Malawi - Demographic and Health Survey - 1994

Publication date: 1994

Mala i Demographic and Health Survey 1992 National Statistical Office ®DHS Demographic and Health Surveys Macro Internatio,~al Inc. A REPUBLIC OF MALAWI Mala i Demographic and Health Survey 1992 National Statistical Office Zomba, Mala~vi Macro International Inc. Calverton, Maryland USA January 1994 This report summarises the findings of the 1992 Malawi Demographic and Health Survey (MDHS) conducted by the National Statistical Office, Zomba, Malawi. Macro International Inc. provided technical assistance. Funding was provided by the United States Agency for International Development (USAID). Additional information about the MDHS may be obtained from the National Statistical Office, P.O. Box 333, Zomba, Malawi; Fax (265) 523-130. Additional information about the DHS programme may be obtained by writing to: DHS, Macro International Inc., 11785 Beltsville Drive, Calverton, MD 20705, USA (Telephone (301) 572-0200; Fax (301) 572-0999). CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Map of Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx CHAPTER 1 INTRODUCTION 1.1 Geography, History, and the Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Population and Family Planning Policies and Programmes . . . . . . . . . . . . . . . . . . 2 1.3 Health Priorities and Programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.4 Objectives, Organisation, and Design of the Survey . . . . . . . . . . . . . . . . . . . . . . . 3 1.5 Data Collection and Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 CHAPTER 2 CHARALq'ERISTICS OF HOUSEHOLDS AND RESPONDENTS 2.1 Demographic Characteristics of Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.2 Economic and Environmental Characteristics of Households . . . . . . . . . . . . . . . 12 2.3 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHAPTER 3 FERTIL ITY 3.1 Current Fertility Levels and Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.2 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.3 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.4 Age of the Mother at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.5 Adolescent Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 CHAPTER 4 FERTIL ITY REGULAT ION 4.1 Knowledge of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 4.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 4.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 4.4 Differentials in Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . 34 4.5 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . 36 4.6 Knowledge of the Fertile Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.7 Sources of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.8 Intention to Use Family Planning Among Nonusers . . . . . . . . . . . . . . . . . . . . . . 40 4.9 Reasons for Non-use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.10 Preferred Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 i i i Page 4.11 Exposure to Family Planning Messages on Radio . . . . . . . . . . . . . . . . . . . . . . . . 45 4.12 Approval of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 CHAPTER 5 PROXIMATE DETERMINANTS OF FERTILITY 5.1 Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5.2 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.3 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.4 Postpartum Amenorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 5.5 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 CHAPTER 6 FERTILITY PREFERENCES 6.1 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 6.2 Demand for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 6.3 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 6.4 Wanted and Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 CHAPTER 7 CHILDHOOD MORTALITY 7.1 Data Quality and Mortality Estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 7.2 Levels and Trends in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 7.3 Socioeconomic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . 72 7.4 Biodemographic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . 74 7.5 High-Risk Fertility Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 CHAPTER 8 MATERNAL AND CHILD HEALTH 8.1 Antenatal Care and Delivery Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 8.2 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 8.3 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 8.4 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 8.5 Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 CHAPTER 9 MATERNAL AND CHILD NUTRITION 9.1 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 9.2 Nutritional Status of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 9.3 Maternal Anthropometric Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 CHAPTER 10 KNOWLEDGE OF AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 iv CHAPTER 11 Page MATERNAL MORTAL ITY 11.1 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 11.2 Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 11.3 Direct Estimates of Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 11.4 Indirect Estimates of Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 CHAPTER 12 AVAILABIL ITY OF HEALTH SERVICES 12.1 Distance and Time to Nearest Health Facility . . . . . . . . . . . . . . . . . . . . . . . . . . 125 12.2 Services Provided at Nearest Health Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 12.3 Distance and Time to Nearest Hospit',d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 12.4 Distance and Time to Nearest Source of Family Planning and Source of Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 12.5 AIDS Education Campaigns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 APPENDICES Appendix A Interview Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Appendix B Estimates of Sampling Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Appendix C Data Quality Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Appendix D Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 .¢ Table 1.1 Table 1.2 Table 2.1 Table 2.2 Table 2.3 Table 2A. 1 Table 2.4.2 Table 2.5 Table 2.6 Table 2.7 Table 2.8.1 Table 2.8.2 Table 2.9 Table 2.10 Table 3.1 Table 3.2 Table 3.3 Table 3A Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 Table 4.1 Table 4.2 Table 4.3 Table 4A Table 4.5 Table 4.6 TABLES Page Selected demographic indices for Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Results oftbe household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Educational level of the household population - males . . . . . . . . . . . . . . . . . . . . . . . . . 10 Educational level of the household population - females . . . . . . . . . . . . . . . . . . . . . . . . 11 School enrolment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Background characteristics of respondents - males . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Background characteristics of respondents - females . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Children ever born and l iving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Adolescent pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Children ever born to adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Knowledge of contraceptive methods and source for methods . . . . . . . . . . . . . . . . . . . . 29 Knowledge of modern contraceptive methods and source for methods . . . . . . . . . . . . . 31 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Current method use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Current method use by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 vii Table 4.7 Table 4.8 Table 4.9 Table 4.10.1 Table 4.10.2 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16.1 Table 4.16.2 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 7.1 Table 7.2 Table 7.3 Page Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 T ime to source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . 40 Future use of contraception - females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Future use of contraception - males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Family planning messages on radio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Acceptability of the use of radio for disseminating family planning messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Discussion of family planning by couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Attitudes of couples towards family planning - female respondents . . . . . . . . . . . . . . . 48 Attitudes of couples towards family planning - male respondents . . . . . . . . . . . . . . . . . 49 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Polygyny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Number of co-wives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Number of wives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Postpartum amenorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Median duration of postpartum amenorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Fertility preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . . . . . . 66 Wanted and unwanted births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Neonatal deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Childhood mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Childhood mortality by socioeconomic charactcristics . . . . . . . . . . . . . . . . . . . . . . . . . 73 viii Table 7A Table 7.5 Table 8.1 Table 8.2 Table 8.3 Table 8A Table 8.5 Table 8,6 Table 8,7 Table 8,8 Table 8,9 Table 8,10 Table 8,11 Table 8.12 Table 8.13 Table 8.14 Table 8.15 Table 9.1 Table 9.2 Table 9.3 Table 9A Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 10.1.1 Table 10.1.2 Table 102 Table 10.3 Table 10.4 Table 10.5 Table 11.1 Table 11.2 Page Childhood mortality by biodemographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . 74 High-risk fertility behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Number of antenatal visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Characteristics of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Vaccinations in the first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . . . . . . . . 91 Prevalence and treatmcnt of fcver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Prevalence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Knowledge and use of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Treatment of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Feeding practices during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Initial breast feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Breastfeeding and supplementation by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Nutritional status by socioeconomic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Anthropometric indicalors of maternal nutritional status . . . . . . . . . . . . . . . . . . . . . . . 108 Differentials in maternal anthropometric indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Knowledge of AIDS - females . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Knowledge of AIDS - males . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Sources of AIDS information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Perceived modes of AIDS transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Perceptions about AIDS prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Attitudes towards AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Data on siblings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Estimates of age-specific adult female mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 ix Table 11.3 Table 11 A Table 11.5 Table 12.1 Table 12.2 Table 12.3 Table 12.4 Table 12.5 Table 12.6 Table 12.7 Table A. 1 Table B. 1 Table B.2 Table B.3 Table B.4 Table B.5 Table B.6 Table B.7 TabTe C.1 Table C.2 Table C.3 Table CA Table C.5 Table C.6 Page Estimates of age-specific female mortality, model life tables . . . . . . . . . . . . . . . . . . . 122 Direct estimates of maternal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Indirect estimates of matemal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Type of nearest health facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Distance and time to nearest health facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Available health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Distance and time to nearest hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Distance and time to nearest source for any family planning method . . . . . . . . . . . . . 129 Distance and time to nearest source of condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 AIDS awareness campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Sample implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 List of selected variables for sampling errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Sampling errors, entire sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Sampling errors, urban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Sampling errors, rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Sampling errors, Northem Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Sampling errors, Central Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Sampling errors, Southern Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Age distribution of eligible and interviewed women and men . . . . . . . . . . . . . . . . . . . 152 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Births by calendar year since birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 FIGURES Figure2.1 Figure 3.1 Figure3.2 Figure 3.3 Figure4.1 Figure 4.2 Figure 4.3 Figure 5.1 Figure 6.1 Figure6.2 Figure 6.3 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 8.1 Figure 8.2 Figure 8.3 Figure 8.4 Figure 9.1 Figure 10.1 Figure 10.2 Page Population pyramid of Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g Age-specific fertility rates, Malawi, 1984 FFS and 1992 MDHS . . . . . . . . . . . . . . . . . 20 Age-specific fertility rates, urban and rural Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Percentage of adolescents who have begun childbcaring, by age . . . . . . . . . . . . . . . . . 27 Percentages of currently married women who know specific contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Percentage of currently married women and men using a contraceptive method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Distribution of current female users of modem contraception by source of supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Percentage of currently married women whose husbands have at least one other wife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Fertility preferences among currently married women 15-49 . . . . . . . . . . . . . . . . . . . . 60 Fertility preferences among currently married women, by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Percentage of women with unmet need and met need for family planning services, by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Under-five mortality in cast and soud~em Africa, selected DHS surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Trends in neonatal, posmconatal, and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Under-five mortality by selected background characteristics . . . . . . . . . . . . . . . . . . . . . 73 Under-five mortality by selected biodcmographic characteristics . . . . . . . . . . . . . . . . . 75 Percent distribution of births by use of selected maternal health services . . . . . . . . . . . 80 Percentage of children age 12-23 months with certain vaccinations . . . . . . . . . . . . . . . 87 Percentage of children age 12-23 months who are fully vaccinated . . . . . . . . . . . . . . . 89 Prevalence of respiratory illness and diarrhoea in the last two weeks, by age of the child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Percentage of children stunted, by age of child and degree of stunting . . . . . . . . . . . . 106 AIDS awareness and knowledge of modes of HIV transmission . . . . . . . . . . . . . . . . . 113 Sources of information about AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 xi ABBREVIATIONS ANC ARI BCG BMI CBR CDC CDD CDR CEB DC DHS DPT EA EPI FFS GDP IEC ISSA IUCD MDHS NCHS NGO NPAC NSO OPC ORS ORT PHC SD TBA TFR UNICEF UN WHO Antenatal care Acute respiratory infections Bacille Bilid de Calmette et Gudrin (vaccine) Body mass index Crude birth rate Centers for Disease Control Control of Diarrhoeal Diseases Crude death rate Children ever born Delivery care Demographic and Health Surveys Diphtheria - poliomyelitis - tetanus (vaccine) Enumeration area Expanded Programme on Immunisation Family Formation Survey Gross domestic product Information, education and communication Integrated system for survey analysis Intra-uterine cervical device Malawi Demographic and Health Survey National Center for Health Statistics (USA) Non-governmental organisations National Population Advisory Committee National Statistical Office Office of the President and Cabinet Oral rehydration salts Oral rehydration therapy Primary health care Standard deviation Traditional birth attendant Total fertitity rate United Nations Children's Fund United Nations World Health Organisation xiii PREFACE This final report presents the major findings of the Malawi Demographic and Health Survey (MDHS). The MDHS fieldwork was carried out by the National Statistical Office (NSO) from September to November 1992; the data were processed and ready for analysis by January 1993. The First Report, which provided a more limited set of demographic and health indices, was published in March 1993. The primary objective of the Malawi Demographic and Health Survey was to provide up-to-date information for policymakers, planners and researchers that would allow guidance in the development and evaluation of bealth and population programmes. Specifically, the MDHS collected information on fertility levels, nuptiality, fertility preferences, knowledge and use of family planning methods, breastfocding practices, nutritional status of mothers and children, early childhood morbidity and mortality, use of maternal and child health services, maternal mortality, AIDS awareness, and availability of basic health services. The MDHS was a nationally representative sample survey designed to provide estimates of various demographic and health indices for the three regions of the country, urban and rural areas, and for the country as a whole. Three types of questionnaires were used: the Household Questionnaire, the Individual Female Questionnaire, and the Individual Male Questionnaire. The contents of these questionnaires were based on the DHS Model B Questionnaire, with modifications that were undertaken by the National Statistical Office in conjunction with the Ministry of Health and Macro International Inc. (Macro) of Columbia, Maryland (U.S.A). I would like to thank Macro for providing technical assistance for the preparation, planning, implementation, and processing of the survey and for the printing of the first and this final report. I would also like to thank USAID for contracting Macro to carry out the MDHS and for providing the funding. Finally, I would like to thank all the members of the MDHS team at NSO who participated in this survey, and a special thanks goes to all of the many respondents who gave their time to make the survey a great success. J. Nowa Actin ~Cnmmissioner for Census and Statistics XV SUMMARY OF FINDINGS The 1992 Malawi Demographic and Health Survey (MDHS) was a nationally representative sample survey designed to provide information on levels and trends in fertility, early childhood mortality and morbidity, family planning knowledge and use, and maternal and child health. The survey was implemented by the National Statistical Office during September to November 1992. In 5323 households, 4849 women age 15-49 years and 1151 men age 20-54 years were interviewed. The findings indicate that fertility in Malawi has been declining over the last decade; at current levels a woman will give birth to an average of 6.7 children during her lifetime. Fertility in rural areas is 6.9 children per woman compared to 5.5 children in urban areas. Fertility is higher in the Central Region (7.4 children per woman) than in the Northem Region (6.7) or Southern Region (6.2). Over the last decade, the average age at which a woman first gives birth has risen slightly over the last decade from 18.3 to 18.9 years. Still, over one third of women currently under 20 years of age have either already given birlh to at least one child or are currently pregnant. Although 58 percent of currently married women would like to have another child, only 19 percent want one within the next two years. Thirty-seven percent would prefer to walt two or more years. Nearly one quarter of married women want no more children than they already have. Thus, a majority of women (61 percent) want either to delay their next birth or end childbearing altogether. This represents the proportion of women who are potentially in need of family planning. Women reported an average ideal family size of 5.7 children (i.e., wanted fertility), one child less than the actual fertility level measured in the survey--further evidence of the need for family planning methods. Knowledge of contraceptive methods is high among all age groups and socioeconomic strata of women and men. Most women and men also know of a source to obtain a contraceptive method, although this varies by the type of method. The contraceptive pill is the most commonly cited method known by women; men are most familiar with condoms. Despite widespread knowledge of family planning, current use of contraception remains quite low. Only 7 percent of currently married women were using a modem method and another 6 percent were using a traditional method of family planning at the time of the survey. This does, however, represent an increase in the contraceptive prevalence rate (modem methods) from about 1 percent estimated from data collected in the 1984 Family Formation Survey. The modem methods most commonly used by women are the pill (2.2 percent), female sterilisation (1.7 percent), condoms (1.7 percent), and injections (1.5 percent). Men reported higher rates of contraceptive use (13 percent use of modem methods) than women. However, when comparing method-specific use rates, nearly all of the difference in use between men and women is explained by much higher condom use among men. Early childhood mortality remains high in Malawi; the under-five mortality rate currently stands at 234 deaths per 1000 live births. The infant mortality rate was estimated at 134 per 10130 live births. This means that nearly one in seven children dies before his first birthday, and nearly one in four children does not reach his fifth birthday. The probability of child death is linked to several factors, most strikingly, low levels of maternal education and short intervals between births. Children of uneducated women are twice as likely to die in the first five years of life as children of women with a secondary education. Similarly, the probablity of under-five mortality for children with a previous birth interval of less than 2 years is two times greater than for children with a birth interval of 4 or more years. Children living in rural areas have a higher rate ofunder-fwe mortality than urban children, and children in the Central Region have higher mortality than their counterparts in the Northem and Southem Regions. xvii Data were collected that allow estimation ofmatemalmortality. It is estimated that for every ! 