING BRAND CONDOMS Women who were currently using male condoms as contraceptives were asked for the brand name of the condoms they last used. As shown in Table 7.5.2, among women using the male condom, the majority (75 percent) were using Protector Plus, followed by an unbranded condom distributed by the public sector (6 percent), Choice Assorted (5 percent), Durex (4 percent), and Ecstasy (less than 1 percent). However, these figures should be interpreted with caution as nearly 10 percent of respondents did not know the brand of condom they were using. Table 7.5.2 Use of social marketing brand condoms Among male condom users age 15-49, the percent distribution of condom brands, by background characteristics, Zimbabwe 2010-11 Background characteristic Condom brands Total Number of women using the condom Choice Assorted Durex Ecstasy Protector Plus Public sector Don't know Age 15-19 (9.0) (0.0) (4.5) (72.1) (3.3) (11.1) 100.0 20 20-24 13.0 3.4 0.0 73.7 5.6 4.3 100.0 49 25-29 1.8 4.8 0.0 81.4 6.2 5.9 100.0 60 30-34 5.7 0.0 0.0 83.8 1.8 8.7 100.0 62 35-39 1.5 8.5 0.0 66.4 9.1 14.5 100.0 61 40-44 (3.8) (0.0) (0.0) (75.7) (6.2) (14.3) 100.0 36 45-49 (3.3) (14.7) (0.0) (58.6) (13.2) (10.1) 100.0 28 Residence Urban 8.9 5.8 0.5 64.7 9.9 10.1 100.0 174 Rural 0.4 2.7 0.0 86.3 1.8 8.8 100.0 143 Province Manicaland (0.0) (0.0) (0.0) (93.2) (6.8) (0.0) 100.0 41 Mashonaland Central (0.0) (0.0) (0.0) (69.7) (0.0) (30.3) 100.0 26 Mashonaland East * * * * * * 100.0 23 Mashonaland West (0.0) (12.8) (0.0) (83.7) (0.0) (3.6) 100.0 30 Matabeleland North (3.6) (2.1) (0.0) (69.4) (0.0) (24.8) 100.0 15 Matabeleland South (0.0) (0.0) (0.0) (93.9) (6.1) (0.0) 100.0 25 Midlands (3.4) (3.8) (2.9) (87.1) (0.0) (2.9) 100.0 31 Masvingo * * * * * * 100.0 13 Harare (10.2) (13.9) (0.0) (55.9) (5.3) (14.7) 100.0 62 Bulawayo 16.1 0.0 0.0 57.0 22.2 4.8 100.0 50 Education No education * * * * * * 100.0 4 Primary 1.0 7.8 0.0 71.2 5.2 14.7 100.0 88 Secondary 6.5 1.2 0.5 77.4 5.4 9.0 100.0 192 More than secondary (7.9) (14.9) (0.0) (64.6) (12.6) (0.0) 100.0 32 Wealth quintile Lowest (1.5) (4.8) (0.0) (82.6) (0.0) (11.1) 100.0 36 Second (0.0) (0.0) (0.0) (94.0) (0.0) (6.0) 100.0 37 Middle 0.0 3.9 0.0 82.9 5.8 7.3 100.0 50 Fourth 1.0 2.3 1.0 76.6 7.6 11.5 100.0 91 Highest 14.1 7.9 0.0 58.8 9.6 9.6 100.0 103 Total 5.1 4.4 0.3 74.5 6.2 9.5 100.0 317 Note: Condom use is based on women's reports. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 7.7 INFORMED CHOICE Women who are currently using a modern contraceptive method and who started the last episode of use within five years of the survey were asked whether they were informed about the side effects or problems with use of the method, what to do if they experienced side effects, and other methods that they could use. This is a measure of the quality of family planning service provision. Table 7.6 shows the results from the 2010-11 ZDHS, by method and by source of the current episode of use. Family Planning • 87 Table 7.6 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the five years preceding the survey, the percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods they could use, by method and initial source, Zimbabwe 2010-11 Method/source Among women who started last episode of modern contraceptive method within five years preceding the survey: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if experienced side effects Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Female sterilisation * * * 21 Pill 49.6 44.9 58.9 2,128 IUD * * * 11 Injectables 59.7 50.2 65.0 483 Implants 78.8 76.0 82.4 175 Initial source of method1 Public sector 55.1 49.0 63.8 2,315 Government hospital/clinic 56.6 49.1 67.4 708 Rural/municipal clinic 53.8 46.1 61.2 746 Rural health centre 53.7 50.1 62.4 701 ZNFPC clinic 64.4 59.1 73.1 80 MOH mobile clinic 56.8 55.5 64.9 50 ZNFPC CBD/depot holder (63.6) (57.4) (57.8) 23 Other * * * 7 Mission facility 56.9 52.5 65.2 136 Private medical sector 41.6 40.7 49.3 299 Private hospital/clinic 54.0 51.7 67.3 75 Private doctor (77.1) (53.9) (77.3) 30 Pharmacy 30.0 33.3 38.0 180 CBD * * * 11 Other * * * 3 Retail outlet (13.6) (10.3) (16.3) 33 Other (51.1) (46.5) (34.8) 34 Total 53.2 47.8 61.4 2,817 Note: Table includes users of only the methods listed individually. Users who got their method from friends/relatives are excluded from this table. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. CBD = Community-based distribution 1 Source at start of current episode of use About half of all current users of modern contraceptive methods were informed about side effects of the method used (53 percent) and what to do if they experienced them (48 percent). Six in 10 women were informed of other methods they could use. Women who used implants were the most likely to be informed of side effects, what to do if they experienced side effects, and other methods that they could use. Women who got their contraceptive from the public sector or a mission facility were more likely than those who got their modern contraceptive from another source to be informed of side effects, what to do if they experienced side effects, and other methods that they could use. 7.8 RATES OF DISCONTINUING CONTRACEPTIVE METHODS Couples can realise their reproductive goals only when they consistently use reliable methods of contraception. Of particular concern to family planning programmes is the rate at which users discontinue contraceptive methods and the reasons for such discontinuation. Armed with this information, family planning providers will be able to better advise potential users of the advantages and disadvantages of each contraceptive method, allowing women to make a more informed decision about the method that best suits their needs. Women who started an episode of contraceptive use within the five years preceding the survey and discontinued it within 12 months were asked the reason for the discontinuation. Table 7.7 88 • Family Planning presents discontinuation rates, by contraceptive type and by reason for discontinuation. Among all methods, 24 percent of episodes were discontinued within 12 months. The male condom was most often discontinued (37 percent), followed by injectables (33 percent), the pill (21 percent), and implants (8 percent). The reason for discontinuation varied greatly by method. For example, whereas 15 percent of episodes of injectable use were discontinued because of side effects/health concerns, only 1 percent of episodes of male condom use were discontinued for this reason. Table 7.7 12-month contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months, by reason for discontinuation and specific method, Zimbabwe 2010-11 Method Reason for discontinuation Switched to another method4 Method failure Desire to become pregnant Other fertility- related reasons2 Side effects/ health concerns Wanted more effective method Other method- related reasons3 Other reason Any reason Pill 2.6 5.2 2.6 4.7 1.3 2.0 2.3 20.7 3.7 Injectables 1.4 7.5 1.3 15.3 2.2 3.3 1.7 32.8 10.3 Implants 0.3 0.5 0.8 5.3 0.0 0.0 0.8 7.7 4.5 Male condom 1.8 6.4 9.1 1.4 7.9 3.4 6.9 37.0 12.5 All methods1 2.4 5.5 2.9 5.9 2.2 2.2 2.7 23.8 5.9 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months preceding the survey. 1 Lactational amenorrhoea method (LAM), IUD, female condom, foam/jelly, rhythm, withdrawal, and other methods are included in the discontinuation rate for all methods, but are not listed separately. 2 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation 3 Includes lack of access/too far, costs too much, and inconvenient to use 4 Used a different method in the month following discontinuation or said they wanted a more effective method and started another method within two months of discontinuation. 7.9 REASONS FOR DISCONTINUING CONTRACEPTIVE METHODS Table 7.8 shows the percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method. In total, 4,228 discontinuations occurred within this time period. Across all contraceptive methods, the most common reason for discontinuation was the desire to become pregnant (40 percent), followed by concern over side effects/health concerns (17 percent), and method failure (12 percent). Across specific contraceptive methods, the reasons for discontinuation vary widely. For example, among pill users, 47 percent of discontinuations were because users wanted to become pregnant, 15 percent because of side effects/health concerns, and 13 percent because the user became pregnant while using. In contrast, among users of injectables, side effects/health concerns were a much more common reason for discontinuation: 35 percent of discontinuations of injectables were because of side effects/health concerns, 32 percent were because the user wanted to become pregnant, and only 5 percent were because the user became pregnant. A similar pattern of reasons for discontinuation was observed for users of implants. Family Planning • 89 Table 7.8 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method, Zimbabwe 2010-11 Reason Pill Injectables Implants Male condom Withdrawal Other All methods1 Became pregnant while using 13.0 5.4 6.0 8.9 31.6 * 11.7 Wanted to become pregnant 46.6 32.2 24.6 17.4 26.5 * 40.3 Husband/partner disapproved 1.8 0.7 0.0 8.5 2.0 * 2.3 Wanted a more effective method 4.1 5.0 1.9 17.4 20.7 * 5.9 Side effects/health concerns 14.5 34.9 46.0 3.5 1.4 * 16.9 Lack of access/too far 2.3 4.8 2.6 2.4 0.0 * 2.7 Cost too much 1.0 3.4 4.5 0.3 0.0 * 1.4 Inconvenient to use 2.9 3.5 0.0 5.8 1.0 * 3.3 Up to God/fatalistic 0.1 0.1 0.0 0.2 0.0 * 0.1 Difficult to get pregnant/menopausal 0.4 0.4 0.0 0.6 1.4 * 0.4 Infrequent sex/husband away 6.0 3.7 2.0 22.2 8.1 * 7.1 Marital dissolution/separation 2.2 1.5 0.0 5.4 0.7 * 2.3 Other 2.0 2.4 8.4 4.5 3.5 * 2.7 Don't know 0.3 0.9 0.0 1.0 0.0 * 0.5 Missing 2.6 1.1 4.0 1.9 3.0 * 2.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 2,903 721 54 391 96 23 4,228 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Male sterilisation, IUD, female condom, lactational amenorrhoea method (LAM), and rhythm are included in the discontinuation rate for all methods, but are not listed separately. Method failure as a reason for discontinuation was highest for withdrawal (32 percent) and lowest for injectables (5 percent) and implants (6 percent). Withdrawal was also discontinued, more than any other method, because the user wanted a more effective method (21 percent of discontinuations). In contrast, only 5 percent of episodes of injectable use and 2 percent of episodes of implant use were discontinued because users wanted a more effective method. 7.10 KNOWLEDGE OF THE FERTILE PERIOD An elementary knowledge of reproductive physiology provides a useful background for successful practice of coitus-associated methods such as withdrawal and condom use. Such knowledge is particularly critical in the use of the rhythm method. The 2010-11 ZDHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during the menstrual cycle. Respondents were asked, “From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?” If the reply was yes, the respondent was further asked whether that time was just before a woman’s period begins, during her period, right after her period has ended, or halfway between two periods. Table 7.9 shows that knowledge of the fertile period is minimal among women and men in Zimbabwe. Only 16 percent of women and 15 percent of men correctly reported when the fertile period occurs, i.e., a woman is most likely to conceive halfway between two periods. 90 • Family Planning Table 7.9 Knowledge of fertile period Percent distribution of women and men age 15-49 by knowledge of the fertile period during the ovulatory cycle, Zimbabwe 2010-11 Perceived fertile period All women All men Just before her menstrual period begins 12.6 18.9 During her menstrual period 0.4 1.3 Right after her menstrual period has ended 32.4 24.5 Halfway between two menstrual periods 16.3 14.5 Other 0.3 0.1 No specific time 11.4 13.8 Don't know 26.5 26.9 Total 100.0 100.0 Number of respondents 9,171 7,480 7.11 NEED AND DEMAND FOR FAMILY PLANNING The proportion of women who want to stop childbearing or who want to space their next birth is a crude measure of the extent of the need for family planning, given that not all of these women are exposed to the risk of pregnancy and some of them may already be using contraception. This section discusses the extent of need and the potential demand for family planning services. Women who want to postpone their next birth for two or more years or who want to stop childbearing altogether but are not using a contraceptive method are said to have an unmet need for family planning. Pregnant women are considered to have an unmet need for spacing or limiting if their pregnancy was mistimed or unwanted. Similarly, amenorrhoeic women are categorised as having unmet need if their last birth was mistimed or unwanted. Women who are currently using a family planning method are said to have a met need for family planning. The total demand for family planning services comprises those who fall in the met need and unmet need categories. Tables 7.10.1 and 7.10.2 presents data on unmet need, met need, and total demand for family planning for currently married women, all women, and women who are not currently married. These indicators help to evaluate the extent to which the family planning program in Zimbabwe is meeting the demand for services. The definitions of met need, unmet need, and total demand for family planning are further explained in Tables 7.10.1 and 7.10.2. Family Planning • 91 Table 7.10.1 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Zimbabwe 2010-11 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning3 Per- centage of demand satisfied Per- centage of demand satisfied by modern methods Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 16.9 0.3 17.1 32.5 3.7 36.2 50.3 4.0 54.3 68.5 65.2 452 20-24 10.2 1.4 11.6 52.9 7.3 60.2 65.7 8.7 74.5 84.4 79.3 1,210 25-29 8.2 2.8 11.0 45.2 18.2 63.4 55.1 21.3 76.4 85.6 81.1 1,329 30-34 5.5 4.6 10.0 32.0 31.9 63.9 39.4 37.4 76.8 87.0 82.0 1,012 35-39 4.7 10.7 15.4 17.3 43.0 60.3 23.0 55.1 78.0 80.2 76.0 815 40-44 3.0 13.1 16.0 5.1 54.4 59.5 8.1 69.4 77.5 79.3 74.8 488 45-49 0.1 15.0 15.1 1.6 42.6 44.2 1.8 57.9 59.7 74.6 69.0 397 Residence Urban 6.5 5.2 11.6 34.1 27.4 61.5 41.7 33.3 75.0 84.5 80.5 1,937 Rural 7.8 5.6 13.4 32.5 24.5 57.0 41.9 30.7 72.7 81.6 76.6 3,766 Province Manicaland 9.1 5.7 14.8 35.0 21.2 56.2 45.6 27.9 73.5 79.9 74.2 798 Mashonaland Central 5.4 3.8 9.1 39.0 24.7 63.8 46.4 29.8 76.2 88.0 80.8 626 Mashonaland East 6.1 4.7 10.8 32.1 30.3 62.5 40.0 35.1 75.1 85.6 80.9 541 Mashonaland West 5.9 4.2 10.0 33.5 28.7 62.1 41.6 33.2 74.8 86.6 81.9 718 Matabeleland North 6.2 7.0 13.2 27.2 23.6 50.8 33.9 30.6 64.5 79.5 76.5 257 Matabeleland South 13.7 12.5 26.2 17.8 28.4 46.2 31.7 41.5 73.2 64.3 61.7 230 Midlands 7.0 7.1 14.2 32.3 26.3 58.5 40.5 34.2 74.7 81.0 77.2 695 Masvingo 9.0 2.7 11.7 31.1 23.1 54.2 41.8 26.4 68.2 82.8 79.2 626 Harare 7.1 5.5 12.6 35.5 23.9 59.4 43.5 30.0 73.5 82.8 79.1 972 Bulawayo 6.1 8.2 14.3 30.0 31.0 61.0 38.5 40.2 78.7 81.8 75.2 239 Education No education 4.1 9.2 13.3 17.9 25.1 43.0 22.0 36.4 58.4 77.2 71.9 154 Primary 8.2 6.9 15.1 27.0 27.6 54.5 36.5 34.9 71.5 78.9 74.0 1,827 Secondary 7.4 4.4 11.8 36.9 23.8 60.7 46.0 28.9 74.9 84.2 79.6 3,485 More than secondary 1.6 7.2 8.8 32.5 34.9 67.4 35.6 42.5 78.1 88.7 85.3 237 Wealth quintile Lowest 9.4 5.9 15.3 32.7 21.6 54.3 43.8 28.1 71.8 78.8 72.9 1,109 Second 9.7 6.9 16.6 32.1 22.2 54.3 43.5 29.8 73.3 77.3 72.5 1,085 Middle 7.3 4.6 12.0 31.6 26.0 57.6 39.8 31.4 71.3 83.2 79.2 1,077 Fourth 6.2 5.4 11.6 35.3 25.9 61.2 43.3 31.6 75.0 84.6 80.1 1,291 Highest 4.3 4.6 8.9 33.1 31.4 64.6 38.7 37.0 75.6 88.2 84.1 1,141 Total 7.3 5.5 12.8 33.0 25.5 58.5 41.9 31.6 73.5 82.6 77.9 5,703 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted, but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted, but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here 3 Nonusers who are pregnant or amenorrhoeic and whose pregnancy was the result of a contraceptive failure are not included in the category of unmet need, but are included in total demand for contraception (since they would have been using had their method not failed). 92 • Family Planning Table 7.10.2 Need and demand for family planning for all women and for women who are not currently married Percentage of all women and women not currently married age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning and the percentage of the demand for contraception that is satisfied, by background characteristics, Zimbabwe 2010-11 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning3 Per- centage of demand satisfied Per- centage of demand satisfied by modern methods Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total ALL WOMEN Age 15-19 4.6 0.1 4.8 9.1 1.2 10.3 13.9 1.3 15.2 68.8 66.1 1,945 20-24 7.2 1.1 8.3 38.8 6.2 45.0 47.9 7.3 55.2 85.0 80.1 1,841 25-29 7.0 2.4 9.4 38.9 17.0 55.9 47.5 19.9 67.4 86.0 81.3 1,686 30-34 4.4 4.2 8.5 27.1 28.5 55.6 33.2 33.5 66.7 87.2 82.3 1,296 35-39 3.7 8.6 12.2 14.4 38.4 52.8 18.8 48.1 66.8 81.7 77.8 1,051 40-44 2.1 9.0 11.1 3.6 42.7 46.3 5.7 53.2 59.0 81.1 76.6 732 45-49 0.1 10.3 10.4 1.0 32.0 33.0 1.1 42.7 43.8 76.3 71.0 620 Residence Urban 4.1 3.2 7.3 21.6 18.1 39.7 26.6 21.7 48.3 84.8 80.9 3,548 Rural 5.5 4.0 9.4 23.4 19.0 42.3 30.0 23.5 53.4 82.4 77.5 5,623 Province Manicaland 6.1 3.9 10.0 24.3 15.8 40.1 31.4 20.6 52.0 80.8 75.0 1,227 Mashonaland Central 4.0 2.9 7.0 30.0 19.4 49.4 35.6 23.3 58.9 88.2 81.1 871 Mashonaland East 4.1 3.2 7.3 22.9 22.7 45.6 28.2 25.9 54.1 86.5 82.3 824 Mashonaland West 4.5 3.2 7.7 24.4 22.3 46.6 30.5 25.7 56.2 86.3 81.8 1,026 Matabeleland North 4.3 4.5 8.8 19.9 18.7 38.7 24.6 23.2 47.8 81.5 79.2 443 Matabeleland South 7.6 7.1 14.7 13.5 21.1 34.6 21.2 28.7 49.8 70.5 68.4 467 Midlands 4.5 4.4 8.9 21.6 19.1 40.7 26.8 24.1 51.0 82.6 78.9 1,123 Masvingo 6.2 2.0 8.2 22.3 17.9 40.1 29.9 20.4 50.3 83.7 79.3 909 Harare 4.7 3.4 8.1 22.1 15.4 37.6 27.6 19.2 46.8 82.6 78.7 1,722 Bulawayo 3.5 4.5 8.0 19.0 18.8 37.8 23.9 23.7 47.5 83.2 77.6 558 Education No education 3.6 6.9 10.5 13.2 20.2 33.4 16.8 28.7 45.5 76.9 71.9 212 Primary 6.2 5.3 11.5 20.7 23.2 43.9 28.0 29.0 57.0 79.8 75.0 2,568 Secondary 4.6 2.8 7.5 23.9 16.4 40.2 29.6 19.7 49.2 84.8 80.4 5,966 More than secondary 2.0 4.0 6.0 23.2 21.7 44.9 26.6 26.0 52.6 88.5 84.4 424 Wealth quintile Lowest 7.1 4.3 11.4 24.9 17.7 42.6 33.1 22.5 55.7 79.5 74.0 1,546 Second 6.9 4.9 11.8 23.5 17.2 40.7 31.7 22.7 54.4 78.3 73.3 1,594 Middle 4.8 3.5 8.3 22.3 20.0 42.3 28.1 24.1 52.2 84.1 79.6 1,681 Fourth 4.2 3.6 7.8 24.5 19.8 44.2 29.9 23.5 53.4 85.4 81.4 2,073 Highest 2.8 2.6 5.5 19.4 18.2 37.6 23.0 21.3 44.3 87.7 83.8 2,278 Total 4.9 3.7 8.6 22.7 18.6 41.3 28.7 22.8 51.5 83.3 78.7 9,171 WOMEN NOT CURRENTLY MARRIED Age 15-19 0.9 0.1 1.0 2.0 0.4 2.4 2.9 0.5 3.4 70.2 70.2 1,493 20-24 1.4 0.6 2.0 11.7 4.1 15.8 13.7 4.7 18.3 89.1 86.2 631 25-29 2.3 1.2 3.5 15.3 12.9 28.2 19.4 14.6 33.9 89.6 82.8 357 30-34 0.6 2.8 3.3 9.7 16.4 26.1 11.3 19.5 30.8 89.1 85.0 284 35-39 0.0 1.2 1.2 4.3 22.4 26.7 4.3 23.9 28.2 95.6 94.8 236 40-44 0.5 0.8 1.3 0.6 19.5 20.1 1.1 20.8 22.0 94.0 89.2 244 45-49 0.0 1.9 1.9 0.0 13.2 13.2 0.0 15.5 15.5 88.0 84.6 223 Residence Urban 1.2 0.9 2.2 6.7 6.9 13.5 8.4 7.8 16.2 86.5 83.3 1,611 Rural 0.7 0.6 1.3 4.8 7.8 12.6 5.8 8.7 14.5 90.7 86.6 1,857 Province Manicaland 0.5 0.6 1.1 4.4 5.8 10.2 5.1 6.9 12.1 90.9 84.6 428 Mashonaland Central 0.6 0.8 1.4 7.0 5.5 12.5 8.0 6.7 14.7 90.5 85.1 245 Mashonaland East 0.2 0.3 0.5 5.3 8.2 13.5 5.5 8.4 14.0 96.4 96.4 283 Mashonaland West 1.4 0.9 2.3 3.2 7.3 10.5 4.8 8.3 13.1 82.3 80.4 308 Matabeleland North 1.7 1.0 2.7 10.0 12.0 21.9 11.7 13.0 24.7 88.9 88.9 186 Matabeleland South 1.7 1.9 3.5 9.3 14.1 23.4 11.0 16.2 27.2 86.9 86.1 237 Midlands 0.3 0.0 0.3 4.3 7.5 11.8 4.6 7.8 12.4 97.6 95.5 428 Masvingo 0.0 0.3 0.3 2.7 6.3 9.0 3.5 7.1 10.6 96.8 81.3 283 Harare 1.6 0.7 2.3 4.8 4.5 9.3 7.0 5.2 12.2 81.1 76.0 750 Bulawayo 1.6 1.7 3.2 10.7 9.6 20.3 12.9 11.3 24.1 86.6 83.4 319 Education No education 2.2 0.9 3.1 0.8 7.4 8.1 3.0 8.3 11.3 72.3 72.3 58 Primary 1.2 1.6 2.8 5.3 12.5 17.8 6.9 14.4 21.3 86.9 82.7 741 Secondary 0.8 0.6 1.3 5.5 6.0 11.5 6.5 6.7 13.2 89.9 86.9 2,481 More than secondary 2.5 0.0 2.5 11.4 5.1 16.5 15.2 5.1 20.3 87.7 79.9 187 Wealth quintile Lowest 1.1 0.4 1.6 5.1 7.8 12.8 6.2 8.5 14.7 89.2 87.1 437 Second 0.8 0.7 1.5 5.1 6.6 11.8 6.3 7.7 14.0 89.2 82.3 509 Middle 0.3 1.4 1.7 5.6 9.4 15.0 7.1 11.0 18.1 90.5 82.6 603 Fourth 0.9 0.7 1.6 6.6 9.5 16.1 7.6 10.2 17.8 91.2 90.4 781 Highest 1.4 0.6 2.0 5.6 4.9 10.5 7.2 5.6 12.8 84.3 82.0 1,137 Total 1.0 0.8 1.7 5.7 7.3 13.0 7.0 8.3 15.3 88.7 85.0 3,468 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrhoeic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrhoeic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 3 Nonusers who are pregnant or amenorrhoeic and whose pregnancy was the result of a contraceptive failure are not included in the category of unmet need, but are included in total demand for contraception (since they would have been using had their method not failed). Family Planning • 93 Table 7.10.1 shows that 13 percent of currently married women have an unmet need for family planning services (7 percent for spacing and 6 percent for limiting births). Six in ten married women are currently using a contraceptive method Three in four currently married women have a demand for family planning. At present, about four-fifths of the potential demand for family planning is being met. Thus, if all married women who said they want to space or limit their children were to use family planning methods, the contraceptive prevalence rate would increase from 59 percent to 74 percent. As shown in Table 7.10.1, as expected, unmet need for spacing is high among younger women, while unmet need for limiting childbearing is high among older women. There is essentially no difference in unmet need between rural and urban areas, with urban areas at 12 percent and rural areas at 13 percent. Matabeleland South has the highest unmet need (26 percent) with Mashonaland Central having the lowest (9 percent). Unmet need in other provinces ranges between 10 percent and 15 percent. Unmet need is negatively associated with a woman’s education; it is lower among women with more than secondary education (9 percent) than among those with primary education (15 percent). Unmet need is also inversely associated with a woman’s wealth status. Among women in the lowest two wealth quintiles, unmet need is 15 to 17 percent, while it is 9 percent among their counterparts in the highest wealth quintile. Wealth is positively associated with the use of family planning services. Married women in the highest wealth quintile have a higher met need for family planning than those in the lowest wealth quintile (65 and 54 percent, respectively). The need for family planning services for all women and women not currently married is presented in Table 7.10.2. The panel on all women follows the trends of currently married women. The total family planning demand for all women is high, between 55 and 67 percent for each age group between 20 and 39 years. These age groups constitute women of childbearing age. The low level of unmet need among unmarried women (2 percent) is due to the fact that many are younger women who have not yet started their families. 7.12 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which nonusers plan to use contraceptive methods in the future, as this is a forecast of potential demand for services. Currently married women age 15-49 who were not using contraceptives at the time of the survey were asked about their intention to use family planning in the future. Table 7.11 shows that 69 percent of the currently married nonusers indicated that they intend to use family planning methods in the future, while 27 percent said that they do not intend to use a method. The proportion of women who intend to use a method is highest among women with one to two children and lowest among those with at least four children. 94 • Family Planning Table 7.11 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Zimbabwe 2010-11 Intention to use in the future Number of living children1 Total 0 1 2 3 4+ Intends to use 69.5 79.6 78.7 73.3 49.4 69.1 Unsure 6.0 3.3 3.1 3.7 3.1 3.6 Does not intend to use 24.5 17.1 18.2 23.0 47.5 27.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 262 554 524 389 636 2,365 1 Includes current pregnancy. 7.13 EXPOSURE TO FAMILY PLANNING MESSAGES IN THE MEDIA Radio, television, newspapers and/or magazines, and pamphlets and/or posters are the major sources of information about family planning in the media in Zimbabwe. Information on the level of public exposure to a particular type of media allows policymakers to ensure the use of the most effective media for the various target groups. To assess the effectiveness of such media on the dissemination of family planning information, women and men in the 2010-11 ZDHS were asked whether they had heard messages about family planning on the radio or seen them on television or in newspapers/magazines or pamphlets/posters during the few months preceding the survey (Table 7.12). Overall, 21 percent of women reported that they had recently heard a family planning message on the radio, 19 percent had seen a message on television, 18 percent saw messages in newspapers and magazines, and 21 percent saw messages in pamphlets and posters. These proportions do not vary significantly by the woman’s age. However, contrasts in access to media messages are observed between women in urban areas and those in rural areas. Women in urban areas are more likely than those in rural areas to have access to family planning messages on the radio (26 percent and 18 percent, respectively). They are three times more likely than those in rural areas to have access to family planning messages broadcast on television, and more than two times as likely to have access to family planning messages through newspapers and magazines. Similarly, women in urban areas more often access messages on family planning through pamphlets and posters than their rural counterparts Family Planning • 95 Table 7.12 Exposure to family planning messages Percentage of women and men age 15-49 who heard or saw a family planning message on the radio, on television, in a newspaper or in a pamphlet or posters in the past few months, according to background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Radio Television News- paper/ magazine None of these three media sources1 Pamphlets or posters Number of women Radio Television News- paper/ magazine None of these three media sources1 Pamphlets or posters Number of men Age 15-19 12.8 12.3 13.1 75.0 14.4 1,945 14.0 12.8 13.0 73.5 11.2 1,735 20-24 21.8 18.7 18.0 64.4 21.0 1,841 23.7 22.1 26.6 56.5 19.4 1,372 25-29 22.5 21.8 20.1 61.7 22.5 1,686 31.5 27.1 34.3 49.0 29.0 1,236 30-34 23.9 21.6 20.7 61.8 23.4 1,296 34.9 29.4 33.8 45.6 29.1 970 35-39 23.5 19.9 19.8 63.3 23.9 1,051 35.8 30.4 38.3 44.8 31.9 828 40-44 25.0 21.2 17.3 62.4 23.4 732 37.3 30.2 40.7 42.4 36.4 589 45-49 23.0 19.4 15.7 66.0 19.8 620 42.9 31.1 37.4 42.1 34.5 379 Residence Urban 25.5 33.0 27.9 52.2 24.5 3,548 30.3 38.8 43.7 40.3 32.8 2,621 Rural 17.9 9.7 11.3 74.0 18.2 5,623 26.3 15.1 19.9 62.9 18.9 4,488 Province Manicaland 22.8 15.8 17.7 65.6 13.0 1,227 33.8 22.3 29.0 52.6 20.7 972 Mashonaland Central 19.9 11.8 12.2 70.4 15.3 871 26.1 16.0 22.3 59.2 23.4 738 Mashonaland East 32.2 18.1 21.2 55.1 30.5 824 30.0 17.4 27.0 54.8 21.8 667 Mashonaland West 19.4 15.2 14.0 72.1 24.0 1,026 37.6 29.7 32.4 46.6 29.9 872 Matabeleland North 3.7 4.0 7.5 88.6 13.2 443 10.0 9.2 13.2 79.8 13.5 349 Matabeleland South 21.6 14.7 18.1 66.7 50.1 467 20.2 14.5 18.8 66.9 20.0 352 Midlands 11.9 11.5 11.2 76.7 18.1 1,123 24.5 17.6 25.0 60.3 24.5 885 Masvingo 12.6 6.3 7.7 81.3 6.0 909 12.5 10.4 11.1 77.8 7.6 585 Harare 28.7 36.7 28.1 48.4 24.2 1,722 33.2 41.6 45.1 37.5 35.8 1,307 Bulawayo 24.0 37.4 33.4 47.6 24.3 558 25.3 36.4 37.5 42.8 22.0 382 Education No education 8.5 4.8 1.2 88.3 5.1 212 3.5 5.1 1.5 93.1 0.7 56 Primary 14.4 7.9 6.1 79.4 14.4 2,568 19.6 9.2 9.3 72.8 11.2 1,508 Secondary 23.1 21.6 20.8 61.2 22.4 5,966 29.6 26.2 31.5 51.7 26.0 5,027 More than secondary 34.1 49.6 52.8 32.3 41.4 424 36.3 45.0 61.0 25.4 44.8 519 Wealth quintile Lowest 8.3 2.9 4.1 88.3 13.3 1,546 16.6 4.8 8.4 78.1 11.8 1,074 Second 16.1 5.3 8.7 77.6 16.5 1,594 25.7 11.3 17.5 65.3 18.6 1,216 Middle 23.5 10.2 12.3 69.2 20.1 1,681 27.5 15.1 19.9 61.5 19.7 1,371 Fourth 25.4 24.7 22.1 57.8 22.8 2,073 31.6 31.8 34.9 46.7 28.0 1,664 Highest 26.6 39.5 33.3 46.2 27.0 2,278 32.5 43.0 49.5 35.0 34.8 1,786 Total 15-49 20.9 18.7 17.7 65.6 20.6 9,171 27.8 23.8 28.7 54.5 24.0 7,110 50-54 na na na na na na 37.3 30.4 33.5 44.8 29.1 370 Total 15-54 na na na na na na 28.2 24.1 28.9 54.1 24.3 7,480 na = Not applicable 1 Percentage of women and men who have neither seen nor heard a message on radio, television, or newspaper/magazine The proportion of women who were exposed to family planning messages on the radio varies among provinces from 4 percent in Matabeleland North to 32 percent in Mashonaland East. Similarly, the proportion exposed to family planning information through television ranges from 4 percent in Matabeleland North to 37 percent for Harare and Bulawayo, and through newspapers and magazines, from 8 percent in Masvingo and Matabeleland North to 33 percent in Bulawayo, and through pamphlets or posters, from 6 percent in Masvingo to 50 percent in Matabeleland South. Exposure to family planning messages increases as the respondent’s education level and wealth status increases. In general, men seem to have had more exposure to family planning messages through the media than women. Like women, however, exposure to family planning messages on the radio, television, newspapers/magazines, and pamphlets/posters varies among provinces. Exposure to family planning messages varies with men’s education; men with at least a secondary school level of education are more exposed to family planning messages through the media than those with a primary school level of education or no education at all. Men’s exposure to family planning messages through the media also increases with wealth. 96 • Family Planning 7.14 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS In the 2010-11 ZDHS, women who were not using any contraceptive method were asked whether they had been visited by a fieldworker who talked with them about family planning in the 12 months preceding the survey. This information is especially useful for determining whether family planning outreach programmes reach nonusers. Nonusers were also asked if they had visited a health facility in the preceding 12 months for any reason, and if so, whether any staff member at the facility had spoken to them about family planning. These questions help to assess the level of missed opportunities to inform women about contraception. The results shown in Table 7.13 indicate that 4 percent of nonusers reported discussing family planning when a fieldworker visited them. Nine percent of nonusers reported that they had visited a health facility and discussed family planning, while 16 percent of the nonusers had visited a health facility but did not discuss family planning. Table 7.13 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the last 12 months were visited by a fieldworker who discussed family planning, the percentage who visited a health facility and discussed family planning, the percentage who visited a health facility but did not discuss family planning, and the percentage who did not discuss family planning either with a fieldworker or at a health facility, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of women who were visited by fieldworker who discussed family planning Percentage of women who visited a health facility in the past 12 months and who: Percentage of women who did not discuss family planning with a fieldworker or at a health facility Number of women Discussed family planning Did not discuss family planning Age 15-19 2.7 3.4 11.1 94.2 1,745 20-24 5.4 11.0 19.3 85.6 1,013 25-29 4.4 14.1 20.0 83.6 743 30-34 6.3 14.9 17.7 81.6 575 35-39 3.3 12.0 17.3 85.7 496 40-44 3.1 11.5 19.2 86.7 393 45-49 5.3 9.1 16.6 88.2 415 Residence Urban 3.2 7.0 15.6 90.7 2,138 Rural 4.7 10.9 16.5 86.2 3,243 Province Manicaland 6.4 13.2 24.2 82.6 735 Mashonaland Central 7.2 12.3 29.5 83.3 441 Mashonaland East 4.7 8.1 9.1 89.0 448 Mashonaland West 1.8 6.1 7.8 93.2 548 Matabeleland North 1.9 8.1 14.0 90.6 272 Matabeleland South 3.3 13.6 25.9 83.8 306 Midlands 3.0 8.3 16.6 89.9 666 Masvingo 6.8 14.0 7.4 83.0 544 Harare 2.3 4.1 12.6 93.9 1,075 Bulawayo 4.2 13.2 21.4 83.5 347 Education No education 4.5 4.4 16.3 91.9 141 Primary 4.8 10.2 15.4 86.7 1,440 Secondary 3.7 9.0 15.9 88.7 3,566 More than secondary 5.8 13.0 24.5 83.7 234 Wealth quintile Lowest 3.9 11.6 14.9 86.5 888 Second 3.8 10.6 14.7 87.6 945 Middle 5.3 10.3 15.9 85.8 971 Fourth 3.7 8.4 17.6 88.8 1,156 Highest 3.9 7.4 17.0 90.1 1,421 Total 4.1 9.4 16.2 88.0 5,381 Family Planning • 97 Staff at health facilities are more likely to discuss family planning with women age 20-44 than with younger women age 15-19 or older women age 45-49. Urban women are somewhat less likely than rural women to visit a health facility and discuss family planning (7 percent versus 11 percent), and they are equally likely to visit a health facility but not discuss family planning (16 percent versus 17 percent). The proportion of nonusers who visited a health facility and discussed family planning is highest in Masvingo and Matabeleland South (14 percent), and is lowest in Harare (4 percent). Women with no education are less likely than those with any level of education to visit a health facility and discuss family planning with a provider. Women in lower wealth quintiles are more likely to visit a health facility and discuss family planning with a provider than women in higher wealth quintiles. Overall, 88 percent of nonusers did not discuss family planning with a fieldworker or a staff member at a health facility. This represents a large pool of potential users of family planning who could be targeted for family planning counselling. A more vigorous outreach programme will be needed to reach these women. Infant and Child Mortality • 99 INFANT AND CHILD MORTALITY 8 nformation on levels, trends, and differentials in neonatal, infant, and child mortality is important in the demographic assessment of the population and the evaluation of health policies and programmes. Estimates of infant and child mortality are used for population projections, particularly if the level of adult mortality is known from another source or can be inferred with reasonable confidence. Information on mortality of children serves the needs of agencies providing health services by identifying subgroups of the population at high risk of mortality. 8.1 BACKGROUND AND ASSESSMENT OF DATA QUALITY The rates of childhood mortality presented in this chapter are defined as follows: • Neonatal mortality: the probability of dying within the first month of life • Postneonatal mortality: the arithmetic difference between infant and neonatal mortality • Infant mortality: the probability of dying between birth and the first birthday • Child mortality: the probability of dying between exact age 1 and the fifth birthday • Under-5 mortality: the probability of dying between birth and the fifth birthday All rates are expressed as deaths per 1,000 live births, except child mortality, which is expressed as deaths per 1,000 children surviving to the first birthday. Information drawn from the questions asked in the birth history section of the Woman’s Questionnaire is used to calculate the mortality rates presented in this chapter. First, the respondents were asked a series of questions about their childbearing experience. In particular, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In the birth history, for each live birth, information was collected on sex, month, and year of birth; survivorship status; and current age or, if the child had died, age at death. The quality of mortality estimates calculated from retrospective birth histories depends on the mother’s ability to recall all of the children she has given birth to, as well as their birth dates and ages at death. Potentially the most serious data quality problem is the selective omission from the birth histories of those births that did not survive. If the problem of omission is serious, it can result in underestimation of childhood mortality. If selective omission of childhood deaths occurs, it is usually most severe for deaths early in infancy. Generally, if deaths are substantially underreported, the result I Key Findings • The under-5 mortality rate in Zimbabwe is 84 deaths per 1,000 live births. The infant mortality rate is 57 deaths per 1,000 live births, and the neonatal mortality rate is 31 deaths per 1,000 live births. • Approximately two-thirds of childhood deaths occur during infancy, with more than one- third taking place during the first month of life. 100 • Infant and Child Mortality is a low ratio of early neonatal deaths (deaths within the first week of life) to all neonatal deaths and a low ratio of neonatal deaths to infant deaths. Appendix Table C.5 shows that the proportion of all neonatal deaths that took place within the first seven days of birth was 81 percent for the five-year period prior to the 2010-11 ZDHS.1 Consistent with this finding, the proportion of early neonatal deaths in the 2010-11 ZDHS is also modestly higher than the proportions recorded 5 to19 years before the survey, which ranged between 79 percent and 73 percent. This proportion is higher than the proportions recorded for the five-year periods prior to the 1994 ZDHS (71 percent), 1999 ZDHS (76 percent), and 2005-06 ZDHS (74 percent) but is within the expected range. Looking at the ratio of neonatal deaths to all deaths under 12 months, Appendix Table C.6 shows that the proportion was 56 percent for the five-year period prior to the 2010-11 survey. This is somewhat higher than the proportions recorded for the five-year periods prior to the 1994 ZDHS (48 percent), the 1999 ZDHS (47 percent), and the 2005-06 ZDHS (41 percent). It is also higher than the proportions reported in the 2010-11 ZDHS for the periods 5-19 years before the survey, which ranged between 39 percent and 55 percent. Another potential data quality problem involves the displacement of birth dates, which may distort mortality trends. This can occur if an interviewer knowingly records a birth as occurring in a different year, which could happen if an interviewer were trying to cut down on his or her overall work load, because live births occurring during the five years preceding the interview are the subject of a lengthy set of additional questions. In the 2010-11 ZDHS questionnaire, the cut-off year for these questions was 2005. Appendix Table C.4 shows little evidence of severe transference of deceased children from 2005 to earlier years. A third factor that affects childhood mortality estimates is the quality of reporting of age at death. Misreporting of the child’s age at death may distort the age pattern of mortality, especially if the net effect of the age misreporting is to transfer deaths from one age bracket to another. For example, a net transfer of deaths from under 1 month to a higher age will affect the estimates of neonatal and postneonatal mortality. To minimise errors in reporting age at death, ZDHS interviewers were instructed to record age at death in days if the death took place in the month following the birth, in months if the child died before age 2, and in years if the child was at least age 2. They also were asked to probe for deaths reported at age 1 to determine a more precise age at death in terms of months. Appendix Table C.6 shows that, for the five years preceding the survey, the number of reported deaths at age 12 months, or 1 year, is fewer than the number of deaths reported at 11 months and comparable with the number reported at 13 months, indicating no apparent distortion of the infant mortality rate. Note, however, that the number of deaths at 9 months is more than double the number at 8 months and four times the number at 10 months. The cause of the spike is unclear and is similar to that observed in the 2005-06 ZDHS. Finally, any method of measuring childhood mortality that relies on the mothers’ reports (e.g., birth histories) assumes that female adult mortality is not high, or if it is high, that there is little or no correlation between the mortality risks of the mothers and those of their children. In countries like 1 There are no models for mortality patterns during the neonatal period. However, one review of data from several developing countries concluded that, at neonatal mortality levels of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma, 1988). Infant and Child Mortality • 101 Zimbabwe that have high rates of female adult mortality, primarily due to the AIDS epidemic (see Chapter 14), these assumptions may not hold, and the resulting childhood mortality rates will be understated to some degree. 8.2 INFANT AND CHILD MORTALITY LEVELS AND TRENDS Table 8.1 presents childhood mortality rates for the three five-year periods before the 2010-11 ZDHS. The data show that, for the five-year period immediately prior to the survey, the under-5 mortality was 84 per 1,000 live births; that is, around 1 of every 12 Zimbabwean children died before reaching their fifth birthday during the five-year period. The infant mortality rate was 57 deaths per 1,000 live births, and the neonatal mortality rate was 31 per 1,000 births. Thus, two-thirds of the childhood deaths occurred during infancy, with slightly more than one third taking place during the first month of life. An examination of the mortality levels across the three successive five-year periods shown in Table 8.1 suggests that under-5 mortality rose from a level of 62 deaths per 1,000 births during the late 1990s (circa 1996 to 2000) to 84 deaths per 1,000 births during the second half of the last decade and the beginning of the current decade (circa 2006 to 2010). Most of the rise in mortality occurred outside of the neonatal period. Trends in mortality in early childhood can also be explored by examining the mortality results from successive rounds of DHS surveys in Zimbabwe. Table 8.2 shows the infant and under-5 mortality rates for the five-year periods preceding the 1988, 1994, 1999, 2005-06, and 2010-11 ZDHS surveys. The overall pattern suggests that mortality levels increased slightly in the 1980s and early 1990s, surged in the mid to late1990s, and then declined in the early 2000s. Table 8.2 Mortality rates for the five years preceding the survey Survey Approximate time period of estimated rates Neonatal mortality Postneonatal mortality Infant mortality Child mortality Under-5 mortality 2010-11 ZDHS 2006-2010 31 26 57 29 84 2005-06 ZDHS 2001-2005 24 36 60 24 82 1999 ZDHS 1994-1999 29 36 65 40 102 1994 ZDHS 1989-1994 24 28 53 26 77 1988 ZDHS1 1983-1988 27 22 49 23 71 1Estimates published in the 1988 ZDHS report (CSO and IRD, 1989) were based on calendar years prior to the survey; estimates presented here are calculated on years of exposure prior to the survey to be comparable with other survey estimates. Table 8.1 Early childhood mortality rates Neonatal, post-neonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey, Zimbabwe 2010-11 Years preceding the survey Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 31 26 57 29 84 5-9 25 27 51 19 70 10-14 25 21 46 17 62 1 Computed as the difference between the infant and neonatal mortality rates 102 • Infant and Child Mortality The direction of the trend in mortality during the second half of the last decade is, however, less certain. A comparison of the under-5 mortality for the five-year period prior to the 2010-11 ZDHS with the rate for the five-year period prior to the 2005-06 ZDHS suggests that mortality has barely changed. It rose from a level of 82 deaths per 1,000 births at the time of the 2005-06 survey to 84 deaths at the time of 2010-11 ZDHS. Most of the difference in under-5 mortality between the two most recent ZDHS surveys would appear to result from increases in both neonatal mortality and child mortality. Further examination of the rates from the two most recent ZDHS surveys, however, raises questions about the comparability of the mortality results from the two surveys. For example, the 5-9 year rates from the 2010-11 ZDHS (an infant mortality rate of 51 and under-5 mortality rate of 70) and the 0-4 year rates from the 2005-06 survey (an infant mortality rate of 60 and an under-5 mortality rate of 82) are not comparable, although they refer to approximately the same time frame (i.e., circa 2001-2005). Additional analysis is, therefore, needed to investigate the recent pattern of early childhood mortality in Zimbabwe before one may conclude that mortality has increased over the period between the 2005-06 and 2010-11 ZDHS surveys. As discussed above, possible factors that may be affecting the mortality estimates include reporting errors during the surveys and excess mortality among mothers. Sampling variability also should be considered. 8.3 SOCIOECONOMIC DIFFERENTIALS IN EARLY CHILDHOOD MORTALITY Table 8.3 shows differentials in infant and child mortality by residence, mother’s level of education, and type of antenatal care and delivery assistance. The mortality estimates are calculated for the 10-year period before the survey so that the rates are based on a sufficient number of cases in each category to ensure statistically reliable estimates. Table 8.3 Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 28 25 53 26 77 Rural 28 27 55 24 78 Province Manicaland 38 23 61 38 97 Mashonaland Central 37 33 70 27 95 Mashonaland East 22 19 41 17 57 Mashonaland West 38 32 70 26 93 Matabeleland North 10 13 23 13 36 Matabeleland South 9 20 29 11 40 Midlands 17 33 49 29 77 Masvingo 24 31 55 20 74 Harare 35 22 57 22 78 Bulawayo 15 26 41 (21) (61) Mother's education No education (32) (16) (48) (43) (89) Primary 30 32 62 28 89 Secondary 26 24 51 22 71 More than secondary (36) (12) (47) * * Wealth quintile Lowest 30 25 55 32 85 Second 31 30 61 28 88 Middle 30 27 57 25 81 Fourth 24 25 49 23 71 Highest 23 25 48 11 58 Note: Figures in parentheses are based on 250-499 unweighted person-years of exposure to the risk of death. An asterisk indicates that a rate based on fewer than 250 unweighted person-years of exposure to the risk of death and has been suppressed. 1 Computed as the difference between the infant and neonatal mortality rates Infant and Child Mortality • 103 Child mortality rates barely differ between urban and rural areas. The under-5 mortality rate is 77 deaths per 1,000 births in areas, compared with 78 deaths per 1,000 births in rural areas. In marked contrast, there is substantial variation in child mortality across provinces. Under-5 mortality is highest in Manicaland (97 deaths per 1,000 births) and lowest in Matabeleland North (36 deaths per 1,000 births). The wealth quintile into which a child is born also relates to survival. The under-5 mortality rate is substantially lower in the highest wealth quintile (58 deaths per 1,000 births) than in the lowest, second lowest, or middle quintiles (81-88 deaths per 1,000 births). 8.4 BIODEMOGRAPHIC DIFFERENTIALS IN EARLY CHILDHOOD MORTALITY The relationship between early childhood mortality and various demographic variables is examined in Table 8.4. Although the pattern is not uniform at all ages, male children experience higher mortality than their female counterparts. Infant mortality for males and females is 64 and 44 deaths per 1,000 births, respectively, and under-5 mortality rates for males and females are 87 and 68 deaths per 1,000 births, respectively. Table 8.4 Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child, and under-five mortality rates for the 10-year period preceding the survey, by demographic characteristics, Zimbabwe 2010-11 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child's sex Male 34 31 64 24 87 Female 22 22 44 25 68 Mother's age at birth <20 28 27 55 26 79 20-29 27 24 50 24 73 30-39 32 33 65 24 88 40-49 * * * * * Birth order 1 24 21 45 21 65 2-3 25 27 53 28 79 4-6 36 31 67 22 87 7+ (56) (33) (89) (30) (116) Previous birth interval2 <2 years 52 57 110 43 148 2 years 28 24 52 20 71 3 years 18 27 45 26 70 4+ years 31 25 56 25 80 Birth size3 Small/very small 73 (30) (104) na na Average or larger 22 26 48 na na Note: Figures in parentheses are based on 250-499 unweighted person-years of exposure to the risk of death. An asterisk indicates that a rate based on fewer than 250 unweighted person-years of exposure to the risk of death and has been suppressed. na = Not applicable. 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey The relationship between childhood mortality and mother’s age at birth shows the expected U-shape pattern for both the neonatal and postneonatal periods. The childhood mortality rates generally rise with the child’s birth order, although not uniformly. 104 • Infant and Child Mortality Studies have shown that a longer birth interval seems to increase a child’s chance of survival. Data from the 2010-11 ZDHS support this observation. For example, children born fewer than two years after a preceding sibling are more than twice as likely to die in infancy as those born two to three years after a preceding sibling (110 compared with 45-52 per 1,000). This link between the pace of childbearing and child survival rates is observed in all age groups. These findings point out the potential for mortality reduction that could result from successful efforts to promote birth spacing in Zimbabwe. A child’s size at birth is an indicator of the risk of dying during infancy, particularly during the first months of life. In the 2010-11 ZDHS, in addition to recording the actual birth weight, interviewers asked mothers whether the reference child was very small, small, average size, large, or very large at birth. This type of subjective assessment has been shown to correlate closely with actual birth weight. Survey results indicate that newborns perceived by their mothers to be very small or small were more likely to die in their first year than those perceived as average or larger in size; the differential is especially large during the neonatal period. However, because the numbers of small babies born in the last five years among survey respondents are small, these data should be interpreted with caution. 8.5 PERINATAL MORTALITY Pregnancy losses occurring after seven completed months of gestation (stillbirths) plus deaths of live births within the first seven days of life (early neonatal deaths) constitute perinatal deaths. The distinction between a stillbirth and an early neonatal death is recognized as a fine one, often depending on observing and then remembering sometimes faint signs of life after delivery. Furthermore, the causes of stillbirths and early neonatal deaths are closely linked, and examining just one or the other can understate the true level of mortality around delivery. For this reason, deaths around time of delivery are combined into the perinatal mortality rate. Information on stillbirths is available for the five years preceding the survey and was collected using the calendar at the end of the Women’s Questionnaire. Infant and Child Mortality • 105 Table 8.5 indicates that the perinatal mortality for the country as a whole is 39 deaths per 1,000 pregnancies. Differentials in perinatal mortality across selected background characteristics of the mothers vary widely. Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother's age at birth <20 14 28 38 1,104 20-29 47 69 37 3,159 30-39 22 37 46 1,289 40-49 3 3 51 125 Previous pregnancy interval in months4 First pregnancy 27 37 36 1,755 <15 5 17 102 209 15-26 14 14 51 541 27-38 8 11 23 855 39+ 32 59 39 2,317 Residence Urban 42 50 54 1,707 Rural 43 87 33 3,969 Province Manicaland 16 27 50 857 Mashonaland Central 4 16 33 606 Mashonaland East 3 11 26 533 Mashonaland West 2 29 45 702 Matabeleland North 4 3 24 268 Matabeleland South 6 2 29 279 Midlands 7 8 21 707 Masvingo 8 6 22 635 Harare 31 35 77 856 Bulawayo 5 1 26 232 Mother's education No education 2 1 24 95 Primary 31 47 43 1,843 Secondary 50 83 37 3,570 More than secondary 3 6 52 169 Wealth quintile Lowest 13 29 33 1,288 Second 13 33 39 1,191 Middle 18 22 37 1,087 Fourth 16 38 44 1,205 Highest 25 16 45 905 Total 85 137 39 5,676 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months' duration, expressed per 1000. 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. 8.6 HIGH-RISK FERTILITY BEHAVIOUR Typically, infants and young children have a higher risk of dying if they are born to very young mothers or older mothers, if they are born after a short interval, or if their mothers have already had many children. In the following analysis, mothers are classified as too young if they are less than 18 years old at the time of birth of the child and too old if they are age 35 years or more at the time of the birth. A short birth interval is defined as less than 24 months, and a high-order birth is defined as occurring after three or more previous births (i.e., birth order 4 or higher). A birth may be at an elevated risk of dying owing to a combination of characteristics. 106 • Infant and Child Mortality The first column of Table 8.6 shows the percentage of births in the five years before the survey classified by various risk categories. Overall, 36 percent of births are in at least one high-risk category; 26 percent are in a single high-risk category, and 10 percent have multiple high-risk characteristics. The second column in Table 8.6 presents risk ratios, which represent the increased risk of mortality among births in various high-risk categories relative to births not having any high-risk characteristics. The primary factor leading to heightened mortality risk in Zimbabwe is mother’s age greater than 34 (1.30). The largest percentage of high-risk births in Zimbabwe are of high birth order (birth order >3) and have a comparably modest increased risk of mortality (1.19). This acts to reduce the risk ratios in the overall single high-risk category (1.17) and in the overall multiple high-risk category (1.55). Table 8.6 High-risk fertility behaviour Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Zimbabwe 2010-11 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high risk category 38.9 1.00 28.2a Unavoidable risk category First-order births between ages 18 and 34 years 25.1 0.88 5.8 Single high-risk category Mother's age <18 7.1 1.08 1.1 Mother's age >34 1.7 1.30 5.5 Birth interval <24 months 3.5 1.20 14.1 Birth order >3 14.1 1.19 10.8 Subtotal 26.4 1.17 31.4 Multiple high-risk category Age <18 and birth interval <24 months2 0.2 * 0.4 Age >34 and birth interval <24 months 0.0 * 0.3 Age >34 and birth order >3 7.2 1.14 22.0 Age >34 and birth interval <24 months and birth order >3 0.6 (4.26) 3.4 Birth interval <24 months and birth order >3 1.6 2.19 8.5 Subtotal 9.6 1.55 34.6 In any avoidable high-risk category 36.0 1.27 66.0 Total 100.0 na 100.0 Number of births/women 5,596 na 5,703 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. Ratios in parentheses are based on 25-49 unweighted births. An asterisk indicates that a ratio based on fewer than 25 unweighted births that has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women The third column of Table 8.6 shows the distribution of currently married women by the risk category into which a birth conceived at the time of the survey would fall. The data in the table show that 28 percent of women are not in any elevated mortality risk category, and 6 percent are only at risk of having their first birth between ages 18 and 34, which is considered to be an unavoidable risk. Among those who are in an elevated mortality risk category (66 percent of women), 31 percent have a single high risk, and 35 percent have multiple risks. Maternal Health Care • 107 MATERNAL HEALTH CARE 9 The health care services that a mother receives during pregnancy, childbirth, and the immediate postnatal period are important for the survival and wellbeing of both the mother and the infant. The 2010-11 ZDHS obtained information on the extent to which women in Zimbabwe receive care during each of these stages. These findings are important to those who design policy and implement programmes to improve maternal and child health care services. 9.1 ANTENATAL CARE Antenatal care (ANC) from a skilled provider is important to monitor the pregnancy and reduce the risks for mother and child during pregnancy and at delivery. Antenatal care enables (1) early detection of complications and prompt treatment (e.g., of sexually transmitted infections); (2) prevention of diseases through immunisation and micronutrient supplementation; (3) birth preparedness and complication readiness; and (4) health promotion and disease prevention through health messages and counselling of pregnant women. Collecting information on antenatal care is of great value in identifying subgroups of women who do not use ANC services and in planning improvements in service delivery. In the 2010-11 ZDHS, women who had given birth in the five years preceding the survey were asked whether they had received antenatal care for their last live birth. If the respondent had received ANC for her last birth, she was then asked as series of questions about the care she received, such as the type of provider, number of visits made, stage of pregnancy at the time of the first visit, and services and information provided during the visit. For women with two or more live births during the five-year period preceding the survey, data refer to the most recent birth. Table 9.1 presents information about the type of provider from whom antenatal care services were received for the most recent birth, according to background characteristics. For women who reported more than one source of antenatal services, only the provider with the highest qualifications is presented in the table. Ninety percent of women age 15-49 received ANC from a skilled provider (doctor, nurse-midwife, or nurse) during their last pregnancy. This figure is slightly lower than that recorded in the 2005-06 ZDHS (94 percent) and the 1999 ZDHS (93 percent). Eighty percent of Key Findings • Ninety percent of women age 15-49 who gave birth in the five years preceding the survey received antenatal care from a skilled provider during pregnancy for their most recent birth. However, only 19 percent of the women received any antenatal care during their first trimester. • Fifty-four percent of the women who gave birth in the five years preceding the survey had sufficient tetanus toxoid injections to ensure that their most recent birth was protected against neonatal tetanus. • Sixty-five percent of live births in the five years preceding the survey took place in a health facility; 66 percent of live births were delivered by a skilled provider. • Among women who gave birth in the two years preceding the survey, 27 percent received a postnatal checkup in the first two days after birth. • Among women’s last births in the two years preceding the survey, 12 percent of newborns received a postnatal checkup in the first two days after birth. 108 • Maternal Health Care women received care from a nurse-midwife or nurse, and 10 percent received care from a doctor. Less than 1 percent of women received care from a village health worker or other unskilled provider. Ten percent of the women received no antenatal care. Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving antenatal care from a skilled provider for the most recent birth, according to background characteristics, Zimbabwe 2010-11 Background characteristic Antenatal care provider No ANC Total Percentage receiving antenatal care from a skilled provider1 Number of women Doctor Nurse- midwife Nurse Village health worker Other Mother’s age at birth <20 8.4 19.6 58.3 0.3 0.0 13.3 100.0 86.4 758 20-34 9.7 21.5 59.5 0.0 0.2 9.0 100.0 90.7 3,207 35-49 14.2 15.5 59.5 0.0 0.0 10.7 100.0 89.3 462 Birth order 1 12.1 20.4 58.1 0.1 0.2 9.0 100.0 90.6 1,305 2-3 9.9 22.3 58.7 0.0 0.1 9.0 100.0 90.9 2,058 4-5 7.9 18.7 62.2 0.1 0.4 10.4 100.0 88.9 765 6+ 6.2 13.5 60.9 0.0 0.0 19.4 100.0 80.6 298 Residence Urban 18.4 23.9 47.6 0.0 0.3 9.9 100.0 89.9 1,382 Rural 6.1 19.0 64.6 0.1 0.1 10.0 100.0 89.8 3,044 Province Manicaland 10.8 23.7 52.2 0.1 0.5 12.4 100.0 86.7 628 Mashonaland Central 11.4 40.7 39.7 0.4 0.0 7.8 100.0 91.8 471 Mashonaland East 5.7 23.5 57.6 0.0 0.0 13.2 100.0 86.8 426 Mashonaland West 7.1 7.2 73.1 0.0 0.0 12.6 100.0 87.4 552 Matabeleland North 2.5 7.3 83.1 0.0 0.0 7.1 100.0 92.9 215 Matabeleland South 8.1 3.3 84.5 0.0 0.0 3.9 100.0 95.9 213 Midlands 10.3 22.3 59.0 0.0 0.0 8.5 100.0 91.5 548 Masvingo 3.7 10.6 79.8 0.0 0.0 5.9 100.0 94.1 496 Harare 16.4 27.8 42.8 0.0 0.5 12.5 100.0 87.0 689 Bulawayo 24.4 21.0 46.7 0.0 0.4 7.6 100.0 92.1 189 Education No education 1.0 14.6 74.8 0.9 0.0 8.7 100.0 90.4 77 Primary 5.1 17.8 62.2 0.2 0.2 14.5 100.0 85.1 1,375 Secondary 10.8 22.4 58.7 0.0 0.2 8.0 100.0 91.8 2,835 More than secondary 46.3 13.9 34.5 0.0 0.0 5.4 100.0 94.6 139 Wealth quintile Lowest 4.5 15.7 67.6 0.2 0.2 11.6 100.0 87.9 957 Second 4.4 19.0 65.0 0.1 0.2 11.3 100.0 88.5 908 Middle 7.5 20.5 60.8 0.0 0.1 11.1 100.0 88.7 847 Fourth 11.8 23.7 55.1 0.0 0.0 9.4 100.0 90.6 971 Highest 24.4 24.5 45.3 0.0 0.4 5.4 100.0 94.2 743 Total 10.0 20.5 59.3 0.1 0.2 9.9 100.0 89.8 4,426 Notes: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. Total includes women for whom information on antenatal care is missing. 1 Skilled provider includes doctor, nurse-midwife, and nurse Usage of antenatal care services by a skilled provider does not vary much by the mother’s age at birth: 86 percent of mothers younger than age 20 and 89 to 91 percent of mothers age 20 and older receive care from a skilled provider. Birth order is inversely related to the use of antenatal care: women with higher-order births are less likely to receive antenatal care from a skilled provider. Ninety-one percent of women pregnant with their first through third child received antenatal care from a skilled provider compared with 81 percent of women with births of order six or higher. Although there are no differences by urban-rural residence in the percentage of women who receive antenatal care from a skilled provider (90 percent each), urban women are three times more likely than rural women (18 percent versus 6 percent) to receive antenatal care from a doctor. Nurses are more likely to provide antenatal care in the rural areas (65 percent) than in the urban areas (48 percent). Antenatal care coverage by a skilled provider is highest in Matabeleland South Maternal Health Care • 109 (96 percent) and lowest in Manicaland, Mashonaland East, Mashonaland West, and Harare (87 percent each). There are only small differences in education and wealth of the percentages of women who received antenatal care from a skilled provider. However, women with more than secondary education are much more likely to receive ANC services from a doctor (46 percent) compared with women with less education (1 to 11 percent). Women’s economic status also correlates with ANC provider type. Women in the highest wealth quintile (24 percent) are most likely to receive ANC from a doctor compared with those in the lowest wealth quintile (5 percent). 9.2 NUMBER AND TIMING OF ANTENATAL VISITS Antenatal care is more effective in preventing adverse pregnancy outcomes when sought early in the pregnancy and continued through to delivery. Health professionals recommend that the first antenatal visit should occur within 12 to 16 weeks of pregnancy. The second visit should occur at 28 weeks, the third visit at 32 weeks, and the fourth visit at 36 weeks. Under normal circumstances, WHO recommends that a woman without complications should have at least four visits. Women with complications, special needs, or conditions beyond the scope of basic care may require additional visits. In the 2010-11 ZDHS, respondents were asked how many ANC visits they made during the pregnancy preceding their last live birth in the five years before the survey and how many months pregnant they were at the time of the first visit. Table 9.2 shows that 89 percent of women who had a live birth in the five years preceding the survey had at least one ANC visit. Sixty- five percent had four or more visits, and 21 percent had two to three visits. Ten percent of the women received no antenatal care, up from 5 percent in the 2005–06 ZDHS. There are no major differences by place of residence on the number of visits made by women. Table 9.2 also shows that 19 percent of the women had their first ANC visit within the first trimester of their pregnancy, and 5 percent had visits from the eighth month onwards. The largest segment of women (40 percent) had their first visit in the fourth to the fifth month of pregnancy. The median duration of pregnancy at the first visit was 5.3 months, up from 5.0 months in the 2005-06 ZDHS. This is later than the recommended period for the first ANC visit. 9.3 COMPONENTS OF ANTENATAL CARE The content of antenatal care is an essential component of the quality of services. Apart from receiving basic care, every pregnant woman should be monitored for complications. Ensuring that pregnant women receive information on and undergo screening for complications should be a routine part of all antenatal care visits. To assess ANC services, respondents were asked whether they had Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Zimbabwe 2010-11 Number and timing of ANC visits Residence Total Urban Rural Number of ANC visits None 9.9 10.0 10.0 1 3.0 2.4 2.6 2-3 19.5 22.0 21.2 4+ 66.0 64.3 64.8 Don't know/missing 1.7 1.3 1.4 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 9.9 10.0 10.0 <4 19.0 19.6 19.4 4-5 35.5 41.3 39.5 6-7 28.9 24.8 26.1 8+ 6.2 4.0 4.7 Don't know/missing 0.4 0.3 0.3 Total 100.0 100.0 100.0 Number of women 1,382 3,044 4,426 Median months pregnant at first visit (for those with ANC) 5.5 5.3 5.3 Number of women with ANC 1,246 2,738 3,984 110 • Maternal Health Care been advised of complications or received certain screening tests during at least one of the antenatal care visits. Table 9.3 presents information on the content of ANC services, including the percentages of women who took iron supplements, took drugs for intestinal parasites, were informed of the signs of pregnancy complications, and received routine selected services during antenatal care visits for their most recent birth in the past five years. Overall, 50 percent of women took iron tablets or syrup during the pregnancy of their last birth. The likelihood that a woman took iron supplements increases with age (48 percent for those under age 20 compared with 54 percent for those age 35-49) but correlates inversely with birth order. For instance, 53 percent of women received iron supplements for first order births compared with 45 percent of women for sixth or higher birth order. There is slight variation by urban-rural residence in the proportion of women who took iron supplements (51 percent in urban areas compared with 49 percent in rural areas). More extreme differences are observed by province: women in Midlands are the least likely to take iron supplements (42 percent), and women in Matabeleland South are the most likely (61 percent). The percentage of women who took iron supplements generally increases with the level of education (44 percent of women with a primary education only compared with 62 percent of women with more than a secondary education). Fifty- seven percent of women in the highest wealth quintile took iron supplements compared with 42 to 53 percent of women in the other wealth quintiles. As a component of antenatal care, the administration of drugs to treat intestinal parasites is much less common than the administration of iron supplements. Overall, only 2 percent of women took drugs to treat intestinal parasites during their last pregnancy. Little variation was observed by background characteristic. Sixty-three percent of the women who received antenatal care for their most recent birth were informed of the signs of pregnancy complications. Women over the age of 20 are more likely to receive information on pregnancy complications than younger women. Birth order does not strongly correlate with receiving information on signs of pregnancy complications. Women in urban areas were more likely to receive information than those in rural areas (70 percent versus 59 percent). Differences are also reported by province; four in five women in Mashonaland East and Matabeleland South were informed of pregnancy complications compared with one in two women in Mashonaland Central. Education and wealth quintile have a strong positive association with being informed of the signs of pregnancy complications. Seventy-eight percent of women with more than secondary education and 73 percent in the highest wealth quintile were informed of the signs of pregnancy complications compared with only 44 percent of women with no education and 54 percent in the lowest quintile. Among the various other ANC services, overall, 88 percent of women who receive ANC had their blood pressure measured, 60 percent had a urine sample taken, and 84 percent had a blood sample taken. By background characteristics, the likelihood of women receiving each of the ANC services increases with increasing age, education level, and wealth. In addition, women in urban areas were more likely than those in rural areas to receive each ANC service. For example, urban women are more likely than their rural counterparts to have their blood pressure measured (95 percent and 85 percent, respectively), urine sample taken (71 percent and 55 percent, respectively), and blood sample taken (90 percent and 81 percent, respectively). Maternal Health Care • 111 Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the five years preceding the survey, the percentage who took iron tablets or syrup and drugs for intestinal parasites during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the five years preceding the survey, the percentage receiving specific antenatal services, according to background characteristics, Zimbabwe 2010-11 Background characteristic Among women with a live birth in the past five years, the percentage who during the pregnancy for their last birth Number of women with a live birth in the past five years Among women who received antenatal care for their most recent birth in the past five years, the percentage with the selected services Number of women with ANC for their most recent birth Took iron tablets or syrup Took intestinal parasite drugs Informed of signs of pregnancy complications Blood pressure measured Urine sample taken Blood sample taken Mother’s age at birth <20 48.2 2.6 758 56.8 83.6 53.1 82.9 657 20-34 49.3 2.2 3,207 63.5 88.5 60.4 83.9 2,915 35-49 53.6 2.2 462 66.1 91.4 68.7 84.2 412 Birth order 1 52.8 2.6 1,305 60.8 86.1 56.7 84.3 1,187 2-3 48.0 2.0 2,058 64.0 88.4 60.8 85.5 1,873 4-5 49.7 2.6 765 61.0 89.4 65.6 79.8 684 6+ 44.9 2.0 298 65.4 90.0 54.8 79.0 240 Residence Urban 51.4 0.9 1,382 69.7 94.6 71.1 89.8 1,246 Rural 48.7 2.9 3,044 59.4 85.0 55.0 81.0 2,738 Province Manicaland 56.6 2.9 628 54.7 86.6 55.3 85.9 549 Mashonaland Central 46.1 1.4 471 51.1 84.1 52.1 82.2 434 Mashonaland East 51.7 2.1 426 81.0 92.6 67.4 81.3 369 Mashonaland West 48.1 3.2 552 55.1 80.7 56.1 80.3 483 Matabeleland North 56.4 3.8 215 71.1 92.8 50.3 89.9 200 Matabeleland South 61.3 4.3 213 78.7 92.7 57.0 92.6 204 Midlands 41.8 1.7 548 61.6 83.1 55.0 73.6 501 Masvingo 50.4 3.3 496 53.1 86.8 59.5 81.0 467 Harare 42.9 1.0 689 72.4 95.1 73.3 90.3 603 Bulawayo 57.1 0.0 189 64.7 94.8 74.4 92.9 175 Education No education 48.9 4.5 77 44.3 76.0 48.1 68.9 71 Primary 43.5 2.6 1,375 53.6 83.5 49.1 77.4 1,175 Secondary 51.8 2.2 2,835 66.5 89.8 64.1 86.5 2,607 More than secondary 62.2 1.5 139 77.9 99.2 83.5 95.5 132 Wealth quintile Lowest 42.2 3.1 957 53.7 81.7 47.2 75.9 845 Second 52.5 2.0 908 57.3 84.6 52.0 79.2 805 Middle 47.7 3.1 847 65.4 86.6 61.3 85.0 752 Fourth 50.1 2.1 971 65.7 93.3 65.1 88.1 880 Highest 56.7 1.0 743 72.8 94.3 76.8 91.8 703 Total 49.5 2.3 4,426 62.6 88.0 60.0 83.8 3,984 9.4 TETANUS TOXOID Tetanus toxoid injections are given during pregnancy to prevent neonatal tetanus, a leading cause of early infant death in many developing countries that is often due to poor hygiene during delivery. For full protection of her newborn baby, a pregnant woman should receive at least two injections during the pregnancy. If a woman has been vaccinated during a previous pregnancy, however, she may only require one or no doses for the current pregnancy. Five doses are considered to provide lifetime protection. Table 9.4 presents the percent distribution of women who had a live birth in the five years preceding the survey by whether their last birth was protected against neonatal tetanus. 