Egypt - Demographic and Health Survey - 1999

Publication date: 1999

EGYPT DEMOGRAPHIC AND HEALTH SURVEY 1998 Egypt Demographic and Health Survey 1998 EI-Zanaty and Associates Cairo, Egypt Macro International Inc. Calverton, Maryland The 1998 Interim Egypt Demographic and Health Survey (EIDHS-98) is part of the international Demographic and Health Surveys project. Additional information about the EIDHS-98 may be obtained from: EI-Zanaty and Associates, 62 Mossadaq Street, Cairo, Egypt (Telephone: 20-2-349-6936; Telefax: 20-2-336-4120; and E-mail: edhs@idsc.gov.eg). Additional information about the worldwide DHS project may be obtained from: Macro International Inc. , 11785 Beltsville Drive, Calverton, MD 20705 (Telephone: 301-572-0200; Telefax: 301-572-0999; and E-mail: reports@macroint.com). Table of Contents 1 2 3 4 5 6 7 Introduction . 1 1.1 Survey Design and Implementation . 1 1.2 Coverage of the Sample . 3 1.3 Background Characteristics of respondents . 3 Fertility . 7 2.1 Current Fertility . 7 2.2 Trends in Fertility . 8 Family Planning Knowledge and Use . 11 3.1 Knowledge and Ever Use . 11 3.2 Levels and Trends in Current Use . 11 3.3 Differentials in Current Use . 13 3.4 Trends in Current Use by Background Characteristics . 15 Family Planning Services . 17 4.1 Source of Family Planning Methods . 17 4.2 Cost of Family Planning Methods . 19 4.3 Information Received at Pharmacies . 20 4.4 Assessing Services at Clinical Providers . 20 Nonuse of Family Planning and Intention to Use . 23 5.1 Discontinuation Rates . 23 5.2 Trend in Discontinuation Rates . 23 5.3 Future Use of Family Planning . 24 5.4 Reasons for Nonuse of Family Planning . 24 Fertility Preferences and Unmet Need for Family Planning . 27 6.1 Desire for Children . 27 6.2 Unmet Need for Family Planning . 28 Maternal Health . 31 7.1 Care During Pregnancy . 31 7.2 Tetanus Toxoid Vaccinations . , . 33 7.3 Overlap Between Tetanus Toxoid Coverage and Medical Care . 33 7.4 Advice About ANC/FP . 33 7.5 Assistance at Delivery . 34 7.6 Differentials in Maternal Health Indicators . 34 7.7 Trends in Maternal Health Indicators . 36 8 Child Health . 37 8.1 Vaccination Coverage . 37 8.2 Prevalence of Childhood Illnesses . 39 8.3 Treatment of Diarrhea . 40 8.4 Treatment of Respiratory Illnesses . 42 8.5 Infant and Child Mortality . 42 9 Infant Feeding and Child Nutrition . 45 9.1 Breastfeeding and Supplementation . 45 9.2 Nutritional Status of Children . 49 References . 53 Appendix A Appendix B Appendix C ~o~.~'j°~tt.~ttO-t~'~°~.I''°~j-~°~.~°e**~*~e0~eO~i~oe~**0~oo-tjg'~Oo~-~'~00~*0~OB000"Oo0OO6iI''00*~Q55 o°~°~**~o°~°~°~0~00~jO~oj*~*~'~*~0eeoo~~0~'0I~o°~o~*0°i~I'°°°~e~*~9 List of Tables Page 1.1 Sample results . 3 1.2 Background characteristics of respondents . 4 2.1 Current fertility by residence . 7 2.2 Trends in fertility . 8 2.3 Trends in fertility by residence . 9 3. I Family planning Knowledge and ever use . I I 3.2 Trends in current use of family planning methods . 12 3.3 Current use of family planning methods by residence . 14 3.4 Current use of family planning methods by selected demographic and social charactertistics . 15 3.5 Trends in current use of family planning methods by social and demographic characteristics, Egypt 1988-1998 . 16 4.1 Sources for modem family planning methods . 17 4.2 Sources o f lUD by residence, 1995 -1998 . 18 4.3 Cost of the pill . 19 4.4 Cost of the IUD . 19 4.5 Cost of injectables . 19 4.6 User assessment of services at clinical providers by type of source . 21 5.1 Contraceptive discontinuation rates according to specific method . 23 5.2 Intention to use in the future by residence . 24 5.3 Main reason for not using family planning . 24 6.1 Fertility preferences . 27 6.2 Need for family planning services . 28 7.1 Antenatal care . 31 7.2 Other Antenatal Care . 32 7.3 Medical examination and laboratory tests . 32 7.4 Tetanus toxiod coverage . 33 7.5 Antenatal Care, Other Care and Tetanus toxiod Coverage . 33 7.6 Assistance at delivery . 34 7.7 Maternal health indicators by background characteristics . 35 7.8 Trends in maternal health indicators . 36 8.1 Vaccinations by background characteristics . 38 8.2 Trends in vaccination coverage, Egypt 1988-1998 . 39 8.3 Prevalence of childhood illnesses by background characteristics . 40 8.4 Treatment of diarrhea . 41 8.5 Treatment of cough . 42 8.6 Levels and trends in early childhood mortality . 43 8.7 Early childhood mortality by socio-economic characteristics . 44 8.8 Early childhood mortality by demographic characteristics . 44 9. I Timing of intiation of breastfeeding . 46 9.2 Breastfeeding status . 47 9.3 Types of food received by children in the preceding 24 hours . 48 9.4 Median duration and frequency of breastfeeding . 48 9.5 Nutritional status by demographic characteristics . 50 9.6 Nutritional status by socio-economic characteristics . 51 9.7 Trends in nutrition status of children . 52 iii 2.1 2.2 3.1 3.2 3.3 4.1 4.2 4.3 5.1 6.1 6.2 7.1 7.2 8.1 8.2 9.1 List of Figures Page Total fertility rates, Egypt 1975-1998 . 8 Trend in fertility rates by Urban-Rural residence, Egypt 1988-1998 . 9 Current use of family planning, Egypt 1980-1998 . 12 Trend in method mix, Egypt 1980-1998 . 13 Current use by place of residence, Egypt 1998 . 14 Source for family planning methods, Egypt 1998 . 17 Reliance on public sector sources among IUD users, Egypt 1995-1998 . 18 IUD and injectables: median cost in pounds, Egypt 1998 . 20 Contraceptive discontinuation rates, Egypt 1992-1998 . 23 Desire for children, Egypt 1998 . 27 Trends in unmet need for family planning . 29 Information/Advice at time of tetanus toxoid injection, Egypt 1998 . 34 Maternity care indicaotrs for rural areas, Egypt 1998 . 35 Vaccination coverage: children fully imunized, Egypt 1988-1998 . 38 Trends in under 5 mortality . 43 trend in stuniting, 1992-1998 . 51 iv 1 Introduction The 1998 Egypt Interim Demographic and Health Survey (1998 EIDHS) was the second interim survey bemg undertaken in Egypt. The survey was designed to obtain information needed to track progress toward the achievement of the GOE's and USAID's goals in population, health and nutrition. The principal objectives of the 1998 interim Egypt Demographic and Health survey were to: • Collect data at the national level which will allow the calculation of demographic rates, particularly, fertility and infant mortality rates; • Measure the level of contraceptive knowledge and practice of women by method; • Collect quality data on family health: immunizations, prevalence and treatment of diarrhea and other diseases among children under three, prenatal visits, assistance at delivery and breastfeeding. To achieve these objectives, the interviews were conducted in the 1998 EIDHS with a nationally representative survey of ever-married women age 15-49. The 1998 EIDHS was more limited in content than earlier DHS surveys in Egypt, focusing on the collection of information on a number of key family planning and maternal and child nealth indicators. The sample for the survey was similar in size to that selected for the 1997 Interim DHS, including around half the households covered in the 1995 DHS survey. This report presents a summary of findings related to the principal topics in the survey. 1.1 Survey Design and Implementation The ~998 EIDHS was carried out by EI-Zanaty and Associates. Macro International provided technical support for the survey through the measure DHS+ project, which is sponsored by the United States Agency for International Development (USAID) to assist countries worldwide to obtain information on key population and health indicators. USAID/Cairo provided funding for the survey under the Population and Family Planning Ill project. Sample Design and Selection The sample for the 1998 EIDHS was designed to provide estimates of population and health indicators including fertility and mortality rates for the country as a whole and for five major subdivisions (Urban Governorates, urban Lower Egypt, rural Lower Egypt, urban Upper Egypt, and rural Upper Egypt). The Frontier Governorates, which represent less than 2 percent of the total population, were excluded from the survey. A systematic random sample of around 6,000 households was chosen for the 1998 EIDHS. The 1998 EIDHS sample was drawn from 467 primary sampling units (shaikhas and villages) which were originally selected for the 1995 EDHS (EI-Zanaty et al., 1996). Each of the the PSUs selected for the 1995 survey had been divided into parts, with one part selected from smaller PSUs and two parts Selected from larger PSUs. A total of 934 segments were then chosed from the selected parts, and a household listing was prepared within each segment. These household listings were used in selecting the final household samples in both the 1995 DHS and the 1997 Interim Survey in all of the governorates except Assuit and Souhag. In Assuit and Souhag governorates, new segments were i The 1998 EIDHS is the fifth Demographic and Health Survey to be implemented in Egypt; earlier rounds included lull-scale DHS surveys conducted in 1988. 1992 and 1995 as well as an Interim DHS survey conducted in 1997. Other national-level surveys lbr which results are shown in Ihis report include the 1980 Egyptian Fertility Survey (EFS-80), the 1984 Egypt Contraceptive Prevalence Survey (ECPS-84) and the 1991 Egypt Maternal and Child Health Survey (EMCHS-91 ). chosen for the 1997 Interim Survey from the parts that had been selected for the 1995 DHS, and a household listing operation was undertaken in the newly selected segments prior to the final household selection in the two governorates (EI-Zanaty and Associates and Macro International Inc., 1998). In planning for the 1998 EIDHS, it was decided that it would be preferable to obtain new household listings for most PSUs rather than employing the listings from the 1995 survey for a third time. Therefore, in all governorates except Assuit and Souhag, the first stage in the process of drawing the 1998 sample involved the selection of two segments from the segments created at the time of the 1995 survey. This procedure resulted in the selection of new segments in all but 23 PSUs; in the latter PSUs, the number of segments created at the time of the 1995 DHS were not sufficient to allow two new segments to be selected for the t998 survey-'. A household listing operation was carried out in the segments chosen for the 1998 EIDHS in all of the governorates except Assuit and Souhag. Using the listings, a systematic random sample of households was selected within each segment. In Assuit and Souhag, the household lists prepared for the t997 Interim Survey were used in selecting a new independent household sample from these governorates for the 1998 EIDHS. In order to allow for sub-regional estimates, the final number of households selected from each governorate in the 1998 EIDHS is disproportionate to the size of the population in the govemorate. Thus, the 1998 EIDHS sample is not self-weighting at the national level. Questionnaires Two questionnaires were used in the 1998 EIDHS: a household questionnaire and a woman's questionnaire. The household and woman questionnaires were based on the questionnaire used in the EIDHS-97, and on model survey instruments developed in the DHS program. However, because of the interim nature of the survey, the content of the 1998 questionnaires was more limited in scope than in the main EDHS earlier surveys. The questionnaires were developed in English and translated into Arabic. A pretest of the household and woman questionnaires was conducted in September 1998. The household questionnaire was used to enumerate all usual members of and visitors to the selected households and to collect information on the socioeconomic status of the households. The first part of the household questionnaire collected information on the age, sex, marital status, educational attainment and drop out, and relationship to the household head of each household member or visitor. This information was used to identify the women who were eligible for the individual interview. It also provides basic demographic data for Egyptian households. In the second part of the household questionnaire, there were a limited number of questions on housing characteristics (e.g., the number of rooms, the flooring material, etc.) and on ownership of a variety of consumer goods. The individual questionnaire for women obtained information on the following topics: respondent's background characteristics, reproduction, contraceptive knowledge and use, fertility preferences and attitudes about family planning, pregnancy care and infant feeding practices, child 2 In 15 PSUs, a new part was selected. A quick count was carried out in order to divide the new part into the segments and two segments were selected fi-om each of the new pans lor the 1998 survey. In 8 PSUs, however, there were no additional pans available in which new segments could be selected. In 7 of these PSUs, the pan originally selected for the 1995 survey included one segment in addition to the two that had been chosen for the 1995 survey. For these PSUs, thai segment was included in the 1998 sample, and the second segment was randomly selected from the two segments that had been chosen in 1995. Finally, there was one PSU in which were no additional parts or segments were available; accordingly, both segments that had been selected lbr the 1995 survey were used in the 1998 EIDHS. immunization and health, marriage and husband's background, and height and weight of children and mothers. In addition to the monthly calendar that included information on births, contraceptive use, discontinuation, source of method and marriage status of women. The calendar covered a period more than five years. Data Collection and Processing Eight teams collected data for the 1998 EIDHS; each team consisted of four interviewers and a field editor, and the team supervisor. The interviewers and editors were all females, while the supervisors were all males. One team was assigned for Cairo, and one team for Alexandria and Behera. Each of the other teams was assigned to work in three governorates. The field staff was trained during a four-week period in October 1998. The main fieldwork began on November 2 nd' 1998. All interviews, callbacks, and re-interviews were completed by the first week of December1998. Questionnaires were returned to the EIDHS survey office in Cairo for data processing. The office editing staff first checked that questionnaires had been received for all selected households and eligible respondents. In addition, the few questions which had not been pre-coded (e.g., occupation) were coded at this time. The data were then entered and edited using microcomputers and the ISSA (Integrated System for Survey Analysis) software which was developed in the DHS program to facilitate processing of survey data using eight computers. For verification, the data were double entered. Office editing and data processing activities were initiated almost immediately after the beginning of fieldwork and were completed by mid December 1998. 1.2 Coverage o f the Sample Table 1.1 presents information on the results of the household and individual interviews. A total of 6,894 households were selected for the 1998 EIDHS sample. Household interviews were completed for 6,759 households, which represents 99 percent of the sample households. As noted above, an eligible respondent was defined as an ever-married woman age 15-49 who was present in Table 1.1 Sample results Percent distribution of households and eligible women by the result of the interview, and response rates, 1998 Egypt Interim Demographic and Health Survey Urban Lower Egypt Upper Egypt Result of interview Gover- and response rate Urban Rural norates Total Urban Rural Total Urban Rural Total Households (HH) Sampled 3,552 3.342 1,801 2,770 970 1,800 2.323 781 1,542 6,894 Found 3,502 3,325 1,770 2,753 962 1.791 2,304 770 1,534 6,827 Interviewed 3,460 3.299 1,751 2,729 952 1.777 2,279 757 1,522 6.759 FIH response rate 98.8 99.2 98.9 99. I 99.0 99.2 98.9 98.3 99.2 99.0 Eligible women (EW) Identified 2.919 3,535 1,469 2.663 787 1,876 2,322 663 1,659 6,454 Interviewed 2,902 3.504 1,459 2,646 784 1,862 2,301 659 1,642 6,406 EW response rate 99.4 99.1 99.3 99.4 99.6 99.3 99.1 99.4 99.0 99.3 the household on the night before the interview. A total of 6,454 eligible women were identified in the interviewed households in the 1998 EIDHS sample. Of these women, 6,406 were successfully interviewed, with a response rate of 99.3 percent. The response rate does not vary much by region. 1.3 Background Characteristics of Respondents Table 1.2 presents the distribution of ever-married women 15-49 interviewed in the 1998 EIDHS by selected background characteristics. Almost all of the respondents were married at the time of the interview, with 5 percent reporting that they were widowed, and 2 percent that they were divorced. Considering the age distribution, 21 percent of the sample were under age 25, 35 percent were in the 25-34 age group, and 44 percent were over age 35. The age distribution of the 1998 EIDHS reflects the fact that the age at first marriage has been steadily increasing over time in Egypt. The majority of the 1998 EIDHS respondents were from rural Egypt (55 percent), with 30 percent residing in rural areas in Lower Egypt and 25 percent in rural areas in Upper Egypt. Around half of the urban residents--23 percent of the entire sample--were living in one of the four Urban Governorates. Table 1.2 Background characteristic,,; of respondent,,; Percent distribution of ever-married women 15-49 by selected background characteristics. Egypt 1998 Number of women Background Weighted Weighted Unweighted characteristics percent number number Marital status Currently married 93,2 5.971 5,977 Widowed 4.8 306 302 Divol~ed 2 .t) 129 127 Age 15-19 5.2 331 328 20-24 15.6 1,001 99 I 25-29 18.3 1,174 1.182 30-34 16.7 1.068 1,09 I 35-39 16.8 1.078 I .