00,000 live births, 620 women die due to causes related to pregnancy and childbearing. The height and weight of children under five years old and their mothers were collected in the survey. The results show that nearly one half of children under age five are stunted, i.e., too short for their age; about half of these are severely stunted. By age 3, two-thirds of children are stunted. As with childhood mortality, chronic undernutrition is more common in rural areas and among children of uneducated women. The duration of breastfeeding is relatively long in Malawi (median length, 21 months), but supplemental liquids and foods are introduced at an early age. By age 2-3 months, 76 percent of children are already receiving supplements. Mothers were asked to report on recent episodes ofilloess among their young children. The results indicate that children age 6-23 months are the most vulnerable to fever, acute respiratory infection (ARI), and diarrhoea. Over half of the children in this age group were reported to have had a fever, about 40 percent had a bout with diarrhoea, and 20 percent had symptoms indicating ARI in the two-week period before the survey. Less than hal fof recently sick children had been taken to a health facility for treatment. Sixty-three percent of children with diarrhoea were given rehydration therapy, using either prepackaged rehydration salts or a home-based preparation. However, one quarter of children with diarrhoea received less fluids than normal during the illness, and for 17 percent of children still being breastfed, breastfeeding of the sick child was reduced. Use o f basic, preventive maternal and child health services is generally high. For 90 pereent of recent births, mothers had received antenatal care from a trained medical person, most commonly a nurse or trained midwife. For 86 percent of births, mothers had received at least one dose of tetanus toxoid during pregnancy. Over half of recent births were delivered in a health facility. Child vaccination coverage is high; 82 percent of children age 12-23 months had received the full complement of recommended vaccines, 67 percent by exact age 12 months. BCG coverage and first dose coverage for DPT and polio vaccine were 97 percent. However, 9 percent of children age 12-23 months who received the first doses of DPT and polio vaccine failed to eventually receive the recommended third doses. Information was collected on knowledge and attitudes regarding AIDS. General knowledge of AIDS is nearly universal in Malawi; 98 percent of men and 95 percent of women said they had heard of AIDS. Further, the vast majority of men and women know that the disease is transmitted through sexual intercourse. Men tended to know more different ways of disease transmission than women, and were more likely to mention condom use as a means to prevent spread of AIDS. Women, especially those living in rural areas, are more likely to hold misconceptions about modes of disease transmission. Thirty percent of rural women believe that AIDS can not be prevented. xviii MALAWl TANZANIA NORTHERN REGION ZAMBIA • ii II :.% ¢. LAKE CENTRAL REGION ~ ~ • ; • • i l l •• SOUTHERN REGION MOZAMBIQUE ~CTED SAMPLE POtNTS • Rural and Small Urban Sample Points 2 in Zomba Municipality {~) 7 in Mzuzu City 1~ 15 in I-ilongwe City (capital) (~ 17 in Blantyre City • "| r" • QQ.m ~ XX CHAPTER 1 INTRODUCTION 1.1 Geography, History and the Economy Geography Malawi is a landlocked country bordered to the north and northeast by the United Republic of Tanzania, to the east, south and southwest by the People's Republic of Mozambique and to the west by the Republic of Zambia. It is 901 kilometres long and ranges in width from 80 to 161 kilometres. The country has a total area of 118,484 square kilometres, of which 94,276 square kilometres is land area. Fifty-six percent of the land area is arable. Malawi's most striking topographic feature is the Rift Valley which runs through the entire length of the country, passing through Lake Malawi in the northem and central part of the country to the Shire Valley in the south. To the west and south of the lake are fertile plains and high mountain ranges whose main peaks range from 1,698 to 3,002 metres. The country is divided into three administrative regions; Northern, Central and Southern. There are twenty-four districts, five in the Northern Region, nine in the Central Region and ten in the Southern Region. In each district there are Traditional Authorities (or chiefs) and the smallest administrative unit is the village. There are 43 Traditional Authorities in the Northcrn Region, 79 in the Central Region and 83 in the Southern Region. Malawi experiences a tropical continental climate with some maritime influences. Rainfall and temperature are greatly influenced by the lake and altitude, which varies from 37 to 3,050 meters above sea level. From May to August, the climate is cool and dry. From September to November, average temperatures rise and the rainy season begins towards the end of this period. The rainy season extends to April or May. History Based on the examination of earliest human remains and stone-aged tools, people who are known as Abathwa, Akafula or Mwandionerakuti lived in Malawi since around 8000 BC. During the 9th Century AD, a group of people known by the name of Pule, Lenda or Katanga from the shores of Lake Tanganyika settled in Malawi. Between the 13th and 16th Century AD, Bantu speakers known as Maravi settled in central and southern Malawi. Those who eventually settled in central Malawi are known as Chewa while those who settled in southern Malawi are known as Mang'anja or Nyanja. The Tumbuka, Tonga, Ngonde, and Lambya eventually came to settle in northem Malawi. Later, during the 19th Century AD, the Ngoni, Yao, Lomwe and Sena settled in Malawi. It was also during this period that Europeans arrived in Malawi. On 14th May 1891, the British declared the country a British Protectorate under the name of Nyasaland District Protectorate which was then changed to British Central African Protectorate in 1893. Opposition to colonial adminstration culminated in the uprising led by John Chilembwe in 1915. In 1953 the Federation of Rhodesia and Nyasaland, which was also known as the Centred African Federation, was instituted comprising three countries, namely, Zimbabwe (then Southern Rhodesia), Zambia (then Northern Rhodesia) and Malawi (then Nyasaland) despite protests from Africans in Malawi through the Nyasaland African Congress, which was a nationalist movement founded in 1944. On 3rd March 1959 a state of emergency was declared by the colonial government and the Nyasaland African Congress, whose leaders were arrested and detained, became a banned party. In September 1959 the Malawi Congress Party was formed and on 19th September 1959 the Malawi News was launched as the official organ of the Party. On 15th August 1961 the first multiparty general election was held wherein four political parties contested. The Malawi Congress Party won all twenty seats on the lower roll plus two which it contested on the higher roll. As a result of the general election, the country formed an internal self-government. In April 1964 another general election was held wherein all candidates of the Malawi Congress Party were returned unopposed. On 6th July 1964 Nyasaland became the independent state of Malawi under the monarchical constitution which was replaced by a republican constitution as of 6th July 1966 when Malawi bec~une a Republic and a one-party state. On 14th June 1993 a National Referendum was eonductcd which resulted in Malawi becoming a multiparty state. The Economy Malawi is predominantly an agricultural country. Agricultural produce accounts for 90 percent of Malawi's exports; tobacco, tea and cotton are the major export commodities. The country is largely self- sufficient in food. The economy of Malawi improved in 1991 over performance in the three preceding years. Real gross domestic product (GDP) grew at a rate of 7.8 percent in 1991 compared to growth of 4.8 percent, 4.1 percent and 3.3 percent recorded in 1990, 1989 and 1988, respectively. The agricultural and distribution sectors accounted for most of the increase in real GDP. 1.2 Population and Family Planning Policies and Programmes The major source of demographic data is the population census. Population censuses have been taken in Malawi during the years 1891, 1901, 1911, 1921, 1926, 1931, 1945, 1956, 1966, 1977 and 1987. Additional popula- tion data have been collected through nationwide demographic and other related surveys. These are the Malawi Population Change Survey in 1970-72, the Malawi Demographic Survey in 1982, the Malawi Labour Force Survey and the Survey of Handicapped Persons in 1983, and the Family Formation Survey in 1984. Table 1.1 provides some demographic indices for Malawi. The population of Malawi is growing at a rate of around 3.2 percent per year based on the 1987 census, up from 2.9 percent in 1977 (this considers only natural or intrinsic growth and does not include refugee populations, esti- mated at about 1 million persons in 1992). The total Malawian population in the 1987 census was enumerated at around 8 million persons, having roughly doubled since the 1966 census. Given current growth rate estimates, the 1994 population will reach approximately 10 million Table 1.1 Selected demographic indices fi~r Malawi Census year Index 1966 1977 1987 Population I 4039583 55474611 7988507 Intercensal growth rate 2 - 2.9 3.2 Total area (sq. kin.) 118484 118484 118484 Land area (sq. kin.) 94079 94276 94276 Density (pop./sq. kin.) 43 59 85 Percentage urban 5.0 8.5 10.7 Women of childbearing age as percentage of female population 47.6 45.1 44.2 Sex ratio 90 93 94 Crude birth rate 48.3 41.2 Total fertility rate 7.6 7.63 Crude death rate 25.0 14. I Infant mortality rate 165 1513 Life expectancy' Male 39.2 41 4 Female 42 4 44.6 IDe facto population 2Natural increase; excludes migration, refugees 3Based on the 1984 Family Formation Survey 2 persons. With a doubling of the size of Malawi's population over the last two decades has come a doubling of the population density from 43 to 85 persons per square kilometre during the period 1966 to 1987. By 1994, Malawi's population density will exceed 100 persons per square kilometre. A national population policy for Malawi has been prepared. The policy aims at achieving lower population growth rates compatible with attainment of the country's social and economic objectives in addition to reducing morbidity and mortality among mothers and children. It aims at improving the status of mothers and children in all spheres of development as well as improving information, education and communication on the use of contraceptives and benefits of small family sizes. In the education sector, the policy will enhance the relevance of formal and informal education. The policy stresses the importance of the creation of employment and food self-sufficiency especially for pregnant and lactating mothers as well as children. Last but not least, the policy aims at improving the collection, analysis and dissemination of demographic, environment and employment data, by gender, and the utilisation of these data for social and economic planning. A technical secretariat for the National Population Advisory Committee (NPAC) composed of all relevant ministries and non-government organisations (NGOs) was recently established in the Office of the President and Cabinet (OPC). The Secretariat's overall responsibility is to coordinate and monitor the implementation of population programmes and projects and to develop population guidelines for the country. 1.3 Health Priorities and Programmes Health services in Malawi are provided by the Ministry of Health, the Ministry of Local Government and the NGOs, particularly mission organisations. The Ministry of Health is responsible for planning and developing health policies and for providing health care in all government hospitals. The Ministry of Local Govemment is in charge of health care delivery at the district level and below. NGOs provide services to both hospitals and smaller medical units. In Malawi, the provision of curative services takes a large proportion of the total government funds allocated to the health sector. The lack of an effective outreach capacity in the system has been recognised by the Ministry of Health, and strategies for creating a community-based distribution system are being implemented despite a severe lack of trained medical personnel in the country. Currently, the government is developing a health policy with the goal of achieving health for all by the year 2(g30. 1.4 Objectives, Organisation, and Design of the Survey Objectives The Malawi Demographic and Health Survey (MDHS) was a national sample survey of women and men of reproductive age designed to provide, among other things, information on fertility, family planning, child survival, and health of mothers and children. Specifically, the main objectives of the survey were to: Collect up-to-date information on fertility, infant and child mortality, and family planning Collect information on health-related matters, including breastleeding, antenatal and maternity services, vaccinations, and childhood diseases and treatment Assess the nutritional status of mothers and children Collect information on knowledge and attitudes regarding AIDS • Collect information suitable for the estimation of mortality related to pregnancy and childbearing Assess the availability of health and family planning services. Organisation The MDHS was conducted by the National Statistical Office (NSO) from September to November 1992. Financial support for the survey was provided by the United States Agency for International Development (USAID) while technical assistance was provided by Macro International Inc. (Macro) of Columbia, Maryland (USA) through its contract with USAID. Survey Design Based on the 1987 Malawi Population and Housing Census, the country is demarcated into 8,652 enumeration areas (EAs) of roughly equal population size. This sampling frame of census EAs was stratified by urban and rural areas within each of the three administrative regions, making six sampling strata in total. Within each sampling stratum, districts were geographically ordered, thereby providing additional implicit stratification. The MDHS sample of households was selected in two stages. First, 225 EAs were selected from the 1987 census frame of EAs with probability proportional to population size. The distribution of selected sample points (EAs) is shown in the map of Malawi on page xx. The measure of EA size was based on the number of households enumerated during the 1987 census. NSO staff, after being trained in listing procedures and methods for updating maps, were sent to the selected EAs to list all households and produce maps which provided the orientation for later data collection teams in finding selected households. Households in refugee camps and institutional populations (army barracks, police camps, hospitals, etc.) were not listed. In the second stage, a systematic sample of households was selected from the above lists, with the sampling interval from each EA being proportional to its size based on the results of the household listing operation. In these households, all women age 15-49 years were eligible lot interview. Further, a one-in-tln'ce systematic subsample of households was drawn, within which both eligible men age 20-54 years and women age 15-49 years were interviewed. Because the objective of the survey was to produce region-level and urban/rural estimates of some indicators, an oversample of households in the Northern Region and in urban areas was necessary. Thus the MDHS sample is not self-weighting at the national level, but it is self-weighting within each ol the six region/urban-rural strata. Four types of questionnaires were used: the Household Questionnaire, the Individual Female Questionnaire, the Individual Male Questionnaire, and the Health Services Awfilability Questionnaire. The contents of these questionnaires were based on the DHS Model B Questionnaire, which is designed for use in countries with a low level of contraceptive use. Modification of the questionnaires was undertaken by NSO in consultation with the Ministry of Health and Macro. The questionnaires were pretested in April 1992. Approximately 250 interviews were conducted over a two-week period, and further adjustments to the questionnaires were made based on lessons drawn fi'om the interviews and analysis of the data. 4 The Household Questionnaire was used to list all the usual members and visitors of selected households. A household is defined as one that consists of one or more persons, related or unrelated, who make common provisions for food, or who regularly take all their food from the same pot or same grainstore (Nkhokwe), or who pool their incomes for the purpose of purchasing food. Persons in a household may live in one or more dwelling units. Information was collected on the characteristics of each person listed, including his/her age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women who were eligible for individual interview, namely, those age 15-49 years. For those women who were either absent or could not be interviewed during the first visit, a minimum of three visits were made before recording nonresponse. Women were interviewed with the individual female questionnaire. In the course of administering the household questionnaire, eligible men, namely, those age 20-54 were also identified. The individual male questionnaire was administered to all men age 20-54 living in every third household in the selected sample. The male questionnaire collected much of the same information found in the female questionnaire, but was considerably shorter because it did not contain questions on reproductive history, and maternal and child health. During the household listing operation (i.e., before the main survey), one Health Services Availability Questionnaire was completed in each of the 225 MDHS sample points. Leaders in the community provided information that allowed an assessment of the availability of health and family planning services to persons living in the respective localities. A three-week training course for the main survey was held in July and August of 1992. A total of 80 field staff was trained. The training course consisted of instruction in general interviewing techniques, field procedures, a detailed review of items on the questionnaires, instruction and practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews in areas outside MDHS sample points. Only trainees who performed satisfactorily in the training programme were selected for fieldwork. Team leaders were NSO staff who had previously participated in the MDHS pretest. 1.5 Data Collection and Data Processing The fieldwork for the MDHS was car- ried out by ten interviewing teams, each con- sisting of one team leader, one field editor, five female interviewers, one male interviewer and one driver. Additionally, senior NSO staff co- ordinated and supervised fieldwork activities. Data collection began 1 September and was completed on 10 November 1992. Table 1.2 shows the results of house- hold and individual interviews for the urban and rural sample and for Malawi as a whole. A more detailed presentation of interview results by re- gion and urban-rural residence is given in Appendix A. A total of 5,811 households was selected in the MDHS sample, of which 5,396 were currently occupied. Of the 5,396 occupied households, 5,323 were interviewed, yiclding a Table 1.2 Results of the household mad indivldua[ interviews Number of households, number of interviews, and response rates, Malawi 1992 ResuLt Urban Rural Malawl Households sampled 1413 4398 5811 Households occupied 1360 4036 5396 Households interviewed 1339 3984 5323 HOUSEIIOLD RESPONSE RATE 98 5 98.7 98.6 Eligible women 1359 3661 51120 Eligible women interviewed 1316 3533 4849 ELIGIIILE WOMEN RESPONSE RATE 96.8 96 5 96.6 Eligible men 416 872 1288 Eligible men lnlerviewed 364 787 1151 ELIGIBLE MEN RESPONSE RATE 87.5 903 89.4 household response rate of 98.6 percent. Rural and urban response rates at the household level did not differ significantly. Within the interviewed households, 5020 eligible women (15-49 years) were identified of which 4849 were interviewed, yielding an individual female response rate of 96.6 percent. In the one-in-three subsample of households, 1,288 eligible men were identified, of which 1,151 were successfully interviewed (89.4 percent response). The principal mason for nonresponse among both eligible men and women was the failure to find them at home despite repeated visits to the household. The lower response rate among men than women was due to more frequent and longer-term absence of men. The refusal rate in the MDHS was extremely low (0.1 percent). Response rates were marginally better in rural areas than in urban areas in the male survey (rural, 90.3 percent; urban, 87.5 percent), but nearly the same in the female survey (rural, 96.5 percent; urban, 96.8 percent). Completed questionnaires were retumed to NSO for data processing. The processing operation consisted of office editing, coding of open-ended questions, data entry and editing of errors found by the computer programs. Data entry, editing, and analysis were accomplished on personal computers, using a software program called ISSA (Integrated System for Survey Analysis). Data processing started on 14 September 1992 and was completed on 21 January 1993. 6 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 2.1 Introduction An understanding of the background characteristics of the households interviewed in the survey and the individual survey respondents is essential to the interpretation of the MDHS data and provides an indication of the representativeness of the survey sample. Information on age and educational level of household members, household composition, and household possessions and amenities was collected in the survey. This chapter presents this information in three parts: • Demographic characteristics of households Economic and environmental characteristics of households Characteristics of survey respondents. 