112 • Maternal Health Care Forty-five percent of women received two or more tetanus toxoid injections during the pregnancy of their last live birth. Women age 35-49 were less likely to have received two or more injections (37 percent) than their counterparts less than 34 years of age (45-46 percent). The likelihood of receiving two tetanus toxoid injections during the last pregnancy decreases with birth order. Women in urban areas are slightly less likely to have received two or more tetanus toxoid injections during the last pregnancy than women in rural areas (42 and 46 percent, respectively). Matabeleland South has the highest proportion of women who received two or more tetanus toxoid injections during their last pregnancy (69 percent), and Harare has the lowest proportion (38 percent). The proportion of women who received two or more tetanus toxoid injections during pregnancy varies by level of education and wealth. Forty-five percent or more of women with secondary education or more than secondary education received two or more tetanus toxoid injections during the last pregnancy compared with 37 percent of women with no education. Women in the fourth wealth quintile were more likely than women in other wealth quintiles to receive two or more tetanus toxoid injections (47 percent). Overall, 54 percent of women’s last births were protected against neonatal tetanus. Births to women age 20-34 were more likely than younger or older women to be protected against neonatal tetanus. Births of order one through three are more likely than births of order four or more to be protected against neonatal tetanus. Matabeleland South has the highest proportion of mothers whose last births were protected against neonatal tetanus (83 percent); Masvingo has the lowest proportion (46 percent). The proportion of mothers whose last births were protected against neonatal tetanus generally increases with increasing education level and wealth quintile. Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the five years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last live birth was protected against neonatal tetanus1 Number of mothers Age at birth <20 46.0 50.0 758 20-34 45.2 55.3 3,207 35-49 37.0 48.6 462 Birth order 1 48.2 55.1 1,305 2-3 44.5 54.5 2,058 4-5 40.6 51.3 765 6+ 38.0 48.1 298 Residence Urban 42.1 52.9 1,382 Rural 45.6 54.1 3,044 Province Manicaland 41.3 48.9 628 Mashonaland Central 44.9 50.9 471 Mashonaland East 61.7 71.4 426 Mashonaland West 44.1 57.0 552 Matabeleland North 43.7 50.3 215 Matabeleland South 69.1 82.8 213 Midlands 39.7 48.1 548 Masvingo 38.7 45.7 496 Harare 38.2 49.0 689 Bulawayo 41.4 52.4 189 Education No education 36.5 42.1 77 Primary 40.8 48.5 1,375 Secondary 46.5 56.5 2,835 More than secondary 44.7 54.6 139 Wealth quintile Lowest 39.9 47.4 957 Second 45.1 55.3 908 Middle 45.1 54.3 847 Fourth 47.3 56.1 971 Highest 45.1 56.1 743 Total 44.5 53.7 4,426 1Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within 10 years of the last live birth), or five or more injections at any time prior to the last birth Maternal Health Care • 113 9.5 PLACE OF DELIVERY Increasing the number of women who deliver in health facilities is an important factor in reducing health risks to the mother and the newborn child. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and infections that can cause morbidity and mortality to either the mother or the infant. Table 9.5 presents the percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics. Table 9.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Zimbabwe 2010-11 Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector Mission hospital Mother's age at birth <20 55.5 1.5 6.6 35.3 1.1 0.1 100.0 63.6 1,091 20-34 56.1 3.0 7.1 32.4 1.4 0.1 100.0 66.1 3,976 35-49 51.8 3.4 5.4 37.9 1.5 0.0 100.0 60.7 528 Birth order 1 62.9 3.2 7.9 25.2 0.7 0.1 100.0 74.0 1,798 2-3 56.4 3.2 6.6 32.1 1.7 0.0 100.0 66.2 2,490 4-5 47.8 1.7 6.2 42.7 1.3 0.3 100.0 55.7 944 6+ 33.6 0.0 5.0 59.5 1.9 0.0 100.0 38.5 364 Antenatal care visits1 None 26.4 0.5 1.1 69.6 2.0 0.5 100.0 28.0 442 1-3 55.7 1.4 4.6 37.0 1.3 0.0 100.0 61.7 1,054 4+ 61.0 4.0 8.6 25.3 1.1 0.0 100.0 73.6 2,868 Residence Urban 75.7 7.0 2.4 14.2 0.6 0.1 100.0 85.1 1,666 Rural 47.0 0.9 8.7 41.6 1.6 0.1 100.0 56.7 3,930 Province Manicaland 49.5 0.9 10.5 35.7 3.2 0.2 100.0 60.9 843 Mashonaland Central 38.2 0.8 11.4 48.4 1.1 0.2 100.0 50.3 603 Mashonaland East 52.3 0.5 6.2 39.6 1.3 0.0 100.0 59.0 530 Mashonaland West 49.0 0.5 3.1 46.0 1.1 0.2 100.0 52.6 701 Matabeleland North 55.1 1.0 7.4 36.1 0.4 0.0 100.0 63.5 265 Matabeleland South 66.3 1.4 1.6 29.2 1.1 0.3 100.0 69.3 273 Midlands 51.4 2.4 9.6 35.5 1.1 0.0 100.0 63.4 701 Masvingo 59.5 4.0 9.9 25.5 1.1 0.0 100.0 73.4 627 Harare 72.3 8.7 1.7 16.9 0.5 0.0 100.0 82.7 826 Bulawayo 80.9 6.2 1.2 10.9 0.9 0.0 100.0 88.3 227 Mother’s education No education 30.0 0.0 5.6 60.8 2.1 1.5 100.0 35.6 95 Primary 41.6 0.6 6.4 49.9 1.5 0.1 100.0 48.5 1,814 Secondary 63.4 2.9 6.8 25.6 1.3 0.0 100.0 73.1 3,521 More than secondary 58.1 25.1 11.8 5.0 0.0 0.0 100.0 95.0 166 Wealth quintile Lowest 38.5 0.2 7.4 51.8 1.8 0.2 100.0 46.2 1,277 Second 46.0 0.7 7.9 43.8 1.7 0.0 100.0 54.6 1,178 Middle 52.1 0.8 9.9 35.7 1.4 0.1 100.0 62.8 1,070 Fourth 73.2 2.4 4.0 19.3 1.0 0.1 100.0 79.6 1,190 Highest 73.5 11.8 4.6 9.5 0.6 0.0 100.0 89.9 880 Total 55.6 2.7 6.8 33.5 1.3 0.1 100.0 65.1 5,596 Note: total includes 63 cases for which the number of antenatal care visits is missing. 1 Includes only the most recent birth in the five years preceding the survey Table 9.5 shows that 65 percent of births occurred in health facilities. This figure is slightly lower than that recorded in the 2005-06 ZDHS (68 percent) and 1999 ZDHS (72 percent). Fifty-six percent of births took place in public health facilities, 3 percent happened in private health facilities, and 7 percent occurred in mission hospitals. Thirty-four percent of live births in the five years preceding the survey occurred at home compared with 31 percent in the 2005-06 ZDHS and 23 percent in the 1999 ZDHS. 114 • Maternal Health Care Women age 20-34 are somewhat more likely to deliver in a health facility (66 percent) compared with younger (64 percent) and older women (61 percent). Higher-order births have a greater likelihood of being delivered at home: 60 percent of sixth or higher-order births occurred at home compared with 25 percent of first births. Furthermore, there is a strong relationship between uptake of antenatal care and place of delivery. Only 28 percent of live births to women who received no antenatal care services took place in a health facility compared with 74 percent of live births to women who received four or more ANC visits. Place of delivery varies greatly by urban-rural residence; 85 percent of births in urban areas were delivered in a health facility compared with 57 percent of births in rural areas. A child in a rural area is nearly three times more likely to have been born at home than a child in an urban area (42 percent compared with 14 percent). More than eight in ten births in Harare (83 percent) and Bulawayo (88 percent) were delivered in a health facility. In other provinces, the percentage of births delivered in a health facility ranges from a low of 50 percent in Mashonaland Central to a high of 73 percent in Masvingo. Home deliveries are most common in Mashonaland Central (48 percent) and least common in Bulawayo (11 percent). There is a marked correlation between a mother’s education and place of delivery. Births to mothers with more than secondary education are much more likely to take place in a health facility than births to mothers with no education (95 percent compared with 36 percent). Notably, however, the percentage of births to women with more than secondary education that took place at home has increased in the 2010-11 ZDHS (5 percent) compared with the 2005-06 ZDHS (1 percent) or the 1999 ZDHS (1 percent). There is a strong correlation between household wealth and place of delivery. Mothers in the highest wealth quintile are nearly twice as likely to give birth in a health facility as mothers in the lowest wealth quintile (90 percent and 46 percent, respectively). 9.6 ASSISTANCE DURING DELIVERY Obstetric care from a skilled provider (doctor, nurse-midwife, or nurse) during delivery is recognized as a critical element in the reduction of maternal and neonatal mortality. Births delivered at home are usually more likely to be delivered without assistance from a skilled provider, whereas births delivered at a health facility are more likely to be delivered by a trained health professional. Table 9.6 shows the percent distribution of live births in the five years preceding the survey by person providing assistance at delivery and the percentage of births delivered by Caesarean section (C-section), according to background characteristics. Maternal Health Care • 115 Table 9.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by person providing assistance during delivery, percentage of births assisted by a skilled provider, and the percentage delivered by Caesarean-section, according to background characteristics, Zimbabwe 2010-11 Background characteristic Person providing assistance during delivery Total Per- centage delivered by a skilled provider1 Per- centage delivered by C-section Number of births Doctor Nurse- midwife Nurse Village health worker Traditional birth attendant Relative/ other No one Don't know/ missing Mother's age at birth <20 7.9 26.6 30.3 4.9 14.2 15.1 1.0 0.1 100.0 64.8 3.5 1,091 20-34 8.0 28.2 30.9 5.2 12.4 12.9 2.3 0.1 100.0 67.1 4.6 3,976 35-49 11.2 22.4 29.2 5.1 13.1 11.1 7.9 0.0 100.0 62.7 6.1 528 Birth order 1 10.7 31.5 32.7 3.7 10.9 10.0 0.4 0.1 100.0 74.9 5.1 1,798 2-3 8.1 28.2 31.1 5.3 12.4 12.9 1.9 0.0 100.0 67.4 4.7 2,490 4-5 6.1 22.2 28.4 7.0 15.9 14.6 5.5 0.3 100.0 56.8 3.9 944 6+ 3.6 14.4 21.8 6.3 17.6 26.3 9.9 0.0 100.0 39.9 2.2 364 Place of delivery Health facility 12.5 41.4 45.3 0.1 0.1 0.5 0.1 0.0 100.0 99.2 6.9 3,644 Elsewhere 0.4 1.2 3.0 14.6 36.7 36.8 7.2 0.0 100.0 4.7 0.0 1,947 Residence Urban 15.8 42.3 27.9 1.7 5.0 6.1 1.2 0.1 100.0 86.0 7.8 1,666 Rural 5.1 21.0 31.7 6.6 16.1 16.2 3.1 0.1 100.0 57.9 3.1 3,930 Province Manicaland 7.3 27.9 25.4 6.5 15.4 16.0 1.4 0.2 100.0 60.5 3.5 843 Mashonaland Central 7.8 32.4 11.2 5.5 24.6 13.8 4.5 0.2 100.0 51.4 3.7 603 Mashonaland East 5.7 21.7 32.5 4.4 21.5 10.9 3.3 0.0 100.0 59.9 2.5 530 Mashonaland West 4.0 24.3 26.7 14.0 13.9 12.5 4.4 0.2 100.0 55.0 2.5 701 Matabeleland North 6.9 11.5 47.3 1.6 16.6 12.9 3.2 0.0 100.0 65.7 4.0 265 Matabeleland South 8.7 10.2 52.8 2.0 6.0 19.1 1.0 0.3 100.0 71.6 6.1 273 Midlands 8.9 22.1 33.6 2.8 9.1 20.7 2.8 0.0 100.0 64.6 4.4 701 Masvingo 3.7 20.3 51.2 3.9 6.5 12.2 2.1 0.0 100.0 75.2 4.7 627 Harare 14.5 45.0 24.0 2.8 7.0 5.9 0.8 0.0 100.0 83.5 7.0 826 Bulawayo 22.2 45.6 20.5 0.6 1.9 6.6 2.5 0.0 100.0 88.4 10.5 227 Mother’s education No education 0.0 19.1 19.8 8.7 18.2 19.1 13.6 1.5 100.0 38.9 0.3 95 Primary 4.0 18.0 27.9 7.8 18.4 20.4 3.5 0.1 100.0 49.8 3.0 1,814 Secondary 9.4 32.2 32.5 3.9 10.3 9.8 1.9 0.0 100.0 74.1 5.0 3,521 More than secondary 36.3 32.9 25.8 0.9 2.1 2.0 0.0 0.0 100.0 95.0 13.8 166 Wealth quintile Lowest 4.1 13.6 29.8 6.6 18.8 21.9 5.0 0.2 100.0 47.5 2.5 1,277 Second 4.4 20.5 31.0 7.1 17.4 17.0 2.6 0.0 100.0 55.9 2.6 1,178 Middle 5.1 25.2 33.3 7.9 14.1 12.1 2.1 0.1 100.0 63.6 3.3 1,070 Fourth 11.1 38.6 31.2 2.4 7.9 7.3 1.4 0.1 100.0 80.9 6.2 1,190 Highest 19.7 43.9 27.0 0.8 3.1 4.5 1.0 0.0 100.0 90.6 9.2 880 Total 8.3 27.4 30.6 5.1 12.8 13.2 2.6 0.1 100.0 66.2 4.5 5,596 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. Total includes 5 cases for which place of delivery is missing. 1 Skilled provider includes doctor, nurse-midwife and nurse Sixty-six percent of live births in the five years preceding the survey were delivered by a skilled provider, with 8 percent of the deliveries assisted by a doctor, 27 percent by a nurse-midwife, and 31 percent by a nurse. Five percent of births were assisted by a village health worker, 13 percent by a traditional birth attendant, and 13 percent by relatives or others. Three percent of births were delivered without any assistance at all. Overall, the percentage of live births delivered by a skilled provider observed in the 2010-11 ZDHS (66 percent) represents a slight reduction from the figures reported in the 2005-06 ZDHS (69 percent) and the 1999 ZDHS (73 percent). The percentage of live births delivered by a skilled provider does not differ markedly by mother’s age at birth. In contrast, large variations occur by birth order, place of delivery, urban-rural residence, education, and wealth quintile. First-order births are more likely to receive assistance from a skilled provider (75 percent) compared with higher-order births (40 to 67 percent). Almost all births where delivery took place in a health facility were delivered by a skilled provider (99 percent) compared with just 5 percent of births that occurred elsewhere. Among births that occurred outside a health facility, 15 percent were assisted by a village health worker, 37 percent by a traditional birth attendant, and 37 percent by a relative or other. 116 • Maternal Health Care In urban areas, 86 percent of births were assisted by a skilled provider compared with 58 percent in rural areas. Doctors assisted 16 percent of births in urban areas compared with 5 percent in rural areas. More than eight in ten deliveries in Harare (84 percent) and Bulawayo (88 percent) were assisted by a skilled provider. In other provinces, the delivery assistance from a skilled provider ranged from 51 percent in Mashonaland Central to 75 percent in Masvingo. Mashonaland Central has the highest percentage of deliveries by traditional birth attendants (25 percent), and Bulawayo has the lowest percentage (2 percent). Assistance at delivery came from a relative or other in about one fifth of births in Matabeleland South and Midlands. Mother’s education is strongly related to the type of assistance at delivery. Births to women with secondary and higher education were much more likely to receive assistance from a skilled provider during delivery compared with births to women with no education (95 percent and 39 percent, respectively). Nineteen percent of births to women with no education and 20 percent of birth to women with primary education only were assisted by relatives or others compared with 2 percent of births to women with more than secondary education. Fourteen percent of births to women with no education were assisted by no one at all. As with education, wealth quintile is strongly associated with type of assistance at delivery. Births to women in the highest wealth quintile were more likely to get assistance at delivery from a skilled provider (91 percent) compared with births to women in the lowest wealth quintile (48 percent). Furthermore, births to women in the highest wealth quintile were five times more likely than births to women in the lowest wealth quintile to be assisted by a doctor (20 percent and 4 percent, respectively). Respondents were also asked whether each of their live births in the five years preceding the survey were delivered by Caesarean (C-section). Five percent of births were delivered by C-section; this figure is unchanged from the one reported in the 2005-06 ZDHS (5 percent) but is slightly lower than the one reported in the 1999 ZDHS (7 percent). C-sections are most common among first through third births (5 percent), urban births (8 percent), births to women in urban provinces (11 percent for Bulawayo and 7 percent for Harare), births to women with more than secondary education (14 percent), and births to women in the highest wealth quintile (9 percent). 9.7 POSTNATAL CARE FOR THE MOTHER A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Thus, prompt postnatal care (PNC) is important for both the mother and the child to treat complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. Safe motherhood programmes recommend that all women receive a check on their health within two days after delivery. Women who deliver at home should go to a health facility for postnatal care services within 24 hours, and subsequent visits (including those by women who deliver in a health facility) should be made at three days, seven days, and six weeks after delivery. It is also recommended that women who deliver in a health facility should be kept for at least 48 hours (up to 72 hours depending on the capacity of the institution) for the mothers and infants to be monitored by skilled personnel. Maternal Health Care • 117 To assess the extent of postnatal care utilization, respondents were asked, for the last birth in the two years preceding the survey, whether they had received a checkup after delivery, the timing of the first checkup, and the type of health provider performing the postnatal checkup. This information is presented according to background characteristics in Tables 9.7 and 9.8. Table 9.7 Timing of first postnatal checkup for the mother Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution of the mother's first postnatal checkup for the last live birth by time after delivery, and the percentage of women with a live birth in the two years preceding the survey who received a postnatal checkup in the first two days after giving birth, according to background characteristics, Zimbabwe 2010-11 Background characteristic Time after delivery of mother's first postnatal checkup No neonatal checkup1 Total Percentage of women with a postnatal checkup in the first two days after birth Number of women Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don't know Age at birth <20 15.5 4.2 4.3 1.7 9.3 2.2 62.8 100.0 23.3 437 20-34 17.9 5.7 5.1 1.9 12.3 1.7 55.5 100.0 28.0 1,760 35-49 17.7 7.3 2.7 2.6 12.2 2.4 55.2 100.0 27.0 251 Birth order 1 18.5 6.4 5.3 1.7 11.5 1.6 55.0 100.0 29.6 711 2-3 18.6 5.9 4.8 1.9 11.6 1.8 55.4 100.0 28.6 1,161 4-5 15.5 3.5 4.6 2.3 11.8 2.2 60.0 100.0 23.4 407 6+ 10.1 4.8 1.3 2.5 13.0 2.4 65.9 100.0 14.8 170 Place of delivery Health facility 24.9 7.4 4.6 1.6 11.6 2.7 47.0 100.0 36.9 1,562 Elsewhere 4.4 2.3 4.8 2.4 11.9 0.3 73.9 100.0 9.7 886 Residence Urban 27.6 7.6 5.6 2.2 11.0 2.6 43.3 100.0 40.6 718 Rural 13.2 4.7 4.3 1.8 12.0 1.5 62.3 100.0 21.5 1,730 Province Manicaland 10.9 4.3 4.2 0.6 12.7 0.6 66.6 100.0 19.4 366 Mashonaland Central 13.8 4.0 6.3 3.4 11.1 0.4 61.0 100.0 24.1 254 Mashonaland East 7.0 3.9 4.7 1.2 10.7 0.0 72.6 100.0 15.5 257 Mashonaland West 24.4 3.7 3.1 2.4 14.6 0.7 51.2 100.0 27.0 296 Matabeleland North 18.5 2.8 5.3 2.6 14.4 4.0 52.3 100.0 25.9 115 Matabeleland South 27.4 7.5 3.0 2.1 13.8 0.7 45.6 100.0 36.9 124 Midlands 14.8 8.0 4.1 1.3 5.8 2.9 63.1 100.0 26.9 298 Masvingo 10.5 3.7 4.2 1.9 20.1 2.7 57.0 100.0 18.4 277 Harare 30.1 8.6 3.9 2.5 5.6 4.7 44.6 100.0 42.2 352 Bulawayo 25.7 11.6 13.5 2.7 14.1 1.8 30.7 100.0 50.8 111 Education No education (8.3) (0.0) (3.7) (4.1) (6.5) (0.0) (77.4) 100.0 (12.0) 28 Primary 12.7 3.1 3.5 1.5 11.3 1.4 66.6 100.0 18.6 767 Secondary 19.1 6.5 5.0 2.2 11.9 2.1 53.3 100.0 29.9 1,573 More than secondary 35.1 12.3 10.0 1.0 14.5 2.9 24.3 100.0 57.3 80 Wealth quintile Lowest 11.2 2.3 2.9 1.5 12.2 1.8 68.0 100.0 15.7 543 Second 14.5 5.1 4.2 1.7 11.7 1.8 61.1 100.0 22.9 515 Middle 13.1 4.6 4.3 2.8 13.5 1.0 60.7 100.0 21.2 478 Fourth 21.8 8.1 4.4 1.1 10.0 2.6 52.0 100.0 33.8 519 Highest 29.6 8.6 8.7 2.8 11.3 2.0 37.0 100.0 46.6 393 Total 17.5 5.6 4.7 1.9 11.7 1.8 56.8 100.0 27.1 2,448 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes women who received a checkup after 41 days 118 • Maternal Health Care Table 9.8 Type of provider of first postnatal checkup for the mother Among women age 15-49 giving birth in the two years preceding the survey, the percent distribution by type of provider of the mother's first postnatal checkup in the two days after the last live birth, according to background characteristics, Zimbabwe 2010-11 Background characteristic Type of health provider of mother's first postnatal checkup No postnatal checkup in the first two days after the birth Total Number of women Doctor Nurse- midwife Nurse Village health worker Traditional birth attendant Age at birth <20 3.6 3.3 16.5 0.7 0.0 76.0 100.0 437 20-34 6.5 5.9 15.5 0.5 0.2 71.3 100.0 1,760 35-49 9.6 5.3 12.1 0.3 0.3 72.4 100.0 251 Birth order 1 6.6 6.3 16.7 0.6 0.0 69.8 100.0 711 2-3 6.9 5.6 16.2 0.4 0.3 70.7 100.0 1,161 4-5 5.5 4.4 13.5 0.0 0.2 76.4 100.0 407 6+ 3.4 2.5 8.9 1.4 0.0 83.8 100.0 170 Place of delivery Health facility 9.4 8.0 19.4 0.0 0.0 63.1 100.0 1,562 Elsewhere 0.8 0.8 8.2 1.3 0.5 88.5 100.0 886 Residence Urban 11.7 10.0 19.0 0.2 0.1 59.2 100.0 718 Rural 4.1 3.5 13.8 0.6 0.2 77.7 100.0 1,730 Province Manicaland 4.9 5.1 9.5 0.0 0.0 80.6 100.0 366 Mashonaland Central 6.5 5.6 11.9 0.0 0.0 75.9 100.0 254 Mashonaland East 2.0 1.8 11.8 0.0 0.0 84.5 100.0 257 Mashonaland West 4.8 6.4 15.8 3.5 0.7 68.8 100.0 296 Matabeleland North 1.7 4.3 19.8 0.0 0.8 73.4 100.0 115 Matabeleland South 7.2 1.2 28.4 0.0 1.0 62.1 100.0 124 Midlands 9.0 4.5 13.4 0.0 0.0 73.1 100.0 298 Masvingo 2.6 0.6 15.2 0.0 0.0 81.6 100.0 277 Harare 11.0 9.9 21.3 0.3 0.0 57.4 100.0 352 Bulawayo 15.6 17.7 17.4 0.0 0.0 49.2 100.0 111 Education No education (0.0) (6.3) (5.7) (0.0) (0.0) (88.0) 100.0 28 Primary 2.7 3.4 12.5 0.6 0.1 80.7 100.0 767 Secondary 6.8 6.3 16.9 0.5 0.2 69.4 100.0 1,573 More than secondary 34.3 6.1 16.9 0.0 0.0 42.7 100.0 80 Wealth quintile Lowest 2.9 1.6 11.2 0.6 0.2 83.6 100.0 543 Second 3.2 4.4 15.3 0.7 0.1 76.3 100.0 515 Middle 4.5 4.0 12.6 0.4 0.5 78.0 100.0 478 Fourth 7.0 8.4 18.5 0.3 0.1 65.8 100.0 519 Highest 16.4 9.8 20.3 0.3 0.0 53.1 100.0 393 Total 6.3 5.4 15.4 0.5 0.2 72.3 100.0 2,448 Note: Figures in parentheses are based on 25-49 unweighted cases. Overall, 43 percent of mothers received a postnatal checkup for the most recent birth in the two years preceding the survey. Eighteen percent of the mothers received a postnatal checkup in fewer than 4 hours after delivery, 6 percent within 4 to 23 hours, 5 percent within 1 to 2 days, 2 percent within 3 to 6 days, and 12 percent within 7 to 41 days after delivery. Fifty-seven percent of the mothers had no postnatal check-up. In total, only 27 percent of women received a postnatal check-up within the first two days after delivery, the recommended time period. Women less than 20 years old were slightly less likely to have had a postnatal check-up within two days of delivery than older women. Women with six or more births were also less likely to have a postnatal check-up within two days after delivery compared with women with fewer births (15 percent compared with 23 to 30 percent). Women who delivered in a health facility, who resided in urban areas, who had higher levels of education, and who were in the highest wealth quintiles were much more likely to receive a postnatal check-up within two days of delivery compared with other women. For instance, 37 percent of women who delivered at a health facility received a postnatal check-up within two days after birth compared with 10 percent who delivered elsewhere. Similarly, 41 percent of women living in urban Maternal Health Care • 119 areas had a postnatal check-up within two days compared with 22 percent of women living in rural areas. Likewise, mothers living in the urban provinces of Bulawayo (51 percent) and Harare (42 percent) were most likely to have a postnatal check-up within two days of delivery. Women living in Mashonaland East and Masvingo were least likely to have had a postnatal check-up within the same period of time (16 and 18 percent, respectively). The postnatal care coverage for women who received a checkup within two days of delivery in the remaining provinces ranges from 19 percent in Manicaland to 37 percent in Matabeleland South. Mothers with more than secondary education are three times as likely as mothers with primary education only to have had a postnatal checkup within two days of delivery (57 percent and 19 percent, respectively). Mothers in the highest wealth quintile are also three times as likely as mothers in the lowest quintile to have had a checkup within two days of delivery (47 percent and 16 percent, respectively). Table 9.8 shows the type of provider of the mother’s first postnatal checkup that took place within two days after the last live birth: 6 percent of women received a postnatal checkup from a doctor, 5 percent from a nurse-midwife, and 15 percent from a nurse. Less than 1 percent received a check-up from either a traditional birth attendant or a village health worker. Differentials by background characteristics are similar to those observed for women who received a postnatal check- up within two days after delivery (Table 9.7). 9.8 POSTNATAL CARE FOR THE NEWBORN As discussed, a significant proportion of neonatal deaths occur during the first few hours of life (48 hours) after delivery. The provision of postnatal care services for newborns should therefore start as soon as possible after the child is born. The timing of the postnatal check-up for the newborn is similar to that of the mother in that it should occur within two days after birth. Table 9.9 shows that 14 percent of last births in the two years preceding the survey received a postnatal check-up. Three percent of the newborns received a postnatal check-up less than 1 hour after birth, 5 percent within 1 to 3 hours, 2 percent within 4 to 23 hours, 2 percent within 1 to 2 days, and 1 percent within 3 to 6 days. The vast majority of newborns (86 percent) did not receive a postnatal check-up. Overall, only 12 percent of births received a checkup in the first two days after birth. 120 • Maternal Health Care Table 9.9 Timing of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by time after birth of first postnatal checkup, and the percentage of births with a postnatal checkup in the first two days after birth, according to background characteristics, Zimbabwe 2010-11 Background characteristic Time after birth of newborn's first postnatal checkup No postnatal checkup1 Total Percentage of births with a postnatal checkup in the first two days after birth Number of births Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don't know Mother's age at birth <20 2.7 6.5 1.0 2.2 0.6 1.1 85.8 100.0 12.4 437 20-34 2.2 5.2 1.6 2.2 1.4 0.5 86.9 100.0 11.2 1,760 35-49 5.1 4.9 1.5 2.2 3.4 1.3 81.6 100.0 13.7 251 Birth order 1 2.8 6.7 1.9 1.2 0.9 0.9 85.6 100.0 12.7 711 2-3 2.5 5.8 1.5 2.8 1.5 0.2 85.8 100.0 12.5 1,161 4-5 2.8 3.5 0.6 2.3 2.3 1.4 87.1 100.0 9.2 407 6+ 1.9 2.2 2.3 1.8 1.2 1.9 88.7 100.0 8.2 170 Place of delivery Health facility 3.9 7.2 1.9 1.3 0.6 0.9 84.1 100.0 14.3 1,562 Elsewhere 0.3 2.2 0.8 3.7 2.9 0.4 89.7 100.0 7.0 886 Residence Urban 4.2 8.8 2.3 2.5 1.3 1.6 79.3 100.0 17.9 718 Rural 1.9 4.0 1.2 2.0 1.5 0.4 89.0 100.0 9.2 1,730 Province Manicaland 2.9 5.3 2.2 1.5 0.7 0.0 87.4 100.0 11.9 366 Mashonaland Central 1.0 3.7 0.2 2.5 2.8 0.0 89.7 100.0 7.5 254 Mashonaland East 2.3 3.3 0.0 2.5 0.5 0.0 91.4 100.0 8.1 257 Mashonaland West 5.3 3.8 1.6 2.3 0.3 0.5 86.2 100.0 13.0 296 Matabeleland North 4.3 3.7 0.7 1.2 1.0 1.7 87.4 100.0 9.9 115 Matabeleland South 7.6 6.0 0.4 3.0 0.9 0.0 82.1 100.0 17.0 124 Midlands 0.0 6.5 2.0 2.8 2.6 1.0 85.1 100.0 11.3 298 Masvingo 0.0 2.3 1.1 1.3 1.4 0.5 93.4 100.0 4.7 277 Harare 1.9 12.3 3.0 1.1 2.2 2.5 76.9 100.0 18.3 352 Bulawayo 7.2 2.8 2.4 6.9 1.2 0.6 79.0 100.0 19.3 111 Mother’s education No education (0.0) (3.5) (0.0) (8.5) (6.9) (0.0) (81.0) 100.0 (12.1) 28 Primary 2.0 2.6 0.5 2.0 1.1 0.2 91.5 100.0 7.1 767 Secondary 2.8 6.7 1.8 2.1 1.5 0.9 84.1 100.0 13.4 1,573 More than secondary 5.8 7.9 5.6 2.5 0.8 1.0 76.3 100.0 21.8 80 Wealth quintile Lowest 1.5 3.4 1.0 1.6 1.8 0.0 90.6 100.0 7.6 543 Second 1.1 2.3 1.4 2.2 1.7 0.6 90.8 100.0 7.0 515 Middle 2.9 5.4 0.5 1.6 1.3 1.1 87.3 100.0 10.3 478 Fourth 3.1 8.8 2.5 2.6 1.0 0.8 81.2 100.0 17.1 519 Highest 5.1 7.7 2.3 3.1 1.4 1.3 79.1 100.0 18.2 393 Total 2.6 5.4 1.5 2.2 1.4 0.7 86.2 100.0 11.7 2,448 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Includes newborns who received a checkup after the first week Place of delivery, urban-rural residence, mother’s education level, and mother’s wealth status are closely linked to the timing of the first postnatal check-up for the newborn. Newborns whose mothers deliver in a health facility, live in urban areas, have more than secondary education, and who are in the highest wealth quintile have a higher likelihood of receiving a postnatal check-up within two days after birth when compared with those newborns whose mothers delivered elsewhere, reside in rural areas, are less educated, and are members of households in the lower wealth quintiles. For instance, 14 percent of newborns whose mothers delivered in a health facility received a check-up within 2 days compared with 7 percent whose mothers delivered elsewhere. Eighteen percent of newborns with mothers living in urban areas had a postnatal check-up within two days after birth compared with 9 percent of newborns with mothers living in rural areas. Newborns with mothers living in Bulawayo (19 percent) and Harare (18 percent) were most likely to have a postnatal check-up within two days after birth. Those whose mothers were living in Masvingo were least likely to have had a postnatal check-up within the same two day time period (5 percent). Maternal Health Care • 121 Newborns whose mothers have more than secondary education are more likely to have a postnatal check-up within two days after birth when compared with their counterparts whose mothers have primary education only (22 percent and 7 percent, respectively). Newborns of mothers in the highest wealth quintile are more than two times as likely as newborns of mothers in the lowest quintile to have had a check-up within two days after birth (18 percent and 8 percent, respectively). Table 9.10 shows the type of provider of the newborn’s first postnatal check-up that took place within two days after birth: 2 percent of newborns received a postnatal check-up from a doctor, 2 percent from a nurse-midwife, and 8 percent from a nurse. Less than 1 percent of newborns received a postnatal checkup from a traditional birth attendant. For 88 percent of newborns, there was no postnatal checkup within the first two days after birth. Differentials by background characteristics are similar to those observed for last births in the two years preceding the survey by time of newborn’s first postnatal checkup (Table 9.9). Table 9.10 Type of provider of first postnatal checkup for the newborn Percent distribution of last births in the two years preceding the survey by type of provider of the newborn's first postnatal checkup during the two days after the last live birth, according to background characteristics, Zimbabwe 2010-11 Background characteristic Type of health provider of newborn's first postnatal checkup No postnatal checkup during the first two days after the birth Total Number of births Doctor Nurse- midwife Nurse Traditional birth attendant Mother's age at birth <20 1.5 2.0 8.6 0.4 87.6 100.0 437 20-34 2.0 2.0 7.1 0.2 88.8 100.0 1,760 35-49 3.8 0.8 9.1 0.0 86.3 100.0 251 Birth order 1 2.1 2.1 8.3 0.2 87.3 100.0 711 2-3 2.3 2.3 7.7 0.3 87.5 100.0 1,161 4-5 1.7 0.9 6.6 0.0 90.8 100.0 407 6+ 1.3 0.8 6.1 0.0 91.8 100.0 170 Place of delivery Health facility 3.0 2.6 8.7 0.0 85.7 100.0 1,562 Elsewhere 0.4 0.6 5.5 0.5 93.0 100.0 886 Residence Urban 4.0 3.3 10.3 0.3 82.1 100.0 718 Rural 1.3 1.3 6.4 0.1 90.8 100.0 1,730 Province Manicaland 2.6 3.5 5.8 0.0 88.1 100.0 366 Mashonaland Central 1.5 1.3 4.7 0.0 92.5 100.0 254 Mashonaland East 0.0 1.2 6.8 0.0 91.9 100.0 257 Mashonaland West 1.0 2.1 9.6 0.3 87.0 100.0 296 Matabeleland North 2.4 1.3 5.1 1.0 90.1 100.0 115 Matabeleland South 3.4 0.4 12.8 0.5 83.0 100.0 124 Midlands 3.1 1.0 7.3 0.0 88.7 100.0 298 Masvingo 0.4 0.0 4.3 0.0 95.3 100.0 277 Harare 3.6 3.3 11.1 0.4 81.7 100.0 352 Bulawayo 4.1 4.5 10.0 0.6 80.7 100.0 111 Mother’s education No education (0.0) (0.0) (12.1) (0.0) (87.9) 100.0 28 Primary 0.8 1.0 5.1 0.2 92.9 100.0 767 Secondary 2.1 2.3 8.8 0.2 86.6 100.0 1,573 More than secondary 13.6 3.6 4.7 0.0 78.2 100.0 80 Wealth quintile Lowest 1.2 0.6 5.4 0.3 92.4 100.0 543 Second 1.0 1.1 4.9 0.0 93.0 100.0 515 Middle 0.7 1.6 7.8 0.1 89.7 100.0 478 Fourth 2.7 4.4 9.7 0.3 82.9 100.0 519 Highest 5.3 1.9 10.7 0.2 81.8 100.0 393 Total 2.1 1.9 7.6 0.2 88.3 100.0 2,448 Note: Figures in parentheses are based on 25-49 unweighted cases. 122 • Maternal Health Care 9.9 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from accessing medical advice or treatment for themselves when they are sick. Information on such factors is particularly important in understanding and addressing the barriers women may face in seeking care during pregnancy, delivery, and the postnatal period. In the 2010-11 ZDHS, women were asked whether each of the following factors would be a big problem (or not) in seeking medical care: getting permission to go for treatment, getting money for treatment, distance to a health facility, and not wanting to go alone. Table 9.11 shows that 60 percent of women reported at least one of these concerns as a big problem when it came to accessing health care. Table 9.11 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Zimbabwe 2010-11 Background characteristic Problems in accessing health care Number of women Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone At least one problem accessing health care Age 15-19 8.6 45.6 32.7 16.6 57.5 1,945 20-34 7.6 47.8 33.4 13.1 58.4 4,824 35-49 7.4 58.6 37.0 13.7 66.8 2,403 Number of living children 0 7.3 41.1 27.3 14.1 52.4 2,510 1-2 7.1 49.0 32.0 12.3 58.5 3,731 3-4 8.3 55.8 39.7 14.8 66.8 2,052 5+ 10.6 67.5 50.1 19.2 76.9 878 Marital status Never married 7.0 41.7 25.9 13.6 51.7 2,197 Married or living together 8.3 50.2 37.2 14.4 61.7 5,703 Divorced/separated/widowed 6.8 64.4 34.9 12.8 69.9 1,271 Employed past 12 months Not employed 9.0 52.7 36.9 14.6 63.1 5,212 Employed for cash 6.2 46.5 29.8 12.5 56.2 3,730 Employed not for cash 5.6 52.4 44.8 24.9 69.5 229 Residence Urban 5.0 36.8 10.5 7.4 41.9 3,548 Rural 9.6 58.6 49.1 18.2 72.1 5,623 Province Manicaland 7.8 52.7 39.9 25.7 66.5 1,227 Mashonaland Central 5.6 52.1 45.7 15.3 68.9 871 Mashonaland East 5.0 53.1 39.2 13.9 65.1 824 Mashonaland West 6.4 48.0 31.5 11.2 57.8 1,026 Matabeleland North 24.4 60.4 48.2 19.2 70.3 443 Matabeleland South 7.7 65.0 61.1 14.0 74.5 467 Midlands 2.4 51.5 35.9 4.1 60.7 1,123 Masvingo 18.2 61.6 47.4 24.9 73.8 909 Harare 5.5 37.3 13.6 8.4 43.3 1,722 Bulawayo 5.6 38.7 5.9 6.6 42.9 558 Education No education 11.6 75.1 58.8 24.4 85.0 212 Primary 10.8 63.9 47.9 18.5 74.7 2,568 Secondary 6.7 45.9 29.0 12.4 56.1 5,966 More than secondary 2.9 14.0 11.4 4.7 22.5 424 Wealth quintile Lowest 13.4 69.7 60.6 22.3 81.0 1,546 Second 9.4 65.7 51.7 18.9 77.5 1,594 Middle 7.8 56.9 44.1 17.0 71.5 1,681 Fourth 5.7 42.4 20.7 10.1 51.7 2,073 Highest 4.6 28.0 8.9 6.3 34.3 2,278 Total 7.8 50.1 34.2 14.0 60.4 9,171 Maternal Health Care • 123 The most important factor impeding women from accessing health care for themselves is getting money to pay for treatment; 50 percent of the women highlighted this concern. This problem was most often reported by women who had five or more living children (68 percent); were divorced, separated, or widowed (64 percent); resided in the rural areas (59 percent); lived in Matabeleland South (65 percent); had no education (75 percent); or were in the lowest wealth quintile (70 percent). Distance to a health facility was cited by one-third of women as a big problem in accessing health care (34 percent). Not unexpectedly, women residing in rural areas were more likely than those in urban areas to report distance as a big problem (49 percent compared with 11 percent). Eight percent of women reported getting permission to go and 14 percent reported not wanting to go alone as big problems in accessing health care. Child Health • 125 CHILD HEALTH 10 his chapter presents findings about child health and survival, including characteristics of the neonate (birth weight and size), the vaccination status of young children, and treatment practices—particularly contact with health services—among children suffering from three childhood illnesses: acute respiratory infection (ARI), fever, and diarrhoea. Because appropriate sanitary practices can help prevent and reduce the severity of diarrhoeal disease, information is also provided on how children’s faecal matter is disposed of. These results from the 2010-11 ZDHS are expected to assist policymakers and program managers as they formulate appropriate strategies and interventions to improve the health of children in Zimbabwe. In particular, the results will be used to assess coverage of current strategies such as Integrated Management of Childhood Illness (IMCI), which seeks to prevent deaths from pneumonia, malaria, and diarrhoea, and to plan for improvements in these initiatives. 10.1 CHILD’S WEIGHT AND SIZE AT BIRTH Birth weight is an important indicator when assessing a child’s health in terms of early exposure to childhood morbidity and mortality. Children who weigh less than 2.5 kilograms, or are reported to be “very small” or “smaller than average,” are considered to have a higher-than-average risk of early childhood death. In the 2010-11 ZDHS, for births in the five years preceding the survey, birth weight was recorded in the Woman’s Questionnaire based on either a written record or the mother’s report. The mother’s estimate of the infant’s size at birth was also obtained because birth weight may be unknown for many infants. Although the mother’s estimate of size is subjective, it can be a useful proxy for the child’s weight. T Key Findings • By mothers’ estimates, 12 percent of all infants born alive in the five years preceding the survey, were very small or smaller than average at birth. Among those with a reported birth weight, 10 percent weighed less than 2.5 kg. • Sixty-five percent of children age 12-23 months were fully vaccinated at the time of the survey; 56 percent had received all basic vaccinations by age 12 months. • Four percent of children under age 5 experienced symptoms of an acute respiratory infection (ARI) in the two weeks preceding the survey. Among those with symptoms, advice or treatment from a health facility or provider was sought for about half (48 percent), and 31 percent received antibiotics. • Ten percent of children under age 5 had a fever within the two weeks preceding the survey. Among those with a fever, 37 percent were taken to a health facility or provider for advice or treatment. Two percent received antimalarial drugs, but over ten-fold more (23 percent) received antibiotics. • Thirteen percent of children under age 5 had diarrhoea in the two weeks preceding the survey. More than one-third of the children with diarrhoea (36 percent) were taken to a health facility or provider. Seventy-four percent of the children with diarrhoea were treated with oral rehydration therapy (ORT) or increased fluids. One in five children with diarrhoea did not receive any type of treatment. 126 • Child Health Table 10.1 shows that birth weight is reported for 69 percent of the live births that occurred in the five years preceding the survey; 10 percent of these infants had low birth weights (less than 2.5 kg). Older mothers, age 35-49, are more likely to have infants with low birth weight than mothers age 20-34. By birth order, first births (10 percent) are slightly more likely than subsequent births to result in low birth weight. Birth weights in urban areas are more likely than those in rural areas to be less than 2.5 kg (11 and 8 percent, respectively). Table 10.1 Child's weight and size at birth Percentage of live births in the five years preceding the survey that have a reported birth weight; among live births in the five years preceding the survey with a reported birth weight, and percent distribution by birth weight; percent distribution of all live births in the five years preceding the survey by estimate of baby's size at birth, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of all births that have a reported birth weight1 Percent distribution of births with a reported birth weight1 Percent distribution of all live births by size of child at birth Less than 2.5 kg 2.5 kg or more Total Number of births Very small Smaller than average Average or larger Don't know/ missing Total Number of births Mother's age at birth <20 67.8 10.0 90.0 100.0 739 3.9 10.9 82.4 2.8 100.0 1,091 20-34 70.0 9.0 91.0 100.0 2,784 3.0 8.7 86.0 2.4 100.0 3,976 35-49 64.1 12.6 87.4 100.0 339 4.0 7.7 84.6 3.7 100.0 528 Birth order 1 76.3 10.1 89.9 100.0 1,373 3.4 10.7 84.0 1.9 100.0 1,798 2-3 70.8 9.2 90.8 100.0 1,764 3.3 8.4 86.0 2.2 100.0 2,490 4-5 60.6 9.1 90.9 100.0 572 2.7 7.0 86.6 3.8 100.0 944 6+ 42.1 8.5 91.5 100.0 153 3.8 9.9 81.4 4.9 100.0 364 Residence Urban 88.8 11.2 88.8 100.0 1,479 3.1 11.1 84.9 1.0 100.0 1,666 Rural 60.6 8.4 91.6 100.0 2,383 3.4 8.1 85.3 3.2 100.0 3,930 Province Manicaland 61.8 9.7 90.3 100.0 521 3.9 8.3 85.4 2.4 100.0 843 Mashonaland Central 55.8 8.2 91.8 100.0 337 5.0 4.9 89.2 0.9 100.0 603 Mashonaland East 61.1 7.1 92.9 100.0 324 2.4 8.4 88.8 0.4 100.0 530 Mashonaland West 59.6 9.2 90.8 100.0 418 2.1 6.3 80.4 11.2 100.0 701 Matabeleland North 68.0 10.9 89.1 100.0 180 2.8 14.0 79.5 3.7 100.0 265 Matabeleland South 77.1 10.3 89.7 100.0 211 1.3 7.6 90.7 0.3 100.0 273 Midlands 68.3 7.8 92.2 100.0 478 4.7 11.0 82.6 1.7 100.0 701 Masvingo 74.6 6.7 93.3 100.0 467 2.5 6.7 89.6 1.2 100.0 627 Harare 86.2 14.0 86.0 100.0 712 2.9 13.9 82.4 0.8 100.0 826 Bulawayo 93.9 7.7 92.3 100.0 213 3.7 10.7 85.4 0.3 100.0 227 Mother’s education No education (31.7) (8.9) (91.1) 100.0 30 0.6 11.1 80.8 7.5 100.0 95 Primary 53.3 9.1 90.9 100.0 967 3.4 7.8 84.7 4.2 100.0 1,814 Secondary 76.9 9.6 90.4 100.0 2,709 3.4 9.5 85.4 1.7 100.0 3,521 More than secondary 93.9 9.2 90.8 100.0 156 1.1 10.5 88.4 0.0 100.0 166 Wealth quintile Lowest 50.8 9.9 90.1 100.0 649 4.3 9.2 82.8 3.7 100.0 1,277 Second 57.7 7.6 92.4 100.0 680 2.5 6.7 87.4 3.5 100.0 1,178 Middle 67.8 10.2 89.8 100.0 725 2.7 10.1 83.9 3.3 100.0 1,070 Fourth 83.5 9.9 90.1 100.0 993 3.4 9.4 85.8 1.5 100.0 1,190 Highest 92.6 9.5 90.5 100.0 815 3.4 10.0 86.3 0.3 100.0 880 Total 69.0 9.5 90.5 100.0 3,862 3.3 9.0 85.2 2.6 100.0 5,596 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Based on either a written record or the mother's recall Among the provinces, Masvingo and Mashonaland East have the lowest proportion of low birth weight infants (7 percent each), and Harare has the highest proportion (14 percent). There is no clear relationship between low birth weight and mother’s education or wealth quintile. Table 10.1 also includes information on the mother’s estimate of the infant’s size at birth. Three percent of births are reported as very small, and 9 percent are reported as smaller than average. Patterns by background characteristics are similar to those for births reported to be less than 2.5 kg. Child Health • 127 10.2 VACCINATION OF CHILDREN The induction of an immune response through vaccination is a widely accepted public health strategy for the prevention of vaccine-preventable infectious diseases. To enable evaluation of the Zimbabwe Expanded Programme of Immunisation (ZEPI), the 2010-11 ZDHS collected information on vaccine coverage for all children born since January 2005. To be fully vaccinated, a child should have received one dose of BCG vaccine, three doses each of DPT and polio vaccines, and one dose of measles vaccine. BCG protects against tuberculosis, and DPT protects against diphtheria, pertussis (whooping cough), and tetanus. Since 2008, DPT has not been given to infants in Zimbabwe as a stand-alone vaccine. Instead, it has been combined with other antigens that protect against hepatitis B and Haemophilus influenza type b (DPT-HB-Hib vaccine, also known as pentavalent vaccine). Thus, the 2010-11 ZDHS report on DPT coverage includes coverage by DPT or pentavalent vaccines. Zimbabwe has defined a schedule for the administration of all basic childhood vaccines. BCG should be given shortly after birth. DPT/pentavalent and polio vaccines require three vaccinations to be given at approximately age 3, 4, and 5 months, and measles vaccine should be given at or soon after reaching age 9 months. Sources of Information Information on vaccination coverage was obtained in two ways – from child health cards and from mothers’ verbal reports. All mothers were asked to show the interviewer the child health cards in which immunisation dates were recorded for all children born since January 2005. If a card was available, the interviewer recorded onto the questionnaire the dates of each vaccination received by the child. If a child never received a health card, if the mother was unable to show the card to the interviewer, or if a particular vaccination was not recorded on the child’s health card, the vaccination information for the child was based on the mother’s report. Questions were asked for each vaccine type. Mothers were asked to recall whether the child had received BCG, polio, DPT or pentavalent (DPT-HepB-Hib), and measles vaccinations. If the mother indicated that the child had received the polio or DPT/pentavalent vaccines, she was asked about the number of doses that the child received. The mother was then asked whether the child had received other vaccinations that were not recorded on the card, and they too were noted on the questionnaire. The results presented here are based on both health card information and, for children without a card, information provided by the mother. Vaccination Coverage Table 10.2 shows vaccination coverage by source of information for children age 12-23 months, the age by which they should have received all vaccinations. Overall, 65 percent of children age 12-23 months were fully vaccinated at the time of the survey: 87 percent had received the BCG vaccination, 73 percent had received DPT 1-3 or pentavalent 1-3, 73 percent had received polio 1-3, and 79 percent had received the measles vaccine. The coverage of the first dose of DPT/pentavalent and polio vaccines is very high (86 percent and 87 percent, respectively). However, only 73 percent of children received the third dose of each. This represents a dropout rate between the first and third dose of 15 percent for DPT/pentavalent and 16 percent for polio vaccine. Twelve percent of children age 12-23 months did not receive any vaccinations. Table 10.2 also shows vaccination coverage for children who have reached age 12 months. The rates for each vaccination by the time the child reaches age 12 months is a measure of children receiving vaccines on time. Overall, 56 percent of children are fully immunised by 12 months of age. 128 • Child Health Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage vaccinated by age 12 months, Zimbabwe 2010-11 Source of information BCG DPT/pentavalent Polio Measles All basic vaccinations1 No vaccinations Number of children 1 2 3 1 2 3 Vaccinated at any time before survey Vaccination card 66.9 66.6 64.9 60.9 67.1 64.8 59.3 61.3 53.7 0.2 701 Mother's report 20.0 19.0 16.1 12.0 19.6 17.7 13.6 17.9 10.8 12.0 332 Either source 86.9 85.6 81.0 72.9 86.7 82.5 72.9 79.1 64.5 12.2 1,034 Vaccinated by 12 months of age2 86.6 85.1 80.0 70.0 86.6 80.3 69.3 69.3 55.6 12.5 1,034 1 BCG, measles, and three doses each of DPT or pentavalent vaccine and polio vaccine 2 For children whose information is based on the mother's report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccination. Table 10.3 presents information on vaccine coverage among children age 12-23 months from vaccination cards and mothers’ reports, by background characteristics. Vaccination cards were seen for 68 percent of children. Female children were somewhat more likely to be fully immunized than male children (66 percent and 63 percent, respectively). Equal proportions of male and female children (12 percent) had not received any vaccine by the time of the survey. Higher birth order is negatively associated with vaccination coverage; whereas 68 percent of first-order births had received all vaccinations, only 46 percent of sixth- or higher-order births were fully vaccinated. Higher-order births were also more likely not to have received any vaccinations (26 percent) than other births. Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother's report), and percentage with a vaccination card, by background characteristics, Zimbabwe 2010-11 Background characteristic BCG DPT/pentavalent Polio Measles All basic vaccinations1 No vaccinations Percentage with a vaccination card seen Number of children 1 2 3 1 2 3 Sex Male 87.3 85.3 80.3 71.4 86.3 81.8 70.8 78.1 62.7 12.0 66.4 519 Female 86.5 85.8 81.7 74.4 87.2 83.1 75.1 80.2 66.3 12.4 69.3 515 Birth order 1 84.6 84.9 82.0 76.7 85.2 82.2 75.4 79.6 68.0 14.1 69.1 331 2-3 91.0 88.8 85.5 75.7 90.9 86.4 76.4 81.8 67.4 8.3 70.0 458 4-5 86.9 84.4 73.5 66.5 84.6 79.1 67.7 75.1 57.8 13.1 64.9 174 6+ 71.4 70.8 65.8 53.2 72.0 66.7 51.9 69.5 45.6 25.8 55.9 71 Residence Urban 87.3 87.4 84.6 75.1 87.6 85.9 77.3 83.1 69.9 12.0 63.6 298 Rural 86.7 84.9 79.6 72.1 86.4 81.1 71.1 77.5 62.3 12.3 69.6 736 Province Manicaland 71.1 67.7 61.6 52.9 70.1 64.2 52.1 65.0 46.5 26.7 54.9 175 Mashonaland Central 90.3 90.0 86.7 78.4 91.0 86.7 78.6 81.0 67.3 9.0 82.6 91 Mashonaland East 88.5 87.8 86.5 85.9 88.4 87.1 84.9 82.0 79.6 10.9 68.6 120 Mashonaland West 93.9 92.3 90.7 83.9 92.0 88.3 81.8 80.8 73.1 6.1 77.6 107 Matabeleland North 98.0 92.6 91.0 80.2 98.0 95.1 81.4 91.0 65.7 2.0 74.2 54 Matabeleland South 95.6 95.6 90.3 82.8 97.3 91.0 77.5 85.4 72.4 2.7 61.8 62 Midlands 86.8 87.0 76.4 67.1 87.2 79.1 69.9 80.6 57.8 10.7 71.8 123 Masvingo 88.4 87.0 79.8 69.3 88.4 82.7 69.2 77.9 55.9 11.6 71.1 110 Harare 85.7 85.7 82.7 70.1 85.7 85.1 72.9 81.1 67.7 14.3 57.3 143 Bulawayo 95.0 94.0 92.0 89.3 95.0 91.7 89.3 88.0 83.3 5.0 77.6 49 Mother’s education No education * * * * * * * * * * * 11 Primary 84.4 82.8 75.2 63.2 83.8 76.8 63.4 72.7 52.4 15.2 65.3 302 Secondary 87.8 86.6 83.3 76.6 87.8 84.6 76.8 81.5 69.1 11.0 69.4 686 More than secondary (88.0) (88.0) (88.0) (84.2) (88.0) (88.0) (84.2) (88.0) (84.2) (12.0) (56.1) 35 Wealth quintile Lowest 85.0 82.6 78.6 66.7 85.4 79.9 65.3 77.7 54.6 13.3 67.0 227 Second 86.0 84.0 75.8 71.2 85.1 79.8 69.4 74.6 62.3 13.2 68.0 209 Middle 87.0 86.2 81.1 70.1 86.9 80.3 69.4 73.5 60.8 12.2 70.7 212 Fourth 89.1 88.1 85.0 78.8 88.6 87.0 82.3 86.9 74.1 10.7 63.4 214 Highest 87.7 87.6 85.3 79.4 87.9 86.3 79.9 83.7 72.8 11.5 70.7 172 Total 86.9 85.6 81.0 72.9 86.7 82.5 72.9 79.1 64.5 12.2 67.8 1,034 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 BCG, measles, and three doses each of DPT or pentavalent vaccine and polio vaccine Child Health • 129 Children in urban areas are more likely than rural children to have received all basic vaccinations (70 percent compared with 62 percent, respectively). At the provincial level, full vaccination coverage ranges from a high of 83 percent in Bulawayo to a low of 47 percent in the Manicaland. Children in Manicaland were also most likely to have received no vaccinations (27 percent). A mother’s level of education relates to immunisation coverage; 69 percent of children whose mothers have at least some secondary education are fully immunised compared with 52 percent of children whose mothers have only primary education. Children in the fourth and fifth wealth quintiles are more likely to be fully vaccinated (74 percent and 73 percent, respectively) than their counterparts in other wealth quintiles (55 to 62 percent). Trends in Vaccination Coverage Table 10.4 and Figure 10.1 present data from the 1994, 1999, 2005-06, and 2010-11 ZDHS surveys showing trends in vaccination coverage for children age 12-23 months who received specific vaccines at any time before the survey. Although vaccination coverage in Zimbabwe steadily decreased between 1994 and 2005-06, data from 2010-11 indicate that vaccination coverage has begun to rebound; whereas only 53 percent of children age 12-23 months were fully vaccinated in 2005-06, 65 percent were fully vaccinated in 2010-11. Likewise, over the 5-year period between the 2005-06 and 2010-11 ZDHS surveys, the percentage of children with no vaccinations has decreased from 21 to 12 percent. Table 10.4 Trends in vaccination coverage Percentage of children age 12-23 months who received specific vaccines at any time prior to the survey, and percentage with a vaccination card, Zimbabwe 1994-2011 Source BCG DPT Polio Measles All basic vaccinations1 No vaccinations Percentage with a vaccination card seen Number of children 1 2 3 1 2 3 1994 ZDHS 95.7 94.2 91.5 85.2 94.5 91.9 85.4 86.3 80.1 4.1 79.1 691 1999 ZDHS 88.1 87.5 85.0 80.9 87.7 85.1 80.7 79.1 74.8 11.6 68.6 699 2005-2006 ZDHS 75.7 76.9 71.8 62.0 77.0 73.5 65.7 65.6 52.6 21.0 72.3 1,019 2010-11 ZDHS2 86.9 85.6 81.0 72.9 86.7 82.5 72.9 79.1 64.5 12.2 67.8 1,034 1 BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth) 2 2010-11 ZDHS data include DPT received as either DPT1-3 or pentavalent 1-3. 130 • Child Health Figure 10.1 Trends in Vaccination Coverage among Children 12-23 Months ZDHS 2010-11 80 96 94 92 85 95 92 85 86 75 88 88 85 81 88 85 81 79 53 76 77 72 62 77 74 66 66 65 87 86 81 73 87 83 73 79 All BCG DPT1 DPT2 DPT3 Polio 1 Polio 2 Polio 3 Measles 0 20 40 60 80 100 Percentage of children with specific vaccines 1994 ZDHS 1999 ZDHS 2005-06 ZDHS 2010-11 ZDHS 10.3 PREVALENCE AND TREATMENT OF ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality throughout the world. Among acute respiratory diseases, pneumonia is the most serious for young children. Early diagnosis and treatment with antibiotics can prevent a large number of deaths caused by ARI. In the 2010-11 ZDHS, ARI prevalence was estimated by asking mothers whether their children under age 5 had been ill with a cough accompanied by short, rapid breathing, which was chest-related, and/or by difficult breathing, which was chest-related in the two weeks preceding the survey. It should be noted that these data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Table 10.5 shows the prevalence of ARI symptoms among children under age 5 during the two-week period preceding the interview and the actions that mothers took in response to their children’s illness. Overall, 4 percent of children are reported to have had ARI symptoms in the two weeks preceding the survey. Differentials by background characteristics were generally very small. Children in urban areas are less likely than those in rural areas to have symptoms of ARI (3 and 5 percent, respectively). Children in the Midlands are most likely to have ARI symptoms (7 percent); children in Mashonaland East are the least likely to have ARI symptoms (2 percent). ARI symptoms among children generally decrease as the level of the mother’s education or wealth increases. Mothers who reported that their children had had ARI symptoms were asked about the actions they had taken to treat the illness. Among children with ARI symptoms, advice or treatment was sought from a health facility or a health provider for 48 percent, and 31 percent received antibiotics. This represents an increase from the 2005-06 ZDHS where advice or treatment was sought from a health facility or health provider for 25 percent of children with ARI symptoms, and only 8 percent were given antibiotics. Child Health • 131 Table 10.5 Prevalence and treatment of symptoms of ARI Among children under age five, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey and among children with symptoms of ARI, the percentage for whom advice or treatment was sought from a health facility or provider and the percentage who received antibiotics as treatment, according to background characteristics, Zimbabwe 2010-11 Background characteristic Among children under age five: Among children under age five with symptoms of ARI: Percentage for whom advice or treatment was sought from a health facility or provider2 Percentage who received antibiotics Number of children Percentage with symptoms of ARI1 Number of children Age in months <6 3.2 687 (39.7) (32.8) 22 6-11 5.3 660 (57.0) (45.8) 35 12-23 5.0 1,034 57.6 31.0 52 24-35 4.1 999 (36.6) (23.1) 41 36-47 3.4 986 (41.9) (35.1) 33 48-59 4.0 841 (49.4) (20.2) 34 Sex Male 4.3 2,592 41.0 23.4 110 Female 4.1 2,616 55.2 38.8 107 Cooking fuel Electricity or gas 2.6 1,200 (40.1) (35.3) 31 Kerosene/paraffin 1.9 111 * * 2 Charcoal * 5 * * 2 Wood/straw3 4.7 3,867 50.4 30.7 182 Other fuel including jelly * 24 * * 0 Residence Urban 2.5 1,548 (43.7) (27.7) 38 Rural 4.9 3,660 48.9 31.7 179 Province Manicaland 5.1 766 (35.8) (29.1) 39 Mashonaland Central 2.9 563 * * 16 Mashonaland East 1.8 505 * * 9 Mashonaland West 4.2 628 (37.1) (15.6) 26 Matabeleland North 4.7 256 * * 12 Matabeleland South 5.7 263 (42.9) (33.1) 15 Midlands 7.0 660 (48.2) (44.0) 46 Masvingo 4.6 588 (64.5) (40.4) 27 Harare 2.5 761 * * 19 Bulawayo 3.4 219 * * 7 Mother’s education No education 4.4 89 * * 4 Primary 6.1 1,672 43.0 22.3 102 Secondary 3.4 3,291 53.0 39.5 111 More than secondary 0.5 156 * * 1 Wealth quintile Lowest 6.3 1,189 52.1 30.4 75 Second 4.3 1,087 (43.7) (29.3) 47 Middle 3.8 997 (53.6) (36.0) 38 Fourth 3.4 1,101 (48.0) (20.8) 38 Highest 2.4 833 * * 20 Total 4.2 5,208 48.0 31.0 217 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1Symptoms of ARI (cough accompanied by short, rapid breathing, which was chest-related, and/or by difficult breathing, which was chest-related) is considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 3 Includes grass, shrubs, crop residues 10.4 PREVALENCE AND TREATMENT OF FEVER Fever is a symptom of malaria, but it may also accompany other illnesses including pneumonia, common colds, and influenza. Because malaria is a major cause of death in infancy and childhood in many developing countries, the presumptive treatment of fever with antimalarial medication has been advocated in many countries where malaria is endemic. Information relating to the prevention and treatment of malaria is discussed in detail in Chapter 12. 132 • Child Health In the 2010-11 ZDHS, fever prevalence was estimated by asking mothers whether their children under age 5 had been ill with fever in the two weeks preceding the survey. For children with fever, mothers were also asked about the actions they took to treat fever, including whether or not the child had been given any drug to treat the fever, and, if so, what drug the child was given. Table 10.6 shows that the percentage of children under age 5 with fever during the two weeks preceding the survey was 10 percent. The prevalence of fever varies with children’s age. Children age 6-11 months are more likely to be sick with fever (14 percent) than children in other age groups. Children in urban areas are nearly as likely as those in rural areas (9 and 10 percent, respectively) to have had fever. Among provinces, 16 percent of children in Manicaland had fever in the two weeks preceding the survey compared with only 5 percent of children in Midlands. Children of mothers with no education and children in the lowest wealth quintile have a higher prevalence of fever than those whose mothers are educated or who are in higher wealth quintiles. Table 10.6 Prevalence and treatment of fever Among children under age five, the percentage who had a fever in the two weeks preceding the survey and among children with fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who received antibiotics as treatment, by background characteristics, Zimbabwe 2010-11 Background characteristic Among children under age five: Among children under age five with fever: Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children Percentage with fever Number of children Age in months <6 7.1 687 32.7 0.0 18.4 49 6-11 13.9 660 43.7 2.0 26.7 92 12-23 10.2 1,034 33.9 2.0 19.4 105 24-35 11.2 999 31.1 1.4 23.9 112 36-47 7.6 986 46.0 6.4 15.8 75 48-59 8.6 841 33.8 1.8 29.3 73 Sex Male 9.5 2,592 36.3 2.1 21.1 246 Female 10.0 2,616 37.1 2.5 23.9 261 Residence Urban 8.7 1,548 29.8 3.6 22.4 134 Rural 10.2 3,660 39.2 1.8 22.6 372 Province Manicaland 16.2 766 35.7 2.4 27.4 124 Mashonaland Central 15.2 563 42.2 2.0 26.6 85 Mashonaland East 7.5 505 (34.6) (2.1) (11.2) 38 Mashonaland West 8.3 628 (24.9) (0.0) (20.2) 52 Matabeleland North 13.8 256 49.9 14.4 10.2 35 Matabeleland South 10.4 263 56.2 0.0 42.6 27 Midlands 5.1 660 (39.3) (0.0) (20.1) 34 Masvingo 6.7 588 (31.9) (0.0) (17.0) 40 Harare 7.0 761 (31.7) (1.9) (22.1) 54 Bulawayo 7.9 219 (20.9) (0.0) (11.1) 17 Mother’s education No education 16.1 89 * * * 14 Primary 10.5 1,672 38.6 2.7 18.6 176 Secondary 9.2 3,291 36.1 1.9 23.7 304 More than secondary 8.0 156 * * * 12 Wealth quintile Lowest 11.4 1,189 38.1 0.5 18.7 136 Second 8.9 1,087 44.2 4.1 24.0 97 Middle 9.6 997 37.6 1.6 24.3 96 Fourth 9.1 1,101 29.3 1.6 31.8 100 Highest 9.3 833 33.4 4.9 13.0 78 Total 9.7 5,208 36.7 2.3 22.5 506 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1Excludes pharmacy, shop, and traditional practitioner Advice or treatment was sought from a health facility or provider for 37 percent of the children with fever. Children with fever were more likely to have received an antibiotic than an antimalarial drug during the episode of the fever (23 percent versus 2 percent, respectively). Advice or treatment for fever was just as commonly sought for female children as male children (37 and 36 percent, respectively), but was more common for children in rural areas (39 percent) than for those Child Health • 133 children in urban areas (30 percent). The percentage of children who took antimalarial and antibiotic drugs also varies by background characteristics. 10.5 DIARRHOEAL DISEASE Dehydration caused by severe diarrhoea is a major cause of morbidity and mortality among young children. Exposure to diarrhoea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta. The 2010-11 ZDHS obtained information on the prevalence of diarrhoea among young children by asking mothers whether their children under age 5 had had diarrhoea during the two weeks preceding the survey. When a child was identified as having had diarrhoea, information was collected on treatment and feeding practices during the diarrhoeal episode. The mother was also asked whether there was blood in the child’s stools. Diarrhoea with blood in the stools indicates cholera or other diseases that need to be treated differently from diarrhoea in which there is no blood in the stools. 10.5.1 Prevalence of Diarrhoea Table 10.7 shows that 13 percent of children under age 5 had a diarrhoeal episode in the two weeks preceding the survey and 1 percent had blood in the stool. The prevalence of diarrhoea jumped from 6 percent among children less than age 6 months to 21 percent among children age 6-11 months, and peaked at 24 percent among children age 12-23 months. This observation is expected because children age 6 months and older are typically introduced to complementary foods. Diarrhoea is somewhat more prevalent among children whose households do not have an improved source of drinking water (16 percent) compared with children from households that do (12 percent). Similarly, the prevalence of diarrhoea is higher among children whose households do not have an improved toilet facility or who share a facility with other households (14 percent) compared with households that have an improved, unshared toilet facility (11 percent). Urban children were slightly more likely to have had diarrhoea than rural children (15 versus 13 percent, respectively.) The prevalence of diarrhoea varies regionally: it was highest in Manicaland and Harare (16 percent each) and lowest in Matabeleland South (8 percent). Table 10.7 Prevalence of diarrhoea Percentage of children under age five who had diarrhoea in the two weeks preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Diarrhoea in the two weeks preceding the survey Number of children All diarrhoea Diarrhoea with blood Age in months <6 6.0 0.4 687 6-11 20.6 1.6 660 12-23 23.6 1.7 1,034 24-35 13.6 1.5 999 36-47 9.1 1.1 986 48-59 4.8 0.3 841 Sex Male 14.3 1.4 2,592 Female 12.1 0.9 2,616 Source of drinking water1 Improved 12.4 0.9 3,907 Not improved 15.6 2.0 1,301 Toilet facility2 Improved, not shared 11.3 0.6 1,556 Non-improved 14.1 1.4 3,652 Residence Urban 14.9 0.8 1,548 Rural 12.5 1.2 3,660 Province Manicaland 15.8 2.1 766 Mashonaland Central 14.2 0.6 563 Mashonaland East 12.3 0.3 505 Mashonaland West 14.6 0.7 628 Matabeleland North 14.2 1.0 256 Matabeleland South 7.5 1.0 263 Midlands 13.2 2.5 660 Masvingo 8.5 0.9 588 Harare 15.6 0.6 761 Bulawayo 9.7 0.7 219 Mother’s Education No education 9.6 1.6 89 Primary 13.9 1.6 1,672 Secondary 13.2 0.9 3,291 More than secondary 7.7 0.0 156 Wealth quintile Lowest 13.2 1.7 1,189 Second 14.3 1.4 1,087 Middle 12.0 0.8 997 Fourth 14.3 1.0 1,101 Highest 12.0 0.4 833 Total 13.2 1.1 5,208 1 See Table 2.1 for definition of categories. 2 See Table 2.2 for definition of categories. 134 • Child Health 10.5.2 Treatment of Diarrhoea A simple and effective response to dehydration caused by diarrhoea is oral rehydration therapy (ORT). Since 1982, the use of a home-based salt sugar solution (SSS) to combat dehydration from diarrhoea has been a method of ORT promoted by the Control of Diarrhoeal Disease Programme in the Ministry of Health and Child Welfare (Nathoo et al., 1987). Oral rehydration salt (ORS) sachets are also available in Zimbabwe. Table 10.8 shows that advice or treatment was sought from a health facility/provider for 36 percent of the children suffering from diarrhoea. Advice and treatment were sought more often for children with bloody diarrhoea than for those with non-bloody diarrhoea (52 and 34 percent, respectively). Some form of ORT, either fluid from ORS sachets or recommended home fluids (RHF), was used to treat the diarrhoea in the majority of children (63 percent). Fifty-five percent of these children suffering from diarrhoea in the two weeks preceding the survey were given RHF, and 21 percent were given fluid from ORS sachets. Thirty-eight percent of the children were given increased amounts of other fluids. The majority of children (74 percent) were given either ORT or increased fluids. The other treatments given to children with diarrhoea were antibiotics (17 percent) and anti-motility drugs (3 percent) while a negligible proportion of children received zinc supplements or intravenous solutions. Home remedies were used to treat 9 percent of children. One in five children with diarrhoea did not receive any treatment. Child Health • 135 Table 10.8 Diarrhoea treatment Among children under age five who had diarrhoea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of children with diarrhoea for whom advice or treatment was sought from a health facility or provider1 Oral rehydration therapy (ORT) In- creased fluids ORT or in- creased fluids Other treatments No treat- ment Number of children with diarrhoea Fluid from ORS sachets Recom- mended home fluids (RHF) Either ORS or RHF Anti- biotic drugs Anti- motility drugs Zinc supple- ments Intra- venous solution Home remedy/ other Age in months <6 (16.6) (12.4) (25.7) (28.0) (24.3) (47.9) (11.8) (3.0) (0.0) (0.0) (15.9) (39.7) 41 6-11 34.5 15.7 48.3 54.2 34.0 65.4 10.3 3.0 0.0 0.0 6.2 30.4 136 12-23 40.2 23.3 56.6 66.3 37.7 76.1 18.0 3.6 0.0 0.0 8.2 17.6 244 24-35 36.6 21.2 62.0 70.0 42.6 82.2 19.8 2.2 0.5 1.0 8.8 10.7 136 36-47 37.3 32.8 64.2 76.2 42.8 80.9 18.4 0.0 0.0 0.0 14.9 13.4 90 48-59 (26.6) (4.9) (56.6) (59.9) (33.6) (68.6) (18.2) (0.0) (0.0) (0.0) (8.3) (19.1) 41 Sex Male 34.4 21.2 55.4 62.6 38.4 72.8 16.7 3.0 0.2 0.0 8.5 20.5 371 Female 37.4 20.6 54.9 64.0 36.6 74.7 16.4 1.9 0.0 0.4 10.1 18.6 317 Type of diarrhoea Non-bloody 34.1 20.4 54.4 62.4 37.9 72.9 16.1 1.9 0.1 0.2 8.8 20.3 628 Bloody 52.4 24.0 65.1 72.2 32.5 81.5 21.7 9.0 0.0 0.0 14.5 13.0 59 Residence Urban 37.2 25.9 61.4 68.0 47.7 79.6 22.6 2.1 0.0 0.6 6.5 14.5 230 Rural 35.1 18.4 52.0 60.9 32.5 70.8 13.5 2.7 0.2 0.0 10.7 22.2 458 Province Manicaland 38.4 19.5 57.0 62.1 42.0 78.2 15.7 7.3 0.0 1.2 11.7 14.6 121 Mashonaland Central 30.6 25.1 42.7 60.9 42.7 67.1 11.2 1.0 0.0 0.0 7.9 28.6 80 Mashonaland East 49.6 22.7 63.8 78.1 28.6 81.5 20.8 1.1 0.0 0.0 7.1 11.5 62 Mashonaland West 21.3 9.6 43.4 44.4 28.4 61.3 6.7 0.0 0.0 0.0 8.4 36.1 92 Matabeleland North 60.0 21.7 50.3 59.2 25.1 63.4 24.9 4.0 1.9 0.0 17.1 20.1 36 Matabeleland South (34.9) (12.3) (71.2) (77.6) (48.0) (85.9) (8.2) (0.0) (0.0) (0.0) (10.8) (10.1) 20 Midlands 30.7 28.4 50.5 61.7 35.8 71.3 14.2 1.2 0.0 0.0 9.5 22.3 87 Masvingo (46.1) (14.1) (66.1) (68.1) (17.0) (69.1) (14.3) (3.1) (0.0) (0.0) (10.3) (18.8) 50 Harare 32.9 27.7 59.9 68.3 55.0 82.3 29.3 1.6 0.0 0.0 6.6 10.9 119 Bulawayo (34.0) (10.4) (77.7) (77.7) (28.9) (82.2) (8.9) (4.5) (0.0) (0.0) (7.6) (15.4) 21 Mother’s education No education * * * * * * * * * * * * 9 Primary 31.6 15.4 54.1 60.9 28.3 69.2 14.4 1.7 0.0 0.0 12.6 23.1 233 Secondary 38.4 24.0 56.0 64.9 42.2 76.3 18.5 3.0 0.2 0.3 7.2 17.9 434 More than secondary * * * * * * * * * * * * 12 Wealth quintile Lowest 37.4 17.8 47.6 58.0 31.3 63.9 8.6 2.7 0.4 0.0 12.6 25.3 157 Second 34.6 20.2 60.3 68.4 28.7 76.9 13.6 2.1 0.0 0.0 11.7 19.1 155 Middle 30.2 17.5 45.9 52.0 42.2 69.2 12.2 3.3 0.0 0.0 8.7 27.5 120 Fourth 36.7 23.1 59.7 67.1 46.3 81.3 18.6 0.6 0.0 0.0 5.2 13.5 157 Highest 40.3 27.6 63.1 71.0 41.8 77.5 35.6 4.9 0.0 1.4 7.4 11.8 100 Total 35.8 20.9 55.2 63.3 37.6 73.7 16.5 2.5 0.1 0.2 9.3 19.6 688 Notes: ORT includes fluid prepared from oral rehydration salt (ORS) sachets and recommended home fluids (RHF). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes pharmacy, shop, and traditional practitioner 10.5.3 Feeding Practices during Diarrhoea When a child has diarrhoea, mothers are encouraged to continue feeding their child the same amount of food as they would if the child did not have diarrhoea, and they are also encouraged to increase the child’s fluid intake. These practices help to reduce dehydration and minimise the adverse consequences of diarrhoea on the child’s nutritional status. In the 2010-11 ZDHS, mothers were asked whether they gave their child with diarrhoea less, the same amount, or more fluids and food than usual. Table 10.9 shows, by feeding practices, the percent distribution of children under age 5 who had diarrhoea in the two weeks preceding the survey, according to background characteristics. 