Turkey - Demographic and Health Survey - 1999

Publication date: 1999

Turkey World Summit for Children Indicators: Turkey 1998 Value BASIC INDICATORS Childhood mortality Childhood undernutrition Clean water supply Sanitary excreta disposal Basic education Children in especially difficult situations Infant mortality rate Under-five mortality rate Percent stunted Percent wasted Percent underweight Percent of boaseholds within 15 minutes of a safe water supply I Percent of households with flush toilets or VIP latrines Percent of women 15-49 with completed primary education Percent of men 15-49 with completed primary education Percent of gir|s 6-12 attending school' Percent of boys 6-12 attending school Percent of women 15-49 who are literate Percent of children who are orphans (both parents dead) Percent of children who do not live with their natural mother Percent of children who live in single adult households 42.7 per 1,000 52.1 per 1,000 16,0 1,9 8,3 74,4 87.7 78.3 94.5 69.7 78.7 84.5 0A 3.5 2.1 SUPPORTING INDICATORS Women's Health Birth spacing Safe motherhood Family planning Nutrition Maternal nutrition Low birth weight Breast feeding Child Health Vaccinations Diarrhoea control Percent of births within 24 months of a previous birth Percent of blrths with medical antenatal care Percent &births with antenatal care in first trimester Percent of births with medical assistance at delivery Percent of births in a medical facility Percent of births at high risk Contraceptive prevalence rate (any method, currently married women) Percent of currently married women with an unmet demand for family planning Percent of currently married women with an unmet need for family planning to avoid a high-risk birth Percent of mothers with low BMI • Percent of births at low birth weight (of those reporting numeric weight) Percent of children under 4 months who are exclusively breastfed Percent of children whose mothers received tetanus toxoid vaccination during pregnancy Percent of children 12-23 months with measles vaccination Percent of children 12-23 months fully vaccinated Percent of children with diarrhoea in preceding 2 weeks who received oral rehydratien therapy (sugar-salt-water solution) 262 67,5 46.4 80.6 72.5 40.2 63.9 lO.I 7.7 2.5 14.4 9.2 43,8 78.5 45.7 26.9 Piped, well, and bottled water Turkish Demographic and Health Survey 1998 Hacettepe University, Institute of Population Studies Ankara, Turkey Macro International Inc. Calverton, Maryland, USA General Directorate of Mother and Child Health/Family Planning, Ministry of Health, Ankara, Turkey with the contributions of United Nations Population Fund, New York, USA U.S. Agency for International Development, Washington DC, USA October 1999 This report summarises the findings of the 1998 Turkish Demographic and Health Survey (TDHS-98) conducted by the Institute of Population Studies, Hacettepe University (HIPS) in collaboration with the General Directorate of Mother and Child Health/Family Planning, Ministry of Health. Technical and financial support for the survey were provided both by the United Nations Population Fund (UNFPA) and Macro International Inc. through its MEASURE/DHS+ project, a project sponsored primarily by the United States Agency for Interuational Development (USAID) to carry out population and health surveys in developing countries. ÷ The TDHS-98 is part of the Worldwide Demographic and Health Surveys (MEASURE/DHS+) program, which is designed to provide decision-makers in survey countries with a database and analyses useful for informed policy choices, to expand the international population and health database, to advance survey methodology, and to develop in participating countries the skills and resources necessary to conduct high-quality demographic and health surveys. The TDHS-98 survey is the most recent in a series of demographic surveys carried out in Turkey by bliPS to provide iuformation on fertility and child mortality levels; family planning awareness, approval and use; and basic indicators of maternal and child health. Additional information on the TDHS-98 can be obtained from Hacettepe University, Institute of Population Studies, 06100 Ankara, Turkey (Telephone: 312-3107906; Fax: 312-3118141; E-mail: hips@haeettepe.edu,tr). Information on the worldwide MEASUR/DHS+ program may be obtained by writing: MEASURE/DHS+, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA (Telephone: 301-572-0200; Fax: 301 - 572-0999). CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Summary of Findings . i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Map of Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii CHAPTER I INTRODUCTION Sunday I3ner and Banu Akadh ErgSgmen . 1 1.1 Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Administrative Divisions and Political Organisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.4 Social and Cultural Features . 2 1.5 Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.6 Regional Breakdown . 4 1.7 Population . : . 5 1.8 Population and Family Planning Policies and Programs . 6 1.9 Health Priorities and Programs . : . 6 1.10 Health Care System in Turkey . 7 1.11 Objectives and Organisation of the Survey .; . 7 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS /smet Kog and Attila Hanclo~lu . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2,1 Population by Age and Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.2 Household Composition . 16 2.3 Fosterhood and Orphanhood . 16 2,4 Educational Level of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 2.5 School Enrollment,.= . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.6 Housing Characteristics . 19 2.7 Household Durable Goods . 22 2.8 Background Characteristics . 23 2.9 Respondents' Level of Education by Background Characteristics . 24 2.10 Reasons for Leaving School . 25 2,11 Differentials in Characteristics of Couples . 27 2.12 Exposure to Print Media . 28 2.13 Employment and Occupation . . . 29 2.14 Decision on Use of Earnings . 31 2.15 Child Care While Working . 31 111 CHAPTER 3 3.1 3.2 3.3 3.4 3.5 Page FERTILITY Aykut Toros . 35 Current Fertility . 35 Children Ever Born and Living . 40 Birth Intervals . 41 Age at First Birth . 42 Teenage Pregnancy and Motherhood . . 43 CHAPTER 4 FERTILITY REGULATION Turgay lJnalan and lsmet Ko~; . £ . 45 4.1 Knowledge of Family Planning Methods . 45 4.2 Ever Use of Family Planning Methods . , . 46 4.3 Current Use of Contraceptive Method . .~. . 47 4.4 Trend in Contraceptive Use . 51 4.5 Number of Children at First Use of Contraception . 52 4.6 Knowledge of the Fertile Period . ,. 53 4.7 Timing of Female Sterilisation . £ . 55 428 Sources for Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 4.9 Discontinuation of Contraceptive Use . 57 4.10 Future Use of Family Planning . 59 4.11 Exposure to Family Planning Messages in the Electronic Media . . 61 4.12 Acceptability of Use of Electronic Media to Disseminate Family Planning Messages . 63 4.13 Exposure to Family Planning Messages in the Print Media . 63 4.14 Attitudes of Couples Toward Family Planning . 65 CHAPTER 5 5.1 5.2 5.3 5.4 5.5 5.6 ABORTIONS AND STILLBIRTHS Banu Akadlt Ergiigmen and Turgay Unalan . 69 Life-time Experience of Women . 69 Current Levels and Trends . 71 Contraceptive Use Before and After Induced Abortions . 72 Reasons for Induced Abortion . 73 Timing of Induced Abortions . 74 Provider . 75 CHAPTER 6 6.1 6.2 6.3 6.4 6.5 OTHER I~ROXIMATE DETERMINANTS OF FERTILITY Banu Akadh Erg~$:men and lsmet Ko~ . 77 Current Marital Status . 77 Age at First Marriage . 78 Age At First Sexual Intercourse . 81 Postpartum Amenorrhoea, Postpartum Abstinence, and Insusceptibility . 82 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 IV CHAPTER 7 7.1 7.2 7.3 7.4 Page FERT IL ITY PREFERENCES Turgay 0nalan and El i f Kur tu lu , . 87 Desire for More Children .~ . 87 Need for Family Planning Services . 91 Ideal and Actual Number of Children . 2 . 92 Fertility Planning . 95 "CHAPTER8 8.1 8.2 8.3 8.4 8.5 INFANT AND CHILD MORTAL ITY Attila Hanclo~lu . ~ . 97 Definitions of Infant and Child Mortalib, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Assessment of Data Quality . .= . 97 Levels and Trends in Infant and Child Mortality . 98 Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 O0 High-risk Fertility Behaviour . 102 CHAPTER9 9.1 9.2 9.3 MATERNAL AND CHILD HEALTH Banu Akadh ErgSsmen . 105 Antenatal Care and Delivery Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Immunisation of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Prevalence and Treatment o f Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 CHAPTER 10 INFANT FEEDING, MATERNAL AND CHILDHOOD NUTRIT ION Ergi i l Tun~bilek, E l i f Kurtulu~, and Attila Hanclo~lu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 10.1 Breastfeeding and Supplementation . 123 10.2 Nutritional Status . 128 10.3 Maternal Nutrition . 132 CHAPTER 11 KNOWLEDGE OF A IDS AND SEXUALLY TRANSMITTED D ISEASES Atti la Hanclo~iu and A. Sinan Ti i rky i lmaz . 135 11.1 Source of Information about AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 11.2 Knowledge o f Ways to Prevent AIDS . 138 11.3 Perception of Risk of AIDS . . . . . : . 141 REFERENCES . i . . 145 APPENDIX A PERSONNEL INVOLVED IN THE TURKISH DEMOGRAPHIC AND HEALTH SURVEY . 147 V APPENDIX B Page SURVEY DESIGN A. Sinan T i i rky l lmaz and Alfredo Al iaga . 151 B.1 Sample Design and Implementation . 153 B.2 Sample Frame . 154 B.3 Stratification . 154 B:4 Sample Allocation . 155 B.5 Sample Selection . 156 B.6 Questionnaire Development and Pre-Test . 157 B.7 Data Collection Activities . 160 B.8 Data Processing and Analysis . 161 B.9 Calculation of Sample Weights . 161 APPENDIX C ESTIMATES OF SAMPLING ERRORS Alfredo Aiiaga and A. SinanTurkyllmaz . 169 APPENDIX D DATA QUALITY TABLES . 183 APPENDIX E QUESTIONNAIRES . 191 V1 Table 1. I Table 2.1 Table 2,2 Table 2.3 Table 2A Table 2.5 Table 2,6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 2.1 t Table 2.12 Table 2,13 Table 2.14 Table 2.I5 Table 2.16 Table 2.17 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 4.1 Table 4.2 Table 4,3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.1 l Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 4.19 TABLES Page Results of the household and individual interviews . 11 Household popu la t ion by age, residence and sex . 14 Population by age from selected sources . 15 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Fosterhood and orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Educational level of the household population . 18 School enrolment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Household durable goods . 22 Background characteristics of respondents . 23 Level of education ._; . 25 Reasons for leaving school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Differential characteristics between spouses. . 27 Exposure to print media. . 28 Employment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Decision on use of women's earnings. . 32 Child care while working . 33 Currem fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Fertility by background characteristics . 37 Age-specific fertility rates . 38 Fertility by marital duration . 39 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Birth intervals . 41 Age at first birth, . 42 Median age at first birth by background character i s t i cs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Teenage pregnancy and motherhood . 44 Knowledge of contraceptive methods and source for methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Couples' knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Ever use Of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Current use of contraception . 48 Current use &contraception by background characteristics . 50 Trends in current use of contraception. . 52 Trends ill current use &contraception by residence and region . 52 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Knowledge of fertile period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Timing of sterilisation . 55 Source of supply for modern contraceptive methods . 56 Source of supply for selected modem methods, 1993 and 1998 . 57 Contraceptive discontinuation rates . . . . . . . . . . . . . . . . 58 Reasons for discontinuation of contraception . 58 Future use of contraception . .'. . . . . . . . . . . . . 59 Reasons for not using contraception . 60 Preferred method of contraception for future use . 61 Heard about family planning on radio and television . 62 Acceptability of family planning messages on radio and television. . 63 vn Table 4.20 Table 4.21 Table 4.22 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 Table 7.4 Table 7.5 Table 7.6 Table 7.7 Table 7.8 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 9.9 Table 9.10 Table 9.11 Table 9.12 Table 9.13 Page Heard about family planning through print media . 64 Wives' perceptions of couple's attitude toward family planning . 65 Attitudes of couples toward family planning . . 67 Number o f abortions and stillbirths . 70 Induced abortions by background characteristics . 70 Abortions and stillbirths per 100 pregnancies . : . 71 Trend in induced abortions . 71 Method used before abortion . 72 Method used after abortion . . . ; . ,. 73 Reasons for induced abortion . 74 Timing of induced abortions . 75 Abortion providers . 75 Current marital status . ~ . 77 Age at first marriage . 79 Median age at first marriage . 80 Age at first sexual intercourse . : . 82 Median age at first intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Postpartum amenorrhoea, abstinence and insusceptibility . ; . 83 Median duration of postpartum insusceptibility by background characteristics . 85 Termination of exposure to risk &pregnancy . . 85 Fertility preference by number of living children . 88 Fertility preference by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Desire to limit (stop) childbearing . 90 Need for family planning services . 91 Ideal and actual number of children . 93 Mean ideal number &children by background characteristics . 94 Fertility planning status . 95 Wanted fertility rates . 96 Infant and child mortality . 99 Neonatal, post-neonatal, infant, child, and under-five mortality by socioeconomic characteristics . 101 Neonatal, post-neonatal, infant, child, and under-five mortality by biodemographic characteristics . 102 High-risk fertility behaviour . 103 Antenatal care . 106 Number of antenatal care visits and stage of pregnancy . 108 Tetanus toxoid vaccinations . 109 Place of delivery . 110 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Delivery characteristics: caesarean section, birth weight and size . 113 Delivery complications . 114 Vaccinations by source of information . 115 Vaccinations by background characteristics . 116 Vaccinations in first year o f life by current age . 117 Prevalence of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Treatment o f diarrhoea ., . 120 Feeding practices during diarrhoea . 121 viii Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 10.6 Table 10.7 Table 11.1.1 Table 11.1.2 Table 11.2 Table 11.3.1 Table 11.3.2 Table 11.4.1 Table 11.4.2 Table B.1 Table B.2 Table B.3.t Table B.3.2 Table B.4 Table B.5 Table B.6 Table C.I Table C.2 Table C.3 Table C.4 Table C.5 Table C.6 Table C.7 Table C.8 Table C.9 Table D. 1 Table D.2 Table D.3 Table D.4 Table D.5 Table C.6 Page Initial breastfeeding . 124 Breastfeeding status . 125 Median duration and frequency o f breastfeeding . 126 Types of food received by children in the preceding 24 hours . 127 Nutritional status of children by background characteristics . 129 Anthropometric indicators of maternal nutritional status . 130 Nutritional status of mothers by background characteristics . 134 Knowledge of AIDS and sources of AIDS information: women . 136 Knowledge of AIDS and sources of AIDS information: husbands . 137 Knowledge of AIDS and sexually transmitted diseases (STDs) . 138 Knowledge of ways to avoid HIV/A1DS: women . 139 Knowledge of ways to avoid HIV/AIDS: husbands . 140 Knowledge o f AIDS-related issues: women . 142 Knowledge of AIDS-related issues: husbands . 143 Allocation o f sample households . 155 Distribution of sample clusters . 156 Design weights and nonresponse factors: women sample . 163 Design weights and nonresponse ractors: husbands sample . 164 Final sample weights . 165 Sample implementation: women . 167 Sample implementation: husbands . 168 List of selected variables for sampling errors . 173 Sampling errors - National sample . 174 Sampling errors - Urban areas . 175 Sampling errors- Rural areas . 176 Sampling errors - West region . 177 Sampling errors - South region . 178 Sampling errors - Central region . 179 Sampling er rors - North region . 180 Sampling errors - East region . 181 Household age dlstribution. . 185 Age distribution of eligible and interviewed women . 186 Completeness of reporting . 186 Births by calendar years . 187 Reporting &age at death in days . 188 Reporting of age at death in months . 189 IX FIGURES Figure 2.1 Figure 2.2 Figure 2.3 Figure 3.1 Figure 3.2 Figure 4. l Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 6.1 Figure 6.2 Figure 6.3 Figure 7.1 Figure 7.2 Figure 8.1 Figure 9.1 Figure 9.2 Figure 9.3 Figure 9.4 Figure 10.1 Page Population Pyramid . 14 Number of Persons Reported at Each Age by Sex . 15 School Enrolment by Age and Place of Residence . 20 Age-Specific Fertility Rates by Urban-Rural Residence . 36 Age-Specific Fertility Rates during the Last 20 Years . 39 Current Use of Family Planning Methods, Turkey 1993 and 1998 . 49 Current Use of Family Planning by Region and Method . 5 l Knowledge of Fertile Period among All Women . 54 Source of Supply of Modern Contraceptive Methods . 56 Ever Use of Contraception among Non-Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Attitudes toward Family Planning as Reported by Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Marital Status of Women Age 15-49 . 78 Median Age at First Marriage among Women 25-49 and Men 25-64 . 81 Percentage of Births Whose Mothers are Amenorrhoeic, Abstaining, or Insuscept ib le . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Fertility Preferences of Currently Married Women, Age 15-49 . 87 Under-Five Mortality by Selected Demographic Characteristics . 85 Trends in Infant and Child Mortality . 100 Source of Antenatal Care by Maternal Age and Birth Order . 106 Antenatal Care by Region and Residence . 107 Place of Delivery by Maternal Age and Birth Order . 111 Percentage of Children Under Five Years with Diarrhoea, by Age, Sex, Birth Order and Residence . 119 Growth of Children Under Five Years, Mean Z-scores by Age in Months . 131 XI FOREWORD It is a great pleasure for me to introduce the main findings of the 1998 Turkish Demographic and Health Survey. The findings presented in this volume highlight the major changes that are taking place in the Turkish demographic and health situation. The population of Turkey is going through a structural transition. Mortality rates are going down. Advancements in infant mortality are impressive. Fertility is becoming a matter of choice rather than fate. Replacement levels of fertility are within sight. Significant changes are taking place in age distribution. The proportion of the population living in urban areas is approaching the level observed in industrial societies. These factors, which are both a cause as well as consequence of each other, illustrate the shifting state of Turkish demographic forces. In view of the dynamic nature of the demographic situation, there is a continuing need for good demographic data in Turkey. "Valid, reliable, timely, culturally relevant and internationally comparable data form the basis for policy and program development, implementation monitoring and evaluation" writes the ICPD Programme of Action adopted at the International Conference on Population and Development in I994. Good governance is built upon good data. Within this context, data collected through the World Fertility Survey (WFS) and Demographic and Health Survey (DHS) programs have proven their merit globally. Hacettepe Institute of Population Studies (HIPS) is one of the first academic institutions to collect survey data in the form defined by the WFS-DHS heritage. In fact, HIPS has been contributing to this heritage since its 1968 survey, and preparatory international pilot studies for WFS in the mid-1970s. In the 30 years since 1968, HIPS has successfully carried out six nationwide surveys at regular five-year intervals. The 1998 Turkey D/IS is the seventh in its series, I believe that there are not many examples of a similar survey series in the world. The 1998 Turkish Demographic and Health Survey (TDHS-98) was conducted through an agreement with Macro International Inc. under the auspices of a the MEASRE DHS+ project supported by the United States Agency for International Development. The TDHS-98 is the second demographic survey carried out in collaboration with Macro International Inc. Contributions of the United Nations Population Fund also were critical in realisation of the survey in its present scope. Without the UNFPA contribution, the scope of the survey would have been much more limited. The TDHS-98 findings are crucial in monitoring trends in demographic and health variables and in understanding the factors that contribute to differentials in fertility and contraceptive use among various population subgroups. The data also are important for understanding the factors that influence the health and survival of infants and young children. In addition, the TDHS-98 provides a wealth of information for husbands and never-married women. Beyond providing insights into population and health issues in Turkey, it is hoped that the TDHS-98 will also lead to an improved global understanding of population and health problems, as one of more than 80 surveys implemented and sponsored by the Demographic and Health Surveys Program. This TDHS-98 could have been realised only with the industrious contributions of many individuals. I would like to express my appreciation to the HIPS staff for their devotion and sincere efforts in accomplishing the planned activities on time and to Dr. Banu Ergfgmen and Dr. Edilberto Loaiza for preparing this presentation of the survey findings. I would like to thank Dr. Ann Way who had a large part at the inception of the project as well as at the finalization of the main report. Dr. Pinar Senlet, USAID mission in Turkey, tactfully paved the way through difficulties. I also would like to acknowledge the contributions of Dr. Mona Kaidbey and other UNFPA staff through their representative, Dr, Alain P. Mouchiroud. The Population Sector of the State Planning Organisation through her able director Dr Samira Yener was critically instrumental in getting the smwey started. I thank them all. My Xln thanks are also due to the Steering Committee Members for their valuable contributions and to the State Institute of Statistics for their assistance in sample selection. I would like to express my gratitude to Prof. Dr. Siileyman Sa~lam, the Rector of Hacettepe University, for his continuous encouragement and support during all phases of the survey. Finally, my special thanks go to Dr. Rifat K6se and to his dedicated staff at the General Directorate of Mother and Child Health/Family Planning in the Ministry of Health. Their support was indeed crucial and is a good example of a cooperation between a governmental body and an academic institution. Altogether it was a tough task to accomplish, although it was a pleasant enterprise for those who did it. Prof. Dr. Aykut Toros Director Institute of Population Studies Hacettepe University XLV SUMMARY OF FINDINGS The 1998 Turkish Demographic and Health Survey (TDHS-98) is a nationally representative sample survey designed to provide information on fertility levels and trends, infant and child mortality, family planning, and maternal and child health. Survey results