2.1 Demographic Character ist ics of Households Age Structure The age distribution of the household population in the MDHS is shown in Table 2.1. The age structure, depicted by way of the population pyramid in Figure 2.1. is one typical of high-fertil ity populations, Table 2.1 Household population by ager residence and sex Percent distribution of the de facto household population by five-year age group, according to urban-rural residence and sex, Malawi 1992 Urban Rural Total Age group Male Female Total Male Female Total Male Female Total 0-4 14.8 15.3 15.0 17.3 15.7 16.5 17.0 15.7 16.3 5-9 15.1 15.3 15.2 16.4 15.6 16.0 16.2 15.5 15.9 10-14 12.3 19.0 15.5 15.0 15.0 15.0 14.7 15.5 15.1 15-19 12.6 9.7 11.2 10.6 9.4 10.0 10.9 9.4 10.2 20-24 9.9 10.1 10.0 7.5 7.8 7.6 7.8 8.0 7.9 25-29 8.8 9.0 8.9 5.9 6.3 6.1 6.3 6.6 6.4 30-34 7.7 6.3 7.0 4.7 5.3 5.0 5.1 5.4 5.3 35-39 4.9 4,7 4,8 3,9 4,4 4,2 4,0 4,5 4,2 40-44 4.5 3.0 3.7 4.3 4.4 4.3 4.3 4.2 4.3 45-49 2.8 1.9 2.4 2.7 3.1 2.9 2,7 2.9 2.8 50-54 2.5 2.2 2.3 2.7 3.7 3.2 2.7 3.5 3.1 55-59 1.3 1.1 1.2 2.1 2.6 2.4 2.0 2.4 2.2 60-64 1.4 0.9 1.2 2.3 2.3 2.3 2.2 2.1 2.2 65-69 0.4 0.6 0.5 1.4 1.4 1.4 1.3 1.3 1.3 70-74 0.4 0.3 0.3 1.4 1.3 1.4 1.2 1.2 1.2 75-79 0.2 0.4 0.3 0,6 0.8 0.7 0.6 0.7 0.7 80+ 0.4 0.3 0.4 0.9 0.9 0.9 0.8 0.8 0.8 Don't know/Missing 0.1 0.0 0.1 0.2 0.1 0.1 0.2 0.1 0.1 Total 100.0 I00.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1464 1334 2798 9770 10518 20288 11234 11853 23087 8(} ÷ , , ) t~ tt 2' ~'1 I L , 1 , I F gure 2 1 Populatio Pyramid ol ' qalawl , I , ! r r F',ID ~ I~ . 19!97 i.e., a very wide-based population pyramid indicating large numbers of recent births relative to the adult population. A comparison of urban and rural age distributions indicates an excess of adult males in the urban setting and an excess of adult females in the rural setting. Table 2.2 shows the percentage distribution of the de facto household population under age 15, 15 -64 years old, and 65 years and older indicated by the 1966, 1977 and 1987 national censuses, and the 1992 MDHS. The percentage of the population undcr age 15 years has risen from 43.9 percent in 1966 to 47.3 Table 2.2 Population by age from selected sources Percent distribution of the population by age group and dependency ratio, from 1992 MDHS and 1966. 1977, and 1987 censuses, Malawi 1992 MDItS 1992 Census Age group De jure l)e facto 1987 1977 1966 Less than 15 46.6 47.3 46.0 44.6 43.9 15-64 49.2 48.6 50.0 50.9 52.1 65+ 4.1 4.0 4.0 4.5 4.0 Don't know/Missing 0.1 0.1 Total 100.0 100.0 llX/.O 100.0 100.0 Dependency ratio 1.05 1.00 0.96 0.92 percent in 1992. Consequently, over the period 1966 to 1992, the dependency ratio ~ has risen from 0.92 in 1966, to 0.96 in 1977, to 1.00 in 1987, to 1.05 in 1992. There exists a substantial difference in the dependency ratio between urban and rural settings, due to a larger proportion of the population in rural areas at ages under 15 and ages over 64. For each person 15- 64 years old in rural areas, there are 1.08 dependents in the household; in urban areas the dependency ratio is 0.90. Size of Househo lds and Relat ionship Structure Table 2.3 gives the percentage distri- bution of households by sex of the household head, size of the household, relationship struc- ture within the household, and presence of fos- ter children 2 in the household. Three-quarters of Malawian households are headed by a man. Thirteen percent of urban households are head- ed by a woman compared to 26 percent of rural households. The average number of persons l iving in a household is 4.5. Urban households tend to be larger (4.8 persons) than rural households (4.4 persons). This pattern is typical of coun- tries in this region and is evidently due to a greater percentage of urban households having a very large number (9+) of members. The most common relationship structure was one where two adults of the opposite sex lived to- gether in the household (44 percent). Of the re- maining households, most had 3 adult mem- bers who were related (29 percent). Interesting- ly, rural households were nearly 50 percent more likely than urban households to have only one adult resident. Urban households, on the other hand, were twice as likely as rural households to have an "other" arrangement, which in large part represents households with large numbers of adult residents. The MDHS also found that a greater percentage of urban households than rural households contained foster children. Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, kinship structure, and presence of foster children, according k~ urban-rural residence, Malawi 1992 Residence Characteristic Urban Rural Total Household headship Male 87.4 73.9 75.4 Female 12.6 26.1 24.6 Number of usual members 1 9.1 7.9 8.1 2 14.2 15A 15.3 3 13.7 17,2 16.8 4 14.2 16,5 16.3 5 12.2 14,1 13.8 6 11.0 10,9 10.9 7 8.3 7,1 7.3 8 6.6 4,7 4.9 9+ 10.6 6,1 6.6 Mean size 4.8 4,4 4.5 Relatinnship structure One adult 12.8 18,8 18.1 Two related adults: Of opposite sex 41.5 44,8 44.4 Of same sex 4.5 4.2 4.2 Three ur more related adults 32.3 28,0 28.5 Oilier 8.6 4,0 4.6 With foster children 24.0 19.2 19.8 XThe dependency ratio is the ratio of persons 0-14 years and 65 years and older over persons 15-64 years. 2A foster child is a child under 15 years, neither of whose parents live in the same household as the child. Education Level of Household Members Tables 2.4.1 and 2.4.2 present the distribution of the de facto population of housebold members by level of education by sex and five-year age group. For Malawi as a whole, 30 percent of males and 48 percent of females had never been to school. Once having attended school, males also tended to stay in school longer than females; 6 percent of males had been to secondary school compared with only 2 percent for females. Looking at changes by age group in the percentage never attending school, male non-attendance starts to rise only after age 35-39, whereas the same occurs to females starting at age 15-19, indicating a more recent improvement in school attendance for females. In the youngest age groups, which better reflect the current situation, attendance among boys and girls is nearly equal. Table 2.4.1 Educational level of the household population - males Percent distribution of the de facto male household population age five and over by highest level of education auended, according to selected background characteristics, Malawi 1992 Level of education Number Median Background Primary Primary of number characteristic None 1-4 5-8 Secondary+ Total men of years Age 5-9 56.4 43.2 0.3 0.1 100.0 1815 0.0 10-14 22.3 65.0 12,6 0.2 100.0 1645 2,4 15-19 19.5 34,3 42.2 4.0 100.0 1224 4.6 20-24 23.0 26.2 36.2 14.6 100.0 876 5.1 25-29 20.1 20.8 43.6 15.5 100.0 702 5.9 30-34 20,2 21.2 43.6 15.0 100.0 566 6.2 35-39 20,1 23,2 41.6 15.0 100.0 448 5.8 40-44 24.0 29.4 35.8 10.8 100.0 488 4.6 45-49 22.1 25.3 45.2 7.3 100 0 305 5 3 50-54 26.2 35.8 29.9 8.1 100.0 303 4.2 55-59 34.7 36,4 26,6 2.3 100.0 224 3.2 60-64 40.0 30.0 26.4 3 5 100.0 247 2.6 65+ 42.3 35.11 21.4 1.3 100.0 435 2.4 Don't know/Missing 85.6 0.0 3.9 10.5 10(/.0 12 0.0 Residence Urban 14.3 28.6 36.4 20.7 100.0 1241 6.1 Rural 32.7 39.2 24.3 3.8 100.0 8050 2.4 Region Northern 13.0 38.1 38.1 10.8 100.0 1108 4.9 Central 33.2 36.8 25.1 4.9 100.0 3611 2.5 Southern 32.1 38.5 23.6 5.8 100.0 4572 2 5 Total 30.2 37.8 25.9 6.1 100.0 9291 2.8 Tables 2.4.1 and 2.4.2 also show school attendcnce by urban-rural residence and region. Three- quarters of females and 86 percent of males in the urban areas have been to school; 11 percent of females and 21 percent of males go to secondary school or beyond. But for the nearly 90 percent of Malawi's population that live in rural areas, educational attainment is much lower, with over hal f of females and nearly one third 10 Table 2.4,2 Educational level of the household population - females Percent distribution of the de facto female household population age five and over by highest level of education attended, according to selected background characteristics, Malawi 1992 Level of education Number Median Background Primary Primary of number characteristic None 1-4 5-8 Secondary+ Total women of years Age 5-9 52.7 46.9 0.3 0.0 100.0 1833 0.0 10-14 27.2 59.2 13.4 0.2 100.0 1832 2.2 15-19 30.3 32,1 33.5 4,1 100.0 1118 3,5 20-24 40.9 24.4 28.1 6.6 100.0 953 2.9 25-29 44.7 23.1 27.0 5.3 100.0 778 2.1 30-34 55.8 21.4 18.4 4.4 100.0 645 0.0 35-39 58.5 22.4 15.7 3.4 100.0 529 0.0 40~.4 57.3 25.6 14.9 2.1 100.0 498 0,0 45-49 69,5 18.2 11.2 1.1 100.0 347 0,0 50-54 69.5 24.3 5.8 0.4 100.0 417 0.0 55-59 73.2 21.5 5.3 0.0 100.0 283 0.0 60-64 68.3 27.0 4.7 0.0 10O.0 254 0.0 65+ 77.1 18.5 4.5 0.0 100.0 479 0,0 Don't know/Missing 64.3 35.7 0.0 0.0 100.0 8 0.0 Residence Urban 24.8 34.7 29.2 11.2 100.0 1130 3.7 Rural 50.9 35.0 13.1 1.0 100.0 8847 0.0 Region Northern 25.2 40.3 30.4 4.1 100.0 1153 3,1 Central 49.2 35.9 13.0 1.9 100,0 3953 0.9 Southern 52.3 32,9 12.9 1,9 100.0 4870 0.0 Total 47.9 34.9 15.0 2.2 100.0 9976 1.0 of males never having attended school. Only 1 percent of females and 4 percent of males have reached secondary school level in rural Malawi. The MDHS data show that the Northern Region has significantly higher levels of school attendance than the Central and Southern Regions, which have roughly similar levels. Northern residents are half as likely as persons who live in the rest of the country to have never been to school and twice as likely to have ever attended secondary school. This pattem is exhibited among both males and females. Current School Enrolment Table 2.5 shows the percentage distribution of the de facto household population 6-24 years of age currently enrolled in school by age, sex and urban-rural residence. According to the MDHS, 52 percent of children age 6-10 were enrolled in school at the survey date. The percentage enrolment rises to 66 percent in the age group 11-15 years and begins to fall thereafter, reaching 10 percent in the age group 21-24 years. About three-quarters of urban 6-10 ycar-olds are currently 11 Table 2.5 School enrolment Percentage of the de facto household population age 6-24 years enrolled in school, by age group, sex, and urban- rural residence, Malawi 1992 Age group Male Female Total Urban Rural Total Urban Rural Total Urban Rural Total 6-10 71,9 48.1 50.8 75.7 51.1 53.8 73.9 49.6 52.3 11-15 83.5 67.5 69.4 74.7 61.5 63.3 78.6 64.5 66.3 6-15 77.4 57.0 59.3 75.2 55.8 58.2 76.2 56.4 58.7 16-20 58.1 49.0 50.5 44,8 20,7 23.4 52.4 34.2 36.7 21-24 23.2 12.3 14.1 10.7 4.6 5.5 17.0 8.4 9.7 enrolled, compared with 50 percent in rural areas. Girls are only slightly less likely than boys to be enrolled in school in rural areas during ages 6-15. But for ages 16-20 and 21-24, percentage enrolment drops off much more sharply for females than males. In conclusion, while girls and boys apparently receive roughly the same opportunity to start school, boys have a greater chance to stay in school and reach more advanced levels. This gender-related differential is particularly marked in rural areas. 2.2 Economic and Environmental Characteristics of Households In order to assess the economic and environmental characteristics of households, a series of questions was asked of household respondents regarding features of their dwelling units. In addition to reflecting the socioeconomic status of a household, source of water, method of excreta disposal, mad crowding conditions are important determinants of the health status of household members. Table 2.6 shows that about 20 percent of urban households and 1 percent of rural households have access to electricity in the home. Overall, 3 percent of Malawian households have electricity. The vast majority of urban households (82 percent) have access to piped water, but most of these get water from a public tap (49 percent). Sixty-four percent of rural households, on the other hand, obtain their water from a well; 24 percent from a protected (covered) well, and 41 percent from an unprotected well. At the national level, over half (53 percent) of all households obtain their water from a source that can be considered unsafe (i.e., unprotected well or natural sources). Over two-thirds of households use a traditional pit latrine; 82 percent of urban households and 68 percent of rural households. In urban areas, the second most common method of excreta disposal is a flush toilet (14 percent), either in one's own household (12 percent) or shared with other households (2 percent). in rural areas, nearly all of the households that do not use a traditional pit latrine do not use any toilet or latrine facility (31 percent). The large majority of households live in dwellings with floors made of packed earth (87 percent). About 93 percent of rural households have mud/earth floors compared with 44 percent in urban households. Households having cement floors were much more common in urban areas (55 percent) than in rural areas (7.1 percent). 12 Table 2.6 Housing characteristics Percent disa'ibution of households by housing characteristics. aeoording to urban-rural residence, Malawi 1992 Residence Housing characteristic Ui'ben Rural Total Electricity Yes 19,8 1.1 3.2 No 80,1 98.9 96.8 Total 100,0 100.0 100.0 Source of drinking water Piped into reaidence 11,1 0.6 1.8 Piped into yardkplot 22,5 1.2 3.6 Public tap 48,5 16.2 19.8 Protected well 8,8 23.6 21.9 Unpmtected well 6,7 40.7 36.9 River/S a'eara/Spring 1,0 15.8 14.2 Lake/Pond/Dam 1,2 1.7 1.6 Don't know/Missing 0.2 0.1 0.1 Total 100,0 100.0 100.0 Sanitation facility Own flush 11,6 0.3 1.6 Shared flush 2,4 0.3 0.5 Traditional pit latrine 81,7 67,9 69.5 Vent. imp. pit latrine 1.2 0.6 0.7 No facility/Bush 3,1 30.8 27.7 Don't know/Missing 0,1 0.0 0.0 Total 100,0 100.0 100,0 Flooring Mud/Earth 43,7 92.6 87.1 Cement 54,7 7.1 12.5 Other 1.6 0.3 0.4 Total 100,0 100.0 100.0 Persons per sleeping room 1-2 57,3 55,6 55,8 3-4 34.4 33.4 33.5 5-6 5.8 8.0 7.7 7+ 1,5 2.5 2.3 Missing/Don't know 1.0 0.6 0.6 Total 100.0 100.0 100.0 Mean persons per room 2.7 2.8 2.8 Number of households 603 4720 5323 As a measure of household crowding and the potential for spread of infection among household members, the number of persons per the room used for sleeping was calculated. Crowding conditions varied little between urban and rural households. The mean number of household members per sleeping room was 2.8 in rural areas and 2.7 for urban areas. For the country as a whole, 56 percent of households sleep with 1 or2 persons per room and 34 percent with 34 persons per room. About 10 percent of households have 5 or more persons per sleeping room. 13 Household Durable Goods Table 2.7 gives the percentage of house- holds possessing a radio, a paraffin lamp, a bi- cycle, a motorcycle, a car, or an oxcart. For the country as a whole, about 33 percent of house- holds had radios in working condition; 65 per- cent in urban areas and 29 percent in rural areas. The majority of the households (83 per- cent) reported possessing a paraffin lamp; this percentage did not vary substantially by urban- rural residence. Possession of a bicycle was slightly more common in rural households (22 percent) than in urban households (17 percent), but was more than offset by the much more fre- quent possession of motorised vehicles (motor- cycles and cars) in urban households. Table 2.7 Household durable goods Percentage of households possessing specific durable consumer goods, by urban-rural residence, Malawi 1992 Residence Dureh~ goods Urban Rur~ Total Radio 65.1 28.6 32.8 Par alTm lamp 83.9 82.5 82.6 Bicycle 17.0 21.8 21.2 Motorcycle 2.6 0.7 0.9 Car 6.1 0.5 1.1 Oxc~t 0.8 3.0 2.8 Number of households 603 4720 5323 2.3 Characteristics of Survey Respondents A person's age, marital status, educational level, and residence have an important influence on decisions regarding health and family planning. Tables 2.8.1 and 2.8.2 show the percentage distribution of all women (15-49 years) and men (20-54 years) interviewed in the survey according to age group, marital status, education level, urban-rural residence, and region of the country. Nearly a quarter of male respondents are in the youngest age group interviewed, 20-24 years, while 22 percent of female respondents are 15-19 years of age. As expected, the percentage of men and women in each age group declines with increasing age. Despite the older average age of males interviewed, a larger percentage of male respondents reported never having been married (19 percent) than female respondents (16 percent). Similarly, more men (7 percent) are in an informal union than women (3 percent). On the other hand, women respondents are more likely than men to be widowed (3 versus 1 percent), divorced (7 versus 3 percent), or separated (3 versus 2 percen0. All women and men interviewed in the MDHS were asked if they attended school. Those who had auended were further asked the highest level that they achieved according to Malawi's formal education system, and at that level, how many years had they completed. Respondents were grouped into four education categories: those with no education, those with 1-4 years of primary education, those with 5-8 years of primary education and those with at least some secondary education or above. The distribution of respondents by educational attainment parallels that already reported using the household data) That is, male respondents have more commonly attended school at all and have progressed to more advanced educational levels than female respondents. Only 4 percent of female respondents and 14 percent of males have had some secondary education. ~l'he figures differ slightly from those presented using the household data because here the information comes directly from the respondent, whereas in the household data, information concerning the respondent's education may be reported by someone else (i.e., any competent household member). 14 Table 2.8.1 Background characteristics of respondents - males Percent distribution of men by selected background characteristics, Malawi 1992 Number of men Background Weighted Un- characteristic percent Weighted weighted Age 20-24 24.1 277 270 25-29 17.8 205 222 30-34 14.6 168 175 35-39 12.4 143 140 40-44 13.9 160 158 45-49 8.2 95 95 50-54 8.9 102 91 Marltalstatus Never married 18.5 213 229 Married 68.1 784 777 Living together 7.1 81 69 Widowed 0.9 10 12 Divorced 3.2 37 36 Separ~ed 2.2 26 28 Education No education 20.5 236 183 Primary 1-4 29.1 335 267 Primary5-8 36.7 423 460 Secondaa-y+ 13.6 157 241 Residence Urban 15.8 181 364 Rur~ 84.2 970 787 Region Northern 12.0 139 345 Centr~ 38.5 443 381 Southern 49.4 569 425 All men 100.0 1151 1151 Table 2.8.2 Background characteristics of respondents - females Percent distribution of women by selected back- ground characteristics, Malawi 1992 Number of women Background Weighted Un- characteristic percent Weighted weighted Age 15-19 22.3 1082 1105 20-24 19.5 944 990 25-29 16.0 777 804 30-34 13.5 656 664 35-39 11.1 537 517 40-44 10.5 510 458 45-49 7.1 343 311 Marital status Never married 15.7 761 839 Married 68.8 3335 3347 Living together 3.2 157 142 Widowed 2.5 121 121 Divorced 6.8 329 266 Separated 3.0 146 134 Education No education 47.2 2287 1834 Primary 1-4 24.6 1192 1117 Primary5-8 23.9 1157 1515 Secondary+ 4.4 212 382 Residence Urban 12.3 594 1316 Rur~ 87.7 4255 3533 Region Northern 11.9 578 1442 Centlal 38.6 1872 1606 Southern 49.5 2398 1801 All women 100.0 4849 4849 The data indicate that 12 percent of women age 15-49 years live in urban areas. There are slightly more men (16 percent) age 20-54 years that live in the urban areas, reflecting a pattern of rural-urban migration. About halfofwomenlive in the Southern Region, 39 percent in the Central Region, and 12 percent in the Northern Region. The distribution of interviewed men by region is the same as that for women. 15 Respondent Level of Education by Background Characteristics Table 2.9 presents the percentage distribution of interviewed women and men by educational level attained according to age, urban-rural residence, and region. Education is inversely related to age, that is, Table 2.9 Levelofeducation Pe~cnt distribution of women and men by highest level of education attended, according to selected background characteristics, Malawi 1992 Level of education Background Primary Primary characteristic None 1-4 5-8 Secondary+ Total Number MALES Age 20-24 18.1 26.0 39.6 16.3 100.0 277 25-29 19.9 25.4 39.5 15.1 100.0 205 30-34 18.8 28.4 36.0 16.8 100.0 168 35-39 14.0 26.2 44.9 14.8 100.0 143 40-,~1 21.2 37.1 32.2 9.5 100.0 160 45-49 27.1 26.6 37.1 9.3 100.0 95 50-54 33.1 40.2 19.9 6.9 100.0 102 Residence Urban 9.2 11.5 37.1 42.1 100.0 181 Rural 22.6 32.4 36.7 8.3 100.0 970 Region Northern 7.7 15.0 52.7 24.6 100.0 139 Central 23.2 25.7 41.4 9.8 100.0 443 Southern 21.6 35.3 29.2 13.9 100.0 569 Total 20.5 29.1 36.7 13.6 100.0 1151 FEMALES Age 15-19 28.9 32.8 33.8 4.5 100.0 1082 20-24 41.5 24.2 28.1 6.3 100.0 944 25-29 44.8 23.5 26.5 5.2 100.0 777 30-34 56.8 19.5 18.9 4.7 100.0 656 35-39 59.6 20.9 16.0 3.5 100.0 537 40-44 58.0 24.6 15.3 2.0 100.0 510 45-49 71.5 17.5 10.l 0.9 100.0 343 Residence Urban 22.7 17.6 38.8 20.9 100.0 594 Rural 50.6 25.6 21.8 2.1 I00.0 4255 Region Northern 20.2 23.2 48.7 7.9 100.0 578 Central 48.7 25.2 22.1 4.0 100.0 1872 Southern 52.4 24.5 19.3 3.8 100.0 2398 Total 47.2 24.6 23.9 4.4 100.0 4849 16 older women and men are typically less edu- cated than younger women and men. For ex- ample, 72 percent of women and 27 percent of men 45-49 years old have not been to school, compared to 42 percent and 18 percent for 20- 24 year-old women and men, respectively. Rural men and women are education- ally disadvantaged compared to those in urban areas. Whereas 42 percent ofurhan men and 21 percent of urban women have been to secon- dary school, only 8 percent of rural men and 2 percent of rural women have done so. Rural men and women are twice as likely to have never been to school than their urban counter- parts. Regional differentials also exist. North- em men and women tend to have much greater educational opportunities to attend school and then to be able to continue to more advanced levels than persons in other regions. Access to Mass Media Respondents were asked if they usual- ly read a newspaper or listen to a radio at least once a week. This information can be useful to programme planners seeking to reach men and women with media messages concerning fami- ly health. Table 2.10 shows the percentage of men and women who have access to mass me- dia by background characteristics. The MDHS shows that for Malawi as a whole, 75 percent of men and 52 percent of women listen to the radio and 41 percent of men and 19 percent of women read a newspaper at least once a week. Media contact is related to age of the respond- ent. Men and women in the older age groups tend to read the newspaper and listen to radio less frequently than younger men and women. This would be in part related to the fact that younger men and women in Malawi also tend to be better educated. Education leads to infor- marion-seeking behaviour, including following the media. Both radio listening and especially newspaper reading are highly correlated with education of the respondent. Men and women without education have, for obvious reasons, very limited access to messages sent through Table 2.10 Access to mass media Percentage of women and men who usually reed a newspaper once a week or listen to radio once a week, by selected background characteristics, Malawi 1992 Read Listen to Background newspaper redio characteristic weekly weekly Number MALES Age 20-24 47.2 77.7 277 25-29 37.9 72.5 205 30-34 43.6 79.5 168 35-39 49.4 81.2 143 40-44 34.1 69.2 160 45-49 35.0 68.5 95 50-54 26.4 65.9 102 Education No education 4.7 62.5 236 Primary 1-4 33.2 69.6 335 Primary 5-8 49.4 77.3 423 Secondary+ 86.8 95.5 157 Residence Urban 63.7 88.0 181 Rural 36.3 72.0 970 Region Northern 32.6 70.5 139 Cen~'al 32.1 67.7 443 Southern 49.2 80.8 569 Total 40.6 74.5 1151 FEMALES Age 15-19 25.6 58.4 1082 20-24 21.7 54.9 944 25-29 20.0 58.0 777 30-34 14.5 49.3 656 35-39 13.9 48.1 537 40-44 12.0 45.2 510 45-49 7.7 35.6 343 Education No education 0.7 37.4 2287 Primary 1-4 16.6 54.3 1192 Primary 5-8 43.8 72.1 1159 Secondary+ 81.9 92.8 212 Residence Urb~ 47.9 82.0 594 Rural 14.4 48.1 4255 Region Northern 26.8 55.9 578 Central 15.2 51.8 1872 Southern 19.0 51.7 2398 Total 18.5 52.3 4849 17 newspapers; only 5 percent of men and 1 percent of women without formal education reported reading the newspaper at least once a week. Yet over 80 percent of men and women who attended secondary school read the newspaper regularly. A similar, but less pronounced, relationship is observed between radio listening and education. In the interim before education is more nearly universal, important messages to the public will get widespread reception only through radio. Them are important geographic differences in media contact. Men and women in urban areas have vastly better use of newspapers and radios to receive information. This is especially true for women; for example, urban women am over three times more likely to read a newspaper weekly than women in rural areas. Of course, part of this association is due to differences in the educational level of rural and urban women. Women in the Northern Region have greater exposure to both printed media and radio messages than their counterparts in other regions. However, men in the Southern Region have greater access to radio and newspaper messages than men in the Northern and Central Regions. 