13 6 • C hi ld H ea lth Ta bl e 10 .9 F ee di ng p ra ct ic es d ur in g di ar rh oe a P er ce nt d is tri bu tio n of c hi ld re n un de r a ge fi ve w ho h ad d ia rr ho ea in th e tw o w ee ks p re ce di ng th e su rv ey b y am ou nt o f l iq ui ds a nd fo od o ffe re d co m pa re d w ith n or m al p ra ct ic e, th e pe rc en ta ge o f c hi ld re n gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g du rin g th e di ar rh oe a ep is od e, a nd t he p er ce nt ag e of c hi ld re n w ho c on tin ue d fe ed in g an d w er e gi ve n O R T an d/ or i nc re as ed f lu id s du rin g th e ep is od e of d ia rr ho ea , by b ac kg ro un d ch ar ac te ris tic s, Z im ba bw e 20 10 -1 1 B ac kg ro un d ch ar ac te ris tic A m ou nt o f l iq ui ds g iv en A m ou nt o f f oo d gi ve n P er ce nt ag e gi ve n in cr ea se d flu id s an d co nt in ue d fe ed in g1 P er ce nt ag e w ho co nt in ue d fe ed in g an d w er e gi ve n O R T an d/ or in cr ea se d flu id s1 N um be r o f ch ild re n w ith di ar rh oe a M or e S am e as us ua l S om ew ha t le ss M uc h le ss N on e D on 't kn ow To ta l M or e S am e as us ua l S om ew ha t le ss M uc h le ss N on e N ev er ga ve fo od D on 't kn ow To ta l A ge in m on th s <6 (2 4. 3) (5 1. 4) (1 0. 0) (1 0. 2) (4 .1 ) (0 .0 ) 10 0. 0 (0 .0 ) (4 6. 8) (4 .9 ) (3 .2 ) (2 .7 ) (4 2. 4) (0 .0 ) 10 0. 0 (1 9. 7) (2 6. 8) 41 6- 11 34 .0 41 .6 14 .4 7. 6 2. 4 0. 0 10 0. 0 5. 0 34 .2 22 .6 19 .1 9. 6 9. 5 0. 0 10 0. 0 19 .4 35 .8 13 6 12 -2 3 37 .7 32 .2 17 .5 12 .1 0. 1 0. 4 10 0. 0 9. 7 28 .5 25 .7 24 .3 10 .1 1. 3 0. 4 10 0. 0 24 .1 45 .9 24 4 24 -3 5 42 .6 35 .6 12 .9 8. 0 0. 9 0. 0 10 0. 0 8. 9 34 .1 27 .9 21 .4 7. 1 0. 5 0. 0 10 0. 0 33 .2 57 .6 13 6 36 -4 7 42 .8 32 .4 14 .6 8. 7 1. 5 0. 0 10 0. 0 3. 9 32 .5 35 .2 25 .9 2. 5 0. 0 0. 0 10 0. 0 30 .3 54 .4 90 48 -5 9 (3 3. 6) (3 3. 3) (2 1. 4) (1 1. 7) (0 .0 ) (0 .0 ) 10 0. 0 (5 .8 ) (3 3. 6) (2 4. 7) (3 5. 9) (0 .0 ) (0 .0 ) (0 .0 ) 10 0. 0 (1 1. 8) (3 7. 5) 41 Se x M al e 38 .4 35 .3 15 .2 10 .5 0. 6 0. 1 10 0. 0 7. 7 31 .2 24 .9 24 .1 7. 1 4. 8 0. 1 10 0. 0 25 .5 44 .8 37 1 Fe m al e 36 .6 36 .8 15 .6 9. 1 1. 8 0. 2 10 0. 0 6. 2 34 .4 26 .1 20 .2 7. 7 5. 1 0. 2 10 0. 0 24 .0 46 .8 31 7 Ty pe o f d ia rr ho ea N on -b lo od y 37 .9 36 .6 14 .7 9. 4 1. 3 0. 2 10 0. 0 7. 0 33 .7 25 .5 21 .3 7. 2 5. 2 0. 2 10 0. 0 25 .1 45 .9 62 8 B lo od y 32 .5 30 .0 23 .0 14 .5 0. 0 0. 0 10 0. 0 7. 6 22 .8 23 .5 34 .1 8. 9 3. 0 0. 0 10 0. 0 20 .1 42 .0 59 R es id en ce U rb an 47 .7 29 .2 11 .2 9. 4 2. 0 0. 5 10 0. 0 10 .7 30 .6 25 .8 25 .0 6. 1 1. 3 0. 5 10 0. 0 35 .0 51 .2 23 0 R ur al 32 .5 39 .3 17 .5 10 .0 0. 7 0. 0 10 0. 0 5. 2 33 .7 25 .4 21 .0 8. 0 6. 8 0. 0 10 0. 0 19 .7 42 .9 45 8 Pr ov in ce M an ic al an d 42 .0 23 .3 23 .7 9. 7 1. 3 0. 0 10 0. 0 8. 1 25 .9 28 .3 22 .8 9. 5 5. 4 0. 0 10 0. 0 29 .7 47 .5 12 1 M as ho na la nd C en tra l 42 .7 38 .6 11 .8 7. 0 0. 0 0. 0 10 0. 0 1. 7 36 .5 27 .0 22 .5 12 .3 0. 0 0. 0 10 0. 0 22 .2 39 .2 80 M as ho na la nd E as t 28 .6 48 .0 20 .5 1. 4 1. 5 0. 0 10 0. 0 4. 7 37 .9 22 .8 9. 2 17 .0 8. 5 0. 0 10 0. 0 14 .4 49 .8 62 M as ho na la nd W es t 28 .4 47 .2 13 .2 9. 2 1. 6 0. 4 10 0. 0 6. 8 40 .7 28 .1 10 .3 6. 8 6. 9 0. 4 10 0. 0 25 .0 45 .6 92 M at ab el el an d N or th 25 .1 48 .3 19 .7 6. 9 0. 0 0. 0 10 0. 0 1. 9 36 .2 39 .3 11 .1 3. 4 8. 1 0. 0 10 0. 0 15 .6 51 .0 36 M at ab el el an d S ou th (4 8. 0) (4 2. 8) (9 .2 ) (0 .0 ) (0 .0 ) (0 .0 ) 10 0. 0 (1 3. 0) (5 6. 1) (1 2. 0) (1 8. 9) (0 .0 ) (0 .0 ) (0 .0 ) 10 0. 0 (3 1. 6) (6 7. 0) 20 M id la nd s 35 .8 36 .7 17 .4 10 .1 0. 0 0. 0 10 0. 0 6. 6 31 .0 23 .9 26 .8 4. 8 7. 0 0. 0 10 0. 0 18 .3 38 .1 87 M as vi n g o (1 7. 0) (4 4. 6) (1 3. 4) (2 5. 0) (0 .0 ) (0 .0 ) 10 0. 0 (1 .9 ) (2 9. 6) (1 1. 2) (4 4. 8) (3 .9 ) (8 .5 ) (0 .0 ) 10 0. 0 (7 .3 ) (2 6. 3) 50 H ar ar e 55 .0 23 .1 9. 1 11 .9 0. 9 0. 0 10 0. 0 14 .7 28 .2 28 .9 25 .8 1. 1 1. 1 0. 0 10 0. 0 43 .2 58 .4 11 9 B ul aw a y o (2 8. 9) (3 5. 1) (5 .4 ) (1 4. 0) (1 3. 5) (3 .1 ) 10 0. 0 (3 .2 ) (1 8. 0) (1 0. 0) (4 0. 2) (1 8. 8) (6 .6 ) (3 .1 ) 10 0. 0 (1 1. 4) (2 5. 3) 21 M ot he r’s e du ca tio n N o ed uc at io n * * * * * * 10 0. 0 * * * * * * * 10 0. 0 * * 9 P rim ar y 28 .3 40 .6 20 .6 10 .1 0. 4 0. 0 10 0. 0 6. 2 30 .3 26 .2 21 .2 8. 5 7. 6 0. 0 10 0. 0 18 .7 41 .8 23 3 S ec on da r y 42 .2 33 .5 12 .9 9. 5 1. 6 0. 2 10 0. 0 7. 8 33 .5 25 .7 22 .3 7. 0 3. 4 0. 2 10 0. 0 27 .9 48 .2 43 4 M or e th an s ec on da r y * * * * * * 10 0. 0 * * * * * * * 10 0. 0 * * 12 W ea lth q ui nt ile Lo w es t 31 .3 45 .0 14 .9 8. 8 0. 0 0. 0 10 0. 0 6. 3 32 .5 23 .3 20 .8 6. 4 10 .7 0. 0 10 0. 0 16 .1 34 .9 15 7 S ec on d 28 .7 41 .2 17 .3 12 .4 0. 4 0. 0 10 0. 0 5. 2 35 .5 23 .1 23 .2 9. 0 3. 9 0. 0 10 0. 0 16 .3 45 .7 15 5 M id dl e 42 .2 31 .9 14 .9 8. 6 2. 5 0. 0 10 0. 0 4. 9 37 .3 30 .3 19 .0 6. 5 2. 1 0. 0 10 0. 0 33 .3 48 .8 12 0 Fo ur th 46 .3 28 .5 14 .7 7. 5 2. 3 0. 7 10 0. 0 10 .8 28 .2 27 .3 22 .4 6. 9 3. 8 0. 7 10 0. 0 33 .3 53 .9 15 7 H i g he st 41 .8 30 .2 14 .7 12 .6 0. 7 0. 0 10 0. 0 7. 7 30 .0 24 .0 27 .1 8. 4 2. 8 0. 0 10 0. 0 28 .1 46 .1 10 0 To ta l 37 .6 36 .0 15 .4 9. 8 1. 1 0. 2 10 0. 0 7. 0 32 .7 25 .5 22 .3 7. 4 5. 0 0. 2 10 0. 0 24 .8 45 .7 68 8 N ot es : I t i s re co m m en de d th at c hi ld re n sh ou ld b e gi ve n m or e liq ui ds to d rin k du rin g di ar rh oe a an d fo od s ho ul d no t b e re du ce d. F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. A n as te ris k in di ca te s th at a fig ur e is b as ed o n fe w er th an 2 5 un w ei gh te d ca se s an d ha s be en s up pr es se d. 1 C on tin ue d fe ed in g pr ac tic es in cl ud e ch ild re n w ho w er e gi ve n m or e, th e sa m e as u su al , o r s om ew ha t l es s fo od d ur in g th e di ar rh oe a ep is od e. 136 • Child Health Child Health • 137 Thirty-six percent of children with diarrhoea were given the same amount of liquids as usual, and 38 percent were given more. It is of concern that 15 percent of the children were given somewhat less to drink than usual, and that 10 percent were given much less to drink during the diarrhoea episode. Thirty-three percent of children were given the same amount of food as usual, 7 percent were given more food, 26 percent were given somewhat less food, and 22 percent were given much less food. Seven percent of children were not given any food during the diarrhoea episode. Overall, only 25 percent of children had increased fluid intake and continued feeding. Forty-six percent of children were given ORT and/or increased fluids, and continued feeding. 10.6 Knowledge of ORS Sachets To ascertain respondents’ knowledge of ORS in Zimbabwe, women were asked whether they had heard of a special product called an ORS sachet that can be used to treat diarrhoea. Table 10.10 presents information on the percentage of mothers with a birth in the five years preceding the survey who had heard of ORS sachets. Forty-nine percent of women are aware of ORS sachets. Knowledge of ORS sachets generally increases with age, from a low of 40 percent among women age 15-19 to a high of 51 percent among women age 25-34. Knowledge of ORS sachets is more common among women who reside in urban areas (57 percent) than among those in rural areas (45 percent). Women in Matabeleland South are least likely to have heard of ORS sachets (25 percent); women in Harare and Mashonaland West are the most likely to know of ORS sachets (60 percent each). Knowledge of ORS sachets rises with education level and wealth quintile. 10.6 DISPOSAL OF CHILDREN’S STOOLS The proper disposal of children’s faeces is important in preventing the spread of disease. If faeces are left uncontained, disease may be spread by direct contact or through animal contact. The safe disposal of children’s faeces is of particular importance because children’s faeces are more likely to be the cause of faecal contamination to the household environment than other causes as they are often not disposed of properly and may be mistakenly considered less harmful than adult faeces. Children’s stools are considered to be safely disposed of if the child uses a toilet or latrine, the child’s stool is put or rinsed into a toilet or latrine, or the stool is buried. Table 10.10 Knowledge of ORS sachets Percentage of women age 15-49 with a live birth in the five years preceding the survey who know about ORS sachets for treatment of diarrhoea by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of women who know about ORS sachets Number of women Age 15-19 40.2 361 20-24 48.6 1,259 25-34 50.9 2,059 35-49 47.3 748 Residence Urban 57.4 1,382 Rural 44.8 3,044 Province Manicaland 56.3 628 Mashonaland Central 56.1 471 Mashonaland East 47.4 426 Mashonaland West 60.4 552 Matabeleland North 27.4 215 Matabeleland South 24.6 213 Midlands 40.7 548 Masvingo 33.2 496 Harare 60.4 689 Bulawayo 47.9 189 Education No education 24.3 77 Primary 39.5 1,375 Secondary 52.8 2,835 More than secondary 72.1 139 Wealth quintile Lowest 38.7 957 Second 44.4 908 Middle 48.6 847 Fourth 52.0 971 Highest 63.0 743 Total 48.8 4,426 ORS = Oral rehydration salts 138 • Child Health Table 10.11 presents information on the disposal of faecal matter of children under age 5, according to background characteristics. Eighty-three percent of children had their last stool disposed of safely. Access to an improved toilet or latrine is clearly a factor in determining whether or not faecal matter was safely disposed of. For example, 95 percent of children who had access to an improved, non-shared toilet facility had their last stool disposed of safely compared with 78 percent of children who did not. Children in urban areas were more likely than those in rural areas to have had their last stool safely disposed of (95 and 77 percent, respectively). The proportion of children whose last stool was disposed of safely also rose with the mother’s education and the wealth quintile. Table 10.11 Disposal of children's stools Percent distribution of youngest children under age five living with the mother by the manner of disposal of the child's last stool, and percentage of children whose stools are disposed of safely, according to background characteristics, Zimbabwe 2010-11 Background characteristic Manner of disposal of children's stools: Total Percentage of children whose stools are disposed of safely1 Number of children Child used toilet or latrine Put/rinsed into toilet or latrine Buried Put/rinsed into drain or ditch Thrown into garbage Left in the open Other Age of child in months <6 4.7 60.6 11.4 13.3 4.0 6.0 0.1 100.0 76.7 678 6-11 4.5 57.5 15.5 15.3 3.6 3.5 0.2 100.0 77.5 647 12-23 8.8 53.2 20.3 7.5 4.4 5.4 0.2 100.0 82.4 963 24-35 32.7 31.6 22.6 3.0 2.2 7.8 0.2 100.0 86.8 787 36-47 51.5 15.3 22.4 1.1 0.7 9.0 0.2 100.0 89.1 571 48-59 59.4 10.2 16.0 0.4 0.8 12.6 0.2 100.0 85.6 385 Toilet facility Improved, not shared2 31.0 57.8 5.5 2.9 1.4 1.4 0.0 100.0 94.3 1,208 Non-improved or shared 19.6 34.4 23.9 9.1 3.5 9.2 0.3 100.0 77.8 2,823 Residence Urban 35.0 58.1 1.9 3.4 1.1 0.2 0.2 100.0 95.1 1,221 Rural 17.7 34.2 25.5 8.9 3.6 9.8 0.2 100.0 77.4 2,810 Province Manicaland 18.9 51.2 15.3 8.7 2.4 3.2 0.0 100.0 85.4 572 Mashonaland Central 17.9 42.6 16.0 5.1 3.5 15.0 0.0 100.0 76.4 428 Mashonaland East 24.7 44.3 20.4 7.7 1.3 1.3 0.3 100.0 89.5 403 Mashonaland West 28.8 34.1 20.6 6.7 2.2 7.0 0.7 100.0 83.5 504 Matabeleland North 6.3 23.8 41.2 9.1 6.0 13.3 0.3 100.0 71.3 201 Matabeleland South 15.4 38.2 11.0 8.2 7.8 18.8 0.6 100.0 64.6 196 Midlands 17.4 31.6 32.4 7.7 1.0 9.9 0.0 100.0 81.4 505 Masvingo 22.3 24.2 26.4 11.8 6.4 8.8 0.0 100.0 72.9 455 Harare 33.8 59.2 1.5 4.7 0.6 0.0 0.1 100.0 94.6 600 Bulawayo 37.0 58.3 0.3 0.4 3.7 0.3 0.0 100.0 95.6 167 Mother’s education No education 17.9 21.0 35.5 6.4 4.0 13.8 1.3 100.0 74.5 70 Primary 17.4 30.9 26.0 10.0 4.2 11.3 0.2 100.0 74.3 1,252 Secondary 25.6 45.9 15.0 6.2 2.3 4.9 0.1 100.0 86.5 2,593 More than secondary 28.4 68.5 0.0 2.2 1.0 0.0 0.0 100.0 96.8 115 Wealth quintile Lowest 11.1 15.3 38.0 12.1 5.4 17.7 0.3 100.0 64.3 892 Second 16.9 31.7 29.1 9.6 4.0 8.7 0.1 100.0 77.7 842 Middle 22.4 48.8 14.3 7.3 2.2 4.9 0.2 100.0 85.5 780 Fourth 32.7 57.2 4.3 4.0 0.9 0.8 0.2 100.0 94.2 877 Highest 34.9 60.2 1.2 2.0 1.5 0.1 0.1 100.0 96.3 641 Total 23.0 41.4 18.4 7.3 2.9 6.9 0.2 100.0 82.8 4,031 Note: Total includes 1 case for which manner of disposal of stools was missing. 1Children's stools are considered to be disposed of safely if the child used a toilet or latrine, if the faecal matter was put/rinsed into a toilet or latrine or if it was buried. 2Non-shared facilities that are of the types: flush or pour flush into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrine; and a pit latrine with a slab Nutrition of Children and Adults • 139 NUTRITION OF CHILDREN AND ADULTS 11 his chapter focuses on the nutritional status of children and adults and complements other recent surveys on nutrition that have been conducted in Zimbabwe (MOHCW and FNC, 2011). The chapter describes the nutritional status of children under age 5; infant and young child feeding practices, including breastfeeding and feeding with solid/semisolid foods; diversity of foods fed and frequency of feeding; and micronutrient status, supplementation, and fortification. The discussion also covers the nutritional status of women and men age 15-49. 11.1 NUTRITIONAL STATUS OF CHILDREN The anthropometric data on height and weight collected in the 2010-11 ZDHS permit the measurement and evaluation of the nutritional status of young children in Zimbabwe. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. Marked differences, especially with regard to height-for-age, weight-for-height, and weight-for-age, are often seen among different subgroups of children within the country. 11.1.1 Measurement of Nutritional Status among Young Children The 2010-11 ZDHS collected data on the nutritional status of children by measuring the height and weight of children under age 5 in all sampled households, regardless of whether their mother was interviewed in the survey. Data were collected with the aim of calculating three indices: height-for-age, weight-for-height, and weight-for-age. Weight measurements were obtained using lightweight SECA mother-infant scales with a digital screen, designed and manufactured under the guidance of UNICEF. Height measurements were carried out using a Shorr Productions measuring board. Children younger than 24 months were measured lying down on the board (recumbent length), and standing height was measured for older children. T Key Findings • Among children under age 5 at the time of the survey, 32 percent were stunted (short for their age), 3 percent were wasted (thin for their height), and 10 percent were underweight (thin for their age). Six percent of children were overweight (heavy for their height). • Among last-born children under age 2, 97 percent were breastfed at some point in their life. Only 31 percent of children were exclusively breastfed throughout the first six months of life. • Among children born in the three years preceding the survey, the median breastfeeding duration is 17.8 months. Exclusive breastfeeding, in contrast, is relatively short, with a median duration of 1.1 months. • Feeding practices of only 11 percent of children age 6-23 months meet the minimum standards with respect to all three of the infant and young child feeding (IYCF) practices. • More than half of Zimbabwean children (56 percent) age 6-59 months are anaemic, 27 percent are mildly anaemic, 29 percent are moderately anaemic, and 1 percent are severely anaemic. • Sixty-six percent of children age 6-59 months received vitamin A supplements in the past 6 months, and 94 percent live in households with iodized salt. • Overall, 62 percent of women and 75 percent of men have a body mass index (BMI) in the normal range. Nearly one in three women are overweight, and 11 percent are obese. • Twenty-eight percent of women and 14 percent of men are anaemic. 140 • Nutrition of Children and Adults For the 2010-11 ZDHS, the nutritional status of children was calculated using new growth standards published by WHO in 2006. These standards were generated through data collected in the WHO Multicentre Growth Reference Study (WHO, 2006). That study, which involved a sample of 8,440 children drawn from six countries across the world, was designed to describe how children should grow under optimal conditions. The WHO child growth standards can therefore be used to assess children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. Each of the three nutritional status indicators described below is expressed in standard deviation units from the median of the Multicentre Growth Reference Study sample. The nutritional status of children in the 2010-11 ZDHS according to the NCHS/CDC/WHO reference population, which was used in previous ZDHS reports, is shown in Appendix Table C.7. Each of these indices—height-for-age, weight-for-height, and weight-for-age—provides different information about growth and body composition that can be used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age (stunted), or chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period and is also affected by recurrent and chronic illness. Height-for age, therefore, represents the long-term effects of malnutrition (specifically, undernutrition) in a population and is not sensitive to recent, short-term changes in dietary intake. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) from the median of the reference population are considered thin (wasted), or acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey. It may result from inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) are considered severely wasted. Overweight and obesity are other forms of malnutrition that are increasingly becoming concerns for some children in developing countries. Children whose Z-scores are plus 2 standard deviations (+2 SD) above the median for weight-for-height are considered overweight. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the median are considered severely underweight. Z-score means are also calculated as summary statistics representing the nutritional status of children in a population. These mean scores describe the nutritional status of the entire population without the use of a cutoff. A mean Z-score of less than 0 (i.e., a negative value for stunting, wasting, or underweight) suggests that the distribution of an index has shifted downward and that most if not all children in the population suffer from undernutrition relative to the reference population. 11.1.2 Data Collection Height and weight measurements were obtained for 5,976 children under age 5 who were present in the ZDHS sample households at the time of the survey. The following analysis focuses on Nutrition of Children and Adults • 141 the 5,260 children (88 percent) for whom complete and credible anthropometric and age data were collected. 11.1.3 Levels of Child Malnutrition Table 11.1 and Figure 11.1 show the percentage of children under age 5 classified as malnourished according to the three anthropometric indices of nutritional status (height-for-age, weight-for-height, and weight-for-age). Overall, at the time of the 2010-11 ZDHS, 32 percent of children were stunted, 3 percent were wasted, 10 percent were underweight, and 6 percent were overweight. The percentage of stunting initially increases with a child’s age, with prevalence peaking in the age range of 24-35 months (49 percent), before declining somewhat as children approach their fifth birthday (26 percent of children age 48-59 months are stunted). Twenty percent of Zimbabwean children age 18-23 months are severely stunted. The prevalence of wasting is highest among children age 9-11 months (8 percent), and children age 18-23 months are most likely to be underweight (16 percent). As can be seen in Table 11.1, boys are more likely to be malnourished than girls across all indices. Rates of stunting, wasting, and underweight are higher among children reported as very small and small at birth than among children reported as average or larger at birth. In addition, the prevalence of stunting, wasting, and underweight is higher among children born to underweight mothers than among those born to normal-weight or overweight mothers. Undernutrition levels vary by residence; rates of stunting, wasting, and underweight are higher among rural children than urban children. By province, Mashonaland East has the highest prevalence of stunting (35 percent), while Matabeleland North has the highest prevalence of wasting and underweight (6 percent and 14 percent, respectively). The prevalence of stunting is correlated with the education level of the mother. Stunting is highest among children whose mothers have no education (41 percent) and lowest among children whose mothers have more than a secondary education (19 percent). Wasting and underweight are also less prevalent among children of mothers with more than a secondary education than among children of mothers with less education, although the relationship is not linear. Similarly, children in the highest wealth quintile are less likely to suffer from undernutrition than those in lower wealth quintiles, but, with the exception of underweight, the relationship is nonlinear. By age, the prevalence of overweight is highest among children under 6 months (13 percent). The prevalence of overweight children differs only slightly by sex or size at birth, but children whose mothers are overweight or obese are more likely than other children to be overweight (7 percent compared with 3-5 percent). The prevalence of overweight children is nearly identical in urban and rural areas but varies by province: Manicaland has the highest prevalence of overweight children (9 percent) and Mashonaland Central the lowest (3 percent). The prevalence of overweight children increases with the education level of the mother and, to a lesser extent, with wealth quintile. Fifteen percent of children whose mothers have more than a secondary education are overweight, compared with 4 percent of those whose mothers have no education or only a primary education. 142 • Nutrition of Children and Adults Table 11.1 Nutritional status of children Percentage of children under age five classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Zimbabwe 2010-11 Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children Percent- age below -3 SD Percent- age below -2 SD2 Mean Z- score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z- score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z- score (SD) Age in months <6 3.6 9.8 -0.3 1.4 5.3 13.1 0.3 1.4 5.3 2.9 0.0 580 6-8 3.1 13.6 -0.6 1.6 3.7 4.9 0.1 0.7 5.1 1.4 -0.3 320 9-11 8.8 17.3 -0.9 1.6 8.1 6.9 0.0 2.8 10.7 2.5 -0.5 312 12-17 10.0 30.3 -1.3 0.8 3.4 5.5 0.0 1.7 10.2 1.4 -0.6 595 18-23 20.3 47.4 -1.8 1.0 5.4 5.7 0.0 3.4 15.8 1.2 -0.9 434 24-35 17.9 48.5 -1.9 0.4 1.7 5.7 0.4 2.4 11.0 1.1 -0.8 1,065 36-47 11.4 37.2 -1.7 0.1 1.2 3.5 0.2 1.8 10.0 0.1 -0.8 1,039 48-59 5.5 25.9 -1.4 0.1 1.7 2.3 0.0 1.0 8.7 0.2 -0.8 915 Sex Male 12.5 35.7 -1.5 0.8 3.6 6.3 0.2 1.8 11.1 1.4 -0.7 2,604 Female 9.0 28.3 -1.3 0.5 2.4 4.7 0.1 1.9 8.4 0.8 -0.6 2,656 Birth interval in months3 First birth4 9.8 30.7 -1.4 1.0 2.7 5.3 0.2 1.3 7.7 0.5 -0.7 1,308 <24 12.8 35.6 -1.5 0.0 2.5 4.8 0.3 1.9 12.4 0.9 -0.7 232 24-47 11.6 34.2 -1.4 0.8 4.0 6.0 0.2 2.6 10.1 1.2 -0.7 1,309 48+ 9.9 27.9 -1.2 0.5 2.9 4.6 0.1 1.1 9.9 1.3 -0.6 1,459 Size at birth3 Very small 24.0 49.8 -2.0 0.9 3.8 4.7 -0.1 6.3 24.6 0.0 -1.3 117 Small 14.0 37.8 -1.7 1.8 4.8 4.4 -0.2 4.1 19.8 0.2 -1.1 365 Average or larger 9.7 29.8 -1.3 0.6 3.0 5.4 0.2 1.3 8.0 1.2 -0.6 3,729 Mother's interview status Interviewed 10.5 31.1 -1.3 0.7 3.1 5.3 0.2 1.6 9.4 1.0 -0.6 4,309 Not interviewed but in household 11.7 29.3 -1.3 0.6 3.4 9.4 0.2 3.6 10.5 3.0 -0.5 185 Not interviewed and not in household5 11.8 37.6 -1.6 0.2 1.9 5.8 0.2 2.6 10.9 0.8 -0.8 766 Mother's nutritional status6 Thin (BMI < 18.5) 17.5 40.3 -1.6 0.4 8.2 3.2 -0.5 6.1 22.5 0.6 -1.2 276 Normal (BMI 18.5-24.9) 11.0 32.1 -1.4 0.9 3.4 4.8 0.1 1.6 9.8 0.7 -0.7 2,835 Overweight/ obese (BMI ≤ 25) 8.4 26.5 -1.2 0.4 1.6 6.8 0.4 1.0 6.3 2.0 -0.4 1,256 Residence Urban 8.0 27.5 -1.3 0.6 2.1 5.4 0.2 1.3 8.1 1.6 -0.5 1,304 Rural 11.7 33.4 -1.4 0.7 3.2 5.5 0.1 2.0 10.2 0.9 -0.7 3,956 Province Manicaland 9.1 33.7 -1.5 0.1 2.1 8.8 0.4 1.7 8.1 1.5 -0.6 786 Mashonaland Central 10.5 32.9 -1.4 0.3 3.8 2.9 0.0 2.2 12.0 0.6 -0.8 576 Mashonaland East 13.5 34.9 -1.4 1.1 3.8 5.0 0.1 2.5 9.5 1.0 -0.7 569 Mashonaland West 12.0 31.2 -1.3 1.1 2.4 6.4 0.2 1.6 10.2 1.7 -0.6 642 Matabeleland North 10.8 33.8 -1.4 1.9 5.8 4.8 -0.1 2.2 14.4 0.4 -0.9 258 Matabeleland South 12.7 30.7 -1.4 1.4 4.1 5.3 0.1 2.1 12.0 1.2 -0.7 304 Midlands 11.9 32.7 -1.4 0.2 2.7 4.2 0.1 1.8 10.5 0.3 -0.8 715 Masvingo 9.9 30.7 -1.3 0.6 2.1 5.5 0.3 1.5 6.5 1.3 -0.5 618 Harare 9.3 29.0 -1.4 0.8 2.8 4.6 0.2 2.0 8.9 1.1 -0.6 601 Bulawayo 5.1 26.2 -1.2 0.0 2.3 6.8 0.3 0.8 7.9 1.8 -0.4 191 Mother’s education7 No education 11.9 40.5 -1.6 1.2 2.8 4.4 0.1 2.6 10.8 2.2 -0.9 95 Primary 11.9 33.6 -1.4 0.9 3.6 4.3 0.1 2.0 11.3 0.8 -0.7 1,493 Secondary 10.0 29.8 -1.3 0.7 3.0 5.7 0.2 1.6 8.8 1.2 -0.6 2,793 More than secondary 5.8 18.5 -0.8 0.0 1.0 15.2 0.6 1.0 2.1 4.2 0.0 113 Wealth quintile Lowest 12.8 36.8 -1.5 0.9 3.2 4.4 0.1 2.2 12.0 0.8 -0.8 1,249 Second 11.3 32.0 -1.4 0.8 3.3 4.2 0.1 2.4 11.1 1.0 -0.7 1,173 Middle 12.9 35.0 -1.5 0.3 2.9 5.8 0.2 2.3 9.0 0.5 -0.7 1,087 Fourth 8.6 28.6 -1.3 0.8 3.7 6.8 0.2 1.2 8.8 1.5 -0.5 1,028 Highest 6.1 23.8 -1.1 0.3 1.1 7.1 0.3 0.6 5.7 2.0 -0.4 723 Total 10.7 32.0 -1.4 0.7 3.0 5.5 0.2 1.9 9.7 1.1 -0.7 5,260 Note: Table is based on children who stayed in the household on the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO child growth standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used 1977 NCHS/CDC/WHO reference. The table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 98 cases with information missing on size at birth that are not shown separately. 1 Recumbent length is measured for children under age 2 and in the few cases when the age of the child is unknown and the child is less than 85 cm; standing height is measured for all other children. 2 Includes children who are below -3 standard deviations from the WHO growth standards population median 3 Excludes children whose mothers were not interviewed 4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 5 Includes children whose mothers are deceased 6 Excludes children whose mothers were not weighed and measured. Mother’s nutritional status in terms of BMI (body mass index) is presented in Table 11.10. 7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. The mean stunting, wasting, and underweight Z-scores for children under age 5 are -1.4, 0.2, and -0.7, respectively. Scores of less than zero on these indices suggest that nutritional status is poorer on average than that of the reference population. Nutrition of Children and Adults • 143 Figure 11.1 Nutritional Status of Children by Age ZDHS 2010-11 # # ### ##### ######## ########################## ################) ) ))))))))))))))))))) ))))))))))))))))))))))))))))))))))))))) 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Age (months) 0 10 20 30 40 50 60 Percent Stunted Wasted Underweight) # Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a 5-month moving average. Classifications of nutritional status are based on the WHO child growth standards. 11.1.4 Trends in Child Malnutrition Figure 11.2 shows trends in the nutritional status of children in Zimbabwe using anthropometric measurements from the 1999 ZDHS, 2005-06 ZDHS, and 2010-11 ZDHS. To assess trends, the anthropometric measures from the 1999 and 2005-06 surveys were recalculated using the new WHO growth standards. The results show that the prevalence of stunting and underweight increased slightly between 1999 and 2005-06 and decreased between 2005-06 and 2010-11. In contrast, the prevalence of wasting and overweight shows a continuous decline since 1999. 144 • Nutrition of Children and Adults Figure 11.2 Trends in Nutritional Status of Children under Age 5 ZDHS 2010-11 34 8 10 10 35 7 13 8 32 3 10 6 Stunting Wasting Underweight Overweight 0 5 10 15 20 25 30 35 40 Percent 1999 2005-06 2010-11 Note: Classifications of nutritional status are based on the WHO child growth standards. 11.2 BREASTFEEDING ZDHS data can be used to evaluate infant feeding practices, including breastfeeding duration, introduction of complementary weaning foods, and use of feeding bottles. The pattern of infant feeding has important influences on both the child and the mother. Feeding practices are the principal determinants of a child’s nutritional status. Poor nutritional status in young children exposes them to greater risks of morbidity. Biologically, breastfeeding suppresses the mother’s return to fertile status and affects the length of the birth interval as well as the level of fertility. These effects are influenced by both the duration and frequency of breastfeeding and the age at which the child receives foods and liquids to complement breast milk. 11.2.1 Initiation of Breastfeeding Early breastfeeding practices determine the successful establishment and duration of breast- feeding. Moreover, during the first three days after delivery, colostrum, an important source of nutrition and protection for the newborn, is produced and should be given to the newborn while awaiting the letdown of regular breast milk. Thus, it is recommended that children be put to the breast immediately or within one hour after birth and that prelacteal feeding (i.e., feeding newborns anything other than breast milk before breast milk is regularly given) be discouraged. The Ministry of Health and Child Welfare promotes rooming-in of all new infants in maternity hospitals and breastfeeding within the first hour of birth to foster bonding and protect children from harsh external environments. Table 11.2 shows that 97 percent of last-born children who were born in the two years preceding the survey were breastfed at some point in their life. Differences by background characteristics generally were not large, although infants whose mothers had no assistance at delivery were least likely to ever have been breastfed (89 percent). Nutrition of Children and Adults • 145 Table 11.2 Initial breastfeeding Among last-born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth; and among last-born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, Zimbabwe 2010-11 Background characteristic Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within one hour of birth Percentage who started breastfeeding within one day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 95.9 65.3 91.7 1,225 11.5 1,174 Female 97.2 65.1 91.8 1,224 14.8 1,190 Assistance at delivery Health professional3 96.4 70.4 92.8 1,588 9.4 1,531 Traditional birth attendant 96.4 55.4 90.4 342 18.3 329 Village health worker 100.0 68.2 96.3 109 29.9 109 Other 97.7 54.3 88.7 340 20.8 332 No one 89.1 44.7 80.7 69 8.7 62 Place of delivery Health facility 96.4 69.8 92.6 1,562 9.4 1,506 At home 96.9 57.5 90.2 850 20.1 823 Other (96.0) (47.9) (88.3) 36 (9.9) 34 Residence Urban 94.8 64.5 90.5 718 12.8 681 Rural 97.3 65.5 92.2 1,730 13.3 1,683 Province Manicaland 96.6 61.3 92.3 366 11.5 353 Mashonaland Central 97.8 49.5 87.4 254 24.4 248 Mashonaland East 98.5 75.1 94.3 257 8.5 253 Mashonaland West 96.0 59.5 91.2 296 19.5 284 Matabeleland North 97.8 82.5 95.7 115 10.9 112 Matabeleland South 94.4 74.0 90.1 124 10.9 117 Midlands 98.9 71.0 94.3 298 12.2 295 Masvingo 98.2 70.8 95.4 277 4.7 272 Harare 92.2 61.9 87.4 352 16.3 324 Bulawayo 95.0 59.4 90.5 111 5.5 105 Mother’s education No education (100.0) (61.9) (94.1) 28 (5.9) 28 Primary 96.4 68.7 91.7 767 15.5 740 Secondary 96.8 63.5 91.8 1,573 12.2 1,523 More than secondary 91.7 66.7 88.8 80 11.1 73 Wealth quintile Lowest 96.3 66.2 92.0 543 13.7 523 Second 97.5 65.3 92.4 515 14.6 503 Middle 97.8 64.2 93.2 478 12.9 467 Fourth 96.2 67.3 90.5 519 13.7 499 Highest 94.7 62.2 90.1 393 9.9 372 Total 96.6 65.2 91.7 2,448 13.1 2,364 Notes: Table is based on last-born children born in the two years preceding the survey regardless of whether the children were living or dead at the time of the interview. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse-midwife, or nurse Sixty-five percent of infants were breastfed within one hour of birth, and 9 of 10 began breastfeeding within one day of birth (92 percent). The proportion of children breastfed within one hour of birth was higher among those delivered in a health facility (70 percent) than among those born at home (58 percent). The likelihood of an infant breastfeeding within one hour of birth varied markedly by province, ranging from a low of 50 percent in Mashonaland Central to a high of 83 percent in Matabeleland North. The practice of giving prelacteal feeds limits the frequency of suckling by the infant and exposes the baby to the risk of infection. Table 11.2 shows that most infants were not given prelacteal feeds. Overall, only 13 percent of newborns received prelacteal feeds, with the practice being most common among infants delivered at home (20 percent), those delivered by a village health worker 146 • Nutrition of Children and Adults (30 percent), those whose families resided in Mashonaland Central (24 percent), and those whose mothers had only a primary education (16 percent). Infants in the highest wealth quintile were less likely to receive a prelacteal feed than infants in the other wealth quintiles. 11.2.2 Breastfeeding Status by Age Breast milk contains all of the nutrients needed by children in the first six months of life and is an uncontaminated nutritional source. Complementing breast milk before age 6 months is unnecessary and is indeed discouraged because the likelihood of contamination and resulting risk of diarrhoeal disease are high. Early initiation of complementary feeding also reduces breast milk output because the production and release of breast milk is modulated by the frequency and intensity of suckling. Table 11.3 shows breastfeeding practices by child age.1 Although only 31 percent of infants under age 6 months are exclusively breastfed, this is a 9 percentage point increase from the figure reported in the 2005-06 ZDHS (22 percent). Contrary to the recommendation that children under 6 months be exclusively breastfed, 26 percent of infants consume plain water, 2 percent consume non- milk liquids, 1 percent consume other milk, and 36 percent consume complementary foods in addition to breast milk. More than 8 in 10 children age 6-9 months receive timely complementary foods, and 70 percent of children age 18-23 months have been weaned. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under age two who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under age twp using a bottle with a nipple, according to age in months, Zimbabwe 2010-11 Age in months Breastfeeding status Percentage currently breast- feeding Number of youngest children under two years living with their mother Percentage using a bottle with a nipple Number of all children under two years Not breast- feeding Exclusively breastfed Breast- feeding and consuming plain water only Breast- feeding and consuming non-milk liquids1 Breast- feeding and consuming other milk Breast- feeding and consuming comple- mentary foods Total 0-1 2.7 60.6 24.3 0.5 1.9 10.0 100.0 97.3 167 1.5 169 2-3 4.1 30.2 25.2 3.5 1.5 35.5 100.0 95.9 236 6.6 238 4-5 2.9 14.8 28.0 2.0 0.6 51.6 100.0 97.1 275 8.8 280 6-8 3.5 4.5 9.4 0.0 0.3 82.2 100.0 96.5 326 8.7 333 9-11 6.5 0.2 3.4 1.3 0.3 88.5 100.0 93.5 321 9.1 327 12-17 17.4 1.8 2.1 0.2 0.1 78.4 100.0 82.6 586 9.1 600 18-23 70.3 0.4 0.8 0.4 0.2 27.9 100.0 29.7 377 6.7 434 0-3 3.5 42.8 24.8 2.3 1.7 24.9 100.0 96.5 403 4.4 407 0-5 3.3 31.4 26.1 2.2 1.2 35.8 100.0 96.7 678 6.2 687 6-9 4.3 3.6 8.6 0.5 0.2 82.7 100.0 95.7 423 8.6 430 12-15 12.7 1.7 2.7 0.2 0.0 82.7 100.0 87.3 411 9.6 418 12-23 38.1 1.3 1.6 0.2 0.2 58.6 100.0 61.9 963 8.1 1,034 20-23 80.5 0.6 0.9 0.0 0.0 17.9 100.0 19.5 252 5.7 296 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, and breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semisolids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus, children who receive breast milk and non-milk liquids and who do not receive complementary foods are classified in the non-milk liquid category even though they may also be given plain water. Any children who receive complementary food are classified in that category as long as they are breastfeeding as well. 1 Non-milk liquids include juice, juice drinks, clear broth, and/or soup or other liquids. 1 When comparing the results of the 2010-11 ZDHS with previous ZDHS surveys, note that the 2010-11 table on breastfeeding status by age is restricted to the youngest children and all children under age 2 living with their mothers, instead of the youngest children and all children under age 3 living with their mothers (as in the 1999 ZDHS and 2005-06 ZDHS). Nutrition of Children and Adults • 147 Feeding children using a bottle with a nipple is discouraged and is not a common practice in Zimbabwe; only 6 percent of children below age 6 months are fed using a bottle with a nipple. The prevalence of bottle-feeding is highest among children age 12-15 months (10 percent). Figure 11.3 depicts the transition of feeding practices among children up to age 2. The rapid drop in exclusive breastfeeding from 61 percent among infants under age 2 months to 15 percent among children age 4 to 5 months demands attention. The early introduction of complementary foods to 10 percent of children under age 2 months is also a cause for concern. Figure 11.3 Infant Feeding Practices by Age ZDHS 2010-11 <2 2-3 4-5 6-7 8-9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 Age in months 0 20 40 60 80 100 Percent Exclusively breastfed Breast milk and plain water only Breast milk and non-milk liquids/juice Breast milk and other milk Breast milk and complementary foods Not breastfeeding Figure 11.4 presents 2010-11 ZDHS results on infant and young child feeding (IYCF) indicators related to breastfeeding status. Detailed descriptions of these indicators can be found in recent WHO publications (WHO, 2008, and WHO, 2010). 148 • Nutrition of Children and Adults Figure 11.4 IYCF Indicators on Breastfeeding Status ZDHS 2010-11 31 15 87 86 20 58 60 8 IYCF 2 Exclusive BF IYCF 3 IYCF 4 IYCF 10 IYCF 11 IYCF 12 IYCF 14 0 20 40 60 80 100 Percentage of children IYCF 2: Exclusive breastfeeding under 6 months of age Exclusive breastfeeding at 4-5 months of age IYCF 3: Continued breastfeeding at 1 year IYCF 4: Introduction of solid, semisolid, or soft foods (6-8 months) IYCF 10: Continued breastfeeding at 2 years IYCF 11: Age-appropriate breastfeeding (0-23 months) IYCF 12: Predominant breastfeeding (0-5 months) IYCF 14: Bottle feeding (0-23 months) 11.2.3 Median Duration of Breastfeeding Table 11.4 shows that the median duration of any breastfeeding (i.e., the length of time in months for which half of children are breastfed) is 17.8 months. Children are breastfed almost two months longer on average in rural areas than in urban areas. Median durations of any breastfeeding are shorter for children in the highest wealth quintile (15.9 months) than for children in the other quintiles. Comparisons by province or mother’s education level are not possible because, in several categories, there are too few children. Overall, the median duration of exclusive breastfeeding for Zimbabwean children is just over one month, whereas the median duration of predominant breastfeeding (i.e., the period in which an infant receives only water or other non-milk liquids in addition to breast milk) is just over three months. Infants in urban areas (1.8 months) and those in the highest wealth quintile (2.4 months) are exclusively breastfed for longer periods than infants in rural areas (0.8 months) and those in lower wealth quintiles. Differences in median duration of predominant breastfeeding are small. Median durations of exclusive and predominant breastfeeding have increased modestly from those reported in 2005-06, when the median duration of exclusive breastfeeding was 0.6 months and the median duration of predominant breastfeeding was 1.6 months. Nutrition of Children and Adults • 149 Table 11.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breast- feeding Exclusive breast- feeding Predominant breast- feeding2 Sex Male 17.4 1.1 3.1 Female 18.2 1.1 3.3 Residence Urban 16.6 1.8 3.0 Rural 18.4 0.8 3.3 Province Manicaland 17.6 (1.7) 3.4 Mashonaland Central (18.8) (0.7) 2.1 Mashonaland East 18.6 * 3.1 Mashonaland West 17.7 0.6 3.9 Matabeleland North (19.5) (1.3) (3.5) Matabeleland South 18.2 * 3.6 Midlands 18.4 1.2 3.2 Masvingo 18.1 * 2.4 Harare 16.8 (2.1) 3.1 Bulawayo (14.7) (0.7) (4.0) Mother’s education No education * * * Primary 18.2 1.2 3.5 Secondary 17.8 1.0 3.0 More than secondary * * * Wealth quintile Lowest 18.6 (0.6) 3.6 Second 18.4 0.7 3.4 Middle 18.7 1.3 3.1 Fourth 17.1 1.1 2.6 Highest 15.9 2.4 3.3 Total 17.8 1.1 3.2 Mean for all children 17.3 2.8 4.8 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 It is assumed that non-last-born children and last-born children not currently living with their mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water and/or non-milk liquids only 11.3 DIETARY DIVERSITY AMONG YOUNG CHILDREN In the 2010-11 ZDHS, women who had at least one child living with them who was born in 2008 or later were asked questions about the types of liquids and foods the child had consumed during the day or night preceding the interview. Mothers who had more than one child born in 2008 or later were asked questions about the youngest child living with them. Mothers were also asked about the number of times the child had eaten solid or semisolid food during the period. The results from these data are subject to a number of limitations. For example, they do not apply to the full universe of young children. Unlike previous ZDHS surveys, the information in Table 11.5 is restricted to the youngest children under age 22 living with their mother at the time of the survey. The dietary data on children are subject to recall errors on the mother’s part. In addition, the 2 In earlier surveys, the comparable table to Table 11.5 was restricted to the youngest children under age 3 who were living with their mothers at the time of the survey. 150 • Nutrition of Children and Adults mother may not be able to report fully on the child’s intake of food and liquids if the child was fed by other individuals during the period. Despite these problems, the information collected in the 2010-11 ZDHS on the types of foods and liquids consumed by young children is useful in assessing the diversity of children’s diets. 11.3.1 Foods and Liquids Consumed by Infants and Young Children Appropriate nutrition includes feeding children a variety of foods to ensure that nutrient requirements are met. Fruits and vegetables rich in vitamin A should be consumed daily. Although eating a range of fruits and vegetables, especially those rich in vitamin A, is important, studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients. Therefore, it has been recommended that meat, poultry, fish, or eggs be eaten daily or as often as possible (WHO, 1998). Table 11.5 is based on information from mothers about the foods and liquids consumed by their youngest child during the day or night preceding the interview. As expected, the proportions of children consuming foods or liquids included in the various food groups generally increase with age. Children who are still breastfed are less likely than children who are not being breastfed to consume other types of liquids and solid/semisolid foods with the exception of fortified baby foods. For example, 92 percent of nonbreastfeeding children age 6-23 months consumed foods made from grains the day or night preceding the interview, compared with 85 percent of breastfeeding children in that age group. Similarly, 67 percent of nonbreastfeeding children age 6-23 months consumed foods rich in vitamin A, as compared with 50 percent of breastfeeding children in the same age group. Half of nonbreastfeeding children and 29 percent of breastfeeding children age 6-23 months consumed meat, fish, and poultry. Fewer than 1 in 4 nonbreastfeeding children age 6-23 months consumed eggs, foods made from legumes and nuts, or cheese, yogurt, and other milk products; among breastfeeding children in the same age group, the proportions were closer to 1 in 10. Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age two who are living with their mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Zimbabwe 2010-11 Age in months Liquids Solid or semisolid foods Any solid or semi- solid food Number of children Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry5 Eggs Cheese, yogurt, other milk products BREASTFEEDING CHILDREN 0-1 0.0 1.9 2.2 1.8 6.7 0.6 0.0 0.6 0.7 0.0 0.0 0.0 10.3 163 2-3 1.7 3.5 8.6 10.7 25.8 3.0 0.0 0.7 1.4 0.7 0.7 1.5 37.0 226 4-5 2.1 1.8 10.7 12.1 40.6 5.0 1.7 0.4 2.0 1.4 1.5 2.5 53.2 267 6-8 2.1 3.4 39.6 17.9 74.0 21.9 10.8 8.0 6.2 8.8 4.9 9.4 85.3 314 9-11 1.8 5.7 58.8 14.5 88.7 49.1 22.4 15.1 15.7 29.3 12.8 9.4 94.6 300 12-17 0.8 8.9 61.2 6.5 89.0 63.5 24.1 14.6 13.3 40.7 13.1 13.8 94.8 484 18-23 0.0 13.0 59.9 7.6 89.0 72.5 23.6 9.0 14.3 39.0 15.2 14.5 93.7 112 6-23 1.3 7.1 54.9 11.5 85.0 50.0 20.2 12.5 12.1 29.4 11.1 11.7 92.2 1,211 Total 1.3 5.4 38.3 10.7 64.7 33.5 13.3 8.3 8.4 19.4 7.5 8.1 72.8 1,867 NONBREASTFEEDING CHILDREN 0-11 23.8 26.6 36.4 20.5 57.2 20.8 10.8 7.0 6.7 16.2 11.1 13.5 72.5 55 12-17 7.8 15.5 75.6 14.5 90.2 67.4 33.9 26.4 17.8 55.6 21.4 30.3 97.0 102 18-23 1.6 11.2 70.9 5.7 94.5 70.3 35.3 23.0 15.4 51.8 22.1 18.2 96.9 265 6-23 5.0 14.4 71.0 9.1 92.3 66.7 33.6 23.0 15.7 50.8 21.6 21.7 96.7 399 Total 6.0 14.2 67.5 9.7 88.6 63.1 31.8 21.8 14.9 48.1 20.5 20.5 93.8 421 Note: Breastfeeding status and food consumed refer to a “24-hour” period (yesterday and last night). 1 Other milk includes fresh, tinned, and powdered animal milk. 2 Does not include plain water. Includes juice, juice drinks, clear broth, and other non-milk liquids. 3 Includes fortified baby food 4 Includes pumpkin, carrots, squash, sweet potatoes, butternuts, yellow and orange yams, dark green leafy vegetables, mangoes, papayas, and other fruits and vegetables that are rich in vitamin A 5 Includes insects such as locusts, mopane worms, ishwa, and harurwa Nutrition of Children and Adults • 151 11.3.2 Infant and Young Child Feeding (IYCF) Practices Appropriate IYCF practices include breastfeeding through age 2, introduction of solid and semisolid foods at age 6 months, and gradual increases in the amount of food given and frequency of feeding as the child gets older. The minimum frequencies for feeding children in developing countries are based on the energy output of complementary foods. The energy needs of children are based on age-specific total daily energy requirements plus 2 standard deviations (to cover almost all children), minus the average energy intake from breast milk. Infants with low breast milk intake need to be fed more frequently than those with high breast milk intake. However, care should be taken that feeding frequencies do not exceed the recommended input from complementary foods because excessive feeding can result in displacement of breast milk (PAHO/WHO, 2003). According to recommendations, breastfed children age 6-23 months should receive animal- source foods and vitamin A-rich fruits and vegetables daily (PAHO/WHO, 2003). Because first foods almost always include a grain- or tuber-based staple, it is unlikely that young children who eat food from less than three groups will receive both an animal-source food and a vitamin A-rich fruit or vegetable. Therefore, three food groups are considered the minimum number appropriate for breastfed children (Arimond and Ruel, 2004). Breastfed infants age 6-8 months should receive complementary foods two to three times per day, with one or two snacks; breastfed children age 9-23 months should receive meals three to four times per day with one or two snacks (PAHO/WHO, 2003; WHO, 2008, and WHO, 2010). Nonbreastfed children age 6-23 months should receive milk or milk products two or more times a day to ensure that their calcium needs are met. In addition, they need animal-source foods and vitamin A-rich fruits and vegetables. Four food groups are considered the minimum number appropriate for nonbreastfed young children. Nonbreastfed children age 12-23 months should be fed meals four to five times per day, with one or two snacks (WHO, 2005; WHO, 2008, and WHO, 2010). The results presented in Table 11.6 indicate that 79 percent of Zimbabwean children age 6-23 months living with their mother received breast milk or breast milk substitutes during the day or night preceding the interview. Twenty-four percent of children had an adequately diverse diet—that is, they had been given foods from the appropriate number of food groups—and 45 percent had been fed the minimum number of times appropriate for their age. The feeding practices of only 11 percent of Zimbabwean children age 6-23 months meet the minimum standards with respect to all three IYCF feeding practices. The IYCF indicators for minimum acceptable diet by breastfeeding status among Zimbabwean children age 6-23 months are summarized in Figure 11.5. 152 • Nutrition of Children and Adults Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Among breastfed children 6-23 months, percentage fed: Number of breastfed children 6-23 months Among nonbreastfed children 6-23 months, percentage fed: Number of non- breastfed children 6-23 months Among all children 6-23 months, percentage fed: Number of all children 6-23 months 4+ food groups1 Minimum meal frequency2 Both 4+ food groups and minimum meal frequency Milk or milk products3 4+ food groups1 Minimum meal frequency4 With 3 IYCF practices5 Breast milk, milk, or milk products6 4+ food groups1 Minimum meal frequency7 With 3 IYCF practices Age in months 6-8 5.1 53.9 3.5 314 * * * * 12 98.8 6.3 54.6 4.1 326 9-11 20.0 38.5 13.4 300 * * * * 21 95.1 20.0 38.9 12.8 321 12-17 25.1 44.7 16.6 484 19.6 42.1 51.5 5.8 102 86.0 28.0 45.9 14.7 586 18-23 28.4 51.3 22.2 112 11.6 36.9 36.8 4.3 265 37.9 34.3 41.1 9.6 377 Sex Male 19.0 46.8 12.4 586 18.6 37.7 44.8 5.8 211 78.5 24.0 46.3 10.6 797 Female 18.9 45.6 13.4 625 13.0 36.9 39.1 4.5 188 79.8 23.0 44.1 11.3 813 Residence Urban 29.6 54.2 21.3 318 19.6 44.6 48.7 9.7 142 75.2 34.2 52.5 17.7 459 Rural 15.2 43.3 9.9 893 14.0 33.3 38.5 2.7 257 80.8 19.2 42.2 8.3 1,150 Province Manicaland 20.7 64.4 17.1 196 (8.1) (43.5) (37.6) (2.3) 55 79.7 25.7 58.5 13.8 252 Mashonaland Central 13.8 42.8 5.9 139 (14.6) (45.0) (47.4) (8.0) 27 86.1 18.8 43.6 6.2 167 Mashonaland East 20.0 48.3 14.4 151 (4.3) (24.9) (34.5) (0.0) 38 80.6 21.0 45.5 11.5 189 Mashonaland West 10.8 25.3 5.3 136 (18.1) (33.3) (30.5) (7.3) 46 79.4 16.5 26.6 5.8 182 Matabeleland North 3.0 30.3 2.5 67 (0.0) (4.9) (22.3) (0.0) 23 74.4 3.5 28.2 1.9 90 Matabeleland South 29.0 44.0 18.1 64 33.1 30.1 48.4 2.6 28 79.4 29.4 45.4 13.4 92 Midlands 14.6 40.0 7.8 154 (11.0) (37.6) (29.7) (2.1) 46 79.5 19.9 37.6 6.5 200 Masvingo 21.8 40.9 14.1 117 (28.9) (35.2) (46.5) (6.5) 41 81.6 25.3 42.3 12.1 158 Harare 28.8 51.5 21.7 145 (21.0) (51.2) (53.8) (14.2) 61 76.6 35.5 52.2 19.5 207 Bulawayo 34.8 80.2 30.0 41 18.7 45.6 68.9 2.6 33 63.7 39.6 75.2 17.8 73 Mother’s education No education * * * 16 * * * * 4 * * * * 20 Primary 12.7 41.8 7.2 386 11.6 24.1 33.8 1.5 108 80.7 15.2 40.1 5.9 494 Secondary 21.4 48.2 15.1 771 17.4 41.3 44.2 6.6 276 78.2 26.7 47.1 12.9 1,048 More than secondary (39.6) (55.2) (29.8) 37 * * * * 11 (83.4) (43.1) (60.1) (24.6) 48 Wealth quintile Lowest 10.8 43.9 7.1 301 12.4 18.1 35.5 3.9 69 83.7 12.2 42.3 6.5 369 Second 13.4 41.7 8.6 264 10.9 35.7 36.1 0.0 83 78.6 18.7 40.4 6.5 347 Middle 21.7 45.7 14.2 246 9.3 40.3 39.0 1.9 70 79.9 25.8 44.2 11.5 316 Fourth 22.7 46.8 16.6 232 19.9 39.6 39.7 8.4 99 76.0 27.7 44.7 14.2 332 Highest 33.2 57.0 23.0 168 25.4 50.4 60.3 10.7 78 76.4 38.6 58.0 19.1 246 Total 18.9 46.2 12.9 1,211 15.9 37.3 42.1 5.2 399 79.2 23.5 45.2 11.0 1,610 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c. vitamin A-rich fruits and vegetables; d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts. 2 For breastfed children, minimum meal frequency is receiving solid or semisolid food at least twice a day for infants 6-8 months and at least three times a day for children 9-23 months. 3 Includes two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 4 For nonbreastfed children age 6-23 months, minimum meal frequency is receiving solid or semisolid food or milk feeds at least four times a day. 5 Nonbreastfed children age 6-23 months are considered to be fed with a minimum standard of three IYCF practices if they receive other milk or milk products at least twice a day, receive minimum meal frequency, and receive solid or semisolid foods from at least four food groups not including the milk/milk product group. 6 Breastfeeding or not breastfeeding and receiving two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt 7 Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in footnotes 2 and 4. Nutrition of Children and Adults • 153 Figure 11.5 IYCF Indicators on Minimum Acceptable Diet ZDHS 2010-11 19 46 13 37 42 5 24 45 11 IYCF Indicator 5: Minimum dietary diversity IYCF Indicator 6: Minimum meal frequency IYCF Indicator 7: Minimum acceptable diet 0 10 20 30 40 50 Percent Breastfed Nonbreastfed All children 6-23 months Breastfed children (46 percent) are slightly more likely than nonbreastfed children (42 percent) to be fed the minimum number of times per day but are much less likely to receive the minimum number of food groups (19 percent and 37 percent, respectively). Children age 12-17 months are more likely to meet the minimum feeding standards than older or younger children. Children in urban areas (18 percent) are more than twice as likely to be fed according to the recommended IYCF guidelines as children in rural areas (8 percent). There are marked differences in children’s feeding practices by province; 20 percent of children in Harare are fed according to the three IYCF practices, compared to only 2 percent of children in Matabeleland North. However, these results should be interpreted with caution because of the small number of children reported on in the different regions. As expected, children in the highest wealth quintile (19 percent) are more likely to be fed according to the recommended three IYCF practices than children in lower wealth quintiles (7-14 percent). In the period between the 2005-06 ZDHS and the 2010-11 ZDHS, the definition of standard IYCF indicators changed to reflect more restrictive requirements. In order to compare the IYCF results presented here with results from the 2005-06 ZDHS, the 2010-11 data were recalculated according to the definitions used in 2005-06. This comparison indicates that the percentage of children age 6-23 months fed with an adequate diet (i.e., with all three IYCF practices) has declined from 31 percent in 2005-06 to 20 percent in 2010-11 (data not shown). However, this result should be interpreted with caution because the difference could be mostly due to methodological differences in data collection between the two surveys. The 2005-06 ZDHS included questions on an expanded list of complementary food items (e.g., foods made with oil, fat, or butter); the 2010-11 ZDHS did not include questions about these items. Thus, changes in the questions between the 2005-06 ZDHS and 2010-11 ZDHS make trend analysis both difficult and of limited value. 154 • Nutrition of Children and Adults 11.4 ANAEMIA PREVALENCE IN CHILDREN Anaemia is a condition that is marked by low levels of haemoglobin in the blood. Iron is a key component of haemoglobin, and iron deficiency is estimated to be responsible for half of all anaemia globally. Other causes of anaemia include malaria, hookworm and other helminths, other nutritional deficiencies, chronic infections, and genetic conditions. Anaemia is a serious concern for children because it can impair cognitive development, stunt growth, and increase morbidity from infectious diseases. The 2010-11 ZDHS included direct measurement of haemoglobin levels using the HemoCue system. This system consists of a battery-operated photometer and a disposable microcuvette3 coated with a dried reagent that serves as the blood collection device. For the test, a drop of capillary blood taken from a child’s fingertip or heel is drawn into the microcuvette. The blood in the microcuvette is analyzed using the photometer, which displayed the haemoglobin concentration. Haemoglobin testing was carried out among children age 6-59 months. Haemoglobin levels were successfully measured for 80 percent of the children eligible for testing. During the fieldwork, parents/caretakers were given the results of their child’s test immediately. In cases in which the haemoglobin reading was below 7.0 g/dl, the parent/caretaker was referred to MOHCW facilities for follow-up. Table 11.7 presents anaemia levels for children 6-59 months at the time of the survey by selected background characteristics. Children with haemoglobin levels below 11.0 g/dl were defined as anaemic. Overall, 56 percent of children suffered from some degree of anaemia. Twenty-seven percent of children were classified as mildly anaemic, 29 percent were moderately anaemic, and 1 percent were severely anaemic. Anaemia is more prevalent among children under age 18 months than among older children, with a peak rate of 74 percent observed among children 9-17 months. Boys are slightly more likely to be anaemic than girls. Anaemia prevalence varies by province, from a low of 45 percent in Mashonaland West to a high of 63 percent in Mashonaland East. 3 A microcuvette is a small, transparent laboratory vessel. Nutrition of Children and Adults • 155 Table 11.7 Prevalence of anaemia in children Percentage of children age 6-59 months classified as having anaemia, by background characteristics, Zimbabwe 2010-11 Background characteristic Anaemia status by haemoglobin level Number of children Any anaemia (<11.0 g/dl) Mild anaemia (10.0-10.9 g/dl) Moderate anaemia (7.0-9.9 g/dl) Severe anaemia (<7.0 g/dl) Age in months 6-8 71.3 25.3 43.3 2.6 235 9-11 74.3 28.6 44.1 1.6 295 12-17 74.3 28.7 43.9 1.7 534 18-23 68.9 31.3 36.5 1.1 386 24-35 56.1 30.6 24.8 0.7 984 36-47 46.1 22.7 22.9 0.4 926 48-59 40.5 24.1 16.2 0.1 860 Sex Male 58.1 25.9 31.2 1.0 2,093 Female 54.5 27.9 25.9 0.7 2,128 Mother's interview status Interviewed 58.2 27.0 30.1 1.0 3,333 Not interviewed, but in household 63.5 35.7 27.8 0.0 135 Not interviewed, and not in household1 46.8 25.1 21.5 0.2 753 Residence Urban 58.5 27.1 30.4 1.0 930 Rural 55.7 26.9 28.0 0.8 3,291 Province Manicaland 61.4 25.5 35.1 0.9 644 Mashonaland Central 55.4 29.9 25.2 0.2 476 Mashonaland East 62.8 25.5 36.7 0.5 492 Mashonaland West 45.0 24.5 20.1 0.4 473 Matabeleland North 56.1 24.6 29.7 1.8 237 Matabeleland South 60.4 31.8 26.0 2.6 279 Midlands 57.0 25.3 30.3 1.5 609 Masvingo 49.7 27.3 22.1 0.3 471 Harare 57.5 32.6 24.0 0.9 408 Bulawayo 59.7 20.0 39.7 0.0 132 Mother’s education2 No education 66.2 33.1 31.3 1.8 86 Primary 60.3 27.9 31.6 0.8 1,170 Secondary 57.3 26.6 29.6 1.1 2,142 More than secondary 49.3 33.7 15.7 0.0 71 Wealth quintile Lowest 56.6 25.2 30.3 1.1 1,061 Second 57.1 27.7 28.6 0.8 973 Middle 53.5 26.0 26.8 0.7 902 Fourth 59.1 28.4 29.7 1.0 779 Highest 54.7 28.3 25.8 0.7 506 Total 56.3 26.9 28.5 0.9 4,221 Note: Table is based on children who stayed in the household on the night before the interview and who were tested for anaemia. Prevalence of anaemia, based on haemoglobin levels, is adjusted for altitude using formulas in CDC, 1998. Haemoglobin is in grams per decilitre (g/dl). 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 156 • Nutrition of Children and Adults Figure 11.6 depicts trends in anaemia prevalence by degree of anaemia among children 6-59 months. There has not been a marked change in the anaemia status of children in the last five years. There has been only a 1 percent decline in the prevalence of mild and moderate anaemia and no change in the prevalence of severe anaemia. Figure 11.6 Trends in Anaemia Status among Children Age 6-59 Months ZDHS 2010-11 58 28 30 1 56 27 29 1 Any anaemia Mild Moderate Severe 0 10 20 30 40 50 60 70 Percent 2005-06 2010-11 11.5 MICRONUTRIENT INTAKE AND SUPPLEMENTATION AMONG CHILDREN Micronutrient deficiency is a major contributor to childhood morbidity and mortality. Micro- nutrients are available in foods and can also be provided through direct supplementation. Breastfeeding children benefit from supplements given to the mother. Iron deficiency is one of the primary causes of anaemia, which has serious health consequences for both women and children. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency (VAD) can cause eye damage and is the leading cause of childhood blindness. VAD also increases the severity of infections such as measles and diarrhoeal disease in children and slows recovery from illness. VAD is common in dry environments where fresh fruits and vegetables are not readily available. Vitamin A supplementation is an important tool in preventing VAD among young children. Information was collected on food consumption during the day and night preceding the interview among the youngest children under age 2 living with their mothers; these data are useful in assessing the extent to which children are consuming food groups rich in two key micronutrients— vitamin A and iron—in their daily diet. In addition, the ZDHS included questions designed to Nutrition of Children and Adults • 157 ascertain whether young children had received vitamin A supplements or deworming medication in the six months preceding the survey. Table 11.8 shows the intake of foods rich in vitamin A and iron by the youngest children age 6-23 months living with their mother and recent vitamin A supplementation among all children age 6-59 months. Sixty-six percent of children consumed vitamin A-rich foods in the 24 hours preceding the interview, and 40 percent consumed iron-rich foods. As expected, intake of both vitamin A-rich and iron-rich foods increases as children are weaned. Nonbreastfeeding children are more likely to consume foods rich in vitamin A and iron than breastfeeding children. Intake of these two micronutrients varies considerably by province. Table 11.8 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron- rich foods in the day or night preceding the survey; among all children 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey and who were given deworming medication in the six months preceding the survey; and among all children age 6-59 months who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Zimbabwe 2010-11 Background characteristic Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Among children age 6-59 months living in households tested for iodized salt: Percentage who consumed foods rich in vitamin A in past 24 hours1 Percentage who consumed foods rich in iron in past 24 hours2 Number of children Percentage given vitamin A supplements in past 6 months Percentage given deworming medication in past 6 months3 Number of children Percentage living in households with iodized salt4 Number of children Age in months 6-8 27.8 13.6 326 50.5 1.3 333 93.1 294 9-11 60.7 34.2 321 62.5 0.9 327 95.0 293 12-17 77.7 48.4 586 68.6 1.1 600 93.2 522 18-23 84.1 53.4 377 71.2 2.8 434 93.4 391 24-35 na na na 67.1 3.5 999 94.5 906 36-47 na na na 66.6 3.6 986 91.7 882 48-59 na na na 64.8 2.3 841 94.3 750 Sex Male 65.0 39.2 797 65.1 3.0 2,244 93.0 2,001 Female 66.4 40.2 813 66.1 2.1 2,277 94.0 2,036 Breastfeeding status Breastfeeding 60.2 33.7 1,211 62.6 1.3 1,248 93.4 1,095 Not breastfeeding 82.6 58.0 399 66.8 3.0 3,270 93.5 2,940 Mother's age 15-19 64.4 40.4 184 52.2 1.0 278 93.2 236 20-29 65.5 41.4 963 65.7 2.8 2,709 93.0 2,406 30-39 65.5 34.7 400 67.7 2.5 1,315 94.4 1,191 40-49 74.6 43.5 63 68.1 2.3 219 94.1 205 Residence Urban 64.8 55.0 459 68.9 3.1 1,353 92.4 1,282 Rural 66.1 33.6 1,150 64.2 2.3 3,168 94.0 2,756 Province Manicaland 73.7 50.7 252 56.8 3.3 677 96.1 515 Mashonaland Central 71.0 36.2 167 69.6 1.8 491 94.6 445 Mashonaland East 64.3 28.7 189 63.6 1.7 451 91.1 357 Mashonaland West 64.2 35.2 182 70.9 4.0 537 88.6 512 Matabeleland North 50.8 19.7 90 52.5 2.2 233 97.9 203 Matabeleland South 68.4 47.6 92 68.4 1.6 234 94.5 214 Midlands 66.6 38.4 200 61.0 2.5 567 95.3 548 Masvingo 63.1 30.3 158 65.1 2.6 488 96.1 435 Harare 59.8 53.4 207 74.0 2.6 654 90.4 624 Bulawayo 68.6 49.1 73 75.1 1.2 190 94.7 185 Mother’s education No education * * 20 56.7 1.0 82 93.0 73 Primary 61.1 31.4 494 60.2 2.4 1,447 94.5 1,284 Secondary 68.1 43.2 1,048 68.3 2.6 2,858 92.8 2,558 More than secondary (61.2) (52.2) 48 71.0 4.8 134 98.0 123 Wealth quintile Lowest 63.0 25.6 369 60.1 1.8 1,042 95.5 922 Second 62.0 31.1 347 62.4 2.7 939 93.1 814 Middle 70.0 40.7 316 66.9 2.7 864 91.3 738 Fourth 66.2 49.0 332 70.1 2.8 951 92.7 867 Highest 68.9 59.2 246 70.2 2.9 725 94.7 697 Total 65.7 39.7 1,610 65.6 2.6 4,520 93.5 4,038 Notes: Information on vitamin A is based on both mother’s recall and the immunization card (where available). Information on iron supplements and deworming medication is based on the mother’s recall. Total includes 2 cases with missing information on breastfeeding status that are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, carrots, squash, sweet potatoes, butternuts, yellow and orange yams, dark green leafy vegetables, mangoes, papayas, and other fruits and vegetables that are rich in vitamin A 2 Includes meat (and organ meat), fish, poultry, and eggs 3 Deworming for intestinal parasites is commonly done for helminths and for schistosomiasis. 4 Excludes children in households in which salt was not tested 158 • Nutrition of Children and Adults Sixty-six percent of children age 6-59 months received a vitamin A supplement in the six months preceding the survey. The likelihood of a child being given a vitamin A dose rose with mother’s education and with wealth quintile. Only 3 percent of children age 6-59 months received deworming medication in the six months preceding the survey. Ninety-four percent of children age 6-59 months live in households using iodized salt. 11.6 Presence of Iodized Salt in Households Salt is used for several purposes in a household. It plays a role in cooking and food preservation. In line with food and drug regulations, household salt should be fortified with iodine to at least 15 parts per million (ppm). Iodine is an essential micronutrient, and iodized salt prevents goitre among children and adults. The 2010-11 ZDHS tested for the presence of iodine in household salt; overall, salt was tested in 88 percent of households (Table 11.9). Among households in which salt was tested, 94 percent had iodized salt. There were only modest variations in the percentages of households with iodized salt by urban-rural residence, province, and wealth quintile. It should be noted that household salt was tested for the presence or absence of iodine only; the iodine content in the salt was not measured. Table 11.9 Presence of iodized salt in household Among all households, the percentage with salt tested for iodine content, the percentage with salt not tested for iodine content, and the percentage with no salt in the household; and among households with salt tested, the percentage with iodized salt, according to background characteristics, Zimbabwe 2010-11 Background characteristic Among all households, the percentage: Among households with tested salt: With salt tested With salt not tested With no salt in household Number of households Percentage with iodized salt Number of households Residence Urban 93.4 5.4 1.1 3,290 92.1 3,073 Rural 85.1 13.7 1.2 6,466 95.0 5,504 Province Manicaland 73.5 25.0 1.5 1,436 95.9 1,055 Mashonaland Central 90.0 9.0 1.0 890 95.5 801 Mashonaland East 80.4 18.7 1.0 1,042 92.3 838 Mashonaland West 92.8 6.1 1.1 1,077 91.2 999 Matabeleland North 88.0 11.2 0.8 495 96.7 436 Matabeleland South 90.8 6.3 2.9 511 93.1 464 Midlands 96.7 2.5 0.8 1,153 94.7 1,115 Masvingo 85.0 14.0 1.0 1,066 98.2 906 Harare 93.7 5.2 1.0 1,564 91.0 1,466 Bulawayo 95.5 2.8 1.7 522 93.4 499 Wealth quintile Lowest 87.9 10.2 1.9 1,835 96.0 1,613 Second 85.3 13.6 1.1 1,785 93.5 1,522 Middle 83.5 15.6 0.9 1,933 94.0 1,614 Fourth 89.5 9.4 1.1 2,144 92.5 1,919 Highest 92.7 6.2 1.0 2,059 94.0 1,909 Total 87.9 10.9 1.2 9,756 94.0 8,578 Nutrition of Children and Adults • 159 11.7 ADULTS’ NUTRITIONAL STATUS 11.7.1 Nutritional Status of Women The 2010-11 ZDHS collected anthropometric data on height and weight for 96 percent of the women age 15-49 interviewed in the survey. These data were used to calculate several measures of nutritional status, specifically maternal height and body mass index (BMI). Maternal height is an outcome of nutrition during childhood and adolescence. It is useful in predicting risk of difficult delivery, because small stature is frequently associated with small pelvis size. The risk of low birth weight babies is also higher for short women. The cutoff point—that is, the height below which a woman is considered to be at nutritional risk—is defined as 145 centimetres. Table 11.10.1 shows that less than 1 percent of Zimbabwean women age 15-49 are shorter than this cutoff. Table 11.10.1 Nutritional status of women Among women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Zimbabwe 2010-11 Background characteristic Height Body mass index1 Mean BMI Normal Thin Overweight/obese Number of women Percent- age below 145 cm Number of women 18.5- 24.9 (total normal) <18.5 (total thin) 17.0- 18.4 (mildly thin) <17 (moderately and severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Age 15-19 1.2 1,863 21.6 74.0 13.5 9.9 3.6 12.6 10.8 1.7 1,716 20-29 0.6 3,391 23.4 66.7 6.5 5.2 1.3 26.8 20.2 6.6 2,896 30-39 0.6 2,248 24.9 53.5 5.0 4.3 0.8 41.5 25.8 15.6 2,018 40-49 0.6 1,304 26.2 46.4 3.1 2.5 0.6 50.5 26.7 23.8 1,274 Residence Urban 0.4 3,326 24.9 54.2 5.3 4.1 1.2 40.5 24.9 15.6 3,030 Rural 0.9 5,480 23.2 66.2 8.2 6.5 1.7 25.5 18.0 7.5 4,874 Province Manicaland 1.6 1,180 24.0 62.2 6.0 5.1 0.8 31.8 21.7 10.1 1,052 Mashonaland Central 0.2 850 22.8 69.1 8.5 6.3 2.3 22.4 17.0 5.3 761 Mashonaland East 1.2 807 23.8 65.2 6.2 5.1 1.1 28.6 18.1 10.4 734 Mashonaland West 0.9 1,004 23.4 63.8 7.5 5.9 1.6 28.7 20.7 7.9 897 Matabeleland North 0.4 425 22.4 62.1 14.9 10.5 4.4 23.0 16.7 6.3 384 Matabeleland South 0.6 454 23.2 63.8 11.0 7.5 3.4 25.2 14.7 10.5 420 Midlands 0.4 1,088 23.6 63.0 6.9 6.0 0.9 30.0 21.7 8.4 979 Masvingo 1.0 881 23.8 65.6 5.5 4.6 0.9 28.9 17.6 11.2 758 Harare 0.3 1,630 25.1 51.8 5.3 4.0 1.3 43.0 25.7 17.3 1,465 Bulawayo 0.6 486 24.3 57.2 6.5 5.0 1.5 36.2 23.8 12.5 454 Education No education 0.3 203 24.2 59.5 5.1 3.3 1.8 35.5 25.0 10.4 186 Primary 1.1 2,479 23.6 64.1 7.1 5.5 1.6 28.8 19.3 9.5 2,190 Secondary 0.6 5,714 23.8 61.5 7.6 6.0 1.6 31.0 20.8 10.2 5,142 More than secondary 0.3 409 26.1 50.4 1.9 1.8 0.1 47.7 24.8 23.0 385 Wealth quintile Lowest 1.2 1,507 22.2 71.2 11.2 9.3 1.9 17.6 13.6 4.0 1,320 Second 0.8 1,550 22.9 67.2 9.0 6.9 2.1 23.8 17.0 6.7 1,349 Middle 1.0 1,637 23.5 65.1 6.5 5.0 1.5 28.4 19.9 8.4 1,459 Fourth 0.5 1,955 24.4 56.6 5.9 4.6 1.3 37.4 23.9 13.6 1,766 Highest 0.3 2,157 25.2 53.4 4.5 3.5 1.0 42.0 25.4 16.6 2,010 Total 0.7 8,805 23.8 61.6 7.1 5.6 1.5 31.3 20.7 10.6 7,904 Note: The body mass index is expressed as the ratio of weight in kilograms to the square of height in metres (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding two months 160 • Nutrition of Children and Adults Information on BMI is also presented in Table 11.10.1. BMI is calculated by dividing weight in kilograms by height in metres squared (kg/m2). Pregnant women and women who had a birth in the two months preceding the survey were excluded from the calculation of BMI. A BMI cutoff of 18.5 has been recommended for assessing chronic energy deficiency among nonpregnant women. At the other end of the BMI scale, women are considered overweight if their BMI falls between 25.0 and 29.9 and obese if their BMI exceeds 30.0. Overall, 62 percent of women have a BMI in the normal range, 7 percent are thin, and 31 percent are overweight or obese. Six percent of women are classified as mildly thin and 2 percent are moderately or severely thin. Eleven percent of women in Zimbabwe are classified as obese. Hence, among women of reproductive age, overweight and obesity may be more of a concern than underweight in Zimbabwe. Women in the 15-19 age group (14 percent), those living in Matabeleland North (15 percent) and Matabeleland South (11 percent), and those in the lowest wealth quintile (11 percent) are more likely than other women to be thin (BMI below 18.5). The proportion of women who are overweight or obese increases linearly by age and wealth quintile. Forty-one percent of urban Zimbabwean women are overweight or obese, compared with 26 percent of rural women. Harare (43 percent) has the highest proportion of overweight or obese women and Mashonaland Central (22 percent) the lowest. Figure 11.7 depicts trends in nutritional status among women age 15-49 since 1999. The percentage of women who are thin (indicative of undernutrition) has declined in the last five years by 2 percentage points. In contrast, the proportion of women who are overweight or obese (indicative of overnutrition) has increased by 6 percentage points since 2005-06. Figure 11.7 Trends in Nutritional Status among Women Age 15-49 ZDHS 2010-11 6 27 9 25 7 31 Undernutrition (chronic energy deficiency) Overnutrition (overweight/obese) 0 5 10 15 20 25 30 35 Percent 1999 2005-06 2010-11 Note: Undernutrition BMI <18.5 and overnutrition BMI > 25.0 Nutrition of Children and Adults • 161 11.7.2 Nutritional Status of Men For the first time in a ZDHS, anthropometric data on height and weight were collected for men. Overall, this information was collected for 95 percent of the men interviewed in the survey. These data are useful in the calculation of BMI, which can be used as a measure of chronic energy deficiency among men (BMI calculations and cutoff points were the same for men and women). In addition, BMI can be used to measure overweight and obesity, risk factors for nutrition-related chronic diseases such as diabetes mellitus and cardiovascular disease. Table 11.10.2 shows BMI information for Zimbabwean men. Overall, 76 percent of men age 15-49 have a BMI in the normal range, 15 percent are thin, and 9 percent are overweight or obese. Men age 15-19 are about four times more likely to be thin than men in older age groups. Men from Matabeleland North (24 percent) and those in the lowest wealth quintile (19 percent) are more likely to have a BMI below 18.5 than men from other provinces or in higher wealth quintiles. Only 2 percent of men are classified as obese, with a peak prevalence of 4 percent in the 40-49 age group. Overweight and obesity increase with increasing age. The prevalence of overweight or obesity is higher among urban (15 percent) than rural (6 percent) men and higher among men in Harare (16 percent) than among men in the other provinces (6-15 percent). Men with more than a secondary education have the highest prevalence of overweight and obesity (29 percent). Overweight and obesity also increase with increasing wealth. Overall, however, the prevalence of overweight or obesity among men is strikingly lower than the prevalence among women (9 percent and 31 percent, respectively). Table 11.10.2 Nutritional status of men Among men age 15-49, mean body mass index (BMI) and the percentage with specific BMI levels, by background characteristics, Zimbabwe 2010-11 Background characteristic Body mass index Mean BMI Normal Thin Overweight/obese Number of men 18.5- 24.9 (total normal) <18.5 (total thin) 17.0- 18.4 (mildly thin) <17 (moder- ately and severely thin) ≥25.0 (total over- weight or obese) 25.0- 29.9 (over- weight) ≥30.0 (obese) Age 15-19 19.4 64.3 34.7 21.5 13.2 1.0 0.8 0.2 1,647 20-29 21.4 85.1 8.8 7.9 0.9 6.1 5.1 1.0 2,488 30-39 22.0 75.8 9.1 8.0 1.1 15.1 12.2 3.0 1,711 40-49 22.3 71.2 9.8 7.5 2.3 19.0 14.7 4.4 919 Residence Urban 21.9 72.2 13.0 9.8 3.2 14.7 11.4 3.3 2,416 Rural 20.8 77.7 16.6 11.9 4.7 5.7 4.8 0.9 4,349 Province Manicaland 21.3 78.6 13.5 10.6 2.9 8.0 6.0 2.0 929 Mashonaland Central 20.6 74.5 19.0 14.2 4.8 6.5 5.2 1.3 708 Mashonaland East 20.9 80.2 13.8 10.4 3.4 6.0 4.3 1.7 651 Mashonaland West 20.9 79.0 14.9 10.1 4.7 6.2 5.1 1.0 859 Matabeleland North 20.6 69.3 23.5 17.1 6.4 7.1 6.6 0.5 322 Matabeleland South 20.4 70.7 23.1 15.2 7.9 6.1 6.0 0.1 337 Midlands 20.8 77.6 16.8 11.6 5.2 5.6 4.4 1.3 857 Masvingo 21.6 78.5 11.1 9.1 2.1 10.4 8.4 1.9 559 Harare 22.0 72.6 11.5 8.2 3.3 15.9 13.0 2.8 1,207 Bulawayo 21.5 67.7 17.7 13.7 4.0 14.6 10.4 4.2 335 Education No education 21.1 80.6 14.1 8.9 5.1 5.4 1.2 4.1 52 Primary 20.7 76.8 19.1 13.7 5.4 4.1 3.2 0.9 1,432 Secondary 21.1 76.6 15.1 11.0 4.1 8.3 6.9 1.4 4,789 More than secondary 23.5 63.9 6.7 5.7 1.0 29.4 21.8 7.7 492 Wealth quintile Lowest 20.5 79.3 18.5 13.5 5.0 2.1 1.7 0.4 1,030 Second 20.6 77.3 18.2 12.3 5.8 4.5 3.6 0.9 1,172 Middle 20.7 79.3 16.2 12.7 3.5 4.5 4.0 0.5 1,318 Fourth 21.4 77.0 12.6 8.9 3.7 10.3 8.7 1.7 1,582 Highest 22.2 68.5 13.2 9.9 3.3 18.3 14.0 4.3 1,662 Total 15-49 21.2 75.8 15.3 11.2 4.1 8.9 7.1 1.8 6,765 50-54 22.3 66.7 13.7 10.1 3.6 19.7 14.2 5.4 355 Total 15-54 21.2 75.3 15.2 11.1 4.1 9.4 7.5 1.9 7,120 Note: The body mass index is expressed as the ratio of weight in kilograms to the square of height in metres (kg/m2). 