Bangladesh - Demographic and Health Survey - 2001

Publication date: 2001

Bangladesh 1999-2000Demographic andHealth SurveyDem ographic and H ealth Survey B angladesh 1999-2000 World Summit for Children Indicators: Bangladesh 1999-2000 __________________________________________________________________________________________________ Value__________________________________________________________________________________________________ BASIC INDICATORS__________________________________________________________________________________________________ Infant mortality Infant mortality rate 66 per 1,000 Under-five mortality rate 94 per 1,000 Childhood undernutrition Percent stunted 44.7 Percent wasted 10.3 Percent underweight 47.7 Clean water supply Percent of households with a safe water supply1 97.3 Sanitary excreta disposal Percent of households with flush toilets or VIP latrines 35.8 Basic education Percent of women 15-49 with completed primary education 43.8 Percent of men 15-49 with completed primary education 54.1 Percent of girls 6-12 attending school 80.6 Percent of boys 6-12 attending school 76.9 Percent of women 15-49 who are literate 45.7 Children in especially difficult situations Percent of children who live in single-adult households 3.0 __________________________________________________________________________________________________ SUPPORTING INDICATORS__________________________________________________________________________________________________ Women's Health Birth spacing Percent of births within 24 months of a previous birth 16.3 Safe motherhood Percent of last births with medical prenatal care 33.3 Percent of births with prenatal care in first trimester 12.0 Percent of births with medical assistance at delivery 12.1 Percent of births in a medical facility 5.6 Percent of births at high risk 53.2 Family planning Contraceptive prevalence rate (any method, married women) 53.8 Percent of currently married women with an unmet demand for family planning 15.3 Percent of currently married women with an unmet need for family planning to avoid a high-risk birth 11.6 Nutrition Maternal nutrition Percent of mothers with low BMI 45.4 Breastfeeding Percent of children under 4 months who are exclusively breastfed 52.8 Child Health Vaccinations Percent of children (last birth) whose mothers received tetanus toxoid vaccination during pregnancy 81.2 Percent of children 12-23 months with measles vaccination 70.8 Percent of children 12-23 months fully vaccinated 60.4 Diarrhea control Percent of children with diarrhea in preceding 2 weeks who received oral rehydration therapy (sugar-salt-water solution) 73.6 Acute respiratory infection Percent of children with acute respiratory infection in preceding 2 weeks who were seen by medical personnel 27.2 __________________________________________________________________________________________________ 1 Piped, well, and bottled water Bangladesh Demographic and Health Survey 1999-2000 National Institute of Population Research and Training (NIPORT) Dhaka, Bangladesh Mitra and Associates Dhaka, Bangladesh ORC Macro Calverton, Maryland USA May 2001 CONTRIBUTORS TO THE REPORT S.N. Mitra Ahmed Al-Sabir Tulshi Saha Sushil Kumar The Bangladesh Demographic and Health Survey (BDHS) is part of the worldwide Demographic and Health Surveys program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information about the BDHS may be obtained from: NIPORT Azimpur Dhaka, Bangladesh Telephone: 862-5251 Fax: 862-3362 Mitra and Associates 2/17 Iqbal Road, Block A Mohammadpur, Dhaka, Bangladesh Telephone: 811-8065 Fax: 911-5503 Additional information about the MEASURE DHS+ project may be obtained from: ORC Macro 11785 Beltsville Drive Suite 300 Calverton, MD 20705 USA Telephone: 301-572-0200 Fax: 301-572-0999 Internet: http://www.measuredhs.com Suggested citation: National Institute of Population Research and Training (NIPORT), M itra and Associates (MA), and ORC Macro (ORCM). 2001. Bangladesh Demographic and Health Survey 1999-2000. Dhaka, Bangladesh and Calverton, Maryland [USA]: National Institute of Population Research and Training, Mitra and Associates, and ORC Macro. Contents * iii CONTENTS Page TABLES AND FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii MAP OF BANGLADESH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxii CHAPTER 1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Geography and Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Population, Family Planning and Maternal and Child Health Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.4 Organization of the 1999-2000 Bangladesh Demographic and Health Survey . . 4 Survey Objectives and Implementing Organizations . . . . . . . . . . . . . . . . . . . . . . 4 Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Response Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . 9 2.1 Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Age and Sex Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.2 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Household Possessions and Availability of Food . . . . . . . . . . . . . . . . . . . . . . . 18 2.3 Background Characteristics of Women and Men Respondents . . . . . . . . . . . . . 20 General Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Differential Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Exposure to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Employment and Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Women's Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 iv * Contents Page CHAPTER 3 FERTILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 3.2 Current Fertility Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 3.3 Fertility Differentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.4 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3.5 Children Ever Born and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.6 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 3.7 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 3.8 Teenage Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 CHAPTER 4 FERTILITY REGULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 4.1 Knowledge of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Trends in Knowledge of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . 46 4.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 4.3 Knowledge and Ever Use of Menstrual Regulation . . . . . . . . . . . . . . . . . . . . . . 50 4.4 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Trends in Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Differentials in Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . 55 Contraceptive Use Reporting Among Married Couples . . . . . . . . . . . . . . . . . . . 58 4.5 Number of Children at First Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 4.6 Problems with Current Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.7 Use of Social Marketing Brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.8 Age at Sterilization and Sterilization Regret . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4.9 Source of Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 4.10 Contraceptive Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 4.11 Nonuse of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Future Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Reasons for Nonuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Preferred Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 4.12 Family Planning Outreach Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4.13 Discussion about Family Planning between Spouses . . . . . . . . . . . . . . . . . . . . . 73 4.14 Attitudes of Male and Female Respondents Toward Family Planning . . . . . . . . 74 4.15 Family Planning Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 CHAPTER 5 OTHER PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . 77 5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 5.2 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 5.3 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 5.4 Postpartum Amenorrhea, Insusceptibility, and Menopause . . . . . . . . . . . . . . . . 80 Contents * v Page CHAPTER 6 FERTILITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 6.1 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 6.2 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 6.3 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 6.4 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 CHAPTER 7 INFANT AND CHILD MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 7.2 Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 7.3 Levels, Trends, and Differentials in Infant and Child Mortality . . . . . . . . . . . 101 7.4 Socioeconomic Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . 102 7.5 Demographic Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . 104 7.6 Perinatal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 7.7 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 CHAPTER 8 REPRODUCTIVE AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . 111 8.1 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Prevalence and Source of Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Number and Timing of Antenatal Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Components of Antenatal Care Checkup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Tetanus Toxoid Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 8.2 Delivery Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Place of Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Assistance During Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 8.3 Caesarean Section and Child Size at Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 8.4 Childhood Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Vaccination Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Differentials in Vaccination Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Trends in Vaccination Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 8.5 Childhood Illness and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Childhood Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Treatment of Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Vitamin A Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Perceived Problems in Accessing Women’s Health Care . . . . . . . . . . . . . . . . . 129 CHAPTER 9 INFANT FEEDING AND CHILDHOOD AND MATERNAL NUTRITION . . . 133 9.1 Infant Feeding Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Prevalence of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Timing of the Introduction of Supplementary Foods . . . . . . . . . . . . . . . . . . . 135 Duration of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 9.2 Children’s Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 9.3 Nutritional Status of Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 vi * Contents Page CHAPTER 10 KNOWLEDGE OF AIDS AND SEXUALLY TRANSMITTED INFECTIONS . . . 147 10.1 Knowledge of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 10.2 Knowledge of Ways to Avoid AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 10.3 Perception of AIDS and Communication with Spouses . . . . . . . . . . . . . . . . . . 152 10.4 Awareness and Prevalence of Sexually Transmitted Infections (STIs) . . . . . . . 154 CHAPTER 11 COMMUNITY CHARACTERISTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 CHAPTER 12 IMPLICATIONS FOR POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 12.1 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 The Fertility Decline and Future Population Growth . . . . . . . . . . . . . . . . . . . . 165 Population Momentum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 12.2 Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Contraceptive Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Contraceptive Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Sources of Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 12.3 High Desired Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Unmet Need for Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 12.4 Minimizing Population Momentum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Marriage and Initiation of Childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Policies to Reduce Fertility and Minimize Population Momentum . . . . . . . . . 171 12.5 Reproductive Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 12.5.1 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 12.6 Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 APPENDIX A SAMPLE IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 APPENDIX B ESTIMATES OF SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 APPENDIX C DATA QUALITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 APPENDIX D PERSONS INVOLVED IN THE 1999-2000 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . 205 APPENDIX E QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Contents * vii TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . . . . . . . . . . . . . . . . . . 7 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Table 2.1 Household population by age, residence, and sex . . . . . . . . . . . . . . . . . . 10 Table 2.2 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 2.3 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Table 2.4 Educational level of the female and male household population . . . . . . . 13 Table 2.5 School attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table 2.6 Employment status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 2.7 Housing characteristics and level of food consumption . . . . . . . . . . . . . . 17 Table 2.8 Household durable goods and land ownership . . . . . . . . . . . . . . . . . . . . . 19 Table 2.9 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . 20 Table 2.10 Differentials in age and education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Table 2.11 Level of education by background characteristics . . . . . . . . . . . . . . . . . . 23 Table 2.12 Exposure to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Table 2.13 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table 2.14 Form of earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Table 2.15 Household decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Figure 2.1 Population Pyramid, Bangladesh 1999-2000 . . . . . . . . . . . . . . . . . . . . . . 10 Figure 2.2 Distribution of De Facto Household Population by Single Year of Age and Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Figure 2.3 Percentage of Males and Females with No Education by Age Group . . . . 14 CHAPTER 3 FERTILITY Table 3.1 Current fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Table 3.2 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Table 3.3 Trends in current fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Table 3.4 Percent pregnant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Table 3.5 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Table 3.6 Trends in fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Table 3.7 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table 3.8 Trends in children ever born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Table 3.9 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Table 3.10 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Table 3.11 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Table 3.12 Teenage pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 viii * Contents Page Figure 3.1 Age Specific Fertility Rates by Residence . . . . . . . . . . . . . . . . . . . . . . . . . 32 Figure 3.2 Total Fertility Rates by Selected Background Characteristics . . . . . . . . . . 33 Figure 3.3 Trends in Total Fertility Rates, 1971-1999 . . . . . . . . . . . . . . . . . . . . . . . . 35 Figure 3.4 Age Specific Fertility Rates, 1989, 1991, 1993-1994, 1996-1997, 1999-2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 CHAPTER 4 FERTILITY REGULATION Table 4.1 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Table 4.2 Trends in knowledge of family planning methods . . . . . . . . . . . . . . . . . . 47 Table 4.3 Knowledge of contraceptive methods among couples . . . . . . . . . . . . . . . 48 Table 4.4 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Table 4.5 Trends in ever use of family planning methods . . . . . . . . . . . . . . . . . . . . 50 Table 4.6 Menstrual regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Table 4.7 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Table 4.8 Trends in current use of contraceptive methods . . . . . . . . . . . . . . . . . . . . 53 Table 4.9 Current use of contraception by background characteristics . . . . . . . . . . . 56 Table 4.10 Comparison of reported contraceptive use by spouses . . . . . . . . . . . . . . . 57 Table 4.11 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . 58 Table 4.12 Problems with current method of contraception . . . . . . . . . . . . . . . . . . . 59 Table 4.13 Use of pill brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table 4.14 Use of condom brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Table 4.15 Timing of sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Table 4.16 Sterilization regret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Table 4.17 Source of supply of modern contraceptive methods . . . . . . . . . . . . . . . . . 64 Table 4.18 Contraceptive discontinuation rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table 4.19 Reasons for discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Table 4.20 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Table 4.21 Reason for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Table 4.22 Contact with family planning and health worker . . . . . . . . . . . . . . . . . . . 71 Table 4.23 Satellite clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Table 4.24 Discussion of family planning with husband . . . . . . . . . . . . . . . . . . . . . . 73 Table 4.25 Wives’ perception of couple's attitude toward family planning . . . . . . . . . 74 Table 4.26 Exposure to family planning messages . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Figure 4.1 Trends in Contraceptive Use (%) Among Currently Married Women 10-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Figure 4.2 Trends in Use of Specific Contraceptive Methods Among Currently Married Women Age 10-49 . . . . . . . . . . . . . . . . . . . . . 54 Figure 4.3 Trends in Contraceptive Method Mix . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Figure 4.4 Distribution of Current Users of Modern Contraception by Source of Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 CHAPTER 5 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 5.1 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Table 5.2 Trends in proportion never married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Contents * ix Page Table 5.3 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table 5.4 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Table 5.5 Postpartum amenorrhea, abstinence, and insusceptibility . . . . . . . . . . . . 82 Table 5.6 Median duration of postpartum insusceptibility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Table 5.7 Indicators of termination of exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Figure 5.1 Trends in Proportion Never Married Among Women 15-19 and 20-24 . . . 79 CHAPTER 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . 86 Table 6.2 Fertility preference by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Table 6.3 Want no more children by background characteristics . . . . . . . . . . . . . . . 89 Table 6.4 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Table 6.5 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Table 6.6 Mean ideal number of children by background characteristics . . . . . . . . . 95 Table 6.7 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Table 6.8 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Figure 6.1 Fertility Preferences Among Currently Married Women 10-49 . . . . . . . . . 87 Figure 6.2 Percentage of Currently Married Women and Men Who Want No More Children by Number of Living Children . . . . . . . . . . . . . . 87 Figure 6.3 Fertility Preferences Among Married Couples . . . . . . . . . . . . . . . . . . . . . 89 Figure 6.4 Percentage Married Women With Two Children Who Want No More Children by Background Characteristics . . . . . . . . . . . . . . 90 Figure 6.5 Trends in Unmet Need for Family Planning by Division . . . . . . . . . . . . . . 92 Figure 6.6 Percent Distribution of Births by Planning Status . . . . . . . . . . . . . . . . . . . 96 CHAPTER 7 INFANT AND CHILD MORTALITY Table 7.1 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Table 7.2 Infant and child mortality by socioeconomic characteristics . . . . . . . . . . 103 Table 7.3 Infant and child mortality by demographic characteristics . . . . . . . . . . . 104 Table 7.4 Perinatal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Table 7.5 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Figure 7.1 Trends in Infant and Childhood Mortality, 1989-1993 and 1995-1999 . 102 Figure 7.2 Under-five Mortality by Background Characteristics . . . . . . . . . . . . . . . 103 Figure 7.3 Under-five Mortality by Selected Demographic Characteristics . . . . . . . 105 CHAPTER 8 REPRODUCTIVE AND CHILD HEALTH Table 8.1 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Table 8.2 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . . 114 x * Contents Page Table 8.3 Components of antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Table 8.4 Tetanus toxoid vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Table 8.5 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Table 8.6 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Table 8.7 Delivery characteristics: caesarean section, birth weight, and size . . . . . 120 Table 8.8 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Table 8.9 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . 123 Table 8.10 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . 125 Table 8.11 Treatment for fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Table 8.12 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Table 8.13 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Table 8.14 Treatment with vitamin A capsules . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Table 8.15 Perceived problems in accessing women's health care . . . . . . . . . . . . . . 131 Figure 8.1 Percent Distribution of Births by Antenatal and Delivery Care . . . . . . . . 113 Figure 8.2 Percentage of Children 12-23 Months Who Have Received Specific Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Figure 8.3 Percentage of Children 12-23 Months Who Have Received All Vaccinations by Background Characteristics . . . . . . . 122 Figure 8.4 Trends in Vaccination Coverage Among Children Age 12-23 Months . . . 124 CHAPTER 9 INFANT FEEDING AND CHILDHOOD AND MATERNAL NUTRITION Table 9.1 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Table 9.2 Breastfeeding status by child's age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Table 9.3 Median duration and frequency of breastfeeding by background variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Table 9.4 Foods received by children in preceding 24 hours . . . . . . . . . . . . . . . . . 139 Table 9.5 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . 142 Table 9.6 Nutritional status of children by background characteristics . . . . . . . . . 144 Table 9.7 Maternal nutritional status by background characteristics . . . . . . . . . . . 146 Figure 9.1 Median Duration of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Figure 9.2 Percentage of Children under Five, Who Are Stunted, According to Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . 143 Figure 9.3 Percentage of Children under Five, Who Are Stunted, According to Socioeconomic Characteristics . . . . . . . . . . . . . . . . . . . . . 145 CHAPTER 10 KNOWLEDGE OF AIDS AND SEXUALLY TRANSMITTED INFECTIONS Table 10.1 Knowledge of HIV/AIDS and sources of AIDS information . . . . . . . . . . . 148 Table 10.2 Knowledge of ways to avoid HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . 150 Table 10.3 Knowledge of specific ways to avoid HIV/AIDS . . . . . . . . . . . . . . . . . . . 151 Table 10.4.1 Perception of AIDS and communication with spouses: women . . . . . . . 152 Table 10.4.2 Perception of AIDS and communication with spouses: men . . . . . . . . . . 153 Table 10.5.1 Knowledge of signs and symptoms of STIs: women . . . . . . . . . . . . . . . . 154 Table 10.5.2 Knowledge of signs and symptoms of STIs: men . . . . . . . . . . . . . . . . . . 155 Contents * xi Page Table 10.6 Gynecological health problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Table 10.7 Symptoms of sexually transmitted disease in men . . . . . . . . . . . . . . . . . 157 Figure 10.1 Percentage of Ever Married Women and Currently Married Men Who Have Heard of AIDS, by Background Characteristics . . . . . . . . . . . 149 CHAPTER 11 COMMUNITY CHARACTERISTICS Table 11.1 Availability of general services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Table 11.2 Distance to nearest education facility . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Table 11.3 Availability of income-generating organizations . . . . . . . . . . . . . . . . . . 162 Table 11.4 Availability of family planning and health services . . . . . . . . . . . . . . . . 162 Table 11.5 Distance to nearest selected health and family planning services . . . . . . 163 CHAPTER 12 IMPLICATIONS FOR POLICY Figure 12.1 Changes in Neonatal, Infant, and Under-five Mortality by Urban-rural Residence, 1989-1993 to 1995-1999 . . . . . . . 173 Figure 12.2 Changes in Neonatal, Post-neonatal, and Child (1-4 yrs.) Mortality by Gender, 1989-1995 to 1995-1999 . . . . . . . . . . . . . . . . . . . 176 APPENDIX A SAMPLE IMPLEMENTATION Table A.1.1 Sample implementation: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Table A.1.2 Sample implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Figure A.1 Urban Sampling Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Figure A.2 Rural Sampling Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Bangladesh 1999-2000 . . 188 Table B.2 Sampling errors - National sample, Bangladesh 1999-2000 . . . . . . . . . . 189 Table B.3 Sampling errors - Urban sample, Bangladesh 1999-2000 . . . . . . . . . . . . 190 Table B.4 Sampling errors - Rural sample, Bangladesh 1999-2000 . . . . . . . . . . . . 191 Table B.5 Sampling errors - Barisal, Bangladesh 1999-2000 . . . . . . . . . . . . . . . . . 192 Table B.6 Sampling errors - Chittagong, Bangladesh 1999-2000 . . . . . . . . . . . . . . 193 Table B.7 Sampling errors - Dhaka, Bangladesh 1999-2000 . . . . . . . . . . . . . . . . . 194 Table B.8 Sampling errors - Khulna, Bangladesh 1999-2000 . . . . . . . . . . . . . . . . . 195 Table B.9 Sampling errors - Rajshahi, Bangladesh 1999-2000 . . . . . . . . . . . . . . . . 196 Table B.10 Sampling errors - Sylhet, Bangladesh 1999-2000 . . . . . . . . . . . . . . . . . . 197 xii * Contents Page APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Table C.2 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . 200 Table C.3 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Table C.4 Births by calendar year since birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Table C.5 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Table C.6 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Preface * xiii Director General National Institute of Population Research and Training (NIPORT) PREFACE The 1999-2000 Bangladesh Demographic and Health Survey (BDHS) is a nationally representative survey that was implemented through a collaborative effort of the National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ORC Macro (USA). The 1999-2000 BDHS provides updated estimates of the basic national demographic and health indicators. The information collected in the 1999-2000 BDHS will be instrumental in identifying new directions for the national health and family planning program in Bangladesh. Data concerning fertility levels, contraceptive method mix, and infant mortality levels are crucial indicators in evaluating policies and programs and in making projections for the future. The survey report will hopefully contribute to an increased commitment to improving the lives of mothers and children. The Technical Review Committee (TRC) was composed of members with professional expertise from government, non-government and international organizations as well as researchers and professionals working in the Health and Population Sector Program, who contributed their valuable comments in major phases of the study. In addition, a Technical Task Force (TTF) was formed with representatives from NIPORT, Mitra and Associates, USAID/Dhaka, ICCDR,B, Dhaka University and ORC Macro for designing and implementing the survey. I would like to extend my gratitude and appreciation to the members of the TRC and TTF for their valuable contributions at different phases of the survey. The preliminary results of the 1999-2000 BDHS with its major findings were released in a dissemination seminar held in June 2000. The final report supplements the preliminary report released earlier. I hope the survey results will be useful for monitoring and implementation of the Health and Population Sector Program. The contributors of the various chapters of this report deserve special thanks. I express also my heartfelt thanks to the professionals of the research unit of NIPORT, Mitra and Associates, ORC Macro, and USAID/Dhaka for their sincere efforts in successful completion of the survey. xiv * Contents Foreword * xv Secretary Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh FOREWORD The 1999-2000 Bangladesh Demographic and Health Survey (BDHS) is a nationally representative sample survey designed to provide information on basic national indicators of social progress including fertility, contraceptive knowledge and use, fertility preference, childhood mortality, maternal and child health, nutritional status of mothers and children and awareness of AIDS. The 1999-2000 BDHS provides a comprehensive look at levels and trends in key health and demographic parameters for policy makers and program managers. The fertility has declined from 6.3 children per women in 1975 to 3.3 in 1999-2000. The pace of fertility decline has slowed in the most recent period compared to the rapid decline during late 1980s and early 1990s. The BDHS 1999-2000 findings also show the increasing trend of contraceptive use, declining childhood mortality, and improving nutritional status. The findings of this report together with other national surveys are very important in assessing the achievements of the Health and Population Sector Program. The 1999-2000 BDHS will furnish policy makers, planners and program managers with factual, reliable and up-to-date information in evaluating current programs and in designing new strategies for improving Health and Family Planning Services for the people of Bangladesh. The need, however, for further detailed analysis of BDHS data remains. It is hoped that the academicians, researchers and program personnel will carry out such analysis to provide more in- depth knowledge for future direction and effective implementation of the National Health and Population Sector Program. The success of the survey accrues to the dedicated support and involvement of a large number of institutions and individuals. In conclusion, I would like to extend my thanks to the National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ORC Macro (USA) for their sincere efforts in conducting the 1999-2000, BDHS. The U.S. Agency for International Development (USAID), Dhaka deserves thanks for financial assistance that helped ensure the ultimate success of this important undertaking. xvi * Contents Summary of Findings * xvii SUMMARY OF FINDINGS The 1999-2000 Bangladesh Demo- graphic and Health Survey (BDHS) is a nation- ally representative survey that was imple- mented by Mitra and Associates under the authority of National Institute for Population Research and Training (NIPORT) from Novem- ber 1999 to March 2000. The 1999-2000 BDHS is a follow-on to the 1993-1994 and 1996-1997 BDHS surveys and provides updated estimates of the basic demographic and health indicators covered in the earlier surveys. Like the 1993-1994 BDHS and the 1996-1997 BDHS, the 1999-2000 BDHS was designed to provide information on levels and trends of fertility, family planning knowledge and use, infant and child mortality, maternal and child health, and knowledge of AIDS. The BDHS data are intended for use by programme managers and policymakers to evaluate and improve family planning and health program- mes in Bangladesh. Survey data show the increasing trend of contraceptive use, declining childhood mortality, and improving nutritional status; however, many challenges still await. Fertility: The 1993-1994, 1996-1997, and 1999-2000 BDHSs results show that Ban- gladesh continues to experience a fairly rapid decline in fertility. At current fertility levels, a Bangladeshi woman will have an average 3.3 children during her reproductive years. In general, urban women tend to have smaller families than rural women (2.5 and 3.5 chil- dren per woman, respectively). The low level of fertility is also found in Khulna (2.7) and Rajshahi (3.0) divisions. Fertility differentials by women’s education status are notable; women who had no formal education have an average of 4.1 children, while women with at least some secondary education have 2.4 chil- dren. Bangladeshi couples have accepted the small family norm. About 60 percent of women prefer a two-child family, and another more than 20 percent consider a three child family ideal. Overall, the mean ideal family size among married women is 2.5 children and has not changed since 1993-1994. The desire for additional children de- clined noticeably in Bangladesh over the past decade. In 1991, 45 percent of married women with two children wanted to have another child in future; in the 1999-2000 survey the propor- tion is only 30 percent. More than half (52 per- cent) of currently married women in Bangla- desh say they want no more children and an additional 7 percent have been sterilized. Twenty four percent say they would like to wait two or more years before having their next child. Thus, the majority of married women want either to space their next birth or to limit childbearing altogether. This represents the proportion of women who are potentially in need of family planning services. Despite the relatively high and increas- ing level of contraceptive use, the data indicate that unplanned pregnancies are still common. Overall, one-third of births in Bangladesh can be considered as unplanned; 19 percent were mistimed (wanted later) and 14 percent were unwanted. If all unwanted births were avoided, the fertility rate in Bangladesh would fall from 3.3 to replacement level of 2.2 children per women. Family Planning: Since 1989, know- ledge of family planning in Bangladesh has been universal, and the pill, female steriliza- tion, injectables, IUDs, and condoms are widely known. A major cause of declining fertility in Bangladesh has been the steady increase in contraceptive use over the last 25 years. In 1975, only 8 percent of currently married women reported using a family planning method, compared with 54 percent in 1999- 2000. The prevalence of modern methods has increased even faster, more that eightfold, from 5 percent in 1975 to 43 percent in 1999-2000. xviii * Summary of Findings However, increases in modern methods appear to have slowed down in the three years since the 1996-97 BDHS. The dominant change in contraceptive prevalence since the late 1980s has been a large increase in the number of couples using oral contraception. The level of contraceptive use is higher in urban areas (60 percent) than in rural areas (52 percent). Contraceptive use is highest in Khulna Division, closely followed by Rajshahi and Barisal divisions, while it is lowest in Sylhet Division. Contraceptive use varies by women’s level of education. Fifty-one percent of married women with no formal education are currently using a method, com- pared with 59 percent of those with at least some secondary education. Public sector is the predominant source of family planning methods supply. Almost two-thirds (64 percent) of current users of modern methods obtain their methods from a public sector source. Twenty-two percent of modern method users get their methods from private medical sources such as pharmacies and private doctors and clinics, while 7 percent use nonmedical private sources such as shops and friends or relatives. Only 5 percent of users rely on an NGO source. One in five (21 percent) women re- ported having been visited by a fieldworker and almost all of them were visited by government workers (19 percent). Fieldworker’s visits for family planning were highest for women resid- ing in Khulna Division (33 percent) and lowest in Chittagong and Sylhet divisions (14 to 15 percent). Fieldworker visitations for health services were lower. Only 16 percent of women are visited for health services and almost all of the visits by government health workers. About two-thirds (68 percent) of women mentioned that there was a satellite clinic in their commu- nity, but only about one-third (35 percent) of those reporting a clinic said they had visited a clinic in the previous three months. Fifteen percent of married women in Bangladesh have an unmet need for family planning services—8 percent for spacing pur- poses and 7 percent for limiting birth. Thus, if all married women who say they want to space or limit their births were to use family planning methods, the contraceptive prevalence rate would increase from 54 percent to 71 percent. Currently, 78 percent of the demand for family planning is being met. One challenge for family planning program is to reduce the high levels of contra- ceptive discontinuations. BDHS data indicate that almost half of contraceptive users in Ban- gladesh stop using within 12 months of start- ing; one-fifth of those who stop do so as a result of side effects or health concerns with the methods. Antenatal Care: Nearly two-thirds of mothers in Bangladesh do not receive antenatal care. Those who receive care tend to receive it from doctor (24 percent) or nurses, midwives, and family welfare visitors (10 percent). The median number of antenatal care visit is only 1.8 far fewer than the recommended 12 visits. Furthermore, about one in four women at- tended the first antenatal care visit before the sixth months of gestation and for another 9 percent of women did not receive antenatal care until the sixth or seventh month of preg- nancy. Among all last births in the last five years, more than one-third mothers were weighed and received iron tablets or syrup. Mother of only 16 to 19 percent of births had their blood and urine tested during their preg- nancy and received advice on the danger sign of pregnancy. Delivery Characteristics: Almost all births (92 percent) in Bangladesh are delivered at home. Use of health facilities for delivery is much more common in urban areas (16 percent of births), among mothers with some secondary education (13 percent), and among mothers who received at least four antenatal care visits (7 percent). Sixty-four percent of births in Bangladesh are assisted by a traditional birth attendant and only 12 percent of births are assisted by a medically trained personnel. Summary of Findings * xix Childhood Vaccination: Sixty percent of Bangladeshi children age 12-23 months have been vaccinated against six diseases (tuberculo- sis, diphtheria, pertussis, tetanus, polio, and measles). Fifty-three percent of children com- pleted the vaccination schedule by the time they turned one year. The proportion fully immunized among children age 12-23 months has increased from 54 percent in 1996-1997 to 60 percent in 1999-2000 which is almost en- tirely due to an increase in the proportion receiving the third doze of polio vaccine (from 62 percent in 1996-97 to 71 percent in 1999- 2000). Childhood Diseases: In the 1999-2000 BDHS, mothers were asked whether their children under age of five years had been ill with a cough accompanied by rapid, difficult breathing in the two weeks preceding the survey. Based on mother’s reports, 18 percent of the children had had the illness. Twenty- seven percent of children with respiratory illness were taken to a health facility for treat- ment. Overall, 6 percent of the children under age five had experienced diarrhea at some time in the two weeks preceding the survey. About one-quarter (24 percent) of children whose mothers reported that they had had diarrhea were taken to a health provider for treatment. More than 60 percent of children with diarrhea were given a solution made from ORS packets, while 25 percent were given a recommended homemade fluid. Childhood Mortality: Data from sur- veys indicate the improvement in child survival since the early 1980s. Under-five mortality declined from 133 deaths per 1,000 births in 1989-1993 to 116 in 1992-1996 to 94 for the period 1995-1999. The infant mortality rate decline over the same period: from 87 in 1989- 1993 to 82 in 1992-1996 and to 66 in 1995- 1999. Despite overall decline in infant and child mortality, one in every 15 children born during the five years before 1999-2000 died within the first year of life and one in every 11 children died before reaching age five. Clearly, child survival programs in Bangladesh need to be intensified to achieve further reductions in infant and child mortality. Nutrition: Breastfeeding is universal in Bangladesh; 97 percent of children born in the past five years were breastfed at some time. Although almost all babies are breastfed at some time, only 17 percent are put to the breast within one hour of birth and less than two-thirds (63 percent) of children are put to the breast within the first day of life. The mean duration of any breastfeeding, exclusive breast- feeding, and breastfeeding with water only are 30.1 months, 3.8 months and 5.5 months, respectively. In the BDHS, all children under five and their mothers were both weighed and mea- sured to obtain data for estimating the level of malnutrition. The results indicate that 45 percent children under five are stunted (i.e., short for their age), a condition reflecting chronic malnutrition; 10 percent are wasted (i.e., thin for their height), a problem indicat- ing acute or short-term food deficit; and 48 percent are underweight, which may reflect stunting, wasting, or both. Malnutrition is substantially higher in rural areas than urban areas. Differences by divisions show that chil- dren in Sylhet and Barisal divisions are some- what more likely and those in Khulna division somewhat less likely to be malnourished than in other divisions. The nutritional status of women is represented by two indices: the height and body mass index (BMI). The BMI is computed as the ratio of weight in kilograms to the square height in centimeters (kg/cm2). Women whose BMI falls below 18.5 and women whose height is below 145 cm are considered at nutritional risk. The BMI in the 1999-2000 BDHS is 19.3 and 45 percent of women have a BMI of less than 18.5. The average height of women is 150.4 cm, and 16 percent women are shorter than 145 cm. AIDS Related Knowledge and Behav- ior: Only 31 percent of women and half of men have heard of AIDS. Urban residence and education have a very strong positive associa- tion with AIDS knowledge. Sixty-four percent of urban women and 76 percent of urban men xx * Summary of Findings have heard of AIDS compared with only 23 percent of rural women and 44 percent of rural men. Knowledge of AIDS increases from only 12 percent among illiterate women to 68 per- cent among women who have at least some secondary school. Similar patterns exist for men. Respondents from Sylhet and Rajshahi divisions are less likely to know of AIDS than other divisions. About one-tenth of respondents reported that there was no way to “avoid getting AIDS”. It is encouraging to note that percentage who say there is no way to avoid AIDS has declined since 1996-1997 BDHS, from 41 to 12 percent of women and from 27 to 11 percent of men. The BDHS collected information from women on their gynecological health problems in the past year and from men on the preva- lence of some common symptoms of sexually transmitted diseases in the six months preced- ing the survey. Twenty-one percent of women reported having had either abdominal pain or a urinary problem in the 12 months preceding the survey. Seven percent of women report genital sores or ulcers, while 15 percent report problems with vaginal itching or irritation during menstruation and 10 percent fever with vaginal discharge. One in twenty men reported having had an STD in the six months preceding the survey and most of them reported having an ulcer or sores on their penis. Community Characteristics: As a part of the 1999-2000 BDHS, a Service Provision Assessment (SPA) survey collected information on socioeconomic characteristics of the selected sample points (i.e. communities) as well as information on the accessibility and availability of health and family planning services. Ninety percent of women in Bangladesh live within 5 kilometers of a daily market, weekly market, post office, and primary school. Availability of income-generating activities in communities is also common. More than half of Bangladeshi women live in communities that have a mother’s club, Grameen Bank member, or a cooperative society; 83 percent live in villages where an NGO is working. Regarding family planning, more than half of women live in areas where shops sell temporary, non-clinical family planning meth- ods. However, urban women have more access to these than rural women. Ninety percent of women live in areas covered by a satellite health clinic and most live within 1 kilometer of the clinic. Among women for whom a clinic is available, more than two-thirds of these clinics offer pills, condoms, and injectables as family planning methods. About 80 percent of women live in a community where child immu- nization is available and two-thirds of them can get an ORS packet in the village. Summary of Findings * xxi xxii * Map of Bangladesh Introduction * 1 INTRODUCTION 1 1.1 GEOGRAPHY AND ECONOMY Bangladesh, a small country of 147,570 square kilometers and more than 120 million people, gained independence on March 26, 1971 after a war of liberation from Pakistan. The country is almost entirely surrounded by India, except for a short southeastern frontier with Myanmar and a southern coastline on the Bay of Bengal. The most significant feature of the landscape is the extensive network of large and small rivers that are of primary importance to the socioeconomic life of the nation. Chief among these, lying like a fan on the face of the land, are the Ganges-Padma, Brahmaputra-Jamuna, and Megna rivers. The climate of Bangladesh is dominated by seasonal monsoons. The country experiences a hot summer season with high humidity from March to June; a somewhat cooler but still hot and humid monsoon season from July through early October; and a cool, dry winter from November to the end of February. The fertile delta is frequented by natural calamities such as floods, cyclones, tidal bores, and drought. For administrative purposes, the country is divided into 6 divisions, 64 districts, and 490 thanas (subdistricts) (BBS, 1997a:3). Muslims constitute almost 90 percent of the population of Bangladesh, Hindus constitute about 10 percent, and others constitute less than 1 percent. The national language of Bangladesh is Bangla, which is spoken and understood by all. Agriculture is the most important sector of the nation’s economy. It accounts for 30 percent of the gross domestic product (GDP) and employs 64 percent of the workforce (BBS, 1997a:270,159). Jute is the main nonfood crop and the main cash crop of Bangladesh. Less than 20 percent of the cropped land area is used for crops other than jute and rice (BBS, 1997a:187,188). Industry, although small, is increasing in importance as a result of foreign investments. Prospects for mineral resources, gas, coal, and oil appear to be bright. However, the per capita income is only US$275 and half of Bangladesh’s population entered the 1990s with an income below the poverty line (GOB, 1994:2; World Bank, 1995:xvii). Unemployment/ underemployment is a serious problem, and pressure on the land in rural areas has led to movement of people from rural to urban areas. 