(~9 40-44 13.4 856 838 4549 [ 4,t) 899 907 Urban-rural residence tlrban 45.3 2,901 2,902 Rural 54.7 3.505 3,504 Place of residence Urbal"l Governorates 22.7 1,453 1.459 Lower Egypl 41.6 2,666 2.646 Urban I 1.5 736 784 Rural 30.1 1.930 1,862 Upper Egypt 35.7 2,287 2,30 I Urban I 1.1 712 659 Rural 24.6 1,575 1,642 Educational level No education 42.6 2,731 2,66 I Some primary 16.2 1,041 1.026 Primary completed/Some secondary 12.3 786 799 Secondary completed/Higher 28.9 1,849 1.920 Total 100.0 6,406 6.406 The educational attainment of 1998 EIDHS respondents varied considerably. More than four in ten women in the sample had never attended school, 16 percent had less than a primary education, 12 percent had completed the primary but not secondary level, and 29 percent had completed at least the secondary level. 4 1.4 Content of the Report The remaining sections of this report provide an overview of the main results of the 1998 EIDHS. Wherever possible those findings are compared with the results from earlier surveys in Egypt in order to assess trends in key demographic and health indicators. Appendix A provides the sampling errors from the 1998 EIDHS for these indicators. Appendix B includes an assessment of the • significance of recent trends (since 1995) in a number of these indicators. 2 Fertility Monitoring change in fertility levels and differentials has been one of the primary reasons for conducting a series of demographic surveys in Egypt during the last decade. The fertility data in the 1998 EIDHS were obtained from all respondents through, retrospective reproductive histories. In collecting these histories, each woman was first asked about the number of sons and daughters living with her, the number living elsewhere and the number who had died. She was then asked for a history of all her births, including the child's name, sex, the month and year in which each child was born, if dead, the age at death, and, if alive, the current age and whether the child was living with the mother. The information on the age and/or date of birth of children is used to estimate current levels of fertility in Egypt. 2.1 Current Fertility Measures of current fertility presented in Table 2.1 include the total fertility rate, age-specific fertility rates, the general fertility rate, and the crude birth rate. The rates are shown for the three-year period before the survey (i.e., for the approximate calendar period 1996-1998) according to the mother's place of residence at the time of the interview. Tahle 2.1 Current fertility hv residence Age-specific [E~'tility rates (per 1.000 women) and total erti v and the crude birth rate and the general lerlility rate tot the three years preceding the survey. Egypt 1998 Urban Lower Eg.vpt Upper Egypt Gover- A~e Urban Rural norates Total Urban Rural Total Urban Rural Total 15-19 32 90 35 47 15 51 101 40 110 64 20-24 150 229 137 194 145 205 227 173 230 192 25-29 183 204 178 176 158 179 228 205 230 194 30-34 120 149 112 120 I I 1 122 175 148 190 135 35-39 63 83 65 58 45 63 98 76 108 73 40-44 15 29 17 18 9 23 29 17 37 22 45-49 I I 0 2 t) 3 2 5 0 I TFR 15-4-4 2.8 3.9 2.7 3.1 2.4 3.2 4.3 3.3 4.5 3.4 TFR 15-49 2.8 3.9 2.7 3.1 2.4 3.2 4.3 3.3 4.5 3.4 GFR 93 138 90 107 84 117 148 115 166 117 CBR 23 31 22 25 19 27 33 26 34 27 Note: Rates are lbr the period 1-36 months preceding the survey. Rates lbr the age group 45-49 may be slightly biased due to truncation. TFR -Total fertility rate (births per woman) GFR - General felaility rate (births per 1.000 women 15-44) CB R - Crude birth rate (births per I.~)0 population) The total fertility rate indicates that, if fertility rates were to remain constant at the level prevailing during the period 1996-1998, an Egyptian woman would bear 3.4 children during her lifetime. Rural women are having more children than urban women. At current levels, rural women will have 3.9 births by the end of the childbearing period, one birth more than urban women. A more detailed examination of the age-specific rates presented in Table 2.1 suggests that much of the overall urban-rural differential is the result of significantly higher fertility levels among rural women under age 25 compared to urban women in the same age group. For example, the age-specific fertility rate for rural women 15-19 is almost three times the rate among urban women in the same age group, and the rate for rural women 20-24 is around 50 percent higher than that for urban women in the same age group. Differences in fertility levels in the the 15-24 age group reflect both earlier ages at marriage and lower rates of adoption of contraception in rural compared to urban areas. By place of residence, fertility levels are lowest in the Urban Governorates, followed by Lower Egypt. Upper Egypt, where the average woman is having 4.3 live births, has the highest level. Within Upper Egypt, the urban-rural differential in fertility is fairly large; rural women in Upper Egypt are having an average of 4.5 births, a rate more than one birth higher than the level among urban women in the region. In contrast, the fertility rate for rural Lower Egypt is 3.2 births. Urban women in Lower Egypt are giving birth at less rate than women living in the Urban Governorates. Estimates of the general fertility rate and crude birth rate are also presented in Table 2.1. For the period 1996-1998, the general fertility rate was 117 births per thousand women and the crude birth rate was 27 births per thousand population. There are substantial differences by residence in both the CBR and the GFR. The lowest rates are found in urban Lower Egypt where the CBR is 20 births per thousand populations and the GFR is 84 births per thousand women. In contrast, in rural Upper Egypt where these rates are highest, the CBR was estimated to be 34 births per thousand populations, and the GFR was 166 births per thousand women. 2.2 Trends in Fertility Using data from earlier surveys as well as from the 1998 EIDHS, Figure 2.1 and Table 2.2 show the trend in fertility in Egypt since the late 1970s. Overall, from Figure 2.1 it is clear that fertility levels fell by 2 births during the nearly 20-year period, from 5.3 births at the time of the 1980 Egypt Fertility Survey to 3.4 births at the time of the 1998 EIDHS. Considering the decline in the age-specific rates as Table 2.2 shows, fertility fell at a faster pace among women age 30 and over than among younger women. Figure 2.1 Total Fertility Rates Egypt 1975-1998 $.3 ,Lv DHS DI[ ~ l Y97 1 'Jq ~4 I I )H~ lU l lS Year Table 2.2 Trends in fertility Age-specific t~nility rates (per 1,000 women) and total |ertdity rates, Egypt 1979-1998 EFS-80 ECPS-84 EDHS-88 EMCHS-91 EDHS-92 EDHS-95 EDHS-97 EDHS-98 1979- 1983- 1986- 1990- 1990- 1993- 1995- 1996- A~e 1980' 19841 19882 199P 1992: 19952 1997" 19982 15-19 78 73 72 73 63 61 52 64 20-24 256 205 220 207 208 200 186 192 25-29 280 265 243 235 222 210 189 194 30-34 239 223 182 158 155 140 135 135 35-39 139 151 118 97 89 81 65 73 40-44 53 42 41 41 43 27 18 22 45-49 12 13 6 14 6 7 5 I TFRI5-49 5.3 4.9 4.4 4.1 3.9 3.6 3.3 3.4 Rates are for the 12-month period preceding the survey. -' Rates are for the 36-month period preceding the survey. Note: Rates for the age group 45-49 may be slightly biased due to truncation. Source: EI-Zanaty and Associates and Macro International Inc., 1998. Table 2.2 8 Table 2,3 Trend.s._in fertility by residence Total fertility rates by urban-rural residence and place of residence, Egypt 1986-1998 . . . i . EDHS-88 EMCHS-9t EDHS-92 EDHS-95 EDHS-97 EDHS-98 1986- t 990- 1990- 1993- 1995- 1996- Residence t 988 1991 1992 1995 1997 1998 Urban-rural residence Urban 3.5 3.3 2.9 3.0 2.7 2.8 Rural 5,4 5.6 4.9 4.2 3.7 3.9 Place of residence Urban Governorates 3.0 2.9 2.7 2.8 2.5 2.7 Lower Egypt 4.5 U 3.7 3.2 3.0 3. I Urban 3.8 3.5 2.8 2.7 2.6 2.4 Rural 4.7 4.9 ,4. l 3.5 3.2 3.2 Upper Egypt 5.4 U 5.2 4.7 4.2 4.3 Urban 4.2 3.9 3.6 3.8 3.3 3.3 Rural 6.2 6.7 6.0 5.2 4.6 4.5 TFR 15-49 4.4 4. I 3.9 3.6 3.3 3.4 Rates are lot the 12-month period preceding the survey. z Rates are for the 36-month period preceding the survey. U-Unavailable Note: Rates for the age group 45-49 ,ray be slightly bia~d due to truncation. Source: EI-Zanaty & Associate, and Macro international Inc., 1998, Table 2.2 The trend in fertility by residence is shown in Table 2.3 for the period between the 1988 EDHS and the 1998 EIDHS. Rural fertility declined more rapidly than urban fertility throughout this period (see figure 2.2). As a result, the gap between the rural and urban fertility rates decreased from almost 2 births in the mid-1980s to one birth in the late 1990s. By place of residence, Table 2.3 shows that the decline in fertility during the past decade was greatest in Lower Egypt. In urban areas in that region, there was around a 35 percent decline in the total fertility rate between the 1988 EDHS and the 1998 EIDHS. This was a more rapid decline than that experienced in the Urban Governorates, or in urban Upper Egypt. Fertility also fell at a somewhat faster pace in rural areas in Lower Egypt than in rural Upper Egypt. Among rural women in Lower Egypt, the total fertility rate decreased by 32 Figure 2,.2 Trend in Total Fertility Ra~es lay Udla~Rural Residence Egn~ I~S.1998 $,4 3. - 3,'P 3.5 . t Urban Rura l o . . . . . . q . . . . . . . . percent, from 4.7 births at the time of the 1988 EDHS to 3.2 births at the time of the 1998 EIDHS. In rural Upper Egypt, fertility fell by 27 percent during the period from 6.2 births to the current level of 4.5 births. 9 3 Family Planning Knowledge and Use The 1998 EIDHS collected information on the knowledge and use of family planning. To obtain these data, respondents were first asked about which contraceptive methods they had heard about. All methods named in response to this question were recorded as spontaneously recognized. For methods not mentioned spontaneously, a description of the method was read, and the respondents were asked if they had heard about the method. For each method that they recognized, respondents were asked whether they had ever used the method and if they knew of a place where they could obtain the method. Finally, each currently married woman was asked if she was currently using a method, and, if so, which method was she using and from where did she obtain that method. 3.1 Knowledge and Ever Use Knowledge of family planning methods is crucial in the decision of using a contraceptive method and which method to use. Table 3.1 indicates that knowledge of family planning methods is almost universal among Egyptian women. With regard to knowledge of specific methods, the EIDHS- 98 results indicate that virtually all currently married women have heard about the pill, IUD, and injectables. With respect to the other methods, the results indicate that more than 60 percent know Table 3.1 Family planning knowledge and ever use Percentage of currently married women 15-49 who know a family planning method and who have ever used a family planning method, by method, Egypt 1998 Ever Knowing using Method method method Any method 99.4 72.2 Any modern method 99.4 70.1 Pill 99.2 38.0 IUD 99.2 54.1 Injectables 97.5 I 0. I Norplant 61.1 0.2 Diaphragm, foam or jelly 38.2 1.7 Condom 49.7 5.1 Female sterilization 65.3 1.3 Male sterilization 8.4 Any traditional method 72.1 12.4 Periodic abstinence 30.3 3.1 Withdrawal 22.2 1.8 Prolonged breastt~eding 66.0 8.4 Other methods 2.8 0.4 Number of women 5,971 5,971 3.2 Levels and Trends in Current Use about Norplant, and nearly 65 percent have heard of female sterilization. In contrast, recognition of male methods is less widespread; half of currently married women in EIDHS-98 know about the condom, 22 percent about withdrawal, and less than 10 percent about male sterilization. The 1998 EIDHS findings indicate that 72 percent of currently married women in Egypt have used a family planning method at some time. Table 3.1 indicates that among the currently married women, 70 percent have used a modem method and around 12 percent have used a traditional method. This result confirms that almost all of the women who have ever used a method have used a modern contraceptive. Looking at ever use of specific methods, the IUD and the pill are the most widely adopted methods; 54 percent of married women ever used the 1UD at some time while 38 percent have ever used the pill. Around one in ten married women report ever use of injectables. The most widely used traditional method is prolonged breastfeeding (8 percent). The 1998 EIDHS results show that overall, 52 percent of currently married women were currently using a contraceptive method at the time of the survey, with around 50 percent depending on a modern method (Table 3.2). With regard to the method mix, the IUD is the principal method used by Egyptian couples to control their fertility. At the time of the 1998 EIDHS, 34 percent of married women--nearly two-thirds of all current users---were using an IUD. The pill, used by 9 percent of married women, is the second most popular method followed by injectables (4 percent). II Table 3.2 Trends irt current use of family planning methods Percent distribution of currently married women by the family planning method used. Egypt 1980-1998 currently EFS ECPS EDHS EDHS EDHS EIDHS EIDHS Method 1980 1984 1988 1992 1995 1997 1998 Any method 24.2 30.3 37.8 47. I 47.9 54.5 51.7 Any modern method 22.8 28.7 35.4 44.8 45.5 51.8 49.5 Pill 16.6 I6.5 15.3 [2.9 10.4 10.2 8.7 IUD 4.1 8.4 15.7 27.9 30.0 34.6 34.3 Injectables 0.3 0. I 0.5 2.4 3.9 3.9 Norplant 0.0 0.0 0. l 0.0 Vaginal methods 0.3 0.7 0.4 0.4 0. I 0.2 0. I Condom 1. I 1.3 2.4 2.0 1.4 1.5 1. I Female sterilization 0.7 1.5 1.5 ~. I 1. I 1.4 1.3 Male sterilization 0. I 0.0 0.0 0.0 0.0 0.0 Any traditional method 1.4 1.6 2.4 2.3 2.4 2.7 2.3 Periodic abstinence 0.5 0.6 0.6 0.7 0.8 0.6 0.8 Withdrawal 0.4 0.3 0.5 0.7 0.5 0.4 0.3 Prolonged breastleeding 0.6 1.1 0.9 1.0 1.5 I. I Other methods 0.3 0. l 0.2 0.1 0.1 0.1 0.1 Not using 75.8 69.7 62.2 52.9 52. I 45.5 48.2 Totalpercent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 8.012 9,158 8,221 9,153 13,710 5,157 5,971 Note: A dash (-) indicate~that inlbrmation on the method was not collected or reported. Source: EI-Zanaty & A.~soeiates and Macro International Inc, 1998, Table 3.2 Table 3.2 presents the trend in the use of family planning between 1980 and 1998. The use rate rose quite rapidly during this period. As a result, by 1992, 47 percent of married women were using family planning, almost twice the rate at the time of the 1980 Egypt Fertility Survey (24 percent). The pace of change in use rates then slowed substantially during the period 1992-1995, before accelerating again following the 1995 EDHS. Figure 3.1 shows that much of the growth in use rates in Egypt has been a result of the increased use of the IUD. Overall, the proportion of married women who reported current Figure 3.1 Current Use of Family Planning Egypt 1980-1998 All methods 55 48 47 48 . / / ~-~" / / 38 / /~ / 35 34 24 . /~ 24 Pill ! / - 17 17 16 16 8 15 Injectables 4 1980 1984 1988 13 10 10 9 0 1 2 _. 4_ . . . . . .4 1990/91 1992 1995 1997 1998 use of the IUD rose from 4 percent in 1980 to 34 percent in the late 1990s. In contrast to the continuous increase in IUD, there was a steady decline in the use of the pill throughout the period. Between the 1988 and 1998 DHS surveys, the level of use of the pill decreased by around 40 percent, 12 from 15 percent to 9 percent. The slowing of the growth in the overall level of contraceptive use in Egypt during the first half of 1990s was owed, at least in part, to the decline in the pill use rates. 100 The introduction of the injectable 80 as a program method broadened the choice of family planning methods ~;0 available to Egyptian women and helped in some measure to offset the effects of 4o the decline in use of the pill. Overall, use 20 of injectables rose from less than one percent in 1992 to 4 percent at the time of the 1998 EIDHS. o Figure 3.2 Trend in the Method Mix Egypt 1980-1998 • ~ 5 ~ @~ 7 , ! ~ ,.i i / : ~.i :r7'2 • ,~ -~, • . , . . . . , . I i I i 1980 1984 1988 1992 1995 1997 Trends in the method mix ]llPill OILD O~er 1998 The effects of the rising rates of IUD use and falling rates of pill use on the method mix among family planning users are clearly evident in Figure 3.2. In I980, more than two in three users were relying on the pill to prevent pregnancy .and 17 percent were eml:ioyi~g an IUD. By the late 1990s, the method mix was reversed, with two in three current users relying on an IUD and 17 percent relying on the pill. The trend in the method mix away from the pill and toward the IUD is important since both failure and discontinuation rates are generally lower for IUD users than for pill users. 3.3 Differentials in Current Use Residence Table 3.3 presents differentials in current use by residence. The results show marked differences in the level of current use of family planning methods by residence within Egypt. At the time of the 1998 EIDHS, the level of current use among currently married women was 59 percent in urban areas compared to 46 percent in rural areas. Most of the diffi,~rential in the prevalence level between urban and rural Egypt is the result of significantly greater use ot the IUD among urban women (40 percent) compared to rural women (29 percent). Urban-rural differentials in use rates are much smaller in the case of the observed in the use of the pill (!P percent versus 8 percent, respectively) and injectables (3 percent and 5 percent, respectively). 