162 • Nutrition of Children and Adults 11.8 ANAEMIA PREVALENCE IN ADULTS 11.8.1 Anaemia Prevalence among Women Anaemia among women and men was measured using similar procedures as for children age 6-59 months except that capillary blood was collected exclusively from a finger prick. Table 11.11.1 shows anaemia prevalence among women age 15-49 adjusted for pregnancy status, altitude, and smoking status. Pregnant women with haemo- globin levels below 11.0 g/dl and nonpregnant women with haemoglobin levels below 12.0 g/dl were defined as having anaemia. Overall, 28 percent of women in Zimbabwe suffer from anaemia. The majority (20 percent) are classified as mildly anaemic, 7 percent are moderately anaemic, and 1 percent are severely anaemic. As expected, pregnant women are more likely to be anaemic than breastfeeding women and women who are neither breast- feeding nor pregnant (32 percent, 27 percent, and 28 percent, respectively). Anaemia levels also vary by province. The prevalence of anaemia among women residing in Matabeleland South (45 percent) is twice as high as the prevalence among women from Masvingo or Mashonaland West (22 percent each). Figure 11.8 compares trends in anaemia prevalence between the 2005-06 ZDHS and the 2010-11 ZDHS. There has been a 10 percentage point reduction in the prevalence of any anaemia since the 2005-06 ZDHS. The majority of this decrease is due to a decline in mild anaemia from 27 percent in 2005-06 to 20 percent in 2010-11. Table 11.11.1 Prevalence of anaemia in women Percentage of women age 15-49 with anaemia, by background characteristics, Zimbabwe 2010- 11 Background characteristic Anaemia status by haemoglobin level Number of women Any Mild Moderate Severe Not pregnant <12.0 g/dl 10.0-11.9 g/dl 7.0-9.9 g/dl < 7.0 g/dl Pregnant <11.0 g/dl/) 10.0-10.9 g/dl/) 7.0-9.9 g/dl/) < 7.0 g/dl/) Age 15-19 25.7 18.6 6.6 0.5 1,723 20-29 28.7 21.1 6.9 0.7 3,162 30-39 28.4 20.7 7.2 0.6 2,073 40-49 30.1 20.4 8.7 1.0 1,211 Number of children ever born 0 29.0 20.1 7.9 1.0 2,127 1 30.0 20.6 8.5 0.8 1,533 2-3 26.5 19.8 6.2 0.5 2,757 4-5 29.5 22.3 6.7 0.6 1,216 6+ 25.9 19.1 6.7 0.1 537 Maternity status Pregnant 32.4 17.2 14.5 0.6 674 Breastfeeding 26.6 21.4 4.9 0.2 1,708 Neither 28.2 20.4 7.0 0.8 5,788 Smoking status Smokes cigarettes/tobacco 28.5 20.2 8.3 0.0 43 Does not smoke 28.2 20.4 7.2 0.7 8,126 Residence Urban 30.6 21.4 8.2 1.0 2,996 Rural 26.9 19.7 6.6 0.5 5,173 Province Manicaland 30.7 22.9 7.6 0.2 1,092 Mashonaland Central 23.2 18.2 4.6 0.4 796 Mashonaland East 29.4 20.6 8.5 0.3 757 Mashonaland West 22.2 16.9 4.9 0.4 923 Matabeleland North 26.7 18.9 6.9 0.9 406 Matabeleland South 44.6 27.6 15.4 1.7 429 Midlands 29.9 22.2 7.4 0.3 1,033 Masvingo 22.4 17.1 4.7 0.7 824 Harare 27.2 18.7 7.4 1.1 1,482 Bulawayo 37.9 27.1 8.9 1.9 428 Education No education 29.8 21.2 6.7 1.9 182 Primary 27.8 20.1 6.5 1.2 2,306 Secondary 28.0 20.3 7.3 0.4 5,302 More than secondary 32.5 22.5 9.3 0.6 380 Wealth quintile Lowest 28.0 21.0 6.3 0.7 1,422 Second 27.2 20.2 6.4 0.6 1,448 Middle 26.7 19.0 7.4 0.3 1,540 Fourth 29.7 20.9 8.0 0.8 1,801 Highest 28.9 20.6 7.5 0.8 1,959 Total 28.2 20.4 7.2 0.7 8,169 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC, 1998. Nutrition of Children and Adults • 163 Figure 11.8 Trends in Anaemia Status among Women Age 15-49 ZDHS 2010-11 38 27 9 1 28 20 7 1 Any anaemia Mild Moderate Severe 0 10 20 30 40 50 Percent 2005-06 2010-11 11.8.2 Anaemia Prevalence among Men Table 11.11.2 presents anaemia prevalence among men age 15-49. Men with haemoglobin levels below 13.0 g/dl are defined as having anaemia. Fourteen percent of Zimbabwean men are anaemic. The prevalence of anaemia is higher among men age 15-19 (22 percent) than among older men (8-17 percent) and higher among rural (16 percent) than urban (10 percent) men. By province, the prevalence of anaemia in men is highest in Matabeleland South (33 percent) and lowest in Harare (8 percent). Anaemia levels in men decline as household wealth increases, and men with more than a secondary education are much less likely to be anaemic than those with less education. In comparison with young Zimbabwean children (56 percent) and women (28 percent), the anaemia rate among men is moderate (14 percent). From a public health perspective, the anaemia prevalence among men and women is serious and the prevalence among children is critical. 164 • Nutrition of Children and Adults Table 11.11.2 Prevalence of anaemia in men Percentage of men age 15-49 with anaemia, by back- ground characteristics, Zimbabwe 2010-11 Background characteristic Any anaemia <13.0 g/dl Number of men Age 15-19 21.8 1,483 20-29 8.2 2,221 30-39 13.3 1,506 40-49 17.4 812 Smoking status Smokes cigarettes/tobacco 11.8 1,390 Does not smoke 14.7 4,631 Residence Urban 10.4 2,042 Rural 15.9 3,979 Province Manicaland 16.0 847 Mashonaland Central 12.4 651 Mashonaland East 18.1 574 Mashonaland West 10.0 768 Matabeleland North 16.7 297 Matabeleland South 32.6 305 Midlands 14.5 790 Masvingo 13.8 493 Harare 8.1 1,037 Bulawayo 12.8 260 Education No education 15.3 47 Primary 18.7 1,289 Secondary 13.4 4,273 More than secondary 6.4 413 Wealth quintile Lowest 18.3 951 Second 17.5 1,085 Middle 14.8 1,187 Fourth 12.6 1,382 Highest 9.4 1,416 Total 15-49 14.1 6,022 50-54 21.4 317 Total 15-54 14.4 6,339 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC, 1998. 11.9 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Table 11.12 includes a number of measures that are useful in assessing women’s intake of vitamin A and iron. Nutrition of Children and Adults • 165 Table 11.12 Micronutrient intake among mothers Among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child, the percent distribution by number of days they took iron tablets or syrup during the pregnancy of the last child, and the percentage who took deworming medication during the pregnancy of the last child; and among women age 15-49 with a child born in the past five years and who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Zimbabwe 2010-11 Background characteristic Among women with a child born in the past five years: Among women with a child born in the last five years who live in households that were tested for iodized salt: Percentage who received vitamin A dose post- partum1 Number of days women took iron tablets or syrup during pregnancy of last birth Percentage of women who took deworming medication during pregnancy of last birth Number of women None <60 60-89 90+ Don't know/ missing Total Percentage living in households with iodized salt2 Number of women Age 15-19 32.3 46.1 39.3 3.5 6.7 4.5 100.0 2.8 361 93.2 309 20-29 42.0 50.6 35.5 3.2 5.1 5.6 100.0 2.2 2,518 92.7 2,249 30-39 39.6 49.5 36.8 2.9 4.1 6.8 100.0 2.4 1,325 94.4 1,200 40-49 35.7 48.2 41.0 1.8 3.8 5.1 100.0 1.7 222 94.0 202 Residence Urban 43.1 47.7 35.4 3.9 4.9 8.0 100.0 0.9 1,382 92.3 1,307 Rural 38.8 50.7 36.9 2.6 4.8 4.9 100.0 2.9 3,044 93.9 2,653 Province Manicaland 32.7 43.2 38.2 5.2 10.0 3.4 100.0 2.9 628 96.1 485 Mashonaland Central 25.7 52.9 36.7 1.8 5.7 2.9 100.0 1.4 471 94.7 425 Mashonaland East 59.1 48.3 40.0 4.3 5.7 1.7 100.0 2.1 426 90.5 337 Mashonaland West 42.9 50.1 34.5 2.4 1.8 11.2 100.0 3.2 552 89.1 526 Matabeleland North 33.9 42.7 41.6 3.4 5.4 6.8 100.0 3.8 215 97.6 187 Matabeleland South 46.3 38.2 50.8 5.6 3.5 1.9 100.0 4.3 213 93.7 195 Midlands 39.4 57.5 28.7 2.8 1.8 9.3 100.0 1.7 548 94.8 530 Masvingo 42.5 49.6 40.7 1.1 4.0 4.7 100.0 3.3 496 96.8 439 Harare 42.2 56.4 32.1 2.0 3.5 5.9 100.0 1.0 689 90.2 654 Bulawayo 39.3 41.5 33.0 4.4 10.0 11.0 100.0 0.0 189 94.7 182 Education No education 29.3 49.9 41.2 1.5 1.5 5.9 100.0 4.5 77 92.5 68 Primary 32.2 55.9 34.0 2.1 3.7 4.3 100.0 2.6 1,375 94.6 1,223 Secondary 43.9 47.5 37.4 3.4 5.3 6.5 100.0 2.2 2,835 92.6 2,539 More than secondary 48.8 36.9 39.5 7.0 8.7 7.9 100.0 1.5 139 97.1 129 Wealth quintile Lowest 33.4 57.1 32.0 2.0 3.8 5.1 100.0 3.1 957 95.2 854 Second 36.6 47.3 39.9 3.8 4.0 5.0 100.0 2.0 908 92.6 785 Middle 40.6 50.9 35.7 2.1 6.3 5.0 100.0 3.1 847 91.3 722 Fourth 43.7 49.4 35.2 3.5 5.1 6.7 100.0 2.1 971 92.6 893 Highest 48.1 42.6 40.5 3.9 5.3 7.7 100.0 1.0 743 95.0 707 Total 40.2 49.8 36.5 3.1 4.9 5.8 100.0 2.3 4,426 93.4 3,960 1 In the first two months after delivery of the last birth 2 Excludes women in households where salt was not tested Breastfeeding children benefit from the micronutrient supplementation that mothers receive, especially vitamin A. The ZDHS included questions to ascertain whether mothers had received iron supplements during pregnancy and vitamin A supplements within two months postpartum. Table 11.12 includes measures of vitamin A and iron supplementation among mothers of young children and also presents the proportion of women who took deworming medication while pregnant and who live in households with iodized salt. A single dose of vitamin A given within two months of childbirth treats night blindness and increases the vitamin A content of breast milk, reducing the risk of VAD among breastfed children. Table 11.12 shows that 40 percent of women with a child born in the five years before the survey received a vitamin A dose in the first two months after the birth of their last child. Supplementation rates were highest among urban women (43 percent), women living in Mashonaland East (59 percent), women with more than a secondary education (49 percent), and women in the highest wealth quintile (48 percent) 166 • Nutrition of Children and Adults As mentioned earlier, pregnant women are more likely to be anaemic than other women. Iron status among pregnant women can be improved by means of iron supplements as well as by increased consumption of iron-rich foods and control of parasites and malaria. Table 11.12 shows the percent distribution of women who gave birth during the five years prior to the survey by the number of days they took iron tablets during the pregnancy for their last-born child. The majority of women who took supplements took them for less than 60 days (37 percent), and 50 percent did not take iron supplements at all. Only 5 percent of women took iron supplements for the recommended period of time (more than 90 days). Women living in Midlands were least likely to have taken iron tablets or syrup during their last pregnancy (33 percent), and women in Matabeleland South were most likely to have done so (60 percent). Only 2 percent of women took deworming medication during their last pregnancy. Ninety-three percent of women with a child born in the past five years live in households using iodized salt. Malaria • 167 MALARIA 12 alaria is one of the leading causes of death in sub-Saharan Africa. While malaria is endemic in Zimbabwe and is a common cause of hospital admissions for all age groups, it is important to note that malaria is found only in specific areas of the country. This factor should be taken into account when reviewing the malaria prevalence and treatment data described in this chapter. The 2010-11 ZDHS obtained data on a number of topics related to the prevention and treatment of malaria, including ownership of mosquito nets, use of mosquito nets by children and pregnant women, prophylactic use of antimalarial drugs by pregnant women, and the prevalence and prompt treatment of fever among young children. The survey also obtained information on the use of indoor residual spraying. 12.1 OWNERSHIP OF MOSQUITO NETS Insecticide-treated nets (ITNs) are a principal tool in efforts to reduce malaria transmission in Zimbabwe. All households in the 2010-11 ZDHS were asked whether they owned a mosquito net and, if so, how many of the various types of nets. Table 12.1 shows household ownership of nets by degree of protection offered and selected background characteristics. Four in 10 households have at least one mosquito net, up from 2 in 10 households in 2005-06. Three in 10 households have at least one net meeting one of the ITN criteria, that is, a factory-treated net that does not require retreatment, a pretreated net obtained within the previous 12 months, or a net soaked in insecticide at some time within the 12 months prior to the survey. Most ITNs in Zimbabwe are long-lasting insecticidal nets (LLINs); overall, one-quarter of households have an LLIN. The government promotes universal coverage of or access to LLINs. M Key Findings • Forty-one percent of all households had at least one mosquito net; 29 percent had at least one insecticide-treated mosquito net (ITN), the majority of which were long-lasting insecticidal nets. • Seventeen percent of households reported that they had received indoor residual spraying during the past 12 months. • On the night before the survey, 14 percent of children under age 5 slept under a mosquito net. Among households with at least one ITN, 30 percent of children under 5 slept under an ITN. • Overall, 15 percent of pregnant women slept under some type of mosquito net the night before the survey. Among pregnant women living in households that possess an ITN, 3 in 10 slept under an ITN the night before the survey. • Seven percent of women who had their last birth in the two years preceding the survey received intermittent preventive treatment during their pregnancy, that is, they took two or more doses of SP/Fansidar and received at least one during an antenatal care visit. 168 • Malaria Table 12.1 Household possession of mosquito nets Percentage of households with at least one and more than one mosquito net (treated or untreated), insecticide-treated net (ITN), and long-lasting insecticidal net (LLIN), and the average number of nets per household, by background characteristics, Zimbabwe 2010-11 Background characteristic Any type of mosquito net Insecticide-treated mosquito net (ITN)1 Long-lasting insecticidal net (LLIN) Number of households Percentage with at least one Percentage with more than one Average number of nets per household Percentage with at least one Percentage with more than one Average number of ITNs per household Percentage with at least one Percentage with more than one Average number of LLINs per household Residence Urban 46.9 16.5 0.7 23.2 6.9 0.3 19.2 5.6 0.3 3,290 Rural 38.2 19.1 0.7 31.6 16.5 0.6 27.5 13.4 0.5 6,466 Province Manicaland 52.5 29.4 1.0 46.1 26.1 0.9 41.1 22.3 0.7 1,436 Mashonaland Central 44.6 22.8 0.8 32.9 17.4 0.6 29.5 15.5 0.6 890 Mashonaland East 37.8 15.2 0.6 25.9 11.3 0.4 19.7 7.7 0.3 1,042 Mashonaland West 33.5 13.9 0.5 22.0 10.8 0.4 18.0 8.3 0.3 1,077 Matabeleland North 49.0 23.6 0.9 41.4 19.0 0.7 36.0 15.3 0.6 495 Matabeleland South 14.4 3.3 0.2 7.4 1.3 0.1 6.8 1.3 0.1 511 Midlands 42.7 19.7 0.7 35.6 16.2 0.6 33.7 15.2 0.6 1,153 Masvingo 35.2 16.9 0.6 29.4 14.2 0.5 24.0 9.3 0.4 1,066 Harare 41.4 12.1 0.6 15.5 3.0 0.2 11.0 1.9 0.1 1,564 Bulawayo 52.6 21.2 0.8 26.1 8.1 0.4 24.3 6.9 0.3 522 Wealth quintile Lowest 39.2 21.1 0.7 35.1 19.2 0.6 29.7 15.1 0.5 1,835 Second 35.1 18.0 0.6 29.7 16.1 0.5 25.2 12.6 0.4 1,785 Middle 36.0 15.3 0.6 28.9 13.0 0.5 25.4 10.9 0.4 1,933 Fourth 40.4 12.6 0.6 24.4 8.2 0.4 21.2 7.1 0.3 2,144 Highest 53.7 24.3 0.9 26.8 10.8 0.4 22.7 9.0 0.4 2,059 Total 41.1 18.2 0.7 28.8 13.2 0.5 24.7 10.8 0.4 9,756 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. While urban households (47 percent) are more likely than rural households (38 percent) to have a mosquito net (treated or untreated), rural households are more likely to have an LLIN. Household ownership of at least one mosquito net varies from a low of 14 percent in Matabeleland South to a high of 53 percent in Manicaland and Bulawayo. Household ownership of at least one LLIN varies from a low of 7 percent of households in Matabeleland South to a high of 41 percent in Manicaland. There is no clear pattern of association between net ownership and household wealth. 12.2 INDOOR RESIDUAL SPRAYING Indoor residual spraying (IRS) is another component of efforts to control malaria transmission in Zimbabwe. To obtain information on the prevalence of indoor residual spraying, all households interviewed in the 2010-11 ZDHS were asked whether the interior walls and outside eaves of their dwelling had been sprayed against mosquitoes during the 12-month period before the survey and, if so, who had sprayed the dwelling. Nationally, 17 percent of households reported receiving IRS in the past 12 months (Table 12.2), compared with 15 percent in 2005-06. Eight in 10 households sprayed were sprayed by government workers or government-sponsored programmes (data not shown). IRS rates vary markedly by residence. Rural households were six times as likely as urban households to report receiving IRS (24 percent and 4 percent, respectively). Also, households in the lower wealth quintiles were more likely to have been sprayed than households in the higher wealth quintiles. By province, the prevalence of IRS varied from 2 percent in Harare to 40 percent in Matabeleland North. Sixty percent of households in Matabeleland North had either been sprayed in the past 12 months or had at least one ITN. Malaria • 169 Table 12.2 Indoor residual spraying against mosquitoes Percentage of households in which someone has come into the dwelling to spray the interior walls against mosquitoes (IRS) in the past 12 months, and the percentage of households with at least one ITN and/or IRS in the past 12 months, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of households with IRS1 in the past 12 months Percentage of households with at least one ITN2 and/or IRS in the past 12 months Number of households Residence Urban 3.8 25.3 3,290 Rural 23.7 40.9 6,466 Province Manicaland 26.0 52.6 1,436 Mashonaland Central 36.9 51.2 890 Mashonaland East 19.9 32.5 1,042 Mashonaland West 8.5 24.3 1,077 Matabeleland North 40.1 60.0 495 Matabeleland South 16.5 22.7 511 Midlands 13.4 38.5 1,153 Masvingo 15.9 36.6 1,066 Harare 2.1 17.3 1,564 Bulawayo 2.7 27.7 522 Wealth quintile Lowest 28.0 45.3 1,835 Second 22.5 37.9 1,785 Middle 18.6 36.0 1,933 Fourth 9.1 28.6 2,144 Highest 8.9 31.9 2,059 Total 17.0 35.6 9,756 1 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private or non-governmental organization. 2 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 12.3 USE OF MOSQUITO NETS BY PERSONS IN THE HOUSEHOLD The 2010-11 ZDHS asked about use of mosquito nets by household members during the night before the survey. Use of nets on the night before the survey is taken as typical of net usage, but caution should be exercised in interpreting the results described here. Because the prevalence of mosquitoes varies within Zimbabwe according to season and other climatic conditions, net usage on the night before the survey may not be representative of the patterns of usage during periods of high malaria transmission. Table 12.3 shows that 12 percent of the household population slept under a mosquito net the night before the survey. Overall, 9 percent of the household population slept under an ITN the night before the survey and 7 percent of the household population slept under an LLIN. Twenty-eight percent of the population living in households that own at least one ITN slept under an ITN the night before the survey. 170 • Malaria Table 12.3 Use of mosquito nets by persons in the household Percentage of the de facto household population who slept the night before the survey under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months; and among the de facto household population in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Household population Household population in households with at least one ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Percentage who slept under an ITN1 last night or in a dwelling sprayed with IRS2 in the past 12 months Number Percentage who slept under an ITN1 last night Number Age (in years) <5 13.6 9.7 8.1 24.8 5,984 29.9 1,941 5-14 8.0 6.3 5.5 23.3 11,272 19.6 3,613 15-34 12.6 8.6 7.2 22.1 13,510 28.6 4,063 35-39 17.0 11.7 10.1 23.3 4,717 39.2 1,403 50+ 13.9 10.2 8.8 25.7 4,859 35.1 1,408 Sex Male 11.3 8.1 6.9 23.0 19,094 26.6 5,827 Female 12.8 9.1 7.8 23.7 21,249 29.4 6,601 Residence Urban 14.7 7.4 6.1 10.6 12,303 31.4 2,916 Rural 11.0 9.2 8.0 29.0 28,040 27.1 9,511 Province Manicaland 17.4 15.7 14.2 36.0 5,572 31.6 2,766 Mashonaland Central 16.7 13.5 12.2 43.4 3,926 38.4 1,377 Mashonaland East 10.3 7.2 4.9 24.3 4,181 26.5 1,141 Mashonaland West 9.6 6.1 4.7 13.0 4,683 27.5 1,046 Matabeleland North 14.7 13.1 10.4 49.1 2,143 29.3 957 Matabeleland South 4.1 2.3 2.0 20.6 2,260 35.7 146 Midlands 10.3 8.3 7.9 19.4 5,222 21.8 1,994 Masvingo 8.4 6.3 5.4 21.2 4,404 18.4 1,511 Harare 11.0 4.1 2.7 6.2 5,927 26.2 928 Bulawayo 20.5 10.5 9.8 13.4 2,024 37.9 561 Wealth quintile Lowest 11.3 10.2 8.6 34.2 7,962 27.2 2,972 Second 9.8 8.3 7.0 27.2 8,063 26.2 2,555 Middle 10.7 8.6 7.6 24.0 8,090 27.7 2,498 Fourth 13.4 8.2 7.1 16.4 8,102 31.0 2,145 Highest 15.4 8.1 6.6 15.4 8,125 29.1 2,257 Total 12.1 8.7 7.4 23.4 40,343 28.1 12,428 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or non-governmental organization. 12.3.1 Use of Mosquito Nets by Children Under Five Years Given children’s vulnerability to malaria, it is especially important for young children to sleep under mosquito nets. In areas of endemic malaria, antibodies acquired from the mother during pregnancy protect children for about six months following birth. This acquired immunity is gradually lost, and children start to develop their own immunity to malaria. The pace at which immunity is developed depends on children’s exposure to malaria infection, and in high malaria-endemic areas children are thought to attain a high level of immunity by their fifth birthday. Such children may subsequently experience episodes of illness caused by malaria but usually do not suffer from severe, life-threatening malaria. Immunity in areas of low malaria transmission is acquired more slowly. Table 12.4 presents data on the extent to which children under age 5 slept under various types of nets on the night before the interview. Overall, 14 percent of children slept under a mosquito net, 10 percent under an ITN, and 8 percent under an LLIN. The likelihood of sleeping under a net generally declined with increasing age of the child. Children in urban areas were more likely to sleep under a net than children in rural areas (19 and 12 percent, respectively). Among children who live in Malaria • 171 households that possess an ITN, an even greater difference in mosquito net usage by urban-rural residence was observed: 39 percent of children in urban areas slept under an ITN, compared with 27 percent of children in rural areas. Net usage among children living in households with an ITN was lowest in Masvingo (14 percent) and highest in Bulawayo (54 percent). Net usage increased somewhat with increasing wealth quintile. Table 12.4 Use of mosquito nets by children Percentage of children under age five who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months; and among children under age five in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Children under age five in all households Children under age five in households with at least one ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Percentage who slept under an ITN1 last night or in a dwelling sprayed with IRS2 in the past 12 months Number of children Percentage who slept under an ITN1 last night Number of children Age (in months) <12 15.7 10.9 9.2 25.6 1,420 33.4 464 12-23 15.8 11.3 9.2 24.4 1,155 33.9 385 24-35 13.1 9.9 8.1 23.4 1,180 30.4 383 36-47 12.3 8.7 7.8 25.1 1,184 27.0 380 48-59 10.1 7.3 5.9 25.1 1,045 23.2 330 Sex Male 12.9 9.2 7.7 24.2 2,982 28.2 974 Female 14.2 10.2 8.5 25.3 3,003 31.6 967 Residence Urban 18.8 10.3 8.3 13.8 1,623 39.3 427 Rural 11.6 9.5 8.1 28.8 4,362 27.3 1,514 Province Manicaland 18.8 16.4 14.8 35.5 881 32.3 449 Mashonaland Central 16.2 13.5 12.3 43.7 614 38.7 215 Mashonaland East 13.4 10.0 5.8 27.6 622 31.8 196 Mashonaland West 8.6 5.0 3.7 11.7 700 26.4 133 Matabeleland North 20.4 18.2 14.8 52.0 299 35.8 152 Matabeleland South 5.0 2.6 2.1 23.5 347 (50.0) 18 Midlands 10.8 8.7 8.2 19.7 789 22.2 309 Masvingo 7.8 4.9 4.1 19.9 703 13.7 249 Harare 14.3 6.0 4.2 8.2 778 32.9 143 Bulawayo 28.6 16.7 15.4 19.7 252 54.4 77 Wealth quintile Lowest 11.1 9.7 8.3 33.7 1,387 25.3 529 Second 11.1 9.2 7.2 27.1 1,290 29.6 399 Middle 12.3 9.5 8.2 23.6 1,200 30.1 378 Fourth 15.3 9.4 7.9 17.3 1,209 33.6 339 Highest 20.2 11.2 9.3 19.2 898 34.1 296 Total 13.6 9.7 8.1 24.8 5,984 29.9 1,941 Notes: Table is based on children who stayed in the household the night before the interview. Figures in parentheses are based on 25-49 unweighted cases. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private or non-governmental organization. 12.3.2 Use of Mosquito Nets by Pregnant Women In malaria-endemic areas, adults usually have acquired some degree of immunity to severe, life-threatening malaria. However, pregnancy leads to a depression of the immune system so that pregnant women, especially those in their first pregnancy, have a higher risk to malaria. Moreover, malaria among pregnant women may be asymptomatic. Malaria during pregnancy is a major contributor to low birth weight, maternal anaemia, infant mortality, spontaneous abortion, and stillbirth. Pregnant women can reduce the risk of the adverse effects of malaria by sleeping under insecticide-treated mosquito nets. 172 • Malaria Table 12.5 shows the percentage of pregnant women who slept under any mosquito net (treated or untreated), an ITN, or an LLIN the night before the survey. Overall, 15 percent of women slept under some type of net, which is higher than the 7 percent reported in the 2005-06 ZDHS. Ten percent of pregnant women slept under an ITN, and 9 percent slept under an LLIN. Among pregnant women living in households that possess an ITN, 3 in 10 slept under an ITN the night before the survey. Table 12.5 Use of mosquito nets by pregnant women Percentage of pregnant women age 15-49 who, the night before the survey, slept under a mosquito net (treated or untreated), under an insecticide-treated net (ITN), under a long-lasting insecticidal net (LLIN), and under an ITN or in a dwelling in which the interior walls have been sprayed against mosquitoes (IRS) in the past 12 months; and among pregnant women age 15-49 in households with at least one ITN, the percentage who slept under an ITN the night before the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Among pregnant women age 15-49 in all households Among pregnant women age 15-49 in households with at least one ITN1 Percentage who slept under any net last night Percentage who slept under an ITN1 last night Percentage who slept under an LLIN last night Percentage who slept under an ITN1 last night or in a dwelling sprayed with IRS2 in the past 12 months Number of women Percentage who slept under an ITN1 last night Number of women Residence Urban 16.5 8.6 8.0 11.1 251 35.3 61 Rural 13.6 10.1 9.4 28.9 513 28.1 185 Province Manicaland 15.6 14.5 14.5 37.4 110 (29.1) 54 Mashonaland Central 22.7 16.2 16.2 44.3 83 * 25 Mashonaland East 18.7 10.8 8.4 38.5 62 * 23 Mashonaland West 10.8 6.1 6.1 13.5 91 * 18 Matabeleland North 15.7 14.6 10.6 37.8 33 * 15 Matabeleland South 7.8 7.8 7.8 19.8 31 * 4 Midlands 16.7 11.5 11.5 15.9 88 (27.3) 37 Masvingo 11.1 5.8 4.9 19.5 102 (14.8) 40 Harare 9.0 2.8 1.7 3.7 139 * 21 Bulawayo (30.2) (19.2) (19.2) (19.2) 25 * 9 Education No education * * * * 13 * 3 Primary 13.8 8.9 8.3 24.0 249 27.7 80 Secondary 14.5 9.7 9.0 22.3 484 29.9 157 More than secondary * * * * 18 * 6 Wealth quintile Lowest 13.9 12.2 10.8 34.4 156 28.3 67 Second 10.5 8.6 7.7 26.2 167 (32.1) 45 Middle 15.5 8.9 8.9 21.0 167 (25.2) 59 Fourth 13.9 7.3 6.4 15.6 158 (28.5) 41 Highest 20.6 11.9 11.9 16.5 115 (39.4) 35 Total 14.5 9.6 8.9 23.1 764 29.9 246 Notes: Table is based on women who stayed in the household the night before the interview. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 An insecticide-treated net (ITN) is (1) a factory-treated net that does not require any further treatment (LLIN), (2) a pretreated net obtained within the past 12 months, or (3) a net that has been soaked with insecticide within the past 12 months. 2 Indoor residual spraying (IRS) is limited to spraying conducted by a government, private, or non-governmental organization. Malaria • 173 12.4 USE OF INTERMITTENT PREVENTIVE TREATMENT OF MALARIA IN PREGNANCY Pregnant women are particularly vulnerable to malaria because their immune systems are suppressed. To protect the mother and her child from malaria, it is recommended that pregnant women receive intermittent preventive treatment during pregnancy (IPTp) through provision of at least two doses of sulfadoxine-pyrimethamine (SP)/Fansidar during routine antenatal care visits in the second and third trimesters of pregnancy. Table 12.6 presents data on the use of antimalarials and receipt of IPTp by women during the pregnancy for their last live birth in the two years preceding the survey. Overall, one in four women who had a live birth in the two years before the survey took an antimalarial drug during their pregnancy. Around one-half of pregnant women who took any antimalarial drug—14 percent of all pregnant women—took at least one dose of SP/Fansidar during their pregnancy. Eight percent reported taking two or more doses of SP/Fansidar. Almost all of the women who took at least two doses of SP/Fansidar received at least one dose during an antenatal care (ANC) visit. Table 12.6 Prophylactic use of antimalarial drugs and use of intermittent preventive treatment (IPTp) by women during pregnancy Percentage of women age 15-49 with a live birth in the two years preceding the survey who, during the pregnancy preceding the last birth, took any antimalarial drug for prevention, who took one dose of SP/Fansidar, and who received intermittent preventive treatment (IPTp)1, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who took any antimalarial drug SP/Fansidar Intermittent preventive treatment1 Number of women with a live birth in the two years preceding the survey Percentage who took 2+ doses of SP/Fansidar Percentage who took 2+ doses of SP/Fansidar and received at least one during an ANC visit Percentage who took any SP/Fansidar Percentage who received any SP/Fansidar during an ANC visit Residence Urban 19.3 11.2 9.9 6.4 5.4 718 Rural 28.0 15.1 14.7 8.3 8.1 1,730 Province Manicaland 42.6 24.3 22.9 13.8 12.8 366 Mashonaland Central 45.0 24.5 23.8 12.6 12.3 254 Mashonaland East 20.1 8.8 8.4 6.0 5.6 257 Mashonaland West 24.3 13.3 13.0 4.7 4.4 296 Matabeleland North 37.0 28.1 27.3 16.3 15.9 115 Matabeleland South 11.6 9.7 8.9 4.6 4.2 124 Midlands 18.0 10.7 10.4 6.5 6.2 298 Masvingo 26.7 12.1 11.6 9.3 8.9 277 Harare 11.0 4.9 4.2 2.3 1.6 352 Bulawayo 5.3 1.1 1.1 0.6 0.6 111 Education No education (53.3) (16.3) (12.7) (10.5) (10.5) 28 Primary 23.6 13.5 13.1 7.6 7.2 767 Secondary 25.5 13.9 13.2 7.8 7.3 1,573 More than secondary 31.7 18.4 17.9 7.9 7.4 80 Wealth quintile Lowest 27.7 14.9 14.7 9.0 8.8 543 Second 28.8 14.5 13.7 9.0 8.5 515 Middle 27.7 15.5 14.2 7.6 6.4 478 Fourth 23.0 12.8 12.5 6.5 6.3 519 Highest 18.3 11.5 10.8 6.4 5.9 393 Total 25.4 13.9 13.3 7.8 7.3 2,448 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 IPTp: Intermittent preventive treatment during pregnancy is preventive treatment with two or more doses of SP/Fansidar. 174 • Malaria A higher percentage of rural women take an antimalarial during pregnancy than urban women (28 and 19 percent, respectively). Across the provinces, use of antimalarial drugs is highest among pregnant women in Mashonaland Central (45 percent) and lowest among women in Bulawayo (5 percent). Use of an antimalarial drug is less common among women in the highest wealth quintile than women in the other quintiles. Use of SP/Fansidar (28 percent) was highest among pregnant women living in Matabeleland North. Around one in six pregnant women in Matabeleland North reported that they had received at least two doses of SP/Fansidar and that at least one of the doses was received during an ANC visit. In contrast, 1 percent of women who gave birth in Bulawayo in the two years prior to the survey received this intervention. The percentage of pregnant women who received at least two doses of SP/Fansidar at least one of which was received during an ANC visit was essentially unchanged from the figure reported in the 2005-06 ZDHS (7 percent versus 6 percent). 12.5 PREVALENCE, DIAGNOSIS, AND PROMPT TREATMENT OF FEVER AMONG YOUNG CHILDREN Fever is a major manifestation of malaria in young children, although it also accompanies other illnesses. As discussed in Chapter 10, mothers were asked whether their children under age 5 had had a fever in the two weeks preceding the survey and, if so, what was done to treat the fever. Table 12.7 shows the percentage of children under 5 who had a fever in the two weeks preceding the survey and, among those who had a fever, the percentage who had blood taken from a finger or heel, took antimalarial drugs, and received antimalarial treatment soon (the same or the next day) after the onset of fever, by selected background characteristics. Table 12.8 shows the types of antimalarial drugs received by children with a fever in the two weeks before the survey and the proportion of children with fever who were given antimalarial drugs on the same day or the day after the fever developed. Ten percent of children under age 5 had a fever in the two weeks preceding the survey. Among children with fever, 7 percent had blood taken from a finger or heel for testing. Only 2 percent of children with fever were given antimalarial drugs, most of whom received the drugs the same day or the day after the fever started. The differentials in treatment patterns in Table 12.7 and Table 12.8 must be interpreted with caution because comparatively few children were suffering from fever in many subgroups, and very few children were given antimalarials. Half of children receiving antimalarials were given coartemether (artemether lumefantrine), an artemisinin combination therapy (ACT) that is Zimbabwe’s first-line drug against uncomplicated malaria (MOHCW, 2008). Other children were given chloroquine, quinine, or SP/Fansidar. Malaria • 175 Table 12.7 Prevalence, diagnosis, and prompt treatment of children with fever Percentage of children under age five with fever in the two weeks preceding the survey, and among children under age five with fever, the percentage who had blood taken from a finger or heel, the percentage who took antimalarial drugs and the percentage who took the drugs the same or next day following the onset of fever, by background characteristics, Zimbabwe 2010-11 Background characteristic Among children under age five: Among children under age five with fever: Percentage with fever in the two weeks preceding the survey Number of children Percentage who had blood taken from a finger or heel for testing Percentage who took antimalarial drugs Percentage who took antimalarial drugs same or next day Number of children Age (in months) <12 10.5 1,348 6.0 1.3 1.3 141 12-23 10.2 1,034 7.3 2.0 1.6 105 24-35 11.2 999 7.4 1.4 1.4 112 36-47 7.6 986 7.5 6.4 6.4 75 48-59 8.6 841 9.7 1.8 0.0 73 Sex Male 9.5 2,592 8.1 2.1 2.1 246 Female 10.0 2,616 6.6 2.5 1.8 261 Residence Urban 8.7 1,548 4.5 3.6 3.3 134 Rural 10.2 3,660 8.4 1.8 1.5 372 Province Manicaland 16.2 766 6.6 2.4 1.3 124 Mashonaland Central 15.2 563 12.2 2.0 2.0 85 Mashonaland East 7.5 505 (6.7) (2.1) (2.1) 38 Mashonaland West 8.3 628 (10.2) (0.0) (0.0) 52 Matabeleland North 13.8 256 13.0 14.4 13.2 35 Matabeleland South 10.4 263 1.9 0.0 0.0 27 Midlands 5.1 660 (7.5) (0.0) (0.0) 34 Masvingo 6.7 588 (4.3) (0.0) (0.0) 40 Harare 7.0 761 (2.7) (1.9) (1.9) 54 Bulawayo 7.9 219 (0.0) (0.0) (0.0) 17 Mother’s education No education 16.1 89 * * * 14 Primary 10.5 1,672 7.1 2.7 1.9 176 Secondary 9.2 3,291 7.5 1.9 1.9 304 More than secondary 8.0 156 * * * 12 Wealth quintile Lowest 11.4 1,189 5.1 0.5 0.5 136 Second 8.9 1,087 13.9 4.1 2.7 97 Middle 9.6 997 5.1 1.6 1.6 96 Fourth 9.1 1,101 2.4 1.6 1.6 100 Highest 9.3 833 12.3 4.9 4.3 78 Total 9.7 5,208 7.4 2.3 1.9 506 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 176 • Malaria Table 12.8 Type and timing of antimalarial drugs taken by children with fever Among children under age five with fever in the two weeks preceding the survey, the percentage who took specific antimalarial drugs and the percentage who took each type of drug the same or next day after developing fever, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of children who took drug: Percentage of children who took drug the same or next day: Number of children with fever SP/ Fansidar Chloroquine Quinine Coartemether1 SP/ Fansidar Chloroquine Quinine Coartemether1 Age (in months) <12 0.6 0.0 0.0 0.7 0.6 0.0 0.0 0.7 141 12-23 0.0 0.4 1.6 0.0 0.0 0.0 1.6 0.0 105 24-35 0.0 0.8 0.0 0.6 0.0 0.8 0.0 0.6 112 36-47 0.0 1.0 0.0 5.4 0.0 1.0 0.0 5.4 75 48-59 0.0 1.8 0.0 0.0 0.0 0.0 0.0 0.0 73 Sex Male 0.3 0.0 0.7 1.1 0.3 0.0 0.7 1.1 246 Female 0.0 1.3 0.0 1.1 0.0 0.7 0.0 1.1 261 Residence Urban 0.0 0.3 1.3 2.0 0.0 0.0 1.3 2.0 134 Rural 0.2 0.8 0.0 0.8 0.2 0.5 0.0 0.8 372 Province Manicaland 0.0 1.1 0.0 1.3 0.0 0.0 0.0 1.3 124 Mashonaland Central 0.0 2.0 0.0 0.0 0.0 2.0 0.0 0.0 85 Mashonaland East (2.1) (0.0) (0.0) (0.0) (2.1) (0.0) (0.0) (0.0) 38 Mashonaland West (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 52 Matabeleland North 0.0 1.1 4.8 8.5 0.0 0.0 4.8 8.5 35 Matabeleland South 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 27 Midlands (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 34 Masvingo (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 40 Harare (0.0) (0.0) (0.0) (1.9) (0.0) (0.0) (0.0) (1.9) 54 Bulawayo (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 17 Mother’s education No education * * * * * * * * 14 Primary 0.4 1.3 0.0 1.0 0.4 0.5 0.0 1.0 176 Secondary 0.0 0.0 0.6 1.3 0.0 0.0 0.6 1.3 304 More than secondary * * * * * * * * 12 Wealth quintile Lowest 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.5 136 Second 0.0 2.3 0.0 1.7 0.0 1.0 0.0 1.7 97 Middle 0.8 0.8 0.0 0.0 0.8 0.8 0.0 0.0 96 Fourth 0.0 0.0 0.0 1.6 0.0 0.0 0.0 1.6 100 Highest 0.0 0.5 2.2 2.2 0.0 0.0 2.2 2.2 78 Total 0.2 0.7 0.3 1.1 0.2 0.3 0.3 1.1 506 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Coartemether is an artemisinin-based combination therapy (ACT). 12.6 PREVALENCE OF ANAEMIA IN CHILDREN One of the objectives of the 2010-11 ZDHS was to assess the prevalence of anaemia among children age 6-59 months. Table 11.7 in the previous chapter on nutrition presents the percentage of children who are anaemic (children are classified as anaemic if their haemoglobin level is below 11.0 g/dl and as severely anaemic if their haemoglobin level is below 7.0 g/dl). However, poor dietary intake of iron is only one of numerous causes of anaemia; malaria infection can also result in a person becoming anaemic. A haemoglobin concentration of less than 8.0 g/dl is considered an indication that an individual may have malaria. Malaria • 177 Table 12.9 shows that 4 percent of children age 6-59 months have haemoglobin levels below 8.0 g/dl. The percentage of children with haemoglobin levels below 8.0 g/dl declines almost steadily with increasing age, from a high of 8 percent among children age 6-8 months to a low of 1 percent among children age 4. Matabeleland North has the highest prevalence of anaemia (6 percent), while the prevalence in Harare and Mashonaland Central is lowest (2 percent). There is no substantial difference in anaemia levels by urban-rural residence. The percentage of children with haemoglobin levels below 8.0 g/dl is inversely associated with wealth status, decreasing from 5 percent of children in the lowest wealth quintile to 2 percent of children in the highest wealth quintile. Table 12.9 Haemoglobin < 8.0 g/dl in children Percentage of children age 6-59 months with haemoglobin lower than 8.0 g/dl, by background characteristics, Zimbabwe 2010-11 Background characteristic Haemoglobin < 8.0 g/dl Number of children Age (in months) 6-8 8.2 235 9-11 6.4 295 12-17 5.1 534 18-23 5.8 386 24-35 3.7 984 36-47 2.3 926 48-59 1.0 860 Sex Male 4.4 2,093 Female 3.0 2,128 Mother's interview status Interviewed 4.2 3,333 Not interviewed but in household 2.0 135 Not interviewed and not in household1 1.6 753 Residence Urban 3.9 930 Rural 3.6 3,291 Province Manicaland 4.1 644 Mashonaland Central 2.4 476 Mashonaland East 3.3 492 Mashonaland West 2.5 473 Matabeleland North 6.0 237 Matabeleland South 5.2 279 Midlands 5.3 609 Masvingo 2.7 471 Harare 2.2 408 Bulawayo 4.5 132 Mother’s education2 No education 2.9 86 Primary 4.3 1,170 Secondary 4.2 2,142 More than secondary 0.0 71 Wealth quintile Lowest 4.5 1,061 Second 3.9 973 Middle 3.2 902 Fourth 3.6 779 Highest 2.3 506 Total 3.7 4,221 Note: Table is based on children who stayed in the household the night before the interview. Haemoglobin levels are adjusted for altitude using CDC formulas (CDC, 1998). Haemoglobin is measured in grams per decilitre (g/dl). 1 Includes children whose mothers are deceased 2 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 179 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13 imbabwe continues to experience one of the worst HIV infection rates in sub-Saharan Africa. As of 2009, an estimated 1.1 million adults and children in the country were living with HIV (MOHCW, 2009). Because of the increased burden of disease due to HIV, Zimbabwe has continued not only to scale up prevention, care, and treatment programmes to combat the disease but also to strengthen monitoring and evaluation systems for these programmes. Measuring changes in HIV risk behaviours is important for successful tracking of the drivers of the epidemic in generalized epidemic states such as Zimbabwe. The principal mode of HIV transmission in Zimbabwe is heterosexual contact, which accounts for 92 percent of all HIV infections in the country (Zimbabwe National AIDS Council, 2005). The second most important mode of HIV transmission in Zimbabwe is vertical transmission, in which the mother passes HIV to her child during pregnancy, childbirth, and breastfeeding. The prevention of mother-to-child transmission of HIV (PMTCT) programme in Zimbabwe is a priority in the fight against HIV/AIDS in children. The programme seeks to prevent paediatric HIV infection through primary prevention of HIV infection in the childbearing population, prevention of unintended pregnancies, PMTCT through a single-dose nevirapine regimen, and provision of care and follow-up psychosocial support. The future course of Zimbabwe’s AIDS epidemic depends on a number of variables such as levels of HIV/AIDS-related knowledge among the general population, social stigmatisation, risk Z Key Findings • Knowledge of HIV and /AIDS is universal in Zimbabwe. Ninety-eight percent of women and men age 15-49 have heard of AIDS. • Fifty-six percent of women and 53 percent of men have what can be considered comprehensive knowledge about the modes of HIV transmission and prevention: knowing that use of condoms and having just one uninfected faithful partner can reduce the chances of getting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about HIV transmission or prevention. • Eighty-six percent and 78 percent of women and men age 15-49, respectively, know that HIV can be transmitted by breastfeeding. Eighty-six percent of women and 76 percent of men know that the risk of mother-to-child transmission can be reduced by a mother taking special drugs during pregnancy. • One percent of women and 11 percent of men had two or more sexual partners during the 12 months preceding the survey. Among respondents who had two or more partners in the past 12 months, 48 percent of women and 33 percent of men age 15-49 reported that they used a condom during their most recent sexual intercourse. • Point prevalence and cumulative prevalence of concurrent sexual partners among women were both less than 1 percent; among men, point prevalence was 4 percent and cumulative prevalence was 9 percent. • Three percent of men had paid for sexual intercourse in the past 12 months; among these men, 88 percent reported using a condom during their most recent paid sexual intercourse. • Ninety-one percent of women and 88 percent of men know where to get an HIV test. Fifty- seven percent of women and 36 percent of men have been tested for HIV and received the results of their last test. • Ten percent of women and 7 percent of men reported that they had a sexually transmitted infection (STI) or symptoms of an STI in the 12 months preceding the survey. 180 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour behaviour modification, access to high-quality services for sexually transmitted infections (STIs), provision and uptake of HIV counselling and testing, and access to care and antiretroviral therapy (ART), including prevention and treatment of opportunistic infections. The principal objective of this chapter is to establish the prevalence of relevant knowledge, perceptions, and behaviours at the national level and also within geographic and socioeconomic subpopulations. In this way, the AIDS control programme in Zimbabwe can target those groups of individuals most in need of information and most at risk of HIV infection. To facilitate comparisons between sexes, findings in this chapter refer to the 15-49 age group unless otherwise noted. The chapter concludes with a discussion of the findings for young people age 15-24. 13.1 HIV/AIDS KNOWLEDGE, TRANSMISSION, AND PREVENTION METHODS ZDHS respondents were asked whether they had heard of AIDS. Those who reported having heard of AIDS were asked a number of questions about whether and how HIV/AIDS could be avoided. Table 13.1 provides information on overall AIDS knowledge in Zimbabwe. Knowledge levels are high (98 percent) among both women and men in all subgroups for which information is presented in the table. The lowest knowledge level was recorded among men with no education (84 percent). Similarly high levels of knowledge of AIDS were reported in the 2005-06 ZDHS. Table 13.1 Knowledge of AIDS Percentage of women and men age 15-49 who have heard of AIDS, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Have heard of AIDS Number of women Have heard of AIDS Number of men Age 15-24 96.9 3,786 97.3 3,107 15-19 96.0 1,945 96.0 1,735 20-24 97.8 1,841 98.9 1,372 25-29 98.6 1,686 99.2 1,236 30-39 98.4 2,347 99.4 1,798 40-49 98.2 1,352 99.3 968 Marital status Never married 97.0 2,197 97.3 3,221 Ever had sex 96.9 539 98.5 1,430 Never had sex 97.0 1,658 96.3 1,791 Married/living together 97.9 5,703 99.4 3,584 Divorced/separated/ widowed 98.8 1,271 98.9 304 Residence Urban 99.1 3,548 99.5 2,621 Rural 97.0 5,623 97.8 4,488 Province Manicaland 97.3 1,227 99.1 972 Mashonaland Central 99.6 871 99.7 738 Mashonaland East 99.4 824 99.3 667 Mashonaland West 97.6 1,026 99.5 872 Matabeleland North 95.3 443 90.5 349 Matabeleland South 97.0 467 97.7 352 Midlands 97.7 1,123 96.2 885 Masvingo 93.8 909 98.3 585 Harare 99.4 1,722 99.7 1,307 Bulawayo 98.3 558 99.3 382 Education No education 93.5 212 83.7 56 Primary 95.6 2,568 96.5 1,508 Secondary 98.8 5,966 99.0 5,027 More than secondary 99.0 424 99.8 519 Wealth quintile Lowest 94.2 1,546 96.5 1,074 Second 97.4 1,594 97.3 1,216 Middle 98.4 1,681 98.4 1,371 Fourth 98.8 2,073 99.1 1,664 Highest 99.1 2,278 99.8 1,786 Total 15-49 97.8 9,171 98.4 7,110 50-54 na na 98.4 370 Total 15-54 na na 98.4 7,480 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 181 HIV/AIDS prevention programmes in Zimbabwe focus their messages and efforts on four important aspects of behaviour: use of condoms, limiting the number of sexual partners or staying faithful to one partner, male circumcision, and delaying sexual debut among young people (i.e., abstinence). Table 13.2 shows that 8 in 10 respondents (81 percent of women and 82 percent of men) know that using condoms is a way to prevent HIV transmission. Ninety percent of respondents recognize that the risk of getting HIV can be reduced by limiting sexual intercourse to one uninfected partner. Approximately 8 in 10 respondents (77 percent of women and 79 percent of men) recognize both using condoms and limiting sexual intercourse to one uninfected partner as methods to reduce the risk of getting HIV. Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting HIV by using condoms every time they have sexual intercourse and by having one sex partner who is not infected and has no other partners, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Percentage who say HIV can be prevented by: Number of women Percentage who say HIV can be prevented by: Number of men Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Age 15-24 75.9 86.6 71.5 3,786 78.5 87.0 72.7 3,107 15-19 70.9 83.4 65.7 1,945 74.5 82.9 67.2 1,735 20-24 81.2 90.0 77.6 1,841 83.4 92.2 79.7 1,372 25-29 84.9 91.8 81.7 1,686 85.5 94.2 82.7 1,236 30-39 84.4 92.6 81.3 2,347 85.5 94.4 83.0 1,798 40-49 84.0 91.7 80.8 1,352 85.6 94.2 83.0 968 Marital status Never married 74.5 85.5 69.5 2,197 79.0 87.2 73.5 3,221 Ever had sex 84.7 89.6 80.5 539 84.7 91.2 80.0 1,430 Never had sex 71.2 84.2 66.0 1,658 74.4 84.0 68.3 1,791 Married/living together 82.3 91.2 79.1 5,703 85.3 94.4 82.6 3,584 Divorced/separated/ widowed 86.0 91.4 82.2 1,271 85.4 93.4 82.6 304 Residence Urban 83.9 91.7 80.4 3,548 85.6 94.0 82.7 2,621 Rural 79.1 88.7 75.3 5,623 80.6 89.4 76.0 4,488 Province Manicaland 77.6 87.2 73.0 1,227 86.6 94.9 84.5 972 Mashonaland Central 81.4 91.1 77.4 871 82.1 91.7 76.9 738 Mashonaland East 83.1 94.8 80.8 824 80.9 90.1 74.9 667 Mashonaland West 80.3 89.7 76.3 1,026 88.3 96.2 85.7 872 Matabeleland North 75.7 78.8 68.8 443 55.7 64.0 47.0 349 Matabeleland South 88.1 92.4 85.6 467 82.5 88.7 77.7 352 Midlands 81.9 91.0 78.7 1,123 77.9 88.5 73.4 885 Masvingo 77.3 86.1 73.8 909 83.8 91.8 80.3 585 Harare 80.9 91.5 77.7 1,722 84.5 93.5 81.4 1,307 Bulawayo 87.4 91.8 83.9 558 87.3 94.1 83.7 382 Education No education 65.8 75.4 60.3 212 49.3 59.0 39.5 56 Primary 76.3 85.1 71.5 2,568 75.9 84.0 69.4 1,508 Secondary 82.9 91.9 79.5 5,966 83.6 92.9 80.2 5,027 More than secondary 89.1 97.4 88.4 424 93.6 97.4 92.3 519 Wealth quintile Lowest 74.6 83.8 69.7 1,546 75.2 84.6 70.3 1,074 Second 79.3 89.6 75.9 1,594 80.3 89.4 75.7 1,216 Middle 81.5 90.0 77.2 1,681 80.6 90.8 76.4 1,371 Fourth 82.6 90.9 79.4 2,073 83.9 91.4 79.7 1,664 Highest 84.4 93.1 81.4 2,278 88.3 96.0 85.7 1,786 Total 15-49 80.9 89.9 77.2 9,171 82.4 91.1 78.5 7,110 50-54 na na na na 86.2 92.8 83.1 370 Total 15-54 na na na na 82.6 91.2 78.7 7,480 na = Not applicable 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 182 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.2 also presents differences in the levels of knowledge of prevention methods by background characteristics. Young people age 15-24 generally have lower levels of knowledge than those in older age groups, and never-married respondents who have not yet had sex also are less likely to know about prevention modes than those who have married or ever had sex. As expected, urban residents are generally more knowledgeable about prevention modes than rural residents. There is considerable variation in knowledge levels by province; for example, 86 percent of men in Mashonaland West recognize using condoms and limiting sexual intercourse to one uninfected partner as a way to avoid getting HIV, compared with 47 percent of men in Matabeleland North. Women and men with higher levels of education are more likely than those with less education to be aware of the various prevention methods. For instance, 60 percent of women and 40 percent of men with no education say that the risk of getting HIV can be reduced by using condoms and limiting sex to one uninfected partner, as compared with 88 percent of women and 92 percent of men with more than a secondary education. Similarly, women and men in the higher wealth quintiles are more likely than those in the lower quintiles to know about actions that can be taken to reduce the risk of getting HIV. As part of the effort to assess HIV/AIDS knowledge, the 2010-11 ZDHS obtained information on several common misconceptions about HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have HIV and the chances of getting HIV from mosquito bites, by supernatural means, or from sharing food with a person who has AIDS. Tables 13.3.1 and 13.3.2 show the proportions of women and men who know that a healthy- looking person can have HIV and who reject common misconceptions about HIV transmission. Eighty-seven percent of women and men agreed that a healthy-looking person can have HIV. With respect to misconceptions about avenues of infection, 81 percent of women and 76 percent of men said HIV cannot be transmitted by mosquitoes. Ninety-two percent of women and 91 percent of men knew that HIV cannot be transmitted by supernatural means. Eighty-eight percent of women and 86 percent of men said a person cannot become infected by sharing food with a person who has AIDS. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 183 Table 13.3.1 Comprehensive knowledge about HIV/AIDS: Women Percentage of women age 15-49 who say that a healthy-looking person can have HIV and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of HIV, and the percentage with comprehensive knowledge about HIV/AIDS, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of women who say that: Percentage who say that a healthy- looking person can have HIV and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about HIV/AIDS2 Number of women A healthy- looking person can have HIV HIV cannot be transmitted by mosquito bites HIV cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 83.7 81.5 91.3 87.8 66.8 51.9 3,786 15-19 79.3 80.7 89.7 85.4 62.6 46.3 1,945 20-24 88.2 82.4 93.0 90.2 71.4 57.9 1,841 25-29 89.7 81.4 92.7 89.8 71.0 61.4 1,686 30-39 89.6 81.7 92.2 88.0 69.5 59.0 2,347 40-49 89.1 75.3 89.2 85.9 63.7 55.0 1,352 Marital status Never married 83.2 83.4 91.3 87.4 67.7 51.9 2,197 Ever had sex 88.3 79.6 90.2 88.3 70.1 59.9 539 Never had sex 81.6 84.7 91.7 87.2 66.9 49.3 1,658 Married/living together 87.6 79.9 91.5 87.5 67.4 56.7 5,703 Divorced/separated/ widowed 91.3 79.0 91.6 90.8 70.2 59.5 1,271 Residence Urban 91.8 84.9 94.2 91.5 75.1 62.7 3,548 Rural 84.1 77.9 89.8 85.7 63.2 51.6 5,623 Province Manicaland 83.5 80.1 91.4 87.1 64.8 51.8 1,227 Mashonaland Central 83.0 82.3 90.4 90.2 65.7 54.0 871 Mashonaland East 91.7 81.5 92.2 91.6 72.4 61.5 824 Mashonaland West 86.1 79.6 92.5 86.1 64.7 52.1 1,026 Matabeleland North 76.1 64.5 82.7 80.5 46.8 37.4 443 Matabeleland South 89.2 67.1 90.0 82.9 55.8 50.7 467 Midlands 90.7 84.0 94.3 89.1 75.5 62.7 1,123 Masvingo 80.5 77.9 86.4 81.7 61.6 50.7 909 Harare 92.3 86.5 94.2 91.4 75.7 60.6 1,722 Bulawayo 90.7 83.4 92.8 91.1 74.3 66.3 558 Education No education 74.8 51.9 68.4 72.5 38.9 30.0 212 Primary 81.0 71.0 86.0 80.7 55.9 44.7 2,568 Secondary 89.4 84.9 94.4 91.1 72.5 60.0 5,966 More than secondary 98.0 93.4 94.9 95.0 89.2 80.0 424 Wealth quintile Lowest 78.5 72.5 84.9 79.1 54.4 43.0 1,546 Second 84.5 77.5 90.3 86.5 62.9 52.1 1,594 Middle 86.2 79.4 91.1 88.5 66.0 54.2 1,681 Fourth 90.0 82.6 93.9 90.7 72.2 59.6 2,073 Highest 92.7 87.5 94.9 92.1 77.7 65.3 2,278 Total 87.1 80.6 91.5 87.9 67.8 55.9 9,171 1 Two most common local misconceptions: mosquito bites and sharing food with a person who has AIDS 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about transmission or prevention of HIV. 184 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.3.2 Comprehensive knowledge about HIV/AIDS: Men Percentage of men age 15-49 who say that a healthy-looking person can have HIV and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of HIV, and the percentage with comprehensive knowledge about HIV/AIDS, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of men who say that: Percentage who say that a healthy- looking person can have HIV and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about HIV/AIDS2 Number of men A healthy- looking person can have HIV HIV cannot be transmitted by mosquito bites HIV cannot be transmitted by supernatural means A person cannot become infected by sharing food with a person who has AIDS Age 15-24 82.2 74.4 89.6 84.7 58.6 47.0 3,107 15-19 80.3 71.0 86.8 81.7 54.6 41.7 1,735 20-24 84.7 78.6 93.1 88.5 63.6 53.7 1,372 25-29 89.5 78.2 93.2 88.4 66.2 57.3 1,236 30-39 90.9 78.3 92.3 87.9 66.8 59.1 1,798 40-49 89.1 76.0 88.2 85.0 61.8 55.6 968 Marital status Never married 82.7 75.5 89.3 84.9 60.2 49.2 3,221 Ever had sex 85.7 75.9 92.0 86.8 62.1 53.4 1,430 Never had sex 80.3 75.2 87.1 83.3 58.7 45.8 1,791 Married/living together 90.0 77.1 91.9 87.4 64.4 56.2 3,584 Divorced/separated/ widowed 88.7 74.0 92.7 86.0 62.5 55.7 304 Residence Urban 89.3 81.9 91.8 90.6 69.9 60.8 2,621 Rural 85.1 73.0 90.1 83.6 58.0 48.5 4,488 Province Manicaland 88.3 78.2 93.6 89.1 66.1 58.9 972 Mashonaland Central 87.9 79.1 90.3 86.3 65.2 54.4 738 Mashonaland East 87.7 69.9 86.7 79.5 52.6 41.8 667 Mashonaland West 90.9 82.6 96.7 91.6 71.5 63.7 872 Matabeleland North 62.5 65.3 77.7 69.3 36.0 24.1 349 Matabeleland South 83.3 62.6 87.1 77.8 48.0 40.1 352 Midlands 86.5 71.6 89.4 85.0 61.5 50.3 885 Masvingo 88.3 74.1 90.5 84.9 59.9 50.4 585 Harare 86.0 82.1 91.7 90.7 67.2 58.3 1,307 Bulawayo 93.5 78.9 92.2 90.5 70.9 61.4 382 Education No education 54.7 50.1 63.4 48.9 23.0 12.6 56 Primary 79.6 62.3 84.4 75.2 44.3 35.5 1,508 Secondary 88.1 78.9 92.5 89.0 65.7 55.8 5,027 More than secondary 95.9 94.0 94.6 94.7 87.4 81.3 519 Wealth quintile Lowest 80.5 66.9 86.6 79.9 49.8 40.4 1,074 Second 84.5 71.6 90.2 82.5 57.5 47.7 1,216 Middle 85.9 73.1 90.3 82.8 57.0 47.0 1,371 Fourth 86.7 78.2 90.9 88.5 64.3 55.0 1,664 Highest 92.2 85.6 93.7 93.0 75.8 67.0 1,786 Total 15-49 86.6 76.3 90.7 86.2 62.4 53.0 7,110 50-54 90.3 65.5 86.2 81.0 55.1 49.1 370 Total 15-54 86.8 75.7 90.5 85.9 62.1 52.8 7,480 1 Two most common local misconceptions: mosquito bites and sharing food with a person who has AIDS 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about transmission or prevention of HIV. Two composite measures of HIV/AIDS knowledge are included in Tables 13.3.1 and 13.3.2. The first measure indicates that about two-thirds of respondents (68 percent of women and 62 percent of men) know that the two most common misconceptions about HIV/AIDS (i.e., HIV can be transmitted by mosquitoes or by sharing food with a person who has AIDS) are incorrect and also are aware that a healthy-looking person can have HIV. The second measure shows that more than half of Zimbabwean women (56 percent) and men (53 percent) have what can be considered comprehensive knowledge of HIV/AIDS prevention and transmission; that is, they know that both condom use and limiting sexual intercourse to one uninfected partner can prevent HIV, they are aware that a healthy- looking person can have HIV, and they reject the two most common local misconceptions (that HIV HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 185 can be transmitted through mosquitoes and that a person can become infected with HIV by sharing food with a person who has AIDS). The youngest (age 15-19) respondents and respondents who have never been married and never had sex are less likely to have comprehensive knowledge of HIV/AIDS than older respondents, never-married women and men who have ever had sex, and those who have ever been married. Those in urban areas are more likely than rural residents to have comprehensive knowledge. The level of comprehensive knowledge is highest among women in Bulawayo (66 percent) and men in Mashonaland West (64 percent). Conversely, comprehensive knowledge is particularly low among women (37 percent) and men (24 percent) residing in Matabeleland North. Among both women and men, comprehensive knowledge of HIV/AIDS rises with education level and wealth quintile. The difference by education among men is particularly striking; only 13 percent of men with no education have comprehensive knowledge about HIV/AIDS, compared with 81 percent of men with more than a secondary education. The corresponding proportions among women are 30 percent and 80 percent. The percentage of women and men with comprehensive knowledge of HIV/AIDS has increased since 2005-06, when it was reported that less than half of respondents age 15-49 had comprehensive knowledge (44 percent of women and 47 percent of men). 13.2 KNOWLEDGE ABOUT MOTHER-TO-CHILD TRANSMISSION Increasing the level of general knowledge about transmission of HIV from mother to child and reducing the risk of transmission using antiretroviral drugs are critical in reducing mother-to-child transmission of HIV (MTCT). To assess MTCT knowledge, respondents were asked whether HIV can be transmitted from a mother to a child through breastfeeding and whether a mother with HIV can reduce the risk of transmission to her baby by taking certain drugs during pregnancy. Table 13.4 shows that women are more aware than men (86 percent versus 78 percent) that HIV can be transmitted through breastfeeding and that the risk of MTCT can be reduced by taking special drugs (86 percent versus 76 percent). Overall, 79 percent of women and 65 percent of men are aware that HIV can be transmitted through breastfeeding and that this risk can be reduced by taking special drugs. In 2005-06, only 52 percent of women and 39 percent of men were aware that HIV can be transmitted through breastfeeding and that this risk can be reduced by taking special drugs; thus, there has been a substantial increase in knowledge about MTCT in Zimbabwe. MTCT knowledge levels generally increase with age, are higher among urban than rural residents, and increase with educational attainment and wealth status. Residents of Matabeleland North are least likely to be knowledgeable about MTCT (74 percent of women and 48 of percent men), while women in Mashonaland East (86 percent) and men in Mashonaland West (71 percent) are most likely. 186 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs during pregnancy, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Percentage who know that: Number of women Percentage who know that: Number of men HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding Risk of MTCT can be reduced by mother taking special drugs during pregnancy HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by mother taking special drugs during pregnancy Age 15-24 81.7 80.3 72.0 3,786 74.3 68.5 56.8 3,107 15-19 77.6 73.3 64.6 1,945 70.4 60.3 48.9 1,735 20-24 85.9 87.7 79.9 1,841 79.3 78.9 66.6 1,372 25-29 89.5 91.3 85.2 1,686 80.4 82.4 69.3 1,236 30-39 88.3 89.4 83.1 2,347 83.5 83.5 73.0 1,798 40-49 86.1 88.4 80.4 1,352 79.8 81.1 68.9 968 Marital status Never married 79.3 77.1 68.0 2,197 73.5 68.6 56.1 3,221 Ever had sex 84.8 85.2 77.6 539 77.1 72.8 60.3 1,430 Never had sex 77.5 74.5 64.9 1,658 70.7 65.2 52.7 1,791 Married/living together 87.0 88.2 81.2 5,703 82.6 83.3 72.3 3,584 Divorced/separated/ widowed 89.2 90.3 84.8 1,271 81.0 78.5 66.4 304 Pregnancy status Pregnant 85.0 85.5 77.7 758 na na na na Not pregnant or not sure 85.5 85.9 78.6 8,413 na na na na Residence Urban 87.5 90.0 82.5 3,548 77.2 84.3 68.4 2,621 Rural 84.2 83.2 76.0 5,623 79.2 71.9 62.5 4,488 Province Manicaland 82.0 84.8 75.1 1,227 79.4 77.9 66.9 972 Mashonaland Central 85.3 86.8 76.5 871 81.0 78.6 67.1 738 Mashonaland East 92.1 90.5 86.2 824 78.5 74.7 63.0 667 Mashonaland West 84.4 84.1 77.5 1,026 84.6 79.2 71.1 872 Matabeleland North 82.6 80.0 74.0 443 70.8 52.8 48.3 349 Matabeleland South 85.8 83.4 78.2 467 79.3 57.4 51.3 352 Midlands 83.7 82.1 75.1 1,123 76.9 75.5 63.6 885 Masvingo 83.0 81.5 74.9 909 81.8 73.3 64.8 585 Harare 88.3 90.9 83.8 1,722 74.9 84.5 66.9 1,307 Bulawayo 86.0 88.7 80.5 558 73.4 83.5 65.0 382 Education No education 76.9 68.8 62.9 212 57.9 44.2 38.0 56 Primary 81.9 79.6 72.6 2,568 75.3 62.0 54.0 1,508 Secondary 86.9 88.4 81.0 5,966 79.6 79.5 67.3 5,027 More than secondary 90.0 95.7 87.7 424 78.5 92.0 73.3 519 Wealth quintile Lowest 80.7 76.7 70.1 1,546 77.4 65.1 57.4 1,074 Second 84.8 83.9 77.1 1,594 79.3 72.2 62.9 1,216 Middle 85.3 85.2 77.8 1,681 79.6 71.9 62.5 1,371 Fourth 86.5 88.9 81.0 2,073 78.2 80.1 66.9 1,664 Highest 88.3 91.1 83.7 2,278 77.8 86.2 69.9 1,786 Total 15-49 85.5 85.9 78.5 9,171 78.4 76.4 64.7 7,110 50-54 na na na na 79.4 77.9 66.5 370 Total 15-54 na na na na 78.5 76.5 64.8 7,480 na = Not applicable HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 187 13.3 ATTITUDES TOWARDS PEOPLE LIVING WITH HIV/AIDS Widespread stigma and discrimination in a population can adversely affect both people’s willingness to be tested and their adherence to antiretroviral therapy (ART) in ART programmes such as the one currently being scaled up in Zimbabwe. Thus, reduction of stigma and discrimination in a population is an important indicator of the success of programmes targeting HIV/AIDS prevention and control. In the 2010-11 ZDHS, respondents who had heard of AIDS were asked a number of questions to assess the level of stigma associated with HIV/AIDS. Respondents were asked about their willingness or unwillingness to buy vegetables from an infected shopkeeper or vendor, to let others know the HIV status of family members, and to take care of a member of their family with AIDS in their own household. They were also asked whether an HIV-positive female teacher who is not sick should be allowed to continue teaching. Tables 13.5.1 and 13.5.2 present results for women and men, respectively. Table 13.5.1 Accepting attitudes toward those living with HIV/AIDS: Women Among women age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of women who: Percentage expressing accepting attitudes on all four indicators Number of women who have heard of AIDS Are willing to care for a family member with AIDS in the respondent's home Would buy fresh vegetables from a shopkeeper who has HIV Say that a female teacher who has HIV but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with HIV Age 15-24 92.9 75.7 87.0 51.7 36.0 3,669 15-19 91.3 72.6 84.9 48.1 31.5 1,868 20-24 94.5 78.9 89.2 55.4 40.6 1,801 25-29 95.2 79.6 90.4 56.1 41.6 1,663 30-39 95.9 80.5 89.3 56.5 43.2 2,310 40-49 97.0 76.9 84.9 59.0 41.9 1,327 Marital status Never married 91.7 77.3 88.6 51.0 37.3 2,131 Ever had sex 93.6 82.2 90.9 53.4 41.7 522 Never had sex 91.0 75.7 87.8 50.2 35.8 1,609 Married/living together 95.2 76.6 87.5 56.3 39.9 5,583 Divorced/separated/ widowed 97.6 84.5 88.5 54.8 43.2 1,256 Residence Urban 95.8 84.3 94.6 56.6 46.2 3,514 Rural 94.0 73.7 83.6 53.7 35.6 5,455 Province Manicaland 94.8 79.4 82.6 49.6 35.5 1,194 Mashonaland Central 96.6 69.4 75.4 55.2 34.6 868 Mashonaland East 93.4 79.5 87.6 57.0 38.1 819 Mashonaland West 95.8 75.6 89.0 45.3 34.1 1,002 Matabeleland North 91.7 75.0 81.4 65.5 43.5 422 Matabeleland South 93.6 73.6 91.7 53.4 41.2 454 Midlands 96.1 82.4 91.9 53.1 41.5 1,097 Masvingo 90.6 67.0 83.2 61.4 36.0 853 Harare 95.1 84.2 96.1 56.3 45.4 1,713 Bulawayo 96.7 83.3 93.7 61.6 51.0 549 Education No education 97.2 63.9 69.1 57.0 36.0 199 Primary 92.8 67.2 79.3 52.9 32.2 2,455 Secondary 95.3 81.8 91.3 55.0 41.9 5,896 More than secondary 95.8 91.5 99.5 63.5 56.2 420 Wealth quintile Lowest 92.4 65.7 77.3 55.9 31.9 1,457 Second 94.3 74.5 83.3 53.7 36.0 1,553 Middle 94.5 76.3 86.3 52.7 37.0 1,655 Fourth 95.7 82.2 92.3 53.6 42.4 2,048 Highest 95.7 85.2 95.1 57.6 47.0 2,257 Total 94.7 77.9 87.9 54.8 39.8 8,970 188 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.5.2 Accepting attitudes toward those living with HIV/AIDS: Men Among men age 15-49 who have heard of AIDS, percentage expressing specific accepting attitudes toward people with HIV/AIDS, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of men who: Percentage expressing accepting attitudes on all four indicators Number of men who have heard of AIDS Are willing to care for a family member with the AIDS in the respondent's home Would buy fresh vegetables from a shopkeeper who has HIV Say that a female teacher who has HIV but is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with HIV Age 15-24 93.3 77.0 79.6 51.8 33.5 3,023 15-19 92.1 74.0 75.6 49.4 29.2 1,666 20-24 94.7 80.7 84.6 54.7 38.9 1,357 25-29 96.5 83.4 87.3 56.4 42.4 1,226 30-39 96.5 83.6 87.4 58.1 43.5 1,788 40-49 96.8 80.8 84.0 60.4 43.5 961 Marital status Never married 93.3 77.2 80.7 52.8 34.6 3,134 Ever had sex 94.8 79.2 82.5 56.4 37.9 1,409 Never had sex 92.1 75.6 79.3 49.8 31.9 1,725 Married/living together 96.7 83.0 86.2 57.8 43.0 3,563 Divorced/separated/ widowed 95.4 81.1 81.6 55.0 37.8 301 Residence Urban 96.9 85.8 92.6 53.8 43.6 2,607 Rural 94.1 77.1 78.2 56.4 36.3 4,391 Province Manicaland 97.8 84.3 81.6 55.5 42.3 964 Mashonaland Central 95.4 74.2 76.6 53.9 32.8 736 Mashonaland East 94.2 78.7 78.5 49.8 31.5 662 Mashonaland West 96.5 86.3 86.1 56.9 43.9 868 Matabeleland North 74.5 56.9 66.2 60.4 24.2 316 Matabeleland South 90.7 68.4 75.7 62.1 35.3 344 Midlands 96.7 78.9 84.9 53.5 36.3 851 Masvingo 96.1 81.3 81.1 59.3 42.4 575 Harare 96.9 85.7 94.3 52.9 42.8 1,303 Bulawayo 96.6 84.7 90.6 61.2 47.7 380 Education No education 81.1 45.3 44.5 48.9 13.6 47 Primary 89.9 65.9 68.2 56.9 28.4 1,455 Secondary 96.7 83.4 86.9 55.8 42.0 4,978 More than secondary 95.9 94.2 98.4 48.1 42.6 518 Wealth quintile Lowest 91.1 69.1 71.6 61.0 33.9 1,036 Second 94.1 77.8 77.1 55.6 34.4 1,183 Middle 95.5 77.1 80.5 52.8 34.8 1,349 Fourth 96.5 84.3 88.1 55.0 42.5 1,648 Highest 96.7 87.3 92.9 54.4 44.9 1,782 Total 15-49 95.1 80.3 83.6 55.4 39.0 6,998 50-54 97.5 75.5 78.4 60.2 42.3 365 Total 15-54 95.3 80.1 83.3 55.6 39.2 7,362 Both women and men tend to express more accepting attitudes toward HIV-infected relatives than toward shopkeepers or teachers. Ninety-five percent of both women and men would be willing to care for a relative with AIDS in their home. Eighty-eight percent of women and 84 percent of men agreed that a female teacher with HIV should be allowed to continue teaching. Seventy-eight percent of women and 80 percent of men would buy fresh vegetables from a shopkeeper with HIV. More than half of both women and men indicated that they would not want to keep secret that a family member was infected with HIV. Overall, 40 percent of women and 39 percent of men expressed accepting attitudes with regard to all four situations (i.e., they would care for a family member with AIDS in their own home, would buy fresh food from a shopkeeper with HIV, would allow an HIV-positive female teacher to continue teaching, and would not want to keep the HIV-positive status of a family member a secret). In contrast, in 2005-06, 17 percent of women and 11 percent of men expressed accepting attitudes regarding these same four situations. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 189 There were associations between stigma levels and most of the background characteristics shown in Tables 13.5.1 and 13.5.2. With the exception of men’s attitude toward keeping a family member’s HIV status secret, accepting attitudes were generally more common among urban than rural residents. There were marked differences by province in the proportions of women and men expressing accepting attitudes, with men and women from Bulawayo being most likely to express accepting attitudes with respect to all four indicators. Interestingly, women and men from the same province often expressed different attitudes; for example, in Matabeleland North, 44 percent of women and 24 percent of men expressed accepting attitudes on all four indicators. In general, accepting attitudes on all four indicators increased with increasing education level and wealth quintile. The finding that the vast majority of women and men (95 percent) reported that they are willing to care for a family member with AIDS at home may indicate a widespread societal norm to care for family members who are in need. However, only slightly more than half of respondents indicated that they would not want to keep secret that a family member was infected with HIV. Older men and those living in rural areas; those in Matabeleland South, Matebeleland North, and Bulawayo; and those in the lowest wealth quintiles are generally more likely to say that they would not want to keep secret that a family member was infected with HIV. Men with no education and more than a secondary education are less likely not to want to keep a family member’s HIV status secret than men with only a primary education or at least some secondary education. A different pattern is observed among women. Urban women, women in Matabeleland North, those with no education and more than a secondary education, and those from the highest wealth quintile are more likely to say that they would not want to keep secret that a family member was infected with HIV. 13.4 ATTITUDES TOWARDS NEGOTIATING FOR SAFER SEXUAL RELATIONS WITH HUSBANDS Knowledge about HIV transmission and ways to prevent it is of little use if people feel powerless to negotiate safer sex practices with their partners. In an effort to assess the ability of women to negotiate safer sex with their husbands, women and men were asked whether they thought that a wife is justified in refusing to have sexual intercourse with her husband if she knows he has sex with women other than his wives or asking that he use a condom if she knows he has an STI. Table 13.6 shows that 8 in 10 women and men believe that a wife is justified in asking her husband to use a condom if she knows he has an STI. Sixty-eight percent of men believe a woman has a right to refuse sexual intercourse with her husband if she knows he has sex with women other than his wives. There are differences by background characteristics; most strikingly, only 38 percent of men with no education believe a woman has a right to refuse sexual intercourse with her husband if she knows he has sex with women other than his wives, compared with 87 percent of men with more than a secondary education. Respondents in Matabeleland North are least likely to think that a wife is justified in refusing to have sexual intercourse with her husband or asking that he use a condom. 190 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.6 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI), and percentage of men age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with women other than his wives, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Woman is justified in: Number of women Woman is justified in: Number of men Refusing to have sexual intercourse with her husband if she knows he has sex with women other than his wives Asking that they use a condom if she knows that her husband has an STI Asking that they use a condom if she knows that her husband has an STI Age 15-24 75.3 3,786 65.7 77.1 3,107 15-19 68.6 1,945 63.9 73.5 1,735 20-24 82.4 1,841 68.0 81.8 1,372 25-29 83.0 1,686 68.0 86.9 1,236 30-39 84.2 2,347 71.1 89.7 1,798 40-49 83.9 1,352 71.4 87.4 968 Marital status Never married 71.9 2,197 67.0 77.7 3,221 Ever had sex 79.9 539 67.3 81.8 1,430 Never had sex 69.3 1,658 66.7 74.4 1,791 Married/living together 82.1 5,703 69.5 88.3 3,584 Divorced/separated/ widowed 86.4 1,271 66.5 87.2 304 Residence Urban 81.9 3,548 76.9 88.1 2,621 Rural 79.2 5,623 63.2 80.7 4,488 Province Manicaland 85.6 1,227 68.5 85.6 972 Mashonaland Central 88.7 871 63.1 82.6 738 Mashonaland East 86.3 824 62.5 77.2 667 Mashonaland West 78.3 1,026 69.3 87.4 872 Matabeleland North 66.7 443 44.1 49.8 349 Matabeleland South 87.0 467 67.3 76.8 352 Midlands 76.6 1,123 62.4 83.6 885 Masvingo 70.9 909 71.6 90.7 585 Harare 77.1 1,722 79.2 88.0 1,307 Bulawayo 87.3 558 78.7 91.1 382 Education No education 72.9 212 37.7 48.7 56 Primary 77.1 2,568 54.9 73.5 1,508 Secondary 81.2 5,966 70.6 85.6 5,027 More than secondary 89.7 424 87.4 94.8 519 Wealth quintile Lowest 73.3 1,546 56.0 75.4 1,074 Second 79.0 1,594 60.7 77.6 1,216 Middle 81.3 1,681 64.6 82.2 1,371 Fourth 82.6 2,073 72.6 86.5 1,664 Highest 82.9 2,278 79.4 90.2 1,786 Total 15-49 80.2 9,171 68.2 83.4 7,110 50-54 na na 67.7 87.9 370 Total 15-54 na na 68.2 83.7 7,480 Note: Due to a problem with the 2010-11 ZDHS Woman’s Questionnaire, data were missing for many women on whether or not they believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with women other than his wives. For this reason, the data that are available are not reliable and are not shown. na = Not applicable 13.5 ATTITUDES TOWARDS CONDOM EDUCATION FOR YOUNG PEOPLE Condom use is one the main strategies for combating the spread of HIV. However, educating young people about condoms is sometimes controversial, with some saying it promotes early sexual experimentation. To gauge attitudes toward condom education, ZDHS respondents were asked whether they thought that children age 12-14 should be taught about using a condom to avoid getting AIDS. Because the focus is on adults’ opinions, results are tabulated for respondents age 18-49. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 191 Less than half of adults support teaching children age 12-14 about condoms (Table 13.7). Men are somewhat more likely than women to support education about condom use (48 percent and 38 percent, respectively). Younger respondents (age 18-19), those currently married, and rural residents are less likely than other respondents to believe that children should be taught about using a condom. Support is highest among those living in Bulawayo, where 6 in 10 women and men approve of condom education for children. Women in Manicaland and Mashonaland Central (30 percent) and men in Mashonaland East (40 percent) are least likely to agree that children should be educated about condoms. Support for teaching children about condoms increases with level of education and wealth status. For example, only 27 percent of women with no education support education of children on condoms, compared with 52 percent of women with more than a secondary education. The level of support for teaching children about condoms is essentially unchanged from that reported in the 2005-06 ZDHS (41 percent among women age 18-49 and 48 percent among men age 18-49). Table 13.7 Adult support of education about condom use to prevent AIDS Percentage of women and men age 18-49 who agree that children age 12-14 should be taught about using a condom to avoid AIDS, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Percentage who agree Number of women Percentage who agree Number of men Age 18-24 35.4 2,625 46.3 2,048 18-19 31.9 784 41.2 675 20-24 37.0 1,841 48.8 1,372 25-29 39.9 1,686 52.9 1,236 30-39 37.4 2,347 48.3 1,798 40-49 38.5 1,352 46.6 968 Marital status Never married 42.1 1,201 49.4 2,164 Married/living together 35.7 5,552 47.2 3,584 Divorced/separated/ widowed 40.7 1,257 53.2 303 Residence Urban 43.4 3,135 55.3 2,316 Rural 33.6 4,874 43.9 3,734 Province Manicaland 29.9 1,070 44.5 814 Mashonaland Central 30.1 766 42.4 633 Mashonaland East 31.9 721 40.3 564 Mashonaland West 34.4 901 44.5 742 Matabeleland North 35.1 382 53.0 289 Matabeleland South 56.0 381 56.8 271 Midlands 37.4 971 48.3 741 Masvingo 36.3 793 49.9 490 Harare 41.2 1,549 52.1 1,176 Bulawayo 57.7 475 63.7 329 Education No education 26.5 210 36.1 50 Primary 32.3 2,302 40.6 1,220 Secondary 39.1 5,074 48.4 4,260 More than secondary 51.9 423 66.3 519 Wealth quintile Lowest 29.2 1,359 39.4 922 Second 33.6 1,369 40.4 979 Middle 36.2 1,453 41.8 1,119 Fourth 39.2 1,857 52.4 1,449 Highest 45.1 1,972 59.1 1,581 Total 18-49 37.5 8,010 48.3 6,050 50-54 na na 43.9 370 Total 18-54 na na 48.0 6,421 na = Not applicable 192 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.6 MULTIPLE SEXUAL PARTNERS Given that most HIV infections in Zimbabwe are contracted through heterosexual contact, information on sexual behaviour is important in designing and monitoring intervention programmes to control the spread of the epidemic. The 2010-11 ZDHS included questions on respondents’ sexual partners during their lifetimes and over the 12 months preceding the survey. Men were also asked whether they paid for sex during the 12 months preceding the interview. In addition, information was collected on women’s and men’s use of condoms during their most recent sexual intercourse with each type of partner. These questions are sensitive, and it is recognized that some respondents may have been reluctant to provide information on recent sexual behaviour. Tables 13.8.1 and 13.8.2 show the percentages of women and men, respectively, who had two or more partners in the 12 months preceding the survey. Among those with two or more partners in the past 12 months, the tables also show the percentage who used a condom during their last sexual intercourse. Finally, the tables provide information on the mean number of lifetime sexual partners among those who have ever had sexual intercourse. Table 13.8.1 Multiple sexual partners: Women Among all women age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for women who ever had sexual intercourse, by background characteristics, Zimbabwe 2010-11 Background characteristic All women Among women who had 2+ partners in the past 12 months: Among women who ever had sexual intercourse1: Percentage who had 2+ partners in the past 12 months Number of women Percentage who reported using a condom during last sexual intercourse Number of women Mean number of sexual partners in lifetime Number of women Age 15-24 1.3 3,786 (38.5) 48 2.0 2,219 15-19 0.9 1,945 * 17 1.3 660 20-24 1.7 1,841 (54.0) 31 2.3 1,559 25-29 1.2 1,686 * 19 2.1 1,619 30-39 0.7 2,347 * 17 2.3 2,289 40-49 1.2 1,352 * 16 2.7 1,340 Marital status Never married 0.9 2,197 (41.6) 19 3.3 530 Married/living together 0.7 5,703 (22.9) 38 2.0 5,675 Divorced/separated/ widowed 3.4 1,271 (72.8) 44 2.8 1,262 Residence Urban 1.4 3,548 (66.6) 51 2.6 2,713 Rural 0.9 5,623 28.5 49 2.0 4,753 Province Manicaland 0.8 1,227 * 10 1.5 1,006 Mashonaland Central 0.5 871 * 5 1.7 751 Mashonaland East 0.9 824 * 8 1.7 694 Mashonaland West 1.4 1,026 * 14 3.8 868 Matabeleland North 0.2 443 * 1 2.1 375 Matabeleland South 3.0 467 (20.1) 14 3.2 382 Midlands 1.0 1,123 * 12 1.6 893 Masvingo 0.1 909 * 1 1.3 763 Harare 1.7 1,722 * 29 3.1 1,330 Bulawayo 1.4 558 * 8 2.2 404 Education No education 0.9 212 * 2 1.6 205 Primary 1.4 2,568 (26.7) 36 2.3 2,343 Secondary 1.0 5,966 60.4 61 2.3 4,571 More than secondary 0.5 424 * 2 1.7 348 Wealth quintile Lowest 0.7 1,546 * 11 2.1 1,360 Second 0.8 1,594 * 13 2.1 1,359 Middle 1.9 1,681 (47.3) 31 2.2 1,416 Fourth 1.2 2,073 * 26 2.3 1,699 Highest 0.9 2,278 * 20 2.5 1,632 Total 1.1 9,171 48.0 101 2.2 7,467 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 193 Table 13.8.2 Multiple sexual partners: Men Among all men age 15-49, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse; and the mean number of sexual partners during their lifetime for men who ever had sexual intercourse, by background characteristics, Zimbabwe 2010-11 Background characteristic All men Among men who had 2+ partners in the past 12 months: Among men who ever had sexual intercourse1: Percentage who reported using a condom during last sexual intercourse Number of men Mean number of sexual partners in lifetime Number of men Percentage who had 2+ partners in the past 12 months Number of men Age 15-24 7.7 3,107 50.5 238 3.5 1,392 15-19 2.5 1,735 66.2 43 2.3 417 20-24 14.2 1,372 47.0 195 4.0 975 25-29 14.4 1,236 34.1 178 5.1 1,070 30-39 13.8 1,798 19.3 248 6.7 1,682 40-49 8.9 968 23.2 87 8.3 891 Marital status Never married 6.3 3,221 76.4 202 4.1 1,372 Married/living together 14.1 3,584 11.6 504 6.1 3,383 Divorced/separated/ widowed 14.8 304 (79.7) 45 9.8 280 Type of union In polygynous union 73.0 162 6.1 119 12.1 157 In non-polygynous union 11.3 3,422 13.4 385 5.8 3,225 Not currently in union 7.0 3,525 77.0 247 5.0 1,652 Residence Urban 11.8 2,621 40.3 309 6.5 1,837 Rural 9.8 4,488 28.1 442 5.4 3,198 Province Manicaland 12.2 972 27.1 118 4.7 689 Mashonaland Central 11.5 738 26.3 85 5.3 567 Mashonaland East 9.3 667 38.6 62 6.3 459 Mashonaland West 8.4 872 29.9 73 6.3 587 Matabeleland North 9.4 349 (28.6) 33 6.2 253 Matabeleland South 10.2 352 40.7 36 5.9 265 Midlands 10.7 885 31.8 95 6.2 641 Masvingo 9.9 585 25.4 58 4.7 404 Harare 12.0 1,307 39.0 157 6.5 922 Bulawayo 9.0 382 (54.3) 34 5.0 247 Education No education 7.1 56 * 4 (7.6) 37 Primary 9.2 1,508 27.9 138 5.4 1,121 Secondary 10.7 5,027 34.5 537 5.8 3,446 More than secondary 13.8 519 33.1 72 6.3 431 Wealth quintile Lowest 11.5 1,074 18.4 123 5.5 834 Second 9.6 1,216 24.8 117 5.5 842 Middle 10.4 1,371 35.6 142 5.6 948 Fourth 10.2 1,664 31.6 170 5.9 1,177 Highest 11.1 1,786 46.9 197 6.1 1,234 Total 15-49 10.6 7,110 33.1 751 5.8 5,034 50-54 10.6 370 (11.0) 39 9.8 310 Total 15-54 10.6 7,480 32.0 790 6.0 5,344 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Means are calculated excluding respondents who gave non-numeric responses. A much larger proportion of men than women reported having had more than one sexual partner (11 percent and 1 percent, respectively) at some time in the past 12 months. Men age 20-39, those who had ever been married, and those with more than a secondary education were more likely than their counterparts to have had more than one sexual partner in the past 12 months. As would be expected, the proportion of men with multiple sexual partners in the past 12 months was exceptionally high among those in polygynous unions (73 percent). By residence, men in urban areas and those in Manicaland, Mashonaland Central, and Harare were more likely to have had more than one sexual partner than men living in other areas. Although the likelihood of having more than one sexual partner 194 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour generally increased with wealth, the pattern was not uniform. Data for women are not discussed by background characteristics due to the small number of women with more than one sexual partner. Among respondents who had more than one sexual partner in the past 12 months, women were more likely to report using a condom during their last sexual intercourse than men (48 percent and 33 percent, respectively). On average, men had had 5.8 sexual partners over their lifetimes, and women had had 2.2 partners. Among those with more than one sexual partner in the past 12 months, never-married men were much more likely to report condom use during their most recent sexual intercourse than those who were married (76 percent and 12 percent, respectively). Urban men were more likely to report using a condom during their last sexual intercourse than rural men (40 percent and 28 percent, respectively). Condom use among men during last sexual intercourse varied by province and generally increased with education level and wealth. Mean number of lifetime sexual partners increased with age, with men age 40-49 reporting an average of 8.3 lifetime partners and women in the same age group reporting an average of 2.7 partners. Among men, those in a polygynous union and those who were divorced, separated, or widowed had the highest average numbers of lifetime sexual partners (12.1 and 9.8 partners, respectively). Among women who had ever had sexual intercourse, those who had never been married had more partners on average (3.3 partners) than those who were divorced, separated, or widowed (2.8 partners) and those who were married (2.0 partners). Urban men reported an average of 6.5 lifetime sexual partners, compared with 5.4 sexual partners among rural men. Among women, those living in urban areas reported an average of 2.6 lifetime sexual partners, and those living in rural areas reported an average of 2.0. Mean reported number of lifetime sex partners among men varied from 4.7 in Manicaland and Masvingo to 6.5 in Harare. Among women, mean number of lifetime sex partners varied from 1.3 in Masvingo to 3.8 in Mashonaland West. Point prevalence and cumulative prevalence of concurrent sexual partners are new concepts that were incorporated for the first time in the 2010-11 ZDHS. The point prevalence of concurrent sexual partners is defined as the percentage of respondents who had two (or more) sexual partners concurrently at the point in time six months before the survey. The cumulative prevalence of concurrent sexual partners is defined as the percentage of respondents who had two (or more) sexual partners concurrently at any time during the 12 months preceding the survey. Table 13.9 shows the point prevalence and cumulative prevalence of concurrent sexual partners among all respondents during the 12 months before the survey. It also shows the percentage of respondents who had concurrent sexual partners among those who had multiple sexual partners during the 12 months before the survey. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 195 Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners Percentage of all women and men age 15-49 who had concurrent sexual partners six months before the survey (point prevalence1), and percentage of all women and all men age 15-49 who had any concurrent sexual partners during the 12 months before the survey (cumulative prevalence2), and among women and men age 15-49 who had multiple sexual partners during the 12 months before the survey, percentage who had concurrent sexual partners, Zimbabwe 2010-11 Background characteristic Among all respondents: Among respondents who had multiple partners during the 12 months before the survey: Point prevalence of concurrent sexual partners1 Cumulative prevalence of concurrent sexual partners2 Number of respondents Percentage who had concurrent sexual partners2 Number of respondents WOMEN Age 15-24 0.2 0.6 3,786 (50.3) 48 15-19 0.2 0.3 1,945 * 17 20-24 0.3 1.0 1,841 (57.8) 31 25-29 0.3 0.7 1,686 * 19 30-39 0.4 0.5 2,347 * 17 40-49 0.3 0.7 1,352 * 16 Marital status Never married 0.1 0.4 2,197 (52.3) 19 Married/living together 0.2 0.5 5,703 (69.3) 38 Divorced/separated/widowed 0.9 1.7 1,271 (50.7) 44 Residence Urban 0.5 0.8 3,548 (55.4) 51 Rural 0.2 0.5 5,623 60.9 49 Total 15-49 0.3 0.6 9,171 58.0 101 MEN Age 15-24 1.4 4.8 3,107 62.0 238 15-19 0.2 0.9 1,735 35.0 43 20-24 3.0 9.7 1,372 67.9 195 25-29 4.3 12.0 1,236 83.3 178 30-39 6.8 12.6 1,798 91.1 248 40-49 5.1 8.2 968 92.0 87 Marital status Never married 1.1 3.7 3,221 58.2 202 Married or living together 6.3 13.0 3,584 92.4 504 Divorced/separated/widowed 2.1 6.0 304 (40.6) 45 Type of union In polygynous union 59.4 71.6 162 98.0 119 In non-polygynous union 3.8 10.2 3,422 90.7 385 Not currently in union 1.2 3.9 3,525 55.0 247 Residence Urban 3.8 9.3 2,621 78.8 309 Rural 3.8 8.0 4,488 81.0 442 Total 15-49 3.8 8.5 7,110 80.1 751 50-54 7.7 10.0 370 (94.4) 39 Total 15-54 4.0 8.5 7,480 80.8 790 Note: Two sexual partners are considered to be concurrent if the date of the most recent sexual intercourse with the earlier partner is after the date of the first sexual intercourse with the later partner. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 The percentage of respondents who had two (or more) sexual partners that were concurrent at the point in time six months before the survey 2 The percentage of respondents who had two (or more) sexual partners that were concurrent at any time during the 12 months preceding the survey Among women, both point prevalence and cumulative prevalence were less than 1 percent; among men, point prevalence was 4 percent and cumulative prevalence was 9 percent. Among both female and male respondents, point prevalence and cumulative prevalence were generally similar in urban and rural areas. Men in polygynous unions had the highest cumulative prevalence (72 percent), and those not currently in a union had the lowest (4 percent). Not surprisingly, cumulative prevalence rates were much higher among respondents who reported having multiple partners during the 12 months before the survey than among those who did not report multiple partners (58 percent versus less than 1 percent among women and 80 percent versus 9 percent among men). 196 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.7 PAID SEX The act of paying for sex introduces an uneven negotiating ground for safer sexual intercourse. Condom use is an important indicator in efforts to ascertain the level of risk associated with sexual intercourse involving payments. Table 13.10 presents information on the extent to which men ever engaged in paid sex and engaged in paid sex in the 12-month period before the survey and on condom use during last paid sexual intercourse in the 12-month period. Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse Percentage of men age 15-49 who ever paid for sexual intercourse and percentage reporting payment for sexual intercourse in the past 12 months, and among them, the percentage reporting that a condom was used the last time they paid for sexual intercourse, by background characteristics, Zimbabwe 2010-11 Background characteristic Among all men: Among men who paid for sex in the past 12 months: Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Percentage reporting condom use at last paid sexual intercourse Number of men Age 15-24 5.8 2.5 3,107 90.4 77 15-19 1.5 1.2 1,735 * 20 20-24 11.2 4.1 1,372 (90.7) 57 25-29 19.6 5.5 1,236 90.3 68 30-39 26.3 3.3 1,798 83.9 59 40-49 30.4 1.6 968 * 16 Marital status Never married 6.3 2.7 3,221 91.1 86 Married/living together 24.5 3.2 3,584 85.5 113 Divorced/separated/ widowed 35.2 6.4 304 * 20 Residence Urban 20.3 4.1 2,621 89.9 108 Rural 14.6 2.5 4,488 86.8 111 Province Manicaland 18.1 3.8 972 (93.8) 37 Mashonaland Central 19.1 2.6 738 * 19 Mashonaland East 19.0 2.9 667 * 19 Mashonaland West 12.8 2.2 872 * 19 Matabeleland North 10.2 1.6 349 * 6 Matabeleland South 7.4 2.4 352 * 9 Midlands 18.5 3.2 885 (91.2) 29 Masvingo 12.8 1.9 585 * 11 Harare 22.5 5.0 1,307 (88.7) 66 Bulawayo 10.1 1.2 382 * 4 Education No education 10.1 4.0 56 * 2 Primary 16.7 3.6 1,508 79.1 54 Secondary 16.3 2.9 5,027 90.7 145 More than secondary 21.6 3.4 519 * 18 Wealth quintile Lowest 14.5 2.2 1,074 (81.4) 24 Second 13.5 2.3 1,216 (85.5) 28 Middle 16.8 3.9 1,371 (92.1) 53 Fourth 18.7 2.9 1,664 (84.9) 49 Highest 18.4 3.7 1,786 91.6 65 Total 15-49 16.7 3.1 7,110 88.3 219 50-54 41.6 1.9 370 * 7 Total 15-54 17.9 3.0 7,480 87.8 226 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 197 Seventeen percent of men reported ever paying for sex; 3 percent reported paying for sex at least once during the 12 months preceding the survey. Men age 25-49 (20-30 percent), ever-married men (25-35 percent), and urban men (20 percent) were most likely to have ever paid for sex. By province, the percentage of men who had ever paid for sex ranged from 7 percent in Matabeleland South to 23 percent in Harare. Payment for sexual intercourse was positively associated with education and wealth. For example, 10 percent of men with no education and 15 percent of men in the lowest wealth quintile had ever paid for sexual intercourse, compared with 22 percent of men with more than a secondary education and 18 percent of men in the highest wealth quintile. Divorced, widowed, or separated men (6 percent) had the highest rate of paid sex during the 12 months preceding the survey. Eighty-eight percent of men who had engaged in paid sex in the past 12 months used a condom the last time they paid for sex. A comparison of the 2005-06 and 2010-11 ZDHS results suggests that while there have been essentially no changes in the percentage of Zimbabwean men who paid for sex in the 12 months preceding the interview, those who did engage in paid sex were more likely to use a condom. Specifically, 4 percent of men paid for sex in the past 12 months and 73 percent reported condom use during their last paid intercourse in 2005-06, whereas in 2010-11 3 percent of men paid for sex in the last 12 months and 88 percent used a condom the last time they paid for sex. 13.8 COVERAGE OF HIV TESTING SERVICES Knowledge of HIV status helps HIV-negative individuals make specific decisions to reduce risk and increase safer sex practices so that they can remain disease free. Among those who are HIV infected, knowledge of their status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. To assess awareness and coverage of HIV testing services, ZDHS respondents were asked whether they had ever been tested for HIV. If they said that they had, they were asked whether they had received the results of their last test and where they had been tested. If they had never been tested, they were asked whether they knew a place where they could go to be tested. 198 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.11.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 85.0 44.9 2.1 53.0 100.0 47.0 30.0 3,786 15-19 77.6 24.7 1.8 73.5 100.0 26.5 18.4 1,945 20-24 92.9 66.3 2.4 31.3 100.0 68.7 42.2 1,841 25-29 95.8 75.6 2.3 22.0 100.0 78.0 44.1 1,686 30-39 94.9 67.3 2.7 30.0 100.0 70.0 36.1 2,347 40-49 92.5 52.7 2.0 45.4 100.0 54.6 26.4 1,352 Marital status Never married 80.6 26.4 1.3 72.3 100.0 27.7 16.8 2,197 Ever had sex 90.4 60.1 1.3 38.6 100.0 61.4 40.0 539 Never had sex 77.4 15.5 1.3 83.2 100.0 16.8 9.2 1,658 Married/living together 93.3 67.0 2.7 30.3 100.0 69.7 39.9 5,703 Divorced/separated/ widowed 96.4 68.1 2.0 29.9 100.0 70.1 34.4 1,271 Residence Urban 92.4 59.4 2.0 38.7 100.0 61.3 33.1 3,548 Rural 89.6 56.2 2.5 41.3 100.0 58.7 34.0 5,623 Province Manicaland 90.0 57.3 2.7 40.0 100.0 60.0 32.8 1,227 Mashonaland Central 95.6 58.5 2.9 38.7 100.0 61.3 35.9 871 Mashonaland East 94.1 57.0 1.9 41.1 100.0 58.9 29.3 824 Mashonaland West 90.2 56.8 3.2 40.0 100.0 60.0 37.8 1,026 Matabeleland North 87.2 60.9 0.9 38.2 100.0 61.8 33.6 443 Matabeleland South 91.6 61.7 1.7 36.6 100.0 63.4 38.9 467 Midlands 88.4 51.1 1.5 47.4 100.0 52.6 31.4 1,123 Masvingo 85.0 54.8 2.9 42.3 100.0 57.7 33.0 909 Harare 91.7 59.8 2.4 37.8 100.0 62.2 33.2 1,722 Bulawayo 92.5 61.0 1.2 37.7 100.0 62.3 32.9 558 Education No education 83.6 43.2 2.5 54.3 100.0 45.7 27.1 212 Primary 86.5 51.6 2.8 45.6 100.0 54.4 31.1 2,568 Secondary 92.2 59.5 2.2 38.4 100.0 61.6 34.4 5,966 More than secondary 97.6 71.1 1.2 27.7 100.0 72.3 41.2 424 Wealth quintile Lowest 85.0 51.9 3.1 44.9 100.0 55.1 31.4 1,546 Second 90.2 55.1 2.3 42.7 100.0 57.3 33.5 1,594 Middle 89.9 59.1 2.7 38.2 100.0 61.8 34.8 1,681 Fourth 92.9 61.7 2.3 36.0 100.0 64.0 35.6 2,073 Highest 93.3 57.7 1.4 40.9 100.0 59.1 32.5 2,278 Total 90.7 57.4 2.3 40.3 100.0 59.7 33.6 9,171 1 Includes “don't know/missing” HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 199 Table 13.11.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 80.1 20.8 1.5 77.8 100.0 22.2 13.6 3,107 15-19 72.6 10.3 1.2 88.4 100.0 11.6 7.0 1,735 20-24 89.6 33.9 1.7 64.4 100.0 35.6 22.1 1,372 25-29 94.8 47.5 3.2 49.4 100.0 50.6 28.0 1,236 30-39 94.5 47.4 3.2 49.4 100.0 50.6 25.7 1,798 40-49 92.8 48.3 3.1 48.7 100.0 51.3 23.1 968 Marital status Never married 80.4 21.3 1.5 77.2 100.0 22.8 12.8 3,221 Ever had sex 88.6 30.8 1.8 67.3 100.0 32.7 18.3 1,430 Never had sex 73.9 13.8 1.2 85.0 100.0 15.0 8.3 1,791 Married/living together 94.8 47.9 3.2 48.9 100.0 51.1 26.6 3,584 Divorced/separated/ widowed 89.1 48.4 2.6 49.0 100.0 51.0 28.9 304 Residence Urban 93.4 41.3 1.6 57.1 100.0 42.9 22.1 2,621 Rural 85.0 32.7 2.9 64.4 100.0 35.6 19.5 4,488 Province Manicaland 91.8 39.6 2.9 57.6 100.0 42.4 25.1 972 Mashonaland Central 90.5 37.8 1.1 61.1 100.0 38.9 21.9 738 Mashonaland East 89.6 32.7 3.1 64.3 100.0 35.7 16.1 667 Mashonaland West 88.1 37.9 2.4 59.7 100.0 40.3 22.1 872 Matabeleland North 72.3 32.1 8.1 59.7 100.0 40.3 15.0 349 Matabeleland South 80.3 25.0 2.4 72.6 100.0 27.4 16.6 352 Midlands 82.3 28.2 2.5 69.3 100.0 30.7 18.4 885 Masvingo 84.4 33.0 1.5 65.5 100.0 34.5 18.2 585 Harare 93.9 40.6 1.8 57.6 100.0 42.4 21.0 1,307 Bulawayo 91.2 43.2 0.8 56.0 100.0 44.0 24.7 382 Education No education 57.0 13.3 8.5 78.2 100.0 21.8 7.0 56 Primary 77.3 24.0 3.6 72.4 100.0 27.6 13.1 1,508 Secondary 90.5 37.0 2.1 61.0 100.0 39.0 21.7 5,027 More than secondary 99.0 62.4 1.8 35.8 100.0 64.2 31.1 519 Wealth quintile Lowest 81.2 27.6 4.3 68.1 100.0 31.9 14.9 1,074 Second 83.1 27.7 2.5 69.9 100.0 30.1 16.4 1,216 Middle 86.7 32.7 2.2 65.0 100.0 35.0 19.6 1,371 Fourth 89.9 38.0 2.2 59.8 100.0 40.2 22.1 1,664 Highest 94.9 46.9 1.6 51.5 100.0 48.5 25.7 1,786 Total 15-49 88.1 35.9 2.4 61.7 100.0 38.3 20.5 7,110 50-54 92.8 41.6 3.2 55.2 100.0 44.8 19.7 370 Total 15-54 88.3 36.2 2.5 61.4 100.0 38.6 20.4 7,480 1 Includes “don't know/missing” Tables 13.11.1 and 13.11.2 show that the majority of respondents (91 percent of women and 88 percent of men) knew of a place where they could get an HIV test. Younger respondents (age 15-19) were less likely than those age 20-49 to know a place where they could go to be tested. Never- married respondents who had never had sex were less likely than others to know a place to get an HIV test. Knowledge of a place to get an HIV test increased with both increasing education and wealth quintile and was somewhat more common among urban than rural residents, although the difference was more pronounced among men. In general, differences by province were not large. 200 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Tables 13.11.1 and 13.11.2 also show the coverage of HIV testing services. A larger proportion of men (62 percent) than women (40 percent) had never been tested. Most of those who had been tested said that they had received the result of the last test they took. Overall, 57 percent of women and 36 percent of men had ever been tested and had received the result of the last test. Among women the likelihood of having ever had an HIV test and receiving the results was highest in the 25-29 age group (76 percent); among men rates were highest among those age 25-49 (47-48 percent). Urban residents were more likely than rural residents to have been tested and to have received the result, although the difference was more pronounced for men than women. Among women, the percentage who were ever tested for HIV and received the result of the last test varied from 51 percent in Midlands to 62 percent in Matabeleland South, while the percentage among men ranged from 25 percent in Matabeleland South to 43 percent in Bulawayo. Among men, testing coverage increased markedly with education and wealth. Among women, testing coverage increased with increasing educational attainment, but the association between HIV testing and wealth was not clear. Thirty-four percent of women and 21 percent of men had been tested in the 12-month period preceding the survey and had been told the result of the last test they took. Overall, relative to the data reported in the 2005-06 ZDHS, the proportion of respondents who know where to get an HIV test and the proportion who have ever been tested and received results have increased dramatically. For instance, the proportion of respondents who know where to get an HIV test has increased from 75 percent to 91 percent among women and from 74 percent to 88 percent among men. Likewise, the proportion of respondents who have ever been tested for HIV and have received their test results has increased from 22 percent to 57 percent among women and from 16 to 36 percent among men. Screening for HIV in pregnant women is a key tool in reducing transmission of HIV from a mother to her child. Table 13.12 shows that 64 percent of women who gave birth during the two years preceding the survey received HIV counselling during antenatal care. Fifty-four percent received post- test counselling. Fifty-nine percent of women reported they had both received counselling about HIV and had been offered, accepted, and received the results of an HIV test during antenatal care. Women were most likely to have been counselled and tested and to have received the result of the test if they had more than a secondary education (76 percent) or lived in Matabeleland South (82 percent). Women were least likely to report receiving the full range of voluntary counselling and testing services during antenatal care if they were in the lowest wealth quintile (49 percent) or if their educational attainment did not extend beyond primary school. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 201 Table 13.12 Pregnant women counselled and tested for HIV Among all women age 15-49 who gave birth in the two years preceding the survey, the percentage who received counselling on HIV during antenatal care, the percentage who received an HIV test during antenatal care for their most recent birth by whether they received their results and post-test counselling, and percentage who received an HIV test at the time of delivery for their most recent birth by whether they received their test results, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who received counselling on HIV during antenatal care1 Percentage who were tested for HIV during antenatal care and who: Percentage who received counselling on HIV and an HIV test during ANC, and the results Percentage who had an HIV test during labour and who2: Number of women who gave birth in the past two years3 Received results and: Did not receive results Received post-test counselling Did not receive post-test counselling Received results Did not receive results Age 15-24 59.8 51.2 20.7 1.9 55.4 1.8 0.3 1,068 15-19 50.5 40.1 24.0 2.1 44.9 1.9 0.4 304 20-24 63.6 55.6 19.4 1.8 59.6 1.8 0.3 764 25-29 71.6 59.9 16.5 2.2 66.5 2.5 0.4 677 30-39 65.8 54.2 17.4 2.3 58.8 1.5 0.3 617 40-49 54.9 37.7 24.8 1.3 49.1 3.4 0.0 86 Marital status Never married 67.5 43.8 38.3 0.5 65.1 2.7 0.0 110 Ever had sex 67.5 43.8 38.3 0.5 65.1 2.7 0.0 110 Married/living together 65.1 56.3 16.3 2.2 59.7 1.7 0.3 2,137 Divorced/separated/ widowed 55.2 34.0 34.8 1.4 49.3 4.5 1.0 201 Residence Urban 69.6 58.3 19.8 1.9 65.8 4.2 0.2 718 Rural 62.3 52.1 18.5 2.1 56.3 1.1 0.4 1,730 Province Manicaland 59.8 47.1 22.7 1.9 54.9 1.2 0.3 366 Mashonaland Central 49.7 52.0 22.9 2.7 47.0 0.7 0.3 254 Mashonaland East 69.2 61.4 9.7 2.8 62.9 1.9 0.0 257 Mashonaland West 55.7 49.6 18.1 1.9 49.2 1.4 0.0 296 Matabeleland North 70.2 64.2 16.5 1.1 67.6 3.0 0.0 115 Matabeleland South 84.5 67.3 19.9 1.2 82.1 0.4 0.0 124 Midlands 66.7 45.3 22.4 1.7 57.5 1.5 0.9 298 Masvingo 68.9 57.0 14.7 2.9 61.2 0.8 0.7 277 Harare 64.2 53.6 19.7 2.1 60.7 5.2 0.4 352 Bulawayo 80.7 64.7 19.4 0.6 78.0 4.3 0.0 111 Education No education (37.1) (41.2) (28.5) (3.3) (37.1) (3.6) (0.0) 28 Primary 53.6 44.4 17.7 2.2 48.2 0.9 0.5 767 Secondary 69.3 58.3 18.9 2.1 63.9 2.4 0.3 1,573 More than secondary 80.5 61.1 25.1 0.0 76.1 4.0 0.0 80 Wealth quintile Lowest 55.7 44.4 16.7 3.1 48.9 0.6 0.4 543 Second 61.1 49.6 19.2 1.7 54.8 1.1 0.7 515 Middle 61.6 52.4 20.5 2.4 56.3 1.2 0.2 478 Fourth 69.3 59.3 20.1 1.9 65.2 4.5 0.3 519 Highest 77.8 67.1 17.7 0.9 74.1 2.7 0.0 393 Total 64.4 53.9 18.8 2.1 59.1 2.0 0.3 2,448 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 In this context, counselling on HIV means that someone talked with the respondent about all three of the following topics: (1) babies getting HIV from their mother, (2) preventing the virus, and (3) getting tested for the virus. 2 Women were asked whether they received an HIV test during labour only if they were not tested for HIV during ANC. 3 Denominator for percentages includes women who did not receive antenatal care for their last birth in the past two years. 13.9 MALE CIRCUMCISION Circumcision is a common practice in many parts of sub-Saharan Africa for traditional, health, and other reasons. Recently, male circumcision has been associated with a lower risk of HIV transmission from women to men (Williams et al., 2006; WHO and UNAIDS, 2007). To examine this practice at the national level, men interviewed in the 2010-11 ZDHS were asked whether they had been circumcised and when they were circumcised. The results are presented in Table 13.13. 202 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Table 13.13 Male circumcision Percentage of men age 15-49 who report having been circumcised, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage circumcised Number of men Age 15-24 6.5 3,107 15-19 5.3 1,735 20-24 8.1 1,372 25-29 10.6 1,236 30-39 11.2 1,798 40-49 11.5 968 Residence Urban 9.7 2,621 Rural 8.7 4,488 Province Manicaland 13.5 972 Mashonaland Central 5.9 738 Mashonaland East 5.4 667 Mashonaland West 7.4 872 Matabeleland North 13.8 349 Matabeleland South 9.6 352 Midlands 9.4 885 Masvingo 8.0 585 Harare 8.5 1,307 Bulawayo 12.1 382 Religion Traditional 13.0 280 Roman Catholic 9.2 712 Protestant 9.4 991 Pentecostal 9.6 1,030 Apostolic Sect 8.1 1,968 Other Christian 7.0 550 Muslim (78.1) 42 None 8.0 1,526 Other * 10 Total 15-49 9.1 7,110 50-54 10.8 370 Total 15-54 9.2 7,480 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Relatively few men of reproductive age in Zimbabwe report that they have been circumcised (9 percent). The greatest variations in the proportion of men who have been circumcised are observed by province. Mashonaland East has the lowest percentage of men who have been circumcised (5 percent), and Matabeleland North and Manicaland have the highest (14 percent each). 13.10 SELF-REPORTING OF SEXUALLY TRANSMITTED INFECTIONS In the 2010-11 ZDHS, respondents who had ever had sex were asked whether they had had a sexually transmitted infection or symptoms of an STI (a bad-smelling, abnormal discharge from the vagina/penis or a genital sore or ulcer) in the 12 months preceding the survey. Table 13.14 shows the self-reported prevalence of STIs and STI symptoms among both men and women. Women were somewhat more likely than men to report having had an STI or having experienced STI symptoms. Among women, in the 12 months preceding the survey, 4 percent reported that they had an STI; 6 percent had a bad-smelling, abnormal discharge; and 5 percent had a genital sore or ulcer. Among men, 3 percent reported that they had an STI; 3 percent had a bad-smelling, abnormal discharge; and 4 percent had a genital sore or ulcer. Taken together, 10 percent of women and 7 percent of men had either had an STI or symptoms of an STI during the 12 months preceding the survey. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 203 Among both women and men, the prevalence of STIs and STI symptoms was higher among those who were divorced, separated, or widowed than among those who were married and those who had never been married but were sexually active. There were variations among women in the prevalence of STIs or their symptoms by residence, education, and wealth. Women in rural areas were more likely than women in urban areas to have had an STI or STI symptoms. The prevalence of STIs or STI symptoms was highest among women in Matabeleland South (16 percent) and those in Mashonaland West and Masvingo (15 percent each); the prevalence was lowest in Bulawayo (5 percent). Women with a primary education (13 percent) and those in the three lowest wealth quintiles (12-13 percent) had the highest prevalence of STIs or STI symptoms. There was no substantial variation in the prevalence of STIs or STI symptoms among men by urban-rural residence; however, STI prevalence peaked among men in Matabeleland North (16 percent) and tended to be higher among less educated and less wealthy men. Table 13.14 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Percentage of women who reported having in the past 12 months: Number of women who ever had sexual intercourse Percentage of men who reported having in the past 12 months: Number of men who ever had sexual intercourse STI Bad smelling/ abnormal genital discharge Genital sore or ulcer STI/genital discharge/ sore or ulcer STI Bad smelling/ abnormal genital discharge Genital sore or ulcer STI/genital discharge/ sore or ulcer Age 15-24 2.4 5.6 4.0 9.2 2,226 2.9 3.5 4.3 7.6 1,431 15-19 1.4 6.6 3.6 9.2 662 1.8 4.5 4.0 8.4 428 20-24 2.8 5.3 4.1 9.2 1,564 3.4 3.1 4.5 7.2 1,003 25-29 4.2 6.4 4.5 10.5 1,626 3.0 3.9 3.6 7.0 1,153 30-39 4.2 6.3 5.2 11.0 2,309 3.6 2.3 3.5 6.4 1,770 40-49 3.3 5.1 4.4 8.9 1,348 3.2 2.0 3.9 6.6 961 Marital status Never married 2.1 4.1 3.8 5.8 539 2.0 3.2 3.4 6.5 1,430 Married/living together 3.4 5.9 4.0 9.8 5,700 3.5 2.7 3.7 6.6 3,581 Divorced/separated/ widowed 4.6 6.9 7.2 12.6 1,271 6.2 3.8 7.3 12.0 304 Circumcision Yes na na na na na 3.6 4.1 3.3 7.7 548 No na na na na na 3.2 2.8 3.9 6.8 4,767 Residence Urban 3.0 3.9 3.4 7.7 2,739 3.2 2.6 3.9 7.1 1,993 Rural 3.8 7.1 5.2 11.3 4,770 3.3 3.1 3.8 6.7 3,322 Province Manicaland 3.3 8.2 7.0 13.4 1,009 4.4 2.6 4.6 8.0 712 Mashonaland Central 3.9 6.3 4.5 10.5 753 3.6 2.5 3.3 6.5 575 Mashonaland East 3.4 2.6 4.6 7.1 696 2.2 3.3 4.1 7.4 488 Mashonaland West 5.0 9.6 6.3 14.8 870 0.8 0.7 0.7 1.2 642 Matabeleland North 2.1 2.0 2.0 3.8 383 11.7 8.6 6.2 15.5 260 Matabeleland South 6.0 11.1 10.8 15.5 385 3.6 3.3 4.9 7.6 272 Midlands 2.8 2.6 1.1 4.9 899 3.1 5.2 6.7 9.7 659 Masvingo 2.8 10.4 5.3 14.5 766 3.2 2.7 3.9 6.9 424 Harare 3.7 3.7 3.2 8.2 1,333 2.5 2.0 2.9 6.1 992 Bulawayo 1.9 2.2 1.8 4.6 416 1.2 1.6 2.6 4.5 292 Education No education 1.8 5.7 4.2 9.3 207 3.6 1.3 2.7 7.5 40 Primary 4.1 8.0 6.2 12.9 2,358 4.9 4.5 4.9 9.1 1,161 Secondary 3.3 5.2 4.0 8.9 4,595 2.7 2.5 3.8 6.6 3,653 More than secondary 2.6 2.1 0.6 4.4 350 2.6 2.2 1.3 3.7 462 Wealth quintile Lowest 3.7 8.0 5.3 11.7 1,371 4.8 4.4 4.9 8.4 856 Second 3.5 6.6 5.3 11.5 1,362 2.8 3.2 4.1 7.4 874 Middle 4.8 6.7 6.4 12.6 1,419 3.7 3.2 3.6 7.2 993 Fourth 3.7 5.7 4.1 9.3 1,710 2.4 2.4 4.2 6.6 1,263 Highest 2.0 3.1 2.1 5.8 1,647 2.9 2.0 2.6 5.5 1,330 Total 15-49 3.5 5.9 4.5 10.0 7,510 3.2 2.9 3.8 6.9 5,316 50-54 na na na na na 2.3 2.9 3.2 6.5 370 Total 15-54 na na na na na 3.2 2.9 3.8 6.8 5,685 Na = Not applicable 204 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour Nearly half of women and men who had an STI or STI symptoms sought advice or treatment from a clinic, hospital, private doctor, or other health professional (Figure 13.1). Men were more than three times as likely as women to seek treatment from a traditional healer or other source (11 percent and 3 percent, respectively). Fifty-one percent of women and 43 percent of men did not seek any treatment when they had an STI or STI symptoms. Figure 13.1 Women and Men Seeking Advice or Treatment for STIs ZDHS 2010-11 47 0 3 51 48 1 11 43 Advice or medicine from shop/pharmacy No advice or treatment 0 10 20 30 40 50 60 Percent Women Men Clinic/hospital/private doctor/other health professional Advice or treatment from traditional healer or any other source 13.11 INJECTIONS Injection overuse in a health care setting can contribute to the transmission of blood-borne pathogens because it amplifies the effect of unsafe practices such as reuse of injection equipment. To measure the potential risk of transmission of HIV associated with medical injections, ZDHS respondents were asked whether they had received any injections from a health worker in the 12 months preceding the survey and, if so, whether their last injection was administered with a syringe from a new, unopened package. It should be noted that self-administered medical injections (e.g., insulin injections for diabetes) were not included in the calculations. Table 13.15 shows the reported prevalence of injections and of safe injection practices. Women were almost twice as likely as men to report receiving an injection from a health worker during the 12 months preceding the survey (22 percent and 14 percent, respectively). Among women, the prevalence of injections was lower among those age 40-49 (17 percent) than among younger women (22-24 percent) but showed little variation by marital status or urban-rural residence. Among men, injection prevalence was highest among those age 15-19 (21 percent) and among those who had never had sex (20 percent), but there were no differences by urban-rural residence. Considerable variation was reported by province; injection prevalence among women was highest in Mashonaland Central (31 percent) and lowest in Matabeleland North (14 percent). Among men, injection HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 205 prevalence was highest in Midlands (17 percent) and lowest in Matabeleland North (8 percent). In the case of both women and men, the reported prevalence of injections in the past 12 months increased with educational attainment and wealth quintile. Table 13.15 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the past 12 months, the average number of medical injections per person in the past 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the past 12 months Percentage who received a medical injection in the past 12 months Average number of medical injections per person in the past 12 months Number of men For last injection, syringe and needle taken from a new, unopened package Number of men receiving medical injections in the past 12 months Age 15-24 22.3 0.5 3,786 98.3 843 16.3 0.7 3,107 97.5 508 15-19 22.2 0.4 1,945 98.1 431 20.6 0.7 1,735 97.2 357 20-24 22.4 0.6 1,841 98.6 412 11.0 0.8 1,372 98.3 151 25-29 23.7 0.8 1,686 98.5 399 10.3 0.6 1,236 95.9 127 30-39 22.6 0.8 2,347 98.2 531 12.5 0.7 1,798 96.9 224 40-49 17.1 0.6 1,352 97.5 231 13.4 1.0 968 99.7 129 Marital status Never married 19.9 0.5 2,197 97.8 437 16.8 0.6 3,221 97.2 541 Ever had sex 22.7 0.9 539 99.4 122 13.1 0.6 1,430 98.6 187 Never had sex 19.0 0.4 1,658 97.2 315 19.8 0.7 1,791 96.5 354 Married/living together 23.0 0.7 5,703 98.5 1,312 11.3 0.8 3,584 97.5 404 Divorced/separated/ widowed 20.1 0.9 1,271 97.5 256 14.2 0.7 304 (100.0) 43 Residence Urban 22.5 0.9 3,548 98.0 797 14.3 0.9 2,621 98.5 376 Rural 21.5 0.5 5,623 98.4 1,207 13.6 0.7 4,488 96.8 613 Province Manicaland 24.6 0.8 1,227 98.8 301 14.7 0.8 972 96.2 143 Mashonaland Central 30.6 0.9 871 99.6 267 15.0 0.6 738 99.3 110 Mashonaland East 14.9 0.3 824 98.6 123 13.5 0.7 667 96.2 90 Mashonaland West 21.6 0.6 1,026 97.3 221 13.0 0.4 872 97.2 113 Matabeleland North 14.3 0.3 443 97.0 63 7.7 3.4 349 (92.2) 27 Matabeleland South 24.4 0.5 467 97.1 114 14.0 0.3 352 95.2 49 Midlands 23.8 0.5 1,123 98.0 267 16.5 0.5 885 98.7 146 Masvingo 17.3 0.3 909 99.7 157 11.2 0.2 585 98.3 66 Harare 19.5 1.0 1,722 97.3 335 14.0 0.6 1,307 98.5 182 Bulawayo 27.8 1.4 558 98.1 155 16.1 1.1 382 97.1 61 Education No education 11.2 0.5 212 (100.0) 24 2.3 0.1 56 * 1 Primary 19.0 0.7 2,568 99.2 487 12.4 0.8 1,508 96.1 188 Secondary 23.3 0.7 5,966 97.9 1,392 14.2 0.8 5,027 97.5 716 More than secondary 23.9 1.0 424 98.5 101 16.0 0.4 519 100.0 83 Wealth quintile Lowest 18.2 0.6 1,546 98.7 282 10.6 1.0 1,074 96.4 113 Second 20.7 0.4 1,594 98.6 330 13.5 0.6 1,216 96.8 164 Middle 22.2 0.6 1,681 99.3 373 13.5 0.4 1,371 96.9 185 Fourth 22.4 0.8 2,073 99.3 464 14.3 0.7 1,664 97.8 238 Highest 24.4 0.9 2,278 96.2 556 16.1 0.9 1,786 98.4 287 Total 15-49 21.9 0.7 9,171 98.2 2,004 13.9 0.7 7,110 97.5 988 50-54 na na na na na 14.0 1.0 370 95.7 52 Total 15-54 na na na na na 13.9 0.7 7,480 97.4 1,040 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or any other health worker. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable In the past 12 months, the average number of medical injections per woman or man was less than one. Ninety-eight percent of recent injections among women and men were administered with a syringe taken from a newly opened package. More than 9 in 10 women and men in all subgroups who had had a medical injection reported that the syringe used for the last injection came from an unopened package. 206 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour 13.12 HIV/AIDS-RELATED KNOWLEDGE AND BEHAVIOUR AMONG YOUNG PEOPLE This section addresses HIV/AIDS-related knowledge among Zimbabwean young people age 15-24 and also assesses the extent to which Zimbabwean young people are engaged in behaviours that may place them at risk of contracting HIV. 13.12.1 Knowledge about HIV/AIDS and Source for Condoms Knowledge of how HIV is transmitted is crucial to enabling people to avoid HIV infection, and this is especially true for young people, who are often at greater risk because they may have shorter relationships with more partners or engage in other risky behaviours. Table 13.16 shows the level of comprehensive knowledge of HIV/AIDS among young people and the percentage of young people who know a source for condoms. As discussed earlier in the chapter, comprehensive knowledge of HIV/AIDS is defined as knowing that both condom use and limiting sexual intercourse to one uninfected partner are HIV prevention methods, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about HIV transmission. Table 13.16 shows that 52 percent of young women and 47 percent of young men have comprehensive knowledge of HIV/AIDS. Among both sexes, the proportion with comprehensive knowledge increases with age and educational attainment. Urban young people are more likely than rural young people to have comprehensive knowledge of HIV/AIDS. Table 13.16 Comprehensive knowledge about HIV/AIDS and of a source of condoms among young people Percentage of young women and young men age 15-24 with comprehensive knowledge about HIV/AIDS and percentage with knowledge of a source of condoms, by background characteristics, Zimbabwe 2010-11 Background characteristic Women age 15-24 Men age 15-24 Percentage with comprehensive knowledge of HIV/AIDS1 Percentage who know a condom source2 Number of women Percentage with comprehensive knowledge of HIV/AIDS1 Percentage who know a condom source2 Number of men Age 15-19 46.3 55.2 1,945 41.7 75.0 1,735 15-17 44.1 49.9 1,161 39.6 69.0 1,059 18-19 49.5 63.2 784 45.1 84.5 675 20-24 57.9 73.9 1,841 53.7 91.9 1,372 20-22 57.3 71.6 1,147 49.9 91.9 856 23-24 58.9 77.6 695 60.1 91.8 517 Marital status Never married 50.0 57.0 1,900 46.9 81.1 2,693 Ever had sex 56.0 79.2 344 48.9 93.6 1,017 Never had sex 48.6 52.1 1,557 45.6 73.5 1,676 Ever married 53.9 71.6 1,886 48.1 91.6 414 Residence Urban 59.1 62.8 1,512 56.5 87.9 1,069 Rural 47.2 65.3 2,275 42.1 79.6 2,038 Education No education * * 12 * * 19 Primary 36.5 60.6 836 25.2 73.1 665 Secondary 55.4 64.7 2,838 52.2 84.9 2,330 More than secondary 83.5 85.7 101 81.5 98.7 93 Total 51.9 64.3 3,786 47.0 82.5 3,107 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting HIV, knowing that a healthy- looking person can have HIV, and rejecting the two most common local misconceptions about transmission and prevention of HIV. The components of comprehensive knowledge are presented in Tables 13.2, 13.3.1, and 13.3.2. 2 For this table, the following responses are not considered a source for condoms: friends, family members, and home. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 207 Although only approximately half of young people have comprehensive knowledge of HIV/AIDS, knowledge of a source for condoms is relatively common. Sixty-four percent of young women and 83 percent of young men know a place where they can obtain a condom. 13.12.2 First Sex Age at first sex is an important indicator of exposure to risk of pregnancy and sexually transmitted infections. Young people who initiate sex at an early age are typically at higher risk of becoming pregnant or contracting an STI than young people who initiate sex later. Consistent condom use can reduce such risks. In Zimbabwe, comparatively few young women and men initiate sexual activity before age 15, with only 4 percent of those in the 15-24 age group reporting having sex before age 15 (Table 13.17). In contrast, among those age 18-24, 39 percent of young women and 25 percent of young men report having had sex by age 18. Table 13.17 Age at first sexual intercourse among young people Percentage of young women and young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and young men age 18-24 who had sexual intercourse before age 18, by background characteristics, Zimbabwe 2010-11 Background characteristic Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 3.9 1,945 na na 3.6 1,735 na na 15-17 4.6 1,161 na na 4.1 1,059 na na 18-19 2.9 784 39.4 784 2.7 675 29.7 675 20-24 3.7 1,841 38.0 1,841 4.2 1,372 22.9 1,372 20-22 3.4 1,147 39.1 1,147 5.3 856 25.2 856 23-24 4.1 695 36.4 695 2.5 517 19.1 517 Marital status Never married 1.0 1,900 12.7 904 3.7 2,693 23.8 1,635 Ever married 6.6 1,886 52.0 1,720 5.1 414 30.4 412 Knows condom source1 Yes 4.1 2,435 40.9 1,856 4.4 2,562 26.8 1,832 No 3.2 1,352 32.5 769 1.3 545 11.2 216 Residence Urban 1.5 1,512 27.0 1,099 3.9 1,069 25.2 763 Rural 5.3 2,275 46.7 1,526 3.8 2,038 25.1 1,285 Education No education * 12 * 10 * 19 * 14 Primary 11.2 836 65.0 569 6.4 665 32.4 378 Secondary 1.7 2,838 32.3 1,946 2.9 2,330 23.4 1,563 More than secondary 0.0 101 5.7 100 8.3 93 24.6 93 Total 3.8 3,786 38.5 2,625 3.9 3,107 25.2 2,048 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. As expected, the proportion of young people initiating sexual intercourse early is higher among those who have ever been married than among those who were not yet married at the time of the survey. Rural young women are much more likely than their urban counterparts to have initiated sex before age 15 or age 18, a pattern that is partly attributable to the greater prevalence of earlier marriage among rural women than urban women (see Chapter 4, Table 4.4). Among women, initiation of sexual intercourse before age 18 varies according to knowledge of a condom source; those who know a condom source are more likely than those who do not to have had sexual intercourse before age 18 (41 percent versus 33 percent). Variations by education level are 208 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour vast: approximately two-thirds of women age 18-24 with only a primary education (65 percent) had sexual intercourse before age 18, compared with 32 percent of women with at least some secondary education and just 6 percent of women with more than a secondary education. There are large variations among the proportion of young men who had sexual intercourse before age 18 by whether they know of a condom source; for example, 27 percent of men age 18-24 who know a source of condoms initiated sex before age 18, compared with 11 percent of men who do not know a condom source. The variation by education is not as pronounced as among young women; however, nearly one-third of men age 18-24 with only a primary education had sexual intercourse before age 18, as compared with one-quarter of men with at least some secondary school or more than a secondary education. Figure 13.2 examines trends in age at first sexual intercourse among young people. The percentage of young people age 15-19 who have had sex by age 15 has declined slightly since 2005-06 (from 5 percent to 4 percent among both young women and young men). In contrast, whereas 36 percent of women age 18-19 reported that they had sexual intercourse before age 18 in the 2005-06 ZDHS, this figure had increased to 39 percent in the 2010-11 ZDHS. Among young men age 18-19, however, a slight decline was observed (from 32 percent in 2005-06 to 30 percent in 2010-11). Figure 13.2 Trends in Age at First Sexual Intercourse 5 5 36 32 4 4 39 30 Women 15-19 Men 15-19 Women 18-19 Men 18-19 0 10 20 30 40 50 Percent ZDHS 2005-06 ZDHS 2010-11 Had sexual intercourse before exact age 15 Had sexual intercourse before exact age 18 13.12.3 Premarital Sex The period between age at first sex and age at marriage is often a time of sexual experimentation. Table 13.18 presents information on the patterns of sexual activity among never- married young people age 15-24 in Zimbabwe, including the percentage who have never had sexual intercourse, the percentage who engaged in sexual intercourse in the 12 months before the survey, and, among those who had sexual intercourse in the past 12 months, the percentage who used a condom during their most recent sexual encounter. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 209 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among young people Among never-married women and men age 15-24, the percentage who have never had sexual intercourse, the percentage who had sexual intercourse in the past 12 months, and, among those who had premarital sexual intercourse in the past 12 months, the percentage who used a condom at the last sexual intercourse, by background characteristics, Zimbabwe 2010-11 Background characteristic Never-married women age 15-24 Never-married men age 15-24 Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married women Among women who had sexual intercourse in the past 12 months: Percentage who have never had sexual intercourse Percentage who had sexual intercourse in the past 12 months Number of never- married men Among men who had sexual intercourse in the past 12 months: Percentage who used a condom at last sexual intercourse Number of women Percentage who used a condom at last sexual intercourse Number of men Age 15-19 88.9 8.0 1,440 39.9 115 76.2 16.0 1,716 64.5 275 15-17 93.9 4.8 996 37.5 48 85.6 9.0 1,057 52.8 95 18-19 77.8 15.1 444 41.6 67 60.9 27.3 658 70.7 180 20-24 60.0 28.5 460 56.5 131 37.8 46.3 977 77.7 453 20-22 62.7 25.9 345 54.6 89 41.3 42.3 679 73.8 287 23-24 51.6 36.4 115 (60.7) 42 29.7 55.5 298 84.6 165 Knows condom source1 Yes 74.9 18.8 1,084 53.1 204 56.4 31.4 2,183 73.7 686 No 91.3 5.2 817 27.9 42 87.2 8.0 510 (56.6) 41 Residence Urban 80.1 14.4 915 59.0 131 60.8 26.6 948 80.5 252 Rural 83.6 11.7 985 37.0 115 63.0 27.2 1,744 68.6 475 Education No education * * 4 nc 0 * * 17 * 4 Primary 75.6 17.4 268 29.7 47 58.3 31.9 565 58.0 180 Secondary 83.9 11.4 1,539 50.5 176 64.1 24.9 2,025 76.4 505 More than secondary 66.6 26.1 89 * 23 42.7 44.9 86 (94.7) 39 Total 81.9 13.0 1,900 48.8 246 62.2 27.0 2,693 72.7 727 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. nc = No cases 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Never-married young women age 15-24 are much more likely than never-married young men age 15-24 to report that they have never engaged in sexual intercourse (82 percent and 62 percent, respectively). The percentage of never-married young people who have never had sex declines rapidly with age; 94 percent of young women and 86 percent of young men age 15-17 report that they have not yet had sexual intercourse, compared with 52 percent of women age 23-24 and 30 percent of men age 23-24. Never-married young women and men who know a condom source are considerably less likely than those who do not to have never had sexual intercourse: 75 percent of young women who know a condom source have never had sexual intercourse, compared with 91 percent of young women who do not know a condom source. Similarly, 56 percent of young men who know a condom source have never had sexual intercourse, compared with 87 percent of young men who do not know a condom source. Variations in the percentages of young people who had sexual intercourse in the past 12 months by knowledge of a condom source are even more striking: 19 percent of young women and 31 percent of young men who know of a condom source had sexual intercourse in the past 12 months, compared with only 5 percent of young women and 8 percent of young men who do not know of a condom source. Overall, 27 percent of never-married young men reported that they had sexual intercourse during the 12 months preceding the survey, compared with 13 percent of never-married young women. Among never-married young people who had intercourse in the past 12 months, condom use 210 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour at last sexual intercourse was more common among young men than young women (73 percent and 49 percent, respectively). There are large differentials by background characteristics in the percentages of never- married young people using condoms during their most recent sexual intercourse in the past 12 months. Condom use at last sexual intercourse increases with age and education and, not surprisingly, is more common among those who know a condom source. Condom use at last sexual intercourse is also more common among never-married young women and young men in urban areas (59 percent and 81 percent, respectively) than among those in rural areas (37 percent and 69 percent, respectively). 13.12.4 Multiple Sexual Partners The most common means of transmission of HIV in Zimbabwe is through unprotected sex with an infected person. To prevent HIV transmission, it is important that young people practice safe sex. Tables 13.19.1 and 13.19.2 present data on the percentage of young people who had engaged in sexual intercourse with more than one partner in the 12 months before the survey and the rate of condom use at last sex. Table 13.19.1 Multiple sexual partners in the past 12 months among young people: Women Among all young women age 15-24, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months, and among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse, by background characteristics, Zimbabwe 2010-11 Background characteristic Among all women age 15-24 Among women age 15-24 who had 2+ partners in the past 12 months Percentage who had 2+ partners in the past 12 months Number of women Percentage who reported using a condom at last intercourse Number of women Age 15-19 0.9 1,945 * 17 15-17 0.6 1,161 * 7 18-19 1.3 784 * 10 20-24 1.7 1,841 (54.0) 31 20-22 1.4 1,147 * 16 23-24 2.2 695 * 15 Marital status Never married 0.8 1,900 * 15 Ever married 1.7 1,886 (36.6) 33 Knows condom source1 Yes 1.7 2,435 (38.4) 41 No 0.5 1,352 * 7 Residence Urban 1.8 1,512 * 28 Rural 0.9 2,275 * 21 Education No education * 12 * 0 Primary 1.9 836 * 16 Secondary 1.1 2,838 (52.9) 31 More than secondary 0.8 101 * 1 Total 15-24 1.3 3,786 (38.5) 48 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1For this table, the following responses are not considered a source for condoms: friends, family members, and home. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 211 Table 13.19.2 Multiple sexual partners in the past 12 months among young people: Men Among all young men age 15-24, the percentage who had sexual intercourse with more than one sexual partner in the past 12 months, and among those having more than one partner in the past 12 months, the percentage reporting that a condom was used at last intercourse, by background characteristics, Zimbabwe 2010-11 Background characteristic Among all men age 15-24 Among men age 15-24 who had 2+ partners in the past 12 months Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom at last intercourse Number of men Age 15-19 2.5 1,735 66.2 43 15-17 1.4 1,059 * 14 18-19 4.3 675 (71.7) 29 20-24 14.2 1,372 47.0 195 20-22 12.7 856 41.3 108 23-24 16.8 517 54.0 87 Marital status Never married 5.2 2,693 72.9 141 Ever married 23.5 414 18.1 98 Knows condom source1 Yes 9.2 2,562 51.0 235 No 0.6 545 * 4 Residence Urban 10.9 1,069 58.1 116 Rural 6.0 2,038 43.2 122 Education No education * 19 * 1 Primary 6.6 665 39.5 44 Secondary 7.9 2,330 52.1 184 More than secondary 10.4 93 * 10 Total 15-24 7.7 3,107 50.5 238 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Young men were much more likely than young women to report having multiple sexual partners in the 12 months preceding the survey (8 percent and 1 percent, respectively). Among young people who had ever been married, only 2 percent of young women reported having had sexual intercourse with more than one partner in the previous 12 months, compared with 24 percent of young men. The percentage of young people who reported having sexual intercourse with more than one partner in the past 12 months increased with age, although the correlation was much more profound for young men than for young women. Among young men who had multiple partners in the past 12 months, 51 percent reported that they used a condom during their most recent sexual intercourse. The number of women who had multiple partners in the last 12 months was too small to measure condom use at last sexual intercourse with confidence. 13.12.5 Age-mixing in Sexual Relationships In many societies, young women have sexual relationships with men who are considerably older than they are. This practice can contribute to the spread of HIV and other STIs because if a younger, uninfected partner has sex with an older, infected partner, this can introduce the virus into a younger, uninfected cohort. To investigate this practice, women age 15-19 who had a sexual partner in the 12 months preceding the survey were asked the age of the partner. Table 13.20 shows that in the 212 • HIV/AIDS-Related Knowledge, Attitudes, and Behaviour year preceding the survey, 15 percent of young women age 15-19 who had sexual intercourse had sex with a man 10 or more years older. Similarly, young men age 15-19 who reported that they had a sexual partner in the past 12 months were asked the age of the partner. Less than 1 percent reported having a partner 10 or more years older. Table 13.20 Age-mixing in sexual relationships among women and men age 15-19 Among women and men age 15-19 who had sexual intercourse in the past 12 months, percentage who had sexual intercourse with a partner who was 10 or more years older than themselves, by background characteristics, Zimbabwe 2010-11 Background characteristic Among women age 15-19 who had sexual intercourse in the past 12 months Among men age 15-19 who had sexual intercourse in the past 12 months Percentage who had sexual intercourse with a man 10+ years older Number of women Percentage who had sexual intercourse with a woman 10+ years older Number of men Age 15-17 15.1 205 0.0 97 18-19 15.4 372 0.5 197 Marital status Never married 4.8 115 0.4 275 Ever married 17.9 462 * 19 Knows condom source1 Yes 14.0 384 0.4 272 No 17.9 193 (0.0) 22 Residence Urban 15.8 172 1.4 73 Rural 15.1 405 0.0 221 Education No education nc 0 * 2 Primary 18.9 215 0.0 102 Secondary 13.3 361 0.5 187 More than secondary * 2 * 2 Total 15.3 578 0.3 294 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. nc = No cases 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. 