Kazakstan - Demographic and Health Survey - 1995

Publication date: 1995

Kazakstan Demographic and Health Survey 1995 National Institute of Nutrition Academy of Preventive Medicine of Kazakstan ®DHS Demographic and Health Surveys Macro International Inc. World Summit for Children Indicators: Kazakstan 1995 Value BASIC INDICATORS Childhood mortality Maternal mortality Childhood undernutrition Clean water supply Sanitary excreta disposal Basic education Children in especially difficult situations Infant mortality rate Under-five mortality rate Maternal mortality ratio Percent stunted (of children under 3 years) Percent wasted (of children under 3 years) Percent underweight (of children under 3 years) Percent of households within 15 minutes of a safe water supply 2 Percent of households with flush toilets or VIP latrines Percent of women 15-49 with completed primary education Percent of men 15-49 with completed primary education Percent of girls 6-12 attending school Percent of boys 6-12 attending school Percent of women 15-49 who are literate Percent of children who are orphans (both parents dead) Percent of children who do not live with their natural mother Percent of children who live in single adult households 40 per 1,000 46 per 1,000 77 per 100,000 ] 15.8 3.3 8.3 86.6 42.6 98.6 98.8 81.3 80.4 99.8 0.1 8.1 4.1 SUPPORTING INDICATORS Women's Health Birth spacing Safe motherhood Family planning Nutrition Maternal nutrition Low birth weight Breast feeding Iodine Child Health Diarrhea control Percent of births within 24 months of a previous birth 3 Percent of births with medical prenatal care Percent of births with prenatal care in first trimester Percent of births with medical assistance at delivery Percent of births in a medical facility Percent of births at high risk Contraceptive prevalence rate (any method, married women) Percent of currently married women with an unmet demand for family planning Percent of currently married women with an unmet need for family planning to avoid a high-risk birth Percent of mothers with low BM[ Percent of births at low birth weight (of those reporting numeric weight) Percent of children under 4 months who are exclusively breastfed Percent of households with iodised salt Percent of children with diarrhea in preceding 2 weeks who received oral rehydration therapy (sugar-salt-water solution) Acute respiratory infection Percent of children with acute respiratory infection in preceding 2 weeks who were seen by medical personnel i Data from the Ministry of Health 2 Piped. well, and bottled water 3 First births are excluded. 34.3 92.5 58.9 99.6 98.4 38.7 59.1 15.7 12.5 7.9 9.1 12.0 52.9 31.2 47.7 Kazakstan Demographic and Health Survey 1995 National Institute of Nutrition Almaty, Kazakstan Academy of Preventive Medicine of Kazakstan Almaty, Kazakstan Macro International Inc. Calverton, Maryland USA November 1996 This report summarizes the findings of the 1995 Kazakstan Demographic and Health Survey (KDHS) conducted by the National Institute of Nutrition [Kazakstan]. Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development. The KDHS is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information about the Kazakstan survey may be obtained from the National Institute of Nutrition, 66 Klotchkov St., Almaty, Kazakstan 480008 (Telephone: (73272) 429-111 ; Fax: (73272) 420-720). Additional information about the DHS program may be obtained by writing to: DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (Telephone: 301-572-0200; Fax: 301-572-0999). Recommended citation: National Institute of Nutrition [Kazakstan] and Macro International Inc. 1996. Kazakstan Demographic and Health Survey, 1995. Calverton, Maryland: National Institute of Nutrition and Macro International Inc. CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Map of Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvi CHAPTER 1 1.1 1.2 1.3 1.4 1.5 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Almaz Sharmanov Geography, History, and Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.1 Geography and Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.2 Pre-Soviet Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.3 Kazakstan During the Soviet Era . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.1.4 Social Programs and the Educational System . . . . . . . . . . . . . . . . . . . . . . 2 1.1.5 Kazakstan During the Socioeconomic Transition . . . . . . . . . . . . . . . . . . . 3 Health Care Sytem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.1 Socialistic Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.2 Health Care Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2.3 Health Care Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Maternal and Child Health and Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . 6 Demographic and Health Data Collection System in Kazakstan . . . . . . . . . . . . . . 7 Objectives and Organization of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.1 Sample Design and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.2 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.5.3 Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.5.4 Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.5.5 Response Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 CHAPTER 2 2.1 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . 13 Shamshiddin A. Balgimbekov and Raimbek Sissemaliev Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.1.1 Sex and Age Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.1.2 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.1.3 Educational Level of Household Members . . . . . . . . . . . . . . . . . . . . . . 16 iii 2.2 2.3 Page Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.2.1 Household Durable Goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 2.3.1 Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 2.3.2 Educational Level of the Respondents . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.3.3 School Attendance and Reasons for Leaving School . . . . . . . . . . . . . . . 24 2.3.4 Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 2.3.5 Women's Employment Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.3.6 Employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.3.7 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 2.3.8 Decisions on Use of Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2.3.9 Child Care While Working . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 CHAPTER 3.1 3.2 3.3 3.4 3.5 3.6 3 FERTIL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Vassily N. Devyatko and Kia L Weinstein Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Children Ever Bom and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Pregnancy and Motherhood Among Women Age 15-19 . . . . . . . . . . . . . . . . . . . 42 CHAPTER 4 CONTRACEPT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Nina A. Kayupova, Nailya M. Karsybekova, and Khazina M. Biktasheva 4.1 Knowledge of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 4.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 4.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.4 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . 53 4.5 Knowledge of Fertile Period and Contraceptive Effects of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 4.6 Source of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 4.7 Intention to Use Family Planning Among Nonusers . . . . . . . . . . . . . . . . . . . . . 59 4.8 Reasons for Nonuse of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.9 Preferred Method of Contraception for Future Use . . . . . . . . . . . . . . . . . . . . . . 60 4.10 Exposure to Family Planning Messages in the Electronic Media . . . . . . . . . . . . . 61 4.11 Acceptability of Use of Electronic Media to Disseminate Family Planning Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.12 Exposure to Family Planning Messages in Print Media . . . . . . . . . . . . . . . . . . . 63 4.13 Attitudes of Couples toward Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 65 iv CHAPTER 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Page 5 INDUCED ABORTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Jeremiah M. Sullivan, Nailya M. Karsybekova, and Kia L Weinstein Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Lifetime Experience with Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Rates of Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Time Trends in Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Abortion Rates from the Ministry of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Impact of Contraception on Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Contraceptive Use Before Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Service Providers and Procedures Used for Abortion . . . . . . . . . . . . . . . . . . . . . 76 Complications of Abortion and Medical Treatment . . . . . . . . . . . . . . . . . . . . . . 76 CHAPTER 6.1 6.2 6.3 6.4 6.5 6.6 6 OTHER PROXIMATE DETERMINANTS OF FERTIL ITY . . . . . . . . . . . . . . . 77 Kia L Weinstein Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Age at First Sexual Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Postpartum Amenorrhea, Abstinence and Insusceptibility . . . . . . . . . . . . . . . . . . 84 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 CHAPTER 7.1 7.2 7.3 7.4 7 FERTIL ITY PREFERENCES Kia L Weinstein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Wanted and Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAt t ieR 8.1 8.2 8.3 8.4 8.5 8.6 8 INFANT AND CHILD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Jeremiah M. Sullivan Background and Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Levels and Trends in Early Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . 100 Mortality Rates from the Ministry of Health . . . . . . . . . . . . . . . . . . . . . . . . . 101 Socioeconomic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . 102 Demographic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . 103 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 CHAPTER 9 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Page MATERNAL AND CHILD HEALTH Amangeldy D. Duisekeev and Temirkhan K. Bekbosynov . . . . . . . . . . . . . . . 107 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Assistance and Medical Care at Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Characteristics of Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 CHAPTER 10 10,1 10.2 10.3 NUTRITION OF WOMEN AND CHILDREN Toregeldy S. Sharmanov and Temirkhan K. Bekbosynov . . . . . . . . . . . . . . . . 121 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 10.1.1 Initiation of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 10.1.2 Age Pattern of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 10.1.3 Types of Supplemental Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 10.1.4 Frequency of Food Supplementation . . . . . . . . . . . . . . . . . . . . . . . 126 10.1.5 Differentials in Food Supplementation . . . . . . . . . . . . . . . . . . . . . . 126 Nutritional Status of Children under Age Three . . . . . . . . . . . . . . . . . . . . . . 128 10.2.1 Measures of Nutritional Status in Childhood . . . . . . . . . . . . . . . . . 128 10.2.2 Levels of Child Undemutrition in Kazakstan . . . . . . . . . . . . . . . . . 129 Women's Anthropometric Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 CHAPTER 11 11.1 11.2 11.3 11.4 11.5 ANEMIA Almaz Sharmanov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Anemia Measurement Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Anemia Prevalence Among Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Anemia Prevalence Among Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 APPENDIX A SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Thanh L~ A. 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 vi Page A.2 Characteristics of the KDHS Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 A.3 Sample Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 A.4 Stratification and Systematic Selection of Clusters . . . . . . . . . . . . . . . . . . . . . 154 A.5 A.4.1 Almaty City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 A.4.2 Other urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 A.4.3 Rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Sampling Probabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 A.5.1 Almaty City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 A.5.2 Other urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 A.5.3 Rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 APPENDIX B ESTIMATES OF SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Thanh L~ APPENDIX C DATA QUALITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 APPENDIX D PERSONS INVOLVED IN THE 1995 KAZAKSTAN DEMOGRAPHIC AND HEALTH SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 APPENDIX E QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 vii Table 1.1 TaMe 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 ~I able 2.6 tab le 2.7 Table 2.8 Table 2.9 TaMe 2.10 Table 2.11 Table 2.12 TaMe 2.13 Table 2.14 Table 2.15 Table 2.16 TaMe 2.17 Table 2.18 TaMe 2.19 Table 3.1 TaMe 3.2 Table 3.3 Table 3.4 TaMe 3.5 Table 3.6 Table 3.7 TaMe 3.8 Table 3.9 TaMe 3.10 TaMe 3.11 TABLES Page Results of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . 12 Household population by age, le.,idence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Fosterhood and orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Educational level of the female household population . . . . . . . . . . . . . . . . . . . . . . 17 Educational level of the male household population . . . . . . . . . . . . . . . . . . . . . . . . 18 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Ethnicity, religion and residence by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 School attendance and reasons for leaving school . . . . . . . . . . . . . . . . . . . . . . . . . 25 Access to m~ss media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Decision on use of earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Child care while working . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Trends in fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . .~ . . . . . . . . . 38 Trends in fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Pregnancy and motherhood among women age 15-19 . . . . . . . . . . . . . . . . . . . . . . 42 Children born to women age 15-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 ix Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 4.19 Table 4.20 Table 5.1 Table 5.2 Table 53 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 6.1 Table 6.2 Table 63 Page Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Knowledge of contraceptive methods by background characteristics . . . . . . . . . . . . 47 Ever u~e of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . . . 51 Pill use and possession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Use of pill brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Number of children ~t first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Perceived contraceptive effect of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Source of supply for modern contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . 57 Satisfaction with current sources of supply for contraceptive methods . . . . . . . . . . . 58 Future u,,e of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Heard about family planning on radio and television . . . . . . . . . . . . . . . . . . . . . . . 62 Acceptability ( f media messages on family planning . . . . . . . . . . . . . . . . . . . . . . . 63 Family planning messages in print . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Discussion of family planning by couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Wives ' perceptions of their husbands' attitude toward family planning . . . . . . . . . . . 66 Pregnancy outcomes by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . 68 Lifetime experience with induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Induced abortion rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Induced abortion rates by background characteristics . . . . . . . . . . . . . . . . . . . . . . . 72 Trends in age-specific induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Comparison of abortion lates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Time trends in contraception and abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Use of contraception prior to pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Source cf services, type cf provider, and procedure used for abortion . . . . . . . . . . . 76 Health problems following abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Sexual relationships of nonmarried women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table 6A Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 6.9 Table 6.10 Table 7.1 Table 7.2 Table 7.3 Table 7.4.1 Table 7.4.2 Table 7.4.3 Table 7.5 Table 7.6 Tat le 7.7 Table 7.8 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 9.9 Table 9.10 Page Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Age at first ~exual intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Median age at first intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Recent sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Postpartum amenorrhea, abstinence and insusceptibility . . . . . . . . . . . . . . . . . . . . . 84 Median duration of postpartum amenorrhea, abstinence and insusceptibility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 86 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . 87 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Need for family planning services: currently married women . . . . . . . . . . . . . . . . . 91 Need for family planning services: unmarried women . . . . . . . . . . . . . . . . . . . . . . 92 Need for family planning services: all women . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Mean ideal number cf children by background characteristics . . . . . . . . . . . . . . . . . 96 Fertility planning ~,tatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Comparison of infant mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . . 102 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . 104 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Number cf antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . 109 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Delivery characteristics: caesarean ,,ection, birth weight and size . . . . . . . . . . . . . 112 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Prevalence of acute respiratory infection and fewr . . . . . . . . . . . . . . . . . . . . . . . 116 Knowledge of diarrhea care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 xi Table 9.11 Table 9.12 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 10.6 Table 10.7 Table 10.8 Page Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Feeding practices during diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . 124 Types of foods received by children in preceding 24 hours . . . . . . . . . . . . . . . . . . 125 Types of food received by children in preceding week . . . . . . . . . . . . . . . . . . . . . 126 Types of food received by children by background characteristics . . . . . . . . . . . . . 127 Nutritional status of children by demographic characteristics . . . . . . . . . . . . . . . . . 129 Nutritional status of children by background characteristics . . . . . . . . . . . . . . . . . 131 Table 10.9 Anthropometric indicators of female nutritional status . . . . . . . . . . . . . . . . . . . . . 132 Table 10.10 Nutritional status of women by background characteristics . . . . . . . . . . . . . . . . . . 133 Table 11.1 Table 11.2 Table 11.3 Table 11.4 Table A. 1 Table A.2 Table A.3 Table A.4 Table A.5 Table A.6 Table B.1 Table B.2 Table B.3 Table B.4 Table B.5 Table B.6 Table B.7 Table B.8 Table B.9 Table B.10 Table B. 11 Anemia among women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Anemia among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Anemia among children by demographic characteristics . . . . . . . . . . . . . . . . . . . . 141 Anemia among children born to anemic mothers . . . . . . . . . . . . . . . . . . . . . . . . . 142 Population distribution (1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Percent distribution of population (1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Proportional sample allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Proposed sample allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Number of sample points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Proposed number of sample points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 List of selected variables for sampling errors . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Sampling errors - National sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Sampling errors - Urban sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Rural sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Almaty City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 South Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 West Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Central Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 North and East Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Kazak ethnic group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Russian ethnic group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 xii Table B.12 Sampling errors - Other ethnic groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Table C. 1 Table C.2 Table C.3 Table CA Table C.5 Table C.6 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . 180 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Births by calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 xiii FIGURES Figure 1.1 Figure 2.1 Figure2.2 Figure2.3 Figure 3.1 Figure 3.2 Figure 3.3 Figure 4.1 Figure 4.2 Figure 4.3 Figure 5.1 Figure 5.2 Figure5.3 Figure 6.1 Figure 7.1 Figure 7.2 Figure 7.3 Figure 8.1 Figure 8.2 Figure 9.1 Figure 9.2 Figure 9.3 Figure 10.1 Figure 10.2 Figure 11.1 Figure 11.2 Figure 11.3 Page Oblast Composition of Regions in Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Population Pyramid of Kazakstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 School Enrollment by Age and Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Housing Characteristics by Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Age-specific Fertility Rates by Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Total Fertility Rate by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . 36 Trends in Age-Specific Fertility Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Use of Specific Contraceptive Methods among Currently Married Women . . . . . . . . 