1.2 POPULATION The population of the area that now constitutes Bangladesh has grown from about 42 million in 1941 to about 120 million in 1995 (BBS, 1997a:149,140), making the nation the ninth most populous country in the world and one of the most densely populated. The intercensal population growth rate peaked in the early 1970s at about 2.5 percent per annum, followed by a decline to 2.2 percent during the 1981-1991 period (BBS, 1997a:149). The relatively young age structure of the population indicates continued rapid population growth in the future; according to the 1991 census, 45 percent of the population is under 15 years of age, 52 percent are between 15 and 64 years, and 3 percent are age 65 or over (BBS, 1997a:139). This young age structure 2 * Introduction constitutes a built-in “population momentum,” which will continue to generate population increases well into the future, even in the face of rapid fertility decline. For example, in 1992, Bangladesh had about 22 million married women of reproductive age; by the year 2001, this number is projected to rise to 31 million (GOB, 1994:8). Even if replacement-level fertility is achieved by the year 2005—as targeted by government policy—the population will continue to grow for 40 to 60 years. One projection suggests that the population of Bangladesh may stabilize at 211 million by the year 2056. Bangladesh has undergone a remarkable demographic transition over the last two decades. The total fertility rate has declined from about 6.3 in the early 1970s (MOHPC, 1978:73) to 3.3 in the mid-1990s (Mitra et al., 1997:31). The crude death rate has also fallen dramatically, from about 19 per 1,000 population in 1975 to 8 in 1995 (GOB, 1994:4; BBS, 1997a:144). Although infant and under-five mortality rates are declining, they are still high. The infant mortality rate was 150 deaths per 1,000 live births in 1975 and fell to 87 in the 1989-1993 period (GOB, 1994:5; Mitra et al., 1994:92). Maternal mortality has declined from 6.2 deaths per 1,000 births in 1982 to 4.4 in 1995. This small but important decline is mainly attributed to increased availability of family planning and immunization services, improved antenatal and delivery care, and a reduction in the number of births to high-risk mothers (GOB, 1994:5; BBS, 1997a:144). Because of the mortality decline, there is evidence of modest improvement in life expectancy during the past decade. Life expectancy at birth was 46 years for males and 47 years for females in 1974 (UN, 1981:60). It increased to 59 years for men and 58 years for women in 1995 (BBS, 1997a:145). Striking changes have also been observed in the fertility preferences of married Bangladeshi women. In 1975, when married women were asked how many children they would ideally like to have, the response was an average of 4.1 children (Huq and Cleland, 1990:53,54). By 1993-1994, the mean ideal family size had dropped to 2.5 (Mitra et al., 1994:88). 1.3 POPULATION, FAMILY PLANNING AND MATERNAL AND CHILD HEALTH POLICIES AND PROGRAMS Family planning was introduced in the early 1950s through the voluntary efforts of social and medical workers. The government, recognizing the urgency of moderating population growth, adopted family planning as a government-sector program in 1965. The policy to reduce fertility rates has been repeatedly reaffirmed since liberation in 1971. The First Five-Year Plan (1973-1978) of Bangladesh emphasized “the necessity of immediate adoption of drastic steps to slow down the population growth” and reiterated that “no civilized measure would be too drastic to keep the population of Bangladesh on the smaller side of 15 crore (i.e., 150 million) for sheer ecological viability of the nation” (GOB, 1994:7). From mid-1972, the family planning program received virtually unanimous, high-level political support. All subsequent governments that have come into power in Bangladesh have identified population control as the top priority for government action. This political commitment is crucial in understanding the fertility decline in Bangladesh. In 1976, the government declared the rapid growth of the population as the country’s number one problem and adopted a broad-based, multisectoral family planning program along with an official population policy (GOB, 1994:9). Population planning was seen as an integral part of the total development process, and was incorporated into successive five- year plans. Policy guidelines and strategies for the population program are formulated by the National Population Council (NPC), which is chaired by the prime minister. Introduction * 3 Bangladesh’s population policy and programs have evolved through a series of developmental phases and have undergone changes in strategies, structure, contents, and goals. In the mid-1970s, the government instituted the deployment of full-time, local Family Welfare Assistants (FWAs)—community-based family planning motivators and distributors who numbered almost 24,000 at the height of the program a few years ago. A social marketing program to promote the sale of birth control pills and condoms was also initiated in the mid-1970s. Another characteristic of the population program is the involvement of more than 200 nongovernmental organizations. Since 1980, the program has stressed functionally integrated health and family planning programs. The goal is to provide an essential package of high-quality, client-centered reproductive and child health care, family planning, communicable disease control, and limited curative services at a one-stop service point. The Fifth Five-Year Plan (FFYP) has been formulated keeping in view the principles of the Health and Population Sector Strategy (HPSS) with a single sector for both health and population. The main objective of the FFYP is to ensure universal access to essential health care services of acceptable quality and to further slow population growth. The most important basis of the FFYP will remain the reduction of infant mortality and morbidity, reduction of maternal mortality and morbidity, improvement of nutritional status, and reduction of fertility to reach replacement-level fertility by the year 2005 (GOB,1998:7). The government’s policy of providing health care is based on the principles of universal coverage and accessibility; optimum utilization and development of human resources for health; appropriate use of technology; gender equity; improvement of the quality of life; priority service for the most vulnerable groups including women, children, and the poor; and promotion of health as an integral part of overall socioeconomic development. Although no comprehensive health policy has been formulated since independence, development of such a policy is a high priority of the current administration. Private-sector involvement in both health and population services is being encouraged. Numerous factors have contributed to the increase in contraceptive use over the past 20 years. The elements identified as having contributed to the success of the program are 1) strong political commitment to family planning programs by successive governments, 2) successful promotion of a small family norm through information and educational activities and other multisectoral programs, 3) establishment of a widespread infrastructure for delivering family planning and health services down to the village level, 4) increased involvement of nongovernmental organizations to supplement and complement the government’s efforts, 5) flexibility to make policy and programmatic adjustments in response to emerging needs, and 6) strong support of the program by the international aid community (GOB, 1994:36). The success achieved so far in the national family planning program is encouraging and has increased the confidence that it is possible to achieve further progress. But there remain several issues of concern, such as the tremendous growth potential built into the age structure as a consequence of past high fertility. Due to the increasing population entering childbearing age, the program will have to expand efforts substantially just to maintain the current level of contraceptive use. If demand for family planning also increases, that will put even more strain on the program. Other concerns are lack of a steady supply of contraceptives from external sources, which affects program performance; the need for further improvement in access to and quality of facilities and services; and the need for men to participate more actively in family planning acceptance. 1 The proportion urban was 12 percent in the previous BDHS surveys (1993-1994 and 1996-1997). Both these surveys were based on the Integrated Multi Purpose Master Sample (IMPS) of the Bureau of Statistics, which categorized “other urban” areas (Thana headquarters, smaller town) as rural areas. So, com parison of rural- urban differentials with the 1993-1994 and 1996-1997 surveys is not possible). 4 * Introduction 1.4 ORGANIZATION OF THE 1999-2000 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY SURVEY OBJECTIVES AND IMPLEMENTING ORGANIZATIONS The Bangladesh Demographic and Health Survey (BDHS) is intended to serve as a source of population and health data for policymakers and the research community. In general, the objectives of the BDHS survey are to— ! Assess the overall demographic situation in Bangladesh ! Assist in the evaluation of the population and health programs in Bangladesh ! Advance survey methodology. More specifically, the objective of the BDHS survey is to provide up-to-date information on fertility and childhood mortality levels; nuptiality; fertility preferences; awareness, approval, and use of family planning methods; breastfeeding practices; nutrition levels; and maternal and child health. This information is intended to assist policymakers and administrators in evaluating and designing programs and strategies for improving health and family planning services in the country. The 1999-2000 BDHS survey was conducted under the authority of the National Institute for Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. The survey was implemented by Mitra and Associates, a Bangladeshi research firm located in Dhaka. Macro International Inc. of Calverton, Maryland, provided technical assistance to the project as part of its international Demographic and Health Surveys program, and financial assistance was provided by the U.S. Agency for International Development (USAID)/Bangladesh. SAMPLE DESIGN Bangladesh is divided into 6 administrative divisions, 64 districts (zillas), and 490 thanas. In rural areas, thanas are divided into unions and then mauzas, a land administrative unit. Urban areas are divided into wards and then mahallas. The 1999-2000 BDHS survey employed a nationally representative, two-stage sample that was selected from the master sample maintained by the Bangladesh Bureau of Statistics for the implementation of surveys before the next census (2001). The master sample consists of 500 primary sampling units (PSUs) with enough PSUs in each stratum except for the urban strata of the Barisal and Sylhet divisions. In the rural areas, the primary sampling unit was the mauza, while in urban areas, it was the mahalla. Because the primary sampling units in the master sample were selected with probability proportional to size from the 1991 census frame, the units for the BDHS survey were subselected from the master sample with equal probability to make the BDHS selection equivalent to selection with probability proportional to size. A total of 341 primary sampling units were used for the BDHS survey (99 in urban areas and 242 in rural areas).1 Since one objective of the BDHS survey is to provide separate survey estimates for each division as well as for urban and rural areas separately, it was necessary to increase the sampling rate for the Barisal and Sylhet divisions and for urban areas relative to the other divisions. Thus, Introduction * 5 the BDHS sample is not self-weighting and weighting factors have been applied to the data in this report. Mitra and Associates conducted a household listing operation in all the sample points from September to December 1999. A systematic sample of 10,268 households was then selected from these lists. Every third household was selected for the men’s survey, meaning that in addition to interviewing all ever-married women age 10-49, interviewers also interviewed all currently married men age 15-59 in those selected households. It was expected that the sample would yield interviews with approximately 10,000 ever-married women age 10-49 and 3,000 currently married men age 15-59. QUESTIONN AIRES Four types of questionnaires were used for the BDHS survey: a Household Questionnaire, a Women’s Questionnaire, a Men’s Questionnaire, and a set of questionnaires for the Service Provision Assessment (SPA) (community, health facilities, fieldworkers). The contents of these questionnaires were based on the MEASURE DHS+ Model A Questionnaire, which is designed for use in countries with relatively high levels of contraceptive use. These model questionnaires were adapted for use in Bangladesh during a series of meetings with a small Technical Task Force (TTF) that consisted of representatives from NIPORT; Mitra and Associates; USAID/Dhaka; the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B); Dhaka University; and Macro International Inc. (see Appendix A for a list of members). Draft questionnaires were then circulated to other interested groups and were reviewed by the BDHS Technical Review Committee (see Appendix A). The questionnaires were developed in English and then translated into and printed in Bangla. The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including his/her age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for individual interview. In addition, information was collected about the dwelling itself, such as the source of water, type of toilet facilities, materials used to construct the house, and ownership of various consumer goods. The Women’s Questionnaire was used to collect information from ever-married women age 10-49. These women were asked questions on the following topics: • Background characteristics (age, education, religion, etc.) • Reproductive history • Knowledge and use of family planning methods • Antenatal and delivery care • Breastfeeding and weaning practices • Vaccinations and health of children under age five • Marriage • Fertility preferences • Husband’s background and respondent’s work • Height and weight of children under age five and of their mother • HIV and AIDS. 6 * Introduction The Men’s Questionnaire was similar to that for women except that it omitted the sections on reproductive history, antenatal and delivery care, breastfeeding, vaccinations, and height and weight. The questionnaire for the Service Provision Assessment was completed for each sample point and included questions about the existence in the community of income-generating activities and other development organizations and the availability and accessibility of health and family planning services. Detailed analysis of the SPA data will be presented in a separate report. TRAINING AND FIELDWORK The BDHS Women’s Questionnaire was pretested in May 1999, and the Men’s Questionnaire was pretested in October 1999. For the pretest, male and female interviewers were trained at the office of Mitra and Associates. After training, the teams conducted interviews in various locations in the field under the observation of staff from Mitra and Associates and members of the Technical Task Force. Altogether, 309 Women’s and 137 Men’s Questionnaires were completed. Based on observations in the field and suggestions made by the pretest field teams, the TTF made revisions in the wording and translations of the questionnaires. In October 1999, candidates for field staff positions for the main survey were recruited. Recruitment criteria included educational attainment, maturity, ability to spend one month in training and at least four months in the field, and experience in other surveys. Training for the main survey was conducted at a rented center for four weeks (from October 9 to November 9, 1999). Initially, training consisted of lectures on how to complete the questionnaires, with mock interviews between participants to gain practice in asking questions. Toward the end of the training course, the participants spent several days in practice interviewing in various places close to Dhaka. Trainees whose performance was considered superior were selected as supervisors and field editors. Fieldwork for the BDHS survey was carried out by 12 interviewing teams. Each consisted of 1 male supervisor, 1 female field editor, 5 female interviewers, 1 male interviewer, 1 porter for the anthropometric equipment, and 1 cook, for a total of 120 field staff. Mitra and Associates also fielded four quality control teams of two people each to check on the field teams. In addition, NIPORT monitored fieldwork using their quality control team. Moreover, staff from USAID, Macro International Inc., and NIPORT monitored the fieldwork by visiting teams in the field. Fieldwork commenced on November 10, 1999 and was completed on March 15, 2000. Fieldwork was implemented in four phases. DATA PROCESSING All questionnaires for the BDHS survey were returned to Dhaka for data processing at Mitra and Associates. The processing operation consisted of office editing, coding of open-ended questions, data entry, and editing inconsistencies found by the computer programs. The data were processed on six microcomputers working in double shifts and carried out by ten data entry operators and two data entry supervisors. The BDHS data entry and editing programs were written in ISSA (Integrated System for Survey Analysis). Data processing commenced in mid-December 1999 and was completed by end of April 2000. RESPONSE RATES Table 1 shows response rates for the survey and reasons for nonresponse. A total of 10,268 households were selected for the sample, of which 9,854 were successfully interviewed. The shortfall is primarily due to dwellings that were vacant or in which the inhabitants had left for an Introduction * 7 extended period at the time they were visited by the interviewing teams. Of the 9,922 households occupied, 99 percent were successfully interviewed. In these households, 10,885 women were identified as eligible for the individual interview (i.e., ever-married and age 10-49) and interviews were completed for 10,544 or 97 percent of them. In the one-third of the households that were selected for inclusion in the men’s survey, 2,817 currently married men age 15-59 were identified, of which 2,556 or 91 percent were interviewed. The principal reason for nonresponse among eligible women and men was the failure to find them at home despite repeated visits to the household. The nonresponse rate was low. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, Bangladesh 1999-2000 Residence Result Urban Rural Total Household interviews Households sampled 2,997 7,271 10,268 Households occupied 2,891 7,031 9,922 Households interviewed 2,857 6,997 9,854 Household response rate 98.8 99.5 99.3 Individual interviews: women Eligible women 3,274 7,611 10,885 Eligible women interviewed 3,150 7,394 10,544 Eligible woman response rate 96.2 97.1 96.9 Individual interviews: men Eligible men 851 1,966 2,817 Eligible men interviewed 771 1,785 2,556 Eligible man response rate 90.6 90.8 90.7 Characteristics of Households * 9 2CHARACTERISTICS OF HOUSEHOLDSAND RESPONDENTS This chapter presents information on social and economic characteristics of the household population and the individual survey respondents, such as age, sex, residence, and educational level. Also examined are environmental conditions such as housing facilities and household characteristics. This information on the characteristics of the households and the individual women and men interviewed is essential for the interpretation of survey findings and can provide an approximate indication of the representativeness of the survey. 2.1 HOUSEHOLD POPULATION The BDHS Household Questionnaire was used to collect data on the demographic and social characteristics of all usual residents of the sampled household and visitors who had spent the previous night in the household. This approach makes it possible to distinguish between the de jure population (those usually resident in the household) and the de facto population (those who spent the night before the interview in the household). A household is defined as a person or group of people who live together and share food. AGE AND SEX COMPOSITION The distribution of the household population covered in the BDHS survey is shown in Table 2.1 by five-year age groups, according to sex and urban-rural residence. The BDHS households constitute a population of 50,446 people. The population is equally divided into females (50 percent) and males (50 percent). Because of relatively high levels of fertility in the past, there are more people in the younger age groups than in the older age groups of each sex (Figure 2.1). Thirty- nine percent of the population is below 15 years of age and 4 percent is age 65 or older. The proportion below age 15 is relatively higher in rural areas (40 percent) than in urban areas (35 percent). Overall, the number of women slightly exceeds the number of men. This pattern is especially pronounced at age 15-29, which may be due in part to international migration of young men for work. However, some combination of overreporting of ages of men and/or underreporting of ages of women may account for the excess of men over women at age 65 and above. Figure 2.2 presents the distribution of the male and female household population by single year of age (see also Appendix Table C.1). The data indicate that there is some misreporting of ages, including considerable preference for ages ending in particular digits, especially 0 and 5. One of the most commonly used measures of digit preference in age reporting is Myer’s Index (United Nations, 1995). The theoretical range of Myer’s Index is 0, representing no heaping, to 90, which would result if all ages were reported at a single digit, say 0 (Shryock et al., 1976). Values of Myer’s Index computed for the age range 10-69 in the household sample population in Bangladesh are 5 for females and 27 for males. The index is often used as one indicator of survey quality. The lower estimate for females is probably due to the emphasis during the interviewer training on obtaining accurate age information for women to correctly determine the eligibility of women for the individual interview. Women also provided a detailed history of all their births, which is likely to have resulted in more accurate reporting of their own ages due to probing the dates of birth of their children. 