are presented at the national level, by urban and rural residence and for each of the five regions in the country. The survey was fielded between August and November 1998. Hacettepe University Institute of Population Studies (HIPS) carried out the TDHS-98 in collaboration with the General Directorate of Mother and Child Health and Family Planning, Ministry of Health. Funding for the TDHS-98 was provided both by the U.S. Agency for International Development through the MEASURE/DHS+ program and United Nations Population Fund. Interviews were carried out in 8,059 households, with 8,576 women, and with 1,971 husbands. All women at ages 15-49 who were present in the household on the night before the interview or who generally live in that household were eligible for the survey. In half of the selected households for women interview, husbands (of currently married eligible women), who were present in the household on the night before the interview or who generally live in that particular household were eligible husbands for the survey. Survey results indicate that if Turkish women maintain current fertility rates during their reproductive years, they can expect to have an average of 2.6 children by the end of their reproductive years. The highest fertility rate is observed for the age group 20-24. There are marked regional differences in fertility rates, ranging from 4.2 children per woman in the East to 2.0 children per woman in the West. Fertility also varies widely by urban-rural residence and by education level. A woman living in rural areas will have ahnost one child more than a woman living in an urban area. However, when compared with evidence from previous surveys it is worth noting that the urban/rural gap appears to be closing. Women who have no education have almost one child more than women who have a primary-level education and ahnost 2 children more than women with secondary-level education. The first requirement of success in family planning is the knowledge of family plauning methods. Knowledge of modern method is almost universal among Turkish women. The IUD and pill are the most widely known family planning methods among women and husbands followed by the condom and female sterilisation. Eighty-four percent of currently married women have used a method sometime in their life. Thirty-nine percent of currently married women report ever using the IUD. Overall, 64 percent of currently married women are currently using a method. The majority of these women are modern method users (38 percent), but more than one fourth use traditional methods (26 percent). The IUD is the most commonly used modern method (20 percent), followed by the condom (8 percent) and the pill (4 percent). Regional differences are substantial. The level of current use is 42 percent in the East, 71 percent in the West and more than 60 percent in the other three regions. A basic knowledge of reproductive physiology is necessary, especially in the use of coitus-related methods. However, only 18percentofal lwomenknowthecorrectt imeofovulat ion. lnforlnation on the sources of methods is important for planning the services. The majority of modern method users (56 percent) obtain the methods from public sector. Health centres are the major public sector suppliers (23 percent) and pharmacies are the major private sector suppliers (25 percent). The discontinuation rate of the IUD is the lowest among all methods. Information on the intentions of current non-users was also collected for the estimation of future demand. Of this group, 44 percent do not intend to use any method in the future whereas half of the currently married women who are not using any XV contraception have the intention to use in future. Of the latter women, more than one third report that their method of choice will be the IUD. During the five year period before the survey, almost one in four pregnancies terminated in other than a live birth. Only about 2 out of every 100 pregnancies ended in a stillbirth and of the 23 abortions per 100 pregnancies 15 were induced. More than one fourth of ever-married women reported ever having had an induced abortion during their reproductive lives. However, among the women who had had an induced abortion, around half had had only one induced abortion. Women living in the East region and in the rural settlements are the least likely to have ever had an induced abortion. There is little variation by education in the proportion of ever-married women who have had an induced abortion. There is a very important opportunity for family planning counselling alter an abortion. However, the results slmw that this opportunity is not utilised well. In the month after an induced abortion, 32 percent of women did not use any method and 27 percent used withdrawal. The main reason for obtaining an abortion was the desire not to have any more children (62 percent). Overall, 68 percent of abortions took place in the first month of pregnancy, 23 percent in the second month, and 9 percent in the third or later months of pregnancy. Some 74 percent of abortions took place at a private sector; there is variation between regions in terms of the place where induced abortions are performed. The age at first marriage is one of the important determinants of fertility. TDHS-98 results suggest that there is a steady increase in the median age at first marriage, with respect to cohorts. The median age at first marriage has increased from 18.4 years for the 45-49 age group to 20 years for the 25-29 age group. There are differences in the age at marriage across places of residence and regions. Even more pronounced differences are observed by educational level of women. Among women age 25-49, there is a difference ofahnost 6 years in the timing of entry into marriage between those with little or no education and those who completed at least the secondary level. The survey findings indicate that husbands enter into first marriage at much later age than women. The median age at first marriage is 23.5 for the husbands in age group 25-29, and it is 24 for the 30-34 and 35-39 age groups. Two-thirds of currently married women in Turkey say that they do not want any more children or are already sterilised for contraceptive purposes. An additional 14 percent want to wait at least two years before having another child. Sixty percent of husbands at ages 30-34 want to have no more children. A strong desire for a two-child family is evident. Results from the survey suggest that if all unwanted births were eliminated, the total fertility rate at the national level would be 1.9 children per woman, almost one child lower than the actual level of 2.6. Nineteen percent of the births in the five years preceding the survey were unwanted births and 11 percent of them were mistimed. The unmet need for family planning in Turkey indicates that there is potential for further increases in contraceptive use. Ten percent of currently married women are considered to be in need of a family planning method either for spacing or for limiting. For the five years preceding the TDHS-98, the infant mortality rate is estimated at 43 per thousand, the child mortality rate at 10 per thousand, and the under-five mortality rate at 52 per thousand. For the same period, results show that in Turkey, the neonatal mortality rate is higher than the postneonatal mortality rate, and that all the indicators of infant and child mortality have declined rapidly in recent years. The TDHS-98 findings point to significant differences in infant and child mortality between regions and urban and rural areas, and show that the educational level of the mother and the presence of medical maternity care are important correlates of infant and child mortality. In addition to the differentials observed between socioeconomic groups, infant and child mortality rates also appear to correlate strongly with demographic variables. Age of mother at birth and order of birth show the expected U-shaped relationship with infant and child mortality. High birth order and short birth intervals are the major factors contributing to elevated risks of mortality. XVI Among the maternal health indicators, antenatal care was received from trained health personnel by 68 percent of pregnant women. It is preferred that antenatal care is sought early in pregnancy and is continued throughout a pregnancy. In Turkey, in 58 percent of the births, antenatal care was sought before the sixth month of pregnancy and the median number of antenatal care visits is 4.2. Tetanus toxoid coverage for women is low, with 15 percent having one dose and 29 percent having two doses or more. The TDHS-98 shows that 73 percent of all deliveries took place at a health facility. One of the major child health indicators is immunisation coverage. Among children age 12-23 months, the coverage rates for BCG and the first dose of DPT are 87 and 86 percent respectively, with most of the children receiving those vaccines before age one. The results indicate that only 40 percent of the children had received all vaccinations at some time before the survey. On a regional basis, coverage is significantly lower in the East region, followed by the West and Central regions. Diarrhoea is a prevalent disease of children under age five in Turkey. In the two weeks preceding the survey, the prevalence of diarrhoea was 30 percent for children under age five. Among children with diarrhoea 70 percent were given more fluids than usual. Breastfeeding in Turkey is widespread. Almost all Turkish children (95 percent) are breastfed for some period of time. The median duration of breastfeeding is 14 months, but supplementary foods and liquids are introduced at an early age. Almost half of the children are being given supplementary food as early as one month of age, By age five, almost one-quarter of children are stunted (short for their age), compared to an international reference population. Stunting is more prevalent in rural areas, in the East, among children of mothers with little or no education, among children who are of higher birth order, and among those born less than 24 months after a prior birth. Overall, wasting is not a problem. Two percent of children are wasted (thin for their height), and 8 percent of children under five are underweight for their age. The survey results show that obesity is a problem among mothers. According to Body Mass Index (BMI) calculations, 52 percent of mothers are overweight, of which 19 percent are obese. AIDS is widely known in Turkey. Overall 84 percent of women and 93 percent of husbands have heard about AIDS. However, although women and husbands generally know AIDS, knowledge of ways to avoid it appears to be poor among a substantial minority of both groups. Additionally, the general perception of the disease in Turkey is that it is almost always fatal; 65 percent of women and 74 percent of husbands stated AIDS as an almost always a fatal disease. Sexually transmitted diseases (STD) other than AIDS are not known as widely as AIDS is known. Thirty-five percent of currently married women and 27 percent of never-married women reported having heard ofSTDs. STDs are more widely known by husbands; 54 percent of the husbands mentioned knowing STDs. xvn TURKEY RI A~K .c;FA REGIONS AND PROVINCES V~ST Sou'rH CEN'rP,/¢ NOmH 09 Aydm 01 Ada~a 03 A~3~ct 5'1 ~ 06 10 B~kedr 07 /~ntalya 05 Amawa 6O Tokat 28 Gimsun 16 Bursa 15 Bu{dur 06 Ankara 64 U~ 37 ~ n u 17 C ~ 27 Ga~ 11 B~'lec~ 66 Yo~ 52 Om~u 20 Den~i 31 Hatay 14 Bolu 68 Ak~ray 53 Ri~ 22 £dlme 32 .tspatta 18 Ctankm 70 K, tnc~_,n 55 Smtt,s~ 34 .Istard~l 33 I;e~ 19 Qomm 71 K~nkkide 57 ~nop 35 Iz~r 48 Mu~ 26 ~ i r 61 T~bzon 39 Kiddandf 79 Kills 38 Kays~ 67 Zonguldak 41 KocaeE 80 Osmaniye 40 K ~ 74 Bartm 45 ~ 42 Konya ;'8 Karab0k 54 S=k¢,~ 43 ~ya SO Te,,~a~ " SO ,,, 77 Yalova 02~an 47 Mardin 04 49 MW "12 B]n~ 56 S~t 13 Bitli= 5B Sivas 21 D lya l~ 62 Tul'¢~i 23 r,.,,~. 63 ~;.Uda 24 F.rz~can 65Van 2s S~rum Ss Ba,/ourt 29 G O ~ 72 Barman SO Hald~d 73 ,~m~:" 36 Fats 75 AIdahan 44 Mx~Ca T6 ~x 46 K. M¢'~ CHAPTER 1 INTRODUCTION Sunday liner and Banu Akadh Ergfgmen 1.1 Geography Turkey occupies a surface area of 774,815 square kilomelres. About three percent of the total area lies in Southeastern Europe (Thrace) and the remainder in Southwestern Asia (Anatolia or Asia Minor). Turkey has borders with Greece, Bulgaria, Syria, lraq, lran, Georgia, Armenia, and Nahcivan (Azerbaijan). The shape of the country resembles a rectangle, stretching iu the east-west direction for approximately 1,565 kilometres and in the north-south direction for 650 kilometres. The three sides of Turkey are surrounded by seas: in the north, the Black Sea; in the northwest, the Sea of Marmara; in the west, the Aegean Sea; and in the south, the Mediterranean Sea. The total coastline of Turkey is approximately 8,333 kilometres. Anatolia lies on a semi-arid central plateau that is surrounded by mountains. It is for the most part an elevated steppe-like plateau enclosed by mountains on all sides but the west. The Taurus Mountains in the south and the Northern Anatolia Monntains in the north stretch parallel to the coastline, these two mountains meet in the eastern part of the country. The average altitude of the country is approximately 1,130 metres above sea level. However, there are vast differences among regions, ranging from an average of 500 metres in the west to 2,000 metres in the east. The climate is characterized by variations of temperature and rainfall, depending on topography of the country. The average rainfall is 500 millimetres; however, it ranges from 2,000 millimetres in Rize, a province on the Black Sea coast, to less than 300 millimetres in parts of Central Anatolia. The typical climatic conditions of Turkey include dry, hot summers and cold, rainy winters. In summer, temperatures do not vary greatly across the country, whereas in winter, the temperature ranges from an average of -10°C in the east to +10°C in the south. 1.2 History Before becoming the core of the Ottoman Empire, Anatolia was dominated by the Seljuqs for almost two centuries (1055-1243) and later became the core of the Ottoman Empire. The Ottoman Empire was one of the most powerful forces in the Middle East and Europe for nearly 600 years. Following the War of Independence led by Mustafa Kemal AtatiJrk, the Republic of Turkey was founded in 1923. Subsequently, the country's borders were shaped by a number of agreements, with its present borders finally established following the annexing in 1939 of Hatay, a province on the southern border. The founding of the Republic not only marked the end of the Ottoman era and the establishment of the present borders of modern Turkey, but also signified a revolutionary change in the social and economic structure of the country. A modern constitution was introduced, the Sultanate and Caliphate were abolished, as were the veil and tile traditional headgear. The Latin alphabet was adopted instead of Arabic script. The schools were taken out of the hands of the religious authorities, and a program of free, compulsory education was set up. Islamic Law was abandoned and replaced with modified versions of the European civil, penal and commercial codes, and religious courts were closed. In short, the direction of change, led by Atattirk, was one from a religious, oriental Empire to a modern, westernised secular Republic. From the foundation of the Turkish Republic to 1950, the country was governed by one party. This changed in 1950 as a result of the wind of democracy that caught up the country after the Second World War. In the first multiparty election held in 1950, the Democrat Party won, putting the Republican People's Party into the opposition. With the introduction of multi-party period, Turkey achieved a more liberal and democratic environment. Although Turkish political history included three military interventions (1960, 1971, and 1980), Turkey has succeeded in preserving a parliamentary, multi-party system until today. With the foundation of the republic, Turkey turned her face to the 'Western world', establishing close relations with European countries and especially with the United States of America. Turkey is a member of the United Nations, the Council of Europe and the North Atlantic Treaty Organization (NATO) and an associate member of the European Community. Turkey also maintains close relations with th e countries of the Middle East, stemming from deep-rooted cultural and historical links. 1.3 Administrative Divisions and Political Organisation Since the founding of the Republic, three Constitutions (1924, 1961, and 1982) have shaped the Turkish administrative structure. These three coustitutions proclaimed Turkey to be a Republic with a parliamentary system and specified that the will of the people is vested in the Turkish Grand National Assembly (TGNA). All three constitutions adopted basic individual, social and political rights, and accepted the principle of separation of powers. The legislative body of the Republic is the TGNA. The TGNA is composed of 550 deputies, who are elected for five-year terms. The President of the Republic is elected by the TGNA for a seven-year term. The Prime Minister and other Cabinet Ministers compose the Council of Ministers, the executive branch of the Republic. The judiciary consists of the Court of Appeals, the Court of Jurisdictional Disputes, the Military Court of Appeals, the Constitutional Court, and the civil and military Courts. Turkey is administratively divided into 80 provinces. These are further subdivided into districts (ilge), subdivisions (bucak), and villages. The head of the province is the governor, who is appointed by and responsible to the central government. The governor, as the chief administrative officer in the province, carries out the policies of the central government, supervises the overall administration of the province, coordinates the work of the various ministry representatives appointed by the central authority in the capital Ankara, and maintains law and order within his/her jurisdiction. A mayor and a municipal council administer local government at the municipality level. The municipal electoral body elects them for a term of four years. Every locality with a population of more than 2,000 is entitled to form a municipal administration. Municipalities are expected to provide basic services such as electricity, water, gas, the building and maintenance of roads, and sewage and garbage disposal facilities. Educational and health services are mainly provided by the central government, but municipalities also provide some health services. 1.4 Social and Cultural Features Turkey has a highly heterogeneous social and cultural structure. There are sharp contrasts between population groups. The "modern" and "traditional" exist simultaneously within the society. Attitudes to life are reminiscent of those in the Western world, especially for the inhabitants of metropolitan areas. On the other hand, people living in rural areas are more conservative and religious. Family ties are strong and influence the formation of values, attitudes, aspirations, and goals. Although laws are considered to be quite liberal on gender equality, patriarchial ideology still may characterize the social life. Citizens of Turkey are predominantly Muslim. About 98 percent of the population belong to the Sunni and Alawi sects of the Muslim religion, with the Sunnis forming the overwhelming majority. Turks predominate ethnically. Kurdish, Arabic, Greek, Circassian, Georgian, Armenian, and Jewish communities of varying sizes complete the ethnic mosaic of the rich and complex culture of the Turkish society. One of the most striking achievements since the founding of the Republic has been the increase in both literacy and education. In 1935, only 10 percent of females and 29 percent of males were literate in Turkey. According to tile 1990 census figures, the femal and male literacy rates for the population age 6 and over were 72 and 89 percent, respectively. Educational attainment has also increased dramatically. The rate for primary school attendance today is around 90 percent. Moderate advances have also been made in increasing the proportions of males and females with higher than primary-level education. In 1998, an eight-year education became compulsory in Turkey, with primary school encompassing the first 5 years and junior high school, 3 years. Despite these achievements, considerable regional and urban-rural differences in literacy and educational attainment continue to exist in the country in addition to the gender differences. 1.5 Economy The Turkish Republic inherited from the Ottoman Empire not only a bankrupt country, but also centuries-old traditions of instability and insolvency. After the foundation of file Turkish Republic, various economic development strategies were tried. In the early years of the Republic, the Turkish economy was very weak. The economy was almost exclusively based on the agriculture, and it was totally undeveloped and poor. The creation and development of industry was clearly the first step that had to be taken to achieve a healthy and balanced economy. Throughout the 1920s, the government promoted file development of industry through private enterprise, encouraged and assisted by favourable legislation and the introduction of credit facilities. These liberal policies continued until 1929, and moderate improvements were realised in the mechanisation of agriculture. In the following decade, the state, under the so-called dtatiste system, assumed the role of entrepreneur, owning and developing large sectors of agriculture, industry, mining, commerce and public works. The origins of modern industrialisation in Turkey can be traced to the era of the 1930s. Although the beginnings of the industrialisation drive were evident in the immediate aftermath of the formation of the republic in 1923, the real breakthrough occurred in the context of the 1930s. Although Turkey did not actually participate in the Second World War (Turkey initially remained neutral during the Second World War but eventually sided with Allies), the country was faced with heavy restraints on the economy, which slowed down the industrialization process. A "mixed economy" regime followed the war, with the transition to democracy in 1950 signifying a shift towards a more liberal economic order; private enterprise gained recognition side by side with the state economic enterprises. Also, more emphasis was placed on trade liberalization, agricultural and infastructural development, and the encouragement of foreign capital. A series of Five-Year Development Plans were prepared after the military intervention in 1960. The first of these plans became operative in 1963. Imports were limited, and protectionism was established as tile dominant economic strategy during the 1960s and the 1970s. A basic objective was to replace the era of unplanned and uncontrolled expansion during the 1950s. In the 1980s, governments followed a strategy of renewing economic growth based on an export-oriented strategy. Following the stagnation of the late 1970s, growth recovered in response to a combination of an increased flow of exports and inputs of foreign capital. The liberal economic strategy followed in the 1980s was not unique to that period. The differences between the liberal and &atiste phases are not only the nature of the trade regime and the attitude toward foreign direct investment (FDI), 3 but also the mode of state intervention in the economy. Respectable rates of economic growth were achieved during the 1980s; however, in reeeltt years, macro instability has manifested itself once again, Industrialization during the 1990s has been shaped by three dynamics. First, the state's direct influence on the distribution of the resources was lessened. Second, competition gained importance, with increased emphasis on industrial performance and reconstruction .of the industry. Third, general globalisation and integration into the European Union gained speed. During the 1990s, privatisation also gained importance as a solutiou to economic problems, A committee was founded in order to regulate privatisation. Some of the state enterprises were privatised during this program. Turkey is a self-sufficient country in terms of its agricultural production. Wheat, barley, sugar beets, potatoes, and rice are grown in the interior, and cotton, tobacco and citrus are grown for export around the coastal areas. Turkey is not rich in mineral resources. One of the country's main problems is the inadequacy of primary energy resources. Copper, chromium, borax, coal, and bauxite are among the mineral resources in the country. The main industries are steel cement, textiles, and fertilizers. Machinery, chemicals and metals are imported mainly from the OECD countries. In recent years, there has been a significant increase in the amount of industrial goods exported to Europe and Arab countries. Turkey cata be classified as a middle-income country in the late 1990s. The rate of economic growth has been comparatively high in recent years, and the economy has undergone a radical transformation, from an agricultural base to an industrial one, particularly within the last 20 years. 