50 Current Use of Family Planning by Background Characteristics . . . . . . . . . . . . . . . 52 Distribution of Current Contraceptive Users by Source of Supply . . . . . . . . . . . . . . 57 Age-specific Rates of Fertility and Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . 71 Total Induced Abortion Rate by Background Characteristics . . . . . . . . . . . . . . . . . . 71 Age-specific Abortion Rates by Time Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Marital Status of Women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Fertility Preferences among Currently Married Women 15-49 . . . . . . . . . . . . . . . . . 88 Fertility Preferences among Currently Married Women by Number of Living Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Percentage of Currently Married Women with Unmet Need and Met Need for Family Planning Services by Background Characteristics . . . . . . . . . . . . . 94 Trends in Infant Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Under-five Mortality by Selected Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 103 Percent Distribution of Births by Antenatal Care and Delivery Characteristics . . . . 109 Percentage of Children Age 12-23 Months with Specific Vaccinations . . . . . . . . . . 114 Prevalence of Respiratory Illness and Diarrhea in the Last Two Weeks by Age of the Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Prevalence of Stunting by Age of Child and Length of Birth Interval . . . . . . . . . . 130 Prevalence of Stunting by Background Characteristics . . . . . . . . . . . . . . . . . . . . . 131 Prevalence of Moderate Anemia among Women Age 15-49 by Pregnancy Status and Breastfeeding Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Percent Distribution of Hemoglobin Levels among Women Age 15-49 . . . . . . . . . 138 Percentage of Women with Moderate or Severe Anemia among Those Who are Currently Using or Not Using the IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 XV LIST OF CONTRIBUTORS Toregeldy S. Sharmanov, M.D., Ph.D. Director, National Institute of Nutrition President, Academy of Preventive Medicine 66 Klotchkov Street Almaty, Kazakstan 480008 Jeremiah M. Sullivan, Ph.D. Deputy Director, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA Vassily N. Devyatko Minister of Health, Republic of Kazakstan Ministry of Health 63 Abylaikhan Street Almaty, Kazakstan 480004 Amangeldy D. Duisekeev, M.D., Ph.D. First Deputy Minister of Health, Republic of Kazakstan Ministry of Health 63 Abylaildaan Street Almaty, Kazakstan 480004 Nina A. Kayupova, M.D., Ph.D. Director, National Research Center of Maternal and Child Health 125 Dostyk Street Almaty, Kazakstan 480020 Almaz T. Sharmanov, M.D., Ph.D. Health Specialist, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA Kia I. Weinstein, Ph.D. Consultant, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA Thanh L~ Sampling Statistician, Demographic and Health Surveys Macro International Inc. 11785 Beltsville Drive Calverton, MD 20705, USA xvii Nailya M. Karsybekova, M.D. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 Temirkhan K. Bekbossynov, M.D. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 Khazina M. Biktasheva, M.D. Senior Researcher, National Research Center of Maternal and Child Health 125 Dostyk Street Almaty, Kazakstan 480020 Shamshiddin A. Balgimbekov, M.D. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 Raimbek Sissemaliev, D.D.S. Senior Researcher, National Institute of Nutrition 66 Klotchkov Street Almaty, Kazakstan 480008 xviii PREFACE The 1995 Kazakstan Demographic and Health Survey (KDHS) was the first national level population and health survey in Kazakstan. The purpose of the survey was to provide the Ministry of Health of Kazakstan with information on fertility, reproductive practices of women, maternal care, child health and mortality, child nutrition practices, breastfeeding, nutritional status and anemia. This information is important for understanding the factors that influence the reproductive health of women and the health and survival of infants and young children. It can be used in planning effective policies and programs regarding the health and nutrition of women and their children. This is especially important now during this the time of economic transition which involves virtually all aspects of life for the people of Kazakstan. The survey provides data important to the assessment of the overall demographic situation in the country. It is expected that the findings of the KDHS will become a useful source of information necessary for the ongoing health care reform in Kazakstan. The successful completion of the KDHS and publication of this volume is due to the contribution of many people. I would like to express appreciation to the KDHS senior technical staff: Drs. Nailya Karsybekova and Temirkhan Bekbosynov; KDHS field coordinators: Drs. Igor Tsoy, Yuri Sinyavskyi, Shamshuddin Balgimbekov, and Ms. Nagima Esenalinova; and to all interviewing teams and data entry groups for their devotion and sincere efforts in accomplishing the survey activities. The survey fieldwork was completed smoothly and successfully with the support of the Ministry of Health, and also with the help of government officials and public health workers at the levels ofoblasts, raions and villages of Kazakstan. Our thanks are also due to the members of the National Survey Advisory Committee and to all specialists who were involved in the survey and contributed to its success. The KDHS is part of an international program that has executed more than 60 national-level surveys around the world. Kazakstan is the first country among the republics of the former Soviet Union to participate in this international program. The KDHS would not have been feasible without financial support of the U.S. Agency for International Development and technical assistance which was provided by the Demographic and Health Surveys (DHS) program of Macro International Inc. First, I would like to thank Dr. Jeremiah M. Sullivan, DHS Deputy Director, for assisting with overall project design, analyses of the survey results, and report production. I would also like to thank the following Macro staff: Drs. Almaz Sharmanov and Kia Weinstein for assisting with questionnaire development, fieldstaff training, analysis of the survey results, and writing chapters of this report; Mr. Trevor Croft for writing the computer programs, setting up the data processing operation, and producing the tabulations; and Ms. Thanh L8 for the sampling design. Special thanks are also due to Ms. Anne Cross and Dr. Elisabeth Sommerfelt for their valuable reviewing of various chapters of the report. Many others we have not mentioned have also put long hours into ensuring the successful completion of this task; their names are listed in Appendix D. Dr. Toregeldy S. Sharmanov KDHS National Director Director of the National Institute of Nutrition President of the Academy of Preventive Medicine xix SUMMARY OF FINDINGS Toregeldy S. Sharmanov The 1995 Kazakstan Demographic and Health Survey (KDHS) is a nationally representative survey of 3,771 women age 15-49. Fieldwork for the KDHS was conducted from May to September 1995. The KDHS was sponsored by the Ministry of Health (MOH), Republic of Kazakstan and was funded by the United States Agency for International Development. The National Institute of Nutrition implemented the survey with technical assistance from the Demographic and Health Surveys program. The Kazakstan Academy of Preventive Medicine participated in analysis and report writing. The purpose of the KDHS was to develop an information base to be used by the MOH in developing policies pertaining to the health and nutrition of women and children. The KDHS provides information on many factors which determine the health status of women and children such as fertility, contraception, induced abortion, maternal care, infant mortality, and nutritional status. Some statistics presented in this report are currently available to the MOH from other sources. For example, the MOH collects and regularly publishes information on fertility, contraception, induced abortion and infant mortality. However, the survey presents information on these indices in a manner which is not currently available, i.e., by population subgroups such as those defined by age, marital duration, education, ethnicity, etc. Additionally, the survey provides statistics on some issues not previously available in Kazakstan: for example, breastfeeding practices and anemia status of women and children. Thus, existing data and the KDHS data are complementary; when considered together, they provide a more complete picture of the health conditions in Kazakstan than was previously available. Decreasing Fertility. Survey results indicate a total fertility rate (TFR) for all of Kazakstan of 2.5 children per woman. Fertility levels differ for different population groups. The TFI, t is lowest among women in Almaty City (1.5 children per woman) and the North and East Region (2.8), intermediate in the West and Central Regions (2.7 each), and highest in the South Region (3.4). The TFR for ethnic Russian women (1.7 children per woman) is substantially lower than for Kazak women (3.1). The re suits of the 1989 Census and the 1995 KDHS show that fertility has declined in Kazakstan over the past five years from a TFR of 2.9 to 2.5 children per woman. Over the same period, the TFR among ethnic Kazaks has declined from 3.6 to 3.1 and among ethnic Russians from 2.2 to 1.7. The declining trend in fertility can also be seen by comparing the completed family size of women near the end of their childbearing years with the current TFR. Completed family size among women 45-49 is 3.4 children which is nearly one child more than the current TFR (2.5). Overall, one-third of non-first births (34 percent) in Kazakstan take place within 24 months of the previous birth. Birth intervals are significantly longer among births to Russian mothers (median interval length of 44 months) than among Kazak mothers (median interval length of 28 months). Births to urban women have a median interval length of 39 months, while births to rural women have a median interval length of 29 months. The age at which women in Kazakstan begin childbearing has not changed significantly over time. Overall, approximately 15 percent of women have their first birth at age 18 or 19, an additional 25-30 percent have their first birth at age 20 or 21, and 25-30 percent at age 22-24. xxi The majority of married women in Kazakstan (60 percent) don't want to have more children, and a large majority of women (79 percent) want to either delay their next birth (l 9 percent) or stop childbearing altogether. These are the women who are potentially in need of some method of family planning. Decreasing Childhood Mortality. In the KDHS, infant mortality data were collected based on the international definition of a live birth which, irrespective of the duration of pregnancy, is a birth that breathes or shows any sign of life (such as the beating of the heart or movement of voluntary muscles) after separation from the mother. Infant deaths are deaths of live-born infants under one year of age (United Nations, 1992). For the period 1990-94, infant mortality in Kazakstan is estimated at 40 infant deaths per 1,000 births. The estimates of neonatal and postneonatal mortality are about equal at 20 per 1,000. The estimate of child mortality (ages 1-5) is much lower at 6 deaths per 1,000 population. During the period between 1980-1984 and 1990-1994, the infant mortality rate in Kazakstan declined from 44 to 40 per 1,000 births (by about 10 percent). All of this decline occurred in the postneonatal period. The pace of mortality decline was more pronounced for children (ages 1-5 ), and over the l 0-year period, child mortality rates fell from 10 to 6 per 1,000 population (by about 38 percent). The MOH publishes infant mortality rates annually but the definition of a live birth used by the MOH differs from that used in the survey. As is the case in most of the republics of the former Soviet Union, a pregnancy that terminates at less than 28 weeks of gestation is considered premature and is classified as a late miscarriage even if signs of life are present at the time of delivery. Only if a premature birth survives for seven days is the child classified as a live birth. Thus, some events classified as late miscarriages in the MOH system would be classified as live births and infant deaths according to the definitions used in the KDHS. Because of this difference, the infant mortality estimates of the MOH are consistently about 30 percent lower than the KDHS estimates. Nevertheless, the 15 percent decline in the MOH estimates between 1980-84 (32 per 1,000) and 1990-94 (27) is of the same order of magnitude as the decline indicated by the KDHS estimates. Increasing Use of Contraception. Knowledge of contraceptive methods is very high among women in Kazakstan. Knowledge of at least one method is nearly universal (98 percent of respondents know of at least one method). High levels of knowledge are the norm for women of all ages, all regions of the country, all educational levels, and all ethnicities. Women have knowledge of, on average, five methods of contraception. Among currently married women, 84 percent report having used a method of contraception at some time. The women who are the most likely to have ever used a method of contraception are those in the broad age group 25-44 (83-90 percent of these women have used a method of contraception at some time). Overall, among currently married women, 59 percent report that they are currently using a contraceptive method. Forty-six percent are using a modem method of contraception and another 13 percent are using a traditional method. The IUD is by far the most commonly used method; two out of every three currently married women who are using contraception are using the IUD. One out of five currently married women who are using contraception are using either periodic abstinence, withdrawal, or douche. The level of modem contraceptive use is similar for women of various population subgroups. Most of the differentials observed in overall levels of use are due to differentials in use of traditional methods. For example, Kazak and Russian women are equally likely to be using a modem method of contraception (47 and 45 percent, respectively); however, Russian women are more likely than Kazak women to be using a xxii traditional method (20 and 7 percent, respectively), resulting in a higher overall level of use among Russian women. Statistics from the MOH show that, between 1988 and 1993, the percent of women of reproductive age who were IUD and pill users increased by approximately 48 percent from 20 to 29 percent. The vast majority of women obtain their contraceptives through the public sector (92 percent). Forty- four percent of users obtain their method from a hospital or polyclinic, 26 percent from a women's consulting center, and 19 percent from public pharmacies. The source where women obtain their methods depends on the method they are using. Most women using IUDs obtain them at hospitals (34 percent) or women's consulting centers (31 percent). Pharmacies supply 58 percent of pill users and 60 percent of condom users. Of the 41 percent of currently married women who are not using contraception, about half (48 percent) report that they intend to use contraception in the future; 28 percent within the next 12 months, 17 percent at some more distant time, while the remaining 3 percent are unsure when they will use a method. The majority (79 percent) of nonusers who intend to use in the future indicate that the IUD is their preferred method. Decreasing Levels of Induced Abortion. As in most of the republics of the former Soviet Union, induced abortion has been a primary means of fertility control in Kazakstan. In a manner analogous to the analysis of the fertility data, the total abortion rate (TAR)--the number of abortions a woman will have in her lifetime based on the currently prevailing abortion rates--was calculated at the national level and for various population subgroups. At current rates, a woman in Kazakstan will have an average of nearly two abortions (1.8) over her lifetime. The TAR is higher in urban areas (2.0 abortions per woman) than in rural areas (1.5). Additionally the TAR is substantially higher among ethnic Russian women (2.7) than among ethnic Kazak women (1.1). As expected, levels of abortion and fertility are inversely correlated. In the high-fertility South Region, the TAR is lowest (0.9 abortions per woman). In the West and Central Regions where fertility levels are intermediate, abortion rates are also intermediate (1.0 and 1.6, respectively), while in the relatively low fertility areas of the North and East Region and Almaty City, abortion rates are highest (2.5 and 3.0, respectively). The KDHS data indicate a 20 percent decline in the general abortion rate between the time periods 1986-90 and 1993-95. This is in agreement with the abortion statistics published by the MOH, which indicate a 17 percent decline in induced abortion over the same time periods. A finding of considerable interest which is based on both KDHS and MOH data concerns the link between the use of contraception and the level of abortion. The data indicate that over an interval of about five years, the pill and IUD prevalence rate in Kazakstan has increased by 32 percent, and over the same period the abortion rate has declined by 15 percent. This is clear and convincing evidence that contraceptive use has been a substitute for abortion. Maternal and Child Health. Kazakstan has a well-developed health system with an extensive infrastructure of facilities that provide maternal care services. This system includes special delivery hospitals, the obstetrics and gynecology departments of general hospitals, women's counseling centers, and doctor's assistant/midwife posts (FAPs). There is an extensive network of the latter mentioned facilities throughout the rural areas, xxiii Virtually all births in Kazakstan (98 percent) are delivered at health facilities: 96 percent in delivery hospitals and another 2 percent in either general hospitals or FAPs. Only 2 percent of births are delivered at home. Almost all births (99 percent) are delivered under the supervision of medically trained persons: 78 percent by a doctor and 21 percent by a nurse or midwife. As expected, the survey data indicate that a high proportion of respondents (93 percent) receive antenatal care from professional health providers: the majority from a doctor (69 percent) and a significant proportion from a nurse or midwife (23 percent). Only 7 percent of women report no antenatal care. The general pattern in Kazakstan is that women seek antenatal care early and continue to receive care throughout their pregnancies. The median number of antenatal care visits reported by respondents is 11. The practice in Kazakstan is to keep child health cards at the health facilities rather than in the possession of the child's mother so that most of the information on vaccination coverage in the KDHS is based on mother's recall. Among children 12-23 months of age, mothers report that a high proportion of children have received the BCG vaccine (97 percent), the first dose of DPT (98 percent), and polio (100 percent). However, approximately half of those who started the DPT and the polio series did not finish. In the case of the measles vaccine, 72 percent of children 12-23 months of age have been vaccinated. Nutrit ional Status. Breastfeeding is almost universal in Kazakstan; 96 percent of children born in the three years preceding the survey are breastfed. Overall, 10 percent of children are breastfed within an hour of delivery and 40 percent within 24 hours of delivery. The median duration of breastfeeding is lengthy (14 months). However, durations of exclusive breastfeeding, recommended by the World Health Organization, are short (0.4 months). Supplementary feeding starts early in Kazakstan. At age 0-3 months, a significant proportion of breastfeeding children are given infant formula (20 percent) and powdered or evaporated milk (17 percent). By 4-7 months of age, 25 percent of breastfeeding children are given foods high in protein (meat, poultry, fish, and eggs) and almost half are given cereals and fruits or vegetables. Among nonbreastfeeding children age 0-3 years, a high proportion are given powered or evaporated milk in the last 24 hours (about 80 percent), and after the first birthday, a high proportion receive high protein foods (about 80 percent of children). In the KDHS, the height and weight of children under three years of age was measured. These data, in conjunction with information on age, are used to determine the nutritional status of children, i.e., the proportion of children who are stunted (short for their age, a condition which may reflect chronic undernutrition) and the proportion who are wasted (underweight according to their height, a condition which may reflect an acute episode of undemutrition resulting from a recent illness). In a well-nourished population of children, it is expected that about 2.3 percent of children will be measured as moderately or severely stunted or wasted. For all of Kazakstan, the survey found that 16 percent of children are severely or moderately stunted and 3 percent are severely or moderately wasted. Particularly in terms of the stunting index, undernutrition differs between subgroups of children. Moderate or severe stunting is found to be high among children 12-23 months of age (23 percent) compared to infants under 6 months of age (4 percent) and age 6-11 months (10 percent), and among children born after a birth interval of less than 24 months (28 percent) compared to those born after longer birth intervals of 24- 47 months (20 percent) and 48 months or more (7 percent). Moderate or severe stunting is also particularly high among children in rural areas (22 percent), in the South and Central Regions (23 and 22 percent, respectively), and among the children of ethnic Kazak women (21 percent). xxiv Anemia Status. Testing of women and children for anemia was one of the major efforts of the 1995 KDHS. Anemia is recognized as a major public health problem throughout the world, and has been considered a major public health problem in Kazakstan for decades. Nevertheless, this was the first anemia study in Kazakstan done on a nationally representative sample. The study involved hemoglobin (Hb) testing for anemia using the Hemocue system. Approximately, half (49 percent) of the women in Kazakstan suffer from some degree of anemia. Thirty-seven percent of these women have mild anemia, 11 percent have moderate anemia, and 1 percent are severely anemic (Hb level less than 7.0 g/dl). The highest overall rate of anemia (59 percent) is found in the West Region while Almaty City has the lowest overall rate (38 percent). With respect to ethnicity, the rate of anemia is higher among ethnic Kazak women (57 percent) than among ethnic Russian women (42 percent) and women of other ethnic groups (43 percent). Sixty-nine percent of children under the age of three in Kazakstan suffer from some degree of anemia. About the same proportions of children have mild (30 percent) and moderate anemia (34 percent). A smaller, but substantial, proportion of children is severely anemic (6 percent). As is the case for women, the highest overall rate of anemia among children is found in the West Region (81 percent) and the lowest rate in Almaty City (48 percent). Ethnic Kazak children have higher overall rates of anemia (78 percent) than ethnic Russian children (59 percent) or children of other ethnic groups (55 percent). Perhaps the most significant finding of the study is the high rate of severe anemia among Kazak children (9 percent), while no ethnic Russian children are severely anemic, and the prevalence for other ethnic groups is 1 percent. There are some demographic predisposing factors which increase the likelihood of anemia in children. These factors include the age of 12-23 months, high birth order, and having an anemic mother. XXV ~< x _<. KAZAKSTAN West Kazakstanskaya Oblast Atyrauskaya Oblast Caspian Sea Mangistauskaya Oblast North Kazakstanskaya Oblast \ \ \ Oblas t I ~ r , u r ,~ , .