10 * Characteristics of Households Table 2.1 Household population by age, residence, and sex Percent distribution of the de facto household population by five-year age groups, according to urban-rural residence and sex, Bangladesh 1999-2000 Age group Urban Rural Total Male Female Total Male Female Total Male Female Total 0-4 11.5 10.4 10.9 13.7 13.1 13.4 13.3 12.6 12.9 5-9 11.1 10.9 11.0 13.7 12.7 13.2 13.2 12.4 12.8 10-14 12.5 13.5 13.0 13.6 13.7 13.6 13.4 13.6 13.5 15-19 10.9 13.4 12.2 10.3 12.4 11.3 10.4 12.6 11.5 20-24 9.3 10.7 10.0 7.1 9.3 8.2 7.6 9.6 8.6 25-29 8.3 9.8 9.1 7.1 8.1 7.6 7.3 8.4 7.9 30-34 7.1 8.2 7.7 5.9 6.3 6.1 6.2 6.7 6.4 35-39 7.5 5.8 6.6 6.5 5.4 5.9 6.7 5.4 6.1 40-44 6.6 5.0 5.8 4.8 4.5 4.6 5.2 4.6 4.9 45-49 4.4 3.1 3.8 4.0 3.6 3.8 4.1 3.5 3.8 50-54 3.4 2.3 2.9 3.1 2.8 2.9 3.2 2.7 2.9 55-59 1.9 2.0 1.9 2.3 2.5 2.4 2.3 2.4 2.3 60-64 1.9 1.3 1.6 2.3 2.2 2.2 2.2 2.0 2.1 65-69 1.2 1.3 1.2 1.6 1.2 1.4 1.6 1.2 1.4 70-74 1.2 0.9 1.0 1.8 1.0 1.4 1.7 1.0 1.4 75-79 0.4 0.4 0.4 0.7 0.3 0.5 0.7 0.3 0.5 80 + 0.8 1.0 0.9 1.2 1.0 1.1 1.1 1.0 1.1 Missing /Don’t know 0.0 0.1 0.1 0.0 0.1 0.0 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 Number 4,816 4,834 9,649 20,197 20,595 40,796 25,013 25,428 50,446 Characteristics of Households * 11 Table 2.2 compares the broad age structure of the population from the 1989 Bangladesh Fertility Survey (BFS); the 1989 and 1991 Contraceptive Prevalence Surveys (CPS); and the 1993- 1994, 1996-1997, and 1999-2000 Bangladesh Demographic and Health Surveys. There has been a decline in the proportion of population less than 15 years of age and an increase in the proportion age 15-59. This pattern is consistent with a decline in fertility. Table 2.2 Population by age from selected sources Percent distribution of the de facto population by age group, selected sources, Age group 1989 BFS 1989 CPS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS <15 43.2 43.2 42.7 42.6 41.0 39.2 15-59 50.9 50.9 51.2 51.2 53.1 54.4 60+ 5.9 5.9 6.0 6.2 5.9 6.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Median age u u u 18.4 18.8 19.5 u = Unknown (not available) Source: Huq and Cleland, 1990:28; Mitra et al., 1993:14; Mitra et al., 1997:9 12 * Characteristics of Households HOUSEHOLD COMPOSITION Table 2.3 shows that a small minority of households in Bangladesh are headed by females (9 percent), with more than 90 percent headed by males. Female-headed households are equally uncommon in rural and urban areas. The average household size in Bangladesh is 5.2 people, with no variation between rural and urban areas. Single-person households are rare in both rural and urban areas. Table 2.3 Household composition Percent distribution of households by sex of head of household and household size, according to urban-rural residence, Bangladesh 1999-2000 Residence Characteristic Urban Rural Total Household headship Male 90.4 91.6 91.3 Female 9.6 8.4 8.7 Number of usual members 1 1.1 1.6 1.5 2 6.9 6.3 6.4 3 14.8 13.8 14.0 4 21.2 20.5 20.6 5 19.7 20.5 20.3 6 14.4 15.7 15.4 7 8.9 9.0 9.0 8 5.3 5.3 5.3 9 + 7.7 7.4 7.4 Total 100.0 100.0 100.0 Mean size 5.2 5.2 5.2 Note: Table is based on de jure members, i.e., usual residents. EDUCATION Education is a key determinant of the lifestyle and status an individual enjoys in a society. It affects almost all aspects of human life, including demographic and health behavior. Studies have consistently shown that educational attainment has strong effects on reproductive behavior, contraceptive use, fertility, infant and child mortality, morbidity, and issues related to family health and hygiene. Table 2.4 provides data on educational attainment of the household population listed in the 1999-2000 BDHS survey. Education has become more widespread over time in Bangladesh. This is apparent from the differences in levels of educational attainment by age groups. A steadily decreasing percentage of both males and females have never attended school in each younger age group. For men, the proportion who have never attended school decreases from 51 percent in the oldest age group (65 years or more) to 13 percent among those age 10-14. For women, the decline is more striking: from 85 percent to 11 percent (see Figure 2.3). Characteristics of Households * 13 Table 2.4 Educational level of the female and male household population Percent distribution of the de facto female and male household population age six and over by highest level of education attended and median number of years of schooling, according to selected background characteristics, Bangladesh 1999-2000 Background characteristic Level of education No education Primary incomplete Primary complete Secondary+ Don’t know/ Missing Total Number Median FEMALE Age 6-9 18.8 80.1 0.5 0.5 0.1 100.0 2,586 0.0 10-14 10.9 49.9 6.8 32.4 0.0 100.0 3,464 3.3 15-19 19.7 17.4 10.6 52.2 0.1 100.0 3,193 5.0 20-24 31.5 17.3 10.0 41.1 0.1 100.0 2,437 4.1 25-29 43.7 16.8 10.2 29.3 0.0 100.0 2,140 1.4 30-34 48.7 17.3 8.8 25.3 0.0 100.0 1,700 0.0 35-39 55.7 17.0 8.6 18.7 0.1 100.0 1,383 0.0 40-44 58.5 16.3 9.0 16.3 0.0 100.0 1,161 0.0 45-49 64.0 14.8 9.2 11.8 0.1 100.0 890 0.0 50-54 73.9 12.9 5.5 7.5 0.1 100.0 680 0.0 55-59 74.9 14.6 4.5 5.1 0.9 100.0 603 0.0 60-64 82.5 11.8 1.6 3.6 0.5 100.0 510 0.0 65+ 85.2 7.5 3.8 3.0 0.5 100.0 899 0.0 Residence Urban 28.7 23.7 7.6 39.8 0.2 100.0 4,233 3.6 Rural 40.1 30.3 7.4 22.1 0.1 100.0 17,431 0.7 Division Barisal 26.0 36.0 11.8 26.1 0.1 100.0 1,460 2.4 Chittagong 34.5 27.3 8.4 29.6 0.1 100.0 4,366 1.9 Dhaka 39.5 28.7 6.4 25.2 0.1 100.0 6,664 0.8 Khulna 34.0 31.1 6.8 28.0 0.1 100.0 2,482 1.8 Rajshahi 41.7 28.6 6.9 22.6 0.1 100.0 5,250 0.6 Sylhet 44.9 26.6 7.6 20.8 0.1 100.0 1,442 0.3 Total 37.8 29.0 7.4 25.6 0.1 100.0 21,664 1.2 MALE Age 6-9 19.0 79.9 0.5 0.5 0.1 100.0 2,644 0.0 10-14 12.5 53.0 7.5 26.7 0.3 100.0 3,341 2.5 15-19 16.7 18.1 9.0 55.8 0.4 100.0 2,602 5.4 20-24 20.6 15.9 9.1 53.8 0.6 100.0 1,889 5.7 25-29 32.2 14.3 8.5 44.4 0.7 100.0 1,822 4.3 30-34 38.0 14.7 7.2 39.6 0.4 100.0 1,539 3.3 35-39 38.7 16.5 8.1 36.0 0.7 100.0 1,684 2.7 40-44 38.6 14.6 9.0 36.8 1.0 100.0 1,296 3.1 45-49 38.1 13.3 8.0 40.1 0.5 100.0 1,023 3.5 50-54 40.4 13.9 8.3 37.1 0.3 100.0 793 2.6 55-59 41.2 15.1 9.8 31.8 2.0 100.0 566 1.9 60-64 46.1 14.0 9.6 28.8 1.6 100.0 560 0.5 65+ 51.0 16.5 7.5 23.0 1.9 100.0 1,268 0.0 Residence Urban 18.0 22.6 6.8 51.8 0.7 100.0 4,162 5.1 Rural 30.6 31.3 7.5 30.0 0.6 100.0 16,873 2.0 Division Barisal 20.3 33.9 8.4 36.6 0.8 100.0 1,362 3.4 Chittagong 22.6 31.5 7.9 37.6 0.4 100.0 4,112 3.3 Dhaka 30.7 27.9 6.6 33.9 0.9 100.0 6,565 2.2 Khulna 25.3 28.6 5.6 39.7 0.7 100.0 2,406 3.3 Rajshahi 31.3 29.3 8.0 31.0 0.4 100.0 5,216 2.2 Sylhet 33.1 30.6 8.8 27.2 0.3 100.0 1,375 1.6 Total 28.1 29.6 7.3 34.3 0.6 100.0 21,035 2.6 14 * Characteristics of Households One way to assess more recent trends in educational attainment is to compare the 1996- 1997 and 1999-2000 BDHS surveys with regard to the percentage of males and females age six and above who are uneducated. Between 1996-1997 and 1999-2000, the percentage of females age six and above who have no education declined from 44 percent to 38 percent. For males age six and above, the percentage with no education also declined from 33 percent to 28 percent. Despite this improvement in the spread of education, levels of educational attainment still remain low in Bangladesh, with a strong differential persisting between males and females. Generally, educational attainment is higher for males than for females, although this varies substantially by age. Twenty-eight percent of men and 38 percent of women age six years and above have not received any formal education. The median number of years of schooling is 2.6 for men and a little more than 1 full year for women. In almost every age group, there are smaller proportions of men than women with no education and more men than women with secondary education. However, over time, the sex differential is narrowing. For example, at age group 6-19, differences in educational attainment between boys and girls are insignificant (see Figure 2.3). Substantial urban-rural gaps in educational attainment persist. Thirty-one percent of rural men have never attended school, compared with less than one-fifth of urban men (18 percent). The differences are also striking for women—40 percent of rural women have never attended school, compared with only 29 percent of urban women. Conversely, the proportions of men and women with some secondary education are almost twice as high in urban areas as in rural areas. As for differences by division, the proportion of the population with no education is lower in Barisal. Men and women in Sylhet Division are the most educationally disadvantaged. Characteristics of Households * 15 Table 2.5 presents school attendance by age, sex, and residence of the population age 6-24 years. Of every ten children age 6-15 years, seven (74 percent) are attending school. But enrollment drops substantially after age 15; only one-third of older teenagers are still in school and only 17 percent of the population in their early twenties are still in school. The substantial decline after age 15 may be partly because many families need their grown children (age 16-24) for work or do not have the means to bear their educational expenses. Table 2.5 School attendance Percentage of the de facto household population age 6-24 years attending school by age, sex, and urban-rural residence, Bangladesh 1999-2000 Male Female Total Age group Urban Rural Total Urban Rural Total Urban Rural Total 6-10 80.9 77.9 78.4 78.7 80.6 80.3 79.8 79.2 79.3 11-15 65.4 66.8 66.5 64.5 69.6 68.6 64.9 68.2 67.6 6-15 72.9 72.6 72.6 71.2 75.2 74.5 72.0 73.9 73.5 16-20 48.4 37.6 39.8 33.7 25.7 27.4 40.4 31.1 33.0 21-24 36.9 22.7 26.4 19.6 7.9 10.4 27.5 13.7 17.0 It is encouraging that urban-rural gaps in school attendance of children have become virtually nonexistent. In fact, a slightly higher proportion of rural than urban children in age group 11-15 years are in school. However, rural attendance rates still lag far behind urban rates among children older than 15. At age 16-20, only 31 percent of rural adolescents are still in school, compared with 40 percent of urban youth. At age 21-24, only 14 percent of rural young adults are in school, compared with 28 percent in urban areas. The sex differential in school enrollment also seems to be disappearing, at least among younger children. At age 6-15, the proportions of boys and girls attending school are indistinguishable. However, by age 16-20, men are much more likely than women to be enrolled (40 versus 27 percent), presumably due to early marriage or social seclusion, which cause young women to drop out of school. EMPLOYMENT The 1999-00 BDHS Household Questionnaire included questions on whether each person age five and above was working for cash. The resulting information is shown in Table 2.6 for males and females by age group according to urban-rural residence. Men are much more likely than women to be employed, regardless of age group or residence. Overall, 44 percent of male members in the household are employed, compared with only 10 percent of female members. As expected, employment rates are higher among both men and women in their twenties and thirties and decline among men and women in their late fifties and sixties. Paid employment begins early in Bangladesh; at age 10-14, 12 percent of boys and 3 percent of girls are working for cash. By age 15- 19, more than one-third (36 percent) of boys and 7 percent of girls are engaged in paid employment. Since similar questions were asked in the 1993-1994 BDHS survey, it is possible to assess the recent trends in employment. Between 1993-1994 and 1999-2000, the percentage of school-age children engaged in paid employment declined. For example, paid employment for boys age 10-14 years declined from 17 to 12 percent, and for boys 15-19 years, it declined from 47 to 36 percent. Similar trends are also observed for girls. 16 * Characteristics of Households Table 2.6 Employment status Percentage of the male and female household population working for cash, by age group and urban-rural residence, Bangladesh 1999-2000 Male Female Age Urban Rural Total Urban Rural Total 5-7 0.0 0.3 0.2 0.0 0.0 0.0 8-9 3.0 0.8 1.1 2.3 0.2 0.5 10-14 15.1 11.2 11.9 8.9 2.1 3.4 15-19 35.7 35.7 35.7 13.7 5.9 7.4 20-24 54.8 53.6 53.9 17.5 11.9 13.1 25-29 78.1 65.1 67.8 19.7 15.3 16.3 30-34 90.4 72.6 76.4 25.6 19.5 20.9 35-39 94.0 73.9 78.1 24.9 18.5 19.8 40-44 93.8 70.6 76.2 24.1 18.4 19.5 45-49 93.9 70.0 74.9 20.3 10.8 12.4 50-54 91.3 68.1 72.9 13.8 7.1 8.2 55-59 80.1 59.2 62.6 13.6 7.7 8.7 60-64 70.5 46.8 50.6 2.3 5.2 4.8 65+ 43.4 29.4 31.3 2.4 2.0 2.1 Total 55.5 41.5 44.2 14.5 8.5 9.7 2.2 HOUSING CHARACTERISTICS Information on the characteristics of sampled households is shown in Table 2.7. The physical characteristics of the households have an important effect on environmental exposure to disease and reflect the household’s economic conditions. About one-third (32 percent) of the households in Bangladesh have electricity, up from 18 percent in 1993-1994 and 22 percent in 1996-1997. There are significant differences in access to electricity between rural and urban areas; 81 percent of urban households have electricity compared with 21 percent of rural households. Tube wells are the major source of drinking water in Bangladesh. Overall, nine in ten households obtain their drinking water from tube wells. Only 4 percent depend on surface water such as surface wells, ponds, and rivers/streams. Piped water is available mostly in urban areas. Among urban households, 24 percent have water piped into the residence, 6 percent obtain drinking water from taps outside the residence, and 69 percent get their drinking water from tube wells. In rural areas, tube wells are the only major source of drinking water; 95 percent of rural households obtain their drinking water from tube wells. There has been little change in sources of drinking water since 1996-1997. About 80 percent of Bangladeshi households have some type of toilet facilities; however, only 54 percent have hygienic toilets (septic tank/modern toilets, water-sealed/slab latrines, and pit toilets). As expected, sanitation facilities vary between rural and urban areas. In rural areas, only 49 percent of households have hygienic toilets, compared with 75 percent of urban households. Moreover, 24 percent of rural households have no facility at all, compared with only 3 percent of urban households. Characteristics of Households * 17 Table 2.7 Housing characteristics and level of food consumption Percent distribution of households by housing characteristics and household food consumption, according to urban-rural residence, Bangladesh 1999-2000 Residence Characteristic Urban Rural Total Electricity Yes 81.2 20.5 32.0 No 18.8 79.5 68.0 Total 100.0 100.0 100.0 Source of drinking water Piped into residence 24.2 0.1 4.6 Piped outside residence 6.4 0.3 1.5 Tube well 68.6 95.2 90.2 Surface well 0.3 1.1 1.0 Pond/lake 0.4 2.6 2.2 River/stream 0.0 0.6 0.5 Total 100.0 100.0 100.0 Sanitation facility Septic tank, modern 35.1 4.3 10.1 Water sealed/slab latrine 28.7 25.0 25.7 Traditional pit toilet 10.8 20.0 18.3 Open latrine 20.8 23.0 22.6 Hanging latrine 1.3 3.7 3.2 No facility/bush 3.0 23.8 19.9 Other 0.0 0.1 0.1 Missing 0.3 0.2 0.2 Total 100.0 100.0 100.0 Roof material Katcha (bamboo/thatch) 6.8 23.6 20.5 Tin 64.8 71.7 70.4 Cement/concrete 28.4 4.5 9.0 Other 0.0 0.1 0.1 Total 100.0 100.0 100.0 Wall material Jute/bamboo/mud 32.5 68.0 61.3 Wood 1.7 3.1 2.8 Brick/cement 54.1 8.3 16.9 Tin 11.7 20.2 18.6 Other 0.1 0.5 0.4 Total 100.0 100.0 100.0 Floor material Earth/bamboo 43.7 93.6 84.2 Wood 0.6 0.4 0.4 Cement/concrete 55.6 6.0 15.4 Total 100.0 100.0 100.0 Food consumption Deficit in whole year 12.8 18.9 17.7 Sometimes deficit 32.6 44.0 41.8 Neither deficit nor surplus 39.1 28.0 30.1 Surplus 15.3 9.0 10.1 Total 100.0 100.0 100.0 18 * Characteristics of Households Tin is the most common roofing material in Bangladesh, accounting for 70 percent of both urban and rural households. However, urban and rural households vary widely in the use of other types of roofs. In urban areas, 28 percent of households live in dwellings with cement or concrete roofs, while in rural areas, bamboo or thatch (24 percent) is the most common roofing material after tin. Six in ten households in Bangladesh live in structures with walls made of natural materials such as jute, bamboo, or mud. Seventeen percent live in houses with brick or cement walls, and 19 percent live in houses with tin walls. Urban households live in more solid dwellings than rural households. More than half of urban households live in structures with brick or cement walls, compared with only 8 percent of rural households. The most commonly used floor material in Bangladesh is earth, followed by cement. Fifty-six percent of urban households have cement floors; earth flooring is almost universal in rural areas (94 percent). HOUSEHOLD POSSESSIONS AND AVAILABILITY OF FOOD The possession of durable goods is another indicator of a household’s socioeconomic level, although these goods may also have other benefits. For example, having access to a radio or television may expose household members to innovative ideas or important information about health and family planning, a refrigerator prolongs the wholesomeness of food, and a means of transportation allows greater access to services outside the community in which the household is located. Possession of household durable goods is not common in Bangladesh, since many families cannot afford them. Nationally, 84 percent of households own a cot or bed, 62 percent own a table or chair, 55 percent own a watch or clock, 26 percent own an almirah (wardrobe), and only 18 percent a bench. As for more valuable items, 32 percent of households own a radio, 20 percent own a bicycle, 18 percent own a television, 6 percent own a sewing machine, and only 2 percent own a motorcycle (Table 2.8). One in ten households owns none of the items asked about. More urban than rural households possess every durable good asked about except bicycles and benches, which reflects, among other things, the relatively better economic conditions in urban areas. There is also evidence that the socioeconomic status of Bangladeshi households has improved over time, since there has been an increase in the proportion of households owning almost all the durable goods asked about (Mitra et al., 1994:18; Mitra et al., 1997: 14) (Figure 2.4). Almost 90 percent of Bangladeshi households own a homestead. Half of Bangladeshi households own land other than a homestead, and 11 percent are homeless. Ownership of a homestead or land is less common in urban areas than in rural areas. In the 1999-2000 BDHS survey, respondents were asked whether they thought their household was a surplus or deficit household in terms of food consumption. Only 10 percent of Bangladeshi household respondents indicated that they have a surplus of food, while 30 percent of households mentioned that they have neither a deficit nor a surplus of food. Sixty percent of the households mentioned that they have a food deficit: 18 percent of households always have a deficit, and 42 percent sometimes have a deficit. Food deficits are more common in rural households (63 percent) than in urban households (45 percent). Characteristics of Households * 19 Table 2.8 Household durable goods and land ownership Percentage of households possessing various durable consumer goods and ownership of land, according to urban-rural residence, Bangladesh 1999-2000 Residence Ownership Urban Rural Total Durable good Almirah1 50.1 20.9 26.4 Table/chair 72.1 59.1 61.6 Bench 11.6 19.5 18.0 Watch/clock 77.8 49.9 55.2 Cot/bed 92.6 81.4 83.6 Radio 45.2 28.5 31.6 Television 49.0 10.1 17.5 Sewing machine 15.6 4.1 6.3 Bicycle 18.4 20.7 20.3 Motorcycle 4.0 1.3 1.8 None of the above 3.9 12.0 10.5 Land ownership Owns a homestead 80.9 88.2 86.8 Owns other land 37.4 53.7 50.6 None of the above 16.6 9.6 10.9 Number of households 1,861 7,993 9,854 1 Wardrobe 20 * Characteristics of Households 2.3 BACKGROUND CHARACTERISTICS OF WOMEN AND MEN RESPONDENTS GENERAL CHARACTERISTICS Table 2.9 shows the distribution of female and male respondents by selected background characteristics. To assess their age, respondents were asked two questions in the individual interview: “In what month and year were you born?” and “How old were you at your last birthday?” Interviewers were trained to probe in situations in which respondents did not know their age or date of birth, and they were instructed as a last resort to record their best estimate of the respondent’s age. Table 2.9 Background characteristics of respondents Percent distribution of ever-married women and currently married women and men by background characteristics, Bangladesh 1999-2000 Ever-married women Currently married women Currently married men Number of women Number of women Number of men Background characteristics Weighted percent Weighted Un- weighted Weighted percent Weighted Un- weighted Weighted percent Weighted Un- weighted Age 10-14 1.8 186 171 1.9 181 166 na na na 15-19 14.4 1,514 1,451 15.1 1,468 1,405 0.9 23 21 20-24 18.3 1,935 1,910 19.0 1,846 1,819 5.9 151 138 25-29 18.7 1,975 2,012 19.3 1,878 1,908 13.5 345 346 30-34 15.4 1,621 1,675 15.7 1,523 1,575 16.3 418 412 35-39 12.7 1,335 1,337 12.1 1,174 1,174 19.3 492 500 40-44 10.7 1,126 1,143 9.8 948 950 15.4 394 403 45-49 8.1 853 845 7.2 702 699 13.0 333 333 50-54 na na na na na na 8.6 219 222 55-59 na na na na na na 7.1 181 181 Marital status Married 92.2 9,720 9,696 100.0 9,720 9,696 100.0 2,556 2,556 Widowed 4.3 456 468 na na na na na na Divorced 1.1 121 120 na na na na na na Separated/deserted 2.3 247 260 na na na na na na Residence Urban 19.6 2,071 3,150 19.5 1,893 2,878 19.9 508 771 Rural 80.4 8,473 7,394 80.5 7,827 6,818 80.1 2,048 1,785 Division Barisal 6.5 688 981 6.6 638 914 6.2 159 230 Chittagong 18.6 1,965 1,950 18.5 1,795 1,781 16.7 426 448 Dhaka 30.9 3,257 2,539 31.0 3,009 2,340 32.7 835 670 Khulna 12.2 1,281 1,817 12.3 1,198 1,700 12.6 322 453 Rajshahi 25.9 2,728 2,118 26.0 2,527 1,959 26.7 682 515 Sylhet 5.9 624 1,139 5.7 552 1,002 5.2 133 240 Education No education 45.9 4,843 4,575 44.3 4,306 4,037 34.9 891 839 Primary incomplete 18.3 1,928 1,900 18.5 1,799 1,766 23.1 590 580 Primary complete 10.2 1,074 1,097 10.5 1,019 1,037 7.5 192 187 Secondary+ 25.6 2,699 2,972 26.7 2,596 2,856 34.5 883 950 Religion Islam 87.7 9,251 9,135 87.9 8,540 8,418 86.1 2,202 2,187 Hindu ism 11.0 1,165 1,293 10.9 1,056 1,167 12.1 308 326 Buddhism 0.9 96 86 1.0 93 83 1.4 35 33 Christianity 0.3 30 27 0.3 29 25 0.2 6 6 Other 0.0 1 1 0.0 1 1 0.0 0 0 Missing 0.0 1 2 0.0 1 2 0.1 4 3 Total 100.0 10,544 10,544 100.0 9,720 9,696 100.0 2,556 2,556 na = Not applicable Characteristics of Households * 21 The age distribution of ever-married women is very similar to that found in the 1993-1994 and 1996-1997 BDHS surveys; a little more than half (51 percent) of ever-married women are age 15-29. The currently married men interviewed are older than the ever-married women, in large part because men marry at older ages than women. Twenty percent of respondents live in urban areas, while 80 percent live in rural areas. The distribution of respondents by division of residence is similar to that of the 1996-1997 BDHS survey; almost one-third of female and male respondents live in Dhaka Division, while roughly one-fourth live in Rajshahi Division, and one in five live in Chittagong Division. About 12 percent of respondents live in Khulna Division, 7 percent in Barisal Division, and only 6 percent in Sylhet Division. About half (46 percent) of ever-married women have never attended school, 28 percent have attended only primary school or completed primary education, and more than one-quarter (26 percent) have some secondary school. Although educational attainment of women in the sample is low, it is interesting to note that the proportion of women with some secondary education has increased from 18 percent of ever-married women in 1996-1997 to 26 percent in 1999-2000. In general, married men are better educated than women, with the majority having some education and 35 percent having some secondary school, compared with only 26 percent of ever-married women. About nine in ten respondents are Muslim, with most of the remainder being Hindu. The composition by religion is similar to that reported in the 1993-1994 and 1996-1997 BDHS surveys (Mitra et al., 1994 and 1997). Because the married men interviewed in the BDHS survey were selected from a subsample of households in which ever-married women were interviewed, it is possible to match male respondents with their wives to obtain a data set of matched couples. Table 2.10 shows husband- wife differentials in age and education for 2,280 couples. For almost all married couples, the husband is older than the wife—generally 5 to 14 years older. The mean age difference is nine years. Regarding educational differences, in one-fourth of married couples, neither the husband nor the wife has any education, while in another 44 percent, both have some education. For the remaining one-third of couples, the proportion in which the husband has some education and the wife has none is twice that in which the wife is educated and the husband is not (21 versus 10 percent). 