13.12.6 Coverage of HIV Testing Services Seeking an HIV test may be more difficult for young people than adults because many young people lack experience in accessing health services for themselves and because there are often barriers to young people obtaining services. Table 13.21 presents data on the percentage of sexually active young people being tested and receiving the results within the past year. HIV/AIDS-Related Knowledge, Attitudes, and Behaviour • 213 Table 13.21 Recent HIV tests among young people Among young women and young men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who were tested for HIV in the past 12 months and received the results of the last test, by background characteristics, Zimbabwe 2010-11 Background characteristic Among women age 15-24 who have had sexual intercourse in the past 12 months Among men age 15-24 who have had sexual intercourse in the past 12 months Percentage who have been tested for HIV in the past 12 months and received results of the last test Number of women Percentage who have been tested for HIV in the past 12 months and received results of the last test Number of men Age 15-19 39.6 578 13.0 294 15-17 32.8 205 7.8 97 18-19 43.4 372 15.6 197 20-24 47.6 1,394 27.5 840 20-22 45.2 823 26.6 460 23-24 51.0 571 28.5 379 Marital status Never married 43.2 246 20.5 727 Ever married 45.5 1,726 29.5 406 Knows condom source1 Yes 48.1 1,444 24.7 1,061 No 37.3 528 9.3 72 Residence Urban 47.2 669 26.2 371 Rural 44.2 1,303 22.5 763 Education No education * 6 * 6 Primary 38.9 575 17.1 277 Secondary 47.5 1,358 25.4 805 More than secondary (55.0) 34 (36.0) 45 Total 45.2 1,972 23.7 1,134 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 For this table, the following responses are not considered a source for condoms: friends, family members, and home. Overall, young women are much more likely than young men to have been tested for HIV and to have received the results of the test (45 percent and 24 percent, respectively). Urban young people and those who know a condom source are more likely than other young people to have had a test and received the results. Among both young women and young men, uptake of HIV testing is correlated positively with education and age. Coverage of HIV testing services among young people has improved dramatically over the last five years. In the 2005-06 ZDHS, 7 percent of young women and 5 percent of young men were tested for HIV and received their results in the 12 months preceding the survey. HIV Prevalence • 215 HIV PREVALENCE 14 uch of the information on national HIV prevalence in Zimbabwe derives from surveillance of HIV in special populations, such as women attending antenatal clinics, individuals enrolled in research studies, and young people. However, these surveillance data results do not provide an estimate of the HIV prevalence among the general population. As part of the 2005-06 ZDHS, it was therefore decided to test a representative sample of women age 15-49 and men age 15-54. The 2005-06 ZDHS provided, for the first time, direct estimates of HIV prevalence among the general female and male populations in Zimbabwe and detailed information about HIV prevalence by age, residence, province, and other socioeconomic characteristics. In addition, HIV prevalence was analyzed according to demographic characteristics and sexual behaviour to identify factors associated with the epidemic. Given that large population-based surveys such as the ZDHS cannot be repeated every year, the 2005-06 ZDHS findings were used to calibrate estimates based on the sentinel surveillance system in order to monitor the epidemic over time on a regular basis. In order to obtain a new estimate of HIV prevalence among the general population and provide updated information on the characteristics of the epidemic, it was decided to repeat HIV testing as part of the 2010-11 ZDHS. Again, the results of this testing will be used to refine HIV prevalence estimates based on the sentinel surveillance system and allow better monitoring of the epidemic. The methodology used in conducting HIV testing as part of the 2010-11 ZDHS is described in detail in the first chapter of this report. This chapter addresses the results of the testing and provides information on HIV testing coverage rates among eligible survey respondents. It also compares HIV prevalence estimates from the 2005-06 ZDHS and 2010-11 ZDHS and discusses levels and differentials in HIV prevalence among those who were tested. M Key Findings • Fifteen percent of Zimbabwean adults age 15-49 are infected with HIV. In the 2005-06 ZDHS, the HIV prevalence rate for adults was 18 percent. Thus, the national HIV prevalence is estimated to have declined by three percentage points over the five-year period between the 2005-06 ZDHS and the 2010-11 ZDHS. • The HIV prevalence rate is 18 percent among women and 12 percent among men. Among women, HIV prevalence peaks at 29 percent in the 30-34 and 35-39 age groups; among men, HIV prevalence peaks at 30 percent in the 45-49 age group. • Among all respondents age 15-49, HIV prevalence is somewhat higher in urban areas than in rural areas (17 percent versus 15 percent). Differentials are also observed by province: Matabeleland South has the highest prevalence (21 percent) and Harare the lowest (13 percent). • HIV prevalence is higher among respondents who reported having had a sexually transmitted infection (STI) or STI symptoms in the past 12 months than among those who did not. • Men age 15-49 who were circumcised were slightly more likely to be HIV positive than those who were uncircumcised (14 percent and 12 percent, respectively). • Nearly 2,700 cohabiting couples were tested for HIV in the 2010-11 ZDHS. In 79 percent of couples, both partners were HIV negative. In 10 percent of couples, both partners were HIV positive. Eleven percent of couples were discordant, that is, one partner was infected with HIV and the other was not. 216 • HIV Prevalence 14.1 COVERAGE RATES FOR HIV TESTING Table 14.1 shows the distribution of women age 15-49 and men age 15-54 eligible for HIV testing by testing outcome. Overall, 75 percent of ZDHS respondents who were eligible for testing were both interviewed and tested. Testing coverage rates were higher among women than among men (80 percent and 69 percent, respectively). Among all respondents eligible for testing, 14 percent refused to provide blood and 8 percent were absent at the time of blood collection. Among both women and men, refusal was a larger component of nonresponse than absence. A comparison of the 2005-06 ZDHS and 2010-11 ZDHS indicates that HIV coverage rates have improved markedly, from 76 percent to 80 percent among women and from 63 percent to 69 percent among men. Table 14.1 Coverage of HIV testing by residence and province Percent distribution of women age 15-49 and men age 15-54 eligible for HIV testing by testing status, according to residence and province (unweighted), Zimbabwe 2010-11 Background characteristic Testing status Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Total Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed WOMEN 15-49 Residence Urban 69.8 0.8 16.1 3.8 2.1 4.5 2.2 0.5 100.0 3,808 Rural 86.2 0.6 6.7 0.7 1.1 2.6 1.1 0.8 100.0 6,023 Province Manicaland 82.3 1.3 9.7 1.6 0.5 2.8 1.0 0.9 100.0 1,082 Mashonaland Central 86.7 0.0 6.6 1.2 2.0 1.5 1.2 0.9 100.0 937 Mashonaland East 86.7 0.0 8.2 0.6 0.7 2.6 0.8 0.5 100.0 879 Mashonaland West 83.4 0.6 8.1 0.6 2.0 1.4 3.6 0.3 100.0 999 Matabeleland North 80.8 0.5 9.1 2.5 1.2 4.9 0.5 0.6 100.0 838 Matabeleland South 80.4 1.8 6.9 0.2 2.0 3.9 3.9 0.9 100.0 896 Midlands 86.3 0.5 8.5 1.1 0.5 2.0 0.5 0.7 100.0 1,022 Masvingo 82.9 1.3 9.3 1.0 0.9 3.0 0.8 0.8 100.0 869 Harare 73.9 0.3 13.4 5.3 1.4 4.4 1.1 0.3 100.0 1,332 Bulawayo 58.4 1.1 21.9 4.0 3.9 7.0 2.4 1.3 100.0 977 Total 79.9 0.7 10.4 1.9 1.5 3.3 1.6 0.7 100.0 9,831 MEN 15-54 Residence Urban 54.0 0.6 19.2 6.8 2.8 13.0 2.2 1.6 100.0 3,253 Rural 78.4 0.5 9.1 1.3 1.4 6.6 1.4 1.2 100.0 5,470 Province Manicaland 74.3 1.2 10.0 2.6 1.5 7.6 1.5 1.4 100.0 944 Mashonaland Central 79.5 1.0 7.4 1.3 3.0 5.3 1.9 0.6 100.0 902 Mashonaland East 75.9 0.2 12.3 1.6 1.0 7.1 0.7 1.2 100.0 829 Mashonaland West 75.6 0.5 10.6 1.5 1.9 6.2 3.1 0.6 100.0 970 Matabeleland North 65.1 0.1 12.7 5.0 1.4 13.4 0.5 1.8 100.0 740 Matabeleland South 72.8 0.9 8.5 0.9 3.0 8.2 3.9 1.7 100.0 764 Midlands 78.8 0.1 10.4 1.9 0.5 6.6 0.2 1.5 100.0 951 Masvingo 70.9 0.6 11.6 2.2 1.7 10.9 1.6 0.6 100.0 645 Harare 58.1 0.6 16.8 8.8 1.9 11.1 1.6 1.1 100.0 1,198 Bulawayo 41.7 0.3 28.6 5.9 3.5 14.7 1.8 3.6 100.0 780 Total 69.3 0.6 12.9 3.4 1.9 9.0 1.7 1.4 100.0 8,723 TOTAL (WOMEN 15-49 AND MEN 15-54) Residence Urban 62.5 0.7 17.5 5.2 2.4 8.4 2.2 1.0 100.0 7,061 Rural 82.5 0.6 7.9 1.0 1.2 4.5 1.3 1.0 100.0 11,493 Province Manicaland 78.5 1.2 9.8 2.1 0.9 5.0 1.2 1.1 100.0 2,026 Mashonaland Central 83.1 0.5 7.0 1.3 2.5 3.4 1.5 0.7 100.0 1,839 Mashonaland East 81.4 0.1 10.2 1.1 0.8 4.8 0.8 0.8 100.0 1,708 Mashonaland West 79.5 0.6 9.3 1.1 1.9 3.8 3.4 0.5 100.0 1,969 Matabeleland North 73.4 0.3 10.8 3.7 1.3 8.9 0.5 1.1 100.0 1,578 Matabeleland South 76.9 1.4 7.7 0.5 2.5 5.9 3.9 1.3 100.0 1,660 Midlands 82.7 0.3 9.4 1.5 0.5 4.2 0.4 1.1 100.0 1,973 Masvingo 77.7 1.0 10.3 1.5 1.3 6.3 1.1 0.7 100.0 1,514 Harare 66.4 0.4 15.0 7.0 1.6 7.5 1.3 0.7 100.0 2,530 Bulawayo 51.0 0.7 24.9 4.8 3.7 10.4 2.1 2.3 100.0 1,757 Total 74.9 0.6 11.5 2.6 1.7 6.0 1.6 1.0 100.0 18,554 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, that is, positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. HIV Prevalence • 217 Coverage of HIV testing among all eligible respondents was higher in rural areas (83 percent) than in urban areas (63 percent). Among provinces, coverage rates varied from a low of 51 percent in Bulawayo to a high of 83 percent in Mashonaland Central and Midlands. Bulawayo, in fact, had the lowest coverage rates for both men and women (42 percent for men and 58 percent for women). Mashonaland Central had the highest coverage rate for men (80 percent) and shared the highest coverage rate for women with Mashonaland East (87 percent). Table 14.2 shows generally uniform coverage rates for HIV testing among women across all age groups (79-82 percent). Age differentials in testing coverage were greater among men, with men age 15-19 (73 percent) and age 50-54 (74 percent) being more likely than men age 20-49 (66-70 percent) to have a test result. Among both women and men, coverage levels were lowest among those who had no education and those with more than a secondary education. Women and men in the two highest wealth quintiles had lower coverage rates than those in the three lowest wealth quintiles. Table 14.2 Coverage of HIV testing by selected background characteristics Percent distribution of women age 15-49 and men age 15-54 eligible for HIV testing by testing status, according to selected background characteristics (unweighted), Zimbabwe 2010-11 Background characteristic Testing status Number DBS tested1 Refused to provide blood Absent at the time of blood collection Other/missing2 Total Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed Inter- viewed Not inter- viewed WOMEN 15-49 Age 15-19 79.1 0.6 9.3 2.0 2.1 4.0 2.2 0.7 100.0 2,137 20-24 79.5 0.7 10.5 1.9 1.1 4.1 1.5 0.7 100.0 1,962 25-29 81.7 0.8 9.9 2.0 1.3 2.8 1.1 0.4 100.0 1,804 30-34 78.2 0.6 11.9 2.6 1.7 3.0 1.3 0.7 100.0 1,382 35-39 80.3 1.3 10.9 1.6 1.6 2.1 1.2 1.0 100.0 1,099 40-44 80.6 0.4 10.5 1.5 1.0 3.3 1.4 1.2 100.0 778 45-49 80.6 0.7 10.3 1.2 1.3 3.3 2.1 0.4 100.0 669 Education No education 67.4 3.7 10.7 1.5 1.9 1.9 3.0 10.0 100.0 270 Primary 83.4 0.8 8.9 1.0 1.0 2.4 1.7 0.7 100.0 2,787 Secondary 79.4 0.5 10.7 2.1 1.7 3.7 1.5 0.3 100.0 6,326 More than secondary 74.2 0.9 14.3 4.8 1.6 3.2 0.5 0.5 100.0 434 Missing 0.0 0.0 0.0 28.6 0.0 64.3 0.0 7.1 100.0 14 Wealth quintile Lowest 86.7 0.5 6.2 0.9 0.9 2.8 1.1 0.9 100.0 1,799 Second 85.5 0.7 7.4 0.3 1.0 3.2 1.1 0.8 100.0 1,667 Middle 85.9 0.9 7.3 0.9 1.0 2.0 1.1 1.0 100.0 1,669 Fourth 76.8 0.7 12.9 2.1 1.7 3.2 2.1 0.4 100.0 2,202 Highest 69.8 0.8 15.1 4.3 2.4 4.9 2.0 0.6 100.0 2,494 Total 79.9 0.7 10.4 1.9 1.5 3.3 1.6 0.7 100.0 9,831 MEN 15-54 Age 15-19 72.5 0.4 11.2 2.2 1.7 8.4 2.5 1.0 100.0 2,101 20-24 70.1 0.5 13.4 3.1 1.9 8.6 0.9 1.4 100.0 1,541 25-29 66.6 0.8 13.1 4.4 2.3 9.3 1.8 1.6 100.0 1,415 30-34 68.5 0.5 13.3 3.3 1.8 9.5 1.5 1.7 100.0 1,132 35-39 66.8 0.6 14.0 4.6 2.2 9.3 1.4 1.1 100.0 967 40-44 65.7 0.7 13.5 4.5 2.0 10.6 1.6 1.3 100.0 688 45-49 68.3 0.4 13.7 3.3 2.4 9.0 1.1 1.8 100.0 454 50-54 73.9 0.7 12.5 2.1 0.7 7.1 1.4 1.6 100.0 425 Education No education 56.3 3.0 11.9 5.2 1.5 5.9 0.7 15.6 100.0 135 Primary 75.4 0.8 10.2 1.4 1.7 6.8 1.6 2.1 100.0 2,128 Secondary 68.6 0.4 13.4 3.7 2.0 9.5 1.7 0.8 100.0 5,842 More than secondary 61.4 0.5 18.6 5.5 2.4 9.1 1.5 1.0 100.0 585 Missing 0.0 3.0 0.0 21.2 0.0 63.6 0.0 12.1 100.0 33 Wealth quintile Lowest 76.9 0.8 8.2 1.4 1.6 8.4 1.6 1.0 100.0 1,458 Second 77.9 0.7 8.7 1.2 1.7 6.8 1.5 1.5 100.0 1,450 Middle 76.8 0.3 10.3 1.7 1.1 7.1 1.3 1.4 100.0 1,582 Fourth 66.0 0.6 14.9 4.5 2.0 9.7 1.4 0.8 100.0 2,002 Highest 56.3 0.5 18.6 6.2 2.8 11.3 2.3 1.9 100.0 2,231 Total 69.3 0.6 12.9 3.4 1.9 9.0 1.7 1.4 100.0 8,723 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, that is, positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g., technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 218 • HIV Prevalence Additional tables describing the relationship between participation in HIV testing and characteristics related to HIV risk are presented in Appendix A (see Tables A.6-A.9). Overall, the results in Tables A.6-A.9 do not show a systematic relationship between participation in testing and variables associated with a higher risk of HIV infection. 14.2 HIV PREVALENCE 14.2.1 HIV Prevalence by Age and Sex The adult HIV prevalence observed in the 2010-11 ZDHS is 15 percent (Table 14.3). Among women age 15-49, the prevalence is 18 percent, compared with 12 percent among men age 15-49. These findings are in line with other recent estimates. For ex- ample, using data from ante-natal clinic surveillance and mathe- matical modelling, the adult pre- valence of HIV in 2009 was estimated to be 13.7 percent, with a 95 percent confidence interval of 11.9 percent to 15.0 percent (MOHCW, 2009). Among both women and men, HIV prevalence initially increases with age and then declines. For women, HIV prevalence increases from 4 percent among those age 15-19 to a peak of 29 percent in the 30-34 and 35-39 age groups before slightly declining to 23 percent among women age 45-49. For men, HIV prevalence increases from 3 percent among those age 15-19 to 30 percent among those age 45-49 and then decreases to 20 percent among those age 50-54. A comparison of the 2005-06 ZDHS and 2010-11 ZDHS HIV prevalence estimates indicates that HIV prevalence has declined from 18 percent to 15 percent among adults age 15-49. Prevalence among women has declined from 21 to 18 percent, and prevalence among men has declined from 15 to 12 percent. As shown in Figure 14.1, the 95 percent confidence intervals (CIs) for the 2005-06 and 2010-11 HIV prevalence estimates for all adults age 15-49 (16.9-19.3 and 14.3-16.1, respectively) do not overlap. Thus, the decline in HIV prevalence observed between the two surveys is statistically significant. By sex, the declines are statistically significant among women; however, among men, the confidence intervals for the 2005-06 and 2010-11 HIV prevalence estimates overlap slightly. For women, the 95 percent confidence interval is 16.6-18.8 compared with 19.6-22.6 reported in 2005-06. For men, the 95 percent confidence interval is 11.3-13.3 compared with 13.2-15.9 reported in 2005-06 ZDHS. Table 14.3 HIV prevalence by age Among de facto women age 15-49 and men age 15-54 who were interviewed and tested, the percentage HIV positive, by age, Zimbabwe 2010-11 Age Women Men Total Percent- age HIV positive Number Percent- age HIV positive Number Percent- age HIV positive Number 15-19 4.2 1,553 3.4 1,569 3.8 3,121 20-24 10.6 1,463 3.8 1,204 7.5 2,667 25-29 20.1 1,354 10.3 1,082 15.8 2,437 30-34 29.0 1,010 17.3 845 23.7 1,855 35-39 29.1 843 25.2 710 27.3 1,554 40-44 25.7 588 26.2 506 25.9 1,094 45-49 22.5 501 29.9 333 25.5 834 50-54 na na 19.5 334 na na Total 15-49 17.7 7,313 12.3 6,250 15.2 13,563 Total 15-54 na na 12.7 6,584 na na na = Not applicable HIV Prevalence • 219 18.1 15.2 21.1 17.7 14.5 12.3 10 12 14 16 18 20 22 24 Total 2005-06 ZDHS Total 2010-11 ZDHS Women 2005-06 ZDHS Women 2010-11 ZDHS Men 2005-06 ZDHS Men 2010-11 ZDHS Percent Figure 14.1 HIV Prevalence among All Adults Age 15-49, and by Sex, Zimbabwe 2005-06 and 2010-11 Midpoint of 95% CI ZDHS 2010-11 The HIV prevalence estimate for the 15-19 age group is assumed to represent new infections and therefore serves as a proxy for HIV incidence among young people. A comparison of HIV prevalence estimates in the 15-19 age group between the 2005-06 ZDHS and the 2010-11 ZDHS reveals a small decline in prevalence (5 percent in 2005-06 versus 4 percent in 2010-11). This decline is entirely due to a decrease in HIV prevalence among young women (6 percent in 2005-06 versus 4 percent in 2010-11); HIV prevalence among young men did not change between the 2005-06 ZDHS and the 2010-11 ZDHS (3 percent in each). 14.2.2 HIV Prevalence by Other Socioeconomic Characteristics Table 14.4 shows the variation in HIV prevalence among women and men age 15-49 by socioeconomic characteristics. HIV prevalence is higher among individuals who are employed (17 percent) than among those who are not employed (13 percent) and is modestly higher in urban areas than rural areas (17 percent and 15 percent, respectively). Differentials by province, on the other hand, are large. Matabeleland South has the highest prevalence estimate (21 percent), followed by Bulawayo (19 percent). Harare has the lowest prevalence estimate (13 percent), followed by Mashonaland Central, Manicaland, and Masvingo (14 percent). 220 • HIV Prevalence Table 14.4 HIV prevalence by socioeconomic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by socioeconomic characteristics, Zimbabwe 2010-11 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Religion Traditional 17.1 49 16.3 283 16.5 332 Roman Catholic 19.8 607 12.7 615 16.2 1,221 Protestant 19.2 1,203 10.2 877 15.4 2,080 Pentecostal 15.8 1,500 10.4 855 13.8 2,355 Apostolic Sect 17.0 2,843 11.0 1,733 14.7 4,576 Other Christian 18.7 607 10.7 467 15.2 1,074 Muslim (25.7) 36 (20.0) 36 22.8 72 None 20.0 466 15.7 1,379 16.8 1,845 Other * 2 * 5 * 7 Employment (past 12 months ) Not employed 15.0 4,223 9.1 1,976 13.1 6,199 Employed 21.4 3,090 13.8 4,274 17.0 7,363 Residence Urban 19.6 2,297 13.1 1,866 16.7 4,163 Rural 16.8 5,015 12.0 4,384 14.6 9,399 Province Manicaland 17.9 1,005 9.8 886 14.1 1,891 Mashonaland Central 15.1 768 12.3 713 13.7 1,480 Mashonaland East 17.8 740 13.2 660 15.7 1,401 Mashonaland West 17.8 863 11.5 819 14.8 1,682 Matabeleland North 20.2 353 16.1 304 18.3 657 Matabeleland South 22.7 407 19.3 333 21.2 739 Midlands 17.4 939 13.0 814 15.4 1,752 Masvingo 16.3 757 11.8 525 14.4 1,282 Harare 16.7 1,122 9.3 919 13.4 2,041 Bulawayo 21.1 360 16.5 277 19.1 637 Education No education 15.2 168 15.8 50 15.4 218 Primary 20.1 2,156 13.6 1,402 17.6 3,559 Secondary 16.9 4,688 12.1 4,402 14.6 9,090 More than secondary 13.7 300 9.3 396 11.2 696 Wealth quintile Lowest 17.1 1,375 14.7 1,040 16.1 2,415 Second 16.3 1,411 12.2 1,200 14.5 2,611 Middle 19.9 1,457 12.0 1,296 16.2 2,753 Fourth 19.7 1,527 11.6 1,383 15.8 2,910 Highest 15.5 1,544 11.5 1,330 13.7 2,874 Total 15-49 17.7 7,313 12.3 6,250 15.2 13,563 50-54 na na 19.5 334 na na Total 15-54 na na 12.7 6,584 na na Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable The HIV prevalence estimate for Harare in the 2005-06 ZDHS was above 19 percent, which, at the time, made it the province with the third highest HIV prevalence. The finding in the 2010-11 ZDHS that Harare has the lowest HIV prevalence estimate among the provinces therefore warrants further inspection. According to the 2010-11 ZDHS, the prevalence of HIV in Harare is 17 percent among women and 9 percent among men. In contrast, in the 2005-06 ZDHS, the prevalence of HIV in Harare was 21 percent among women and 17 percent among men. Thus, although HIV prevalence has declined among both sexes, the decline has been far greater among men than women (an 8 percentage point decline for men versus a 4 percentage point decline for women). Only 66 percent of 2010-11 ZDHS respondents in Harare were tested for HIV (74 percent of female respondents and 58 percent of male respondents), making it possible that these relatively low testing coverage rates, especially among men, have led to an underestimate of HIV prevalence in Harare. Notably, however, HIV testing coverage rates in Harare were markedly lower in 2005-06 than in 2010-11 (62 percent of female respondents and 46 percent of male respondents were tested for HIV in the 2005-06 ZDHS), and thus the observed decline may reflect reality. HIV Prevalence • 221 Among men age 15-49 who were tested, HIV prevalence declined as educational level increased, from 16 percent among those with no education to 9 percent among those with more than a secondary education. Among women who were tested, HIV prevalence did not vary in a consistent fashion, with the lowest estimate found among those with more than a secondary education (14 percent) and the highest found among those with only a primary education (20 percent). Among men, HIV prevalence is inversely correlated with wealth; prevalence decreases from 15 percent in the lowest wealth quintile to 12 percent in the highest. Among women, variations in HIV prevalence by wealth quintile do not exhibit a clear pattern, with the lowest rate found in the second and highest quintiles (16 percent) and the highest observed in the third and fourth quintiles (20 percent). 14.2.3 HIV Prevalence by Other Sociodemographic and Health Characteristics Table 14.5 shows that marital status and HIV prevalence are related, with the highest infection rates among widows (56 percent) and widowers (61 percent). One in three women and men who were divorced or separated were HIV positive, compared with around one in six of those who were currently married or living with a partner. Among never-married women who reported that they had ever had sexual intercourse, 20 percent were HIV positive, compared with 5 percent among never-married men who had ever had sexual intercourse. A sizeable proportion (4 percent) of respondents who said they had never had sex were HIV positive, indicating that some women and men failed to report sexual activity or that there is some degree of nonsexual transmission of HIV. Among women and men age 15-49 who were tested, those in polygynous unions were more likely to be HIV positive than those in non-polygynous unions (20 percent versus 16 percent). Notably, however, when examined by sex, the pattern becomes more complex. Whereas women in polygynous unions are more likely than those in non-polygynous unions to be HIV positive (21 percent versus 15 percent), the opposite is true for men: 16 percent of men in polygnynous unions are HIV positive, compared with 18 percent in non-polygynous unions. The likelihood of HIV infection was higher among respondents who slept away from home five or more times during the 12-month period before the survey than among those who had been away less frequently or not at all, but differences between groups were small. HIV prevalence also differed only modestly between respondents who had spent more than one month away in the 12-month period and those who had been away for a shorter period or not at all. Women who were pregnant at the time of the survey had a lower HIV infection rate than those who were not pregnant or who were unsure of their pregnancy status (12 percent and 18 percent, respectively). HIV prevalence was lower among women who received antenatal care (ANC) for their last birth in the three-year period preceding the survey (15 percent) than among those who had no ANC or did not give birth in the period (19 percent) regardless of whether ANC was provided through the public sector or another source. HIV prevalence was slightly higher among men who reported that they had been circumcised than among those who reported that they had not been circumcised (14 percent and 12 percent, respectively). The relationship between circumcision and HIV prevalence is discussed further in Section 14.5. 222 • HIV Prevalence Table 14.5 HIV prevalence by demographic characteristics Percentage HIV positive among women and men age 15-49 who were tested, by demographic characteristics, Zimbabwe 2010-11 Demographic characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Marital status Never married 7.6 1,694 4.0 2,845 5.3 4,539 Ever had sexual intercourse 19.8 428 4.5 1,274 8.4 1,702 Never had sexual intercourse 3.5 1,266 3.6 1,571 3.5 2,837 Married/living together 16.1 4,569 17.7 3,131 16.8 7,701 Divorced or separated 29.0 582 31.2 217 29.6 799 Widowed 55.8 467 60.7 56 56.3 523 Type of union In polygynous union 20.9 503 15.8 133 19.9 636 In non-polygynous union 15.2 3,882 17.8 2,998 16.3 6,881 Not currently in union 20.3 2,744 6.9 3,118 13.2 5,862 In union, polygyny status unknown 21.8 184 nc 0 na na Times slept away from home in past 12 months None 17.2 3,027 12.3 2,965 14.8 5,992 1-2 17.0 2,094 10.2 1,234 14.5 3,328 3-4 17.8 914 13.3 649 15.9 1,563 5+ 20.1 1,278 13.7 1,401 16.8 2,679 Time away in past 12 months Away for more than 1 month 18.2 1,187 12.7 999 15.7 2,186 Away for less than 1 month 18.0 3,099 12.1 2,285 15.5 5,384 Not away 17.2 3,027 12.3 2,965 14.8 5,992 Pregnancy status Pregnant 11.9 607 na na na na Not pregnant or not sure 18.2 6,706 na na na na ANC for last birth in the last 3 years ANC provided by the public sector 14.7 2,196 na na na na ANC provided by other than the public sector 14.8 287 na na na na No ANC/no birth in last 3 years 19.2 4,829 na na na na Male circumcision Circumcised na na 14.1 556 na na Not circumcised na na 12.2 5,650 na na Don’t know na na (7.3) 43 na na Total 15-49 17.7 7,313 12.3 6,250 15.2 13,563 50-54 na na 19.5 334 na na Total 15-54 na na 12.7 6,584 na na Note: Total includes 1 case for which information on ANC is missing. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable nc = No cases 14.2.4 HIV Prevalence by Sexual Risk Behaviour Several recent studies have suggested that the declines in HIV prevalence in Zimbabwe since the peak of the epidemic in the late 1990s are due in part to changes in sexual behaviour (Gregson et al., 2010; Halperin et al., 2011). Table 14.6 presents HIV prevalence rates by sexual behaviour characteristics among respondents who have ever had sexual intercourse. In reviewing these results, it is important to remember that responses about sexual risk behaviours may be subject to reporting bias. Also, sexual behaviour in the 12 months preceding the survey may not adequately reflect lifetime sexual risk. Nor is it possible to know the sequence of events (e.g., whether any reported condom use occurred before or after HIV transmission). HIV Prevalence • 223 Table 14.6 HIV prevalence by sexual behaviour Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by sexual behaviour characteristics, Zimbabwe 2010-11 Sexual behaviour characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age at first sexual intercourse <16 22.7 1,010 14.6 506 20.0 1,516 16-17 20.3 1,732 15.5 845 18.8 2,578 18-19 19.9 1,489 16.0 1,166 18.2 2,655 20+ 19.2 1,447 14.1 2,020 16.2 3,467 Don’t know/missing 26.0 366 26.2 140 26.0 506 Multiple sexual partners and partner concurrency in past 12 months 0 33.4 974 10.5 424 26.4 1,398 1 18.0 4,907 15.8 3,563 17.1 8,470 2+ 34.0 79 14.9 638 17.0 717 Had concurrent partners1 * 20 13.6 231 13.5 251 None of the partners were concurrent 41.7 59 15.7 407 18.9 466 Missing 18.3 84 20.3 52 19.0 136 Condom use at last sexual intercourse in past 12 months Used condom 41.4 701 19.4 1,140 27.8 1,841 Did not use condom 14.5 4,285 14.3 3,061 14.4 7,346 No sexual intercourse in last 12 months 32.2 1,058 11.6 477 25.8 1,534 Number of lifetime partners 1 12.1 3,867 4.0 866 10.6 4,733 2 32.2 1,345 12.3 830 24.6 2,176 3-4 40.6 608 13.8 1,249 22.6 1,858 5-9 46.9 137 20.6 983 23.8 1,119 10+ 40.6 62 27.2 544 28.6 606 Don’t know (52.8) 24 25.9 206 28.7 230 Paid for sexual intercourse in past 12 months Yes na na 13.4 183 na na Used condom na na 14.2 161 na na Did not use condom na na * 22 na na No/no sexual intercourse in past 12 months na na 15.3 4,494 na na Total 15-49 20.7 6,044 15.2 4,677 18.3 10,721 50-54 na na 19.5 333 na na Total 15-54 na na 15.5 5,011 na na Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives.) Table 14.6 shows a decrease in HIV prevalence with increasing age at sexual debut among women who ever had sex. HIV prevalence was 23 percent among women who first had sexual intercourse before age 16 and 19 percent among women who first had sexual intercourse at age 20 or older. Among men who had ever had sex, there was no clear correlation between HIV prevalence and age at first sexual intercourse. The association of HIV prevalence with multiple sexual partners and partner concurrency was also examined in the 2010-11 ZDHS. A respondent was considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. Among men, this included those who had overlapping sexual partnerships with two or more wives. HIV prevalence was higher among men who had one or more sexual partners in the past 12 months (15-16 percent) than among those who had no sexual partners in the past 12 months (11 percent). However, HIV prevalence was slightly lower among men who had concurrent partners (14 percent) than among those who did not (16 percent). 224 • HIV Prevalence Among women, HIV prevalence was higher among those who had no sexual partners (33 percent) or two or more sexual partners (34 percent) in the past 12 months than among those who had only one partner in the past 12 months (18 percent). Due to the small number of women who had more than one partner in the past 12 months, it was not possible to compare the relationship between partner concurrency and HIV prevalence. Among both women and men, there was a marked increase in the likelihood of being HIV infected with increasing number of lifetime partners. For example, 4 percent of men who had had only one sexual partner in their lifetime were HIV positive, compared with 27 percent of men with 10 or more lifetime sexual partners. Likewise, 12 percent of women who had had only one sexual partner in their lifetime were HIV positive, as compared with more than 40 percent of women with three or more lifetime sexual partners. Table 14.6 also shows that condom use at last sexual intercourse was linked to HIV status among both women and men. Women who used a condom during their most recent sexual intercourse in the 12-month period before the survey were nearly three times as likely to be HIV positive as those who did not use a condom during their last sexual intercourse (41 percent and 15 percent, respectively). Although the difference in HIV prevalence was less extreme than for women, men who used a condom during their most recent sexual intercourse in the 12-month period before the survey were also more likely to be infected than men who did not use a condom (19 percent and 14 percent, respectively). One possible explanation for this pattern is that HIV-positive respondents are more likely to use condoms because they either know or suspect that they are infected with HIV and use condoms to prevent transmission (rather than to avoid being infected). The HIV prevalence estimate among men involved in a paid sexual encounter during the 12 months before the survey is 13 percent. However, the number of men who paid for sex and did not use a condom is too small to enable a comparison of HIV prevalence with those who paid for sex and used a condom. In summary, the results presented in Table 14.6 do not demonstrate a consistent relationship between sexual risk behaviour and HIV prevalence. More detailed analysis is clearly necessary to understand these relationships because they are often confounded by other factors that are associated with both behavioural measures and HIV prevalence such as age, marital status, and residence. 14.3 HIV PREVALENCE AMONG YOUNG PEOPLE Young people in the 15-24 age range are an important group for monitoring reduction of HIV incidence in the population as specified in the United Nations General Assembly Special Session (UNGASS) on HIV and AIDS, whose principal objective is to decrease the infection rate among individuals age 15-24. Table 14.7 shows that 6 percent of respondents age 15-24 (7 percent of young women and 4 percent of young men) are HIV positive. The HIV prevalence among young adults who have never had sex (3 percent) suggests that there may be other underlying determinants of HIV transmission that will need to be targeted in order to reduce the incidence of HIV in this population. It may also reflect underreporting of sexual activity among young people. HIV Prevalence • 225 Table 14.7 HIV prevalence among young people by background characteristics Percentage HIV positive among women and men age 15-24 who were tested for HIV, by background characteristics, Zimbabwe 2010-11 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Age 15-19 4.2 1,553 3.4 1,569 3.8 3,121 15-17 3.6 927 2.7 947 3.1 1,874 18-19 5.2 626 4.4 622 4.8 1,248 20-24 10.6 1,463 3.8 1,204 7.5 2,667 20-22 8.6 892 3.1 754 6.1 1,646 23-24 13.6 571 5.2 450 9.9 1,021 Marital status Never married 5.2 1,483 3.2 2,409 4.0 3,892 Ever had sex 14.3 282 3.0 932 5.6 1,214 Never had sex 3.1 1,201 3.4 1,477 3.3 2,679 Married/living together 8.4 1,346 4.1 324 7.6 1,669 Divorced/separated/ widowed 15.7 187 (21.1) 40 16.7 227 Currently pregnant Pregnant 8.7 279 na na na na Not pregnant or not sure 7.2 2,737 na na na na Residence Urban 9.0 1,006 4.5 787 7.0 1,793 Rural 6.5 2,010 3.2 1,986 4.8 3,995 Province Manicaland 4.5 411 2.2 390 3.4 801 Mashonaland Central 6.6 299 3.9 319 5.2 617 Mashonaland East 8.6 287 5.5 299 7.0 586 Mashonaland West 6.3 337 2.5 343 4.4 680 Matabeleland North 10.4 135 6.6 143 8.5 278 Matabeleland South 11.2 190 7.2 185 9.2 375 Midlands 6.7 405 2.9 370 4.9 774 Masvingo 6.3 295 2.6 220 4.7 515 Harare 8.2 486 2.9 378 5.9 864 Bulawayo 8.8 171 2.1 128 5.9 299 Education No education * 9 * 18 (11.2) 27 Primary 9.3 687 3.2 626 6.4 1,313 Secondary 6.8 2,246 3.5 2,060 5.2 4,306 More than secondary 3.2 73 7.0 69 5.0 142 Wealth quintile Lowest 7.0 520 3.1 396 5.3 916 Second 6.2 575 3.1 565 4.6 1,140 Middle 7.3 613 3.7 640 5.4 1,253 Fourth 9.0 615 4.3 633 6.6 1,247 Highest 7.0 693 3.6 540 5.5 1,233 Total 15-24 7.3 3,016 3.6 2,773 5.5 5,789 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable Young people living in urban areas are somewhat more likely to be infected than those in rural areas. Among young women, Matabeleland South (11 percent) has the highest HIV prevalence and Manicaland the lowest (5 percent). Among young men, HIV prevalence is highest in Matabeleland North and Matabeleland South (7 percent each) and lowest in Bulawayo and Manicaland (2 percent each). Results by marital status show that HIV prevalence was greatest among the comparatively small numbers of young women and men who were widowed, divorced, or separated. The lowest prevalence estimates were found among young people who had not yet married (5 percent among never-married young women and 3 percent among never-married young men). However, the prevalence estimate among never-married young women who had ever had sex was higher than the estimate among their married counterparts (14 percent and 8 percent, respectively). 226 • HIV Prevalence Table 14.8 shows HIV prevalence among young people by sexual behaviour. As was the case for women and men age 15-49 who had ever had sex, the variations in HIV prevalence according to the measures of sexual behaviour included in Table 14.8 are difficult to interpret. Among young women who had ever had sex, those who had no partners in the past 12 months were more likely to be HIV positive than those who had one partner. The opposite was true for young men. Among both young women and young men, there were too few cases of respondents having concurrent partners to make inferences about the relationship between partner concurrency and HIV status. Condom use also has an inconsistent relationship with HIV prevalence among young people. Table 14.8 HIV prevalence among young people by sexual behaviour Percentage HIV positive among women and men age 15-24 who have ever had sex and were tested for HIV, by sexual behaviour, Zimbabwe 2010-11 Sexual behaviour characteristic Women Men Total Per- centage HIV positive Number Per- centage HIV positive Number Per- centage HIV positive Number Multiple sexual partners and partner concurrency in the past 12 months 0 13.4 183 1.4 246 6.6 429 1 9.3 1,556 4.4 838 7.6 2,395 2+ (31.1) 39 4.8 197 9.1 236 Had concurrent partners1 * 7 (0.0) 37 (0.0) 43 None of the partners were concurrent (37.6) 32 5.9 160 11.2 193 Condom use at last sexual intercourse in past 12 months Used condom 17.0 190 3.7 546 7.1 736 Did not use condom 8.9 1,406 5.2 489 7.9 1,895 No sexual intercourse in past 12 months 11.9 216 1.4 260 6.1 477 Total 10.1 1,812 3.8 1,296 7.5 3,108 Notes: Total includes 33 women and 14 men for whom information on multiple sexual partners and partner concurrency in the past 12 months is missing. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives.) 14.4 HIV PREVALENCE BY OTHER CHARACTERISTICS RELATED TO HIV RISK Table 14.9 presents HIV prevalence by other characteristics related to HIV risk among women and men age 15-49 who have ever had sex. The table shows that women and men with a history of a sexually transmitted infection (STI) or STI symptoms have much higher rates of HIV infection than those with no history or symptoms. Table 14.9 HIV prevalence by other characteristics Percentage HIV positive among women and men age 15-49 who ever had sex and were tested for HIV, by whether had an STI in the past 12 months and by prior testing for HIV, Zimbabwe 2010-11 Background characteristic Women Men Total Percentage HIV positive Number Percentage HIV positive Number Percentage HIV positive Number Sexually transmitted infection in past 12 months Had STI or STI symptoms 32.9 641 27.1 334 30.9 975 No STI, no symptoms 19.2 5,366 14.4 4,333 17.0 9,699 Prior HIV testing Ever tested 22.0 4,252 18.5 2,192 20.8 6,444 Received results 22.0 4,115 18.6 2,057 20.9 6,172 Did not receive results 22.4 137 17.0 135 19.7 272 Never tested 17.6 1,792 12.3 2,485 14.5 4,277 Total 15-49 20.7 6,044 15.2 4,677 18.3 10,721 Notes: Total includes 36 women and 10 men for whom information on sexually transmitted infections in the past 12 months is missing. HIV Prevalence • 227 The table also shows that individuals who had been tested for HIV previously were more likely to be HIV positive than those who had never been tested (21 percent and 15 percent, respectively). Among men but not women who had been tested previously, the HIV infection rate was higher among those who reported that they had received the result from their last test than among those who reported that they had not received the result. Table 14.10 provides further information about the relationship between prior HIV testing and the actual HIV status of respondents. The results show that the majority of individuals who are HIV positive have been tested previously and received the result of their last test. Sixty-three percent of infected respondents (71 percent of infected women and 51 percent of infected men) received the result of their last HIV test. This represents a vast increase from the 2005-06 ZDHS, in which only 26 percent of infected women and 19 percent of infected men who had been previously tested reported that they had received the result of their last test. However, 36 percent of HIV-positive respondents have never been tested or have not received the results of their last test and therefore do not know that they can transmit HIV if they have unprotected sex. Table 14.10 Prior HIV testing by current HIV status Percent distribution of women and men age 15-49 who tested HIV positive and who tested HIV negative by HIV testing status prior to the survey, Zimbabwe 2010-11 HIV testing prior to the survey Women Men Total HIV positive HIV negative HIV positive HIV negative HIV positive HIV negative Previously tested Received result of last test 71.0 55.9 51.4 34.2 63.7 45.6 Did not receive result of last test 2.6 2.3 3.3 2.4 2.9 2.3 Not previously tested 25.0 39.6 45.3 63.4 32.6 50.9 Missing 1.4 2.2 0.0 0.0 0.9 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,295 6,018 769 5,481 2,064 11,499 14.5 MALE CIRCUMCISION AND HIV PREVALENCE Male circumcision is assumed to reduce the risk of HIV infection, in part because of physiological differences that decrease the susceptibility to HIV infection among circumcised men. Several recent studies in sub-Saharan Africa, including clinical trials conducted in South Africa, Kenya, and Uganda (Auvert et al., 2005; NIAID, 2006), have documented that the protective effect of male circumcision is significant. Table 14.11 presents data on the relationship between HIV prevalence and male circumcision among the 5,650 men age 15-49 who were tested for HIV in the survey and who responded to the question about their circumcision status. The table shows that men who reported being circumcised had a slightly higher infection rate than uncircumcised men (14 percent and 12 percent, respectively). In general, the relationship between male circumcision and HIV prevalence according to the background characteristics shown in Table 14.11 conforms to the national pattern (i.e., circumcised men are more likely to be HIV infected than uncircumcised men). 228 • HIV Prevalence Table 14.11 HIV prevalence by male circumcision Among men age 15-49 who were tested for HIV, the percentage HIV positive by whether circumcised, according to background characteristics, Zimbabwe 2010-11 Background characteristic Circumcised Uncircumcised Percentage HIV positive Number of men Percentage HIV positive Number of men Age 15-19 5.4 83 3.3 1,466 20-24 1.3 96 4.1 1,098 25-29 9.0 109 10.5 970 30-34 18.3 80 17.1 763 35-39 22.0 90 25.8 616 40-44 (27.3) 55 26.0 450 45-49 (31.0) 44 29.7 289 Religion Traditional (13.5) 39 16.9 243 Roman Catholic (16.8) 51 12.3 563 Protestant 14.8 79 9.8 793 Pentecostal 8.9 88 10.6 766 Apostolic Sect 12.6 140 10.9 1,573 Other Christian (21.5) 30 9.9 431 Muslim (20.3) 29 * 7 None 15.2 100 15.9 1,269 Other nc 0 * 5 Residence Urban 17.1 178 12.7 1,678 Rural 12.7 378 11.9 3,972 Province Manicaland 8.2 128 10.1 756 Mashonaland Central (16.0) 44 12.1 660 Mashonaland East (8.7) 34 13.5 625 Mashonaland West 23.4 55 10.8 754 Matabeleland North 20.8 38 15.2 262 Matabeleland South 24.3 32 19.0 294 Midlands 15.3 71 12.8 743 Masvingo (7.4) 37 12.2 485 Harare 13.9 88 8.9 824 Bulawayo (12.2) 28 17.1 248 Education No education * 4 (16.1) 44 Primary 12.8 132 13.6 1,251 Secondary 15.4 374 11.9 4,006 More than secondary (6.6) 46 9.6 349 Wealth quintile Lowest 12.7 100 14.9 930 Second 11.0 84 12.3 1,105 Middle 10.4 107 12.2 1,182 Fourth 17.3 134 11.0 1,238 Highest 16.9 132 11.0 1,196 Total 15-49 14.1 556 12.2 5,650 50-54 (22.8) 33 19.1 300 Total 15-54 14.6 589 12.5 5,951 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. nc = No cases 14.6 HIV PREVALENCE AMONG COUPLES A total of 2,675 cohabiting couples were tested for HIV in the 2010-11 ZDHS. The results shown in Table 14.12 indicate that, among 79 percent of cohabiting couples, both partners tested negative for HIV. Both partners were HIV positive in 10 percent of cohabiting couples, while 11 percent of couples were discordant, that is, one partner was infected and the other was not. In 7 percent of couples, the male partner was infected and the woman was not, while in less than 5 percent of couples, the woman was infected and the man was not. HIV Prevalence • 229 Table 14.12 HIV prevalence among couples Percent distribution of couples living in the same household, both of whom were tested for HIV, by HIV status, according to background characteristics, Zimbabwe 2010-11 Background characteristic Both HIV positive Man HIV positive, woman HIV negative Woman HIV positive, man HIV negative Both HIV negative Total Number Woman's age 15-19 2.2 5.5 1.6 90.7 100.0 216 20-29 8.9 5.6 3.6 81.9 100.0 1,273 30-39 14.0 8.4 6.6 71.0 100.0 848 40-49 11.5 7.3 4.6 76.6 100.0 337 Man's age 15-19 * * * * 100.0 11 20-29 5.2 3.7 3.1 88.0 100.0 816 30-39 12.1 6.6 4.6 76.6 100.0 1,072 40-49 14.3 11.7 6.6 67.4 100.0 578 50-54 10.8 5.3 3.4 80.4 100.0 197 Age difference between partners Woman older 10.2 7.0 12.7 70.1 100.0 136 Same age/man older by 0-4 years 8.2 5.3 4.1 82.4 100.0 1,066 Man older by 5-9 years 10.7 6.9 3.4 78.9 100.0 1,031 Man older by 10-14 years 12.4 8.9 5.6 73.1 100.0 327 Man older by 15+ years 20.6 11.4 4.6 63.4 100.0 114 Type of union Non-polygynous 10.2 6.8 4.1 78.9 100.0 2,381 Polygynous 12.2 6.1 7.2 74.6 100.0 202 Don’t know 8.7 5.9 8.8 76.6 100.0 91 Multiple partners in past 12 months1 Both no 10.3 6.7 4.5 78.5 100.0 2,239 Man yes, woman no 10.6 7.2 3.6 78.6 100.0 375 Woman yes, man no * * * * 100.0 11 Both yes * * * * 100.0 1 Either missing (8.0) (6.2) (5.0) (80.7) 100.0 48 Concurrent sexual partners in past 12 months2 Both no 10.2 6.8 4.5 78.4 100.0 2,480 Man yes, woman no 11.7 5.3 3.9 79.1 100.0 193 Woman yes, man no * * * * 100.0 1 Both yes * * * * 100.0 1 Residence Urban 12.8 5.9 3.9 77.4 100.0 688 Rural 9.4 7.0 4.7 78.9 100.0 1,986 Province Manicaland 10.2 5.3 4.0 80.5 100.0 368 Mashonaland Central 8.2 5.9 4.5 81.3 100.0 378 Mashonaland East 10.2 8.0 5.6 76.2 100.0 277 Mashonaland West 8.2 8.0 6.7 77.2 100.0 398 Matabeleland North 11.1 11.2 6.3 71.5 100.0 115 Matabeleland South 12.4 13.5 10.7 63.4 100.0 80 Midlands 13.5 6.5 2.2 77.8 100.0 384 Masvingo 10.8 6.5 2.5 80.2 100.0 258 Harare 8.6 3.9 3.0 84.6 100.0 348 Bulawayo 20.9 7.4 7.0 64.7 100.0 69 Woman's education No education 3.4 6.1 5.2 85.3 100.0 61 Primary 9.3 7.1 4.9 78.6 100.0 932 Secondary 11.3 6.6 4.2 77.8 100.0 1,604 More than secondary 6.8 5.1 3.7 84.5 100.0 77 Man's education No education (6.6) (7.8) (0.0) (85.5) 100.0 30 Primary 10.9 7.1 5.0 77.0 100.0 704 Secondary 10.4 6.9 4.4 78.3 100.0 1,756 More than secondary 8.1 3.5 3.9 84.5 100.0 184 Wealth quintile Lowest 10.6 5.7 3.2 80.5 100.0 604 Second 7.7 8.9 4.5 78.9 100.0 558 Middle 11.5 7.8 5.4 75.3 100.0 521 Fourth 11.8 5.1 4.9 78.2 100.0 558 Highest 9.9 6.1 4.7 79.3 100.0 433 Total couples 10.3 6.7 4.5 78.5 100.0 2,675 Notes: The table is based on couples for which a valid test result (positive or negative) is available for both partners. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 A respondent is considered to have had multiple sexual partners in the past 12 months if he or she had sexual intercourse with two or more people during this time period. (Respondents with multiple partners include polygynous men who had sexual intercourse with two or more wives.) 2 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives.) 230 • HIV Prevalence The percentage of couples in which both the man and the woman are HIV negative is lowest in couples in which the man is age 40-49 (67 percent) and the man is older than his partner by 15 or more years (63 percent). In this latter group, both partners are HIV positive in 21 percent of couples. The percentage of couples in which the man and woman are both HIV negative is strikingly lower in Matabeleland South (63 percent) and Bulawayo (65 percent) than in other provinces (72-85 percent). In Matabeleland South, the breakdown is fairly even: in 12 percent of couples, both partners are HIV positive; in 14 percent of couples, the male partner is infected and the female partner is not; and in 11 percent of couples, the female partner is infected and the male partner is not. The pattern in Bulawayo is different: in 21 percent of couples, both partners are HIV positive; in 7 percent of couples, the male partner is infected and the female partner is not; and in 7 percent of couples, the female partner is infected and the male partner is not. Women’s Empowerment and Demographic and Health Outcomes • 231 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 his chapter explores women’s empowerment in terms of earnings, control over earnings, and magnitude of earnings relative to those of their partners. In addition, responses to specific questions are used to define two different indicators of women’s empowerment: women’s participation in household decision making and women’s attitudes towards wife beating. The extent to which women’s empowerment influences maternal health, contraceptive use, and child mortality is also examined. 15.1 WOMEN’S AND MEN’S EMPLOYMENT Table 15.1 shows, by type of earnings received, the percent distribution of currently married women and men age 15-49 who were employed in the 12 months preceding the survey. Employment is assumed to go hand-in-hand with payment for work. Not all women and men receive earnings for the work they do, however, and among those who do receive earnings, not all receive cash. T Key Findings • Almost one-third of currently married women who receive cash earnings report deciding themselves how their own earnings will be used; 62 percent say they decide on use of earnings with their husband. • The majority of women report that they do not own a house (63 percent) or land (64 percent). Twenty-seven percent of women say that they own a house jointly with someone else; similarly, 25 percent of women report that they own land jointly. Overall, 9 percent of women own their own house, and 9 percent own their own land. • The majority of currently married women (60 to 69 percent) report that each of three household decisions is made jointly with their husbands. About 24 percent of women report that they alone make decisions about their own health care; 20 percent make decisions to visit their families and relatives, and 19 percent make decisions about major household purchases. • Forty percent of women believe that a husband is justified in beating his wife for at least one of five specified reasons (if she burns the food, if she goes out without telling him, if she neglects the children, if she argues with him, or if she refuses to have sexual intercourse with him). Only 34 percent of men believe that a husband is justified in beating his wife for at least one of these same five specified reasons. 232 • Women’s Empowerment and Demographic and Health Outcomes Table 15.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Zimbabwe 2010-11 Age Among currently married respondents: Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Total Number of respondents Percentage employed Number of respondents Cash only Cash and in-kind In-kind only Not paid WOMEN 15-19 24.2 452 60.0 29.5 0.7 9.7 100.0 109 20-24 35.2 1,210 66.3 26.7 1.8 5.2 100.0 426 25-29 43.7 1,329 73.5 22.3 0.6 3.6 100.0 580 30-34 49.9 1,012 69.4 25.4 1.0 4.1 100.0 505 35-39 50.8 815 70.4 23.1 1.8 4.8 100.0 414 40-44 59.4 488 64.4 28.2 1.2 6.2 100.0 290 45-49 48.0 397 56.8 37.3 0.3 5.6 100.0 190 Total 15-49 44.1 5,703 68.1 25.9 1.1 4.9 100.0 2,515 MEN 15-19 * 17 * * * * 100.0 12 20-24 81.1 358 73.1 15.1 2.4 9.5 100.0 290 25-29 87.6 800 79.3 13.8 1.1 5.8 100.0 700 30-34 84.6 802 78.4 13.5 1.1 7.0 100.0 678 35-39 86.5 740 76.1 15.3 1.1 7.5 100.0 640 40-44 85.3 528 73.9 17.2 1.7 7.2 100.0 450 45-49 82.9 341 70.8 18.8 1.6 8.7 100.0 282 Total 15-49 85.2 3,584 76.3 15.2 1.3 7.2 100.0 3,053 50-54 78.8 329 71.1 16.7 1.2 11.0 100.0 259 Total 15-54 84.6 3,913 75.9 15.3 1.3 7.5 100.0 3,313 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Forty-four percent of currently married women reported being employed at any time in the 12 months preceding the survey. Of employed women, nearly seven in ten women received cash earnings, 26 percent received both cash and in-kind earnings, and 1 percent received in-kind earnings only. Five percent did not receive any form of earnings for their work, a marked decrease from that reported in the 2005-06 ZDHS (27 percent). The percentage of currently married women who are employed increases with age, peaking in the age group 40-44 (59 percent) and then declining among women age 45-49. Eighty-five percent of currently married men age 15-49 were employed during the 12 months preceding the survey. Among employed men, more than nine in ten received earnings, either cash only, in-kind only, or a combination of cash and in-kind earning, for the work they did. Seven percent of men did not get paid for their work. 15.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS To assess women’s autonomy, currently married women who earned cash for their work in the 12 months preceding the survey were asked who the main decision maker is with regard to the use of their earnings. This information allows the assessment of women’s control over their own earnings. Women who earned cash for their work were also asked the relative magnitude of their earnings compared with those of their husband. It is expected that employment and earnings are more likely to empower women if women themselves control their own earnings and perceive them as significant relative to those of their husband. Table 15.2.1 shows the degree of control women have over the use of their earnings, and their perception of the magnitude of their earnings relative to those of their husband, by background characteristics. Almost one-third of currently married women who receive cash earnings report that Women’s Empowerment and Demographic and Health Outcomes • 233 they mainly decide how their earnings are used, while 62 percent say they decide jointly with their husband. Only 7 percent of women report that their husband mainly decides how their earnings will be used. These findings are similar to those reported in the 2005-06 ZDHS. Table 15.2.1 Control over women's cash earnings and relative magnitude of women's cash earnings: Women Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife's cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Zimbabwe 2010-11 Background characteristic Person who decides how the wife's cash earnings are used: Total Wife's cash earnings compared with husband's cash earnings: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing More Less About the same Husband has no earnings Don't know/ Missing Age 15-19 28.2 64.5 6.4 1.0 0.0 100.0 6.0 68.1 18.4 6.7 0.8 100.0 98 20-24 27.6 63.4 8.2 0.6 0.2 100.0 12.1 62.7 18.1 6.1 1.0 100.0 397 25-29 29.2 62.6 8.2 0.0 0.0 100.0 10.4 67.5 15.9 5.1 1.2 100.0 556 30-34 29.3 63.7 7.0 0.0 0.0 100.0 14.5 58.2 19.1 7.4 0.9 100.0 479 35-39 35.0 58.0 7.1 0.0 0.0 100.0 15.8 58.5 19.0 5.6 1.0 100.0 387 40-44 35.2 59.7 5.0 0.0 0.0 100.0 17.5 53.4 19.9 7.8 1.4 100.0 268 45-49 34.0 59.9 5.7 0.4 0.0 100.0 18.8 47.3 23.1 10.8 0.0 100.0 179 Number of living children 0 32.1 62.0 5.9 0.0 0.0 100.0 16.2 62.5 13.3 8.0 0.0 100.0 152 1-2 29.4 63.8 6.5 0.3 0.1 100.0 12.8 63.4 17.5 5.5 0.8 100.0 1,185 3-4 32.8 60.5 6.6 0.0 0.0 100.0 14.0 57.7 19.2 7.7 1.4 100.0 761 5+ 31.6 56.1 12.0 0.3 0.0 100.0 15.1 52.1 23.9 7.8 1.0 100.0 266 Residence Urban 32.6 60.0 7.4 0.0 0.0 100.0 18.0 63.3 10.7 7.0 1.0 100.0 982 Rural 29.7 63.0 7.0 0.3 0.0 100.0 10.6 58.0 24.1 6.3 1.0 100.0 1,381 Province Manicaland 36.7 54.7 8.4 0.2 0.0 100.0 16.8 57.7 17.5 6.8 1.2 100.0 387 Mashonaland Central 29.4 66.4 4.2 0.0 0.0 100.0 9.4 67.1 21.0 1.9 0.6 100.0 377 Mashonaland East 26.4 68.3 5.2 0.0 0.0 100.0 11.9 49.7 30.5 7.9 0.0 100.0 222 Mashonaland West 28.3 65.4 6.3 0.0 0.0 100.0 14.2 55.9 21.6 7.6 0.7 100.0 261 Matabeleland North 41.6 45.2 8.3 3.4 1.6 100.0 7.8 65.0 9.8 15.8 1.6 100.0 38 Matabeleland South 27.2 68.5 4.3 0.0 0.0 100.0 13.4 54.0 23.2 9.4 0.0 100.0 58 Midlands 24.0 63.6 11.9 0.5 0.0 100.0 14.5 53.8 23.2 6.1 2.4 100.0 237 Masvingo 39.0 54.9 5.4 0.6 0.0 100.0 9.0 68.3 18.2 2.9 1.7 100.0 150 Harare 29.0 61.8 9.2 0.0 0.0 100.0 17.5 62.4 10.3 8.9 0.9 100.0 519 Bulawayo 41.6 56.2 2.2 0.0 0.0 100.0 8.3 70.7 12.4 7.5 1.1 100.0 116 Education No education 34.9 54.6 10.5 0.0 0.0 100.0 16.5 57.2 23.2 3.1 0.0 100.0 55 Primary 32.4 58.8 8.4 0.4 0.0 100.0 11.2 56.3 22.3 9.2 1.0 100.0 657 Secondary 31.3 61.4 7.1 0.1 0.0 100.0 14.7 63.0 15.4 5.7 1.1 100.0 1,451 More than secondary 21.8 76.0 2.2 0.0 0.0 100.0 13.3 53.5 27.5 5.7 0.0 100.0 200 Wealth quintile Lowest 33.3 56.6 9.7 0.4 0.0 100.0 11.1 55.5 24.2 7.9 1.4 100.0 317 Second 29.8 63.3 6.9 0.0 0.0 100.0 8.8 54.5 26.5 8.6 1.6 100.0 371 Middle 31.2 61.0 7.1 0.5 0.1 100.0 12.6 59.5 20.6 6.5 0.9 100.0 421 Fourth 33.8 59.0 7.1 0.1 0.0 100.0 15.7 65.1 13.9 4.6 0.7 100.0 599 Highest 27.7 66.3 6.0 0.0 0.0 100.0 16.5 61.7 14.2 6.8 0.8 100.0 655 Total 30.9 61.8 7.1 0.2 0.0 100.0 13.7 60.2 18.5 6.6 1.0 100.0 2,363 234 • Women’s Empowerment and Demographic and Health Outcomes Women age 35-49 are more likely to make independent decisions on their earnings than younger women. The number of living children a woman has does not correlate with her control over her cash earnings with the exception of the finding that women who have five or more children are more likely to have their husband decide on how to use their earnings (12 percent) relative to women with fewer children (6 to 7 percent). There is also little difference in control over women’s cash earnings by urban-rural residence: nearly one-third of both urban and rural currently married women report that they mainly decide how to spend their earnings. However, the provincial data vary greatly in the way decisions are made on how women’s earnings are used. The percentage of women who mainly decide for themselves how their earnings will be spent ranges from a low of 24 percent in Midlands to a high of 42 percent in Matabeleland North and Bulawayo provinces. About one in three women with no education decide independently how to spend their earnings (35 percent), compared with one in five women with more than a secondary education. Women in the latter group are most likely to jointly decide with their husband how to spend their earnings (76 percent), while women with no education are least likely to do so (55 percent). Only 2 percent of women with more than secondary education report that their husband mainly makes decisions about how their cash earnings will be spent; in contrast, 11 percent of women with no education report that their husband mainly decides how their earnings will be used. Only minor differences are observed by wealth quintile. Regarding relative magnitude of women’s earnings compared with those of their husbands, 14 percent report that they earn more than their husband, 60 percent earn less than their husband, and 19 percent earn about the same as their husband. Seven percent of women report that their husband has no earnings. Older women, women who reside in urban areas, and women in the highest wealth quintile are more likely than other women to report that they earn more than their husbands. Table 15.2.2 shows the degree of control men have over their earnings. Seven percent of men age 15-49 report that their wife mainly decides how their earnings are used, 83 percent say that they and their wife jointly make the decision, and 10 percent report they mainly make the decision on their own. The percentage of men who say their wife mainly decides how their cash earnings are used increases steadily with men’s age (5 percent of men age 20-24 compared with 10 percent of men age 45-49). Conversely, younger men are more likely than older men to report that they alone decide on how their cash earnings are used (20 percent of men age 20-24 compared with 8 to 9 percent of men age 30-49). Large differences are not observed by urban-rural residence or wealth quintile, but there is variability by number of living children, province, and education level. Women’s Empowerment and Demographic and Health Outcomes • 235 Table 15.2.2 Control over men's cash earnings Percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women age 15-49 whose husbands receive cash earnings, by person who decides how husband's cash earnings are used, according to background characteristics, Zimbabwe 2010-11 Background characteristic Men Women Person who decides how the husband’s cash earnings are used: Total Number of men Person who decides how the husband’s cash earnings are used: Total Number of women Mainly wife Husband and wife jointly Mainly husband Other Mainly wife Wife and husband jointly Mainly husband Other Age 15-19 * * * * 100.0 12 10.4 71.6 16.7 1.2 100.0 420 20-24 5.0 74.0 20.4 0.6 100.0 256 14.0 70.8 14.8 0.4 100.0 1,152 25-29 5.7 83.5 10.9 0.0 100.0 652 11.6 74.7 13.6 0.1 100.0 1,262 30-34 6.0 84.7 9.3 0.0 100.0 624 11.8 76.4 11.7 0.2 100.0 960 35-39 6.3 85.7 7.8 0.1 100.0 585 14.1 71.0 14.8 0.1 100.0 770 40-44 7.7 83.0 9.4 0.0 100.0 410 13.6 72.6 13.8 0.0 100.0 453 45-49 10.0 81.9 8.0 0.0 100.0 253 13.3 69.3 16.3 1.1 100.0 363 Number of living children 0 5.7 77.2 17.0 0.2 100.0 258 10.8 71.3 16.8 1.1 100.0 436 1-2 6.5 83.1 10.3 0.1 100.0 1,347 13.3 72.9 13.4 0.3 100.0 2,707 3-4 7.1 85.1 7.8 0.0 100.0 840 11.8 74.5 13.6 0.1 100.0 1,576 5+ 6.1 82.1 11.8 0.0 100.0 347 13.4 69.7 16.4 0.4 100.0 660 Residence Urban 6.8 83.3 10.0 0.0 100.0 1,204 16.2 71.2 12.6 0.1 100.0 1,849 Rural 6.4 82.9 10.6 0.1 100.0 1,587 10.9 73.7 14.9 0.4 100.0 3,530 Province Manicaland 4.8 87.9 7.4 0.0 100.0 387 12.1 63.4 23.9 0.6 100.0 746 Mashonaland Central 4.6 78.9 16.1 0.4 100.0 389 7.4 81.2 11.3 0.0 100.0 615 Mashonaland East 7.4 74.9 17.7 0.0 100.0 265 12.7 73.1 13.5 0.7 100.0 482 Mashonaland West 7.1 86.8 6.0 0.0 100.0 382 14.3 73.1 12.4 0.2 100.0 683 Matabeleland North 13.7 75.7 10.6 0.0 100.0 78 13.5 69.2 17.0 0.0 100.0 207 Matabeleland South 6.0 88.9 4.6 0.6 100.0 93 5.0 80.1 14.5 0.2 100.0 220 Midlands 7.9 83.1 8.9 0.0 100.0 309 10.8 74.6 14.0 0.6 100.0 675 Masvingo 9.7 79.6 10.7 0.0 100.0 139 13.8 75.0 10.9 0.4 100.0 607 Harare 6.3 84.1 9.6 0.0 100.0 620 17.8 70.5 11.6 0.1 100.0 921 Bulawayo 5.0 85.3 9.7 0.0 100.0 131 12.4 75.2 12.4 0.0 100.0 223 Education No education * * * * 100.0 14 9.5 71.0 17.2 2.3 100.0 142 Primary 7.1 79.9 12.9 0.1 100.0 531 13.4 69.7 16.5 0.4 100.0 1,687 Secondary 6.2 83.4 10.4 0.1 100.0 1,962 12.5 74.2 13.1 0.2 100.0 3,325 More than secondary 7.6 87.0 5.4 0.0 100.0 285 12.2 78.1 9.7 0.0 100.0 225 Wealth quintile Lowest 5.1 79.5 15.4 0.0 100.0 337 11.6 71.3 17.0 0.1 100.0 1,011 Second 7.2 82.4 10.4 0.0 100.0 397 11.8 72.9 14.4 1.0 100.0 1,018 Middle 6.0 84.3 9.5 0.2 100.0 517 12.2 72.5 14.8 0.4 100.0 1,020 Fourth 7.3 84.9 7.7 0.2 100.0 768 14.6 71.9 13.5 0.0 100.0 1,246 Highest 6.5 82.3 11.2 0.0 100.0 772 12.8 75.7 11.3 0.1 100.0 1,085 Total 15-49 6.5 83.1 10.3 0.1 100.0 2,792 12.7 72.9 14.1 0.3 100.0 5,380 50-54 9.5 81.1 9.4 0.0 100.0 228 na na na na na na Total 15-54 6.8 82.9 10.3 0.1 100.0 3,019 na na na na na na na = Not applicable Note: Total includes 1 woman for whom information on the person who decides how the husband’s cash earnings are used was missing. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Currently married women age 15-49 whose husbands receive cash earnings were also asked who decides how the husband’s cash earning are used. As shown in Table 15.2.2, thirteen percent report that they mainly decide on how their husbands’ cash earnings are used, 73 percent report that they and their husband jointly decide, and 14 percent report that their husband mainly decides. Cross-tabulations by the person in the household who decides how the wife’s cash earnings are used and how the husband’s cash earnings are used, by the woman’s earnings relative to her husband’s are presented in Table 15.3; they provide some insight into a woman’s empowerment in the family and the extent of her control over decision making in the household. Table 15.3 shows that currently married women who earn more than their husband are more likely to decide how their husband’s earnings are used (25 percent) than those who earn less (14 percent) or the same as their husband (9 percent). Women who earn the same as their husband are most likely to make joint decisions on how their earnings (77 percent) and their husband’s earnings 236 • Women’s Empowerment and Demographic and Health Outcomes (78 percent) are used. Husbands are more likely to mainly make decisions on the use of their earnings among the group of women who reported that they earn more than their husband (17 percent) compared with husbands of women who earn the same (15 percent) or less than their husband (13 percent). Table 15.3 Women's control over their own earnings and over those of their husbands Percent distribution of currently married women age 15-49 with cash earnings in the last 12 months by person who decides how the wife's cash earnings are used and percent distribution of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband's cash earnings are used, according to the relation between wife's and husband's cash earnings, Zimbabwe 2010-11 Women's earnings relative to husband's earnings Person who decides how the wife's cash earnings are used: Total Number of women Person who decides how husband's cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Mainly wife Wife and husband jointly Mainly husband Other More than husband 37.9 53.7 8.3 0.0 100.0 323 25.4 57.5 17.1 0.0 100.0 323 Less than husband 34.8 58.0 7.1 0.1 100.0 1,423 14.4 70.9 14.5 0.2 100.0 1,423 Same as husband 15.3 76.9 7.8 0.0 100.0 438 9.1 78.3 12.6 0.0 100.0 438 Husband has no cash earnings or did not work 20.5 73.8 3.6 2.1 100.0 156 na na na na na 0 Woman worked but has no cash earnings na na na na na 0 7.9 80.9 9.6 1.6 100.0 145 Woman did not work na na na na na 0 11.1 74.4 14.0 0.4 100.0 3,027 Total 30.9 61.8 7.1 0.2 100.0 2,363 12.7 72.9 14.1 0.3 100.0 5,380 Note: Total includes 23 cases where a woman does not know whether she earned more or less than her husband. na = Not applicable 15.3 WOMEN’S OWNERSHIP OF ASSETS The 2010-11 ZDHS asked respondents questions regarding the ownership of land and houses. Ownership of land is considered a measure of women’s empowerment, and to this effect, the government of Zimbabwe has prioritised giving land to women to address imbalances. Table 15.4.1 shows the percentage of women age 15-49 who reported owning a house or land alone, jointly, or both alone and jointly, and the percentage who do not own a house or land. Overall, 9 percent of women own a house alone, and 9 percent own land alone. Twenty-seven percent of women say that they own a house jointly with someone; similarly, 25 percent of women report that they own land jointly. Two percent of women own a house both alone and jointly, and 2 percent own land both alone and jointly. More than six in ten report that they do not own a house (63 percent) or land (64 percent). Ownership of either asset alone increases with age, with younger women much less likely to own house or land, either alone or jointly, compared with older women. Women’s Empowerment and Demographic and Health Outcomes • 237 Table 15.4.1 Ownership of assets: Women Percent distribution of women age 15-49 by ownership of housing and land, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who own a house: Percentage who do not own a house Total Percentage who own land: Percentage who do not own land Total Number of women Alone Jointly Alone and jointly Alone Jointly Alone and jointly Age 15-19 1.7 5.9 0.3 92.0 100.0 1.5 6.5 0.4 91.6 100.0 1,945 20-24 4.4 20.4 1.2 74.0 100.0 4.8 19.2 1.6 74.4 100.0 1,841 25-29 7.6 28.6 1.7 62.1 100.0 8.0 28.6 1.7 61.8 100.0 1,686 30-34 10.4 34.1 1.5 53.9 100.0 10.9 32.4 2.2 54.5 100.0 1,296 35-39 13.9 41.4 3.0 41.6 100.0 13.4 40.6 2.3 43.6 100.0 1,051 40-44 20.7 41.2 3.0 35.0 100.0 17.2 39.4 2.6 40.8 100.0 732 45-49 26.2 44.5 5.0 24.3 100.0 24.4 38.0 3.4 34.1 100.0 620 Residence Urban 3.9 10.5 2.0 83.7 100.0 3.3 9.8 1.8 85.1 100.0 3,548 Rural 12.5 36.6 1.6 49.3 100.0 12.4 35.3 1.6 50.7 100.0 5,623 Province Manicaland 11.4 31.0 1.0 56.6 100.0 10.9 31.3 0.7 57.1 100.0 1,227 Mashonaland Central 6.4 50.7 1.2 41.6 100.0 5.4 49.4 1.8 43.4 100.0 871 Mashonaland East 8.6 32.7 1.7 57.0 100.0 8.5 34.0 1.5 56.0 100.0 824 Mashonaland West 8.5 28.4 1.6 61.6 100.0 8.6 28.9 1.6 61.0 100.0 1,026 Matabeleland North 11.4 36.5 1.7 50.4 100.0 8.9 34.1 1.8 55.2 100.0 443 Matabeleland South 7.8 22.7 1.7 67.7 100.0 6.2 22.7 0.5 70.6 100.0 467 Midlands 6.0 31.6 1.0 61.4 100.0 6.0 26.6 0.9 66.4 100.0 1,123 Masvingo 29.8 22.7 2.3 45.2 100.0 29.9 19.8 2.5 47.8 100.0 909 Harare 2.1 10.0 3.3 84.6 100.0 3.3 10.5 3.4 82.8 100.0 1,722 Bulawayo 4.3 8.1 0.6 87.0 100.0 1.6 4.9 0.6 93.0 100.0 558 Education No education 22.7 45.6 2.9 28.8 100.0 18.9 41.3 1.5 38.2 100.0 212 Primary 13.8 40.2 1.8 44.2 100.0 13.3 36.8 1.9 48.0 100.0 2,568 Secondary 6.9 20.4 1.5 71.1 100.0 6.6 20.8 1.6 70.9 100.0 5,966 More than secondary 5.3 19.0 4.4 71.3 100.0 8.0 14.0 1.7 76.3 100.0 424 Wealth quintile Lowest 17.6 47.6 1.4 33.4 100.0 15.3 43.7 1.5 39.6 100.0 1,546 Second 13.4 39.8 2.1 44.6 100.0 13.7 37.5 2.1 46.8 100.0 1,594 Middle 9.5 26.8 1.3 62.4 100.0 9.5 27.5 1.6 61.4 100.0 1,681 Fourth 5.2 15.5 1.9 77.5 100.0 5.4 15.6 2.0 77.0 100.0 2,073 Highest 3.8 12.6 2.0 81.6 100.0 3.7 12.1 1.5 82.7 100.0 2,278 Total 9.2 26.5 1.8 62.6 100.0 8.9 25.4 1.7 64.0 100.0 9,171 Rural women in Zimbabwe are more likely than urban women to own house or land alone or jointly with someone else. For instance, half of rural women own a house or land alone and/or jointly compared with about one in six women in urban areas. About one in three women in Masvingo owns a house or land alone, making them much more likely to own a house or land alone compared with women in other provinces. Women in the urban provinces of Bulawayo and Harare are the least likely to own a house or land, alone or jointly. Ownership of a house or land inversely correlates with education and wealth. For example, 29 percent of women with no education and 33 percent of women in the lowest wealth quintiles do not own a house compared with 71 percent of women with more than secondary education and 82 percent of women in the highest wealth quintile. Table 15.4.2 shows that two in three men in Zimbabwe do not own a house or land, which is comparable to the situation among women. The percentage of men who own a house or land either alone or jointly generally increases with age. Men in rural areas are more likely to own house or land compared with men in the urban areas; 59 percent of rural men do not own a home and 60 percent do not own land, whereas 80 percent of urban men do not own a home and 77 percent do not own land. Ownership of assets varies by province and wealth quintile. In contrast with the situation among women, however, the ownership of house or land among men does not vary much based on educational attainment. 