13 Table 3.3 Current use of family planning methods by residence Percent distribution of currently married women 15-49 by the filmily planning meth(xl currently used, according IO residence, Egypt 1998 Urban Lower Egypt Upper Egypt Gover- Method Urban Rural norates Total Urban Rural Total Urban Rural Total Any method 59.3 45.6 62.1 59.2 62.2 58.1 36.5 50.8 29.9 51.8 Any modern method 56.4 43.8 58.4 57.0 59.7 55.9 34.9 48.8 28.5 49.5 Pill 9.3 8.2 7.4 10.1 I 1.3 9.7 7.9 11.2 6.4 8.7 IUD 40.4 29.3 42.9 39.6 42.3 38.6 22.6 33.2 17.7 34.3 Injeclables 3. I 4.6 3.9 4.6 2.6 5.3 3.2 2. I 3.7 3.9 Norplant 0.0 0.0 0.0 0.0 0.0 0.0 0,0 0.0 0.0 0.0 Vaginal methods 0.2 0. I O. I 0.2 (1.2 0. I O. I 0.4 0.0 O. I Condom 1.7 (1.5 2.2 I. I 1.9 0.8 0.3 0.5 0.2 1. I Female sterilization 1.7 1.0 2,0 1.4 1.4 [.4 (1.8 1.5 0.5 1.3 Male sterilization Any traditional method 3.0 1.8 3.7 2.3 2.5 2.2 1.6 1.9 1.4 2.3 Periodic abstinence 1.5 0.3 1.6 0.8 1.7 0.5 0.3 0.9 0.1 0.8 Withdrawal (I.4 0.1 0.4 0.2 (1.5 0.1 0.3 0.4 0.2 0.3 Prolonged breastleeding 1.0 1.2 1.6 1.2 0.4 1.5 0.8 0.7 0.9 1. I Other methods 0. I 0.2 0.1 0.1 0.0 0.1 0.2 0.0 0.3 0.1 Not using 40.7 54.4 37.9 40.8 37.8 41.9 63.5 49.2 70.1 48.2 Total percent 100.0 1130.0 100,0 100.0 100.0 100.0 100.0 100.0 I00.0 100,0 Number of women 2,700 3.271 1.348 2,503 683 1,820 2.119 668 1.451 5.971 Figure 3.3 highlights differentials in the use rates by place of residence. At the time of the 1998 survey, use rates were considerably higher in the Urban Governorates (62 percent) and Lower Egypt (59 percent) than in Upper Egypt (37 percent). Differentials in use levels between Lower Egypt and Upper Egypt were evident in both urban and rural areas. The use rate in urban Lower Egypt (62 percent) was more than 20 percent than the use rate among women in urban Upper Egypt (51 percent). The differential between rural Lower Egypt and rural Upper Egypt was even greater, 58 percent of currently married women in rural Lower Egypt were using a method at the time of the EIDHS-98 compared to 30 percent of married women in rural Upper Egypt. Figure 3,3 Current Use by Place of Residence Egypt 1998 (;,~h,qpr~l¢~ U¢l~n Kw¢).l Urhn Ru,~l 14 Demographic and Social Characteristics Table 3.4 examines differentials in current use levels at the time of the 1998 survey by other selected social and demographic characteristics. Younger and older women are less likely to be using contraception than women in the age group 25-44. The lowest level of use is observed among women age 15-19 ('20 percent), while the highest level is for women aged: 35-39 (70 percent). Use rates also are related to family size. The prevalence rate is zero among women with no children, suggesting that women in Egypt do not consider adopting contraception before having the first birth. After the first child, contraceptive use increases sharply with the number of living children, peaking at 69 percent among women with 3 children, after which it declines slightly. Current use levels increase directly with the educational level of the woman, increasing from 47 percent among women who never attended school to 58 percent among women who have completed the secondary level or higher. Table 3.4 Current use of family 10annine methods bv selected demnl~raDhiC and social characteristics Percent distribmion of currently married women 15-49 by contraceptive method currently used accordin~ IO selected demographic and social characteris its Egypt 1998 Pro+ Pc[i- Female Any longed odic Number Background Any Any Lnlee- Vagin Nor- Con- sterili- tradi- breast- ahsti- Nol Total of characteristics method modern Pill IUD Tablcs -alx plum dora zation tional feedin~ nence Other usin~ percent women Age 15-/9 19.7 [8.1 2.8 14.7 0.7 00 0.0 00 0.0 [5 1.5 0.0 0.0 803 100,0 324 20-24 390 37.4 52 286 3.1 02 00 0.3 0.0 1.6 1.6 00 0.0 61.0 100,0 984 25-29 51.6 48.8 7.8 370 2,7 0.0 00 0.9 03 29 2.3 0.3 0.3 48.4 i00.0 1,141 30-34 63.9 61.9 11.6 43,9 47 0.0 00 0,7 0,8 20 I.I 0.6 0.3 36.1 100.0 t.015 35-3 t) 69.5 66.4 127 434 6.5 0.1 0,0 1.5 2,2 3.2 09 1,3 I.I 30.5 100.0 1,016 4f1-44 59.1 56.3 117 35,5 53 02 00 20 1.6 28 0.2 20 0.6 409 100.0 759 45=4 t) 34.6 329 48 194 23 05 00 15 4,1 1.7 0.0 1.4 0,3 65.4 100.0 731 Numl)~r M l i~ing children 0 0.0 0.0 0.0 0.0 00 0.0 0,0 00 00 0.0 0,0 0.0 0.0 100.0 100.0 640 I 390 36.2 5.2 29.4 1.0 0,2 00 0.4 01) 2.8 2.0 0 6 0.2 61.0 leO.0 839 2 61.4 58.1 8,2 4<,t .g 2.8 0.1 0.0 1.9 0.4 3.3 1.6 1.4 0,3 38,6 100.0 1.125 3 69.0 65.6 119 46.4 43 0.1 0.0 17 I1 3.4 1.5 I I 07 31.0 100.0 1.138 4+ 579 56.1 112 34.6 65 0.2 00 0,8 2.7 1.8 0.7 0.7 0.4 423 leo.0 2.229 Educa0oo NO educatiun 46,6 451 9.3 28,1 5.5 01 00 03 I. ¢) 1.6 1.2 0.1 0.3 53.4 100.0 2,515 Some primaly 53.1 50.4 8,5 357 4.0 00 0.0 I I I.I 2.6 1,4 0.5 0.7 46.9 100.0 935 Prim.eomWsomesec. 52.7 51,2 9.8 35.7 3.0 0.3 0,0 15 1.0 E5 0.3 I,I 0.0 -47.3 100.0 731 Sec.comp./higher 58.1 54.4 7.6 41.8 20 0.2 0.0 1.9 0.8 3.6 1.3 1.8 0.5 419 100.0 1.789 Total 51,8 49.5 83 34.3 3.9 0.1 0.0 I I 1.3 2.3 I I 0.8 04 48.2 100.0 5.971 3.4 Trends in Current Use by Background Characteristics Table 3.5 presents the trends in contraceptive use during the period between 1988 and 1998 by selected background characteristics of women for all methods and for the pill, IUD, and injectables. Looking at the entire period, use rates increased markedly in all residential groups. However, the absolute change in use rates among rural women, especially those living in Lower Egypt, was greater than the change in the urban areas and in the population as a whole. As a result, the urban-rural differential in use rates narrowed during the decade between 1988 and 1998. 15 Tal)le 3,5 Tren(t~ in eurren! u~ of family planning methods by social and demographic c ha r set ertsli¢:'.~, Egypt 1988-1998 Percentage of currently n~tried women 1549 currently using any mclhod, the pill. IUD and injeclablcs by selccled background characteristics, DHS surveys 1988.19~8 An)" metl~od Pill ItID Iniectahles Background cheraclcristics 1088 1992 1995 ITS)7 1908 1988 1992 1995 1997 ITS)8 1988 1992 1995 1997 1998 1988 1992 1995 194~7 1998 Urban-rural Urban 51.8 57,0 56.4 63.1 5!}.3 18.4 140 110 10.8 9.3 23,0 34.6 36.2 417 40.4 0.1 ()5 2.4 3.0 3.1 Rund 24.5 38.4 4(I.5 47 1 45.6 12.4 I I 0 9 9 9.7 8 2 8.l~ 22.(I 24.6 284 29.3 0.1 ().5 2.5 4.6 4 6 I"1a¢¢ of residence I.IrbaoGovernordles 560 59.[ 58.1 67 62.1 169 12.5 8.4 10.7 74 26.8 368 4()2 441 42.9 0.1 0.3 2.2 3.3 3.9 LowerEgypt 41.2 53.5 55.4 61.6 59.2 19.2 15.1 12,6 12.2 10.1 16.2 32,6 34.7 ,~0.0 39.6 0,1 0.5 2.8 ,13 4.6 Urban 54.5 60.3 59.1 659 62.2 24.2 173 14.3 12.8 11,3 21.2 36.3 34.4 424 42.3 0.0 03 30 3.4 2.6 RurJI 35.6 50.5 53.8 59.9 58.1 17.2 14.1 11.9 11.9 9,7 I-LI 310 348 39.1 38.6 0.1 0.5 2.7 4.7 53 UppcrEgypt 221 314 321 3%4 365 tOO [07 91 75 7.9 79 16.4 t7.7 214 226 01 0.6 2.0 3.7 3.2 Urban 415 481 499 521 5(18 16(1 138 126 8.51 11.2 176 276 303 358 332 02 06 18 18 21 Rural [15 24.3 24() 30.3 29,9 67 9.3 7,5 69 6.4 2.7 116 119 ~4.5 177 00 06 2.1 45 37 Age [5-19 5.5 L3.3 I6A 21.4 19.7 35 4. L 3.2 3,1 28 17 84 11.3 129 147 0.0 0.0 I.I 1.5 ¢)7 20-24 24.3 29.7 33.2 40.3 39.0 10.8 6.8 6.6 50 52 10,7 21.2 21.7 30,7 28.6 0.0 0.2 21 1.7 3.1 25-29 37.1 46,(} 47.6 53.3 51.6 149 13.3 98 9.8 7.8 17.7 29.3 33I 351 37.0 00 0.2 2,2 42 27 30-34 46.8 58.8 58,1 63.9 639 19.2 162 13.3 128 11.6 20.2 367 37.3 42.4 439 0.2 0.5 3.2 3.8 4.7 35-39 52.8 59.6 60.7 68.7 69.5 23.2 18.2 13 8 13.5 I2.7 21 2 34.0 37.2 432 434 OI 0.8 3.2 4 6 65 6.4 5.3 -~0-44 47.5 55,5 588 610 59. I 155 14(I 1_5 12.2 11.7 18.5 289 344 338 35.5 03 I.I 25 45-49 23.4 34.5 33.3 39,4 34,6 86 79 76 78 48 66 149 162 21(I 19,4 0.0 (1.5 t2 2.3 23 Numl~r of li~ing children 0 0.7 0.5 12 0.7 00 O.I 0.3 0.5 03 00 0.4 02 05 0.0 0.0 0.0 00 O0 O0 O0 , , .4 23.3 29.1 29.4 0.0 0.0 0.9 0.8 10 I 23.1 31.6 31.6 38.8 390 7.6 6.7 47 55 5,2 114 ~' 2 43.4 52.5 535) 61.9 61.4 14.7 12 7 8 9 t~6 8.2 205 34.3 38 9 44.7 44.8 0.0 rio t 6 2.0 2.8 3 478 59.3 65.4 67.6 69.0 19.9 171 137 123 119 196 34.8 40.3 44.6 464 (}.l} 0.5 3.8 34 4.3 4+ 444 54.3 53.9 60.2 57.9 17 I 15.8 13,9 13 11.2 I? I 30 306 33,3 34.6 0.2 1.0 3.2 67 6.5 Education Noeducafon 27.5 37.5 4(}.6 45.6 466 134 120 110 97 q3 1(10 20.7 238 260 28.1 0. I 0.5 23 46 55 Sonleprifllary 42.5 535 50.5 5%1 531 203 17.6 122 12,7 85 163 29.4 302 . , I 35.7 0.1 0.5 31 6.1 40 Primary.comp sonlesecond. 52.3 56.1 51.2 58.4 52.7 15.6 13.7 IOI 100 9.8 239 34.(I 32.8 39.8 35.7 0.0 06 2.3 3,6 30 Secondary eonlp./higher 53,2 580 56.5 64.7 58.1 13.8 98 8.3 9.4 7.6 27. t 40.(} 30.(I 47.0 41.8 0.1 04 2(1 1.3 2.0 Total 37.8 47[ 47.9 54.5 51.8 15.3 120 104 10.2 8.7 157 27.9 30.0 34.6 343 0 [ 0.5 24 3.9 39 Considering the age patterns, an examination of the results in Table 3.5 indicates that increases in use rates were fairly uniform across age groups. Within each family size category, use levels also generally increased substantially throughout the period, except among women who had not yet begun childbearing. Among women in the latter group, fewer than 1 percent were using at any time during the period. Much of the change in use rates over the past decade in Egypt was among women with less than a primary education. For example, between 1988 and 1998, use rates increased by 19 percentage points among women who never attended school (from 28 percent to 47 percent). Somewhat smaller increases were observed during the period among better-educated women. As a result, differentials in use rates across educational groups narrowed during the period. 16 4 Family Planning Services The 1998 EIDHS obtained information on a number of aspects of the family planning service delivery including the source from which users had obtained their method, the cost of obtaining services, and the extent of information provided to women obtaining family planning services from pharmacies or clinical sources. 4.1 Sources of Family Planning Methods Detailed information was collected in the 1998 EIDHS on sources from which family planning methods were obtained. Current users of modem methods were asked for the name and location of the source where they had most recently gotten their method. The findings of 1998 EIDHS presented in Table 4.1 and Figure 4,1 indicate that the users are slightly more likely to obtain their Tab.le 4.1 Sources for modern family piannina methods Percent distribution of current users of modern family planning. methods by the most recent source for their method, according to the meth~nl used, Egypt 1998 Injec- AIt Source Pill IUD tables methods Public sector 9.9 55.5 76.0 47.9 Ministry of Health (MOH) 8.9 52.1 73.6 44.9 Urban hospital 0.7 11,0 5,8 8.4 Urban health unit 2.5 23.3 22.2 19.0 Rural hospital 0,8 2.5 3.8 2.2 Rural health unit 3.5 9.1 34.4 10.0 Mobile units 0.8 3.2 5.7 2.9 Other MOH 0.6 3.0 1.7 2.4 Teaching hospital 0.3 1.0 0.0 0.8 HIOtCCO 0.0 1.6 i.4 1.4 Other governmental 0,7 0.8 1.0 0.8 Private sector 90.7 44.5 2 t .5 51.9 NGOfPVO clinics 0.7 6.3 2.5 4.9 EFPA 0.5 2.0 0.5 1.6 CSI 0.0 3.0 2.0 2.3 Other NGO/PVO 0.2 1.3 0.0 1.0 Mosque/church health unit 0.9 4.6 4.6 3.9 Private hospital/clinic 0.0 2.6 1.5 2.0 Private doctor 7.4 31.0 9.6 24.3 Pharmacy 81.0 0.0 3.8 16.8 Other vendor 0.0 0.0 0.0 0.0 Other 0.3 0.0 2.2 0.2 Other 0.0 0.0 0.0 0.0 Friend~relatives 0.3 0.0 2.2 0.2 Don't know 0.0 0.0 0.0 0.1 Total percent 100.0 100.0 100.0 100.0 Number of users 521 2,049 234 2,875 MOH - Ministry of Health HIO - Health Insurance Organization CCO * Canltive Care Organization NGO. Nongovernmental organization PVO - Private voluntary organization EFPA - Egypt Family Planning Association CSI - Clinical Services Impmvemen! pro)eet methods from the private sector facilities (52 percent) than public sector facilities (48 percent). Figure 4.1 Source for Family Planning Methods, Egypt 1998 Private r J~nr l macy 17"/. Table 4.1 shows that the source from which users obtain services varies according to the method used. The majority of pill users obtain their method from pharmacies (81 percent). More than half of IUD users had the method inserted at a public health facility (56 percent), 34 percent at a private doctor or clinic, 6 percent from clinics operated by nongov- ernmental (NGO) or private voluntary (PVO) organizations, and 5 percent at mosque or church clinics. The principal providers of the injectables are the public sector (76 percent), private doctors and hospitals/clinics (11 percent). 17 Table 4.2 takes into account residence in presenting tire distribution of IUD users by source. Tbe table shows that the percentage of users reporting that the IUD was inserted at a public sector source at the time of the 1998 EIDHS varied by type of residence (urban--rural) but not by region. Overall, 61 percent of IUD users obtained the method from public sources in rural areas compared to 51 percent in urban areas• Table 4.2 Sources of IUD by residence, Ewfpt 1995-1998 Percent distribution of IUD users by the type of source [br the method at the time of the EIDHS-98 and the percentage of IUD users obtaining the method from public sector sources at Ihe time of the EDHS-95. EIDHS-97. and EIDHS-98 according to residence. Egypt 1995 - 1998 Urban Lower E~ypt Upper E~ypt Gover- Melhod Urban Rural norates Tolal Urban Rural Total Urban Rural Tolal EIDHS-98 Public sector 50.9 60.9 55.1 55.8 44.7 603 55.7 47.8 62.5 55.5 Private sector 49.1 39.0 44.9 44.3 55.3 39.7 44.3 52.3 37.4 44.5 NGO/PVO clinic 6.0 6.7 6.7 7.0 6.2 7.3 4.6 3.7 5.3 6.3 Private doctor/clinic/hospital 35.6 3[.2 28.8 35.3 44.7 31.4 35.8 41.8 30.7 33.6 Mosque/church clinic 7.5 1. [ 9.4 2.0 4.4 1.0 3.9 6.8 1.4 4.5 Pharmacy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other/Not sure 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total percent 100.0 100.0 100.0 l[g).0 100.0 10l].0 100.0 100.0 1000 10(}.0 Number of IUD users 1,089 960 578 99[ 289 702 479 222 258 2,049 EDHS-95 Public sector 42.8 46.7 46.5 44.4 37.4 47.3 42.1 39.9 44.5 44.5 EIDHS 97 Public sector 47.7 49.9 54.7 47.9 39.3 51.6 42.0 40.4 43.8 48.7 NGO -- Nongovernmental organization PVO - Private voluntary organization The results presented in Table 4.2 also can be used to look at the trend in the percentage of IUD users relying on public sector sources during the period 1995-1998. Overall, as Figure 4.2 indicates, the percentage of IUD users who reported the method was inserted at public sector source increased from 45 percent in 1995 to 56 percent in 1998. Increases in the proportion of users inserted the IUD at public sector providers were observed in all places of residence. During the period, the largest increase in the percentage obtaining the IUD from public sector facilities was observed for rural Upper Egypt. Figure 4.2 Reliance on Public Sector Sources among IUD lasers, Egyl~ 1995-1998 56 49 / 45 1995 1997 1998 18 4.2 Cost o f Fami ly P lann ing Methods Table 4.3 Cost ofthe pill Percent distribution of current users of the pill by the cost of a cycle, Egypt 1998 Cost of c),cle ( in piasters) Free 0.7 1-10 2.9 11-30 0.6 31-50 2.14 51-75 34.0 76-100 35.3 More than 100 21.3 Not sure 3. I Total 1003] Number 521 Median 95.1 Mean 110.7 Table 4.3 looks at the information provided by current users about the amount they paid for the most recent packet (cycle) of pills. The majority of users (69 percent) paid between 51 piasters and one pound for a cycle of pills. The median price paid per cycle was 95 piastres. Table 4.4 shows that there is considerable variabil ity in the cost o f IUD services. Relat ively few IUD users received the method free (7 percent). Around 40 percent of the IUD users paid less than 5 pounds for the method. Most of the users paying less than 5 pounds relied on public sector source (67 percent compared with 8 percent at private health facilities). The median cost o f an IUD was 3.3 pounds at public sources and 20.9 pounds at private sources. A similar pattern is observed in the case of injectable users (Table 4.5). The median amount paid by all injectable users was 3.8 pounds. Among users obtaining the method from public sector sources, the median amount paid was 3.7 pounds, around half the amount paid by users going to private sector providers (7.3 pounds). Table 4.4 Cost ofthe IUD Percent distribution of current users of the IUD by Ihe cost of obtaining the method according to the type of source. Egypt 1998 Public Private Cost of method health health tin pounds) tacilit~' facilit), Total Free 7.7 5.5 6.7 < 3 35.7 4.0 21.3 3-4 31.0 3.8 18.6 5-6 13.7 2.3 8.5 7-8 2.4 1.3 1.9 9-10 3.7 5.5 4.5 11-15 3.3 14.0 8.1 16-20 1.0 15.2 7.4 21-30 0.9 20.6 9.8 31-50 0.4 16.8 7.8 >5[) 0.4 10.8 5,1 Not sure 0.0 0.2 0. I Total 100.0 100.0 100.0 Number 1,121 928 2,049 Median 3.3 20.9 5.5 Mean 4.6 28.7 15.4 Note: Private health facilities include private doctors, clinics or hospitals: NGO/PVO clinics: mosque or church clinics and other private sector providers. Table 4.5 Cost of iniectables Percent distribution of current users of the injectables by the cost of obtaining the method at the beginning of the period of use. Egypt 1998 Cost of method Public Private (in pounds) health health lhcilit~' facility Total Free 5.3 0.0 4.0 < 3 4.6 0.0 3.5 3-4 72.4 29.1 62.2 5-6 7.0 14.7 8.8 7-8 5.7 24.7 10.2 9-10 1.2 9.1 3.1 > 10 2.7 23.2 6.6 Not sure 1.1 3.1 1.6 Total 100.0 100.0 100.0 Number 179.0 55.0 234.0 Median 3.7 7.3 3.8 Mean 3.6 7.5 4.6 Note: Private health facilities include private doctors, clinics or hospitals; NGO/PVO clinics: mosque or church clinics and other private sector providers. 19 Figure 4.3 indicates that on average, IUD users pay more than five times as much at private provides as at public sector sources, and injectable users pay nearly twice as much. 4.3 Information Received at Pharmacies As shown in Table 4.1, the majority of women using the pill (8 in l0 users) reported that the most recent source for the method was a pharmacy. Pill users who cited the pharmacy as the most recent source were asked if they themselves had actually obtained the method at the pharmacy. In addition, current users of the pill who reported a source other than a pharmacy, were asked whether they had obtained the pill themselves from a pharmacy at ~igure 4-~ IUI) and Injeclahl es: Median Cost in Pounds Egypt 1998 20.9 RID lnjectaldes [Irubllc ~,,r m rava~ ~r [ any time during the current episode of use. The results confirm the findings reported in earlier DHS surveys that around only half of all pill users had actually gone themselves to get the method at a pharmacy. Pill users who had actual experience in getting the method themselves from a pharmacy were asked several questions about the information that they had received at the pharmacy (data not shown in table). Overall, relatively few women who had visited a pharmacy to obtain the pill reported receiving any information from the pharmacy staff. If they did receive information, they were most likely to have been shown how to use the pill (17 percent). Less than one in ten women who obtained the pill at a pharmacy reported that the possible side effects from the method had been described to them, and 8 percent said that they had been told about other methods. 