18 CHAPTER 3 FERTILITY Measures of current and completed fertility presented in this chapter are based on the reported reproductive histories of women age 15-49 who were interviewed during the survey. Each woman was asked about the number of sons and daughters living with her, the number living elsewhere and the number who had died. She was then asked for a complete history of all of her live-born children, including month and year of birth, name, sex, and if dead, the age at death and if alive the current age and whether she/he was living with the respondent. Current fertility (age-specific and total fertility) and completed fertility (number of children ever born) are examined below, and then in connection with various background characteristics. 3.1 Current Fertility Levels and Trends The most widely used measures for cur- rent fertility are the total fertility rate and its component age-specific fertility rates. The total fertility rate is defined as the number of births a woman would have if she survived to age 50 and experienced the currently observed rates of age-specific fertility. To obtain the most recent estimate of fertility possible without compro- mising the statistical precision of estimates, the 3-year period immediately prior to the survey will be used. ~ For analysis of fertility trends, four-year rates will be used to avoid biases that could be introduced from birth date misreport- ing around the years 1986 and 1987 (Appendix C, Table C.4). Current total and age-specific fertility rates are presented in Table 3.1. If fertility were to remain constant at the current levels meas- ured in the MDHS (1-36 months before the sur- vey), a woman would bear an average of 6.7 children in her lifetime. This is lower than the rate of 7.6 estimated for the 1980-83 period from the 1984 Family Formation Survey (FFS), implying a decline of about 12 percent over the last decade. Figure 3.1 shows that much of the decline in total fertility between the two surveys occurred in the peak childbearing ages, 20-34 years. Table 3.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-rural residence for 1992 MDHS and 1984 Family Formation Survey (FFS). Malawi 1992 MDHS 1992 FFS Age group Urban Rural Total 1984 15-19 135 165 161 202 20-24 268 291 287 319 25-29 242 273 269 309 30-34 210 261 254 273 35-39 149 202 197 201 40-44 86 123 120 129 45-49 12 62 58 83 TFR 15-49 5.51 6.88 6.73 7.58 TFR 15-44 5.45 6.57 6.44 7.29 GFR 201 226 223 264 CBR 40.5 43.2 42.9 52.0 Note: MDHS rates are for the period 1-36 months preceding the survey, FFS rates are for the 4 years preceding the survey, Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate expressed as children per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1.000 woman CBR: Crude birth rate. expressed per 1,000 population 1Numerators of the age-specific fertility rates from the MDHS data in Table 3.1 are calculated by summing the number of live births that occurred in the period 1-36 months preceding the survey (determined by the date of interview and date of birth of the child), and classifying them by the age (in five-year groups) of the mother at the time of birth (determined by the mother's date of birth). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. 19 350 ASFR (110O0) Figure 3.1 Age-Specific Fertility Rates Malawi, 1984 FFS and 1992 MDHS 3OO 25O 20O 150 1 0O 5O 0 15-19 i i 25 29 30-34 Age Group of Women 45 49 MDHS 1992 ASFR (/1000) 350 30O 250 200 150, 0 Figure 3.2 Age-Specific Fertility Rates Urban and Rural Malawi 15 19 i 25 29 30 34 Age Group of Women 45 49 MDHS 1992 20 As expected, fertility among rural women is higher (6.9 children per woman) than among urban women (5.5 children per woman). Figure 3.2 shows that the urban-rural difference in total fertility is due to lower fertility in urban areas at all ages, but especially at age 30 years and above. Table 3.2 presents total fertility rates and completed fertility (average number of children ever born to women at the end of their childbearing period, age 45-49) by selected background characteristics. In addi- tion to the urban-rural difference, there exists notable variation in total fertility among the regions, ranging from 6.2 children per woman in the South, to 6.7 in the North, to 7.4 in the Centre. A woman's fertility is closely linked to her level of education. Women who have attended secondary school have 4.4 children compared to 7.2 for those without any education. The level of fertility among women with no education is about 0.5 children more than that among women with lower primary education, which is itself about 0.5 children more than that of women with higher primary education. Table 3.2 also allows a crude assessment ofdi fferential trends in fertility over time among population subgroups. The mean number of children ever bom to women age 45-49 years is a measure of fertility during the past. A comparison of current (total) fertility with past (completed) fertility shows that the largest differ- ences occur in urban areas and among women with more education, suggesting that these groups have experienced the largest recent decline in fertility. Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 45-49, by selected background characteristics, Malawi 1992 Mean number of children Total ever born Background fer til~ty to women characteristic rate age 45-49 Residence Urban 5.51 7.39 Rural 6.88 7.29 Region Northern 6.74 7.51 Central 7.44 8.09 Southern 6.17 6.55 Education No education 7.16 7.36 Primary 1-4 6.70 7.04 Primary 5-8 6.17 7.48 Secondary+ 4.37 * Total 6.73 7.30 IRate for women age 15-49 years * Based on less than 25 cases 21 More direct evidence of fertility decline is obtained by looking at changes in age-specific fertility rates across the three four-year calendar periods before the survey using data from the respondents' birth histories (Table 3.3). Within each age group of women, fertility has declined steadily over the 8-11 year period before the sur- vey to the 0-3 year period before the survey. Be- cause of truncated observation, fertility declines in the older age groups are difficult to ascertain with precision. Table 3.4 presents fertility rates forever- married women by duration since first marriage for four-year periods preceding the survey. Though the table is analogous to Table 3.3, it is confined to ever-married women and age is re- placed with duration since first marriage. Within Table 3.3 Age-specific fertility rates Age-specific fertility rates for four-year periods preceding the survey, by mother's age at the time of birth, Malawi 1992 Number of years preceding the survey Mother's age 0-3 4-7 8-11 12-15 15-19 159 180 193 201 20-24 285 302 319 339 25-29 264 292 323 329 30-34 252 253 287 285 35-39 190 228 [232] [270] 4044 121 [128] 45-49 [64] Note: Age-specific fertility rates are births pet 1,000 women- ye~s of exposure. Estimates enclosed in brackets ~e truncated. each marriage duration group, one observes a decline in fertility with increasing proximity to the survey date. These marriage duration-specific estimates of fertility confirm the decline in fertility, and that the decline has occurred within marriage. Table 3.4 Fertility by marital duration Fertility rates for ever-married women by duration since first marriage, in years, for four-year periods preceding the survey, Malawi 1992 Marriage Number of years preceding the survey duration at birth 0-3 4-7 8-11 12-15 0-4 333 351 364 376 5-9 286 308 338 348 10-14 256 281 296 314 15-19 235 225 260 259 20-24 143 190 [199] [231] 25-29 89 [99] Note: Duration-specific fertility rates are births per 1,000 women. Estimates enclosed in brackets are truncated. 3.2 Children Ever Born The distribution of women by number of children ever bom is presented in Table 3.5 for all women and for currently married women. The table also shows the mean number of children ever born (CEB) to women in each five-year age group. On average, women have given birth to three children by their late twenties, six children by their late thirties, and over seven children by the end of their childbearing years. Of the 7.3 children ever born to women 45-49, only 4.8 will have survived. 22 Table 3.5 Chi ldren ever born and living Percent distribution of all women and of currently married women age 15-49 by number of chi ldren ever born (CEB) and mean number ever born and living, according to five-year age groups, Malawi 1992 Number of children ever bona (CEB) Number Mean no. Mean no. Age of of of living group 0 1 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN Age 15-19 72.7 21.1 5.1 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1082 0.34 0.27 20-24 19.4 27.3 28.7 16.7 6.3 1.0 0.5 0.2 0.0 0.0 0.0 100.0 944 1.69 1.31 25-29 6.1 10.9 14.6 22.5 24.0 14.3 5.2 2.3 0.1 0.0 0.0 100.0 777 3.23 2.47 30-34 2.7 4.5 7.9 l l . l 14.3 17.5 19.8 12.1 7.0 2.9 0.3 100.0 656 4.87 3.68 35-39 2.7 2.9 4.6 8.8 9.9 13.8 13.0 15.6 14.1 7.2 7.3 10(3.0 537 5.90 4.39 40~14 1.8 2.6 3.8 4.4 6.7 9.6 13.7 15.2 12.1 9.5 20.6 100.0 510 6.93 4.92 45-49 1.1 2.3 5.2 5.6 6.1 7.2 10.1 10.9 12.3 14.0 25.1 100.0 343 7.30 4.80 Total 21.9 13.1 11.4 10.4 9.2 7.9 7.2 6.1 4.7 3.2 4.8 100.0 4849 3.48 2.55 CURRENTLY MARRIED WOMEN Age 15-19 43.0 41.5 13.0 2.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 I00.0 388 0.75 0.58 20-24 13.8 26.1 32.0 18.5 7.7 1.1 0.6 0.2 0.0 0.0 0.0 100.0 743 1.87 1.44 25-29 4.3 10.1 12.9 24.1 25.7 15.1 5.3 2.5 0.1 0.0 0.0 100.0 661 3.36 2.61 30-34 2.5 4.0 7.8 9.8 14.7 18.1 20.4 11.9 7.3 3.3 0.3 100.0 584 4.95 3.73 35-39 2.7 2.4 5.1 8.4 9.1 12.9 12.6 15.7 15.6 7.9 7.7 100.0 455 6.01 4.47 40~14 1.8 2.9 4.4 4.8 5.1 S.l 15.1 14.8 11.1 9.2 22.8 100.0 408 7.01 4.98 4549 1.5 1.4 4.6 3.8 5.4 Z7 8.8 10.4 10.7 16.0 29.7 lt~O.O 253 7.69 5.06 Total 9.6 13.5 13.5 12.4 11.1 9.3 8.6 7.0 5.3 3.8 5.9 100.0 3492 4.10 3.02 The distribution of women by number of births indicates that over one-quarter of women age 15-19 have already borne at least one child, and that one-quarter of women age 45-49 have borne ten or more children. The results for younger women who are currently married differ from those for the sample as a whole because of the large number of young unmarried women with minimal fertility. Differences at older ages, though minimal, generally reflect the impact of marital dissolution (either divorce or widowhood). Since desire for children is nearly universal in Malawi, the proportion of married women at 45-49 years who arc childless is a rough measure of primary infertility, or the inability to bear children. The MDHS results suggest that primary infertility is low, with ordy 1.5 percent of Malawian women unable to bear children. It should be emphasised that this estimate of primary infertility does not include women who may have had one or more births but who are unable to have more (secondary infertility). 3.3 Birth Intervals Research has shown that children born too soon after a previous birth are at increased risk of dying, particularly when the interval between births is less than 24 months, Table 3.6 shows the percent distribution of births in the five years before the survey by the number of months since the previous birth. More than one of every five births in Malawi occurs less than two years after the birth of the previous child. The overall median birth interval length is 32.7 months. 23 Table 3.6 Birth intervals Percent distribution of births in the five ye~s preceding the survey by number of months since previous birth, according to demographic and socioeconomic charact~istics, Malawi 1992 Number of months since previous birth Characteristic 7-17 18-23 24-35 36~,7 48+ Median number of Number months since of Total previous birth births Age of meth~r 15-19 26.5 23.1 34.1 12.5 3.9 100.0 24,2 78 20-29 8.8 15.6 43.8 18.0 13.8 100.0 30.7 1692 30-39 6.4 10.9 37.2 23.5 22.0 10O.0 34.6 1406 40+ 7.9 8.1 33.1 21.3 29.6 100.0 36.5 563 Birth erder 2-3 8.9 15.3 40.3 18.5 16.9 100.0 31.6 1360 4-6 7.1 12.0 39.4 22.1 19.3 100.0 33.4 1429 7+ 8.5 10.6 38.5 20.7 21.7 100.0 33.4 949 Sex of prier blrtlz Male 7.7 13.3 39.0 20.8 19.2 100.0 33.0 1875 Female 8.6 12.4 40.0 20.1 18.9 100.0 32.4 1864 Survival of prier birth Living 4.5 10.5 42.1 22.8 20.1 100.0 34.0 2861 Dc, ed 19.9 20.6 31.0 12.8 15.6 100.0 26.7 878 Residence Urban 9.7 12.7 37.9 19.8 19.8 100.0 32.1 404 Rural 7.9 12.9 39.7 20.5 19.0 100.0 32.8 3335 Region Northern 6.3 10.3 41.2 24.7 17.4 100.0 33.8 427 Central 9.5 14.5 38.6 18.7 18.6 100.0 31.2 1591 Southern 7.3 11.9 39.9 21.0 19.8 100.0 33.2 1720 FAItwatUoa No education 7.3 12.8 38.2 18.9 22.8 100.0 33.2 2005 Prima~ 1-4 10.4 13.2 40.3 22.3 13.8 100.0 31.7 863 Primary 5-8 8.0 11.8 43.0 22.8 14.4 100.0 32.2 774 Secondary+ 6.2 19.5 31.5 18.0 24.8 10O.0 34.8 97 Total 8.1 12.9 39.5 20.5 19.1 100.0 32.7 3739 Note: First-order lirthi are excluded. In Malawi, birth intervals tend to be shorter when the mother is young and at lower birth orders (second and third births). The median birth interval length is 7 months shorter when the previous child died than when the previous child survived. Whereas only 15 percent of children whose previous siblings were still alive were born after less than 24 months, 41 percent of children whose previous sibling was dead were born after less than 24 months. This is due to behavioural and biological mechanisms that operate to rapidly "replace" deceased children. 24 Although birth spacing varies little by urban-rural residence, regional differences do emerge in the MDHS data. On average, birth intervals in the Central Region are 2 months shorter than in the Southern region and 2.5 months shorter than in the Northern Region. Further, 24 percent of births follow a short interval in the Central Region versus 19 percent in the Southern and 17 percent in the Nor, hem Regions. Not coincidentally, this characteristic oftbe Central Region is consistent with its relatively lower level of fertility regulation (Chapter 4) and higher level of childhood mortality (Chapter 7). The relationship between birth interval length and maternal education follows a U-shaped pattern, with the longest interval length associated with both no education and higher education. The shortest intervals occur when the mother has had only some primary education. 3.4 Age of the Mother at First Birth The age at which women start childbearing is an important demographic and social indicator in society. Early childbearing generally leads to a large family size if not coupled with contraception, and is associated with increased health risks for the mother. It also tends to diminish a woman's educational and employment opportunities. A rise in the age at first birth is usually a reflection of a rise in the age at first marriage (see Chapter 6) and in many countries has contributed greatly to overall fertility decline. Table 3.7 presents the distribution of women 15-49 by age at first birth. Two pattems are evident in the data. First, there is fairly clear evidence of a displacement of first births of older women from a period further to a period closer to the survey date, the result of which is that an implausibly large percentage of older women appear to have had their first birth at 25 years or older. This, of course, inflates the median age at first birth. This problem apparently is focused on women 35 years and older. Second, among women currently under 35 years of age, there is clear evidence of an increase in the average age at first birth, from 18.3 years to 18.9 years over the last decade or so. In support of this, the percentage of births that occurred at a very young age (< 15 years) have decreased considerably from about 11 percent among women currently age 30-34 to 3 percent among women now age 15-19. Table 3.7 Age at first birth Percent distribution of women age 15-49 by age at first bkth, according to current age, Malawi 1992 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 72.7 3.0 17.3 7.0 NA NA NA 100.0 1082 a 20-24 19.4 8.9 28.6 25.8 13.9 3.4 NA 100.0 944 18.9 25-29 6.1 9.3 31.2 25.3 16.4 9.5 2.3 100.0 777 18.7 30-34 2.7 10.8 34.5 25.0 13.0 8.6 5.5 100.0 656 18.3 35-39 2.7 9.7 24.0 26.0 14.4 11.7 11.6 100.0 537 19.3 40~M 1.8 10.7 23.3 22,6 13.8 15.1 12.8 100.0 510 19.4 45-49 1.1 7.6 22.5 16.7 12.4 21,7 18.0 100,0 343 20,5 NA = Not applicable aLess than 50 percx, nt of the women in the age group x to x+4 have had a birth by age 25 Table 3.8 shows the median age at first birth by background characteristics of the woman. There is very little variation in the median age at first birth between women by urban-rural residence or by region. Age at first birth does, however, varies significantly with a woman's level of education, from about 19 years for women with no education or primary education to 21 years among women with secondary education or higher. Table 3.8 Median age at first birth Median age at first birth among women age 20-49 years, by current age and selected background characteristics, Malawi 1992 Current age Background Ages Ages charactezisdc 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 Residence Urban 19.4 19.5 19.0 18.9 19.1 19.2 19.2" 19.2 Rural 18.8 18.6 18.2 19.3 19.5 20.7 18.9 18.9 Region Northern 19.0 18.9 18.5 18.9 19.1 18.8 18.9 18.8 Central 19.3 19.1 18.5 19.4 18.8 20.4 19.1 19.1 Southern 18.5 18.3 18.2 19.2 20.0 21.1 18.8 18.9 Education No education 18.3 18.0 18.0 19.6 19.8 21.2 18.8 18.9 Primary 1-4 18.8 18.8 18.1 18.6 18.8 20.7 18.8 18.8 Primary 5-8 19.1 19.2 18.8 18.5 19.3 (18.5) 19.0 18.9 Secondary+ a 22.8 (20.8) (20.7) (19.9) 21.4" a 21.4 Total 18.9 18.7 18.3 19.3 19.4 20.5 18.9 19.0 Note: The medians for cohort 15-19 could not be determined because half the women have not yet had a birth. aMedians were not calculated for these cohorts because less than 50 percent of women in the age group x to x+4 have had a birth by age x. ( ) Based on 25-49 cases * B~ad on less than 25 cases 3.5 Adolescent Fertility The issue of adolescent fertility is an important one on both health and social grounds. Children born to adolescent mothers are at increased risk of sickness and death. The young mothers themselves are more likely to experience adverse pregnancy outcomes and, in any case, are less able to pursue educational opportunities than their counterparts who delay childbearing. Table 3.9 shows the percentage of adolescents (under age 20) who are mothers or pregnant with their first child, by background characteristics. Among women under 20, over one-third have already entered the family formation pathway--and most are already mothers of at least one child. Motherhood increases sharply between ages 15 (6 percent) and 19 (55 percent). Two-thirds of 19-year-olds have either had a child or are pregnant with their first (Figure 3.3). 