1.6 Regional Breakdown The diverse geographical, climatic, cultural, social, and economic characteristics of different parts of the country is the basis for the conventional regional breakdown within Turkey. Five regions (West, South, Central, North, and East) are distinguished, reflecting, to some extent, differences in socioeconomic development levels and demographic conditions among sections of the country. This regional breakdown is frequently used for sampling and analysis purposes in social surveys. The West region is the most densely settled, the most industrialized, and the most socioeconomically advanced region of the country. The region includes both lstanbul, (previously the capital of the Ottoman Empire), which is Turkey's largest city, and the country's manufacturing and commercial centre, and lzmir, the country's third largest city. Coastal provinces form a relatively urbanized, fast-growing area. The Aegean coast is also a major agricultural area, where cotton is grown in the river valleys, and fruit is cultivated on the hillsides. With dry summers and mild, rainy winters, agricultural yields from the fertile soils are good. Most of the industrial establishments are situated in the West. The region contributes most of the gross domestic product of the country. The South includes highly fertile plaius and some rapidly growing industrial ceutres. Adaua, one of the new metropolises of Turkey, is located in this region. Steep mountains cut off the semitropical coastal plains from the Anatolian highlands to the nortb. Hot, dry summers and mild, wet winters describe the climatic conditions of the region. Cultivation of cotton and citrus provide high incomes and export earnings; recent decades have witnessed an industrial boom and an inflow of migrants, especially from the East region. The Central region is an arid grazing area and includes Ankara, the capital and second largest city. Industrial production in the region is low, except for some minor industries located around Ankara. The region specializes in the production of cereals. Given the dry, temperate climate, fruit tree cultivation and sheep and cattle raising are also common. The North region has a fertile coastal strip, but in most places it is only a few kilometres wide; the region is relatively isolated from the rest of the country by mountainous terrain. The region specialises 4 in small-scale, labour-intensive crops like hazelnuts and tea. The region receives large quantities of rainfall. Zouguldak, a western province, has extensive coal reserves aud is a centre for mining and the steel industry. The East region is considered as the least developed part of fl~e country. Rugged mountainous terrain, short summers, and the severe climate are suited to animal husbandry rather than settled farming. However, with the "Southeast Anatolia Project", the economy in the East has improved in the recent years. Huge irrigation channels were constructed and water was provided to arid and semi-arid lands, leadi~ig to agricultural development in the Southeast Anatolia. In addition to economic benefits, the project is also expected to reverse the migration flow from the region to the rest of the country. Although the capacity of agriculture has increased, the region is still poor in terms of industrial production. 1.7 Population In 1927, Turkey's population was 13.6 million according to the census, which was conducted four years after the establishment of the Republic. Beginning with the 1935 census, subsequent population censuses were undertaken at 5-year intervals, with the last complete census occurring in 1990. In order to be able to prepare the electoral rolls, a General Population Register was carried out iu 1997; the results of the Register put the population of Turkey at 62.8 million, Turkey is among the 20 most populous countries of the world and is the most populous country of the Middle East (State [nstitnte of Statistics, 1999; Population Reference Bureau, 1999). Intercensal estimates of population growth have been around 20-25 per thousand siuce the 1970s. The latest estimate of the population growth rate was 15.1 per thousand for the 1990-1997 period. According to the projections, the population of Turkey is expected to reach 76 million in the year 2010 arid 88 million in 2025 (Population Reference Bureau, 1999). Turkey has a young population structure as a result of the high fertility and growth rates of the recent past. Recent decades have witnessed dramatic declines especially in fertility rates. In the early 1970s, the total fertility rate was around 5 children per woman, whereas the estimates in the early 1990s put the total fertility rate at less than 3 children. The crude birth rate is estimated at 22 per thousand for the mid-1990s (Population Reference Bureau, 1999). There is a shortage of information on mortality in Turkey, particularly adult mortality. However, due to the estimation of the indicator through fertility surveys, infant mortality rates can be traced back for a relatively long period of time. The infant mortality rate in the late 1950s was around 200 per thousand. It declined to about 130 per thousand during the mid-1970s and to an estimated 53 per thousand during the early 1990s. Crude death rates have also declined from around 30 per thousand in the 1940s to 7 per thousand in the mid-1990s. The latest estimates put life expectancy in Turkey at 66 years for males and 71 for females (Population Reference Bureau, 1999). Marriage, predominantly civil, is widely practised in Turkey. Religious marriages also account for a significant proportion of the marriages; however, the main custom is to undergo a civil as well as a religious ceremony. The universality of marriage in Turkey is observed in the proportio~s never married. According to the 1990 Population Census, in the age group 45-49 which marks the end of the reproductive ages, only two percent of females bad never married, whereas the corresponding figure for males in the same age group was three percent. Marriages in Turkey are also known to be very stable; divorce rates are very low (Hanclo~lu and Akadh Erg69men, 1992). The population of Turkey has undergone an intensive process of urbanization, especially fi'om the 1950s onwards. According to the 1997 Population Count, 65 percent of the population in Turkey are living in urban settlements (province and district centers). The rate of urbanisation has been approximately 50 per thousand during the 1970-1990 period. The process of urbanisatiou has inevitably 5 caused problems in the provision of services and the emergence of large areas of squatter housing in unplanned cities. Since the early 1960s, Turkey has had a long history of external migration to Western European countries, principally Germany. Migration to Western Europe continued throughout the 1960s and 1970s; at that point, migration increasingly was directed towards oil-producing countries of the Middle East. During the past two decades, however, the political turmoil in region and changes in policies and practices governing the labour force in the European Union have led to a reversal in migration trends. There has been an increase in the number of expatriate workers returning from Europe, either because of loss of opportunity or as a result of having achieved their savings targets. Meanwhile, political conditions in neighbouring countries have led to waves of immigration into Turkey, as well (UNFPA, 1995). 1.8 Population and Family Planning Policies and Programs Policies related to population have been formulated since the establishment of the Turkish Republic in 1923. The government of the Turkish Republic implemented a somewhat pronatalist population policy aimed at increasing the population size, until the mid-1960s, after which an antinatalist policy was adopted. Tl~e shift in policy is manifested in the Population Planning Law of 1965. During the early years oftbe Republic there was an apparent need to increase fertility, since the country was suffering from the heavy human losses during the First World War and the War of Independence. The defence needs of the country and the shortage of manpower, as well as high infant and child mortality rates, led Turkey to follow a pronatalist population policy until the late 1950s. A number of laws having direct or indirect implications for encouraging population growth were passed. These laws included monetary awards to women with more than 5 children, prohibitions on the import and sale of contraceptives, and prohibitions on abortions on social grounds. The high population growth rates prevailing in the 1950s produced medical problems, particularly the high maternal mortality caused by illegal abortions, which brought the population debate into the political agenda. High urban population growth and employment problems were also factors contributing to the new antinatalist environment in government circles. The State Planning Organisation and the Ministry of Health pioneered the policy change, allowing limited importation of contraceptives. As mentioned earlier, the Population Planning Law was enacted in 1965. The law mandated the Ministry of Health with the responsibility for implementing the new family planning policy. In addition, the State Planning Organisation incorporated the notion of population planning in the First Five-Year Development Plan. In 1983, the Population Planning Law was revised and a more liberal and comprehensive law was passed. The new law legalized abortions (up to the tenth week of pregnancy) and voluntary surgical contraception. It also permitted the training of auxiliary health personnel in inserting IUDs and included other measures to improve family planning services and mother and child health. 1.9 Health Priorities and Programs Mother and child health and family planning services have been given a priority status in the policies of the government in recent decades. These services gained importance due to the large proportion of women of reproductive ages and children in the Turkish population, the high infant, child and maternal mortality rates, the high demand for family planning services, and the limited prenatal and postnatal care. A number of programs to improve services are being implemented, with special emphasis on provinces which have been designated as priority development areas as well as on squatter housing districts in metropolitan cities, rural areas, and special risk groups. The initiatives include programs in immunisation, childhood diardloeal diseases, acute respiratory infections, promotion of breastfeeding and 6 growth monitoring, nutrition, reproductive health, and antenatal and delivery care, safe motherhood. Information, Education, and Communication programs to promote the mother and child health and family planning activities also are being widely implemented. 1.10 Health Care System in Turkey The Ministry of Health is officially responsible for designing and hnplementiug nationwide health policies and delivering health-care services. Besides the Ministry of Health, other public sector institutions and non-goverumeutal organisations contribute to providing health services. At the central level, the Ministry of Health is responsible for the implementation of curative and preventive health-care services throughout the country, within the principles of primary health care. The responsibility for delivering the services and implementing specific Primary Health Care programs is shared by various General Directorates (Primary Health Care, Mother and Child Health and Family Planning, Health Training) and by various Departments (Departments of Tuberculosis Control, Malaria Control, Cancer Control). At the provincial level, the health care system is the responsibility of Health Directorates, under the supervision of the Governor. The provincial Health Director is responsible for delivering all primary health-care services aswell as curative services. The present network of Health Centres and Health Houses was formed on the basis of "Legislation for the Socialization of Health Services" so that services and facilities are extended down to the village level. A substantial proportion of villages has health ceutres or health houses. These are located so as to provide easy access to other villages. The most basic element of the health service is the Health House, which serves a population of 2500-3000 and is staffed by a midwife. The Health Centre serves a population of 5,000-10,000 and is staffed by a team consisting of a physician, a nurse, a health officer, midwives, an environmental health technician, and a driver. Health Centres mainly offer integrated, polyvalent primary health-care services. Mother and Child Health and Family Planning Centres and Tuberculosis Dispensaries also offer preventive health services. This network of health facilities are responsible for delivering primary health services, maternal and child health, family planning, and public education services. These health facilities are also the main sources of the health information system. 1.11 Objectives and Organisation of the Survey Objectives The 1998 Turkish Demographic and Health Survey (TDHS-98) is the latest in a series of national- level population and health surveys that have been conducted during the last thirty years in Turkey. The primary objective of the TDHS-98 is to provide data on fertility and mortality, family planning, materaal and child health, and reproductive health. The survey obtained detailed information on these issues from a sample of women in the reproductive ages (15-49) and from fl~e husbands of cun'ently married eligible women. More specifically, the objectives of the TDHS were to: Collect data at the national level that allow the calculation of demographic rates, particularly fertility and childhood mortality rates; Obtain information on direct and indirect factors that determine levels and trends in fertility and childhood mortality; Measure the level of contraceptive knowledge and practice by method, region, and urban- rural residence; Collect data on mother and child health, including innnunisations, prevalence and treatment of diarrhoea among children under five, antenatal care, assistance at delivery, and breastfeeding; Measure the nutritional status of children under five and of their mothers using anthropometric measurements. The TDHS-98 information is intended to contribute data to assist policy makers and administrators to evaluate existing programs and to design new strategies for improving demographic, social and health policies in Turkey. ~Organisation The TDHS-98 was implemented by the Institute of Population studies, Hacettepe University, in collaboration with the General Directorate of Mother and Child Health/ Family Planning, Ministry of Health. Technical and financial support for the survey were provided both by United Nations Population Fund (UNFPA) and Macro International Inc. Macro's assistance was provided through the MEASURE/ DHS+ project, a project sponsored by the United States Agency for International Development (USAID) to carry out population and health surveys in developing countries. A steering committee consisting representatives of the Institute of Population Studies, Hacettepe University, the General Directorate of Mother and Child Health/Family Planning, Ministry of Health. the State Planning Organization, the State Institute of Statistics, the United Nations Population Fund (UNFPA) and Macro International Inc. participated in all phases of the project. Questionnaires Four main types of questionnaires were used in the TDHS-98: the Household Questionnaire and three Individual Questiommires, one for ever-married women of reproductive ages, one for never-married women, and one for husbands. The contents of the questionnaires were based on the DHS Model 'A' Questionnaire, which was designed for the DHS program for use in countries with high contraceptive prevalence Additions, deletions and modifications were made to the model questionnaire in order to collect information partictdarly relevant to Turkey. In developing the questionnaire, close attention was paid to obtaining the data needed for program planning in Turkey as specified during eousultations with population and health agencies. Ensuring the comparability of the TDHS-98 findings with previous demographic surveys carried out by the Hacettepe Institute of Population Studies also was a goal during questionnaire development. The questionnaires were developed in English and translated into Turkish. The Household Questionnaire was used to enumerate all usual members of and visitors to tile selected households and to collect information relating to the socioeconomic situation of the households. In the first part of the household questionnaire, basic information was collected on the age, sex, educational attainment, marital status and relationship to the head of household of each person listed as a household member or visitor. The objective of the first part of the Household Questionnaire was to obtain the information needed to identify women and husbands who were eligible for the individual interview as well as to provide basic demographic data for Turkish households. The second part of the Household Questionnaire included questions on the welfare of the aged people, lu the third part of the Household Questionnaire, questions were included on tile dwelling unit, such as the nulnber of rooms, the flooring material, the source of water, and the type of toilet facilities, and on the household's ownership of a variety of consumer goods. The Individual Questiomaaire for women I covered the following major topics: Background characteristics Reproduction Marriage Knowledge and use of falnily planning Maternal care and breastfeeding Other issues relating to contraception Immunisation and heaRh Fertility preferences Husband's background Women's work and status Sexually transmitted diseases and AIDS Maternal and child anthropometry. The ever-married womeu's questionnaire included a monthly calendar, which was used to record l~rtility, contracepiion, marriage and migration histories for an approximate period of six years, beginning in January 1993 through the month of interview. The monthly calendar in the never-married women's questionnaire included only the migration history. In addition, the fieldwork teams measured the heights and weights of children under age five and of all women ages 15-49. The Individual Questionnaire for husbands covered the following major topics: Background characteristics Reproduction Knowledge and use of family planning Marriage Fertility preferences Sexually transmitted diseases and AIDS Attitudes Sample The sample for tile TDHS-98 was designed to provide estimates of population and health indicators including fertility and mortality rates for the nation as a who/e, for urban and rural areas, and for tile five major regions of tile country (West, South, Central, North and East). A weighted, multi-stage, stratified cluster sampling approach was used in tile selection of the TDHS-98 sample. The optima[ distribution with a target sample size of I0,000 selected households was based on the provisional results of the 1997 General Population Count. Selection of the TDHS-98 sample was undertaken in three stages. Tile sampling units at tile first stage were tile settlements stratified by population size. The ti'ame for the selection of the primary sampling units (PSU) was prepared using the provisional results of the 1997 Population Count. The fi'ame was divided into two groups, one including those settlements with populations of more than 10,000 and the other including settlements with populations less than 10,000. The selection of the settlement in each group was carried out with probability proportional to size (1997 poptdatiou). For the never-nlarried women some of the topics were not covered in tile questiollnaire. 