4.4 Assessing Services at Clinical Providers The perception of women on the quality of services they received at the clinical providers has an influence on both the level and discontinuation of use. Women who reported that they had gone to a clinical provider to obtain their methods were asked a number of questions to obtain information about their perceptions on the services that they received. These findings should be interpreted cautiously since they are subject to a number of potential sources of bias ~. Table 4.6 presents findings with regard to users' perspectives on the services that they had received. In general, users seem to be satisfied with most aspects of the services that they are receiving from clinical providers; overall, more than 90 percent of current users found their provider to be offering quick service, polite treatment, privacy during consultation, clean surroundings, and an affordable cost. An area of still greater concern regarding the services women are receiving from clinical providers is the information they are given about family planning methods. Around 2 in 5 users who obtained services from a clinical provider reported that the provider did not offer them information on any methods other than the one they adopted. Around one in 2 users reported that they were not given any information about side effects. Mosque and church clinics had the lowest proportion reporting that they had received information about other methods or about the possible side effects of the method that they had adopted. One potential bias comes fl'om difficulties women may have in recalling aspects of the experiences that they had at a provider, particularly if they have been using their method tbr an extended period of time. Respondents also may be unwilling to complain about the services Ihat they had received or to admit that the services had been too costly. The questions also do not capture the experiences of women who may not be using a method because of problems they experienced in obtaining services. 20 Table 4.6 User assessment of services at clinical nroviders bv tvve of ~urce Percentage of current users of modern methods obtaining their methods from a clinical source who said that Ihey had received various components of services at the source by type of source, Egypt 1998. Public sector facility Private Other All NGO/ doclor/ Mosque Gold public public PVO clinic/ clinic/ Service indicator Star facility facilities clinic hospital church Total Quick service 95.4 93.7 93.9 91.2 96.3 77.1 93.7 Polite treatment 100.0 97.8 98.1 99.1 99.7 80.1 97.8 Inlormation about methods 74.2 55.5 58.1 71.4 68.3 49.8 61.9 Inlormation about side effects 64.6 49.5 51.6 58.7 66.4 50.4 57.1 Privacy during consultation 94.5 91.4 91.8 94.4 97.1 78.0 93.1 Clean surroundings 98.7 97.2 97.4 99.2 99.4 8 I. I 97.3 Affordable costs 98.9 98.4 98.4 100.0 94.0 78.3 95.9 Number of users 21)1 1.266 1.468 144 960 146 2,717 NGO- Non governmental organization PVO -- Private voluntary organization 21 5 Nonuse of Family Planning and Intention to Use One of the main goals of Egypt's family planning program is to improve the quality of contraceptive use. The rate at which users discontinue using a method of contraception is one of the major indicators of the quality of use. One of the major objectives of DHS surveys is to provide information on reasons for nonuse and intention to use family planning. Topics relating to these issues: levels and trends of family planning discontinuation, reasons for discontinuation, reasons for nonuse, and intention to use in the future will be presented in the following. 5.1 Discontinuation Rates A key concern for family planning programs is the rate at which users discontinue use of contraception and the reasons for such discontinuation. Table 5.1 presents life table discontinuation rates based on information collected in the calendar in the 1998 EIDHS questionnaire. The rates presented in Table 5.1 are cumulative one-year discontinuation rates and presenttheproportion of users discontinuing by 12 months after the start of use. The reasons are classified in the table into four main categories: method failure, desire to become pregnant, side effects/health concerns and all other reasons. Table 5.1 Contraceptive discontinuation rates according to specific method One-year contraceptive discontinuation rates due to method failure, desire Ibr pregnancy, side eflecls/health reasons, or other reasons. according to specific method, Egypt 1998 Side To effects/ All Contraceptive Melhod Become health other All melhod failure pregnant concerns reasons reasons Pill 6.1 6.7 14.5 I 1.3 38.7 IUD 0.7 3.1 6.4 1.5 11.7 Injeclable 2. I 3.3 32.5 9.4 47.4 All methods 3.1 4.0 9.8 7.2 24.1 The results of Table 5.1 indicate that almost one in four users stops using within 12 months of starting use. Three percent stop using due to method failure, 4 percent because they want to become pregnant, 10 percent as a result of side effects/health concerns, and 7 percent due to other reasons. The one- year discontinuation rates vary by method, with the lowest level observed among IUD users (12 percent), and the highest level among injectable users (47 percent). The rate for the pill (39 percent) is lower than for injectables but considerably higher than for the IUD. Looking at the reasons for discontinuation shown in Table 5.1, side effects/health concerns is the major reason for discontinuation for all methods. Fifteen percent of pill users discontinue during the first year of use because of side effects or health concerns, 6 percent due to method failure, 7 percent as a result of the desire to become pregnant, and II for all other reasons. IUD users are most likely to discontinue during the first 12 months because they experience side effects or health concerns (6 percent) than for other reasons; only I percent reports stopping because of method failure. Side effects/health concerns is the main reason for discontinue using injectables (33 percent). 5.2 Trend in Discontinuation Rates Figure 5. I presents the one-year discontinuation rates for all methods for the period 1992-1998. The rate appears to have declined Figure5.t Contrat~plivediscontinuation rates, Egypt1992-1998 29 30 ~ 1992 1995 1997 1998 23 somewhat in the latter half of the decade from the levels observed in the first part of the decade. This is at least in part due to the change in the method mix toward the IUD. 5.3 Future Use of Family Planning To obtain information about the potential demand for farnily planning services, all currently married women who were not using contraception at the time of the survey were asked about their interest in adopting family planning in the future. Table 5.2 presents the distribution of currently married women who were not using family planning at the time of interview by their intention in the future. Fifty-four percent of nonusers reported that they intend to use in the future, 30 percent within the next 12 months. Differentials by region are existing. Intention to use is higher in Lower and Upper Egypt than in Urban governorates. More than one third of non-users have no intention to use in the future. Table 5.2 Intention to use in the l~ture hy residence Percent distribution ol currenlly married women who are ntn using family planning by intention to use in Ihc ftllure according to residence, Egyp11998 Urban Lower Egypt Upper Egypt Gover- Inlention to use Urban Rural notates Tolal Urban Rural Total Urban Rural Tolal In next 12 months 29.(I 31.4 26.6 36.2 31.8 37.7 27.5 30.5 26.5 30.4 Later 22.4 24.5 22.6 20.8 16.2 22.3 26.3 26.9 26.1 23.6 Unsure as to timing 6.4 6.4 9.6 6.3 4.5 6.9 5.3 2.7 6. I 6.4 Unsure as to inlenbon 2.4 2.9 2.0 1.8 2.9 1.4 3.7 2.5 4. I 2.7 Do not intend to use 39.9 34.8 39.2 35.(I 44.7 31.7 37.2 37.3 37.2 36.8 Total 10t].0 I0().0 10[).0 I(NhO 100.0 100.0 100.0 t00.0 100.0 100.0 Number 1.144 1,812 537 1.055 267 787 1.364 339 1,025 2.956 5.4 Reasons for Nonuse of Family Planning The reasons given by women who do not use family planning are of particular interest to the family planning program in Egypt. Table 5.3 presents the distribution of currently married non-users women who do not intend to use in the future by the main reason for not using. The primary reason for not using is menopausal/hysterectomy; 20 percent of nonusers said they are not using because they are menopausal/ hysterectomy. Desire for more children is the second reason tbr nonuse, where 16 percent of non-users women mentioned this reason. Around 15 percent mentioned that they are subfecund/ infecund as the reason for not using contraception. Fears of side effects or health concerns were mentioned by around 15 percent of Table 5.3 Main reason for not using family planning Percent distribution of currently married women who plan never to use lamily planning by the main reason lot not using according to residence, Egypt 1998. Main reason for not Age intending to ever use a method < 30 30+ Total No sex 2.6 3.9 3.6 Infrequent sex 3.8 7.1 6.3 Menopausal/Hysterectomy 0.0 25.7 19.8 Subtecund / lnt~cund 6.0 18.0 15.3 Wants more children 44.0 8.0 16.4 Respondent opposed 2.6 1.7 1.9 Husband opposed 10.5 1.7 3.7 Religious Prohibition 1.3 0.4 0.6 Knows no method 0.6 0.0 0.1 Knows no source 0.0 0.2 0. I Health concerns 1.5 7.2 5.9 Fear of side eftects 12.8 8.2 9.3 Cost too much 0.0 0.1 0. I Inconvenient Io use 0.0 0. I 0. I Interferes with body's normal process 0. I 0.2 0.2 Other 7.4 16.3 [ 4.2 DK 6.7 1.1 2.4 Total 100.0 I IN).0 100.0 Number 305.0 1,014.0 1,319.0 24 nonusers as the reason for not using. Infrequent sex was mentioned by fewer percentages (6 percent). Foul" percent of nonusers reported husband opposed as the reason for nonuse. Religion was mentioned by less than one percent as the reason for nonuse of family planning. There are significant differences in the answer given by women under age 30 and those who are 30 and over. Nonusers under age 30 were more likely to mention the desire to have more children than older nonusers. 44 percent of non-users under age 30 mentioned that reason compared with only 8 percent among older non-users. More than one in four older women also mentioned being menopausal or having had a hysterectomy as a reason for not using. Husband opposition was mentioned by younger women (11 percent) more than older women (2 percent). 25 6 Fertility Preferences and Unmet Need for Family Planning The EDHS included a number of questions on women's fertility preferences. To gain an insight into childbearing preferences, 1998 EIDHS respondents were asked about whether they wanted to have another child and, if so, how soon. This information can be used to assess the extent to which women who are not using any contraceptive method are in need of family planning to achieve their childbearing goals. However, women's attitudes toward childbearing change over time, and women may not be able to act on their preferences due to social pressures or the desires of other family members, particularly the husband. Data on fertility preferences are important in assessing women's motivation to use family planning. 6.1 Desire for Children Table 6.1 and Figure 6.1 summarize the information on women's reproductive preferences. The majority of all married women express a desire to control future childbearing. Around two-thirds of the women reported that they do not want another child or were sterilized or infecund. Moreover, although they wanted another, 8 percent who say that they want to wait at least two years before the birth of their next child. The desire to delay childbearing is largely concentrated among women who have one or two chddren. As expected, the proportion wanting no more children increases rapidly with the pregnancy). Figure 6.1 Desire for Children, Egypt 1998 number of living children (including the current Table 6.1 Fertility preferen.ces Percent distribution of currently married women by desire for more children according to the number of living children, Egypt 1998 Number of living children plus current pregnancy Desire tbr more chi Idren 0 t 2 3 4 5 6+ Total Have another soon 88.8 55,6 20,0 6.8 3.2 i,8 0.7 20.8 Have another later 0.4 31.5 13,0 2.9 1.0 0,3 0,0 8.0 Wants. unsure timing 0.3 3.1 1.8 1.2 0,6 0,5 0. I !.3 Undecided 0. I 1. I 5,9 2.9 2.8 !,0 0,9 2.5 Wants no more 0.8 5,7 54.8 80.5 84. I 84.1 80,6 59,4 Sterilized 0.0 0,0 0,4 1. I 2.2 2.3 3.4 1.3 Declared infecund 8.2 2.2 3.6 4.t 6.1 10,1 14,2 6.2 Total percent 100.0 100.0 I00.0 100.0 100.O I00,0 I00.0 I00.0 Number of women 430 898 I,t 69 1,181 913 590 789 5,971 27 6.2 Unmet Need for Family Planning Data on fertility preferences can be combined with information on a woman's current contraceptive status to define a woman's need for family planning. Table 6.2 presents estimates of unmet need and met need for family planning and the total demand for family planning. Unmet need for family planning includes nonusers who are in need of family planning for spacing purposes, i.e., pregnant or amenorrheic women whose pregnancy or last birth was mistimed as well as other women who want to delay the next birth for two or more years or who are unsure when or if they want another birth. Unmet need for Jamily planning also includes nonusers who are in need of family planning for lhniting purposes, i.e., pregnant or amenorrheic women whose pregnancy or last birth was not wanted as well as other women who want no more children. Menopausal and infecund women are excluded from the unmet need category, as are pregnant and amenorrheic women who became pregnant while using a method (these women are in need of better contraception). Met need .for family planning includes women who are currently using family planning. The total demands for family planning represents the sum of the unmet and met need as well the proportions of pregnant and amenorrheic women who became pregnant while using a method. Table 6.2 Need for l~mily planning services Percent distribution of currendy maffied women 15-49 by need fi~r lamily planning according to selected backgrl~und characteristics. Egypt 1998 Unmet need Met need (usin~l Demaad Percentage of Background demand Nmnber of Cbaracterisfics Space Limit Total Space Limit Total Space Limit Total safsfied women Al~e 15-19 8.5 2.7 I1.1 20-24 9.3 4.2 13.5 25-29 5.8 6.4 12.2 3{)-34 2.3 10.2 12.5 35-39 1.0 I 1.2 12.2 40-44 0.0 19.9 19.9 45-49 0.2 20.9 2 I. l Urban-rural R~itlen(,e Urban 3.1 9.0 12.] Rural 4.2 12.3 16.5 Place of residence Urban Governorates 3.1 8.1 I 1.2 Lower Egypt 3.1 8.1 l l . I Urban 2.6 7.6 10.2 Rural 3.3 8.2 11.5 Upper Egypt 4.8 15.7 20.6 Urban 3.6 12.4 15.9 Rural 5.4 17.3 22.7 Education No education 3.0 14.5 17.5 Some primary 1.9 [4.5 16.5 Prima~ comp./ some secondary 5.8 8.7 14.5 Secondary comp./higher 4.6 4.5 9.2 Total 3.7 10.8 14.5 17.1 2.5 19.7 25.6 5.2 30.8 63.8 324 26,7 12.2 39 36.1 16.4 52,5 74.3 984 17.5 34.1 5 t.6 23.5 40.5 64 80.9 1,141 8.2 55.7 63.9 10.5 65.9 76.4 83.6 1,015 3.4 66.2 69.5 4.4 77.4 81,7 85.1 1,016 1.2 57.9 59,1 1.2 77.7 78.9 74.8 759 1,5 33.0 34.6 1.7 53.9 55.6 62.1 731 ~2 47.3 59.3 15.1 56,4 71.4 83.1 2,7(X) 10.2 35.4 45.6 14.4 47.7 62.1 73.5 3.271 12.6 49.5 62.1 15.7 57.6 73.3 84.7 1.348 12.1 47.2 59.2 15.2 55.2 70.4 84.2 2.51)3 11.9 50.3 62.2 14.5 57.9 72.4 85.9 683 12.1 46.0 58.1 15.5 54.2 69.7 83.5 1,820 8.7 27.8 36.5 13.5 43.5 57.(I 64.0 2,119 10.8 40.0 50.8 14.4 52.3 66.7 76.1 668 7.7 22.2 29.9 13.1 39.5 52.6 56.9 1,451 5.8 40.8 46.6 8,9 55.3 64,1 72.7 2,515 9.3 43.8 53.1 11.4 58.3 69.7 76.3 935 15 37.7 52.7 20.8 46.4 67.2 78.4 731 17.5 40.5 58.1 22.2 45 67.2 86.3 1,789 11.0 40.8 51,8 14.7 51.6 66.3 78,1 5,971 According to Table 6.2, the total unmet need for family planning is majority of the unmet need is for limiting purposes (11 percent). Similarly, the met need for family planning (contraceptive use) is for limiting purposes. 15 percent. The the majority of 28 Overall, the total demand for family women. Presently, 78 percent of that demand rural than urban women (17 percent and t2 residence, unmet need varies from II percent in Urban governorates to 23 percent in rural Upper Egypt. Unmet need vanes also by educational level, from the highest of 18 percent among women who never attended school to only 9 percent among women with secondary and higher education. Using the results from earlier rounds of the DHS in Egypt in addition to the 1998 EIDHS, Figure 6.2 shows an overall decline in the level of unmet need from 20 percent in 1992 to 15 percent in 1998. in all of the surveys, the majority of women defined as in need of family planning were in need to avoid unwanted births rather than to space wanted births. planning comprises 66 percent of married is being met. Unmet need is greater among percent, respectively). Considering place of Figure 6.2 Trends in Unmet Need for Family Planning 20 1992 1995 1997 1998 29 7 Maternal Health Both mother and child benefit when a woman receives proper maternal health care during pregnancy and childbirth. To obtain data on these issues, women were asked a series of questions for each birth during the five-year period before the survey. These questions seek information on antenatal care, other medical care received during pregnancy, tetanus toxoid vaccination, the assistance received at delivery and whether the delivery was caesarian or normal. 