26 Table 3.9 Adolescent pregnancy and motherhood Percentage of adolescents (age 15-19) who are mothers or pregnant with their first child, by selected background characteristics, Malawi 1992 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of charactaristic Mothers child bearing adolescents Age 15 5.7 3.2 8.9 205 16 11.5 4.6 16.1 222 17 22.1 9.1 31.2 214 18 41.3 10.0 51.3 235 19 55.2 10.0 65.1 205 Residence Urban 23.4 5.2 28.6 127 Rural 27,8 7.7 35.5 956 Region Northern 18.9 8.6 27.5 148 Central 23.2 10.4 33.6 402 Southern 32.6 4.8 37.4 533 Education No education 36,0 6,8 42.8 313 Primary I-4 29.2 9.3 38.5 355 Primary 5-8 19.0 7.0 26.0 365 Secondary+ 18.6 1.0 19.6 49 Total 27.3 7.4 34.7 1082 Figure 3,3 Percentage of Adolescents (age 15-1 9) Who Have Begun Childbearing, by Age Percentage 7O 6O 50 4O 3O 2O 10 0 15 16 17 18 Age (years) 19 MDHS 1992 27 In rural areas, 36 percent of adolescents have begun childbearing as compared to 29 percent in urban areas. Regional differences also exist--37 percent of adolescents in the South are either mothers or are pregnant with their first child versus 34 percent in the Centre and 28 percent in the North. A strong link between a woman's education and early childbearing is evidenced here. Although 43 percent of adolescents (15-19 years) without any education have started childbearing, only 20 percent of those with some secondary education have done so. Table 3.10 shows the distribution of adolescents by number of children ever born. The MDHS shows that 21 percent of adolescents have had one child and 6 percent have had at least two children. About 18 percent of women age 19 years have had at least two children. The mean number of children ever born (CEB) to women 15-19 is 0.34. Table 3.10 Children ever born to adolescents Percent distribution of adolescents (age 15-19) by number of children ever born (CEB), Malawi 1992 Age 0 1 2+ Number of Mean children ever born number Number of of Total CEB adolescents 15 94.3 5.0 0.8 100.0 0.06 205 16 88.5 10.5 1.0 100.0 0.12 222 17 77.9 19.5 2.6 100.0 0.25 214 18 58.7 32.3 9.0 100.0 0.52 235 19 44.8 37.7 17.5 100.0 0.76 205 Total 72.7 21.1 6.1 100.0 0.34 1082 28 CHAPTER 4 FERTILITY REGULATION 4.1 Knowledge of Contraception Acquiring knowledge about fertility control is an important step to- wards gaining access to and then using a suitable method in a timely and effec- tive manner. Information about knowl- edge of contraceptive methods was col- lected by asking the respondent to name ways or methods by which a cou- ple could delay or avoid pregnancy. If the respondent failed to mention a par- ticular method spontaneously, the inter- viewer described the method and asked if she/he recognised it. Seven modem methods--the pill, IUCD, injection, vaginal methods (foaming tablets, jelly, sponge and diaphragm), condoms, fe- male sterilisation and male sterilisa- tiorv--were described, as well as two traditional methods--natural family planning (periodic abstinence or the rhythm method) and withdrawal. Any other methods mentioned by the re- spondent, such as herbs, strings or breastfeeding, were also recorded. For each method recognised, the respond- ent was asked if she/he knew where a person could go to get the method. If the respondent reported knowing about natural family planning, she/he was asked where a person could obtain the advice on how to use the method. Table 4.1 indicates that nine of ten women age 15-49 years know at least one method of family planning. Knowledge of methods is slightly high- er among currently married women than among all women. Since it is cur- rently married women who are at great- est risk of pregnancy, they are the pri- mary focus of this chapter. Table 4.1 Knowledge of comraceptive methods and source for methods Percentage of all women and men and currently married women and men who know specific contraceptive methods and who know a source (for services), by specific methods, Malawi 1992 Know method Know a source Currently Currently All married All married Contraceptive women/ women/ women/ women/ method men men men men FEMALES Any method 90.4 94.6 80.1 85.1 Any modern method 87.7 91.8 78.5 83.3 Modern method Pill 76.4 82.9 66.5 72.8 IUCD 41.5 46.3 35.3 39.6 Injection 61.6 68.3 54.8 61.1 Diaphragm/Foam/Jelly 42.6 47.8 35.5 39.9 Condom 70.1 73.2 58.6 61.9 Female sterilisation 58.0 63.1 48.9 53.5 Male sterilisation 17.3 18.8 14.0 15.3 Any traditional method 69.3 76.5 32.3 36.8 Natural method 43.9 49.1 32.3 36.8 Withdrawal 41.1 46.4 NA NA Other 46.0 52.0 NA NA Number of women 4849 3492 4849 3492 MALES Any method 95.8 97.3 85.6 86.8 Any modern method 93.7 94.6 84.0 85.1 Modern method Pill 70.0 72.1 56.0 58.6 IUCD 42.0 43.6 31.0 32.1 Injection 55.7 59.0 48.9 51.5 Diaphragm/Foam/Jelly 44.6 45.6 31.9 32.9 Condom 88.8 89.7 73.6 74.7 Female sterilisation 63.6 66.2 55.4 57.9 Male sterilisation 28.0 27.7 24.3 24 5 Any traditional method 78.7 80.7 45.6 46.7 Natural method 61.5 62.7 45.6 46.7 Withdrawal 54.1 55.7 NA NA Other 33.5 37.6 NA NA Number of men 1151 866 I 151 866 NA = Not applicable 29 A high proportion of married women reported knowing a modem method (92 percent) and 77 percent of them have some knowledge about a traditional method. The most widely known methods among married women are the pill (83 percen0, the condom (73 percent), injections (68 percent) and female sterilisation (63 percent) (Figure 4.1). Women are relatively unfamiliar with male sterilisation; only 19 percent said they knew of the method. Regarding traditional methods, about half of married women said they knew of natural family planning, withdrawal, and other traditional methods. Most of the other traditional methods cited by women were medicinal strings and herbal preparations of various types. Figure 4.1 Percentage of Currently Married Women Who Know Specific Contraceptive Methods Pill ,JI [ ] ~ 46 r' I, , 'li ir ~ 6~ L] dkih[,) I 'h'~carr/x,', I f ~ 48 Oir,J< m/" ii __~ . . , , .'' i i-i:" . " /'3 I rru /I,. _,'(/rlllC ~tl< ' 3 ~ (}3 k,1,~l,' :tr~ 'lilt ~'i, ,p ~ 19 \<:{,r<ll M < l h , , , l ~ 49 f, Ir!/i J' .+'/ .I ~ ~ 46 0 20 40 (lC 83 e]f; 1 (,) F~ rl f:r I P . I 1J.~ Knowledge of fertility regulation was also very high among men; 96 percent of all men and 97 percent of all married men knew of some method of family planning. Nearly all men who knew of a method knew of at least one modem method of contraception. Knowledge of specific family planning methods among men follows a pattem similar to that observed among women. Looking at modem methods, condoms and sterihsation are slightly better known by men than women; the other methods are better known by women. Regarding traditional methods, men reported knowing of natural family planning and withdrawal more commonly than women, but women tended to be more familiar with other traditional methods (i.e., strings and herbal preparations). Knowledge of sources for obtaining family planning methods is widespread in Malawi. Eighty-three percent of currently married women and 85 percent of currently married men knew of a source for obtaining a modem method of contraception. Women responded more commonly than men that they knew where to obtain pills, the IUCD, injections, and barrier methods, whereas men reported more frequently than women that they knew a source of condoms and sterilisation services. 30 Table 4.2 shows that women in their 20s and 30s are more likely to know of at least one method, at least one modem method, and a source to obtain a modem method than adolescent women and women age 40 years or older. In the same way, men between 25 and 39 years tend to be more familiar with meth- otls and method sources than young- er and older men. In particular, knowledge of a source of modem contraception goes down sharply with increasing age of men. As ex- pected, men and women living in ur- ban areas are more likely to know of family planning methods and to know where to obtain them than their rural counterparts. Regional differences in contraceptive knowl- edge are negligible. Formal education is related to a person's knowledge of contra- ception. About one-quarter of both men and women without any educa- tion do not know of a source of mod- em contraception, whereas source knowledge is nearly universal among men and women with at least some secondary eduction. 4.2 Ever Use of Contraception All women and men who said that they had heard era method of family planning were asked if they had ever used it. Forty-one per- cent of currently married women and 57 percent of men have used a meth- od of family planning at some time in the past (Table 4.3). Ever-use of modem methods was reported by 19 percent of women and 30 percent of men. The difference between male and female ever-use of modem con- traception is explained by far greater condom use among men. Table 4.2 Knowledge of modem contraceptive methods and source for methods Percentage of cuxrently married women and men who know at least one modem contraceptive method mad who know a source (for services), by selected background characteristics, Malawi 1992 Know a Number Know Know source for of Background any a modem modem women/ characteristic method method 1 method men FEMALES Age 15-19 88,0 84.2 72.5 388 20-24 95.9 94.2 86.3 743 25-29 96.7 95.1 89.8 661 30-34 96.3 93.8 87.5 584 35-39 95.4 93.4 83.2 455 40-44 93.2 88.3 77.2 408 45-49 91.7 86.3 74,6 253 Residence Urban 97.2 96.3 91.4 411 Rural 94.2 91.2 82.2 3081 Region Northern 93.7 89.6 80.8 430 Central 94.3 92.3 84.8 1402 Southern 95.0 92.0 82.7 1660 Education No education 92.2 88.2 77.3 1815 Primary I-4 95.4 93.7 85.5 819 Primary 5-8 98.5 97.5 93.3 750 Second~y+ 99.6 99.6 98.9 107 Total 94.6 91.8 83.3 3492 MALES Age 20-24 97.0 94.9 83.6 100 25-29 99.1 99.1 91.7 163 30-34 98.0 97.0 91.0 147 35-39 96.5 94.9 86.8 129 40-44 95.8 92.2 84.7 147 45-49 95.6 91.7 79.1 83 50-54 98.3 89.2 69.4 95 Residence Urban 98.9 98.7 90.4 126 Rural 97.0 93.9 84.2 739 Region Northern Central Southern Education No education 95.7 90.I 74.8 183 Primary 1-4 95.8 91.5 78.3 255 Primary 5-8 98.6 98.0 92,5 330 Secondary+ 100.0 100.0 97.1 97 Total 97.3 94.6 85,1 866 1Includes pill, IUCD, injection, vaginal methods (foaming tablets/diaphragm/ foam/jelly), condom, female sterilisation, and male sterilisation. 99.5 97.3 88.0 99 95.3 94.0 85.6 347 98.5 94.6 83.9 419 31 Table 4.3 Ever use of contraception Percentage of currently marr ied women and men who have ever used any contraceptive method, by specific method and age, Malawi 1992 Any naa- l'emale Male Number modem In phragm/ sten sten Any Natural of Any meth- jec- Foam/ hsa- hsa- trad meth- With women/ Age method od Pill IUCD tion Jelly Condom uon tion method od drawal Other men CURRENTLY MARRIED WOMEN 15-19 24.2 12.1 3.8 0.4 2 1 0.8 7,3 0.0 0.5 17 1 11 I 8,5 5.4 388 20-24 38.6 18.3 7.5 0.5 1.9 0.8 122 0.0 I).2 29.0 174 12.4 8.0 743 25-29 444 23.0 12.1 1.7 3.0 1.3 10,0 1.2 0.0 32.3 19.8 15.3 12.2 661 30-34 47.0 21.2 10.5 2.1 4.0 1.2 8.7 25 06 39.1 21.6 16.9 13.7 584 35-39 46.5 22.8 10.8 2 2 7.5 1.3 8.4 3.2 0.0 35.5 17.3 14.8 16.7 455 40-44 43.5 17.5 6.0 1.1 8.3 1 3 4.2 3 8 0.8 32.3 16.3 15 3 12 3 408 45-49 31.4 12.4 5.7 07 7.6 0,3 2.2 2.4 0.0 264 11 9 11,4 12.7 253 Total 40.6 191 8,6 1.3 4.4 1.0 85 1.7 113 31.1 173 13.9 114 3492 CURRIINTLY MARRII'D MEN 20-24 50.4 30.3 8.5 0.2 1.0 1.7 26.8 07 0.0 33.8 27 1 122 3 2 100 25-29 55.4 33.3 9.1 0.9 2.1 1 2 27.6 0.0 0.0 40.1 260 24.4 7.2 163 30-34 64.9 42.3 9 4 3.4 3.2 0.0 32 8 1.0 0.3 43.7 32 2 23 3 9,0 147 35-39 66.7 35.7 12.3 1.1 3 8 0.4 25.8 1.3 oo 498 27.6 33.4 16.8 129 40-44 55.2 226 8.0 1.3 6.0 0.5 15.6 2.3 0.0 42.2 34.0 18.7 12.3 147 45-49 57.0 23.8 7.6 2.9 8.3 0 8 111.0 5.4 0.9 45.2 33.4 24.1 12.2 83 50-54 45.0 18.3 9.1 1 6 10.6 0.7 6.6 2 0 0.7 42.1 311.7 16 4 15 2 95 Total 57.1 30.4 9.2 1,6 4.6 07 22 1 1 6 0.2 425 300 223 m,7 866 Ever-use of modem contraception peaks during ages 25-29 for women and during ages 30-34 for men. The most commonly reported modem methods ever used by women arc the pill (9 percent) and condom (9 percent) followed by injections (4 percent) and female sterilisation (2 percent). The mcthod-specific pattern reported by men follows a pattern very similar to women, except that condoms arc much more commonly reported by men (22 percent) than women. The age pattern of ever-use varies by the method used. Ever-use of injections and sterilisation increase steeply while condom use tends to decrease with increasing age. Ever-use of the pill is highest at ages 25-29 for married women and 35-39 for married men. 4.3 Current Use of Contraception Although 90 percent of married women in Malawi have heard of and 41 percent have ever used a family planning method, only 13 percent reported that they were currently using a method at the time of the survey (Table 4.4). Only 7 percent of married women arc using modem methods, whereas 6 percent are using traditional methods. The most popular modem methods are the pill, female sterilisation, condoms, and injections, each used by about 2 percent of women. Natural family planning is the most commonly used traditional method (2 percent). 32 Table 4.4 Current method use Percent disu'ibution of currently married women and men and all women and men by contraceptive method currently used, according to age, Malawi 1992 Any Dia- Female Male Number modem In phragm/ *teri- steri- Any Natural Not of Any meth- jec- Foam/ liza- lisa- trad. meth- With- currently women/ Age method od pill IUCD tion JeUy Condom tion tion method od drawal Other using To~al men CURRENTLY MARRIED WOMEN 15-19 7.3 3.4 0.9 0.0 0.5 0.0 2.0 0.0 0.0 3.9 1.4 0.4 2.1 92.7 I00.0 388 20-24 12,0 5.3 2.2 0,0 0.2 0.0 2,9 0.0 0,0 6.6 2.9 1.8 2.0 88.0 100.0 743 25-29 14.8 8.4 3.9 0.7 0.9 0.0 1.8 1.2 0.0 6.4 2.6 2.3 1.5 85.2 100.0 661 30-34 16.2 8.2 2.3 0.5 1.3 0.2 1.2 2.5 0.3 8.0 2.9 2.4 2.8 83.8 100.0 584 35-39 16.4 11.3 2.0 0.6 3.2 0.3 1.9 3.2 0.0 5.2 1.2 1.4 2.5 83.6 100.0 455 40-44 13.2 9.3 1.3 0.0 3.9 0.4 0.0 3,8 0.0 3.9 2.2 0.0 1.6 86.8 100.0 408 4549 6.4 4.6 0.6 0.0 L6 0.0 0.0 2.4 0.0 1.8 0,8 0.4 0,7 93.6 100.0 253 Total 13.0 7.4 2.2 0.3 1.5 0.1 1.6 1.7 0.0 5.6 2.2 1.5 2.0 87.0 10(3.0 3492 CURRENTLY MARRIED MEN 20-24 15.9 9.3 0.7 0.0 0.5 0.2 7.8 0.2 0.0 6.6 6.6 0.0 0.0 84.1 1(](3.0 100 25-29 23.4 13.5 2.8 0.0 0.0 0.0 10.7 0.0 0.0 9.9 7.7 1.3 0.9 76.6 1130.0 163 30-34 27.0 15.8 3.4 0.5 1.5 0.0 9.1 1.0 0.3 II.2 6.9 2.1 2.2 73.0 I00.0 147 35-39 33.2 14.3 4.6 0.0 0.8 0.0 7.7 1.2 0.0 19.0 8.2 5.1 5.6 66.8 I00.0 129 40-44 26.2 10.9 4.1 0.3 2.4 0.0 2.2 1.9 0.0 15.2 9.6 0.8 4.9 73.8 100.0 147 45-49 31.8 16.2 1.5 1.5 5.3 0.2 2.4 4.6 0.9 15.5 9.5 3.2 2.8 68.2 I00.0 83 50-54 15.9 5.3 2.5 1.6 0.0 0.0 0.5 0.0 0.7 10.6 7.0 3.6 0.0 84.1 10(3.0 95 Total 25.1 12.5 3.0 0.5 1.3 0.0 6.3 1.1 0.2 12.6 7.9 2.2 2.5 74.9 100.0 866 ALL WOMEN 15-19 3.5 1.8 0.5 0.0 0.3 0.0 1.0 0.0 0.0 1.7 0.6 0.1 0.9 96.5 100.0 1082 20-24 II.I 5.8 2.4 0.0 0.3 0.0 2.9 0.2 0.0 5.3 2.4 1.4 1.6 88.9 100.O 944 25-29 13.5 8.0 3.7 0.6 O.7 0.0 1.8 1.2 0.0 5.5 2.3 1.9 1.3 86.5 100.0 777 30-34 15.5 8.3 2.2 0.6 1.2 0.I 1.2 2.8 0.2 7.1 2.6 2.1 2.5 84.5 I00.0 656 35-39 15.3 10.1 1.9 0.5 3.0 0.3 1.6 2,7 0.0 5.2 1.3 1.2 2.7 84.7 100.0 537 40-44 11.5 8.4 1.3 0.0 3.1 0.3 0.0 33 0.0 3.1 1.8 0.0 1.3 88.5 100.0 510 4549 6.1 4.8 0.4 0.5 1.6 0.0 0.0 2.3 0.0 1.4 0.6 0.3 0.5 93.9 100.0 343 Total 10.5 6.3 1.8 0.3 1.2 0.I 1.4 1.5 0.0 4.3 1.7 1.1 1.5 89.5 100.0 4849 ALL MEN 20-24 ]4.8 H.5 0.9 0.0 0.2 0.1 10.3 0,I 0.0 3.3 3.3 0.0 0.0 85.2 ]00.0 277 25-29 23.0 12.6 2.5 0.0 0.0 0.0 10.1 0,0 0.0 10.4 8.6 1.0 0.7 77.0 100.0 205 30-34 26.3 16.5 3.3 0.4 1.3 0.0 10.3 0.9 0.3 9.8 6.0 1.8 2.0 73.7 100.0 168 35-39 30.0 12.9 4.2 0.0 0.7 0.0 6.9 1.0 0.0 17.1 7.4 4.7 5.1 70.0 100.0 143 40-44 24.0 10.1 3.8 0.3 2.2 0.0 2.0 1.8 0.0 14.0 8.8 0.7 4.5 76.0 100.0 160 4549 27.9 14.3 1.3 1.3 4.6 0.2 2.1 4,0 0.7 13.7 8.4 2.8 2.5 72.1 100.0 95 50-54 14.8 4.9 2.3 1.5 0.0 0.0 0.5 0,0 0.7 9.8 6.5 3.4 0.0 85.2 IO0.0 102 Total 22.2 12.0 2.5 0.3 1.0 0.0 7.2 0,9 0.2 10.2 6.6 1.7 1.9 77.8 100.0 1151 33 Reported current use among married men (25 percent) is higher than among married women (13 percent), largely because of much higher reported use of condoms (6 percent) and of natural family planning (8 percent). Otherwise, the method-specific pattern of use for men follows closely that observed for women. Contraceptive use is highest among married women age 35-39 and lowest among women age 15-19 and 45-49 years. Lower use among younger women is related to having just begun childbearing and thus having fewer than their desired number of children. For the same reason, younger women who do use family planning tend to use less effective methods such as withdrawal or temporary methods such as the condom, whereas older women are more likely to use more effective, long-term methods such as female sterilisation. About three percent of married women age 35 years or older have been sterilised. Use among the oldest women (i.e., 45-49) may be lower because they perceive themselves as unable to have more children and thus not in need of family planning. Among married men, current use of contraception is highest during ages 35-39 and lowest during ages 20-24 and 50-54. As among women, condom use is more frequent at younger ages, while more effective, longer-term methods such as sterilisation and injections are more commonly used at older ages. 4.4 Di f ferent ia ls in Cur rent Use of Fami ly P lann ing While overall use of family planning is quite low, the data indicate that some married women and men are more likely to be using contraception than others. Table 4.5 and Figure 4.2 show the percentages of currently married women and men using specific methods by background characteristics. The use of family planning increases with increasing parity of the woman, suggesting that demand for methods to space or limit births increases as a woman reaches her desired number of children. This pattern is especially pronounced regarding modem method use, presumably because modem methods are recognised by couples to be more effective in achieving their desired family size. Large differences are observed between urban and rural women in the current use of any method of family planning (23 percent in urban areas and 12 percent in rural areas). The difference is explained wholly by the much higher use of modem methods by urban women; current use of traditional methods varies little between urban and rural women. The largest urban-rural differentials occur regarding female sterilisation, the IUCD, and the pill. The most commonly used methods in rural areas are natural family planning and other traditional methods, whereas pills and female sterilisation are the most popular methods among urban women. Regional differences in use of modem contraception are negligible. However, traditional methods are more commonly practiced in the Northern Region. Interestingly, this pattern of relatively higher use of traditional methods in the North is explained by the much more common practice of withdrawal among couples in that Region. This finding is supported by an even more pronounced difference reported by males. Use of contraception, especially use of modem methods, is also related to a persons's level of education. Use of a modem method was reported by 5 percent of married women without schooling, 6 percent of women with 1-4 years of primary school, 11 percent of women with 5-8 years of primary school, and 38 percent of women with at least some secondary schooling. A very similar pattern of results was obtained when looking at information obtained from males. 34 Table 4.5 Current method use by background characteristics Percem distribution of currently married women and men by contraceptive method currently used, according to background characteristics, Malawi 1992 Any Dia- Female Male Number Background modem In phragnd steri- steri- Any Natural Not of characlet- Any meth- jec- Foam/ lisa- lisa- trad. meth- With- currently women/ is~c method od Pill JUCD lion Jelly Condom ticn tion melhod cd drawal Other using Tc4al men CURRENTLy MARRIED WOMEN Residence Urban 22.9 17,2 5.7 1,3 2,2 0.3 2.9 4.9 0,0 5.6 2.1 0.8 2.7 77,1 100,0 411 Rural 11.7 6.0 1,7 0,1 1.4 0.1 1.5 1.2 0.1 5,6 2,2 1.5 1.9 88.3 100,0 3081 Region Northern 17.9 6.9 1.1 0.0 0.7 0.0 3.9 1,1 0.0 11.0 2.5 7.2 1.3 82.1 100.0 430 Central 13,1 8.2 2.4 0.2 2,6 0.1 1.3 1.6 0.0 4.8 2.6 0.5 1,8 86.9 100.0 1402 Sc~athern 11.7 6.8 2,2 0,4 0,7 0.2 1.3 1.8 0,1 4.9 1,8 0.8 2,3 88.3 |00.0 1660 EducaUoh No education 10.0 4.8 1.3 0.0 1.4 0.1 0.6 1.4 0.0 5.2 2.0 1,2 2.0 90.0 100.0 1815 Primary I-4 11.1 6.0 1,6 0,0 1,6 0.0 1.7 1,1 0.0 5,1 2.3 1.0 1.8 88.9 100.0 819 Primary 5-8 18.0 10.6 3.4 0.6 1,3 0.1 3.3 1.9 0.0 7.4 2.6 2.6 2,2 82.0 100.0 750 Secondary+ 43.0 37.9 11.4 5.4 3.0 1,9 5.7 9.0 1,5 5.1 2.4 1.7 1.1 57.0 100.0 107 No, of living children None 3.0 1,6 0,1 0.0 0.0 0.0 1.1 0,3 0.0 1.5 0,5 0.4 0.6 97.0 100.0 464 1 10,9 5.3 1,9 0.3 0,2 0.0 2.3 0,6 0,0 5.6 2.5 1.3 1.9 89.1 100.0 6~0 2 11.4 6,3 2.1 0.2 0.9 0.0 2.4 0.7 0.0 5.1 1,5 1.1 2.5 88,6 100.0 615 3 14.9 7.8 2.5 0.4 0.8 0,0 1,6 2.0 0.3 7.1 3,6 1.8 1.7 85.1 100.0 494 4+ 17.5 10.7 2.9 0.4 3.0 0.3 1.1 2,9 0,O 6.8 2,5 2.0 2.4 82.5 100.0 1319 Total 13.0 7.4 2.2 0.3 1.5 0.1 1.6 1.7 0.0 5.6 2,2 1.5 2.0 87.0 100.0 3492 CURRENTLY MARRIED MEN R~dence Urban 38.9 23.8 7,6 1.9 3.3 0.3 8.0 1.3 1.5 15.0 9.4 2,3 3.3 61.1 100.0 126 Rural 22.7 10.5 2.2 0.2 1.0 0.0 6.0 1.1 0.0 12.2 7.7 2.2 2.3 77.3 100.0 739 Reglon Northern 31.6 12.0 2.3 0.0 0.2 0.4 8.3 0.9 0.0 19.6 8.1 11.1 0.4 68.4 I00.0 99 Central 28.8 13.0 2.3 0,7 2,9 0,0 5.5 1.4 0.1 15,8 11.7 1.7 2,4 71.2 100.0 347 Soutbem 20.4 12.1 3.7 0.3 0.3 0.0 6.5 1.0 0.3 8.3 4.8 0.5 3.0 79.6 100.0 419 Educatlott No education 15.1 5.1 0.0 0.0 1.9 0.0 1.7 0.8 0.7 10.0 6.8 1.5 1.7 84.9 100.0 183 Primary 1-4 17.4 7.7 1.9 0.2 0.6 0.0 4.2 0.9 0.0 9.7 7.4 0.2 2.1 82.6 100.0 255 Primary 5-8 30.9 15.7 4.1 0.5 1.2 0.I 8.0 1.8 0.2 15.1 8.7 3.4 3.0 69.1 100.0 330 Secondary+ 44.3 27.5 7.9 2.0 2.7 0.2 14.6 0.2 0.0 16.8 8.6 4.8 3.3 55.7 100.0 97 Total 25.1 12.5 3.0 0.5 1.3 0.0 6.3 1.1 0.2 12.6 7.9 2.2 2.5 74.9 100.0 866 35 Figure 4 2 Percentages of Currently Married Women and Men Using a Contraceptwe Method Females VL'~#< , MALAWI RESIDENCF Urban Rura~ REGION N, ,rtnerr C~nrra' Sou'herr] LbJCA7 ON No Educatlor] Prlmar¢ 1 -i Prm/ary 5 8 :-,eL or'dary + ,0 12 I ~ 11W '1:3 40 30 20 10 0 Per en', ll, r, 117 Is2 ]29 12o 10 MA[ AWl RESIDENCE Urban Rural REGION Ntlrtbern Central Soulherq EEbL( "A] !()N No Fct, oalk,rl Prmsary 1 4 J31 Primary ~ 8 ,1,1 St/.~ "/d/iy 20 30 40 50 MDH2, 19:~2 4.5 Number of Chi ldren at First Use of Contracept ion In many cultures, family planning is used only when couples have already had as many children as they want. However, as the concept of family planning gains more general acceptance, couples may choose to use contraception for spacing births as well as for limiting family size. In addition, unmarried young women may be particularly motivated to use family p!anning to avoid an unwanted pregnancy. By looking at differences in the number of living children at first use of family planning by current age of women, one can assess time trends in fertility control behaviour. Table 4.6 shows the number of children ever-married women had when they first used contraception, by age group. For the older cohorts (35-49 years), well over half of those women who have ever used a Table 4.6 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, according to current age, Malawi 1992 Number of living children at time Never of first use of contraception Number Current used of age contraception 0 1 2 3 4+ Missing Total women 15-19 75.5 10.7 11.8 1.5 0.0 0.0 0.5 100.0 446 20-24 62.0 5.9 22.7 6.3 1.7 0.9 0.4 100.0 850 25-29 57.3 3.1 15,8 12,9 7.0 3.3 0.6 100.0 759 30-34 53.8 1.4 11.7 12.2 8.1 12.3 0.5 100.0 651 35-39 54,3 1.7 9.0 8.9 5.6 20.2 0.3 100.0 531 40-44 56,7 0.8 7.5 8.7 6.2 19,6 0.6 100.0 507 4549 69.0 0.9 7.6 5.6 4.1 12.2 0.6 100.0 343 Total 60,2 3.6 13.5 8.5 4.8 8.8 0,5 100.0 4088 36 method started using only after they had three or more children. For the younger cohorts (15-29 years), women are more likely to have started using family planning after their first or second child. For instance, while 45 percent of ever-users currently age 25-29 first used a method before their second child was born, only 19 percent of ever-users age 40-44 had first used contraception by that point in their reproductive lives. Also, use of family planning before the first birth has risen sharply from 1 percent in the 4049 year-old cohort to 11 percent among 15-19 year-olds. These findings reflect a clear trend in Malawi towards earlier use of family planning for delaying childbearing and for spacing purposes. 4.6 Knowledge of Fertile Period A basic knowledge of reproductive physiology is useful for the successful practice of coitus-dependent methods such as withdrawal, the condom, or barrier methods, but itis especially important for users of natural family planning (periodic abstinence). The successful practice of natural family planning depends on an under- standing of when during the ovulatory cycle a woman is most likely to conceive. Table 4.7 presents the percent distributionofall female respondents and those who have ever used natural family planning by reported knowledge of the fertile period in the ovulatory cycle. Twenty-seven percent of the women interviewed said they did not know when a woman is most likely to conceive and an additional 39 percent said that there is no particular time when coitus is most likely to result in pregnancy. Only 12 percent of women gave the correct response: that a woman is most likely to conceive in the middle of her ovulatory cycle. Ever-users of natural family planning are only slightly more knowledgeable Table 4.7 Knowledge of fertile period Percent distribution of a/l women and of women who have ever used the natural method by knowledge of the fertile period during the ovulatory cycle, Malawi 1992 EVCT user5 of the Perceived All natural fertile period women method During menstrual period 0.4 0.7 Right after period has ended 13.7 17.4 In the middle of the cycle 12.1 14.4 Just before period begins 7.6 19.9 No particular time 38.9 30.3 Don't know 27.0 17.3 Missing 0.3 0.0 Total 100.0 100.0 Number 4849 708 about the ovulatory cycle than women in general. Although fewer ever-users of natural family planning responded "don't know" or "no particular time," still only 14 percent gave the correct response, i.e., "middle of the cycle." In conclusion, while these findings may understate genuine knowledge of the fertile period by Malawian women, it is also apparent that many women who claimed to be using natural family planning as a means to avoid pregnancy are either using it ineffectively or really do not understand what the method involves. 