9 The second stage of selection required the selection of the assigned nnmber of clusters in each selected settlement. For the majority of the settlements (340 clusters), the selection of clusters was based on the household lists that were available from the 1995 Structure Schedules. The State Institute of Statistics (SIS) selected the clusters and provided to Hacettepe Institute of Population Studies a description of each selected cluster. Each cluster included approximately 100 households. For those settlements where SIS was not able to provide information (140 clusters), the lists of households were prepared in the field. Following the selection of the secondary sampling units (SSUs), a household listing was prepared or updated for each SSU by the TDHS-98 listing teams. Using the household lists, a systematic random sample of fixed number of households (25 in clusters located in settlements over 10,000 and 15 in those less than 10,000) was chosen within each cluster for the TDHS-98. All women at ages 15-49 who were present in the household on the night before the interview were eligible for the survey. In half of the selected households for women interview, husbands of currently married eligible women, who were present in the household on the night before the interview or who usually lived in the household were eligible for the husband survey. A more technical and detailed description of the TDHS sample design, selection and implementation is presented in Appendix B. Fieldwork and Data Processing The TDHS-98 data collection was carried out by 16 teams2: each team consisted of four to five female interviewers, one male interviewer, a field editor, and a team supervisor. The male interviewer and the field editor worked as measurers as well. There were four regional coordinators who visited the teams on a continuous basis. The field staff was trained during a three-week period in Jtdy 1998. The main fieldwork for the TDHS-98, including initial interviews, call-backs and reinterviews, began in the first week of August 1998 and was completed in mid-November. Questionnaires were returned to the Institute of Population Studies in Ankara for data processing. The office editing staff checked the questionnaires returned from the field, Those questions which bad not been pre-coded (e.g., occupation) were coded by the office team. The data were then entered and edited using microcomputers and the ISSA (Integrated System for Survey Analysis) package. The office editing and data processing activities were started in the third week of August, two weeks after the beginning of fieldwork, and were completed by the end of November 1998. During the data entry process, almost hundred percent verification was done by double entry. The relatively few questionnaires that were not verified largely consisted of call-back questionnaires. The results of the household and individual questionnaires are summarized in Table 1.1. Information is provided on the overall coverage of the sample, including household and individual response rates. In all, 9,970 households were selected for the TDHS-98. At the time of the survey, 8,596 households were considered occupied and, thus, available for interview. The main reasons the field teams were unable to interview some households was because some dwelling units that had been listed were 2 Fieldwork for the TDHS-98 began in August with 12 teams, in October, four new teams were formed to complete the fieldwork in the remaining provinces. The teams were composed of staff from the original teams who had completed their assignmems. I0 Table I.I Results of the household and individual interviews Number of households, number of interviews, and response rates. Turkey 1998 Residence Result Urban Rural Total WOMEN Household interviews Dwellings sampled 6,989 2,981 9,970 Households found 5,938 2,658 8,596 Households interviewed 5,480 2,579 8.059 Household response rate 92.3 97.0 93.8 Individual interviews: women Eligible women Eligible women interviewed 6,322 3,146 9.468 5,702 2,874 8,576 E|igible woman response rate 90.2 91.4 90.6 HUSBANDS Household interviews Dwellings sampled 3,496 1,487 4.983 Households found 2,988 1.333 4,32 I Households interviewed 2,765 1,298 4,063 Household response rate 92.5 97.4 94.0 Individual interviews: husbands Eligible husbands Eligible husbands interviewed 2,087 956 3,043 1,312 659 1.971 Eligible husband response rate 62.9 8.9 64.8 found to be vacant at the time of the interview or the household was away for the extended period. Of tile 8,596 occupied households 94 percent (8,059 households) were successfully interviewed. In the interviewed households, 9,468 women were identified as eligible for the individual interview, i.e. they were women at reproductive ages (15-49) who were present in the household on the night before the interview. Interviews were successfully completed with 8,576 of these women (91 percent). Among the eligible women not interviewed ill the survey, the principal reason for non-response was the failure to find tile women at home after repeated visits to the household. In half of the selected households, husbands of currently married eligible women who were present in the household on the night before the interview or who usually lived in that particular household were eligible for the husband survey. A total of 4,983 households were selected for the husband interview. In the households interviewed (4,321 households), 3,043 husbands were identified as eligible for the individual interview. These husbands were present in the household on the night before tile interview and they were currently married to women at reproductive ages. Of the 3,043 husbands designated as eligible for individual interview, 65 percent (1,971) were suceessfidly interviewed. A more complete description of the fieldwork, coverage of tile sample, and data processing is presented in Appendix B. 11 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND SURVEY RESPONDENTS ismet Ko~ and Attila Hanmo~lu Tile main objective of this chapter is to describe the general characteristics of the sample population, including age, sex, household composition, and education. This infm'naation is not only useful in itself but it can also be used to evaluate the quality of the TDHS-98 data and to investigate changes in social and economic conditions over time. The other objective of this chapter is to describe the environment in which respondents and their children live. Household-level indicators relating to housing facilities and the ownership of durable goods are presented. These data are useful in assessing the household's living standard, which is an important influence on nuptiality, fertility and contraceptive behaviour, as well as maternal care and child mortality. The TDHS household questionnaire included two questions distinguishing between the de jure population (persons who are usual residents in the selected households) and the de facto population (persons who spent the night before the interview in the selected households). The differences between these two populations are small and since past surveys and censuses were based on de facto populations, all tabulations in this report are based on the de facto population in the selected households, unless otherwise stated. A household was defined as a person or a group of persons living together and sharing a common source of food. 2.1 Population by Age and Sex Table 2.1 and Figure 2.1 present tile age distribution of tile de facto population by five-year age groups according to urban-rural residence and sex. In addition to providing a background against which various demographic processes are occurring, the age strncture of the population incorporates the past history of the population. As was observed in the 1993 Turkish Demographic and Health Survey (TDHS- 93), tile age distribution conforms to the pattern typical of countries that experienced relatively high fertility in the recent past. Evidence of recent declines in fertility is reflected in tim fact that there is a smaller proportion of children under age 5 than age 5 to 9. As Table 2.1 shows, the proportion under 15 is greater in tile rural population than tile urban population. The differences in the age distributions are evidence of lower recent fertility in urban areas compared with rural areas. Overall, the number of women significantly exceeds the number of men. This pattern is especially prononnced at ages 15-29, which may partly be explained by migration of young men for work and for military service. Figure 2.2 presents the distribution of the male and female household population by single year of age. The data shows the evidence of a preference, for reporting ages that end in zero or five that is common in countries where ages are not well known, Digit preference is considerably more prononnced for men than for women. This is probably due to the fact that many of the household interviews were completed with women wbo were able to provide more accurate information on their own ages thaa on men's ages. 13 Table 2.1 Household ~opulation bv age, residence and sex Percent distribution of the de facto household population by five-year age groups, according to urban-rural residence and sex, Turkey 1998 Age group Urban Rural Total Male Female Total Male Female Total Male Female Tota-['- 0-4 10.6 5-9 10.5 I0-14 10.4 15-19 11.0 20-24 8.4 25-29 9.0 30-34 7,9 35-39 7.2 40-44 6.4 45-49 5.2 50-54 3.7 55-59 2.8 60-64 2.5 65-69 2.0 70-74 1.3 75-79 0.7 80+ 0.4 Don't know/Missing 0.1 9.6 10.1 11.4 9.5 10.4 10.9 9.5 10.2 10.1 10.3 11.7 10.2 10.9 10.9 10.1 10.5 9.7 10.0 12.1 12.0 12.0 I1.1 10.5 10.8 10.6 10.8 10,2 11.6 10.9 10.7 I 1.0 10.8 10.6 9.5 7.5 8.5 8.0 8.1 9.8 9.0 9.5 9.3 6.9 6.9 6.9 8.2 8.6 8.4 8.0 8.0 5.8 5.9 5.9 7.1 7.2 7.2 7.1 7.2 5.1 5.9 5.5 6.5 6.7 6.6 6.0 6.2 5.1 5.0 5.1 5.9 5.6 5.8 4.7 4.9 4.3 4.2 4.3 4.9 4.5 4.7 3.6 3.6 4.0 4.6 4.3 3.8 3.9 3.9 3.2 3.0 4.1 4.3 4.2 3.3 3.6 3.4 2.3 2.4 4.0 3.5 3.7 3.1 2.7 2,9 2.2 2.1 3.6 3.4 3.5 2,5 2.6 2.6 1.4 1.3 2.3 2.3 2.3 1.7 1.7 1.7 0.7 0.7 1.2 1.0 1.1 0.9 0.8 0.8 0.8 0.6 0.7 1.2 1.0 0.5 1.0 0,8 0.0 0.1 0.1 0.1 0.I 0.I 0.0 0.1 Total 100.0 100.0 I00.0 IO0.O 100.0 100.0 I00.0 I00.0 100.0 Number 10,533 10,897 21,430 5.930 6,443 12,374 16A64 17,340 33.804 Age 80+ 75.79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 10 Figure 2.1 Population Pyramid, Turkey, 1998 4 2 0 2 4 6 8 10 Percen! TI)tlS 1998 14 Figure 2.2 Number of Persons Reported at Each Age by Sex 700 600 S00 400 300 200 100 0 Nu tuber of Persons Q 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 70+ Age I--Male "~ Female TDHS 1998 The distribution of the TDHS-93 sample population by broad age groups is presented 'in Table 2.2, along with comparable data from 1990 Census and TDHS-93. There has been a decline in the proportion of population less than 15 years of age and an increase in the proportion of ages 15-64 and 65 and over. Again this pattern is typical of populations that are experiencing a fertility decline. Table2.2 Pooulation bv agc from selected sources Percent distribution of the population by age group, selected sources, Turkey 1990-1998 CP TDHS TDHS Age group 1990 1993 1998 Less than 15 35.0 33.0 31.5 15-64 60.7 61.4 62.6 65+ 4.3 5.5 5.9 Total 100.0 100.0 100.0 Median age 22.2 23.1 24.3 Dependency ratio 64.7 62.7 59.7 Sources: 1990CensusofPopulation, SIS, 1993; 1993 TDHS, HIPS, 1994 The dependency ratio, defined as the ratio of the non-reproductive population (persons under age 15 and age 65 and over) to reproductive population (persons age 15-64), is calculated based on broad age distribution of the survey population. The dependency ratio decreased from 65 in 1990 to 60 in 1998, indicating a gradual lessening in the burden placed on persons in the productive ages to support older and younger household members. Table 2.2 also indicates that the median age of household population is 24.3 15 years, two years higher than the median age in 1990. Both changes in dependency ratio and in the median age of population are consistent with the gradual aging of the'population that occurs as fertility declines. 2.2 Househo ld Compos i t ion Table 2.3 presents the distribution of households by the sex of the head of the household, size of the household and presence of foster children. The size and composition of the household may affect the allocation of financial resources among household members, which in turn influences the overall well being of the members. Household size may be associated with crowding in the dwelling, which can lead to unfavourable health conditions. In cases where women are heads of household, financial resources are often limited. The TDHS-98 shows that 10 percent of households are headed by women. The proportion is slightly higher in. urban areas than in rural areas (11 percent and 9 percent, respectively). Seven in ten households have between two and five members. The average household size is 4.3 persons, 4.0 persons in urban areas, and 4.9 persons in rural areas. Only one percent of households include one or more children under age 15 who are living with neither their natural father nor their natural mother. Table 2~3 Household comnosition Percent distribution of households by sex of head of household, household size, and relationship structure, according to urban- rural residence, Turkey 1998 Residence Characteristic Urban Rural Total Household headshi p Male 88.9 90.9 89.6 Female 11.1 9.1 10.4 Number of usual members 0 1.4 L' 5.2 2 16.1 3 17.2 4 21.9 5 14.8 6 9.4 7 5.1 8 3.1 9+ 5.9 1.1 2.1 5.3 5.0 16.1 16.1 19.3 12.7 25.2 14.7 15.0 14.4 8.4 11.6 4.0 7.3 2.1 5.3 3.6 10.8 Total 100.0 100.0 100.0 Mean size 4.0 4.9 4.3 Percent with foster children 1.2 1.6 1.3 Number of households 5,497 2,562 8,059 2.3 Fos terhood and Orphanhood Information on the proportion of households including fostered or orphaned children was presented in Table 2.3. Table 2.4 considers information regarding fosterhood and orphanhood for the population of children under 15 years of age. Ninety-four percent of children under 15 years of age are living with both parents, four percent are living with their mothers (but not with their fathers), one percent are living with their fathers (but not with their mothers), and one percent are living with neither their 16 Table 2.4 Fosterhood and omhanhood Percent distribution of de jure children under age 15 by survival of parents and child's living arrangements, according to child's age, sex, residence, and region, Turkey 1998 Living with Living with mother but father but Not living with either parent Missing Living not father not mother infer- with Father Mother marion Number Background both Father Father Mother Mother Both only only Both on father/ of characteristic parents alive dead alive dead alive alive alive dead mother Total children A0g-• 97.0 2.0 0.3 0.1 0.1 0.4 0.0 0.0 0.0 0.1 100.0 2,045 3-5 96.1 1.8 0.8 0.3 0.3 0.5 0.0 0.1 0.0 0.1 100.0 1,976 6-9 94.0 2.0 2,0 0.6 0,5 0,6 0.3 0.1 0.0 0.0 100.0 2,871 10-14 90.0 2.2 3.7 0.7 1.5 1.2 0.2 0,4 0.1 , 0.0 100.0 3,693 Sex Male 93.7 2.1 1.9 0.4 0.7 0.7 0.I 0.2 0.I 0.0 I00.0 5,386 Female 93.4 1.9 2.1 0.5 0.8 0.8 0.2 0.2 0.0 0.0 100.0 5,198 Residence Urban 94.1 2.1 1.6 0.5 0.7 0.7 0.1 0.1 0.1 0.1 100.0 6,608 Rural 92.7 1.9 2.8 0.5 0.8 ' 0.8 0.2 0.3 0.0 0.0 100.0 3,977 R•Vge i°n st 94.5 2.1 0,7 0.7 1.0 0.6 0.1 0.2 0.1 0.1 100.0 3,202 South 93.1 1.8 2,5 0.5 0.4 1.4 0.1 0.2 0.1 0.0 100.0 1,574 Central 93.0 3.0 1.6 0.6 0.3 0.8 0.3 0.2 0.1 0.1 100.0 2,228 North 93.2 2.4 2,5 0.1 0.3 1.2 0.0 0.2 0.0 0.0 100.0 825 East 93.2 1.1 3,5 0.2 1.1 0.4 0.2 0.1 0.0 0.1 100.0 2,756 Total 93.6 2.0 2,0 0.5 0.7 0.8 0.2 0.2 0.1 0.0 100.0 10,585 Note: By convention foster children are those who are not living with either biological parent, This includes orphans, i.e., ch dren w th both parents dead. natural father nor natural mother. Of children under 15 years of age, two percent and one percent have lost their mothers. Less than one percent of children have parents. have lost their fathers lost both their natural 2.4 Educational Level of the Household Population The education level of household members is perhaps their most important characteristic. Many phenomena, such as reproductive behaviour, use of contraception, health of children, and proper hygienic habits, are affected by the education of household members. In the TDHS-98, information on educational attainment was collected for every member of the household. Table 2.5 shows the distribution of the de facto female and male household populations age six and over by the highest level of education attended and the median number of years of schooling completed, according to selected background characteristics. Primary education is compulsory in Turkey; it starts at age 6 or 7 and in accordance with the recent curriculum reform lasts eight years. Seventy-five percent of men and 60 percent of women have completed at least primary school, and 19 percent of men and 12 percent of women have completed secondary school or higher. Table 2.5 also shows the median number of years of schooling attained by males and females. Overall, males have a median duration of schooling of 4.7 years, 0.4 years longer than females. The gap in the median number of years of schooling between males and females is more than 1 year for the population above age 15, but is negligible among those age 10-14 years. Table 2.5 also presents the educational level of household .members by urban-rural residence and region. The proportion of persons with no education is much higher in rural areas than in urban areas, and this difference is observed for both males and females. More than three-fourths of males and nearly two- 17 Table 2.5 Educational level of the household ooualation Percent distribution of the de facto householdpopulation age six and over by highest level of education attended. according to selected background characteristics, Turkey 1998 Level of education Don~t Median Background No Pr imary Primary Secondary Secondary know/ number characteristic education incomplete complete incomplete complete+ Missing Total Number of years MALE POPULATION A6g• 27.I 70.5 0.7 0.2 0.0 1.5 100.0 1,466 0.6 10-14 3.0 30.1 25.1 41,3 0.4 0.2 100.0 1,820 4.6 15-19 1,2 2.8 26.0 45.5 24.3 0.1 100.0 1,757 7.8 20.24 1.5 1,2 32,9 21.8 42.4 0.1 100,0 1,327 7.7 25.29 2.1 1.4 41.6 22.4 32.5 0.1 100.0 1,355 5.8 30.34 3,5 1.8 44,7 212 28.6 0.3 100.0 1,175 5.0 35-39 3.9 2.0 48.9 16.3 28.8 0.2 100.0 1,064 4.9 40 9OM44 4.8 2.0 48,8 17.3 27.0 0.0 100.0 978 4.9 45-49 9.4 4.0 50.2 13.8 22.6 0.0 100.0 801 4.7 50.54 20.3 7.0 42.8 14.0 15.1 0.7 100.0 620 4.5 55-59 26.3 8.9 45.5 6.0 12,0 1.4 100.0 536 4.3 60-64 30.7 10.2 45.8 5.9 5.9 1.5 100.0 504 4.2 65+ 41.9 10.3 33.1 6.0 6.8 1.9 100.0 920 2.4 Residence Urban 7.5 13.1 30.1 23.8 24.9 0.5 100.0 9,214 4.9 Rural 16.4 15.3 41.5 16.8 9.3 0.6 I00.0 5,124 4.4 Region West 6.7 11.2 35.2 23.9 22.4 0.5 100.0 5,337 4.9 South 9.1 15.4 39.1 20.2 15.7 0.5 100.0 2,103 4,6 Central 8.0 13,3 34.2 22.2 21.7 0.6 100.0 3,250 4.8 North 12.1 15.0 33.6 21.5 17.2 0.5 100.0 1,130 4.6 East 23.4 18.8 28.1 15.4 13.9 0.4 100.0 2,517 4.3 Total 10.7 13.9 34.2 21.3 19.4 0.5 100.0 14,338 4.7 FEMALE POPULATION Age 6-9 29.8 67.9 1.1 0.1 0.0 1.0 100.0 1,441 0.6 10-14 7.3 24.4 36.1 31.7 0.3 0.2 100.0 1,823 4.5 15-19 6.3 4.3 43.4 27.7 18.2 0.1 100.0 1,907 4.9 20-24 10.2 2.6 50.1 9.2 27.7 0.2 100.0 1,701 4.7 25-29 13.6 2.7 51.3 10.7 21.6 0.1 100.0 1,483 4.7 30-34 15,9 3.6 54.2 8.3 17.9 0.0 100.0 L256 4.6 35-39 22.1 6.3 49.5 6.3 15.6 0.2 I00.0 1,154 4.4 40-44 30.3 9.4 39.8 7.1 t3.4 0.0 100.0 975 4.3 45-49 39.5 8.6 36.5 5.4 9.6 0.5 100.0 787 4.0 50-54 50.0 10.0 31.5 2.6 4.5 1.4 100.0 684 0.0 55-59 56.6 12.1 25.8 1.7 3.7 0.0 100.0 619 0.0 60.64 61,3 12.4 20.1 2,1 3.7 0.4 100.0 471 0.0 65+ 75.0 8.3 11,6 2.7 1.5 0.9 100.0 1,061 0.0 Don't know/Missing 100.0 0.0 0.0 0.0 0.0 0.0 100.0 8 0.0 Residence Urban 20.9 13.2 34.2 14,4 17.0 0.4 100.0 9,662 4.4 Rural 33.1 15.4 40,8 6.8 3.5 0.3 100.0 5,707 4.0 Region West 17.0 13.1 39.8 13.7 16.2 0.4 100.0 5,548 4.5 South 25.2 15,3 38. I I 1.4 9.8 0.2 100.0 2,186 4.2 Central 20.8 13.5 39.8 12.3 13.3 0.4 100.0 3,524 4.4 North 28.0 13.7 36.7 llA 9.8 0.5 100.0 1,241 4.2 East 46.4 15.8 25.7 6.8 4.9 0.3 100.0 2,870 0.6 l~otal 25.4 14.0 36.7 I 1.6 12.0 0.3 100.0 15,369 4.3 18 thirds of females in the urban areas are graduates of at least primary school. In rural areas, the proportions completing at least the primary level are lower for both males (68 percent) and females (51 percent). The proportion of secondary school graduates also differs between urban and rural areas for males and, in an even more pronout~ed way, for females. The proportion of secondary school graduates is around five times higher for females in urban areas than in rural areas. Regional differences in education are considerable. The highest proportions of women (46 percent) and men (23 percent) with no education are found in the East region. The West region has the lowest proportions of male and female respondents with no education (7 and 17 percent, respectively). 2.5 School Enrolment Table 2.6 presents information on school enrollment by age, sex, and residence. These rates are simple ratios of the number of enrolled persons in a specific age group to the total number in that age group. According to the TDHS, 72 percent of children age 6-10 were enroled in school at the survey date. The proportion enrolled drops to 64 percent in the age group 11-15 years. Enrolment after age I5 drops significantly; whereas two in three children age 6-15 are in school, among the population age 16-20, the ratio drops to only one in four, and by age 21-24, only around one in ten are attending school. At all ages, the rural and/or female population has consistently lower school enrolment than the urban and/or male population (Figure 2.3). Moreover, as age increases, the gap between males and females widens. These results show that both gender and residential differences persist in the proportion of the population currently attending school in Turkey. Table 2.6 School enrolment Percentage of the de facto household population age 6-24 years enrolled in school, by age group, sex, and urban- rural residence, Turkey 1998 Male Female Total Age group Urban Rural Total Urban Rural Total Urban Rural Total 6-10 78.2 68.3 74.4 73.7 65.0 70.4 76.0 66.7 72.4 11-15 79.4 64.5 73.6 67.1 38.3 55.1 73.3 50.6 64.2 6-15 78.8 66.5 74.0 70.4 50.8 62.6 74.7 58.5 68.3 16-20 36.7 22.1 31.6 25.5 10.3 19.6 30.9 15.4 25.1 21-24 18.1 7.5 14.7 11.5 3.0 8.9 14.5 5.1 11.5 2.6 Housing Characteristics To assess the economic and environmental conditions in which household members live, the household questionnaire included questions about sources of drinking water, time to the water source, sanitation facilities, flooring material, and the number of rooms used for sleeping. Information on these characteristics is useful from a public health point of view, as well as indirectly reflecting the household socioeconomic status. 19 Figure 2.3 School Enrolment by Age and Place of Residence Percent enrolled 90 / 80 70 60 50 40 3O 2O I0 / 0 76 73 :::::::::::::::::::::::: ::::::::::::::::::::::: ii!ii iii i!iii i iii ::::::::::::::::::::::::::::: 51 • 6-10 11-15 16-20 21-24 Age lDUrban mRura] l TDHS 1998 This information on household characteristics is given in Table 2.7. Overall, more than 5 in 10 households get their drinking water from pipes, mainly within their dwelling. The source for drinking water differs considerably by area of residence. Among urban households, 67 percent get drinking water from pipes in their residence, and only one percent obtains water from a public tap. The second most common source of drinking water in urban areas is bottled water (15 percent), and nine percent get drinking water from a water station (commercial outlets selling spring water). Around two-thirds of rural households report having piped water; however, for nearly half of these households, the source for the piped water is a river, stream or other surface water. Nearly one-fifth of rural households obtain water from a spring. Households in rural Turkey are somewhat more likely to be relying on well water than households in urban Turkey (9 percent and 2 percent respectively). For most households, the source for drinking water is within their dwelling or not far from the residence. Overall, 91 percent of households obtain drinking water in their dwelling or from within 15 minutes of the residence. Urban households tend to be somewhat closer to the source of water than rural areas; 93 percent of households in urban areas report that the source for drinking water is in the house or within 15 minutes of dwelling compared with 88 percent of rural households. Two-thirds of households have modern sanitation facilities in Turkey. Another 29 percent use an open pit or latrine, and only two percent report having no toilet facilities. There are substantial differences in the type of toilet facilities available to households by urban-rural residence. Households in urban areas are much more likely to have modern sanitation facilities than households in rural areas (89 percent and 25 percent, respectively). Only ten percent of urban households use pit toilets or report that they have no toilet facilities. In comparison, 70 percent of rural households use a pit or latrine, and five percent report that they have no toilet facilities. 