22 * Characteristics of Households Table 2.10 Differentials in age and education Percent distribution of couples by differences between spouses in age and level of education, Bangladesh 1999-2000 Characteristic Percent Number Age (husband’s age minus wife’s age) Wife older 1.8 41 0-4 years 13.9 318 5-9 years 41.2 940 10-14 years 30.7 699 15 years + 12.4 282 Mean age difference (years) 9.3 2,280 Education Both husband and wife not educated 24.7 562 Wife educated, husband not 10.3 235 Husband educated, wife not 20.8 474 Both husband and wife educated 44.2 1,008 Total 100.0 2,280 DIFFERENTIAL EDUCATION Presented in Table 2.11 are the distribution of female and male respondents by highest level of education attended, according to selected characteristics. Among ever-married women, education is inversely related to age, that is, older women are less educated than younger women. For instance, 29 percent of ever-married women age 15-l9 years have never attended school, compared with 64 percent of those age 45-49. Among currently married men, except those 15-19 years old, the distribution by educational level is more uniform across age groups. Among both women and men, urban residents have more education than rural residents. For example, 49 percent of rural women have had no education at all, compared with 32 percent of urban women. In contrast, while about four in ten urban women (43 percent) have attended secondary school, only 21 percent of rural women have done so. Women and men in the Barisal, Chittagong, and Khulna divisions are better educated than those in the other divisions. Forty-two percent or fewer women and one-third or fewer men in these divisions have no education. Respondents in these divisions are also more likely than respondents in other divisions to complete primary school and to attend secondary school. Characteristics of Households * 23 Table 2.11 Level of education by background characteristics Percent distribution of ever-married women and currently married men by highest level of education attended, according to age, residence, and division, Bangladesh 1999-2000 Background characteristic Level of education Total Number No education Primary incomplete Primary complete Secondary+ EVER-MARRIED WOMEN Age 10-14 21.9 33.8 19.1 25.2 100.0 186 15-19 29.0 21.5 12.7 36.8 100.0 1,514 20-24 37.6 19.1 10.5 32.8 100.0 1,935 25-29 45.6 17.4 10.0 27.0 100.0 1,975 30-34 48.4 17.2 9.2 25.2 100.0 1,621 35-39 55.6 17.6 8.9 17.9 100.0 1,335 40-44 59.3 16.1 9.2 15.4 100.0 1,126 45-49 63.5 15.3 8.6 12.5 100.0 853 Residence Urban 32.3 14.4 9.9 43.4 100.0 2,071 Rural 49.3 19.2 10.3 21.2 100.0 8,473 Division Barisal 26.9 28.1 18.4 26.5 100.0 688 Chittagong 41.9 14.5 12.0 31.6 100.0 1,965 Dhaka 48.4 17.9 8.6 25.1 100.0 3,257 Khulna 39.1 22.1 8.6 30.3 100.0 1,281 Rajshahi 50.9 18.2 9.6 21.4 100.0 2,728 Sylhet 59.0 14.1 9.5 17.3 100.0 624 Total 45.9 18.3 10.2 25.6 100.0 10,544 CURRENTLY MARRIED MEN Age 15-19 12.7 37.4 25.3 24.7 100.0 23 20-24 37.2 28.0 10.8 24.1 100.0 151 25-29 37.9 19.1 8.1 34.8 100.0 345 30-34 36.8 19.4 7.2 36.5 100.0 418 35-39 35.2 26.2 5.8 32.8 100.0 492 40-44 36.0 22.6 7.7 33.7 100.0 394 45-49 28.1 20.3 8.9 42.8 100.0 333 50-54 35.6 24.5 2.9 36.9 100.0 219 55-59 33.6 28.9 9.3 28.1 100.0 181 Residence Urban 24.1 15.9 7.1 52.9 100.0 508 Rural 37.5 24.9 7.6 30.0 100.0 2,048 Division Barisal 28.4 30.2 8.3 33.2 100.0 159 Chittagong 33.1 21.1 8.8 37.0 100.0 426 Dhaka 36.7 21.2 7.0 35.0 100.0 835 Khulna 28.8 23.8 5.4 42.1 100.0 322 Rajshahi 36.8 23.8 8.1 31.3 100.0 682 Sylhet 41.2 27.1 7.9 23.8 100.0 133 Total 34.9 23.1 7.5 34.5 100.0 2,556 24 * Characteristics of Households EXPOSURE TO MASS MEDIA Female and male respondents were asked in the BDHS survey whether they usually read a newspaper, listen to the radio, or watch television at least once a week. Table 2.12 shows the percentage of respondents exposed to different types of mass communication media by age, urban- rural residence, division, and educational level. It is important to know which types of people are more likely to be reached by the media for purposes of planning programs intended to spread information about health and family planning. About 9 percent of women and 26 percent of men read a newspaper or magazine weekly, 35 percent of women and 53 percent of men watch television at least once a week, and 29 percent of women and 53 percent of men listen to the radio at least once a week. Four percent of women and 13 percent of men are exposed to all three of these media sources. Forty-four percent of women and 21 percent of men have no access to mass media. Table 2.12 Exposure to mass media Percentage of ever-married women who usually read a newspaper once a week, watch television once a week, or listen to a radio once a week, by selected background characteristics and percentage of men who carry out these activities, Bangladesh 1999-2000 Mass media Background characteristic No mass media Read news- paper weekly Watch tele- vision weekly Listen to radio daily All three media Number Age 10-14 37.4 6.6 35.8 32.9 3.3 186 15-19 36.2 7.5 38.0 37.3 3.8 1,514 20-24 37.0 9.8 41.1 34.7 5.5 1,935 25-29 42.5 9.5 37.1 29.4 4.8 1,975 30-34 44.9 10.2 35.9 25.3 4.4 1,621 35-39 50.0 8.3 29.7 23.9 3.6 1,335 40-44 50.0 8.3 29.5 23.2 3.6 1,126 45-49 54.8 7.1 26.8 19.4 2.9 853 Residence Urban 16.9 23.4 70.4 33.3 11.1 2,071 Rural 50.2 5.3 26.5 27.7 2.6 8,473 Division Barisal 52.3 7.3 21.3 27.5 3.0 688 Chittagong 38.4 10.1 39.3 32.5 5.2 1,965 Dhaka 40.1 9.5 39.4 29.3 4.7 3,257 Khulna 39.9 10.1 41.0 31.4 5.1 1,281 Rajshahi 48.2 7.2 29.7 25.8 3.1 2,728 Sylhet 56.7 8.0 27.0 23.6 3.9 624 Education No education 62.3 0.0 19.5 17.4 0.0 4,843 Primary incomplete 45.0 0.9 32.2 27.2 0.3 1,928 Primary complete 33.9 6.2 38.6 34.2 2.5 1,074 Secondary+ 13.1 31.4 64.0 48.1 15.4 2,699 All women 43.6 8.8 35.2 28.8 4.3 10,544 All men 20.9 25.8 53.3 52.5 13.4 2,556 Characteristics of Households * 25 Differentials in exposure to media are shown only for ever-married women. They indicate that younger women are somewhat more likely than older women to listen to the radio. Exposure to all three media is higher among urban and more educated women. For example, the proportion of women who watch television at least once a week ranges from 20 percent of those with no education to 64 percent of those with some secondary school. Differentials by division are not large, except that women in Sylhet Division have less exposure to all three media than women in other divisions. Since the 1996-1997 BDHS survey, the percentage of women exposed to television has increased sharply (from 27 to 35 percent), while the percentage who listen to the radio has declined (from 39 to 29 percent). EMPLOYMENT AND OCCUPATION The BDHS survey collected information from women on their current employment status. Table 2.13 shows that 77 percent of ever-married women reported being unemployed and 22 percent reported being employed at the time of the survey. Most employed women work all year, with a minority working seasonally. The proportion unemployed is higher among younger and better educated women. Women in Rajshahi Division are more likely to be employed than women in the other divisions. Table 2.13 Employment Percent distribution of ever-married women by employment status and continuity of employment, according to background characteristics, Bangladesh 1999-2000 Currently employed Background characteristic Not employed Work all year Work season- ally Work occasion- ally Missing Total Number Age 10-14 94.5 5.5 0.0 0.0 0.0 100.0 186 15-19 86.9 9.5 2.2 1.3 0.1 100.0 1,514 20-24 81.2 14.4 2.9 1.4 0.1 100.0 1,935 25-29 77.2 18.0 3.1 1.5 0.2 100.0 1,975 30-34 70.6 23.9 3.8 1.5 0.1 100.0 1,621 35-39 70.5 23.8 3.3 2.2 0.2 100.0 1,335 40-44 71.7 21.8 4.2 2.4 0.0 100.0 1,126 45-49 80.2 15.5 3.0 1.3 0.1 100.0 853 Residence Urban 76.3 19.9 1.8 1.9 0.2 100.0 2,071 Rural 77.7 17.2 3.4 1.5 0.1 100.0 8,473 Division Barisal 83.2 10.9 3.8 1.9 0.2 100.0 688 Chittagong 80.1 16.2 2.2 1.4 0.1 100.0 1,965 Dhaka 79.0 17.1 2.7 1.1 0.1 100.0 3,257 Khulna 80.7 14.5 3.2 1.5 0.1 100.0 1,281 Rajshahi 68.9 24.4 4.3 2.3 0.1 100.0 2,728 Sylhet 85.2 11.1 2.2 1.3 0.2 100.0 624 Education No education 71.6 21.2 4.7 2.4 0.1 100.0 4,843 Primary incomplete 79.6 16.6 2.6 1.0 0.2 100.0 1,928 Primary complete 85.3 12.3 1.5 1.0 0.0 100.0 1,074 Secondary+ 83.2 14.6 1.3 0.8 0.1 100.0 2,699 Total 77.4 17.7 3.1 1.6 0.1 100.0 10,544 26 * Characteristics of Households Women who reported themselves as employed at the time of the survey were asked whether they earned cash for their work (Table 2.14). Among those who are working, 71 percent earn cash only, 17 percent earn both cash and kind, and only 4 percent work for nothing. Eight percent are paid in kind only. Cash earnings are more common in urban areas and among women with higher education, women from Khulna Division, and women who work in the nonagriculture sector. Table 2.14 Form of earnings Percent distribution of currently employed women by type of earnings, (cash, in kind, no payment), according to background characteristics, Bangladesh 1999-2000 Background characteristic Earns cash only Earns kind only Both cash and kind Not paid Don’t know/ Missing Total Number Age 10-14 * * * * * 100.0 10 15-19 71.0 4.4 20.1 4.4 0.0 100.0 197 20-24 73.5 6.5 15.3 4.3 0.4 100.0 362 25-29 69.8 8.4 16.6 3.6 1.7 100.0 450 30-34 73.2 5.4 18.0 3.0 0.3 100.0 476 35-39 68.2 11.3 17.1 2.9 0.4 100.0 394 40-44 70.3 9.6 15.2 4.6 0.3 100.0 319 45-49 62.5 9.9 23.8 3.8 0.0 100.0 168 Residence Urban 80.3 2.5 14.4 2.1 0.7 100.0 490 Rural 67.9 9.3 18.1 4.2 0.5 100.0 1,887 Division Barisal 71.3 14.2 7.1 5.3 2.2 100.0 116 Chittagong 76.1 5.7 14.4 3.7 0.2 100.0 391 Dhaka 66.2 5.2 25.9 2.0 0.6 100.0 684 Khulna 80.7 5.5 10.7 2.8 0.3 100.0 247 Rajshahi 68.8 10.7 14.7 5.5 0.3 100.0 848 Sylhet 65.5 9.6 20.9 1.9 2.1 100.0 92 Education No education 64.2 11.1 20.1 4.1 0.6 100.0 1,373 Primary incomplete 68.3 5.2 20.6 5.6 0.4 100.0 393 Primary complete 79.0 3.3 14.9 2.9 0.0 100.0 158 Secondary+ 88.6 2.1 7.0 1.6 0.7 100.0 453 Occupation Agricultural 62.2 6.2 28.2 2.7 0.7 100.0 774 Non-agricultural 74.6 8.8 12.2 4.2 0.2 100.0 1,495 Total 70.5 7.9 17.3 3.8 0.6 100.0 2,377 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 108 cases with occupation not stated. Characteristics of Households * 27 WOMEN 'S AUTONOMY Education, exposure to media, and work participation are some of the means by which women gain status and autonomy, both important aspects of their empowerment. To measure women’s autonomy and empowerment more directly, the BDHS survey asked about women’s participation in household decisionmaking (such as what items to cook, obtaining health care for herself and child, purchasing household items) and their freedom of movement. As expected, women in Bangladesh are most likely to participate in the decision about what to cook: two-thirds of women make this decision on their own and another one-fifth make the decision jointly with their husband or someone else in the household (Table 2.15). Thirteen percent of women are not involved in the decision about what to cook. In addition, 46 percent of women are not involved at all in decisions about seeking health care for themselves, while 35 percent are not involved at all in decisions about seeking health care for their child, and 38 to 40 percent are not involved in deciding about purchasing large household items, purchasing daily household items, and visiting friends and relatives. Table 2.15 Household decisionmaking Percent distribution of currently married women by person who makes specific household decisions, according to type of decision, Bangladesh 1999-2000 Person who has final say Household decision Respondent only Respondent & husband jointly Respondent & someone else jointly Husband only Someone else only Missing Total Her own health care 17.1 32.1 5.1 40.2 5.4 0.0 100.0 Child health care 15.8 39.1 5.9 29.2 6.2 3.8 100.0 Large household purchases 7.3 42.5 10.0 31.9 8.3 0.1 100.0 Daily household purchases 16.5 36.3 8.9 29.5 8.8 0.1 100.0 Visits to family or relatives 10.7 41.4 8.4 31.9 7.5 0.1 100.0 What food to cook each day 66.4 11.3 9.0 4.4 8.9 0.1 100.0 Note: Table is based on 9,720 currently married women. Women’s participation in household decisionmaking alone or jointly with others in the household increases with age (Table 2.16). Urban women are more likely to participate in decisions about seeking health care for themselves and their children, purchasing household items, or visiting friends and relatives, but decisionmaking about what to cook does not vary much by residence. Except in Sylhet Division, decisionmaking varies little by division. Women from Sylhet Division are less likely than women in other divisions to participate in decisionmaking alone or jointly with others. Table 2.16 also gives information on another dimension of women’s autonomy measured in the BDHS survey: women’s freedom of movement. Women were asked whether they go alone or can go alone outside the village or to a health center or hospital. Only 14 percent of women say that they go alone or can go alone outside the village and 27 percent of women say that they go alone or can go alone to the hospital or health center. Freedom of movement increases with age. Urban women have more freedom to move than their rural counterparts. 28 * Characteristics of Households Table 2.16 Final say in household decisions Percentage of currently married women who say that they alone or jointly have the final say in specific household decisions, and percentage who say they go or can go alone outside the village or town or to a hospital or health center, according to background characteristics, Bangladesh 1999-2000 Household decision Women who go or who can go outside alone Background characteristic Own health care Child health care Large household purchases Daily household purchases Visits to family or relatives What food to cook each day Number Outside the village/ town/city To health center or the hospital Number Age 10-14 41.7 34.4 41.0 43.0 44.7 53.8 181 4.0 7.5 181 15-19 43.6 43.8 49.4 50.6 48.6 71.2 1,468 7.9 15.5 1,468 20-24 50.6 57.7 55.7 56.6 55.5 81.6 1,846 9.6 22.5 1,846 25-29 57.2 65.0 62.8 64.8 64.0 90.7 1,878 13.7 29.9 1,878 30-34 59.7 66.6 65.6 68.6 64.9 93.4 1,523 15.0 32.1 1,523 35-39 57.8 68.0 63.7 66.0 66.9 94.1 1,174 19.3 33.4 1,174 40-44 60.1 69.6 64.1 66.6 66.0 94.3 948 22.5 32.3 948 45-49 57.6 63.8 63.8 66.0 65.5 92.1 702 23.4 32.3 702 Number of living children 0 47.7 32.5 49.5 51.3 51.9 68.5 1,159 10.6 15.8 1,159 1-2 54.2 64.3 59.9 60.9 60.6 85.1 4,123 14.0 27.4 4,123 3-4 57.4 66.1 63.7 66.6 63.5 92.6 2,908 15.9 31.1 2,908 5+ 54.0 62.9 59.6 62.4 61.0 93.1 1,531 14.9 26.9 1,531 Residence Urban 59.5 66.2 65.5 66.5 66.7 87.5 1,893 17.2 36.1 1,893 Rural 53.1 59.5 58.4 60.5 59.0 86.4 7,828 13.6 24.9 7,827 Division Barisal 53.0 62.3 56.8 58.3 60.9 81.9 639 12.5 23.6 638 Chittagong 57.0 61.9 57.2 60.1 60.5 86.2 1,795 14.8 28.6 1,795 Dhaka 53.3 60.7 59.4 62.6 59.2 88.0 3,009 13.3 28.2 3,009 Khulna 52.2 60.4 61.6 63.5 62.6 85.7 1,198 18.4 30.4 1,198 Rajshahi 57.6 62.7 64.9 65.1 63.9 87.6 2,527 13.6 24.5 2,527 Sylhet 43.1 48.5 46.0 46.4 47.0 83.5 553 14.7 24.3 552 Education No education 53.6 59.0 57.7 59.6 58.0 89.8 4,307 15.1 25.9 4,306 Primary incomplete 51.6 60.1 57.7 61.5 59.4 87.1 1,799 13.1 24.4 1,799 Primary complete 54.9 62.2 62.3 64.1 62.6 86.9 1,019 10.9 22.3 1,019 Secondary+ 57.4 63.8 63.7 64.3 64.7 80.9 2,596 15.2 32.8 2,596 Current employment Not employed 63.4 69.9 70.6 71.0 68.5 92.2 1,728 23.1 37.8 1,728 For cash 57.5 62.8 68.5 64.7 65.5 91.0 207 21.8 34.3 206 Not for cash 52.3 58.8 57.1 59.5 58.6 85.3 7,772 12.2 24.5 7,772 Total 54.4 60.8 59.8 61.7 60.5 86.6 9,720 14.3 27.1 9,720 Men were asked about their attitudes toward a wife’s role in household decisionmaking. Table 2.17 presents the results. It is encouraging to note that almost 90 percent of currently married men mentioned that wives should have a say in decisions about large or daily household purchases. Eighty-four percent of men said that wives should have a say in when to visit family or relatives, and 76 percent support a wife’s role in making decisions to spend her earnings. As expected, educated men and men from urban areas are more liberal in their views toward their wife’s role in decision making. Men from Sylhet Division are somewhat more conservative than men in other divisions in their attitudes toward a wife’s role in decisionmaking. Characteristics of Households * 29 Table 2.17 Men's attitudes towards a wife's role in household decision making Percentage of currently married men who say that a wife should have a say in specific household decisions, according to background characteristics, Bangladesh 1999-2000 Wife should have a say in decisions about: Background characteristic Large household expenses Daily household expenses When to visit family, relatives or friends What to do with her earnings In all specified decisions In no specified decisions Number Age 15-19 * * * * * * 23 20-29 88.8 88.1 82.1 75.7 64.7 5.0 497 30-39 89.6 88.7 84.2 77.3 70.3 5.1 910 40-49 90.1 90.0 87.0 78.0 71.4 5.5 727 50-59 86.6 85.5 80.4 67.6 62.1 8.5 400 Residence Urban 90.3 90.2 86.0 78.6 70.6 4.0 508 Rural 88.8 88.1 83.5 74.9 67.5 6.1 2,048 Division Barisal 94.3 93.8 89.9 72.3 69.5 4.0 159 Chittagong 86.3 88.7 82.0 68.3 62.8 8.1 426 Dhaka 90.1 89.0 85.0 76.2 67.7 4.3 835 Khulna 88.3 86.3 79.1 64.7 54.3 6.0 322 Rajshahi 90.1 88.8 88.0 87.0 80.0 5.5 682 Sylhet 82.6 82.6 68.9 68.4 58.9 8.9 133 Education No education 85.6 84.9 78.4 70.6 62.9 8.2 891 Primary incomplete 88.2 87.7 83.9 74.1 66.0 5.3 590 Primary complete 90.5 89.3 89.4 77.4 69.6 3.7 192 Secondary+ 93.0 92.6 88.6 81.4 74.5 3.9 883 Total 89.1 88.5 84.0 75.7 68.1 5.7 2,556 Note: An asterisk represents fewer than 25 cases and the numbers are suppressed. Domestic violence is not uncommon in Bangladesh. Although questions on domestic violence were not asked of female respondents, currently married men were asked whether they thought it was justified for a husband to beat his wife in specific situations. Table 2.18 shows that about one- quarter of men agree with a husband beating his wife if the wife goes out without telling her husband or if she neglects the children or argues with her husband. Only 9 percent of men feel it is justifiable for a man to beat his wife if she fails to provide food on time. Urban and educated men agree less than their counterparts with a husband beating his wife. 30 * Characteristics of Households Table 2.18 Men's agreement with reasons for wife beating Percentage of currently married men who agree with specific reasons justifying a husband beating his wife and percentage who agree with at least one or with none of the reasons, according to background characteristics, Bangladesh 1999-2000 Reason justifying husband beating his wife Background characteristic Goes out without telling him Neglects the children Argues with her husband Fails to provide food on time Agrees with at least one specified reason Agrees with no specified reasons Number Age 15-19 * * * * * * 23 20-29 25.2 25.7 28.2 10.0 39.8 58.3 497 30-39 25.2 23.5 27.3 11.1 38.2 59.6 910 40-49 23.9 23.0 20.2 6.4 34.2 63.9 727 50-59 23.0 20.2 19.9 5.7 32.6 65.9 400 Residence Urban 18.2 14.7 15.3 4.7 26.4 71.3 508 Rural 26.2 25.5 26.5 9.6 39.1 59.0 2,048 Division Barisal 32.9 34.5 33.7 17.3 48.5 46.0 159 Chittagong 22.5 20.4 19.0 5.4 33.0 63.5 426 Dhaka 21.0 21.3 17.9 5.3 31.6 68.2 835 Khulna 32.2 26.0 29.9 9.4 45.4 50.3 322 Rajshahi 25.8 25.3 31.1 12.3 39.7 59.8 682 Sylhet 19.8 15.2 22.0 8.6 28.0 66.9 133 Education No education 31.3 29.6 34.6 13.3 47.0 51.7 891 Primary incomplete 27.9 25.6 26.7 8.4 40.4 58.0 590 Primary complete 23.2 23.8 25.2 7.9 39.0 59.1 192 Secondary + 16.0 15.4 12.2 4.2 23.0 74.2 883 Total 24.6 23.3 24.3 8.6 36.6 61.5 2,556 Note: An asterisk represents fewer than 25 cases and the numbers are suppressed. 1 Numerators of the age-specific fertility rates are calculated by summing the number of live births that occurred in the period 1-36 months preceding the survey (determined by the date of interview and the date of birth of the child) and classifying them by the age (in five-year groups) of the mother at the time of birth (determined by the mother’s date of birth). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. Since only women who had ever-married were interviewed in the BDHS survey, the numbers of women in the denom inators of the rates were inflated by factors calculated from information in the household questionnaire on proportions ever-married in order to produce a count of all women. Never-married women are presumed not to have given birth. Fertility * 31 FERTILITY 3 3.1 INTRODUCTION The assessment of Bangladesh’s fertility dynamics has been an important objective of the Bangladesh Demographic and Health Survey. The focus on fertility is due to its important role in determining Bangladesh’s population growth rate. This chapter presents a description of current and past fertility, cumulative fertility and family size, birth intervals, age at first birth, and reproductive behavior of adolescents. Most of the fertility measures presented in this chapter are based on reports provided by ever-married women age 15-49 regarding their reproductive histories. Each woman was asked to provide information on the number of sons and daughters to whom she had given birth who were living with her, the number living elsewhere, and the number who had died. The women were then asked for a history of all their live births, including such information as name, month and year of birth, sex, and survival status. For children who had died, information on age at death was solicited. Interviewers were given extensive training in probing techniques designed to help respondents report this information accurately. Despite the measures to improve the data quality, BDHS information is subject to the same types of error that are inherent in all retrospective sample surveys, namely, the omission of some births (especially births of children who died at a very young age) and the difficulty of determining the date of birth of each child accurately. These difficulties can bias estimates of fertility trends. A brief discussion of the quality of the BDHS fertility data appears in Appendix C.2 and shows that such errors are minimal. 3.2 CURRENT FERTILITY LEVELS The most widely used measures of current fertility are the total fertility rate (TFR) and its component age-specific fertility rates (ASFRs). The TFR 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 currently observed age-specific rates.1 The general fertility rate represents the annual number of births in a population per 1,000 women age 15-44. The crude birth rate is the annual number of births in a population per 1,000 people. Both these measures are calculated using the birth history data for the three-year period before the survey and the age and sex distribution of the household population. 32 * Fertility The results in Table 3.1 indicate that the total fertility rate for the three years before the survey (approximately 1997 through 1999) is 3.3 children per woman. The age-specific rates indicate a pattern of early childbearing, with a peak at age group 20-24. Three-quar- ters of childbearing occurs before age 30. The total fertility rate is higher in rural areas (3.5 children per woman) than in urban areas (2.5 children per woman). The difference is especially large at younger ages, which prob- ably reflects longer education and later mar- riage of women in urban areas (Figure 3.1). 3.3 FERTILITY DIFFERENTIALS Table 3.2 and Figure 3.2 show differen- tials in fertility by residence, administrative division, and education. Fertility is highest in Sylhet and Chittagong divisions, with total fertility rates of 4.1 and 4.0 children per woman, respectively. Fertility is lowest in Khulna (2.7) and Rajshahi (3.0) divisions. Barisal and Dhaka divisions have intermediate levels of fertility, with total fertility rates of 3.3 and 3.2 children per woman, respectively. This pattern is similar to that found in the 1996-1997 BDHS survey. Table 3.1 Current fertility rates Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-rural residence, Bangladesh 1999-2000 Residence Age group Urban Rural Total 15-19 101 155 144 20-24 142 201 188 25-29 140 172 165 30-34 78 104 99 35-39 23 50 44 40-44 6 21 18 45-49 0 3 3 TFR 15-49 2.45 3.54 3.31 TFR 15-44 2.45 3.52 3.29 GFR 97 135 127 CBR 25.3 31.3 30.2 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate, expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Fertility * 33 Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 40-49, by selected background characteristics, Bangladesh 1999-2000 Background characteristic Total fertility rate1 Mean number of children ever born to women age 40-49 Residence Urban 2.45 4.84 Rural 3.54 5.72 Division Barisal 3.26 5.65 Chittagong 3.96 5.65 Dhaka 3.21 5.71 Khulna 2.70 5.17 Rajshahi 3.02 5.42 Sylhet 4.08 5.31 Education No education 4.12 5.77 Primary incomplete 3.30 5.84 Primary complete 3.42 5.46 Secondary+ 2.40 4.30 Total 3.31 5.55 1Women age 15-49 years 34 * Fertility Table 3.3 Trends in current fertility rates Age-specific and total fertility rates (TFR) among women age 15-49, selected sources, Bangladesh, 1975 to 1999-2000 _________________________________________________________________________________________________ Survey and approximate time period __________________________________________________________________________________ 1975 1989 1991 1993-1994 1996-1997 1999-2000 BFS BFS CPS BDHS BDHS BDHS _________ _________ _________ _________ _________ __________ Age group 1971-1975 1984-1988 1989-1991 1991-1993 1994-1996 1997-1999 _________________________________________________________________________________________________ 15-19 109 182 179 140 147 144 20-24 289 260 230 196 192 188 25-29 291 225 188 158 150 165 30-34 250 169 129 105 96 99 35-39 185 114 78 56 44 44 40-44 107 56 36 19 18 18 45-49 35 18 13 14 6 3 TFR 15-49 6.3 5.1 4.3 3.4 3.3 3.3 __________________________________________________________________________________________________ Note: For the 1975 and 1989 BFS surveys, the rates refer to the 5-year period preceding the survey; for the other surveys, the rates refer to the 3-year period preceding the survey. The BFS and BDHS surveys utilized full birth histories, while the 1991 CPS used an 8-year truncated birth history. Source: 1975 BFS (MHPC, 1978:73); 1989 BFS (Huq and Cleland, 1990:103); 1991 CPS (Mitra et al., 1993 :34); 1993- 94 BDHS (Mitra et al., 1994: 24); 1996-97 BDHS (Mitra et al., :30) Educational attainment of women is strongly related to fertility levels. At current rates, women with no formal education would give birth to an average of 4.1 children in their lifetime, compared with 2.4 for women with at least some secondary education, a difference of 42 percent. Women with either incomplete primary or complete primary education have intermediate fertility rates between these two extremes. Table 3.2 also allows a crude assessment of trends in fertility over time among population subgroups. One way of examining trends in fertility over time is to compare the total fertility rates for the three years preceding the survey with the average number of children ever born to women who are now at the end of their childbearing period, age 40-49. The former is a measure of current fertility, while the latter is a measure of past or completed fertility. A comparison of current fertility with past fertility shows that there has been a substantial decline in urban and rural areas, in all divisions, and in the four education categories. Except in Chittagong and Sylhet divisions, the decline is more than two children per woman in all divisions. Overall, comparison of past and present fertility indicators suggests a decline of more than two children per woman, from 5.6 to 3.3 children per woman. 3.4 FERTILITY TRENDS Trends in current fertility in Bangladesh can be examined by observing a time series of estimates produced from demographic surveys fielded over the last two and half decades, beginning with the 1975 Bangladesh Fertility Survey (BFS). The estimates shown in Table 3.3 describe the ongoing Bangladeshi fertility transition. The TFR has declined dramatically from 6.3 children per woman in 1971-1975 to 3.3 in 1997-1999 (Figure 3.3), a decline of 48 percent over a 25-year period. The pace of fertility decline has slowed in the most recent period compared to the exceptionally rapid decline during the late 1980s and early 1990s. The total fertility rate dropped almost imperceptibly from 3.4 for the period 1991-1993 to 3.3 in 1994-1996 and then remained constant in 1997-1999. Investigation of the age pattern of fertility shows no anomalies; the decline since the mid-1980s has been fairly uniform over all age groups of women except those age 25-29 (Figure 3.4). Fertility * 35 36 * Fertility Table 3.4 Percent pregnant Percentage of currently married women who were pregnant at the time of interview, by age group, selected sources, Bangladesh, 1975-2000 ________________________________________________________________________ 1975 1989 1991 1993-1994 1996-1997 1999-2000 Age group BFS BFS CPS BDHS BDHS BDHS __________________________________________________________________________ 15-19 15.2a 14.7a 19.6 17.1 14.7 15.9 20-24 15.5 13.3 16.2 13.0 10.3 11.8 25-29 14.9 10.4 11.2 9.0 8.9 8.5 30-34 11.2 8.3 7.1 7.0 5.1 4.8 35-39 10.7 4.8 4.2 2.7 3.4 2.4 40-44 u u 1.5 0.8 1.3 1.0 45-49 u u 0.2 0.0 0.0 0.4 Total 12.5 9.3 10.7 8.7 7.7 7.8 _________________________________________________________________________ u = Unknown (not available) a Currently married women less than 20 years Source: 1975 BFS and 1989 BFS (Cleland et al., 1994:21); 1991 CPS (Mitra et al., 1993:39); 1993-1994 BDHS (Mitra et al., 1994: 31); 1996-1997 BDHS (Mitra et al., :34) Table 3.4 shows trends in the proportion of currently married women who reported that they were pregnant at the time of the survey, according to age group. Reports on current pregnancy are almost surely underestimates, since many women may be pregnant but not yet aware of their status. However, the data are useful because, while fertility rates depend to some extent on accurate reporting of dates of events, the proportion pregnant is a “current status” indicator. Change over time in the percentage pregnant is an independent indicator of fertility change. In Bangladesh, the proportion pregnant has generally declined over time, although not in a steady fashion. In the 1975 BFS, 13 percent of currently married women reported themselves pregnant at the time of the survey. By 1989, this proportion had declined to 9 percent; it then increased to 11 percent in 1991, again declined to 9 percent in the 1993-1994 BDHS survey and then to 8 percent in 1996-1997 and 1999-2000. Although it is entirely possible that such fluctuations are real, misreporting may also be a factor. Table 3.5 provides further insight into the fertility decline discussed above. The table gives the age-specific fertility rates for five-year periods preceding the survey, using data from respondents’ birth histories. Figures in brackets represent partial fertility rates due to truncation; women 50 years of age and older were not included in the survey, and the further back in time rates are calculated, the more severe the truncation. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years before the survey because those women would have been over age 50 at the time of the survey and thus were not interviewed. The data show generally declining fertility experienced by women in most age groups during the last two decades. Trends in fertility rates calculated from retrospective birth histories must be viewed with caution since they may suffer from errors due to misreporting of age and date of birth. Fertility * 37 Table 3.6 presents fertility rates for ever-married women by duration (years) since first marriage for five-year periods preceding the survey. It is analogous to Table 3.5, but is confined to ever-married women and replaces age with duration since first marriage. The data show that the decline in fertility is appar- ent for all marriage durations in the two de- cades preceding the survey, with the exception of those married 0-4 years. This pattern im- plies that fertility control tends to be practiced later in marriage and that newly married cou- ples continue to have children at more or less the same rate as before. 3.5 CHILDREN EVER BORN AND LIVING The distribution of all women and currently married women by age and number of children ever born is presented in Table 3.7. The table also shows the mean number of children ever born to women in each five-year age group, an indicator of the momentum of childbearing. On average, women in their late twenties have given birth to almost three chil- dren, women in their late thirties have had more than four children, and women currently at the end of their childbearing years have had more than six children. Figures for currently married women do not differ greatly from those for all women at older ages; however, at youn- ger ages, the percentage of currently married women who have had children is much higher than the percentage among all women. Of the 6.1 children ever born to all women age 45-49, only 4.9 have survived. Among all women age 15-49, the average number of children who have died per woman is 0.40. Among currently married women it is 0.48, i.e., 15 percent of children born to currently married women had died. The proportion of children ever born who have died increases with women’s age. Among currently married women, for example, the proportion of children ever born who have died increases from 9 percent for women age 20-24 to 20 percent for women age 45-49. The percentage of women in their forties who have never had children provides an indicator of the level of primary infertility—the proportion of women who are unable to bear children at all. Since voluntary childlessness is rare in Bangladesh, it is likely that married women with no births are unable to bear children. The BDHS results suggest that primary infertility is low, about 2 percent. It should be noted that this estimate of primary infertility does not include women who may have had one or more births but who are unable to have more (secondary infertility). Table 3.5 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by women's age at the time of birth, Bangladesh 1999-2000 Number of years preceding the survey Women’s age at birth 0-4 5-9 10-14 15-19 15-19 147 181 207 212 20-24 193 232 272 276 25-29 163 189 227 248 30-34 103 131 173 [212] 35-39 50 82 [128] - 40-44 20 [31] - - 45-49 [5] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Table 3.6 Trends in fertility by marital duration Fertility rates for ever-married women by duration (years) since first marriage for five-year periods preceding the survey, Bangladesh 1999-2000 Number of years preceding the survey Marriage duration 0-4 5-9 10-14 15-19 0-4 261 257 268 244 5-9 214 245 284 285 10-14 156 186 229 254 15-19 102 135 179 [225] 20-24 56 93 [140] - 25-29 22 [45] - - Note: Duration-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 38 * Fertility Table 3.7 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born (CEB) and mean number ever born and living, according to five-year age groups, Bangladesh 1999-2000 Age Group Number of children ever born (CEB) Total Number of women Mean no. of CEB Mean no. of living children0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 70.2 23.2 5.9 0.7 0 0 0 0 0 0 0 100.0 3,149 0.37 0.33 20-24 27.3 26.7 29.6 13.1 2.7 0.6 0 0 0 0 0 100.0 2,373 1.39 1.26 25-29 8.6 13.2 29.0 26.1 13.4 6.5 2.4 0.8 0 0 0 100.0 2,062 2.56 2.26 30-34 3.3 7.0 17.6 23.6 19.9 14.3 7.2 4.7 1.7 0.7 0.3 100.0 1,622 3.62 3.11 35-39 2.5 5.4 11.9 16.8 19.4 17.3 12.7 7.3 3.5 1.9 1.2 100.0 1,338 4.29 3.53 40-44 2.3 3.0 8.6 12.4 15.9 14.7 15.0 10.6 8.9 5.1 3.5 100.0 1,126 5.13 4.12 45-49 1.7 2.5 3.3 6.7 11.8 14.8 16.2 15.2 10.6 7.9 9.3 100.0 853 6.09 4.87 Total 25.2 15.0 16.4 13.4 9.6 7.2 5.1 3.5 2.1 1.3 1.1 100.0 12,523 2.58 2.18 CURRENTLY MARRIED WOMEN 15-19 37.2 48.6 12.6 1.5 0.1 0 0 0 0 0 0 100.0 1,468 0.79 0.70 20-24 10.0 31.9 37.2 16.7 3.5 0.7 0 0 0 0 0 100.0 1,846 1.74 1.58 25-29 3.5 13.0 30.4 27.9 14.5 7.2 2.7 0.8 0 0 0 100.0 1,878 2.73 2.41 30-34 2.4 5.6 17.6 24.4 20.1 14.7 7.5 5.0 1.8 0.7 0.3 100.0 1,523 3.71 3.19 35-39 1.0 4.0 11.3 17.6 19.7 18.0 13.4 7.6 4.0 2.0 1.3 100.0 1,174 4.46 3.68 40-44 1.7 2.3 7.2 11.8 15.4 14.9 16.2 11.8 9.6 5.4 3.7 100.0 948 5.32 4.32 45-49 1.2 1.9 2.9 5.6 11.9 15.1 16.5 16.0 10.8 8.0 10.1 100.0 702 6.24 5.00 Total 9.1 18 20.3 16.6 11.6 8.7 6.2 4.2 2.5 1.5 1.3 100.0 9,540 3.13 2.65 A comparison of the mean number of children ever born reported in the 1999-2000 BDHS survey and various other surveys is presented in Table 3.8. The comparison does not highlight recent changes in fertility, but rather is an indication of the cumulative changes in fertility over the decades prior to the surveys. Despite the fluctuations between surveys, the data generally show only modest declines until the late 1980s. Between 1985 and 1989, the decline in mean number of children ever born was substantial in all but the youngest and oldest age groups. Although there was then little change between 1989 and 1991, the rates again decline considerably between 1991 and 1993-1994, especially among women age 25 and above, and show further decline between 1993-1994 and 1999-2000 at all ages except 15-19. 3.6 BIRTH INTERVALS A birth interval, defined as the length of time between two successive live births, indicates the pace of childbearing. Information on birth intervals provides insight into birth-spacing patterns which have far-reaching impact on both fertility and child mortality levels. Research has shown that children born too soon after a previous birth are at increased risk of dying at an early age. Table 3.9 shows the percent distribution of non-first births that occurred in the five years before the BDHS survey by the number of months since the previous birth. The data show that birth intervals are generally long in Bangladesh. Nearly one in six children (16 percent) are born after a “too short” interval (less than 24 months). More than half (57 percent) of non-first births occur three or more years after the previous birth, while 27 percent of births take place 24-35 months after the previous birth. The median birth interval is 39 months. Fertility * 39 Table 3.8 Trends in children ever born Mean number of children ever born by age group, selected sources, Bangladesh, 1975-1999 __________________________________________________________________________________________________________ 1975 1981 1983 1985 1989 1989 1991 1993-1994 1996-1997 1999-2000 Age group BFS CPS CPS CPS BFS CPS CPS BDHS BDHS BDHS _________________________________________________________________________________________________________ 15-19 0.6 0.5 0.6 0.4 0.4 0.4 0.4 0.3 0.4 0.4 20-24 2.3 2.0 2.2 2.0 1.7 1.8 1.7 1.6 1.5 1.4 25-29 4.2 3.7 3.8 3.6 3.1 3.3 3.2 2.9 2.8 2.6 30-34 5.7 5.4 5.5 5.1 4.7 4.7 4.5 4.1 3.9 3.6 35-39 6.7 6.4 6.5 6.5 5.9 5.9 5.7 5.2 4.8 4.3 40-44 7.1 7.3 7.4 7.4 6.6 7.0 6.7 6.4 5.6 5.1 45-49 6.7 7.6 7.5 7.2 7.3 7.5 7.4 6.9 6.4 6.1 Total u u u u u u 3.5 3.0 2.8 2.6 __________________________________________________________________________________________________________ u = Unknown (not available) Source: 1983 and 1985 CPSs (Kantner and Frankenberg, 1988:21); 1991 CPS (Mitra et al., 1993:31); 1993-1994 BDHS (Mitra et al., 1994:33); 1996-1997 BDHS (Mitra et al., 1997: 36); all others (Cleland et al., 1994:11). Table 3.9 Bir th intervals Percent distribution of non-first births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Bangladesh 1999-2000 Characteristic Total Median number of months since previous birth Number Number of months since previous birth 7-17 18-23 24-35 36-47 48+ Age of mother 15-19 19.3 21.5 34.8 18.2 6.1 100.0 26.9 226 20-29 6.7 10.0 28.6 22.5 32.2 100.0 37.8 2,939 30-39 5.1 7.7 23.9 20.9 42.4 100.0 42.7 1,500 40+ 3.1 7.9 17.2 21.5 50.3 100.0 48.1 222 Birth order 2-3 6.6 9.4 24.7 21.1 38.1 100.0 40.6 2,900 4-6 6.8 9.3 29.2 22.6 32.2 100.0 37.7 1,513 7+ 6.1 12.7 33.4 23.3 24.5 100.0 35.0 473 Sex of prior birth Male 7.1 9.0 26.2 21.6 36.0 100.0 39.4 2,468 Female 6.1 10.4 27.6 22.0 33.9 100.0 38.2 2,419 Survival of prior birth Living 4.4 8.9 26.9 22.8 36.9 100.0 40.4 4,279 Dead 22.0 15.0 27.3 14.7 21.0 100.0 28.0 608 Residence Urban 7.2 10.8 21.7 18.3 42.1 100.0 43.2 752 Rural 6.5 9.5 27.9 22.4 33.7 100.0 38.3 4,135 Division Barisal 7.1 5.7 27.4 22.6 37.2 100.0 40.6 314 Chittagong 6.7 10.7 31.6 23.0 28.0 100.0 36.3 1,139 Dhaka 7.1 9.6 26.1 20.4 36.8 100.0 39.6 1,466 Khulna 4.7 9.3 21.2 19.2 45.7 100.0 45.5 463 Rajshahi 6.3 9.4 22.9 24.0 37.4 100.0 41.4 1,113 Sylhet 7.4 11.6 34.2 19.8 27.1 100.0 34.8 392 Education No education 6.4 10.0 28.4 22.7 32.5 100.0 37.7 2,638 Primary incomplete 6.1 9.5 28.0 23.4 33.1 100.0 39.2 888 Primary complete 8.4 8.9 23.5 24.1 35.0 100.0 39.4 485 Secondary+ 6.7 9.5 23.4 16.2 44.2 100.0 43.5 876 Total 6.6 9.7 26.9 21.8 35.0 100.0 38.8 4,887 Note: First births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 2 The data are based on all women, including those who have never married (see Footnote 1 for a description of the inflation factors used to estimate the total number of women). 40 * Fertility This is slightly longer than the median birth interval of 35 months reported in the 1993-1994 BDHS survey and 37 months in the 1996-1997 BDHS survey (Mitra et al., 1994:34; Mitra et al., 1997:38). As expected, younger women have shorter birth intervals than older women, presumably because they are more fecund and want to build their families. The median birth interval for women age 15-19 is 27 months, compared with 48 months for women over age 40. The median birth interval is slightly shorter if the previous child was a girl than if it was a boy. Birth intervals are much shorter if the previous child died (28 months) than if the previous child survived (40 months). In part, this reflects the shortening of postpartum amenorrhea that occurs when the preceding child dies in infancy and breastfeeding stops prematurely. Women are also less likely to use contraception to postpone fertility if the previous child died and they want to “replace” the dead child. Birth intervals are five months shorter among rural women than among urban women, perhaps because breastfeeding is shorter among urban women. The longest birth intervals are found among women in Khulna Division and the shortest are among women in Sylhet Division. There is a tendency for birth intervals to increase with education. Mothers with some secondary education have a median birth interval that is six months longer than the interval for uneducated mothers. 