4.7 Sources of Family Planning Methods All current users of modem methods of family planning were asked to report the source from which they most recently obtained their methods. Since respondents often do not know exactly which category the source they use falls into (e.g., government hospital, primary health centre, etc.), interviewers were instructed to write the name of the source. Supervisors and field editors were instructed to verify that the reported name and the type of source were consistent, asking cluster informants for the names of local family planning sources if necessary. This practice was designed to improve the reporting of data on sources of family planning. 37 Table 4.8 and Figure 4.3 indicate that a large majority of female users of modem contraception (70 percent) obtained their methods from government sources d2 percent from government hospitals, 16 percent from government primary health centres, and 11 percent from govemment dispensaries/matemity clinics. Twenty-two percent of current users repotted the private medical sector as their source of current method. Half of these women obtained their method at a private hospital or clinic. Lastly, six percent of current users, mostly those using condoms, repotted their source as a shop, pharmacy, or friends and relatives. Table 4.8 Source of supply for modem contraceptive methods Percent distribution of current users of modern contraceptive methods by most recent source of supply or information, according to specific methods, Malawi 1992 Female Con- sterili- Source of supply Pill IUCD ilom sation Other Total FEMALES Public 77.7 75.9 62.1 62.8 69.0 69.9 Government hospital. 40.2 27.3 34.2 62.8 50.3 42.3 Primary health centre 25.4 30.5 6.8 0.0 11.8 15.5 Dispensary/Maternity climc 12.I 15.5 16.1 0.0 6.9 10.5 Mobde clinic 0.0 2.5 5.0 0.0 0.0 1.6 Private (medical) 18.8 24.1 12.8 32.0 31.0 22.3 Priv ate hc~pital/Cli nic 6.1 7.2 4.2 26.9 19.2 11.5 Private health centre 4.1 5.9 4.7 0.7 8.3 4.0 Dispensary/Maternity clinic 5.0 8.4 4.0 4.4 3.5 5.2 Mobile clinic 0.7 2.5 0.0 0.0 0.0 0.7 Private doctor 2.9 0.0 0.0 0.0 0.0 0.9 Other private 2.9 0.0 24.9 0.0 0.0 6.4 Shop/Phaxmacy 1.5 0.0 22.6 0.0 0.0 5.5 Friends/Relatives 1.5 0.0 2.3 0.0 0.0 0.9 Other 0.5 0.0 0.0 0.0 0.0 0.2 Don't know 0.0 0.0 0.3 0.0 0.0 0.1 Missing 0.0 0.0 0.0 5.2 0.0 1.2 Total 100.0 100.0 100.0 100.0 i00.0 100.0 Number 89 58 68 71 19 304 MALES Public 83.9 49.9 66.4 60.2 Government hospital 61.7 23.1 42.3 34.9 Primary health centre 5.2 10.3 13.4 9.9 Dispensary/Maternity chrac 17.0 12.8 5.4 12.2 Mobile chnic 0.0 3.6 29.2 3.2 Private (medical) 11.9 24.1 23.8 22.6 Private hospital/Clinic 0.0 3.9 0.0 7.1 Private health centre 3.4 8.6 5.4 5.8 Dispensary/Maternity clinic 8.5 10.4 0.0 9.0 Mobile clinic 0.0 0.6 0.0 0.4 Private doctor 0.0 0.6 0.0 0.4 Other private 4.2 24.2 0.0 15.3 Shop/Pharmacy 2.5 19.7 0.0 12.2 Friends/Relatives 1.7 4.5 0.0 3.0 Missing 0.0 1.8 4.4 2.0 Total 100.0 100.0 100.0 100.0 Number 29 82 28 139 38 Figure 4,3 Distribution of Current Female Users of Modern Contraception by Source of Supply Government Hospit~ 42% Govl Health Centre 16% Govt C]inic/Dispens/Mob Olinic Don't Know/Missing 1% Other 6% Private (medicaJ) 22% MDHS 1992 The distribution of male users by source of modern method shows a different pattern than that of female users, largely because over half of current male users report using the condom. Half of the condom users report having obtained their last supply in the public sector, most commonly at a government hospital. The remaining half are split equally between those who obtained their condoms from the medical private sector and those who obtained them from shops, pharmacies, and friends. The source a woman uses to obtain contraceptive methods depends on many things, one of which is the type of method she has chosen. About two-thirds of sterilisation procedures are done in government hospitals. The source of pills is much more varied, but government hospitals, health centres and clinics together account for over three-quarters of reported user sources. While condoms are also obtained from many sources, 38 percent of women users and 48 percent of male users report getting their condoms from non-governmental sources, the most common single source of which is shops. Women and men who were currently using a modern contraceptive method were asked how long it takes to travel from their home to the place where they obtain the method. Non-users were asked if they knew a place where they could obtain a modern method and, if so, how long it would take to travel there. The results are presented in Table 4.9. Among the women currently using a modem method, 19 percent are within 30 minutes (one-way travel time) of the place to which they go to get their method, while 13 percent are 30 minutes to one hour from their source. Fifty-nine percent of users of modem methods are one hour or more from their source of supply. Nearly 10 percent could not provide a quantitative estimate of time to their source. As expected, urban users are generally closer than rural users to their supply sources. Thirty-six percent of urban users are within 30 minutes of their supply sources as compared to only 12 percent of the rural users. Two-thirds of the latter have to travel for one hour or more to get their supplies. 39 Table 4.9 Time to source of supply for modem contraceptive methods Perc~mt distribution of women and men who are currently using a modern contraceptive method, who are not using a modern method, and who know a method, by time to reach a source of supply, according to urban-rural residence, Malawi 1992 Time (minutes) Currently using a modern method Not currently using a modem method Know a contraceptive method Urban Rural Total Urban Rural Total Urban Rural Total FEMALES 0-14 22.6 9.3 13.0 9.5 5.2 5.7 11.9 5.9 6.7 15-29 12.9 2.9 5.7 12.0 2.8 3.9 12.7 3.1 4.3 30-59 24.2 8.8 13.0 21.4 6.9 8.6 22.7 7.7 9.6 60 or more 35.2 67.2 58.5 39.3 53.8 52.2 40.3 59.4 56.9 Does not know time 4.4 10.2 8.6 2.9 5.2 4.9 3.3 5.9 5.6 Does not know source 0.0 0.0 0.0 14.6 25.7 24.5 8.8 17.6 16.4 Not stated 0.8 1.4 1.2 0.2 0.3 0.3 0.3 0.4 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 83 221 304 511 4033 4545 568 3817 4385 MALES 0-14 25.1 17.5 19.7 14.6 6.7 7.9 17.2 8.2 9.7 15-29 22.3 4.3 9.6 8.9 3.1 3.9 12.1 3.2 4.6 30-59 29.9 11.1 16.6 23.8 13.6 15.0 25.5 13.9 15.7 60 or more 18.6 63.9 50.8 27.1 50.1 46.9 25.3 53.2 48.7 Does not know time 1.8 1.0 1.2 1.4 1.l 1.1 1.5 1.1 1.2 Does not know source 0.0 0.0 0.0 22.5 25.1 24.7 16.6 19.9 19.4 Not stated 2.2 2.2 2.2 1.6 0.2 0.4 1.8 0.5 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of mext 40 98 139 141 871 1012 179 924 1103 Among women who are not using a modem method, almost one-quarter do not know a source for a modem contraceptive method. It should be noted that this question was asked of all nonusers and thus includes the 10 percent of women who do not know any method. Since these women presumably do not know of a source for family planning, they would account for almost half of those nonusers who do not know of a source. The last panel of Table 4.9 is based on all women who know a contraceptive method. Among women who know at least one family planning method, 11 percent are within 30 minutes of a source for a modem method, but 16 percent say they do not know of a place to get a modem method. 4.8 Intention to Use Family Planning Among Nonusers Women and men who were not us ing a cont racept ive method at the t ime o f the survey were asked i f they thought they wou ld do someth ing to prevent p regnancy at any t ime in the future. The resu l ts are shown in Tab les 4 .10.1 and 4 .10 .2 by whether or not the woman/man had ever used a method in the past. 40 Table 4.10.1 Future use of contraception - females Percent disVribution of currently married women who are not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living children, Malawi 1992 Past experience Number of living children t with contraception and future intentions 0 1 2 3 4+ Total Never used contraception Intends to use in next 12 months 13.8 28.6 25.3 29.0 25.7 25.4 Intends to use latex 19.2 13.5 7.7 6.7 5.0 8.8 Unsure as to timing 4.2 l , l 1.2 1.2 0.7 1.3 Unsure as to intention 7.9 8.7 8.1 4.6 6.1 6.9 Does not intend to use 38.6 26.6 23.5 21.9 24.2 25.7 Missing 0.0 0.0 0.3 0.3 0.0 0.1 Previously used contraception Intends to use in next 12 months 6.0 9.9 17.5 17.6 22.8 16.9 Intends to use later 4.8 4.0 5.9 5.5 3.9 4.6 Unsure as to timing 1.3 0.6 1.0 0.6 0.7 0.8 Unsure as to intention 0.6 1.6 2.3 2.5 1.3 1.6 Does not intend to use 3.5 5.0 7.1 9.9 9.7 7.7 Missing 0.0 0.3 0.0 0.l 0.0 0.1 Tota/ 100.0 100 .0 100 .0 100 .0 100.0 100.0 All currently married nonusers Intends to use in next 12 months 19,9 38.6 42,8 46.6 48.5 42.3 Intends to use later 24.0 17.5 13.6 12.2 8.8 13.4 Unsure as to timing 5.6 1.7 2.2 1.8 1.4 2.1 Unsure as to intention 8.5 10.3 10.5 7.1 7.4 8.6 Does not intend to use 42.1 31.6 30.6 31.7 33.9 33.4 Missing 0.0 0.3 0.3 0.4 0.0 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 330 558 542 456 1151 3038 tincludes current pregnancy Among all currently married female nonusers, 42 percent reported intending to use a method within the next 12 months, while another 13 percent intend to use family planning but only at a later time. Nine percent were not sure whether they would ever use a method, but a third of women said that they do not intend to ever use contraception. Intention to use family planning in the future is closely tied to the number of children a woman has. Intent to use in the next 12 months jumps from 20 percent among women with no living children to 49 percent among women with 4 or more living children. Also, while 42 percent of women without children say they will never use family planning, 34 percent of women with 4 or more children say the same. Sixty-one percent of women who intend to use contraception in the future have not used it in the past. If constraints to use (i.e., cost, access, etc.) are minimised, and thus intentions to use are manifest in future behaviour, the contraceptive prevalence rate in Malawi will increase substantially over the ensuing years. Overall, intent to use in the next twelve months is only slightly higher among men (46 percent) than women (42 percen0. More significant male-female differences do, however, emerge when looking at the relationship between reptvductJ ve history and intention to use. Whereas among women, one observes a fairly strong increase in intention to use associated with the current number of living children, this pattem is not observed among male respondents; in fact, the inverse may be true. The results for males however must be interpreted cautiously because they are based on small numbers. 41 Table 4.10.2 Future use of contraception - males Percent distribution of curreaatly married men who axe not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living childran, Malawi 1992 Past experience with contraception and future intentions Number of living children 0 1 2 3 4+ Total Never used contraception Intends to use in next 12 months 26.4 15.9 23.5 25.3 19.7 21.2 Intends to use later 17.3 15.9 8.6 8.8 8.5 10.7 Unsure ~ to timing 1.4 0.0 2.1 0.0 1.5 1.2 Unsure as to intention 9.4 2.9 0.4 7,0 4.1 4.2 Does not intend to use 10.4 16.7 18.4 20.6 23.0 19.5 Missing 0.0 0.0 1.7 0.8 0.0 0.4 Previously used contraception Intends to use in next 12 months 19.4 31.6 23.7 24.8 23.2 24.5 Intends to use latex 4.3 8.6 5.1 4.2 4.3 5.1 Unsure as to timing 4.5 2.0 4.3 0.6 1.8 2.4 Unsure as to intention 1.4 3.0 1.7 4.2 1.9 2.3 Does not intend to use 5.6 3.2 10.2 3.7 11.9 8.4 Missing 0.0 0.0 0.2 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 All currently married nonusers Intends to use in next 12 months 45.7 47.5 47.2 50.2 42.9 45.7 Intends to use later 21.6 24.5 13.7 13.0 12.8 15.8 Unsure as to timing 5.9 2.0 6.4 0.6 3.3 3.6 Unsure as m intention 10.8 5.9 2.2 11.2 6.0 6.5 Does not intend to use 15.9 20.0 28.7 24.3 34.9 28.0 Missing 0.0 0.0 1.9 0.8 0.0 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number ofmen 69 104 115 86 274 649 4.9 Reasons for Non-use Table 4.11 presents the main reasons for not using contraception given by married women and men who are not using any contraceptive method and do not intend to use it in the future. Thirty percent of women say they do not intend to use because they want children, while another 35 percent cite infecundity (either "difficult to get pregnant" or "menopausal") as the reason. Other reasons commonly given are concerns about side effects or other more serious health effects (10 percent) and lack of knowledge (9 percent). The younger cohort of women (under age 30) are much more likely to say they do not to intend to use contraception in the future because they want more children or because they lack knowledge, while those age 30 and over are more likely to cite reasons such as being menopausal or infecund. 42 Table 4.11 Reasons for not using contlaception Percent distribution of currently married women and men who are not using a contraceptive method and who do not intend to use in the future by main reason for not using, according to age, Malawi 1992 Age Less 30 Reason for not using than or more contraception 30 years years Total FEMALES Wants children Lack of knowledge Partner opposed Costs too much Side effects Health concerns Hard to get methods Religion Opposed to family planning Fatalistic Other people opposed Infrequent sex Difficult to get pregnant Menopausal/Had hysterectomy Inconvenient Not married Other Don't know 47.3 21.3 30.3 15.9 5.9 9,4 4.4 1.8 2.7 0.1 0.2 0.2 3.4 4.6 4.2 6.4 5.2 5.6 0.l 0.0 0.0 0,7 0.1 0.3 0,8 1.2 1.1 5.6 3,9 4.5 0,0 0.6 0.4 0,7 1.2 1.0 7,1 36.3 26,2 0.1 14.2 9.3 0.6 0.5 0,5 0.4 0.1 0.2 0.8 1.1 1.0 5.4 1.7 3.0 Total Number I00.0 100.0 100.0 352 664 1016 MALES Wants children 51.8 19,8 24.6 Lack of knowledge 24.9 8.6 11.1 Partner opposed 0.0 2,0 1.7 Side effects 0.0 3,9 3~3 Health concerns 1.8 2,5 2.4 Opposed to family planning 0.0 0.4 0.4 Fatalistic 0.0 3.2 2.8 Other people opposed 0.0 1.9 1.6 Infrequent sex 5.5 2,0 2,6 Difficult to get pregnant 5.5 36.8 32,1 Menopausal/Had hysterectomy 6.1 16.1 14,6 Inconvenient 1.8 0.1 0.4 Other 0.0 0,5 0.4 Don't know 2,6 1,9 2,0 Total 100.0 100.0 100.0 Number 27 154 181 The results for men are very similar to those obtained for women, except that men tend to cite desire for more children less often and infecundity and lack of knowledge more often than women do. The results for men should be viewed with caution since they are based on a small number of respondents. 43 4.10 Preferred Method Non-users who said that they d/d intend to use family planning in the future were asked which method they preferred to use. The results are presented in Table 4.12. Most women said they preferred to use the pill (51 percent), and injections were the next most preferred method ( 16 percent). The same pattern of method preference is noted among women regardless of whether they intend to use in the next 12 months or later. There is a tendency for women who are unsure about the timing of future use to also be unsure of which method they might use. The preferred method among men is the condom (40 percent) followed by the pill (28 percent). Table 4.12 Preferred method of contraception for future use Percent distribution of currently married women and men who are not using a contraceptive method but who intend to use in the future by prefea"red method, according to whether they intend to use in the next 12 months or later, Malawi 1992 Intondtouse In next After Unsure Preferred method 12 12 as to of contraception months months timing Total FEMALES Pill 51.9 51.8 41.2 51.4 IUCD 1.2 1.6 0.0 1.2 Injection 17.3 13.5 13.6 16.3 Diaphragm/Foam/Jelly 1.6 0.9 2.3 1.5 Condom 6.3 8.3 3.3 6.6 Female sterilisation 5.2 3.5 7.3 4.8 Male stetilisation 0.1 0.0 0.0 0.1 Natural method 6.1 4.2 4.8 5.6 Withdrawal 1.8 1.7 2.2 1.8 Other 4.3 4.1 5.6 4.3 Unsure 4.3 10.5 19.7 6.3 Total 100.0 100.0 100.0 100.0 Number 1284 408 65 1757 MALES Pill 27.4 32.9 15.5 28.0 IUCD 1.4 0.5 0.0 1.1 Injection 6.9 3.1 5.0 5.8 Diaphragm/Foam/Jelly 1.3 0.0 0.0 0.9 Condom 42.1 38.7 24.1 40.2 Female storilisation 7.3 0.0 19.3 6.2 Male sterilisation 0.0 1.6 0.0 0.4 Natural method 8.2 15.5 10.6 10.0 Withdrawal 0.5 1.1 10.5 1.2 Other 3.4 4.7 10.0 4.0 Unsure 1.6 1.9 5.0 2.1 Total 100.0 100.0 100.0 100.0 Number 296 103 23 422 44 4.11 Exposure to Family Planning Messages on Radio All respondents were asked if they had heard a message about family planning on radio in the month pre- ceding the interview. Only one-quarter of women and about half of men said that they had heard a message on the radio (Table 4.13). The percentage who had heard family planning messages in the month prior to the survey varied widely by background characteristics. Rural men and women and those with little orno education were less likely to have heard a family planning message. Table 4.14 presents the results from a question on whether women and men believe it is acceptable or not ac- ceptable to air family planning messages over the radio. Eighty-four percent of women and 93 percent of men said that such messages are acceptable to them. Young women (15-19 years) were much more likely than others to re- spond "don't know," and men and women 45 years of age or older were more likely to say that family planning messages on the radio were unacceptable. Patterns of ac- ceptability across region, urban-rural residence and educa- tion were small or negligible. 4.12 Approval of Family Planning An indication of the acceptability of family plan- ning is the extent to which couples discuss the topic with each other. Table 4.15 shows the results obtained by ask- ing married, non-sterilised women and men who know of a contraceptive method questions conceming communica- tion about family planning with their spouse. Fifty-seven percent of these women and 63 percent of these men said they had discussed family planning with their spouse in the year prior to the survey. Not only am men more likely to have said they have discussed family planning with their spouse, but they report having discussed it more often than women report. While 38 percent of men said they dis- cussed family planning three or more times over the last year, only 24 percent of women said the same. Men and women age 35-39 years were most likely to have recently discussed family planning with their spouse, with such communication becoming increasingly less common among the older and younger age groups. Table 4,13 Family planning messages on radio Percent distribution of all women and men by whether they have heard a family planning message on radio in the month preceding the survey, according to selected background characteristics, Malawi 1992 Heard family Number planning of Background message women/ characteristic on radio men FEMALES Residence Urban 48,3 594 Rur~ 23.7 4255 Region Northern 28.8 578 Centr~ 25.0 1872 Southem 27.6 2398 Education No education 19.0 2287 Primary 1-4 24,6 1192 Primary 5-8 38.2 1159 Secondary+ 60.1 212 Total 26.8 4849 MALES Residence Urban Rural Region Northern Centr~ Southexn 61.3 181 46.3 970 52.7 139 44.9 443 50.7 569 Education No education 42.8 236 Primary 1-4 36.3 335 Primary5-8 51.8 423 Secondary+ 75.8 157 Total 48.7 1151 45 Table 4.14 Acceptability of the use of radio for disseminating family planning messages Percentage of women and men who believe that it is acceptable to have messages about family planning on radio, by age and selected background characteristics, Malawl 1992 Number Not of Background Accept- acc t , - Don't know/ women/ characteristic able able Missing Total men FEMALES Age 15-19 76.8 13.2 10.0 100.0 1082 20-24 88.6 7.9 3.5 100.0 944 25-29 88.0 8.7 3.3 100.0 777 30-34 83.9 11.4 4.7 100.0 656 35-39 86.4 10.0 3.6 100.0 537 40~14 83.1 9.9 7.0 100.0 510 45-49 77.3 16.0 6.7 100.0 343 Residence Urban 88.3 9.0 2.7 1GO.0 594 Rural 83.0 10.9 6.1 100.0 4255 Region No~bem 80.4 10.0 9.6 100.0 578 Central 83.8 11.6 4.6 100.0 1872 Southern 84.3 10.1 5.6 100.0 2398 ~duc.