20 Table 2.7 Housin~ characteristics Percent distribution of households by housing characteristics, according to urban-rural residence, Turkey 1998 Residence Housing characteristic Urban Rural Total Source of drinking water Piped into residence/garden 65.9 32.7 55.3 Pdblie tap 0,8 1.3 1.0 We|I in residence/garden 1,6 5.6 2.8 Public well 0.3 3.0 1.2 Piped surface water in house/garden 1.4 34.7 12.0 Spring/public fountain 4,7 19.0 9.2 River]stream 0.2 1,0 0.5 Rainwater 0,0 0.1 0.0 Tanker truck 0.6 0.8 0.7 BoRled water/Demi John 14,9 1.0 10.5 Water station 9. I 0.2 6.3 Other 0,4 0.5 0.5 Total 100.0 100.0 100.0 Time to water source Water within 15 min./ on premises 92.6 87.6 91.0 T~pe oftoUet facility wn flush toilet 87.6 24.0 67.4 Shared flush toilet 1.6 0.7 1.3 Open pit toilet 2,4 25.9 9.9 Closedpit latrine 7.5 43.6 19.0 No facility/bush 0,3 5.0 1.8 Other 0.3 0.7 0.5 Missing 0.3 0.1 0.2 Total 100.0 100.0 100.0 Main floor material Earth 2.4 16.7 6.9 Wood planks 12.9 24.4 16.5 ParqueUpolished wood 14.5 2.0 10.5 Karo I 1.6 3.7 9.1 Cement 23.3 41.8 29.2 Carpet 10.1 6.3 8.9 Marley 19.3 3.5 14.2 Mosam 4.9 1.0 3.7 Other 0.8 0.6 0.7 Missing 0,3 0.2 0.3 Total 100.0 100.0 100.0 Persons per sleeping room 1-2 78.6 64.9 74.3 3-4 18.2 27.4 21. I 5-6 2.4 5.1 3.3 7 + 0.7 2.4 1.3 Don't knowfMissing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Mean persons per room 2,2 2,6 2.3 Number of households 5,497 2,562 8,059 21 With regard to flooring, 29 percent of the households live in dwellings with cement floors, an additional 27 percent have a wooden floor, and 14 percent have marley floors. There are significant differences in the flooring materials in urban and rural dwellings, Cement is the most common flooring material in both rural areas (42 percent) and urban areas (23 percent). Wood is also a common flooring material; about one-fourth of urban and rural households live in dwellings with wood floors. Seventeen percent of households in rural areas have earth floors, compared to only two percent of households in urban areas. Information on the number of rooms that a household uses for sleeping was collected to determine the extent of crowding. Table 2.7 shows that 74 percent of households have one or two persons per sleeping room, and 21 percent have three to four persons per sleeping room. The overall mean is 2.3 persons per sleeping room. Rural households are more crowded than urban households. The mean number of persons per sleeping room is 2.2 persons in urban areas compared with 2.6 persons in rural areas. ~.7 Househo ld Durab le Goods The availability of durable consumer goods is a good indicator of household socioeconomic level. Moreover, particular goods have specific benefits. For example, having access to a television exposes household members to innovative ideas, and a refrigerator prolongs the wholesomeness of foods. Table 2.8 presents the availability of selected consumer goods by residence. Most of the population in Turkey enjoys the convenience of electrical appliances. More than nine in ten households own a television set or a refrigerator, while almost eight in ten households have a telephone, and more than six in ten households own an oven, a vacuum cleaner or a washing machine. Ownership of various durable goods varies by place of residence, with higher proportions of ownership for all items reported among households in urban areas than in rural areas. Table 2.8 Household durable ~oods Percentage of households possessing specific durable consumer goods, by urban-rural residence, Turkey 1998 Residence Durable goods Urban Rural Total Refrigerator 96.2 86.7 93.2 Gas or electric oven 77.0 47.5 67.6 Dishwasher 22.4 3.3 16.4 Washing machine 76.1 36.9 63.6 Vacuum cleaner 77.7 38.0 65.1 Television 94.8 84. I 91.4 Video recorder 14.3 3.7 10.9 Camera 40.7 18.9 33.8 CD player 19.8 5.0 15.1 Telephone 80.4 69.7 77.0 Mobile telephone 17.9 3.5 13.3 Computer 6.0 0.4 4.2 None of the above 1.5 4.4 2.4 Number of households 5,497 2,562 8,059 22 2.8 Background Characteristics A description of the basic characteristics of the women and husbands interviewed in the TDHS is essential as background for interpreting findings presented later in the report. Table 2.9 provides the percent distribution of women and husbands by age, marital status, level of education, urban-rural residence, and region. Table 2.9 Background characteristics of respondents Percent distribution of women and husbands by selected background characteristics. Turkey 1998 Number of women Number of husbands Background Weighted Un- Weighted Un- characteristic percent Weighted weighted percent Weighted weighted Age 15-19 20.1 1,720 1,763 * * 3 20-24 18.2 1,558 1,539 5.5 109 105 25-29 16.3 1,397 1,373 17.4 342 314 30-34 14.0 1,202 1,195 18.5 364 362 35-39 12.6 1,081 1,104 17.9 352 366 40-44 10.3 885 890 17.0 335 344 45-49 8.5 733 712 12.2 240 245 50+ NA NA NA I 1.4 226 232 Current marital status Never married 27.7 2,380 2,424 NA NA NA Married 69.0 5,921 5,893 100.0 1,971 1,971 Widowed 1.7 147 153 NA NA NA Divorced 1.1 96 77 NA NA NA Separated 0.4 34 29 NA NA NA Residence Urban 66.5 5,704 5,702 68.3 1,347 1,312 Rural 33.5 2,872 2,874 31.7 624 659 Region West 37.4 3,204 2,170 38.9 767 546 South 14.7 1,258 1,678 14.4 285 400 Central 23.1 1,985 1,706 24.4 481 413 North 8.1 692 1,258 7.6 150 299 East 16.8 1,437 1,764 14.6 287 313 Education No education 16.7 1,435 1,590 6.6 13I 135 Primary incomplete 5.0 426 442 3.7 73 76 Primary complete 48.0 4,117 4,013 42.8 844 849 Secondary incomplete 12.1 1,041 1,029 20.8 409 401 Secondary complete+ 18.1 1,556 1,502 26.0 513 510 Total 100.0 8,576 8,576 100.0 1,971 1,971 NA -- Not applicable Note: An asterisk indicates that an item is based on fewer then 25 persons and has been suppressed. Women and husbands were asked two questions in the individual interview to assess their age: "In what month and year were you born?" and "How old are you?" Interviewers were trained to probe in situations in which respondents knew neither their age nor date of birth; as a last resort, interviewers were instructed to record their best estimate of the respondent's age. The age data indicate that 38 percent of women and six percent of'husbands are under age 25, 30 percent of women and 36 percent of husbands 23 are in the age group 25-34 and slightly more than 30 percent of women and 47 percent of husbands are in the age group 35-49. Around 10 percent of husbands are age 50 or older. Data on the women's marital status at the time of survey indicate that 69 percent were currently married, while 28 percent had never married, and the rest were widowed, divorced, or separated. The latter proportion indicates the rarity of marital dissolution in Turkey. As described earlier, the men's sample included husbands of eligible currently married women living in a subsample of the households covered in the TDHS. Thus, the men's sample does not include never-married men or men who were widowed, divorced or separated. About two-thirds of women and men live in urban areas, and the rest live in rural areas. According to the data, more than one-third of the respondents live in the West region, one-fourth live in the Central region, around one-sixth live in the East and in the South, and less than 10 percent live in the North region. The proportion of women who have never attended school is more than twice that of husbands (17 percent and 7 percent, respectively). About 48 percent of women and 43 percent of husbands have a primary education only, while 30 percent of women and 47 percent of husbands have gone beyond primary school education. Fewer than one in five women have coml~leted secondary school or higher. 2.9 Respondents' Level of Education by Background Characteristics Table 2.10 shows the distributions of women and husbands by the highest level of education attended, according to selected characteristics, The table is shown as a first effort to clarify the relationship between education and other explanatory, or background variables used in later tabulations. Differences in the educational composition of respondents from different age groups, regions, and urban- rural backgrounds are highlighted. As mentioned before, men are generally better educated than women. For both groups, education is inversely related to age; older women and men are generally less educated than younger women and men. The percentage of women with no education rises rapidly with age, from six percent in the 15-19 • age group to 40 percent in the age group 45-49. This suggests that younger women have had better educational opportunities than older women. This is also reflected in the higher percentage of women in the age group 20-24 who completed secondary education (27 percent), compared to women age 45-49 (9 percent). Urban women and men in Turkey are much more likely to have higher education than their rural counterparts. Twenty-two percent of rural women have no education, compared to only 14 percent of urban women. Conversely, while 39 percent of urban women have gone to school beyond the primary level, while only 14 percent of rural women have been educated beyond primary school. Similar urban rural differentials in education are observed for husbands. A comparison of the results for regions shows that East region has the highest proportions of women and husbands with no education (40 percent and 21 percent respectively), while the West region has the lowest proportion of women and husbands with no education (10 percent and 4 percent, respectively). The highest proportions of women and husbands with secondary or more education is also observed in the West region. 24 Table 2.10 Level of education Percent distribution of women and husbands by the highest level of education attended, according to selected background characteristics, Turkey 1998 Level of education Number of Background No Primary Primary Secondary Secondary women/ characteristic education incomplete complete incomplete complete+ Total husbands WOMEN 15-19 5.8 4.8 44.4 27.7 17.3 100.0 1,720 20-24 9.4 2.4 51.3 9.9 26.9 100.0 1,558 25-29 13.3 2.5 54.1 10.4 19.7 100.0 1,397 30,34 15.5 3.8 54.1 8.2 18.4 100.0 1,202 35-39 22.9 6.6 49.2 6.5 14.9 100.0 1,081 40-44 31.6 9.4 39.7 6.4 12.9 100.0 885 45-49 39.5 9.5 36.2 5.6 9.3 100.0 733 Residence Urban 14.1 3.9 43.3 14.5 24.2 100.0 5,704 Rural 21.9 7.1 57.3 7.5 6.2 100.0 2,872 Region West 9.9 3.2 49.8 14.3 22.8 100.0 3,204 South 18.2 5.9 49.8 11.4 14.6 100.0 1.258 Central 9.8 5.4 52.4 12.1 20.3 100.0 1,985 North 18.3 4~8 49. I I 1.6 16.2 100.0 692 East 39.5 7,6 35.9 8.2 8.8 100.0 1.437 Total 16.7 5,0 48.0 12.1 18. I 100.0 8,576 HUSBANDS Age 15-24 0,0 3,0 42,9 27.7 26.4 100.0 I 13 25-29 1.8 2,8 38.3 25.3 31.8 100.0 342 30-34 3,9 3.4 38,8 24.2 29,8 100.0 364 35-39 3.9 2,7 45.9 17.9 29.5 100.0 352 40-44 5.9 2.2 47,9 17,7 26,2 100.0 335 45-49 8.5 4,0 47.7 19.3 20.5 100.0 240 50÷ 25,1 9.6 38,4 15,4 I 1,5 100,0 226 Residence Urban 4.7 2.6 36.4 22.5 33.7 100.0 1,347 Rural 10.8 6,2 56.6 17.0 9.5 100.0 " 624 Region West 3.6 3.2 41.0 22.0 30.3 100.0 767 South 6.4 6,1 49.1 20.7 17.7 100.0 285 Central 4.0 2.2 42.6 23.7 27.5 100.0 48 I North 5. I 3.5 50.6 16.0 24.7 100.0 150 East 20.5 5.3 37.8 15.2 21.2 100.0 287 Total 6.6 3.7 42.8 20.8 26.0 100.0 1,971 2,10 Reasons for Leaving School Information about the reasons that lead women to drop out of school can provide guidance to programs seeking to improve educational opportunities for women. To obtain some insight into this issue, women under age 25 years who were not currently attending school were asked during the TDHS interview about the main reason for leaving school. Table 2.11 shows the distribution of women 15-24 years according to whether they are currently attending school and, if not, their reasons for leaving school, according to the highest level of education attended. 25 Table 2. I 1 Reasons for leavimz school Percent distribution of women age 15-24 who had ever attended school but were not currently attending by reason for leaving school, according to highest level of education attended, Turkey 1998 Highest level of education Reason stopped Primary Primary Secondary Secondary attending sehool incomplete complete incomplete complete Higher Total URBAN Currently attending 3.6 0.6 52.2 16.6 67.5 23.7 Got pregnant 0.0 0.0 0.0 0.1 0.0 0.0 Got married 0,0 2.3 4.1 9.8 3.9 4.3 Take care of children 0.0 0.1 0.9 0.0 0.0 0.3 Family needed help 3.2 1.2 0.6 0.3 0.0 ~ 0.8 Could not pay school fees 4.3 7.4 1.4 1.8 0.0 3.9 Needed to earn money 1.9 2.1 0.4 2.4 1.0 1.6 Graduated/had enough school 0.0 0.6 0.1 6.5 21,3 3.9 Did not pass exams 2.4 0,0 0.3 35,8 0,0 7.2 Did not like school 16,3 23.9 17.6 5.4 0.3 16.0 School not accessible 1.3 3.7 0.4 0.2 0.0 1.7 Parents did not send to school 30.5 36.2 9.1 4.9 1.4 19.5 Other 36.5 19.1 11.8 15.4 3.7 15.4 Don't know/Missing 0.0 2.8 1.0 0.7 1.0 1.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 55 829 482 386 210 1,963 RURAL Currently attending 1.7 0.5 45,6 16.7 (57.1) 9.7 Got pregnant 0.0 0.0 0.0 0.0 0,0 0.0 Got married 1.6 2.0 4.7 11.7 (3.0) 3.2 Take care of ehiidren 1.5 0.1 0.0 0.0 0 .0 0.2 Family needed help 7.3 2.0 0.0 1.5 0.0 2.0 Could not pay school fees 1.5 3,6 1.6 0.0 0,0 2.8 Needed to earn money 1,0 0.6 0.4 2.7 0.0 0.8 Graduated/had enough school 0.0 0.7 0.0 3.3 (31.0) 1.6 Did not pass exams 0.0 0.2 0.0 36,1 0.0 3.2 Did not like school 6,2 14.4 13.4 7.3 0.0 12,8 School not accessible 4.3 7.5 6.4 0.0 0.0 6.3 Parents did not send to school 40.4 44.6 16.5 3.5 0.0 35.8 Other 31.I 22.0 8,8 17.1 (8.9) 19.9 Don't know/Missing 3.4 1.7 2.6 0.0 0 .0 1.7 Total 100.0 100.0 I00.0 100.0 100.0 100.0 Number 66 734 148 91 29 1,068 TOTAL Currently attending 2.6 0.6 50.6 16,7 66.2 18.8 Got pregnant 0.0 0,0 0.0 0.1 0.0 0.0 Got married 0.9 2.1 4.3 10, I 3.8 3,9 Take care of children 0.8 0. I 0.7 0.0 0,0 0.2 Family needed help 5,4 1.6 0.5 0.6 0.0 1.2 Could not pay school fees 2.7 5.6 1.4 1.4 0.0 3,5 Needed to earn money 1.4 1.4 0.4 2.4 0.9 1.3 Graduated/had enough school 0.0 0.7 0. I 5.9 22.5 3, I Did not pass exams 1.1 0.1 0.2 35.9 0.0 5,8 Did not like school 10.8 19.4 16.6 5.8 0.3 14.8 School not accessible 3.0 5,5 1.8 0.1 0.0 3.4 Parents did not send to school 35.9 40.1 10.8 4.7 1.2 25.2 Other 33.5 20.4 11.1 15.7 4.3 17.0 Don't know/Missing 1.9 2.3 1.4 0.6 0.9 1,7 Total 100,0 100.0 100.0 100,0 100.0 I00.0 Number 121 1,563 630 478 239 3,031 Note: Parentheses indicate that a figure is based on 25-49 respondents. 26 Only 19 percent of TDHS respondents 15-24 were attending school at the time of interview. The reasons for leaving school vary with the level of school women had attained at the time they left school. Women who had not completed primary school are most likely to say that they had left because parents did not send them (36 percent) or because they had not liked school (11 percent). Failure to pass examinations (36 percent) is the principal reason for dropping out of school among women who left after completing the secondary level, while eight percent report that they stopped going to school because they married. 2.11 Differentials in Characteristics of Couples Because the married men interviewed in TDHS were selected from a subgroup of households it is possible to match male respondents with their wives to obtain a couple dataset. Table 2.12 shows husband-wife differentials in age and education for the 1,896 couples interviewed in the TDHS. For most of the couples, the husband is older than the wife; in the case of the majority of couples, the age difference is between 0 and 9 years. Among 10 percent of couples, the wife is older than her husband. On average, men are five years older than their wives. Regarding educational differences, in about five percent of couples, neither the husband nor the wife has been to school, while among eight in ten couples, both the husband and wife are educated. For the remaining couples, the proportion in which the husband has some education and the wife has none is much higher than that of tile wife is educated and the husband is not (14 percent and 2 percent, respectively). Table 2.12 Differential characteristics between spouses Percent distribution of couples by differences in age and level of education between the husband and wife. Turkey 1998 Percent/ Characteristic years Age difference Husband younger than wife 9.8 Husband older by: 0-4 years 44.7 5-9 years 32.9 10-14 years 9.6 15 years+ 2.9 Mean age difference 5.0 Education Both husband and wife not educated 4.9 Wife educated, husband not 1.7 Husband educated, wife not 13.8 Both husband and wife educated 79.6 Total 100.0 Number of couples 1,896 27 2.12 Exposure to Print Media Women and husbands were asked how often they read newspapers Or magazines. This information is important t o program planners seeking to reach people with family planning and health messages through the media. Table 2.13 presents the percentage of women and husbands exposed to printed media by age, residence, region and level of education. Results show that 32 percent of women and 61 percent o f husbands read newspapers or magazines weekly. Access to media is somewhat higher among younger respondents and among those living in urban as opposed to rural areas. Print media access is more widespread among women and husbands living in the West compared with among those living in the other regions. As expected, educated persons are more likely to read newspaper or magazines than less educated persons. Table 2.13 Exoosnre to print media Percentage of women/husbands who usually read a newspaper at least once a week, by selected background characteristics, Turkey 1998 Women Husbands Read Number Read Number Background newspaper of newspaper of characteristic weekly women weekly husbands Age 15-19 36.6 1,720 * 4 20-24 39.1 1,558 56.1 109 25-29 33.1 1,397 66,7 342 30-34 29.8 1,202 66.8 364 35-39 27.8 1,081 64.5 352 40-44 26.2 885 59.5 335 45-49 25.4 733 56.9 240 50-54 NA NA 43.6 226 Residence Urban 40.9 5,704 68.2 1,347 Rural 15.4 2,872 44.1 624 Region West 45.1 3,204 74.3 767 South 23.9 1,258 48.0 285 Central 30.3 1,985 57.7 481 North 28.5 692 64.5 150 East 16.3 1,437 39.2 287 Education No education 1.9 1,435 12.7 131 Primary incomplete 9.2 426 33.2 73 Primary complete 24.2 4,117 52.2 844 Secondary incomplete 53.2 1,041 67.4 409 Secondary complete+ 74.6 1,556 85.1 513 Total 32.4 8,576 60.6 1,971 NA = Not applicable Note: An asterisk indicates ~.hat an item is based on fewer than 25 persons and has been suppressed. 28 2.13 Employment and Occupation In the TDHS-98, information was collected about current employment. Although data were collected from both women and husbands, the analysis in this section concentrates on women. Table 2.14 indicates that 39 percent of women report being employed during the 12-month period before the TDHS interview with the majority (35 percent) working at the time of the survey. Nearly half of the women who were currently employed at the time of the survey worked all year, 43 percent worked in seasonal jobs, and only 11 percent worked occasionally. The proportion not currently employed is higher among older women, rural women, and women with no education than other women. Women in the West and Central regions are more likely to he employed than women in other regions. The North region has the highest proportion of women reporting seasonal employment. Rural women are much more likely to be employed seasonally than urban women, presumably as agricultural laborers. Table 2.14 Emolovment Percent distribution of women by employment status and continuity of employment, according to selected background characteristics, Turkey 1998 Not currently employed Currently employed Did not Worked All year work in in Number Background last 12 last 12 5+ days <5 days Season- Occasion- of characteristic months months per week per week ally ally Missing Total women Age 15-19 60.3 6.1 12.2 1.0 17.5 2.5 0.4 100.0 1,720 20-24 59.4 5.4 17.4 0.6 13.1 3.8 0.3 100.0 1,558 25-29 62.5 4.0 16.5 0.9 11.8 4.0 0.3 100.0 1,397 30-34 60.1 3.4 15.1 1.4 14.9 5.1 0.0 100.0 1,202 35-39 57.2 2.3 18.5 2.1 15.0 '4.9 0.0 100.0 1,081 40-44 60.6 2.2 14.5 2.0 16.5 3.9 0.2 100.0 885 45-49 66.1 2.0 9.6 0.9 17.6 3.7 0.0 100.0 733 Residence Urban 68.3 4.4 17.7 1.2 4.8 3.3 0.3 100.0 5,704 Rural 45.4 3.2 9.8 1.2 35.2 5.1 0.0 100.0 2,872 Region West 57.7 5.5 22.6 1.4 8.7 3.5 0.4 100.0 3,204 South 65.1 3.2 10.7 1.2 16.2 3.6 0.1 100.0 1,258 Central 57.5 3.5 12.1 1.2 21.0 4.5 0.1 100.0 1,985 North 44.1 3.6 14.6 1.8 32.0 3.9 0.1 100.0 692 East 75.4 2.2 6.3 0.6 1 |.5 4.0 0.0 100.0 1,437 Education No education 68.7 1.9 6.7 0.9 18.0 3.9 0.0 100.0 1,435 Primary incomplete 63.2 1.9 I 1.2 1.0 19.4 3.3 0.0 100.0 426 Primary complete 59.1 3.8 11.1 1.0 19.8 4.9 0.2 100.0 4,117 Secondary incomplete 70.2 5.7 10.7 1.0 7.7 4.1 0.6 100.0 1,041 Secondary complete+ 50.0 5.9 37.2 2.3 3.3 1.3 0.1 100.0 1,556 Total 60.6 4.0 15.1 1.2 15.0 3.9 0.2 100.0 8,576 Table 2.15 presents the distribution of women who were employed at the time of the survey by occupation, according to selected background characteristics. Forty-nine percent of employed women worked in agriculture, among whom more than six in ten worked on their family land. The table also shows that women who worked outside the agricultural sector were most often employed in professional and technical occupations, followed by skilled manual labors. Most of the remaining women worked in household and domestic occupations and sales and services. 29 Table 2.15 Occupation Percent distribution of currently employed women by occupation and type of agricultural land worked or type of non- agricultural employment, according to selected background characteristics, Turkey 1998 Agricultural Nonagricultural Pro£/ Background Own Family Rented Other's teehJ Sales/ characteristic land land land land manag, services Un- House- Number Skilled skilled hold and of manual manual domestic Missing Total women Alg5e- 19 2.2 38.2 3.8 13.7 10.7 4.5 18.9 4.5 3.1 0.5 100.0 573 20-24 1.3 28.0 3.3 8.5 25,1 6.6 23.2 1.7 2.2 0.2 100.0 545 25-29 2.2 28.4 3.4 8.0 29,1 2.7 21.1 2.3 2.3 0.5 100.0 464 30-34 3.1 31.7 0.8 11.3 23.2 4.0 19.1 1.7 4.1 0.8 100.0 439 35-39 4.9 28,5 3,0 10.7 21.5 3,0 17.5 2.0 8.7 0.3 100.0 438 40-44 6.2 30.0 3.1 15.6 19,5 4.5 10.7 3.1 7.0 0.2 100.0 327 45-49 11.8 37.1 1.5 14.6 8.5 3.8 13.9 1.1 7.4 0.3 100.0 233 Residence Urban 1.3 7.2 I.I 7.4 36,2 7.4 26.6 4.2 8.2 0.6 100.0 1,544 Rural 6.2 57.0 4.7 15.6 3.6 1.0 10.2 0.7 0.7 0.3 100.0 1,475 Region West 2.4 18.0 2.2 5.2 26.7 6.4 26.9 4.1 7.7 0.4 100.0 1,164 South 3,6 25.0 1.0 28.8 18.0 5.7 10.1 1.4 4.9 1.5 100.0 399 Central 3.4 40.5 3.2 11.1 19.4 2.0 16.3 2.2 1.7 0.2 100.0 773 North 6.4 62.6 1.3 4.0 9.9 2.7 8.5 1.2 3.3 0.0 I00.0 362 East 6.4 31.9 8.2 21.1 13.7 2.0 16.0 0.0 0.7 0.2 100.0 322 Education No education 9.1 39.5 4.2 24.0 1.6 1.6 10.5 1.8 7.6 0.1 100.0 422 Prlmary incomplete 7.0 38.3 3.2 17.7 7.1 3.2 12.9 1.9 8.1 0.4 100.0 149 Primary complete 3.8 43.3 3.9 12.6 2.4 3.8 23.3 2.0 4.5 0.3 100.0 1,516 Secondary incomplete 1.5 21.1 I.I 6.5 23.1 5.6 34.8 2.5 2.4 1.4 100.0 246 Secondary complete+ 0.2 2.9 0.1 1.3 73.2 6.5 8.5 4.0 2.7 0.5 100.0 686 Total 3.7 31.5 2.8 11.4 20.3 4.2 18.6 2.5 4.5 0.4 100.0 3,019 Note: Professional/technical/managerial includes professional, technical, clerical and managerial occupations. Women's occupations vary by age. The proportion o f women who worked in agriculture is highest for those in the youngest and oldest age groups. The proportion declines from 58 percent of working women age 15-19 to 47 percent of women age 30-34, and it increases to 65 percent for women age 45-49. On the other hand, the proportion of women employed as professional and technical workers, has an opposite pattern: low at younger ages, peaking at age 25-29, and then declining for older women. Manual occupations attract younger women. Table 2.15 also shows that women's occupations vary significantly by urban-rural residence and region. While 84 percent o f working women ill rural areas were engaged in agricultural sector, the corresponding proportion in urban areas was only 17 percent. In contrast, urban women were more likely to be employed in professional, technical and managerial occupations (36 percent), as skilled manual labors (27 percent), in household and domestic jobs (8 percent), or in sales and services (7 percent). An examination o f regional differences shows that non-agricultrual employment is more common in the West than in other regions; 72 percent of the employed women in the West work in the non-agricultural sector, with the vast majority working in professional, technical and managerial occupations (27 percent) and unskilled manual jobs (27 percent). As expected, the majority o f employed women in the other regions 30 work in the agricultural sector; almost six in ten women in the South and Central regions and around seven in ten women in the North and East regions are engaged in agricultural jobs. Women's education is inversely related to their propensity to work in agriculture; employed women with no education were much more likely to have been working in agriculture than better- educated women. For example, 77 percent of working women with no education worked in the agricultural sector, compared with only five percent of women who have completed secondary school. Moreover, women who had completed the secondary level were more likely to be employed in professional and technical occupations or in skilled manual occupations. 