==°uo , I _ Oblast Aktiubinskaya Oblast Tourgaiskaya Oblast / " Aral Sea KzyI-Ordins Oblast _s - - J h. Akmolinskaya Oblast Zhezkazganskaya Oblast Oblast • South • Kazakstanskay~ ~1 Oblast / RUSSIA Pavlodarsk Oblast aandinskaya Oblast Semipalatinskaya Oblast S Almatinskaya l Oblas~ Oblast CHINA UZBEKISTAN ~. ~ "" ALMATY CITY CHAPTERI INTRODUCTION A~az ~ ~armanov 1.1 Geography, History, and Economy I.I.I Geography and Population Kazakstan, the second largest republic after Russia in the former Soviet Union, has a territory of over 1 million square miles (2.7 million square kilometers). It borders Russia to the north and west, the Central Asian republics of Uzbekistan, Kyrgyzstan, and Turkmenistan to the south, and China to the east. The northern part of Kazakstan consists of grasslands, while most of the south and center consists of desert and steppe. Kazakstan has access to both the Caspian Sea and the Aral Sea and it is crossed by the Siberian river of Ertys, and the rivers of Esil, Oral, and Syr Darya (Goskomstat, 1996). Kazakstan is divided into 19 administrative regions (oblasts), which are further broken down into 220 smaller administrative areas called raions. The country has a population of 16.5 million (Goskomstat, 1996). With 16.4 persons per square mile (6.4 per square kilometer), Kazakstan has one of the lowest population densities in the world. The population is comprised of more than 100 nationalities and ethnic groups. Forty- five percent of the population is Kazak, 35 percent Russian, 4 percent German, and 4 percent Ukrainian in origin. Other significant subpopulations are Uzbeks, Tatars, Uighuers, and Koreans. Traditional Kazak culture is influenced by Islam. The Russian population has a loose affiliation with the Russian Orthodox Church. 1.1.2 Pre-Soviet Kazakstan Prior to the 20th century, the people of Kazakstan were mainly nomadic. For centuries, the Kazak people grazed their horses and sheep on the grasslands of the north and on the pastures of the south. In the 13th century, the Kazaks, who were originally Turkik speaking tribes, were invaded and influenced by the Mongols. The ethnic Kazak population is homogeneous in terms of its cultural traditions and language. It is common, however, to divide it into three major tribes or zhoozes: Uly (senior) Zhooz (southeastern Kazakstan), Orta (middle) Zhooz (central and northern Kazakstan), and Kishi (junior) Zhooz (western Kazakstan). The Kazak state was formally established in the 16th century during the rule of Qasym-khan. Later, the representatives of all three Zhoozes, facing the threat of Dzhungar's conquest, gathered in Ulu-Tau (currently Dzhezkazgan oblast), and declared the nation's unification (Baishev et al., 1979). In the 18th century, Ablai-khan, the most eminent person in Kazak history, was able to politically unify the Kazak state. He was, however, the last independent Kazak khan, deriving his power solely from the Kazak people (Olcott, 1995). Beginning in the 18th century, the territory of Kazakstan was subject to Russian conquest and was incorporated into the Russian Empire. At the end of the 19th and beginning of the 20th centuries, Kazakstan was a destination of intensive migrations of Russian, Ukrainian, and Polish peasants. 1.1.3 Kazakstan During the Soviet Era After the communist revolution of 1917, an autonomous republic was established in the territory of Kazakstan. In 1936, the territory became the Soviet Socialist Republic of Kazakhstan, member of the USSR. The Stalin era of collectivization of farmland in the 1920s and 1930s resulted in huge numbers of Kazaks starving due to losses of livestock and poor harvests. It has been estimated that 1,750,000 Kazaks (about 40 percent of Kazakstan's population) died as a result of famine and Stalin's repression (Abylgozhin et al., 1989). Prior to and during World War II, Stalin deported many Germans, Koreans, Chechens, and Crimean Tatars to Kazakstan from central Russia, the Far East, Caucasus, and Crimea. They now constitute a significant portion of Kazakstan's population. In the mid-1950s, Nikita Khmshchev announced the Virgin Lands campaign which was designed to bring the enormous acreage of pasture land in Kazakstan under plow. The next 10 years brought another wave of immigrants from Russia, Byelorussia, and Ukraine to settle the Kazak steppes. Some 64 million acres of pasture were plowed and hundreds of collective farms were established, mainly in the central and northern areas of Kazakstan, which became major producers of grain. The southern part of Kazakstan remained populated mainly by Kazaks who produced cotton, fruits, and vegetables. The industrial development of Kazakstan, initiated in the mid- 1950s, benefitted from the country's abundance of natural resources. Kazakstan is one of the most mineral rich countries in the world, with deposits of copper, chromium, magnesium, iron ore, gold, titanium, lead, zinc, bauxite, and other minerals (UNDP, 1995). During the last three decades, Kazakstan has developed national industries in iron and steel production, chemical fertilizers, copper, machinery and construction of coal and hydroelectric plants. The economic development of Kazakstan since the 1950s has been tremendously accelerated by the military industry and the space program. The Semipalatinsk region of Kazakstan was designated as the Soviet nuclear bomb testing zone. Baikonour, the area in the middle of Kazakstan's southern deserts, became a Soviet space harbor, similar to the United States' Cape Canaveral. The Soviet government considered Kazakstan's borders with China strategically important and stationed large numbers of troops along the border forming the Central Asian Military Zone. Thus, two major demographic trends characterize Kazakstan in the 20th century: rapid urbanization and a shift in ethno-national structure. Kazakstan's present ethnic spectrum is the result of an intensive migration process, initiated and influenced by industrialization and political changes throughout Kazakstan's history. The migration process brought millions of ethnic Slavs, mostly Russians, who settled predominantly in the northern territories of Kazakstan and now constitute a majority of the population. The central and southern regions remain populated primarily by ethnic Kazaks. 1.1.4 Social Programs and the Educational System During the Soviet era, Kazakstan developed advanced social and educational programs. In 1992, more than nine million people (about half of the population) were covered by some kind of social welfare and social security system, such as pensions, maternity leave, disability protection, etc. With a strong public commitment to education, which is free of charge, a high level of literacy is now nearly universal in Kazakstan. The 1989 Census reported a mean number of 9.7 years of schooling by the age of 25 (Goskomstat, 1990). The country's primary and secondary educational system has three levels: primary (classes 1-4, age 6/7 - 10/11 years); principal (classes 5-9, age 11-15 years); secondary (classes 10-11, age 16-17 years). In 1995, there were 8,801 schools operating in Kazakstan, more than two-thirds of which offered all three levels 2 of primary/secondary education. The national teacher/pupil ratio was estimated to be 1:11 (Goskomstat, 1996). The primary and principal education levels are compulsory. Those who leave after the principal level of education (9 classes) may continue in secondary-special (vocational) education. Those who finish all three levels of primary/secondary school can continue their education at a higher level--at universities or academic training institutes. The secondary-special (vocational) educational system in Kazakstan includes 251 schools providing a combination of general education and technical skills to students age 15-20 during 2-4 years of schooling. The number of years in the secondary-special schools depends on the curriculum profile and professional orientation of the student. In 1995, there were 65,200 students who were enrolled in these schools (Goskomstat, 1996). In 1995, there were 71 universities and academic training institutes in Kazakstan offering formal higher education, and there were 260,000 students enrolled in these institutions (Goskomstat, 1996). Currently, the secondary-special and higher education systems are undergoing changes to meet a growing demand for new types of professional skills, particularly for professionals with market management and business administration skills. 1.1.5 Kazakstan During the Socioeconomic Transition With the collapse of the former Soviet Union in 1991, Kazakstan was granted formal independence and became a sovereign republic. The country opened its doors to the world community and became a member of the United Nations and many other international organizations. The head of the newly independent state is the President, Mr. Nursultan Nazarbayev. Under transition from a centrally-planned economy to a market economy, Kazakstan is now experiencing rapid social and economic changes. The process to date has produced disruption in most sectors of the economy, causing economic decline, inflation, and instability of the new national currency. Almost all sectors of the economy experienced dramatic decreases in production from 1991 to 1995. Not until the beginning of 1995 was an increase in the production of ferrous and nonferrous metallurgy and the chemical industries noticeable (Goskomstat, 1996). The Government of Kazakstan liberalized consumer prices as part of an economic transition program. This induced tremendous inflation which was estimated at almost 50 percent per month in June 1994 for food and nonfood commodities. Despite the fact that the overall monthly inflation rate has fallen since 1994 to 2-5 percent in 1995-96, the increasing gap between personal income and the cost of living continues to affect most household budgets (Goskomstat, 1996). The country's declining economy and budget deficits place downward pressure on expenditures for social programs, education, and health care (see also section 1.2.2. on the health care crisis). The inability of the Government to collect and maintain sufficient pension funds has led to new legislation that raises the retirement age from 55 to 58 years for women and from 60 to 63 for men by the year 2001. The Government of Kazakstan, facing economic and social crisis, has initiated a number of activities to restructure the economy by attracting foreign investments and rebuilding economic relations with Russia and other former Soviet republics. In 1995, the Government of Kazakstan initiated the transfer of major enterprises, including Karaganda steel, Dzhezkazgan copper, and Donskoi chromium plants, to the management of foreign companies such as British Ispat Corporation and Korean Samsung. Such transfers are intended to assist in the move from a Soviet planned economic system to a market economy. Kazakstan has also urged other former Soviet republics to form a Euro-Asian Union comparable to the European Union. In 3 March 1996, Kazakstan signed an agreement with Russia, Byelorussia, and Kyrgyzstan to form a union intended to eliminate trade barriers and restore economic and financial relationships. 1.2 Health Care Sytem 1.2.1 Socialistic Health Care System In 1978 the historic International Conference on Primary Health Care was held in Kazakstan under the aegis of the World Health Organization (WHO) and UNICEF. The Alma-Ata Declaration was drawn up and the "Health for All" strategy was developed, calling for primary care driven health systems that would guarantee equal access for all citizens (WHO, 1978). During the 1970s and early 1980s, Kazakstan became an example of how a multiethnic state in a developing and industrialized setting could achieve this goal. The system of comprehensive and planned health care that was developed in Kazakstan provided adequate access to health services and maintained a focus on prevention. With six medical schools and 10 medical colleges, Kazakstan has been successful in training medical doctors, nurses, and other medical professionals. The country has reached one of the world's highest per capita rates of physicians and hospital beds. In 1995 there were 365 doctors per 100,000 population. Figures for the U.S., Japan, and China were 288, 225, and 154, respectively. The number of hospital beds was 1,169 per 100,000 population, which was also one of the world's highest rates (Ministry of Health, 1996). The planned system, developed under the Soviet health care system, maintains a network of primary health care institutions. The network includes doctor' s assistant/midwife post (FAP), district polyclinics, and rural hospitals at the primary level; district hospitals and dispensaries at the secondary level; and central hospitals and clinical research institutes at the highest level. It has proven efficient and successful in providing adequate health services for the majority of the population, including those residing in the most remote areas of Kazakstan. However, maintaining such a system depends entirely on substantial and continuous budgetary support, and requires enormous resources of manpower and managerial skill. 1.2.2 Health Care Crisis Unfortunately, Kazakstan's declining economy has reduced health care expenditures. The country is currently experiencing a health care crisis and the system is continually threatened with severe financial cutbacks. The health care budget has declined to 1.1 percent of the Gross National Product (GNP) (Goskomstat, 1996). This compares with average health care expenditures of 6-10 percent of the GNP in most developed countries. Meanwhile, Kazakstan's GNP has also decreased tremendously in the past few years producing an even greater tightening of the budget (UNDP, 1995). Since 1990, Kazakstan's health care system has become highly decentralized and less manageable. Due to lack of funding, some regions reduced the number of hospital beds and supplies of essential drugs and medical equipment. Physicians in Kazakstan are now paid less on average than factory workers. Hospitals and other health facilities are in poor condition; many are lacking in sanitary conditions, running water, and electricity (Barr and Field, 1996; Sharmanov et al., 1996). The crude death rate in Kazakstan has increased from 7.7 deaths per 1,000 population in 1990 to 10.1 in 1995 (Goskomstat, 1996). Average life expectancy at birth decreased from 68.6 years (63.8 for men and 73.1 for women) in 1990 to 66.8 (60.7 for men and 71.1 for women) in 1994 (Ministry of Health, 1996). The major causes of death in Kazakstan are cardiovascular diseases, cancer, and respiratory diseases (in 1995 there were 484, 134, and 93 deaths per 100,000 population, respectively). While the incidence rate of infectious diseases such as diarrhea has declined, morbidity from noncommunicable diseases has risen in the 4 past decade. In 1995, 26 percent of people in Kazakstan had respiratory diseases and 4 percent had infectious diseases or parasite infestation. Pulmonary tuberculosis is one of the most serious health problems in Kazakstan. The highest levels are observed in the northern and western regions. The number of new cases of tuberculosis increased from 59.7 per 100,000 population in 1994 to 67.1 in 1995. The overall morbidity rate from tuberculosis in Kazakstan in 1995 was 271.1 per 100,000 population, which was the highest in Central Asia, and one of the highest in the world (Ministry of Health, 1996). Drug-resistant forms of tuberculosis have become more prevalent in the past decade, resulting in high rates of mortality and disability. Many of the health problems in Kazakstan have arisen from deteriorating environmental conditions. Radioactive contamination around the Semipalatinsk nuclear bomb testing zone, and agro-chemical pollution in the area of ecological crisis of the Aral Sea have provoked international attention over the last several years. There is great concern in the health community that malignant neoplasms and genetic and mental disorders in these geographic areas have increased significantly. In addition to environmental factors, behaviors such as heavy smoking, excessive alcohol consumption, and a high-fat diet contribute significantly to the deteriorating health condition of the general population of Kazakstan. Nutrition-related diseases, particularly those caused by malnutrition and micronutrient deficiencies, are a major public health concern in Kazakstan, since they appear to be important predisposing factors for infectious diseases and underlying causes of many noncommunicable diseases. Among nutrition-related diseases, iron deficiency anemia has been considered a major health problem in Kazakstan for decades. 1.2.3 Health Care Reform It has become clear that success in health care will not be solely determined by the number of physicians or hospital beds. Even if the medical care system is efficient and affordable, the health of the society will depend on its ability to cope with non-medical issues. The challenge for the Kazakstan Government is to reform the health system in such a way that it will be both financially viable and provide comprehensive service to the population at large, including the most vulnerable groups. In April 1996, a national compulsory health insurance system was introduced in Kazakstan. The system has been developed to attract private funds to expand the health care sector and to move it away from govemment control. Under the new system, physicians are to operate within a group of private practitioners financed by the national insurance fund. Funds are meant to be employment-based, providing government funding for the elderly, students, the unemployed, and the disabled. Kazakstan is currently in the initial stages of transition from the former government-owned health care system, which fell into financial crisis, to the new system that is expected to be competitive and market-oriented. Meanwhile, the Ministry of Health of Kazakstan is in the process of developing programs to restructure the primary health care system, and improve maternal, child, environmental, and occupational health. As part of an intersectoral approach in health care reform, the National Nutrition Policy has been developed by the National Institute of Nutrition with technical assistance from UNDP, UNICEF, and WHO (National Institute of Nutrition, 1996). The Policy outlines emerging nutrition and health issues in Kazakstan during economic transition and stresses the needs in such areas as maternal and child nutrition, development of iron and iodine fortification programs, promotion of breastfeeding, improvement of the national food control and nutrition surveillance systems, coordination of food production and marketing, food provision for socially deprived population groups, etc. 1.3 Maternal and Child Health and Family Planning For many years, the Government of Kazakstan promoted policies to encourage women to have more children. Women in Kazakstan who had seven or more children were traditionally glorified and recognized as a "mother-hero" and provided with a number of benefits, including bonuses, housing assistance, extensive paid maternity leave, child benefits, support for day care, etc. Kazaks have historically been in favor of large families. A long history of pronatalist policies and traditions provides the backdrop within which all fertility policies must be designed. First, a fertility program must be supported by adequate maternal and child health services. Second, any introduction of family planning approaches must address fears, voiced by national political groups, regarding the reduction of the proportion of ethnic Kazaks within the overall ethnic structure of Kazakstan. Therefore, the Ministry of Health of Kazakstan incorporates family planning within a more comprehensive program of maternal and child health services, without specifying any demographic targets. To promote maternal and child health services, the Government of Kazakstan has built a nationwide multilevel network of health care facilities. The main health facility in this network that provides delivery assistance is the delivery hospital. Some births are delivered in the obstetrics/gynecology department of regular hospitals. In remote areas of Kazakstan, pre-doctoral delivery assistance is provided by the staff of doctor's assistant/midwife posts (FAPs). The major facilities responsible for antenatal care and family planning in urban areas are women's consulting centers and polyclinics. In rural areas, family planning services and antenatal care are the responsibility of the staff of rural hospitals and the FAPs. This system makes antenatal and delivery care available to women in virtually all regions, both urban and rural, including the remote areas of Kazakstan. Obstetricians and gynecologists in the facilities also provide family planning services; their main objectives are to reduce complications due to inadequately spaced pregnancies and to reduce the number of induced abortions. Despite initial successes in improving maternal and child health and overall reductions in maternal and child mortality during the last two decades, Kazakstan maintains morbidity and mortality patterns typical of developing countries. For instance, almost 80 percent of children in Kazakstan reportedly had some illness in 1995, mainly respiratory or diarrheal disease (Ministry of Health, 1996). Many children suffer from various forms of malnutrition and micronutrient deficiency. The infant mortality rate, which has remained relatively static since 1980, was 26.8 per 1,000 live births in 1995, according to the data of the Kazakstan State Committee on Statistics (Goskomstat, 1996). Data from the Kazakstan National Research Center on Maternal and Child Health show the 1994 and 1995 maternal mortality rates in Kazakstan to be 69.3 and 77.3 deaths per 100,000 live births, respectively. Most industrialized countries report rates of 3 to 10 deaths per 100,000 live births. The major causes of maternal death in Kazakstan are hemorrhage, induced abortion, extragenital diseases, and late gestosis, each accounting for 15 to 23 percent of the total deaths (Ministry of Health, 1996). Predisposing factors of maternal death are infection, extragenital diseases, malnutrition, iron-deficiency anemia, and other micronutrient deficiencies. Most of these maternal deaths could be prevented if steps were taken to identify high-risk pregnancies and implement preventive measures. Induced abortion is a significant cause of maternal mortality in Kazakstan. It accounts for 19 percent (41 cases) of maternal deaths in 1995 (Ministry of Health, 1996). Almost half of the maternal deaths caused by induced abortion were related to cases of illegal abortions. The rate of induced abortion in Kazakstan is reported by the Ministry of Health Statistical Office at 54.7 per 1,000 women of reproductive age in 1995, similar to the high levels observed in most Eastern European countries. 