3.7 AGE AT FIRST BIRTH The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. In many countries, postponement of first births—reflecting an increase in the age at marriage—has contributed greatly to overall fertility decline. Early initiation into childbearing is generally a major determinant of large family size and rapid population growth, particularly in countries where family planning is not widely practiced. Moreover, bearing children at a young age involves substantial risks to the health of both the mother and child. Early childbearing also tends to restrict educational and economic opportunities for women. Table 3.10 presents the percent distribution of women by age at first birth according to current age.2 For women age 20 and over, the median age at first birth is presented in the last column of the table. Childbearing begins early in Bangladesh, with the large majority of women becoming mothers before they reach the age of 20. The median age at first birth is between 17 and 19. The data show that the median age at first birth has increased slightly from about 17 for older women to about19 for women in their early twenties. This slight change to later age at first birth is reflected in the smaller proportion of younger women whose first birth occurred before age 15; about 18 percent of women in their forties report having had their first birth before age 15, compared with only 7 percent of women age 15-19. Comparisons with data from other sources confirm that the age at which women in Bangladesh have their first child has increased steadily over time, in line with increases in age at marriage, with the exception of the past few years. For example, in 1975, the median age at first birth among women age 20-24 was 16.8; in 1989, it had risen to 18.0, in 1996-1997 to 18.4, and by 1999-2000, to 18.7. Fertility * 41 Table 3.10 Age at first birth Percent distribution of women by age at first birth, according to current age, Bangladesh 1999-2000 Current age Women with no births Number Median age at first birth Age at first birth <15 15-17 18-19 20-21 22-24 25+ Total 15-19 70.2 6.5 20.3 3.0 na na na 100.0 3,149 a 20-24 27.3 10.1 33.5 17.7 8.3 3.0 na 100.0 2,373 18.7 25-29 8.6 10.1 37.6 18.7 12.4 9.4 3.2 100.0 2,062 18.2 30-34 3.3 11.3 39.1 21.4 12.3 8.0 4.6 100.0 1,622 18.0 35-39 2.5 11.1 38.1 20.6 12.1 9.0 6.5 100.0 1,338 18.1 40-44 2.3 16.6 41.9 17.6 8.3 8.1 5.2 100.0 1,126 17.2 45-49 1.7 17.8 48.3 16.7 7.1 5.1 3.2 100.0 853 16.9 na = Not applicable a Omitted because less than 50 percent of the women in the age group 15-19 have had a birth by age 15. Table 3.11 summarizes the median age at first birth for different age cohorts across urban- rural, division, and educational subgroups. Urban women start childbearing later than rural women; the median age at first birth is 19.0 for urban women and 17.8 for rural women age 20-49. Women in Sylhet Division consistently have higher median ages at first birth than women in the other divisions, while women in Rajshahi Division generally have the lowest median ages at first birth. Women with secondary education start childbearing later than those with less or no education. Among women age 25-49, the median age at first birth is 17.3 for women with no education and 19.7 for women with at least some secondary education. Table 3.11 Median age at first birth Median age at first birth among women age 20-49 years, by current age and selected background characteristics, Bangladesh 1999-2000 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Age 20-49 Age 25-49 Residence Urban 20.9 19.4 19.0 18.5 17.5 17.2 19.0 18.6 Rural 18.3 17.9 17.8 18.0 17.0 16.8 17.8 17.6 Division Barisal 18.8 17.6 17.7 17.5 16.7 17.1 17.7 17.4 Chittagong 19.2 18.1 18.2 18.6 18.4 17.4 18.4 18.2 Dhaka 18.8 18.8 18.6 18.4 17.1 16.8 18.2 18.1 Khulna 18.4 18.4 17.4 18.0 16.8 16.4 17.8 17.6 Rajshahi 17.8 17.6 17.4 17.6 16.7 16.5 17.4 17.2 Sylhet a 19.6 19.3 18.3 18.2 18.0 19.3 18.9 Education No education 17.1 17.4 17.7 17.9 16.7 16.6 17.3 17.3 Primary incomplete 17.4 17.3 17.5 17.6 17.2 17.3 17.4 17.4 Primary complete 18.0 18.0 17.6 18.0 17.2 17.0 17.8 17.7 Secondary+ a 20.7 19.4 19.2 19.2 18.3 a 19.7 Total 18.7 18.2 18 18.1 17.2 16.9 18.0 17.8 Note: The medians for cohort 15-19 could not be determined because half the women have not yet had a birth. a Medians were not calculated for these cohorts because less than 50 percent of women in the age group 20-24 had a birth by age 20. 42 * Fertility 3.8 TEENAGE FERTILITY Early childbearing, particularly among teenagers (those under 20 years of age) has negative demographic, socioeconomic, and sociocultural consequences. Teenage mothers are more likely to suffer from severe complications during delivery, which result in higher morbidity and mortality for both themselves and their children. In addition, the socioeconomic advancement of teenage mothers in the areas of educational attainment and accessibility to job opportunities may be curtailed. Table 3.12 shows the percentage of teenagers age 15-19 who are mothers or pregnant with their first child, according to various background characteristics. Thirty percent of teenage women in Bangladesh are mothers, and another 5 percent are pregnant with their first child. Thus, 35 percent of teenage women have begun childbearing. There has been a slight decline in this proportion since the 1996-1997 BDHS survey, which indicated that 36 percent of women age 15-19 had begun childbearing (31 percent had delivered a child and 5 percent were pregnant with their first child) (Mitra et al., 1997). As expected, the proportion of women who have begun childbearing rises rapidly with age, from 16 percent of those age 15 to 57 percent of those age 19 (see Table 3.12). Those residing in rural areas and especially those residing in the Rajshahi and Khulna divisions are also more likely than others to have begun childbearing, while girls in Sylhet Division are the least likely to have started childbearing. Education is strongly related to early childbearing. Girls with no education are far more likely to have begun childbearing than those with primary and especially those with some secondary education. Fertility * 43 Table 3.12 Teenage pregnancy and motherhood Percentage of women 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Bangladesh 1999-2000 Background characteristic Percentage who are: Percentage who have begun child- bearing NumberMothers Pregnant with first child Age 15 11.6 4.3 15.9 704 16 22.2 3.8 26.0 703 17 30.8 5.7 36.5 584 18 39.0 6.0 45.0 638 19 52.5 4.8 57.3 520 Residence Urban 22.0 3.6 25.5 627 Rural 31.8 5.2 37.0 2,522 Division Barisal 25.4 5.4 30.8 178 Chittagong 21.6 4.8 26.4 625 Dhaka 29.4 5.6 35.0 1,008 Khulna 37.2 4.4 41.6 344 Rajshahi 38.1 4.8 42.9 760 Sylhet 19.3 2.9 22.2 231 Education No education 50.6 5.1 55.7 635 Primary incomplete 40.2 5.1 45.3 554 Primary complete 36.0 7.3 43.3 331 Secondary+ 16.7 4.2 20.9 1,652 Total 29.8 4.9 34.7 3,149 Fertility Regulation * 45 FERTILITY REGULATION 4 4.1 KNOWLEDGE OF FAMILY PLANNING METHODS In the 1999-2000 BDHS survey, knowledge of family planning methods was assessed through a series of questions, as in the earlier two BDHS surveys. Respondents were first asked to name the ways or methods by which a couple could delay or avoid pregnancy. When a respondent did not mention a particular method spontaneously, the interviewer described the method and asked whether the respondent had heard of it. Knowledge of family planning methods thus assessed is presented in Table 4.1, separately for ever-married women, currently married women, and currently married men. Table 4.1 Knowledge of contraceptive methods Percentage of ever-married and currently married women and of currently married men who know any contraceptive methods, by specific methods, Bangladesh 1999-2000 Contraceptive method Ever- married women Currently married women Currently married men Any method 99.9 99.9 100.0 Any modern method 99.9 99.9 100.0 Pill 99.7 99.8 99.9 IUD 89.0 89.6 69.5 Injectable 97.8 98.1 92.6 Condom 89.0 89.8 97.2 Female sterilization 97.4 97.5 94.8 Male sterilization 76.6 77.0 87.4 Norplant 55.5 56.3 24.6 Any traditional method 79.0 79.9 82.4 Periodic abstinence 66.1 66.9 73.8 Withdrawal 55.7 56.8 47.2 Lactational amenorrhea 16.0 16.2 0.0 Other 7.6 7.8 8.0 Number of women/men 10,544 9,720 2,556 Mean number of method known 9.2 9.3 8.4 Information about knowledge was sought for seven modern methods: the pill, IUD, injection, condom, female and male sterilization, and Norplant, as well as three traditional methods: periodic abstinence (safe period or rhythm method), withdrawal, and lactational amenorrhea. Other methods, if mentioned by a respondent, were also recorded. It should be noted that information about lactational amenorrhea was not sought in the two earlier BDHS surveys. 46 * Fertility Regulation Knowledge of family planning methods is high among Bangladeshi couples. Virtually all respondents know at least one modern method of family planning, and eight out of ten (79 to 82 percent) know at least one traditional method. There is practically no difference in knowledge between ever-married women and currently married women. The most commonly known family planning methods among women in Bangladesh are the pill, injectables, and female sterilization, closely followed by condoms and the IUD. Nearly all currently married women say they have heard of the pill, injectables, and female sterilization, and about 90 percent have heard of the IUD and condoms. Other methods known to at least half of currently married women are male sterilization (77 percent), periodic abstinence (safe period or calendar rhythm—67 percent), withdrawal (57 percent), and Norplant (56 percent). Only sixteen percent of currently married women know of lactational amenorrhea as a method of family planning. Fewer than 10 percent of currently married women mentioned methods that were not on the list, mostly traditional methods like ayurvedic methods, plants, and herbs. For ever-married women, the data also show similar levels of knowledge of specific methods. The pill is universally known among currently married men and married women. There is also little difference between currently married women and men in knowledge of female sterilization and injectables. However, the gaps in knowledge between men and women were pronounced for the remaining methods. Men are less likely to know about the IUD, Norplant, and withdrawal, while they are more likely to have heard about periodic abstinence and the two male modern methods, the condom and male sterilization. While men are generally more likely to know of methods used by men and less likely to know of methods used by women, it is interesting to note that a higher proportion of currently married men than women reported knowing of periodic abstinence (74 versus 67 percent) and a lesser proportion reported knowing of withdrawal (47 versus 57 percent). TRENDS IN KNOW LEDGE OF FAMILY PLANNING METHODS Trends in knowledge of family planning methods are shown in Table 4.2 in terms of the proportion of ever-married women who have heard of specific methods. Knowledge of at least one method reached universal proportions among ever-married women of reproductive age in Bangladesh in 1983. Thereafter, knowledge of specific methods has become more widespread, growing continuously with time to reach more than nine out of every ten women by 1996-1997 for almost every modern method. Knowledge of periodic abstinence and withdrawal, the two traditional methods, also grew significantly over the same period, reaching at least 50 percent of women by 1991. Since 1996-1997, there have been few changes in knowledge of family planning methods, remaining as high in the 1999-2000 BDHS survey as in the 1996-1997 BDHS survey. With family planning methods being widely known, there are no variations in knowledge of at least one method by subgroups of the population, as noted in the earlier two BDHS surveys. Knowledge of at least one method, particularly a modern method, is universal among both women and men in all age groups, in both urban and rural areas, in all the divisions, and across all categories of educational attainment (data not shown). These findings are an indication of the success of program efforts in providing contraceptive information to all eligible couples across the country. Fertility Regulation * 47 Table 4.2 Trends in knowledge of family planning methods Percentage of ever-married women age 10-49 who know specific family planning methods, selected sources, Bangladesh 1975-1999 Method 1975 BFS 1983 CPS 1985 CPS 1989 CPS 1989 BFS1 1991 CPS 1993- 1994 BDHS 1996- 1997 BDHS 1999- 2000 BDHS Any method 81.8 98.6 99.6 99.9 100.0 99.9 99.7 100.0 99.9 Any modern method 80.0 98.4 99.5 99.9 99.0 99.8 99.7 100.0 99.9 Pill 63.9 94.1 98.6 99.0 99.0 99.7 99.5 99.9 99.7 IUD 40.1 41.6 65.4 80.4 78.0 88.9 89.4 91.4 89.0 Injectables u 61.8 74.1 87.5 81.0 95.2 96.3 98.0 97.8 Vaginal methods 10.0 19.4 26.3 25.8 24.0 u u u u Condom 21.1 59.0 75.5 76.9 83.0 85.6 86.6 91.0 89.0 Female sterilization 53.1 95.5 97.8 99.2 98.0 99.4 98.8 98.9 97.4 Male sterilization 51.4 72.9 84.3 84.0 87.0 87.4 82.9 83.4 76.6 Any traditional method 49.0 54.8 62.8 71.7 u 83.3 75.0 76.6 79.0 Periodic abstinence 28.0 26.4 41.2 40.1 46.0 68.0 64.0 68.2 66.1 Withdrawal 15.1 19.8 20.8 14.4 30.0 48.6 49.0 49.8 55.7 Number of women 6,515 8,523 8,541 10,293 11,907 10,573 9,640 9,127 10,544 u = Unknown (no information) 1 Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1974 BFS (MHPC, 1978:A245 and Vaessen, 1980:16); 1983 CPS (Mitra and Kamal, 1985:85, 89); 1985 CPS (Mitra, 1987:67, 70); 1989 CPS (Mitra et al., 1990:81, 84); 1989 BFS (Huq and Cleland, 1990:60); 1991 CPS (Mitra et al., 1993:42); 1993-1994 BDHS (Mitra et al., 1994:40); 1996-1997 (Mitra et al., 1997:45) Table 4.3 shows the distribution of couples interviewed in the 1999-2000 BDHS survey by contraceptive knowledge, according to specific methods. Generally, spouses have a high degree of correspondence in their knowledge of contraceptive methods; if one partner knows a method, the other is likely to know it as well. However, there is less consistency for such female methods as the IUD, Norplant, and periodic abstinence, and for such male methods as condoms, male sterilization, and withdrawal; wives are generally more likely to know the female methods than their husbands, while husbands are more likely to know the male methods than their wives. The only exceptions are periodic abstinence and withdrawal, the former being known to more husbands than wives and the latter to more wives than husbands. 4.2 EVER USE OF CONTRACEPTION Both female and male respondents in the BDHS survey who said that they had heard of a method of a family planning were asked whether they had ever used the method, that is, whether they had used it at least once. Ever use of family planning methods in the BDHS survey thus refers to use of a method at any time without making a distinction between past and current use. Collection and analysis of ever use data has special significance for family planning programs. These data indicate the proportion of the population exposed to contraceptive use at least once. Therefore, data on ever use indicate the success of programs in promoting use of family planning methods among eligible couples. In addition, data on ever use—together with data on current use—are valuable for studying couples who discontinue use. 48 * Fertility Regulation Table 4.3 Knowledge of contraceptive methods among couples Percent distribution of couples by contraceptive knowledge, according to specific methods, Bangladesh 1999-2000 Contraceptive method Both know method Only husband knows method Only wife knows method Neither knows method Total Any method 99.9 0.0 0.0 0.0 100.0 Any modern method 99.9 0.0 0.0 0.0 100.0 Pill 99.7 0.2 0.1 0.0 100.0 IUD 65.9 4.9 24.8 4.4 100.0 Injectables 91.6 1.5 6.8 0.1 100.0 Condom 88.9 8.4 2.0 0.8 100.0 Female sterilization 92.6 2.1 4.8 0.4 100.0 Male sterilization 69.2 18.2 8.8 3.8 100.0 Norplant 17.1 7.9 41.6 33.5 100.0 Any traditional method 68.9 13.1 12.5 5.5 100.0 Periodic abstinence 53.8 20.7 14.9 10.6 100.0 Withdrawal 32.4 15.0 27.6 25.0 100.0 Note: Figures are based on 2,280 couples. Table 4.4 shows the percentage of ever-married women, currently married women, and currently married men interviewed in the 1999-2000 BDHS survey who have ever used specific family planning methods. The data for women are given by age group. Among ever-married women, three-fourths (75 percent) have ever used a method and nearly seven in ten (68 percent) have used a modern method, while more than a quarter (29 percent) reported having ever used a traditional method. The pill is, as expected, by far the most commonly used method; more than half (55 percent) of ever-married women say they have ever used this method. The next most commonly ever used methods are injectables (20 percent), condoms (19 percent), periodic abstinence (19 percent), withdrawal (14 percent), female sterilization (7 percent), and the IUD (7 percent). Very few women report having ever used male sterilization, Norplant, and lactational amenorrhea. As expected, currently married women are more likely than ever-married women to have ever used a family planning method. Men report higher ever use of contraception than women. Eighty-seven percent of currently married men, compared with 78 percent of currently married women, report having ever used a family planning method; 79 percent compared with 71 percent for a modern method and 43 percent compared with 30 percent for a traditional method. The differences are largely due to two methods, condoms and periodic abstinence. Thirty-two percent of currently married men, compared with only 20 percent of currently married women, report having ever used condoms, and 36 percent of currently married men, compared with only 20 percent of currently married women, report having ever used periodic abstinence. Men also report considerably higher ever use of the pill, compared with women—66 versus 58 percent among currently married men and women. Similar variations between men and women in reporting ever use for condoms, periodic abstinence, and the pill were also noted in the 1996-1997 BDHS survey. Fertility Regulation * 49 Table 4.4 Ever use of contracept ion Percentage of ever-marr ied and currently married women and current ly married men who have ever used any contracept ive method, by specif ic method and age, Bangladesh 1999-2000 Modern method Traditional method Age Any method Any mo dern method Pill IUD Inject- ables Condom Fem ale sterili- zation M ale sterili- zation No r- plant Menstrual regu- lation Any trad. method Period ic ab sti- nence With- drawal Other method Num ber EVER-MARRIED W OM EN 10-14 39.8 30.9 23.8 0.0 0.9 11.2 0.0 0.0 0.0 0.4 17.3 7.8 11.9 0.0 186 15-19 60.9 54.1 44.7 1.1 8.9 18.3 0.1 0.0 0.2 1.5 20.2 10.4 12.7 0.5 1,514 20-24 76.0 70.3 61.6 3.7 20.0 22.8 0.7 0.1 1.0 3.7 25.4 15.1 14.1 1.2 1,935 25-29 81.9 76.6 66.4 7.4 27.6 21.8 2.6 0.1 1.0 5.1 29.9 18.8 16.3 1.7 1,975 30-34 82.9 77.7 65.1 11.6 26.9 21.8 6.8 0.7 0.8 6.3 33.5 22.3 15.7 3.9 1,621 35-39 79.5 72.7 54.8 10.6 23.1 17.2 14.0 0.9 0.7 7.9 33.3 24.7 14.6 3.2 1,335 40-44 74.9 66.8 49.1 9.9 18.6 14.1 17.0 1.6 0.2 5.3 34.7 25.0 13.5 4.3 1,126 45-49 62.5 50.7 32.1 5.9 11.4 5.4 16.9 1.9 0.2 4.1 28.0 21.7 8.3 3.7 853 Total 74.6 67.9 55.4 6.9 20.1 18.6 6.6 0.6 0.6 4.7 28.8 18.9 14.0 2.4 10,544 CURR ENTLY MARR IED WO MEN 10-14 41.0 31.9 24.5 0.0 0.9 11.6 0.0 0.0 0.0 0.4 17.8 8.0 12.3 0.0 181 15-19 61.9 54.9 45.4 1.1 9.1 18.8 0.1 0.0 0.2 1.5 20.7 10.7 13.0 0.5 1,468 20-24 77.6 72.0 63.0 3.9 20.4 23.7 0.7 0.1 1.0 3.8 25.9 15.4 14.5 1.2 1,846 25-29 84.4 79.2 68.7 7.6 28.6 22.8 2.7 0.2 1.1 5.1 30.7 19.3 16.8 1.8 1,878 30-34 85.7 80.8 67.5 12.0 28.3 22.8 7.2 0.8 0.9 6.5 34.7 23.2 16.2 4.1 1,523 35-39 85.1 78.7 59.9 11.7 25.4 18.8 14.9 1.1 0.7 8.4 34.9 25.5 15.6 3.3 1,174 40-44 81.2 73.1 54.0 10.8 20.7 15.6 18.1 1.7 0.3 6.3 37.9 27.1 14.8 5.0 948 45-49 68.7 56.4 36.4 6.8 13.5 6.3 18.3 2.3 0.2 4.7 31.5 24.2 9.6 4.3 702 Total 77.8 71.2 58.2 7.2 21.3 19.7 6.7 0.6 0.7 4.9 29.9 19.5 14.7 2.5 9,720 CURR ENTLY MARR IED MEN Total 86.5 78.5 65.6 6.8 18.9 32.2 7.4 0.8 0.4 5.5 42.7 36.0 10.6 2.6 2,556 Ever use varies with the age of women. It is lowest among the youngest women, rises with age to a high among women age 30-34, and then declines among older women. Among currently married women, only 41 percent report having ever used a method in the youngest age group and 69 percent report ever use in the oldest age group, compared with 86 percent of those in the 30-34 age group. There has been a steady increase in the level of ever use of family planning over the past 25 years in Bangladesh. In 1975, only 14 percent of ever-married women of reproductive age had ever used a family planning method, compared with 78 percent in 1999-2000, more than a fivefold increase (Table 4.5). For modern methods, the increases have been even steeper, with ever use of the pill increasing the most rapidly from only 5 percent of ever-married women in 1975 to more than 55 percent in 1999-2000. Between 1996-1997 and 1999-2000, ever use of traditional methods has increased from 23 percent of ever-married women to 29 percent, compared with modern methods increasing from 63 percent to 68 percent over the same period. Use of both male and female sterilization has been declining since 1991. Use of the IUD also appears to have either reached a plateau or started to decline since 1993-1994. 50 * Fertility Regulation Table 4.5 Trends in ever use of family planning methods Percentage of ever-married women age 10-49 who have ever used specific family planning methods, selected sources, Bangladesh 1975-1999 Method 1975 BFS 1983 CPS 1985 CPS 1989 CPS 1989 BFS1 1991 CPS 1993- 1994 BDHS 1996- 1997 BDHS 1999- 2000 BDHS Any method 13.6 33.4 32.5 44.2 45.0 59.0 63.1 69.2 74.6 Any modern method u 23.8 25.9 37.5 u 49.2 56.4 63.0 67.9 Pill 5.0 14.1 14.3 23.3 22.0 34.1 42.0 48.9 55.4 IUD 0.9 2.2 2.7 4.6 4.0 6.2 7.3 6.9 6.9 Injectables u 1.2 1.3 2.8 2.0 6.6 11.0 15.7 20.1 Vaginal methods 0.5 2.2 1.6 2.4 1.0 2.9 u u u Condom 4.8 7.1 5.7 9.3 6.0 13.4 13.9 15.0 18.6 Female sterilization 0.3 5.8 7.4 8.7 9.0 8.0 7.9 7.6 6.6 Male sterilization 0.4 1.4 1.6 1.6 1.0 1.4 1.4 1.2 0.6 Any traditional method u 17.3 11.9 15.3 u 29.6 24.0 23.0 28.8 Periodic abstinence 4.5 11.0 7.8 9.7 13.0 21.5 16.5 16.7 18.9 Withdrawal 2.6 5.3 2.9 3.6 7.0 11.1 10.1 9.5 14.0 Number of women 6,515 8,523 8,541 10,293 11,907 10,573 9,640 9,127 10,544 u = Unknown (no information) 1 Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1975 BFS (MHPC, 1978:A275);1983 CPS (Mitra and Kamal, 1985:117,122);1985 CPS (Mitra, 1987:108- 112); 1989 CPS (Mitra et al., 1990:88, 92); 1989 BFS (Huq and Cleland, 1990:61); 1991 CPS (Mitra et al., 1993:52); 1996-1997 BDHS (Mitra et al., 1997:47) 4.3 KNOWLEDGE AND EVER USE OF MENSTRUAL REGULATION As in the 1996-1997 BDHS survey, respondents were also asked whether they knew about or had ever used menstrual regulation (MR). More than 80 percent of ever married and currently married women know about MR in contrast to only slightly more than half of currently married men (Table 4.6). Although ever use of MR has increased since 1996-1997, it is still negligi- ble, with only about 5 percent of women and 6 percent of men saying they had ever used MR. Levels of ever use are highest among respondents who are currently in their thir- ties. Table 4.6 Menstrual regulation Percentage of ever-married and currently married women and of currently married men who know of menstrual regulation (MR) and the percentage who have ever used MR by age group, Bangladesh 1999-2000 Age group Ever- married women Currently married women Currently married men Know of MR 81.6 82.1 53.5 Ever used MR 10-14 0.4 0.4 - 15-19 1.5 1.5 - 20-24 3.7 3.8 - 25-29 5.1 5.1 - 30-34 6.3 6.5 - 35-39 7.9 8.4 - 40-44 5.3 6.3 - 45-49 4.1 4.7 - Total 4.7 4.9 5.5 Note: Data are not shown for men by age group due to small sample size. Fertility Regulation * 51 4.4 CURRENT USE OF CONTRACEPTION In the BDHS survey, current use of contraception is defined as the proportion of women and men who report they are using a family planning method at the time of interview. Although ever- married women age 10-49 were interviewed, only women who were currently married at the time of the survey were asked the questions on current use of family planning. Table 4.7 shows the percent distribution of currently married women and men interviewed in the 1999-2000 BDHS survey by their current contraceptive use status according to five-year age group. Table 4.7 Current use of contraception Percent dis tr ibut ion of current ly married women and men by contraceptive method currently used, according to age, Bangladesh 1999-2000 Age Any method Modern method Traditional method Not curre ntly us ing Total Nu mb er Any mo dern method Pill IUD Inject- ables Condom Fem ale sterili- zation M ale sterili- zation No r- p lant Any trad. method Period ic ab sti- nence With- drawal Other method CURREN TLY MARRIED W OM EN 10-14 25.7 16.1 11.5 0.0 0.9 3.8 0.0 0.0 0.0 9.6 3.1 6.5 0.0 74.3 100 .0 181 15-19 38.1 31.2 21.0 0.7 4.9 4.3 0.1 0.0 0.1 6.9 3.2 3.5 0.3 61.9 100 .0 1,468 20-24 47.1 40.1 26.6 0.8 7.2 4.0 0.7 0.1 0.6 7.0 3.2 3.5 0.4 52.9 100 .0 1,846 25-29 58.1 49.0 29.5 1.4 10.2 4.3 2.7 0.2 0.8 9.0 4.3 4.1 0.6 41.9 100 .0 1,878 30-34 64.2 53.0 27.8 1.9 8.8 6.1 7.2 0.6 0.5 11.1 5.8 4.1 1.1 35.8 100 .0 1,523 35-39 67.7 53.8 22.1 1.7 9.3 4.2 14.9 0.9 0.6 13.9 7.8 4.7 1.4 32.3 100 .0 1,174 40-44 61.9 43.5 13.4 1.8 5.1 3.6 18.1 1.4 0.1 18.3 10.7 5.6 2.0 38.1 100 .0 948. 