7.1 Care During Pregnancy It is very important to provide mothers with medical care during pregnancy to reduce the risks of pregnancy and ensure the survival for both mother and child. To be more effective, the care should be regular throughout a pregnancy. Therefore, it is recommended that all mothers see a trained provider at least four times during pregnancy. In the 1998 EIDHS, women were asked about whether they had received any antenatal care (care for the pregnancy) prior to delivery and, if so, who had provided the antenatal care and how many times the woman had visited the provider for such care. Both women who had received antenatal care and those who had received no antenatal care were asked an additional question about whether they had seen a medical provider for any reason other than antenatal care during the pregnancy. Women who received antenatal or other medical care were asked about whether certain physical checks (height, weight, and blood pressure) or laboratory investigations (blood and urine samples) were conducted during any of the visits that they had during the pregnancy. Antenata l care Overall, the EIDHS-98 found that antenatal care was received from a trained provider for 47 percent of the births during the five-year period before the survey (Table 7.1). In the case of the majority of these births, women had received the antenatal care from a private doctor or clinic; public sector facilities were consulted in 11 percent of all births compared to 37 percent in which a private doctor or clinic was consulted. Not all of the births in which mothers reported having had antenatal care received regular antenatal care, the mother reported that she had four or more antenatal care visits in only 33 percent of all births. Other med ica l care in addition to the questions on antenatal care, mothers were asked in the 1998 EIDHS about whether they had seen a medical provider at any time during the pregnancy for reasons other than care for the pregnancy. Overall, mothers reported seeing a medical provider for reasons other than care for the pregnancy in the case of 41 percent of all births in the five-year period before the Table 7.1 Antenatal care Percent distribution of births during the five-year period be/ore the survey in which the mother received antenatal care by the type of provider from whom the care was received, and the type of lacility at which the care was given. Egypt 1998 Antenatal care indicators Tyl~ of orovider Doctor 46.7 Trained nurse/midwife 0.5 Other/missing 0. I No care 52.7 Type of facility Public sector 10.6 Private sector 36.9 Both 0.3 Other 0.2 No care 52.7 Number of antenatal care visits None 54.1 1 2.7 2 5.0 3 5.0 4 or more 33.1 Don't know 0.1 Total percent 100.tl Number of births 5,483 survey (Table 7.2). in the case of 76 percent of the births in which mother reported receiving such care, the care was provided at public sector facilities (not shown in table). Both public and private sector providers were seen in the case of 3 percent of the births, and private doctors or clinics were consulted in 21 percent of births. 31 Table 7.2 combines the information from the 1998 EIDHS on other medical care along with that on antenatal care. The results indicate that women reported that they had seen a medical provider at some point during pregnancy in the case of 70 percent of all births during the five-year period before the survey. Mothers reported receiving antenatal care and other medical care in the case of 18 percent of all births, while mothers had seen a medical provider only for antenatal checkups in the case of 29 percent of all births. Finally, mothers said that they had no antenatal checkups but had Table 7.2 Other Antenatal Care Antenatal and Other Medical Care during Pregnancy. Percent distribution of births during the five-year period before the survey by whether the mother had received antenatal care and other medical care from health professionals during the pregnancy, Egypt 1998. Antenatal Other care care Had care No care Total Had care 18.3 28.9 47.2 No care 22.8 30.0 52.8 Total 41.1 58.9 100.0 seen a medical provider for some type of other care in the case of an additional 23 percent of the births. Medical examinations and laboratory tests Women who had seen a medical provider during pregnancy for antenatal or other care were asked about whether, at any point, their height, weight or blood pressure had been checked and urine or blood samples taken. Table 7.3 shows that three in four mothers had had at least one of the examinations or tests during pregnancy. They were more likely to have had their blood pressure (60 percent) and weight (54 percent) measured than to have their height taken (22 percent). Forty-five and forty-one percent had had given a blood or urine sample, respectively. Women who reported that they had antenatal care were much more likely than women who did not report getting antenatal checkups to say that they had the various examinations or tests about which questions were asked in the 1998 EIDHS. Overall, 86 percent of women who had both antenatal and other care and 83 percent of the women saying that they had had only antenatal checkups during the pregnancy had had at least one of the tests or examinations compared to only 50 percent of the women had seen a provider during the pregnancy but did not have an antenatal checkup. .Table 7.3 Medical Examinations and Laboratory Tests Percentage of births during the five-year period before the survey in which the mother reported having had various medical examinations or laboratory tests during the pregnancy by the type of care received from health professionals during the pregnancy, Egypt 1998. Blood Urine Blood Any No Antenatal/other care Weight Height pressure sample sample check/test check/test Both antenatal and other care 71.7 28.0 71.0 60.2 54.2 86.2 13.8 Antenatal care only 56.4 20.8 72.2 51.8 47.6 83.0 17.0 Other care only 36.7 18.6 34.2 23.3 22.6 49.8 50.2 Total 54.0 21.9 59.5 44.7 41.2 73.1 26.9 32 7.2 Tetanus Toxoid Vaccinations Tetanus toxoid injections are given during pregnancy in order to prevent neonatal tetztnus, a frequent cause of infant deaths where sterile procedures are not observed in cutting the umbilical cord following delivery. The 1998 EIDHS obtained information on whether women received tetanus toxoid vaccinations during pregnancy for each birth in the five-year before the survey and, if so, the number of injections. Table 7.4 shows that mothers had received at least one tetanus toxoid injection during pregnancy in the case of 71 percent of births during the five-year period before the survey. Public sector facilities are responsible for providing the majority of tetanus toxoid injections. Overall, 64 percent of women received a tetanus toxoid vaccination at public, sector facilities. Table 7.4 Tetanus toxiod coveraee Percent distribution of births during the five- year period betbre the survey by the number of tetanus toxiod injections received, Egypt 1998 Tetanustoxoid coverage Number of tetanus toxoid injections None 29.4 One dose 30.6 Two doses 39.5 Not sure/missing 0.5 Type of fadlity Public sector 64.3 Private sector 5.3 Other 1,1 No injections 39,5 Total percent 100.0 Number of births 5,483 7.3 Overlap Between Tetanus Toxoid Coverage and Medical Care Many women who received tetanus toxoid vaccinations during pregnancy did not report seeing a doctor for antenatal care or other medical care. In some cases, women who had had antenatal or other care receive tetanus toxoid injections. Table 7.5 shows the overlap between medical care and tetanus coverage. Overall, the majority of mothers who reported seeing a provider for medical care (either antenatal checkups or other care) reported receiving tetanus toxoid vaccinations. Among women who said that they had not consulted a provider for medical care at all during the pregnancy, 44 percent said that they had had a tetanus toxoid injection. Table 7.5 Antenatal Care. Other Care and Tetanus Toxoid Coveraee Percent distribution of births during the five-year period before the survey by whether the mother had received antenatal care or other medical care from health professionals during the pregnancy by whether she had had a tetanus toxoid injection, Egypt 1998. Antenatal/other care Tetanus toxoid injection Total Yes No Both antenatal and other care 88.3 11.0 100.0 Antenatal care only 70.2 29.2 100.0 Other care only 91.2 8.8 100.0 No care 44.4 54.3 100.0 Total 70.6 28.7 100.0 7.4 Advice About ANC/FP In order to increase the proportion of Egyptian women receiving antenatal care, the Ministry of Health and population has instituted a program in which pregnant women who come to public sector facilities for tetanus toxoid vaccinations will be advised about the importance of antenatal care and given information about family planning. To provide a baseline figure for use in monitoring this program, mothers who received tetanus toxoid injections were asked whether they had been advised that they should go for antenatal care. 33 They were also asked if someone had talked to them about family planning when they obtained tbeir tetanus injection. The results presented in Figure 7,1 show that the majority of women who went for tetanus toxoid vaccinations at public sector facilities did not receive advice about the need for antenatal care or family planning use (data not shown in table). Among those women who are given advice, they are more likely to receive recommendations about the need for antenatal care ( 16 percent) than information about family planning (9 Figure 7.1 lnformathm/Advice at "lime or Tetanus Toxiod Injection, ,Egypt 1998 16 . . . . 2 i Antenata l care Fami ly planning percent). It worth mentioning that the percentage of women who received advice about antenatal care and family planning is very low and also is declining over time. Generally, women do not receive advice about other reproductive health services at the time they receive a tetanus toxoid injection. 7.5 Assistance at Delivery Table 7.6 Assistance at delivery Percent disuibution of births during the five-year period before the survey by the lype of provider assisting at delivery and the place where the mother delivered. Egypl 1998 Delivery ass i s tance Tvne of orovider Doctor 46.8 Trained nurse/midwile 8.4 Traditional birth attendant 41.9 Relative/other 1.8 No assistance 1. I Don't know/missing Tvoe of facility Public sector 19.6 Private sector 20. I At home 60.2 Other DK/missing Total percent 100.0 Number of birlhs 5,483 In addition to the questions of antenatal care and tetanus toxoid vaccinations, the EIDHS- 98 collected information on two other important aspects of maternity care: the place of delivery and the person(s) assisted in delivery• Table 7.6 presents information on these indicators for births during tbe five-year period before the survey, Of all births in the five-year period before the 1998 EIDHS, the majority of deliveries took place at home. Among the deliveries in facilities, roughly half occurred in public sector facilities and half in private sector• A doctor or trained nurse/midwife assisted at the delivery of 55 percent of cases. Most of the remaining births were assisted by dayas (traditional birth attendant). Women who delivered with the assistance of doctors were also asked whether the birth was a caesarian or normal delivery. Fifteen percent of physician assisted deliveries were reported as caesarian births. Women assisted by physicians or nurse - midwifes were asked about instruments used in the delivery. These mothers reported a total of 15 percent of births in which instruments were used in the delivery (10 percent forceps and 5 percent ventouse ). 7.6 Differentials in Maternal Health Indicators Table 7.7 examines variations in maternity care indicators according to selected socio- economic and demographic background characteristics. Considering age patterns, women with age delivery from a trained medical provider and to deliver in a medical facility. Tetanus toxoid vaccination coverage is, however, more common among younger than older women. 34 There is a negative association between the birth order of the child and the maternal health indicators. For example, the proportion receiving regular antenatal care decreases from 46 percent among first births to women to 16 percent among births of order six or higher. Table 7.7 Maternal health indicators bv background characteristics Percentage of births in the five-year period whose mothers received any antenatal care and regular antenatal care from a trained medical provider and at least one tetanus toxoid vaccination and whose mothers were assisted at delivery by a medical provider and defivered in a medical facility, Egypt 1998 Any Regular Tetanus Assisted by Delivery Background antenatal Antenalai toxoid trained medical In medical Characteristic care Care in)ections provider facility Aee under 20 43.4 26.4 77.9 47.6 31.4 20-34 48.6 34.7 70.3 56.9 41.4 35-49 42.3 30.4 56.9 53.2 39.4 Birth order I 60.9 45.6 82.4 69.4 52.8 2-3 48,6 34.5 72.1 56.6 40.7 4-5 39.0 25.2 60.7 42.7 29.0 6 or more 29.3 16. I 54.3 4 [ .4 27.3 Urban-rural residence Urban 61.0 49.9 67. I 71.6 61.8 Rural 38.5 22.3 71.9 44.8 25.7 Place of residence Urban Governorates 59. I 51.2 62.9 70.6 65. I Lower Egypt 48.8 34.6 76.1 62.3 41.6 Urban 65.8 54,4 74.4 80.7 68,4 Rural 43.7 28.6 76.6 56.8 33.5 Upper Egypt 40.5 23.6 67.6 41.8 26.8 Urban 60.3 44.0 68.2 65.8 51.0 Rural 33.4 16.3 67.4 33,2 18.2 Education No education 29.4 16.0 64.6 36.3 23,2 Some primary 42.7 27.8 70.9 51.3 33.6 Primary comp./ Some secondary 52.7 35.8 72.8 60.7 45.3 Completed secondary/Higher 72.2 58.4 76.2 81.2 63.5 Total 47.2 33.1 70.1 55.2 39.7 Note: A woman is considered to have had regular antenatal care if she had 4 or more visits lor care durin~ the pregnancy,, Urban-rural residence and region are strongly associated with both antenatal care and assistance. Rural women, especially those living in Upper Egypt are less likely than urban women to receive care during pregnancy or assistance at delivery from trained medical providers. Figure 7.2 shows that both regular antenatal care and medical assistance a! delivery are more common among women living in rural areas in Lower Egypt than in Upper Egypt. With regard to tetanus Figure 7.2 Maternity Care Indicators thr Rurad Areas Egypt 1998 57 29 Ik Regular antenatal care ct Lowe r ~z~ypt Trained medical assisLqnoeat I I Upl~r E~pt [ 35 toxoid vaccinations, however the differential between rural Lower Egypt and Rural Upper Egypt is much less marked. 7.7 Trends in Maternal Health Indicators Table 7.8 looks at the trends in key maternal health indicators during the period 1988-1998. The table suggests that there has been a very sharp increase in the proportions of women who receive tetanus toxoid injections during pregnancy. Improvements in other maternal health indicators were more gradual but steady during the period. Table 7.8 Trends in maternal health indicators For births during the five-year period belbm the survey, the percentage whose mothers had at least one tetanus Ioxoid injection, antenalal care ti'om a doctor or trained nude-midwife, and tbur or more antenatal care visits and the percentage whose mothers assisted at delivery by a trained medical provider and delivered in a medical facilily, Egypt 1988-1998 1988 1990/I 1992 1995 1997 1998 Maternal health indicator DHS EMCHS EDHS EDHS EIDHS EIDHS Antenalal care Any 52.8 52.1 52.9 39.1 52.0 47.2 Regular U U 22.5 28.3 31.8 33.I Tetanus toxoid injection I 1.4 42.5 57.3 69.5 72.1 70.1 Medical assistance at delivery 34.6 36.5 40.7 46.3 56.4 55.2 Delivered in medical fiteility 22.9 U 27. I 32.5 39.7 39.7 U=unknown (not available) The proportion of births in which the mother had regular antenatal care increased from 23 to 33 percent between 1992 and 1998. The decline in the total proportion of births in which the mother received any antenatal care is not a genuine trend but the result of changes in study procedures between the 1992 and 1995 surveys. The proportion of births attended by a doctor or trained nurse/midwife increased from 35 percent in 1988 to 55 percent in 1998. 36 8 Child Health The 1998 EIDHS obtained information on a number of key child health indicators, including immunization of young children, childhood illnesses and treatment, breastfeeding nutrition status of children (based on height and weight measurements of children under age five), and infant and child mortality. The information included here can be used in efforts to plan and monitor the outcome of maternal and child health programs. 