6 Since the legalization of induced abortion in 1955, it has been a primary method of birth control in Kazakstan. High prevalence of abortion is the result of both wide availability of providers who can perform the procedure free of charge, and public tolerance of the practice. Another contributing factor is an insufficient supply of alternative methods of birth control, such as oral contraceptives. In 1974, the Ministry of Health of the former Soviet Union published On the side effects and complications of oral contraceptives, a document which practically banned the distribution and use of oral contraceptives. In addition, in 1987, the former Soviet Government introduced and legalized vacuum aspiration for mini-abortions. These two regulations enabled unlimited use of various methods of inducing abortions and restricted women's choices of other safe methods of birth control. Only intrauterine devices were widely available. Despite some indications that the number of induced abortions has declined in the last several years, the abortion issue remains a great public health concern due to the prevalence of complications and overall adverse effects on women's health. Thus, while Kazakstan has indeed developed an advanced system of maternal and child health services, several health indicators have declined in the last several years as a result of deteriorating socioeconomic conditions, environmental problems, and cutbacks in health expenditures during the transition to a market economy. The challenge for the Government of Kazakstan is to develop appropriate long-term health strategies and to define priorities, particularly in the area of maternal and child health. Policy planning requires population-based data on reproductive health, fertility, infant mortality, and the nutritional status of women and children. Such data were collected in the Kazakstan Demographic and Health Survey. 1.4 Demographic and Health Data Collection System in Kazakstan The demographic and health data collection system in Kazakstan is based on the registration of events and periodic censuses. The data on births, deaths, marriages, and divorces are registered at the local admini- strative level of an internal passport control system. These data are then forwarded to the State Committee on Statistics ("Goskomstat") through the raion and oblast level statistical offices. Goskomstat is responsible for conducting censuses and maintaining this registration system. The last census in Kazakstan was conducted in 1989, and the data were made available in the 1990 publication of census results (Goskomstat, 1990). In addition, Goskomstat is responsible for tabulating and publishing an annual report of information on major economic and demographic categories generated by the registration system. Collection of health data in Kazakstan is a primary responsibility of the Statistical Department of the Ministry of Health. The original health information is generated under the responsibility of staff at the local health care facility and then sent to the Statistical Department through the raion and oblast level health de- partments. The Statistical Department of the Ministry of Health compiles and analyzes these data and issues annual reports entitled Health of the Population of the Republic of Kazakstan and Health Services. The re- ports are distributed on the national and oblast levels for use by health administrators, health professionals, etc. The health data collected and published by the Statistical Department of the Ministry of Health consists of the following major categories: 1) morbidity specified by type of disease (infectious and non- infectious); 2) mortality specified by causes of death; 3) infant deaths, including data on antenatal, perinatal, and early neonatal deaths; 4) maternal mortality specified by causes of maternal death; 5) data on maternal and child health, including antenatal care and delivery assistance, 'contraceptive clients, induced abortion rates, pediatric services, vaccination coverage, etc; 6) number of health facilities, medical personnel, hospital beds, and length of average stay in the hospital; and 7) health data specified by type of medical services including medical care for patients with cancer, tuberculosis, mental disorders, drug abuse, and sexually transmitted diseases. These data are usually tabulated at the national and oblast levels, and for some categories, by the age groups 0-14 and 15 or more years. 1.5 Objectives and Organization of the Survey The purpose of the 1995 Kazakstan Demographic and Health Survey (KDHS) was to provide an information base to the Ministry of Health for the planning of policies and programs regarding the health and nutrition of women and their children. The 1995 KDHS collected data on women's reproductive histories, knowledge and use of methods of contraception, breastfeeding practices, nutrition indicators, vaccination coverage, and episodes of diseases among children under age three. The survey also included measurement of hemoglobin levels in the blood to assess the prevalence of anemia, and measurements of height and weight to assess nutritional status. A secondary objective of the survey was to enhance the capabilities of institutions in Kazakstan to collect, process, and analyze population and health data so as to facilitate the implementation of future surveys of this type. The 1995 KDHS was the first national level population and health survey in Kazakstan. It was implemented by the National Institute of Nutrition, Republic of Kazakstan. The Kazakstan Academy of Preventive Medicine contributed significantly to the analysis of the KDHS results. The 1995 KDHS was funded by the United States Agency for International Development (USAID) and technical assistance was provided by Macro International Inc. (Calverton, Maryland USA) through its contract with USAID. 1.5.1 Sample Design and ImpLementation The 1995 KDHS employed a nationally representative probability sample of women age 15-49. The country was divided into five survey regions (Figure IA). Four survey regions consisted of groups of contiguous oblasts (except the East Kazakstanskaya oblast which is not contiguous). Almaty City constituted a survey region by itself although it is part of the Almatinskaya oblast. The five survey regions were defined as follows: I) Almaty City 2) South Region: Taldy-Korganskaya, Almatinskaya (except Almaty city), Dzhambylskaya, South Kazakstanskaya, and Kzyl-Ordinskaya 3) West Region: Aktiubinskaya, Mangistauskaya, Atyrauskaya, and West Kazakstanskaya 4) Central Region: Semipalatinskaya, Zhezkazganskaya, and Tourgaiskaya 5) North and East Region: East Kazakstanskaya, Pavlodarskaya, Karagandinskaya, Akmolinskaya, Kokchetauskaya, North Kazakstanskaya, and Koustanaiskaya It is important to note that the oblast composition of regions outside of Almaty City was determined on the basis of geographic proximity, and in order to achieve similarity with respect to reproductive practices within regions. The South and West Regions are comprised of oblasts which traditionally have a high proportion of Kazak population and high fertility levels. The Central Region contains three oblasts in which the fertility level is similar to the national average. The North and East Region contains seven oblasts situated in northern Kazakstan in which a relatively high proportion of the population is of Russian origin, and the fertility level is lower than the national average. Figure 1.1 OBLAST COMPOSITION OF REGIONS IN KAZAKSTAN, 1995 KDHS RUSSIA '~ ULD=I~IO i ,~1~ ~ ALMA1Pt CITy ALMATY CiTY SOUTH WEST CENTRAL NORTH and EAST CITY OF ALMATY SOUTH 1. KzyI-Ordinskaya 2. South Kazakstanskaya 3. Zhambylskaya 4. Almatinskaya 5. Taldy-Korganskaya WEST 6. Aktiubinskaya 7. Atyrauskaya 8. Mangistauskaya 9. West Kazakstanskaya CENTRAL 10. Tourgaiskaya 11. Zhezkazganskaya 12. Semipalatinskaya NORTH and EAST 13. Koustanaiskaya 14. North Kazakstanskaya 15. Kokchetauskaya 16. PavIodarskaya 17. Akmolinskaya 18. Karagandinskaya 19. East Kazakstanskaya 9 In Almaty City, the sample for the 1995 KDHS was selected in two stages. In the first stage, 40 census counting blocks were selected with equal probability from the 1989 list of census counting blocks. A complete listing of the households in the selected counting blocks was carried out. The lists of households served as the frame for second-stage sampling; i.e., the selection of the households to be visited by the KDHS interviewing teams. In each selected household, women age 15-49 were eligible to be interviewed. In the rural areas, the primary sampling units (PSUs) were the raions which were selected with probability proportional to size, the size being the 1993 population published by Goskomstat (1993). At the second stage, one village was selected in each selected raion, from the 1989 Registry of Villages. This resulted in 50 rural clusters being selected. At the third stage, households were selected in each cluster following the household listing operation as in Almaty City. In the urban areas other than Almaty City, the PSUs were the cities and towns themselves. In the second stage, one health block was selected from each town except in self-representing cities (large cities that were selected with certainty) where more than one health block was selected. The selected health blocks were segmented prior to the household listing operation which provided the household lists for the third stage selection of households. In total, 86 health blocks were selected. On average, 22 households were selected in each urban cluster, and 33 households were selected in each rural cluster. It was expected that the sample would yield interviews with approximately 4,000 women between the ages of 15 and 49. Because of the nonproportional distribution of the sample to the different survey regions, sampling weights have been applied to the data in this report. Details concerning the KDHS sample design are provided in Appendix A and the estinaation of sampling errors are included in Appendix B. 1.5.2 Questionnaires Two questionnaires were used for the 1995 KDHS: the Household Questionnaire and the Individual Questionnaire. The questionnaires were based on the model survey instruments developed in the DHS program. They were adapted to the data needs of Kazakstan during consultations with specialists in the areas of reproductive health, child health and nutrition in Kazakstan. The Household Questionnaire was used to enumerate all usual members and visitors in tile sample households and to collect information relating to the socioeconomic position of a household. In the: first part of the Household Questionnaire, information was collected on age, sex, educational attainment, marital status, and relationship to the head of household of each person listed as a household member or visitor. A primary objective of the first part of the Household Questionnaire was to identify women who were eligible for the individual interview. In the second part of the Household Questionnaire, questions were included on the dwelling unit, such as the number of rooms, the flooring material, the source of water, the type. of toilet facilities, and on the availability of a variety of consumer goods. The Individual Questionnaire was used to collect information from women age 15-49. These women were asked questions on the following major topics: Background characteristics Pregnancy history Outcome of pregnancies and antenatal care Child health and nutrition practices Child immunization and episodes of diarrhea and respiratory illness 10 Knowledge and use of contraception Marriage and fertility preferences Husband's background and woman's work Anthropometry of children and mothers Hemoglobin measurement of women and children One of the major efforts of the 1995 KDHS was testing women and children for iron-deficiency anemia. Testing was done by measuring hemoglobin levels in the blood using the Hemocue technique. Before collecting the blood sample, each woman was asked to sign a consent form giving permission for the collection of a finger-stick blood droplet from herself and her children. Results of anemia testing were kept confidential (as are all KDHS data); however, strictly with the consent of respondents, local health care facilities were informed of women and children who had severely low levels of hemoglobin (less than 7 g/dl). 1.5.3 Training and Fieldwork The 1995 KDHS questionnaires were pretested in December 1994. Six female interviewers were trained over a two-week period at the Institute of Nutrition. The pretest included one week of interviewing in an urban area (AImaty City) and one week in a rural area. A total of 124 women were interviewed. Based on the pretest experience, the questionnaires were modified. Pretest interviewers were retained to serve as supervisors and field editors for the main survey. Female nursing students of the National Medical College were recruited as interviewers and male students were recruited as medical technicians for the main survey. A total of 40 students were trained at the Medical College for four weeks from mid-April to mid-May 1995. Training consisted of in-class lectures and practice, as well as interviewing in the field. Interviewers were selected based on their performance during the training period. The data collection was carried out by four teams. Each team consisted of eight members: the team supervisor, one editor, one household interviewer, four individual women interviewers, and one medical technician (responsible for height and weight measurement and anemia testing). All team members other than the medical technician were female. Fieldwork for the KDHS was conducted from May to September 1995. 1.5.4 Data Processing Questionnaires were returned to the Institute of Nutrition in Almaty for data processing. The office editing staff checked that the questionnaires for all selected households and eligible respondents were retumed from the field. The few questions which had not been precoded (e.g., occupation, type of chronic disease) were coded at this time. Data were then entered and edited on microcomputers using the ISSA (Integrated System for Survey Analysis) package, with the data entry software translated into Russian. Office editing and data entry activities began in May 1995 (i.e., the same time that fieldwork started) and were completed in September 1995. 1.5.5 Response Rates Table 1.1 presents information on the coverage of the 1995 KDHS sample including household and individual response rates. A total of 4,480 households were selected in the sample, of which 4,241 were occupied at the time of fieldwork. The main reason for the difference was that some dwelling units which were occupied at the time of the household listing operation were either vacant or the household members were away for an extended period at the time of interviewing. Of the 4,241 occupied households, 4,178 were interviewed, yielding a household response rate of 99 percent. 11 In the interviewed households, 3,899 women were eligible for the individual interview (i.e., all women 15-49 years of age who were either usual residents or visitors who had spent the previous night in the household). Interviews were successfully completed with 3,771 of these women, yielding a response rate of 97 percent. The principal reason for nonresponse was the failure to find an eligible woman at home after repeated visits to the household. The overall response rate for the survey--the product of the household and the individual response rates- -was 95 percent. Table 1.1 Results of the household and individual interviews Number of households, number of interviews and response rates, Kazakstan 1995 Residence Result Urban Rural Total Household interviews Households sampled 2,808 1,672 4,480 Households found 2,627 1,614 4,241 Households interviewed 2,570 1,608 4,178 Household response rate 97.8 Individual interviews Number o f eligible women 2,131 Number of eligible women interviewed 2,056 Eligible woman response rate 96.5 99.6 98.5 1,768 3,899 1,715 3,771 97.0 96.7 12 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Shamshiddin A. Balgimbekov and Raimbek Sissemaliev Data about the background characteristics of the households and respondents are presented in this chapter. Since demographic and health parameters are largely determined by sociobiological factors, this information is important in interpreting results. Moreover, data on characteristics of households and respondents can serve as an indicator of the representativeness of the sample and of the quality of the data obtained. This chapter includes three sections: characteristics of the household population (household structure, age-sex characteristics, level of education of the household members); housing characteristics (presence of electricity, source of drinking water, sanitation, etc.) and background characteristics of survey respondents (residence, age, ethnicity, marital status, occupation, etc.). 2.1 Household Population The KDHS Household Questionnaire was intended to elicit data on the sociodemographic characteristics of the members and visitors in each identified household. A household was defined as a person or group of persons usually living and eating together and jointly running the household's economy (de jure population). Visitors were persons who were not household members but had spent the night before the interview in the selected household. All female household members and visitors 15-49 years of age were eligible as respondents for the individual interview. The total de facto population in the selected households was 15,635 people. 2.1.1 Sex and Age Composition Table 2.1 presents the distribution of the de facto household population by five-year age groups according to sex and residence. Almost one-third of the population consists of children under 14 years of age (32 percent), with the proportion of children in mral areas higher than in urban areas (37 and 26 percent, respectively). Starting from age group 35-39, there is a gradual decrease in the proportion of subsequent age groups. In general, the number of women exceeds the number of men. This difference is more notable in urban areas. One-fourth of the de facto household population consists of women 15-49 years of age who are the main KDHS respondents. As seen in Figure 2.1, the age-sex structure of the Kazakstan population has the form of a pyramid with a wide base, gradually tapering to a sharp peak. The relatively small size of the male and female population in the age interval 50-54 is a reflection of the low birth rates during World War II (i.e., 50 to 55 years prior to the KDHS). It is interesting to compare 1995 KDHS data with the 1989 Census (Table 2.2). Correspondence of the percent distribution of the population in broad age groups between the 1995 KDHS and the 1989 Census confirms the representativeness of the KDHS sample. 13 Table 2.1 Household population by age~ residence and sex Percent distribution of the de facto household population by age, according to sex and residence, Kazakstan 1995 Age Urban Rural Total Male Female Total Male Female Total Male Female Total 0-4 7.8 6.7 7.2 12.3 I 1.5 11.9 10.3 9.2 9.7 5-9 9.4 9,0 9.2 13.4 12.2 12.8 11.6 10.7 11.1 10-14 10.4 9.6 10.0 11.8 I 1.7 11.8 11.2 10.7 10.9 15-19 9.3 8.4 8.9 9.8 8.9 9.4 9.6 8.7 9.1 20-24 7.8 6.1 6.9 9.0 8.4 8.7 8.4 7.3 7.9 25-29 7.2 7,1 7.1 8.5 6.3 7.4 7.9 6.7 7.3 30-34 8.6 6.7 7,6 7.5 7.5 7.5 8.0 7.1 7.5 35-39 8.2 8.2 8.2 6.6 6.2 6.4 7.3 7.2 7.2 40-~ 8.6 8.1 8.3 4.4 4.7 4.6 6.3 6,3 6.3 45-49 5.6 5.4 5.5 4.6 3.8 4.2 5.0 4.5 4.8 50-54 3.7 4.4 4.1 2.5 3.4 2.9 3.0 3.9 3.5 55-59 5.2 6.0 5.6 4.2 4.6 4.4 4.6 5.3 4.9 60-64 2.9 3.4 3.2 2.0 3.1 2.5 2.4 3.2 2.8 65-69 3.3 4.3 3.8 1.4 2.8 2.1 2.3 3.5 2.9 70-74 1.2 2.8 2.1 1.3 2.0 1,7 1.3 2.4 1.9 75-79 0.5 1.7 1.2 0.5 1.3 0,9 0,5 1.5 1.0 80+ 0.5 2.0 1.3 0.3 1.5 0.9 0.4 1.7 1.1 Missin~Don't know 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,358 3,864 7,222 4,137 4,277 8,413 7,495 8,141 15,635 Ago 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Figure 2.1 Population Pyramid of Kazakstan 6 5 4 3 2 1 0 1 2 3 Percent KDHS1995 14 2.1.2 Household Composition Table 2.3 presents information on the size and composition of households according to urban-rural residence. The head of house- hold (as recognized by other members) and the relationship of each household member to the head was determined in each household. In general, heads of households mainly were males (68 percent), and in urban areas the proportion of households headed by men (61 percent) was less than in rural areas (77 percent). About 70 percent of households consist of 1-4 members, with the average size of a household in Kazakstan being 3.8 mem- bers. There are significant differences in the household size between urban and rural areas, with the average urban household consisting of 3.1 members compared to 4.7 in rural households. Only 3 percent of households include a child under 15 neither of whose parents were household members. Table 2.2 Population by age from selected sources Percent distribution of the de jure popu- lation by age group, selected sources, Kazakstan 1989 and 1995 1995 1989 Age KDHS Census <15 31,0 31.8 15-64 62.1 62.5 65+ 6.9 5.7 Total 100.0 100.0 Median age 26.5 26.9 Dependency ratio 61.0 60.0 Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, and percentage of households with foster children, according to residence, Kazakstan 1995 Characteristic Residence Urban Rural Total Household headship Male 61.3 76.6 68.0 Female 38.7 23.4 32.0 Total 100.0 100.0 100.0 Number of members 1 16.2 5.6 11.6 2 23.6 11.4 18.3 3 20.8 14.l 17.9 4 21.5 19.9 20.8 5 10,0 16.7 12.9 6 4.6 13.5 8.4 7 1.5 8.8 4.7 8 0.6 4.8 2.4 9+ 0.9 5.2 2.8 Total 100.0 100.0 100.0 Mean size 3.1 4.7 3.8 Percent with foster children 2.2 4.4 3,1 Note: Table is based on de jure members; i.e., usual residents. Table 2.4 presents information on children under age 15 by survival status of the parents according to selected sociobiological factors. Seventy-nine percent of children under age 15 live with both parents. As children get older, fewer of them live with both parents; 86 percent of children in age group 0-2 live with both parents, compared to 75 percent in the age group 12 years or more. Rural chil- dren are more likely than urban children to live with both parents. It is notable that a greater percent of chil- dren live with both parents in the Soutbern and Western Regions (83 percent in each region). Twelve percent of children under 15 are living with only their mother; of these, 3 percent have lost their fathers and 9 percent have fathers who are still alive. There are distinctions in this parameter depending on age of children, sex, and place of residence. It is notable that a significant number of children (6 percent) are not living with their parents though both parents are alive. Regarding orphanhood, about 4 percent of chil- dren under 15 have fathers who have died and less than 1 percent have mothers who have died, while only a tiny fraction have lost both parents. 