2.14 Decision on Use of Earnings When assessing the status of women, one valuable indicator is their independence in making decisions on the use of their earnings. Table 2.16 shows that around half(49 percent) of employed women make their own decisions about the use of their earnings, while 29 percent decide jointly with their husband, and 15 percent are not involved in making the decisions. Independent decision-making with regard to the use of earnings tend to be higher among younger women, women in urban areas and among single and formerly married women. There also is variation across regions in the percentages of women who indicate that they alone make decisions about the money they earn. The percentage of women who make their own decisions ranges from 43 percent in the South to 51 percent in the West. The percentage of women who report making the decision together with their husbands varies from a low of 18 percent (East) to a high of 33 percent (North). Twelve percent in the East report that husbands alone decide on how to spend their earnings; in the remaining regions, the percentage citing the husband as the prime decsion-maker fall below 10 percent. 2.15 Child Care While Working The welfare of children under six years of age whose mothers are employed is the focus of Table 2.17. Overall, one in four women who worked in the 12 months prior to the survey have one or more children under age six. This proportion varies by residence, education, region, and occupation. Less educated women, women working in the agricultural sector, women working occasionally, and women living in the rural areas are more likely to have children under six. Reflecting regional fertility differentials, women living in the East are more likely to have children under age six than women living in other regions. Among working women with children under age six, 34 percent take care of their children while they work. Relatives and older female siblings are the other most common caretakers for children of working women (36 and 11 percent, respectively). The role of female siblings in child care is significant in families where the mother has limited education, works in agriculture or as seasonal worker, lives in the East, or lives in the rural areas. Children whose mothers have attended secondary school, live in urban areas or the West region, are employed all year, or work in non-agricultural occupations are more likely to be cared for by servants or hired help. Across all sub-groups, husbands and male siblings have a very limited role in child minding while the mother is at work. 31 Table 2.16 Decision on use of women's earnings Percent distribution of women receiving cash earnings by person who decides how earnings are used, according to selected background characteristics, Turkey 1998 Person who decides how earnings are used Jointly Jointly with with Number Background Self Husband/ husband/ Someone someone of characteristic only partner partner else else Missing Total women Age 15-19 47.8 1.9 1.3 32.2 15.7 1.0 100.0 306 20-24 60.4 2.0 16.8 11.4 9.4 0.0 100.0 347 25-29 51.1 4.8 37.0 2.6 4.3 0.3 100.0 291 30-34 44.8 9.3 38.6 3.7 3.6 0.0 100.0 259 35-39 38.7 10.6 49.6 0.0 1.0 0.0 100.0 271 40-44 51.5 12.5 33.9 0.0 1.7 0.4 100.0 180 45-49 44.6 13.2 40.1 0.0 2.1 0.0 100.0 109 Residence Urban 54.5 3.4 29.1 6.4 6.3 0.2 100.0 1.316 Rural 33.3 16.1 28.2 15.8 6.1 0.4 100.0 447 Region West 50.8 6.0 30.9 5.4 6.7 0.2 100.0 877 South 43.3 5.6 28.8 13.4 8.5 0.3 100.0 242 Central 50.2 7.0 27.5 10.0 5.0 0.3 100.0 379 North 49.1 5.3 33.1 7.8 4.6 0.0 100,0 114 East 46.9 11.7 17.7 18.8 4.5 0.5 100.0 151 Education No education 41.9 18.2 25.3 II.0 3.2 0.4 100.0 185 Primary incomplete 46.3 12.4 19.6 16.7 2.1 2.9 100.0 71 Primary complete 42,4 8,7 27,9 13.5 7,3 0,1 100.0 703 Secondary incomplete 62.1 0.9 15.9 8.1 12.5 0.6 100.0 166 Secondary complete+ 55.6 1.8 35.4 2.3 4.8 0.0 100.0 639 Marital status Not married 67.9 0.0 0.0 18.2 13.5 0.4 100.0 778 Currently married 34.3 11.9 51.7 1.4 0.5 0. I 100.0 985 Total 49.2 6.6 28.9 8.8 6.3 0.3 100.0 1,763 32 ho Table 2.17 Child care while working Percent distribution of currently employed women by whether they have a child under six years of age at home, and the percent distribution of employed mothers who have a child under six by person who cares for child while mother is at work, according to selected background characteristics, Turkey 1998 One or Child's caretaker while mother is at work No child more Not under chikiran Re- Neigh- Child Other Other worked Number of Background six under six spond- Husband/ Other bor/ Hired is in female male since employed characteristic at home at home ent partner relative Friend help school child child birth I Other Miasin 8 Total women Residence Urban 78.1 21.9 36.5 1.9 26.6 0.8 9.3 13.6 6.6 0.4 1.2 1.4 1,8 100.0 1,544 Rural 70.7 29.3 32.0 0.1 44.1 0.5 0.5 0.4 13.7 1.6 1.1 3.0 3,0 100.0 1,475 Education No education 72.9 27.1 36.5 1.2 19.3 0.0 0.0 0.0 28.2 1.6 1.8 7.2 4,3 100.0 422 Primary inoompleta 80.0 20.0 27.7 0.0 40.5 2.2 3.5 0.0 18.1 3.3 0.0 4.7 0,0 100.0 149 Primary complete 71.9 28.1 39.3 0.7 42.9 0.5 0.5 0.3 9.0 1.I 0.7 1.9 3,1 100.0 1,516 Secondary inoomplete 78.7 21.3 45.5 0.0 39.7 0.0 0.0 6.7 6.1 0.0 1.3 0.0 0,7 100.0 246 Secondary complete+ 78.3 21.7 13.8 1.8 29.1 1.3 20.7 28.8 1.7 0.4 2.1 0.0 0,5 100.0 686 Region West 79.9 20.1 31.5 0.7 34.6 0.6 6.4 9.8 9,1 0.1 1.2 2.2 3,7 100.0 1,164 South 80.0 20.0 32.7 1.8 37.1 3.5 5.2 2.6 8.5 2.6 3.4 0.8 1,7 100.0 399 Central 70.5 29.5 38.2 1.1 37.4 0.0 2.8 7.8 7,1 0.4 1.0 2.1 2.0 100.0 773 North 67.9 32.1 27.1 0.4 44.9 0.4 2.2 1.8 13.9 3.6 0.7 1.8 3,2 100.0 362 East 64.8 35.2 38.4 0.6 28.9 0.0 5.1 2.7 18,7 0.5 0.0 4.5 0,6 100.0 322 Occupation Agricultural 70.3 29.7 28.6 0.2 46.1 0.6 0.2 0.0 16,1 1.7 0.4 2.4 3.6 100.0 1,494 Non-agricultural 78.6 21.4 40.9 1.8 23.1 0.6 10.2 14.8 3,2 0,2 2.1 2,2 1.0 100.0 1.513 Employment status All year, full week 77.8 22.2 31.1 0.8 29.4 0.7 10.4 15.3 6,1 0.2 1.1 2.2 2.9 100,0 1,292 All year, part week 82.3 17.7 31.1 5.5 28.6 0.0 9.1 21.5 4,1 0.0 0.0 0.0 0.0 100.0 105 Seasonal 72.2 27.8 27.7 0.8 47.2 0.6 0.4 0.0 15,8 2.0 0.4 2.3 2.8 100,0 1,286 Occasional 67.8 32.2 62.8 0.7 20.6 0.6 1.0 0.0 6,6 0.3 3.8 3.0 0.7 100.0 334 Total 74.5 25.5 34.0 0.9 36.4 0.6 4.4 6.2 10.6 1.0 1.1 2.3 2.5 100.0 3,019 Note: Total includes 3 women for whom information on employment status was not available and 13 women for whom information on oceupation is not available. Respondent is currently employed but has not worked since last birth. CHAPTER 3 FERTILITY Aykut Toros The fertility measures presented in this chapter are based on the retrospective reproductive histories of ever-married women age 15-49 interviewed in the TDHS. Each ever-married woman was asked the number of sons and daughters living with her, the number living elsewhere, and the number who had died. She was then asked for a history of all her births, including the month and year, and the name and sex of each birth; if deceased, the age at death was also asked. If alive, the current age and whether the child was living with the mother were also asked. Based on this information, measures of completed fertility (number of children ever born) and current fertility (age-specific rates) were calculated. These measures are analyzed in connection with various background characteristics. Cumulative fertility and children ever born are also looked at in this chapter. The tables display the data on children ever born by the woman's current age and by her age at marriage. The chapter concludes with an analysis of information on the age of the woman at the time of her first birth. The data are important because they indicate the beginning of the woman's reproductive life. 3.1 Cur rent Fert i l i ty The current level of fertility is the most important topic in this chapter because of its direct relevance to population policies and programs. Age-specific fertility rates (ASFR) for the three-year period before the survey are presented in Table 3.1 and Figure 3.1 for the country as a whole and for urban and rural areas. In addition, the total fertility rate (TFR) for women 15-44 years is shown in the table. Numerators for the age-specific fertility rates in Table 3.1 are calculated by isolating live births that occurred during the three years preceding the survey (determined from the date of birth of the child), and classifying them by age of the mother (in five-year age groups) at the time of birth (determined from the date of birth of the mother). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the three years preceding the survey. The crude birth rate (also shown in Table 3.1) is calculated by summing the product of the age- specific rates multiplied by the proportion of women in the specific age group out of the total de facto population, male and female. The general fertility rate is calculated as the number of births per thousand women in the reproductive age groups. Age-specific fertility rates are estimated for the three years preceding the survey. As is typical, the distribution is skewed towards the younger ages. The highest fertility rate is observed for the age group 20-24. After age 24, the rates decline steadily, implying modern levels of fertility control in upper ages. 35 Table 3.1 Current fertiliW Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-raral residence, Turkey 1998 Age group Residence Urban Rural Total 15-19 55 68 60 20-24 141 211 163 25-29 139 178 150 30-34 97 85 93 35-39 32 60 42 40-44 14 12 13 45-49 0 2 I TFR 15-49 2.39 3.08 2.61 TFR 15-44 2.39 3.08 2.61 GFR 87 107 94 CBR 22.8 24.7 23.4 Note: Rates are for the period 1-36 months preceding the survey, Rates for age group 45-49 may be slightly biased due to truncation, TFR: Total fertility rate expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women 250 Figure 3.1 Age-Specific Fertility Rates by Urban-Rural Residence Births per 1,000 women 200 150 I00 $0 15-19 20-24 20-29 3034 35-39 40-44 Age Iyurb,n TRur*l ~rot.i I 4.~ ! ~9 TDHS 1998 36 The total fertility rate (number of children a woman would bear if she lived through these rates throughout her reproductive life span) is slightly over three children (3.1) for women living in rural areas, and decreases to around two children (2.4) in urban areas. The national average is 2.6 children per woman. When compared with evidence from previous surveys (see HIPS, 1980, 1987, and 1989) the urban/rural gap appears to be closing. The crude birth rate has fallen to the lower twenties. As expected, birth rates are higher in rural areas (24.7 per thousand) than in urban areas (22.8 per thousand). The national average (23.4 per thousand) implies a rather low population growth rate even if the crude death rate is very low. The total fertility rates for the three-year period prior to the TDHS-98 are summarized in Table 3.2 for major groups in the population. The table also provides a basis for inferring trends in fertility by comparing current synthetic measures with the average number of children ever born to women currently 40-49 years of age. Although comparison of completed fertility among women age 40 or more with the total fertility rate can provide an indication of fertility change, such an approach is vulnerable to an understatement of parity for older women. The findings on contraceptive use (Chapter 4) and nuptiality (Chapter 6) are also of crucial importance in reaching a balanced judgment about fertility trends. Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 40-49, by selected background characteristics, Turkey 1998 Mean number of children Total Percentage ever born Background fertility currently to women characteristic rate pregnant age 40-49 Residence Urban 2.39 4.8 3.82 Rural 3.08 5.4 5.02 Region West 2.03 3.5 3.43 South 2.55 5.3 4.46 Central 2.56 5.5 3.84 North 2.68 4.4 4.36 East 4.19 8.0 7.00 Education No educ./Pri, incomp, 3.89 6.0 5.63 Pri. comp./Sec, incomp. 2.55 5.4 3.40 Sec. comp./+ 1.61 2.6 1.84 Total 2.61 5.0 4.22 Rate for women age 15-49 years There are clear variations in fertility levels by region and education. These variations are evident for past fertility experience (mean number of children for women age 40-49) as well as current fertility levels (total fertility rates). Regional variations of fertility involve three regional groupings. The Eastern region is notable as a high fertility region, with a total fertility rate exceeding four children (4.2). The North, Central and South regions constitute another group, with rates well under three children (2.7, 2.6, and 2.6, respectively). The lowest rate (2.0) is found in the West region and is comparable to that of many Western European countries. 37 The regional groupings based on current levels of fertility are also cogent for examining differences in the past fertility experience. Although the mean number of children born to women age 40-49 is much higher (between 50 to 75 percent) than the corresponding TFRs in each of the regions, notable variations are observed as with current fertility. The table suggests an overall decline in fertility, keeping regio~ml differences almost the same, during the last three decades. Past experience as well as current levels of fertility show strong variations by levels of education. Both the total fertility rate and the number of children ever born are more than fifty percent lower among women with at least a secondary level of education compared to women with no education. Fertility trends can be analyzed in two ways. One is to compare TDHS data with the results of previous surveys. Fertility trends can also be examined based on TDHS data alone. Having the complete birth history provides more direct evidence on trends, thereby permitting more accurate conclusions, However, use of birth histories for analysis of trends places a great burden on the quality of data, which should always be interpreted with caution. Table 3.3 shows the age-specific fertility rates for five-year periods preceding the survey, The age-specific schedule of rates in Table 3.3 is progressively truncated as time before the survey increases. The bottom diagonal of estimates (enclosed in brackets) is also truncated. Total fertility rates can be calculated from the age-specific rates in Table 3.3, but only by summing across ages unaffected by truncation. Table 3.3 A~e-spe~ifie fertility, rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age, Turkey 1998 Number of years preceding lhe survey Mother's age 0-4 5-9 10-14 15-19 15-19 62 79 90 122 20-24 169 190 221 259 25-29 148 166 189 221 30-34 91 103 119 II76] 35-39 40 52 [70] 40-44 14 [20] 45-49 11] Note: Age-specific fertility rates are per 1,000 women. Esti- mates enclosed in brackets are truncated. The decline of fertility over time, which is implied by the earlier tables, is seen much more clearly in Figure 3.2. Cumulation of the ASFRs up to age 40 shows a recent decline in fertility of fourteen percent, from 3 births per woman in the period 5 to 9 years before the survey to 2.6 births per woman in the five-year period immediately preceding the survey, Table 3.4 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. These rates are similar to those presented in Table 3.3 and the same admonitions apply in their interpretation. Fertility early in marriage often remains resistant to change, even when fertility is declining, because fertility decline usually begins at the older ages (when women start to limit the number of births) and not among young couples postponing births. Therefore, a complete examination of duration-specific trends requires interpretation in the light of other evidence. 38 300 • Figure 3.2 Age-Specific Fertility Rates during the Last 20Years Births per 1,000 women 250 - ~ i i 200 150 100 50 0 15-19 20-24 25-29 30-34 35-39 40-44 Molher'sAge [~1994-1998 "7'1989-1993 "5"1984-1988 ")-1979-1983 I Note: Dates are approximate and refer to September 1998, the mid-pointoffieldwork. 45-49 TDItS 1998 Fertility rates are declining in general, but as shown earlier, the decline is greater among women who are in their later years of childbearing. Table 3.4 indicates that a decline of fertility by around one- fifth, from 358 to 293, among women married 0-4 years and, thus, in the early years of childbearing; in fact, this decline is slightly more than the decline observed in TDHS-93. An even more substantial decline (by almost 40 percent from 264 to 164) is observed for women married 5-9 years and very dramatic changes (around than sixty percent) occurred among women who had been married for longer durations. Althougb this pattern is quite common among populations with increasing fertility control, the speed of change is noteworthy. The table also indicates that the decline in fertility was more rapid during the early 1990s than during the late 1980s. Table 3.4 Fertility by marital duration Fertility rates for ever-married women by duration since first marriage in years, for live-year periods preceding the survey. Turkey 1998 Marriage Number of yeats preceding the survey duration at birth 0-4 5-9 I0-14 15-19 0-4 293 309 335 358 5 -9 164 | 82 214 264 10-14 85 107 147 210 15-19 49 75 104 [161] 20-24 23 50 [106] 25-29 12 [21] Note: Fertility rates are per 1,000 women. Estimates enclosed in brackets are truncated. 39 3.2 Children Ever Born and Living The distribution of women by number of children ever born is presented in Table 3.5 for all women and for currently married women. In the TDHS-98 questionnaire, the total number of children ever born was ascertained by a sequence of questions designed to maximize recall. Life-time fertility reflects the accumulation of births over the past 30 years and, therefore, its relevance to the current situation is limited. Table 3,5 Children e'~er born and livin~ Percent distribution of all women and of currently married women by number of children ever born (CEB) and mean number ever born and living, according to five-year age groups, Turkey 1998 Number of children ever born (CEB) Number Mean no. Mean no Age of of of living group 0 I 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN 15-19 92,1 6.7 0.9 0.2 0,0 0.0 0,0 0.0 0.0 0.0 0,0 I00,0 1,720 0.09 0.09 20-24 53.9 24.1 15.8 4.3 1.3 0.4 0.I 0.0 0.0 0.0 0.0 100.0 1,558 0.76 0.72 25-29 22.8 22,5 32.0 13,g 4,S 2.6 1.0 0.4 0.2 0.1 0,0 t00,0 1,397 1.71 1.60 30-34 10.2 12.7 33.2 20.5 12.0 5.1 2.5 2.1 1.0 0.4 0.4 100.0 1,202 2.59 2.39 35-39 6.0 7.6 29.3 21.2 15.5 7.5 4.6 2.7 2.4 1.6 1.6 100,0 1,081 3.27 2.95 40-44 3.8 5.6 22.4 20.7 14.6 10.9 7.1 3.9 4,6 3.5 2.9 100.0 885 3.96 3.51 45-49 3.7 4.5 15.7 17.8 16.0 11.7 10.1 5.8 5.5 3.0 6.1 100,0 733 4.54 3.80 Total 34.9 13.1 20.3 12.3 7.5 4.3 2.7 1.6 1.4 0.9 1.1 100.0 8,576 2.01 1.80 CURRENTLY MARRIED WOMEN 15-L9 49.6 42.9 6.2 I.l 0.2 0.0 0.0 0.0 0.0 0.0 0.0 100.0 262 0.59 0.56 20-24 23.8 39,7 26.3 7.3 2.2 0.6 0.1 0.0 0.0 0.0 0,0 100.0 924 1.27 1.20 25-29 11.1 25.5 37.1 16.0 5.2 3.1 1.1 0.5 0.2 0.1 0.0 100.0 1,196 1.97 I.g5 30-34 3.7 13.1 35.6 22.2 13.3 5.5 2.7 2.2 1.1 0.4 0.4 100.0 1,090 2.79 2.57 35-39 3.6 7.0 30.0 22.4 16.3 7.5 4.7 2.7 2.4 1.7 1.7 100.0 1,014 3,37 3.04 40-44 1.7 5.5 22.3 20.3 15.4 11.7 7.9 4.1 5.0 3.4 2,8 1O0.0 789 4.08 3.62 45-49 2.2 3.6 15.7 18.5 16.7 12,4 10.3 6.0 4.9 2.9 6.6 100.0 645 4.64 3.89 Total 9.9 18.0 28.2 17.1 I0.5 5.9 3.7 2.2 1.9 1.2 1.5 100.0 5,921 2.76 2.49 The results in Table 3.5 for younger women who are currently married differ from those for the sample as a whole because of the large number of unmarried women with minimal fertility. Differences at older ages, though minimal, generally reflect the impact of marital dissolution. The parity distribution for older currently married women provides a measure of primary infertility, A comparison of the mean number of children ever born with the mean number of children surviving offers a quick evaluation of the survival status of the children. Around one.in six children born by womeu age 45-49 had not survived at the time of the survey (4,5 versus 3,8). The proportion of children surviving among younger women is much higher. This may not only reflect the shorter exposure to risk by the children of the younger cohorts, but also is evidence of hnproved mortality conditions in general. Of all children born (mean of 2.0), 90 percent (mean of 1.8) were still alive at the time of the survey. As marriage is universal in Turkey (see Chapter 6), the proportion of women remaining childless is very low. The proportion of women with no children declines in tandem with the proportion remaining single, and almost all women who are married by the age of 45-49 have children. Just over 2 percent of fl~e currently married women who are about to complete their reproductive period remain childless, probably largely due to sterility rather than preference. 40 3.3 Birth Intervals There has been a fair amount of research to indicate that short birth intervals are deleterious to the health of babies. This is particularly true for babies born at intervals of less than 24 months. Table 3.6 shows the percent distribution of non-first births in the five years preceding the survey by the number of months since the previous birth. Table 3,6 Birth intervals Percent distribution of births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Turkey 1998 Number ormonths since previous birth Characteristic 7-17 18-23 24-35 36-47 48+ Median number of month Number since of previous Total births birth Age of mother 15-19 (29.1) (27.0) (30.8) (13.1) (0.0) 100.0 23 23.4 20-29 18.5 16.4 24.2 17.9 23.0 100.0 |.187 30.7 30-39 8.1 7.8 19.9 15,7 48.6 100.0 919 46.6 40+ 3.4 7.9 15.1 9,0 64.6 I00.0 125 Birth order 2-3 13.6 13.3 20.2 17.2 35.6 100.0 1,482 37.6 4-6 14.0 9.3 23.6 15.2 37.8 100.0 544 37.5 7+ 11.8 14.8 29.7 14,6 29. I 100.0 229 33.6 Sex of prior birth Male 13,3 11,3 21,7 16.9 36.8 100.0 1.141 38.0 Fenmle 13.7 13.8 22.4 16,0 34,2 100.0 1,113 36.1 Survival of prior birth Living 11.6 12.0 22,0 17,0 37.4 100.0 2,096 38.4 Dead 39.5 20.0 22.0 8.9 9.7 100.0 158 21,6 Residence Urban I1.1 10.9 20.0 17,7 40.4 100.0 1,359 40.6 Rural 17.2 15.1 25.1 14,5 28.1 100.0 895 31.6 Region West 10.0 7.8 17.6 193 45.2 100.0 594 44.3 South t 0.0 11.8 20.3 18.1 39.8 100.0 311 39,4 Central 11.2 13.8 20.8 14.6 39.6 100.0 496 38,5 North 15.0 10.9 24.4 13.3 36.3 100.0 182 35,7 East 19.5 16.5 26.9 15.4 21.6 100.0 672 28,7 Education No edue./Pri, incomp. | 4.4 14.0 29.7 15.0 26.9 100.0 790 32,1 Pri. comp./Sec, incomp. 13.5 12.4 18.5 17.4 38.2 [00.0 1,279 39, l See. comp,/+ 9.9 7.1 13.2 16. I 53.6 100.0 185 49,9 Tota] 13.5 ]2.5 22.0 16.5 35.5 I00.0 2.254 37.0 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. ( ) Figures in parentheses are based on 25-49 unweighted births. 41 The median birth interval is sligbtly over three years (37 mouths). This is more than a year longer than the minimum considered safe. One-fourth of non-first births were born with intervals of less than 24 months. This percentage shows striking variations by background variables. Among births to women with at least a secondary education, the percentage born within 24 months of a prior birth is about 40 percent lower than the percentage of short interval births among women with no education (17 percent and 28 percent, respectively). The smallest proportion of short birth intervals is observed in the West region and the highest proportion in the East regiou (18 percent and 36 percent, respectively). Short intervals following a female birth are more frequent than for male births (28 percent and 25 percent, respectively). Among all the factors presented in the table, the survival status of the preceding child appears to be strongly related to the proportion of short birth intervals (24 percent for surviving children and 60 percent for deceased children). 