45-49 43.1 31.7 7.5 0.6 1.6 1.7 18.3 1.8 0.2 11.5 7.5 2.8 1.1 56.9 100 .0 702 Total 53.8 43.4 23.0 1.2 7.2 4.3 6.7 0.5 0.5 10.3 5.4 4.0 0.9 46.2 100 .0 9,720 CURR ENTLY MARR IED MEN 15-19 * * * * * * * * * * * * * * 100 .0 23 20-24 56.9 47.4 32.1 1.0 5.4 8.4 0.0 0.0 0.4 9.5 7.1 2.4 0.0 43.1 100 .0 151 25-29 52.9 441 .2 28.3 0.4 5.3 7.2 0.0 0.0 0.0 11.7 9.8 1.1 0.6 47.1 100 .0 345 30-34 60.2 49.9 32.9 0.5 6.2 7.2 2.3 0.6 0.2 10.2 7.6 1.7 0.9 39.8 100 .0 418 35-39 69.0 58.2 34.7 2.3 11.2 4.4 4.2 0.3 1.1 10.8 7.8 1.4 0.8 31.0 100 .0 492 40-44 68.3 57.6 33.0 1.5 10.4 4.1 8.2 0.4 0.0 10.7 8.0 1.7 0.9 31.7 100 .0 394 45-49 74.8 58.2 25.0 1.3 6.5 8.3 15.7 1.0 0.3 16.6 10.0 5.4 1.2 25.2 100 .0 333 50-54 68.2 53.0 16.9 1.8 3.7 6.1 20.8 3.7 0.0 15.2 12.6 2.7 0.0 31.8 100 .0 219 55-59 45.0 28.7 9.1 1.7 3.7 1.0 11.5 1.7 0.0 16.3 14.1 1.8 0.4 55.0 100 .0 181 Total 63.5 51.3 28.6 1.3 7.2 5.9 7.1 0.8 0.3 12.2 9.1 2.2 0.7 36.5 100 .0 2,556 Note: an asterisk indicates fewer than 2 5 unw eighted cases. Overall, 54 percent of currently married women in Bangladesh are using a contraceptive method. Modern methods are much preferred (43 percent of married women) over traditional methods (10 percent). Although modern methods account for nearly 80 percent of overall use, traditional methods still remain a major means of contraception in Bangladesh, with as many as 10 percent of women reporting that they rely on them. The pill continues to be by far the most popular method of contraception, used by 23 percent of currently married women. Use of the pill accounts for 43 percent of all contraceptive use and 53 percent of modern method use in the country. Other commonly used methods are injectables and female sterilization (7 percent each), periodic abstinence (5 percent), and condoms and withdrawal (4 percent each). A negligible 1 percent of married women report the use of the IUD, and even fewer report the use of male sterilization and Norplant. 52 * Fertility Regulation Men are more likely than women to report that they are currently using a family planning method—64 versus 54 percent among currently married men and women. Such a large discrepancy may be due to overreporting by men, either to appease the interviewer or because they were embarrassed to admit that they were not practicing family planning. It could also be due to underreporting by women who were using a family planning method but were too shy to report that they were. Although there is no clear basis to discard the information given by either women or men as unreliable, it seems that women are more likely to be reliable reporters of contraceptive use because they are the actual users in most cases. Although men report higher use than women for all methods except withdrawal and Norplant, the largest differences are for the pill and periodic abstinence. The latter has been found in other DHS surveys and may be due to men’s misunder- standing of the difference between periodic abstinence and abstinence for other reasons. Current use of contraception varies considerably by age. Contraceptive use is highest among married women in their thirties, more than two-thirds of whom are using some method of family planning. The drop in current use among older women may reflect declining fecundity—whether real or perceived—while lower levels of use among younger women probably are due to their desire to have more children. However, 38 percent of married women age 15-19 are using a method and most of them are using a modern method. This confirms the findings documented in the earlier BDHS surveys that younger women have begun to appreciate the advantages of deliberately controlling childbirth early in marriage. Since 1993-1994, over a period of six years, contraceptive use has increased among women 15-19 by nearly 50 percent, from 25 to 38 percent in the 1999- 2000 BDHS survey. There are also variations by age in the methods that women use. The pill is by far the most popular method among married women under age 20 as well as among women in their twenties and thirties. Among women in their twenties, injectables are the second most popular method after the pill. But with a gradual shift to long-term methods among older women, the popularity of female sterilization increases, becoming second to the pill by age 35-39 and the most widely used method among women in their forties. TRENDS IN CURRENT USE OF FAMILY PLANNING Contraceptive prevalence has steadily grown in Bangladesh since 1975 (Table 4.8 and Figure 4.1) In 1975, only 8 percent of currently married women reported using a family planning method, compared with 54 percent in the 1999-2000 BDHS survey—a sevenfold increase in the contracep- tive prevalence rate for any method over the last 25 years. The prevalence of modern methods has increased even faster, more than eightfold, from 5 percent in 1975 to 43 percent in 1999-2000. However, increases in modern method use appear to have slowed in the three years since the 1996- 1997 BDHS survey. Between the 1996-1997 and 1999-2000 BDHS survey, overall contraceptive use increased by 9 percent, from 49 to 54 percent of currently married women, almost as much as it had increased between the 1993-1994 and 1996-1997 BDHS survey. But the increases since 1996-97 have been largely due to the use of traditional methods, which increased by 34 percent (7.7 to 10.3 percent) among married women. Modern method use has increased only marginally by 4 percent (41.6 to 43.4 percent). Fertility Regulation * 53 Table 4.8 Trends in current use of contraceptive methods Percentage of currently married women age 10-49 who are currently using specific family planning methods, selected sources, Bangladesh 1975-1999 Method 1975 BFS 1983 CPS 1985 CPS 1989 BFS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS Any method 7.7 19.1 25.3 30.8 39.9 44.6 49.2 53.8 Any modern method 5.0 13.8 18.4 23.2 31.2 36.2 41.6 43.4 Pill 2.7 3.3 5.1 9.6 13.9 17.4 20.8 23.0 IUD 0.5 1.0 1.4 1.4 1.8 2.2 1.8 1.2 Injectables u 0.2 0.5 0.6 2.6 4.5 6.2 7.2 Vaginal methods 0.0 0.3 0.2 0.1 u u u u Condom 0.7 1.5 1.8 1.8 2.5 3.0 3.9 4.3 Female sterilization 0.6 6.2 7.9 8.5 9.1 8.1 7.6 6.7 Male sterilization 0.5 1.2 1.5 1.2 1.2 1.1 1.1 0.5 Any traditional method 2.7 5.4 6.9 7.6 8.7 8.4 7.7 10.3 Periodic abstinence 0.9 2.4 3.8 4.0 4.7 4.8 5.0 5.4 Withdrawal 0.5 1.3 0.9 1.8 2.0 2.5 1.9 4.0 Other traditional methods 1.3 1.8 2.2 1.8 2.0 1.1 0.8 0.9 Number of women u 7,662 7,822 10,907 9,745 8,980 8,450 9,720 u = Unknown (no information) 1 Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1975 BFS (Islam and Islam, 1993:43); 1983 CPS (Mitra and Kamal, 1985:159); 1985 CPS (Mitra, 1987:147); 1989 BFS (Huq and Cleland, 1990:64); 1991 CPS (Mitra et al., 1993:53); 1993-1994 BDHS (Mitra et al., 1994:45); 1996-1997 BDHS (Mitra et al., 1997:50) 54 * Fertility Regulation The dominant change in contraceptive prevalence in Bangladesh since the late 1980s has been a large increase in the number of couples using oral contraception. The proportion of married women using the pill increased by more than two percentage points in the last three years, from 21 percent in 1996-1997 to 23 percent in 1999-2000 (Figure 4.2). Use of short-term methods like injectables and condoms has also increased over the same period, although by smaller margins. But the use of long-term methods such as sterilization and the IUD has further declined in the 1999- 2000 BDHS survey. Among traditional methods, use of withdrawal has increased considerably between the 1996-1997 and 1999-2000 BDHS surveys, while use of periodic abstinence has remained almost unchanged between the two surveys. With the use of long-term methods declining and that of short-term methods, especially the pill, increasing, the proportional share that each method contributes to the overall use of contraception—known as the “method mix”—has changed over time. For example, the pill now accounts for 43 percent of all contraceptive use, compared with 35 percent in 1991 (Figure 4.3). However, the share contributed by female sterilization has dropped from 23 percent in 1991 to 12 percent in 1999-2000. Fertility Regulation * 55 DIFFERENTIALS IN CURRENT USE OF FAMILY PLANNING Use of contraception varies by women’s characteristics (See Table 4.9). The level of current contraceptive use is higher in urban areas (60 percent) than in rural areas (52 percent among women). The urban-rural gap has narrowed compared with the 1993-1994 and 1996-1997 BDHS surveys. This might have been due to changing the definition of urban areas in the 1999-2000 BDHS survey. The pill is the most popular method among both urban and rural women. The condom is the next most widely used method among urban couples, while injectables are the second most popular method for rural women. There is a sharp difference in condom use between urban (10 percent) and rural (3 percent) couples, probably reflecting easier access to the method in urban areas. There is, however, little variation between urban and rural areas in use of the remaining methods. Differentials in current use of family planning by the six administrative divisions of the country are large. Contraceptive use is highest in Khulna Division, closely followed by the Rajshahi and Barisal divisions, while it is lowest in Sylhet Division. Sixty-four percent of married women in Khulna Division and 59 percent of those in the Rajshahi and Barisal divisions are using a family planning method, compared with only 34 percent of married women in Sylhet Division. Intermediate levels of use are reported for women in Dhaka Division (54 percent) and Chittagong Division (44 percent). Contraceptive use has increased in all divisions except Rajshahi Division since the 1996-1997 BDHS survey; however, it has increased relatively more rapidly (by 69 percent) in Sylhet Division. 56 * Fertility Regulation Table 4.9 Current use of contraception by background characteristics Percent distribution of currently married women and men by contraceptive method currently used, according to selected background characteristics, Bangladesh 1999-2000 Modern method Traditional method Background character istic Any method Any mo dern method Pill IUD Inject- ables Condom Fem ale sterili- zation M ale sterili- zation No r- plant Any trad. method Period ic ab sti- nence With- drawal Other method No t cur- rently us ing Total Num ber CURRENTLY MARRIED WOM EN Residence Urban 60.0 48.7 24.6 1.4 5.7 9.8 6.3 0.4 0.4 11.3 5.5 5.2 0.6 40.0 100.0 1,893 Rural 52.3 42.2 22.6 1.2 7.6 2.9 6.8 0.6 0.5 10.1 5.4 3.8 0.9 47.7 100.0 7,827 Division Barisal 59.2 45.7 20.0 1.7 10.6 2.9 8.2 1.7 0.5 13.5 6.9 6.0 0.7 40.8 100.0 638 Chittagong. 44.1 34.9 18.8 1.2 6.1 3.6 4.9 0.1 0.2 9.1 5.0 3.0 1.1 55.9 100.0 1,795 Dhaka 53.9 42.1 23.1 0.8 5.7 5.0 6.8 0.2 0.5 11.8 5.9 5.0 0.9 46.1 100.0 3,009 Khulna 64.0 50.8 25.8 2.1 9.7 6.6 5.0 1.0 0.6 13.2 6.8 6.0 0.4 36.0 100.0 1,198 Rajshahi 58.6 51.1 27.5 1.5 8.5 3.3 9.0 0.7 0.5 7.6 3.6 2.9 1.0 41.4 100.0 2,527 Sylhet 34.0 25.0 13.5 0.7 4.0 3.0 3.6 0.3 0.0 9.0 7.3 1.2 0.5 66.0 100.0 552 Education No education 51.0 41.5 20.0 1.2 8.3 1.0 9.6 0.8 0.7 9.5 5.4 2.9 1.1 49.0 100.0 4,306 Primary incomplete 53.3 44.0 24.1 0.9 8.5 3.4 6.2 0.5 0.4 9.3 5.4 3.4 0.5 46.7 100.0 1,799 Primary complete 52.7 41.5 23.4 1.0 8.1 4.3 4.2 0.2 0.2 11.2 5.7 4.2 1.2 47.3 100.0 1,019 Secondary+ 59.1 47.0 27.2 1.7 4.2 10.2 3.2 0.1 0.3 12.2 5.2 6.4 0.5 40.9 100.0 2,596 Number of living children None 20.7 13.5 8.0 0.0 0.2 5.1 0.2 0.1 0.0 7.1 2.6 4.6 0.0 79.3 100.0 1,159 1 48.9 40.6 27.5 0.6 5.6 5.0 1.2 0.3 0.3 8.4 4.5 3.5 0.3 51.1 100.0 1,942 2 61.0 52.5 29.2 1.9 9.8 5.2 5.6 0.5 0.4 8.5 4.2 3.6 0.7 39.0 100.0 2,181 3 64.8 53.5 25.8 1.8 8.5 3.7 12.2 0.4 1.0 11.3 5.6 4.9 0.7 35.2 100.0 1,760 4+ 58.5 44.5 19.5 1.4 8.5 2.9 10.8 0.9 0.5 14.0 8.1 4.0 1.9 41.5 100.0 2,679 Total 53.8 43.4 23.0 1.2 7.2 4.3 6.7 0.5 0.5 10.3 5.4 4.0 0.9 46.2 100.0 9,720 CURRENTLY MARRIED MEN Residence Urban 68.3 56.2 31.8 1.2 5.3 11.3 5.5 0.6 0.3 12.1 9.1 2.3 0.7 31.7 100.0 508 Rural 62.3 50.1 27.8 1.3 7.7 4.6 7.5 0.8 0.3 12.2 9.2 2.1 0.7 37.7 100.0 2,048 Division Barisal 66.6 49.4 21.0 2.7 13.3 3.2 8.0 1.2 0.0 17.2 12.2 3.5 1.0 33.4 100.0 159 Chittagong 57.3 46.9 27.9 1.1 5.9 5.1 6.5 0.0 0.4 10.4 7.7 2.3 0.4 42.7 100.0 426 Dhaka 59.7 46.6 26.5 0.9 6.5 6.5 5.3 0.7 0.3 13.1 9.8 2.3 0.6 40.3 100.0 835 Khulna 72.9 56.8 31.2 1.7 9.6 7.9 5.6 0.5 0.3 16.0 11.9 3.7 0.1 27.1 100.0 322 Rajshahi 71.2 61.5 34.2 1.6 7.4 5.2 11.0 1.5 0.4 9.8 7.2 1.3 1.3 28.8 100.0 682 Sylhet 40.6 30.7 18.4 0.5 2.5 6.6 2.7 0.0 0.0 9.9 9.2 0.2 0.5 59.4 100.0 133 Education No education 57.2 47.6 25.0 1.2 7.8 2.5 9.5 1.4 0.3 9.6 7.9 0.8 0.6 42.8 100.0 891 Primary incomplete 61.1 47.0 25.4 1.0 8.8 3.0 7.2 0.9 0.7 14.1 11.2 1.4 1.2 38.9 100.0 590 Primary complete 64.5 55.3 35.6 0.7 6.6 5.1 7.3 0.0 0.0 9.2 8.1 0.8 0.2 35.5 100.0 192 Secondary+ 71.1 56.9 33.0 1.8 5.8 11.5 4.6 0.2 0.1 14.2 9.2 4.3 0.6 28.9 100.0 883 Number of living children None 30.9 22.4 12.5 0.0 0.3 9.3 0.3 0.0 0.0 8.6 7.7 0.9 0.0 69.1 100.0 254 1 59.3 47.5 33.5 0.9 5.4 6.2 0.9 0.3 0.2 11.8 9.0 2.0 0.6 40.7 100.0 473 2 73.2 62.4 38.2 1.3 8.2 7.7 5.6 1.1 0.4 10.8 8.4 1.9 0.4 26.8 100.0 565 3 73.1 61.7 30.6 1.9 9.9 4.6 12.9 1.1 0.8 11.4 8.8 2.3 0.3 26.9 100.0 452 4+ 64.0 49.0 23.1 1.7 8.3 4.2 10.6 0.9 0.1 15.0 10.3 2.8 1.5 36.0 100.0 812 Total 63.5 51.3 28.6 1.3 7.2 5.9 7.1 0.8 0.3 12.2 9.1 2.2 0.7 36.5 100.0 2,556 Fertility Regulation * 57 Contraceptive use varies by women’s level of education. A little more than half of married women with no formal education are currently using a method, compared with 53 percent of women with either incomplete or complete primary school and 59 percent of those with at least some secondary education. Among women in all educational categories, the pill is the most widely used method. The second most popular method among women who have no education is female sterilization, among those with incomplete or complete primary education it is injectables, and among those with at least some secondary education, the condom is the second most widely used method. It is interesting to note that more educated women are more likely to use traditional methods. Contraceptive use rates also vary according to family size (number of living children). As expected, fewer women use contraception before having their first birth. After the first child, contraceptive use increases sharply, peaking at 65 percent among women with three children, after which it declines slightly. Differentials in contraceptive use as reported by currently married men are more or less similar to those reported by women, except that the levels of use are generally higher among men. A more precise way to compare discrepancies in contraceptive use reporting between men and women is to compare husbands and wives (see discussion of Table 4.10 below). Table 4.10 Comparison of reported contraceptive use by spouses Percent distribution of couples according to wife’s and husband’s reported current contraceptive use status, Bangladesh 1999-2000 Wife: current contraceptive method Husband: current contraceptive method Pill IUD Inject- ables Condom Female sterili- zation Male sterili- zation Nor- plant Periodic absti- nence With- drawal Other method Not using Total Pill 24.0 0.2 0.5 0.3 0.2 0.0 0.0 0.5 0.5 0.2 3.3 29.7 IUD 0.0 1.3 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 1.4 Injectables 0.3 0.1 6.3 0.0 0.0 0.0 0.1 0.2 0.0 0.0 0.7 7.7 Condom 0.4 0.1 0.2 3.4 0.0 0.0 0.0 0.2 0.3 0.1 1.0 5.7 Female sterilization 0.0 0.0 0.0 0.0 7.0 0.0 0.0 0.0 0.0 0.0 0.2 7.3 Male sterilization 0.0 0.0 0.0 0.0 0.1 0.5 0.0 0.1 0.0 0.0 0.0 0.7 Norplant 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0 0.0 0.0 0.3 Periodic abstinence 0.7 0.1 0.2 0.4 0.0 0.0 0.0 2.5 1.2 0.3 3.7 9.0 Withdrawal 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 1.4 0.0 0.5 2.2 Other 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.3 0.8 Not using 0.8 0.2 0.4 0.3 0.2 0.0 0.0 1.7 0.8 0.2 30.4 35.0 Total 26.4 1.9 7.6 4.3 7.6 0.5 0.4 5.6 4.3 1.1 40.3 100.0 58 * Fertility Regulation CONTRACEPTIVE USE REPORTING AMONG MARRIED COUPLES As shown earlier, there is a marked discrepancy in reporting of contraceptive prevalence between currently married men (64 percent) and currently married women (54 percent). Part of the discrepancy is assumed to be due to contraceptive use with nonmarital partners, which is presumably higher among men than women. Another explanation could be marriages in which the spouses are not currently cohabiting, thus reducing the need for contraceptive use. Such a situation is likely to be more common among women than men, for example, when men work overseas on a labor contract. However, misreporting and lack of communication between spouses is also a possible explanation. Fortunately, it is possible to link wives and husbands who were both interviewed and compare their individual responses about contraceptive use. Table 4.10 shows the extent of agreement (shown in the diagonal) in reporting of contraceptive use between husbands and wives interviewed in the 1999-2000 BDHS survey. Among the matched couples, 65 percent of husbands report that they are using a family planning method, compared with only 60 percent of wives. The discrepancy is mostly observed in reporting of the use of periodic abstinence, the pill, and condoms. Again, most of the discrepancy for these methods is due to couples in which the husband says they are using these methods while the wife says they are not using any method at all. Whereas at least some of the discrepancies between husbands and wives in reporting of contraceptive use could be due to extramarital use, some may be due to misunderstanding of the method. For example, higher reporting of periodic abstinence use among men than women has been observed in many countries and may be due to confusion between periodic and long-term abstinence. Finally, underreporting of contraceptive use among women because of embarrassment or ignorance (e.g., condom use by husband without her knowledge) is also a possible explanation for the discrepancy. 4.5 NUMBER OF CHILDREN AT FIRST USE The BDHS survey included a question for all women who had ever used a method as to how many living children they had when they first used a method. Table 4.11 shows the distribution of ever-married women in the 1999-2000 BDHS survey by the number of living children they had when they first used a method, according to five-year age group. These data enable the examination of both periodic and cohort changes in the timing of the initiation of contraceptive use during the family-building process. Table 4.11 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at the time of first use of contraception and median number of children at first use, according to current age, Bangladesh 1999-2000 Current age Never used contra- ception Number of living children at time of first use of contraception Total Number Median number of children at first use0 1 2 3 4+ Missing 10-14 60.2 38.7 0.6 0.4 0.0 0.0 0.0 100.0 186 0.0 15-19 39.1 35.7 22.8 2.2 0.1 0.0 0.1 100.0 1,514 0.0 20-24 24.0 25.8 36.4 11.1 2.0 0.5 0.0 100.0 1,935 0.3 25-29 18.1 17.0 34.0 17.5 9.4 3.8 0.1 100.0 1,975 0.7 30-34 17.1 10.4 24.7 19.2 15.5 13.1 0.0 100.0 1,621 1.3 35-39 20.5 7.4 14.8 16.6 15.6 25.0 0.1 100.0 1,335 2.1 40-44 25.1 4.4 11.3 13.7 12.7 32.8 0.0 100.0 1,126 2.6 45-49 37.5 2.8 7.4 7.8 9.6 34.7 0.2 100.0 853 3.3 Total 25.4 17.0 23.8 12.8 8.6 12.3 0.1 100.0 10,544 0.9 Fertility Regulation * 59 Overall, 54 percent of women initiated contraceptive use when they had fewer than three living children, with 17 percent initiating use before having the first child. The results also indicate that Bangladeshis are adopting family planning methods at an earlier age than before. Younger cohorts of women show a tendency to initiate family planning use at lower parities. For example, although less than 22 percent of women age 35 and older initiated family planning use before having two children, the proportion rises with younger cohorts, reaching about 60 percent among women age 15-24. This trend toward initiating family planning use at lower parities can also be seen by comparing data from all three BDHS surveys. For example, whereas in 1993-1994, 39 percent of women reported initiating contraceptive use when they had fewer than three children, the proportion rose to 46 percent in 1996-1997 and to 54 percent in 1999-2000. 4.6 PROBLEMS WITH CURRENT METHOD In the BDHS survey, women currently using modern family planning methods were asked whether they were experiencing any problems using their current method, and if so, what those problems were. Problems in using family planning methods may reduce the effectiveness with which they are used or even lead to termination of use. An understanding of the problems users experience is therefore important in efforts to improve family planning service delivery in Bangladesh. Table 4.12 presents information from the 1999-2000 BDHS survey on the problems reported by women who were currently using modern family planning methods. Table 4.12 Problems with current method of contraception Among women who are currently using a method of family planning, percentage who are having problems with their method, by specific method and type of problem, Bangladesh 1999-2000 Contraceptive method Problem Pill IUD Inject- ables Con- dom Female sterili- zation Nor- plant Total Any problem 24.8 23.5 45.5 5.1 33.8 50.9 28.7 Weight gain 0.8 1.0 1.2 0.1 0.2 0.0 0.7 Weight loss 2.1 1.4 3.0 0.3 6.4 12.8 2.8 Excessive bleeding 1.0 7.8 3.2 0.4 4.0 11.7 2.1 Hypertension 0.3 2.2 1.2 0.0 1.0 0.0 0.6 Headache 14.0 3.1 12.3 0.1 8.3 13.7 11.1 Nausea 5.0 0.7 1.4 0.0 1.0 0.0 3.1 No menstruation 1.8 1.0 28.8 0.2 2.1 23.5 6.4 Weak/tired 12.0 10.9 16.6 2.3 20.7 21.0 13.2 Dizziness 5.1 1.2 5.7 0.8 4.5 10.5 4.7 Husb

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