15 Table 2.4 Fosterhood and orphanhood Percent distribution of de facto children under age fifteen by their living arrangement and survival status of parents, according to child's age, sex, residence, and region, Kazakstan 1995 Living Living with mother with father Not living with but not father but not mother either parent Living Missing with Father Mother info. on Number Background both Father Father Mother Mother Both only only Both father/ of characteristic parents alive dead alive dead alive alive alive dead mother Total children Age 0-2 85.9 10.1 0.8 0.0 0.0 2.9 0.0 0.0 0.0 0.4 100.0 870 3-5 81.6 10.7 1.2 0.7 0.2 5.0 0.1 0.3 0.0 0.2 1130.0 981 6-8 78.1 10.2 2.6 0.2 1.0 7.3 0.0 0.1 0.0 0.3 100.0 1,056 %11 76.7 6.5 4.6 1.0 0.9 9.4 0.0 0.2 0.0 0.6 100.0 1,033 12+ 74.6 7.4 6.1 1.6 1.4 6.9 0.3 0.3 0.3 1.0 100.0 1,034 Sex Male 80.2 7.9 3.6 1.0 1.1 5,5 0.1 0.1 0.1 0.4 100.0 2,478 Female 78.2 9.9 2.8 0.4 0.3 7.3 0.1 0.2 0.1 0.6 100.0 2,496 Residence Urban 75.7 12.3 2.8 0.8 0.5 6.6 0.2 0.2 0.0 0.8 100.0 1,907 Rural 81.3 6.8 3.4 0.6 0.8 6.3 01 0.2 0.1 0.4 100.0 3,067 Region Almaty City 68.6 18.7 6.0 1.0 0.0 3.7 0.6 0.6 0.0 0.8 100.0 188 South 82.7 5.6 3.1 0.7 0.9 6.5 0.1 0.0 0.1 0.4 100.0 2,286 West 82.7 7.5 3.4 0.4 1.5 3.9 0.1 0.3 00 0.4 100.0 718 Central 75.2 9.7 4.6 0.1 0.8 8.1 0.4 0.1 0.1 0.8 100.0 447 North and East 74.1 13.7 2.4 1.1 0.1 7.4 0.0 0.4 0.0 0.7 100.0 1,335 Total 79.2 8.9 3.2 0.7 0.7 6.4 0.1 0.2 0.1 0.5 100.0 4,974 Note: By convention, foster children are those who are not living with either parent. This includes orphans, i.e., children both of whose parents are dead. 2.1.3 Educational Level of Household Members One of the most important background characteristics is the level of education of the household members. The parameters of reproductive health of women and the health status of children in many respects depend on educational level. According to the Constitution of the former Soviet Union, every person has a guarantee in getting secondary, secondary-special or higher education. In Kazakstan, most children begin to attend school at seven years of age (see chapter 1.1.4 on the educational system in Kazakstan). 16 The KDHS results confirm the high educational level of the Kazakstan population. As can be seen in Table 2.5, 95 percent of women have had at least some education. A high percentage of the women have secondary-special and higher education, especially those in the 20-49 age group. The educational level of urban women is higher than for rural women. There are educational differences between women in Almaty city and other regions. The median number of years of schooling is 10 for women. Table 2.5 Educational level of the female household population Percent distribution of the de facto female household population age seven and over by highest level of education attended, and median number of years of schooling, according to selected background characteristics, Kazakstan 1995 Level of education Median Background No Primary/ Secondary- years of characteristic education Secondary Special Higher Missing Total Number schooling Age 7-9 12,0 88.0 0,0 0.0 0.0 100,0 520 2.2 10-14 0.1 99.9 0.1 0.0 0.0 100.0 873 6,6 15-19 02 66.9 25.9 7.1 0.0 100.0 709 10,5 20-24 06 35.6 494 14.4 0.0 1000 597 11 0 25-29 0,0 25.6 49.7 24.7 0.0 100.0 543 110 30-34 0.0 30.4 49.9 19.7 0.0 100.0 580 10,9 35-39 0.4 36.8 43.8 18.3 0.7 100.0 583 10,8 40-44 04 34.8 46.8 17.3 06 100.0 515 109 45-49 13 42.2 36,7 18.3 1.5 100,0 370 10,9 50-54 0,2 63.2 21,7 14.4 0,5 100,0 316 102 55-59 3,6 61.9 23,6 9.8 1,2 100.0 428 9,1 60-64 15.5 63.1 12.3 9.1 0.0 100.0 263 70 65+ 23.0 62.7 10.5 3.5 0.3 100.0 741 4.8 Residence Urban 3.6 473 32.4 16,2 05 100.0 3,471 104 Rural 5.0 655 23.1 6,2 01 100.0 3,567 95 Region Ahnaty City 2.1 40.7 26.2 30.7 0.3 100.0 435 10,9 South 52 62.4 23.7 84 0.2 100.0 2,638 9.9 West 4.2 57.2 28.4 10.2 0.0 100.0 963 10.0 Central 3.2 52.9 31.8 12 0 0.1 100.0 628 10.1 North and East 4.0 53.6 31.0 10,8 0.6 100,0 2,374 10.1 Total 43 56.5 277 I 1.2 0.3 100.0 7,038 10 1 17 Data in Table 2.6 show that men in Kazakstan also have a high educational level. Thirty-eight percent of men have secondary-special and higher education, and in certain age groups, the proportion is about 60 percent. The proportion of men with higher education is greater in urban areas than rural (18 and 7 percent, respectively). The median duration of studying is higher in Almaty(10.8 years), than in the other four regions, where this parameter is almost identical (10.1-10.3 years). Table 2.6 Educational level of the male household population Percent distribution of the de facto male household population age seven and over by highest level of education attended, and median number of years of schooling, according to selected background characteristics. Kazakstan 1995 Level of education Median Background No Primary/ Secondary- years of characteristic education Secondary Special Higher Missing Total Number schooling Age 7-9 13.8 86.2 0.0 0.0 0.0 100.0 520 2.1 10-14 0.2 99.8 0.0 0.0 0.0 100.0 837 6.5 15-19 1.0 75.1 18.5 5.4 0.0 100.0 718 10.1 20-24 0.1 50.0 37.6 12.2 0.1 100.0 631 11.0 25-29 0.1 39.3 43.9 16.2 0.6 100.0 593 11.0 30-34 0.7 39.3 40.9 18.1 1.0 100.0 599 11.0 35-39 0.0 38.5 44.3 16.6 0.6 100.0 547 109 40-44 0.3 39.5 41.0 18.7 0.5 100.0 470 10.8 45-49 0.0 45.5 35.7 17.3 1.5 100.0 375 11.0 50-54 0.7 53.7 24.7 19.3 1.7 100.0 225 10.7 55-59 1.7 54.0 26.5 17.3 0.6 100.0 346 10.2 60-64 8.8 58.9 18.3 13.7 0.2 100.0 180 7.6 65+ 8.3 58.6 17.9 14.4 0.8 100.0 330 7.5 Residence Urban 1.7 49.2 30.9 17.5 0.6 100.0 2,957 10.5 Rural 2.6 68.1 22.6 6.5 0.4 100.0 3,417 10.0 Region Almaty City 1.6 455 23.0 29.6 03 100.0 329 10.8 South 2.7 63.4 22.1 11.5 0.4 100.0 2,550 10.3 West 2.0 63.4 23.8 10.7 0.0 1000 865 10.2 Central 1.6 56.9 29.4 I 1.6 0 5 1000 546 10.1 North and East 1.8 55.5 32.6 9.3 0.8 100.0 2,084 10.1 Total 2.2 59.3 26.4 11.6 0.5 100.0 6,374 10.2 To predict a general educational level of the population of the country, it is important to have information about school enrollment of the children and young people under age 24. As can be seen in Table 2.7 and Figure 2.2, 85 percent of children age 7-17 were enrolled in school, with only slight differences by residence and sex. Not everyone continues studying in secondary-special and higher educational institutions after high school. Only one in four of those age 18-20 and only one in ten of those age 21-24 are enrolled in school. As age increases, the urban-rural gap widens such that the proportion enrolled in school is more than twice in urban than in rural areas. Although women generally have slightly higher enrollment rates than men, this advantage reverses among those age 21-24. 18 Table 2.7 School enrollment Percentage of the de facto household population age 7-24 years enrolled in school, by age, sex, and residence, Kazakstan 1995 Male Female Total Age Urban Rural Total Urban Rural Total Urban Rural Total 7-17 86.4 81.4 83.4 87.2 87.1 87.1 86.8 84.2 85.2 18-20 35.5 13.3 23.4 36.7 19,9 28.1 36.1 16.5 25.8 21-24 17.2 8.5 12.1 16.0 4.1 8.8 16.6 6.3 10.4 Figure 2.2 School Enrollment by Age and Sex 100 80 60 40 20 0 Percent , . . . . . . . . . . . T . . . . . . . . . . . . . . . . . . . . . ] - 7-17 19-20 21-24 Age Group [-~ M--aie~ F--em-ffie i KDHS 1995 2.2 Housing Characteristics In order to assess the socioeconomic conditions of respondents, appropriate information on housing was collected. Table 2.8 presents the data on source of drinking water, sanitation, quality of the floor and crowding, which are important determinants of the health status of household members, particularly of children. 19 As can be seen from Table 2.8 and Figure 2.3, all households in Kazakstan are supplied with electrici- ty. That is the result of the successful policy of universal electrification that took place in the former Soviet Union. The source of drinking water usually determines its quality. Eighty-five percent of households in Kazak- stan have piped water, mostly piped into the residence. Most other households use well water. Almost all urban households use piped water (97 percent), almost all of which have the pipes inside. In rural areas, 70 percent of households have piped water, while more than one-fifth of the population uses water from wells. It is rare for people to use drinking water from tanker trucks, rivers, and other open water sources. Almost 90 percent of households in Kazakstan are within 15 minutes of the source of their water. One indicator of sanitary conditions is the type of toilet in a household. In Kazakstan, a majority of households (57 percent) have pit toilets (latrines) and 42 percent have flush toilets. In urban areas, 73 percent of households have flush toilets, while in rural areas, 96 percent have traditional pit toilets. During the interview, interviewers noted the type of material from which the floor in each household was made. As can be seen from the data, 75 percent of households have a wooden floor and 22 percent of households use linoleum. In rural areas, floors are main- ly made from wood (94 percent) and in cities, along with wood, people use linoleum (37 percent). An important indicator of housing conditions is the level of crowding, which was estimated by the num- ber of persons sleeping in one room and the average number of persons per sleeping room. Both in cities and in villages, more than 90 percent of households have between one and two persons sleeping in a room. The average number of persons per room is a little bit higher in rural areas than in urban areas (1.6 and 1.3 percent, respectively). 2.2.1 Household Durable Goods One criterion of the socioeconomic well-being of a household is ownership of various durable goods Table 2.8 Housing characteristics Percent distribution of households by housing characteristics, according to residence, Kazakstan 1995 Residence Characteristic Urban Rural Total Electricity Yes 99.9 99.9 99.9 No 0.1 0.1 0.1 Total I00.0 100.0 100.0 Source of drinking water Piped into residence 90.5 32.5 65.4 Public tap 6.4 37.0 19.6 Well in residence 1.7 11.2 5.8 Public well 0.5 I 1.8 5.4 Spring 0.0 1.0 0.4 River/stream 0.1 3.2 1.4 Pond/lake 0.0 0.3 0.1 Tanker truck 0.8 2.9 1.7 Other 0.0 0.2 0.1 Total 100.0 100.0 100.0 Time to water source (in minutes) <15 minutes 96.7 75.9 87.7 Median time to source 0.5 4.1 0.7 Sanitation facility Own flush toilet 72.8 2.4 42.3 Shared flush toilet 0.3 0.0 0.2 Traditional pit toilet 26.6 95.9 56.6 Ventilated improved pit latrine 0.2 0.0 0.1 No facility/bush 0.1 1.7 0.8 Total 100.0 100.0 100.0 Floor material Wood planks 60.5 93.9 75.0 Linoleum 36.9 3.1 22.3 Parquet/polished wood 2.0 0.6 1.4 Earth/sand 0.0 1.9 0,8 Cement 0.0 0.3 0.1 Other 0.4 O. 1 0.3 Total 100.0 100.0 100.0 Personspersleepingroom 1-2 95.2 92.4 94.0 3-4 4.3 7.0 5.5 5-6 0.5 0.3 0.4 7+ 0.0 0.3 0.1 Total 100.0 100.0 100.0 Mean persons per sleeping room Number of households 1.3 1.6 1.4 2,368 1,810 4,178 (radio, television, telephone, and refrigerator), and means of transport (bicycle, motorcycle, and private car). Presence of a radio and television set in a household is also an indicator of availability of information. 20 Figure 2.3 Housing Characteristics by Residence 100 80 60 40 20 0 Percent of Households Electricity Piped Water Flush Toilet (in residence) TOTALj KDHS 1995 Table 2.9 shows that urban households are more likely than rural households to have these durable goods, especially radios, telephones, television sets, and refrigerators. An approximately equal proportion of urban and rural households own bicycles and private vehicles. The higher proportion of rural than urban households owning a motorcycle is due to the greater need for transport in rural areas. Overall, 90 percent of households in Kazakstan have television, 82 percent have refrigerators, but only half have radios and only 38 percent have telephones. Less than one in four households owns a car. 2.3 Characteristics of Survey Respondents 2.3.1 Background Characteristics The information in this section is important for interpretation of the main results of the study. Table 2.10 presents the percent distribution of women 15-49 by age, marital status, residence, region, educational level, religion, and ethnicity. Table 2.9 Household durable goods Percentage of households possessing various durable consumer goods, by residence, Kazakstan 1995 Residence Durable goods Urban Rural Total Radio 62.0 36.9 51.1 Television 92.7 85.6 89.6 Telephone 48.9 22.6 37.5 Refrigerator 92.4 69.3 82.4 Bicycle 17.7 16.7 17.3 Motorcycle 7.0 15.9 10.9 Private car 24.0 21.3 22.9 None of the above 1.7 6.2 3.7 Number of households 2,368 1,810 4,178 To obtain the exact age of the women, the KDHS questionnaire included two questions: "In what month and year were you born?" and "How old are you?" To these questions special attention was given during the training of the interviewers. Interviewers learned how to use probing techniques for situations in which respondents did not know their date of birth. 21 Table 2.10 Background characteristics of respondents Percent distribution of women 15-49 by selected background characteristics, Kazakstan 1995 Number of women Background Weighted Un- characteristic percent Weighted weighted Age 15-19 17.7 669 660 20-24 15.0 567 586 25-29 13.8 521 530 30-34 14.8 557 558 35-39 14.9 564 562 40-44 14.3 537 505 45-49 9.4 355 370 Marital status Never married 23.5 885 912 Married 64.0 2,413 2,371 Living together 2.5 94 86 Widowed 2.9 108 115 Divorced 5.4 204 221 Not living together 1.8 67 66 Residence Urban 56.6 2,133 2,056 Rural 43.4 1,638 1,715 Region Almaty City 7.2 271 615 South 32.0 1,206 920 West 12.7 477 830 Central 9.5 358 726 North and East 38.7 1,458 680 Education Primary/secondary 36.6 1,380 1,397 Secondary-special 45.6 1,721 1,630 Higher 17.8 670 744 Respondent still in school Yes 11.9 449 455 No 88.1 3,322 3,316 Religion Muslim 50.8 1,914 2,106 Christian 32.8 1,238 1,110 Other 1.3 51 41 Not religious 13.2 499 455 Don't know 1.8 69 59 Ethnicity Kazak 45.0 1,696 1.937 Russian 34.7 1.309 1.178 Ukrainian 3.8 141 120 German 3.8 142 116 Byelorussian 0.9 35 28 Tatar 1.6 61 68 Uzbek 1.1 42 28 Other 9.1 344 296 Total 100.0 3,771 3,771 As shown in Table 2.10, female respondents are rather equally distributed by age groups, except for a smaller proportion at age 45-49. The majority of the women are married or l iving with a man (67 percent), but there is also a significant proportion of never-married women (24 percent), and widowed, divorced, or separated women (10 percent). More than half of women 15-49 live in urban areas (57 percent). More than 70 percent of the respondents live in the South and the North and East Regions. All women 15-49 have at least some education and 63 percent have secondary-special or higher education. Twelve percent are still in school. 22 More than half of the female respondents are Muslim, while one-third are Christian. There are a significant number of women (13 percent) who are not religious. The ethnic structure of the respondents basically represents two large ethnic groups: Kazaks (45 percent) and Russians (35 percent). Table 2.11 shows the distribution of women 15-49 by ethnicity, religion, and residence according to region. It shows that the South, West and Central Regions have a higher than average concentration of Kazaks, while Russians make up a majority of the respondents in Almaty city and the North and East Region. Similarly, Muslims tend to be concentrated in the South, West and Central Regions, while Christians are concentrated in Almaty City and the North and East Region. Table 2.11 Ethnicity, religion and residence by region Percent distribution of women 15-49 by ethnicity, religion and residence, according to region, Kazakstan 1995 Region North Background Almaty and characteristic City South West Central East Total Ethnicity Kazak 25.7 67.5 69.0 53.5 20.0 45,0 Russian 55.6 12.2 21.0 30.9 54.9 34.7 Ukrainian 3.9 0.3 2.9 2.9 7.1 3.8 German 1.6 0.6 1.3 5.2 7.2 3.8 Byelorussian 0.3 0.1 0.7 1.0 1.8 0.9 Tatar 2.3 0.8 1.4 3.8 1.7 1.6 Uzbek 0.5 3.1 0.0 0.0 0.3 1.1 Other 10.1 15.4 3.7 2.7 7.1 9.1 Religion Muslim 30.7 83.0 69.6 51.7 21,4 50.8 Christian 49.1 12.1 24.0 26.0 51.5 32.8 Other 1.5 0.9 0.2 1.3 2.1 1.3 Not religious 16.9 3.7 5.6 18.7 21,6 13.2 Don't know 1,8 0.4 0.6 2.3 3.3 1.8 Residence Urban 100,0 41.6 55.7 55.9 61.3 56.6 Rural 0.0 58.4 44.3 44.1 38.7 43.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 271 1,206 477 358 1,458 3,771 2.3.2 Educational Level of the Respondents Table 2.12 shows the percent distribution of women by the highest level of education attended, according to background characteristics. As will be seen later in the report, differences in the reproductive health of the women in many respects are related to differences in the level of education. Thirty-seven percent of respondents have attended primary/secondary schools, 46 percent have attended secondary-special schools, and 18 percent have reached higher education schools. Women age 25- 44 tend to have more education than younger or older women. There are significant differences in education between urban and rural areas and between regions. The proportion of respondents with higher education in 23 Table 2.12 Level of education Percent distribution of women by the highest level of education attended, according to selected background characteristics, Kazakstan 1995 Highest level of education Number Background Primary/ Secondary- of characteristic Secondary special Higher Total women Age 15-19 63.5 28.6 7.9 100.0 669 20-24 35.5 49.5 15.0 100.0 567 25-29 22.3 50.9 26.7 100.0 521 30-34 27.2 52.0 20.8 1 (30.0 557 35-39 32.2 48.4 19.3 100.0 564 40-44 30.5 50.6 18.9 100.0 537 45-49 39.5 41.7 18.7 100.0 355 Residence Urban 27.9 48.3 23.8 100.0 2,133 Rural 48.0 42.1 9.9 100.0 1,638 Region Almaty City 25.9 33.3 40.8 100.0 271 South 45.7 40.1 14.2 100.0 1,206 West 41.5 42.4 16.1 l (30.0 477 Central 31.2 50.0 18.7 100.0 358 North and East 30.8 52.5 16.7 100.0 1,458 Ethnicity Kazak 39. I 40.2 20.6 100.0 1,696 Russian 27.4 54.4 18.2 100.0 1,309 Other 46.8 42.5 10.7 100.0 766 Total 36.6 45.6 17.8 100.0 3,771 urban areas is twice that in rural areas, and almost three times more in Almaty city than in the other regions. Russian women are more educated on average than Kazak women, with the latter more likely to have only primary/secondary education; on the other hand, Kazak women are slightly more likely than Russian women to have reached higher education. 2.3.3 School Attendance and Reasons for Leaving School Because of the apparent effect of women's education on so many demographic and health itldicators, it is interesting to analyze the reasons why women leave school. As shown in Table 2.13, 35 percent of women age 15-24 currently attend school. The main reasons for leaving school are marriage and the sufficiency of obtained education. Ten percent of the women declare that they left school in order to earn money. Women who leave school early in their education are more likely to leave to get married or to earn money or because they did not like school, compared to those who leave at a higher level of education. 