3.4 Age at First Birth The age at which childbearing begins has important demographic consequences as well as important consequences for the mother and child. In many countries, postponement of first births, reflecting an increase in the age at marriage, has contributed greatly to overall fertility decline. The proportion of women who become mothers before the age of 20 is also a measure of the magnitude of adolescent fertility, which is a major health and social concern in many countries. Table 3.7 presents the distribution of Turkish women by age at first birth, according to their current age. Table 3.7 Age at first birth Percent distribution of women 15-49 by age at first birth, according to current age, Turkey 1998 Median Women Age at first birth Number age at with no of first Current age births <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 92.1 0.3 5.2 2.4 NA NA NA 100.0 1.720 a 20-24 53.9 0.9 10.0 15.3 13.5 6.4 NA 100.0 1,558 a 25-29 22.8 1.7 12.7 15.6 18.1 20.2 8.8 100.0 1,397 22.2 30-34 10.2 1.8 13.0 17.2 18.9 20.9 18.0 100.0 1.202 21.9 35-39 6.0 3.0 17.4 21.2 16.2 17.8 18.3 100.O 1.081 20.9 40-44 3.8 1.6 18.4 24.2 20.7 16.7 14.6 100.0 885 20.5 45-49 3.7 3.7 20.0 20.2 19.3 20.0 13.3 100.0 733 20.6 NA = Not applicable ° Less than 50 percent of the women in group x to.r + 4 have had a birth by age x. Age of childbearing is increasing gradually. The median has risen from 20.6 years among women age 45-49 years to 22.2 years among women age 25-29 years, The table indicates dramatic changes in adolescent fertility. Some 26 percent of women age 20-24 during the survey had become mothers before age 20; this percentage is substantially lower than the percentage for women age 30-34 (32 percent). Among women aged 35-44 at the time of the survey, more than 40 percent or more had become mothers in their teens. The median age at first birth for different cohorts is summarised in Table 3.8 and the entry age into motherhood for different subgroups of the population can be compared (the medians for cohorts 15- 19 and 20-24 could not be determined because half the women had not yet had a birth). 42 Table 3.8 Median age at first birth by background characteristic8 Median age at first birth among women 25-49. by current age and selected background characteristics, Turkey 1998 Current age Women Background age characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Residence Urban 22.6 22.2 21.1 20.8 20.8 21.7 Rural 21.6 21.3 20.5 19.9 20.4 20.7 Region West 22.7 22.4 21.5 20.9 20.8 21.8 South 23.0 21.9 21.6 20.4 19.9 21.5 Central 22.0 21.4 20.5 20.4 20.9 21.1 North 22.2 22.2 20.7 20.4 20.9 21.3 East 20.7 20.5 20.2 19.7 19.8 20.2 Education No educ./Pri, ineomp. 20.1 19.5 19.9 19.5 19.7 19.7 Pri. comp./Sec, incomp. 21.6 21.5 20.3 20.7 20.7 21.1 See. comp./+ 25.9 24.9 23.8 24.7 Total 22.2 21.9 20.9 20.5 20.6 21.3 Note: The medians for cohorts 15-19 and 20-24 could not be determined because some women may still have a birth before reaching age 20 or 25, respectively. The median age at first birth is over 21 years (21.3) among all women 25-49. It varies considerably according to background variables. Women living in urban areas had their first birth one year later than women living in rural areas. When they first become mofl~ers, women living in the East region were 1.6 years younger than women living in the West region. The level of education shows the biggest differentials among the background variables considered in this table, For example, women age 30-34 with no education became mothers on average at the age o f 19.5, while women in the same cohort with at least a secondary level o f education waited an additional six years before they had the first birth. 3.5 Teenage Pregnancy and Motherhood Table 3.9 shows the percentage of women age 15-19 who are mothers or pregnant with their first child. About one in twelve (9 percent) of women age 17 have become mothers or are pregnant with their first child. The proportion increases steeply to more than one in six (16 percent) among women age 18 and close to one in four (23 percent) among women age 19. Higher proportions o f teenagers living in rural areas have begun childbearing than teenagers living in urban areas (l 1 percent and 9 percent, respectively). Although fertility is highest ill the East region, tile proportion of teenagers who have begun childbearing is virtually the same in the Central and South regions as in the East. Education appears to have the strongest association with teenage fertility, not only because the time spent in school results in later marriage and postponed births, but also because of changes in childbearing attitudes. 43 Table 3.9 Teenaee ore2nancv and motherhood Percentage of teenagers 15-19 who are mothers or pregnant with their first child, by selected background characteristics. Turkey 1998 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of characteristic Mothers child hearing teenagers Alg5 e 1.3 0.5 1.8 305 16 1.6 0.3 1.9 372 17 4.9 3.8 8.8 347 Ig 12.2 3.7 16.0 396 19 20.1 3.0 23.1 301 Residence Urban 7.4 2.0 9.4 1,034 Rural 8.6 2.8 I 1,4 686 Region West 7.2 2.2 9.3 539 South 8.4 2.6 I 1,0 26 I Central 8.8 2.4 11,2 380 North 4.3 2.5 6.7 136 East 8.8 2.2 11.0 404 Education No educ./Pri, incomp. 15.3 6.7 22.0 183 Pri. comp/Sec, incomp 8.3 2.1 10,4 1,239 See. comp./+ 1.6 0.4 2.0 297 Total 7.9 2.3 10.2 1,720 Note: The sum of the absolute values does not add up to the total value in the last three categories due to the ever-married factors used, 44 CHAPTER4 FAMILY PLANNING Turgay Unalan and Ismet Ko~ This chapter presents the TDHS-98 results regarding various aspects of contraceptive knowledge, attitudes and behaviour. While the focus is on women, some results from the husband survey will also be presented, since men play an important role in the realisation of reproductive goals. To get an indication of interspousal communication and agreement (perceived) in the attitudes and knowledge of couples regarding family planning, the responses of men were, where possible,'paired with responses obtaiaed from their wives in the same household. To obtain the data on knowledge and use of family planning, respondents were first asked to name all of the methods of family planning that they knew or had heard about. For methods which were not mentioned spontaneously, a description of the method was read and the respondents were asked if they had heard of the method. Respondents were then asked if they were currently using a method and, if so, from where they had obtained the currently used method. 4.1 Knowledge of Family Planning Methods Table 4.1 presents the levels knowledge of contraceptive methods for female respondents by marital status and for husbands. Knowledge of modern methods is almost universal. Knowledge of traditional methods is also high among married respondents (91 percent among currently married women and 88 percent among husbands). However, knowledge of traditional methods is much lower amm}g never-married women, with only about three in five recognizing any traditional method. Tile IUD and Table 4.1 Knowledge of contraceptive methods and source for methods Percentage of all women currently'marrled women, and husbands who know any contraceptive method, by spee fie method, Turkey 998 Never- CurrentLy Contraceptive All married mameo method women women women Husbands Any method 98.2 96.5 9-g?:.9 9"7"N'--- A~i~( I modern method 98.0 96.5 98.7 97.1 94.4 91.0 95.8 92.5 IUD 94.9 89.7 97.0 87.0 Ir~iections 72.8 64.9 76.2 61.7 DiaNwaRm/Foam/Jelly 45.0 30.5 50.5 26.0 CoridoJff 79.9 66.9 85. I 84.6 Female sterilisation 79. I 67.9 83.4 68.8 Male sterilisation 41.4 32.2 45.0 49.4 Implant 22.2 15.1 24.8 13.1 Any traditional method 81.7 59.0 90.6 87.8 Periodic abstinence 43.6 38.3 45.4 61.0 Withdrawal 77.4 46.5 89.4 83.9 Other methods 6.0 2.7 7.2 2.9 Any tradltlonal/folk method 82.0 59.3 90.8 87.8 Total 8,576 2,380 5,921 1,971 Mean 6.6 5.5 7.0 6.3 45 pill are the most widely known family planning methods among women and husbands followed by the condom and female sterilisation. Withdrawal, a traditional method of avoiding pregnancy, is known to 89 percent of currently married women and 84 percent of husbands, but to only 47 percent of never- married women. The mean number of methods known is a rough indicator of the breadth of family planning methods. On average, 7 methods are known by currently married women, 6.3 methods are known by husbands, and 5.5 methods by never-married women. Table 4.2 shows the correspondence between the contraceptive knowledge of husbands and wives for tile 1,896 couples interviewed in the TDHS-98. The proportion of couples where both spouses know at least one method of contraception is 97 percent. This proportion is 96 percent for modern methods and 81 percent for traditional methods. Eighty-six percent of couples know tile IUD and 89 percent know the pill. The proportion of couples with withdrawal knowledge is also high (78 percent), For couples where only one partner knows of a method, wives are more likely to know tile method than their husbands; the exceptions are mate sterilisation and periodic abstinence. Table 4.2 Couples' knowledge of contraceptive methods Percent distribution of couples by knowledge of specific contraceptive methods, Turkey 1998 Wife Husband knows Both knows inethod, Number Contraceptive know method, not hus- Neither of method method not wife band know Total couples Any method 97.0 1.0 1.8 0.2 100.0 1,896 Any modern method 95.9 1.4 2.5 0.2 100.0 1.896 Pill 88.9 3.9 6.1 1.1 100.0 1,896 IUD 85.9 1.3 10.7 2.1 100.0 1,896 Injectiolas 49.6 12.5 26.4 I 1.5 100.0 1.896 Diaphragm/Foam/lelly 16.3 9.2 34.4 40. I | 00.0 | ,896 Condom 75.7 8.9 9.6 5.9 I00,0 1,896 Female sterilisation 59.4 9.6 22.8 8.2 I 0O.0 1,896 Male sterilisation 28.3 21.2 16.3 34.2 100.0 1,896 Implant 6.4 6.7 17 ,g 69. I 100.0 1,896 Any traditional method 81.4 6.4 9.3 2.9 100.0 1,896 Periodic abstinence 34.3 26.5 12.1 27.0 100.0 1,896 Withdrawal 77.6 6.4 11.8 4.2 100.0 1,896 Any |blk method 0.3 2.7 7.4 89.6 100.0 1,896 Any traditional/folk method 81 .g 6.1 9.3 2.9 100.0 1,896 4.2 Ever Use of Family Planning Methods Ever-married women and husbands interviewed in the TDHS-98 who reported that they had heard of a method of family planning were asked if they had ever used that method. Table 4.3 looks at the extent to which women and husbands report having had experience with the use of contraceptive methods. The proportion of currently married women who have ever used any contraceptive method is 84 percent. Overall, modem methods are much more frequently adopted than traditional methods; 67 percent of all currently married women and 68 percent of husbands have used a modern method while 60 percent of currently married women and 56 percent of husbands have used a traditional method. 46 Table 4.3 Ever use of contraception Among currently married women and husbands, the percentage who have ever used a contraceptive method, by specific method, according to age, Turkey 1998 Modem methods Traditional methods Dia- Female Male Peri- Any Number Any phragm/ steri- steri- Any odie With- Other trad./ of Any modern Injee- Foam/ Con- lisa- lisa- Ira- trod. absti, draw- meth- fo lk womerd Age method method Pill IUD tion Jelly dora tion tion plants method nenee al ads method husbands CURRENTLY MARRIED WOMEN 15-19 54.9 26.4 7.6 9.6 0.8 1.0 16.5 0.0 0.0 0.0 44.7 3.6 44.2 0.0 44,7 262 20-24 74.8 49.7 17.5 23.4 1.5 3.0 29.5 0.3 0.0 0.0 56,2 3.8 55.2 0,7 56.6 924 25-29 85.6 70.8 29.8 40.9 3.5 4.1 35.4 1.8 0.0 0.1 61.4 ~8.5 59.2 0.7 61.8 1,196 30-34 90.2 ' 77.3 39.7 46.4 3.3 7.1 36.9 5.9 0.0 0.1 63.6 9.0 61.1 1.3 63.9 1,090 ' 35-39 89.2 75.7 41.3 52.8 2.5 10.5 32.8 7.1 0.0 0,2 62.0 9.7 59.8 3.0 63.3 1,014 40-44 87.7 71.9 43.3 42.3 3.5 12.8 29.2 7.0 0.0 0.0 63.2 9.7 61.0 4.2 65.2 789 45-49 84.5 66.9 45.2 30.5 3.9 13.1 20.3 5.7 0.2 0.0 56.6 9.7 54.4 4.2 58.3 645 Total 84.2 67.3 34.2 38.9 2.9 7,6 31.0 4.2 0.0 0.1 60.1 8.1 58.1 2.0 61.0 5,921 HUSBANDS 15-24 60.4 30.9 11.7 8.6 1.7 0.8 15.2 1.2 0.0 0.0 46.1 7.4 41.6 0.0 46.1 112 25-29 78.6 60.2 21.6 24.4 5.1 0.9 38.2 0.2 0.0 0.0 56.8 16.5 51.3 0.5 57.1 342 30-34 84.8 70.5 28.0 38.2 1.6 3.2 45.5 2.8 0.4 0.2 60.9 20.1 56.4 0.9 60.9 364 35-39 90.1 78.4 36 .8 45,7 4.7 3.2 38.3 5.2 0.4 0.4 60.0 20.4 54.3. 1.4 60.4 352 40-44 85.5 75.6 37.9 45.0 6.1 2.6 34.8 6.8 0.0 0.0 51.9 17.0 48.5 1.8 51.9 335 45-49 85.5 70.1 47.0 35.3 9.9 8.7 32.0 6.9 0.0 0,0 59.4 21.3 53.1 0.8 59.5 240 50+ 72.7 59.8 34.0 31.5 6.3 6.6 26.4 3.3 0.0 0.0 46.2 14.0 42.7 0.4 46.5 226 Total 82.1 67.5 32.2 35.5 5,1 3.6 35.6 3.9 0.1 0.1 55.8 17.7 51.0 0.9 56.0 1,971 With regard to the ever use of specific methods of contraception, slight differences are observed between the levels reported by women and husbands. The proportion of those who reported ever use of the pill, IUD and the diaphragm, foam and jelly, were slightly higher among women while the proportions ever reporting use of.condom and injections were slightly higher among husbands. With respect to traditional methods, women were somewhat more likely to report ever use of withdrawal then men, while men were more likely to report ever use of periodic abstinence. 4.3 Current Use of Contraceptive Methods The level of current use of family planning is one of the indicators most frequently used to assess the success of the family planning programme activities. It is widely used as a measure in the analysis of. the determinants of fertility. This section focuses on the levels and differentials in family planning use, with particular emphasis on the method mix among users. 47 Table 4.4 presents the level of current use of contraceptives for currently married women and husbands by age group. Overall, 64 percent of currently married women in Turkey are currently using a method of contraception. Of the users, the majority rely on a modern method (Figure 4.1). One in five currently married women are using the 1UD. The condom, which is the second most popular modern method, is used by approximately 8 percent of married women and 11 percent of the husbands. Withdrawal, a traditional method, is the most popular method among currently married women in Turkey, with 24 percent currently using the method. Table 4.4 Current use ofcontraceotion Percent distribution of all women, currently married women, and husbands, by contraceptive method currently used, according to age, Turkey 1998 Modern methods Traditional methods Any Any modem Age method method Pill IUD Dia- Female Male Pert- Not Number phragm/ steri- steri- Any odie With- Other cur- of Injec- Foam/ Con- lisa- lisa- trad. absti- draw- meth- rently women/ tion Je l ly dora tion tion method hence al ods using Total Imsbands CURRENTLY MARRIED WOMEN 15-19 33.6 15.7 1.9 7.4 0.5 0.0 6.0 0.0 0.0 17.8 0,5 17.3 0.0 66.4 100.0 262 20-24 52.9 30.8 4,8 16.3 0.3 0.3 8.8 0.3 0.0 21.9 0.3 21.6 0.2 47,1 100,0 924 25-29 67.0 43.3 6.1 22.9 1.1 0.5 10.9 1.8 0.0 23.4 0.5 22.9 0.3 33.0 100.0 1,196 30-34 74.3 47.3 5.2 25.6 0.3 0.5 9.7 5.9 0.0 26.7 0.8 25.8 0.4 25.7 100.0 1.090 35-39 76.3 46.6 3.9 27.4 0.7 0.8 6.8 7.1 0.0 28.8 1.3 27.5 0.9 23.7 100.0 1,014 40-44 70.0 36.6 3.4 16.6 0.0 1.0 8.6 7.0 0.0 31.9 1.9 30.0 1.5 30.0 100.0 789 45-49 41.4 17.6 2.1 6.4 0.0 0.8 2.5 5.7 0.2 22.6 2.6 20.1 I.I 58.6 100.0 645 Total 63.9 37.7 4.4 19.8 0.5 0.6 8.2 4.2 0.0 25.5 I.I 24.4 0.6 36.1 100.0 5,921 HUSBANDS 15-24 33,9 17.7 5.8 7.9 0.0 0,0 2.9 t.2 0.0 16.2 0.0 16,2 0.0 66A 100.0 112 25-29 60.4 39.4 6,8 14.9 1.4 0.2 15.9 0.2 0.0 20.8 1.8 19.0 0.2 39.6 100.0 342 30-34 69.6 50.0 8.8 21.7 0.2 0.4 15.8 2.8 0.4 19.2 1.2 18.0 0.4 30.4 100.0 364 35-39 75,4 50.0 7,7 24.3 0,2 0.4 12.3 4.8 0,4 24.5 1.9 22.7 0.9 24.6 100.0 352 40-44 68.9 50.6 7.0 26,2 I.I 0.5 9.0 6.8 0.0 17.9 1.2 16.7 0.4 31.1 I00.0 335 45-49 61.8 40.2 7.1 15.7 0.0 1.6 8.8 6.9 0.0 21.5 2.3 19.2 0.1 38.2 100~0 240 50+ 40.7 23.8 1.8 9.5 0.0 2.7 6,6 3,3 0,0 16,7 2,4 14,3 0,2 59,3 100,0 226 Total 62.6 42.2 6.8 18.8 0.5 0.7 11.4 3.9 0.J 20.0 1.6 18.4 0.4 37.4 100.0 1,971 48 Figure 4.1 Current Use of Family Planning Methods, Turkey 1993 and 1998 Withdrawal Rhythm Traditional Methods Female Sterilisation Condom IUD Pill Modern Methods ~ 8 i [ 1920 38 10 20 30 Percefil fr -~igHS-33U T n H~9i~ 40 TDHS 1998 Table 4.4 also shows the variation in current use levels by age. Younger and older women are much less likely to be using contraception than women 25-44. As Table 4.5 shows, contraceptive use also increases rapidly with the number of living children, peaking at 78 percent among women with two children, after which it declines to 59 percent among women with four or more children. There appears to be only limited effort to delay the first birth; 18 percent of the currently married women with no children are using a method. The proportions of women currently using correlates positively with educational level, with the largest proportion observed among women with a secondary or higher education. Women with secondary or higher education are also more likely to be using modern contraceptive methods, especially the IUD and the condom, than less educated women. More than half of all women in this education group are users of a modern method, with almost a quarter using the IUD. There are marked differences by residence in the proportion of women currently using a modem contraceptive method. Urban women are considerably more likely to be using a modem mefllod than rural women. While 71 percent of currently married women in the West region are using some kind of contraception, the proportion is to 42 percent in the East (Figure 4.2). The proportions using a modern method are highest in the Central and West regions (43 and 41 percent, respectively) followed by the South, North and the East regions. The use of withdrawal seems to be popular across the country but principally in the North (31 percent) and the West (28 percent). 49 Table 4.5 Current use ofcontraeeotion by background characteristics Percent distribution of currently married women and husbands by contraceptive method currently used, according to selected background characteristics. Turkey 1998 Modern methods Traditional methods Din- Any phragm/ Background Any modern Injec- Foam/ Con- characteristic method method Pill IUD tion Jolly dora Female Male Pert- Not Number steri- steri- Any odic With- Other cur- of lisa- lisa- trod. absti- draw- meth- rently women/" lion lion method nenee al ods using Total husbands CURRENTLY MARRIED WOMEN Number of living children None 17.6 9.2 3.3 0.1 0.0 0.2 5,5 0,0 0.0 8.4 0.5 8.0 0.0 82.4 100.0 613 1 59.6 33.1 3.9 17.9 0.7 0.1 10.4 0.1 0.0 26.2 1.5 24.7 0.3 40.4 100.0 1,132 2 78.1 49.3 5.1 27.3 0.6 0.8 11.1 4.3 0.1 28,4 1,5 26.9 0.4 21.9 100.0 1,802 3 76.4 43.8 5.6 23.5 0.3 0.7 6.8 6.9 0.0 ' 31.3 0.6 30.6 1.3 23,6 100.0 1,096 4+ 59.0 34.0 3.1 17.1 0,5 1,0 4.8 7.5 0.0 23.9 0.7 23.1 1.1 41.0 I00.0 1,279 Residence Urban 66.7 40.8 4.6 21.0 0.5 0.6 9.3 4.7 0.0 25.2 1.4 23.8 0.6 33.3 100.0 3,978 Rural 58.1 31.4 3.8 17.3 0,3 0.6 6.0 3.3 0.0 26.0 0.5 25.5 0.7 41.9 100.0 1,943 Region West 70.5 40.5 5.4 20,5 0.3 0.7 9.4 4.2 0.1 29.2 1.6 27.6 0.9 29.5 I00.0 2,261 South 60.3 35.1 2.3 20.9 0.5 0.7 6.2 4.5 0.0 24.6 0.4 24.2 0.6 39.7 100.0 851 Central 68.3 42.8 4.9 24.2 0.5 0.6 9.2 3.4 0.0 24.7 1.1 23.7 0.8 31.7 100.0 1,426 North 67.0 35.2 4.5 12.4 0.0 0.7 9.2 8.4 0.0 31.5 0,7 30.9 0.3 33.0 100.0 474 East 42.0 26.7 2.9 14.0 1.1 0.2 5.2 3.3 0.0 15.2 0.7 14.4 0.1 58.0 100.0 909 EducatiOn No edue./ Pd. tneomp. 50.4 27.9 3.1 14.0 0.5 0.8 4.0 5.6 0.0 21.5 0.4 2l.I 0.9 49.6 100.0 1,546 Pri. eomp./ See. incomp. 67.1 38.6 4.4 21.4 0.5 0.5 8.1 3.6 0.0 27.9 0,6 27.3 0.7 32.9 I00.0 3,570 See. comp.+ 75.3 52.7 6.4 23.8 0,2 0.8 17.0 4.5 0.0 22.5 4,4 18.1 0.l 24.7 100.0 804 Total 63.9 37.7 4.4 19.8 0,5 0,6 8,2 4,2 0,0 25.5 1.1 24.4 0.6 36.1 100.0 5,921 HUSBANDS Number of living children None 26.0 14.7 6.1 0.5 0.0 0.0 8.0 0.0 0.0 11.3 2.9 8.4 0.0 74.0 100.0 187 1 66.2 42.8 7.2 18.6 0.4 0.4 15.8 0.4 0.0 23.1 2.5 20.6 0.4 33.8 100,0 372 2 77.4 53.3 6.7 25.9 0.5 0.8 15.5 3.5 0.5 24.0 1,5 22.5 0.2 22.6 100.0 566 3 68.3 46.3 7.6 21.3 1.0 1.2 9.3 5.9 0.0 21.5 1,2 20.3 0.5 31.7 100.0 334 4+ 53.3 37.1 6.3 16,3 0.4 1.0 6.2 6.9 0.0 15.7 0,9 14.7 0.6 46.7 I00.0 512 Residence Urban 66.0 45.9 7.4 20.0 0.5 0.7 13.2 3.8 0.2 19.7 2,0 17.8 0.4 34.0 I00.0 1,347 Rural 55.4 34A 5.4 16.2 0,4 0.8 7.5 4.1 0.0 20.7 0,9 19.7 0.3 44.6 100.0 624 Region West 70.0 South 60.6 Central 67,9 North 58.5 East 38.1 Education No education/ Pri, ineomp. 32.7 Pri. eomp./ Sec. ineomp. 62.4 See. eomp,+ 75.1 Total 62.6 43.8 7.8 19.4 0,2 0,9 12.6 2.6 0.3 25.8 2.5 23.3 0.4 30.0 100.0 767 41.7 3.0 21.4 0.7 1.6 9.7 5.3 0.0 19.0 0.9 18.0 0.0 39.4 100.0 285 49,9 8,5 22,4 0.9 0,6 12.7 4.8 0.0 17.4 1,6 15,8 0.6 32.1 I00.0 481 . 36.9 7.9 11,2 0.0 0.6 11.5 5.7 0.0 21.1 0,4 20.7 0.5 41.5 100.0 150 28,5 4.3 12.9 0.7 0.0 7.4 3.2 0.0 9.4 0.5 8.9 0.2 61.9 100.0 287 17.9 0.8 11,3 0.5 0.0 2.2 3.2 0.0 14.8 0,3 14.4 0.0 67.3 100.0 204 41.5 7.5 18.6 0.3 0.9 10.0 4.3 0.0 20.5 0.8 19.7 0.4 37.6 100.0 1,253 53.7 7.5 22.5 0.8 0.8 18.6 3.1 0.5 21.0 4,1 16.9 0.4 24.9 100.0 513 42.2 6.8 18.8 0.5 0.7 11.4 3.9 0.1 20.0 1.6 18.4 0.4 37.4 100.0 1,971 50 100 80 60 40 20 0 F igure 4.2 Cur rent Use of Fami ly P lann ing by Region and Method Percent EINot Using []Other [::]Withdrawal inF. Sterilisation [Condom DIUD [Pi l l West South Central North East TDHS 1998 4.4 Trend in Contracept ive Use Table 4.6 uses data from the 1988 TPHS, 1993 TDHS and the 1998 TDHS to provide the background to recent trends in current use of contraception in Turkey. A plateauing in contraceptive use at around 63 percent is apparent. However, there are a number of changes in the level of use of specific methods that are noteworthy. The proportions of women using IUD and female sterilisation in the TDHS-98 are higher than the levels reported in 1988 and 1993. In 1988, 14 percent of the currently married women were using the IUD, in 1993, 19 percent were IUD users and in 1998, 20 percent were using the IUD. In contrast, there has been a continuous decline in the proportion of women using the pill, from 6 percent in 1988 to 4 percent in 1998. Use levels for most other modem and traditional methods were almost unchanged in 1998 from the levels reported in 1988 and 1993. Thus, the overall pattern of change in contraceptive use in Turkey between 1988 and 1998 was an increasing shinto the use of moderm methods. Table 4.7 shows the recent trend in contraceptive use by urban-rural residence and region: Both urban and rural areas in Turkey have shared the increase in use of modem methods. The use of traditional methods appears to have declined among both urban and rural women; albeit in a somewhat more pronounced way in rural areas. Overall, the change in the period from 1993 to 1998 seems to have been characterized by an increase in the overall contraceptive use in rural areas, and a decline in the use of traditional methods, especially in the urban areas. 51 Table 4.6 Trends in current Use of contraception Percent distribution of currently married women by contraceptive method currently used, 1988 TPHS, 1993 TDHS and 1998 TDHS Contraceptive method TPHS-88 TDHS-93 TDHS-98 Any method 63.4 62.6 63.9 Any modern method 31.0 34.5 37.7 Pill 6.2 4.9 4.4 IUD 14.0 18.8 19.8 Condom 7.2 6.6 8.2 Female sterilisation 1.7 2.9 4.2 Other modem methods 2.0 1.3 1.1 Any traditional method 32.3 28.1 25.5 Periodic abstinence 3.5 1.0 1.1 Withdrawal 25.7 26.2 24.4 Other methods 3.1 0.9 0.6 Not currently using 36.6 37.4 36.1 Table 4,7 Trends in current use of contraception by residence and region Percentage of currently married Women 15-49 currently using any method, a modern method, or a traditional method, by residence and region, 1993 TDHS and 1998 TDHS TDHS-93 TDHS-98 Any Any Any Any Residence/ Any modern traditional Any modern traditional Region method method method method method method Residence Urban 66,2 38,9 27,3 66,7 40,8 25,2 Rural 56.1 26.8 29.3 58.1 31.4 26.0 Region West 71.5 37.3 34,2 70.5 40,5 29,2 South 62.8 36.7 26.0 60.3 35.1 24.6 Cantral 62.7 36,6 26. I 68,3 42 ~8 24,7 North 64.2 29.8 34.4 67.0 35.2 31.5 East 42.3 26.3 16.0 42.0 26.7 15.2 Total 62.6 34.5 28.1 63.9 37.7 25.5 The trends are mixed by region. Overall contraceptive use is found to have increased between 1993 and 1998 in the Central region (from 63 to 68 percent) and in the North (from 64 to 67 percent). Most of this increase can be attributed to the increases in the use of modern methods. Contraceptive use decreased slightly in the West and South between 1993 and 1998. In the East, both the proportion of currently married women using contraception and the level of use of modern methods remained unchanged between 1993 and 1998. 