8.1 Vacc inat ion Coverage In the 1998 EIDHS, information on childhood immunizations was collected for all children born during the five-year period before the survey. In Egypt, immunizations are recorded on a child's birth record (certificate) or on a special health card'• For each child, mothers were asked whether they had the birth record or health card for the child and, if so, to show the document to the interviewer. When the mother was able to show the birth record or health card, the dates of vaccinations were copied from the document to the questionnaire• If a birth record or health card was not available (or a vaccination was not recorded), mothers were asked questions to determine whether the child had received each vaccine. The estimates of immunization coverage among children 12-23 months in Table 8.1 are based on the information taken from the birth record or health card, or for those whom no document was seen (or a vaccination not recorded), information provided by the mother on the child's immunization status• Mothers were able to provide birth records for 65 percent of the children. The World Health Organization guidelines for childhood immunizations call for all children to receive: a BCG vaccination against tuberculosis, three doses of the DPT vaccine to prevent diphtheria, pertussis and tetanus; three doses of polio vaccine; and a measles vaccination. Egypt has added the hepatitis vaccine to its child immunization program. However, although it is shown in the table, hepatitis immunizations are not taken into account in calculating the proportion of children who are considered to be fully immunized. Thus, a child is considered to have had the full schedule of immunizations if they have received a BCG and measles vaccination and three doses of the DPT and polio vaccines. Levels and Dif ferent ials in Vaccination Coverage Table 8.1 shows that, among Egyptian children 12-23 months, 84 percent are regarded as fully immunized. Less than one percent had received no vaccinations (exactly 0.3 percent). Looking at coverage levels for individual vaccines, the proportion of children who have received the BCG vaccination was 98 percent, while 87 percent had received three doses of DPT and 90 percent three doses of the polio vaccine. Ninety-three percent had also received the measles vaccine. Although hepatitis vaccine coverage is somewhat lower than the levels for the other vaccines, 81 percent of children had received three doses of the hepatitis vaccine• Considering differentials in immunization coverage, there are very minor differences in the levels of immunization between boys and girls. By residence, however, there are clear differences. Urban children are more likely to be immunized than rural children are (93 percent vs. 80 percent, respectively). Looking at place of residence, the percentage considered to be fully immunized was lowest in rural Upper Egypt, where 2 in l0 children Dunng earher rounds of he DHS n Egypt, vaccination data usually were obtained only from the birth record. A new health card was introduced during the 1996. Theretore, the 1997 EIDHS, and the 1998 EIDHS questionnaires were modified so that intbrmation from either document could be easily recorded, 37 had not received all recommended vaccinations. As expected, the percentage of children that have received all vaccines increases with education of mother. Table 8.1 Vaccinations bv back2round characteristics Among children 12-23 months, the percentage who had vaccination records seen by the interviewer and the percentage who had received each vaccine (according to the vaccination record or the mother's report) by selected background characteristics, Egypt 1998. DPT Polio Hepatitis Fully Number Background Record Mea- immun- Of Characteristics seen BCG I 2 3 I 2 3 I 2 3 sles ized None chilth~en Sex Male 65.9 98.4 98.1 96.3 87.2 99.3 97.4 89.0 95.0 90.5 81.0 94.8 85.5 0.5 448 Female 63.3 97.9 98.6 96.6 88.0 99.8 97.8 90.3 92.9 89.9 81.8 91.1 83.0 0.0 389 Urban-rural Urban 62.1 99.9 99.6 98.9 96.0 100.0 99.0 96.8 95.9 94.0 90.1 95.9 93.1 0.0 299 Rural 66,1 97.2 97.6 95.0 82.8 99.2 96.8 85.6 93.0 88.1 76.5 91.5 79.5 0.4 538 Place of residence UrbanGovernorates 61.7 100.0 100.0 100.0 100.0 100.0 I00.0 99.9 99.0 97.9 97.8 97.3 97.3 0.0 139 Lower Egypt 66.0 98.9 98.9 96.3 86.2 99.6 97.3 88.2 94.8 89.9 79.6 93.3 82.4 0.4 343 Urban 64.9 100.0 98.5 95.8 89.9 100.0 96.2 92.0 94.1 90.5 82.3 94.2 86.7 0.0 72 Rural 66.3 98.6 99.0 96.5 85.2 99,5 97.6 87.2 94.9 89.8 87.9 93.0 81.3 0.5 271 UpperEgypt 64.5 96.7 97.2 95.1 84.0 99.2 96.9 86.9 91.4 87.4 76.6 91.3 81.2 0.3 355 Urban 60.5 99.6 100.0 99.6 94.8 I00.0 99.6 96.0 92.5 90.8 84.2 95.1 91.7 0.0 88 Rural 65.8 95.7 96.2 93.6 80.4 98.9 96.0 84.0 91.0 86.3 74.1 90,0 77.7 0.4 267 Education No education 71.3 96.2 97.2 95.4 85.0 99.4 97.2 88.3 91.5 86.8 77.9 91.7 80.7 0.3 316 Some primary 64.5 98.6 97.4 93.2 80.0 99.3 95.8 86.3 94.2 87.1 75.0 86.8 76.5 0.0 123 Primary comp./ somc~econdary 63.8 98.5 98.6 96.2 88.6 98.8 97.1 88.0 92.3 89.8 83.9 93.8 84.6 1.2 113 Secondary comp./higher 57.7 100.0 100.0 99.0 93.2 100.0 99.0 93.1 97.4 95.5 86.9 97.1 91.6 0.0 285 Total 64.7 98, I 98.4 96.4 87.5 99.5 97.6 89.6 94.0 90.2 81.4 93.1 84.3 0.3 837 Note: Children are fully immunized if they have received BCG, measles, and three doses of DPT and polio vaccines. Trends in Vaccinat ion Coverage Figure 8.1 and Table 8.2 show vaccination coverage rates in Egypt during the period 1988- 1998. The percentage of children 12-23 months who were fully immunized increased steadily during the period, from 54 percent in 1988 to 84 percent in 1998. The table also documents the rapid expansion in hepatitis coverage rates after the inclusion of the vaccine in the country's immunization program. Figure 8.1 Vaccination Co~rage: Claildt'en Fully Immunized Egypt 198S-1998 83 79 [ I . ({s ? : ! i{ ! ) s.a.4 t988 1992 1995 1997 1998 38 Table 8.2 Trends in vaccination coveraae, E2vot 1988-1997 Among children 12-23 months, the percentage who had received specific vaccinations and the percentage t~tlly immunized, Egypt 1988-1998 Specific vaccinations 1988 1992 1995 1997 1998 BCG 70 90 95 96 98 DPT 3 66 76 83 90 88 Polio 3 66 79 84 91 90 Measles 76 82 89 89 93 Hepatitis NA NA 57 77 81 Full)' immunized 54 67 79 83 84 Note: Children are tully immunized if they have received BCG. measles, and three doses of DPT and polio vaccines. Source: EI-Zanaty Associates and Macro International Inc., 1998, Table 8.2. 8.2 Prevalence of Childhood Illnesses Two main illnesses, as well as their treatment, are discussed in this section due to their importance for infant and child survival. They are acute respiratory infection and diarrhea. In the 1998 EIDHS, mothers of children under age five were asked if their children had had diarrhea during the two-week period before the survey. If the child had had diarrhea, the mother was asked about what she had done to treat the diarrhea. Mothers were also asked about the presence of fever and of the symptoms of acute respiratory infection (cough with short, rapid breathing) among children during the two-week period before the survey. If the child had symptoms of respiratory illness, the mother was asked about the actions taken to treat the illnesses. Since the prevalence of diarrhea and acute respiratory illnesses varies seasonally, the results pertain only to the pattern during the period November 1998 when the EIDHS interviewing took place. In assessing the information on the prevalence of these illnesses, it should be remembered that the mother's assessment is subjective. Table 8.3 presents information on the prevalence of childhood illnesses among young children. Overall, 11 percent of children under age five were reported to have had diarrhea in the two-week period before the survey, and around 1 percent was reported as having bloody stools. As expected, diarrhea is more prevalent among children age under 24 months. This pattern is believed to be associated with increased exposure to the illness as a result of both weaning and the greater mobility of the child as well as to the immature immune system of children in this age group. 39 Table 8.3 Prevalence of childhood illnesses by background characteristics Percentage of children under age live reported as having diarrhea, diarrhea with bloody stools, lever or a cough with short, rapid breathing during the two-week period before the survey, Egypt 1998 Diarrhea Cough with Number Background All with blood short, rapid of characteristic diarrhea in stools Fever breathing children Child's age < 6 months [ 6.6 0.5 25.4 I 1.0 512 6-11 months 23.6 1.7 34.0 17.4 529 12-23 months 16.1 0.8 32.9 14.5 979 24-35 months 8.0 0.6 24.4 I 1.4 1,072 36-47 months 5.2 0.4 22.4 I 1.2 1,146 48-59 months 4.7 0.8 [ 8.7 9.5 975(I Sex Male I 1.5 0.7 26.3 12.9 2.686 Female 9.9 0.7 24.8 I 1.3 2,526 Urban-rural residence Urban 9. I 0.4 24. I 12. I 2,057 Rural 11.8 0.9 26.5 12.2 3,I55 Place of residence Urban Governorates 8.6 0.5 19.2 I I. I 99 I Lower Egypt 13.6 1.0 32.5 13.3 2,052 Urban 10.7 0.5 32.0 12.6 482 Rural 14.4 1.2 32.7 13.5 [,570 Upper Egypt 9.0 0.6 21,8 I 1.6 2,169 Urban 8.5 0.3 25.8 13.3 585 Rural 9.2 0.7 20,4 10.9 1,584 Education No education 9.0 0.7 22,6 11.6 2,172 Some primary 12.6 I. 1 26,3 13.5 734 Primary comp./Some secondary 12.5 1.0 26.8 12.4 720 Secondary comp./Higher I 1.4 0.5 28.8 12.2 1,586 Total 10.7 0.7 25.6 12.2 5,212 Table 8.3 also shows the prevalence of fever and of symptoms of acute respiratory infection (ARI) among young children. More than 26 percent of children were reported to have had a fever during the two-week period before the survey, and 12 percent had had a cough with short, rapid breathing. Differentials in the prevalence of these illnesses are generally small. The peak prevalence for both illnesses is found among children 6-11 months old. 8.3 Treatment of Diarrhea The 1998 EIDHS included questions with regard to the actions mothers took to treat children who had had diarrhea. Table 8.4 presents the findings from these questions. The table shows that mothers sought advice from a medical provider in 44 percent of the cases. Among mothers reporting that medical advice was sought, the majority said that ~. private doctor was consulted, where 27 percent went to private facility to treat the diarrhea and 18 percent went to public facility. 40 'Fable 8.4 Treatment of diarrhea Percentage of chddren under age five ill with dialrhea during the two-week period before the survey who received various treatments by seie¢led background characteristics. Egypt 1998 Taken to health facility Oral rehydmtion therapy Either Number Background ORS ORS/ Increased Anti- Injee- Of chaeactcristics Any Public Private packets RHS RHS fluids biotics tion Other None children ~ex Male 42.3 17.8 24.5 29.9 11.7 36.5 21.4 28.3 9.3 40.8 3.2 308 Female 46.4 17.8 29.2 34.7 I I . I 41.8 23.5 27.7 It.0 35,6 3.5 251 Urban-rural Llrban 45.3 19.7 25.5 27.1 9.9 32.8 23.2 29.6 4.9 38.9 4.0 187 Rural 43.6 16.8 27.1 34.5 L2.2 42.0 21.9 27.2 12.6 38.2 3.0 372 Place or residence U]'ban Go~. 45.9 24.1 21.8 28.4 12.6 32.3 31.8 32. I 8.9 42,7 1.7 86 Lower Egypt 44.9 13.5 31.9 29.8 12.5 39.3 28.8 31.5 11.3 38.0 3.8 278 Urban 43.8 17.1 26.7 20.6 12.() 31.4 22.5 36.8 2.2 30.2 2.5 51 Rural 45.2 12.6 33.1 31.9 12.6 41.0 30.2 30.3 13.4 39,7 4.1 227 Upper Egypt 42.3 21.2 21,1 36.8 9,4 41.3 9.0 21.2 8.7 37,2 3.5 195 Urban 45.7 15.0 30.8 31.8 3.[ 34.9 9.0 17.9 0.7 41,5 9.4 50 Rural 41.1 23.3 17.7 38,5 11.5 43.4 9.0 22.3 11.4 35.8 1.5 145 Education No education 42.1 19.6 23.1 34.7 8.4 38.7 17.5 22.9 7.6 33.3 2.0 195 Some primary 52,7 23.4 29.3 42.9 14.3 48.0 22.4 28.2 15.6 40,5 1.1 93 Primary completed/ Some secondary 46.5 19.2 27.3 25.3 9.6 33.4 17.8 32,5 9.0 31,3 6.3 90 Secondary comp./Higher 4(I.8 12.3 28.5 26.9 14.1 37.2 29.8 31.1 10.2 46,5 4.5 181 Total 44.1 17.8 26.6 32.0 11.4 38.9 22.3 28.0 10.0 38,4 3.4 559 Note: Oral rehydration therapy (ORT) includes solutions prepared from ORS packets and recommended home solution (RHS). e@. su~zar-salt soluticms. Increased fluids includes increased frequency of breastfeedin~z. The administration of oral rehydration therapy (ORT) is a simple means of countering the effects of dehydration accompanying diarrhea. During ORT, the child is given a solution either prepared by mixing water with the salts in a commercially prepared rehydration packet (ORS) or by making a homemade solution using sugar, salt and water. Around 39 percent of tile children who had diarrhea were treated with oral rehydration therapy (either ORS packets or a homemade solution). ORS packets were used more often than homemade solutions. Among the other common responses to diarrheal episodes was to increase the amount of fluids a child was given. Table 8.4 shows that 22 percent of mothers had given the children with diarrhea increased fluids (other than ORS or RHS solutions). Mothers also reported that children were frequently given antibiotics (28 percent) or home remedies to treat the diarrhea (38 percent). Table 8.4 shows that there are relatively minor differences by gender in the treatment practices mothers reported. Mothers were slightly more likely to seek medical advice for episodes of diarrhea among girls than among boys. Also, girls were more likely than boys to be treated with some form of ORT. Considering the other differentials shown in Table 8.4, a medical provider was consulted more often for children living in urban areas than for rural children. However, rural children were more likely than urban children to have received some form of ORT. Mothers with less than primary education were more likely to report using some form of ORT than better educated mothers. 41 8.4 Treatment of Respiratory Il lnesses The 1998 EIDHS also included questions with regard to whether medical advice was sought when a child had the symptoms of an acute respiratory infection. Table 8.5 shows that mothers sought advice from a medical provider in 66 percent of cases where the child had a cough with short, rapid breathing. As was the case with diarrheal illnesses, among mothers who sought medical advice, the majority reported that a private doctor was consulted (46 percent). 'There was no significant difference by gender in the likelihood that medical advice would be sought when a child was ill. However, medical advice was less likely to be sought in the case of rural children than urban children were and for children whose mothers were from Upper Egypt. The likelihood of seeking medical advice was also directly associated with the mother's educational level. Because there is over utilization of Antibiotics, mothers were asked if they gave the children Antibiotics to treat cough. Around 11 percent (not shown in table) of children, who had cough in the two weeks period preceding the survey, were given Antibiotics. Table 8.5 Treatment of cough Percentage of children under age five ill with cough with short rapid breathing during the two-week period before the survey who were taken to a health facility lot treatment by selected background characteristics, Egypt 1998 Taken to health l;,cility Number Background of characteristics An)' Public Private children Sex Male 68.7 16.8 53 .3 2.686.0 Female 61.7 24.1 38.0 2.526.0 Urban-rural residence Urban 75.9 28. I 49.2 2.057.0 Rural 58.8 14.9 44.6 3,155.0 Place of residence Urban Governorates 8 ] .2 35.5 47. I 991.0 Lower Egypt 68.9 [ 7.9 50 .9 2,052.0 Urban 82.5 24.8 57.7 482.0 Rural 64.9 15.9 49.0 1,570.0 Upper Egypt 55.0 15.7 41 .1 2.169.0 Urban 63.3 20.2 45.4 585.0 Rural 51.3 13.6 39 .2 1,584.0 Education No education 56.6 23.3 33 .7 2,172.0 Some primary 67.3 19.9 48.8 734.0 Primary comp./Some Secondary 64.0 18.9 45. I 720.0 Secondary comp./Higher 77.0 16.6 62 .3 1,586.0 Total 65.5 20. I 46.4 5,212.0 8.5 Infant and Child Mortal ity Trends in Early Childhood Morta l i ty This section presents information on levels, trends and differentials in neonatal, post- neonatal, infant and child mortality. This information is central to an assessment of the demographic situation in Egypt. it is also important to improve child survival programs in Egypt by helping to identify those segments of the child population that are'at increased risk. 42 Data on children's birth dates, survivorship status and age at death obtained in the birth histories collected in the 1998 EIDHS were used to estimate the levels and trends in mortality among children under the age of five in Egypt. Table 8.6 presents the information on early childhood mortality for a 5-year period prior to the survey. The results suggest that mortality among young children has fallen steadily during the period since 1988. Overall, under-five mortality has fallen from an estimated level of 103 Figure 8.2 Trends in Uder 5-years Morta l i ty 120 - - 100 80 60 40 20 0 1984-1988 1989-1993 19q4-1998 deaths per 1,000 births during the period 1984-1988 to 58 deaths per 1,000 births during the five-year period immediately prior to the EIDHS-98. Table 8.6 Levels and trends in early childhood mortality Early childhood mortality rates for the five-year periods belbre the 1998 EIDHS Approximate calendar period Neonatal Post-neonatal Infant Childhood Under-five 1994-1998 20.8 24.7 45.5 13.1 58.0 1989-1993 25.4 30.3 55.7 16.6 71.4 1984-1988 37.5 34.9 72.4 33.2 103.2 Differentials in Ear ly Ch i ldhood Morta l i ty Although there has been a steady decline in mortality levels among young children in Egypt, Tables 8.7 and 8.8 show that there remain significant differentials in mortality levels in the population. The mortality rates shown in these two tables are calculated for a ten-year period before the survey because most subgroups were not sufficiently large to permit reliable estimation of five-year rates. Considering the relationship with socio-economic measures, Table 8.7 shows that mortality levels are higher in rural areas than in urban areas. Place of residence is also associated with mortality levels, with the highest levels observed in Upper Egypt, particularly in rural areas where the under-five mortality rate is 88 compared with 64 in rural Lower Egypt. As expected, Table 8.7 also indicates that mortality levels are negatively associated with the educational level of the mother. The under-five mortality rate among children born to women with no education is 81 deaths per 1,000 births compared to 35 deaths per 1,000 births among children born to women who have completed the secondary school or higher. 