24 Table 2.13 School attendance and reasons for leaving school Percent distribution of women 15 to 24 by whether attending school and reason for leaving school, according to highest level of education attended and residence, Kazakstan 1995 Educational attainment Reason for Incomplete Complete leaving school secondary secondary Higher Total TOTAL Currently attending 44.1 23.9 72.0 35.1 Got pregnant 0.7 1.0 1.1 0.9 Got married 10.2 17.6 0.8 13.6 Take care of younger children 1.2 0.8 0.3 0.9 Family need help 5.4 7.2 1.4 6.0 Need to earn money 9.2 11.1 2.2 9.5 Graduated/Enough school 6.2 16.8 20.2 14.1 Did not pass exams 2.5 7.0 0.0 4.9 Did not like school 12.4 6.0 1.9 7.4 School not accessible 3.3 0.7 0.0 1.4 Applying for school 1.1 6.2 0.0 4.0 Other 3.6 1.4 0.0 1.9 Don't know/missing 0.0 0.4 0.0 0.3 Total 100.0 100.0 100.0 100.0 Number 358 739 138 1,235 URBAN Currently attending 54.1 27.8 75.6 42.3 Got pregnant 0.0 1.4 0.4 0.9 Got married 8.1 13.5 0.0 9.9 Take care of younger children 1.5 1.7 0.0 1.4 Family need help 4.9 3.0 0.0 3.0 Need to earn money 6.3 11.4 1.9 8.5 Graduated/Enough school 7.0 18.3 19.6 15.7 Did not pass exams 2.5 7.0 0.0 4.7 Did not like school 9.8 6.1 2.5 6.4 School not accessible 0.8 0.6 0.0 0.6 Applying for school 2.3 7.0 0.0 4.7 Other 2.6 1.6 0.0 1.5 Don't know/missing 0.0 0.6 0.0 0.4 Total 100.0 100.0 100.0 100.0 Number 154 363 103 620 RURAL Currently attending 36.5 20.1 61.2 27.9 Got pregnant 1.2 0.6 3.3 0.9 Got married 11.7 21.6 3.3 17.3 Take care of younger children 1.0 0.0 1.3 0.4 Family need help 5.8 11.2 5.6 9.1 Need to earn money 11.4 10.7 3.3 10.5 Graduated/Enough school 5.6 15.3 22.2 12.5 Did not pass exams 2.5 7.1 0.0 5.2 Did not like school 14.4 5.9 0.0 8.4 School not accessible 5.3 0.8 0.0 2.2 Applying for school 0.2 5.4 0.0 3.4 Other 4.4 1.2 0.0 2.2 Don't know/missing 0.0 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 Number 204 376 35 615 25 2.3.4 Access to Mass Media During the KDHS interviews, women were questioned about the availability of mass media, which are important potential sources of disseminating awareness of certain issues, including family planning. These data facilitate the development of recommendations for drawing up programs on radio and TV, publications in the newspapers, and magazines on reproductive health, family planning, and other topics. Table 2.14 shows that 94 percent of women watch TV weekly, while 78 percent read a newspaper at least once a week. Daily radio listening is less widespread at only 40 percent. While there is little difference by age in newspaper reading and TV watching, older women listen to the radio more than younger women. Women in Almaty City have more access to all three types of mass media (63 percent) than women in the South Region (24 percent). It is notable that there is a connection between the availability of mass media and respondents' educational level; the higher the educational level, the more often women watch TV, read newspapers, and listen to the radio. Russian women are more likely than Kazak women to avail themselves of all three of these media. Table 2,14 Access to mass media Percentage of women who usually read a newspaper once a week, watch television once a week, or listen to radio daily, by selected background characteristics, Kazakstan 1995 Mass media No Read Watch Listen to All Number Background mass newspaper television radio three of characteristic media weekly weekly daily media women Age 15-19 1.1 76.8 94.7 29.7 23.5 669 20-24 1.5 79.2 93.1 32.5 25.8 567 25-29 4.0 79.5 92.8 38.5 34.4 521 30-34 2.0 77.8 94.9 41.6 33.1 557 35-39 1.8 79.9 93.3 43.7 36.6 564 40-44 2.1 77.1 93.7 46.9 38.4 537 45-49 3.9 75.0 91.1 54.0 44.4 355 Residence Urban 0.8 82.6 96.3 48.3 41.6 2,133 Rural 4.0 72.0 89.9 29.0 21.3 1,638 Region Almaty City 0.5 94.1 98.2 66.7 63.4 271 South 3.9 65.8 91.7 32.3 24.0 1,206 West 2.6 84.6 90.0 38.7 32.3 477 Central 1.6 81.4 94.0 39.8 33.5 358 North and East 1.1 82.1 95.2 41.7 34.4 1,458 Education Primary/Secondary 3.8 69.2 90.6 32.7 23.7 1,380 Secondary-special 1.4 79.9 94.9 39.9 33.4 1,721 Higher 0.9 91.3 96.1 54.8 49.9 670 Ethnicity Kazak 3.1 75.6 91.0 35.8 28.3 1,696 Russian 1.4 83.6 95.4 46.5 40.0 1,309 Other 1.7 73.9 95.9 37.8 30.4 766 Total 2.2 78.0 93.5 39.9 32.8 3,771 26 2.3.5 Women's Employment Status The reproductive health of women depends to some extent on their economic status, especially their employment. The economic crisis in Kazakstan is characterized by a recession in manufacturing, the closing of a majority of enterprises, and an increase in the number of unemployed people, especially women. Table 2.15 presents information on women's employment status according to age, residence, region, educational level, and ethnicity. Overall, 47 percent of women are not currently employed and 40 percent have not been employed for the last 12 months. Unemployment is more common among younger women, those living in rural areas, those in the South, West and Central Regions, those with lower educational level, and Kazak women. Almost one-fifth of the employed women work for less than five days a week and 5 percent of the women are employed only seasonally or occasionally. Table 2.15 Employment Percent distribution of women by whether currently employed and distribution of employed women by continuity of employment, according to background characteristics, Kazakstan 1995 Not currently employed Currently employed Did not work Worked All year in last in Background 12 last 12 5+ days <5 days Season- Occasion- characteristic months months per week per week ally ally Total Number Age 15-19 75.6 6.9 8.4 2.6 4.7 1.7 100.0 669 20-24 53.2 6.1 30.6 4.2 3.7 2. l 100.0 567 25-29 46.7 5.5 37.5 5.9 3.5 0.9 100.0 521 30-34 33.1 6.2 43.3 11.9 4.1 1.4 100.0 557 35-39 25.8 41 55.5 9.1 4.3 1.2 100.0 564 40 44 15.0 6.8 60.6 11.2 4.9 1.4 100.0 537 45-49 16.7 8.5 60.5 12.3 1.7 0.3 100.0 355 Residence Urban 34.5 6.1 45.5 10.5 1.7 1.8 100.0 2,133 Rural 47.9 6.4 33.6 4.3 7.0 0.8 100.0 1,638 Region AImaty City 30.1 8.0 46.7 8.9 3.9 2.4 100.0 271 South 51.0 5.2 31.6 5.7 6.2 0.2 100.0 1,206 West 40.5 6.0 44.7 6.3 1.7 0.8 100.0 477 Central 40.9 6.5 40.7 8.2 2.7 1.0 100.0 358 North and East 33.2 6.7 44.8 9.7 3.2 2.4 100.0 1,458 Education Primary/Secondary 52.0 5.7 27.6 6.4 7.0 1.3 100.0 1,380 Secondary-special 35.0 7.1 43.9 9.8 2.8 1.4 100.0 1,721 Higher 29.9 5.2 57.3 5.5 0.8 1.3 100.0 670 Ethnicity Kazak 47.1 5.4 37.3 5.3 4.0 0.8 100.0 1,696 Russian 32.7 6.9 45.2 11.2 2.2 1.8 100.0 1,309 Other 38.4 6.8 38.5 7.4 7.0 1.9 100.0 766 Total 40.3 6.2 40.3 7.8 4.0 1.4 100.0 3,771 27 2.3.6 Employer Table 2.16 shows the percent distribution of currently employed women by type of employer, according to background characteristics. Eighty-three percent of employed women work in state enterprises. Eleven percent of women work for themselves or in enterprises owned by their relatives. This type of employment is highest for younger women, women who live in urban areas, and those who live in Almaty City. Women in Almaty City are also more likely to work in a private finn. Kazak women are more likely to work in a government enterprise, while Russian women are slightly more likely than Kazak women to work for a private finn. Table 2.16 Employer Percent distribution of currently employed women by employer, according to background characteristics, Kazakstan 1995 Employer Govern- ment or State Family, Private Background enter- own firm, Self- characteristic prise business person employed Total Number Age 15-19 69.6 7.7 4.6 18.0 100.0 117 20-24 75.3 3.2 8.0 13.5 100.0 231 25-29 82.0 2.5 6.8 8.7 100.0 250 30-34 81.2 4.0 6.0 8.9 100.0 338 35-39 80.0 3.1 8. I 8.9 100.0 395 40-44 90.4 1.0 5.3 3.3 100.0 420 45-49 88.2 2.5 6.4 2.9 100.0 265 Residence Urban 77.1 2.9 10.0 10.0 100.0 1,268 Rural 91.7 3.0 0.7 4.5 100.0 748 Region Almaty City 64.8 3.7 20.2 11.3 100.0 168 South 84.6 5.5 2.7 7.3 100.0 528 West 89.6 1.5 3.4 5.5 100.0 255 Central 88.1 1.2 5.1 5.7 100.0 188 North and East 81.5 2.0 7.5 8.9 100.0 877 Education Primary/Secondary 82.1 4.0 3.6 10.4 100.0 585 Secondary-special 82.3 2.6 7.5 7.7 I IJ0.0 996 Higher 83.8 2.3 8.4 5.4 100.0 435 Ethnicity Kazak 87.7 2.6 3.3 63 100.0 805 Russian 79.2 2.7 10.0 8.1 100.0 791 Other 78.9 3.9 6.4 10.8 100.0 420 Total 82.5 2.9 6.6 8.0 100.0 2,016 Note: Private firm/person includes 9 women who do not earn cash. 28 2.3.7 Occupation Kazakstan is mainly an agrarian country. However, only 10 percent of employed women work in agriculture (Table 2.17) and the majority of them work on state land. Women in the South Region are more likely to be working in agriculture, either on state land, or on their own or rented land. A higher proportion of less educated women work in agriculture, compared to better educated women. Ninety percent of employed women are not engaged in agriculture. Almost half work in professional, technical, and managerial occupations; 20 percent in sales and trade; and 21 percent in manual labor. These parameters differ by age, residence, region, and respondent's ethnicity. Significant differences are also seen by educational level--women with higher education are engaged mainly in professional and technical fields, with few employed in manual labor. Table 2.17 Occupation Percent distribution of currently employed women by occupation and type of agricultural land worked or type of nonagricultural employment, according to background characteristics, Kazakstan 1995 Agricultural Nonagricultural Prof./ Background Own Family Rented State tech./ Sales/ Skilled Unskilled Other/ characteristic land land land land manag, services manual manual Missing Total Number Age 15-19 0.0 1.0 3.3 11.6 25.8 34.6 10.7 12.6 0.4 100.0 117 20-24 0.0 0.0 2.0 5.5 47.1 22.7 9.6 12.8 0.2 100.0 231 25-29 0.0 0.0 3.2 5.0 55.0 20.3 8.1 8.4 0.0 100.0 250 30-34 1.1 0.0 0.8 7.5 52.2 20,3 9.2 8.8 0.0 100.0 338 35-39 0.4 0.1 1.4 8.9 45.0 19.1 11.3 13.7 0.0 100.0 395 40-44 0.0 0.0 0.4 I1.1 49.9 18.5 9.8 10.3 0.0 100.0 420 45-49 0.2 0.0 0.4 6.7 52.6 14,9 I 1.4 13.9 0.0 100.0 265 Residence Urban 0.2 0.0 0,2 0.3 53.0 23.5 13.1 9.6 0.0 100.0 1,268 Rural 0.5 0.2 3.4 21.3 41.1 14.3 4.8 14.5 0.0 100.0 748 Region Almaty City 0.3 0.3 0.3 0.3 51.4 28.6 10.5 8.1 0.3 100.0 168 South 1.0 0.2 5.0 12.1 49.3 15,4 6.7 10.4 0.0 100.0 528 West 0.2 0.0 0.2 4.9 50.8 15.7 12.2 16.0 0.0 100.0 255 Central 0.0 0.0 0.0 3.5 53.8 16.3 12.1 14.0 0.3 100.0 188 North and East 0.0 0.0 0,0 9.2 45.9 23.3 10.9 10.7 0.0 100.0 877 Education Primary/Secondary 1.0 0.2 3.2 16.4 20.2 22.6 12.5 23.9 0.0 1130.0 585 Secondary-special 0.0 0.0 0.9 6.6 50.3 22.2 11.4 8.5 0.1 100.0 996 Higher 0.0 0.0 0.0 0.5 82.9 11.9 3.5 1.1 0.1 100.0 435 Ethnlelty Kazak 0.1 0.1 1.5 9.6 55.8 14.3 7.0 11.5 0.2 100.0 805 Russian 0.0 0.0 0.2 3.8 49.5 21.6 13.5 11.4 0.0 100.0 791 Other 1.3 0.1 3.4 13.4 33.1 28.5 9.3 11.0 0.0 100.0 420 Total 0.3 0.1 1.4 8.1 48.6 20.1 10.0 11.4 0.0 100.0 2,016 Note: Professional, technical, managerial includes professional, technical, clerical and managerial occupations. 29 2.3.8 Decisions on Use of Earnings When the socioeconomic status of women is being assessed, their independence in making decisions on the use of their earnings is a valuable indicator. Table 2.18 shows that almost 45 percent of employed women make their own decisions on the use of their earnings, while 42 percent decide together with their husband or partner, and 9 percent make decisions jointly with someone other than a husband. Only 2 percent of women report that their husbands alone decide how to spend their wives' earnings. Independent decision making on use of earnings tends to be higher among women in urban areas, especially Almaty City, and among women who are not married. Table 2.18 Decision on use of earnings Percent distribution of women receiving cash earnings by person who decides on use of earnings, according to background characteristics, Kazakstan 1995 Person who decides how earnings are used Jointly with Jointly Background Self Husband/ husband/ Someone with characteristic only partner partner else someone Total Number Age 15-19 36.7 0.0 13.5 15.0 34.8 100.0 115 20-24 46.3 0.9 23.1 5.5 24.2 100.0 230 25-29 36.9 3.5 44.0 1.7 13.8 100.0 250 30-34 45.3 2.7 44.8 1.5 5.7 100.0 336 35-39 46.9 1.7 47.6 0.2 3.6 100.0 393 40-44 44.3 1.8 50.3 0.1 3.5 100.0 420 45-49 50.2 1.6 43.6 0.4 4.1 100.0 264 Residence Urban 48.3 2.1 40.4 1.0 8.2 100.0 1,263 Rural 38.4 1.6 44.6 3.8 11.6 100.0 744 Region Almaty City 50.4 2.9 35.7 2.4 8.7 100.0 168 South 37.6 2.2 47.6 4.4 8.3 100.0 525 West 45.6 2.0 38.0 2.7 I 1.7 100.0 251 Central 50.1 1.1 40.6 0.5 7.7 100.0 186 North and East 46.3 1.7 41.2 0.7 10.0 100.0 877 Education Primary/Secondary 42.0 1.8 39.1 3.6 13.5 100.0 580 Secondary-special 48.3 2.1 42.3 1.3 6.0 100.0 992 Higher 39.8 1.8 44.8 1.7 11.9 100.0 435 Ethnicity Kazak 43.2 2.1 42.5 2.6 9.7 100.0 799 Russian 45.5 1.5 44.5 1.0 7.4 100.0 789 Other 45.7 2.4 36.1 3.0 12.8 100.0 420 Marital status Not married 67.2 0.0 03 4.8 27.8 100.0 592 Currently married 35.2 2.7 59.4 0.9 1.7 100.0 1,414 2,007 Total 44.6 1.9 41.9 2.1 9.4 100.0 2.3.9 Child Care While Working Preschool age children in the family pose employment obstacles, since child care requires significant time and appropriate conditions. When child care is provided completely by the mother, her work possibilities are limited. 30 As Table 2.19 shows, less than one-fourth of employed women have a child under age six at home. It is notable that the likelihood of a working woman having a child under six years is greater in rural areas (32 percent), the South Region (30 percent) and among Kazaks (31 percent). Among employed women with young children, only 7 percent care for the children themselves, 7 percent are cared for by the husband or partner, and 28 percent are cared for by relatives. One-third of employed women with young children use preschool child care institutions despite the mass shutdown during recent years. Use of institutional child care is greatest in urban areas (47 percent), the North and East Region (43 percent), and among Russian women (48 percent). When other children are used as child care providers, the caretaker is much more likely to be a sister (10 percent) than a brother (4 percent). The role of other people (neighbors, servants) in providing child care is insignificant. Table 2.19 Child care while working Percent distribution o f currently employed women by whether they have a child under six years of age, and the percent distribution of employed mothers who have a child under six at home by person who cares for child while mother is at work, according to background characteristics, Kazakstan 1995 Background characteristic Employed women with: Child's caretaker while mother is at work One or more No chil- child dren Hus* Serv- Child Not Number under under Re- band/ Other ants/ Institu- Other Other lives worked of six at six at spond- part- rela- Neigh- Hired tional female male else- since employed home home ent aer tire bor help care child child where birth I Other Total women Residence Urban 80.8 19.2 4.7 8.2 22.7 1.9 I1 46.8 4.6 2.7 1.2 5.9 0.2 100.0 1,268 Rural 68.3 31.7 10.2 5.8 32,4 0.2 00 18.6 16.3 4.6 0.7 8.7 2.6 100.0 748 Education No education 75.4 24.6 13,6 6.9 25.0 1.6 0.0 24.5 15.4 5,9 0.0 5.8 1.3 10~.0 585 Primary 76,9 23.1 5.1 5.4 28,7 1.2 1.0 35.1 9.4 2.7 1.6 8.8 I,I 10~.0 996 Secondary+ 75.6 24.4 4.0 10.8 28,3 0.0 0,4 39.3 5.7 2.5 0.8 6.0 2.3 10~.0 435 Work status For family member 74,5 25.5 0.0 13.0 36.8 0.0 0.0 14.3 22.5 7.5 5.9 0.0 0.0 100,0 59 For someone else 87.9 12.1 0.0 13.4 21.4 0.0 2.8 56.2 0.0 3.5 2.8 0.0 0.0 100.0 132 Self-employed 66,7 33.3 21.2 10.1 32.6 0.0 0.0 26.4 2.5 0.8 0.0 6.4 0.0 100,0 160 Region Almaty City 84.3 15.7 0.0 6.7 41.7 0.0 1.7 36.7 1.7 3.3 8.3 0.0 0.0 100.0 168 South 69.7 30.3 10,2 5.3 29.6 0.0 0.0 18.8 13.1 3,9 0.7 18.4 0.0 100.0 528 West 72.7 27.3 4,2 5.5 28.7 0.0 0.0 37.6 10.4 3,7 17 3.3 4.9 100.0 255 Central 75.4 24.6 8.3 10.7 28,7 09 00 31.7 11.3 3.3 0,0 2.1 3.1 100.0 188 North and East 79.7 20.3 7.0 8.2 227 2.6 1,3 43.4 9.0 3.5 0.0 1.3 I I 100.0 877 Ethnicity Kazak 69,2 30.8 4.9 7.7 28.7 0.2 1.1 26.1 I 1.2 4.1 1.5 12.0 2.5 100.0 805 Russian 81.0 19.0 6.2 6.9 21.5 30 00 48.0 7.9 3.1 0.3 2.7 0,4 100.0 791 Other 80.4 19.6 17.1 5.3 34.8 00 0,0 25.4 12.3 3.2 0.5 1,4 0.0 100.0 420 Occupation Agricuhural 65.5 34.5 13.7 7.0 31.6 0.0 0.0 5.3 25.7 4.5 1.6 9,9 0.6 100.0 199 Nonagricultural 77.3 22.7 6,3 7.0 26.8 1.2 0.7 37.5 7.8 3.5 0.8 6.8 1.5 100.0 1,817 Employment status All year, full week 77.0 23.0 4.9 6.4 27.9 1.4 0,1 36.0 10.2 3.0 0.9 7,6 1.5 100.0 1,520 All year, part week 77.1 22.9 6.8 13.3 21.4 0,0 3.4 31.4 10.7 6.6 0.7 5.1 0.7 100.0 294 Seasonal 67.7 32.3 12.6 4.1 34.8 0.0 0.0 17,1 12.5 5.0 1.8 10.3 1.8 100,0 150 Occasional 72.4 27,6 53.6 3.1 22.4 0.0 0.0 16.1 4.8 0.0 0.0 0.0 0.0 100.0 521 Total 76.2 23.8 7.4 7.0 27.5 1.0 0.6 32.9 10.4 3.6 0.9 7.3 1.4 100.0 2,016 Note: Totals include 1 woman with occupation missing. Figures may not add to 100.0 due to rounding. I Respondent was employed but had not actually worked since the birth; therefore, current caretaker status is not applicable. 31 CHAPTER 3 FERTILITY Vassily N. Devyatko and Kia I. Weinstein A complete pregnancy history was collected from each woman interviewed in the 1995 KDHS. To encourage complete reporting of all pregnancies, respondents were asked separate questions about pregnancies that resulted in live births, induced abortions (including mini-abortions), miscarriages, and stillbirths. Accounting of live births was achieved by asking separately about the number of sons and daughters living with the respondent, the number living elsewhere, and the number who had died. To encourage complete reporting of all pregnancies, all pregnancy intervals of four or more years in duration were additionally probed for intervening pregnancies. The pregnancy history was collected in reverse chronological order from the most recent to the first pregnancy. Pregnancy outcome (live birth, abortion, miscarriage, or stillbirth) and date (month and year) of termination was recorded for each pregnancy. For each live birth, sex of child, survival status, and age (for living children) or age at death (for dead children) were also collected. This chapter presents the findings pertaining to live births. Because ethnicity is a major determinant of fertility in Kazakstan, fertility data are shown separately for ethnic Kazaks and ethnic Russians, in addition to overall rates for all of Kazakstan. Chapter 5 presents the findings pertaining to pregnancy loss. 3.1 Current Fertility Table 3.1 and Figure 3.1 present age-specific fertility rates for the three-year period preceding the survey (mid- 1992 to mid- 1995).~ Rates are expressed per 1,000 women. The sum of the age-specific rates, known as the total fertility rate (TFR), is used to summarize the current level of fertility. The TFR is interpreted as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed age-specific rates. Two other summary measures are presented in Table 3.1, the general fertility rate (GFR), and the crude birth rate (CBR). The GFR represents the annual number of births in the population per 1,000 women age 15-44. The crude birth rate (CBR) is the annual number of births in the population per 1,000 population. The latter two measures are calculated from the birth history data for the three-year period preceding the survey, and the age and sex distribution of the household population. Fertility among urban women is lower than among rural women throughout all the childbearing years, resulting in a TFR among urban women that is one child lower than among rural women. If fertility were to remain constant at current levels, a Kazakstan woman would give birth to an average of 2.5 children; urban women would have 2.0 children, while rural women would have 3.1 children. The peak childbearing years for both urban and rural women are during the early twenties (age 20-24). Numerators for age-specific fertility rates are calculated by summing the number of live births which occurred in the 1-36 months preceding the survey (determined from the date of interview and birth date of the child), and classifying them by age (in five-year groups) of the mother at the time of birth (determined from the birth date of the mother). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. 33 Table 3.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by residence and ethnicity, Kazakstan 1995 Residence Ethnicity Age Urban Rural Kazak Russian Other Total 15-19 51 78 37 97 79 64 20-24 145 235 229 125 174 190 25-29 132 140 180 73 131 136 30-34 46 92 100 27 55 67 35-39 22 56 60 15 26 35 40-44 4 11 14 1 5 7 45-49 0 0 0 0 (0) 0 TFR 15-49 2.00 3.06 3.11 1.69 (2.35) 2.49 TFR 15-44 2.00 3.06 3.11 1.69 2.35 2.49 GFR 62 109 109 52 76 83 CBR 15 24 19 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. TFR: Total fertility rate, expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Figure 31 Age-specific Fertility Rates by Ethnicity Births per l,OOO Women 250 200 150 100 sot/ i 0 ! . . . . • 15-19 20-24 i l 25-29 30-34 Age Group I÷Totai ~Kazak ÷RussianJ 351_39 40~14 KDHS 1995 34 Ethnic Kazaks and ethnic Russians both experience their peak childbearing years during their early twenties. However, ethnic Kazaks achieve a TFR that is higher (3.1 children per woman) than the overall TFR, and ethnic Russians a TFR that is lower (1.7 children per woman). No respondents age 45-49 report having a live birth in the previous three years. Table 3.2 and Figure 3.2 present TFRs for the three years preceding the sur- vey by background characteristics. It can be seen that regional variation in fertility is substantial, varying by as much as two chil- dren. The TFR is lowest among women in Almaty city (1.5 children per woman) and the North and East Region (1.8), interme- diate in the West and Central Regions (both 2.7) and highest in the South Region (3.4). Women in Kazakstan exhibit a childbearing pattern, observed in many societies, of decreasing fertility with in- creasing education. The TFR declines from 2.9 children per woman among women with primary or secondary schooling to 2.4 among women with secondary-special schooling and then down to 2.0 children per woman among those with higher education. Trends in fertility can be inferred by comparing the TFR (a measure of cur- rent fertility) with the mean number of chil- dren ever born (CEB) to women age 40-49 (a measure of completed fertility). If there had been no change in fertility for three or more decades prior to the survey, the TFR Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage currently pregnant and mean number of children ever born to women age 40-49, by selected background characteristics, Kazakstan 1995 Mean number of children Total Percentage ever born Background fertility currently, to women characteristic rate I pregnant I age 40-49 Residence Urban 2.00 2.21 2.46 Rural 3.06 5.81 4.36 Region Almaty City ( 1.45) 1.46 1.94 South (3.44) 5.47 4.27 West (2.69) 4.40 3.42 Central (2.69) 3.24 3.17 North and East (1.76) 2.73 2.54 Education Primary/Secondary 2.93 3.69 4.09 Secondary-special 2.38 3.75 2.77 Higher (1.99) 4.01 2.21 Ethnicity Kazak 3.11 4.82 4.21 Russian 1.69 2.42 2.25 Other (2.35) 3.77 2.95 Total 2.49 3.77 3.11 Note: Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. 1 Women age 15-49 years and CEB would be nearly the same. The fact that the "I'I~R (2.5 children per woman) is lower than the CEB (3.1) indicates that fertility has declined in Kazakstan over the past three decades. The TFR is lower than the CEB among both urban and rural women, and in every region, education level, and ethnicity. Table 3.2 also presents the percent of women who report themselves to be currently pregnant. Because women at early stages of pregnancy may not yet know they are pregnant, this proportion may be underestimated. Percentages are generally low, commensurate with fertility that is overall relatively low. The percent of women pregnant generally exhibits the same patterns by background characteristics as the TFR. Women with higher education are the one exception; unlike their fertility level, they exhibit the highest percentage pregnant. 35 Figure 3.2 Total Fertility Rate by Background Characteristics KAZAKSTAN RESIDENCE Urban Rural EDUCATION Pnma~ISeconda~ Secondanj-special Higher ETHNICITY Kazak Russian Other REGION Almaty City South West Central 2.5 "i//////////////////////IJded/~/////I/////ll///////~ 20 " i l l / l l l l l l l l l l l l l l / l l l l l~) ' / / I / - i l l / / l l / / l l~/ l l l l~// l l l / / l l l l l l l l l l l l l~ 31 2 ~\ \ \ \ \ \~ ,~\ \ \ \ \ \ \ \ \ '~ 3.1 ~\ \ \ \ \ \ \ \ \ \ \ \ \ \~ \ \~ 23 34 .~,~, 2.7 ~ ' ~ 2.7 North and East ~ 18 O0 10 2.0 30 40 50 Births per Woman 60 KDHS 1995 3.2 Fertil ity Trends The most direct way of observing fertility trends is to examine changes in age-specific rates over time. Table 3.3 compares age-specific fertility rates (ASFRs) from the KDHS (which were shown in Table 3.1) with ASFRs reported in the 1989 Census. The data provide evidence of declines in fertility among women of all age groups, with the exception of 15-19 year olds, and among both ethnic Kazaks and ethnic Russians. The decline in ASFRs results in an overall decline of the TFR from 3.6 to 3.1 among ethnic Kazaks, and 2.2 to 1.7 among ethnic Russians. The TFR for all of Kazakstan declines from 2.9 to 2.5. Figure 3.3 shows the decline in ASFRs for all Kazakstan. 