238 • Women’s Empowerment and Demographic and Health Outcomes Table 15.4.2 Ownership of assets: Men Percent distribution of men age 15-49 by ownership of housing and land, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who own a house: Percentage who do not own a house Total Percentage who own land: Percentage who do not own land Total Number of men Alone Jointly Alone and jointly Alone Jointly Alone and jointly Age 15-19 3.2 3.7 0.9 92.2 100.0 3.1 4.6 0.8 91.4 100.0 1,735 20-24 6.7 8.9 2.1 82.3 100.0 8.8 9.1 1.8 80.3 100.0 1,372 25-29 14.4 14.3 5.1 66.2 100.0 15.2 15.3 4.5 65.0 100.0 1,236 30-34 20.8 19.6 7.3 52.3 100.0 24.0 19.5 7.1 49.4 100.0 970 35-39 23.5 21.9 11.2 43.4 100.0 24.2 20.2 10.4 45.2 100.0 828 40-44 29.3 25.5 9.5 35.6 100.0 31.5 21.9 8.7 37.9 100.0 589 45-49 36.2 25.9 13.3 24.6 100.0 35.6 22.4 10.8 31.2 100.0 379 Residence Urban 9.4 6.8 4.0 79.8 100.0 12.2 7.7 3.4 76.7 100.0 2,621 Rural 17.5 18.0 6.1 58.5 100.0 17.8 17.0 5.6 59.6 100.0 4,488 Province Manicaland 16.3 22.5 3.5 57.6 100.0 15.2 20.8 4.0 59.9 100.0 972 Mashonaland Central 16.1 19.9 4.1 60.0 100.0 14.6 19.2 5.7 60.5 100.0 738 Mashonaland East 22.4 12.3 4.1 61.2 100.0 25.1 13.1 4.9 56.9 100.0 667 Mashonaland West 19.1 8.7 7.5 64.7 100.0 19.9 8.7 7.3 64.1 100.0 872 Matabeleland North 11.7 18.1 6.9 63.3 100.0 10.7 16.1 5.2 68.0 100.0 349 Matabeleland South 4.8 11.4 11.3 72.5 100.0 3.7 5.0 10.7 80.6 100.0 352 Midlands 10.5 22.5 5.6 61.5 100.0 12.3 20.6 3.0 64.1 100.0 885 Masvingo 21.1 13.2 7.4 58.3 100.0 24.0 14.2 5.7 56.1 100.0 585 Harare 10.8 3.4 3.9 81.9 100.0 14.5 7.1 3.0 75.4 100.0 1,307 Bulawayo 6.0 9.3 3.5 81.2 100.0 8.2 6.5 2.5 82.8 100.0 382 Education No education 15.0 10.3 10.5 64.2 100.0 18.2 11.9 5.0 65.0 100.0 56 Primary 19.1 15.4 7.1 58.5 100.0 17.6 14.8 5.8 61.8 100.0 1,508 Secondary 13.0 13.6 4.7 68.7 100.0 15.3 13.2 4.6 66.9 100.0 5,027 More than secondary 15.5 11.9 5.2 67.3 100.0 13.9 13.7 4.5 67.9 100.0 519 Wealth quintile Lowest 24.0 25.2 9.4 41.4 100.0 22.0 23.6 7.2 47.2 100.0 1,074 Second 19.4 18.9 7.5 54.2 100.0 18.5 16.5 7.7 57.2 100.0 1,216 Middle 16.3 13.8 4.6 65.3 100.0 17.6 13.8 4.6 63.9 100.0 1,371 Fourth 8.8 8.8 4.4 78.0 100.0 12.3 8.2 3.7 75.8 100.0 1,664 Highest 9.4 8.2 2.8 79.6 100.0 11.7 10.3 2.6 75.4 100.0 1,786 Total 15-49 14.5 13.8 5.3 66.4 100.0 15.7 13.6 4.8 65.9 100.0 7,110 50-54 32.6 24.3 14.1 28.9 100.0 35.8 25.2 10.9 28.1 100.0 370 Total 15-54 15.4 14.4 5.7 64.5 100.0 16.7 14.1 5.1 64.0 100.0 7,480 15.4 WOMEN’S AND MEN’S PARTICIPATION IN DECISION MAKING Decision making can be a complex process, and the ability of women and men to make decisions that affect the circumstances of their own lives is essential to their status in the household and in society. The number of decisions in which a woman either alone or jointly with her husband has the final say is assumed to be directly related to the woman’s empowerment and reflects the degree of decision making control the woman is able to exercise in areas that affect her life and environment. Women’s Empowerment and Demographic and Health Outcomes • 239 To assess women’s decision making autonomy, the 2010-11 ZDHS sought information on women’s participation in three types of household decisions: the respondent’s own health care; making major house-hold purchases; and visits to family or relatives. Similarly, men were asked about their participation in two types of household decisions: the respondent’s health care and making major household purchases. Table 15.5 shows the percent distribution of currently married women and men according to the person in the household who usually makes decisions concerning these matters. Women and men are considered to participate in decision making if they make decisions alone or jointly with their spouse. The strength of the role of women in decision making varies with the type of decision. In Zimbabwe, the majority of currently married women (60 to 69 percent) report that each of three household decisions is made jointly by husband and wife. Twenty-four percent of currently married women report that they alone make the decisions about their own health care, 19 percent say that they mainly make decisions about major household purchases, and 20 percent say that they mainly decide on visiting their families and relatives. More than three quarters of men report that they jointly make decisions with their wives with regard to their own health care and also on major household purchases. Approximately 8 percent of men stated that decisions about their own health care are made mainly by their wife. Fourteen percent of men indicated that it is mainly the responsibility of their wife to make decisions on major household purchases. Table 15.6.1 shows the percentage of currently married women who report that they usually make specific household decisions either by themselves or jointly with their husbands, according to background characteristics. Over 8 in 10 women participate in each of the three specific decisions. Seventy-five percent of currently married women participate in all three decisions. Only 4 percent of women report that they participate in none of the three decisions. Table 15.5 Participation in decision making Percent distribution of currently married women and currently married men age 15-49 by person who usually makes decisions about various issues, Zimbabwe 2010-11 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Total Number WOMEN Own health care 24.1 60.1 14.4 1.2 0.1 100.0 5,703 Major household purchases 19.4 68.1 12.0 0.4 0.1 100.0 5,703 Visits to her family or relatives 19.9 68.8 10.7 0.4 0.3 100.0 5,703 MEN Man’s own health care 8.2 77.2 14.0 0.5 0.2 100.0 3,584 Major household purchases 13.8 75.7 10.1 0.4 0.0 100.0 3,584 240 • Women’s Empowerment and Demographic and Health Outcomes Table 15.6.1 Women's participation in decision making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Zimbabwe 2010-11 Background characteristic Specific decisions Percentage who participate in all three decisions Percentage who participate in none of the three decisions Number of women Woman's own health care Making major household purchases Visits to her family or relatives Age 15-19 76.9 78.7 79.0 61.4 8.7 452 20-24 82.9 86.1 86.1 71.4 4.3 1,210 25-29 84.7 88.0 89.2 75.9 4.2 1,329 30-34 85.9 87.6 90.6 76.4 3.6 1,012 35-39 83.9 88.1 89.6 75.6 4.5 815 40-44 86.9 91.9 93.0 79.8 2.3 488 45-49 87.9 92.6 93.4 81.1 2.4 397 Employment (past 12 months) Not employed 83.1 85.6 88.6 73.5 5.0 3,188 Employed for cash 85.7 90.3 89.4 76.5 3.0 2,363 Employed, not for cash 83.2 82.8 78.1 64.6 7.0 152 Number of living children 0 80.2 85.2 83.2 68.4 6.0 468 1-2 84.5 87.3 88.5 74.7 4.2 2,840 3-4 84.6 87.6 89.6 75.3 3.8 1,686 5+ 84.5 89.0 90.5 76.3 4.1 708 Residence Urban 85.7 89.5 90.2 77.1 3.7 1,937 Rural 83.4 86.4 87.8 73.2 4.5 3,766 Province Manicaland 67.5 79.5 79.9 54.3 7.3 798 Mashonaland Central 86.3 88.5 87.2 74.0 3.3 626 Mashonaland East 88.3 90.3 90.9 80.2 3.2 541 Mashonaland West 73.2 86.5 89.3 67.1 5.0 718 Matabeleland North 88.8 81.2 87.8 75.3 5.7 257 Matabeleland South 97.3 89.2 93.1 87.0 1.3 230 Midlands 91.5 88.6 91.3 82.9 4.7 695 Masvingo 89.8 90.2 90.0 82.0 3.8 626 Harare 87.8 90.5 91.7 79.2 3.2 972 Bulawayo 89.9 89.8 87.3 77.6 1.7 239 Education No education 80.3 86.7 90.5 71.8 4.5 154 Primary 81.1 85.8 86.5 71.2 5.7 1,827 Secondary 85.2 87.8 89.1 75.4 3.7 3,485 More than secondary 95.5 95.3 96.5 89.7 1.1 237 Wealth quintile Lowest 83.1 83.6 86.8 72.0 6.3 1,109 Second 82.5 88.4 88.9 73.1 3.3 1,085 Middle 84.4 85.8 85.2 72.5 4.9 1,077 Fourth 82.0 87.2 89.4 72.5 3.9 1,291 Highest 89.1 92.1 92.5 82.5 3.0 1,141 Total 84.2 87.5 88.6 74.5 4.2 5,703 Older women, women employed for cash, women with five or more children, women with more than secondary education, and women in the highest wealth quintile are more likely than other women to have participated in all three decisions. Women’s Empowerment and Demographic and Health Outcomes • 241 The total number of decisions in which a woman participates is one simple measure of her empowerment. Figure 15.1 shows the distribution of currently married women according to the number of decisions in which they participate either alone or jointly with their husband. Seventy-five percent of currently married women participate in all three household decisions, and 16 percent participate in two decisions. Six percent of women participate in one decision, and 4 percent do not participate in any decisions. Figure 15.1 Number of Decisions in which Currently Married Women Participate ZDHS 2010-11 4 6 16 75 0 1 2 3 Number of decisions 0 20 40 60 80 Percent Table 15.6.2 shows the percentage of men who report that they alone or jointly with their wives participate in specific household decisions, according to different background characteristics. Eighty percent of currently married men participate in both decisions (their own health care and making major household purchases). Only four percent report that they do not participate in either of the two decisions. 242 • Women’s Empowerment and Demographic and Health Outcomes Table 15.6.2 Men's participation in decision making by background characteristics Percentage of currently married men age 15-49 who usually make specific decisions either alone or jointly with their wife, by background characteristics, Zimbabwe 2010-11 Background characteristic Specific decisions Both decisions Neither of the two decisions Number of men Man's own health care Making major household purchases Age 15-19 * * * * 17 20-24 92.0 86.8 80.9 2.1 358 25-29 92.5 84.9 80.5 3.1 800 30-34 92.0 87.5 82.4 2.9 802 35-39 89.5 86.5 80.4 4.4 740 40-44 90.4 85.1 79.3 3.8 528 45-49 90.4 81.4 77.0 5.2 341 Employment (past 12 months) Not employed 93.2 84.6 82.0 4.3 531 Employed for cash 90.6 86.0 80.1 3.5 2,792 Employed, not for cash 93.0 86.1 81.3 2.2 262 Number of living children 0 91.4 84.0 79.2 3.8 355 1-2 92.0 86.8 81.8 3.1 1,665 3-4 90.0 86.8 80.7 4.0 1,068 5+ 90.8 81.4 76.1 3.8 497 Residence Urban 92.9 86.9 82.5 2.7 1,301 Rural 90.2 85.1 79.2 4.0 2,283 Province Manicaland 92.2 81.5 77.9 4.2 496 Mashonaland Central 87.9 87.6 78.5 3.0 421 Mashonaland East 87.5 81.0 72.5 4.0 334 Mashonaland West 93.6 94.4 90.3 2.4 468 Matabeleland North 79.2 73.9 69.7 16.6 160 Matabeleland South 89.3 84.1 78.2 4.8 124 Midlands 92.3 87.8 82.6 2.5 450 Masvingo 94.8 83.0 80.1 2.2 320 Harare 92.6 87.5 82.1 2.0 653 Bulawayo 93.6 85.1 81.2 2.6 159 Education No education (88.4) (76.0) (73.4) (8.9) 31 Primary 89.8 84.2 78.2 4.2 788 Secondary 91.9 86.4 81.2 2.9 2,461 More than secondary 88.8 85.6 80.6 6.2 304 Wealth quintile Lowest 89.4 82.3 76.7 5.0 637 Second 89.3 87.6 79.8 2.9 615 Middle 93.0 85.6 81.8 3.2 646 Fourth 91.2 87.7 82.4 3.5 857 Highest 92.5 85.1 80.7 3.1 829 Total 15-49 91.2 85.8 80.4 3.5 3,584 50-54 89.3 80.9 75.8 5.5 329 Total 15-54 91.0 85.4 80.0 3.7 3,913 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 15.5 ATTITUDES TOWARDS WIFE BEATING The critical problems that women face are many and diverse. One of these, and among the most serious, is the issue of violence against women. It is described as the most serious because it concerns the personal security of women, and the right of personal security is fundamental to all other rights. If violence against women is tolerated and accepted in a society, its eradication is made more difficult. Women’s Empowerment and Demographic and Health Outcomes • 243 To assess women’s and men’s attitudes towards wife beating, respondents were asked whether a husband is justified in hitting or beating his wife in each of the following five situations: if she burns the food; if she argues with him; if she goes out without telling him; if she neglects the children; and if she refuses to have sexual intercourse with him. A woman’s responses to these five situations are used to generate the women’s empowerment indicator, “Number of reasons wife beating is justified,” described below (see section 15.6). All respondents were also asked whether a husband is justified in hitting or beating his wife if she commits infidelity. However, “commits infidelity” is not included in the women’s empowerment indicator. The results to this series of questions for women and men are summarised in Tables 15.7.1 and 15.7.2, respectively. Forty percent of women believe that a husband is justified in beating his wife for at least one of the five specified reasons (Table 15.7.1). Twenty-two percent of women believe that a husband is justified in beating his wife if she goes out without telling him, 21 percent for neglecting the children, 17 percent for refusing to have sexual intercourse with him, 16 percent for arguing with him, and 8 percent if she burns the food. In addition, nearly 6 in 10 women believe that a husband is justified in hitting or beating his wife if she commits infidelity. Younger women, women who are employed, but not for cash, married women, women from Mashonaland Central and Masvingo, women with no education, and women in the lowest wealth quintiles are more likely than other women to agree with at least one of the five specified reasons justifying wife beating. As shown in Table 15.7.2, overall, 34 percent of men age 15-49 believe that a husband is justified in beating his wife for at least one of the five specified reasons. Twenty percent of men believe that a husband is justified in beating his wife if she goes out without telling him, 19 percent for neglecting the children, 14 percent for arguing with him, 7 percent for refusing to have sexual intercourse with him, and 5 percent if she burns the food. One-third of men believe that a husband is justified in hitting or beating his wife if she commits infidelity. Remarkably, for each of the specified reasons that respondents were asked about, men were less likely than women to agree that wife beating was justified. By background characteristics, the pattern of men who agree with at least one of the five specified reasons justifying wife beating is very similar to the pattern observed among women. 244 • Women’s Empowerment and Demographic and Health Outcomes Table 15.7.1 Attitude toward wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Zimbabwe 2010-11 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one of five specified reasons2 Number of women Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Commits infidelity1 Age 15-19 10.2 20.8 28.2 26.4 15.7 65.1 47.7 1,945 20-24 7.5 17.2 23.8 24.2 19.0 62.7 41.7 1,841 25-29 6.8 13.5 20.5 19.6 15.5 56.8 37.3 1,686 30-34 5.9 13.2 20.6 18.9 16.7 53.8 36.4 1,296 35-39 7.3 11.9 19.0 19.2 15.8 53.8 35.2 1,051 40-44 6.2 13.5 18.1 16.8 17.1 53.4 33.2 732 45-49 6.2 13.8 18.9 16.0 20.9 51.1 35.5 620 Employment (past 12 months) Not employed 8.0 16.8 22.7 21.2 16.9 60.3 40.3 5,212 Employed for cash 6.5 13.7 21.7 21.0 16.9 55.2 37.9 3,730 Employed, not for cash 11.7 17.7 24.0 31.1 18.4 63.4 48.0 229 Number of living children 0 8.4 15.7 23.2 22.5 12.1 57.2 40.0 2,510 1-2 6.9 15.5 21.8 21.2 18.5 59.4 39.5 3,731 3-4 6.8 14.1 21.0 20.1 17.4 56.7 37.9 2,052 5+ 8.9 18.9 25.4 21.6 23.3 61.0 42.1 878 Marital status Never married 8.1 13.8 20.8 21.1 9.7 54.3 37.2 2,197 Married or living together 7.3 16.8 23.1 22.0 19.2 60.7 40.8 5,703 Divorced/separated/ widowed 7.5 13.4 21.4 19.0 19.3 54.7 38.1 1,271 Residence Urban 3.8 10.5 14.5 15.5 9.2 47.6 29.3 3,548 Rural 9.8 18.8 27.3 25.0 21.8 65.1 46.0 5,623 Province Manicaland 8.8 19.1 31.4 25.3 20.1 62.8 48.8 1,227 Mashonaland Central 12.3 20.4 34.8 35.7 24.9 70.3 56.3 871 Mashonaland East 7.0 10.3 16.2 22.4 20.4 63.3 38.7 824 Mashonaland West 10.2 18.0 25.4 24.3 20.4 67.7 43.5 1,026 Matabeleland North 4.2 23.5 19.9 23.6 15.1 56.4 41.1 443 Matabeleland South 2.6 12.2 12.3 15.0 6.1 42.6 24.7 467 Midlands 5.1 13.4 23.1 15.7 14.0 59.0 35.8 1,123 Masvingo 15.6 24.7 29.8 25.7 29.6 70.2 51.2 909 Harare 3.9 8.9 13.3 14.3 9.9 46.5 27.6 1,722 Bulawayo 2.1 10.1 10.9 12.8 3.8 36.0 23.9 558 Education No education 13.7 25.4 30.7 27.7 30.8 70.6 52.6 212 Primary 11.2 22.7 29.6 27.9 26.3 66.6 50.6 2,568 Secondary 6.1 13.1 20.1 19.5 13.5 57.1 36.5 5,966 More than secondary 1.3 1.7 5.3 4.2 2.4 19.4 9.8 424 Wealth quintile Lowest 12.2 25.3 30.2 27.1 25.9 69.8 51.5 1,546 Second 11.4 19.4 29.1 27.0 24.4 68.9 49.4 1,594 Middle 8.8 18.1 27.7 26.2 21.1 64.6 45.7 1,681 Fourth 4.3 12.2 18.5 18.2 11.3 54.0 34.0 2,073 Highest 3.5 7.5 11.8 12.8 7.8 42.5 25.1 2,278 Total 7.5 15.6 22.3 21.4 16.9 58.3 39.6 9,171 1 “Commits infidelity” is not included in the women's empowerment indicator “Number of reasons for which wife beating is justified” presented in subsequent tables. 2 The five reasons included in the column “Percentage who agree with at least one of five specified reasons” are “Burns the food,” “Argues with him,” “Goes out without telling him,” “Neglects the children,” and “Refuses to have sexual intercourse with him.” It does not include “Commits infidelity” in order to conform to the standard definition of the women's empowerment indicator “Number of reasons for which wife beating is justified”. Women’s Empowerment and Demographic and Health Outcomes • 245 Table 15.7.2 Attitude toward wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Zimbabwe 2010-11 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one of five specified reasons2 Number of men Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Commits infidelity1 Age 15-19 10.7 21.2 28.0 27.3 9.9 50.8 47.6 1,735 20-24 4.9 16.1 20.6 19.4 6.2 38.2 37.8 1,372 25-29 2.9 13.4 18.9 18.1 5.9 31.5 31.6 1,236 30-34 3.1 11.6 17.3 16.5 5.7 27.3 28.4 970 35-39 2.7 8.1 13.2 11.9 5.0 23.5 21.6 828 40-44 0.8 5.1 10.8 8.2 2.9 18.6 18.1 589 45-49 4.5 12.6 15.0 14.1 6.1 25.4 25.3 379 Employment (past 12 months) Not employed 6.9 16.2 22.4 21.0 7.1 41.3 37.4 2,209 Employed for cash 3.4 12.8 17.7 16.6 6.0 30.4 30.6 4,304 Employed, not for cash 10.5 17.2 23.9 24.7 9.0 40.5 42.0 597 Number of living children 0 7.5 17.9 23.3 22.2 8.0 42.8 40.7 3,594 1-2 2.6 10.8 16.1 15.7 5.3 28.5 27.5 1,889 3-4 2.8 10.1 16.1 14.5 5.1 23.6 25.7 1,122 5+ 2.7 10.0 15.2 13.1 4.5 24.3 24.0 504 Marital status Never married 8.0 18.1 23.3 22.8 8.3 44.3 41.2 3,221 Married or living together 2.5 10.8 16.7 15.1 4.9 26.2 27.0 3,584 Divorced/separated/ widowed 4.4 12.6 16.3 16.0 7.8 31.9 31.9 304 Residence Urban 2.2 10.8 14.1 14.9 5.0 30.4 27.1 2,621 Rural 6.8 16.2 23.0 20.8 7.5 37.1 37.5 4,488 Province Manicaland 6.3 14.4 23.8 23.5 8.3 44.8 39.2 972 Mashonaland Central 8.0 14.4 29.4 28.9 9.0 36.7 44.3 738 Mashonaland East 7.2 15.5 27.5 19.4 8.9 38.3 40.5 667 Mashonaland West 1.0 11.2 11.1 9.1 3.0 21.5 18.7 872 Matabeleland North 5.5 15.1 11.7 16.0 6.1 23.9 25.8 349 Matabeleland South 3.0 21.3 17.9 18.6 2.9 35.0 35.7 352 Midlands 7.5 19.4 20.7 21.2 7.7 39.0 38.6 885 Masvingo 10.7 15.7 26.9 24.6 9.5 45.0 44.3 585 Harare 1.6 10.3 15.1 13.7 5.1 31.9 27.3 1,307 Bulawayo 1.5 9.7 7.8 11.2 3.2 21.0 20.5 382 Education No education 2.4 9.6 15.1 11.9 4.3 29.4 26.0 56 Primary 6.9 19.2 24.1 21.9 8.9 38.5 39.8 1,508 Secondary 5.0 13.8 19.7 18.7 6.1 34.9 33.9 5,027 More than secondary 1.5 3.9 6.8 9.7 4.3 21.1 14.2 519 Wealth quintile Lowest 7.4 18.3 23.1 23.2 7.9 36.1 38.5 1,074 Second 8.1 17.5 25.4 22.4 7.6 39.7 41.0 1,216 Middle 6.8 16.3 23.9 20.6 8.1 39.5 38.8 1,371 Fourth 4.1 14.1 18.1 17.2 5.6 32.7 32.2 1,664 Highest 1.3 8.0 12.0 13.1 4.8 28.3 23.1 1,786 Total 15-49 5.1 14.2 19.7 18.6 6.6 34.6 33.7 7,110 50-54 1.4 7.9 11.9 10.7 7.2 22.5 21.1 370 Total 15-54 4.9 13.9 19.3 18.2 6.6 34.0 33.0 7,480 1 “Commits infidelity” is not included in the women's empowerment indicator “Number of reasons for which wife beating is justified” presented in subsequent tables. 2 The five reasons included in the column “Percentage who agree with at least one of five specified reasons” are “Burns the food,” “Argues with him,” “Goes out without telling him,” “Neglects the children,” and “Refuses to have sexual intercourse with him.” It does not include “Commits infidelity” in order to conform to the standard definition of the women's empowerment indicator “Number of reasons for which wife beating is justified”. 15.6 WOMEN’S EMPOWERMENT INDICATORS Two sets of empowerment indicators, namely, women’s participation in making household decisions and women’s attitudes towards wife beating can be summarised in two indices. The first index shows the number of decisions (see Table 15.6.1 for the list of decisions) in which women participate either alone or jointly with their husbands. This index ranges from 0 to 3 246 • Women’s Empowerment and Demographic and Health Outcomes and reflects the degree of decision-making control that women are able to exercise in areas that affect their own lives and the level of women’s empowerment in a society. The second index, which ranges from 0 to 5, is the number of reasons (see Table 15.7.1 for a list of reasons) for which a woman thinks that a husband is justified in beating his wife. A low score on this indicator is interpreted as reflecting a higher status of women in the household and society. Table 15.8 shows how the two indices relate to each other. The findings indicate that women who participate in all three household decisions asked about are more likely to disagree with all five reasons justifying wife beating than women who participate in fewer or no household decisions. Similarly, women who do not believe that wife beating is justified for any reason are more likely to participate in all household decision making than women who believe there are reasons for which wife beating is justified. Table 15.8 Indicators of women's empowerment Percentage of currently married women age 15-49 who participate in all decision making and the percentage who disagree with all of the reasons justifying wife-beating, by value on each of the indicators of women's empowerment, Zimbabwe 2010-11 Empowerment indicator Percentage who participate in all decision making Percentage who disagree with all the reasons justifying wife-beating Number of women Number of decisions in which women participate1 0 na 52.1 241 1-2 na 48.5 1,211 3 na 62.7 4,251 Number of reasons for which wife beating is justified2 0 78.9 na 3,377 1-2 70.4 na 1,545 3-4 63.6 na 640 5 65.0 na 141 na = Not applicable 1 See Table 15.6.1 for the list of decisions. 2 See Table 15.7.1 for the list of reasons. Women’s Empowerment and Demographic and Health Outcomes • 247 15.7 CURRENT USE OF CONTRACEPTION BY WOMEN’S EMPOWERMENT A woman’s desire and ability to control her fertility and her choice of contraceptive method are in part affected by her status in the household and her own sense of empowerment. A woman who feels that she is unable to control her life may be less likely to feel she can make and carry out decisions about her fertility. Table 15.9 presents the distribution of currently married women by contraceptive method use, according to the two empowerment indicators. There is generally a positive relationship between women’s empowerment and use of contraception, although differences are not great. Women who participate in one or more household decisions are more likely to use any method of contraception than women who do not participate in any household decisions (59 percent and 52 percent, respectively). Likewise, women who believe that wife beating is not justified for any reason are more likely than other women to use any method of contraception (61 percent compared with 52 to 58 percent). Table 15.9 Current use of contraception by women's empowerment Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women's status, Zimbabwe 2010-11 Empowerment indicator Any method Modern methods Any traditional method Not currently using Total Number of women Any modern method Female sterilisation Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 51.9 50.0 1.0 47.3 1.7 1.9 48.1 100.0 241 1-2 58.9 57.8 0.7 53.4 3.7 1.1 41.1 100.0 1,211 3 58.8 57.5 1.3 53.3 3.0 1.3 41.2 100.0 4,251 Number of reasons for which wife beating is justified3 0 60.5 59.1 1.5 54.2 3.5 1.4 39.5 100.0 3,377 1-2 57.2 56.2 1.0 52.7 2.5 1.0 42.8 100.0 1,545 3-4 51.5 50.2 0.0 47.5 2.7 1.3 48.5 100.0 640 5 57.5 56.4 0.0 54.7 1.7 1.1 42.5 100.0 141 Total 58.5 57.3 1.1 53.0 3.1 1.3 41.5 100.0 5,703 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, female condom, diaphragm, foam/jelly and lactational amenorrhea method. 2 See Table 15.6.1 for the list of decisions. 3 See Table 15.7.1 for the list of reasons. 15.8 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S EMPOWERMENT A woman’s fertility preference—for example, her preference for an ideal number of children—is typically lower than that of her husband (see Chapter 6, Table 6.4). As a woman becomes more empowered to negotiate fertility decision making, she has more control over her ability to access and use contraceptives to space and limit her family size. Women who have a desire to space or limit their births but who are not using family planning are defined as having an unmet need for family planning. Table 15.10 shows how women’s ideal family size and their unmet need for family planning vary by the two empowerment indicators. 248 • Women’s Empowerment and Demographic and Health Outcomes Currently married women who participate in none of the household decisions have a higher ideal number of children than women who participate in three decisions (4.3 children compared with 4.0). Women who participate in at least one decision have a slightly lower overall unmet need for family planning (13 percent) compared with women who do not participate in any household decisions (15 percent). Table 15.10 Women's empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women's empowerment, Zimbabwe 2010-11 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of currently married women For spacing For limiting Total Number of decisions in which women participate3 0 4.3 234 9.8 5.3 15.1 241 1-2 4.2 1,203 8.7 4.4 13.1 1,211 3 4.0 4,219 6.8 5.8 12.6 4,251 Number of reasons for which wife beating is justified4 0 3.6 5,495 6.5 6.0 12.5 3,377 1-2 3.9 2,453 9.0 4.8 13.8 1,545 3-4 4.2 941 7.9 4.9 12.7 640 5 4.4 200 7.1 1.7 8.8 141 Total 3.8 9,089 7.3 5.5 12.8 5,703 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.10.1 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 15.6.1 for the list of decisions. 4 See Table 15.7.1 for the list of reasons. Desired family size increases with the number of reasons a woman thinks that wife beating is justified, from 3.6 children among women who do not agree with any of the reasons justifying wife beating to 4.4 children among women who agree with all five reasons justifying wife beating. The total unmet need for family planning is lowest among women who agree with five reasons justifying wife beating (9 percent) and is equivalently higher among all other women, whether they agree with none of the reasons justifying wife beating or one to four reasons justifying wife beating (13 to 14 percent). 15.9 WOMEN’S EMPOWERMENT AND REPRODUCTIVE HEALTH CARE Table 15.11 shows women’s use of antenatal, delivery, and postnatal care services from health care workers by level of empowerment, as measured by the two empowerment indicators. Increased empowerment of women is likely to increase their ability to seek out and use health services, enabling them to better meet their reproductive health goals, including safe motherhood. The results in Table 15.11 show that, overall, there is a correlation between women’s empowerment and reproductive health care. Women who participate in all three household decisions are more likely to receive antenatal care (91 percent), delivery care (68 percent), or a postnatal check- up within the first two days after birth (30 percent) than women who participate in fewer or no household decisions. Women who agree with none of the five reasons justifying wife beating were generally more likely to receive antenatal care or delivery care from a skilled provider or a postnatal check-up within the first two days following delivery than women who agree with fewer or no reasons. For example, Women’s Empowerment and Demographic and Health Outcomes • 249 32 percent of women who disagree with all five reasons justifying wife beating received postnatal care within two days following birth compared with 16 percent of women who agree with all five reasons justifying wife beating. Table 15.11 Reproductive health care by women's empowerment Percentage of women age 15-49 with a live birth in the five years preceding the survey who received antenatal care, delivery assistance, and postnatal care from health personnel for the most recent birth, by indicators of women's empowerment, Zimbabwe 2010-11 Empowerment indicator Percentage receiving antenatal care from a skilled provider1 Percentage receiving delivery care from a skilled provider1 Percentage of women with a postnatal check-up in the first two days after birth2 Number of women with a child born in the past five years Number of decisions in which women participate3 0 82.5 60.9 22.1 164 1-2 89.7 65.3 21.3 829 3 90.8 68.3 30.1 2,775 Number of reasons for which wife beating is justified4 0 90.2 71.1 32.0 2,564 1-2 90.4 65.2 23.7 1,234 3-4 87.8 58.7 18.2 508 5 82.7 45.3 15.7 121 Total 89.8 67.3 27.6 4,426 1 Skilled provider includes doctor, nurse-midwife, or nurse. 2 Includes women who received a postnatal checkup from a doctor, nurse midwife, nurse, village health worker or traditional birth attendant (TBA) in the first two days after the birth. Includes women who gave birth in a health facility and those who did not give birth in a health facility. 3 Restricted to currently married women. See Table 15.6.1 for the list of decisions. 4 See Table 15.7.1 for the list of reasons. 15.10 DIFFERENTIALS IN INFANT AND CHILD MORTALITY BY WOMEN’S EMPOWERMENT The abilities of women to access information, make decisions, and act effectively in their own interest, or in the interest of those who depend on them, are essential aspects of the empowerment of women. If women, the primary caretakers of children, are empowered, the health and survival of their infants will be enhanced. In fact, maternal empowerment fits into Mosley and Chen’s framework on child survival as an individual-level variable that affects child survival through the proximate determinants (Mosley, W.H., and L.C. Chen, 1984). Table 15.12 presents mortality rates by the two empowerment indicators. Children of women who participate in one to two decisions have an under-5 mortality rate (110 deaths per 1,000 live births) that is higher than those of children of mothers who participate in three decisions (64 deaths per 1,000 live births). 250 • Women’s Empowerment and Demographic and Health Outcomes Table 15.12 Early childhood mortality rates by indicators of women's empowerment Infant, child, and under-five mortality rates for the 10-year period preceding the survey, by indicators of women's empowerment, Zimbabwe 2010-11 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which women participate1 0 (59) (19) (77) 1-2 81 32 110 3 45 20 64 Number of reasons for which wife beating is justified2 0 44 19 62 1-2 62 27 87 3-4 73 29 100 5 * * * Note: Figures in parentheses are based on 250-499 unweighted person- years of exposure to the risk of death. An asterisk indicates that a rate based on fewer than 250 unweighted person-years of exposure to the risk of death and has been suppressed. 1 Restricted to currently married women. See Table 15.6.1 for the list of decisions. 2 See Table 15.7.1 for the list of reasons. There is a positive correlation between women’s negative attitudes towards wife beating and reduced under-5 mortality. Children whose mothers believe wife beating is not justified for any of the specified reasons have a lower mortality rate (62 deaths per 1,000 live births) than children whose mothers believe wife beating is justified for either one to two reasons (87 deaths per 1,000 live births) or three to four reasons (100 deaths or higher per 1,000 live births). Domestic Violence • 251 DOMESTIC VIOLENCE 16 ender-based violence against women has been acknowledged worldwide as a violation of basic human rights. An increasing amount of research also highlights the health burdens, intergenerational effects, and demographic consequences of such violence (United Nations, 2006). The World Health Organisation defines such violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (Krug et al., 2002). This chapter focuses on domestic violence, a form of gender-based violence, which is defined here as any act of violence resulting in physical, sexual, or psychological harm or suffering to women, girls, and also men, including threats of such acts, coercion, or arbitrary deprivation of liberty. In Zimbabwe, domestic violence is widely acknowledged to be of great concern, not just from a human rights perspective but also from an economic and health perspective. In 2006, Zimbabwe enacted the Domestic Violence Act “to make provision for the protection and relief of victims of domestic violence” (Domestic Violence Act [Chapter 5:16] Act 14/2006). Despite the new legislation and ongoing efforts to protect women and vulnerable populations against violence, there is widespread recognition in Zimbabwe that much remains to be done to protect victims. Also, reliable data are needed to further inform and educate the population about the problem. To collect these data, the 2010-11 ZDHS again included the same module with questions on domestic violence that was included in the 2005-06 ZDHS. This series of questions focuses on specific aspects of domestic and interpersonal violence. The module addresses women’s experiences of acts of physical and sexual violence. Information is collected on both domestic violence (also known as spousal violence or intimate partner violence) and violence by other family members or unrelated individuals. Specifically, this chapter presents the findings of women age 15-49 who experience interpersonal physical or sexual violence. It describes when and from whom they sought help. The chapter also provides detailed information from ever-married women on their experience of spousal emotional, physical, and sexual violence, ever and in the past 12 months, the physical consequences of the violence and when the violence first began in the relationship. Information is also included on women’s perpetration of spousal violence. In the final section of the chapter, key G Key Findings • Thirty percent of women age 15-49 have experienced physical violence since age 15; 18 percent of women have experienced physical violence within the past 12 months. • The most common perpetrator of physical violence against women is the woman’s current or former husband or partner. • Twenty-two percent of women who have had sexual intercourse reported that their first experience was forced against their will. • Overall, 27 percent of women reported that they have experienced sexual violence. In nine of ten cases, their current or former husband, partner, or boyfriend committed the act. • Only 37 percent of women who experienced physical or sexual violence have sought help. Most turned to family (58 percent), in-laws (36 percent), and friends or neighbours (13 percent) for assistance. 252 • Domestic Violence indicators of violence from the 2010-11 ZDHS are compared with those from the 2005-06 ZDHS to document any change. 16.1 MEASUREMENT OF VIOLENCE Collecting valid, reliable, and ethical data on intimate partner violence poses particular challenges because (1) what constitutes violence or abuse varies across cultures and individuals and (2) a “culture of silence” can create sensitivity and affect reporting. Assuring the safety of respondents and interviewers when asking questions about domestic violence in a familial setting and protecting those women who disclose violence raise specific ethical concerns. The responses to these challenges that are posed by the 2010-11 ZDHS are described below. 16.1.1 The Use of Valid Measures of Violence The 2010-11 ZDHS measures violence committed by spouses and by other household members. Accordingly, information was obtained from ever-married women on violence by spouses and others, and from never-married women on violence by anyone, including boyfriends. International research on violence shows that intimate partner violence is one of the most common forms of violence against women. Thus, spousal/partner violence was measured in more detail than violence by other perpetrators through use of a greatly shortened and modified Conflict Tactics Scale (CTS) (Straus, 1990). Specifically, spousal violence by the husband/partner for currently married women and the most recent husband/partner for formerly married women was measured by asking all ever-married women the following set of questions: Does (did) your (last) husband/partner ever: a) Say or do something to humiliate you in front of others? b) Threaten to hurt or harm you or someone close to you? c) Insult you or make you feel bad about yourself? Does (did) your (last) husband/partner ever do any of the following things to you? d) Push you, shake you, or throw something at you? e) Slap you? f) Twist your arm or pull your hair? g) Punch you with his fist or with something that could hurt you? h) Kick you, drag you, or beat you up? i) Try to choke you or burn you on purpose? j) Threaten or attack you with a knife, gun, or any other weapon? k) Physically force you to have sexual intercourse with him even when you did not want to? l) Force you to perform any sexual acts you did not want to? When the answer to any of these questions was “yes,” women were asked about the frequency of the act in the 12 months preceding the survey. A “yes” answer to one or more of items (a) to (c) above constitutes evidence of emotional violence, a “yes” answer to one or more of items (d) to (j) constitutes evidence of physical violence, and a “yes” answer to items (k) or (l) constitutes evidence of sexual violence. Domestic Violence • 253 This approach of asking about specific acts to measure different forms of violence has the advantage of not being affected by different understandings of what constitutes a summary term such as violence. By including a wide range of acts, the approach also has the advantage of giving the respondent multiple opportunities to disclose any experience of violence. In addition to these questions asked only of ever-married women, all women were asked about physical violence perpetrated by others with the question: From the time you were 15 years old, has anyone [other than your current (last) husband/partner] hit, slapped, kicked, or done anything else to hurt you physically? Respondents who answered this question in the affirmative were asked who had done this to them. A similar question was used to ask women who had ever been pregnant about violence during pregnancy. Women were also asked about sexual violence by anyone other than the current husband/partner using the following question: At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts? Finally, information was also obtained from women who had ever had sex regarding whether or not their sexual initiation was forced. Although this approach to questioning is generally considered to be optimal, the possibility of underreporting of violence cannot be entirely ruled out in any survey. 16.1.2 Ethical Considerations Three specific protections were built into the questionnaire in accordance with the World Health Organisation’s ethical and safety recommendations for research on domestic violence (WHO, 2001): 1. Only one eligible woman in each household was administered the questions on violence. The DHS protocol specifies that the domestic violence module can only be administered to one randomly selected woman per household. Therefore, in households with more than one eligible woman, the respondent for the module was selected using a CSPro random generation function. Interviewing only one woman in each household for the domestic violence module provides assurance to the selected respondent that other respondents in the household will not know about the questions the selected respondent was asked. 2. Informed consent for the survey was obtained from the respondent at the beginning of the individual interview. In addition, at the beginning of the domestic violence section, respondents were read an additional statement informing them that the subsequent questions could be sensitive and reassuring them of the confidentiality of their responses. 3. The domestic violence module was implemented only if privacy could be obtained. If privacy could not be obtained, the interviewer was instructed to skip the module, thank the respondent, and end the interview. Complete privacy is also essential for ensuring the security of the respondent and the interviewer. Asking about or reporting violence, especially in households where the perpetrator may be present at the time of interview, carries the risk of further violence. Further, collection of such sensitive information requires the establishment of rapport between the interviewer and the respondent. Accordingly, interviewers were provided with specific training for implementing the domestic violence module to enable the field staff to collect violence data in a secure, confidential, and ethical manner. 254 • Domestic Violence 16.1.3 Subsample for the Violence Module In keeping with the ethical requirements, only one woman per household was selected for the module. In all, 6,694 women (unweighted) were eligible for the module, of which 6,542 were interviewed. Two percent of eligible women were not interviewed with the module because complete privacy could not be obtained. Specially constructed weights were used to adjust for the selection of only one woman per household and to ensure that the domestic violence subsample was nationally representative. 16.2 WOMEN’S EXPERIENCE OF PHYSICAL VIOLENCE This section provides information on women’s ex- perience of physical violence since age 15 and also describes the perpetrators of the violence. In Zimbabwe, women from all socio- economic and cultural backgrounds are subject to violence. Table 16.1 shows the percentage of women age 15-49 who have ever experienced any form of physical violence since age 15,1 by back- ground characteristics. Over-all, 30 percent of women experienced physical violence since age 15, and 18 percent have experienced such violence in the past year. Women’s experience of physical violence since age 15 varies little by age among women age 20-49; however, women age 15-19 are less likely than older women to have experienced vio- lence since age 15. Women who never married and women with no children are also less likely than ever-married women and women with children to have experienced physical violence. Employed women, particularly if they are not earning cash for their work, have higher rates of violence than women who are not employed (36-41 percent, compared with 25 percent). 1 For women who report only spousal violence and were married before age 15, the violence could have first occurred before age 15. Table 16.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced physical violence during the 12 months preceding the survey, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who have ever experienced physical violence since age 15: Number of women Ever1 In the past 12 months Often Sometimes Any Age 15-19 22.7 2.1 14.4 16.5 1,341 20-24 34.9 3.0 19.3 22.4 1,357 25-29 33.3 4.8 18.1 22.8 1,219 30-39 28.7 2.9 13.1 16.0 1,691 40-49 30.7 4.2 9.7 13.9 934 Employment (past 12 months) Employed for cash 35.9 4.2 16.0 20.2 2,635 Employed not for cash 40.9 3.3 19.8 23.1 165 Not employed 25.2 2.7 14.3 16.9 3,742 Marital status Never married 18.2 1.1 7.6 8.7 1,526 Married/living together 31.2 3.9 17.8 21.7 4,094 Divorced/separated/ widowed 43.3 4.5 15.4 19.9 921 Number of living children 0 21.1 1.9 10.2 12.1 1,734 1-2 33.5 3.6 18.8 22.5 2,719 3-4 32.2 4.4 15.0 19.4 1,477 5+ 33.0 3.2 12.7 15.8 613 Residence Urban 28.9 3.1 15.0 18.1 2,469 Rural 30.5 3.4 15.2 18.6 4,073 Province Manicaland 36.0 5.0 16.4 21.4 885 Mashonaland Central 45.5 3.8 19.7 23.5 634 Mashonaland East 27.6 3.9 14.2 18.1 605 Mashonaland West 32.6 2.5 17.3 19.8 745 Matabeleland North 14.2 2.3 4.7 7.0 322 Matabeleland South 25.9 2.0 11.1 13.1 332 Midlands 25.4 2.5 13.2 15.7 805 Masvingo 24.3 3.2 17.0 20.2 657 Harare 29.9 3.8 17.3 21.1 1,160 Bulawayo 24.3 1.7 8.2 9.9 398 Education No education 38.3 4.7 12.3 17.1 155 Primary 36.4 4.5 17.8 22.3 1,848 Secondary 27.8 2.9 14.7 17.6 4,245 More than secondary 14.5 0.3 5.8 6.1 293 Wealth quintile Lowest 30.7 3.8 16.2 20.0 1,117 Second 34.8 4.1 16.4 20.5 1,150 Middle 30.6 3.1 15.1 18.2 1,220 Fourth 28.8 3.6 14.5 18.1 1,464 Highest 26.3 2.4 13.8 16.2 1,590 Total 29.9 3.3 15.1 18.4 6,542 1 Includes in the past 12 months Domestic Violence • 255 There is little variation in women’s experience of physical violence by urban-rural residence; however, the prevalence of physical violence since age 15 varies greatly by province. The percentage of women age 15-49 who have experienced physical violence since age 15 varies from a relative low of 14 percent in Matabeleland North to a high of 46 percent in Mashonaland Central. Women’s experience of violence declines sharply with education, from 38 percent among women with no education to 15 percent among women with more than secondary education. Women’s experience of violence varies inconsistently with wealth, although women in the highest wealth quintile are less likely than women in other wealth quintiles to have experienced violence since age 15. Women’s experience of physical violence in the past 12 months varies similarly with most background characteristics. Notably, most women who have experienced any physical violence in the past 12 months report experiencing such violence “sometimes” (15 percent). Three percent of all women have experienced physical violence often in the past 12 months. Table 16.2 shows the percent distribution of women reporting any physical violence since age 15 by the person or persons who committed the acts of violence against them, according to marital status. Among all women who experienced violence since age 15, a total of 57 percent reported that their current husband/ partner was the perpetrator, and 20 percent reported that the perpetrator was a former husband/partner. Five percent of all women who have experienced physical violence since age 15 reported that the perpetrator was their mother or stepmother and 7 percent reported ‘other relative’ as the perpetrator. Most ever-married women who report physical violence, report their current or former husband/partner to be the perpetrator. Among never-married women, the most common perpetrators are family members. Of particular note is that more than one in four never-married women reports “other relative” as the perpetrator of the violence, followed by mother/stepmother and father/stepfather. For 16 percent of never-married women, a teacher was reported as a perpetrator. 16.3 FORCE AT SEXUAL INITIATION Table 16.3 shows the percentage of women, among all women age 15-49 who have ever had sex who report that their first sexual intercourse was forced against their will. The table shows that 22 percent reported that their first sexual intercourse was forced against their will. Table 16.2 Persons committing physical violence Among women age 15-49 who have experienced physical violence since age 15, percentage who report specific persons who committed the violence, according to the respondent's marital status, Zimbabwe 2010-11 Person Marital status Total Ever married Never married Current husband/partner 66.4 na 57.0 Former husband/partner 23.7 na 20.3 Current boyfriend 0.1 1.1 0.2 Former boyfriend 1.6 9.4 2.7 Father/step-father 2.4 14.3 4.1 Mother/step-mother 2.7 21.8 5.4 Sister/brother 3.0 11.7 4.3 Daughter/son 0.1 0.0 0.1 Other relative 3.5 25.5 6.6 Mother-in-law 0.1 na 0.3 Other in-law 1.2 na 1.0 Teacher 1.6 16.1 3.6 Employer/someone at work 0.3 0.6 0.3 Police/soldier 0.2 0.0 0.2 Other 3.7 15.2 5.4 Number of women 1,678 277 1,956 na = Not applicable 256 • Domestic Violence Table 16.3 Force at sexual initiation Percentage of women age 15-49 who have ever had sexual intercourse who say that their first experience of sexual intercourse was forced against their will, by age at first sexual intercourse and whether the first sexual intercourse was at the time of first marriage or before first marriage, Zimbabwe 2010-11 Background characteristic Percentage whose first sexual intercourse was forced against their will Number of women who have ever had sex Age at first sexual intercourse <15 28.0 319 15-19 23.3 3,370 20-24 16.8 1,179 25-29 18.7 169 30-49 * 19 Don’t know/missing 18.7 348 First sexual intercourse was: At the time of first marriage/first cohabitation 21.0 2,848 Before first marriage/first cohabitation1 22.8 2,208 Don’t know/missing 18.7 348 Total 21.6 5,405 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes never married women Notably, the likelihood that a woman’s sexual initiation was forced varies by age at first sex but not by whether the first intercourse took place within or before marriage. Twenty-eight percent of women who first had sex before age 15 said that they were forced against their will to have the sex, compared with 17 to 19 percent of women who first had sex at age 20 or later. 16.4 EXPERIENCE OF SEXUAL VIOLENCE Table 16.4 shows that overall 27 percent of women reported that they have experienced sexual violence at some point in their lives. The percentage of women who have ever experienced sexual violence increases with age, from 18 percent among women age 15-19 to 33 percent among women age 25-29 and then declines. Domestic Violence • 257 Table 16.4 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who have ever experienced sexual violence1 Number of women Age 15-19 18.0 1,341 20-24 30.1 1,357 25-29 32.7 1,219 30-39 28.8 1,691 40-49 26.3 934 Employment (past 12 months) Employed for cash 32.8 2,635 Employed not for cash 34.8 165 Not employed 22.9 3,742 Marital status Never married 12.1 1,526 Married/living together 30.7 4,094 Divorced/separated/ widowed 36.8 921 Number of living children 0 16.2 1,734 1-2 33.0 2,719 3-4 29.1 1,477 5+ 28.0 613 Residence Urban 28.0 2,469 Rural 26.7 4,073 Province Manicaland 32.8 885 Mashonaland Central 32.9 634 Mashonaland East 26.6 605 Mashonaland West 32.4 745 Matabeleland North 10.0 322 Matabeleland South 18.5 332 Midlands 25.6 805 Masvingo 23.0 657 Harare 29.9 1,160 Bulawayo 20.4 398 Education No education 26.3 155 Primary 27.8 1,848 Secondary 27.2 4,245 More than secondary 24.0 293 Wealth quintile Lowest 26.5 1,117 Second 26.1 1,150 Middle 27.9 1,220 Fourth 29.8 1,464 Highest 25.7 1,590 Total 27.2 6,542 1 Includes those whose sexual initiation was forced against their will. The variation in women’s experience of sexual violence by most background characteristics is similar to the variation in their experience of physical violence, with a few notable exceptions. Unlike physical violence, the percentage of women who have experienced sexual violence varies little by education or wealth. Table 16.5 presents information on the age at first experience of sexual violence for women age 15-49 who have ever experienced sexual violence, according to current age. Nine percent of women who have ever experienced sexual violence were age 14 or younger when they first experienced sexual violence, and 49 percent were between age 15 and age 19. Among women age 15-19 who report sexual violence, more than one in five experienced the violence before age 15. 258 • Domestic Violence Table 16.5 Age at first experience of sexual violence Percent distribution of women age 15-49 who have experienced sexual violence by age at first experience of sexual violence, according to current age, Zimbabwe 2010-11 Current Age Age at first experience of sexual violence Total Number of women Less than 10 years 10-14 years 15-19 years 20-49 years Don't know1 15-19 2.1 19.2 66.3 na 12.3 100.0 242 20-24 0.2 3.6 60.7 13.5 22.0 100.0 409 25-29 1.3 6.5 42.1 18.0 32.2 100.0 398 30-39 0.6 4.9 38.9 24.8 30.8 100.0 486 40-49 2.8 8.1 44.0 12.5 32.7 100.0 245 Total 1.2 7.3 49.0 15.6 26.9 100.0 1,780 na = Not applicable 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed and whose sexual initiation was not forced against their will. For these women, the age at first experience of sexual violence was not asked. Table 16.6 shows the perpetrators of sexual violence, for women age 15-49 who have experienced sexual violence, according to age at first experience of sexual violence and current marital status. Overall, the large majority (92 percent) of women reported that the sexual violence was committed by their current or former husband/partner or boyfriend. Eighty-six percent of ever-married women reported that the perpetrator was a current or previous husband/partner, and 62 percent of never-married women reported that the perpetrator was a current or former boyfriend. The perpetrators most frequently reported by women whose first sexual intercourse took place before they were age 15 include relatives (19 percent report the perpetrator to be a relative, and 1 percent report a stepfather), family friends (4 percent), teacher (2 percent), and stranger (8 percent).These data suggest that at least about one-fourth of the sexual violence against young children is perpetrated by people who are trusted by the child and the child’s family. Table 16.6 Persons committing sexual violence Among women age 15-49 who have experienced sexual violence, percentage who report specific persons committing sexual violence according to age at first experience of sexual violence and current marital status, Zimbabwe 2010-11 Person Age at first experience of sexual violence Marital status Total < 15 years 15 years or higher Don't know1 Ever married Never married Current husband/partner 29.1 47.4 78.1 60.3 na 54.0 Former husband/partner 19.8 23.9 21.3 25.5 na 22.8 Current/former boyfriend 10.0 21.8 0.4 9.6 62.2 15.0 Stepfather 1.0 0.2 0.0 0.2 0.0 0.2 Other relative 18.5 2.2 0.1 1.8 13.6 3.0 In-law 0.0 0.8 0.0 0.1 3.9 0.5 Own friend/acquaintance 1.8 0.4 0.0 0.3 1.3 0.4 Family friend 4.4 1.2 0.0 0.3 8.5 1.2 Teacher 1.5 0.1 0.0 0.2 0.0 0.2 Employer/someone at work 0.0 0.2 0.0 0.1 0.0 0.1 Police/soldier 1.1 0.0 0.0 0.1 0.0 0.1 Priest/religious leader 0.0 0.2 0.0 0.1 0.0 0.1 Stranger 8.0 1.3 0.2 1.0 6.2 1.6 Other 4.9 0.4 0.0 0.3 4.4 0.7 Number of women 151 1,151 478 1,596 184 1,780 na = Not applicable 1 Includes women who report having ever experienced sexual violence committed only by their current husband if currently married or most recent husband if divorced, separated, or widowed and whose sexual initiation was not forced against their will. For these women, the age of first experience of sexual violence was not asked. 16.5 EXPERIENCE OF DIFFERENT FORMS OF VIOLENCE Table 16.7 shows information by current age on the percentage of women age 15-49 who reported having experienced physical violence, sexual violence, or both. Overall, 43 percent of women reported that they have experienced physical or sexual violence, whether it was physical only (16 percent), sexual only (14 percent), or both physical and sexual (14 percent). Women’s experience Domestic Violence • 259 of all the different forms of violence does not vary linearly with age, although the younger women are consistently less likely to have experienced each of the different types of violence. Table 16.7 Experience of different forms of violence Percentage of women age 15-49 who have experienced different forms of violence by current age, Zimbabwe 2010-11 Age Physical violence only1 Sexual violence only2 Both physical and sexual violence3 Physical and/or sexual violence4 Number of women 15-19 13.9 9.2 8.8 31.9 1,341 15-17 13.5 6.9 6.2 26.7 781 18-19 14.5 12.4 12.3 39.3 561 20-24 17.7 12.9 17.2 47.8 1,357 25-29 16.1 15.4 17.3 48.7 1,219 30-39 15.5 15.6 13.2 44.3 1,691 40-49 18.7 14.3 11.9 45.0 934 Total 16.2 13.5 13.7 43.4 6,542 1 Women who reported physical violence only. 2 Women who reported sexual violence only. Includes forced sexual initiation. 3 Women who reported that they were both physically and sexually abused. Includes forced sexual initiation. 4 Total women who reported physical abuse, sexual abuse, or physical and sexual abuse. 16.6 VIOLENCE DURING PREGNANCY Experiencing violence during pregnancy not only affects the health of the woman but also can have serious consequences for the unborn child. In the 2010-11 ZDHS, women who had ever been pregnant were asked whether they had experienced any type of physical violence during any of their pregnancies and who the perpetrator of the violence was. Table 16.8 presents findings on violence during pregnancy according to selected background characteristics. Overall, 5 percent of women who have ever been pregnant reported that they experienced violence during one or more of their pregnancies. 260 • Domestic Violence Table 16.8 Violence during pregnancy Among women age 15-49 who have ever been pregnant, percentage who have ever experienced physical violence during pregnancy, by background characteristics, Zimbabwe 2010-11 Background characteristic Percentage who have ever experienced physical violence during pregnancy Number of women who have ever been pregnant Age 15-19 7.4 330 20-24 6.3 1,045 25-29 5.8 1,129 30-39 3.7 1,637 40-49 4.0 912 Marital status Never married 8.8 211 Married/living together 4.4 3,958 Divorced/separated/ widowed 6.7 885 Number of living children 0 4.5 246 1-2 5.0 2,719 3-4 5.4 1,477 5+ 4.7 613 Residence Urban 5.7 1,736 Rural 4.7 3,318 Province Manicaland 6.9 715 Mashonaland Central 5.8 528 Mashonaland East 5.0 490 Mashonaland West 4.5 611 Matabeleland North 4.5 248 Matabeleland South 3.2 241 Midlands 5.0 619 Masvingo 1.8 508 Harare 6.1 832 Bulawayo 4.6 262 Education No education 2.9 148 Primary 5.7 1,617 Secondary 5.1 3,095 More than secondary 0.5 193 Wealth quintile Lowest 5.4 953 Second 5.4 956 Middle 6.0 977 Fourth 4.1 1,145 Highest 4.5 1,022 Total 5.0 5,054 Violence during pregnancy is highest, at 7 percent, among women currently age 15-19 and declines with age to 4 percent among women currently age 30-49. Violence during pregnancy does not vary much by number of living children. Notably, the category of women who have the highest prevalence of violence during pregnancy is never-married women: 9 percent of them have experienced violence during pregnancy. The prevalence of violence during pregnancy varies little by urban-rural residence but shows greater variation by province. Prevalence of violence during pregnancy was highest among women in Manicaland (7 percent) and lowest among women in Masvingo (2 percent). Prevalence of violence varies little with wealth. Women who have the most education are the least likely to have experienced violence during pregnancy. Domestic Violence • 261 16.7 MARITAL CONTROL BY HUSBAND OR PARTNER Attempts by husbands/partners to closely control and monitor their wives’ behaviour have been found to be important early warning signs and correlates of violence in a relationship. A series of questions were included in the 2010-11 ZDHS to elicit the degree of marital control exercised by the husband/partner over the respondent. Controlling behaviours most often manifest themselves in terms of extreme possessiveness, jealousy, and attempts to isolate the woman from her family and friends. Because the concentration of such behaviours is more significant than the display of any single behaviour, the proportion of women whose husbands display at least three of the specified behaviours is highlighted. To examine the degree of marital control by husbands of their wives, ever-married women were asked whether they experienced any of the following six controlling behaviours by their husbands: (1) he is jealous or angry if she talks to other men; (2) he frequently accuses her of being unfaithful; (3) he does not permit her to meet her female friends; (4) he tries to limit contact with her family; (5) he insists on knowing where she is at all times; and (6) he does not trust her with any money. Table 16.9 presents the percentage of ever-married women whose husbands or partners display each of the listed behaviours, by selected background characteristics. Table 16.9 shows that the main controlling behaviours women experience from their husbands are jealousy or anger if they talk to other men and insistence on knowing where they are at all times (53 percent and 44 percent, respectively). Less than one-fifth of ever-married women said that their husbands frequently accuse them of being unfaithful (17 percent), do not permit them to meet their female friends (16 percent), do not trust them with money (12 percent), and try to limit their contact with their families (12 percent). Husbands of almost one in four women display three or more of the specific behaviours; husbands of more than one-third of women do not display any of the controlling behaviours. 262 • Domestic Violence Table 16.9 Degree of marital control exercised by husbands Percentage of ever-married women age 15-49 whose husband/partner ever demonstrates specific types of controlling behaviours, according to background characteristics, Zimbabwe 2010-11 Background characteristic Percentage of women whose husband: Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Does not trust her with any money Displays 3 or more of the specific behaviours Displays none of the specific behaviours Number of women Age 15-19 55.6 18.0 17.1 15.2 53.9 14.6 28.6 27.2 357 20-24 53.7 17.0 16.8 11.5 47.5 9.6 25.3 31.5 1,010 25-29 56.5 16.8 17.1 12.6 46.7 12.9 25.1 29.7 1,109 30-39 51.2 15.8 14.4 10.3 41.0 13.4 22.4 35.2 1,627 40-49 47.4 16.5 13.8 10.6 36.6 11.2 20.7 40.0 912 Employment (past 12 months) Employed for cash 55.7 18.9 16.4 11.5 48.4 14.8 26.3 29.3 2,190 Employed not for cash 55.3 16.2 18.9 13.7 51.5 14.2 26.5 28.7 132 Not employed 49.7 14.7 14.7 11.3 39.4 10.0 21.5 37.3 2,693 Number of living children 0 51.7 15.4 17.6 12.6 49.7 14.9 26.5 32.8 395 1-2 55.0 16.7 16.5 12.1 46.0 12.9 24.9 29.8 2,546 3-4 52.2 16.3 13.0 9.5 41.3 10.3 21.8 36.1 1,465 5+ 43.2 16.9 16.3 12.9 35.8 12.1 21.6 43.4 609 Marital status and duration Currently married women 51.5 14.9 14.5 10.7 42.0 10.4 21.2 34.8 4,094 Married only once 50.4 13.5 13.7 10.0 41.1 9.8 19.8 35.6 3,521 0-4 years 52.2 12.7 16.1 12.0 45.6 10.5 22.6 33.0 1,154 5-9 years 53.2 14.6 12.3 9.5 42.6 9.1 19.1 31.8 817 10+ years 47.6 13.5 12.7 8.8 37.0 9.6 18.0 39.6 1,550 Married more than once 58.3 23.1 19.4 15.3 47.2 14.2 30.0 29.4 573 Divorced/separated/ widowed 56.8 24.0 20.3 14.7 51.3 20.1 35.0 28.2 921 Residence Urban 54.2 16.8 18.7 12.6 46.7 16.6 28.4 30.1 1,695 Rural 51.6 16.4 14.0 10.9 42.1 9.9 21.3 35.3 3,320 Province Manicaland 46.7 15.8 17.4 13.2 41.5 10.5 21.7 37.7 721 Mashonaland Central 63.2 22.7 14.0 9.9 54.9 6.7 23.4 21.8 540 Mashonaland East 63.0 16.0 10.2 7.6 39.0 10.9 21.9 28.6 495 Mashonaland West 51.9 16.5 17.3 12.3 45.0 12.0 24.2 33.9 625 Matabeleland North 42.0 7.9 13.2 9.7 39.1 10.6 18.2 43.0 229 Matabeleland South 43.7 11.0 8.5 6.6 34.5 4.3 13.8 49.5 202 Midlands 54.4 18.6 15.1 12.7 44.9 10.4 24.1 34.0 619 Masvingo 47.2 16.4 16.7 12.7 39.0 14.7 22.8 35.8 524 Harare 51.9 15.1 20.3 13.2 46.7 21.7 31.7 31.0 839 Bulawayo 51.4 19.0 9.6 9.0 39.5 6.1 19.8 37.8 221 Education No education 46.4 28.0 23.2 14.8 40.4 9.6 26.4 39.2 150 Primary 50.8 19.2 15.4 11.6 42.7 13.3 23.9 34.6 1,628 Secondary 54.0 14.9 15.6 11.5 44.6 11.8 24.2 32.7 3,039 More than secondary 47.7 10.9 11.0 6.9 40.5 11.5 13.9 33.8 198 Wealth quintile Lowest 50.9 17.6 15.5 11.3 41.5 11.3 22.1 34.9 945 Second 51.7 17.4 13.5 12.5 42.4 10.1 21.8 33.8 960 Middle 55.6 17.9 15.7 12.5 45.4 12.8 26.3 33.1 981 Fourth 51.8 15.4 14.4 10.4 45.3 13.3 23.5 33.1 1,139 Highest 52.4 14.5 18.9 10.9 43.4 13.1 24.7 32.8 990 Total 52.5 16.5 15.6 11.5 43.7 12.2 23.7 33.6 5,016 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Overall, differences in the proportions of women reporting three or more controlling behaviours are not large across different background characteristics. Divorced, separated, or widowed women (35 percent) are, however, noticeably most likely of all women to report that their last husband/partner displayed three or more controlling behaviours, and the most educated women (14 percent) and women in Matabeleland South (14 percent) are least likely to report three or more controlling behaviours by their husbands. Domestic Violence • 263 16.8 FORMS OF SPOUSAL VIOLENCE Table 16.10 shows the percentage of ever-married women by their experience of physical, sexual, and emotional spousal violence. It should be noted that different types of violence are not mutually exclusive, and women may report multiple forms of violence. The data show that 29 percent of ever-married women reported having ever experienced any form of physical violence, 26 percent reported any sexual violence, and 27 percent reported any emotional violence. The majority of women who have ever experienced each of these forms of violence have also experienced the same violence in the past 12 months. Table 16.10 Forms of spousal violence Percentage of ever-married women age 15-49 who have experienced various forms of violence ever or in the 12 months preceding the survey, committed by their husband/partner, Zimbabwe 2010-11 Type of violence Ever In the past 12 months Often Sometimes Any Physical violence Any 28.8 3.9 16.8 20.7 Pushed her, shook her, or threw something at her 10.0 2.3 5.6 7.9 Slapped her 24.0 2.9 14.0 16.8 Twisted her arm or pulled her hair 4.8 0.7 1.5 2.2 Punched her with his fist or with something that could hurt her 9.4 1.8 4.9 6.7 Kicked her, dragged her, or beat her up 8.6 1.6 4.5 6.1 Tried to choke her or burn her on purpose 1.6 0.5 0.8 1.4 Threatened her or attacked her with a knife, gun, or any other weapon 2.0 0.5 0.9 1.4 Sexual violence Any 26.0 3.6 9.7 13.3 Physically forced her to have sexual intercourse with him even when she did not want to 13.3 3.0 8.3 11.2 Forced her to perform any sexual acts she did not want to 8.6 1.8 5.4 7.2 Sexual initiation was with current or most recent husband and was forced 14.8 na na na Emotional violence Any 26.5 6.2 16.5 22.7 Said or did something to humiliate her in front of others 10.5 2.8 6.2 9.0 Threatened to hurt or harm her or someone close to her 9.4 2.5 5.5 7.9 Insulted her or made her feel bad about herself 21.3 4.4 14.0 18.4 Any form of physical and/or sexual violence 42.3 6.3 20.9 27.2 Any form of physical and sexual violence 12.5 1.2 4.6 5.8 Any form of emotional, physical and/or sexual violence 49.6 9.4 25.9 35.3 Any form of emotional, physical and sexual violence 8.4 0.9 2.9 3.8 Number of women 5,016 5,016 5,016 5,016 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. na = Not applicable As Table 16.10 and Figure 16.1 show, the most common form of spousal physical violence is slapping (24 percent), followed by pushing, shaking, having something thrown at her (10 percent), punching (9 percent), kicking, dragging, or beating (9 percent), and arm twisting or hair pulling (5 percent). Seventeen percent of women reported that they had been slapped within the past 12 months preceding the survey. 264 • Domestic Violence Figure 16.1 Percentage of Ever-married Women Who Have Experienced Specific Forms of Violence Committed by Their Most Recent Husband/Partner, Ever and during the Past 12 Months 10 24 5 9 9 2 2 13 9 42 8 17 2 7 6 1 1 11 7 27 Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here Form of violence here 0 10 20 30 40 50 Percent Ever Past 12 months ZDHS 2010-11 Pushed her, shook her, or threw something at her Punched her with his fist or with something that could hurt her Kicked her, dragged her, or beat her up Tried to choke her or burn her on purpose Threatened her or attacked her with a knife, gun, or any other weapon Physically forced her to have sexual intercourse with him even when she did not want to Forced her to perform any sexual acts she did not want to At least one of these acts Twisted her arm or pulled her hair Slapped her With respect to spousal sexual violence, 13 percent of women reported their husband/partner forced them to have sexual intercourse, and 9 percent said they were made to perform other sexual acts against their will. Thirteen percent of ever-married women reported experiencing one or both of these acts of spousal sexual violence during the 12 months preceding the survey. Fifteen percent of ever-married women said that their sexual initiation was with their current husband and was forced. The most common form of emotional spousal violence is a husband insulting or making his wife feel bad about herself (21 percent), followed by humiliating the wife in front of others (11 percent) and threatening to harm her or someone close to her (9 percent). Overall, half of all ever- married women have ever experienced some form of physical, sexual, or emotional violence by their current or most recent husband, and 35 percent have experienced such violence in the past 12 months. Further, 42 percent of ever-married women have ever experienced spousal physical or sexual violence and 27 percent have done so in the past 12 months. Table 16.11 presents the percentage of ever-married women by their experience of emotional, physical, or sexual spousal violence, according to selected background characteristics. Younger ever- married women are more likely than older women to have experienced most forms of violence: (58 percent of women age 15-19 have experienced physical, sexual, or emotional violence, compared with 45 percent of women 30 years or older). Women who are employed are more likely than women who are not to have experienced each of the different forms of spousal violence. Although experience of emotional violence and physical violence does not vary much by number of children, experience of spousal sexual violence declines with number of children. Divorced, widowed, and separated women have the highest experience of one or more of the three forms of spousal violence (56 percent). Among currently married women, experience of violence varies little by duration of marriage. Domestic Violence • 265 Table 16.11 Spousal violence by background characteristics Percentage of ever-married women age 15-49 by whether they have ever experienced emotional, physical, or sexual violence committed by their husband/partner, according to background characteristics, Zimbabwe 2010-11 Background characteristic Emotional violence Physical violence Sexual violence Physical and/or sexual violence Physical and sexual violence Emotional, physical, and/or sexual violence Emotional, physical, and sexual violence Number of women Age 15-19 29.6 29.1 38.3 48.6 18.9 57.9 14.0 357 20-24 30.6 34.8 29.3 48.6 15.5 54.8 10.4 1,010 25-29 26.6 31.1 28.9 45.7 14.3 52.4 9.1 1,109 30-39 24.0 24.8 22.9 37.5 10.3 45.4 6.8 1,627 40-49 24.7 26.3 19.6 37.6 8.3 45.0 5.8 912 Employment (past 12 months) Employed for cash 29.3 32.0 28.1 46.7 13.3 53.8 9.3 2,190 Employed not for cash 36.9 38.8 30.5 52.5 16.8 62.2 11.4 132 Not employed 23.7 25.8 24.1 38.3 11.6 45.7 7.5 2,693 Number of living children 0 26.1 27.0 33.2 44.6 15.6 50.2 12.4 395 1-2 27.5 29.7 27.1 43.8 12.9 51.2 8.6 2,546 3-4 24.7 27.8 24.1 40.2 11.7 48.2 7.1 1,465 5+ 26.3 28.8 21.6 39.8 10.7 46.2 7.9 609 Marital status and duration Currently married women 24.9 26.9 25.7 40.9 11.7 48.1 7.8 4,094 Married only once 24.3 26.2 27.0 41.5 11.7 48.4 7.7 3,521 0-4 years 26.3 26.0 28.3 41.1 13.3 48.6 9.1 1,154 5-9 years 24.4 30.8 28.5 45.4 13.9 50.8 9.3 817 10+ years 22.7 24.0 25.2 39.8 9.4 47.0 5.7 1,550 Married more than once 28.7 31.1 17.8 37.3 11.5 46.5 8.6 573 Divorced/separated/ widowed 33.3 37.2 27.4 48.6 16.1 56.4 11.0 921 Residence Urban 25.5 26.2 26.8 40.5 12.4 47.6 8.5 1,695 Rural 27.0 30.2 25.6 43.3 12.5 50.7 8.3 3,320 Province Manicaland 33.1 31.9 33.7 49.1 16.5 56.7 11.1 721 Mashonaland Central 31.4 41.6 30.8 56.4 16.0 62.5 9.7 540 Mashonaland East 20.2 29.9 25.3 42.0 13.3 47.2 8.1 495 Mashonaland West 29.2 30.8 29.2 46.7 13.3 54.6 9.8 625 Matabeleland North 17.0 12.5 7.7 16.6 3.7 25.2 3.1 229 Matabeleland South 29.5 30.7 14.1 35.7 9.1 45.1 8.0 202 Midlands 27.2 25.8 25.1 39.0 12.0 47.6 9.0 619 Masvingo 23.2 25.9 23.6 40.1 9.4 46.8 5.2 524 Harare 22.5 25.6 27.2 40.3 12.4 47.3 7.9 839 Bulawayo 26.5 22.0 15.2 29.2 8.1 37.6 6.3 221 Education No education 27.5 33.6 25.1 42.9 15.7 51.2 8.9 150 Primary 28.7 34.0 24.1 44.8 13.3 52.3 9.9 1,628 Secondary 25.7 26.9 27.4 42.1 12.2 49.3 7.8 3,039 More than secondary 18.5 11.9 21.2 26.0 7.0 32.7 4.9 198 Wealth quintile Lowest 26.2 30.9 23.4 42.0 12.3 49.9 7.4 945 Second 30.6 33.9 26.1 46.6 13.5 53.3 9.4 960 Middle 27.1 30.2 25.6 43.1 12.8 51.4 8.1 981 Fourth 24.7 25.6 28.6 42.2 12.0 50.3 8.0 1,139 Highest 24.0 24.1 25.8 38.0 11.9 43.2 9.0 990 Respondent's father beat her mother Yes 31.1 36.5 31.2 50.6 17.1 57.4 11.6 1,874 No 22.2 23.0 22.0 35.9 9.1 43.4 5.9 2,703 Don't know 32.6 31.8 28.6 46.5 13.9 54.6 9.6 438 Total 26.5 28.8 26.0 42.3 12.5 49.6 8.4 5,016 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Ever-married women’s experience of spousal violence varies little by urban-rural residence, but there is substantial variation by province. One or more forms of the three different forms of spousal violence are most common among women in Mashonaland Central (63 percent) and least common among women in Matabeleland North (25 percent). Overall, women with secondary or higher education are less likely to experience spousal violence than uneducated women or those with only primary education. Although a higher wealth status is also associated with a lower occurrence of spousal violence, it is important to note that over 266 • Domestic Violence two-fifths of women, even in the highest wealth quintile, have experienced some form of spousal emotional, physical, or sexual violence. Over half of ever-married women who reported experiencing any form of spousal abuse also reported that their father beat their mother (57 percent). Despite some variation by background characteristics, what is most notable about the results of ever-married women’s experience of spousal violence is the high prevalence of such violence among all categories of women. At least two in five women in almost all categories have experienced spousal physical or sexual violence, and almost half have experienced emotional, physical, or sexual violence. 