43 Table 8.7 Early childhood mortality by socio-economic characteristics Early childhood mortality rates for the ten-year period preceding the survey economic characteristics. Egypt 1998. by selected socio- Background characteristic Neonatal Post-neonatal Infant Childhood Under-rive Urban-rural residence Urban 14.6 23.4 38.1 10A 47.8 Rural 28.9 29.6 58.6 18.8 76.2 Place of residence Urban Governorates 12.2 19.2 31.4 9.4 40.5 Lower Egypt 26.8 21.3 48.1 14.0 6 t .4 Urban 17.2 28.4 45.7 7.2 52.5 Rural 29.8 19.0 48.9 [ 6.4 64.4 Upper Egypt 25.0 36.8 61.8 19.4 80.0 Urban 16.7 26.8 43.5 14.2 57.1 Rural 28.0 40.5 68.5 21.3 88.3 Education No education 27.0 34.8 61.8 20,0 80.5 Some primary 29.4 30.6 60.0 15,3 74.4 Primary comp./Some sec. 18.5 24.0 42.5 13.2 55.1 Secondary comp./Higher 15.5 13.3 28.8 6.2 34.8 Total 23.2 27.2 50.4 15.2 64.8 Table 8.8 shows that the mortality levels do not vary greatly with the sex of the child. However, the interval since the previous birth is strongly related to a child's survival chances. Mortality levels decline significantly as the interval since the previous birth increases. It is clear from the table that mortality level among children with births interval less than two years is more than twice the mortality level among children with long birth interval. Mortality levels are also significantly greater for children of birth order six or higher and for births to women under age 20 and over age 35. Table 8.8 Early childhood mortality by demoeraphic characteristics Early childhood mortality rates lor the ten-year period preceding the survey by selected demographic characteristics, Egypt 1998 Background characteristic Neonatal Post-neonatal Infant Childhood Under-rive Sex Male 23.9 27.3 51.3 15.2 65.7 Female 22.4 27.0 49.4 15.2 63.9 Mother's age at birth Less than 20 34.1 41.1 75.3 18.0 91.9 20-34 19.8 25.2 45.0 14.6 58.9 35 or more 33.7 22.0 55.6 16.3 71.1 Birth order 1 18.8 22.2 40.0 7.7 47.3 2-3 21.7 25.6 47.3 13.1 59.8 4-5 22.1 30.1 52.2 23.8 74.8 6+ 35.6 36.3 71.8 19.6 90.0 Previous birth interval Less than 2 years 39.9 45.9 85.8 31.7 I 14.7 2-3 years 15.9 22.0 37.8 I 1.9 49.3 4 years or more 20.1 19.3 39.4 9.5 48.6 44 9 Infant Feeding and Child Nutrition The 1998 EIDHS obtained data on several important aspects of the nutritional status of Egyptian children and their mothers. Infant feeding practices including breastfeeding and supplementation patterns and the prevalence of bottle-feeding, are considered first. Then anthropometric data (height and weight) collected in the survey are used to assess the current nutritional status of children under age five. 9.1 Breastfeeding and Supplementation The pattern of infant feeding has an important influence on the health of children. Feeding practices are among the principal determinants of a young child's nutritional status, and poor nutritional status has been shown to increase the risk of illness and death among children. Breastfeeding practices also have an effect on the mother's fertility. More frequent breastfeeding for longer duration as well as delays in the age at which longer birth intervals and lower fertility. Initiation of Breastfeeding Early initiation of breastfeeding is beneficial for a number of reasons. For the mother, early sucking promotes the release of hormone that helps uterus to achieve a contracted state and reduces the risk of postpartum hemorrhage. For the child, it is important to receive the colostrum which is contained in the first breast milk after delivery. Colostrum is rich in antibodies that are needed since the child's own immune system is immature. According to the 1998 EIDHS results presented in Table 9.1, almost all-Egyptian children are breastfed for some period of time. Differentials in the proportion of children ever breastfed are small with at least 92 percent of children in every subgroup reported as having been breastfed. The timing of initiation of breastfeeding for the last-born child is also examined in Table 9.1. Around one in three Egyptian children is put to the breast within an hour of birth and around seventy- five percent within the first day. The timing of initiation of breastfeeding varies in a fairly narrow range with the background characteristics shown in Table 9.1. From a programmatic standpoint, perhaps the most relevent differential in breastfeeding practices is that found between children born in facilities and those whose mothers deliver at home. Table 9.1 indicates that children born in a health facility are somewhat more likely to be put to the breast within an hour of birth than children born at home (28 percent versus 38 percent, respectively). Children whose mothers delivered in a health facility also are less likely to be put to the breast within 24 hours of birth than children who were born at home (78 percent versus 72 percent, respectively). 45 Table 9.1 Timing of initiation of breastfeeding Percentage of children born in the five years preceding the survey who were ever breastfed and the percentage of last-born children who started breastt~eding within one hour of birth and within one day of birth, by selected background characteristics, Egypt 1998 Among last-born children, percentage who started breast feeding: Background Percentage ever Within 1 hour Within l day Number of characteristics bl~astfed of birth of birth children Sex MaLe 94.6 32.9 74.6 1,742 FemaLe 94.1 34.5 75.2 1,550 Urban.Rural residence Urban 94. I 34.4 77.4 1,357 Rural 94.6 33.2 73. I 1,934 Place of residence Urban Govemorates 94.0 38.6 79.[ 665 Lower Egypt 95.3 29.8 77. I 1,326 Urban 94.2 26.6 79.7 319 Rural 95.6 30.8 76.3 1,007 Upper Egypt 93.7 35.1 70.5 1,30 I Urban 94.2 33.5 72.6 373 Rural 93.5 35.8 69.7 928 Mother's education No education 95.1 37.3 75.4 1,276 Some primary 92.9 29.9 70.9 468 Primary through econdary 93.6 32.1 74.6 460 Completed secondary/higher 94.4 31.7 76.2 1,088 Assistance at delivery Medically-trained personnel 93.4 30.5 73.7 1,974 Daya 95.7 38.5 76.9 1,227 Other or none 95.5 39.2 74.4 90 Place of delivery Health facility 92,4 27.7 7 [ .6 1,453 At home 95.8 38.4 77.5 1,838 All children 94.4 33.7 74.9 3,291 Introduction of Supplements Breast milk contains all of the nutrients needed by young infants so that supplementing breast milk before 4 months of age is not necessary. In fact, early supplementation is discouraged for a number of reasons. First of all, the early introduction of breast milk supplements increases the exposure of an infant to pathogens, which may cause diarrheal disease. Undernutrition is another risk. The breast milk supplements given a child may not be sufficient to provide all of the calories that the infant needs, particularly if the supplements are watered down, as is often the case. Since the production of breast milk is influenced by the intensity and frequency of sucking, early supplementation may reduce breast milk output, again exposing the child to increase risk of under- nutrition. Data on the current breastfeeding status of all surviving children under age 5 was obtained from mothers in the 1998 EIDHS. In addition, the mother was asked whether various types of liquids 46 or solid foods had been given to child "yesterday" or "last night". These data are used to derive the information on the age patterns of breastfeeding and supplementation presented in Table :9.2. Children are considered exclusively breastfed if they receive breast milk only. Children who are fully breastfed receive only plain water in addition to breast milk. The World Health Organization recommends that children should be exclusively breastfed for the first 4-6 months of life. Table 9.2 indicates that two-third of infants under two months receive only breast milk. The proportion of exclusively breastfed children drops off to 34 percent among children 2-3 months of age and only 14 percent among children 4-5 months. Table 9.2 Breastfeedin~ status Percent distribution of living children by breastteeding status, according to child's age in months, Egypt 1998 Age in months Percentase of livin~ children who are: Breastl~d and given: Number Not Exclusively Plain water Supple- of living breastt~d breast|~d only ments Total children < 2 3.4 66.6 0.6 29.4 100.0 135 2-3 3.5 34.0 10.7 51.8 100.0 185 4-5 5.2 13.9 15.7 65.2 100.0 164 6-7 7.7 5.5 8.9 77.9 100.0 152 8-9 10.3 1.8 5.4 82.5 100.0 154 10-11 16.0 0.8 7.0 76.2 100.0 I70 12-13 13.9 1.5 6.3 78.3 100.0 157 14-15 18.5 0.5 1.2 79.8 100.0 152 16-17 28.9 0.6 2.5 68.0 100.0 143 18-19 45.8 0.0 0.8 53.4 100.0 108 20-21 52.0 0.0 0.0 48.0 100.0 130 22-23 73.0 0.0 1.0 26.0 100.0 147 24-25 87.9 0.0 0.4 I 1.7 I {30.0 173 26-27 93.5 0.0 0.0 6.5 100.0 149 28-29 94.7 0.0 0.0 5.3 100.0 148 30-31 96.8 0.0 0.0 3.2 1{30.0 114 32-33 98.9 0.0 0.0 1.1 100.0 148 34-35 99.3 0.0 0.0 0.7 100.0 133 Note: Breastfeeding status reters to preceding 24 hours. Children classified as breastfed and plain water only receive no supplements. Types of Supplemental Foods Table 9.3 presents more detailed information on the types of foods given to children under age three during the 24-hour period before the survey. The results suggest that Egyptian mothers are much less likely to give a child infant formula than other types of food. This was very clear for children age less than 2 months. Milk supplements and solid or semi-solid foods are associated with the child's age. Up to 2 years age, milk supplements increase with increasing age. The solid and semi solid foods continue increasing with increasing ages, as they are the common weaning foods. Feeding with a bottle with a nipple increases the risk of illness among young children. Moreover, the use of a bottle with a nipple can reduce the period when the mother is not at risk of conception since bottle feeding is associated with lessening of the intensity of breastfeeding and a consequent shortening of the period of postpartum amenrrhea. Overall, bottle feeding is minor among Egyptian children, especially in the early ages. The maximum percentage of children fed with bottle was among children with age 6-7 months (24 percent) (not shown in the table). 47 Table 9.3 Types of food received by children in the preceding 24 hours Percentage of children under 36 months of age who received specific types of lood in the 24 hours before the interview and the percentage using bottle with a nipple, by breas0eeding status and child's age in months, Egypt 1998 Any Using Number Age in Infant Other Other solid/ bottle with of months tbrmula milk liquid semi-solid a nipple children < 2 0.8 9. I 25.9 1.0 16.6 130 2-3 8.4 19.2 41.4 12.4 21.0 179 4-5 12.7 26.0 44.9 "55.8 23.9 155 6-7 25.4 32.1 52.9 54.6 24.0 140 8-9 22.7 37. I 56.9 73.5 18.4 138 I (1- I I 14.8 54.9 59.5 81.6 13.8 143 12-13 16.6 52.0 53.1 87.5 13.3 135 14-15 8.9 61.9 69.5 90.9 9.0 124 16-17 15.0 53.2 64.4 93.6 6. I 102 18-19 9.9 44.4 57.0 95.9 9.1 59 20-21 20.5 56.0 67.7 95.8 2.6 62 22-23 8.2 68.4 66.9 96.4 9.4 40 Di f ferent ia ls in the Durat ion of Breast feed ing Table 9.4 shows the median duration of breastfeeding by background characteristics. The median duration of breastfeeding is 19 months. The median duration of breastfeeding is slightly longer for male children, rural children, and children born to mothers less than a primary education. Table 9.4 Median duration and frequency of breastfeedine Median duration of any, exclusive and full breastleeding among children according u) background characteristics, Egypt 1998. Back[round characteristic Sex Male Female Urban-rural residence Urban Rural Place of residence Urban Govemorates Lower Egypt Urban Rural Upper Egypt Urban Rural Mother's education No education Some primary Primary through secondary Completed secondary/higher Assistance at delivery Medically-trained personal Daya Other or none All children Mean Prevalence/Incidence mean Median duration of breastleedin~ in months Number of An}, Exclusive Full children 19.6 1.6 2.0 1,504 18.6 1.6 2.(1 1.296 18.3 0.9 1.0 1,072 19.6 2.0 2.5 1,728 17.6 0.7 0.7 520 19.4 2.0 2.4 1.070 17.9 1.7 2.0 232 19.6 2.1 2.5 838 19.7 1.6 2.3 1.209 19.6 0.7 0.7 319 19.6 1.9 2.6 890 19.5 1.9 2.4 1,112 19.7 1.6 2.0 395 18.2 1.8 2.2 386 18.7 1.2 1.4 907 19.0 1.6 1.9 1,653 19.2 1.9 2.5 1,068 24.3 0.4 0.4 79 19.1 1.6 2.0 2,800 18.4 3.0 4.1, 18.4 2.4 3.7 48 The median duration of exclusive breastfeeding is 1.6 months. The duration of exclusive breastfeeding is longer for children in rural areas than in urban areas and for children of mothers with less than a primary education. 9.2 Nutritional Status of Children Nutritional status is a major determinant of a child's susceptibility to disease, thus the risk of dying. Both inadequate or unbalanced diets and chronic illness are associated with poor nutritional status among children. To assess nutritional status, all children of women interviewed in the 1998 EIDHS who had been born since January 1993 were weighed and their heights were measured. Using these anthropometric measurements as well as information on the ages of the children, three standard indices of physical growth describing the nutritional status of children are constructed: height-for-age, weight-for-height, and weight-for-age. Each index measures a somewhat different aspect of nutritional status. The height-for-age index provides an indicator of linear growth retardation and, thus, assesses the proportion of children who are stunted. Stunting of a child's growth may be the result of a failure to receive adequate nutrition over a long period of time or of the effects of recurrent or chronic illness. The weight-for-height index measures body mass in relation to body length and provides a measure of the proportion of children who are wasted. Wasting is an outcome of a failure to receive adequate nutrition during the period immediately before the survey. It may be the result of recent episodes of illness or acute food shortages. The weight-for-age index is a composite index of height-for-age and weight-for-height, and, thus, does not distinguish between the effects of acute malnutrition (wasting) and chronic malnutrition (stunting). A child can be underweight because he is wasted, stunted or both. As recommended by the World Health Organization (WHO), evaluation of nutritional status in this report is based on the comparison of the indices for the population of children in the survey with those reported for a reference population of well-nourished children. Use of a reference population is based upon the finding that well-nourished children in all population groups follow similar growth patterns and, thus, exhibit similar distributions with respect to height and weight at given ages (Martorell and Habicht, 1986). One of the most commonly used reference populations, and the one used for this study, is the international reference population defined by the U.S. National Center for Health Statistics (NCHS) and accepted by WHO and the U.S. Center for Disease Control (CDC). Children whose values on an index fall below minus two standard deviations (-2 SD) from the median for the reference population is considered as undernourished and those values fall below minus three standard deviations (-3 SD) from the reference population median are considered to be severely undernourished. In a well-nourished population, only 2.3 percent of children fall below minus two standard deviations for each of the three indices. Levels and Differentials in Nutrition Status Table 9.5 shows the percentage of children under age five who are classified as malnourished according to the height-for-age, weight-for-height, and weight-for-age indices by the child's age and selected other demographic characteristics. Overall, around one-fifth of children under age five are considered to be stunted or too short for their age and 5 percent are wasted, or too thin for their height. The proportion considered as underweight is 11 percent. The child's age is closely associated with nutrition status. Children under age 6 months are much less likely to be undernourished than older children. The highest level of stunting is found among children in the 12-23 month age group, while the highest proportions of children who are wasted or underweight are observed for children age 6-11 months. The table shows that a child's gender is not closely associated with the likelihood that the child will be undernourished. However, the likelihood that a child will be undernourished generally rises with a child's birth order and declines as the length of the birth interval increases. 49 Table 9.5 Nutritional status b~, demographic characteristics Percentage of children under five years of age who are classified as undernourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-lbr-age, by selected demographic characteristics, Egypt 1998 Height-for-age Weight-lor-height (stunting) . (wasting) Percentage Percentage Percentage Percentage Demographic below below below below characteristics --3 SD -2 SD ~ --3 SD --2 SD ~ Weight-lbr-age (underweight) Percentage Percentage Number below below of --3 SD -2 SD I children Age <6 months 1.7 8.0 1.8 7.8 0.8 4.3 418 6-1 I months 11.8 27.9 2.5 8.6 7.9 21.9 436 12-23 months 16.0 31.5 1.4 4.8 3.5 15.6 740 24-35 months 9. I 23.1 1.8 6.4 2.5 12.3 803 36-47 months 5.4 16.4 0.7 3.4 1.9 6.9 81 I 48-59 months 5.7 14.8 0.5 2.3 0.8 5.7 790 Sex Male 9.3 21.3 1.6 5.6 2.6 I 1.4 2,066 Female 7.6 19.9 1.0 4.5 2.7 10.0 1,391 Birth order I 7.6 17.7 0.8 4.0 2.4 10.0 1,080 2-3 8.2 19.7 1.0 4.2 2.2 9.4 1,595 4-5 9. I 24.1 1.9 6.9 3.3 12.8 775 6+ 10.0 24.1 2.4 7.4 3.3 13.2 547 Birth interval First birth 7.6 17.8 0.8 4.0 2.4 9.9 1,087 <24 months 12.0 24.7 1.9 6.4 3.3 14.0 711 24-47 months 7.4 21.7 1.7 5.5 2.4 10.9 1,395 48+ months 8.5 19.0 0.8 4.6 2.9 8.6 804 All children 8.5 20.6 ! .3 5. I 2.6 10.7 3,997 Note: Figures are for children born in the 0-59 months preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international reference population. Children are classified as undernourished if their z-scores are below minus two standard deviations (-2 SD) from the median of the reference population and as severely undernourished if their z-scores are below minus three standard deviations I-3 SO) from the median of the reterence population. Includes children who are below --3 SD. Data on the nutrit ion status indicators are presented in Table 9.6 by res idence and the educat ional level o f the child's mother. Rural chi ldren, especial ly those l iv ing in Upper Egypt, are less wel l of f than urban chi ldren with regard to all o f the indicators o f nutrit ion status. The level of stunt ing among rural chi ldren, for example, is 22 percent compared to 19 percent among urban chi ldren. As expected, a chi ld's nutrit ion status also is posit ively related to the mother's educat ional level. For example, the proportion o f chi ldren who are stunted varies from 15 percent among chi ldren o f mother's who have at least a secondary education to 24 percent among chi ldren whose mothers have no education. 