36 Table 3.3 Trends in fertility Age-specific fertility rates and total fertility rates, 1989 Census and 1995 KDHS Kazak Russian Total I Age of Census KDHS Census KDHS Census KDHS woman 1989 1995 1989 1995 1989 1995 15-19 31 37 59 97 45 64 20-24 232 229 182 125 215 190 25-29 208 180 110 73 159 136 30-34 140 1(30 63 27 96 67 35-39 76 60 27 15 45 35 40-44 27 14 7 1 14 7 45-49 3 0 0 0 1 0 Total fertility rate 3.58 3.11 2.24 1,69 2.88 2.49 Note: Single-year period rates are used for the Census; three-year period rates are used for the KDHS. I Includes Kazak, Russian, and other ethnic groups. Figure 3.3 Trends in Age-specific Fertility Rates 1989 Census and 1995 KDHS 250 Births per 1,O0O Women 200 150 100 50 15-19 20-24 25-29 35-34 35-39 40-44 Age group [ !1989 Census ,.~-1995 KDHS 1 45-49 37 Evidence of a recent decline in fertility is also supported by the ASFRs calculated over time from the KDHS data. Table 3.4 presents age-specific fertility rates for five-year periods preceding the survey using data on live births from respondents' pregnancy histories. 2 The decline is steadily greater with increasing age, a pattern indicative of increasing fertility control. The decline from 5-9 to 0-4 years prior to the survey steadily increases from a 5 percent decline among 20-24 year-olds to a 41 percent decline among 35.-39 year- olds. Unlike women of other ages, 15-19 year-olds actually show an increase in fertility over time. Table 3.5 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. The decline in fertility has occurred at all marital durations; however, the decline is greatest among women of longer marital durations. Fertility within the first several years of marriage typically remains less resistant to change, even when fertility is declining, because fertility decline usually begins among older women who want to stop their childbearing and not by young couples postponing births. Table 3.5 shows dramatic declines in fertility for all marital durations of five or more years. Table 3.4 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of birth, Kazakstan 1995 Number of years preceding the survey Mother's age 0-4 5-9 10-14 15-19 15-19 65 45 40 38 20-24 202 212 197 226 25-29 141 173 178 180 30-34 74 97 123 [151] 35-39 33 56 [60] 40-44 7 [16] 45-49 [0] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 3.3 Children Ever Born and Living Table 3.5 Trends in fertility by marital duration Fertility rates for ever-married women by duration (years) since first marriage for five-year periods preceding the survey, Kazakstan 1995 Marriage duration at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 0-4 312 320 313 336 5-9 113 156 160 179 10-14 59 86 102 142 15-19 20 52 94 * 20-24 7 35 * 25-29 3 * Note: Duration-specific fertility rates are per 1,000 women. An asterisk indicates that a rate is based on fewer than 125 unweighted years of exposure and has been suppressed. Table 3.6 presents the distribution of all women and currently married women by number of children ever born. Fifty-six percent of 20-24 year-olds have had one or more children. The modal number of children among all women age 25 and above is two. Thirty-five percent of women age 45-49 have had four or more children. The greatest difference between the data for currently married women and the total sample occurs among young women, due to the large number of unmarried young women with minimal fertility. Differences at older ages reflect the generally fertility-reducing impact of marital dissolution (divorce or widowhood). The table also shows the mean number of children ever born and the mean number surviving by five- year age group of the mother. On average, women in their early twenties have had 0.8 children, women in their early thirties have had 2 children, and women in their early forties have had 3 children. 2 The rates for the older age groups (shown in brackets in Table 3.4) represent partial fertility rates due to truncation. Women 50 years of age and older were not included in the survey, and the further back into time that the rates are calculated, the more severe is the truncation. For example, rates cannot be calculated for women age 40-44 for the period 10-14 years before the survey because these women would have been over age 50 years at the t ime of the survey and thus were not interviewed. 38 Table 3.6 Children ever born and l iv ing Percent distribution of all women and of currently married women age 15-49 by number of children ever born (CEB) and mean number ever born and l iving, according to five-year age groups, Kazakstan 1995 Number of children ever born (CEB) Number Mean no. Mean no. Age of of of living group 0 I 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN 15-19 93.2 6.1 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 669 0.07 0.07 20-24 44.2 3%9 14.5 2.9 0.6 0.0 0.0 0.0 0.0 0.0 0.0 100.0 567 0.78 0.75 25-29 17.1 28.7 37.3 11.6 4.4 0.5 0.3 0.0 0.0 0.0 0.0 100.0 521 1.60 1.52 30-34 7.4 18.2 41.1 18.3 8.6 4.8 1.1 0.4 0.0 00 0.0 100.0 557 2.23 2.14 35-39 6.8 13.2 36.1 18.2 12.6 6.5 4.0 2.1 0.4 0.1 0.0 100.0 564 2.65 2.50 40-44 5.0 9.9 378 18.4 9.4 9.5 4.6 2.6 1.7 04 0.7 100.0 537 2.96 2.79 45-49 4.6 12.5 32.2 16.2 9.5 5.8 7.1 5.1 4.1 0.4 2.5 100.0 355 3.35 3.07 Total 28.8 18.0 27.3 11.6 6.1 3.7 2.1 1.2 0.7 0.1 0.3 100.0 3,771 1.82 1.71 CURRENTLY MARRIED WOMEN 15-19 50.1 44.6 5.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 80 0.55 0.54 20-24 18.8 54.8 21.9 3.6 1.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 347 1.13 1.09 25-29 6.3 30.5 42.6 14.1 5.4 0.6 0.4 0.0 0.0 0.0 0.0 100.0 425 1.85 1.76 30-34 2.1 14.9 44.9 20.8 10.1 5.3 1.4 0.5 0.0 0.0 0.0 1130.0 458 2.46 2.36 35-39 3.2 9.5 39.1 20.4 135 7.0 4.4 2.3 0.4 0.1 0.0 100.0 482 2.85 2.70 40-44 1.6 7.6 404 19.1 10.3 11.0 4.9 2.6 1.6 0.5 0.5 100.0 447 3.11 2.91 45-49 1.0 11.0 30.4 17.1 11.0 7.3 7.9 6.3 44 0.4 3.3 100.0 268 3.70 3.40 Total 6.7 21.3 36.6 15.8 8.5 5.1 2.9 1.7 0.8 0.1 0.4 100.0 2,507 2.43 2.30 A cursory view of the survival status of children can be made by comparing the mean number of children ever born to the mean number surviving. Eight percent of children born to women age 45-49 at the time of the survey had not survived. The proportion of children surviving gradually increases among younger women. This may not only be due to shorter exposure to risk among children of younger women, but also due to improved mortality conditions. Overall, of all children born, 94 percent had survived to the time of the survey. 3.4 Birth Intervals The length of birth intervals is an important component of childbearing. Research has shown that children born too close to a previous birth have an increased risk of dying, especially when the interval between births is less than 24 months. Table 3.7 presents the percent distribution of second- and higher-order births in the five years prior to the survey by the number of months since the previous birth. Overall, one- third of births (34 percent) were born within 24 months of the previous birth. The median birth interval length is 32 months or about 2.6 years. The length of birth intervals by region mimics the pattern of fertility; regions with the highest fertility have the shortest birth intervals. In the lowest fertility regions of Almaty city and the North and East Region, birth intervals are the longest, with median lengths of 40 and 41 months, respectively. The West and Central Regions, which have intermediate levels of fertility, both have median birth intervals of 34 months. Women in the South, who have the highest level of fertility, also have the shortest birth intervals. The median length is 27 months; 39 percent of non-first births in the South were born within 24 months of the previous birth. Birth intervals are significantly longer among births to Russian mothers (median interval length of 44 months) than among births to Kazak mothers (median interval length of 28 months). Thirty-nine percent 39 Table 3.7 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Kazakstan 1995 Number of months since previous birth Characteristic 7 17 [ 8-23 24-35 36-47 48+ Total Median number of Number months since of previous birth births Age of mother 15 19 * * * * * 100.0 * 4 20 29 230 23.6 27.9 13.0 12.5 100.0 24.8 414 30-39 11.5 I 1.6 19.6 155 41.7 100.0 40.6 391 40 + 0.0 8.6 14.8 6.3 703 100.0 i 45 Birth order 2 3 18.1 18.6 22.0 13.9 27.5 100.0 30.7 611 4-6 13.8 15.5 24.8 13.2 32.6 100.0 33.2 220 7+ (0.0) (11.1) (43.2) 115.7) (30.0) 100.0 (336) 22 Sex of prior birth Male 17,6 18.2 22.2 13.3 28.7 100.0 31.0 447 Female 15.4 16.9 24.5 14.2 29.0 100.0 32.2 406 Survival of prior birth Living 154 17.6 22.9 14.2 29.9 100.0 32.1 800 Dead 33.1 17.6 29.4 68 13 I 10031 23.9 53 Residence Urban 12.4 13 3 23.1 12.6 38.7 100.0 38.6 322 Rural 19.0 20.2 23.4 14.4 22.9 100.0 28.7 532 Region Almaty City 86 20.0 18.6 8.6 44.3 100.0 40.0 31 South 18.9 20.1 28.1 11.7 21.1 100.0 26.6 423 West 12.4 19.0 22.2 16.9 29.5 100.0 34.4 119 Central 15.1 17.3 20.3 122 35.1 100.0 33.9 79 Norlh and East 15.7 I 1.2 15.6 17.5 40.1 100.0 41.4 201 Education Primary/Secondary [ 6 7 20.4 25.9 11.6 25.3 100.1/ 29.6 339 Secondary-special 179 159 20.9 16.4 291) 100.0 32.5 391 Higher 118 15.2 238 111.9 38.3 100.0 34.6 123 Ethnicity Kazak 17.7 20.9 23.8 13.5 24.1 100.0 28.0 556 Russian 16.3 5.3 16.5 233 38.7 100.0 43.8 146 Other 12.3 17.3 27.8 5.5 37.1 100.0 33.3 151 Total 16.5 17.6 23.3 13.7 28.9 100.0 31.6 853 Note: First births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in ~arentheses are based on 25-49 unweighted cases. Median number is more than 48 months. of births to Kazak mothers were born within 24 months of the previous birth while 22 percent of births to Russian women were born within 24 months of the previous birth. Urban and rural women also exhibit significant differentials in birth intervals. Births to urban women have a median interval length of 39 months while births to rural women have a median interval length of 29 months. 3.5 Age at First Birth The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. Early initiation into childbearing is generally associated with large family size and rapid population growth when family planning is not widely practiced. 40 Table 3.8 presents the percent distribution of women by age at first birth according to current age. Initiation into childbearing has a relatively narrow age range in Kazakstan, and the age at which women begin childbearing has not changed significantly over time. One exception seems to be that 20-24 year-olds are beginning childbearing at younger ages than women have in the past. Nearly one-third of the 20-24 year-olds have had a birth by age 20. Table 3.8 Age at first birth Percent distribution of women 15-49 by age at first birth, according to current age, Kazakstan 1995 Current age Women Median with Age at first birth Number age at no of first births <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 93.2 0.0 3.5 3.3 NA NA NA 100.0 669 a 20-24 44.2 0.0 6.5 22.8 18.0 8.5 NA 100.0 567 a 25-29 17.1 0.1 3.3 14.4 25.5 30.4 9.1 I00.0 521 22.5 30-34 7.4 0.0 4.1 14.1 27.3 30.4 16.8 100.0 557 22.4 35-39 6.8 0.0 2.2 15.1 29.8 25.7 20.4 100.0 564 22.2 40-44 5.0 0.0 3.4 12.7 33.5 27.6 17.8 100.0 537 22.0 45-49 4.6 0.0 7.9 16.4 23.8 28.9 18.4 100.0 355 22.1 NA = Not applicable a Omitted because less than 50 percent of the women in the age group x to x+4 have had a birth by age x Table 3.9 presents the median age at first birth for cohorts age 25 and above across background characteristics. The median age at first birth hovers around age 22 for all age cohorts. The greatest differentials are by education; the median age increases by two to three years with increasing education. Table 3.9 Median age at first birth Median age at first birth among women age 25-49 years, by current age and selected background characteristics, Kazakstan 1995 Current age Background Ages characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 22.3 22.7 22.4 22.6 22.5 22.4 Rural 22.8 22.3 21.9 21.5 21.6 22.1 Region Almaty City 22.8 23.2 23.4 23.1 23.3 23.1 South 22.7 23.0 22.1 2L9 22.2 22.4 West 23.2 23.2 22.6 22.0 21.8 22.7 Central 23.1 22.4 22.7 22.1 22.0 22.4 North and East 21.8 21.7 21.9 22.0 22.0 21.9 Education Primary/Secondary 21.0 21.7 21.9 21.6 20.5 21.5 Secondary-special 22.3 22.2 22.0 21.9 22.6 22.1 Higher 24.0 23.8 23.4 23.9 24.6 23.9 Ethnieity Kazak 23.3 22.9 23.0 22.4 22.7 22.9 Russian 21.6 21.7 21.6 21.7 21.8 21.7 Other 22.0 22.6 22.1 22.2 21.7 22.2 Total 22.5 22.4 22.2 22.0 22.1 22.3 Note: The medians for cohorts 15-19 and 20-24 could not be determined because half the women have not yet had a birth. 41 3.6 Pregnancy and Motherhood Among Women Age 15-19 Fertility among women age 15-19 warrants special attention because young mothers at this age as well as their children are at high risk of encountering social and health problems. There has been much research on this topic, and the causality of the problems has proven difficult to identify. Children born to young mothers are associated with higher levels of illness and mortality during childhood than are children born to older mothers. Table 3.10 presents the percentage of women age 15-19 who are mothers or are pregnant with their first child. Overall, 9 percent of women age 15-19 have begun childbearing (have already given birth, or are pregnant with their first child at the time of the survey). However, the percentage of women who become mothers increases during the teenage years, so that one-quarter (26 percent) of 19 year-olds have begun childbearing. Table 3.10 Pregnancy and motherhood among women age 15-19 Percentage of women 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Kazakstan 1995 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of characteristic Mothers child bearing women Age 15 0.0 0.0 0.0 144 16 0.0 0.0 0.0 136 17 3.3 1.7 5.0 140 18 10.4 5.1 15.5 125 19 22.5 3.3 25.8 123 Residence Urban 7.1 1.0 8.1 356 Rural 6.5 2.9 9.4 313 Region Almaty City 5.3 0.0 5.3 34 South 6.7 2.7 9.3 255 West 8.4 1.6 10.0 85 Central 7.9 0.7 8.6 65 North and East 6.2 1.8 8.1 230 Education Primary/Secondary 4.8 1.8 6.6 425 Secondary-special 12.8 2.1 14.9 191 Higher (1.1) (2.1) (3.2) 53 Ethnicity Kazak 5.0 2.1 7.0 327 Russian 9.9 2.3 12.2 212 Other 6.3 0.9 7.1 130 Total 6.8 1.9 8.7 669 Note: Figures in parentheses are based on 25-49 unweighted cases. 42 The percent of women age 15-19 who have begun childbearing varies from 5 to 10 percent across the regions of Kazakstan. Women age 15-19 with secondary-special education are the most likely to become mothers (13 percent have already given birth). Women age 15-19 of Russian ethnicity are more likely than women of Kazak ethnicity to have begun childbearing (12 versus 7 percent). Table 3.11 indicates that 20 percent of women age 19 have one child, and that 3 percent have two or more children. The percentage of women age 15-19 with one or more children increases with age from 3 percent among women age 17 to 23 percent among those age 19. Table 3.11 Children born to women age 15-19 Percent distribution of women 15-19 by number of children ever born (CEB), according to single year of age, Kazakstan 1995 Age 0 1 2+ Number of Mean children ever born number Number of of Total CEB women 15 100.0 0.0 0.0 100.0 0.00 144 16 100.0 0.0 0,0 100.0 0.00 136 17 96.7 3.3 0.0 100.0 0.03 140 18 89.6 9.9 0.5 100.0 0.11 125 19 77.5 19.6 3.0 100,0 0.25 123 Total 93.2 6.1 0.6 100.0 0.07 669 43 CHAPTER 4 CONTRACEPTION Nina A. Kayupova, Nailya M. Karsybekova, and Khazina M. Biktasheva The primary function of family planning programs is to advocate conscious entry into parenthood for both men and women, i.e., to grant families the right to define their desired number of children and provide them the means to achieve that goal. Family planning involves the control of reproductive behavior, including conception, preservation of the fetus, and childbearing, as well as prevention of conception and interruption of pregnancy. Family planning not only helps couples to avoid undesired pregnancies, but also allows them to control the timing of their childbearing. By controlling the time they enter into parenthood, the time they stop childbearing, and the intervals between births, couples can achieve their ultimate desired family size. Family planning has positive effects on the overall health of both mother and child, and is also a contributing factor in the reduction of maternal and infant mortality, and secondary sterility. The efficacy of family planning depends on people's knowledge of methods and on the availability of methods to meet the varying needs of a wide spectrum of potential users. Availability of methods, in turn, depends on the quality and quantity of service providers and on available financial and technical resources. In the republics of the former Soviet Union, family planning primarily consisted of the use of traditional contraceptive methods through the 1960s. Low levels of infrastructure and technology, as well as knowledge and attitudes towards family planning, limited use of modern methods. Historically, the status of a Kazak woman in the family was such that the number of children she was to bear was determined not only by the husband and wife as a couple, but also by the husband's family. These factors, as well as many others, have resulted in high levels of reliance on induced abortion as a means of fertility control. Only recently has the Ministry of Health actively engaged in efforts to reduce the heavy reliance upon abortion by providing safe and effective modern contraceptive methods (Foreit and McCombie, 1995). Family planning offices have been opened in most oblasts and regional centers, in both large cities and villages. These offices, spanning most of the Republic, offer women professional advice and a supply of family planning methods. With the transition of the Republic to a market economy and the accompanying general reduction in living standards, desires to limit family size seem to be on the rise. Statistics on the number of IUD and pill users obtaining supplies from government facilities have been maintained by the Ministry of Health since 1988. These statistics indicate a substantial increase in contraceptive use between 1988 and 1993: the prevalence rate for these two methods increased by 48 percent, from 20 to 29 percent of all women age 15-49 (Church and Koutanev, 1995). Family planning topics addressed in this chapter include knowledge of contraceptive methods, sources of supply, use of methods in the past and present, reasons for nonuse, desire to use in the future, and attitudes and exposure to family planning messages. These data can serve as an information base for the Ministry of Health and family planning organizations to better define the need for contraceptives and better define the allocation of resources. 4.1 Knowledge of Contraceptive Methods Determining levels of knowledge and use of contraceptive methods was one of the major objectives of the KDHS. Data on knowledge were collected by asking the respondent to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent failed to mention a particular method 45 spontaneously, the interviewer described the method and asked if she recognized it. The respondent was also asked whether she had ever used each method. Current use of contraception was determined by asking whether the respondent (or her partner) was currently using any method, and if so, which one. Contraceptive methods include both modem and traditional methods. Modem methods include the pill, IUD, injectables, female sterilization, and the barrier methods (diaphragm, foam, jelly, and condom). Traditional methods include periodic abstinence (rhythm method), withdrawal, and vaginal douching. Information on knowledge of contraceptive methods is presented in Table 4.1 for all women interviewed, and separately for currently married women, ~ sexually active unmarried women, and women who have never had sexual intercourse. The knowledge of at least one method of contraception is nearly universal (98 percent). Also, 98 percent of respondents know at least one modem method and 75 percent know at least one traditional method. Women know, on average, five methods of contraception. The average number of methods known varies by marital status of the respondents. Currently married women know an average of 5.8 methods, while unmarried women who are sexually active know of 6.7 methods, and women who have never had sex know on average 3.7 methods (71 percent of women who have never had sex are women age 15-19). Table 4.1 Knowledge of contraceptive methods Percentage of all women, of currently married women, of sexually active unmarried women, and of women who have never had sex, who know specific contraceptive methods, by specific methods. Kazakstan 1995 Sexually Women Currently active who Contraceptive All married unmarried never method women women women had sex Any method 97.6 99.3 99.2 91.7 Any modern method 97.6 99.3 99.2 91.7 Pill 78.8 81.8 97.2 62.7 IUD 95.9 99.0 98.8 84.8 Injectables 33.3 35.2 54.0 21.9 Diaphragm/Foam/Jelly 43.2 48.7 63.4 19.4 Condom 87.6 89.2 99.2 78.8 Female sterilization 59.2 64.5 68.3 36.2 Any traditional method 75.2 82.8 93.8 42.8 Periodic abstinence 68.3 75.1 87.5 37.8 Withdrawal 55.3 61.3 81.2 25.8 Douche 18.8 22.0 15.0 6.0 Other 3.3 3.4 6.3 1.2 Any traditional/folk method 75.3 82.8 93.8 42.9 Number of women 3,771 2,507 136 751 Mean number of methods 5.4 5.8 6.7 3.7 1 The currently married category includes women in both formal unions (civil or religious) and informal unions (living together). 46 The most commonly known method is the IUD (known by 96 percent of all women). The condom and the pill are the next most commonly known methods, known by 88 and 79 percent of women, respectively. The lesser known modem methods are still known by a significant proportion of women--59 percent have knowledge of female sterilization (although historically this method was carried out only for medical reasons), 43 percent know vaginal barrier methods such as the diaphragm, foam or jelly, and 33 percent know injectables. The data in Table 4. I show that sexually active unmarried women are generally more informed about modem methods than are currently married women. Knowledge of the IUD, condom, and pill is universal among sexually active unmarried women (99, 99 and 97 percent, respectively), and they are also more likely to know of the lesser known modem methods as well. While women who have never had sex are less likely to know of methods than are married or sexually active unmarried women, more than three-quarters of such women do know of the IUD (85 percent) and the condom (79 percent). For purposes of communicating family planning information, women of reproductive age who have not yet engaged in sexual intercourse are an equally important audience as are sexually active women because these women are certain to engage in sexual activity in the near future. Periodic abstinence and withdrawal are commonly known traditional methods among currently married and sexually active unmarried women. Periodic abstinence is known by 75 per- cent of currently married women and 88 percent of sexually active unmarried women; withdrawal is known to 61 percent and 81 percent, respec- tively. Traditional methods are not as commonly known among women who have never had sex (38 percent have heard of periodic abstinence and 26 percent have heard of withdrawal). Vagi- nal douche is known to 22 percent of married women and 15 percent of sexually active unmar- ried women. Folk methods mentioned by re- spondents include herbs, segment of a lemon, aspirin, iodine, vinegar, wine and others. Table 4.2 presents the percent of cur- rently married women who know of at least one method of contraception (modem or traditional) and the percent who know of at least one modem method, by background characteristics of the re- spondents. Virtually all currently married wom- en know of at least one modem method of con- traception. This level of knowledge includes women of all ages, all regions of the country, all educational levels, and all ethnicities. 