4.5 Number of Children at First Use of Contraception Family planning methods may be used by couples for either spacing births or limiting family size. To explore the possible motivation for use of contraceptives, a question was asked on the number of 52 children the respondent had when contraception was first used. These data enable an examination of the cohort changes in the timing of adopting contraceptive use. Table 4.8 shows the dist6bution of ever- married women by age and the number of children the woman had when she first used contraception. More than one-third of women started using contraception after they had one child. Younger cohorts of women reported first use at lower parities than older cohorts of women. For example, the oldest cohort (age 45-49) of ever-married women first used after having 3.4 births on average, while younger cohorts began use on average before having one child. From another perspective, 10 percent of the age cohort 25-29 cohort of ever-married women started contracepting before the birth of flleir first child, compared with three percent of the age 45-49 cohort. Table 4.8 Number of children at first use ofeontraceptlon Percent distribution of ever-married women by number of living children at the time of flrst use of contraception, and median number of children at first use, according to current age, Turkey 1998 Median Never number used Number of children at time of first use of contraception Number of ehil- contra- of dren at] Current age eeption 0 I 2 3 4+ Missing Total women first use 15-19 63.9 20.2 13.5 2.5 0.0 0.0 0.0 I00.0 309 0,0 20-24 40.6 18.3 29.1 9.1 1.9 1.1 0.0 100.0 1,007 0.4 25-29 31.5 10.1 28.3 17.8 6.9 5.3 0.1 100.0 1,197 0.9 30-34 29.6 6.0 21.3 14.7 11.2 17.1 0.0 100.0 926 1.5 35-39 30.9 3.1 14.4 10.4 9.8 31.1 0.3 100.0 963 2.7 40-44 38.8 2.1 8.3 6.7 8.2 35.4 0.5 100.0 618 3.7 45-49 47.1 3.0 7.7 7.6 5.9 28.6 0.0 I00.0 489 3.4 Total 36.8 8.7 19.9 11.4 ' 6.9 16.2 0.1 100.0 5,509 1.3 Among ever-marrled women who have ever used contraception 4.6 Knowledge of the Fertile Period A basic knowledge of reproductive physiology is necessary for successftil practice of coital- related methods, such as withdrawal, condom, and vaginal methods (diaphragm, foam or jelly). Knowledge is particularly critical in the case of periodic abstinence or the rhythm method. The successful practice of periodic abstinence depends on an understanding of when during the ovulatory cycle a woman is most likely to conceive. Table 4.9 presents the percent distribution of all respondents and those who have ever used periodic abstinence and withdrawal by reported knowledge of the fertile period in the ovulatory cycle. Overall, women in Turkey do not have adequate knowledge of the timing of the ovulation. Only 18 percent of all women know the correct time of ovulation, 44 percent have no idea as to the time, and 38 percent have incorrect knowledge (Figure 4.3). Women who have ever used the rhythm method have better knowledge than all women; 55 percent know the correct time of ovulation, nine percent report that they do not know about the time of ovulation, and 36 percent have incorrect knowledge. Ever users of withdrawal are less likely to be able to identify the time in the cycle when a woman is most likely to conceive; 21 percent know the correct time of ovulation, 36 percent are unsure when a woman was fertile, and 43 have incorrect knowledge. 53 Table 4.9 Knowtedge of fertile neriod Percent distribution of all women, women who have ever used periodic abstinence, and women who have ever used withdrawal, by knowledge of the fertile period during the ovulatory cycle, Turkey 1998 Ever users Ever users Perceived All of periodic of with- fertile period women abstinence drawal During period 0.3 0.3 0.3 After period ends 9,3 12.7 12.6 Middle of the cycle 17.6 54.8 21.3 Before period begins 1.5 1.3 1.3 At any time 22,0 9,1 21.3 Other 5.5 13.2 7.2 Don't know/Missing 43.8 8.5 36.0 Total I00.0 I00.0 I00.0 Number 8,576 503 3,552 Figure 4.3 Knowledge of Fertile Period Among All Women Don't know 44% her % After period ended 9% Middle of the cycle 18% At any time 22% TDHS 1998 54 4.7 Timing of Female Sterilisation Table 4.10 shows the distribution of sterilised women by their age at the time of sterilisation. These findings should, however, be treated with caution since the number of women sterilized is small and misreporting of ages can distort the results. The results indicate that around two-thirds of women who are sterilised had the operation between age 25 and 34. The median reported age at sterilisation was 32 years, as was found in 1993 TDHS. T~able4.10 Timing of sterillsation Percent distribution of sterilised women by age at the time of sterilisation, Turkey 1998 Percentage of Age at time of sterilised sterilisation women <25 6.2 25-29 27.7 30-34 36.4 35-39 22.1 40-44 6.1 45-49 1.5 Total 100.0 Number of women 257 Median age 1 31.7 l Median age was calculated only for women less than 40 years of age to avoid problems of censoring. 4.8 Sources for Family Planning Methods Information on sources of modern contraceptives is useful for family planning programme managers and implementors. In the TDHS, women who reported using a modern method of contraception at the time of the survey were asked where they obtained the method last time (Table 4.11). In interpreting the results, it is important to note that some of the women may misreport the type of the place where they obtained the method, since the distinction between hospitals and clinics, or between public and private sources may not be clear to them. In general, the dominance of the public sector sources in the provision of modern contraceptive services is evident. Overall, 56 percent of users of modern methods said that they relied on a public sector provider. Specifically, health centres (primary health care units) are the most frequent source from where women obtain methods (Figure 4.4). In the case of the pill and the condom, the majority of users go to the private sector for supplies, in particular to pharmacies. In the case of the IUD, most users obtained the IUD from the public institutions, but private doctors are also important providers of the IUD; more than one in four IUD users obtained the method from a private sector provider. 55 Table 4.12 compares the distribution of users of selected methods by the service provider reported in the TDHS-98 with the distribution reported in the TDHS-93. Looking at all methods, the major change is a somewhat decreased reliance upon public sector in the ease of female sterilisation. The percentage of women obtaining sterilisation from a private sector provider has increased from 16 in 1993 to 21 percent in 1998. Among non-users of contraception, when they were asked about whether they know a source for obtaining modern contraceptives, 56 percent knew about a public sector source, 20 percent cited a private sector source, and 24 percent stated did not know about any source (data not shown). Table 4.12 Source of supply for selected modern methods, 1993 and 1998 Percent distribution of current users of the pill, IUD, condom, and female stcrilisation, by source of supply, 1993 TDHS and 1998 TDHS Female Pill IUD Condom sterilisation Source of supply TDHS-93 TDHS-98 TDHS-93 TDHS-98 TDHS-93 TDHS-98 TDHS-93 TDHS-98 Public sector 24.2 26.0 70.9 71.8 28.7 27.7 83.4 76.9 Private sector 75.3 73.6 28.1 27.5 66.2 66.8 15.5 20.8 Other 0.5 0.4 1.0 0.7 5.1 5.5 1.1 2.3 4.9 Discontinuation of Contraceptive Use Couples can realise their reproductive goals only when they use contraceptive methods consistently. Therefore, a particular concern for family planning programmes is the rate at which users discontinue use of contraception and the reasons for such discontinuation. In the TDHS calendar, all segments of contraceptive use between January 1993 and the date of interview were recorded along with reasons for any discontinuation of use during the period. The discontinuation rates presented here refer only to episodes of contraceptive use that begun during the period of time covered by the calendar, not all episodes that occurred during this period. Specifically, the rates presented in Table 4.13 refer to the 60 month period, 3-63 months prior to the survey. The mouth of interview and the 2 prior months are ignored in order to avoid the bias that may be introduced by unrecognized pregnancies. One-year contraceptive discontinuation rates based on the information collected in the TDHS calendar are presented in Table 4.13, according to specific methods. The results indicate that one in three family planning users in Turkey stops using a contraceptive method within 12 months of starting use. The one-year discontinuation rate is as low as nine percent for IUD, while it is 52 percent for injections, 56 percent for the pill, and 38 percent for withdrawal• Five percent of users stopped using because they want to become pregnant, 7 percent stopped as a result of method failure, another five percent stopped due to side effects or health concerns, and the remammg 17 percent stopped due to other reasons. Side effects or health concerns accoutlt for a large portion of the relatively high discontinuation rates for the pill and injection (21 and 29 percent, respectively). On the other hand, method failure accounted for an substantial portion of the discontinuation rates of withdrawal (12 percent)• 57 Table 4.13 Contraceative discontinuation rates First-year contraceptive discontinuation rates by reason for discontinuation, according to method, Turkey 1998 Reason for diseontinuation Side To effects/ Contraceptive Method become health Other All method failure pregnant concerns reason reasons Pill 6.6 4.8 21.4 23.6 56.4 IUD 0.9 0.4 6.0 2.0 9.4 Condom 6.0 8.1 0.8 28.6 43.3 Withdrawal 12.0 7.2 0.3 18.7 38.2 Total 7.4 5.2 5.0 17.2 34.9 Table 4,14 presents the distribution of all diseontinuations during the five-year period before the survey according to tile reason for discontinuation and tile method used. The desire to become pregnant accounted for one-fifth of all discontinuations. Side effects and health concerns were frequently mentioned as reasons for discontinuation of modern methods. Accidental pregnancy was more common among withdrawal users (33 percent) than modern method users. However, 16 percent of condom discontinuations and 13 percent of pill discontinuations also were due to method failure. Table 4.14 Reasons for discontinuation of comracention Percent distribution of contraceptive method discontinuatloas in the five years preceding the survey by main reason for discontinuation, according to specific methods, Turkey 1998 Contraceptive method Diaphragm/ Reason for Foam/ With- All t discontinuation Pill IUD Jelly Condom drawal methods Became pregnant 12.7 5.6 15.9 15.6 33.1 21.2 To become pregnant 13.3 21.4 9.2 22.5 21.4 [9.9 Husband disapproved 0.3 0.1 3.8 12.6 2.6 3.0 Side effects 29.5 24.7 7.1 1.0 0.3 10.7 Health concerns 9.1 16.4 7.0 1.5 0.4 5.5 Access/Availability 0.7 0.0 2.3 2.2 0.0 0.5 More effective method 2.3 0.5 12.3 10.7 13.0 8.3 Inconvenient to use 1.2 0.6 1.8 4.7 1.0 1.4 Infrequent sex 6.4 1.7 0.0 2. I 3.1 3.1 Cost 0.5 0.0 0.8 0.5 0.0 0.2 Fatalistic 0,0 0.1 0.0 0.3 0.0 0.0 Menopause 1.9 1.7 2.3 0.9 3.0 2.3 Marital dissolution 0.7 2.8 1.1 1.2 0,8 1.3 Other 11.4 17.0 25.4 10.6 4.1 9.2 Don't know 0.1 0.0 0.0 0.4 0.2 0. I Missing 10.0 7.2 11.1 13.3 17.1 13.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 729 836 89 566 1,871 4,229 I Includes discontinuations of injection, periodic abstinence, and folk methods 58 4.10 Future Use of Family Planning An important indicator of the demand for family planning is the extent to which nonusers plan to use family planning in the future. Women who were not using contraception at tile time of the survey were asked about their intention to use family planning in the future. The results are presented in Table 4.15. Around half of the currently married women who are not using any contraception report that they intend to use family planning in the future and 36 percent plan to use in the next 12 months (Figure 4.5). Table 4.15 Future use ~feontraception Percent distribution of currently married women and husbands who are not using a contraceptive method by intention to use in the future, according to number of living children, Turkey 1998 • . . ] Number of hvmg chddren Future use of contraception 0 1 2 3 4+ Total CURRENTLY MARRIED WOMEN Intend use in next 12 months 1%1 48.1 Intend to use later 43,0 18.0 Unsure as to timing 1,3 3.1 Unsure as to intention 5,5 4.1 Do not intend to use 32,6 25.3 Don't know/Missing 0,4 1.4 45.9 38.5 25.0 35.3 8.7 4.8 4.5 14.7 1.7 0,2 0.2 1.4 3.4 2.6 2.7 3.6 39.3 52.6 65.7 43.7 1.0 1,3 1.8 1.2 Total 100,0 100.0 Number 345 488 100.0 100.0 100.0 100.0 460 291 556 2,139 HUSBANDS Intend use in next 12 months 26,9 37.4 23.2 22.6 22.3 26.0 Intend to use later 27,8 22.6 7.1 3.8 4.1 12.2 Unsure as to timing 3,8 0.2 1.8 0.0 0.6 1.2 Unsure as to intention 4.7 5.9 5.1 1.4 2.7 3.9 Do not intend to use 35,4 31.6 56.5 67.0 67,8 53.4 Don't know/Missing 1.4 2.3 6.2 5.2 2.5 3.3 Total I00,0 I00.0 100.0 100.0 100.0 100.0 Number 139 126 128 106 239 737 i Includes current pregnancy The proportion intending to use, and especially the timing of the intended use, varies with the number of living children. While the proportion who intend to use within the next 12 months is 17 percent among childless nonusers, almost half of the women with 1 or 2 children plan to use soon. Among husbands, the proportion who intend to use family planning is 39 percent. The proportion intending to use among husbands also varies with number of living children, peaking at 60 percent among those with one child. 59 Figure 4.5 Future Use of Contraception Among Non-User Women [Insure aboul liming= %1 [nlend'~ In use later %15 UIISIIre abollt II %4 lnll~llth, to use Sootl %35 Missing %1 Does not intend 1o use %44 TNSA 1998 l 'able 4.16 presents the main reasons for not using family planning reported by currently married mmusers v, ho do not intend to use a contraceptive Inethod ill the future. A desire for more children accounts for one-third of nonuse among women less than 30 years of age. The reasons cited most tiequently by nonusers age 30 years and over were related to perceived subfecundity and infecundity or being inenopausal. Spouse's opposition or concern about religious prohibitions were mentioned as leasons f\~r uonuse by less than 10 percent of women. Fable 4.16 Reasons for not using contraception Pcrccnt disllibution of~somcn wbo are not using a contraceptive metbod and ~ho do not intend to use in the future by' main reason lbr not using. according to age, and percent distribution of husbands v, ho are not using contlaception and vdlo do not intend to tISC bv mat reaso For n us i1~. lurke 5 1998 " Ag~ Reason for not l'otal Total using coutraccplion ~0 30+ women husbands IPffequent sex 2. I 226 2.5 29 M enopausal/hvstereclonw 00 35.9 307 242 Sublecund, Pl ~cund 175 30.8 28.9 116 364 5.1 9.6 96 7.0 16 2.4 3.7 86 2.3 3.2 01 0(1 0. I 0. I 0.0 58 3.1 3.5 5 2 10 1.0 1.0 2 4 I).4 I),4 0.4 0.0 4.5 1.7 2.1 4.1 04 0,3 (13 I 2 1.7 03 05 #,)6 0,0 0.1 0.1 00 0.0 0.2 0.2 0.0 9.7 12.2 I 1.8 22.9 3.5 1,7 2.(1 78 1.3 04 0.5 0.5 Wants more children Respondent opposed [ kbband opposed Others opposed P, digious prohibition Kn&s no method Kllow5, i)o source Health concerns Fear side el]~cts (osts too much [nconvenieilt to use Interferes with body processes Other Don't kllow Missing ]oral Number 100.0 100.0 100.0 100.0 135 800 935 394 60 One-fourth of all husbands stated that they were not using contraception because their wives were menopausal or had had a hysterectomy. A further 12 percent were not using because their wives were subfecund or infecund. Future demand for specific methods of family planning was assessed in the TDHS by asking nonusers who planned to use a family planning method in the future which method they intended to use (Table 4.17). More than one-third of currently married women who are not using a contraceptive method intend to use IUD, down from 51 percent in the TDHS-93. Proportions intending to use other modern methods generally increased. Women who intend to use family planning in the next 12 months and those planning to use later have similar preferences (data not shown). Table 4.17 Preferred method of contracep- tion for future use Percent distribution of currently married women who are not using a contraceptive method but who intend to use in the future by preferred method, Turkey 1998 Preferred method of contraception Total Piii 10.1 IUD 36.5 Injection 8,5 Diaphragm/Foam/Jelly 0.5 Condom 5.7 Female sterilisation 6,4 Male sterilisation 0.4 Implants 1.1 Periodic abstinence 0.3 Withdrawal 9,8 Folk method 5.1 Don't know/Missing 15.6 Total 100.0 Number 1,101 4.11 Exposure to Family Planning Messages in the Electronic Media Information on the level of public exposure to a particular type of media allows policy-makers to ensure the use of the most effective media for reaching various target groups. Radio and television are major potential sources of information about family planning. To assess the effectiveness of these electronic media for the dissemination of family planning information, all women and husbands in the survey were asked if they had heard messages about family planning on radio or seen them on television during the last few months preceding the survey. Table 4.18 shows that around half of all women and husbands reported that they had heard or seen a family planning message on radio or television. On the other hand, 10 percent of women and 14 percent of husbands reported that they had heard or seen a family planning message on radio and television. Overall, family planning messages are seen more often on television rather than heard on radio. The differences in the percentages who had seen a message by type of place of residence, region, and education are greater for women than for men. For both women and men, sharp contrasts in access to media messages are observed between less educated and educated respondents. 61 Table 4.18 Heard about family nlannine on radic! and television Percent distribution of all women and of husbands by whether they heard a radio and/or television message about family planning in the few months prior to the interview, according to selected background characteristics, Turkey 1998 Heard Number on both Tele- Heard of Background radio Radio vision on women/ characteristic and TV only only neither Missing Total husbands CURRENTLY MARRIED WOMEN Age 15-19 8.0 1.1 34.6 56.3 0.0 100.0 1,720 20-24 9.1 1.3 43.0 46.3 0.2 I00.0 1,558 25-29 9.4 0.6 42.9 47.1 0.0 100.0 1,397 30-34 I 0,4 0.5 41,4 47.7 0.0 100.0 1,202 35-39 11.5 0.7 34.9 52.8 0.0 100.0 1,081 40-44 10.9 0.4 34.5 54.2 0.0 100.0 885 45-49 12.4 0.8 29.2 57.5 0.1 100.0 733 Residence Urban 10.0 0.7 41.1 48.1 0.1 100.0 5,704 Rural 9.8 1.0 31.8 57.3 0.1 100.0 2,872 Region West 9.2 0.9 41.7 48.1 0.1 100.0 3,204 South 10,0 0.4 34.9 54.6 0.0 100.0 1,258 Central 10.0 0.8 40.9 48.1 0.1 100.0 1,985 North 7,8 0.9 40.6 50.6 0. I 100.0 692 East 12.0 0.9 27.2 59.9 0.0 100.0 1,437 Education No educ./Pri, incomp. 10.0 0.5 24.2 65.1 0.2 100.0 1,861 PrL comp./Sec, incomp. 9,4 1.0 38.7 51.0 0.0 100.0 5,158 Sec. comp./+ 11,5 0.7 52.4 35.3 0. I 100.0 1,556 All women 9,9 0.8 38.0 51.2 0.1 I00.0 8,576 HUSBANDS Age 15-24 12,3 4.2 51.1 32.6 0.0 100.0 113 25-29 9.7 1.2 41.4 47.4 0.4 100.0 342 30-34 9,5 0.1 42.4 47.8 0.2 100.0 364 35-39 14,2 0.8 33.3 51.1 0.8 100.0 352 40-44 15,3 0.6 33.7 50.4 0.0 100.0 335 45-49 16,3 1.3 33.8 48.6 0.0 100.0 240 50+ 22,4 0.0 26.9 47.9 2.6 100.0 226 Residence Urban 13,3 1.1 38.1 4%0 0,4 I00,0 1,347 Rural 14,8 0.2 34.0 50.9 0.0 100.0 624 Region West 12,9 1.4 38.2 47.4 0.2 I00.0 767 Sooth 17,4 1.1 33.5 47.8 0.2 100.0 285 Central 11.8 0.1 39.6 47.9 0.6 100.0 481 North 7.6 0.9 38.8 52.4 0.2 100.0 150 East 19,5 0.3 30.8 49.4 0.0 100.0 287 Education No educ./Pri, incomp. 18.6 1. I 25.9 54.0 0.3 100.0 204 Pri. comp./Sec, incomp. 14.4 0.6 34.1 50.5 0.3 I00.0 1,253 Sec. comp./+ 10.5 1.3 47.8 40.4 0.0 100.0 513 All men 13.8 0.8 36.8 48.3 0.3 100.0 1,971 62 4.12 Acceptability of Use of Eleetronie Media to Disseminate Family Planning Messages To determine the level of acceptance of the dissemination of family planning information through the media, the TDHS asked women and husbands whether it was acceptable to disseminate family planning htformation on radio and television. Overall, the majority of women (89 percent) atld men (87 percent) interviewed reported that it was acceptable to use radio or television to air family planning messages (Table 4.19). Acceptability of radio and television as a source of information is highest alnong women and husbands in urban areas, in the West, and among those with high levels of education. Table 4.19 Acceptability of family planning messages on radio and television Percentage of women and husbands who think it is acceptable to have messages about family planning on radio and television, by selected background characteristics. Turkey 1998 Women Husbands Background characteristic Percent Number Percent Number Age 15-19 86.2 1,720 * 4 20-24 90.1 1,558 80.9 109 25-29 91,2 1,397 88.1 342 30-34 91,2 1,202 87.0 364 35-39 89.8 1.081 90.0 352 40-44 88.6 885 89.0 335 45-49 85.0 733 87.1 240 50+ NA NA 76.7 226 Residence Urban 91.5 5,704 88.9 1,347 Rural 84.1 2,872 81.8 624 Region West 92.6 3,204 92.8 767 South 90.2 1,258 84.4 285 Central 92.1 1,985 85.3 481 No~xh 87.0 692 85.8 150 East 76.7 1.437 75.0 287 Education No educ./Pri, incomp. 74.8 1,861 67,1 204 Pri. eomp,/See, incornp. 91.8 5,158 86.6 1.253 Sec, comp./+ 97.0 1,556 94.5 513 Total 89.0 8,576 86.6 1.97 I NA = Not applicable Note: AI~ asterisk indicates a figure is based on t'ex~er than 25 respondents and has been suppressed. 4.13 Exposure to Family Planning Messages in Print Media Women were asked if they had been exposed to a family planning message through a newspaper/magazine article, a poster, or a leaflet/brochure (i.e., through print media) during the few months prior to the interview. The results are presented in Table 4.20. Twenty-seven percent of the women interviewed reported that they had exposed to at least one of these media that contained family planning infoi'mation. The most commonly reported source was newspaper/magazine (19 percent). Women in older age groups, living in the East, or who were less educated were less likely to have been exposed to print media on family planning than those in younger age cohorts, living in urban areas or in the West and more educated women. 63 : Table 4,20 Heard about of family nlarming through orint media Percentage of women and husbands who had seen a message about familyplanning through print media in the few months prior to the interview, by source of message and selectedbackground characteristics, Turkey 1998 Print media Number of Background Any Newspaper/ LeafleV womeo/ characteristle source Magazine Poster Brochure hsubands CURRENTLY MARRIED WOMEN Alg5e- 19 27.2 19.7 8.5 10.3 1,720 20-24 31.6 22.6 13.6 12.4 1,558 25-29 29.7 21.0 13.2 10.8 1,397 30-34 27.2 19.7 12.1 9.6 1,202 35-39 25.0 17.3 10.2 9.1 1,081 40-44 21.5 15.1 10.4 9.2 885 45-49 17.1 13.5 6.1 6.2 733 Residence Urban 31.7 Rural 16.7 23.1 13.0 12.2 5,704 11.2 6.8 5.8 2,872 R•Vgc i°n st 33.6 23.9 15.3 12.9 3,204

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