50 Table 9.6 Nutritional status bv socio-economlc characteristics Percentage of children under five years o1" age who are classified as undernourished according to three anthroporoetric indices of nutritional status: height-tbr-age, weight-lor-beight, and weight-for-age, by selected socio-econoroic characteristics, Egypt 1997 Height-tot-age Weight-tbr-height Weight-for-age (stunting) (wasting) (underweight) Percentage Percentage Percentage Percentage Percentage Percentage Number Socio-econoroic below below below below below below of characteristics --3 SD --2 SD ~ --3 SD --2 SD ~ --3 SD --2 SD ~ children Urban-rural residence Urban 7.7 19,1 0.6 3.7 2.1 8.9 1,559 Rural 9.0 21.6 1.8 5.9 3.0 11.9 2,439 Place of residence Urban Governorates 8.2 21.9 0.6 3.3 2.5 9.2 737 Lower Egypt 6.0 16.3 1.0 3.7 2 8.4 1,59 I Urban 4.7 10.3 0.6 3.6 0.6 4.7 377 Rural 6.4 18.2 1.1 3.7 2.4 9.5 1.214 Upper Egypt 10.9 24.1 1.9 7.2 3.3 13.7 1,669 Urban 9.5 22. I 0.5 4.6 2.9 12.1 444 Rural 11.4 24.9 2.4 8.1 3.5 14.2 1,225 Education No education 9.8 23.5 1.6 5.9 3.8 12.6 1,627 Some primary 9.2 22.3 0.8 5.2 1.9 9.7 561 Primary corop./ some secondary 9. l 22.3 2.2 5.5 2. I 11.4 563 Secondary comp./ Higher 62 15.3 0.8 3.7 1.6 8.5 1,246 All children 8.5 20.6 1.3 5.I 2.6 10.7 3,997 Note: Figures are lor children born in the 0-59 months preceding the survey. Each index is expressed in ternt~ of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international ret~rence population. Children are classified as undernourished if their z-scores are below minus two standard deviations (-2 SD) from the median of the reference population and as severely undernourished if their z-scores are below minus three standard deviations 1-3 SDI from the median of the reference population. Includes children who are below --3 SD Trends in Nutrition Status Figure 9.1 looks at recent trends in the percentage of stunting children under age 5 in Egypt, using data from the 1992, 1995, 1997 and 1998 DHS surveys. The figure suggests the level of stunting among young children has been gradually declining since 1995. Figure 9.1 Trend of Stunting, 1992-1998 30 26 ~ 25 1~2 1~5 1997 1~8 Table 9.7 presents the trends in the nutritional status of children under age five by background characteristics. The results indicate that levels of under-nutrition increased between 1992 and 1995, before declining slowly in the next three years. The level of wasted remained relatively stable to a 51 level between 3-4 percent. Dur ing the study period, 10-12 percent were considered to be underweight. .1'able 9.7 Trends in nutrition status uf children Among children under age live. the percenlage classified as undernourished according to height-ibr-age, weight-l~,r- heighl, and weight-for-age by residence, Egypt 1992-[998 Hei~ht-tor-a~c Weisht-lbr-hei~ht Weighl-lbr-a~e Residence 1992 1995 1997 1998 1992 1995 1997 1998 1992 1995 1997 1998 Urban-rural residence Urban 20./I 22.8 20.0 19.1 3.4 4.7 5.5 3.7 7.[ 9.9 9.5 8.9 Rural 29.6 34.4 22.8 21.6 3.4 4.5 6.5 5.9 11.6 14.1 13.1 11.9 Place of residence Urban Governorates 16.8 18.4 18.4 21.9 4.5 5.4 5,9 3.3 7.7 9. I I t 9.2 Lower Egypt 27.0 28.0 21.5 16.3 2.6 3./1 4.6 3.7 8.1 9.6 9. I 8.4 Urban 20.5 25.6 17.6 10.3 2.3 2.4 4.6 3.6 4.5 8.8 7.4 4,7 Rural 29.1 28.8 22.8 18.2 2.7 3.2 4.6 3.7 9.3 9.9 9.7 9.5 Upper Egypl 28.7 36.5 31.4 24.1 3.7 5.2 7.8 7.2 12.6 16.1 14.6 13.7 Urban 24.6 27.2 24.7 22.1 2.8 4.7 5.7 4,6 8.8 11 8.9 12.1 Rural 30.0 39.7 34.0 24.9 4.0 5.3 8.6 8.1 13.8 17.8 16.8 14.2 Total 26.0 29.8 24.9 20.6 3.4 4.6 6.1 5.1 9.9 12.5 11.7 10.7 Note: Figures are 1or children born in the 0-59 months preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) unils fl'om the median of the NCHS/CDC/WHO international reference population. Children are classilied as undernourished if their z-scores are below minus two standard deviations (-2 SD) from the median of the relerence population. With regard to the patterns by residence, urban chi ldren were less l ikely to be stunted or underweight than rural chi ldren throughout the period. Chi ldren in the Urban Governorates exhibited the least ev idence o f under-nutr it ion at all points in time, whi le chi ldren in rural Upper Egypt consistently had the highest levels of both acute and chronic under-nutr it ion throughout the period. 52 References Abdel-Azeem, F., Farid, S., and Khalifa, A.M. 1993. Egypt Maternal and Child Health Survey. Central Agency for Public Mobilization and Statistics [Arab Republic of Egypt] and the Pan Arab Program for Child Development [Arab League]. EI-Zanaty and Associates, and Macro Int., 1998. Egypt DemographicandHealth Survey, 1997. Cairo, Egypt, Calverton, Maryland: EI-Zanaty and Associates ]Arab Republic of Egypt] and Macro International Inc. EI-Zanaty, F., Hussein, Enas M., Shawky, Gihan A., Way, Ann and Kishor, Sunita. 1996. Egypt Demographic and Health Survey 1995. Calverton, Maryland: National Population Council [Arab Republic of Egypt] and Macro International Inc. EI-Zanaty, F. 1995. Contraceptive Use in Egypt: Trends and Determinants. In Perspectives on Fertility and Family Planning in Egypt, edited by M. Mahran, F. EI-Zanaty and A. Way. Calverton, Maryland: National Population Council [Arab Republic of Egypt] and Macro International Inc. EI-Zanaty, F., Sayed, H. A. A., Zaky, H. and Way, Ann. 1993. Egypt Demographic and Health Survey 1992. Calverton, Maryland: National Population Council [Arab Republic of Egypt] and Macro International Inc. Hallouda, A. M., Amin, S.Z., and Farid, S., editors. 1983. The Egyptian Fertility Survey. 4 vols. Cairo: Central Agency for Public Mobilization and Statistics. Martorell, R. and J.P. Habicht. 1986. Growth in early childhood in developing countries. In Human growth: A comprehensive treatise, ed. F. Falkner and J. M. Tanner, Vol.3. New York: Plenum Press. 241- 262. Sayed, H. A. A., EI-Khorazaty, M. N., and Way, A. A. 1985. Fertility andFamily Planning in Egypt. Columbia, Maryland: Egypt National Population Council [Arab Republic of Egypt] and Westinghouse Public Applied Systems. Sayed, H. A. A., Osman, M., EI-Zanaty, F., and Way, Ann. 1989. Egypt Demographic and Health Survey 1988. Columbia, Maryland: National Population Council [Arab Republic of Egypt] and Institute for Resource Development/Macro Systems, Inc. Sommerfelt, A. E. and Piani, A. L. 1997. Childhood bnmunizatlon: 1990-1994. DHS Comparative Studies No. 22. Calverton, Maryland: Macro International Inc. 53 Appendix A Table A.1 List of variables selected for sampling error calculation, Egypt Interim Survey 1998 Variable name Estimate Base population No education Ever used any contraceptive method Currently using any contraceptive method Currently using a modern method Currently using pill Currently using IUD Currently using injectables Using public sector source Want no more children Want to delay al least 2 years Mothers received tetanus injection Mothers received medical care at delivery Had diarrhea in last 2 weeks Treated with ORS packets Consulted medical personnel about diarrhea Having immunization record Received BCG vaccination Received DPT vaccination (3 doses) Received polio vaccination (3 doses) Received measles vaccination Received hepatitis vaccination (3 doses) Fully immunized Weight-lot-height Height-lbr-age Weight-for-age Total tertility rate (0-3 years) Neonatal mortality rate (0-9 years) Posmeonatai mortality rate (0-9 years) Int~mt mortality rate (0-9 years) Child mortality rate (0-9 years) Under-five mortality rate (0-9 years) Propornon Proportion Proportion Proporl~on Proportion Proporuon Propornon Propornon Propornon Proportion Proporllon Proportion Proportton Proportton Proportxon Propornon Proporllon Proporllon Proportton Proportion Proportmn Propomon Proportion Proportmn Proportion Rate Rate Rate Rate Rate Rate Ever-married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently married women 15-49 Currently mamed women 15-49 Currently married women 15-49 Currently married women 15-49 Births in last 5 years Births in last 5 years Children 0-59 months Children under 5 with dian'hea in last 2 weeks Children under 5 with diarrhea in last 2 weeks Children 12-23 months Children 12-23 months ChildrerL 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 0-59 months Children 0-59 months Children 0-59 months Women-years of exposure to childbearing Number of births Number of births Number of births Number of births Number of births 57 TableA.2 Samplingerrors--Nationalsample. Egypt lnterim Survey 1998 Confidence Number of cases limits Standard Design Relative Value error Unweighted Weighted effect error Variable (R) (SE) (N) (WN) (DEFT) (SE/R) R-2SE R+2SE No education 0.426 0.013 6406 6406 2.030 0.029 0.401 0.451 Ever used any contraceptive method 0.723 0.010 5977 5971 1.744 0.014 0.703 (I.743 Currently using any contraceptive method 0.518 0.010 5977 5971 1.550 0.019 0.498 0.538 Curren0y using a modern method 0.495 0.010 5977 5971 1.504 0.020 (I.475 0.514 Currently using pill 0.087 0.004 5977 5971 1.197 0.050 0.078 0.096 Currently using IUD 0.343 0.008 5977 5971 1.377 0.025 0.326 0.360 Currently using injectables 0.039 0.003 5977 5971 1.200 0.077 0.033 0.045 Using public sector source 0.479 0.015 2900 2953 1.560 0.031 0.449 0.508 Want no more children 0.594 0.008 5977 5971 1.192 0.013 0.579 0.609 Want to delay at least 2 years 0.080 0.004 5977 5971 1.094 0.051 0.072 0.089 Mothers received tetanus injection 0.701 0.041 4657 4642 1.364 0.058 0.619 0.783 Mothers received medical care at delivery 0.552 0.047 4657 4642 1.454 0.210 0.458 0.646 Had diarrhea in last 2 weeks 0.107 0.006 4430 4411 1.255 0.052 0.096 0.118 Treated with ORS packets 0.320 0.022 583 537 1.056 0.069 0.276 0.364 Consulted medical personnel about diarrhea 0.441 0.023 583 537 1.082 0.051 0.396 0.487 Having immunization record 0.647 0.018 861 837 1.079 0.028 0.611 0.683 Received BCG vaccination 0.981 0.006 861 837 1.245 0.006 0.970 0.993 Received DPT vaccination (3 doses) 0.875 0.014 861 837 1.198 0.016 0.848 0.903 Received polio vaccination (3 doses) 0.896 0.013 861 837 1.246 0.014 0.871 0.921 Received measles vaccination 0.931 0.010 861 837 1.079 0.011 0.911 0.951 Received hepatitis vaccination (3 doses) 0.814 0.016 861 837 1.174 0.020 0.781 0.846 Fully immunized 0.843 0.015 861 837 1.204 0.018 0.813 0.874 Weight-for-height 0.051 0.005 4048 3997 1.251 0.091 0.040 0.600 Height-for-age 0.206 I).008 4048 3997 1.213 0.039 0.190 0.222 Weight-lot-age 0.107 0.007 4048 3997 1.237 0.061 0.094 0.120 Total lertility rate (0-3 years) 3.404 0.066 NA 162102 1.061 0.019 3.273 3.536 Neonatal mortality rate (0-9 years) 20.807 2.431 9093 9102 1.061 0.117 15.946 25.669 Postneonatal mortality rate (0-9 years) 24.767 2.621 9111 9121 1.057 0.106 19.526 30.009 Intant mortality rate (0-9 years) 45.575 3.533 9112 9122 1.021 0.078 38.508 52.642 Child mortality rate (0o9 years) 12.911 2.015 9125 9136 1.083 0.156 8.881 16.940 Under-five mortality rate (O-9 years) 57.897 4.072 9145 9156 1.056 0.070 49.752 66.042 58 Appendix B An Evaluation of the Significance of Recent Trends in Key Demographic and Health Indicators for Egypt Egypt had three Demographic and Health Surveys within a three-year period between 1995 and 1998. The following examines the issue of the statistical significance of the changes that were observed in key demographic and health indicators between these surveys. In general, the assessment indicates that statistically significant changes can be documented between the 1995 and 1997 surveys and the 1995 and 1998 surveys. However, in the case of most indicators, the changes observed between the 1997 and 1998 surveys were not statistically significant. Trends in Family Planning and Maternal and Child Health Indicators An assessment of the significance of differences in the results of the three Demographic and Health surveys was undertaken for the following key family planning and maternal and child health indicators: Family planning Percentage using any method Percentage using the IUD Percentage using injectables Percentage using the pill Maternal and child health Percentage of births in which mother received any antenatal care Percentage of births in which mother received regular antenatal care Percentage of births in which mother was assisted at delivery by medical personnel Percentage of births in which the mother received tetanus toxoid injections Percentage of children fully immunized Table I summarizes information on the levels of each indicator estimated in 1995Demographic and Health Survey, the 1997 Interim Demographic and Health Survey, and the 1998 Interim Demographic and Health Survey. Information on the sampling errors calculated for each of these indicators for the various surveys is shown in Appendix A. Table 1 Trends in family planning and maternal and child health indicators, 1995-1998 1995 1997 1998 Indicator Population DHS IDHS IDHS Family alanninn % using any method % using IUD % using pill % using injectables Maternal and child health % receiving antenatal care % receiving regular antenatal care % assisted at delivery by medical personnel % receiving tetanus toxoid injection % tully immunized Currently married women 15-49 47.9 54.5 51.8 Currently married women 15-49 30.0 34.6 34.3 Currently married women 15-49 10.4 10.2 8,7 Currently married women 15-49 2.4 3.9 3.9 Births 0-4 years before survey 39. I 52,0 47,2 Births 0-4 years before survey 28.3 31.8 33,1 Births 0-4 year before survey 46.3 56,4 55.2 Births 0-4 years before survey 69.5 72. I 70,1 Children 12-23 months 79.1 82.8 84.3 61 A t-test was performed to assess the significance of the differences between the estimates of these indicators for each pair of DHS surveys (i.e., 1995 and 1997, 1995 and 1998, and 1997 and 1998). The procedure used in performing the tests is described in the Appendix C. Table 2 summarizes the results of the significance testing of the key indicators for the various pairs of surveys. Table 2 indicates that the differences between the estimates from the 1995 DHS and 1997 IDHS were uniformly statistically significant. Thus, for example, the increase in family planning use observed in the current use of family planning between the 1995 DHS (47 percent) and 1998 IDHS (55 percent) was found to be significant. The differences between the estimates for the 1995 DHS and 1998 IDHS were also generally found to be statistically significant for all of the indicators shown in Table 2. The situation is less uniform with respect to the differences in the estimates from the 1997 IDHS and the 1998 IDHS. The decrease in the overall rate of family planning use between the two surveys (from 54.5 percent in the 1997 survey to 51.8 percent in the 1998 survey) was found to be significant; this was largely due to the significant decline in the rate of pill use between the two surveys. With regard to the health indicators, the changes in the antenatal care indicators between the 1997 and 1998 surveys were found to be significant. The absence of significant changes between the 1997 and 1998 surveys is not surprising. It is likely due to the comparatively short time between the two surveys. Table 2 Results of test of the differences between estimates of t~tmily planning and maternal and child health indicators tbr the 1995-1998 DHS surveys in Egypt 1995 DHS- 1995 DHS- 1997 IDHS- Indicator 1997IDHS 1998 IDHS 1998 IDHS Family Dlannim~ % using any method S S S % using IUD S S NS % using pill NS S S % using injectables S S NS ,.M.,aternal and child health % receiving antenatal care S S S % receiving regular antenatal S S S care % assisted at delivery by medical S NS NS personnel % receiving tetanus toxoid S NS NS injection % fully immunized S NS NS 62 Appendix C Testing the Significance of Differences in Survey Results The significance of the differences in the estimates from DHS surveys carried out in Egypt during the period 1995 to 1998 was assessed by performing a t-test on the differences. In order to perform the test or any characteristic of interest, the following information was obtained for the characteristic in question from each pair of DHS surveys: the estimated values of the characteristic for each cluster in both surveys, the weight variables used in both surveys, and, the overall sample estimated values and their sampling errors in both surveys. Clusters which were not common to the surveys were excluded from consideration. In order to test the difference, a 95% confidence interval was computed using the sampling error of the difference between the survey results. The sampling error of the difference is calculated as follows: SE(ml -m2)=4 ' + ' 2 SE- (mj ) SE ' (m2) - pxSE(ml )xSE(m2) where mt and m2 are the estimated values from the first and second survey, respectively, SE (m~), i = 1, 2 designates the sampling error of the estimated value obtained from survey i, is the corelate between mj and m2. This correlation is computed from the data to be used for the t-test as is shown below: (re,j- mi)( m2i" m,_ ) P = (re,j" m, )2 x Zj , (m2 " m,_ )2 where mii is the estimated value of the characteristic for clusterj during survey i, and m~ is the weighted mean of the ~ 0 s, and Ej is the sum over all clusters. If the confidence intervals included zero, then the difference between the estimates from the pair of DHS surveys was not considered statistically significant. /9 65 Front Matter Title Page Contact Information Table of Contents List of Tables List of Figures Chapter 01 - Introduction Chapter 02 - Fertility Chapter 03 - Family Planning Knowledge and Use Chapter 04 - Family Planning Services Chapter 05 - Nonuse of Family Planning and Intention to Use Chapter 06 - Fertility Preferences and Unmet Need for Family Planning Chapter 07 - Maternal Health Chapter 08 - Child Health Chapter 09 - Infant Feeding and Child Nutrition References Appendix A Appendix B Appendix C

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