&t Ion No education 78.7 14.7 6.5 100.0 2287 Primary 1-4 85.6 7.7 6.7 100.0 1192 Primary 5-8 89.8 6.3 3.8 100.0 1159 Secondary+ 91.2 8.0 0.8 100.0 212 Total 83.6 10.7 5,7 100.0 4849 MALES Age 20-24 93.4 3.2 3.3 100.0 277 25-29 94.9 2.4 2.6 100.0 205 30-34 94.6 3.6 1.8 100.0 168 35-39 93.9 3.4 2.7 100.0 143 40-44 94.4 3.7 1.8 1(30.0 160 45-49 86.7 10.3 3.0 100.0 95 50-54 87.7 10.3 1.9 100.0 102 Residence Urban 90.0 6.9 3.1 100.0 181 Rural 93.6 4.0 2.4 100.0 970 Region Nonhero 85.8 7.2 7.1 1(30.0 139 Central 95.1 3.5 1.4 100.0 443 Southern 93.1 4.5 2.4 100.0 569 Ec:l uc~itlon No education 92.8 2.9 4.4 100.0 236 Primary 1-4 93.9 4.0 2.2 100.0 335 Primary 5-8 93.8 3.9 2.3 100.0 423 Secondary+ 89.5 9.3 1.2 1130.0 157 Total 93.0 4.4 2.5 100.0 1151 46 Table 4.15 Discussion of family planning by couples Percent disla'ibution of currently married, non-st~ilised women and men who know a contraceptive method by the number of times family planning was discussed with spouse in the year preceding the survey, according to current age, Malawi 1992 Number of times family planning discussed Once or Three Age Never twice or more Missing Total Number FEMALES 15-19 50.4 37.2 11.9 0.6 100,0 341 20-24 42.3 33.8 23.3 0.7 100,0 713 25-29 37.7 34.0 28.0 0.2 100,0 632 30-34 39.1 34.2 25.7 0.9 1120,0 546 35-39 34.7 34.9 29.4 1.0 100,0 419 40-44 49.3 24.5 25.8 0.4 100.0 364 45-49 59.9 20.4 18.1 1.6 100,0 226 Total 42.7 32.4 24.1 0.7 100,0 3242 MALES 20-24 50.9 19.2 29.8 0.2 100.0 97 25 -29 34.2 30.4 35.2 0. t 100.0 162 30-34 26.3 26.1 46.6 1.0 100.0 144 35-39 24.2 22.6 52.0 1.2 100.0 125 40-44 36.6 24.6 36.8 2.0 100.0 141 45-49 31.5 25.6 37.9 5.0 100.0 79 50-54 58.1 18.5 23.4 0.0 100.0 92 Total 36.1 24.5 38.3 1.2 100.0 840 In order to obtain more direct information about the acceptability of family planning, respondents were asked if they approved or disapproved of couples using a method to avoid pregnancy. Although all women and men were asked this question, the data presented in Tables 4.16.1 and 4.16.2 are confined to currently married, non-sterilised respondents and exclude those who had never heard of a contraceptive method. Currently married, non-sterilised women and men were a/so asked if they thought that/heir spouse approved of the use of family planning. It should be noted that the respondent's opinions of their spouse's attitudes may be incorrect, either because they have misconstrued their spouse's attitudes or because of a tendency to report their spouse's attitudes as similar to their own. 47 Table 4.16.1 Attitudes of couples toward family planning - female respondents Among cttrreafly married, non-sterilised women who know a contiaceptive method, the percentage who approve of family planning, by their perception of their husband's attitude and selected background characteristics, Malawi 1992 Respondent approves Respondent disapproves Unstll-e Ul?dtffe Both Husband of Husband Husband of Respondent Characteristic approve disapproves husband approves disapproves husband unsure Percent Total Age 15-19 69.2 8.6 15.9 0.2 2.3 2.5 1.3 100.0 341 20-24 73.1 7.2 10.7 1.9 2.0 3.5 1.6 100.0 713 25-29 74.1 10.4 10.1 1.1 1.1 2.6 0.6 100.0 632 30-34 69.4 12.9 10.3 2.2 1.4 2.8 l. l 100.0 546 35-39 70.3 8.5 9.6 3.1 2.5 4.5 1.4 100.0 419 40-44 69.9 8.6 14.3 0.4 1.5 4.8 0.5 100.0 364 45-49 62.0 9.0 15.8 2.3 2.0 7.4 1.6 100.0 226 Residence Urban 74.8 9.9 9.5 1.5 0.8 2.6 1.0 100.0 380 Rural 70.2 9.3 12.0 1.6 1.9 3.8 1.2 100.0 2862 Region Northern 69.8 10.l 11.8 1.7 3.0 2.1 1.5 100.0 398 Central 72.5 9.6 10.2 1.7 1.4 3.8 0.8 100.0 1299 Southea-n 69.5 9.0 13.0 1.5 1.7 3.9 1.4 100.0 1545 Education No education 67.5 9.1 13.4 1.9 2.2 5.0 0.8 100.0 1648 Primary I-4 71.6 9.7 10.8 1.6 1.9 2.9 1.4 100.0 773 Primary 5-8 75.2 9.9 9.8 1.2 0.8 1.8 1.3 100.0 725 Secondary+ 86.2 7.0 3.0 0.5 0.0 0.0 3.3 100.0 96 Total 70.8 9.4 11.7 1.6 1.8 3.6 1.1 100.0 3242 Overall, 92 percent of married women and 96 percent of married men who know a contraceptive method approve of family planning. Women are more likely than men to report that they do not know their spouse's view on family planning or that their spouse disapproves. Less educated men and women are more likely to disapprove of family planning themselves, and are also more likely to say that their spouses disapprove or that they do not know their spouse's views. Comparison of results among regions and between urban and rural respondents suggest that only very small to negligible differences in attitudes towards family planning exist across these lines. Further, only very small differences exist in attitudes by age of the respondents, although there is a slight tendency for older men and women to disapprove of family planning. 48 Table 4.16.2 Attitudes of couples toward family planning - male respondents Among currendy married, non-sterilised men who know a conU'aceptive method, the percentage who approve of family planning, by their perception of their wife's attitude and selected background characteristics, Malawi 1992 Respondent approves Respondent disapproves Unsure Unsure Both Wife of Wife Wife of Respondent Characteristic approve disapproves wife approves disapproves wife unsure Percent Total Age 20-24 90.0 0.0 7.4 0.0 2.4 0.0 0.2 100.0 97 25-29 92.3 1.2 4.6 0.0 0.0 1.8 0.l 100.0 162 30-34 90.3 2.3 4.2 2.2 0.0 0.0 1.0 100.0 144 35-39 92.4 1.0 1.7 3.0 0.6 0.1 1.2 100.0 125 40-44 87.0 2.3 5.2 0.4 1.1 2.0 2.0 lO0.O 141 45-49 88.2 1.3 0.6 0.2 1.9 2.7 5.0 100.0 79 50-54 80.3 8.7 6.0 0.6 3.4 1.1 0.0 100.0 92 Residence Urban 85.1 2.8 5.2 1.7 1.2 2.4 1.6 100.0 123 Rural 89.8 2.2 4. I 0.8 1.1 0.9 1.2 100.0 717 Region Northern 89.2 2.5 5.0 0.4 0.0 1.7 1.2 100.0 98 Central 88.3 1.1 4.5 2.1 1.4 1.1 1.5 100.0 330 Southern 89.7 3.1 3.9 0.2 1.1 1.0 1.0 100.0 411 Education No education 85.7 6.1 4.0 0.9 1.7 0.7 0,9 100.0 174 Primary 1-4 84.1 2,0 7.5 1.4 2.0 2.2 1.0 100.0 244 Primary 5-8 93.0 0.4 2.9 0.8 0.2 0.7 1.8 100.0 325 Secondary+ 94.5 2.1 1.3 0.5 0.7 0.5 0.4 100.0 97 Total 89.1 2.2 4.3 1.0 1.1 1.1 1.2 100.0 840 49 CHAPTER 5 OTHER PROXIMATE DETERMINANTS OF FERTILITY This chapter addresses two of the principal factors other than contraception that affect a woman's risk of becoming pregnant: nuptiality and postpartum amenorrhoea. Nuptiality (marriage) is a primary factor influencing the exposure of a woman to the risk of pregnancy and therefore is important in understanding fertility dynamics. Populations in which age at first marriage is low tend to be populations with early childbearing and high fertility. One of the first signs of a transition from high to lower fertility levels is a rise in the age at first marriage. Postpartum amenorrhoea is another factor that directly influences exposure to the risk of pregnancy. A woman is normally amenorrhoeic for a few weeks or months following the termination of a pregnancy. During this time, she is less susceptible to the risk of pregnancy and, although the correlation is not an exact one, this period of amenorrhoea can be lengthened by breastfeediag. Inversely, by curtailing the length of breastfeeding without adopting other fertility control measures, a woman will become susceptible to the risk of pregnancy at an earlier postpartum date. 5.1 Marital Status Table 5.1 shows the distribution of women and men by age and marital status at the time of the survey. The term "married" refers to legal or formal marriage, whereas "living together" refers to informal unions. In this report, these two categories are combined and referred to collectively as "currently married" Table 5.1 Current marital status Percent distribution of women and men by current marital status, according to age. Malawi 1992 Marital status Number of Age Never Living Not living women/ (years) married Married together Widowed Divorced together Total men FEMALES 15-19 58.8 34.6 1.2 0.3 3.6 1.5 100.0 1082 20-24 10.0 74.4 4.3 1.2 7.9 2.3 100.0 944 25-29 2.2 82.2 3.0 2.4 7.1 3.2 100.0 777 30-34 0.6 84.8 4.3 2.9 4.9 2.5 100.0 656 35-39 1.1 80.6 4.1 3.8 6.1 4.4 100.0 537 40-44 0.6 76.3 3.7 3.9 11.4 4,2 100.0 510 45-49 0.0 70.4 3.4 8.6 11.2 6.4 100.0 343 Total 15.7 68.8 3.2 2.5 6.8 3.0 100.0 4849 MALES 20-24 60.8 32.8 3.4 0.0 1.2 1.8 100.0 277 25-29 14.5 72.5 7.3 0.9 3.5 1.3 100.0 205 30-34 5.5 77.0 10.3 1.0 4.0 2,2 100,0 168 35-39 1,8 77,4 13,0 1,0 1.2 5,6 100,0 143 40-44 0.6 85.2 6.7 2.3 4.5 0.7 100.0 160 45-49 0.0 79.8 8.1 0.5 8.1 3.5 100.0 95 50-54 1.6 90.4 2.3 1.0 3.1 1.6 100.0 102 Total 18.5 68.1 7.1 0.9 3.2 2.2 100.0 1151 51 or "currently in union." Along with the currently married, respondents who are widowed, divorced, or no longer living together (separated) make up the remainder of the "ever-married" or "ever in union" category. Marriage is almost universal in Malawi; in other words, nearly everyone is married at some time in his/her life, and the majority of people are currently married. By the time women reach ages 25-29 and men reach ages 35-39, 98 percent have been married. More women than men marry in their adolescent years (before 20 years), and more men than women remain married at older ages. Among women, the percentage currently married declines after age 35, so that approximately 7 out of 10 women are currently married by the age of 45-49. Among men, 90 percent are currently married in the age group 50-54. The percentage of respondents who are not currently married (but were at one time) is twice as high among women than among men. 5.2 Polygyny Married women were asked whether their husbands have other wives and, if so, how many other wives. Married men were asked whether they have more than one wife and, if so, how many other wives. Table 5.2 shows the percentage of currently married women and men who are in polygynous unions, by age Table 5.2 Polygyny Percentage of currently married women and men in a polygynous union, by age and selected background characteristics, Malawi 1992 Age of woman Background characteristic 15-19 20-24 25 29 30-34 35-39 40-44 45-49 Total Residence Urban 12.5 11.2 8.3 14.6 13.4 16 2 13.6 12 0 Rural i0.4 13.2 24.5 24.9 24.8 29 5 34.0 21.9 Region Northern 14.8 18.8 29.2 40.2 31.2 3/).0 46.5 28.3 Central 12.9 13.1 20.0 24.1 27.8 34.4 41.2 22.7 Southern 8,0 10.9 22,0 19,1 18.5 23,4 2(I,5 17 2 Education No education 10.9 14.6 21.5 25.7 23.8 30./I 32.8 22.7 Primary 1-4 12.0 12.9 22.1 19.5 19.0 27.5 31.3 18.9 Primary 5-8 8.6 10.2 24.9 25.3 30.1 24.5 (30 4) 19.5 Secondary+ * (13.1) 8.6 (7.9) (7.4) * * 10,2 Total 10.6 12.9 22.1 23.6 23.4 28.5 32.2 2(/.8 Age of man Background characteristic 20-24 25-29 30 34 35-39 40-44 45 49 50k54 Total Residence Urban * (0.9) 2.0 (3.9) (9.0) (10.4) * 4.3 Rural 4.0 2.1 9.9 17.6 10.6 15 2 13.9 9.8 Total 3.8 1.9 8 4 15.2 10.4 14.3 12 6 9.0 ( ) Based on 25-49 persons • Based on less than 25 persons 52 Figure Percentage of Currently Married Women Whose Husbands Have at least One Other Wife MALAW 21 RESIDENCE Urban 12 Rural 22 REGION Central Northern [ 23 [ 28 Soulherr J 1T EDUCATIOK No Educal~or Pnma~y 1-4 Primary 5 8 Secondary ~ ~ 20 5 10 15 20 Percent 25 30 MDHS 1992 and background characteristics. Figure 5.1 shows the polygyny prevalence data for married women. Overall, 21 percent of currently married women are in a polygynous union, and 9 percent of currently married men have more than one wife. Polygyny exists in all regions and among all socioeconomic groups, although the prevalence varies. Among women, polygyny increases with age, from 11 percent among women age 15-19 to 32 percent of women age 45-49. Women and men in rural areas are about twice as likely to be in a polygynous union as their urban counterparts. Polygyny is more common in the Northern Region (28 percent of women) than in the Central Region (23 percent) and Southern Region (17 percent). Education among women is associated with a lower prevalence of pelygyny; 23 percent of uneducated women arc in a polygynous union versus only 10 percent of women with some secondary education. Of those women in polygynous unions (21 percen0, 60 percent have a single co-wife (Table 5.3). This means that 8 percent of all currently married women have at least two other co-wives. The likelihood of a woman having more than one co-wife increases with age, from 2 percent among women age 15-19 to 16 percent of women age 45-49. Women living in urban areas, in the Southem Region, and those with secondary education are least likely to have multiple co-wives. Only two percent of men have more than two wives (Table 5.4). As among female respondents, pelygyny among males is much less common in urban areas, in the Southern Region, and among men with more formal education. 53 Table 5.3 Number of co-wives Percent distribution of currently married women by number of co-wives, according to selected background characteristics. Malawi 1992 Number of co-wives Number Background of characteristic 0 1 2+ Missing Total women Age 15-19 89.4 7.4 2.2 0.9 100.0 388 20-24 87.1 9.1 3.4 0.4 100.0 743 25-29 77.9 13.8 8.2 0.1 100.0 661 30-34 76.4 14.4 8.9 0.2 100.0 584 35-39 76,6 13.8 9.6 0.0 100.0 455 40-44 71.5 i9.0 9.4 0.0 100.0 408 45~.9 67.8 15.7 15.9 0.6 100.0 253 Residence Urban 88.0 7.1 4.5 0.4 100.0 411 Rural 78.1 13.7 7.9 0.3 100.0 3081 Region Northern 71.7 17,3 10,7 0,3 100.0 430 Central 77.3 11.4 11.0 0.3 100.0 1402 Southern 82.8 13.1 3.7 0.3 100.0 1660 Education No education 77.3 14.4 7.9 0.4 100.0 1815 Primary I-4 81.1 11.7 7.0 0.2 100,0 819 Primary 5-8 80.5 11.6 7.8 0.1 100.0 750 Secondary+ 89.8 6.6 2.6 1.1 100.0 107 Total 79.2 12.9 7.5 0.3 100.0 3492 Table 5.4 Number of wives Percent dista'ibution of currently married men by number of wives, according to selected background characteristics. Malawi 1992 Number of wives Number Background of characteristic 1 2 3+ Total men Age 20-24 96.2 3.8 0.0 100.0 100 25 29 98.1 1.9 0.0 100.0 163 30-34 91.6 7.1 1.2 100.0 147 35-39 84.8 13.7 1.5 100.0 129 40-44 89.6 6.0 4.4 100.0 147 45-49 85.7 9.8 4.5 100.0 83 50-54 87.4 9.4 3.2 100.0 95 Residence Urban 95.7 4.2 0.1 100.0 126 Rural 90.2 7.5 2.3 100.0 739 Region Northern 85.1 13.2 1.7 100.0 99 Central 87.4 9.6 3.0 100.0 347 Southern 95.3 3.5 1.2 100.0 419 Education No education 95,0 3.9 1.1 100.0 183 Primary 1-4 89.2 7.5 3.3 100.0 255 Primary 5-8 89.0 9.0 2.0 100.0 330 Secondary+ 94.6 5.2 0.2 100.0 97 Total 91.0 7.1 2.0 100.0 866 54 5.3 Age at First Marriage Women marry for the first time, on average, 5 to 6 years earlier in life than men (Table 5.5). The median age at first marriage is 18 years for women and about 24 years for men. By age 20, three-quarters of women are married, whereas fewer than one in five men are married by this age. Nearly all women are married by age 25. Table 5.5 Age at first marriage Percentage of women and men ever married by specific exact ages and median age at first marriage, according to ctwrent age, Malawi 1992 Percentage ever married Percentage by specific exact age: who had neve]" Current age 15 18 20 22 25 married Number Median aeat marriage FEMALES 15-19 7.8 NA NA NA NA 58.8 1082 a 20-24 14.8 54.8 76.6 NA NA 10.0 944 17.7 25-29 16.3 53.7 76.9 88.1 95.2 2.3 777 17.7 30-34 20.8 61.0 80.3 89.3 95.3 0.6 656 17.2 35~39 16.4 51.2 73.3 85.0 92.5 1.1 537 17.9 40.44 18.0 49.4 69.0 79.9 93.3 0.6 510 18.1 45-49 17.8 44.9 65.9 79.9 93.1 0.0 343 18.4 20-49 17.1 53.5 74.8 85.9 93.1 3.3 3767 17.7 MALES 20-24 1.3 4.8 13.7 NA NA 60.8 277 a 25-29 2.2 5.5 18.0 38.1 58.2 14.5 205 24.0 30-34 1.9 4.8 14.0 37.1 67.6 5.5 168 23.0 35-39 0.0 7.0 20.7 43.2 64.4 1.8 143 23.1 40-44 0.9 4.8 21.4 40.4 65.9 0.6 160 23.3 45-49 2.2 11.1 20.5 31.5 56.6 0.0 95 24.5 50-54 1.6 11.4 22.0 33.9 67.0 1.6 102 23.5 25-54 1.5 6.8 19.0 38.0 63.3 5.0 874 23.5 NA = Not applicable aOmiued because less than 50 percent of the women in the age group x to x+4 were first married by age x Trends in age at marriage can be described by comparing the cumulative distribution married for successive five-year age groups) The data show that there has been a decline in the proportion of women and men marrying at early ages. The proportion of women marrying before age 15 has declined from 21 percent of the 30-34 year-olds to 8 percent of the 15-19 year-olds. The decline in age at first marriage is not quite as marked among men; the percentage married by age 20 has dropped from 21 among men currently age 35-49 to 14 percent among men aged 20-24. ~For each age-group cohort, the accumulated percentages stop at the lower age boundary of the cohort to avoid censoring problems. For instance, for women currently age 15-19, accumulation stops with the percentage married by exact age 15. 55 Although the decline in marriage at early ages has not been sufficient to change substantially the national median age at first marriage, there are differentials between subgroups of the population. Table 5.6 presents median ages at first marriage by background characteristics. Only the results for women are presented due to the small male sample. Urban women under age 35 marry for the first time one year later than rural women. Regional differences in age at marriage arc small, although recent cohorts of women in the Southern Region are marrying at a slightly earlier age than women of the same age in the Northern and Central Regions. The association between greater education and later age at marriage, witnessed in countries around the world, is also seen among Malawian women. As an example, in the cohort age 25-29 years, women with secondary education have a median age at marriage of 22 compared to age 17 for women without education. Table 5.6 Median age at first marriage Median age at first marriage for women by current age and selected background characteristics, Malawi 1992 Age of woman Women Background age characteristic 20-24 25-29 30-34 35-39 40 44 45-49 20-49 Residence Urban 18.9 18.6 18.2 18.0 18.1 18.3 18,5 Rural 17 5 17.6 17.0 17.9 18.1 18.4 17.6 Region Northern 17.9 17.8 17.2 17.9 17.7 17 7 17.7 Central 17.9 18.0 17.4 17.8 17.9 18 1 17.8 Southern 17.3 17.4 16.9 18.0 18.4 18.7 1%6 Education No education 16.8 17.3 16.6 18.0 18.0 18.5 17,4 Primary 1-4 17.6 17.2 17.1 17.0 18.0 18 4 17.5 Primary 5-8 18.2 18.4 17.8 17.5 18.0 (17.4) 18.1 Secondary+ a 22.4 (20 5) (20.6) * * a Total 17.7 17.7 17.2 17.9 18.1 18.4 17.7 aOmitted because less than 50 percent in the age group were first married by age 20. ( ) Based on 25-49 cases • Based on less than 25 cases 5.4 Postpar tum Amenorrhoea Postpartum amenorrhoea is defined as the timc between the birth of a child and the return of the menstrual cycle. During this time without menses, a woman is normally not ovulating, and is therefore insusceptible to the risk of pregnancy. This period of insusceptibility can be prolonged by breastt~eding. Once her menses returns, a woman is once again susceptible to the risk of becoming pregnant. Table 5.7 shows the percentage of mothers who are postpartum amenorrhoeic at the time of the survey by number of months since birth. More than three-quarters of women remain amenorrhoeic lor at least six months following a birth. After six months, the percentage remaining amenorrhocic drops signilicantly, so that by the time a child is 18-19 months old, only 22 percent of mothers are still insusceptible. Overall, more than one-half of women become susceptible to the risk of pregnancy within one year of the birth of a child. 56 Table 5.7 Postpartum amenorrhoea Percentage of births whose mothers are postpartum amenorrhoeic, by number of months smce birth, and median and mean durazion~, Malawi 1992 Number Months Amenor- of since birth rhoeic births < 2 88.7 171 2-3 89.8 173 4-5 83.0 189 6-7 81.6 156 8-9 64.9 210 10-11 51.8 160 12-13 47.3 178 14-15 42.4 135 16-17 34.1 115 18-19 21.9 161 20-21 19.7 156 22-23 8.9 152 24-25 12.5 147 26-27 1.9 122 28-29 2.5 142 30-31 6.3 147 32-33 2.6 136 34-35 2.1 14 Total 39.7 2800 Median 11.9 Mean 13.5 Prevalence/Incidence Mean 14.1 Table 5.8 shows the median durations ofamenorrhoca by background characteristics of the mother. Mothers age 30 and over are amenorrhoeic 3.2 months longer than younger mothers. Urban mothers have shorter durations of amenorrhoea, reflecting in large part differences in breastfeeding durations and patterns. Regional differentials are negligible. The duration of amenor- rhoea decreases steadily with increasing education, from a length of 15 months among women with no education, to 7 months among women with secondary schooling. It is interesting to note that the differential by education is larger than the educational differential in duration of breast feeding (see Table 9.4). This sug- gests that a diminution in the frequency as well as the overall duration of breastfeeding is associated with higher education levels. 5.5 Termination of Exposure to Pregnancy Later in life, the risk of pregnancy begins to decline with age, typically beginning around age 30. While the onset of infe- cundity is difficult to determine for any individual woman, there are ways ofeslimating it for a population. Table 5.9 presents an indicator of decreasing exposure to the risk of pregnancy for women age 30 and above--the percentage of women who have entered menopause. Here, a woman is considered menopausal if Table 5.8 Median duration of postpartum amenorrhoea Median number of months of postpartum amenorrhoea, by selected background characteristics, Malawi 1992 Amenor- Number Background rhoeic of characteristics (months) births Age (years) <30 11.3 171)5 30+ 14.5 109 Residence Urban 10,0 315 Rural 12,3 2485 Region Northern 11,9 331 CenZral 11.5 1170 Southern 12.3 1299 Education No education 14.6 I410 Primary 1-4 11.5 675 Primary 5-8 9.2 628 Secondary+ 7.4 86 Total 11.9 2800 Note: Medians are based on current status. 57 she is not pregnant or postpartum amenorrhoeic, and she has not had a menstrual period in the six months preceding the survey. As expected, the percent of women who are menopausal (based on this definition) steadily increases with age, from 7 percent of women age 30-34 to nearly a third of women age 48-49. Table 5.9 Menopau~ Percentage of non-pregnant, non- amenorrhoeic married women age 30-49 whose last menstrual period occurred six or more months preceding the survey or who report that they axe menopausal, by age, M',dawi 1992 Number Percentage of Age menopausal women 30-34 7.2 314 35-39 5.2 272 40-41 14.9 113 42-43 16.1 134 44-45 20.3 99 46-47 31.5 84 48 49 32.5 84 Total 13.5 1101 58 CHAPTER 6 FERTILITY PREFERENCES Women and men were asked several questions in order to ascertain their fertility preferences: their desire to have another child, the length of time they wanted to walt before having a child, and the number of children they considered to be ideal. These data make the quantification of fertility preferences possible and, in combination with data on contraceptive use, allow an estimation of the demand for family planning, either to space or to limit births. 