16.9 VIOLENCE BY SPOUSAL CHARACTERISTICS AND WOMEN’S INDICATORS Table 16.12 presents information on ever-married women’s experience of spousal violence by husband’s characteristics and women’s empowerment indicators. Women whose husbands have more than secondary education are less likely than women with husbands with no or lower education to experience spousal violence. However, women’s experience of violence varies little by spousal age and educational differences. As expected, a husband’s alcohol consumption is strongly associated with women’s experience of any form of violence; nonetheless, even among women whose husbands do not drink at all, the proportion reporting any form of spousal violence is very high (42 percent). Table 16.12 Spousal violence by husband's characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have ever suffered emotional, physical, or sexual violence committed by their husband/partner, according to his characteristics, marital characteristics, and empowerment indicators, Zimbabwe 2010-11 Background characteristic Emotional violence Physical violence Sexual violence Physical and/or sexual violence Physical and sexual violence Emotional, physical and/or sexual violence Emotional, physical and sexual violence Number of women Husband's/partner's education No education 32.5 33.4 18.8 41.4 10.8 51.3 8.1 127 Primary 28.2 30.9 22.7 42.4 11.3 50.4 8.2 1,009 Secondary 26.6 28.9 28.1 43.5 13.5 50.6 8.8 3,398 More than secondary 18.6 21.3 22.1 35.1 8.3 40.9 5.4 357 Don’t know 25.9 25.4 15.2 30.8 9.9 41.5 8.1 124 Husband's/partner's alcohol consumption Does not drink 21.1 20.7 22.5 34.1 9.2 41.6 5.9 2,635 Drinks alcohol but is never drunk 24.6 23.8 23.3 36.8 10.4 45.3 6.6 57 Is sometimes drunk 26.3 33.0 26.6 46.9 12.7 53.6 7.5 1,674 Is often drunk 48.8 51.4 39.0 64.7 25.7 72.8 20.8 648 Spousal age difference1 Wife older 26.9 30.1 19.2 37.2 12.1 42.8 9.6 136 Wife is same age 21.7 33.1 24.4 45.8 11.7 50.3 6.9 161 Wife's 1-4 years younger 26.0 27.5 25.8 40.8 12.5 48.6 7.9 1,450 Wife's 5-9 years younger 25.2 26.5 27.6 42.3 11.9 49.7 8.1 1,461 Wife's 10+ years younger 23.0 24.9 23.6 38.6 10.0 45.1 7.0 885 Spousal education difference Husband has more education 26.7 31.1 26.9 44.3 13.7 51.2 9.2 2,448 Wife has more education 28.8 25.3 23.6 38.9 10.0 47.5 7.9 893 Both have equal education 24.7 27.0 26.7 41.9 11.9 48.8 7.3 1,492 Neither has any education (30.3) (27.9) (26.7) (36.0) (18.6) (41.2) (16.1) 27 Missing 24.9 30.7 19.6 37.1 13.2 47.3 7.7 156 Number of marital control behaviours displayed by husband/partner1 0 10.1 12.9 13.8 22.9 3.8 27.3 1.8 1,683 1-2 24.4 28.1 27.7 45.0 10.8 53.0 6.0 2,143 3-4 47.5 48.0 37.5 61.6 23.9 71.8 18.0 938 5-6 74.4 69.5 51.0 78.2 42.3 87.6 36.5 252 Number of decisions in which women participate2,3 0 33.2 28.0 25.0 41.7 11.2 52.6 8.1 189 1-2 30.8 34.0 32.6 49.4 17.2 55.8 12.0 835 3 22.8 24.9 23.9 38.6 10.2 45.8 6.6 3,070 Number of reasons for which wife-beating is justified4 0 23.3 24.8 23.4 37.8 10.4 44.6 7.4 2,996 1-2 30.2 34.8 31.1 48.9 17.1 56.8 10.5 1,345 3-4 34.1 36.0 28.8 51.3 13.6 59.3 9.3 540 5 27.5 29.5 21.3 42.5 8.3 50.4 5.2 135 Total 26.5 28.8 26.0 42.3 12.5 49.6 8.4 5,016 Notes: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in parentheses are based on 25-49 unweighted cases. Total includes 2 cases for which husband’s/partner’s alcohol consumption is missing. 1 See Table 16.9 for a list of behaviours. 2 Currently married women 3 See Table 15.6.1 for the list of decisions. 4 See Table 15.7.1 for the list of reasons. Domestic Violence • 267 Women’s experience of spousal violence and the number of marital control behaviours exhibited by the husband are strongly associated: 27 percent of women whose husbands do not display any of the six marital control behaviours asked about have experienced emotional, physical, or sexual spousal violence, compared with 88 percent of women whose husbands display five to six behaviours. Women’s empowerment is negatively associated with women’s experience of spousal violence. Women who participate in all three household decisions (46 percent) and those who reject all reasons for wife beating (45 percent) are less likely than women who participate in zero to two decisions (53-56 percent) and women who accept one or more reasons for wife beating (50-59 percent) to have ever experienced emotional, physical, or sexual spousal violence. 16.10 FREQUENCY OF SPOUSAL VIOLENCE In the 2010-11 ZDHS, women who reported any spousal violence were asked whether they had experienced the violence often, sometimes, or not all in the past year. Table 16.13 shows the percent distribution of ever-married women reporting spousal emotional violence and spousal physical or sexual violence by how often the violence had occurred in the 12 months prior to the survey, according to background characteristics. The data show that 86 percent of ever-married women who have ever experienced emotional violence by their current or most recent husband/partner, experienced the violence in the past 12 months, with the vast majority experiencing the violence “sometimes” rather than “often” in the past 12 months. Nonetheless, one in four women who reported any spousal emotional violence experienced such violence often in the past 12 months. Similarly, among women who reported experiencing spousal physical or sexual violence, more than three in four experienced the violence in the past 12 months, including 18 percent who experienced physical or sexual violence “often” during the period. Among women who have ever experienced spousal violence, experience of the violence in the past 12 months varies strongly and inversely with age—the older the women, the less likely they are to have experienced the violence recently. Employed women are less likely than their unemployed counterparts to have experienced violence in the past 12 months. Similarly, although less educated women are more likely than women with more education to have ever experienced spousal violence, they are less likely to have experienced the violence recently. 268 • Domestic Violence Table 16.13 Frequency of spousal violence Percent distribution of ever-married women age 15-49 who have ever suffered emotional violence committed by their current husband/partner by frequency of violence in the 12 months preceding the survey and percent distribution of those who have ever suffered physical or sexual violence committed by their current or most recent husband/partner by frequency of violence in the 12 months preceding the survey, according to background characteristics, Zimbabwe 2010-11 Background characteristic Frequency of emotional violence in the past 12 months Frequency of physical or sexual violence in the past 12 months Often Sometimes Not at all Total Number of women Often Sometimes Not at all Total Number of women Age 15-19 29.2 70.0 0.9 100.0 106 21.8 76.7 1.5 100.0 133 20-24 23.2 66.9 9.9 100.0 309 15.3 70.4 14.4 100.0 412 25-29 25.9 67.2 6.9 100.0 295 20.5 63.6 15.9 100.0 425 30-39 21.1 60.0 18.9 100.0 391 17.4 54.2 28.5 100.0 500 40-49 22.1 50.0 28.0 100.0 225 16.6 40.0 43.4 100.0 288 Employment (past 12 months) Employed for cash 26.6 56.1 17.3 100.0 641 17.0 57.2 25.9 100.0 852 Employed not for cash 16.4 62.9 20.7 100.0 49 17.0 48.4 34.6 100.0 61 Not employed 20.9 68.4 10.6 100.0 637 18.8 62.9 18.3 100.0 845 Number of living children 0 31.8 52.6 15.6 100.0 103 19.9 59.6 20.5 100.0 137 1-2 23.4 64.2 12.5 100.0 701 16.7 64.9 18.3 100.0 918 3-4 21.8 63.1 15.1 100.0 362 20.7 54.8 24.5 100.0 491 5+ 22.4 58.5 19.2 100.0 160 14.8 47.8 37.4 100.0 212 Marital status and duration Currently married women 24.2 70.2 5.6 100.0 1,020 19.6 65.6 14.8 100.0 1,370 Married only once 22.9 71.4 5.7 100.0 856 17.7 67.5 14.8 100.0 1,157 0-4 years 24.6 72.9 2.6 100.0 304 16.6 77.4 6.0 100.0 370 5-9 years 20.2 76.0 3.8 100.0 199 15.3 72.1 12.6 100.0 307 10+ years 23.1 67.5 9.4 100.0 353 20.1 56.9 23.0 100.0 480 Married more than once 30.7 64.0 5.3 100.0 164 29.6 55.6 14.8 100.0 213 Divorced/separated/ widowed 21.1 35.9 43.0 100.0 307 11.7 38.4 49.8 100.0 388 Residence Urban 25.8 61.7 12.5 100.0 432 17.3 64.1 18.6 100.0 537 Rural 22.4 62.5 15.1 100.0 895 18.1 57.6 24.3 100.0 1,221 Province Manicaland 27.2 56.9 15.9 100.0 239 23.0 54.9 22.1 100.0 296 Mashonaland Central 25.2 54.6 20.2 100.0 169 18.7 51.8 29.5 100.0 273 Mashonaland East 35.3 45.6 19.1 100.0 100 22.2 51.4 26.4 100.0 170 Mashonaland West 14.8 77.1 8.1 100.0 182 12.0 67.0 21.0 100.0 248 Matabeleland North 16.8 66.0 17.2 100.0 39 26.6 41.4 32.0 100.0 34 Matabeleland South 9.1 70.0 20.9 100.0 60 10.1 51.6 38.3 100.0 69 Midlands 22.4 65.3 12.3 100.0 169 15.3 64.8 19.9 100.0 189 Masvingo 23.4 73.1 3.5 100.0 122 17.3 76.5 6.2 100.0 163 Harare 27.1 60.9 12.0 100.0 189 16.3 65.5 18.2 100.0 260 Bulawayo 21.0 51.6 27.5 100.0 59 20.0 42.7 37.4 100.0 56 Education No education (27.4) (45.6) (27.0) 100.0 41 17.3 37.9 44.8 100.0 55 Primary 22.7 64.7 12.6 100.0 468 19.6 55.5 25.0 100.0 656 Secondary 23.7 61.6 14.6 100.0 781 17.3 62.9 19.8 100.0 1,009 More than secondary (23.4) (64.0) (12.6) 100.0 37 (2.2) (76.9) (20.9) 100.0 38 Wealth quintile Lowest 23.4 67.0 9.6 100.0 248 19.7 58.7 21.5 100.0 353 Second 23.5 61.8 14.7 100.0 294 18.0 55.1 26.9 100.0 389 Middle 21.7 59.6 18.7 100.0 266 18.0 55.5 26.5 100.0 354 Fourth 26.4 61.5 12.1 100.0 281 20.0 62.5 17.5 100.0 362 Highest 22.1 61.8 16.1 100.0 238 12.6 68.1 19.4 100.0 300 Total 23.5 62.3 14.2 100.0 1,327 17.8 59.6 22.5 100.0 1,758 Notes: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in parentheses are based on 25-49 unweighted cases. Domestic Violence • 269 16.11 ONSET OF SPOUSAL VIOLENCE To study the timing of the onset of marital violence, the 2010-11 ZDHS asked ever-married women who experienced physical or sexual spousal violence when the first episode of violence took place after marriage. Table 16.14 shows the interval between marriage and the first episode of spousal physical or sexual violence. Table 16.14 Onset of marital violence Percent distribution of ever-married women by number of years between marriage and first experience of physical or sexual violence by husband/partner, if ever, according to marital status and number of unions, Zimbabwe 2010-11 Duration since marriage Years between marriage1 and first experience of violence Total Number of women Experienced no violence Before marriage <1 year 1-2 years 3-5 years 6-9 years 10+ years Don't know/ missing Currently married 59.1 2.4 22.0 6.7 5.4 1.9 1.7 0.8 100.0 4,094 Married only once 58.5 2.3 22.9 6.4 5.5 1.8 1.8 0.9 100.0 3,521 < 1 year 68.7 1.5 28.1 na na na na 1.7 100.0 266 1-2 years 57.1 2.0 30.2 8.8 na na na 2.0 100.0 434 3-5 years 55.3 2.4 23.4 12.7 4.6 na na 1.6 100.0 627 6-9 years 54.2 1.6 22.0 8.0 11.5 2.2 na 0.6 100.0 644 10+ years 60.2 2.7 20.1 3.7 5.8 3.2 4.0 0.4 100.0 1,550 Married more than once 62.7 3.5 16.4 8.1 5.0 2.5 1.5 0.3 100.0 573 Divorced/separated/ widowed 51.4 2.8 23.6 7.7 8.2 3.1 2.1 1.1 100.0 921 Total 57.7 2.5 22.3 6.9 5.9 2.1 1.8 0.9 100.0 5,016 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated or widowed women. na = Not applicable 1 For couples who are not married but are living together as if married, the time of marriage refers to the time when the respondent first started living together with her partner. The results indicate that among all ever-married women, almost one in four have experienced physical or sexual spousal violence even before they have been married for a year, including 3 percent who said that the abuse began before marriage. Thirty-eight percent of ever-married women have experienced spousal physical or sexual violence before they were married less than six years. This implies that among women who report any spousal physical or sexual violence, almost 9 out of 10 first experienced the violence very early in the marriage—within six years. 16.12 TYPES OF INJURIES TO WOMEN DUE TO SPOUSAL VIOLENCE Table 16.15 presents information on the types of injuries ever-married women have endured as a result of spousal violence. One-fourth of women who have ever experienced spousal physical or sexual violence, received cuts, bruises, or aches; 7 percent had eye injuries, sprains, dislocations, or burns; and 7 percent had deep wounds, broken bones, broken teeth, or other serious injuries as a result of the violence. Overall, 28 percent of women who have ever experienced spousal physical or sexual violence have experienced one or more of these injuries. Women’s experience of injuries varies little by the type of violence or its timing. 270 • Domestic Violence Table 16.15 Injuries to women due to spousal violence Percentage of ever-married women age 15-49 who have experienced specific types of spousal violence by types of injuries resulting from what their husband/partner did to them, according to the type of violence and whether they have experienced the violence ever and in the 12 months preceding the survey, Zimbabwe 2010-11 Type of violence experienced Cuts, bruises, or aches Eye injuries, sprains, dislocations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of women Experienced physical violence Ever1 29.1 8.9 7.9 32.5 1,445 In the past 12 months 31.1 9.8 8.4 34.9 1,036 Experienced sexual violence Ever1 27.9 7.7 7.3 29.8 779 In the past 12 months 28.6 7.5 7.0 30.6 666 Experienced physical or sexual violence Ever1 25.2 7.4 6.5 28.0 1,764 In the past 12 months 26.0 7.7 6.5 29.0 1,362 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. 1 Includes in the past 12 months 16.13 VIOLENCE BY WOMEN AGAINST THEIR HUSBAND In cases of domestic violence, either person can be the instigator of violent behaviour. In the 2010-11 ZDHS, ever-married women were asked about instances when they were the instigator of spousal violence. Specifically, all ever-married women were asked if they had ever tried to instigate physical violence against their husband when he was not already hitting or beating them. Table 16.16 presents the percentages of ever-married women who have committed physical violence against their husband/partner when he was not already harming them, by selected characteristics. Four percent of ever-married women reported that they have ever instigated physical violence against their current or most recent husband, and 2 percent reported that they have done so in the past year. This proportion varies little by women’s and husbands’ characteristics. Notably such violence is more common among women who have themselves experienced physical violence by their spouse ever or in the past 12 months (9 to10 percent) than among women who have not experienced any such violence (1 percent). Domestic Violence • 271 Table 16.16 Violence by women against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their husband/partner when he was not already beating or physically hurting them ever and in the past 12 months, according to women's own experience of spousal violence and their own and husband's/partner's characteristics, Zimbabwe 2010-11 Background characteristic Percentage of women who have committed physical violence against their current or most recent husband/partner1 Number of women Ever In past 12 months Often Sometimes Any Woman's experience of spousal physical violence Ever 9.2 0.7 6.6 7.3 1,036 In the past 12 months 9.6 0.0 1.2 1.2 409 Never 1.3 0.0 0.8 0.8 3,570 Age 15-19 2.9 0.0 2.3 2.3 357 20-24 3.6 0.1 1.9 1.9 1,010 25-29 3.6 0.2 2.1 2.3 1,109 30-39 3.5 0.2 2.1 2.3 1,627 40-49 4.4 0.2 1.9 2.2 912 Employment (past 12 months) Employed for cash 5.0 0.0 2.7 2.8 2,190 Employed not for cash 2.6 1.6 0.5 2.1 132 Not employed 2.6 0.2 1.5 1.7 2,693 Number of living children 0 4.6 0.0 2.0 2.0 395 1-2 3.4 0.1 2.1 2.2 2,546 3-4 3.7 0.3 1.9 2.2 1,465 5+ 4.2 0.0 2.1 2.1 609 Marital status and duration Currently married women 3.4 0.2 2.0 2.1 4,094 Married only once 3.1 0.2 1.8 2.0 3,521 0-4 years 3.7 0.2 2.1 2.2 1,154 5-9 years 2.3 0.1 1.4 1.5 817 10+ years 3.1 0.2 1.8 2.0 1,550 Married more than once 4.8 0.4 2.8 3.2 573 Divorced/separated/ widowed 5.0 0.0 2.3 2.3 921 Residence Urban 3.6 0.0 2.4 2.5 1,695 Rural 3.7 0.2 1.8 2.0 3,320 Province Manicaland 4.1 0.2 2.3 2.5 721 Mashonaland Central 6.9 0.4 3.7 4.1 540 Mashonaland East 4.1 0.1 2.1 2.2 495 Mashonaland West 5.1 0.0 2.9 2.9 625 Matabeleland North 0.7 0.0 0.3 0.3 229 Matabeleland South 1.6 0.0 0.4 0.4 202 Midlands 2.1 0.3 1.0 1.3 619 Masvingo 2.9 0.4 1.9 2.2 524 Harare 2.9 0.0 2.0 2.0 839 Bulawayo 3.2 0.0 1.2 1.2 221 Education No education 3.9 0.0 2.8 2.8 150 Primary 3.8 0.1 2.5 2.6 1,628 Secondary 3.6 0.2 1.8 2.0 3,039 More than secondary 2.3 0.0 1.8 1.8 198 Husband's/partner's education No education 5.7 0.0 1.0 1.0 127 Primary 3.0 0.0 1.8 1.8 1,009 Secondary 3.7 0.2 1.9 2.2 3,398 More than secondary 5.4 0.0 4.5 4.5 357 Don’t know 1.1 0.0 0.4 0.4 124 Husband's/partner's alcohol consumption Does not drink 2.6 0.1 1.7 1.7 2,635 Drinks alcohol but is never drunk 5.2 0.0 1.2 1.2 57 Is sometimes drunk 4.0 0.0 2.0 2.0 1,674 Is often drunk 7.1 0.8 3.7 4.5 648 Spousal age difference1 Wife older 9.1 2.4 5.0 7.4 136 Wife is same age 3.6 0.0 3.6 3.6 161 Wife is 1-4 years younger 3.8 0.2 2.2 2.4 1,450 Wife is 5-9 years younger 3.1 0.1 1.9 2.0 1,461 Wife is 10+ years younger 2.2 0.0 0.9 0.9 885 Spousal education difference Husband has more education 4.0 0.2 2.5 2.7 2,448 Wife has more education 3.4 0.4 1.1 1.5 893 Both have equal education 3.4 0.0 1.9 1.9 1,492 Neither has any education (11.1) (0.0) (4.9) (4.9) 27 Missing 1.3 0.0 0.3 0.3 156 Wealth quintile Lowest 2.1 0.2 1.1 1.3 945 Second 3.3 0.2 1.5 1.7 960 Middle 5.6 0.1 2.9 3.0 981 Fourth 3.8 0.3 2.4 2.7 1,139 Highest 3.4 0.0 2.2 2.2 990 Total 3.6 0.1 2.0 2.2 5,016 Notes: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Figures in parentheses are based on 25-49 unweighted cases. Total includes 2 cases for which husband’s/partner’s alcohol consumption is missing. 1 Currently married women 272 • Domestic Violence 16.14 HELP-SEEKING AMONG WOMEN WHO HAVE EXPERIENCED VIOLENCE Table 16.17 presents information on help-seeking among women who have ever experienced violence, by type of violence experienced and background characteristics. Women who reported violence only in the form of a violent sexual initiation were not asked questions about seeking help and are thus not included in this table. Table 16.17 Help seeking to stop violence Percent distribution of women age 15-49 who have ever experienced physical or sexual violence by whether they have told anyone about the violence and whether they have ever sought help from any source to end the violence, according to type of violence and background characteristics, Zimbabwe 2010-11 Background characteristic Never sought help Have sought help from any source Total Number of women Never told anyone Told someone Type of violence Physical only 48.0 15.4 36.5 100.0 1,060 Sexual only 72.2 7.6 20.2 100.0 369 Both physical and sexual 40.7 14.4 44.9 100.0 896 Age 15-19 46.0 14.3 39.7 100.0 371 20-24 48.9 12.9 38.2 100.0 546 25-29 51.8 11.3 36.9 100.0 486 30-39 51.4 15.9 32.6 100.0 586 40-49 44.6 14.5 40.9 100.0 336 Employment (past 12 months) Employed for cash 47.4 13.3 39.3 100.0 1,108 Employed not for cash 50.1 11.0 38.9 100.0 79 Not employed 50.6 14.4 35.0 100.0 1,137 Number of living children 0 48.2 14.8 37.0 100.0 444 1-2 49.3 12.9 37.9 100.0 1,086 3-4 48.4 14.5 37.0 100.0 558 5+ 51.1 14.3 34.6 100.0 237 Marital status and duration Never married 43.2 16.8 40.0 100.0 334 Currently married women 51.7 12.8 35.6 100.0 1,543 Married only once 54.3 12.5 33.1 100.0 1,274 0-4 years 49.0 12.5 38.5 100.0 426 5-9 years 59.3 11.7 28.9 100.0 335 10+ years 55.5 13.1 31.3 100.0 514 Married more than once 39.0 13.9 47.1 100.0 269 Divorced/separated 40.5 11.9 47.6 100.0 291 Widowed 51.8 20.7 27.6 100.0 156 Residence Urban 45.4 16.4 38.2 100.0 848 Rural 51.2 12.2 36.6 100.0 1,477 Province Manicaland 45.7 17.9 36.4 100.0 377 Mashonaland Central 43.0 14.3 42.7 100.0 329 Mashonaland East 54.0 8.5 37.5 100.0 191 Mashonaland West 49.4 10.7 39.9 100.0 295 Matabeleland North 48.6 13.4 38.0 100.0 55 Matabeleland South 57.8 16.3 26.0 100.0 101 Midlands 39.5 14.6 45.9 100.0 253 Masvingo 72.9 13.1 14.0 100.0 193 Harare 49.9 12.1 38.0 100.0 416 Bulawayo 38.7 19.0 42.3 100.0 115 Education No education 40.3 12.2 47.6 100.0 64 Primary 53.8 13.5 32.7 100.0 780 Secondary 46.6 13.8 39.6 100.0 1,411 More than secondary 53.3 18.3 28.4 100.0 70 Wealth quintile Lowest 50.5 14.2 35.3 100.0 411 Second 54.7 8.6 36.7 100.0 466 Middle 44.6 14.1 41.3 100.0 441 Fourth 50.3 16.2 33.5 100.0 497 Highest 45.3 15.6 39.1 100.0 510 Total 49.1 13.8 37.2 100.0 2,325 Note: Women who experienced forced sexual initiation but not other forms of physical or sexual violence were not asked the questions about seeking help and are, thus, excluded from this table. Domestic Violence • 273 Table 16.17 shows that only 37 percent of women who have ever experienced any physical or sexual violence have sought help from any source. Another 14 percent have not sought help but have told someone that they were victims of violence. The remainder, almost half of all women who have ever experienced physical or sexual violence, have never told anyone that they were victims of violence or sought help. Women who experienced both physical and sexual violence were more likely to seek help (45 percent) than women who experienced only physical (37 percent) or only sexual violence (20 percent). Help seeking does not vary consistently with age, and does not vary much by employment, number of living children, urban-rural residence, and wealth. Not surprisingly, divorced or separated women and women married more than once are more likely to have sought help (47 to 48 percent) than women in other marital categories. According to province, women living in Midlands were most likely to have sought help for the violence (46 percent), followed by women in Mashonaland Central and Bulawayo (43 and 42 percent, respectively) and women in Masvingo were least likely to have sought help (14 percent). Notably, help seeking for violence declines sharply with education, from 48 percent of women with no education ever seeking help to only 28 percent of women with more than secondary education seeking help. Table 16.18 presents information on the sources of help by type of violence. The majority of women who have experienced any form of violence and sought help did so from a family member (58 percent). Other common sources from which abused women seek help include: in-laws (36 percent), friends or neighbours (13 percent), and religious leaders (4 percent). Only 13 percent of abused women have ever sought help from the police, and 2 percent have ever sought help from a social service organization. Table 16.18 Sources from where help was sought Percentage of women age 15-49 who have ever experienced physical or sexual violence and sought help, according to source from which help was sought, by type of violence experienced, Zimbabwe 2010-11 Sought help from: Type of violence Total Physical only Sexual only Both physical and sexual Own family 57.4 63.6 56.9 57.7 In-laws 38.2 20.8 36.6 35.9 Husband/partner boyfriend 1.9 1.3 0.9 1.3 Friend/neighbour 13.0 15.2 12.7 13.1 Religious leader 3.6 3.0 5.3 4.3 Doctor/medical personnel 1.0 1.6 2.4 1.7 Police 11.0 8.0 15.0 12.6 Lawyer 0.2 0.0 0.9 0.5 Social service organization 0.8 1.4 2.2 1.5 Other 4.3 0.0 2.8 3.2 Number of women 387 75 402 864 Note: Women who experienced forced sexual initiation but not other forms of physical or sexual violence were not asked the questions about seeking help and are, thus, excluded from this table. 274 • Domestic Violence 16.15 CHANGES IN DOMESTIC VIOLENCE BETWEEN 2005-06 AND 2010-11 Information on domestic violence was collected in both the 2005-06 ZDHS and the 2010-11 ZDHS, which permits an examination of the change in key indicators of violence over the five years between the two surveys. Such a comparison is particularly timely since the 2006 Domestic Violence Act was passed during the period between the two surveys. The comparison thus provides information on whether the implementation of the Act has begun to change the level of domestic violence in the country. Since the two surveys being compared were only five years apart and represent largely the same age cohorts of women (women who were 15-44 in 2005-06 are 20-49 in 2010-11), indicators based on women’s ever-experience of violence cannot be expected to have changed much. To detect change over a short period of time it is more appropriate to examine women’s experience of recent violence, i.e., violence in the past 12 months. Accordingly, Table 16.19 shows indicators for women’s experience of recent spousal physical and/or sexual violence for all ever-married women except widows. Widows are excluded in this comparison since the 2005-06 ZDHS did not collect information on recent spousal violence for widows. Table 16.19 Trends in domestic violence in the past 12 months Selected indicators of domestic violence in the 12 months preceding the 2005-06 and 2010-11 Zimbabwe DHS Indicator ZDHS 2005-06 ZDHS 2010-11 Percentage of ever-married women who, in the 12 months preceding the survey, experienced Spousal physical violence 25.3 21.6 Spousal sexual violence 12.7 14.1 Spousal physical or sexual violence 30.5 28.6 Spousal physical and sexual violence 9.3 6.1 Number of women1 4,188 4,623 1 Excludes widows Table 16.19 shows that in the five years between 2005-06 and 2010-11, there has been a slight decline in women’s reported experience of spousal physical or sexual violence, from 31 percent in 2005-06 to 29 percent in 2010-11. Declines are also observed for the same period in women’s recent experience of spousal physical violence (from 25 to 22 percent) and spousal physical and sexual violence (from 9 to 6 percent). However, the data suggest that women’s experience of spousal sexual violence has not declined, and may in fact have increased in the same period (from 13 to 14 percent). Thus, while the declines in the prevalence of spousal physical violence and physical and sexual violence are encouraging, the declines are small. Further, there is no similar decline observed in women’s experience of spousal sexual violence. These findings together suggest that much work remains to be done if women are to be protected against all forms of violence. Adult and Maternal Mortality • 275 ADULT AND MATERNAL MORTALITY 17 arlier in this report, estimates of mortality during the first years of life were presented and discussed. Early childhood mortality varies substantially as an index of social and economic development and thus tends to be predictably high in disadvantaged settings. Mortality during later childhood and adolescence is, on the other hand, relatively low in all societies but begins to rise with age starting in the late teenage years. The pattern and pace of the rise in adult mortality with increasing age are tied closely to the occupational profile, fertility pattern, and epidemiological characteristics of a population. Two aspects of adult mortality dynamics are of particular interest in the Zimbabwean context. First, although the prevalence of HIV infection and AIDS (discussed in Chapter 14) has declined relative to its peak in the middle to late 1990s, Zimbabwe is expected to continue suffering the effects of both female and male adult mortality (due to AIDS) in the near term. Second, mortality related to pregnancy and childbearing (maternal mortality) is an important indicator for women’s and reproductive health programmes in the country. The 2010-11 ZDHS questionnaire included a sibling history, which is a detailed account of the survivorship of all of the live-born children of the respondent’s mother (i.e., maternal siblings). These data allow direct estimation of overall adult mortality by sex, as well as maternal mortality in particular. The direct approach to estimating adult and maternal mortality maximises use of the available data, using information on the age of surviving siblings, the age at death of siblings who died, and the number of years ago the siblings died. This approach allows the data to be aggregated to determine the number of person-years of exposure to mortality risk and the number of sibling deaths occurring in defined calendar periods. Adult mortality rates are obtained by dividing female or male adult deaths in a calendar period by person-years of exposure to death. Similarly, maternal mortality rates are obtained by dividing maternal deaths in a calendar period by person-years of exposure to death. 17.1 DATA To obtain the sibling history, each female respondent was initially asked to give the total number of her mother’s live births. The respondent was next asked to provide a list of all children born to her mother starting with the first-born child. Then the respondent was asked whether each of these siblings was still alive at the survey date. For living siblings, current age was collected; for deceased siblings, age at death and years since death were collected. Interviewers were instructed that when a respondent could not provide precise information on age at death or years since death, approximate (quantitative) answers were acceptable. For sisters who died at age 12 or above, three E Key Findings • Adult male mortality is comparable to female mortality in the reproductive-age population (11.5 and 11.4 deaths per 1,000 years of exposure, respectively). • The rate of mortality associated with pregnancy and childbearing is 1.3 maternal deaths per 1,000 woman-years of exposure. • The estimate of the maternal mortality ratio for the seven-year period preceding the 2010-11 ZDHS is 960 deaths per 100,000 live births; that is, for every 1,000 births in Zimbabwe, there are about 10 maternal deaths. 276 • Adult and Maternal Mortality questions were asked to determine whether the death was maternity related: “Was (NAME) pregnant when she died?” and, if not, “Did (NAME) die during childbirth?” and, if not, “Did (NAME) die within two months after the end of a pregnancy or childbirth?” Estimation of adult and maternal mortality by either direct or indirect means requires reasonably accurate reporting of the number of sisters and brothers the respondent ever had, the number who have died, and (for maternal mortality) the number of sisters who have died of maternity- related causes. There is no definitive procedure for establishing the completeness or accuracy of retrospective data on sibling survivorship. However, the 2010-11 ZDHS sibling history data do not show any obvious defects that would indicate poor data quality or systematic underreporting. Table 17.1 shows the number of siblings reported by the respondents and the completeness of data reported on current age, age at death, and years since death. Of the 43,434 siblings reported in the sibling histories of ZDHS respondents, survival status was not reported for 41 (about 0.1 percent). Current ages (used to estimate exposure to death) were missing for 3 percent of surviving siblings. Reporting of age at death and years since death was complete for 85 percent of deceased siblings. In 8 percent of cases, either age at death or years since death was missing, while in 7 percent of cases both of these items were missing. Rather than excluding siblings with missing data from further analysis, information on the birth order of siblings in conjunction with other information was used to impute the missing data.1 The sibling survivorship data, including cases with imputed values, were used in the direct estimation of adult and maternal mortality. Table 17.1 Data on siblings Number of siblings reported by survey respondents and completeness of the reported data on age, age at death (AD), and years since death (YSD), Zimbabwe 2010-11 Females Males Total Number Percentage Number Percentage Number Percentage All siblings 21,870 100.0 21,564 100.0 43,434 100.0 Surviving 18,629 85.2 18,124 84.0 36,753 84.6 Deceased 3,214 14.7 3,426 15.9 6,640 15.3 Missing information 27 0.1 14 0.1 41 0.1 Surviving siblings 18,629 100.0 18,124 100.0 36,753 100.0 Age reported 18,024 96.7 17,608 97.2 35,631 96.9 Age missing 606 3.3 516 2.8 1,122 3.1 Deceased siblings 3,214 100.0 3,426 100.0 6,640 100.0 AD and YSD reported 2,793 86.9 2,871 83.8 5,665 85.3 Missing only AD 150 4.7 212 6.2 362 5.4 Missing only YSD 62 1.9 103 3.0 165 2.5 Missing both AD and YSD 208 6.5 240 7.0 448 6.7 17.2 DIRECT ESTIMATES OF ADULT MORTALITY One way to assess the quality of data used to estimate maternal mortality is to evaluate the plausibility and stability of overall adult mortality. It is reasoned that if estimated rates of overall adult mortality are implausible, rates based on a subset of deaths (maternal deaths in particular) are unlikely to be free of serious problems. As described above, levels and trends in overall adult mortality have 1 The imputation procedure is based on the assumption that the reported birth ordering of siblings in the history is correct. The first step is to calculate birth dates. For each living sibling with a reported age and each dead sibling with complete information on both age at death and years since death, the birth date was calculated. For a sibling missing these data, a birth date was imputed within the range defined by the birth dates of the bracketing siblings. In the case of living siblings, an age was then calculated from the imputed birth date. In the case of dead siblings, if either age at death or years since death was reported, that information was combined with the birth date to produce the missing information. If both pieces of information were missing, the distribution of the ages at death for siblings for whom years since death was not reported but age at death was reported was used as a basis for imputing age at death. Adult and Maternal Mortality • 277 very important implications in their own right for health and social programmes in Zimbabwe, especially given the AIDS epidemic. 17.2.1 Levels of Adult Mortality Table 17.2 shows age-specific mortality rates among men and women age 15-49 for the seven-year period preceding the 2010-11 ZDHS. These results allow assessment of the recent level of mortality in the reproductive-age population in Zimbabwe. Because the number of deaths on which the age-specific rates are based is not very large (between about 45 and 265 deaths per age group for each sex), the estimated age- specific rates are subject to considerable sampling variation. The results in Table 17.2 show that male mortality is comparable to female mortality in the reproductive-age population (11.5 and 11.4 deaths per 1,000 years of exposure, respectively). Mortality levels rise rapidly with age among both women and men but level off among women age 40-49. 17.2.2 Trends in Adult Mortality Table 17.2 also shows the adult mortality rates reported in the 2005-06 ZDHS (12.7 and 13.3 deaths per 1,000 years of exposure among women and men, respectively). A comparison of the results from the 2005-06 ZDHS with those from the 2010-11 ZDHS reveals similar trends in mortality by age. For example, in the 2005-06 ZDHS, the female adult mortality rate increased from 2.7 deaths per 1,000 years of exposure among women age 15-19 to 25.5 deaths among women age 45-49; similarly, in the 2010-11 ZDHS, the female mortality rate rose from 2.5 deaths per 1,000 years of exposure among women age 15-19 to 22.6 deaths among women age 45-49. The male mortality rate in the 2005-06 ZDHS rose from 1.7 deaths per 1,000 years of exposure among men age 15-19 to 36.5 deaths among men age 45-49, and the rate in the 2010-11 ZDHS increased from 2.3 deaths per 1,000 years of exposure among men 15-19 to 32.0 deaths among men age 45-59. Table 17.2 Adult mortality rates Age-specific mortality rates for women and men age 15-49 based on the survivorship of sisters and brothers of survey respondents for the 7-year period preceding the 2010-11 ZDHS and 2005-06 ZDHS 2010-11 ZDHS 2005-06 ZDHS Age Deaths Exposure Mortality rate Mortality rate WOMEN 15-19 46 18,384 2.5 2.7 20-24 122 23,592 5.2 5.5 25-29 210 21,783 9.6 12.3 30-34 265 16,149 16.4 20.4 35-39 237 11,425 20.7 25.0 40-44 182 7,796 23.3 25.2 45-49 112 4,985 22.6 25.5 15-49 1,173 104,114 11.4a 12.7a MEN 15-19 43 18,208 2.3 1.7 20-24 78 22,801 3.4 3.4 25-29 137 21,447 6.4 9.0 30-34 238 17,019 14.0 20.1 35-39 266 11,510 23.1 27.7 40-44 207 6,900 30.0 37.1 45-49 135 4,232 32.0 36.5 15-49 1,104 102,116 11.5a 13.3a a Rates are age-standardised. 278 • Adult and Maternal Mortality 17.3 DIRECT ESTIMATES OF MATERNAL MORTALITY Maternal deaths are a subset of all female deaths and are associated with pregnancy and childbearing. Two survey methods are generally used to estimate maternal mortality in developing countries: the indirect sisterhood method (Graham et al., 1989) and a direct variant of the sisterhood method (Rutenberg and Sullivan, 1991). In this report, the direct estimation procedure is applied. Age-specific estimates of maternal mortality from the reported survivorship of sisters are shown in Table 17.3 for the seven-year period preceding the survey. These rates were calculated by dividing the number of maternal deaths by woman-years of exposure. To remove the effect of truncation bias (the upper boundary for eligibility among women interviewed in the survey is 49 years), the overall rate for women age 15-49 was standardised by the age distribution of survey respondents. A maternal death was defined as any death reported as occurring during pregnancy, childbirth, or within two months after the birth or termination of a pregnancy.2 Estimates of maternal mortality are therefore based solely on the timing of the death in relationship to pregnancy. The results in Table 17.3 indicate that the rate of mortality associated with pregnancy and childbearing is 1.3 maternal deaths per 1,000 woman-years of exposure, up from 0.8 in the 2005-06 ZDHS.3 The estimated age-specific mortality rates display a plausible pattern, being generally higher during the peak childbearing ages than in the younger and older age groups. However, the age-specific pattern should be interpreted with caution because of the small number of events: only 136 maternal deaths among women of all ages. Maternal deaths represent 12 percent of all deaths among women age 15-49 during the seven-year period preceding the survey (136 maternal deaths divided by 1,173 female deaths). This proportion is higher than that measured in the 2005-06 ZDHS (7 percent of all deaths among women age 15-49 during the 7-year period preceding the survey), indicating that the proportion of maternal deaths among all female deaths has increased in the interim between the two surveys. The maternal mortality rate can be converted to a maternal mortality ratio by dividing the rate by the general fertility rate during the seven-year period preceding the 2010-11 ZDHS. The maternal mortality ratio is expressed per 100,000 live births in order to emphasise the obstetrical risk of pregnancy and childbearing. The estimate of the maternal mortality ratio for the seven-year period preceding the 2010-11 ZDHS is 960 deaths per 100,000 live births; that is, for every 1,000 births in Zimbabwe, there are about 10 maternal deaths. It should be noted that maternal mortality is a difficult indicator to measure because of the large sample sizes required to calculate an accurate estimate. (This is evidenced by the fact that the 2 This time-dependent definition includes all deaths that occurred during pregnancy and two months after pregnancy, even if the death was due to nonmaternal causes. However, this definition is unlikely to result in overreporting of maternal deaths because most deaths among women during the two-month period are due to maternal causes, and maternal deaths are more likely to be underreported than overreported. 3 The 2005-06 ZDHS reported mortality estimates for maternal deaths occurring during the 10-year period preceding the survey. For comparison purposes, these estimates have been recalculated for the 7-year period preceding the 2005-06 ZDHS. Table 17.3 Maternal mortality Maternal mortality rates for the 7-year period preceding the survey the survey, based on the survivorship of sisters of survey respondents, Zimbabwe 2010-11 Age Maternal deaths Exposure (years) Mortality rate (1,000) 15-19 12 18,384 0.6 20-24 28 23,592 1.2 25-29 39 21,783 1.8 30-34 25 16,149 1.6 35-39 20 11,425 1.7 40-44 8 7,796 1.1 45-49 4 4,985 0.8 Total 15-49 136 104,114 1.3a General fertility rate1 0.132 Maternal mortality ratio2 960 a Rates are age-standardised. 1 Expressed per 1,000 woman-years of exposure 2 Expressed per 100,000 live births; calculated as maternal mortality rate divided by general fertility rate Adult and Maternal Mortality • 279 maternal mortality ratio is expressed per 100,000 live births, demonstrating that it is a relatively rare event.) As a result, maternal mortality estimates are subject to large sampling errors. The 95 percent confidence interval surrounding the maternal mortality estimate is 778-1142 deaths per 100,000 live births. To facilitate comparison with the 2010-11 ZDHS, the 2005-06 ZDHS maternal mortality ratio was recalculated for the 7-year period preceding the 2005-06 ZDHS.4 The 2010-11 ZDHS maternal mortality ratio is higher than that measured in the 2005-06 ZDHS (612 maternal deaths per 100,000 live births with a 95 percent confidence interval of 458-767 deaths per 100,000 live births). Nevertheless, given the wide 95 percent confidence intervals, caution should be taken when interpreting these measurements. The maternal mortality ratio was also measured in the 1994 ZDHS (283 deaths per 100,000 live births in the 10-year period preceding the survey) and 1999 ZDHS (695 deaths per 100,000 live births in the four-year period preceding the survey). Although a determination of the statistical significance of the differences in maternal mortality ratio in the 1994, 1999, 2005-06, and 2010-11 ZDHS will require additional analysis, the upward trend strongly suggests that maternal mortality in Zimbabwe has risen sharply over the past two decades. 4 The maternal mortality ratio presented in the 2005-06 ZDHS report (555 maternal deaths per 100,000 live births with a 95 percent confidence interval of 429-681 deaths per 100,000 live births) was calculated for the 10-year period preceding the survey. References • 281 REFERENCES Arimond, M., and M. T. Ruel. 2004. Dietary Diversity Is Associated with Child Nutritional Status: Evidence from 11 Demographic and Health Surveys. Journal of Nutrition 134:2579-2585. Auvert, B., D. Taljaard, E. Lagarde, J. Sobngwi-Tambekou, R. Sitta, and A. Puren. 2005. Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med 2(11): e298. doi:10.1371/journal.pmed.0020298. Boerma, T. 1988. Monitoring and Evaluation of Health Interventions: Age- and Cause-Specific Mortality and Morbidity in Childhood. In Research and Interventions Issues Concerning Infant and Child Mortality and Health, 195-218. Proceedings of the East Africa Workshop, International Development Research Center, Manuscript Report 200e. Ottawa, Canada. Centers for Disease Control and Prevention (CDC). 1998. Recommendations to Prevent and Control Iron Deficiency in the United States. Morbidity and Mortality Weekly Report 47 (RR-3):1-29. Central Statistical Office (CSO) [Zimbabwe]. 2002. Census National Report. Harare, Zimbabwe: CSO. Central Statistical Office (CSO) [Zimbabwe] and the Institute for Resource Development (IRD)/Macro Systems Inc. 1989. Zimbabwe Demographic and Health Survey 1988. Columbia, Maryland, USA: CSO and IRD/Macro Systems Inc. Central Statistical Office (CSO) [Zimbabwe] and Macro International Inc. 1995. Zimbabwe Demographic and Health Survey 1994. Calverton, Maryland, USA: CSO and Macro International Inc. Central Statistical Office (CSO) [Zimbabwe] and Macro International Inc. 2000. Zimbabwe Demographic and Health Survey 1999. Calverton, Maryland, USA: CSO and Macro International Inc. Central Statistical Office (CSO) [Zimbabwe] and Macro International Inc. 2007. Zimbabwe Demographic and Health Survey 2005-06. Calverton, Maryland, USA: CSO and Macro International Inc. Graham, W., W. Brass, and R. W. Snow. 1989. Estimating Maternal Mortality: The Sisterhood Method. Studies in Family Planning 20(3):125-135. doi:10.2307/1966567. Gregson, S., E. Gonese, T. B. Hallett, N. Taruberekera, J. W. Hargrove, B. Lopman, E. L. Corbett, R. Dorrington, S. Dube, K. Dehne, and O. Mugurungi. 2010. HIV Decline in Zimbabwe Due to Reductions in Risky Sex? Evidence from a Comprehensive Epidemiological Review. International Journal of Epidemiology 39(5):1311-1323. doi:10.1093/ije/dyq055. Halperin, D. T., O. Mugurungi, T. B. Hallett, B. Muchini, B. Campbell, T. Magure, C. Benedikt, and S. Gregson. 2011. A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe? PLoS Med 8(2): e1000414. doi:10.1371/journal.pmed.1000414. Krug E. G., L. L. Dahlberg, J. A. Mercy, A. B. Zwi, and R. Lozano (eds.). 2002. World Report on Violence and Health. Geneva, Switzerland: World Health Organization. Ministry of Economic Planning & Investment Promotion (MEPIP) [Zimbabwe]. 2011. 2011-2015 Medium Term Plan (MTP) Harare, Zimbabwe: MEPIP 282 • References Ministry of Health and Child Welfare (MOHCW) and Food and Nutrition Council (FNC) [Zimbabwe]. 2011. Zimbabwe National Nutrition Survey 2010. Harare, Zimbabwe: MOHCW and FNC. Ministry of Health and Child Welfare (MOHCW) [Zimbabwe]. 2008. Zimbabwe National Malaria Strategic Plan 2008-2013. Harare, Zimbabwe: MOHCW. Ministry of Health and Child Welfare (MOHCW). 2009. Zimbabwe National HIV and AIDS Estimates 2009. Harare, Zimbabwe: MOHCW. Mosley, W. H., and L. C. Chen 1984. An Analytical Framework for the Study of Child Survival in Developing Countries. Population and Development Review 10 (supplement):25-45. Nathoo, K. J., R. Glyn-Jones, and M. Nhembe. 1987. Serum Electrolytes in Children Admitted with Diarrhoeal Dehydration Managed with Simple Salt Sugar Solution. Central African Journal of Medicine 33(8):200-204. National Institute of Allergy and Infectious Diseases (NIAID). 2006. Adult Male Circumcision Significantly Reduces Risk of Acquiring HIV. Press Release. Washington, DC, USA: NIAID. http://www.nih.gov/news/pr/dec2006/niaid-13.htm. Pan American Health Organization (PAHO) and World Health Organization (WHO). 2003. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC, USA, and Geneva, Switzerland: PAHO and WHO. Rutenberg, N., and J. Sullivan. 1991. Direct and Indirect Estimates of Maternal Mortality from the Sisterhood Method. In Proceedings of the Demographic and Health Surveys World Conference, Vol. 3, 1669-1696. Columbia, Maryland, USA: IRD/Macro International Inc. Rutstein, S. 1999. Wealth versus Expenditure: Comparison between the DHS Wealth Index and Household Expenditures in Four Departments of Guatemala. Calverton, Maryland, USA: ORC Macro (unpublished). Rutstein S., K. Johnson, and D. Gwatkin. 2000. Poverty, Health Inequality, and Its Health and Demographic Effects. Paper presented at the 2000 Annual Meeting of the Population Association of America, Los Angeles, California. Straus, M. A. 1990. Measuring Intrafamily Conflict and Violence: The Conflict Tactics (CT) Scales. In M. A. Straus and R. J. Gelles (eds.), Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families. New Brunswick, New Jersey, USA: Transaction Publishers. United Nations. 2006 Secretary-General’s In-depth Study on All Forms of Violence against Women. New York, USA: United Nations. US Department of Health and Human Services. 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA, USA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Williams, B. G., J. O. Lloyd-Smith, E. Gouws, C. Hankins, W. M. Getz, J. Hargrove, I. de Zoysa, C. Dye, B. Auvert. 2006. The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa. PLoS Med 3(7):e262. doi:10.1371/journal.pmed.0030262. Windham, G. C., A. Eaton, and B. Hopkins. 1999. Evidence for an Association between Environmental Tobacco Smoke Exposure and Birth Weight: A Meta-Analysis and New Data. Paediatric and Perinatal Epidemiology 13:35-37. References • 283 World Health Organization (WHO). 1998. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: WHO World Health Organization (WHO). 2001. Putting Women First: Ethical and Safety Recommendations for Research and Domestic Violence against Women. Geneva, Switzerland: WHO. World Health Organization (WHO). 2005. Guiding Principles for Feeding Nonbreastfed Children 6 to 24 Months of Age. Geneva, Switzerland: WHO. World Health Organization (WHO). 2008. Indicators for Assessing Infant and Young Child Feeding Practices. Part I: Definitions. Conclusions of a consensus meeting held 6-8 November 2007 in Washington, DC, USA. http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf. World Health Organization (WHO). 2010. Indicators for Assessing Infant and Young Child Feeding Practices. Part II: Measurement. Geneva, Switzerland: WHO. http://whqlibdoc.who.int/publications/2010/9789241599290_eng.pdf. World Health Organization (WHO). 2011. WHO Report on the Global Tobacco Epidemic, 2011: Warning about the Dangers of Tobacco. Geneva, Switzerland: WHO. World Health Organization (WHO). 2011. Indoor Air Pollution and Health. Fact sheet N°292. Geneva, Switzerland: WHO. http://www.who.int/mediacentre/factsheets/fs292/en. World Health Organization (WHO) Multicentre Growth Reference Study Group. 2006. WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Height and Body Mass Index-for Age: Methods and Development. Geneva, Switzerland: WHO. World Health Organization (WHO) and Joint United Nations Program on HIV/AIDS (UNAIDS). 2007. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. Geneva, Switzerland: WHO and UNAIDS. Accessed 6 March 2012. http://libdoc.who.int/publications/2007/9789241595988_eng.pdf World Health Organization and United Nations Children’s Fund (WHO/UNICEF) Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Types of Drinking-Water Sources and Sanitation. Accessed 12 January 2012. http://www.wssinfo.org/definitions-methods/watsan-categories Zimbabwe National AIDS Council (NAC). 2005. Behaviour Change Research. Harare, Zimbabwe: NAC. Zimbabwe National Family Planning Council and Westinghouse Public Applied Systems. 1985. Zimbabwe Reproductive Health Survey 1984. Columbia, Maryland, USA: Zimbabwe National Family Planning Council and Westinghouse Public Applied Systems. Appendix A • 285 SAMPLE DESIGN AND IMPLEMENTATION Appendix A A.1 INTRODUCTION The 2010-11 Zimbabwe Demographic and Health Survey is the fifth DHS survey conducted in Zimbabwe. As was the case in all of the previous DHS surveys, the primary objective of the 2010-11 ZDHS is to provide up-to-date information on key indicators needed to track progress in Zimbabwe’s population and health programmes including fertility and child mortality levels, maternal mortality, fertility preferences and contraceptive use, utilization of maternal and child health services, women’s and children’s nutrition status, knowledge, attitudes and behaviours relating to HIV/AIDS and other sexually transmitted diseases, and domestic violence. In addition, the 2010-11 ZDHS includes three “biomarkers”: anthropometry, anaemia testing, and HIV testing. To obtain these data, a nationally representative sample of households was selected. All women age 15-49 and all men age 15-54 who were usual residents of the sampled households or slept in the households on the night before the interview were eligible for interview in the ZDHS and for anaemia and HIV testing. In addition, all children age 6-59 months were eligible for anaemia testing. In all households, height and weight measurements were recorded for children age 0-59 months, women age 15-49, and men age 15-54. The domestic violence module was administered to one selected woman in each of surveyed households. The 2010-11 ZDHS sample was designed to yield representative information for most indicators for the country as a whole, for urban and rural areas, and for each of Zimbabwe’s ten provinces (Manicaland, Mashonaland Central, Mashonaland East, Mashonaland West, Matabeleland North, Matebeleland South, Midlands, Masvingo, Harare, and Bulawayo). A.2 SAMPLING SELECTION The 2010-11 ZDHS sample was selected using a stratified, two-stage cluster design.The frame used for the first stage of the selection of the 2010-11 ZDHS sample was based on the last population census in Zimbabwe, which was carried in 2002. Table A.1 shows the distribution of population and households at the time of the 2002 census by the geographic domains of interest for the ZDHS, i.e., province and urban-rural areas. Table A.1 Population Distribution of the 2002 census population by region and residence, Zimbabwe Population in frame Percent of total population Percent urban Province Urban Rural Total Manicaland 259,495 1,309,435 1,568,930 13.5 16.5 Mashonaland Central 102,873 892,554 995,427 8.6 10.3 Mashonaland East 117,521 1,009,892 1,127,413 9.7 10.4 Mashonaland West 344,806 879,864 1,224,670 10.5 28.2 Matabeleland North 102,948 602,000 704,948 6.1 14.6 Matabeleland South 68,457 584,597 653,054 5.6 10.5 Midlands 349,595 1,114,398 1,463,993 12.6 23.9 Masvingo 134,251 1,186,187 1,320,438 11.4 10.2 Harare 1,873,111 23,023 1,896,134 16.3 98.8 Bulawayo 676,650 na 676,650 5.8 100.0 Zimbabwe 4,029,707 7,601,950 11,631,657 100.0 34.6 na = Not applicable Source: Central Statistical Office, 2002 286 • Appendix A Administratively, each of Zimbabwe’s provinces is divided into districts and each district into smaller administrative units called wards. For purposes of the 2002 Population Census, each of the wards was subdivided into smaller enumeration areas (EAs), typically including around 100 households. The small size of the EAs and the availability of sketch maps and other materials to delimitate their geographic boundaries made census EAs an ideal unit for use as the frame for the first stage of the selection of the ZDHS sample. Households were the units for the second stage of sampling. The target sample for the 2010-11 ZDHS was set at 406 clusters and 10,828 households, taking into account the interest in obtaining estimates of adequate precision for key domains, the level of non- response at the household and individual woman level experienced in the 2005-06 ZDHS, and available resources (financial and human) for carrying out the survey. A complete listing of households was carried out in July and August 2010 in each of the 406 EAs selected for the ZDHS. Maps were drawn for each of the clusters, and all private households were listed. If an EA was too large, the EA was segmented into smaller units following specified guidelines, and one of the resulting segments was selected with probability proportional to size. That segment was then listed and the listing used in the selection of the final household sample. A.3 SAMPLE ALLOCATION Table A.2 shows the allocation of these EAs and number of households by province, according to residence. The sample allocation among provinces was not done in proportion to the number of households in the province at the time of the 2002 census. If that approach had been adopted, some of the less populated provinces would have received a too-small sample size. Instead the number of EAs in each province was determined in such a way to provide an adequate sample in each province. Table A.2 Sample allocation of clusters and households Sample allocation of clusters and households by province, according to residence, Zimbabwe, 2010- 11 Province Allocation of clusters Allocation of households Urban Rural Total Urban Rural Total Manicaland 11 35 46 242 1050 1292 Mashonaland Central 5 29 34 110 870 980 Mashonaland East 5 33 38 110 990 1100 Mashonaland West 15 25 40 330 750 1080 Matabeleland North 8 28 36 176 840 1016 Matabeleland South 6 29 35 132 870 1002 Midlands 14 26 40 308 780 1088 Masvingo 6 32 38 132 960 1092 Harare 56 0 56 1232 0 1232 Bulawayo 43 0 43 946 0 946 Zimbabwe 169 237 406 3718 7110 10828 Table A.3 shows the expected number of completed women and men’s interviews in each of the provinces, by residence. The expected numbers of women and men’s interviews are based on the assumption that the average number of eligible women and men interviewed per sample household would be similar in the 2010-11 ZDHS to that achieved in the 2005-06 ZDHS. Appendix A • 287 Table A.3 Sample allocation of completed interviews with women and men Sample allocation of expected number of completed interviews with women and men by province, according to residence, Zimbabwe, 2010-11 Province Women 15-49 Men 15-54 Urban Rural Total Urban Rural Total Manicaland 200 867 1067 139 682 821 Mashonaland Central 81 639 720 165 614 778 Mashonaland East 71 637 708 116 461 577 Mashonaland West 233 529 762 205 529 734 Matabeleland North 144 688 832 156 501 657 Matabeleland South 103 681 784 123 431 553 Midlands 279 706 985 286 705 991 Masvingo 112 812 923 161 682 842 Harare 1,221 0 1222 686 0 686 Bulawayo 933 0 933 560 0 560 Zimbabwe 3,377 5,559 8936 2595 4604 7199 A.4 SAMPLE IMPLEMENTATION An examination of response rates for the 2010-11 ZDHS indicates that the survey was successfully implemented. Table A.4 and Table A.5 present the interview response rates in the 2010-11 ZDHS for women and men, respectively, by urban and rural area and province. Overall, the number of completed interviews exceeds the expected number for both women and men, reflecting the generally higher response rates achieved in the 2010-11 ZDHS compared to 2005-06 survey. Table A.4 Sample implementation: Women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall women response rates, according to urban-rural residence and province (unweighted), Zimbabwe 2010-11 Result Residence Province Total Urban Rural Manica- land Mashona- land Central Mashona- land East Mashona- land West Matabele- land North Matabele- land South Mid- lands Mas- vingo Harare Bula- wayo Selected households Completed (C) 89.4 90.5 88.4 91.7 94.5 91.3 85.5 92.1 91.3 86.1 91.0 89.2 90.1 Household present but no competent respondent at home (HP) 2.4 1.0 1.9 0.8 1.5 0.3 2.3 0.8 0.5 1.6 1.6 3.9 1.5 Postponed (P) 0.5 0.2 0.3 0.0 0.0 0.0 0.1 0.0 0.0 1.2 0.8 0.1 0.3 Refused (R) 2.9 0.4 1.2 0.6 0.1 0.1 0.9 0.3 0.6 1.5 4.0 3.0 1.2 Dwelling not found (DNF) 0.5 0.9 0.9 0.3 0.3 2.6 1.1 1.0 0.7 0.5 0.2 0.1 0.8 Household absent (HA) 2.7 4.0 4.3 2.9 3.3 3.3 4.6 3.5 2.8 7.4 1.4 2.2 3.6 Dwelling vacant/address not a dwelling (DV) 1.5 2.6 2.7 3.4 0.5 1.9 4.5 2.0 3.7 1.6 0.9 1.4 2.2 Dwelling destroyed (DD) 0.0 0.4 0.2 0.3 0.0 0.5 0.9 0.3 0.4 0.0 0.0 0.0 0.2 Other (O) 0.1 0.1 0.2 0.0 0.0 0.1 0.1 0.0 0.2 0.2 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 3,718 7,110 1,292 980 1,100 1,080 1,016 1,002 1,088 1,092 1,232 946 10,828 Household response rate (HRR)1 93.5 97.3 95.3 98.1 98.1 96.9 95.2 97.8 98.1 94.8 93.2 92.6 96.0 Eligible women Completed (EWC) 90.3 95.2 93.4 96.5 96.4 97.1 91.5 93.2 95.8 93.9 89.8 86.6 93.3 Not at home (EWNH) 4.1 2.7 3.1 1.6 2.4 1.5 5.3 4.8 2.4 1.5 3.2 7.0 3.3 Postponed (EWP) 0.7 0.4 0.6 0.0 0.0 0.1 0.0 0.0 0.0 2.3 1.2 0.6 0.5 Refused (EWR) 4.1 0.5 1.8 1.1 0.6 0.3 1.8 0.2 0.8 1.0 5.2 4.8 1.9 Partly completed (EWPC) 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.2 0.0 0.0 Incapacitated (EWI) 0.6 1.1 1.1 0.9 0.7 0.9 1.3 1.2 0.9 1.0 0.3 0.8 0.9 Other (EWO) 0.1 0.1 0.0 0.0 0.0 0.1 0.1 0.4 0.1 0.2 0.2 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 3,808 6,023 1,082 937 879 999 838 896 1,022 869 1,332 977 9,831 Eligible women response rate (EWRR)2 90.3 95.2 93.4 96.5 96.4 97.1 91.5 93.2 95.8 93.9 89.8 86.6 93.3 Overall women response rate (ORR)3 84.3 92.7 89.1 94.7 94.5 94.0 87.1 91.1 94.0 89.0 83.7 80.2 89.5 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C _______________________________ C + HP + P + R + DNF 2 The eligible women response rate (EWRR) is equivalent to the percentage of interviews completed (EWC). 3 The overall women response rate (OWRR) is calculated as: OWRR = HRR * EWRR/100 288 • Appendix A Table A.5 Sample implementation: Men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men and overall men response rates, according to urban-rural residence and province (unweighted), Zimbabwe 2010-11 Result Residence Province Total Urban Rural Manica- land Mashona- land Central Mashona- land East Mashona- land West Matabele- land North Matabele- land South Mid- lands Mas- vingo Harare Bula- wayo Selected households Completed (C) 89.4 90.5 88.4 91.7 94.5 91.3 85.5 92.1 91.3 86.1 91.0 89.2 90.1 Household present but no competent respondent at home (HP) 2.4 1.0 1.9 0.8 1.5 0.3 2.3 0.8 0.5 1.6 1.6 3.9 1.5 Postponed (P) 0.5 0.2 0.3 0.0 0.0 0.0 0.1 0.0 0.0 1.2 0.8 0.1 0.3 Refused (R) 2.9 0.4 1.2 0.6 0.1 0.1 0.9 0.3 0.6 1.5 4.0 3.0 1.2 Dwelling not found (DNF) 0.5 0.9 0.9 0.3 0.3 2.6 1.1 1.0 0.7 0.5 0.2 0.1 0.8 Household absent (HA) 2.7 4.0 4.3 2.9 3.3 3.3 4.6 3.5 2.8 7.4 1.4 2.2 3.6 Dwelling vacant/address not a dwelling (DV) 1.5 2.6 2.7 3.4 0.5 1.9 4.5 2.0 3.7 1.6 0.9 1.4 2.2 Dwelling destroyed (DD) 0.0 0.4 0.2 0.3 0.0 0.5 0.9 0.3 0.4 0.0 0.0 0.0 0.2 Other (O) 0.1 0.1 0.2 0.0 0.0 0.1 0.1 0.0 0.2 0.2 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 3,718 7,110 1,292 980 1,100 1,080 1,016 1,002 1,088 1,092 1,232 946 10,828 Household response rate (HRR)1 93.5 97.3 95.3 98.1 98.1 96.9 95.2 97.8 98.1 94.8 93.2 92.6 96.0 Eligible men Completed (EMC) 78.1 90.3 87.2 91.8 89.9 91.1 79.7 88.2 89.9 85.7 78.4 75.5 85.8 Not at home (EMNH) 12.1 6.9 6.4 6.2 7.7 6.0 15.5 8.8 8.0 8.4 9.9 13.3 8.9 Postponed (EMP) 1.4 0.2 0.3 0.0 0.1 0.1 0.0 0.0 0.0 3.1 2.4 0.4 0.7 Refused (EMR) 7.2 1.0 4.2 0.9 1.1 1.5 2.3 0.7 1.3 1.6 8.3 9.0 3.3 Partly completed (EMPC) 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Incapacitated (EMI) 1.0 1.5 1.6 1.0 1.2 0.9 2.4 2.2 0.7 1.1 0.9 1.7 1.3 Other (EMO) 0.2 0.1 0.2 0.1 0.0 0.3 0.0 0.1 0.1 0.2 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 3,253 5,470 944 902 829 970 740 764 951 645 1,198 780 8,723 Eligible men response rate (EMRR)2 78.1 90.3 87.2 91.8 89.9 91.1 79.7 88.2 89.9 85.7 78.4 75.5 85.8 Overall men response rate (ORR)3 72.9 87.9 83.1 90.1 88.2 88.3 75.9 86.3 88.2 81.2 73.0 70.0 82.3 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C _______________________________ C + HP + P + R + DNF 2 The eligible men response rate (EMRR) is equivalent to the percentage of interviews completed (EMC). 3 The overall men response rate (OMRR) is calculated as: OMRR = HRR * EMRR/100 The coverage of HIV testing was also markedly improved in the 2010-11 ZDHS relative to the 2005-06 survey. Tables A.6-A.9 present response rates for the HIV testing by background characteristics. Appendix A • 289 Table A.6 Coverage of HIV testing by social and demographic characteristics: Women Percent distribution of interviewed women age 15-49 by HIV testing status, according to social and demographic characteristics (unweighted), Zimbabwe 2010-11 Characteristic HIV test status Total Number of women DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Marital status Never married 83.9 11.7 2.3 2.1 100.0 2,332 Ever had sex 85.3 10.1 2.2 2.4 100.0 673 Never had sex 83.3 12.4 2.4 1.9 100.0 1,659 Married/living together 85.6 11.5 1.3 1.6 100.0 5,578 Divorced/separated 88.8 8.2 1.8 1.2 100.0 680 Widowed 88.8 8.3 1.7 1.2 100.0 581 Type of union In polygynous union 83.2 13.8 1.2 1.8 100.0 607 In non-polygynous union 86.2 10.9 1.3 1.6 100.0 4,683 Not currently in union 85.6 10.5 2.1 1.8 100.0 3,593 In union, polygyny status unknown 81.3 15.6 1.4 1.7 100.0 288 Ever had sexual intercourse Yes 86.1 10.8 1.4 1.6 100.0 7,509 No 83.3 12.4 2.3 1.9 100.0 1,662 Currently pregnant Pregnant 86.4 10.7 1.4 1.5 100.0 723 Not pregnant or not sure 85.5 11.2 1.6 1.7 100.0 8,448 Times slept away from home in past 12 months None 84.9 11.5 1.7 1.9 100.0 4,038 1-2 85.7 11.4 1.5 1.5 100.0 2,507 3-4 87.5 10.0 1.3 1.3 100.0 1,039 5+ 86.2 10.3 1.8 1.7 100.0 1,587 Time away in past 12 months Away for more than 1 month 87.2 10.0 1.3 1.5 100.0 1,423 Away for less than 1 month 85.8 11.1 1.6 1.5 100.0 3,710 Not away 84.9 11.5 1.7 1.9 100.0 4,038 Religion Traditional 87.3 6.3 4.8 1.6 100.0 63 Roman Catholic 85.5 10.9 1.4 2.2 100.0 764 Protestant 86.0 10.2 2.4 1.4 100.0 1,511 Pentecostal 86.3 11.5 1.0 1.2 100.0 1,850 Apostolic Sect 85.2 11.3 1.7 1.8 100.0 3,396 Other Christian 84.7 11.6 1.6 2.1 100.0 953 Muslim 87.5 12.5 0.0 0.0 100.0 40 None 86.6 10.9 0.8 1.7 100.0 589 Other 60.0 40.0 0.0 0.0 100.0 5 Total 15-49 85.6 11.1 1.6 1.7 100.0 9,171 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, that is, positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g. technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 290 • Appendix A Table A.7 Coverage of HIV testing by social and demographic characteristics: Men Percent distribution of interviewed men 15-54 by HIV testing status, according to social and demographic characteristics (unweighted), Zimbabwe 2010-11 Characteristic HIV test status Total Number of men DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Marital status Never married 80.7 14.7 2.3 2.3 100.0 3,329 Ever had sex 81.3 14.7 2.3 1.6 100.0 1,520 Never had sex 80.1 14.6 2.3 2.9 100.0 1,809 Married/living together 80.9 15.3 2.2 1.6 100.0 3,794 Divorced/separated 81.5 15.3 1.5 1.8 100.0 275 Widowed 81.7 14.6 1.2 2.4 100.0 82 Type of union In polygynous union 75.3 20.9 2.7 1.1 100.0 182 In non-polygynous union 81.2 15.0 2.2 1.6 100.0 3,612 Not currently in union 80.7 14.7 2.2 2.3 100.0 3,686 Ever had sexual intercourse Yes 81.1 15.1 2.2 1.6 100.0 5,669 No 80.1 14.7 2.3 2.9 100.0 1,811 Male circumcision Circumcised 78.0 17.7 2.7 1.6 100.0 696 Not circumcised 81.1 14.8 2.2 1.9 100.0 6,725 Don’t know 76.3 13.6 3.4 6.8 100.0 59 Times slept away from home in past 12 months None 79.8 15.3 2.5 2.4 100.0 3,729 1-2 83.9 13.2 1.8 1.1 100.0 1,397 3-4 85.7 10.3 1.7 2.3 100.0 698 5+ 78.5 17.9 2.2 1.4 100.0 1,656 Time away in past 12 months Away for more than 1 month 83.2 13.5 2.0 1.2 100.0 1,125 Away for less than 1 month 81.3 15.2 1.9 1.6 100.0 2,626 Not away 79.8 15.3 2.5 2.4 100.0 3,729 Religion Traditional 90.0 8.2 0.7 1.1 100.0 281 Roman Catholic 78.7 17.6 1.2 2.5 100.0 752 Protestant 82.8 14.3 1.7 1.1 100.0 990 Pentecostal 78.2 16.6 3.0 2.2 100.0 1,038 Apostolic Sect 80.6 15.1 1.9 2.3 100.0 2,025 Other Christian 78.3 17.1 2.8 1.9 100.0 580 Muslim 75.0 22.7 0.0 2.3 100.0 44 None 81.9 13.3 3.0 1.8 100.0 1,761 Other 55.6 44.4 0.0 0.0 100.0 9 Total 15-54 80.8 15.0 2.2 2.0 100.0 7,480 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, that is, positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g. technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. Appendix A • 291 Table A.8 Coverage of HIV testing by sexual behaviour characteristics: Women Percent distribution of interviewed women age 15-49 who ever had sexual intercourse by HIV test status, according to sexual behaviour characteristics (unweighted), Zimbabwe 2010-11 Sexual behaviour characteristic HIV test status Total Number of women DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Age at first sexual intercourse <16 88.8 8.0 1.3 1.8 100.0 1,246 16-17 86.6 10.1 1.7 1.6 100.0 2,155 18-19 86.8 10.4 1.0 1.7 100.0 1,843 20+ 83.5 13.6 1.4 1.5 100.0 1,797 Don’t know/missing 84.0 12.4 2.6 1.1 100.0 468 Multiple sexual partners and partner concurrency in past 12 months 0 87.9 9.6 1.7 0.8 100.0 1,191 1 85.8 11.1 1.4 1.7 100.0 6,101 2+ 85.1 8.9 1.0 5.0 100.0 101 Had concurrent partners3 82.6 17.4 0.0 0.0 100.0 23 None of the partners were concurrent 85.9 6.4 1.3 6.4 100.0 78 Missing 85.3 11.2 3.4 0.0 100.0 116 Condom use at last sexual intercourse in past 12 months Used condom 83.9 11.7 2.1 2.2 100.0 940 Did not use condom at last sexual intercourse in past 12 months 86.1 10.9 1.2 1.7 100.0 5,262 No sexual intercourse in past 12 months 87.7 9.7 1.8 0.8 100.0 1,307 Number of lifetime partners 1 86.0 11.2 1.3 1.5 100.0 4,598 2 87.6 9.8 1.0 1.6 100.0 1,729 3-4 86.2 9.6 2.4 1.8 100.0 842 5-9 86.3 8.3 2.0 3.4 100.0 204 10+ 78.5 16.5 2.5 2.5 100.0 79 Don’t know 61.4 33.3 5.3 0.0 100.0 57 Prior HIV testing Ever tested 87.8 9.5 1.2 1.5 100.0 5,218 Received results 87.9 9.5 1.2 1.5 100.0 5,057 Did not received results 87.0 11.2 0.6 1.2 100.0 161 Never tested 82.2 13.8 2.1 2.0 100.0 2,291 Total 15-49 86.1 10.8 1.4 1.6 100.0 7,509 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, that is, positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g. technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 3 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. 292 • Appendix A Table A.9 Coverage of HIV testing by sexual behaviour characteristics: Men Percent distribution of interviewed men age 15-54 who ever had sexual intercourse by HIV test status, according to sexual behaviour characteristics (unweighted), Zimbabwe 2010-11 Sexual behaviour characteristic HIV test status Total Number of men DBS Tested1 Refused to provide blood Absent at the time of blood collection Other/ missing2 Age at first sexual intercourse <16 85.5 10.8 1.9 1.9 100.0 593 16-17 81.7 14.3 2.4 1.6 100.0 1,037 18-19 82.6 14.5 1.6 1.2 100.0 1,375 20+ 80.2 15.9 2.2 1.6 100.0 2,439 Don’t know/missing 65.8 24.9 5.8 3.6 100.0 225 Multiple sexual partners and partner concurrency in past 12 months 0 83.4 13.3 2.0 1.2 100.0 488 1 81.6 14.7 2.1 1.7 100.0 4,331 2+ 79.2 16.6 2.9 1.3 100.0 754 Had concurrent partners3 78.9 16.8 3.2 1.1 100.0 279 None of the partners were concurrent 79.4 16.4 2.7 1.5 100.0 475 Missing 60.4 31.3 3.1 5.2 100.0 96 Condom use at last sexual intercourse in past 12 months Used condom 80.4 16.0 1.8 1.8 100.0 1,396 Did not use condom at last sexual intercourse in past 12 months 81.5 14.6 2.3 1.5 100.0 3,689 No sexual intercourse in past 12 months 79.6 16.3 2.2 1.9 100.0 584 Paid for sexual intercourse in past 12 months Yes 83.1 11.8 3.1 2.1 100.0 195 Used condom 81.5 12.5 3.6 2.4 100.0 168 Did not use condom 92.6 7.4 0.0 0.0 100.0 27 No /no sexual intercourse in past 12 months 81.0 15.2 2.2 1.6 100.0 5,474 Number of lifetime partners 1 79.7 16.8 2.2 1.3 100.0 1,017 2 82.4 14.9 1.3 1.5 100.0 936 3-4 82.6 13.4 2.3 1.7 100.0 1,490 5-9 83.9 12.3 2.3 1.4 100.0 1,176 10+ 81.4 14.0 2.4 2.1 100.0 705 Don’t know 64.1 29.9 3.5 2.6 100.0 345 Prior HIV testing Ever tested 82.5 14.2 1.9 1.4 100.0 2,546 Received results 82.5 14.2 1.9 1.5 100.0 2,372 Did not received results 82.8 14.9 1.7 0.6 100.0 174 Never tested 79.9 15.9 2.4 1.8 100.0 3,123 Total 15-54 81.1 15.1 2.2 1.6 100.0 5,669 1 Includes all dried blood samples (DBS) tested at the lab and for which there is a result, that is, positive, negative, or indeterminate. Indeterminate means that the sample went through the entire algorithm, but the final result was inconclusive. 2 Includes (1) other results of blood collection (e.g. technical problem in the field), (2) lost specimens, (3) noncorresponding bar codes, and (4) other lab results such as blood not tested for technical reason, not enough blood to complete the algorithm, etc. 3 A respondent is considered to have had concurrent partners if he or she had overlapping sexual partnerships with two or more people during the 12 months before the survey. (Respondents with concurrent partners include polygynous men who had overlapping sexual partnerships with two or more wives). A.5 SAMPLE PROBABILITIES AND SAMPLE WEIGHTS As described above, the 2010-11 ZDHS was selected with unequal probability in order to ensure an adequate number of cases for analysis in key domains. Therefore, sampling weights must be calculated and used in the analysis of the ZDHS results to ensure the representativeness of the survey results at the national level. Since the ZDHS sample is a two-stage stratified cluster sample, sampling weights are based on sampling probabilities calculated separately for each sampling stage and for each cluster where: P1hi: first-stage sampling probability of the ith cluster in stratum h (defined in terms of province and urban-rural residence) P2hi: second-stage sampling probability within the ith cluster (households) Appendix A • 293 The following describes the calculation of these probabilities: Let ah be the number of EAs selected in stratum h, Mhi the number of households according to the sampling frame in the ith EA, and M hi the total number of households in the stratum. The probability of selecting the ith EA in the 2010-11 ZDHS sample is calculated as follows: M M a hi hih  Let hib be the proportion of households in the selected cluster compared to the total number of households in EA i in stratum h if the EA is segmented, otherwise 1=hib . Then the probability of selecting cluster i in the sample is: hi hi hih 1hi b M M a = P × Let hiL be the number of households listed in the household listing operation in cluster i in stratum h, and let hig be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster is calculated as follows: hi hi hi L gP =2 The