4.2 Ever Use of Contraception All respondents who had heard of a Table 4.2 Knowledge of contraceptive methods by background characteristics Percentage of currently married women who reported having heard of at least one method and at least one modern method by selected background characteristics, Kazakstan 1995 Knowledge of contraception Knows Knows Number Background any modem of characteristic method method women Age 15-19 95.8 95.8 80 20-24 99.7 99.6 347 25-29 99.6 99.6 425 30-34 99.8 99.8 458 35-39 99.1 99.1 482 40-44 99.1 99.1 447 45-49 99.0 99.0 268 Residence Urban 99.6 99.6 1,398 Rural 98.9 98.9 1,109 Region Almaty City 1(30.0 100.0 164 South 98.4 98.4 811 West 99.4 99.4 298 Central 99.5 99.3 235 North and East 99.8 99.8 1,000 Education Primary/Secondary 98.4 98.3 797 Secondary-special 99.7 99.7 1,259 Higher 99.7 99.7 450 Ethnicity Kazak 98.7 98.6 1,064 Russian 100.0 100.0 930 Other 99.2 99.2 513 Total 99.3 99.3 2,507 method of contraception were asked whether they (or a partner with them) had ever used the method; each method was inquired about separately. An additional probe for use was made for women who reported no contraceptive use. Results are presented in Table 4.3 for all women by five-year age groups, for currently married women by five-year age groups, and for sexually active unmarried women. 47 Overall, 84 percent of currently married women and 78 percent of sexually active unmarried women have used a method of contraception at some time in their life. Sixty-five percent of all women age 15-49 have used a method at some time. Levels of ever-use among all women are somewhat lower than among currently married women because the former includes women who are not sexually active; the most significant differential is among 15-19 year-old women. While 51 percent of currently married 15-19 year- olds have ever used a method, only 12 percent of all 15-19 year-olds have done so; however, only 20 percent of all 15-19 year-olds have ever had sex. The women who are the most likely to have ever used a method of contraception are those age 25-44 among the currently married and age 30-44 among all women (83-90 percent of these women have used a method of contraception). These women are also the most likely to have used a modem method of contraception. The method that is by far the most widely ever used is the IUD. Overall, 46 percent of all women of reproductive age have used an IUD at some time. Three out of four currently married women in their thirties have used an IUD at some time in their life (and two out of three women age 25-29 and 40-44 have done so). Condoms are the next most commonly tried method; approximately one of ew:ry three currently married women has used a condom at some time. Condoms are the most likely method to have been tried among sexually active unmarried women. Pills are the third most commonly tried modem method; Table 4.3 Ever use of contraception Percentage of all women, of currently married women, and of sexually active unmarried women who have ever used any contraceptive method, by specific method and age, Kazakstan 1995 Modem method Traditional method Any Any Any Periodic trad./ Number Any modern Other trad. absti- With- Other folk of Age method method Pill IUD Condom modern j method hence drawal Douche methods method women ALL WOMEN 15-19 11.9 82 2.1 1.2 6.4 0,2 9.7 44 5.6 2.8 01 9,7 669 20 24 55.7 472 8.7 268 272 1,2 354 18.3 21.1 I 1.9 0.9 35,5 567 25-29 74.7 712 20,5 587 34.5 3.8 356 20.0 19.4 9.2 0.3 35.7 521 30-34 84.2 79.5 19.9 68.3 33.3 7.6 448 26.6 20.5 14.6 08 44.8 557 35-39 82.8 77.1 20.9 68.0 33.4 5.6 47.8 30.6 22.3 15.8 14 48.0 564 40-44 85.9 78,7 17.5 648 39.0 6.9 49.4 30.7 25.6 17.0 18 50.0 537 45-49 74.5 63.1 11.7 44.8 316 7.8 452 28,3 21.5 17.5 1,8 463 355 Total 64.9 58.8 14.2 46,1 28.4 44 37.0 21.9 189 122 0.9 37.3 3,771 CURRENTLY MARRIED WOMEN 15-19 50.9 31.5 6.9 7.6 18.4 0.5 423 15.9 18.6 17.3 0.8 42.3 80 20-24 71.7 61.9 11.0 38.6 33.6 1.6 419 19.0 25.7 140 0.7 42.0 347 25-29 83.3 80.3 22.8 670 38.9 4.3 382 21.6 21.1 102 01 38.2 425 30-34 89.6 86.0 21.5 73.7 35.6 7.6 46.6 269 225 152 0.8 46.6 458 35-39 88.3 83.1 21.6 74,3 35.6 6.2 51.1 327 239 16.8 0.9 51.4 482 40-44 89.6 82,6 18.4 691 41.6 8.1 53.3 330 28.7 173 1.9 540 447 45-49 79.1 67.1 128 49.5 33.4 76 470 300 226 174 1.3 47,6 268 Total 83.5 76.8 18.3 62.3 36.2 58 46 5 27 I 24.0 15 2 09 46.7 2,507 SEXUALLY ACTIVE UNMARRIED WOMEN Total 784 68.9 25.0 31.1 49.0 3.9 59,7 39.4 34.5 119 19 60.0 136 t Includes injectables and diaphragm 48 nearly one in five currently married women has used them at some time in their life. Other modem methods (injectables and diaphragm) have been used at some time by only 6 percent of married women. While more women have used modem than traditional methods, many women have in fact used a traditional method at some time. Overall, nearly half of all currently married women have used a traditional method at some time in their life, while 37 percent of all women have done so. The sexually active unmarried women are the most likely to have ever used a traditional method (60 percent). Periodic abstinence and withdrawal are the traditional methods most likely to have been tried by women at some time in their life. Twenty-seven percent of married women have used periodic abstinence at some time, and 24 percent have used withdrawal at some time. Sexually active unmarried women are more likely to have used both of these methods at some time in their life (39 percent have used periodic abstinence and 35 percent have used withdrawal at some time). Fifteen percent of married women and 12 percent of sexually active unmarried women have used vaginal douching as a method of contraception at some time in their life. 4.3 Current Use of Contracept ion Table 4.4 presents levels of current use of contraception for all women by five-year age groups, for currently married women by five-year age groups, and for sexually active unmarried women. Figure 4.1 shows the distribution of currently married women by method currently used. Table 4.4 Current use of contraception Percent distribution of all women, of currently married women, and of sexually active unmarried women who are currently using a contraceptive method by specific method, according to age, Kazakstan 1995 Modem method Traditional method Any Any Periodic Not Number Any modern Other trad, absti- With- currently of Age method method Pill IUD Condom modern I method nence drawal Douche using Total women ALL WOMEN 15-19 7,1 47 0.8 1.0 2.8 0.0 2.4 0.4 1.0 1.0 92.9 100.0 669 20-24 35,1 250 2.0 18.0 4.8 0.3 10A 4.9 2.6 2.6 64.9 100.0 567 25-29 53.3 445 2,5 38,1 3.0 1.0 8.8 3.7 3.1 2.0 46.7 100.0 521 30-34 64.9 53.7 1.5 4%5 3.3 1.4 11.2 6.1 3.0 2.1 35.1 100.0 557 35-39 61.8 48.4 1,7 41.7 4.6 0.5 13.3 8.8 2.1 2.4 38.2 100.0 564 40-44 54.8 409 1.4 35.3 2.5 1.7 14.0 7.6 3.3 3.1 45,2 100.0 537 45-49 28.5 19.6 0.0 16,0 2.6 1.0 8.7 4,7 0.3 3.7 71.5 100.0 355 Total 43.3 33,6 15 27.9 34 0.8 9,6 5.0 2.3 2.3 56.7 1 t~9,0 3,771 CURRENTLY MARRIED WOMEN 15-19 31.5 14.4 6.1 6.5 1,8 0.0 17.1 3.2 6.2 77 68.5 100.0 80 20-24 47.0 34.1 2.5 27,2 4.1 0.3 12.9 5,2 3.8 40 53.0 100.0 347 25-29 61.0 51.0 2.3 44.1 3.4 1.2 10.0 4,2 3.4 2.4 39.0 100,0 425 30-34 71.7 60.6 1,1 54.0 3.9 1.5 11.1 5.5 3.5 2.1 28.3 100,0 458 35-39 69.5 54.6 1.9 47.4 4.9 0,5 14.9 9.6 2.5 2,8 30.5 100.0 482 40-44 63,3 470 1.7 404 2,8 2.0 16.4 8.7 4,0 3.8 36.7 100.0 447 45-49 32.6 21,7 0.0 18.1 3.3 0.3 107 5.4 0.4 49 67,4 100.0 268 Total 59.1 46.1 1.8 39.6 3,7 1,0 13.0 6.5 3.2 3.3 40.9 100.0 2,507 SEXUALLY ACTIVE UNMARRIED WOMEN Total 57,9 39.1 50 13.7 19.3 1.1 18,8 14.0 4.5 0.3 42.1 100,0 136 Note: Totals may not add to 100.0 due to rounding. i Includes injectables and diaphragm 49 Figure 4.1 Use of Specific Contraceptive Methods among Currently Married Women IUD 40% Condom 4% Other modem methods 1% Traditional methods 13% Pill 2% Not currently using 41% KDHS 1995 One out of every three women of reproductive age is currently using a modem method of contraception (34 percent); one out of every 10 is using a traditional method (10 percent). Nearly one out of every two currently married women is currently using a modem method of contraception (46 percent), and 13 percent are using a traditional method] The IUD is by far the most commonly used method---two out of every three currently married women who are using some method of contraception are using the IUD. The collection of traditional methods represents the second most commonly used method; one out of five currently married women who are using some method of contraception are using either periodic abstinence, withdrawal, or douche. Prevalence among sexually active unmarried women (58 percent) is the same as among currently married women; however, the former exhibit a greater method mix than the latter. There is much less reliance upon the IUD among sexually active unmarried women and greater use of all other methods (both modem and traditional) compared to married women. Condoms are the most commonly used method (19 percent) and sexually active unmarried women are as equally likely to be using periodic abstinence (14 percent) as they are to be using the IUD (14 percent). Five percent of these women are using pills, and 5 percent are using withdrawal. 2 It is worth comparing the contraceptive prevalence statistics which are published by the Ministry of Health (MOH) with those computed from KDHS data. The MOH collects data and publishes statistics on IUD and pill users relative to all women of reproductive age (i.e., all women 15-49). According to the MOH data, the percentage of IUD and pill users among women age 15-49 for 1993 were 27.8 and 1.4, respectively (Church and Koutanev, 1995). These are virtually identical to the KI)HS rates of 27.9 and 1.5 for 1995 (Table 4.4). In spite of the two-year time difference in the date to which these statistics apply, the results are remarkably similar, substantiating the reliability of the data collected by the MOH and the KDHS survey. 50 Use of contraception increases steadily by age, peaking at age 30-34 (61 percent of currently married women are using a modem method), and then declines. Use of traditional methods remains relatively constant over all ages. Of course, the desire to avoid pregnancy varies greatly over the course of one's reproductive life; use of contraception in relation to the age and fertility preferences of women is discussed in Chapter 7. Levels of contraceptive use by background characteristics of respondents are presented in Table 4.5 and Figure 4.2 for currently married women. Perhaps the most significant finding of Table 4.5 and Figure 4.2 is that the level of modem contraceptive use observed for the population as a whole is maintained across background characteristics of respondents. Most of the differentials observed in overall levels of use can be attributed to differential levels of use of traditional methods. For example, urban women are slightly more likely than rural women to be using a method of contraception (62 and 56 percent, respectively), but most of the differential can be attributed to higher use of traditional methods among urban women. Table 4.5 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to selected background characteristics, Kazakstan 1995 Modem method Traditional method Any Any Periodic Not Number Any modern Other trad. absti- With- currently of Characteristic method method Pill IUD Condom modern I method nence drawal Douche using Total women Residence Urban 61.9 47.0 2.3 39.2 4.4 1.0 14.8 7.9 2.1 4.8 38.1 100.0 1,398 Rural 55.6 44.9 1.1 40.0 2.8 0.9 10.7 4.7 4.5 1.5 44.4 100.0 1,109 Region Almaty City 64.4 47.2 5.1 29.9 9.2 3.0 17.3 11.3 1.9 4.0 35.6 100.0 164 South 50.2 44.3 0.6 41.5 1.6 0.6 5.9 3.3 0.8 1.8 49.8 100.0 811 West 51.9 41.6 0.8 37.5 3.0 0.2 10.1 6.2 1.5 2.4 48.1 100.0 298 Central 66.2 52.5 1.5 44.8 4.6 1.5 13.5 5.3 2.7 5.5 33.8 100.0 235 North and East 66.0 47.2 2.6 39.0 4.5 1.1 18.8 8.6 5.9 4.2 34.0 100.0 1,000 Education Primary/Secondary 51.9 41.8 0.7 36.6 3.5 0.9 10.0 3.4 4.1 2.5 48.1 100.0 797 Secondary-special 62.0 48.2 1.9 42.3 3.0 I.I 13.7 7.2 3.1 3.4 38.0 100.0 1,259 Higher 64.0 47.6 3.4 37.2 6.2 0.8 16.3 9.9 1.8 4.7 36.0 100.0 450 Ethnicity Kazak 53.5 46.8 0.5 43.6 2.0 0.6 6.7 4.0 0.7 2.1 46.5 100.0 1,064 Russian 65.1 45.3 3.9 35.3 4.5 1.6 19.7 9.6 5.1 5.1 34.9 100.0 930 Other 59.9 46.0 0.5 38.9 6.0 0.7 13.9 6.0 5.0 2.9 40.1 100.0 513 Number of living children 0 13.8 5.5 1.8 1.4 2.1 0.2 8.3 4.5 0.6 3.2 86.2 100.0 181 I 51.1 36.2 2.9 29.3 3.5 0.6 14.9 6.9 4.0 4.0 48.9 100.0 562 2 68.6 54.4 1.8 46.9 4.4 1.3 14.1 7.6 3.2 3.3 31.4 100.0 938 3 71.0 56.8 0.7 50.4 4.9 0.9 14.1 7.1 3.9 3.1 29.0 100.0 396 4+ 57.0 47.8 1.3 43.2 2.1 1.3 9.1 3.8 2.4 2.9 43.0 100.0 431 Total 59.l 46.1 1.8 39.6 3.7 1.0 13.0 6.5 3.2 3.3 40.9 100.0 2,507 Includes injectables and diaphragm 51 Figure 4.2 Current Use of Family Planning by Background Characteristics KAZAKSTAN RESIDENCE Urban Rural REGION West Central North and East EDUCATION Primary/Secondary Secondary-Special Higher NO. LIVING CHILDREN ~///////////////////////////i//////////////////////////////////////////////////////////////~ h ~ i7~!~] 59 ~//////~/////j/////~//////////////////~////////////////////////jy/~///////~y////////~:~;~ ~.W> i; ~ 55 <<.: >: : :I 52 ~B~'Z~'~W2~/2x / /~/~/2x~/~/~/~ ,~;,~ ,: ,: ~ ~ 7~ ~ 7~ ~ 7~ 7~ : I 66 r / ~ i x ~ i ~ ~ i ~ x ;Q~3 ~ ~- ~ 54 ~//~/~/~/~/~//~/~//~/~/~/~/////~//~//~//~/~/~/7~p'~'~ :. ) !" )" i : i i ~:T: !~ 65 2 ~//[//////////,¢/i//7////////////,¢///~¢7/,e~'# /~ ' : : ~ ;G{; : ;~] 69 3 V/~~/2~/y~'~7~/ j~2y/~7"~e~J / J /~ ;~;~; ;~ ~C~L] 71 4+ V///////////////////////////////////////////////////////////////////////////////////////////////~` ~S~:~ I 57 0 20 40 60 80 J~M~lern Methods ~Traditional/Folk Method-- Note: Currently married women age 1549 KDHS 1995 Contraceptive use by region does not vary to the degree that might be expected from the fertility differentials by region. Approximately one out of every two women is using a method of contraception in both the South and West Regions, while two in three are using a method in the Central, the North and East, and the Almaty City Regions. The correlation of contraceptive use with fertility levels is not very clear by region; for example, the West has an intermediate level of fertility and a relatively lower level of use (one in two women is using a method), while the Central Region, which also has an intermediate level of fertility, has a relatively higher level of use (two in three women is using a method). A more complete investigation of regional fertility differentials would have to consider factors such as age at marriage, breastfeeding practices, and induced abortion, in addition to the use of contraception. Women with primary or secondary education have lower levels of contraceptive use (52 percent) than do women with more education. However, women with secondary-special and higher education have similar levels of use (62 and 64 percent). Kazak and Russian women are equally likely to be using a modem method of contraception (47 and 45 percent, respectively). However, Russian women are more likely than Kazak women to be using a traditional method (20 percent and 7 percent, respectively) resulting in a higher overall level of use among Russian women. The level of contraceptive use increases with increasing numbers of living children, but then declines among women with four or more children. Use of contraception among married women with no children is quite low (6 percent are using a modem method and 8 percent are using a traditional method). Any differentials in method mix are overshadowed by the heavy reliance on the IUD among women of all background characteristics (the only exception being women with no children). However, the broadest method mix is observed among women in Almaty City. While use of the IUD still predominates (30 percent), use of modem methods other than the IUD is higher in Almaty City than any other region: condoms (9 percent), the pill (5 percent), and other modem methods (3 percent). Nevertheless, even with this broader 52 mix of modem methods, periodic absti- nence still ranks as the second most com- monly used method (11 percent) among women in Almaty City, as it does for Kazakstan as a whole. Users of the pill were asked to pre- sent their pill package to the interviewer, who then proceeded to record the brand name of the pills. Respondents who were unable to present the package were asked to report the brand name of their pills. Table 4.6 presents the percentage of women who are using the pill and the percentage of pill users who presented their pill packages to interviewers, by background characteristics of respondents. Table 4.7 presents the dis- tribution of pill users by their brand of pills. Both tables present data for all pill users, regardless of marital status. Pill use is highest among women age 25-29 years (3 percent), urban women (2 percent), women living in Almaty (5 per- cent), women with higher education (3 per- cent), and Russian women (3 percent). Overall, 70 percent of pill users were able to present their packets to the interviewer; however, there was variability in the ability to do so by background characteristics of the respondents. Urban women were twice as likely (80 percent) as rural women (40 Table 4.6 Pill use and possession Percentage of all women using the pill and the percentage of pill users who have a packet at home, by background characteristics, Kazakstan 1995 Percentage of users who Background Percent Number could show characteristic using pill of women package Age 15-19 0.8 669 57.1 20-24 2.0 567 84.3 25-29 2.5 521 73.7 30-34 1.5 557 78.5 35-39 1.7 564 74.5 40-44 1.4 537 38.3 45-49 0.0 355 Residence Urban 2.0 2,133 79.5 Rural 0.8 1,638 39.7 Region Almaty City 5.0 271 58.1 South 0.4 1,206 62.4 West 1.0 477 74.5 Central 1.1 358 54.4 North and East 1.9 1,458 79.1 Education Primary/Secondary 0.6 1,376 59.6 Secondary-special 1.4 1,721 61.0 Higher 3.3 670 84.2 Ethnicity Kazak 0.5 1,696 54.8 Russian 3.3 1,309 72.4 Other 0.4 766 84.6 Total 1.5 3,771 70.3 percent) to present a packet to the interviewer. Women with higher education were more likely to show a packet (84 percent) than women with less education (60 percent). And Table 4.7 Use of pill brands Percent distribution of pill users by the brand of pills used, Kazakstan 1995 Pill brand Total Diane-35 8.1 Lo-femenal 1.6 Marvelon 2.4 Microgynon 5.0 Non-ovlon 8.5 Ovidon 7.0 Postinor 5.0 Rigevidon 8.7 Triquilar 21.0 Triquilar ED Fe 14.5 Anteovin 2.4 Don't know/missing 15.8 Total 100.0 Number 55 finally, 72 percent of Russian women presented a packet, while 55 percent of Kazak women did so. Table 4.7 reveals that there are 11 brands of pills being used, with the most common being Triquilar (36 percent). 4.4 Number of Children at First Use of Contraception To make some assessment of the motivations behind using family planning methods, women were asked how many living children they had at the time they first used a method of family planning. Women who use a method before ever having a child presumably want to delay their childbearing to some time in the future. Women who first employ a method after they have had one or two children may either want to delay the next child or limit their childbearing to one or two children. Women who use a method for the first time after having several children 53 are more likely to be using family planning to stop childbearing, rather than simply spacing their childbearing. Table 4.8 presents the percent distribution of all ever-married women by the number of living children they had at the time they first used a method of family planning. Use of family planning to delay the first pregnancy is uncommon in Kazakstan (11 percent of women have done so). However, the steady increase in percent of first-time users with no children at younger ages indicates that the number of women who wish to delay their first child has been increasing over time. Twenty-four percent of ever-married 20-24 year-olds and 31 percent of 15-19 year-olds have used a method before ever having a child. The decreasing median number of living children at time of first use at younger ages also indicates that more women are now acting to delay their first pregnancy than they have in the past. Older women (over the age of 35) had a median of 2.0 children before they first used contraception; younger women have a median of approximately 1.5 children at their first use of contraception. Thirty-seven percent of ever-married women had one living child at the time they first used a method of contraception; this percent does not change greatly with age, with the exception of 15-19 year-olds, among whom 17 percent first used a method after having one living child. Table 4.8 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at the time of first use of contraception, and median number of children at first use, according to current age, Kazakstan 1995 Never Number of living children at time used of first use of contraception Number contra- of Current age ception 0 1 2 3 4+ Total women Median 15-19 48.8 30.5 17.4 3.3 0.0 0.0 100.0 90 0.8 20-24 27.5 24.2 38.9 9.2 0.3 0.0 100.0 387 1.3 25-29 18.5 17.3 37.0 22.9 2.6 1.6 100.0 468 1.6 30-34 12.4 9.9 40.5 26.4 6.9 4.0 100.0 531 1.8 35-39 14.4 6.0 38.2 24.2 7.1 10.1 100.0 540 2.0 40-44 12.4 4.3 38.9 22.4 9.3 12.7 100,0 525 2.0 45-49 24.5 4.5 33.1 18.0 6.5 13.4 100.0 345 2.0 Total 18.3 11.3 37.4 20.7 5.5 6.8 100.0 2,886 1.8 4.5 Knowledge of Fertile Period and Contraceptive Effects of Breastfeeding Knowledge of reproductive physiology is an important prerequisite for effective use of traditional contraceptive methods. To

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