6.1 Desire for More Children Table 6.1 presents fertility desires among women and men by the number of living children. Although 58 percent of currently married women would like to have another child, only 19 percent want one within two years. T/tiny-seven percent would prefer to wait two or more years. Nearly a quarter of married women want no more children than they already have. Thus, a majority of women (61 percent) want either to space their next birth or end childbearing altogether (Figure 6.1). This represents the proportion of women who are potentially in need of some method of family planning. Table 6.1 Fertility preferences Percent distribution of currently married women and men by desire for more children, according to number of living children, Malawl 1992 Number of living children I Desire for children 0 1 2 3 4 5 6+ Total FEMALES Have anolher soon 2 58.9 23.4 22,4 12,7 11.6 6,6 3.2 18.5 Have another later 3 12.6 56.5 49.8 47.4 36.8 26.5 17,0 37,3 Have another, undecided when 11.6 3.3 1,8 2,0 1.8 0,2 0.1 2,6 Undecided 6.7 5.4 8.2 11,8 10.0 13,6 11.2 9,4 Wants no more 1.2 5.2 l 1.3 16.0 31.9 42.6 56,0 23,3 Sterilised 0.5 0.6 0.7 2,2 2.5 2,0 3.6 1,7 Declared infecund 8,5 5.4 5.8 7.9 5,4 8.5 8.6 7.1 Missing 0,0 0.2 0.0 0,0 0.0 0.0 0.3 0,1 Total 100.0 100.0 100,0 100.0 100,0 100.0 100.0 100.0 Number of women 344 623 613 530 403 396 584 3492 MALES Have aaaother soon 42.0 18.5 21.9 21.1 19.6 14.2 3.5 17.7 Have another later 45.1 66.2 52.9 42.8 37.5 35.8 27.7 43.3 Have another, undecided when 5.1 0.9 1.7 2.8 0.9 0.0 1.3 1.7 Undecided 4.8 3.0 3.8 5.2 3.6 3.6 3.8 3.9 Wants no more 2.9 6.7 12.5 20.4 29,1 35.2 50.8 25.1 S terilised 0.0 0.1 1.3 1,2 2.9 1.7 1.8 1.4 Declared infecund 0.0 4.6 5,8 6.6 6.5 9,6 11.2 6.9 Missing 0.0 0.0 0.0 0,0 0.0 0.0 0.1 0,0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 104).0 Number of women 75 127 149 121 110 82 202 866 llncludes current pregnancy 2Wants next birth within 2 years 3Wants to delay next birth for 2 or more years 59 Figure 6,1 Fertility Preferences among Currently Married Women 15-49 Undecided 9% Sterilised 2S~ Infeeund 7% Want child, undecided 3% Wants child soon 19% Wants no more 23% i ~n[sch~ldtater 37% Nole: Soon = wilhrn 2 years; la~er = atler 2 years. MDHS 1992 1 ^ ^ Figure 6,2 Fertility Preferences among Currently Married Women by Number of Living Children Percent 0 1 2 8 4 5 Number of Living Children 6+ MDHS 1992 60 As expected, the desire to discontinue childbearing increases sharply with increasing number of l iving children, from 1 percent among married women without a child to 56 percent among women with 6 or more children (Figure 6.2). A similar pattem of changing fertility desires with number of l iving children is also observed among men. Table 6.2 shows similar data according to the age of women and men. The desire to l imit births rises rapidly with age, from 4 percent of married women age 15-19 to 45 percent of those age 45-49. Conversely, the desire to space births declines with age. In other words, the potential need for family planning services is greatest among older women for l imiting childbearing and among younger women for spacing births. The net effect of these two opposing pattems is that the proportion of women falling into one of these two groups is roughly constant at between 50-60 percent. This pattern of a shift in spacing and l imiting desires with increasing age is also observed among men. However, the overall desire to space or l imit is greater among men than women. About one-third of both men and women at older ages (women 45-49, men 50-54) declared themselves infecund. Table 6.2 Fertility preferences by age Percent distribution of currently married women and men by desire for more children, according to age, Malawi 1992 Age of woman Desire for children 15-19 20-24 25-29 30-34 35-39 40-44 45-~9 Total Have another soon 1 26.7 25.7 21.6 15.7 14.6 7.8 7.0 18.5 Have another late~ 56.2 56,2 47.7 31.3 23,8 12.9 4.0 37.3 Have another, undecided when 7.3 2.6 2.9 2.1 1.5 1.0 0.0 2.6 Undecided 5.4 7.5 7.6 15.0 10.6 10.4 9.5 9.4 Wealts no more 4.0 7.6 17.1 28.8 37.5 43.3 45.1 23.3 S teailised 0.0 0.0 1.2 2.7 3.2 3.8 2.4 1.7 Declared infecund 0.4 0.5 2.0 4.3 8.8 20.6 31.3 7.1 Missing 0.0 0.0 0.0 0.0 0.0 0.4 0.6 0.1 Total 100.0 100.0 100.0 1{30.0 100.0 100.0 100.0 100.0 Number 388 743 661 584 455 408 253 3492 Age of man Desire for children 20-24 25-29 30-34 35-39 40~4 45-49 50-54 Total Have another soon I 27.1 23.0 23.5 18.8 12.0 10.5 3.2 17.7 Have another later 2 60.1 60.4 44.7 38.8 41.2 32.8 12.1 43.3 Have another, undecided when 1.6 2.4 1,0 1.3 1,6 2.0 1.7 1,7 Undecided 4.1 1.0 6.8 2.8 6.6 3.3 2.1 3.9 Wants no more 6.9 11.2 22.3 32.9 29.8 35.0 46.1 25.1 Sterilised 0.2 0.0 1.4 1.2 1.9 5.4 0.7 1.4 Declared infecund 0.0 2.0 0.3 4.0 6.8 10.8 33.9 6.9 Missing 0.0 0.0 0.0 0.1 0.0 0.2 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 100 163 147 129 147 83 95 866 XWants next birth within 2 years 2Wants to delay next birth for 2 or more years 61 Table 6.3 presents the percentage of currently married women and men who want no more children by number of living children and selected background characteristics. Women living in urban areas more frequently reported wanting no more children (32 percent) than did women in rural areas (24 percent). This difference becomes more pronounced as the number of living children increases; 80 percent of urban women with 6 or more living children want no more children, compared to 57 percent of rural women. Interestingly, the widening of the urban-rural differential at a higher number of living children is not as marked for men. Regional differences in the desire for no more children are not large, especially at lower parities. At higher parities, however, women from the Central Region more frequently report that they prefer no more children than women from the Northern and Southern Regions. The desire to have no more children is related to the education of the woman; however, only at the level of secondary education is a greater desire to limit births clearly observed. Table 6.3 Desire to limit (stop) childbearing Percentage of cta"rently married women and men who want no more children, by number of living children and selected background characteristics, Malawi 1992 Number of living children ~ Background char~t~ist ic 0 1 2 3 4 5 6+ Total FEMALES Residence Urban (1.2) 5.2 18.1 25.8 36.6 (59.9) 79.6 31.5 Rural 1.7 5.8 11.2 17.2 34.1 42.7 57.1 24.2 Region Northern (1.2) 3.9 10.9 20.7 28.0 (45.2) 61.9 25.5 Central 1.7 5.2 11.0 22.6 41.3 48.4 70.7 29.5 Southern 1.6 6.8 13.1 13.3 30.6 40.9 48.2 21.2 Education No education 3.5 5.7 11.7 18.1 35.8 41.4 54.9 25.7 Primary 14 0.0 7.2 10.9 16.2 30.9 39.3 61.3 22.4 Primary 5-8 0.0 4.3 12.6 16.1 27.2 54.6 66.8 23.6 Secondary+ 0.0" 6.2* 24.4* 45.8* 73.5* 80.7* 95.6* 44.6 Total 1.6 5.8 12.1 18.2 34.4 44.6 59.6 25.0 MALES Residence Urban (4.3) (4.9) (20.3) (17.9) (46.8) (43.5) 58.4 30.7 Rural 2.6 7.2 13.1 22.5 29.3 35.6 51.6 25.8 Total 2.9 6.8 13.9 21.7 31.9 36.9 52.5 26.5 Note: Women and men who have been sterilised are considered to want no more children. qncludes current pregnancy for women ( ) Based on 2.5 J,9 cases * B~ed on less than 25 cases 6.2 Demand for Family Planning Services Women who are currently married and who say either that they do not want any more children or that they want to wait two or more years before having another child, but are not using contraception, are 62 considered to have an unmet need for family planning, t Women who are using family planning methods are said to have a met need for family planning. Women with unmet and met need together constitute the total demand for family planning. Table 6.4 presents data on unmet need, met need and total demand for family planning, according to whether the need is for spacing or limiting births. Over one-third of married women have an unmet need for family planning services, 20 percent for spacing purposes and 17 percent for limiting births. Combined with the 13 percent of married women who are currently using a contraceptive method, the total demand for family planning comprises half the married women in Malawi. Thus, if all women who say they want to space or limit their children were to use methods, the contraceptive prevalence rate could be increased from 13 percent to 50 percent of married women. At present, only about one-quarter of the potential demand for family planning is being met (next-to- last column in Table 6.4). Table 6.4 Need for family planning services Percentage of currently married women with unmet need for family planning, met need for fanfily planning, and the total demand for family planning services, by selected background characteristics, Malawi 1992 Met need for Unmet need for family planning. Total demand for Percentage family planning I (currently ~ing)" family planning of demand Background For For For For For For satis- characteristic spacing limiting Total spacing limiting Total spacing limiting Total fled Total Age 15-19 20.1 6.4 26.5 6.9 0.4 7.3 27.0 6.8 33.8 21.5 388 20-24 27.5 4.6 32.1 10.9 1.1 12.0 38.4 5.7 44.0 27.2 743 25-29 24.2 12.3 36.5 11.3 3.5 14.8 35.5 15.8 51.3 28.8 661 30-34 19.8 17.1 37.0 7.8 8.4 16.2 27.6 25.5 53.2 30.4 584 35-39 18.2 24.0 42.2 5.2 11.2 16.4 23.4 35.3 58.7 28.0 455 40-44 10.6 32.8 43.5 1.2 11.9 13.2 11.9 44.8 56.6 23.3 408 45-49 3.2 36.6 39.8 0.0 6.4 6.4 3.2 43.1 46.2 13.9 253 Resldenee Urban 16.3 19.5 35.8 10.9 11.9 22.9 27.2 31.4 58.6 39.0 411 Rural 20.3 16.1 36.4 6.9 4.8 11.7 27.2 20.9 48.1 24.3 3081 Region Northern 18.6 12.4 31.1 10.6 7.2 17.9 29.3 19.6 48.9 36.5 430 Central 18.2 19.0 37.2 6.6 6.5 13.1 24.7 25.5 50.3 26.0 1402 Southern 21.5 15,4 37.0 7.2 4.5 11.7 28.7 20.0 48.7 24.0 1660 Education No education 19.1 17.4 36.5 5.5 4.5 10.0 24.6 21.9 46.5 21.6 1815 Primary 1-4 21.3 15.7 37.1 6.7 4.4 11.1 28.0 20.2 48.2 23.0 819 Primary 5-8 21.2 15.6 36.8 11.3 6.7 18.0 32.4 22.3 54.8 32.9 750 Secondary+ 11.4 13.6 25.0 16.2 26.8 43.0 27.5 40.5 68.0 63.2 107 Total 19.8 16.5 36.3 7.4 5.7 13.0 27.2 22.2 49.3 26.4 3492 IUnmet need for spacing refers to pregnant women wh~e pregnancy was mistimed, amenorrhoeic women whose last birth was mistimed, and women who are neither pregnant nor ata~norrhoeic and who are not using any method of family planning and say they want to wait two or more years for their next birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrhoeic women whose last child was unwanted, and women who are neither pregnant nor amenorrhoeic and who are not using any method of family planning and who want no more children. Also excluded are menopausal women, defined in Table 5.9. 2Using for spacing refers to women who ate using some method of family planning and who say they want to walt two or mote years for their next child. Using for limiting refers to women who are using and who want no more children. Note that the specific methods used are not taken into aceounL For an exact description of the calculation, see footnote 1, Table 6.4. 63 The overall unmet need for family planning increases with age. As expected, unmet need for spacing purposes is higher among younger women, while unmet need for limiting childbearing is higher among older women. There is almost no difference in the level of unmet need among urban and rural women, although there is a slightly higher unmet need in the Southern and Central Regions than in the Northern Region. Unmet need is lower among women with some secondary education than among other women, even though there is a greater overall demand in this group of women. This is primarily due to the fact that a much larger proportion of secondary educated women are currently using family planning, leading to a larger percent of their demand being satisfied (i.e., met need), as shown in Figure 6.3. Figure 6,3 Percentage of Women with Unmet Need and Met Need for Family Planning Services by Background Characteristics RESIDENCE Urban Rural REGION Northern Central Southern MATERNAL EDUCATION No Education Primary 1-4 Primary 5-8 Secondary + 10 2O 3O 40 50 Percent 60 70 80 90 100 Note: Unmet need plus met need equals total demand (need) for contraceplion MDHS 1992 6.3 Ideal Family Size Information on what women and men feel is the ideal family size was elicited through two questions. Respondents who had no children were asked, "If you could choose exactly the number of children to have in your whole life, how many would that be?" For respondents who had children, the question was rephrased as follows: "If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?" Some respondents, especially those for whom fertility control is an unfamiliar concept, may have had some difficulty in answering this hypothetical question. The data in Table 6.5 indicate that the majority of women and men were able to give a numeric answer to this question; nevertheless, 13 percent of women and 8 percent of men gave a non-numeric answer, such as "it is up to God," "any number" or "do not know." Those who gave numeric responses generally want to have large families. Over one-quarter (29 percent) of all women said they would choose to have six or more children, with an average numeric response of 5.1 children. There is a possibility that some women may report their actual number of children as their ideal number, since they may find it difficult to admit that they would not choose to have so many children if they could start afresh. Indeed, women who have fewer 64 Table 6.5 Ideal and actual number of children Percent distribution of all women and men by ideal number of children and mema ideal number of children for all women and men and for currently married women and men, according to number of living children, Malawi 1992 Number of living children 1 Ideal number of chiidron None 1 2 3 4 5 6+ Total FEMALES 0 0.5 0.1 0.2 0.3 0. l 0.1 0.0 0.2 1 1.7 2.5 0.6 0.3 0.0 0.3 0.3 1.0 2 11.5 6.0 5.8 4.1 4.5 3.2 2.2 6.0 3 14.9 12.9 8.9 8.4 5.3 3.7 3.0 9.2 4 25.2 28.7 28.8 20.6 16.2 14.6 10.4 21.8 5 21.7 21.8 22.3 22.6 15.6 18.8 12.3 19.7 6+ 13.7 17.5 22.3 31.2 42.6 41.7 51.5 28.5 Non-numeric response 10.8 10.6 11.1 12.5 15.6 17.5 20.3 13.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1086 829 718 607 474 465 670 4849 Mean ideal number 4.2 4.5 4.8 5.2 5.6 6.0 6.4 5.1 Number of women 969 741 638 531 400 384 534 4197 Mean for married women 4,6 4.5 4.8 5.2 5.6 6.0 6.4 5.3 Number of ram-led women 313 552 541 462 334 323 461 2985 MALES 0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1 1.2 2.0 1.0 0.0 0.0 0.0 0.0 0.7 2 9.9 6.0 4.3 0.9 4.9 2.9 3.2 5.3 3 20.9 14.2 8.2 10.5 5.1 5.6 4.3 11.3 4 30.7 35.9 35.3 31.3 30.2 15.4 10.4 27.2 5 17.5 19.9 15.1 19.5 10.1 18.2 4.0 14.6 6+ 15.1 15.3 28.6 31.7 40.1 47.8 63.9 32.7 Non-numeric response 4.7 6.6 7.6 6.0 9.5 10.1 14.1 8.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 293 159 159 128 115 89 208 1151 Mean ideal number 4.1 4.3 4.9 5.0 5.3 6.2 7.3 5.2 Number of men 279 149 147 120 104 80 178 1057 Mean for married men 4.3 4.4 4.9 5.0 5.3 6.2 7.2 5.4 Number of married men 72 119 141 113 99 75 173 791 Note: The means exclude respondents who gave non-numeric responses. llncludes current pregnancy for women children do report smaller ideal family sizes than women with more children. For example, the average ideal family size is 4.5 among women with one child, compared to 6.4 among women with six or more children. Many of the women with fewer children are young and, to the extent that their fertility preferences do not increase over time and that they can realise their ideal number of children, fertility in Malawi may decline. The data show evidence of unwanted fertility; for example, more than one-quarter of the women with six or more children said that they would ideally like to have had fewer than 6 children. 65 Interviewed men reponed very similar family size ideals as women, with the ideal number ol children only slightly higher (5.2) than among women (5,1) Table 6.6 shows the mean ideal number of children for all women and men by age according to selected background characteristics. The mean ideal family size increases with age of the respondent from 4.3 to 6.4 children, from the youngest age group of women (15-19) and men (20-24) to the oldest age group of women (45-49) and men (50-54). At every age, rural womcn and men have higher family-size norms than urban women and men. Very little regional variation in ideal family size is observed. However, ideal family size is negatively related to education level attained; as the education of a woman increases, her desired family size decreases. Table 6.6 Mean ideal number of children by background characteristics Mean ideal number o[ children for all women and men, by age and selected background characteristics, Malawi 1992 Age of woman Background characteristic 15 19 20-24 25 29 30-34 35 39 40-44 45 49 Total Residence Urban 4.1 3.9 4.4 5.1 5 3 5.9 (5 5) d, fi Rural 4.3 4.5 5 0 5.6 5 7 6.3 6 5 5.1 Region Northern 4.3 4.6 5.0 5.7 5.8 6.4 6.8 5.1 Central 4.0 4.2 5.2 5.7 5.6 5 9 6.3 5.1) Southern 4.5 4.4 4.7 5.5 5.7 6 5 6.5 5 1 Education No education 4.5 4.6 5 0 5.8 5.5 6.5 6.4 5 4 Primary 1-4 4.4 4.5 5.1 5.8 6.[ 5.8 6.8 5.[ Primary 5-8 4.2 4.3 4.9 5.1 5.8 6.4 6 3 4.7 Secondary+ 4.1 3.5 4.1 (4.1) (4.5) * * 4 0 Total 4.3 4.4 4.9 5.6 5.6 6.3 6.4 5 1 Age of man Background characteristic 20-24 25 29 30-34 35 39 40 44 45 49 50 54 Total Residence Urban 3.9 3.9 4.3 (5.2) (5.2) (5 2) (5.9) -1 5 Rural 4 4 4.5 4.9 5.9 6.3 6.9 6.5 5 3 Total 4.3 4.4 4.8 5.8 6.2 6.6 6.4 5.2 ( ) Based on 25-49 cases * Based on less than 25 cases 6.4 Wanted and Unwanted Fertility There are two ways of estimating levels of unwanted fertility from MDHS data. One is based on responses to a question on whether each birth in the five years before the survey was planned (wanted then), mistimed (wanted, but at a later time), or unwanted (wanted no more children), These data arc likely to result in underestimates of unplanned childbearing, since women may rationalisc unplanned births and declare them as planned once they are born. The other method of measuring unwanted [i~rtility utilises the data on ideal 66 family size to calculate "wanted" fertility rates. These too may suffer from underestimation to the extent that women are reluctant to report an ideal family size lower than their actual family size. Table 6.7 shows the percent distribution of births in the five years before the survey (including current pregnancies) by whether a birth was wanted then, wanted later, or not wanted. Fourteen percent of recent births were reported to be unwanted and 27 percent were reported as mistimed (wanted later). The percentage of births that was mistimed or unwanted goes up with birth order, from 31 percent of first births to 52 percent of 6th and higher births. Similarly, a much larger proportion of births to older women are unwanted than are those to younger women. While less than 10 percent of births to women under age 25 are unwanted, one-third of births to women 40 and older are unwanted. Table 6.7 Wanted and unwanted births Percent distribution of births in the five years preceding the survey (including current pregnancies) by whether birth was wanted and when, according to birth order and mother's age. Malawi 1992 Planning status of birth Birth order Wanted Number and mother's Wanted Wanted no of age then later more Missing Total births Birth order 1 68.1 21.0 9.8 1.1 100.0 949 2 66.4 25.3 7.5 0.8 100.0 811 3 62.1 28.6 9.1 0.2 100.0 708 4 59.3 29.6 10.4 0.7 100.0 640 5 58.0 28.3 13.3 0.4 100.0 537 6+ 47.6 28.0 24.1 0.4 100.0 1523 Age of mother at birth <20 62.4 26.7 9.7 1.2 100.0 943 20-24 63.4 26.4 9.6 0.6 100.0 1372 25-29 61.7 26.2 11.5 0.6 100.0 1109 30-34 53.7 30.5 15.6 0.2 100.0 792 35-39 52.9 25.6 21.3 0.2 100.0 570 40-44 46.4 20.4 32.8 0.5 1(30.0 303 45-49 39.4 26.3 34.4 0.0 100.0 79 Total 58.8 26.6 14.0 0.6 100.0 5168 Note: Birth order includes current pregnancy. Table 6.8 presents wanted fertility rates. The wanted fertility rate is calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. (Note: Women who did not report a numeric ideal family size were assumed to want all their births.) This rate represents the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been prevented. A comparison of the total wanted fertility rate and the actual total fertility rate suggests the potential demographic impact of the elimination of unwanted births. 67 The wanted total fertility rate was 5.7 for Malawi as a whole, one child lower than the actual total fertility rate. Moreover, this difference of one child between the wanted and actual total fertility rates is uniformly exhibited across all population subgroups. Table 6.8 Wmated fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by selected background characteristics, Malawi 1992 Total wanted Total Background f~r tillty feztility characteristic rate rate Residence Urbma 4.38 5.51 Rural 5.92 6.88 Region Northern 5.76 6.74 Centlal 6.39 7.44 Southern 5.23 6.17 Education No education 6.19 7.16 Primary 1-4 5.75 6.70 Primary 5-8 5.12 6.17 Secondary+ 3.26 4.37 Total 5.74 6.73 Note: Rates are based on births to women 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 3.2. 68 CHAPTER 7 CHILDHOOD MORTALITY One of the major objectives of the survey was to estimate rates of childhood mortality. Information on past and current levels of childhood mortality is an integral part of an overall demographic assessment and crucial to the evaluation of health and population programmes. Furthemaore, through estimation of mortality by age group and across characteristics of households and women, this chapter alms to identify sectors of the population that are at high risk of poor health and survival. 7.1 Data Quality and Mortality Estimation The childhood mortality rates presented here were calculated using information collected in the birth histories of female respondents. For each child who died, the respondent was asked to provide an age at death. If the child died in the first month after birth, the age at death data was recorded in units of days. If the death was before the second birthday, the age at death was collected in units of months, in order to minimise age heaping at "1 year." If the death occurred at 24 months of age or later, the age at death was recorded in years. From these data, period-specific, age-specific probabilities of mortality were estimated using a conventional life-table approach. The rates, actually true probabilities, presented in this report are: Neonatal mortality rate--the probability of dying within the first month of life Post-neonatal mortality rate--the difference between infant and neonatal mortality Infant mortality rote the probability of dying before the first birthday Child mortality rate---the probability of dying between the first and fifth birthday Under-five mortality rate--the probability of dying between birth and the fifth birthday. The term childhood mortality is used here simply to speak generally of mortality during childhood and carries no specific meaning regarding age period of risk. Unreported birth dates are a potential problem in this type of data, hut were uncommon in the MDHS; only 0.1 percent of births lacked a year of birth. A further 3.7 percent of births had a year of birth but lacked a month of birth, thus requiring imputation of a birth date within a fairly short 12-month range. Furthermore, only 0.2 percent of deaths recorded in the birth histories lacked an age at death. In the case of missing age at death a "hot deck" procedure was used to impute this information. ~ Misreporting of age at death will bias estimates of the age pattem of mortality if the net result of the misreporting is the transference of deaths between age segments for which rates are calculated. For example, an overestimate of child mortality (1-4 years) and an underestimate of infant mortality may result if children dying during the first year of life (say, month 10 or 11) are reported as having died at 12 months of age or 1 year. This phenomenon of reporting preferred digits is called "heaping." There was surprisingly little heaping on particular months of death in the MDHS and, due to strong emphasis during training and field supervision, very few deaths were reported to have occurred at age one year (see Appendix C, Table C.6), making any adjustment in infant and child mortality rates unnecessary. Underreporting of childhood deaths is a potentially serious problem in data of this type and is thought most likely to occur for deaths during the first few days after birth. If early neonatal deaths are selectively IThis procedure assigns an age at death equal to that of the last death in the data file of the same birth order. 69 underreported, the result would be an abnormally low ratio of deaths under seven days to all neonatal deaths. Moreover, if such underreporting is more common for deaths occurring in less recent periods or is related to the sex of the child, then this ratio would also be differentially affected. It should, however, be borne in mind that this type of internal consistency check will be insensitive to all but large- scale underreporting. Table 7.1 shows the ratio of deaths in the first week after birth (0-6 days) to all neonatal deaths (0-30 days) by sex of the child and calendar period of death. There is only minor variation in the ratio among the three time periods and between males and females. The ratios for females tend to be more variable--still, the lowest (0.63) and highest (0.72) ratios are very similar and are at an acceptable overall level. This suggests that gross under- reporting of early neonatal deaths is not a problem in these data, and that selective underreporting, if it has occurred, is minor. Table 7.1 Neonatal deaths Ratio of deaths in the first week (0-6 days) to all neonatal deaths (0-30 days), by sex of child. Malawi 1992 Years before survey Sex of child 0-4 5-9 10-14 Male 0.67 0.66 0.68 Female 0.72 0.63 0.65 Both sexes 0.70 0.64 0.67 These check

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